BS.

L HNG THNH

Ming

Mi, m, li, khu ci, rng, hu

Cc tuyn nc bt Thc qun D Dy

Gan
Ty

Rut non
Rut Gi

 Trong l ming chnh Ngoi l tin nh ming

ng gia khu ci

Li g gia

Tuyn khu ci Tuyn hnh nhn (amidan)

Tuyn mang tai

Tuyn di li Nh nht Tuyn di hm

Ln nht

Dy TK mt i qua tuyn mang tai

Rng ca Rang nanh Rng tin ci Rng ci

Rng sa (6-30 thng) Rng ca hm di mc u tin

 2/3 trc l thn 1/3 sau l r Ngn cch nhau bi rnh ch V (gi l rnh tn cng) Mt trn thn li c hng trm nh
Nh Ch Nh nm Nh i (ln nht) Nh l (tng din tch tip xc)

Nh c n v gic (tr nh ch)

Phn mi

Phn ming

L con dng chung ca h hp tiu ha C 3 phn

Phn Thanh Qun

Cu to c 4 lp

stt

Cc Lp
Thanh mc (serosa) C trn (muscularis)
Di nim mc (submucosa) Nim mc (mucosa)

c im
Bao ph bn ngoi, gm phc mc thnh & phc mng tng c dcc vng, d dy c thm c cho
T chc LK x, nhiu MM, TK & mch bch huyt, mt s TB bit ha thnh cc tuyn tit ra dch tiu ha

Lt mt trong ng tiu ha

stt

Cc Lp
Thanh mc (serosa) C trn (muscularis)

Thc Qun

D Dy

Rut Non/Gi

X X

(dc vng cho)

X
(dc vng)

Di nim mc (submucosa) Nim mc (mucosa)

X X

X X

X X

 L ng c sau Kh qun (KQ) i xuyn qua c honh, xung thm 3-4 cm ri ni vi d dy l tm v ngang mc S ngc 10

 Lp c ngoi
1/3 trn l c vn 1/3 gia l c vn & c trn 1/3 di l c trn

Nut l qu trnh chuyn t t ch sang khng t ch

Eo sn nhn

Eo ph ch

Eo honh

= Ch ni vi tm v

 L phn dn to nht ca ng TH Ni gia thc qun & rut non Nm vng thng v, rn & h sn tri

5 phn: Tm v y v Thn v Hang mn v Mn v 2 b cong (ln & nh)

3 lp c, t ngoi vo trong l Dc Vng Cho

C vng bao kn ton th d dy, rt dy mn v to nn c tht mn v

 Gia D dy & rut gi T mn v n l hi manh trng Nm di mc treo KT ngang 3 phn: t trn xung T trng Hng trng Hi trng
Di # 6,5m Rng gim dn t 3 cm 2 cm.

 4 on (D1-4) on di ng: 2/3 trn ca D1(hnh t trng), on c nh: 1/3 di D1, v D2,3,4.

Hnh t trng

 D1: phn trn = tip ni mn v D2: Phn xung = nm trc thn P. D3: Phn ngang = vt ngang ct sng (d b tn thng khi va chm bng) D4: phn ln = bn tri ct sng, cnh MC, kt thc ti gc t hng trng.

Hng Trng
ng knh Thnh MM Ln hn Dy hn Nhiu hn

Hi Trng
Nh Mng t

Np vng cao M bch huyt V tr cc quai Ti tha

Nhiu hn Nang n c Ngang, bn tri bng Ko c

t Mng bch huyt Dc, bn P v di 1-3% c (ti tha Meckel)

Ch U ngc, vy quanh rut non T P sang T gm:

1. Manh trng & rut tha 2. KT ln 3. Gc KT (P) 4. KT ngang 5. Gc KT (T) 6. KT xung 7. KT sigma 8. Trc trng 9. ng hu mn

 Di # rut non (1,4 1,8 m) Rng gim dn (3-7cm)

