VIM GAN CP

ThS BS TRN TH KHNH TNG

BM Ni HYK PHM NGC THCH

I TNG : Sinh vin y3

THI GIAN : 2 tit
MC TIU :
Nm vng nh ngha vim gan cp
K c cc nguyn nhn gy vim gan cp
Nu c cc triu chng lm sng ca 3 giai on vim gan cp
K tn 5 loi virus gy vim gan cp v cch truyn bnh
Nm vng cc triu chng cn lm sng ca vim gan virus cp v
huyt thanh chn on vim gan virus.
M t c cc c im lm sng v cn lm sng ca vim gan do
thiu mu cc b.

VIM GAN CP
I CNG :
Vim gan cp (VGC) l tnh trng vim cp tnh ca gan do nhiu
nguyn nhn khc nhau. Nhim trng c bit l virus hng gan A,B,C l
nguyn nhn gy VGC thng gp nht. Cc nguyn nhn khng nhim
trng c th l vim gan do thuc, c t, thiu mu.. a s BN phc hi
hon ton. Mt s nh chuyn sang vim gan mn, x gan v ung th gan
NH NGHA :
Vim gan cp c c trng bi s ph hy t bo gan v s hin
din t bo vim trong m gan ko di di 6 thng.
NGUYN NHN :
Virus vim gan : A,B,C,D,E, G.
Virus khc : CMV, EBV, quai b, Rubella...
Vi trng : nhim trng nng do Leptospira, thng hn...
K sinh trng nh amip.
Thuc : acetaminophen, thuc khng lao, thuc gy m...
Ru v c t .
Vim gan do thiu mu cc b (ischemic hepatitis ): gp trong
chong, suy tun hon hay bnh suy tim phi , chn p tim.
Khng r nguyn nhn

 Virus hng gan v thuc l 2 nguyn nhn thng gp nht.

TRIU CHNG LM SNG
Rt thay i t khng c triu chng n c y triu chng hay
suy gan bng pht.
1. Giai on tin vng da
Mt mi, suy nhc, st nh.
Bun nn, chn n, thay i v gic.
au h sn phi do gan ln.
au c, khp, nhc u, ni ban da...
2. Giai on vng da
Vng mt, vng nim v da.
Nc tiu sm mu.
Phn c th nht mu.
Cc triu chng giai on u c th gim i nh st, mt mi...
3. Giai on phc hi
Vng da gim dn, tiu nhiu, cm gic khe hn, n ngon hn.
i khi cm gic mt, vng da c th ko di vi tun.
TRIU CHNG CN LM SNG
1. Xt nghim sinh ha gan mt
1.1 nh gi tnh trng hoi t
Men gan AST, ALT tng cao thng trn 10 ln gii han trn bnh
thng (upper limit of normal : ULN).
VGC do virus ALT tng cao hn AST, do ru AST thng cao hn
gp 2 ln ALT v thng di 300 U/L.
Vim gan do thiu mu (ischemic hepatitis) : men gan tng rt cao
c th trn 100 ln ULN v tr v bnh thng rt nhanh khi tnh trng thiu
mu c ci thin sau 3-10 ngy, km vi LDH tng cao.
1.2 nh gi tnh trng mt : ALP thng tng di 3 ln bnh
thng.
1.3 Bilirubin : c th tng Bilirubin kiu hn hp hay tng ch yu
bilirubin trc tip.
1.4 nh gi chc nng gan : Prothrobin time, INR ko di nu c suy
gan cp.
2. Siu m bng : Gan to, tng sng, cu trc bnh thng.
3. Xt nghim tm nguyn nhn
VG VIRUS : cc du n huyt thanh.

VIM GAN VIRUS CP

I CNG
Virus hng gan l nguyn nhn thng gp nht a n bnh l
gan ni chung, VGC ni ring. Gm 5 loi virus l A,B,C,D,E.
Biu hin lm sng VGC tng t nhau d do loi virus no.
Nhiu t vim gan cp do virus khng r rng do khng c triu
chng lm sng, khng c triu chng vng da .
a s vim gan virus cp phc hi hon ton. Vim gan cp virus
B,C,D c th dn n vim gan mn, x gan hay ung th gan.
Gy cht 1-2 triu ngi/ nm do cc hu qu ca n nh cc bin
chng ca x gan hay ung th gan.
TC NHN GY BNH V CC KIU TRUYN BNH
1. Tc nhn ly ngoi ng tiu ha :
Virus B (HBV) : 3 kiu
- Tip xc vi mu v cc vt phm ca mu, dch tit nh tinh dch,
dch tit m o, dch mng phi, bng, dch no ty...
- Qua ng tnh dc.
- T m sang con.
Virus C (HCV) : Ch yu ng mu
- ng tnh dc v t m sang con : tn sut v hiu qu thp.
Virus D (HDV) : tng t virus B, ch xy ra trn ngi nhim virus
B.
2. Tc nhn ly qua ng tiu ha:
Virus A (HAV) : ly t ngi sang ngi ( ng phn-ming) do
thc n, nc b nhim.
Virus E (HEV ) : tng t HAV, phn ln qua ngun nc.

