XUAT HUYET TIEU HOA TREN VA DU6I ThS.BS. Dink Thi Ngoc Minh ThS.BSCKIL. Vit Quéc Béo myc TIEU Sau khi hoc xong bai nay, hoc vién cé thé: 1. Trinh bay duege dinh nghia ctia xudt huyét tiéu hoa 2, Trinh bay duge triéu ching lam sang ctia xudt huyét tiéu héa trén va xudt huyét tiéu héba dieéi 3. Lit ké duge cdc phuong tién chain dodn edn lam sang cita xudt huyét 4. Chan dodn duge mét truréng hop xudt huyét tiéu héa: chdn dodn xéc dink vj tri, chan dodn phan biét, phan loai mite a6, ngity co, chan dodn nguyén nhén. iéu hda trén va dueci NOI DUNG BAI GIANG 1, DAICUONG Xuét huyét tiu héa (XHTH) trén: tn thuong tir thye quan cho dén géc Treitz, bénh nhan GN) c6 thé vita 6i ra méu, i tiéu ra phan den hay ra méu 45 hog chi 6 6i ra méu & giai doan iu hofe chi cé tiéu ra mau, La m6t edp citu n6i hay ngoai khoa thudng gip va la bién ching ciia ahidu bénh. XHTH cé thé do tén thong trén duéng tiéu héa hofe ngodi during tiéu héa gay chay ttrumie 46 nhe dén ning cé thé gay s6c. KHTH cé thé xay ra moi lita tudi, thudng gip 6 ngwoi lon higu hon tré em, nam nhiéu hon nif. XHTH chia lim 2 logi: + XHTH trén: tn thong tir thyre quin cho én géc Treitz, bénh nhan ¢6 thé vita 6i ra méu, di tiéu ra phiin den hay ra méu dé hoi chi cé 6i ra mau & giai dogn dau hog chi cé tiéu ra mau + XHTH dudi: tén thuong tir géc Treitz tro xudng, BN thurdng tidu ra mau d6, 06 thé di cau phan den. 2. LAM SANG 21 ‘Tien cin ALL Tidn cain bénh n in vé nhting lin XHTH truéc néu o6, vi 60% bénh nh je init huyét nay o6 thé chy mau eting mot vi tl, MBC khéc, khei th : ry mau cing oe ‘edith nguyén nhin gay xudt huyét hay nhting vin dé anh hudng dén vige dieu tr. Mot s6 tién can goi ee a goi ¥ nguyén nhfin ee XHTH do gifin vo tinh mach thye quan hay finh mach phinh vj gap 6 BN cé tién cin. bénh Jin (BN) cé tin cin XHTH trén thi Khai thc tién efin bénh 6 thé gitip an hay nghién nrgu Scanned with CamScanner+ XHTH do loan sin mach méu gip & BN 6 tién cin bab thén, hep dng mach chi, gitn tinh mach gay xuat huyét cé tinh di truyén - XHTH do loét da day ta tring gip @ BN tién cin nhiém Helicobacter pylori, ding NSAIDS hay hit thudc - + XHTH do bénb ly 4c tinh thuéng gip @ BN 6 th6i quen hiit thudc lé, nghién regu, hay nhiém Helicobacter pylori. Chi ¥ hoi nhiing bénh nén anh huéng én xi tri XHTH nu: + Nhting bénh khién BN dé gidm Oxy méu (vi dy: bénh mach vanb, bénh phdi). Nhiing BN nay yéu cau duy tri mite Hemoglobin cao hon nhiing BN khéc + Nhing BN dé qué tai tuan hoin khi duge truyén djch hay mau (bénh thén, suy tim). Khi truyén phai theo doi ky ~ Nig BN cé tinh trang chay mau khé kiém soat do 6 bénh vé réi loan déng cim méu, suy gan ning, Bi khi cn truyén thém tiéu cau hay huyét tuong tuoi d6ng lanh ~ BN dé bj hit sic (nhu hén mé, bénh nfo gan), Nhting BN nay can xem xét dit n6i khi quén. 2.1.2. Tién cén ding thude Nén lun y nhiing thuédc BN da sir dung: + Ding Aspirin hay NSAIDS gay loét da day, td tring ~ Nhiing thuéc gay téa thuong thye quan (Kali, phosphonates) + Thudc gay chay méy ning hon: thude Khang két tap tiéu cdu (vi dy clopidogrel), thuée Khang déng 4 ~ _Nhitag thude géy anh huéng biéu hign lim sing nhur ding sét, bismuth, 2.2. Céc hinh thite xudt huyét tiéu hoa 221 Nonramdu + Vi tri: chic chin la XHTH trén S6 Iugng thay d6i Tinh chat: méu 46 tuoi, 48 bim, nu den, cue, Tong Vin thite an do tae déng cua acid clohydric, pepsin va mau tao thinh hematine Phin biét v6ichay mau cam, in tiét canh, ho ra méu (méu 48 tuoi, bot, khong o6 tht 3, pH kiém). 2.2.2, Tiéu phin den + Vitel: thuong XHTH trén, cé thé do XHTH duéi Tinh chét mau ty vio; vj ti chay mu, thai gian di chuyén trong rugt, lugng mit Goi edn mt lugng méu 60 ml, thoi gian trong dudmg tiéu ha & gid s& gay teu phi den, XHTH trén voi lugng 200-400 ml sé gay tiégu phan den giéng nhu hic in. duéi o6 thé gay tiéu phan den nhung hiém khi nhu hic in. Tiéu phan den cé thé x4Y ta don dc hay sau khi 61 mau hay déng thai. Scanned with CamScannerCin phan biét v6i tiéu phin den do thuée (bismuth, sit, than hoat), téo bén. 223 Tidu mu dé = Thudng do XHTH duéi hay d6i khi do XHTH trén Ing nhiéu va nhanh, 10% XHTH trén gay tiéu mau dd «Tinh chét: méu 46 tuoi, lugng it hay nhiéu, mét hay nhidu lin trong ngay - Cin phin biét tigu phan 6 do uéng thuée nhw rifamycine, 224, Trigu ching co ning khéc - Dau thugng vi, dau bung, séi rugt = Hoa mit, a tai, chong mat, khat nude, 23, Kham thie thé 23.1. Trigu ching mat mau cap + Daniém: da lan, niém nhgt, tring béch = Mach: nhanh nhe, khé bit + Huyét 4p: gidm - Tinh trang tri gidc: tinh, mét, li bi, vat va. 23.2. Phat hign cdc trigu chitng ca bénh cin nguyén + Déw higu bénh gan man - Dékhing thanh bung + Thm tryc trang: thi thugt phai lam trong moi trudmg hop XHTH dé dénh gid tinh chat phin va phat hién tin throng ¢ hau mén tryc trang. Dau higu séc = Thay di huyét dng, thé nhanh néng va yéu - Huyét dp tut, kep, hay bing 0 + Chi lan, 16 Han. 234, Cie tigu ching kde + Sét: 80% trudng hop XHTH trén oh te gi | i * Hi ching nguy kich ho hip cfp o6 thé xiy ra trong 24 gid ca sbe gidm he eh + Thuyén tic phéi: Wet + Thiéu nigu wt + Hon mé gan. we 233. Sonde mii da diy Paria ae vata Khong nén dang & moi trang hop XHTH trén, Chi nén ding Khi cn loai bd ‘cde vat cén, ' tuoi, mau cye khi ching lm edn tri ndi soi. Scanned with CamScanner3. CANLAM SANG 3.4. Xét nghigm mau va djch tiét 3.1.1. Dung tich hong cau Dung tich hing ciu do ngay trong lite chdy may hay ngay sau 46 khéng phan anh ding lugng mau mit. Can