B Y T

HNG DN

CHN ON V IU TR
BNH NI TIT - CHUYN HA
(Ban hnh km theo Quyt nh s 3879/Q-BYT ngy 30 thng 09 nm 2014
ca B trng B Y t)

NH XUT BN Y HC
H NI - 2015

B Y T

CNG HA X HI CH NGHA VIT NAM

S: 3879 /Q-BYT

c lp - T do - Hnh phc
H Ni, ngy 30 thng 09 nm 2014

QUYT NH
V vic ban hnh ti liu chuyn mn
Hng dn chn on v iu tr bnh ni tit - chuyn ha
B TRNG B Y T
- Cn c Lut khm bnh, cha bnh nm 2009;
- Cn c Ngh nh s 63/2012/N-CP ngy 31/8/2012 ca Chnh Ph quy nh
chc nng, nhim v, quyn hn v c cu t chc ca B Y t;
- Theo ngh ca Cc trng Cc Qun l Khm, cha bnh,
QUYT NH:
iu 1. Ban hnh km theo Quyt nh ny ti liu chuyn mn Hng dn chn
on v iu tr bnh ni tit - chuyn ha.
iu 2. Ti liu Hng dn chn on v iu tr bnh ni tit - chuyn ha ban
hnh km theo Quyt nh ny c p dng ti cc c s khm bnh, cha bnh.
Cn c vo ti liu hng dn ny v iu kin c th ca n v, Gim c c s
khm bnh, cha bnh xy dng v ban hnh ti liu Hng dn chn on v iu tr
bnh ni tit - chuyn ha ph hp thc hin ti n v.
iu 3. Quyt nh ny c hiu lc k t ngy k ban hnh.
iu 4. Cc ng, b: Chnh Vn phng B, Chnh Thanh tra B, Cc trng Cc
Qun l Khm, cha bnh, Cc trng v V trng cc Cc, V thuc B Y t, Gim
c cc bnh vin, vin c ging bnh trc thuc B Y t, Gim c S Y t cc tnh,
thnh ph trc thuc trung ng, Th trng Y t cc B, Ngnh v Th trng cc
n v c lin quan chu trch nhim thi hnh Quyt nh ny./.
Ni nhn:
- Nh iu 4;
- B trng B Y t ( b/c);
- Cc Th trng BYT;
- Bo him X hi Vit Nam ( phi hp);
- Cng thng tin in t BYT;
- Website Cc KCB;
- Lu VT, KCB.

KT. B TRNG
TH TRNG
k
Nguyn Th Xuyn

LI NI U
Trong thi gian qua, di s lnh o ca ng, Nh nc v s quan tm, lnh
o, ch o tch cc ca Lnh o B Y t cng vi s quan tm chm sc ca cc cp
chnh quyn, vi s n lc vn ln trn mi gian kh ca cc gio s, bc s, dc s
v ton th cn b, cng chc, vin chc trong ton ngnh, ngnh Y t Vit Nam
ginh c nhiu thnh tu to ln trong cng tc phng bnh, khm cha bnh v chm
sc sc khe nhn dn.
Cng vi mng li y t c s c cng c v tng bc hon thin, h thng
khm, cha bnh trong ton quc cng c ci to v nng cp tt c cc tuyn t
trung ng n a phng. Nhiu k thut y hc hin i ln u tin trin khai thnh
cng Vit Nam nh chp v nong ng mch vnh tim, th tinh trong ng nghim,
ghp thn, gp phn nng cao cht lng khm, cha bnh cho nhn dn v thc
y nn y hc Vit Nam pht trin.
Cht lng khm, cha bnh cn ph thuc nhiu vo nng lc chn on v iu
tr ca cc tuyn y t cng nh ca cc thy thuc. V vy ngy 05 thng 02 nm 2010,
B trng B Y t ra quyt nh s 453/Q-BYT v vic thnh lp Ban Ch o bin
son Hng dn iu tr, quyt nh s 2387/Q-BYT 05 thng 5 nm 2010 v vic
thnh lp Ban bin son Hng dn iu tr.
Trong , Tiu ban bin son hng dn chn on v iu tr bnh Ni tit c
quyt nh thnh lp ngy 27 thng 7 nm 2010 (quyt nh s 2679/Q-BYT) bao gm
cc nh khoa hc u ngnh trong lnh vc Ni tit v chuyn ha ca c ba min Bc,
Trung, Nam.
Ti liu Hng dn chn on v iu tr bnh Ni tit - chuyn ha c xy
dng vi s n lc cao ca cc nh khoa hc u ngnh v Ni tit - chuyn ha ca Vit
Nam. Ti liu bao gm 5 chng v 36 bi hng dn mt s bnh v Ni tit - chuyn
ha. Trong , tp trung vo hng dn thc hnh chn on v iu tr, v vy ti liu s
rt hu ch cho cc thy thuc a khoa, chuyn khoa trong thc hnh lm sng hng ngy.
Chng ti trn trng cm n s ch o st sao ca PGS.TS. Nguyn Th Kim
Tin, B trng B Y t v cc thnh vin ban bin son, cc chuyn gia thm nh
rt c gng, dnh nhiu thi gian qu bu bin son, thm nh cun sch ny. y l
ln xut bn u tin ca cun sch, chc chn cn nhiu thiu st, chng ti rt mong
nhn c s ng gp t Qu c gi v ng nghip cun sch ngy mt hon thin.

Trng ban bin son

GS. TS. Thi Hng Quang

Ch bin
PGS.TS. Nguyn Th Xuyn
ng ch bin
PGS.TS. Lng Ngc Khu
GS.TS. Thi Hng Quang
Ban bin son v thm nh ti liu
GS.TS. Thi Hng Quang
GS.TS. Nguyn Hi Thy
GS.TS. Trn Hu Dng
PGS.TS. T Vn Bnh
PGS.TS. o Th Da
PGS.TS. Nguyn Th Bch o
PGS.TS. Nguyn Th Hon
PGS.TS Nguyn Thy Khu
PGS.TS. Nguyn Th Lm
PGS.TS. Nguyn Kim Lng
PGS.TS. Trung Qun
PGS.TS. Nguyn Khoa Diu Vn
PGS.TS. Hong Trung Vinh
TS.BSCKII. Trn Th Thanh Ha
TS.BS. Nguyn Vinh Quang
TS.BS. Trn Qu Tng
TS.BS. Hong Kim c
Ban Th k bin son
ThS.BS. Phm Th Lan
ThS.BS. L Quang Ton
ThS.BS. Nguyn c Tin
ThS.DS. Ng Th Bch H
ThS.BS. Trng L Vn Ngc

MC LC
Trang
Li ni u

Chng 1. BNH TUYN YN V VNG DI I

U tuyn yn

Bnh to u chi

16

Suy tuyn yn

22

Bnh i tho nht

34

Hi chng tit ADH khng thch hp

42

Chng 2. BNH TUYN GIP

51

Cng chc nng tuyn gip

51

Chn on v iu tr cn nhim c hormon gip cp

71

Suy tuyn gip bm sinh tin pht

81

Suy gip ngi ln

87

Hn m do suy chc nng tuyn gip

96

Bu gip n thun

101

U tuyn c ca tuyn gip

105

Bu gip c a nhn

110

Vim tuyn gip Hashimoto

115

Vim tuyn gip bn cp

121

Vim tuyn gip m

124

Ung th tuyn gip

127

Chng 3. BNH TUYN THNG THN

143

Suy thng thn cp

143

Suy thng thn mn tnh

147

Hi chng Cushing

154

Suy thng thn do dng Corticoids

161

Cng Aldosteron tin pht

165

Cng chc nng ty thng thn

168

Chng 4. BNH I THO NG

174

Bnh i tho ng

174

Ph lc 1. Cc thuc iu tr T

183

Ph lc 2. Tiu chun chn on tha cn bo ph

da vo s o BMI v vng eo p dng cho ngi Chu - TBD

187

Ph lc 3. Lin quan gia glucose huyt tng trung bnh v HbA1c

187

Nhim toan ceton - hn m nhim toan ceton do i tho ng

188

Hn m tng p lc thm thu do i tho ng

197

H glucose mu

202

Bnh tim mch v i tho ng

208

Bnh mch vnh

208

Tng huyt p ngi bnh i tho ng

212

Suy tim

214

t qu

216

Bnh mch mu ngoi vi

219

Bnh l bn chn do i tho ng

222

Bnh i tho ng v thai k

228

i tho ng thai k

234

Bnh l cu thn trong bnh i tho ng

237

Chng 5. BNH BO PH

247

Bnh bo ph

247

Ri lon chuyn ha lipid mu

255

Tng calci mu

265

H calci mu

272

Chng 1. BNH TUYN YN V VNG DI I

U TUYN YN (PITUITARY ADENOMA)
I. I CNG
U tuyn yn chim khong 10% cc khi u trong no, khi u c th lnh hoc c
tnh, tit hoc khng tit hormon. Tu theo kch thc khi u m phn loi u nh
(ng knh < 10mm), hoc u ln ( 10mm). Khi u tin pht thng gp nht l u
tuyn tuyn yn (pituitary adenoma), thng lnh tnh, pht sinh t t bo thu trc
tuyn yn, c th chia ra nh sau:
U tit hormon tng trng GH, lm sng biu hin bng hai bnh: to u chi
(acromegaly) v bnh khng l (gigantism), chim t l khong 15% cc khi u tuyn yn.
U tit prolactin chim khong 25% khi u tuyn yn c triu chng.
U tit TSH, chim khong 1% cc khi u tuyn yn, c th c hoc khng c
triu chng cng gip.
U tit ACTH, chim khong 15% cc khi u tuyn yn, lm sng l Bnh
Cushing hoc Hi chng Nelson (sau ct c hai bn tuyn thng thn).
U tit hormon sinh dc, chim khong 10% cc khi u tuyn yn, lm tng tit
FSH, v t gp hn l LH.
U tit nhiu hormon, chim khong 15% cc khi u tuyn yn, ngoi tng GH
v prolactin, thng phi hp vi bnh acromegaly v cng gip.
U t bo khng tit hormon, chim khong 20% cc khi u tuyn yn, khng
c du n v t chc hc, min dch, hoc trn knh hin vi in t v tit hormon.
II. NGUYN NHN
Cc khi u tuyn yn pht sinh l do:
Tng sinh mt dng t bo tuyn yn.
t bin cc gen gy ung th hoc cc gen km hm sinh u, hu ht l c tnh,
nhng t gp.
Mt s t bin khc lin quan vi u tuyn tuyn yn (pituitary adenomas) nh
hot ha t bin gen, gp 40% cc u tuyn tit GH, t bin im gen tiu n v alpha
ca protein G lm tng AMP vng, do vy tng tit GH v tng sinh t bo, t bin gen
H-ras xc nh c trong cc ung th tuyn yn do di cn. Gen bin i khi u
tuyn yn gp rt nhiu trong hu ht cc typ khi u tuyn yn, c bit u tit prolactin.
Ngoi ra, cc t bin t thn, cc yu t ca vng di i c th kch thch
v duy tr s pht trin cc t bo u tuyn b bin i. ang c nhng kin v h

thng cc yu t pht trin nguyn bo si, ri lon iu ha cc protein kim sot chu
chuyn t bo, v mt mng li reticulin c vai tr quan trng trong hnh thnh khi u
tuyn yn.
III. CHN ON
1. Lm sng
Gm nhng triu chng do khi u tit qu nhiu hormon, hoc triu chng do
khi u chn p. Hu ht u tuyn yn l khi u lnh tnh, nhng cng c th xm ln ti
ch vo t chc xung quanh, c hoc khng tit hormon, tin lng tng i tt.
Ngc li, cc khi u cnh h yn thng c tnh, xm ln, tin lng xu hn.
1.1. Khi u tit hormon
Triu chng do khi u chn p t chc xung quanh:
au u: thng gp, khng tng ng vi kch thc khi u.
Chn p v pha trn v chn ln giao thoa th gic, c th gy bn manh thi
dng hai bn, m mu , c nhiu im ti, m hon ton.
Xm ln sang bn c th chm n xoang bm lm tn thng cc dy thn
kinh s no III, IV, VI, V1 gy song th, sp mi, lit c mt, v mt s thn kinh mt.
Cn ng kinh, ri lon bn th, mt khu gic c th c nu cc thu no thi
dng v trn b xm ln do pht trin ca khi cnh h yn.
Nn ti pht c hoc khng c tn thng ng ngoi thp hoc ng thp.
Sinh dc-ni tit: c th dy th sm tr nh, suy sinh dc ngi ln.
Ngoi ra c th b i tho nht hon ton hoc khng hon ton, c bit v
ri lon c ch kht, hi chng tit khng thch hp ADH, ri lon gic ng, ri lon
nhit , ri lon s ngon ming (bo ph, n nhiu, hoc chn n, mt cm gic kht
hoc cung ung u c th gp trn lm sng).
Triu chng do tng tit hormon:
U tit prolactin (prolactinomas): tng nng prolactin mu lm mt kinh
nguyt v chy sa ph n, gim libido v ri lon cng nam gii. Khi u kch
thc ln c triu chng do chn p thn kinh th gic, thn kinh s no v suy chc
nng thy trc tuyn yn.
U tit hormone tng trng: Ty thi gian xut hin bnh trc hay sau tui
trng thnh m sinh bnh to u chi (acromegaly) hay bnh khng l (gigantism)
(xem bi tng ng).
U tit ACTH: xem Bnh Cushing.
U tit TSH: biu hin cng chc nng tuyn gip (hi hp, nh trng ngc,
ri lon nhp, st cn, run tay..) v bu c to. Khi u thng ln, trn 60% c xm ln
ti ch gy cc triu chng chn p v th gic, thn kinh s no.

10

 U tuyn yn tit gonadotropin: thng c kch thc ln. Ngi bnh thng
c ri lon v nhn, cc triu chng suy chc nng tuyn yn, nhc u. Mt s khi u
tng tit FSH, LH hoc tiu n v alpha, ngi bnh c triu chng suy sinh dc do
gim iu ha chc nng tuyn sinh dc.
Suy chc nng tuyn yn (hypopituitarism): xem bi Suy tuyn yn.
Suy tuyn yn bm sinh hay bnh xut hin lc nh s gy nhng ri lon nng v
tuyn gip, sinh dc, thng thn, s pht trin v cn bng nc.
Gim tit ACTH gy h huyt p, sc, h ng huyt, bun nn, mt l, h Na+
mu. Cn nh lng cortisol v ACTH trc khi ch nh glucocorticoid. Cn lm
nghim php kch thch bng Cosyntropin mt vi tun sau khi xut hin triu chng
gim nng ACTH mu (xem thm bi Suy thng thn).
Ngi bnh thng c triu chng suy gip trn lm sng; tuy nhin, ngay c khi
khng c triu chng, cn nh lng FT4 nh gi tnh trng bnh.
Ri lon chc nng sinh dc: ph n thng c ri lon kinh nguyt hoc mt
kinh, nng LH hoc FSH khng tng; nam gii c triu chng ri lon sinh dc v
gim testosterone. iu tr thay th hormon sinh dc rt quan trng phng long
xng. Thiu GH thng xy ra khi thiu 2 hormon.
1.2. Mt s u tuyn yn khng tit hormon
Nang h yn/ nang cnh h yn (Sella/parasella cysts):
Thng gp nht l cc u s hu (craniopharyngiomas), l nhng nang b vi
ha, cc khi u trn h yn pht sinh t nhng phn st li ca t bo c vy trong bo
thai ca khe Rathke (Rathkes cleft).
Thng xut hin vo hai nh tui: tr em t 5-10 tui, v cui tui trung nin.
Thng gp n, hu ht cc nang l nhng khi trong hoc trn h yn b vi ha.
Tr thng ku nhc u, nn, hp th trng v khng pht trin.
Ngi ln c th c bn manh hai thi dng (bitemporal hemianopsia), cc
triu chng bt thng thn kinh s no (thn kinh III, IV, VI v V1), gim tit cc
hormon thy trc tuyn yn v bnh i tho nht.
Cc nang khe Rathke (Rathkes cleft cyts) thng lnh tnh, tn thng khng
b vi ha, ging u tuyn ni tit khng hot ng hoc u s hu. Cc nang ny c t l
ti pht thp sau phu thut ct b.
U nguyn sng (Chordomas):
L nhng khi u t gp, pht sinh t phn cn li ca nguyn sng
(notochordal remnant) trong mt dc (clivus). Cc u ny thng gy ph hy xng
cng vi vim ti ch, hay ti pht.
Nam gii thng gp hn, tui t 30-50.
Hay gp triu chng bnh l thn kinh s no v song th. Ri lon chc nng
ni tit khng thng xuyn, khi u b vi ha ch gp 50% trng hp.

11

 U t bo mm (Germinomas):
Pht sinh trong tuyn yn/trn tuyn yn, bao gm vng di i, giao thoa
thn kinh th gic v vng tuyn tng.
Ngi bnh c triu chng suy hoc cng chc nng tuyn yn; dy th sm,
i tho nht, ri lon th trng v cc triu chng tng p lc s no.
Khi u di cn vo h thng thn kinh trung ng khong 10% trng hp.
U dng b (Dermoid tumors):
Khi u t pht trin tr em, gy vim mng no ti pht do s thot ra cc thnh
phn ca khi u.
Di cn n tuyn yn:
Cc di cn ung th n tuyn yn thng gp nht ngi gi, thng pht
sinh t ung th v ph n v ung th phi.
Ung th tin pht cc v tr khc di cn n tuyn yn nh ung th ng tiu ha,
thn, tuyn tin lit v da.
Triu chng thng gp: Ri lon chc nng thy trc tuyn yn, ri lon th
trng, i tho nht, lit cc dy thn kinh s no. Khi u to ln nhanh cng chng t
khi u do di cn.
Phnh mch (aneurysms):
Cc phnh mch c th pht sinh t xoang hang, hoc t cc ng mch cnh
trong trn hoc di chm, mch phnh c th t vo thn kinh mt v giao th gy
hp th trng thi dng, lit nhn cu, au u nhiu, au trn mt. Phnh mch c
th pht trin vo trong h yn chn p trc tip vo tuyn yn lm suy chc nng tuyn
yn v tng tit prolactin. U phnh mch c th xc nh bng MRI hoc chp mch
bng cng hng t - MRA (MR angiography) rt cn thit quyt nh sinh thit qua
xng bm.
Cc u ht tuyn yn:
Vim mng no do lao c th xy ra ngay ti h yn hoc cnh h yn. Cc u
lao c th c trong h yn hoc trn h yn, kt hp vi cc triu chng suy chc nng
tuyn yn, ri lon th trng v i tho nht.
Bnh sacoid (Sarcoidosis) vng di i - tuyn yn, hu ht ngi bnh c
nhng triu chng ca h thn kinh trung ng v c th l nguyn nhn lm suy chc
nng thy trc tuyn yn c hoc khng c triu chng khi u trong h yn.
Sarcoidosis rt hay gp vng di i, thy sau tuyn yn v thn kinh s no. Ri
lon ni tit thng gp nht l suy chc nng sinh dc do thiu tit hormon sinh dc
(gonadotropic hypogonadism), tng tit prolactin va phi, v i tho nht.
U ht t bo khng l (Giant cell granuloma - Granulomatous hypophysitis) l
u ht t bo khng l khng b u ha, him gp, chim ch mt phn hoc ton b
tuyn yn v khng c tn thng cc c quan khc, thng gp nht ph n tui
trung nin v ln tui.

12

Nguyn nhn cha r, triu chng lm sng thng gp l suy chc nng thy
trc tuyn yn v tng prolactin mu.
Histiocytosis X (HX): C th l bnh u ht t bo i toan mt hoc nhiu
hoc th c tnh hn - bnh Letterer- Siwe. HX thng gp trong vng di i, mt na
ngi bnh c i tho nht. Tr em c th chm pht trin, suy gim hormon thy trc
tuyn yn. Bnh HX gm c ba triu chng: i tho nht, li mt v tiu hy xng.
Vim tuyn yn t bo lympho (lymphocytic hypophysitis), gp ch yu n,
60-70% xy ra vo giai on cui thai k hoc sau . Cc bnh t min khc (vim
tuyn gip t min) gp khong 20-25%, khi u trong/ trn tuyn yn c th to, suy
chc nng thy trc tuyn yn, i tho nht, v/hoc ri lon th trng (50-70%).
S phc hi chc nng tuyn yn c th t pht hoc bng corticosteroid v iu
tr thay th cc hormon khc. Chn on bng t chc hc, hoc khi phu thut khi u.
Phu thut cn thit nu c cc triu chng v ri lon th trng hoc triu chng chn
p ngy cng tng.
p xe tuyn yn: Him gp, xy ra do nhim khun, thm nhim trc tip cc
c quan ph cn trong xoang bm, v nhim khun h thn kinh trung ng khc.
Ngi bnh c triu chng ri lon v th gic, suy chc nng tuyn yn, i tho nht
(50%). Chp MRI pht hin.
Chy mu v nhi mu trong tuyn yn: Chy mu v nhi mu trong tuyn
yn l do tn thng do thiu mu h thng ca tuyn yn, trn lm sng suy chc nng
tuyn yn khi 75% tuyn b tn thng. Tn thng ch gii hn n thy trc,
chc nng thy sau cn nguyn vn. Hi chng Sheehan xy ra sau chy mu nng sau
, hi chng t gp.
Ung th tuyn yn (Pituitary carcinomas): Him gp, c th tit cc hormon
nh GH, ACTH hoc prolactin, hoc cng c th khi u khng c hot ng chc nng.
Chn on ch xc nh c khi c di cn.
Tng sn tuyn yn (Pituitary hyperplasia): To tuyn yn ton b, tng sn t
bo tit TSH do suy tuyn gip tin pht ko di; Tng sn t bo tit hormon sinh dc
khi suy sinh dc tin pht ko di. Tng sn t bo tit sa trong thi k c thai.
U lympho h thng thn kinh trung ng tin pht (Primary central nevous
system lymphoma), tn thng c th khu tr tuyn yn, vng di i gy nn
nhng triu chng thn kinh, i khi kt hp vi suy gim hormon tuyn yn thy trc
v / hoc thy sau.
t qu (ngp mu) tuyn yn (Pituitary apoplexy):
L mt cp cu ni tit, do chy mu t pht trong khi u tuyn yn hoc sau
chn thng u.
Bnh tin trin sau 1-2 ngy vi triu chng au u d di, cng gy, tn thng
thn kinh s no ngy cng nng, try tim mch, thay i thc, ri lon th trng.
Suy chc nng tuyn thng thn cp hay gp.

13

 Chp tuyn yn pht hin chy mu trong khi u v lch cung tuyn yn.
Phn ln ngi bnh phc hi mt cch t pht, nhng kinh nghim cho thy
v sau s suy chc nng tuyn yn. Lit c mt (ophthalmoplegia) c th ht i mt
cch t pht, nhng khi c du hiu gim th trng, nhng bin i v thc, cn ch
nh phu thut qua xng bm gii phng chn p.
2. Cn lm sng
2.1. Cc xt nghim sng lc u tuyn yn
Ty thuc vo triu chng lm sng m ch nh nh lng cc hormon tng
ng xc nh chn on v theo di kt qu iu tr (xem thm cc bi tng ng).
2.2. Nghin cu hnh nh
Khi u tuyn yn c chn on tt nht bng MRI hoc chp ct lp vi tnh tp
trung vo tuyn yn.
IV. IU TR V THEO DI
1. Cc khi u tuyn yn khng tit hormon
Chp cng hng t ht nhn (MRI) chn on v theo di. MRI c th hai
nm lm li mt ln, nu nh khng c du hiu pht trin ca tn thng.
Phu thut ch nh khi khi u ln c xu hng ngy cng pht trin.
Nu tn thng khng c triu chng, MRI cn lm li sau 6 thng n 1 nm,
sau hng nm. Phu thut c th tr hon, tr khi c du hiu khi u pht trin.
Nu c triu chng chn p vo giao thoa th gic, xm ln vo xoang hang,
hoc suy chc nng tuyn yn, phu thut s c tin hnh v cn nhc iu tr bng
tia x (c bit dao gamma, iu tr bng chiu tia t ngoi). 10% cc khi u p ng
vi bromocriptine gim kch thc khi u.
2. Cc khi u tuyn yn tit hormon
2.1. Cc khi u tit prolactin
iu tr bng thuc i khng th th dopamin.
2.2. U tit GH Acromegaly
Phu thut qua xng bm l phng php c chn, 70% ngi bnh c nng
GH t < 5ng/mL v nng IGF bnh thng, nhng ti pht 5-10%. Sau khi iu
tr bng tia x truyn thng, 40% ngi bnh t c nng GH < 5ng/mL sau 5
nm, v 60-70% sau 10 nm .
2.3. Bnh Cushing
Phu thut qua xng bm p dng cho 80-90% ngi bnh. T l ti pht 510%, trc di i - tuyn yn - thng thn c th b c ch ti 1 nm. iu tr bng

14

tia c ch nh cho cc ngi bnh khng iu tr bng phu thut, nhng ngi bnh
ct b thng thn hai bn hoc b hi chng Nelson. 61% ngi bnh gim bnh c
12 thng, 70% c 24 thng.
2.4. U tit TSH
Phu thut qua xng bm, nhng t hiu qu. Hu ht ngi bnh p ng tt
vi octreotide acetate (sandostatin) lm nh khi u. iu tr bng tia ty thuc khi
khng phu thut c. iu tr bng cc thuc cng gip nh iu tr cc trng hp
cng gip khc.
TI LIU THAM KHO
1. Thi Hng Quang (2008). Bnh Ni tit. Nh xut bn Y hc.
2. Mai Th Trch, Nguyn Thy Khu (2003). Ni tit hc i cng. Nh Xut
bn Y hc - Chi nhnh Thnh ph H Ch Minh.
3. The Washington Manual (subspecialty consult series) (2009). Endocrinology
subspecialty consult. Second Edition.
4. The Washington Manual of Medical Therapeutics. 33rd Edition (2010).
5. David G. Gardner. Dolores Shoback. Greenspans Basic and clinical Endocrinology,
9th Edition. 2011.

15

BNH TO U CHI (ACROMEGALY)

I. I CNG
Acromegaly l bnh c c im tit qu mc hormon tng trng (GH), thng
do u tuyn yn.
Khi khi u pht sinh trc tui dy th c th gy nn suy sinh dc cng vi
chm kt thc pht trin mng xng gy nn bnh khng l (gigantism).
Acromegaly khi xy ra sau dy th triu chng m thm, ko di, thi gian t
khi pht bnh cho ti khi c chn on c th ti 10 nm.
T l bnh mi mc thp, 3 trng hp/ 1 triu ngi/ nm. Hin nay, s lm
dng GH cc vn ng vin v nhng ngi mun c ngun sinh lc di do tui
tr, lm tng t l mi mc bnh acromegaly do thuc.
To u chi l mt bnh hay gp trong cc bnh ca tuyn yn, nhng trong lm
sng ni khoa ni chung l mt bnh t gp, t l 1/5000 - 1/15000 ngi bnh. Nam v
n gii c t l mc bnh nh nhau. Tui thng gp t 30 n 40 tui, t ngi bnh
c theo di bnh t tui dy th.
II. NGUYN NHN
Acromegaly thng lnh tnh, khi u n dng do cc t bo somatotroph ca
thy trc tuyn yn tng tit hormon tng trng (GH), nhng t bo bnh thng
c kch thch bi hormon gii phng GH t vng di i v yu t tng trng
ging insulin-1 (IGF-1) t t chc ngoi vi. Hu ht tc dng ca GH trung gian qua
IGF-1 mt yu t pht trin v bit ha c sn xut t gan. GH v IGF-1, lm pht
trin xng v sn, lm ri lon dung np glucose, bin i chuyn ha m v protein.
Triu chng lm sng l do tit qu mc GH v sau tng tng hp IGF-1.
Chn on phn bit vi nhng nguyn nhn khc gy tng tit GH nh s dng
GH t ngoi, khi u tit GH ngoi tuyn yn rt t gp. Nhng khi u gia nh ca tuyn
yn bao gm ung th tit nhiu hormon (multiple endocrine neoplasia), hi chng
McCune-Albright, hi chng Carney.
III. CHN ON
1. Lm sng
1.1. Triu chng ch quan ca ngi bnh
Nhc u: l triu chng hay gp nht (87%), c th ch nhc u thong qua
nhng cng c trng hp au u thng xuyn, d di kch lit, thng au nhiu
vng trn, vng thi dng.
au u c th do u chn p vo honh yn, hay do pht trin qu mc cc xoang
mt, xoang trn; nu b vim xoang km theo, ngi bnh cng au u nhiu.
16

 C trng hp bnh m u bng triu chng d cm, au but tay, chn.

au trong cc khp xng, nht l vng ct sng tht lng. T bn thn ngi
bnh cng thy cc xng to ra, nht l bn tay, bn chn, tng c s giy hng nm.
Ri lon kinh nguyt l triu chng hay gp ph n.
Mt mi, ri lon th gic nh s nh sng, song th, mt khu gic, tai,
chng mt.
1.2. Khm thc th
Nhng thay i b mt ca ngi bnh to u chi l triu chng u tin lm
ngi ngoi ch :
Xng s pht trin khng u, xng hm di pht trin mnh lm cho cm d
v pha trc (prognathism), gc gia ngnh ng v ngnh ngang ca xng hm di
rng ra, hai hm rng khng khp c vo nhau, hm rng di a ra pha trc,
xng mi, xng g m v cung di lng my pht trin, do vy h mt su, rt t
ngi bnh to u chi c li mt. Tai, li u to. T chc phn mm pht trin song
song vi s pht trin ca xng mt lm cho ngi bnh to u chi c b mt c bit
v thng ging nhau.
Da, lp m di da: Da dy, nhiu np nhn, c bit trn mt. C th c sm
da, da m, nhn v tng tit cc tuyn m hi v tuyn b. L chn lng rng.
Tc cng. ph n c khi c triu chng mc nhiu lng (hypertrichosis),
lng mc nhiu mt, cm, trn mi, trn mu v, cng tay, cng chn; mc nhiu lng
c th do tng tit androgen ca thng thn, hoc do tc dng trc tip ca GH trn
cc cu lng.
H c xng:
C: trong giai on u c hin tng ph i, tng trng lc c, v sau, cng
ngy c cng yu dn do teo t, thoi ho t chc c.
Xng: c nhng thay i v xng nh t trn. Mt s xng khc cng
c hin tng pht trin khng cn i nh:
Xng sng: mng xng pht trin mnh, c bit mt trc, g xng phn
xng sng vng ngc, v n (lordosis) ct sng tht lng.
Xng sn dy v di ra lm cho lng ngc c hnh thng, th tch lng ngc
tng, ngc d ra pha trc do xng sn d v pha trc nhiu, xng n, xng
c dy.
Cc xng di ca chi trn v chi di cng dy, c bit in hnh l nhng thay
i xng bn tay v bn chn, bn tay to, rng, cc ngn tay to, cc mch hnh tr do
mng xng v t chc lin kt pht trin, mng tay di.
Sn thanh qun v dy thanh m dy ln, ging ni ca ngi bnh thp v trm.
Tim mch: Tim to gp hu ht cc ngi bnh b to u chi. V giai on
cui ca bnh c thoi ho, x ho m k c tim nn c th a n suy tim. Huyt p

17

thay i khng c hiu, c trng hp huyt p cao hoc c va x ng mch vnh l

nguyn nhn a n suy tim.
Phi: do lng ngc bin dng, gim thng kh phi do gim ng tc h hp
ca xng sn. C th vim ph qun, kh thng phi.
Gan: gan to nhng kh s thy v lp di b sn dy.
Thn: to, trng lng c hai thn c th ti 870g. Tiu cu thn c th to gp
hai ln bnh thng, cc ng thn to hn bnh thng.
Chc nng thn cng thay i r rng. nhng ngi bnh nghin cu ca
Gershberg, thanh thi inulin tng ti 325ml/pht (bnh thng 131ml/pht). Chc
nng ti hp thu ca thn i vi glucose cng tng ti 1068 mg/pht (bnh thng 385
mg/pht). Chc nng bi tit ca ng thn i vi paraaminohippurat cng tng ti
165mg/pht (bnh thng 76mg/pht), GH cng lm tng ti hp thu ng thn i vi
phosphat v lm tng phosphat trong mu va phi.
1.3. Cc tuyn ni tit
Tuyn gip c th to hn bnh thng, bu c lan to gp 25%. giai on
u, khong 5% c cng chc nng gip, hu nh khng gp tnh trng suy gip. V
sau suy gip thng kt hp vi suy chc nng thng thn.
Tuyn cn gip: to hn bnh thng, c th c cc adenom trong tuyn.
C th chy sa bnh l ph n, v to nam gii. Chy sa bnh l do:
Prolactin v GH c cu trc ho hc ging nhau.
Hoc khi u va tit ra GH v prolactin.
c ch tit PIH (prolactin inhibiting hormone).
Tuyn ty ni tit: ri lon dung np glucose gp 50% ngi bnh to u chi;
nhng i tho ng lm sng ch gp 10%. Thng c hin tng khng insulin,
ngay c nhng ngi bnh b bnh ny dung np vi glucose bnh thng cng c hin
tng khng insulin.
Bin chng ca cc mch mu nh (microangiopathia) rt t gp nhng ngi
bnh b i tho ng do bnh to u chi.
Tuyn thng thn: mc du trng lng tuyn c tng, nhng chc nng
tuyn t thay i. Mt s ngi bnh c hin tng tng tit androgen ca thng thn,
biu hin trn lm sng bng hin tng rm lng, tng 17-cetosteroid niu. Giai on
cui ca bnh, c th c suy chc nng thng thn v tuyn yn tit khng ACTH.
Tuyn sinh dc: cc triu chng ri lon chc nng tuyn sinh dc thng sm,
ph n c ri lon kinh nguyt, nam gii thi gian u ca bnh thng tng dc
tnh, cng dng; giai on cui: lit dng, mt dc tnh. Ngi bnh n b to u
chi rt t khi c thai ngay c khi kinh nguyt cha ri lon. nam gii, s lng v kh
nng di ng ca tinh trng gim yu, sinh thit tinh hon c hin tng thiu sn c
quan to tinh trng.
Cng thc mu bnh thng, c th tng bch cu i toan, bch cu n nhn.
18

2. Cn lm sng
2.1. X quang xng
Xng s v h yn: thng thy h yn rng hnh qu bng, h yn pht trin
theo chiu su v di theo chiu dc, nn l v h yn khng dn rng.
y h yn thng c hai b khng ng u, lng yn mng, mm bm b n
mn (nn nhn), mm bm trc di ra.
Xoang trn pht trin mnh, b trn h mt d ra pha trc, xng hm trn dn
rt rng, xng g m to ra nn vng xng g m d ra v pha trc.
Xng chm nhiu hi, li chm ngoi thng c gai xng, khung xng s ni
chung dy.
Ct sng: phim chp nghing thng thy mt ta-luy phn lng ca thn t
sng ngc, c hai hoc nhiu vin, chng t c hin tng chng lp xng mi ln trn
lp xng c. C nhiu m xng, tn thng khp sau t sng, ct ho sm sn sn.
Bn chn v bn tay dy, to, nht l cc xng ngn. Cc xng di ca tay,
chn to ra, c bit cc sn u xng. Ch dnh ca c v dy chng li, g gh.
2.2. nh lng nng GH v IGF-1
Nu nng GH < 0,4mcg/l v nng IGF-1 trong gii hn bnh thng
(iu chnh theo tui v gii) loi tr chn on acromegaly.
Nu cc xt nghim trn bt thng, tin hnh lm nghim php dung np
glucose 2 gi ng ung nh sau:
Ly mu xt nghim glucose v GH khi i (baseline).
Cho ngi bnh ung 75g glucose.
Ly mu nh lng glucose v GH 30 pht mt ln, trong 2 gi lin.
Nu nng GH gim xung < 1mcg/L trong qu trnh lm nghim php, loi tr
chn on acromegaly. Dng tnh gi c th xy ra ngi bnh i tho ng, vim
gan mn tnh, suy thn v bing n (anorexia).
2.3. Chp cng hng t ht nhn (MRI) u, c hoc khng thuc cn quang
gadolinium nh gi khi u.
IV. IU TR
Ngi bnh Acromegaly thng cht sm (nguy c tng i gp 1,5 ln) v
tng t l mc hng nm khng insulin, ph i tht tri, v cht do cc bnh tim mch.
Acromegaly hnh nh lin quan n tng nguy c sinh bnh ung th i trng, do vy
nn soi i trng cho tt c cc ngi bnh ny.
1. Mc tiu iu tr
Nhiu nghin cu cho thy, gim nng GH s ci thin thi gian sng cn
ca ngi bnh. C th ni khoa, phu thut, v/hoc phng x.

19

 Mc ch ca iu tr l nng GH < 2mcg/L, hoc IGF-1 gii hn bnh

thng khi hiu chnh vi tui v gii.
2. Phu thut
Lm gim nhanh nht nng GH, tuy nhin kt qu iu tr ph thuc vo:
kch thc khi u, kinh nghim ca phu thut vin.
Phu thut l ch nh thch hp nht cho microadenomas, l phng php iu
tr cho 90% ngi bnh. Kt qu i vi macroadenomas tht vng hn, <50% ngi
bnh ch c iu tr bng phu thut.
3. iu tr bng thuc
Somatostatin analogs nh Octreotide (Sandostatin) v Lanreotide (Somatuline)
l nhng thuc c tc dng tt hn iu tr Acromegaly. Chng tc dng nh l
agonist trn receptor ca somatostatin khi u v km hm IGF-1 ti 50% ngi bnh.
Liu khi u c th t 2,5mg x 2ln/ngy; da trn nng GH v IGF-1 ca ngi
bnh; thuc c th c tim tc dng ko di hng thng.
Dopamin agonists: Bromocriptine (Parlodel) v Cabergoline (Dostinex) c ch
tit GH bng cch kch thch receptors dopaminergic trn khi u. Bromocriptine c hiu
qu <20% ngi bnh Acromegaly, Cabergoline hnh nh c kt qu tt hn. Liu khi
u thp trnh nn.
Pegvisomant (Somavert) c ch tc ng ca GH trn t chc ngoi vi bi s
ging nhau vi receptor GH, bnh thng c nng IGF-1 89% ngi bnh, tuy
nhin, tng c ngha nng GH cng gp. S tng ny khng c chng minh
do tng kch thc khi u, tuy nhin, 2 ngi bnh cn phi phu thut do tuyn yn
to ra nhanh khi iu tr bng Pegvisomant. Theo di chc nng gan 6 thng mt ln v
c thng bo v tng enzym gan AC.
4. iu tr bng tia x
C iu tr bng phng x tng phn truyn thng v Stereotactic Radiotherapy
(Gamma-Knife) u c p dng iu tr u tuyn yn, trong c u tit GH.
p ng y i vi iu tr bng phng x tng phn c th khng t c trong
15 nm, iu tr bng dao gamma hnh nh bnh thng c nng GH nhanh hn,
cng vi t tn thng t chc no xung quanh hn. iu tr bng dao gamma b hn
ch bi kch thc khi u v khi u nm gn thn kinh th gic.
C ti 60% ngi bnh b suy chc nng tuyn yn sau iu tr. Radiotherapy s
khng c ch nh v l bin php iu tr u tin, ngoi tr nhng ngi bnh
khng ng hoc khng c kh nng iu tr bng phu thut.

20

TI LIU THAM KHO

1. Thi Hng Quang (2008). Bnh Ni tit. Nh xut bn Y hc.
2. Mai Th Trch, Nguyn Thy Khu (2003). Ni tit hc i cng. Nh Xut
bn Y hc - Chi nhnh Thnh ph H Ch Minh.
3. The Washington Manual (subspecialty consult series) (2009). Endocrinology
subspecialty consult. Second Edition.
4. The Washington Manual of Medical Therapeutics. 33rd Edition (2010).
5. David G. Gardner. Dolores Shoback. Greenspans Basic and clinical Endocrinology,
9th Edition. 2011.

21

SUY TUYN YN
I. I CNG
Suy tuyn yn l s gim tit cc hormon tuyn yn c th do bnh ca tuyn yn
hoc do bnh vng di i (hypothalamus) gim tit cc hormon gii phng, v vy
s lm gim tit cc hormon tuyn yn tng ng.
Triu chng lm sng suy tuyn yn ph thuc vo nguyn nhn cng nh typ v
mc thiu ht hormon. Ngi bnh c th khng c triu chng, c triu chng do
thiu ht hormon, do chn p ca khi u, hoc nhng triu chng khng c hiu (nh
mt mi v v..).
Dch t: Nghin cu cng ng cho thy: T l suy tuyn yn l 46 trng hp
trn 100.000 ngi, t l mc hng nm l 4/ 100.000 ngi/ nm.
II. NGUYN NHN
1. Bnh tuyn yn
Bt k bnh no c nh hng n tuyn yn u c th lm hn ch tit mt hoc
nhiu hormon ca tuyn yn, nh bnh do khi u, phu thut ly khi u, v nhiu bnh
l khc.
1.1. Nhng tn thng khi (Mass lesions)
Bao gm: U tuyn (adenoma), nang, vim tuyn yn thm nhim t bo
lympho (lymphocytic hypophysitis), di cn ung th, v nhiu tn thng khc.
Bt c tn thng no trong h yn u c th gy tn thng tm thi hoc
vnh vin do tng chn p t bo tuyn yn. Khi lm gim kch thc khi, gii phng
chn p, c th phc hi chc nng tuyn yn.
1.2. Phu thut tuyn yn
Phu thut vin ct b adenoma tuyn yn tuy c gng bo v t chc tuyn
yn lnh gn k, nhng kh c kh nng nu hai tn thng lnh v bnh khng phn
bit c bng mt thng. Nu t chc lnh nguyn vn v tnh b ct b, suy tuyn
yn s xy ra.
1.3. Tia x
Tia x adenoma tuyn yn thng phng ti pht do t chc tuyn cn li sau
phu thut. Khi s dng tia x gamma hoc tia proton hoc yu t gia tc di (linear
accelerator) cng gy nn suy tuyn yn vi t l kh cao sau khong 10 nm. Suy gim
hay khng cn tit bt k hormon no ca tuyn yn c th xy ra vi thng n t nht 10
nm sau tia x, tng hormon cng c th xy ra sau tia x 6 thng hay c th sau 10 nm.

22

1.4. Thm nhim

Vim tuyn yn thm nhim t bo lympho (lymphocytic hypophysitis). t gp,
biu hin u tin bng thm nhim t bo lympho, tuyn yn to ra, tip theo sau giai
on ny l ph hy t bo tuyn yn, bnh thng xy ra vo cui thai k hay sau .
Bnh c ngun gc t min.
Ngi bnh thng ku au u ngy cng tng t l vi kch thc tn
thng v tnh trng suy tuyn yn. Thng gp nht suy chc nng t bo tit ACTH
v TSH, a n suy chc nng tuyn thng thn, suy chc nng tuyn gip, c th kt
hp vi vim tuyn gip t min.
Chp CT v MRI pht hin hnh nh c trng khi tuyn yn ging nh hnh
nh adenoma. MRI cn cho thy tng cn quang lan ta v ng nht thy trc tuyn
yn, hin tng ny c th xut hin mun hoc c th khng c thy sau tuyn yn.
Lch s t nhin ca th bnh ny: tuyn yn b teo ngy cng nng thay th
bng t chc x, tuy nhin c th c phc hi t nhin t nht mt phn chc nng thy
trc v thy sau tuyn yn. iu tr bng glucocorticoid liu cao (pulse therapy) c th
gim c nh hng ca khi u mt s trng hp.
1.5. Nhi mu trong tuyn yn (Pituitary infarction), hi chng Sheehan
Nhi mu tuyn yn do chy mu sau c ghi nhn t lu l nguyn nhn
gy suy tuyn yn, gi l hi chng Sheehan. cc nc pht trin, hi chng Sheehan
t gp hn do ci thin sn sc sau . Tuy nhin, cc nc ang pht trin, nhi mu
tuyn yn sau vn l nguyn nhn thng gp ca suy tuyn yn.
Thng gp: Ngi bnh c tin s chy mu sau nng, phi truyn ti vi n
v mu. Suy tuyn yn c th xut hin vi ngy hoc vi tun sau vi cc triu
chng: Ngi bnh l m, chn n, st cn, khng tit sa. Bnh nh hn c th xut
hin sau vi tun, vi thng; biu hin bng gim tit sa, khng ti lp chu k kinh, rng
lng mu v, mt mi, chn n, st cn. Mc nh nht, suy tuyn yn c th khng xut
hin nhiu nm sau . Trong hai nghin cu gm 48 ngi bnh b hi chng Sheehan
do chy mu sau , tt c u c thiu ht GH, gonadotropin, prolactin v ch yu l
thiu TSH v ACTH. Tit vasopressin thng di mc bnh thng, nhng i tho nht
trung ng lm sng th rt him gp. Hu ht ngi bnh c kch thc tuyn yn nh
hoc bnh thng, i khi chp MRI thy h yn rng (empty sella).
nh gi tnh trng suy tuyn yn sau c tin hnh bt k lc no nu c
nghi ng suy tuyn yn kt hp vi mt mu nng bt thng. Nu mt mu nng, c
bit c h huyt p, phi nh gi chc nng thng thn v iu tr suy thng thn
ngay lp tc. S thiu ht cc hormon khc c th c nh gi 4 n 6 tun sau .
iu tr cng tng t nh iu tr cc nguyn nhn khc gy suy tuyn yn.
Thiu ht prolactin lm mt kh nng tit sa, nhng khng cn thit phi iu tr, nh
lng prolactin thi gian ngn sau chy mu d bo kh nng tit sa cha c
nghin cu.
Nguyn nhn t gp nhi mu tuyn yn ngi bnh ln tui l suy mch xy ra
trong khi phu thut ni ng mch vnh (coronary artery bypass surgery).

23

1.6. Ngp mu tuyn yn (pituitary apoplexy)

Chy mu t ngt trong tuyn yn gi l ngp mu tuyn yn. Xut huyt xy ra
trong adenoma, triu chng ni bt nht l xy ra mt cch t ngt cn au u kch lit,
song th (diplopia) do chn p thn kinh vn nhn, v suy tuyn yn. Thiu ht tt c cc
hormon tuyn yn c th xy ra, nhng thng gp nht l suy gim t ngt ACTH, lm
gim tit cortisol gy h huyt p nghim trng, e da cuc sng ngi bnh.
Suy tuyn yn, cng nh song th c th ci thin sau khi phu thut gii phng
chn p tuyn yn, hoc cng c th c ci thin mt cch t nhin do mu c hp
thu vi tun hoc vi thng sau xut huyt. C th s dng liu cao corticosteroid, i
vi ngi bnh c u tit prolactin cho ng vn dopamin (dopamin agonist) lm
gim khi u.
1.7. Bnh di truyn
Thiu ht bm sinh mt hoc nhiu hormon tuyn yn c ghi nhn t lu;
gn y, khim khuyt di truyn l nguyn nhn ca mt vi thiu ht bm sinh c
xc nh. Nhng khim khuyt ny nm trong cc gen m ha cc yu t phin m
(transcription factors), s bc l cc gen ny rt cn thit bit ha t bo thy trc
tuyn yn.
Nhng t bin c pht hin cc gen m ha trong s cc yu t phin m
ny gm HESX-1, LHX-3 v LHX-4, cc yu t phin m ny quan trng i vi s
hnh thnh tuyn yn (pituitary organogenesis) v bit ha sm t bo tuyn yn, Prop-1
rt cn thit bit ha typ t bo tin cht cc t bo somatotroph, lactotroph,
thyrotroph v gonadotroph. Pit-1 (gi l POU1F1 ngi), tc ng ngay sau Prop-1 v
cn thit i vi bit ha typ t bo, l tin cht ca t bo somatotroph, lactotroph, mc
t hn l t bo thyrotroph. TPIT cn thit i vi bit ha c hiu cc t bo
corticotroph.
Nhng t bin trong HEXS-1, LHX-3 v LHX-4, v chng tc ng sm
trong qu trnh bit ha cc t bo tuyn yn, nn l nguyn nhn gy thiu ht nhiu
hormon tuyn yn, nh cc hormon GH, prolactin, TSH, LH v FSH. t bin trong
LHX-3 gy nn nhng bt thng v thn kinh do n bc l trong h thn kinh trung
ng. Nhng t bin trong gen PROP-1 hnh nh l nguyn nhn thng gp nht ca
c bnh bm sinh gia nh, tn pht kt hp vi thiu ht hormon tuyn yn.
1.8. H yn rng (empty sella)
H yn rng l turcica h yn to ra, nhng khng chim ht ton b tuyn yn, c
hai typ:
H yn rng th pht: phi hp vi mt bnh c th xc nh c ca tuyn
yn, nh adenoma tuyn yn lm thay i h yn sau c phu thut hay x tr,
hoc nhi mu. Suy tuyn yn l do bn thn adenoma, do iu tr hoc do nhi mu,
phn cn li ca adenoma ly i mt phn c th cn chc nng.
Th khc h yn rng l bm sinh, bt thng yu t phin m (transcription
factor) cn thit bit ha tuyn yn, sella turcica bnh thng, nhng tuyn yn nh.
24

H yn rng c c trng bi thiu honh yn do vy dch no ty (CSF) chn p lm

h yn to ra. Thiu tit mt hoc vi hormon tuyn yn t gp.
2. Bnh vng di i (Hypothalamic disease)
Bnh vng di i c th nh hng ti tit mt hoc nhiu hormon vng di
i, v nh vy s gy ri lon tit cc hormon tuyn yn tng ng. Khc vi cc bnh
gy tn thng trc tip tuyn yn, bt k tn thng no vng di i u c th hn
ch tit vasopressin gy nn bnh i tho nht. Ch c tn thng tuyn yn n thun
khng gy nn bnh i tho nht, v mt s thn kinh tit vasopressin tn cng vng
li gia (median eminence).
2.1. Tn thng khi (mass lesions)
Cc khi u lnh trong vng di i nh u s hu (craniopharyngioma), di cn
ca cc khi u c tnh nh ung th phi, ung th v.
2.2. Tia x vng di i (hypothalamic radiation)
Sau tia x iu tr u no, ung th mi hng tr em hoc ngi ln.
2.3. Tn thng thm nhim (infiltrative lesions)
Bnh sarcoidose, Langerhans cell histiocytosis c th gy nn thiu ht hormon
thy trc tuyn yn v bnh i tho nht; Nhim khun; Vim mng no do lao.
3. Cc bnh khc
Tn thng do chn thng s no, chy mu di mng nhn thng gy nn
chy mu, hoi t v tn thng ng (stalk) tuyn yn.
III. CHN ON
1. Lm sng
i vi ngi suy hon ton chc nng thy trc tuyn yn (nh phu thut ct
b thy trc tuyn yn) m khng c iu tr thay th th ngi bnh s cht, ngc
li mt s nguyn nhn khc, do u, nhi mu... th suy chc nng tuyn yn thng
khng hon ton, biu hin lm sng c th nh hn.
1.1. Triu chng suy chc nng tuyn thng thn v gim tit ACTH
L triu chng sm nht xut hin t ngy th 4 n ngy th 14 sau khi ngng
cc thuc iu tr thay th nhng ngi bnh ct b hon ton tuyn yn.
Ngi bnh thng nn, bun nn, mt mi, huyt p h, chn n, st cn, c th
c cn h ng huyt t nhin, khi c stress cc triu chng trn cng r.
Tit aldosteron trong suy thng thn th pht bnh thng hoc thp hn bnh
thng.
Ri lon chc nng thi tit nc tiu ca thn trong suy tuyn yn mt phn do
chc nng tuyn thng thn; mt khc, do gim tit hormon tng trng (GH) lm
25

gim chc nng lc cu thn, gim dng mu qua thn, bng cortisol hay thyroxin c
th iu chnh c tnh trng ri lon trn.
Nng natri mu ni chung bnh thng, nhng cng c trng hp natri mu
rt h, ngi bnh c th hn m v c cc triu chng tng tit ADH (hi chng
Schwartz Barttrer).
1.2. Triu chng suy chc nng tuyn gip do gim tit TRS
Thng xy ra t u tun 4 n tun th 8 sau khi ngng iu tr hormon
thyroxin cho ngi bnh ct b hon ton tuyn yn.
Nu l suy th pht khng phi do phu thut, triu chng suy c th ko di t 5
n 10 nm mi xut hin.
Lm sng ging suy tuyn gip tin pht, nhng thng nh hn: Ngi bnh
th vi ngoi cnh, khng chu c lnh, da kh, ph nim mc.
Cholesterol trong mu tng.
hp thu iod phng x 131 ca tuyn gp thp nhng s tr li bnh thng
sau khi iu tr t 1 - 5 ngy bng thyreotropin.
Nng T3, T4 trong huyt thanh thp.
Sau khi ct hon ton tuyn yn, mt s ngi bnh c bit khng c suy
chc nng tuyn gip, trn c s bu nhn c th pht trin thnh bu c lp
(thyroidautonomy). Mt s t trng hp li cng chc nng tuyn gip, nguyn nhn
c l lin quan vi vai tr ca LATS (long acting thyroid stimulator), hin tng bt
bnh thng ny chng t rng LATS khng ph thuc vo chc nng tuyn yn.
1.3. Triu chng do gim tit hormon tng trng (GH)
Thiu GH v ACTH s a n gim ng mu lc i, tng tnh mn cm i
vi insulin. Hoi t tuyn yn ngi bnh hn m do i tho ng c th lm cho
tnh trng bnh i tho ng tt hn (hin tng Houssay). Liu iu tr insulin gim
i 1/4 so vi liu trc phi iu tr.
1.4. Triu chng suy chc nng sinh dc do gim tit gonadotropin
Teo cc c quan sinh dc: nam gii tinh hon teo nh, mm, dc tnh (libido)
v cng dng gim, khng c tinh trng. n gii gim hoc mt dc tnh, mt kinh
thng l du hiu sm nht do u tuyn yn, teo bung trng, teo m o, lm phin
m o biu hin r tnh trng thiu oestrogen. Gonadotropin trong nc tiu gim.
1.5. Triu chng ngoi da
Da nh sp, nhiu np nhn trn da xung quanh mt v ming lm cho ngi bnh
gi trc tui.
Nhng vt xm trn da thng nht dn, ngay vng xm da u v cng c th
tr thnh trng. Nhng ch da xm do tip xc nh sng mt tri cng nht dn hoc
26

mt hn. Nhng triu chng trn y rt c gi tr chn on phn bit gia bnh
Sheehan vi bnh Addison (suy thng thn tin pht).
Lng nch, lng mu v tha dn, lng my tha.
2. Cn lm sng
2.1. Xt nghim v mu
Thng c thiu mu ng sc do gim yu t kch thch sinh hng cu. Suy chc
nng tuyn gip th pht cng tham gia vo c ch thiu mu trong suy tuyn yn. Trn
thc nghim ng vt cng nh ngi, suy chc nng tuyn gip ko di c th a
n gim sinh hng cu, thiu mu nh.
iu tr thay th bng hormon tuyn gip thng khng phc hi tnh trng
thiu mu. mt s ngi bnh, iu tr phi hp hormon tuyn gip vi testosteron
phc hi li c t l hemoglobin mu. Trong bnh Sheehan, v mu chy nhiu sau
c th a n thiu mu nng. Mt s ngi bnh suy tuyn yn mn tnh lu ngy c
th gy thiu mu c tnh.
2.2. nh gi suy gim tit Corticotropin
Cortisol huyt tng:
ngi bnh thng, nng cortisol vo lc 8 gi sng khong 5-25mcg/dL
(138690 nmol/L).
Nu cortisol 3mcg/dL (83nmol/L), sau hai ln lm xt nghim, l bng chng
rt c gi tr v gim tit cortisol, thng gp ngi bnh suy tuyn yn. Nu km
theo c ACTH huyt tng thp, chng t suy thng thn th pht (do bnh tuyn yn
hoc bnh vng di i). Nu ACTH cao hn bnh thng l suy thng thn tin pht
(suy ti tuyn thng thn).
Nu Cortisol 18mcg/dL (497nmol/L) chng t c thiu tit ACTH nn, v c
kh nng tit y trong khi gng sc th lc (physical stress).
Nu nng cortisol huyt tng > 3mcg/dL nhng < 18mcg/dL, xt nghim li
vn nh vy, cn phi nh gi v d tr ACTH.
nh gi d tr ACTH (ACTH reserve): c tin hnh nhng ngi bnh
c nng cortisol trung bnh. C nhiu cch nh gi, mi phng php c nhng
thun li v bt li khc nhau, cc phng php l:
Nghim php metyrapone (Metyrapone test).
Metyrapone c tc dng chn (block) enzyme 11-beta-hydroxylase (CYP11B1),
mt enzyme xc tc chuyn 11-deoxycortisol thnh cortisol, do vy s gim tit cortisol.
Gim nng cortisol, nu trc di i-tuyn yn-thng thn bnh thng, s tng
tit ACTH v tng tng hp steroid trong c 11-deoxycortisol.
ngi bnh thng, ung 750mg metyrapone mi 4 gi mt ln, lin tc trong
24 gi, 8 gi sng hm sau xt nghim mu s thy cortisol huyt tng gim

27

<7mcg/dL (172nmol/L) v 11-deoxycortisol tng 10mcg/dL (289nmol/L). ngi

bnh ang ung phenytoin, chuyn ha metyrapone nhanh hn bnh thng; do vy,
mi liu metyrapone s l 1500mg. Sau 8 gi sng, ly mu th v cho tim tnh mch
100mg hydrocortisone phc hi tnh trng thiu cortisol do metyrapone. ngi
bnh gim d tr do bnh tuyn yn hay di i, nng 11-deoxycortisol huyt
tng s di 10 mcg/ dL (289 nmol/L).
Kt qu nghim php i hi metyrapone phi c ch y sn xut cortisol.
Nu 11-deoxycortisol < 10mcg/dL (289nmol/L), v cortisol 7mcg/dL
(193nmol/L), nguyn nhn lm tng khng 11-deoxycortisol c th do metyrapone
c ch cha . Khi , phi tm xem nguyn nhn c ch khng y c phi do
ung khng metyrapone, thuc chuyn ha nhanh, hay thuc km hp thu? Sau
phi lm li vi liu gp i.
Thun li ca test ny l c th tin hnh ngi ln cho bt k tui no, kt qu
tng quan vi p ng ca cortisol huyt tng khi stress do phu thut. Trong thi
gian lm nghim php, cn theo di mch, huyt p t th nm v t th ng trc mi
ln ung thuc. Nu c h huyt p t th, test s kt thc v cho truyn tnh mch
100mg hydrocortison.
Test metyrapon nhanh: cho mt liu duy nht 750 mg vo ban m, sau
nh lng 11-deoxycortisol v cortisol lc 8 gi sng; tuy nhin, test nhanh khng tch
ra c bnh thng, khng bnh thng nh test di.
Nghim php h ng huyt do insulin: l test kch thch y tit ACTH,
do vy cng tng tit cortisol.
Tin hnh: tim insulin tnh mch, liu 0,1 n v/1kg trng lng c th; nh
lng glucose v cortisol huyt tng trc v sau khi tim cc thi im 15, 30, 60,
90, v 120 pht. Bnh thng cortisol huyt thanh tng 18 mcg/dL (498nmol/L), khi
glucose huyt thanh gim xung <50 mg/dL (2,8mmol/L).
Thun li ca nghim php: kt qu tng quan tng i vi p ng cortisol
huyt thanh khi stress phu thut. Bt li l c th h ng huyt nguy him cho
nhng ngi bnh ln tui, ngi bnh c bnh tim mch, bnh mch mu no, bnh
ng kinh. Do vy phi theo di cht trong sut gi th nht sau khi tim insulin, theo
di nhng triu chng thn kinh do h ng huyt, nu c, iu tr kp thi bng
tim glucose tnh mch.
Nghim php kch thch bng ACTH (Cosyntropin (ACTH) stimulation test).
Teo tuyn thng thn, khi khng c kch thch trong thi gian di, tuyn thng
thn s khng tit cortisol bnh thng p ng khi a vo mt liu bolus ACTH.
Tin hnh: tim bp hoc tnh mch 0,25mg (25 n v) cosyntropin (ACTH tng
hp); nh lng nng cortsol 6 gi sau khi tim. ngi bnh thng, nng
cortisol sau 6 gi 18 mcg /dL (497nmol/L).
Test ny t c s dng v ngi bnh b thiu ht ACTH, tuyn thng thn
khng p ng bnh thng vi cosyntropin cng s c nng cortisol huyt thanh
28

nn lc 8-9 gi sng 3 mcg/dL (83nmol/L), v vy s khng cn tin hnh test d tr

ACTH. Mt khc, ngi bnh b thiu ACTH khng hon ton c th p ng bnh
thng vi cosyntropin v cn thit phi lm test d tr ACTH.
Nghim php kch thch cosyntropin liu thp c cho l t dng tnh gi hn,
nhng cng c nhng bt li nh test liu chun. Do vy nhiu nh lm sng khuyn
khng nn lm c hai phng php ny.
2.3. nh gi suy gim tit Thyrotropin
ngi bnh bit c bnh vng di i hoc bnh tuyn yn, c th nh
lng thyroxine huyt thanh (T4) hoc T4 t do. Nu nng T4 huyt thanh bnh
thng, tit TSH cng bnh thng, nu T4 thp, tit TSH cng thp.
ngi bnh b suy chc nng tuyn gip do tn thng vng di i hoc
tuyn yn, nng TSH thng khng gip chn on suy tuyn gip v nng T4
thp thng lin quan vi nng TSH huyt thanh trong gii hn bnh thng.
V vy, mt mnh TSH huyt thanh khng c s dng lm test sng lc suy
chc nng tuyn gip ngi bnh b bnh di i hoc bnh tuyn yn.
2.4. nh gi suy gim tit gonadotropins
Tin hnh chn on thiu ht gonadotropin ngi bnh bit b bnh tuyn
yn hoc vng di i thay i ty gii ca ngi bnh.
nam gii b suy tuyn yn, thiu ht luteinizing hormon (LH) c th c
xc nh tt nht bng nh lng nng testosteron huyt thanh. Nu nng
testosteron thp nhiu ln t 8 gi n 10 gi sng, tit LH di mc bnh thng, c
th kt lun ngi bnh b suy chc nng sinh dc (hypogonadism) th pht. Khi nng
testosteron huyt thanh thp, nng LH huyt thanh thng trong gii hn bnh
thng, nhng thp so vi nng tng trong suy sinh dc tin pht. Nu c kh nng
sinh sn, phi m tinh trng xc nh.
i vi ph n tui tin mn kinh b bnh tuyn yn hay vng di i nhng
kinh nguyt bnh thng, khng lm xt nghim thm d v tit LH hoc FSH (folliclestimulating hormone), v chu k kinh nguyt bnh thng l mt du chng chng t chc
nng tuyn yn-sinh dc cn nguyn vn, v c gi tr hn bt k test sinh hc no khc.
Nu ngi ph n b thiu kinh (oligomenorrhea) hoc v kinh (amenorrhea), s
nh lng LH v FSH huyt thanh, xc nh chc chn LH v FSH khng phi tng
do bnh ca bung trng. Ngoi ra, cn nh lng estradiol huyt thanh. Cho 10mg
medroxyprogesterone mi ngy, trong 10 ngy lin xc nh: Nu xut hin chy
mu m o sau ngy th 10, v nu hin tng chy mu ging v s lng, thi
gian nh khi ngi bnh c kinh nguyt, c th kt lun ngi bnh bnh thng.
Kt qu di bnh thng nhng xt nghim ny ch ra rng thiu ht estradiol
l hu qu ca thiu tit gonadotropin v cn xem xt cho iu tr bng estrogen.
Kt qu bnh thng, khi kt hp vi thiu kinh hoc v kinh c th tit
gonadotropin y duy tr tit estradiol nn y , nhng khng gy rng
29

trng v tit progesterone bnh thng, trong trng hp ny s xem xt cho iu tr

bng progestin theo tng giai on ca chu k kinh (intermittent progestin treatment).
p ng ca LH huyt thanh sau khi cho mt liu bolus gonadotropin-releasing
hormone (GnRH) khng gip chn on phn bit suy sinh dc th pht do bnh tuyn
yn v bnh vng di i, v ngi bnh b suy sinh dc do bnh tuyn yn c th c
nng LH p ng bnh thng hay di bnh thng i vi GnRH.
2.5. nh gi suy gim tit hormon tng trng (Growth hormone)
o nng nn GH huyt thanh khng phn bit c tit GH bnh thng
hay di bnh thng ngi ln mt cch chc chn. Tuy nhin c ba tiu chun khc
c p dng:
Thiu ht cc hormon tuyn yn khc: ACTH, TSH v gonadotropins khong 95%.
Nng IGF-1 huyt thanh thp hn gii hn di bnh thng so vi tui
nhng ngi bnh b bnh tuyn yn thc th, c th chn on thiu ht GH.
Hoc l h ng huyt do tim insulin, hoc phi hp arginine vi growth
hormone-releasing hormone (GHRH) l nhng yu t kch thch mnh gii phng GH.
Tng di bnh thng nng GH huyt thanh (< 5,1ng/mL khi lm nghim php h
ng huyt do tim insulin; 4,1ng/mL i vi nghim php phi hp arginin vi
GHRH) nhng ngi bnh b bnh tuyn yn thc th, chng t c thiu tit GH.
Nghim php phi hp arginin vi GHRH thch hp hn v tai bin thp, trong khi
test insulin c th gy ng kinh, au tht ngc - c bit ngi gi - v nhng triu
chng thn kinh do h ng huyt c th xy ra cho ngi bnh tt c cc la tui.
Nhng cht kch thch khc nh arginine, clonidine, L-DOPA v phi hp arginin
v L-DOPA rt yu, c th cho kt qu dng tnh gi.
Cc nghim php kch thch tit GH thng cho kt qu dng tnh gi ngi
bo ph.
2.6. nh gi suy gim tit prolactin
Xt nghim nh gi thiu tit prolactin khng cn thit, khng thc t, tn
km v ch. Khng cn thit v vai tr sinh l ch yu ca prolactin l i vi ngi cho
con b, khng thc t v n rt kh phn nh nng thp vi nng prolactin huyt
thanh bnh thng, v khng c mt test chun v d tr prolactin, tn km v ch v
khng c sinh kh dng iu tr cho ph n c bnh tuyn yn bit, nhng ngi ny
khng cho con b v thiu prolactin.
Tm li: Ch nh xt nghim thm d chc nng tuyn yn ty thuc vo nh
gi ca thy thuc theo biu hin lm sng ca ngi bnh.
nh gi tit ACTH bng nh lng cortisol t 8 gi n 9 gi sng vi hai
thi im hoc nhiu hn. Nu < 3mcg/dL, ngi bnh c thiu tit cortisol; nu >
18mcg/dL, ngi bnh tit cortisol y . Nu kt qu lun mc trung bnh, xt
nghim d tr ACTH (nh nghim php metyrapone) s phi tin hnh.
30

 nh gi tit TSH bng nh lng thyroxine huyt thanh ton phn v hp

th T3, T4 thp; TSH khng phi l xt nghim nh gi suy chc nng tuyn gip
th pht.
nh gi tit gonadotropin nam gii bng nh lng testosteron huyt thanh
ton phn t 8 n 9 gi sng hai thi im hoc nhiu hn. Nu testosteron thp,
ngi bnh khng bo (hoc testosteron t do nu ngi bnh c bo), LH khng tng,
chng t ngi bnh suy sinh dc th pht.
Tit gonadotropin ph n tui tin mn kinh b v kinh c nh gi bng
nh lng estradiol. Nu nng estradiol huyt thanh thp v FSH khng tng, chng
t ngi bnh b suy sinh dc th pht.
Tit GH c th di bnh thng nu ngi bnh c:
Bnh tuyn yn thc th.
Thiu ht ACTH, TSH v cc hormon sinh dc.
IGF-1 huyt thanh theo tui hoc p ng ca GH i vi kch thch bng
Arginine-GHRH di bnh thng.
IV. IU TR SUY TUYN YN
1. iu tr thiu ht ACTH
Hydrocortisone hoc glucocorticoid khc: xem bi Suy thng thn.
Thuc v liu lng thay i ty mc nng nh, tnh trng stress nu c. Liu
khng s lm cho triu chng thiu ht Cortisol ko di hoc bnh ti pht, nu qu
liu s gy nn cc triu chng tha Cortisol v mt xng. lch rt nh t liu ti u
khng xc nh c v khng c mt test sinh hc no c cng nhn xc nh s
y liu. nh lng nng ACTH huyt thanh khng c s dng, v gi tr thp
hoc bnh thng trc khi iu tr. Gi tr Cortisol huyt thanh thay i ph thuc rt
nhiu vo liu Hydrocortison a vo, gi tr Cortisol nc tiu cng khng chc chn.
Tc dng ph khng thng xuyn ca iu tr thay th bng Glucocorticoid l
bc l bnh i tho nht trung ng tim tng t trc, biu hin l i nhiu. iu
chnh thiu ht Cortisol c th lm tng huyt p v dng mu qua thn, nhng ngi
bnh i tho nht khng hon ton s gim tit Vasopressin. Tt c nhng bin i ny
s lm tng o thi nc tiu.
Khng ging vi kch thch trong suy thng thn tin pht, iu tr thay th bng
Mineralocorticoid t cn thit hn ngi bnh suy tuyn yn. Angiotensin II v Kali
(khng phi ACTH), l nhng yu t ch yu iu ha tit aldosteron.
2. iu tr thiu ht TSH
Thiu ht TSH do vy thiu Thyroxin s c iu tr thay th bng L-Thyroxin.
Cc yu t nh hng n liu cng ging cc yu t trong suy tuyn gip tin pht.
Nhng iu tr suy tuyn gip th pht khc hai im: T4 s khng c ch nh khi

31

chc nng thng thn, k c d tr ACTH c nh gi cha bnh thng, v nhng

ngi bnh cng b suy tuyn gip v suy thng thn ch iu tr suy tuyn gip n
thun c th lm tng thanh thi mt s nh Cortisol c tng hp, do vy s lm
cho thiu Cortisol cng nng hn. nh lng TSH huyt thanh cng khng cn p
dng nh l mt hng dn v nh gi liu y hay cha khi iu tr L-Thyroxin
thay th.
Mc tiu iu tr l nng T4 huyt thanh t mc trung bnh ca gii hn
bnh thng.
3. iu tr thiu ht LH v FSH
iu tr thiu ht LH v FSH ph thuc vo gii v ngi bnh c mun sinh con
hay khng.
i vi nam gii:
iu tr thay th bng Testosteron l cho ngi bnh nam b suy sinh dc
v h khng quan tm n sinh sn. Liu chn iu tr khng khc vi liu iu tr
cho ngi bnh suy sinh dc tin pht, nh lng Testosteron huyt thanh nh gi
liu hay cha (khng phi LH).
Ngi bnh nam b suy sinh dc th pht c nhu cu sinh con c th iu tr
bng Gonadotropins nu ngi bnh b bnh tuyn yn, hoc Gonadotropins hoc
Gonadotropin-Releasing Hormone (GnRH) nu ngi bnh b bnh vng di i.
i vi ph n:
Ph n b suy chc nng tuyn sinh dc nh thiu ht Estradiol v Progesteron,
khng c nhu cu sinh s iu tr thay th bng Estrogen-Progestin. Mc ch ca
iu tr khng ging nh iu tr cho ph n sau mn kinh - cho Estrogen v Progestin
lm gim bt cm gic nng nu cn thit. Mc ch iu tr cho ph n tui tin
mn kinh b suy sinh dc do bnh tuyn yn cng ging nh iu tr thay th Thyroxine
v Cortisol, ngha l thay th cc hormon b thiu ht c th t c nh sinh l.
t c mc tiu ny c th iu tr bng Estradiol qua da (estradiol
transdermally), Estradiol s c hp thu vo h thng tun hon ging nh khi n
c tit ra bi bung trng. Cng c th cho Estradiol theo chu k vi Progesterone
hoc Progestin. Mt phc iu tr cho Estradiol t ngy 1 n ngy th 25 ca mt
thng v Progesterone t ngy 16 n ngy 25. Mc ch l t c c nng
Estradiol huyt thanh ca Follicul giai on mun bnh thng v kinh nguyt ngi
bnh c ti lp xem nh bnh thng. Phc ny cng tng t nh phc c
p dng iu tr suy bung trng sm. Phc n gin hn cho Estradiol qua da
lin tc sut c thng v cho Progesterone t ngy 1 n ngy 10 lch hng thng, mt
s ngi bnh cho rng phc ny d nh.
i vi ph n suy sinh dc th pht c nhu cu sinh , thch hp l kch
thch phng non (ovulation induction). Ngi bnh n b thiu ht GnRH, cho iu tr
Gonadotropin hoc Pulsatile GnRH, thiu ht Gonadotropin do bnh tuyn yn ch iu
tr bng Gonadotropin.

32

 ph n b suy tuyn yn, c bit ngi bnh b thiu ht c gonadotropin v

ACTH, nng androgen huyt thanh gim nhiu hn so vi ngi c kim sot
bnh thng.
4. iu tr thiu ht GH
Mt s thuc ang c thnh hnh trn th trng nh: Humatrope, Nutropin,
Serostim, v Genotropin iu tr thiu ht GH ngi ln.
Ngi bnh thiu ht GH ngi ln thng c ri lon chuyn ha lipid, tng
m, gim khi lng c, gim t trng khong xng C nhng bng chng chc
chn rng, iu tr bng GH cho nhng ngi bnh ny kt qu thuyt phc nht l tng
khi lng c, gim m, nhng tc dng khc nh ci thin t trng khong xng, sc
mnh ca c v ci thin ri lon lipid cha thng nht, c nhiu kt qu nghin cu
ngc chiu nhau. V vy, khng nn ch nh iu tr GH nh l iu tr thng quy
i vi tt c ngi bnh xut hin thiu ht GH ngi ln.
5. iu tr thiu ht prolactin
Ch c nhng biu hin thiu ht prolactin l mt kh nng tit sa sau sinh, hin
nay khng iu tr.
6. iu tr cc bnh phi hp nu c
B sung vitamin v nng cao th trng.
TI LIU THAM KHO
1. Thi Hng Quang (2008). Bnh Ni tit. Nh xut bn Y hc.
2. Mai Th Trch, Nguyn Thy Khu (2003). Ni tit hc i cng. Nh Xut
bn Y hc - Chi nhnh Thnh ph H Ch Minh.
3. The Washington Manual (subspecialty consult series) (2009). Endocrinology
subspecialty consult. Second Edition.
4. The Washington Manual of Medical Therapeutics. 33rd Edition (2010).
5. David G. Gardner. Dolores Shoback. Greenspans Basic and clinical Endocrinology,
9th Edition. 2011.

