SINH L - SINH L BNH

TI LIU SU TM TNG HP DCH

Gii thiu Information Mc lc


Bin son ebook : L nh Sng
I HC Y KHOA H NI
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Khng c chuyn mn , khng phi l nhn vin y t , bn khng c php t s dng nhng
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c hay khng mt phn rt ln, khng ch da vo sc lc, s kin tr ca ngi to ra b
sch ny , th nhng ng gp, xy dng, gp , b sung, hiu chnh ca ngi c chnh l
ng lc to ln b sch ny c pht trin. V mt mc tiu tr thnh mt b sch tham
kho y khoa tng hp ph hp vi nhu cu v tnh hnh thc tin trong lnh vc y t ni ring v
trong cuc sng ni chung . Tc gi b sch mong mi bn c nhng li ng gp chn
thnh mang tnh xy dng, nhng ti liu qu m bn mun san s cho cng ng , v mt
tng lai tt p hn. l tt c nim mong mi m khi bt u xy dng b sch ny , ti
vn kin tr theo ui .
Ni dung b sch ny, c th ch ng trong mt thi im nht nh trong qu kh v hin ti
hoc trong tng lai gn. Trong thi i cch mng khoa hc cng ngh tin nhanh nh v bo
nh hin nay, khng ai bit trc c liu nhng kin thc m bn c c c th p dng
vo tng lai hay khng . tr li cu hi ny, ch c chnh bn thn bn , phi lun lun
khng ngng-T MNH-cp nht thng tin mi nht trong mi lnh vc ca i sng, trong
c lnh vc y khoa. Khng ai c th, tt nhin b sch ny khng th, lm iu thay bn.
Nghim cm s dng b sch ny di bt kz mc ch xu no, khng c php thng mi
ha sn phm ny di bt c danh ngha no. Tc gi b sch ny khng phi l tc gi bi vit
ca b sch , nhng mt rt nhiu cng sc, thi gian, v tin bc to ra n, v li ch
chung ca cng ng. Bn phi chu hon ton trch nhim vi bt kz vic s dng sai mc ch
v khng tun th ni dung b sch ny nu ra.
Mi l thuyt u ch l mu xm, mt cun sch hay vn cun sch cng ch l l thuyt, ch c
thc t cuc sng mi l cun sch hon ho nht, bn khng phi l c gi m l din
vin chnh. V Bch Khoa Y Hc cng ch l mt ht thc nh, vic s dng n xo nu hay
nhn ging l hon ton ty thuc vo bn c. V ngi to ra ht thc ny s vui mng v
c truyn thm ng lc tip tc c gng nu bit rng chnh nh bn m bit bao ngi
khng cn phi xp hng ch cu tr.
Mi ng gp lin quan n b sch xin gi v cho tc gi theo a ch trn. Rt mong nhn
c phn hi t cc bn c gi cc phin bn sau c tt hn.
Knh chc bn c, gia quyn v ton th ngi Vit Nam lun c sng trong khe mnh,
cuc sng ngy cng m no hnh phc.
Lng, Ngh An. Thng 8/2010



