🔙 Quay lại trang tải sách pdf ebook Sổ Tay Tiêu Hóa Thực Hành Ebooks Nhóm Zalo Sd TAY TIEU HO A THISC HAlNH t s . n g u yI n TH! van hong SO TflV TI€U HOfl THl/C HflNH NHA XUAT BAN Y HOC HA NQI-2006 LOI m 6 d a u Benh tieu hoa la mot benh ly rat pho bien tren the gicii, dac biet d Viet Nam. Do co nhiing dac thu rieng nhii dieu kien khi hau, dieu kien song thap kem cung nhtf ve sinh khong dam bao... so vdi cac c0 quan khac cua cd the co le ong tieu hoa la ndi chiu nhieu anh hiidng nhat. Cung chrnh vi vay ma benh ly d khu vUc nay rat phong phu va da dang. Tii nhiing benh ddn gian den nhijfng benh ma nguyen nhan va cd che cho den nay van con nhieu van de phai ban cai. V6i muc dich giup cac ban doc nam b it cac van de ve benh ly tieu hoa mot cach de dang, chung toi da co gang trinh bay nhiing thong tin ngan gon va de hieu ve hau het cac chutng benh thifdng gap cua he tieu hoa. Chung toi mong cuon “So tay tieu hoa thilc hanh” thvfc svi la cam nang cho tat ca cac doi tUdng sinh vien, bac si noi tru va bac si noi khoa. Cuon sach se giup cac ban co difdc suy nghi dung hvidng khi chan doan va diia ra nhiing quyet dinh dieu tri dung dan khi lam lam sang. Cuon sach se la ban dong hanh cua cac ban trong nhiing dem triic khi dang con phan van khong biet nen giai quyet van de nhu the nao. Bo" cuc sach hdp ly se giup cac ban tra ciiu rat nhanh cac thong tin can thiet. Chung toi co" gang het siic trong qua trinh bien soan de co difdc mot cuon sach tot nhat co the; tuy nhien khong the het difdc khiem khuyet mong nhan dtfdc s\i gop y chan thanh tii cac doc gia va cua cac ban dong nghiep de cuon sach diidc hoan thien d lan tai ban sau. 3 AC Khang the AINS Thuoc chong viem giam dau non steroid BMI Chi so can nSng cd the so vdi chieu cao CEA Carcinome embrryonnaire antigene CPRE Chup mat tuy ngifdc dong CRP Protein C reactive (protein C phan ifng) CT Chup cSt I6p vi tinh CTM Cong thufc mau DM Dong mach OT Dai trang H/C Hoi chifng HAV Viem gan virus viem gan A HBV Viem gan virus viem gan B HCP Ho chau phai HCT Ho chau trai HCV Viem gan virus viem gan C HP Helicobacter Pylori IPP Thuoc (le che bdm proton IRM Chup cong hudng tCr NS Noi soi P Phai PCR Phan ifng khuyech dai chu6i PT Phau thuat SA Sieu am ST Sinh thiet T Trai TH Tieu hoa TM Tinh mach TMH Tai mui hong TP Ty le prothrombin TR Tham tn/c trang XHTH Xuat huyet tieu hoa EBO CRP. Creactive CT3 PCR Protein (JhtifUnj 1 BENH LY THUC QUAN ■ ■ THOAT Vj HOANH 1. Dai ci/dng Dinh nghia: mot phan cua da day chui len long ngiic xuyen qua lo thiic quan. Giai phau: Co th it tren thuc quan nSm 0 vi tri 15 cm cach cung rang tren va ngang miic dot song co 6, dai khoang 3cm Co th&t diidi thUc quan dai khoang 4 cm. Binh thiidng tam vi trung vdi vi tri dUdng Z co them sU trO giup cua cd hoanh 2. Lam sang Thoat vi hoanh gom 2 the thoat vi: - 95% thoat vi triidt: vi tri tam vi chui cao vao trong long ngUc. Do mat 1 phan giai p h lu giup co bop tam vi lam dich da day trao ngifdc len thiic quan - 5% thoat vi cuon (tam vi co dinh, phinh vi chui vao trong long ngilc). Chan doan xac dinh de dang b^ng: chup X quang ngilc va noi soi tieu hoa tren. Tuy trildng hdp co the chup them transit. Bien chiing chinh: - Trao ngiiOc da day thvfc quan va nhflng bien chiing cua trao ngifdc. 5 - Loet 6 co thoat vi. - Xuat huyet tieu hoa cap tinh hay man ti'nh Bieu hien: thieu mau thieu sat man tinh hay cap ti'nh doi khi ket hop voi thrombose tui mat tai phat - Thoat vi nghet (thoat vi do cuon). 3. Dieu trj - Thoat vi trUdt: dieu tri trao ngiidc da day thac quan va bien chiing. - Thoat vi cuon: phau thuat. 6 TRAO N G l/O C DA DAY DAY - THl/C QUAN 7 i Noi soi Khong co viem thUc quan hay viem khong nang Giai doan 1 - II 80% so benh nhan. Dieu tri: IPP 20mg/ngay x Viem thi/c quan nang Giai doan III - IV 20% so benh nhan IPP 20mg/ngay x 8 tuan. Du Dieu tri Kiem tra noi soi 4 tuan phong xuat hien bien chang Dieu tri nong thUc quan bang noi soi neu co hep Khong Co Dieu tri duy tri Chi dinh can nhac Neu co tai phat sdm He thong IPP vdi lieu toi thieu co hieu qua Dieu tri noi khoa khong ket qua Khong co CCD phlu thuat P hlu thuat (Fundoplicature) phai chon loc benh nhan 1 Dieu trj: - Goi dau cao it nhat 20 cm. - Giam can neu qua beo. - Sau an khong di/pc nam ngay. - Dung thuoc lam giam tritong li/c cd that dudi thi/c quan (Theophylin, chen calci, d in xuat nitrin). 8 KHO NUOT 9 1r 1. Hep do ton thUdng thanh thifc quan * K thi/c quan. * Viem thi/c quan (hep -hach). * Seo hep thi/c quan do hoa chat. * Tui thi/a thi/c quan: -Tui thC/a khi quan - thuc quan (Zenker): hdi thd chua, 0 nong, ho ve dem, sung cd. - Tui thi/a 1/3 giCra va dtfdi thtfc quan: thCr phat sau roi loan van dong. - Viem thi/c quan do vi khuan (Candida, herpes), thuoc (Cycline, AINS), tia xa 2. De vao thi/c quan - Khoi u: K phe quan, hach trung that, u tuyen Lfc, tuyen giap nSm trong long ngtfc, lao dot song vdi o ap xe lanh. - Mach mau: phinh dong mach chu ngUc, nhl trai gian, DM difdi don phai lac chd. 3. Nguyen nhan trong long thuc quan (hiem) - Vong Schatzki - Hoi chi/ng Plummer - Vinson: ton tai mang thi/c quan cd, thieu mau, thieu sat, nguy cd K thuc quan cao. 10 1. Roi loan van dong thifc quan tien phat * Phinh gian tht/c quan khong ro nguyen nhan (Achalasie) - Doi tifdng 40 - 60 tuoi, kho nuot kieu cd nfing, dau ngi/c. - Noi soi tieu hoa cao: cam giac kho khan khi qua tam vi. - Chup Transit: hep dan va deu phan di/di thi/c quan. - Do van dong thac quan (Manometrie) +++: song nhu dong va tang trUdng li/c cd that tam vi. - Bien chiing: benh phoi do sSc va ung thu bieu mo (theo doi). - PhUdng phap dieu tri gian cd (chen dong calci dan xuat Nitrin) nong thi/c quan bang khi, phau thuat: tao hinh tam vi. * Benh co that thac quan Ian toa. * Thi/c quan dang vo hat de 2. Roi loan van dong thtir phat - Xd cung bi (giam trudng lufc cd th lt tam vj) va cac benh khac (Lupus ban do he thong, viem khdp dang thap). - Trypanosomiase: phinh to thac quan khong ro c3n nguyen, chan doan bang huyet thanh. - Dai thao di/dng, amylose, trao ngiidc da day - thi/c quan. UNG THlf THI/C QUAN 1. Dai ci/dng Dich te: - Diing thd 4 trong ung thu tieu hoa. - Tuoi trung binh 60. - Ket hdp v6i K vom khoang 15% so BN. Benh can: - K bieu mo chiem 80%: + Nghien riidu - thuoc la. + Yeu to' dinh diiOng: do uong nong, suy dinh dtfdng, che do an co nhieu nitrosamin. + Khac: ton thUdng seo sau bong hoa chat, chay tia, hoi chiing Plummer - Vinson, phinh gian thuc quan khong ro nguyen nhan, benh Coeliaque. - Adenocarcinome chiem 20% + EBO (Endobrachyoesophage): la ton thUdng cua niem mac thuc quan do viem thuc quan trao ngtfdc, co hien tUOng di san: thay the niem mac thvfc quan b&ng te bao niem mac ruot. + EBO bien chiing 0 10% so' BN trao ngiidc da day thuc quan. - Theo doi: noi soi va sinh thiet nhieu manh 2 nam/1 lan. - Neu di san giai doan cao: cat thifc quan. 2. Chan doan Lam sang: - Nuot kho tang dan, gay sut. 11 - Dau sau xiiOng tic, d nong. - Bien chiing: + Hay bi benh phoi tai phat (3 nguyen nhan: liet day quat ngifdc, ro thUc quan - phe quan, K phe quan ket hdp). + Khac: kho thd do chen ep khi quan, mat giong do ton thUdng day quat ngiidc, H/C Claude - Bernard - Horner do chen ep hach giao cam co, H/C chen ep tinh mach chu tren, viem mang tim carcinoid, tran mu mang phoi. Can lam sang: Noi soi tieu hoa cao: - Nhin an, gay te hay tien me kiem tra dong mau: - Hinh anh noi soi: + Khoi u loet sui. + Hep. + Lan rong va khong dong deu. + Tim vi tri khu tru ton thUdng thil 2. + Nhuom mau va sinh thiet nhieu manh dan trai d vi tri nghi ngd tren nhuom mau (chan doan xac dinh, chan doan phan biet). - Transit: neu hep may khong soi dUdc, nghi ngd co ro, tham do trUdc mo (hep, chen ep, khong deu, lo e t). - Sinh hoa tim dau hieu: thieu mau, di can (ll mat, tang calci mau), marker ung thuf. Tham dd triidc dieu tri: - Phat hien ung thu ket hdp (kham TMH, noi soi, noi soi khi phe quan). 12 - Bilan trtfdc mo de loai trif nhiing triidng hdp co chong chi dinh phau thuat: - Xac dinh xam lan tai cho: + CT ngUc xam lan cd quan lan can: + Sieu am noi soi thuc quan (xam lan cua khoi u vao cac 16p thanh thuc quan va hach). + Kham TMH va noi soi (ton thUdng than kinh quat ngifdc). + Noi soi phe quan (xam lan, ro). - Xac dinh di can + Transit di can: gan, phoi, xUdng, nao. + Lam sang: gan to, cd triicjng, nhan K, tham true trang, hach Troisier. + Sieu am bung + XQ phoi. + Neu co dau hieu nghi ngd: Scintigraphe xUdng, CT nao. - Danh gia tinh trang chung (rifOu - thuoc la): + Kham lam sang: can, chi so BMI. + Tim: dien tim, +/- bSng chiing gang sUc, chup mach vanh. + Phoi: XQ phoi, CTM, khi mau, chtic nang ho hap. + Gan: chiic nang gan, TP +/- sinh thiet gan (neu nghi ngd). + + Than: miic loc cau than, creatinin. 