33

BNH I THO NHT

I. I CNG
Bnh i tho nht (TN) l ri lon cn bng nc do o thi qua thn nc
khng thm thu. Bnh thng do khim khuyt tit arginine vasopressin (AVP) t thy
sau tuyn yn (TN trung ng), hoc do thn khng p ng vi AVP (TN do thn).
ADH c tng hp t nhn trn th v nhn cnh tht ca vng di i, sau
c chuyn xung thy sau tuyn yn tch tr v gii phng theo nhu cu hot ng
ca c th. Cc th th thm thu trong vng di i rt nhy cm vi nhng thay i
v thm thu huyt tng c xc nh trc ht bng nng Natri (Na). Gii
phng ADH b c ch khi thm thu tng trn mc ngng, sau tit ADH tng
ln nhanh chng cng vi thm thu huyt tng.
ADH trc ht tc ng ng ln xa v ng gp lm tng tnh thm v ti hp
thu nc. Tc dng ca ADH trung gian qua V2 receptor cp vi protein G, nhng tn
hiu chuyn v cc knh aquaporin-2 vo mng nh ca t bo chnh trong ng gp.
Khi lin kt vi knh aquaporin-3 v aquaporin-4 trn mt bn nn nhng t bo ny,
nc c chy xung t do nh chnh thm thu t dch ng thn tng i long
n ty thn c c c cao, do vy gim sn xut v gim hot tnh ca ADH gy
nn ri lon ti hp thu nc trong tiu cu thn, lm cho nc tiu b ha long v mt
nc t do.
Mt s tnh trng khc lin quan n tit ADH nh nn, gim th tch trong lng
mch, h ng huyt cp, gim glucocorticoid, thao tc trong phu thut ng chm
ti cc c quan trong bng, stress sinh l v bnh l, ht thuc.
Hai ri lon c bn gy TN: TN trung ng v TN do thn.
TN trung ng do cc t bo tit ADH b tn thng, lm gim ADH lu
hnh trong mu, c th TN hon ton hoc khng hon ton, nng ADH tng
khng p ng vi kch thch thm thu mnh nh khi mt nc.
TN do thn, nguyn nhn l do ri lon p ng ca thn vi ADH do ri
lon ng gp. TN do thn c th hon ton do ng thn khng p ng vi bt k
nng no ca ADH, hoc TN khng hon ton nh khi tng nng ADH trong
mu s gy nn p ng thn khng y .
II. NGUYN NHN BNH I THO NHT TRUNG NG
Bnh TN trung ng c c im l gim gii phng hormon chng bi niu
(ADH) gy nn a niu nhng mc khc nhau. Thiu ADH l do ri lon mt
hoc nhiu v tr lin quan n tit ADH nh cc receptor thm thu vng di i,
nhn trn th, nhn cnh tht hoc phn cao ca ng trn th-tuyn yn. Ngc li, tn
thng phn thp, vng li gia hoc thy sau tuyn yn ch gy a niu khng thng
xuyn, v ADH c sn xut vng di i vn tit vo h thng tun hon qua h
thng ca vng li gia.
34

Ngi bnh TN trung ng c triu chng a niu, c th c gim t trng

khong ca xng, ct sng tht lng v c xng i, ngay c ngi bnh ang c
iu tr bng desmopressin (dDAVP).
Nguyn nhn thng gp nht ca TN trung ng l do phu thut thn kinh,
chn thng, nhng khi u tin pht hoc th pht, bnh thm nhim (nh Langerhans
cell histiocytosis), v TN khng r nguyn nhn.
Bt k th no ca TN trung ng cng c th bng pht hoc xut hin ln u
trong khi c thai, v trong khi c thai, qu trnh thoi ging ADH tng do rau thai tit
nhiu vasopressinase.
1. i tho nht khng r nguyn nhn
Chim khong 30-50% TN trung ng, thng lin quan vi s ph hy t bo
tit hormon nhn vng di i, cc qu trnh t min c vai tr quan trng trong c
ch bnh sinh th bnh ny, cc khng th trc tip khng li t bo tit vasopressin
pht hin c nhng ngi bnh b cc bnh ni tit t min m lc u cha c
triu chng i tho nht trung ng. Qu trnh t min c trng bi thm nhim t
bo lymphocyte thn tuyn yn v thy sau tuyn yn, xy ra sau khi cc thn kinh ch
b ph hoi.
Chp MRI sm trong qu trnh din bin bnh thng pht hin dy hoc m
rng thn tuyn yn. Dy thn tuyn yn l du hiu khng c hiu, mt s tr em c
du hiu ny theo di v sau pht trin u mm hoc bnh m bo, dy tin trin thn
tuyn yn, chp MRI hng lot rt c gi tr trong pht hin u mm.
Gim tit cc hormon thy trc tuyn yn nh GH, TSH, ACTH cng c th c
hoc xy ra nhng ngi bnh b TN trung ng khng r nguyn nhn. Tuy nhin,
mt s ngi bnh c bnh ni tit thy trc tuyn yn vi nm sau khi c triu chng
bnh TN trung ng, nh pht hin c khi u tuyn yn hoc khi u trn h yn,
chng t nhng ri lon bnh l ban u ca bnh chnh b che khut bi triu chng
bnh TN.
i tho nht trung ng gia nh, cn c tn Familial neurohypophyseal diabetes
insipidus (FNDI) l bnh tri nhim sc th thng (autosomal dominant disease), do
nhng t bin gen arginin-vasopressin (AVP).
2. Phu thut thn kinh hoc chn thng
TN trung ng c th gy nn do phu thut thn kinh hoc do chn thng
vng di i v thy sau tuyn yn. T l dao ng t 10-20% nu phu thut ly khi
u khu tr trong h yn, n 60-80% sau phu thut ly khi u kch thc rt ln. Nh
nhng thnh tu phu thut ni soi, t l ny gim ng k (2,7%-13,6%).
Nng natri huyt tng > 145mmol/L trong 5 ngy u sau phu thut c gi
tr cao d bo pht trin TN ko di. Ngc li, ngi bnh c nng natri huyt
tng < 145 mmol/L trong 5 ngy u sau phu thut s rt t xy ra TN ko di. y
l thng s c gi tr d bo tt.

35

Tn thng nng vng di i hoc ng tuyn yn do phu thut thn kinh hoc
do chn thng thng gy nn phn ng ba pha rt c trng:
Pha u tin l a niu, trong 24 gi u, ko di 4-5 ngy. Pha ny phn nh
s c ch gii phng ADH do ri lon chc nng vng di i.
Pha tip theo: chng bi niu, t ngy th 6 n ngy th 11, cc hormon tch
tr c gii phng t t t thy sau tuyn yn ang thoi ha. Trong giai on ny,
ung nc qu nhiu c th a n h Na+ mu ging nh trong hi chng tit ADH
khng thch hp.
Pha th 3: TN xy ra khi hormon thy sau tuyn yn tch tr gim.
Hu ht TN khng ko di. V d, ngi bnh b tn thng vng di i hoc
ng tuyn yn khng nng lm thng c TN trung ng thong qua, bt u 24-48
gi sau phu thut v c th ht sau mt tun. Khng phi tt c cc ngi bnh u tin
trin qua ba pha nh vy, mt s ngi bnh khng c khi u bng triu chng a
niu, ch c triu chng h Na+ mu, sau tr li bnh thng.
Mc du t l tng i cao TN trung ng nhng ngi bnh tri qua
phu thut, nhng cn lu a niu c th xy ra do dng thuc iu tr vi mc ch
hn ch ph no bng manitol hoc glucocorticoids. Nhng trng hp ny c th phn
bit vi TN bng o thm thu niu, p ng vi hn ch nc v tim ADH.
3. Ung th
Tin pht hoc th pht (thng gp nht l ung th phi, leukemia hoc
lymphoma), cc khi u no c th vng di i-tuyn yn gy nn TN trung ng.
Trong mt s trng hp bnh di cn, a niu l triu chng thng gp.
4. Bnh thiu oxy no
Bnh thiu oxy no hoc thiu mu no nng c th lm gim gii phng ADH.
Mc thay i t nh, khng c triu chng n a niu r. V d, a niu r trn lm
sng thng t gp ngi bnh b hi chng Sheehan ngay c khi tit ADH di mc
bnh thng. S xut hin TN nhng ngi bnh ny n nh, thnh thong c cc
du hiu bnh l ang lm so v teo trong nhn trn th v thy sau tuyn yn.
5. Nhng bnh do thm nhim
Ngi bnh b Langerhans cell histiocytosis (cn c tn histiocytosis X v
eosinophilic granuloma) c nguy c cao c bit i vi TN trung ng do bnh vng
di i-tuyn yn. C ti 40% ngi bnh c a niu trong bn nm u, c bit nu
pht trin nhiu h thng v li mt.
Bnh thm nhim tng t c th xy ra khi b sarcoidosis, n c th gy nn a
niu v i tho nht do thn (do tng calci mu), hoc do ung nhiu tin pht. Nhng
bnh thm nhim khc t gy TN trung ng l: Wegeners granulomatosis v vim
tuyn yn t min thm nhim t bo lympho (autoimmune lymphocytic hypophysis),
bnh ny c th t khi.

36

6. Sau cn nhp nhanh trn tht

a niu thong qua i khi gp sau iu chnh nhp nhanh trn tht, c hai triu
chng o thi nhiu nc v Na+ qua nc tiu c th gp do gim tit ADH v tng
gii phng peptid o thi natri qua nc tiu ca nh. Nhng thay i v hormon ny
c th trung gian bi tng p lc nh tri v tng huyt p h thng, bng cch hot
ha receptor th tch ti ch.
7. Chn n do thn kinh
Gii phng ADH thng thp hn bnh thng hoc khng n nh ngi bnh
chn n do thn kinh, c l do ri lon chc nng no. Khim khuyt ny thng nh,
khi c a niu trc ht do kht.
8. Gan nhim m cp ngi c thai (acute fatty liver of pregnancy)
TN trung ng thong qua kt hp vi nhim m gan cp ngi c thai. C
ch bnh sinh cha r.
9. Hi chng Wolfram hoc hi chng DIDMOAD
C c im TN trung ng, i tho ng, teo th v ic, l bnh di truyn
ln nhim sc th thng vi s thm nhim khng hon ton.
Hi chng Wolfram c nguyn nhn t nht do hai gen khc nhau: WFS1 v
ZCD2, c hai c m ha trong cc protein ca li ni bo, hnh nh c tc dng n
cn bng calci ni m. Wolframin, l sn phm ca WFS1 c bc l trong mt s t
chc nh ty, nhn cnh tht v nhn trn th ca no. i tho nht trong nhng bnh
ny l do mt cc thn kinh tit vasopressin trong nhn trn th v ri lon qu trnh
chuyn ha tin cht ca vasopressin. Nhng bin i ca WFS1 cng l bm t ca i
tho ng typ 2.
III. CHN ON XC NH
Kht, ung nhiu, i nhiu, lng nc tiu trong ngy trn 3 lt, t trng nc
tiu thp (1,001-1,005), mt kh nng c c nc tiu, khng c thay i bnh l trong
thnh phn nc tiu. Vasopressin c tc dng iu tr c hiu.
IV. CHN ON PHN BIT
Hi v xut hin i nhiu, tin s gia nh gip chn on nguyn nhn TN.
Cn lm mt s nghim php sau y gip chn on phn bit:
1. Nghim php nhn nc
Ch nn tin hnh cho ngi bnh c i nhiu nhc trng, nng natri v
thm thu huyt tng bnh thng. Cch tin hnh nh sau:
Ngng cc thuc c nh hng n tc dng v tit ADH nh caffein, ru,
thuc l t nht 24 gi, cc yu t kch thch khc i vi tit ADH nh nn, h huyt
p cn c theo di gip cho phn tch kt qu.
37

 Nghim php c tin hnh vo bui sng. Theo di tng gi mt cn nng,

thm thu huyt tng, nng natri huyt tng, thm thu v th tch nc
tiu ca ngi bnh.
Ngi bnh c yu cu nhn ung nc ti khi cn nng c th gim 5%,
nng natri v thm thu huyt tng t ti gii hn cao ca bnh thng (Na >
145 v thm thu > 295 mOsm/kg, hoc thm thu niu o hng gi n nh
(bin thin < 5% trong vng 3 gi).
nh gi kt qu:
Nu thm thu nc tiu khng t c 300mOsm/kg trc khi nhng
thng s ny t c, loi b kh nng ung nhiu tin pht.
i tho nht khng hon ton: thm thu nc tiu s ln hn thm
thu huyt tng, nhng nc tiu vn cn c c di mc ti a.
i tho nht hon ton: thm thu nc tiu s duy tr thp hn thm
thu huyt tng.
Phn bit gia i tho nht trung ng v i tho nht do thn.
Tim di da Desmopressin liu 0,03 mcg/kg cn nng. o thm thu nc
tiu sau 30, 60 v 120 pht. i tho nht trung ng: thm thu nc tiu s tng
hn 50% so vi khi mt nc. i tho nht do thn: thm thu nc tiu c th
tng, nhng khng tng c trn 50%.
Nng ADH thu c trc, trong khi lm nghim php nhn nc c
biu din trn mt th c th gip phn bit gia i tho nht trung ng khng
hon ton, i tho nht do thn khng hon ton, v ung nhiu tin pht.
2. Nghim php truyn dung dch natri u trng
Nghim php nhn nc khng c kh nng phn bit gia ngi bnh c kh
nng c c nc tiu di mc ti a trong qu trnh nhn nc, truyn dung dch natri
u trng l cn thit t c mc ch ny.
Ngi bnh i tho nht khng hon ton (trung ng hoc thn) c th c kh
nng c c mt phn nc tiu tng xng vi khim khuyt v tit v tc dng ca
ADH. Truyn dung dch natri u trng v o nng ADH s gip phn bit gia
ung nhiu tin pht, i tho nht trung ng khng hon ton, i tho nht khng
hon ton do thn.
Cch tin hnh:
Truyn dung dch natri u trng (3%) vi tc 0,05-0,1 mL/kg/pht. Trong
1 n 2 gi, c 30 pht mt ln o natri v thm thu huyt tng.
nh lng ADH khi natri v thm thu huyt tng t n mc gii hn
trn ca bnh thng (Na >145 mEq/L v osmolality > 295 mOsm/kg).
Lp ng biu din sau phn bit gia ung nhiu tin pht, i tho
nht trung ng hay do thn khng hon ton.
38

Nghim php ny chng ch nh i vi ngi c nguy c gy tng gnh th tch

(nh ngi bnh ang c bnh tim hoc suy tim huyt).
V. IU TR
1. iu tr i tho nht trung ng
Thuc c ch nh nhiu nht iu tr TN trung ng l ng vn ADHdDAVP. So vi ADH (vasopressin), dDAVP (desmopressin) thi gian bn hy di hn,
khng gy co mch, t tc dng ph.
Thuc c th cho theo ng tim (di da, tnh mch), ng mi, hoc ng
ung.
dDAVP tim di da hoc tnh mch tc dng xut hin nhanh, thng cho
vi liu 1 n 2 mcg mt hoc 2 ln /ngy.
Theo ng mi, tc dng xut hin cng nhanh, c th cho liu 1 n 4 ln
xt/ngy (10 mcg mt ln xt) chia ra 1 n 3 ln ngy.
Theo ng ung, thuc tc dng sau 30 60 pht, liu 0,1 n 0,4 mg t 1
n 4 ln /ngy, liu ti a 1,2 mg /ngy. dDAVP ung rt c tc dng, nhng b hn
ch mt s ngi bnh v rut hp thu km, gim sinh kh dng.
Thay i t ng mi sang ng tim s tt hn v gim liu ti 10 ln. V sinh
kh dng thay i khi ung, nn khi iu tr bng ng ung cn iu chnh liu.
i vi ngi bnh n nh, dung np tt vi thuc ng ung, gim kht,
phng php n gin, an ton, cho liu dDAVP bt u 0,1 mg ung v nh gi s
p ng ca ngi bnh (nh gim lng nc tiu, tng p lc thm thu nc tiu,
gim kht).
Nu trong vi gi ngi bnh khng p ng hoc p ng khng y , c th
tng liu, c vi gi tng 0,1 mg cho ti khi t c hiu qu. Trong qu trnh iu tr
ngi bnh s c theo di lng nc tiu bi xut 24 gi, thm thu nc tiu, t
trng nc tiu.
Liu c th tng ti mc ti a 0,4 mg x 3-4 ln ngy (1,2mg) v nhng liu cao
hn c th ko di thi gian tc dng, nhng kh nng c c nc tiu thng khng
c tc dng hn. Trong sut qu trnh iu chnh liu ny, khuyn ngi bnh ch ung
nc khi kht trnh kh nng ng c nc v h natri huyt tng. Tng t,
khuyn ngi bnh ung nc khi kht phng tng natri mu v gim th tch
huyt tng ti li khi dDAVP ht tc dng. Cng thc ny c th p dng cho bt
k ngi bnh no n nh m c ch kht khng b nh hng (bnh thng), v c
tc dng c bit cho nhng ngi bnh b i tho nht thong qua (nh sau phu thut
tuyn yn hoc chn thng u), cn dDAVP s c chnh liu nu ngi bnh tip
tc c bng chng i tho nht. Theo di st trong thi gian di cho nhng ngi bnh
v cn bng nc v tnh trng i nhiu.
i vi ngi bnh b i tho nht mn tnh nhng c ch kht khng b ri lon,
c th p dng phc iu tr liu dDAVP c nh. C th cho liu thp nht lm
39

gim triu chng i tho nht n mc dung np c vi nguy c ti thiu h natri

huyt. V ngi bnh c kh nng b tnh trng tng natri huyt bng cch tng ung
nc bt k lc no khi kht, nhng khng c cch tng t xc nh tnh trng h
natri huyt nu ngi bnh ung nhiu do nguyn nhn khc. Nhiu ngi bnh cho
mt liu trc khi i ng gim i i m.
Nhng ngi bnh i tho nht khng ung nhiu (adipsic DI) iu tr cc k
kh, nhng ngi bnh ny cho dDAVP liu c nh, theo di st tnh trng mt nc
v iu chnh lng nc vo bng cc thng s gin tip nh cn bng nc in gii
(o cn nng hng ngy).
Mt s thuc khc cng c tc dng iu tr i tho nht trung ng:
Chlopropamid (Diabinese) l thuc h ng huyt, n c tc dng lm tng
ti hp thu nc qua ADH, liu thng thng 125 n 500mg mt ngy, c th cho ti
4 ngy vi liu ti a.
Carbamazepin, liu 100 n 300mg hai ln /ngy c tc dng tng p ng i
vi ADH.
Clofibrat liu 500mg c 6 gi cho mt ln ci thin tnh trng i nhiu do
tng gii phng ADH.
Ch n gim mui kt hp vi li tiu thiazid c tc dng iu tr i tho
nht trung ng do gim th tch nh, tng ti hp thu natri v nc ng ln gn,
thuc c tc dng tt hn khi iu tr i tho nht do thn.
Indomethacin l thuc chng vim khng thuc nhm steroid c th lm tng
kh nng c c nc tiu ca thn do c ch tng hp prostaglandin thn, gim tc
lc v tng p ng ca thn i vi ADH.
Mt s trng hp ngi bnh i tho nht c triu chng nn, bun nn, au
u, chng mt, gy ri lon nc v in gii, cn bi ph nc in gii v kp thi.
iu tr cc bnh phi hp nu c.
Nng cao th trng, b sung cc vitamin thit yu.
2. iu tr i tho nht do thn
V thn khng p ng vi ADH, dDAVP khng c hiu qu. Nu i tho nht
do thn mc phi, tnh trng c c nc tiu s c ci thin mt cch nhanh chng
sau khi ngng thuc gy i tho nht v iu chnh ri lon in gii.
iu chnh bng ch n hn ch mui v li tiu thiazid (v d
hydrochlorithiazid, 25mg ngy 1-2 ln). Thiazid c tc dng lm gim chung bi xut
nc t do v in gii do kch thch hp th natri ng ln gn v hn ch o thi
natri ng ln xa. Theo di tnh trng gim th tch v h kali mu.
Amilorid c th lm tng tc dng ca li tiu thiazid do lm tng bi xut natri
v do tc dng chng bi niu a n gim th tch cn gim bi xut kali. Amilorid
cng dng iu tr ngi bnh i tho nht do ung lithi ko di, v n chn knh
natri ng gp, qua knh ny lithi i vo v tng tc gia ng thn vi ADH.

40

Cc thuc chng vim khng thuc nhm steroid cng c tc dng tt iu tr i

tho nht do thn v n lm gim mc lc thn, gim tng hp prostaglandin l i
khng vi tc dng ca ADH.
V mt s trng hp i tho nht do thn l i tho nht khng hon ton,
dDAVP cng c th c hiu qu i vi nhng ngi bnh ny.
VI. THEO DI BNH NHN
Ngi bnh i tho nht trung ng c iu tr bng phc liu c nh cn
theo di tnh trng h natri huyt, i khi th ngng dDAVP xem a niu c ti li
khng, v natri huyt thanh cng c kim tra nh k.
Ngi bnh i tho nht nn mang trong mnh th y t ghi r tnh trng bnh
ca mnh (nh ngi bnh i tho ng), khi c cp cu t xut, nhn vin y
t d x l.
TI LIU THAM KHO
1. Thi Hng Quang (2008). Bnh Ni tit. Nh xut bn Y hc.
2. Mai Th Trch, Nguyn Thy Khu (2003). Ni tit hc i cng. Nh Xut
bn Y hc - Chi nhnh Thnh ph H Ch Minh.
3. The Washington Manual (subspecialty consult series) (2009). Endocrinology
subspecialty consult. Second Edition.
4. The Washington Manual of Medical Therapeutics. 33rd Edition (2010).
5. David G. Gardner. Dolores Shoback. Greenspans Basic and clinical Endocrinology,
9 Edition. 2011.
th

41

HI CHNG TIT ADH KHNG THCH HP

(Syndrome of Inappropriate AntiDiuretic Hormone - SIADH)

I. I CNG
Hi chng tit hormon chng bi niu khng thch hp (SIADH- Syndrome of
inappropriate antidiuretic hormone) l nguyn nhn thng gp nht gy h natri mu,
do tit khng thch hp ADH t thy sau tuyn yn hoc t ngoi tuyn yn.
Phn loi:
H natri mu nh: Na huyt tng < 135 mmol/L; gp 15-20% ngi bnh
SIADH, v khong 7% ngi bnh iu tr ngoi tr.
H natri mu trung bnh: Na huyt tng < 130mmol/L; gp khong 1-7%
ngi bnh nm iu tr ni tr trong bnh vin.
Tuy nhin, gn y ngi ta xc nh c mt t bin trong receptor ca
vasopressin l nguyn nhn gy nn mt hi chng, trong c y cc tiu chun
chn on SIADH, nhng nng ADH thp hoc khng xc nh c. V vy, mt
s tc gi gi y l Hi chng bi niu khng thch hp (Syndrome of inappropriate
antidiuresis- SIAD). Tuy nhin, th bnh ny t gp nn hin ti vn s dng cm t
SIADH trn lm sng.
ADH (hoc arginin vasopressin-AVP) l thnh phn ch yu tham gia vo c ch
cn bng ni m iu ha s cn bng nc trong c th. ADH c tit t thy sau
tuyn yn khi tng thm thu (osmolality) huyt tng v gim th tch trong lng
mch. thn, ADH tc ng thng qua vasopressin V2 receptor lm tng tnh thm
nc ng ln xa v ng gp, tng ti hp thu nc nhng v tr ny. Cng vi tng
tit ADH, h natri mu ha long (dilutional hyponatremia) do nc khng th bi xut
ra ngoi nh bnh thng.
SIADH c th xy ra khi ADH c tit ra t ngoi tuyn yn cc t chc c
tnh hoc t chc b vim.
Triu chng chnh ca SIADH l tng mt cch khng thch hp thm thu
nc tiu, trong khi thm thu huyt tng thp, c trng hn l gim natri mu
nhc trng, nc tiu c c tng i, nhng th tch mu bnh thng (euvolemia),
chc nng thn, tuyn gip, v thng thn u bnh thng.
II. NGUYN NHN
1. Ti h thn kinh trung ng
Gii phng ADH qu nhiu), i ra porphyril cp tng lc, chy mu
(hematoma/hemorrhage), tai bin mch mu no, chng m sng do nghin ru, hi
chng Guilain-Barre, chn thng u, no ng thy (hydrocephalus), nhim khun
(vim mng no, vim no, p xe), khi u.
42

2. Do thuc
Bromocriptin mesylat (bromocriptin), Carbamazepin (Tegretol), Chlopropamid,
Clofibrat, Cyclophosphamid, Desmopressin (DDAVP), Ecstasy, Haloperidol (Haldol),
Nicotin, Opiat, Oxytocin, Phenotiazin, Selective serotonin reuptake inhobitors (SSRIs),
Tricyclicantidepressants, Vinblastin, Vincristin.
3. Cc nguyn nhn khc
HIV, nn, nhng ri lon thn kinh-tm thn (tng kht, tng nhy cm ca thn
i vi ADH), au, tnh trng sau phu thut (truyn mt lng nc qu nhiu).
4. Ung th (Tit ADH ngoi tuyn yn)
Carcinoma hnh t trng, u lympho bo, u trung biu m (mesothelioma), u nguyn
bo thn kinh khu gic (olfactory neuroblastoma), carcinoma tuyn tin lit, carcinoma t
bo nh phi, u tuyn c, cc bnh phi, dn ph qun, bnh phi tc nghn mn tnh
(COPD), x nang (cystic fibrosis), vim phi, PCP (Pneumocystic carrinii pneumonia), lao,
nm (aspergillosis), thng kh p lc dng (positive pressure ventilation).
III. CHN ON
1. Lm sng
Cng nh cc nguyn nhn khc gy h natri mu, triu chng ca SIADH ph
thuc vo mc h natri mu v s pht trin nhanh ca bnh. Him khi gp hi
chng khi nng natri huyt tng 125 mEq/L, nhng khi h natri mu cp (< 48
gi), ngi bnh c th c triu chng: kh , nn.
Khi natri huyt tng < 125 mEq/L, ngi bnh c th c cc triu chng thn
kinh tm thn t mt mi, yu c, au u, ng lm (lethargy), mt iu ha (ataxia) v
bnh tm thn, n ph no, tng p lc ni s, chng mt, hn m.
SIADH c chn on bng cch loi tr, v vy cc nguyn nhn khc gy h
natri mu cn c loi b.
2. Cn lm sng
thm thu (osmolality) huyt tng thp (< 275 mOsm/kg nc l c SIADH.
thm thu nc tiu v nng natri nc tiu tng khng thch hp:
thm thu nc tiu > 100 mOsm/kg nc, nng natri nc tiu > 20 n 40 mEq/L
(thng xuyn gp trong SIADH).
Th tch huyt tng bnh thng, chc nng thn, thng thn, tuyn gip
bnh thng.
Khng dng cc thuc li tiu trong thi gian gn y.
3. Tiu chun chn on b sung
Nghim php ti nc khng bnh thng: Cho ung nc 20 mL/kg trng
lng c th trong 10-20 pht, sau 4 gi khng thi c 80% lng nc a vo
43

v/hoc khng ha long thm thu nc tiu n 100 mOsm/kg nc. Nghim php
ny s c thc hin sau khi nng natri huyt tng > 125 mEq/L bng cch hn
ch nc v / hoc cho mui.
Nng ADH huyt tng tng khng thch hp lin quan vi thm thu
huyt tng.
IV. CHN ON PHN BIT
Khng ging nh tng natri mu thng xuyn u trng, h natri mu c th
nhc trng, ng trng hoc u trng.
1. H natri mu u trng (hypertonic or translocational hyponatremia)
Xy ra khi cc dung dch c p lc thm thu (nh glucose hoc mannitol) ko
nc t trong t bo ra ngoi. C tng mi 100mg/dL (5,6 mmol/L) glucose huyt
tng, th nng natri huyt tng gim 1,6-2,4mmol/L.
2. H natri mu ng trng
L do tch mt th tch ln dch ng trng khoang ngoi t bo (nh dung
dch mannitol ng trng) khng cha natri.
C h natri mu u trng v ng trng thng d xc nh da vo lch s
bnh, cc thm d ha sinh hoc c hai.
3. Th gi h Na mu (Pseudohyponatremia)
L th h natri mu ng trng, nguyn nhn l do nh lng sai natri mu khi
c tng triglycerid v paraprotein mu, trn thc t, sai st ch xy ra khi s dng nhng
k thut o khng c hiu, ch cn tham kho kin cc nh ha sinh c kinh nghim
l c th loi tr c.
Chn on phn bit SIADH l chn on vi nhng nguyn nhn lm h natri
mu nhc trng. H natri mu nhc trng thng do nc a vo qu nhiu v/
hoc do ri lon bi tit nc tiu ca thn, c th xp loi theo tnh trng th tch
mu nh sau:
4. H natri mu nhc trng tng th tch (Hypervolemic hypotonic hyponatremia)
c trng bi natri mu v tng nc trong ton c th. Nguyn nhn thng
gp l suy tim tr, x gan, hi chng thn h, suy thn cp v mn tnh, c thai. Tt c
nhng tnh trng trn y u c th xc nh c trn lm sng.
5. H natri mu nhc trng gim th tch (Hypovolemic hypotonic hyponatremia)
c trng bi h natri mu v mt nc ton thn. Nguyn nhn thng gp l:
dng li tiu (thuc hoc thm thu), bnh thn mt mui, suy thng thn cp, mt
in gii qua ng tiu ha, ra m hi qu nhiu, mt mu, mt s bnh l khc nh
vim ty cp hoc bng nng.

44

Mt s ngi bnh b bnh hoc tn thng thn kinh, mt mui no (cerebral salt
wasting) l nguyn nhn khc ca gim natri mu nhc trng gim th tch, thng b
nhm vi SIADH khi tnh trng th tch kh xc nh. Nhng ngi bnh b mt mui
no c th khng gim th tch mu trn lm sng, nhng c th pht hin tnh trng
gim th tch khi theo di tht cn thn (nh theo di chnh xc lng nc vo v
lng nc ra). C ch bnh sinh ca th bnh ny cha c hiu y , ngi ta cho
rng do gim xung thn kinh n thn hoc tng gii phng yu t o thi natri lu
hnh trong mu (nh atrial natriuretic peptide hoc brain natriuretic peptide) lm mt
natri v gim th tch mu.
6. H natri mu nhc trng th tch bnh thng (Euvolemic hypotonic
hyponatremia)
c trng bi nng natri ton thn thp hoc bnh thng, nc ton thn bnh
thng hoc tng, nguyn nhn thng gp nht l SIADH, nhng cng c th do suy
chc nng tuyn gip, suy thng thn, ung nhiu tin pht (primary polydipsia),
potomania, dng li tiu thiazide, tp luyn qu nhiu, reset osmostat, hoc hi chng
thn ca SIADH.
Chi tit v nhng nguyn nhn ny nh sau:
7. Suy chc nng tuyn gip
t gp, c ch sinh bnh ca h natri huyt do suy tuyn gip cho ti nay cha r,
ngi ta cho rng do ri lon iu ha gii phng hoc thanh thi ADH, hoc c hai,
hoc do tc ng trn trng lc mch mu, cung lng tim v dng mu qua thn.
8. Suy chc nng tuyn thng thn
Cng l nguyn nhn gy h natri mu, nhng khng thng xuyn. ADH l
hormon kch thch tit ACTH v ty thuc vo c ch ngc m tnh ca
glucocorticoids. H natri mu c th xy ra trong c hai tnh trng suy thng thn tin
v th pht, c th do mt c ch ngc m tnh i vi tit ADH, ngoi ra, do mt tc
dng ca hormon chuyn ha khong (mineralocorticoid) trong suy thng thn tin
pht (nhng khng phi suy thng thn th pht).
9. Ung nhiu tin pht (primary polydipsia)
C th gy nn h natri mu nu nh lng nc a vo vt qu kh nng bi tit
ca thn. Bnh thng ung nc nhiu mt lc khng lm h natri mu, v ngi bnh
thng c kh nng bi tit trn 20 lt nc tiu trong ngy. H natri mu ch xy ra mt
s t ngi bnh b ung nhiu tin pht, nhng c ch ca hin tng ny cng cha r.
Nhng ngi bnh ny hnh nh c ri lon iu ha thm thu thanh lc nc t do, ri
lon ny ph thuc khng r vi tit v tc ng ca ADH khi b bin i.
10. Potomania
Gp nhng ngi ung qu nhiu bia, hin nay thng gp hn nhng ngi
c thi quen n ung bt thng hoc ri lon n (chng bing n do thn kinh).
45

Nhng ngi bnh ny thng c h natri mu nhc trng v nc tiu ha

long do dch vo v ra thp. Thanh thi nc t do ph thuc vo bi tit nc tiu ti
thn, v bi tit nc tiu ph thuc vo dch a vo. V vy, nu nh dch a vo
gim do n king, bi tit nc tiu cng s b gim, v thn s mt kh nng o thi
nc. Khi kh nng bi tit nc tiu ca thn gim, ch c khong 2-3 lt nc tiu
c bi tit trong ngy, nh vy, nu lng nc a vo vt qu 2-3 lt /ngy, s
nc d s b tch li trong c th v tham gia vo h natri mu.
11. Thuc li tiu Thiazid
Nguyn nhn c hiu nht gy h natri mu kt hp vi gim th tch, nhng
ngi bnh c th c th tch bnh thng nu nh a vo mt lng nc t ngoi
b tr cho tnh trng gim th tch v kht.
12. Gim natri mu do tp luyn
Hin nay c xc nh l mt th ca SIADH, thng xy ra nhng vn ng
vin chy marathon. Nhng ngi ny c th c triu chng thn kinh nng, ph no v
c th t vong, ri lon ny l do nc a vo qu nhiu trong tnh trng gim th tch
v mt nhiu nc do mt nhiu m hi trong thi gian di. Nhng ngi bnh ny c
tt c cc tiu chun chn on SIADH, c nng ADH tng khng thch hp trong
khi h natri mu nghim trng.
13. Hi chng thm thu do sp t li (Reset osmostat syndrome)
L mt hnh thi khc ca SIADH, trong c s dch chuyn im ct (setpoint) gii phng ADH lm thp hn thm thu, v vy, ngi bnh c th c
nc tiu c c khng thch hp trong khi natri mu h nhc trng, nhng c kh
nng nc tiu s c ha long bnh thng p ng khi nc a vo nhiu, v c
c nc tiu khi mt nc.
14. Hi chng thn do chng bi tit nc tiu khng thch hp (Nephrogenic
syndrome of inappropriate antidiuresis)
L mt hi chng di truyn mi c m t, trong c tt c cc tiu chun
chn on SIADH, nhng nng ADH khng xc nh c. Nhng t bin
vasopressin V2 receptor c xc nh nh l nguyn nhn u tin ca hi chng ny
hai tr nam h natri mu triu chng. V sau, nhiu c th khc cng c pht
hin nhng t bin tng t nh vy, trong c gia nh bc l cc phenotyp khc
nhau ca hi chng ny c nam v n.
V. IU TR
SIADH l hi chng t hn ch, chin lc iu tr u tin l iu chnh theo c
ch bnh sinh ca bnh c bn. Tuy nhin, k hoch iu tr tc th da trn mc
nng ca h natri mu v cc hi chng i cng
1. H natri mu triu chng (symptomatic hyponatremia)
Nguyn tc:
46

 H natri mu c triu chng cp l mt cp cu ni khoa, iu tr trc ht ty

thuc vo mc nng ca triu chng, sau l ty theo nng natri mu.
Cc triu chng thn kinh nng (nh mt tri gic, co git, hn m) phi c
iu tr nhanh chng bng dung dch mui u trng (3%) cho ti khi ht cc triu
chng trn.
Tuy nhin, iu chnh nng natri huyt tng qu nhanh (trn 12mmol/L
trong 24 gi), c th lm tiu myelin do thm thu (osmotic demyelination). Tiu
myelin cu no trung ng v ngoi cu no gy tn thng nng v thn kinh: lc
u l ng g (lethargy); sau cm, lon cn ngn (dysarthria), lit c t u, lit gi
hnh. V vy, iu chnh tnh trng h natri mu lun phi tin hnh thn trng.
Nu tc h natri mu nhanh (< 48 gi), tc iu chnh nhanh phi thch hp
bo m an ton.
Vi h natri mu ko di, mc tiu u tin l iu tr cc triu chng, vic iu
chnh nng natri mu s c tin hnh thn trng hn. C th, vi trng hp h
natri mu cp tnh hoc mn tnh khng xc nh c, tc iu chnh c gii hn
t 1 n 2 mEq /L/gi trong 3 n 4 gi u tin, v khng qu 0,5 mEq /L/gi. iu
chnh ti a 8 n 10 mEq /L trong 24 gi. Cc triu chng thng s mt i khi natri
mu thay i vi dung dch < 5% hoc t 3 n 7mEq /L.
Cch tnh t l dung dch natri u trng. Hai cch n gin nht nh sau:
Cch th 1:
Na huyt tng ([Na+] plasma) cn tng, bng n v mEq/L cho mt lt dch
truyn (gn ng) theo phng trnh sau y:
[Na+]plasma cn tng = ([Na+] dch truyn + [K+] dch truyn [Na+]huyt tng)
(Nc ton thn + 1).
Trong :
* [ Na +] dch truyn = mEq /L Na trong dch truyn
(v d: 513mEq /L ca dung dch Na 3%).
* [ K+] dch truyn = mEq /L K+ trong dch truyn
* Nc ton thn = cn nng c th (Kg) X (0,6 i vi nam v 0,5 i vi n).
V d:
Nu mt ngi n ng nng 70kg ang c nhng cn co git, nng natri
huyt tng l 110mEq/L;
Nng natri cn tng c tnh trong mt lt dung dch Na 3% s l:
(513 + 0 110) (0,6 X 70 + 1) = 9,4 mEq/L.
Nh vy, tng nng natri tc ban u l 2 mEq/L gi, dung dch NaCl
3% s truyn vi tc 213 mL/gi (2mEq/L/gi 9,4 mEq/L X 1000mL).

47

 Cch th hai:
i khi, dung dch Na 3% c th c khuyn co vi tc 1-2 mL/kg cn nng
c th trong mt gi lm tng nng Na t 1 n 2 mEq /L/gi.
Nhng ngi bnh hn m hoc c cn co git, tc ban u c th gp i.
Nhng ngi bnh nh, cho vi mt na tc .
V d, ngi bnh c cn nng cng 70kg, nng natri mu 110 mEq/L, c triu
chng co git, tc khi u dung dch NaCl 3% s l 210 n 280 mL/gi (3 n 4
mL /kg /gi X 70kg) .
Cn nhn mnh rng: Nu tnh trng mt nc ang tin trin, hoc nu li tiu
quai c ch nh lm tng bi tit nc t do v phng qu ti th tch, tc
truyn s c gim. Vi bt k cch tnh no, natri mu, v tnh trng th tch cn
phi c nh gi thng xuyn (bt u c 2 gi mt ln, v gim xung 4 gi mt
ln khi tc iu chnh n nh) theo di v tin hnh iu chnh iu tr.
i vi cc triu chng nh n trung bnh, dung dch Na 3% c th c s dng
mt cch cn thn lm tng nng natri mu v gim cc triu chng. i khi,
dung dch Na bnh thng cng vi li tiu quai c th c ch nh thay th dung
dch natri 3%, hoc vasopressin receptor antagonist cng c th cn nhc ch nh,
nhng phi ch , ch nh mt mnh dung dch natri bnh thng c th s lm xu i
tnh trng h natri mu nu nh thn khng c kh nng ha long nc tiu n
thm thu thp hn dung dch natri bnh thng (~ 300 mOsm/L). Du l cch tnh no,
tc iu chnh ban u s khng vt qu 2 mEq/L/gi v s gim nhanh ti khng
qu 0,5 mEq/L/gi (t ti a 8 n 10 mEq/L/ngy). Nng natri huyt tng v tnh
trng th tch cn phi nh gia thng xuyn theo di v iu chnh.
Thuc: Cc cht i khng receptor ca vasopressin c nhiu ha hn trong
iu tr SIADH.
Conivaptan (Vaprisol) l thuc u tin trong nhm thuc mi ny, c s dng
M nm 2005, tim tnh mch iu tr h natri mu th tch mu bnh thng (k c
SIADH), v nm 2007 iu tr h natri mu tng th tch (hypervolemic hyponatremia).
Conivaptan l cht i khng khng chn lc receptor ca vasspressin (V1a v
V2) chuyn ha theo ng CYP3A4.
Thuc chng ch nh khi h natri gim th tch (hypovolemic), hay cho cng vi
nhng cht c ch mnh CYP3A4 nh ketoconazol, itraconazol, clarithromycin,
ritonavir v indinavir.
Liu 20mg truyn tnh mch trn 30 pht, sau truyn lin tc 20 mg/ngy t 1
n 3 ngy (ti a 4 ngy). Liu c th tng ti 40mg /ngy nu nng natri khng
tng mc mong i.
Phn ng ti ch tim thng nh, nhng thng xy ra 50% ngi bnh, v vy
nn lun chuyn v tr tim trong ngy. H huyt p ng mch cn quan tm v tc
dng i khng receptor V1a ca thuc, nhng y khng phi l tc dng ph nghim
trng. Nhn chung thuc dung np tt.
48

2. H natri mu khng triu chng (asymptomatic hyponatremia)

H natri mu c th khng c triu chng nu mc h natri mu nh, hoc
nu bnh tin trin t t theo thi gian, cc triu chng nng v thn kinh thng t xy
ra khi tnh trng h natri mu tin trin t t, mn tnh, nhng nguy c xy ra tiu
myelin do thm thu (khi iu chnh h natri mu) c th nhiu hn, v vy k hoch
iu tr l lm tng dn dn natri mu.
iu c bn nht trong iu tr h natri mu khng triu chng do SIADH l
hn ch nc, cho bi tit nc t do trong nc tiu vt qu nc a vo trong
ch n. Ch nh thch hp i vi hn ch nc c th c xc nh bng nh
lng natri mu v mt mu nc tiu ly ngay (tc th) nh lng Na+ v K+, xc
nh t s in gii gia nc tiu v huyt tng mu.
U/P ratio = ([Na+]nc tiu + [K+]nc tiu) [ Na+]huyt tng
Trong :
* [Na+] nc tiu = mEq /L Na trong nc tiu
* [K+] nc tiu = mEq/L K trong nc tiu
* [ Na+]huyt tng = mEq/L Na trong huyt tng
Nu nh: t l U/P 1,0
0,5 1,0

Hn ch nc ti a
Hn ch nc 500mL/ngy

0,5
Hn ch nc 1000mL/ngy
Nu h natri mu nng hn (di 110mEq/L), ngi bnh tng nguy c xy ra
nhng triu chng nng, v vy, ngay c khi khng c triu chng cng phi iu chnh
h natri mu vi tc ti a 0,5 mEq/L/gi, v khng vt qu 8 n 10 mEq/L trong
24 gi. Dung dch NaCl u trng (hypertonic saline) hoc cht i khng receptor
vasopressin cng c th p dng t c mc tiu, nhng phi ngng sm khi nng
natri mu t xp x 120- 125 mEq/L, sau bt u iu tr bo tn.
Cn cung cp y mui v protein trong khu phn n, v thn thanh thi ti
a nc t do ph thuc vo dch vo v o thi ra. Cho ngi bnh ung ure 30 gram
/ngy c chng minh c hiu qu, nhng ngi bnh km dung np nn khng
c p dng rng ri.
C th b sung li tiu quai lm tng bi xut nc t do.
Nu ngi bnh b SIADH, t bn thn khng th, hoc khng tun th ch
hn ch nc c th cho Demeclocycline (Declomycin). Declomycin c ch tc dng
ca ADH trn thn, c th ci thin nng natri huyt tng m khng phi hn ch
nc, liu khi u 600mg/ngy, chia ung 2-3 ln, ung sau n 1-2 gi. Thuc bt u
tc dng sau khi ung t 3 n 6 ngy. Tc dng ph ch yu l nhim c thn, v vy
chc nng thn phi c theo di cht.
Cc thuc i khng receptor vasopressin c hiu vi receptor V2 (tolvaptan,
lixivaptan) l thuc mi c trin vng iu tr lu di cho nhng ngi bnh SIADH
kh iu tr, nhng cha p dng ph bin trn lm sng.
49

VI. TIN LNG

Tin lng ph thuc vo nguyn nhn chnh, cng nh mc nng h natri
mu v nhng triu chng i km. H natri mu nng hoc h natri mu triu chng c
t l bnh v t l t vong cao hn h natri mu nh hoc khng triu chng, mn tnh.
SIADH thng khi khi iu tr dt im nguyn nhn chnh gy nn hi chng ny.
TI LIU THAM KHO
1. Thi Hng Quang (2008). Bnh Ni tit. Nh xut bn Y hc.
2. Mai Th Trch, Nguyn Thy Khu (2003). Ni tit hc i cng. Nh Xut
bn Y hc - Chi nhnh Thnh ph H Ch Minh.
3. The Washington Manual (subspecialty consult series) (2009). Endocrinology
subspecialty consult. Second Edition.
4. The Washington Manual of Medical Therapeutics. 33rd Edition (2010).
5. David G. Gardner. Dolores Shoback. Greenspans Basic and clinical Endocrinology,
9 Edition. 2011.
th

50

Chng 2. BNH TUYN GIP

CNG CHC NNG TUYN GIP
I. I CNG
Cng chc nng tuyn gip hay cng gip l thut ng ch tnh trng tuyn
gip tng tng hp v gii phng hormon.
Khi nng hormon tuyn gip lu hnh trong mu tng cao s tc ng gy ri
lon chc nng ca cc c quan v t chc trong c th dn n nhim c hormon
tuyn gip.
Nhim c gip l thut ng ch nhng biu hin sinh ha, sinh l ca c th
gy ra do d tha nng hormon tuyn gip lu hnh trong mu.
Trng thi lm sng ca cng gip ph thuc vo nguyn nhn gy bnh, c ch
bnh sinh v mc bnh. Tuy nhin, bnh cnh lm sng chung l tnh trng nhim
c gip. Trong nhiu trng hp khi nim cng gip v nhim c gip c th s
dng thay th cho nhau.
II. NGUYN NHN, PHN LOI
1. Phn loi nguyn nhn gy cng gip
Da theo sinh l bnh hc c th xp loi cng gip thnh hai nhm chnh.
1.1. Cng gip do tng s kch thch
Bnh Basedow (bnh Grave).
Cha trng hoc choriocarcinoma (carcinoma m nui), u qui gip bung
trng (struma ovarii).
Ung th tuyn gip.
Adenom thy trc tuyn yn tit qu nhiu TSH.
Ngoi tr adenom thy trc tuyn yn, tt c cc trng hp cn li u c nng
TSH thp do b c ch bi lng hormon tuyn gip qu nhiu lu hnh trong mu.
1.2. Cng gip t ch
Mt phn m ch tuyn gip tng sinh v tr nn cng chc nng. Hu qu l s
kim sot t tuyn yn b c ch, m ch gip ngoi vng tn thng cng b c ch theo.
Bu tuyn gip n nhn hoc a nhn c cng gip.
Vim tuyn gip bao gm vim tuyn gip bn cp, vim tuyn gip c au,
vim tuyn gip thm lng, vim tuyn gip sau .

51

 Hin tng iod-Basedow.

Do dng thuc (amiodaron), hormon tuyn gip.
2. Phn loi nguyn nhn gy nhim c gip
2.1. Tng tng hp hormon ko di
Bnh Basedow.
U c tuyn gip a nhn.
U c tuyn gip n nhn (adenom).
Hin tng iod-Basedow.
Ung th m nui.
Do tng tit TSH.
Trong s cc nguyn nhn trn, ngoi tr hin tng iod-Basedow, cn li tt c
u c tng tp trung I131 ti tuyn gip.
2.2. Nhim c gip c gim tp trung I131 ti tuyn gip.
Nhim c gip t gi (Thyrotoxicosis factitia).
Vim tuyn gip bn cp.
Vim tuyn gip c nhim c thong qua (vim tuyn gip c au, vim tuyn
gip thm lng, vim tuyn gip sau ).
T bo tuyn gip lc ch - u qui gip bung trng (struma ovarii), ung th
tuyn gip di cn.
III. BNH BASEDOW
1. nh ngha, danh php
nh ngha: Bnh Basedow c c trng vi tuyn gip to lan ta, nhim c
hormon gip, bnh mt v thm nhim hc mt, i khi c thm nhim da.
Bnh c gi di mt s danh php khc nhau ty thuc vo thi quen ca tng
quc gia, chu lc. Nhng quc gia s dng ting Anh thng gi l bnh Grave, a s
cc nc thuc chu u gi l bnh Basedow. Vit Nam bnh thng c s dng
di hai danh php: bnh Basedow hoc bu gip lan ta nhim c. Tuy tn gi khc
nhau song khng c s khc nhau v bn cht v biu hin ca bnh.
Bnh Basedow l th in hnh v hay gp nht trong s cc bnh c cng chc
nng tuyn gip.
2. Yu t nguy c v c ch bnh sinh
2.1. Yu t nguy c
Bnh Basedow khng c nguyn nhn, song tn ti mt s yu t nguy c cho s
xut hin bnh, bao gm:
52

 Yu t gen, di truyn: cc thnh vin trong gia nh ngi bnh c th mc mt

s bnh t min nh vim tuyn gip Hashimoto, i tho ng typ 1, bnh thiu mu
c tnh. Bnh di truyn theo dng gi.
Nhim trng khng c hiu.
Chn thng tm l (stress).
Gii n sau tui dy th. T l mc bnh n/nam dao ng 7-10/1.
Thai sn.
S dng iod hoc thuc c cha iod nh amiodaron.
Nhim phng x.
2.2. C ch bnh sinh
Bnh Basedow l bnh c c ch t min, biu hin bng ri lon min dch t
bo v min dch dch th.
Ri lon min dch t bo c trng bi gim s lng v chc nng t bo
lympho T c ch (Ts-T suppresser), tng t bo lympho T h tr (Th-T helper). Cc
khng nguyn lp I ca h HLA tham gia vo hin tng cm ng ca Ts c t bo l
CD8, ng thi s din t lc ch khng nguyn HLA-DR trn b mt t bo tuyn
gip l iu kin tin quyt khi ng cc ri lon min dch. Cc t bo Th vi s
c mt ca monocyte v khng nguyn c hiu, mt mt sn xut ra interferon
(IFN), mt khc kch thch t bo lympho B c hiu sn xut ra khng th kch thch
tuyn gip m quan trng nht l khng th khng th th TSH (TRAb). y l khng
th kch thch t bo tuyn gip tng tng hp v gii phng hormon vo mu gy
cng chc nng ngi bnh Basedow.
3. Chn on
3.1. Lm sng
Biu hin bng s thay i chc nng ca nhiu c quan do hin tng d tha
hormon tuyn gip. Trong s cc c quan b nh hng, r nt nht gm h thn kinh,
tim mch, tuyn gip, mt, da v c, mt s tuyn ni tit v ri lon chuyn ha, iu
ha thn nhit.
3.1.1. Ri lon chuyn ha v iu ha thn nhit
Ngi bnh thng c biu hin ung nhiu, kht, n nhiu, mau i, gy st
cn. Lun c cm gic nng bc, ra nhiu m hi, c th st nh 37o5 38oC. Lng bn
tay m, m t, mng nc bn tay Basedow.
Khong 50% trng hp tiu chy khng km au qun vi s lng 5-10
ln/ngy do tng nhu ng rut v gim tit cc tuyn ca ng tiu ha.
Tng nng hormon tuyn gip dn n lon dng protid, lipid ca gan.
Bnh nng c th tng cc enzym gan, gim protein, ri lon tng hp v phn hy
53

cholesterol. Nhng ri lon trn cui cng c th dn n lon dng hoc x gan.
Chc nng tuyn ty cng c th ri lon gy tng glucose mu.
3.1.2. Biu hin tim mch
Tng nng hormon tuyn gip tc ng ln h tim mch thng qua ba c ch
ch yu: tc ng trc tip ln t bo c tim gy tng co bp ca t bo, tng tc vi
h thn kinh giao cm gy cng chc nng, v tc ng ln tun hon ngoi vi gy
tng tiu th oxy ngoi bin. Biu hin tim mch ngi bnh Basedow c trng bi
bn hi chng sau:
Hi chng tim tng ng:
Cc biu hin nh hi hp nh trng ngc, nhp tim nhanh thng xuyn gp
hu ht ngi bnh. Tn s tim dao ng trong khong 100-140 chu k/pht, i khi
c cn nhp nhanh kiu Bouveret, nhp nhanh kch pht trn tht.
Mch quay ny mnh, cng. Tng huyt p tm thu cn huyt p tm trng
bnh thng hoc gim.
Nghe tim c th thy T1 anh mm, ting thi tm thu gian sn III-IV
cnh c tri.
in tim thng c tng bin cc sng P, R, T. Khong PQ ngn li, tng
ch s Sokolow Lyon tht tri m khng c dy tht tri. Siu m tim thy tng cung
lng tim, tng phn xut tng mu v ch s co c tht tri.
Hi chng suy tim:
Ri lon huyt ng nng v ko di dn n suy tim, giai on u thng l suy
tim tng cung lng. Cung lng tim c th tng t mc 8-14lt/pht. Phn xut tng
mu c th t 65-75%. Suy tim thng xut hin ngi bnh cao tui, c bnh tim
mch trc , nhim c hormon mc nng. Tim to ch yu tht tri do ph i c
tim. Do tng cung lng tim nn cc triu chng suy tim trn lm sng thng ngho
nn, khng in hnh.
Rung nh: l bin chng hay gp do nhim c gip, c mt s c im sau:
Lc u ch l cn kch pht ngn, sau xut hin thng xuyn.
Trn in tim thy p ng tht nhanh, bin cc sng f, R cao c th km
theo cung ng nh.
Thng xut hin ngi cao tui, bnh nng. Rung nh c th t ht khi iu
tr ngi bnh v bnh gip.
Rung nh ngi bnh Basedow vn c th hnh thnh huyt khi nh tri gy
tc mch no.
Hi chng suy vnh:
Tng cung lng tim ko di dn n ph i c tim, lm cho cng ca c tim
tng dn n tng nhu cu oxy i vi c tim gy cn au tht ngc. Cn au tht ngc
54

c th xut hin c khi gng sc v khi ngh. Nhi mu c tim rt him gp. Tn thng
ch yu l do co tht ng mch vnh. Nu c cn au tht ngc th khi chp ng
mch vnh thng khng thy hp c ngha. Cn au tht ngc s gim hoc ht khi
ngi bnh v bnh gip.
3.1.3. Biu hin thn kinh - tinh thn - c
Triu chng thn kinh - tinh thn:
Thng biu hin bng tnh trng bn chn, tnh tnh thay i, d cu gt, xc
ng, gin d.
C th au u, chng mt, s nh sng, ri lon gic ng, mt mi, gim kh
nng lao ng.
Ri lon vn mch nh mt tng lc, tot m hi.
Run tay tn s cao, bin nh, thng u ngn, c th run li, mi, u, chn.
Ri lon tm thn c th xy ra nhng rt him, c th c cn kch ng hoc
l ln, hoang tng.
Tn thng c biu hin cc mc khc nhau nh mi c, yu c, nhc
c hoc lit c chu k. Tn thng c hay gp ngi bnh nam, tin trin t t, nng
dn. Khi kt hp vi bnh nhc c th yu c xut hin cc c vn ng nhn cu, c
nhai, nut, ni. Nu bnh nng c th lit c h hp. Lit c chu k c th xut hin t
vi gi n vi ngy, c th km theo gim nng kali huyt.
3.1.4. Bu tuyn gip
Tuyn gip to cc mc khc nhau, c c im bu lan ta (i khi hn
hp), mt mm, thy phi thng ln hn thy tri, khng c biu hin ca vim
tuyn gip trn lm sng.
Tuyn gip to ging nh bu mch v c th s thy rung miu, nghe thy ting
thi tm thu hoc lin tc ti cc cc ca tuyn, nht l cc trn.
Nu eo tuyn gip cng to s to ra bu hnh nhn chn p kh qun gy kh th.
C bit mt s ngi bnh, tuyn gip c th lc ch nm sau xng c hoc gc
li, pht hin c da vo x hnh tuyn gip.
3.1.5. Bnh mt do Basedow
Khong 50% ngi bnh Basedow c biu hin bnh mt trn lm sng. Bnh mt
l biu hin in hnh, c trng ca c ch t min ngi bnh Basedow.
C ch bnh sinh bnh mt do Basedow c th tm tt nh sau: Cc t khng
th, nht l TRAb sau khi hnh thnh s kt hp vi thyroglobulin hoc t bo lympho
Th to thnh phc hp khng nguyn khng th lu hnh trong mu ti hc mt. Ti
, phc hp ny kt hp vi cc c hc mt v t chc sau nhn cu gy ra hin tng
vim. Hu qu ca qu trnh vim l hin tng ph n, gi nc, ng cc

55

mucopolysaccharid v cc acid c tnh ht nc mnh nh acid hyaluronic, acid

chondrohytinsulfuric gy cn tr lu thng dng mu tnh mch, tng sinh t chc lin
kt, thm nhim cc t bo lympho v tng bo (plasmocyt). C ch ch yu ca li
mt l tng sinh thm nhim, ph t chc sau nhn cu, vim v thm nhim cc c vn
nhn dn n tng p lc sau nhn cu, y nhn cu ra pha trc gy li mt, x ha
cc cu trc ngoi nhn cu (gim lc gi nhn cu v tr sinh l) do vy li mt s
kh hi phc.
c im li mt ngi bnh Basedow:
Li mt c th xut hin c hai bn, cn xng hoc khng. 10-20% trng hp li
mt mt bn. Li mt c th xut hin khng song hnh vi bnh chnh; khong 20% s
ngi bnh li mt xut hin trc khi biu hin cng gip trn lm sng, 40% xut
hin ng thi vi bnh chnh v 40% xut hin sau cc triu chng ch yu ca bnh
thm ch khi bnh gip hoc suy gip sau iu tr. V tin trin, li mt c th gim
hoc ht khi ngi bnh bnh gip song nhiu trng hp s duy tr lu di.
Triu chng bnh mt do Basedow:
Triu chng c nng thng l cm gic chi mt, cm nh c bi bay vo
mt hoc au nhc h mt, chy nc mt.
Li mt c th km theo ph n mi mt, kt mc, gic mc, sung huyt gic
mc, au khi lic mt hoc xut hin nhn i (song th).
Nu li mt mc nng c th tn thng gic mc, dy thn kinh th gic
gy mt th lc (m).
Vim thm nhim cc c vn nhn lm xut hin mt s du hiu ri lon
trng lc thn kinh ca cc c ny dn n ri lon hi t nhn cu hai bn, h khe mi,
mt ng vn gia nhn cu vi mi mt v c trn, mi mt nhm khng kht.
Chp ct lp in ton hc mt c th thy biu hin vim dy, ph i thm
nhim cc c gi nhn cu.
3.1.6. Bin i chc nng mt s tuyn ni tit
Ri lon chc nng tuyn ni tit sinh dc n gy ri lon chu k kinh nguyt.
Bnh nng c th teo t cung, bung trng hoc tuyn sa. C th sy thai hoc v sinh.
Nu bnh xut hin tui dy th th ngi bnh thng chm xut hin kinh nguyt v
cc biu hin sinh dc th pht. ngi bnh nam xut hin gim ham mun tnh dc,
v to hoc chy sa.
Ri lon chc nng tuyn thng thn. Nu bnh nng, ko di c th gy
gim chc nng tuyn thng thn vi biu hin gim tng hp, gii phng hormon
corticoid dn n cm gic mt mi, v lc, xm da, h huyt p.
Cng sn tuyn c v h thng lympho (hch, lch) hay gp ngi bnh
tui thiu nin, dy th hoc bnh mc nng.

56

3.1.7. Mt s biu hin khc him gp

Ph nim trc xng chy gp 5-10% trng hp do thm nhim da. Trn
lm sng rt him gp biu hin ny.
Bnh to u chi do tuyn gip thyroid acropachy, biu hin bng ph i u
ngn chn, tay, i khi c ngn tay di trng, thng gp ngi bnh c ph nim
trc xng chy hoc li mt.
Vt bch bin da, vim quanh khp vai.
3.2. Cn lm sng
3.2.1. nh lng hormon
Tng nng T3, T4, FT3, FT4; gim nng TSH.
3.2.2. tp trung iod phng x ti tuyn gip c mt s c im:
Ch s hp thu ti cc thi im tng so vi ngi bnh thng.
Tc tng nhanh, sm cc gi u (2-6 gi).
Ch s hp thu cao nht cc thi im 6-8 gi sau gim nhanh to ra gc
thot (gc chy) trn th.
3.2.3. nh lng nng cc t khng th
Quan trng nht l TRAb: bnh thng m tnh hoc nng rt thp khng
ng k. ngi bnh Basedow, TRAb dng tnh gp 80-90% trng hp.
Cc t khng th khng thyroglobulin - TGAb, khng th khng peroxidase
TPOAb bin i khng c hiu, khng c gi tr chn on bnh Basedow.
3.2.4. Mt s xt nghim bin i khng c hiu
Bao gm: gim cholesterol, tng glucose hoc calci huyt, gim bch cu ht.
3.2.5. Siu m tuyn gip
Gip xc nh th tch v th loi ca tuyn gip (lan ta, nhn hay hn hp).
3.2.6. Chp ct lp vi tnh in ton hoc cng hng t hc mt
S xc nh c biu hin ph i ca cc c vn nhn khi c li mt.
3.3. Chn on xc nh
Tuy bnh Basedow c nhiu triu chng lm sng, cn lm sng, song chn on
xc nh da vo mt s triu chng ch yu:
Bu tuyn gip to lan ta (hoc hn hp).
Nhp tim nhanh thng xuyn.

57

 Li mt.
Mt mi, nng bc, ra nhiu m hi, n nhiu, ung nhiu, st cn.
Thay i tnh tnh, d cu gt, ri lon gic ng, yu hoc lit c chu k, run tay
u ngn.
Tng nng hormon tuyn gip, gim TSH.
Tng tp trung 131I ti tuyn gip.
TRAb dng tnh hoc tng nng .
3.4. Cc th lm sng bnh Basedow
3.4.1. Th thng thng, in hnh
Nh m t.
3.4.2. Th bnh tr em v tui trng thnh
Thng c tuyn gip to hn, tr pht trin nhanh v chiu cao v xng nhanh
ct ha, biu hin sinh dc th pht chm pht trin, tr nh gim, kt qu hc tp km,
run tay bin ln.
3.4.3. Bnh Basedow ngi cao tui
Bnh Basedow la tui ny thng c biu hin rm r v tim mch song tuyn
gip to va phi, run tay bin ln, t c triu chng v mt.
3.4.4. Bnh Basedow ph n c thai
Ngi bnh Basedow khi mang thai d b xy thai, non hoc thai cht ngay sau
sinh. Thi gian u ca thai k, cc triu chng ca bnh nng ln, sau gim i v n
nh n khi sinh con. Sau khi sinh con v trong thi gian cho con b, bnh c th li
nng ln.
3.4.5. Th bnh theo triu chng lm sng
Th tim: Biu hin tim mch rm r, ni tri (cardiothyrotoxicosis).
Th tng trng lng: Thng gp ngi bnh n, tui tr, hay km theo mt
kinh, gp 5% cc trng hp bnh Basedow ni chung.
Th suy mn hay cn gi l th v cm: Thng gp ngi gi, triu chng
lm sng ni tri l gy st nhiu.
Th tiu ha: Tiu chy nhiu, gy st nhanh.
Th gi lit chu k thng km theo c h kali mu.
Th c ri lon tm thn biu hin bng cn kch ng hoc tnh trng l ln
hay hoang tng.

58

 Th theo triu chng sinh ha:

Cng gip do tng nng T3, cn T4 vn bnh thng, gp 5-10%
trng hp.
Cng gip do tng nng T4, cn T3 bnh thng. Th ny rt t gp.
3.5. Chn on phn bit
Bu nhn c (bnh Plummer) c biu hin tuyn gip to th nhn, trn x
hnh th hin l vng nng, khng c li mt, triu chng tim mch rm r, TRAb(-).
Vim tuyn gip bn cp c cng gip. Tuyn gip vim c au, to khng i
xng gia hai thy, mt chc, c biu hin ca vim.
Vim tuyn gip Hashimoto: khi bnh Basedow biu hin kn o hoc giai
on khng c nhim c hormon gip, i khi cn chn on phn bit vi vim tuyn
gip Hashimoto c tuyn gip to, mt chc nh g, TRAb (-) cn TGAb, TPOAb li
tng cao.
4. iu tr
4.1. Mc tiu v nguyn tc iu tr
Mc tiu trc mt l a ngi bnh v tnh trng bnh gip.
Duy tr tnh trng bnh gip trong mt khong thi gian t c khi bnh
bng cc bin php.
D phng v iu tr bin chng nu c.
La chn phng php iu tr thch hp vi tng ngi bnh.
C ba phng php iu tr c bn, bao gm: Ni khoa, phu thut tuyn gip
hoc iu tr bng phng x.
4.2. iu tr ni khoa
4.2.1. Chng li tng hp hormon tuyn gip
Thuc khng gip tng hp: l dn cht ca thionamid gm hai phn nhm:
* Phn nhm thiouracil (benzylthiouracil - BTU 25 mg; methylthiouracil - MTU
50mg, 100mg; propylthiouracil - PTU 50mg, 100mg).
* Phn nhm imidazol: methimazol, carbimazol (neo-mercazol), tt c u c hm
lng 5mg.
C ch tc dng ca thuc: ti tuyn v ngoi tuyn gip.
* Ti tuyn gip: (1) Ngn cn s hu c ha iod bng cch c ch gn iod vi
thyroglobulin; (2) Ngn cn s hnh thnh v kt hp ca monoiodotyrosin v
diiodotyrosin to ra hormon tuyn gip th hot ng (T3, T4); (3) Bin i cu trc
v km hm tng hp thyroglobulin.
59

* Ngoi tuyn gip: (1) c ch min dch (c th c trong v ngoi tuyn gip) th
hin bng gim trnh din khng nguyn, gim prostaglandin v cytokin c t bo
tuyn gip gii phng ra, c ch hnh thnh gc t do trong t bo lympho T v B; (2)
ngn cn s chuyn ngc t T4 v T3 ngoi vi.
Tc dng khng gip ca phn nhm imidazol mnh hn phn nhm thiouracil
khong 7 - 15 ln (trung bnh 10 ln), ng thi tc dng cng ko di hn (thi gian
bn thi ca imidazol 6 gi, thiouracil 1,5 gi); cho nn khi dng liu trung bnh c th
ch s dng 1 ln trong ngy. Ngc li, phn nhm thiouracil t gy d ng hn. Do
thuc gn vi protein mnh hn nn t ngm qua nhau thai v sa. V vy c th dng
cho ngi bnh mang thai hoc cho con b.
Liu lng v cch dng:
Ni chung liu iu tr v liu c c khong cch kh ln nn an ton cao. S
dng thuc thuc phn nhm no l ty theo thi quen ca bc s v ca tng quc gia,
chu lc. cc quc gia Bc M quen dng PTU, methimazol; cn chu u li hay
dng BTU, MTU, methimazol, carbimazol.
Liu thuc khng gip tng hp khc nhau ty giai on iu tr:
* Giai on iu tr tn cng: trung bnh 6 - 8 tun. Khi chn on chc chn
cng gip, nn dng ngay liu trung bnh hoc liu cao. Sau 10 - 20 ngy, nng
hormon tuyn gip mi bt u gim, v sau 2 thng mi gim r c th t c
tnh trng bnh gip.
Methimazol: 20 - 30 mg/ngy, chia 2 ln;
PTU: 400 - 450 mg/ngy chia 3 ln.
Cc tc gi Nht s dng liu ban u methimazol l 30 - 60mg/ngy; PTU l 300
- 600 mg/ngy; chia 3 - 4 ln trong ngy.
* Giai on iu tr duy tr: trung bnh 18 - 24 thng. giai on ny, liu thuc
gim dn mi 1 - 2 thng da vo s ci thin ca cc triu chng.
Methimazol mi ln gim 5 - 10mg; liu duy tr 5 - 10mg/ngy.
PTU mi ln gim 50 - 100 mg; liu duy tr 50 - 100mg/ngy.
Liu tn cng v duy tr cao hay thp ty thuc vo mc nng, nh ca bnh v
p ng ca tng ngi bnh, ty thuc vo ln ca tuyn gip, nng hormon
tuyn gip v TRAb.
Sau 6 - 8 tun u ca giai on iu tr tn cng, nu cc triu chng gim dn
v mc bnh thng v t c tnh trng gi l bnh gip th coi nh kt thc giai
on tn cng.
Tiu chun bnh gip:
* Ht cc triu chng c nng.
* Nhp tim bnh thng.

60

* Tng cn hoc tr li cn trc khi b bnh.

* Chuyn ha c bn < 20%.
* Nng T3, T4 (FT4) tr li bnh thng. Nng TSH s vn mc thp ko
di vi thng khi m nng T3, T4 tr v bnh thng.
Khi no ngng iu tr cc thuc khng gip tng hp: nu tnh trng bnh gip
c duy tr lin tc trong sut thi gian iu tr th sau 18 n 24 thng c th ngng.
Kt qu iu tr: 60-70% khi bnh. C khong 30-40% b ti pht sau khi ngng iu
tr vi thng. iu tr thi gian qu ngn, hoc khng lin tc thng l nguyn nhn ti
pht ca bnh.
* Nhng yu t cho php d on tin trin tt l:
Khi lng tuyn gip nh i.
Liu duy tr cn thit cn rt nh (thiouracil 50mg; hoc imidazole 5mg).
Nghim php Werner (*) tr li.
Trong huyt thanh khng cn hoc cn rt t TRAb.
I131 ti gi th 24 < 30%.
Tc dng khng mong mun ca thuc khng gip tng hp:
* D ng: vo ngy th 7 - 10 sau khi bt u iu tr, c th c st nh, mn
ngoi da, au khp, ch cn gim liu hoc cho cc thuc khng histamin, khng cn
ngng iu tr tr khi c d ng rt nng.
* Gim bch cu: khong 0,5% c th b mt bch cu ht, xy ra trong 3 thng
u iu tr. Trc khi iu tr cn th cng thc bch cu v trong cng gip cha
iu tr c th c gim bch cu l mt du hiu ca bnh.
Khi bch cu < 4000G/l hoc bch cu a nhn trung tnh < 45% th cn ngng
thuc khng gip tng hp.
* Ri lon tiu ho: t gp v thng ch thong qua. Hi chng hong m
thng do tc mt trong gan hoc vim gan (thc t rt him gp, c th xy ra nhng
ngi bnh th trng yu). Nu c hi chng hong m nn thay bng liu php iod,
dung dch lugol tm thi hoc vnh vin.
Chng ch nh dng cc thuc khng gip tng hp:
* Bu tuyn gip lc ch, c bit vi bu sau lng ngc.
* Nhim c ph n c thai hoc cho con b.
* Suy gan, suy thn nng.
* Bnh l d dy - t trng.
Iod v cc ch phm cha iod:
Iod v c l thuc khng gip xa nht m ngi ta bit, c dng ln u tin
bi Plummer (Mayo Clinic) nm 1923 c kt qu trong bnh Basedow.

61

 Nhu cu iod sinh l bnh thng ca mi ngi l 150 - 200g/ngy. Nu a vo

c th mt lng ln iod 200mg/ngy v ko di, s gy ra hin tng iod-Basedow.
Nu dng iod vi liu trong khong 5 - 100mg/ngy s c nhiu tc dng c
th dng iu tr bnh Basedow. Vi liu nh trn iod s:
* c ch gn iod vi thyroglobulin dn n gim s kt hp mono - v
diiodotyrosin v hu qu l gim tng hp T3, T4 dn n hiu ng Wolff- Chaikoff.
* Gim s phng thch hormon tuyn gip vo mu.
* Lm gim s ti mu tuyn gip a m gip v trng thi ngh ngi.
* c ch chuyn T4 thnh T3 ngoi vi.
Liu lng:
* Liu bt u 5 mg/ngy, liu ti u 50 - 100 mg/ngy.
* Liu iu tr thng thng:
Dung dch iod 1% 20 - 60 git (25 - 75,9mg), (1ml dung dch lugol 1% tng
ng 20 git c cha 25,3 mg iod).
Cch dng: chia lm 2-3 ln, pha vi sa, nc, ung vo cc ba n chnh.
Iod c tc dng sm nhng ngn, sau vi ngy thuc bt u c tc dng v mnh
nht t ngy th 5 - 15. Sau tc dng gim dn, mun c tc dng tr li cn c thi
gian ngh 1 - 2 tun.
Ch nh dng iod:
* Basedow mc nh.
* Phi hp iu tr cn cng gip cp: chng li s phng thch hormon gip
vo mu.
* Chun b cho phu thut tuyn gip: 2 tun trc v 1 tun sau phu thut, tc
dng gim ti mu v bt chy mu lc m, lm m gip chc li.
* Ngi bnh c bnh l gan (vim gan).
* C bnh tim km theo, cn h nhanh nng hormon gip.
Ngoi dng dung dch, iod cn c sn xut dng vin: bilivist vin nang 500mg,
iopanoic acid (telepaque) vin nn 500 mg.
4.2.2. c ch giao cm
C tc dng c ch hot ng ca thn kinh giao cm, c ch qu trnh chuyn
ngc t T4 v T3 ngoi vi. Thuc c tc dng sm sau vi ngy s dng, gim
nhanh mt s triu chng nh hi hp, nh trng ngc, run tay, bn chn, ra nhiu m
hi Vi liu trung bnh, thuc lm gim nhp tim song khng gy h huyt p.
Thuc c tc dng ngoi vi nn khng gim c cng gip, v vy phi
lun kt hp vi thuc khng gip tng hp. Trong cc thuc chn giao cm,
propranolol c khuyn co dng rng ri nht (Perlemuter - Hazard), liu 20-80 mg
mi 6-8 gi do tc dng ca thuc nhanh nhng ngn, c th dng 4 - 6 ln/ ngy.

62

 Chng ch nh: hen ph qun v bnh phi tc nghn mn tnh.

Thuc c dng trong giai on iu tr tn cng. C th dng thay th bng
metoprolol 1 ln/ngy do thuc c tc dng ko di. Nu c chng ch nh vi chn
giao cm, c th thay th bng thuc chn knh calci nh diltiazem liu 180 360mg/ngy chia 4 - 6 ln.
4.2.3. Kt hp thuc khng gip tng hp vi thyroxin.
Tc dng ca thyroxin khi phi hp vi thuc khng gip tng hp l:
Duy tr nng TSH mc thp (khong 0,05 - 0,1UI/ml) s gim c
nguy c bng n t khng nguyn cng vi tc dng gim hot tnh ca TRAb.
D phng suy gip do thuc khng gip tng hp.
Liu lng thyroxin trung bnh 1,8g/kg/ngy, thng ch nh trong giai on
iu tr duy tr sau khi bnh gip. d phng TRAb ti tng tr li c th duy tr
thyroxin n c 2 - 3 nm sau khi ngng thuc khng gip tng hp. Khi dng
thyroxin phi hp, nng TRAb gim c 60 - 70% ngi bnh. Methimazol
thng c ch nh kt hp vi thyroxin hn l PTU.
4.2.4. Corticoid
Tuy bnh Basedow c c ch t min dch, song trong iu tr, bn thn thuc
khng gip tng hp cng c tc dng c ch min dch, do vy corticoid v cc thuc
iu bin min dch khc khng c ch nh dng trong phc iu tr thng quy.
Corticoid ch nh dng ngi bnh Basedow khi:
C ch nh p dng b sung cc bin php iu tr li mt, khi dng liu
cao ng ung hoc tim truyn, thm ch dng liu xung (pulse - therapy).
Dng phi hp khi xut hin cn bo gip.
Khi ngi bnh c d ng vi thuc khng gip tng hp.
iu tr ph nim trc xng chy.
4.2.5. Cc thuc khc
Thuc an thn, trn tnh: Thng dng seduxen dng ung khi c ch nh
trong giai on tn cng.
iu tr thuc h tr v bo v t bo gan sut thi gian dng thuc khng gip.
B sung cc vitamin v khong cht.
4.2.6. iu tr li mt
Li mt l mt biu hin ca bnh Basedow, c th dn n mt s bin chng
nh nhn i (song th), gim hoc mt th lc. Li mt c th xut hin v tin trin
khng song hnh vi bnh chnh. Do , trong mt s trng hp cn b sung bin
php iu tr li mt.

63

 Ch nh iu tr li mt:
li mt trn 21 mm.
Li mt khng thuyn gim m tip tc tin trin khi bnh gip.
Vim mc nng hoc lot gic mc.
Ngi bnh nhn i hoc gim th lc < 8/10.
L do thm m.
Bin php iu tr li mt:
iu tr li mt phi kt hp vi iu tr bnh chnh t c bnh gip.
Bin php bo v ti ch: eo knh rm trnh gi, bi. Nh thuc chng kh
mt v vim kt mc. Nm u cao gim ph mt.
c ch min dch: S dng corticoid liu cao 40 - 60 mg/ngy dng ng
ung, trong 2 - 3 tun sau gim dn liu, c 10 ngy gim 10mg. t iu tr ko di
2 thng c khi ti 4 - 6 thng.
Ngoi ung c th tim corticoid hu nhn cu hoc di kt mc.
C th phi hp corticoid vi 6-mercaptopurin, cyclophosphamid, cyclosporin A.
Li tiu: gim ph t chc quanh v sau nhn cu. C th dng furosemid
40mg/ngy, mi tun dng 2 - 3 ngy.
Kt hp khng gip tng hp vi thyroxin: c tc dng gim nng v hot
tnh ca TRAb.
Khong 80 - 90% biu hin bnh l mt c ci thin khi phi hp khng gip
tng hp vi thyroxin. Liu thyroxin trung bnh 1,6 - 1,8 g/kg/ngy.
Chiu x hc mt: Tc dng chiu x hc mt c th gy ion ha, hnh thnh
gc t do, tc ng ln cc t bo trung gian nh macrophages, lymphocyt hoc lm
thay i s hnh thnh cc cht trung gian.
Chiu x hc mt cn c tc dng gim ph n cc t chc lng lo ca mt.
Nu kt hp vi corticoid s cho kt qu cao hn.
iu tr phu thut li mt c p dng khi cc bin php iu tr bo tn
khng hiu qu. Phu thut gim p lc hc mt bng phng php to l khuyt sn
di hc mt, ly ch cho nhn cu h xung. Phu thut cn nhm sa cha cc c
gi nhn cu b ph i, iu tr lc.
4.3. iu tr ngoi khoa bnh Basedow
4.3.1. Ch nh
iu tr ni khoa kt qu hn ch, hay ti pht.
Bu gip qu to.

64

 Basedow tr em iu tr bng ni khoa khng c kt qu.

Ph n c thai (thng th 3 - 4) v trong thi gian cho con b.
Khng c iu kin iu tr ni khoa.
4.3.2. Chun b ngi bnh
iu tr bng thuc khng gip tng hp sau 2 - 3 thng a ngi bnh v
trng thi bnh gip, hoc dng carbimazol liu cao 50 - 60mg/ngy trong mt thng
(Perlemuter-Hazard).
Iod: dung dch lugol 1% liu lng 30 60 git/ ngy, cho 2 - 3 tun trc khi
m, corticoid 20 - 30mg/ngy trc phu thut 1 - 2 tun.
Nu cho propranolol th phi ngng thuc trc phu thut 7 - 10 ngy.
4.3.3. Phng php m
Ct gn ton b tuyn gip li 2 - 3g mi thy trnh ct phi tuyn cn gip.
4.3.4. Bin chng ca phng php iu tr ngoi khoa
Chy mu sau m.
Ct phi dy thn kinh qut ngc gy ni khn hoc mt ting.
Khi ct phi tuyn cn gip gy cn tetani.
Cn nhim c hormon gip kch pht c th dn n t vong.
Chun b ngi bnh tt trc m l bin php phng xut hin cn nhim c
hormon gip kch pht trong phu thut.
Suy chc nng tuyn gip: suy chc nng tuyn gip sm xut hin sau m vi
tun. Suy chc nng tuyn gip mun xut hin sau m vi thng.
Bnh ti pht: nhng trung tm ln, 20% cc trng hp ti pht.
T l t vong di 1%.
4.4. iu tr bng ng v phng x I131.
4.4.1. Ch nh
iu tr ni khoa thi gian di khng c kt qu.
Ngi bnh > 40 tui c bu khng ln lm.
Ti pht sau phu thut.
Bnh Basedow c suy tim nng khng dng c khng gip tng hp di
ngy hoc khng phu thut c.

