Vim gan B

(Phn 1)

Phm vi ca vn ?
Khong mt phn ba dn s th gii mt lc no c tip xc vi HBV. Hn
na, c tnh 350 triu ngi khp th gii l b nhim HBV mn tnh ( thi gian lu
di ). H qu l dn n 2 triu ngi cht mi nm do nhng bin chng ca nhim
trng HBV.
Theo tnh ton ca trung tm kim sot bnh tt ( CDC),140000 n 320000
trng hp vim gan B cp tnh ( nhim trng gan do HBV trong thi gian ngn ) mi
nm M. Tuy nhin, khong 50% trng hp cp tnh l c triu chng. Trong s c
triu chng th c n 8400 ti 19000 phi nhp vin v 140 n 320 ngi cht mi
nm M. Trong nhng thp nin qua, t l mc bnh vim gan B cp gim hn 70%.
S gim xung ny l do s hiu bit trong cng ng c gia tng v HIV v AIDS v
thc hin bin php tnh dc an ton ( HBV v HIV ly qua ng ny rt nhiu ).
Hin nay t l mc bnh vim gan B cp cao nht ngi tr, c bit l ngi da en
v ngi gc Ty Ban Nha, t 20 n 30 tui.
Hu ht ngi tr (>95%) b vim gan B cp s hi phc hon ton. Kt qu
l h to nn min dch (y l mt hnh thc bo v) vi vic nhim HBV sau ny.
Ngc li, hu ht nh nhi v tr em b nhim HBV cp s tr thnh mn tnh. Do
vy, M c tnh t 1 n 1,25 triu ngi nhim HBV mn tnh. Hn na, 5000
n 6000 ngi cht mi nm bnh gan do nhim HBV v bin chng bao gm c ung
th gan nguyn pht.
mt vi ni trn th gii nhim trng HBV lun lun tn ti (bnh a
phng) trong cng ng. V d, Nam v Trung Phi, c khong 15-20% ngi tr
nhim HBV mn tnh. M, t l nhim trng mn tnh cao ch thy mt vi qun
th nhn chng c bit. Bao gm, ngi gc Alaska, t cc o Thi Bnh Dng v
nhng nh nhi ca ngi m thuc th h u tin di c t nhng nc c t l nhim
HBV cao.
HBV thuc loi vi rt no ?
HBV thuc h DNA vi rt gi l Hepadnaviridae. Nhng vi rt ny u tin
nhim vo t bo gan. Tn gi xut pht t Hepa ngha l gan, DNA c ngha l n c
deoxyribonucleic acid, l cht liu di truyn ca vi rt, v viridae ngha l vi rt.
Nhng loi vi rt khc thuc h ny c th gy vim gan mt s loi vt. Nh vi rt
vim gan sc Bc Phi, sc v vi rt vim gan vt. Hepadnaviridae tung t vi
nhng vi rt . T , mt vi loi vt trn c dng nghin cu nh gi
thuc mi iu tr HBV.
Gen ca HBV cha m di truyn to ra mt vi loi protein, bao gm khng
nguyn b mt ( HBsAg ) khng nguyn li ( HBcAg ) khng nguyn e ( HBeAg ) v
DNA polymerase. Bn loi protein ny c vai tr quan trng nhn bit bi v c th
o lng c qua kim tra mu chn on HBV.
HBV n gin bao gm phn li ( trung tm ) v lp bao ph bn xung
quanh ( lp o bn ngoi). Phn li to nn HBcAg, cn lp v to nn HBsAg. Phn
li cha HBV DNA, HBeAg v DNA polymerase. HBeAg c ni r sau, l mt ch
im kh nng ly nhim ca vi rt. DNA polymerase l mt phn quan trng trong
qu trnh sinh sn ca vi rt. iu c lin quan n vn ny l HIV cng c tin
trnh sinh sn tng t. Nh l h qu, nhng thuc ang c pht trin kim ch
qu trnh sinh sn trong iu tr HIV c th c hiu qu trong iu tr nhim trng
vim gan B mn. HBV gy tn thng gan nh th no ?
HBV t n khng gy tn thng gan trc tip. Hn na, h min dch ca c
th p ng vi vi rt ( l vt l) gy ra tn thng. V vy, trong nhim trng HBV,
min dch ca c th c hai nhim v l hn ch HBV pht trin trong c th v hi
phc khi nhim trng. Cng lc ny tn thng t bo gan l do hot ng ca h
min dch chng li HBV trong t bo gan.
