BAÙNG BUÏNG VAØ

CHOÏC DOØ MAØNG BUÏNG

BS. CKII HUYØNH THÒ KIEÅU

BOÄ MOÂN NOÄI - ÑHYD
 TIEÁP CAÄN BN BAÙNG BUÏNG

I.DÒCH TEÃ :
1.Giôùi nöõ :HC Meigs, Kbuoàng tröùng di caên MB
2.Tuoåi: Treû Lao MB
Giaø K maøng buïng nguyeân phaùt/tp
II.LYÙDOVAØOVIEÄN:Buïng to –ñau-soát…
III.BEÄNH SÖÛ :Thôøi gian,ñaëc ñieåm BB,ñaùp öùng ñieàu
trò, tình traïng hieän taïi
IVTIEÀNCAÊN: Hoûi tìm nguyeân nhaân BB
V:LÖÔÏC QUA CAÙC CÔ QUAN
 TIEÁP CAÄN BN BAÙNG BUÏNG
VI:KHAÙM :
1.Toång traïng :Tri giaùc, theå traïng,sinh hieäu,da nieâm
2.Khaùm vuøng :
a.Ñaàu maët coå :Haïch, TM coå noåi ,TM coå ñaäp
b.Ngöïc :-Tim :TDMT, co thaét MNT, Suy tim P
-Phoåi: TDMP,lao phoåi
c.Buïng :-Nhìn :Buïng to beø/goïn ,roán loài ,THBH
u haï söôøn P di ñoäng theo nhòp thôû .
-Nghe: daáu baùn taéc ,aâm thoåi ôû gan
-Sôø vaø goõ :Xaùc ñònh BB toøan theå / khu truù
 TIEÁP CAÄN BN BAÙNG BUÏNG

 Khoâng
coù phuø khoâng?
coù
-BB do kích thích PM: -Xô gan maát buø
Lao,K,VPM -Suy tim
-BBdöôõng chaáp -HCTH
-HC Meigs -Suy DD
-Xô gan maát buø giai
ñoïan ñaàu
 CHOÏC DOØ MAØNG BUÏNG
VAØ XEÙT NGHIEÄM DÒCH BAÙNG
CHÆ ÑÒNH VAØ CHOÁNG CHÆ ÑÒNH
CHÆ ÑÒNH :Taát caû BN baùng buïng nhaäp vieän
1.Chaån ñoaùn :xaùc ñònh,nguyeân nhaân ,bieán chöùng
2.Ñieàu trò :giaûi aùp ,baùng buïng khaùng trò
3.Theo doõi ñaùp öùng ñieàu trò
CHOÁNG CHÆ ÑÒNH:
1.RLÑM: Ñoâng maùu noäi maïch lan toûa.
2. Mang thai, baøng quang caêng ,chöôùng ruoät ,dính
ruoät ,taéc ruoät.
3.Traùnh choïc vaøo : cô thaúng buïng 2 beân( vì coù ÑM
thöôïng vò döôùi),seïo moå cuõ,THBH,vuøng da bò vieâm
nhieãm.
 INDICATIONS
1. Evaluation of new onset ascites
2. Evaluation for spontaneous bacterial peritonitis in all patients
with ascites and abdominal pain, fever, or unexplained
encephalopathy
3. Evaluation for subclinical infection in all patients with ascites
admitted to the hospital
4. Treatment of symptomatic ascites

HANDBOOK OF GASTROENTEROLOGIC PROCEDURES - 4th Ed. (2005)