65

4.4.2. Chng ch nh
Ph n c thai, ang cho con b.
Bu nhn, bu sau lng ngc.
H bch cu thng xuyn.
4.4.3. Chun b ngi bnh
Cn dng thuc khng gip tng hp bnh gim hoc t bnh gip.
Ngng thuc khng gip tng hp 5 - 7 ngy, sau o tp trung iod I131
tuyn gip xc nh liu x.
Ngng s dng iod hoc cc dn cht c iod trc 2 - 3 tun.
4.4.4. Liu I131
Khong 80120Ci/ gam tuyn gip (tnh bng x hnh hoc siu m).
4.4.5. Tc dng khng mong mun ca bin php iu tr bng phng x
Gim bch cu.
Ung th tuyn gip.
Cn bo gip xut hin khi iu tr phng x cho ngi bnh ang c nhim
c gip mc nng hoc cha bnh gip ni chung.
Suy gip tm thi hoc vnh vin.
5. Tin trin v bin chng ca bnh Basedow
5.1. Tin trin
Bnh Basedow thng khng t khi m cn phi iu tr.
Khi c iu tr bnh, c th khi hon ton, song cng c th ti pht hoc
suy gip do tai bin iu tr.
5.2. Bin chng
Suy tim, lc u tng cung lng sau suy tim tr mn tnh.
Rung nh.
Cn bo gip.
Vim gan do lon dng sau c th x gan.
Song th, mt th lc (m) do li mt.
Suy gip hoc ung th ha lin quan n iu tr.

66

IV. CNG GIP DO MT S NGUYN NHN KHC

1. Bu tuyn gip a nhn c nhim c
C ch ca bnh cha hon ton sng t song nhiu trng hp c biu hin
lin quan n t bin gen ca th th TSH.
Mc tng tit hormon tuyn gip thng nh hn so vi ngi bnh
Basedow do biu hin nhim c gip cng t in hnh, khng rm r.
Biu hin tim mch thng ni tri nh nhp tim nhanh, rung nh, c th suy
tim. Cm gic mt mi, run tay cng hay gp. Khng bao gi c li mt.
Thng gp ngi bnh trn 50 tui, n hay gp hn so vi nam.
Nng hormon tuyn gip tng nh, TSH c th gim thp. Siu m pht
hin tuyn gip c a nhn vi cc kch thc khc nhau.
tp trung iod 131I ti nhn tng hp thu xen k gia cc nhn nng v lnh.
iu tr bng 131I l bin php ch yu.
Thuc khng gip tng hp v c ch giao cm dng cho ngi bnh t
bnh gip song phi ngng t nht 3 ngy trc khi iu tr bng phng x.
Phu thut ct b nhn tuyn gip sau mt t iu tr ni khoa hoc sau mt vi
liu phng x trc .
2. Adenom tuyn gip c nhim c (bnh Plummer)
C ch gy bnh do t bin gen ca th th TSH.
Nhn tuyn gip nm mt thy hoc eo tuyn, di ng, khng c tnh cht
bu mch, di ng, mt nhn.
a s trng hp c nhim c gip in hnh, triu chng tim mch cng
thng rm r. Khng c li mt.
Tui thng gp: 30 40 tui.
Xt nghim c tng nng hormon tuyn gip, gim TSH. Trong mt s
trng hp tng T3, cn T4 bnh thng.
X hnh tuyn gip biu hin bng nhn nng, vng cn li c th khng bt x.
iu tr ch yu bng phng x iod 131I hoc phu thut ct b khi u. Thuc
khng gip tng hp, c ch giao cm ch nh dng trc phu thut cho nhng
ngi bnh c biu hin nhim c gip r.
3. Cng gip thong qua do vim tuyn gip
Cng gip thong qua do vim tuyn gip bao gm vim tuyn gip bn cp,
vim tuyn gip thm lng, vim tuyn gip sau .
3.1. Vim tuyn gip bn cp t bo khng l
Bnh hay gp n, tui 30 - 50.

67

 Biu hin t t hoc t ngt, cc triu chng ca vim nh au lan ra gc hm

v tai, tng nhy cm ti tuyn gip, c th c nhim c hormon gip.
Tuyn gip to mt hoc hai bn, mt chc.
Tng nng hormon tuyn gip, gim TSH giai on u sau c th suy
gip gp 5 - 10%.
tp trung iod 131I ti tuyn gip gim.
Chc ht tuyn gip thy thm nhim nhiu bch cu lympho v a nhn trung
tnh cng vi cc u ht v t bo khng l nhiu nhn.
iu tr:
Corticoid liu cao 40 - 60 mg/ngy sau gim liu.
Dng aspirin hoc chng vim gim au khng steroitd.
Nu c cng gip th dng thuc khng gip tng hp, c ch giao cm
1 - 2 tun.
Khi c suy gip th dng hormon tuyn gip.
3.2. Vim tuyn gip thm lng
Cn gi l vim tuyn gip bn cp khng au c biu hin cng gip
thong qua.
Tin trin qua ba giai on: Giai on c nhim c gip vi nhiu biu hin
nh nhp tim nhanh, nng bc, ra nhiu m hi, st cn, au c, lit c chu k, tuyn
gip to lan ta, i xng mt hi chc. Sau giai on nhim c gip l giai on suy
gip thong qua v sau l giai on hi phc.
iu tr biu hin nhim c do vim tuyn gip thm lng ch cn dng c ch
giao cm, khng cn dng thuc khng gip tng hp v tng hormon tuyn gip l do vim.
3.3. Vim tuyn gip sau
Biu hin tng t nh vim tuyn gip thm lng.
Cng gip thong qua trong 3 - 6 thng xut hin sau giai on ton pht v
sau l suy gip trong vi thng v cui cng l giai on hi phc.
Tuyn gip to va phi, khng th khng TPO dng tnh.
iu tr tng t nh vim tuyn gip thm lng.
4. Cng gip do dng thuc c iod
Dng thuc c iod ko di, iod hu c dng chp X quang, amiodaron iu
tr lon nhp.
Biu hin cng gip km theo c hay khng c li mt.

68

 Nng T4 tng hn l tng T3. tp trung iod I131 thp hoc mt hn.
Sau khi ngng thuc c iod, biu hin cng gip c th thoi lui. Nu vn cn
tn ti cng gip th c th s dng thuc khng gip tng hp, c ch giao cm
trong 1 - 2 tun.
5. Cng gip do carcinom tuyn gip
Tuyn gip c th to, mt chc.
Biu hin nhim c gip gm: mt mi, st cn, hi hp, nh trng ngc,
nhp tim nhanh. Khng c triu chng li mt.
C th tng nng hormon tuyn gip, gim TSH thong qua.
Bin php iu tr: Ct b ton b tuyn gip sau x tr vi liu cao cho kt
qu tt.
6. Cng gip do cha trng (carcinoma m nui)
Triu chng lm sng, cn lm sng in hnh ca cng gip.
Khng c tuyn gip to, triu chng mt m tnh.
C ch: cc m ca m nui tit hCG-Human chorionic gonadotropin, c tc
dng ging TSH.
Cng gip ht nhanh sau khi no u m nui hoc ha tr liu.
7. Cng gip do u qui gip bung trng
U qui bung trng c th c m ca tuyn gip v m ny tr thnh cng
chc nng.
Biu hin cng gip thng nh nh nhp tim nhanh, st cn. Khng c tuyn
gip to v khng c li mt.
Hormon tuyn gip tng nh, tp trung I131 ti tuyn gip bnh thng song
iod phng x li tp trung h chu.
Bnh hi phc sau khi ct b u qui.
8. Cng gip do tuyn yn tit qu nhiu TSH
Hay gp adenoma thy trc tuyn yn. Mt s ngi bnh khng c u tuyn yn
gi l hi chng tit TSH khng tng thch.
Khi c u tuyn yn s c cng gip nh vi bu gip to, v kinh.
Tng ng thi hormon tuyn gip v TSH.
Hp th trng thi dng. Khi chp CT scanner s no s pht hin khi u
tuyn yn.

69

 iu tr: Thuc khng gip tng hp, phu thut ly khi u sau x tr. Nu
khng c khi u tuyn yn th y l mt kiu khng vi hormon tuyn gip ca
tuyn yn.
Nu ch c khng vi hormon tuyn gip tuyn yn th lm sng s c bu
gip to km cng chc nng v tng FT4, TSH. Nu khng vi hormon tuyn gip
c tuyn yn v ngoi bin th s c bu gip to, tng ng thi hormon tuyn gip
v TSH song chc nng gip li bnh thng hoc gim nh.
Nu c cng gip m khng c u tuyn yn th dng bromocriptin c tc dng
gim TSH v s kim sot c triu chng cng gip.
9. Cng gip di lm sng
Khi TSH gim nh song hormon tuyn gip vn bnh thng.
Triu chng lm sng c th st cn, lo lng, bn chn, rung nh.
Nguyn nhn c th l Basedow mc nh, u tuyn gip a nhn c, vim
tuyn gip thong qua.
Nu khng c biu hin triu chng trn lm sng th cn da vo xt nghim
hormon tuyn gip v TSH chn on.
Nu ngi bnh Basedow c biu hin cng gip di lm sng c th dng
mt t ngn thuc khng gip tng hp liu lng thp. Nu bu c th nhn th
dng x tr I131, nht l ngi bnh cao tui c nguy c cao gy ri lon nhp tim.
TI LIU THAM KHO
1. Thi Hng Quang (2008). Bnh Basedow. Bnh Ni tit. Nh xut bn Y hc, tr
111-158.
2. Mai Th Trch, Nguyn Thy Khu (2003). Cng gip. Ni tit hc i cng.
Nh Xut bn Y hc Chi nhnh Thnh ph H Ch Minh, tr 145-162.
3. Hong Trung Vinh (2008). Bnh Basedow. Bnh hc Ni khoa tp 2. Nh xut
bn Qun i nhn dn, tr 107-130.
4. Terry F.D, Larsen PR (2009). Thyrotoxicosis. Williams Textbook of endocrinology
10th edition, vol 1, pp 342 - 374.
5. Braverman LE; Utiger RD. Thyroid disease thyrotoxicosis. The thyroid A
fundamental and clinical text 8th edition. Lippincott Williams and Wilkins. pp 515-715.

70

CHN ON V IU TR CN NHIM C GIP CP

(Thyrotoxic crisis diagnosis and treatment)

I. I CNG
Cn nhim c gip cp (thyrotoxic crisis) l mt cp cu ni tit xy ra trn
ngi bnh c bnh l cng gip. Cn nhim c gip cp cn c gi l cn bo
gip (thyroid storm), mt bin chng nng nht trong qu trnh din tin ca bnh
cng gip, nht l bnh Basedow vi t l 1-2% trng hp nhim c gip nhp vin.
Cn nhim c gip cp c xem l tnh trng mt b ca cng gip c th gy nguy
him n tnh mng ngi bnh. Trc y thng gp trong bi cnh hu phu ngi
bnh cng gip, vi t l t vong rt cao. Nh chun b tin phu tt vi thuc khng
gip tng hp v Iod cng nh cc phng tin iu tr tch cc khi cn xy ra, hin nay
tin lng cho ngi bnh ci thin rt nhiu.
II. YU T THUN LI
1. Ni khoa
1.1. Lin h n iu tr
Khng c iu tr thuc khng gip tng hp.
Ngng t ngt thuc khng gip tng hp.
Ngng iu tr Lugol t ngt.
Bnh Basedow khng c iu tr.
Ung hormon gip (T3,T4) liu cao.
Nhim c Digital
Phn ng cp do thuc.
1.2. Sang chn th cht, tinh thn
Nhim trng cp, nng.
Chn thng (gy c xng i).
Nhim c thai nghn, gng sc lc sinh.
Nhim toan cetone trong i tho ng.
Bnh tim mch cp (Nhi mu c tim, tai bin mch mu no .. )
Suy tim
Suy thng thn cp.

71

 Nhi mu phi.
S pht trin ca mt s di cn lm tng tit hormon gip.
Sang chn tinh thn nng.
S nn tuyn gip nhiu ln (bu gip Basedow)
2. Ngoi khoa
Thng xy ra cc phu thut ct gim gip m ngi bnh cng gip khng
c chun b tt trc , cha t n bnh gip. Cng c khi bnh khi pht do mt
phu thut c quan ngoi tuyn gip ngi bnh mc bnh cng gip.
3. Y hc ht nhn
Sau iu tr bng Iode phng x liu qu cao. Ngi bnh c iu tr bng x tr
ti gip hay vng gn tuyn gip nhng khng c chun b tt.
III. C CH BNH SINH
Mt s cc gi thuyt c ghi nhn bao gm:
Gia tng qu mc nng hormon gip: Da vo cc triu chng lm sng
cng nh cn lm sng ging nh trong nhim c gip.
Gim nng hormon gip: Da vo cc thay i trn in tm nh: Sng T
thp hoc T1, T2 o ngc hoc PQ ko di, coi l du hiu do h Thyroxin gy ra.
Ri lon chc nng gan: Lin quan gia suy gan nng vi cn bo gip. Cc
triu chng au bng, i lng, phn nhy mu, ni lm nhm, c coi l mt giai on
ca hn m gan. Gia tng nng hormon gip c th lm cn ngun glycogen ca gan.
Cn bo gip c th tri qua nm giai on ni tip nhau ht sc nhanh, to
thnh mt vng lun qun, lm nng ln nhau bao gm:
(1) Cng trng lc ca h thng v no, h no, tuyn yn, tuyn gip c
sn trong cng gip.
(2) S tit cp tnh v tit qu nhiu hormon gip sau mt sang chn tm l
lm nng thm khu trn, dn ti nhim c hormon ti v no.
(3) Cng trng lc h no-giao cm vi s phng ra cc cht cng
adrenergic c duy tr bi sang chn tm l. S tit nhiu hormon gip tc ng xu
ti c tim.
(4) Suy thng thn cp do cn ngun hormon v thng thn.
(5) Suy gan cp v nng kt hp cathecholamine c phng thch lm tng
phn hu glycogene v lm tng tnh trng thiu oxy, lm nng thm cc triu chng
no ca nhim c gip.
Nhng nghin cu gn y ghi nhn nng T4 v T3 ngi bnh b cn bo
gip khng cao hn so vi ngi bnh cng gip n thun. Khng c bng c chng
t bo gip do gia tng sn xut Triiodothyronin.
72

C bng c cho thy ngi bnh cng gip c s gia tng cc im gn ca

Catecholamin, do t chc c tim v thn kinh c s gia tng s nhy cm i vi
Catecholamin. Hn na c s gim gn vi TBG (Thyroxin Binding Globulin) cng vi
s tng lng t do FT3, FT4.
Quan im hin nay cho rng vi s gia tng cc im gn ca Catecholamin i
km vi mt thng tn cp, nhim trng, hoc sang chn do phu thut gy nn s
phng thch Catecholamin, phi hp vi gia tng FT4, FT3 lm xut hin cn cng
gip cp.
IV. TRIU CHNG LM SNG
Thng din bin qua hai giai on.
1. Giai on bn cp
Gm bn hi chng ch yu:
Ri lon chuyn ha: St cao cao 39-40C, c khi trn 41C.
Nhp th nhanh 35-50 ln/pht.
V m hi, mt nc.
St cn, c khi mt t 5-10kg.
Ri lon tim mch: nhp tim nhanh, c khi > 140 ln/ pht, nhp nhanh xoang,
nhp nhanh kch pht trn tht, rung nh hoc Flutter.
Huyt p ng mch tng, nu huyt p h l du hiu xu.
Suy tim sung huyt tin trin nhanh dn n ph phi cp, tru mch.
Ri lon tm thn kinh-c: Mt ng, mt mi nhiu, teo c nhanh, run, kch
thch, c th gi lit c (ri lon nut), vt v, ri lon tm thn - vn ng.
Ri lon d dy, rut v gan: Ri lon tiu ha, nn, bun nn, tiu chy, au
bng, vng da.
Ngoi ra, mt s ngi bnh Basedow c th b li mt nng hn, bu gip to thm.
2. Giai on cp
Tnh trng ri lon thc, ni nhm, hoang tng, li b, co git, hn m. Trng
hp nng do ph no hoc xut huyt no.
V. TRIU CHNG CN LM SNG
Nng T3, T4, FT3 v FT4 gia tng.
Nng TSH gim.
Tuy nhin, nng hormon gip khng cao hn nhiu so vi ngi bnh
Basedow khng b cn bo gip. iu ny gii thch do cc yu t khi pht tim v t
chc thn kinh b tng nhy cm vi catecholamin lu hnh. Mt khc, ngi ta thy
ngoi s gia tng cc th th catecholamin, cn c s gim TBG (Thyroxin Binding
Globulin) a n gia tng FT3 v FT4.
73

 Cholesterol huyt tng gim.

Natri gim.
Ure mu tng.
Calci mu tng
Glucose mu tng. Tuy nhin nu h glucose mu l yu t tin lng do gim d tr
glycogen v gia tng s dng glucose ngoi bin v gim tn sinh ng do suy gan.
Nu tng kali, gim natri v tng calci mu th cn theo di suy v thng thn i km.
Ri lon chc nng gan vi bilirubin mu tng, thi gian prothrombin ko di,
men gan tng.
Cng thc mu: Hng cu tng nh, bch cu tng (ngay c khi khng c
nhim trng phi hp).
ECG: Sng T o ngc, rung nh hoc Flutter, PQ di hoc bloc nh tht hon ton.
Siu m tim nhm nh gi tnh trng suy chc nng, hnh thi v cu trc tim
rt thun li cho vic s dng thuc tim mch, nht l rung nh.
Ngoi ra, mt s xt nghim khc cn lm pht hin yu t thun li gy cn
cng gip cp nh: cy mu, chp X quang tim phi, xt nghim nc tiu...
VI. CHN ON
1. Lm sng
Giai on bn cp: Trn ngi bnh cng gip c st cao, tim p nhanh, ri
lon tiu ha nng, c triu chng kch thch tm thn vn ng, c th ngh n cn
cng gip cp.
Trong giai on cp: Da trn tnh trng ri lon tri gic, st cao, mch rt
nhanh, li b hoc hn m.
Bng 1: Bng nh gi cc tiu ch lm sng gi chn on cn bo gip
ca Burch v Wartofsky (2003)
Tiu ch chn on
Ri lon iu
nhit
(Nhit t)

ho

nh hng thn kinh

trung ng

74

im

37,2 - 37,7C

37,8 38,2C

10

38,3 38,8C

15

38,9 39,4C

20

39,5 39,9C

25

40C

30

Khng c

Nh (kch thch)

10

Trung bnh (ni sng, ri lon tm thn, l )

20

Nng (co git hoc hn m)

30

Tiu ch chn on
Ri lon d dy rut
v gan

Ri lon tim mch

(Tn s tim/pht)

Suy tim

Yu t thun li

nh gi:

im

Khng c

Tiu chy, nn, bun nn, au bng

10

Vng da (khng tm c nguyn nhn)

20

90-109

110-119

10

120-129

15

130- 139

20

140

25

Khng c

Nh (ph)

Trung bnh (ran m phi)

10

Nng (ph phi)

15

Rung nh

10

Khng c

10

Nu di 25 im th t kh nng b bo gip,
25-44 im: c kh nng l cn bo gip, v
Trn 45 im: th c nhiu kh nng l cn bo gip

2. Cn lm sng
T3, T4, FT3 v FT4 u tng
TSH gim.
VII. IU TR
1. iu tr ni khoa trong cn bo gip
y l iu tr cp cu chuyn khoa v th ngi bnh phi c nhp vin
khoa hi sc cp cu, cn nhanh chng iu tr ngay c khi chn on cn nghi ng,
khng i cc kt qu xt nghim. Trng hp ngi bnh b bnh khc khng phi
cng gip cp, mt liu thuc khng gip ban u s khng lm nng thm bnh cnh.
Ngi bnh cn c iu tr nguyn nhn song song vi iu tr triu chng:
1.1. Gim tng hp hormon gip
Dng thuc c ch tng hp hormon gip.
C ch tc dng:
Cc thuc khng gip u c tc dng c ch phn ln cc giai on tng
hp hormon gip (nht l iod ha qua trung gian TPO ca thyroglobulin to
thnh T3 v T4).
75

 Carbimazol c ch kh iod tuyn gip.

PTU c ch bin i T4 thnh T3 ngoi vi.
Dc ng hc:
i vi nhm Thiouracil, thi gian na i khong 90 pht, c th bt u vi
liu cao chia nhiu ln, khi t bnh gip th dng liu c nht vo bui sng.
i vi nhm imidazol: thi gian na i khong 6 gi, do c tc dng khng
gip trn 24 gi, dng liu c nht vo bui sng.
Tc dng ph ca thuc xy ra khong 5% trng hp biu hin tng i
a dng:
Nh: ri lon tiu ha, pht ban, ni my ay, st, au khp, mt v gic
(agneusie), vng da tc mt (ngng thuc), tng phosphatase kim.
Tc dng ph nng nh Lupus, hi chng Lyel, rng tc, hi chng thn h,
thiu mu, au a khp, au a r thn kinh, mt v gic.
Gim bch cu trung tnh c tnh: khi bch cu trung tnh <1200/mm3 phi ngng thuc nu e da chng mt bch cu ht, v th cn theo di st.
Mt bch cu ht (Agranulocytose): t l 0,1% (Methimazole) v 0,5% (PTU)
trng hp, c xc nh khi s lng t bo bch cu di 200/mm3, trn lm sng
kh nhn bit c, cn bo trc cho ngi bnh nguy c ny pht hin v iu tr
kp thi. Ngng bt buc thuc khng gip v dng khng sinh ngay khi c du chng
ny, nht l biu hin nhim trng, vim hng. iu tr mt bch cu ht bng
Filgrastim (G - CSF).
Liu thuc khng gip trong cn bo gip:
Propylthiouracil (PTU) 150-250mg/ ng ung mi 6 gi.
Methimazol 20- 30mg/ ng ung mi 12 gi ;
C th tng liu hoc chia khong cch liu ngn hn;
Dng ng ung hoc cho qua sonde d dy hoc hu mn (trng hp
khng ung c) methimazol 60mg/24 gi hoc PTU 400mg/ 6 gi.
Theo di khi s dng thuc khng gip:
Kim tra cng thc bch cu nh k.
FT4 v TSH;
Kim tra chc nng gan.
1.2. Gim phng thch hormon gip
Nng Iodid trong mu cao gp 100 ln so vi bnh thng, tt c hot ng
gip u b c ch trong mt vi tun. Dng iod v c c tc dng lm gim bt gi iod
(bm iod), gim t l iod ha tyrosin lm gim nng T3 v T4, kt qu l gim phng
thch hormon gip vo mu. Do tc dng gim hot ng t bo gip, gim kch thc
76

tuyn gip v gim lu lng mu cung cp cho tuyn gip, thun li cho phu thut.
Nng cc hormon gip gim nhng khng tr v bnh thng, tc dng ny ngn.
Nhu m tuyn gip ngi bnh b tng hot rt nhy cm i vi iod so vi nhu
m gip ngi bnh thng (5g% so vi 20g% huyt tng). Ch cn 6mg Iodid c
ch tuyn gip. Khng s dng iod v c n c m cn phi hp vi thuc khng
gip phng hin tng thot c ch.
Hin nay liu trnh s dng Iod trung bnh l 10 15 ngy.
Cht iopanoic acid v ipodat sodium c tc dng c ch T4 thnh T3 v c ch
phng thch T4, sau 24 gi c ch T3.
Liu iod s dng trong cn bo gip:
Nn s dng hai gi sau khi dng thuc khng gip tng hp vi mc ch hn
ch phng thch hormon gip.
Nn ung ngay thuc c ch phng thch hormon gip vi liu cao.
Natri- Iodid: 0,5 - 1g / tnh mch/ 12 gi; hoc
Dung dch Kali Iodid bo ha (SSIK) 5 git x 4 ln/ngy; hoc
Dung dch Lugol 5% ung 10 git x 3 ln/ngy (1ml = 20 git, c 126,5mg iod).
1.3. Kim sot ri lon tim mch
Trong cn bo gip ngi bnh c th b suy tim tng cung lng hoc gim
cung lng.
Digital khng c tc dng trong iu tr suy tim cng gip tng cung lng, hn
na tnh trng nhim Digital lm thun li cn cng gip xut hin.
Propranolol dng iu tr cn nhp nhanh c suy tim tng cung lng.
Trong cn cng gip, cc cht Catecholamin trong mu u bnh thng, nhng
tc dng ca chng ln cc c quan nhn cm c tng cng ln, do nhp tim tng
ln v propranolol c ch tc dng ny.
Ngoi ra propranolol c tc dng c ch bin i T4 thnh T3, gim cc biu hin
giao cm ca tc dng hormon gip, kim sot nhanh nhp tim nhanh, run tay, lo u v
bnh c gip trng.
Tuy nhin, ngi bnh c suy tim hoc b bnh c tim, s dng propranolol phi
ht sc thn trng. Propanolol khng nh hng trn nng hormon gip, thu nhn
iod v th tch tuyn gip cng nh cc biu hin do tc dng ca hormon v min dch.
Trong cn bo gip c th dng:
Propranolol 0,5-1mg/ tnh mch chm mi 10 pht/ mi 3 gi vi tng liu 10
mg Propranolol 40-80 mg/ 6 gi/ ng ung; hoc
Esmolol loi c ch beta chn lc (1) tc dng nhanh liu 250-500
g/kg/trong 10 pht tnh mch ri 50-100g/kg/pht v theo di monitoring.

77

 Trng hp hen hoc suy tim, c ch beta chng ch nh c th dng thn

trng vi:
Verapamil (c ch calci) liu 5-10mg/6 gi/ tnh mch chm.
C th cho thm li tiu, oxy liu php trong iu tr suy tim.
1.4. Gim tc dng ca hormon gip ngoi bin
Propanolol:
Thuc c ch giao cm cng ng mt vai tr quan trng trong iu tr. Nu
khng c suy tim c th dng Propranolol c tc dng c ch bin i T4 thnh T3
ngoi bin.
Glucocorticoid:
Liu c ch min dch (liu cao prednisolon trn 1 mg/kg).
Liu c ch bin i T4 thnh T3 ngoi bin (dexamethason).
Dexamethason liu 2 mg/ 6 gi c th c ch phng thch hormon gip.
Liu dng trong cn bo gip:
Hydrocortison - hemisucinat 50mg/6 gi ng tnh mch (do cortisol d tr b
gim v nhu cu cortisol tng trong sang chn tm l).
C th dng Dexamethason 2mg/tnh mch/mi 6 gi (hoc hydrocortison
hemisuccinat: 50mg tnh mch mi 6 gi). Thuc c tc dng c ch phng thch
hormon (do c ch TSH), gim s chuyn T4 thnh T3 ngoi bin v cung cp
Corticoid. Nh lm thun li cho qu trnh tn to Glycogen v tch ly gan. (Lm
hn ch s chuyn T4 thnh T3 c tc dng mnh hn cn c vai tr ca Propranolol,
PTU v iod).
Vi s phi hp iu tr PTU, Iod v Dexamethason, nng T3 thng tr v
bnh thng trong vng 24 gi. Phi hp 3 thuc ny cn duy tr cho n khi tnh trng
chuyn ha tr v bnh thng. T gim dn Iod v Corticoid, tr li iu tr thng
quy.
1.5. Bi ph nc v cc cht in gii
Nc, in gii: Da vo kt qu xt nghim in gii , mu, nc tiu.
Truyn tnh mch chm cc dung dch mn, ngt ng trng 4-5 lt trong nhng ngy
u, thm Kali nu cn, cung cp nng lng cho ngi bnh. Khng nn dng ngay
Glucose 30% khi ngi bnh ang cn du hiu mt nc.
1.6. Thuc chng ng
Rung nh chim t l t 10 - 25% ngi bnh Basedow, nht l ngi bnh ln
tui. Thn trng Warfarin d gy xut huyt sau khi iu tr phng x. Aspirin c ch
nh nhng thn trng nu s dng liu cao (do aspirin lm tng FT3 v T4 do gim kt
hp protein).
78

Rung nh nu siu m tim pht hin huyt khi nh tri nguy c cao gy thuyn tc
mch cn iu tr Heparin trng lng phn t thp (Lovenox, Faxiparin).
1.7. iu tr gim thn nhit
Lm gim thn nhit: p khn t, c th dng Acetaminophen ung. Khng
dng Aspirin v Aspirin d gn vi TBG lm T4 c gii phng, hu qu l T4 t do
tng thm.
1.8. iu tr an thn
Nhm barbiturat c tc dng gim lng thyroxin do gia tng thoi bin.
Phenobarbital 0,4 - 0,8g/ngy ngoi tc dng an thn, cn lm thun li thoi bin
nhanh chng T3, T4 ngoi bin, kh hot tnh T3, T4 lm gim nng T3, T4.
2. iu tr cc yu t khi pht v tc nhn c hi
Tm v iu tr cc nguyn nhn gy thun li cn bo gip: nhim khun...
3. Theo di
Ngi bnh cn c theo di bnh vin cho ti khi ht cn. Nu cn bo gip
c s dng phi hp PTU, Iod, Dexamethason ci thin triu chng lm sng v nng
T3 tr v bnh thng sau 24 - 48 gi, thng phi mt 7 - 10 ngy tt c mi tr li
bnh thng.
Kim tra thng xuyn nng hormon gip mi 3 - 4 ngy iu chnh thuc.
Nng T4 thng chm hn.
Nu khng p ng vi cc phng php iu tr nh trn c th p dng bin
php lm gim nng hormon gip tch cc hn bng cch lc huyt tng hoc thm
phn phc mc. Kinh nghim mi 3 gi c th lc 500ml mu, duy nht hng cu c
a tr li cho ngi bnh.
VIII. PHNG BNH
Trnh ngng thuc khng gip tng hp mt cch t ngt, c bit l khi
ang s dng liu cao trong giai on u iu tr cng gip.
Trnh gy chm thng nhiu bu gip, ngay c vic s khm nhiu ln
vng tuyn gip.
Ngi bnh cng gip cn c theo di vic dng thuc nh Digital, Insulin,
cc tnh hung c bit nhim c thai nghn, sinh .
Chun b thuc khng gip tng hp cho cc ngi bnh s iu tr bng I131,
theo di cc ngi bnh ny t nht 3 tun sau khi c iu tr.
Phi hon li nu c mi cuc phu thut d l nh cho n khi ngi bnh
cng gip n nh ti mc bnh gip, k c nhng can thip nh nh nh rng...

79

 Nu bt buc phi can thip phu thut: trong khi v sau khi m phi iu tr
bng thuc khng gip tng hp nh khi iu tr cn cng gip cho n khi tnh trng
nguy him qua.
Phng cn bo gip do phu thut bng cch phi hp iu tr vi Lugol
Propranolol v thuc khng gip tng hp. Trnh gy m bng Cyclopropan v ether v
s gy phn ng tit qu mc Catecholamin.
phng tr em hoc ngi bnh tm thn t s dng mt lng ln Thyroxin
khng c qun l.
IX. BIN CHNG V TIN LNG
Bin chng hay gp l: ri lon v nut, try tim mch.
T vong do cn cng gip cp trc nm 1920 l 100%.
C iu tr th t l t vong trc y l 60-80% cn hin nay l 20-30%.
TI LIU THAM KHO
1. B. Sylvia Vela. Endocrinology and the heart (2003). Current diagnosis and
treatment in cardiology. Micheal H. Crawford. Lange Medical Books/McGraw-Hill.
Second edition. 2003:511-535.
2. David G. Gardner (2011) Endocrine Emergencies. Greenspans basic and
clinical endocrinology. 9th edition. Mc Graw Hill :763-786.
3. David S. Cooper, Paul W. Ladenson. (2011) Greenspans basic and clinical
endocrinology. 9th edition. Mc Graw Hill :163-226.
4. Ernest L.Mazzaferri. The Thyroid. Endorinology. Medical Examination

Publishing Company. USA (1974).

5. Gordon H Williams, Leonard S Lilly, Ellen W. Seely. The Heart in endocrine
and nutritional disorders. 2005
6. J. Hazard. La Thyroide Endocrinologie. Masson (1990).
7. J. Orgiazzi, R Mornex, H Allanic, B Rousset, F Duron, M Malinsky. Pchason,
A Leger, F Leprat, J. L Latapie. Hyperthyroides. La Thyroid. ESF. (1992).
8. Jane F. Desforges. Thyrotoxicosis and the Heart. The new England Journal of
Medicine. Number 2. volume 327. July 9. (1992).
9. Jerome M Hershman (2002). Hypothyroidism and Hyperthyroidism Manual of
Endocrinology and Metabolism. Norman Lavin. Third edition . Lippicott Williams and
Wilkins. 2002 : 396-409
10. Kronenberg. Graves disease. Williams Textbook of Endocrinology. 11th edition. 2008
11. L. Frankart, M.C Vannes. La thyroide du sujet ag. (1998)
12. Sidney H Ingbar, Kenneth A. Woeber. The thyroid gland. Textbook of
Endocrinology. W. B. Saunders Company(1982).
80

SUY TUYN GIP BM SINH TIN PHT

(Sporadic congenital hypothyroidism)

I. I CNG
Suy tuyn gip bm sinh l bnh ni tit do ri lon sn xut hormon tuyn gip
khng p ng nhu cu chuyn ho v qu trnh sinh trng ca c th. Nh vy, bt
k nguyn nhn no trong thi k bo thai hoc sau sinh lm cho tuyn gip hot ng
khng bnh thng, lm gim lng hormon gip trong mu u c th gy ra suy gip.
Ty theo nguyn nhn tc ng vo tuyn gip thi k bo thai hay tui trng thnh
m gy ra suy gip bm sinh hoc mc phi.
Suy gip bm sinh (SGBS) l bnh c tn sut mc kh cao tr em, t l mc t
1/3.000 n 1/5.000 tr s sinh sng sau (4,7). Bnh tuy c t thi k bo thai nhng
cc du hiu lm sng khng xut hin ngay sau m biu hin mun hn thi k b
m hoc trong giai on thanh thiu nin. Khi chn on thng b mun, tr vnh
vin b tn ph tinh thn. V vy, t nhng nm 1960 ngi ta tin hnh chng trnh
sng lc s sinh (CTSLSS) pht hin v iu tr sm SGBS ngay sau sinh, cu hng
triu tr thot khi thiu nng tr tu v mang li cuc sng bnh thng cho tr b
SGBS.
Vit Nam mi nm c khong 1,5 triu tr ra i, c tnh c khong 300 tr b
SGBS. Nhng thc t nhiu tr SGBS cn b b st chn on v b l c hi iu tr
tt nht, hng nm mi c 7% tr c pht hin sm trc 3 thng tui (1). Nm 2007,
CTSLSS bnh SGBS c Tng cc Dn s B Y t a vo chng trnh trng
im quc gia v m rng trn 28 tnh thnh trong ton quc, kt qu cho thy t l mc
SGBS nc ta l 1/5000 tr s sinh.
II. PHN LOI SGBS THEO BNH NGUYN (2,5,7)
Ngoi SGBS a phng do thiu iod v mt s trng hp gy ra bi thy thuc,
hu ht nguyn nhn ca SGBS tn pht cha c bit.
1. Ri lon hnh thnh v pht trin tuyn gip
Ton b: Khng c tuyn gip.
Mt phn: Lc ch tuyn gip hoc thiu sn tuyn gip - l nguyn nhn ph
bin nht, qua CTSLSS ngi ta thy 80-85% tr SGBS l do nguyn nhn ny, t l
mc 1/3000. Ghi hnh tuyn gip tm thy 2/3 cc trng hp l tuyn gip lc ch hoc
thiu sn tuyn gip.
K thut ghi hnh tuyn gip bng Tc 99m pertechnetate c th thy tuyn gip
khng c hoc lc ch c, di li hoc tuyn gip thiu sn.

81

2. Ri lon tng hp hormon gip

Bu c l du hiu c trng ca SGBS do thiu men tng hp hormon gip. T
l mc 1/30.000- 1/50.000. Bnh di truyn ln nhim sc th thng.
Gim bt gi iod ti tuyn gip. Ghi hnh tuyn gip thy tuyn v tr bnh
thng nhng tp trung gim thp. Nguyn nhn cha r rng, ngi ta cho rng
thiu c ch gn ti tuyn gip.
Thiu men trong qu trnh hu c ho iod: Sau khi c bt gi ti tuyn gip,
iod nhanh chng oxy ho v gn vi Tyrosin di tc dng ca men peroxydase. Thiu
men peroxydase c th do thiu s lng, cht lng men Peroxydase hoc mc hi
chng Pendreds.
Chn on bnh: TSH tng cao trong mu. Nghim php ui thiocyanate tuyn
gip (+) hoc men peroxydase tuyn gip thp hoc khng c.
Thiu men trong khu trng hp cc iodotyrosin thnh cc phn t
iodothyronin trong keo gip trng c bit rt t.
Thiu men kh iod: Hormon gip sau khi pht huy tc dng ti t chc c
ging ho bng cch kh iod to thnh cc phn t iodotyrosin, ng thi cc phn t
iodotyrosin trong tuyn gip cng kh iod. Iod c gii phng s ti s dng li tng
hp hormon gip. Nu ngi bnh thiu men kh iod s c mt lng ln iodotyrosin
o thi qua nc tiu dn n thiu hormon v bu c.
Ri lon tng hp Thyroglobulin: Thyroglobulin l yu t quan trng ca keo
gip trng. S tng hp Thyroglobulin thng lin quan vi ch n iod hng ngy
hoc tng hp c nhng thiu men protease nn khng gii phng hormon gip
vo mu. Kt qu nng T4 v T3 gim thp trong mu.
3. Bnh n a phng
Nguyn nhn c bit rt r c lin quan n vng bu c a phng v ch
xy ra vng thiu ht iod nng vi hai th:
Th ph nim: Lm sng ging SGBS tn pht, l ph nim, chm pht
trin tinh thn, vn ng v chm dy th, nhng tr khng b cm ic. Xt nghim:
TSH tng cao, T4,T3 trong mu gim thp. tp trung iod tng cao ti tuyn gip.
Th thn kinh: C c im tn thng ca tiu no, co cng c, cm v ic
km theo chm pht trin tinh thn.
4. Ch nh thuc khi b m ang c thai
Mt s trng hp SGBS do ngi m dng thuc khng gip, iod phng x trong
thi k mang thai lm tuyn gip ca con b ph hy v b SGBS.
5. Thiu TSH
Bnh him gp, t l mc 1/60.000 - 1/100.000 tr mi . Nguyn nhn c th
thiu TSH n thun hoc phi hp, thng km theo suy tuyn yn.
82

6. Thiu c quan nhn cm

Thyrotropin khng p ng: Tr SGBS khng c bu c, xt nghim TSH
tng cao, tp trung iod ti tuyn gip bnh thng.
Hormon gip khng p ng: Tr SGBS c bu c, xt nghim thy T4, T3
trong mu tng cao, TSH bnh thng hoc hi cao khng ph hp vi nng T4 v
T3. Bnh khng c iu tr c hiu.
III. CHN ON
1. Lm sng
Du hiu thng gp l vng da sinh l ko di trn 1 thng, khng tm thy
nguyn nhn bnh l gan mt nn ngh n SGBS. Ngoi ra, c th thy tr khc yu,
ting khc khn. Da kh, lnh, mu vng sp v ni vn tm. Tc kh, tha, d gy,
ng chn tc mc thp trc trn.
B mt ph nim: khong cch hai mt xa nhau, khe mi hp, mi mt nng, mi
tt, m ph, li dy, ming lun h.
Du hiu tiu ho: Tr n t, bng to b, thot v rn v to bn ko di.
Pht trin tinh thn v vn ng thng chm so vi tui. Tr ng nhiu, chm ly,
b, ngi hoc i, chm mc rng, chm lin thp sau. Mc chm pht trin tng dn theo
tui, chm bit i, chm ln, chm ni, chm n trng hoc khng i hc c.
Ri lon pht trin hnh thi: u to, mt th, chn tay ngn, bn tay- bn chn
th, bng to b km theo thot v rn. Tr ln hn vi khun mt ngy ng thiu nng
tr tu v ngi ln d hnh khng cn i.

Ng. Q. Th. 12 thng tui, SGBS

. T. H.Q 7 tui, SGBS

2. Cn lm sng
Xt nghim c hiu: Nng TSH tng cao > 100 UI/ml, T4 gim thp < 50
nmol/l trong mu l tiu chun vng xc nh SGBS.
83

 Xt nghim khng c hiu: Chp tui xng thy chm. Tiu chun da vo
nh gi cc im ct ho c tay tri theo Atllat W.Greulich v S.Pyle.
Xt nghim tm nguyn nhn: Ghi hnh tuyn gip bng Tc 99m xc nh v
tr tuyn gip bnh thng, lc ch hay thiu sn.
3. Chn on xc nh
Bng 1. Bng nhn din nghi ng SGBS trn lm sng (1)
STT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Lm sng v yu t nguy c

im

Ph nim (b mt c bit)
Da ni vn tm
Thot v rn
Thp sau rng > 0,5cm
Chm ln
Chm pht trin tinh thn,vn ng
To bn ko di
Vng da sinh l ko di > 30 ngy
Thai gi thng >42 tun
Cn nng khi to 3,5 kg

2
1
1
1
1
1
2
1
1
1

Tng s im

12

Nghi ng SGBS

4. Chn on phn bit vi suy gip trng th pht

Nguyn nhn ph bin nht ca suy gip th pht l vim tuyn gip t min
Hashimoto hoc gp trong mt s hi chng nh Down, Turner, Klinefelter Ngoi ra
c th gp sau phu thut bu gip do u nng tuyn gip, ung th gip. X tr vng c
trong bnh Hodgkin, hoc u c tnh vng c.
Chn on thng b mun v gia nh b qua cc du hiu ph nim kn o, ln,
chm pht trin tinh thn v chm dy th. Xt nghim thy khng th khng
Thyroglobulin, khng th khng tuyn gip u tng. Nng TSH tng cao v T4
gim thp trong huyt thanh. Tui xng chm nhiu so vi tui thc.
IV. IU TR
Mc ch: a tnh trng suy gip v bnh gip cng sm cng tt.
1. Nguyn tc
Liu php iu tr thay th hormon gip sut i.
2. iu tr c th
Thuc: Hormon gip tng hp c la chn l Thyroxin c tc dng sinh l
ko di, hp thu qua rut t 50-70%. Ti t chc ngoi vi c hin tng chuyn i t
T4 sang T3, d dng kim tra nng thuc a t bn ngoi theo di iu tr.
84

 Cch dng thuc: Ung ngy 1 ln vo trc ba n sng 1 gi.

Thuc Thyroxin: dng vin, hm lng 50g, 100 g.
Liu lng thuc (5):
Tui

g/ngy

g/kg/ngy

0-6 thng

25-50

8-10

6-12 thng

50-75

6-8

1-5 tui

75-100

5-6

6-12 tui

100-150

4-5

12 ngi ln

100-200

2-3

Theo di kt qu iu tr:
Nu qu liu iu tr: tr kch thch, nhp tim nhanh, ra nhiu m hi, kh ng,
tiu chy v nn. Xt nghim thy nng T4 trong mu tng cao > 200 nmol/l, TSH
gim thp < 0,01 UI/ml. Liu cao ko di, tui xng pht trin nhanh, tr s b ln.
Nu cha liu iu tr: Tr vn chm ln, chm pht trin tinh thn. Nng
TSH tng cao nhng nng T4 trong mu bnh thng.
Vi liu iu tr thch hp: Cc du hiu suy gip gim dn. Tr pht trin ui
kp chiu cao so vi tr cng tui. Tr nhanh nhn, i hc bnh thng. Nng TSH
v bnh thng v T4 gii hn cao ca bnh thng. Tui xng bng tui thc.
Theo di nm u iu tr: 3 thng khm li mt ln, nhng nm sau 6 thng
khm mt ln. Cng vi khm lm sng, o ch s DQ/IQ, xt nghim nh lng nng
TSH, T4 trong mu v chp tui xng 6 thng/ 1 ln.
V. TIN TRIN V BIN CHNG
Nu pht hin v iu tr sm SGBS, tr pht trin nh bnh thng, m bo
cht lng sng v tham gia sc sn xut trong x hi.
Nu pht hin mun, tr vnh vin b thiu nng tr tu, khng ha nhp c
cng ng, phi c ngi chm sc c bit.
VI. PHNG BNH
Chnh v triu chng lm sng khng xut hin ngay sau nn tr s sinh cn
phi lm xt nghim ngay sau sinh pht hin v iu tr sm SGBS. Trong bn thp
k qua, CTSLSS bnh SGBS c cng nhn l chng trnh sc khe cng ng v
thit yu nhm gim t l chm pht trin tinh thn.

85

TI LIU THAM KHO

1. Nguyn Th Hon. Gp phn chn on v iu tr sm bnh suy gip trng
bm sinh tn pht tr em Vit Nam. Lun n tin s khoa hc Y dc 1993.
2. Delbert A.Fisher and Annette grueters. Chapter 7. Thyroid Disorders in Childhood
and Adolescence. Sperling Pediatric Endocrinology third Edition 227: 240, 2008.
3. Foley T.P. Sporadic congenital Hypothyroidism (Congenital Hypothyroidism in
basic and clinical Endocrinology, Eds Dussault J.H and Walker P.) 1990.14: 231-258.
4. Newborn Screening in the Asia Pacific Region: New Century, new Goals, New
Opportunities. Proceeding of the 4th Asia Pacific Regional Meeting of the International
Society for Neonatal Screening. Southeast Asian Jounal of Tropical Medicine and
Public Health. Volum 34 suppl.3. 2003.
5. Paul Malvaux. Endocrinologie pediatricque physiologie physiopathologie
Clinique. (J.Bertrand., R.Rapaport., P.K Sizoneuko Directeur de puplication), 1982:
258-273.
6. Smith D.W.,Klein A.M., James R. and Ntinos C. Congenital Hypothyroidism.
Signs and symptoms in the newborn period. J. Pediatr. 1975. 87(6): 958-962.
7. Stephen LaFranchi. Hypothyroidism. Section 2 Disorders of Thyroid Gland,
Chapter 559 Nelson Textbook of Pediatrics. 2011: 1895-1903.

86

SUY GIP NGI LN

I. NH NGHA
Suy gip l tnh trng gim chc nng tuyn gip dn n s thiu ht tng hp v
gii phng hormon tuyn gip.
Danh php tng t: Thiu nng tuyn gip, nhc nng tuyn gip.
II. PHN LOI SUY GIP THEO NGUYN NHN
1. Suy gip tin pht c tuyn gip to
1.1. Suy gip mc phi
Vim tuyn gip Hashimoto (vim tuyn gip t min typ 2A).
Thiu ht iod (bu c a phng).
Do dng mt s thuc c tc dng c ch tng hp hoc gii phng thyroxin
(lithium, ethionamid, sulfamid, iod).
Yu t sinh u trong thc phm hoc do nhim mi trng.
Cc cytokin (interferon , interleukin 2).
Tuyn gip thm nhim (amyloidosis, sarcoidosis, cyetinosis, scleroderma).
1.2. Suy gip bm sinh
Khim khuyt vn chuyn v huy ng iod (NIS hoc t bin pendrin).
Thiu ht bm sinh enzym tham gia tng hp hormon tuyn gip (iodotyrosin
dehalogenase).
Thiu ht hoc ri lon chc nng thyroglobulin.
Khim khuyt tng hp hoc huy ng thyroglobulin.
2. Suy gip khng c tuyn gip to
2.1. Suy gip mc phi
Bnh tuyn gip Hashimoto (vim tuyn gip t min typ 2B).
Sau iu tr bng phng x, phu thut tuyn gip hoc x tr bnh c tnh
ngoi tuyn gip.
2.2. Suy gip bm sinh
Thiu sn hoc lon sn tuyn gip.
Khim khuyt th th ca TSH.
87

 Bt thng protein Gs ca tuyn gip (gi suy cn gip typ 1a).

TSH khng p ng khng r nguyn nhn.
3. Suy gip thong qua sau vim tuyn gip
Gp ngi bnh sau vim tuyn gip bn cp, vim tuyn gip c au hoc vim
tuyn gip sau .
4. Suy gip mc phi do tuyn gip b ph hy
Cu trc hormon tuyn gip b ph hy do trnh din D3 trong cc u mu hoc u
mu ni mc kch thc ln.
5. Suy gip ngun gc trung ng
Suy gip mc phi:
Do tn thng tuyn yn (th pht).
Bnh l vng di i.
Suy gip bm sinh.
Thiu ht hoc bt thng cu trc ca TSH.
Khim khuyt th th tip nhn TSH.
6. Suy gip do khng hormon tuyn gip
Khng hormon tuyn gip ni chung.
Khng hormon tuyn gip u th ti tuyn yn.
III. C CH BNH SINH
1. Suy gip khng c tuyn gip to
Do tai bin iu tr bnh Basedow bng phu thut, phng x gy mt t chc
tuyn gip dn n gim tng hp hormon tuyn gip mc d tc dng kch thch ca
TSH i vi tuyn gip vn cn c bo tn.
Teo tuyn gip c th do bnh tin pht, thng do c ch t min dch vi s
hin din cc khng th khng tuyn gip, khng th th TSH gp ngi bnh trc
c vim tuyn gip bn cp hoc mn tnh.
2. Suy gip c tuyn gip to
Khi gim nng hormon tuyn gip s dn n tng TSH v di tc dng
ca TSH vi nng cao s kch thch lm tuyn gip to ra.
Nguyn nhn hay gp l bnh Hashimoto, thiu ht iod, bnh di truyn c
khim khuyt qu trnh gn iod v c v s gii phng bt thng cc protein gn iod.

88

 Khi TSH tng do u tuyn yn, hoi t tuyn yn sau dn n c ch tng

hp hormon tuyn gip.
IV. CHN ON SUY GIP TIN PHT
1. Lm sng
Bnh cnh lm sng c trng l bnh ph nim myxedema, thng gp ph
n la tui 40-50 tui. Cc triu chng xut hin t t, khng rm r, d nhm vi cc
triu chng ca giai on mn kinh. Lm sng ca suy gip ngi bnh myxedema c
tnh cht h thng, tn thng nhiu c quan.
1.1. Tn thng da, nim mc: l du hiu c trng nht ca bnh myxedema.
Thay i b mt: mt trn nh mt trng, nhiu np nhn, b mt gi trc so
vi tui, th , t biu l tnh cm.
Ph mi mt, nht l mi di, trng nh mng nc.
G m tm v nhiu mao mch b gin, mi dy v tm ti.
Bn chn, tay: dy, ngn tay to, kh gp li, da lnh, gan bn chn, bn tay c
mu vng (xanthoderma).
Nim mc li b thm nhim lm li to ra, dy thanh i hay b thm nhim
nn thng ni khn. Nim mc vi Eustache b thm nhim gy tai, nghe km. Ph
nim mc mi nn khi ng hay ngy to.
Da, lng tc mng: ph cng, da kh d bong vy, tc kh d gy rng, lng
nch, lng mu rng tha tht, mng chn, mng tay mn, d gy.
1.2. Triu chng gim chuyn ha (hypometabolism)
L hu qu ca s thiu ht hormon tuyn gip. C th coi y l du hiu soi
gng ca nhim c gip.
Ri lon iu ha thn nhit biu hin bng cm gic s rt, thn nhit gim,
chn tay lnh v kh.
Ri lon iu tit nc: ung t nc, i tiu t, bi tit rt chm sau khi ung nc.
Thng tng cn tuy n ung km.
1.3. Triu chng tim mch
Nhp tim thng chm <60 chu k/ pht, huyt p thp ch yu l huyt p tm
thu, tc tun hon gim. C th c cn au tht ngc hoc suy tim vi tim to.
Trn dch mng tim vi cc mc khc nhau c khi khng km theo suy tim.
Xt nghim dch mng tim c nhiu protein v cholesterol.
Bin i trn in tim: in th thp, ST chnh xung, sng T dt hoc m tnh.

89

1.4. Ri lon thn kinh - tinh thn - c

Ngi bnh thng mt mi, li b, trng thi v cm, th . Thng c s suy
gim cc hot ng th cht, tr c v sinh dc. Da kh do gim tit m hi.
Ri lon thn kinh t ng biu hin bng to bn ko di, c th km vi
gim nhu ng rut.
Tn thng c vi biu hin yu c, au c, co c khng t nhin, chut rt.
1.5. Bin i ti cc tuyn ni tit
Tuyn gip c th to hoc bnh thng ty thuc nguyn nhn gy suy gip.
ngi bnh n c th rong kinh, ri lon kinh nguyt km chy sa, gim hoc mt kh
nng sinh hot tnh dc. C th c biu hin suy chc nng tuyn thng thn.
2. Cn lm sng
2.1. nh lng hormon
Nng TSH huyt thanh tng cao gp trong suy gip do tn thng ti tuyn
gip c hoc khng c tuyn gip to. Nng TSH bnh thng hoc thp khng th
xc nh c gp trong suy gip do tn thng vng di i hoc tuyn yn.
Nng hormon tuyn gip bao gm hormon t do v hormon ton phn gim
thp gp hu ht cc trng hp. Trong suy gip tin pht, nng T3 gim t hn so
vi T4.
2.2. tp trung I131 ti tuyn gip
Thp hn so vi gi tr bnh thng
2.3. nh lng cc t khng th
Nng TPOAb huyt thanh tng gp ngi bnh suy gip do vim tuyn gip
min dch. Nng TGAb cng c th tng mt s th bnh.
2.4. Chuyn ha c s
Gim thp.
2.5. Xt nghim mu
C th thy tng cholesterol, triglycerid, tng CPK, LDH.
C th thiu mu ng sc hoc nhc sc.
3. Chn on xc nh
Chn on suy gip khng kh i vi cc trng hp in hnh, ch yu da vo
cc triu chng lm sng c trng kt hp vi xt nghim c tng TSH, gim nng
hormon tuyn gip. Chn on nguyn nhn gy suy gip cn da vo mt s c im
ca tng th lm sng.
90

4. Phn loi th lm sng

Ngoi th in hnh m t trong bnh myxedema, cn c nhng th lm sng
c bit khi c mt s biu hin tn thng ni tri.
4.1. Suy gip nh (hay suy gip tim n)
Thng c t triu chng lm sng.
4.2. Suy gip cn b
Khi nng TSH gim, T4 tng nhng T3 bnh thng.
4.3. Suy gip di lm sng
Khi cha c triu chng trn lm sng.
Chn on da vo xt nghim vi nng TSH tng nh, hormon tuyn gip
bnh thng hoc gii hn bnh thng thp.
4.4. Th c mt s triu chng lm sng ni bt nh:
Th thiu mu: thng l thiu mu ng sc hay nhc sc, nng st huyt
thanh gim.
Th c: ph i c hoc ri lon trng lc c.
Th tiu ha: t trng v i trng khng l, ti mt co bp yu, c th c si mt.
Th thn kinh- tm thn: c nhiu triu chng thn kinh- tm thn, c bit c
du hiu tn thng tiu no, ri lon tm thn th trm cm, m sng hoc l ln.
Th trn dch a mng.
Th tim mch: tim to, c biu hin suy tim.
Th hn m do suy gip.
5. Chn on phn bit
Ngi bnh cao tui hoc gi: thng c mt s triu chng d nhm vi suy
gip nh bo, chm chp, da kh, mng tay d gy, thiu mu... song nng TSH v
hormon tuyn gip bnh thng.
Ngi bnh hi chng thn h c biu hin ph, trn dch cc khoang thanh
mc, da xanh, nim mc nht, chm chp... nhng nng TSH v hormon tuyn gip
bnh thng.
Suy dinh dng: thng c biu hin thiu mu, ph, da kh, mng tay d gy
nhng nng TSH v hormon tuyn gip bnh thng.
Ngi bnh tm thn: thng c biu hin sc thi, nt mt, thc ging ngi
bnh suy gip, song xt nghim nng TSH v hormon tuyn gip bnh thng.

91

V. IU TR
1. Mc tiu, nguyn tc iu tr
1.1. Mc tiu
a ngi bnh v tnh trng bnh gip.
Duy tr tnh trng bnh gip thng xuyn, lu di.
D phng v iu tr cc bin chng do suy gip.
1.2. Nguyn tc iu tr
iu tr nguyn nhn gy suy gip.
Bi ph hormon tuyn gip.
Liu lng v loi hormon bi ph ty thuc vo mc suy gip v c im
ca ngi bnh (tui, bnh km theo...).
Hormon tuyn gip thay th thng bt u vi liu nh sau tng dn ti
liu ti a.
2. Bin php iu tr
Ch mt s t trng hp suy gip do tai bin dng thuc khng gip tng hp
hoc suy gip thong qua do vim tuyn gip c th t hi phc, cn li a s cc
trng hp suy gip phi iu tr thay th bng hormon gip.
Theo dc in Hoa K c nm nhm hormon gip v ch phm c cha hormon
c s dng trong lm sng:
Levothyroxin (L-T4).
Liothyronin (L-T3).
Liotrix (L-T4 + L-T3).
Dc phm t nhin v sinh hc.
Tinh cht tuyn gip v thyroglobulin.
Trong s cc loi trn th dc phm t nhin, sinh hc v thyroglobulin ch mang
tnh cht lch s, khng cn c p dng trong iu tr.
2.1. Levothyroxin (L-T4).
L hormon tuyn gip c a dng nht iu tr suy gip tin pht. Mt s
bit dc thng dng nh: levo-T, levothroid, levoxyl, synthroid.
Dng thuc thng dng l vin nn, cng c th dng tim hoc thuc nc ung.
Hm lng mt git =5g, vin nn c hm lng: 25 - 50 - 75 - 100 - 300g;
thuc tim: 200- 500g (100g/ ml).

92

 Levothyroxin c thi gian bn thi di (7 ngy) cho nn ch cn ung mt ln

trong ngy.
Liu khi u trung bnh 1,6 - 1,8g/ kg/ ngy. Tng liu dao ng 25- 300g/
ngy. Ngi bnh n trung bnh 75 - 112g/ ngy. Ngi bnh nam trung bnh 125200g/ ngy.
Sau khi dng levothyroxin t 5- 6 tun, nng T4 huyt thanh s tng ln.
Nu c teo tuyn gip gp ngi bnh Hashimoto hoc ngi bnh Basedow sau iu
tr bng phng x c th bt u vi liu tng thm 25- 50g/ ngy.
Khi t c bnh gip (TSH v hormon tuyn gip v bnh thng) th gim
liu, s dng liu duy tr trung bnh 25 50 - 100g/ ngy ty theo tng ngi bnh.
2.2. Liothyronin (L-T3)
Dng thuc: vin nn, hm lng 5 - 25 - 50 g; Bit dc: cynomel, cytomel.
Thi gian bn thi ngn (24 gi), v vy liothyronin ch c s dng cho nhng trng
hp suy gip tin pht, dng tng t ngn.
Liu thng dng 25- 75g/ ngy, liu khi u vin/ ngy, c th dng 1
n 2 vin /ngy. Thi gian dng lin tc trong 3- 4 tun. Khng dng liothyronin
iu tr ko di cho ngi bnh suy gip. Liothyronin thng c dng iu tr hn
m do suy gip hoc lm nghim php Werner.
2.3. Liotrix (L-T4 phi hp L-T3)
Phi hp liothyronin vi levothyroxin.
Mt s bit dc: euthyral, thyrolar (cha 12,5g T3 v 50g T4).
Mt vin liotrix cha 12,5g T3 v 12,5g T4 c tc dng tng ng
vi100 g T4. Nng L-T4 phi hp vi L-T3 ca liotrix thng l 4/1; 5/1; 7/1. Liu
khi u thng l vin / ngy, liu duy tr 1-1,5 vin / ngy.
2.4. Bt gip ng kh
Bt gip ng kh cn gi l tinh cht tuyn gip, c bo ch t tuyn gip
ca gia sc. Vin nn vi nhiu hm lng khc nhau: 16, 32, 60, 325 mg/ vin. Dc
in Hoa K quy nh 1 vin nn hm lng 1gam tng ng vi 60mg bt gip ng
kh. Mt s bit dc: armoun, thyroid, extract thyroidien choay.
Bt gip ng kh c u im ging vi L-T4 v L-T3 t nhin. Liu khi u
2,5g/ ngy, sau tng dn. Liu duy tr thng l 10- 20g/ ngy.
2.5. Mt s ch khi dng thuc c hormon gip
Thng bt u bng liu nh trong mt tun sau tng dn ti liu ti a.
Nu ngi bnh tr khng c bnh tim mch km theo, c th bt u ngay vi liu cao
(100g L-T4 / ngy).

93

 Ngi bnh cao tui nn bt u bng liu thp (1g/ kg/ ngy). Trong qu
trnh iu tr cn theo di cc biu hin tim mch, in tm . Nu c cn au tht
ngc hoc thiu mu c tim cc b th cn gim liu.
Theo di khi dng thuc: cn nng, tn s tim, to bn, cholesterol mu, T4,
FT4 v TSH xt nghim li c mi 6- 8 tun / ln.
Cc trng hp cn tng liu levothyroxin:
Ngi bnh c thai.
Suy gip ngi bnh Basedow sau iu tr bng phng x.
Suy gip sau vim tuyn gip Hashimoto.
Gim hp thu levothyroxin do dng cholestyramin, colestipol, sulphat st,
hydroxide nhm hoc hi chng rut ngn.
Tng chuyn ha levothyroxin do dng phenytoin, rifampicin, carbamazepin.
Cc trng hp cn gim liu levothyroxin:
S hi phc ton b ca bnh vim tuyn gip Hashimoto do ht cc t khng
th khng TPO (TPOAb).
C du hiu ti pht bnh Basedow.
Tnh trng cp tnh ca cc bu nhn t ch.
Ngi bnh suy gip cao tui.
Dng cc loi thc n hoc thuc c cha hoc c tc dng tng t levothyroxin.
TI LIU THAM KHO
1. Thi Hng Quang (2008). Bnh suy chc nng tuyn gip. Bnh ni tit. NXB
Y hc, trang 159-171.
2. Mai Th Trch (2003). Suy gip. Ni tit hc i cng. NXB Y hc chi nhnh
TP H Ch Minh, trang 163-174.
3. Hong Trung Vinh (2008). Bnh suy chc nng tuyn gip. Bnh hc ni khoa
tp 2. NXB QND, trang 146 155.
4. Larsen PR, Terry F.D (2009). Hypothyroidism and Thyroiditis. Williams
Textbook of endocrinology 10th edition, vol 1, pp 423 - 455.
5. Braverman LE; Utiger RD (2000). Thyroid disease: hypothyroidism. The
thyroid - A fundamental and clinical text 8th edition. Lippincott Williams and Wilkins.
pp 515-715.

94

Triu chng lm sng gi

suy gip tin pht

Xt nghim TSH, FT4

TSH tng. FT4 gim hoc
bnh thng thp

TSH bnh thng/gim; FT4 gim hoc

bnh thng thp; khng dng phenytoin,
salisylat. Hin khng c nhim c gip

Suy gip tin pht

Suy gip trung ng

Xt nghim TPOAb

TPOAb (-)

TPOAb
(+)

Bnh
Hashimoto

MRI

Vim tuyn gip thong qua

Vim TG do virut

Tn thng
tuyn yn
hoc di i

Theo di T4
trong 4 thng

iu tr bng
thyroxin

Bnh thng

Bt thng

Thiu ht TRH, TSH bm

sinh, do thm nhim
tuyn yn, di i

nh gi tuyn thng
thn, sinh dc, prolactin

Nu T4 gim 50% trong 6 tun

-> Xt nghim li TSH

TSH bnh thng

Tuyn gip bnh thng

Tng TSH

iu tr bng phu thut

hoc thuc sau khi iu
chnh chc nng tuyn
thng thn, tuyn gip
v cc thiu ht khc

Suy gip vnh vin

iu tr bng thyroxin

S chn on v iu tr suy gip

95

HN M DO SUY CHC NNG TUYN GIP

I. I CNG
1. Cc im chnh trong chn on bnh
Bin chng nguy kch ca suy gip nng.
Triu chng in hnh ca suy gip: Da kh, phn x chm, yu ton thn, ph
nim, hoc c kha ngang trc phn thp ca c.
Thng tn tnh trng tinh thn (tuy him khi hn m).

H thn nhit (thng < 35oC)

Hn m suy gip l biu hin s mt b trong bnh cnh suy gip, y l mt
bnh tng i t gp nhng tin trin thng nng, t vong khong 50%.
2. Tin s bnh v nguyn nhn
T l hn m do suy gip chim khong 1/1000 trng hp suy gip, tuy nhin
thc t c l cao hn do b st. Bnh thng gp n gii trn 50 tui c suy gip
(c khi cha c chn on) kt hp vi cc yu t khi pht, cc yu t ny qua hi
thn nhn nhiu khi khng th ghi nhn y .
Nguyn nhn bnh cnh suy gip chim hn 90% l suy gip tin pht do bt
k nguyn nhn no: T min, sau phu thut ct tuyn gip, sau iu tr iod phng x,
lm dng iod, iu tr lithium, v cn.
Nhng yu t khi pht kh nhiu, c khi khng r rng, nh: Ngng iu tr
hoc iu tr hormon thay th khng y , nhim lnh, lm dng thuc (ru,
phenothiazin, thuc ng, thuc lm du, thuc li tiu, digital...), chn thng, gy m,
can thip phu thut, nhi mu c tim, tai bin mch no, xut huyt tiu ho, nhim
trng, nht l h h hp, h glucose mu. Hn 50% cc trng hp suy gip nhp vin
trong bi cnh mt bnh khc.
II. CHN ON
1. Lm sng
Chn on khng kh trong trng hp ngi bnh ang mc suy gip.
Trng hp suy gip cha c chn on trc , cn xem xt cc du hiu gi
nh: gng mt ph dng suy gip, thm nhim da, rng lng, tc, da kh, mt sc t,
sc da xanh vng sp. Khm thy bu gip ln c khi tuyn gip teo, hoc so phu
thut vng c, du vt ca mt li...
Biu hin thn kinh: t nh nh du hiu ng g, n nng vi hn m tht s
nhng him khi hn m su. Khong 20% trng hp suy gip c co git.

96

in no kh gi vi lc c sng alpha, sng khng rng, khng p ng

vi kch thch nh sng.
Xt nghim dch no tu thng thy p lc tng do tng protein dch no tu.
Thn nhit gim l du hiu rt c gi tr chn on, chim t l 80% cc
trng hp, nhit khong 30-36oC, c khi xung n 34oC. Thn nhit bnh thng
ngay trong bi cnh ang nhim trng cng gi chn on hn m suy gip. H thn
nhit khng km rt run.
Khm h hp: nhp th chm hoc nhanh, tm thy tiu im nhim trng (c th
l nguyn nhn, c th l hu qu ca hn m), c trng hp b trn dch mng phi.
Khm tim mch: Nhp tim c th chm nhng khng hng nh, huyt p thay
i, thng tng. in tim thng thy nhp chm xoang, in th thp lan rng,
khong QT ko di, i khi c hnh nh thiu mu c tim. Chp phim X-quang lng
ngc thy bng tim ln, c th do trn dch mng tim gp phn. Nu c triu chng suy
tim cn ngh n nhi mu c tim.
Ngoi ra c th thy biu hin tc rut do lit rut, nhim trng ng tiu,
nc tiu.
2. Cn lm sng
Cc xt nghim lin quan n tuyn gip xc nh mt bnh cnh suy gip vi
TSH tng, T4 t do (hoc T4), T3 t do (hoc T3) gim. Rt him nhng cng c th
TSH bnh thng thm ch tng (suy gip do nguyn nhn cao).
Natri mu gim, c th < 110mmol/l (do mc lc cu thn gim).
Biu hin long mu vi hematocrite v protid gim.
thm thu nc tiu tng.
AVP (ADH: hormon lm gim tiu) tng.
Xt nghim kh mu thy toan h hp vi O2 gim, CO2 tng, pH gim.
Huyt cho thy thiu mu ng sc hng cu bnh thng, bch cu bnh
thng d c nhim trng.
Cc men: Creatine-kinase, aspartate-amino-transferase, lactico-dehydogenase
gia tng d khng km hoi t c tim.
Glucose mu c th gim.
3. Chn on phn bit
Ni chung chn on hn m suy gip thng r nu bnh cnh y cc triu
chng lm sng cng nh cn lm sng.
Cn lu chn on phn bit hn m do nhng nguyn nhn khc xy ra trn
ngi bnh suy gip, cc trng hp ny s thiu nhiu triu chng in hnh ca hn

97

m suy gip, cn tch cc tm nguyn nhn hn m. Vn phc tp ch chnh bn

thn cc bnh c th gy hn m ny li l iu kin thun li gy hn m suy gip trn
ngi bnh c sn bnh cnh suy gip trc .
Mt bnh cnh khc cn phn bit l Hi chng bnh bnh gip (euthyroid sick
syndrome). Bnh cnh xy ra trn ngi bnh gip b mt thng tn nng khng phi
trn gip. Xt nghim thy T3, T4 gim nhng FT4 bnh thng, TSH khng tng. y
ch l tnh trng gim chuyn ho phn ng sinh l c li thong qua nhm gim tiu
hao nng lng mt ngi suy dinh dng.
III. SINH L BNH
Ri lon thc xy ra trong hn m suy gip thng khng tng quan vi mc
gim T4, thng do nhiu yu t gp phn nh:
Natri mu h, bn thn Natri mu h bt k nguyn nhn no cng c th gy
hn m.
Gim O2, tng CO2, nhim toan.
H glucose mu.
Triu chng co git trc ht do Natri mu h, cng c th do glucose mu h.
Thn nhit h do s gim sinh nhit v suy gip, c th kt hp vi ri lon iu
ho nhit no.
Cc triu chng tim mch c l l hu qu gin tip ca gim sinh nhit. C s
kch thch tng i alpha-adrenergic lm co mch ngoi bin, tng huyt p tm trng
v lm gim nhp tim, gim cung lng tim.
Gim Natri mu ch yu do ADH tng tit, hu qu ca gim cung lng tim v
th tch mu hiu qu. Tnh trng ny s ci thin vi iu tr bng hormon gip. Natri
mu gim y khng phi do mt mui v suy thng thn, Natri mu gim s khng
ci thin vi iu tr corticoid.
H glucose mu ch yu do gim phn hu glycogen v gim tn to glucose.
Gim O2, tng CO2 do nhiu yu t kt hp: Gim thng kh do li ln, thm
nhim nim dch ng h hp trn, c h hp km co bp v thm nhim, trn dch
mng phi, nhim trng phi. Ngoi ra trung tm h hp b c ch trong bi cnh suy
gip, nhy cm vi CO2 gim, tnh trng thiu mu cng gp phn trong c ch ny.
Nhim trng c lm d bi gim protein, phi thi tr cht tit km, t cc
catheter.
IV. IU TR
Hn m suy gip cn c nhanh chng iu tr tch cc ti trung tm hi sc
ngay khi ch mi gi chn on, khng cn i y cc xt nghim cn lm sng,
nhng cng cn trnh dng qu liu thuc v tnh trng ng c nc. Cn iu tr cc
yu t thc y, ngay c khi nghi ng, yu t thc y thng l nhim trng.

98

Lm tng thn nhit vi lm m th ng bng p chn. Khng nn tng thn nhit

ch ng mnh c th gy gin mch, chong trn mt ngi bnh ang gim th tch
mu. Cng c ch nh trn, khng c cho li tiu d ngi bnh c ph chn. Nu
nhit trung ng xung di 30oC c th phi hp ch nh truyn mu ton phn.
Tr tim mch nn thn trng, nu huyt p h, ch nh truyn dch ph hp,
thuc co mch phi ht sc thn trng, dopamin nhm bo tn mu qua mch vnh. Nu
c chong cn truyn mu ton phn. Nu suy tim sung huyt vi tng p tnh mch,
digital dng mt cch thn trng.
H hp h tr cn nhanh chng thc hin: t ni kh qun th oxy, c khi phi
th my km theo di kh mu. Trnh cc c ch h hp ngay c khi c co git.
Dng hormon thay th vi Levothyroxin 50 n 100 mcrg tim tnh mch, c 6
gi n 8 gi tim mt ln trong 24 gi, sau cho 70 n 100 mcrg/ngy, cho ti khi
c th cho ung bng ming. Hiu qu lm sng xut hin sau vi gi iu tr. TSH
gim dn trong 24-48 gi. Vic s dng T3 dnh cho nhng trng hp c s gim
chuyn T4 thnh T3.
Nu khng c dng chch, c th cho vo sonde d dy liu lng 2,5-25g cho
ngy u. Ni chung ch nn dng liu thp, liu cao c th gy lon nhp tim, nhi mu
c tim. Gn y c ngh dng kt hp T4 v T3 tim tnh mch, liu u tin 100g T4
cng vi 20g T3, sau cho 10g T3 mi 8 gi cho n khi ngi bnh c p ng.
Corticoid c a s cc tc gi ng tnh, nhm ngn nga suy thng thn, d
hiu qu iu tr vn cn bn ci, thuc khng c nguy c ng ngi, tim tnh mch
hydrocortison hemisuccinat liu lng rt thay i t 100-1200mg chia 2 n 4 ln
trong ngy u, cc ngy sau c th tip tc nu c suy thng thn.
iu tr h Natri mu ch cn hn ch nc l . Nu Natri di 110mmo/l, mt
cch ht sc thn trng c th truyn ph thm NaCl u trng km furosemid. Lun
phng suy tim sung huyt.
iu tr co git cn thn trng, vi barbituric v benzodiazepin c th lm chm
ci thin tri gic v c ch trung tm h hp. Ni chung ch nn da vo iu tr nguyn
nhn: H Natri mu, thiu oxy, h glucose mu. C th cung cp glucose bng ng
tnh mch. Trng hp thiu mu r c th truyn hng cu khi.
Tch cc tm kim v iu tr cc yu t thc y nh nhim trng, nhim khun
huyt, dng thuc qu liu...
Ni chung hn m suy gip l mt bnh nng, do lun c thi phng
bng chn on sm, iu tr v theo di y tnh trng suy gip.
V. TIN TRIN V TIN LNG
Hn m suy gip lun c tin lng nng. iu tr kt qu tt ch khong 50%.
Nu iu tr hiu qu, bnh ci thin kh nhanh chng sau vi gi hoc vi ngy, ngay
c khi phi iu tr cc ri lon h hp hoc bin chng nhim trng. Nguyn nhn t
vong thng l suy h hp.

99

Cc yu t tin lng xu:

Tui ln.
Nhp tim qu chm.
Thn nhit lc u < 30oC, hoc thn nhit khng tng vi x tr.
Du hiu suy tun hon nng.
Can thip h hp h tr chm, hoc ngng h hp h tr khi tnh trng ngi
bnh vn ang rt cn.
Lm dng iu tr T3 hoc li tiu.
Ton cnh suy gip nng.
TI LIU THAM KHO
1. Trn Hu Dng, Nguyn Hi Thy (2008). Gio trnh sau i hc chuyn
ngnh Ni tit v Chuyn ha. NXB i Hc Hu. 2008. 221 245.
2. David M.Cline, O.John Ma et al (2000). Emergency Medicine. McGraw Hill.
651-666.
3. Fliers E, Wiersinga WM (2003). Myxedema coma. Rev Endocr Metab Dis
2003; 4: 137-141.
4. Greet Van Den Berghe (2008). Acute Endocrinology From Cause to
consequence. 255-270.
5. P. Reed Larsen, Henry M. Kronenberg (2003). Williams Textbook of Endocrinology.
1509-1584.
6. Rodriguez I, Fluiters E, Perez-Mendez LF, Luna R, Paramo C, Garcia-Mayor
RV. (2004) Factors associated with mortality of patients with myxoedema coma:
prospective study in 11 cases treated in a single institution. J Endocrinol 2004; 180(2):
347-350.