ABOUT

ebook editor: Le Dinh Sang
Hanoi Medical University
Website: www.ykhoaviet.tk
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Tel: 0973.910.357
NOTICE OF MEDICAL ENCYCLOPEDIA PUBLICATION 2010:
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MC LC
PHN 1. SINH L Y HC
BI 1. SINH L MU-TUN HON
1. H TUN HON
2. SINH L MU
3. RI LON LM SNG MU
4. SINH L CM MU V NG MU
5. CU TO - CHC NNG CA HNG CU
6. TIU CU
7. BCH CU
8. CHNG NG MU
9. HUYT TNG
10. NHM MU V AN TON TRUYN MU
11. RI LON C CH CM MU
BI 2. SINH L[ CO C
12. S CO C
13. SINH L C VN
14. SINH L C TRN
BI 3. SINH L H TK THC VT
15. GII PHU H THN KINH THC VT
16. CHC NNG CA H THN KINH THC VT
17. CC CHT DN TRUYN V RECEPTER THUC H TK THC VT
18. TC NG CA THUC LN H TK THC VT
19. CUNG PHN X V CC PHN X THC VT
BI 4. SINH L TIU HA
20. CHC NNG GAN
21. SINH L TIU HA I CNG
22. TIU HO MING
23. TIU HO D DY
24. TIU HO RUT NON
25. HP THU THC N RUT NON
BI 5. SINH L SINH DC
26. SINH L SINH DC N
27. SINH L SINH DC NAM
BI 6. SINH L THN
28. QU TRNH TO NC TIU
29. SINH L THN
30. IU HA CHC NNG THN
31. MT S NGHIM PHP THM D CHC NNG THN
BI 7. SINH L CC DCH C TH
32. CC DCH CA C TH
33. CC DCH KHC CA C TH
34. THN IU HA CN BNG NI MI
PHN 2. SINH L BNH Y HC
35. I CNG SINH L BNH
36. KHI NIM V BNH
37. QU TRNH BNH L
38. MIN DCH BNH L
39. BNH SINH HC
40. BNH CN HC
41. SINH L NHIM TRNG
42. RI LON CN BNG AXIT BAZ
43. RI LON CHUYN HA GLUCID
44. RI LON CHUYN HA LIPID
45. RI LON CHUYN HA NC IN GII
46. RI LON CHUYN HA PROREIN
47. RI LON QU TRNH PHT TRIN - U C
48. RI LON IU NHIT
49. SINH L BNH GAN
50. SINH L BNH QU TRNH VIM
51. SINH L BNH THIU XY
52. SINH L BNH H TUN HON
53. SINH L BNH H TIT NIU
54. SINH L BNH H TIU HA
55. SINH L BNH H THN KINH
56. SINH L BNH H NI TIT
57. SINH L BNH MU V TO MU
58. SINH L BNH H HP
59. BNH L DI TRUYN NGI




PHN NI DUNG




PHN 1. SINH L Y HC


BI 1. SINH L MU-TUN HON

1. H TUN HON

Theo Free Health Encyclopedia



H tun hon ca c th bao gm h tim mch v h bch huyt.
Hai h ny vn chuyn oxy, cht dinh dng, nhng t bo cht, hormon v nhng cht khc
n v i khi cc t bo trong c th.

Hng t t bo trong c th ngi nhn cht dinh dng v thi ra nhng cht b hng ngy,
hng gi, hng pht.
Mc d s trao i ny c th gia tng khi hot ng v chm li khi ngh ngi nhng lc no n
cng hot ng lin tc.
Nu n dng li, c th s cht. Trong 2 h, h tim mch ng vai tr vn chuyn chnh, h
bch huyt ch h tr thm bng nhng chc nng ring bit ca n.

NHNG THNH PHN CA H TIM MCH

Nhng thnh phn chnh ca h tim mch l tim, cc mch mu v mu. C th m t mt cch
hnh tng h tim mch bng hnh nh sau: mt ci bm bng c (tri tim) bm dch (mu)
chy qua mt chui nhng ng dn ln v nh (cc mch mu) i khp c th.
Khi di chuyn qua mt h thng cc mch mu phc tp, mu ly oxy t phi, cht dinh dng
t rut non v hormon t cc tuyn ni tit.
Sau n phn phi li cho cc t bo ca c th ri ly v CO2 (c to thnh khi t bo
dng ng v m sn xut ra nng lng) v nhng cht thi khc. Mu s mang nhng
cht thi n phi v thn thi ra ngoi.