Ngoi tr Trc trng, rut tha & ng hu mn, cc phn cn li c c im sau RNon:
C 3 di c dc C Ti phnh KT C ti tha mc ni

 Thng nm H chu P Gc ca rut tha dnh pha sau trong manh trng, cch pha di gc hi manh trng 2-3 cm, L ni hi t ca 3 di c dc

Nm gia ng ni
Rn Gai chu trc trn bn P

 C nhiu ct hu mn (np dc nh) Trn HM 2 cm, c van hu mn Trn van l vng TR (m ri TM di NM) khi b mu d phnh ra xut huyt

BS. L HNG THNH

 Dch t hc: l bnh l cp cu ngoi khoa thng gp, 15 30 tui, nam/n = 1,7/1 C ch: tc nghn (ph hch bch huyt, d vt, si phn, u bu,)

 au bng: quanh rn/thng v h chu Phi C th St nh/ nn i/ chn n.

n au h chu P, Mac Burney (+) C th: Phn ng di (+)

n au im Mac Burney

im Macburney (+) trong VRT Nm 1/3 ngoi ng ni GCTT bn P rn

au thng v/ quanh rn lan xung HCP Chn n St nh/ Bch cu mu tng Bng n au khu tr HCP, Macburney (+)

1. Vim phc mc 2. p xe rut tha 3. m qunh rut tha

1. Vim phc mc Sau 24h, au tng, lan rng. St tng (39-400C) Bng chng hi, gng cng c Nu VPM ton th: n au khp bng Nu VPM chu: n au di rn

C ch Vim phc mc

V RT, c t VK thot ra (m,dch, mu) Do PM c mng bn thm, hp thu cht c nhanh shock D lan trn bng do c nhu ng rut

2. p xe RT

3. m qunh RT Sau 24h, bt au Khng st

S bng thy 1 khi chc chc vng HCP

Sau 24h, au tng,

khu tr HCP. St tng (39-400C) Bng xp/ thy 1 khi hi g ln h chu P, n vo rt au.

BS. L HNG THNH

Ming & TQ

D Dy

Rut non

Rut gi

C ng

Nhai & nut

Nghin, y xung 10-20 giy

Co bp & ng m mn v

Lc l, co rt, nhu ng

Tc dng

Nho Trn, y thc n xung 6-8 gi

y cn b xung 15 gi

Thi gian

Nc: 98,5-99%; HCO3- , Cl-, K+ cao gp 7 ln Plasma Cht nhy (Muxin): bi trn, d nut, d ni V sinh rng ming (0,5 ml/pht) Men: Ptyalin (Amylase) thy phn tinh bt thnh ng nhai cm cng lu cng ngon, cng ngt Thc qun ch tit nhy, ko tit nc bt. Tr em: tuyn nc bt ch pht trin t 3-4 thng tr ln

Phn x c K

Tit nc bt

(+) tit nc bt Gp 8 20 ln

(+) ph giao cm tng tit nc bt

Ko nut nc bt mt nhiu Kali lit

 Dn, cha nhiu thc n (1,5 L) Co bp trng lc: nho trn Co bp = sng nhu ng: y xung t trng
Co bp i (Nh, tng dn tng mnh khi h ng huyt) Khi n > 1 gi, hang v co tht C tht mn v m ra, y v trp xung t trng. H tit dch v (thn kinh, hormon gastrin)

Tm mn v : Cht nhy
Thn y v: 3 loi TB - TB chnh: pepsinogen - TB vin: HCl & yu t ni ti - TB c tuyn: nhy

Hang v: Gastrin

 Men pepsin: thy phn protein pH Acid (pH<5) HCl:

Hot ha pepsinogen pepsin To pH acid Pepsin hot ng Dit khun Thy phn cellulose ca thc vt non