100

BU GIP N THUN
I. I CNG
Bnh c m t 2700 nm trc Cng nguyn Trung Quc. Bu gip n
thun hoc bu gip khng c cn c gi l bu gip bnh gip, c nh ngha
l tnh trng tuyn gip ln nhng khng km suy gip hay cng gip, khng b vim
hoc u. Tn gi bu gip n thun, nhng bnh xut hin trong nhiu bt thng
khc nhau. Bnh thng gp n gii, t l c cao hn trong cc giai on dy th, thai
k, tui mn kinh.
Bnh thng v hnh thi, tuyn gip c dng hnh vung: 6 x 6cm. Eo tuyn gip:
cao 1,5 cm, rng 1cm. Mi thy: Cao: 2,5 - 4cm, rng 1,5 - 2cm, dy 1 - 1,5cm. Tuyn
gip bnh thng nng 10 - 20g. Tuyn mu nu, mm, di ng.
C ba th bu gip n: Th lan ta, th nhiu nt, th mt nt (c tc gi gi l
th nhiu nhn, th mt nhn). Th nhiu nt thng gp tui cao hn th lan ta,
triu chng thng khng r, a s khng cn iu tr, cn sinh thit xt nghim t bo
hc loi tr ung th. Th mt nt thng lnh tnh, tuy nhin c khong 5% l ung
th biu m, cn sinh thit bng kim nh lm r chn on, vi th mt nt lnh tnh
cn ti khm nh k, bnh thng khng p ng gim th tch vi iu tr thyroxine.
II. NGUYN NHN
Do thiu iod tuyt i (bu gip dch t) thng do nc ung trong vng b
thiu iod, tuy nhin c nhiu vng trn th gii khng thiu iod ngay c vng tha iod
vn c th b bu gip dch t, ngoi ra khng phi tt c ngi sng vng thiu iod
u b bu gip n thun. iu ny cho thy ngoi yu t mi trng cn c yu t di
truyn trong bnh sinh bu gip, cc yu t ny c th tc dng tng h.
Do tc dng ca cc cht lm ph i tuyn gip: Mt s loi thc n nh qu
su c cha nhng cht lm ln tuyn gip, gii thch s xut hin bu gip dch t
mt s vng. Ngoi ra mt s cht nh thiocyanat, acid para-amino-salicylic (PAS),
mui lithium, cobalt, thuc khng gip tng hp c th gy bu gip n thun.
III. CHN ON
1. Lm sng
Bnh thng kn o, khng c triu chng c nng. Bu gip c th do ngi
bnh hoc ngi xung quanh pht hin, hoc c pht hin khi khm sc khe tng qut.
Khm tuyn gip thy tuyn gip ln gia c, ranh gii r, khng dnh vo da,
tuyn ln lan ta hoc dng nt, di ng theo nhp nut, khng au. Mt tuyn gip c
th tch bnh thng khng bao gi s thy d ngi bnh rt gy.
Khm lm sng, kt hp nhn v s nn. Ngi khm c th ng pha trc
ngi bnh, nhn tuyn gip, dng hai ngn tay ci s tuyn gip. Khi s cn nh r
101

ranh gii, ln, mt ca bu, cng lc cho ngi bnh nut, bu s di ng theo
nhp nut. Bu gip n thun thng c mt mm trong trng hp bu gip nhu
m lan ta, cng c khi mt chc thng thy trong bu gip th nhn.
Bu ln c th gy cc du hiu chn p c quan v t chc xung quanh nh:
Chn p kh qun gy kh th.
Chn p dy thn kinh qut ngc gy ni kh, ni khn, ni hai ging.
Chn p tnh mch ch trn gy ph kiu o khoc: Ph mt, c, lng ngc,
hai tay km tun hon bng h ngc.
Sau khi s bu gip, c th dng thc dy o vng c ca ngi bnh, o
ngang qua ni tuyn gip ln nht, gip theo di din bin qua iu tr.

Ngun: Goitre - Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Goitre

102

Bng. Phn bu gip theo T chc Y t Th gii hin nay

c im

Tuyn gip khng ln (khi nhn cng nh khi s)

S thy bu gip ln, nhng khng nhn thy vi t th c bnh thng. Khi di
ng theo nhp nut khi s.

Nhn thy bu gip ln vi t th c bnh thng. Hnh nh bu gip ln ph

hp vi khm khi s c (bu gip nhn thy v s thy).

2. Cn lm sng
Xt nghim nh lng TSH huyt thanh c gi tr cao, kt hp vi hormon
gip t do l xt nghim sng lc u tin cn thc hin. Kt qu cho tr s bnh thng
i vi bu gip n. Tuy nhin t l T3/T4 c th tng do s iod ha ca
thyroglobulin b thng tn.
Cc thm d v hnh nh hc cng hu ch trong nh gi bu gip, nht l
trong trng hp bu gip dng nt. Siu m tuyn gip, x hnh tuyn gip gip chn
on v iu tr. X hnh tuyn gip gip pht hin nhn nng trong nhu m tuyn gip,
t c nh hng iu tr.
Siu m tuyn gip l thm d hu ch trong nh gi tuyn gip, gip nh gi
hnh thi v ln tuyn gip. C khong 30-50% ngi bnh bu gip dng nt s
tuyn gip bnh thng c siu m tuyn gip pht hin. Siu m cc bu gip dng
nt cho bit s lng, hnh dng nt, ng thi gip hng dn chc ht bng kim nh
chn on t bo hc. Siu m gip theo di sau iu tr.
Chp phim X quang quy c vng c v vng trung tht trn nn thc hin, c
th thy hnh nh chn p kh qun nu c.
Chp ct lp vi tnh, chp cng hng t v x hnh tuyn gip cn c ch
nh trong trng hp bu gip lc ch khu tr trong ngc.
3. Chn on phn bit
Bu gip n cn phn bit vi bnh Basedow hoc bnh Hashimoto.
Vi bnh Basedow trong giai on nhim c gip khng nng v thiu triu
chng thng tn mt, thng kh phn bit vi bu gip n, nhng trng hp ny
cn nh lng khng th c hiu ca Basedow phn bit.
Vi bnh Hashimoto, nhiu khi cng kh chn on phn bit, mc du vi
bnh Hashimoto khi s thng thy tuyn gip c mt chc hn v khng u. Cn
xt nghim khng th c hiu, nu c chun cao cn hng v bnh cnh t min
ca bnh Hashimoto.
Phn bit vi ung th tuyn gip, nht l vi th bu gip nhiu nt. Cn
khm lm sng, xt nghim, thm d cn lm sng tm nhng triu chng gi . Xc
nh chn on ung th tuyn gip vi xt nghim t bo hc.
IV. IU TR
Trng hp bu gip nh, khng c triu chng lm sng: ch cn theo di
nh k bng khm lm sng v siu m tuyn gip nh gi ln. S pht trin

103

tuyn gip rt khc nhau mi ngi bnh, mt s trng hp bu gip n nh trong

nhiu nm.
iu tr c ch gip thng qua c ch TSH tuyn yn vi thyroxin lm gim
th tch tuyn gip khong 60% cc trng hp sau 9 thng iu tr. Tuy nhin, siu m
tuyn gip sau 3 thng ngng iu tr, ngi ta thy tuyn gip tr li kch thc trc
iu tr. Nh th mun duy tr gim th tch bu gip, cn tip tc iu tr lu di.
Ni chung bu gip n th nt thng p ng km hn th bu gip n
lan ta. Kt qu iu tr vi thyroxine thng tt hn ngi bnh tr, bu gip khng
qu ln v bnh mi pht hin.
i vi bu gip n ri rc (sporadic nontoxic goiter) vi nng TSH >
1mU/L c th ch nh iu tr levothyroxin lm gim TSH huyt tng xung mc
di bnh thng (0,5 1,0mU/L), khng nn cho gim thp hn mc ny. Nu tuyn
gip gim th tch hoc n nh c th tip tc iu tr v theo di TSH nh k.
iu tr c ch thyroxin lu di c th gy tc dng xu trn xng v tim. C
th gy long xng, nht l i vi ph n mn kinh, tuy nhin mt s nghin cu
khc cho thy iu tr ny khng gy long xng. Quan im hin nay chp nhn s c
ch TSH vi liu levothyroxin hiu qu thp nht, thng trong khong 1,5 2,0g/kg
trng lng c th/ngy, cn theo di TSH v T3 t do iu chnh liu nhm gim
thiu tc dng khng mong mun.
Khng nn phu thut bu gip n thun v sau c th gy suy gip, tr
trng hp nhm gii phng s chn p sau khi tht bi vi levothyroxin. T l ti pht
sau phu thut khong 10-20% cc trng hp. Bin chng do phu thut chim 7- 10%.
iu tr d phng levothyroxin sau phu thut c th khng ngn chn c s ti pht
bu gip n.
iu tr vi I131 nhm lm gim th tch bu c th p dng cho bu gip
n qu ln ngi ln nhng chng ch nh phu thut hoc nhng trng hp b ti
pht sau phu thut. Khng p dng phng php ny vi ngi tr, cng nh trng
hp bu gip ln sau xng c, c th lm sng cp tnh tuyn gip gy p kh
qun nng hn. Ni chung I131 t ra hiu qu v an ton i vi bu gip n th nhiu
nt, tuy nhin t l suy gip kh cao: 22%-40% trong 5 nm.
TI LIU THAM KHO
1. Mai th Trch (1992). Ni tit hc Tp I. Nh Xut bn Y hc Chi nhnh Thnh
ph H Ch Minh.
2. Trn Hu Dng, Nguyn Hi Thy (2008). Gio trnh sau i hc chuyn
ngnh Ni tit v Chuyn ha. NXB i Hc Hu. 2008.
3. The Washington Manual of Medical Therapeutics 32nd Edition (2007)
4. Williams Texbook of Endocrinology 12 edition (2011).
5. World Health Organization, UNICEF and International Council for Control of
Iodine Deficiency Dysorders. Indicators for Assessing Iodine Deficiency Dysorders and
the Control through Salt Iodization. Geneva 1994.
104

U TUYN C CA TUYN GIP

(Adnome toxique, toxic nodular goiter, Plummer's disease)

I. I CNG
U tuyn c tuyn gip (bnh Plummer) l tnh trng cng chc nng tuyn gip
vi s gia tng sn xut hormon gip do u tuyn t ng (autonomous adenoma).
Nguyn nhn v c ch cha r. C th lin quan n t bin gen ca th th TSH lm
tng hot ng nang tuyn m khng lin quan vi TSH. Mt c ch khc c th l u
tuyn t ng thng phi hp vi t bin gen protein G (gen G protein).
Plummer (1913) l ngi u tin phn bit bnh Basedow v cng gip km
theo nhn gip. Sau , O Copa v J. C. Savoie dng ng v phng x nh gi
chc nng hot ng ca nhn v t chc ngoi nhn gip. l mt nhn nng trn x
hnh tuyn gip khng b hm khi s dng hormon gip ngoi sinh.
Danh t u tuyn c (adnome toxique) ca tuyn gip, cn gi l bu gip
nhn c (goitre nodulaire toxique) c hiu l c tnh trng cng gip, l u tuyn
gip bn cht lnh tnh nhng thot khi s kim sot ca tuyn yn v hot ng t tr
gy nhim c gip.
U tuyn c tuyn gip l mt trong nhng nguyn nhn ca cng gip. T l
thay i ty tng quc gia khong 5% (M v Anh) cho n 46% (o).
Tui khi pht bnh thng ln, khong 40-60 tui, trung bnh 6015 tui, th
nhn t ng khng km cng gip khong 46 14 tui. Tuy nhin cng c th gp
tui 20.
Ph n thng chim u th hn nam gii, t l n/ nam # 4/1.
II. CC TH LM SNG V SINH HC
1. U tuyn c km cng gip
Bnh cnh lm sng l mt nhim c gip n thun km nhn gip, thng l
mt nhn gip n c, i khi b che khut sau xng c. U tuyn thng nh v
mt thy, thy cn li th tch nh hn bnh thng (do b c ch pht trin).
Cn lm sng ghi nhn:
Nng hormon gip cao, thng u th T3.
TSH thp.
Test TRH khng p ng.
Khng th khng gip khng tm thy.
Siu m gip pht hin t chc u tuyn c v t chc gip cn li.

105

Hnh 1. Hnh nh x hnh v siu m u tuyn c tuyn gip

X hnh gip biu hin dng nhn nng.

Test hm Werner (75 - 100g Cynomel (L.Triiodothyronine)/ ngy trong 7
ngy) khng p ng.
Test Querido (100 U.TSH/ngy trong 3 ngy lin tip) phn nhu m cn li thu
nhn iod, chng t nhu m tuyn gip ngoi u tuyn b hm.

Hnh 2. Hnh nh x hnh trc v sau lm test Werner u tuyn c thy tri

Hnh 3. Hnh nh x hnh sau test Querido v phu thut ct thy tri gip

106

2. U tuyn t ng khng km cng gip

Nng hormon gip trong phn ln trng hp bnh thng nhng TSH thp v
khng p ng vi test TRH (tin nhim c gip, cng gip tin lm sng).
c im ca x hnh l hnh nh bt x ca u tuyn c. Lm sng c th l
cng gip kn o vi ri lon nhp tim khng gii thch c. Thng bin chng tim
mch gp ngi ln tui. Ghi nhn c s gia tng SBP (Sex Binding Protein). Cc ri
lon trn bin mt sau khi iu tr u tuyn.
Tn sut cc u tuyn tin c (adnome prtoxique) trong cc u tuyn t ng
thay i ty theo cch nh gi, mt na theo phn nhm lm sng. Trong mt s
trng hp khng nhn bit c. U tuyn xut hin trn x hnh l mt nhn t ng,
nh lng TSH bui sng bnh thng v cn p ng vi test TRH. iu ny kh gii
thch s bin mt phn nhu m lnh mnh v ti xut hin khi ct b u tuyn, mt s tc
gi cho rng do s hm mt phn TSH km bin mt pic tit v m.

Hnh 4. Hnh nh siu m v x hnh u tuyn c tuyn gip

3. U tuyn t ng v ung th
Cc nhn nng tuyn gip thng lnh tnh v chn on ung th thng da vo
x hnh. Tht vy nhn nng khi thm d vi cht techntium nhng c th tr thnh
nhn lnh khi s dng Iod phng x v c kh nng ung th.
Aschraft v cng s (1981) ghi nhn 4% trng hp ung th tuyn gip khi phu
thut cc trng hp nhn nng v thng gp nhn c ng knh trn 3 cm.
4. Tin trin u tuyn c tuyn gip
S tin trin ca mt nhn gip chc nng thng chm, nhiu tc gi nh gi
khong mi nm k t khi hnh thnh cho n lc sn xut hormon gip gy nhim
c gip lm sng.
Trn x hnh nhn gip ban u ng x, khng b mt, chc nng hot ng ngy
cng tng dn tr thnh nhn nng c tnh t tr ri tr thnh c tnh.

107

III. IU TR U TUYN C TUYN GIP

1. iu tr ni khoa
C th s dng thuc khng gip tng hp v c ch beta iu tr triu chng
tm thi, hoc chun b tin phu vi thuc khng gip nh propylthiouracil 100 mg/ 6
gi/ngy hoc carbimazol 40 mg/ ngy.
2. iu tr Iod phng x
U tuyn gip c c th s dng iod phng x (I131). Tuy nhin c mt s c
im cn lu :
S nhy cm vi cht phng x ca t chc u tuyn c thng km hn so
vi nhu m gip trong Basedow. Nang tuyn ln, iod c bt gi bi cc cht dng
keo v i mi nhanh lm gim hiu qu khi iu tr (liu t 20 - 40 miliCuries, iu
ny khng ph hp i vi ngi tr).
iu tr iod phng x c th lm nng thong qua tnh trng cng gip, nguy
him cho ngi ln tui v ngi c bnh l tim mch tim n. V th c th d phng
vi khng gip trc , lm gim iod cha trong nhn gip, hoc dng iod trong 6 tun
cho n khi TSH tr li bnh thng trnh cht phng x ph hy t chc lnh.
Ngc li vi quan im trc y, suy gip th pht thng gp. Theo
Goldstein v cng s, theo di 4 - 16 nm sau khi iu tr Iode phng x, c n 8/23
(36%) ngi bnh b suy gip khng lin quan n kch thc u tuyn v liu x.
Khong 64% u tuyn vn tn ti v c th pht trin ln ra.
3. iu tr phu thut
Can thip phu thut bao gm ct b thy gip hoc loi b nhn gip ty theo
kch thc ca tn thng sau khi chun b tt vi thuc khng gip. Bransom theo di
sau su nm ngi bnh phu thut khng thy b ti pht, tuy nhin 5/35 (14,3%)
ngi bnh b suy gip phn ln iu tr trc bng khng gip trong mi nm v
mt trng hp c iu tr iod phng x.
4. Bm cn iod vo u tuyn
Bm cn vo u tuyn di hng dn ca siu m l phng php gy hy tuyn
khng phu thut. Cn c bm qua da vo nhu m tuyn mi tun, t 5 - 8 tun.
5. iu tr bng Laser
iu tr quang ng Laser t chc k (interstial laser photocoagulation) di s
hng dn ca siu m nhm hy cc nhn t ng.
6. Ch nh iu tr
i vi u tuyn gip c, phng php chn la l phu thut nhng cn loi tr
ung th gip.
iu tr phng x c ch nh nu c kh khn khi can thip phu thut (ngi
gi, t chi phu thut).
108

Nu ng knh u tuyn trn 3 cm v du hiu cng gip nh cn xt n can

thip phu thut mc d nng hormon gip cn bnh thng.
Tin trin ca u tuyn a n c tnh khng c nguyn tc. Silvestein theo di
chn trng hp nhn gip t tr khng c tnh sau hai - by nm cho thy cc nhn
trn hoc khng thay i, hoc tr nn ng x v ph thuc TSH, hoc tr thnh nang
ha v mt chc nng. Mt trng hp tng th tch v khng thy trng hp no b
nhim c gip. Tuy nhin theo di trn c s lng t v thi gian theo di tng i
ngn. Tht vy cn mt mt thi gian trung bnh khong mi hai nm mt nhn
ng x chuyn sang dng mt nhn c tnh. Hai phng php bm cn qua da v
laser liu php di s hng dn ca siu m cha c ng dng rng ri, cn nhiu
nghin cu nh gi hiu qu.

109

BU GIP C A NHN
(Goitre multihtronodulaire toxique, toxic multinodular goiter)

I. I CNG
Bu gip c a nhn l bu gip khng ng nht bn cnh t chc lnh mnh
thng phi hp vi nhiu cu trc t ng gy tng hot gip nh u tuyn c.
Sau Basedow, bu gip c a nhn l mt trong nhng nguyn nhn thng
gp trong cng gip. y l th cng gip ng hng u xy ra ngi bnh ln
tui. Thng k M (1985) ghi nhn t l bu gip c a nhn / Basedow l 1/50.
Mt iu tra 17 trung tm ca 6 nc chu u cho thy 14,5% bu gip c a nhn
trong 850 trng hp cng gip. T l bu gip c a nhn chim 12 - 17,7% trng
hp nhim c gip c m, 37% trong s ngi bnh c iu tr iod phng x
(Riems) v 42% (Metz-Thioville).
Thng xy ra ph n ln tui, ph n 90 - 95% trng hp, tui thng gp
60 - 70 tui, tin s c bu gip a nhn v c tnh cht gia nh.
II. CHN ON
1. Lm sng
1.1. Bu gip

Hnh 1. Hnh nh bu gip c a nhn

Bn thn ngi bnh nhn bit mnh b bu gip trc nhiu nm (trung
bnh mi nm) nhng khng c triu chng chn p kh qun hoc thc qun, khng
c cm gic au n. Tuyn gip thng rt ln, s nn c th c nhiu nhn vi cu
trc khng ng cht, khng tn sinh mch mu, khng c hch km, c th c hin
tng calci ha bn trong nhn gip. Mt s trng hp bu gip ln hoc pht trin
trong lng ngc c th gy chn p.

110

1.2. Triu chng nhim c gip

Du tng chuyn ha:
Gy l triu chng thng gp, c th st cn t 20 - 30 kg, s st cn ny thng
xy ra t t trong mt thi gian, khin lc u ngi bnh t ch . Tuy nhin cm gic
ngon ming khng thay i.
Chng s nng v tng tit m hi thng d nhm vi du bc ha ca ph n
tui mn kinh.
Du tim mch: hi hp, kh th khi gng sc, nhp tim nhanh i khi b che
du bi cc thuc c ch .
Ri lon nhp: thng gp vi rung nh hoc nhng cn nhp nhanh km suy
tim, cn kim tra bnh l tim tim n khi xut hin chng ri lon nhp hon ton.
Du tm thn kinh: chng kch thch thng gp, t tp trung v run tay.
Du c: c lc gim, nht l phn gc km mt mi ton thn. Ri lon v nut
v thay i ging ni cng c ghi nhn.
Du tiu ha: tiu chy thng gp hn l to bn.
1.3. Triu chng m tnh
Khng bao gi c du mt.
Cc th nng ngi bnh nhp vin trong nhng bi cnh nh:
nh hng tim: gp ngi ln tui, c th bnh l tim thiu mu c sn.
Chnh cn lon nhp nhanh hoc suy tim cp pht hin cng gip.
Long xng gy gy xng hoc xp t sng.
Tn thng h c mt cch ng k km nh hng n ton thn nh kh ni,
kh nut hoc bnh l no cp.
Ri lon tm thn kinh.
Ghi nhn tnh trng nhim iod trn ngi bnh ny.
Cng gip trong bu gip c a nhn thng khi pht sau khi s dng Iode
(cn gi l Basedow ha hay cng gip do iod). Mt vi nhn gip khng chu hiu
ng Wolff Chaikoff v khng th nhn Iode, v th tng tng hp hormon gip bi nng
cao iod. C ch ny gii thch ti sao d b cng gip sau khi dng thuc cha iod
(cordaron).
Theo di bu gip c a nhn thng kh khn, khng ch nhim c gip
bng thuc khng gip, tip n ct b tuyn gip gn ton phn l phng thc c
chn la. Nhng phn ln ngi bnh ny ln tui thng km mt s bnh l khc, v
th c th gp kh khn trong qu trnh phu thut. Bu gip c n nhn c kt qu
vi iu tr Iode phng x, nhng bu gip c a nhn vn cn tn ti, mt s nhn
khc vn cn tnh cht c tnh i hi nhiu liu trnh.
111

Cordaron cha 37,3% Iod. Trong c th thuc tp trung t chc m, c tim, gan,
phi. Thi gian bn hy khong 50 ngy. Khong 2% ngi bnh s dng cordaron b
cng gip. y l vn quan trng i vi ngi bnh s dng cordaron c bnh l
tim km theo v i khi cn phi ngng thuc.
Nu nhim c gip nh, c th kim sot vi methimazol 40 - 60 mg/ngy
trong khi cordaron vn tip tc s dng.
Nu bnh nng c th s dng thm KClO4 liu 250 mg/ 6 gi nhm bo ha
bm iod v ngn cn thu nhn iod vo tuyn gip. Dng KClO4 ko di thng km
thiu mu bt sn ty v i hi theo di thng xuyn cng thc mu.
Mt bin php c th lm loi i mt lng ln hormon gip l phu thut ct
gim gip - c th thc hin c nu ngi bnh chu ng c stress do phu thut.
2. Cn lm sng
2.1. nh lng hormon gip
T3 v T4 huyt tng tng, i khi tng T3 l ch yu.
TSH huyt tng gim.
C th pht hin thm chng nhim iod (iod huyt tng v nc tiu tng,
tp trung iod phng x ti gip b gim).
Test TRH hu nh khng p ng.
2.2. Cc thm d min dch hc
Khng th khng th th TSH v khng tuyn gip hu nh khng pht hin.
2.3. Thm d sinh hc
Calci mu v SBP tng nhng khng hng nh.
2.4. Thm d hnh nh hc
X hnh gip vi Tc 99m hoc 131I hoc 123I ghi nhn cht phng x tp trung
khng ng cht nhiu vng vi kch thc khng ng u xen k vng tng thu
nhn vi vng gim x, c th c vng ng x.
Trong trng hp nhim Iod tuyn gip c th bt x rt km.
X quang khng chun b: vng c hoc ngc cho thy hnh nh tuyn gip
chm, chn p kh qun v calci ha.

Hnh 2. Hnh nh bu gip c a nhn qua x hnh I131 v Tc99m

112

 CT scanner hoc cng hng t (IRM) kho st cu trc, kch thc v mt s

bt thng khc i km.
Siu m gip: c th thy tuyn gip trn ba bnh din, khng nh s khng
ng cht, cu trc, cc nhn, calci ha trong t chc v o c kch thc cc nhn
v thy gip.
III. IU TR
1. Phu thut
L bin php iu tr c bn va cha lnh bnh, ng thi ly i cc nhn lnh
cha loi tr ung th ha. Sau khi chun b tt vi khng gip, phn ln phu thut vin
ly t chc kh rng trnh ti pht, t bc nhn n ct b ton b tuyn gip. Tt nhin
cng c mt s tai bin nh phu thut Basedow (suy cn gip, lit dy thn kinh qut
ngc...) v i hi liu php hormon gip v lu di.
2. Iod phng x
Thng dng I131. I131 tp trung vo cc vng nhn nng hy dit t chc tng
hot. Liu thng phng x cao hn nhiu so vi iu tr Basedow (6 - 20 milicurie), c
th chia thnh nhiu liu (thng c chia lm hai liu, khong cch gia hai t iu
tr trung bnh 10 ngy).
Nhiu tc gi khuyn nn chun b khng gip trc trnh cc tai bin trong
qu trnh iu tr phng x (cn cng gip cp).
So vi phu thut, phng php iu tr bng iod phng x c kt qu thng
chm, tr v bnh gip sau 4 - 6 thng, i khi cn iu tr b tc. Ngoi ra nguy c ung
th, suy gip cn phi thng xuyn theo di.
3. Khng gip tng hp
Thng chun b cho phu thut hoc iu tr Iod phng x (xem iu tr u
tuyn c ca tuyn gip).

113

TI LIU THAM KHO

1. Ernest L.Mazzaferri. The Thyroid. Endorinology. Medical Examination
Publishing Company. USA (1974).
2. J Orgiazzi, R Mornex, H Allanic, B Rousset, F Duron, M Malinsky. Pchason, A
Leger, F Leprat, J. L Latapie. Hyperthyroides. La Thyroid. ESF (1992).
3. J. Hazard. La Thyroide Endocrinologie. Masson (1990).
4. L Frankart, M.C Vannes. La thyroide du sujet ag (1998)
5. Sidney H Ingbar, Kenneth A. Woeber. The thyroid gland. Textbook of
Endocrinology. W. B. Saunders Company (1982).
6. Jerome M Hershman (2002). Hypothyroidism and Hyperthyroidism Manual of
Endocrinology and Metabolism. Norman Lavin. Third edition. Lippicott Williams and
Wilkins. 2002 : 396-409.
7. David S. Cooper, Paul W. Ladenson. (2011) Greenspans basic and clinical
endocrinology. 9th edition. Mc Graw Hill :163-226.
8. David G. Gardner (2011) Endocrine Emergencies. Greenspans basic and
clinical endocrinology. 9th edition. Mc Graw Hill :763-786.

114

VIM TUYN GIP HASHIMOTO

I. I CNG
Bnh c Hashimoto m t t nm 1912 vi cc c im: Tuyn gip thm
nhim rt nhiu t bo lympho, tuyn gip b x ho, teo t bo tuyn gip, ng thi
xut hin nhiu t bo i toan mnh. Vim tuyn gip Hashimoto l mt biu hin vim
mn tnh thm nhim lympho bo.
Nm 1956, Rose v Witebsky gy bnh thc nghim trn th. Sau cc khng
th khng gip c Doniach v Roitt pht hin trong huyt tng ngi bnh vim
gip Hashimoto.
C ch bnh sinh cha c hiu r hon ton, tuy nhin tt c cc tc gi u
cng nhn y l mt bnh t min. Trc y khi cha tm c t khng th trong
mu ngi bnh, bnh thng ch c chn on xc nh qua sinh thit tuyn gip.
Bnh cn c cc tn gi khc nh: Vim tuyn gip t min, vim tuyn gip
lympho mn tnh. Hin nay cc tc gi thng nht c hai dng:
Vim tuyn gip Hashimoto i vi th kinh in.
Cc dng vim tuyn gip t min khc, trong c nhng bin dng ca
Hashimoto, mt s dng thng tn gn ging vi Hashimoto nh vim tuyn gip
lympho tr em v thiu nin, vim tuyn gip teo (cc dng ny gy myxoedeme v
cn), vim tuyn gip teo khng c triu chng.
V dch t hc, tuy cha c iu tra c bn nhng nhiu ghi nhn cho thy vim
gip Hashimoto kh ph bin, tn sut c chiu hng gia tng. Bnh xy ra n nhiu
hn (90%), bnh xy ra mi la tui, nhng thng gp t 30-60 tui, c yu t gia
nh, c th xy ra cng lc vi mt s bnh t min khc nh: thiu mu c tnh, i
tho ng, teo tuyn thng thn v cn, suy cn gip v cn, nhc c, vim khp
dng thp, vim gan mn tn cng, bch bin, bc tc sm, x gan do mt, hi chng
Sjogren. Ring hi chng Schmidt bao gm cc bnh sau: Vim tuyn gip Hashimoto,
suy thng thn v cn, suy cn gip, i tho ng, suy bung trng.
II. BNH NGUYN V BNH SINH
Vim tuyn gip Hashimoto l mt bnh min dch, c s phi hp gia min
dch t bo v min dch th dch.
Min dch t bo: Qu trnh t min gy tn thng t bo tuyn gip.
T bo tuyn gip tr thnh cc t khng nguyn, biu hin trn b mt ca t
bo. Nguyn nhn su xa dn n hin tng ny cha c r, khng nguyn phn
ng trong mt din tin phc tp vi cc khng th c hiu, vi cc t bo c kh nng
min dch v b th cui cng gy hu hoi t bo tuyn gip.

115

Bng 1. Cc loi khng nguyn gm:

Trng
lng
phn t

Cu trc

Thyroglobulin (Tg)

660

5496 acid amin

Tin hormon gip

Cht keo chnh

Thyroid peroxydase
(TPO)

102

926 acid amin

Tng hp T3,T4

Gn mng t bo

Th th TSH (TSHR)

100

744 acid amin

Chuyn thng tin

TSH

Khng th c th
kch thch hoc
c ch

Khng nguyn

Chc nng

Ch thch

Cc khng th trong bnh vim gip Hasimoto gm: khng th khng

Thyroglobulin (Tg Ab), khng th khng Thyroid peroxydase (TPO Ab), c gi l
khng th khng microsom; v khng th khng th th TSH (TSH-R Ab). Trong giai
on u ca bnh vim gip Hashimoto, Tg Ab tng r, TPO Ab tng va; sau Tg
Ab gim dn v c th bin mt, nhng TPO Ab vn tn ti nhiu nm. TSH-R Ab (loi
c ch) thng ch tng trong th vim gip teo km ph nim v nhng ngi m
sinh con khng c tuyn gip.
S tng cc khng th Tg Ab v TPO Ab rt c gi tr trong chn on vim gip
Hashimoto, trong lc TSI (Thyroid stimulating immunoglobulin: globulin min dch
kch thch gip) v TSH-R Ab gip chn on bnh Basedow ch cn thit khi lm sng
khng r.
Cc t bo c kh nng min dch lm tng sinh mt cch bt thng mt dng
lympho T ph, din tin ny xy ra do khim khuyt lympho T c ch. Ngi ta bit c
hai nguyn nhn gp phn trong s tng sinh ny: cc yu t di truyn v yu t mi
trng (virus, chuyn ho...). Khi t bo lympho T ph tng sinh, chng s tc ng ln
lympho B sn xut t khng th (do s kt hp) v nhng lympho T tiu hu
(Lymphocytes T tueur) trc tip tn cng v tiu hu t bo tuyn gip.
Min dch th dch:
S hot ho cc lypmpho B bi cc lypmpho T ph dn n s tng sinh v bit
ho lypmpho B thnh tng bo. Cc tng bo ny c kh nng sn xut khng th
chng li cc thnh phn ca tuyn gip. Trong vim gip Hashimoto, ngi ta thy
nng cc khng th khng Thyroglobulin v khng th khng Microsome, ngoi ra
ngi ta cng pht hin cc khng th chng li cc cu cht khc ca tuyn gip
(khng mitochondrie, khng b my Golgi).
Sau ht cng cn nhn mnh s hin din ca khng th chng li cc phn ng
min dch, c gi l khng th khng idiotypes, cc khng th ny c kh nng chng
li cc tnh trng bnh l.
Tng quan vi bnh Basedow: Basedow cng l mt bnh t min, c nhng
im tng ng kh r rt vi vim gip Hashimoto, khng loi tr nhng trng hp
Basedow c tin trin dn n mt vim gip Hashimoto.
Gii phu bnh: C th thy cc hnh nh m hc khc nhau trn vim gip
Hashimoto nh sau:
116

 Trong th c tuyn gip ln, ngi ta thy tuyn gip gia tng th tch vi lp
v dy, nhu m tuyn gip mu vng nht kh ng cht, t bo tuyn gip tuy c gim
v s lng nhng li ph i v th tch vi cht keo (colloid), t bo tuyn c nhng
hc nh, tnh acid cao vi ht nhn gia tng s bt mu (gi l t bo Asknazie hoc t
bo Hurthle). im ch yu l s thm nhim t bo lympho v tng bo.
Trong th teo tuyn gip: Do hu qu ca s x ho chim u th, trong lc s
thm nhim lympho v tng bo khng mnh bng.
c hai th, cc khng th gn ln t bo mng y, dng min dch hunh quang
c th pht hin c hin tng ny.
Bng 2. Phn bit cc biu hin min dch gia vim gip Hashimoto v Basedow
Basedow

Vim gip Hashimoto

Triu chng sinh hc

Thm nhim lympho

Thng gp

Gn nh lun lun c

Globulin min dch trong

cht m

Loi thm nhim m hc

Lympho B v T

Lympho B v T

Phc hp min dch lu

thng

Ph i tuyn c

Thng gp

Thng gp

Tng gammaglobulin

Him

Thng gp

TSI (khng th kch thch gip)

Gn nh lun c

Rt him

TSH-R Ab

Thng c

Him (th teo gip)

TgAb

Him

Tng r giai on u

TPOAb

Him

Tng va nhiu nm

Min dch trung gian t bo

Bt thng lympho T c ch

Cc bnh t min c th kt hp:

Thiu mu Biermer
i tho ng
Nhc c
Bnh Addison
Xut huyt gim tiu cu
Bch bin

Thiu mu Biermer
i tho ng
Nhc c
Bnh Addison
Vim gan mn tn cng
Hi chng Sjorgren

HLA B8-DRw 3

Th teo tuyn gip: HLA B8-DRw3

Th tuyn gip ln: HLA DR5.

Nhm HLA:

III. CHN ON
1. Lm sng
Vim gip Hashimoto c th c chn on do cc biu hin ca vim tuyn
gip hoc cc du hiu ca ri lon chc nng gip.
117

 Cc biu hin vim ti tuyn gip: Tuyn gip ln gn y, c khi km triu

chng au m h tuyn gip, trong giai on ny c khi pht hin mt biu hin
nhim c gip nh.
Tuyn gip c th ln lan to c hai thy, i xng, theo hnh dng ca tuyn gip,
mt n hi. Cng c th gp mt tuyn gip khng u n, c nhiu nt nh,
khng i xng, tri ln mt thy, to mt vng cng chc.
C th gp trng hp tuyn gip ln p cc c quan ln cn gy kh nut nh
do p thc qun, thay i ging ni do p dy thn kinh qut ngc...
Du hiu suy gip: Mt s trng hp cc biu hin suy gip gip hng ti
chn on. Tuyn gip ln km suy gip ngi ln rt gi chn on vim gip
Hashimoto. Ring ngi gi, vim gip Hashimoto c th gp di dng mt bnh
cnh suy gip nng vi tuyn gip teo, cng (trc y gi l suy gip v cn).
2. Cn lm sng
Cc xt nghim thng quy t hu ch trong chn on. Tc lng mu tng
nh, in di protein thy gammaglobulin tng.
Thm d gip chn on: Hormon gip gim, TSH tng, Thyroglobulin tng.
tp trung I131 ti tuyn gip gim.
X hnh tuyn gip thy tuyn gip trng trong phn ln cc trng hp. Ch
nn lm x hnh tuyn gip trong trng hp tp trung iod phng x khng qu thp,
hnh nh tuyn gip ln thng i xng, khng ng cht, iod tp trung khng ng
u, tng vng m nht khc nhau.
Siu m tuyn gip l phng tin rt c gi tr trong chn on, thy hnh nh
tuyn gip khng ng cht.
Xt nghim min dch hc gip chn on xc nh: TPO Ab v Tg Ab dng
tnh trong hu ht cc trng hp Hashimoto, trong TPO Ag nhy hn (TPO Ab: 90100%, Tg Ab: 90%). Ngoi ra cc khng th khc cng hin din nhng t l thp hn
nhiu: TBI Ab (Thyrotropin binding inhibiting antibodies) 15-20%, TGI (Thyroid
growth immunoglobulin), TGBI (Thyroid growth blocking immunoglobulin), khng th
khng T3, T4, khng th khng th th TSH loi c ch.
Chc ht sinh thit tuyn gip bng kim nh cng gip chn on: thy hnh
nh thm nhim rt nhiu t bo lympho v hin din t bo Hurthle (l t bo nang gip
d sn i toan - t bo Hurthle cng c th gp trong u gip lnh tnh hoc c tnh).
IV. BIN CHNG
Bin chng chnh ca vim gip Hashimoto l dn n suy gip. cc ngi
bnh tr ch c 10-15% vi bnh cnh tuyn gip ln km suy gip s a n suy gip
vnh vin. ngi gi thng gp bin chng suy gip vnh vin hn, vi mt bnh
cnh dng tnh vi cc test t khng th v TSH tng cn iu tr lu di.

118

Him khi vim gip Hashimoto dn n mt bnh cnh Lymphoma tuyn gip,
tuy nhin hai bnh cnh ny c lin quan vi nhau hay khng, cho n nay vn cha
c r. Lymphoma tuyn gip biu hin bi s tng nhanh th tch tuyn gip d ang
c iu tr hormon lin tc. Lymphoma tuyn gip c chn on da trn kt qu
phu thut, sinh thit.
Cha tm thy bng chng adenocarcinoma gip xy ra nhiu hn trn vim gip
Hashimoto, tuy nhin hai bnh ny c th ng thi xy ra trn tuyn gip ca ngi
bnh. Cn ngh n ung th gip khi c nt cng tuyn gip khng ci thin vi iu
tr tch cc vi hormon gip. Cn sinh thit bng kim nh lm r chn on.
V. IU TR
Corticoid khng hiu qu trn din tin t min ca vim gip Hashimoto.
Thuc ch c ch nh trong rt t trng hp c vim ti ch r.
iu tr ch yu l hormon thay th vi L.Thyroxin liu trung bnh: 80100g/ngy, ung ngy 1 ln, nhm c ch TSH v iu chnh s suy gip. Khng nn
dng T3 v thuc tc dng mnh, c th lm ngi bnh kh chu v phi ung 2
ln/ngy.
V phu thut: Rt him khi c ch nh.
VI. TIN LNG
V phng din tuyn gip, c khi tuyn ln dn gy chn p cc c quan ln cn,
s thy tuyn gip cng, cn cnh gic ung th ho. C khi tuyn gip n nh hoc
gim th tch dn.
Din tin n suy gip xy ra gn nh hu ht vim gip Hashimoto, y l giai
on cui ca bnh.
Khng iu tr vim gip Hashimoto thng dn n ph nim. Tuyn gip ln v
ph nim thng ci thin tt vi iu th hormon thay th. Vim gip Hashimoto c
khi tri qua giai on gia tng phng thch T3,T4 gy triu chng nhim c gip
thong qua. Biu hin ny trc y c gi l cng gip t khi (spontanous
resolving hyperthyroidism) vi biu hin tp trung iod phng x gim. Tuy nhin
biu hin ny cng c th gp trong vim gip bn cp: tuyn gip khng mm, mu
lng khng tng, t khng th khng gip dng tnh mnh, chc ht sinh thit bng
kim nh thy thm nhim lympho, v t bo Hurthle. Ch iu tr triu chng, dng
propranolol cho n khi triu chng ci thin, ph tr thm T4 c khi cng cn thit.
Hashimoto c khi nm trong bi cnh bnh l a ni tit t min, do cn theo
di thm cc biu hin t min khc nh thiu mu c tnh, suy thng thn, suy gip,
hoc i tho ng. Hashimoto c khi dn n mt bnh Basedow vi li mt v thng
tn da nng. Vim gip mn tnh Hashimoto c th lm gim triu chng nhim c gip
do vy bnh Basedow trong trng hp ny thng ch biu hin tn thng mt v da
rm r m khng c nhim c gip, bnh cnh c gi l Basedow bnh gip.

119

TI LIU THAM KHO

1. Trn Hu Dng, Nguyn Hi Thy (2008). Gio trnh sau i hc chuyn
ngnh Ni tit v Chuyn ha. NXB i hc Hu. 2008. 221 245.
2. Mai Th Trch, Nguyn Thy Khu (2003). Ni tit hc i cng, NXB Y hc
- Chi nhnh Thnh ph H Ch Minh.
3. Brent GA, Larsen PR, Davies TF. Hypothyroidism and thyroiditis. In:
Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams Textbook of
Endocrinology. 11th ed. Philadelphia, Pa: Saunders Elsevier; 2008: chap 12.
4. Fauci, Braunwald et al (2008). Harrisons Principles of Internal Medicine.
2214-2320.
5. G Michael Besser and Michael O Thorner (2003). Comprehensive clinical
endocrinology. 3rd edi. 2003.
6. Ladenson P, Kim M. Thyroid. In: Goldman L and Ausiello D, eds. Cecil
Medicine. 23rd ed. Philadelphia, Pa: Saunders; 2007: chap 244.

120

VIM TUYN GIP BN CP (DE QUERVAIN)

I. NGUYN NHN V C CH BNH SINH
Vim tuyn gip bn cp cn c coi l vim gip do virus (vim gip t bo
khng l). Thng xy ra sau nhim virus vi tun.
Hiu gi khng th khng virus cm, adenovirus, corsackie virus thng tng v
gim sau vi thng. Tuy nhin khng tm thy th vi ca virus trong m tuyn gip v
cy cng him khi cho kt qu dng tnh.
Tn thng tuyn gip cng ging tn thng vim gan do virus.
Vim tuyn gip ph hu cc t bo tuyn gip, gii phng FT3, FT4, TSH h
thp - gy ra hi chng nhim c gip. Hp thu Iod v tng hp hormon gim dn do
t bo tuyn gip b ph hu. Thm nhun n bo v a nhn trung tnh.
C s hin din ca cc u ht vi cc t bo epithelioid bao quanh, v s hin din
ca t bo khng l nhiu nhn. Giai on mun c th thm nhun m si. D tuyn
gip b ph hy nhiu trong giai on ton pht nhng sau cu trc nhu m hc li
tr li bnh thng.
II. CHN ON
1. Lm sng
Thng gp n, tui 40 - 50.
1.1. Triu chng chung
Xut hin hi chng cm, mt, au u, au mi c, au khp, au hng; Gy st
cn. St nh 37,5 - 38oC.
1.2. au vng c
Xut hin t t hoc t ngt, au tng khi nut.
Tuyn gip sng to gp 2-3 ln bnh thng.
au mt bn hoc hai bn lan ln tai, au khp c, hm hoc vng thi dng.
(C th au ht thy phi vi tun ri li xut hin au sang thy tri).
Khng c triu chng au vng c cng khng loi tr chn on vim tuyn gip
bn cp.
1.3. Bu c
Bu chc cng, to u c hai thy, c th to khng u; au khi thm khm.
1.4. Du hiu nhim c gip
Nhp tim nhanh, run tay, v m hi. Cc du hiu cng gip khc c th gp (st
cn, mt...).
121

Giai on nhim c gip c th ko di t mt n hai thng. Ht giai on

nhim c gip l giai on bnh gip, 1/3 n 2/3 s l giai on suy gip thong qua.
2. Cn lm sng
2.1. Hi chng vim
S lng bch cu tng, t l t bo lympho bnh thng; mu lng cao.
in di protein: tng v globulin.
2.2. Xt nghim chc nng tuyn gip
Giai on cp: TSH gim, FT3 v FT4 tng.
Giai on sau, FT3 v FT4 v bnh thng.
Khng th khng tuyn gip (khng microsome, khng peroxydase, anti
thyroglobuline v anti recepteur TSH) thng (-).
X hnh tuyn gip: tuyn gip khng bt I131.
Siu m tuyn gip nhu m tuyn gip khng u c hnh nh gim m.
3. Chn on phn bit
Cc nguyn nhn au vng trc c.
Xut huyt trong nang tuyn hay trong tuyn gy au khu tr.
Vim gip Hashimoto khi c biu hin cp cng au.
Vim gip do vi trng sinh m c phn ng vim mnh hn, bch cu tng cao,
c phn ng st.
Trong th bnh khng au, vim gip u ht bn cp giai on ton pht c
th b chn on nhm l bnh Basedow. Tuy nhin bnh Basedow khng au vng
tuyn gip v tp trung I131 thng l cao.
Ngi bnh c tuyn gip ln v au t ngt cn phi loi tr ung th di cn,
cn phi chc t bo bng kim nh chn on phn bit.
III. TIN TRIN
Chc nng tuyn gip bnh thng sau 6 tun.
au gim sau 15 ngy.
Mu lng tr v bnh thng nhng chm.
T l khong 1-5% biu hin suy gip vnh vin.
C mt s trng hp khi hon ton.
Bnh c th dn n vim gip t min mn tnh.

122

IV. IU TR
Bnh i khi t khi nn ch yu l iu tr triu chng.
Nh: Gim au:
Aspirin (Aspegic): 1 - 3g/ngy
Chng vim nonsteroid: Voltaren 50mg 3ln/ngy hoc Paracetamol.
Nng: Prednisolon 20 - 40mg/ngy ung trong 2 - 3 tun, gim dn liu trong 3
tun, sau 6 tun c th ngng.
p ng tt vi iu tr Prednisolon l mt gi chn on. Mt s trng
hp ngi bnh c triu chng tr li khi ngng prednisolon.
Trng hp c biu hin cng gip, iu tr chn giao cm Arlocardyl 1 - 2
vin/ngy chia nhiu ln
Suy gip ko di c th iu tr bng Levothyrox.
Khng c ch nh iu tr bng thuc khng gip.
TI LIU THAM KHO
1. Trn Hu Dng, Nguyn Hi Thy (2008). Gio trnh sau i hc chuyn
ngnh Ni tit v Chuyn ha. NXB i Hc Hu. 2008. 221 245.
2. Thi Hng Quang (2001). Bnh Ni Tit. Nh xut bn Y hc
2. Mai Th Trch, Nguyn Thy Khu (2003). Ni tit hc i cng, NXB Y hc
- Chi nhnh Thnh ph H Ch Minh.
3. David G. Gardner (2011). Endocrine Emergencies. Greenspans basic and
clinical endocrinology. 9th edition. Mc Graw Hill: 763-786.

123

VIM TUYN GIP M

I. I CNG
Vim tuyn gip m l mt bnh t gp. Bnh cn c gi l vim tuyn gip cp
tnh, vim tuyn gip cp tnh do vi khun
Tuyn gip ni chung c kh nng khng khun cao, mt phn do c nhiu mch
mu, h bch huyt, c lng ln iod ti m tuyn gip, s to hydrogen peroxide trong
tuyn gip tng hp hormon gip, hn na tuyn gip nm trong bao tch bit vi
cc t chc xung quanh.
Tuy nhin, mt s trng hp, nht l tr em s tn ti l r thng t pyriform
sinus pha tri tuyn gip d dn n to p xe. p xe c th ti pht bn tri tuyn
gip do l r xoang cung hng th t (fourth branchial arch sinus fistula). Thng k 526
trng hp tn ti bm sinh l r ny ghi nhn c 45% cc trng hp b vim tuyn
gip cp nhim trng.
Vim tuyn gip m l bnh him gp, tuy nhin hin nay vi s gia tng cc
trng hp suy gim min dch, bnh c chiu hng tng theo. Vim tuyn gip m
chim khong 0,1 - 0,7% cc bnh tuyn gip, t l t vong c th n 12% hoc hn
nu khng iu tr. Ni chung t l gp tr em nhiu hn do lin quan n tnh trng
l r thng t pyriform sinus, c n 90% cc trng hp thng tn pht trin t thy
tri tuyn gip. Khong 8% gp tui trng thnh (20-40 tui), v 92% gp tr em.
ngi suy gim min dch c th gp vim tuyn gip do nm. C khi vim
tuyn gip m gp trn tr em ha tr liu cha ung th.
II. NGUYN NHN
Vi trng gy bnh vim tuyn gip m thng gp l Streptococcus,
Staphylococcus, Pneumococcus, Salmonella, Klebsiella, Bacteroides, cng c th gp
Pallidum, Pasteurella, Multocida, Porphyromonas, Eikenella v lao.
Mm bnh c th n tuyn gip bng ng mu, bch huyt hoc trc tip t
nhim khun ln cn hay vt thng.
Ngoi ra vim tuyn gip m cng c th do cc loi nm nh: Coccidioides
immitis, Aspergillus, Actinomycosis, Blastomycosis, Candida albicans, Nocardia,
Actinobacter baumanii, Cryptococcus v Pneumocystis. Cc loi sau thng gp trn
cc i tng suy gim min dch nh AIDS, ung th.
p xe tuyn gip cng c th gp trong bi cnh bnh c tnh km thng l r.
Vim tuyn gip m do Clostridium perfringens v Clostridium septicum dng
nh lun lun i lin vi ung th i trng, ngoi ra cng gp cc trng hp vim
tuyn gip m do ung th v di cn.
Chc ht bng kim nh trong xt nghim t bo hc cng l mt yu t c th gy
vim tuyn gip m.
124

V sinh l bnh, trong bi cnh nhim trng tuyn gip thm nhim bch cu a
nhn, bch cu lympho trong giai on u, thng km vi hoi t v p xe ha. Giai
on lui bnh c s x ha. Chc ht bng kim nh xt nghim gip chn on vi
khun gy bnh qua nhum Gram, tm nm, hoc cy bnh phm tm khng sinh .
III. M BNH HC
Sau khi vi khun hoc virus xm nhp vo tuyn gip gy ra qu trnh vim lan
ta trong nhu m tuyn v t chc lin kt. Tuyn gip sng to, ph n do cc hin
tng sung huyt, xm nhp bch cu a nhn trung tnh vo nhu m tuyn gip, nhiu
ni lm m, hoi t.
Vim m gy ph hy cc t chc x, si, t chc lin kt, thoi ho trong dn
n gim nhu m v chc nng ca tuyn.
IV. CHN ON
1. Lm sng
Phn ln cc trng hp din bin xy ra t t, song cng c trng hp xy ra
cp tnh vi hi chng nhim trng.
au vng tuyn gip l triu chng ni bt, c th s thy tuyn gip ln,
nng, mm.
Ngi bnh khng th ngng c, thng ngi ci u trnh cng gy au
vng tuyn gip.
Nut au.
Ni kh, khn ting.
C th c biu hin vim t chc ln cn tuyn gip, hch c ln, au.
Thn nhit tng.
C th c rt run nu c nhim trng huyt.
Khi c p xe, khm vng tuyn gip c th thy cc du hiu ca khi p xe
nh: nng, au, v lng nhng.
Triu chng lm sng tr em thng r hn ngi ln: ngi ln c th ch
thy khi au m h vng c, c th khng st.
Vim tuyn gip m c th lan xung ngc gy hoi t trung tht, vim mng
ngoi tim nhng trng hp khng c l r pyriform sinus. Bnh thng xy ra vo
ma thu, ng theo sau nhim trng ng h hp trn.
Thng khng km cng gip hoc suy gip, tuy nhin c bit c th c biu
hin ri lon chc nng gip khi vim lan rng, nh trong cc trng hp vim tuyn
gip do nm, do lao. Vim c th gy thng tn cu trc lm phng thch mt lng
hormon gy triu chng ca nhim c gip.
C khong 12% nhim c gip v 17% suy gip vim tuyn gip cp ni
chung. Chnh tnh trng chc nng gip khng ng b ny gy kh khn cho chn
on phn bit gia vim tuyn gip cp v vim tuyn gip bn cp khi c hai trng
hp u c au tuyn gip. Trng hp lc u c nhim c gip sau l suy gip ri
tr v bnh gip sau iu tr c th vim tuyn gip, thng l bnh cnh ca vim
tuyn gip m.
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2. Cn lm sng
Cng thc mu c bch cu tng cao, a nhn chim u th.
Tc lng mu tng.
X hnh gip thy vng khng bt gi iod (nhn lnh).
Siu m tuyn gip thy vng gim m trong giai on u. Nu p xe c
thnh lp, siu m gip xc nh chn on. Trong giai on lui bnh do iu tr p
ng tt, siu m c th thy vng gip bin dng kiu teo vng thng tn, ti kh
m gip v so m quanh tuyn gip.
Chc ht tuyn gip bng kim nh rt quan trng gip phn bit vim tuyn
gip m v vim tuyn gip bn cp, chc ht thy m khng nh chn on, xt
nghim gip xc nh nguyn nhn gy bnh, khng sinh gip nh hng khng
sinh iu tr. Chc ht cn c th gip lm gim s chn p kh qun cc trng hp
vim tuyn gip m c lm di lch kh qun.
Khng c khng th.
V. CHN ON PHN BIT
Chn on phn bit vi cc bnh l c khi tng cm v au cp tnh vng c
trc nh:
Vim tuyn gip dng u ht bn cp tnh (bnh De Quervain).
Vim m lng lo vng c trc, nhim khun khoang su vng c trc, nang
ng gip-li hay nang mang bi nhim.
Bu gip th nang bin chng chy mu cp tnh trong nang.
U tuyn gip lnh hoc c tnh.
VI. IU TR
Dng khng sinh ton thn thch hp da trn khng sinh , nht l i vi
cc trng hp vim nng.
Ti ch c th dng: chm nng, chiu tia cc tm. Nu sau mt tun dng
khng sinh tch cc nhng chc ht thy c m th cn phi rch tho m, dn lu v
sau 6-8 tun tin hnh ct b thy vim.
Trng hp vim tuyn gip do Candida albican c th dng amphotericin B
v 5 fluconazol 100 mg/ngy.
Phu thut ly l r sau khi iu tr khng sinh phng ti pht.
VII. TIN LNG
Bnh vim tuyn gip m thng ko di 3-6 tun. Cng c trng hp c din
bin xu, mt s trng hp thng tn tuyn gip nng gy suy gip, do trc mt
vim gip nht l cc trng hp vim lan ta cn theo di chc nng tuyn gip c
thi iu tr thch hp. Phu thut ly l r trnh ti pht.
126

UNG TH TUYN GIP

I. DCH T HC
Ung th tuyn gip l loi bnh l ung th tin trin thm lng v c tui th ko
di t 15 n 20 nm. Theo Hip hi Quc t chng ung th, ung th gip chim 0,5 1% trong tng s ngi bnh ung th c iu tr, t l 1% khi gii phu t thi ng
lot. T l ung th gip gia tng ti cc vng bu c a phng. Theo Hip hi ung
th M (American Cancer Society, nm 2014) c khong 62.980 ca ung th gip mi
mc (47.790 n v 15.190 nam); 1.890 ca t vong (1.060 n v 830 nam). Ung th gip
gp ngi tr hn l ngi ln tui, trong 2/3 trng hp di 55 tui v 25% gp
tr em.
Ti Vit Nam, theo Nguyn B c, t l ung th gip chim 2% tng s trng
hp ung th ti H Ni v tn sut khong 3 trng hp/ triu dn/ nm. Ti Bnh vin
K (1976 - 1985), c 214 trng hp ung th gip trong ph n chim 72%. Ti
Trung tm Ung bu TP. HCM (1990 - 1992) ung th gip chim 1,4% trong s cc
trng hp ung th.
T l ung th gip tng i t ph bin, c gii thch mt phn do kch thc khi
u nh v tin trin bnh tng i chm, thng pht hin giai on mun v di cn.
II. YU T NGUY C
Theo Gregory P. Sadler v cng s (ti M) c hai nguy c thng gp i vi
ung th biu m gip l:
1. Tin s ngi bnh c chiu hoc nhim x, nht l tr em
Chiu x tuyn hung (M) c xem l nguyn nhn gy ra ung th gip. Tin s
chiu x vng u-c iu tr u thanh qun, tuyn hnh nhn qu pht, hch c, u
vm hng v.v... lun xt n ngi bnh tr tui.
Tn sut ung th gip tng r rt sau nhim phng x Hiroshima v Nagasaki,
sau tai nn ht nhn Chernobyl lm gia tng nguy c ung th biu m tuyn gip bit
ho vi nguy c t 12 n 25 nm sau khi tip xc. V th vic hn ch liu cao phng
x khi thm d tuyn gip, x hnh I123 hoc Tc 99m thay th cho I131.
2. Yu t gia nh
Tin s gia nh c thn nhn b ung th gip, nht l ung th ty gip trng.
Khong 6% ngi bnh b ung th gip dng nh c yu t gia nh v loi ung th ny
cng thng xy ra ngi bnh mc bnh polip gia nh, bnh a ni tit, hi chng
Pendred, hi chng Gardner v hi chng Cowden.

127

3. Mt s yu t lin quan khc

Tui: thng gp mi tui, chim t l cao tui t 1020 v t 4060.
Sau 60 tui, ung th gip th khng bit ha chim 10-15% cc loi ung th gip.
Gii tnh: t l mc bnh n cao gp 2-3 ln so vi nam gii.
Nhng bt thng tuyn gip:
Ung th gip thng xy ra trn ngi bnh c bu gip nhn n c (gim
tp trung iod phng x): 15 - 20% b ung th.
Tin s bu gip (bu gip a phng). Bu gip mt phn do s kch
thch nhu m gip bi TSH (De Vicher v Becker). V vy d phng ung th gip bng
cch dng L.Thyroxine. Vng bu gip dch t thng gp ung th biu m dng
nang hay ung th biu m khng bit ho. Ung th biu m dng nh thng gp
vng y iod.
Ung th gip phi hp vi cng gip rt him, 1/5.887 trng hp bnh
Basedow (Herbst).
Gim tit hormon gip c th lm bc pht ung th gip, c bit sau khi phu
thut ct gim tuyn gip ton phn. V vy suy gip phi hp vi ung th gip l mt
yu t tin lng xu. Vim tuyn gip Hashimoto v vim gip mn tnh cng c th
phi hp vi ung th gip.
Phi nhim cht hexachlorobenzene v tetracholorodibenzo-para-dioxin.
Cc t bin v gen sinh u v gen c ch sinh u trong ung th tuyn gip.
Hot ho cc gen tyrosine kinase: ti sp xp gen sinh u RET/PTC nhim sc
th 10 xy ra trong 5-35% ung th biu m dng nh t pht.
Gia tng biu l gen sinh u MET c trong 70% carcinoma dng nh.
t bin gen sinh u RET cng thy trong ung th biu m dng tu c tnh gia nh.
Gen sinh u RAS v ng dn truyn tn hiu t bo: t bin RAS thng gp
trong ung th biu m dng nang vng thiu iod.
Gen c ch sinh bu p53: t bin im gen p53 lm bt hot ho gen ny,
thy trong 80% ung th biu m khng bit ho.
III. PHN LOI GII PHU BNH
Gii phu bnh l mt yu t tin lng quan trng v quyt nh cc biu hin
lm sng, iu tr v tin lng. C trng hp ung th gip dng vi th nhng c
pht hin khi c di cn hch hoc c quan ni tng xa. Theo Hedinger v cng s
(1988) phn loi ca T chc Y t Th gii v phn loi t chc hc cc u c tnh ca
tuyn gip nh sau:
1. U tin pht c tnh dng biu m
Ung th biu m bit ha.
T nang tuyn (dng nang, dng nh).
128

 T t bo C (ung th ty gip trng).

Ung th biu m khng bit ha.
Ung th biu m khc.
2. U tin pht c tnh khng phi biu m
Sarcom.
U lympho c tnh.
Cc loi u khc (u t bo hnh thoi km theo nang, u qui c tnh...).
3. Cc u th pht
4. Cc u khng xp loi
IV. C IM UNG TH GIP THEO GII PHU BNH
1. Ung th biu m dng nh
Thng gp nht chim 80% cc loi ung th gip, tr em (75%), u th phi n,
t l n / nam = 2 vi tui 30 - 40 tui. T l cao nhng ngi c tin s phi
nhim x vng c (85 - 90%).
Phn ln ngi bnh c chc nng gip bnh thng. Trong th ung th biu m
dng nh thng l mt nhn cng, chc, khng au, c th kh nut, kh th v khn
ging. Di cn xa chim t l 1 - 15%, di cn phi thng gp ngi tr.
X hnh gip biu hin bng nhn lnh. Trn siu m, cu trc c v tch bit vi
cu trc nhu m gip cn li. Trong th nhiu nhn kch thc thay i, th cht cng,
tch bit vi t chc cn li. Khong 10% ung th biu m dng nh, c bit l tr em,
nhiu hch ln c nhng thng l nhn lnh. Him trng hp xut huyt, hoi t v
to thnh nang trong nhn c tnh. Cc thng tn ny trn siu m gip phn bit cc
thng tn gia dng bn nang c tnh v lnh tnh (dch m). Sau cng, ung th biu
m dng nh c th tm thy mt cch tnh c qua t chc tuyn gip c ly t ngi
bnh Basedow v bu gip a nhn.
V phng din vi th, khi u gm mt lp t bo tuyn gip sp xp trong
thnh mch mu (vasculary stalks), vi cc nh lan dn vo cc khong ging nh
nang nh. Nhn t bo ln v nht, cha nhng cu trc trong. Khong 40% ung th
dng nh lm thnh qu cu calci ha tng phin. Tin lng loi ung th biu m
gip dng nh kh quan.
Chc ht ti u gip hoc ti hch qua hng dn ca siu m nu khi u nh hoc
lm xt nghim gii phu bnh t chc u gip ngay khi phu thut khng nh chn
on, phn loi v nht l nh hng cho vic x tr tch cc ban u.
2. Ung th biu m dng nang
Chim t l 10% bnh l c tnh ca tuyn gip. Thng gp nhiu ph n, t l
n / nam = 3, tui trung bnh 50 tui. Thng gp vng thiu iod.
129

Biu hin bi nhng nhn cng, rt t trng hp tng th tch nhanh hoc c bu
gip trc . T chc l nhng nang nh t to keo, ung th biu m dng nang kh phn
bit vi u tuyn nh nh v v tn sinh mch mu nhng ch 1% tng hot gip.
U thng xm ln nhanh hn so vi u dng nh v c th lan n hch vng hoc
theo dng mu di cn xa n xng v phi. V phng din vi th, cc t bo ht u,
nhn ln sp xp xung quanh nang thng cha cht keo c.
Ngoi tr pht hin do di cn cc c quan, chc ht t bo bng kim nh khng
khng nh hon ton ung th gip dng ti v khng th phn bit t bo ti gia ung th
biu m gip dng nang vi u tuyn nang lnh tnh. Cc khi u c kh nng thu nhn iod
phng x to thyroglobulin hoc T3 v T4 (him hn). Chnh l do ny m ung th
biu m dng nang p ng vi iu tr iod phng x. Nu khng iu tr, ngi bnh t
vong do s thm nhim ti ch hoc do di cn n xng, phi v ni tng.
Chc ht ti u gip hoc ti hch qua hng dn siu m nu khi u nh hoc lm
xt nghim gii phu bnh t chc u gip ngay khi phu thut khng nh chn on,
phn loi v nht l nh hng x tr.
3. Ung th t bo Hurthle
Ung th biu m t bo Hurthle chim 3% trong s ung th gip. Theo phn loi
ca T chc Y t Th gii, cc u ca t bo Hurthle c xem nh l mt bin th ca
t chc tn sinh biu m dng nang. U cha nhiu mnh ca t bo a base cht y ti
lp th. Chng c ngun gc t t bo a oxy ca tuyn gip v chc nng loi t bo
ny vn cha r. U t bo Hurthle c th th TSH v sn xut Thyroglobulin nhng ch
10% loi u ny bt gi iod.
Ung th biu m t bo Hurthle khc vi ung th biu m dng ti ch chng
c nhiu ni v c hai bn, di cn hch ti ch (25%) v khng bt iod phng x.
U t bo Hurthle c chn on qua chc ht t bo bng kim nh v 20% c
tm thy l dng c tnh. Grant v cng s ghi nhn t l t vong di 1% 642 trng
hp u tuyn t bo Hurthle. U tuyn ny ging nh u tuyn ti khng c mch mu hoc
thm nhim vo bao.
4. Ung th ty gip trng
Chim t l 5% ung th biu m gip, pht trin t t bo C, t bo cn nang gip
(William v cng s), c ngun gc t mo thn kinh ca phi v thuc vo h thng
Amine Precursor Uptake Decarboxylation (APUD) ca Pearse.
Ung th ty gip trng gp n nhiu hn nam, t l n / nam = 1,5. Th tn pht
thng gp tui ln (50 - 60 tui) trong khi th gia nh gp tui tr hn. Ngi
bnh thng c khi u c v c hch i km (15-20%). au vng c thng gp km
kh nut, kh ni, kh th, c th b tiu chy trng hp di cn rng.
Ung th biu m ty gip trng t lin quan vi gii tnh. Loi ung th ny i khi
kt hp vi ung th biu m ng tiu ha, u ty tng, u ty thng thn, u tuyn cn
gip, bnh Recklinghausen. Ngoi tit calcitonin, cc t bo C c th cn tit peptid lin

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quan n gen calcitonin, CEA, serotonin, kinin, histamin, prostaglandin E2 v F2 .

Khong 2-4% ngi bnh c hi chng Cushing, si thn xy ra ngi bnh cng
cn gip v tng huyt p thng gp trong trng hp u ty thng thn.
Chn on ung th ty gip trng cn lu bnh s gia nh v ung th ty gip
trng gm hai th chnh: th tn pht (70% trng hp mi pht hin), hoc th gia nh
(30% trng hp mi pht hin).
Ung th ty gip trng gia nh xy ra nh MEN IIA, MEN IIB hoc nh ung
th ty gip trng khng km bnh ni tit khc. i khi cng c th phi hp ung
th biu m nh.
MEN IIA: hi chng bao gm ung th ty gip trng, u ty thng thn, hoc
tng sn ty thng thn v cng cn gip. Tng sn t bo C c hu ht cc trng
hp v thng c pht hin trc khi pht trin thnh u ty thng thn. U ty
thng thn hai bn chim t l trn 50% trng hp, cng cn gip chim khong
25%. Mt s ngi bnh c km thm bnh Hirschsprung v dng bt da (cutaneous
amyloidosis).
MEN IIB: bao gm ung th ty gip trng, u ty thng thn hai bn v u hch
thn kinh nh hng b mt nim mc tm thy ngi bnh. Ngi bnh c khun
mt c bit vi mi v li dy, dng Marphan, u xng ngn, ngc lm.
Ngi bnh MEN IIB c ung th ty gip trng c tnh nht, trong khi ngi bnh
ung th ty gip trng gia nh khng km bnh t min khc, t c tnh nht.
Tt c cc ngi bnh mi pht hin u phi qua test sng lc t bin im RET
v u ty thng thn qua nh lng VMA (Vanillylmandelic acid), catecholamin,
metanephrin niu trong 24 gi. Khm lm sng, nh lng calcitonin hoc CEA, calci
mu, sinh thit kim nh.
Phenotype c hiu ca ung th ty gip trng cng phi hp t bin ca RET
c hiu (ung th ty gip trng gia nh l 768 v 804, MEN IIA l 609, 611, 618, 620
v 634, MEN IIB l 918).
5. Ung th biu m gip th khng bit ha (lon sn)
Chim khong 1% ti M, c l lin quan n d phng tt cc ri lon do thiu
Iod. Bnh thng him gp trc 50 tui, t l n / nam = 1,5.
Lm sng gi trc mt bu gip ln mt cch ng k, pht trin gn y, to
nhanh, mt hoc c hai thy vi tnh cht cng nh , c th dnh vo kh qun (mt
di ng ca vic nut) va dnh vo phn nng, du chn p, xut hin nhanh vi khn
ging (chn p thanh qun), kh pht m (ging i do lit dy thn kinh qut ngc),
kh ni v kh th.
X hnh gip biu hin bng nhn lnh, tng Thyroglobulin, Calcitonin v EAC bnh
thng. Di cn xa xy ra khong 20% ngi bnh, thng l phi. Tin lng loi ung
th gip ny rt xu, ngi bnh t vong nhanh sau khi pht hin trong vi thng.
6. U lympho
Thng gp ph n. Chim 1% bnh gip c tnh v phn ln l loi t bo B
khng Hodgkin. y l loi ung th gip pht trin nhanh nhng p ng vi iu tr,
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c th pht trin mt phn ca u lympho chung hoc c th nguyn pht t tuyn gip.
U lympho tuyn gip c th pht trin t bnh vim gip mn tnh Hashimoto d him
gp, v th kh phn bit vi bnh l ny.
Triu chng lm sng ging ung th gip th khng bit ha, u ln nhanh nhng
khng au. Chn on thng da vo sinh thit kim nh - thy thm nhim t bo
lympho vo nang gip v thnh mch gip phn bit vi u lympho xut pht t vim
gip mn tnh.
7. Ung th tuyn gip th pht (di cn)
Ung th di cn n tuyn gip tng i him gp, t l 2,8 - 7,5%; kho st trn
gii phu t thi t l l 1,9 - 26,4% ngi bnh b ung th. Thng gp sau 50 tui v
khng khc bit v gii tnh.
Ung th tin pht c th t v (20%), phi (10-20%), thn (5-10%), da (malignant
melanoma) 10 - 39%.
Chn on thng da vo t bo hc qua chc ht hoc sinh thit mt bu
gip c nhn lnh pht trin nhanh v c thng tn tin pht. Tin lng ty thuc vo
tn thng tin pht.
V. LM SNG
Ung th gip hay gp ph n, tui t 40 60, tuy nhin cng c th gp mi
la tui ty th bnh. Biu hin lm sng di mt s hnh thc nh:
1. U tuyn gip
1.1. Nhn gip
Mt nhn n c tuyn gip, x hnh cho thy nhn lnh, gim tp trung.
Khng c triu chng c th gip phn bit c tnh hay lnh tnh.
Mt vi tnh cht gi : nhn to nhanh, mt cng, khng au, phn cn li ca
nhu m gip khng b ph i, khng c du hiu ri lon chc nng gip v sau ht l
lit dy thn kinh qut ngc.
1.2. Thoi ha c tnh ca bu gip
Thng l cc bu gip nhiu nhn, nht l cc bu gip a nhn khng ng
nht. Cc du hiu c tnh l: bu to nhanh, mt tr nn cng nh g (), nht l
khi c du hiu chn p hoc c hch c. Theo Kocher: Tt c cc bu gip gy ra
mt bin chng no , phi c coi l thoi ha (c tnh) cho n khi tm c
mt bng chng ngc li. Bng chng ny ch c c khi phu thut.
1.3. Ung th ton khi
Phn ln tng ng vi ung th khng bit ha, c th xy ra trn mt bu gip
c lu, nht l ngi ln tui. Din tin thng qua hai giai on k tip nh sau:

132

 Giai on trong v bc: tuyn gip tng khi lng nhanh mt thy hoc
ton b tuyn, mt tr nn cng.
Giai on ngoi v bc: lm thnh mt khi u ln, cng, khng ng nht,
khng di ng. C th c du hiu chn p, c hch c mt hoc c hai bn.
2. Hch c
Hch c c khi l triu chng pht hin, c th xut hin ng thi vi mt nhn
gip s thy m trc khng v thng cng mt bn vi nhn gip.
Hch ln nhng khng au. Tuy nhin hch c l biu hin u tin, n c ca
ung th gip, c bit l tr em v ngi tr tui. Cc hch, hoc ch c mt hch, c
th cc v tr vng ng-tnh mch cnh, c thanh qun (c nh thn, c trm) mt
trc, hoc c trn n. Khi s nn k tuyn gip vn khng c g bt thng.
3. Di cn
Hay gp nht l xng v phi. Di cn xng vi tnh cht tiu hy gy ra au
xng hoc gy xng t nhin; ct sng s gy ln t sng, c khi p ty. Di cn
phi thng m thm, kiu ht k nhiu hn l dng nt ln hoc nh. Di cn no, gan,
bung trng t gp hn, hu nh ch gp loi ung th biu m ty gip trng.
VI. CN LM SNG
1. Siu m tuyn gip
Siu m gip hin l phng tin chn on hnh nh kh chun chn on
bnh tuyn gip. Phng tin ny an ton, khng c hi, kinh t v rt hiu qu
nh gi cu trc tuyn gip. Ngoi ra siu m c th nh gi chnh xc kch thc, v
tr ca nhn gip v pht hin cc nhn gip khng s thy trn lm sng. Siu m ngy
cng c s dng nhiu hng dn chc ht t bo nhn gip bng kim nh (FNA:
Fine Needle Aspiration). Cc du hiu ca mt nhn gip c tnh nghi ng trn siu m
bao gm tng sinh mch mu trung tm, u gip gim hi m, b khng u, vi ho
bn trong.
2. X hnh tuyn gip vi I123 hoc Tc99m
X hnh tuyn gip dng nh gi s hp thu iod ca cc nhn gip. Cc nhn
nng (thu nhn iod phng x) t c nguy c c tnh hn nhn lnh (khng nhn iod
phng x). Hnh nh nhn lnh trn x hnh tuyn gip nghi ng ung th cho ti khi tm
c bng chng ngc li. Nhn ng x him gp ung th gip. Trng hp bu
gip nhiu nhn c t trc b thoi ha c tnh th rt kh chn on. Nhn lnh n
c ch c t 10 - 20% l ung th.
Hn ch ca phng php: c hi phng x, khng kinh t v nht l ly gii
hnh nh km ch yu hai bnh din. Ngy nay ung th gip thng c chn on
bng FNA v x hnh tuyn gip him khi cn trong nh gi thng quy nhn gip.

