🔙 Quay lại trang tải sách pdf ebook Thực Hành X-Quang Ngực Ebooks Nhóm Zalo 008239 S. Nguyen Van Thanh T H I T C H A N H X-QUANG NGITC (Tcti han Ian thir 2 co sira chua, ho sung) ipi CNJ Nha xuat ban Y hoc - 2013 TS. Nguyen Van Thanh T H I / C H A N H X - Q j U A N G N G I X C (Tai ban Ian this 2 co sCra chCra bo sung) NHA XUAT BAN Y HOC - 2013 Ldri n o i o a u Mac du hien nay chung ta da co nhieu tien bo trong tham do chu,c nang va chan doan hinh anh nhipng X-quang van luon la xet nghiem dim e yeu cau nhieu nhat trong thu’c hanh lam sang. Oieu nay lai cang dung voi chuyen khoa benh phoi, long ngipc. Biet danh gia va phan tich mot phim X-quang nginc la yeu cau co ban doi voi cac bac si lam sang. Tt> nhieu nam nay, tai lieu viet ve X-quang thipong do cac bac si chuyen khoa X-quang viet. Cac tai lieu nay co khuynh hipong trinh bay sau ve kl thuat X-quang. Oieu nay chu’a thu’c s ip phu ho’p voi yeu cau cua cac thay thuoc lam sang. Co nhieu thuat ngO’ mo ta trong chuyen khoa X-quang chu’a tao dtpoc si/ dong thuan khi si> dung voi cac thay thuoc lam sang. Trong khi nhieu thuat ngO pho bien trong y van m m c ngoai tieng Anh lai chu’a dipoc slp dung trong thu’c hanh ca lam sang va chuyen khoa X-quang, lam tro ngai khong it toi viec trao doi thong tin trong nipoc cung nhif ngoai nipoc trong qua trinh hoi nhap. Tu1 goc nhin cua mot thay thuoc thu’c hanh chuyen khoa benh phoi, chung toi soan tap tai lieu nay. Trong tai lieu nay chung toi de cap den nhOng khai niem khai quat va thu’c dung de cac thay thuoc lam sang co the si> dung phat hien, phan tich cac bat thu’ong tren phim X-quang ngi/c. Voi mong muon cac thuat ngCp phan tich va mo ta phim X-quang ngu’c se tro nen quen thuoc va dong thuan trong thu’c hanh voi ngon tu’ quoc te, chung toi da slp dung nhieu thuat ngCp mo ta va cac thi du minh hoa cua Eric J. Stern va Jannette Collins, la tac gia cuon Chest Radiology: The Essentials (2008 Lippincott Williams & Wilkins, 2nd Edition). Sau Ian xuat ban dau tien 2011, cuon sach da nhan du’O’c nhieu nhan xet va de nghi bo sung ti> ban doc. Oe tang them tinh h^ong dan thi/c hanh, trong Ian tai ban nay, chung toi bo sung phan Benh an minh hoa. & noi dung nay co 25 tinh huong benh ly pho bien nhat trong tht/c hanh lam sang benh phoi, du’oc trinh bay thanh nhOng chuyen de n g ln ve chan doan X-quang tren nen tang phan tich benh hoc. Voi tat ca su' co g ln g , tap tai lieu nay se kho tranh khoi sai sot. Chung toi rat biet on neu ti§p tuc nhan dipgc gop y ti> cac dong nghiep. TS. Nguyen Van Thanh Khoa Ho hap, Benh vien Da khoa trung uxyng Can Tha LOfl 6101THIEU Trong thuc hanh lam sang benh ho hap, chan doan hinh anh luon giu vai tro rat quan trong, khong muon noi la quan trong nhat. Tien bo y hoc noi chung va tien bo nganh chan doan hinh anh noi rieng da mang den cho cac nha lam sang nhung kien thuc mai, nang cao chat luang cong viec va giup cho con m§t cua cac thSy thuoc lam sang tinh tuang han khi danh gia qua trinh benh li. Trong chuyen nganh benh li ho hap, khong ai co the bo qua vai tro cua kT thuat X-quang chuan trong thuc hanh mac du hien nay da co nhieu tien bo vcri cac kT thuat hien dai. Nhan biet gia tri cua X-quang phoi thuang qui nhu la kien thi>c nen tang, kien thuc ca ban se giup cho cac thay thuoc lam sang tien xa han, vung vang han trong qua trinh chinh phuc benh tat. Doc X-quang phoi phai co duac nhung kien thuc rat ca ban va kinh nghiem lam sang phong phu thi mai khai thac het gia tri cua no. Nguai ta noi doc X-quang phoi phai dat den trinh do “ mo ti> thi tren ca the song” la vi the. Tu goc do la nguai lam cong tac lam sang va giang day nhieu nam, qua kinh nghiem thu nhan duac tu thuc te va vai nhung ki§n thuc hien dai, tien si NGUYEN VAN THANH cho ra m it ban doc cuon “Thuc hanh X-quang nguc” la mot co g^ng r lt Ian va la mot dong gop rat co gia tri, nhim gop phan cung cac qui d6ng nghiep khai thac toi da uu the cua X-quang I6ng nguc. La mot nguai say me hoc hoi, tim toi de phuc vu sue khoe nhan dan, vua phuc vu nguai benh, vua tham gia giang day, nghien cuu khoa hoc, TS Nguyen van Thanh co hon 40 cong trinh nghien cuu va tai lieu da dang in tren cac tap chi trong nuac va quoc te. LTnh vuc anh quan tam nhieu nhat la kT nang thuc hanh noi khoa ho hap. Hien nay anh la Truang khoa Ho hap Benh vien Da khoa Trung uang Can Tha va la Giang vien kiem nhiem cua Truang Dai hoc Y Dugc Can Tha. Khong nhung chi dam me trong cong tac dieu tri, giang day, anh con tich cuc tham gia cong tac hoi chuyen nganh, la Uy vien Ban chap hanh Hoi Ho hap thanh pho H6 chi Minh, d6ng thai la Pho chu tjch Hoi Lao va Benh phoi Viet Nam. Xin cam an ti§n sT NGUYEN VAN THANH vai nhung dong gop cua minh cho chuyen nganh ho hap. Mong rin g anh se tiep tuc co nhi4u thanh cong han nua trong su nghiep cham soc va bao ve s l f c khoe nhan dan. Xin tran trong giai thieu cuon sach nay vai cac ban dong nghiep. PGS.TS Oinh Ngoc Sy Giam ddc Benh vien Phdi tnjng ircmg Chu tjch Hoi Lao va Benh phoi Viet Nam LON CAM ON oi chan thanh cam an giao slp Ph. Leuenberger va cac ban dong nghiep khoa Ho hap Vien truong Lausanne (Thuy ST) da nhiet tinh cung cap cac tai lieu va da cho toi dong Ilpc soan tap sach nay. Toi xin du’O’c bay to su* biet on cac giao slp Eric J. Stem (Harborview Medical Center, University of Washington, Seattle, Washington) va Jannette Collins (Department of Radiology, University of Wisconsin School of Medicine and Public Health Madison, Wisconsin) da rat Ijch slp cho phep toi slp dung cac thong tin va hinh anh cua ca nhan trong qua trinh soan thao. Toi muon danh loi cam on dac biet PGS.TS Oinh Ngoc Sy, giam doc Benh vien Phoi trung LPong, Chu tich Hoi Lao va Benh phoi Viet Nam da bo thoi gian de gop y cho noi dung cuon sach va danh nhCmg loi tot dep de gioi thieu. PGS. TS Dinh Ngoc Sy luon la nguon dong vien tinh than cho toi trong cong viec va trong qua trinh bien soan cuon sach nay. Tac gia MUC LUC | Phan 1. Nhac lai giai p h iu va sinh ly long ngu>c 11- Giai phau...............................................................................................11 - Giai phau chuc nang.............................................................................13 - Sinh ly .........:.........................................................................................16 - Hinh X-quang nguc thubng quy binh thuang.....................................18 - Chup c lt lap dien toan (CT) nguc va hinh CT nguc binh thuang...........................................................................................22 | Phan 2. Cac dau hieu va hinh anh X-quang ngyc 27 - Dau hieu phe quan h a i.........................................................................27 - Dau hieu liem h a i............................................................................... ..28 - Dau hieu phong ranh lien thuy.............................................................29 - Dau hieu ranh giai ca hoanh lien tu c ...................................................29 - Dau hieu mach do tren C T ...................................................................29 - Dau hieu ranh sau.............................................................................. ..30 - Dau hieu phoi r o i................................................................................ ..30 - Dau hieu phlng doan eo t h lt...............................................................31 - Dau hieu ngon tay trong gang............................................................ ..31 - Dau hieu chu S .................................................................................... .32 - Dau hieu quang sang............................................................................33 - Dau hieu loi Hampton............................................................................33 - Dau hieu moc bd co hoanh..................................................................34 - Dau hieu liem k h i...................................................................................34 - Dau hieu be mat khoi bang tan chay....................................................35 - Dau hieu hinh nhan quanh dong mach................................................35 - Dau hieu day mang phoi.......................................................................36 - Dau hieu Westermark...........................................................................36 - Dau hieu cot song.................................................................................37 - Hinh anh to o n g .....................................................................................38 - Hinh anh day thanh...............................................................................38 - Hinh anh nang..................................................................................... ..39 - Hinh anh n o t........................................................................................ ..40 - Hinh anh mb kieu kinh m d................................................................. ..41 - Hinh anh phoi ma dang kham..............................................................42 - Hinh anh canh cay moc choi.................................................................43 I Phan 3. Cac hoi chi>ng Ian trong X-quang n g irc ......................................... ..45 - Dau hieu bong va nhung van de co lien quan.....................................45 - Hoi chung phe quan.............................................................................47 - Hoi chung lip day phe nang................................................................ 50 - Hoi chung k e ..........................................................................................53 - Hoi chung mach m au.......................................................................... ..60 - Hoi chung trung that............................................................................ 68 - Hoi chung mang phoi...........................................................................79 - Hoi chung hang.....................................................................................86 - Chan doan cac ron phoi Id n ..................................................................87 - Chan doan cac hinh md tron dan doc ben trong mo phoi................ ..93 I Phan 4. Phirang phap phan tich phim X-quang ngirc 100 Phan 5. Benh an minh hoa 105 Tai lieu tham khao 1. Collins, Jannette; Stern, Eric J. Chest Radiology: The Essentials, 2nd Edition 2008 Lippincott Williams & Wilkins 2. Philip Eng; Foong-Koon Cheah. Interpreting chest x-rays Illustrated with 100 cases, www.cambridae.org (2005) 3. J. A. Verschakelen ■ W. De Wever. Computed Tomography of the Lung: A Pattern Approach. Springer-Verlag Berlin Heidelberg, 2007 4. David Sutton. Textbook of radiology and imaging. Seventh edition 2003, Churchill Livingstone 5. D.Antoin; G. Vailiant. Les grands syndromes radiopneumologiques. Sandoz 6 . Ph. Grenier. Imagerie thoracique de I’adulte. Flammarion medicine sciences 1988 7. Felson B. Chest Roentgenology. Philadelphia: WB Saunders; 1973 8 . F.H. Neter. Atlas giai phiu ngipoi (N.Q.Quyen djch). Y hoc 1997. PHAN 1 n h Ac l a i g ia i p h Au vA s i n h l y « O o I. Giai phau 1. Cay khi - phe quan Khi quan la dimng dan khi co sun bao boc, nlm o vung co - trung that trimc. Den cho phan chia dau tien (carina) khi quan chia thanh hai phe quan goc trai va phai. Hai phe quan goc di vao hai ben phoi va la mot trong nhOng thanh phan cua ron phoi (hinh). Moi phe quan goc lai phan chia tiep tuc thanh cac phe quan thuy. Ben phai co ba thuy: tren, giOa va dim i. Ben trai co hai thuy: tren (ti^ong dinong voi thuy tren va giOa ben phai) va du’O’i. Moi phe quan thuy lai tiep tuc phan chia thanh cac phe quan phan thuy. Cac phe quan phan thuy dime danh s6 theo phan loai cua Boyden, mot cach phan loai du’gc slp dung pho bien (hinh va bang 1.1). Ten phe quan Ten tieng Anh The he phan chia Du’O’ng kinh (mm) Khi quan Trachea 0 25 Phe quan goc Main bronchi 1 11 - 19 Phe quan thuy Lobar bronchi 1 - 3 4 - 13 Phe quan phan thuy Segmental bronchi 3 - 6 4 - 7 Phe quan dim i phan thuy Subsegmental bronchi 4 - 7 3 - 6 Phe quan Bronchi 6 - 8 1,5-3 O Phe quan tan cung Terminal bronchi 1 Tieu phe quan Bronchioles 9-15 0.8-1 Tieu phe quan tieu thuy phoi Lobular bronchioles 0.8 Tieu phe quan tan cung Terminal bronchioles 15-16 0.6-0,7 Hinh va bang 1.1. So dd cach danh so cay phe quan, cac thuy phoi va bang ten, kich thuvc cay phe quan 2. Phoi va mang phoi La tang m ang phoi chia phoi thanh cac thuy boi cac ranh lien thuy. Ben phai co hai ranh (ranh Ion va ranh nho hay con goi la ranh chech va ranh ngang), ben trai co m ot ranh tim n g d im n g vo i ranh Ion ben phai (hinh 1.2). Hinh 1.2. Ranh lien thuy nhin thing va nghieng tren so dd. tren phdi that va X-quang. C ac phan thuy phoi d im e tao thanh boi rat nhieu cac tieu thuy phoi (tieu thuy phoi cap 2) (hinh 1.4). C ac tieu thuy phoi co m ot tieu phe quan va m ot dong m ach phoi dong cap di vao (6 vung ron). C ac tTnh mach phoi va bach m ach d im e phan bo d ngoai vi va d im e tap trung lai chu yeu ti> 6 trong thanh cua cac tieu thuy nay (vung vach). Kieu phan bo “ron - vach” la r it dien hinh (xem phan giai phau - chi>c nang). C ac tieu thuy phoi du’O’c tao thanh boi nhi§u cac chum nang (acinus). C ac chum nang nay co m ot tieu ph§ quan tan cung di vao. C ac tieu phe quan tan cung nay ket thuc b£ng cac tieu phe quan ho hap va cuoi cung d u o n g d in khi ket thuc b ln g nhieu 6ng ph§ nang. Ong phe nang dan khi cho m ot tieu thuy phoi cap 1. Tieu thuy phoi cap 1 gom nhieu tui phe nang. Moi tui phe nang gom nhieu phd nang. Co the tom t^ t theo m ot trinh tu5 ti> ngoai vi vao trung tarn nhu' sau: phe nang - tui phe nang - tieu thuy phoi cap 1 - chum nang - tieu thuy phoi cap 2 - phan thuy - thuy O THl/C HANH X-QUANG NGl/C: Nhlc lai giai phau va sinh ly 3. Cac mach mau & phoi co hai he thong tuan hoan. He thong tuan hoan chi>c nang hay tuan hoan phoi (dong mach va tTnh mach phoi) va he thong tuan hoan chi>c phan hay tuan hoan phe quan (dong mach va tinh mach phe quan) (hinh 1.3, 1.5). Hinh 1.3. So do mach mau phoi: Dong mach phoi (A) va tmh mach phoi (B) 4. Trung that Trung that la khoang nlm giOa hai la phoi. Cac ranh gioi bao gom: - Phia tru’O’c la mat sau xu-ong i>c - Phia sau la cot song vung ngi/c - Phia dim i la co hoanh - Phia tren la nen co - Hai ben la mang phoi trung th it Trung that bao gom nhi§u thanh phan: tim, cac dong mach va tTnh mach Ion, tTnh mach don, ong ngi/c, thu’c quan, khi quan, hai phe quan goc, cac day than kinh, chuoi giao cam, mach bach huylt va cac hach. II. Giai phiu - chipc nang Phoi co the co kha nang h ip thu tia X d nhOng mi>c do khac nhau. Co the phan chia mi>c do h ip thu nay thanh hai loai: - Hap thu nhu' moi tru’ong khi (con goi la can tia dang khi): tren phim co hinh anh sang (mau den tren phim am ban). - H ip thu nhu1 moi tru’ong nu’oc (con goi la can tia dang nu’6c): tren phim co hinh anh mo (mau trlng tren phim am ban). 6 ’ giOa hai thai cu’c cua kha nang can tia nay, co rit nhi§u trang thai can tia 6 cac mu'C do trung gian. e Nhlc lai giai phlu va sinh ly: THl/C KgNTTT-UUANO w m /o Mot hinh mo (can tia dang niroc) se chi thay ro dirge khi no dirge bao boc boi mot moi trirong can tia dang khi, va ngugc lai, mot moi trirong can tia dang khi se chi thay ro dirge khi no dirge bao boc boi mot moi trirong can tia dang niroc. Do nguyen ly nay ma binh thirdng dirdng dan khi khong nhin thay tren phim (can tia dang khi dirge bao boc boi moi trirong can tia dang khi). Do vay, trong dieu kien binh thirong nhCrng hinh mo tren phim deu la cac mach mau. Cac hinh mo mach mau nay khong con nhin thay nua khi cach thanh ngire khoang 10-20 mm. Chung phan bo mot cach hai hoa tren hai trirong phoi theo so do West (hinh 1.6). Cac thanh phan giai phau cua phe quan - phoi chi tro nen hCru hinh trong mot so tinh huong benh ly va khi do ngirdi ta moi co the mo ta dirge chung tren X-quang. Cac hinh anh nay tao thanh nhCrng trieu chirng va hoi chirng Ion ve X-quang ma chung ta se de cap den trong cac phan tiep theo. 1. Tieu thuy phoi (hinh 1.4) Nhu mo phoi dirge hinh thanh boi nhCrng don vj hinh thai hoc (cac tieu thuy phoi cap 2 hay con goi la tieu thuy phoi Miller, cac tieu thuy phoi cap 2 dirge bao boc boi mot to chirc vo co lien quan den mang phoi) va cac don vi chirc nang ho h ip (gom cac chum nang va tieu thuy phoi cap 1 khong co to chirc vo rieng). Khi mo long ngire, tren be mat phoi chung ta thay co hinh cac van dang ban co. Cac van nay la to chirc mang phoi tang di sau vao mo phoi tao thanh ranh gioi cua cac don vi hinh thai hoc cua nhu mo phoi. Co khoang 5000 tieu thuy phoi cap 2 cho ca hai phoi. Cac tieu thuy phoi co dang hinh da dien va ngan cach voi cac tieu thuy phoi ben canh bing cac thanh co cau true mo lien ket. Cac c iu true mo lien ket nay dirge goi la mo ke lien hay quanh tieu thuy phoi. o Hinh 1.4. So dd tieu thuy phdi cap 2 - mot don vi hinh thai hoc cua phoi gom 2-5 THi/C HANH X-QUANG NGl^C: Nhlc lai giai phau va sinh ly chum nang (acinus) la cac dcrn vj chirc nang (7,5mm) va 30-50 tieu thuy phoi cap 1 (0,5-1 mm). (A): 1. Vach tieu thuy phoi; 2. Thanh phan cuong (tieu p h i quan va dong mach trung tam tieu thuy); 3. Chum nang; 4. Tinh mach phoi. (B): 1. Thanh phan cuong; 2. Tieu phe quan tan; 3. Tieu phe quan ho hap; 4. Ong phe nang; 5. Tui phe nang; 6. Phe nang; 7. Tinh mach va bach mach quanh thanh tieu thuy phoi. Tieu thuy phoi co chira cac dimng tho tan cung, dong mach phoi va giimng mao mach cua no, vj tri tan cung cua dong mach phe quan. Tieu thuy phoi dime hinh thanh ti> nhieu chum nang. Day la cac don vj co ban cua tieu thuy phoi tren phimng dien thong khi. Cac chum nang lai phan chia thanh cac tieu thuy phoi cap 1 (gom cac nhom tui phe nang). 2. Cau true tan cung cua cay ho hap Phe quan tieu thuy phoi (khoang Ian phan chia thi> 15) di vao dinh cua hinh thap 6 mat cua tieu thuy phoi c ip 2. Tiep theo la cac tieu phe quan tan (lin phan chia thi> 16) roi ti> do cho ra 3-5 chum nang trong moi mot tieu thuy phoi. Sau do cac chum nang phan chia thanh cac tieu phe quan ho hap 1, 2, 3 (Ian phan chia thi> 17, 18, 19) va day la vung chuyen tiep. Cac tieu phe quan tan la don vj phe quan co ban cua tieu thuy phoi. Tiep den la cac tieu phe quan ho hap. Cac tieu phe quan ho hap tiip can voi cac ong phe nang va tiip theo la cac tui phe nang (khoang Ian phan chia thi> 22-23). Day la thanh phan cua cac vung trao doi. & ngimi co khoang 250 - 300.106 phe nang. Toan bo phe nang co the tao ra mot dien tich rong 70 - 90m2, day la be mat trao doi. Cac te bao bieu mo ho hap d khu vi/c nay chuyen thanh cac te bao phe nang. Gifra cac phe nang cung co sir thong nhau blng cac 16 Kohn va cac kenh Lambert. 3. Mang phe nang Be mat phe nang dim e che phu bang bieu mo p h i nang, chung gom hai dang te bao: te bao type I va type II lien ket voi nhau. Cac te bao type I dang dep va trai rong. Cac te bao type II nim xen ke, phong len va chu’a ben trong c h it dien hoat (surfactant), chat tao ra su’c cang be mat cho phe nang khong bj xep lai o thi tho ra. True trung tam cua mang nay du’O’c tao thanh boi mo lien ket long leo. Lop ben kia la cac t i bao noi mac mach mau, chung lien ket voi nhau kern chat che hon. Nhip vay, mang phe nang la mot mang trao doi giOa p h i nang va mach mau. Mang nay r it mong vi chi bao gom hai lop te bao va mot lop mong mo ke nlm 6 giu’a. O 4. Mo lien ket phoi va mo ke Day la khung nang do1 phoi va rieng tCrng dan vi phoi. Nguai ta phan chia duai cach nhin hinh anh hoc mo ke va mo lien ket thanh cac khoang: - Khoang thanh phe nang: Vach phe nang vi the khong the nhin thay trong trang thai binh thirang a tren phim thipang quy (conventional) vd phim c lt lap vi tinh (CT- computed tomography). - Khoang thanh quanh tieu thuy phoi: Ben trong co chira cac bach mach va tTnh mach quanh tieu thuy phoi. Mo lien ket vung nay lien tgc vai la tang cua mang phoi doi vai cac tieu thuy phoi nim a sat ngoai vi. - Khoang quanh phe quan - mach mau: La mo dan di ti> ron phoi den ron cac tieu thuy phoi. Lap vo quanh phe quan - mach mau co chu’a cac lap chun doc va cac lap chun cheo goi la khoang ke dan (hay con goi la khoang ke true). Cac cau true nay cung vai mo ke dipai mang phoi tao thanh mot cau true lien tuc dam bao tinh chun va dan hoi cua phoi. Trong lu’O’i to chi>c ke nay cGng xay ra nhOng thay doi ve dich mot cach sinh ly dim i tac dong cua su> chenh lech ap luc: ap li/c tham thau cua protein, ap lire phe nang, ap li/c thuy tTnh va no co lien quan chat che tai tuan hoan bach huyet. Cac khoang ke quanh tieu thuy phoi va khoang ke dan co the nhin thay bling m lt throng true tiep tren phim thirang hay CT co do phan giai cao. III. Sinh ly Ve sinh ly c ln hieu ve tim i mau phoi va cac thay doi cua chung, ma triFac h§t la moi lien quan giOa tu^n hoan phe quan va tu^n hoan phoi (hinh 1.5). I G iu'O’n g m a o I G lu ’o -n g m a o | m a c h p h * n a n g | m a c h du-tyi m a n g p h 6 i Hinh 1.5. So- do lien quan giu-a giCra tuan hoan phoi va tuan hoan ph4 quan o THI/C HANH X-QUANG NGi/C: Nhac lai