V l , c s cn bng gia bo v v ph hy ca h min dch trong qu
trnh p ng HBV. S cn bng ny s xc nh kt qu ca nhng ngi b nhim
HBV. Theo , mt nhim trng HBV cp c th hi phc (kt qu thng gp), suy
gan cp (him) v thnh thong thnh nhim trng mn tnh. Nhim trng mn c th
dn n tnh trng ngi lnh mang mm bnh (l tnh trng ngi mang vi rt
trong ngi nhng vn khe mnh) v din tin n x gan v bin chng nh ung th
gan. Vim gan B ly truyn nh th no ?
HBV ly nhim khi tip xc vi mu hay dch tit ca c th b nhim HBV. S
tp trung cao lng HBV c tm thy trong mu, tinh dch, dch tit m o, sa m,
v nc bt. Rt t trong nc tiu v khng c trong phn. V vy, HBV khng ly
qua thc phm hay nc ung. Hn na, HBV khng cn ly qua ng truyn mu
na v tt c mu truyn c sng lc loi ra mu b nhim HBV.
M, thanh thiu nin v ngi tr l s lng chnh trong bo co cc trng
hp nhim vim gan B. Tip xc qua ng tnh dc ( giao hp) l con ng ly
nhim nhiu nht. Vi rt c th ly nhim qua mu cha HBV hay dch c th theo
nhiu ng khc nhau. l, dng thuc tim mch hay tim di da, xm mnh, x
l tai, chm cu vi nhng dng c khng v trng. Ngoi ra HBV cn ly do dng
chung bn chi nh rng, dao co ru. Cui cng nhng cn trng ht mu nh mui
v rp vng nhit i c bo co l gy ly nhim HBV.
Sau cng ( nhng khng phi l ht), HBV c th ly do t m sang con trong
lc sinh ( cn gi l ly nhim theo ng dc ). y l con ng ly nhim quan
trng nht nhng vng m tnh trng nhim trng HBV lun lun tn ti nh Nam
, Trung Phi. T l tr sinh ra b ly nhim t m rt cao khong 100% . Hn na, hu
ht cc a b ny s tr thnh nhim trng HBV mn tnh.
Triu chng ca vim gan B cp ?
Vim gan B cp khi pht nhanh trong thi gian ngn sau khi nhim trng
HBV. Khong 70% ngi tr vim gan cp c mt vi triu chng hay khng triu
chng. S 30% cn li c triu chng trong vng 2-4 thng sau khi tip xc HBV.
Khong thi gian t sau khi tip xc HBV n khi c triu chng u tin gi l thi
gian bnh. Nhng triu chng vim gan B cp thng l mt mi, chn n, bun
nn, v au bng vng gan. Vng da thng phi hp vi nhng triu chng ny. Khi
vng da xy ra c xem nh l vim gan vng da cp ( thi k vng da ).
Theo , nhng ngi b vim gan cp c tin triu l nhng triu chng c
trc khi khi pht nhng triu chng ni trn. Nhng triu chng l ging nh
phn ng d ng nh da ni mn, au, sng khp v st nh. Ni cch khc, triu
chng tin triu ging nh l triu chng cm.
Him khi ( < 0,5%) vim gan B cp din tin thnh suy gan cp ( khi pht mt
cch t ngt ). Nhng bnh nhn ny cc k nng vi nhng triu chng ni
trn, ngoi ra cn c vn l ln hay hn m ( bnh no ) v vt bm mu hay chy
mu ( bnh do ri lon ng mu ). Thc t hn 80% trng hp vim gan ti cp,
ngi bnh s t vong trong vng vi ngy n vi tun.
iu g xc nh vim gan B cp ?
Nh cp, mt s ngi c kh nng gii hn HBV trong c th v hi
phc khi vim gan cp ph thuc vo sc mnh ca h min dch c th p ng vi
tnh trng nhim trng. H min dch p ng mnh, a s c th tin l c ch c vi
rt v hi phc. Tuy nhin, ngoi ra p ng min dch mnh cn gy tn thng gan
cp v c triu chng. Mt khc, h min dch p ng yu kt qu l t tn thng
gan v t triu chng hn. Tuy nhin, h min dch p ng yu th kh nng hn ch
vi rt km hn v gn nh l tr thnh nhim trng HBV mn tnh. Qu thc, hu ht
nh nhi v tr con nhim trng HBV cp khng triu chng nhng t l pht trin
thnh vim gan mn hn 95%.
