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CHNG I
TIM MCH
THP TIM
Mc tiu
1. Nm c cc du chng lm sng v cn lm sng ca thp tim.
2. Vn dng chn on v iu tr thp tim.
3. Nm c tm quan trng ca phng thp s cp v th cp.
Ni dung
I. I CNG
1. Thp tim: l mt bnh vim nhim ton th, biu hin nhiu c quan m ch
yu l khp v tim, bnh c nhng c im sau:
- L hu qu chm ca vim ng h hp trn do liu cu tan huyt nhm A.
- Xut hin thnh tng t cch nhau hng thng, hng nm c khi c chc
nm.
- C ch sinh bnh nghing v t min.
- Thng tn van tim c th mn tnh, tin trin a n suy tim.
- Phng bnh hu hiu.
2. Dch t hc
- Tui tr: 5 -15 tui.
- Ma lnh m lm d vim hng.
- Sinh hot vt cht: bnh ca th gii chm pht trinth 3, ca nhng tp
th sng chen chc cht chi.
- Bnh xy ra sau vim hng lin cu nng, c khi sau vim hng lin cu
khng r, d ti pht bnh nhn thp tim c khi b ti nhim lin cu.
II. BNH NGUYN, C CH SINH BNH
1. Bnh nguyn
Lin cu tan huyt nhm A l vi trng gy bnh do hin tng qu mn sau
nhim lin cu. Nu cn c vo Protein M th c khong 60 type khac nhau, lin cu
gy vim hng thuc type 1, 2, 4, 12. T l mc bnh khong 30%.
2. C ch sinh bnh
- Cha r, nghing v t min. C s tng t gia khng nguyn ca lin
cu v khng nguyn tim (mang khng th chng liu cu v tim, protein M, khng
nguyn glycoprotein c bit ging protein ca van tim).
- Khng th (KT) c hiu: Khng th chng tim, chng t bo no, KT chng
Glycoprotein, Antistreptolysin O. Cc khng th ny tng t tun th 1 n tun th
4 ca bnh.
- C a di truyn: D mc bnh, c nguy c ti pht ko di sut i.
III. GII PHU BNH
Thng tn tin trin
2
- Nu khng tn thng tim t u hoc vim tim nhng tim khng to, chn on
v iu tr sm, d phng y , khng ti pht th tin lng tt 90% phng c
bin chng tim.
- Nu tn thng tim t u khng d phng y theo phc th tin lng
xu i nhiu.
- Theo Fridberg v Jones: 10 - 20% bnh sau t thp tim u s tr thnh tr tn
ph. T vong sau 2 - 6 nm.
- S cn li sng n tui trng thnh: - 65% bnh nhn sinh hat bnh thng.
- 25 % sng sc khe gim st nhiu v l gnh nng cho gia nh v XH.
VIII. KT LUN
- L bnh gp ngi tr, nguyn nhn do lin cu.
- Bnh cnh a dng.
- Chn on ban u kh, khi chn on c k c k thut mi th tim b vim.
- Din bin kh lng, d phng sut i ni ln tm quan trng tc ng ln tim
c bit l bung tim tri.
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Mc tiu
1. Nm vng cc triu chng lm sng v cn lm sng ca bnh van hai l.
2. Nm c cc th lm sng ca bnh van hai l.
3.Nm vng cc phng tin iu tr ni khoa bnh van hai l.
4. Nm vng ch nh iu tr ni khoa, iu tr ngoi khoa v phng nga cc bin
chng
Ni dung
I. I CNG
Hp van hai l l mt bnh kh ph bin nc ta chim khong 40,3% cc
bnh tim mc phi. Bnh c pht sinh loi ngi t khi bt u sng thnh tng
qun th do iu kin sinh sng thp km, cht chi thiu v sinh d gy ly nhim
bnh. T 1887 Bouillaud ri Sokolski m t bnh. n 1920 Duckett Jones (Hoa
k) nghin cu bnh ny v n 1944 ng mi cng b by tiu chun chn on
bnh.. Cng nhng nm ny Cutter v Levine Phillipe (Hoa k) tm cch phu thut
hp van hai l ng thi trong nm Souttar ti Anh cng m c hp van hai
l. Giai on ny bnh hp van hai l l bnh tim mch ph bin nht, gy tn ph
v t vong nhiu. T nm 1944 vic pht minh ra Penixillin dit cc loi lin cu v
c bit to ra loi Penixillin chm (Benzathyl Penixillin) c tc dng phng nga
bnh ny do n nay cc nc pht trin nh Thy in, H lan v c bnh
thp tim gn nh mt hn.
Tuy vy, cc nc chm pht trin bnh ny cn ang ph bin. Bnh hay
gp tui lao ng 20 - 30 tui t l bnh hp hai l rt cao khong 60 - 70 %, t l
t vong n 5%. Bnh c nhiu bin chng phc tp v a n tn ph. Bnh gp
n nhiu hn nam (3/1) v nng thn mc nhiu hn thnh th.
II. BNH NGUYN V C CH SINH BNH
Ch yu do thp tim 99%, s cn li do bm sinh, hoc do Carcinoid c tnh,
lupus ban h thng, vim khp dng thp c nghin cu cn cho l do virus
Coxsackie gy ra. Tc nhn gy bnh ch yu l do lin cu khun tan huyt nhm
A gy vim hng gy tn thng thp tim. S d lin cu hng gy bnh thp tim
m khng vo cc c quan khc l do c cc ng thng bch mch gia hng v
tim. Cu trc bo thai hc cho thy c ng ni mch mu v thn kinh gia tim v
c.
Nm 1976 Taranta (Hoa k) chng minh c c ch bnh sinh trc tip ca
c t lin cu khun ln tim. Cc khng th khng tim xut hin bnh nhn thp
tim c vim tim, c c cc phn ng khng nguyn cho gia cc cu trc tim v
lin cu A. Ni tm li c ch sinh bnh nh sau:
- Lin cu khun nhm A xm nhp vo c th gy vim hng ng thi sinh
ra nhng c t. Ngoi ra, trong m tim ngi ta cng tm thy nhng cht liu c
cu trc min dch ging protein M v vy cc khng th hnh thnh cng chng lun
li cc van tim.
- Hin tng t min cho nhm ln gy vim tim v vim khp. Vim tim c th t
khi nhng sau 2 nm n c th li di chng van tim, c 3 bnh nhn th c 1
bnh nhn b di chng van tim nh dy dnh x gy hp van tim.
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- Trn phim nghing c ung bart: thc qun b chn p 1/3 gia. Mt khong
sng trc tim hoc sau xng c (tht phi ln).
2.2. in tm
- Giai on u cha hp kht hoc cha nh hng nhiu trn cc khoang tim: in
tim cn bnh thng.
- Giai on sau: dy nh tri vi P (0,12s hoc P hai pha, pha m ln hn pha
(+) V1. Trc in tim lch phi v dy tht phi.
Ngoi ra cn c th thy tnh trng ri lon nhp nh ngoi tm thu nh, nhp nhanh
nh, rung nh l hay gp hn c. C th c blc nhnh phi khng hon ton.
2.3. Siu m tim
L phng tin chn on xc nh chnh xc hp van hai l nht l khi hp
van hai l trn lm sng khng pht hin c. Siu m cn cho php ta nh gi
van v t chc di van c dy khng ta c quyt nh thay van hay tch van.
Trong hp n thun
- Kiu mt bnh din: Van l van trc v sau dnh vo nhau nn di ng song
song cng chiu, cc l van dy ln. Van c dng hnh cao nguyn hay giy trt
tuyt. dc tm trng EF b gim. Nu hp kht dc tm trng c th gim
<15 mm/s. ng knh nh tri tng. ng knh tht phi tng, vch tht phi dy.
C th thy c du tng p MP gin tip.
- Siu m 2 chiu: Xc nh c s di ng ca van, do kch thc bung
tim ng thi o c din tch l van.
- Siu m Doppler c th pht hin c hp van hai l c kt hp vi cc tn
thng khc c thi x tr thch ng. ng thi o p lc ng mch phi,
theo di p lc ng mch phi trc v sau iu tr.
2.4. Tm thanh c ng
Kt hp vi in tm nh gi mc hp ca van da vo khong Q -
T1 v khong T2 - CM. Nu Q - T1 cng di v T2 - CM cng ngn th hp van hai l
kht, hin nay thm d ny t s dng do c siu m tim
2.5. Thng tim
Thy c s chch lch p tm trng gia nh tri v tht tri, du hiu
c trng ca hp hai l. Hin nay, siu m c tnh cht quyt nh nn t s dng
phng tin ny. Ngi ta ch s dng khi c nghi ng c h hai l hoc cc bnh
van ng mch ch phi hp (him).
IV. CHN ON
1. Chn on xc nh
Da vo cc tiu chun lm sng v cn lm sng, nh m t trn. Quyt
nh nht vn l du nghe tim v siu m tim.
2. Chn on phn bit
- Rung tm trng trong hp van 3 l: RTTr trong mm, T1 khng anh.
in tim c dy nh phi. Siu m tim l quyt nh.
- U nhy nh tri (Myxoma): nghe rung tm trng thay i theo t th. Khng
c T1 anh. Bnh nhn thng hay c ngt. Chn on da vo siu m tim.
3. Chn on giai on
C 4 giai on ca hp hai l
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- Giai on 1: Khng c triu chng c nng k c khi gng sc. Khm lm sng
pht hin tnh c.
- Giai on 2: C hi chng gng sc r: Kh th, hi hp, nh trng ngc, ho
hoc ho ra mu, cha c biu hin suy tim.
- Giai on 3: C kh th nhiu, c suy tim phi nhng iu tr c hi phc.
- Giai on 4: Hp van 2 l c suy tim nng, iu tr khng hi phc.
4. Chn on th
4.1. Th n thun: c th dung np tt, bnh nhn cha c du hiu c nng v
thng pht hin bnh tnh c.
- Th in hnh: Nh m t trn v khi khm lm sng, X quang, in tim c th
chn on c.
- Hp van hi l cm: Bnh nhn c th c hoc khng c triu chng c nng.
Nghe tim khng thy cc du hiu c trng cc hp van hai l. Th ny i hi tm
cc bin chng ca hp van hai l v cn lm sng nht l siu m tim gip chn
on.
- Th tin trin: thng l nhng trng hp hp van hai l khp hay rt kht. Bnh
nhn vo vin vi cc bin chng nng n. Ri lon nhp, hen tim, ph phi cp, tc
mch vv...
4.2. Th phi hp
- Hp hai l phi hp h van hai l: phi phn bit h hai l l chnh, hp l ph hay
ngc li.Nu h van hai l l ch yu: nghe TTT mnh mm tim ting thi to, lan
xa, s c rung miu tm thu. Rung tm trng nh, X quang, siu m, in tim c
dy gin tm tht tri v nh tri. Ch yu siu m tim nh gi c mc h hai
l c bit l vi siu m Doppler.
- Phi hp vi bnh van ng mch ch.
+ Hp van hai l phi hp h ng mch ch: ngoi hp van hai l cn nghe ting
thi tm trng lin sn III bn tri v lin sn II bn phi lan xung dc b c
tri, in tim c dy tht tri, siu m doppler tim cho php chn an.
+ Hp hai l kt hp hp ng mch ch: ngoi triu chng hp van hai l cn nghe
thm ting thi tm thu lin sn III bn phi v lin sn II bn phi lan ln 2 bn
ng mch cnh km s rung mu.
Chn on in tim c dy tht tri tm thu, X quang v siu m tim cho php chn
on.
- Hp van hai l kt hp bnh van 3 l:
+ Hp hai l kt hp h 3 l: nghe TTT trong mm tim hoc ngay mi c. ting
TTT mnh ln khi ht vo su v nn th, c th s gan to v p theo nhp p ca
tim. Tnh mch c p. Phi thng sng hn.
+ Hp van hai l kt thng lin nh: Hp hai l kt hp thng lin nh gi l hi chng
Lutembacher. Chn on xc nh nh siu m tim v thng tim.
Hp van hai l c th cn phi hp vi cc bnh l tim mch khc nh tng huyt p
nhng him gp
5. Chn on bin chng
Hp van hai l thng c cc bin chng sau.
5.1. Ri lon nhp tim
- Ri lon nhp xoang thng l nhp nhanh. Ngoi tm thu nh, cn nhanh trn tht.
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Nam. Phng php ny c ch nh cho bnh nhn tr tui <40, hp van hai l
n thun, van cn mm mi, t chc di van cha h bin nhiu, khng c cc
mu ng nh tri hoc tiu nh. Bin chng ca phng php ny l chc thng
thnh tm nh tri gy ra trn mu mng ngoi tim cp, gy chn p tim cp.
2.2. Nong van hai l kn (close mitral commissurotomy)
- Bng tay hoc dng c: thc hin nhng bnh nhn: c din tch l van hai l
hp <1.5 cm2, van cn mm hoc x ho, cha c vi ho nhp xoang hay rung nh,
nhng khng c tin s tc mch, khng c bnh van ng mch ch, hoc h van
hai l (nu h van hai l nh <2/4 th khng chng ch nh), tui < 40, khng b bi
nhim phi hoc thp tim ang tin trin, khng b Osler.
- Kt qu sau nong c 5-10% trng hp ht triu chng hp van hai l, triu chng
tng p lc ng mch phi gim dn v tr v bnh thng. Mt s bnh nhn
nong van hai l khng kt qu hoc thp tim ti pht gy dnh li cc mp van phi
nong li ln 2 nhng kt qu thnh cng thp hn v t l t vong cao hn 10 ln lc
ban u.
- Bin chng khi nong van v sau khi nong
+ Suy tim v ri lon nhp sau phu thut
+ St
+ Hi chng sau nong van
+ Trn dch mng ngoi tim
+ Tc ng mch no thong qua.
+ H van hai l sau khi nong thng gp nhng bnh nhn b vi ho van h bin
nhiu t chc di van.
+ Ngng tim khi ang nong
+ Hen tim, ph phi cp
+ Lon nhp tim (ngoi tm thu tht, nh, rung cung nh, nhp nhanh kch pht trn
tht v tht, rung nht)
+ Osler gy t dy chng, sa van hai l
2.3. M tim h
Cn c tim phi nhn to
- Sa van hai l: phu thut vin c th m rng hoc thu hp vng van hai l, ct
b phn b si lot, vi ho hoc ly cc mu ng nh, tht, v cc l thng trn
mt l van khu ni cc tr c v dy chng b t. Bnh nhn khng phi thay van
nn gim c nguy c min dch thi ghp, gim nguy c vi ho, tc mch nn
vic chng ng n gin hn thay van, gim nguy c vi ho, tc mch nn liu
php chng ng n gin hn.
- Phu thut thay van: c ch nh trong cc trng hp
+ hp van hai l t chc van x dy vi ho nng
+ Hp kt hp h van hai l nng hay h van hai l n thun.
+ Si lot van do Osder
- Cc loi van thng dng thay van hai l
+ Van Starr-Edwards: c lng gi qu bng bi, khi tht bng bi chuyn ng ln pha
nh ng van nh tht.
+ Van SCDT-Custer l dng van Starr ci tin.
+ Van Magovevu-cromt l van Starr ci tin
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TNG HUYT P
Mc tiu
1. Nm vng kin thc c bn v tng huyt p, mt bnh tim mch ph bin hin
nay.
2. Nm vng phn loi, cc bin chng ca tng huyt p cng nh cc c ch
sinh bnh tng huyt p
3. Nm vng cc nhm thuc v tc dng dc l, ch nh v tc dng ph trong
iu tr tng huyt p.
4. Vn dng c phc iu tr tng huyt p trong thc tin lm sng
Ni dung
I. I CNG
1. Dch t hc
Tng huyt p (THA) l triu chng ca nhiu bnh, nhiu nguyn nhn
nhng c th l mt bnh, bnh tng huyt p, nu khng tm thy nguyn nhn.
cc nc Chu u - Bc M t l tng huyt p trong nhn dn chim 15 - 20%
ngi ln. C th nh sau: Benin 14%- Thi lan: 6.8%- Zaire:14%- Chile: 19-21%,
Portugaise: 30%, Hoa k: 6-8%. Nhn chung t l rt thay i. Vit Nam, t l tng
huyt p chung l 11,8% (B Y T Vit Nam, 1989). T l ny gia tng ng quan
tm v trc 1975 t l ny min Bc Vit nam ch c 1-3%(ng Vn Chung). Ti
BVTW Hu nm 1980 t l THA trong s cc bnh ni khoa ch c 1% nhng 10 nm
sau, nm 1990, tng n 10%. Thng k gn y nht ca Vin Tim Mch ti
Min Bc Vit Nam cho thy t l THA l 16,3% (2002).
2. nh ngha
T chc Tng huyt p Th gii (TCYTTG) v U ban Quc gia Cng lc Hoa
k (1997) u thng nht mt ngi ln b tng huyt p khi huyt p tm thu trn
hoc bng 140mmHg v hoc huyt p tm trng trn hoc bng 90mmHg.
nh ngha ny n gin nhng c nhc im l tr s huyt p khng hon ton
n nh v huyt p thay i theo tui, gii...
II. BNH NGUYN V C CH SINH BNH
1. Bnh nguyn
1.1.Tng huyt p nguyn pht: chim gn 90% trng hp b tng huyt p (theo
Gifford - Weiss).
1.2. Tng huyt p th pht
- Bnh thn: Vim cu thn cp, vim cu thn mn hai bn do mc phi thn
a nng, nc b thn, u thn lm tit rnin, hp ng mch thn...
- Ni tit
+ Bnh v tuyn thng thn, hi chng Cushing, hi chng Conn, u sn
xut qu tha cc Corticosteroid khc (Corticosterone, desoxycortisone), sai lc
trong sinh tng hp Corticosteroid.
+Bnh ty thng thn, u ty thng thn (Pheochromocytome).
- Bnh tim mch: Bnh hp eo ng mch ch, vim hp ng mch ch
bng cho xut pht ng mch thn, h van ng mch ch.
-Thuc: Cc Hormone nga thai, cam tho, carbenoxolone, A.C.T.H.
Corticoides, Cyclosporine, cc cht gy chn n, cc IMAO, cht chng trm cm
vng...
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suy tim, co tht ph qun, hen, hi chng Raynaud, h ng mu, ri lon tiu
ha, mt ng, d ng hoc tc dng di khi ngng iu tr (gy ra cn au tht ngc,
nhi mu c tim cp).
- Cc thuc c ch men chuyn
c ch s to thnh angiotensine II, ngoi ra cn c tc dng:
- Tng cng hot ng h Kali-Krine-Kinine ngn cn s phn hy bradykinine.
- Kch thch s tng hp Prostaglandine. Do sau cng a n dn mch.
Ch nh: Tng huyt p cc giai on, k c loi tng huyt p rnine cao v thp.
Tc dng ph: t c tc dng ph ngoi ri lon v thm n, nga, ho khan, lu khi
phi hp li tiu gi Kali, thuc chng vim, chng Steroid.
Chng ch nh: Khi tng huyt p c hp ng mch thn hai bn hoc ch c mt,
ph n c thai.
C 3 nhm chnh
- Captopril (Lopril, Captolane) vin 25-50mg liu 50mg/ngy.
- Enalapril (Renitec) vin 5-20mg, liu 20mg/ngy.
- Lisinopril (Prinivil, Zestril) vin 5-20mg, liu 20mg/ngy.
Hai nhm sau cng c tc dng ko di v khng c nhm Thiol t tc dng ph nn
c a thch hn.
- Thuc c ch Canxi
Ngn cn s i vo t bo ca ion Ca++. c ch lung Ca++ chm ca knh Ca++
ph thuc in th. Tc dng ny t l vi nng v hi quy khi c ion Calcium. C
hai ni tc dng.
- Trn mch mu: s gim lung Ca++ a n s dn c v lm dn mch. iu
ny lm gim sc cn ngoi bin v ci thin dn n cc mch mu ln.
- Trn tim: lm chm nhp tim cn bng t nhiu phn x nhp nhanh th pht v
gim s co bp c tim.
Cc tc dng ny ty vo loi c ch Ca++ c s dng. Loi 1-4 dihidropyridine c
tc dng chn lc mnh i vi mch mu, cn Verapamil v Diltiazem tc dng ln
c hai ni. Cc loi c ch Ca++ tc dng tt i vi tng huyt p renine thp
(ngi ln tui) c th:
+ Nhm 1-4 Dihydropyridine: Nifedipine (Adalate) vin nhng 10mg-20mg LP, liu 2
vin/ngy.
+ Diltiazem (Tildiem) 300mg LP, liu 1 vin/ngy.
+ Verapamil (Isoptine) 120-240 LP, liu 1-2 vin/ngy.
Tc dng ph chim 10-20% trng hp. Thng thng l nhc u, ph ngoi
bin, phng mt. Him hn l h huyt p th ng, mt, xong, ri lon tiu ha,
hi hp, pht ban, bun ng v bt lc. Cc loi Verapamil, Diltiazem c th gy ri
lan dn truyn nh tht, nhp chm. Khng c dng c ch Canxi khi c thai, i
vi Verapamil v Diltiazem khng dng khi c suy tim, blc nh tht nng nhng
cha t my to nhp.
- Thuc tc dng ln thn kinh trung ng
C nhiu loi nhng hin nay t dng do c nhiu tc dng ph d c hiu qu.
- Anphamethyldopa (Aldomel, Dopegyt): H huyt p do to ra anpha-
methylnoadrenaline lm hot ha cc c quan th cm giao cm no, do c
ch trng lc giao cm. Vin 250mg hoc 500mg, liu t 500mg n 1,5g trong 24
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gi. c s dng khi c suy thn. Tc dng ph: h huyt p th ng, thiu mu
huyt tn, bt lc, suy gan.
- Reserpine vin 0,25mg liu 2-6 vin/ngy. Tc dng ph h huyt p th ng,
thiu mu huyt tn, bt lc, suy gan, hin nay t dng.
- Clonidine (Catapressan): Tc dng ln vng hnh ty cng trng lc giao cm
h huyt p. Vin 0,150mg liu 3-6 vin/ngy. Cn lu phi ngng thuc t t nu
khng s lm huyt p tng vt ln. Tc dng ph: Trm cm kh ming, to bn, ri
lon tnh dc.
- Cc thuc tc dng trung ng khc: Guanabenz, Guafacine, Tolonidine,
Hyperium.
- Thuc dn mch
- Prazosin (Minipres): Tc dng c ch cm th anpha sau tip hp nn c hiu lc
tt. Vin 1mg dng liu tng dn t 1-2 vin - 10 vin/ngy nu cn. Tc dng ph:
chng mt, ri lon tiu ha d kch ng, tiu kh, h huyt p th ng, nht l vi
liu u tin.
- Dihydralazine (Nepressol) vin 25mg, liu t 1-4 vin/ngy. c dng khi c suy
thn, c nhiu tc dng ph. Nhp tim nhanh, gi mui nc, hi chng gi luput ban
, vim a dy thn kinh ngoi bin khng dng khi c suy vnh, phng ng mch
ch bc tch, thng c ch nh trong tng huyt p c suy thn.
- Minoxidil (Loniten) tc dng rt mnh, ch dng khi tng huyt p khng cc loi
khc, suy thn mn; t dng hin nay.
3. iu tr c th
3.1. nh gi THA theo mc nguy c ca T chc y t Th Gii v Hi tng
huyt p Th Gii (ISH) nm 2003.
Theo cc bc sau:
* nh gi cc yu t nh hng n tin lng, bao gm:
+ Yu t nguy c ca bnh tim mch:
- Mc Huyt p tm thu v tm trng (1-3).
- Nam > 55tui.
- N > 65 tui.
- Ht thuc l.
- Cholesterol ton phn > 250mg%.
- Tiu ng.
- Tin s gia nh b bnh tim.
+ Yu t khc nh hng xu tin lng:
- HDL-C gim.
-LDL-C tng.
-Albumine niu vi th bnh nhn tiu ng.
-Ri lon dung np Glucose.
-Bo ph.
-Li sng tnh ti.
-Fibrinogene mu tng.
-Nhm kinh t x hi cao.
-Nhm dn tc nguy c cao.
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Tht bi
Tht bi
SUY TIM
Mc tiu
1. Nu c cc nguyn nhn suy tim.
2. Trnh by c cc triu chng lm sng v cn lm sng.
3. Vn dng c trong chn on suy tim.
4. Hc thuc cc thuc s dng iu tr suy tim
5. Nm vng cc phc iu tr suy tim
Ni dung
I. I CNG
1. nh ngha: Suy tim l trng thi bnh l, trong c tim mt kh nng cung cp
mu theo nhu cu c th, lc u khi gng sc ri sau c khi ngh ngi.
Quan nim ny ng cho a s trng hp, nhng cha gii thch c nhng
trng hp suy tim c cung lng tim cao v c trong giai on u ca suy tim m
cung lng tim cn bnh thng.
2. Dch t hc: Ti chu u trn 500 triu dn, tn sut suy tim c lng t 0,4 -
2% ngha l c t 2 triu n 10 triu ngi suy tim. Ti Hoa K, con s c lng
l 2 triu ngi suy tim trong 400.000 ca mi mi nm. Tn sut chung l khong
1-3% dn s trn th gii v trn 5% nu tui trn 75. Ti nc ta cha c thng k
chnh xc, nhng nu da vo s dn 70 triu ngi th c n 280.000 - 4.000.000
ngi suy tim cn iu tr.
II. NGUYN NHN
1. Suy tim tri: Tng huyt p ng mch, h hay hp van ng mch ch n
thun hay phi hp, nhi mu c tim, vim c tim do nhim c, nhim trng, cc
bnh c tim, cn nhp nhanh kch pht trn tht, cn cung ng nh, rung nh
nhanh, cn nhp nhanh kch pht tht, blc nh tht hon ton, hp eo ng mch
ch, tim bm sinh, cn ng ng mch, thng lin tht.
2. Suy tim phi: Hp van 2 l l nguyn nhn thng gp nht, tip n l bnh phi
mn nh: Hen ph qun, vim ph qun mn, lao x phi, gin ph qun, nhi mu
phi gy tm ph cp. G vo ct sng, d dng lng ngc, bnh tim bm sinh nh
hp ng mch phi, t chng Fallot, thng lin nh, thng lin tht giai on mun,
vim ni tm mc nhim trng, tn thng van 3 l, ngoi ra mt s nguyn nhn t
gp nh u nhy nh tri. Trong trng hp trn dch mng ngoi tim v co tht mng
ngoi tim, triu chng lm sng ging suy tim phi nhng thc cht l suy tm
trng.
3. Suy tim ton b: ngoi 2 nguyn nhn trn dn n suy tim ton b, cn gp cc
nguyn nhn sau: bnh c tim gin, suy tim ton b do cng gip trng, thiu
Vitamine B1, thiu mu nng.
III. C CH BNH SINH
Chc nng huyt ng ca tim ph thuc vo 4 yu t: Tin gnh, hu gnh, sc co
bp c tim v nhp tim.
Sc co bp
Tn s tim
27
thng xuyn, nhng khng c cn kh th kch pht nh suy tim nh suy tim tri.
Xanh tm nhiu hay t ty nguyn nhn v mc ca suy tim phi.
2.1.2.. Du chng thc th: Ch yu l mu ngoi bin vi gan to, b t, mt
nhn, n au tc, iu tr tch cc bng tr tim v li tiu gan nh li, ht iu tr gan
to ra gi l gan n xp, nu gan b mu lu ngy gan khng nh li c gi l
x gan tim vi gan b sc, mt chc. Tnh mch c ni, phn hi gan tnh mch
c (+) t th 450. p lc tnh mch trung ng v tnh mch ngoi bin tng cao.
- Ph: Ph mm lc u 2 chi di v sau ph ton thn, c th km theo c
trng, trn dch mng phi. Tiu t 200-300ml/ 24gi.
- Khm tim: Ngoi cc du hiu ca nguyn nhn suy tim, ta cn nghe nhp tim
nhanh, c khi c ting nga phi phi, thi tm thu van 3 l do h van 3 l c
nng hu qu ca dn bung tht phi. Huyt p tm thu bnh thng, huyt p tm
trng tng.
2.2. Cn lm sng
- X quang: Tr trng hp suy tim phi do hp van ng mch phi c c im l
phi sng, cn li cc nguyn nhn suy tim phi khc trn phim thng phi m, cung
ng mch phi gin, mm tim hch ln do tht phi gin. Trn phim nghing tri
mt khong sng sau xng c.
- in tm : Trc phi, dy tht phi.
- Siu m tim: Tht phi gin to, tng p ng mch phi.
- Thm d huyt ng: Tng p lc cui tm trng tht phi, p lc ng mch ch
thng tng.
3. Suy tim ton b: Bnh cnh suy tim phi thng tri hn. Bnh nhn kh th
thng xuyn, ph ton thn, tnh mch c ni t nhin, p lc tnh mch tng cao,
gan to nhiu, thng c c trng, trn dch mng phi, huyt p tm thu gim,
huyt p tm trng tng, Xquang tim to ton b, in tm c th dy c 2 tht.
V. PHN SUY TIM
1. Theo Hi Tim Mch New York: Chia lm 4 : 1: Bnh nhn c bnh tim
nhng khng c triu chng c nng, hot ng th lc vn bnh thng. 2: Cc
triu chng c nng ch xut hin khi gng sc nhiu, hn ch hot ng th lc.
3: Cc triu chng c nng xut hin ngay c khi gng sc nh, lm hn ch hot
ng th lc. 4: Cc triu chng c nng xut hin thng xuyn k c khi bnh
nhn ngh ngi.
2. Phn suy tim mn theo Trn Trinh & V nh Hi
- Suy tim 1: Kh th khi gng sc, ho ra mu, khng ph, gan khng to.
- Suy tim 2: Kh th khi i li vi vn tc trung bnh, khi i phi ngng li
th, ph nh, gan cha to hoc to t, 2cm di b sn. Phn hi gan tnh mch
c (+) t th 450.
- Suy tim 3: Kh th nng hn hoc gim i, ph ton, gan > 3cm di sn,
mm, phn hi gan tnh mch c (+) t th 450, iu tr gan nh li hon ton.
- Suy tim 4: Kh th thng xuyn, bnh nhn phi ngi dy th, gan >
3cm di b sn, mt chc, b sc, iu tr khng p ng hoc nh li t.
VI. IU TR SUY TIM
1. Cc thuc iu tr suy tim.
1.1. Digitalis
29
IU TR SUY
TIM
IU TR IU TR TNH IU TR CC
NGUYN NHN TRNG SUY YU T LM D
TIM
I Khng iu tr Khng iu tr
II - Hn ch th lc - Hn ch th lc
- Ch n king mui - Ch n king mui
- Digital - Li tiu? c ch men chuyn?
-Digital + Li tiu Thiazid - Li tiu + CMC hoc
Li tiu + Dn mch
III - Digital + Li tiu quai. - Li tiu + CMC hoc Dn mch
- Digital + Li tiu + Dn mch + Digital ? hoc
- Li tiu + CMC hoc Dn mch
IV - Digital + Li tiu + Dn mch
+ thuc tr tim?
+ Thuc tr tim mi
- Chn bta?
- Ghp tim
- Ghp tim.
33
+ nh gi kt qu phu thut mch vnh hay sau nng mch vnh, bilan sau nhi
mu c tim vo ngy th 10 - 15.
+ nh gi chc nng ca mt s bnh van tim (tr hp van ng mch ch).
+ nh gi chc nng ca suy tim cn b.
- Tiu chun nh gi: c da vo nhiu yu t nh: ST chnh xung v nm
ngang trn 1mm hoc i xung trn 0,08 mm sau phc b QRS; ST chnh ln (him
gp); thi gian gng sc; cng ti a t c; xut hin cn T in hnh; in
tm bin i trong hay sau trc nghim gng sc; huyt p v tn s tim; mc t
tn s tim theo l thuyt; xut hin lon nhp khi lm test v/ hoc c du suy tim tri.
Kt qu test gng sc gn lin vi tui v gii ngi bnh (kh kt lun ph n
<55 tui, dng gi >20% ngi < 40 tui trong khi gim cn < 10% ngi > 60
tui).
1.2.2. o in tim Holter trong 24 gi: Gip chn on bnh mch vnh im lng,
chn on v theo di cn TN Prinzmetal, hoc s gia tng kch thch tm tht.
1.2.3. ng v phng x
- Nguyn tc: Kho st s ti mu c tim vng bng cch so snh s phn b cht
ng v phng x Thalium 201 vo c tim khi ang gng sc v sau mt thi gian ti
ti mu khi ngh ngi.
- ch li v hn ch: Nhy hn trc nghim gng sc (80%), c hiu hn (90%) cho
php xc nh vng b thiu mu, nh gi chc nng c tim. Gii hn ca phng
php: dng tnh gi nu c block nhnh tri, gi thnh cao.
- Chp bung tht bng phng x: bm tnh mch cht Technium. C th nh gi
s co bp tng vng v ton b tht tri cng nh chc nng tim tri.
1.2.4. Siu m tim v Doppler
- Siu m 2 chiu: nhm:
+ Phn tch s hot ng tng phn nh gim co bp, khng co bp thm ch ri
lon co bp khu tr, tim bt thng thn chung ca ng mch vnh nh calci
ha.
+ Tnh ch s co hi tht tri nhm nh gi chc nng tht tri ton b.
Vi Doppler gip chn on h van 2 l do thiu mu c tim, p lc mch
phi. Cc bin i v s lm y tht, nh gi lu lng ng mch khi gng sc
v ngh ngi.
- Siu m tim gng sc chn on thng qua vic thy bt thng vn ng thnh
tim cho nhy cm chn on > 90% nu hnh nh tt.
1.2.5. Chp mch: Bm cht cn quang chp ton b h mch vnh v bung tht.
i vi h mch vnh c gi tr nh gi mc , v tr tn thng mch vnh cng
nh tnh trng ti mu, phn b mch mu v s calci ha, cc bt thng bm
sinh, i vi bung tht nhm phn tch s co bp tng phn, chc nng tht tri,
ch s tng mu v h 2 l do thiu mu c tim. Chp ng mch vnh l phng
tin quyt nh dng nh gi nng ca bnh mch vnh cng nh dng
chn on khi cc phng tin thm d khc khng cho php xc nh suy vnh. C
th ni chp mch vnh l xt nghim khng th thiu c i vi bnh l mch
vnh c bit khi cn thit phi can thip ngoi khoa, tuy vy y l k thut tn km
v i hi chuyn vin.
1.2.6. Chp nhp nhy c tim bng Thallium 201 hoc Technitium 99m: c nhy
cm 70-90% v c hiu 60-90% nhng t tin.
37
5.3.Chn on
Theo T chc Y t th gii NMCT c chn on xc nh khi c hai trong 3
du hiu sau: cn au tht ngc bin i, thay i ECG theo tin trin ca bnh v
s gia tng men tim.
Mt s trng hp khng c th chn on xc nh NMCT m ch c th ni
c th c NMCT. Thng th c triu chng lm sng in hnh rt gi nhng m
thiu bng chng khch quan trn ECG v men. Nu lm sng nghi ng nhiu th c
th l NMCT nh. Trc mt bnh nhn nam gii >35 tui, n gii >50 tui c au
ngc th phi xem xt iu tra c NMCT hay khng. Phi chn on phn bit vi
au do vim phi, tc ng mch phi, vim mng ngoi tim, gy xng sn,co
tht thc qun, phnh tch ng mch ch v nhng tnh hung gy bnh cnh au
bng cp tnh do bnh trong bng.
5.4. Bin chng
5.4.1. Ri lon nhp: ngoi tm thu, rung tht, nhp nhanh tht, bloc nh tht...
5.4.2. Suy tim: c chong hoc khng.
5.4.3. Phnh thnh tim.
VII. IU TR
1. Nguyn tc iu tr
1.1 Ci thin cc yu t nguy c
y l bin php hng u c gi tr v t tn km, p dng c cho cc i tng
giu/ngho nhng i hi s quyt tm v cng tc ca bnh nhn. C th nh v
sinh i sng v ch n ung gim m, tp luyn th dc i b, bi li, i xe p,
trnh stress, theo di, khm bnh, xt nghim lipid u n, lm trc nghim gng
sc hng nm.
1.2. iu tr cn nguyn
Nu bit c. Tuy c kh nng ci thin r nhng ch p dng trong nhng c
nhn, n v c iu kin kinh t cao. V d: iu tr x va ng mch bng cc
thuc gim m, iu tr phu thut vi cc tn thng van tim bm sinh hay mc
phi.
2. Phng tin
2.1. iu tr ni khoa
Bng cc thuc nh: dn xut nitrs, molsidomine, chn bta, c ch calci, cc phn
t khc, maleate de perexilline (Pexid), chng ngng tp.
2.2. Nong ng mch vnh qua da (Angioplastie coronaire transluminale percutane)
(PTCA)
X dng mt catheter a vo M vnh qua da xc nh mc hp mch vnh,
sau s x dng mt bong bng nh, ng knh 2-4mm bm ln v tr b hp,
c xem kt qu khi nng c trn 50% so vi khu knh trc, t l thnh cng
thng t n 90-95% trong giai on u tin.
2.3. Phng php phu thut cu ni ch - vnh (Pontage aorto-coronaire)
Phng php c thc hin bng cch ghp tnh mch hin trong v nht l ng
mch v trong vo v tr mch vnh b tn thng. T vong phu thut khong 1-4%,
phng php ny ci thin d hu v triu chng ca bnh nhi mu c tim.
3. iu tr c th cn au tht ngc gng sc
3.1. iu tr ct cn au tht ngc gng sc
39
- Kim sat cn au: Morphine sulfate 2-4 mg TM mi 5-10 pht cho n khi ht au
hoc cc triu chng ph xut hin (x tr bng naloxone 0.4-1.2mg TM) ; h huyt
p (nu nhp tim chm x tr bng atropine 0.5mg TM, nu khng c th chuyn dch
vi s thn trng).
- Nitroglycerine 0.3 mg ngm di li nu HA tm thu trn 100mmHg; nu vn cn
au ngc cn cho TM nitroglycerine (bt u vi 10microgam/pht, tng dn n
mc ti a 200 microgam/pht, theo di cht ch bng monitor).
- Oxygen 2-4 lt/pht bng xng mi, nhm duy tr nng bo ha O2 >90%.
- An thn nh (V d: Diazepam 5 mg ung X 4ln / ngy).
- n nh chng to bn: Dng cc cht nho phn Vd. docusate sodium 100-
200mg/day)
- Chn bta: c tc dng gim tiu th O2 c tim, hn ch din tch nhi mu, gim t
l t vong. Thuc c tc dng tt trong trng hp tng huyt p, nhp tim nhanh,
au tht ngc tn ti; chng ch nh khi suy tim, HA tm thu di 95 mmHg, nhp tim
< 50l/pht, bloc nh tht hoc tin s b bnh co tht ph qun. Cho TM v d
metoprolol 5mg / 5-10 pht cho n liu tng cng 15mg sau cho ng ung
metoprolol 25-100mgX 2 ln/ ngy.
- Thuc chng ng/ thuc chng ngng tp tiu cu:
Bnh nhtsau khi c dng tiu s huyt thng c tip ni chng ng bng
aspirine v heparine, thi gian bt u ty thuc loi tiu si huyt. Trong trng
hp khng th dng tiu si huyt c th cho aspirin 80-325mg/ngy v liu thp
Heparin 5000 v tim di da hoc tim tnh mch / 12 gi. Liu heparin hu hiu
(thi gian PTT gp i thi gian chng) sau duy tr bng thuc chng ng ung
c khuyn co x dng nhng bnh nhn suy tim nng, c cc mu ng tm
tht chn on bng siu m, hoc c vng ri lon vn ng ln trong NMCT trc.
- Cc thuc c ch men chuyn: gim t vong nhng bnh nhn ri lon chc
nng tht tri khng c triu chng sau NMCT (ch s tng mu di 40%) v c th
cho nhng bnh nhn huyt ng n nh. Vd: captopril 6.25mg liu tt u tin
sau tng ln 50mg ung 3ln / ngy.
VIII. D PHNG
Gm nhiu bc tin hnh mt cch c h thng:
1. Xc nh nguy c
Thu thp ng thi cc thng tin v cc yu t nguy c phi hp cho php nh gi
ton b mc rng nguy c mang tnh c th ca ng mch vnh c li
khuyn c hiu.
2. Li khuyn c hiu
Dnh cho c ngi cha b v c ngi b ri
- Ht thuc: b hon ton thuc l. Nguy c ht thuc li ln hn khi c nhiu yu t
phi hp. Vic d phng cn ch c bit nu l nam gii.
- Huyt p: cn c ch iu tr theo di cht ch nhng trng hp mc bnh d
ch mi giai on u tin hoc ch tng huyt p gii hn.
- Tng cholesterol mu: cn ch khi cholesterol mu tng trn 220 mg% vi s
khuyn dng ch n c bit cng nh cn phi c khm xt v iu tr dc
bit khi tng trn 260mg%.
-Tng cng luyn tp v hot ng th lc nhiu hn. Vic gim th trng bao hm
vic gim r cc yu t nguy c.
43
BNH C TIM
Mc tiu
1. Nm c nguyn nhn, c c ch bnh sinh 3 nhm bnh c tim khc
nhau, ch yu vo bnh c tim dn l nhm bnh thng gp nc ta.
2. Nm ca triu chng lm sng v cn sng cc bnh c tim dn gip vn
dng trong thc hnh lm sng.
3. Chn on phn bit c ba loi bnh c tim.
4. Bit vn dng iu tr cc loi thuc theo cc tnh hung cng nh bin
chng ca tng bnh c tim.
5. Bit r cc bin php phng nga cc bnh c tim.
Ni dung
I. NH NGHA
Theo bo co ca Lc lng c nhim T chc Y t th gii (TCYTTG):
Bnh c tim l bnh gy tn thng c tim m nguyn nhn thng khng bit r.
Bnh thng khng lin quan n cc bnh nh tng huyt p, bnh tim bm sinh,
bnh van tim, bnh ng mch vnh hay bnh mng ngoi tim.
II. PHN LOI
C 3 loi da vo c ch sinh bnh
- Bnh c tim dn n hay sung huyt (Dilated cardiomyopathy)
- Bnh c tim hn ch (Restrictive cardiomyopathy)
- Bnh c tim ph i (Hypertrophy cardiomyopathy)
y l cch phn loi thng dng nht hin nay da vo khi nim ban u ca
Goodwin v c TCYTTG cng nhn.
Ngoi ra cn c cch phn loi theo nguyn nhn l bnh c tim tin pht v bnh
c tim th pht nhng hin nay t dng. Bnh c tim tin pht cn c tn gi l bnh
c tim, cn bnh c tim th pht gi l bnh c tim c hiu ngha l cc bnh c
nguyn nhn r rng hoc l hu qu ca bnh ca cc c quan khc.
III. DCH T HC
Bnh c tim c m t u tin t nm 1957 v pht hin khp th gii.
Tuy vy ty theo c im chng tc, vn ha, a l ca tng quc gia m tn xut
ca cc bnh rt khc nhau. Bnh c tim dn l nhm bnh gp hu ht cc ni
trn th gii, cn bnh c tim hn ch l bnh him gp nht. Bnh c tim ph i
chim t l trung bnh. Bnh c tim dn v ph i gp cc nc vng chu v
Thi bnh dng. Trong khi bnh c tim hn ch li gp cc vng chu Phi, Nam
M, Trung M v mt s vng ti n .
T l mc bnh c tim dn ti Thy in c c tnh l 10/10.000 dn/ nm.
Ti Trung quc trong mt nghin cu ti mt nh my trn 60.000 cng nhn ghi
nhn 65 ngi b, trong c 52 ngi b BCT dn v 4 trng hp b BCT ph i.
Ti Chandigarh Chu Phi 3,7% trng hp m t thi c bnh c tim. Trong 38
trng hp pht hin th 28 ca b BCT dn, 9 ca b x ha c tim ni tm mc, 1 ca
b bnh c tim, ph i.
i vi bnh c tim ph i th t l chnh xc cha bit r v d nhm ln cc bnh
khc.
45
I. NH NGHA
Bnh c tim dn l hi chng dn tht tri vi s gia tng khi lng tht ch
yu l tht tri vi ri lon chc nng tm thu hay tm trng m khng c tn
thung nguyn pht mng ngoi tim, van tim hay thiu mu c tim.
Trn lm sng bnh c tim dn c biu th qua s dn hai tht, tht tri
nhiu hn tht phi, do s tr trong bung tht, l ngun gc cc cc mu ng
gy tc mch.
V gii phu bnh, l s x ha k c tim, cc t bo c ph i v thoi
ha khng c hiu.
II. NGUYN NHN: Thng iu tr bng cch loi tr.
1. Mt s yu t c ra nh: Nhim trng (entrovirus), dinh dng, ng c
(ru), tng HA, tn thng vi tun hon vnh, min dch, sau sinh.
2. Chn on bnh c tim dn v cn: Ch xc nh khi loi tr cc nguyn nhn
bit c.
III. SINH L BNH
1. S dn tht v gim co bp: a n s gim ch s tng mu v s gia tng th
tch cui tm trng. iu ny s lm gim s lm rng tm nh, lm tng p lc nh
tri v p lc cui tm trng ca tht tri. giai on u, nhp tim nhanh b tr
vi s gim th tch tng mu tm thu nhm duy tr lu lng tim (Q = FxV). V sau
s xut hin gim lu lng tim, s gia tng p lc mao mch phi (OAP) v sau
cng l s gia tng p lc mao mch phi v suy tht phi.
2. S gim p lc ti mu thn: a n s kch thch h renine - angiotensine -
aldostrone. iu ny lm gia tng th tch mu nhng gy s co mch ngoi bin.
S thiu mu di ni tm mc thng gp do s gim d tr vnh.
VI. LM SNG
1. Hi bnh
1.1. Tin s
- Tin s c nhn v iu tr hin ti hay trc y.
- Gia nh.
1.2. Triu chng c nng:
- Mt mi, kh th cc mc .
- Ph ngoi bin, au ngc, hi hp, tin s thuyn tc ngoi bin hay no.
2. Khm lm sng
- Tim: Nhp tim nhanh, huyt p ng mch bnh thng hay thp, mm tim lch tri,
ting T3, T4, thi tm thu h hai l v/hay h ba l, cc du hiu ca suy tht phi.
- Phi: Ran m phi, trn dch mng phi.
46
V. CN LM SNG
1. X quang phi: Tim to vi s gia tng t l tim/lng ngc, du xung huyt phi, trn
dch mng phi.
2. in tim: Nhp nhanh xoang, bt thng khng c hiu on ST-T, ph i tht
tri, bloc nhnh tri khng hon ton hay hon ton, bt thng nh , sng R gim
bin . i khi c sng Q d nhm hoi t c tim, ri lon nhp nh v nhp tht.
3. Sinh ha: Ion : gim Natri mu, suy thn chc nng, CPK bnh thng.
4. Siu m tim vi Doppler tim
4.1. Siu m 2 bnh in v TM: Dn cc bung tim nht l tht tri, gim ch s co
hi, gim co bp ton th vch tim, c khi khng co bp d nhm suy mch vnh, c
th thy cc mu ng v trn dch mng tim.
4.2. Doppler tim: Tm du h 2 l (c nng), du h 3 l hay h ng mch phi, s
ri lon chc nng tm trng, nh gi cung lng tim.
5. Cc phng php thm d c bit:
5.1. Chp nhp nhy c tim: ch s tng mu gim.
5.2. Thng tim: cho php nh gi p lc bung tim, s hot ng cc bung tim,
cc van tim. Sinh thit c tim ch cn khi mun tm nguyn nhn.
5.3. Holter nhp, trc nghim gng sc, kch thch tim.
VI. TIN TRIN
1. Bin chng: Suy tim ton b, rung nh, nhp nhanh tht v t t, tc mch ngoi
bin v no b, phi.
2. T l sng trung bnh: 6 thng n 3 nm sau khi xut hin cc triu chng, 20%
bnh nhn c din tin thun li hn.
VII. CHN ON PHN BIT
- Bnh c tim thiu mu tin trin.
- Bnh c tim do tng huyt p tin trin.
- Bnh van tim, c bit l h van hai l nng.
- Bnh c tim tc nghn.
Ni chung, bnh c tim dn nguyn pht c chn on khi loi tr sau khi loi
tr tt c cc nguyn nhn dn tht tri, c bit l bnh mch vnh nng hay h
van tim nng.
VIII. HNG IU TR
1. Bin php chung
2. iu tr thuc: kt hp thuc dn mch v li tiu c nh gi cao.
3. iu tr bin chng: nh ph phi cp, chong tim, rung nh, ri lon nhp tht.
4. Ghp tim.
- Nghe tim: thi tm thu (90% ca) kiu tng mu gia k tm thu, vng gia tim lan
ra mm, cng thay i theo thi gian, gia tng khi gng sc, ngoi tm thu tht,
khi lm nghim php Valsalva, gim khi ht vo, cc ting tim bnh thng, c T4
thng. C thi ton k tm thu do h 2 l vi cng gim khi ht Nitrite d Amyle
hay khi lm th thut Valsalva.
3. in tim: Khng c du c hiu.
- Nhp tim: thng l nhp xoang, ngoi ra cn gp rung nh (5-10%), ri lon nhp
tht.
- Ph i tht tri (60%), c khi 2 tht.
- Ph i vch tim: sng Q thanh mnh (< 0,04), su (50%) V5, V6, D1, aVL.
- iu tr phu thut.
- iu tr bin chng nh ph phi cp, rung nh, lon nhp tht.
-Khng sinh d phng.
BNH C TIM HN CH
Verapamil (Isoptine 360 mg/ngy): ci thin triu chng khi khng p ng chn
bta, nhng c nhiu bin chng (h HA, ri lon nt xoang, bloc NT...), v vy ch
dng bnh vin.
+ Disopyramide (Rythmodan)
C li v lm gim lon nhp, gim co bp nn gim tc nghn.
+ Amiodarone (Cordarone)
Gim du hiu c nng dng khi cc loi thuc trn tht bi hay khi lon nhp tht
nng.
* iu tr phu thut
- Phu thut ct c tim vch lin tht phn y.
- Thay van 2 l: khi phu tht trn khng tt, t l t vong do m 5-8%, kt qu gn
90% t 6 thng n 1 nm, lu di ch 70% trong 5 nm.
2.3. Ch nh
* Bnh c tim tc nghn khng triu chng ngi tr
iu tr bng chn (hay verapamil c ch nh khi:
- Tin s gia nh t t.
- Ph i tht tri, r.
- Nghn co bp trong bung tht tri.
Cn theo di lm sng mi 3 thng v siu m mi 6-12 thng.
* Bnh c tim nghn mch nng c triu chng ngi tr
- iu tr ni khoa l ch yu (chn (va /hay verapamil).
- Phu thut cn bn n khi p lc trong bung tht tri trn 50mm tnh trng c
bn.
* Bnh c tim ph i bnh nhn THA ln tui
- Mc ch iu tr l phi kim sot THA, gim khi lng tht tri.
- iu tr ni khoa l chnh, dng thuc liu tng dn, theo di p ng bng siu
m.
2.4. iu tr bin chng
* Ph phi cp
Dng li tiu, chn ((celiprolol, propranolol) v /hay Verapamil.
* Rung nh
Sc in, digital, chng lon nhp loi I.C, Amiodarone, khng vitamin K (ch dng khi
rung nh mn tnh v nh tri gin).
* Lon nhp tht
iu tr thng t hiu qu, c th dng amiodarone n thun hay phi hp chn
(v Verapamil.
* Khng sinh d phng
Khi p dng cc th thut ngn nga vim ni tm mc nhim khun.
3. iu tr bnh c tim hn ch
3.1. iu tr khng c hiu
Khng dng li tiu v dn mch. Digital ch cho khi rng nh. To nhp: khi ri lon
nhp chm trm trng. Chng ng khi c cc mu ng, tc mch.
3.2. iu tr c hiu
55
* Sarcoidose
Corticotd.
* X cng b
Corticoid v hay c ch min dch.
* Nhim thit huyt t
Trch mu. C li nu thc hin sm. Thuc desferoxamine gip lm gim nhim st
c tim.
* iu tr ngoi khoa
Khi iu tr ni khoa tht bi. Ct lc lp ni mc b x v thay van tim b nh hng
ca bnh. C ch trn mt s ngi bnh
* Ghp tim
IX. PHNG NGA BNH C TIM
1. Bnh c tim dn
Vic phng bnh hn ch do nguyn nhn cha r. Tuy vy nguyn nhn nhim
trng, nhim virut chng ta c th quan tm iu tr. i vi bnh c tim c hiu
nh bnh c tim chu sinh hay nghin ru th c th ngn nga bng cch gio dc
v li sng, nng cao sc khe.
2. Bnh c tim ph i
Do bnh c tnh di truyn nn cn qun l cc trng hp mc bnh.
3. Bnh c tim hn ch
Cn pht hin sm tr di 15 tui qua bch cu acid khng ht.
56
VA X NG MCH
Mc tiu
- Nm vng mt s gi thuyt v c ch bnh sinh v cc yu t nguy c va
x ng mch.
- Vn dng c cc triu chng lm sng v cn lm sng trong chn on
va x ng mch.
- Nm vng nguyn tc iu tr, cc phng tin iu tr chnh.
- Bit vn dng cc bin php c th c bit l cc thuc iu tr lipid mu
trong x tr v d phng x va ng mch
Ni dung
I. I CNG
T chc Y t th gii nh ngha: Va x ng mch l s phi hp cc hin
tng thay i cu trc ni mc ca cc ng mch ln v va, bao gm s tch t
cc b cc cht lipid, cc phc b glucid, mu v cc sn phm ca mu, m x v
cn lng acid, cc hin tng ny km theo s thay i lp trung mc.
Ni chung va x ng mch l hin tng x ha thnh ng mch bao
gm cc ng mch trung bnh v ng mch ln. Biu hin ch yu l s lng ng
m v cc mng t bo ti lp bao trong thnh ng mch gi l mng va.
Va x ng mch c pht hin cc xc c Ai cp t 50 nm trc
Cng nguyn. VXM gy ra 2 bin chng nguy him l nhi mu c tim v tai bin
mch no. cc nc cng nghip 50% t vong do tim mch trong nguyn nhn
VXM chim 50%. Ti M ngi trn 60 tui c 88% VXM, ngi gi hn th
khng ngi no khng b VXM. Bnh tuy vy vn gp ngi tr. Trn 300 lnh
M tui trung bnh 22 cht trong chin tranh Triu tin, khi m t thi thy 77% b
VXM vi mc nhiu hay t. nc ta cha c s liu ton dn.
II. NGUYN NHN- C CH BNH SINH
1. C ch bnh sinh
1.1. Nhc li cu to thnh ng mch
Thnh ng mch cu to bi 3 lp ng tm t trong ra ngoi nh sau:
- lp o trong hay lp ni mc: ch c mt lp duy nht cu to bi cc t bo ni
mc nm trong khong di khng c t bo v ngn vi trung mc bi lp n hi
trong.
- lp o gia hay lp trung mc to thnh bi nhng t bo c trn, si collagen v
elastin, gii hn ngoi mc bi lp n hi ngoi.
- lp o ngoi hay ngoi mc l lp m lin kt c cc mch mu nui.
1.2. Qu trnh pht trin VXM
Mng va x ng mch c to thnh do s dy ln ca cc thnh ng mch
bao gm mng li m si bao bc chung quanh bi lp m pht xut t khong
di ni mc ca bao trong. Mng VXM gp ch yu cc thn ng mch ln
(MC bng, m vnh, chu i, cnh v ch xung) c bit hay nhng vng
xoy mu nh nhng ch un cong hay ch i.
Mng VXM xut hin sau nhiu nm vi nhng c ch m ngy nay dn dn
c bit r hn:
- Giai on u do ri lon huyt ng ti ch (hin tng xoy mu) lm bin i
cu trc bnh thng ca lp trong. Tn thng xut hin sm nht l tnh trng ph
57
c xon nh v ngt.
2. Disopyramide (Rythmodan): nhm Ia ca Vaughan-Williams
Liu lng: ngi ln 300-1000mg/kg/ngy, chia lm 4 ln.
Bi tit: 50% qua thn v 50% qua gan.
Tng tc thuc: atenolol, erythromycine lm tng nng disopyramide. Tng tc
dng ca warfarine v tng c tnh ca lidocaine.
Tc dng ph: kh ming, b tiu, nhn m, to bn, lm suy tim nng do gim co
bp tim, gy lon nhp.
3.Lidocaine (Xylocaine): nhm Ib ca Vaughan-Williams.
Liu lng: liu tn cng bng ng tnh mch 0.5-1.0 mg/kg/ln. C th lp li
sau 5-10 pht khi c kt qu, liu ti a l 5mg/kg. Liu duy tr: 20-50microg/kg/pht,
gim liu nu dng thuc trn 24 gi.
Bi tit: qua gan.
Tng tc thuc: thuc c ch bta, cimetidine lm tng nng lidocaine.
Phenyltoine, phenobarbital, rfampycine v isoproterenol lm gim nng . Tng
c tnh lidocaine khi dng phi hp disopyramid.
Tc dng ph: ch yu ln h thn kinh nh co git, d cm, mt cm gic v ngng
h hp.
4. Flecaine: thuc nhm Ic
Liu lng: ngi ln ung 200-400mg/ngy.
Bi tit: 50% gan v 50% thn.
Tng tc thuc: amiodarone, cimetidine lm tng nng thuc trong mu.
Propranolol lm tng nng c hai trong mu. Tng nng digital khong 50%.
Tc dung ph: cc biu hin thn kinh nh run, dau u, d cm, gim i khi gim
liu. Lm gim co bp tim nn khng dng khi c suy tim. C tc dng gy lon nhp
tim nu dng bnh nhn c tn thng c tim.
5. Propranolol: nhm II ca Vaughan-Williams
Liu lng: ung 2-5mg/kg/ngy chia lm 4 ln. ng tnh mch 0.1-0.2mg/kg/liu
trong 5 pht. C th lp li sau mi 6 gi.
Bi tit: qua gan.
Tng tc thuc: cimetidine, furosemide, quinidine lm tng nng thuc.
Phenyltoine, phenobarbital, rifampicine lm gim nng trong mu.
Tc dng ph: lm chm nhp tim, tng bloc tim, tng suy tim, co tht ph qun, lm
tng ng mu, c th trm cm, lit dng.
6. Amiodarone: nhm III ca Vaughan-Williams.
Liu: ung tn cng ngi ln 10mg/kg chia 2 ln / ngy trong 10 ngy sau
gim liu duy tr 5 mg/kg/ ngy trong 2 thng ri gim li na liu.
Tng tc thuc: amiodaron lm tng tc dng ca warfarine khong 100%,
digoxine 70%, quinidine 33% v procainamid 50%. Thuc lm tng nng ca
flecaine, phenyltoine. C tc dng hp ng vi thuc c ch bta, chn canxi nn
khng dng phi hp cc loi ny khi c suy tim.
Tc dng ph: rt t. C th gy vim phi, lng ng kt mc mt, ri lon chc
nng ti gan, tuyn gip, xm da nu iu tr lu di.
7. Adenosine: thuc khng nm trong phn nhm Vaughan-Willams nhng c tc
dng chng lon nhp tim tt nn c tc gi xut nhm VI. (Digital c xut
65
nhm V)
Liu lng: chch tnh mch nhanh liu 50-250microg/kg. C th nhc li sau 5-15
pht.
Bi tit: tc dng cc ngn, ch di 10 giy.
Tng tc thuc: dipyridamol, diazepam lm tng nng adenosine. Theophyliine
v quinidine lm gim nng thuc. Adenosine c th c tc dng hp dng vi
verapamil.
Tc dng ph: kh th, au ngc, nn nhng gim nhanh.
IV CH NH IU TR
- Thuc chng lon nhp Ia: thng dng iu tr lon nhp trn tht.
- Thuc nhm Ib: ch x dng cho lon nhp tht.
- Thuc nhm Ic: ch dng iu tr cc lon nhp trn tht.
- Thuc nhm II: ch yu dng cho lon nhp trn tht bnh nhn c hi chng tin
kch thch v i khi c dng phi hp thuc nhm Ia iu tr bnh nhn rung
nh hay cung nh. Tac dng km i vi lon nhp tht.
- Thuc nhm III: tc dng tt c trn tht v tht.Thng dng khi dng nhm I n
c hoc phi hp nhng tht bi.
- Adenosine: c tc dng ct cn nhp nhanh kch pht trn tht rt tt.
66
IN TM BNH L
Mc tiu
1. Nm vng c ch bnh sinh v in tm cc hi chng bnh l c tim.
2. Vn dng c cc tiu chun in tm trong chn on lm sng.
Ni dung
I. I CNG CC T TH IN HC CA TIM
1. V tr in hc v gii phu ca tim
Tim bnh thng c tm tht phi chim mt trc tim, cn tm tht tri nm
phn tri - bn v sau ca tim. Trc tim bnh thng i t y tim n mm tim trc
tim hng t sau ra trc xung di v qua tri. Tuy vy do nhng yu t bnh l
v sinh l khc nhau, t th in tim c nhiu thay i, nhng thay i ny pht sinh
do tim quay theo 3 trc chnh.
- Trc trc - sau: i qua tm ca qu tim. Khi xoay theo chiu kim ng h, tim s
t th thng ng. Khi xoay ngc chiu kim ng h t th tim s nm ngang.
- Trc dc: i t gia y tim n mm tim. Khi xoay theo chiu kim ng h, tm
tht phi s chim ton b mt trc tim v tm tht tri s chuyn ra sau, xung
di. Khi xoay ngc chiu kim ng h, tm tht tri s chim phn ln pha trc
ca tim.
Bng 1: Cc biu hin ca in tim theo t th tim
Trc xoay ca tim Chuyn o tim Biu hin in tim Biu hin in tim
1- Tim quay quanh Tht (P) ra trc Tht (T) ra trc
trc dc - Trc tim RS V5, V6 RS V2, V1
-D SI Q III QI S III
- VR rS, QR, Qr
2- Tim quay quanh Mm tim sang (P) SI, Mm tim sang (T)
trc trc sau - Ch.o thng dng RIII RI SIII
- VL QS rS qR, qRS
3- Tim quay quanh Mm tim ra trc Mm tim ra sau
trc ngang - Ch.o thng dng QI, Q II, Q III SI, SII, SIII
- aVF qR QS, Rs
- Trc ngang: hng t phi sang tri, i qua trung tm ca khi c tim. Nu
tim quay v pha trc, mm tim s hi xoay ra trc v y tim ra sau. Cn nu tim
quay ra pha sau, s bin i s ngc li. Thc t khi tim quay bao gi cng theo
c 3 trc trn.
2. T th in hc
T th in hc tim gip ta nhn bit c s thay i ca in tm , hiu
thm c ch pht sinh v hnh dng cc sng trn cc chuyn o khc nhau. Thc
t ngi ta hay xc nh t th in tim theo Wilson. Phng thc ny cho php ta
xc nh t th tim quay theo trc hay gp nht l trc trc sau. C 6 t th trong
t th trung gian hay gp nht, tim bnh l v phn ln cc ca dy tht tri
thng c s lin quan gia t th tim v trc in tim.
Bng 2: Cc t th in hc ca tim
T th T Trc T Cc phc hp tht ging nhau
67
Phi Tri
r (1) (3)
(1a)
(1b (1)
(2)
Hnh nh sng in tim chuyn o trc tim phi V1,2 v tim tri V5,6 cng c
ch to thnh cc sng in tim trong dy tht tri.
2.2. Dy tht phi
2.1.1. Nguyn nhn: Hp 2 l, tm ph mn, h 3 l, thng lin nh, t chng Fallot,
hp van MP, thng lin tht, o gc ng mch, thn ng mch chung, tng p
phi tin pht, phc hp Eisenmenger...
2.1.2. Triu chng:
-Phc b QRS: khng dn rng qu gii hn bnh thng.
-Chuyn o trc tim:
+ Chuyn o V1, V2: du hiu quan trng l s tng bin sng R, sng R cao
trn 7mm, ch s Sokolov - Lyon: RV1 + SV5 >11mm c gi tr chn on, c khi R
khng cao trong mt s trng hp nh tm ph mn, kh ph thng, khi QRS
thng c dng rS, W, QS... Nhnh ni in mun 3% - 3,5% nu trn 5% l c
bloc nhnh phi phi hp.
+ Chuyn o V5,V6: sng S su hn bnh thng, c th bng R hay dng rS.
+Vng chuyn tip: lch v V5, V6.
+ Chuyn o ngoi bin: Trc phi, gc ((110 o.
- on ST-T: C 2 kh nng:
+ Tng gnh tm thu: ST-T chuyn tri chiu QRS.
+ Tng gnh tm trng: Bloc nhnh phi.
V1 V2 V5 V6
71
V1, V2 V5, V6
- Bloc nhnh phi hon ton: Thiu nng vnh ngi gi, tng gnh tht tri do THA,
hp MC, NMCT trc vch.
- Bloc nhnh phi khng hon ton: Thng gp trong tng gnh tht phi, thng
nh, thng tht, thng nh-tht, suy tim phi, hp hai l, hp 3 l, bnh tm ph cp
c dn tht phi, ngoi ra cn gp trong tm ph mn, bnh Ebstein.
3.2.2. Triu chng:
- Phc b QRS chuyn o trc tim: Ch yu V1, V2, V3R, V4R. C dng rsR
vi R dn rng, trt m hay c mc vi nhnh ni in i khi 6% -10%; khi c
phi hp dy tht phi th R cng cao. V5, V6 c dng QRS vi S dn rng, trt
m (du hiu gin tip).
- Chuyn o ngoi bin: thng gp nht l aVR dng qR hay QR, rsR, rSR vi
R hay R dn rng trt m.
Ngoi ra cc chuyn o ngoi bin c th gp:
* Bloc Wilson: bloc nhnh phi c trc tri.
* Bloc him: bloc nhnh phi c trc phi rt mnh.
- on ST - T: tri chiu QRS.
BNP khng hon ton hay gp ngi tr v tr em bnh thng. Nu bnh
l, bloc nhnh (P) khng hon ton thng km theo thiu nng vnh, dy tht, tm
ph cp v mn, vim mng ngoi tim.