giai phau va sinh ly 1. So» do West (hinh 1.6) 0 ngudi binh thudng, o’ tu the dipng, tuan hoan phoi khong phan bo mot cach dong deu. Hien tugng nay do tac dong cua trong lugng nen co su khac nhau ve ap luc thuy tTnh va cung do co su khac nhau ve it il f c do cang gian cua phe nang giua cac tang khac nhau. Ngudi ta chia chia phoi thanh ba vung khac nhau ve tuan hoan: - Vung dinh: Ap luc phe nang (Palv) cao hon ap luc dong mach (PA) va ap luc tTnh mach phoi (Pv). Trong tinh trang binh thudng, cac mao mach mau d day it tham gia hon vao cac hoat dong chuc nang, ap luc phe nang cao hon ap luc mao dong mach phoi (Palv > PA), cac phe nang md rong. - Vung day: Co che ngugc lai, ap luc phe nang thap hon ap luc cac dong mach va tTnh mach. Cac mao mach md rong va tham gia vao hoat dong chuc nang nhieu hon (PA >Palv). - Vung trung gian: Ap I l f c dong mach cao hon ap luc phe nang, ap Ilf c phe nang cao hon ap I l f c tTnh mach (PA > Palv > Pv). NhiF vay 6 tu the di>ng hay nlm , tuan hoan deu chu yeu tap trung d vung day. Nhung vung tudi mau tot moi thuc su tham gia vao hoat dong chi>c nang. Con nhung vung khac ton tai nhu la mot phan du tru an toan cho co the khi can glng s l f c . Giudng mao mach phoi la rat co gian va thich i>ng. Ve mat X-quang, mat do va kich thudc cac mach mau phan bo tren phim X-quang uu the hon d hai day. Do vay tren phim tu the dung, hai day phoi md hon hai dinh phoi. Patv > P* > Pv 25 rrvnHg Hinh 1.6. Sty dd West (Palv: ap Il k p h i nang; PA: ap - - - - j mao dong mach p h o i; Pv: ap li/c tloh X ^ Pa > Pv > Patv mach) I a ✓ | Y TE | PHU THO [r T ii/v iE N _ _ -Jl .... ' I ' *U L-U JM 2. So* do Milne va ly thuyet khoang Tuan hoan phoi dugc thuc hien trong khoang gian ph§ nang (Tu3fl— hoan mao mach phoi), trong khoang ke ngoai phe nang theo kieu tach rieng va lien tuc. O H it v a o s * u T h <>' r * B » n a »Crc t T u fin hodn m ao m ach giSm T u £ n h o an m ao m ach tang T u ^ n h o an k h o a n g k£ ngoai Tu S n ho an kh o a n g kS ngodt ph£ n a n g gi6m ph§ n an g ta n g Hinh 1.7. So dd tu in hoan tieu thuy phoi theo Milne Khi hit vao, cac phe nang thuc su gian rong, cac mach mau d thanh phe nang bj ep. Trong khi do, khoang ke lai dugc md rong ra va ap luc d day giam xuong, cac mach mau d day vi the ma rong ra. Tren phim X-quang trong thi hit vao do khi chiem uu the nen phoi co ve sang hon. Trong thi thd ra, cac mach mau d vach gian phe nang to ra trong khi cac phe nang thu nho lai. Tuan hoan d khoang ke thu hep. Phoi co ve md hon. Tuan hoan trong hai khoang (phe nang va ke) nhu vay se khong dong thdi va theo kieu ngugc nhau. Cac tieu thuy phoi cap 2 chua day khi d thi hit vao, cac phe nang gian rong, phoi trd nen sang. 0 thi thd ra, khoang gian phe nang dugc do day mau do cac mach mau gian rong ra, phoi trd nen md. Do nguyen ly nay, tat ca cac trudng hgp co tang ap luc khoang ke hoac ap luc phe nang trong mot vung phoi d§u dan den tinh trang giam tu§n hoan d vung ludi mach gian ph£ nang hoac d vung mao mach phoi khoang ke. Viec nay se dan den tinh trang tang mot cach khong deu trd khang mao mach, tao ra su can trd cho phan bo mach mau trong nhung vung nay. Do hien tugng nay se co hien tugng tai phan bo mach mau d nhung vung phoi khac co ap luc thap han (thi du nhu hien tugng tai phan b6 tuan hoan trong COPD, khi ph§ thung, benh ly tim). IV. Hinh X-quang nguc thudng quy binh thudng 1. Tren phim thang (hinh 1.8 va cac chu thich ben dudi) a. Khung xircmg Xuong sudn co cac cung sau gan nhu nlm ngang, cac cung trudc n£m nghieng va co do can tia kern han nhieu so vdi cung sau. Xuong don co nua ben trong c^t dinh phoi thanh phan phoi tren o TH1/C HANH X-QUANG NGl/C: Nhac lai giai phau va sinh ly Hinh 1.8. Scr do hinh Idng ngisc tren phim thing xuong don. Phan dinh phoi nay ket hop voi cung trudc cua xuong sudn 1 tao thanh mot hinh oval, hai ben can xung (so 1). Xuong ba vai can phai day ra ngoai hai truong phoi khi chup (so 2). Cot song nguc nhin thay ro o phia tren D4. Sau tim va quai dong mach chu cho toi D11 cot song khong nhin thay ro (so 3). b. Mo mem Co uc - don - chum tao thanh mot hinh mo canh co thang dung can tia dam do yeu. Hinh mo nay cSt qua phan phoi tren xuong don, dai ra voi cac phan mem cua co, chay xuong dudi va vong ra ngoai tao thanh mot duong cong lorn. Duong cong nay chay song song d bo tren ngoai xuong don (so 4). Co nguc tao thanh mot hinh mo 6 giua long nguc, co dam do can tia yeu, no keo dai vao trong vung horn nach (so 5). Vu, nhat la d phu nu, tao thanh hai hinh mo can xung 6 nen phoi. Khi bo duoi vu tiep tuyen voi tia, no tao thanh hai hinh mo can xung d nen phoi, ranh gioi rat ro, co dang tron, kha dam va doi xung (s6 6). Co hoanh voi hai duong cong vdm hoanh la ranh gioi duoi cua long nguc. Trong thi hit vao sau, vdm hoanh d khoang ben duoi cung sudn truoc so 6. Chieu cao co hoanh thay doi giua thi tho ra va hit vao khoang 3 cm. Vdm hoanh phai thong thudng cao hon vom hoanh trai 1,5-2 cm. Dudi co hoanh trai la tui hoi da day. Co chi§u cao khoang 1 cm. Tui hoi da day chi co o tu the chup dung. Co hoanh hop voi thanh nguc va cung tim thanh goc sudn - hoanh va goc tam - hoanh. Cac goc nay nhon va goc sudn hoanh nhon hon. c. Hai tru,&ng phoi thang Hai truong phoi thing binh thuong dugc goi la “trong” nhung cung md 6 mot muc dd nhat dinh. Kieu md nay co dang ludi bieu hien hinh O cac mach mau phoi. Hinh mo mach mau phoi thudng dung lai cach ranh gioi xuong sudn cua thanh nguc khoang 2 cm vi tu ranh gioi nay chung kho co the thay dugc tren phim. Cf vung canh tim, cac mach mau va nhat la cac dong mach phoi di vao phoi va tao thanh hinh ron phoi tren phim X-quang. - Ron phoi phai: Dong mach phoi xuat hien d bo trung that d khoang khoang lien sudn sau thu 7 va chia thanh hai nhanh. Nhanh duoi hoac than trung gian la quan trong nhat va de nhin hon. No la hinh mo co chieu rong khoang 15-16 mm, lorn xuong ducri va vao trong, tiep theo la nhanh dong mach thuy duoi chay chech ra ngoai cac mach mau phoi phan bo cho toi ngoai vi va sat vom hoanh. Trong nhieu truong hgp, ngudi ta co the thay hinh mo cac mach mau di qua vom hoanh. Nhanh duoi dong mach phoi luon cach bo phai bong tim mot khoang sang. Nhanh tren cua dong mach phoi luc dau di ngang, sau di chech len tren. Do co diem xuat phat tren phim tu trung that nen no con co ten la dong mach trung that thuy tren. TTnh mach phoi tap trung ve ron phoi d khoang khoang lien suon thu 8, thudng mo kho nhin thay. - Ron phoi trai: Diem khdi dau dong mach phoi ben trai thuong cao hon ben phai khoang 1 cm. Dong mach phoi trai di xuong ducri tao ra mot duong cong doc hon so voi ben phai. No n£m chong len bong tim mot phan hay toan bo nen khong tao ra khoang sang ngan cach no voi bo trai bong tim. TTnh mach phoi trai co su phan bo tuong tu nhu ben phai nhung cung mo va thudng khong thay tren phim X-quang. & tu the dung, tuan hoan phoi phan bo quan trong hon d day. So voi phan b6 tu4n hoan vung dinh thi tuan hoan day theo kieu gap doi (goi la kieu 1/2). Do vay, binh thudng day phoi tu the dung md hon dinh phoi. - Mang phoi: Hinh anh thong thudng nhat cua mang phoi la hinh anh cua ranh lien thuy nho mang phoi phai dudi dang mot vet nlm ngang d khoang giua phoi. Vet nay di tu thanh nguc hudng vao trong nhung khong bao gid tdi dugc trung th lt (hinh 1.2). - Cac phe quan: La cac hinh phan nhanh theo kieu canh cay. tap trung xung quanh ron phoi, co duong kinh khoang 3- 4 mm. Cac hinh © THl/C HANH X-QUANG NGI/C: Nhac Igi giai phau va sinh ly mo kieu nay doi khi khong the phan biet dugc voi hinh md mach mau (thi dg khi trong long chua dich tiet), ngu>di ta ghep chung trong mot thuat ngu “hinh md dang phe quan - mach mau”. Cac phe quan chay theo chieu trudc sau bi c lt ngang ket hop vdi mot mach mau dong cap tao thanh hinh anh hai hinh tron dung ke nhau goi la hinh “m lt kinh” hay “ong nhom”. d. Trung that Phim thing cho cac thong tin rat han che ve trung that. Do cac thanh phan cua trung that hau nhu deu can tia dang nude nen kho xac djnh dugc ranh gioi cua chung. Tuy nhien mot cach gian tiep co the suy luan cac bat thudng d trung that dua tren dau hieu bong va tinh chat pho bien cua cac ton thuong. Hinh 1.9. S khong phai la trung that hay mang phoi. Cac ton thuong nhu mo phoi co the thay hinh anh nay la viem phoi nhilm khuan (thudng chi thay d giai doan dau), ho mau, phu phoi, sarcoidosis... Cung co the thay trong xep phoi khong do tic nghen phe quan trung tam. Mac du ung thu co khuynh hudng tao cac ton thuong dang u dac nhung hinh phe quan hoi cung co the thay va la dac trung cua u lymphoma va ung thu te bao phe quan-phe nang. 2. Dau hieu hinh liem hai (Air crescent sign) Mot khoi phat trien trong mot hang co sin, hoac mot vung viem phoi dang hoai tu va tao hang, co the tao mot khoang khi giua noi dung ben trong va thanh hang va cho hinh anh liim hoi (hinh 2.2). Khoi ben trong thong thudng la khoi u nlm. Hinh 2.2. Hinh d iu hieu IiSm hoi. CT cho th iy ton thuxyng phoi dang ndt uv the duoi mang phdi do thuyen tdc nhiem khuan. Mot so tdn thuxyng not hoa hang va tao ra hinh anh IiSm hoi (mui ten) o THl/C HANH X-QUANG NGl/C: Cac dau hifu va hinh anh X-quang ngire 3. Dau hieu phong ranh lien thuy (Bulging fissure sign) Kinh dien day la hinh anh viem phoi thuy do K.pneumonia. Si/ Ian rong toan bo mot thuy cua ton thuong lam cho ranh lien thuy phong. Hinh 2.3. Hinh dau hieu ranh lien thuy phdng. Tren phim thing (A) va nghieng (B) la hinh anh viem phoi thuy, thuxyng do K.pneumonia. Tren phim nghieng thay ranh giai dudi la ket hap cua hai doan ranh lien thuy (ranh lien thuy nhd phia truxyc - mui ten ngin va doan tren cua ranh lien thuy l&n phia sau - mui ten dai). 4. Dau hieu ranh giai co> hoanh lien tuc (Continuous diaphragm sign) Binh thudng theo nguyen ly dau hieu bong, phan co hoanh dudi bong tim khong nhin th iy vi tim, co hoanh va gan cung nlm tren mot mat phlng va cung can tia dang nude. Trong trudng hop giua tim va co hoanh co mot khoang khi chung ta se thay bd cua gan lien tuc dudi bong tim hay la dau hieu ranh gidi co hoanh lien tuc. Dau hieu nay cho phep chung ta chan doan co tran khi trung that. Hinh 2.4. Dau hieu ca hoanh lien tuc. Tren phim ngisc thing co hinh anh tran khi trung thit, ca hoanh nhin th iy lien tuc (mui ten). Khi trung th it cung dwoc nhin th iy a vung co hai ben (mui ten khong lien net). 