Nucleic acid

Cc c im ca virus gy vim gan

HAV
HBV
HCV
HDV

HEV

RNA

RNA

DNA

RNA

RNA*

ng ly truyn Phn-ming Mu
chnh
Tg bnh (ngy) 15-45
40-180

Mu

Tim chch Nc

20-120

30-180

14-60

Gy dch

Khng

Khng

Khng

Mn tnh

Khng

Khng

Ung th gan

Khng

Khng

SINH L BNH
1. p ng min dch qua trung gian t bo :
Phn ln gy tn thng t bo gan lin quan n p ng t bo
CD8+ v CD4+.
Sn sinh cytokines gan v ton thn.
2. nh hng ca virus trc tip ln t bo gan :
Ch yu trn bnh nhn suy gim min dch, c s nhn i virus
mnh.
TRIU CHNG LM SNG
1. Giai on bnh
Virus nhn i v lan truyn nhng khg c triu chng lm sng
2. Giai on tin vng da : triu chng khg c hiu.
Hi chng ging cm: Mt mi, suy nhc, st nh.
Ho, au u, au c.
M ay, au khp c bit do HBV.
Bun nn, chn n, thay i v gic.
au h sn phi do gan ln.
3. Giai on vng da : sau 3-7 ngy
Cc triu chng ton thn gim, bnh nhn khe hn nhng mt, suy
nhc c th vn cn.
Gan vn to, au, s mm trn lng.
Lch to nh (15-20%).
Vng da ngy cng tng.
Nc tiu sm mu, phn c th bc mu.
4. Giai on phc hi
Sau 4-8 tun t khi c triu chng u tin.
Vng da gim dn sau 2-4 tun, n ngon hn.
Mt s c im khc :

 Vng da c th ko di trong giai on hi phc, d tnh trng vim

gim.
Vim gan khng vng da, ch c triu chng ton thn nh cm
thng VG C, VG A tr em.
VG A, E khi pht thng t ngt ; B,C m hn
VG C thng khg c triu chng giai on cp.
VG A thng khg triu chng, phc hi hon ton sau giai on cp
nhng c th ti pht sm.
VG D biu hin nh VG B cp nng(coinfection) hay t cp ca
ngi VG B mn (superinfection) .
CN LM SNG
1. Xt nghim sinh ha gan mt :
Men gan: tng trn10 ln, ALT >AST
Bilirubin tng, ch yu Bilirubin trc tip, hay tng kiu hn hp.
GGT tng (5-10 ln ULN)
ALP tng khng cao thng di 2ln bnh thng.
Chc nng gan : Albumin gim, PT ko di nu c suy gan.
2. Cc xt nghim khc:
C th gim bch cu, gim bch cu a nhn trung tnh.
Tng gama-globuline khng thng xuyn.
3. Du n huyt thanh:
GIAI ON CP
THI K PHC HI
HAV
HEV
HBV

HDV
HCV

Anti HAV (+)

IgM anti HAV (+)
IgM anti HEV (+) v/hoc
HEV RNA phn(+)
IgG anti HEV c th (+)
HBsAg (+) v
IgM anti HBV (+)
HDV Antigen (+) hay
IgM anti HDV (+) hay
HDV RNA (+)/ HBsAg(+)
Hin din sm HCV RNA(+)
Anti HCV ()

Xut hin IgG anti HAV

Bin mt IgM anti HAV
Mt IgM anti HEV
Mt HEV RNA phn
Xut hin IgG anti HEV
Mt HBsAg , sau
Mt IgM anti HBV
Xut hin IgG anti HBV
Sau cng xut hin anti HBs
Mt HDV Antigen, HDV RNA
Xut hin IgG anti HDV
Mt HCV RNA
Anti HCV (+) ko di

CC BNH CNH LM SNG

1. Vim gan cp t gii hn : qua 3 giai on v phc hi hon ton.
2. Suy gan cp :
Thay i tnh trng tm thn, tri gic
Ph no
Ri lon ng mu (Prothrombin ko di).
Suy a c quan: ARDS, hi chng gan thn, ri lon nhp tim, toan
chuyn ha, nhim trng, xut huyt tiu ha, tt HA.
Bng, ph ton thn.
10-20% ph n c thai 3 thng cui nhim VG virus E.
60% t vong
3. Vim gan mt :
Vng da ni bt v ko di vi thng sau giai on phc hi.
Nga nhiu.
Chn n v tiu chy ko di mt s bnh nhn.
Tin lng rt tt sau khi phc hi hon ton.
Thng gp trong VG A
4. Vim gan ti pht :
Triu chng v xt nghim gan tr li bt thng sau giai on phc
hi hon ton vi tun hay vi thng.
Thng gp VG A (IgM anti HAV vn (+), HAV xut hin li trong
phn.
Tin lng tt phc hi hon ton sau ti pht.
Thng gp tr em.
CHN ON XC NH
Giai on tin vng da : bnh cnh lm sng ging nhim virus khc
do kh chn on.
Giai on vng da : nghi ng VG virus cp ( c th da vo yu t
nguy c) lm xt nghim men gan, ALP .
Nu men gan tng trn 10 ln, ALT >AST, ALP tng khng nhiu :
nghi ng VG virus cp huyt thanh chn on.
CHN ON PHN BIT
Vim gan do thuc v c t
Vim gan do thiu mu cc b
Vim gan t min
Vim gan do ru