V1,V2 V5,V6
Ngng tim
mEq/l 12,5
Hai pha Rung tht
10,5
QRS dn rng
Bnh thng
5,0 T dt
2,5
RLDT Nh tht
Sng U(+)
00
Ngng tim
S bin i in tm theo nng kali mu
4.2. Canxi mu
Ca++ mu c tc dng r vo giai on 2e ca in th hot ng tim.
4.2.1. Gim canxi mu: lm ST di ra v QT di theo. Ca++ cng gim th ST cng
di ra nhiu. Khi nng hn QRS s hp li, sng T c th m hay dng.
4.2.2. Tng Canxi mu: lm ST ngn li, QT cng ngn theo.
Tng Canxi mu Gim Canxi mu
QT ngn QT di
5. Tc dng thuc
5.1. Digital: Vi liu thp Digital ko di giai on in tm ; liu cao (ngm
Digital) s rt ngn giai on 2e v vi liu c lm in th ngh gim i v gim tc
giai on O, tng tnh chu kch thch, gim tnh dn truyn (cc trung tm lc ch.
5.1.1. Liu ngm Digital: ST chnh xung vi c im: c hnh y chn (cn
gi l ru mp kiu Mexico), hoc vung gc, ST chnh theo hng i lp vi QRS.
- Sng T dt, 2 pha ri m (tc dng Conn)
- QT ngn ti (++).
75
ST vung gc ST hnh y
chn
QRS dn rng
Sng P mc
ST chnh xung Tdt Sng U cao
76
Ni dung
I. NH NGHA
Ri lon nhp tim (RLNT) l s ri lon hot ng in sinh hc ca tim v ba mt
- S to thnh xung ng
- S dn truyn xung ng
- Phi hp c hai mt trn
II. NGUYN NHN V C CH SINH BNH
1. Nguyn nhn
- Cc bnh nhim khun: thp tim l nguyn nhn thng gp nht; ri n cc
bnh nhim khun khc nh thng hn, bch hu.
- Do nhim c: thng gp l cc loi chng lon nhp nh: digital, quinidine
procainamid,reserpine, thuc chn beta.
- Do ri lon in gii: nh tng hoc gim kali mu, magn mu, canxi mu.
- Cc bnh ton thn: nht l cng gip, d ng thuc, i tho ng.
- Cc bnh c tim: do nhi mu c tim, thoi ha,lao,unh th, chn thng, cc
bnh tim bm sinh nh thng tht, cn ng ng mch, t chng Fallot.
- Do ri lon thn kinh thc vt: do xc cm hoc gng sc.
- Do phu thut.
- Do di truyn.
2. C ch bnh sinh: RLNT xy ra khi
2.1. Ri lon v s hnh thnh xung ng: c th gp
- Tng tnh t ng ca nt xoang: lm ton b tri tim s p theo vi tn s nhanh
nh nhp nhanh xoang.
- Gim tnh t ng ca nt xoang: tim s p chm gp trong nhp chm xoang,
nhp b ni,
- Tng tnh t ng ca ch nhp di nt xoang: l nhng ngoai tm thu.
- Ngoi ra mt s si c tim c th pht ra xung ng nh trong cn nhp nhanh
tht.
2.2 Ri lon v dn truyn xung ng: khi xung ng b tr ngi lm s dn truyn b
chm i ta gi l bloc. Bloc c th sinh l khng c tn thng thc th ca c tim
xy ra bt k v tr no ca ng dn truyn nh bloc nhnh, bloc nh tht, bloc
xong nh. Bloc cng ch c th theo mt chiu t trn xung, hoc hai chiu. c bit
c th gp c ch vo li trong RLNT l mt c ch c bit gp trong ngoi tm
thu, cn nhp nhanh tht hoc trn tht.
2.3. Phi hp c ri lon dn truyn xung ng v hnh thnh xung ng: c ch ny
77
rm r hn rung nh nht l cn kch pht. Nghe tim thy tim p nhanh u 130-150
ln/pht. Tnh mch c thng p rt nhanh hn tn s tim.
- Chn on: nh vo in tim thy sng P thay bng sng F nh rng ca tn s
250-350 ln/pht. Phc b QRS bnh thng v u nhau.
6. Nhp nhanh kch pht trn tht: thng xy ra trn tim lnh
- Triu chng: hi hp tng cn km theo kh chu tot m hi, lo lng, tiu nhiu
sau cn.
- Chn on: in tim c nhp tim nhanh tn s khong 180 ln/pht u. QRS bnh
thng, sng P thng ln vo QRS, c th c ST chnh xung. n nhn cu
thng ct c cn.
7. Nhp nhanh tht: l cp cu tim mch:
- Nguyn nhn: xy ra trn tim bnh l nh nhi mu c tim, suy vnh ri n thp
tim, bnh van tim, bnh c tim, ng c digital, cc th thut trn tim v v cn.
- Triu chng: rm r vi au ngc, kh th, ngt, ri lon huyt ng. Nhp tim rt
nhanh trn 160 ln/ pht, mch kh bt.
- Chn on: in tim cho thy cc phc b tht nhanh, phc b tht gin rng tn
s 120-160 ln/ pht. Nhp nh chm hn v phn ly vi tht.
8.Xon nh: l cp cu tim mch.
-Thng do nhng nhm thuc chng lon nhp nhm 1 gy ra; gim kali mu cng
l yu t thun li.Triu chng ch yu l ngt, try tim mch. in tim s thy sng
kh cc bin dng ln tn, c ch nh v ch phnh to ty theo chu k.
9. Rung tht: l cp cu tim mch v thng gy ra t t. Nguyn nhn thng do
thiu mu c tim, suy tim, ng c digital, ng c quinidine. Triu chng l t t.
in tim c ri lon nhp tht a dng.
10. Ri lon dn truyn nh tht (Bloc nh tht)
Da vo in tim c 3 loi:
- Bloc nh tht 1:PQ (hoc PR) ko di trn,20 giy
- Bloc nh tht 2: c 2 th:
+ Bloc Mobit 1 (hay Luciani-Wencbach): Khong PQ ko di ri mt dn hn sau
lp li chu k mi nh vy.
+ Bloc Mobit 2 (hay Bloc nh tht mt phn): Hai, ba.. sng P mi c mt sng QRS
- Bloc nh tht 3: Nh v tht phn li hon ton, thng nh chm hn tht.
Da vo triu chng c nng c th chia lm 2 nhm:
+ Bloc nh tht khng c triu chng:
+ Bloc nh tht c triu chng:
Triu chng gi l ngt (cn Adam-Stokes) hay ch c xong.
IV. IU TR RI LON NHP
1. Mc ch
1.1. Lon nhp tim kch pht: Cn ct cn ngay.
1.2. Lon nhp tim dai dng, bn b: a v nhp xoang hoc l kim sot tn s tht
trong trng hp khng vi iu tr chuyn nhp.
2. Ch nh iu tr cp cu
2.1. Suy nng chc nng ca tht tri.
2.2. Biu hin triu chng lm sng hoc l trn ECG thy thiu mu cc b c tim.
79
Lu
- Cn thn khi dng phi hp v d khng dng amiodarone cng vi disopyramide
(lm ko di QT gy xon nh)
- Nhiu loi lm gim s co bp c tim (c bit l disopyramide, flecaine, thuc c
ch. V th phi rt thn trng khi c suy tim.
6. iu tr c th
6.1. Nhp nhanh xoang
iu tr ph thuc vo nguyn nhn. Chng lo lng, h st. Digital v li tiu khi c
suy tim, th oxy khi c thiu kh cp tnh, b mu khi thiu mu v khng gip khi c
cng gip. Nu nhp nhanh xoang do mt thch nghi th lc v / hay lo lng gy ra
s kh chu cho bnh nhn v sau khi loi tr tt c nguyn nhn thc th, c th
cho chn bta liu thp c th lm bt tn s tim khi gng sc. Thng dng
Propranolol khi u 1/4 vin x 2 ln sng v chiu sau tng liu dn nhng
khng qu 1/2 vinx 3 ln/ ngy. iu tr c th ngng khi bnh nhn c luyn tp
th lc ti thch nghi.
6.2. Nhp chm xoang
iu tr c ch nh i vi nhp chm xoang kch pht, giai on cp NMCT sau
di. Atropine c th lm tng nhp v huyt p. Liu Atropine:1mg tim di da
hoc chch tnh mch. Nu huyt p thp c th b dch. Kh khn duy nht l khi
iu tr nhng hi chng phi hp nhp nhanh - nhp chm, khi i lc cn phi
t my to nhp kim sot.
6.3. Rung nh
Lu chuyn nhp thnh cng cn iu chnh yu t nguyn nhn (bnh tim gy
rung nh, cng gip...). Mc tiu iu tr nhm l chuyn nhp v xoang hoc ch
lm chm tn s tht.
* Sc in
Liu 250- 300j. Hn hu mi ch nh cp cu v d nh cn ti lp nhp xoang ngay
trong tnh trng chong, ph phi cp nng, tn s tht > 200ln / pht. Sc in l
iu tr chn la trong trng hp rung nh trn bnh nhn c hi chng tin kch
thch. T l thnh cng khong 85% trng hp.
Ch nh sc in trong trng hp rung nh mn tnh:
+ Rung nh <1nm
+ ng knh nh tri <50mm
+ Tim khng ln lm
+ Dung np huyt ng km.
* iu tr bng thuc
Vi mc ch chuyn nhp hoc ch n gin l hm bt tn s tht.
- Nu khng c suy tim, tim khng ln c th dng Flecaine IV liu 2mg/kg chuyn
trong 10 pht cho php ti lp nhp xoang trong 3/4 trng hp (rung nh mi khi
pht).
- C th ti lp nhp xoang bng Amiodarone (Cordarone) vin 200mg cho liu tn
cng 4-6 vin/ngy (c th ung 1 ln) trong 2 ngy u sau duy tr 1 vin/ ngy
trong 5 ngy. Sau khi ti lp nhp xoang c th iu tr duy tr bng quinidin hoc
Amiodarone. Tuy nhin ngy nay a s dng Amiodarone duy tr.
81
- Trong kh nhiu tnh hung rung nh, ngi ta chp nhn ch cn lm chm tn s
tht bng digital (ngoi tr hi chng WPW), khi cn c th phi hp vi
Amiodarone.
- Nu nh khng c suy tim, tim khng ln, ngi ta c th dng c ch (hoc l c
ch canxi loi lm nhp tim chm (Verapamil, Diltiazem) mt khi m nhp tim vn cn
nhanh qu mc mc du s dng digital.
- Him khi tn s tht vn khng hm c bng iu tr ni khoa, lc ny c th cn
ti k thut ph hy nt nh - tht bng nng lng tn s radio (radiofrequency)
to bloc nh tht kt hp vi t my to nhp.
Trc khi chuyn nhp rung nh mn tnh nht l bnh nhn c nguy c cao tc
mch do huyt khi bung tim (bnh van tim) cn phi s dng thuc chng ng 3
tun phng nga tc mch sau chuyn nhp.
6.4. Cung ng nh
iu tr hiu qu nht l sc in vi nng lng thp 25-50 W sau khi
dng an thn nh. Tuy nhin ngi ta hay a dng nng lng cao hn bi l hay b
rung nh sau khi sc bng nng lng thp. ngi b cung nh sau khi m tim h
hoc l cung nh ti lp trong nhi mu c tim cp c bit l nu ang dng digital
th nn to nhp nh vi tn s 115-130 % tn s cung nh c th chuyn nhp v
xoang. To nhp nh cng c th a cung nh v rung nh v lm cho kim sot tn
s tht d hn. Nu nh tnh trng ngi bnh v mt lm sng khng cho php
chuyn nhp ngay th c th lm chm tn s tht bng cc thuc c ch nt A-V
nh c ch bta, c ch canxi, hay l digital. Digital t c hiu qu nht v i khi li
chuyn cung nh thnh rung nh. Khi dn truyn qua nt A-V b hm bng cc thuc
trn th c th dng cc thuc nhm I (A hoc C) hay amiodarone chuyn nhp.
Trong trng hp cung nh bin chng trong hi chng W.P.W th chng ch nh
digital. Mt khc nu nh ngi bnh ang c dng digital th nn ch vi ngy
sau (thuc c thi ra) mi sc.
- Phng cung nh: cc thuc nh quinidine, flecaine, propafenone, amiodarone.
6.5. Nhp nhanh trn tht
* Nhp nhanh b ni, nt xoang, nh do c ch vo li
Nu tnh trng bnh nhn tt khng c tt huyt p th c th dng cc th th
cng ph v ct cn c trong 80% trng hp (nn nh khng c xoa
xoang cnh ngi c thi tm thu ng mch cnh). Nu vn khng c c th
cho adenosine 6-12mg IV hoc Verapamil 2.5-10mg IV. Cng c th dng Digital, c
ch bta. Phng php to nhp nh hoc tht ct cn c dng khi thuc
khng c tc dng. Sc in p dng khi c thiu mu cc b c tim nng hoc l tt
huyt p.
Phng nga:
- Cc thuc digital, c ch bta, c ch canxi hoc l nhm IA, IC.
- Phng php t b ng dn truyn bng sng nng lng tn s radio.
* Nhp nhanh nh c c ch tng tnh t ng
C th do ng c digital hoc l gp trong bnh phi hoc tim nng c gim
kali hoc ang dng theophylline v cc thuc cng giao cm khc. Loi a c
bit hay gp ngi bnh ang dng theophyline. Rung nh gp trong 50-70%
ngi c dng lon nhp ny. Tn s tht khng u do c thay i mc bloc.
Trong lon nhp do digital hay c dng bloc 2/1, iu tr l ngng digital. Trong loi
nhp nhanh c ch t ng khng do digital iu tr kh hn v mc ch ca iu tr
82
- Chp X.Q: tim to b 2 bn cung di, gc honh tim hnh t. Cung tim
ngn. Do hnh tim ging nh qu bu. C th thy hnh tim 2 b (b trong l bng
tim, b ngoi l mng ngoi tim), phi sng: do thiu nng tun hon tm trng.
2.3. Siu m tim
- Cho bit s lng dch v v tr ca dch cc thnh tim quyt nh chc
d mng tim, trong dch c nhiu fibrin v c vch ha khng?
- Xem b dy ca mng ngoi tim c hng iu tr ni hoc ngoi khoa
kp thi. nh gi nhng ri lon huyt ng thng qua hnh nh p tht phi
thi k tm trng. nh gi chc nng tm trng. Thm d p lc trong tim phi.
Thm d sc cng ca thnh tim.
C th trn siu m:
+1 bnh din TM o kch thc ca khong dch k tm tng t tnh ra
d on lng dch mng tim.
+ thm d theo 2 bnh din 2D: quan st ton b tim mt cch tng qut,
xem lngdch khu trr hay ton th
Vi 3 du hiu chnh cn nh gi:
+Khong trng Echo mt sau ca tim.
+Khong trng Echo gim nhiu hoc mt hn ch ni nh tri v tht tri.
+Mng ngoi tim khng vn ng.
Ch : Lng dch: dch mng tim t 30 ml c th pht hin c. Ngi bnh
thng khe mnh c th c 50 ml DMT. Khi lng dch bao ph ton b tim nhn
thy c trn siu m 2D lng dch khong 300 ml.
Xc nh cht cha trong mng tim (phn b sung)
Vn ng bt thng ca tim trong TDMT: vn ng nghch thng vi vch lin
tht.
2.4. Chc dch mng tim
Ly dch chn on xc nh, chn on nguyn nhn c hng iu tr
ng. Dch mng tim thng c 3 mu hay gp.
+Dch vng chanh: Lao, vi rt, d ng, t pht, bnh h thng
+M c trng- nu: Nhim trng huyt, abcs v
+Dch mu : K, lao, chn thng chy mu, do thuc chng ng.
3. Chn an phn bit
- Tim to: Do bnh c tim, suy tim nng
- Cn au tht ngc: Nhi mu c tim, vim phi, v.v....
Vai tr ca siu m rt hu ch trong chn on loi tr d dng.
4. Chn on nguyn nhn
+ Da vo lm sng v xt nghim dch mng tim.
+ Cc nguyn nhn nh ni phn trn.
IV. CHN P TIM CP
1. nh ngha
L tnh trng p lc trong khoang MNT t ngt tng cao, p vo tim v ngn
cn s y mu v tm tht trong k tm trng gy thiu nng tm trng cp,
thiu nng tm thu cp ngn cn tim bp.
87
2.2. Cn lm sng
- X.Quang: tim to t, hoc khng to, b r, c th c vi ha.
- in tm : ST gim, sng T dt hoc m tnh,c th c rung nh.
- Siu m tim: Mng tim dy, co bp khng ng u. Thnh sau tht tri c th
c dng cao nguyn. Nh tri to hn bnh thng.
TM (tnh mch) ch di v TM gan gin. Chc nng tm trng gim. Chc nng
tm thu gim.ng cong vn tc .M.P.(ng mch phi) c dng 2 pha,do vn tc
gim i gia k tng mu. Doppler xung kinh in v Doppler m gip nhn bit
VMNTCT cng nh phn bit bnh c tim hn ch.
- Thng tim: ng cong p lc tht (P) c b nho - cao nguyn (dip-plateau).
p lc tht (P) tng c bit p lc cui tm trng, do mng tim x cng cn tr
c tht dn ra (chn on phn bit vi bnh c tim hn ch loi x chun ni mc).
V. IU TR
1. iu tr ngoi khoa
1.1. Ch nh
- Dch mu, m lu ngy.
- Mng tim dy.
- i vi VMNT co tht ty thuc vo mc dy dnh, vi ha MNT m c
th phu thut ct b ton b MNT hay m ca s.
1.2. Theo di sau m
- Nhim trng.
- Ri lon nhp.
- Cc c quan ln cn nh hng nht l trung tht, mng phi.
2. iu tr ni khoa
2.1. iu tr chung
au do vim mng ngoi tim c th gim bt bng cch cho cc thuc chng
vim khng corticoid nh Aspirine 500 mg/ 4 gi. Nu au ko di qu 48 gi c th
x dng c corticoid liu 1 mg/kg. Sau 5-7 ngy nu gim au c th gim liu v
ngng thuc.
2.2.iu tr nguyn nhn gy bnh
* Vim mang ngoi tim do lao
Dng thuc khng lao sm, mnh, phi hp t nht 3 loi khng lao. Phc iu tr
thay i ty theo tin trin v khng sinh . Thi gian iu tr ko di 12-18 thng.
Trong trng hp din tin thnh co tht mng ngoi tim cn phi tng cng thuc
chng lao v cn nhc xem c nn dng corticoid. Corticoid c th lm bt dch
nhanh tuy vy ch c th dng corticoid khi thuc khng lao c hiu qu. Nhiu
nghin cu cho thy s phi hp hai loi khng lao v corticoid trng hp trn
dch mng ngoi tim ci thin lm sng nhng trng hp khng th phu thut. Tuy
nhin bin php tt nht khi c hin tng dy dnh vn l bc tch mng ngoi tim.
* Vim mng ngoi tim do vi khun sinh m
Dng khng sinh ton thn da vo khng sinh ca cy m mng tim kt hp
khng sinh bm ti ch mng tim. Nu mng tim dy, m c qunh cn phi dn
lu phu thut.
* Vim mng ngoi tim do thp
Corticoid v penicilline.
90
-Vng lin sn VII hoc VIII pha sau tri trn ng gia xng b vai tri,
khi chc tay tri gi cao, v tr ny c dng khi trn dch mng ngoi tim mc
ln chn p vo phi (du Ewart) m kh c th ly c dch theo cc v tr khc.
Nu chc d qua siu m th ng gia mn hinh l ng gia u d v
v tr u d l v tr kim chc, hng u d l hng kim i ti.
* Cch chc d mng ngoi tim
Trc tin phi xem hnh nh cc mt ct trn siu m, nh v tr lng dch
nhiu nht v tuy theo quyt nh ng chc d
+Chun b bnh nhn trc chc d: - Gii thch trn an tinh thn ca bnh
nhn. Bnh nhn nm thng hoc t th 45 .- Cho bnh nhn th oxy. o HA,
nhp tim, mch, khm gan ( so snh vi sau khi ht dch)
+ Chun b thuc men v dng c my mc theo di v cp cu khi cn thit:
my shock in, my theo di in tm , thuc Morphin, Seduxen, Novocain v
cc thuc chng ri lon nhp khc.v.v....
+nh du v tr chc d.
+ Trong khi tin hnh th thut: St trng ti v tr chc d,v xung quanh vng
chc d. Ph tm khn c l sau khi st trng xong.
Cho an thn bng thuc: Mocphin (nu khng c suy h hp) hoc seduxen
tim TM. Dng kim nh gy t ti ch v tr chc (bng xylocain hoc novocain) va
gy t va thm d ht dch ra (chc b trn ca X. sn di)
Ch : Lng dch ly ra t t trnh thay i p lc t ngt lm thay i t th
ca tim. Nu p tim cp cho ly dch nhanh. Sau khi ht dch xong cn bm t kh vo
khoang mng tim, s lng bng 2/3 hoc 1/2 lng dch ly ra.
+ Sau chc d:
- Ly mu dch xt nghim: sinh ha, t bo, vi trng v cy ng thi lm khng
sinh iu tr.
- o li HA, mch, nhp tim, khm li gan: lng dch ly ra ci thin ngay triu
chng c nng. HA khng cn kt. gan nh li, nhp tim chm hn.
- o li .T.: Bin in th cc sng in tim cao hn ht hnh nh in th giao
lu (nu trc khi chc d c).
- Cho bnh nhn nm theo di phng cc tai bin nh: d dch vo trung tht, trn
kh mng phi, ri lon nhp tim.v.v....
- Nn cho bnh nhn i chp li X.Q. tim: xem bng tim nh li, xem mng ngoi tim
c dy mc no c hng iu tr ni hay ngoi khoa kp thi cho bnh nhn
- C iu kin siu m tim li cho bnh nhn nh gi chnh xc hn v lng dch
v dy ca mng ngoi tim sau khi chc d mng tim. S. khng phn bit
c dch MNT do vim,do chn p trn mu hay dng chp nhng phn bit
c: C si fbin, cc mu, hay K mng tim di cn thy cc khi di cn trong mng
tim c dch.
92
1.1. Th lm sng
- L th pht: nm trung tm cn gi l cn l Botal. L hnh trn hoc bu dc,
i khi ko di hoc l dng ca s. ng knh trung bnh vo khong 20-30mm.
- L xoang tnh mch nm trn hoc di:
+L trn ch vo ca tnh mch ch trn, loi ny hu nh lun km bt thng
tr v tnh mch phi khng hon ton (trc tip vo nh phi hoc l phn thp
ca tnh mch ch trn).
+ L phn vch thp: ko di ti tn tnh mch ch di (l xoang vnh).
- L tin pht: him gp hn nhng loi trn. L thng nm phn y ca mng
trc l xoang vnh. N c th n thun hoc l phi hp vi li phu l vch van
hai l.
1.2. Sinh l bnh:
y l loi c lung thng chiu tri phi do p lc nh tri cao hn. ln ca
shunt tu thuc vo kch thc ca l v sc cn tiu ng mch phi. Mc du lu
lng shunt ln nhng p lc ng mch phi khng tng hoc l tng t. Qu ti
th tch lm gin bung tim phi v mch mu phi. Ngc li bung tim tri cng
nh ng mch ch kch thc li nh. V sau tiu ng mch phi b tn thng
(vim tng sinh ni mc, thuyn tc) s lm tng sc cn a ti tng p phi v th
tch shunt gim. Cui cng khi p lc bung tim phi tng qu s lm o shunt v
ngi bnh s c tm.
1.3. Triu chng chn on:
1.3.1. L th pht: trong 90% trng hp s nghe c ting thi tm thu kiu tng
mu van ng mch phi. Ting thi lan dc b tri xng c nhng cc i
lin sn 2 hoc 3 cnh c tri. Ting thi c c tnh cng va phi, m sc
m nhng cng c th c m sc th mnh ging ting thi gp trong hp van ng
mch phi. Ting T2 tch i c nh theo chu chuyn h hp. Trong trng hp
tng p phi nng c th nghe c ting thi tm trng do h van ng mch
phi.
Hnh nh Xquang ni bt cc du chng gin tim phi v ng mch phi. in tm
hay c trc QRS lch phi v nht l hnh nh bloc nhnh phi hay gp th khng
hon ton.
Siu m l phng tin chn on rt hu hiu, trn hnh nh siu m hai
bnh din cho thy tht phi tng kch thc do qu ti th tch tm trng. N cho
thy trc tip hnh nh khuyt vch lin nh v vi siu m mu thy lung shunt qua
vch, siu m cn quang thy vng ra trong nh phi nu shunt tri phi v trong
trng hp o shunt c th thy cht cn quang qua tim tri.
Thng tim: c hai triu chng sau cho php khng nh chn on
- ng thng chy t nh phi sang nh tri d (7-8 ln/10).
- Nng Oxy nh phi giu hn trong tnh mch ch.
Ngoi ra thng tim cng cho php nh gi p lc ng mch phi, o lu lng
ca shunt, o sc cn ng mch phi.
Tin trin
Tu thuc vo ng knh l thng tc l lu lng shunt. Tui th trung bnh 35-40
tui. Bnh nhn lu ngy s tin trin suy tim phi, lon nhp (hay c rung nh), khi
94
1.3.2. L tin pht: chim 20 % cc trng hp thng lin nh. Tui th trung bnh
thp hn (30 tui), phu thut kh hn.
Lm sng ngoi triu chng ca thng lin nh cn c thi tm thu mm do
bt thng van hai l. in tm trc tri trong khi li c bloc cnh phi. Thng tim
c thng lin nh thp cng nh thy dng mu chy ngc ln nh do h hai l.
Siu m Doppler cng cho php chn on tng t.
1.3.3. Thng lin nh phi hp tr v bt thng tnh mch phi: hay gp tr v bt
thng tnh mch thu trn phi hoc gia phi vo phn tn ca tnh mch ch trn
(dng sinus venosus).
Thng tim chp mch cho php chn on rt tt.
1.3.4. Hi chng Lutembacher: phi hp hp hai l v thng lin nh.
2. Thng lin tht: l loi tim bm sinh hay gp nht chim 20-30% cc bnh tim
bm sinh. Nu tnh chung c cc bnh tim bm sinh c thng lin tht phi hp n
chim 50%. y l loi tim bm sinh c shunt tri phi (dng n thun).
2.1. Gii phu bnh hc: c nhiu v tr thng lin tht.
- Hay gp nht l thng phn mng.
- cao v pha trc di van ng mch phi.
- cao pha sau di l vch ca van ba l.
- Thp nm phn c ca vch lin tht.
Tht tri c th thng vi nh phi (khng thc s l thng lin tht), thng phi
hp vi bt thng van 3 l.
2.2. Sinh l bnh: do p lc tht tri cao hn p lc tht phi cho nn s c shunt
tri phi qua vch lin tht. ln ca shunt tu thuc vo kch thc l thng v
sc cn tiu ng mch phi. tr em ng knh l thng >1,2cm2 /m2 c th
(hoc >1/2 l van ng mch ch) th khng cn chnh p gia hai bung tht v
cho th tch shunt ln nu sc cn phi thp to tng p phi cung lng . L
thng c th t ng theo thi gian hoc l shunt s gim (hay ci thin lc 2 tui)
do tng ng knh l van ng mch ch.
Trong loi thng lin tht phn c l thng s nh i k tm thu.
Sc cn tiu ng mch phi tng ln c th do cc yu t sau:
- Tng p phi hu mao mch: to nn do mu v nh tri qu nhiu trong khi van
hai l ng v khi m thot mu khng kp to hp c nng van hai l.
- Tnglu lng phi sau ny c hu qu dy cc si c lp o gia cc mch mu
nh (giai on I), tng sinh ni mc (giai on II), thoi ho hyalin v x ho (giai
on III), hoi t gin khu tr (giai on IV). Lu lng shunt s gim theo nhng p
lc ng mch phi vn tng.
Sinh l bnh s khc nu c hp ng mch phi (bm sinh hoc mc phi do
thch nghi th pht) cho bnh cnh gn ging t chng Fallot.
Ngi ta chia cc nhm thng lin tht chnh nh sau:
- Thng lin tht l nh, c shunt tri phi p lc ng mch phi bnh thng, y
l bnh Roger.
- Shunt ln l to, sc cn tiu ng mch phi bnh thng hoc tng t.
+ Nhm II a: p lc ng mch ph tm thu < 70% p lc h thng.
95
- Thng tim: cho php khng nh chn on khi ng thng t ng mch phi vo
ng mch ch thnh hnh ch (tuy nhin thng khng cn thit.
- Siu m doppler mu: cho php nhn thy ng thng cng nh shunt, nh gi lu
lng shunt cng nh p lc ng mch phi.
3.4. Tin trin:
- Suy tim: tu thuc vo lu lng shunt v p lc ng mch phi. Bnh cnh suy
tim tri sau suy tim ton b tr nhanh vi iu tr tr tim.
- Vim ni tm mc nhim trng trn thnh ng: nng n kh iu tr. C th lm
phnh ng lm phu thut kh khn.
- Phnh ng: c nguy c v.
3.5. Th lm sng:
- Cn ng ng mch tr b: thi tm thu vi ting T2 mnh van ng mch
phi. Chn on c th kh phn bit vi thng lin tht. Nu nh c tng hiu p,
ng mch ch gin cng nh tng m mch phi loi ny thng lm suy tim sm
v cn phi c can thip phu thut sm.
- Cn ng ng mch c tng p phi mnh: kh th, c th tm (nht l chi di),
hay nhim trng phi, du suy tim nng, bin dng lng ngc, chm pht trin th
lc.
Nghe tim khng cn ting thi lin tc, T2 rt mnh i khi c thi tm trng
do h van ng mch phi c nng.
X quang tim ln, cung ng mch phi phng trong khi ngoi vi phi sng lc
tng sc cn tiu ng mch phi v shunt nh.
in tm tng gnh tm trng tht tri phi hp tng gnh tm thu tht
phi (do lu lng shunt ln hoc sc cn phi ln).
Thng tim ngoi vic chn on o p lc ng mch phi cn cho php
phn nh c c ch ca tng p lc (do tng lu lng hay sc cn phi).
- Dng phi hp: hp eo ng mch ch, thng lin tht, hp ng mch ch.
4. Phnh xoang Valsalva
Ti phnh Valsalva thng tim tng v c pht hin tnh c. Tuy nhin c nguy
c v ti phnh v vim ni tm mc nhim trng.
4.1. V: thng nhn mt ng tc gng sc v gy au ngc d di, tnh trng
chong v kh th d di. Thng thng ti phnh v vo tht phi v him khi v
vo nh phi. Khm tim c ting thi lin tc cng mnh nm vng thp b tri
xng c v du hiu ngoi vi ca h van ch. X quang v in tm cho thy
du hiu qu ti c hai tht. Thng tim phi thy shunt tri phi ln tng nh hoc
tht cng nh cho bit mc tng p phi. Siu m doppler cng cho php chn
on v phnh Valsalva. Tin trin t vong nhanh chng trong vng vi tun hoc vi
thng v suy tim.
Nu v ti phnh vo mng tim c th lm trn mu mng ngoi tim, v vo
nh tri to ting thi lin tc nhng khng c shunt, v vo tht tri gy h van ng
mch ch.
Chn on phn bit vi d ng mch vnh, d ch ph.
4.2. Cc bin chng khc: nhim trng ti phnh c th cng lm v. Khi ti phnh
ln v pha vch lin tht c th lm cho ri lon dn truyn.
V. BNH TIM BM SINH C LUNG THNG PHI - TRI
1. T chng Fallot
97
6. Hp eo ng mch ch
Ngoi khoa: Cn t vn phu thut ngay khi bnh nhn cn chu ng c.
Tui l tng l t 10 -15 tui, v sau nguy c cao do b x va phi hp. Nguy c
t vong di 5%. Phu thut bng cch ni tn hoc bt cu ni bng ng nhn to.
7. Phc hp v hi chng EISENMENGER
-Ni khoa: iu tr bin chng suy tim: O2, tr tim, li tiu...
-Ngoi khoa: khng c ch nh phu thut ngoi tr thay tim.
102
Mu v vi khun Ch hp
V tr thng gp ca
vi khun
V trng tuyt i cc dng c phu thut, cc dng c thm khm hoc bng khng
sinh cho cc bnh nhn c bnh tim mc phi hoc bnh tim bm sinh khi c can
thip th thut hay phu thut.
VIII. TIN TRIN V TIN LNG
Khi cha c khng sinh t l t vong 100%, t khi c khng sinh tin lng c kh
hn nhng t l t vong cn cao 20-40%. Tin lng bnh ph thuc vo cc yu t
sau:
1. Tui ln > 70.
2. Khng tm thy ng vo ca vi khun.
3. Suy thn.
4. Biu hin thn nng, tc mch hay suy tim sm.
5. Th cy mu m tnh.
6. Ti pht sau 2 thng tuy iu tr tn gc.
Tin trin: Thng khi trong cc trng hp iu tr sm. Tuy nhin di chng ca
bnh nh vim thn mn vi tng Ur mu, tai bin mch no vi lit na ngi,
tin lng cn ph thuc vo bnh tim c trc v mt s trng hp t vong do
suy thn hay tc mch.
IX. IU TR VIM NI TM MC NHIM KHUN
1. iu tr ni khoa
1.1. iu tr tit cn: ch yu bng khng sinh. Cn x dng khng sinh dit khun,
sm liu cao, lin tc, ko di, s dng nhng khng sinh cng lc trong c vai
tr ca cn lm sng gip chn la thuc ph hp. Cn xc nh s nhy cm vi
khun da vo khng sinh qua vic xc nh nng c ch ti thiu ( Minimum
Inhibitory Concentration = MIC) , nng ti thiu dit khun ( Minimum bactericidal
concentration = MBC) ca khng sinh v kh nng dit khun dn c hoc phi
hp.
- Lin cu (Streptococci) nhy cm vi Penicilline G c MIC 0.1ug/ml: dng mt
trong nhng phc sau:
+ Phc A:PNC G 12-18 triu v/ ngy, tim TM cch 4 gi mt ln trong 4 tun.
+ Phc B: PNC G nh phc A kt hp Gentamycine liu 1 mg/kg tim TM
mi 8 gi, c hai loi dng trong 2 tun.
+ Phc C: Ceftriazone 2g tim TM hoc TB 1 ln/ ngy , trong 4 tun.
+ Phc D: Vancomycin liu 15 mg/kg tim TM mi 12 gi trong 4 tun.
- Lin cu nhy cm PNC c 0.1 ug/ml< MIC< 0.5ug/ml:
+ Phc E: PNC G 18 triu v/ ngy, tim TM cch 4 gi mt ln trong 4tun. Phi
hp Gentamycine 1 mg/kg tim TM mi 8 gi trong 2 tun u.
+ Hoc dng phc D nu bnh nhn d ng PNC.
- Trng cu khun (Enterococci) hoc lin cu khun nhy cm Penicilline c MIC
0.5ug/ml hoc Streptococci viridans bin th dinh dng:
+ Phc F: Penicilline G 18-30 triu v/ ngy hoc Ampicilline 12 g/ ngy tim TN
cch 4 gi mt ln. Phi hp vi Gentamycine 1 mg/kg tim TM mi 8 gi. Dng c
hai loi trong 4-6 tun.
+ Phc G: Vancomycine 15 mg/kg tim TM mi 12 gi . Phi hp Gentamycine
nh phc F. C hai loi dng trong 4-6 tun.
- T cu cn nhy vi Methicilline bnh nhn c van tim t nhin:
108
CHNG 2
TIU HA
LOT D DY T TRNG
Mc tiu
1. Trnh by c c im dch t hc, c ch bnh sinh v cc yu t nguy c gy
bnh.
2. Trnh by c cc triu chng v bin chng lot.
3. Chn on v nu c cc phc iu tr lot.
Ni dung
I. DCH T HC
Tn sut bnh tin trin theo thi gian v thay i ty theo nc, hoc l theo
khu vc. Cui th K 19 Chu u, lot d dy thng gp hn, v ph n. Gia
th k 20, tn sut lot d dy khng thay i, nhng lot t trng c xu hng tng,
v hin nay t l lot t trng /lot d dy l 2/1, v a s gp nam gii. C khong
10-15% dn chng trn th gii b bnh LDDTT. Anh v c l 5, 2-9, 9%, M
l 5-10%. Hin nay c khong 10% dn chng trn th gii b LDDTT.
II. BNH SINH
1. Pepsine: c tit ra di dng tin cht pepsinnogene di tc ng ca acid
HCL bin thnh pepsine hot ng khi pH <3, 5 lm tiu hy cht nhy v collagen.
2. S phn tn ngc ca ion H+: tin trnh lot c khi pht do tng tit HCL do
lng t bo thnh qu nhiu hoc qu hot ng, do lng dch v c bn hoc
sau kch thch rt gia tng, s phn tn ngc v s i vo ca ion H+ lm thng
tn thnh d dy v gy ra lot; do lm trung ha ion H+ lm gim t l lot rt
nhiu. Nguy c lot cng cao khi s tit acid cng nhiu.
3. Yu t bo v ca nim mc d dy
3.1. Hng ro nim dch: chng li s tn cng ca ion H+, yu t chnh l lp
nim dch giu bicarbonate to bi glycoprotine c cha cc phospholipides khng
phn cc, nm trn b mt ca lp gel ny c tnh nhy n hi. Khi pepsine ct
chui peptide phng thch cc tiu n v glycoproteines; chng lm mt tnh cht
nhy n hi ny. Cc ion H+ xm nhp vo lp nhy, nhng chng b trung ha bi
bicarbonate. Nhng khi pH<1, 7 th vt qu kh nng trung ho ca n v ion H+
n c lp nim mc d dy v gy ra lot.
3.2. Lp nim mc d dy: tit ra glycoproteines, lipides v bicarbonate, chng c
kh nng loi b s i vo bo tng ca ion H+ bng 2 cch: trung ha do
bicarbonate, v y ion H+ vo khong k nh bm proton H+- K+ - ATPase.
3.3. Lp lamina propria: ph trch chc nng iu ha. Oxy v bicarbonate c
cung cp trc tip cho h nim mc bi cc mao mch c rt nhiu l h, m cc t
bo ny rt nhy cm vi toan chuyn ha hn l s thiu kh. Mt lng
bicarbonate y phi c cung cp cho t bo nim mc ngn chn s acid
ha trong thnh d dy gy ra bi ion H+ xuyn qua hng ro nim mc ny.
105
* Lot t trng: a s u c tng toan v tng tit nn thng p dng pht phi
hp: 1 khng tit mnh + 1 bo v nim mc. V d: 1 khng H2 mnh nh Ranitidin,
Famotidine hoc Omprazole + Sucralfate, c th l Ranitidine 300mg hoc
Famotidine 40mg ung chia 2 ln sau n hoc mt ln khi i ng + Sucralfate 3g
ung 3 ln trc n 30 ph v 1gr trc lc i ng.
Trong trng hp c H.P, cho thm thuc dit H.P nh trong lot d dy, thi
gian cho khng sinh thng l 2 tun. Kt qu mt s pht iu tr 3 thuc nh
sau:
- Bismuth (480mg/ng)+Tetracycline 1, 5g/ng (hay Amoxicillin)+Mtronidazol (1,
5g/ng) x 2 tun lnh bnh l 85%.
- Ranitidin (300mg/ng)+Amoxicillin (1, 5g/ng)+Metronidazol (1, 5g/ng) x 2 tun,
sau tip tc dng Ranitidine thm 2 tun, t l lnh bnh l 89%.
- Omprazol (40mg/ng) + Clarithromycine (0, 5g/ng) + Tinidazol (1, 5g/ng) x 1
tun, lnh bnh l 93, 2% hoc Omeprazol (40mg/ng)+Clarithromycine (0,
5g/ng)+Amoxicilline (1, 5g/ng) x 1tun, lnh bnh l 90%.
Trong mt s vng t l khng cao ngi ta p dng pht 4 thuc
nh sau: Bismuth+Tetracycline (hoc Amoxicilline)+Metronidazol+ Omeprazole v c
th rt ngn thi gian iu tr xung 2 tun.
3. iu tr ngoi khoa
3.1. Phu thut ct 2/3 d dy: vi lot d dy sau khi iu tr tch cc 6 tun m
lot khng thay i hoc trong trng hp c lon sn th cn phu thut ct b 2/3
theo kiu Bilroth hoc Pan loi tr lot cng nh loi b vng tit gastrine v
acide.
Trong lot t trng, phu thut rt hn ch, ch dng cho lot bt tr. Cc ch
nh phu thut chung: l lot bin chng chy mu cp nng khng cm c bng
phng tin ni khoa, lot gy bin chng hp mn v kht v thc th, lot thng
hoc lot xuyn thu vo ty gy vim ty cp ti pht nhiu ln.
Cc bin chng phu thut bao gm
Hi chng Dumping: thng xut hin na gi sau khi n vi au thng v,
bun nn, chong vng, hi hp, v m hi, mt l do lm y t trng qu nhanh,
do thc n u trng, c ch bnh sinh phc tp do nhiu nguyn nhn:
- Gim th tch do cn bng li p lc thm thu u trng.
- Phn x thc vt, gii phng hormon vn mch nh serotonin, bradykinine,
V.I.P., gy ra do cng dn rut. Cn phn bit vi h ng mu xy ra chm 1-2
gi sau n do tit qu nhiu insulin v hp thu mt lng ln ng. iu tr ch yu
l n c nhiu ba nh, t ng v sa, dng pectine lm chm vi d dy.
Hi chng quai ti: sau phu thut do ng thc n v nht l mt trong
quai ti lm vim thng biu hin bng au v ma ra mt.
Suy dng: do nhiu nguyn nhn:
+ Do ct b d dy qu nhiu gy thiu dch v v n qu t v d dy
qu nh.
+ Km hp thu th pht do thiu mt, ty.
113
VIM D DY
Mc tiu
1.K cc nguyn nhn gy vim d dy cp v mn.
2.Chn on c cc th vim d dy cp va mn thng gp.
3.iu tr tt mt s th bnh vim d dy thng gp.
Ni dung
I. I CNG
Vim d dy l bnh m triu chng lm sng c khi rm r nhng c khi rt nh
nhng, m thm. Chn on cn c ni soi v sinh thit. iu tr c khi n gin
nhng c khi cn nhiu kh khn.
Ngi ta chia vim d dy lm 2 th: Vim d dy cp v vim d dy mn. Chn
on phn bit ty thuc vo nguyn nhn, c im t chc hc v s phn b v
gii phu ca vim d dy.
II. VIM D DY CP
1. Nguyn nhn
- Ru: Gy vim d dy cp i khi gy chy mu, c gi l vim d dy do n
mn. Thng xy ra khi ung ru mt lng ln trong mt thi gian ngn.
- Thuc khng vim khng steroides (NSAIDs), Aspirin.
- Stress
- Ung phi cht n mn (thng l cht kim)
- Virus: CMV, Herpes.
- Vi khun: Lin cu alpha tan mu, Clostridium septicum
- Tng ure mu
- Phng x.
2. Cc th vim d dy
2.1. Vim d dy chy mu hay vim d dy n mn
L nguyn nhn hay gp ca chy mu tiu ha cao nhng t khi nng. S n
mn i khi hon ton m thm. Ni soi cho thy n mn nhiu , c th lan n
ton b nim mc d dy hoc ch khu tr thn, hang v hay phnh v d dy. Nim
mc tr nn rc nh b chy rn nhng c khi gn nh bnh thng.
V m hc, s n mn ch ph hy n lp nim mc, khng lan n lp c
nim do khng nh hng n cc lp mch mu di nim mc. Cc thng
tn thng hi phc hon ton. y l c trng ca loi vim ny. Bt k lc no,
ngi ta c th tm thy nhng b n mn c nhng biu hin nhng giai on
tin trin hay hi phc khc nhau. C th gp thng tn nn phng hay np
gp nim mc. Gia cc n mn l vng mt biu m v thot qun tng hay lan
rng va lp h nim mc (Lamina propria). S n mn c th pht trin trn nim
mc trng c v bnh thng v mt m hc hoc trn nhngnim mc c bin hin
cc giai on vim ca d dy. Nu tin trin ko di, s n mn c th lan n lp
h nim mc to nn lot cp khi chy mu tr nn trm trng hn.
115
- Nguyn nhn hay gp l do dng thuc khng vim khng Steroide. c bit l
Aspirin: mi trng acide dch v Aspirin khng ion ha d c hp th bng s
khuch tn th ng. Vo mi trng trung tnh ca biu m nim mc d dy
Aspirin bin thnh dng acide ion ha, ph hy t bo v to ca m cho hin tng
lot do acide. Khi c dng km vi Bicarbonate Natri, Aspirin khng gy tn
thng nim mc d dy v khng b ion ha, v do khng c hp th d
dy. Khi Aspirin c bc bi mt nang, n s i qua khi d dy v c hp th
rut non. Ngoi ra Aspirin v cc AINS khc cn ngn cn tng hp Prostaglandine
(l yu t bo v nim mc d dy cng nh kch thch tit acide v pepsin d dy)
v vy lm thng tn nim mc d dy. Phenylbutazol v Indomethacine l 2 thuc
d gy vim d dy nht.
- Ru cng l nguyn nhn gy vim d dy cp chy mu nht l khi ung mt
ln nhiu trong thi gian ngn, m trc y khng ung.
- Tng p tnh mch ca cng l mt yu t lm d cho chy mu d dy.
- Cc stress th pht nghim trng nh bng, nhim trng, chn thng, phu thut,
sc, suy h hp, suy thn, suy gan cng thng gy vim hay lot cp. Bnh nguyn
trong cc trng hp ny cha c hiu r ht c l do thay i lng mu n
nim mc d dy dn n hoi t nh nim mc.
Lm sng
Bnh nhn c th kh chu nh vng thng v, chm tiu, snh bng ngay sau n,
hi, bun nn, nn mu km i cu phn en.i khi khng c triu chng. Chn
on tt nht nh soi d dy ngay lc c chy mu v nu khng cc thng tn c
th lnh v bin mt. X quang vi k thut i quang kp c th pht hin c cc
vt n mn cn ny.
2.2. Vim d dy cp phi hp vi H. PYLORI: Khi u ca nhim H.P c th l
hu qu ca d dy d c tng tit acide sn v ko di hn 1 nm. Bnh nhn thy
kh chu nh vng thng v. C nhiu c im dch t hc ca vim d dy cp c
th quy cho H.P nhng c im ni soi v m hc th khng thy r. Nhim H.P cp
l tin cho vim d dy mn hot ng.
III. VIM D DY MN
1. Xp loi
- Vim d dy mn do ho cht: Tro ngc dch mt, dch kim t rut, Cc thuc
khng vim non-steroides.
- Vim d dy c hiu: vim d dy tng Eosine(u hat tng bch cu a acide,
vim d dy rut tng bch cu a acide)
- Vim d dy u ht: Crohn, lao, Histoplasma, giang mai, sarcoidose, d vt, nhi m
k sinh trng, v cn.
- Bnh d dy ph i: bnh Mntrier, gi lymphoma d dy, hi chng Zollinger-
Ellison.
- Bnh d dy sung huyt (tng p ca): khng phi vim d dy tht s
- Vim d dy khng c hiu:
+ Nhm khng n mn: (vim d dy t min type A, vim d dy do mi trng
type B, vim d dy mn c lin quan n HP).
116
1. i cng iu tr
Vim d dy l tn gi chung cho cc bnh l d dy do tn thng nim mc d
dy c hiu hoc khng c hiu. Mt cch phn loi c cc nh lm sng v
gii phu bnh thng dng d l da vo cc tn thng c gi tn theo cc
c im v m bnh hc, vi khun v v tr tn thng ca d dy.V vy, cch iu
tr c th hn v kh chnh xc hn.
Mc ch iu tr l bo v t bo, hi phc s tit acide tr li bnh thng, loi b
nguyn nhn, hn ch bin i lm teo nim mc d dy gp phn ngn nga ung
th.
2. iu tr vim d dy cp.
2.1. Vim d dy do n mn
2.1.1. Vim d dy do ru v thuc khng vim
y l nguyn nhn hay gp do ung ru cp mt lng ln, do dng thuc khng
vim khng corticoides v c corticoides. Tn thng nhiu ch di dng cc vt
nim mc b n mn, chy mu.
iu tr bao gm
- Chm dt nguyn nhn cng sm cng tt.
- m bo th tch tun hon c hiu qu bng dch truyn, nhn n v nui dng
bng ng ngoi ming.
- Ra d dy cm mu bng cch dng nc mui ng trng lnh ha
Adrenalin.
- Thuc khng tit: Cimetidine hoc Ranitidine, hoc Omeprazole tim tnh mch.
- Thuc trung ha Acide.
- Thuc bng nim mc: c th dng Sucralfate dng gel, hoc Misoprostol (cytotec
600g - 800g /ng.
- Truyn cc cht gy co mch nh Vasopressine hoc Sandostatin khi chy mu
nng.
- Cm mu bng laser, nhit hoc quang ng.
- iu tr d phng cho cc trng hp phi dng thuc khng vim: Dng khng
H2 hoc c ch bm proton H+.
2.1.2. Vim d dy do ha cht
Tc nhn gy vim c th l cc kim mnh nh KCl, hoc st, hoc Cocaine. iu
tr trong cc trng hp ny l ;
- Gim au, nhn n, nui dng bng ng tnh mch.
- Hi sc tim mch, h hp.
- Nu c vim x gy hp th c ch nh phu thut ni d dy rut.
2.1.3.Vim d dy do chn thng thc th
Sau t ng thng d dy, sau iu tr cm mu d dy bng ni soi, bng laser,
nhit ng.
iu tr bng nhn n, truyn dch, bng nim mc d dy v khng tit.
118
2.1.4.Vim d dy do x tr
Vim hang v, tin mn v. Tn thng c th su lm thng, chy mu hoc hp.
iu tr bng cc thuc bng nim mc, khng tit v ngng x tr.
2.1.5. Vim d dy do thiu mu
L biu hin ca bnh ton thn nh trong bnh Scholein- Henoch, nhim
Cytomegalovirus.
iu tr bng thuc bng nim mc v khng tit, thuc dit virus.
2.1.6. Bnh d dy xung huyt
Gp trong tng p tnh mch ca ca bnh x gan.
iu tr ch yu bng thuc chn giao cm nh Propanolol, hoc Nadrolol 60mg-
80 mg/ng sao cho mch cn 3/4 so vi trc khi dng phi hp vi khng tit acide.
2.1.7. Vim d dy do nhim trng
Nguyn nhn thng gp l lao, CMV, Candida Albican, Histoplasmosis, bnh
Crohn. iu tr c hiu bng khng sinh, khng nm, thuc dit virus. Trong trng
hp nng th c th phu thut.
2.2.Vim d dy cp khng do n mn phi hp nhim Helicobacter pylorii (HP) cp
hoc mn. iu tr thuc dit HP gm Omeprazo(40mg/ng) phi hp Amoxicillin (1, 5
g/ng), Clarytromycine(500mg/ng) trong 7- 10 ngy.C th km thuc bng nim mc
nh Bismuth.
3. iu tr vim d dy mn
3.1.Vim d dy mn khng do n mn
3.1.1.Vim d dy mn type A
y l vim d dy vng thn, thng l vim teo nim mc, lin quan n thiu
mu c tnh, do hin din trong mu cc khng th khng t bo thnh, khng th
khng yu t ni, thng phi hp vi cc bnh t min khc nh vim tuyn gip
t min, suy thng thn, x ng mt tin pht.
iu tr: cha c iu tr c hiu: thng dng cc thuc trung ha acide, vitamin
C, st, vitamin B12, corticoides. Cn theo di din tin dn n ung th d dy.
3.1.2.Vim d dy mn type B
Tn thng vng hang v d dy gp trong 80% trng hp v rt quan trng, n
cn c gi l vim d dy do HP.
iu tr khng tit phi hp khng sinh dit HP.
3.1.3.Vim d dy type AB
Vim d dy phi hp Tn thng c hang v v thn d dy.
iu tr bao gm thuc khng tit, khng sinh, bng nim mc, Vitamin B12, st
ci thin tnh trng thiu mu.
3.1.4..Vim d dy do tro ngc
Vim d dy vng mn v gp sau ct 2/3 d dy.iu tr bao gm thuc thay i
thnh phn dch mt nh Cholestyramin phi hp sucralfate v Cizapride hoc
Metoclopropramide lm y nhanh thc n ra khi d dy.
119
VIM NG MT - TI MT CP
Mc tiu
1. Trnh by c c ch bnh sinh ca cc loi si mt.
2. Nu c cc c im lm sng v cn lm sng ca vim ng mt ti mt
cp
3. Trnh by c cc bin chng cp v mn ca vim ng mt ti mt cp.
4. Trnh by c cc phng tin iu tr ni khoa vim ng mt- ti mt cp
Ni dung
I. I CNG
Vim ng mt ti mt cp (VMTMC) l mt cp cu ni - ngoi khoa thng
gp, c th c bin chng nng thm ch t vong nu khng c chn on v
iu tr kp thi. VMTMC nc ta c cc c im dch t hc v c ch bnh
sinh khc vi cc nc u M. Vic iu tr v theo di i hi s phi hp ni -
ngoi khoa.
II. DCH T HC
VMTMC nc ta ch yu l do giun hoc si mt, trong 95% l si ng
mt ln. Si mt l bnh ng hng th hai trong cc bnh gan mt nc ta sau
cc bnh vim gan.
Si mt cc nc u M th ch yu l si ti mt (90%) m thnh phn ch yu
l si Cholesterol. Php, t si mt ngi ln khong 10-15%. Ty u v
Nam M t l ny l 10-30%. Nht Bn si mt chim t l 5%, ch yu l si sc
t mt.
III. BNH NGUYN
1. Vim ng mt ti mt cp khng do si
1.1. Giun chui ng mt.
1.2. Nhim khun huyt: thng do E. Coli, thng hn.
1.3. Chn p ng mt: do cc khi U ng mt, u u ty, hch chn p.
1.4. Th thut thm d ng mt: Ni soi ng mt, ct c vng Oddi.
2. Vim ng mt ti mt cp do si: si cholesterol, si sc t mt.
IV. C CH SINH BNH
1. C ch to si Cholesterol
Bnh thng, t bo gan tng hp cc axit mt v bi tit cholesterol vi t l 1 gam
cho mt lt mt. Cholesterol ha tan trong mi trng mui mt to thnh mt dung
dch. Lecithin cng l mt thnh phn ca mui mt gip cho s ha tan ca
Cholesterol.
Thng thng, t l mui mt/ cholesterol (SB/C)> 10, t l Phospholipid/
Cholesterol (L/C)> 3; khi cc t l ny thay i: SB/C gim, L/C gim th c hin
tng bo ha cholesterol to si.
S bo ha cholesterol l tin cho s kt ta cholesterol to si v thng gp
trong cc trng hp sau:
121
2.3. Hi chng tc mt: ty thuc v tr, kch thc v thm ca vin si. C th
nh thong qua, c khi r vi nc tiu vng m, kt mc mt v da vng; t gp
hn l phn bc mu, nga. Vng da thng xut hin 1-2 ngy sau triu chng
au v st.
au, st, vng da lm thnh tam chng Charcot c trng cho si ng mt.
VI. XT NGHIM CN LM SNG
1. Xt nghim sinh hc
1.1. Cng thc mu: bch cu tng ch yu a nhn trung tnh.
1.2. Cy mu: khi cha dng khng sinh, thng gp l E. Coli.
1.3. Xt nghim dch mt: ht dch mt bng thng t trng hoc bng ni soi: cy vi
khun, tm trng giun, sn l gan.
1.4. Bilirubin mu: tng trong tc mt, ch yu loi trc tip.
1.5. Nc tiu: sc t mt, mui mt tng, urobilinogen (-) khi tc mt hon ton.
1.6. Transaminase, Phosphatase kim, gamma GT trong mu tng khi tc mt ko
di.
1.7. Phc hp Prothrombin gim, nghim php Kohler dng tnh.
2. Chn on hnh nh.
2.1. Chp bng khng sa son: thng t thy si.
2.2. Siu m bng: rt c gi tr d s dng. C th thy hnh nh trc tio ca si
(tng m mnh, c bng lng) hoc hnh nh gin tip qua hin tng gin cc
ng mt.
2.3. Chp ct lp t trng: chnh xc hn i vi si ng mt nhng t tin.
2.4. Chp ng mt: Thng c ch nh l chp ng mt ngc dng c
bm thuc cn quang, c th kt hp vi ct c vng Oddi ly si, c gi tr chn
on v iu tr cao.
Chp ng mt qua da: ch tin hnh khi c ch nh phu thut.
VII. CHN ON
1. Chn on xc nh
- au h sn phi km st, vng da vng mt.
- Siu m bng hoc chp ng mt cn quang.
2. Chn on phn bit
2.1. au h sn phi cn phn bit vi
2.1.1.Vim ty cp: au lin tc, c cc im au ty, Amylase mu tng, siu m
bng: Ty ln, ph n, cc ng dch, c th phi hp vi vim ng mt - ti
mt do giun, si
2.1.2. p xe gan amip
St trckhi au, gan to v au, im au khi tr vng gan, thng khng c vng
da vng mt. Chn on da vo siu m v ELISA tm khng th amip
2.1.3. Lot d dy t trng
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Khng st, khng vng da, au c tnh chu k, gim au sau n nh hoc ung
khng toan. Chn on bng ni soi d dy t trng.
2.1.4. Ri lon vn ng ti mt
D nhm vi si mt th khng vng da, thng gp ph n, khng st, khng
vng da, gim au t nhin. Siu m khng c giun hoc si
2.2. Vng da cn phn bit vi
2.2.1.Vim gan
C trng hp au nhiu d nhm vi si mt. Vng da th ht st. Bilirubin gin
tip tng cao, ALAT v ASAT tng rt cao. Siu m gip phn bit.
2.2.2.U u ty: Tc mt t t ngy cng tng, thng khng au, khng st. Chn
on bng siu m bng v nht l CT Scan
VIII. BIN CHNG
1. Bin chng cp tnh
1.1. Bin chng gan v ng mt
1.1.1. Thm mt phc mc: Tc mt lm ti mt cng to v gin mng, cc ng
mt cng cng to lm mt thm ra ngoi, vo bng. Bnh nhn au nhiu hn v
lan ra ton bng. Khm bng c phn ng thnh bng, nht l h sn phi.
1.1.2. Vim hoi t ti mt hoc ng mt ch: Thnh ti mt v ng mt ch c th
b vim dy, trn c nhng ch b hoi t. Nhng ch c th c mc ni hoc
cc tng xung quanh ti dnh bt li hoc bc vo bng gy vim phc mc, gp
ti mt nhiu hn ng mt ch, lm sng c hi chng nhim trng nhim c
nng, bng ngoi khoa. Chn on bng siu m v chp ct lp t trng.
1.1.3. p xe ng mt: nhim trng v tc mt nng, gan ln v au. Siu m pht
hin cc p xe trong gan.
1.1.4. Chy mu ng mt: Do p xe hoi t nhu m gan lm mt nhnh ca ng
hay tnh mch trong gan thng vi ng mt hoc do vim ti mt chy my.
Thng hi chng tc mt nh hoc khng r. bnh nhn thy mt mi, chong
vng, hoa mt, sau i cu phn en hoc nn ra mu, trng hp in hnh trong
cht nn c cc cc mu ng hnh thi bt ch. Chy mu ng mt thng dai
dng v d ti pht.
1.2. Bin chng ton thn v cc c quan khc
1.2.1. Nhim trng huyt v chong nhim trng: Thng do vi khun Gram m. St
cao km rt run, mch nhanh huyt p ty v kp, tay chn lnh, ni vn tm, nc
tiu gim. Cy mu thng dng tnh. Tin lng nng.
1.2.2. Hi chng gan thn vi tiu t, v niu. Ur mu tng nhanh.
1.2.3. Vim ty cp: au lin tc, nn nhiu, cc im ty au, Amylase mu tng.
Siu m hoc chp ct lp t trng thy tn thng ty.
2. Cc bin chng mn tnh
2.1. X gan: do mt v vim nhim ko di v ti pht nhiu ln. Chc nng gan
gim dn v cui cng i ti x gan do mt.
124
+ Trong trng hp cp cu, c km theo chng nhim trng, suy thn cp,
xat huyt tiu ha, vim ty cp...
+ Tn si ngoi c th
- Tn si ngoi c th: c Sauerbruch thc hin ln u tin trn ngi vo nm
1985.
+ C ch: tn si ngoi c th c thc hin nh 2 c ch sau:
Lm tng t l b mt/th tch ca vin si, lm d cho s ho tan si
To ra cc mnh si nh di 3 mm, c th di chuyn d dng xung rut non m
khng gy ra triu chng g.
+ Nguyn l k thut: my tn si ngoi c th s pht ra mt sng va p mnh c
tc dng to ta mt p lc rt cao v tr vin si nhng p lc xung quanh li bnh
thng, do va c tc dng tn nh vin si, va khng gy thng tn cho cc
m ln cn.
Si cholesterol khng cn quang, ng knh di 20 mm.
Ti mt v ng mt khng b tc nghn
+ Chng ch nh:
Khng c cc bin chng nh vim ti mt cp, vim ty cp.
Khng c si ng mt
Khng c ri lon ng mu hay ang dng thuc chng ng.
Ph n c thai.
+Tc dng ph, tai bin: thng ch c vi chm xut huyt nh di da ni tn,
him khi gp tiu mu hoc khi mu t gan.
X. D PHNG
- D phng si cholesterol bng tit thc gim cholesterol, gim m bo ha,
thn trng khi dng thuc nga thai, iu tr bnh huyt tn nu c.
- Tuyn truyn, gio dc v v sinh n ung, v sinh mi trng, x l phn
thi nng thn. Khuyn khch phong tro trng v s dng rau sch. Ra tay
trc khi n.
- X giun nh k mi 2-3 thng
- iu tr tt cc t nhim trng ng mt
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VIM GAN MN
Mc tiu
1. Nm c bnh nguyn v c ch bnh sinh trong vim gan mn.
2. Khm v pht hin c cc triu chng ca vim gan mn.
3. Chn on c v bit cch d phng
4. Trnh by c cc pht iu tr vim gan mn theo tng nguyn nhn gy
bnh.
Ni dung
I. I CNG
Vim gan mn (VGM) l biu hin ca nhiu loi tn thng gan do nhiu loi
nguyn nhn khc nhau trong vim v hoi t t bo gan ko di > 6 thng. Th
nh l th khng tin trin hoc tin trin rt chm v khng a n x hoc ung
th gan cn th nng l th vim hoi t dn dp hoc nhiu t tin trin tn cng
vo t bo gan ri cui cng a n x v ung th ha. Vim gan mn gy ra
do nhiu loi nguyn nhn thng gp l sau vim gan siu vi nht l B, C, v B
phi hp vi D v gn y l vim gan mn G; vim gan mn t min, vim gan mn
do thuc.
II. GII PHU BNH
Cc tn thng thng phi hp gia tm nhun t bo vim, hoi t v x ha.
Tm nhun t bo vim ch yu l khong ca, lm cho khong ca b dn rng
ra, vim cn xy ra quanh cc tiu thy gan, vi cc t bo gan b hoi t. Cc t
bo vim tm nhun ch yu l cc t bo vim n nhn nht l lymphocyte v
plasmocyte v monocyte
Hoi t t bo gan thng l nng v lan rng, c bit l hoi t tng m nh vi
ba t bo ch tip cn vi khong ca, hoi t ny gi l hoi t kiu mi gm, rt
c trng cho vim gan mn hot ng. Mt loi hoi t khc cng thng gp l
hoi t kiu cu ni, ni lin khong ca v tnh mch trung tm tiu thy.
X v nt tn to thay i t nhiu ty theo giai on din tin ca bnh, trong giai
on sau x chim u th v lm cho cu trc gan hon ton b o ln ng thi c
s xut hin ca nt tn to, cn biu hin vim th li gim dn cho hnh nh giai
phu bnh nh trong x gan v cui cng c th b ung th ha.
III. PHN LOI VIM GAN MN
Hin nay ngi ta phn loi da vo s phi hp ca lm sng, huyt thanh hc v
thay i v m hc cho nn cho nhiu gi tr thng tin hn. Phn loi vim gan mn
l da trn cc yu t sau
- Nguyn nhn.
- Hot tnh m hc cn gi l .
- tin trin gi l giai on.
1. Phn loi theo nguyn nhn
Lm sng v huyt thanh cho php chn on c vim gan mn do siu vi, ch
yu l siu vi B, C, phi hp D, cc loi siu vi khc; vim gn mn t min gm cc
129
tiu nhm: type 1, type 2 v type 3; vim gan mn do thuc; vim gan mn khng r
nguyn nhn gi l Cryptogenic chronic hepatitis.
2. Phn loi theo
S phn chia l da vo s lng gi m hc ca hot tnh vim hoi t khi sinh
thit gan. S lng gi v nng m hc bao gm hoi t quanh khong ca
v s ph v lp t bo gan quanh khong ca bi t bo vim hoi t gi l hoi t
kiu mi gm. S ni kt ca cc hoi t ny to thnh hoi t cu ni, ni lin
khong ca v mch mu trung tm, hoc cc khong ca vi nhau. Nhiu h thng
cho im mc hoi t ny, nhng ph bin nht hin nay l bng ch s nh gi
hot tnh m hc (HAI: hepatitis activity index) da trn cng trnh nghin cu ca
Schnell v Ishak. HAI l mt bng o v , n cng lng gi x ha m hin
nay c dng chia giai on bnh. N cng c dng o hot tnh ca
bnh trc v sau iu tr. Lm sng VGM chia ra 3 nh, va v nng.
3. Phn loi theo giai on
Phn loi ny phn nh giai on tin trin ca bnh, da trn mc x gan.
- Khng c x.
- X nh.
- X va.
- X nng c c x cu ni.
- X gan tht s.
