AN TICH XET NGHIEM SINH HOA GAN PHAN TICH XETN TS.BSCKI. Tran Thj Khanh Tieéng MUC TIEU Sau Khi hge xong bai nay, hoc vién o6 thé: ; a iy 1. Ké chege ode xét nghiém sinh héa gan dank gid ton thong te ma, 16n thheong té bao gan vis suy chite nding gan 2. Phan tich dieoc gid tr} ALT va AST theo 3 burée 3. Ké diege nguyén nhdin ctia ede kiéu xét nghigm sink hoa gan bdt theéng M6 ta duege cdc dic diém ctta cdc kiéu xét nghigm sink héa gan bat thueéng. NOI DUNG BAI GIANG 1.MO DAU Cac thiy thuée tiép cn véi céc xét nghiém sinh héa gan bat thuéng trong thy hanh lim sing hing ngiy. Gié tri bat thudng cia céc xét nghiém sinh héa gan c6 thé gay ra béi nhiing bénh ly lién quan dén gan hay khéng lién quan dén gan, thm chi chi ld nhiing thay ddi sinh ly binh thudng. Do 46, bén canh hoi bénh va khém lim sing ky luéng, phan tich cdc xét nghiém sinh héa gan mét céch hgp ly sé gitip cho céc bic sf dénh gié bénh gan chinh xéc hon. Cach tiép cn cia ching t6i phan Idn dya vio huéng din lam sing nim 2017 cha Truong phai Tiéu héa Hoa ky) (American College of Gastroenterology: ACG) vé danh gid cdc xét nghiém sinh hhéa gan bit thuong. 2. PHAN LOAI XET NGHIEM SINH HOA GAN ames ic at i hi 3 nhém: (1) nhom ting cao trong huyét thanh phan éah tia ee ne a, 2) mii angio trong huyét thanh phn anh tinh trang i mét vi @) a6 sinh héa gan thuong sir dung ie ‘the me nh chinh xc ci hai tinh trang trén. Cac xét nghiém dénh gid tinh tang tin thuem wa ai lim sing duge phin lam 4 nhém nbur sau: nhém Transpeptidase (GGT), hm dash gi tinh ernest haar aim ALT va AST, Sch gd Kha nig ner nes thzons té bio gan nh ee aminotras ee gin ALT vA AST, dish g ng tiét va thai de gdm Bilirubin va Amoniac huyét thanb V4 8 chic ning gan gdm Abumin huyétthanb, Prothrobia time/INR- 2.1. Dinh gia tn thuong & mat i is 3 Ton t i is , éng gan ieee ‘oe a ae. do te mat ngoai gan nhu tic nhénh gan tréi, nhénh gan Pal Joan vin chuyén mat (Khon; te ), dng mt chi hofe the ede dung mat nhé trong gan hey 7! 26 bit kj mic d6 nio th beg aa) BEYOng tigu quan mat, Tan thug tt mft c6 thé XY & mAt lb ALP, GGT va 5 na ca mit cho dén dng mat chi, Xét nghigm dénh gis Hn 98 meee ae ole GOT va 5" nucteotidase gitip xéc nhén ngvb” & rucleotidase ft khi duge thye hign, "® °© Phong xét nghigm hign nay tons KH 710 Scanned with CamScannerAlkaline phosphastase (ALP) Khi tiép cfn bénh nin cé ting ALP, bude dau tién clin xe nhfn ALP cé nguén gée & gan hay noi khée. Dé xéo nhgn ALP c6 nguén goc ti gan, nén kiém tra GGT hode 5'- nucleotidase huyét tanh. Tang ALP kém ting GGT cho thiy ngudn géc ALP tir gan, trong khi ting ALP nhung GGT hoe 5 nucleotidase kh6ng ting, nén nghi dén céc bénh xwong ah: giy xwong, lodng xuong, cubng cin gidp, cudng giép, bénh Paget xuong, sarcom xuong va ung thu di cin xwong, Gia trj binh thu’ng cia ALP 1a 20 — 140 IU/L, tuy nhién 6 thé thay di tay phong xét aghiém. Théi gian ban hity cia ALP 14 7 ngay "!, noi dao thai ALP vin chwa r6. Vai trd chinh cia ALP huyét thanh 1a dau an ca tn thong tr mat. Tuy nhién, ting ALP la mét déw hiéu khéng thuing gap nhw ting aminotransferase, GGT va cé thé gap trong nhidu bénh ly khéc ngodi gan (Kai GGT khéng ting). 