Tim Tim l mt cu trc rng, hnh nn lm t c nm pha sau v hi lch v bn tri xng
c. Np mnh vo gia 2 phi, tim c nm trong mt lng xng bo v c to bi xng
c, cc xng sn v ct sng. nh tim nm pha di, c gi l mm tim, hng v
pha hng tri v nm trn c honh (mt mng c phn cch khoang ngc v khoang bng vi
nhau). Phn trn ca tim, c gi l y tim, hng v pha vai tri v nm di xng sn
th 2, cc mch mu quan trng ca c th c ni vo tim phn ny.
Tim c kch thc bng mt nm tay. Khi mi sinh, kch thc tim v nm tay ca tr l bng
nhau. Khi c th pht trin, tim v nm tay cng pht trin vi cng mt tc . ngi ln,
khi lng trung bnh ca tim vo khong t 255 n 310 gram, ca nam ln hn ca n mt
t.
Mng tim l mt ti lm t mng x, cht, bao quanh, bo v v neo gi tim li vi cc cu trc
xung quanh. Lp mng trong bao mt ngoi ca tim v l mt thnh phn ca thnh tim. Lp
x bn ngoi bo v tim v neo tim li vi cc cu trc xung quanh nh l xng c v c
honh. Phn trong ca lp ngoi ny c gii hn bi mt lp khc, sn xut ra huyt thanh.
Cht nc bi trn gia hai lp trong v ngoi ca mng tim ny gip cho 2 lp ny trt ln
nhau c d dng hn v gim ma st khi tim p
Thnh tim c cu to bi 3 lp: lp ngoi (epicardium), lp c (myocardium), v lp ni tm
mc (endocardium). Lp ngoi cng (epicardium) tht cht l lp trong cng ca mng ngoi
tim. Lp gia, myocardium, l mt lp c tim dy c th co bp c tng mu i ra khi
tim. Lp trong cng, ni tm mc, l mt mng mng gip mu c th chy trn tru qua cc
bung tim.
Cc bung tim
Tim c chia ra lm 4 bung. Mt vch c chia tim ra lm 2 phn: phi v tri. Mi phn tip
tc c chia ra lm 2 bung: bung trn v bung di. Hai bung trn, cn c gi l tm
nh, c thnh mng. Chng m nhn chc nng nhn mu v tim. Mu chy v tm nh t cc
mch mu ca c th, sau c bm xung tm tht, l 2 bung nm pha di. Tm tht l
bung m nhn chc nng tng mu i. Thnh ca chng dy v c nhiu c hn tm nh. N
gip tm tht co bp v bm mu ra khi tim n phi v nhng khu vc cn li ca c th.
Trong khi mu chy t bung ny sang bung kia, nhng ci van-mt-chiu ngn khng cho
mu chy ngc tr li bung c. Cc van nm gia tm nh v tm tht c gi l van nh
tht. Van nh tht tri (nm gia tm nh tri v tm tht tri) cn c gi l van hai l. Van nh
tht phi (nm gia tm nh phi v tm tht phi) cn c gi l van ba l. Cc van nm gia
2 tm tht v nhng mch mu ln c chng bm mu c gi l cc van bn nguyt. Van
bn nguyt ng mch phi nm gia tm tht phi v thn ng mch phi. Van bn nguyt
ng mch ch nm gia tm tht tri v ng mch ch.
Cc l van m v ng p ng li vi nhng thay i p lc trong tim. Cc van nh tht m
ra khi tim ngh ngi v ng li khi tm tht co bp. Cc van bn nguyt ng li khi tim ngh
ngi v m ra khi tm tht co bp. Khi cc van ng li s gy ra nhng ting "bm-tc" m bc
s c th nghe thy c qua ng nghe. Khi van nh tht ng s to ra ting "bm", khi van bn
nguyt ng s to ra ting "tc".

H dn truyn ni ti ca tim
Tim c mt h thng thn kinh ring kim sot hot ng ca n c gi l h dn truyn
ni ti, nm bn trong m tim. Nhng tn hiu thn kinh c h ny gi i s lm cc phn
khc nhau ca tim co bp nhng thi im khc nhau. Mt im nt nh bao gm mt loi
m c c bit nm phn trn ca tm nh phi c gi l nt xoang. Do n l im khi
u ca xung ng nn nt xoang cn c gi l nt to nhp. H thng ny cn bao gm
nhng nt khc nh nt nh tht, nm gn y ca tm nh phi, ngay pha trn tm tht. B
nh nht (cn c gi l b His) nm phn trn ca vch ngn gia 2 tm nh. Hai nhnh
chnh t b ny chia ra thnh nhng si nh hn phn b u cc c tim ca cc thnh tm
tht. Chng c gi l nhng si Purkinje.

Mch mu
Cc mch mu to ra mt h thng vn chuyn bao gm cc ng c chiu di khong 96,500
km, hn gp i chiu di ca ng xch o. Ton b h thng mch mu c xem nh l
mt chui nhng con ng v ng cao tc lin kt vi nhau. Mu ri khi tim i vo cc
mch mu ln (ng cao tc) i n c th. nhiu im khc nhau, nhng mch mu ln
ny chia ra thnh nhng mch mu nh hn (ng l). V n lt mnh, nhng mch mu
ny tip tc chia ra thnh nhng mch mu nh hn, nh hn na (c 1 ln xe). Khi quay
ngc tr v, mu i qua nhng mch mu c kch thc tng dn ln (cc ng 1 ln hp li
thnh ng l ri thnh ng cao tc) trc khi tht s tr v tim.
MU C PHI L BIN BN TRONG C TH ?