3. Dieu trj Ngoai khoa: - Chuan bi benh nhan de phau thuat: tang cUdng dinh diidng (difdng an uong hay truyen TM), ly lieu phap 13 giup tang ho hap, dieu tri o nhiem trung (TMH, phe quan) hay khang sinh dil phong trUdc mo, dting rUOu va thuoc la, du phong thuoc an than - Phau thuat triet de + Cat thuc quan va nao vet to chufc K 6 trung that + nao vet hach trung that + lam giai phau benh manh cat. + Thay the thtfc quan bang 1 doan dai trang hoac da day. - Ty le tU vong phau thuat < 5%. - 2 bien chiing s6m sau phau thuat: nhiem trung phoi + ro mieng noi. - 2 bien chiing muon sau phau thuat: suy kiet + K tai phat. 2 chi dinh dieu tri ket hap vdi ngoai khoa, chay tia va hoa chat (5 Fu + Cisplatine). - Tr\J6c mo vdi khoi u to T3. - K 1/3 tren thuc quan khong cat diidc hay BN khong the phau thuat. Noi khoa: khoi u be mat khong vutdt qua ldp cd dieu tri triet de bang noi soi cat niem mac hoac quang dien. Dieu tri tam thdi: nong thuc quan va dat ong thong thuc quan, pha huy khol u bang noi soi, chay tia + hoa chat. 4. Tien lirong Ty le song sau 5 nam la <10% tuy vao khoi u da co di can hay chua. 14 (jfm o n if 2 BENH LY DA DAY TA TRANG VIEM DA DAY Dinh nghla: la viem cap hoac man tmh niem mac da day. Viem da day cap 5 nguyen nhan: - Thuoc (Aspirin, AINS). - Rifdu. - Nhilm HP. - Uong hoa chat. - Stress. Trieu chiing - Dau thudng vi. - Xuat huyet tieu hoa. Noi soi va sinh thiet - Phu ne. - Ton thiidng xung huyet va xuat huyet. - Trot be mat. - Ton thuong loet hoai tif. - Giai phau benh: thay doi bieu mo be mat, xam nhap te bao viem chu yeu bach cau da nhan trung tinh d Idp lien ket va Idp bieu mo. Viem da day man tinh 4 nguyen nhan: - Nhiem HP. - Trao nguoc dich mat. - Aspirin/AINS dung dai ngay. - Tif mien: benh Biermer.viem da day do: granulome, u Lympho,tang bach cau ua acid. Trieu chufrig - Oau thuong vi, hoi chi/ng kho tieu. - ThUdng la khong co trieu chCmg. Noi soi va sinh thiet - Dau hieu hoat dong: co bach cau da nhan trung tinh d Idp dem va bieu mo (dac tinh cua nhilm HP). - Dau hieu viem: bach cau lympho 0 Idp dem. - Dau hieu teo: giam so luting tuyen da day. - Dj san ruot va xd hoa Idp dem: nguy co dj san bieu mo c6 the dan den K hoa - Theo doi noi soi va mo benh hoc 0 BN co viem teo da day man tinh va di san. 15 LOET DA DAY - TA TRANG Yeu to nguy cd Trieu chiing . HP thufdng gap nhat - Aspirin va AINS. - Hut thuoc la. - Hep mon vi - ta trang - H/C Zollinger- Ellison - Benh khac: cJdng can giap, suy than, viem tuy man tinh, xd gan rtfdu. - Loet cap do stress, - Corticoid vdi lieu cao. - Ngoai le: khu tru da day - ta trang cua benh Crohn, sarcoidose va lao. T Noi soi tieu hoa cao 1. Khing dinh chan doan. - Dau quan thudng vi lien tuc - Giam dau bang there an, thuoc trung hoa acid - Nhip dau khoang 2- 4 gid va co chu ky trong nam 4 bien chirng - Xuat huyet tieu hoa - Thung - Hep mon vi - ta trang. - Ung thuda day 2. Mo ta chfnh xac vi tri, hinh dang, kfch thifdc va nhung ton thudng ket hdp (viem hang vi, viem ta trang, viem thac quan). 3. Noi soi tim nhOhg dau hieu ac tinh: bd khong deu, kich thucsc > 1cm. Nep niem mac phu ne dC/hg d cach xa o loet, bd cufhg. 4. Cho phep lam nhieu sinh thiet (-10 mlu): - Tren bd o loet (v6i tat ca loet da day) chan doan phan biet K hach, u lympho. - C5 vung hang vi de tim kiem HP. + Lam mo benh hoc. * i i > + Clotest, test urease. + Nuoi cay (+) khang sinh do (neu khong tieu diet di/dc vi khuan). + Test thd - PCR ft dung. 16 Dieu tri - Dung cac yeu to nguy cd: (thuoc la, AINS va chong dong). - Diet tri/ HP bang 2 khang sinh uong trong 7 ngay, hieu qua 90% - 2 khang sinh. Amocilin 1g x 2 lan/ngay (neu di ifng Flagyl 500mg x 2 lan/ngay) va Clarythromycin 500 mg x 2 lan/ ngay. - Giam tiet vdi khang H2 va IPP vi du lieu Omeprazol 20mg x 2 lan/ ngay. Dung tiep thuoc giam tiet vdi 1 lieu 4- 6 tuan. - Noi soi kiem tra 1 thang sau dieu tri (loet da day bat buoc, loet ta trang neu co nguy cd) de kiem tra: Seo o loet: thanh cong Neu that bai tiep tuc ddt dieu tri thCf 2. Neu that bai ddt dieu tri thCr 3. Neu that bai chi dinh phlu thuat (cat da day va cat day X, noi da day rudt). - Diet tri/ HP cho phep giam tai phat va bien chiing: Tim bang chiing co HP blng sinh thiet hang vi. Neu that bai dieu tri lai vdi khang sinh do, roi kiem tra sau dieu tri bang test thd va test urease I Neu dieu tri that bai can tim: - Theo doi dieu tri khong tot - HP khang thuoc. -AINS. - Thuoc la. - Ci/dng giap. - Hoi chiing Zollinger - Ellison. - Khong dieu tri duy tri. DA! HOC : it I E u v j Li\.r. 17 CAC NHOM THUOC DIEU TRj LOET DA DAY - TA TRANG ■ 1. Cac thuoc co tac dung den vo nao M etoclopramide (Primperan) vien 10mg 10-30mg/ngay Sulpirid (Dogmatil) vien 50mg 2-4vien / ngay 2. Cac thuoc urc che bai tiet acid Cc che day th&n kinh 10 khang cholinergic: Atropin Khang cd quan thu cam Muscarinic M l Gastrozepin, pyrenzepin: tac dung manh hdn, it tac dung phu 3. Cac thuoc giam tiet acid Nhom thuoc lie che thu the H2. Cac the he: cimetidin lieu 800-1000 mg/ ngay, ranitidin 150- 300 mg/ngay, famotidin 20-40 mg/ ngay, nizatidin 20-40 mg/ ngay Nhom thuoc lie che bdm Proton Cac the he: Omeprazol 20- 40 mg / ngay, Lansoprazol 30 mg/ ngay, Pantoprazol 40mg / ngay, Raberprazol 20 mg / ngay, Esoprazol 20 - 40 mg / ngay * i ifj i 4. Cac thuoc bao ve ruemmfctjda day - Tac dung tifdng tu Prostaglandin: misoprostol 800 mg / ngay giup tang tiet nhay 18 - ThuoV boc niem mac da day: Sucrafate, Gastropugite, Gelusil. Tac dung phu: giam hap thu mot so chat: P bloquant, digitalit, diuretique, cyclin - Thuoc trung hoa acid: maalox, phosphalugel, KreminS, Nabica. 5. Nhom Bismuth: Subcitrate Bismuth phoi hop v6i khang sinh lam tang cUOng kha nang diet Hp 6. Thuoc diet Helicobacter Pylori Cac thuoc khang sinh: amocilin, tetracyclin, imidazzol, macrolid Ket hdp tot nhat: Amocilin va clarythromycin 7-10 ngay Neu di ling vdi amocilin doi sang nhom imidazol UNG THlf DA DAY ■ 1. Dai cudng Dich te: - Diing thil nhat trong ung thu tieu hoa. - Tuoi trung binh 60. - Thtfdng gap cf chau A - Nam My. Giai phau benh: - Adenocarcinome xam lan 85%. - Adenocarcinome be mat 5%. - Linite da day 5%. + Khoi u tham nhiem vao 16p cd, 16p lien ket lam day thanh da day va tao nen da day be. 19 + Te bao ac tinh dang dua. + Hinh anh tang am d thanh da day tren sieu am noi soi c&n phai sinh thiet sau va phai sinh thiet nhac lai nhieu lan. + Tien liidng toi: ty le song sau 5 nam = 0%. - U lympho da day 5%. + Type B; miic do ac ti'nh nhe (te bao nho MALT) hoac miic do ac ti'nh nang (te bao tuyen). + Nhiem HP ket hdp trong 95% trUdng hdp. Ba yeu to nguy cd: - HP 50 - 80% benh nhan, viem teo da day. - Di truyen. - Thilc an: man, ca thit hun khoi, nitrosamine, rau hoa qua. Nam ton thitfcfng tien ung thii: Can theo doi va sinh thiet dinh ky hang nam. - Loet da day man tinh - Cat doan da day. - Benh Biermer. - Benh M enetrier (viem da day phi dai). - Polyp tuyen. 2. Chan doan Lam sang: - GSy sut can - Dau kieu loet khong dien hinh. 20 - Bien chiing: non, xuat huyet tieu hoa - Hoi chiing can ung thtf (sot, viem tac tinh mach chi, benh ly than kinh ngoai vi). Noi soi tieu hoa tren: - Khoi u: loet, sui, tham nhiem. - Vi tri khoi u theo thii ttf: hang vi, than vi, tam vi - Xac dinh kich thifdc, hinh dang. - Tim kiem o ung thii be mat (nhuom mau). - Cho phep sinh thiet nhieu manh (> 10 manh, d ngoai vi). - Miic do khoi u gay hep, miic do hep. - Khang dinh chan doan b&ng mo benh hoc (type, biet hoa, tham nhiem thanh). - Chup da day: khong can lam he thong, chi dinh chu yeu la tritdc phau thuat, hinh anh co dinh tren cac phim (hinh khuyet, ciing) Tham kham trifdc dieu tri: - Sii xam lan cua khoi u va di can: + Lam sang: vi tri khoi u, gan to, co trifdng, khoi u khi tham am dao (Krukenberg), hach Troisier. + Sinh hoa: men gan CEA. + CT bung va sieu am noi soi da day tim hieu miic do xam lan vao thanh da day va hach. + Sieu am bung va XQ phoi. + Neu co dau hieu gdi y: Scintigraphie xiidng, CT nao. - Tinh trang chung: 21 + Tuoi, can nang, chi so BMI. + Chute nang song: tim, phoi, gan, than. - Xet nghiem dac biet doi v6i he thong hach da day: + Dien di Protein, dien di m iln dich, mau lang, B2 microglobulin, LDH, HIV. + Kham tai mui hong, noi soi vom. + Sieu am noi soi da day - CT tieu khung. + Transit ruot non, noi soi dai trang va noi soi hoi trang. 