5. Dau hieu mach do tren CT (CT angiogram sign) Dau hieu mach do tren CT dung de chi hinh anh mach mau co thu6c can quang trong mot vung phoi kem thong khi. Cac mach mau dugc O Cac dau hi$u va hinh anh X-quang ngypc: THl/C HANH X-QUANG NGl/C nhin thay uu the tuong phan vai nen phoi md kern can tia han (hinh 2.5). Hinh anh nay gap trong ung thu te bao phe quan-phe nang, lymphoma va cung co the thay trong trong cac benh ly khac, trong do co viem phoi nhiem khuan. Hinh 2.5. Hinh dau hieu mach mau do. Tren phim CT co can quang chung ta thay hinh anh ung thw te bao phe quan-phe nang thuy duxyi trai. Cac mach mau phoi (mOi ten) thay ro tren nen nhu mo phoi can tia kem hem. 6. Dau hieu ranh sau (Deep sulcus sign) Dau hieu nay chi hien tugng tran khi mang phoi tren phim chup tu the nlm . & tu the nay khoang khi mang phoi se khong giong nhu tren phim thang dung (khoang khi nlm doc thanh ben long nguc). Chung ta se th iy vung tran khi lln sau vao phia trong long nguc, khong mang hinh dang tran khi thong thudng, thudng lam cho goc sudn va tam hoanh nhin ro tren phim. Hinh 2.6. Hinh dau hieu ranh sau. (A) Tren phim ngi/c thing tu the n im co hinh anh tran khi mang phdi hai ben. Khoang khi hai ben rong, Ian sau vao trong thanh ngi/c (mOi ten). (B) Cung tren phim ngisc thing tw the n im cua mot benh nhan thd may bi tran khi mang phoi do khi ap. Tren phim chung ta th iy md rong goc suxyn hoanh phai, tran khi trung thit. duxyi da nguc va co. 7. Dau hieu phoi rai (Fallen lung sign) Dau hieu nay chi mot trudng hop phoi xep (thudng do chin thuona O TH1/C HANH X-QUANG NGI/C: CSc dau higu va hinh anh X-quang ngire nguc gay xep phoi) kem theo gay phe quan lam cho phoi khong con dugc treo d vj tri binh thudng tuong xung vdi ron phoi ma nhu bj roi xuong thap va ra ngoai (tu the dung) hay ra sau (tu th i nlm thay tren CT). Hinh anh nay can phan biet vdi xep phoi do tran khi mang phoi. Trong trudng hgp tran khi mang phoi, phoi xep va co lai theo hudng ve ron phoi. Hinh 2.7. Dau hieu phoi roi. Tren phim thing twthe n im mot benh nhan chin thuxyng do tai nan. Co tran khi mang phoi d ben phai ton tai dai ding mac du da duxyc md mang phoi dat ong dan luru. DiSu nay cho th iy khoang trong mang phoi ben ngux: phai khong phai la do tran khi mang phoi ma do xep phoi hau qua cua gay mot phe quan Ian. Phoi bi xep lai, roi xuong duxyi va ra ngoai thay vi co lai ve phia trong, ron phoi. 8. Dau hieu phang doan eo that (Flat waist sign) Dau hieu nay chi hien tugng trd nen phlng d bd ngoai cua hinh loi quai dong mach chu va cua dong mach phoi ke can tren hinh trung that phim nguc thang. Hinh anh nay gap trong trudng hgp xep nang thuy dudi ben trai va tao ra su djch chuyen ve phia ben trai va xoay tron cua tim. Hinh 2.8. Dau hieu phing doan eo. Tren phim thing cho thay vung thuy duxyi ben trai trd nen md do xep. Chung ta khong cdn th iy duxyng cong co hoanh trai d khoang giCra (k it qua cua hien tuxyng d iu hieu bong). Phe quan thuy dudi trai trd nen dirng hon binh thuxyng (mui ten ngin). S y dich v i phia trai va xoay cua tim d vung xep phoi tao ra hien tuxyng phing cua dudng cong hinh loi quai dong mach chu va doan dong mach phdi tiep ndi ben duxyi (mui ten dai). 9. Dau hieu ngon tay trong gang (Finger- in- glove sign) Trong benh nam phoi - phe quan do Aspergillus. Bieu hien blng dj ung thu phat do qua m ln, phe quan chua djch nhay phe quan, xac te bao, bach cau ai toan, sgi nlm . Phe quan ton thuong bieu hien tren X-quang blng nhung hinh md hinh dang de nhan biet. Cac dau hi£u va hinh anh X-quang ngyc: THl/C HANH X-QUANG NGI/C Hinh 2.9. Dau hieu ngon tay trong gang. (A) Tren phim thing benh nhan bi xo hoa nang va nam di ung phoi - phe quan. Phe quan tiep can vung ton thuxyng bi gian cang chira dich nhay, nhieu bach cau ai toan, te bao thoai hoa va spi nam tao nen hinh anh ong va hai giong khoi u (mui ten). Hinh anh nay co the khu tru, thuxyng a day. Co the Ian toa dang gian phe quan. (B) Tren phim CT co hinh gian phe quan thuy duxyi trai trong long chira day dich. 10. Dau hieu chu S (Golden S sign) Khi mot thuy bi xep quanh mot khoi u trung tam se lam cho nhu mo phoi vung xep tang dam do, co lai hudng ve phia khoi u trung tam tao thanh mot hinh anh co chu vi lorn. 6 1 vung trung tam, khoi u la hinh anh co chu vi loi. Lien ket hai bat thudng tang dam do can tia nay se cho hinh anh md co chu vi hinh chip S xuoi hoac nguo’c. Dau hieu nay kha quan trong vi no co y nghTa la co tic nghen trung tam va d ngudi Idn thi nhieu kha nang la ung thu phe quan. Hinh 2.10. D iu hieu chu S. (A) Phim thing cua mot benh nhan ung thu phe quan thuy tren phai. (B) CT cho thay: khoi u noi long phe quan lam xep thuy tren phoi phai va lam dich chuyen ranh lien thuy nhd (mui ten khong lien net) ve phia ron phdi. Khoi u tao ra hinh anh ranh gioi loi vS phia nhu md phoi (mui ten lien net) Bo ngoai cua cac bat thuxyng tren phim tao thanh hinh chu S nguxyc © THl/C HANH X-QUANG NGI/C: Cac dau hi$u va hinh anh X-quang ngire 11. Dau hieu quang sang (Halo sign) Dau hieu nay de chi mot quang md nhat tren phim CT. Quang md nay bao quanh hoac co dang nhu vang md deu quanh mot ton thuo’ng not hay vung dong dac md dam ho’n. Mac du hlu het cac not phoi gay chay mau deu co the tao ra dau hieu nay nhung tren benh nhan leukemia, neu thay dau hieu tren thi can nghT den hien tugng xam nhiem sdm cua nam Aspergillus. Hinh 2.11. Dau hieu quang sang. Tren CT c it ngang vung dinh phoi cho thay cd not mo va vung dong dac hai ben voi quing sang mo nhat hon (dang kinh mo) bao quanh (mui ten). Benh nhan leukemia va hinh anh nay goi y nhiem nam Aspergillus. 12. Dau hieu loi Hampton (Hampton hump sign) Nhoi mau phoi sau thuyen tic phoi tao ra mot vung md bat thudng tren X-quang nguc. Hinh md nay luon tiep xuc vdi mang phoi va co nhieu dang khac nhau. Khi dudng ranh gidi trong co dang tron, no dugc goi la dau hieu loi ma Hampton va Castleman mo ta. V 4 " a ' Hinh 2.12. Dau hieu I6i Hampton. Tren CT cCra so phoi (A) chung ta thay mot hinh mo ngay duxyi mang phdi thuy duoi phoi trai (mui ten). Hinh mo dang loi nay la nhoi mau phoi sau thuyen tic dong mach phoi. Chung ta cung th iy co tran dich mang phoi hai ben. hinh anh hay gap trong thuyen tic dong mach phdi cap. Tren Cac dau hi£u va hinh anh X-quang ngu’c: THt/C HANH X-QUANG hn trong X-quang ngi/c: THl/C HANH X-QUANG NGI/C thay. Thi du chi thay van canh trai cua dong mach chu tren phim thang. 3. Cac loai dau hieu bong va ting dung - Dau hieu b it cheo: La dau hieu che ron phoi, dau hieu hoi tu (xem phan 3. Chan doan cac ron phoi Ion). Hinh 3.2. D iu hieu co - nguc (1. Hinh ton thuxyng & phia sau; 2 Hinh ton thuxyng & phia truxyc; 3. N in co; 4. Xuxyng don c it ngang) - Dau hieu co - ngu’c: Mot khoi u trung that tren chi thay dirge khi no dirge bao boc toan bo boi phoi (khi), co nghTa la no chi co the d phia sau (1). Con khi no nlm d phia trirdc, bo tren cua no bj lap trong khu virc mo m§m vung co - trung that (dam do nirdc) va se khong nhin thay tren phim thing (2) (hinh 3.2). Hinh 3.3. D iu hieu “ngi/c - bung” hay “tang bang noi" (1. Hinh ton thuxyng n trong X-quang ngirc then cua benh sdi, ho ga hoac thuy dau. Hinh “phe quan dan luu” tu mot hang lao hay mot o ap-xe cung nlm trong nhom hinh anh nay (hinh 3.5 B). Trong phu phoi (do tim hay do than) tinh trang tham nhiim mo thanh quanh phe quan cGng cho hinh anh tuong tu. Trong truong hgp nay ta thay hoac la hinh anh la nhung vet md hoac la hinh “m lt kinh” co bieu hien day len cua thanh phe quan (m lt phe quan day). b. Cac p h i quan binh thu’&ng trong mot vung phoi dong dac: Do la hinh “phe quan hoi” kinh dien. Cac phe quan binh thudng chua d ly khi nlm trong mot vung nhu mo phoi bi dong dac (thi du do viem, phu, nhoi mau). Tren phim ngudi ta th iy dugc ben trong hinh md cua nhu mo phoi la cac vet sang phe quan giong nhu hinh cac ngon tay xoe. Dau hieu nay chi co gia trj djnh hudng. Thuc te, mot tinh trang thu hep p h i quan lam giam thong khi cung co th i gay ra hinh p h i quan hoi thoang qua hoac viem phoi d giai doan muon cung khong con hinh p h i quan hoi nua. c. Cac phS quan bi lap day: Vet sang p h i quan khong con nua, long phi quan bj lap day bdi djch, trong khi nhu mo phoi xung quanh con chua khi tuong doi binh thudng. Tren phim ngudi ta thay hinh anh nhung vet md dang ngon tay xoe d ngoai vi phoi (hinh ngon tay deo gang). Cac vet md nay co b i rong thu nho dan ra ngoai vi. Ban than chung kho phan biet vdi cac mach mau. Ngudi ta co th i nhan thay cac hinh anh nay trong cac trudng hgp: - Gian p h i quan. Doi khi ngudi ta cung thay cac hinh md tron nlm xen ke, do la hinh cac ong p h i quan co chieu thing goc vdi p h i quan bj lap day. Doi khi cung co the thay hinh muc nudc-hoi trong cac trudng hgp gian p h i quan dang ken. - Trong benh nhly nhdt (mucoviscodosis). Long p h i quan bj lip d ly bdi chit djch nhly. - Trong benh tui phinh p h i quan. Cac vet md thudng Idn, dang oval, co true hudng theo true p h i quan. - Trong viem p h i quan man tinh. P hi quan cGng bj chua d ly ch it djch do p h i quan qua tilt. d. Cac dang hinh anh mSt kinh hay 6ng nhdm: Cac dang hinh anh nay thiy d trong vung ron phoi. Chung dugc tao thanh do hinh anh c lt ngang cua mot p h i quan va mot dong mach phoi cung c lp (xem Hoi chung mach mau) (hinh 3.6). Su biin doi cua mat phe quan co the do e Cac hoi chtmg lo>n trong X-quang ngi^c: THl/C HANH X-QUANG NGl/C benh ly cua ban than phe quan (gian phe quan, viem man tinh), cung co the thu phat sau benh ly tang ap tuan hoan phoi (phoi - tim, phoi - than) do phu mo ke dan d thanh phe quan. Hinh 3.6. CT ngisc cua benh nhan phu phoi huyet dong: hinh anh day mo ke dudi mang phoi (mui ten tring) va day thanh mSt phe quan tren hinh anh m£t kinh (mui ten den va phong to) 4. Cac hinh anh gian tiep Cac hinh anh gian tilp lien quan den hau qua chuc nang thong khi phoi va tuan hoan cua phe quan bi ton thuong. No bao gom: hau qua co hoc cua su luu thong khi va hau qua tren tuan hoan phoi. - T ic nghen p h i quan tao hinh anh gian tiep la hinh xep phoi (nhu mo phoi giam sang, thu nho dien tich). T ic nghen cung tao hinh anh gian tiep la hinh khi cam (air trapping) (nhu mo phoi qua sang, cang gian). Hinh anh xep phoi dang vet (Fleischner mo ta) nlm d day phoi do hien tugng qua tang ap luc trong o bung (co thai, djch bang). COng co the thay hinh anh nay hai ben do thuyen tic nho hai phoi. - T ic nghen phe quan cung de lai hau qua tren tuan hoan phoi do lam thay doi tuong quan thong khi / tuoi mau: giam tuoi mau vung giam thong khi (giam van mach mau) va tang tuoi mau vung lanh (tai phan bo lai mach mau). III. HOI CHl/NG LAP DAY PH£ NANG 1. Djnh nghTa Do la hinh anh X-quang do hau qua cua su bien mat khong khi thong thudng co chua trong phe nang. Thay vao do phe nang chua dich (dich tiet hoac dich thim), mu, hoac mo tan sinh phat sinh tu trong long p h i nang. Nhu ngudi ta thudng noi "gan hoa phoi” co nghTa la khong thu hep the tich cua nhu mo phoi de phan biet vdi xep phoi. Hinh anh 0 THI/C HANH X-QUANG NGI/C: Cac hpi chi>ng lo>n trong X-quang ngu’c X-quang lap day phe nang thudng dugc mo ta blng thuat ngu “tham nhiem”. Day la khai niem ma trong thuc hanh thudng bi cho la do nhiem khuan. Tuy nhien, tham nhi§m la hinh anh rat khong dac hieu (hinh 3.7). 