HNG DN S DNG CC KHM XT CHN ON HNH NH Hong c Kit dch Li gii thiu Tp ti liu Hng dn s dng tt cc khm xt hnh

nh y khoa (Guide de bon usage des examens dimagerie medicale) c cc tc gi ngnh y t Cng ho Php bin son v hiu chnh trong sut 4 nm t 2001 n 2004 v c xut bn nm 2005 ti Php. Cc tc gi tham gia bin son bao gm nhiu nhm chuyn gia ca Hi in quang, Hi L sinh y hc v Y hc ht nhn Php cng nh cc Hi chuyn ngnh lm sng v nhm cc nh chc trch v qun l y t Php. Mc tiu ca ti liu l:

1. Gim chu ng cho ngi bnh bng cch b bt nhng khm xt khng hp l. 2. Gim phi nhim bnh nhn bng s dng nhiu hn cc k thut khm xt khng chiu x ion ho nh
siu m v cng hng t. 3. Ci thin thc hnh lm sng bng ch nh mt cch hp l cc khm xt hnh nh hc. 4. Phc v cc bc s nh mt ti liu tham chiu trn lm sng. Ti Vit Nam hin nay, cc thy thuc lm sng cng nh hnh nh hc c th ch nh v thc hnh hu ht cc k thut chn on hnh nh hin c trn th gii tuy cha c ph bin rng ri ngang tm cc nc pht trin. Ngi dch ti liu ny ngh rng n lc cn c mt ti liu hng dn vic ch nh cc k thut chn on hnh nh ph hp vi 4 mc tiu trn. Do cha c iu kin t chc nghin cu v bin son nh ti chu u v Php nn trc mt chng ti dch v gii thiu tng phn ti liu ny trn tp ch chuyn ngnh chn on hnh nh v y hc ht nhn, mong c qu ng nghip gp kin v s dng bc u. Mt s ch dn khi s dng ti liu:

1. Mc kim chng khoa hc i vi ch nh phng php khm xt

Mc A: xc lp minh chng khoa hc Mc B: qua nghin cu v suy on khoa hc Mc C: Mc kim chng khoa hc cn hn ch 2. Phn bc nhim x ion ha (theo liu hiu qu) Bc 0: Khng nhim x, th d siu m, cng hng t. Bc I: <1mSv, th d X quang ngc chun, X quang chi. Bc II: 1-5mSv, th d chp ct sng tht lng, chp UIV, x hnh xng, CT-Scan s no hoc c Bc III: 5-10mSv, th d CT-Scan ngc hoc bng, x hnh ti mu c tim, PET vi FDG. Bc IV: >10mSv, th d PET-CT, CT-Scan ngc-bng, th thut in quang can thip. 3. Nhng ch vit tt - Angio (Angiography) = chp mch mu - CTA (Computed tomo-angiography) = chp mch mu bng ct lp vi tnh - CT-Scan (Computed Tomography) = chp ct lp vi tnh - DEXA (Double Energy Xray Absorptiometry) = o hp th tia X nng lng kp - ERCP (Endoscopic Retrograde Cholangio-pancreaticography) = chp ng mt-tu ngc dng - HU (Hounsfield Unit) = n v Hounsfield - HSG (Hysterosalpingogrraphy) = chp t cung vi trng

MRA (Magnetic Resonance Angiography) = chp mch mu bng cng hng t MRCP (Magnetic Resonance Cholangio-pancreaticography) = chp ng mt-tu bng cng hng t MRI (Magnetic Resonance Imaging) = chp cng hng t PET (Positron emision tomography) = chp ct lp pht positron 18 FDG PET-CT: Chp ct lp pht positron vi Fluor 18 desoxyglucose = dc cht phng x dng khm PET kt hp CT-Scan SA: khm siu m Sialo: Chp ng tuyn tuyn nc bt SPECT (Single photon emission computed tomography) = chp ct lp pht photon n XR: chp X quang chun