3. Dieu trj ung thu da day Dieu tri ngoai khoa: - Chong chi dinh: suy kiet, tuoi gia, carcinome lan toa o bung. - Chuan bi benh nhan: boi phu niidc dien giai, dinh dUdng, hut dich da day neu co hep mon vi. Phau thuat triet de: - Neu khoi u co the phau thuat dtfdc, khong co di can xa - Doi v6i K tam vi + than vi: cat da day toan phan va noi thiic quan hong trang quai Y K hang vi, mon vi cat 2/3, 3/4, 4/5 da day noi da day hong trang. Ket hdp: nao vet hach + cat bo mac noi + tham kham cac gidi han cua ton thudng va hach. Giai phau benh manh cat ngay khi phau thuat va sau do Dieu tri tam thdi: - Neu khoi u khong the cat difdc hay co di can xa. - Noi da day hong trang hay md thong hong trang cho an. 22 Dieu tri noi khoa - Cat niem mac v6i ung thii sdm - Hoa tri lieu (5FU + Cisplatine). - Theo doi ton thiidng cacinome. 4. Tien lifdng - Sau phau thuat triet de: tien liidng phu thuoc vao mile do xam lan thanh da day, xam lan hach va type mo benh hoc. - Ty le song 5 nam sau phau thuat triet de ung thii da day la 20 - 30%. BIEN CHLflMG SAU CAT DOAN DA DAY ■ ■ 1. Bien chumg sdm Ro mieng noi, chay mau, ap xe trong o bung, ap xe va tu mau thanh bung, viem phoi, tac mach phoi, nhiem trung tiet nieu. 2. Bien chumg muon - Cd hoc: loet mieng noi, tic ruot do day ch&ng hoac cuc phan. - Chile nang + Gay sut. + Hoi chiing da day be (cam giac nang tile sau an). 23 + Hoi chiing Dumping (ia chay, met, xiu sau an khoang 30 phut) do thiic an xuorig ruot nhanh. + Giam diidng mau sau an 2 - 3 gid. + la chay: nhu dong, khong co dich mat, tuy + Hoi chiing quai den (dau, giam khi non) viem mu quai den. - Thieu hut: thieu mau hong cau to (thieu hut vitamin B12), thieu mau hong cau nho (chay mau, cung cap thieu, kho tieu). - Tai phat: cuc bo, hach va di can. 3. Che do 3n va chdm soc sau c lt da day - Cung cap du nang liidng va protein. - Che do an lam nhieu biia (it nhat 5 bHa), nhai ky, an cham. - DCfng roi dan quay trd lai thiic an co diidng va lactose. Doi khi co chi dinh dung somatostatin cham trong hoi chiing Dumping. - Diing do uong co con. - Vitamin tiem bap lg/6 thang. - Theo doi: can nang, roi loan chiic nang, cong thiic mau, albumin, diidng mau, bilan lipide va phospho - calci. 24 O/nKUU/ i BENH LY RUOT NON ■ ■ iA CHAY MAN TINH 1. Dai ctfdng Dinh nghla: ia chay man ti'nh > 300 g/ngay keo dai hdnl thang Chan doan phan biet: - Mat trifdng life cd that hau mon. - Ia chay gia sau tao bon. 2. Chan doan Lam sang Hoi: - Boi canh lam sang: che do an, tuoi, du lich, thuoc, rifdu. - Ti'nh chat phan (bot, nhay, mau, long) va cach tien trien. - Dau hieu ket hdp: gay sut, dau hieu tai tieu hoa va ngoai tieu hoa (ban, dau khdp, hong ban nut). Kham lam sang: - H/C thieu hut: albumin, thieu mau (sat), chay mau (vitamin K), loang xifdng (vitamin D), Tetanie (Ca). - Dau hieu cifdng giap: kham da, mat, hau mon, kh6p. Can lam sang: - Cong thifc mau, mau lang, dien di protein, HIV 25 - Xet nghiem phan, dinh liidng md trong phan (phan md) neu > 6 g / 24 gid. - Test thd Carmin, ky sinh trung trong phan, TSH. - Noi soi tieu hoa cao va soi dai trang va sinh thiet nhieu ndi (chan doan viem dai trang vi the). 3. The lam sang ? Ia chay vdi kem hap thu 10%: Xet nghiem kem hap thu: A, D,E, K, phospho, calci, thieu mau (sat, folate, B 12) Kham ruot non (phan md, Test vdi D - Xylose ) va hoi trang (Shiling +/-) Nguyen nhan triidc ruot - Kho tieu (D - Xylose, thieu A, D, E, K), suy tuy ngoai tiet (viem tuy man, K tuy, M ucoviciclose), thieu hut mat (ii mat, benh hoi trang, cat doan ruot non). - Viem mu do vi khuan d ruot non, nguyen nhan: bat thiidng hinh thai sau phau thuat, hep, tui thiia, giam van dong, trao ngiidc dai trang - ruot non. Nguyen nhan tai ruot - Teo nhung mao: benh Coeliaque, Sprue tropicale, ky sinh trung, thuoc, khong dung nap siia, thieu hut m iln dich. - Cat doan ruot non. Nguyen nhan sau ruot - Benh ly ruot xuat tiet: thieu hut anti trypsin, ton thiidng dai trang, u lympho. 26 - Tham nhiem dif6i niem mac benh Whipple: dai thiic bao PAS (+) trong 16p lamina Propria va Lymphome. *> Ia chay khong co kem hap thu 90%: Ia chay do nhu dong (phan long, so" liidng nhieu, thudng xay ra vao buoi sang, sau an): - Tang tiet hormon: cUdng giap, u carcinoid, u tuy giap trang). - Benh th&n kinh thuc vat: dai diidng, amylose. - Benh dai trang chiic nang: chiem 80% ia chay man ti'nh. I a chay do tang tiet (> 500g/ngay du nhin an): - Hoi chiing Zollinger - Ellison. - Thuoc: nhuan trang loai kich thich, Biguanide, Colchicin, Digitalin. - Viem dai trang vi the, u nhu. - VIPome, benh ly dai thuc bao he thong. Ia chay tham thau (lo th^m thau >50 mosm, nhin an co hieu qua): - Benh do dung thuoc nhuan trang. - Thieu hut disaccharid (nhat la thieu hut lactose). Ia chay xuat tiet (chan doan bang do thanh thai phan cua a,anti trypsin ) - Viem da day phi dai (menetrier). - Ton thudng dai trang (viem loet dai true trang chay mau). 27 MOT SO BENH LY KEM HAP THU 0 RUOT NON THlfONG GAP 1. Benh Coeliaque - Khong dung nap v6i gliadine (cd che mien dich). - Lam sang: hoi chufng kem hap thu thiidng cu (ia chay, gay, phan md). - 5 benh ly ket hdp phai tim hieu: viem da Herpes, dai diidng phu thuoc Insulin, viem tuyen giap, thieu hut IgA va xd gan mat tien phat. - Khang the nhay va dac hieu: IgA anti noi mac (endomysium) va 2 khang the khac (IgG va IgA anti gliadine). - Chan doan bang noi soi tieu hoa tren va sinh thiet ruot non: + Teo nhung mao toan bo hoac kin dao (tieu chuan can thiet de chan doan). + Tang so liidng bach cau lympho dtfdi niem mac, tang san hoc va tang dam do te bao 16p dem. - 4 bien chiing: u lympho ruot non, ung thtf (mui hong, thiic quan, ruot non), that bai cua che do an va benh tai phat. - 3 bien phap dieu tri: che do an khong co gluten (co trong lua mach, lua mi) bu lai thieu hut do che do an. 2. Khoi u Carcinoide - Khu tru: tieu hoa trong 70% (ruot thita, hoi trang) va ngoai tieu hoa trong 30% (phe quan, buong triing). 28 - Hoi chiing Carcinoid: ban da, ia chay, benh tim Carcinoide (viem mang ngoai tim). - Tang ty le Serotonin mau va 5 HIAA niidc tieu. - Noi soi + sinh thiet, cong hudng tut. scintigraphie vdi thu the Somatostatin - Dieu tri phau thuat va dieu tri trieu chiing bang thuoc nhom Somatostatin. 3. Hoi chumg Zollinger - Ellison - Tang tiet acid da day do u tuy, ta trang tiet nhieu gastrin (lanh tinh trong 50% benh nhan) - Trieu chiing: loet da day va nhat la loet ta trang, tai phat, nhieu o. - Tang cung liidng acid cd ban va Gastrin mau (nhat la sau tiem Secretin tinh mach) - Chan doan hinh anh khoi u: CT, scintigraphie vdi thu the somatostatin. 4. Benh ly do nhu dong - Benh tam than nang, dung qua nhieu nhuan trang, hay gap d nil tre, co roi loan ve nhan cach. 0 >> *> . x . O - Ia chay man tinh tham thau + giam K mau. - Noi soi dai trang: mang sac to' dai trang dung thuoc nhuan trang keo dai. - Dau hieu cua phan do dung thuoc nhuan trang. 29 ('^h i/ fm if 4 BENH LY DAI TRANG HOI CHlfNG RUOT KICH THl'CH ■ ■ 1. Dai ctfdng - Chiem 15 - 30% dan so. - Doi ttfdng tre nut/nam = 2. - Chiing day bung, kho tieu gap trong 80% trUdng hdp. - 3 yeu to" tien trieu: roi loan van dong ruot. Tang nhay cam dai trang. Roi loan tam than. 2. Chan doan Trieu chiing: miic do va trieu chiing cd nang da dang doi lap v6i kham lam sang binh thudng va khong co thay doi toan trang chung. - Dau bung: quan, trtfdng, vung quanh ron, dau tilng cdn, dau hieu cai thien bang thuoc giam co that va sau khi trung dai tien. - Roi loan nhu dong: tao bon xen ke ia chay man tinh. - Hinh thai tien trien: bat dau rat lau va tien trien nang len sau stress. Tieu chuan chan doan Rome II 1999 - Dau bung hay kho chiu d bung it nhat trong 3/12 thang - Kem 2 trong 3 trieu chiing sau: 30 + Bdt sau khi di dai tien + So lan di dai tien thay doi + Thay doi hinh dang phan - Cac trieu chiing phu: xuat hien ft nhat trong 1/4 so ngay So l&n di dai tien: >3 lan / ngay hay < 3 lan / tuan Ti'nh chat phan khong binh thudng: phai ran, phan long, cam giac di khong het phan, co nh&y mui Bung chiidng hay cam giac bung cang Chan doan loai trit: - Benh ly thiic the: thay doi tinh trang chung, dung thuoc, ia mau hay phan den, phai thiic day vi dau. - Xet nghiem he thong: cong thiic mau, dien giai, diidng mau, mau lang, TSH. - Ky sinh trung phan (amip), xet nghiem phan neu ia chay man ti'nh. - CD soi dai trang phat hien ton thiidng thiic the va sinh thiet nhieu ndi neu ia chay man ti'nh (viem dai trang vi the): + Tien sU gia dinh: ung thii hoac adenome dai triic trang. + Tuoi > 40. + Trieu chiing mdi xuat hien hay mdi thay doi ti'nh chat, khong dap ling vdi dieu tri trieu chiing. + Co dau hieu bao dong: xuat huyet tieu hoa, bat thiidng khi kham lam sang, g&y sut. - Chup khung dai trang co baryt, chup doi quang kep neu soi dai trang khong toan bo: hinh anh tang co bop 31 hoac mat trtfdng luc thanh hinh ong hoac cac dia xep chong len nhau lien tiep (tang chieu cao). 