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3. Chp ct lp in ton v chp cng hng t tuyn gip

Chp ct lp in ton (computerized tomography - CT) v chp cng hng t
(magnetic resonance imaging - MRI) tuyn gip l phng tin nh gi s lan rng
ung th tuyn gip vo cu trc ln cn v di cn hch. CT c cn quang iod cho thy
hnh nh chi tit tuyn gip v nh gi di cn hch tt hn MRI, CT cng t tn km
hn MRI.
Hn ch ca CT c cn quang iod l ngn cn kh nng hp thu iod trn x hnh
sau v c th gy c gip trng trong trng hp s dng cht cn quang iod liu
cao v ngi bnh c cng gip tim n.
MRI c u im l khng dng cht cn quang iod, khng c hi phng x v c
th cho thy r tuyn gip v cu trc ln cn.
4. Chc ht t bo bng kim nh
Chc ht t bo bng kim nh (fine needle aspiration hay FNA) l phng tin
c la chn hng u nh gi ht gip. Phng tin ny c nhy v c
hiu cao trn 90%. Kt qu FNA gm: c tnh, lnh tnh, khng xc nh c v khng
tiu chun chn on. Kt qu FNA khng xc nh c thng l tn thng dng
nang c th lnh hoc c tnh. Cc ngi bnh ny cn c ct thu tuyn gip ton
phn v ct lnh.
Nhm FNA khng tiu chun chn on chim 10-12% khi khng dng siu
m hng dn v t l ny ci thin cn 0% khi c s dng hng dn ca siu m.
Chc ht ti u gip hoc ti hch qua hng dn ca siu m nu khi u nh hoc
lm xt nghim gii phu bnh t chc u gip ngay khi phu thut khng nh chn
on, phn loi v nht l nh hng cho vic x tr tch cc ban u.
5. Mt s thm d khc
5.1. nh lng LT3, LT4 v TSH
Bnh thng trong phn ln cc trng hp.
5.2. nh lng thyroglobulin
Thyroglobulin l glycoprotein, tng hp trong t bo gip, c d tr trong cht
keo ca nang gip v cha cc kch t gip, bnh thng di 20 ng/mL (phng php
phng x min dch hc).
Tng thyroglobulin l du hiu quan trng trong ung th gip bit ha, nhng c
th tng trong u tuyn l yu t cn c trc khi ch nh phu thut.
Xt nghim cn c gi tr trong qu trnh theo di sau phu thut v x tr liu
cng nh nh gi di cn v ti pht.
5.3. Test Pentagastrine
Tim tnh mch trong vng 3 pht vi 0,5 g/kg cht pentagastrine (Peptavlon)
ha trong 5ml dung dch mui ng trng.
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Ly mu vo cc thi im -5, 0, 3 v 5 pht nh lng calcitonine. Ngi

bnh thng calcitonine cn bn l di 10 pg/ml v mc cao nht l di 30 pg/ ml.
Ung th biu m ty gip trng c mc cao nht trn 100 pg/ml.
Trng hp nghi ng 30 - 100 pg/ml.
Thn trng vi ngi bnh suy mch vnh v c a d ng (lm test trc).
5.4. nh lng ACE (Antigene-carcino-embryonnaire)
Trong ung th gip thng tng i km vi calcitonine.
5.5. X-quang
Vng c vi cc tia mm c th thy cc nt calci ha nh, nht l trong ung th
dng nh. Nhng nt calci ha ln lin quan n ti cu trc, c bit l cc di chng do
xut huyt c v c th gp trong cc bnh lnh tnh, nhng khng nht thit. X quang
cng c th gip pht hin s chn p hoc di lch thanh kh qun.
X quang phi v CT phi tm cc di cn, hoc tm xem c khi u pht trin
xung lng ngc gy chn p hoc di lch kh qun hoc di cn hch trong lng ngc.
X quang xng v ct sng pht hin di cn.
5.6. Khm Tai- Mi- Hng
pht hin mt dy qut ngc b lit.
5.7. Siu m gan
Di cn ca ung th gan, kt hp vi x hnh gip chn on.
5.8. Fludeoxyglucose (FDG)-Positron Emission Tomography (PET)
Nhm pht hin di cn ca ung th gip
VII. TH LM SNG
1. Th theo triu chng
Cp tnh: gp ngi tr, biu hin nh vim tuyn gip cp.
Ung th chai (Squirrhe): ging nh vim tuyn gip mn tnh Riedel.
Cng gip: hn hu.
2. Th phi hp
Vi vim tuyn gip Hashimoto kh chn on, nht l th c bu gip nhn.
Vi bu gip.
3. Th t chc gip lc ch
Ung th pht trin trong lng ngc.
Ung th nh khu hon ton trung tht, pht hin do c chn p.
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4. Th theo gii phu bnh

Ung th dng nh: tin trin chm, gp tr em v ngi tr tui.
Ung th dng nang: xm ln mch mu, nguy c di cn xa nht l khi t bit ha.
Ung th khng bit ha hay lon sn: loi ung th ton khi v tin lng xu.
Ung th ty gip trng: c s hin din mt cht m dng bt (70% trng
hp), trong khi u c nt calci ha.
U lympho tuyn gip nguyn pht: rt t gp (0,03%), c th xut pht t mt
vim gip t min. Gp ph n trn 60 tui, khi u vng c mi xut hin, khng au,
to nhanh, gy chn p, nn thy mt nhn hoc mt khi u ln vng c, cng, c th c
hch c.
Xt nghim t chc hc thy:
U lympho lan ta t chc bo, in di IgM tng.
Nhng th him nh di cn ung th v, phi, thn, u melanin c tnh.
VIII. PHN LOI TNM V UNG TH GIP
Theo Hi chng ung th quc t (International Union Against Cancer) v Hip
hi ung th M (American Joint Commitee on cancer) ngh phn loi theo TNM v
ung th gip nh sau:
Xp hng lm sng theo T,N,M
(T) U nguyn pht:
Tx: U nguyn pht khng th nh gi c
T0: Khng c u nguyn pht
T1: U < 2 cm
T2: U >2 cm v <4 cm
T3: U >4 cm hoc xm ln t
T4a: U n lan khi v bao gip v xm ln bt c cu trc no sau y: m
mm di da, thanh qun, kh qun, thc qun, thn kinh hi thanh qun.
T4b: U xm ln mng cn trc ct sng, mch mu trung tht hoc bc quanh
ng mch cnh.
T4a*: U (bt k kch thc) khu tr trong tuyn gip (ch dnh cho carcinom
khng bit ho).
T4b*: U (bt k kch thc) n lan khi tuyn gip (ch dnh cho carcinom
khng bit ho).
(N) Hch vng:
Nx: Hch vng khng th nh gi c

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 N0: Khng c hch di cn

N1: Hch vng c di cn
N1a: Di cn hch nhm VI (hch trc kh qun v hch cnh kh qun gm
hch trc thanh qun v hch Delphian).
N1b: Di cn cc hch khc cng bn, hai bn hoc hch c i bn hoc hch
trung tht trn.
(M) Di cn xa:
Mx: Di cn xa khng th nh gi c.
M0: Khng c di cn xa.
M1: C di cn xa.
Bng phn giai on ung th tuyn gip theo TNM (M)
Ung th biu m dng nh hoc nang, di 45 tui
Giai on I
Bt k T
Bt k N
M0
Giai on II
Bt k T
Bt k N
M1
Ung th biu m dng nh hoc nang 45 tui, v carcinom dng ty
Giai on 0
T1
N0
M0
Giai on I
T2
N0
M0
Giai on III
Bt k T
N1
M0
Giai on IVa T4a
N0, N1
M0
Giai on IVb T4b
Bt k N M0
Giai on IVc Bt k T
Bt k N M1
Ung th biu m gip khng bit ha
Giai on IV
Tt c cc trng hp

IX. CHN ON UNG TH GIP

1. Chn on chc chn
Nh xt nghim gii phu bnh.
2. Chn on phn bit
2.1. Bnh ngoi tuyn gip
U nang ng gip li.
Hch c do ung th tai- mi- hng.
2.2. Bnh ti tuyn gip
Bu gip nhn.
Th cp tnh (him) biu hin ging nh vim gip cp, chn on xc nh
qua xt nghim t bo hc khi chc d sinh thit.
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 Bu gip nhiu nhn khng ng nht: ngh ti ung th trc s tng khi
lng nhanh chng ca mt nhn gip.
Vim gip Hashimoto nhiu nhn, hiu gi khng th khng gip rt cao. Tuy
nhin, phi ch xt nghim gii phu bnh hc mt cch chc chn.
2.3. Di cn xng
Lu cc ung th khc nh ung th v, ung th thn, ung th tuyn tin lit, ung
th tinh hon cng di cn vo xng.
X. IU TR UNG TH GIP
Ty dng ung th.
1. Cc phng php iu tr
1.1. Ngoi khoa
L phng php c chn u tin, ty tn thng khu tr hay lan rng ngi ta
c th:
Ct b hon ton mt thy cng vi phn eo.
Ct b ton b tuyn gip.
Ct b hon ton tuyn gip, bc cc bch huyt mt bn hay c hai bn c.
1.2. X tr liu
Nu nhu m gip cn kh nng c nh c iod phng x th 131I c th ph hy
cc t chc ung th bit ha. Iod phng x cng c th dng sau khi phu thut
dit tr cc di tch ung th cn st. Phi ngng dng hormon gip TSH hot ha li
nhu m gip th mi p dng iod phng x c.
1.3. Ha tr liu
t tc dng.
1.4. iu tr khi u
1.5. Liu php hormon thay th
D phu thut ct ton b hay mt phn tuyn gip, c hay khng phi hp iod
phng x sau phu thut, s dng L.thyroxin cng cn c ch nh. Liu php
thyroxin nhm hai mc ch:
B s thiu ht hormon gip sau khi ct b tuyn gip.
c ch s tit TSH phng cc t bo ung th cn st khi b kch thch.
Liu L.thyroxin trung bnh 100 n 200 g/ngy nhm t c nng TSH
gii hn di ca mc bnh thng (0,4U/mL).

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1.6. Theo di lm sng v cn lm sng

Kim tra vng tuyn gip, cc hch bch huyt c v trn xng n, ct
sng, gan.
nh lng thyroglobulin nh k, nu cao phi ngh ti ung th ti pht hoc
c di cn.
Khm tai mi hng sau khi phu thut loi tr lit dy qut ngc.
Chp X quang lng ngc mi nm mt ln.
Chp X quang ct sng khi nghi ng (c au dai dng).
Nu c triu chng lm sng m X quang khng c bt thng, cn chp x hnh
vi Pyrophosphat Technetium tm cc di cn xng.
2. Ung th gip ti pht
Thng tuyn gip hoc hch bch huyt.
Nu ti pht ti ch sau khi phu thut n gin ct b khi u th x tr nh i
vi mt nhn gip n c.
Nu ti pht thy i din sau khi ct b mt thy, cn ct b ton b tuyn
gip cn li, km bc ht cc hch bch huyt, hoc ch ct tuyn gip khng thi.
Nu ti pht nh v cc hch mt bn hoc hai bn c sau khi ch ct tuyn
gip: ly hch lm xt nghim gii phu bnh tc th. Kt qu xt nghim nu thy c di
cn th cn bc b mt m hoc ton b cc hch i.
Ti pht hch bch huyt khc sau khi bc b ton b hch vng c, cng
cn phu thut bc hch, sau dng iod phng x vi liu lng 100 miliCurie.
3. Ung th gip di cn
Ung th gip c pht hin nh mt di cn hch: phu thut ct ton b tuyn
gip km bc hch. Sau dng Iod phng x.
Nhng di cn khc, bt k u v bt k nhiu hay t, nu c nh c Iod
phng x th cng s c iu tr bng cht ng v phng x ny.
Nhng di cn khng c nh iod phng x s c x tr bng phng php
dng Cobalt thng thng.
Ung th ty gip trng c theo di bng nng calcitonin v khng nguyn
carcinom bo thai.
XI. TIN LNG V PHNG BNH
1. Theo giai on
Hay v cng s theo di 1500 ngi bnh sau 5 nm, t l t vong giai on I
l 1%, giai on II l 2,06%, giai on III l 5,3% v giai on IV l 77%.
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 De Groot ghi nhn 80-90% giai on I v II sng st 38 nm, 50% giai on III
sng st sau 20 nm, v 0% sng st i vi giai on IV sau 10 nm.
2. Theo m bnh hc
T l sng sau 5 nm: 80 - 90% vi ung th biu m dng nh, 50-70% vi ung
th biu m dng nang l, 40% vi ung th biu m dng ty, ung th biu m khng
bit ha 5%.
2.1. Ung th gip dng bit ha
Qua thng k, cc yu t lin quan n d hu nh sau:
Tui chn on:

trn 40 tin lng xu hn.

Gii tnh:

nam gii t l sng thp hn so vi n.

Kch thc khi u:

trn 4 cm tin lng nng hn.

Mc bit ha ca u nguyn pht. Mc lan ti ch ngay phu thut ln u,

thm nhim ti ch thng tin lng xu hn ch c nhn n c. Nu c hch c, ct
ton b tuyn gip kt hp no sch hch c tin lng kh hn.
X tr liu 131I sau phu thut phn u cn st li, d hu tt hn.
Dng ung th nh c tin lng tt hn dng ung th nang.
Ung th biu m dng bit ha c th ti pht v di cn sau 10 nm k t lc iu
tr, bt k thuc nhm gii phu bnh no v tui no. Phi trn 10 nm mi nh gi
tin lng c.
2.2. Ung th t bo Hurthle
Tin lng xu hn ung th gip bit ha.
2.3. Ung th biu m ty gip trng
Nu khng c di cn xa th tng i tt: 80% c th sng ti 10 nm.
D phng iod c th lm gim t l mc ung th gip. Trnh chiu tia phng x
vng tuyn gip tr em gip gim nguy c ung th tuyn gip. Dng T4 sau phu
thut nhm c ch TSH cng ci thin tin lng mc d vai tr ca c ch TSH trong
vic phng nga ung th gip cha c bit r.
2.4. Ung th gip dng khng bit ha
Tin lng rt xu, t ngi bnh sng qu 6 thng, khng ti 5% sng ti 5 nm.
2.5. U lympho gip
T l sng trn 5 nm 50%. Nu ngi bnh c thng tn ngoi gip phi hp th
thi gian sng thp hn thng tn khu tr ti gip (40% so vi 85%).

140

3. Theo phn c tnh

c tnh

Loi ung th

Thp

Ung th dng nh
Ung th dng nang, xm ln ti thiu
U lympho c tnh t bo B vng b typ MALT

Trung bnh

Ung th dng nang, xm ln lan rng

Ung th dng km bit ho
Ung th dng tu
U lympho c tnh t bo B lan to

Cao

Ung th khng bit ho

Ung th mch mu

XI. KT LUN
Ung th gip l ung th tuyn ni tit thng gp nht v a dng. a s ung th
dng biu m bit ho, tin trin m thm, giai on n bnh ko di, iu tr bao gm
phu thut, x tr liu v ha tr liu. Chn on ngoi lm sng cn lm siu m v gii
phu bnh xc minh dng ung th gip. a s ngi bnh ung th tuyn gip th bit
ha c tin lng tt nu c chn on v iu tr sm, tch cc.
TI LIU THAM KHO
1. Thi Hng Quang. Bnh ca tuyn gip. Bnh ni tit (1998).
2. Nguyn Thy Khu. Ung th gip, Ni tit hc i cng (1999).
3. Nguyn B c. Ung th tuyn gip trng. Bnh tuyn gip v cc ri lon do
thiu Iode. ng Trn Du (Ch bin). NXB Y Hc. H Ni.(1996.)
4. Nguyn Hi Thu. Chn on v iu tr bnh tuyn gip. NXB Y hc. 2000.
5. Nguyn Vn Mo, Nguyn Hi Thy (2012). Phn loi bnh hc tuyn gip v
c im gii phu bnh u tuyn gip. Tp ch Ni tit i tho ng s 8. 2012 ,
trang 221-230
6. Andre J Van Herle (2002). Thyroid tumor in Adults Manual of Endocrinology
and Metabolism. Norman Lavin. Third edition. Lippicott Williams and Wilkins. 2002:
410-421
7. B. Franc, M. Schlumberger, V. Rohmer, N. Ifrah, N. Barbot, J. C. Bigorgne.
Cancer de la thyroide. La Thyroid. ESF (1992).
8. Carling T, Udelsman R: Thyroid tumors. In: DeVita VT Jr, Lawrence TS,
Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa:
Lippincott Williams & Wilkins, 2011, pp 1457-72.
9. Delellis R.A, Williams E.D (2004): Thyroid and parathyroid tumours.
Pathology and genetics of endocrine organs. WHO, IARC Press, Lyon. 48-120

141

10. Ernest L.Mazzaferri. The Thyroid. Endocrinology. Medical Examination

Publishing Company. USA (1974).
11. Francis S Greenspan (2004). The thyroid gland Basic and Clinical
Endocrinology. Francis S Greenspan. Seventh edition. A Lange Medical book
2004 :215-294
12. Haigh PI, Urbach DR: The treatment and prognosis of Hrthle cell follicular
thyroid carcinoma compared with its non-Hrthle cell counterpart. Surgery 138 (6):
1152-7; discussion 1157-8, 2005.
13. J. Hazard. La Thyroide Endocrinologie. Masson (1990).
14. J. Larry Jameson. Anthony P. Weetman (2008). Disorders of the thyroid gland.
Harrisons Internal Medicine. 17th edition 2008: 2224-2247.
15. J.Lubetzki. Pathologie Thyroidienne. Le livre de linterne endocrinologique et
Malaladies metaboliques. (1991).
16. L Frankart, M.C Vannes. La thyroide du sujet g. (1998)
17. Leonard Wartofsky. Diseases of the Thyroid. Harrisons Priciples of internal
medicine (1998).
18. Neff RL, Farrar WB, Kloos RT, et al.: Anaplastic thyroid cancer. Endocrinol
Metab Clin North Am 37 (2): 525-38, xi, 2008.
19. P. Reed Larsen, Terry F Davies, Ian D. Hay. The Thyroid gland. Williams
Textbook of Endocrinology, nineth edition. W.B. Saunders Company. 1998 : 389-516
20. Paul A. Fitzgerald. Endocrinology. Current medical diagnostic and treatment.
37 edition (1998).
21. Rosai J, Carcangiu M.L and Delellis R.A (1994): Tumors of the Thyroid
Gland. Atlas of Tumor Pathology, Armed Forces Institute of Pathology (AFIP). USA.
22. Sidney H Ingbar, Kenneth A. Woeber. The thyroid gland. Textbook of
Endocrinology. W. B. Saunders Company(1982).
23. William E Clutter. Endocrine Diseases. The Washington Manual of Medical
Therapeutics. 29 Edition. (1998).

142

Chng 3. BNH TUYN THNG THN

SUY THNG THN CP
I. I CNG
Suy thng thn cp (STTC) l mt cp cu ni khoa do thiu ht corticoid cp
tnh, t nhiu i km vi thiu corticoid khong. Chn on bnh thng kh khn do
triu chng lm sng v sinh hc khng c hiu. y l mt trong nhng nguyn nhn
gy t t, bnh thng b b st vi chn on try tim mch khng r nguyn nhn.
Do vy cn c iu tr kp thi, ti ch ngay khi cha c chn on xc nh, mi
ch c vi triu chng nghi ng.
STTC thng gp trong bi cnh th pht ca bnh Addison khng c chn
on hoc iu tr khng y . Bnh cng c th gp sau mt t iu tr corticoid
ko di.
II. CHN ON
1. Lm sng
Ri lon tiu ha: au thng v, sau lan ton bng, nhng khm bng vn
mm, c khi km bun nn, nn. Cc biu hin trn c th nhm vi mt bnh l bng
ngoi khoa.
Ri lon tm thn vi mt l n hn m, hoc ngc li kch thch, ni sng,
ln ln.
Try tim mch, huyt p h nhanh chng, tay chn lnh, mch nh, nhanh.
Du hiu mt nc ngoi bo biu hin vi st cn, au c, c khi st d
khng c du hiu nhim trng. Ngoi ra c th phi hp vi cc cn au lan rng nh
au c, au khp, au u.
2. Cn lm sng
Xt nghim sinh hc gip xc nh chn on.
Ri lon in gii mu: Natri gim (80%), Clo gim, Kali tng (60%).
Kali mu tng lm thay i sng in tim vi T cao nhn i xng, c khi i
km vi QRS gin rng, bloc nh tht.
Protid mu tng, Hct tng.
H glucose huyt, i khi rt thp gy nn cc triu chng tm thn kinh.
Ngoi ra c th gp: Tng bch cu i toan, tng calci mu (6%), nhim toan
mu, thiu mu.

143

Trong bi cnh suy thng thn th pht, cc biu hin thng gp l:

H ng mu (50%)
H Natri mu (15%)
Tng bch cu i toan (20%)
Thiu mu
III. NGUYN NHN
STTC c th xy ra trong bi cnh STT tin pht hoc th pht.
1. Nguyn nhn do thng thn
1.1. Trn tuyn thng thn tn thng
STTC c th l biu hin khi pht ca mt bnh STT tin pht d bt k nguyn
nhn no. Cc yu t lm xut hin STTC nh:
Nhim trng, phu thut, nn ma.
Dng thuc nhun trng, a chy hoc li tiu.
m hi nhiu, n nht nhiu v ko di.
B iu tr hormon thay th.
1.2. Xut huyt tuyn thng thn hai bn
Xut huyt v u mu hai bn thng thn l nhng thng tn him, din tin
nng, bnh thng c pht hin khi gii phu t thi. Xut huyt thng thn khng
do chn thng thng do ri lon ng mu. C th do ng mu ri rc trong lng
mch hoc cc bnh gy ng mu (ung th, cc bnh mu), nhng hay gp nht l do
iu tr bng thuc chng ng.
Xut huyt thng thn hai bn cng c th xy ra do iu tr khng thng thn
bng OP'DDD [2,2 bis-(2-chlorophenyl, 4-chlorophenyl)-1,1-dichloroethane].
tr em trong hi chng Waterhouse-Friderichsen, xut huyt thng thn hai
bn chu sinh gy suy thng thn cp thng do try mch lin tip do mt mu.
1.3. Ri lon tng hp hormon thng thn bm sinh
Rt him, ch thy nhi khoa, l bnh cnh ca s mt mui nh nhi c s
chn men 21-hydroxylase. Bnh xut hin sau sinh vi ngy n vi tun vi chn n,
khng tng cn, nn, mt nc v try tim mch. T vong trong bnh cnh suy thng
thn cp nu khng iu tr ng v kp thi. Tr tiu nhiu Natri d Natri mu gim,
km Clor mu gim v Kali mu tng. tr n thng km bt thng c quan sinh
dc ngoi.
Cc loi men khc him hn nhiu, cng gy hi chng mt mui, v d thiu 11hydroxylase, 3.(-ol-deshydrogenase hoc him hn: 20-22 desmolase.
144

1.4. Cc nguyn nhn khc

OP' DDD khng nhng c ch tng hp Cortiosol m cn c tc dng chng
phn bo lm teo tuyn thng thn.
Aminoglutthimide l mt khng thng thn tng hp khc, c ch tng hp
Cortisol vi nguy c gy suy thng thn t nhng ngy u iu tr.
Mt s trng hp suy thng thn cp do iu tr bng Ketoconazol liu cao
lin tc.
Rifampicin l mt cht cm ng men gan, lm tng oxy ha cortisol thnh 6hydroxycortisol.
Mt s thuc cm ng men khc nh Gardenal, Dihydan (phenitoin).
Mt s nguyn nhn khc him hn nh tc mch do cholesterol, huyt khi
mt ng mch hoc mt tnh mch thng thn, nhim nm (cryptococcose).
Phu thut ct thng thn ton phn, cn c iu tr hormon thay th.
2. Nguyn nhn di i-tuyn yn
Phu thut u tuyn thy trc tuyn yn.
Hi chng Sheehan.
Chn thng.
Vim mng no.
V phnh mch mt ng mch cnh trong.
Trn mu tuyn yn (xut huyt u tuyn yn).
Test Mtyrapone c th dn n STTC, nht l vo lc cui ca test.
Phu thut ct mt tuyn thng thn do u.
Xy ra do ngng iu tr t ngt sau mt liu trnh Corticoid ko di.
IV. IU TR
Truyn dch gi ven, bt u bng nc mui sinh l.
Tim Hydrocortison hemisuccinat (HCHS): 100mg bp, 100mg tnh mch.
Sau chuyn ngi bnh n chuyn khoa, iu tr theo ba hng chnh: iu
chnh nc, in gii, hormon thay th. Theo di lm sng, cn lm sng u n.
1. B nc, in gii
Mi 4-6 gi truyn 1 lt dch mui ng trng. Trung bnh 4 lt/24 gi. Nu c
try mch: truyn dung dch trng lng phn t ln hoc mu ton phn vi s kim
sot p lc tnh mch trung ng.

145

2. Hormon thay th
Hydrocortison hemisuccinat tim bp hoc tnh mch, 100mg mi 4-6 gi i
vi tim bp. Trng hp nng: 100mg mi gi.
Desoxycorticosteron acetat (DOCA, Syncortil) hm lng 10mg, bt u tc
dng sau tim bp 2 gi, ko di 24 gi. C th Syncortil 5mg lp li sau 24 gi i vi
th va. Trng hp nng, ngoi cung cp 4 lt dch/24gi, cho Syncortil tim bp mi
12 gi, c khi 10mg/12 gi.
3. Theo di 24 gi u
Trnh di chuyn ngi bnh nhiu.
V lm sng theo di mi gi: tnh trng mt nc, mch, nhit , lng nc
tiu, tri gic.
V cn lm sng, lm xt nghim mi 4-6 gi: in gii mu, niu; ng
huyt, creatinin mu, protid mu ton phn, huyt . Ty tnh hnh, c th lm thm:
cy mu, X quang phi, bng ti ging. ECG nhiu ln. ng thi tm v iu tr
nguyn nhn khi pht (khng sinh...).
4. Cc ngy tip theo
Gim dn liu Hydrocortioson hemisuccinat, tim liu nh v cch qung.
Sau 4-6 ngy Hydrocortison c chuyn thnh loi ung, ri tr li liu duy tr
khong 30mg/ngy.
5. Truyn Hydrocortison hemisuccinat lin tc
Mt s tc gi ngh cho tnh mch lin tc, ban u 25mg tnh mch sau
truyn lin tc 50-100mg/ngy. Khng cn iu tr Mineralocorticoid.
Hiu qu lm sng thng nhanh, cho php sau 24-48 gi c th chuyn thnh
ung. Din tin thng tt nu iu tr kp thi v ng n.
6. iu tr cc bnh phi hp, nu c
Nng cao th trng, b sung cc vitamin thit yu.
B sung thuc h tr v bo v t bo gan.
TI LIU THAM KHO
1. Allolio B. Adrenal insufficiency. N Eng J Med. 2011. 390:2328.
2. Becker KL. Adrenal insufficiency. Principles and practice of endocrinology
and metabolism. 2008.
3. Findling MD. Blake Tyrrell MD. Adrenal insufficiency. Basic and clinical
endocrinilogy 9th ed. 2011.
4. Stewatt. Adrenal corticosteroid biosynthesis, metabolism and action. Endo
Metab Clin North Am. 2010. 34: 293.
5. William RH. Adrenal insufficiency. William textbook of endocrinology 11th 2009.

146

SUY THNG THN MN TNH

(Bnh ADDISON)

I. I CNG
Suy thng thn l tnh trng gim glucocorticoid hoc mineralcorticoid hoc c
hai, do nhiu nguyn nhn:
S ph hu v thng thn dn n suy thng thn nguyn pht (bnh Addison).
Gim sn xut ACTH lm gim Cortisol dn n suy thng thn th pht.
Bnh ch yu gp n, vi t l n/nam = 2,6/1; thng gp tui 30-40. Ngy
nay, suy thng thn mn tnh cn gp do mt s nguyn nhn khc:
Hi chng suy gim min dch mc phi (AIDS).
Suy gan mn tnh...
II. NGUYN NHN
1. Suy thng thn tin pht (tn thng ti thng thn)
1.1. Suy thng thn tin pht do nguyn nhn t min
Qu trnh t min gy ph hu t chc v thng thn v mt s cc c quan khc
ca ngi bnh, v vy c th thy phi hp bnh l t min khc.
1.2. Lao thng thn
Ch yu gp thp k 2030, cc nc chm pht trin. Ngy nay him gp
nguyn nhn do lao.
1.3. Ph hu tuyn thng thn
Ct b tuyn thng thn hai bn trong iu tr bnh Cushing (nay t p dng).
Dng thuc Mitotan (opDDD) trong iu tr ung th thng thn.
1.4. Cc nguyn nhn him gp khc
Nhim nm, HIV, giang mai ton thn gy hoi t thng thn.
Xut huyt thng thn (ri lon ng mu, iu tr thuc chng ng, nhi
mu thng thn hai bn, vim tc ng mch, nhim trng huyt, sc nhim khun...)
Cc bnh thm nhim, xm ln tuyn thng thn: nhim st, sarcoidose, ung
th di cn...
Thoi trin thng thn bm sinh, lon dng cht trng thng thn (him).
Ri lon gen.

147

2. Suy thng thn th pht (tn thng trung ng)

S dng glucocorticoid ngoi sinh ko di.
U tuyn yn hoc vng di i: u tuyn yn, u s hu, nang rathke, tn
thng cung yn.
Nhim khun, thm nhim: lao, di cn ung th, sarcoidosis thn kinh.
Nhi mu no, chy mu no: Sheehan, phnh mch.
Chn thng s.
Vim tuyn yn lympho.
Bt thng tuyn yn do t bin gen.
Thiu ht ACTH n c.
Thiu ht globulin gn cortisol c tnh cht gia nh.
III. CHN ON
1. Lm sng
Bnh thng xy ra t t trong thi gian di mi bc l lm sng, v vy chn
on thng mun. Giai on u c Cortisol b tr di tc dng ca ACTH,
Mineralocorticoid do s iu ho ca h Renin. Khi 90% v thng thn b ph hu th
cc triu chng lm sng mi bc l r.
Khi c xut hin cc yu t thun li nh: stress, nhim trng, phu thut, chn
thng, s xut hin cn Addison cp tnh (suy thng thn cp).
1.1. Mt mi
L triu chng rt thng gp v thng xut hin sm nhng d b qua, cn
hi k pht hin triu chng ny.
Mt v th xc, tinh thn v sinh dc.
Mt xut hin ngay lc mi ng dy, bui sng t hn bui chiu. Mt tng dn
t l vi gng sc, c khi khng i li c.
Mt dn ti chm chp, v cm, trm cm.
N: lnh cm, mt kinh thng do suy kit hn l do suy chc nng bung
trng, rng lng do gim tit androgen.
Nam: suy sinh dc chim 4 17%.
1.2. Gy st
Xut hin t t (2 10 kg) do mt nc v mt mui, km theo gim chc nng
d dy rut, bing n, n km.

148

1.3. Ri lon tiu ho

au bng khng khu tr, i khi nhm vi bnh l ngoi khoa cp.
Bun nn, nn, tiu chy lm bnh nng ln.
Cc ri lon tiu ho cng do ri lon nc, in gii, do hormon gim dn ti
bi tit dch v gim.
1.4. Xm da, nim mc
Xm da nu ng in hnh.
Xm da vng da h (tip xc vi nh sng mt tri), vng c st, vng so mi.
Np gp bn tay, bn chn, gi, ngn chn, khp khuu c mu nu hoc en.
u v, b phn sinh dc thm en.
M, li, sn ming, mt trong m c nhng m mu en.
1.5. H huyt p
L triu chng thng gp, chim 90% trng hp, ch so snh vi huyt p
trc ca ngi bnh, h huyt p ph thuc vo thi gian b bnh v mc tn
thng thng thn.
Huyt p thp, tt huyt p t th.
Mch yu.
Suy thng thn cp gy huyt p kt, sc tru mch.
Tim thng nh hn bnh thng.
1.6. Triu chng khc
H ng huyt: thng gp tr em, t gp ngi ln. Cc triu chng h
ng huyt gp khi ngi bnh b ba hoc qu ba, st, nhim trng hoc khi nn
ma, c bit trong cn suy thng thn cp.
Suy thng thn th pht thng gp h ng huyt hn suy thng thn
nguyn pht.
Triu chng tm thn kinh: Ngi bnh bn chn, lnh m hoc l ln.
Khng c kh nng tp trung suy ngh, xen k giai on bun ng, l m. i khi xen
k trng thi kch thch thn kinh him gp.
au khp, au c; chut rt cng c th gp.
1.7. Cc th bnh c bit
Th nng do stress. Tr em. Ph n c thai.
Kt hp vi cc bnh t min khc (hi chng suy nhiu tuyn ni tit).
149

2. Cn lm sng
2.1. Xt nghim thng thng
Cng thc mu: thiu mu gim sc, gim bch cu a nhn trung tnh. Tng
bch cu a nhn i toan.
ng mu lc i thp: 60 65 mg%.
in gii : Na+ mu, K+ mu.
Ure, creatinin mu tng do gim th tch huyt tng.
in tim: in th thp.
XQ tim phi: tim nh hnh git nc.
XQ bng: Hnh calci ho vng thng thn (lao) c th gp.
2.2. nh lng hormon
Cortisol huyt tng (8 gi sng) gim. Bnh thng 80-540 nmol/l (3-20 g/dl).
17OH corticosteroid niu thp < 3mg/24h (bnh thng: 2 20mg/24h).
17 cetosteroid niu thp:
< 5 mg / 24h vi nam (bnh thng: 7 25 mg/ 24h).
< 3 mg / 24h vi n (bnh thng 4 15 mg/24h)
Aldosteron gim (bnh thng: 140 690 nmol/24h).
nh lng ACTH (bnh thng: < 11 pmol/l).
ACTH ( > 55,5 pmol/l) suy thng thn nguyn pht.
ACTH ( < 4,4 pmol/l) suy thng thn th pht.
2.3. Cc nghim php ng
Test Synacthene Ordinaire (thng, nhanh): ACTH tng hp (121
corticotropin, tetracosactide): y l phng php chn on nhanh, t nguy him (nu
ngi bnh ang dng thuc, ngng thuc 12 gi gia hai ln ung Hydrocortison).
Phng php tin hnh: ly mu lc 8 gi, nh lng cortisol mu.
* Tim bp 1 ng Synacthen ordinair 0,25mg.
* Sau 1 gi (9 gi sng) nh lng li cortisol.
Kt qu:
* Bnh thng Cortisol mu > 200ng/l (tng t nht 70 g/l)
* Suy thng thn ti tuyn: cortisol mu khng i hoc tng t.
* Cortisol mu ch thay i t hoc khng cao tc l tuyn thng thn
ngh trong mt thi gian di do suy tuyn yn (gim tit ACTH) hoc
iu tr cortisol ko di.

150

 Test Synacthen retard (chm, 1 24 corticotropin retard):

Kch thch tuyn thng thn nhng thi gian ko di hn.
Phng php tin hnh:
* 8 gi: nh lng cortisol mu.
* Tim bp 1mg Synacthen retard.
* nh lng cortisol mu 30 pht, 1gi, 2, 3, 4 v 5 gi sau tim.
Sau 1 gi: lng cortisol mu tng gp hai ln cortisol c s.
Sau 2 3 gi: tng gp 3 ln.
Sau 4 5 gi: tng gp 4 ln.
Kt qu nh gi:
* Kt qu (+): khng tng cortisol mu suy thng thn (nguyn pht)
* Kt qu (-): suy tuyn yn (th pht).
Nghim php ROBINSON (gy i nhiu).
Tin hnh:
* Ngi bnh nhn n t na m trc. Thng bng quang cho ht nc tiu.
* Ngi bnh ung 15 ml nc / kg vo lc 7 8 gi sng.
* Ly nc tiu: 8gi, 11gi, 12gi; xc nh s lng v t trng.
nh gi kt qu:
* Bnh thng: lng nc tiu cao nht sau 2 gi, 3 gi th s lng c
thi ra, t trng b pha long < 1,005.
* Addison: ch 2/3 nc tiu c thi ra sau 3 gi, t trng >1,005.
Cc test khc (t dng v nguy him):
Test Metyrapone (c ch tit cortisol, xem bi Suy tuyn yn).
Test gim ng mu bng Insulin (xem bi Suy tuyn yn).
3. Chn on phn bit
Mt do nguyn nhn khc (mt do tm thn).
Da en hoc xm (do bnh l ni tit, chuyn ho, min dch, thuc)
Ri lon sinh ho: gim Natri trong suy thn.
4. Chn on nguyn nhn
4.1. Suy thng thn tin pht
Lao tuyn thng thn.
151

 Teo thng thn nguyn nhn do t min.

Do thy thuc: Do thuc OpDDD, Ketoconazole (Nizoral), phu thut ct
thng thn hai bn trong iu tr bnh Cushing.
Bnh h thng: Hemochromatose, bnh Wilson.
Xm ln thng thn: Leucemie, Hodgkin, di cn ca ung th phi, li, d
dy, h lympho.
Nhim trng: C a suy gim min dch (HIV), do nhim trng c hi (bnh
mycobacteria, toxoplasmose).
Chy mu thng thn hai bn: thng t vong nhanh, sau phu thut.
Bin chng do iu tr thuc chng ng.
tr em: chy mu thng thn hai bn do no m cu (hi chng Waterhouse
Friederichsen).
4.2. Suy thng thn th pht
IV. IU TR
1. iu tr hormon thay th trong suy thng thn th trung bnh
1.1. Glucocorticoide
Hydrocortison vin 10 mg: Liu 0,51 mg/kg/ngy tu theo mc thiu ht,
gii, cn nng, sng 2/3 tng liu, chiu 1/3 tng liu.
Khi c nhim trng, chn thng, khi cn phu thut, phi tng liu
Hydrocortison gp 2 hoc 3 ln. Nu khng ung c c th dng ng tim.
1.2. Mineralocorticoid
9 alpha fluorohydrocortison (Florinef) vin 50g, 1-2 vin/ngy, ung bui sng.
Liu cao c th gy ph, tng huyt p, suy tim sung huyt.
Khong 10-20% trng hp ch cn dng Glucocorticoid v n mui.
2. iu tr suy thng thn cp
2.1. Dng Glucocortisol thay th
Hydrocortisol sodium phosphat hoc sodium succinat: liu 100mg tim tnh
mch 6 gi/ ln trong 24 gi cho ti khi bnh n nh.
Khi bnh n nh th gim liu 50 mg / 6 gi / ln / 24 gi, duy tr 4 5 ngy
v c th cho Mineralocortisol nu thy cn.
Tng liu Hydrocortisol ln 200-400mg/24gi nu ngi bnh c bin chng.
2.2. Theo di: Huyt p, tnh trng mt nc, ng huyt, natri huyt, iu tr yu t
nguy c

152

2.3. iu tr duy tr
Hydrocortisol 15 20 mg ung bui sng v 10 mg vo 4 5 gi chiu.
Fludrocortison: liu 0,05 0,1 mg ung lc 8 gi.
Theo di: cn nng, huyt p, in gii, ngi bnh c t vn bnh, c th bnh.
Tng liu lng thuc Hydrocortisol khi b stress, nhim trng
2.4. iu tr cc bnh phi hp
Nng cao th trng, b sung vitamin thit yu.
3. Ch n, sinh hot
Khuyn ngi bnh n ng, mui. Tng liu Hydrocortison trong trng
hp cn thit. Lun c thuc ng tim d tr.
Lu cc yu t c th gy mt b ca suy thng thn:
Ngng iu tr. Ch n t mui, gng sc, nn, i ngoi, ra nhiu m hi
dn ti mt mui, nhim trng, chn thng, phu thut.
Dng thuc li tiu, an thn, cn quang, c thai.
4. Theo di iu tr
Ngon ming, cn nng, huyt p t th, hot ng th lc. Triu chng xm da tn
ti rt lu.
TI LIU THAM KHO
1. Allolio B. Adrenal insufficiency. N Eng J Med. 2011. 390 : 2328
2. Becker KL. Adrenal insfficiency. Principles and practice of endocrinology and
metabolism. 2008.
3. Findling MD. Blake Tyrrell MD. Adrenal insufficiency. Basic and clinical
endocrinilogy 9th ed. 2011.
4. Stewatt. Adrenal corticosteroid biosynthesis, metabolism and action. Endo
Metab Clin North Am. 2010. 34: 293
5. William RH. Adrenal insufficiency. William textbook of endocrinology 11th 2009.

153

HI CHNG CUSHING
I. I CNG
Hi chng Cushing l mt bnh ni tit do ri lon sn xut hormon v thng
thn gy tng mn tnh hormon glucocorticoids khng km hm c.
Bnh xut hin sm nhng cc du hiu lm sng thng kn o v mun. Ngi
bnh thng khng c pht hin sm v iu tr kp thi nn li nhng hu qu
nng n v th cht v tinh thn, gy ra nhng bin chng nguy him cho tnh mng
ngi bnh.
Nguyn nhn thng gp nht trong lm sng ni khoa l hi chng Cushing do
thuc. Cc nguyn nhn khc l do ri lon chc nng i yn, tuyn yn, bnh l
tuyn thng thn hoc do s tit ACTH lc ch.
Nguyn nhn:
Hi chng Cushing khng ph thuc ACTH tuyn yn:
U t bo tuyn lnh tnh (adenoma).
Ung th v tuyn thng thn (carcinoma).
Hi chng Cushing ph thuc ACTH tuyn yn:
U t bo a kim ca thy trc tuyn yn.
Ri lon chc nng i yn.
Hi chng ACTH hoc CRH ngoi sinh do: ung th phi, tuyn c, d dy,
t cung...
II. PHN LOI
1. Hi chng Cushing do thuc
L nguyn nhn thng gp trn lm sng do iu tr qu liu v ko di cortisol
hoc steroid tng hp ging cortisol.
2. Hi chng Cushing ph thuc ACTH
Do tng tit ko di ACTH lm tng sn vng b, vng li, v th c tng tit
cortisol, androgen v D.O.C (11 deoxycorticosteron).
3. Bnh Cushing
Danh t ny ch hi chng Cushing do tuyn yn tng tit ACTH. Bnh chim
2/3 trng hp hi chng Cushing khng phi do thuc, thng gp n nhiu hn
nam (t l 8/1), tui trung bnh khi bnh t 20 40 tui.

154

4. U khng thuc tuyn yn (u tit ACTH lc ch - hi chng Cushing cn ung th)

Do u h ni tit tng tit ACTH, rt him gp u tng tit CRH. Nguyn nhn ny
chim 15% - 20% hi chng Cushing tu thuc ACTH.
5. Hi chng Cushing khng ph thuc ACTH
Do chnh tuyn thng thn t pht tng tit glucocorticoid, do s c ch s
tng tit ACTH tuyn yn. Chim 10% hi chng Cushing, gp n nhiu hn nam,
adenom nhiu hn carcinom.
6. Adenom tuyn thng thn
7. Carcinom tuyn thng thn
8. Tng sn ht tuyn thng thn
Tng sn dng ht nhim sc t nguyn pht c l do cc globulin min dch
gn vo cc th th ACTH, kch thch tuyn thng thn hot ng.
Tng sn dng ht kch thc ln: c nhiu nhn ln, ng knh 3-6cm hai
bn tuyn thng thn.
Tng sn dng ht tu thuc thc n: mt s ngi bnh tng sn dng ht kch
thc ln c th th vi polypeptid c ch d dy, rut, GIP bt thng nm tuyn
thng thn.
III. LM SNG V CN LM SNG
1. Lm sng
Thay i hnh th v bo l triu chng thng gp nht. Nguyn nhn do s
tng lng ng m. Phn b t chc m cng thay i vi s tng m mng bng
(bo trung tm/ bo thn), trung tht, di da mt (mt trn nh mt trng), trn xng
n (du hiu c o), h thi dng, c, gy (c tru).
Thay i da: thng gp da v da mng. Nguyn nhn do teo lp thng
b v t chc di da, kt hp gin mch di da. Nhng vt rn da mu tm, rng t
0,5 2 cm, s c cm gic lm so vi mt da bnh thng, v tr thng bng, mng,
i, np ln v, nch, khoeo, trng hp nng c th rn da ton thn.
Rm lng v nhiu mn trng c do tng tit androgen. Triu chng ny xut
hin ch yu n. Lng t mc nhiu mt, cng c th bng, ngc, v, i, tc
cng rm hn.
Tng huyt p c ti a v ti thiu.
Ri lon sinh dc do tng androgen n v tng cortisol nam. Ph n cn
hot ng sinh dc b mt kinh hoc b ri lon kinh nguyt, v sinh. m vt to him
gp, nam gii thng gim kh nng tnh dc.
Ri lon thn kinh tm l: hu ht ngi bnh u c d xc ng, thay i
cm xc, chn nn, mt ng, lo lng, gim tr nh v s tp trung.
155

 Yu c teo c gc chi nhng c lc ngn chi vn bnh thng. Nguyn nhn l

do tng qu trnh d ho, gim qu trnh tng hp protein v h kali mu.
Long xng cng hay gp. Ngi bnh thng b au xng nh: ct sng,
xng di. C th gy xng, bnh l ct sng, xng sn, xng bn chn.
Si ng tit niu do tng thi calci qua ng tiu. i khi c cn au qun
thn in hnh. i tho ng t gp.
2. Cn lm sng
2.1. Cc xt nghim c hiu
nh lng cortisol mu 8 gi v 20 gi: bnh thng cortisol mu 8 gi: 120
620 nmol/l; 20 gi: 90 460 nmol/l.
Xt nghim chn on xc nh cng tit cortisol:
Ly nc tiu 24 gi, nh lng cortisol t do v creatinine: cortisol t do >
100 g/dl hoc > 95mg/mg creatinin.
Cho ung 1mg dexamethason lc 11 gi tra v ly mu nh lng cortisol
vo lc 8 gi sng hm sau: chn on khi cortisol huyt > 5 g/dl.
nh lng cortisol mu 8 gi v 20 gi: cortisol tng v ri lon nhp tit.
Trong hi chng Cushing c s tng tit cortisol c sng ln chiu dn ti mt
nhp ngy m.
nh lng cortisol t do trong nc tiu 24 gi (bt: 50250nmol trong 24 gi)
nh lng 17 OHCS trong nc tiu 24 gi (bt: 5,5 28 nmol trong 24 gi )
nh lng Cetosteroid trong nc tiu 24 gi:
Bnh thng:

N: 14 52 nmol/24h ; Nam: 22 28 nmol/ 24h.

Cc nghim php c ch bng Dexamethason c s dng tm sot v

chn on nguyn nhn hi chng Cushing:
Nghim php c ch bng Dexamethason liu thp trong hai ngy.
Ngy th nht, ly nc tiu 24 gi o 17-OHCS v mt mu cortisol mu lc
8 gi. Ngy th hai v th ba, cho ngi bnh ung dexamethason 0,5mg mi 6 gi.
Ngy th 4 ly nc tiu 24 gi o 17OHCS.
nh gi kt qu:
* Bnh thng c ch c khi 17-OHCS ngy th t gim hn so vi ngy th
nht t nht 20%. Cortisol mu 8 gi < 5g/dl. Gp trong hi chng gi Cushing do
thuc, ngi bo, ngi nghin ru.
* Khng c ch c khi 17-OHCS v cortisol mu lc 8 gi khng thay i. Gp
trong hi chng Cushing.
Nghim php c ch bng 1mg dexamethason qua m.
156

 Ngi bnh ung 1mg dexamethason vo 23 gi, 8 gi sng hm sau o

cortisol mu v o lng cortisol t do trong nc tiu 24 gi.
nh gi kt qu:
* Cortisol mu 8 gi sng > 5g/dl v kt hp thm cortisol t do trong nc tiu
24 gi tng th c th chn on l hi chng Cushing.
* Nu cortisol mu 8 gi gim < 3 g/dl c coi l bnh thng.
Nghim php c ch bng dexamethason liu cao (liddle liu cao):
chn on cc nguyn nhn ca hi chng Cushing, gia bnh Cushing v hi
chng Cushing do tit ACTH lc ch hay u tuyn thng thn.
Ngi bnh ung 2mg dexamethason mi 6 gi trong hai ngy th 2 v th 3.
Ly nc tiu 24 gi ngy th nht v ngy th 4 nh lng 17 OHCS.
nh gi kt qu:
* Trong bnh Cushing, lng 17 OHCS trong nc tiu 24 gi ngy th 4 gim
hn 50 % so vi trc khi ung thuc.
* Ngi bnh c u tuyn thng thn hoc u tit ACTH lc ch, khng gim tit
17 OHCS trong nc tiu 24 gi ngy th 4 hoc ch gim rt t.
Nghim php c ch bng dexamethason liu cao qua m:
Ly mu nh lng cortisol 8 gi sng v cho ngi bnh ung 8 mg
dexamethason vo 23 gi m. 8 gi sng hm sau o li cortisol mu.
nh gi kt qu:
* Bnh Cushing: cortisol mu gim hn 50% so vi trc khi ung thuc.
* U tit ACTH lc ch: cortisol mu khng gim nhiu nh trng hp trn.
* Trng hp u tuyn thng thn tit cortisol, s tit t pht nn khng th c
ch c.
Nghim php kch thch bng CRH:
Ngi bnh c truyn tnh mch 100mg CRH. Trc v sau nghim php,
nh lng ACTH mu.
nh gi kt qu:
* ACTH tng gp trong bnh Cushing.
* ACTH khng tng gp trong hi chng ACTH ngoi sinh.
2.2. Cc xt nghim khng c hiu
Cng thc mu: c th tng hng cu v hemoglobin, hematocrit tng nh.
Sinh ho: bnh thng trong a s trng hp. Tng ng huyt sau n
thng xy ra nhanh hn, hu ht ngi bnh u c tnh trng ri lon dung np
glucose. Calci mu bnh thng, c th tng calci niu.
157

 Soi y mt: th lc, th trng c th thay i do u tuyn yn chn p vo giao

thoa th gic v do hu qu ca tng huyt p.
X-quang: bng tim c th to do hu qu ca tng huyt p, c th xp t sng,
gy xng sn. X-quang bng c th thy si tit niu.
in tim : c th thy du hiu dy tht, thiu mu c tim, h kali mu.
2.3. Cc phng php thm d hnh th tuyn ni tit
X quang h yn: bnh thng kch thc h yn l 1 x 1,2cm; mm yn trc
v sau r nt. Ngi bnh u tuyn yn c h yn rng v teo mm yn.
Chp ct lp vi tnh s no (CT scanner, MRI).
MRI tuyn thng thn c th pht hin sm tn thng v thng thn.
Bm hi sau phc mc, siu m tuyn thng thn.
IV. CHN ON
1. Chn on xc nh
Ton thn: thay i hnh th, tng cn, tng huyt p.
Da v t chc lin quan: mt trn , rn da, rm lng, trng c, thm tm da.
C xng: yu c, teo c, mt mi, long xng.
Sinh dc: ri lon kinh nguyt, mt kinh, m vt to.
Tm thn: trm cm v thay i nhn cch.
Ri lon chuyn ho: i tho ng, ri lon dung np glucose.
Si thn.
Xt nghim c hiu:
nh lng cortisol mu: tng cao, mt nhp ngy m. y l yu t quyt
nh cho chn on sm hi chng Cushing.
nh lng cortisol t do trong nc tiu 24 gi: tng
17 OHCS niu: tng
Nghim php c ch bng dexamethasone liu thp: khng c ch c.
2. Chn on nguyn nhn
Hi chng Cushing do dng corticoid ko di: tin s dng thuc.
Bnh Cushing: h yn rng. Nghim php c ch bng dexamethasone liu cao
c ch c. Chp CT pht hin qu sn thng thn hai bn. Lm sng v xt nghim
c hiu ph hp.

158

 Adenom thng thn: lm sng v xt nghim in hnh. Thm d hnh th

tuyn thng thn pht hin khi u. Nghim php c ch bng dexamethason liu cao
khng c ch c. H yn bnh thng.
Ung th thng thn: lm sng din bin nhanh v nng, c bit rm lng vy
gy st. Khi u tuyn thng thn mt bn ln (> 6cm). Phosphatase kim tng. C di
cn. H yn bnh thng.
Nghim php c ch bng dexamethason liu cao khng c ch c.
Hi chng ACTH ngoi sinh: c ung th nguyn pht ngoi thng thn (gan,
phi, t cung...). Din bin lm sng nhanh nng, i khi c xm da. Di cn ung th.
Nghim php c ch bng dexamethason liu cao km p ng.
3. Chn on phn bit
Nghin ru cng c th c tng cortisol huyt v c lm sng tng t nh
hi chng Cushing. Cortisol t do nc tiu bnh thng.
Bo ph: c vt rn da nhng cortisol t do nc tiu bnh thng.
Hi chng gi Cushing do thuc steroid. Mt s thuc: Phenytoin,
phenobarbital, primidone.
Ph n c thai.
V. IU TR
1. Bnh Cushing (qu sn thng thn hai bn do bnh l i - yn)
1.1. Ngoi khoa
Phng php phu thut khi u tuyn yn qua xng bm l ti u nht. Cn
phi iu tr thay th bng Hydrocortison.
Ct thng thn hai bn ton phn hoc bn phn.
1.2. Tia x tuyn yn
Ch nh trong bnh Cushing do u tuyn yn.
1.3. Ni khoa
Ngi bnh khng c ch nh phu thut hoc tia x c th p dng iu tr bng thuc:
Ketoconazol (Nizorale) 200mg / 6gi/ ln, dng thuc ny phi kim tra chc
nng gan thng xuyn.
Metyrapon: ngy 2g chia 2 ln, tng liu iu tr ph thuc vo p ng lm sng.
Aminoglutethimiad: 25mg, ngy ung 2 3 ln.
Mt s thuc khc: mifepriston, octreotid, etomidat
iu tr cc bnh phi hp nu c, nng cao th trng
159

2. Adenoma thng thn

Ch nh phu thut tuyt i.
3. Ung th thng thn
Phu thut ct b khi u v phi hp tia x tr liu.
OpDD (Mitotan): dng 6 12g/ngy, ch kim tra chc nng gan thn.
4. Hi chng ACTH ngoi sinh
Khi u tit ACTH nn ct b v phi hp iu tr ni khoa bng Ketoconazol
hoc Mitotan hoc phi hp c hai.
TI LIU THAM KHO
1. Elamin MD. Murad MH. Accuracy of diagnostic tests for cushing syndrome. J.
clin Endo. Crinol Metab 94: 471. 2011.
2. J. Larry Jameson. Cushing syndrome. Harrison internal medicine. 17th ed.
2214. 2008.
3. Nieman LK. Biller BM. The diagnosis of cushing syndrome an endocrime
society clinical practice guideline. J clin endocrinol Metab. 93: 1526. 2010
4. Ty B Carroll MD. David D. Cushing syndrome. Basic and clinical endocrinology
9th ED 312. 325. 2011.
5. William RH. et. Al. William texbook of endocrinology. 11th ed. 2009.

160

SUY THNG THN DO DNG CORTICOID

(Hi chng gi CUSHING)

I. I CNG
Suy thng thn do iu tr glucocorticoid l nguyn nhn thng gp nht trong
cc nguyn nhn suy thng thn th pht, xy ra do glucocorticoid c ch vng h i
tuyn yn lm gim tit ACTH.
giai on sm, nng ACTH nn v cortisol nn c th bnh thng, tuy
nhin d tr ca ACTH suy gim. Khi c stress th p ng tit cortisol khng p
ng. S thiu ht ko di ACTH lm vng lp b v li v thng thn s teo li dn
ti gim tit cortisol v adrogen thng thn trong khi bi tit aldosteron bnh
thng. Tin trin tip theo l ton b trc h i - yn - thng thn s b suy yu, do
p ng tit ACTH khi c kch thch hoc stress hoc kch thch bng ACTH ngoi
sinh th p ng tit cortisol ca v thng thn cng gim.
Nguyn nhn do dng glucocorticoid ko di: prednisolon, hydrocortisol,
dexamethason loi glucocorticoid ht, tim khp, tim bp, glucocorticoid c trn
trong thuc gia truyn
Phn loi theo c ch c ch trc i- yn - thng thn do steroid ngoi sinh:
Khng c ch trc i - yn - thng thn.
Ch c ch h i yn.
c ch ton b trc h i - yn - thng thn.
II. LM SNG
1. Hi chng Cushing ngoi sinh
Tng t nh hi chng Cushing, nu dng thuc glucocorticoid liu cao,
ngi bnh c triu chng lm sng in hnh hn so vi hi chng Cushing ni sinh
nh: tng cn, mt trn, bo trung tm, m vng c, sau gy, mt trn , da mng, rn
da, yu c gc chi, vt thng kh lnh, ri lon tm thn
Triu chng tng huyt p, rm lng, nam ho t hn hi chng Cushing ni
sinh nhng long xng gp nhiu hn.
2. nh hng ca glucocorticoid
Loi ch phm: thuc, thuc gia truyn.
Dc ng hc ca glucocorticoid.
ng dng: tim, ung, bi, ht.

161

3. Triu chng xy ra khi ngng thuc

Trc h i - yn - thng thn b c ch gy suy thng thn th pht.
Bnh l nn nng ln.
Hi chng ngng thuc: ngi bnh mt mi kh chu khi ngng thuc hay ch
gim liu.
Chn n, au c, nhc u, st, bong vy da.
III. CN LM SNG
H natri huyt, kali huyt khng tng v khng gim aldosterol,
H ng huyt.
Cortisol sng < 3mcg / dl th chn on l suy thng thn.
Nu cortisol sng > 20mcg / dl th loi b suy thng thn.
IV. CHN ON
Lm sng: tin s c dng corticoid, c biu hin lm sng hi chng Cushing
ngoi sinh.
Cn lm sng:
Xt nghim c bn, o mt xng.
Cortisol huyt tng gim.
Cc nghim php nh gi:
Khng c ch
trc h i - yn thng thn

c ch h i yn - thng
thn

Teo v thng
thn chc nng

Kch thch ACTH liu cao

250 mcg

Bnh thng

Bnh thng

Gim

H ng huyt

Bnh thng

Gim

Gim

Metyrapone

Bnh thng

Gim

Gim

Kch thch bng CRH

Bnh thng

Gim

Gim

Kch thch bng ACTH liu

thp 1 mcg

Bnh thng

Gim

Gim

Nghim php

V. PHNG PHP IU TR
1. iu tr suy thng thn (xem Suy thng thn)
2. Phng php cai thuc
Mc d glucocorticoid c dng rng ri nhng cha c nghin cu no tm ra
phng php tt nht ngng thuc. K hoch ngng thuc phi t hai mc tiu:

162

 Trnh tc dng ph ca dng glucocorticoid ko di.

Trnh xut hin suy thng thn chc nng.
2.1. Phng php Harrison
Gim liu prednisolon t t 5mg / ln / mi 5 10 ngy.
Khi liu thuc cn 15 mg/ngy (0,3 mg/ kg/ ngy) th tin ti dng cch nht.
Khi liu prednisolon cn 5 7,5mg/ ngy, c th ngng thuc. Trc khi ngng
thuc, nn kim tra cortisol huyt tng 8 gi nh gi chc nng thng thn.
2.2. Phng php William
Gim t t, t liu cao dc l ti liu sinh l, prednisolon gim t 57,5mg/
ngy, hydrocortisone t 15 20mg/ ngy. Sau khi gim ti liu sinh l th c mt s
cch tip theo c th p dng:
Chuyn sang dng hydrocortisone c tc dng ngn cho php trc h i - yn
- thng thn phc hi.
Chuyn sang dng cch nht glucocorticoid c tc dng trung bnh:
prednisolon dng bui sng cch nhau 48 gi.
Khi ti giai on liu sinh l, o cortisol huyt tng 8 gi sng nh gi
suy thng thn.
Nu cortisol huyt tng 8 gi sng < 3mcg/dl: c thiu cortisol nn, v vy
ngi bnh tip tc dng glucocorticoid liu sinh l.
Nu cortisol huyt tng 8 gi sng > 20mcg/dl: tc l trc h i - yn thng thn phc hi, v vy c th ngng thuc.
Nu cortisol huyt tng 8 gi sng t 320mcg/ dl: c cortisol nn nhng
cha vn c th thiu kh nng p ng vi stress.
Nhng trng hp ny cn lm nghim php kch thch nh gi trc h i - yn
- thng thn, nu khng dng nghim php nh gi trc h i - yn - thng thn th
c th tip tc gim liu glucocorticoid.
Tuy nhin, cn dn d trong 1 nm sau khi ngng ngi bnh phi b thm
glucocorticoid khi b bnh hay chn thng.

163

Bc 1: gim liu glucocorticoid

Bc 2: chuyn sang dng hydrocortisol hoc

prednisolon cch nht

Bc 3: o cortisol huyt tng bui sng lc 8 gi

< 3 mcg

3 20 mcg / dl

Suy thng thn

Tip tc dng glucocorticoid
nh gi li sau 4 6 tun

Lm thm nghim php (NP)

- NP Synacthen 250 mcg
- NP h ng mu
- NP Metyrapone
- NP CRH

> 20 mcg
Khng suy thng thn
C th ngng
Glucocorticoid

S hng dn cai thuc glucocorticoid

TI LIU THAM KHO

1. Becker KL. Adrenal insfficiency. Principles and practice of endocrinology and
metabolism. 2008.
2. Fauci. Braunwald. Harrison principles of internal medicine 17th 2008.
3. Findling MD. Blake tyrrell MD. Adrenal insufficiency. Basic and clinical
endocrinilogy 9th ed. 2011.
4. Stewatt. Adrenal corticosteroid biosynthesis, metabolism and action. Endo
Metab Clin North Am. 2010. 34: 293.
5. William RH. Adrenal insufficiency. William textbook of endocrinology 11th 2009.

164

CNG ALDOSTERON TIN PHT

(HI CHNG CONN)

I. I CNG
Cng Aldosteron tin pht l hi chng phi hp tng huyt p ca aldosteron l
hormon corticoid chuyn ha mui tc dng r nht c tit ra tuyn thng thn.
Hi chng Conn hay cng aldosteron tin pht c Jerom Conn m t ln u tin
vo nm 1955, l tnh trng tng aldosteron mu bt thng do tng sn xut hormon v
thng thn.
Nguyn nhn: c hai dng kinh in. Mt l khi u lnh tnh v thng thn sn
xut aldosteron hot ng t ch, chim 2/3 s ca cng aldosteron tin pht. Hai l
cng aldosteron tin pht do ph i thng thn hai bn v cn, chim gn 1/3 s ca.
Ngoi ra, mt s nguyn nhn him gp hn gy cng aldosteron tin pht: ph
i thng thn mt bn, khi u lnh tnh tit aldosteron nhy cm vi angiotensin II,
cng aldosteron tin pht p ng vi dexamethason, mt vi dng c tnh gia nh.
Dch t: l loi bnh him gp, chim khong 0,1% dn s chung v khong 1%
s ca mc tng huyt p. Bnh hay gp hn ngi tr v gii n.
II. C CH SINH BNH
Aldosteron c tit ra t vng cu ca tuyn thng thn v c iu ha thng
qua h thng renin-angiotensin, nng Kali, v mc nh bi ACTH. Tng tit
aldosteron gy tng trao i Natri, Kali v ion H ng ln xa ca ng thn dn n
tnh trng h Kali mu v kim chuyn ha. Tnh trng d tha mui s gy tng huyt
p v gim nng renin huyt tng.
Cng aldosteron tnh cht gia nh typ1, c gi l cng aldosteron p ng
vi glucocorticoid (GRA), l bnh di truyn tri nhim sc th thng v thng kt
hp vi qu sn thng thn hai bn. Do s ti hp gia vng iu ha ca 11
hydroxylase (CYP11B1) vi vng m ha 18 hydroxylase (CYP11B2) ging nh trong
gen o, ACTH (ch khng phi renin hoc nng kali mu) lm bc l hot ho gen
tng hp v bi tit aldosteron.
III. TRIU CHNG
Khng c hiu: Do tng huyt p (au u), hay do h kali mu (tiu nhiu,
tiu m, chut rt hoc yu c, thm ch lit c).
Cn tm sot bnh nhng i tng c biu hin:
Tng huyt p khng tr vi tr liu thng thng (thng trn 160mmHg
huyt p tm thu hoc trn 100mmHg huyt p tm trng).
C th km theo h kali mu t pht hoc h kali nng khi dng li tiu.
165

 Tng huyt p c km theo h kali mu di <3,5 mmol/l.

Bnh hay xy ra ngi tr tui.
Ngi bnh c u tnh c pht hin trn hnh nh vng thng thn.
Tin s gia nh c tng huyt p ngi tr tui.
Tin s gia nh h hng trc h cng aldosteron tin pht.
IV. CHN ON
1. Chn on xc nh cng aldosteron tin pht
H Kali mu: l triu chng hay gp, nhng 20 n 40% ngi bnh c th c
kali mu bnh thng. H Kali mu c th xy ra sau khi ngi bnh iu tr li tiu
Thiazid hoc li tiu quai, v vy thng gy nng thm tnh trng h kali mu v kh
iu chnh.
Kim chuyn ho. Ch n nht mui c th lm gim mc h kali mu.
Kali niu >30mmol/24h (khi khng dng li tiu) km theo h kali mu gi
cng aldosteron.
ARR: T l aldosteron (ng/dl) /rennin (ng/ml/h) cao. ARR >20 vi aldosteron
mu >15ng/dl cho php ngh n chn on cng aldosteron tin pht. Bt thng
hormon c bn trong hi chng Conn l tng aldosteron mu i km vi h renin mu.
Cng aldosteron tin pht r khi aldosteron huyt tng tng cao trn
180pg/ml khi nm v aldosteron niu > 22g/24h i km vi renin huyt tng thp.
Cc test chn on khc:
Aldosteron niu < 10 mcg/24h sau thc hin n mn, loi tr chn on cng
aldosteron tin pht (Tr trng hp cng aldosteron tin pht nhy vi corticoid).
Aldosteron mu < 5ng/dl sau test truyn tnh mch trong 4 gi 2 lt NaCl 0,9%
- loi tr chn on tt c cc dng cng aldosteron tin pht.
Aldosteron mu > 10ng/dl sau test truyn tnh mch trong 4 gi 2 lt NaCl
0,9% - gi chn on cng aldosteron tin pht.
Kt hp Renin mu thp vi ch n nht mui <40g/ngy, gi chn on
cng aldosteron tin pht.
Lu : nhiu yu t nh hng n tin cy ca kt qu xt nghim ny.
Trc khi nh lng hormon cn iu chnh tnh trng h kali mu nu c.
Thuc h p: Dng cc thuc h p nh hng n kt qu (4 tun vi
Spironolacton, Amilorid; 2 tun vi li tiu, chn Beta, c ch men chuyn hoc khng
th th ATII).
m bo lm xt nghim trong iu kin ch n mui (th hin bng mc
natri niu > 100mmol/l).
166

2. Chn on phn bit cc nguyn nhn cng aldosteron tin pht

Ph i thng thn hai bn: Test t th: Nu aldosteron t th ng khng
tng qu 1/3 ln mc c bn khi nm (ng dy) gi adenoma Conn.
Cng Aldosteron tin pht dng b c ch bi corticoid: dng test c ch bng
dexamethasone.
Test captopril: Phn bit adenoma vi ph i tuyn thng thn.
Chn on gen trong mt s trng hp.
3. Chn on hnh nh
MRI hoc CT scanner thng thn tm u thng thn.
Ly mu mu ven thng thn nh chn on hnh nh can thip a catheter
vo ven thng thn hai bn: tiu chun vng xc nh tng sn xut hormon mt
bn hay hai bn.
X hnh iodocholesterol thng thn: Bt x mt bn ch ra adenoma cng bn.
V. IU TR
1. Ngoi khoa
iu tr la chn hng u ca hi chng Conn do khi u v thng thn l
phu thut ct thng thn bn c khi u.
Tng huyt p khi 70% ngi bnh.
Chun b trc m bng Spironolacton 200-400mg/ng.
2. Ni khoa
Spironolacton: Khng aldosteron liu 200-400mg/ng. Duy tr liu hiu qu thp
nht. Dng trong trng hp ph i thng thn hai bn hoc khi khng xc nh c
nguyn nhn cng aldosteron tin pht.
Amilorid: S dng nu ngi bnh khng dung np tt spironolactons. Liu
dng khi u 5-10mg/ ngy, liu ti a 20 mg/ ngy bng ng ung.
Cng aldosteron tnh cht gia nh typ 1 hay cng aldosteron p ng vi
glucocorticoid (GRA) thng c kim sot bng glucocorticoid liu thp (0,1250,5mg dexamethasone hoc 2,5-5mg prednisolon mt ngy). Spironolacton v Amilorid
iu tr xen k.
iu tr cc bnh phi hp nu c.
B sung vitamin v khong cht.
TI LIU THAM KHO
1. J. Larry Jameson (2008). Primary aldosteronism. Harrison internal medicine 17th ed.
2. Stewart PM (2005). Adrenal corticosteroid biosynthesis, metabolism and action.
Endo Metab Clin North Am, 34: 293 313.
3. Stowasser M (2009). Update in primary aldosteronism, 94(10):3623-30.
4. William RH (2007). Pheochromocytoma. Williams textbook of endocrinology.
5. Young WE (2010). Primary aldosteronism. Ann intern .
167

CNG CHC NNG TY THNG THN

(PHEOCHROMOCYTOM)

I. I CNG
Pheochromocytom l loi khi u thn kinh ni tit tng tit cc catecholamin
(thng thng l Adrenalin v/hoc Noradrenalin, him gp hn l tit dopamin) t cc
t bo a sc t ty thng thn hoc t cc hch cnh cu thn.
Phn ln u thng thn l lnh tnh, l t, mt bn v nm khu tr tuyn
thng thn. Cc khi u ngoi tuyn thng thn (u cn hch) thng gp trn v
di ng mch ch bao gm cc c quan ca Zuckerkandl (75%), bng quang 10%,
ngc 10%, u, c v vng khung chu 5%. Cc u ngoi tuyn thng thn thng gp
ngi bnh tr (di 20 tui), t gp hn ngi trn 60 tui. U tuyn thng thn
hai bn gp trong 5-10% cc trng hp, thng xy ra nh mt phn ca hi chng c
tnh cht gia nh.
y l nguyn nhn gy tng huyt p nng v nguy him, chim khong 0,10,6% trong cc nguyn nhn gy tng huyt p. C th gy t vong nu khng c
chn on hoc iu tr khng ng.
Bnh gp c hai gii, mi la tui, thng c chn on tui t 4050. C khong 90% trng hp bnh c tnh cht c l trong qun th v 10% c tnh
gia nh (MEN IIa v IIb, VHL, Neurofibromatosis).
II. CHN ON
1. Lm sng
Khong 10% ngi bnh khng c triu chng.
Tng huyt p l biu hin lm sng hay gp nht (trn 90% trng hp), thnh
cn hoc thng xuyn, c th c cn tng huyt p c tnh, thng khng tr vi tr
liu thng thng.
Cn tng huyt p kch pht c c im: xy ra bt thnh lnh hoc sau mt
hin tng c hc (chn thng khng ng k vng lng, s nn su vng lng, chp
X quang hay phu thut vng lng), i khi c th do lnh, do xc ng. Khi u bng
mt cm gic nght khng r rng t phn di bng i ln: cm gic kin b u
ngn chn, chut rt au bp chn, au bng, au vng trc tim, nhp tim nhanh ln
t ngt, nht l nhc u c nhp p d di.
Khm thy: Ngi bnh xanh ti, v m hi lnh m a. Cc triu chng
khc c th gp nh h huyt p t th, au ngc, kh th, au bng, bun nn, run tay,
hi hp, lo lng, hong lon Nhp tim rt nhanh, ny mnh, huyt p tng rt cao c
bit l huyt p tm thu.

168

 Cn kch pht ko di t vi pht n vi chc pht. au gim dn, da hng li.

Cn qua i, ngi bnh tuy d chu hn nhng rt mt mi, i khi ngi bnh c cn
tiu nhiu.
Cc cn ti pht vi khong cch khng nht nh v ngy cng dy hn khi
bnh din tin lu ngy.
Khi khai thc cn, cn hi k cc triu chng in hnh nh: Nhc u c nhp
p d di, nhp nhanh bt u t ngt v ht cng nh vy, v m hi nhiu.
Cao huyt p thng xuyn: Huyt p tm thu v tm trng u tng ng k
nhng mc th khc nhau, km theo cc triu chng trn thn kinh cm gic: nhc
u d di, tn thng y mt giai on 3 v 4 (xut tit, xut huyt, ph), dy v tng
gnh tm thu tht tri (biu hin trn in tm ).
Cao huyt p thng xuyn xen ln cn kch pht: trn nn cao huyt p
thng xuyn xy ra nhng thay i c tnh kch pht, nhng biu hin cn th khng
cn in hnh na.
Trn lm sng cn chn on phn bit vi bnh: Cng gip, h ng huyt,
hi chng mn kinh, suy tim, nhi mu c tim.
2. Cn lm sng
Chun b ngi bnh trc khi lm xt nghim chn on:
Khng dng cc thuc sau trong vng 2 tun trc khi lm xt nghim:
Chng trm cm ba vng, thuc c ch men MAO.
Chn bta: Atenolol, Metoprolol, Propranolol, Labetalol.
Clonidine, Levodopa, Methyldopa, thuc li tiu, Theophyllin
Thuc chn knh calci: Nifedipine, Amlodipine, Ditiazem, Verapamil.
Thuc gin mch: Hydralazin, Isosorbid.
Cc cht kch thch: c ph, thuc l, ru.
Khng lm xt nghim nu ngi bnh b t qy, h ng huyt, tng p lc
ni s.
2.1. Cc xt nghim mu
nh lng Catecholamin mu: Catecholamin ton phn > 11,8 nM (2000
pg/ml), nhy 85%, c hiu 80%. Xt nghim c nhy thp ngi bnh
khng c triu chng hoc bi tit catecholamin khng lin tc.
Metanephrin huyt tng: c bi tit lin tc bi u ty thng thn, l xt
nghim c nhy v c hiu cao (97 -99%), tuy nhin 10-15% c dng tnh gi.
Nhn chung metanephrin huyt tng cao gp 3-4 ln bnh thng c th chn
on u ty thng thn. Mc metanephrin >236 ng/l, nometanephrin > 400 ng/l gip
khng nh chn on.
169

2.2. Cc xt nghim nc tiu

L la chn khc gip chn on v loi tr nhng trng hp nguy c thp.
Cathecholamin t do trong nc tiu: ngng chn on > 1480 nmol/24h
(>250 Mcg/24h).
Metanephrin nc tiu: Ngng chn on: gp 2- 3 ln bnh thng.
VMA: t gi tr hn hai xt nghim trn, ngng chn on gp ba ln bnh thng.
Lu : xt nghim c gi tr, cn tun th ng qui trnh thu bnh phm cng
nh cc iu kin yu cu cn thit. Nn lm khi ngi bnh ang c triu chng. Xt
nghim ny c th lm nhiu ln.
2.3. Chn on hnh nh
Gip nh v khi u khi c chn on xc nh v gip tm di cn nu c trong
trng hp c tnh. Khi u c th bn trong hoc bn ngoi thng thn
(Paragangliom). CT- scanner v MRI l phng tin c la chn hng u.
Siu m bng: Pht hin khi u kch thc ln.
MRI (Cng hng t):
Tm u thng thn, u ngoi thng thn trong bng, tm khi u cc v tr
quanh mch mu hoc gn tim. L ng dng la chn vi tr em, ngi bnh c thai
hoc khi b d ng cn quang. 90% c hnh nh khi u tng tn hiu trn T-2.
CT scanner:
Tm khi u kch thc > 0,5-1cm trong thng thn v tm di cn >1-2 cm trong
bng v khung chu. CT xon dng tm nhng khi u nh hn. Khi u nh thng ng
nht, ngm thuc mnh sau tim thuc cn quang, khi u to > 4 cm nhu m khng ng
nht, c th c nang, xut huyt hoc hoi t trong khi.
Lu : CT c cn quang c th gy bc pht cn tng huyt p.
MIBG Scintigraphie (Metaiodobenzylguanidine gn 123I hoc 131I):
L xt nghim hu ch tip theo gip nh v khi u c bit l nhng khi c v
tr bt thng, khi u ti pht hoc di cn.
PET scanner: Cho thng tin chnh xc v s lng v v tr cc khi u.
III. CHN ON PHN BIT
Tng hot ng h giao cm gp trong mt s tnh trng khng phi do u tu
thng thn bao gm:
Tng huyt p v cn.
Ri lon lo u (ang c iu tr vi thuc chng trm cm ba vng).
Ngng t ngt clonidin hay propranolon.

170

 Lm dng cocain v amphetamine.

S dng thuc chng sung huyt v thuc ging giao cm.
Nhi mu c tim.
Phnh tch ng mch ch.
U thng thn pht hin tnh c.
Ri lon chc nng thn kinh t ng (hi chng Guillain Barre).
Ung th t bo thn kinh (Neuroblastoma/Ganglioneuroma) (cc u c tnh ca
thng thn v hch giao cm): tng huyt p t gp v thng gp tr nh.
U t bo thn kinh m (Ganglioneuroma) (cc u lnh ca chui hch giao cm
thng gp trung tht sau); c biu hin tng t nh u cn hch.
ng kinh no trung gian (diencephalic epilepsy).
Cc nguyn nhn khc c du hiu nhm ln vi u tu thng thn bao gm:
Cng gip;
Triu chng mn kinh;
Ri lon bc ho khng r cn nguyn;
Cc du hiu cng giao cm;
Bnh mch thn;
H ng mu;
Bnh t bo ln (bch cu a base);
Hi chng carcinoid.
IV. IU TR
Phu thut l la chn hng u, iu tr ni khoa trc m l rt quan trng c
c cuc m thnh cng.
1. iu tr ni khoa
Thuc c ch alpha-adrenergic receptor:
Lm gim tc dng co mch ca cathecholamin, lm tng lu lng tun hon.
c ch khng chn lc: Phenoxybenzamin l tt nht, khi u vi liu
10mg/ngy, tng dn liu 10-20 mg/ngy cho n khi kim sot c huyt p v
khng xut hin cn tng kch pht. Duy tr liu 40-80mg/ngy.
Alpha1- antagonist (c ch chn lc- Doxazosin- Carduran 2mg): Khng tt
bng nhng cng gip ngn chn cn kch pht. Khi u 1mg, liu duy nht trong 1-2
tun, liu c th tng ln t t 2mg, 4mg, 8mg v ti a 16 mg ty theo p ng ca
ngi bnh, iu chnh liu mi 1-2 tun, liu thng thng 2-4mg x 01 ln/ngy.
171

 c ch beta:
Ch c php dng sau khi c c ch alpha. Gip gim nhp tim nhanh c th
xut hin do dng c ch alpha v nga lon nhp tim. Thuc thng c chn l
Propranolol liu khi u 20 mg/ngy, tng dn liu mi 3-7 ngy t hiu qu.
Thuc chn knh calci:
Dung np tt, c hiu qu trn biu hin tim mch do tng catecholamin nhiu
hn l tc dng trn s tit catecholamin do khi u.
Thuc c la chn l Nicardipine, khi u liu 10 mg, tng dn n khi kim
sot c huyt p.
iu tr cc bnh phi hp nu c, b sung vitamin v khong cht.
2. iu tr ngoi khoa
L iu tr la chn hng u cho a s trng hp.
Nguyn tc: loi b khi u v ton b tuyn thng thn cng bn ngn
nga ti pht v hn ch di cn nu c tnh.
Kh khn: Tiu ch chn on t bo hc khi u tu thng thn kh xc nh
nn cn theo di theo thi gian tt c cc ngi bnh pheochromocytom.
V. THEO DI
Kim tra cathecholamin bi tit hai tun sau phu thut xc nh thnh cng
ca cuc m.
Kim tra nh k mi nm cathecholamin hoc bt k lc no thy c triu
chng ti pht.
Lm sng nghi ng
cng ty thng thn

o metanephrin
huyt tng

172

Bnh thng

Tng ti 3-4 ln gii

hn trn bnh thng

Tng qu 3-4 ln gii

hn trn bnh thng

Loi tr u ty
thng thn

nh lng metanephrin niu,

catecholamin huyt tng

Ngh n u ty thng thn

Chp CT-scaner, MRI, MIBG
xc nh v tr u

TI LIU THAM KHO

1. Guerrero MA (2009). Clinical of pheochromocytoma. J Am coll surg, 56:272.
2. Manger WM (2011). The protean manifestation of pheochromocytoma. Horm
metab, 34: 96.
3. Pacak (2010). Preoperation management of pheochromocytoma. J clin endo
metab, 92 : 4069.
4. Stewart PM (2005). Adrenal corticosteroid biosynthesis, metabolism and action.
Endo Metab Clin North Am, 34: 293 313.
5. William RH (2007). Pheochromocytoma. Williams textbook of endocrinology.

173

Chng 4. BNH I THO NG

BNH I THO NG TYP 2
I. NH NGHA
i tho ng L mt ri lon mn tnh, c nhng thuc tnh sau: (1) tng
glucose mu, (2) kt hp vi nhng bt thng v chuyn ho carbohydrat, lipid v
protein, (3) bnh lun gn lin vi xu hng pht trin cc bnh l v thn, y mt,
thn kinh v cc bnh tim mch do hu qu ca x va ng mch.
II. NGUYN NHN - C CH SINH BNH
1. Nguyn nhn
c im quan trng nht trong sinh l bnh ca i tho ng typ 2 l c s
tng tc gia yu t gen v yu t mi trng.
Yu t di truyn.
Yu t mi trng: l nhm cc yu t c th can thip lm gim t l mc
bnh. Cc yu t l:
S thay i li sng: gim cc hot ng th lc; thay i ch n ung theo
hng tng tinh bt, gim cht x gy d tha nng lng.
Cht lng thc phm: n nhiu cc loi carbohydrat hp thu nhanh (ng
tinh cht, bnh ngt, ko), cht bo bo ha, cht bo trans
Cc stress v tm l.
Tui th ngy cng tng, nguy c mc bnh cng cao: y l yu t khng th
can thip c.
2. C ch bnh sinh
Suy gim chc nng t bo beta v khng insulin:
Tnh trng tha cn, bo ph, t hot ng th lc, l nhng c im thng
thy ngi i tho ng typ 2 c khng insulin. Tng insulin mu, khng insulin
cn gp ngi tin i tho ng, tng huyt p v cn, ngi mc hi chng
chuyn ha v.v
Ngi i tho ng typ 2 bn cnh khng insulin cn c thiu insulin- c
bit khi lng glucose huyt tng khi i trn 10,0 mmol/L.