Hu ht ngi trng thnh ( khong 95%), s ngi vim gan cp c triu
chng, vim gan vng da s hi phc hon ton trong vng 2-3 thng. H cng hnh
thnh min dch v bo v c nhng ln nhim sau . Hn na, nhng ngi ny
him khi pht trin thnh vim gan mn. Ngc li, ch c mt t hay khng c triu
chng trong thi gian vim gan cp th kh nng chng li nhim trng km hn v c
kh nng thnh vim gan mn hn.
Triu chng ca nhim vim gan B mn tnh l g ?
Triu chng vim gan B mn c tho lun qua 5 loi : vim gan B mn, x
gan, x gan din tin, ung th gan, v lin quan n cc c quan ngoi gan. Chn on
nhim HBV tt nht l da trn nhng xt nghim mu chuyn bit cho HBV.
Vim gan B mn
Theo nh ngha l chn on vim gan B mn ch thc hin sau 6 thng k t
khi khi pht vim gan B cp. Thng kh khn nghi ng vim gan B mn nu ch
da trn triu chng ca bnh nhn. L do ca s kh khn nh ni l trong giai
on cp thng khng c hay rt t triu chng.
Hn na, hu ht s ngi vim gan B mn vn khng triu chng trong nhiu
nm thm ch 2 -3 thp nin.
Trong khong thi gian ny cc xt nghim mu ch cho thy c bt thng t,
s vim nhim hay so ha gan din tin t. Tuy nhin, trong s ngi vim gan mn
khng hot ng c th pht trin nhng t tn thng ( ti hot ng) c triu chng
cp tnh, gia tng cc thay i trong xt nghim mu v tnh trng vim gan. Nhng
t tn thng ny gn ging nh vim gan cp, nhng chng c th din tin thnh
so ha gan mn tnh.
Chng c khuynh hng xy ra nhng ngi b nhim trng mn tnh lc tr
tui.
X gan do HBV
Tuy nhin, vo mt thi im no vim gan mn c th din tin thnh x
gan ( so ha nhiu, hay x ho). Nhng bnh nhn ny c th c du hiu hay triu
chng ( du hiu bt thng qua khm lm sng ) ca x gan. V d nh yu ngi,
mt mi, v d b nhim trng. Gim khi c, c bit l vng vai v mng. Thc t,
c th b suy dinh dng v st cn do tiu ha khng cn bnh thng, ri lon hp
thu, hay bt thng chuyn ha dinh dng gan. V vy, s thiu cc cht sinh t
nh vitamin A gy gim th lc vo ban m, vitamin D gy mng xng ct sng v
xng chu. Bnh nhn x gan cng biu hin r nhng du hiu suy t bo gan nh
v to ( n ha), teo tinh hon, lng bn tay son, du dn mch c trng trn da ( sao
mch).
X gan din tin do HBV.
C bn nht, din tin x gan dn ti x gan cp tnh c c trng bi s
pht trin mt vi bin chng. X gan cp tnh cn c ngha l giai on cui ca x
gan hay suy gan mn. Mt vi tc gi s dng thut ng x gan mt b, cng ng
ngha vi x gan cp tnh. Tuy nhin, ni cch khc thut ng x gan mt b dng cho
x gan cp tnh bao gm nhng bin chng c bit m hu qu u tin l tng p lc
h ca. Cn mt vi bin chng ca vim gan cp tnh cn do nhiu nguyn nhn
khc.
Theo , nhng bin chng ca x gan cho thy tnh trng x gan cp tnh
c ni r phn sau. Nhng bin chng ny l hu qu t s tng p lc h ca (
dch, bnh no, xut huyt tiu ha trn, cng lch v hi chng gan thn) cng nh
bnh l ng mu, vng da, v hi chng phi gan.
Tng p lc h ca l t ch s gia tng p lc trong h tnh mch ca xy ra
nhng bnh nhn x gan cp tnh ( h tnh mch ca dn lu mu t rut v cc c
quan trong bng v gan). Bin chng thng gp nht ca x gan m hu qu t
tng p lc h ca l dch c th, bnh no gan, v xut huyt tiu ha trn. S
dch lm cho sng mc c chn ( ph) v ph bng ( bng bng hay c chng). i
khi dch ng b nhim trng ( vim phc mc nguyn pht), gy st v au bng.
Bnh no do gan gy tnh trng ng g, ln ln hay hn m. S dn cc tnh mch
thc qun v d dy m khi v gy ra xut huyt tiu ha. Bnh nhn s i ra mu
ti hay tiu phn en ( thm ch en nh hc n).