4. Phn loi phi hp vi m hc: chia ra 3 loi
4.1. Vim gan mn tn ti: tm nhun t bo vim n nhn lan ta nhng cn gii
hn trong khong ca, ranh gii quanh khong ca cn nguyn vn v khng c s
xm ln ca tin trnh vim hoi t vo tiu thy gan, hoc ch c mt t x quanh
khong ca m khng c x gan. Thng l bnh nhn Khng c triu chng hoc
rt nh nh mi mt, chn n, bun nn. Thc th rt ngho ch c th gan hi ln
hoc bnh thng. Men transaminases ch tng nh v khng c hoc rt t a n
x gan.
4.2. Vim gan mn tiu thy: ngoi vim khong ca, xt nghim m hc c hoi t
v vim trong tiu thy. V hnh thi hc, vim gan mn tiu thy tng t nh tin
trin chm ca vim gan cp. Ranh gii quanh khong ca vn cn nguyn vn,
khng c x quanh khong ca hoc ch hn ch, cu trc thy cn gi c v t
khi chuyn qua vim gan mn hot ng v x gan. V vy vim gan mn tiu thy
c xem nh l mt th ca vim gan mn tn ti. i khi hot tnh trn lm sng
ca vim gan mn tiu thy gia tng mt cch t nhin, hot tnh ca men
transaminase tng t nh trong vim gan cp v c tn thng m hc gan thong
qua. Thut ng hin nay ca vim gan mn tiu thy l tng ng vi th nh hoc
va v giai on l khng c x hoc x ti thiu.
4.3. Vim gan mn hot ng: v lm sng c c trng ca hoi t lin tc
khong ca, quanh khong ca, vim tiu thy gan v x, mc t nh cho n
nng. Vim gan mn hot ng c bit nh l mt tin trnh tn thng gan a
n x, suy v cht. c im v hnh thi hc ca vin gan mn hot ng bao
gm:
130
cng chc n au tc, vng da vng mt, hng ban v dn mch hnh sao. C th
c lch ln 30% nht l khi c tng p ca, km thm c bng; hch ln 15-20%
thng l hch nch v hch c.
Cc biu hin ngoi gan c th gp: ban da, vim tuyn gip t min Hashimoto,
vim mch, vim cu thn, hi chng Sjogren, vim i trc trng lot chy mu,
thiu mu, chy mu do gim tiu cu.
Giai on sau khi c bin chng x gan cc biu hin vim thng gim dn
thay vo l cc triu chng ca x gan vi bng v suy gan l ni bt; hoc cc
triu chng ca ung th gan vi gan rt ln, cng c nhiu khi u ln nhn.
2. Xt nghim
2.1. CTM: BC v HC thng gim c th gim lun c TC, VS thng tng cao.
2.2. Chc nng gan: thay i nhiu.
- Bilirubin tng c trc tip v gin tip.
- Men transaminase thng tng gp >5 ln bnh thng.
- Gammaglobulin tng nhng albumin gim, t A/G rt thp.
- T prothrombin gim, yu t V gim.
- Phosphatase kim tng.
2.3. Min dch
- HBsAg(+), ADN virus, ADN polymerase v HBeAg(+) trong vim gan mn hot
ng B.
- Anti HVC v HVC-RNA (+) trong vim gan mn virus C.
- KT- khng nhn, KT-khng c trn, KT- khng ti lp th (+) trong vim gan t
min.
2.4. Sinh thit gan: l mt xt nghim cn thit gip chn on nguyn nhn v giai
on, trm trng ca vim gan mn cho hnh nh vim hoi t xm nhp tiu thy
gan vi hoi t mi gm, hoi t cu ni, hoi t mng xen ln vi t chc x pht
trin nhiu khong ca xm nhp tiu thy v cc nt tn to trong giai on sau.
V. CHN ON NGUYN NHN
1. Vim gan siu vi
1.1. Vim gan mn B: trong thi k lui bnh c khong t 1-10% bnh nhn vn
mang virus, nguy c mang mm bnh mn c lm d bi tnh trng suy gim
min dch trc . Nhim bnh t s sinh thng im lng nhng c n 90% c
nguy c chuyn thnh mn, trong khi nhim bnh tui thiu nin khi c
min dch, th biu hin lm sng vim gan cp r hn nhng ch c 1% tr thnh
mn tnh. Mc tn thng gan rt thay i t nh, va v nng; mc tn
thng m hc lin quan n trm trng ca bnh. Mt nghin cu c theo di
ko di 5 nm cho thy thi gian sng cn 97% trong VGM tn ti, 55% trong vim
gan mn hot ng.
Ngoi tn thng m hc, s nhn ln ca virus cng rt quan trng trong
vn tin lng, ngi ta chia vim gan mn ra lm 2 pha da trn s ch im
nhn ln ca virus (HBeAg, HBV- DNA), c s hin din ca khng nguyn
nuclocapside ni bo (HBcAg). Trong pha t nhn i virus, khng c mt ca
132
HBeAg v HBV- ADN nhng c anti HBe, khng c mt ca HBcAg ni bo, pha ny
rt t ly nhim, v tn thng gan t. Bnh nhn c pha nhn ln virusk c khuynh
hng nng, trong khi bnh nhn khng c pha nhn ln virus, thng l vim
gan nh hoc va hoc ngi lnh mang bnh. S chuyn t nhin t vim gan
mn c nhn ln sang vim gan mn khng nhn ln hng nm l t 10-15%.
Tn thng gan do nhim virus B mn khng phi trc tip gy ra do virus, m lin
h n phn ng min dch chng li t bo gan do cc khng nguyn ca chng,
nht l HBcAg.
Lm sng ca vim gan mn siu vi B rt thay i t nhim khng triu chng cho
n rt nng n thm ch t vong do suy gan. Khi bnh a s thng m thm, ch
mt s t biu hin nh mt vim gan cp. cc triu chng thng gp l mt mi,
vng da tng t, km chn n, v sau xut hin cc triu chng ca x gan v tng
p ca nh ph, bng, chy mu nht l t tnh mch trng thc qun, ri lon
chy mu ng mu, bnh no gan, lch ln. cc triu chng ngoi gan gn ging
nh vim gan siu vi cp do s lng ng cc phc hp min dch Ag-Ab nh au
khp, vim khp, ban da, vim cu thn, vim mch.
Xt nghim
- Men transaminase tng t 100- 1000 v trong SGPT tng nhiu hn, nhng khi
c x gan th SGOT chim u th hn.
- Phosphatase kim tng va. Bilirubin tng gp 3-5 ln bnh thng.
- Albumin mu gim.
- T prothrombin gim nht l trong giai on nng y cng l yu t tin lng.
- Cc cht ch im l HBeAg v anti HBe, HBV- DNA, HBsAg, anti HBc thng (+).
1.2. Vim gan mn D (Delta): c pht hin nm 1977, y l loi virus c bit n
ch c th pht trin khi c s hin din ca virus B.
Bnh cnh lm sng vim gan mn D tng t nh vim gan mn virus B, nu ng
nhim th bnh cnh lm sng s rt nng nhng dng nh khng lm gia tng
tin trnh a n mn tnh, cn bi nhim ngi vim gan B mn s lm cho tn
thng gan nng ra rt nhiu.
Chn on da vo s hin din ca HDV Ag v anti HDV c 2 type IgG v IgM. S
hin din ca HDV Ag trong gan v HDV- RNA trong huyt thanh chng t c s
nhn ln ca virus. S hin din ca khng th lu hnh khng li microsome gan-
thn (anti LKM: khng liver kidney microsome) l yu t quan trng gip chn on
vim gan D mn, y l la LKM3 khc vi LKM1 trong vim gan t min.
1.3. Vim gan mn C: Trc y gi l 0A0B (khng A khng B). Din tin mn tnh
sau vim gan C l 50-70%. Ngoi ra vim gan mn sau chuyn mu 10 nm 20%
a n x gan. Ngay c cho nhng th nh v va v khng c triu chng v ch
tng nh men transaminase, sinh thit gan ch c thng tn nh v va. T l vim
gan mn C cn b a n x gan l 50%. nhng bnh nhn c anti HVC mc d
khng c triu chng v men transaminase bnh thng. Khi sinh thit gan cng c
tn thng vim gan mn v c th pht hin HCV- RNA lu hnh trong mu. Din
tin ca VGM C thng chm v m thm. Mc tin trin ph thuc vo nng
HCV- RNA v thi gian nhim bnh.
Biu hin lm sng ca VGM. C cng tng t nh B: thng nht l mt mi, vng
da t gp. Cc biu hin ngoi gan do phc hp min dch t gp hn B ngoi tr
133
Liu trnh 1 nm cng ch lm m tnh HBeAg 39% bnh nhn. Lamivudine cng
c dng trong d phng ti nhim virus B trong ghp gan bng phi hp vi
Globuline min dch khng HBsAg. Trong vim gan B phi hp vi nhim HIV dng
liu 300mg/ng cho thy rt hiu qu.
- Famciclovir: liu 1500mg/ng chia 3 ln trong 16 tun lm gim t l ng k AND
virus v hot tnh ca men transaminase sau 1 tun. S dng liu th 2: 750mg/ng
trong 16 tun na cng lm tng ng k s i huyt thanh khng HBe. N cng
dng trong iu tr d phng trong ghp gan, hoc trong trng hp khng iu
tr vi Interferon.
- Adefovir: (Hepsera) vin 10mg/ ngy 1 vin dng 6 thng n 1 nm, cn theo di
chc nng thn.
- Interferon: Loi interferon alpha tc dng qua 2 c ch: mt l c ch RNA virus v
tng hot tnh ca men khng virus. Hai l lm gia tng p ng min dch t bo
bng cch gia tng s trnh by khng nguyn ha hp t bo loi 1 v kch thch
hot ng ca lympho bo T gip v T git. Liu 5 triu n v tim di da hng
ngy hoc 10 triu n v tim di da hoc tim bp tun 3 ln, dng trong 4-6
thng. p ng loi 2 khong 40%. p ng tt hn bnh nhn c nng HBV
DNA < 200pg/mL v bnh nhn c men transaminase > 100-200 .v.
Tc dng ph: - Nh cm cm vi st, nhc u, mi mt.
- Thiu mu, gim bch cu a nhn, gim tiu cu.
- Tc dng ph nng hn nhng t gp v ph thuc c a l: ri lon
tm thn, ng kinh, suy hoc cng gip.
Interferon tc dng ko di: Peginterferon 2a (Pegasys), mi tun ch tim 1 ln, liu
90-180mcg.
- Corticoide: cho trc iu tr Interferon trong 4 tun, v khi dng t ngt s c
phn ng di min dch vi s gia tng hy t bo b nhim virus, s gip cho
Interferon tc dng tt hn, nhng bnh nhn x gan c nguy c suy gan nng.
- Ghp gan: ch nh cho suy gan nng, nhng cng khng trnh c tnh
trng vim gan ti pht trn gan ghp (80%). iu tr interferon trc khi ghp gip
lm chm tin trnh vim ny.
2. iu tr vim gan mn D
Ch c Interferon mi c hiu qu trong iu tr VGM D, nhng thng kh nh gi
hn v bnh nhn ny thng phi hp vi nhim HIV v VGM.C. Vi interferon
alpha p ng c ch s nhn kln ca virus l 50%, ng thi thng km theo s
gim men transaminase, v gim hot ng m hc, nhng him khi t c mt
s ngng hon ton nhn ln ca virus, v khi ngng iu tr s c s ti xut hin
ca khng nguyn v ca RNA virus, cng nh s gia tng tr li ca men
transaminase. Liu interferon cao hn 10triu .v (3 ln/ tun v ko di 6 - 12
thng.
Ghp gan cng c thc hin khi suy gan nng v cng c nguy c vim gan trn
gan ghp.
3. iu tr vim gan mn C: Corticoides khng c kt qu.
* Interferon alpha l thuc iu tr hiu qa nht hin nay. N lm bin mt s tng
men transaminase sau 1-2 thng iu tr. Nhiu nghin cu cho thy interferon lm
137
men transaminase tr li bnh thng trong 50% trng hp, cng nh lm gim
hot tnh m hc. Liu 3 triu n v tun 3 ln tim di da trong vng 6 thng. Cn
thn trng x dng interferon khi c suy gan nng, v khi ngng iu tr s c phn
ng di, v mt hot tnh vim gan mn s lm cho gan b suy thm.
Hiu qu lu di ca vic iu tr interferon vn cha c bit ht. V sau khi
ngng iu tr 3 - 6 thng th gn 1 na c hin tng ti pht. Hin nay c
interferon tc dng ko di: Peginterferon 2a (Pegasys), mi tun ch tim 1 ln, liu
90-180mcg, tc dng tt hn v t tc dng ph hn nhng gi cn cao.
* Ribavirin: l mt cht ng vn nuclotide c ph virus rng, c th dng lm n
tr liu chng virus C, n gip ci thin v m hc v men gan t 30 n 50% bnh
nhn. Tuy nhin n lm gim lng virus khng ng k v p ng sinh hc khng
duy tr c sau khi ngng thuc. Liu dng l 1000-1200mg/ng, dng trong 6
thng.
iu tr ghp gan cng tng t nh VGM B.
2.4. iu tr vim gan t min
Ch yu l dng corticoides v thuc c ch min dch.
* Corticoides: Dng n c th cho liu 30-60mg/ng cho ngi ln trong vng 2-3
tun sau gim liu dn, duy tr men transaminase mc bnh thng, vi liu
thng thng l 10-20mg/ng.
Nu corticoide khng hiu qu th phi hp vi Azathioprine liu 50mg/ng. Liu trnh
ny hiu qu trong 80% trng hp. d n c hay phi hp vi Azathioprine cng
cn ko di t nht l 2 nm. Nu sau thi gian ny thy men bnh thng v khng
cn hoi t t bo gan th ngng iu tr v theo di. Nu ti pht th phi iu tr li
nh t u. Thng t l ti pht l khong 60-90% trng hp, do nhiu khi phi
iu tr sut i.
* Ciclosporine: l thuc c nhiu trin vng hin nay ang dng iu tr trong
trng hp khng vi iu tr corticoides. Liu 5-6mg/kg, dng ko di 1-2 nm.
138
X GAN
Mc tiu
1.K cc triu chng v bin chng ca x gan.
2.Lit k cc tiu chun chn on bnh.
3. iu tr cc bin chng ca x gan nht l nhim trng v xut huyt.
Ni dung
I. I CNG
X gan: tn Hy lp l kirrhose, c ngha l gan b x, do Laennec t ra t
nm1819 khi m t tn thng gan do nghin ru lu ngy.T bnh c mang
tn ng gi l x gan Laennec.
II. NH NGHA
Ngi ta nh ngha bnh x gan da trn cc tn thng gii phu bnh ca gan, .
Do ty theo nguyn nhn m bnh cnh x gan, ngoi cc triu chng chung ca
n, c th km theo cc biu hin lm sng khc c trng cho nguyn nhn gy
bnh.
Tn thng c trng cho x gan l mt qu trnh tn thng mn tnh, khng hi
phc ca x gan km theo s x ha lan ta kt hp vi s thnh lp cc nt nhu
m gan ti sinh. Cc tn thng ny a n hoi t t bo gan, lm xp khung li
nng ca gan t dn n s lng ng ca cc t chc lin kt, cc sn mch
mu trong gan tr nn ngon ngoo khc khyu, cc nhu m gan cn st li pht
sinh thnh tng nt. Tn thng ny l hu qu ca tn thng gan mn tnh do
nhiu nguyn nhn khc nhau.
III. DCH T HC
Php, tn sut x gan c triu chng l 3000/1 triu dn, trong do ru vang
chim a s.(nam: 90%-95%; n: 70%-80%); do bia: 10%, do vim gan mn virus l
10%. S ngi ung nhiu ru:30.000/1 triu dn c nguy c x gan l 10%. Nu
trung bnh ung khong 80gr ru/ngy i vi nam v 60 gr/ngy vi n trong 10
nm th nguy c x gan l 50%. T l t vong do x gan: 300 ngi/1 triu dn/nm.
ng nam , vng Sahara chu Phi, khong 15% dn chng nhim virus vim
gan B, C ngay c khi cn nh tui, trong 25% dn n x gan.
Hoa K, t l nhim virus B t hn, thng gp ngi c nguy c cao nh ng
tnh luyn i nam, nghin ht ma ty, vim gan C sau chuyn mu th c khong
50% dn n x gan, t l sng sau 20 nm l 20%. Vit Nam, cha c s liu
thng k c th.
IV. BNH NGUYN
C nhiu nguyn nhn gy x gan, vn cn 1 s nguyn nhn cha bit r.
1. X gan ru
L nguyn nhn thng gp chu u, gp ngi ung ru nhiu, tuyn mang
tai ln, nt dn mch. SGOT/SGPT >2, GGT tng, xc nh bng sinh thit gan, vi
hnh nh nt dn mch. SGOT/SGPT >2, GGT tng, xc nh bng sinh thit gan,
vi hnh nh
139
- C trng: th t do. Nguyn nhn chnh l do tng p tnh mch ca, ngoi ra
cn do cc yu t khc nh gim p lc keo, gim sc bn thnh mch, yu t gi
mui v nc.
- Tr: thng l tr ni do tng p lc tnh mch mc treo trng di, biu hin bng
i cu ra mu ti.
VII. CN LM SNG
1.Hi chng tng p tnh mch ca
1.1.o p lc tnh mch ca
Bnh thng: 10-15cm nc, tng khi>25cm nc; p lc tnh mch lch tng, thi
gian lch ca ko di.
1.2. ng knh tnh mch ca, tnh mch lch.
Bnh thng 8-11mm, khi c tng p ca th ng knh ln hn 13mm, ng knh
tnh mch lch > 11mm (o bng siu m)
1.3. Ni soi bng Gin tnh mch phc mc, mc treo, tnh mch rn, hoc soi thc
qun d dy thy c trng tnh mch thc qun, d dy.
2. Hi chng suy gan
2.1. Protid mu Gim, nht l albumin, gama- globulin tng, A/G o ngc
2.2 T prothrombin Gim, y l 1 yu t tin lng nng.
2.3. Cholesterol mu: Gim, nht l loi ester ha.
2.4. Cc xt nghim chc nng gan c hiu: Nghim php Galactose niu+, thanh
thi caffein (+).
2.5. Ri lon in gii:Natri mu tng hoc gim, kaki mu gim, natri niu gim
(natri niu < 25 mEq/ 24 gi.
2.6. NH3 mu tng
3. Hi chng vim
3.1. Fibrinogen mu: tng >4g/l.
3.2. LDH>250v, CRP>20mg/l, VS: tng.(khi c x tin trin)
4. Hi chng hy t bo gan
Biu hin khi c vim trong x gan tin trin vi tng ALAT, ASAT.
5. Hi chng thiu mu: ng sc, hoc gim 3 dng t bo mu khi c cng lch.
6. Cc xt ngim ghi hnh
-Siu m gan: gan nh, b khng u, hnh rng ca, dng nt, tnh mch ca tnh
mch lch gin, ti lp tnh mch rn, thuyn tc tnh ca.
-Chp ct lp t trng: cho hnh nh tng t
7. Sinh thit gan
L xt nghim quyt nh trong chn on x gan, gp phn chn on nguyn
nhn v phn loi x gan.
VIII. CHN ON XC NH
142
Da vo cc yu t sau
-Tin s c bnh gan mn tnh
-Lm sng Da vo 2 hi chng tng p ca v hi chng suy gan.
-Cn lm sng: Cc xt nghim mu, siu m, sinh thit gan.
IX. CHN ON PHN BIT
1. Suy dng
C tin s, bnh s b mt protein nh ct on rut, suy kit ko di, thiu n trm
trng. Xt ngim c gim protein mu nhng chc nng gan bnh thng, siu m,
sinh thit gan bnh thng.
2. Thn h: Ph tin trin nhanh, c protein niu> 70mg/kg hay > 3, 5gr/24 gi, in
di protein mu c tng globulin l ch yu, siu m v sinh thit gan bnh thng
3. Lao mng bng: Da vo tin s, bnh s c du nhim lao, bng t do hoc khu
tr, au, bng dch tit ch yu limpho, tm BK trong dch bng.
4. U c tnh bng: Bng dch tit, c t bo l, chn on bng chp ct lp t
trng, sinh thit khi u hay chc ht kim nh.
5. Ung th gan: C th trn 1 gan lnh hoc trn 1 gan x. Gan ln nhanh, cng,
bng c th l dch mu, Alpha - FP (+), DCP(+), siu m, CT, sinh thit.
X.TIN TRIN, BIN CHNG
1 Tin trin: m , ko di qua nhiu nm, t giai on cn b vi rt t triu chng,
chn on bng sinh thit gan, n giai on mt b vi triu chng lm sng r,
cn lm sng in hnh. Giai on ny c nhiu bin chng.
2 Bin chng: Nhiu v phc tp vo giai on cui
2.1. Nhim trng Rut, bng, tnh mch ca, phi, thn.
2.1.1. Nhim trng bng
Khi pht c th gp sau vim rut, vi biu hin bng tng nhanh hn, au bng t
nhin, st. Khm bng au khi n, chc d mng bng dch bng c tng t bo >
500/mm3 v trn 50% l bch cu trung tnh, phn ng rivalta c th (+), cy c th
c vi trng gy bnh.
2.1.2. Huyt khi tnh mch ca do nhim trng: Lm sng c bng tng nhanh, au
bng t nhin, st, i tin ra mu. Chn on bng siu m cho hnh nh huyt
khi trong tnh mch ca.
2.2.Bnh l d dy t trng Lot d dy t trng, bnh d dy tng p ca.
2.2.1.Lot d dy t trng: Hay gp lot hnh t trng hn lot d dy. c im
lot thng rt t triu chng, kh lin so, d ti pht nn c nhiu bin chng nh
thng, chy mu.
2.2.2. Bnh d dy tng p ca: Nim mc d dy rc, nhng thc s khng
phi vim. Dn dn, nim mc c hnh khm v c th km theo trng tnh mch
d dy. Tn thng ny hay xy ra bnh nhn c iu tr tht tnh mch trng
thc qun.
2.3. Chy mu Da, nim mc, ni tng, chy mu t tnh mch trng thc qun, t
tr trong tng p ca.
143
2.3.1. Chy mu t tnh mch trng thc qun: Do p lc tnh mch ca qu cao.
Bnh khi pht t ngt vi nn mu nhng khng c triu chng bo trc. Tnh
trng chy mu c khi rt nng vi biu hin chong do mt mu, e do tnh mng.
Ni soi thc qun c trng tnh mch 3 c chy mu. Ngoi ra c th chy mu
cc v tr trng tnh mch khc nh tr, trng tnh mch d dy vng phnh v,
trng tnh mch rut non (him).
2.3.2.Chy mu do gim yu t ng mu: Chy mu no, chy mu di da.
2.4. Hn m gan L tin trnh ca giai on cui x gan. Thng c cc yu t lm
d nh nhim trng, xut huyt, ri lon nc in gii, sau phu thut ni tt tnh
mch ch cn gi l bnh no gan.
2.5 Hi chng gan thn: L bin chng nng, t vong cao. y l suy thn cp rt
nng, pht khi trn 1 gan suy, bng qu nng, dng li tiu ba bi hoc thuc c
cho thn. Lm sng biu hin tnh trng thiu niu hoc v niu, c du hiu suy
thn, c protein niu, hng cu niu, natri mu gim < 130 mEq/L, thm thu
nc tiu cao hn huyt tng.
2.6. Ung th gan: Thng gp sau x gan ngoi tr x gan do tim v x gan do
mt.
2.7. Ri lon ng mu: C ri lon dung np glucose nhng t khi gy nn bnh
cnh i tho ng tht s, hoc ng mu gim trong suy gan nng.
2.8.Ri lon yu t ng mu
XI. IU TR
1.iu tr nguyn nhn
Mt khi x gan xy ra ri th vn iu tr nguyn nhn tht qa kh. Loi b
nguyn nhn tc hi nh ru, c cht th vi ch n thch hp, ngh ngi, cung
cp dinh dng c th hi phc nu qu trnh x ang giai on sm..
1.1. iu tr triu chng
1.1.1.Ch n ung ngh ngi
Ch hn ch mui rt quan trng. n nht 0, 5g mui/ng, t m < 50g/ng, protide
khong < 2g/kg/ng. Nng lng khong 1500 - 2000 calo/ng, nc ung < 1l/ng da
vo bilan nc.(c th 100g tht/ng hoc thay bng 2 qu trng, khng qu 0, 25l
sa/ng, bnh m khng mui vi b v mayonaise, tri cy, salad, nc st c chua,
khng dng sa chocolate, ko bc h) nn dng m thc vt, hn ch hot ng
th lc.
1.1.2. iu tr c trng
Kh khn hn so vi c trng do cc nguyn nhn khc.n nht v ngh ngi nu
khng gim bng v Na+niu< 25mmol/ngth cn x dng li tiu.
- Li tiu:Thng bt u vi khng Aldosterone nh spironolactone 100-200mg/ng
hoc Amiloride 10mg- 15mg/ng hoc Triamterene. Sau 4 ngy nu p ng km th
thm Furosemide 80mg/ng hoc thiazide 50mg- 100mg/ng, nu khng p ng cn
xem li ch n, huyt p, p lc keo.
Theo di: cn nng, lng nc tiu hng ngy, xt nghim in gii mu 2 ln
/1tun khi cn ang nm vin gip theo di qu trnh iu tr.Ti a gim khng qu
144
2kg/ng v tiu ti a 3 lt/ng khi c ph ngoi bin v khi ht ph th gim liu li tiu
iu tr duy tr tu p ng bnh, km tit thc hn ch mui
- Chc tho bng:Ch nh khi c trng cng; ph to; Child B; Protrombin>40%;
Bilirubin mu < 10mg/dl; Tiu cu> 40.000/mm3; creatinin mu<3mg/dl;Natri
niu>10mmol/24h. Chc tho tun 1 ln, mi ln ly 1 n 5 lt v phi truyn tr li
mi 6g albumin lt/1ldch (c th dng Dextran hoc polygeline).
- Dn lu kn: Dn lu mng bng vo tnh mch c qua 1 ng teflon.
Nu cc phng php trn khng lm gim bng th t shunt phc mc tnh
mch(peritoneovenous shunts) hoc t TIPS v cui cng l ghp gan
1.2.iu tr tng p tnh mch ca
- Ni thng ca ch: lm gim bng nhanh nhng c nguy c gy bnh no gan, v
hiu qu khng ci thin my.
- Thuc chn giao cm: (Propanolol, Nadolol) c tc dng lm gim p lc ca
thng qua nh hng gin mch trn sng mch tng, lm gim kch thc tnh
mch trng v h thng tnh mch ca, kt hp vi gim cung lng tim. Thuc
c dng vi liu sao cho mch cn so vi mch ban u khi ngh ngi vi iu
kin khng c chng ch nh.C th phi hp vi Isosorbide mononitrate(Imdur)
Tuy nhin, tng p ca trong x gan l khng hi phc cho nn phng php iu
tr c chn la l ghp gan.
1.2. iu tr suy gan
Khng c iu tr c hiu.
- Cc thuc chuyn ha m: Cholin, Methionin, Inositol khng lm hi phc c
chc nng gan
- Cc vitamin B, C, A, D, K, acide folic, folate, km
- Testosteron: khng dng v lm v ln hn, t l t vong tng hn.
1.3. Thuc chng x
- Corticoides: Ch dng trong vim gan mn t min.
- Cc cht c ch prolyl hydroxylase nh HOE 077 cn trong th nghim
- Colchicin: lm ngn qu trnh x gan ru, dng 1mg/ng, 5 ngy 1 tun trong
nhiu thng cng cha thuyt phc mnh m
2. iu tr binchng
2.1. iu tr chy mu tnh mch trng thc qun
y l mt iu tr cp cu nhm duy tr th tch tun hon, tuy nhin khi b dch qu
nhiu c th lm tng p lc ca hn, hu qu l chy mu nhiu hn v v vy nn
cn thn.
- Truyn mu ti hoc huyt tng ti v theo di bng p lc tnh mch trung
ng, lng nc tiu, tnh trng tinh thn kinh. Khong 50% trng hp c th t
ngng nhng nguy c chy mu li cn cao.
- Thuc co mch: (dng giai on cp): Vasopressine hoc Somatostatin. Truyn
Vasopressin(Pitressin) 20 v/100ml dextrose 5% IV trong 10ph p lc ca s gim
sau 45- 60 pht, hoc 0, 4v/ml trong 2 gi gy co mch tng lm gim mu trong h
145
Tin lng lu di l xu, 5% sng sau 5 nm, ph thuc bin chng. Tin lng
xu khi c vng da ko di, xut huyt, hn m gan, teo gan vng cp, nhim khun,
Child C ca phn loi Child- Pugh.
Bng 1: Thang im nh gi giai on x gan theo ch s Child - Pugh
1 im 2 im 3im
Bnh no gan khng l ln hn m
Bng khng kn o va phi
Bilirubin < 35 mol/l 35-50 mol/l > 50 mol/l
Albumin > 35 g/l 28-35 g/l < 28 g/l
T Prothrombin > 50 % 40-50 % < 40 %
Thang im nh gi giai on x gan theo ch s Child - Pugh l:
Child A: im 5 hay 6. Child B: im t 7-9. Child C im t 10-15.
147
HN M GAN
Mc tiu
1. K cc nguyn nhn gy hn m gan.
2. Nu c cc triu chng ca cc giai on hn m gan.
3. iu tr tt hn m gan ngoi sinh
Ni dung
I. I CNG
Hn m gan cn gi l bnh no gan, hoc no- ca ch, c nh ngha l nhng
ri lon no th pht gy ra do mt tnh trng suy gan qu nng do nhiu nguyn
nhn hoc khi pht sau phu thut ni thng ca ch.
II. BNH NGUYN
Trong trng hp suy gan qu nng hoc do ni tc ca ch, mu t tnh mch ca
n gan khng cn c t bo gan chuyn ha, tr thnh cc cht c lm ri lon
chuyn ha m nht l no. Cc cht c do bin dng ny bao gm amoniac,
mercaptan, acide gama amino butyri v cc acide amin nhn thm
1.Cc nguyn nhn gy hn m gan ngoi sinh
- Khi pht hn m gan xy ra trn 1 gan x hoc c ni tc ca ch:
- n qu nhiu protid hoc chuyn m
- Xut huyt tiu ha nng
- Dng li tiu mnh lm mt nc v h kali mu
- Dng cc thuc c cho gan:Tetracycline, thuc khng lao, thuc an thn, thuc
ng, thuc h huyt p.
- Sau phu thut trn 1 gan x
- Nhim trng gan, mt, thn, phi, rut.
- Chc tho bng: Thng chc nhiu ln hoc 1 ln qa nhiu lm gim lng tun
hon qua gan
2. Cc nguyn nhn gy hn m gan ni sinh
Do tn thng gan nng n v lan rng nh trong vim gan ti cp, vim gan nhim
c do phospho v c, do Tetraclorure de carbone, do nm Amanite phaloide, do
thuc hay do ung th gan hoc x gan giai on cui.
III. BNH SINH
Yu t quan trng nht trong bnh sinh ca hn m gan l t bo gan b suy nng v
hay ldo s ni tc trong hay ngoi gan, ni mu h ca vi tun hon chung. Hu
qu l nhiu cht c c hp thu t rut khng c gan kh c v a n
nhng bt thng v bin dng trong h thn kinh trung ng.
Cc thuyt hin nay gii thch c ch hn m gan l:
1. Thuyt Amoniac
Cho rng Amoniac t ng tiu ha khng c chuyn ha qua hng ro gan n
no gy c cho no. Ngi ta nhn thy ngi hn m gan c amoniac mu tng
148
2.1. Ammoniac mu
Thng cao nhng khng t l han tan vi nng. Bnh thng t 60-80 mg.
Trong hn m gan, tng trn 160g/ L. Cn lm ammoniac trong mu ng mch.
2..2. Ri lan v in gii v kim toan
Natri mu thng gim, Kali gim, calci t b nh hng, d tr kim tng, pCO2
gim.
2..3. Dch no ty. Glutamin, acide glutamic tng.
2..4. Cc xt nghim v suy chc nng gan.
2-5. in no : in th cao, i xng, sng chm delta.
2.6. CT scan v MRI: C th c teo no vng v hay ph no.
V. CHN ON
Ch yu da vo 4 yu t chnh sau y
- Bnh nhn c tin s mt bnh gan cp hoc mn, hoc sau phu thut ni ca
ch.
- C ri lan nhn thc: l ln ri hn m.
- C cc triu chng thn kinh nh tng trng lc c, tng phn x, rung v cnh,
Babinski, i khi c du ng kinh.
-in no : in th cao, i xng, sng chm..
- Cc triu chng khc: Hi th c mi gan, glutamin dch no ty tng cao.
VI. TIN LNG, D PHNG
y l bin chng nng ca x gan, tin lng rt nng, t vong 90- 95% nht l
hn m gan ni sinh. Ring i vi hn m ngoi sinh nu iu chnh c cc yu
t thun li sau 48- 72 gi bnh nhn c th ra khi hn m.
Tin lng ph thuc cc yu t thun li gy hn m v tin trin ca bnh x gan.
VII. IU TR
- Xc nh v iu tr nguyn nhn khi pht.
- Can thip gim s sn xut v hp th Nit v cc cht c khc trong rut
- Thuc lm thay i cn bng cc cht dn truyn thn kinh mt cch trc tip hoc
gin tip
1. iu tr hn m cp hay bnh no gan cp
+ Ch n: Gim protein cn 20gram/ngy, 2000 calo/ngy. Tng dn khi
hi phc ln tng 10g /ngy trong tng vi ngy mt nhng vi loi hn m gan mn
tnh th hn ch protein thng xuyn.Gii hn dung np l 40-60g/ng, nn dng
protein thc vt.
+ Tht tho loi b cc Nit v Phosphat.
+ Dng lactulose:10-30ml x 3ln /ngy hoc lactilol 0, 3-0, 5g/kg/ng.
+ Neomycin 1g x 4ln /ngy x 1 tun.hoc Metronidazol 200mg x4 ln/ng x 5-7ngy.
+ Duy tr nng lng v dch da vo cn bng nc v in gii.
150
+ Ngng li tiu.
+ Cc thuc an thn: c th dng Oxazepam.
+ Levodopa: tin cht ca Dopamin qua c hng ro mch no, ch s t bnh
nhn chu c.
+ Bromocriptine: mt ng vn receptor dopamin c hiu, tc dng di.
+ Flumazenil: mt i khng receptor benzodiazepine c th lm gim dn truyn
trong 70% trng hp.
+ Thuc tng thi amoniac qua thn: Benzoate de Sodium
+ Cc acide amin nhnh: cha c ng v thuc t.
+ Bt cc nhnh ni ca- ch.
+ Ghp gan.
2. i vi bnh no gan mn: trnh dng cc thuc c cha Nit; protein t thc vt
50gr/ng; i tin 2ln/ng; dng lactulose hay lactilol; nu triu chng xu hn th
chuyn sang iu tr nh ch ngi hn m cp
151
B hoc C) so vi nhng bnh nhn ch c HBsAg dng tnh (50% x gan, trong
65% thuc Child A) v gan thng c nhiu khi u hn
3. X gan: do bt k nguyn nhn no.
4. Aflatoxin B1: c t nm mc (Aspergillus), thng gp trong u phng mc;
c chng minh l cht gy ung th gan chut, gia cm
Vai tr sinh ung th c l qua trung gian cht chuyn ha l Epoxide gn vo cc
acid nucleic v thay i s sao m ADN.
Tng tc vi protein 53 t bin.
5. Cc yu t khc
5.1. Ru: c l thc y qu trnh sinh ung th
5.2. Ni tit t nam Androgen, thuc nga thai ung.
5.3. Ha cht (Thorotrast),
5.4. K sinh trng (Schistosoma japonicum, Sch. mansoni, clonorchis sinensis)
5.5. Thiu alpha 1-antitrypsin, thng gp cc kiu hnh ZZ v MZ.
5.6. Nhim huyt thit t (Hmechromatose), H/c Budd-Chiari.
III.TRIU CHNG
1. Triu chng c nng v ton thn
1.1. au bng: thng gp, cm gic nng tc h sn phi, lan sau lng, him khi
au d di.
1.2. Ri lon tiu ha: chn n, bun nn, nn, i chy.
1.3. St: lin tc, dao ng.
1.4. Gy st r giai on mun.
2. Triu chng thc th
2.1. Gan ln: nhn thy hoc s thy di b sn phi, cng, b mt khng u,
au nhiu hoc t, c khi c nh khng di ng theo nhp th. C khi gan ln vt
qu ng gia.
2.2. Vng da: ch yu do chn p ng mt trong gan.
2.3. Bng: t hoc nhiu, c th gp bng mu, ti to nhanh sau chc tho.
2.4. Nghe: ting thi trn vng gan
3. Sinh hc
3.1. Cng thc mu: thiu mu, c bit c khi c a hng cu.
3.2. Tc lng mu tng tng
3.3. Chc nng gan: ch ri lon trong ung th gan trn nn x gan hoc khi khi U
chim trn 75% th tch gan.
Enzyme gan: Phosphatase kim, gamma GT, 5 Nuclotidase, Alpha-2 Globulin,
SGOT thng cao hn SGPT.
3.4. Cc cht ch im ung th
3.4.1. Alpha Foeto Protein (AFP)
153
* Phng php
Phng tin, dng c:
- K thut tim ethanol c thc hin di s hng dn ca siu m hoc CT
Scan.
- Kim tim Chiba hoc Terumo: 0, 7-0, 9 X 7-15 cm.
- Ethanol tuyt i: 99, 8 %, ng ng 5 cc.
- Lidocain 1%, thuc gim au, dng c st trng.
* K thut
- Xc nh khi u gan cn chc di siu m hoc CT Scan
- Xc nh v tr chc kim, gy t
- Chc kim qua da vo trung tm khi u di s hng dn ca siu m hoc CT
scan
- Tim chm Ethanol vo khi u, va tim va quan st s khuch tn Ethanol ti
ch
- Rt kim ra st v gan, thay ng tim c lidocain gy t v gan
- Rt kim, bng ti ch.
- Liu lng: 1-2 v tr tim/mt ln x 2 ln mi tun; Mi ln tim 2-12 cc.
Tng liu Ethanol phi tim c tnh theo cng thc Sugiura N (Nht Bn) 1983
V = 4/3 (r + 0.5)3.
Trong : V l tng liu Ethanol
R: bn knh khi u
Kt qu s b ca mt s nghin cu: theo nhiu nghin cu ca nhiu tc gi
ngoi nc (Livraghi, Ebara...) v trong nc (Mai Hng Bng) th kt qu rt kh
quan, t l sng thm sau 3 nm l 71% (Child A), v 41% (Child B), mt s bnh
nhn sng trn 7 nm. Phn ln bnh nhn ci thin tt v lm sng, AFP gim r,
t l khi u hoi t hon ton trn siu m l hn 60%. K thut ny cn c th gip
iu tr cm mu trong trng hp v khi ung th gan.
2.2. Phng php gy tc mch
Phng php gy tc mch c s dng ln u tin vo nm 1975 ti M.
Nakamura iu tr gy tc mch cho 200 bnh nhn ung th gan nguyn pht v
cho t l sng thm 2 thng, 12 thng v 24 thng tng ng l 71%, 48, 1% v 20,
8%. Nhm gy tc mch c phi hp vi lipiodol c thi gian sng thm di hn c
ngha
* C ch
Bnh thng, gan nhn 2 ngun mu cung cp l ng mch gan v tnh mch ca,
trong cc khi u nhn mu ch yu t ng mch gan, do vic gy tc mch
bng cch tim vo nhnh ng mch chn lc nui dng khi u s gp phn gy
hoi t khi u nhng khng gin on s ti mu i vi gan lnh. Vic phi hp
tc dng gy thiu mu hoi t vi tc dng ca cc ha cht chng ung th s lm
tng tc dng iu tr.
157
* Cc k thut gy tc mch
+ Bt tt ng mch gan chn lc bng mnh bt b gelatin, a vo nhnh ng
mch nui dng u thng qua ng mch i v ng mch thn tng.
+ Bt tc ng mch gan siu chn lc
+ Bt tc ng mch gan kt hp tim ha cht chng u (TACE), cc ho cht
thng dng l doxorubicine, cisplatin...
+ Bt tc ng mch gan bng ha du (TOCE)
Tc dng ph sau bt tt l: st, au bng, nn, bng, hn m gan, tng
transaminase.
Ngoi ra c th gy bin chng tt mch ngoi gan hoc gy p xe ha.
Cc k thut ny c th lp li sau mt khong thi gian t 3-6 thng.
* Ch nh
+ Cc khi u gan khng phu thut ct b c
+ iu tr cp cu xut huyt phc mc do v khi u gan
+ Gy tc mch trc m lm gim bt kch thc khi u v tng thi gian
sng thm sau m.
+ Trong mi trng hp, tnh mch ca khng c c huyt khi
2.3. Cc iu tr tm thi khc
* Phng x tr liu
Trc y iu tr phng x ngoi cho bnh nhn ung th gan nguyn pht c
s dng. Nhng do kt qu hn ch nn hin nay t c ch nh. Nhng cht
phng x c s dng l I131-antiferritin, khng th n cln gn I 131-anti HCC.
Hin nay chu u cng c nghin cu iu tr tia x chn lc vo khi u vi kt
qu ban du c ko di hi gian sng thm ca bnh nhn.
* Ha tr liu
Cc ha cht thng c s dng l 5 FU, cisplatin, doxorubicin, Mitomycine C...
ng s dng phong ph: ung, tim tnh mch, tim vo dy chng trn, tnh
mch ca...
* Min dch tr liu
Cc phng tin min dch thng c s dng l phng tin c ngun gc vi
sinh vt (BCG, corynebacterrium, ..), ha cht (levamizole, Isoprinosin...) hoc nhm
Cytokin (IL2, IFN-beta, IFN-gamma...). Tuy nhin khng c phng php no hon
ton c hiu.
Mt s tc gi ngh tim BCG di v gan sau khi ct b khi u vi hy vng tng
min dch khng c hiu. Lai v cng s s dng phi hp Doxorubicine + IFN-
alpha 2 cho thy c gim kch hc u, gim cc bin chng so vi nhm chng.
K thut chuyn gen: a cc gen tr liu c hiu n tiu dit cc t bo c tnh
nhng khng lm thng tn t chc gan lnh. Cc vect virus nh adenovirus
thng c s dng. Cc khng th n dng phn ng vi khi u cng dc
s dng phn b cc gen n cc t bo ung th.
158
* Tamoxifene
S ph thuc kch dc t v s hin din ca th th ni tit trong ung th gan, gi
cho s pht trin ca u l do kch thch t, tuy nhin nghin cu s b vi Tamoxifen
cho kt qu cn tranh ci.
* Nhit tr liu
Thng dng sng cao tn (radio frequence ablation:RFA) pht ra nhit nng thng
qua mt cy kim cm sn trong lng khi u, nhit cao s gip tiu hu t bo ung
th. Kt qu bc u kh tt.
VIII. KT LUN
Ung th gan nguyn pht kh ph bin nc ta, triu chng a dng v
thng khi pht m thm, chn on phn ln giai on mun nn iu tr kh
khn, tin lng thng rt xu.
D phng ung th gan ch yu da vo tim chng phng virus vim gan B
v iu tr cc bnh vim gan mn do virus.
159
UNG TH D DY
Mc tiu
1. M t c im dch t hc bnh ung th d dy.
2. K cc yu t nguy c v c ch gy bnh ung th d dy.
3. Lit k cc triu chng lm sng v cn lm sng.
4. nh gi y chn on ung th d dy theo phn TNM tin lng.
5.Ch nh c th iu tr ung th d dy theo tng giai on
Ni dung
I.I CNG
Ung th d dy ng hng u ca cc ung th ng tiu ha. Mc d t l
t vong c chiu hng gim trong sut 60 nm qua nhng t l bnh so vi cc
ung th khc vn cn cao.
II. DCH T
T l bnh ung th d dy thay i gia cc quc gia khc nhau. Nht Bn, Trung
Quc, Chil v Ireland t l mc v t l t vong c xu hng gim ng k.
M, trong nhng nm gn y, t l bnh ny gim ( nam t 28/100.000 dn
xung cn 5/100.000 v n t 27/100.000 xung cn 2, 3/100.000) t l nam/ n
l 1, 7, tui trung bnh l 63. T l t vong gim t 33/100.000 vo nm 1930 xung
cn 3, 7/100.000 vo nm 1990. Nm 1996 c khong 22.800 trng hp ung th
d dy mi mc c chn on v c 14000 ngi cht.
Nht, t l ung th d dy l 69/100.000, tui trung bnh l 55, v tn sut mc
bnh c lin quan n chng tc (ngi M gc da en, da v gc Ty Ban Nha
t l ung th gp 2 ln so vi ngi M da trng). Ngoi ra mi trng, cc cht
c xem l cc carcinogene t thc n cng c lin quan n bnh.V dch t hc,
nguy c ung th d dy cao tng lp c i sng kinh t x hi thp
Ring Vit nam th cha c thng k c th
III. UNG TH BIU M TUYN D DY
Khong 85% ung th d dy thuc loi adenocarcinomas (ung th biu m tuyn d
dy), 15% l loi lymphomas-non-Hodgkin v leio-myosarcomas v cc loi u th
pht t gp.
Ung th biu m tuyn d dy c chia lm hai loi: loi lan ta v loi rut non.
1. Gii phu bnh
1.1. Loi rut non
L loi ung th d dy hay gp. Cc t bo tng sinh c cu trc ng dng tuyn.
Lon sn tuyn (dysplasia) l c trng th bnh ny, lon sn mc cao gp
trong giai on tin trin cng nh giai on im lng ko di t 5 n 15 nm.
Lon sn c th xy ra trn nn vim d dy mn teo tuyn cng nh vng c d
sn rut v c hai phi hp s lm tng nguy c ca Adenocarcinoma d dy. Tn
thng dng lot, thng gp hang v v b cong nh d dy v thng c giai
on tin trin tin ung th ko di. Khi u c ranh gii r, di cn theo ng mu
n gan v theo ng bch huyt n hch, t l gp ngi gi nhiu hn.
160
1.2. Loi lan ta: y l loi ung th t bit ha hn loi rut. T bo tng sinh thm
nhim thnh tng mng, lm dy vch d dy. N pht trin khp ni d dy k c
tm v lm mt kh nng gin d dy (gi l th linitis plastica hoc th t) kh nng
di cn xa. N thm nhim phc mc v sau phc mc, lan ta vo cc ng bch
mch, xng. Loi ny thng gp ni m ung th d dy c xem c nguy c
thp nh Hoa K v gp ngi tr nhiu hn. Loi ny c tin lng xu hn
loi rut. Ngoi ra cn mt dng khc l Adenosquamous tin lng rt xu v tin
trin rt nhanh v di cn sm.
Ty su v rng ca u, chia lm ung th b mt v ung th xm nhp.
1.3.Ung th b mt:
Ch gii hn nim mc v h nim mc, cha n lp c, biu hin 3 dng:
+ Typ I: Li ln hoc dng polype
+ Typ IIa: Np nim mc ch g ln, Typ IIb: Nim mc bng phng, Typ IIc: Nim
nc hi ln xung.
+Typ III. L s o su xung nh hnh hang, c bao quanh bi nhng nt nim
mc. C trng hp phi hp gia cc loi lm cho n c tnh cht ca lot.
1.4.Ung th th xm nhp:
Vt qua lp nim mc n lp c, thanh mc. C 3 loi.
+ Ung th th si: Mt khi trn nn cng v si vo bn trong lng d dy, khng
c lot hay hoi t.
+ Ung th th lot: Cc np nim mc hi t dng li ngoi vng ph n.
+ Ung th th xm nhim: Tn thng lan ta tm nhun ton b d dy (th t)
- Ung th d dy thng lan rng v pha thc qun ch ni d dy thc qun khi
ung th nm thn, phnh v. hang v, ung th thng lan xung v gy hp mn
v, nhng xm ln qua t trng th him. Ung th c th lan n mc ni nh, mc
ni ln, lch, i trng, ty, hch vng k cn.
- Ung th d dy thng di cn n phi, gan, no, xng, hch thng n (hch
Virchow), hch nch tri (hch Irish), hch quanh rn (hch Sister Mary Joseph),
bung trng (u Krukenberg), phc mc, trc trng
2. Cc yu t nguy c v c ch sinh bnh ca ung th d dy
2.1. Cc yu t c khng nh
-Lon sn d dy mc nng: Thng gp cc th vim, lot d dy mn vi
lon sn tuyn. Khong 10% c th tin n ung th d dy sau 5 n 15 nm.
-Vim teo d dy mn, d sn rut.
- Polyp dng tuyn c tnh gia nh (FAP): C lin quan n ung th.
- Adenomas d dy.
- Barrette thc qun: Gy ung th vng tm v.
- Vi khun Helicobacter pylori: Gy vim d dy mn vng hang v, vim teo tuyn d
dy, lot d dy, u limpho d dy (MALT) v ung th d dy.
2.2. Cc yu t c th gy ung th d dy
161
-Khm Bng: C khi bnh thng hoc c khi s c khi u hoc mng ranh gii
khng r vng thng v. Ung th d dy c th lan n thanh mc dnh vo cc
c quan ln cn nh tu, i trng, hch, mc ni, di cn n phc mc, bung
trng (u Krukenberg), hch quanh rn (nt Sister Mary Joseph), di cn n hch
bch huyt vng v hch Virchow.(hch thng n), xng, phi, gan, tu, no.
- Khm tng qut: C th thy thiu mu, ph hoc vng da, c trng.
- Cc biu hin lm sng t gp: (Du chng cn u): Gim sn ty, nhng mng sc
t en da vng nch (Acanthosis nigricans), hi chng Trousseau, vim da c,
thiu mu huyt tn vi th, sng ha tuyn b, bnh thn mng.
4. Cn lm sng
4.1. V mu
- Tng Fibrinogen v cc protein khc ca phn ng vim.
-VS tng va.
-Thiu mu: gim hng cu.
-nh lng CEA (carcinogenic embryonary antigen): Tng, ch thy giai an
mun trong 1/2 trng hp, c ch trong vic theo di din tin sau phu thut ct b
d dy.
4.2. Dch v: Phn tch cho thy v toan do teo d dy trc hoc phi hp vi
ung th.
4.3. Ni soi v sinh thit: L mt tin b trong chn an ung th b mt, cho xc
nh v tr, tnh trng lan rng ca u, tnh trng chy mu.
4.4. Xt nghim t bo hc: bng chi t bo.
4.5. Siu m bng, siu m ni soi, Scanner bng: nh gi rng, su v pht
hin di cn ca ung th.
4.6. Xt nghim ty, chc d no ty, scanner s, sinh thit da: khi c gi di cn.
4.7. X quang: Vi k thut chp nhum Baryte thng thng cho ta hnh nh:
- Hnh nh khuyt vi gc nhn cm vo thnh d dy trong ung th si hoc lot
si
- Co rt v cng trong ung th tm nhun lan rng.
- Let hnh nm (hnh nh tam ti hay hnh li to) trong ung th th lot si.
- K thut i quang kp gip chn an tt cc thng tn nh nm st b, tng
ng vi 3 type ca gii phu bnh. (type 1: polypoide, type 2: lot nng, type 3: let
o hang).
5. Chn on
- Chn an cng sm th c may iu tr khi (giai on Tis), v thi gian sng
cng di. Pht hin da vo X quang v ni soi sinh thit hng lat. Nht, hin
nay pht hin sm ung th d dy n 90% trng hp so vi Hoa K l 40%. y
l giai on T1, T2 v thng t triu chng.
- Vo giai an mun, triu chng cng r v nng, c th di cn xa, iu tr rt hn
ch.
163
- Khi ni soi, cn phi sinh thit t nht 10 mnh. Trong th t, cn phi sinh thit
su. Trong thi k lm so khi iu tr, cn phi sinh thit 2 t.
6. Tin lng
- Ty thuc th m hc ca ung th, v tr ca u, s xm ln ti ch v di cn.
- Tin lng tt: Ung th d dy giai on sm (tn thng nim mc, di nim
mc)
- Ung th lai rut non c gii hn r hn nn tin lng tt hn lai ung th lan
ta, ung th vng tm v v phnh v ln do chn an chm nn tin lng xu hn
ung th phn thp ca d dy, di cn phc mc tin lng xu hn.
- Phn loi theo TNM cho php nh gi v tin lng sng, nhng cn da vo
ln ca u (T), tn thng hch (N) v s xut hin ca di cn (M).
T1: U cha vt qu nim mc, tng ng vi ung th b mt.
T2: U n lp c.
T3: U n thanh mc.
T4: U dnh vo c quan ln cn.
N0: Khng c hch.
N1: ch c hch gn d dy, phm vi quanh 3 cm.
N2: Hach vng b xm nhp nhng c th ct b c.
N3: di cn hch lan rng: Khng th ct b c.
M0: Cha c di cn tng
M1: c di cn
Bng 1: Bng tin lng theo hip hi nghin cu ung th d dayd Nht Bn
G/ TNM Sng n 5 nm (%)
0 Tis N0M0(g/h lp mng nhy nim mc) 100
IA T1N0M0 (xm nhp n/m, h n/m) 95
IB T2N0M0 (xm nhp n lp c) 82
II -T1N2M0 (xm nhp n/m, cn trong vch)
-T2N1M0(xm nhp n/m, cn trong vch 55
-T3N0M0 (lan khi vch)
IIIA -T2N2M0 (xm nhp n c hoc lan vch)
-T3, N1-N2, M0 xm nhp n c hoc lan vch 30
IIIB T4, N0-N1, M0(dnh chung quanh) 15
IV -T4N2M0 (dnh chung quanh hoc) 2
-T1-T4, N0-N2, M1 di cn xa
TIN LNG CC GIAI ON LYMPHOMA D DY THEO ANN ARBOR.
-G/1:Ch d dy:T l tng i gp 26-28%
-G/2:C hch bng: 43-49%.
164
- Chc ht m
- Chp nhp nhy gan vi technitium 99
- Xt nghim amibe trc tip
V.CHN ON
Da vo tin s v bnh s l amibe. Chn on gi khi c tam chng Fontan:
St, gan ln v au.
Chn on t ra khi trn siu m hoc CT cho hnh nh Abcs.
Da vo ch im amibe bng huyt thanh hc:
VI.CHN ON PHN BIT
1.Phn bit abcs gan amibe v abcs mt qun
2.Ung th gan
3.Vim ti mt cp
VII. IU TR
iu tr abces gan amip l mt iu tr ni ngoi khoa hoc kt hp vi th thut
thut chc ht c hng dn siu m hoc CT scanner. Kt qu iu tr ph thuc
vo nhiu yu t nh: tnh trng chung ca bnh nhn, giai on pht trin v chn
on bnh, tnh trng tn thng gan giai on vim, abces giai on sm, kch
thc cn nh (<6 cm), cha ha m ht, s lng, kch thc v v tr ca cc
abces.
1. iu tr ni khoa
1.1 Bin php chung: ngh ngi, n ung cung cp nng lng v cht dinh
dng, gim au v h st nu cn. nh paracetamol 500mg x 3 vin/ngy hoc
Efferalgan (paracetamol+codein) 530mg x 3vin/ngy, Diantalvic (paracetamol+
dextroprofan 530mg x 3 vin/ngy.
1.2 Thuc
+ mtin: l thuc dit amip t chc (amip hot ng) c s dng rt lu c
c tnh khuych tn m rt tt, chit xut t cy Ipca. Thuc c c tnh tp trung
cao gan, phi, lch, thn, thi tr chm qua thn vn cn trong nc tiu 1-2
thng sau iu tr. C ch tc dng l chn s tng hp protein mt cch khng hi
phc do s c ch di chuyn ca Ribosome trn ARN thng tin.
Tc dng ph: bun nn, i chy, au c nhng tc dng ph quan trng nht l tim
mch gy vim c tim nhim c do gy ph v hoi t si c tim, gy suy tim, lon
nhp tim nguy him. Cc triu chng nhim c trn tim l nhp tim nhamh, lon nhp,
au vng trc tim, v suy tim cp; do trnh dng cho bnh nhn c bnh tim
mch, cn kim tra in tim trc, trong v sau khi iu tr. Bt thng in tim trong
trng c emetin l: nhp tim nhanh, P-R ko di, QT di, QRS dn rng, T o
ngc. C hai loi:
- metin Chlohyarate: ng 30, 60, 40 mg. Liu 1 mg/kg dng 7- 10 ngy. Liu trnh
th hai phi sau phi cch liu trnh u 4 tun. p ng tt gim st sau 2- 3 ngy
- Dhydrometine l loi tng hp c c tnh thp hn mtine. Liu 1, 5 mg/kg
dng 10- 15 ngy. Liu trnh th hai phi sau liu trnh u 3 tun.
170
+ Nhm Nitro- imidazole thng: l Mtronidazole (Flagyl, Klion) cng dit amip m,
cn dit amip lng rut, c ch tc dng l do kh ferrodoxin, cht kh ny phn
ng vi cc phn t ln ca vi khun dit chng. Thuc hp thu qua rut nhanh
80% sau 1 gi, thi gian bn hy sau 8 gi. Nng cao trong mu sau 5-7 gi.
Tc dng phu: l nhc u, nn ma, chn n kh ming, c v kim kh, mt, chng
mt. cc sc vt th nghim c th gy d bin gen nn khng dng cho ph n
mang thai. Liu 25 -30 mg/kg trong 10 - 15 ngy. Thuc c trnh by di dng
vin 0, 25mg x 4-6v/ngy hoc l 0, 5g trong 100ml, liu 1g/ ngy; chuyn tnh mch
chia 2 ln trong vng 1 gi.
+ Cc imidazole khc: Tinidazole, Nimorazole, Secnidazole (Flagentyl) v
Ornidazole. Cc thuc ny c thi gian bn hy ko di nn ch cn dng ngy 2 ln,
5-7 ngy. Trong cc loi ny, ch c Tinidazloe (Fasigyne) dit amip tt, cn cc loi
khc km hn mtronidazole trong iu tr amip. Vin 0, 5 g liu 3 vin/ngy, ung
trong 5 ngy.
- Chloroquin c nng cao trong phi gp 200 ln/huyt thanh v trong gan 400
ln/huyt thanh. c ch tng hp DNA v ARN, lm chm s nhn i v sao chp
ca ARN. C th dng ngn nga abces gan amip khi amip rut hot ng, hoc
phi hp vi metine v Mtronidazole trong iu tr abces v c th dng lu di.
Liu lng dng l 1 g trong 2 ngy u v 0, 5 g trong 3- 4 tun.
- Cc khng sinh:
+ Paromomycine (Humatin) thuc nhm Amino glycoside. Liu 25-30 mg/kg trng
lng, dng 5-10 ngy.
+ Nhm Cyclines: Tetracycline vin 0, 25g x 4-6 vin/ngy ; Doxycyclines, vin
100mg x 2in/ngy x 2 tun.
+ Erythromycine, vin 0, 25g hoc 0, 5g ; liu dng 1, 5g/ngy x 2 tun.
Cc khng sinh ny tc dng yu trn amip nn ch dng phi hp.
- Cc thuc dit amip lng rut:
Diloxanide furoat l dn xut ca dichloroacetanide, c ch tc dng cha c bit
r rng. Liu 500 mg x 2 ln/ngy x 10 ngy.
Lodoquinol (Direxiode, Enterovioform). Liu 650 mg x 2 ln/ngy x 3 tun.
2. Th thut: Chc m di s hng dn ca siu m, nh siu m v CT scanner
c th pht hin cc abces cn nh hoc sau khi iu tr bng thuc abces lng
ha hon tan v khng dn sch. Xc nh v tr abces sau chc ht di s
hng dn ca siu m hoc CT scanner, ra sch m sau c th bm trc tip
thuc dit amip vo abces nh dhydroemetin, Flagentyl. V ht lp li nu kim
tra cn m, kt qa rt tt gim au v st rt nhanh rt ngn thi gian iu tr.
3. Phu thut: nay gim dn ch c p dng cho nhng abces qu ln, p xe st
bao gan do v, p xe gan v hoc nm v tr khng chc ht c.
1.Ni khoa
Nhim trng huyt v chong nhim trng Gram m.
Hi chng gan thn.
Trn dch mng phi v mng tim.
Vim ty cp, c th l mt bnh cnh i km.
X gan mt.
2.Ngoi khoa
abcs v vo bng gy vim phc mc.
Thm mt vo mng bng gy vim phc mc mt.
Chy mu ng mt
VII. IU TR
y l bnh cnh nng ngoi nhim trng cn km nhim c v bin chng ngoi
khoa, do cn t trong bi cnh iu tr ni ngoi khoa v hi sc cp cu.
1. iu tr ni khoa
- Bin php chung: cung cp y dinh dng, nng lng v cn bng
nc in gii.
- Khng sinh: cn hng n cc vi trng Gr (-) ng rut k kh, v y l
bnh cnh abces thng km theo tc nghn ng mt nn dng khng sinh ph
rng nng cao trong ng mt, thng dng bng ng tim v di ngy
thng >2 tun l. Tt nht l da vo vi trng, khng sinh v kt hp khng
sinh. Cc khng sinh thng dng l:
- Pnicilline 4 - 6 triu n v/ngy
- Ampiciline 2 - 3 g/ngy
- Cc Cephalosporin th h III: Cfotaxime (Claforan) 3 g/ngy, Ceftriaxone
(Rocphin) 2 g/ng.
- Cc dn cht: Carbenicilline thng nhy cm vi trc khun m xanh v
protus (liu 200 mg/kg/ng), Ureidopenicilline nh: Azlocilline, Piperacilline liu
3g/ng. Tc dng tt vi trc khun m xanh, Proteus hemophilus, Enterocoque.
- Cc Moxalactam, Carbapenem, Monobactam.
- Nhm Aminoglycoside: thng dng Gentamycine liu 3-5 mg/kg trng
lng/ngy, hoc cc khng sinh khc: Amikacin liu 15 mg/kg/ngy; Netilmicine liu
5-7 mg/kg/ngy.
Ch : nhm Aminoglycosides c th gy c tai trong v thn.
- Nhm Quinolone: Ofloxacine (Oflocet) liu 400 mg/ngy; Ciprofloxacine liu
15 - 20 mg/kg/ngy.
- Nhm Mtronidazole: nht l ng tim truyn, thng dng trong trng
hp nhim trng k kh Bacteroide liu 1, 5 g/ngy.
- Gim au v chng co tht ng mt dc dng trong trng hp c si
co tht ng mt vi Spasmaverine 40 mg x 3 vin/ngy. Buscopan ng 10 mg x 2-
174
VIM TY CP
Mc tiu
1. Nm c cc triu chng lm sng v cn lm sng ca Vim ty cp
2. Chn on c cc th v bin chng vim ty cp
3. Trnh by c cc phc iu tr vim tu cp theo th bnh v nguyn nhn.
Ni dung
I. M U
Vim ty cp (VTC) l mt bnh l cp tnh ca tuyn ty, c th thay i t
vim ty ph n cho n hoi t ty trong mc hoi t lin quan n trm
trng ca bnh. Thut ng VTC xut huyt t c ngha trn lm sng bi v mt
lng xut huyt k t nhiu c th thy trong VTC cng nh trong cc ri lon khc
nh chn thng ty hay u ty v cng nh trong suy tim sung huyt nng.
II. BNH NGUYN
- Si
- Do ru gy VTC v vim ty mn
- Sau phu thut bng sau ni soi v chp ng mt ty ngc dng.
- Chn thng vng bng.
- Bin dng
- Nhim trng: quai b, vim gan siu vi, giun a
- Do thuc
- lot d dy t trng thng dnh vo ty
- Ti tha t trng
- ng ty chia i
III. C CH BNH SINH
1 Thuyt tc nghn v tro ngc
Do si giun u lm khi pht VTC. S tc nghn ny thng km theo s tro
ngc dch ty c hot ha c th km theo dch mt l nhng yu t gy hot
ha men ty.
2 Thay i tnh thm ca ng ty
Bnh thng nim mc ng ty khng thm qua cc phn t > 3000Da s gia tng
tnh thm xy ra khi c acide acetyl salicilic, histamin, Calcium v Prostaglandin E2.
Khi hng ro biu m c th thm qua cc phn t t 20.000 - 25.000 Da. iu
ny cho php thot cc phospholipase A, Trypsin v elastase vo m k ty gy
ra VTC.
3 Thuyt t tiu
Thuyt ny cho rng cc men nh trypsinogen, Chymotrypsinogen, prolastase v
phospholipase A2 c hot ha ngay trong ty gy ra VTC.
4 Thuyt oxy ha qu mc
176
Tng trong VTC hoi t khi LDH >350Ul/l th c nghi l tin lng nng.
7. PO2
Thng 60mmHg xy ra 25% trng hp vim ty hoi t nht l trong trng hp
c hi chng suy sp h hp ngi ln.
8. Cng thc mu
Bch cu trung tnh cao, nht l VTC do giun v si, khi bch cu >16000/mm3 l
yu t nng.
9 Siu m ty
Ty ln cu trc ngho hn bnh thng siu m cn gip pht hin dch trong
bng, giun si hay cc bin chng ca n nh p-xe v nang gi ty.
10 Chp ct lp t trng (CT Scanner): c 5 giai on A, B, C, D, E. C ngha tin
lng.
11 X quang
Thng t gi tr trong chn on VTC trong trng hp lit rut nhiu c th c
hnh nh quai rut gc.
VI.CHN ON
1 Chn on xc nh
Cn ngh n vim ty khi bnh nhn c cn au bng cp vng thng v v h
sn tri km nn ma nhiu ton thn c hi chng nhim trng, bng chng
nhiu khm cc im au ty r phi hp vi amylase mu hay niu > 3ln bnh
thng hay h s thanh lc >5. Siu m hay chp ct lp t trng c hnh nh VTC.
2 Chn on gin bit
2.1 Thng tng rng
c bit l thng lot d dy t trng cn da vo tin s lot vi cn au kiu
dao m khm c du bng ngoi khoa v mt vng c trc gan, chp phim bng
khng chun b c lim hi di c honh. y amylase mu khng cao ch tng
2-3 ln bnh thng.
2.2 Vim ng mt ti mt cp
Cn da vo tin s si ng mt, cn au qun gan khm thy cc triu chng
v gan mt vi gan ln, ti mt ln v au vng da vng mt siu m gip pht hin
ti mt ln thnh dy.