75% trrng hop ALP ting hon 4 lin gigi han binh thuéng trén (Upper Limit of Normal: ULN) trong tén thuong i mat, bénh tham nhiém gan (ung thw gan, ung thy di cin gan, amyloidosis, u hat, sarcoidosis) va bénh xuong. Host tinh ALP duge ghi nhén c6 46 nhay 90% dé phat hign ung thw di can gan. Trong tic duéng mat, 90% trrdng hgp cé hoat tinh ALP ting it mhat trén 3 lin ULN. Tuy nhién, mite dé ting ALP huyét thanh khéng gitip phan bigt & mat agoai gan voi tr mat trong gan cfing nh nguyén nhan gay tr mat. ALP khéng dic hiéu trong i mat, ALP cé thé ting nhung 6 mirc d6 thdp hon trong cdc bénh | gy tn thurong té bao gan nhu viém gan do virus, viém gan do rugu, viém gan ty mién.... Trong tn throng té bao gan, ALP 6 thé ting nhe nhung duéi 3 lan ULN, do sy phéng thich ALP cé sin trong té bao gan, khong phdi do ting ting hyp nhw trong ton thuong t mat, Trong truéng hop bilirubin va aminotransferase (ALT va AST) khéng ting, ALP cé nguén géc tir gan ting ggi y tt mit sém thuong do téc éng mat ban phan va bénh gan tham nhiém ({t gp hon)", ALP tang tren 3 lan ULN cé nguén géc tir gan 1a dau 4n chuyén biét nhdt dé dénh gid tn thuong tr m@t. Gamma-glutamyl transpeptidase (GGT) GGT hién dign trong huyét thanh cia ngudi khde manh véi ngudng binh thuong la 12-32 TUIL. Thai gian bén hy clia GGT 14 17 - 26 ngiy. Céc yéu t6 anh huéng host tinh GOT gdm: gi6i (nam cao hon nf), tudi (GGT ting khi trén 40 - 50 tudi), chiing tc (ngudi da den cao hon da tng hay da ving), hit thude Id (ngudi hit thuée ¢6 GGT cao hon nguéi khéng hit thuéc 14) GGT 1a xét nghiém khé nhay 48 phat hign bénh gan mét, nhung khéng chuyén bigt cho bénh gan mét, GGT cé thé ting trong tat cd cdc loai bénh gan, nhung ting cao hit trong bénh gan regu VAG mat trong hog ngodi gan. Trong tén thong gan do rugu cp, GGT ting rat cao thyéng trén 1000 IU/L, cao hon AST va ALT. Trong tr mit, ALP chuyén bigt hon GGT, nhung e6 the it nhay hon Gar. GGT khéng chuyén biét cho bénh gan mat, gié trj lm sing chinh cia GGT lé: (1) Xée dinh ngudn géc ting ALP do bénh ly gan mft. ALP ting nhung GGT khéng ting 8%p nhimg bénh nhdn bj bénh ly xvong. ; 2) GGT ting goi y viém gan nugu elp khi GGT ting cao kém ting AST véi ts ASTIALT > 2. Ngodi ra, GGT con gitip theo doi dap img ditu tr] bénh gan rgu khOng bién ching ©. ™ Scanned with CamScannerGGT huyét than c6 thé ting trong cdc bénh ly kha bao gém te oe eS tn, suy than, bgnh phdi tic nghén man tinh, dai thio duong va nghign rugu. es oa aa ps om tim thay 6 nhiing bénh nhén ding cae loai thuéc nhw phenytoin iO eA a ae e nee i ete GGT bj han ché. GGT ciing tang tam thoi & nhiing ngudi ding mot 86] ce ee m in hole phenytoin, thude chéng co gist, ung thu, chéng tram cam. Tr 10 din a ngui ong, ty Ie 7-GT cao gp 2 dén 3 lan mnie binh thug ma kh6ng c6 bat ky bénh ly ndo. 2.2, Danh gid tin throng té bio gan Céc aminotransferase 1a chi diém rat nhay aspartate aminotransferase (AST) va alanine amin gan, co tim, co xuong, thin, no, ty, phéi, bach J Trong khi d6, ALT chii yéu durge tim thay & gan. Mire d6 tan thurong té bao gan tong quan kém voi nguéng aminotransferase huyét thanh; ngoai ra, ngwong