Mt vi bnh nhn cng lch, mt bin chng do tng p lc h ca. Nhng
bnh nhn ny c lch to, gim hng cu ( thiu mu), gim bch cu, gim tiu cu.
Thiu mu gy yu ngi, mt mi, gim bch cu gp phn d nhim trng v gim
lng tiu cu lm gim kh nng ng mu. Nhng bnh nhn c tng p lc h ca
cng c th b nh hng nghim trng n chc nng thn m khng c tn thng
thn thc th ( hi chng gan thn).
Trong x gan cp tin, nh cp, nhng bin chng khc c th xy ra bn
cnh nhng bin chng do tng p lc tnh mch ca. V d, mt vi bnh nhn c
khuynh hng d c vt bm mu hay chy mu, bi v s gim chc nng gan gy ra
bt thng trong qu trnh ng mu. Bnh nhn x gan cp tin c th vng da bi v
tn thng gan lm mt s cn bng cc sc t gi l bilirubin. Him hn, mt vi
bnh nhn c th kh th do mt vi hormon c phng thch trong x gan cp tin
gy ra bt thng chc nng phi ( hi chng gan phi).
Ung th gan nguyn pht
Ung th gan c th pht trin nhng bnh nhn nhim HBV mn nh l bin
chng ca vim gan cp tin. Ung th gan nguyn pht ny ( ung th gan bt u t t
bo gan) hu ht xy ra nhng ngi c HBV hot ng sinh sn Trung Quc v
nhng ngi da en. Con ng dn ti x gan cha c hiu bit y . c cho
l v mt l do no HBV DNA tr nn kt hp vi DNA ca t bo gan ca bnh
nhn.
Triu chng v du hiu thng gp nht ca ung th gan l au bng v ph,
cng lch, st cn v st. Ngoi ra, khi u gan c th sn xut v phng thch nhng
cht lm tng hng cu, gim ng mu v tng canxi mu. Chn on sng lc ung
th gan thng dng nht l xt nghim o nng alpha-fetoprotein mu v siu m
gan.
HBV lin quan n cc c quan khc ngoi gan.
Him khi nhim trng vim gan B mn li dn n nhng ri lon nh hng
cc c quan khc ngoi gan.
S lng ng cc phc hp min dch c bit nhiu c quan khc nhau c
th gy ra nhng ri lon. Mt phc hp min dch HBV l ton b s gn kt vi
nhau ca khng nguyn v khng th HBV. Khng nguyn l mt cht l i vi c
th v khng th l mt protein c bit c to ra bi t bo bch cu p ng li
khng nguyn .
Phc hp min dch HBV lng xung hay lng ng nhng ng mch nh
khp c th gy ra tnh trng vim nhng mch mu ny, gi l vim a nt quanh
ng mch. Bnh ny c th gy ra nhiu triu chng : yu ngi, tn thng thn
kinh, lot da su, vn thn vi tiu m v i khi gy suy thn, cao huyt p, st
khng gii thch c nguyn nhn v au bng. Phc hp min dch c th gy tn
thng thn theo cch khc. l, phc hp min dch lng ng tiu cu thn ( b
phn lc) gy ra bnh vim cu thn, bnh ny khc vi bnh l thn do vim a nt
quanh ng mch.
Vim gan B c chn on nh th no ?
Vim gan B c chn on t kt qu nhng xt nghim mu chuyn bit (
huyt thanh chn on ) m n phn nh nhng thnh phn khc nhau ca HBV.
Nhng xt nghim huyt thanh chn on khc vi xt nghim chc nng gan ( nh
men gan ALT, AST) m xt nghim ny c th thay i bt thng khi gan b tn
thng do bt k nguyn nhn no bao gm c nhim HBV.
HBsAg v anti- HBs
Chn on nhim vim gan B u tin c ngh khi pht hin khng nguyn
b mt ca HBV trong mu ( HBsAg ). S hin din HBsAg ngha l c nhim HBV
hot ng cn khng c HBsAg ngha l khng c nhim HBV hot ng. Sau khi tip
xc HBV, HBsAg s xut hin trong mu trong vng 4 tun. nhng ngi hi phc
sau vim gan B cp, c ch hay o thi c vi rt th HBsAg ch c trong 4 thng k
t lc xut hin triu chng u tin. Nhim vim gan B mn c nh ngha l s
tn ti HBsAg hn 6 thng.