Cht nhy: bo v d dy khi HCl & Pepsin, bi trn thc n Yu t ni ti: hp thu vitamin B12 hi trng

Phn x c K

Gi l dch v tm l

Thn kinh X (lang thang)

(+) bi tit gastrin

(+) bi tit HCl, Pepsinogen

TKT, vng di i, h vin Theo dy X n D dy

Phn x khng c K

 Gastrin = hang v & t trng (tit ra)

(+) thn v tit HCl, pepsinogen c ch
Hormone ty thng thn (adrenalin, noradrenalin)

Histamin (+) gastrin tng hot ng

Cortisol (+) tit HCL (-) tit nhy

c ch

D gy lot d dy
Somatostatin (do t bo D ca t trng tit ra)

DCH TY (KIM), cha

men ty gip thy phn thc n

Trypsin: protid Amylase: tinh bt Lipase: m

DCH Mt: tiu m, hp thu vitamin A,D,E,K (tan trong du)

C ch TK
- (+) dy X/ h TK rut gii phng Acetyncholin (+) cc TB nang ty tit men ty - Khng c dch, cc men tm thi nm trong cc nang v ng tuyn - Khi no c dch men ty c da vo t trng

C ch Th dch (Hormone) Gastrin: hang v tit ra Cholecystokinnin(CK): v trp (+) TB nim mc t trng & phn trn hng trng tit ra. theo mu n (+) nang ty tit ra men ty, lng dch cn t

 Secretin:

HCl ca v trp (+) t bo S ca nim mc t trng & phn trn hng trng tit ra
n (+) tyn ty bi tit mt lng dch ln, c nhiu ion HCO3 HCO3- gip trung ha acid, to mi trng trung

tnh bo v t trng, to pH kim thch hp cho men ty hot ng

 Nh Dch rut & dch mt Dch rut tit ra do 2 c ch:

C hc: thc n (+) NM rut Ha hc: dch v (+) dch rut

Men Erepsin: tiu Protein, muxin, keratin Men Lipase: tiu Lipid Men tiu ha Glucid (nhiu loi)

Men tiu ha Glucid (nhiu loi)

Men Amylase Sn phm tiu ha Tinh bt mantase

Saccarose Lactase
Maltase

ng Saccarose Glucose ng Galactose Glucose

ng Mantose Glucose

 Thc n tiu ha xong:

D dy: gi l v trp Rut non: gi l dng trp

 Khng c men tiu ha Tiu ha nt thc n cha kp tiu ha h nhng Enzyme RN i xung

Cc vi khun RG tit ra men thy phn cellulose, gy thi ra protid hi H2S VK tham gia tng hp vitamin B,K (nht l tr em)

 D dy: nc & ru RN: qua NM mu TM ca (gan) TMCD mt s cht ng dng trp h bch huyt TM di n RG: hp thu nc phn c c, cht thuc, mui khong, glucose.

BS. L HNG THNH

 T l mc? Nguyn nhn? Yu t nguy c C ch bnh sinh?

Triu chng? Bin chng? Phng php chn on?

Nu c cc phc iu tr?

 Nam (65%) > n (35%) 30-50 tui hay gp > tr em Lot DD: phn ng b cong nh, hang v, tin mn v Lot TT: hnh t trng

 Nhim Helicobacter Pylori (70%) Thuc khng vim non steroid (NSAID) (25%)

Thuc l, ru, caph, stress tm l, ri lon n ung, gi gic ng

 Tng tit acid Gim yu t bo v NM d dy Kt hp C 2 c ch trn

1. C nng: au thng v
khi i (lot TT), khi no (lot DD)

y bng, hi, chua 2. Thc th n au vng thng v

3. Du hiu cnh bo lot sp/ c bin chng au tng, lin tc au li sau lng Nn i Tiu phn en

Xut huyt tiu ha Thng DD-TT cp cu (phu thut) Hp mn v phu thut Ung th DD

 Ni soi DDTT km sinh thit X-quang DD cn quang

u im Nhm xm ln (da trn ni soi tiu ha)