Ch mi hn 350 nm trc, con ngi tng ngh rng mu trong c th chy ti v lui y ht
nh nhng cn thy triu vy. Ngi Hy Lp c i l nhng ngi u tin t ra l thuyt
ny. H tin rng mu ri khi tim, sau rt tr v tim mang theo nhng cht cn bng theo
cng mt mch mu. Gi thuyt ny tn ti cho n hn 1400 nm.
Nm 1628, mt bc s ngi Anh, William Harvey (1578-1657), cng b mt khi nim mi
v tun hon mu. ng xc nhn rng mu chy khng ngng t cc ng mch sau tr v
tim qua cc tnh mch v to nn mt vng tun hon lin tc qua c th.
Ngay lp tc sau , l{ thuyt ca Harvey b khinh mit v n i lp li hon ton nhng hiu
bit c bn v y hc vo thi . Tuy nhin, vo khong 30 nm sau, { tng ca ng c
xc minh do ngi ta pht hin ra s tn ti ca cc mao mch. Do l ngi tin phong nn
Harvey c nhiu ngi xem nh l cha ca nn y hc hin i.
ng mch, mao mch v tnh mch l nhng thnh phn chnh ca h thng vn chuyn. ng
mch l nhng mch mu mang mu i ra khi tim. Cc ng mch ln ri tim sau chia
nhnh ra thnh nhng ng mch nh hn ri i n nhiu khu vc khc nhau ca c th. Sau
chng tip tc chia nh hn thnh cc tiu ng mch. Trong cc m, cc tiu ng mch
chia ra thnh nhng mch mu siu nh c gi l cc mao mch. S trao i cht gia mu
v t bo din ra xuyn qua thnh ca cc mao mch. Trc khi ri khi m, cc mao mch gp
li thnh cc tiu tnh mch. Sau nhng mch mu ny di chuyn n gn tim hn v gp li
thnh nhng tnh mch ngy cng ln hn.
Nhng mch mu ln c nhng cu trc khc nhau. Mc d cc thnh ca c ng mch v tnh
mch u bao gm 3 lp nhng dy ca chng cng khc nhau. ng mch c lp trong v
lp gia dy hn, gip chng n hi hn. Chng c th co v dn d dng khi mu c bm
t tim trn qua. Tnh mch c thnh mng hn gip cc khung c xung quanh chng bp v y
vo thnh p mu trong tr v tim. Nhng van-mt-chiu thnh cc tnh mch gip
ngn khng cho mu chy ngc tr v v gi cho dng mu chy theo 1 hng. Cc van c
nhiu nht chn do mu phi chng li trng lc quay tr v tim. Khng ging vi ng
mch v tnh mch, thnh ca cc mao mch ch dy bng 1 t bo. hu ht cc mao mch,
nhng t bo ny khng dnh cht vi nhau. iu ny gip cho oxy, cht dinh dng v nhng
cht thi c th di chuyn qua li d dng gia mu v dch k lp y nhng khong khng
gian gia cc t bo.
VNG TUN HON PHI V VNG TUN HON H THNG.
C 2 vng tun hon chnh trong c th: vng tun hon phi v vng tun hon h thng.
Nhng mch mu ca vng tun hon phi vn chuyn mu qua li gia tim v phi. Nhng
mch mu ca vng tun hon h thng vn chuyn mu n tt c nhng phn cn li ca c
th.
ng mch chnh ca vng tun hon h thng l ng mch ch. ngi ln, ng mch ch
c cng kch thc vi ng nc ti cy tiu chun. N tri ln khi tim v i ln trn t tm
tht tri khong 1 inch ri sau b hng sang tri ngay pha trn tim (phn ny c gi l
cung ng mch ch) trc khi cong thng xung chia ra cc nhnh cung cp mu cho
nhng phn cn li ca c th.
Cc nhnh ca ng mch ch bao gm ng mch cnh (cung cp mu cho u), ng mch
vnh (cung cp mu cho cc c ca tim), cc ng mch cnh tay (cung cp mu cho cnh tay)
v nhng ng mch i (mang mu xung cung cp cho bp i).
Tnh mch ch l tnh mch ln nht ca vng tun hon h thng. N c 2 nhnh: tnh mch
ch trn nhn mu t u v cnh tay chy v; tnh mch ch di nhn mu t phn c th
pha di chy v. C 2 nhnh ny u mu v tm nh phi.
Cc tnh mch mu v tnh mch ch bao gm: tnh mch cnh (dn mu t u tr v), tnh
mch cnh tay v tnh mch u (dn mu v t cnh tay), tnh mch i (dn mu v t bp
i), v tnh mch chu (dn mu v t vng chu v hng).
Nhng mch mu thuc vng tun hon phi mang mu n phi trao i kh (nhn O2 v
thi CO2 ra), sau quay tr v tim. Nhng mch m chnh l ng mch phi v tnh mch
phi. Hai ng mch phi 2 bn c ngun gc t thn ng mch phi xut pht t tm tht
phi. ng mch phi phi i vo phi bn phi v ng mch phi tri i vo phi bn tri. Sau
khi trao i kh phi, mu c oxy ha (c mang oxy) s c quay ngc tr v tm nh
tri ca tim bi 4 tnh mch phi.