khoang 8 — 12 gid dé co thé diéu chinh nude vao gian bao mdi phan anh ding lrgng mau mat, Do d6, phai theo doi dung tich héng cdu nhiéu lan trong ngay. Trung binh cit mét $00 ml méu, dung tich héng cu gidm 3%. Trung binh cit truyén 500 ml méu, dung tich héng cau ting 3% Hong cau gidm, hong cau Indi ting trong nhing ngay sau Tiéu cdu ting, bach cdu ting khéng qué 15.000/mm?, 3.1.2, BUN ‘Mau chay ra duge hap thu khi qua doan rut non. BUN tang trong % tnrdng hgp do ting azot mau truxéc than (do gidm thé tich), tiéu héa cdc protein va hap thu cdc sin phim ctia nitrogen. BN bj XHTH trén cé ting ty 1 BUNYcreatinine hay urca/creatinin (>20:1 hay 100:1). Ty I nay cng cao cng c6 kha ning xudt huyét ti dung tigu ha trén. 3.13. Clic xét nghigm khde: ty bénh cénh lam sing. 1éu BN mit mau ning. i, Khi mdu dong mach: 3.2, Chan don hinh anh 3.21. Xudt huyét tiéu héa trén Oi soi da diy: lm som ngay néu duge (trong ving 24 gid) trong moi tnring hyp XHTH tréa. NOi soi gitp ta théy hinh anh sang thong va can thigp thi thuét cm mau ngay. Céc chin dodn hinh dink khéc: chyp mach méu, vién nang n6i soi khOng day (thoi gian ehi hinh 18 20 phat), NOi soi dai trang: khi BN di clu phan den nhung n6i soi tiéu héa trén am, 3.2.2, Xudt huyét tidu héa duedi ; Gi soi dai trang: rit htru {ch trong chén dodn vj tri ctia XHTH duéi, sinh thiét Lim giai phi bénh va 06 thé can thigp digu tri mot s6 trudng hgp. Tuy nhién, BN cdn phai chudn bj rugt ky cing va khi tién hanh ngi soi phai gay mé. Chup cOng huéng tir (Radionuclide Imaging): xéc din duge chiy méu téc 46 0,1 - 05 mL/phiit, Id xét nghigm hinh anh nhay nbdt trong chén doén XHTH, Tuy nhién, tinh trang chay miu phai dang dién tién thi mdi cé thé chin dodn dugc. Chup mach méu cit 16p (CT angiography), chyp mach méu: e&n phai mét mau v6i téc 66! ; 1 mLiph m6i ding dé chan doin duge, trong truing hgp khéng xée dah durge vi tl xu ryét, NGi soi rut non bin, tiXHTH, 8 vign nang hay phuong phdp double — balloon cfing cé thé tim dug°¥! Scanned with CamScannerNhing trong hp vj tri xudt huyét da ngumg chay, 24-48 gid. 4, CAC BUOC CHAN DOAN 4d. Chin dodn vj tri XHTH Chin doin XHTH trén hay duéi diva vio tinh chit nén ra méw hay di clu ra méu dang néo 42. Chin dodn mite 49 XHTH ‘ - Céc yéu t6 tién Iugng ning ~ XHTH khdi phat lic nim vién = Tudi> 65 + Cébénh n6i khoa kém theo: suy tim, bénh mach vanh, suy thin man, viém gan ep, xo gan + Tién sir vo tinh mach thye quan Séc hic nhap vién + Nén méu tuoi hay dit sonde da day ra mau tuoi Tigu méu tuoi 8 at + Ure va creatinine ting - Men gan ting. Kkhé phat hign. Nén theo dai BN trong Bang 45.1: Phan 46 nang xudt huyét tiéu hoa (Nguén: Textbook of Clinical Gastroenterology and Hepatology, 2%, Wiley-Blackwell C1 