2.3 Tc rut, lng rut cp.
2.4 Nhi mu c tim
Thng gp ngi gi c tin s cn au tht ngc khm cc im ty khng au.
Gin bit da vo amylase mu v in tm v cc men CPK, CPK-MB v
Troponin mu gia tng.
VII.BIN CHNG
1.Ti ch
-p xe ty: nhim trng nng, st cao 39-40 0 C ko di trn 1 tun vng ty rt au
khm c mng g ln rt au xc nh bng siu m hay chp ct lp t trng.
178
-Nang gi ty: vo tun th 2-3, khm vng ty c khi n cng v tc, amylase cn
cao 2-3 ln siu n c khi echo trng, chp ct lp t trng c du hiu tng t.
-Bng do thng hay v ng ty hay nang gi ty vo bng trong trng hp VTC
xut huyt do hoi t mch mu lm xut huyt trong bng.
2 Ton thn
-Phi: c trn dch nht l y phi tri, xp phi hay vim y phi tri bin chng
nng n nht l hi chng suy h hp ngi ln.
-Tim mch: gim HA hay sc m nguyn nhn do phi hp nhiu yu t nhim trng
nhim c, xut huyt v thot dch.
-Mu: c th gy ra hi chng ng mu ni mach (CIVD) nh trong trng hp
vim rut xut huyt hoi t.
-Tiu ha: vim lot d dy t trng cp, nh l mt bin chng Stress do au hay
nhim trng, nhim c v thng biu hin di dng xut huyt. Thuyn tc tnh
mch ca.
-Thn: thiu hay v niu do suy thn chc nng do gim th tch tun hon, hoi t
thn v thng thn v mt bin chng t gp, do vim lan t ty. Vim tt tnh mch
v ng mch thn l bin chng nm trong bnh cnh chung ca vim tt mch.
-Bin chng chuyn ha: tng ng mu hay h calci mu
VIII. IU TR
iu tr vim tu cp mang tnh cht ca mt iu tr cp cu ni ngoi khoa kt hp
vi hi sc cp cu; ngoi bin php iu tr chung trong vim ty cp cn ch n
iu tr theo nguyn nhn v iu tr bin chng nh trong vim tu cp do giun cn
x dng ngay thuc lit giun v khng sinh, trong vim tu cp do si cn kt hp
iu tr loi tr si.
1. iu tr vim tu cp th thng
1.1. Nguyn tc iu tr: phn ln vim ty cp l th ph (85-90%) iu tr ch yu
bng phng php ni khoa v bnh s thoi trin sau 5-7 ngy. Cc bin php
thng thng l:
- Gip ty ngh ngi lm gim au v gim tit bng nhn, ht dch v.
- B nc v in gii: trong vim ty cp do bnh nhn khng n ung c, st,
nn ma, v hin tng thot dch, nn bnh nhn thng thiu nc.Trong trng
hp nng do hin tng tit dch vim v tng tnh thm thnh mch nn cn chuyn
dch keo hoc c trng lng phn t cao.
- Nui dng bng ng ngoi ming cho n khi cc triu chng au gim nhiu
mi bt u cho n dn, bt u l nc ng, ri h ng ri cho gim s
tit dch ty.
- Cc thuc c ch choline t hiu qu trong vic c ch tit dch ty m cn gy
chng bng v che lp du bng ngoi khoa.
- Cc thuc gim au tht s ch dng khi bin php nhn v ht dch khng lm
gim au, nhng khng dng morphin v c nguy c lm co tht c oddi, c th dng
dolargan hoc Viscralgin.
179
3. iu tr vim tu cp nng
Vim tu cp nng l thut ng m t th vim ty cp xut huyt hoi t. Tuy
nhin ngoi yu t xut huyt hoi t, cn c vn xut tit qu nhiu dch trong
bng qua c ch dng dch vim hin nay (coule inflamatoire), cng nh hin
tng nhim trng nhim c gy p x ha ty cng l yu t gy vim ty cp
nng. y l mt bnh cnh cp cu ni ngoi khoa rt nng, t l t vong c th
n 80%.
3.1. iu tri ni khoa
Trc tin l phi t bnh nhn trong 1 n v hi sc cp cu ni-ngoi khoa. t
1 cathter Swan ganz ln c th gip tip dch sau ny.
* Nui dng bnh nhn: iu quan trng l phi cung cp y cht dinh dng
v giu nng lng. Bt lun din tin ca vim ty cp nng nh th no cng cn
cung cp nng lng ti u vi 60 calo/Kg trng lng, trung bnh 3.000- 3.500
calo/ng ch yu l glucide v lipide. Ban u l cho n bng ng t catther di
n. Ngay khi gim au nhiu v Khng c triu chng tt rut th chuyn qua n
bng ng tiu ha bng cch t sonde d dy mi c 2 nng: nng ngn t
trc mn v, nng di t 30 - 40 cm trong on u ca hng trng.
* iu chnh nc in gii v thng bng Kim toan: bng cch chuyn cc dung
dch ng, mui (in gii) v albumin. iu quan trng l phi duy tr huyt ng
mc bnh thng, ha long ca mu thch hp gip trao i qua mao mch
d dng trnh tt mch do nhn mu tng.
Lng dch chuyn cn da vo mch huyt p, Hct, in gii v nht l p lc
tnh mch trung tm. Thng thng l 3 - 4 lt/ng, trong mt s trng hp nng c
th chuyn n 10 L trong 48 gi u.
Tt nht l chuyn Ringer lactate. Nu Khng c th chuyn 1/2 ng v 1/2 mui
ng trng. C 1 lt dch cho 1 n v albumin huyt thanh ngi (12, 5 g).
Nu hng cu gim >1 triu hoc Hct gim >10% cn chuyn mu ti hoc hng
cu Khi.
* iu tr suy thn: trong giai on u thng l suy thn chc nng, v sau l thc
th do tn thng ng thn. Ngn nga ngay t u bng cch iu chnh tt huyt
ng. Trong trng hp suy thn cp cn s dng Manitol 20% chuyn nhanh hoc
lasix lm test bi niu, c lc cn dng Lasix liu cao 0, 5 - 1g/ 24 gi. Nu tht
bi cn chy thn nhn to, nhng trong nhng trng hp ny tin lng thng
rt nng.
* Ht d dy lin tc: y l mt bin php rt hu hiu gp gim tit dch v, dch
ty, gim chng hi d dy; gip ty c ngh ngi cho nn c tc dng lm gim
au rt tt. y cng l mt phng tin gip theo di chy mu d dy.
* iu tr trn dch mng phi v suy h hp cp: Nu trn dch mng phi nhiu cn
choc dn lu. Suy h hp cp cn h tr bng th my, iu chnh di s theo di
kh mu.
* Chng chong: nu cc bin php tch cc trn thc hin y nhng tnh
trng chong vn xy ra th cn s dng n cc thuc vn mch v nng huyt p
nh: Dopamin ng 200mg c th cho liu trung bnh 10g/Kg/ ph. Dobutamin c
nhiu u im hn dopamin liu 5g/kg/ph. Adrnalin v thm ch c Noradrnalin.
181
- Ung th th thm nhim: Nhim cng v dy vch i trng m khng c lot trn
nim mc. Loi ny t gp hn nhng tin lng xu.
2. Vi th
Phn ln ung th i trng thuc loi biu m tuyn, kh nng bit ha cao, trung
bnh hay thp. C khong 20% thuc loi biu m ch tit nhiu cht nhy, c th
gp loi biu m dng biu b vi t bo lt tng(loi ny him gp).
Tin lng ph thuc bit ha v s lan rng hay di cn xa.
V. TRIU CHNG
1. Lm sng
Ung th i trc trng thng c biu hin m thm vi din tin qua nhiu nm
khng c triu chng hay ch c thay i nh v thi quen i cu. Triu chng
thng c khc nhau ty thuc v tr ca khi u.
- V phn tng i lng khi i qua van hi manh trng i vo i trng phi, cho
nn vi ung th i trng ln, t khi c triu chng nghn rut hoc thay i thi
quen i cu. Tn thng i trng phi thng c dng lot lm mt mu m
mn tnh m khng c thay i phn r rng. Bnh nhn thng c triu chng mt
mi, hi hp biu hin ca thiu mu mn, nhc sc do thiu st, c th s c
khi u vng h chu phi hay di h sn phi. V ung th chy mu tng t
nn xt nghim mu n trong phn c khi m tnh.
- Ung th i trng ngang v i trng xung: Phn c hn, khi ung th pht
trin n ln, n gy hp lng i trng tng i hay hp hon ton, i khi gy
thng. Lm sng biu hin au bng tng cn kiu bn tc v tc rut.
- Ung th i trng sigma v trc trng: Thng c biu hin ca hi chng l vi i
cu phn mu, mt rn, phn b dt km biu hin thiu mu m i khi nhm vi tr
c chy mu. Khm trc trng pht hin c khi u cng, si au v d chy mu
khi ng vo.
V bnh thng din tin m thm nn c khi ch pht hin bnh khi c bin
chng tc rut hay pht hin v tr di cn ca ung th m gan l v tr di cn trc
tin.
2. Cn lm sng
2.1. Soi i trng sigma
y l th thut n gin, nhanh chng gip pht hin 2/3 n 3/4 cc trng hp
ung th trc trng v sigma khi c biu hin hi chng l. N cn gip sinh thit
hoc ct b u khi c th hoc iu tr cm mu ti ch.
2.2. Soi i trng ton b
L phng tin chn on rt tt gip pht hin v tr tn thng cng nh sinh thit
chn on m hc.
2.3. Siu m ni soi, CT scanner
L phng tin chn on tt cc tn thng khu tr di nim mc cng nh
pht hin di cn vo cc c quan k cn, gip chn on giai on TNM.
2.4. Chp phim nhum i trng c baryte
187
Pht hin cc khi u c ng knh > 2 cm, vi hnh nh lot si, hnh nh hp lng
i trng khng u nh hnh li to. Trng hp khi u nh < 1cm th cn dng k
thut chp i quang kp.
2.5. Cng thc mu
Hng cu, Hb gim khi c thiu mu.
2.6. St huyt thanh
Gim khi thiu mu do thiu st.
VI. BIN CHNG
1.Tc rut
L du chng cng nh bin chng thng gp ca ung th i trc trng, c th
tc mt phn hay hon ton. Tc do khi u gy nn hay do chn p ca hch.
2. Thng
Thng c th xy ra ngay ti khi u hoc trn khi u c bit manh trng.
3. Chn p cc c quan ln cn
U v cc hch di cn c th gy chn p vo d dy, chn p bng quang, chn p
h thng tnh mch tng gy c trng, chn p thn kinh chi di gy au.
VII. CHN ON: Da vo
- C hi chng l, thay i hnh dng phn, hay ch c ri lon thi quen bi phn.
- C thiu mu nhc sc.
- au bng, st, st cn.
- Khm trc trng c mu dnh gng, c u.
- Soi trc trng- sigma khi c biu hin hi chng l.
- Soi ton b i trng, sinh thit xt nghim m hc, chp nhum i trng c
baryte.
Bng xp loi v tin lng ca Dukes.
Cc yu t tin lng v nh gi giai on ca ung th i trc trng ty thuc
vo su ca u, s xm ln vo vch rut, hin din ca hch vng cng nh s
di cn xa ca u (TNM). Theo phn loi ca Dukes, ung th i trng c 4 giai on:
- Giai on A (T1N0M0): Tn thng nng, khng xm ln vo lp c hoc hch
vng.
- Giai on B: Tn thng xm ln xung su hn nhng cha n hch vng.
B1: T2N0M0. Tn thng ch gii hn lp c.
B2: T3N0M0. Tn thng xm ln n thanh mc
- Giai on C: TxN1M0. C hch vng
- Giai on D: TxNxM1. C di cn gan, phi, xng.
Di cn ca ung th i trng thng theo ng tnh mch ca n gan l hay gp
nht v l ni di cn u tin, him khi thy di cn n phi no, hch thng n
m thiu di cn n gan. Ngoi l l khi ung th v tr xa trc trng, cc t bo ung
188
VIM RUT MN
Mc tiu
1. K c cc c im chung ca cc bnh l vim rut mn.
2. Trnh by c cc triu chng lm sng v cn lm sng ca bnh crohn v
vim lot i trng
3. K c cc bin chng ca 2 th bnh trn.
4. Bit cch iu tr bnh Crohn v vim lot i trng
Ni dung
I. I CNG
Cc bnh vim rut mn tnh thng gm hai bnh chnh:
Vim i trc trng chy mu (Recto-colite hmorragique) hoc vim lot i trng
(ulcerative colitis) theo cch gi ca cc tc gi Anh M.
Bnh Crohn hay vim rut tng vng.
C 2 u c cc c trng sau
- Mt tnh trng vim mn tnh rut.
- Thng gp thiu nin v ngi tr.
- Tin trin ko di, khi tng khi gim nhng khng bao gi lnh t pht.
- Bnh nguyn cha c bit r.
- Cha c phng php iu tr ni khoa tn gc.
- iu tr bng thuc khng vim, Corticoide, v c ch min dch c hiu qu khng
hng nh.
II. BNH CROHN
1. Bnh nguyn v c ch bnh sinh
Thng tn rut l hu qu ca mt s hot ha khng c kim sot ca
h thng min dch ca nim mc.
Cc yu t nhim khun v di truyn cng tham gia vo c ch bnh sinh.
2. Cc triu chng lm sng
2.1 Cc triu chng thng gp
au bng: thng gp, c v tr thay i, thng au qun dc khung i trng, c
khi c hi chng Koenig
i chy, c khi i chy ra m hoc mu, tn s thay i.
Trong cc t cp thng c suy nhc, chn n, st cn v st nh
C th phn lp mt s biu hin lm sng thng gp nht:
i chy ko di km st.
Hi chng gi rut tha (thng tn hi trng hoc hi trng-i trng phi): au h
chu phi khng r rng, mng gii hn khng r h chu phi.
Hi chng l
194
- Chp i trng cn quang: c ch trong trng hp ni soi khng hon ton hoc
c cc l d khng pht hin c bng ni soi. Cc du hiu X quang bao gm cc
thng tn lot, gi polyp to thnh hnh nh lt , l d, hnh nh hp cc quai
rut, trng hp in hnh c hp nhiu ch cch nhau bi nhng on rut lnh b
dn to.
- Chp ct lp vi tnh bng: trong trng hp c khi bng hoc nghi c nung
m.
5. iu tr bnh Crohn
5.1. Cc phng tin iu tr
5.1.1. Cc dn xut salicylic
- Sulfasalazine: thuc c in nht trong nhm ny, cu to bi sulfapyridine gn vi
acid 5 amino salicylic (5 ASA), t hp thu rut non, khi vo i trng s b cc vi
khun rut phn hy gii phng 5 ASA.
Sulfasalazine ch tc dng trong trng hp c thng tn i trng hoc hi - i
trng, c th dng trong cc t tin trin, khng hiu qu trong duy tr giai on lui
bnh.
- Mesalazine l dn xut Salicylic khng c cha Sulfapyridine v dung np tt hn.
- Cc thuc khc: Asacol, olsalazine, balsalazide.
- C ch tc dng: c ch s tng trng ca t bo T, s trnh din khng nguyn
ln cc t bo T v s sn xut khng th ca t bo B. ngoi ra tc dng khng
vim thng qua s c ch cyclo-oxygenase lm gim s sn xut prostaglandin.
5.1.2. Corticoid
L mt phng tin iu tr quan trng trong cc t cp:
+ Prednisolon liu 1 mg/kg/ng trong 3-7 tun, sau gim liu theo kiu bc thang
mi 10 mg cho n 1/2 liu, sau gim mi 5 mg mi tun ko di cho liu trnh
12 tun.
+Cc loi Corticoid mi: fluticasone propionate, tixocortol pivalate, beclomethasone
dipropionate, v budesonide, cc thuc ny c u im l c i lc ln cc th th
corticoid ln hn loi corticoid c in, ng thi tng s chuyn ha qua gan ln
u nn t tc dng ph ton thn hn.
Trong , Budesonide thng c s dng nhiu trong bnh crohn, thuc gi
phng hi trng v tc dng chnh ln on cui hi trng v i trng phi, vi
liu dng t 6-9mg/ng.
5.1.3. Cc thuc c ch min dch
+ Azathioprine: c hiu qu r nht, c bit cc bnh nhn ph thuc Corticoid
hoc duy tr t lui bnh, cng hiu qu trong iu tr cc l d rut - da hoc d
hu mn- tng sinh mn.
Tc dng chm, triu chng bt u ci thin sau 3 thng
Tc dng ph:c ch ty, vim ty cp, vim gan cp, khng dung np tiu ha v
phn ng d ng.
+ Methotrexate cng hiu qu trong cc th l thuc Corticoid hoc khng p ng
iu tr Azathioprine, tc dng xut hin sm t thng u tin.
196
HI CHNG KM HP THU
Mc tiu
1. Trnh by c cc triu chng lm sng v cn lm sng ca hi chng km
hp thu
2. K c mt s nguyn nhn thng gp ca hi chng km hp thu
Ni dung
I. I CNG
Hi chng km hp thu biu hin tnh trng suy gim mt phn hoc hon
ton chc nng hp thu ca ng tiu ha. Chn on hi chng km hp thu thng
khng kh khn nhng vic chn on nguyn nhn thng phc tp.
II. TRIU CHNG LM SNG
- Gy st mc d vn cn cm gic ngon ming
- i chy
- Chng bng
- Huyt p thp: do thiu nc v suy dng.
- Cc triu chng lm sng v sinh hc ca thiu vitamin: do hu qu ca km hp
thu ko di
- Thiu mu: do km hp thu st, B 12 v acide folic.
- Chy mu
- Cn tetanie: do thiu calci
- Yu c: do suy dng, h Kali mu.
- Qung g: do thiu vitamine A
- Vim a dy thn kinh ngoi bin: do thiu vitamine B12 v B1.
III. XT NGHIM
Cc du hiu sinh hc gin tip
- Thiu mu, Fe huyt thanh gim, folate v vitamin B12 gim.
- Calci mu gim
- T prothrombin gim
- Albumin mu gim
- Cholesterol mu gim
Cc thm d chc nng hp thu
- nh lng m trong phn: > 6 g/24 gi.
- Trc nghim D-Xylose: < 250 mg/l vo lc 2gi.
- Trc nghim Schilling km yu t ni < 10%.
200
CHNG 3
H HP
2.2. m bo thng kh
Nu c suy h hp th dng xy qua sonde mi 5-10 lit/pht ty mc (lu nu
c suy h hp mn th gim liu cn 1-2 lt /pht v ngt qung).
2.3. Cc thuc gin ph qun
Nu c du co tht ph qun c th cho thm Theophylline 100-200 mg x 3
ln/ngy.
2.4. Cc loi thuc ho v long m
- Nu ho nhiu c th dng Codein (Acodin, Neocodeon...) 100 mg x 3 ln/ngy.
- Nu m c v kh khc c th dng cc loi nh Terpin, Benzoat Natri,
Eucaylyptin... hoc Acemuc, Exocemuc, Mucosolvon, Rhinathiol... 2-3 gi/ngy.
Hoc 3-4 vin/ngy.
3. iu tr nguyn nhn
y l iu tr chnh gii quyt nguyn nhn gy bnh. C th l khng sinh,
thuc phi dng sm, ng loi, liu, da vo khng sinh , khi cha c khng
sinh th da vo yu t dch t, din tin lm sng ca bnh,kinh nghim ca thy
thuc, th trng bnh nhn v phi theo di p ng iu tr c hng x tr kp
thi.
3.1. Do ph cu, lin cu
Khng sinh chnh hin nay vn l: Penicilline G. 500.000-1000.000 v x 4 ln/ngy
TB. Nu nng c th tng liu v chuyn tnh mch. C th dng Cefapirine
(Cefaloject) 0,5g-1g mi 8-12 gi.
Nu b d ng vi Penicilline th dng loi Macrolide nh Erythromycine tim hay
ung 2g/ngy chia 4 ln hay Roxythromycine 150mg x 2 ln/ngy.
3.2. Do t cu vng
* T cu vng nhy cm vi Methicilline, c th dng Cefapirine hay nhm
Aminoside nh Amikacine 15mg/kg/ngy tim bp hoc nhm Fluoroquinolone nh
ofloxacine chuyn tnh mch hay ung 400mg/ngy chia 2 ln.
* T cu vng khng Methicilline
C th dng Cefalosporine th h III: nh Cefotaxime (Claforan, Cefomic) 3g/ngy
chia 3 ln hay Vancomycin 30-50 mg/kg/ngy tim tnh mch chia 3 ln.
Nu nng c th phi hp vi Amikacine.
3.3. Do Hemophillus Influenza
C th dng:
- Ampicillne 2-3g/ngy ung chia 3 ln hay TB.hoc Ofloxacine hoc Cefapirine
- Gentamycin 3-4 mg/kg/ngy TB chia 2-3 ln
3.4. Do Mycoplasma, Legionella
C th dng nh iu tr Hemophilus influenzae.
3.5. Do Klebsiella pneumoniae
Thng iu tri phi hp Cefalosporine th h III vi Amikacine.
201
3.6. Do vi khun k kh
- Penicilin G hay Metronidazol 1-2 g/24 gi. Hoc Cefalosporine II, III
3.7. Do ha cht
Khng sinh thng dng l
- Pnicilin G phi hp vi Prednisone 5 mg x 6 - 8v/ngy.
Cc trng hp vim phi c bin chng phi iu tr ko di cho n khi triu
chng lm sng v cn lm sng tr v bnh thng (xt nghim nhiu ln) trnh
bin chng v ti pht.
XI. PHNG BNH
Vim phi l mt trong nhng bnh nhim trng ng h hp di ph bin
nht, ngy nay nh vo nhiu loi khng sinh mi, mnh nn t l bin chng v t
vong gim nhiu. Tuy nhin vn c trng hp xy ra thnh nhng v dch nht l
do virus. phng bnh, gim bin chng phi nng cao th trng, gi m trong
ma lnh, loi b nhng yu lm d nh mi trng khng trong sch, khng ht
thuc l, phng nga v iu tr sm, tn gc cc nhim trng ng h hp trn,
cc t cp ca bnh phi mn tnh, iu tr sm v theo di st giai on sm ca
nhim trng ng h hp, trnh ly lan.
Ngy nay c mt s vaccin ca nhiu loi virus c x dng v c mt s
thuc chng virus.
202
HEN PH QUN
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, c ch sinh bnh v bnh
nguyn hen ph qun.
2. Nu c triu chng lm sng v cn lm sng cn hen ph qun in hnh.
3. Pht hin sm bin chng cn hen ph qun cp nng
4. Nu c cc phc iu tr hen ph qun theo bc v bin php phng nga.
5.Trnh by c phc iu tr cn hen ph qun cp nng
Ni dung
I. NH NGHA
Theo GINA 2002 (Global Initiative for Asthma) th hen ph qun l mt bnh l vim
mn tnh ca ph qun trong c s tham gia ca nhiu t bo v nhiu thnh
phn t bo; vim mn tnh gy nn mt s gia tng phi hp s tng p ng ph
qun dn n nhng t ti din ca ran rt, kh th, b st lng ngc v ho c bit
xy ra ban m hay vo sng sm; nhng t ny thng phi hp vi s tc
nghn ph qun lan rng nhng thay i, s tc nghn ny thng c tnh cch hi
phc t nhin hay do iu tr. Nhng quan im c bn trn y gp phn tch cc
vo vic nng cao cht lng chn on v iu tr hen ph qun.
II. DCH T HC
Hen ph qun l mt bnh thng gp, xut hin mi la tui, tr em chim a s
so vi ngi ln, t l 2/1. Nhng nghin cu dch t hc trong nhng nm gn y
cho thy tn sut trung bnh khong 5 %, tr em di 5 tui 10 %. Rt nhiu nghin
cu gn y cho thy tn sut ny gia tng gp 3 - 4 ln trong nhng thp nin qua.
lu hnh hen ph qun ti Php trong la tui 18 - 65 tui l 3,9 % (Charpin v
c.s 1987, Maladies respiratoires 1993, tr 335), ti trong la tui 5 - 64 tui l 5 %
(Paolette v c.s 1989, Maladies respiratoires 1993, tr 335). Ti Vit Nam, H Ni,
trong nm 1991 l 3,3 %, nm 1995 tng ln 4,3 % (Vng Th Tm v c.s trong bo
co ca hi ngh tng kt 5 nm 1991 - 1995 ca Vin chng lao v bnh phi);
thnh ph H Ch Minh, lu hnh hen ph qun l 3,2 (1,39 % (Phm Duy Linh
v c.s bo co trong Hi tho Y dc hc ln th 5 ti thnh ph H Ch Minh t
ngy 25 - 27/11/1996), thnh ph Hu, lu hnh hen ph qun nm 2000 l
4,58 (1,12% (L Vn Bng).
III. BNH NGUYN
1.Hen ph qun d ng
1.1 Hen ph qun d ng khng nhim khun
- D ng nguyn h hp: thng l bi nh, cc loi b nh nh
Dermatophagoides ptronyssimus, bi chn m, cc lng mng cc loi gia sc
nh ch, mo, chut, th v.v...; phn hoa, cy c, hay ngh nghip trong cc xng
dt.
- D ng nguyn thc phm: thng gp l tm, cua, s, hn, c chua,
trng...
203
8. PHN LOI TRM TRNG HEN PH QUN QUA TRIU CHNG LM SNG
TRC IU TR
BC 1 (TNG CN)
- Nhng triu chng xy ra < 1 ln / tun.
- Nhng t bc pht ngn.
- Nhng triu chng ban m < 2 ln / thng.
+ FEV1 hay PEF 80% so vi l thuyt
+ PEF hay FEV1 bin thin < 20%
BC 2 (DAI DNG NH)
- Nhng triu chng xy ra > 1 ln / tun nhng < 1 ln / ngy.
- Nhng t bc pht c th nh hng n hot ng v gic ng.
- Nhng triu chng ban m > 2 ln / thng.
+ FEV1 hay PEF 80% so vi l thuyt.
+ PEF hay FEV1 bin thin 20 30%.
BC 3 (DAI DNG VA)
- Nhng triu chng xy ra hng ngy.
- Nhng t bc pht nh hng n hot ng v gic ng.
- Nhng triu chng ban m > 1 ln / tun.
- Hng ngy phi s dng thuc kh dung ng vn (2 tc dng ngn
+ FEV1 hay PEF 60 - 80% so vi l thuyt
+ PEF hay FEV1 bin thin > 30%
BC 4 (DAI DNG NNG)
- Nhng triu chng xy ra hng ngy.
- Thng xuyn c nhng t bc pht.
- Nhng triu chng thng xy ra ban m.
- Gii hn nhng hot ng th lc.
+ FEV1 hay PEF 60% so vi l thuyt.
+ PEF hay FEV1 bin thin > 30%
9. Bin chng
9.1. Bin chng cp
9.1.1. Hen ph qun cp nng: c th xut pht t hi chng e da hen ph qun
cp nng, hi chng ny c th tng ng vi tnh trng cn hen cp khng p
ng vi iu tr thng thng v nng dn; hoc xy ra rt cp i khi trong vng vi
pht. l tnh trng nguy cp c tin lng sinh t trong thi gian ngn.
S chn on phi c thc hin sm v c tnh cp cu.
- Nhng du chng h hp
+ Tnh trng nguy cp h hp vi tm, v m hi, kh th nhanh nng, tn s
trn 30 ln/pht km du c ko cc c h hp.
207
10. iu tr
10.1. X tr hen ph qun theo cc bc
+.Bc 1 (Hen ph qun cch khong)
Trong hen ph qun cch khong, trm trng ca t bc pht cp thay i theo
tng bnh nhn v theo thi gian. Nhng t bc pht cp nng rt t gp.
Thuc s dng trong hu ht cc bnh nhn hen ph qun cch khong nh l
thuc ng vn 2 kh dung tc dng nhanh, ngoi ra c th s dng cromone hay
thuc khng leukotriene. Thuc khng cholinergic, ng vn 2 ung, hay
theophylline tc dng ngn c th dng xen k vi thuc ng vn 2 kh dung, mc
d nhng loi thuc ny c thi gian bt u tc dng chm v hay l c nguy c c
nhiu tc dng ph hn. Thng thng nhng t bc pht cp nng hn hay ko
di hn c th i hi s s dng mt t iu tr ngn bng glucocorticoide ung.
+ Bc 2 (Hen ph qun dai dng nh)
Nhng bnh nhn b hen ph qun dai dng nh cn phi c s dng thuc
hng ngy hon thnh v duy tr s kim sot hen ph qun. Tr liu u tin l
thuc khng vim dng hng ngy. iu tr chn la mt loi glucocorticoide kh
dung (200 - 500g Beclometasone dipropionate, hay Budenoside, 1000 - 250g
fluticasone chia 2 ln/ngy). Thuc dng xen k l theophylline thi chm, cromones,
v khng leukotriene, nhng nhng loi thuc ny km hiu qu hn glucocorticoide
kh dung hay ch c hiu qu mt s bnh nhn. iu tr lu di theophylline thi
chm cn phi theo di nng theophylline trong huyt thanh vi nng iu tr l
5 - 15g/ml.
Thm vo iu tr u n trn, bnh nhn hen ph qun bc 2 c th s dng mt
loi thuc ng vn 2 kh dung tc dng nhanh, nhng khng c qu 3 - 4
ln/ngy.
Nhng thuc gin ph qun khc c th c s dung nh thuc khng cholinergic,
ng vn 2 ung tc dng nhanh, hay theophylline tc dng ngn, mc d nhng
loi thuc ny c thi gian bt u tc dng chm v hay l c nguy c c nhiu tc
dng ph hn.
Nu tr liu lu di c bt u vi theophylline thi chm, cromone hay khng
leukotriene, m nhng triu chng tn ti sau 4 tun iu tr, th glucocorticoide kh
dung phi c s dng. Glucocorticoide kh dung c th c s dung ban u
thay v nhng loi thuc khc, hay s dng km vi nhau.
+ Bc 3 (Hen ph qun dai dng va)
Nhng bnh nhn b hen ph qun dai dng va cn phi dng thuc hng ngy
t c v duy tr s kim sot hen ph qun. iu tr chn la l phi hp mt
glucocorticoide kh dung (200 - 1000 g beclometasone dipropionate, 400 - 1000 g
budenoside, 250 - 500 g fluticasone chia 2 - 3 ln/ngy) vi mt ng vn 2 kh
dung tc dng di 2 ln/ngy.
Mt phi hp glucocorticoide kh dung vi mt ng vn 2 kh dung tc dng di l
mt phi hp tt v tin li.
Mc du phi hp glucocorticoide kh dung vi mt ng vn 2 kh dung tc dng
di l c hiu qu nht, nhng nhng bnh nhn hen ph qun dai dng va c th
209
tim t ng, liu lng ban u thng l 0,1 - 0,2 g/kg/pht, tng liu tng 1
mg/gi theo din tin lm sng.
+ Adrnaline: ch nh chi cc thuc kch thch bta 2 b tht bi; liu lng khi
u thng l 0,5 - 1 mg/gi tim tnh mch bng ng tim t ng.
+ Aminophylline: c th kt hp, dng bng ng chuyn tnh mch vi dung
dch Glucoza 5 % lin tc vi liu lng 0,5 - 0,6 mg/kg/gi.
10.3.3. Khng sinh: c s dng khi c nhim trng ph qun - phi km theo, c
th dng Cephalosporines, Macrolides hay Fluoroquinolones h hp.
10.3.4. Corticosteroide: Methylprednisolone (Solumedrol) 60 - 80mg mi 6 gi.
10.3.5. Th my: c ch nh trong th ngt cp hay trong th m iu tr bng
thuc b tht bi gy suy kit c h hp.
10.4. Theo di bnh nhn
Mc ch iu tr cn hen cp l lm th no cc triu chng gim nhanh v ci
thin chc nng h hp cng nhanh cng tt, ng thi gim thiu ti a tc dng
ph ca thuc.
Nu iu tr ban u khng c kt qu, nu PaCO2 cn thp, th c th tip tc iu
tr ti bnh phng; nhng nu PaCO2 tng v pH b toan ha th bnh nhn phi
c chuyn n phng hi sc thc hin thng kh h tr.
i vi hen ph qun cp nng l mt cp cu ni khoa, bt buc phi nhp vin
gp vo khoa hi sc h hp. Nu chn on l hi chng e da hen ph qun cp
nng hay hen ph qun cp nng hay hen ph qun cp nng nh th phi a
ngay bnh nhn n khoa hi sc bng xe cp cu c trang b.
10.5. Phng nga cn hen ph qun ti pht
Hin nay theo GINA ngi ta khuyn co nn dng Seretide trong iu tr duy tr
kim sot cn hen ph qun v ngi ta nhn thy nhng bnh nhn hen ph qun
c iu tr bng Seretide rt t b xy ra cn hen ph qun nng.
10.6. Phng trnh cc yu t bt li ca mi trng
- Trnh cc hot ng th lc khng cn thit.
- Trnh tip xc bi, khi nht l khi thuc l v cc cht kch thch khc.
- Trnh tip xc vi nhng ngi b nhim trng h hp.
- Gi mi trng trong nh trong lnh.
211
SUY H HP CP
Mc tiu
1. Trnh by c nh ngha, bnh nguyn, c ch sinh bnh suy h hp cp
2. Nu c triu chng lm sng v cn lm sng v phn giai on suy h hp
cp
3. Trnh by c phc iu tr theo tng giai on suy h hp cp
4. X tr ban u ng cch theo tng mc v chuyn tuyn ng lc
Ni dung
I. NH NGHA
Suy h hp cp l s ri lon nng n ca s trao i oxy mu; mt cch tng
qut, suy h hp cp l mt s gim thc s p lc ring phn kh oxy trong ng
mch (PaO2) < 60 mmHg, p lc ring phn kh carbonic trong ng mch (PaCO2)
c th bnh thng, gim hay tng.
C 2 loi suy h hp cp
- Suy h hp cp vi thiu oxy mu km kh ccbonic.
- Suy h hp cp vi thiu oxy mu km gim kh ccbonic.
II. BNH NGUYN
1. Nguyn nhn ti phi
1.1.S mt b cp ca nhng suy h hp mn
Yu t lm d l nhim trng ph qun - phi, thuyn tc ng mch phi, trn kh
mng phi.
1.2. Nhng bnh phi nhim trng:
Chng xy ra trn phi lnh th ch gy suy h hp cp khi nhng nhim trng phi
lan rng ra nhiu thy: ph qun ph vim do vi trng m, lao k, nhim virus c
tnh.
1.3. Ph phi cp
1.3.1.Ph phi cp do tim
- Tt c nhng nguyn nhn gy suy tim tri: tng huyt p lin tc hay cn tng
huyt p, suy mch vnh trong nhi mu c tim l nguyn nhn thng gp nht,
hp h van ng mch ch, h van hai l, bnh c tim.
- Hp van hai l.
- Thuyn tc ng mch phi.
1.1.2. Ph phi cp trn tim lnh: do yu t tng p lc mao qun.
- Chuyn dch qu nhiu.
- Nguyn nhn thn kinh: chn thng s no, u hay phu thut chm n thn no,
vim no.
1.1.3. Ph phi cp do tn thng thc th
212
cung lng 4 - 6 lt / pht bng xng mi hay trong nhng trng hp thiu oxy
nng hn th s dng mt n oxy.
- Nhng bnh nhn c nng kh carbonic trong mu cao mn tnh: l nhng
trng hp suy h hp mn, cung lng oxy dng bnh nhn b suy h hp mn
l thp khong 1 - 3 lt / pht, th ngt qung v c kim sot nng cc kh
trong mu.
2.3. t ni kh qun
* Ch nh
- Khi c tr ngi ng h hp trn nh ph n, vt thng thanh qun, hn m gy
tt li.
- Khi cn gim khong cht tng thng kh ph nang, h tr h hp, cn th oxy,
th my.
- Khi c tng kh ccbonic mu.
- Khi cn bo v ng h hp, phng ht sai lc.
* Phng php
C hai phng php:
+ t ni kh qun ng mi
Cn gi l t ni kh qun m, l phng php c dng ph bin, nht l i vi
tr s sinh, tr cn b v tr em, c bit trong bnh un vn v trong hi sc ni
khoa. Bnh nhn t t th Jackson ci tin: nm nga, k vai cao 5-7 cm
nga c va phi hoc t th na ngi, nht l khi s mu, m, dch...t phi bnh
tro sang phi bn kia.
t ni kh qun ng ming
Bnh nhn c t trong t th nh trn: t th Jackson hay na ngi. Cho th
oxy vi pht trc khi t ng.
Thng thng, ng khng t qu 3 ngy.
2.4. M kh qun
* Ch nh
Nh ch nh t ni kh qun hay khng t c ng hay khi cn t ng qu 3
ngy.
* Phng php
- M kh qun cao: d thy kh qun hn
- M kh qun thp.
2.5. Tai bin c th gp khi t ni kh qun v m kh qun
* Tai bin khi t
Chy mu, ph n thanh qun, thng kh qun, co tht thanh mn, ngng tim.
* Tai bin sau khi t
Nhim khun ni t, vim phi, lot, hoi t kh qun, r kh thc qun, tn thng
dy thanh m, xp phi, trn kh mng phi, trn kh trung tht, trn kh di da.
218
2.6. H tr h hp
* Dng c h tr h hp bng tay
Kh th c cung cp cho bnh nhn l kh tri.
- Loi c bng: Ambu, Canister.
- Loi c ti xp: Ranima, Drager.
* Th my
+ Ch nh
Th my c dng khi cc phng php h tr h hp thng thng khng c
hiu qu.
Ba loi bnh nhn ln tng ng vi ba mc khc nhau v kh carbonic trong
mu. Mi loi bnh nhn cn mt cch thc iu chnh h hp nhn to khc nhau:
- Loi bnh nhn th nht: l loi c mt s gia tng nhiu kh carbonic km mt s
gim kh oxy mu, nh s mt b cp ca nhng suy h hp mn, th oxy phi bt
u vi cung lng thp, sau tng dn ln nhng rt chm, kh nng cung cp
oxy (FiO2) cao nht l lc khi u.
- Loi bnh nhn th hai: l loi ang hnh thnh s tng kh carbonic mu, bnh
nhn ny c th h hp hon ton bnh thng vi FiO2 khong 50%.
- Loi bnh nhn th ba: l loi c mt s gim kh carbonic mu. Hin tng tng
h hp th pht sau thiu kh oxy mu. Tuy nhin do c bnh l phi bn di, nn
s tng h hp khng ko theo mt s tng PaO2 c. Bi vy bnh nhn nng
dn dn, cng ngy n oxy cng tr nn trm trng.
- C 5 loi my th:
+ My th to ra chu k da trn tn s.
+ My th to ra chu k da trn th tch.
+ My th to ra chu k da trn p lc.
+ My th to ra chu k da trn dng kh.
+ My th to ra chu k hn hp.
2.7. Chng nhim khun
Cc vi khun gy bi nhim thng l Streptococcus pneumoniae, Haemophilus
influenza, Stapylococcus aureus, Klebsiella pneumoniae, v.v..., nn phi cho cc
khng sinh thch hp.
219
SUY H HP MN
Mc tiu
1. Bit c cc nguyn nhn ca suy h hp mn
2. Hiu uc c ch bnh sinh suy h hp mn.
3. Trnh by c cc triu chng lm sng v cn lm sng ca suy h hp mn.
4. Nu c cc bin php iu tr suy h hp mn va v nng.
5. Trnh by mt s bin php cn d dt trong iu tr suy h hp mn
Ni dung
I. I CNG
Suy h hp mn l mt tnh trng trong lng oxy cn thit cho c th khng th
cung cp hay s dng c khi ngh ngi hay khi gng sc.
Trong thc t, suy h hp mn c chn on khi c ri lon mn tnh cc kh
mu, gim PaO2 v tng PaCO2
II. BNH NGUYN
Nguyn nhn gy suy h hp mn c rt nhiu, a dng, c th b my h hp v
ngoi b my h hp.
Ngi ta phn bit 3 loi suy h hp mn: nghn, hn ch v phi hp.
1 Suy h hp mn nghn: thng gp nht
1.1. Bnh phi tc nghn mn tnh(COPD): l mt tnh trng bnh l ca vim ph
qun mn hoc kh ph thng c hn ch lu lng kh. S tc nghn ny xy ra t
t c khi tng phn ng ph qun v c th khng hi phc hay phc hi mt phn
nh m thi.
Nguyn nhn chnh gy bnh phi tc nghn mn tnh l ht thuc l, sau l ht
thuc l th ng, nhim mi trng, nhim trung ng h hp, v nhim ngh
nghip.
C 4 c im sinh l bnh ca bnh phi tc nghn mn tnh:
+ Nghn tc ng dn kh:
- Do hu hoi nhu m phi l hu qu ca s gim antiprotease trong c
s gim (1 - antitrypsin v/ hay gia tng protease l neutrophil elastase l mt
enzyme c tc dng lm v cc vch ph nang, gy vim ph qun, gim biu m
c lng v tng tit cht nhy.
- Do s bin i ca ng dn kh: do hin tng vim mn l ph, gia
tng t bo ly v t bo tit cht nhy, gia tng s lng v ng knh cc vi mch
ca ng dn kh, ph i v qu sn lp c trn ng dn kh.
+ S gia tng hot ng ca trung tm h hp: gi c mt mc thng
kh ph nang cn thit.
+ S bt thng c h hp: do s gia tng kch thch t trung tm h hp,
thay i v mt hnh hc ca cc c h hp, cc yu t chuyn ho bt li v tnh
trng mt c.
220
- Thuc tr tim: Digoxine khi c suy tim, tuy nhin d gy lon nhp nh vy c hi
hn l c li.
- Li tiu: nh Furosemide c th gy nhim kim, gy c ch trung tm h hp
(nhim kim l do tng thi ion hydro v ti hp thu bicarbonat).
226
I. I CNG
Trn dch mng phi (TDMP) l bnh thng gp trong cc bnh l ca b my h
hp, chn on xc nh TDMP thng khng kh lm, nhng chn on nguyn
nhn mi l iu quan trng v quyt nh hng iu tr.
Ty thuc vo nguyn nhn v din tin bnh m dch mng phi c nhiu tnh cht
khc nhau v mu sc (trong, vng chanh, c, m, mu, trng c..) v sinh ha
(dch thm, dch tit, mu...), v t bo (bch cu a nhn, lymphocyte, hng cu, t
bo ni m), v vi trng v cc tnh cht khc.
II. DCH T HC
Ngoi cc TDMP c nguyn nhn ngoi phi - mng phi, nguyn nhn do nhim
trng c mt vai tr quan trng, bnh thng xy ra ngi c c a xu, c bnh
mn tnh. TDMP chim t l kh cao so vi cc bnh ng h hp di, iu tr ni
khoa nhiu lc khng hiu qu, li nhiu bin chng v d chng lu di nh
hng n chc nng h hp. Ngy nay nh c nhiu loi khng sinh tt v mnh
nn hn ch phn no t l t vong v gim nh bin chng.
1.3. Ung th
Ph qun, phi, mng phi tin pht hay do di cn, Bnh BBS (Besnier - Boeck -
Schaumann)
1.4. K sinh trng
Thng gp do amp (do pxe gan, pxe di c honh v vo xoang mng phi),
sn l.
1.5. Thng tn ng ngc v vo mng phi gy TDMP dng trp.
1.6. D ng, Hodgkin giai on nng, bnh to keo.
1.7. Chn thng ngc, phu thut lng ngc, tai bin chc d mng phi...
1.8. Khng r nguyn nhn.
2. Ngoi phi-mng phi
Thng gp l dch thm do cc bnh l tim (suy tim), gan (x gan), thn (HCTH,
suy thn), suy dinh dng.Hoc u nang bung trng (H/C Demons Meigs), bnh t
min, bnh to keo, vim ty cp.
y ch nhn mnh n nguyn nhn do vi khun sinh m, thng gp l ph
cu, lin cu, t cu vng. E.Coli, Klebsilla pneumoniae, Actinomyces,trc khun m
xanh, nu c mi thi l do hoc phi hp vi cc loi ym kh.
Cc thng tn c th nguyn pht ti mng phi nhng thng l th pht sau cc
thng tn phi, mng tim, hoc t cc c quan khc nh gan, trung tht, abcs
di c honh... hoc t ng mu n (nhim trng huyt) hoc trn mt c a
thng tn phi c sn (lao, ung th...) ri bi nhim hoc trn dch sau trn kh
mng phi.
V.TRIU CHNG
1.Th t do (th ton th): Gm c 2 hi chng
1.1.Hi chng nhim trng cp
Vi st cao dao ng, th trng gy st, bing n, v mt hc hc, li bn, nc
tiu t v sm mu, s lng bch cu tng, bch cu trung tnh tng, VS tng.
1.2. Hi chng trn dch mng phi
228
1.2.1. C nng
- au xc ngc d di, tng ln khi ho hay th su hoc thay i t th. Nu trn
dch t t th t au hn
- Ho: thng l ho khan, nu km thng tn phi th i khi c m trong hoc
m c m, ho khi thay i t th.
- Kh th: Ty theo s lng dch, tc trn dch, c kh th nhanh, kh th mt
phn do st cao v au.
1.2.2. Thc th
Nhn thy lng ngc bn thng tn g cao, gian sn gin, da vng thng tn c
sng , ph n v c th c tun hon bng h. S thy rung thanh gim, n ke
lin sn rt au, g c, v m ph bo gim hay mt, nu dch t c th nghe
c ting c mng phi.
Nu trn dch qu nhiu, nht l trn dch bn tri y tim qua phi c th gy suy h
hp cp (kh th nhiu, v m hi, tm mi v u chi, nhp tim nhanh, huyt p
gim)
1.2.3. Cn lm sng
- X.quang v siu m cho bit c trn dch. Xquang thng cho thy ng cong
Damoiseau, nu c km trn kh th mc dch nm ngang, nu dch t th ch c t
gc sn honh.
- Chc d mng phi thy c dch m c, nhiu bch cu a nhn, t bo ni m
nhiu, protein cao, Rivalta (+), soi ti, cy v lm khng sinh tm thy vi khun
sinh bnh.
Lu khi khm xt phi hi bnh s tht k, khm ton thn v cc c quan ln cn
tm tiu im nhim trng tin pht hay th pht.
2.Th khu tr
Thng gp trn dch mng phi cnh vng phi b thng tn, bnh nhn c hi
chng nhim trng cp, nhng trn dch th kh xc nh bng lm sng, m ch da
vo x.quang, siu m v chc d. Ngi ta chia ra: trn dch th trung tht, th
honh, th nch, th rnh lin thy, th c vch ngn...
VI. CHN ON
1. Chn on xc nh
Chn on trn dch mng phi thng khng kh i vi th t do, da vo lm
sng, X.quang v quyt nh chn on l chc d c dch, vi th khu tr Xquang,
v siu m l quan trng v lm sng kh xc nh.
2. Chn on nguyn nhn
Da vo mu sc,sinh ha, t bo hc v mi hi ca dch mng phi v quan trng
nht l cy dch mng phi v lm khng sinh .
3. Chn on phn bit
229
VIII. IU TR
Nguyn tc l sm, mnh, liu trnh, phi hp, v theo di din tin iu tr.
1. iu tr ni khoa
1.1. iu tr nguyn nhn
Phi cn c vo vi chun ca dch mng phi v khng sinh , nu cha c khng
sinh th da vo bnh cnh lm sng, tnh cht dch mng phi, kinh nghim lm
sng yu t dch t v din tin ca bnh.
Ch yu l khng sinh bng ng ton thn v ti ch vo mng phi.
230
* Khng sinh ng ton thn: Nn phi hp t nht 2 khng sinh dit khun bng
ng tim bp hay tnh mch trong cc trng hp nng, c nguy c khng thuc
cao.
- Do ph cu, lin cu: Khng sinh vn c tc dng tt hin nay l
+ Pnicilline G 1-3 triu n v/6 gi tim bp, c th phi hp vi
+ Gentamycine 3-4 mg/kg/24 gi chia 3 ln nu phn ng vi Pnicillin th dng
+ Erythromycin 1500-2000 mg/ngy chia 3 ln hay Roxycillin 150 mgx 3v/ngy.
- Do t cu vng: Hu ht t cu vng khng vi Pnicillin; nn dng
+ Cefalosporine II: (Ceclor, Keflor...) liu 3-6 g/ngy chia 3 ln TB hay TM hoc
+ Cefalosporine III (Cefomic, cefobis, claforan, Rocphin...) liu nh trn, phi hp
vi mt thuc nhm aminoside nh
+ Amiklin 1 - 2 g/ngy tim bp (TB) hay Gentamycine. Hoc l dng
+ Vancomycine 30-60 mg/kg/ngy TB hay TM phi hp cc loi k trn.
- Do Klebsiella pneu. (Friedlander). Dng nhm aminoside nh
+ Amiklin1 - 2 g/ngy tim bp hay Gentamycine v/hay l
+ Cefalosporine III liu 3-6 g/24 gi chia 3 ln TB hay tnh mch (TM).
+ Tobramycine 3-5 mg/kg/24 gi TB hay TM.
- Do vi khun k kh:
+ Pnicillin G: liu 4- 12 triu n v/ngy TB, TM chia 4 ln phi hp vi
+ Metronidazole 250 mg x 4-8 vin/ngy v thm Gentamycine nu cn, hoc
+ Clindamycin (Dalacin C) 300-450 mg x 4 ln/ngy hoc
+ Cefalosporine III liu nh trn.
- Do Pseudomonas: Dng
+ Cefalosporine III phi hp Gentamycine hay Kanamycine hoc dng
+ Carbenicilline 70 mg/kg/8 gi TB hay TM phi hp 1 aminoside.
Nu khng tm thy vi khun th da vo bnh cnh lm sng, yu t dch t, kinh
nghim thy thuc...
* Khng sinh vo mng phi: Thc hin sau khi chc d tho dch mng phi, sc
ra mng phi bng dung dch mui sinh l, a khng sinh vo mng phi, c ch
nh nht l trong trng hp mng phi dy khng sinh khng th ngm vo c.
Khng sinh ch nh a vo mng phi thng l nhm Lactamin, Gentamycin...
1.2. iu tr triu chng
* Gim au v h st: Paracetamol 500 mg x 3 - 4 ln/ngy, hoc Acetaminophene,
Diantalvic. Nu au nhiu c th dng loi Efferalgan - Codein 2 -3 vin/ngy.
* Nu kh th nhiu tho bt dch, khng qu 500 ml/ln. Hoc th oxy qua sonde
mi.
* Chng dy dnh mng phi
231
- Lao phi
- Nhim khun ph qun - phi (20%)
- Bnh phi tc nghn mn tnh nht l kh ph thng.
- Trong cn hen ph qun
- Ung th ph qun thm nhp hay di cn mng phi.
- Bnh phi k, x phi, bi phi Silic, Sarcoidosis
- Cc bnh phi khc
3. Trn kh mng phi do chn thng, th thut thm d
- Chn thng thng lng ngc, gy xng sn lm thng phi
- Th thut chc d mng phi, sinh thit mng phi, t ni kh qun, chm cu.
- Chc tnh mch di n
- Dn lu mng phi
4. V cn
IV. C CH BNH SINH
Bnh thng p lc trong khoang mng phi l m (-3 n - 5 cm H20) khi khng kh
lt vo mng phi th s lm nhu m phi co li, lng ngc dn ra nn dung tch
sng, dung tch ton phn v dung tch cn gim...
- Mc ri lon chc nng h hp do trn kh mng phi ph thuc vo mc
trn kh (xp phi) v chc nng ca phi trc khi b trn kh - C th c trn mu
mng phi sau trn kh do thng tn dy chng gia 2 mng phi.
- Thng thng th khng kh lt vo mng phi khi th vo v thot ra khi th ra,
nu th ra m kh khng thot ra c l trn kh c van do gy nn kh th tng
dn v a n suy h hp trm trng, y lch trung tht.
- Trn kh mng phi c th gy nn do vt thng xuyn thnh ngc hay qua l
tng do thng, v ph nang, v bng kh, v p xe phi...
- Nu l d ca mng phi c bt li th trn kh s tiu dn.
- Nu trn kh mng phi xy ra trn 1 dy dnh mng phi th s gy trn kh mng
phi khng hon ton.
V. LM SNG
1. Th trn kh mng phi t pht hon ton
Thng gp ngi tr (20-30tui) vi triu chng u tin l cn au ngc t
ngt d di nh dao m, lm bnh nhn khng dm th su, ho d di v ho lm
au tng ln. C th c chong nu trn kh mng phi nhanh v nhiu, mch
nhanh, nh, huyt p h, tay chn lnh, v m hi nhp th nhanh- nng, tinh thn
ht hong lo u... sau triu chng gim dn sau vi gi, vi ngy.
Khm phi nhn thy lng ngc bn tn thng dn ln, cc khong lin sn
rng, g vang nh trng, rung thanh gim v nghe m ph vo mt ton b, c th
nghe c m thi v hay ting vang kim kh. G vang, rung thanh gim v m ph
234
P XE PHI
Mc tiu
1. Trnh by c nh ngha ca p xe phi
2. Bit c nguyn nhn ca p xe phi
3. Trnh by c c s bnh sinh v gii phu bnh
4. Bit r triu chng lm sng ca p xe phi
5. Bit ch nh c iu tr p xe phi
Ni dung
I. I CNG V NH NGHA
p xe phi l mt tnh trng nung m, hoi t ch m phi sau mt qu trnh vim
cp, m nguyn nhn ch yu l vi khunn m, k sinh trng...
Ngi ta chia ra lm hai loi
1. Nung m phi tin pht: L s nung m cp tnh vng phi cha c tn thng
c.
2. Nung m phi th pht: L nung m xy ra trn mt thng tn phi c sn
nh hang lao, nang phi, ung th phi hoi t, gin ph qun.
Bnh c bit t lu, nhng s chn on c r rng hn t khi c quang
tuyn X.
II. DCH T HC
C rt nhiu hi ngh v ti liu ni v p xe phi v bnh ny trc y chim t l
kh cao. Nhng k t khi c cc phng tin gip chn on nguyn nhn v nht
l c nhiu loi khng sinh mi, c hiu nn t l ny gim i nhiu. Ap xe phi
chim t l 4,8 % cc bnh phi (Chu Vn 1991), hay chim 3% cc bnh phi
iu tr ni tr vin lao v bnh phi (Nguyn Vit C 1987)
Bnh thng gp mi la tui, nhng tui trung nin c t l cao hn, bnh xy ra
nhiu hn nhng ngi c a suy kit, gim min dch, nghin ru, thuc l, i
tho ng, cc bnh phi mn tnh. Din tin bnh ty thuc vo chn on
sm, iu tr ng v liu trnh.
III. BNH NGUYN
1. Cc tc nhn gy bnh
1.1. Vi khun k kh: y l nhng vi khun thng gp nht, chim t l khong
60% (Cameron 1980), hay 89% (Barlett 1982), d pht hin chng v hi th v m
rt hi thi, chng c th gy nn nhng p xe lan ta, bn cp v thng kt hp
vi cc loi vi khun khc nh lin cu, ph cu... Cc loi vi khun k kh thng
gp l Bacteroide melaniogenicus, Fusobaterium nucleotum, Bacteroide fragilis
Peptococus, Peptostreptococcus...
1.2. T cu vng: Thng gp tr em nh nht l tr cn b, cc triu chng lm
sng nh st cao, ri lon tiu ha (nn, chng bng...) st cn. Bnh cnh lm
239
sng va phi va mng phi (trn kh, dch mng phi) gy suy h hp, nhim
trng nhim c nng.
1.3.Klebsiella Pneumoniae (Friedlander): Tin trin lan rng rt nhanh, khi huyt,
bnh cnh rt nng v nguy c t vong cao.
1.4.Nhng vi khun khc: Nh ph cu, lin cu,nhm A hay tan mu, cc vi khun
Gram (-) nh Pseudomonas aeruginosa, Hemophillus influenzae, Legionella
pneumophila.
1.5.K sinh trng: Thng gp nht l amip, c th l nguyn pht nhng hu ht l
th pht sau Aaip gan, rut, thng tn thng gp l y phi, phi st vi c
honh v thng km thng tn mng phi (phn ng), m c mu chocolat
nhng thng gp l mu ti. C th t gp hn l nm.
2. Cc nguyn nhn thun li: Gy p xe phi th pht
2.1.Cc u phi, ph qun gy nghn, bi nhim hay hoi t (ung th)
2.2.Gin ph qun: Va l nguyn nhn va l hu qu ca p xe phi
2.3.Trn nhng thng tn phi c sn: hang lao, kn phi bm sinh...
3. Yu t lm d
3.1.Cc chn thng lng ngc h, t ni kh qun.
3.2.Nhng c a xu: i tho ng, suy gim min dch, suy dng nng,
nghin ru...
IV. C CH BNH SINH
a s p xe phi l nguyn pht, vi khun gy ra p xe phi theo cc ng vo sau
y:
1. ng kh- ph qun
Do ht vo t khng kh, cc sn phm nhim trng mi hng, rng - li, amygdal,
cc phu thut tai mi hng, rng hm mt, cc d vt ng th, trong lc hn
m, t ni kh qun, tro dch d dy... Do bnh nhn b ri lon phn x nut,
khng ho v khc m c, lit cc c h hp, c honh, tt nghn ng th
gy ng...
2. ng mu
Do vim tnh mch, vim ni tm mc, gy thuyn tc,nhi mu v p xe ha, hoc
t mt tiu im xa n (nhim trng huyt) thng gy p xe nh c hai phi.
(thng gp do t cu vng)
3. ng k cn
p xe di c honh, p xe gan do amip, p xe mt qun, p xe trung tht, p xe
thc qun, vim mng phi m, vim mng ngoi tim... hay do ng bch mch.
Mt s trng hp p xe phi th pht trn mt hang phi c trc nh hang lao,
kn phi hay mt s bnh c trc nh gin ph qun, ung th phi hoi t hay u
gy tc nghn ph qun...
V. GII PHU BNH
S hnh thnh apxe phi qua giai on
240
- Lc u trong nhu m phi b vim xut hin mt hay nhiu vim ha m, nhu m
phi b ng c, nu iu tr giai on ny th thng tn c th phc hi hon
ton. Nu khng th cc vim ny s hoi t lan rng v kt hp li thnh mt
ln hoi t v c m. y l giai on nung m cp v p xe phi hnh thnh, c
v mng bao bc. Sau thng tn cc ph qun ln cn v bnh nhn s khc ra
m, v cc t chc hoi t.
- Sau mt thi gian (khong 6-8 tun) th vim x bt u bao quanh p xe to nn
nhiu vch ngn, hoc l m s lan qua vng ln cn gy nn cc thng tn mi.
- Sau khong 12 tun l th v x dy v tr thnh p xe phi mn tnh, bn trong
c m ht v biu b ha t cc nhnh ph qun ln cn, nhu m ngm nhiu fibrin
v nhiu t bo lympho, c khi thng tn mch mu gy ra ho ra mu, nu thnh
ph qun b ph hy nhiu s dn n gin ph qun.
VI. TRIU CHNG HC
Do nguyn nhn no, p xe cng u din tin qua 3 giai on.
1. Giai on nung m kn
1.1. C nng: Giai on ny ch c ho khan hoc c khi khc t m. Triu chng
au ngc m , au su v tng ln khi ho hay th su, t kh th tr khi thng tn
phi lan rng hay do tnh trng nhim c nhim trng nng.
1.2. Tng qut: st cao, rt run, mt mi, chn n, gy st, v mt hc hc, nc
tiu t, sm mu.
1.3.Thc th: Thng rt ngho nn,c khi ging mt hi chng ng c phi
khng in hnh.
1.4. Cn lm sng
- Xt nghim mu thy bch cu tng, bch cu a nhn tng, mu lng cao.
- Chp phim phi c th thy mt hnh m trn hay bu dc, thng gp y phi
phi hn.
2. Giai on khi m
Sau thi gian nung m khong 5-7 ngy ty loi vi khun, bnh nhn au ngc tng
ln, ho nhiu, tnh trng suy sp, hi th hi, c th c khi huyt trc ri sau
au ngc v ho nhiu ri c ra nhiu m, thng rt hi thi, s lng c khi 300-
400 ml,c trng hp ch ho ra m t, tng bi c nh hnh ng xu v ke di. Sau
khi c m th ngi cm thy d chu hn, st gim, au ngc gim dn.
3. Giai on nung m h
Sau thi gian t 3-5 ngy,tnh trng nhim trng gim dn, du c nng gim nu c
iu tr tt. Nhng thng l hi chng nhim trng ko di, th trng suy sp nhiu
do m cha c tng ra ht gy vim nhim ko di v c khi lan rng thm, do
iu tr khng ng hay sc khng xu. Biu hin suy h hp mn, ngn tay hnh
di trng.
Khm phi giai on ny c hi chng hang vi ran m to ht, m phi hang v
c th nghe c ting ngc thm.Chp phim phi thy c mt hnh hang trn, b
dy, c mc hi- nc. Quan trng nht l xt nghim m tm nguyn nhn gy
bnh khi cha x dng khng sinh.
VII. CHN ON
241
1. Chn on xc nh
Giai on nung m kn thng kh khn v triu chng ngho nn, khng in hnh,
nu c th th ch da vo X quang v siu m.
Trong giai on c m th chn on tng i d dng hn. Ni chung chn on
da vo:
- Hi chng nhim trng cp.
- Khi m nhiu (hoc m hnh ng xu), hi thi.
- Hi chng hang, quan trng l X quang phi c hnh nh mc hi - nc.
- Ngn tay hnh di trng.
2. Chn on nguyn nhn
Ch yu l cy m, lm khng sinh (khi cha s dng khng sinh) nu tm amip
th phi ly m c mu v em xt nghim ngay.
Lu hi k bnh s, tm yu t thun li gy bnh.
3. Chn on phn bit
3.1. Giai on nung m kn: phn bit vi
- Vim phi: c th din tin lnh hn hay c th s pxe ha.
- Cc khi u phi: c th lnh tnh hay c tnh,hi chng nhim trng khng c, c
khi huyt, lm sng, X quang v soi ph qun... gip chn on phn bit.
3.2. Giai on nung m h: phn bit
- Ung th ph qun - phi hoi t, hay cng c th l nguyn nhn ca p xe phi.
Trng hp ny th trong lng khi u hoi t khng u, khng c mc hi-nc,
ni soi, sinh thit v tm t bo l trong m xc nh.
- Gin ph qun bi nhim: Trong tin s c ho khc m ko di, chp ph qun c
cn quang gip chn on. Lu p xe phi thng l bin chng ca gin ph
qun.
- Hang lao bi nhim: thng hang nm vng nh phi, b mng, ho ra mu, BK
m thng dng tnh, phim phi khng thy mc hi nc.
- p xe gan v vo phi: qu trnh bnh l l triu chng gan trc sau n
phi. Siu m, x.quang gip chn on.
VIII. TIN TRIN V BIN CHNG
Phi theo di bnh lin tc v nhit , triu chng lm sng, s lng v tnh cht
ca m khc ra, cng thc mu, tc mu lng. Phim phi phi c chp hng
tun, sau 1 thng, 3 thng, 6 thng... cho n khi khi hon ton.
1. Din tin
Trc khi c khng sinh th p xe phi l bnh rt nng, t l t vong cao, nht l tr
em v ngi gi.
1.1. Ngy nay nh c khng sinh tt, c hiu nn iu tr ni khoa y c th
khi bnh hon ton. Thng thng nhit gim dn sau khi khi m, s lng m
gim dn v c th ht sau 7-10 ngy iu tr, nhng xt nghim v mu lng v c
242
bit l x.quang th chm hn nhiu c khi 3-6 tun sau, li x hoc khng cn di
chng g trn phim phi c.
1.2. li hang tha: tn ti rt lu v c th xem nh lnh bnh nu trong qu trnh
theo di trn X quang khng c g thay i (v mng, khng c dch...)
1.3. p xe phi mn: Sau 3 thng iu tr tch cc bnh thoi trin, ht hi chng
nhim trng cp, ngng khi m, nhng bnh khng lnh hn v c tng t khi
m tr li thng tn trn phim tn ti mi hay c xu hng lan ta hay thm mt
p xe khc, c du ngn tay di trng r.
2. Bin chng
2.1. Ho ra mu nng: C th do p xe n vo cc mch mu ln.
2.2. Trn dch tng dch si hay trn m mng phi li di chng dy dnh mng
phi, gy suy h hp mn.
2.3. Gin ph qun, x phi
2.4. Nhim trng huyt
2.5. p xe phi mn tnh.
2.6.T vong: do bnh nng, hoc do bin chng, c trng hp t vong ngay sau
khi c m do tt ph qun v phn x co tht ph qun (sc phi)
IX. IU TR
1. Nguyn tc iu tr
iu tr p xe phi phi tun theo nhng nguyn tc sau y
+ iu tr ni khoa kp thi, tch cc, kin tr.
+ Nu c th la chn khng sinh theo kt qu ca khng sinh th p xe
phi s chng khi.
+ Ch nh m sm trc khi c cc bin chng nng nh ho ra mu nng,
vim m mng phi.
2. iu tr c th
2.1. iu tr ni khoa
2.1.1. iu tr h tr
(1) Tit thc: nhiu protide, cung cp y nng lng, c th chuyn huyt
tng ti hay kh hay lipofundin hay cc loi dung dc acide amine nh Alvesine,
Cavaplasmal...phi hp vi vitamine nhm B nh Becozyme tim.
(2) Dn lu t th: cho bnh nhn khc m v m d dng.
(3) Ht ph qun: bng ng ht mm t tn p xe ht m v cc cht
m ra, y l mt phng php dn lu tt hn.
(4) iu chnh ri lon nc v in gii: nu c thng mt nc do st cao,
hay ri lon in gii v toan kim do suy h hp cp, gp trong nhng trng hp
nng.
(5) Th oxy: khi c tnh trng suy h hp cp, bng ng xng mi, cung lng
cao khong 6 lit/pht, nu c suy h hp mn th th oxy vi cung lng thp
khong 2 lt/pht.