Nhc im

XN Urease trn mu m sinh thit

Gii phu bnh Nui cy Nhm khng xm ln

Nhanh, r, d lm

1 s loi kit cn thi gian c ti 24g Ty thuc ng c kq pp nhum

Lm khng sinh c

t, tn thi gian, kinh nghim ng lm

XN hi th 13C hoc 14C D lm, nht l tr em Huyt thanh chn on

Tm KN trong phn

14C

mang liu phng x thp nhm D 1 s kit ko chnh xc

D, nhanh

Phi ngng thuc sau: Khng sinh & Bismuth t nht 4 tun c ch bm proton (omeprazole) t nht 2 tun

XN c gi tr khi nh gi hiu qu sau iu tr: test urease (m sinh thit) Test hi th Tm KN trong phn (ngng KS >8tun)

 c ch Acid tht tt Phi hp 2 khng sinh Khng sinh c tnh cht hp ng v nhy cao vi Hp t khng thuc t gy tn thng gan-thn KS chu c Acid

Lot ng Tiu ha U MALT lymphoma Vim teo DD Sau phu thut K DD C ngi thn (trc h) b ung th d dy (K d dy) BN yu cu

1. Nguyn tc:
Thuc: lm gim acid/ tng bo v NM Nu Hp(+), dng phc dit Hp Ngng NSAID, hn ch ru, thuc l

1. Khng acid (nay t dng): 2. Khng th th H2: cimetidin, ranitidin,

3. c ch bm proton (PPI):
Omeprazole (Losec) 20mg Lansoprazole (Prevacid) 30mg Rabeprazole (Aciphex) 20mg Pantoprazole (Pretonix) 40mg Esomeprazole (Nexium) 40mg Ung 2 ln/ngy (TRC N 30 PHT) 4 TUN

4. Thuc tng bo v NM: Bismuth, sucralfate

Clarithromycin Amoxcilin PPI Bismuth Metronidazole Tetracycline PPI Levofloxacin Amoxcilin PPI

500 mg x 2 ln/ngy

1gx2 2 ln/ngy
524 mg x 4 250 mg x 4 500 mg x 4 2 ln/ngy 250mg x 2 1g x 2 2 ln/ngy

La chn ln u
BN d ng vi penicilin (amoxcilin)/ 3 thuc tht bi

Khi 3 thuc u tin tht bi

Rifabutin Amoxicilin PPI

300 mg x 1 1g x 2 2 ln/ngy

Khi 3 thuc u tin tht bi

 Ch nh:
lot khng p ng thuc lot c bin chng

 Vi khun Hp c tr d dy (>50% dn s th gii) Nguyn nhn chnh gy: Lot DD-TT, ung th (K) d dy.

Nm 1982, Warren & Marshall pht hin v nui cy thnh cng

 Xon khun gram m, i kh, c 4-6 chin mao Sng trong cht nhy d dy/ bm trn NM C 2 dng:
Hot ng: xon khun, tit men urease, phn hy ure NH3 Khng hot ng: cu khun

Hp gy vim d dy mn tnh ko di sut i/ vi khun b tiu dit

Mi trng: v sinh km Tr em <10 tui: d b ly t cha m Di truyn: song sinh ng hp t > di hp Ngun ly: nc (ging, ngm, thi), ngi l k ch chnh. ng ly:
Ming ming Phn ming (tiu chy, thuc lm tng pH y) D dy ming (ni soi)

 C # 300 loi H.p Chia lm 3 nhm chnh

Khng c c va (sinh vim, lot) c mnh (sinh ung th): Lymphoma, Adenocarcinoma

 Chin mao (gip VK di ng nhanh): xuyn lng DD (acid) chy nhy (trung tnh) Tit men Urease: phn hy ureNH3, cung cp N cn thit tng hp protein. Cc yu t gip vk bm dnh

 pH <2 : vn tn ti pH 3-4,5 : sao chp gen pH>7: ngng hot ng hon ton iu tr tt nht.