Hwakey) NHE- ‘TRUNG BINH NANG Maumat =| < 20% 20-30% > 30% 7 6, hoi i Met mai, chéng mat, viimd | Vat v8, bot rit, Khat ing trang | Tét, hoi met mdi y ue wee Da nlém Binh thuong Xanh Xanh xao, chi lanh : - Mach > 120 Sinh higu | Mach < 100 Mach: 100 - 120 Hayét 4p: binh thudmg | Huy&t 6p kep,Tittest (*) Huyét 6p tut S > 30% 20-30% < 20% | Can tu y . Tée 49 méu mét va gmg méu mét Jd quan trong nhst Gngudi te khde + $00 ml miu trong 15 phiit: 06 thé khong 06 trigu chting &4 4p, mét moi ~ 1,000 mi mau tong 15 phi: nh im aan on + 2,000 mi mndu trong 15 phit: se nding, YORE: 19 Scanned with CamScannerSau d6, phai phan ting nguy co XHTH theo bing Rockall ROCKALL Bang 45.2: Phan tang nguy co - {(Nguén: The Washington Manual of Medica! therapeutics,33%, Lippincott Willams & Wilkins) 1 4iém 241m 3.aiém Tudi 60-79 >73 inh higu | Mach > 100 | Huyét ép max < 90 mmHg Bgnh ai 4-Suy tim 4-Suy than kim 2:Nhdi mau co tim-Thigu mau co tim 2-Xo gan '8-Bénh ni khoa khéc: RLOM, tidu duémg, | 3-Benh dc tinh COPD, THA, cvdng gidp, tai bién mach mau no *Nguy co thdp: 0-2 dim, Nguy eo cao: 3-7 diem Bang 45.3: Phan tng nguy oo theo Rockall (chung) {Nguén: The Washington Manual of Medical therapeutics,33%, Lippincott Willams & Wilkins) 0di8m 1diém 2diém 3diém Tudl 60-79 >79 Sinh higu Mach> 100 | Huyét 4p max < 100 mmHg Bgnh di kam 1-Suy tim 4-Suy then 2.Nhbi méu co tim-Thigu méu_| 2-Xo gan cotim 3-Bénh &e tinh 3-Bénh di khoa khéc: ri loan ong mau, tiéu dong, COPD, THA, cvdng gidp, tai bién mach mau no Két quaingt | Malory Wels, | Cac chdn | Bénh dc tinh ung tidy hoa sol khong tén | doan khac thuong Chay mau Mau trong éng tidu hoa Fi, trén ngi sol Fila, Ib (phn 49 Forrest) Phan ting nguy co theo UCLA. + Tudi>6s + Tut huyét 4p tu thé + Méu tuoi ra tir sonde da day Bn kém theo: suy gon, sy thn, bgnh mgch vin Chi can hai yéu 16 tra én ta nguy co cao, 790 Scanned with CamScannerBang 45.4: Phan ting nguy co Blatchford (Nguén:The Washington Me Medic 1, Lippincott Wit ington Manual of Medical therapeutics,39% 1, ae * Lippincott Wiliams & Wikins) 8) [Hien tal ‘Siem [HuySt ap im tha +". 100 - 109 90-99 1 <90 2 BUN 6,5-7,9 mmol 8-9,9 mmol! 40 -24,9 mmol 225 mmol/l Hemoglobin & nam 12-129 gid 10-11,9 g/dl 3 <10.g/dl Hemoglobin 6 nt 10-11,9 g/dl < 10 g/dl Nh@ng théng sé khéc & hign tal Mach 2 100 icdu phan den Ngat Bénh gan ‘Suy tim *Nguy co thép: 0 1 aim. Nguy co’ cao: > 2.além tuy nbign 06 thé chdy ni. Trong Phai pha 90% XHTH 6 thé ty cdm, ; i phfin ting nguy co vi 80-9 ia IT cy i oo aay mig vi gi So som one 6 hing trum, . ig hop phan ting nguy co cao ty cfr " thin, chodng khéng h&i phue, dé tir vong nén cin phat én dinh huyét 6 ~8 gid, 43. Chan doan xudt niét tiéu héa cdn dang tig 43.1, Xudt hide tiéu héa