243
GIN PH QUN
Mc tiu
1. Trnh by c bnh nguyn v gii phu gin ph qun.
2. Lit k c cc triu chng lm sng v cn lm sng gin ph qun.
3. Trnh by c tin trin v bin chng gin ph qun
4. Trnh by c cch iu tr gin ph qun..
5. Nu c cc bin php d phng gin ph qun.
Ni dung
I. NH NGHA
Gin ph qun l s gin khng hi phc cc ph qun nh v trung bnh km theo
s lon dng cc lp ph qun v a tit ph qun, c th do bm sinh hay mc
phi, thng b bi nhim nh k. Gin ph qun gp nam 4 ln nhiu hn n.
II. BNH NGUYN
1. Mc phi
Hin nay c xem nh l thng gp nht; nhng th ny c th khu tr hay
lan ta.
1.1. Th khu tr
- Nhng nguyn nhn gy hp ph qun mt phn: gy nn s dch tit dn
n nhim trng v ph qun b gin ra, i khi trong 2 - 3 tun l. Nhng nguyn
nhn ny thng ch c pht hin nh ni soi ph qun, trc tin l khi u c
th lnh tnh hay c tnh, c th l vt l nht l i vi tr em, c th l lao bi
nhng l d hay u ht t mt lao s nhim tin trin hay trn di chng calci ha.
- p xe phi: di chng so x hay trn mt p xe phi mn tnh.
- Aspergillose ph qun: t gp hn nhng rt c bit l c s phi hp vi
nhng biu hin tng nhy cm type I v type II (tm nhng cht kt ta khng
aspergillus), c th c tng bch cu i toan v khu tr ph qun rt gn gc, nh
vy ch tn thng cc ph qun ln cn cc ph qun trc tn cng cn tt (bnh
Hinton).
1.2. Th lan ta
- Di chng ca cc bnh ph qun - phi cp nng trong thi k thiu nin:
c th b qun lc khi u hi chng a tit ph qun - phi. Si v ho g l 2 bnh
thng gp nht, nhng bnh nhim siu vi nng nht l do Arbovirus l nhng
nguyn nhn gy nn di chng gin ph qun.
- Bnh nhy nht (bnh x ty tng nhy - kn): l nhng bnh bm sinh di
truyn; trong nhng bnh ny c ri lon v tit dch do s thanh lc b chm li, gy
nn nhng nhim trng ph qun - phi ti pht dn n nhng th gin ph qun
rt nng vi suy h hp mn v cht trc thi k trng thnh.
2. Bm sinh
Gin ph qun thng l lan ta, rt t gp.
2.1. Bnh a kn phi: thng phi hp vi a kn thn, ty v gan.
246
Gp phn quan trng trong ri lon chc nng h hp v trong s trao i kh oxy
phi, nhng tn thng ny rt thay i ty ngi bnh, ty v tr cng mt bnh
nhn, l vim phi li teo hay ph i, vim ph nang xut huyt, xp phi.
IV. TRIU CHNG LM SNG
1. Triu chng chc nng
1.1. Khc m
Gp 80 % trng hp gin ph qun.
- Thi im: nhiu nht vo bui sng, i khi ri u trong ngy.
- Lng: thay i ty theo tng bnh nhn, thng l nhiu, khong t 20 -
100 ml / ngy,
hay c th nhiu hn trong t cp; tuy nhin c nhng th kh, khng khc m.
- Mi v: lt, mi thch cao, i khi c mi hi; nu lng s c 4 lp t trn
xung di
l: m bt, m thnh dch nhy trong, m mi nhy, m m c.
- Phn tch: t c v nhim trng thng km theo.
1.2. Ho
L triu chng thng km theo khc m.
1.3. Ho ra mu
Quan trng, gp trong 8 % trng hp, c th km theo m hay i khi n c.
Ho ra mu c th di hnh thc tia mu mu hn l en chng t c t vim
hay ho ra mu c s lng nhiu hn mu chi tng ng vi s chy mu h
thng c xem nh bin chng.
1.4. Kh th
t gp, mc d mt s gin ph qun ch c chn on giai on suy h hp
mn.
2. Nhng biu hin khc
2.1. Nhng nhim trng phi - ph qun cp ti pht nhiu ln
Vi st va 38o - 38o5, c 2 c im l v tr nhim trng c nh gi c bt
thng bn di, tng trng thng khng thay i.
2.2. Trn dch mng phi thanh dch - si hn l m
3. Khm lm sng
3.1. Hi bnh
Chnh xc nhng tnh hung pht hin bnh, thi gian b bnh; trn thc t, thng
khng chnh xc, c th trong thi k thiu nin bnh nhn b bnh ho g hay si
nng. Hi bnh bit tnh chu k a tit ph qun, tn sut nhng t bi nhim
nht l vo ma ng v lin quan n nhng nhim trng mi - hng (vim mi,
vim xoang, vim amian); hi bnh bit n tin s c nhn v gia nh, ht
thuc l v ngh nghip hin ti v qu kh.
3.2. Khm thc th
248
- Khm phi: c th bnh thng ngoi t cp, c th pht hin ran ngy, ran
rt, ran m to ht. Khi b bi nhim c th nghe c ran n kh hay ran n t nh
ht hay hi chng trn dch mng phi.
- Ngn tay hnh di trng.
- Trong nhng th tin trin, c hai bin chng nng l suy h hp mn v
tm ph mn.
V. CN LM SNG
1. m
1.1. T bo
C nhiu t bo biu m ph qun, c nhiu bch cu a nhn trung tnh thoi ha
v cht nhy, khng c si n hi.
1.2. Vi trng: hay gp nht l Haemophilus influenza v ph cu, ngoi ra c th gp
vi trng gram m nh Pseudomonas aeruginosa; vi trng k kh; ngoi ra phi tm
BK.
2. Phim phi
2.1. Phim chun
Thng c hnh m dng li i t rn n co honh; i khi c hnh nh m mt
cch c h thng nhiu nht thy gia v thy di phi; i khi c hnh nh hoa
hng nh ging nh nhng kn kh chng ln nhau, c th c hnh nh mc nc
kh trong giai on m.
2.2. Chp ct lp t trng
Cho php pht hin d dng phn ln cc gin ph qun th hnh tr. Hin nay trong
thc t t chp nhum ph qun; chp ct lp t trng gip chn on chnh xc nht
l nhng bnh nhn b suy h hp mn.
3. Thm d chc nng h hp
3.1. o chc nng h hp: cho thy c s kt hp c hai hi chng hn ch v tc
nghn.
3.2. Kh mu
Ch ri lon trong th nng tc l trong gin ph qun c suy h hp mn v tm
ph mn, c th c PaO2 gim, PaCo2 tng, SaO2 gim.
4. Thm d ph qun
4.1. Ni soi ph qun
xc nh nhng ph qun b vim, ng thi c th ly m kho st vi
trng.
4.2. Chp nhum ph qun
t s dng t khi c chp ct lp t trng, tuy nhin vn cn thit trc khi quyt
nh phu thut; chp nhum ph qun cho thy cc loi gin ph qun sau y:
- Hnh tr hay gp nht.
- Hnh tnh mch trng hay hnh trng ht.
- Hnh bng hay ti.
249
vch ph qun dy ln
X. T BC PHT CP BPTNMT
3 triu chng chnh ca t bc pht cp ca Bnh phi tc nghn mn tnh l: gia
tng kh th, gia tng m m, gia tng lng m.
257
+ Tp luyn
+ Glucocorticosteroid kh dung nu triu chng lm sng v chc nng h
hp c p ng hay nu c nhng t bc pht cp
+ iu tr cc bin chng
+ Oxy liu php lu di nu c suy h hp mn
2. X tr t bc pht cp BPTNMT
2.1. Chp X quang lng ngc
C th cn thit v qua kt qu X quang cho thy trn 23% bnh nhn nhp vin c
nhng biu hin bnh l.
3.2.Thuc gin ph qun
Kh dung thuc ng vn 2 tc dng ngn nh salbutamol v khng cholinergic
nh ipratropium c hiu qu bng nhau trn bnh nhn BPTNMT. Nhng loi thuc
ny cng c tc dng cao trn tt c tc dng ca tt c nhng thuc gin ph qun
s dng bng ng tim bao gm methylxanthines v nhng loi thuc cng giao
cm. Mt s nghin cu cho thy phi hp thuc ng vn 2 tc dng ngn vi
khng cholinergic c hiu qu cao do tc dng hip lc m khng lm gia tng tc
dng ph. Ch sau liu ti a khi u thuc gin ph qun, c th thm mt liu kh
dung gin ph qun t ra c li.
2.3. S dng corticoide
Trong t bc pht cp ca BPTNMT s s dng corticoide h thng trong 2 tun l
c li. Trong 2 tun liu lng c chia nh sau: 3 ngy s dng
methylprednisolone 125 mg/6 gi, sau cho prednisone trong 2 tun (60mg/ngy
t ngy th 4 n ngy th 7, 40mg/ngy t ngy th 8 n ngy th 11, v
20mg/ngy t ngy th 12 n ngy th 15).
2.4. Khng sinh
Khng sinh t ra c hiu qu trong t bc pht cp bnh phi tc nghn mn tnh.
Tu theo loi vi trng thng gy nhim trng ph qun phi m s dng khng sinh
thch hp.C th s dng Cephalosporine th h 3, Macrolides, Fluoroquinolones h
hp.
2.5. Oxy liu php
Trong t bc pht cp bnh phi tc nghn mn tnh v thiu kh, s s dng oxy
l cn thit v c li cho bnh nhn. Tuy nhin vn cn lu chnh l khi s dng
oxy liu php s c nguy c gy tng kh carbonic mu v suy h hp.
2.6. Thng kh p lc dng khng xm nhp
Thng c s dng cho bnh nhn ni tr b t bc pht cp bnh phi tc
nghn mn tnh. Phng php ny khng nhng lm ci thin chc nng h hp v
lm gim PaCO2 m trong mt s trng hp c th trnh s dng t ni kh qun.
2.7. Chng ch nh
Trong iu tr nhng bnh nhn b t bc pht cp bnh phi tc nghn mn tnh,
nhng iu tr sau y khng c li: thuc tan nhy, vt l tr liu lng ngc,
methylxanthines.
p dng thc t
260
Sildenafil hay chuyn ti a Epoprostenol (trung bnh 8ng/kg/ pht). Thi gian tc
dng ca Sildenafil t 120 150 pht.
Cho n nay, Sildenafil l thuc chn la tt nht trong iu tr gin mch phi.
6. Corticoides
Rt c hiu nghim trong iu tr t cp, Prednisone ung 5 mg, 4 vin / ngy hay
kh dung dipropionate de beclomethasone, hay Depersolone 30 mg tim tnh mch
va c tc dng chng vim va c tc dng chng d ng va lm gim tit dch.
7. Khng sinh
Khng sinh ch dng khi c bi nhim ph qun - phi, vi khun thng gp l
Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis,
Mycoplasma pneumoniae, Legionella pneumophila, Staphylococcus aureus.
- Nu nh th thuc thng dng hin nay l
+ Azithromycine: 250 mg x 2 vin / ngy, chia 2 ln trong ngy u sau
250mg x 1 vin trong 4 ngy.
+ Cefadroxil (Droxyl, Oracefal): 500 mg, 3 vin / ngy, chia 3 ln.
+ Ciprofloxacine 500mg x 3 vin / ngy, chia 3 ln.
- Nu nng thuc thng dng bng ng tim tht hay tnh mch
Mt trong cc loi Cephalosporine th h I (Cefapirine: Cefeloject = 2g/ngy chia 2
ln) II (Cefuroxime: Zinnat = 750mgx2 hay 3 chai/ngy chia 2 hay 3 ln) III
(Cefotaxime: Claforan = 2g/ngy chia 2 ln) IV (Axepim = 2g/ngy chia 2 ln) c th
kt hp vi Aminosides (Amikacine: Amiklin = 15mg/kg/ngy, 1 hay 2 hay 3 ln) hay
Fluoroquinolones (Ciprofloxacin: 200mg x 2 l - 4 l chuyn tnh mach).
8. Liu php vn ng
Tp th rt quan trng, lm tng gin n ca phi v lng ngc, tng thng kh
ph nang, nht l th bng c honh.
9. Loi b nhng yu t gy kch thch
Phi cai thuc l, trnh tip xc vi bi bm, cc kh c...
267
- Vim ph qun phi do nghn c c im: vim phi khu tr, p ng chm hay
khng hon ton vi khng sinh thch hp, vim phi lp i lp li cng mt v tr.
1.4. Ting-rt khu tr
Ran wheezing gi nghn khu tr khng hon ton.
1.5. Xp phi
Khi c hi chng xp phi l khi ph qun b hp hon ton.
1.6. Trn dch mng phi
C th l trn dch thanh t huyt hay trn mu, c th do u lan trc tip hay do di
cn, c khi do phn ng ca xp phi.
1.7. au ngc
au c nh v dai dng chng t ung th di cn n thnh ngc, mng phi hay
trung tht.
1.8. Hch ln
Hch c th rn phi, trung tht, c thang, c th din tin m thm hay gy chn
p, n mn cc ph qun, cc mch mu hay cc m ri thn kinh ln cn.
1.9. Biu hin chn p, tc nghn do u, do di cn, do hch vng
+ Tnh mch ch trn trong trung tht b chn p lm c ln ra, sau ph o
khoc, tm mt, gin tnh mch di da vai, ngc.
+ Thn kinh qut ngc tri b chn p, gy khn ging, lit dy thanh m tri
(dy thanh m phi c vng cao quanh ng mch di n nn t b chn p).
+ Thn kinh honh: cc dy thn kinh ny i dc theo trung tht trc mi
bn, mt trong hai c th b chn p, gy lit na c honh tng ng, ch pht hin
nh ri phi, thy c honh di ng ngc chiu.
1.10. Hi chng Pancoast Tobias
Ung th nh phi xm ln mng phi nh chn p cc r di ca m ri thn
kinh cnh tay, thn kinh giao cm c. Hi chng gm au vai, au cnh tay km hi
chng CLAUDE BERNARD HORNER cng bn (ng t co, sp m, hp khe mt)
c khi n mn xng n.
2. Biu hin ngoi lng ngc (di cn)
3 c quan hay b di cn nht l
+ H xng gy au xng, au tri lc nm ngh, ti pht vi cc thuc gim
au thng dng.
+ H thn kinh trung ng: t l u phi di cn ln no rt cao, gy lit cc dy
thn kinh s no, lit na ngi.
+ Gan.
+ Cc di cn khc nh mng bng, thng thn, thn, ng tiu ho.
3. Hi chng h thng
Cc hi chng ny bin mt khi ung th c ct b v ti pht khi di cn pht trin.
3.1. Tng calci mu
271
2. Vim phi
Sau mt thi gian iu tr vim phi, nu sc kho khng tr li bnh thng, cc
tn thng trn phim X.quang khng xo ht, lng mu vn cao... cn ngh n ung
th ph qun phi.
VII. IU TR
V mt iu tr ngi ta chia ung th ph qun phi ra lm 2 nhm chnh.
1. Ung th khng phi ung th t bo nh khng bit ho.
C thi gian nhn i 100-200 ngy, gm 3 loi: ung th dng biu b, ung th dng
tuyn, ung th t bo ln.
1.1. Phu thut l phng php hu hiu nht, p dng cho cc giai on ung th
n, giai on 1 v giai on 2 v mt s trng hp chn lc nh T3, No, Mo hay
T1, N2, Mo.
Kt qu:
- Ung th n: sng st sau 5 nm khong 60%. Theo di k v d b ti pht
khong 5%/nm/ngi.
- Ung th nt n c: m ct b thu phi. Tin lng tu theo kch thc
khi u, theo hch vng v theo s bit ho ca t bo k.
Sng st sau 5 nm khong 40-60% nu kch thc < 3cm v khng c hch vng.
Sng st sau 5 nm khong 20% n < 40% nu kch thc > 3cm v c hch vng.
1.2. Khng phu thut c dng a ho tr liu v x tr liu nu khng c chng
ch nh.
+ X tr liu kt qu khng tt lm, i khi khng hn bnh nhn khng c x tr
liu.
- a ho tr liu
Bng 3: Kt qu mt s a ho tr liu
c im Paclitaxel Gemcitabine Paclitaxel
/carboplatin /carboplatin /Gemcitabine
S bnh nhn 308 309 312
Thi gian sng st trung bnh 7,9 thng 7,6 thng 8,4 thng
Sng st 1 nm 33% 31% 33%
CHNG 4
THN TIT NIU
HI CHNG THN H
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, bnh nguyn, c ch sinh bnh,
sinh l bnh hi chng thn h.
2. Nu c cc triu chng lm sng, cn lm sng ca hi chng thn h.
3. Nm c chn on xc nh v chn on phn bit hi chng thn h
4. Bit ch nh iu tr triu chng v c ch sinh bnh ca Hi chng thn h.
5. Bit cc kh nng xy ra v hng gii quyt sau khi iu tr corticoide.
Ni dung
I. I CNG
Thut ng Thn h c Friedrich Mller dng ln u nm 1906 ch nhng
bnh thn m cc tn thng gii phu bnh ch c tnh cht thoi ha, khng c
c tnh vim. Nm 1908 Munk dng thut ng Thn h nhim m ch mt loi
bnh thn m v lm sng c ph v Protein niu, gii phu bnh c xm nhp th
m lng chit ng thn v cu thn bnh thng.
Ngy nay, nh tin b ca k thut sinh thit thn v knh hin vi in t, ngi ta
thy rng cc bin lon sinh ha ca thn h nhim m xut hin nhiu bnh khc
nhau, tn thng cu thn cng a dng mc d cc biu hin lm sng v sinh ha
tng i ging nhau. Nh vy, thn h nhim m khng phi l mt bnh n
thun nh quan nim trc kia.
Hi chng thn h (HCTH) thng biu hin tn thng ti thiu cu thn hoc
nhng tn thng dy v thoi ha mng y ca mao mch cu thn.
HCTH n thun nguyn pht nhy cm vi Corticoides thng khng c tng
huyt p, suy thn v tiu mu. Mt s ln trng hp khng li di chng tui
trng thnh.
II. DCH T HC
Bnh gp ch yu tr em, 90% trng hp xy ra tui di 16.
Tn sut gp 2/ 30.000 tr em, ngi ln gp t hn 2/300.000.
tr em, HCTH tin pht xy ra tr trai nhiu hn tr gi (t l nam / n l 2/1).
Tui thng gp nht tr em l 2 - 8 tui, v thng l HCTH n thun.
Ngi ln t gp hn, thng l HCTH khng n thun v xy ra c hai gii.
Theo William G. Couser khong 1/3 bnh nhn ngi ln v 10% bnh nhn tr em
c HCTH l triu chng ca mt bnh ton th, thng l i tho ng, Lupus
ban ri rc hoc Amylose thn. S cn li l HCTH nguyn pht.
272
Mt qua nc tiu HDL v apo A1 cng c ghi nhn, nhng nng ca HDL
huyt tng phn ln l bnh thng.
Tc ng sinh x va ca nhng bt thng Lipide ny cha c chng minh mt
cch r rng, c l v thi gian ngn trong tin trin ca HCTH.
Tng Lipde mu cng c th to thun li ngng tp tiu cu v nhng bin chng
huyt khi tc mch, lm gim p ng ca Lymph bo i vi nhng kch thch
khng nguyn. Tng Lipde mu cng c th l mt yu t ca x ho cu thn.
5. Tng ng mu.
Nhiu bt thng cm mu c quan st thy trong HCTH, l nguyn nhn gy ra
tng ng mu v nhng bin chng huyt khi tc mch. Tng ng mu trong
HCTH do cc c ch sau:
- Gia tng fibrinogen mu do tng tng hp gan.
- Gia tng cc yu t II,V,VII,VIII v X, gim cc yu t IX,XI,XII do bi tit trong
trong nc tiu v trng lng phn t thp.
- Gim hot ng tiu fibrin do gim plasminogene v tng antiplasmine (alpha
2 macroglobuline, alpha 2 antiplasmine).
- Thiu ht nhng cht c ch qu trnh ng (Prtin C, antithrombin III).
- Tng ngng tp tiu cu.
Nhng bt thng ny, kt hp vi tng Lipide mu v gim th tch mu, to
thun li xut hin huyt khi tnh mch v tc mch phi.
6. Tng kh nng b nhim trng
Dng nh l do gim gammaglobulin mu, ngoi ra cn do mt b th qua nc
tiu. Chnh nhng iu ny lm sai st ca p ng Lymph bo i vi khng
nguyn.
7 Suy dinh dng v chm pht trin
Ngoi nhng tc dng ca stroide, suy dinh dng v chm pht trin do mt
prtin v mt nhng hocmn gn lin vi cht mang prtin (TBG,T3,T4, Vitamin
D)
V. TRIU CHNG
1. Ph
Thng xut hin nhanh, t ngt, cng c th ph xut hin sau nhim trng nh
ng mi hng.
Tnh cht ca ph: Ph trng mm, n lm, gi du n lu, ph ton thn, khng c
hin tng vim au vng b ph. C th c dch cc mng bng, mng phi,
mng tim, b phn sinh dc.
Cc bin chng nng: ph phi, ph thanh qun thng gp tr em.
2. Triu chng nc tiu
Lng nc tiu thng t 300-400ml/24 gi.
Mt nhiu protein niu: trn 3,5gam/24 gi. C th t 3-10g/24 gi, trng hp nng
c th 30-40g/24 gi.
276
VIM CU THN CP
Mc tiu
1. Trnh by c nh ngha, dch t hc v nguyn nhn ca vim cu thn cp.
2. M t c c ch sinh bnh vim cu thn cp
3. Pht hin c cc triu chng lm sng, cn lm sng vim cu thn cp.
4. Chn on xc nh, chn on phn bit ca vim cu thn cp.
5. iu tr c vim cu thn cp.
Ni dung
I. I CNG V DCH T HC
1. i cng
Hi chng vim cu thn cp l biu hin lm sng ca mt thng tn vim cp
ca nhng cu thn, c trng vi s xut hin t ngt hng cu niu, protein niu,
ph v tng huyt p.
Hin nay, nh nhng tin b khoa hc, nht l k thut sinh thit thn. Ngi ta u
thng nht rng: Vim cu thn cp (VCTC) khng ch l mt bnh n thun m l
mt hi chng gi l hi chng cu thn cp. L do l v bnh cnh lm sng thng
ging nhau nhng tn thng m bnh hc li a dng, bnh pht sinh khng ch do
lin cu m c th sau nhim t cu, ph cu, virus.Hi chng vim cu thn cp
cn biu hin th pht sau cc bnh nh lupus ban h thng, ban dng thp,
vim quanh ng mch dng nt.
Vim cu thn cp c tnh hay vim cu thn bn cp hin nay c gi l vim cu
thn th tin trin nhanh. Tn gi ny c trng cho bnh l tin trin nhanh, t vong
sm do suy thn v t khi ngi bnh qua khi 6 thng nu khng c iu tr .
2. Dch t hc
2.1. T l mc bnh: t l mc bnh VCTC sau nhim lin cu khng c bit mt
cch chnh xc v nhiu trng hp bnh c gi iu tr ngay tuyn trc. Tn
sut bnh gim dn cc nc cng nghip hin i, nhng vn cn thng gp
cc nc nhit i, cc nc ang pht trin. (Chu Phi, vng Carib, Chu , Nam
M...).
Bnh xut hin di dng tn pht, hoc c th thnh tng v dch, c bit
nhng ni i sng v sinh km (nhng v dch Trinidad, Maracaibo, Minnesota)
2.2. Lin quan gii v tui: Bnh rt him trc hai tui, thng gp tr con t 3
n 8 tui, tr nam thng gp hn n (t l nam/n = 2/1). ngi ln t gp hn
so vi tr em.
II. CN NGUYN
Vim cu thn cp c th do nguyn nhn nhim khun hoc khng do nhim
khun.
1. Vim cu thn cp do nhim khun gm
1.1. Vi khun thng gy bnh nht l lin cu tan huyt bta nhm A (group A)
c coi l mu hnh ca vim cu thn cp. Chng thng gy bnh nht l chng
12, cc chng khc (1, 2, 4, 18, 24, 25, 49, 55, 57, 60) cng c th gy bnh nhng
281
him gp hn, Thng chng 4, 12, 24 nu l nhim khun c hng, chng 14,
19, 50, 55, 57 nu l nhim khun ngoi da (khc vi thp khp cp v trong thp
khp cp chng lin cu no cng c th gy bnh).
1.2. Mt s vi khun khc him gp hn cng c th gy vim cu thn cp nh t
cu, ph cu, thng hn, no m cu, Klebsiella Pneumoniae,...
1.3. Mt s siu vi gy vim hng cp dch t, quai b, si, thy u, Epstein Barr,
vim gan siu vi B, Cyto megalo Virus (CMV)...
1.4. Nguyn nhn do nhim nm: Histoplasmose
1.5. Nguyn nhn do nhim k sinh trng: Plasmodium falciparum v Malariae,
Toxoplasma Gondii, sn mng,...
2. Vim cu thn cp khng do nhim khun
2.1. Cc bnh to keo: c bit l luput ban h thng, vim quanh ng mch
dng nt, btut huyt dng thp.
2.2. Cc bnh biu hin qu mn cm vi mt s thuc nh Penicilline, Sulfamide,
Vaccine hay mt s thc n nh tm, cua...
III. S TM TT C CH VIM CU THN CP DO LIN CU
KHUN
Khng nguyn (KN) Khng th (KT)
Lin cu tan huyt bta - AHL (antihyaluronidaza)
- ASLO (antistreptolysin O)
- ANDAZA (antidesoxyribo nucleaza)
- ASK (antistreptokinaza) lu hnh
Phc hp KN - KT
tr lng cu thn Hot tc cc b th
90% bnh nhn c b th mu gim, gim thnh phn C3 l ch yu. Sang tun th
su ca bnh mi tr v bnh thng.
1.2.5. Cc xt nghim khc
Ch yu pht hin lin cu v cc khng th nh ngoy hng tm lin cu khun,
ALSO tng hn 400v Todd, in tim c PR ko di.
1.2.6. Sinh thit thn
Ch cn thit ngi ln tui, gip chn on th gii phu bnh v gip tin lng
bnh.
Trong thc t 2 xt nghim hng cu niu v protein niu cng xc nh
VCTC.
1.3. Tin trin: Vi nhiu kh nng
- Tt: l din tin thng gp ca bnh VCTC, sau 8-15 ngy bnh nhn i nhiu,
ht ph, huyt p v nc tiu tr li bnh thng. C trng hp sau 3 thng, c
khi 6 thng cc triu chng trn mi tr li bnh thng. Nhng trng hp ny gi
l khi chm, t l ny t. tr em, t l khi bnh cao (85-95%) so vi ngi ln
(50-75%).
- Xu
+ Vim cu thn cp th tin trin nhanh hay c tnh ch din tin vi tun hoc vi
thng, c khi dai dng hn, nhng thng t vong trong vng 6 thng,chim t l
di 10%. Lm sng khi pht nhVCTC kinh in nhng dn n suy thn cp
nhanh.
+ Tin trin xu cng dn n t vong ngoi 6 thng: ph v protein niu dai dng,
thng xut hin hi chng thn h, trc y gi l vim cu thn cp bn cp,
bnh dn dn suy thn, khng phc hi.
+ Bnh din tin ko di nhiu nm vi tng t lui bnh, nhng cui cng cng dn
n t vong, hn m do tng ur mu hoc do tai bin mch no do tng huyt p
gi l suy thn mn.
Tt nht cho c ph phi, no, v niu l lc ngoi thn m thn nhn to ng vai
tr hng u.
4.5. Cc triu chng khc
- Tng ur mu, creatinine mu, hn ch lng protid a vo nhng phi
m bo nng lng 1200-1600 calo/ngy chng d ha, c th cho Durabulin
hoc Testosterone 25-50mg/ngy.
- iu tr tng K mu bng glucose 20-30%, 300-500ml + 10-20v insulin truyn tnh
mch trong 1 gi n 1g30 pht hay truyn dung dch kim, hoc c th s dng
Resonium (Kayexalate) ung 30g/ngy.
Hon cc tim phng trong thi gian mc bnh vim cu thn cp v ngay c hai
nm u sau khi ht vim cu thn cp, nht l vaccin chng ho g, un vn.
Trong vim cu thn cp th thng thng iu tr i khi ch cn ngh ngi, n nht
l . Trong khi nhng th nng, ty thuc vo bin chng v c cch iu tr khc
nhau. Cng cn lu rng khi pht hin c nguyn nhn ca vim cu thn cp
th vn iu tr nguyn nhn l quan trng
VII. D PHNG
1. i vi vim cu thn cp sau nhim khun lin cu
- Pht hin sm cc nhim khun do lin cu: vim hng, vim Amygdals,
vim da...
- iu tr trit cc nhim khun do lin cu: khng sinh, ct amydals.
- Nng cao v sinh c nhn: b thuc l, gi m c trong ma lnh i vi
vim hng, v sinh c nhn i vi gh bi nhim.
2. i vi vim cu thn cp khng do nhim khun
- Pht hin sm cc biu hin thn trong cc bnh ton th: lupus ban h
thng, ban xut huyt dng thp.
- iu tr tt cc bnh ton th d phng tn thng vim cu thn.
287
SI H TIT NIU
Mc tiu
1. Nm c dch t, nguyn nhn v c ch sinh bnh ca si h tit niu.
2. Bit c din tin ca si v nh hng ca si i vi ng tit niu.
3. Nu c triu chng lm sng v cn lm sng ca si h tit niu.
4. Chn on c v bit ch nh cc phng php iu tr si h tit niu.
5. Bit c cc phng php iu tr ni khoa v bit cch ch nh iu tr ngoi
khoa si tit niu
Ni dung
I. I CNG
Si thn v h tit niu l bnh thng gp nht ca ng tit niu v thng gp
nam gii nhiu hn n gii. Tui mc bnh thng l t 30 - 55, nhng cng c
th gp tr em (si bng quang). Ti cc nc cng nghip pht trin, si Acide
Urique c chiu hng gp nhiu hn cc nc ang pht trin. Vit Nam, si
Amoni-Magi-Phosphat (Struvit) chim mt t l cao hn. Ch n ung khng
hp l (qu nhiu m, Hydrat Carbon, Natri, Oxalat), nhim khun tit niu hoc
sng vng nng, vng nhit i,... l nhng yu t thun li bnh si thn tit
niu d pht sinh. Cc loi si Calci thng l si cn quang, cn si Urat v Cystin
thng khng cn quang.
Theo tc gi Glenn. H. Pneminger t l mc bnh si thn tit niu trn th gii vo
khong 3% dn s.
II. NGUYN NHN V C CH SINH BNH
1. Cu trc ca si
Bowman v Meckel nghin cu si niu v nhn thy vin si c mt tnh cht
c th gm hai yu t:
- Cht Mucoproteine, c tc dng nh cht keo kt dnh cc tinh th vi nhau to
si.
- Cc tinh th ca cc cht bnh thng c ha tan trong nc tiu, ch yu l
Calci v Oxalat. Bn cnh cc cht thng gp ny cn c cht Phosphat, Magi,
Urat, Cystine.
Vai tr ca Mucoprotein trong c ch to si hin nay vn cn c bit rt t.
C th ni rng khi nc tiu b c c hoc khi pH ca nc tiu thay i, th cc
cht ha tan trong nc tiu s kt tinh li thnh cc tinh th, cc tinh th s b loi
tr theo dng nc tiu. Cn phi c cht Mucoproteine th cc tinh th mi lin kt
li vi nhau to ra vin si. Do nhiu trng hp khi th nc tiu, thy c
nhiu tinh th Oxalate hay Phosphate nhng bnh nhn khng c si thn tit niu.
2. iu kin thun li pht sinh ra si
iu kin thng xy ra nht l s c c qu mc ca nc tiu.
Trong iu kin bnh thng, nu c hai iu kin sau y th cc tinh th ha tan c
th lng ng c:
- Dung dch c yn tnh, khng b khuy ng trong mt thi gian di.
288
+ Bnh Gt (Goutte).
+ Phn hy cc khi ung th khi dng thuc ha tr liu.
3.5. Si Cystin:
c hnh thnh do mt khuyt tt ca vic ti hp thu ng thn ca cht
Xystin tng i t gp nc ta. Si Cystin khng cn quang.
4. L thuyt hnh thnh si
BNH CU THN
Mc tiu
1. Nm c nh ngha, cc cch phn loi ca bnh cu thn
2. Chn on xc nh vim cu thn cp, vim cu thn th tin trin nhanh hay c
tnh.
3. Chn on xc nh c vim cu thn mn nguyn pht, th pht.
4. Bit iu tr cc vim cu thn mn nguyn pht, th pht.
Ni dung
I. I CNG
1.nh ngha
Bnh cu thn l s thng tn chc nng hay thc th biu hin cu thn vi
c im lm sng l ph, Protine niu, tng huyt p, din tin mn tnh v
thng a n suy thn mn. Chn on bnh cu thn ch yu da vo sinh thit
thn. Tin lng ca bnh tu thuc vo nguyn nhn v tn thng m hc trn
sinh thit.
2. Phn loi
C nhiu cch phn loi bnh cu thn, c th k n cc phn loi ca Hambuger
1980, Brenner 1985 v ca Cohn 1991. Di y chng ti cp n cch phn
loi n gin nht c gii thiu bi hip hi cc gio s thn hc Php 2003,
phn loi ny chia bnh cu thn lm hai nhm chnh, tu thuc vo din tin cp
hoc mn tnh ca bnh:
2.1. Cc bnh cu thn cp tnh
- Vim cu thn cp sau nhim lin cu.
- Vim cu thn th tin trin nhanh.
- Bnh cu thn do nhim c thai nghn.
- Bnh cu thn do Lupus.
2.2. Cc bnh cu thn mn tnh
- Bnh cu thn c tn thng ti thiu (thn h nhim m)
- Bnh cu thn x ho v on.
- Vim cu thn mng (trn mng hoc ngoi mng).
- Vim cu thn tng sinh mng.
- Bnh cu thn IgA (bnh Berger)
- Bnh cu thn i tho ng.
- Amylose thn.
- Hi chng Alport.
II.CC TH BNH CHNH THNG GP
1. Vim cu thn cp
296
Nguyn nhn do lin cu khun Beta tan mu nhm A, type 12 in hnh cho mt
vim hng, type 49 in hnh sau vim da m. Lm sng cu th thng thng xut
hin sau 10-21 ngy vim hng t ngt xut hin au vng tht lng hai bn, thiu
niu, ph ch yu hai m mt, mt c chn v thng c st km theo. Nc tiu t,
di 500 ml/24 gi, mu nht do nc tiu c nhiu hng cu, c mu sm
khi tiu mu i th.
Tng huyt p c ti a ln ti thiu l thng gp mc va phi
Xt nghim c ASLO tng trn 400 n v Todd, Proteine niu t 0,2-3 g/24 gi, cn
Addis c hng cu t 100.000-500.000/1 pht, nhng bch cu di 20.000/ 1 pht
(cn gi l tnh trng phn ly hng - bch cu trong nc tiu). Thng thy tr hng
cu, tr ht.
Tin trin thng tt: lnh bnh 75-95 % tr em v 50-70 % ngi ln.
2. Vim cu thn cp th tin trin nhanh hay c tnh
c im lm sng thng nng tin trin nhanh n suy thn thng khng hi
phc. V gii phu bnh l c s tng sinh rng ra ngai mao qun xm ln khang
Bowman, bp cht cc vi huyt qun. Bnh chim khong 1% bnh cu thn vim,
c th gp bt c la tui no, c th khi u sau mt vim hng hay vim da.
2.1. Phn lai theo cc type sau
-Type I: Lng ng IgG trn mng y + Khng th khng mng 20%
-Type II: c hiu vi s lng ng phc h min dch vi IgG v b th 40%
-Type III: Khng c lng ng min dch trn cu thn.
Du hiu lm sng ch yu l thiu niu ri nhanh chng a n v niu vi suy
thn nng. Ph kn o huyt p bnh thng hoc tng nh, trong mu i khi tng
(globulin. Bnh t vong trong vi tun n vi thng. Trong mt s trng hp him
c th tr v bnh thng, thng gp sau nhim lin cu,gii phu bnh l thy
thng tn c trong v ngoi mao qun, cc cu thn b ph hy hon ton trong vi
ba ngy, trn min dch hunh quang lng ng lan ta cht fibrin trn cc thng
tn hnh lim, IgG lng ng trn mng y tng ng vi khng th khng mng
y.
3. Vim cu thn mn
Theo quan nim hin nay, vim cu thn mn sau nhim lin cu khun ch chim
10 %, cn li l th pht sau mt bnh l khc v v cn.
3.1. Vim cu thn mn nguyn pht
l vim cu thn khng r nguyn nhn. Do thiu d kin v cn nguyn, phn
loi da trn gii phu bnh v lm sng.
3.1.1.Hi chng thn h do tn thng ti thiu
Hu qu ca mt Protein niu nhiu ch yu l Albumin, c th bt gp sau nhng
thng tn thn hon ton khc bit nhau. Thng gp l mt hi chng thn h
n thun xut hin t ngt, Protein niu nhiu, ph, gim Protit mu, tng Lipit,
Cholesterol mu. Bnh xut hin khng c mt nguyn nhn r rt, thng gp tr
em, nam nhiu hn n, ngi ln th t l hai gii nh nhau.
Thng tn ti thiu khi sinh thit thn, thy bnh thng trn knh hin vi quang
hc, trn knh hin vi in t thnh mao mch bin i xm nhp lan ta vo chn
297
ng cht Hyalin v tn thng x ho tng , tng on, trn knh hin vi min
dch hunh quang thy c lng ng ca IgM v ca C3 tng on.
Tin lng thng xu, a n suy thn tin trin trong 25% trng hp tr em
v trong 70% trng hp ngi ln. Thng a n suy thn mn giai on cui
trong vng 5 n 20 nm
3.2. Vim cu thn th pht mt bnh ton th
3.2.1. Vim cu thn cp bnh nhn Lupus ban
Vim cu thn chim khong 70% trong lupus ban , thng gp ph n tr vi
c im hng ban da, d cm, vi ban hnh cnh bm mt, gy st, st, au
khp..., xt nghim thy c t bo Hargraves, nht l khng th khng nhn trong
mu. Lm sng gm c hi chng thn h khng c tng huyt p, thng tn
khng c hiu vi s lng ng lm dy mng y to nn vng st, th
hematoxylie trong vng m. Tin lng c th suy thn v thng khng c tng
huyt p.
3.2.2. Hi chng Good Pasture hay vim cu thn th on hoi t vi vim ph
nang xut huyt
Thng gp nam nhiu hn n, khi u bng ho ra mu, hnh nh phi m hai
bn khng r rt, sau gy thng tn thn, sau vi thng gy suy thn, tng
huyt p dn n t vong. Cc ph nang vim xut huyt cha y cc i thc bo
sc t st, thn hai t dng fibrin ri dng trong ha. Ngi ta chng minh
nhng thng tn ny phi hp vi t khng th hat ng ng thi chng c ph
nang v mng y cu thn.
3.2.3. Vim cu thn do ban dng thp hay ban Schonlein-Henoch
Thng tn thn chim 35% trong bnh ny. Lm sng thng c i mu, cu
thn thng tn on, Min dch hunh quang thy lng ng IgA vng m v
thnh. Bnh gy thng tn hu ht cc cu thn, tin lng xu, tin trin dn
sang suy thn.
3.2.4. Bnh Amylose thn
Thng gp trong bnh Amylose ph tng, th pht sau cc bnh nhim trng hoc
vim nhim ko di nh vim xng, lao, vim khp dng thp, phong, lit hai chi
di. Bnh c th nguyn pht. Ti Vit nam cha ghi nhn trng hp no, nhng
vng a trung hi c th gp cc la tui nhiu nht t 50-60 tui.
Lm sng biu hin l hi chng thn h, c th ch c proteine niu n thun km
gan lch to, c th i mu vi th, tng huyt p t gp, dn n suy thn. V tiu
ha biu hin bng i chy, to bn, xut huyt, li to, gan to nhng chc nng
gan bnh thng.
Gii phu bnh thy lng ng cc cht dng bt (amyloide) bt mu sang mu
tm ng nh vi cu trc si c hiu trn knh hin vi in t, cht ny bn cht l
Protein, c tm thy ngoi t bo, trong gian cht v thnh.
3.2.5. Bnh cu thn do i tho ng
L tn thng cu thn do i tho ng gy ra, c hin tng x cng cu thn
lan ta, biu hin ban u l dy khng u mng y mao qun cu thn vi lng
ng ni b. Lm sng giai an u l c proteine niu, c hay khng km theo hi
chng thn h, i mu vi th c xu hng chuyn sang suy thn c tng huyt p.
299
Mc suy thn
305
IV. CHN ON
1. Chn on xc nh: Ch yu da vo: tin s, triu chng lm sng v cn lm
sng.
2. Chn on phn bit: Cn phn bit vi vim cu thn thn mn, da vo:
- Ph hay gp hn, tng huyt p xut hin sm hn
- Nc tiu: hng cu nhiu hn bch cu, khng c m trong nc tiu, lng
Protein niu nhiu hn, ch yu l Albumin.
- Thn nh nhng cn xng, b u.
V. IU TR
1. iu tr nhim trng
Ch yu l cc t cp hoc giai on c vi trng niu mc d khng c triu chng
lm sng nhng pht hin qua theo di t bo vi trng niu.
Dng khng sinh theo khng sinh , trnh cc loi khng sinh c thn.
2. Loi b cc yu t thun li: u, si...
3. iu tr tng huyt p, ri lon toan kim, in gii, thiu mu...
316
SUY THN CP
Mc tiu
1. Lit k c cc nguyn nhn ca suy thn cp.
2. Tp hp c cc triu chng lm sng, cn lm sng ca suy thn cp.
3. Bit r cc bin chng ca suy thn cp.
4. nh gi cc triu chng chn on xc nh, gin bit v th bnh ca suy
thn cp.
5. iu tr c suy thn cp.
Ni dung
I. I CNG V DCH T HC
1.i cng
Suy thn cp l mt hi chng xut hin khi chc nng thn (ch yu l chc nng
lc cu thn) b suy sp nhanh chng, xy ra t ngt bnh nhn khng c suy
thn trc hoc bnh nhn mc suy thn mn. Mc lc cu thn c th b
suy gim nng nhng c th c hi phc hon ton mt cch t nhin hoc di
nh hng ca iu tr nguyn nhn. Suy thn cp th hin trn lm sng c trng
vi v niu, nhng c nhng th bnh vn c lng nc tiu bo tn. Gn y
chn on suy thn cp da vo s gia tng cratinine mu so vi cratinine cn
bn bit: nhiu hn 50mmol/l i vi cratinine cn bn di 250 mmol/l hoc
nhiu hn 100 mmol/l i vi cratinine mu cn bn trn 250 mmol/l.
2. Dch t hc
Suy thn cp l mt hi chng tng i t gp. Trong thc t, tn sut mc bnh
ny ch c th c nh gi bng s lng nhp vin hng nm: 1 - 3% bnh nhn
nhp vin hng nm.
Tin lng ca suy thn cp thng l tt nu kh nng phc hi chc nng thn
tt dn. Tuy vy, cn phi tnh n nhng yu t nguy c lm nng ca suy thn
cp: bnh nguyn, ln tui, c a suy yu, kt hp vi suy cc tng khc, iu kin
iu tr (thm phn, dinh dng) v cui cng l kinh nghim ca i ng iu tr.
II SINH L BNH
Chc nng lc cu thn trong suy thn cp gim hoc mt hn, xy ra do cc c
ch sau:
- Gim dng mu qua thn (gim th tch, sc).
- Tnh khng ca tiu ng mch i gim (dn mch sau cu thn).
- Tnh khng ca tiu ng mch n tng (co mch trc cu thn).
- p lc cu thn (nang Baoman) gia tng (tc nghn trong lng ng thn hoc trn
ng bi tit).
- Ngoi ra suy thn cp cn c th do gim tnh thm ca mch mu thn m c ch
hin nay cn cha c bit r.
III. NGUYN NHN
1. Nguyn nhn trc thn (suy thn cp chc nng)
317
318
rung tht, ngng tim. Khi c Kali mu trn 5mmol/l cn theo di k in tim v x tr
h Kali mu kp thi. Trn in tim tng Kali mu biu hin sm l sng T cao nhn,
i xng ri QRS di, PR di, Bloc xoang nh, mt sng P ri ngng tim c hoc
khng qua giai on rung tht. Trong suy thn cp tng Kali mu ny cng nng
thm do hin tng toan mu.
Toan mu l hu qu t tng chuyn ha, d tr kim gim 1 - 2 mmol/ ngy, bnh
cng nng th gim cng nhanh, d tr kim c khi gim di 10mmol/l, hin tng
ny lm cho Kali mu tng cng nhanh.
Mt khc, ri lon in gii trong suy thn cp cn c gim Calci, Natri, tng Mg v
Phosphate.
- Nhim trng: trong giai on v niu nhim trng l nguyn nhn hng u gy t
vong thng l nhim trng ng h hp, tit niu v ngoi da.
3 Giai on tiu nhiu
Thng bt u t 300ml/24gi sau bnh nhn tiu nhiu, thng vo ngy th
3 ca giai on ny lng nc tiu t 1lt/ngy. Giai on ny gi l khng hong
v nc tiu c khi ti 3 - 4 lt/24 gi v d gy ri lon nc in gii nng, try tim
mch, nhim trng, vim tc tnh mch, nht l d ho c gy gy nhiu. Trong giai
on ny nu iu chnh nc in gii khng hp l th d gy t vong. Cc ch s
v sinh ho trong mu ch bt u gim dn sau vi ngy i nhiu, ngha l trong
nhng ngy u i nhiu th ur mu, creatinine vn cn tng cao v ur, creatinine
niu vn cn thp. Lng ur, creatinine tng cng nhanh trong nc tiu th s
phc hi cng sm v tin lng cng tt, ng nhin l phi gim song song cc
cht ny trong mu v c nh gi chnh xc bng thanh thi creatinine ni
sinh. Gim Kali v Natri c nh gi bng in gii hng ngy b kp thi.
Trong giai on ny, t trng nc tiu thp di 1,005.
4. Giai on phc hi
Ur, creatinine mu gim dn, mc c c nc tiu tng dn, lm sng tt ln,
tuy nhin chc nng thn phc hi rt chm: kh nng c c c khi phi hng nm
mi hi phc. Mc lc cu thn phc hi nhanh hn.
IV. BIN CHNG V TIN LNG CHUNG
- Trc kia, t l t vong rt cao, c khi n 90%. Hin nay nh nhng tin b khoa
hc k thut, nht l trong lnh vc lc ngoi thn v k thut hi sc, t l t vong
cn khong 50%, T l t vong c lin quan vi:
+Bnh l nguyn nhn: sc nhim trng hoc xut huyt, suy h hp, chn thng
nng,vim tu cp, co git.
+ C a: ln tui, bnh mch vnh, suy h hp, i ng, ung th.
+ Nhng bin chng th pht ca hi sc v c bit nhim trng bnh vin (nhim
trng cathether,bnh phi), suy dinh dng
- Nhng bin chng chnh:
+ Nhng bin chng chuyn ho ring ca suy thn cp: Toan chuyn ho v tng
kali mu. Tng th mu v ph phi. Nguy c suy dinh dng.
+ Nhim trng bnh vin (do t Sonde bng quang hoc v niu ko di lm ng
bi niu mt kh nng khng)
321
- Truyn tnh mch Bicarbonat ng trng 1,4 g% hoc trong trng hp cn thit
s dng loi m c 4,2%, 8,4%.
2.5. iu tr lc ngoi thn.
Nht l thn nhn to theo cc tiu chun ca chy thn nhn to trong quan
trng l khi c 1 trong 2 tiu chun sau: Ur >30 mmol/l, Kali mu >6 mmol/l.
3. iu tr suy thn cp sau thn
Suy thn cp sau thn cn gi l suy thn cp tc nghn. Cho nn iu tr quan
trng nht l iu tr loi b yu t tc nghn ny.
4. iu tr nguyn nhn.
Ty tng nguyn nhn iu tr nh iu tr st rt trong nguyn nhn suy thn cp
sau st rt i huyt cu t; m ly si trong suy thn cp sau si tc nghn...
325
SUY THN MN
Mc tiu
1. Trnh by c nh ngha, c ch sinh bnh ca suy thn mn.
2. Xp loi cc nguyn nhn ca suy thn mn.
3. Tp hp c cc triu chng lm sng, cn lm sng ca suy thn mn
4. Chn on xc nh, chn on giai on ca suy thn mn.
5. iu tr suy thn mn trc giai on cui.
6. Ch nh cc phng php iu tr thay th thn suy
Ni dung
I. I CNG V DCH T HC
1. i cng
Suy thn mn l hu qu ca cc bnh thn mn tnh ca thn gy gim st t t s
lng nephron chc nng lm gim dn mc lc cu thn.
Khi mc lc cu thn gim xung di 50% (60ml/pht) so vi mc bnh thng
(120ml/pht) th c xem l c suy thn mn.
Suy thn mn l mt hi chng din bin theo tng giai on: trong giai on sm,
lm sng ch c mt s triu chng rt kn o, ngc li vo giai on cui biu
hin rm r vi hi chng tng ur mu. Qu trnh din bin ca suy thn mn c
th ko di t nhiu thng n nhiu nm.
2. Dch t hc
Xc nh t l mi mc, mc bnh suy thn mn l mt vn kh khn bi trong
suy thn mn giai on u ngi bnh thng t i khm bnh v t hoc khng c
triu chng lm sng. Suy thn mn trc giai on cui t c bit r v khng c
ng k v khng c theo di, nhng t l mi mc suy thn mn giai on cui
cn c iu tr thay th thn suy th ngi ta c th bit c mt cch chnh xc.
Theo thng k Php t l mi mc suy thn mn giai on cui l 120 trng hp
/ 1 triu dn / nm. M v Nht l 300 trng hp / 1 triu dn / nm (s liu nm
2003).
- T l mc bnh suy thn mn c khuynh hng gia tng theo thi gian v khc
nhau gia nc ny v nc khc.
- Suy thn mn l mt bnh l xy ra ch yu ngi ln. Thng k ca Php trong
s 70 bnh nhn mi mc suy thn mn giai on cui th ch c 5 bnh nhn l tr
em v thanh nin, v 65 bnh nhn l ngi ln. Suy thn mn cng c lin quan
vi gii tnh, nam mc bnh hn n hai ln (2/1). tui trung bnh ca s bnh
nhn mi bt u iu tr suy thn mn giai on cui tng dn: nm 1987 l 55 tui,
nm 1998 l 61 tui.
II. NGUYN NHN
Hu ht cc bnh l thn mn tnh d khi pht l bnh cu thn, bnh ng k thn
hay bnh mch thn u c th dn n suy thn mn.
1. Bnh vim cu thn mn
Thng hay gp nht, chim t l 40%
326
- Kali mu: kali mu c th bnh thng hoc gim. Khi Kali mu cao l c biu hin
t cp c km thiu niu hoc v niu.
- Calci mu, phospho mu: trong giai on u calci mu gim, phospho mu tng.
Trong giai on c cng tuyn cn gip th pht th c calci mu v phospho
mu u tng.
- Nc tiu:
+ Protein niu: ty thuc vo nguyn nhn, khi suy thn giai on III, IV th lun c
protein niu nhng khng cao.
+ Hng cu, bch cu: ty thuc nguyn nhn gy suy thn mn.
V. CHN ON
1. Chn on xc nh
Da vo:
- Du chng ca Suy thn:
+ Tng ur, cratinine mu.
+ Mc lc cu thn gim.
- Tnh cht mn ca suy thn: c 3 tiu chun:
+ Tiu chun tin s: c tin s bnh thn, trc y c tng cratinine mu.
+ Tiu chun v hnh thi: Kch thc thn gim (chiu cao < 10cm trn siu m, < 3
t sng trn phim chp thn khng chun b).
+ Tiu chun v sinh hc: C 2 bt thng nh hng n suy thn mn:
* Thiu mu vi hng cu bnh thng khng bin dng.
* H canxi mu.
2. Chn on giai on
Da vo h s thanh thi cratinine, cratinine mu: suy thn mn c chia
thnh cc giai on sau
Giai on Cratinine mu
HSTT cratinine (ml/pht)
suy thn mn micromol / l mg / dl
Bnh thng 120 70-106 0,8 - 1,2
I 60-41 < 130 < 1,5
II 40-21 130 - 299 1,5 - 3,4
IIIa 20-11 300-499 3,5 - 5,9
IIIb 10-5 500-900 6,0 - 10
IV <5 > 900 > 10
3. Chn on nguyn nhn
Tm cc nguyn nhn gy ra suy thn mn c ngha quan trng trong chn on.
Khi loi tr c nguyn nhn th suy thn mn mc d khng hi phc nhng c
th lm chm tin trin ca suy thn mn.
329
Cc nguyn nhn suy thn mn bao gm: bnh cu thn mn, bnh vim thn b
thn mn, bnh mch mu thn, bnh thn bm sinh v di truyn.
4. Chn on phn bit
Cn chn on phn bit vi
- Suy thn cp: da vo Bnh s - Nguyn nhn - Tin trin ca suy thn.
- t cp ca suy thn mn:a vo tin s, t l ur mu / cratinine mu
(mol/l) > 100
5. Chn on bin chng
Ch n cc bin chng trn tim mch, mu, tiu ho, thn kinh, nhim trng, ri
lon nc in gii, kim toan...
6. Chn on cc yu t gy nng nhanh ca suy thn
- Tng huyt p
- Nhim khun, xut huyt tiu ho, mt nc
- Tc nghn ng bi niu
- Dng thuc c cho thn
- n qu nhiu prtin
VI. IU TR
Ty thuc vo giai on ca suy thn mn m bin php iu tr p dng c khc
nhau. Hn na cn ph thuc vo yu t kinh t, x hi nht l cc bin php iu tr
thay th thn suy.
1 iu tr suy thn mn trc giai on cui.
Tng ng vi iu tr suy thn mn cc giai on I, II v IIIa, khi thanh lc cu
thn cn trn 10 ml/pht. Cc bin php ny bo tn chc nng thn cn li
1.1. Nguyn tc chung.
- Khi bnh nhn b mt bnh l thn mn tnh, d cha c suy thn hoc suy thn
nh th cng phi c theo di bi thy thuc chuyn khoa thn, nhm pht hin
v iu tr cc yu t gy nng, theo di c h thng ngi bnh tu thuc vo mc
nng nh ca suy thn mn.
- Mc ch ca theo di bnh
+ Theo di liu trnh iu tr bnh thn.
+ Ngn chn s tin trin ca suy thn mn.
+ Trnh cc thuc c cho thn v iu chnh liu thuc cho ph hp vi mc
suy thn.
+ iu tr cc bin chng ca suy thn mn, cc yu t nguy c tim mch, c bit
l tng huyt p v cc yu t i km.
+ Thng tin cho bnh nhn v chin lc iu tr tu theo tng bnh nhn v tng
giai on ca suy thn.
+ Chun b cho vic iu tr thay th thn suy giai on cui: Chng nga vim
gan Virus B, giai on IIIa c th lm ni thng ng - tnh mch.
330
1.4.5. iu tr thiu mu
- Mc ch ca iu tr l duy tr Hb mu 11 n 12 g/l.
1.4.6. iu tr ri lon nc in gii
- Ch n nht: c p dng trong hu ht cc bnh thn.
- Gim lng nc ung vo trong trng hp c ph.
- iu tr Tng Kali mu
2. iu tr suy thn mn giai on cui.
Khi mc lc cu thn gim di 10 ml/pht, ngoi cc phng php ca iu tr
bo tn nh trn, m bo s sng ca ngi bnh cn thit phi c cc phng
php iu tr thay th thn suy, bao gm:
+ Ghp thn.
+ Thn nhn to.
+ Lc mng bng.
III.D PHNG
- D phng cp 1: Loi tr nhng yu t nguy c dn n bnh l thn, tit niu
nh ch sinh hot c nhn, v sinh, n ung, s dng thuc c vi thn.
- D phng cp 2: Pht hin sm bnh l thn, tit niu bng thm khm lm
sng, protein niu, iu tr trit bnh l thn tit niu.
- D phng cp 3: Khi c suy thn mn. D phng ny bao gm cc bin php
c hiu: xc nh nguyn nhn, iu tr c hiu qu loi tr bnh l nguyn nhn
dn n suy thn mn, hoc nhng bin php khng c hiu: loi tr cc yu t
lm tin trin nng nhanh ca suy thn.
332
- Giai on 5: L giai on suy thn giai on cui. Nhng bnh nhn ny chim mt
phn quan trng trong s bnh nhn c iu tr nhng trung tm lc mu ngoi
thn v ghp thn.
Khi mc bnh i tho ng khng ph thuc insulin (thng gp cao hn 10 ln
so vi nhm khc), bnh thn cng l mt bin chng thng gp, xut hin trong
20 - 40% ca nhng bnh i tho ng typ ny ; 3-8% tin trin n suy thn mn
giai on cui. Trong bnh thn i tho ng ny, khng c s tng lc cu thn.
3. Chn on gin bit
- nhng bnh nhn i tho ng ph thuc Insulin trong thc hnh khng cn
sinh thit thn khng nh chn on nu thi gian i tho ng hn trn 10
nm v c bnh l vng mc do i tho ng. Ngc li, sinh thit thn l cn
thit nu 2 yu t ny l khng hi v hoc bnh cnh lm sng lm nh hng
n mt bnh nguyn khc.
i chiu 2 yu t albumin niu v huyt p thng cho php phn bit gia bnh
nhn i tho ng v bnh i tho ng km tng huyt p c bin chng
thn, khi i chiu 2 yu t ny bnh i tho ng c 6 tnh hung xy ra sau:
Bng 1: Cc tnh hung tng quan gia tng huyt p, albumin niu i tho
ng
Albumin Bnh thng microalbumin macroalbumin niu
niu
niu
Tng huyt p
I II III
C i tho ng + i tho ng + i tho ng v
tng huyt p nguyn tng huyt p nng tng huyt p nng
pht (1) (1,2)
IV V VI
Khng Tt Bnh thn i tho Bnh thn i tho
ng giai on ng
u
(1: C ph i tht tri ; 2: C tn thng nhiu c quan khc ca tng huyt p)
V. D PHNG V IU TR BNH THN I THO NG
1. D phng bnh thn i tho ng
- D phng nguyn pht bnh i tho ng typ 1 c th s bng mt iu tr c ch min
dch bi v y l mt bnh t min.
- Lin quan n i tho ng typ 2: cn chng lai cc yu t nguy c (tng cn qu nhiu
v li sng tnh ti).
- D phng nguyn pht v th pht bnh thn i tho ng bao gm
+ Kim sot ng mu l tng: Bnh thng ho c ng mu l u tin hng
u trong cc bin php iu tr. Bin php iu tr Insulin theo qui c (3,4 ln tim
trong ngy) l thng c p dng. iu ny lm gim nguy c bnh thn bnh i
tho ng typ 1. Li ch ca kim sot ng huyt nghim ngt trong i tho ng
typ 2 c l cng c gi tr tng t. Mc ch chuyn ho c yu cu l HbA1c < 7%.
336
- V l do tin trin nhanh ca bnh thn v nhng bin chng trn mch mu ngoai
bin (calci ho ng mch), vic to ng mch mu lc mu (to l d ng
tnh mch) phi c lm sm hn (khi h s thanh lc cratinin tnh bng cockcroft
khong 20 -25 ml/ pht).
- Nhn chung, nhng bnh thn i tho ng iu tr bng lc mu ngoi thn
hoc ghp thn c tin lng xu hn so vi nhng bmh nhn khng phi i tho
ng, ch yu v l do bin chng tim mch.
- Tin lng sng l xu nhng bnh nhn c suy thn mn giai on cui do
bnh thn i tho ng v nhng bin chng khc km theo nh tim mch, nhim
trng... Mun d phng nhng bin chng ny cn phi can thip giai on cn
sm vo cc yu t nguy c nh tng huyt p, nc mui, thiu mu, calci ho
mch mu v tng lipid mu...
- Ghp thn: Cn lu n ngi tr v c th ghp i (thn, tu) cng lc.
- Lc mu chu k: C nhng kh khn trong to l d ng-tnh mch, v bn thn
bnh l trn mch mu ca bnh i tho ng lm cc l d ng tnh mch d
hng, khng hot ng c.
- Lc mng bng: c p dng trong cc trng hp lc mu gp tr ngi.
338
Furgusson nhn xt rng bnh thn a nang di truyn ngang nhau cho c hai gii
nam v n theo kiu gen thn tri mang n. Dalgard nghin cu ph h 284 bnh
nhn v gia nh khng nh tnh di truyn ca thn a nang.
Cc tc gi Frances A Flinter, Frederic L.Loe v Satish Kathpalial chng minh
rng bnh thn a nang ngi ln tnh di truyn c lin kt trong hu ht cc
gia nh qua phc h gen alpha globulin v gen phosphoglyxeral kinase trn nhnh
ngn ca nhiu sc th 16. Tn sut biu hin ca gen l 100% tui 80 tr ln, c
ngha ngi c bn cht di truyn thn a nang nu sng c t 80 tui tr ln
th kh nng b thn a nang l 100%. Nguyn nhn g dn n ri lon di truyn
th cha bit r.
V c ch hnh thnh nang vn cn bn ci. Nhng ngi ta cng bit chc rng
cc nang ny hnh thnh t nhng thnh phn ca nphron nht l ng gp v quai
Henle. Hai bt thng c th gii thch s hnh thnh nang l:
- C nhng tn thng mng y ng thn, iu ny lm dn ng thn.
- Tng sn cc t bo ng dn n tc nghn tng phn trong lng ng thn.
1.3. Gii phu bnh
Tn thng thn thng c hai bn. Thn gia tng kch thc dn, trng lng ca
1 thn c a nang c th nng t 2000 n 4000g. Trong thn c nhiu nang, ln
nh khng u nhau, ng knh t 0,3 - 0,5 cm.
Cc nang thn cha dch khng mu hoc c mu vng rm, mu nu en c khi c
mu khi c xut huyt trong nang hoc di dng dch keo c.
Nhng thng tn ngoi thn c th gp km trong thn a nang gm: gan a nang
(30%), t gp hn l nang lch, bung trng, tu... Nhng tn thng v mch
mu cng c ghi nhn trong 10 n 20% cu thn a nang bao gm: phnh ng
mch ni s, phnh ng mch ch. Nhng bt thng tim c th gp km theo l
sa van 2 l trong 1/4 trng hp, h van 2 l, van 3 l hoc van ng mch ch.
1.4. Lm sng v cn lm sng
Tuy l mt bnh bm sinh v di truyn nhng thn a nang ngi ln thng
c pht hin tui trn di 40. i lc c pht hin mt cch tnh c qua xt
nghim siu m.
1.4.1.Lm sng
Bnh khng c triu chng lm sng trong mt thi gian di. L do khin bnh nhn
i khm bnh ca bnh thn a nang c th l: cn au qun thn, au tc bng
kh chu, bnh nhn t s thy khi u bng, tiu mu, tng huyt p, i khi bnh
nhn n khm ln u tin nhng l cc triu chng ca suy thn cp hoc suy
thn mn. Triu chng lm sng khi bnh r bao gm:
- Bng to ln, tc bng kh chu.
- au vng hng, tht lng.
- i ra mu: khi bnh thn a nang c si hay khi chn thng, bi nhim nang.
- Tng huyt p: gp 75% trng hp.
- Thn ln khi khm, c tnh cht l b mt g gh, nhiu mi, thn ln thng c
hai bn nhng khng cn xng.
340
Nang thn pht trin do phnh gin ng gp v nm vng nm thn hoc vng
thp Malpighi tu thn. Nang c c hai bn nhng cng c trng hp ch b mt
bn. Nang cha dch c nhiu lng ng calci nn bin chng thng gp nhiu
nht l si thn, tit niu.
2.2. Bnh x nang tu thn
L mt loi bnh thn c nhiu nang c hai bn nhng thn khng to ln m li b co
nh, x so. Triu chng lm sng l i m, i nhiu, kht, t trng nc tiu
thp do c vim k thn. Gim kh nng c c ca thn l triu chng xut hin
sm nht. Tng huyt p l t gp. C trng hp c biu hin tc , c trng
hp kt hp vim vng mc sc t. Triu chng cn lm sng nh i mu, protein
niu, tr niu, bch cu niu, vi khun niu l t gp. Khi c lp i lp li nhng ri
lon v xt nghim nc tiu th cn tm nguyn nhn khc hn l x nang tu thn.
Nang thn trong x nang tu thn khng c v thn, c i xng c hai bn v
pht trin t ng gp v quai Henle. Nang ch khu tr thn, khng c kt hp nang
c quan khc. Khong 50% trng hp c biu hin di truyn kiu gen ln. C
trng hp c di truyn kiu gen tri. Do x nang tu thn c rt nhiu bin th
m nhiu tc gi t tiu l phc hp nang tu thn ch nhm bnh ny.
3. Cc bnh nang thn khc
3.1. Thn nang n
Nang nm v thn, mt nang n c hoc nhiu nang n. Nang nh hn ra
pha trc b mt ca thn. Nang thng l b cha dch trong hoc mu vng rm,
thnh phn ging dch lc cu thn.Bnh thng gp ngi c tui nn d nhm
vi thn a nang. Tuy nhin bnh t c biu hin lm sng v c pht hin thng
l ngu nhin qua chp X quang v siu m bng v nhng l do khc. Khi cn chn
on phn bit c th chc ht dch nang thn. Ung th nu c th trong dch c t
bo ung th hoc mu.
3.2. Bnh thn nhiu nang bm sinh
Bnh thn nhiu nang bm sinh thuc nhm lon sn thn, nang tt c cc la
tui, l hu qu ca s ri lon c ch sinh thn lm cho ton b, mt phn hoc
nhiu ca mt hoc c hai thn bin thnh mt cu trc khng thuc bt c giai
on no ca s hnh thnh thn.