174

3. Bin chng ca bnh

c im cc bin chng ca bnh i tho ng typ 2 l gn lin vi qu trnh
pht sinh v pht trin ca bnh. V th ngay ti thi im pht hin bnh trn lm sng
ngi thy thuc phi tm cc bin chng ca bnh.
III. CHN ON V PHN LOI BNH I THO NG
1. Chn on
1.1. Chn on xc nh i tho ng
Tiu chun chn on bnh i tho ng - WHO; IDF - 2012, da vo mt
trong cc tiu ch:
Mc glucose huyt tng lc i 7,0mmol/l (126mg/dl). Hoc:
Mc glucose huyt tng 11,1 mmol/l (200mg/dl) thi im 2 gi sau
nghim php dung np glucose bng ng ung. Hoc:
HbA1c 6,5% (48 mmol/mol theo Lin on Sinh ha Lm sng Quc tIFCC). Hoc:
C cc triu chng ca i tho ng (lm sng); mc glucose huyt tng
thi im bt k 11,1 mmol/l (200mg/dl).
Nhng im cn lu :
Nu chn on da vo glucose huyt tng lc i v/hoc nghim php
dung np glucose bng ng ung, th phi lm hai ln vo hai ngy khc nhau.
C nhng trng hp c chn on l i tho ng nhng li c glucose
huyt tng lc i bnh thng. Trng hp ny phi ghi r chn on bng phng php
no. V d i tho ng typ 2- Phng php tng glucose mu bng ng ung.
1.2. Chn on tin i tho ng (Prediabetes)
Ri lon dung np glucose (IGT): nu glucose huyt tng thi im 2 gi
sau nghim php dung np glucose mu bng ng ung t 7,8mmol/l (140mg/dl) n
11,0 mmol/l (200mg/dl).
Ri lon glucose mu lc i (IFG): nu glucose huyt tng lc i (sau n 8
gi) t 5,6 mmol/l (100mg/dl) n 6,9 mmol/l (125mg/dl); v glucose huyt tng
thi im 2 gi ca nghim php dung np glucose mu di 7,8mmol/l (< 140 mg/dl).
Mc HbA1c t 5,6% n 6,4%.
2. Phn loi tm tt (Phn loi n gin)
2.1. i tho ng typ 1
L hu qu ca qu trnh hu hoi cc t bo beta ca o tu. Do cn phi s
dng insulin ngoi lai duy tr chuyn ho, ngn nga tnh trng nhim toan ceton c
th gy hn m v t vong.
175

2.2. i tho ng typ 2

2.3. Cc th c bit khc
Khim khuyt chc nng t bo beta, gim hot tnh ca insulin do gen.
Bnh l ca tu ngoi tit.
Do cc bnh ni tit khc.
Nguyn nhn do thuc hoc ho cht khc.
Nguyn nhn do nhim trng
Cc th t gp, cc bnh nhim sc th...
2.4. i tho ng thai k
3. Chn on sm bnh i tho ng typ 2
3.1. i tng c yu t nguy c sng lc bnh i tho ng typ 2
Tui trn 45.
BMI trn 23.
Huyt p tm thu 140 v/hoc huyt p tm trng 85 mmHg.
Trong gia nh c ngi mc bnh i tho ng th h cn k (b, m, anh,
ch em rut, con rut b mc bnh i tho ng typ 2).
Tin s c chn on mc hi chng chuyn ha, tin i tho ng.
Ph n c tin s thai sn c bit (i tho ng thai k, sinh con to-nng
trn 4000 gam, xy thai t nhin nhiu ln, thai cht lu)
Ngi c ri lon lipid mu; c bit khi HDL-c di 0,9 mmol/l v Triglycrid
trn 2,2 mmol/l.
3.2. Cc bc tin hnh chn on bnh
Bc 1: Sng lc bng cu hi, chn ra cc yu t nguy c.
Bc 2: Chn on xc nh theo cc tiu chun WHO, IDF-2012.
Trnh t tin hnh: WHO-2011.

176

XN ln u

HL:

< 5,5 mmol/l

5,5-6,9 mmol/l

7,0 mmol/l

HBK:

< 5,5 mmol/l

5,5-11.0 mmol/l

11,0 mmol/l

5,5-6,9

5,5-11.0

Lm li H lc i

7,0

< 7,0
OGTT

HL:
H2H:

Khng T

XN li 3 nm/ln

< 6,1
v
< 7,8

6,1-6,9
v
< 7,8

RLHL

6,1-6,9
v
7,8-11,0

RLDNG

7,0
hoc
11,1

XN li 1 nm/ln

Ghi ch: XN - Xt nghim, HL - ng huyt lc i, HBK - ng huyt bt k, H

2gi - ng huyt 2 gi sau ung 75g glucose, NPDNGU- Nghim php dung np glucose
ng ung, RLHL - Ri lon ng huyt lc i, RLDNG - Ri lon dung np glucose,
T - i tho ng.
* Xc nh li chn on nu ng mu lc i ban u 5,6-6,9 mmol/l hoc ng
mu bt k 5,6-11,0 mmol/l. Theo Hip hi i tho ng M, ri lon ng huyt lc i khi
glucose huyt lc i t 5,6-6,9 mmol/L.
** Nu glucose huyt tng lc i di 7,0 mmol/l th lm nghim php dung np
glucose ng ung. Nu ng huyt 7,0 mmol/l, chn on l i tho ng.
# Ngi c chn on T hoc RLHL/ RLDNG m khng c xc nh li s phi
xt nghim li sau 1 nm v cn c vo kt qu xt nghim sau 1 nm xc nh ln xt
nghim tip theo.

177

III. IU TR BNH I THO NG TYP 2

Hng dn iu tr ny ch p dng cho nhng ngi mc bnh i tho ng
typ 2 giai on khng c bnh cp tnh v d nhi mu c tim, nhim trng cp,
hoc phu thut, hoc ung th
Hng dn ny khng p dng cho ngi di 18 tui, mc bnh T typ 2.
1. Nguyn tc chung
1.1. Mc ch
Duy tr lng glucose mu khi i, glucose mu sau n gn nh mc sinh l,
t c mc HbA1c l tng, nhm gim cc bin chng c lin quan, gim t l t
vong do i tho ng.
Gim cn nng (vi ngi bo) hoc khng tng cn (vi ngi khng bo).
1.2. Nguyn tc
Thuc phi kt hp vi ch n v luyn tp. y l b ba iu tr bnh i
tho ng.
Phi phi hp iu tr h glucose mu, iu chnh cc ri lon lipid, duy tr s
o huyt p hp l, phng, chng cc ri lon ng mu...
Khi cn phi dng insulin (v d trong cc t cp ca bnh mn tnh, bnh
nhim trng, nhi mu c tim, ung th, phu thut...).
2. Mc tiu iu tr
Ch s
Glucose mu
- Lc i
- Sau n
HbA1c*
Huyt p

n v
Mmol/l

Tt

Chp nhn

Km

6,5
7,8 9,0
> 7,0 n 7,5
130/80 - 140/90

> 7,0
> 9,0
> 7,5
> 140/90

kg/(m)2
Mmol/l

4,4 6,1
4,4 7,8
7,0
130/80**
140/80
18,5 - 23
< 4,5

BMI
Cholesterol
phn
HDL-c
Triglycerid
LDL-c
Non-HDL

18,5 23
4,5 - 5,2

23
5,3

Mmol/l
Mmol/l
Mmol/l
Mmol/l

> 1,1
1,5
< 1,7***
2,5

0,9
2,3
2,0
3,4 - 4,1

< 0,9
> 2,3
3,4
> 4,1

%
mmHg

ton

* Mc HbA1c c iu chnh theo thc t lm sng ca tng i tng. Nh vy, s c

nhng ngi cn gi HbA1c mc 6,5% (ngi bnh tr, mi chn on i tho ng,
cha c bin chng mn tnh, khng c bnh i km); nhng cng c nhng i tng ch cn
mc 7,5% (ngi bnh ln tui, b bnh i tho ng lu, c bin chng mn tnh, c
nhiu bnh i km).
** Hin nay hu ht cc hip hi chuyn khoa thay i mc mc tiu: Huyt p
<140/80 mmHg khi khng c bnh thn i tho ng v <130/80 mmHg cho ngi c bnh
thn i tho ng.
*** Ngi c tn thng tim mch, LDL-c nn di 1,7 mmol/ (di 70 mg/dl).

178

3. La chn thuc v phng php iu tr

Mc tiu iu tr: phi nhanh chng a lng glucose mu v mc tt nht, t
mc tiu a HbA1c v di 7,0% trong vng 3 thng. C th xem xt dng thuc
phi hp sm trong cc trng hp glucose huyt tng cao, th d:
Nu HbA1c > 9,0% m mc glucose huyt tng lc i > 13,0 mmol/l c th
cn nhc dng hai loi thuc vin h glucose mu phi hp.
Nu HbA1C > 9,0% m mc glucose mu lc i > 15,0 mmol/l c th xt ch
nh dng ngay insulin.
Bn cnh iu chnh glucose mu, phi ng thi lu cn bng cc thnh
phn lipid mu, cc thng s v ng mu, duy tr s o huyt p theo mc tiu
Theo di, nh gi tnh trng kim sot mc glucose trong mu bao gm:
glucose mu lc i, glucose mu sau n, v HbA1c c o t 3 thng/ln. Nu
glucose huyt n nh tt c th o HbA1c mi 6 thng mt ln.
Thy thuc phi nm vng cch s dng cc thuc h glucose mu bng ng
ung, s dng insulin, cch phi hp thuc trong iu tr v nhng lu c bit v tnh
trng ngi bnh khi iu tr bnh i tho ng.
i vi cc c s y t khng thc hin xt nghim HbA1c, c th nh gi
theo mc glucose huyt tng trung bnh (Xem ph lc 3: Mi lin quan gia glucose
huyt tng trung bnh v HbA1c), hoc theo di hiu qu iu tr bng glucose mu
lc i, glucose mu 2 gi sau n.
3.1. La chn thuc v phi hp thuc
Tham kho hng dn la chn, phi hp thuc ca IDF 2012

179

Nhng iu cn lu khi s dng phc ny:

La chn ban u- vi ch n tr liu, nn dng Metformin vi nhng ngi
c ch s khi c th (Body Mass Index-BMI) trn 23,0 v/hoc vng eo ln xem tiu
chun IDF cho ngi chu , ngi c BMI di 23 nn chn nhm sulfonylurea.
Lu nhng quy nh ca B Y t Vit Nam v s dng nhm thuc
Thiazolidinedione.
Vi nhng ngi c mc glucose mu cao (glucose lc i trn 13,0 mmol/l;
HbA1c trn 9,0% phi theo hng dn trn).
Xem thm phn ph lc (ph lc 1).
Nhng iu ch khi la chn thuc:
Phi tun th cc nguyn tc v iu tr bnh i tho ng typ 2- mc 2- (la
chn thuc v phng php iu tr);
Trn c s thc t khi thm khm lm sng ca tng ngi bnh m quyt nh
phng php iu tr. Trng hp bnh mi c chn on, mc glucose mu thp,
cha c bin chng nn iu chnh bng ch n, luyn tp, theo di st trong 3 thng;
nu khng t mc tiu iu tr phi xem xt s dng thuc.
3.2. Nhng nguyn tc s dng insulin khi phi hp insulin v thuc h glucose mu
bng ng ung
Khong 1/3 s ngi bnh i tho ng typ 2 buc phi s dng insulin
duy tr lng glucose mu n nh. T l ny s ngy cng tng do thi gian mc bnh
ngy cng c ko di. Duy tr mc glucose mu gn mc sinh l, c chng
minh l cch tt nht phng chng cc bnh v mch mu, lm gim t l t vong,
ko di tui th v nng cao cht lng cuc sng ca ngi i tho ng.
Cn gii thch cho ngi bnh hiu v yn tm vi phng php iu tr phi
hp vi insulin, hng dn ngi bnh cch t theo di khi dng insulin.
Chn ng tim (bm tim-syringe) ph hp vi loi insulin s dng: th d
chai insulin U 100, 1ml cha 100 n v insulin (mt chai 10ml cha 1000 n v
insulin), khi ly thuc tim cho ngi bnh, phi dng ng tim insulin 1ml chia theo
n v, gm 100 n v (U 100).
Bt tim insulin, bao gm ng cha 300 n v, vn nt pha trn bt iu
chnh chn s lng n v insulin tim cho bnh nhn.
CH : insulin tim theo n v quc t (khng dng ml tnh lng
insulin tim cho bnh nhn).
Ch nh s dng insulin:
C th ch nh insulin ngay t ln khm u tin nu HbA1C > 9,0% v
glucose mu lc i trn 15,0 mmol/l (270 mg/dL).
Ngi bnh i tho ng typ 2 ang mc mt bnh cp tnh khc; v d
nhim trng nng, nhi mu c tim, t qu
180

 Ngi bnh i tho ng suy thn c chng ch nh dng thuc vin h

glucose mu; ngi bnh c tn thng gan
Ngi i tho ng mang thai hoc i tho ng thai k.
Ngi iu tr cc thuc h glucose mu bng thuc vin khng hiu qu;
ngi b d ng vi cc thuc vin h glucose mu
Bt u dng insulin: Thng liu sulfonylurea c gim i 50% v ch ung
vo bui sng.
Liu insulin thng bt u vi liu 0,1 n v/kg cn nng (0,1 UI/kg) loi
NPH, tim di da trc lc i ng hoc
Ngy hai mi tim vi insulin hn hp (insulin premixed) ty thuc vo mc
glucose huyt tng v/hoc HbA1c.
CH : liu insulin tnh bng n v quc t (UI), khng tnh bng ml
iu chnh liu insulin:
Khi tng liu insulin ti 0,3U/kg m vn khng lm h c ng mu.
iu chnh mc liu insulin c 3-4 ngy/ln hoc 2 ln/ tun.
3.3. iu tr cc bnh phi hp, cc bin chng nu c; B sung vitamin v khong cht.
V. TIN TRIN V BIN CHNG
1. Tin trin
i tho ng typ 2 l mt bnh tin trin tnh tin. Nhng bin chng ca bnh
lun pht trin theo thi gian mc bnh.
2. Bin chng
2.1. Bin chng cp tnh
Hn m nhim toan ceton:
H glucose mu
Hn m tng glucose mu khng nhim toan ceton
Hn m nhim toan lactic
Cc bnh nhim trng cp tnh.
2.2. Bin chng mn tnh
Thng c chia ra bnh mch mu ln v mch mu nh hoc theo c quan b
tn thng :
Bnh mch mu ln: X va mch vnh tim gy nhi mu c tim, hi chng
mch vnh cp, x va mch no gy t qu, x va ng mch ngoi vi gy tc mch.

181

 Bnh mch mu nh: Bnh vng mc i tho ng, bnh thn i tho
ng, bnh thn kinh i tho ng (Bnh l thn kinh cm gic - vn ng, thn
kinh t ng)
Phi hp bnh l thn kinh v mch mu: Lot bn chn i tho ng.
VI. PHNG BNH
Ni dung phng bnh i tho ng bao gm: phng khng b bnh khi ngi
ta c nguy c mc bnh, phng bnh khng tin trin nhanh v phng gim thiu
ti a cc bin chng ca bnh nhm ci thin cht lng cuc sng cho ngi bnh.
ngha ca vic phng bnh trong i tho ng khng km phn quan trng so vi vic
iu tr bnh v n cng l mt phn ca iu tr.
Phng bnh cp 1: Sng lc tm ra nhm ngi c nguy c mc bnh cao;
can thip tch cc nhm lm gim t l mc bnh i tho ng trong cng ng.
Phng bnh cp 2: vi ngi b mc bnh i tho ng; nhm lm chm
xy ra cc bin chng; lm gim gim mc nng ca bin chng. Nng cao cht
lng sng cho ngi mc bnh.
TI LIU THAM KHO
1. International Diabetes Federation, 2012: Global Guideline for Type 2 Diabetes.
2. John B. Buse; Keneth S, Polonsky; Charles F. Burrant (2008): Type 2 Diabetes
Mellitus: Williams Textbook of Endocrinology- Edition 11; p.1329-1389.
3. Michael Brownlee; Lloyd P. Aiello; Mark E. Cooper; Aaron l. Vinik; Richard
W. Nesto; Andrew J.M. Boulton (2008): Complications of Diabetes Mellitus: Williams
Textbook of Endocrinology- Edition 11p; 1417-1502

182

Ph lc 1

THUC IU TR BNH I THO NG TYP 2

I. CC THUC H GLUCOSE MU BNG NG UNG
1. Metformin (Dimethylbiguanide)
L thuc c s dng rng ri tt c cc quc gia. Trc y 30 nm l thuc
iu tr chnh ca i tho ng typ 2.
Cc loi vin Metformin 500mg, 850mg, 1000 mg. Hin nay Phenformin khng
cn lu hnh trn th trng.
Liu khi u vin 500 hoc 850mg: 500 hoc 850 mg (1 vin/ngy), thng
ung vo bui chiu, trc hoc sau n.
Hin nay liu ti a khuyn co l 2000mg/ngy hoc 850mg x 3 ln/ngy. Tng
liu hn na khng tng thm hiu qu nhng s tng tc dng ph.
Metformin tc ng ch yu l c ch sn xut glucose t gan nhng cng lm
tng tnh nhy ca insulin m ch ngoi vi. Tc ng h glucose trong khong 2-4
mmol/l v c th gim HbA1c n 2%. V n khng kch thch tu ch tit insulin nn
khng gy h glucose mu khi s dng n c.
Metformin cn l thuc c khuyn co la chn dng iu tr ngi i tho
ng tha cn, bo ph, duy tr hoc lm gim cn nng, thuc cn c tc ng c
li n gim lipid mu.
Metformin c th gy ra tc dng khng mong mun ng tiu ho, nn dng
cng ba n v bt u bng liu thp (500 mg/ngy).
* Chng ch nh ca metformin l suy tim nng, bnh gan (k c nghin ru),
bnh thn (creatinin mu > 160 mol/l), ngi c tin s nhim toan lactic, do lm tng
nguy c nhim acid lactic. Metformin cng chng ch nh nhng trng hp c thiu
oxy m cp nh ngi ang c nhi mu c tim, chong nhim trng ...
2. Sulfonylurea
Sulfonylurea kch thch tu tit insulin. Tc ng lm gim glucose trung bnh l
50 60 mg/dl, gim HbA1c ti 2%. Sulfonylurea c dng thn trng vi ngi gi,
ngi b bnh thn (creatinine mu > 200 mol/L) hoc ri lon chc nng gan khi
liu thuc cn c gim i. Sulfonylurea khng c s dng iu tr tng glucose
mu ngi bnh i tho ng typ 1, nhim toan ceton, ngi bnh c thai, v mt
s tnh trng c bit khc nh nhim trng, phu thut...
Cc loi sulfonylurea trn th trng:
Th h 1: thuc thuc nhm ny gm Tolbutamide, Chlorpropamide, vin
500mg - nhm ny hin t c s dng do nhiu tc dng ph.
183

 Th h 2: cc thuc thuc nhm ny gm Glibenclamid (Hemidaonil 2,5mg;

Daonil 5mg; Glibenhexal 3,5mg;); Gliclazid (Diamicron 80mg; Diamicron MR30
mg; Diamicron MR60 mg, Predian 80mg;); Glipizid (minidiab), Glyburid;
Thuc thuc th h ny c tc dng h glucose mu tt, t tc dng ph hn thuc
th h 1. Nhm Gliclazid cc tc dng c hiu ln knh KATP lm phc hi nh tit
sm ca insulin gn ging s bi tit insulin sinh l nn t gy h glucose mu hn cc
thuc sulfonylurea khc. Gliclazid (Diamicron 30mg MR) dng mt ln trong ngy.
Nhm Glimepirid (Amaryl vin 1mg, 2mg v 4mg). Tc dng h glucose mu tt,
ngoi tc dng kch thch t bo beta ca tu bi tit insulin gn ging vi bi tit
insulin sinh l (tc dng c hiu ln knh KATP lm phc hi nh tit sm ca insulin),
cn c tc dng lm tng nhy cm ca m ngoi vi vi insulin. Thuc c t tc dng
ph v t gy tng cn ngi bnh i tho ng tha cn. Ch ung mt ln trong
ngy nn thun tin cho ngi s dng.
Liu thng thng ca nhm Sulfonylurea:
Glipizid t 2,5 mg n 20,0mg/ ngy.
Gliclazid t 40 320mg/ngy.
Gliclazid MR t 30 120 mg/ngy.
Glimepirid t 1,0 6,0 mg/ngy- c bit ti 8,0 mg/ngy.
Glibenclamid t 1,25 15,0 mg/ ngy.
Cc thuc sulfonylurea c s dng rng ri di dng n tr liu hoc phi
hp vi cc thuc nhm Biguanid, Glitazon, thuc c ch men Alpha-glucosidase, c
ch men DPP-4, insulin.
3. Thuc c ch enzym Alpha- glucosidase
Enzym Alpha-glucosidase c tc dng ph v ng i (disaccharide) thnh
ng n (monosaccharide). Thuc c ch Alpha-glucosidase, v th c tc dng lm
chm hp thu monosaccharide, do vy h thp lng glucose mu sau ba n. Nhng
thuc nhm ny gm:
Acarbose: Glucobay (50mg v 100mg). Tc dng khng mong mun: y bng,
a chy
Liu thuc c th tng t 25mg n 50mg hoc 100mg/mi ba n.
Nhm Voglibose: thuc ny hin khng c ti Vit Nam
Ch khi s dng thuc:
Thuc cn s dng phi hp vi mt loi h glucose mu khc.
Thuc ung ngay trong khi n, tt nht l ngay sau ming cm u tin. Trong
ba n phi c carbohydrat thuc tc dng.

184

4. Metiglinide/Repaglinide - thuc kch thch bi tit insulin sau n (khi c tng

glucose trong mu)
V l thuyt nhm ny khng thuc nhm sulfonylurea; nhng n c kh nng
kch thch t bo beta tuyn tu tit insulin- nh c cha nhm benzamido.
V cch s dng c th dng nh mt n tr liu hoc kt hp vi Metformin,
vi insulin. Ngi ta cng c nhng s liu chng minh vic kt hp Repaglinid vi
NPH trc khi i ng t kt qu tt trong iu tr h glucose mu ngi i tho
ng typ 2.
Liu dng: Hin c hai thuc trong nhm ny:
Repaglinid liu t 0,5 n 4 mg/ba n. Liu ti a 16 mg/ngy.
Nateglinid liu t 60 n 180 mg/ba n. Liu ti a 540,0 mg/ngy.
5. Thiazolidinedion (Glitazone)
Thuc lm tng nhy cm ca c v t chc m vi insulin bng cch hot ho
PPAR (peroxisome proliferator-activated receptor ) v vy lm tng thu np glucose
t mu. Thuc lm tng nhy cm ca insulin c vn, m m ng thi ngn cn qu
trnh sn xut glucose t gan
Thuc hin c: Pioglitazon, c th dng n c hoc kt hp vi cc thuc ung
khc hoc insulin. Tc dng ph bao gm tng cn, gi nc v mt xng, tng nguy
c suy tim. Nn lu kim tra chc nng gan. Trc kia c khuyn co khi dng
troglitazon cn xt nghim chc nng gan 2 thng mt ln, hin nay thuc ny b
cm lu hnh.
Liu dng:
Pioglitazon liu t 15 n 45 mg/ngy.
Chng ch nh ca nhm thuc ny: ngi c triu chng hoc du hiu suy tim,
tn thng gan. Nhiu chuyn gia, nhiu quc gia cng khuyn co khng nn phi hp
nhm thuc glitazon vi insulin.
Hin nay ti mt s nc trn th gii khng khuyn co s dng nhm glitazone
do tng nguy c bin c tim mch (rosiglitazon), hoc ung th nht l ung th bng
quang (pioglitazon).
6. Gliptin
Gliptin l nhm thuc c ch enzym DPP-4 (Dipeptidylpeptidase-4) lm tng
nng GLP1 ni sinh, GLP1 c tc dng kch thch bi tit insulin, v c ch s tit
glucagon khi c tng glucose mu sau khi n.
Cc thuc c ch enzym DPP-4 hin c ti Vit Nam nh sau:
Sitagliptin liu 50-100 mg/ngy
Vildagliptin liu 250 mg/ngy.

185

 Saxagliptinliu 2,5 5 mg/ ngy

Linagliptin- liu 5 mg/ngy
II. PHI HP CC THUC VIN H GLUCOSE MU
Cc thuc phi hp hin ti trn th trng Vit Nam.
Vin

Thnh phn

Nng (mg)

Glucovanc

Metformin + Glibenclamid

500:2,5; 500:5,0

CoAmaryl

Metformin+ Glimepirid

500:2,0;

Galvusmet

Metformin + Vildagliptin

500:50; 850:50; 1000:50

Janumet

Metformin + Sitagliptin

500:50; 850:50; 1000: 50;

Komboglyze

Metformin+ Saxagliptin

500: 5

* Ch : Ngi ta thng da vo tc dng ca thuc phn chia liu lng v loi

thuc, sao cho t c tc dng ti a. Khng dng phi hp hai loi bit dc ca cng mt
nhm thuc.

III. INSULIN
1. C s s dng insulin
Ngi bnh i tho ng typ 1 ph thuc vo insulin ngoi sinh tn ti.
Ngc li, ngi bnh i tho ng typ 2 khng phi ph thuc vo insulin ngoi
sinh tn ti. Nhng sau mt thi gian mc bnh, nu khng n nh tt glucose mu,
nhiu ngi bnh i tho ng typ 2 gim st kh nng sn xut insulin, i hi phi
b sung insulin ngoi sinh kim sot glucose mu mt cch y .
S dng insulin t c hiu qu kim sot chuyn ho glucose tt nht i
hi s hiu bit v khong thi gian tc dng ca cc loi insulin khc nhau.
2. Quy trnh tim
Insulin nn c tim vo t chc di da. Ngi bnh c th t tim bng cch
ko nh da gp ln v tim gc 90 . Nhng ngi gy hoc tr em c th dng kim
ngn hoc c th vo da ln v tim gc 45 trnh tim vo c, c bit vng i.
c bit khi dng bt tim insulin, kim nn lu li trong da 5 giy sau khi n ton b
pt tng m bo cung cp ton b liu insulin.
Tim insulin vo t chc di da bng thng c dng, nhng cng c th tim
vo mng, i hoc cnh tay. Quay vng v tr tim l cn thit nga ph i hoc teo
t chc m di da ti ni tim.
3. Bo qun insulin
L insulin nn t lnh, nhng khng trong ngn , trnh insulin tip
xc vi nh nng. Nhit qu cao hoc qu thp v lc nhiu c th lm hng insulin.
Insulin ang s dng c th gi nhit phng hn ch gy kch thch ti v tr tim.

186

Ph lc 2

TIU CHUN CHN ON THA CN, BO PH

DA VO BMI V S O VNG EO P DNG
CHO NGI TRNG THNH CHU - IDF, 2005
Yu t nguy c phi hp
2

Phn loi

BMI (kg/m )

S o vng eo
<90 cm (vi nam) 90cm
<80cm (vi n) 80 cm

Gy

< 18,5

Thp (nhng l yu
t nguy c vi cc
bnh khc)

Bnh thng

Bnh thng

18,5 - 22,9

Bnh thng

Tng

Bo
+ C nguy c
+ Bo 1
+ Bo 2

23
23 - 24,9
25 - 29,9
30

Tng
Tng trung bnh
Nng

Tng trung bnh

Nng
Rt nng

Ph lc 3

LIN QUAN GIA GLUCOSE HUYT TNG

TRUNG BNH V HBA1C

HbA1c %

Glucose huyt tng

(mg/dl)

Glucose huyt tng

( mmol/l)

126

7,0

154

8,6

183

10,2

212

11,8

10

240

13,4

11

269

14,9

12

298

16,5

187

NHIM TOAN CETON - HN M NHIM TOAN CETON

DO I THO NG
I. I CNG
Nhim toan ceton-hn m do nhim toan ceton l mt bin chng nguy him
n tnh mng ngi bnh, nguyn nhn l do thiu insulin trm trng gy ra nhng ri
lon nng trong chuyn ho protid, lipid v carbohydrat.
Tnh trng bnh l ny bao gm b ba ri lon sinh ha nguy him, gm: tng
glucose mu, nhim ceton, nhim toan, km theo cc ri lon nc in gii.
y l mt cp cu ni khoa cn phi c theo di ti khoa iu tr tch cc.
1. c im sinh bnh hc
1.1. Hn m nhim toan ceton
L hu qu ca hai yu t kt hp cht ch, l: thiu insulin v tng tit cc
hormon c tc dng i khng vi insulin ca h thng hormon i lp (glucagon,
catecholamin, cortisol), lm tng glucose mu, xut hin th ceton.
1.2. Thiu insulin, tng hormon i khng insulin lm tng sn xut glucose t gan
v gim s dng glucose cc m ngoi vi
Khi glucose mu tng cao s xut hin glucose trong nc tiu a n tnh trng
mt nc, mt cc cht in gii nh natri, kali. Thiu insulin, tng hormon i khng
insulin lm ly gii m m, phng thch cc acid bo t do, t tng thnh lp th
ceton. Th ceton gm aceton s thi qua hi th, acid acetoacetic v acid 3-hydroxybutyric l nhng acid mnh, khi xut hin trong mu lm gim d tr kim, tnh
trng toan ho mu ngy cng tng, tnh trng ny cng nng thm bi s mt nc v
gim lu lng mu n thn.
1.3. Ri lon nc, in gii v thng bng kim toan
Ngi bnh nhim toan ceton thng mt nc v in gii qua nc tiu v a
niu thm thu; nn cng lm mt nc v in gii. Ngi ta thy khi mt ngi b
mt vo khong 5 - 7 lt dch, s km theo mt lng in gii b mt bao gm:
Natri mt t 7 10 mEq/ kg cn nng;
Kali mt t 3 n 5 mEq/kg cn nng;
Chloride mt t 3 n 5 mEq/kg cn nng;
Calci mt t 1 n 2 mEq/kg cn nng;
Phosphat mt t 5 n 7 mmol/kg cn nng;

188

2. Yu t thun li
Nhim toan ceton i khi xy ra khng r nguyn nhn khi pht.
Bnh nhn i tho ng typ 1 c th b nhim toan ceton khi ngng insulin t
ngt, hoc ang dng insulin nhng c thm mt s cc yu t thun li. Ngi bnh
i tho ng typ 2 cng c th b nhim toan ceton khi glucose mu cha c iu
tr n nh km thm mt s cc yu t thun li nh:
Cc bnh nhim trng nh vim phi, vim mng no, nhim trng ng tiu
ho, nhim trng tit niu, cm cm .
Chn thng: K c cc stress v tinh thn.
Nhi mu c tim, t qu
S dng cc thuc c cocain
Sinh
II. CHN ON
1. Lm sng
1.1. Cc triu chng
Bun nn v nn.
Kht nhiu, ung nhiu v i nhiu.
Mt mi v/hoc chn n.
au bng.
Nhn m.
Cc triu chng v thc nh ng g, m mng.
1.2. Du hiu
Nhp tim nhanh.
H huyt p.
Mt nc.
Da kh nng.
Th kiu Kusmaul.
Suy gim thc v/hoc hn m
Hi th c mi ceton.
St cn.

189

2. Cn lm sng
Glucose mu > 13,9 mmol/l.
Bicarbonat (huyt tng) <15mEq/l
pH mu ng mch < 7,2.
C ceton trong mu v trong nc tiu. Trc kia thng o acid acetoacetic
nc tiu. Hin nay c th o acid beta hydroxybutyric trong mu, bng sau y cho
thy s thay i ca nng acid betahydroxybutyric lin quan vi tnh trng nhim
toan ceton.
Nng (mmol/l)
acid beta hydroxybutyric trong mu

nh gi

< 0,6

Bnh thng

> 1,0

Tng ceton mu

> 3,0

Nhim toan ceton

III. THEO DI V IU TR
Mc ch: Loi b nhng yu t e da n mng sng ngi bnh.
Cn lm ngay: chng mt nc, b lng insulin, phc hi thng bng in
gii, iu tr ri lon toan kim.
Trong thc t, mc tng glucose mu, tnh trng toan ha, tnh trng mt nc
in gii v ri lon tri gic, ph thuc vo mc to ra glucose, phn hu lipid v
mc hnh thnh cc th ceton. Cc yu t khc nh tnh trng dinh dng, thi gian
nhim toan - ceton; mc thiu insulin, cc loi thuc s dng v.v.., u c nh
hng n thc trng v tin lng bnh.
Nu da vo mc nhim toan ceton tin hnh can thip, c th tham kho
tiu chun xut sau:
Acid betahydroxybutyric mu
(mmol/l)
< 0,6
0,6 1,5

1,5 3
> 3,0

X tr
Khng x tr. Theo di lng glucose mu
C 2-4 gi kim tra li glucose v ceton mu (Acid
betahydroxybutyric)
iu tr yu t nguy c.
Nguy c nhim toan ceton. Cn can thip
Can thip tch cc, trnh hn m

1. Theo di ngi bnh i tho ng nhim toan ceton

1.1. Theo di lm sng
Tnh trng tri gic mi gi mt ln.
Cc ch s sinh tn (nhit , mch, huyt p, nhp th) mi gi mt ln.
Lng nc tiu mi gi trong nhng gi u, sau lng nc tiu 24 gi.
190

 Cn nng (nu c th).

Monitoring in tm .
1.2. Theo di cn lm sng
Glucose mu (ti ging) 1gi/1ln
Kali mu, pH 1 -2gi/ 1ln
Na+, Cl-, Bicarbonat 2 - 4 gi/1ln
Phosphat, magnesi 4 - 6 gi/1ln- nu c kh nng
Ure hoc creatinin mu 4 - 6 gi/1ln
Ceton mu (acid betahydroxybutyric): 2 gi mt ln
Th ceton niu: 2 - 4gi (nu khng c iu kin o acid betahydroxybutyric
trong mu). Th ceton trong nc tiu o c bng phn ng nitroprussid l acid aceto
acetic, ch c tnh bn nh lng.
Calci mu: theo ch nh
Hematocrit: theo ch nh
1.3. Cc xt nghim khc (nu cn)
Cy mu
Cy nc tiu, soi tm t bo.
Cng thc mu, c bit quan tm n s lng bch cu.
Amylase mu.
Cholesterol, LDL, HDL cholesterol, triglycerid.
Ht dch d dy xt nghim khi cn v trnh sc ht vo phi.
1.4. Theo di iu tr
Lng dch vo-ra 1-2 gi/1 ln. Khi tnh trng n nh, theo di 4 gi mt ln.
Lng insulin tim truyn (n v/ gi) 1 - 4 gi/1ln
Kali (mmol/l) 1 - 4 gi/1ln
Glucose huyt tng (mmol/l) 1 2 gi mt ln, khi tnh trng ci thin 4 gi/1
ln. Nu khng c iu kin c th th glucose huyt mao mch.
Bicarbonat v phosphat 1 - 4 gi/1 ln
2. Gii thiu mt phc iu tr cp cu hn m nhim toan ceton
Mt nc xy ra tt c mi ngi bnh i tho ng c nhim toan ceton, mt
nc thng km theo mt in gii.
Gi th 1: Dung dch NaCl 0,9% hoc Ringer lactat: 15-20ml/kg (500ml/m2/gi).
Trng hp ngi cao tui hoc ngi c bnh tim km theo, lng dch c th
thp hn.
191

Gi th 2: Dung dch NaCl ng trng 15 ml/kg, nu ngi bnh c tng Natri

mu hoc suy tim huyt th dng dung dch NaCl 0,45%.
Gi th 3: Gim lng dch truyn xung cn 7,5ml/kg/ gi (ngi trng thnh)
hoc t 2 - 2,5ml/kg/ gi ( tr nh), dung dch thng c s dng trong giai on
ny l NaCl 0,45%.
Gi th 4: Tu din bin lm sng m xem xt lng dch vo ra.
Khi lng glucose mu xp x 13,9 mmol/l (250mg/dl) c th thay dung dch
NaCl 0,9% bng dung dch glucose 5% trong khi vn tip tc truyn insulin, hoc dng
dung dch mn ngt ng trng. Tip tc ng truyn tnh mch cho ti khi ngi
bnh c th n c (ht nn v bun nn).
Phc trn c th thay i ty tnh trng ngi bnh v din tin bnh. Nhng
khi glucose huyt gim n 13,9 mmol/l cn b sung truyn glucose cho ngi bnh.
3. S dng insulin
Thiu insulin trm trng ng vai tr trung tm trong vng xon bnh l ca
nhim toan ceton do i tho ng. B insulin l yu t cn thit sa cha tnh
trng nhim toan ceton ca ngi i tho ng.
Ch insulin tc dng nhanh (cn gi l insulin thng-regular insulin) mi c
dng trong cp cu. ng vo tt nht l ng tnh mch (tim hoc truyn).
Sau y xin gii thiu mt phc cp cu vi insulin dng ng tnh mch.
3.1. Liu ban u t 0,1- 0,15 IU/kg/gi (tim tnh mch)
Sau tip tc truyn tnh mch vi liu v tc 0,1 IU/kg/ gi.
Thay i liu v tc truyn insulin:
Khng c p ng sau 2 - 4 gi (glucose huyt khng gim 3,9 mmol/l70mg/dl/gi), phi tng liu truyn gp hai ln (trc khi tng liu insulin cn kim tra
k m bo lng insulin ch nh c a vo c th ngi bnh v ngi
bnh c b nc).
Nu lng glucose mu <13,9mmol/l (250mg/dl); gim liu truyn ca insulin,
thm dung dch Glucose 5% (Dextrose).
Trng hp ngi bnh hn m khng o c cn nng, c th da vo nng
glucose huyt tng ch nh liu insulin truyn tnh mch.
3.2. Khi ngi bnh tnh to v bt u n c qua ng ming
S cn nhc cc yu t sau trc khi chuyn t insulin truyn tnh mch sang
insulin tim di da:
Tnh trng lm sng tt ln (cc du hiu biu hin chc nng sng n nh:
mch, nhit , huyt p, tri gic tnh to).
pH mu >7,3, nng bicarbonat huyt tng > 18 meq/L, in gii mu tr
li bnh thng (chng t tnh trng toan mu c gii quyt).
192

 Ngi bnh c th n ung c m khng b nn hoc bun nn.

Cc yu t stress (nh nhim trng, chn thng...) c kim sot.
Nn dng insulin bn chm tim di da trc khi chuyn t tim tnh mch sang
di da, nhm to ra sn trong mu mt lng insulin cn thit, khng xy ra thiu
ht insulin d trong giai on ngn. Liu lng insulin ph thuc vo hm lng
glucose trong mu.
4. Theo di v b Kali
H Kali mu c 5% ngi b nhim toan ceton.
Ngi bnh i tho ng nhim toan ceton v thc cht b mt nhiu kali, d
nng kali mu bnh thng hoc tng (do tnh trng toan mu).
Trong thc t lng kali c th mt qua ng thn (do a niu thm thu, do mt
kh nng ti hp thu) hoc do nn ma, do a chy
Bng. Cc yu t lm thay i nng kali trong nhim toan ceton
Nguyn nhn
Thiu insulin

C ch

Hu qu

Ngn kali vo trong t bo

+

Mt K ni bo
+

Toan chuyn ho

Trao i cc K v H

K t ni bo thm ra ngoi bo, H

chuyn t ni bo ra ngoi bo

Tng bi niu

Mt kali

Mt K qua nc tiu

Nn

Tnh trng nhim toan

Mt K qua ng tiu ho

Suy thn

Mt nc, gim lng mu

n thn

Gi kali

+
+

b lng kali cn lm r nhng im sau:

Xc nh chnh xc lng nc tiu xem ngi bnh c suy thn khng?
Nu trong gi u tin ngi bnh tiu c 60ml/gi, thn cn chc nng lc.
nh lng Kali mu.
Theo di in tim: Tng Kali nu c sng T cao v nhn. H Kali mu nu
sng T thp v c sng U.
Nu ngi bnh b v niu, phi ht sc thn trng. Vic theo di bng in
tim khng nh gi, trng hp ny cn phi theo di lng Kali huyt tng, hi
chn chuyn khoa iu tr v niu cp.
Trong trng hp phi b Kali, nn truyn tnh mch ngoi vi.
Bng. Bng tham kho v ch truyn Kali thay th, tnh theo lng dch truyn tnh mch
Nng kali trong huyt tng
(mmol/l)

Lng Kali thay th (mmol/l) pha

trong dch truyn

> 5,5

Khng truyn Kali

T 3,5 n 5,5

20 mmol/lt dch truyn

< 3,5

40 mmol/lt dch truyn

193

Khng dng insulin tnh mch nu nng K+ di 3,3 mmol/L.

Kim tra nng kali mu 2gi/1 ln nu nng kali huyt tng thp <4,0
mmol/l hoc cao > 6,0 mmol/l, u phi c thi theo di, can thip tch cc.
Loi kali s dng trong cp cu thng l Potassium hoc KCl.
Trong trng hp phi b kali, nn truyn tnh mch ngoi vi.
Khi bt u truyn insulin, lng kali trong mu c th b gim xung do tng vn
chuyn kali tr li trong t bo. Nu lng kali xung qu thp, c th gy ra lon
nhp tim. Trong thc hnh cp cu lm sng nu khng kp lm xt nghim in gii,
ngi ta thng bt u cho kali sau khi truyn insulin c 1 - 2 gi ng h.
Duy tr nng Kali huyt tng gia 3,5 - 5,5 mmol/l l ph hp. Trng hp
dng Natribicarbonat phi tng thm kali - v bicarbonat thc y nhanh qu trnh kali
thm nhp vo t bo, do vy lm tng kh nng h kali trong dch ngoi bo.
5. Bicarbonat v phosphat
5.1. B bicarbonat
C nhiu kin khc nhau, tm tt:
Nhng ch li ca vic s dng Natricarbonat:
iu chnh li toan ngoi bo
Lm gim lng chlorid d tha
Ci thin tnh trng h hp
Gim lon nhp
Tng p ng ca h thng mch mu vi cc tc nhn gy tng huyt p.
Nhng tc hi ca vic s dng Natribicarbonat:
Khi tnh trng nhim toan ngoi bo c iu chnh, bicarbonat lm gim
nng kali huyt tng do tng kali i vo ni bo.
Tng gnh Natri, nht l ngi bnh cao tui
C th lm trm trng tnh trng toan ni bo.
Lm thay i tnh thm ca CO2 vi hng ro mu no, gy tnh trng nhim
toan nghch l h thn kinh trung ng, nh hng n trung tm iu ho h hp.
S dng bicarbonat cn lm tnh trng toan ho hi phc qu nhanh, lm nng
2,3diphosphatglycerat trong t bo hng cu chm hi phc, y l nguyn nhn lm
gim kh nng cung cp oxy cho m.
V nhng l do ny, s dng bicarbonat ch c xem xt khi pH < 7,0; mt s
nh lm sng cn thn trng hn, ch dng bicarbonat khi nhim toan nng (pH < 6,9)
km theo nhng du hiu e do tnh mng nh tt huyt p, chong, lon nhp tim, ri

194

lon tri gic. Trng hp buc phi dng bicarbonat, ch nn dng Natribicarbonat ng
trng 1,4%, khng nn dng loi u trng 8,4%.
Nu pH mu < 6,9; pha 100ml NaHCO3 vo 400 ml nc tinh khit v truyn vi
tc 200ml/gi cho n khi cho n khi pH >7. Nu pH khong 6,9-7,0; pha 50ml
NaHCO3 vo 200ml nc tinh khit v truyn vi tc 200ml/gi.
5.2. Phosphat
Khng c ch nh dng thng quy, tr khi ngi bnh c gim chc nng tim,
thiu mu, suy h hp hoc phosphat mu< 1mg/dl. Khi , pha 20-30 mEq Potassium
phosphat vo dch ang truyn.
5.3. La chn dch truyn
Khi ngi bnh b hn m nhim toan ceton hoc sm hn na l vo tnh
trng nhim ceton, ngi ta thng dng dung dch mui ng trng thay th
lng dch mt.
6. Nhng vn c bit khc
Tm v iu chnh cc yu t thun li dn n nhim toan ceton: stress, nhim
trng...; Chm sc ton din nht l khi ngi bnh hn m.
phng nhng tai bin thng gp trong qu trnh iu tr.
Ti nhim toan tr li, tin lng s xu i rt nhiu.
Ph no, thm ch t vong c th xy ra. m bo an ton, nn duy tr lng
glucose mu xung quanh 11,1mmol (200mg/dl) trong 12-24 gi u.
Nn v bun nn gy sc thc n, gy ra vim phi do hi chng tro ngc.
Hi chng ri lon h hp: Xy ra t ngt, thng khi din bin lm sng
ang c v tt ln; biu hin bng th nhanh, nng, tnh trng thiu oxy tr nn nng
n, tin lng ngi bnh xu hn i.
H glucose mu c th xy ra. phng, phi duy tr glucose mu mc
11,1mmol/l - 13,9mmol/l; nu tnh trng nhim toan vn cn, nn duy tr liu insulin t
1-2 n v/gi.
Cc loi dch thay th (c bit l mui ng trng) c th lm tng tnh trng
suy tim huyt.
Khi ch nh chuyn sang tim insulin di da, cn lu :
(1) hiu qu ca insulin tim di da chm hn tim tnh mch, v th mi
tim di da u tin nn bt u trc khi ngng truyn insulin tnh mch 1-2 gi.
(2) phng tnh trng "ti nhim toan ceton" v "nhim c ng", nn
dng liu insulin. Ty tnh trng ngi bnh, s chn insulin tc dng nhanh trong
24 - 72 gi u, hoc nu tnh trng ngi bnh n nh c th dng insulin bn chm.

195

 (3) Trong nhng tun u sau khi b nhim toan ceton, ngi bnh c th xut
hin khng insulin nh, bi th liu insulin c th cao hn liu dng thng thng. Khi
tr li bnh thng nu khng ch c im ny iu chnh liu insulin s d
gy h glucose mu.
Liu php Heparin liu thp nn c s dng, nht l nhng ngi c yu t
nguy c mc bnh l tnh mch, ngi cao tui, ngi c tin s tc mch, mt nc nng.
IV. PHNG NGA NHIM TOAN CETON
Nhim toan ceton ngi i tho ng c th ngn nga bng cch gio dc
cho ngi bnh nhng kin thc cn thit v s chm sc ca thy thuc.
1. Ngi bnh
Bit cch t theo di lng glucose mu v ceton nc tiu.
Lin h ngay vi thy thuc khi c mc thm mt bnh khc, khi xut hin cc
triu chng bt thng nh bun nn, st, au bng, a chy hoc nng glucose mu
cao, ceton trong nc tiu dai dng y l nhng du hiu bo trc kh nng nhim
toan ceton.
Khng bao gi c t gim liu tim insulin, hoc t b thuc ngay c
khi mc mt bnh khc.
2. Thy thuc
Thng bo cho ngi bnh bit tnh hnh bnh tt, cch pht hin nhng triu
chng hoc du hiu nguy him cn i khm bnh.
Khi thm khm phi t m pht hin nhng din bin bt thng ca bnh.
Phn loi ngi bnh theo giai on bnh c k hoch chm sc cho ph hp.
TI LIU THAM KHO
1. George S. Eisenbath; Kenneth S. Polonsky; JohnB Buse: Type 1 Diabetes
Mellitus; Williams Textbook of Endocrinology - Edition 11(2008); p 1407- 1411.
2. Philip E. Cryer: Glucose Homeostasis and Hypoglycemia; Williams Textbook of
Endocrinology - Edition 11(2008); p 1503-1533.
3. Saul Gennuth, MD: Therapy for Diabetes Mellitus and related Disorders; 2004.
Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State in Adults; p: 87-99.

196

HN M TNG P LC THM THU

DO I THO NG
I. C IM SINH L BNH
1. c im
y l hi chng thng gp ngi mc i tho ng typ 2 trn 60 tui, n
thng gp hn nam.
Bnh c tin lng xu, t l t vong cao ngay c khi c cp cu nhng trung
tm c y phng tin v c nhng chuyn gia gii, nu c qua khi cng thng
li di chng.
Tng p lc thm thu mu do tng glucose mu khng nhim toan ceton c th
gp ngi cha bao gi c chn on i tho ng typ 2 v thng l nguyn
nhn phi vo vin cp cu ngi bnh i tho ng typ 2.
Hn m do tng p lc thm thu tng glucose mu c nhiu im ging vi hn
m nhim toan ceton. Tuy nhin c nhiu im khc nhau, nht l v mc tn
thng. c im chnh ca bnh l tng glucose mu, mt nc v in gii. Ngi
hn m do tng p lc thm thu tng glucose mu khng nhim toan ceton c c im
ln nht l mt nc, a phn l mt nc nng. Thng khi c triu chng ri lon
thc trn lm sng, lng nc mt c th chim ti 25% trng lng c th.
c im quan trng phn bit vi hn m nhim toan ceton l khng c th
ceton hoc c rt t trong nc tiu. l do:
Nng insulin tng cao h thng ca lm gim kh nng to ra th ceton
ti gan.
H thng hormon i lp khng b tng tit nhiu, khng gim lng insulin
mu, nn gim kh nng ly gii triglycerides, t gim kh nng to th ceton gan.
Bn thn s tng p lc thm thu c th c ch s phn hu lipid - ngun to ra
acid bo t do gan tng hp nn cc th ceton, v th lng ceton cng khng tng ln.
2. Nguyn nhn v yu t thun li cho bnh xut hin
Bnh thng xut hin ngay sau mt nhim trng cp, cng c khi sau mt stress
v tinh thn hoc thc th; nhng nhiu trng hp khng tm thy nguyn nhn trc
tip no.
C ti 40% cc trng hp hn m do tng p lc thm thu tng glucose mu
khng nhim toan ceton l iu kin pht hin ra ngi bnh b i tho ng typ 2.

197

Bng 1. Cc yu t thun li lm xut hin hn m do tng p lc thm thu mu,

tng glucose mu khng nhim toan ceton
Cc thuc

Qu trnh iu tr

Bnh mn tnh

Bnh cp tnh

Glucocorticoid
Li niu
Diphenylhydantoin
Thuc chn Andrenergic Diazoxide
L - asparaginase
Cc thuc c ch min
dch

Lc mng bng
Thm phn mu
Stress ngoi khoa
Truyn nhiu glucose.
Sau phu thut

Bnh thn
Bnh tim
Tng huyt p
t qu
Ung ru
Bnh tm thn
Mt cm gic
kht

Nhim trng
Nhim khun tit niu.
Lot g
Nhim trng mu
Chy mu ng tiu ho.
Tai bin mch no
Nhi mu c tim
Vim tu cp.

3. Thut ng
Thut ng Tnh trng tng p lc thm thu do tng glucose mu c Ennis
v Kreisberg - nm 1994, ngh thay bng tnh trng tng p lc thm thu do tng
glucose mu khng nhim toan ceton v nng hn l Hn m tng p lc thm thu do
tng glucose mu khng nhim toan ceton. Thut ng ny bao hm cc ngha sau:
Tnh trng tng p lc thm thu do tng glucose mu; lm sng c th c
tnh trng nhim toan ceton vi nhiu mc khc nhau.
Cc mc ri lon thc khc nhau c th gp lm sng, nng nht l tnh
trang hn m.
II. TRIU CHNG V DU HIU
1. Lm sng
C bn c im chnh:
Lng glucose mu tng cao 33,3mmol/l (600mg/dl) thng t 55,5
(1000mg/dl) - 111,1mmol/l (2000mg/dl).
Khng c th ceton trong nc tiu hoc c rt nh.
p lc thm thu huyt tng hoc huyt thanh trn 330 mOsm/kg nc.
Du hiu mt nc nng.
Ngoi ra cn c nhiu cc bt thng v thn kinh khc nh mt ngn ng, lit
nh mt na ngi, bn manh, rung git nhn cu v thm ch c c du hiu Babinski,
cng c th gp trong hn m tng glucose mu khng nhim toan ceton.

198

Bng 2. S khc bit chnh v lm sng gia hn m do tng glucose mu khng

nhim toan ceton vi hn m do nhim toan ceton. C th so snh nh sau:
Cc yu t
Tui
Din bin
T l t vong (%)
Glucose mu
p lc thm thu
Natri mu
Bicarbonat

Nhim toan ceton

Bt k la tui no
Vi gi hoc vi ngy
> 5%
Cao
Cao
Bnh thng hoc thp
< 15 mEq/L

Tng p lc thm thu

Thng trn 60 tui
Vi ngy hoc vi tun
50%
Rt cao
Rt cao
Bnh thng hoc cao
Bnh thng hoc hi thp

Ceton mu
ang iu tr

++++
Insulin

m tnh hoc (+) nh

Ch n thuc vin h glucose mu

2. Cc xt nghim cn lm sng
Buc phi c chn on v theo di:
Glucose mu
in gii mu, nht l Natri mu
Kali mu.
Ure v Creatinin mu
Bicarbonat, c th tng nh do lng acid lactic b tch li (do h huyt p v
tc tun hon ngoi bin b suy gim).
C th da vo cng thc sau tnh p lc thm thu mu:
p lc thm thu mu = 2 (Na + K) + Urea + Glucose.
(n v tnh cc ch s l mmol/l ).
Chn on xc nh khi p lc thm thu > 330 mosmol/kg nc.
3. Chn on phn bit
Bng 3. Chn on phn bit gia tnh trng nhim toan ceton
v hi chng tng p lc thm thu- tng ng mu
Tng
thm thu

Nhim toan ceton

pH mu M
Bicarbonate
Ceton mu
ALTT mu
Anion gap
Tri gic

Nh
(G.ht> 13,9
mmol/l)
7,25- 7,30
15-18 mEq/L
Dng tnh
Thay i
>10,0
Tnh to

Trung bnh
G.ht> 13,9
mmol/l)
7,0-<7,24
10-<15 mEq/L
Dng tnh
Thay i
>12,0
Tnh to/l m

Nng
G.ht> 13,9
mmol/l)
< 7,00
< 10,0 mEq/L
Dng tnh
Thay i
>12,0
Sng s/hn m

G.ht> 33,3
mmol/l)
>7,3
>15mEq/L
+ nh
>330 mOsm/kg
Thay i
Sng s/hn m

Ghi ch: G.ht: Glucose huyt tng;

ALTT mu = 2 (Na + K) + Ure + Glucose (mmol/l ).
+
Anion gap: ( Na )- [( Cl + HCO3 mEq/l]

199

III. NGUYN TC IU TR
S dng insulin, dch truyn v kali cho ph hp l iu kin a ngi bnh
ra khi tnh trng hn m. Tuy nhin, nu nh trong cp cu hn m nhim toan ceton
s dng insulin c quan tm hng u, th trong hn m tng p lc thm thu mu,
vic b ph nc, in gii phi c u tin nht.
1. Bi ph nc, in gii
L yu t quan trng nht, dch c chn l cc dung dch ng trng. iu cn
nh l khi nng glucose mu gim xung, s mt cn bng th pht gia p lc
trong v ngoi t bo li xy ra.
trnh hin tng ny, ngi ta khuyn nn phc hi s mt nc mc
ph hp vi tui v tnh trng ngi bnh, c bit vi ngi cao tui thng km theo
cc bnh l v thn v tim mch.
im quan trng xc nh lng dch truyn vo l phi tnh c lng Na+
thc t. C th tham kho cng thc tnh sau.
A= Na+ + 1,6 ( G- 5,5)/5,5.
D = 0,6* P * [(A/140)-1]
(A l lng Na+ thc t; Na+ l lng o c trong huyt tng ngi bnh tnh
bng mmol/l); D l lng dch cn b sung, tnh bng lt; P l trng lng c th, tnh
bng kg; G l lng glucose huyt tng tnh bng mmol/l).
V d, mt ngi bnh nhp vin c chn on l hn m tng ng mu
khng nhim toan ceton, nng khong 60 kg, xt nghim c lng Glucose mu l 35
mmol/l; Na+ huyt tng l 143 mmol/l.
Lng Na+ thc l:
A= Na+ + 1,6(G- 5,5)/5,5 = 143 + 1,6(35 5,5)/5,5 = 151,6.
Lng dch cn b l:
D = 0,6*P * [(A/140)-1] = 0,6 * 60 * (151,6/140 1) = 2,98 lt # 3 lt
y l lng dch cn b cho c th b mt trong mt thi gian di. Tuy nhin
cch b nh th no phi ph thuc vo tnh hnh thc t ca ngi bnh c ch nh
ph hp. Tt nht l t catheter theo di p lc tnh mch trung tm v iu chnh
lng dch truyn.
Cn lu nu nng Triglycerid tng qu cao cng s lm thay i nng
Na+ mu.
Cng cn ch theo di v iu chnh Kali trong mu ngi bnh.
2. Insulin
V ngi bnh thng khng c tnh trng nhim toan ceton nng v mc ch
phn u l lm gim nng glucose mu t 3-5 mmol/gi, nn vic s dng insulin

200

vi liu nh cn c ch nh sm. Ngi bnh hn m tng p lc thm thu thng

nhy cm vi insulin, do vy d b h glucose mu, nht l khi truyn tnh mch.
Thng thng ngi ta bt u vi liu 1- 2 n v/gi (tng ng 0,05 n
v/kg/gi), sau phi tip tc theo di tng liu cho ti khi t c mc ch gim
glucose mu t 3 - 5 mmol/gi. ch t ti nn duy tr mc glucose huyt tng t 1416,7 mmol/L cho ti khi tnh trng tri gic ca ngi bnh c ci thin.
3. Chng ng mu
Khc vi ngi hn m nhim toan ceton, ngi bnh hn m do tng p lc thm
thu c nguy c tc mch cao hn nhiu, v th vic s dng cht chng ng mu l
bt buc cho mi trng hp (nu khng c chng ch nh).
4. iu tr cc bnh phi hp nu c, b sung vitamin v khong cht.
TI LIU THAM KHO
1. Ennis ED, Stahl EJVB, Kreisberg RA: The Hyperosmolar hyperglycaemic
syndrome. Diabetes Rev, 1994; 2: 115-126.
2. John B. Buse; Keneth S, Polonsky; Charles F.Burrant: Type 2 Diabetes
Mellitus; Williams Textbook of Endocrinology - Edition 11(2008); p. 1329-1389.
3. Saul Gennuth, MD: Therapy for Diabetes Mellitus and related Disorders; 2004.
Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State in Adults; p: 87-99

201

H GLUCOSE MU
I. I CNG
1. c im sinh l
Triu chng h glucose mu thng xy ra khi lng glucose huyt tng cn
khong 2,7-3,3 mmol/l. Nu glucose huyt tng lc i < 2,8 mmol/l (50 mg/dl) l h
glucose mu nng, cn khi lng glucose mu < 3,9 mmol/l (< 70 mg/dl) bt u
c xem l c h glucose mu. Ngi bnh tr tui c xu hng biu hin lm sng
mc glucose huyt tng cao hn (3,8 mmol/= 68 mg/dl) so vi ngi trng thnh
(3,1 mmol/l= 56 mg/dl).Tu theo mc glucose trong huyt tng s c nhng biu hin
lm sng tng ng.
H glucose mu l hu qu ca tnh trng mt cn bng gia hai qu trnh cung
cp v tiu th glucose trong mu (h tun hon).
Cc nguyn nhn thng gp l:
S dng thuc lm tng bi tit insulin vi liu khng ph hp (insulin l
hormon c tc dng c ch sn xut glucose ti gan, kch thch tiu th glucose c
vn v m m).
Gim tip nhn thc n (do ch n ung kht khe hoc c vn v ri lon
hp thu).
Tng mc luyn tp (lm tng s dng glucose c vn).
Khi glucose mu h thp, c th s t bo v bng cch tng tit cc hormon c
c im lm tng glucose mu, cn gi l cc hormon iu ha ngc hay hormon c
tc dng i khng vi insulin: v d glucagon, catecholamin (adrenalin), cortisol.
Glucagon, adrenalin c vai tr quan trng; chng l nhng cht kch thch bi tit
glucose ti gan; ngoi ra adrenalin cn lm tng glucose mu bng cch gim thu np
glucose ti m.
Cc phn ng sinh l c tnh c bn nh gim bi tit insulin (phn ng c bn
th nht), tng tit glucagon (phn ng c bn th hai), thng xy ra c tnh tc thi
v nhiu khi khng km triu chng lm sng. T phn ng tng tit adrenalin (c
xem nh phn ng c bn th ba) bt u c biu hin r v lm sng, ng thi
gy ra nhng ri lon khc ngoi h glucose mu. Phn ng ny cng ch xut hin khi
glucagon khng kh nng iu ho li glucose mu mt cch sinh l.
Tuy nhin cc ngi bnh i tho ng typ 1, p ng vi h glucose mu s
bt thng, do:
Suy gim bi tit glucagon.
Khi thi gian mc bnh ko di, s bi tit ca adrenalin cng suy gim.
Lng insulin hp thu qua ng di da thay i s ph v th cn bng vn
mng manh gia hai h thng hormon iu ho glucose mu.
202

2. Nhng c im cn lu khc
H thng hormon iu ho glucose mu v cc triu chng bo ng ca h
thng thn kinh t ch gim i sau nhiu nm b i tho ng.
Mt vi loi thuc c s dng iu tr i tho ng v bin chng cng c
kh nng gy h glucose mu hoc lm m i cc du hiu sm ca h glucose;
Liu php iu tr tch cc bng insulin lm tng nguy c h glucose mu
khng triu chng, nht l ngi bnh b bnh lu, ngi bnh ln tui.
Mt s bng chng cho thy vic s dng insulin ngi cng lm tng t l h
glucose mu khng triu chng.
II. CHN ON
1. Chn on xc nh phi da vo xt nghim sinh ha
Sinh ho: Khi nng glucose mu < 2,8mmol/l (50 mg/dl) l h glucose mu
nng, cn khi glucose mu <3,9mmol/l (< 70mg/dl) bt u c xem l c h
glucose mu (h glucose mu sinh ha).
2. Lm sng
C nhiu mc .
2.1. Mc nh
Thng l cc triu chng v m hi, run chn tay v i. y l triu chng ca
h thn kinh t ch.
Cc triu chng ny s mt i khong 10 -15 pht sau khi n, ung 10 15 gram
carbohydrate. mc ny ngi bnh c kh nng t iu tr c.
2.2. Mc trung bnh
mc ny, c cc triu chng lm sng do p ng ca h thng thn kinh t
ch v ca h thn kinh trung ng vi gim lng glucose m nh: au u, thay i
hnh vi, d b kch thch, gim kh nng ch , ng g.
Thng thng ngi bnh khng tnh to kt hp iu tr vi thy thuc.
Thi gian phc hi s lu hn. Nu khng can thip kp thi, ngi bnh cng mau
chng chuyn sang mc nng.
2.3. Mc nng
Lc ny lng glucose mu h rt thp. Biu hin lm sng bng hn m, mt
cm gic hoc nhng cn co git. Cp cu lc ny cn truyn glucose tnh mch
v/hoc glucagon (tim bp hoc tim di da).
2.4. H glucose mu tim tng hay h glucose mu khng triu chng
Trc y ngi ta cho rng h glucose mu khng c triu chng cnh bo - hay
h glucose mu tim tng - l rt him. Tht ra tai bin ny rt hay gp, nht l nhng
203

ngi bnh c p dng phng php tr liu tch cc. Nhng ngi c cn h glucose
mu khng triu chng lp li nhiu ln s gy ra nhng tc hi:
Lm "cn" i c ch hot ng ca h thng hormon ngn chn h glucose mu.
H thp ngng "bo ng" v nguy c h glucose mu ca c th.
chn on xc nh ngi bnh cn nh lng glucose mu, khi lng glucose
mu <3,1mmol/l (< 55mg/dl) bt u c xem l c h glucose mu tim tng trn lm
sng, lc ny cn n s can thip ca cc nh chuyn mn c kinh nghim.
Khi c h glucose mu khng triu chng, khng nn iu khin phng tin
giao thng, khng nn tip tc luyn tp...
III. IU TR CN H GLUCOSE MU
1. Vi th nh
Ch cn 10-15g carbohydrate ung l glucose mu nhanh chng tr li bnh
thng (ung ng, nc ng).
Cn nh, khng dng socola v kem iu tr h glucose mu cp.
Trng hp ngi bnh ang i trn ng, hoc ngi bnh ang iu khin
phng tin giao thng, c du hiu h glucose mu, tt nht l nn dng li 10 - 15
pht i khi glucose mu tr li bnh thng hy tip tc cng vic.
2. Th trung bnh
C th dng ng ung can thip, nhng cn thi gian di hn v liu dng
ln hn glucose mu tr li bnh thng. C th dng glucagon tim bp hoc di
da kt hp vi ung carbohydrat (ng, nc ng).
3. H glucose mu nng
Do ngi bnh mt thc nn khng c kh nng nut, v th cho ung c th s b
sc vo ng th. Nhng ngi bnh ny buc phi tim bp hoc tim di da glucagon
v tim tnh mch glucose u trng v sau tip tc truyn tnh mch glucose.
Thng thng tnh trng lm sng s kh ln sau 10 - 15 pht tim glucagon v 1 5 pht sau truyn glucose. Nu h glucose mu lu v mc ng trong mu qu
thp, vic phc hi tm thn c th lu hn (trong nhiu gi). Trong trng hp ny c
truyn ng na hay khng l tu thuc vo hm lng glucose trong mu.
Nu h glucose mu c triu chng thn kinh, giai on sau c th c au u,
trng thi u m, mt tr nh v nn ma. Trng hp ny c th dng thuc an thn
iu tr triu chng.
Sau khi qua giai on cp cu, ngi bnh nn phng bng cch hoc l tng
ch n hoc n ba n ph (t l ~10% tng s calo trong ngy).
3.1. Glucagon
Liu Glucagon cn cho iu tr h glucose mu th trung bnh hoc nng:
204

 Vi tr <5 tui liu dng 0,25 - 0,4mg.

Tui t 5 - 10 tui liu dng 0,5 - 1,0mg.
Trn 10 tui liu dng l 1,0mg.
ng dng: C th tim di da, tim bp (Glucagon khng dng ng tim
tnh mch). Glucagon ch c hiu qu nu ngi bnh cn d tr glycogen trong gan.
Cch s dng glucagon phi c hng dn cho ngi thn ca ngi bnh,
thm ch cho c nhng ch nh tr hoc nhn vin khch sn h c th s dng c
trong nhng trng hp cp cu.
3.2. Glucose qua ng tnh mch
L phng php iu tr c bn nht nu c sn nhn vin y t phc v. Trong
trng hp h glucose mu nng, glucose tim tnh mch phi hp vi glucagon c
xem l phng php cp cu hon ho nht. Hn ch ca phng php ny l phi c
nhn vin y t. Thng khi bt u cp cu ngi ta thng dng:
10 - 25g (trong dung dch Dextrose 50%, hoc glucose 50%).
50 - 100ml dung dch glucose 30%.
Thi gian tin hnh cp cu ban u t 1-3 pht. Cp cu ban u tim glucose
vo ng tnh mch sau s tip tc duy tr ng truyn tnh mch.
Liu cp cu tip theo ph thuc p ng ca ngi bnh. Thng thng, ngi
ta cho glucose ng tnh mch vi liu 510g/gi. Glucose s c tip tc truyn cho
n khi ngi bnh hi phc hon ton v c kh nng t n, ung c.
4. H glucose mu khng c cnh bo hay h glucose mu khng triu chng
Theo nghin cu DDCT (Diabetes Cotrol and Complication Trial) th 1/3 cc
trng hp h glucose mu nng xy ra khi ngi bnh thc. c bit h glucose mu
th ny thng xy ra nhng ngi bnh c iu tr tch cc, nhng khng km
theo cc du hiu hoc triu chng ngi bnh c th nhn bit ngn nga cc triu
chng v thn kinh ca thiu glucose ti m.
phng chng, cch tt nht l gio dc cho ngi bnh cch t theo di
glucose mu, t iu chnh li ch luyn tp, ch n ung.
Ngc li vi h glucose mu trung bnh v nng c th gy nguy him n tnh
mng, trong h glucose mu khng triu chng, lng glucose mu tng nh c duy
tr mc an ton. Nhng cn h glucose mu kiu ny xy ra vi thi gian di hoc
ngn nhng lin tc s rt nguy him v n c kh nng gy hu hoi h thng thn kinh
trung ng. c bit nguy him nu nhng cn ny xy ra ngi tr. Mt s ngi
bnh pht trin n cm gic s hi do h glucose mu hoc nhng nhn thc sai lch
khc. Cm gic s hi do h glucose mu dn n n qu nhiu, lm cho mt tc dng
iu tr ca insulin. Nu hin tng xy ra, cn phi hp liu php iu tr lm n
nh tinh thn cho ngi bnh. Trong thi gian ny cn duy tr lng glucose mu
gii hn t 11,1 16,7 mmol/l.
205

5. Lu hiu ng Somogyi (tng glucose huyt phn ng sau cn h glucose mu)

Nguyn l ca hiu ng ny l khi lng glucose mu h thp s kch thch h
thng hormon i khng tc dng ca insulin, bi tit cc hormon c tc dng lm tng
glucose huyt (Glucagon, Adrenalin, Cortisol, hormon tng trng). Qu trnh phng
thch glucose t glycogen d tr gan c kch thch, do vy lm tng lng glucose
trong mu. iu ng lu l chnh cc hormon ny c th l nguyn nhn khng
insulin t 12 n 48 gi. Cng cn mt nguyn nhn na lm tng glucose mu l do
lng ng a vo cp cu qu nhiu so vi yu cu ca c th.
Hiu ng Somogyi c th xy ra sau mt cn h glucose mu ban u, nhng
cng c khi xy ra bt c lc no sau khi c cn h glucose mu. Hiu ng Somogyi rt
hay gp trong qu trnh iu tr, nht l khi ngi bnh s dng thuc h glucose mu
khng hp l.
phng trnh hiu ng Somogyi v m, c th gim liu insulin bui ti hoc
n ba ph trc khi i ng.
Hiu ng Somogyi c th a n chn on lm l tng glucose mu do cha
liu insulin, chn on hiu ng ny cn o insulin trong vi gi lin tip, nu
glucose huyt thay i nhanh t thp n cao, th d glucose mu o ln u l 40 mg/dl,
2-3 gi sau glucose mu tng n 400 mg/dl th l hiu ng Somogyi hay tng
glucose mu do phn ng.
IV. PHNG V CHNG H GLUCOSE MU
phng chng cn h glucose mu c hiu qu, vic cn lm l tm hiu nhng
nguyn nhn c th gy ra h glucose mu.
1. Cc nguyn nhn hay gp ca h glucose mu
1.1. Nhng nguyn nhn c lin quan n s dng insulin
Do qu liu.
Thi gian tim khng ph hp vi ba n hoc loi insulin dng khng ph hp.
Liu php iu tr tng cng bng insulin.
Tht thng hp thu ca insulin ti ni tim.
Hp thu nhanh hn nu tim vng hay vn ng.
V tr tim c vn : teo lp m di da hoc lon dng vng tim...
S dng nhiu insulin tinh khit hoc i t dng tng hp sang cc dng
insulin trn hoc insulin ngi lm thay i tc hp thu.
1.2. Ch dinh dng
n t. Ba n khng lng carbohydrate so vi liu insulin.
Thi gian gia cc ba n cha ph hp.
1.3. Luyn tp
Khng c k hoch, hoc mc v thi gian luyn tp khng ph hp.
1.4. Ung ru v s dng phi hp vi mt s thuc
Kh nng tn to ng ti gan b suy gim khi ung ru.
206

Cc nguyn nhn gy h glucose mu hay gp nht l nhng sai st trong ch nh

liu lng insulin, lch trnh cc mi tim, s phn b cc ba n khng ph hp, y l
nhng nguyn nhn chnh gy ra h glucose mu.
1.5. Cc nguyn nhn khc
Ngi ta cng ghi nhn nhng l do tng nh him gp khc; v d:
Ng mun hn l thng cng l mi nguy him tim tng cho ngi bnh, v
n lm v th cn bng gia thi gian tim insulin v vic thu nhn thc n ca c th.
Nhiu trng hp h glucose mu nng, thm ch t vong, xy ra sau cc ba
tic do ngi bnh ung nhiu ru, hoc sau khi c tng hot ng t ngt m khng
gim liu thuc hoc khng c ch b p cho s nng lng b tiu hao.
2. Cc yu t lin quan n phng cn h glucose mu
Mt ch iu tr ph hp bao gm ch n, ch ngh ngi, ch tim
thuc, ch luyn tp ph hp, l bin php phng chng hu hiu nht.
2.1. Gic ng
m bo an ton, ngi ta thng tim insulin bn chm vo bui ti. Vi liu
d tnh thng thng ngi bnh c th ng thm 30-60 pht. Nhng nu ngi bnh
ng thm trn 1 gi phi b sung nng lng hoc i liu insulin. V d nu ngi
bnh nh ng thm trn 60 pht, c th gim 10-15% liu insulin bn chm hoc chm
ca mi tim ti hm trc. Cng c th ngi bnh vn s dng thuc ng liu lng,
nhng c nh thc dy ng gi, lm test kim tra glucose mu, n sng, tim mi
insulin bui sng ri li ng tip.
2.2. Ch luyn tp
Luyn tp lm tng s hp thu, tng nhy cm ca insulin m ch. iu quan
trng trnh h glucose mu khi luyn tp l ngi bnh phi c ngun carbohydrate
b sung kp thi, nhanh chng. Trng hp ang luyn tp m c du hiu h glucose
mu phi ngng tp ngay. Nu h glucose mu xy ra sau khi tp, phi c ba n ph
trc khi tp. trnh h glucose mu khi luyn tp ngi ta cn khuyn nn gim liu
insulin. y l bin php d phng khng tng nng lng, thng p dng cho nhng
i tng khng mun tng cn.
3. Gio dc, hng dn ngi bnh t theo di, iu chnh ch iu tr
ngi bnh hiu v t theo di bnh lun l mc ch quan trng nht ca
cng tc gio dc sc kho cng ng. Vic t theo di glucose mu phi c gio dc
cho tt c ngi bnh i tho ng, k c ngi cha c iu kin s dng my theo
di ng huyt.
TI LIU THAM KHO
1. Philip E Cryer, MD, Irene E. and Michael M. Karl (2004). Hypoglycemia
During Therapy of Diabetes; Therapy for Diabetes Mellitus and related Disorders.
2. Philip E. Cryer: Glucose Homeostasis and Hypoglycemia; Williams Textbook of
Endocrinology-Edition 11th (2008) ; p 1503-1533.
207

BNH TIM MCH V I THO NG

Bnh tim mch bao gm bnh mch vnh (BMV), t khng triu chng n au
tht ngc, nhi mu c tim, t t do BMV, suy tim, bnh van tim, bnh mch mu no.
Bnh tim mch l nguyn nhn chnh ca t vong trn ton th gii.
Bnh mch vnh, t qu, bnh mch mu ngoi vi (thuc nhm bin chng mch
mu ln ca bnh i tho ng) l ba nguyn nhn gy 80% trng hp t vong
ngi i tho ng (T). Ngi bnh i tho ng tng nguy c b bnh c tim
thiu mu, bnh c tim khng do thiu mu v t t.
Qun l bnh tim mch ngi bnh T cn mt i ng bao gm bc s
chuyn khoa ni tit chuyn ha, bc s tim mch v bc s ni khoa, cc chuyn vin v
dinh dng, luyn tp th lc, iu dng.
Vai tr ca cc bc s tuyn c s l nhn bit cc yu t nguy c tim mch, iu
tr tch cc cc yu t nguy c ny, nhn bit cc trng hp cp cu (th d hi chng
mch vnh cp) s cu v chuyn vin kp thi.