aminotransferase huyét thanh cé it gid tr tign Iugng vi gan cé thé hoi phuc hau nt céc dang tén thuong cap tinh, Gid tr] binh thuing va céc yéu t6 anh hwéng oat tinh cit céc aminotransferase trong huyét thanh phan anh téc 6 aminotransferase duge dua vio va léy ra khdi bé twin hoin. Sy dio thai cia cdc aminotransferase huyét thanh twong ty hu eée protein khéc va lién quan dén qué trinh dj héa boi hé théng luéi n6i m6. AST dugc dio thai nhanb hon so voi ALT, thoi gian ban hiy cia ALT 1a 47 gid trong khi AST 1a 17 gid (a, ‘Tuéi, gidi va BMI anh huéng dén hoat tinh ALT, AST trong huyét thanh. ALT, AST cia nam gidi cao hom nit gidi va ngudi c6 BMI lén hon 6 néng 49 ALT vi AST cao hon. Hoa tinh ALT, AST ting din tir tudi thiéu nién cho dén 60 tudi, sau d6 c6 khuynh hudng giém dan 7, Tit ning nghién ctu tnrée day, hung din nfm 2017 eta Trxdng phi Tiéu hoa Hoa KY (American College of Gastroenterology: ACG) xéc dinh ngudng ALT & nguéi khoé manh binh thuong va-khéng c6 eéc yéu t6 nguy co bénh gan ld 29 —33 U/L d6i véi nam va 19-25 U/L ai v6i nt (bing 49.1), ACG cling xéc dinh ALT, AST tang trén nguéng ULN & ngudi khOng 06 yeu ny cg bénh gan lién quan dén tang ty I¢ tir vong lién quan dén gan dya vio céc nguyén ciru 6 sang 49.2. trong danh gid ton thuong té bao gan bao gbm otransferase (ALT). AST duge tim thay trong néng clu v6i hoat tinh theo thir ty giam din, Bang 49.1: Cac nghién ciru v8 ULN va ALT eae NgwéngULN ALT Ngwéng ULN ALT tet i) Bin ugn Newsnet a a ilo 019) owns 0s aowun Cio ua enti Brande bint nrc OH fea 421UN onamv6iBM'$23 31 LUN &n0 vol BM VAESIUntuah> 23, weaalunndueMt>z3 OO MUUbHeh ain HCY Prat cx (24) mien an 91 o iu ty din 38 tha kno ee 251 TBtedbgnh 6 ain Did gan bi tng ae za1un 221 Do 1gu ir NHANES e x un : ib ti Knog ob ay kde BL ‘ALT, ala amincansttase: erase; AST, aspartate aminotransferase; BM, body mass Index: ULN, upper lint of normale, ene 8 72 Scanned with CamScannerBang 49.2: ALT va ti vong lén quan bénh g jan pldm eft ALTIAST Mire ALTIALT lim ting uni ae _ nguy 66 ti vong, Plats ea asrie “AST 18 “at : Sit vl te aint te veng ALT + ae ee ot yong eo gen 3g dOs cae tSoramage : ct ee (15-258)6n0 es : ees Aur 45—e0 wn ae Lee, 08.29) 45 UN par, 29108 — tae (og 35 28=881UNend. i 2, M2 a a 12 omatai tH ‘atsounsnan ioturend | NT220NN Onan urn pain Tr no 2 veng equ tiga suit Evert (30) ‘tar nipdnslrese AST, eeparaleamitanseran:ULN upper init froma tg ey. ‘Ting AST v8 ALT of thé xdy rao nig bénk nhfn bj bénh ly Geo. Teng dang thoi creatine shokinase (CPK), LDH hoi aldolase cho thy AST, ALT ting cé nguén gbe chi yéu 6 co. Ngay sau hi chén thuong co bap, ty s6 AST/ALT thug > 3, kéo dai trong vai ngiy, do suing AST gidm nhanh hon ALT (thoi gian ban hiy ta AST 17 gig mhanh hon ALT i 47 gid) séntjsény gidm sau vai ngay. Mire 46 ting cha AST ‘yi ALT khéc nhau. AST ting tir 235 VL és 10.000 TUML trong Khi ALT ting tir 115 TUL dén 850 IU/L. “Aminotransferase tng con BBP trong suy gidp, cudng gidp, suy thuong thin, nhiém tring. é phan tich gid trj ALT va AST trén the hanh lam sing, 3 bude: (1) ALT va AST cé ting khéng? ste Theo ACG 2017, tht ca cdc trrdmg hop ALT, AST trén ‘ULN oF as ve a fis dhivti nt) nen dg efe ty tube nh gi hom na v2 BEDS ENE se eee. Tuy Hie, ‘quan dén gan, Nhu vay ALT, AST durge xem ya ting khi 1én hon gid is) i gutng ALT, AST binh thudng cé thé khong Joai trix duge bénh gam dang ke. @) Mie d6 tang ALT va AST ( Vigm gan cép: ALT, AST ting c20 thug (omvin do HCY, ALT va AST thing HE who VAAST ting rat cao thurdng > 25 lin ULN. Ty Vigm gan man: ALT, AST thuéng ting mite 46 nhe be Aaa: Tyy nhién, trong dgt bing phat cfp cia viem Ba" man (hepati viém gan cd, Di véixo gan; ALT, AST ting nus vier BB ae i gon rugu: AST ting tir2~ 10 lin ULN, thu 10 lin ULN. Tr008 vig ga clp do vin 1g cao). TOMB viém gan c&P do thude, dé #, UA). LN, (thug < 300 4 < 10 lan ve a ALT 6 hu f thé tang. 6 the HONE TY 300 Uils ALT vn GOT ane 73 Scanned with CamScanner6 ‘onalcoholic steatohepatitis: NASH), ALT mu ieee areety 0 U/L va ALT > AST. a ‘AST, ALT ting rat cao thuémg > 50 tn ULN, aty van sau d gidm nhanh Khi tinh trang huyét d6ng ca ALT va AST va ty sé ALT/LDH < 1,5. ‘Trong viém gan hid AST thudng ting <4 lin ULN, ‘Tén throng gan do thigu méu ove v6: tn thuong gay ting men gan ca0 nat, tuy ahi thign, LDH thudng ting sm hom, tang 20 hon Ty sb ASTIALT . To ASTIALT 4 nguoi binh thudng khong 08 vi rahe ahd hon 1. 6 mét s6 tnring hop, t 86 nay thay 46i lin hon 1 gitip goi y chdn doan mot : bénh gan. : ‘Trong viém gan rugu, thudng ty so AST /ALT > 2. M@t phan do ALT ting tong 46i thép so v6i AST vi thiéu pyridoxal-6-phosphate trong gan & ngudi nghign nrgu, day 14 mgt dng yéu té cho hoat dng cla ALT. rong xo gan, ty s6 AST/ALT thuéng >1. Tuy nhién trong tnréng hgp xo gan khéng do nugu, ty 88 AST/ALT hiém khi > 2. Trong m6t nghién cifu trén 139 bénh nbn, ty sé AST/ALT trang binh cao hon & nhiing bénh nhan bi xo gan so véi nhiing ngudi khdng bi xo gan. Do 6, kai AST/ALT > 1 6 ngudi khong nghign raga, ching ta nén xem xét kha ning bénh nhin bj xo gen, gc bigt néu c6 tinh trang tiéu cu thip duéi 150. 000/mm?. ‘Hiiu hét ede bénh gan cp hay man Kkhéc nhu: viém gan do virus, NASH, viém gan ty mi Hemochromatosis, téc mit...ty s AST/ALT <1. 2.3. Dénh gid kha ning tiét vA thai de Bilirubin Gia trj binh thuémg cia bilirubin toin phan (TP); 0,8 — 1,2 mg/dl, bilirubin tryc tiép (TD: 02 - 04 medi, bilirubin gidn tiép (GT); 0,6 - 0,8 mg/dl. Img/l bilirubin tuong duong 17 micromol/. Bilirubin TP ting > 2,5 mg/dl gay ving da; ting 2 — 2,5 mg/dl chua gay ving da eo! 1 ving da duéi lam sing. Sena iee age | Ty 86 bilirubin T/ilirubin TP <20%: ting bilirubin GT wu thé gp trong tin huyds mith ube gly edn 6 sy qué tinh thu nh bilirubin GT vao gan hay lam giim kha ning két bep ¥% acid glucuronic, h6i chimg Gilbert, Crigler- Najjar, Bilirubin TT/bilirubin TP > 50%: ilirubi y v i 4: ting bilirubin TT wu thé gap trong cdc bénh ly gly ‘°° thuong tai gan hay tic nghén dung mgt ngoai gan, ap trong oie Pe Bilirubin TT/bilirubin TP 20 — 50%: oy ga IF gay tén thyong tai gan. ting bilirubin hén hgp thudng gap trong cf b Té bio gan bj tén thuon; { lim anh slucuronic va gidm kha ning te bi ee bio ‘On hon kha ning tiét bilirubin i kha nding tiét bilirubin TT bi i, A i acid n anh