2. Cac hinh anh X-quang a. Cac hinh anh ccy ban: dang chum not hoac tieu thuy phoi Kinh dien, cac hinh anh nay the hien hinh anh co ban cua tinh trang lap day phe nang d cac chum ong phe nang (tieu thuy phoi cap 1 hay 2). Kich thudc cua cac hinh nay true tiep bieu hien don vj giai phau benh (chum ong phe nang hay tieu thuy phoi). Chung tao ra cac hinh md dang tron hoac oval, dam do khac nhau kich thudc tu dang dau ghim den hinh md dang n6t nho hoac to. Co the cac hinh anh nay tao ra mot hinh anh ke (miliary) phe nang that su, do la ke trong trudng hgp sau ho mau, vi soi phe nang (hiem gap)- Co the cac hinh anh nay co cum lai vdi nhau de tao thanh cac hinh anh “dang hoa hong”. Thi du ro nhat ve hinh anh nay la hinh anh cac chum nang trong chup phe quan can quang (lap day phe nang trong chup phe quan). Cuoi cung, trong mot so trudng hgp (thi du viem phoi phat hien muon) ngudi ta thay cac hinh md dam dang dau ghim dung ke ben cac hinh sang (tuyen nang chua hoi). Luc nay hinh anh X-quang kho phan biet vdi hoi chung ke. b. Cac hinh anh ket ho’p Cac hinh anh chum ong ph§ nang hoac tieu thuy phoi nhanh chong ket hgp lai vdi nhau de tao thanh hinh anh ket hgp. Trong nhung trudng hgp nay co the ngudi ta nhan thay cac hinh md he th6ng, ranh gidi khong ro rang, kieu dam may don doc hay da dang, khu tru hay tan man, mot ben hoac hai ben, dam it hay nhieu, thudng la d vung day phoi hoac canh ron phoi de cho hinh anh dang canh budm. Cac ton thuong dang nay cung co the co dang md khu tru nhu trong lao phoi, co dang phe quan - phoi tan man trong phu phe nang huy§t dong hay phu phe nang ton thuong hoac trong phe quan - phe viem nhiem khuan. Ngugc lai, cac hinh md co the co he thong d tam phan thuy, thuy, cho hinh anh dam, dong nhat, bd ro va deu dan ma thuc chat do la gidi han cua cac ranh lien thuy mang phoi (trong viem phoi thuy dien hinh). O Cac hoi chi>ng lo>n trong X-quang ngipc: THl/C HANH X-QUANG NGI/C Viem phe nang lam thoat dich ri viem, fibrin va bach cau vao trong long phe nang tao ra hien tugng lap day phe nang. Di§u nay giai thich tai sao co su ph6ng len cua cac ranh mang phoi lien thuy. Hinh anh ngugc lai la hinh xep phoi. Trong trudng hop nay thi ranh mang phoi lien thuy lom. Trong long hinh md ngudi ta co the thay hinh phe quan hoi. Dau hieu phe quan hoi co gia trj khang dinh co hien tuong lap day phe nang trong khu vuc xung quanh hinh phe quan hoi. Hoi chung lip day phe nang co the gap d dang nang, ton thuong chiem toi da hai trudng phoi va tao nen hinh anh “phoi trln g ”, tien lugng rat nang. O' mot so trudng hgp viem phoi do virus ho hap, ngudi ta co the thay hinh anh ton thuong dang “phoi trln g ” nhu vay. Hinh 3.7. Hinh minh hoa ton thuxyng dang tham nhiem co nhieu nguyen nhan (a: ho mau trong hoi chirng Goodpasture; b: Benh protein phe nang; c: K te bao phe quan-phe nang: d: U hat Wegener; e: Phdi hit sau x u it huyet da day: f: Viem phoi tren ngudi AIDS 3. Cac can nguyen a. Lap dSy phS nang khu tru: Dugc tao ra mot cach cap tinh: - Viem phoi thuy hay phan thuy dien hinh - Nhoi mau phoi sau thuyen tic Dugc tao ra mot cach ban cap hoac man tinh: - Tham nhiem lao - Ung thu phe nang khu tru © TH1/C HANH X-QUANG NGI/C: Cac hpi chirng lo>n trong X-quang ngire - Tham nhiem Hodgkin - Tham nhiim mau bay b. Lap d iy ph4 nang tan man hoac hai ben: Dugc tao ra mot cach clip tinh hay dot ngot: - Phu phoi cap huyet dong hay ton thuong - Viem phoi vi khuan, virus hay nam Dugc tao nen ban cap hoac man tinh: - Benh protein p h i nang - Ung thu phe nang tan man - Nam phoi - Vi soi phe nang - Viem phoi troc vay (desquamative) cua Liebow mo ta - Viem phoi man tinh tang bach cau ai toan 4. Tom lai Co 4 can nguyen noi bat cua hoi chung lap day phe nang: Neu khu tru: - Viem phoi khoi - Nhoi mau phoi Neu tan man: - Phu phoi huyit dong hoac ton thuong - Phe quan-phi viem cap do nhiem khuan, virus hay nam IV. HOI CHU’NG KE 1. Djnh nghTa Hoi chung ke X-quang gom d6ng thdi cac thong tin the hien ton thuong d mot hoac nhieu phln cua mo ke phoi (hinh 3.8): - Phan mo ke quanh phe quan- mach mau, con goi la mo ke dan (ngoai tieu thuy phoi). - Phan mo ke quanh tieu thuy va lien tieu thuy - Phan mo ke dudi mang phoi - Phan mo ke thanh-phe nang hoac trong tieu thuy phoi Cac hoi chung lo>n trong X-quang ngyc: THl/C HANH X-QUANG NGI/C Hinh 3.8. So do phan loai cac khoang mo ke (1. Md ke dudi mang phoi; 2. Mo ke d in hay mo ke true; 3. Mo ke thanh-phe nang) Binh thudng mo ke phoi khong nhin thay tren phim X-quang vi no rat mong. Mo ke chi tro nen nhin th iy dim e trong cac tinh huong benh ly co lam d ly cac c lu true collagen nay. Co the la: - Tham nhi§m dich: phu phoi ke (huyet dong hoac ton thuang) - O’ mau tTnh mach hoac u bach huyet (viem bach mach do K di can) - Phan chia te bao hoac mo b it thudng: U hat mo ke, xo ke tan man Hoi chung X-quang cua mo ke chi x u lt hien khi no la ton thuong don doc. Mo ke b it thudng (dam do nude) chi nhin th iy dugc neu phe nang chua khi (dam do khi). Hinh anh mo ke co the bi che lip neu co them hoi chung lap day phe nang. Trong nhieu benh ly thudng co su chuyen tu ton thuong dang ke sang ton thuong dang phe nang do vay ma ton thuong dang ke co the chi thay trong mot giai doan tien trien cua benh. 2. Cac tieu chuan co ban cua hinh anh Do la cac hinh md bd khong ro, khong tiep noi vdi nhau, khong he th6ng, khong co hinh phe quan hoi, khong d vj tri cua mach mau, khong phai la p h i quan, thudng tien trien cham. Cac ton thuong ro rang nhlt la mo ke dan, mo ke dudi mang phoi va quanh tieu thuy phoi. Ton thuong mo ke thanh - phe nang n lm trong tieu thuy phoi kho nhin th iy hon. CGng c ln luu y la tran djch mang phoi co ban c h it la ton thuang mo ke va tran djch mang phoi phdi hgp vdi ton thuong cua phln ke dudi mang. Thi du: tran djch mang phoi do K di can ket hgp vdi viem bach mach dudi mang hoac tran djch mang phoi do suy tim ket hgp vdi phu ke. Hinh anh X-quang co the nhan th iy duac tiiy thuoc vao kich thudc o THl/C HANH X-QUANG NGI/C: Cac hpi chi>ng lo>n trong X-quang ngtfc cua ton thuang, vao vi tri cua chung, va vao giai doan tiln trien cua chung. Tuy the, cGng khong nen co glng dong hoa khai niem ke cua giai phau benh hoc vdi hinh anh ke cua X-quang. Ngudi ta thudng chia hinh anh co ban chat ke thanh ba nhom: - Cac hinh anh not va ke - Cac hinh anh vet va bo - Cac hinh anh ludi va to ong. B Dang lird iA Dang ve t D dang n6t C Dang lu-oi t6 ong E Dang iLfoi-not Hinh 3.9. Phan loai cac dang ton thuvng ke (theo Eric J. Stern va Jannette Collins) 3. Phan loai X-quang a. Hinh anh n o t: Do la hinh anh dang tron, ranh gidi ro, s6 lugng va kich thudc thay doi, tan man, nhieu hay it d hai phe trudng. Ngudi ta phan nhom theo kich thudc X-quang. + Hinh anh “kinh m d”: Hinh anh dac trung tren X-quang la hinh anh ke dac biet nho, nlm d ranh gidi cua kha nang nhin thiy, uu the d day phoi va ron phoi, tao ra hinh anh canh budm. Neu nhu phong to len (thi du nhin qua kinh lup), ngudi ta th iy cac don vi cua ton thuong khong tach rieng ra dugc va dac biet nho. Hinh X-quang phoi trong nhu bj udt, md. Hinh anh nay noi chung la bieu hien cua ton thuong cua mo ke thanh - phe nang nlm trong tieu thuy phoi. Cac can nguyen co the la: - U hat phoi dang dj ung - mien djch (benh ly phoi co khang the k§t tua). Co hai loai benh thudng gap dang nay la benh phoi cua nhung O Cac hoi chung Ian trong X-quang ngi/c: THl/C HANH X-QUANG NGI/C ngudi lam nong trai va benh phoi cua nhung ngudi nuoi chim. Viec hdi tien slp va chan doan huyet thanh la cach thu’c chan doan thong thudng. Tien trien cua benh co the dua den xo hoa mo ke vung lien va quanh tieu thuy phoi. - Cac viem phoi ke do virus hoac vi khuan nhip: Pneumocystis carinii, Cytomegalovirus. Benh canh d day la benh canh co hoi tren nhCrng co dia thuan loi (dang da hoa trj lieu, ghep tang, corticosteroid tri lieu hay AIDS...). Sinh thiet phoi se cho chan doan. + Hinh anh ke that sir. Hinh anh nay co kich thudc Idn hon. Khong nen nhlm lin hinh anh ke nay vdi hinh anh not cua chum nang trong hoi chung lap day phe nang (thi du ke sau chup lipiodol). Ngudi ta co thoi quen su dung phan loai de nghj cua Vien lao dong quoc te trong benh bui phoi. - < 1.5 mm: Benh nhiem bui s it -1.5 - 3 mm: Silicosis, lao - > 3 - 10 mm: Silicosis, ung thu Hinh anh ke dugc xep trong khuon kho cua hoi chung k§ vi da so cac hinh ke co vj tri ton thuong d vung ke. Tuy nhien cung co nhung hiim , ton thuong ke d phe nang (nhu benh vi soi phe nang, sau chup lipiodol, sau ho mau). CGng do ly do nay ma co tac gia (Heizmann) de nghj co mot hoi chung X-quang ke-not rieng. Su lien quan giai phau - X-quang cua hinh anh ke con nhilu ban cai. Thuc te thi mot ton thuong giai phau nho hon 6 mm khong the nhin thay dugc tren phim X-quang. Da s6 cac tac gia cho ring nhilu hinh anh ke khong phai la hinh anh thuc ma chi la hinh anh “de nghj". Cac nguyen nhan se dugc Net ke sau day thong thudng la cac can nguyen d in d§n su hinh thanh u hat d mo ke va thudng la d trong tieu thuy phoi. Cac benh nay co the dan d in xo hoa va can-xi hoa (ke can-xi hoa): - Do nhiem khuan: lao, tu clu, virus (nhlt la thuy dau). - Do nlm : Candidosis, Histoplasmosis. - Do bui: S it, silic - Do K hoac do benh mau: K ke di can, Hodgkin - Do tim: Chung nhiem hemosiderin phoi cua benh tim (benh phoi do van hai la). - Do benh tao u hat “nguyen phat” khong ro can nguyen: Sarcoidosis 0 TH1/C HANH X-QUANG NGI/C: Cac hpi chirng lo>n trong X-quang ngu’c histiocytosis, reticulosis X (u hat tang bach cau ai toan cua phoi), chung nhiem hemosiderin cua phoi tu* phat. Cac yeu to co the Net ke de chan doan nguyen nhan thi rat nhieu do hinh anh ke la it dac hieu. Trong thu’c te, de chan doan trudc mot hinh anh ke can khai thac cac “tinh huong”: - Tinh huong lam sang: ke “nong” hay “lanh” - Tinh huong nghe nghiep - Tinh huong co cac ton thuang X-quang k it hop (hach, can-xi hoa, khoi d phoi, tran djch mang phoi...) - Tinh huong sinh hoc Can luu y mot so tieu chuan dac biet de xac djnh: - Ke rat nho: Co the nhiem bui s it cua tho mo sit, tho han hoac benh phoi do nhiem hemosiderin (benh phoi trong benh van hai la hay chung nhiin hemosiderin tu1 phat). - Ke ung thu: Uu the d th lp vi ban ch it la Ian theo dudng mau. Ke ung thu co kich thudc Idn (type n), cho hinh anh “rlc hoa g ily ”. Co the phoi ho’p vdi viem bach mach (hinh anh rang luge quanh ron phoi, van Kerley, tran djch mang phoi). Trong nhung trudng hgp nay can tim ung thu nguyen phat d da dly, tien liet tuyen, tuyen giap. - Ke trong sarcoidosis: Thudng kich thudc khong deu, phan bo giong hinh anh canh budm, phoi hgp vdi hach ron phoi hai ben va theo he thong. - Ke silicosis: Kich thudc thay doi (type m, n), thudng la dam, uu the d 2/3 tren cua phoi (vi ban ch it Ian theo dudng thd), thudng co hach trung th it bi can-xi hoa (hinh anh “vo trung”) hoac khoi nhu mo gia u d dinh va ngoai vi dang hinh thoi. - Ke can-xi hoa: Co the ggi y mot so chan doan: lao, histoplasmosis, silicosis, thuy dau). + Hinh anh not l&n: Oo la hinh anh tha bong, dac trung blng hinh anh md to nho khong deu, tron, kich thudc thudng Idn tu 1-10 mm. Can nguyen thudng tuy thuoc tuoi va gidi: - Ngudi tre: Thudng phai tim K tinh hoan, K xuong. - Ngudi Idn tuoi: Thudng phai tim K than, K ruot, K Tai-Mui-Hong doi vdi nam gidi. K sinh due, noi tiet: vu, tuyen giap, tu cung doi vdi nu. © Cac hpi chirng lorn trong X-quang ngi/c: TH1/C HANH X-QUANG NGI/C b. Hinh mo dang vet: Day la dang X-quang khong tron ma co dang CQt, bo, it nhieu thing, khong phan nhanh. Thudng co dinh khu n h lt djnh. Ngudi ta chia thanh cac nhom: - Van Kerley A, B, C, D - Cac hinh van quanh ron phoi, hinh anh “rang luge" hay hinh anh “tia ning”. + Nhom hinh anh van Kerley: Van Kerley the hien ton thuang vung vach hoac thanh lien tieu thuy hoac quanh tieu thuy. Cac van Kerley B tuong ung vai mot vach, cac van A, C, D tuong ung vai su ke tiep cua vach, tao ra cac tia lien tiep va hinh thanh vet lien tuc. - Van Kerley B (vung thlp): La thudng th iy nhlt. D ugc biet nhieu nhat la d day phoi, lien tuc vdi mang phoi va thing goc vdi mang phoi. Thudng la ngln (2-3 cm), manh (dly khoang dudi 2 mm). Chung tao thanh hinh bac thang, thudng th iy d d goc sudn - hoanh, phia sau. - Van Kerley A (vung dinh): Dugc biet it han. Thudng th iy d phan tren cua phoi. Dai hon van B (5-6 cm) va day han (3-4 cm), nlm gan trung tam hon, trong nhu mo phoi. Van nay hoi cong nhung tach han khoi cuong p h i quan - mach mau. - Van Kerley D (phia trudc): Van nay d ly hon, nlm d phia trudc. Co the th iy tren phim nghieng d khoang vung giua hay thuy ludi. Trong trudng hgp nay khong nen nhlm lin vdi hinh xep phoi dang vet (Fleischner). Vdi su hien dien cua cac van Kerley, c ln phai nghT d in mot so benh: - Phu ke huylt dong (phoi - tim), hoac phu ke ton thuang (phoi soc). - Viem mach bach huyet do K: do di can, do xam lin tai cho cua K p h i quan. - Xo phoi ke: silicosis, sarcoidosis. © THI/C HANH X-QUANG NGI/C: Cac hpi chung ln trong X-quang ngu>c X-quang phoi chi co mot vai tro kha han che ve mach do (P. Bernadac). (y day chung ta chi de cap den bieu hien nhin th iy dugc tren X-quang cua tuoi mau phoi blng hinh anh cac dong mach va tTnh mach phoi tao thanh luai trong khoang sang nhu mo. Tuan hoan phoi la tuin hoan co nhung dac diem: - Co cung lugng Ian, cung lugng th it phai g in blng th it trai. - Ap luc thlp (5 lin th lp han ap luc dai tuin hoan) - Tro khang yeu. - R lt co gian trong giuang mao mach phoi (rlt khac nhau giua trang thai nghi va trang thai glng sue). Su phan bo dong mau phoi tuong ung vai so do West (hinh 1.6). Day phoi tuoi mau nhieu g lp hai Ian dinh phoi. Mot cach khai quat nguoi ta chia tuan hoan phoi ra thanh hai khu vuc: truac mao mach (tuin hoan dong mach) va sau mao mach (tuin hoan tTnh mach). Cac benh ly phoi man tinh deu co the lam thu hep giuang mao mach va hau qua la lam tang ap luc mach phoi truac mao mach (benh tim- phoi man tinh). Cac benh ly tim trai deu lam tang ap luc mach phoi sau mao mach va sau do la mao mach phoi (benh phoi - tim). 2. Cac bat thuong X-quang ccy ban De xac djnh t it ca cac thay doi ve tuin hoan phoi c ln phai nghien cuu tren X-quang phoi ba loai ylu t6: a. Nghien ciiu sis phan bd mach mau & hai vung phdi: Phan bo mach mau o tu th<§ dung vung dinh phoi/vung day theo kieu 1/2 (binh thuong) hay 1/1 hoac 2/1 (bat thuong). Trong truang hop dang phan bo 1/1 (dong nhat tuoi mau phoi): Cac mach mau phoi co duong kinh giong nhau o dinh cung nhu a day (phoi mo). Dung tich phoi dugc bao hoa tuoi mau boi su tang len cua cung lugng va the tich tu in hoan. Day la hinh phoi trong tinh trang glng sue (tang cung lugng tam thu). Day cung la hinh phoi trong truang hgp co shunt trai-phai (thong lien nhT, thong lien thit), cGng nhu trong cac truong hgp phoi-than (truac loc mau), tuoi mau phln phoi con lai sau phau thuat c lt mot phln phoi. Trong truang hgp dang phan b6 2/1: Day la dang dao ngugc phan bo mach mau hay tai phan bo tuin hoan vung dinh. Su tai phan b6 nay gap trong tang ap luc tTnh phoi mach sau mao mach trong suy th it trai O Cac hpi chung Ion trong X-quang ngyc: THl/C HANH X-QUANG NGI/C hoac hep hai la. Cung c ln luu y la hien tipgng tai phan bo tuan hoan vung dinh phoi cung co the th iy trong tru’ong hgp khi thung phoi a hai day. b. Nghien ciru vS s i/ ddng nhat v i tis&i mau phoi: Tim kiem su tang sang. Tuoi mau phoi la dong nhat va dugc dieu hoa theo he thong hai vung phoi. Do Ion cua cac mach mau giam dan theo huang tu ron phoi ra ngoai vi. Tuan hoan phoi co the nhin thay dugc cho d in khi cach thanh nguc 2 cm. Su phan b6 binh thuong nay se bi thay doi trong hai tinh huong. - Toan bo mot vung phoi khong dugc tuoi mau nua. Luc nay phoi rat sang, khong con cau true mach mau voi dam do nuac nua: van phoi bien mat. Vung qua sang nay co the khu tru hoac co the mo rong ra toan bo mot thuy hoac toan bo mot ben phoi (hoi chung Janus). Trang thai bat thuong nay gap trong tat ca cac truong hgp co gian doan tuan hoan phoi: thuyen tic phoi khoi Ion, hep mot nhanh dong mach phoi m lc phai hay blm sinh. - Co su thua d in tuin hoan phoi ra ngoai vi, cac van mach mau bien m lt truac khi cach thanh nguc 2 cm. Phoi luc nay sang o’ ngoai vi mot cach can xung. Bieu hien nay thuong ket hgp mot cach tuang phan voi cac mach mau r6n phoi Ion len, dam hon va gian ra (hinh anh “ria mep vien canh binh” ). Chi so Johnson-Wood luon tren 16 mm (binh thuong duoi 15 mm) (hinh 3.12). Su thay doi nay gap trong nhung truong hgp co tang ap luc tuan hoan truoc mao mach (tam phe man tinh). Hinh 3.12. Chi so Johnson-Wood: Do cat ngang nhanh xuong cua dong mach phoi phai, & ci/c duxyi ron phoi. c. Nghien ciru mach mau ron phdi va hinh anh “m£t kinh": © THl/C HANH X-QUANG NGI/C: Cac hoi chi>ng lo>n trong X-quang ngu’c Nghien cuu mach mau ron phoi la quan trong. Nguai ta co the thay: + Mach mau ron phoi l&n mot ben: - Thuyen tic Ian va hoi chung Westermark (ron phoi Ion, mo, phoi sang ben bi thuyen tic). - Gian bam sinh mot dong mach phoi (ron phoi Ion, mo, phoi mo hay binh thuang). + Mach mau rdn phoi nhd mot ben (dau hieu Danelius): Ron phoi “teo nho” lien quan den thieu san dong mach phoi mot ben, thuong ket hop voi hinh phoi sang mot ben. + Phi dai ron phoi hai ben nguon goc mach mau: - Phoi hgp vai phoi sang ngoai vi: Truong hgp tang ap luc mach phoi dang truac mao mach. - Phoi hgp vai phoi ma: Truang hgp shunt trai - phai hoac tang ap luc hon hgp truoc va sau mao mach (hep hai la tien trien). + Thu nho rdn phdi hai ben cung vdi phoi sang hai ben: Truong hgp hep than dong mach phoi hay hep lo (van) dong mach phoi. Nghien cuu ron phoi mach mau khong the tach roi voi viec nghien cuu hinh anh m lt kinh hay ong nhom. Hinh anh m lt kinh thay dugc o ron phoi hay gan ron phoi (xem Hoi chung phe quan). • o , 9 0 , 1. Hinh anh ong nhom binh thirong. • O 3 2 Hinh mat mach mau to hon trong tang ap mach mau trudc mao mach, 3 Hinh mat ph4 quan day trong trong tang ap mach mau sau mao mach Hinh 3.13. Cac dang cua hinh anh mSt kinh 3. Vj tri CT trong chan doan benh mach mau Khi co kha nang chup dong mach ky thuat s6 thi CT khong phai la giai phap tot n h lt de nghien cuu cac benh mach mau. Tuy nhien cac dang hinh anh benh ly co ban ve mach mau cung can phai bi§t vi no © Cac hoi chung lo>n trong X-quang ngi^c: THl/C HANH X-QUANG NGI/C co the gap trong cac khao sat trung that co khi vi ly do khac. Cac bat thuong mach mau thong thuong nhat la: - Dong mach duoi don nlm sau thuc quan. - Quai dong mach chu nlm 6 ben phai khi quan. - Phinh cac mach mau trung thit. - Boc tach quai dong mach chu. 4. Cac hinh anh benh ly: Cac thay doi huyet dong phoi va can nguyen cua chung M.Simon chia hinh anh X-quang cua thay doi huyet dong thanh cac hoi chung: - Hoi chung X-quang cua tinh trang tang tuoi mau do tang cung lugng dan den hinh anh phoi mo. - Hoi chung X-quang cua tinh trang giam tuoi mau do giam cung lugng dan den phoi sang. - Hoi chung tang trd khang tuin hoan phoi truoc, sau mao mach va hdn hgp. a. Hoi chCmg tang tifo i mau Tao ra do su tang len toan bo cung lugng mach mau phoi. Tinh trang tang tuoi mau dien ra tren toan bo phoi va phoi trd' nen md. Co su gia tang toan bo giudng mao mach phoi, nhlt la vung dinh. Do vay co su quan binh tuan hoan phoi, phan bo mach mau theo kieu 1/1. Ron phoi it thay doi. Trong nhung tinh huong nay ngudi ta c ln phai nghT den: - Uu nang giap - Phoi - than (trudc loc) - Shunt trai - phai (thong lien nhT, thong lien thit) - Trd ngugc tinh mach phoi b it thudng. Hinh anh nay cGng co the mang y nghTa sinh ly trong trudng hgp phu nCr mang thai, sdt cao, glng sue do co tang cung lugng tim nen tang the tich tuin hoan phoi. b. Hoi chirng giam tw&i mau Tao ra do su giam the tich tuin hoan phoi. Giam ddng bo hoac khu tru tuin hoan phoi va phoi co hinh anh sang. + Giam tw&i mau ddng bo: Giam it nhieu cung lugng phoi va giam dong thdi giudng mao mach phoi. Ngudi ta th iy tren X-quang phoi O THt/C HANH X-QUANG NGI/C: Cac hpi chirng lo>n trong X-quang ngu’c - Giam doi xung the tich ron phoi - Mo rong vung sang cua phoi ngoai vi Su bat thuong nhu vay cung it gap, no tuong ung voi mot benh ly tim bam sinh co hep than dong mach hoac hep lo van dong mach phoi. + Giam tw&i mau phoi mot ben (hoi chisng Janus): Su giam tuoi mau do giam cung lugng 6 day chi xay ra d mot ben phoi. Bieu hien blng: mot ben phoi sang hon ben doi dien, co giam ca so lugng va giam ca do Ion cua cac mach mau phoi (luu y khong lam voi nhung truong hgp co mot vu, dung khong thang). Su giam tuoi mau (phoi sang mot ben) co the phoi hgp voi: - Ron phoi nho mot ben (dau hieu Danelius): . Kem phat trien hay khong phat trien bam sinh