Bnh thn nhiu nang bm sinh khc hn vi thn a nang l khng c tnh cht di
truyn v ch thng b mt bn. Tn sut khng ln cho nn khng c t liu. Pht
hin c c tr em trong gia nh cng b. Bn cnh nang c nhng m t chc
thn bnh thng, t chc m bit ho khng y , mt s ng thn c biu m
khng in hnh, c nhng c t chc m, sn v t chc to huyt. Chn on
pht hin. Chn on xc nh nh chp ng mch thn. Vng nang thn l khng
c chc nng.
V iu tr th cn kt hp ct thn khi c chn thng chy mu, nhim khun ti
pht. Tin lng ngi ln l tt, ch b c mt bn.
3.3. Thn a nang mc phi
L mt bnh cnh mi c m t trong nhng nm gn y v xut hin ch yu
l nhng bnh nhn c lc mu thn nhn to chu k trn 3 nm. Bnh nhn
khng c tin s thn a nang v mi xut hin trong qu trnh lc thn nhn to.
343
- Bnh Takayashu
2. Phn loi theo din tin
Da vo din tin, bnh l ng mch thn c chia lm hai loi nhanh (cp tnh)
hoc chm (mn tnh), ch rng mt s nguyn nhn c th c din tin cp hoc
mn tnh tu thuc tng bi cnh (v d: tc mch do tinh th cholestrol).
2.1 Nhng bnh l ng mch thn cp hoc din tin nhanh
- Nhng bnh vi mch huyt khi (mao mch cu thn v tiu ng mch)
- X ho mch mu thn c tnh (mch mu trong thn ca tt c c)
- Thuyn tc do tinh th cholestrol (ng mch trong thn ca c nh)
- Vim quanh ng mch dng nt i th (ng mch c trung bnh)
- Cn x cng b cp (mch mu trong thn ca tt c c)
2.1 Nhng bnh l ng mch thn din tin theo kiu mn tnh
- Hp ng mch thn
- Thuyn tc do tinh th cholestrol
- X ho mch mu thn lnh tnh
- Hi chng khng phospholipid
- Thi ghp mn ca ghp thn
III. NGUYN NHN CA BNH L NG MCH THN
( y ch cp n cc bnh l hp ng mch thn th pht)
1. X va ng mch thn
L nguyn nhn thng gp nht ca tng huyt p do bnh l mch thn (chim
2/3 trng hp). y l bnh l gp ngi ln sau 45 tui. Thng tn x va
gy hp thng xut hin v tr l xut pht ng mch thn t ng mch ch
hoc on 1/3 u ca ng mch thn. Nhng tn thng x va c th c
tm thy nhng ng mch khc nh ng mch cc chi, ng mch vnh, ng
mch cnh...
Tin trin ca tn thng x va dn n hp ng mch thn gp trong khong
50% trng hp, trong gn 20% l tc nghn hon ton ng mch thn.
2. Lon sn x ho lp c ng mch thn
Chim t l 25% trong cc nguyn nhn gy tng huyt p ca bnh l ng mch
thn. Thng gp l lon sn lp o gia ca ng mch. Bnh l ny gp ch
yu l cc ph n tr trc 40 tui. Thng tn trn ng mch thn thng thy
on 2/3 xa gc hoc nhng nhnh phn chia ca ng mch thn, hnh thnh
lin tip nhng on hp v nhng on gin (du hiu chui trng ht trn phim
chp ng mch thn). Thng tn lon sn x ho ny cn c th thy cc ng
mch khc nh ng mch cnh, ng mch chu. Cc loi lon sn khc nh tng
sn ni mc, x ho lon sn xung quanh lp gia l rt him gp.
3. Nhng tn thng mch mu khc
348
VIM NG THN CP
Mc tiu
1. Trnh by c nguyn nhn ca vim ng thn cp.
2. M t c c ch sinh bnh ca vim ng thn cp.
3. Tp hp c cc triu chng lm sng, cn lm sng vim ng thn cp.
4. Chn on xc nh, chn on phn bit ca vim ng thn cp
5. Bit cch iu tr vim ng thn cp theo tng giai on.
Ni dung
I. I CNG
Vim ng thn cp l bnh l thng gp gy nn suy thn cp, cn c gi l
hoi t ng thn cp hoc l bnh ng k thn cp. Tn thng ch yu ca bnh l
ny l hoi t lin bo ng thn, l mt bnh l nng v t l t vong cn rt cao nu
khng c x tr mt cch kp thi v c hiu qu.
II. NGUYN NHN
C rt nhiu nguyn nhn gy nn vim ng thn cp nhng tu trung c th chia
lm 3 nhm ln:
1.Hoi t ng thn sau thiu mu.
Tt c nhng nguyn nhn no m lm cho s ti mu thn gim st ko di u
c th lm cho thn thiu mu v gy nn thng tn di dng hoi t ng thn.
Nguyn nhn gim ti mu thn c chia lm 2 nhm:
1.1.Ngun gc trc thn
- Sc gim th tch mu: sau m, sau chn thng, bng, sy no thai, mt nc,
mt mui.
- Sc nhim khun, nhim c.
- Sc tim.
1.2.Ngun gc ti thn
Thng gp nht l do nhng tc dng ngoi ca mt s thuc khi s dng trn
mt vi c a c bit: thuc khng vim khng phi stroids, thuc h huyt p,
thuc c ch men chuyn khi s dng bnh nhn hp ng mch thn hai bn.
2. Hoi t ng thn cp do ng c
C th trc tip ln trn t bo ng thn hoc gin tip ln c ch mch mu v t
gy thiu mu thn.
2.1.Thuc
- Cc thuc khng sinh, nht l nhm Aminosides. Trong nhm ny c nht l
Nomycin, cc loi khc t c hn nh Streptomycine, Kanamycine, Gentamycine.
Cc cphalosporine c vi thn nht l Cfaloridine.
- Cc sn phm iod cn quang.
- Cc thuc chng U: Ciplastine, Cilosporine, Interfron.
354
- Hn ch tng Kali mu
- Hn ch tng ur mu
3.2.1 Nc
bnh nhn v niu m bo cn bng m ngha l lng nc vo t hn lng
nc ra. Thng thng cho khong 500ml nc k c n ln ung. Trong nhng
trng hp v niu do mt nc mt mui th phi b dch.
3.2.2 in gii v toan mu
- iu tr tng Kali mu
+ Hn ch a Kali t ngoi vo: rau qu nhiu kali, thuc dch truyn c kali
+ Loi b cc hoi hoi t, chng nhim khun.
+ Li tiu: nhm o thi nc in gii, c bit l kali, c ch nh khi khng c
bng chng c tc nghn sau thn, bt u c th d liu bng Lasix 20mg x 4 ng
tim tnh mch, c th cho liu cao 200mg - 500mg/ 24 gi.Liu rt cao c th c
ch nh nh Furosmide 1000mg/24 gi bng truyn chm qua bm tim in.
Ngoi furosemide c th s dng bumtamide hoc acide etacrynic.
+ Truyn natribicacbonat
C th truyn natribicacbonat 1,4% hoc 4,2% khi ngi bnh c mt lng nc
tiu nht nh (V d 300 - 500ml). C th tim tnh mch natribicacbonat 8,4% nu
mun hn ch lng nc a vo, B Natri bicacbonat gip ci thin toan mu, t
hn ch vic di chuyn kali t ni bo ra ngoi bo.
+ Truyn glucose u trng km insulin tc dng nhanh nhm y kali vo khu vc
ni bo
+ Cho Canxi tim tnh mch chm trong cc trng hp tng kali mu nng, cp
cu (nht l c biu hin tim mch).
+ C th dng cc Rsin trao i ion nh resonium, Kayexalat (30 gam/24 gi)
thi kali qua ng phn
+ Nu kali mu 6,5 mmol/l th cn ch nh lc mu ngoi thn.
3.2.3 iu tr cc ri lon in gii khc
+ Natri v clo: Natri mu h thng l do nc. Tt nht l hn ch nc. Khi
Natri mu h nhiu cn phi b Natri.
+ Canxi: Trong vim ng thn cpt khi c h Canxi mu. Nu c xut hin Ttani do
h Canxi mu c th cho Canxi clorua hoc Canxi gluconate.
3.2.4. iu tr tng ur mu
- Ch n gim m, calo t nht l 35 kcalo/kg / 24 gi, vitamin.
- Cc thuc tng ng ha prtide nh Durabolin 25mg/ngy, Testosteron
25mg/ngy.
- B sung thm vin ketosteril: 1 vin 600mg cho 5 kg cn nng/ ngy.
- Loi b cc nhim khun
- Ch nh lc mu: nn ch nh lc mu sm bng thn nhn to hoc thm phn
mng bng. Ch nh lc mu khi:
358
CHNG 5
C XNG KHP
IV. CN LM SNG
Gm X quang, du sinh hc v sinh thit
1. X quang: Giai on u thy mt vi vng u xng. Sau l khuyt xng
hay n mn xng phn tip gip vi sn khp, ri hp khe khp. Sau cng l hu
phn sn khp v u xng gy dnh v bin dng khp.
2. Du sinh hc: Gm du vim, ri lon min dch, dch khp.
- Tc lng mu tng, 2 globulin tng, hng cu gim.
- Waaler Rose: Pht hin yu t thp trong huyt thanh. Phn ng dng tnh khi
ngng kt vi pha long huyt thanh bnh nhn t 1/32.
- Dch khp: gim nhy, tng bch cu, t bo hnh nho 10% s t bo dch khp.
t bo hnh nho l nhng bch cu a nhn trung tnh nut nhng phc hp min
dch.
3. Sinh thit: Mng hot dch hay ht di da.
Sinh thit mng hot dch thy nm tn thng: s tng sinh cc hnh lng ca
mng hot dch, tng sinh cc lp ph hnh lng, xut hin nhng m hoi t ging
nh t huyt, tng sinh mch mu tn to, thm nhp nhiu t bo vim quanh cc
mch mu. Khi c t ba tn thng tr ln c th hng n chn on xc nh.
Sinh thit ht di da: gia l mt m hoi t dng t huyt, chung quanh bao
bc bi nhiu t bo Lympho v tng bo.
V. CHN ON
1. Chn on xc nh: Cn phi sm iu tr c kt qu
1.1. Tiu chun ca hi thp hc M 1987: Gm 7 im, trong tiu chun t 1 - 4
phi c thi gian t nht 6 tun, chn on dng tnh cn t nht 4 tiu chun, l
- Cng khp bui sng: ko di t nht 1 gi.
- Sng au t nht 3 nhm khp trong s 14 nhm: ngn tay gn, bn ngn tay, c
tay, khuu, gi, c chn, bn ngn chn (2 bn = 14).
- Sng au 1 trong 3 khp ca bn tay: ngn gn, bn ngn, c tay.
- Sng khp i xng.
- C ht di da.
- Phn ng tm yu t thp huyt thanh dng tnh (Waaler-Rose +).
- Hnh nh X quang in hnh.
1.2. Tuyn c s thiu cn lm sng: chn on c th da vo cc im sau
- Ph n 30-50 tui.
- Vim nhiu khp xa gc chi.
- Khi u t t, tin trin t nht 6 tun.
- au tri v m v cng khp bui sng.
2. Chn on phn bit
- Giai on u (< 6 tun): Cn phn bit vi:
358
THOI KHP
Mc tiu
1. Trnh by c nh ngha v dch t hc ca thoi khp.
2. M t c nguyn nhn c ch sinh bnh, v gii phu bnh.
3. Trnh by c triu chng chnh v lm sng, cn lm sng v chn on thoi
khp.
4. Trnh by c cc phng tin iu tr ni khoa v vt l tr liu thoi khp.
Ni dung
I. I CNG
1. nh ngha: L mt bnh mn ca cc khp k c ct sng gy au v bin dng.
2. Dch t hc
- Bnh gp mi dn tc, nam v n mc bnh ngang nhau. Tui cng tng t
l cng cao.
- Bnh vin Bch Mai H Ni: thoi khp chim 10,41% khoa c xng khp
- Php thoi khp chim 28,6% cc bnh xng khp
- M: 80% ngi > 55 tui c du X quang l thoi khp.
Thoi khp theo th t thng gp l: ct sng tht lng, ct sng c, gi,
hng...
II. NGUYN NHN V C CH SINH BNH
1. S lo ho
L nguyn nhn chnh ca thoi khp nguyn pht, xut hin mun thng ngi
ln tui (>60), nhiu v tr, tin trin chm, khng nng. T bo sn gi dn, kh
nng tng hp cc cht to nn si collagen v mucopolysacharide s gim v ri
lon, cht lng sn km dn, tnh chu lc v n hi gim, hn na t bo sn
ngi trng thnh khng c kh nng sinh sn v ti to.
2. Yu t c hc
Ch yu gy thoi khp th pht, thng gp ngi tr (di 40 tui), khu tr mt
vi v tr, nng v tin trin nhanh. Yu t ny th hin bng s tng bt thng lc
nn trn mt khp, gi l hin tng qu ti. Gm:
- Tng cn qu mc do bo ph, tng trng ti do ngh nghip.
- Bin dng khp th pht sau chn thng, vim, u, lon sn lm thay i
hnh thi, tng quan ca khp.
- D tt bm sinh lm thay i din tch nn ca cc mt khp.
3. Yu t khc
- Di truyn: c a gi sm
- Ni tit: mn kinh, i tho ng, long xng do ni tit.
- Chuyn ho: bnh thng phong, bnh da xm nu.
4. Xu hng mi
362
V nhiu bnh nhn mc bnh tui gi nn cn theo di chc nng gan thn trc
v sau khi iu tr bng thuc chng vim nonstroid, c bit i vi nhng bnh
nhn dng thuc ko di.
Khng dng Corticoid ton thn, khi au v sng nhiu c th dng ti ch.
1.2. Tng cng dinh dng sn
Tc dng khng chc chn nh: ni tit t sinh dc (Testosterone),
thuc tng ng ha. Philatop, cao xng...
1.3. Thuc tc dng chm.
1.3.1. Glucosamine sulfate
- L hp cht sulfat ca Glucosamine aminomonosaccharide t nhin.
Glucosamine, mt thnh phn t nhin cu thnh glycosaminoglycan sn khp v
dch khp. C ch tc dng ca Glucosamine sulfat cho n nay cha hon ton
sng t. Cc tc dng nh c ch gc t do superoxide, c ch sinh tng hp nitric
oxide cng l mt cch gii thch tc dng nhanh ca thuc trn cc th nghim lm
sng ngn hn. Tuy nhin trong th nghim lm sng di hn th tc dng ca thuc
c l do bin i chuyn ho ca sn khp bao gm kch thch hot ng ng ha
nh tng tng hp proteoglycan, gim hot ng d ha ca sn khp nh tc dng
trn cc enzyme metalloprotease.
- Trnh by v liu lng: vin 0,25g, gi 1,5g.
Liu hng ngy l 1,5g. Thi gian dng: nhiu nm. Thuc c an ton cao,
cha thy tc dng ph c ghi nhn.
1.3.2. Chondroitine sulfate
Tc dng bng cch c ch cc men tiu sn, nht l men metalloprotase.
- Trnh by di dng vin, liu trung bnh: 3 vin ngy.
- Thi gian dng: t nht 1-2 thng.
1.3.3. Mt s loi thuc ang c th nghim
Bao gm chloroquine, Doxicycline, thuc tng hp glycoaminoglycine hoc
hyaluronate, c th tng cng s phc hi sn hoc gim s hu sn hoc bao
gm c hai.
1.3.4. Liu php thay th cht nhn
Trong thoi khp c gim nng cng nh trng lng phn t ca acide
hyaluronic lm gim nhy ca dich khp. V vy tim vo khp acide hyaluronic
c trng lng phn t cao c tc dng b sung nhn ca dch khp.
- Trnh by di dng sodium hyaluronat (Hyruan) ng 200mg/2,5ml.
- Liu lng v cch dng: ph thuc khp ln, khp nh.
i vi khp gi: Tim vo khp 1 ln 1ng 2,5ml/tun, trong 5 tun lin tip.
Tc dng ph: au nh, cm gic nng khp sau khi tim.
2. Vt l tr liu
- Cc bi tp th dc cho tng v tr thoi khp.
- iu tr bng tay: xoa bp, n huyt, tp vn ng.
365
BNH GT
Mc tiu
1. Trnh by c chuyn ho ca acid uric v c ch sinh bnh Gt
2. M t c triu chng lm sng v cn lm sng
3. Trnh by c tiu chun chn on.
4. M t c cc bin php iu tr cn gt cp.
5. Trnh by c cc phng tin iu tr hi chng tng acid uric mu
Ni dung
I. I CNG
- Bnh hay gp tng lp ngi c mc sng cao, t l mt s nc chu
u khong 0,5% dn s, nam gp 10 ln so vi n. Vit Nam bnh gp cha
nhiu song trong thp nin gn y thy bnh tng ln r.
- Gt l mt bnh chuyn ho, c trng l c nhng t vim khp cp v c
hin tng lng ng natri urat trong cc t chc, xy ra do tng acid uric trong mu.
II. CHUYN HO CA ACID URIC
Acid uric l sn phm thoi ging ca nucleotid c base l purin. C 3 ngun
cung cp acid uric:
+ Do thoi ging acid nucleic t thc n a vo.
+ Do thoi ging acid nucleic t cc t bo b cht
+ Do tng hp ni sinh v chuyn ho purin trong c th nh cc men c
hiu.
Acid uric c o thi qua nc tiu 450-500 mg/ngy v trong phn
200mg/ngy. Khi qua thn, urat c cu thn lc hon ton, ri ti hp thu gn
hon ton ng ln gn cui cng c ng ln xa bi tit. Trong phn, acid uric
c cc vi khun phn hu.
Nng acid uric trong mu theo hng s ca ngi Vit Nam l 4510mg/l
(208-327 mol/l). Khi nng > 70mg/l (>416,5 mol/l) th c gi l tng acid uric
mu.
Cc nguyn nhn lm tng acid uric mu:
. Tng sn xut acid uric: dng nhiu thc n c cha nhiu purin, tng thoi
ging nucleoprotein t bo, tng tng hp purin ni sinh.
. Gim o thi acid uric niu: gim lc cu thn, gim bi tit ca ng thn.
i khi gim phn hy acid uric do vi khun trong phn.
III. PHN LOI CC HI CHNG TNG ACID URIC MU V BNH GT
1. Hi chng tng acid uric mu v cn v bnh gt nguyn pht
Th ny hay gp nht chim ti 85% cc trng hp, c tnh gia nh v di
truyn do ri lon chuyn ho purin.
2. Hi chng tng acid uric mu v bnh gt ri lon men
Ni chung th ny him gp.
367
vnh tai khuu tay, ngn chn ci, gt chn, mu bn chn, gn Achille. Kch thc t
vi milimet n nhiu centimet, hi chc hoc mm, khng di ng do dnh vo nn
xng bn di.
2.2. Bnh khp do urat: Khp b cng, au khi vn ng v lm hn ch vn ng,
khp sng va, khng i xng, cng c th c tphi km theo. Trn X quang thy
hp khe khp, khuyt xng, hnh hc u xng.
3. Biu hin thn
Urat lng ng ri rc t chc k thn, b thn, niu qun.
3.1. Si thn: 10 - 20% cc trng hp gt, iu kin thun li l pH nc tiu qu
toan, nng acid uric cao. Si urat thng nh v khng cn quang.
3.2. Tn thng thn: lc u ch c protein niu, c th c hng cu, bch cu vi
th, sau tin dn n suy thn. Suy thn hay gp th c tphi, tin trin chm v l
nguyn nhn gy t vong.
VI. TIU CHUN CHN ON
1. Tiu chun Rome 1963
- Acid uric mu > 70mg/l (416,5 mol/l)
- C tphi
- C tinh th natri urat trong dch khp hay lng ng urat trong cc t chc khi
soi knh hin vi hay kim tra ho hc.
- Tin s c vim khp r, t nht lc khi u bnh, vim khp xut hin t
ngt, au d di v khi hon ton sau 1 - 2tun.
Ch cn c 2 tiu chun l chn on chc chn.
2. Tiu chun New York 1966
- t nht c 2 t vim cp mt khp chi, c khi bnh t ngt v khi sau 1-2tun.
- C mt t nh trn nhng lin quan n khp bn ngn chn ci
- C tphi
- Dng colchicin bt vim nhiu trong 48 gi.
Ch cn c 2 tiu chun l
VII. IU TR
1. Ch n
- Gim cc cht c nhiu purin nh ph tng ng vt, tht, c, tm, cua... khng n
qu mc. Gim calo nu bo.
- Khng ung ru.
- Ung nhiu nc 2 - 4l/ngy nht l nc c bicarbonat.
2. Thuc
- Mc tiu iu tr
+ iu tr vim khp trong cn gt cp.
369
2.2. Ct sng
Thng xut hin mun hn cc khp chi.
- Ct sng tht lng: 100% au lin tc v m , hn ch vn ng, teo c cnh ct
sng.
- Ct sng lng: thng mun hn vng tht lng, au m , hn ch vn ng, bin
dng (g) hoc cng, teo c.
- Ct sng c: c th mun hn hoc sm hn cc on khc, bin dng hn ch
vn ng.
2.3. Khp cng chu
- L du hiu sm, c hiu (ch yu trn Xquang)
- au vng cng chu, lan xung i
- Teo c mng
- Nghim php gin cnh chu (+)
2.4. Nhng biu hin khc
- St, gy st
- Mt: vim mng mt, vim mng mt th mi
Nc ngoi: chim 20 - 30% trng hp
Vit Nam: khong 3%
- Tim: 5% c ri lon dn truyn, h van ng mch ch
- Cc biu hin him gp khc:
+ X teo da
+ X phi
+ Chn p r thn kinh tu
+ Thot v bn, rn
3. Tin trin
- Xu hng chung: nng dn, dn n dnh khp, bin dng. Nu khng c iu
tr sm, ng, bnh nhn c nhiu t th xu, tn ph.
- Bin chng: suy h hp, tm ph mn, lao phi, lit hai chi do chn p tu v r
thn kinh.
- Tin lng:
+ Xu: Tr tui, vim nhiu khp ngoi vi, st, gy st nhiu.
+ Tt hn: B bnh sau 30 tui, th ct sng l ch yu.
- 50% tin trin lin tc, 10% tin trin nhanh.
III. XT NGHIM V X QUANG
1. Xt nghim
1.1. Xt nghim chung: t c gi tr chn on
- Lng mu tng (90%)
373
Nguyn nhn cha r, khng c bng chng v min dch nhng c bng chng v
vai tr ca nhim khun.
375
LAO CT SNG
Mc tiu
1. M t c cc yu t dch t, c a
2. Trnh by c triu chng lm sng v cn lm sng ca tng giai on bnh:
khi pht, ton pht v giai on cui.
3. Trnh by c chn on xc nh v chn on phn bit.
4. M t c cc nguyn tc dng thuc chng lao.
5. Trnh by c cc phng php phc hi chc nng, bt ng, ngoi khoa.
Ni dung
I. I CNG
- Bnh c m t ln u tin vo cui th k 19 do mt thy thuc ngoi khoa
ngi Anh tn l Percivall Pott, nn cn gi l bnh Pott.
- Thng th pht nht l sau lao phi, vi khun lao n ct sng bng ng mu.
- Cn gp nhiu cc nc ang pht trin, bnh chim khong 2/3 cc trng hp
lao xng khp. trung tm chn thng chnh hnh TP. HCM nm 1998 c 191
trng hp lao xng khp, trong lao ct sng chim 67,02%.
- Thng gp 20 - 40 tui, nam v n mc bnh ngang nhau.
- Tn thng on lng v tht lng chim hn 90% (t lng 8 n tht lng 2)
II. TRIU CHNG
1. Giai on khi pht
1.1. Du c nng ch yu l au
- au ti ch: au vng ct sng b tn thng, c nh mt v tr khng thay i.
au lin tc c ngy m, tng khi vn ng, i li, gim khi ngh ngi; dng thuc
gim au t hiu qu.
- au kiu r: Do tn thng chn p vo mt vi nhnh ca r thn kinh, au lan
theo ng i ca r v dy thn kinh, c lan xung vai v gy, lng lan theo
dy thn kinh lin sn, tht lng lan theo thn kinh ta. au tng khi ho, ht hi,
rn mnh.
1.2. Thm khm
- Ct sng: Thy mt on ct sng cng , hn ch cc ng tc khng gin ra
khi ci. C 2 bn ct sng c th co cng, g vo vng gai sau ca on tn thng
thy au r.
- Ton thn: C th thy du nhim lao, c tn thng lao phi hp > 50% trng
hp (phi, mng phi, hch...).
1.3. Xquang v xt nghim
- Xquang: Rt quan trng gip chn on.
+ a m hp so vi cc on khc.
+ Thn t sng b nham nh, m phn trc v mt trn.
379
+ a m b ph hy gn nh hon ton.
+ Thn t sng b ph hy nhiu, nht l phn trc to nn hnh chm, di lch
trt ra pha sau.
+ Hnh nh p xe lnh: trn phim chp thng thy hnh m quanh tn thng, c th
khng ng u, c ch vi ha m hn.
- Xt nghim
+ Tc lng mu tng
+ Chc kim cnh ct sng d tm thy tn thng lao in hnh.
+ Chc dch no ty chn on p ty v vim mng no tu.
3. Giai on cui
Khng c iu tr hoc c th qu suy yu: bnh nng dn, lit nng, bi nhim,
lao lan sang b phn khc nh lao mng no, lao mng tim, mng phi v cht v
suy kit.
III. CHN ON
1. Chn on xc nh
Da vo cc triu chng lm sng v Xquang. chn on sm cn chp ct lp
v chc ht cnh t sng. Trong giai on ton pht chn on d v y cc
du hiu, nht l Xquang.
2. Chn on phn bit
- Vim ct sng do vi khun m (V d: t cu): Du nhim trng nng, iu kin
khi pht (nht, hu bi), Xquang khng c p xe lnh.
- Cc tn thng u: ung th, di cn, u mu... da vo cc du hiu ton thn,
Xquang khng c hnh nh p xe lnh. Nu nghi ng, tin hnh chc ht xc nh
chn on.
IV. IU TR
Hin nay ch yu l iu tr ni khoa bng cc thuc chng lao kt hp vi phc hi
chc nng. Vic bt ng v phu thut c ch nh ring cho mt s trng hp.
1. Ni khoa
Dng cc thuc chng lao theo nguyn tc sau
- iu tr cng sm cng tt.
- Phi hp ti thiu 3 thuc chng lao: Rimifon, Streptomycine, Pyrazynamide,
Ethambutol, Rifampicine trong 3 thng, sau gim bt mt loi v tip tc dng
thuc t 6 - 12 thng.
- Lu vn khng thuc ng .
- Nn dng thuc mt ln trong ngy, bui sng, bng i.
- Theo di tnh trng ton thn, tn thng ti ch, tc dng ph ca thuc.
- Thc hin ch n ung, ngh ngi hp l.
2. Phc hi chc nng
- Xoa bp nh nhng cc c km tp luyn ct trnh teo c cng khp.
381
BNH A U TY XNG
Mc tiu
1. M t c nh ngha v cc yu t dch t.
2. Trnh by c cc triu chng lm sng v cn lm sng
3. M t c chn on xc nh, chn on phn bit v chn on giai on
bnh.
4. Trnh by c cc phng tin iu tr gc v cc bin php iu tr khc.
5. M t c cc yu t nh gi tin trin v tin lng
Ni dung
I. I CNG
1. nh ngha
a u tu xng l mt bnh tng sinh c tnh cht c tnh ca tng bo
(plasmocyte) ty xng v mt s c quan khc.
Tng sinh tng bo dn n:
- Tng cc globulin min dch trong mu.
- To thnh nhiu tiu xng dn n gy xng bnh l.
- Ri lon chc nng nhiu c quan: suy thn, thiu mu, tng canxi mu, cc triu
chng thn kinh...
2. Dch t
- T l mc bnh khong 3 - 4/100.000 dn; 1 - 2% cc bnh c tnh.
- Tui thng gp: > 40 ; nam > n.
- Ngi da en gp 2 ln ngi da trng v tui khi bnh sm hn.
- Nguyn nhn v bnh sinh vn cn cha r. Tuy nhin, nghin cu v dch t hc
cho thy rng liu thp phng x lm tng t l mc bnh.
II. TRIU CHNG
Do ngun gc v chc nng, tng bo c mt hu ht cc c quan, b phn
trong c th, do khi tng sinh c tnh s biu hin triu chng nhiu ni. Bnh
thng bt u t t tng dn triu chng tn mn nn d nhm vi cc bnh khc:
suy sp ton thn, biu hin xng, thn, mu, thn kinh...
1. Biu hin xng
1.1. Lm sng
- au xng (90%): v tr thng gp l vng ct sng, chu hng, lng ngc, au
tng khi vn ng v gim khi ngh ngi, v sau au lin tc, c khi thy au theo
kiu p r thn kinh.
- Gy xng t nhin (50%): gy xng sn, xng n, xng c, ln v di lch
t sng gy g vo ct sng. Thng c pht hin qua chp Xquang.
390
- Th phi hp vi Leucmie.
- Th theo globulin: th chui nh, th IgM, th 2 dng phi hp.
4. Chn on giai on bnh: C 3 giai on
+ Giai on I: gm cc tiu chun: ( 1).
. Hemoglbin > 100g/l.
. Canxi mu < 3mmol/l (< 12 mg%).
. Xquang xng bnh thng hoc mt tn thng n c.
. in di min dch: IgG < 50g/l
IgA < 30g/l
Chui nh niu < 4g/24 gi.
+ Giai on II: gia giai on I v III
+ Giai on III: 1 trong cc tiu chun sau:
. Hemoglobin < 85g/l
. Canxi mu > 3mmol/l
. XQ: nhiu tn thng
. in di min dch: IgG > 70g/l
IgA > 50g/l
Chui nh niu > 12g/24gi
- Da vo chc nng thn:
A: Creatinin mu < 177 mol/l (<2mg%)
B: Creatinin mu > 177 mol/l (>2mg%)
- Phi hp tiu chun giai on v chc nng thn ngi ta nh gi tin
lng bnh (theo Dan.L.Longo):
IA sng trung bnh c: 61 thng
IIA, B sng trung bnh c:55 thng
IIIA sng trung bnh c: 30 thng
IIIB sng trung bnh c: 15 thng
V. IU TR
a u ty l mt bnh gy tn thng ty xng v nhiu c quan ngoi xng do
tng sinh c tnh cht c tnh ca tng bo. Do iu tr bao gm cc vn
chnh sau: au xng v ph hy cu trc xng, tng calci mu, suy ty vi thiu
mu dai dng, gim tiu cu v gim bch cu, suy thn v nhim trng bi nhim.
Hu ht bnh nhn cn c iu tr h thng ha cht kim sot khi u v iu
tr triu chng ngn nga bin chng.
1. iu tr gc
1.1. Truyn tnh mch tng t, trong cc loi sau
- L.Phenylalanin Mustard (L-PAM, Melphalan): 8mg/m2/ngy
393
- Cng thc mu: gim cc dng huyt cu mt phn hay ton th, gim ngoi ty:
+ Hng cu gim (thng thng l thiu mu huyt tn) 65%
+ Bch cu gim, ch yu l a nhn trung tnh 32%
+ Tiu cu gim 10%
- Tc lng mu tng cao 92%, si huyt tng 45%
- in di huyt thanh: Globulin tng 86%
- Tm thy phc hp min dch trong mu.
- Phn ng BW (+).
2.2. Cc xt nghim c hiu
2.2.1. T bo Hargraves (LE): l nhng bch cu a nhn thc bo nhng mnh
nhn ca t bo khc b tiu hy do khng th khng nhn xut hin trong bnh
Lupt.
Ngi ta thng tnh t l % ca t bo LE so vi tng s bch cu trong mu. T l
5% th c gi tr chn on. Trong Lupt 60% - 90% c t bo LE.
2.2.2. Tm cc khng th th dch
- KT khng nhn: c xem l dng tnh khi pha long huyt thanh > 1/32.
- KT khng DNA rt c hiu trong bnh Lupt.
- KT chng li cc khng nguyn nhn ha tan: KT khng Sm (+) trong 50%.
- KT khng hng cu, khng Limpho bo, khng tiu cu.
- B th gim trong mu.
- Gim t l Lympho bo so vi t bo B.
2.3. Sinh thit
- Sinh thit da: lng ng globulin min dch: IgM, IgG v b th thnh mt lp gia
thng b v trung b ca da (+ 70%).
- Thn: vim cu thn, dy mng y do lng ng IgG, IgM v b th.
- Mng hot dch khp: tn thng gn ging vim khp dng thp.
IV. TIN TRIN: Ty thuc th bnh
1. Th cp: Tn thng nhiu ni tng v nng, tin trin nhanh v t vong sau vi
thng do cc thng tn thn, thn kinh, phi nhim khun.
2. Th mn: t tn thng ni tng, biu hin ngoi da nh, tin trin chm, tin
lng tt.
3. Th bn cp: Tin trin tng t, ngy cng nng dn. Bnh nng thm nu c
thai, nhim khun, chn thng, phu thut, Stress, lm dng thuc. Thng t
vong v cc bin chng thn, thn kinh, nhim khun. Thi gian sng trung bnh 5
- 10 nm.
4. Hi chng Sharp: l th bnh hn hp gia Lupt v x cng b, c cc du vim
a khp, hi chng Raynaud, ngn tay sng to hnh khc di ln, x hp thc qun,
vim a c. Do t biu hin ni tng nn tin lng tt hn v nhy cm vi Steroid.
397
V. CHN ON
1. Chn on xc nh: Da vo 11 tiu chun ca hi thp hc M, c ci tin nm
1997, chn on xc nh khi c t nht 4 tiu chun:
- Ban hnh cnh bm mt.
- Ban dng a mt, thn.
- Xm da do nng.
- Lot ming hoc mi hu.
- Vim a khp.
- Vim mng tim hoc mng phi.
- Tn thng thn: Protein niu > 0,5g/24 gi hoc tr niu.
- Tn thng thn kinh: co git hoc lon thn.
- Ri lon v mu:
+ Thiu mu tan mu (tng hng cu li); Bch cu < 4000/mm3.
+ Limpho < 1500/mm3 hoc tiu cu < 100.000/mm3.
- Ri lon min dch: trong mu c
+ Khng th khng ADN hoc khng th khng Sm.
+ Nng bt thng ca IgG hoc IgM anti - Cardiolipine, hoc hin din yu t
chng ng lu hnh (anticoagulant circulant).
- Khng th khng nhn (+).
2. Chn on phn bit
- Thp khp cp.
- Vim khp dng thp.
- Bnh trong nhm to keo: x cng b, vim a c, vim nt quanh ng mch.
- Vi cc th c bit ca Lupt cn phn bit vi cc bnh c triu chng tng t:
xut huyt gim tiu cu, vim cu thn, hi chng thn h. Vim mng tim mng
phi do nguyn nhn khc.
3. Thc t Vit Nam: khi c 5 yu t sau y xut hin trn 1 bnh nhn n, tr
tui th c hng chn on Lupt
- St dai dng ko di khng tm thy nguyn nhn.
- Vim nhiu khp.
- Ban hnh cnh bm mt.
- Protein niu.
- Tc lng mu cao.
VI. IU TR
Chung cho mi trng hp Lupt: Gio dc bnh nhn trnh nhng iu c hi nh
thuc l, trnh nh nng mt tri trc tip hoc gin tip, k hoch ha gia nh,
trnh lm dng thuc.
398
CHNG 6
NI TIT
I THO NG
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, bnh nguyn v c ch bnh
sinh
2. Trnh by c tiu chun chn on i tho ng
3. Phn loi i tho ng.
4. Trnh by c cc triu chng cn lm sng v bnh.
5.Bin chng cp v mn ca i tho ng
6. Trnh by c cch tit thc trong i tho ng
7. Trnh by c mt s loi thuc thng dng trong iu tr i tho ng
Ni dung
I. NH NGHA I THO NG
- Theo TCYTTG 1999: "i tho ng (T) l mt tnh trng ri lon chuyn ha
a nguyn nhn c trng bi tnh trng tng glucose mu mn tnh vi cc ri lon
chuyn ha carbohydrate, m, protein do hu qu ca khim khuyt tit insulin,
khim khuyt hot ng insulin hoc c hai".
- Theo TCYTTG 2002: T l mt bnh mn tnh gy ra do thiu sn xut insulin
ca ty hoc tc dng insulin khng hiu qu do nguyn nhn mc phi v/hoc do
di truyn vi hu qu tng glucose mu. Tng glucose mu gy tn thng nhiu h
thng trong c th, c bit mch mu v thn kinh.
- Theo Hi T Hoa K 2004: T l mt nhm cc bnh l chuyn ha c trng
bi tng glucose mu do khim khuyt tit insuline, khim khuyt hot ng insuline,
hoc c hai. Tng glucose mu mn tnh trong T s gy tn thng, ri lon chc
nng hay suy nhiu c quan, c bit l mt, thn, thn kinh, tim v mch mu .
II. DCH T HC
30-50% bnh nhn mc T type 2 khng c chn on.
- Tn sut bnh T trn th gii: trn th gii, T chim khong 60-70% cc
bnh ni tit. Trong nm 1995 cc quc gia c s ngi mc T nhiu nht v s
ngi d on mc T vo nm 2025 l n (19 ln 57 triu), Trung Quc (16
ln 38 triu), Hoa K (14 ln 22 triu); trong n l nc c t l tng nhanh
nht.
1985: 30 triu ngi mc T; 2000: 171 triu; 2030: d bo 366 triu; trong a
s bnh nhn = 65 tui cc nc pht trin v t 45-64 tui cc nc ang pht
trin.
3,2 triu ngi T t vong do bin chng T hng nm, tng ng 6 trng
hp/pht
397
1.1. Di truyn
T type 1 phi hp cao vi s gia tng thng xuyn ca khng nguyn HLA, KN
HLA u th phi hp vi T type 1 thay i ty theo chng tc, HLA B8, B14,15,
B18, Cw3, DR3 v DR4 gp bnh nhn T chng tc da trng, trong khi HLA
398
DR3, DR4 c lin quan vi T th 1 chu , chu Phi v chu M Latinh. HLA DR3
hoc DR4 gp 95% T type 1 so vi 45-50% nhm chng chng tc da trng.
Nghin cu nhng cp sinh i ng hp t gi rng nh hng di truyn T
type 1 t gp hn l type 2. Ch c 30% nhng cp sinh i ging ht nhau b T
type 1 s pht trin thnh bnh. iu ny cng gi rng yu t mi trng lin
quan n bnh sinh T. Ngc li, cp sinh i ging nhau ca T type 2 d xy
ra trong vng nm u tin b bnh nhiu hn l anh ch em rut.
1.2. Yu t mi trng
T type 1 l hu qu ca s nhim trng, nhim c lm tn thng ty, h thng
min dch tn cng v ph hy t bo bta ty. Yu t mi trng kt hp vi tn
thng chc nng t bo o ty bao gm virus (quai b, rubella, virus coxsackie
B4), tc nhn c ha hc (nitrophnyl-urea c cho chut), v cc cht c hy
hoi t bo khc nh hydrogen cyanide t bt sn h hng hay t c sn.
1.3. Yu t min dch
1.3.1. Min dch th dch
Khng th lu hnh chng li nhng t bo o ty c tm thy phn ln bnh
nhn T type 1 ngay lc c chn on (60 - 90%) ri gim. Cng c nghin cu
cho rng t KT khng t bo tiu o (ICA: islet cell autoantibody) c pht hin
trong 5 tun u sau khi khi bnh 85-90% T th 1. Ngoi ra > 60% KT khng
insuline c tm thy trc khi iu tr insuline (autoantibody to insuline: IAA).
Ngoi ra cn c KT khng Tyrosine phosphatase IA-2 v IA2.
Ngoi ra, phn ln KT khng t bo o trc tip chng li Glutamic Acid
Decarboxylase (GAD hay GADA), mt loi men nh v trong t bo bta ca ty. C
s ging ht gia thnh phn protein ca virus coxsackie cha chui 24 amino acid
tng ng vi GAD65.
1.3.2. Min dch t bo
Cng ng vai tr trong bnh sinh T type 1: ngi ta nghin cu trn chut
BB v nh vo KT n dng cho thy ri lon TB lympho lin quan n T type 1
(gim lympho T c ch, v tng t lympho T gip /lympho T c ch). Nhng
nghin cu rt gn y gi rng bnh l min dch ca o ty bt u nhiu nm
trc khi chn on lm sng; tin trnh min dch xy ra chm v tip tc.
Cc yu t khc ngoi liu php min dch c th nh hng n din tin t nhin
ca suy t bo trong T type 1
Bng 1: Cc yu t nh hng n T
Yu t Tc dng
Tui Tui cng tr th lng insulin ni sinh cn li cng thp
Cc t khng Bnh nhn c ICA + th tc ph hy TB cng nhanh. Cc t khng
th th khc t c gi tr tin on hn.
khng Bnh nhn T type 1 thng c bng chng ca khng insulin;
insulin y c th l mt yu t thc y s mt b chuyn ha.
Gii Mt s nghin cu cho thy nam gii bnh din tin nhanh hn
iu tr T iu tr mnh T lm chm tc gim sn xut insulin.
2. T type 2
2.1. Yu t di truyn
399
Endopeptidase
Des 64,65 Proinsulin
Insulin
Proinsulin C peptide
Des 31, 32 Proinsulin
3. Glucose huyt tng hai gi sau ung 75g glucose 200 mg/dl
(11,1mmol/l) khi lm nghim php dung np glucose bng ng ung (OGTT).
Giai on trung gian:
+ Ri lon glucose mu i (IFG: Impaired Fasitng Glucose): khi
glucose mu i Go (FPG) 110 mg/dl (6,1 mmol/l) nhng < 126 mg/dl (7,0 mmol/l).
+ Ri lon dung np glucose (IGT: Impaired Glucose Tolerance): khi
glucose mu 2 gi sau OGTT (G2) 140 mg/dl (7,8 mmol/l), nhng < 200 mg/dl (11,1
mmol/l).
- Go < 110 mg/dl (6,1 mmol/l): glucose i bnh thng.
- Go 126 mg/dl (7,0 mmol/l): chn on tm thi l theo di T (chn on
chc chn l phi iu kin nu trn).
nh gi kt qu khi lm nghim php dung np glucose bng ng ung:
- G2 < 140 mg/dl (7,8 mmol/l): dung np glucose bnh thng.
- G2 140 mg/dl v < 200 mg/dl (11,1 mmol/l): ri lon dung np glucose
(IGT).
- G2 200 mg/dl (11,1 mmol/l): chn on tm thi l T.
Lu : TCYTTG cn s dng glucose mao mch chn on T (cn lu n
tnh chnh xc ca my o dng huyt mao mch); trong khi Hi T Hoa K
(ADA) ch s dng glucose huyt tng tnh mch trong chn on T.
Bng 2: Tiu chun chn on T v cc ri lon glucose mu khc (theo TCYTTG -
1999)
Nng glucose mmol/L (mg/dL)
Mu ton phn Huyt tng
Tnh mch Mao mch Tnh mch Mao mch
T:
+ Go 6,1 ( 110) 6,1 ( 110) 7,0 ( 126) 7,0 ( 126)
+ G2 10,0 ( 180) 11,1 ( 200) 11,1 ( 200) 12,2 ( 220)
IGT:
+ Go (nu c) < 6,1 (< 110) < 6,1 (< 110) < 7,0 (< 126) < 7,0 (< 126) v
v v v v
+ G2 6,7 ( 120) 7,8 ( 140) 7,8 ( 140) 8,9 ( 160)
v < 12,2 (< 220)
IFG:
+ Go v 5,6 ( 100) 5,6 ( 100) 6,1 ( 110) = 6,1 (= 110) v
v v v < 7,0 (< 126)
< 6,1 (< 110) < 6,1 (< 110) < 7,0 (< 126)
+ G2 (nu o) < 6,7 (< 120) < 7,8 (< 140) < 7,8 (< 140) < 8,9 (< 160)
401
I THO NG
G2 7,8-11,1 RLDNG
7,8-11,1 RLDNG G2
7,8
7,8 nh gi thm
(Na 2) + G mmol/L >320 mOsm/Kg nc hoc (Na +K+ ) 2 + G + Ur > 340 mOsm/Kg nc
1.2. H glucose mu
L triu chng ng ngi, nht l bnh nhn gi T type 2 iu tr bng
sulfonylureas. Nu bnh nhn T c bin chng thn kinh t ng lm mt p
ng tit catcholamine, lm che du triu chng h glucose mu nn bnh nhn
cng nh thy thuc khng cnh gic c. H glucose mu bnh nhn T gi
l ngun gc ca tai bin mch mu no hoc mch vnh, cng tng t sut T,
ngay c du h glucose mu mc va nhng nu lp li nhiu ln cng rt nguy
hi v khng hi phc.
1.3. Nhim toan acid lactic
Xy ra bnh nhn T type 2 ln tui, thng c tn thng suy t bo gan, hoc
suy thn, v thng do iu tr bng Biguanide. Him gp
1.4. Nhim toan cetone i tho ng (DKA: Diabetic Ketoacidosis)
Gp bnh nhn T type 1, type 2 him. Tin triu c th rt kn o: mt mi,
chn n, nn ma. au vng thng v, c hiu theo tht lng. Tiu nhiu v kht
nc nhiu, nc tiu c cetone > ++ l triu chng bo ng, ngay c khi khng c
triu chng lm sng. C vi trng hp nhim toan cetone nng xy ra trong vi
gi, hoc vi ngy, v tc xut hin l yu t chnh gip tin lng.
Du lm sng r vi kh th do nhim toan: th nhanh 25 l/ph, kh th 4 th ca
Kussmaul. Ri lon thc, thng thng khng c du thn kinh khu tr v Babinski
(-). C du mt nc ni v ngoi bo. Ri lon tiu ho (nn ma, au bng nhiu,
i chy cng lm mt in gii). Hi th c mi acetone, h nhit thng gp. Dn
ng t.
Cn lm sng: glucose niu (++++) v cetone niu (+++).
407
- ECG: phi thc hin mt cch h thng ngay khi bnh nhn mi vo vin,
nh gi bin sng T v xem c bt thng v dn truyn tim tng ng vi kali
mu
- Glucose mu: 3 - 5g/l.- Th ceton trong HT rt cao
- HCO3- gim < 10 mEq/l, pH gn 7,0 hoc thp hn (BT: 7,30)
- Ri lon kali mu: gi u bnh thng hoc tng, nhng gim nhanh trong
3 gi sau. V th theo di in tim u n l cn thit.
408
Bng 7: Tiu chun chn on nhim toan ceton T (DKA) v tng thm thu do
tng glucose mu (HHS) - (theo ADA 2004)
DKA HHS
Nh Va Nng
G huyt tng (mg/dl) > 250 > 250 > 250 > 600
pH ng mch 7,25-7,30 7,00-7,24 < 7,00 > 7,30
HCO-3 huyt tng 15-18 10 - < 15 < 10 > 15
(mEq/L)
Ceton niu + + + t
Ceton huyt thanh + + + t
Posm huyt thanh * Thay i Thay i Thay i > 320
Khong trng anion ** > 10 > 12 > 12 Thay i
Tnh trng tri gic Tnh Tnh/ng g Sng s/hn Sng s/hn
m m
*: Posm (mOsm/kg) = 2 Na (mEq/L) + G (mmol/L)
**: Khong trng anion = Na+ - (Cl- + HCO3-) (mEq/L)
2. Bin chng mn tnh
2.1. Bin chng vi mch
2.1.1. Bnh l vng mc T
Nguyn nhn chnh gy m. Gm 2 giai on: bnh l vng mc T khng tng
sinh (NPDR: nonproliferative diabetic retinopathy) v bnh l vng mc T tng
sinh (PDR: proliferative diabetic retinopathy).
Bng 8: Cc giai on bnh l vng mc T
Giai on Thay i bnh hc thng gp
Thay i lu lng mu qua vng mc
Giai on tin lm sng Mt TB quanh mao mch vng mc
Dy mng y
on li tr. Thng phi hp vi bnh l vng mc, bnh l thn to thnh tam
bnh (triopathie) c hiu ca T.
- Bnh l TK cm gic cp tnh: him, xy ra sau 1 thi gian kim sot chuyn ha
km (nh nhim toan ceton) hay do thay i t ngt kim sot glucose (vim TK
do insulin). Triu chng cm gic xy ra cp tnh v ni bt, tng ln v m, khng
c du hiu TK khi khm LS.
- Bnh l a dy TK vn ng - cm gic mn tnh: cn gi l bnh l TK xa gc i
xng. Thng gp nht, > 50% trng hp. ng vai tr ch yu trong bnh sinh
lot bn chn T.
Biu hiu lm sng ch yu cm gic bng, cm gic chm chch, cm gic in
git, d cm, tng cm gic au v cm gic au su. Triu chng nng v m. Xy
ra ch yu bn chn v chi di. 50% khng c triu chng v ch c chn
on khi thm khm; c khi c biu hin lot bn chn khng au.
Khm thy mt cm gic rung (dng m thoa 128 Hz), cm gic p lc (dng dng
c si n 10g - 10g monofilament), cm gic au v cm gic nhit, mt phn x
gn gt.. Thng km cc du hiu ri lon thn kinh t ng ngoi bin: bn
chn lnh hay nng, i lc tnh mch mu chn dn, da kh, nt chai vng t .
- Bnh l mt dy thn kinh: t gp, khi pht t ngt. Tn thng TK gia (5,8%),
TK tr (2,1%), TK quay (0,6%), TK mc chung. Tn thng TK s (III, V, VI, VII) rt
him gp (0,05%). Khong 1/3 bnh nhn c biu hin chn p TK (TK tr, TK gia,
TK mc v TK gia bn tay). Bnh l teo c do T thng gp bnh nhn
T type 2 ln tui vi triu chng au nhiu, yu v teo c gn gc mt hay hai
bn.
- Bnh l thn kinh t ng (BLTKT):
S tm tt bin chng thn kinh t ng cc c quan:
Bt thng Bt thng Bt lc
v ng t iu ho nhit
ngc dng v suy thn. Nhim trng da v nim mc: nht t cu vng, vim m
h, vim bao qui u.., i khi chnh bi cnh nhim trng ny lm khi pht T c
sn.
4. Cc bin chng khc
4.1. Tng HA
Thng phi hp vi T, i khi c trc khi T xut hin, hoc thng thng
do bnh l cu thn, x va; tn sut gp nhiu T type 2 nht l bo ph v c
s tng quan gia bo ph v THA.
4.2. Bin chng da
Ngoi tn thng nht nhim trng, da cn c nhng biu hiu sau: vim teo dng
m biu hiu bng nhng nt m phn trung tm teo li, vng vin xung quanh tm
dn, nh v ngn tay hay chi di, d ng da do insuline, ph i m m hoc teo
m m.
4.3. Bn chn T
- Sinh bnh hc nhim trng bn chn T: 3 yu t phi hp
+ Bnh l mch mu ngoi bin (vi mch v mch mu ln).
+ Bnh l thn kinh ngoi bin.
+ Suy gim min dch: do gim chc nng TB lympho, do tng glucose mu,
do dy mng y.
- Phn loi nhim trng
+ Mc nh:
Lot b mt.
Chy m hay huyt thanh.
Hoi t khng c hay rt t.
Khng c biu hin nhim c ton thn.
+ Mc va:
Lot b mt su hn.
Thng c chy m.
Hoi t m mc trung bnh.
Vim xng tu xng c th c.
Biu hin ton thn nh: st, BC tng.
+ Mc nng:
Lot b mt hay su hn (vo m di da, xng, khp).
Chy m.
Hoi t m nng v lan rng.
Biu hin nhim c ton thn nng n: nhim toan, nhim khun
huyt.
VII. IU TR
1. iu tr i tho ng tp 1
1.1. Mc tiu iu tr:
- Lm bin mt triu chng, trnh bin chng lu di, bng cch kim sot glucose
mu tt, vi t HbA1c < 7%, kt hp iu chnh ri lon lipide, protide tt, trng lng
412
n nh bnh thng, v trnh nhim cetone. Trnh pht trin bin chng thoi ha
(hn ch bin chng cp v mn tnh).
- Trnh tai bin do iu tr (teo m m, h glucose mu) v gio dc bnh nhn bit
bnh ca h.
413
Bng 9: Mc tiu iu tr T
Mc tiu iu tr c khuyn co ca Chu Thi Bnh Dng
Xt nghim Tt Kh Xu
Go (mmol/l) 4,4 - 6,1 <7 >7
G bt k (mmol/l) 4,4 - 8 < 10 > 10
HbA1c < 6,2% 6,2 - 8% > 8%
Mc tiu iu tr ca ADA (Hip Hi T Hoa K)
XN B/Thng Mc tiu phi t n Cn thay i k hoch
khi iu tr iu tr
* Cch tim v ng tim: thng thng bng ng TDD, trng hp bin chng
cp nh hn m toan ceton hoc tng thm thu th truyn TM, tim TM.
Ch : Ch c insuline nhanh l c th tim bng ng TM, cn cc loai trung gian,
chm, km th khng dng ng TM
* Cch bo qun insulin: insulin n nh nhit t 7 oC-27oC, tuy nhin tt nht
nn bo qun 4 -8 oC, khng nn tim ngay sau khi ly t t lnh ra.
* Tc dng ph insulin
.- H glucose mu
- Phn ng min dch do iu tr insulin: D ng insulin: di dng m ay. Hin nay
him gp v c loi insulin bn sinh hc hay insulin ngi.
- khng insulin.
- Lon dng m m ti ch tim: c 2 biu hin: teo m m di da; ph i m
m di da vn cn l vn kh trnh.
- Tng glucose mu mu thun: hiu ng Somogyi: qu liu insulin lm h glucose,
gy kch thch cc hormon lm tng glucose mu (catecholamin, cortisol, glucagon),
cng lm nng thm cc bin chng.
- Ph: do gi mui gi nc.
* Ch nh iu tr insulin
- T tp 1: iu tr thay th sut i
- T tp 2: iu tr tng cng hay vnh vin tu thuc vo bin chng hay bnh
phi hp
- T thai nghn
* Phc iu tr insulin
- i vi insulin nhanh: ch nh trong trng hp cp cu nh hn m toan ceton,
hn m tng thm thu (truyn TM, bng seringue chuyn hoc bm). Ngoi ra
insulin nhanh thng c ch nh khi glucose mu dao ng, kh kim sot. Tim
di da trc n 30 pht. Tim nhiu ln, hoc tim 2 mi hoc 3 mi nhanh trc
ba n, hoc phi hp thm vi insulin chm hoc hn hp vo bui ti
- i vi insulin NPH: hoc ch nh trong T m glucose mu n nh, cn tim
2mi/ngy: 1 bui sng v 1 vo bui chiu. Hoc phi hp vi insulin nhanh trong
k thut 3 hoc 4 mi tim: trung gian tim vo ti, insulin nhanh th tim sng, tra
v ti.
8 gi 12 gi 20 gi 8 gi
Trc n Trc n Trc n
sng 30pht tra 30pht ti 30pht
415
8 gi 12 gi 20 gi 22 gi 8 gi
Trc n Trc n Trc n
sng 30ph tra 30pht ti 30pht
S 2: S iu tr insulin vi 4 mi tim/ngy (3 nhanh + NPH)
Hn hp (nhanh+NPH) Hn hp (nhanh+NPH)
8 gi 20 gi 8 gi
Trc n Trc n
sng 30ph ti 30ph
S 3: S iu tr insulin vi 2 mi tim/ngy (2 loi hn hp)
tng hp Poly (ADP ribose) (mt loi men phc hi s thng tn NAD) nhm lm
suy yu t bo cung cp NAD.
1.2.5. Ghp tu
2. iu tr T tp 2.
2.1. Mc tiu iu tr:
- Kim sot glucose mu tt nh ni trn
- iu tr cc yu t nguy c phi hp (thuc l, HA. Ri lon lipid mu)
2.2. Cc phng tin iu tr:
- Gio dc bnh nhn
- Tit thc v vn ng th lc, gim cn nng.
- Thuc h glucose mu: Gm cc nhm thuc ung chng i tho ng sau:
+ Thuc tng tit insulin
Sulfamides (Sulfonyl Urase)
Metiglinide (Repaglinide) v D. phenylalanine (Nateglinide)
+ Biguanide: Tng s dng glucose m (c, t bo m).
+ c ch -glucosidase
+ Cc nhm thuc khc: cng to iu ho glucose mu tt qua c ch ti rut, v
gim tng glucose mu sau n. Hoc nhm Thiazolidinedione gip ci thin
khng insulin
2.3. p dng thc t
i vi T tp 2, nht l i vi ngi tr tui hn, tit thc v vn ng th lc
l c chn la u tin. bnh nhn c glucose mu tng nh < 200 mg/dl v
HbA1c < 8.5% nn p dng 4-6 vn ng v tit thc, nu khng ci thin c
glucose mu tt th mi s dng thuc ung h glucose mu
2.3.1. Tit thc:
* Khu phn thc n hng ngy:
- Tit thc gim calo bnh nhn bo ph (20 kcalo/kg/ngy)
- Duy tr calo bnh nhn c trng lng bnh thng (30 kcalo/kg/ngy).
- Tng calo bnh nhn gy (40 kcalo/kg/ngy)
* Tn trng cn bng tit thc gia 3 loi thc n sau
- Glucide: 50-55% (50%) khu phn calo hng ngy ( l khu phn cn
bn). Dng tri cy trong mi ba n, nhng cng hn ch. ng chm hay ng
a (loi c bt) v nhng loi c si (lgume kh) lm chm tng ng sau n v
hp thu chm. Hn ch dng ng n (hp thu nhanh). C th s dng cc cht
ngt nhn to nh ng saccharine, Aspartam
- Lipide: 30-35% (trung bnh 35%) khu phn calo hng ngy. u tin l du
thc vt
- Protide: 15% khu phn calo hng ngy.
- Ru: ung bia ru vi lng va bnh nhn T c th chp nhn
c, vi iu kin phi tnh calo/ngy (1g ru cho 7 Calo) v khng nn dng khi
bng i, d h glucose mu.
2.3.2. Vn ng, tp th dc:
Gim cn; ci thin c ng mu trong v sau khi vn ng th lc (gim
khng insulin, tng tnh nhy cm insulin ngoi bin). Gim LDL-C, tng HDL-C. Tc
418
dng c li trn tim mch. Tng kh nng ti a s dng oxy, lm chm li nhp tim
lc ngh ngi v lc gng sc, gim va phi HA
2.3.3. Cc thuc ung h glucose mu:
* Thuc c tc dng kch thch tit insulin:
- Nhm Sulfonyl Urase: Chuyn ho gan, 1/2 i khc nhau, thi theo ng mt
hay thn, lin kt proteine mu cao, nguy c h glucose mu v kch thch tu tit
insulin.
+ Tc dng ca Sulfonyl urase (S.U). S.U. c tc dng ch yu l kch thch tu tit
insulin
Hot ng ngoi tu-trn tng hp glucose ti gan, vn chuyn glucose, gii phng
glucagon
S.U gim khng insulin v gim glucose mu sau n do gim c tnh glucose,
v tng tim lc trc tip trn gan, khi glucose mu gim th t bo gan nhy cm
hn i vi insulin
S.U cn c tc dng lm tng tnh nhy cm sau th th.
+ Cc nhm thuc S.U.
* Th h I: c 1/2 i ko di: hin nay t dng
- Chlorpropamide: Diabnse 500mg/vin (thi gian 1/2 i l 36 gi)
- Carbutamide: Glucidoral, vin 500mg, Tc dng 1/2 i l 45 gi. Tc dng
ko di 24 - 60 gi. Liu dng 1/2 - 1 vin/ng, dng 1 liu duy nht.
* Th h II: gm:
- Gliclazide: Diamicron 80 mg, Prdian, Glucodex, Clazic, vin 80mg. Tc
dng 1/2 i l 12 gi. Tc dng ko di 12 - 24 gi. Liu dng 1-3 vin/ng. Dng 2
ln/ng (trc hoc trong ba n sng v trong ba n ti). i vi ngi ln tui,
gim 1/2 liu.
Diamicron MR 30 mg, Clazic SR 30mg, tc dng chm, ung 1 ln bui sng,
liu 1-2 vin/ln
- Glibenclamide: Daonil 5mg, Hmi-Daonil 2,5mg, Daonil faible 1,25mg (5
gi). Tc dng 1/2 i 6 - 16 gi. Tc dng ko di 12 - 24 gi. Liu dng thng
thng 1-2vin/ng, c th tng 3v/ng. Ung ngay trc ba n chnh. 1 - 3 ln/ng
- Glipizide: Glibnse, Minidiab: tc dng 1/2 i l 3-7 gi; tc dng ko di
6-12 gi; 5mg/vin; liu 5 - 20mg/ngy, 2 ln/ng.
* Th h III: Glimepiride (Amaryl*, Amarel*) vin 1mg, 2mg, 3mg. Tc dng 1/2 i l
5 - 8 gi. Tc dng ko di 12-24 gi, Liu dng l 1mg/ng, c th tng dn theo
bc cp 1mg, 2mg, 3mg, 4mg, 6mg, thi gian tng theo khong cch 1-2 tun; thng
thng liu 1-4 mg/ng. Ung trc ba n im tm hoc ba n chnh, ung mt
liu duy nht trong ngy.
- Glinide: c tc dng kch thch tit insulin khi glucose mu cao, nn iu ho c
glucose trong ba n, kim sot c ng mu sau n. Gm:
+ Rpaglinide (Novonorm*, Prandin*): vin 0,5mg, 1mg, 2mg; liu 4mg/ngy
chia hai, ung trc n 15 pht. Ko di 3 gi
+ D-phenylalanine (Natglinide). Starlix*, vin 60-120mg, liu 60-120mg/lnx
3 ln/ngy, cho trc n; ko di 1 gi 30 pht
* Biguanides:
a. Metformin (Dimethylbiguanide):
419
3.3.2. Myo-inositol: c tng thm s dn truyn TK, nhng khng ngn chn c
s Sorbitol.
3.3.3. c ch Sorbitol-dehydrogenase: gim oxyde ha sorbitol thnh Fructose bng
cht S.0773 l mt tin dc (prodrug) c cung cp bi Geinsen v cng s, liu
100mg/kg/ngy/3ngy.
3.3.4. iu tr h HA t th
Trong thi gian u, thng thng phi sa i tnh trng gim th tch mu, phi
hp vi thuc. Thuc iu tr hiu qu nht l
- Khong-corticoid nh Fludrocortison, liu 100 - 300(g/ngy (vi thc n
nhiu mui, 2-6 g mui/ngy).
- Mtoclopramid (primperan): thuc i khng dopaminergic, liu primperan
10mg/vin x 3ln/ngy,.
- Thuc i khng th th alpha-adrenergic tin synap
+ yohimbin vin 2mg, liu 4mg x 3 ln/ngy
+ Cn thn bnh nhn c tin s TBMMN
- Dihydroergotamin: thuc co ng mch, ngoi iu tr migrain cn iu tr h
HA t th do thn kinh, do c tc dng i khng th th serotonin 5 HT2, nhng liu
cao c tc dng ng vn th th adrenergic v tc dng serotonic.
+ Tamik*, vin 3mg x 2 vin/ngy, trong khi n;
+ Seglor* nang 5mg, ikaran LP* vin 5mg, liu 10mg/ngy, chia 2
+ Khng nn phi hp bta-bloquant
- c ch bta: mt s rt t bnh nhn c tng th th bta, th propanolol
c ch nh (liu thp).
- Thuc ng vn alpha 1: Nu tht bi khi dng cc loi thuc trn, th dng
cht ng vn alpha 1 nh midodrine (gutron). Liu 2.5-4 mg mi 6 gi, thng
thng phi hp vi dihydroergotamin v cafein.
- Thuc ng vn ca somatostatin c tc dng di: i vi cc th h HA t
th kh tr, xy ra trong thi k sau n, th dng Octreotid liu 0,1-0,5 g/kg TDD vo
bui sng hoc ti
- Thuc c ch tng hp prostaglandin: nh indometacin, ibuprofen, cng c
kh nng sa i h HA t th sau n bnh nhn T.
3.3.5. iu tr lit d dy:
- Lit d dy gy bun nn, hay nn th iu tr
+ Metoclopramid (primperan), cht i khng dopamin, vin 10mg, ung 4
ln/ngy, Nhng nu d dy lit nng th phi dng ng tim v hp thu thuc ti
d dy km.
Cc thuc khc nh:
+ Cisapride (prepulside*): c th lm gia tng phng thch acetylcholine t
tng thn kinh c rut (plexux myenteric), kch thch vn ng hang v v t trng,
liu 10-40 mg trc n 30 pht
+ Dopaminobloquant: domperidone (motilium), ci thin ri lon nhp in d
dy, 20mg/vin, liu 10-40 mg/ngy, c th 80mg/ngy chia bn ln, cho 30 pht
trc n.
+ Thuc ng vn cholinergic (ging ph giao cm): bethanechol chloride
10mg, 2 ln/ngy
423
H GLUCOSE MU
Mc tiu
1.Trnh by c c ch bnh sinh v bnh nguyn ca h glucose mu.
2. Trnh by c nhng triu chng lm sng v cn lm sng lin quan n h
glucose mu.
3. Bit cch x tr v theo di bnh nhn b h glucose mu theo tng mc .
4. Bit phng thc tm kim nguyn nhn v bin php d phng h glucose mu.
Ni dung
I. NH NGHA
H glucose mu cn c gi l h ng huyt, din t nhng biu hin lm
sng v cn lm sng xy ra i vi c th ngi khi nng glucose huyt tng
tnh mch (50 mg/ dl (2,7 mmol / l).
H glucose mu l mt trong nhng cp cu ni khoa thng gp trn lm sng, l
mt trong nhng nguyn nhn gy t vong bnh nhn i tho ng s dng
insulin hoc sulfamide h ng huyt trong t l t vong 3 - 7% bnh nhn i
tho ng tp1. Tuy nhin thc t lm sng gii hn nng ng mu ni trn
c th thay i do tnh hung lm sng cp hay mn ty thuc vo tui cng nh
bnh l i km nht l bnh nhn i tho ng c thi gian mc bnh ko di.
II. BNH NGUYN
1. H ng huyt lc i km cng insulin
1.1. Phn ng insulin
- Ch n khng y v s v cht lng hoc l do qun ba n bnh nhn
i tho ng iu tr.