3. Dieu trj - Lang nghe benh nhan ke va lam yen long benh nhan - Kham tam than. - Hoat dong the thao, tranh rifdu va do uong co gaz. - Che do an khong qua nghiem ngat va rat can doi: + Biia an deu dan vao gid co dinh, ngheo xO neu co ia chay. + Tranh thiic an len men neu co chvfdng bung. + Uong na6c nhieu va che do an co nhieu xd (tang dan tCf 5g tdi 20 - 30g /ngay) neu co tao bon. - Thuoc: + Tao bon hay luan phien ia chay - tao bon: nhuan trang. + Ia chay: Imodium 2 vien/ngay + 1 vien sau moi lan di dai tien long). + Dau: giam co that (Spasfon) hay khang Cholinergic (visceralgin), nguy cd glaucome cap va bi tieu tien neu co adenome tien liet tuyen. + Chu6ng bung: than hoat (Carbosylane). + Kho tieu: Prokinetique (Motilium). 32 TAO BON 1. D|nh nghTa: tao bon la so' lan dai tien < 3 lan / tuan trong thdi gian > 2 thang. 2. Trieu chumg lam sang Trieu chiing ccf nang: - Bieu hien man ti'nh hay m6i xay ra - Khai thac chi tiet: so lan dai tien, mau sac phan, cac trieu chiing kem theo dau bung chiidng hdi, sut can. - Khai thac tien sii chan thiidng, san khoa, tien sii dung thuoc: thuoc ngu, thuoc ha huyet ap, thuoc chong tr&m cam. - Che do an thieu chat xd. - Tao bon co the co ti'nh chat gia dinh - Thdi diem khdi phat benh gdi y mot so' nguyen nhan. + Tuoi sd sinh can nghi benh Hirschsprung + Tuoi hoc sinh do nhin dai tien keo dai + Phu nii sau mo, sau de do cham van chuyen. + Tuoi gia: ung thii dai - triic trang, chit hep do tui thOta. Trieu chiing thiic the - Tam ly lo lang va tram cam. - Tim dau hieu cua cac benh than kinh, chuyen hoa nhii suy giap, Parkinson. - Kham bung: phat hien cuc phan, thiing dai trang, khoi u. 33 - Kham: tim ntit ke hau mon, lo ro, ap xe, ung thu tai cho. - Tham tnic trang: tim khoi u trong ngoai trtfe trang, chit hep hau mon - triic trang. Co mau hoac nhav theo tay Trieu chiing can lam sang CTM: danh gia miic do thieu mau Sinh hoa: calci, dien giai, TSH Chup: khung dai trang, transit, bung khong chuan bi. - Noi soi dai trang neu >40 tuoi, trieu chiing mdi xuat hien hoac dau hieu kem theo (phan mau, hoi chiing true trang, g iy sut can). - Do van dong (Manometrie) hau mon - tnic trang. - Chup hau mon dong: danh gia chiic nang thai phan 3. Nguyen nhan Tao bon khong ro ton thvfOng thiic the: hai cd che noi sinh - Roi loan van dong dai trang: che do an ngheo xd. - Roi loan thao phan tnic trang (kho dai tien). + Hau mon: tang triidng liic cd that hau mon, nhu dong dao. + Tang ngiidng nhan biet d true trang khi co phan. Nguyen nhan thufc the: - Hep do khoi u: + Ung thii dai true trang. ung thii hau mon, khoi u lanh tinh + Khoi u ngoai de vao (buong triing, tu cung, tien het tuyen), carcinose phuc mac. 34 - Hep khong do u: viem tui thita dai trang sigma, hep do thieu mau, tia xa hoac Crohn. - Do thuoc: chong tram cam, buy than kinh, khang cholinergic, thuoc phien, muoi nhom, cholestyramine. - Nguyen nhan chuyen hoa: suy giap, tang calci mau, giam kali mau, dai diidng, porphyries - Nguyen nhan th in kinh: tai bien mach nao, liet, benh Parkinson, xd ciing tuy rai rac. - Ton thiidng ong tieu hoa: Hirschprung, ro hau mon, viem triic trang, to tnic trang, khong ro nguyen nhan. 4. Dieu trj An nhieu xd, uong du nU6c. Di dai tien vao gid nhat dinh. Noi khoa - cac nhom thuoc dieu tri: - Thuoc tang tao khoi liidng phan: methyl cellulose, cam tho. Neu khong uong du niidc co the bi tac ruot - Thuoic tay tham thau: Sulfatehydroxide magie, mannitol, lactulose, muoi natri. Co the gay roi loan dien giai. - Thuoc tay kich thi'ch: Phenolphthalein, bisacodyl, senna, cascara, danthron. Co the lam thiidng ton niem mac dai trang neu dung keo dai. - Cac chat lam mem phan: dau paraffin. Co the gay viem phoi do sac dau. - Cac thuoc gay thai phan d tnic trang: vien dan glycerin, chat thut. Co the gay thiidng ton cd that hau mon neu dung khong dung. Dieu tri ngoai khoa chi dinh het siic han che. 35 - Md cd vong, hau mon nhan tao - Sxia chfla day chau: sa niem mac hoac sa tang sinh mon BENH CROHN 1. Dai ci/dng Benh Crohn la viem ruot man ti'nh, nguyen nhan khong ro, co the gay ton thiidng cac doan orig tieu hoa va tien trien tifng ddt. Dich te: Tien sif gia dinh 10%. Tuoi tii 15 - 30 tuoi. Giai phau benh: Vi tri ton thiidng: - Ton thiidng khong dong deu (xen lan niem mac lanh) - Hoi trang, dai trang, hau mon. Dai the: - Viem do, loet (aptoide), hep, ro - Thiidng ton xuyen thanh, day thanh, xd hoa Vi the: - Vem nhiem: lympho, plasmocyt hay viem nang lympho. - Granulome bieu mo va te bao khong lo: 50% trtfdng hdp. 2. Chan doan Dau hieu lam sang: - Thay doi tinh trang toan than, chan an, sot. 36 - Ia chay man tinh doi khi ia mau. - Dau bung (ha siidn phai, ho' chau phai). - Khoi u ho chau phai. - Thiidng ton hau mon + quanh hau mon, rach, ap xe, ro. - Bieu hien ngoai tieu hoa (1/3 so' BN): + Xiidng khdp (ban do nut, loet mom), viem mu da. + Mat (viem mang bo dao), gan mat: amylose thii phat. - Cdn nang danh gia bang bang diem Best (ce 8 tieu chuan: so' lan dai tien, ciidng do dau, tinh trang toan than, bieu hien ngoai tieu hoa, can phai dung thuoc giam ia chay, co khoi u o bung, hematocrite, can nang). Can lam sang: - Hoi chiing viem - Noi soi tieu hoa cao va thap kem sinh thiet va giai phau benh. Chan doan: tvfng doan hep gian xen ke, viem loet tiing doan, thiidng ton nang theo doi noi soi dinh ky. - Chup Transit - sieu am bung, hep khong dong deu, thanh day, loet, ro. - Bilan kem hap thu. - 2 chan doan loai trii: + Viem dai trang vi khuan (Yersinia) ky sinh trung, cay phan, huyet thanh chan doan. + Lao hoi manh trang. 3. Bien chumg - The nang: viem dai trang nang. 37 - Hep, ro va ap xe. - Chen ep vao cd quan lan can. - Xuat huyet tieu hoa, thung, teo dai trang (hiem) - Cham 16n 0 tre em. - Ruot non ngan (cat nhieu ruot non) - Ckt hoi trang va cat mat Valve Bauhin - ia chay, kem hap thu (md, vitamin B12) soi mat va soi oxalat tiet nieu. - Ac tinh hoa: bien chiing muon va it. 4. Dieu trj - Tam ly lieu phap. - Difng thuoc la (yeu to' khdi phat) - Khi co ddt tien trien: + An kieng: che do an khong co ba. + Salicyles (uong hay thut). + Corticoid (uong, thut loai khong hap thu). + Khang sinh (metronidazole) khi co thiidng ton hau mon. - The man ti'nh, nang hay khang lai Corticoid: + Dinh diidng theo 2 diidng. + XJc che mien dich (Imurel, methotrexat, cyclosporine). + Dieu hoa mien dich (thuoc khang huy hoai to chiic, Infliximab). - Ngoai khoa: danh cho bien chiing (hep, ap xe, ro) va that bai v6i dieu tri noi khoa, han che chi dinh het miic co the vi tai phat sau phau thuat nhieu. 38 - Theo doi: bang soi dai trang + sinh thiet hang nam. Khi co viem toan bo dai trang tien trien > 10 nam. VIEM LOET DAI - TRlfC TRANG CHAY MAU 1. Dai cirdng - Viem ruot man tinh nguyen nhan khong ro va tien trien thanh tifng ddt. - Tuoi khdi phat benh tut 15 - 30 tuoi. Giai phau benh: - Hinh thai: + Thiidng ton lien tuc, mot dang, khong co vung niem mac lanh xen giiia. + Thiidng ton nhieu nhat la d tnic trang va dai trang sigma. Dai the: niem mac do, day len nhii da lat diidng va de chay mau, loet. Vi the (khong co dau hieu dac hieu): - Viem niem mac va diidi niem mac (tham nhiem lympho + plasmocyte d 16p dem, ap xe cryptique, mat 16p nhay). - Khong tim thay dau hieu cua benh Crohn. 