dong mach phoi mot ben . Hep than phe quan goc: thi du do mot khoi lanh tinh lam hep long phe quan goc, hien tugng thieu oxy dan den hieu ung shunt lam co mach phan xa, doi khi phoi hgp voi hien tugng khi cam. . Hoi chung Mac-Leo: Co su giam the tich phoi va co hien tugng khi cam thi thd ra. Khong co gi bat thuong 6 cac phe quan dau gan, nhung cac phe quan dau xa thi bj hep, co le lien quan d in mot benh ly vung phe quan dau xa m lc phai. - Ron phoi Ion va mo mot ben: . Thuyen tic phoi Ion xay ra tren mot than Ion cua donh mach phoi. Trong truong hgp nay r6n phoi Ion, md, ket hgp vdi mot phoi sang. Sau vung nghen mach, hinh anh tuin hoan mau bj bien m lt. . Cung phai nghT den trudng hgp co khoi u Idn vung ron phoi khong co ban ch it mach mau lam giam tuan hoan phoi cung ben do de ep vao mach mau hoac lin vao dong mach phoi. . Doi khi rdn phoi Idn md lai nlm doi ben vdi ben benh ly: trudng hgp huyet khdi Idn nhanh phai dong mach phoi nlm trong hinh md trung thit. Trong trudng hgp nay se thiy: ron phoi phai nho, giam tuan hoan phoi phai, ron phoi trai Idn, tang tuoi mau phoi trai O Cac hoi chtmg I6»n trong X-quang ngi/c: THI/C HANH X-QUANG NGI/C Hinh 3.14. Sa do cap tim-phoi giai thich ca che hinh thanh tang ap phoi + Giam tuSn hoan phoi khu tru: Phoi qua sang mot vung tuong ting vdi thuy hoac phan thuy. Co che hinh thanh cung tuong tu do hep mach mau hay do co th it mach mau phan xa dan den giam tudi mau. Co che nay co the xay ra: - £y mot vung thuy phoi co gian phe quan - & mot so vung khi thung co bieu hien khi cam - Trong K phe quan co xam Ian lam hep mach mau c. Cac hoi chijng tang trey khang Trong hoi chung nay co su tang len it hay nhieu ap luc mach phoi trudc, sau mao mach hoac dong thdi ca hai. + Tang ap iisc sau mao mach: Ngudi ta gap trong benh ly phoi-tim do hep hai la, suy th it trai, d day co ti mau nhT trai, tang ap luc trong tinh mach va mao mach phoi. Hinh anh X-quang tuy thuoc vao muc do quan trong cua tang ap luc ma ngudi ta co the udc tinh dugc trong khi tien hanh do ap luc mao mach phoi bit blng ky thuat thong tim phai. - N lu do ap luc dugc tu 12 - 25 torr (1 torr x lp xi 1mmHg), ngudi ta th iy co su phan bd lai mach mau ma day la d lu hieu d lu tien cua su bu tru cua ben trai. Tren X-quang co d lu hieu phan bo mach mau theo kieu 2/1. - N§u nhu ap luc do dugc tu 25 - 35 torr, co d lu hieu phu ke xult hien: d lu hieu d ly thanh m lt phe quan trong hinh anh m lt kinh (phu phe quan), xu lt hien cac van Kerley A, B d thanh, chu yeu la d day va tui cung sau (phu quanh tieu thuy), xu lt hien cac van vien mang phoi (phu dudi mang phoi) vung nach va vung nen. Cac hinh md mach mau do THI/C HANH X-QUANG NGI/C: Cac hoi chung lorn trong X-quang ngu’c phu mo ke dan quanh phe quan - mach mau: hinh anh rang luge, md quanh ron phoi, dang gia viem bach mach quanh ron phoi va d day. Neu nang hon co the thay xuat hien tran dich mang phoi khoang Idn hay tran dich mang phoi ranh lien thuy (u ma). - Neu ap luc qua 35 torr, ngudi ta thay co phu phe nang vdi hinh anh dac trung la lap day phe nang: hinh md dang dom Id md nhu bong hai ben, hgp lai vdi nhau lam mat vi§n bong tim va co hoanh quanh ron phoi, can xung va tao ra liinh anh “canh budm”. Hinh 3.15. Hinh phu phoi huyet dong: Ma rong tinh mach azygos (mui ten liSn net); Day thanh m it phe quan (mui ten khong liSn net) va tang chi so tim nguc (a/b). Tat ca nhung hinh anh nay thudng kem theo vdi su thay doi ro rang cua bong tim (chi so tim/nguc > 0,5), that trai to ra, quai dong mach chu dudi ra cung vdi hinh anh vua-xo va can-xi hoa... + Tang ap li/c trudc mao mach: Thong thudng day la hau qua cua mot ton thuong phe quan - phoi co trudc (tang ap luc trudc mao mach trong tam phe man tinh) do hien tugng pha huy giudng mao mach phoi hay hien tugng co mach phan xa (khi co giam oxy mau). Ngudi ta cung co the thay trong trudng hgp co tic nghen nhieu mach mau phoi do cac cuc mau dong nho. Cung co the tang ap luc la nguyen phat. Trong moi trudng hgp deu co tinh trang tang ap dong mach phoi vdi ap luc cao hon muc trung binh sinh ly la 20 mmHg. Ve X-quang, can nhan manh la co su ton tai tuong phan giua phoi sang, cac mach mau thu nho nhanh, md rong vung sang ngoai vi vdi su hien dien cua ron phoi Idn hai ben, can xung, gidi han ro (hinh bo ria vien canh binh), cung vdi chi so Johnson-Wood tren 16mm, ph6i hop O Cac hoi chi>ng I6»n trong X-quang ngi^c: THI/C HANH X-QUANG NGI/C vdi cac thay doi cua hinh anh m lt kinh (m lt mach mau Idn han m lt phe quan). + Cac dang tang trdkhang hon hop: Day la cac dang tang trd khang kha hay gap, co the gap trong hai tinh huong: - Trong hep hai la tien trien: tang ap Ilfc sau mao mach sau do dan den tang ap luc trudc mao mach do hieu ung ngugc. - Trong su phoi hgp cua hai qua trinh benh ly khac nhau: Benh ly phoi-phe quan tic nghen man tinh va suy tim trai. Su phoi hgp nay hay gap d ngudi Idn, nam gidi. Trong nhung trudng hgp nay ngudi ta th iy tren phim dong thdi dlu hieu cua ca tang ap luc trudc va sau mao mach. Cung can nhlc lai ring tinh trang khi phe thung luon ket hgp vdi dang gia tai phan bo tuan hoan vung dinh. Mau bi d ly len vung cac thuy tren do co su tang len cua ap luc cac phe nang. 5. Tom lai C ln phai quan sat va theo doi ky ludng tinh trang tudi mau phoi. Trong nhung trudng hgp nay c ln phai tim: - Co tang hay giam tudi mau, tan man hay khu tru. - Xac djnh kich thudc cua r6n phoi va su can xung cua no. cac dang hinh anh m lt kinh. - Co hay khong tang ap luc mao mach phoi, dang trudc hay sau mao mach hay ca hai. Phoi la dang hinh anh phan anh sdm va trung thanh cua roi loan chuc nang tim mach. VI. HOI CHl>NG TRUNG THAT 1. Djnh nghTa Hoi chung trung th it la cac d lu hieu X-quang the hien su co mat cua khi, dich va mo benh ly trong trung thit. Cac ton thuong co dam do nude la hay gap nhlt, thudng v l lam sang la kha yen tinh, doi khi chi dugc phat hien tren X-quang qua chup mot cach he thong. CT nguc la cach khao sat tot n h lt cac b it thudng trung thit. Ba dang hinh anh co the thiy: - Cac bong md trung th it THI/C HANH X-QUANG NGI/C: Cac hoi chQpng lo>n trong X-quang ngu’c - Cac hinh tang sang - Cac hinh voi hoa 2. Phan tich cac dang ma, cac khoi u trung that tren phim thuong quy a. Cac dac tinh chung: Ngoai tri> khi quan, tat ca cac tang trong trung that deu co dam do nude va khong the thay dugc trong hinh md trung that. Chung chi nhin thay dugc khi chung co bong tren nen khi chua trong khi phe quan, trong phoi va doi khi trong thuc quan. Phim nghieng phoi phai hay trai la hinh anh bo sung cua trung that, nhung chi co tren phim thang ngudi ta mdi co the khlng djnh tinh chat trung that cua mot hinh md benh ly. Do la mot hinh md co tinh chat: Dam do nude, dong nhat, ranh gidi ngoai ro va lien tuc, loi ve phia phoi va tiep noi vdi chieu cong cua trung that, ranh gidi trong khong thay do bj che bdi bong md trung that. Hinh md nay dan den su thay doi hinh anh bd ngoai trung that. Cac dau hieu X-quang khac phoi hgp la: - Djch chuyen vj tri cua mot tang trung that co the nhan thay dugc, nhu cua khi quan do mot budu giap chim, nhu cua than phe quan goc do khoi hach Idn lien khi phe quan. Cac cau true ph6i va trung th at tren phim thang (A) va nghieng (B) Hinh 3.16. Hinh cac c iu true phoi va trung that: (A) Phim thing: 1. Khi quan; 2. Phe quan goc phai: 3. Phe quan goc trai; 4. Quai DMC; 5. TM azygos cho dd vao TMCT; 6. DMP phai; 7. DMP trai; 8. DMP thuy tren phai; 9. TMP thuy duxyi phai; 10. NhT phai; 11. That trai; (B): Phim nghieng: 1. Khoang sang sau ire; 2. DMC doan len; 3. Quai dong mach chu; 4. TM canh tay d iu ; 5. Khi quan; 6. Phe quan thuy tren phai; 7. Phe quan thuy tren trai; 8. DM phoi phai; 9. DM phoi trai; 10. Hoi luu tinh mach phoi. Cac hoi chung Ion trong X-quang ngi^c: THI/C HANH X-QUANG NGI/C - Dich chuyen mot hay nhieu van trung that (cac mat phing lien trung that - phoi): trudc, sau, canh cot song, canh dong mach chu. canh khi quan, van canh tTnh mach don - thuc quan (hinh 3.16) va su thay doi nay chi co the thay dugc tren phim co dam do xuyen cua tia Idn. - Cac dau hieu co - nguc cua mot khoi vung trung that - Dau hieu cac mach mau tap trung vao ron phoi. - Dau hieu che phu ron phoi. - Dau hieu “tang bang noi”. - Dau hieu “keo thuc quan”: Mot khoi nlm canh mot ben trung that giua, neu khong day hoac khong keo thuc quan thi no co ban chit la thuc quan. b. Cac can nguyen: Suy luan can nguyen cua mot khoi u trung th it trudc tien suy luan tu vj tri cua no. Ngudi ta phan chia trung th it theo quy udc ra thanh mot so ngan tren X-quang, chu yeu tren phim nghieng, tu trudc ra sau, tu mat sau xuong uc den bd trudc cot song. Hinh 3.17. Cac ngan trung that tren phim X-quang (nghieng) va cac loai u trung that thuxyng gap: 1. Buxyi co tru’dc; 2. U tuyen uc; 3. Bucru co sau; 4. U th in kinh; 5. Ken mang phoi - mang tim. - Ngan trung th it trudc: g6m khoang tu phia sau xuong uc den mat phang di ngang phia trudc khi quan cho phan chia phe quan goc. Khoang trudc lai dugc chia thanh cac khoang nhd hon: trudc - tren, trudc - giu'a va trudc - dudi. - Ngan trung th it giua: tuong ung vdi khoang tu trung th it trudc tdi © THI/C HANH X-QUANG NGI/C: Cac hoi chirng lo>n trong X-quang ngire mat phing di qua mat sau khi phe quan, va cung dupe chia tuong tu thanh 3 khoang nho nhu trung th it trudc. - Ngan trung th it sau: tu khoang trung th it giua tdi gidi han sau la mang sudn - song va cung dugc chia thanh cac khoang nho tuong tu. + Trung th it trudc - tren: Budu giap thong hay budu co - nguc trudc: Md dam, ranh gidi ngoai loi va d ly cac van trung thit, d ly cac van mach mau “mach mau” tren, thudng d ly khi quan va co d lu hieu co - nguc trudc. Cac hinh md nay thudng co dinh tot 1131 + Trung th it trudc - giua: - Cac khoi u va ken tuyen uc, cac hinh, md chieu thing vao ron phoi thudng co khoi lugng Idn. Tren phim thing chung thudng co d lu hieu bit cheo trung th it va dong thdi co d lu hieu che trung th it d phia trudc va bd cua bong md tim. - Hiem gap hon la cac trudng hgp u quai hoac ken dang bieu bi (loan di san phdi). - U nang san bao. - Phinh dong mach chu doan xuong hoac xoang Valsava. Hinh 3.18. U trung th it trudc dudi co ban chat la ken mang tim tren phim thing (A), nghieng (B) va CT (C) + Trung th it trudc - dudi - Hang d lu la ken mang phoi - mang tim (kh6i u lanh tinh, khong loan san va chua dich): Md dam, Idn, trdn, dong nhlt thudng la d phan mom tim trai hoac trong tui cung tam - hoanh ben phai, tiep giap ngay xuong co hoanh va bong md che vien ngoai tim. Tren phim nghieng no nlm trong goc sudn - hoanh trudc (hinh). O Cac hoi chirng Ian trong X-quang ngyc: THI/C HANH X-QUANG NGI/C - Cac can nguyen hiem gap: Cac khoi u lanh dan doc, u md, u xo. Thoat vj mac noi qua khe Larrey hoac thoat vi sau sudn - uc. Bom hoi mang bung gop phan quan trong trong chan doan. No giup xac djnh vj tri trong long nguc hay dudi co hoanh cua cac khoi u don doc d phia trudc hoac ken mang phoi - mang tim ma hinh anh cua chung do chua dich nen co the bj bien dang. Bom hoi mang bung co ich trong chan doan thoat vi vi khi xam Ian vao trong tui thoat vi se tao ra mot hinh anh dien hinh. + Trung that giCra: Thu gon chu yeu trong cac nhom hach trung - Nhom hach canh khi quan phai, trai (1, 2) cho hinh anh co dien la hinh ong khoi canh khi quan. - Nhom ron phoi, lien ph§ quan (3, 4) - Nhom lien - khi phe quan, dudi carina (5) Dang luu y hon ca trong nhom nay la bieu hien hach canh khi quan. Su hien dien cua hach khi quan c ln nghT den ba nhom chan doan: - K phe quan ma trudc het la carcinoma te bao nhd - Hach di can thu phat - Sarcoma mau Hodgkin hay khong Hodgkin. - Hach so nhiem lao hay hach sarcoidosis. Cac can nguyen khac hiem gap hon nhieu gom: - Phinh quai dong mach chu co can-xi hoa hay khong - Ken phe quan, co hinh anh dac biet: Md dam, ddng nhat. ranh gidi ro, nhu bj cot vao rdn phoi tao ra hinh anh “cay vat" hay "qua le”. + Trung that sau: Day la vi tri thong thudng cua u than kinh lanh 0 THI/C HANH X-QUANG NGI/C: Cac hpi chimg lorn trong X-quang ngu’c tinh hoac ac tinh, co the nhin thay tiep xuc voi cot song, nlm trong mang sudn - song: u than kinh, u xo than kinh, u than kinh Schwannome, u hach than kinh, u than kinh giao cam... Cac u than kinh bieu hien dudi dang mot hinh md hoan toan, ranh gidi ro, trdn, kich thudc thay doi tu vai cm den tren 10 cm. Co the thay no co vi tri ben ngoai mang phoi va cOng co the thay co dau hieu an mon cung sau xuong sudn. Trong khoang trung that nay cung co the thay: - U mang nao, dang u hinh “cuc ao so-mi” lam rong lo khe lien dot song. - Phinh dong mach doan xuong cua dong mach chu, lam di chuyen van canh dong mach va tao ra hinh anh “phinh dang con thoi” sau tim. - Budi giap thong sau, chi thay d ben phai. Tren phim thing cho hinh anh md canh khi quan, co d lu hieu co nguc sau. - U thuc quan: ung thu thuc quan, u co tron, dj dang thuc quan doi, thoat vi hoanh... CT nguc da r lt giup ich trong chan doan ve vj tri cung nhu ve c lu true cua u trung thit. 3. Phan tich cac khoi trong trung that tren phim CT nguc Nghien cuu dam do can tia tu nhien cua cac khoi trong trung th it va su thay doi sau khi tiem thuoc can quang cho phep tach ra cac khoi u cua trung th it thanh ba nhom Idn: Cac khoi u md, cac khoi u ch ic (co tudi mau), cac khoi u djch (khong tudi mau) (bang 3.2). Tuy nhien, mot so khoi u chic (teratoma) co ch it chua ben trong hon hgp (djch, md, chit dac). Nhieu khoi u cung co the chua cac not can-xi hoa. Mot so kh6i u dac do tudi mau kem bj hoai tu trung tam cung co the tao muc dich. M6i mot dang cua khoi u trung th it co mot vj tri thudng gap d trung thit va ngudi ta co the dua ra cac du doan ve chin doan dua tren vj tri cua chung. a. Trung th it tru'&c Trung th it trudc - tren thudng thiy: Cac khoi u tuyen giap, lymphoma, u tuyen uc, u quai, adenoma can giap lac cho. Trung th it trudc-giua thudng thiy: u tuyen uc, lymphoma, u quai. Trung th it trudc-dudi thudng thiy: khdi md goc tam hoanh, ken mang phoi-mang tim, thoat vj khe Larrey, cac benh ly hach, co the nhung hiem la u tuyln uc. © Cac hoi chtrng lo>n trong X-quang ngyrc: THi/C HANH X-QUANG NGI/C Bang 3.1. Cac khoi u trung that dang k6n Khoi u dang ken: - Ken mang phoi - mang tim. - Ken nguon goc phe quan - Thi/c quan doi - Thoat vj mang nao tuy Khoi u co the co thanh phSn ken: - U tuyen t>c - Teratoma (U quai) - Lymphoma Bang 3.2. Cac khoi u trung that trudc Tang tren: - U tuyen i>c * - Lymphoma (hach)* - Bifai giap trong long ngu’c * - Adenoma can giap * - U quai - Lymphagioma (hemangioma) Ting giCra: - U tuyen lfc * - Lymphoma (hach)* - Teratoma (U quai) Ting dw&i: - Khoi ma canh tim-co hoanh* - Ken mang phoi - mang tim. - U tuy§n uc - Teratoma (U quai) - Thoat vj qua khe Larrey - Hach (*) Dang hay gap o THI/C HANH X-QUANG NGM'C: Cac hpi chimg Ian trong X-quang ngire Hinh 3.20 . Hinh u ken tuyen ire (eh O’ C). Hinh ma dang trdn, mat do dich dong nhat, co can-xi hoa vung vo. b. Trung that giCra Cac khoi u thong thudng nhat la cac benh ly hach, cac ken co nguon goc phe quan. Cac ken phe quan co the co dam do can tia cao (toi 120 UH) nhung lai khong thay doi sau khi tiem chat can quang. Cac khoi u khi quan, phe quan, thuc quan cung co the d trung that giua giong nhu thuc quan doi. Bang 3.3. Cac khoi u trung that giCra - Ken nguon goc phe quan* - Cac benh ly hach * - U thu’c quan - Thoat vi mang nao tuy phia triro’c - U than kinh (than kinh X, than kinh hoanh) - U khi quan - Ken mang phoi - mang tim - Bifai giap thong sau khi quan (*) Dang hay gap Cac hpi chirng lorn trong X-quang ngi^c: THI/C HANH X-QUANG NGj/C Hinh 3.21. Hinh ken phe quan phoi trai tren phim thing, nghieng va CT. Hinh mcr dang trdn, mat do dich, thuin nhat va khong bieu hien xam lin. c. Cac khoi u ca tren ba tin g trung that sau La cac khoi u than kinh. CT cho phep phat hien do dai ben trong tuy qua lo lien hop cua mot khoi u than kinh. Cac khoi u khac hiem gap nhung co the thay trong u trung that: cac angioma (u mach), lymphangioma, choriocarcinoma, u tinh (seminoma). Bang 3.4. Cac khoi u trung th it sau - U than kinh* - Thoat vi mang nao tuy ben - Lymphangioma - Adenopathy - Tao hong cau ngoai tuy - Kh6i u tuy (*) Dang hay gap o THI/C HANH X-QUANG NGI/C: CSc hpi chi>ng lo>n trong X-quang ngyc i \ Hinh 3.22 . Tao hong cau ngoai tuy / \ (benh nhan thalassemia): hinh md u mat do mo m4m & hai ben tuy song (mui ten) CT cho phep nghien cuu ve tinh chat va muc do xam Ian cua khoi u. Su hien dien cua si/ xam Ian, si/ phat hien ra di can s§ goi y ban chat ac tinh cua khoi u trung that. Tuy nhien, neu khong co nhung dau hieu nay thi cung khong co nghTa la khoi u khong ac tinh. Hinh anh cac hach co the thay ro trong trung that: kich thudc hach binh thudng co the tdi 10mm. CT co the phat hien hach vdi do tin cay cao. Day la co sd de xac djnh tinh chat Ian rong cua ton thuong ac tinh. Cac hach thudng co hinh anh khoi trdn hay thuon dai, it khi dugc tudi mau. Ranh gidi cua chung thudng ro net tru khi vo hach bj pha vd. Hach co do can tia kha dam va dong nhat. Tuy nhien co hinh anh giam sang d trung tam hach co the ggi y hach ung thu, lao hay mot nhiem khuan khac. Trong benh ly hach Hodgkin hay u hach khong Hodgkin thudng thay ton thuong tuyen uc ket hgp co pha huy xuong uc. Hinh 3.23 . Hinh hach trung th it hai ben do sarcoidosis (mui ten) Tren co sd phan tich giai phau benh ly, Bariety va Coury (1958) ghi nhan ve ban c h it u trung th it nhu sau: - U th in kinh: 20 - 25% - U phoi khong dj san: 15 - 20% - U phoi co dj san: 15 - 18% - Hach trung thit: 12 - 15% O Cac hoi chirng lo>n trong X-quang ngi/c: THI/C HANH X-QUANG NGI/C - U tuyen uc: 10% - Budu giap: 8 - 10% - U nang bao san phoi: 0.5 - 1% - Thoat vj mang nao: 0.05% 4. Cac dau hieu qua sang cua trung that Mot hinh anh qua sang tan man hoac khu tru co the bieu hien sg hien huu cua: tran khi trung that, thoat vj khe, bat thudng thuc quan, va hiem gap la ap-xe trung that. a. Tran khi trung that Tren phim thing la cac vet sang thing dung dpc theo trung th it va boc vien tim. Tren phim nghieng cung la nhung vet sang lam md cac thanh phln cua trung th it (tim, khi quan, dong mach chu...). Tran khi trung th it thudng phoi hop vdi tran khi dudi da, doi khi la tran khi mang phoi. Co the gap trong con hen, chin thuong khi quan hoac phe quan, vd bong khi phe thung, benh mang trong cua tre so sinh, sau noi soi hoac cung khong xac djnh dugc nguyen nhan. Trong trudng hgp tran khi mang ngoai tim, do khi tach tim ra khoi co hoanh nen co d lu hien “co hoanh lien net”. b. Thoat vj khe Thudng bieu hien blng hinh anh sang sau tim, d ly van canh thuc quan d phia dudi, hoac dudi dang hinh anh khi - nude. Thong thudng no phoi hgp vdi m lt tui hoi da d ly nlm dudi co hoanh trai. Cac hinh anh sang hoac cac hinh anh nude hoi nay nlm tren co hoanh va d phia sau nhin tren phim nghieng. Khong nen chin doan chung vdi ap-xe phoi hay cac ken trong nhu mo phoi. Hinh anh nay co tinh c h it dac biet la thay doi theo thdi gian tuy theo su an uong. Chup da d ly - thuc quan can quang cho phep chin doan xac djnh de dang. No cho hinh anh ve vj tri cua da d ly trong long nguc, thudng la bj xoln. Co mot sd hilm cac trudng hgp co thoat vj ruot phia trudc qua khe Larrey. c. Cac b it thu'&ng cua thiic quan Thuc quan binh thudng co khoang 30% cac trudng hgp co chua khi nhung khong bi phinh va nlm d vj tri binh thudng. Phinh thuc quan dan d in su djch chuyen van canh thuc quan va thong thudng bieu hien blng mot vet dly, dam, duac bao quanh phan O THI/C HANH X-QUANG NGI/C: Cac hpi chung Ion trong X-quang ngu’c nay hay phan khac blng khi trong nhu mo phoi. Ngudi ta thudng thay co muc nude - hoi. d. Ap-xe trung that Hiem gap. Bieu hien dudi dang hinh u d phia sau tren, doi khi co hinh muc nude nhung kho nhin thay ro. Tren phim thang no khong lam thay doi vi tri cua khi quan, ngugc lai vdi budu giap thong d phia sau. 5. Hinh can-xi hoa trung that Hinh anh thay doi theo v| tri: a. O tim hach - Cac cho can-xi hoa khong deu thanh dam (do lao, hiem khi do u hach bach huyet co dieu tri, do histoplasmose). - Cac can-xi hoa dang hinh cung cua vo trung (silicose, hiem hon co the gap trong sarcoidose va mycose). b. O’ tim mach mau Oo la cac hinh can-xi hoa nhd dang ban khuyen d dong mach chu, thudng la d vung quai (vi tri vua-xo), rat hiem khi d dong mach phoi. c. O tim tim - Viem mang ngoai tim can-xi hoa - Can-xi hoa van tim - Rat hiem: phinh tim can-xi hoa d. O tim cac khdi u trung that - Cac not can-xi hoa cua tuyen giap thong djch chuyen khi nuot. - Cac thanh phan co can-xi cua u quai (teratoma) - Cac can-xi hoa hiem ga+p cua tuyen uc - Cung rat hiem gap can-xi hoa ngoai vi cua mot ken phe quan. VII. HOI CHIJNG MANG PH6l 1. Djnh nghTa Hoi chung mang phoi gom cac trieu chung tren phim nguc cho thay co su co mat cua tran khi hoac tran djch (dich trong, djch mau, djch mu), tu do hay khu tru, nlm trong khoang Idn hay nlm trong ranh lien thuy, hoac co su co mat cua phat trien mot mo ung thu tu trong long cua no. 2. Tran djch mang phoi Luon la hinh md. Hinh anh X-quang tuy thuoc vao muc do, vj tri, tinh chat tu do hay khu tru, tu the cua ngudi benh.