- Hot ng th lc qu mc: ngi khng b i tho ng lng thu nhn
glucose ca c vn (tng 20-30 ln trn mc cn bn) c b tn sinh ng
gan. iu ny l do gim insulin lu hnh do tng catecholamine do vn ng lm
c ch t bo beta. iu ha ny b gim bnh nhn ang iu tr insulin. Khi cc
ni lng ng thuc di da tip tc phng thch insulin trong qu trnh hot ng v
tng hp thu insulin nhng vng c gn gc.
- H thng iu ha glucose b tn thng bnh nhn i tho ng b bnh lu
ngy. Phn ln bnh nhn i tho ng tp 1 c s km p ng glucagon khi h
ng huyt
- Qu liu insulin. Do khng nhn r hoc do thay i nng Insulin trong l thuc
(40 UI/ ml thay th 100 UI/ ml)
- Qu liu sulfamide h ng mu, thuc c tc dng ko di (Chlopropamide c
thi gian bn hy trn 35 gi...) c bit bnh nhn c thng tn gan, thn, ngi
ln tui d c nguy c h ng huyt.
- Cc nguyn khc
+ Stress: Khi b stress (bnh tt, nhim trng, phu thut...) thng tng liu Insulin
cn bng ng mu. Khi stress chm dt cn phi gim liu.
+ Suy v thng thn (bnh Addison) gy h ng huyt v th cn gim liu
Insulin.
+ Bnh l d dy i tho ng: Bnh l thn kinh thc vt cc tng lm d dy
gim trng lc lm chm a thc n t d dy vo rut, nguy c h ng sau
n bnh nhn s dng Insulin.
426
+ Thai nghn. Nhu cu tiu th ng tng trong thai nghn v th cn gim liu
Insulin trong 3 thng u.
+ Suy thn: Lm ging ha Insulin v thuc h ng huyt b ko di.
+ Thuc dng phi hp: Bnh nhn i tho ng c phi hp thuc iu tr nh:
Allopurinol, c ch beta, clofibrate, cimetidine, thuc chng ng, hydralazine,
indomethacine, Maleate de perhexilline, miconazole, phenolbarbitale phenylbutazole,
probenecide, salycile, sulfamide chng nhim khun, IMAO.quinine, quinidine, c
ch men chuyn, disopyramide, tricycliques, propoxyphene, octreotide, tetracycline,
mebendazole, cibenzoline, stanozolol, fluoxetine, ethanol, sertaline, tromethamirne,
gancilovir, lithium, temafloxacilline.
+ H ng huyt gi (dng ln lt Insulin v cc thuc h ng huyt): lin quan
n bnh nhn c bnh l tm thn phi hp.
+ H ng huyt t min. C khng th khng Insulin. H ng huyt xy ra 3 - 4
gi sau n v c quy cho s phn ly gia phc hp min dch khng th & Insulin
lm phng thch Insulin t do... H ng huyt t min do tch ly s lng khng
th ln c kh nng phn ng vi Insulin ni sinh, c ghi nhn bnh nhn
iu tr methimazole trong bnh Basedow ti Nht Bn, cng nh mt s bnh nhn
lymphoma, a u ty, hi chng lupus, trong paraprotein v khng th phn ng
cho vi Insulin.
H ng huyt do khng th khng th th Insulin tng i him, bnh nhn ny
c thi k khng Insulin v chng gai en (acanthosis nigricans).
H glucose mu cng c ghi nhn s p ng vi iu tr glucocorticoid m
khng thy trong lc huyt tng v c ch min dch.
- H ng huyt do dng Pentamydine: Loi thuc dng iu tr nhim khun
Pneumocystic carinii bnh nhn AIDS, thuc lm tng Insulin cp do tc dng trn
t bo beta (10 - 20% bnh nhn).
- U t bo beta tuyn tu.
1.2. H ng huyt lc i khng cng insulin.
1.2.1. Cc ri lon phi hp vi gim lu lng glucose gan.
- Do mt mt s lng t bo gan nh teo gan vng cp, nhim c gan cp.
- Do ri lon cung cp acid amin n gan (chn n thn kinh, nhn i lu ngy, hi
chng uree mu cao, suy v thng thn).
-Do bt thng chuyn ha glucose tr s sinh (thiu men thoi bin glycogen,
men tn sinh glucose).
1.2.2. H ng huyt do ru
Ru (ethanol) chuyn ha ti gan nh NAD v xc tc bi ethanol dehydrogenase.
V th dng ru lu ngy lm gim lng NAD gan. y l cht cn thit trong
phn ng tn sinh ng. H ng huyt do ru do gim tn sinh ng km
gim ngun d tr glycogen ti gan. Ngoi ra insulin mu gim thun li cho tng
cetone mu v trong nc tiu.
Bnh nhn h ng huyt do ru thng km thiu vitamine B1 (Beriberi) cp v
th ngoi s dng glucose cn phi hp vi vitamine B1. Ngoi ra do hai yu t ni
trn vic s dng Glucagon trong h ng huyt do ru khng c tc dng.
Triu chng thng xy ra sau n t 8 - 12 gi. Bnh nhn trc ung nhiu
ru v s lng cng nh thi gian lm gim ngun d tr glycogen mt phn do
n ung khng y .
427
+ Khng p dng tiu chun cn bng ng huyt l tng nhng bnh nhn
T trn 60 tui.
+ Cn ch hin tng Somogyi gy tng ng huyt th pht vo bui sng do
h ng huyt trong m
4.2. iu tr cc bnh l gy h glucose mu
- U ty tit insuline: Phu thut,Diazoxide (ung hoc tnh mach) liu 300-1200 mg /
ngy + thuc li tiu. Octreotide tim di da liiu 100-600 (g / ngy. Ha tr liu
bng Streptozotocine- 5 fluoro uracile.Chng h ng huyt bng chuyn glucose
v iu tr thm Sandostatine.
- U ngoi ty tit insuline:Phu thut, Chng h ng huyt (kh) bng chuyn
Glucose, chuyn di da lin tc Glucagon bng bm theo nhp khng lin tc.
- Bnh nhn b phu thut ct d dy: Gio dc bnh nhn v thn nhn du hiu v
cc x tr h ng huyt.Glucagon v Glucose u trng lkun c sn nh.Chia
u nhiu ba n. Gim loi ng hp thu nhanh. Thc n phi hp protide v
glucide.
VIII. D PHNG
+ Cn gio dc h glucose mu cng nh cch s tr h ng mu cho bnh nhn
i tho ng v thn nhn ca h.
+ X tr h glucose mu cn phi cp thi, ti ch bng mi bin php c th thc
hin trc khi chuyn bnh nhn vo vin, khng nn ch i kt qu ng mu.
+ Lu tc dng h ng huyt ca mt s thuc khi phi hp.
+ Trnh t tng ng l k th i bnh nhn i tho ng
+ Phng chm KHNG N KHNG DNG THUC H NG HUYT, NU
DNG THUC H NG HUYT BT BUC PHI N cn p dng cho tt c
bnh nhn i tho ng..
434
BO PH
Mc tiu
1. Trnh by c nh ngha, bnh nguyn v sinh l bnh ca bo ph
2. Trnh by c tiu chun chn on v phn loi bo ph
3. Triu chng, cc phng php nh gi bo ph
4. Bit r cc bin chng ca bo ph
5. Trnh by c tit thc, hot ng th lc v tp th dc gim bo ph
6. Trnh by c thuc iu tr bo ph
Ni dung
I. NH NGHA: c nhiu cch nh ngha
1. Bo ph c nh ngha bng s qu ti lng m c th, c bit lin quan n
chuyn ha nng lng, ko theo hu qu xu cho sc khe.
2. Hoc gi l bo ph khi tng trn 25% trng lng c th v c nh gi da
vo kch thc v gii.
3. i a s dng cng thc BMI nh gi mc bo ph. BMI t 20-25kg/m2
c xem l tt, qu ti trng lng khi BMI >27kg/m2 v theo phn loi hin nay,
c quc t chp nhn, bo ph c nh ngha bng BMI (30 kg/ (m2). T gi tr
ny, ngi ta xem nh l s tch m qu nhiu, bi v n ko theo mt s gia tng
c ngha v bnh sut v t sut.
II. TN SUT: Bo ph cng ngy cng gia tng nht l cc nc pht trin kinh
t trn th gii; c bit trong 10 nm li y, la tui gp cao nht l >30 tui. Tn
sut bo ph ph thuc vo tiu chun chn on. Tn sut bo ph thay i tu theo
tui, gii tnh v a d, chng tc, tnh trng kinh t x hi:
- Tui: 2% lc 6-7 tui, 7% tui dy th, v cao nht tui (50 (u M).
- Gii: n gp nhiu hn nam (25% so 18%).
- a d, chng tc: min ng nc Php l 33%, min Ty 17%. Ti Nam Phi bo
ph gp cc tnh pha Nam nhiu hn cc tnh pha Bc. Trong thp k qua, t l
bo ph ca ton nc M t 25 - 33%, tng 1/3. Ph n da en tui t 45-55 tui c
t l bo ph gp 2 ln so n da trng cng tui.
chu u, gn y khong chng 15 nghin cu dch t v s qu ti trong lng
17 nc ca chu u. S s dng tiu chun chn on khc nhau tu theo
nghin cu (BMI, hoc cng thc Lorentz, hoc cng thc Broca).
- iu kin kinh, x hi c lin quan n ch dinh dng, phong cch sng:
+ Trung Quc, s tr em bo ph tng cao trong nhng nm gn y, do c
nung chiu, n ung qu mc, t khi c ch trng mi gia nh ch c mt con;
+ Singapore, tr em bo ph ti cc trng tiu hc gia tng mt cch ng k.
+ Ti thnh ph H Ch Minh, do mc sng ngy cng cao, nn s bo ph tr em
cng nh ngi ln gia tng.
Nhng ngc li ti M mc kinh t x hi thp th tn sut bo ph cao hn so vi
mc sng kinh t x hi cao.
Nhng ngi ln bo ph c khong 50-100% nguy c cht sm so ngi c BMI
khong 20-25 kg/m2.
435
Bo ph
khng insulin
Gim bt gi glucose mc t bo
gai on sau n
1.2. Cng thc Lorentz: tnh trng lng l tng (TLLT), cng thc ny da vo
trng lng bnh nhn tnh bng kg v chiu cao tnh bng cm nh nu trn:
439
BO PH
Acid bo t
d
Glucose mu
i tho ng type 2
3. Bin chng tim mch: Bo ph l mt trong nhng yu t nguy c cho bnh l tim
mch nh
- Tng guyt p (THA): lin quan cht ch gia bo ph v tng HA, tn sut
THA tng trong bo ph bt k nam hay n. Huyt p gim khi gim cn. C ch
tng HA trong bo ph cha r ht, ngoi x va ng mch hay gp, cn c gi
thuyt do tng insuline mu v khng insuline, lm tng hp thu Natri ng thn
v tng tit catecholamine lm co mch.
Hnh
- Suy mch2: Vai
vnh: trogp,
thng cua
ngaybeo
c khi ph
khngtrong
c thmhi chng
cc yu t nguy c
chuyn
khc nh T, tng lipide mu, tng HA. hoa
- Cc bin chng khc nh suy tim tri, tai bin mch mu no.
4. Bin chng phi
- Gim chc nng h hp do lng ngc di ng km do qu bo.
- Hi chng Pickwick: ngng th khi ng.
- Tng hng cu, tng CO2 mu.
5. Bin chng v xng khp
Ti cc khp chu lc cao (khp gi, khp hng, ct sng) d b au, thoi
khp.
Tn sut hoi t thiu mu u xng i gia tng.
Thot v a m, trt t sng hay gp
Cc bin chng ny tng ln ph n mn kinh.
6. Bin chng v ni tit
- Tng insuline mu v khng insuline v T th 2, do tc dng bta-
endorphine hoc gim s lng v cht lng insulin, kch thch t bo bta do n
nhiu glucide.
- Chc nng ni tit sinh dc: gim kh nng sinh sn. Chu k kinh ko di
khng phng non. Rm lng.
7. Cc bin chng khc
443
- Nguy c ung th gia tng: ung th t cung, v, i trng, tin lit tuyn.
- Bin chng tng nng ln do bo ph:
+ Gan mt: Si mt, gan nhim m.
+ Thn: tc tnh mch thn, protein niu.
+ Sn khoa: nhim c thai nghn, sinh kh, m ly thai tng.
+ Da: rn da, nm k, tng sng ho gan bn chn, bn tay.
IX. IU TR
M hnh iu tr bo ph: da vo 3 phng cch chnh sau y:
- Tit thc gim trng lng
- Tng nng lng tiu dng (Tp th dc).
- Thay i chuyn ha thc n.
Phng cch 1 v 2 bao hm tit thc v tp th dc.
1. Tit thc gim trng lng v tp th dc
Gim trng lng l mc tiu chnh iu tr, vi gim trng lng mc nh t 5%
n 10% trng lng ban u, bng tit thc v tp th dc cng ci thin lm sng
c ngha, ci thin c bnh tng HA, bt thng lipide cng nh glucose mu.
Khong 80% bnh nhn T tp 2 c tng trng hoc bo ph, nu gim trng
lng t 5% n 10% th ci thin c ngha HbA1c.
Theo Chng trinh T Phn Lan v Chng trnh Ngn nga bnh T cho
thy rng nhng bnh nhn c ri lon dung np glucose mu, nu gim trng
lng chng 7% s gim c nguy c T tp 2 chng 58%.
1.1. Tit thc gim trng lng
- Tit thc gim trng lng: l phng cch u tin v c p dng mt cch
rng ri. Cch thc chnh l tit thc gim calo, gim m v vi thc n khc c kh
nng gim sinh nng lng cho c th. Nu nng lng a vo thp hn nhu cu
sinh l, th nng lng thm vo l t m m d tr. S khc bit ln gia nhu cu
a vo v nng lng l do s i. Khi khng c thc n a vo, nng lng
c rt ra t m m d tr l 1500-3000 kcal. M c th cha 7500 kcal/kg. Vi
cn bng calo m tnh 1500 kcalo/ngy, th s lm gim trng lng c th 1 kg mi
5 ngy. Lm gim trng lng khong t 0,5-1 kg/tun l thch hp cho mt tit thc
gim trng lng.
i vi ngi ln tui va, 1200 kcalo/ngy duy tr mt > 0,5 kg/tun.
Ni chung lng calo cho mi bnh nhn tt nht phi da vo cn nng hin ti.
Tit thc gim calo khi lng calo dng 20-25 Kcalo/kg/ngy
Nh vy nu lng calo cung cp gim di 500 Kcalo/mi ngy, th s lm gim
mt trng lng khong 0,5kg/tun. Thnh cng iu tr tu vo tui bnh nhn (bo
ph thiu nin phi c iu tr rt sm) v ng lc bnh nhn rt cn cho iu tr.
i vi nhng bnh nhn c thi quen n nhiu, chp nhn hn ch thc n trong
sut cuc sng l rt kh khn.
Tit thc t m, gim thc n giu-carbohydrat v tit thc m n khng bo ho
ci thin c bnh mch vnh. Nn dng nhiu tri cy, cc loi rau, v nhng loi
ton ht, giu cht x. Nn thay th thc n c cht dinh dng thp, giu calo bng
nhng thc n c cht dinh dng cao, t nng lng
trnh cc bnh l tim mch, nn dng cc loi rau, tri cy, cc loi ton ht, c
v cc thc n c ch bin t m km luyn tp th dc.
444
ngi lun c cm gic mau i v thm n nhiu, Reductil cng lm gim t VB/VM,
gim lipide mu v glucose mu. Tc dng ngoi ca thuc l kh ming, to bn,
au u nh, cm gic hi hp, tng nhp tim THA mt s ngi (him). Thn
trng: khng dng cho ngi THA v c bnh mch vnh. CC: tr em, mn cm
vi thuc, c thai cho con b.
Siburtramine l loi c ch chn lc s ti thu gi c 2 loai serotonin v
norepinephrin, n lm gim ngng ngon ming (do tc dng trung ng lm cho
bnh nhn c cm gic no sm) v tng sinh nhit, gim vn tc bin dng, nn
gim trng lng.
Orlistat, c ch lipase tu, gim hp thu rut. Tc dng ph l km hp thu m,
gim cc viatmin du nh vitamin D v E, nn phi tng cng thm vitamin.
447
BASEDOW
Mc tiu
1. Trnh by c nh ngha, c ch bnh sinh v bnh nguyn ca bnh.
2. Nu c nhng triu chng lm sng v cn lm sng lin quan n bnh.
3. Bit cch chn on bnh Basedow.
4. Trnh by c cch iu tr bnh Basedow.
5. X tr c nhng bin chng chnh ca bnh
Ni dung
I. NH NGHA
Basedow l mt trong nhng bnh l cng gip thng gp trn lm sng vi cc
biu hin chnh: nhim c gip km bu gip ln lan ta, li mt v tn thng
ngoi bin.
Bnh Basedow mang nhiu tn gi khc nhau Bnh Graves. Bnh Parry. Bu gip
c lan ta. Bnh cng gip t min. Nh s tin b ca min dch hc, ngy cng
nhiu khng th hin din trong huyt tng ngi bnh c pht hin, v th hin
nay bnh c xp vo nhm bnh lin quan t min.
II. BNH NGUYN
Bnh xy ra mi tui, nht l tui 20 - 40 tui, u th ph n, t l nam /
n = 1/5 - 1/7 vng khng b bu c a phng. Tuy nhin, vng dch t t l
ny thp hn. Theo Volp c l lin quan n s khim khuyt ca t bo lympho T
c ch, l yu t c bn trong bnh l t min tuyn gip. Mt vi yu t ghi nhn
c th gy p ng min dch trong Basedow nh
- Thai nghn nht l giai on chu sinh (hu sn)
- Dng nhiu iod, c bit dn c sng trong vng thiu iod, c th iod lm khi pht
bnh Basedow tim tng.
- Dng lithium lm thay i p ng min dch.
- Nhim trng v nhim virus.
- Ngng corticoid t ngt.
- Ngi c HLA B8, DR3 (dn vng Caucase) HLA BW 46, B5 (Trung Quc) v HLA
B17 (da en).
- Vai tr Stress cha c khng nh.
- Lin quan di truyn vi 15% bnh nhn c ngi thn mc bnh tng t v
khong chng 50% ngi thn ca bnh nhn c t khng th khng gip trong
mu.
III. BNH SINH
C s khim khuyt ca t bo lympho T c ch (Ts, T8), cho php t bo lympho T
h tr (T H) kch thch t bo lympho B tng hp cc khng th chng li tuyn gip.
Globulin min dch kch thch tuyn gip (TSI: Thyroid stimulating immunoglobulin
hoc TSH. R Ab (Stim): khng th kch thch th th TSH) gy tnh trng nhim c
gip. Ngoi ra cn tm thy nhiu loi khng th khng thyroglobulin, khng th
khng enzyme Peroxydase gip hoc khng th khng tiu th. Ngoi ra tin trnh
vim nhim c hc mt do s nhy cm ca cc t bo lympho T c t bo
(cytotoxic T lymphocyte) hoc cc t bo git (killer cell) i vi khng nguyn hc
mt trong s kt hp vi cc khng th c t bo. Tuyn gip v mt c th c lin
quan bi mt khng nguyn chung gia tuyn gip v nguyn bo hc mt. Tuy
449
nay t dng v c TSH siu nhy v chp nhp nhy tuyn gip.
+ Test TRH v test Querido (kch thch tuyn gip bng TSH): hin nay t c ch
nh.
3. Xt nghim hnh thi v cu trc tuyn gip
+ Siu m tuyn gip: tuyn gip ph i, eo tuyn dy, cu trc khng ng nht,
gim m (nhm vim tuyn gip). Siu m Doppler nng lng c th thy hnh nh
cu trc tuyn gip hn lon nh hnh nh m chy trong thi k tm thu v tm
trng vi cc mch mu gin trong tuyn gip, ng mch cnh nht l ng mch
cnh ngoi ny mnh, (ng mch cnh nhy ma). Trong nhiu trng hp khng
in hnh (khi u hoc iu tr) kh phn bit vi hnh nh ca Hashimoto.
+ X hnh tuyn gip (chp nhp nhy tuyn gip) gip xc nh phn no hnh thi
v chc nng tuyn gip vi I123 hoc Tc 99m: cht phng x tp trung ng u
ton b hai thy tuyn gip - tuyn gip ph i - gip phn bit cc thng tn ca
cc bnh l cng gip khc (bu gip c a nhn, bu gip c, vim tuyn
gip...).
+ Chp ct lp tuyn gip (CT Scanner) v MRI t c s dng trong chn on v
cu trc t khc bit so vi mt s bnh l vim tuyn gip.
+ Hnh nh gii phu bnh: Tuyn gip ln u c hai thy, tnh cht lan ta, mm
v tn sinh nhiu mch mu. Nhu m gip ph i v tng sn, gia tng chiu cao
ca t bo thng b v tha ln vch nang tuyn, to ra cc np gp dng nh
phn nh t bo tng hot ng. S lon sn nh trn thng km thm nhim t
bo lympho, iu ny phn nh bn cht min dch ca bnh v lin quan n nng
khng th khng gip trong mu.
4. Thm d thng tn mt
o li nhn cu bng thc HERTEL (i t b ngoi hc mt n mt phng tip
tuyn mt trc nhn cu): phng php n gin, thc hin nhiu ln, tr s thay
i. Hn ch ca phng php ny l khng nh gi trc tip thng tn tm
nhun sau hc mt.
- Tm kim du vim gic mc.
- Khm y mt; o trng lc nhn cu.
- Chp ct lp vng hc mt nhm pht hin sm cc bt thng hc mt, c vn
nhn, thn kinh th gic khi cha biu hin lm sng (giai on tin lm sng) v
gip phn bit cc nguyn nhn gy li mt khc.
- Siu m mt: nh gi bt thng c vn nhn v t chc hu nhn cu (c th o
c b dy ca t chc tm nhun sau hc mt)
5. Xt nghim thng tn da: Sinh thit vng ph mm trc xng chy, nhum
PAS (+) c s lng ng cht glycosaminoglycan.
6. Chp X quang xng u chi: Mng xng dy
VI. CHN ON
1. Th in hnh
Gp ph n tr vi y cc du chng lm sng nh trn.
2. Th triu chng
u th mt s c quan
Biu hin tim.
Biu hin thn kinh.
453
Biu hin c.
Nhc c nng v Basedow.
Bnh xng nhim c gip.
Biu hin tiu ha.
Basedow v nn ma.
Biu hin huyt hc.
Th v to v Basedow.
Basedow v tng cn.
3. Th lin quan nguyn nhn
Phi hp vi cc bnh l t min khc
Suy v thng thn v Basedow.
i tho ng v Basedow.
4. Cc th sinh hc
- Tng T3 ch yu.
- Tng T4 ch yu.
5. Cc th tin trin
Th in hnh : tr v bnh gip sau iu tr.
Th thoi trin t pht : 10-20%
Th cp v bn cp : trong th bn cp thng phi hp vi du gy nhiu, tiu
chy, ri lon nhp tim, c st v biu hin tm thn; th cp thng xy ra do sai
lm iu tr, c bit chun b ni khoa khng tt bnh nhn c ch nh phu thut.
Th v tnh cm (apathies): thng gp ngi ln tui, bnh cnh tri v yu c,
lit, chn n v ri lon nut. Thng chn on kh.
6. Chn on phn bit
- Teo c trong trng hp bnh c nng cn phn bit bnh c nguyn pht.
- Lit chu k gip trng thng xy ra ph n Chu , gy lit t ngt v gim kali
mu, i khi xy ra t pht, c th d phng bng dng kali v thuc c ch .
- Tim trong cng gip: khi u lon nhp c hi phc, khng p ng vi digoxin,
km tng cung lng tim.
- Khong 50% khng c bnh l tim tim tng, bnh p ng vi thuc khng gip.
- Ngi ln tui biu hin st cn, bu gip khng ln, rung nh chm v trm cm
(nng gi l cng gip v tnh cm = apathic hyperthyroidism).
- Ngi ph n tr i khi khi u vi mt kinh, v sinh.
- Hi chng cng thyroxin do ri lon albumin gia nh: do c bt thng albumin
lin kt ch yu vi T4, lin kt km vi T3, kt qu tng T4, FT4I nhng FT4, FT3
v TSH bnh thng, cn phn bit tnh trng bnh gip trong cng gip.
VII. BIN CHNG
Do c ch bnh sinh lin quan t min bnh c th hi phc t pht hoc do iu tr.
Trong qu trnh din bin bnh thng gp hai bin chng nh sau:
1. Bnh c tim nhim c gip: Thng biu hin di 2 dng
1.1. Ri lon nhp tim. a dng vi nhp nhanh xoang, ngoi tm thu, nhp nhanh kch
pht trn tht...
1.2. Suy tim cng gip
454
Cn phn bit 2 giai on: (1) Giai on u suy tim tng cung lng (nhp tim
nhanh, huyt p tng, c tim tng co bp...) v (2) Giai on sau l th bnh c tim
(ph, kh th, tim ln, ri lon nhp, suy tim, huyt p gim, chc nng co bp tim
gim...).
2. Cn cng gip cp
- Thng xy ra bnh nhn khng iu tr hoc iu tr km.
- Khi pht sau mt sang chn (phu thut, nhim trng h hp, chn thng, tai
bin tim mch, sau sinh...).
- Khi iu tr trit (phu thut, x tr liu) khng c chun b tt. Bnh cnh lm
sng vi cc triu chng:
+ St cao 40-41(, m hi, mt nc.
+ Nhp tim rt nhanh, ri lon nhp, suy tim, chong try mch.
+ Run, kch thch, thng tn c (ri lon nut), m sng, hn m.
+ Tiu chy, au bng, bun nn, nn ma, vng da.
+ C th gp cn bo gip v cm (apathetic storm) vi c trng yu c, v tnh
cm, ri lon tm thn. Chn on da vo cc d kin lm sng c gi . Nn
iu tr tch cc ngay, khng nn ch i kt qu xt nghim.
3. Li mt c tnh: (xem phn tn thng mt)
VIII. IU TR
Hin nay c nhiu phng php v phng tin iu tr bnh Bassedow. Vic chn
la phng php iu tr tu thuc vo kinh nghim ca thy thuc, iu kin y t c
s, s dung np v tun th ca bnh nhn trong qu trnh iu tr. Di y l mt
s phng php v phng tin iu tr:
1. iu tr ni khoa
1.1. Nhm thuc c ch tng hp hormone gip
- Trnh by: thng c s dng lm sng chia lm 2 loi
Carbimazole (neomercazole) 5mg, Methimazole 5mg
Propylthiouracil (PTU) 50mg, Benzylthiouracil (BTU) 25mg
- C ch tc dng:
- c ch phn ln cc giai on tng hp hormone gip
- Carbimazole c ch kh iod tuyn gip.
- PTU c ch bin i T4 thnh T3 ngoi vi.
- Carbimazole liu cao (> 60mg/ ngy) c tc dng c ch khng th khng gip
(gim trnh by khng nguyn gip, gim phng thch prostaglandin v cytokin t t
bo gip, c ch sinh sn cc gc t do t t bo T v B c bit t bo trnh by
cc khng nguyn v th lm gim khng th).
- Hiu qu tc dng: hng nh lng hormone lin quan n thi gian na i ca
T4 v do lng hormone tch tr trong tuyn gip. Hiu qu sau 1 - 2 tun, r rng
sau 3 - 6 tun.
- Liu lng thuc khng gip tng hp
- 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 dng liu c nht bui sng. PTU 100-
150mg/6gi/ngy. Sau 4 - 8 tun gim 50 - 200mg/mt hoc hai ln/ ngy.
- i vi nhm imidazole: thi gian na i khong 6 gi, do c tc dng khng gip
trn 24 gi, dng liu c nht bui sng bt u 40mg/ ngy trong 1-2 thng sau
455
Thn trng bnh nhn c bnh l tim mch v ri lon chuyn ha, nht l mt
nc liu dng 300 - 450 mg / 8m gi v duy tr nng 1 mEq/l.Ch x dng khi
bnh nhn d ng vi Thionamide hoc iode.
1.2.4. Glucocorticoide
Dexamethasone liu 2 mg/ 6 gi c th c ch phng thch hormonee gip.
1.2.5. Thuc c ch ((propranolol, atenolol, esmolol)
Liu propranolol trung bnh 20 - 80 mg/ 6 - 8 gi.
1.2.6. Thuc chng ng
Rung nh chim t l t 10 - 25% bnh nhn Basedow, nht l bnh nhn ln tui.
Warfarin d gy xut huyt sau khi iu tr phng x. Aspirin c ch nh nhng thn
trng nu s dng liu cao (aspirine lm tng FT3 v T4 do gim kt hp protein).
1.2.7. An thn. Nn chn nhm barbiturate c tc dng gim lng thyroxine do gia
tng thoi bin.
1.2.8. Cholestyramine. Dng 4 mg, ngy 4 ln c th lm gim T4.
2. Phu thut ct gim tuyn gip gn ton phn
2.1. Ch nh
+ Bnh ti pht sau nhiu ln iu tr.
+ Tuyn gip qu ln.
+ Cng gip ph n c thai p ng km vi iu tr ni khoa.
2.2.Chun b trc m
Tt nht nn iu tr ni khoa t bnh gip trc khi phu thut.
2.3. Theo di sau m
Theo di mi 4 - 6 tun pht hin suy gip hoc cng gip tr li. Lu c th
c suy gip nh t hi phc trong vng 4 - 6 tun. Suy ph gip khong 3%, lit dy
thn kinh qut ngc v th i hi phu thut vin c kinh nghim.
3. iu tr Iode phng x
Dng I131 tp trung ti tuyn gip ph hy nhu m tuyn gip ti ch, hin l
phng php iu tr c chn la do hiu qu cao, kinh t v khng c phn ng
ph nghim trng, cha c bng chng cho rng iu tr iod phng x nh hng
trn bnh l mt trong Basedow hoc gia tng nguy c c tnh.
3.1. Ch nh
- C th t 35 tui tr ln
- Bnh ti pht nhiu ln - khng phu thut c
- Kh khn trong theo di (ngi ln tui)
- Suy tim
- D ng thuc khng gip
Trng hp suy tim, nhim c gip nng, tuyn gip c th tch ln (trn 100 gam),
nn iu tr t c bnh gip trc khi iu tr iod phng x.
3.2. Chng ch nh
Tuyt i trng hp thai nghn, tuy nhin cha c bng chng cho rng iu tr iod
phng x c th gy ra mt s hu qu xu t cung (nguy c bt thng bm sinh
thai nhi ph n sau khi iu tr phng x) v bung trng (phng x vo bung
trng rt thp tng ng vi liu thm d X quang).
4. iu tr mt s tnh hung c bit
457
+ Suy tim gim cung lng.: Bn cnh thuc khng gip tng hp cn phi hp vi
thuc tr tim, li tiu, thn trng thuc c ch bta.
4.5. iu tr Basedow ph n c thai
- Chng ch nh iu tr I131
- Khng dng iod trong qu trnh iu tr, gy suy gip tre s sinh.
- iu tr ni khoa.
+ Khng gip tng hp: Ba thng u dng PTU v ba thng gia c th phu thut.
+ Propranolol c th s dng (lu suy h hp v km pht trin thai nhi nu s
dng liu cao v ko di).
Trong thi gian cho con b c th s dng PTU v thuc qua sa m khng ng k.
Thai nhi cn c theo di st trong qu trnh s dng thuc khng gip.
4.6. iu tr chng gim - mt bch cu ht
Trong qu trnh iu tr thuc khng gip tn hp thng xuyn kim tra cng thc
bch cu nu pht hin s lng bch cu ht di 1200 mm3 cn phi theo di st
do c nguy c mt bch cu ht nu bch cu di 200 / mm3. Ngng thuc khng
gip v tu mc v x dng thm Neupogen (Filgrrstim) hoc Leucomax
(Molgramostim)
IX. TIN LNG
Tin lng bnh nhn tu thuc th bnh, phng tin iu tr v theo di.
459
BU GIP N
Mc tiu
1. Bit phn bit bu c n thun v bu c dch t.
2. Hiu c cc nguyn nhn gy bu c.
3. Chn on xc nh, phn bit v chn on mc bu gip n
4. Cc bin chng ca bu gip n
5. Ch nh c iu tr bu gip n.
6. Trnh by c cch s dng iode phng bnh bu c
Ni dung
I. NH NGHA
1. Bu c dch t: cn gi l bu gip a phng hay bu gip lu hnh: Khi
nhu cu sinh l ca iode khng trong qun th dn chng, th s pht sinh hng
lot bt thng, bao gm tn thng chc nng tuyn gip va, khi thiu iode trm
trng gy ra bu c dch t hay n n dch t, gim thng minh v tng t sut
chu sinh v s sinh. Nhng bin chng ny tht s l 1 tr ngi ln cho s pht
trin ca qun chng v c nhm li thnh mt tn chung l ri lon do thiu iode.
T ngi ta nh ngha bu c dch t nh l s ph i ca tuyn gip khu tr
hay ton th trong hn 10% qun chng.
2. nh ngha bu c ri rc: l s ph i t chc tuyn gip c tnh cht lnh tnh
ton b hay tng phn khng c triu chng suy hay cng gip, khng do vim,
khng c tnh cht a phng (tc vng khng c dch t), cc yu t gy bnh
khng nh hng trong qun th chung.
Nhiu nguyn nhn khc nhau lm tuyn gip ln c l l chung cho c bu c l
t v bu c dch t.
II. DCH T HC
Bu gip n thng gp n nhiu hn nam, t l mc bnh cao mt s a
phng. Trn th gii c nhng vng a d thiu iode: nh vng ni c nguy c
bu c rt cao: vng tuyt ph, Hy m lp sn (Himalaya, Andes)
Tuy nhin ngi ta cng thy thiu iode nhng vng c bin thp, rt xa i
dng nh lc a vng Trung Phi, lc a Chu u hin nay. Khng c con s chnh
xc cho bit s lng nhn loi c nguy c pht trin ri lon do thiu iode.
Mt nh gi c xem l c th ang kim chng > 800 triu, trong c 3 triu b
n n dch t.
Ti Vit nam, theo iu tra ca B Y t (1993) v iode niu tr em 9 - 11 tui, c
94% thiu iod.
III. BNH NGUYN
1. Thiu iode: gp trong vng a d c bit nh vng ni v mt s vng nu
trn.
2. Ri lon kch thch t n: xy ra ph n dy th, c thai, tin mn kinh
3. Do cht khng gip: bp ci trng hay thuc khng gip tng hp hoc cht ngn
cn s ti iode nh Thiocyanate, Perchlorate
Sn cng gy bu c dch t, v sn c cha Glucoside cyanognique, Linamarin,
cht ny khi b thy phn gii phng cyanure, trong c th cyanure b kh c thnh
thiocyanate, m thiocyanate c ch bm iode tuyn gip v gia tng s thanh thi
iode thn, hu qu l thiu iode c th
460
+ Yu t lm gim T4: suy dng, gim protid mu, x gan, thuc androgene,
corticoide liu cao..
+ Yu t ngn cn s kt hp vi protein ti: hydantoin, clofibrate, hparine,
phenylbutazone.
- TSH cc nhy (TSH us) bnh thng (TSH = 0,3 - 4mUI/L).
TSH kim sot TG, s tit TSH c iu ha rt nhy bi nng hormone gip
ngoi bin qua c ch hi tc (feed back).
Dng k thut cc nhy th h II hin nay l 0,1mUI/L, th TSHus < 0,1mUI/L l
cng gip. Th h III l 0,01mUI/L th TSH us < 0,01mUI/l l cng gip.
- tp trung I131 bnh thng, tr trng hp bu n ho iode, cn lm
thm nghim php Werner loi tr cng gip.
Bnh thng tp trung I131 ti tuyn gip cc thi im 2 gi l 15%, 6 gi l
25%, sau 24 gi l 40%.
- Chp nhp nhy x hnh gip (Sintigraphie): cho bit hnh thi tuyn gip,
chc nng tuyn gip, kh nng bt gi phng x I131 hoc 99 Techntium ca ch
m gip (xt nghim ny cn thit trong ch nh bu hn): trong bu n, iode
phn b u khp tuyn gip.
- nh lng T3, T4 t do bnh thng.
- TSH cc nhy bnh thng
- tp trung I131 bnh thng, tr trng hp bu n ho iode
- Sinh thit: c khi cn thit, cho thy cc bin i lnh tnh nh trong phn gii phu
bnh.
- i vi bu c dch t hay bu c a phng, cn o iode niu/ngy, hoc t l
iode niu/cratinine niu nh gi s trm trng ca thiu ht iode:
+ Mc nh: 50 - 99 (g/ngy hoc 50 - 99 (g/g cratinine niu.
+ Mc trung bnh: 25 - 49 (g/ngy hoc 25 - 49 (g//g cratinine niu.
+ Mc nng < 25 (g/ngy hoc 25 (g/g cratinine niu.
- Siu m bit cu trc TG v th tch TG
1
Tui 6 7 8 9 10 11 13 14 15 16 17
2
V(ml)
3,5 4 4,5 5 6 7 8 9 10,5 12 14 16
Gii hn trn
Th tch ti a (gii hn trn) ngi trng thnh 18 ml.
VI. CHN ON
1. Chn on xc nh
Dch t v lm sng cng chn on.
Trng hp bu c l t, nn khm k hn v lm sng v xt nghim thm d
chc nng tuyn.
2. Chn on phn bit
2.1. Bu gip c suy gip: ch khc nhau v triu chng suy gip.
2.2. Bu gip c cng gip nh Basedow, bu gip c lm sng c du
cng gip, tnh cht c bit ca bu v cn lm sng gip cho chn on d.
2.3. Bu gip n kt hp vi ri lon thn kinh thc vt: c triu chng ging
nhau l c bu c, km d mt hay hi hp, nhp tim nhanh nhng nhp tim d tr
462
li bnh thng khi ngh ngi hay dng an thn, lng bn tay c nhiu m hi nhng
khng nng, cc XN thm d chc nng tuyn gip bnh thng.
2.4. Bu gip n ho iode: khng c du hiu cng gip, ch c tp trung
I131 cao, nhng nghim php Werner > 50%, cc XN khc bnh thng.
2.5. K tuyn gip: rt cng, c th c triu chng chn p v hch di cn, khng tp
trung I131, sinh thit loi tr.
2.6. Vim tuyn gip bn cp v mn (Hashimoto, Riedel), bu gip lan ta, c khi
nhiu nhn, cng, tc mu lng tng, (globulin tng, t khng th khng gip cao,
KT khng TPO, sinh thit t chc gip loi tr.
2.7. U ngoi tuyn gip: khng di ng theo nhp nut
VII. BIN CHNG
1. Xut huyt trong bu: bu to nhanh, au v nng, du chn p cp
2. Cng gip: thng xy ra bu nhiu nhn, bu lu nm, Basedow ha
phn tuyn bnh thng xen k gia cc nhn, thng do cung cp iode qu nhiu
(iode- Basedow).
3. Ung th ha.
4. Ring i vi bu c do thiu iode ngi m mang thai: c th nh hng n
s chm pht trin v tinh thn v th cht ca thai nhi
VIII. IU TR
1. Nguyn tc iu tr
Nhm bnh thng ha nng hormonee tuyn gip, m khng i hi tuyn gip
phi tng hot v ph i, do nu bnh nguyn:
Thiu iode th cung cp iode, khng do thiu iode, cung cp thm hormonee gip
tng hp.
Trong bu gip n do thiu iode, iu tr bng iode hay hormonee gip lm tuyn
gip nh li nhiu hay t thay i tu thuc nhiu yu t, nh thi gian xut hin
bu, kch thc bu, x ho ca bu.
Trong nhng nguyn nhn khc gy bu gip n lan to khng c,
Levothyroxine c th c dng vi mc ch nhm gim kch thc tuyn gip
2. iu tr c th
2.1. iu tr bu gip n lan to (khng c).
2.1.1. iu tr ngoi khoa
Hn ch ti a phu thut v bu gip trong trng hp ny ln l do hot ng
b, nu ct b d b suy gip, nht l him khi ch nh i vi cc bu ln lan to.
Tuy nhin can thip phu thut c th t ra trong nhng trng hp sau:
Bu gip qu ln gy chn p (kh nut, kh th, ni khn). Bu gip lu nm d
b ung th ho hoc nghi ng ung th ho. Bu nhiu nhn
V l do thm m.
Sau khi phu thut, phi thng xuyn kim tra FT4, TSH pht hin suy gip kp
thi
2.1.2. iu tr ni khoa
* i vi bu gip do thiu iode hay bu gip a phng:
Phn ln khng hoc nh hng rt t n chc nng tuyn gip, nhng nguyn
nhn chnh l do thiu iode, nn tt nht l a iode vo iu tr v d phng, Iode
c nhiu dng:
463
- Iode di dng iodur de potassium (IK) (Lugol) 1 mg mui KI/ngy, ti thiu trong 6
thng, hoc iodat de potassium (KIO3).
Cn theo di bin chng Iode-Basedow
Tuy nhin v c ch Feedback cn bnh thng, nn c th s dng hormonee gip
lm gim th tch tuyn gip. L. Thyroxine vin c ch nh khi:
+ Lm sng v siu m xc nh bu gip ln.
+ Nng Thyroxine gim v TSH huyt tng tng.
+ Th tch tuyn gip c nh li so vi trc khi iu tr
- Thyroxin (Levothyroxine, L-Thyroxine, Levothyrox) (T4), vin 50g, 75g, 100g,
liu tu thuc vo tnh trng bnh nhn 0.5- 2 vin/ng
Levothyroxine c 1/2 i l 7 ngy, hp thu tt, dng bui sng trnh mt ng
- Triiodothyronine (Liothyronine) (T3) vin 25 g, 1- 2 vin/ng, t dng v hp thu
nhanh, 1/2 i ngn, hiu qu ch thong qua. Khng dng bnh nhn THA, bnh
mch vnh.
ngi tr, liu bt u 100 g/ngy, v ngng khi TSH mc bnh thng-thp
Theo di cho tng liu dn t hiu qa tt, theo di bin chng cng gip
(mch nhanh, gy).
bnh nhn gi, liu khi u 50 g/ngy, cn cho liu tng dn theo di cn au
tht ngc v o in tim.
Kt qu
- Bi v c kh nng bnh tuyn gip t min tim tng, nn thn trng khng dng
thyroxine c bit khi khi TSH gii hn thp.
- bnh nhn gi, bu nhn hoc bu x ho, kh nng bu co nh li chng
1/3, bnh thng gim sau 3-6 thng iu tr, nu sau thi gian ny khng gim th
kh c hiu qu tt.
* i vi bu c l t khng do thiu iode:
Vn iu tr bng thyroxine liu nh trn, nhm gim ph i tuyn gip
* iu tr bu gip a nhn khng c.
- Phn ln bu gip a nhn khng c c th bo tn.
- Cung cp thyroxine him khi lm tuyn gip nh li.
Nu dng Levothyroxine, dng liu khi u l 50 g/ngy, c th tng dn liu,
nhng theo di TSH.
Cht cn quang hoc cc cht cha iode nn trnh v c nguy c a n cng
gip do iod (iod-Basedow) do tng sn xut hormonee gip ca cc nhn gip.
- X tr liu ngy cng c ch nh v lm kch thc tuyn nh li, v c th
ct b chn lc cc nhn t tr. Liu I131 ph thuc vo kch thc tuyn gip, v s
bt gi iode phng x. Thng khong 100 Curie/gram m tuyn. iu tr c th
lp li nu cn. Phn ln bnh nhn, kch thc tuyn gip gim khong 40-50%.
- Khi c s chn p cp xy ra, glucocorticoid hoc phu thut c th cn thit
c ch nh.
Suy gip sau x iu tr bu gip a nhn khng c t xy ra hn so sau x iu
tr Basedow. Tuy nhin khong trn 5% suy gip t min c th xy ra sau iu tr
bnh bu gip a nhn khng c.,.
IX. PHNG BNH
i vi vng thiu iode
464
SUY GIP
Mc tiu
1. Nu c nguyn nhn suy gip.
2. Nu c cc triu chng lm sng v cn lm sng suy gip.
3. Nu c phng php chn on suy gip.
4. Nu c nguyn tc v phng php iu tr c th suy gip.
Ni dung
I. I CNG
Suy gip (SG) l mt bnh cnh xut hin do s thiu ht hormone gip, gy nn
nhng tn thng m, nhng ri lon chuyn ha. Nhng thay i bnh l ny
c gi l triu chng gim chuyn ha (hypometabolism).
Bnh kh thng gp, t l tri n, t l bnh gia tng theo tui. T l mc bnh
khong 1% n v 0,1% nam, t l suy gip tng hn nhiu nhng vng c
bu gip a phng.
II. NGUYN NHN
1. Suy gip tin pht. Bnh xy ra do tn thng ti chnh tuyn gip, chim hn
90% cc trng hp suy gip.
1.1. Vim tuyn gip Hashimoto: y l nguyn nhn hay gp nht. Tuyn gip c
th ln hoc teo, c khi i km vi Addison v cc ri lon ni tit khc.
1.2. Tai bin do iu tr: nht l vi iode phng x, phu thut tuyn gip, ring vi
thuc khng gip tng hp, t gp hn.
1.3. Cung cp iode khng hp l (tha iode, thiu iode): suy gip do thiu iode ang
cn l vn Vit Nam.
1.4. Vim tuyn gip bn cp, vim gip sau sinh: thng xy ra sau giai on
nhim c gip trc , suy gip y ch tm thi.
1.5. Cc nguyn nhn suy gip tin pht khc: (him).
- Thiu enzyme tng hp hormne gip bm sinh.
- Cc cht khng gip trong thc n
- Lithium: iu tr bnh tm thn.
2. Suy gip th pht. Suy tuyn yn do u lnh (adenoma) tuyn yn, do phu thut
tuyn yn, hoc do tuyn yn b hoi t trong bnh Sheehan.
3. Suy gip tam cp. Do ri lon chc nnhng yn gip ti vng di i, bnh
cnh him.
4. Suy gip do khng hormone gip ngoi bin. Bnh t gp.
III. BNH HC
Suy gip tin php - Bnh ph nim (myxedema). Hay gp n, xung quanh la
tui 50. Bnh thng xut hin t t d ln vi cc triu chng ca mn kinh.
1. Lm sng: Da, nim mc b thm nhim bi mt cht dng nhy cha nhiu
polysaccarid acid ht nc, gy ph cng n khng lm.
1.1. Da nim mc
Mt trn nh mt trng, v mt v cm. Nhiu np nhn trn trng gi trc tui.
Mi mt ph, r mi di, g m hi tm, c nhiu mao mch gin, mi dy tm ti,
phn cn li ca da mt c mu vng bng.
466
Bn tay dy, cc ngn tay kh gp, da lnh i khi tm ti, gang bn tay bn chn c
mu vng (xanthoderma).
Li to, ging khn trm (do thm nhim dy thanh i), tai, nghe km (do thm
nhim vi Eustache). Khi ng ting ngy to (do nim mc mi, hu hng b ph
nim).
Da ph cng, kh, bong vy. Tc kh d rng, ui my rng, lng nch, lng mu
rng. Mng tay, chn c vch, d gy.
1.2. Triu chng gim chuyn ha
L du soi gng ca nhim c gip.
- S lnh, thn nhit gim, tay chn lnh, kh.
- Ung t, tiu t, bi tit nc tiu chm sau ung.
- Tng cn d n km
- Tiu ha: to bn ko di, km gim nhu ng rut.
- Yu c, chut rt, au c.
- Du tm thn kinh v ri lon thn kinh thc vt: trng thi v cm, th . Suy
gim cc hot ng c th, hot ng tr c, hot ng sinh dc.
Gim tit m hi.
1.3. Tim mch
- Tim chm < 60l/ pht, huyt p thp (ch yu tm thu), tc tun hon gim cc
biu hin ny do gim chuyn ha.
- Cc du thm nhim c tim, mng ngoi tim.
au trc tim hoc cn au tht ngc tht s, kh th khi gng sc. Nghe tim: ting
tim m, chm,c khi ting tim khng u.
ECG: nhp chm, in th thp cc phc b QRS, c khi ST chnh xung, sng T
dt hoc o ngc. Hnh nh in tim s tr li bnh thng sau iu tr bng
hormone gip.
X quang bng tim to, p yu. C khi trn dch mng ngoi tim, dch c nhiu protein
v cholesterol. Siu m tim gip phn bit trn dch mng tim vi thm nhim mucoid
c tim. C khi huyt p tng do x va ng mch.
1.4. Triu chng h hp
Th nng, tn s chm, p ng h hp km i vi s tng CO2 mu hoc gim
O2 mu. Suy h hp cp l mt triu chng ch yu ca hn m ph nim.
1.5. Chc nng thn
Gim chc nng thn, gim mc lc cu thn, gim kh nng thi nc khi qu ti,
do d dn n ng c nc bnh nhn suy gip nu nc t do c a
vo c th qu nhiu.
1.6. Thiu mu
C t nht 4 c ch dn n thiu mu bnh nhn suy gip:
- Gim tng hp hemoglobuline do thiu Thyroxine.
- Thiu st do mt nhiu st v rong kinh, ng thi gim hp thu st rut.
- Thiu mc c tnh: thiu mu nguyn hng cu khng l vi thiu vitamine B12.
Thiu mu c tnh thng l mt phn trong bnh cnh bnh t min gm ph nim
do vim gip mn tnh phi hp vi t khng th khng t bo thnh, i tho
ng phi hp vi t khng th khng o ty v suy thng thn phi hp vi t
khng th khng thng thn (Hi chng Schmidt)
467
+ Tin trin: Lnh t nhin sau 2-4 thng, t khi chm hn. Suy gip thong
qua kh thng gp. C th ti pht mt nhim c gip rt lu sau . Bu gip
c th tn ti lu di.
+ Ghi ch: Vim tuyn gip khng au rt ging vi vim tuyn gip bn cp,
ch khc nhau triu chng au, mt im khc na vim tuyn gip im lng l t
min bnh. Lm dng idoe c th gy biu hin tng t, phn bit da vo iode
mu, iode niu bnh thng trong vim gip im lng.
2.4. Vim tuyn gip lympho (Hashimoto).
L bnh t min, trn cc i tng thuc nhm HLA B8 DR3. Thm nhim
gip vi lympho v tng bo, vi nhng nang gip b ph hu bn cnh nhng
nang gip tng sn. Din tin mn tnh c th dn n suy gip.
+ Lm sng: Bu gip ln lan to, mt chc, gii hn r, khng au,
hch ln cn khng ln. Biu hin bnh gip, c khi nhanh chng dn n suy gip
(suy gip ngi trng thnh + bu gip ln = Hashimoto). C khi biu hin
nhim c gip thong qua.
+ Cn lm sng: Hin din khng th khng thyroglobuline, khng th khng
microsome tuyn gip, khng th khng peroxydase. nh lng hormone gip bnh
thng hoc thp vi TSH tng. Rt him nhng c th T3,T4 tng km TSH gim
trong giai on nhim c gip. X hnh gip c hnh lm m khng ng nht. VS
bnh thng hoc tng nh.
+ Tin trin: Rt thay i, c khi tn ti bnh cnh bu gip bnh gip, c khi
dn n suy gip vi tuyn gip teo nh.
+ Lu :
- Hin din khng th khng gip khng ch ring Hashimoto, cn c trong bnh
Basedow.
- T l ln suy gip ngi ln km teo tuyn gip c nguyn nhn vim gip
Hashimoto m giai on khi pht b b qua.
- Hashimoto c th phi hp vi nhng bnh khc nh suy thng thn, bung
trng, i tho ng. Hoc bnh bch bin, Biermer; hoc thng tn mt kiu
Basedow (him).
2.5. Vim tuyn gip ho si (Riedel)
Bnh him, cha r nguyn nhn, tin trin nng.
+ Lm sng: Bu gip cng nh , ban u khu tr, sau lan ton tuyn
gip. S x ho lan rng n cc c c, c quan ln cn gy cm gic b cht c,
kh nut, kh th. Bnh c th phi hp x ho sau mng bng, trung tht, sau hc
mt, tuyn l.
+ Cn lm sng: T3,T4, TSH bnh thng, VS bnh thng, tp trung iode
phng x gim.
+ Tin trin: T vong khng trnh khi, iu tr duy nht l phu thut, nhng
kh nng phu thut rt hn ch.
Bng 1: Phn bit cc loi vim gip
Cp Bn cp Im lng Hashimoto Riedel
au +++ +++ 0 0 0
Gip Abces Rt chc Chc Rt cht Cng nh
474
Du ton ++ ++ 0 0 0
thn
FT3, FT4 BT BT hoc BT hoc BT hoc BT
TSH BT BT hoc BT hoc BT hoc BT
Khng th 0 0 hoc + 0 hoc + +++ 0
VS (hoc BT BT BT
X hnh Vng lnh Khng bt Khng bt Khng ng Vng lnh
iode iode cht
II.UNG TH TUYN GIP
1.Phn loi.
Ung th tuyn gip chim t l 1% trong s nhng trng hp t vong do ung
th, y l mt nhm bnh c tin lng rt khc nhau, ngi ta chia ra:
- Nhng ung th biu m t bo tuyn gip bao gm:
+ Ung th bit ho, tin lng tt nu iu tr ng, bnh d xut hin khi chiu x
c t tui thiu nin hoc nhim nguyn t.
+ Ung th khng bit ho tin lng rt xu.
- Nhng ung th biu m tu, pht trin t t bo C ca tuyn gip.
- C bit c lymphoma hoc ung th ni khc di cn n
1.1. Ung th tuyn gip bit ho.
T l gp cao, nht l ph n tr, tin lng tt. i khi c kh nng bt gi iode,
nhng him khi l u tit.
1.1.1. K biu m nh (carcinome papillaire)
Chim 50% cc trng hp, gp mi la tui, nhng hay gp tr em v thanh
nin trc 40 tui, chiu x vng c l iu kin thun li gy K biu m nh, K lan
rng theo ng bch huyt, c khi bnh c gi ban u t mt hch di cn
vng c.
X hnh u bt iode km (vng lnh).
1.1.2. K biu m nang (carcinome folliculaire)
Chim di 25% cc trng hp, hay gp la tui 40-60, di cn bng ng mu
n xng, phi, gan.
X hnh u c th bt iode khng u, im di cn cng c th bt gi iode phng x.
1.1.3. K biu m tu (carcinome medullaire)
Hoc cht m dng bt (struma amyloide), hoc cn nang (parafolliculaire), chim
di 5% cc trng hp, thng gp sau 50 tui, lan rng bng ng mu v
ng bch huyt, c khi phi hp vi cc u khc nh pheochromocytome (Hi
chng Sipple), c th c tinh gia nh.
X hnh u khng bt iode (vng lnh). Chn on da vo nh lng calcitonine
huyt tng tng, nh lng sau kch thch vi pentagatrine thy calcitonine tng
rt nhiu. Khng nguyn biu m phi (ACE) thng tng.
1.2. Ung th tuyn gip khng bit ho
K biu m khng bit ho, chim khong 20% cc trng hp, thng xut hin sau
50 tui, t mt nt n c lan rt nhanh n vng ln cn, gy triu chng chn p.
Din tin nng nhanh trong vng vi thng.
475
I THO NHT
Mc tiu
1. Nu c sinh l v ADH.
2. Nu c phn loi i tho nht.
3. Nu c bnh hc i tho nht.
4. Nu c nguyn tc iu tr i tho nht
5. Nu c cc loi thuc iu tr i tho nhtt.
Ni dung
I. NH NGHA
i tho nht (TN) l tnh trng bnh l do mt kh nng ti hp thu nc ng
thn, hu qu ca s thiu ADH tng i hoc tuyt i dn n tiu nhiu, ung
nhiu, nc tiu c t trng thp v ung nhiu, bnh c th xy ra do km phng
thch ADH (TN trung ng hoc thn kinh) hoc do thn p ng km vi ADH
(TN thn). C khong 50% trng hp TN khng r nguyn nhn.
II. SINH L
ADH (antidiuretic hormone) c tit ra t vng di i, t n ni cha l thu
sau tuyn yn. ADH tc ng ln s iu ho nc do iu chnh s ti hp thu
nc thn.
ADH ngi cn gi l arginine-vasopressin (AVP) l mt polypeptide c 8 acid
amin (octapeptide). ln arginine c thay bng lysine (LVP). ng ch trn
ngi LVP cn c th kch thch tit ACTH.
Vi thm thu huyt tng 280mOsm/kg, ADH o c trong mu l < 2pmol/l
(=pg/ml), ADH s tng ln 10-12pmol/l khi thm thu ca mu t 310mOsm/Kg.
Thi gian na i ca ADH rt ngn: 10-20 pht. ADH b phn hy nhanh chng do
enzyme c quan ch ch yu thn (2/3), s cn li c phn hy gan (1/3).
thm thu huyt tng = (natri mu +kali mu) x 2 + ure mu + glucose mu.
Tt c tnh bng n v mM/l. Tr s bnh thng: 290-300mOsm/kg
1.Tc dng sinh l: Tc dng ch yu ca ADH xy ra thn, ADH lm tit kim
nc t do. Thn lc 120ml nc/pht (hoc 172 lt/24h). Hn 85% nc c ti
hp thu bt buc ng ln gn cng vi Na+, nh vy cn 23,5 lt c ti hp thu
do vai tr ca ADH.
Thiu ADH tuyt i chc chn s gy mt nc cp nu khng ung . Tuy nhin
thc t cho thy s tiu nhiu do thiu ADH khng vt qu 8-12 lt (1/2 ca lng
23,5 lt l thuc ADH theo l thuyt).
2. C ch tc dng
ADH tc dng thng qua 2 loi th th V1 v V2:
+ Th th V1 lm co c trn mch mu, kch thch s tng hp prostaglandine v
phn hy glycogne gan. Tc ng ln th th ny lm gia tng phn hy
phosphatidylinositol gy nn s huy ng calci.
+ Th th V2 chu trch nhim ca tc dng vasopressin trn thn. ADH lm tng
tnh thm nc ca lp thng b ng gp. Thiu ADH s ti hp thu nc b gim
dn n tiu nhiu. C ADH th ngc li, tnh thm ca lp thng b tng r, nc
c ti hp thu. Tc dng ny xy ra do ADH gn vi th th V2.
Trn tim mch ADH tc dng ln th th V1 trn cc tiu ng mch ngoi bin
lm tng huyt p. Tuy nhin bn thn ADH li lm chm nhp tim, c ch thn kinh
477
lm gim tiu, c ch cha hon ton r, thuc kch thch tit ADH. Tc dng ph
quan trng l c ch tu xng.
2.3.2. Ch nh
i tho nht trung ng, ng kinh, au dy thn kinh tam thoa. Do thuc c nhiu
tc dng ph v vy thuc ch nn ch nh khi cc thuc khc khng dng c.
2.3.3. Liu lng, chng ch nh
100-200mg hai ln mi ngy. Chng ch nh: D ng vi thuc, mang thai (nht l 3
thng u), suy gan, ri lon to mu, bnh tng nhn p, ong nc tiu, cc ri
lon v tim mch.
2.4. Hydrochlorothiazide
2.4.1. Bit dc, trnh by, dc ng hc, ch nh
Dichlotride (Merck, Sharp, Dohm), Esidrex (Ciba-Geigy)...Trnh by vin 25mg.
Thuc thng c dng gip tng thi mui v nc nhng trng hp ch nh
thng thng nh ph, tng huyt p, suy tim... tuy nhin thuc c tc dng gim
tiu mt cch nghch l tt c nhng trng hp TN, tc dng ny xt hin th
pht sau khi nc tiu b long nhnh ln ca quai Henle, cng nh th pht sau
khi th tch gim nh ng ln xa. Vi liu lng tiu chun, thuc lm gim 30-
50% lng nctiu tt c cc th TN, do thuc rt hu ch khi dng h tr
vi cc thuc ung khc trong iu tr TN trung ng cng nh TN do thn
2.4.2. Liu lng, chng ch nh
1-5mg/kg/ngy. Khng dng thuc khi suy thn nng, ph n mang thai, cho con b,
d ng vi sulffamide, bnh gout mn, h Natri, k Kali mu.
3. Mt s nguyn tc trong iu tr
3.1. Gio dc, theo di
Gio dc bnh nhn ch ung nc khi tht s kht. Theo di thy Natri huyt tng
< 130mEq/l xut hin 2 ln xt nghim chng t ung qu nhu cu tht.
3.2. Thi gian ca liu trnh
i vi TN trung ng trong phn ln cc trng hp phi iu tr sut i, ngay
c nhng trng hp nguyn nhn gy bnh c loi b, mt s rt t cc
trng hp bnh c ci thin n mc ngng iu tr, thng khng phi do AVP
hi phc s tng tit m c th do cc yu t khc nng hn nh suy thng thn,
tit AVP lc ch t u c tnh, tnh trng mt nc trm trng do ri lon c ch kht
nc. Tuy nhin c nhng bo co bnh hi phc do mi nm nn th ngng
iu tr vi ngy nh gi s hi phc.
3.3. Tch cc tm nguyn nhn
Cn tch cc tm hiu nguyn nhn gy bnh bng nhiu phng tin v chn on
hnh nh hc, cc xt nghim dch no tu cng nh nhng thm d v ni tit vng
di i, thu trc tuyn yn ngay c khi hnh nh h yn bnh thng.
3.4. i tho nht ngi mang thai
Thuc duy nht c dng l DDAVP, liu dng thng cao hn mt t so vi bnh
nhn TN khng mang thai do nhau thai sn xut vasopressinase, Trong thai k
chp nhn natri mu thp hn 5mEq/l so vi ngi TN khng mang thai. DDAVP
khng c tc dng ln co c t cung. Thai k khng c dng cc thuc ung iu
tr TN do kh nng gy qui thai.
3.5. Ung nhiu tin pht
483
m hi. Cc triu chng y thng xut hin sau mt thi gian di vi teo da,
mt mu da, suy nhc vi tt c du chng suy tin yn.
1.5. Cn lm sng
Chn on sinh ho ca suy tuyn yn cho thy cc hormone u mc thp. V d
FT4 thp vi TSH thp gi l suy gip th pht. Tng t testosterone thp m
khng c gia tng gonadotropin gi gim nng tuyn sinh dc do suy tuyn yn
gim tit gonadotrophin.
488
Tt TRH: 200-500 g TM o TSH, PRL: 0, 20, TSH tng >5 mU/l, tr phi
60 hormon gip gia tng
LH, FSH LH, FSH, testosterone, Tt c bn LH, FSH tng ph n
489
estrogen mn kinh.
Testosteron thp khi Lh,
FSH thp.
Tt GnRH: o LH, FSH 0,30, 60 Phn ln ngi trng
thnh, LH tng n 10 IU/l
GnRH 100g TM
V LH tng 2 IU/L. p
ng BT l thay i
CN LM SNG B SUNG
- XQ s no xem h yn: Hc xng hm v trn rng ra, s dy, khng u,
nht l phn ngoi. H yn c th rng ra, hoc su hn, cc ng vch khng r,
mm gc yn b mng i, c hnh mm chim.
- Scanner s no.
- o STH (GH) trong 24 gi hoc ngy hoc m mi 20 - 60 pht (v STH c tit
ra theo nhp iu ngy m.
+ o STH niu /24 gi.
+ Somatomdine, hoc IGF huyt tng..
+ o STH trong khi lm Test hm bng cch cho ung ng (HGPO),
Bnh thng STH hoc GH cn bn l < 5ng/ml, sau nghim php dung np
glucose ung, STH < 2ng/ml, nu l bnh to cc vin cc, th test hm suy yu 2
ng/ml.
+ Khm th trng: c gii hn th trng.
491
Triu chng lm sng khng c hiu, bnh nhn nh cm thy yu mt; nng hn
gy nhc u, hi hp, ung nhiu, tiu nhiu, tiu m v d cm. Bnh nhn
thng n khm v cc triu chng ca h kali mu v tng huyt p.
Triu chng thc th: tng huyt p t nh n nng, y mt giai on I, II; gim
kali nng c th c h p t th khng km tim p nhanh v gim cm nhn ca
th th p lc. Khi kim mu nng c th c triu chng nh h calci mu
(Chvostek, Trousseau).
3. Cn lm sng
Kali mu gim trong trng hp in hnh, Natri mu hi tng, ri lon dung np
glucose.
4. Chn on
4.1. Tm sot
Nn tm sot cng aldosteron nguyn pht khi c h kali mu c km tng hyt
p, v a s l tng huyt p khng iu tr.
4.1.1. Kali mu
Trnh n nhiu kali v ngng thuc li tiu t nht 3 tun. 20% bnh nhn c kali
mu bnh thng hoc gii hn thp ca bnh thng.
4.1.2. nh gi h thng renin-angiotensin-aldosteron
o hot tnh renin huyt tng bt k (PRA): gim trong cng aldosteron nguyn
pht.
o nng aldosteron trong huyt tng (PAC) lc 8h sng sau t nht 4h nm ngh
v n y mui vo my hm trc.
Nu PAC/PRA > 30 v PAC > 20 ng/mL: cng aldosteron nguyn pht vi nhy
90%, c hiu 91%.
4.1.3. Nghim php Captopril
Ung 25mg Captopril sng, 2h sau ly mu th, bnh nhn t th ngi.
Bnh thng: PAC gim, PRA tng.
Cng aldosteron nguyn pht: PAC v PRA khng i. PAC/PRA > 50, PAC > 15
ng/dL.
4.2. Xc nh chn on
Dng nghim php c ch aldosteron bng NaCl ung hay truyn tnh mch xc
nh aldosteron trong nc tiu v huyt tng khng b c ch c.
4.2.1. Nghim php c ch bng NaCl ung
n mui liu cao trong 3-4 ngy, b sung KCl 40-200mEq/ngy. Ngy sau cng ly
nc tiu 24h o aldosteron, natri, creatinin. Nu Natri nc tiu > 200mEq/L v
aldosteron nc tiu > 10-14 g th gip chn on xc nh.
4.2.2. Nghim php truyn tnh mch NaCl
Nhn i qua m, nm; truyn tnh mch 2L dung dch NaCl 0,9%. Sau o
aldosteron huyt tng (PAC). Chn on xc nh khi PAC > 10 ng/mL.