huéng dén kha nang két hgp ota bilirubin GT voi ae ilirubin TT ra tiéu quin mat, Kha ning két hop thuons : trong céc bénh ly gay tén throng tai gan. Tang bili iu bln gp kh ed hai ud eed en UemE iu hom so vei ka ning két hop va HO Ls linet cra ua trinh két hyp va tiét bilirubin bj anh hudng nhu nhau. 4 Ii, do 45 KGa gp ONS Ba Lat tba thong: tBa thuong té bao gan v2 in hues P Phin bigt hai lopitén thuong nay, ma phéi da vio ALP, GOT at oh 14 Scanned with CamScanner' bilirubin c6 ¥ nghifa tién lxgng be : ay Mite 46 tng gng bénh gan. Mi Ree ea a thy theo nguyen nan: Ge d6 ting bilirubin o6 thé kde Trong tin huyét bilirubin TP hiém khi vgt qua 5 mg/dl H6i chimg Gilbert itubin < 6 mg/dl, Crigler-Najjar I: Bilirubi a Crigler-Najjar I: Bilirubin ti 6 dén 25 mg/dl, Dubin-Johnson SBeae mgdl, mg/dl vi hoi chimg Rotor: Bilirubin < 10 mg/l 2 Bénh nhu mé gan, tic mat ngoai gan do s6i, Bilirubin ting thép h sith mit do bénb I &e tinh, Pine Soe eg Ammonia Ammonia mau ting trong 90% tnréng hop bénh nfo gan. Vai trd bénh sinh eta ammonia 4uge ching minh bing sy cAi thign bénh nfo gan Ichi idu trj nhim gidm ammonia huyét trong. ‘Tuy nhién,thigu sy tuomg quan gitta ndng d6 ammonia huyét tuong véi d6 ning cia bénh nfo gan Ol pig nay c6 thé gidi thich do sw khée bigt gitta néng 40 ammonia huyét twong va néng 46 ammonia 6 hang rio mau nfo, Néng 46 ammonia mau finh mach ting khong hang djnh trong bénh Hogan. Tuy nhién, ndng 46 ammonia mau dng mach chinh xéc hon méu tinh mach do gin bing véindng 4 ammonia & hang rao méu nao. CCée nguyén nbn ngoai gan gay tng ammonia méu bao g6m: xuét huyét tiéu héa, bénh thén, nhiém tring tiéu do vi khudn sinh uréase, chéng, hit thuéc 14, khiém khuyét chu trinh uré bam sinh, toan huyét, théng néi cira chi, nuéi in bing tinh mach, sau héa tri, thudc nhw valproic acid, barbiturates, narcotics, Igi tiéu, nrgu, nhiém de salicylate... 24, Dinh gid chite ning gan Albumin ‘Atbumin huyét thanh duge tng hp hodn toin do céc 18 bio gen, chim 65% - 85% iran Protein méu, Albumin c6 thei gian ban hity 14 18-20 ngay va gidm khodng 4 % nbi nay. v hed albumin huyét thanh khong phai la m6t chi didm t6t vé r6i loan chite nang gan cP tinh hoje nh¢. Albumin chi thay déi rét it trong trong béah gan cdip tinh nur viém ttuong gan do thuée va ving da the mét. Trong viém gan clip, albumin ie Xem x41 kha ning dgt bing phit cia bgnh gan man tinh. Gidm albumin WM ET hap ‘th gan man tinh nhur xo gan va thudng phin énh tdn thuong gan ning oe Albumin, Tuy nhién, albumin huyét thanh khéng chuyén bigt cho bénh oi eee ‘A? do mgt s6 tinh trang nhur suy din dong, ‘mt protein nhur beak at ate xe vi nidm ring man tinh 6 lin quan v6is gia tans KO daindng ‘6 hoa ti khdi u, 18 cytokine tte ché tng hop albumin Prothrombin time ca goin time phan Anh sy bign dign cba ¢ ve tb aoe dong mau ngoai sinh. Tat cd cfc yéu dOnB ‘ng méu Il, VII, X cén vitamin K dé tong hop: SY, mat in tit i che “MC ning téng hop. Vi rothrombin time id hic nang pan ing hgp. Vi vay, Pt gan cdp do virus, tn dt thanh <3 g/dL néa 1g gip hom trong ce et 1, V, Vi va X) ob jc yéu 6 dng miu fr, trong 46 06 3 ‘du do gan sin xult, 9 I ge! 1 dong