2. Chan doan The thiiofng gap: viem loet tnic trang dai trang sigma miic do vOia. - The trang thiidng khong thay doi d nhiing ddt dau 39 - Kham lam sang binh thiidng. - Cdn dau dai trang. - Phan n h iy mau. - Bieu hien ngoai tieu hoa 1/3 so" benh nhan: + Xildng khdp (dau khdp, viem kh6p, loang xtfdng). + Da, niem mac (ban do nut, loet mieng, viem mu da). + Mat (viem mang bo dao, xd gan mat, amylose thii phat). Can lam sang - Noi soi dai trang - hoi trang va sinh thiet. - Giai phau benh: chan doan miic do nang, theo doi. - Chup khung dai trang co baryt: hinh anh dai trang ciing, hinh ong. 3 chan doan cdn phai phan biet: - Benh Crohn (ket qua sinh thiet, noi soi tieu hoa cao, transit ruot non). - Viem dai trang vi khuan. - Lao hoi manh trang. The nang: viem toan bo dai trang nang: - Thay doi tinh trang chung: sot, gay, xanh. - Dau bung, phan mau, nhay. - Sinh hoa: thieu mau, bach cau da nhan trung tinh tang, mau lang tang, giam albumin mau. 2 tham do cap: - Chup bung khong chuan bi: loai trrf phinh gian dai trang. - Noi soi (khi khong co thung): tim loet rong va sau. Dieu tri: cap. Tien liidng xau. 3. Bien chiirng - Gian dai trang (megacolon), chup bung khong chu&n bi dai trang gian> 6 cm = tien trieu cua thung. - Thung. - Chay mau. - Nhiem trung huyet. - Cham day thi 0 tre em. - Nguy cd ung thii hoa doi v6i viem toan bo dai trang (Pancolite) > 10 nam. 4. Dieu trj Noi khoa: che do an khong xd - Salicyles (uong hoac thut). - Corticoide (uong, thut loai khong hap thu). The nang: - Nuoi diidng diidng tinh mach. - Truyen mau va khang sinh. - Corticoid tinh mach, ilc che mien dich. - Dieu tri bao ton bang salicyle (giam tai phat). Ngoai khoa: cat dai trang toan bo va noi hoi trang hau mon. Cho phep chifa khoi benh hoan toan. - Chi dinh trong: 41 The nang That bai sau dieu tri noi khoa tich cilc. Thung, chay mau, ung thu. Th§ man ti'nh suy kiet. - Theo doi bang soi dai trang + sinh thiet hang nam, doi v6i triidng hdp viem toan bo dai trang benh tien trien > 10 nam. TUI THlfA DAI TRANG 1. Dai cirdng Dinh nghia: tui thila dai trang la thoat vi cua niem mac va cua 16p cd ve phi'a 16p thanh mac. Sinh ly benh: giam chat chiia trong long dai trang do che do an ngheo chat xd, tang van dong va tang ap liic vao thanh dai trang - tao thanh thoat vi: tui thtfa. 2. Chan doan tui thira dai trang the khdng trieu chumg - Rat thiidng gap (30% Ilia tuoi > 50 va 50% liia tuoi > 70). - Co tui thufa khong co bien chiing (Sigma trong 90% triidng hdp). - Thiidng khong co trieu chiing. - Phat hien tui thila bang soi dai trang va chup khung dai trang co Baryt (hinh anh tron noi vdi thanh bang mot co hep lai). - Luon tim them nguyen nhan khac neu BN co trieu chiing (viem tui thula ket hdp). 42 - Dieu tri noi khoa: tang so' liidng phan hang che do an giau chat xd. Chu y: 3 dau hieu thudng di kem vdi nhau: tui thiia dai trang, soi tui mat, thoat vi hoanh. 3. Chan doan tui thira dai trang the co trieu chumg - Viem tui thCfa Sigma cap: la bien chiing thiidng gap cua tui thCfa 25%. Lam sang: benh canh viem ruot thCfa ben trai d benh nhan > 40 tuoi luon phai nghia den benh canh viem tui thiia. - Dau duf doi dai dang d ho' chau trai, sot, roi loan nhu dong, hoi chiing kich thi'ch triic trang, tui mat. - Co mang hoac phan ling d ho chau trai, tham triic trang dau. - H/C viem, cay mau, tang bach cau da nhan trung tinh. Xet nghiem: - Chup cat 16p vi tinh o bung va tieu khung cap vdi hinh anh khoi dam ong tieu hoa. + KhSng dinh chan doan: day thanh Sigma, viem quanh dai trang, tui thiia nhin ro. + Tim bien chiing: ap xe, ro. + Loai truf benh tiet nieu, phu khoa. - Co the chup khung dai trang doi quang kep. - Noi soi dai trang cap khong can thiet va nguy hiem. Se can soi dai trang sau khi qua giai doan cap, triicfc phau thuat de loai trii ung thii Sigma. Tien trien: hay tai phat. 43 Dieu tri: - Noi khoa: giam dau, chiidm da tren bung, khang sinh tinh mach hoat pho rong, co tac dong tdi vi khuan Gram (-) va ky khi trong 15 ngay, che do an khong co ba, theo doi lam sang nghiem ngat de phat hien bien chiing. - Ngoai khoa: + Dam bao nguyen tac khong chi dinh tai tao liiu thong ong tieu hoa ngay. + Cap ciiu. - Chi dinh: neu dau lien tuc hoac sot hoac co bien chiing. - Hinh thiic: cat dai trang Sigma dong mom triic trang diia dau dai trang ra ngoai (phau thuat Hartmann), d nhiing trUOng hop can thiet noi tat dai trang - triic trang va lay mau dai trang Sigma lam mo benh hoc. - Muon sau 2 - 3 thang: + Muc dich: phong tai phat. + Chi dinh: sau 2 cdn viem tui thiia hoac ngay sau cdn dau tien. + Hinh thiic: cat dai trang Sigma tdi van triic trang Sigma + tai lap liiu thong ong tieu hoa (mo noi soi), lam giai phau benh manh cat. 2 bien chiing thiidng gap cua viem tui thiia Sigma cap - Viem phuc mac do thung tui thiia: + Chi dinh phau thuat cap. + Ty le tii vong cao 15 - 35%. - Ap xe quanh Sigma: 44 trai. + Hoi chiing nhiem trung nang, khoi u va dau d ho chau + Chup khung dai trang doi quang (hinh anh de ep t\i ngoai, doi khi thay lo ro), chup cat 16p vi tinh. + Dieu tri: Noi khoa: dieu tri ban dau, khang sinh pho rong va ket hdp khang sinh Ngoai khoa thi 2: Dan liiu qua da hay cat dai trang Sigma 3 bien chiing hiem gap cua tui thiia: Ro:£ - O ap xe quanh Sigma vao tang lan can. - Ro dai trang - bang quang thiidng gap nhat (50% nhiem trung tiet nieu, dai ra khi, dai ra mau). - Ro dai trang am dao va Sigma - triic trang hiem gap. - Chan doan bang CT. - Dieu tri ngoai khoa lanh. Hep dai trang Sigma va tac (loai trii K dai trang Sigma) bang noi soi dai trang: - Xet nghiem: chup khung dai trang doi quang (hep dai trang Sigma dong tam, deu). Chup CT bung, tieu khung, soi dai trang (sau khi loai tri* thung) - Dieu tri noi khoa (hoi siic va khang sinh) - Dieu tri ngoai khoa neu noi khoa that bai hoac co bien chiing (thung xa vao ca manh trang, cat dai trang Sigma vdi noi dai trang - triic trang, neu gian dai trang nhieu: phau thuat Hartmann hoac hau mon nhan tao. Chay mau: hiem, thiidng la bien chiing cua tui thiia dai trang phai. 45 UNG THU DAI - TRUC TRANG ■ ■ 1. Dai ctfdng - Thiidng gap diing hang thii 3 trong ung thii tieu hoa - Tuoi trung binh 65 tuoi. - Khu tru: dai trang sigma 45%, triic trang 30% Giai phau benh: - Adenocarcinome Liberkurhnien 80%. - Adenocarcinome khong dien hinh loai te bao tru, te bao dua 20%. 2. Chan doan Lam sang: - Thay doi toan than. - Dau bung (quan hoac triidng bung giam dau bang thuoc giam co that hay trung tien + dai tien). - Phan mau do - den. - Roi loan van dong mdi xuat hien. - Hoi chiing triic trang (mot dan, buot mot, dau tiic). - The co bien chiing: nhiem trung (dai trang phai), tac ruot, thung, chay mau (dai trang trai) Noi soi dai trang: Nhin doi, gay me toan than, khong co dau hieu tac ruot. Chuan bi soi dai trang (uong thuoc Fortrans va co the che do an khong xd trong 3 ngay) soi triic trang (thut), kiem tra dong 46 mau kin can cat bang thong long nhiet. bien chiing hiem (1/1000, thung, chay mau). Nhin thay khoi u. - Danh gia: vi tri, kich thildc, lan toa ra xung quanh, ti'nh chat. - Cho phep sinh thiet nhieu manh (> 10 manh, bd trong va chu vi). - Kham xet toan bo khung dai trang polyp ket hdp 25%, u thanh dai trang 5%. Chup KDT khi co tac ruot hay nghi ngd thung, khi noi soi dai trang khong toan bo. Hinh khuyet bd khong deu hoac hinh polyp. Hep tti mot ben thanh dai trang khong deu, loet. Phat hien sdm K dai true trang: - Neu tien sii gia dinh K dai triic trang < 60 tuoi: noi soi dai trang / 5 nam bat dau til 45 tuoi. - Tham tnic trang hang nam til tuoi sau 50. - Tim hong cau trong phan / 2 nam, neu (+) noi soi dai trang - 20% so triidng hdp phat hien adeneme > 1cm va 5% co adenocarcinome. Tham triic trang: - Phat hien khoi u neu ciic diidi khoi u cach cd that hau mon 8cm. - Vi tri khoi u so vdi cd that. - Danh gia khoi u (ranh gidi, bd va chieu cao). - Dac diem: loet hay loet sui. 47 - Xam lan vao vung tieu khung: khoi u co dinh tren xUdng cung, xam lan vao tien liet tuyen hoac dinh tnic trang am dao. 3. Tham do tri/dc dieu trj - Xam lan lan can : - Hoi (di truyen) va kham lam sang tham tnic trang, gan to, co triidng, hach Troisier. - Chup CT bung + tieu khung hay IRM. - Sieu am noi soi tnic trang: xam lan thanh, hach (nghi ngd neu hach tron, tang am, ranh gi6i ro >lcm , xac dinh vi tri so vdi cd that). - UIV neu sieu am gian dai be than va soi bang quang neu nghi ngd xam la'n bang quang. - Di can: + Sieu am bung. + XQ phoi, co the CT Scan ngiic. + Neu dau hieu nghi ngd : Scintigraphie xildng, CT nao. - Sinh hoa: CEA, thieu mau, vi mat. - Bilan toan than. 4. Dieu trj ung thu dai - true trang Dieu tri ngoai khoa: - Chong chi dinh: suy mon, tuoi cao, carcinose lan toa. - Chu&n bi benh nhan triidc phau thuat: truyen mau neu thieu mau nang, dinh diidng va boi phu ntfdc dien giai, chuan bi dai tnic trang, khang sinh triidc mo, thong 48 bao cho benh nhan biet kha nang lam hau mon nhan tao +/- va nguy cd that bai. - Md bung: danh gia miic do tham nhiem, sinh thiet gan, phuc mac, te bao dich co triidng, kham buong triing va cac tang khac. - Cat bo khoi u: ranh gidi an toan cach vung ton thiidng 5cm vdi dai trang, 2cm vdi triic trang nao vet hach. + Dai trang: cat n ia dai trang (phai, trai hoac ngang). Noi hoi trang - dai trang, dai trang - triic trang, cat dai trang toan bo vdi noi hoi trang - hau mon. + Triic trang: cat rong triic trang va mac treo triic trang Neu 1/3 tren (> 10cm cach cd that hau mon): cat triic trang sigma va noi dai trang - triic trang. Neu 1/3 giuia: cat triic trang - sigma, noi dai trang - hau mon. - Neu 1/3 diidi (4-6 cm cach cd that hau mon) cat dai trang trai va hau mon nhan tao. Chu y: - Neu khoi u khong cat ditc)c, co the noi tat dai trang hay hau mon nhan tao ket hdp vdi chay tia hay lazer. - Neu khoi u da di cdn: co the chi dinh phau thuat cat dai trang va cat bo khoi di cdn (phoi, gan) ket hap chay tia va hoa chat. 3 bien chiing sau phau thuat - Ia chay man tinh nhat la cat nvfa dai trang phai. - Roi loan tieu tien va tinh due. 49 - Tai phat. Noi khoa : Hoa tri lieu Chi dinh - Tiep sau dieu tri ngoai khoa - K tien trien giai doan C (phan loai Dukes): giam tien trien va tvf vong. - Dieu tri tam thdi (K di can): cai thien chat ltfdng cuoc song. 5 Fu + acid folinic tinh mach trong 6 thang. 