III. CNG V THNG THN SINH DC
1. Nguyn nhn
1.1. Cng v thng thn
Tng sn, u tuyn, ung th biu m.
1.2. Tng sn thng thn bm sinh do thiu men
494
CHNG 7
TNG QUT
40% 15% 5%
Phi
Da
Tiu ho
Ni bo Ngoi bo Thn
489
Cm gic mt l.
Ri lon thc dng kch thch.
St.
Co git
Hn m.
Xut huyt no - mng no.
+ Kht: i lc rt d di.
+ Nim mc kh: c bit mt trong ca m.
+ Hi chng ung nhiu, tiu nhiu trong trng hp nguyn nhn do thn.
+ Gim cn.
- Triu chng cn lm sng:
+ Thm thu huyt tng > 300 mmol/l.
+ Natri mu > 145 mmol/l.
V. NC NI BO
1. nh ngha: l tnh trng tng th tch dch ni bo do Bilan nc dng tnh phi
hp vi gim thm thu huyt tng, Natri mu gim <135 mmol/l.
2. Nguyn nhn
- Hp thu nc nhiu hn kh nng bi tit: bnh tm thn ung nhiu.
- Bi tit khng thch hp hoc mn ADH (SIADH).
- Do gim bi tit nc trong x gan, suy tim, hi chng thn h,...
- Trong suy thn mn nng (mc lc cu thn < 20 ml/pht).
3. Chn on
3.1. Triu chng lm sng
+ Ri lon thn kinh: khng c hiu, lin quan n mc Natri mu: bun nn,
nn ma, chn n, nhc u, u m thc, hn m, co git.
+ Tng cn va phi.
+ Khng kht, ngc li khng thch ung nc.
3.2. Triu chng cn lm sng:
+ Thm thu huyt tng < 270 mosmol/l.
+ Natri mu < 135 mmol/l.
VI. TNG KALI MU
1. nh ngha: Tng Kali mu c nh ngha khi nng Kali mu trn 5,0 mmol/l.
Tng Kali mu t ngt c th e do tnh mng ngi bnh.
494
2. Triu chng
2.1. Triu chng tim mch
c biu hin ch yu trn in tm
- Sng T cao, nhn v i xng.
- Bt thng dn truyn trong nh (gim bin sau l mt sng P), ri lon dn
truyn nh tht (Bloc xoang-nh, Bloc nh-tht).
- Sau : ri lon dn truyn trong tht: phc b QRS gin rng.
- Nng hn: nhp nhanh tht, rung tht v ngng tim.
2.2. Triu chng thn kinh c: thng khng c hiu: d cm u chi v quanh
ming. Nng hn c th thy yu c hoc lit khi pht chi di v tin trin dn ln.
3. Nguyn nhn
3.1. Cung cp qu nhiu Kali: him gp ngi bnh thng, thng do iu tr Kali
ng tnh mch hoc ng ung.
3.2. Do Kali t ni bo ra ngoi bo
- Nhim toan chuyn ho.
- Tng phn hu t bo:
+ Hu c vn v dp nt c.
+ Bng nng, tn huyt nng.
+ Hu khi u t pht hoc do ho liu pht.
+ Xut huyt tiu ho nng.
- Hot ng th lc nng.
- Cc nguyn nhn do thuc:
+ c ch Bta khng chn lc
+ Ng c Digital
+ Ng c Fluor v Cyanure.
3.3. Gim tit Kali qua thn
- Suy thn cp.
- Suy thn mn.
- Thiu cc Corticoides khong: Suy thng thn.
- Do thuc: khng vim khng Steroide, cyclosporine A, Heparine, c ch men chuyn,
c ch th th Angiotensin II.
4. Chn on
Tt c cc trng hp nghi ng tng Kali mu phi lm in tm , in gii . Phi
chn on sm cc ri lon dn truyn iu tr cp cu.
495
VII. H KALI MU
1. nh ngha: Gi l h Kali mu khi nng Kali mu di 3,5 mmol/l. N c th e
da n tnh mng ca bnh nhn v gy ri lon tim mch.
2. Triu chng
2.1. Tim mch: Chm ti cc tht do ko di thi k tr.
- Triu chng in tm tu thuc mc gim Kali mu
+ on ST lm xung.
+ Sng T o ngc.
+ Tng bin sng U.
+ Ko di khong QU.
+ Gin QRS sau th ri lon nhp trn tht hoc nhp tht (ngoi tm thu, nhp
nhanh tht, xon nh, rung tht.)
2.2. Triu chng c
- Chut rt
- au c
- Yu c, lit.
- Khi nng dn n c th hu c vn.
2.3.Triu chng tiu ho: bn (do lit rut)
2.4. Triu chng thn: gim Kali mu mn tnh nng c th l
- Biu hin 1 hi chng tiu nhiu ung nhiu
- Nhim kim chuyn ho.
- Bnh thn k mn tnh.
3. Nguyn nhn
3.1.Gim cung cp Kali.
3.2. Chuyn Kali t ngoi bo vo ni bo
- Nhim kim chuyn ho hoc h hp
- iu tr Insulin trong i tho ng.
- Cc tc nhn kch thch Adrenergic
+ Pheochromocytome
+ Salbutamol, Dobutamin, ng c Theophylline
- Bnh lit chu k gia nh.
3.3.Mt qu nhiu Kali
- Qua ng tiu ho: tiu chy, d rut non.
496
- Mt qua ng thn:
+ Li tiu quai v Thiazide
+ Tng tit Hormon Steroid tuyn thng thn, cng Aldosterone nguyn pht,
th pht.
- Bnh thn k
- Bnh ng thn do nhim c: Amphotericine B, Aminoside.
4. Chn on
- Chn on xc nh: da vo nh lng Kali mu v in tm
- Chn on nguyn nhn: thng kh, phi da vo bi cnh lm sng, vo tin s
bn thn, gia nh v Kali niu,...
VIII. NHIM TOAN CHUYN HO
1. nh ngha - pH mu ng mch di 7,38.
- HCO3- di 22 mmol/l.
- PCO2 gim th pht do tng thng kh b.
2. Triu chng
- H hp: + Tng thng kh
+ Sau suy h hp khi nng
- Tim mch: + Gim cung lng tim, thn,gan
+ Lon nhp
+ Gim nhy cm vi Catecholamine
- Thn kinh: + ri lon thc, hn m.
- Xt nghim: Tng Kali mu
IX. NHIM KIM CHUYN HO
1. nh ngha - pH mu ng mch trn 7,4
- HCO3- mu trn 27 mmol/l.
- Tng PCO2 th pht (b).
2. Nguyn nhn
- Cung cp qu nhiu cht kim trong iu tr.
- Ri lon bi tit cht kim ca thn.
- Do gim th tch mu, kch thch h Renin-Angiotensin: thng phi hp gim Kali
mu v cng Aldosterone th pht.
- Do cng Aldosterone nguyn pht, hi chng Cushing...
3. Triu chng
497
Tng tnh thm thnh mch.lm cho nc thot ra khong k lm gim th tch mu
hu hiu.
Gim tiu cu: Tiu cu b ph hy s phng thch ra cc cht trung gian nh
Serotonine, Adrnaline, Thromboxan 2 gy co mch.
Bch cu ht gim: Bch cu b ph hy phng thch ra cc men tiu t bo v cc dn
cht ca Arachidonic qua ng b th v ng Properdine
i thc bo sn xut ra TNF v Interleukin gy gin mch nhanh, toan chuyn ha,
hot ha h thng ng mu, xut huyt ty, thng thn.
Thiu Oxy t bo gy ra:
Ri lon chc nng to Glycogen, ri lon chu trnh Krebs, ri lon to mt, tng
Lactate mu.
Ni c t
Gy co tht c trn trc v sau mao mch (tc dng ln th th lm ng mu
phi, bng, thn).
Thng qua yu t Hageman (XII) lm hot ha Bradykinine l cht gin mch gy
ng mu t chc ngoi bin. Bradykinine cn lm tng tnh thm mao mch.
Ngi ta c nu ln tc hi ca Acide Arachidonic v opi ni sinh (Endorphine). Dng
Imidazole ngn cn s hnh thnh Thromboxan A2 hoc dng Prostacycline i khng
vi Thromboxan A2 s khng gy c Shock ni c t. Trn ngi thn v oi l hai
c quan b Shock ni c t nh hng trc tin: gi l thn Shock, phi Shock.
Giai on u: s tit ni c t c tc dng tng t Catcholamine lng va phi
nn gy co mch va phi do tc dng ca Gy co mch da, c, thn, cc tng)
dn mu cho tim, thn, no ng thi kch thch va phi lm tng lu lng tim, giai
on ny c li cho bnh nhn, tuy nhin thn v co mch nn lng nc tiu t
dn.
Giai on sau: S sn xut ni c t qu nhiu lm co qu mc cc huyt qun do tc
dng ca nht l co c vng sau mao mch, mu li trong cc mao mch khng v
tim c lm gim lu lng mu ton c th. S mu ton c th ng thi s to
s thiu Oxy trong cc m, trong t chc. Cc t bo s phn ng bng chuyn ha
theo c ch k kh dn n sn xut ra sn phm chuyn ha toan lm m rng c
vng u mao mch lm mu thm trong cc mao mch bnh htng c mu v c
nhng mao mch bnh thng khng c mu. Hu qu l mu cng ng cc mao
mch dn n cng gim thm lu lng tun hon. ng thi s tr s lm tng p
lc thy tnh, nc in gii thot ra ngoi. iu ny s lm lu lng mu cng gim
thm. Tm li c hai hu qu chnh
Gim lu lng tun hon.
Thiu mu, thiu Oxy m.
M hai hu qu ny chnh l nh ngha ca Shock.
Cc khu trong c ch bnh sinh cng xc tc thc y cho nhau i theo mt vng ln
qun khng hi phc c do Shock nng dn, cui cng s dn n ng mu ri
501
L thuc dit khun, thi gian bn hu tu thuc chc nng thn, khng hp thu bng
ng ung, thuc khuych tn vo phn ln cc t chc v th dch ca c th, trong
ti nhu m thn cao hn huyt tng. Thuc hp thu km mt, tin lit tuyn,
khng qua hng ro nhau thai, sa m v hng ro mu no., h thn kinh trung ng
v mt.
Thuc thi tr qua nc tiu 65% sau 6 gi, 85% sau 24 gi.
Ch nh
-Nhim trng Gram m ti thn v h tit niu, nhim khun huyt
Tc dng ph v c tnh
-Ri lon thnh gic: tin nh b c gy chng mt, mt iu ho, rung git nhn cu,
tai, gim hoc mt thnh lc. Trng hp nng tn thng s khng hi phc.
-c vi thn: thuc thi tr, tch ly v thn v gy bnh ng thn cp. Tc dng ny
thng xy ra ngi ln tui, c bnh thn hoc mt bnh l gy mt nc.
Liu lng:
-Amikacin 15 mg/ kg / ngy chia 2 ln.
-Gentamicin 5 mg/ kg / ngy chia 2 - 3 ln / ngy.
Nhm Nitroimidazole: (Metronidazole)
L thuc khng khun, hp thu nhanh gn 80% sau 1 gi, nng trong huyt tng
khi s dng bng ng ung v ng tim tng ng nhau, thi gian bn hu t
8 - 10 gi. Thuc gn vo Protein khong 20%, thuc khuych tn nhanh, mnh phi,
gan mt dch no tu, thn nc bt, tinh dch, dch m o. Thuc thm qua nhau thai
v sa m.
Thuc chuyn ho qua gan, nng cao gan v mt. Thuc thi tr ch yu qua
nc tiu v c mt lng nh khi thi tr cn nguyn hot tnh nn lm cho nc tiu
c mu nu.
Tc dng ph v c tnh:
-Ni my ay, nga, chn n, bun nn, c v kim loi ming, vim ming, i tin
phn lng, nhc u chng mt, gim bch cu a nhn, vim dy thn kinh v nu
dng ko di c th ri lon tm thn.
Nhm Quinolone: l thuc dit khun bao gm:
Th h 1: cc Nalidixic acide, Oxonilic acide, Pipemidic
Th h 2: (Fluoroquinolone) Norfloxacin, Ofloxacin, Ciprofloxacin, Enoxacin, Pefloxacin,
Lomefloxacin, Levofloxacin.
Th h 3: Sparfloxacin (Zagam)
Hp thu tt nhng c i lc vi kim loi nng, b c ch khi dng chung vi Fe, Calci,
v mt s Cation. t nng cao khi dng trc n 1 gi hoc sau n 2 gi
Hp thu: thuc c hp thu nhanh v rt tt hu nh t 100% nng cao nht t
trong huyt tng sau ung 6 gi, thi gian bn hu 6 - 8 gi. Thuc c phn b
504
khp t chc v dch nh phi, da, c t cung, bung trng, m v dch tin lit tuyn,
m. Thuc thi ch yu qua thn (80%).
Tc dng ph v c tnh
-Ri lon tiu ho, au vng thng v, bun nn, nhc u, chng mt, ng g, o
gic, l ln, co git.
-au c, au khp, ni my ay pht ban
-Tng men SGOT, SGPT v LDH, tng BC acid, gim BC trung tnh gim tiu cu.
-Tng tc dng ca Theophyllin, Warfarin.
-Zagam gy ri lon nhp tim trong trng hp QT ko di nn khng c vi
Cordarone.
Chng ch nh
C thai, dang cho con b, tr s sinh, ngi gi trn 70 tui suy gan suy thn, ngi
ang mc bnh tm thn, thiu men G6 PD.
Khng nn dng khi ang li xe, ngi ang lm vic trn cao, s dng my mc.
4. Bin php khc
- Corticoide tim tnh mch liu cao chng s thm qua mng mao mch.
- H tr h hp bng Oxy liu cao, thng kh c hc, khai thng ng h hp trn cho
bnh nhn.
- Thuc tng sc co bp c tim.
- Huyt tng ti, mu ti c th gip cho bnh nhn khi phc lng mu, chng
chy mu.
- Cui giai on II, u giai on III c dng Heparine chng ng mu nhng
kh nguy him. Hin nay ngi ta c th dng Acide Aminocaproide.
- iu tr loi b nhim trng nh ct ti mt, iu tr p xe...
505
Xung ng
Ach
Phospho hu c
(-)
Acetylcholinestrase
Atropin
- H hp: nh ht phi hi thuc khi m bnh thuc kn, ht phi kh dung khi bm thuc
- Tiu ha: do t t hay ung nhm.
S hp th rt d dng bng mi ng k trn rt nhanh v hon ton, nhanh nht l
qua ng h hp, chm nht l qua da. Chng c th b trung ha phn no bi cht
kim v Hypochlorite.
Trong c th chng b thoi bin bi cc men thy phn v oxy ha, nht l trong gan,
nhng s thoi bin ny rt chm. i vi cht phospho hu c phi hp vi
Acetylcholinestrase, ch thi di dng thoi bin thnh Paranitrophenol.
5. c tnh
Trong cc phospho hu c th thiophot (parathion) l c c tnh ln nht, trung bnh l
mthyl parathion (wolfatox) v nh hn l malathion. v d liu ng c ca parathion l
<5mg/kg th trng, mthyl parathion l 5-50mg/kg th trng, malathion l 50-500mg/kg
th trng. c tnh ny tng gp ln hng chc ln khi 2 th thuc c phi hp vi
nhau.
III.TRIU CHNG
1. Thi gian tim tng: thay i ty theo nhiu yu t.
1.1. ng xm nhp: t nhanh n chm: h hp, tiu ha, da.
1.2. trm trng ca s nhim c: cng nng th thi gian tim tng cng ngn. V
d ng c trung bnh th cc triu chng lm sng thng xut hin sau 1 gi, nhng
nhng trng hp nng th ngn hn ch sau 15- 30 pht v trong trng hp rt nng
nhiu lc ch 30 pht n 1 gi bnh nhn cht.
1.3. Th trng bnh nhn: cng nh tui thi gian tim tng cng ngn (v nng
AchE km). Ngi gi triu chng ng c cng nng hn.
1.4. Yu t nhim mn: Ngi b ng c nh tim tng trc cng b trng c
nhanh hn. Ngi b ng c mn tnh, du nhim c nhanh v nng hn nu c
nhim cp.
1.5. Bng i, ung ru: cng lm trng c bng ng tiu ha xy ra nhanh hn.
1.6..Phi hp nhiu ng nhim c: lm ngn thi gian tim tng.
2. Th t xut hin cc du chng
Du chng dng Muscarine xut hin trc tin. Du chng dng Nicotine v thn kinh
trung ng thng kh phn tch hn, xut hin chm hn. Nhng nu trng c trm
trng th c 3 loi du chng xut hin ng thi.
3. Cc du chng trn cc c quan
3.1. Mt: c du Muscarine r nht, sung huyt kt mc, teo ng t c th rt mnh
bng u kim gm, nhng vn cn p ng vi nh sng, hn lon iu tit, gim p
lc ni nhn. Du teo ng t l du Muscarine rt nhy nn c th l mt trong nhng
du nh gi trm trng lc ban u, tr trng hp mt b tc dng trc tip ca
tr su do thuc bn trc tip vo mt th du ny sm v nng nhng c th du
nhim c ton thn khng nng.
509
3.2. Da: cng l ni biu hin du dng Muscarine r, sung huyt, chy m hi.
3.3. Tiu ha: du chng dng Muscarine. Tit nc bt rt nhiu, tng tit dch tiu
ha nht l dch d dy, tng nhu ng, co tht trn tiu ha gy au qun bng, kh
nut, bun nn, nn. Nu trng c trm trng c nh hng n thn kinh trung ng
th c du i tin v thc.
3.4. Du h hp: biu hin 3 loi tc dng: Muscarine, Nicotine, thn kinh trung ng.
Tc dng muscarine lm tng tit dch ph qun gy ho, tng tit m gii, bt ph qun
gy kh th, nghe ran n t to nh ht, ng thi lm co tht c trn ph qun gy
kh th thm.
Tc dng Nicotine giai on lm lit s lm lit c h hp gy suy h hp nng. Tc
dng ny cng lm nhn li gy tt li lm bt ng h hp.
Tc dng thn kinh trung ng giai on lit s lm lit trung tm h hp, tng cc tc
dng ni trn.
Suy h hp cp, l biu hin tt nhin ca trng c nng, l nguyn t vong chnh.
3.5. Du tun hon: cng biu hin phi hp 3 loi tc dng.
Tc dng Muscarine lm mch chm, huyt p h.
Tc dng Nicotine v thn kinh trung ng: gy cng trc giao cm v kch thch cc
trung tm iu ha tim mch, t nht l trong giai on kch thch a n mch nhanh,
huyt p cao. Trong giai on lit ca tc dng Nicotine, thn kinh trung ng, cc du
chng c th ngc chiu tr li l try tim mch.
3.6. Du c vn: biu hin tc dng Nicotine v thn kinh trung ng.
- Giai on kch thch
Rung c, tht s l rung cc th c l mt du chmg quan trng cho bit trng c
kh trm trng, cn tm k pht hin nht l c ngc,bng, cnh tay, vai v i. Cn
phn bit vi rung c v lnh.
- Giai on lit c: yu c ri n lit c, quan trng nht l c h hp lm ngng th.
Nu trng c ko di, lm tm vn ng b thoi ha th lit c s ko di rt lu.
3.7. Du thn kinh trung ng: biu hin do c 3 loi tc dng
- Muscarine v Nicotine gy thiu kh no, v tc dng thn kinh trung ng trc tip
ca phospho hu c.
- Trong giai on u l kch thch, bt an, co git.
- Trong giai on cui, gim phn x gn xng, ri mt phn x, hn m, lit cc trung
tm thn kinh sinh thc.
- St c th du chng nhim c thn kinh trung ng ca phospho hu c.
IV.TIN TRIN
1. Khng iu tr
510
BNH T MIN
Mc tiu
1.Nm c c ch bnh sinh bnh t min
2. Bit c cc bnh t min thng gp.
Ni dung
I. I CNG
Bnh t min l tnh trng bnh l xy ra do b my min dch mt kh nng phn bit
cc khng nguyn bn ngoi v t khng nguyn. T khng nguyn l thnh phn ca
c th, v l do no tr thnh vt l, t khng th ca c th chng li cc t khng
nguyn ny lm bnh t min xy ra.
Cn phn bit bnh t min vi phn ng t min, phn ng t min lm xut hin cc
t khng th nhng khng gy bnh, nh cc t khng th c to sau s hoi t m
gp phn loi b cc cht phn hu.
Bnh cn c mang nhiu tn khc nhau nh: Bnh do t khng th, bnh do t cng
kch, bnh do t duy tr, bnh t d ng, bnh t mn cm, tn gi thng c dng
nhiu nht l bnh t min.
II. C CH BNH SINH
Cha c c ch no c th gii thch tt c cc trng hp bnh t min, c th c ch
thay i theo bnh.
Bnh thng cc thnh phn ca c th trong thi k bo thai tip xc vi h li
ni m, sau ny tip xc li s c nhn bit l ca c th, khng lm pht sinh khng
th chng li, l tnh dung np min dch. Tnh dung np min dch ny v lm pht
sinh bnh t min trong 4 trng hp sau:
1. Trng hp 1
C s trng hp ngu nhin gia mt khng nguyn l vi mt thnh phn ca c th.
C th sn xut khng th chng li khng nguyn ny (v d vi khun) ng thi chng
lun b phn c cu trc ging khng nguyn. V d bnh thp tim, cht hexosamine c
trong lin cu (tan huyt nhm A cng c trong glucoprotein van tim, do khng th
khng lin cu, khng lun van tim.
2. Trng hp 2
Do tc ng ca nhim c, nhim khun, chn thng, mt s t bo ca c th b tn
thng v thay i cu trc tr thnh vt l, cc t bo min dch coi chng l khng
nguyn l v sn xut khng th chng li. V d vim gan virus.
3. Trng hp 3
Mt s b phn ca c th mu khng tip xc trc tip, t bo min dch khng n
c, khi chng xut hin trong mu (v d chn thng) c th s to khng th
chng li, nh trong bnh nhn mt, khi b tn thng mt bn lm xut hin khng th
chng lun mt kia gy nn bnh vim mt giao cm (ophtalmie sympathique).
517
4. Trng hp 4
Do tn thng hoc suy yu kh nng kim sot ca chnh cc t bo min dch. H
thng c ch tng hp t khng th b suy yu, do vy cc t bo min dch pht trin
v sn xut khng th chng li cc thnh phn vn vn quen thuc ca c th. V d
mt s bnh ca h lin vng ni m thng c km thiu mu huyt tn do xut hin
cc khng th hng cu t sinh.
III. CC LOI T KHNG TH, HU QU CC PHN NG T MIN
1. Cc loi t khng th
Cc t khng th trong bnh t min tc ng gy bnh bng nhiu cch nh hu hoi,
lm thng tn, c khi li kch thch c quan ch gy nn nhng biu hin khc nhau.
C hai loi t khng th
- T khng th chnh: gy bnh tht s nh t khng th chng b mt hng
cu, chng bch cu, chng mng nn, chng th th acetylcholine.
- T khng th ph: i km bnh t min ch khng quyt nh s gy bnh. V
d: t khng th chng t bo thnh d dy trong bnh Hashimoto l mt t khng th
khng c hiu cho c quan bnh l gip, t khng th chng cc ht nhn, chng ti lp
th, chng c tim.
2. Hu qu ca cc phn ng t min
- Tiu t bo do thc bo, b th, lympho T c t bo (thiu mu tan mu)
- Lng ng phc hp min dch ti cc m ch (lupus ban h thng)
- Vim mn vi thm nhim t bo n nhn (Hashimoto)
- Hoi t t bo, thoi ha dng t huyt (vim cu thn cp)
- Kch thch t bo (Basedow).
IV. C TNH CHUNG CA CC BNH T MIN
Vi quan nim v bnh t min nh nu trn do c s lm dng trong chn
on, ngoi vn cn c nhiu kin ngc nhau trc nhiu bnh c tht s l bnh t
min hay khng ? Ni chung hiu bit v bnh vn cn phi tip tc tm hiu thng
nht. Sau y l mt s c im ca bnh t min:
- Bnh thng gp ngi tr hoc ng tui (thng t 20 n 40 tui). Tr
em v ngi gi t gp hn. N gp nhiu hn nam. Thng c yu t di truyn, c tnh
cht gia nh.
- Bnh tin trin tng t, nng dn (v vy bnh c tn l bnh t duy tr) din
tin thng phc tp, a dng t cp tnh, ti cp n nh, dai dng.
- C th tn thng ng thi nhiu c quan.
- Khng c nguyn nhn trc tip r rt. Tuy nhin bnh c th xy ra sau cc
tnh hung sau: Nhim c, nhim trng cp, mn, thai nghn, sang chn tinh thn hoc
th cht, tc nhn vt l nh chy nng, K, sau dng mt s thuc, bnh c th p
ng kh tt vi mt s thuc c ch min dch nht l corticoide.
518
V phng din chn on, khng c tiu chun chung cho cc bnh t min tuy nhin
bnh cnh lm sng, din tin v mt s xt nghim gi hng n bnh t min nh
gim v c hng cu, bch cu, tiu cu c th km tng lympho, tng tc lng mu,
tng gamma - globulin...
Chn on chnh xc da trn s pht hin cc t khng th, cng c hiu, cng
chnh xc, iu ny ch c th c thc hin cc trung tm chuyn su.
V. XP LOI
Nhng bnh t min l tp hp mt nhm bnh khng ng nht, c ch sinh bnh
cha c hiu r hon ton v s xp loi cn tranh ci. Sau y l s xp loi c
nhiu ngi ng :
1. Cc bnh t min chc chn
pht hin c t khng nguyn v t khng th. Bnh c th thc nghim
c, v d bnh Lupus ban h thng, hi chng Goodpasture, bnh nhc c,
vim tuyn gip Hashimoto.
2. Cc bnh rt c th l t min
pht hin c t khng th, v d thiu mu c tnh vi t khng th chng yu t
ngoi lai v chng t bo thnh ca nim mc d dy.
3. Cc bnh c th l TM
Do cc biu hin lm sng v s ci thin sau iu tr bng c ch min dch, v d
vim lot i trng xut huyt.
4. Phn ng TM
Gm nhiu bnh, pht hin c t khng th nhng ngi ta khng r cc t
khng th ny c ng vai tr gy bnh hay ch n thun nh mt du ch im ca
bnh. V d khng th khng myeline trong bnh x cng ri rc.
VI. MT S BNH T MIN CHNH
1. Cc bnh cht to keo
1.1. Lupus ban h thng Do cc t khng th chng cc khng nguyn nhn, nh
ADN, Ro, Sm.
Thng xy ra n, tr (90%). Tn thng nhiu c quan. Da: ban hnh cnh bm
mt, lot nim mc ming, rng tc. C xng khp: vim, au c, vim nhiu khp.
Thn: gy hi chng thn h. Thn kinh: tn thng nhiu ni ca thn kinh. Tim
mch: vim mng ngoi tim kh, c dch, co tht, vim c tim, vim ni tm mc, nhi
mu c tim do vim mch vnh, huyt khi mao mch. Phi: vim phi km theo xp,
x phi, vim mng phi. Huyt hc: ri lon ng mu, thiu mu, tan mu. Tiu ha:
tiu chy, thng rut, gi tc rut, vim ty cp, tng men gan. Mt: vim mch mu
vng mc gy m, vim lot kt mc, vim thn kinh th, kh mt.
1.2. Vim khp dng thp Do t khng th khng HLA DR4, DR1, nguyn nhn khi
pht c th l virus Epstein Barr.
519
5. Tiu ha gan mt
5.1. X gan do mt tin pht do t khng th khng Mitochondrie
5.2. Vim gan mn tn cng do t khng th chng c trn, t khng th chng
lipoprotein ca t bo gan.
5.3. Bnh Coeliakie do t khng th chng Reticuline.
5.4. Vim lot i trng xut huyt: cha tm thy t khng th.
5.5. Bnh Crohn gy hp tng on ng tiu ha nht l i trng, lm sng v cn
lm sng d ln vi lao i trng, cha tm thy t khng th.
6. Thn
6.1. Mt s bnh vim cu thn v vim ng thn k: do t khng th chng khng
nguyn nhn v khng nguyn u, khng IgG.
6.2. Hi chng Goodpasture: do t khng th chng mng nn cu thn.
7. Phi
Hi chng Goodpasture: do t khng th chng mng nn ph nang phi. Vim ph
nang x ha v cn. Bnh u ht ca Wegener, hai bnh sau ny cha r t khng th.
8. Da
Pemphigus tht s: T khng th chng cht lin bo ca thng b. Pemphigus bot:
t khng th chng mng nn ca thng b. Vitiligo t khng th chng melanocyte.
9. Vim mch
Nh cc bnh vim ng mch thi dng, bnh u ht ca Wegener, bnh Churg
Strauss, vim nt quanh ng mch. Cc bnh ny cha r t khng th.
VII. KT LUN
Bnh t min l mt tp hp bnh phc tp m nguyn nhn gy bnh, c ch bnh
sinh cn nhiu iu cha r, do iu tr cn nhiu iu cha nh mun, trong
tng lai iu tr c hiu bng khng th n dng c nhiu ha hn.
521
1.3. Dc ng hc
Penicillin phn b cc t chc. (thp mt, tuyn tin lit, t chc xng v dch
no ty (ngoi tr trong vim mng no).Thuc thi qua nc tiu (60 - 90% trong 6
gi). Penicilline thi qua thn (10% lc cu thn v 90% tit ng thn v b c ch mt
phn bi Probenecid. Thuc qua nhau thai v c trong sa m. Thuc nhy cm vi
lin cu, ph cu, lu cu, no m cu, trc khun gram dng, xon khun
(Leptospira, Giang Mai, Borrelia), vi khun k kh. Thuc b khng t nhin vi trc
khun gram m (Bacteroide, Legionella, Mycoplasma, Mycobacterium...). khng vi
t cu (85 - 95%), lu cu (15%), v ph cu.
Penicilline c ch nh trong nhim trng do lin cu, ph cu, no m cu, xon
khun (treponeme), clostridium perfingens v d phng nhim trng hoi th. Nhim
trng h hp, rng ming, tai mi hng, thn, sinh dc, da, t chc mm, ni tm mc,
nhim trng mu vi cc vi khun ni trn.
1.4. Liu dng
Penicillin G: 2 - 4 triu V / TM 4gi thng ch nh trong giang mai thn kinh.
Penicillin V: 250 - 500 mg/ ln/ ngy 4 ln.vim thanh qun do lin cu nhm A.
Benzathine penicilline 1,2 - 2,4 triu V/ 3 - 4 tun 1 ln hin x dng trong d phng
thp tim, vim cu thn, vim thanh qun do lin cu..
Procaine penicillin ; hin t dng.
Vim mng no hoc vim ni tm mc: 10 - 24 triu V / ngy, dng tnh mch ngt
qung 2-4 gi ln.
2. Nhm Penicillin c ph rng
Trnh by: Aminopenicillin,Caeboxypenicillin, Uredopenicilli.;
Dc ng hc: Penicilline A c khun ph rng i cu khun rut v trc khun gram
m. Thuc phn b khp cc t chc v dch c th (30% dch no ty), thi tr trong
nc tiu (75% trong 6 gi), ng mt (20%) qua nhau thai v sa m.
Ch nh: Penicilline A c ch nh vim mng no, nhim trng tai, mi, hng, phi,
thn, sinh dc, ng mt, tiu ha, ni tm mc, nhim trng huyt, thng hn, bnh
Lyme, bnh pasterella, bnh do listeria.
Ampicilline:250-500 mg/ 6 gi ng ung trong vim xoang, vim thanh qun, vim tai
gia, ng tiu.
Liu ampicilline 2 - g/ TM 4 - 6 gi nhim trng gram (-) nng
3. Dng kt hp
Nhm penicillin + c ch beta lactamase (clavulanic, sulbactam,tazobactam).
Augmentine (Amoxicilline + Acide clavulanique.) vim xoang, vim tai gia v nhim
trng da.
Unasyn (ampicillin + sulbactam): k kh, vim ng h hp trn v di do gram (-),
ng tit niu, nhim trng t chc mm,
525
Timentin (Ticarcillin + clavulanic acid) vi khun k kh, vi khun rut, nhim trng ti t
chc mm
Zosyn (piperacillin + tazobactam) ch nh nh trn
4. Nhm Penicillin khng penicillinase
Trnh by: Methicillin, Oxacillin, Cloxacycillin, Dicloxacillin, Nafcillin..
Dc ng hc: Penicilline M ngoi ch nh nh trn cn c ch nh i t cu
cc c quan c, khp, t chc mm, phi, sinh dc, ni tm mc, nhim trng huyt.
Penicilline M hp thu qua ng ung (ngoi tr meticilline) tc dng i vi t cu.
Tc dng ph c tnh ca penicilline v dn cht
Chong phn v, vim thn k, thiu mu, gim bch cu. Vim gan (oxacillin v
nafcillin)
D ng: biu hin ngoi da (nga, ni m ay, hng ban), bnh huyt thanh (st, vim
khp, hch to, lch to, giam bch cu).Lon khun rut: tiu chy (Amocillin).
au ti ch, vim huyt khi, nhim Na, Kali. Chch Penicilline gn thn kinh ta cng
gy tc dng tng t.Bnh no cp; ri lon thc, co c, tng phn x, co git, hn
m. Dng liu cao penicillin (> 20 triu), liu cao oxacillin, cloxacillin, ticarcillin.Xut
huyt khi dng > 40 triu penicillin/ngy, carbenicillin, ticarcillin, azlocillin, piperacillin
(trn 3 tun).
Liu cao Nafcillin gy gim bch cu, ticarcillin, mezlocillin v pipericillin gy gim kali
kim ha, tng men gan v c ch ngng tp tiu cu
5.Nhm cephalosporine
5.1. Trnh by v phn loi
- Th h I: cefazolin, cephalothin, cephapirin, cephradine, cefadroxyl.
- Th h II:
+ cefuroxime, cefonicid, cefamandole
+ cefoxitin, cefotetan
+ cefmetazole
+ cefuroxime axetil, cefprozyl, cefdinir, cafaclor, lobracarbef
- Th h III: cefotaxim,, ceftriaxone, ceftizoxime, cefoperazone)
- Th h IV: Cefepime
5.2. Dc ng hc
Cephalo I hp thu tt qua ng tiu ha (ch yu l cephalexine, cefadroxil,
cefatrizine, cefradine), thuc phn b khp c th ngoi tr dch no ty, thi tr qua
nc tiu, thuc qua nhau thai v sa m.
Thuc tc ng trn nhiu khun rut (Klebsiella, Escherichia coli, Proteus miabilis,
shiigella, salmonella), Haemophilus Influenzae, t cu, lin cu, bch cu clostridium
perfingens, xon khun, leptospira. khng mt vi chng ca E.coli (10%), Klebsiella
526
6.3. Dc ng hc
Tc dng kim khun Hp thu ng tiu ha khng u. Phn b cc t chc (ngoi
tr no, dch no ty v nc tiu), thi tr ch yu qua dch mt.
Thuc tc dng i cu khun v gram m, mt vi trc khun gram m, k kh.
khng t nhin vi vi khun rut (pseudomonas, Mycoplasma hominis). khng cho
vi haemophilus influenzae (60%), cu khun rut (50 - 70%), t cu (15 - 30%), ph
cu (22%), lu cu, trc khun.
6.4. Ch nh
Cc bnh l thng c ch nh nh vim hng, vim xoang, vim xng, vim ph
qun, vim phi, nhim trng da (mn trng c).
6.5. Tc dng ph v c tnh
Ri lon tiu ha, au thng v, nn, tiu chy, au bng.Tn thng gan min dch d
ng: mt, vng da. tai v kch tnh mch (chuyn tnh mch).
Tng tc dng thuc chng ng, digoxin, theophyllin, khng histamin,cyclosporine (do
c ch cytochrome P450).
Erythromycine 250 - 500 mg/ mi 6 gi hoc 0,5 - 1 g/ TM mi 6 gi.
Trnh liu trn 4 gam/ ngy.
Dirithromycin 250 - 500 mg/ ung mi 12 gi
Clarithromycin 250 - 500 mg/ uonongs mi 12 gi
Azithromycin 500 mg ung/ ngy u ri 250 mg/ ngy trong 4 ngy
7. Lincosamide.
7.1. Tn th trng
Lincomycin (lincocine), clindamycin (dalacine)
7.2. C ch tc dng
Trn s tng hp protein bng cch lin kt vi tiu n v 50S ribosom
7.3. Dc ng hc
Tc dng dit khun, hp thu ng tiu ha hon ton (clindamycine tt nht), thuc
phn b khp c th c bit xng v khp (rt km dch no ty), chuyn ha
gan, thi tr qua mt v phn, lng t hn nc tiu. Clindamycine c tc dng tt
hn.
Tc dng i vi nhm k kh, lin cu, ph cu, t cu. khng t nhin i vi
Haemophilus nluenzae, lu cu, no m cu v vi khun gram m. Nhy cm khng
thng xuyn i vi t cu vng khng erythromycine v methicilline, mt s
clostridiae (10 - 30%) v bacteroides (20%).
7.4. Ch nh
Nhim trng nng c bit do t cu v vi khun k kh (ngoi tr vim mng no,
nhim trng thn v h tit niu).
528
8. Nhm cycline
8.1. Tn th trng
Tetracycline, oxytetracycline, doxycycline, minocycline.
8.2. C ch tc dng
Tc ng trn s tng hp protein bng cch lin kt vi tiu n v 50S ribosom
8.3. Dc ng hc
Thuc c tc dng kim khun, thuc phn phi t chc ni v ngoi bo (ngoi tr
no, dch no ty v khp), thuc t b chuyn ha (ngoi tr doxycycline), thi tr di
dng hot tnh qua ng mt v trong nc tiu.
Thuc hp thu khng u qua ng tiu ha, hp thu km khi dng chung aluminum
hydroxide, gim tc dng khi dng Ca, Fe.
8.4. Ch nh
Bnh Brucella, st hi quy, st Q, vim phi khng in hnh, bnh mt ht, nhim
trng c quan sinh dc, bnh ht xoi (Nicolas favre) dch hch. St rt khng
chloroquine, mn trng c. Thuc c ph khun rng. khng t nhin vi Seratia, vi
khun rut, mt vi loi proteus, Pseudomenas aeruginosa, mycobacterium. khng
hin nay vi vi khun k kh (80%), trc khun rut (75%), lin cu nhm B (50%), lin
cu nhm C v G (45%), lin cu nhm A (30%), ph cu (16%), t cu (30%),
Escherichia coli (50%), Klebsiella (50%), Salmonella (25%), Shigella (40%).
8.5. Tc dng ph v c tnh
Di ng.Ri lon tiu ha, vim ming - hu hng - thc qun,.Vim gan, suy thn, tng
p ni s.Dng Demeclocyclin gy i tho nht (c ch ADH), tng ure mu nu dng
chung vi li tiu.Gn vo xng, rng tr em gy chm pht trin xng, hng rng,
vng rng.Thuc qua nhau thai gy tc dng tng t cho bo thai. Ri lon nhp tim.
Chong phn v khi dng ng tnh mch (doxycycline), hin tng cm quang. Ri
lon tin nh,Nhim nm candidose tiu ha.
9. Nhm Phenicol
9.1. Tn th trng
Chloramphenicol, Thiamphenicol. (hin khng dng ti M).
529
9.2. C ch tc dng
Tc ng trn s tng hp protein bng cch lin kt vi tiu n v ribosom 50S
9.3. Dc ng hc
Tc dng km khun, thuc khuch tn cc t chc v th dch (dch no ty 50%),
Thuc thi di dng cn hot tnh trong nc tiu (70% i vi thiamphenicol v 15%
i vi chloramphenicol) trong mt (5 - 6%) v trong phn (20%). Thuc qua nhau thai
v c trong sa m. Thuc khng t nhin vi pseudomonas, Acinetobacter,
Mycobacterium...)
9.4. Ch nh
Nhim trng cp tnh ng h hp, gan mt, mng no (Haemophilus), niu o
(gonococcus), tiu ha nh do thng hn hoc salmonella, vi khun k kh.
9.5. Liu lng
12,5 - 25 mg/kg/ TM mi 6 gi, liu ti a 1 gam/ TM mi 6 gi.
9.6. Tc dng ph v c tnh
Thiu mu: Ty thuc vo liu dng v thi gian s dng, c bit ngi c suy gan, s
hi phc sau vi tun.. Bt sn ty: khng ph thuc liu dng cng nh thi gian dng,
tin lng nng. Hi chng xm: gp tr em v tr em non, nn, nhp th nhanh,
tm nhanh, phn xanh, ng lm, try mch v t vong. Dng ko di gy vim thn kinh
th gic, vim thn kinh ngoi vin, ri lon tiu ha, gy ni m ay v pht ban. Trnh
khi c thai, cho con b, tr s sinh, suy gan, thiu mu.
10. Nhm Aminoglycoside
10.1. Tn th trng
Streptomycin, gentamycin, tobramycin, amykacin, neltimycin, framycetin, sisomicin,
paromomycin, kanamycin, dibekacin...
10.2. C ch tc dng
Tc ng trn s tng hp protein bng cch lin kt tiu n v ribosome 30S.
10.3. Dc ng hc
Thi gian bn hy ty thuc chc nng thn., Khng hp thu bng ng ung.
Thuc khuch tn vo phn ln t chc v th dch ca c th, trong ti nhu m thn
cao hn huyt tng. Thuc hp thu km mt, tuyn tin lit, khng qua hng ro
nhau thai, sa m v hng ro mu no, h thn kinh trung ng, mt.Thuc thi qua
nc tiu siu lc ch yu (65% sau 6 gi, 85% trong 24 gi).
- Ch nh: Nhim trng vi khun gram m ti thn v h tit niu, nhim khun huyt v
vim ni tm mc, nhim trng da, nhim trng h hp v khp xng.
10.4. Liu dng
Streptomycine: 15 - 25 mg / kg / ngy. Chia 1 - 2 ln
Amikacin: 15 mg / kg / ngy.. chia 2 ln.
530
11.6. Chng ch nh
C thai, ang cho con b, tr s sinh, ngi gi trn 70 tui.Suy gan, suy thn, bnh
nhn b tm thn, thiu men G6PD. Ngi li xe, lm vic trn cao, s dng my mc.
12. Nhm Nitroimidazole
12.1. C ch tc dng
Tc ng trn tng hp DNA bng cch tch lu cc cht chuyn ho c tch nh
hng trn nhiu tin trnh sinh hc
12.2. Trnh by
Metronidazole, Ornidazole, Tinidazole, Secnidazole
12.3. Dc ng hc
Thuc khng khun, hp thu nhanh, t nht 80% sau 1 gi, nng huyt tng khi s
dng bng ng ung v tim truyn gn ging nhau, thi gian bn hy t 8 - 10 gi.
Lin kt vi protein khong 20%. Thuc khuch tn nhanh, mnh vi nng cao
phi, thn, gan, mt, dch no ty, nc bt, tinh dch, dch tit m o. Thuc qua nhau
thai v sa m.
Thuc chuyn ha qua gan, nng cao gan v mt, thp rut, t bi tit qua phn,
m ch yu qua nc tiu v c mu nu.
12.4.Ch nh
Bnh do Amibe, Trichomonas, Giardia intestinalis, vi khun k kh
12.5. Tc dng ph v c tnh
Ni m ay, nga. Chn n, bun nn, v kim loi ming, vim ming, nim li, li
en, i lng.Nhc u chng mt, c th gy vim no v co git, vim ty.Gim bch
cu a nhn, gim bch cu nu dng ko di. Vim a dy thn kinh (cm gic v vn
ng).Thn trng: ph n c thai (3 thng u), ang cho con b.Bnh tm thn v
thiu mu Gy ung th sc vt th nghim.
13. Nhm sulfamide
13.1. C ch tc dng
c ch chuyn ho acid folic bng cch cnh tranh c ch cc enzyme trong 2
giai on sinh tng hp acid folic.
13.2. Trnh by
Sulfamides + Trimethoprime: Bactrim (Cotrimoxazole)
Sulfamide: Adiazine (sulfadiazine), sulfamide chm (fanasyl, fansidar)
13.3. Dc ng hc:
Bactrim c kh nng dit khun, hp thu nhanh v gn nh hon ton (90%), phn b
khp cc t chc nh dch no ty, tuyn tin lit, mt, tai gia, phi. Thoi bin gan,
thi ra trong nc tiu, dch mt v phn. Thuc c khun ph rng i vi vi khun
ng rut (E coli, proteus, citrobacter, salmonella, shigella, vibrio chlera, listeria,
532
20-30 mg/kg/ngy chia 2 hoc 3 ln, chch tnh mch 10 mg/kg trn 20 pht. thi gian
bn hu c th ln n 8 ngy.
14.5. Tc dng ph v c tnh
Phn ng lin quan n tim truyn (ging nh chong phn v, ni m ay, nga).
Truyn chm (1 gam/ chuyn trn 60 pht) c tnh trn thn do liu lng cao. c
cho tin nh c tai. Gy ic v chng mt (nng huyt tng qu 80 g/ml). Gim
bch cu (2%), Vim tnh mch, cc phn ng khc (st, bun nn, lnh run, hi chng
Stevens Johnson).
15. Nhm thuc khng lao
15.1. Isoniazid
+ C ch tc dng: c ch tng hp thnh phn lipid ca vch t bo vi khun
+ Dc ng hc: Thuc thu tt qua ng tiu ha, Phn b khp cc t chc k c
TKT.Thi trong nc tiu
+ Liu trung bnh 15 mg/kg/ ngy, ngi ln 300 mg/ ngy, ti a 900 mg/ngy
+ Tc dng ph: mt ng, bt an, au c, tng phn x, co git, ng kinh. Vim gan
(20%) ngng thuc khi men tng gp 3 ln.Vim dy TK ngoi bin (phi hp
Pyridoxin5 25 - 50 mg/ ngy) c bit ngi gi, c thai, i tho ng, suy thn,
nghin ru, tm thn.
15.2. Rifampin
- C ch tc dng: Tc ng trn s tng hp DNA bng cch c ch enzyme
polymerase RNA ph thuc DNA (DNA- dependent RNA polymerase).
- Dc ng hc: Phn b khp tt chc k c thn kinh trung ng(nng 50% so
vi huyt tng), Thi ch yu qua gan v t hn nc tiu
- Liu lng:
Rifampin: 10 - 20 mg/kg (600 mg/ ngy)
Rifabutin: (300 mg/ ngy) dnh cho bnh nhn nhim HIV.
Rifapentine (600 mg/ 2 ln mt tun trong 2 thng)
- Giao thoa thuc: Thuc lm tng chuyn ha thuc chng ng, thuc nga thai,
Thuc lm gim nng mt s thuc methadone, ketoconazone, chloramphenicol,
thuc h ng huyt, thuc chng lon nhp v ciclosporine.
- Tc dng ph nh pht ban da, ri lon tiu ho, viem gan, vim thn k, tng acid
uric (rifapentine).
15.3. Pyrazinamide
- C ch tc dng: dit vi khun trong i thc bo nhng c ch khng r
Tc dng dit khun Phn b khp cc t chc k c mng no (tng ng huyt
tng)
- Liu 15 - 30 mg/kg/ ngy, ti a 2 gam.
534
- Tc dng hip ng
c ch cc giai on khc nhau trong cng mt chu trnh chuyn ha ca vi khun.
Bactrime (Sulfamethoxazole + Trimethoprime)
Augmentine (Amoxilline + acide clavulanique) cht sau c tc dng c ch men beta
lactamase (beta lactamine khng b phn hy, pht huy tc dng.
Mi loi khng sinh tc ng vo mt trong nhng qu trnh ca tng hp vch vi khun
Khi phi hp lm tng tc dng (Ampicilline + Oxacilline, Ampicilline + Ticarcilline)
Khng sinh tc ngvo vch to iu kin cho khng sinh khc xm nhp ni bo.
Phi hp Penicilline + Streptomycine.
Oxacilline + Gentamycine (Tobramycine) iu tr t cu.
Carbenicilline hoc Ticarcilline + gentamycine iu tr Pseudomonas aeruginosa.
Cephalothine + Gentamycine iu tr Klebsiella.
3. Cch thc phi hp ( c thc nghim trn lm sng)
Nhm Penicilline + nhm Penicilline hoc cht c ch Beta lactamase
Nhm Penicilline + nhm Nitroimidazole hoc nhm Aminoglycoside
Nhm Penicilline + Aminoglycoside + Nitroimodazole hoc Lcosamide
Nhm Cephalosporine + nhm Penicilline
Nhm Cephalosporine + nhm Penicilline+ Licosamide
Nhm Aminoglycoside + Licosmide hoc Nitroimodazole
VII. KHNG KHNG SINH.
1. C ch khng thuc khng sinh ca vi khun.
1.1 Tng ph hy hoc bin i cu trc ca thuc khng sinh
Do men (qua trung gian ca Plasmid); men betalactamaza khng nhm beta
lactamine; men cephalosporinaza khng cephalosporine; men phosphorylaza,
adeylaza, acetylaza bt hot aminoside; men acetylaza bt hot chloramphenicol.
1.2. Bin i Receptor ca thuc
Lm bin i protein c hiu vi thuc Ribosome lm thay i s gn vo th th
ca thuc, v th VK tr nn khng vi khng sinh (khng aminoside, Erythromycine,
rifampicin, Bactrime...)
1.3. Gim tnh thm mng nguyn tng
Do mt (khng aminoside) hoc lm thay i h thng vn chuyn mng nguyn
tng (khng Beta lactamine, chloramphenicol, quinolone, tetracycline, bactrime...)
khng sinh khng thm vo ni bo
1.4. Tng s to thnh mt men mi
Mt s VK c mang plasmid khng thuc, c kh nng to nn mt men mi c i
536
3. Ch nh
Ch nh Liu lng
HKP D phng bnh l tc mch: Calciparine TDD 5000 v 2 gi trc
ri chch mi 8 gi.
- Nguy c va.
- Calciparine TDD mi 8 gi vi TCA
- Nguy c cao
gp 1.5 ln chng.
iu tr bnh l tc mch: - Heparine TM:
- NMCT cp. 500 v/kg/ngy +/- liu tn cng 100
v/kg TM chuyn TM lin tc hoc gin
- TBMN thiu mu
on (IVD/ 2gi)
- Tc ng mch.
- Calciparine TDD
- ng mu ri rc ni mch
5000 v/ kg/ngy trong 3 ln chch lin
tip.
HPTT D phng bnh l thuyn tc - Fragmine 2.500 v
- Nguy c va: chch trc mi - Lovenox 20 mg
th nht di da 4 gi ri chch
- Clivarine 1750 v
mi ngy 1 mi.
- Nguy c cao: chch mi th
nht 12 gi trc ri 1 mi/ ngy. - Fragmine 5000 v
- Lovenox 40 mg
- Clivarine 4200 v
iu tr: -Fragmine 100v/kg 2 ln/ngy
au tht ngc khng n nh - Lovenox 1mg/kg/2 ln/ngy
- Clivarine 175 v/kg 2 ln/ ngy
4. Chng ch nh
- Tuyt i: D ng Heparine, xut huyt ang tin trin nht l xut huyt no (< 2
tun) hoc xut huyt ni tng (< 10 ngy), phu thut thn kinh- nhn khoa hoc chn
thng s no nng (< 3 tun), ri lon cm mu (bnh tiu si huyt, gim tiu cu),
chch vo bp tht hoc vo khp.
- Tng i: Hu phu, THA nng, lot d dy tin trin, dng phi hp thuc khng
vim khng steroid, aspirine, ticlopidine; vim ni tm mc nhim khun tr phi thay van
c hc hoc rung nh ; vim mng ngoi tim, bc tch ng mch, tc dng ph.
5. Bin chng v x tr
5.1. Xut huyt
- Nh: iu tr triu chng, kim sot thi gian cephalin (TCA) hoc hot ho khng anti
Xa, vic ngng heparine t khi cn thit tr khi qu liu hoc khng kim sot xut huyt
c.
Nng: iu tr triu chng, kim sot TCA hoc hot ho khng anti Xa, ngng
heparine, dng cht i khng nu qu liu: protamine 1m TM/ 100 v heparine.
544
Cng gip
6. Tc dng ph
6.1.Xut huyt
- Xut huyt nng (TBMN, xut huyt tiu ho, u mu c y chu hoc sau phc
mc): ngng ngay khng vitamine K, chuyn PPSB ngi (nu qu liu), chch vitamine
K, duy tr Heparine chch TM qua bm in khi INR < 1.5 vi TCA: 1.2-1.5.
- Xut huyt nh khng qu liu: INR> 5: ngng hoc gim khng vitamine K trong
24 gi ri duy tr li vi 1/2 hoc 3/4 liu.
- Cm mu ti ch.
- Vitamine K ung nu qu liu nng INR > 8-10
6.2. Phn ng d ng vi indanedione
Him nhng nng: phn ng da, gim bch cu, gim tiu cu, bnh thn, vim gan.
6.3.Tc dng ph ca coumarine
au d dy, nn, nga, rng lng, lot ming.
6.3.Bnh no do coumarine
Xy ra ngay c vi pindione vo tun th 6 v tun th 9, l nguyn nhn teo mi,
canxi ho u xng, chm pht trin thn kinh vn ng.
7. Cch cho thuc
7.1.Trc khi cho thuc
Loi tr cc chng ch nh hoc tng tc thuc. Loi tr ri lon ng mu (INR,
TCA) hoc suy thn, suy gan, c sn nhm mu.
Bt u liu 1vin/ ngy (3/4 nu bnh nhn ln tui, nh cn, suy gan hoc suy thn
va), INR nh lng sau 48-96 gi.
7.2.Thay i liu mi 1/4 vin
nh lng INR v sau mi 48 n 96 gi cho ton b vic iu chnh liu. INR mi 48
gi khi trong gii hn iu tr. Mi tun cho n khi n nh trong hai ln kim tra mu
lin tip.
7.3. Cp bnh nhn mt phiu theo di thuc chng ng.
552
chc lin kt, da, cht hot dch u hp thu tt cc cht ny. X dng dng ester tan
trong nc dng ng tnh mch hoc tim bp tht vi tc dng ko di hn.
+ Cc phn t lin kt vi proteine huyt tng: Vi liu thp. Transcortine b bo ha,
khi dng liu cao cc cht albumine dng ph thm (lin kt mnh hn). S lng dng
hot ng ph thuc vo liu v gim albumine huyt tng l nguyn nhn ca tc
dng ph. Ngay c thai nghn v x dng estrogene c th nh hng trn s lin kt
proteine.
+ Chuyn ha ch yu gan v to thnh dng ester hoc glucuronide khng hot ha
v thi trong nc tiu. Chuyn ha chm trong trng hp thai nghn, x gan, tng
hot gip v dng thuc salicyl.
+ Thi gian na i huyt tng ca cc dn cht tng hp thng di hn so vi
cortisol ni sinh nhng tc dng sinh hc th khng lin quan n thi gian na i (c
ch tc dng ni bo).
Bng 1: Phn loi glucocorticoid tng hp
Thi gian Tng Tim Tim Thi gian
1/2 i ng (mg) nng nng 1/2 huyt
sinh hc tng
Gluco corticoid
(gi) (pht)
khong
corticoid
Nhm Glucocorticoide
Tc dng ngn
Cortisol 20 1 2 90 8-12
Cortisone 25 0.8 2 80-118 8-12
Tc dng trung gian
Prednisone 5 4 1 60 18-36
Prednisolone 5 4 1 115-200 18-36
Triamcinolone 4 5 0 30 18-36
Methylprednisolone 4 5 0 180 18-36
Tc dng ko di
Dexamethasone 0.5 25-50 0 200 36-54
Betamethasone 0.6 25-50 0 300 36-54
Nhm corticoid khong
Aldosterone - 0.3 300 15-20 8-12
Florocortisone 2 15 150 200 18-36
Desoxycorticosterone - 0 20 70 -
acetate
Prednisolone c cu trc cortisol vi cu ni i gia C-1 v C-2, lm tng tc dng
glucocorticoid v gim tc dng corticoid khong. Thm nhm alpha-fluoro C-9 lm
554
tng tc dng c hai, ngc li thm nhm hydroxyl hoc methyl C-16 lm gim tc
dng corticoid khong.
Dexamethasone c ni i C-1 v C-2, nhm fluoro C-9, v nhm alpha methyl
C-16, c tc dng glucocorticoid gp 25-50 ln.
Cu ni i C-2 v C-3, v methyl ha C-2 v C-16 ko di thi gian na i huyt
tng,
2. Liu php glucocorticoide ton thn gin tip
+ Thng dng ACTH tng hp trong thnh phn C tn cng 25-39 hoc 26-39 b
loi b, c tc dng ci thin dung np.
+ Cc cht ACTH tng hp ny lm tng phng thch cc steroide thng thn, cortisol
tng ti a trong vng 30 - 60 pht i vi loi trung gian v tng sau 4 gi v ko di
24 - 36 gi i vi loi chm.
+ Dng polypeptidique ch dng bng ng chch.
3. Cc dng khc
3.1. Tc dng ti ch
Khng gy c nu dng ngn ngy. Nhm steroid cha fluorinated (dexamethasone,
triamcinolone acetonide, betamethasone v beclomethasone) xuyn qua da tt hn
nhm khng cha thnh phn ny nh l hydrocortisone.
3.2. Glucocorticoid dng cho mt
Tn thng t min hoc v cn phn trc ca mt (mng mt, mng mch nho
ca mt), vim nhim sau phu thut hoc do chn thng s dng nhm hn ch ph
n.
3.3. Glucocorticoid dng ht
Trong bnh hen ph qun v bch hu thanh qun.
3.4. Glucocorticoid ng mi
Kh dung trong vim mi d ng.
3.5. Glucocorticoid bnh khp
Dng chch vo khp (cn v trng)
II. TC DNG CA GLUCOCORTICOIDE
1. Mc t bo
+ Glucocorticoide dng t do tc ng ln th th c hiu ni bo.
+ Phc hp steroide - th th c hiu c hot ha v di chuyn vo nhn t bo,
kch thch sao chp ARN v tng tng hp proteine.
2. Mc chuyn ha
Glucocorticoide lm bilan azote m tnh bng cch tng thoi bin v c ch ng ha
proteine (ti gan tng tng hp protein v RNA). Tng thoi bin lipide thng xuyn
555
+ Bnh mu: Hogdkin, ung th mu,thiu mu huyt tn, xut huyt gim tiu cu v
cn, bnh bch cu n nhn,
+ Da: biu hin da ca bnh mu, pempigus c tnh, hng ban a dng, bong biu b
cp, bnh li ni m, hng ban nt
+ Tiu ha: vim gan mn, vim gan hoi t cp, vim i trng let
+ Bnh thn: hi chng thn h, vim cu thn cp,
+ Thn kinh: x cng ri rc.
+ Hi chng West.
+ Hi chng suy h hp cp tnh (SARD) ngi ln.
1.2. Nguyn tc th hai
+ Nguyn tc th hai l tn trng cc chng ch nh kinh in:
- Lot d dy t trng (liu prednisolone di 15 mg/ ngy t gy tai bin ny)
- i tho ng (khng n nh ng huyt)
- Tng huyt p (do tc dng gi mui)
- Nhim trng tin trin.
- Gim th trng r.
- Tin s tm thn.
- Cn kim tra trc khi x dng glucocorticoid vi liu dc l.
+ Hin din lao phi hay nhim trng mn tnh khc (X quang phi, IDR).
+ C ri lon dung np glucose hoc tin s i tho ng thai k.
+ C du hin tin long xng (m xng ph n mn kinh).
+ Tin s let t trng, vim d dy hoc vim thc qun.
+ C tng huyt p hoc bnh tim mch.
+ Tin s ri lon tm thn.
2. Cch thc s dng
2.1. Chn loi liu php
Thng u tin l dng trc tip hn l gin tip do nhiu l do: liu chnh xc, thch
ng r, t tc dng corticoide khong, khng tc dng kch thch hc t v lu di v c
th chuyn dng ng chch thay ng ung.
2.2.Chn ng dng
+ ng ung thng c a chung nht.
+ ng tnh mch dng trong trng hp cp cu, v dng liu tn cng ngay t u
m ng ung b hn ch.
558
Nc tiu T BO Mu
3Na+
Na+
2K+
566
567
Qu trnh ti hp thu Na gm 2 bc
-Na i vo t bo thng qua 1 knh c trn mng t bo pha trn u.
-Vn chuyn Na xuyn qua mng pha y nh bm Na/K ATPase.
2. C ch tc dng ca thuc li tiu quai
- NaCl c lc trong lng ng thn i vo cc t bo nhnh ln quai Henle qua trung
gian 1 cht ti ng vn Na- K - 2 Cl nm mng pha u ca t bo. Nng lng cho
vic vn chuyn ny c cung cp bi Gradient in th thch hp ca Na (ngoi
thp ca ni bo, in tch m ca t bo).
- Cc li tiu quai c ch trc tip s ti hp thu ca Na, K, Cl, nh tranh chp vi v tr
Cl ca cht ti, cc thuc nhm ny cho php thi 20-25% lng Na c lc (trong
ng thn). Cc thuc li tiu ny ng thi c 1 tc dng ln o thi Canxi (c ch ti
hp thu Nacl ua n c ch ti hp thu Calci)
3. C ch tc dng ca li tiu nhm Thiazide
- ng ln xa, Na i vo t bo nh vo cht ti NaCl nm t bo pha u.
- Cc cht Thiazide c ch trc tip ti hp thu ca NaCl bng cch tranh chp v tr Cl
ca cht ti, chng kch thch 1 cch gin tip ln s ti hp thu Ca.
- Tc dng ca ca nhm thuc ny thng yu, ch cho php o thi 5- 10% lng
Na c lc (trong ng thn)
4. C ch tc dng ca li tiu gi Kali
Lin quan n phn v ca ng gp.
- Na i vo t bo qua 1 knh Na biu m trn mng t bo. Nng lng c cung
cp bi Gradient ca Na. Sau Na c bi tit pha mng y ca t bo thng
qua 1 bm ph thuc Na- K- ATPase.
- Aldosterone lm tng s lng knh Na v s lng cc bm ph thuc Na-K-
ATPase.
- Cc thuc li tiu gi Kali (nh Amiloride) c ch trc tip cc knh Na trong khi
Spironolactone i khng vi tc dng ca Aldosterone.
- Tc dng thi Na ca nhm thuc ny thp, cho php bi tit 1-3% lng Na c lc
(trong ng thn)
5. C ch tc dng nhm li tiu gn
- Mannitol li tiu theo c ch thm thu.
- Acetazolamid c ch ng ln gn v c ng ln xa men anhydrase carbonique
theo phn ng:
CO2 + H2O H2CO3 H+ + HCO3-
: cn anhydrase carbonique
: khng cn anhydrase carbonique
568
Acetazolamid (Diamox0, dng vin 125mg, 250mg, 500mg: liu lng 250mg-
500mg/ngy.
Dichlorophenamide (DARANIDE), vin 50mg, liu lng 200mg/ngy.
Cc thuc trong nhm ny thng c s dng iu chnh ri lon toan kim trong
suy h hp mn, lm gim p lc nhn cu ca bnh Tng nhn p (Glaucome), trong
bnh ng kinh.
3. Loi thuc li tiu mui: L nhm thuc tng o thi Natri, Kali. L mt trong nhng
nhm thuc c s dng vi mc ch li tiu nhiu nht hin nay, gm:
3.1. Cc Thiazides: l loi sulfamide li tiu v trong cu trc ca chng c gc
sulfonamide. Trong nhm thuc ny c nhiu bit dc, ch k tn mt s thng dng:
- Chlorothiazide (Diuril) vin 0,5mg, liu lng 1-2vin/ngy
- Hydrochlorothiazide (Hypothiazide) vin 25mg, liu lng 2-3vin/ngy. L loi
thuc thng c dng trong iu tr tng huyt p.
- Clopamid (Brinaldix) vin 20mg, liu lng 1-2vin/ngy
3.2. Cc thuc nhm li tiu quai (quai Henl: bao gm:
- Furosemide (Lasix - Lasilix) vin 40mg, ng 20mg: l thuc c ch nh kh rng
ri v tc dng nhanh (ung sau 45 pht, tim tnh mch sau 10 pht) v mnh.
- Acid tacrynique (Edecrine) vin 50mg, ng 50mg. Vi ng dng tnh mch,
thuc c tc dng nhanh sau 1/2 gi tim v ko di 6-8 gi.
4. Spironolactone
n thun nh Aldactone vin 50mg, liu lng 2-6vin/ngy. Liu duy tr 2 vin/ngy.
Spironolactone phi hp vi Thiazide nh Aldactazine (Spironolactone 25mg + Altizide
15mg) liu lng 3-4 vin/ngy, liu duy tr 1-2 vin.
Cn lu hiu qu c ch aldostrone ko di nhiu ngy sau khi ngng thuc cho nn c
th gy tai bin nng n do mt nc nu liu trnh khng chm dt ng lc.
5. Triamtrne
n thun nh Teriam vin 100mg, liu tn cng 2-3 vin/ngy, liu duy tr 1 vin trong
ngy hoc 2 ngy.
Triamtrne phi hp vi Thiazide nh cyclotriam (triamtrne 150mg + cyclothiazide
3mg)
6. Amiloride
Cng l loi li tiu gi Kali bit dc Modamide vin 5mg, liu lng 1-4vin/ngy.
7. Cc nhm thuc khc c tc dng gy li tiu
7.1. Cc Corticoides: Thng c kh nng gy li tiu sau 3-4 ngy iu tr, ban u l
li tiu n thun tip theo l li tiu thm thu vi bi tit Kali v Natri c th gy gim
Kali ng k.
7.2. Li tiu thm thu
570
4.1. Trong suy tim khng dng cc loi li tiu thm thu
4.2. Trong c trng do x gan khng dng loi thy ngn v Acetazolamide.
4.3 Trong i tho ng khng dng loi li tiu mui v Acetazolamide.
4.4. Trong suy thn khng dng li tiu thy ngn v mui
4.5. Nu c tng Kali mu khng dng Spironolactone. Triamtrne.