u (bao gm bnh l tai - mi - hng) Bnh cnh lm sng TBMMN Khm xt CT-Scan MRI MRA SA Doppler CTA Thiu mu no thong qua TIA MRI MRA SA Doppler CTA X cng a , bnh l cht trng U no MRI MRI CT-Scan au u cp, d di CT-Scan MRI MRA CTA au u mn tnh XR s, xoang CT-Scan Mc kim chng A A B B B B C A A B B B B C C Khuyn co Rt c ch trong xc nh xut huyt no nhng km nhy so vi MRI trong tai bin thiu mu. u th trong pht hin thiu mu giai on cp v tn thng h sau, tm nguyn nhn mch mu. Tm tn thng mch vng c c th gy tai bin mch no. Tm phnh mch no v d dng mch no lp k hoch can thip iu tr. Tm tn thng no do thiu mu, loi tr cc tn thng gy triu chng ging thiu mu. nh gi h thng mch mu no. Pht hin tn thng ng mch vng c c th gy tai bin mch no. nh gi cc trc ng mch u c nu khng chp c MRA hoc nghi ng trn SA. MRI l phng php chn lc i vi bnh l cht trng, nht l x cng a . CT-Scan thng m tnh. MRI pht hin v nh gi tt cc u no, nht l vng h sau v ng gia . MRI khuych tn v quang ph t c ch trong chn on phn bit. Nu c chng ch nh MRI. CT-Scan c ch cho phu thut vng tuyn yn qua ng sau mi. CT-Scan c th chn on xut huyt di nhn trong nhng ngy u, hoc kt hp no ng thu. C th m tnh nu qu 7 ngy hoc chy mu khng nhiu. MRI nhy hn CT-Scan trong chy mu di nhn. MRA c th pht hin bt thng mch ni s. Nu c chng ch nh MRA nhm pht hin nguyn nhn xut huyt di nhn. t ngha chn on nu khng thy du hiu nh khu. Ch nn thc hin khi c du hiu tng p ni s hoc Liu x II 0 0 II/III 0 0 II/III 0 0 II II 0 II/III I I

Khi chon ch vng yn

MRI MRI MRA CT-Scan

B Mc kim chng B B B B

triu chng nh khu MRI rt u th trong phn tch tn thng vng ynbm v xoang hang, vng trn yn, i th. MRA nh gi ng mch cnh trong v bnh l lin quan vi xoang tnh mch hang Nu c chng ch nh MRI Khuyn co MRI c th chn on v tm nguyn nhn gy no ng thu ng thi theo di c tnh trng dn lu no tht bng ng thng. CT-Scan thay th MRI nu c chng ch nh. CT-Scan c th theo di c tnh trng dn lu no tht. Nn ch nh khi ri lon nhn thc mi xy ra, mc tiu l loi tr cc nguyn nhn khng phi thoi ho no (khi chon ch ni s, no ng thu p lc bnh thng, tn thng do mch mu. MRI/CT-Scan cng c th pht hin cc nguyn nhn thoi ho nh teo hi m, teo trnthi dng hoc trn nh. Him khi cn tim thuc i quang. CT-Scan c th thay th MRI nu bnh nhn km hp tc. 18FDG-PET c th chn on sm v phn bit cc th thoi ho thn kinh gy sa st tr tu MRI nhy hn CT-Scan trong phn tch chi tit cc bt thng no, c bit l mt trong ca thu thi dng. MRI c th gip loi tr nguyn nhn thc th nu nghi ng trn lm sng thn kinh. MRI c th loi tr nguyn nhn u, mch mu v lm r vng teo no khu tr. Bn thn bnh Parkinson khng cn ch nh chp MRI. PET v lp bn th th D2 Dopaminergic c th tham gia chn on nguyn nhn cc hi chng Parkinson v phn bit vi chng run git khc. MRI u th hn CT-Scan v c th nh gi tn thng chnh xc hn trn 3 mt phng. CT-Scan hu ch trong phn tch xng nn s nh l sng, cc l nn s, thnh h mt v pht hin cc vi ho. Nn ch nh trc mt bng lm sng no-mng no. CT-Scan u th hn MRI nht l vi bnh do vim. MRI nn ch nh nu nghi ng bin chng ni s hoc theo di sau m. MRI c a thch trong chn on cc u dy thn kinh,

0 0 II Liu x 0

Bnh cnh lm sng No ng thu

Khm xt MRI CT-Scan

Ri lon nhn thc

MRI CT-Scan

0 II

ng kinh mn tnh, khng thuc Ri lon tm thn Vn ng d thng

PET PET-CT MRI MRI MRI PET

C B C C C

II III 0 0 0

Tn thng nn s v dy thn kinh s

MRI CT-Scan

A B

0 II

Bnh l nhim trng thn kinh Bnh l tai gia Triu chng

MRI CT-Scan MRI

B B C

II 0

tai trong, ic tip nhn Vim xoang cp Vim xoang mn tnh

MRI XR CT-Scan

B C B

u dy VIII v d dng mch mu. CT-Scan ch b sung trong mt s trng hp c th Ch chp X quang trng hp khng in hnh hay nghi c bin chng CT-Scan l khm xt thch hp i vi bnh l mn tnh ca xoang (chn on, nh gi trc m, theo di) v tm lin quan vi bt thng ca rng. Cn nhc nhim x nhn cu nu ch nh chp ln 2 Ch nn chp khi nghi ng u trn CT-Scan Hai phng php b sung nhau trong chn on cng nh nh gi lan rng. CT-Scan lm r cu trc xng, MRI xem no Cn thit nhm tm nguyn nhn vim xoang hm, sng hm mt bn. MRI cung cpc im cu trc v lin quan ca tn thng vi dy th, c bit ti nh h mt. Chng ch nh nu nghi c d vt c nhim t. Khm xt cn ch nh u tin. SA v MRI c th thay th nhau (u th khng gy nhim x th thu tinh). Ch nh bt buc trc khi chp MRI loi tr hon ton d vt kim loi, rt cn vi bnh nhn c tin s lm vic vi kim loi. MRI cho php khm xt ton din cc ng th gic.