5 Fu + acid folinic, Oxaliplatin Ininotecan + chi dinh tia xa. chi dinh tia xa: trtfdc p h lu thuat: K trtic trang T3 - Giam nguy cd tai phat tai cho va cai thien thdi gian song. - 45 Gy (nhieu lieu) rai ra trong 5 tuan. 5. Theo doi sau dieu tri ngoai khoa - Trong 5 nam: trong 2 nam dau 3 thang / 1 lan. trong 3 nam sau 6 thang / 1 lan. Kham lam sang, sieu am bung, XQ phoi, sieu am noi soi true trang, IRM va CEA. Noi soi dai trang hang nam trong 2 nam, sau do 2 nam / 1 lan, 5 nam / 1 lan neu binh thifdng Kiem tra 1 nam / 1 lan: neu Adenome Villeux > 3 thiidng ton, Adenom kich thifdc > 1 cm Tien liidng: thdi gian song sau 5 nam: Dukes A 90%, B 55%, C 30%, D 1%. 50 MOT SO THlfONG TON TIEN UNG THU 1. Polyp tuyen - Thiidng gap 20% sau 60 tuoi. - 90% K dai trang - trvic trang co Polyp tuyen. - Chi 10 - 15% polyp tuyen ung thu hoa. - Nguy cd khi polyp thay doi (bieu mo > tuyen) va kich thiidc > 1 cm. - Tat ca polyp phat hien khi soi dai trang phai diidc cat de kiem tra giai phau benh: leai, miic do loan san, xam lan thanh. - Neu phat hien adenocarcinome trong polyp: + Theo doi noi soi dai trang 3 nam, hoi trang 5 nam. Neu co tat ca tieu ch u ln sau: biet hoa cao, khong viidt qua lcip cd, khong xam lan vao he thong bach huyet, ranh gi6i vung lanh > 1 mm, phau thuat cat niem mac triet de. + Neu khong c lt dai trang nhii trong ung thii dai trang. 2. Hoi chumg ung thu dai - true trang di truyen (HNPCC) khong Polyp - 5% K dai triic trang. - Di truyen gen troi, ket hdp vdi cac ung thtf khac: noi mac tii cung, buong triing, tiet nieu. - KhSng dinh lam sang khi co 3 tieu chuan (tieu chuan Amsterdam): 51 + Tieu chuan so" ngUdi > 3 ngUdi co ung thii dai tnic trang. + Tieu chuan bo" me: 2 the he lien tiep co it nhat mot ngildi mac benh. + Tieu chuan tuoi < 50 tuoi. - Neu nghi ngd tim bang chiing gen (tim genotype: hMLHj va hMSH2 - Dieu tra trong gia dinh hM LH 1; hM SH2 neu (+): + Theo doi noi soi dai trang toan bo / 2 nam / 1 lan til nam 25 tuoi. + Kham san phu khoa hang nam sau 30 tuoi (sieu am noi soi am dao). 3. Polyppose tuyen gia dinh (polypose adenomatose) - Benh hiem (1% ung thii dai triic trang). - Di truyen gen troi dot bien gen A P C tren nhiem sac the 5. - Tien trien thanh ung thut. - 3 bieu hien ngoai dai trang: adenome cua ta trang va cua bong Vater, bien dang rang va xildng, phi dai Idp te bao sac to" d vong mac. - Dieu tri cat dai trang toan bo tut tuoi 15 va noi hoi trang - hau mon tranh diidc nguy cd ung thii dai tnic trang. - Theo doi 3 nam II lan v6i cac ton thiidng da day ta trang bang noi soi tieu hoa tren va sinh thiet, sieu am noi soi (nghi ngd u ac tmh hoa). - Phat hien tinh chat gia dinh +++: tim cac dot bien gen d ngiidi benh va gia dinh the he thii mot neu dudng tinh, noi soi dai trang hang nam til 10 - 40 tuoi. 52 3 loai Polyppose dai triic trang gia dinh khac: - Hoi chiing Gardner (nguy cd nhil Polyppose Adenomatose gia dinh + nguy cd khoi u xd o bung rat to va thudng til vong). - Polypose thieu nien (Zuvenile) di truyen gen troi u Hamartome ruot non - dai trang, hiem khi thanh ac tinh. - Benh Peutz - Zeghers di truyen gen troi, u Hamartome kem not ruoi son quanh cac lo, khong chuyen thanh ac tinh. 3. MICI Viem man tinh dai trirc trang - Nguy cd gap nhieu d BN viem loet dai tnic trang chay mau > benh Crohn. - Noi soi dai trang + sinh thiet 2 nam / 1 lan, viem toan bo dai trang thiidng tien trien thanh ung thii sau 10 nam. PHAN LOAI UNG THU - DAI TRUC TRANG ■ ■ ■ 1. Phan loai TNM Khoi u (T = tumeur): - Tis: khoi u chi d tai cho, khoi u d 16p niem mac hay xam lan 16p LaminaPropria (trong niem mac) khong t6i 16p difdi niem mac. - Tp khoi u xam lan t6i 16p dildi niem mac nhiing chila vUdt qua Idp dildi niem mac. 53 - T2: khoi u xam lan t6i 16p ccf nhiing chtfa vUdt qua Idp cd. - T3: khoi u xam lan qua 16p cd qua 16p thanh mac va tdi to chiic quanh dai trang chUa t6i 16p phuc mac. - T4: khoi u xuyen thung 16p phuc mac tang hoac xam lan vao cac tang lan can. Hach (N = Nodes): - N0: khong co hach. - N,: hach di can tCf 1 - 3 hach. - N2: hach di can > 4 hach. - Nx: nhieu hach khong xac dinh diidc. Di can (M = Metastases): - M0: khong c6 di can. - Mj: co di can gan. - M2:di can xa. 2. Phan loai cua Dukes - Giai doan A: khong vildt qua 16p cd. - Giai doan B: viidt qua 16p cd. - Giai doan C: xam lan hach. - Giai doan D: co di can. 54 BENH TRl 1. Dai cUdng: la benh thudng gap. 2. Lam sang - Di ngoai ra mau do tiidi: thanh giot hay thanh tia - Cam giac kho chiu 6 hau mon: dau, rat cang tile kho chiu - Tham kham hau mon triic trang: + Nhin ngoai: co the thay bui tri to sa ra ngoai ong hau mon hoac bao benh nhan ran thay bui tri to ldi ra ngoai + Soi hau mon triic trang: xac dinh so" liidng, do cac bui tri Tri noi do I: cac tinh mach gian ciidng tu, doi niem mac phong len vao trong long triic trang Tri noi do II: cac tinh mach tri gian nhieu hdn va tao thanh cac bui ro ret. Khi ran cac bui tri sa ra d hau mon Tri noi do III: khi ran nhe la sa ra ngoai khong til len diidc phai day len d 1cm 3. Bien chumg Chay mau keo dai gay nen tinh trang thieu mau, nghet bui tri, viem tac tinh mach, loet, hoai til. 4. Cac phirdng phap dieu trj tri - Tranh lao dong thiidng xuyen d tuf the ngoi hay dting lau. 55 - Khong an cac chat kich thi'ch chua cay, khong rudu bia thuoc la, an nhieu rau qua tUdi va chat xo tranh tao bon. Tap luyen thoi quen di dai tien vao gid nhat dinh - Thuoc co tac dung tang ciidng he TM: Daflon, Ginkofort. - Cac thuoc nhuan trang neu co tao bon - Diidng tai cho: thuoc trd TM va giam dau: thuoc boi hay vien dat Cac phiidng phap can thiep dieu trj tri co hieu qua cao. + Tiem xd + Dung tia hong ngoai + Dot dien + Laser T h lt bui tri bang vong cao su Phau thuat chi nen chi dinh han che khi cac phiidng phap dieu tri khong ket qua va nhat la tri da co mot so" bien chiing. 56 NLfT k e h a u m o n 57 Oh lio n t( 5 BENH LY GAN MAT ■ ■ GAN TO 58 HUdNG CHAN DOAN 6 BENH NHAN TANG TRANSAMINASE KEO DAI > 6 THANG Thiidng gap 2 - 5% dan so 59 h i/Gn g c h a n d o a n 6 BENH n h a n t a n g TRANSAMINASE CAP > 10 LAN 60 / THl/ONG TON GAN DO Rl/OU Steatose nodule to Steatose nodule nho Viem gan ri/ou cap Benh sinh Tich tu triglyceride trong te bao gan (roi loan tong hop va bai tiet). Hoai tCfte bao gan Lam sang Sinh hoa * Thudng gap. * Thudng khong co trieu chting. * Gan to it dau va chic 70%. * Transaminase va GGT tang gap 3 lan binh thudng *Triglycerid mau tang, thieu mau tan mau, steatose nodule to: hoi chiing Zieve (hiem) * Hiem. * Bieu hien thudng kin dao. * Doi khi ram ro vang da benh nao gan. * Huy hoai te bao, if mat nang. * Dau hieu suy te bao gan, giam TP va yeu to V bilirubin tang, giam albumin mau * The dien hinh: gan to dau, vang da, sot. * The nang: hon me gan, vang da co trudng, tan mau. * Huy hoai te bao < 10 lan binh thudng (ASAT / ALAT >1). * Dau hieu suy te bao gan: giam yeu to V, giam TP, giam albumin, tang bilirubin * Nang: TP < 50% va bilirubin >100 (imol Sieu am Gan tang sang Khong co dau hieu dac hieu. 61 * Giot md Idn trong bao tUdng te bao gan. * Nhan te bao tu tap lai d ngoai vi. 