mau ke trén gidm khi gan § 1. ea seem nur Hb gt xét nEHEM inh 715 Scanned with CamScannerthé anh hong én con dung d6ng méu lam é au va (ii) gidm cung of A ihm tan gp ede yéu tb d6ng mé i gid ra Aare K trong 3 ngay lién tiép c6 thé gitp phan big vemin K (do tt mat hog céc nguyén nhin Kchéc) v6i giim ‘Trong bénh gan, mét sb co ché bénh sinh c6 ko dai prothrombin time, bao gom: yathotc hap thu vitamin K, Tim 1 2 Prothrombin time kéo dai git gidm vit tng hgp trong suy gan. 3, CAC KIBU XET NGHIEM SINH HOA GAN BAT THUONG 3.1. Kiéu tin thong té bao gan Diic diém ; ALP ting <3 lan ULN: day 1é die diém quan trong nhit 4é nhan dién tén thurong té bio gan, Tuy nhién mot s6 trzdng hop tén thuong té bao gan kém theo ton thuong tr mgt (kiéu hin hgp) nh viém gan do thuée va hiém gap hon la viém gan do virus va rugu gay ting ALP > 3 lin ULN. = ALT, AST ting cao hon so véi ALP, bilirubin cé thé ting ho&c khéng ting, Prothrombin time kéo dai khi ¢6 suy gan. Nguyén nhan - Do virus: HAV, HEV, HBV, HCV, HDV; Epsteinbar virus, Cytomegalo virus, Herpes simplex = Rugu, thude, de t6 Bénh chuyén héa: NAFLD, bénh tr sit di trayén is) va tr dng di truyéi a lemor (bénh Wilson) 1yén (Hemochromatosis) va tr dng di truyén - Ty mién: viém gan ty min - Tén thuong gan do thiéu mau eye b6 - Nguyén nan khéc: thiéu Al Khuyén cdo m6i cla ACG ni bee ee im 2017 vé céc xét nghigm tim nguyén nhan gy ton thong Ipha 1 antitrypsin, celiac sprue... + xXét 7 yéu ape nana vn Ban virus C man gém: anti - HCV va HCV - RNA. Cie xin, x8 18 Lek ce fa nee virus C bao gdm tién str ding ma tiy hoge tiém chich, sinh ra gitta nim 1945 ‘ya Sa a hinh vi tinh duc o6 nguy co cao va nhig ngudi anti-HCV va HCV - RNA Kayo nghigm chan dodn viém gan virus C ofp 26 So manh, bing ching rét thd a ig rat thap). o man tinh g8m: HBsAg, vi irus B of? a HBsA, HBe. Ci gdm; HBsAg, viém gan virus B c#? sinh ra 6 ede ving 66 1g HBG PAM Ain 6 nguy ea eao nb: nhmg ne nai ting tim chich ma is mace nam c6 quan hé tinh dye déng giéi, nhtms thai va thanh vién tr a din than chay thé . shy nit 6 nhiém HBV. (kn rong sia dinh ngudi bj nhidne | Sea tao, nhitm HIV, pl al bi + (Khuyén céo manh, bing chimg rt thé , ‘va cé quan hé tinh dye a! fp). x = & e 2 é 5 E E 4 Scanned with CamScannerXét nghiém chan dodn viém gan virus A oe . cp 1a IgM anti-H. A fi 4 AV nén thyte hié a eset ates gan clp va cb thé tp xtc phn ming, Xét nghiem eee Jogi B cp tinh 1a IgM antl ~ HEV nén thye hign § nhig bénh nhi es i cho viém gan juu hanh ™ cdc xét nghiém chin dodn viém gan virus A, B, C cdp am ti ve tir che ving manh, mic 46 chimg ctr rat thip), » B, C cap Am tinh (Khuyen cdo Bénh nhén c6 BMI cao va cé hdi chim 3, ig chuyén héa be : di 5 hope béo phi, ing lipid mu hoe ting huyét dp 06 ALT on ea tho ng hot ne si ; nén sing loc bing ea (Khuyén céo manh, bing chimg rit thép), Phy uédng trén 140g rugu/tuin hog nam gidi udng hon 210g rugu/tuin, cb AST > ALT duge xem la o6 nguy co’bj bénh gan rugu va nén duge te van ngung uéng regu. (Khuyén céo manh, bing chimg rit thip). Tht @ cf bénh min e6 xét nghifm sinh hoa gan bt thudng, khong c6 viém gan cp e phai lam cic xét nghi¢m tm soat