 Nhim Hp

p ng Vim

p ng MD
H.P gy iu ha xung

Hu ht ko biu hin LS 15 % lot DDTT, k biu m tuyn DD, lymphoma

 Hp l nguyn nhn ch yu ca:

Lot t trng (90-95%) Vim DD (60%) Lot DD (60-70%) Ung th DD (80%)

Ngi b nhim Hp tng nguy c 3 ln b cc bnh trn 1 s chng Hp gip bo v NM thc qun chng vim tro ngc DD- TQ

 Ph thuc 3 yu t
Chng Hp Mc cm ca k ch Mi trng: n qu mn, thuc l, thc n bo qun (p mui ng hp) n tri cy & vitamin C gip gim nguy c

 Vim hang v DD lot TT Vim ton b DD lot DD, ung th DD

C ch lot TT: Hp gy gim t bo D hang v DD gim tit somatostain gim c ch tit Gastrin tng Gastrin tng tit acid (TB vin)

 Hp gy thiu mu thiu st

Do Hp gy thiu toan, gim hp thu Fe

Hp bo v TQ khi s vim do tro ngc do thiu toan

A. Xon khun gram m B. Vi i kh C. C 4-6 chin mao D. Sng ch yu trong t bo nim mc DD

A. Dch v B. Nc bt C. Cao rng D. Mu E. phn

A. Thuc l B. n mn C. n thc n ng hp D. Ung ru

 Tng ln nht Mt : Chc, d v khi chn thng (chy nhiu mu) Gan P > gan T TB gan c kh nng ti sinh

 i chiu ngc: gan

cao # gian sn 4 trn ng v P Gan nm trong di honh P, ln sang thng v & di honh T

Gan Cu

1. TMCD 2. Dy chng honh gan 3. DC vnh 4. DC tam gic (P & T) 5. Dy chng lim 6. Mc ni nh 7. DC trn ca gan 8. DC TM Gan vn di ng theo c honh khi th

 2 Bao gan: thanh mc ngoi & lp x trong M gan = TB gan + MM + ng mt Cc TB gan sp xp thnh nhiu b to nn tiu thy gan Gia mi tiu thy c TM trug tm tiu thy Xen gia TB gan l nhng ng dn mt nh & li MM nan hoa

 Tiu thuz gan

n v chc nng gan C 50.000-100.000

khong ca (LK gia cc tiu thy gan):

nhnh of tnh mch ca nhnh of ng mch gan nhng ng dn mt nh

ng gan chung

TB gan (tit mt) Ri gan

ng gan (P, T)
ng ti mt

ng gan chung (4cm)

Tiu qun mt

ng mt ch ng ty
Nh t ln (t trng)

1. To Glycogen (d tr) 2. To ur: bin NH3 (c) ur (d thi) 3. To m (d tr) & tiu m (to NL) 4. Bi tit mt: d tr ti mt 5. Chng c: chuyn ha & o thi

6. D tr Ferritin: mui st (60%) 7. Tham gia c ch ng mu: Gan tng hp cc yu t ng mu II, VII, IX, X (nh vitamin K) 8. D tr vitamin: A (10 thng), D (3-4

thng), B12 (1-vi nm)

 Sau d dy u ty p vo t trng (phn xung)

 3 phn:
u Thn ui Ch c ui ty l di ng

ng ty ph vo nh t b

ng ty chnh, cng OMC vo nh t ln (bng vater)

 ng ty (2 ng) Nang ty: tit dch ty o ty: m TB ri rc gia cc nang ty

 NI TIT:
Tit ra Insulin vn chuyn Glucose t mu vo gan & d tr di dng Glycogen Tit Glucagon phn gii Glycogen Glucose