Abdominal Paracentesis - Kimberly L. Beavers
 CONTRAINDICATIONS

- Coagulopathy should preclude paracentesis only when

there is clinically evident fibrinolysis or clinically evident
disseminated intravascular coagulation .
-There is no data to suggest coagulation parameter
cutoffs beyond which paracentesis should be avoided
Patients with cirrhosis without fibrinolysis or
disseminated intravascular coagulation (DIC) do not
bleed seriously from needle sticks unless a blood vessel
is entered .
 CHUAÅN BÒ DUÏNG CUÏ
-Gaêng voâ truøng ,champ coù loå
-Coàn iode ,Boâng goøn
-OÁng tieâm 10cc, kim 20G ñeå choïc huùt .OÁng
tieâm 5cc –kim 23- 25 G ñeå gaây teâ
-Moät catheter 18G -7 ½, moät chaïc ba , oáng tieâm
60cc
-Thuoác teâ : Lidocain 2% 2ml -2 oáng
-Daây truyeàn dòch ,chai chöùa dòch , 3 loï ñöïng
dòch laøm XN ,baêng keocuoän, gaïc voâ truøng
 CHUAÅN BÒ BN
1.Giaûi thích söï caàn thieát phaûi choïc doø vaø nhöõng
tai bieán coù theå xaûy ra .
2.Cho BN ñi tieåu / ñaët sonde tieåu
3.Tö theá BN naèm :
-Ngöûa khi löôïng dòch nhieàu
-Nghieâng ,khi löôïng dòch töø ít - trung bình
- Doác45 ñoä , khi choïc ñöôøng giöõa
 CHUAÅN BÒ BEÄNH NHAÂN
CHOÏN ÑIEÅM CHOÏC DOØ
-Ñieåm hoá chaäu :
Töø gai chaäu
tröôùc treân moãi
beân laáy 2 khoùat
ngoùn tay höôùng
leân treân vaø vaøo
ñöôøng giöõa
-3 cm döôùi roán
theo ñöôøng
traéng giöõa
Choïc doø döôùi höôùng daãn cuûa sieâu aâm
 TIEÁN HAØNH CHOÏC DOØ
Tuaân thuû nguyeân taéc voâ truøng vaø kyû thuaät
nheï nhaøng :
- Saùt truøng roäng vuøng choïc doø
- Röûa tay  Traõi champ  Saùt truøng laïi
- Gaây teâ
- Tieán haønh choïc doø
- Sau choïc doø : Baêng kín ñieåm choïc doø
- Ñaùnh giaù tình traïng BN , ghi hoà sô
SAÙT TRUØNG ROÄNG VUØNG CHOÏC DOØ
Traõi champ coù loå voâ truøng leân vuøng choïc doø
Gaây teâ ñieåm choïc doø
KYÛ THUAÄT CHOÏC DOØ
 KYÛ THUAÄT CHOÏC DOØ
Luoàn catheter phuû kim
KYÛ THUAÄT CHOÏC DOØ
KYÛØ THUAÄT CHOÏC DOØ
 KYÛ THUAÄT CHOÏC DOØ
Ruùt noøng kim , löu catheter .
 KYÛ THUAÄT CHOÏC DOØ
Ruùt dòch laøm xeùt nghieäm
 KYÛ THUAÄT CHOÏC DOØ
Laáy dòch laøm xeùt nghieäm