 Tc ng mt cp.
PHNG NGA
V sinh c nhn tt ngn nga ly truyn virus A, virus E theo ng
phn-ming.
Trnh tip xc vi mu v dch tit nhim virus B,C.
Chng nga : c vaccin chng nga virus A,B.

VIM GAN DO THIU MU CC B

NH NGHA:
Vim gan do thiu mu , cn gi l sc gan (shock liver) hay vim gan do
gim oxy (hypoxic hepatitis) l tnh trang tn thng t bo gan lan to do
gim ti mu cp tnh.
NGUYN NHN:
Do bt k nguyn nhn no lm gim p lc mu:
- Ri lon nhp
- Mt nc
- Mt mu nng
- Suy tim
- Nhim trng
- Huyt khi ng mch gan (ghp gan, tin s c huyt khi tnh mch
ca)
- Ph n mch mu (vim mch mu)
C IM LM SNG:
- Bnh cnh lm sng: tt c nhng nguyn nhn gy sc hoc gy bt
n huyt ng, ngng cung cp mu cho gan t ngt, suy h hp
nng, gim oxy mu h thng, ngng th khi ng.
- Cc triu chng thng gp: bun nn, nn, chn n, mt mi v au
vng gan (1/4 bng trn phi).
- Vng da: him xy ra hoc ch thong qua.
- Thay i tri gic: him, thng do gim ti mu no hn l bnh no
gan.

C IM CN LM SNG:
1. Aminotransferase:
- Tng sm, tng nhanh, nhiu (nh trong vim gan do virus, vim
gan do c t)
- Thng tng 25-250 ln tr s bnh thng (thng > 1000UI/L
hoc > 50 ln). nh tng: 1-3 ngy
- Nu tnh trng huyt ng n nh men gan s gim dn v v bnh
thng trong vng 7-10 ngy.
2. LDH: tng nhiu, nhanh nh tng Aminotransferase
3. Bilirubin:
- Thng bt u tng khi Aminotransferase bt u gim.
- Thng tng < 4 ln tr s bnh thng
4. Alkaline phosphatase:
- Thng tng < 2 ln tr s bnh thng
5. Xt nghim chc nng gan:
- Thng vn bnh thng hoc suy gim nh (Prothrombin time:
nu tng, thng < 3s)
6. Creatinin:
- Tng, nu c hoi t ng thn cp (do gim ti mu )
CHN ON:
Gi chn on da vo bnh cnh lm sng v c im ng hc ca xt
nghim sinh ho gan:
1. Sc hoc huyt ng khng n nh
2. Aminotransferase v LDH tng cao, sm v nhanh.
3. Aminotransferase gim nhanh sau khi iu tr phc hi tun hon.
4. T l AST / LDH <1.5
5. Km tn thng cc c quan khc do gim ti mu c quan: hoi
t ng thn cp
6. Cc xt nghim gip nh gi: test huyt thanh vim gan virus,
t (Acetaminophen), siu m Doppler (nh gi h ng-tnh mch
ca).
BIN CHNG:
Suy gan: him xy ra nhng l bin chng nng e do tnh mng.
IU TR:
- Khng c iu tr c hiu

- X tr ch yu vo nhm mc ch ci thin cung lng tim, phc

hi cc nguyn nhn gy ri lon huyt ng.

TI LIU THAM KHO

1. Mario Rizzetto and Fabien ZoulimViral hepatitis. Text book of
Hepatology, 3th edition, 2007.
2. Raymond S. Koff. Acute viral hepatitis. Handbook of Liver Disease,
2th edition, 2004.
3. Jay H. Hoofnagle. Acute viral hepatitis. Goldman: Cecil Medicine,
23rd ed.
4. Janus P. Ong, MD, MPH. Acute Viral Hepatitis. Practical
Management of Liver Diseases 2008.
5. Kenneth E. Sherman. Viral Hepatitis. G/I Liver Secrets,
3th edition
6. Jules L. Dienstag. Acute hepatitis. Harrisons
Gastroenterology and Hepatology 2010.
7. Florence Wong and Laurence M Bends. The liver in
heart failure. Handbook of Liver Disease, 2th edition, 2004.