hemochromatosis di truyén véi sit huyét thanh, a bao hia transferin va ferritin huyét thanh, Phan tich dét bién gen HFE nén durge thyc hign 6 nhimg bgnh nhén c6 49 bio hoa transferrin > 45% vashoge tang ferritin huyét thanh, (Khuyén céo manh, bing chimg rét thép), Bénh nhén cé AST va ALT bit thudmg, dic bigt la nhting bénh nhén c6 bénh tw mign djch khic, cn lm céc xét nghiém tim soét viém gan ty mién bao gdm: ANA, SMA va globulin. (Khuyén céo manh, bing ching rit thap). Bénh nbin c6 AST va ALT ting cao lign tue, dfc bigt Ia bénh niin < 55 tudi, nén sing loc bénh Wilson bing xét nghiém ceruloplasmin huyét thanh, Néu ceruloplasmin thép, clin xdc dinh bing dinh rgng déng trong nude tigu 24 gid va tim vong Kayser-Fleischer & mit bing dén khe. (Khuyén céo manb, bing chimg lit thdp). : Bénh nhin ting AST hoe ALT dai ding ein phi sing loc a kiém tra thigu alpa-1 anti-trypsin (A1AT) bing alpha-1 anti-trypsin ‘phenotype. (Khuyén cdo manh, bing chtmg rit thap). : oad Cée thy thudc nén héi b@nh nhan vé cfc logi thudc ké toa vi khong ké toa, céc loai thude bd sung hot thay thé khong ké toa va ccc chit bb sung ché 46 fn wong ho§e thao duge vi cé thé lién quan dén tn thuong gan do thube (Khuyen céo manh, bing ching rat thap). H r fai Sinh thiét gan 6 thé duge xem xét khi xét nghigm mu va hinh ee e i tinh chin doén hod khi'cd nbiéu chin dosn. CKhuyén cho man, bing wie : 2. = te AST <5 lin ULN, nén lim xét nghiém dfnh gt G nang beh abe a ATID hemochromatosis, bénh Wilson, thiéu alpha- vim gan vinis B va C, rugu va N. em ube (Khuyén c&o man, bing chimg 1-trypsisi, viém gan tyr mién va ton thuong gan do rit thé). ., ‘i id vi ‘s AST 5-15 lan ULN, cfing nén dénh gif viém Gnhiing bgnh hin o6 mie ALT viMhoke AST ay ting AST/ALT duéi 5 lén gan virus A, B-va C cfip cong v6i tat cf 8° guy’ ULN. (Khuyén céo manh, mite 46 ching cut rat thp)- m7 Scanned with CamScannerhim; ahi 15 lin ULN hoe ALT > 10.000 Tur, ¥énh nhdn e6 mire ALT vi/ho&e AST > N 0.009 . oe ee ngd ‘be acetaminophen va ton thiong do thiéu mau cuc bé (s6¢ gan) nm z, (Khuyén cdo manb, bing ching rat thép). 3.2, Kiéu tn thong tt mit 7 Die diém : + ALP (kém GGT ting) > 3 - 4 Jin 1 ote é 61 " ‘tar iubin c6 thé ting hay khéng ting; ALT, AST binh thei ny, ng hing thudng < $00 IU/L. Tuy nhién, trong tic duong mat cdp do soi (s6i dang di chuyén) AST, ALT c6 thé tang rit cao >1.000 UA, nhung sau dé gidm nhanh, ‘Trong tie dudng mat cép do s6i éng mat chu hay éng gan chung, AST va ALT ting li déu higu sém nhit, hic dé ALP, GGT va bilirubin chua ting. Vi vay, 46i khi chin dodn nhim viém gan cdp vi dudmg mét chua gin va khéng phét hién soi duéng mét ngogi trr 6 thé phat hign si tii mat, Trigu chitng dau quan mit gidp phan biét. Nguyén nhan Tic éng mat ngoai gan, trong gan (s6i, giun, ‘Bénh ly thém nhiém (ung thnr gan, ung thr di cin gan, amyloidosis, u hat, sarcoidosis), Bénh ly dudng mat ty mign: + Viém duéng mét xo héa nguyén phat + Vigm dudng mét t mét nguyén phat (trede dy goi li xo gan tr mat nguyén phit), ‘Viém dudng mat ty mign Thube gay r6i Togn tiét mat ra tiu quan mat nhu: Estrogen, Chlopromazine, Thiabendazole, Imipramine, Tolbutamide, Sulindac, Cimetidine