NGOI TIT:

dch ty

 Mn tnh Bin dng cu trc gan do tn thng Tng sinh & x ha gan, to cc cc nh trong gan

RU Vim gan B/C Bnh ng mt ko di Bnh chuyn ha: Wilson ( ng), thiu men anpha 1chymotrypsin Thuc, c cht: methotrexate, Amodarone Sn l gan,

 Ri lon tiu ho: n km, kh tiu, nn Mt, au tc HSP Khm: gan hi to/ko, lch to, sao mch (+) CN gan: bt/ hi yu

Ri lon tiu ha tng au HSP, St cn, Xm da Vng da mt Sao mch c, ngc Chy mu: chn rng, mi, tr, i tin mu C chn ph, bng bng nh Khm: gan c th teo nh/ to di b sn

1. Hi chng tng p lc TM ca
C trng (Bng bng) Da bng cng bng Tun hon bng h Tiu rt t/ v niu

2. Hi chng suy TB gan

Vng sm da mt Xut huyt tiu ha Hn m gan

Lng bn tay son

Tun hon bng h

L ln
Rm lng Sao mch

Nho c

Bng bng

Dn MM (tun hon bng h)

bn tay son Vng da

Yu sinh l

Xt nghim CN gan XN bilirubin Siu m XN tm nguyn nhn

 X gan khng th phc hi Nga tn thng, gim bin chng Tt nht da vo nguyn nhn

Bnh cnh
Tng AL TM Ca

Thuc la chn
c ch bta (propanolol, nadolol)

Xut huyt do v TM Sandostatin + tht bi TM ni soi TQ Ph (bng bng) Li tiu: spironolacton (Aldacton)/ Furosemid (Lasix) Chc ht dch mng bng (nng)
Lactulose (Cholac, Duphalac), tht tho

Bnh No-gan

Suy gan nng

Ghp gan

 Virus VG C cha c vaccin Chch nga (virus VG B) Trnh tip xc ngi b nhim virus B, C Trnh KST: sn l gan

 L tn thng nhu m gan. VG cp: < 6 thng Nhiu nguyn nhn: hay gp l VG do virus Bnh cnh lm sng, din tin, cch iu tr ty thuc mi nguyn nhn

VG mn x gan K gan

 Xt nghim: tng men gan (AST,ALT)

 a s khng c triu chng r rng

25 %: Vng da, au h sn P
Tnh c XN bit VG

1 - bnh 2 - tin vng da 3- vng da (2-6 tun)

- Vi tun vi thng, ko c triu chng r rt - # 1 tun trc khi vng da - Mt mi, n km, au c khp # cm cm, st nh ko lnh run - i khi c au tc h sn P, tiu vng sm

- Gim/ht st - Vng da tng dn, tiu vng sm, phn c th bc mu, tiu t. - i khi nga da, bun nn, nn, ngn m (ko dung np m) - S gan c th to mp m b sn, trn lng, au tc. - Lch c th hi to
- Gim vng da, tiu nhiu ------ khe hn.

4- Hi phc

C th tip theo sau G cp (>6 thng) Mt mi, n km, d RL tiu ha Xt nghim: men gan vn bt thng Tin trin m thm x gan/ K gan i khi c 1 vi t bng pht # cp (men gan tng cao, vng da sm, au HSP. 1 s nng: bng bng, hn m, RL ng mu t vong

 Tng men gan (AST, ALT): c th gp 1000 ln Tng ALT>AST: VG cp Tng AST>ALT: VG mn tin trin x gan/ VG do ru Tng LDH: VG do thuc Tng GGT: VG do ru, gan nhim m, thuc (acetaminophen, phenyltoin,) Tng ALP: tc mt Tng Bilirubin: vng da

 Chc nng ng mu: c th ri lon ty bnh nng/nh Sinh thit gan: khng lm khi VG cp Siu m: hnh nh tc mt