MU

Mu l cht dch c tim bm vo cc mch mu i n khp cc b phn ca c th. N l
m lin kt. Theo ng nh tn gi ca n, m lin kt l nhng loi m kt ni cc phn khc
nhau ca c th li vi nhau nng , cha ng v bo v. M lin kt c tm thy
khp ni trong c th v l loi m c nhiu nht trong 4 loi m ca c th (3 loi m cn li
l: biu m, m c v m thn kinh). Trong tt c cc m ca c th th mu l loi m duy nht
tn ti di dng dch.
Mu c rt nhiu chc nng trong c th. N mang tt c nhng vt cht c th vn chuyn
c t ni ny sang ni khc trong c th: oxy, cht dinh dng cho cc t bo, hormon (l
nhng cht truyn tin ha hc) n cho cc m v nhng cht thi n cho cc c quan m
nhn nhim v thi chng ra ngoi khi c th. N gip bo v c th bng c ch ng mu v
bo v c th khi nhng vi sinh vt l. N cng gip nhit c th c gi tr khng i bng
cch ly nhit ra khi t bo.
Nht v nng hn nc, mu sc ca mu thay i t ti sang c ty thuc vo lng
oxy m n ang mang (oxy cng nhiu th mu sc cng sng). Khi bn trong c th, mu c
nhit vo khong 38C. Mu chim khong 8% trng lng ca c th. Mt ngi nam gii
trng thnh c khong 5.6l mu bn trong c th, n c khong 4.5 lt. Nam c khuynh hng
c nhiu mu hn n do c s hin din ca testosterone, l mt loi hormon sinh dc nam c
tc dng kch thch s to thnh mu.
Mu bao gm c thnh phn rn v lng. Nhng thnh phn rn bao gm hng cu, bch cu
v tiu cu nm l lng trong huyt tng, l mt cht dch ging nc mu vng nht. Cc t
bo mu chim khong 45% mu v huyt tng chim 55% cn li.
HUYT TNG

Huyt tng c 92% l nc. C trn 100 cht khc nhau tan trong , bao gm cht dinh
dng, kh h hp, hormon, protein huyt tng, mui v nhiu loi cht thi. Trong s ,
protein huyt tng chim t l cao nht. Nhng loi protein ny hu ht c gan sn xut ra
v c nhiu chc nng khc nhau. Fibrinogen l mt loi protein quan trng gip ng mu.
Albumin gip gi nc li bn trong mu. Gamma globulin l mt loi khng th gip bo v c
th chng li nhng cht l.
Mui hin din trong huyt tng bao gm: natri, kali, magne, clo v bicarbonate. Chng tham
gia vo nhiu chc nng quan trng ca c th, bao gm co c, dn truyn cc xung ng thn
kinh v iu ha thng bng pH (kim-toan) ca c th.
HNG CU



L loi t bo c nhiu nht trong 3 loi t bo mu. S lng ca n vo khong 5 triu t bo
trong mi milimet khi mu (1 milimet khi tng ng vi mt git mu rt nh nhn
thy c bng mt thng). Chc nng chnh ca n l vn chuyn oxy t phi n cc t bo
ca c th. Hng cu c cu trc hnh a phng v lm xung trung tm, kch thc gip
chng c th lch vo c cc mao mch nh.