Prochlorperazine, Enythromycin estolate, Trimethoprim-Sulfamethoxazole... : ~ Viém gan thé tt mat hay tén thuong hdn hop (Virus, rugu...) hiém < 5%, Cach tiép cn ; Khuyén cdo cia ACG nim 2017 v8 kiéu tn thong tr mat nhur sau: - oe oe a Aue ee g6c cia gan bing GGT ting, Do thiéu tinh dic higu cho of cde xét nghigm sinh ha eau not xétnghifm sing Ioe cho bn gan Kh ks vids) San bat thuéng khéc. (Khuyén cdo manh, mire 46 ching ct BEnh nhén c6 ALP ting c6 howe kha Meta . mt me nguyén phit Gree Khong c6 biirubin ting cao nén sing loc viém duiug H (truée day go} ; Khéng thé khing ty thé AMA. (Kin 89% lA xo gan tr mat nguyén phét) vei xét mghié™ a , iuyén cao manh mé, mit ‘ rit thép). Bénh nhfinc6 é mite 4§ chimg cit rit thép) ding xo he wre ne tins cba tng cao nén de sag 9c viv ‘manh, mite 49 ching cit rt thé), MRCP hay ERCP két hop véi IgGd. (Kiuyén Scanned with CamScannerTing bilirubin don doc ‘Ting bilirubin don dGc thuréng do 3 co ché gdm: ting sin xuat Bilirubin GT, gidm thu nhén bilirubin GT vio gan va gidm Itha nang két hop véi acid glucuronic. ‘Tang bilirubin don 4c (Isolated hyperbilirubinemia) khi ting bilirubin nhumg AST, ALT va ALP binh thudng, gip trong cdc nguyén nhén sau: + Ting bilirubin GT don de: hi ching Gilbert’, Crigler-Najjar, tin buyét, tao hing ctu Ong higu qud, ving da so sinh, nhiém tring, suy tim sung huyét, théng néi cita chi, thuée (Pregnanediol, Chloramphenicol, Novobiocin, Rifampin va Rifamycin, Probenecid...) ‘Tang bilirubin TT chiém tir 60% tré lén bilirubin toan phan (TP) kém ting bilirubin GT: hi chimg Dubin-Johnson, bénh dur trit trong gan (Hepatic Storage Disease). Ting ALP don dée Dic diém: Aminotransferase va bilirubin trong gidi hgn binh thuéng, ALP ting c6 hay khong cé ting GGT. Nguyén nhan gay ting ALP don d6c bao gdm: + ALP ting do bénh gan mat (GGT tang) + Thc during mat bén phan (do ung thr tuy, ung thu déng mft hay viém dong mat xo héa nguyén phit) + The éng mat trong gan, vi du do soi + Thc dng mat trong gan nhiéu vj tri do bénh thm nhiém 6 gan (ung thu gan, ung thir di cin gan, amyloidosis, u hat, sarcoidosis) Trong cdc trang hop Ké trén, durong mit tic khéng hodn toin do dé bilirubin s® durge thai bi tnt qua nhtng dudng mft khdng tic, vi thé Bilirubin kh6ng ting va Kh6ng gay ton thuong 18 bao gan nén aminotransferase cfing khéng ting. + ALP ting do bénh ngodi gan khi GGT khéng ting nhw: bgnh ly xwong, ru6t, thén, haw thai (isoenzyme khéc nhau); ting dang ké trong bénh xwong Paget's, di cin xuong, tic rugt va c6 thai, Ting GGT don doc Tang GGT don d6c khi aminostranferase, ALP, Bilirubin va Prothrombin time/INR trong gi6i han binh thuong, Cac nguyén nin gay ting GGT don déc gdm: = Che bénb ly cia cée co quan khée ngoai gan mét nhu bénh tuyén ty, nhéi méu co tim, suy thén, bénh phdi tic nghén man tinh, dai théo dudng va nghign regu. = GGT ting cao don déc c6 thé xay ra nhiing bénh nhan ding cfc logi thude nhu- thudc an thin hoc phenytoin. Sau khi uéng rugu, ngay cd khi chua gay tn thuong gan, céc xét nghiém sinh héa gan khéc nhu ALP, AST, ALT va bilirubin déu binh thudng, nhung GGT da ting. Scanned with CamScanner