'Ton thudng tap trung d trung tam tieu thuy. Sinh thiet gan ' Giot md nho trong bao tuong te bao gan. * Nhan trung tam. * Tht/c hien theo duOng TM canh khi co roi loan dong mau. * Ket hdp hai dau hieu ton thudng trung tam tieu thuy (te bao gan nd to + hoai tO) va tham nhiem bach cau da nhan trung tinh. * The Mallory 65% BN nhung khong dac hieu * Ket hdp vdi cac thiidng ton khac: Steatose, Fibrose, Cimhose. * Thiic te: neu cai rtfdu cac dau hieu lam sang + sinh hoa + sieu am trd ve binh thudng nhanh, se tranh phai sinh thiet gan. * Chi so Maddrey: TPBN - Tien trien Tien trien tot neu bo rudu, dau hieu Steatose bien mat sau 1-6 tuan. TP chung x 4,6 + BT / 17,6. * Viem gan tien trien nang neu chi so >32 hay co hon me gan, nguy cd tif vong 50% * Bo nA3u + tiem vitamin * The nang vao khoa dieu tri tich cut + dieu tri bten Dieu tri Bo rudu.bo sung vitamin nhom B (B,, B6, PP) chung hon me gan. xuat huyet tieu hoa) + Cortkxnd: 1 mg/kg giam dan lieu Chan doan phan biet 62 Cac tafcJng hdp co the g§p: -Dung corticoid keo dal -Benh nhan beo -BN dai thao dudng -Suy dinh dudng - Dung Amiodaron keo dai -Dung thuoc tranh thai -Nhiem doc thai nghen -Steatose cap nang -H/C Reye -Dung add Valproic -Tetracyclin vdi lieu cao. -Viem dudng mat, viem tui mat cap -Viem gan virus cap HUCJNG CHAN DOAN 6 BENH NHAN TANG GGT DON THUAN 63 HUCJNG CHAN DOAN 0 BENH NHAN TANG PHOSPHATASE KIEM 64 VIEM GAN VIRUS CAP . Dai cudng * Virus viem gan: - A, B, C, D, E. - 4 tac nhan cd hoi: EBV, CMV, Herpes, sot vang. * Hinh thiic lay truyen: - Viem gan A, E: diidng tieu hoa. - Viem gan B: tinh due, me sang con, truyen mau. - Viem gan C: tiem chi'ch, truyen mau, tai nan y te. * Virus A, C, D, E la ARN, virus B la ADN. * Ty le ngiidi mang HBsAg man tinh 10% d chau A. * Nhiem virus D kem nhiem virus B hay tren doi tiidng mang HBsAg man tinh. 2. Chan doan Lam sang: - The dien hinh diia tren 3 dau hieu met, hoi chiing gia cum va vang da (80- 90% so BN viem gan virus cap la khong co trieu chiing) - 2 giai doan: triidc vang da (hoi chiing gia cum, hiem: dau dau, ban, dau kh6p, tam chiing Caroli) thdi gian 3-10 ngay roi den giai doan vang da. - Xay ra d nhom co nguy cd. 65 - Thdi gian u benh (virus A: 1 thang, virus B 2 - 3 thang, virus C 1- 2 thang, virus D: 3 - 6 tuan). Can lam sang: - Huy hoai te bao gan transaminase tang. - Marker huyet thanh: IgM khang virus viem gan A, HBsAg va IgM anti HBc, IgM,anti HDV, AC anti HVC diidng ti'nh sau 1- 3 thang - Phat hien sdm virus viem gan bang phufdng phap khuyech dai gen PCR. - Sieu am bung binh thiidng. - 2 dau hieu nang cua benh: hon me gan va TP < 50% phai vao vien neu co 2 dau hieu nang - Nguy cd chuyen sang man tinh: 0% vdi viem gan virus A, 10% vdi viem gan virus B (90% d tre em), 70% vdi viem gan virus C, 90% doi vdi viem gan virus B + D. 3. Bien chung va dir phong Co 3 bien chiing: - Viem gan kich phat (virus A, B, B+D, han hiiu C). Dau hieu suy te bao gan (benh nao gan) va bien loan ve sinh hoa (chiem 50%). Nguyen nhan tvf vong chinh la tang ap luc tinh mach ciia va benh nao gan. Mot phiidng phap dieu tri duy nhat ghep gan cap. - Viem gan virus man tinh va xd gan (virus B, B+D. C). - Ung thii te bao gan (virus B, B +D, C). 66 Du phong: - Loai bo nhiing ngiidi cho mau co HBsAg (+), Ac anti HBc, Ac anti HCV hoac co transaminase cao. - Vacxin phong viem gan A va viem gan B. - Phong dich: bien phap ve sinh, dieu tra gia dinh, djnh liidng transaminase va marker virus, vacxin phong viem gan A- B. 4. Dieu trj - Doi vdi viem gan virus C cap: dieu tri ngay bang thuoc diet virus (Interferon a ddn tri lieu cho tdi khi transaminase binh thiidng) vi nguy cd chuyen sang man ti'nh cao. - D in g riidu va thuoc doc vdi gan. - Theo doi: lam sang (benh nao gan) chiic nang gan (TP) huyet thanh virus. - Tim hieu cac benh ly dich te kem theo: sot thiidng han trong viem gan virus A, dong nhiem HIV trong viem gan B va viem gan C. - Kiem tra gia dinh (dinh liidng transaminase va marker chan doan viem gan) Immunoglobuline vdi viem gan A, B, D. 67 VIEM GAN VIRUS MAN TINH 1. Djch te Tren the gidi co 350 trieu ngUdi mac viem gan B va 170 trieu ngUdi mac viem gan C Viet Nam 15% dan so mang HBsAg, khoang 1 trieu ngUdi m&c viem gan B man ti'nh. Nguy cd mac viem gan B va viem gan C ngay cang tang Nguy cd chuyen sang man ti'nh: viem gan virus A: 0%. viem gan virus B: 10% (90% doi vdi tre em), viem gan virus C: 70%, viem gan virus B + D: 90% 2. Chan doan Lam sang: - Met, kham lam sang thudng la binh thudng. - Bieu hien ngoai tieu hoa cua viem gan virus C; cryoglobulin benh cau than, porphyries da, bieu hien benh tu miln. - Bieu hien ngoai tieu hoa cua viem gan B: viem nut quanh dong mach, benh ly cau than. - Tim hieu cac benh ly kem theo: sot thUdng han (trong viem gan virus A), dong nhiem HIV trong viem gan B va viem gan C. Sinh hoa: - Tang tUng luc va khong hang dinh transaminase (nhat la doi vdi virus viem gan C) vdi ALAT / ASAT > 1. 68 - Co the tang gammaglobulin mau da dong. Giai phau benh: * Sinh thiet gan la c&n thiet de khang dinh ch&n doan tien liidng va quyet dinh dieu tri 3 loai ton thiidng: - Tham nhiem viem (te bao ddn nhan) trong khoang ciia va tieu thuy gan. - Hoai tu te bao gan. - Xd hoa: gidi han d khoang ciia va trong tieu thuy gan. * NhUng yeu to" mo benh hoc dac hieu: - HBV: day trong te bao gan. - HCV: ton thudng dUdng mat, nang lympho trong khoang cUa, te bao gan thoai hoa md. * 2 tieu chuan danh gia thUdng ton: - Knodell: hoai tu quanh tinh mach cUa / hoai tu bac c£u (giuta khoang ciia va tinh mach trung tam tieu thuy) hoai tu thuy gan tham nhiem viem va fibrose. - Metavir: viem hoat dongva fibrose. 3. Bien chumg va dir phong Bien chvfng: - Viem gan virus kich phat: (virus A, B, B + D, han hflu C) Dau hieu suy te bao gan (benh nao gan) va bien loan ve sinh hoa (chiem 50%). Nguyen nhan tu vong chinh la tang ap luc tinh mach ciia va benh nao gan 69 Mot phiidng phap dieu tri duy nhat: ghep gan cap - Viem gan virus man tinh va xd gan (virus B. B+D. C) - Ung thii te bao gan (virus B, B+D, C) Dtf phong: - Loai bo nhiing ngiidi cho mau co HBsAg (+), antiHCV (+) hoac co transaminase cao - Vacxin phong viem gan A, B - Phong dich: bien phap ve sinh, dieu tra gia dinh, dinh liidng transaminase va marker virus, vacxin phong viem gan A, B. - Kiem tra gia dinh: dinh liidng transaminase va marker chan doan viem gan 4. Dieu trj viem gan virus B man tinh Cac dang benh nhan nhiem viem gan B - Ngiidi mang man ti'nh khong co trieu chiing: HBsAg + Transaminase binh thiidng khi kiem tra nhieu lan lien tiep, khong co virus nhan len [khong co HBVADN, HBeAg(-)] mo benh hoc binh thiidng. - Viem gan man tinh hoat dong yeu 30%. - Viem gan man ti'nh hoat dong 30% chi nen dieu tri viem gan bang cac thuoc diet virus vao giai doan nay: cac marker virus viem gan thiidng diidng ti'nh: HBVADN, HBsAg, HBeAg, IGMHBc. •K , - 0 mot so BN co virus nhan len (HBVADN+) khong co HBeAg (-) tinh trang huyet thanh nay diidc goi la virus dot bien. Dieu tri thiidng kho doi vdi the benh dot bien. 70 D ie u tr i: Muc tieu: cat dilt hien ttfdng virus nhan len va dilng viem gan hoat dong nham ngan can qua trinh tien trien den xd gan. Chi dinh dieu tri: lam sang co the co trieu chiing HBsAg (+) keo dai > 6 thang HBVADN > 100000 copies / ml ALAT > 2 lan binh thiidng M6 benh hoc: viem hoai til > 4 diem Knodell Cac thuoc dieu tri: Interferon: L/u diem: khong tao dong virus dot bien, co kha nang lam mat HBsAg (ma khong co doi vdi cac thuoc khac), thdi gian dieu tri ngan hdn Nhiidc diem: nhieu tac dung phu, phai lila chen benh nhan phu hdp vdi chi dinh - Interferon a (3 - 6 trieu UI 31an / tuan) trong 6 thang, trong triidng hdp viem gan B +D lieu con tang hdn. - Interferon Pegyle (Pegasys): 180pg tiem dildi da 1 lan / tuan it tac dung phu co hieu qua cao Lamivudin diicfc chi dinh thii 2 lOOmg / ngay. Dap ilng 30% ty le tai phat cao, it tac dung phu Adefovir: lieu dung lOmg/ngay. Uu diem khong co khang thuoc cheo giila cac nhom thuoc co hoat chat nucleoside. Sil dung ddn gian co the dung keo dai. Ghep gan chi danh cho cac benh nhan co benh gan nang khong co virus nhan len trildc phau thuat. 