CHARLES DREW v cch bo qun huyt tng

Charles Drew
Mu c 4 nhm chnh l A, B, O, v AB, y l khm ph ca cc nh nghin cu y hc vo u
th k 20. Khm ph ny ci thin ng k hiu qu ca vic truyn mu. Tuy nhin, vo thi
im , mu ton th ch c th gi c trong vng 7 ngy trc khi b h. Do vn lm
sao c c ng loi nhm mu cn thit sn sng trong cp cu vn cn tn ti.
Vo nhng nm cui thp nin 30 ca th k trc, mt bc s ngoi khoa ngi M, Charles
Drew (1904-1950) bt u khm ph ra c kh nng dng huyt tng thay th cho mu
ton th truyn. Do huyt tng khng c hng cu nn n c th c truyn cho bt kz
bnh nhn no m khng cn quan tm n nhm mu ca h. Tnh cht ny ca huyt tng
lm cho n tr thnh l{ tng s dng trong cp cu.
Khong nm 1940, Drew pht minh ra c cch x l v bo qun huyt tng bng cch
kh nc ca n do nn n c th em i xa c v bo qun trong mt thi gian di. Khi
cn thit, huyt tng kh (ging nh bt) c th c ti to tr li dng ban u bng cch
thm nc vo.
Vic s dng huyt tng truyn mu chng t c vai tr c bit quan trng ca
mnh trong sut th chin th II (1939-1945), thi im mu dng iu tr vt thng
b thiu ht trm trng. Do nghin cu trn, ng c tn thng v cu mng c v
s ngi.
ngi ln, hng cu c to ra bi phn ty ca xng sn, ct sng, xng c v
xng chu (ty xng l mt cht tng t nh bt bin, xp c trong cc khoang bn trong
hu ht cc xng ca c th). Thnh phn c bn ca hng cu l mt loi protein sc t c
tn l hemoglobin. Phn t hemoglobin chim 1/3 trng lng mi t bo hng cu. phn
trung tm ca mi phn t hemoglobin l 1 nguyn t st to mu sc cho hng cu. Ti phi,
t bo st kt hp vi oxy to ra mt hp cht c tn l oxyhemoglobin. Chc nng chnh
ca hng cu l vn chuyn oxy di dng ny n cc t bo khp c th. Sau khi oxy c
trao i, hemoglobin kt hp vi CO2 thi ra t t bo v hng cu quay tr li phi c
thi bt ra.
Do hng cu thng xuyn b p vo nhng mao mch nh li ti nn mng ca n d b h hi v
xi mn rt nhiu do mi t bo hng cu ch tn ti trong khong 4 thng. Nhng t bo
hng cu mi c sn xut lin tc ty xng thay th nhng t bo c.
Hnh nh hng cu chy qua cc mch mu.



NHM MU.
Hng cu mang nhng protein c gi l khng nguyn, l nhng cht gip c th nhn bit
nhng vt l xm nhp, mng ca mnh. Ngi ta da trn nhng khng nguyn ny quy
nh nhm mu: A, B, AB, hoc O. Ngi nhm mu A c tt c cc t bo hng cu trong c
th mang khng nguyn A. Ngi nhm mu B c tt c cc t bo hng cu trong c th mang
khng nguyn B. Ngi nhm mu AB c tt c cc t bo hng cu trong c th mang khng
nguyn A v B. Ngi nhm mu O c tt c cc t bo hng cu trong c th khng mang
khng nguyn no c.