BNH MCH VNH

I. I CNG
Ngi bnh T c t l mc BMV gp 2-4 ln ngi khng b T.
T l tn thng mch vnh c pht hin khi lm chp hnh in ton nhiu lt
ct (MSCT) ngi c nguy c BMV nhng khng c triu chng cao hn r rt
ngi T so vi ngi khng c T, 91% so vi 68%.
T c xem l tng ng vi yu t nguy c ca BMV. Ngi bnh T
khng b nhi mu c tim c nguy c b bin c tim mch chnh tng ng (# 20%)
vi ngi khng T b nhi mu c tim, sau 7 nm theo di.
Bnh mch vnh trn ngi T thng xy ra tui tr hn so vi ngi
khng T.
Biu hin bnh l ca bnh mch vnh rt a dng: t khng triu chng n cn
au tht ngc n nh, cn au tht ngc khng n nh, nhi mu c tim cp, bnh c
tim thiu mu mn tnh, suy tim sung huyt, ngng tim t ngt.
II. TRIU CHNG
Kh chu vng ngc, t bng n cm khi gng sc, kh th, yu mt, gim kh
nng i b hoc luyn tp, chng mt, hi hp, ng ngy, ri lon gic ng, ph chn,
208

tng cn. Triu chng au tht ngc c th thay i ty theo tui, gii, trnh hc vn,
chng tc, thi gian b bnh T. Ngi bnh T thng khng c triu chng au
tht ngc.
Khm thc th: Tm cc du hiu thng i km vi x va ng mch v bnh
T. Vng cung lo ha gic mc, vim rng li, du hiu x cng ng mch, tng
khong cch gia huyt tm thu - tm trng (>50mmHg), m thi ng mch cnh
hay m thi hp ng mch ch, ting nga phi tim, gim phn x gn gi, gim bin
mch mu chn, chai chn, lot chn.
Lm test kim sot chc nng nhn thc.
Gim cng nam gii tr i tho ng lin quan vi tng nguy c bnh
mch vnh.
III. CC YU T GIP CHN ON
Ch cc bnh l c nguy c cao b bin c mch vnh: tin s b bnh mch
vnh, suy tim, t qu.
Tin s gia nh c BMV sm (<55 tui nam, <65 tui n), nu c cha m v
anh ch em u b bnh, nguy c s tng rt cao.
o huyt p, nm v ngi hoc ng.
nh gi nguy c mch vnh:
Cc yu t nguy c ca bnh mch vnh c ghi nhn ngi bnh i tho
ng bao gm: tnh trng khng insulin, tng glucose huyt, tiu albumin, tng
huyt p, ri lon chuyn ha lipid, ht thuc l v bo ph.
i vi ngi bnh i tho ng c th dng thang im nh gi theo UKPDS
(http:// dtu.ox.ac.uk/riskengine/index.php) www hay ca Hip hi o tho ng M
(http://www.diabetes.org/living-with-diabetes/complications/diabetes-phd/
IV. CN LM SNG
o b m gm cholesterol ton phn, triglycerid, HDL v LDL cholesterol, t
s cholesterol ton phn/HDL. Nu t s ny >3/1 th c lin quan vi din tin ca tng
b by lp o trong ng mch cnh.
o CRP siu nhy cng c li ngi bnh c nguy c trung bnh.
in tim: ch cc du dy nh tht tri, bloc nhnh tri, khong cch QT hiu
chnh ko di, rung nh, ngoi thu tm nh/tm tht, nhp tim khng thay i theo nhp th.
Cc nghim php gng sc: thm ln, nghim php gng sc dng thuc v
hnh nh hc khi c ch nh (cn c kin ca chuyn khoa tim mch).
X quang: vi ha cung ng mch ch thng lin h vi thi gian b bnh
T v c th lin h n bnh nhiu nhnh ca mch vnh.
Siu m Doppler mch mu: khi nghi ng c hp ng mch ngoi vi.
Siu m tim nh g dy tht tri v o chc nng tht tri, phn sut tng
mu tht tri, siu m ng mch cnh tm b dy lp o trong.
209

 CT mch vnh xem tnh trng calci ha ng mch vnh, calci ha ng mch
vnh c th tin on phn no tc hp.
V. IU TR PHNG NGA BNH MCH VNH NGI BNH T
t cc mc tiu iu tr tt nht: HbA1c <7%, huyt p <140/80 mmHg, LDL <
100 mg/dL (2,6mmol/L) nu ngi bnh khng c bin c tim mch v < 70 mg/dL
(1,8mmol/L) nu ngi bnh c bin c tim mch.
1. iu tr T
Hin nay metformin v acarbose c chng minh c li cho tim mch trong
nghin cu.
Tuy nhin cc nghin cu gn y cho thy gim glucose huyt c gip phng
nga bnh tim mch, nht l khi iu tr ton din cng vi ch n, luyn tp, iu tr
tng huyt p v ri lon chuyn ha lipid.
2. iu tr tng huyt p
c ch men chuyn v c ch th th l thuc c la chn hng u. Tip theo
l li tiu, chn knh calci. Hin nay c khuynh hng phi hp nhiu thuc vi liu
thp gim tc dng ph m vn t mc tiu iu tr.
Thuc li tiu vi liu tng ng Chlorthalidon 12,5mg nh hng ln glucose
huyt khng ng k.
3. iu tr ri lon chuyn ha lipid (tham kho phn ri lon chuyn ha lipid)
C th kim sot tt lipid bng statin tc dng ko di th d rosuvastatin 5-10mg
hoc atorvastatin 10-20 mg mi ngy. Liu cao statin (atorvastatin 40-80mg/ngy) c
th c dng sau khi ngi bnh c hi chng mch vnh cp.
4. S dng aspirin
Aspirin khng c ch nh trong phng nga tin pht ngi bnh T theo
khuyn co ca Hip hi T M. Aspirin c ch nh khi ngi bnh c tin s
bnh mch vnh, v trn ngi T c nguy c b bnh mch vnh trong vng 10 nm
>10% v khng c nguy c xut huyt. ngi bnh khng dung np aspirin c th
thay th bng clopidogrel.
5. Dinh dng v luyn tp
5.1. Dinh dng iu tr
i vi a s ngi bnh, dinh dng ph hp nht bao gm cc thc n m
ngi bnh dng hng ngy. Khng ch tng s nng lng l vn quan trng hng
u, sau s chn la thc n ty theo khu v ca ngi bnh. Nguyn tc tnh ton
cc thnh phn thc n tht cht ch kim sot glucose huyt khng c chng
minh r rng qua cc nghin cu. Cng cn hn ch m v ng n.
Ngi bnh cn gim cn nu tha cn, bo ph. Hin nay c nhiu nghin cu v
cc khu phn gim cn, trong mt s ngi thnh cng trong thi gian ngn vi
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khu phn c thnh phn m cao v carbohydrat thp. Do iu quan trng l gim
cn v bc s cng ngi bnh s theo di hiu qu ca khu phn gim cn iu
chnh kp thi.
Ngoi ra cng cn quan tm n tnh hnh ti chnh v nn tng vn ha ca ngi
bnh. Th d, ngi bnh n chay trng khng dng tht c th thiu st, acid folic,
sinh t B12. Nu n nhiu carbohydrat nht l ng t tri cy c th tng triglycerid.
Ngi nhn n trong thi k Ramadan ca o Hi rt d b cc bin chng cp
ca T. Do ngi bnh nhn n t lc mt tri mc n lc mt tri ln nn cn theo
di glucose huyt, liu, thi gian dng thuc, v cn s gip ca nhn vin y t.
Gim cn: Gim cn 5-10% c th ci thin cc yu t nguy c tim mch nh
gim HbA1c, huyt p, triglycerid, v tng HDL. Hiu qu s ln hn nu gim c
10-15% cn nng. Cng c nghin cu chng minh gim 7% cn nng c th c li cho
ngi bnh gan nhim m.
Khu phn i Trung Hi (thnh phn cht bo cao, carbohydrat <50%) c th c
li trong vic gim cn v gim mt s yu t nguy c tim mch ngi bnh T typ
2 mi chn on.
Khu phn tng m khng tt hn khu phn carbohydrat cao trong iu tr T
tp 2. ngi c ri lon glucose huyt lc i v ri lon dung np glucose vi nguy
c tim mch cao, khng c bng chng l acid bo n-3 lm gim bin c tim mch k c
t vong do bnh tim mch.
5.2. Luyn tp
Tt c ngi bnh T typ 2 u c li khi luyn tp hoc gia tng vn ng.
Cc hot ng tiu th oxy lm tng tnh nhy cm vi insulin v c th gip ci thin
glucose huyt rt tt.
Mt chng trnh luyn tp c cu trc ph hp khong 30 pht mi ngy,
cc ngy trong tun, s gip gim HbA1c r rt vi iu kin phi kt hp vi n ung
ng cch.
Ngi bnh nn chn loi hnh ph hp vi sc chu ng v sc khe ca mnh.
i b l loi hnh ph hp vi a s v d p dng v khng tn km. Ngi bnh th
ng cha bao gi tp luyn cn bt u t t. Ngi bnh gi, b bnh lu, c nhiu
bnh i km, c nhiu yu t nguy c, c triu chng x va ng mch cn c
kim tra tim mch k trc khi luyn tp theo chng trnh, c th cn phi lm nghim
php gng sc.
Nu ngi bnh theo mt chng trnh luyn tp c chuyn vin hun luyn v theo
di th thng kt qu s tt hn, nhng iu ny t khi thc hin c ti Vit Nam.
5.3. Phu thut d dy
ngi bnh T typ 2 bo ph vi cc bin chng nguy him n tnh mng
(ti cc nc phng Ty thng BMI 40/kg/m2, hoc BMI thp hn nhng c km
cc yu t nguy him n tnh mng ca bo ph), c th phu thut d dy.
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Tuy nhin can thip ny cn mt i ng chuyn khoa sa son tin phu, bc s

phu thut, bc s ni tit chuyn ha, bc s tim mch, chuyn gia dinh dng c th
duy tr hiu qu lu di.

TNG HUYT P NGI BNH I THO NG

I. I CNG
Khong 20 - 60% bnh nhn T c tng huyt p (THA). Ti Vit Nam, theo
mt s nghin cu ti tng vng, t l tng huyt p ngi bnh T thay i t 5070%.
ngi bnh T typ 1, THA thng xut hin sau khi ngi bnh b bnh
thn T, tuy nhin ngi bnh vn c th c mt bnh khc i km, th d u ty
thng thn
Ngi bnh T typ 2 c th c THA ngay t lc mi chn on (THA v T
cng hin din khi ngi bnh c hi chng chuyn ha) hoc THA khi c bin chng
thn, hoc khi c mt bnh i km.
Ngoi ra THA cng c th c chn on trc T typ 2.
II. TRIU CHNG
Ngi bnh c th khng c triu chng, hoc c khi cm thy nhc u, au
ngc, kh th.
Khm thc th c th nghe c m thi ng mch cnh, thy du hiu dy
tht tri. Cn bt mch ngoi vi v so snh hai bn, khm y mt tm du hiu co
tht tiu ng mch, mch lu, xut tit, xut huyt Siu m tim tm du hiu dy tht
tri, ri lon chc nng tm thu, tm trng.
Cc du hiu gi THA th pht:
Mch i yu so vi mch chi trn (huyt p chi di thp hn huyt p chi
trn) gi hp eo ng mch ch;
m thi tm thu bng gi hp ng mch thn;
Khi gim kali huyt khng tng xng vi liu thuc li tiu cn loi tr
cng aldosteron;
Cn tng huyt p km chng mt, m hi gi u ty thng thn;
Rm lng, mt trn, da mt ng , du rn nt da gi hi chng Cushing;
Mch nhanh ko di, gim cn nhanh, THA ch yu tm thu gi cng gip;
Ng ngy, hay bun ng ban ngy gi tnh trng ngng th khi ng.

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III. CHN ON
THA ngi bnh T c chn on khi huyt p (HA) tm thu 130 mmHg
v/ hoc huyt p tm trng 80mmHg sau hai ln o hai ngy khc nhau, ngi
bnh t th ngi.
Cc xt nghim c bn cn lm ngi bnh THA: cng thc mu, cc cht in
gii, b m, phn tch nc tiu ch trng tm albumin hoc m.
Cc xt nghim khc s ch nh khi nghi ng c mt nguyn nhn khc gy THA
(ch nh cn kin ca bc s chuyn khoa ni tit chuyn ha hoc tim mch).
nh gi loi tr tng huyt p th pht trong cc trng hp sau y: huyt p
khng kim sot c nu phi hp t ba loi thuc tr ln (tuy nhin cn hi k
xem ngi bnh ung thuc trong n hay khng?), huyt p t ngt tng cao,
huyt p cao nhiu d iu tr (>180/110 mmHg), cc c quan ch b tn thng
trm trng, ngi bnh <20 tui hoc >50 tui, khng c tin cn gia nh b THA,
khm lm sng hoc xt nghim nghi ng c nguyn nhn th pht.
Cc nguyn nhn THA th pht c th l: hp ng mch thn, bnh l ch m
thn, hp eo ng mch ch, cng aldosteron, u ty thng thn, hi chng Cushing,
cng gip (THA ch yu tm thu), ngng th khi ng, n qu nhiu mui, ung
estrogens.
IV. IU TR
Mc tiu huyt p: tm thu < 140mmHg v huyt p tm trng < 80mmHg nu
cha c bin chng thn v huyt p < 130/80mmHg nu c bin chng thn.
Tham kho thm phn Bnh thn T.
iu tr gm cc phng tin khng dng thuc v thuc.
Khi huyt p tm thu trong khong 130-139 mmHg v hyt p tm trng trong
khong 80-89 mmHg, c th khng dng thuc trong vng ti a 3 thng, ch dn ch
dinh dng v luyn tp ph hp vi ngi bnh, nu sau huyt p cn cao s
dng thuc.
1. Dinh dng
Hn ch Natri khong 2 gam/ngy.
Dinh dng DASH (dietary to stop hypertension) thng c khuyn co: n
nhiu tri cy, rau, sa gim bo, t lipid v t acid bo bo ha, ung ru va phi (2
sut vi nam v 1 sut vi n mi ngy).
1 sut c 14 gam ru (1 lon bia # 330 ml c 4-5 cn cha khong 14 gam
ru, ru vang c 12 cn, 120 ml cha 1 sut # 14 gam ru). Cn lu cn
trong bia v ru thay i ty hng sn xut, nn tham kho bao b.
Ngoi ra cng cn lu , nu ung qu nhiu nc tri cy s tng triglycerid mu.
2. Luyn tp
Luyn tp u n t nht 30 pht mi ngy, hu ht cc ngy trong tun.
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3. Thuc
Thuc c chn la u tin iu tr l nhm c ch h renin angiotensin
(gm c ch men chuyn, c ch th th angiotensin II), la chn tip theo l li tiu,
chn knh calci.
Dng thuc li tiu nhm thiazid khi lc cu thn c tnh (LCT c tnh)
30mL/pht/1,73m2 v li tiu quai khi LCT c tnh < 30mL/pht/1,73m2.
Ngi bnh T c THA thng cn n 2-3 loi thuc h p t mc tiu
iu tr huyt p < 130 mmHg.
Thuc chn beta c s dng khi ngi bnh c bnh c tim thiu mu.
Hin nay c vin phi hp c nh c ch men chuyn (hoc c ch th th)
vi liu thp li tiu, hoc c ch men chuyn (hoc c ch th th) vi chn knh calci.
V. THEO DI IU TR
o huyt p ngi bnh nm v ngi mi khi ngi bnh n khm bnh.
Nn theo di huyt p lin tc ti nh.
Khi dng thuc c ch h renin v li tiu cn theo di LCT v kali huyt nht
l khi bt u dng thuc hoc tng liu.
Nu dng thuc li tiu ko di, cn ch trng kim tra kali, nht l ngi bnh
ln tui.

SUY TIM
I. I CNG
nh ngha suy tim: Khi tim hot ng trong tnh trng p lc y mu bnh
thng nhng khng th bm mu p ng nhu cu ca c th, a n cc p
ng khng thch hp nh sung huyt, kh th v mt, tng nguy c t t.
Suy tim sung huyt l t c s dng khi triu chng sung huyt ni bt. Tuy
nhin nhiu ngi bnh suy tim khng c triu chng ny d BNP/ ProBNP gia tng.
Suy tim tm thu: khi phn sut tng mu <45%.
Suy tim tm trng: c triu chng suy tim khi phn sut tng mu 45%.
T lm tng nguy c suy tim t 3-5 ln, n nhiu hn nam.
Tng huyt p, bnh mch vnh thng kt hp vi T v/hoc hi chng
chuyn ha l nguyn nhn hng u ca suy tim cc nc pht trin. cc nc
ang pht trin, nguyn nhn thng gp l bnh van tim hu thp, nhim HIV, bnh k
sinh trng, suy dinh dng thiu sinh t B1.
Ht thuc l cng lin h mnh vi suy tim.
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II. TRIU CHNG

Thng gp triu chng kh th, kh th khi gng sc, kh th phi ngi, kh th
kch pht v m, mt yu, ph vng thp, tng cn, trng bng, tiu m, tay chn
lnh. Cc triu chng t gp hn l thay i nhn thc, sng ln, bun i, y bng, tiu
t, chn n, tm ti. Ho v m thng xut hin trc tnh trng mt b t 1-2 tun.
Suy tim sung huyt c th km thm tnh mch c ni, gan to, ph chi di.
Bnh nhn suy tim cn b thng khng b ph nu cung lng tim lc ngh cn
bo tn, nu cung lng tim lc ngh thp, ngi bnh s lnh tay chn.
Ngi bnh gi b suy tim mt b cp thng hay sng ln, sau khi iu tr qua
cn cp tnh, chc nng nhn thc cng thng gim. Ngi bnh gi suy tim c th
mt b cp tnh khi b vim phi, nhim trng huyt, nhi mu c tim, lon nhp tim th
d cn rung nh. Hp van ng mch ch cng c th l nguyn nhn gy suy tim
ngi gi c T v bnh c tim thiu mu.
Lu cc du chng lm sng gi nguyn nhn ca suy tim.
III. CN LM SNG
in tim: tm du dy tht tri, lon nhp tim, bnh c tim thiu mu.
X quang phi: tm du hiu tim ln, o t s tim/lng ngc >0,5, du hiu sung
huyt phi.
Xt nghim BNP, ProBNP c gi tr tin on m cao. Nu kt qu m tnh s loi
tr chn on suy tim. im ct chn on thay i theo tui v chc nng thn.
Khi nng tng cao vn cn kt hp vi lm sng chn on xc nh.
Cn o BNP v ProBNP khi chn on khng chc chn th d loi tr bnh
phi mn tnh giai on nng, o nhiu ln c th gip nh gi d hu.
BNP v ProBNP khng gip phn bit suy tim tm trng v tm thu.
Troponin I c th tng cao trong suy tim mt b cp, d ngi bnh khng c
bnh mch vnh. Nguyn nhn ca tng Troponin I trong trng hp ny l do thiu
mu di ni mc khi p lc cui tm trng tht tri tng cao.
Nu nghi suy tim do bnh mch vnh c th cn thng tim.
IV. IU TR
iu tr cn kin ca bc s chuyn khoa tim mch.
iu tr cc triu chng sung huyt, sau iu tr cc nguyn nhn lm suy tim
trm trng thm.
1. Suy tim mt b cp tnh
Cn nhp vin, y l trng hp khn. Thng iu tr vi li tiu, oxy, ngi
bnh t th ngi, morphine tim tnh mch nu ngi bnh kch ng do kh th.

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2. Suy tim mn tnh

Ngoi cc thuc do bc s ch nh, ch hn ch mui trong khu phn (khong
2 gam Natri/ngy).
Hn ch nc khong 1500 ml/ngy khi c triu chng h natri huyt.
(Na<135mEq/L), y l mt trong cc triu chng ca ngi bnh suy tim nng. Nhiu
ngi bnh gi c mui v nc v kh iu tr tnh trng h natri huyt bng nhn nc.
3. Suy tim tm thu
Dng li tiu, c ch men chuyn hoc c ch th th, chn beta, thuc khng
aldosteron, digitalis; nu ngi bnh c bnh c tim thiu mu, dng statin. Kim sot
nhp tim v huyt p.
4. Suy tim tm trng
Thng gp ngi bnh bo ph, T, ri lon gic ng. Dng li tiu iu
tr sung huyt, kim sot nhp tim, huyt p, lipid, tng glucose huyt.
5. S dng thuc h glucose
Insulin nu dng liu cao c th gi mui v lm tng th tch dch, nn bt u
bng liu thp v theo di cn thn trn lm sng, ngi bnh cn hn ch mui.
Metformin: hin nay c quan thuc v dc phm M (FDA) khng cn cnh bo
trong thng tin k n ca metformin v suy tim, tuy nhin cn ch n chc nng thn.
Khng dng thiazolidinedion khi ngi bnh suy tim hoc c tin s suy tim.

T QU
I. I CNG
t qu xy ra khi gim ti mu no vi thi gian lu lm cht t bo v
gy ra triu chng thn kinh cc b.
t qu xut huyt: mu chy t mch mu v m no.
t qu thiu mu: do tc nghn mch mu. C nhiu loi: tc nghn mch mu
ln, thuyn tc mch t tim, tc mch mu nh.
Cc nguyn nhn khc ca t qu: tng ng, bc tch ng mch, bnh hng
cu hnh lim.
T lm tng nguy c t qu ln khong 2-5 ln.
T c nhiu yu t nguy c lm tng t qu: T tng kh nng b x va
ng mch v cc bnh l mch mu nh, T cng thng kt hp vi cc tnh trng
tng ng v/hoc tng nguy c bnh tim mch th d bo ph, THA, ri lon chuyn
ha lipid.

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Kiu t qu thng kt hp vi T l dng l khuyt do tc mch mu nh, tuy

nhin cng c th gp thuyn tc do cc mu ng t tim (gp trong bnh van tim, rung
nh), tnh trng tng ng v cc dng khc.
t qu do xut huyt t gp ngi T hn ngi khng T.
Khong 1/3 ngi t qu nhp vin c glucose huyt tng cao. Glucose huyt
tng cao lin h vi d hu xu.
II. TRIU CHNG
Thay i ty theo vng no b tn thng, tuy nhin cc triu chng thng xut
hin t ngt trong t qu.
Cc triu chng thng gp: T hoc yu c mt, tay v/ hoc chn; ni kh, khng
hiu c ngn ng ca ngi tip xc; chng mt, mt thng bng, tht iu vn ng; ri
lon th gic, nhn i, m mt, mt th gic mt bn, gii hn th trng mt.
t qu xut huyt thng i km vi nhc u, bun i, i ma.
Cc triu chng do t qu c c th tr nn r rt hn khi ngi bnh T c
mt bnh l cp tnh nh tng, h glucose huyt, nhim trng.
ngi bnh T c x va ng mch, cn h glucose huyt c th gy ra
triu chng thn kinh nh v.
III. CHN ON
Cn kin ca bc s chuyn khoa thn kinh, nht l khi ch nh cc xt nghim
hnh nh hc.
Hnh nh cng hng t no (MRI no) c nhy v chuyn bit tt hn
chp hnh ct lp in ton (CT).
Chp hnh mch mu no tm ch tc mch mu.
Chp hnh ti mu no vi MRI, CT xem vng no nguy c c th cu vn c.
Siu m ng mch cnh, siu m tim tm cc mu ng, mng x va v bnh
nn tng.
Cc xt nghim mu: nh gi tnh trng bnh ca ngi bnh v cc bnh c
th gy t qu, tm cc yu t thun li ca t qu: glucose huyt, in gii, m tiu
cu, yu t ng mu, b lipid, troponin.
in tim: tm du hiu ca bnh c tim thiu mu, rung nh.
IV. IU TR
Thuc chuyn khoa thn kinh.
Cc nguyn tc ca iu tr bao gm:
Cn bit chnh xc thi gian bt u ca triu chng t qu quyt nh s
dng tPA (tissue plasminogen activator) lm gim tc hi ca t qu thiu mu.

217

 Can thip loi b cc mu ng trong trng hp thuyn tc mch mu.

Dng thuc khng ng trong thi gian nm vin: khi ngi bnh c cc mu
ng nh tim, t van tim nhn to. a s cc trng hp t qu thiu mu khng
cn khng ng trong lc nm vin.
C th bt u aspirin 24-48 gi sau khi t qu, aspirin gip gim t qu ti pht.
Nu ngi bnh khng dung np aspirin, c th dng clopidogrel.
iu tr huyt p:
Trong giai on t qu thiu mu cp, ch can thip gim huyt p nu huyt p
tm thu >220 mmHg, hoc huyt p tm trng >120 mmHg, vi mc tiu gim huyt
p 15-25% trong ngy u tin. Cng cn lu chng ch nh dng tPA khi huyt p
tm thu> 185mmHg v huyt p tm trng >110mmHg.
Glucose huyt cn c gi trong gii hn bnh thng trong cn t qu cp.
Tng glucose huyt s lm tng nhu cu chuyn ha no v do c th lm xu i
tnh trng ph no. Kim sot glucose huyt c bit quan trng trong giai on cp sau
t qu.
Nu c nhu cu chp hnh vi thuc cn quang, khng nn dng metformin.
V. THEO DI
Vt l tr liu ti s dng vng c th b tn thng, gio dc sc khe cho
ngi bnh nhn bit cc triu chng ca t qu ti pht.
Hi bnh s k tm cc bin chng ca t qu nh ng kinh, hi chng au,
co cng c, trm cm.
Lm xt nghim, nh gi cc yu t nguy c. Kim sot ti u glucose huyt,
lipid huyt.
Dng aspirin, hoc clopidogrel. Nu ngi bnh b thuyn tc do cc mu ng
nn dng warfarin.
Tip tc duy tr ch n ung ngi c nguy c tim mch.
VI. PHNG NGA T QU
Thay i cch sng: gim cn, hn ch mui, khu phn gim m nu c tng
cholesterol, luyn tp th lc u n ph hp vi tnh trng bnh l ca ngi bnh,
ngng ht thuc.
Kim sot cht ch glucose huyt, HbA1c <7%; nu ngi bnh yu, khng th t
chm sc bn thn, c nhiu bnh l i km c th chp nhn mc glucose huyt cao hn.
Huyt p mc tiu <140-130/80 mmHg, kim sot tt huyt p gim c khong
30-40% nguy c t qu.
Lipid huyt: mc tiu LDL <70 mg/dL (1,8mmol/L). Trong nghin cu Heart
protection study, dng statin gim c 28% nguy c t qu ngi bnh T, c
lp vi mc LDL nn, bnh mch mu sn c, loi T (typ 1 hoc 2), thi gian b
bnh T v s kim sot glucose huyt.
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BNH MCH MU NGOI VI

I. I CNG
Bnh mch mu ngoi vi bao gm bnh ca ng mch v tnh mch nm ngoi
cc mch mu tim v no. Trong phn ny tp trung ni n bnh ng mch ngoi vi.
Ngi bnh T c nguy c cao b tc hp ng mch chi di, gp 15 ln ngi
khng b T.
Bn chn T thng do phi hp ca bnh l mch mu v bnh l thn kinh.
Tc ng mch ngoi vi thng gp ngi ln tui, nu xy ra ngi <50 tui
thng l ngi T vi cc yu t nguy c khc ca x va ng mch nh ht
thuc l, ri lon chuyn ha lipid, tng huyt p.
II. TRIU CHNG
Triu chng thay i t giai on nh n nng. Ngi bnh c th khng c triu
chng hoc c triu chng i cch hi, au khi ngh, lot, hoi t ngn chn.
au cch hi: triu chng au xut hin sau khi ngi bnh i b mt khong
cch, gim khi ngh. Triu chng au s xut hin tr li sau khi i b mt khong cch
tng t. Khi bnh tr nng, khong cch i c trc khi b au s ngn dn.
Bnh ti ng mch ch v ng mch hng s gy au bng, bnh ti vng
ng mch i v nhng chn s gy au bp chn khi i b. Triu chng khng
xut hin khi ngi hoc ng.
Hi chng Leriche bao gm i cch hi, gim cng, mch i gim hoc mt.
Hi chng ny do hp phn xa ca ng mch ch.
au khi ngh do thiu mu thng ngn chi do kt hp bnh mch mu ngoi
vi v gim ti mu. Bnh thng nng thm khi gim cung lng tim. Triu chng c
th gim mt phn hay hon ton khi ngi bnh bung thng chn, ti mu s tt hn
do nh hng trng lc.
Lot do thiu mu ng mch c cng au rt mnh, lot do nguyn nhn
thn kinh khng au v thng vt lot nm mt lng bn chn, ch chu p lc, lot
do tnh mch ch gy au nh.
Cn phn bit vi cc bnh l c th gy au vng chn: chn p c hc r thn
kinh, thoi khp, vim khp, ti phnh ng mch, nang Barker nhng chn, hi
chng chn p khoang.
Triu chng ngoi vi bao gm: mt mch, yu lit, d cm, au, tm ti.
nh gi bn nh lng mc ti ca da chn c th gip cho chn on.
nh gi mc ti ca da chi di khi ngi bnh nm. Nu da ti khi chn dui trn

219

mt phng, nh gi l 4. Nu da chn bnh thng khi dui thng, nng chn ln cao
60 , nu da ti xut hin trong vng 30 giy, nh gi l 3, nu di 60 giy, l
2, da ti lc 60 giy l 1, nu da chi khng ti sau khi nng cao 60 trong vng 60
giy l 0.
III. CHN ON
o ch s c chn cnh tay (ankle brachial index-ABI) bng siu m Doppler
mch mu hoc o huyt p:
ABI < 0,9: pht hin bnh ng mch ngoi vi vi nhy 95%, v chuyn c
th ln n 100%.
ABI < 0,5: t l sng st sau 5 nm rt thp.
ABI c th bnh thng khi ngh do h thng mch bng h pht trin. Do c
th o sau khi vn ng.
ABI > 1,0 c th gp ngi bnh T do thnh ng mch b calci ha v
khng p c.
Nu d nh can thip, cn nh gi mc v v tr hp.
Siu m duplex: xc nh v tr v mc hp.
Chp hnh ng mch vi thuc cn quang: khi d nh can thip ti ti mu.
Cn quan tm chc nng thn.
in tim tm du hiu dy dn cc bung tim, lon nhp tim, nhi mu c tim.
Cc xt nghim nh gi bnh l nn v yu t nguy c: glucose huyt, lipid
huyt cng thc mu, tnh trng ng mu, BUN creatinin.
cc trung tm chuyn su, c th o cc ch du ca hin tng vim. Gia tng
nng D Dimer, CRP siu nhy, interleukin 6, homocystein thng lin h vi gim
kh nng vn ng chi di.
IV. IU TR
Nu ngi bnh c triu chng au khi ngh, lot hoi t, cn hi chn vi chuyn
khoa phu thut mch mu.
Thay i cch sng: ngng ht thuc, luyn tp 3 ln/tun, mi ln 30-45 pht
trong t nht 12 tun c th gip gim triu chng.
Chm sc v sinh bn chn, i giy ph hp.
Kim sot huyt p, huyt p mc tiu <140-130/80 mmHg.
Kim sot lipid, mc tiu LDL<70mg/dL (1,8mmol/L). Statin c tc dng ci
thin chc nng c lp vi tc dng gim LDL.
Kim sot glucose huyt khng nh hng nhiu n bnh mch mu ngoi vi.
Aspirin 75-325mg/ngy c ch nh ngi bnh hp ng mch nng v c
bnh tim mch, phng nga cc bin c tim mch v t qu. Dng clopidogrel nu
ngi bnh khng dung np aspirin.
Cilostazol c ch nh khi ngi bnh c triu chng au nhng khng th can
thip phu thut. Pentoxifylline khng c cc tc gi M nh gi l c hiu qu.
220

V. THEO DI
Theo di tnh trng tun tr ca ngi bnh, iu chnh liu thuc h p, h lipid
huyt, ch dn cch chm sc bn chn.
TI LIU THAM KHO
1. Abbott RD, et al. Diabetes and the risk of stroke. The Honolulu Heart Program.
JAMA 1987; vol 257:949-52
2. American Diabetes Association. Standards of medical care in diabetes 2014. Diabetes Care. 2014;37(suppl 1):S14-S80.
3. Arauz-Pacheco C et al. The treament of hypertension in adult patients with
diabetes. Diabetes Care 2002; vol 25: 134-47
4. David G. Gardner. Dolores Shoback. Basic and Clinical endocrinology - 9th
edition. 2011
5. Chobanian AV et al. The seventh report of the Joint National committee on
Prevention, Detection, Evaluation and Treatment of High Blood Pressure: the JNC 7
report. JAMA 2003; vol 289:2560-72
6. Haffner SM et al. Mortality from coronary heart disease in subjects with typ 2
diabetes and in nondiabetic subjects with and without prior myocardial infarction.
NEJM. 1998; vol 339:29-34
7. Hirsch AT et al ACC/AHA 2005. Practice Guidelines for the management of
the patients with peripheral arterial disease (lower extremity, renal, mesenteric, and
abdominal aortic: a collaborative report. Circulation 2006; vol 113: e 463-654.
8. Iwasaki K et al. Prevalence of atherosclerosis in asymptomatic diabetic patients
by 64 slice computed tomography. Coronary Art Disease 2008; vol 19: 195-201).
9. Lazo M, Solga SF, Horska A, Bonekamp S, Diehl AM, Brancati FL, et al.
Effect of a 12-month intensive lifestyle intervention on hepatic steatosis in adults with
typ 2 diabetes. Diabetes Care. 2010; vol 33(10):2156-63.
10. Momsen AH et al. Drug therapy for improving walking distance in
intermittent claudication: a systematic review and meta-analysis of robust randomized
controlled studies. Eur J Vasc Endovasc Surg. 2009; vol 38: 463-74.
11. Umpierre D, Ribeiro PA, Kramer CK, Leito CB, Zucatti AT, Azevedo MJ, et
al. Physical activity advice only or structured exercise training and association with
HbA1c levels in typ 2 diabetes: a systematic review and meta-analysis. JAMA. 2011; vol
305(17): 1790-9.
12. Wing RR, Lang W, Wadden TA, Safford M, Knowler WC, Bertoni AG, et al.
Benefits of modest weight loss in improving cardiovascular risk factors in overweight
and obese individuals with typ 2 diabetes. Diabetes Care. 2011;vol 34(7):1481-6.
13. The ORIGIN Trial Investigators. n-3 Fatty Acids and Cardiovascular
Outcomes in Patients with Dysglycemia. N Engl J Med. 2012; vol 367(4): 309-318.
14. The Washington manual of Medical Therapeutics 33rd ed; 2010.

221

BNH L BN CHN DO I THO NG

I. I CNG
Bn chn i tho ng theo nh ngha ca WHO v s thng nht ca nhm
chuyn gia quc t v bn chn i tho ng l nhim trng, lot v/ ph hy cc m
su c kt hp vi nhng bt thng v thn kinh v cc mc khc nhau v ca bnh
mch mu ngoi bin chi di.
T l b bnh l bn chn ca ngi b i tho ng thay i rt khc nhau ty
theo iu kin kinh t, x hi ca tng quc gia, tng khu vc. cc nc ang pht
trin t l bnh l bn chn i tho ng khong 5 %. Nhng cc nc ang pht
trin t l ny cao hn, c th n 40%. Theo Dyck v cng s 60-70% s ngi bnh
i tho ng s pht trin bnh thn kinh ngoi bin hoc mt cm gic bn chn.
C th 25% nhng ngi bnh ny s pht trin lot chn. Trn 50% nhng trng hp
lot chn s nhim trng, cn nhp vin, v 1/ 5 s b on chi. C mi 30 giy, bt k
ni no trn th gii, c 1 trng hp mt chi do hu qu ca i tho ng. c bit
ngi c tin s lot bn chn i tho ng, nguy c t vong trong vng 10 nm
nhiu hn 40% so vi ngi ch c i tho ng n thun. Ti Hoa K, hn 50%
trng hp on chi khng do chn thng xy ra trn ngi bnh i tho ng.
Nhng hn 50% cc trng hp on chi ny c th phng nga c bng chm sc
ng cch.
II. NGUYN NHN
Tn thng bn chn ngi bnh i tho ng l hu qu ca:
Bnh a dy thn kinh
Bnh l mch mu ngoi bin
Nhim trng c hi
Chn thng.
Phi hp cc bin chng k trn (thng gp).
Thng thng, nhng tn thng thng bt u bn chn b mt cm gic, bin
dng v/hoc thiu mu do chng d b chn thng, to chai, nhim trng v hoi th.
Trong a s ngi bnh i tho ng c tn thng bn chn, c ch sinh l
bnh ban u l s mt cm gic bn chn do bin chng bnh a dy thn kinh ngoi
bin. S mt cm gic thng (nhng khng phi lun lun) i km vi gim cm gic
rung v mt phn x gn gt. Ngoi vic lm mt cm gic, bin chng thn kinh c th
khin bn chn bin dng do co rt gn c, a n gim c ng cc ngn chn, bt
thng vng chu lc, to vt chai v bin dng in hnh ngn chn hnh ba. Bin
chng thn kinh cng khin gim tit m hi v da bn chn s kh rp, dn n dy,
nt n to iu kin cho nhim trng v lot. C n 50% bin chng thn kinh do i
tho ng khng c triu chng v ngi bnh c nguy c b tn thng bn chn do
mt cm gic. Biu hin thng gp nht ca bin chng thn kinh do i tho ng l
222

ri lon chc nng ca cc si thn kinh ngoi bin cm gic vn ng hoc t ch.
Bin chng thn kinh cm gic vn ng c c im i xng, ban u xut hin
ngn chi. Triu chng thay i ty thuc vo loi si thn kinh cm gic b nh hng.
Triu chng thng gp nht l cm gic chm chch, au lin quan n thn kinh si
nh. S mt cm gic cng c xy ra bn chn ang au hoc d cm. S xut hin v
nng ca bin chng thn kinh lin quan n thi gian b i tho ng v mc
tng ng huyt. ngi bnh i tho ng typ 2, bin chng thn kinh c th xut
hin lc chn on.
Bin chng thn kinh khp (bn chn Charcot) l mt bin chng thn kinh do i
tho ng t c ch , c th gy ra bin dng v mt chc nng ca bn chn. Nm
1868, Jean Martin Charcot m t u tin v bnh l ny. Bin chng xy ra ngay c khi
tun hon bn chn bnh thng. c trng ca bin chng ny l s mt lin kt, xo
trn ca cc xng vng di cng chn v bn chn, i khi c th lm nng hn bi
mt chn thng nh. Pht hin sm v iu tr ng cch c th lm gim ng k s
bin dng vnh vin.
S xut hin cp tnh ca mt tn thng bn chn gy au, thng l sau mt
chn thng, c th bo hiu bnh l mch mu ngoi bin tim n. Mc bnh v
kh nng iu tr bng can thip mch mu s ty thuc vo siu m Doppler v chp
mch mu. Tuy nhin, can thip phu thut trn ngi bnh i tho ng khng phi
lc no cng hiu qu do tn thng mch mu lan ta.
Nhim trng l mt bin chng thng gp ca lot bn chn do nguyn nhn
mch mu hay thn kinh. Cc nghin cu cho thy tc nhn nhim trng thng l hn
hp, vi vi trng gram dng chim u th.
Cc yu t nguy c dn n on chi thay i ty theo nghin cu, thng l:
Tnh trng kim sot ng huyt.
Thi gian pht hin i tho ng.
Tui ngi bnh.
Bnh l thn kinh ngoi vi.
Bnh l mch mu ngoi bin.
III. CHN ON
1. Triu chng v du hiu ca bnh l bn chn i tho ng
Bng 1. Cc triu chng v du hiu cnh bo cc vn bn chn i tho ng
Mch
mu

Triu chng

Du hiu khi khm

Chn lnh
au cch hi bp chn hoc bn
chn
au khi ngh, c bit v m.

Mt mch mu chn, mch khoeo hoc

mch i.
m thi vng i
Lng bn chn nht khi nng bn chn ln
v khi thng hai chn xung.
Tng thi gian y mao mch (> 3-4
giy).
Da chn lnh.

223

Thn
kinh

Triu chng

Du hiu khi khm

Cm gic: nng rt, chm chch,

au, d cm, lnh chn.

Cm gic: khim khuyt cm gic rung, s

nng su, au v nhit , tng cm
gic.
Hi chng ng c tay: d cm, mt cm
gic vng do thn kinh gia chi phi.
Vn ng: gim hoc mt cm gic phn
x gn su (gn gt Achilles, chy), yu
c, teo c.
T ng: gim hoc khng tit m hi.
Nng v ph do tng shunt ng - tnh
mch.

Triu chng bn tay

Vn ng: yu c (bn chn ri)
T ng: gim tit m hi

C
xng

Thay i hnh dng bn chn cp

tnh hoc mn tnh, km ph v
khng c tin s chn thng.
Yu cc c bn tay

Vm chn cao vi ngn chn co qup.

Bn chn ri.
Bn chn bt (Rocker-bottom)
Bn chn Charcot
Teo c

Da

Vt thng rt au hoc khng

au.
Vt thng khng lnh hoc lnh
chm, hoi t.
Thay i mu sc da (xanh tm, )
Chn bong vy, nga hoc kh
Nhim trng nhiu ln

Da: kh bt thng.
Nhim nm mng mn tnh.
Tn thng to sng c th km theo xut
huyt.
Lot thiu dng.
Lng: gim hoc mt.
Mng: thiu dng
Nm mng
Mng qup

2. Thm khm
nh gi bn chn bao gm:
2.1. Hi tin cn
Ngi bnh c b cc vn bn chn hoc triu chng au cch hi hay khng
2.2. Khm ton din c hai chn
Tm kim cc du hiu v triu chng bo hiu c vn bn chn bao gm: bin
dng, vt chai, vt lot. Quan st thy mt lng mu bn chn v ngn chn. Da bng, c
b teo. C th thy cc tn thng thc th nh vt lot, nt phng, cc chai chn, tnh
trng mng hay bin dng ngn chn, bn chn.
2.3. Khm kim tra mch mu (mu chn, chy sau, i)
2.4. Khm phn x v cm gic ngn chn, bn chn
Khm thn kinh s dng monofilament Semmes-Weinstein 5.07 (p lc l
10-g) v rung m thoa 128-Hz.

224

Bng 2. Khm monofilament

- Mi trng khm bnh cn yn tnh v ngi bnh ngi thoi mi.
- Yu cn ngi bnh nhm mt.
- u tin s dng monofilament trn tay ngi bnh gip h nhn bit cm gic. Ngi
bnh vn phi nhm mt
- Ba v tr cn thc hin: ngn ci, u t bn ngn 1 v ngn 5
- t monofilament vung gc vi b mt da vi lc filament gp gc 45 ; Khm
trong khong 2 giy
- Hi ngi bnh c/khng v v tr cm gic
- Khm lp li hai ln mt v tr mi chn
- Ghi li kt qu di dng t l, v d nh 4/6 ngha l ngi bnh cm nhn ng 4 ln
trong 6 ln khm.
- Trong qu trnh khm, cn th ngi bnh. Nu ngi bnh tr li c cho d ngi khm
khng dng filament, th phi hy kt qu khm, gii thch li tm quan trng v khm li
ton b.

Khm cm gic v nhit.

2.5. Chp X-quang bn chn
Mi tn thng lot ca bn chn ngi i tho ng u chp X-quang
nh gi tnh trng tn thng ca ty xng, ca xng.
2.6. Siu m doppler mch mu chi di
2.7. C th chp ct lp vi tnh hoc MRI khi cn thit
2.8. nh gi long xng
2.9. nh gi s phn b lc ln bn chn
nh gi tn thng bn chn i tho ng:
Bao gm v tr tn thng, hnh thi tn thng ( su, rng), sinh thit, thm d
mch mu.
Bng 3. Phn loi Wagner
Phn

Mc tn thng

Khng c tn thng, nhng c cc yu t nguy c nh nt chai

Lot trn b mt.

Lot su ti gn, dy chng, cn c, xng hoc khp.

Vim ty xng hoc p xe su

Hoi t khu tr: ngn, phn trc ca bn chn hoc gt chn.

Hoi t nng (lan rng v su)

IV. IU TR LOT BN CHN I THO NG

Vn iu tr bnh l bn chn i tho ng cn s tham gia ca nhiu bc s
chuyn khoa (ni tit, chnh hnh, chm sc vt thng) ty theo mc tn thng ca
bn chn.
225

1. Nguyn tc iu tr
iu tr tng qut v iu tr ti ch (vt lot).
2. iu tr tng qut
Kim sot tnh trng chuyn ha tt, c bit l kim sot ng huyt cht ch.
m bo tnh trng dinh dng thch hp.
Trnh thiu mu.
m bo ti mu tt.
Kim sot nhim trng.
iu tr cc bnh phi hp nu c
B sung vitamin v khong cht
Nng cao th trng, truyn m, nu c thiu mu nng truyn khi hng cu
hoc cc thnh phn khc ca mu ty thuc vo tng ngi bnh.
3. iu tr ti ch
Nguyn tc: Bo tn ti a. Nu phi ct ct chi th ct mc thp nht c th.
Ct lc trit m hoi t.
Khng c lot nhng c cc tn thng nt chai th cn c loi b.
Lot nng: loi b tn thng nt chai l lot nng. Chp X-quang xc
nh tnh trng tn thng xng (nu c nhim trng xng l sang 3)
Nhng tn thng nh khng nhim trng c th iu tr bng dung dch ra vt
thng khng khun, thay bng mi ngy v cho bn chn ngh ngi. iu tr ti ch
nhim trng nu c.
Nhng vn nghim trng hn nh bin dng bn chn, nhim trng, vim
xng cn n khm bc s chuyn khoa.
Nhim trng bn chn thng phi iu tr vi khng sinh ng tnh mch,
nm ngh ti ging, k cao chn v ct lc m hoi t. Gim p lc t mt lng bn
chn bng s dng np bt hoc nhng giy chuyn bit gip lm mau lnh vt thng.
Vt lot bn chn i tho ng rt kh lnh. Cn s dng cc tin b trong
k thut chm sc lm mau lnh vt thng. S dng cc bng gc gi m vt
thng, gc c cha Ag phng thch chm, Dermagraft - Vicryl ph Fibroblast,
Regranex - Gel ti ch vi lng nh growth factors. Tng lai l cc sn phm pht
trin t t bo gc, nui cy da nhn to.
Ty theo mc vt thng c th s dng cc ch phm nh yu t tng trng
thng b dng xt (Easyef) hay dng tim trong v xung quanh vt lot (Heberprot P)
gip nhanh ln m ht lm y vt lot nhanh.

226

Cc yu t cn tr qu trnh lnh vt thng bao gm: mch mu b va x, tng

nht mu; Thn kinh: mt cm gic bn chn, bin dng bn chn; Nhim trng: ct
lc m hoi t cha y , kh nng ti mu gim, tc vi mch, nhim nhiu vi
khun, vim ty xng Hoc cc yu t c hc nh ph, ch lot b t khi ng
hoc tnh trng dinh dng km.
Cc yu t bo hiu tin lng xu nh vt lot tng tit dch, tng ln, ty
tng dn, vt lot c mi hi, vim bch huyt, hoi t, nhit ti ch/ nhit ton
thn tng.
V. PHNG NGA BN CHN I THO NG
Phng nga bao gm chm sc chn ng cch, cng nh pht hin sm v iu
tr kp thi nhng tn thng.
Bng 4. Gio dc ngi bnh chm sc bn chn
- Ngi bnh hoc ngi thn c vai tr chnh trong phng nga cc vn v bn chn.
- Ct ngang mng chn v quan st chn mi ngy pht hin vt try sc, bng nc.
- Ra chn thng xuyn v lau kh sau .
- S dng cc cht lm m nh lanolin
- Trnh ngm chn qu lu, trnh dng cc ha cht mnh nh mui epsom hoc iodine
- Trnh: nng, lnh, i xa vi giy mi, tt chn(v) qu cht v i chn t, c bit l
ngi bnh c bin chng thn kinh.

TI LIU THAM KHO

1. T Vn Bnh. Nhng nguyn l nn tng bnh i tho ng Tng glucose
mu. NXB Y hc. 2007.
2. Dyck et al. Diabetic Neuropathy. 1999.
3. Singh, Armstrong, Lipsky. J Amer Med Assoc. 2005.
4. Lavery, Armstrong, et al. Diabetes Care. 2006.
5. DFCon11, Bakker (after Boulton), DFCon.com Boulton, The Lancet (cover),
Nov. 2005).
6. Iversen, et al, Diabetes Care 32:2193-2199, 2009.

227

BNH I THO NG V THAI K

C hai tnh hung cn phn bit:
Tnh hung th nht: ngi bnh c chn on i tho ng, trong qu
trnh din tin ca bnh, ngi bnh c thai.
Tnh hung th hai: tnh trng tng ng huyt c pht hin ln u tin trong
thai k, khng loi tr trng hp ngi bnh c i tho ng nhng khng c
chn on. Trng hp ny c gi l i tho ng thai k. Mun xc nh xem
ngi bnh b i tho ng nhng cha c chn an hoc i tho ng thai k
thc s th lm nghim php dung np glucose trong khang 6-12 tun l sau sinh.
Ngi bnh i tho ng typ 1 v typ 2 u c th th thai. to iu kin tt
nht cho b m v thai nhi, ngi bnh nn ln k hoch c thai trc v n nh ng
huyt tht tt trc khi th thai. Khi c thai, ngi bnh cn c phi hp chm sc
ton din bi bc s a khoa, bc s chuyn khoa i tho ng, bc s sn ph khoa,
bc s chuyn khoa bnh l s sinh v n h sinh.
I. CC VN CN QUAN TM KHI NGI BNH I THO NG
C THAI
1. Ngi bnh i tho ng c thai c th xy ra tai bin g?
Thng cc tai bin ch xy ra nu ng huyt khng c n nh tt, hoc
ngi bnh c cc bin chng trc khi c thai.
i vi em b:
Sinh non;
D tt thai;
Thai to hoc chm tng trng trong t cung so vi tui thai bnh thng;
Thai cht lu;
Thai b thiu surfactant ph nang;
Cc ri lon chuyn ha lc s sinh: a hng cu, tng bilirubin gy vng da
ko di, h calci huyt, h ng huyt s sinh.
i vi thai ph:
Tng huyt p thai k (c th b tin sn git).
a i.

228

2. Thai k c th nh hng nh th no n din tin bnh i tho ng?

2.1. nh hng ln chuyn ha ng
Qu 1: c tnh trng ng ha thai ph v tng insulin huyt, tng nhy cm
vi insulin. Nu ngi bnh i ma nhiu, d b h ng huyt v nhim ceton.
Qu 2: thai ph c tnh trng d ha, khng insulin, tng nhu cu v insulin.
ng huyt c khuynh hng tng cao.
Qu 3: tnh trng khng insulin tng nhiu hn. ng huyt c khuynh
hng tng cao v tng nguy c b nhim toan ceton.
2.2. Cc bin chng thoi bin
y mt: bnh vng mc T c khuynh hng nng thm. Nu ngi bnh
rn lc sinh, hoc c cn tng huyt p, c th gy xut huyt vng mc hoc xut huyt
vo th knh.
Thn: tng m niu, tng kh nng b nhim trng tiu, nu ngi bnh b
bnh thn mn tnh, thng tnh trng suy thn s gia tng, tng nguy c tin sn git.
Tim mch: nu ngi bnh c bnh c tim thiu mu, s tng kh nng b suy
tim v nhi mu c tim cp.
3. Nu ngi bnh khng mun c thai, c th dng bin php trnh thai no?
Phng php tt nht l da trn chu k kinh nguyt tnh ngy rng trng
trnh th thai. Tuy nhin, trn thc t phng php ny t thnh cng v i hi ngi
ph n phi c kinh rt u.
t vng trnh thai: khng c khuyn co dng cho ph n cha sinh n.
Hormon estrogens v progestogens, nu khng c chng ch nh v trn ngi
bnh T di 15 nm.
Thuc progestogens dng ung hoc cy di da.
II. IU TR I THO NG LC C THAI
1. n nh ng huyt
Mc tiu ng huyt:
Glucose mu ton phn lc i t 60-90 mg/dL (3,33-5,0mmol/L) hay
95mg/dL (5,3mmol/L), glucose mu ton phn 1 gi sau n < 140mg/dL (7,8mmol/L)
v 2 gi sau n < 120mg/dL (6,7mmo/L). Cng khng nn mc glucose huyt lc
i thp hn 60mg/dL. Ceton trong mu v trong nc tiu phi m tnh nu ngi
bnh n ung ng cch.
Nu dng glucose huyt tng tnh mch, th glucose huyt tng mc tiu lc
i l < 100mg/dL (5,6 mmol/L), v glucose huyt tng sau n <130mg/dL
(7,2mmol/L). Khng glucose huyt <60-70mg/dL (3,3-3,9mmol/L)
229

 Nhiu thai ph c th gi mc glucose huyt n nh sau khi n ung ng

cch v luyn tp u n.
2. Dinh dng iu tr
Tng s nng lng mi ngy dnh cho ngi bnh i tho ng thai k
c tnh da trn cn nng l tng.
Trn ph n c cn nng l tng, tng s nng lng l 30 kilocalo/kg cn
nng ang c mi ngy.
Ph n c cn nng di 80% cn nng l tng cn 40 kilocalo/kg cn nng
ang c/ ngy.
Ph n nng cn vt qu t 120% n 150% cn nng l tng cn 25
kilocalo/kg cn nng ang c/ ngy. Nu cn nng l tng ca ngi bnh vt qu
150% cn nng l tng, cn gii hn tng s nng lng khong 12 kilocalo/kg cn
nng ang c/ngy.
Ch n s tng trng cn thit trong thai k: 0,45kg (1lb) mi thng trong
qu u, 0,2-0,35kg (0,5-0,75lb) mi tun trong qu 2 v 3 ca thai k.
Thnh phn ca mi nhm thc n nh sau: 40-55% tng s nng lng dnh
cho carbohydrat hay ti thiu > 150 gam carbohydrat mi ngy. 20-25% tng s nng
lng dnh cho protid v 25-40% tng s nng lng dnh cho lipid. T l phn trm
ca tng s nng lng trn c th thay i i cht ty theo cc trng phi.
Tng s nng lng c chia u cho ba ba n chnh v ba ba n l. Nn
nhn mnh n carbohydrat hp thu chm (ng phc v cc cht x). Ph n c thai
c bit nhy cm vi tc dng ca glucocorticoid vo bui sng, do khng nn n
nhiu carbohydrat vo bui sng, nhiu khi ch cn gii hn lng carbohydrat trong
ba sng, glucose huyt ca ngi bnh cng n nh.
3. iu tr bng thuc
Nu ngi bnh khng th n nh glucose huyt bng tit ch n thun s
phi dng n Insulin iu tr. Hin nay c nghin cu cho thy thuc glyburide qua
nhau thai khng ng k, nhng thuc ny cha c cc Hip hi T ti hu ht cc
nc chp nhn dng cho thai ph T. Ngoi ra nhm thuc Biguanides c
dng trong iu tr bung trng a nang v c mt s trng hp ngi bnh c th c
thai nhng nhm thuc ny hin nay vn cha c chp nhn dng cho thai ph.
Loi Insulin c s dng thng nht l Insulin thng tc dng nhanh
(Regular Insulin- Insulin Actrapid) v Insulin bn chm NPH. C th dng di dng
pha sn 30/70 gm 1/3 l Insulin thng v 2/3 l Insulin tc dng bn chm. Liu trung
bnh lc khi u l 0,7 n v/ kg cn nng mi ngy. Liu trong ngy c th chia tim
ba ln hoc hai ln mi ngy, trc ba n. Nu tim hai ln mi ngy th thng 2/3
tng liu s c tim trc khi n sng v 1/3 tng liu s c tim trc khi n
chiu. Trong trng hp khng khn cp, Insulin c tim di da. Vng tim tt nht
l vng bng, khng c bng chng v tr tim ny c hi cho thai nhi.
230

 Mt s ngi bnh T typ 1 cn tim liu insulin NPH nh trc ba ba n

to mc insulin nn v dng insulin tc dng ngn (analog) trc cc ba n.
i vi ngi bnh T typ 2, c th dng insulin thng hoc insulin analog
tc dng ngn trc mi ba n v mt liu insulin nn NPH trc khi i ng.
Cc loi insulin analog tc dng ngn nh insulin aspart, lispro, phi tim ngay
trc khi n. Cc loi Insulin nn nh insulin glargine, insulin detemir ch cn tim mt
ln trong ngy. Tuy nhin cc insulin analog k trn khng phi l la chn hng u
cho thai ph. Theo FDA, insulin aspart, lispro c khuyn co mc B, v Insulin
glargine, detemir c khuyn co mc C.
Nu c iu kin, ngi bnh nn c mt my t theo di ng huyt mao
mch ti nh v lin h vi bc s khi glucose huyt thay i bt thng. C th theo di
glucose huyt lc i, 1-2 gi sau n v mt ln bui ti trc khi i ng.
Ch tm th ceton trong mu hoc trong nc tiu khi glucose huyt khng
n nh, hoc khi thai ph i ma nhiu.
Ngoi mc glucose huyt, cn cn quan tm n huyt p, m niu, ph, tin
sn git hoc sn git. Mc tiu sau cng ca iu tr l bo m sc kho cho c thai
ph v thai nhi, ngn nga cc trng hp thai cht lu, suy h hp, thai to a n cc
tnh hung phi m bt con hoc trt khp vai thai nhi nu sinh qua ng m o.
III. THEO DI THAI K
1. Theo di thai ph
Cn nng, huyt p, ph, ng huyt, m niu v nc tiu nn c ch
trng mi ln ti khm ngoi khm tng qut thng quy.
2. Theo di sc kho thai nhi
Nghe tim thai mi ln khm thai, m s ln thai my mi gi, siu m o
vng bng ca thai nhi.
Tun l th 8-12 ca thai k d on c th lm siu m xc nh tui thai.
Tun l 18-22, siu m thai nhi.
Trn thai ph c nguy c thp siu m li vo tun l 28 v 37 theo di s
tng trng ca thai nhi.
Trn thai ph c nguy c cao, lm siu m mi 3-8 tun. Nguy c thai to khi
vng bng ca thai nhi ln hn bch phn v 70 tr ln.
Theo di thai my:
T tun l 28, nu thai my (m s ln thai nhi ng chn vo bng thai ph)
di 4 ln mi gi phi nghi c suy thai.
Theo di tim thai:
Thai ph nguy c thp: theo di mi tun k t tun th 36.

231

Thai ph c nguy c cao: theo di tim thai t tun l th 27, mi 1-3 ln/tun.
Theo di nguy c thiu surfactant phi bng cch chc d dch i. y l
phng php xm ln, ch thc hin trn thai ph c nguy c cao.
Nguy c c da trn mc glucose huyt c n nh tt hay khng v cc bin
chng mch mu sn c ca thai ph.
IV. THI GIAN SINH V PHNG PHP SINH
Trn thai ph c nguy c thp, c th sinh vo tun l th 39-40 tr khi c cc
vn ph khoa hoc e do sinh con to.
cc thai ph c nguy c cao, ng huyt khng n nh, nu thai nhi khng
c e do b suy h hp, thiu surfactant phi, nn cn nhc tr hon n tun l th
38-40.
Nu quyt nh cho thai ra sm trc tun l th 37, cn phi chc d nc i,
o cc thng s xem nguy c tr c th b suy h hp hay khng.
Nu thai nhi khng c e do b suy h hp, ch nn m bt con nu cn nng
d tnh ca thai nhi > 4000-4200 gam trnh cc tai bin nh trt khp vai. Khi sinh
qua ng m o, cn theo di tim thai lin tc, nu glucose huyt ca m ln hn
150mg/dL (8,3mmol/L), kh nng thai nhi b thiu oxy s cao.
V. S DNG INSULIN TRONG LC SINH
Trong khi sinh nn dng Insulin thng tc dng nhanh truyn qua ng tnh
mch, liu trung bnh 1-2 n v mi gi cng vi 7,5gam glucose. Nu cn m bt con
liu dng cng tng t. D gy m ton hon hay gy t ty sng, gy t mng cng
thai nhi cng khng b nh hng nu ng huyt ca m n nh.
ng huyt ca thai ph nn c duy tr < 110 mg/dL.
Bng sau y gip iu chnh liu Insulin cho thai ph trong khi sinh
Nu glucose huyt >130mg/dL (7,2mmol/L), truyn tnh mch Lactat Riger vi tc 125
ml/gi.
Nu glucose huyt < 130 mg/dL (7,2mmol/L) gi thng tnh mch vi Lactat Ringer sau
truyn tnh mch Lactat Ringer v Glucose 5% vi tc 125 mL/gi iu chnh bng bm
truyn.
Pha Insulin thng (regular insulin)100 n v trong 100 mL NaCl 9 sao cho 1 n v cha
trong 1 mL dch. Chai insulin ny c ni vi ng truyn gi hong tnh mch, iu
chnh liu insulin theo bng di y nu glucose huyt ln hn 70mg/dL (3,9 mmol/L). Mc
tiu glucose huyt trong khong 70-110 mg/dL (3,9-6,1mmol/L). Dung dch insulin c th
truyn qua mt bm in. Theo di glucose huyt bng my th glucose huyt mao mch.

232

Glucose huyt
mg/dL (mmo/L)

Insulin (n v/gi)
T typ 1

T typ 2

T thai k

Khng truyn
Insulin

Khng truyn
insulin

Khng truyn
insulin

0,5 v/gi

Khng truyn
insulin

Khng truyn
insulin

91-110 (5,1-6,1)

1 v/gi

1v/gi

Khng truyn
insulin

111-130 (6,2-7,2)

1,5

1 v/gi

131-150 (7,3-8,3)

151-170 (8,4-9,4)

2,5

171-190 (9,5-10,6)

<70 (<3,9)
71-90 (3,9-5)

>190 (>10,6)

Th ceton, hi chn chuyn khoa

Phc ny cng dng cho thai ph ang cn nhn n. Nu ngi bnh ang iu
tr bng corticosteroid, thng cn liu insulin cao hn. Nu ngi bnh n, cn tim
insulin tc dng nhanh trc ba n.
Khi truyn tnh mch Insulin phi theo di glucose huyt, tt nht l mt gi mt
ln bng my th mao mch chnh liu cho chnh xc.
Cng cn theo di Kali ca ngi bnh trc khi truyn tnh mch glucose, nht
l khi ngi bnh n ung km, v theo di Kali trong lc truyn glucose tu kt qu
xt nghim.
Sau khi sinh, tnh trng khng insulin ca thai k s ci thin nhanh. Ngi
bnh T typ 1 v typ 2 ang iu tr bng insulin c th tr li liu c ngay khi ngi
bnh n c. Bnh nhn T typ 2 iu tr bng thuc c th khng cn dng thuc
trong vng 24-48 gi sau sinh.
Khi cho con b, c th iu tr bng insulin hoc dng metformin v /hoc
glyburide, c nghin cu cho thy hai thuc ny an ton khi cho con b.

233

I THO NG THAI K
I. I CNG
Theo nh ngha, i tho ng thai k l tnh trng ri lon dung np glucose
v/hoc tng ng huyt c pht hin ln u tin trong thai k. nh ngha ny
khng loi tr trng hp ngi bnh c T t trc m khng bit. nh ngha ny
cng khng phn bit sau khi sinh, ngi bnh cn tng ng huyt hay khng.
i tho ng thai k c xut thay i ty tiu ch chn on v ty chng
tc. Thng thng, t l lu hnh ca i tho ng thai k thay i t 1-14%. Ti Vit
Nam, theo mt nghin cu thc hin ti Qun 8 thnh ph H Ch Minh, t l i tho
ng thai k khong 4%. Mt s nghin cu ti cc a phng khc cho thy t l c
th ln n khong 7-10%. Ti M t l ny vo khong 4%, nhng trn ph n da trng
khng thuc gc Ty Ban Nha t l ny vo khong 2%.
Trong mt s him trng hp, trong lc c thai ngi bnh b T typ 1.
II. C CH BNH SINH
Trn ngi bnh i tho ng thai k, khi lm nghim php dung np glucose,
nh sm ca s tit Insulin v p ng tit Insulin i vi kch thch tng ng huyt
u gim so vi ph n khng b i tho ng thai k. Ngoi ra, nng ProInsulin
cng cao hn, chng t ngi bnh i tho ng thai k c s gim tit Insulin ngoi
cc bt thng do thai nghn gy ra.
III. TM SOT I THO NG TRONG THAI K
1. Khuyn co pht hin v tm sot i tho ng trong thai k (Hip hi i
tho ng M)
Ngay khi thai ph n khm thai ln u, nn nh gi cc yu t nguy c. Nu
thai ph c yu t nguy c s phi th glucose huyt lc i ngay. Nu glucose huyt
lc i 126 mg/dL hoc glucose huyt bt k 200mg/dL, th li glucose huyt vo
ngy sau chn on. Nu glucose huyt bnh thng s thc hin tm sot vo tun l
th 24-28 ca thai k.
Bng 1. Cc yu t nguy c ca T thai k
+ Tui thai ph > 37 tui.
+ Thuc sc tc c nguy c (n , ng Nam , Rp/ a Trung Hi, chu Phi/ Vng
bin Carib).
+ Bo ph.
+ Tin s gia nh b i tho ng (cha m, anh ch em rut).
+ Tin s sinh con to (cn nng lc sinh > 4000gam), a i.
+ Tin s thai cht lu khng c nguyn nhn.
+ Hi chng bung trng a nang.

234

2. Tm sot i tho ng thai k

2.1. Tm sot mt bc (Theo khuyn co ca Hi sn ph khoa M)
Thc hin nghim php dung np glucose 75 gam, o glucose huyt i, 1 gi
v 2 gi sau.
i tng ph n c thai vo tun l 24-28, cha c chn on i tho
ng trc khi c thai.
Nghim php thc hin vo bui sng, thai ph nhn i 8 gi qua m, ung
75 gam glucose trong 200-250 ml nc. Ly mu tnh mch o glucose huyt tng lc
i, 1 gi v 2 gi sau khi ung glucose.
Chn on T thai k khi c mt trong cc kt qu glucose ln hn hoc
bng tr s sau y: glucose huyt i 92 mg/dL (5,1 mmol/L), 1gi 180 mg/dL
(10,0mmol/L), 2 gi 153mg/dL (8,5 mmol/L).
2.2. Tm sot hai bc (theo ng thun ca Vin sc khe Quc gia M)
i tng: thai ph cha c chn on i tho ng, vo tun l 24-28
ca thai k.
Bc 1: lm nghim php ung 50 gam glucose, khng cn nhn i, o
glucose huyt 1 gi sau khi ung glucose.
Nu glucose huyt sau 1 gi 140mg/dL (10,0mmol/L), lm tip bc 2.
Bc 2: ngi bnh nhn i, lm nghim php dung np glucose vi 100 gam
glucose, chn on T thai k khi glucose huyt o vo gi th 3 sau khi ung 100
gam glucose 140mg/dL (7,8 mmol/L).
2.3. Hin nay khng khuyn co dng tiu ch chn on i tho ng trong thai
k theo ngh ca Carpenter v Coustan.
Ngoi ra ngi ta cng ang c gng ton cu ho tiu ch chn on i tho
ng trong thai k theo WHO, dng 75g glucose.
Sau y l bng tm sot i tho ng thai k theo T chc Y t Th gii
(WHO) v Hip hi nghin cu i tho ng chu u (EASD):
Bng 2. Tm sot i tho ng thai k
Hip hi - T chc

Ti glucose

0 gi

2 gi sau ung glucose

WHO

75 gam

7 mmol/L

7,8 mmol/L

EASD

75 gam

6 mmol/L

9 mmol/L

Ch thch: mun i t mmol/L thnh mg/dL, nhn tr s ca mmol/L vi 18.

IV. IU TR
Hin nay khuyn co kim sot cht ch glucose huyt, mc tiu cng ging nh
thai ph c T t trc.

235

Dinh dng hp l l nn tng ca iu tr. Thai ph cng c khuyn co nn

luyn tp t mc nh n trung bnh.
Nu dinh dng v luyn tp khng t mc tiu, insulin l la chn hng u.
Nu c i tho ng thai k, sn ph s c tm sot bnh i tho ng sau
khi sinh khong 6-12 tun v tip tc theo di sau t nht 3 nm mt ln kp pht
hin i tho ng hoc tin i tho ng.
TI LIU THAM KHO
1. David G. Gardner. Dolores Shoback. Basic and Clinical endocrinology - 9th
edition. 2011.
2. American Diabetes Association. Standards of medical care in diabetes 2012. Diabetes Care. 2012;35(suppl 1):S11-S63.
3. Joslins Diabetes Mellitus by Joslin Diabetes Center. 14th edition 2005.
4. Hanna FWF, Peters JR. Screening for Gestational Diabetes; past, present and
future. Diabetic Medicine 19: 351-358. 2002.
5. Report of the Pregnancy and Neonatal Care Group of the European
Association for the Study of Diabetes. Diabetic Medicine, 13: S43-S53, 1996.
6. WHO Consultation: Definition, Diagnosis and Classification of Diabetes
Mellitus and its Complications: Report of a WHO Consultation. Part 1: Diagnosis and
Classification of Diabetes Mellitus. WHO/NCD/NCS/99.2, Geneva: World Health
Organization. 1999.

236

BNH L CU THN TRONG BNH I THO NG

I. I CNG
Bnh l cu thn trong bnh i tho ng (T) thng c gi tt l bnh
thn T, thuc nhm bin chng mch mu nh ca bnh.
Bnh thn T c cc c im:
Tiu albumin lin tc (>300mg/ngy hoc >200g/pht) xc nh t nht hai
ln trong vng 3-6 thng.
Gim dn lc cu thn.
Tng huyt p, c th xut hin giai on u (bnh T typ 2) hoc tr.
T l lu hnh ca bnh thn T vo khong 40%, c s khc bit gia bnh
T typ 1 v typ 2.
Ngi bnh T typ 1 cha c bin chng khi mi mc bnh, nu khng iu
tr ng v y , sau 20 nm, khong 30-40% ngi bnh s c bin chng thn.
Ngi bnh T typ 2 c th c albumin niu ngay lc mi chn on, nu
khng iu tr tch cc, khong 15-20% s c bnh thn T. Tuy nhin v t l lu
hnh ca T typ 2 nhiu hn nn s c nhiu ngi bnh T typ 2 b bnh thn giai
on cui.
T l nguyn nhn hng u a n bnh thn giai on cui v lc thn.
II. SINH BNH L - DIN TIN
Nguyn nhn chnh xc ca bnh thn T cha c xc nh r, tuy nhin, c
nhiu yu t tc ng: tng glucose huyt (lm tng lc cu thn v tn thng thn),
cc sn phm cao cp ca qu trnh glycat ha (advanced glycosylation end productsAGE), v hot ha cc cytokin. Tng glucose huyt lm tng biu l yu t chuyn dng
tng trng beta (transforming growth factor-beta -TGF-) cu thn, v cc protein
nn c kch hot bi cytokin ny. TGF-beta v yu t tng trng ni mc mch mu
(vascular endothelial growth factor -VEGF) c l gp phn lm ph i t bo, kch
thch tng hp collagen, v cc thay i mch mu trong bnh thn T. Tng
glucose huyt cng hot ha protein kinase C, men ny gp phn lm tng lc cu
thn v cc bin chng mch mu.
Mt s sc dn c bit nhy cm vi bnh thn T nh M da en, ngi gc
Ty Ban Nha, v M bn a.
Ngi bnh T typ 1 nu c cha v m b tng huyt p cng d b bin chng thn.
Bng 1 Trnh by din tin t nhin ca bnh thn T. Tuy nhin nu iu tr
tt ngi bnh c th ci thin.

237

Bng 1: Din bin t nhin ca bnh thn T

LCT (ti
thiu)

Bi sut
albumin niu

Tng lc
cu thn

Tng
trong T
typ 1 v 2

Giai on
yn lng

Dy mng
y, tng
sinh lp
trung m

Giai
on 3

Giai on
tim n

Giai
on 4
Giai
on 5

Tn

c im

Huyt p

Thi gian

Giai
on 1

Tng chc
nng v
ph i

C th tng

Typ 1: BT
Typ 2: BT
hoc tng

Hin din
ngay thi
im chn
on

Giai
on 2

Bnh
thng

Typ 1: BT
Typ 2: c th
albumin t
<30mg-300
mg/ngy

Typ 1: BT
Typ 2: BT
hoc tng

Trong 5
nm u
tin

Albumin
niu

LCT bt
u gim

30-300
mg/ngy

Typ 1: THA
Typ 2: BT,
THA

5-15 nm

Bnh thn
lm sng

Tiu m

LCT
di mc
BT

>300mg/ngy

THA

15-25 nm

Hi chng
ur huyt
cao

BTGC

0-10
ml/pht

Gim

THA

25-30 nm

Ch thch:

BT: Bnh thng

LCT: lc cu thn

THA: Tng huyt p

BTGC: Bnh thn giai on cui

III. TRIU CHNG - CHN ON

1. Lm sng
Bnh thn T c albumin niu v gim lc cu thn.
nh ngha albumin trong nc tiu ty thuc cch ly nc tiu. Hin nay,
thng dng nht l mu nc tiu bui sng v tm t s albumin/creatinin. Ly nc
tiu qua m hay nc tiu 24 gi khng thun tin cho ngi bnh. Bng 2 cho bit
cc gii hn ca nng albumin trong nc tiu.
Bng 2: Cc mc albumin trong nc tiu
Cc mc
tiu m

Ly nc tiu bui sng

Khng
chnh

Chnh vi creatinin trong nc tiu

T s albumin/creatinin

Qua m

24 gi

g/mL

mg/g

g/pht

mg/24 gi

Bnh thng

<20

Tiu albumin

20-200

Tiu m

238

Ly nc tiu trong
mt khang thi gian

>200

<30
30-300
>2,5-25 mg/mmol (nam)
>3,5-35 mg/mmol (n)
>300

<20

<30

20-200

30-300

>200

>300

 ngi bnh T typ 1, albumin niu l biu hin u tin ca tn thng thn.
bnh nhn T typ 2, ngay lc mi chn on c th ngi bnh c tng huyt p,
albumin niu. Ngoi ra, khong 20% ngi bnh T typ 2 din tin n n bnh thn
mn tnh nhng khng c albumin trong nc tiu. Albumin niu tng quan c lp
vi nguy c tim mch.
2. Chn on bnh thn T
Chn on da trn:
2.1. Cc yu t lm sng
Tin s c bnh T.
Albumin niu (cn loi tr cc nguyn nhn khc ca albumin niu, xem bng 5).
Tng huyt p.
Cc bin chng thng i km bnh thn T: cc bin chng mch mu nh
bnh vng mc T, bnh thn kinh T; bnh mch mu ngoi vi.
2.2. Xt nghim
Albumin, m trong nc tiu.
Creatinin huyt thanh c th bnh thng, tng. Nn tnh thanh thi creatinin
bng cng thc Cockcroft-Gault hoc lc cu thn c tnh bng cng thc t nghin
cu MDRD (Bng 3). Bng 4 trnh by cc giai on ca bnh thn mn tnh ngi
bnh T da trn lc cu thn c tnh.
Khong 20-25% ngi bnh T c tng lc cu thn (>120/ml/pht) giai
on sm ca bnh, tnh trng ny s tng gp ba ln kh nng din tin n bnh thn
T.
Siu m thn loi tr cc bnh l khc thn nh thn a nang, si thn
Sinh thit thn: khng thc hin chn on bnh thn T nu ngi bnh
c din tin in hnh. C th cn sinh thit trong cc trng hp nghi ng c bnh l
khc thn nh bnh cu thn tin trin nhanh, bnh thoi bin dng bt
Nn ngh n cc bnh thn khng do T trong cc trng hp sau y:
Tiu m i lng khi mi chn on T di 5 nm
m niu xut hin t ngt
Gim lc cu thn nhng khng km tiu m
Suy thn cp hoc chc nng thn suy nhanh trong thi gian ngn
C hng cu bin dng trong nc tiu
Khng c bnh l vng mc i km (nht l bnh nhn T typ 1).

239

Bng 3: Cng thc tnh lc cu thn c tnh

Cng thc CockcroftGault

(140-Tui) x cn nng/72 x creatinin huyt thanh (mg/dL)

Nu l n, t s s l:
(140-Tui) x cn nng x 0,85

Cng
thc
theo
nghin cu MDRD

GFR (mL/pht/1,73 m ) = 186 x (Cr HT)

-0,203
(Tui)
x (0,742 nu l n) x (1,210 nu l da en)
Cr: creatinin; GFR Glomerular filtration rate: lc cu thn

-1,154

Bng 4: Cc giai on ca bnh thn mn tnh theo KDIGO

(Kidney disease: Improving Global outcomes)
LCT c tnh
2
(mL/pht/1,73m )

Giai on

c im

Bnh T vi LCT BT hoc tng cng vi tiu

albumin trng din

90

Bnh T vi LCT gim nh cng vi tiu

albumin trng din

60-89

3a

Gim LCT nh n trung bnh

45-59

3b

Gim LCT trung bnh n trm trng

30-44

Gim LCT trm trng

15-29

Suy chc nng thn

<15 (hay lc thn)

Bng 5: Cc nguyn nhn c th lm tng albumin thong qua

- Tng glucose huyt nng, cp
- Tng huyt p nng kim sot km
- n qu nhiu m
- Luyn tp
- Nhim trng ng tiu, tiu mu
- Suy tim
- Bnh nhim gy st cp tnh
- Ln dch tit m o trong mu nc tiu

IV. QUN L BNH THN I THO NG

Bao gm dinh dng, kim sot glucose huyt, iu tr tng huyt p, ch trng
hn ch phospho v kali bnh thn giai on cui.
Bnh cn c theo di bi cc bc s chuyn khoa ni tit. Khi cn, c th hi
chn vi bc s chuyn khoa thn (t giai on 3 ca bnh thn mn tnh) v tim mch.
Mc tiu iu tr ca ngi bnh b bnh thn T:
HbA1c # 7%
Huyt p < 130/80 mmHg
Kim sot lipid huyt: LDL <100mg/dL (2,6mmol/L) nu cha c bin c
tim mch.
240

1. iu tr tng glucose huyt

Cc nghin cu cho thy tng glucose huyt l mt trong cc yu t quyt nh
chnh lm bnh thn tin trin.
giai on u, kim sot glucose huyt tt s gim tnh trng tng lc cu thn.
giai on 1-3, kim sot glucose huyt tch cc lm gim din tin albumin niu,
n nh, thm ch o ngc bnh thn T. Mc tiu HbA1c lc ny c th l 6,5 -7%.
Tuy nhin, do hu ht cc thuc iu tr tng glucose huyt u c thi qua thn
nn cn thn trng chn la hoc chnh liu thch hp trnh nguy c h glucose huyt.
giai on 4-5 ca bnh thn mn tnh, tnh trng khng insulin lm glucose
huyt kh n nh, thng cn liu insulin cao hn. Tuy nhin, n giai on cui, s
thoi ging insulin thn suy gim, ngoi ra ngi bnh thng chn n, do cn liu
insulin thp hn. Cn theo di k trnh cc cn h glucose huyt. Trong bnh thn
giai on cui c th khng cn dng n insulin.
Bng 6, 7 cho bit cc loi thuc iu tr T hin ang lu hnh ti Vit Nam v
cc chi tit cn lu ngi bnh c bnh thn mn tnh.
Bng 6: La chn thuc iu tr tng glucose huyt ngi bnh T
c bnh thn mn tnh.
Thuc iu tr tng
glucose huyt
Metformin

Cn nhc v khuyn co khi dng thuc

- C nguy c nhim toan lactic; dng n tr liu t c kh nng gy h
glucose huyt.
- Khng khuyn co s dng khi lc cu thn c tnh < 50
2
mL/pht/1,73m .
- Khng s dng Metformin bnh thn mn tnh giai on 4-5
- T in dc phm Anh, Hip hi thn Nht khuyn co khng s
2
dng metformin khi LCT <30 ml/pht/1,73m .