1.Sinh hoaù
2.Teá baøo
3Vi truøng
 KYÛ THUAÄT CHOÏC DOØ
Noái vôùi daây truyeàn dòch ñeå daãn löu
 KYÛ THUAÄT CHOÏC DOØ
Daãn löu dòch hoaëc laáy dòch laøm cell-block
Ruùt kim –Baêng kín ñieåm choïc doø
 Diagnostic Paracentesis
1. Position the patient in the bed with the head elevated 45° to 90° to
allow fluid to accumulate in the lower abdomen.
2. Identify the point of aspiration on either flank, usually two finger
breadths cephalad and two finger breadths medial to the anterior
superior iliac spine. An alternative location is in the midline midway
between the umbilicus and pubic bone. Although the midline is
avascular, the abdominal wall in the left lower quadrant is thinner, and
there is usually a larger pool of fluid than the midline (4). Be careful to
avoid abdominal wall scars, as bowel may be fixed to the wall. The rectus
muscles should also be avoided because the epigastric arteries travel
within the rectus sheath
3. Confirm dullness to percussion in the site selected for needle entry.
4. Put on sterile gloves.
5. Sterilize the site with an iodine solution.
6. Arrange sterile draping towels.
7. Infiltrate the skin and subcutaneous tissue with a local anesthetic.
8. Attach a 20- or 22-gauge needle to a 10-cc syringe. Spinal needles (3.5-
in. needles) are needed only in the setting of a large panniculus.
 Diagnostic Paracentesis
9. Insert the needle into the peritoneal cavity using a "Z-tract" to
minimize leakage of ascites after the procedure. To create a Z-tract,
use one gloved hand to move the skin approximately 2 cm in any
direction in relation to the deep abdominal wall, and then insert the
paracentesis needle. The skin is not released until the needle has
penetrated the peritoneum and fluid flows. When the needle is
removed, the skin slips back into its original position and seals the
leak.
10. When fluid is flowing, stabilize the needle to ensure a steady flow,
and attach a larger syringe to the needle. It is not unusual for flow to
stop as bowel or omentum are suctioned over the bevel of the needle.
When flow stops, twist the needle 90° and reinsert in 1- to 2-mm
increments.
11. For a diagnostic paracentesis, at least 25 mL of ascites is required.
12. Remove the needle, and place an adhesive bandage or pressure
dressing over the site. The patient may resume normal activities.
 Therapeutic Paracentesis
1. Obtain the necessary equipment including a paracentesis tray with paracentesis catheter
(7 in. long, with no. 14-gauge ´ 2-in. needle) and multiple 1-L vacuum bottles.
2. Prepare the patient as for diagnostic paracentesis. Select the paracentesis site as
described above. Clean and drape the selected site. Infiltrate the skin and subcutaneous
tissue with local anesthetic.
3. Place an intravenous heparin lock if an albumin infusion of 5 g for each liter removed
has been planned. Albumin has been recommended for removal of greater than 5 L to
minimize increases in renin and aldosterone, and, therefore, to minimize volume
depletion (5). However, no study has demonstrated a survival advantage for patients
who have received albumin.
4. Using the paracentesis catheter attached to a 10-cc syringe, slowly advance the needle
and catheter into the peritoneal cavity using the Z-tract technique. Intermittently
aspirate fluid until a steady flow is achieved.
5. Attach tubing to the catheter and insert it into a 1-L vacuum bottle, or attach to a wall
suction with a large canister.
6. Aspirate 4 to 6 L of ascitic fluid using this apparatus over 30 to 60 minutes.
7. Remove the catheter, and place a bandage or absorbable suture at the puncture site. A
pressure bandage may be applied.
8. Send a sample of fluid from each paracentesis for white blood cell count and
differential to detect the onset of unsuspected bacterial peritonitis.
HANDBOOK OF GASTROENTEROLOGIC PROCEDURES - 4th Ed. (2005)
Abdominal Paracentesis - Kimberly L. Beavers
 BIEÁN CHÖÙNG CHOÏC DOØ