Sau khi HBsAg c c ch trong c th, khng th chng li HBsAg (anti-
HBs) xut hin. Nhng anti- HBs to nn min dch trong nhng ln nhim trng
HBV sau ny. ng thi, nhng ngi c chng nga bng vacxin thnh cng cng
c o anti- HBs trong mu.

Anti- HBc
Khng nguyn li ca vi rt vim gan B ch c tm thy trong gan v khng
th pht hin c trong mu. S hin din s lng ln khng nguyn li ca vi rt
vim gan B cho thy vi rt ang trong qu trnh sinh sn. iu ny c ngha l vi rt
ang hot ng. Khng th khng li khng nguyn li (anti- HBc) c pht hin
trong mu. T vn , c hai loi khng th anti-HBc ( IgM v IgG) c to ra.
IgM anti- HBc l du hiu nhim trng HBV cp. IgM anti- HBc c thy
trong mu trong giai on vim gan cp v tn ti ti a 6 thng k t lc khi pht
triu chng. IgG anti- HBc xut hin trong giai on vim gan cp v tn ti sau ,
du hiu ch im nhng ngi hi phc hay qua giai on vim gan mn. Theo ,
ch IgM anti- HBc mi c dng chn on nhim vim gan B cp . Hn na, ch
xc nh anti- HBc ton phn ( khng xc nh hai thnh phn ) th khng gip ch cho
chn on.
HBeAg, anti- HBe v th bin chng.
Khng nguyn e ca HBV v khng th ca n, anti- HBe xc nh s ly
nhim ca vi rt ngi nhim HBV mn. S pht hin c hai HBeAg v anti- HBe
thng ring r nhau. Theo , s hin din HBeAg ngha l vi rt ang hot ng v
c kh nng ly nhim cho ngi khc, cn s hin din anti- HBe du hiu tnh trng
vi rt khng hot ng v t nguy c ly nhim hn.
mt vi ngi b nhin HBV, cht liu di truyn ca vi rt b bin i mt
phn gi l th bin chng. Kt qu ca s bin chng ny l khng kh nng to ra
HBeAg, ngay c khi vi rt ang giai on sinh sn. iu ny c ngha l mc d khng
pht hin HBeAg trong mu ngi nhim th bin chng th vi rt HBV vn cn
hot ng nhng ngi ny v vn c th ly nhim cho ngi khc.
HBV DNA
nh du c bit nht s sinh sn vi rt HBV l o lng HBV DNA trong
mu. DNA l cht liu di truyn ca HBV. HBV DNA c nng cao cho thy vi rt
ang giai on sinh sn v hot ng. Nng thp hay khng pht hin c HBV
DNA l ng vi giai on vi rt khng hot ng ngi b nhim HBV. Cc phng
th nghim c gi tr o lng HBV DNA khc nhau.
PCR ( phn ng chui polymerase ) l phng php nhy cm nht xc nh
mc HBV DNA. C ngha l PCR l phng php tt nht pht hin mt lng nh
HBV. Phng php ny c thc hin bng khuch i cht liu di truyn ln hng t
ln pht hin. V vy, PCR c th o lng ch vi khong 50-100 HBV/ml mu.
Tuy nhin, phng php ny qu nhy cm cho vic s dng chn on.
Mc ch o lng HBV DNA thng xc nh c nhim HBV hot ng
hay khng hot ng. S phn bit ny c th da trn s lng HBV DNA trong
mu. Mc DNA cao cho thy s nhim trng ang hot ng trong khi mc DNA
thp ch ra rng tnh trng nhim trng ang yn lng hay khng hot ng. V vy,
bnh nhn vi tnh trng tim tng khng hot ng th c khong 1 triu HBV/ml
mu, cn bnh nhn c bnh ang din tin th c khong vi t HBV/ml mu. Do ,
bt k ngi no c HBsAg dng tnh ngay c khi s nhim trng HBV khng hot
ng, s c th pht hin c HBV DNA bng phng php PCR do n rt nhy
cm.
i vi nhng mc ch ring bit, HBV DNA c th c o lng bng cch
s dng phng php sn xut ging lai, phng php ny t nhy cm hn PCR.
Khng ging nh PCR, phng php ny o lng vi rt m khng c s khuch i.
Theo , xt nghim ny c th pht hin HBV ch khi c nhiu vi rt hin din trong
mu, ngha l s nhim trng ang hot ng. Ni cch khc, t mt phng din
khc nu HBV DNA c pht hin vi phng php ny ngha l s nhim trng
HBV ang hot ng