dang tip dién __ Dinh gié XHTH dang tiép dién hey Iie 46 khét, nude tid. andy ib sin tn dt 'Ud5 nging chay. ip dign hay tai phat fp, da niém, én djnh dua vio tinh trang mach, huyét dp, iu tang c6 thé daniém bing, 6 nude tiéu lai, coung lurgng nude tie a n, da ni 7 TA Scanned with CamScanner al6 the Néu cfc déw higu ngay cang x4u di, nghia 1 sau vai gid diéu tri mdi khoa (bi mau va djeh) 1 XHTH dang tiép din, Néu nhu dng nut binh thurdng (10-20 Lan/phat) c6 thé la dau higu mau ngung chay, Cac déu higu cf lim sing cho thay XHTH tiép dign: = Dung tich héng edu, héng clu khong ting di da truyén mau + NOi soi thdy 6 loét hay gidin tinh mach thyc quan cdn dang chay mu. 4.3.2. Chin dodn tai phat Khi BN 4a én dinh vai gid hay vai ngly sau dt nhién nén ra méu, tiéu ra méu Iai, hay dt nhién 6 dau higu toan than cla XHTH. 44. . Chin doan phan bigt Hora méu + Chay mau cam Tiéu phan den do thuéc + Phan nhiéu mat + Phin bén, 4.5. Chan doan nguyén nhan ‘Céc nguyén nhan thuimg gip 45.1, Neuyén nhin chung cia XHTH trén vi duedi: thurong do r6i loan co ché. déng cam mau 4.5.2, + Giém tiéu cau + Sét xudt huyét + Bénh Hemophilia + Suy gan + Do thiéu Vitamin K ~ Do diing thuéc chéng dong (Warfarin, Heparin), Nguyén nhén XHTH trén + Thye quan H6i chimg Mallory weiss ‘V6 gian tinh mach thc quan, tinh mach phinh vj + Loét thyte quan + Da day td tring + Loét da diy - ta trang ‘Ung thu da day/Polyp da day ta tring ‘Viém xudt huyét tigu hoa 8 Sang thurong mach mu; Diculafoy, Hemangioma, loan sén mech méu Chay mau duang mit. 22 Scanned with CamScannersa. Neuyén nhiin XETH dedi Ruét non: hiém - Unigtnon - Laorugt = Viém rugt hoai tir - Dei tring Bénh viém loét dai trang va bgnh Crohn Viém dai tring do xa trj ung thy ving chau - Lyamib = Viém dai trang do thiéu mau nudi = Chay méu tii thira dai trang = Ung thu dai tryc tring - Polyp dai tryc tring - Ti + Cée sang thong mach mau: Angiodysplasia. TOM TAT BAL Xuét huyét tigu héa 1a tinh trang mdu chy ra khdi long macl ngoti bing efch nén ra méu hay tigu ra mau, Litmt efp otra ngi hay ngoai khoa thing bién chimg cia nhiéu bénh. XHTH chia lim 2 loai: XHTH trén va duéi. Céc bude chin doin XHTH gém: chin dodn pI chin don vj tri XHTH, chdn doan mite 46 XHTH, chan dogn nguyén nbn, Ja vio durimg tiéu héa va thai ra gip vala han bigt xudt huyét c6 phai tir durémg tieu héa, chin doin XHTH cén tiép dién hay khong, TUKHOA i ' si quan. Xudt huyét tiéw héa, thang diém Rockall, thang diém Blatchford, n6i sol de diy thve@ CAU HOI TY LUQNG GIA avs 1. Héitién c&in trong chin doan XHTH him myc tiéa, NGOAT TRE: A. Chan dodn vj tri B. Chin don nguyén nhan C. Tim bénh nén D. Chan doén mite 46 XHTH Can phan biét tigu phan den voi: A. Bismuth 2 am Scanned with CamScanner