II 0 II 0 I 0 0 0

U hoc gi u ca xoang v hc mi Tn thng h mt ngoi nhn cu Tn thng ni nhn cu D vt kim loi trong h mt Gim th lc, ri lon th lc Ri lon th trng

MRI CT-Scan MRI RX Panorama MRI SA MRI RX MRI MRI CT-Scan

C B B B B B A B B C

MRI cho php khm xt ton din cc ng th gic v cu trc ni s Nu nghi c khi trong h mt (li mt) nh gi lan rng ca bnh, nht l cu trc xng.

0 II

C (phn mm) Bnh cnh lm sng Nhn gip, bu gip bnh gip Khm xt SA Mc kim chng B Khuyn co Nhn gip hay gp v thng lnh tnh, tin trin mn tnh. S nn bng tay c nhy v kh nng ti lp thp. Vi tng k ban u gm lm sng, nh lng TSH v SA c th nh hng: theo di n thun/lm thm x hnh tuyn gip/chc ht t bo kim nh hoc chc ht di SA. Ch nh trong trng hp c bit Chc ht kim nh khm t bo hc l khm xt tham vn chn on ung th tuyn gip. Liu x 0

X hnh Khm t bo hc

B A

I/II 0

Chc ht di SA Theo di xa nhn gip trn 1cm hoc bu gip SA

B C

X hnh T bo hc Cng gip X hnh

B C A

SA Nhc gip ngi ln SA

A C

X hnh Bu gip chm Bu gip chm trc iu tr X hnh SA CT-Scan MRI

C C C C C

Nhn gip kh s thy, nhn gip ngi c nguy c cao nh chiu x c... cn c SA hng dn. Cc nhn bnh gip, t bo hc m tnh cn theo di di ngy. Cc nhn gip di 1cm pht hin tnh c ch cn theo di lm sng . SA c ch trong theo di hnh thi cc nhn gip ngay c nhn kh s thy hoc a nhn. X hnh c ch nu cha thc hin ln no. o TSH nu l nhn nng v bu t ch. Theo di SA hoc t bo hc nu l nhn lnh. Nn khm li t bo hc d kt qu ln 1 lnh tnh. Chn on cng gip l ca xt nghim sinh hc. X hnh gip phn bit cc th bnh khc nhau v cho nhng ch dn v hnh thi, chc nng c th ch nh iu tr bng 131-Iode. SA c ch trong xc nh nhn gip v hng dn iu tr. Kt hp SA Doppler c th nh hng tm nguyn nhn cng gip. Chn on nhc gip phi da trn xt nghim sinh hc v o khng th khng thyroperoxydase rt hu ch trong chn on nguyn nhn (vim gip t min) SA gip xc nh nhn, o th tch tuyn v nh gi cu trc m (gim m trong vim t min) X hnh tuyn gip l khm xt b xung tm nguyn nhn (bm sinh, qu ti iode, vim tuyn) Hai phng php ny kt hp cho thy r phn bu chm sau c v hin nh phn t ch trn x hnh. Trc can thip phu thut hoc 131-Iode, CT-Scan khng tim iode hoc MRI u c ch trong xc nh c im hnh thi hc nh phn chm sau c v mc chn p kh qun... SA v X hnh vi MIBI-99mTc gip nh v trc m. Nu tht bi ln m th nht, hai khm xt ny c th nhc li tm ngun cng ni tit. SA Doppler mu cung cp thng tin hnh thi v c nng cc trc ng mch xut pht t quai ng mch ch v c th gii thch ngun gc ting thi. SA (c hoc khng Doppler mu) cho php chn on nh khu v gi nguyn nhn. Bc tip theo, MRI hoc CT-Scan b xung ngun gc v khm xt thm ng h hp trn. Chp X quang tuyn (Sialography) c th thc hin trc SA nu nghi si ng dn nc bt. MRI cho php khm cng lc 4 tuyn nc bt. SA rt nhy v pht hin tt cc khi thu su, cc vng su ca mt, nn ch nh trc tin. Rt c ch i vi thu su tuyn mang tai hoc u ti pht