1. Taïi choã:Xuaát huyeát da buïng ,Hematoma thaønh buïng
,nhieãm truøng, doø ræ dòch ra da .Taïo tuùi dòch choã choïc
2. Toøan thaân :-Ngaát do ñau ,shock phaûn veä do thuoác gaây teâ.
-Maát ñaïm do choïc doø nhieàu laàn
3. HC sau choïc doø löôïng lôùn  Taêng hoaït tính renin-
angiotensin seõ gaây roái loaïn tuaàn hoaøn sau choïc doø:
- Baùng buïng taùi laäp nhanh
- Haï natri maùu
- HC gan thaän .
4. Trong oå buïng :-Thuûng taïng roãng
-Raùch maïch mauù lôùn
-Chaûy maùu phuùc maïc töï phaùt
 NHAÄN XEÙT ÑAÏI THEÅ DÒCH BAÙNG
1. Dòch baùng traéng trong( ñaïm raát thaáp )
hoaëc vaøng nhaït trong .
2. Vaøng chanh: Dòch khoâng do taêng aùp cöûa, gaëp trong Lao,
K, vieâm phaûn öùng.
-Vaøng saäm( naâu ) :Thuûng tuùi maät
3. Hoàng ( HC > 10.000/mm3) : K, lao, vieâm tuïy caáp
xô gan coù roái loaïn ñoâng maùu.
4. Ñoû maùu khoâng ñoâng (HC > 50.000/mm3 ) :
K , chaán thöông .
5. Ñuïc nhö nöôùc vo gaïo:Döôõng chaáp
6. Ñuïc nhö muû :VPM
7. Dòch baùng maøu ñen:VT hoaïi töû ,hoïai töû ruoät
 XEÙT NGHIEÄM DÒCH BAÙNG
1. XN Thöôøng quy:
Ñeám teá baøo, Albumin vaø protid toøan phaàn
2.XN tuøy choïn :
a.LDH : Taêng cao trong K maøng buïng ,VPM thöù phaùt.
b. Amylase : Khi nghi ngôø baùng do tuî
c. Glucose :< ½ glucose /maùu => Nhieãm truøng
d. Caáy trong moâi tröôøng maùu ( 10 ml dòch mb vaøo chai mtcaáy )
3.XN ít söû duïng :
a.Teá baøo hoïc ( Cell block )ñoä nhaïy trong chaån ñoùan K maøng
buïng =58-75%
b. Triglycerid :Trong baùng döôõng chaáp TG cao gaáp 2 -8 laàn TG
huyeát töông hay TG > 1100 mg/dl
c.Bilirubin :Neáu Bili/ db > Bili /maùu = Thuûng tuùi maät / taù traøng
d. PCR lao :Döông tính ôû 30% BN lao MB
 5 BÖÔÙC BIEÄN LUAÄN DÒCH BAÙNG
1.Nhaän xeùt ñaïi theå :Maøu saéc
2.Tính SAAG : ≥ 1,1g/dl( Taêng aùp) hay < 1,1 g/dl
3.Protid DB : cao hay thaáp
4.Toång soá teá baøo baïch caàu ≥ 500 hay < 500 /mm3
Vôùi BC ña nhaân trung tính / lympho /ñôn nhaân
≥ 250 vaø öu theá hay < 250 /mm3
5.Keát hôïp xn khaùc: ≥
- Glucose, LDH ( VPMNK nguyeân phaùt hay thöù phaùt ? )
Vieâm PMNK thöù phaùt:,glucose thaáp, protein thay ñoåi
LDH cao .BCÑN > 250/mm3. Caáy > 1 loaïi vi truøng .
- Amylase,TG, Bilirubin .
- CellBlock
- PCR lao. ADA .
- Caáy
 CHAÅN ÑOAÙN NGUYEÂN NHAÂN
DÖÏA VAØO KEÁT QUAÛ XN
LAO : SAAG < 1,1g/ dl
Protein / db > 2,5 g/ dl ( Ñieån hình > 5g/dl)
BC > 500/mm3( > 300) ,Lympho öu theá
LDH db < LDH maùu
ADA > 40
K : SAAG < 1,1 g/ dl
Protein / db > 2,5g / dl . HC >1000 /mm3
BC > 500/mm3 ,Lympho öu theá
LDH db > LDH maùu .
Cell –Block : Coù teá baøo aùc tính
Baùng döôõng chaáp : SAAG < 1,1g/ dl
Protein/ db > 2,5 g/ dl
TG / db> huyeát thanh .
CHAÅN ÑOAÙN NGUYEÂN NHAÂN DÖÏA VAØO KEÁT
QUAÛ XN
Xô gan : SAAG >/=1,1g/dl
Protein / db < 2,5 g/ dl.
( < 1g/ dl => Nguy cô NTDB cao )
Suy tim : SAAG >/= 1g/dl
Protein/ db > 2,5g/dl
HCTH : SAAG < 1,1
Protein/db < 2,5g/dl
Ascites tuî SAAG < 1,1 g/dl
Protein/db > 2,5 g/dl
Amylase / db > huyeát thanh ( > 1000 U/L)
 PHAÂN LOÏAI NHIEÃM TRUØNG DÒCH BAÙNG
1. Dòch baùng vôùi BCÑN >= 250/mm3, caáy (+) vôùi moät loaïi
vi truøng vaø khoâng coù oå nhieãm trong oå buïng
=>VPMNK töï phaùt
2. Dòch baùng vôùi BCÑN >/= 250/mm3 ,caáy (-) vaø khoâng coù
oå nhieãm trong oå buïng .Ñieàu trò nhö VPM töï phaùt .
Vì caáy (-) coù theå do moâi tröôøng caáy/ söû duïng KS tröôùc ñoù .
Cuõng neân loïai tröø caùc nguyeân nhaân sau :
-K maøng buïng ,Lao mbuïng, vieâm tuïy, beänh taïo keo
xuaát huyeát vaøo trong dòch baùng .
3. Dòch baùng vôùi BCÑN </=250/mm3,caáy (+) vôùi moät loaïi
vi truøng => Du khuaån baùng .
PHAÂN LOÏAI NHIEÃM TRUØNG DÒCH BAÙNG

4. Dòch baùng vôùi BCÑN </=250/mm3,caáy (+) vôùi nhieàu

loaïi vi truøng
-Do choïc vaøo ruoät ( Thöôøng töï laønh ,hieám khi gaây
VPM thöù phaùt ),tuy nhieân neân choïc laïi ñeå xem ñaùp
öùng cuûa BCÑN vaø söï caàn thieát duøng KS
-Neáuchoïc laïicoù ñaùp öùng cuûa BCÑN  KS phuû Gr -
Gr(+) vaø kî khí.Choïc ñaùnh giaù sau 48 giôø ñt KS
5. Dòch baùng vôùi BCÑN >= 250/mm3, caáy (+) vôùi
nhieàu loaïi vi truøng vaø coù oå nhieãm trong oå buïng
=> VPMNK thöù phaùt.