71 Diing riidu bat buoc. Tieu chuan danh gia khoi benh hoan toan: HBVADN < 4000 copies / ml HBsAg (-), GPT < 40UI/ml Thdi gian keo dai > 6 thang sau dieu tri 5. Viem gan virus C man tinh Chan doan: Dtfa vao huyet thanh chan doan: anti HCV diidng ti'nh (2 lan lien tiep). - PCR xac dinh ARN HCV. - Genotype HCV - Sau giai doan cap tien trien co the theo 3 cach: + Khoi 15%. + Viem gan C man ti'nh khong co trieu chiing 25% transaminase binh thiidng, ton thiidng mo benh hoc it. + Viem gan man tinh hoat dong 60% trong do xd gan chiem 20% trong 10 - 20 nam. Nguy cd ung thii gan 1- 4%. Dieu tri viem gan C man tmh Muc dich: diet virus. Chi dinh: the hoat dong ve sinh hoa va mo hoc. Dieu tri: hoa tri lieu Interferon pegyle (3 trieu UI x 3 lan / tuan) + Ribavirin trong 6 -12 thang tuy vao Genotype va so liidng virus. Do so liidng virus PCR 3 thang / 1 lan khong dieu tri ngat quang nguy cd tai phat cao. - Ket qua: 72 Dap ling vdi dieu tri marker virus am ti'nh sau 6 thang dieu tri Khong dap ilng: virus (+) du co dieu tri That bai: virus (+) lai sau khi da (-) cuoi ddt dieu tri. Nhin chung: dap ilng vdi dieu tri 40%. - Theo doi: dung nap va hieu qua dieu tri (transaminase, so' liidng virus, sinh thiet gan). - Chi dinh ghep gan giong nhii vdi benh nhan xd gan do riidu. - Bo riidu, thuoc la, giam can. XO GAN 1. Chan doan Lam sang: - Gan cilng chac, bd diidi sac. - 4 dau hieu tang ap liic tinh mach ciia: lach to, tu&n hoan bang he, co triidng va xuat huyet tieu hoa. - Dau hieu suy te bao gan: met, da (vang, sao mach, sam), tay (ban tay son, ngon tay din trong, mong dom tr&ng, Asterisix), co triidng, hoi chiing xuat huyet tieu hoa (giam Prothrombin, giam tieu c&u). Can lam sang: - Sinh hoa: te bao mau giam, chilc nang gan (tang bilirubin mau, giam yeu to’ dong mau, giam albumin, tan mau), dien di mien dich (tang IgA - giam p, y). 73 - Sieu am bung (hinh thai gan thay doi, tang ap liic tinh mach ciia). - Noi soi tieu hoa tren (gian tinh mach thiic quan. gian tinh mach phinh vi, mosaique than vi). - Sinh thiet gan: chan doan xac dinh +++. Chan doan giai doan xd gan Bang diem Child - Pugh Ten 1 diem 2 diem 3 diem Ty le Prothrombin % >55 45-55 <45 Albumin mau g/l >35 28-35 <28 Bilirubin mau mmol/ml <35 35-50 >50 Co trUdng Khong it Nhieu Hon me gan Khong Tien hon me Hon me A = 5 - 6 diem , B = 7 - 9 diem , C = 10 - 15 diem. 2. Nguyen nhan - Riidu chiem ty le cao + Khong tim thay cac nguyen nhan khac. + Dau hieu tang hormon sinh due (ban do, gian mach d mat, tuyen mang tai to) va bieu hien ngoai gan. + Gan to, tang GGT, ASAT > ALAT, sinh thiet gan steatose. - Viem gan virus C va B (huyet thanh chan doan). - Hemochromatose di truyen: ti'nh he so bao hoa transferin. - Viem gan tii mien: nii tre xet nghiem ve mien dich, khang the khang cd trdn (typ I), khang the khang bach 74 cau da nhan (typ II), sinh tlnet gan +++. Dieu tri corticoid + Azathioprin. - Xd gan mat tien phat. - Benh gan do thuoc: Cordaron, Methotrexat, a Methyldopa. - Viem xd hoa diidng mat. - Benh Wilson: + Doi tiidng tre, di truyen gen lan. + Hoi chiing ngoai thap + tam than. + Tan mau, vong Kayser - Fleisher. + Giam Ceruloplasmine, tang Cu nU6c tieu / 24 gid. + Tim hieu gia dinh. + Dieu tri bang D - Penicillamine. - Mucoviciclose. - Thieu hut dj - Anti Trypsine. 3. Theo doi - Cai riidu. - Kham cac bien chiing. Kham lam sang. - Sieu am gan va dinh liidng a FP 4 - 6 thang II lan. - Noi soi tieu hoa: + Khong co gian tinh mach thiic quan: 2 nam. + Gian tinh mach thiic quan do I: 1 nam. + Gian TM thiic quan do II - III: dii phong bang that gian tinh mach thiic quan, P bloquant, isosorbide mononitrat. Phat hien K di kem (tai mui hong, ham mat, phoi). 75 4. Dieu trj - Cai rUdu vinh vien. - Dieu tri nguyen nhan xd gan do viem gan virus B. C neu tim thav hang chiing virus nhan len - Che do an, vacxin phong viem gan B, A, tim lieu thuoc chap nhan diidc d BN xd gan, chong CD thuoc: an than, aspirin, AINS, aminosid. - 3 chi dinh ghep gan: + Xd gan Child- Pugh: B, C + Tang ap liic tinh mach ciia dieu tri that bai. + K te bao gan (1 khoi duy nhat < 5 cm, hay < 3 khoi <3cm) 5. Bien chiing xd gan Kha nang thanh xd gan mat bu = 10% / nam. Cac bien chiing thiidng gap nhat sau Phu co triidng: - 1 im yeu to khdi phat (choc dich co triidng, cav mau. cay nUcfc tieu, cay phan) Yeu to khoi phat: xd gan tien trien, che do an man, khong du calo, viem gan tien trien (riidu, virus), xuat huyet tieu hoa, nhiem trung, K gan, khong tuan thu dieu tri. Dieu tri: * Dieu tri yeu to khdi phat. * Che do an giam muoi va ldi tieu (Aldactol, Lasix) theo doi lam sang - sinh hoa. * 3 chong chi dinh dieu tri: giam natri mau, suy than, xd gan mat bu vi dap ling kem vdi dieu tri hay ldi tieu khong co ket qua. 76 - Tai choc djch co trifdng bu lai dung dich cao phan tii, albumin neu thao > 3 lit dich. Shunt Leveen - TIPS. * Co triidng to: dai diing, tai phat sdm < 1 thang du che do an nhat, dieu tri ldi tieu lieu cao (300mg Aldacton, 120mg lasix), ty le 10% so" benh nhan xd gan. Nhiem trung dich co triidng: - Dieu tri cap - Dau hieu gdi y: dau bung, sot, co triidng tang, roi loan tiru hoa, tang bach cau. - Khang dinh chan doan bang bach cau da nhan trung tinh > 250mm3 hay cay dich tim thay vi khuan Xvi tri: - Diing riidu, thuoc doc vdi gan va ldi tieu (hoi chiing gan - than) vitamin, phong hon me gan lactutose, truyen glucose + bo sung niidc dien giai. - Khang sinh: Augmentin, Cephalosporin the he 3 trong 5 - 7 ngay, choc dich kiem tra sau 48gid, theo doi lam sang - sinh hoa. - Phong thOt phat bang Noroxin 400mg / ngay (vi 70% tai phat sau 1 nam). - Tien liidng nang: 50% song sau 6 thang Benh nao gan: * Bien chiing than kinh - tinh than do suy gan. * Roi loan y thiic 3 giai doan: - Giai doan 1: Asterexis. - Giai doan 2: Asterexis + lan Ion. 77 - Giai doan 3: hon me gan (tien trien nhanh thiidng phu nao). * 2 dau hieu gdi y: hoi thd mui gan song va hoi chiing tang triidng liic ngoai thap (rung vay - Flapping Tremor). * Chan doan lam sang la chinh, cac xet nghiem it co gia trj chan doan, EEG song cham, song Theta, IRM tang dam do Pallidum T,. * 4 nguyen nhan khdi phat phai tim kiem (hoi, kham lam sang vdi tham triic trang va xet nghiem vi khujm): xuat huyet tieu hoa, thuoc (Benzodiazepin, ldi tieu), nhiem trung, ton thiidng gan cap do rtfdu, virus * Dieu tri: - Dieu tri nguyen nhan khdi phat. - Lactulose (giam hap thu chat doc thin kinh, tang nhu dong) va Neomycin (giam vi khuan dai trang), Ornicetil tinh mach 5 - 15 g/ 24 gid tuy tinh trang benh. - Dii phong: chong chi dinh an than, diing Lactulose neu xuat huyet tieu hoa Xuat huyet tieu hoa: * Nguyen nhan: vd gian tinh mach thiic quan hay tinh mach phinh vi 75%, loet da day - ta trang / Mallory - Weiss 25%. * Dieu tri: xem XHTH Ung thif te bao gan: - Yeu to" benh can: xd gan, virus B va C, Alflatoxin. Ch^n doan: * Xd gan mat bu, met, dau ha siidn phai, gan to, nghe thoi vung gan 78 * Tang a FP > 500 mg / ml +++. * U mat ft, hoi chiing can K (polyglobulin, tang calci mau, giam glucose mau). * Hinh anh: sieu am, CT bung khoi u giam am, giam ty trong vdi tiem thuoc can quang (tang mach mau, xam lan nhanh tinh mach ciia). * Sinh thiet gan neu nghi ngd chan doan. Dieu tri: * Bilan trU6c dieu tri (khoi u xam lan, tinh trang toan than, miic do xd gan). * K te bao gan < 5 cm hay 3 nhan < 3 cm khong co Thrombose tinh mach ciia, khong co xam lan ra ngoai gan 20%: phau thuat, ghep gan, tiem con, dot song cao tan. * Dieu tri tam thdi trong 80% so" benh nhan. * Phong benh: dieu tri benh gan man tmh do virus B va C, Vacxin phong viem gan B, phat hien s6m xd gan, sieu am bung va a FP 4 - 6 thang /I lan. Cac bien chiing khac: - Than: hoi chiing gan - than (bien chiing thiidng gap) suy than chiic nang do hep dong mach than va benh cau than do IgA (hiem). - Nhiem trung (mat chiic nang cua he thong lien vdng noi mac). - Phoi: tran dich mang phoi, tang ap dong mach phoi va hoi chiing gan - phoi ket hdp vdi giam oxy dong mach va gian mach trong phoi. - Vang da: bilirubin tang ca hai loai va lam nang len hoi chiing suy te bao gan, bilirubin tnic tiep tang do K gan hay soi diidng mat chinh. 79 - Mau: thieu mau (thieu hut folate, chav mau, lach to, tan mau), giam bach cau va giam tieu cau (lach to, CIVD). - Chuyen hoa: dai diidng va suy sinh due. - Tim: benh cd tim do rtfdu. - Tieu hoa: loet da day ta trang va soi mat. - Ngoai khoa: gay me toan than co nhieu bien chiing. HOI CHLfNG TANG AP Ll/C TiNH MACH ClfA ■ ■ ■ 1. Djnh nghTa: tang ap liic tinh mach ciia la ap liic tinh mach ciia cao tren 7 Kpa (15mmHg) hay la chenh lech ap liic tinh mach ciia va tinh mach chii la 0,7 Kpa (5 mmHg). 2. Nguyen nhan Tac trong gan: - Xd gan. - Chen ep vao he thong tinh mach ciia: thiidng la K cac tang lan can nhii tuy, da day, viem tuy man, hach to. - Xam lan cua to chiic K vao he thong tinh mach ciia, thiidng gap nhat la do K gan xam lan vao he thong tinh mach cUa trong gan, than tinh mach ciia con binh thiidng. - Tac he thong tinh mach ciia do thrombose gom nhieu nguyen nhan + Hoi chiing tuy tang sinh. 80