0 0

I/II 0 I/II

0 0

I/II

Cng bng gip trng Ting thi mch cnh khng triu chng Khi chon ch c cha bit nguyn nhn Tc ng dn nc bt Khi u tuyn nc bt

SA X hnh SA Doppler SA MRI/ CT-Scan SA RX tuyn SA MRI

B B B C C C C B C

0 I/II 0 0 0 III 0 II 0 0 0

CT-Scan Kh ming, bnh t chc lin kt Bt thng chc nng khp thi dng-hm SA Sialo X hnh XR Panorama MRI CT-Scan Chp khp MRI khp

C B B C B B

sau m. Ch nn s dng trong trng hp cn xem tn thng xng hm v nn s SA him khi s dng. X quang tuyn c th tham gia chn on nhng x hnh tuyn nc bt nh gi c nng 4 tuyn tt nht. Khng s dng v X quang lun bnh thng. Nn thc hin mt cch h thng loi tr bnh khc (gy xng hm c, nguyn nhn do rng, do tuyn nc bt). MRI tt nht khm trc tip ri lon c nng khp nhng khng c gi tr vi th c. MRI nn thc hin nu d nh phu thut. C ch nu c ri lon c nng a khp. Chp khp cn quang nh gi ng hc khp, hin c thay th bng chp khp MRI

II 0 II II I I 0 II II 0

Ngc Bnh cnh lm sng Kim tra sc kho, bnh phi ngh nghip Kim tra trc m ni chung Nhim khun ng h hp trn Theo di bnh nhn hen Vim phi thu (chn on) Vim phi (theo di iu tr) Trn dch mng phi Khm xt RX Mc kim chng B Khuyn co Ch nn chp X quang ngc khi phi theo yu cu ca ni gi hoc khng c phim ngc mi chp trong thi gian 6 thng. Khng cn chp phim ngc nu bnh nhn di 60 tui v khng c tin s bnh tim-phi. Khng c kim chng khoa hc cho ch nh chp X quang ngc. X quang ngc c ch nu c bin i trn lm sng hoc khng p ng iu tr. Cn chp i vi vim phi ngi ln Tr em c ch nh ring Thng phi sau 4 tun l, hnh vim phi mi xo ht. Ch nn chp kim tra cho nhm c nguy c u phi (nghin thuc l hoc trn 50 tui). X quang ngc c th chn on khi lng dch nh SA cho php xc nh dch mng phi, pht hin vch Liu x I

RX RX RX RX RX RX SA

B Khng ch nh Ch nh nu cn thit : B B B B B

I I

I 0

CT-Scan Trn kh mng phi t pht Ho ra mu Bnh nhn ang hi sc cp cu hoc ang chy thn nhn to RX CT-Scan RX CT-Scan RX SA CT-Scan

C C C A B B B Trng hp c bit: C B B Trng hp c bit: C C C C C

ngn trong trn dch v hng dn chc d C th cn khi nghi ng c tnh. Cho php phn tch nhu m phi di mng phi sau khi ht dch Cha c ng thun v ch nh CT-Scan cho trn kh ngi tr v cn. Cc trng hp khc nn ch nh X quang ngc l ch nh u tin CT-Scan cng nh ni soi ph qun thng c th pht hin gin ph qun hoc u ph qun phi X quang ngc pht hin mt s bnh cp tnh bnh nhn th my hoc sau khi avo cng nh ly i mt dng c cp cu trong c th ngi bnh. SA ti ging pht hin loc loi tr trn dch hay trn kh mng phi. Trc din bin lm sng bt thng, CT-Scan c th hu ch. CT-Scan phn gii cao cho php pht hin bt thng ph nang hoc t chc k khng thy trn X quang ngc chun. Phi nhim mnh: RX 2 nm mt ln t 10 nm sau bt u tip xc. Phi nhim trung gian: 2 nm mt ln RX ngc (theo ng thun ANAES 1999). Ch nh khi tip xc trc tip vi lao BK + hoc lao hang. Ch nh nu phn ng Tuberculin >10mm trn ngi cha tim BCG hoc tim BCG trn 10 nm CT-Scan nn ch nh sau khi loi tr 4 nguyn nhn thng gp: chy nc mi sau, hen, tro ngc thc qun, dng thuc c ch man chuyn angiotensine. CT-Scan phn gii cao tm gin ph qun.

III I III I III I 0 III

Bnh phi kn o, RX ngc bnh thng Theo di ngi phi nhim amiant Tip xc vi bnh nhn lao phi Ho ko di khng thy nguyn nhn Nhiu dch ph qun

CT-Scan RX RX RX CT-Scan RX CT-Scan

III I

I III I III

(Cn na)