Sulfonylurea th h
th nht

a s khng ph hp cho ngi bnh b bnh thn mn tnh trung

bnh n nng, do tng nguy c h glucose huyt v gim thanh lc
sulfonylurea v cc cht chuyn ha ca cht ny.
2

Chlorpropamid: LCT 50-80ml/pht/1,73m : gim 50% liu. LCT <50

2
ml/pht/1,73m - khng dng.
Khng dng Tolbutamide.
Sulfonylurea th h
th hai

ngi bnh bnh thn mn tnh trung bnh v nng, thuc nn c

chn la l glipizid. Gliclazid v glimepirid c th dng liu thp.
Khng dng glyburid.

Meglitinide

Repaglinide c th dng cc giai on bnh thn mn tnh t nh

n nng.
2

Nu LCT <30ml/pht/1,73m - thn trng bt u t liu 0,5mg trc

mi ba n.

241

Thuc c ch men
alpha-glucosidase

Acarbose dng c bnh thn mn tnh nh v trung bnh.

Thiazolidinedion

Khng cn gim liu pioglitazon; c th gim bi sut albumin v

protein niu. (Rosiglitazon b cm nhiu th trng do tng nguy
c bin c tim mch). Khng dng khi ngi bnh c nguy c suy tim,
gy xng.

Insulin

Liu Insulin khng da trn nng ca gim chc nng thn, nhng
cn iu chnh liu t mc tiu kim sot glucose huyt m khng
lm tng nguy c h glucose huyt.

Khng dng khi LCT <30ml/pht/1,73m

Bng 7: Chuyn ha/Thanh lc cc nhm thuc c ch men DPP-IV

ngi bnh T typ 2 c bnh thn mn tnh
Thuc
Sitagliptin

Chuyn ha/thanh lc
Thn

iu chnh liu trong bnh thn mn tnh

50 mg/ngy nu TL Cr 3050mL/pht
25 mg/ngy nu TL Cr < 30mL/pht

Saxagliptin

Gan/ thn

2,5 mg/ngy nu TL Cr 3050mL/pht

2,5 mg/ngy nu TL Cr < 30 mL/pht

Vildagliptin

Thn

50 mg/ngy nu TL Cr 3050mL/pht
50mg/ngy nu TL Cr < 30 mL/pht

Linagliptin

Gan

Khng cn chnh liu

BTM = Bnh thn mn tnh;

TL Cr = thanh lc creatinin

LCT = lc cu thn;

BTGC = bnh thn giai on cui

2. iu tr tng huyt p
Kim tra huyt p mi ln khm bnh, v nu c th c, o huyt p thng
xuyn ti nh.
Mc tiu huyt p < 130/80 mmHg.
Thuc c la chn hng u l nhm c ch h renin angiotensin (gm
nhm c ch men chuyn v c ch th th Angiotensin II), li tiu, chn knh calci.
Thng ngi bnh cn phi hp thuc kim sot huyt p. Nu phi hp ba loi
thuc, mt thuc s l thuc li tiu.
i khi c th n nh huyt p bng thuc li tiu thiazides hoc li tiu quai.
Thuc c ch men chuyn hoc c ch th th gip gim huyt p, kim sot m
niu, v c ch nh trong ri lon chc nng tm thu tht tri. Phi hp c ch men
chuyn v c ch th th c th lm chc nng thn suy gim thm nn thng khng
c khuyn co.
Khng dng c ch men chuyn v c ch th th khi ph n c thai hoc d nh
c thai, ngi bnh c khuynh hng b mt nc, tng kali huyt khng tr, hoc
creatinin tng 0,6mg/ dL sau khi bt u dng thuc.

242

Thuc chn beta c th dng khi ngi bnh b suy tim, c bnh mch vnh, thn
trng khi ngi bnh b suyn. Thuc chn knh calci c th gy ph chi di v to bn.
Thuc chn knh calci, d thuc nhm dihydropyridin hay khng dihydropyridin
u c li. Loi khng dihydropyridine bo v thn (c th lm gim m niu) nhng
c th gy gim chc nng c tim.
Bng 8. Cc thuc iu tr tng huyt p ngi bnh i tho ng
c bnh thn mn tnh.
Khong liu dng
(thp nht-cao nht)

Thuc
c ch men chuyn
Benazepril

10-40mg/ngy, chia 1-2 ln

25-200mg/ngy chia 2-3 liu
2,5-40 mg/ngy chia 1-2 ln
5-40 mg/ngy chia 1-2 ln
5-80mg/ngy
1,25-20mg/ngy
1-4 mg/ngy

Captopril
Enalapril
Lisinopril

Tc dng ngoi

Lu

Ho,
Tng kali huyt,
Mn nga,
Mt v gic;
Him: (<1%) ph,
gim bch cu

C tc dng bo v
tim mch ngi
bnh suy tim v/hoc
bnh c tim thiu
mu; c bng chng
ngi bnh c bnh
thn T typ 1, cn
chnh liu theo chc
nng thn

Tng kali huyt;

Him: (<1% ngi
bnh) ph

Tc dng bo v thn
c chng minh
ngi bnh c bnh
thn T typ 2.
Khng cn chnh liu
theo chc nng thn.

- Ph (Amlodipin,
nifedipin, felodipin)
- Chm nhp tim,
chm dn truyn nh
tht, ph i nu
rng
(diltiazem,
verapamil),
- To bn (verapamil)

Cc thuc c ch men
CYP3A4 c tim nng
gim chuyn ha ca
thuc chn knh calci
thuc
nhm
dihydropyridin, nn c
th lm tng hoc ko
di tc dng ca nhm
thuc ny.
Khng ung nifedipin
cng vi nc bi

Quinalapril
Ramipril
Trandolapril
c ch th
angiotensin II
Candesartan
Irbesartan
Losartan

th

Telmisartan
Valsartan
Thuc chn knh
calci
Nhm
dihydropyridine
Amlodipin
Felodipin
Isradipin
Nicardipin
Nifedipin
Nifedipin
phng
thch chm
Nhm khng
dihydropyridin
Diltiazem
Diltiazem
thch chm
Verapamil
Verapamil
thch chm

phng

8-32 mg/ngy
150-300mg/ngy
25-100mg/ngy chia 1-2 ln
20-80 mg/ngy
80-320 mg/ngy

2,5-10mg/ngy
2,5-10 mg/ngy
2,5-10 mg/ngy
20-120 mg/ngy
10-120mg/ngy
30-90 mg/ngy

30-360mg/ngy chia 2 ln
60-360mg/ngy
80-480mg/ngy chia 2 ln
120-480mg/ngy

phng

243

Khong liu dng

(thp nht-cao nht)

Thuc
Thuc chn th th
beta
Atenolol
Bisoprolol
Metoprolol
Metoprolol
thch chm

Tc dng ngoi

Lu

Co tht ph qun,
Chm nhp tim,
Chm dn truyn nh
tht,
Suy tim,
Che m triu chng
h glucose huyt,
Gim tun hon ngoi
vi,
Gim cng dng vt

C tc dng bo v
tim ngi bnh b
suy tim, bnh c tim
thiu mu hoc c hai

H huyt p t th
Co tht ph qun

C tc dng bo v
tim mch ngi
bnh suy tim, bnh c
tim thiu mu hoc c
hai. Cn chnh liu
theo chc nng thn.

H kali huyt, ri lon

dung np glucose

u tin chn la
ngi bnh c chc
nng
thn
bnh
thng

H kali huyt

u tin dng bnh

nhn suy thn, dch
tun hon. Cn chnh
liu theo chc nng
thn. C th gim bt
nguy c tng kali mu
do thuc c ch h
thng
renin
angiotensin

25-100mg/ngy

Tng kali huyt

ngi bnh suy thn
nht l khi dng
chung vi thuc c
ch
h
renin
angiotensin

C th lm tng tc
dng gim m niu
ca thuc c ch h
renin angiotensin. Bo
v tim ngi bnh
suy tim.

250-2000mg/ngy chia ung

2-3 ln

Mch
chm,
kh
ming, h huyt p t
th, bun ng, chy
sa. Methyldopa c
th gy dng tnh
vi
nghim
php
Coombs
(25%),
khng th khng nhn
(10%).

25- 100mg/ngy chia 1-2 ln

2,5 -20 mg/ngy chia 1-2 ln
50-450 mg/ngy chia 2 ln
25-400 mg/ngy

phng

Thuc chn th th
alpha v beta
Carvedilol

Thuc li tiu
Nhm thiazides
Chlorthalidon
Chlorothiazid
Hydrochlorothiazid
Indapamide

6,25- 50 mg/ngy chia 1-2 ln

12,5-50mg/ngy
125-1000mg/ngy
12,5-50mg/ngy
1,25-5mg/ngy

Thuc li tiu quai

Furosemid
40-500mg/ngy chia 2-3 liu

Thuc li tiu gi
kali
Spironolacton

Thuc tc
giao cm
ng
Methyldopa

ng
trung

Ch : liu thuc trn c tnh tham kho. Hin nay c khuynh hng phi hp
cc loi thuc dng vi liu thp hn v gim tc dng ph.
Thuc c u tin chn la l nhm c ch h renin angiotensin, li tiu v chn
knh calci.
244

3. Dinh dng
Tng lng calo trong ngy thay i ty tnh trng ca tng ngi bnh. Khi bnh
thn tin trin, ngi bnh cn gim m trong khu phn n, khong 0,8 -1gam/kg
cn nng/ngy, c th lm chm tin trin bnh thn.
Cng cn hn ch lng mui trong khu phn, khong 5-6 gam/ngy.
Khi bnh thn tin trin cng cn hn ch phospho bng cc cht gn phosphat v
hn ch kali.
4. Cc phng tin khc
Bnh thn T thng km tng triglycerid, gim HDL, LDL c th tng hoc
bnh thng. Do LDL lin h vi gia tng nguy c tim mch r nn mc tiu LDL l <
100mg/dL (2,6 mmol/L). C th dng statin bt u vi liu thp v ch bin chng ly
gii c vn.
Khng c ch luyn tp c bit hoc hn ch luyn tp bnh thn T. Tuy
nhin khi ngi bnh b bnh tim mch, thiu mu nng, cn c ch luyn tp ring,
theo kin chuyn gia.
5. Phng nga bnh thn i tho ng
Ngng ht thuc v iu tr cc yu t nguy c nh tng huyt p, tng lipid.
Mc tiu chuyn bit ca phng nga bao gm:
Kim sot ti u glucose huyt (HbA1c < 7%)
Kim sot huyt p (Huyt p < 120/70 mmHg)
Trnh cc thuc gy c thn, nh thuc khng vim khng steroid, khng
sinh nhm aminoglycosides.
Pht hin sm v iu tr T, nht l nhng ngi c tin s gia nh T.
6. Qun l lu di
Theo di iu tr u n l iu quan trng qun l tt bnh thn T.
ngi bnh T typ 1, tm albumin niu sau khi chn on bnh c 5 nm.
ngi bnh T typ 2, tm albumin niu ngay lc mi chn on v sau
mi nm nu albumin niu m tnh.
Th creatinin huyt mi nm, t tnh lc cu thn c tnh.
o huyt p mi ln khm bnh v nu c th, theo di huyt p thng xuyn
ti nh. Theo di huyt p nm, ngi v ng.
Ngi bnh T v bnh thn mn tnh giai on 1-2 cn c theo di chc
nng thn mi 6 thng.
Ngi bnh T v bnh thn mn giai on 3-5 cn c theo di chc nng
thn mi ba thng. Cng cn theo di thm m niu, cht in gii (natri, kali, clor,

245

CO2) cht khong, hormon c lin quan n xng (calci, phospho, PTH), tnh trng
dinh dng (albumin, BUN), tnh trng thiu mu (huyt sc t, dung tch hng cu Hct,
st huyt thanh). Giai on ny cn tham kho kin ca bc s chuyn khoa thn, nht
l khi n giai on lc thn, bnh thn giai on cui.
T v bnh thn mn tnh giai on 1-2: c th o ngc din tin bnh
bng kim sot cht ch glucose huyt, kim sot huyt p, dng thuc c ch h renin
angiotensin, nht l T typ 1.
T v bnh thn mn tnh giai on 3-4: lm chm din tin tin bnh bng
cc phng tin iu tr k trn, trnh cc thuc gy c thn.
Giai on tr (giai on 5), cn trnh gy ra tnh trng suy thn cp trn nn suy
thn mn tnh, th d chp hnh mch vnh vi thuc cn quang, hoc, iu tr duy tr
trong khi ch i lc thn hoc ghp thn.
iu tr kp thi cc bin chng khc ca T nh bnh vng mc T, bn
chn T, bnh tim mch.
Trong tt c cc giai on, cn ch cc bnh i km c th iu tr c nh
nhim trng tiu, b tiu, u lnh tin lit tuyn...
TI LIU THAM KHO
1. American Diabetes Association; Nephropathy in Diabetes; Diabetes Care.
2004; vol 27, suppl 1: s 79-s83.
2. American Diabetes Association; Standards of Medical care in Diabetes 2012;
Diabetes care. 2012; vol 35; suppl 1: s4-s10.
3. David G. Gardner. Dolores Shoback. Basic and Clinical endocrinology - 9th
edition. 2011.
4. Deacon CF. DPP-4 inhibitors in the treatment of type 2 diabetes: a
comparative review. Diabetes Obesity and Metabolism. 2011;13:7-18.
5. KDOKI clinicalpractice guidelines in diabetes and KDOKI update 2012; Am J
Kidney Dis.2012; 60 (5): 850-886.
6. Levey AS et al. The definition, classification, and prognosis of chronic
kidney disease: a KDIGO Controversies Conference report. Kidney International
2011; 80:17-28.
7. The Washington manual of Medical Therapeutics 33rd ed; 2010.

246

Chng 5. BNH BO PH
BNH BO PH
I. NH NGHA
Bo ph l tnh trng tng trng lng c th mn tnh do tng khi lng m qu
mc v khng bnh thng, lin quan n dinh dng v chuyn ha. S pht trin kinh
t - x hi lm thay i ch dinh dng, cung nhiu hn cu, kt hp phong cch
sng tnh ti nhiu hn vn ng, dn n tnh hnh bo ph tng ln vi tc bo
ng, khng nhng cc quc gia pht trin, m cn cc quc gia ang pht trin.
Bo ph l nguy c ca nhiu bnh khng ly nhim nh i tho ng, ri lon
lipid mu, x va ng mch, tng huyt p, thoi ha khp, ung th
Mc bo ph c nh gi theo nhiu phng php, trong cng thc BMI
(Body Mass Index: ch s khi c th) n gin, d s dng v c Quc t cng nhn:
Trng lng (Kg)
BMI =
[Chiu cao (m)]2
ph hp vi c im cc nc vng chu , t nghin cu thc t cc quc
gia ly tiu chun ban hnh nm 2000 nh bng 1.
Bng 1. Tiu chun ban hnh nm 2000 v phn loi bo ph
Loi
Gy

BMI
< 18,5

Bnh thng

18,5 - 22,9
Nguy c

Tng cn

23 - 24,9

Bo ph 1

25 29,9

Bo ph 2

30

Bng 2. nh gi mc bo ph theo T chc Y t Th gii

Loi
Gy

BMI
< 18,5

Bnh thng

18 - 24,9

Tng cn

25 - 29,9

Bo ph

Bo ph 1

30 - 34,9

Bo ph 2

35 - 39,9

Bo ph 3

40

247

II. NGUYN NHN

Yu t mi trng:
L nhng yu t lin quan n tnh trng cung cp nhiu calo so vi nhu cu ca
c th:
n nhiu: dn n d tha calo, c bit cc loi thc n nhanh, thc n cha
nhiu glucid. n nhiu c th do thi quen c tnh cht gia nh, hoc n nhiu trong
bnh l tm thn.
Gim hot ng th lc: do ngh nghip tnh ti hoc hn ch vn ng do tui
gi. Gim hot ng th lc nn s dng nng lng t dn n d tha v tch ly.
Di truyn:
C nhiu bng chng kt lun di truyn c ng vai tr trong bnh bo ph, nh
gia nh c b v m bo ph th con b bo ph n 80%, c b hoc m bo ph th con
bo ph thp hn 40%, v b m khng bo ph th ch 7% s con b bo ph.
Nguyn nhn ni tit:
Hi chng Cushing: phn b m nhiu mt, c, bng trong khi t chi gy.
U tit insulin: tng cm gic ngon ming v tng tn sinh m m t glucid.
Suy gip: bo ph do chuyn ha c bn gim.
Bo ph-sinh dc: m phn b nhiu thn v gc chi km suy sinh dc.
III. CHN ON
1. Lm sng
Bo ph trn lm sng biu hin s tng cn c xc nh bng phng php o
nhn trc (anthropometry) lm sng:
Ch s khi c th (BMI) (bng 1 v bng 2).
Cng thc Lorenz (Trng lng thc/trng lng l tng) x 100%
> 120-130%: tng cn
> 130 % : bo ph
dy ca np gp da: phn nh lp m di da. C th o bng compar,
nhiu v tr. Trn lm sng thng o cnh tay (c tam u), gia vai v i. Trung
bnh, dy np gp c tam u l 16,5 i vi nam v 12,5 i vi n.
Ch s cnh tay i: 0,58 i vi nam, 0,52 i vi n.
Ch s vng bng vng mng: < 0,9 i vi nam, <0,85 i vi n.
2. Cn lm sng
Siu m: o dy m m ti v tr mun xc nh nh cnh tay, i, bng
Chp ct lp t trng: xc nh c lng m phn b da v cc tng.
Impedance Metri: o lng m hin c v lng m l tng ca c th t
tnh ra lng m d tha.
248

3. Chn on xc nh
p dng ch s BMI cho cc nc chu (bng 1).
p dng ch s BMI theo TCYTTG (bng 2).
Da vo cng thc Lorenz:
> 120-130%: tng cn
> 130% : bo ph
4. Phn loi bo ph
4.1. Theo tui
Bo ph bt u tui trng thnh (th ph i): s lng t bo m khng
tng, bo ph do gia tng s tch t m trong mi t bo. iu tr bng gim glucid
thng c kt qu.
Bo ph thiu nin (th tng sn - ph i): va tng th tch, va tng s lng
t bo m, th bo ph ny kh iu tr hn.
4.2. Theo s phn b m
Bo ph dng nam (bo ph kiu bng, bo ph kiu trung tm) (androide
obesity = male pattern): phn b m u th phn cao trn rn nh: gy, c, mt, vai,
cnh tay, ngc, bng trn rn.
Bo ph dng n (gynoid obesity = female pattern): phn b m u th phn
di rn i, mng, cng chn.
Bo ph hn hp: m phn b kh ng u. Cc trng hp qu bo ph
thng l bo ph hn hp.
IV. IU TR
1. Nguyn tc chung
Ch nh u tin l ch tit thc gim cn, phi hp vi tng cng tp luyn
- vn ng th lc tng tiu hao nng lng.
Nu cha t mc ch, ch nh thuc v cc can thip khc.
Mc ch iu tr l gim cn, gim 5-10% trng lng ban u cng ci thin cc
bin chng ca bo ph nh ri lon lipid mu, i tho ng, tng huyt p
2. iu tr c th
2.1. Tit thc gim trng lng
iu tr bo ph cha c bin chng ch yu da vo tit thc gim calo v
gim m. Nng lng a vo phi t hn nhu cu c th, c th huy ng nng
lng t m m. S cn bng m v calo s gip gim trng c th (khong 0,5-1
Kg/tun l ph hp).
249

 Hn ch nng lng khong 20-25 kcalo/kg/ngy. p dng ch tit thc

gim cn v mc cung cp nng lng cn ph thuc tui, hot ng th lc, v mc
tiu gim cn.
Khu phn n c s cn i gia glucid, lipid v protid. Trnh dng nhiu
glucid (nng lng do glucid cung cp khong 50 % nng lng ca phn n, lipid
khong 30% v protid khong 20%), hn ch ng n, m bo ha.
Hn ch bia - ru.
B sung cht x, vitamin, yu t vi lng t cc loi rau, c v hoa qu.
Chia nhiu ba (t nht 3 ba).
Nhn i gim cn l nguy him. Khi i, m v protid s b d ha nhiu,
thiu mui, thiu cc yu t vi lng. V vy, d tn thng cc c quan.
Tit thc gim carbohydrat: Cambridge diet: cung cp y yu t vi lng,
gim glucid, gim cn c hiu qu, khng gy tai bin.
2.2. Tng cng tp luyn-vn ng th lc tng s dng nng lng
Gip gim cn, duy tr cn nng l tng.
Gim TC, TG, LDL-c v Tng HDL-c.
Gp phn kim sot tt ng huyt v huyt p.
Thi gian tp luyn-vn ng th lc khong 60 n 75 pht mi ngy, cng
v thi gian tp ty thuc vo tnh trng sc khe nht l nhng ngi c bnh l
huyt p, mch vnh, suy tim
2.3. Thay i hnh vi (Behavitor modification)
Tr liu thay i hnh vi l mt tr liu tm l ngi bnh bo ph tha nhn
bo ph l mt bnh l, t tch cc tun th cc bin php iu tr nh tit thc gim
calo, tng cng tp luyn - vn ng th lc tng s dng nng lng.
2.4. Thuc
Thuc iu tr bo ph t c kt qu nu khng phi hp vi tit thc gim cn v
tng cng vn ng th lc tng s dng nng lng.
Mt khc dng thuc phi p dng liu trnh lu di v s tng cn tr li khi
ngng thuc.
Mt s ngi bnh khng p ng vi thuc gim cn: sau 4 tun iu tr, cn
khng gim, hoc s gim cn dng li sau 6 thng iu tr, hoc sau mt nm iu tr
c s tng cn tr li mc d thuc vn tip tc dng.
V vy, phn ln cc trng hp bo ph khng nn dng thuc iu tr do
nhiu tc dng ph. Mt s thuc c th dng phi hp vi tit thc gim cn v tng
cng vn ng th lc tng s dng nng lng:
250

Theo United States Food and Drug Aministration, mt s thuc c dng

iu tr bo ph da trn cc tc dng gy chn n, c ch men lipase lm cho m khng
hp thu c.
Sibutramine (meridia): c ch ti hp th Norepinephrine, serotonin, dopamin
vo h thn kinh, dn n tng nng ca chng trong mu gy chn n.
Orlistat (Xenical): c ch men lipase lm cho m khng hp thu c ti h
tiu ha.
Lu , khng bao gi gim cn bng cc thuc li tiu, hormon gip, ring
thuc lm gim lipide ni chung khng nn cho ngay lc u.
2.5. Mt s iu tr c bit
t bng vo d dy, gy cm gic y d dy, cm gic no v hn ch n.
Phu thut ni shunt hng trng d dy lm gim hp thu thc n.
Khu nh d dy
Phu thut ly m bng.
Cc iu tr ny ch dnh cho ngi qu bo, bo ph lm hn ch mi sinh hot,
bo ph gy tn ph cho ngi bnh sau khi tit thc y , tng cng vn ng
th lc, thay i hnh vi khng hiu qu.
Nhn chung vic iu tr bo ph t hiu qu nh mong mun, tt nht l phng
nga bo ph da tit thc gim cn v tng cng vn ng th lc khi mi pht hin
vt trng lng l tng.

251

BO PH
BMI > 23

iu tr

Bc 1

Tit thc gim cn

Tng vn ng th lc tng s dng calo
Thay i hnh vi

Bc 2

Thuc:
Sibutramin
Orlistat

Mt s iu tr c bit:
- t bng vo d dy
- Phu thut ni shunt hng trng d dy
- Khu nh d dy
- Phu thut ly m bng.
iu tr bo ph

V. BIN CHNG CA BO PH
1. Bin chng chuyn ha
Bo ph l mt thnh t ca hi chng chuyn ha (HCCH), s gia tng khi
lng m m qu mc l yu t nguy c ca nhiu thnh t khc trong HCCH.
Ri lon chuyn ha glucid: c tnh trng khng insulin, cng insulin nn dn
n bnh l tin i tho ng, i tho ng typ 2.
Ri lon lipid mu: ngi bo ph, tng nng triglycerid, VLDL-c, gim
HDL-c. Nhiu acid bo t do c gii phng t m m n gan, chng c ester ha

252

ti t bo gan v tr thnh triglycerid. Chng cng c tch vo VLDL ri c gii

phng v lu thng vo tun hon. Tng nng insulin mu cng thc y qu trnh
tng hp acid bo ti gan. Khu phn n cha nhiu carbohydrats cng dn n gan
tng tng hp VLDL. Khi gim cn th nng HDL-c tng, triglycerid, VLDL-c gim.
Ri lon chuyn ha acid uric (Goute): lin quan tng triglycerid, ch tng
acid uric do iu tr thuc chng bo ph (tng thoi bin protein) gy goute cp.
2. Bin chng tim mch
Tng huyt p: do ri lon lipid mu gy x va ng mch. Ngoi ra, tng
huyt p c lin quan khng insulin, cng insulin lm tng hp th Na+ ng thn v
tng cathecholamin lm co mch. C s lin quan gia tng huyt p vi bo ph, khi
gim cn huyt p cng gim theo.
Bnh mch vnh: thiu mu c tim v nng hn na l nhi mu c tim. Bin
chng mch vnh xy ra ngay c khi khng c cc yu t nguy c khc nh tng HA,
T v s trm trng hn khi c phi hp vi cc yu t nguy c ny.
3. Bin chng v tiu ha
Gan nhim m: gan ln tin trin thnh vim gan m, x gan.
Si ti mt: do tng cholesterol trong dch mt v kt tinh thnh nhn ca si.
Vim ty cp: lin quan n tng t l si mt ngi bo ph.
Tro ngc d dy thc qun: ngi bo ph thng xy ra bnh l tro
ngc d dy thc qun hn ngi khng bo ph.
4. Bin chng phi
Gim chc nng h hp: bo ph lm hn ch di ng ca lng ngc khi ht th
nn dn n suy h hp.
Ngng th khi ng (hi chng Pickwick), ng ngy: cng thng gp ngi
bo ph.
5. Bin chng v xng khp
Thoi ha khp (khp gi, khp hng, ct sng), thot v a m, trt ct sng,
hay xy ra ngi bo ph do thng xuyn chu lc nn cao hn so vi ngi
khng bo ph.
6. Bin chng v thn kinh
Bo ph cng l yu t nguy c ca nhi mu no hay xut huyt no do ri lon
lipid mu, x va ng mch, tng huyt p.
7. c thy tinh th (Cataract)
Nguy c tng t l c thy tinh th c lin quan n khng insulin.
253

8. Bin chng v sinh dc

Gim kh nng sinh dc, ri lon kinh nguyt.
9. Bin chng khc
Chng rm lng, tng nguy c ung th, si mt, tc tnh mch, sng ha gan bn
tay, bn chn, rn da, nhim c thai nghn, kh sinh.
VI. D PHNG
Ch tit thc hp l.
Tng cng vn ng - tp luyn th lc.
o BMI pht hin bo ph sm, iu tr kp thi.
Khi pht hin bo ph phi khm huyt p, xt nghim lipid mu, glucosse mu,
acid uric pht hin sm bin chng bo ph v c thi iu tr tch cc.
TI LIU THAM KHO
1. Khuyn co ca Hi Tim mch hc Vit Nam v cc bnh l tim mch v
chuyn ha (2010), trang 1-5
2. Trn Hu Dng (2008), Bo ph, Gio trnh sau i hc chuyn ngnh Ni titchuyn ha, trang 304-312
3. Williams textbook of endocrinology (10th Edition), Disorders of lipid
metabolism, Section 8, pp 1619-1635.
4. Harrisons (18th Editon), Endocrinology and Metabolic, Part 06, chapter 77-78.

254

RI LON CHUYN HA LIPID MU

I. I CNG
Lipid l nhng phn t k nc kh tan trong nc. Lipid c tm thy trong
mng t bo, duy tr tnh nguyn vn ca t bo v cho php t bo cht chia thnh ngn
to nn nhng c quan ring bit.
Lipid l tin thn ca mt s hormon v acid mt, l cht truyn tn hiu ngoi bo
v ni bo. Cc lipoprotein vn chuyn cc phc hp lipid v cung cp cho t bo khp
c th.
Lipid l ngun cung cp nng lng chnh cho c th, tham gia cung cp 25%30% nng lng c th. 1g lipid cung cp n 9,1 kcal. Lipid l ngun nng lng d
tr ln nht trong c th, dng d tr l m trung tnh triglycerid ti m m. Bnh
thng khi lng m thay i theo tui, gii v chng tc.
Nhu cu v lng cha c chnh xc, vo khong 1g/kg th trng ngy, nn
dng lng lipid vi 2/3 du thc vt (acid bo khng bo ha) v 1/3 m ng vt
(acid bo bo ha) vi lng cholesterol di 300 mg/ngy.
Ri lon lipid mu (RLLPM) l tnh trng bnh l khi c mt hoc nhiu thng
s lipid b ri lon (tng cholesterol hoc tng triglicerid, hoc tng LDL-c, hoc gim
HDL-c). RLLPM thng c pht hin cng lc vi mi s bnh l tim mch-ni
tit-chuyn ha. ng thi RLLPM cng l yu t nguy c ca bnh l ny. Nguyn
nhn ca RLLPM c th do nguyn pht nh di truyn hoc th pht do phong cch
sng khng hp l. iu tr RLLPM thay i li sng (tng cng vn ng th lc,
thay i ch n: hn ch bia ru, m ng vt) hoc dng thuc gim lipid mu.
iu tr RLLPM gp phn vo iu tr bnh nguyn ca nhiu bnh tim mch, ni tit,
chuyn ha.
Cc loi lipid mu theo kch thc:
Chilomicron vi dng chp cha triglycerid
VLDL (very low dencity lipoprotein)
LDL (low dencity lipoprotein)
HDL (high dencity lipoprotein)
II. NGUYN NHN
1. Ri lon lipid mu tin pht
RLLPM tin pht do t bin gen lm tng tng hp qu mc cholesterol (TC),
triglicerid (TG), LDL-c hoc gim thanh thi TC, TG, LDL-c hoc gim tng hp HDLc hoc tng thanh thi HDL-L. RLLPM tin pht thng xy ra sm tr em v ngi tr
tui, t khi km th trng bo ph, gm cc trng hp sau:
255

 Tng triglycerid tin pht: L bnh cnh di truyn theo gen ln, biu hin lm
sng thng ngi bnh khng b bo ph, c gan lch ln, cng lch, thiu mu gim
tiu cu, nhi mu lch, vim ty cp gy au bng.
Tng lipid mu hn hp: L bnh cnh di truyn, trong gia nh c nhiu ngi
cng mc bnh. Tng lipid mu hn hp c th do tng tng hp hoc gim thoi bin
cc lipoprotein. Lm sng thng bo ph, ban vng, khng insulin, i ng tp 2,
tng acid uric mu.
2. Ri lon lipid mu th pht
Nguyn nhn ca RLLPM th pht do li sng tnh ti, dng nhiu bia-ru, thc
n giu cht bo bo ha. Cc nguyn nhn th pht khc ca RLLPM nh i tho
ng, bnh thn mn tnh, suy gip, x gan, dng thuc thiazid, corticoides, estrogen,
chn beta giao cm.
Tng triglycerid th pht:
i tho ng: thng tng triglycerid mu do hot tnh enzyme lipoprotein
lipase gim. Nu glucose mu c kim sot tt th triglycerid s gim sau vi tun.
Tng TG mu l yu t nguy c x va ng mch ngi bnh i tho ng
Cng cortisol (Hi chng Cushing): c tnh trng gim d ha cc lipoprotein
do gim hot tnh enzyme lipoprotein lipase. Tnh trng ny cng r hn trong trng
hp km khng insulin v i tho ng.
S dng estrogen: ph n dng estrogen thi gian di, c s gia tng TG do
tng tng hp VLDL. Trong thai k, nng estrogen tng cng lm gia tng TG gp
2-3 ln v s tr li mc bnh thng sau sinh khong 6 tun.
Nghin ru: lm ri lon lipid mu, ch yu tng triglycerid. c bit, ru
lm tng ng k nng triglycerid mu nhng ngi tng sn TG nguyn pht
hoc th pht do cc nguyn nhn khc. Hi chng Zieve tng TC mu, ru chuyn
thnh acetat lm gim s oxyd ha acid bo gan nn acid bo tham gia sn xut TG
gy gan nhim m v tng sn xut VLDL, chc nng gan gim dn n gim hot tnh
enzyme LCAT (Lecithin cholesterol acyltransferase: enzyme ester ha cholesterol) nn
cholesterol ng trong hng cu lm v hng cu gy thiu mu tn huyt.
Bnh thn: trong hi chng thn h, tng VLDL v LDL do gan tng tng hp
b v lng protein mu gim do thi qua nc tiu. TG tng do albumin mu gim
nn acid bo t do gn vi albumin cng gim, acid bo t do tng gn vo lipoprotein
lm cho s thy phn TG ca cc lipoprotein ny b gim.
III. CHN ON
1. Lm sng
Ri lon lipid mu l bnh l sinh hc, xy ra sau mt thi gian di m khng th
nhn bit c, v RLLPM khng c triu chng c trng. Phn ln triu chng lm
sng ca ri lon lipid mu ch c pht hin khi nng cc thnh phn lipid mu

256

cao ko di hoc gy ra cc bin chng cc c quan nh x va ng mch, nhi mu

c tim, tai bin mch no, cc ban vng mi mt, khuu tay, u gi, RLLPM c th
gy vim ty cp. RLLPM thng c pht hin mun trong nhiu bnh l khc nhau
ca nhm bnh tim mch - ni tit - chuyn ha.
1.1. Mt s du chng c hiu ngoi bin ca tng lipid mu
Cung gic mc (arc cornea): Mu trng nht, hnh vng trn hoc khng hon
ton, nh v quanh mng mt, ch im tng TC (typ 2a hoc 2b), thng c gi tr i
vi ngi di 50 tui.
Ban vng (xanthelasma): nh v m mt trn hoc di, khu tr hoc lan ta,
gp typ 2a hoc 2b.
U vng gn (tendon xanthomas): nh v gn dui ca cc ngn v gn
Achille v v tr cc khp t bn ngn tay, c hiu ca typ 2a.
U vng di mng xng (periostea xanthomas): Tm thy c chy trc,
trn u xng ca mm khuu, t gp hn u vng gn.
U vng da hoc c (cutaneous or tuberous xanthomas): nh v khuu v u gi.
Dng ban vng lng bn tay (palmar xanthomas): nh v cc np gp ngn
tay v lng bn tay.
1.2. Mt s du chng ni tng ca tng lipid mu
Nhim lipid vng mc (lipemia retinalis): Soi y mt pht hin nhim lipid
vng mc (lipemia retinalis) trong trng hp Triglycerides mu cao.
Gan nhim m (hepatic steatosis): Tng vng hoc ton b gan, pht hin qua
siu m hoc chp ct lp, thng km tng TG mu.
Vim ty cp: Thng gp khi TG trn 10 gam/L, dng vim cp, bn cp ph
n, amylase mu khng hoc tng va phi.
X va ng mch: L bin chng lu di ca tng lipoprotein, thng phi
hp vi tng lipoprotein khng bit trc , c th phi hp vi mt s yu t nguy c
khc nh thuc l, i tho ng. Tn thng ng mch c khu knh trung bnh v
ln nh tn thng ng mch vnh v tai bin mch mu no thng lin quan nhiu
hn so vi vim tc ng mch hai chi di (u tin n thuc l).
2. Cn lm sng
nh lng bilan lipid: Cc thng s lipid tng ln sau n, nn chn on
chnh xc RLLPM, cn phi ly mu vo bui sng khi cha n (khi i). Cc thng s
thng c kho st: Cholesterol (TC) mu, Triglycerid (TG), LDL-Cholesterol
(LDL-c), HDL-Cholesterol (HDL-c).
Chn on RLLPM c gi khi c mt s du chng ca RLLPM trn lm
sng nh th trng bo ph, ban vng, cc bin chng mt s c quan nh TBMMN,

257

bnh mch vnh Chn on xc nh bng xt nghim cc thng s lipid khi c mt

hoc nhiu ri lon nh sau:
Cholesterol mu > 5,2 mmol/L (200mg/dL)
Triglycerid > 1,7 mmol/L (150mg/dL)
LDL-cholesterol > 2,58mmol/L (100mg/dL)
HDL-cholesterol < 1,03mmol/L (40 mmol/L)
3. Phn loi
Bng 1. Phn loi ri lon lipid mu theo Fredrickdson (1956)
Typ
Lipoprotein
elevated

IIa

Chylomicrons

LDL

IIb

III

LDL and
VLDL

Chylomicron
and
VLDL
remnants

IV
VLDL

V
Chylomicrons
and VLDL

Triglycerides

Cholesterol
(ton phn)

N/

LDL-c

HDL-c

N/

Plasma

Trong

Trong

M (Turbid)

Ban vng
(Xanthomas)

Sn vng

U vng gn
hoc c

Khng

C-sn vng
lng bn
tay

Khng

Sn vng

Vim tu

+++

+++

Bnh
mch
vnh do x
va

+++

+++

+++

+/

+/

X va mch
Mch
mu
ngoi bin

++

+/

+/

Khim khuyt
phn t
(Molecular
defects)

LPL
ApoC-II

Danh php di
truyn
(Genetic
nomenclature)

FCS

LDL receptor,
ApoB-100,
PCSK9,
LDLRAP,
ABCG5
v
ABCG8
FH,
FDB,
ADH, ARH,
sitosterolemia

FCHL

ApoE

ApoA-V

ApoA-V
v
GPIHBP1

FDBL

FHTG

FHTG

(ADH, autosomal dominant hypercholesterolemia; Apo, apolipoprotein; ARH, autosomal

recessive hypercholesterolemia; FCHL, familial combined hyperlipidemia; FCS, familial
chylomicronemia
syndrome;
FDB,
familial
defective
ApoB;
FDBL,
familial
dysbetalipoproteinemia; FH, familial hypercholesterolemia; FHTG, familial hypertriglyceridemia;
LPL, lipoprotein lipase; LDLRAP, LDL receptor associated protein; GPIHBP1,
glycosylphosphatidylinositol-anchored high density lipoprotein binding protein1; N, normal).

258

IV. IU TR
1. Nguyn tc chung
iu tr RLLPM phi kt hp thay i li sng v dng thuc. Thay i li sng
l ch nh u tin, bao gm tng cng tp luyn - vn ng th lc, nht l nhng
ngi lm cng vic tnh ti, v iu chnh ch tit thc hp l vi th trng v tnh
cht cng vic.
chn la k hoch iu tr thch hp, ngy nay ngi ta thng da trn bo
co ln ba ca Chng trnh Gio dc Quc gia v Cholesterol ti M (NCEP-National
Cholesterol Education program) v ca y ban iu tr tng Cholesterol ngi trng
thnh (ATPIII-Adult Treatment Panel III). Hng dn ca NCEP da trn im ct lm
sng ti c s gia tng nguy c tng i ca bnh l mch vnh.
Bng 2. nh gi ri lon lipid mu theo NCEP ATPIII (2001)
Thng s lipid

Nng

nh gi nguy c

< 200
200-239
240

Bnh thng
Cao gii hn
Cao

< 150
150-199
200-499
500

Bnh thng
Cao gii hn
Cao
Rt cao

LDL-c (mg/dL)

< 100
100-129
130-159
160-189
190

Ti u
Gn ti u
Cao gii hn
Cao
Rt cao

HDL-c (mg/dL)

< 40
60

Thp
Cao

CT (mg/dL)

TG (mg/dL)

2. Tp luyn - vn ng th lc
Gip gim cn, duy tr cn nng l tng.
Gim TC, TG, LDL-c v Tng HDL-c
Gp phn kim sot tt ng huyt v huyt p
Thi gian tp luyn - vn ng th lc khong 30 n 45 pht mi ngy, 5 ngy
mi tun, cng v thi gian tp ty thuc vo tnh trng sc khe nht l nhng
ngi c bnh l huyt p, mch vnh, suy tim
3. Ch tit thc
Hn ch nng lng nht l nhng ngi bo ph.
Hn ch m cha nhiu acid bo bo ha nh m trong tht heo, tht b, tht
cu, gim cholesterol c trong lng trng, b, tm Tng lng acid bo khng
bo ha c trong cc loi thc vt nh du u nnh, du liu, du bp, trong m c
259

 Khu phn n c s cn i gia glucid, lipid v protid. Trnh dng nhiu

glucid (nng lng do glucid cung cp khong 50% nng lng ca phn n, lipid
khong 30% v protid khong 20%).
Hn ch bia - ru.
B sung cht x, vitamin, yu t vi lng t cc loi rau, c v hoa qu.
4. Thuc gim lipid mu
Thay i li sng sau 2-3 thng m khng em li hiu qu nh mong mun th
ch nh iu tr vi cc loi thuc h lipid mu:
4.1. Nhm statin (HMG-CoA reductase inhibitors)
Tc dng: c ch enzym Hydroxymethylglutaryl CoA Reductase l mt enzym
tng hp TC, lm gim TC ni sinh, kch thch tng tng hp th th LDL-c nn tng
thu gi LDL-c ti gan. Kt qu s gim LDL-c, VLDL, TC, TG v tng HDL-c. Ngoi
ra nhm statin cn gim qu trnh vim ca ni mc mch mu, gip thoi trin mng
x va, tng tng hp nitric oxide (ON) ca t bo ni mc.
Liu lng v tn thuc:
Atorvastatin: 10-20mg/ngy, liu ti a 80 mg/ngy.
Rosuvastatin: 10-20mg/ngy, liu ti a 40 mg/ngy.
Simvastatin: 10-20 mg/ngy, liu ti a 80 mg/ngy.
Lovastatin: 20-40 mg/ngy, liu ti a 80 mg/ngy.
Fluvastatin: 20-40 mg/ngy, liu ti a 80 mg/ngy.
Pravastatin: 20-40 mg/ngy, liu ti a 80 mg/ngy.
Tc dng khng mong mun c th gp: tng men gan, tng men c khi dng
liu cao, hoc c a ngi gi, hoc ang dng nhiu loi thuc nh khng sinh nhm
macrolide.
Thn trng i vi ngi bnh c bnh l gan.
Ch nh: tng LDL-c, tng TC.
4.2. Nhm fibrate
Tc dng: lm gim TG do kch thch PPAR alpha lm tng oxy ha acid bo,
tng tng hp enzym LPL, lm tng thanh thi cc lipoprotein giu TG, c ch tng hp
apoC-III gan, tng thanh thi VLDL. Cc fibrat cng lm tng HDL do thc y trnh
din apoA-I v apoA-II.
Liu lng v tn thuc:
Gemfibrozil: liu thng p dng trn lm sng: 600 mg/ngy.

260

 Clofibrat: 1000 mg/ngy.

Fenofibrat: 145 mg/ngy.
Tc dng khng mong mun:
Cc triu chng ri lon tiu ha nh y hi, trng bng, bun nn, gim
nh chc nng gan, tng men gan, si mt, tng men c, pht ban. Tc dng ph thng
xy ra khi dng liu cao, hoc c a ngi gi, hoc c bnh l thn, gan trc.
Lm tng tc dng thuc chng ng, nht l nhm khng vitamin K.
Khng dng cho ph n c thai hoc cho con b, ngi bnh suy gan, suy thn.
Ch nh iu tr: tng TG.
4.3. Nhm acid Nicotinic (Niacin, vitamin PP).
Thuc c tc dng gim TG do c ch phn hy t t chc m v gim tng
hp TG gan, c ch tng hp v ester ha acid bo ti gan, tng thoi bin apo B,
gim VLDL, gim LDL, v tng HDL (do gim thanh thi apoA-I).
Liu lng v cc bit dc (Niacor, Niaspan, Slo-niacin):
Loi phng thch nhanh: 100 mg/dL, liu ti a 1000 mg/ngy.
Loi phng thch nhanh: 250 mg/dL, liu ti a 1500 mg/ngy.
Loi phng thch nhanh: 500 mg/dL, liu ti a 2000 mg/ngy.
Tc dng khng mong mun: phng mt, nga, cc triu chng ri lon tiu
ha nh y hi, trng bng, bun nn, gim nh chc nng gan, tng men gan, si
mt, tng men c, pht ban, tng khng insulin. Tc dng ph thng xy ra khi
dng liu cao, hoc c a tui ngi gi, hoc c bnh l thn, gan trc.
Ch nh: tng LDL-C, gim HDL-C, tng TG.
4.4. Nhm Resin (Bile acid sequestrants)
Resin trao i ion Cl- vi acid mt, tng tng hp acid mt t cholesterol, lm
tng bi tit mt v gim cholesterol gan, kch thch tng hp th th LDL-c, tng thi
LDL-c.
Liu lng v tn thuc:
Cholestyramin: 4 -8 g/ngy, liu ti a 32 mg/ngy.
Colestipol liu: 5 -10 g/ngy, liu ti a 40 mg/ngy.
Colesevelam: 3750 g/ngy, liu ti a 4375 mg/ngy.
Ch nh trong trng hp tng LDL-c.
Tc dng khng mong mun: cc triu chng ri lon tiu ha nh y hi,
trng bng, bun nn, to bn.
261

4.5. Ezetimibe
Thuc c ch hp th TC ti rut, lm gim LDL-c v tng HDL-c.
Tc dng ph: thuc rt t tc dng ph, c th gp tng men gan.
Liu lng: 10mg/ngy.
Ch nh: tng LDL-c.
4.6. Omega 3 (Fish Oils)
C ch tng d ha TG gan.
Liu thng p dng trn lm sng: 3g/ngy, liu ti a 6g/ngy.
Tc dng khng mong mun: cc triu chng ri lon tiu ha nh y hi,
trng bng, tiu chy.
Ch nh trong trng hp tng TG.
* Ch :
Cc thuc iu tr ri lon lipid mu u chuyn ha qua gan. Do vy trong thi
gian s dng thuc h lipid mu, cn cho cc thuc h tr v bo v t bo gan.
V. TIN TRIN V BIN CHNG
Ri lon lipid mu khng c iu tr c th gy ra bin chng cc c quan:
Mt s du chng c hiu ngoi bin ca tng lipid mu: cung gic mc,
cc ban vng mi mt, u vng gn khuu tay, u gi, bn tay, gt chn, mng xng.
Mt s du chng ni tng ca tng lipid mu: nhim lipid vng mc
(lipemia retinalis), gan nhim m, c th gy vim ty cp.
X va ng mch: tn thng ng mch c khu knh trung bnh v ln
nh tn thng ng mch vnh gy nhi mu c tim, tn thng mch mu no gy tai
bin mch no, tn thng ng mch hai chi di gy vim tc thiu mu hoi t bn chn.
VI. D PHNG
Ch tit thc hp l.
Tng cng vn ng-tp luyn th lc.
Xt nghim lipid mu nh k, nht l i vi ngi c yu t nguy c nh i
tho ng, bo ph
Khi pht hin c ri lon lipid mu nn iu tr sm.

262

TI LIU THAM KHO

1. Khuyn co ca Hi Tim mch hc Vit Nam v cc bnh l tim mch v
chuyn ha (2010), trang 1-5
2. Nguyn Hi Thy (2008), Ri lon lipid mu, Gio trnh sau i hc chuyn
ngnh Ni tit-chuyn ha, trang 246-303
3. Williams textbook of endocrinology (10th Edition), Disorders of lipid
metabolism, Section 8, pp 1642-1706.
4. Harrisons (18th Editon), Endocrinology and Metabolic, Part 16, chapter 356.

263

Chn on RLLPM

TG > 150mg/dL

TC > 200mg/dL

LDL-c >100mg/dL

HDL-c < 40 mmol/L

iu tr

Bc 1

Thay i li sng

nh gi Bilan lipid sau 2-3 thng

t mc tiu

Cha t mc tiu

Thay i li sng

TC > 200mg/dL

TG > 150mg/dL

LDL-c >100mg/dL

HDL-c < 40 mmol/L

Bc 2
Thay i li sng
Thuc gim lipid

Statin

Fibrate
Nicotinic
Omega 3

Acid

Statin
Acid Nicotinic Resin
Ezetimibe

iu tr ri lon lipid mu

264

Acid Nicotinic

TNG CALCI MU
I. I CNG
Calci rt cn hnh thnh xng v hot ng chc nng thn kinh c. Gn 99%
calci ca c th trong xng, ch 1% duy tr trong huyt tng v dch ngoi bo.
Khong 50% calci huyt tng dng ion t do (Ca2+), cn li dng kt hp, ch yu
kt kp vi albumin (40%), vi cc anion khc nh phosphat v citrat (10%). S thay
i ca albumin huyt tng, c bit s gim albumin, lm thay i calci huyt tng
ton phn, nhng khng lm thay i calci ion. Nu albumin huyt tng khng bnh
thng, th quyt nh lm sng phi da vo nng calci ion, cn khong 4,6 n
5,1mg/dl cho hot ng bnh thng chc nng thn kinh c.
Chuyn ha calci c iu chnh bi hormon cn gip (Parathyroid hormone PTH) v chuyn ha vitamin D. PTH lm tng calci huyt tng do kch thch tiu
xng, tng ti hp thu calci ti thn, tng cng chuyn dng vitamin D v cc hot
ng chuyn ha ca vitamin D. PTH cng lm tng tit phosphate thn. Ch c calci
ion c vai tr iu chnh tit PTH qua c ch feedback: gim calci kch thch tit PTH
v tng calci c ch tit PTH.
Vitamin D c hp thu t thc n v tng hp trong da sau khi tip xc vi nh
nng mt tri. Gan chuyn ha n thnh 25-hydroxyvitamin D3 [25(OH)], quay tr li
chuyn dng bi thn thnh 1,25(OH)2D3. S tng hp 1,25(OH)2D3 c kch thch
bi PTH v gim phosphate huyt tng, v b c ch bi tng phosphat huyt tng.
Khu cui cng chuyn ha lm tng calci l tng hp thu calci, tng hp thu phosphat
ti rut.
Calci trong t bo dng calci ion t do (Ca2+), nng calci trong t bo l
0,1mol/l, nh hn 10.000 ln so vi ngoi t bo. duy tr chnh ca calci trong
v ngoi t bo, s vn chuyn calci qua mng t bo ph thuc vo bm calci v s
thay i ca ion Na+, Ca2+.
Bng 1. Hm lng calci bnh thng huyt tng v trong t bo
Calci ton phn huyt tng

8,5 10,5 mg/dl

2,1 2,6 mmol/l

Calci ion huyt tng

4,4 5,2 mg/dl

1,1 1,3 mmol/l

Calci lin kt protein huyt tng

4,0 4,6 mg/dl

0,9 - 1,1 mmol/l

Phc hp calci huyt tng

0,7 mg/dl

0,18 mmol/l

Calci ion trong t bo

0,00018 mmol/l

180 nmol/l

II. NGUYN NHN

Tng calci mu lun l nguyn nhn ca tng calci vo dch ngoi bo (t tiu
xng hoc tng hp thu ti rut) v gim bi tit ti thn. Hn 90% cc trng hp do
bnh ca tuyn cn gip hoc bnh c tnh.
265

1. Tng calci mu do cng tuyn cn gip

Cng cn gip nguyn pht gy ra phn ln nhng trng hp tng calci mu
ngi bnh cp cu. y l bnh thng gp, c bit l ph n ln tui, chim
khong 2/1000 trng hp tai nn hng nm. Gn 85% l do u mt tuyn, 15% do ph
i m ca c bn tuyn v 1% do ung th tuyn cn gip.
2. Tng calci mu trong cc bnh c tnh
Thng thy tng calci mu phn ng, gp a s cc trng hp ngi bnh ni
tr. Tng calci mu theo hai c ch ch yu:
Tng calci mu do tiu xng ti ch, pht trin t bo u, cc cytokine vng
hot ng kch thch hy xng. Dng tng calci mu c tnh ch xy ra vi cc xng
dt lin quan n cc khi u, thng do u v, u ty xng v u lympho.
Tng calci mu th dch (humoral hypercalcimia) nhng bnh c tnh, cc
dch tit t khi u nh hng ti ton thn kch thch tiu xng, trong nhiu trng
hp lm gim thi calci. Cc peptide lin quan n PTH l marker rt quan trng trong
hi chng ny (nhng hot ng theo con ng receptor th khng pht hin c
bng phn ng min dch PTH); c th cc yu t pht trin (growth factors) cng tham
gia vo qu trnh pht trin u. Tng calci mu th dch phn ln trong bnh c tnh nh
ung th biu m vy ca phi, vng u, c, thanh qun, hoc ung th thn, bng quang,
bung trng.
Ngi bnh c bnh c tnh thng c tng calci mu trc khi bnh c triu
chng lm sng r rt.
3. Tng calci mu do nhng nguyn nhn khc
Bnh Sarcoid, ng c vitamin D, cng gip trng, s dng lithium, hi
chng nhim kim v gi bt ng. Dng li tiu thiazid lm tng calci mu ko di.
Bnh tng calci mu gim calci niu gia nh rt t gp, bnh t nhim sc nh
hnh gen tri, c trng bi hi chng tng calci mu khng triu chng t nh v c
tin s gia nh tng calci mu.
III. CHN ON
1. Lm sng
Triu chng lm sng thng xut hin khi calci mu vt qu 12mg/dl v c xu
hng nng hn khi tng calci mu tin trin nhanh.
Triu chng thn bao gm a niu (polyuria) v si thn.
Hi chng GI bao gm suy nhc, nn, thiu mu, mt mi, l m, trng thi
sng s, hn m.
a niu, nn c th l nguyn nhn gy ra mt nc, lm gim thi calci v
lm xu i nhanh tnh trng tng calci mu.

266

2. Cn lm sng
Calci mu trn 12 mg/dl.
PTH huyt tng trn 72 pg/ml, trong 90% trng hp cng cn gip, cn xt
nghim PTH huyt tng ring, c lp vi chc nng thn.
Nng 1,25(OH)2D3 tng trong bnh Sarcoid.
in tim thy khong PQ ngn.
3. Chn on xc nh
Da vo (1) tng calci mu, (2) tin s si thn, (3) triu chng lm sng ca bt c
nguyn nhn no gy tng calci mu, (4) hi chng v cc du hiu lm sng ca bnh.
4. Chn on phn bit
Trng hp tng albumin huyt tng c th lm tng nh calci ton phn, khng
nh hng n calci ion. Bi th cn xt nghim calci ion xc nh tng calci mu
tht s.
IV. IU TR
1. Nguyn tc chung
Nguyn tc iu tr tng calci mu l tng thi calci v gim tiu xng.
Mc ch iu tr l gim triu chng, hn l a calci huyt tng v mc gn
bnh thng.
Bc u tin l b th tch tun hon, tip theo l li tiu mui (saline
diuresis). Thuc c ch tiu xng cn c s dng sm.
2. iu tr cp cu tng calci mu
Khi nng calci mu trn 12 mg/dl
2.1. Phc hi th tch tun hon
Truyn dung dch Natriclorua 0,9% ngay t u cho nhng ngi bnh c tng
calci mu nng, nhng ngi ny thng c gim khi lng tun hon. Mc ch
nhm phc hi mc lc cu thn v bnh thng.
Tc truyn lc u c th ti 300- 500ml/gi. Khi th tch tun hon c
p ng mt phn th gim tc truyn. t nht trong ngy u phi truyn c 3-4lt
dch, nhng ngy sau lng dch gim dn, cho ti khi lng dch cn bng 2l/ ngy.
2.2. Li tiu mui
Sau khi th tch tun hon c phc hi, truyn dung dch Natriclorua 0,9% vi
tc 100-200 ml/gi. Furocemid 20-40 mg, tim tnh mch mi 2 gi. Khng dng li
tiu thiazid v n lm gim thi calci.
267

Cn theo di cc du hiu ca suy tim phng suy tim tin trin. Theo di in
gii , calci, magie mi 6-12 gi, bo m kali v magie.
2.3. Thuc c ch tiu xng
Pamidronat l mt bisphosphonat c ch qu trnh hy xng.
Liu n: 60mg + 500ml Naclorua 0,9% hoc Dextro 5% truyn trong 2-4 gi.
Trng hp tng calci nng (> 13,5 mg/dl): 90 mg + 1000ml dch ng trng
truyn trong 2-4 gi.
Phn ng h calci c th thy trong vng 2 ngy v nh cao l khong 7 ngy,
c th ko di vi tun hoc lu hn.
iu tr c th nhc li nu tng calci ti din. Tc dng khng mong mun
bao gm: h calci, h magie, h phosphat, st nh thong qua.
Zonedronat l thuc c kh nng nh hng ti bisphosphonat nhiu hn, c
ch nh trong trng hp tng calci mu ngi c bnh c tnh.
Liu n: 4mg + 100ml dung dch Nacl 0,9% hoc Dextro 5% c truyn ti
thiu trong 15pht. iu tr nhc li khng c di 7 ngy.
Trong thi gian iu tr bng bisphosphonate c th gy gim chc nng thn
do s kt ta bisphosphonat calci. Bi ph nc phi c tin hnh trc khi s dng
bisphosphonat, nhng ngi bnh c thiu nng chc nng thn chng ch nh s dng
nhng thuc ny.
Calcitonin: c ch s tiu xng v tng thi calci thn.
Calcitonin c hi 4-8 UI/kg tim bp hoc di da mi 6-12 gi, 60-70%
ngi bnh c calci huyt tng thp hn 1- 2mg/dl trong vng vi gi.
H calci mu c th xy ra sau vi ngy do tc dng ca thuc.
Calcitonin c tc dng km hn nhng thuc c ch tiu xng khc nhng
khng gy ng c nng, an ton cho ngi suy thn, c th c tc dng gim au
nhng ngi bnh c di cn c. Nn s dng thuc sm trong iu tr tng calci mu
nng c p ng nhanh. S dng ng thi vi bisphosphonat s mang li tc dng
ko di.
Tc dng khng mong mun: bng mt, bun nn, him gp phn ng d ng.
2.4. Glucocorticoid
Lm gim calci mu bi c ch gii phng cytokine, nh hng trc tip ln
mt s t bo u, c ch hp thu calci rut v tng thi calci qua nc tiu.
Ch nh cho ngi bnh tng calci do u ty, cc bnh mu c tnh, ung th
hch (bnh Sarcoidosis), v nhim c vitamin D. Rt him c p ng ca cc u khc.

268

 Liu bt u ca prednisolon ung l 20-50mg/ngy. Calci huyt tng gim

sau 5- 10 ngy. Sau khi nng calci huyt tng n nh, gim dn liu ti liu ti
thiu cn kim sot hi chng tng calci mu v hn ch ng c do lm dng (s
dng thuc khng ng trong thi gian s dng ko di).
2.5. Phosphat ung
c ch hp thu calci, v tng chuyn calci vo xng v t chc mm.
C th s dng n thun nu nng phosphoras < 3mg/dl v chc nng thn
bnh thng, nguy c calci ha t chc mm mc ti thiu. Phosphate 0,5 -1,0
mg/ln, ung ngy 2-3 ln.
Thng xuyn theo di calci, phosphorus, creatinin mu, gim liu khi
phosphorus > 4,5 mg/dl hoc cc phc hp calci v phosphorus > 60 mg/dl.
Tc dng khng mong mun: a chy, nn, calci ha t chc mm.
Phosphate khng bao gi c ch nh tim tnh mch.
2.6. Thm phn
Lc mu v lc mng bng c hiu qu trong iu tr tng calci mu. Nhng
phng php ny c s dng gip cho ngi bnh suy tim cp hoc suy thn khng
th dung np c nc.
3. iu tr tng calci mu mn tnh
3.1. iu tr cng cn gip nguyn pht
Phu thut ct tuyn cn gip:
L phng php duy nht iu tr hiu qu bnh cng cn gip nguyn pht.
Bnh s t nhin ca hi chng cng cn gip cha c bit y , nhng nhiu
ngi bnh c ri lon lnh tnh th dch (course), vi rt t thay i tm thy trn lm
sng hoc nng calci mu tng trong nhiu nm. C th qu trnh mt khi lng
xng v tng nguy c gy xng l nhng lin quan chnh, nhng kh nng xut hin
bin chng ny thp. C th thy tn thng chc nng thn, nhng khng phn bit
c vi gim chc nng do si thn.
Ch nh phu thut tuyn cn gip bao gm:
* Hi chng tng calci mu;
* Si thn;
* Gim khi lng xng > 2SD di mc trung bnh so vi tui;
* Calci huyt tng > 12mg/dl;
* Tui < 50;
* Khng c kh nng iu tr theo thi gian di.

269

 Phu thut l mt la chn ph hp nhng ngi bnh khe nn thng

thnh cng cao, t l ti mc v t l t vong thp. Nhng ngi bnh khng c triu
chng phi theo di bng sng lc nh gi lm sng v calci, creatinin mu trong
khong 6- 12 thng. nh gi khi lng xng hng hng nm. Phu thut li nn
c cn nhc nu c bt c mt trong cc tiu chun trn tin trin, hoc mt khi
lng xng v gim chc nng thn tin trin.
Phu thut thnh cng 90- 95%. Sau phu thut thng c mt giai on ngn
bnh an (t 1-2 ngy), h calci mu khng triu chng. Mt s trng hp bnh xng
r, h calci mu c th xy ra nng v ko di (gi l hi chng xng i), i hi
iu tr tn cng bng calci v vitamin D. Nhng bin chng khc bao gm: h calci
mu vnh vin v tn thng dy thn kinh thanh qun cp. Nhng trng hp phu
thut li c t l thnh cng thp v nguy c bin chng cao, cn thc hin nhng
trung tm c uy tn.
iu tr ni khoa khng c hiu qu i vi cng cn gip nguyn pht.
Tuy nhin, ph n thi k mn kinh, iu tr thay th bng estrogen c tc dng
bo v khi lng xng, vi nh hng t nht ti calci ion huyt tng hoc lng
PTH. Nhng ngi bnh cng tuyn cn gip t chi phu thut hoc khng th chp
nhn c phu thut th khuyn khch hot ng th lc, ng thi vi ch n nhiu
mui, dch (2-3lt dch v 8-10 g mui mi ngy). Hn ch thc n c nhiu calci,
khng c dng li tiu thiazid. Ung phosphat c th s dng khi ngi bnh c hi
chng tng calci mu khng phu thut c, nhng li ch v nguy c tng ng
nhau.
3.2. iu tr tng calci mu do cc bnh c tnh
Kh c kt qu trong mt thi gian di, ch kim sot c hi chng tng calci
mu khi iu tr ung th c hiu qu.
iu tr tng calci mu c th lm du i hi chng chn n, bun nn, kh chu.
Sau giai on tng calci mu cp, nn duy tr ch luyn tp th lc v cn
bng th dch, vi lng dch 2-3lt/ngy. Ch n bo m 8-10g mui, ba n hn
ch calci khng c li. C th s dng thuc nh sau:
Nhc li liu Pamidronat tim tnh mch nu c tng calci mu ti din.
Plicamycin l mt thuc c ch tiu xng, c th c s dng iu tr nh
dng th hai nu Pamidronat khng hiu qu, thuc c nh hng khng tt ti mu,
thn, gan.
Prednisolon 20-50 mg/ln, ung 2-3 ln/ngy, thng xuyn kim tra calci
mu trong bnh a u ty xng v cc bnh mu c tnh khc.
Ung phosphat c th c p dng nu phospho huyt tng thp v chc
nng thn bnh thng.

270

3.3. Tng calci mu do cc bnh l khc

Nn iu tr bng prednisolon v ba n gim calci (< 400mg/ngy). Tng
calci mu do Sarcoidosis thng p ng vi prednisolon, liu 10-20mg/ngy c th
kim sot lu di.
Vitamin D c th lm gim au trong thi gian 2 thng t khi s dng, nhng
ng c vitamin D s lm gim thi gian sng.
V. TIN TRIN V BIN CHNG
Nhng trng hp tng calci mu do cng tuyn cn gip nguyn pht khng
c triu chng tng calci mu lm sng, c pht hin ngu nhin thy nng PTH
tng th c din bin nh, an ton cho ngi bnh.
Tng calci mu do bnh c tnh hoc nhng bnh him gp khc th lun c
nhng bng chng v tin s, khm thc th, xt nghim thng thng thy nng
PTH khng tng. nhng ngi bnh ny thng c hi chng tng calci mu nng v
pht trin nhanh.
Tng calci mu, gim calci niu gia nh rt him gp, PTH khng tng, bnh din
bin nh, nhiu trng hp khng c triu chng lm sng.
Khi tng calci v phosphat huyt tng d lng ng mui phosphate calci gy
si thn, c xng (osteopenia), hoc c th gp vim xng x ha.
TI LIU THAM KHO
1. Gordon J. Strewler, MD (1997), Hypercalemia, Francis S. Greenspan, Gordon J.
Strewler, Basic and Clinical endocriology, fifth edition. Prentice- Hall International Inc.
Appleton and Lange, PO Box 120041, Stamford, USA, 276- 286.
2. Gordon J. Strewler, MD (1997), Parathyroid hormon, Francis S. Greenspan,
Gordon J. Strewler, Basic and Clinical endocriology, fifth edition. Prentice- Hall
International Inc. Appleton and Lange, PO Box 120041, Stamford, USA, 264- 269.
3. Harry Giles, Anitha Vijayan (2005), Fluid and electrolyte management, Gopa
B. Green, Lan S. Harris, Grace A. Lin, Kyle C. Moylan, The Washington Manual TM of
medical therapeutics, 31st edition. Lippincott Williams and Wilkins, USA, 39- 65.
4. Paul A. Fitzgerald (2009), The Parathyroids, Stephen J. McPhee, Maxine A.
Papadakis, Current medical diagnosis and treatment 2009, forty- eighth edition. The
McGraw- Hill Companies, Inc.USA, 1004- 1012.

271

H CALCI MU
I. I CNG
H calci mu l mt bnh hay gp do nhiu nguyn nhn gy ra. Triu chng ca h
calci mu xy ra l do tng kch thch thn kinh c. Nng calci huyt tng t 7-9mg/dl
l mc thp nht c th xut hin triu chng kch thch thn kinh c do h calci mu.
Hormon tuyn cn gip (PTH: Parathyroid hormone) v vitamin D (1,25
(OH)2D3) c chc nng duy tr hm lng calci mu v c coi nh l trung tm bo
v chng h calci mu.
50% calci huyt tng v dch ngoi bo dng calci ion, cn li dng lin kt
vi albumin (40%) v cc anion khc nh phosphat, citrat (10%). Calci dng phc
hp l cht tr khng chu s iu chnh ca hormon. Ch c calci ion (Ca2+) lin quan
n PTH v vitamin D trong s iu chnh hm lng calci huyt tng v dch ngoi
bo, nu calci ion bnh thng th khng c triu chng ca ri lon chuyn ha calci.
H calci mu mn tnh c th l hu qu ca gim tit PTH, thiu vitamin D, hoc
suy gim phn ng ti PTH hoc vitamin D.
Bng 1. Hm lng calci bnh thng trong huyt tng
Calci ton phn

8,5 10,5 mg/dl

2,1 2,6 mmol/l

Calci ion

4,4 5,2 mg/dl

1,1 1,3 mmol/l

Calci lin kt protein

4,0 4,6 mg/dl

0,9 - 1,1 mmol/l

Phc hp calci

0,7 mg/dl

0,18 mmol/l

II. NGUYN NHN

Gim calci huyt tng c nhiu nguyn nhn: suy thn, thiu nng tuyn cn
gip, h magnesi mu nng, tng magnesi, vim ty cp, thiu vitamin D, khng PTH,
tiu c vn, hi chng phn gii u, him gp ng c citrate trong truyn mu nhiu
citrat. Mt s thuc c th gy h calci mu nh thuc chng tng sinh u (ciplatin,
cytosin arabinossid), thuc khng sinh (pentamidin, ketoconazol, foscarnet), li tiu
quai v nhng thuc iu tr tng calci mu.
Calci huyt tng gim cn gp ngi bnh m nng c ri lon hp thu gy
gim albumin huyt tng. i khi h calci mu khng tm thy nguyn nhn.
III. CHN ON
1. Lm sng
Triu chng lm sng thay i theo mc v tc khi u: triu chng rt
in hnh trong trng hp h calci mu cp; h calci mu mn tnh c th khng c
triu chng.
272

Khm lm sng cn lu nhng du hiu (1) so vng c (c th lin quan n

phu thut tuyn cn gip), (2) bnh tuyn cn gip, (3) h calci mu c tnh cht gia
nh, (4) Thuc gy h calci mu hoc magnesi mu, (5) nhng iu kin gy thiu
vitamin D, (6) pht hin gi thiu nng tuyn cn gip (ln, xng bn tay ngn). H
calci mu c th l nguyn nhn gy ra c thy tinh th, vi ha hch y (basal
ganglia calcification), vi ha da.
Cn h calci mu in hnh (cn tetany):
u tin ngi bnh c cm gic t b u chi, li v quanh ming, km theo
cm gic lo u, mt mi, hi hp; cc du hiu vn ng khng bnh thng nh: co
tht cc nhm c u chi, chut rt xut hin t nhin hoc khi g vo.
au bng kiu chut rt, co rt bn chn, nhn i, i rt, co tht thanh mn.
Du hiu Trousseau v du hiu Chvostek dng tnh. Du hiu Trousseau
xut hin khi o huyt p v gi mc cao hn huyt p ng mch 20 mmHg trong 3
pht. Du hiu Chvostek dng tnh khi g nh vo v tr dy thn kinh mt pha trc
di tai 2cm.
C th co git cc th c.
Cc c co bp khng t ch c th gy c ng bt thng lm ngi bnh
au n: c tay gp vo cng tay, ngn tay gp vo bn tay nhng vn dui cng, ngn
tay khp vo trong - hnh dng ca bn tay ngi . Cc du hiu ny xut hin nu
ngi bnh th nhanh su, hoc nu buc ga r cm mu cnh tay.
Nng hn, cc c chi di cng c th gp: hng v u gi dui cng, i
khp li, bn chn v ngn chn dui ti a.
Trng hp h calci mu nng dn ti chng ng lm, tm thn ln xn, m h.
Him gp co tht c thanh qun, cn au t ngt hoc suy tim. tr nh, thanh mn
c th b co tht, gy kh th vo, dn n suy h hp v i khi t vong.
2. Cn lm sng
Calci huyt tng thp di 8,8 mg/dl (di 2,2mmol/l), calci ion ha di
4,48 4,92 mg/dl (di 1,12 1,23 mmol/l).
Phosphate tng, phosphatase kim bnh thng;
PTH gim trong thiu nng tuyn cn gip;
Hm lng vitamin D thp, magnesi thp.
in tim c th thy sng QT ko di do ST di, nhng khng c sng U, sng
T v QT bnh thng.
Chp ct lp vi tnh s no c th thy hnh nh vi ha hch y, xng c
hn bnh thng.
3. Chn on xc nh
Du hiu tetany, co cng c khp (carpopedal spalms), kch thch xung quanh
ming, chn, tay; chut rt chn tay v c bng, thay i tm l.
Du hiu Chvostek v Trousseau dng tnh.

273

 Xt nghim mu: calci thp, phosphat huyt tng tng, phosphatase kim bnh
thng, magnesi c th thp.
Calci niu gim.
4. Chn on phn bit
Un vn (co cng c ton thn vi triu chng u tin l cng hm, khng
p ng khi tim calci tnh mch).
Ng c strychnine, m tin.
Bnh bch hu, hi chng vim no, ng kinh.
IV. IU TR
1. iu tr h calci mu cp
1.1. Ngi ln hoc tr ln (trn 6 tui)
Calci clorid hay calci gluconat 2g tim chm tnh mch (20ml dung dch
calcigluconat 10%) trong 10 pht
Sau c th tim ngy nhiu ln hoc truyn 6g calcigluconat pha trong
500ml dung dch Dextro 5% trong 4-6 gi. Tc truyn phi ph hp, trnh ti din
hi chng h calci v duy tr mc calci mu trong khong 8-9 mg/dl (2mmol/l). Lng
dch truyn gim dn.
Lu :
Khng c pha trn calci v bicarbonate truyn v dung dch kim lm
tng gn calci vi albumin v lm tng nhy ca hi chng.
nhng ngi bnh s dng Digoxin phi theo di in tim.
Tim calci nhanh tnh mch c th gy ngng tim, nu tim ra ngoi mch
mu s gy hoi t da v t chc di da xung quanh v tr tim.
1.2. Tr nh
Trong mi trng hp, cn cho ung calci loi 10%, 15 ml mi ln, 3-4 ln/ngy
hoc hn dch calcilactat 6% mi ln 5ml, 3-4 ln/ngy.
2. iu tr h calci mu mn tnh
Bi ph calci ung: Calcicarbonat (vin 250 hoc 500mg)
Khi u 1-2g/ngy.
Thi gian iu tr ko di, ung 0,5 -1g/ngy. Calcicarbonat hp thu rt tt vi
thc n, k c vi nhng ngi bnh b thiu toan dch v.
Vitamin D:
Trng hp thiu vitamin D trong ba n hng ngy c th cho ung 4001000v/ngy.
Cc bnh h calci mu khc i hi liu vitamin D cao hn, liu khi u
50.000UI/ngy, liu duy tr 25.000 100.000 UI/ ngy. C th tng liu trong thi gian
4-6 tun.
274

 Trng hp tng phosphate mu nng (di 6,5 mg/dl), bt buc ung

phosphate trc khi ung vitamin D.
Calcitriol (vin 0,25 hoc 0,5g) c tc dng nhanh. Ung liu khi u
0,25g/ ngy, c th tng liu thuc sau 2 n 4 tun. Liu duy tr t 0,5 n 2g/ ngy.
Calcitriol t hn vitamin D, nhng t nguy c ng c, y l la chn tt nht cho a
s ngi bnh.
V. TIN TRIN V BIN CHNG
H calci mu nh hng n h thn kinh trung ng, 20% tr em b h calci
mu mn tnh tin trin thnh thiu nng tr tu. Nhng ngi bnh h calci mu mn
tnh do thiu nng tuyn cn gip hoc gi thiu nng tuyn cn gip hay gp vi ha
hch y. Bi th, mc d khng c triu chng nhng h calci mu mn tnh vn dn
ti nhng bt thng v h vn ng.
Tng calci mu tin trin do thuc: khi c triu chng tng calci mu th phi
dng calci, vitamin D v calcitriol cho ti khi calci mu tr v bnh thng, bt u
dng thuc tr li vi liu nh. Tng calci mu do calcitriol c th iu chnh c v
bnh thng trong 1 tun, nn nh lng calci huyt tng mi 24 n 48 gi. Tng
calci mu do vitamin D, i hi 2 thng iu chnh. Hi chng tng calci mu do
vitamin D cn iu tr bng Prednisolon. Vi nhng trng hp ng c vitamin D mc
nh cn theo di calci huyt tng hng tun ti khi nng calci tr v bnh thng.
TI LIU THAM KHO
1. B Y t (2005), Cn h calci mu, L Ngc Trng, Khng Chin, Hng
dn iu tr, Tp I. NXB Y hc H Ni, 32- 34.
2. Gordon J. Strewler, MD (1997), Hypocalcemia, Francis S. Greenspan, Gordon
J. Strewler, Basic and Clinical endocriology, fifth edition. Prentice- Hall International
Inc. Appleton and Lange, PO Box 120041, Stamford, USA, 286- 290.
3. Gordon J. Strewler, MD (1997), Parathyroid hormon, Francis S. Greenspan,
Gordon J. Strewler, Basic and Clinical endocriology, fifth edition. Prentice- Hall
International Inc. Appleton and Lange, PO Box 120041, Stamford, USA, 264- 269.
4. Harry Giles, Anitha Vijayan (2005), Fluid and electrolyte management, Gopa
B. Green, Lan S. Harris, Grace A. Lin, Kyle C. Moylan, The Washington Manual TM of
medical therapeutics, 31st edition. Lippincott Williams and Wilkins, USA, 39- 65.
5. Paul A. Fitzgerald (2009), The Parathyroids, Stephen J. McPhee, Maxine A.
Papadakis, Current medical diagnosis and treatment 2009, forty-eighth edition. The
McGraw- Hill Companies, Inc.USA, 1004- 1012.

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