Bit c nhm mu ca bnh nhn l iu rt quan trng nu mun thc hin truyn mu.
Ngi c nhm mu A khng th nhn c mu nhm B v h c mang khng th chng li
khng nguyn B. Tng t, nhm mu B mang khng th chng li khng nguyn A. Nhm mu
AB khng mang khng th chng li khng nguyn no c, nhng nhm mu O th li mang
khng th chng li c hai khng nguyn A v B. Nu bnh nhn b cho lm nhm mu th cc t
bo mu s vn cc li v lm tc nghn nhng mch mu nh. Phn ng ny, cn c gi l
phn ng kt dnh, c th gy t vong.
Hng cu cn c 1 loi khng nguyn khc c gi l khng nguyn Rh (n c ci tn ny do
loi khng nguyn ny c xc nh ln u tin kh Rhesus). Hu ht nhng ngi Vit Nam
mang nhm mu Rh dng (Rh+), iu c ngha l h c mang khng nguyn Rh. Nhng
ngi mang nhm mu Rh m (Rh-) th khng mang khng nguyn Rh. Khng ging vi nhm
mu ABO, cc khng th chng li khng nguyn Rh khng c tm thy mt cch t nhin
trong mu. Vn duy nht ch tht s xy ra khi ngi mang nhm mu Rh- c truyn vo
c th mu c Rh+. Khi , c th ca h s phn ng li bng cch to ra khng th chng li
khng nguyn Rh. ln truyn mu k tip, nu vn tip tc c truyn mu c Rh+ th khng
th chng li Rh c to ra t ln truyn mu trc s tn cng mu c truyn vo.
BCH CU
Bch cu c rt t nu so vi hng cu, khong 4.000 n 11.000 mi millimet khi mu, chim
t hn 1% tng th tch mu. Mc d chim s lng t nh vy nhng bch cu li ng mt
vai tr quan trng trong h thng min dch ca c th. N gip c th phng th, chng li s
tn cng ca vi khun, virus, k sinh trng v t bo ung th. Ging nh hng cu, bch cu
cng c to thnh t ty xng (mt s bch cu c to ra t cc m lympho). Trong khi
hng cu phi i theo dng chy ca mu th bch cu khng nh vy m n c th len qua cc
vch ca cc mao mch i thng n nhng khu vc b nhim trng hoc b tn thng ca
c th.
KHNG NGUYN Rh V THAI KZ
Yu t Rh ng mt vai tr quan trng trong thai kz khi ph n c Rh- ang mang thai a b
c Rh+. Trong qu trnh mang thai, nhng vt t trn mng nhau gip m c th tip xc c
vi mu ca tr c Rh+ (mng nhau l 1 loi mng lt t cung, cc cht dinh dng v oxy di
chuyn t m i xuyn qua mng ny cung cp cho tr), khi c th ca m s to ra
khng th chng li khng nguyn Rh. ln mang thai k tip, nu con tip tc c nhm mu
Rh+ th khng th chng li Rh ca m s i qua mu ca con v tiu dit cc t bo hng cu
ca b.
phng nga iu ny, bc s s cho nhng thai ph c Rh- RhoGAM, mt loi khng th
chng li Rh trong vng 72 gi ca ln sinh u tin. RhoGAM s tiu dit nhng hng cu Rh+
i vo h tun hon ca m trc khi h min dch c thi gian to ra khng th.
C 5 loi t bo bch cu trong mu: bch cu a nhn trung tnh (neutrophil), bch cu i toan
(eosinophil), bch cu i kim (basophil), mono bo v lympho bo. Mi loi gi mt vai tr
khc nhau trong h thng phng th ca c th v c huy ng chng li nhng loi bnh
khc nhau. Chng hn nh trong nhng bnh nhim trng mn tnh (ko di) nh lao phi th
mono bo gia tng s lng. i vi bnh nhn b hen suyn v trong nhng t d ng th
bch cu i toan gia tng s lng.

Hnh nh i thc bo ( pha sau) v lympho bo ( pha trc)

Cc t bo bch cu xc nh c mc tiu cn n nh nhng loi ha cht c bit. Khi m
b nhim trng hoc tn thng, n s phng thch nhng cht ha hc ra cc m xung quanh
li ko nhng t bo bch cu thch hp n chin u chng li. Tin trnh ny c gi l
ha ng ng.
TIU CU
Tiu cu khng phi l mt t bo tht s ging nh hng cu v bch cu. Chng l nhng
mnh v nh c dng hnh a ca nhng t bo rt ln c gi l t bo nhn khng l
(megakaryocyte) nm trong ty xng. T bo nhn khng l b v ra to thnh khong 50
mnh nh hoc hn v sau nhanh chng hnh thnh mng tr thnh tiu cu. C khong
300.000 tiu cu mi millimet khi mu, chng gip kim sot chy mu trong mt qu trnh rt
phc tp c gi l cn bng ni mi.
Khi mch mu b tn thng gy chy mu, cc tiu cu bt u tin trnh ng mu bng cch
dnh vo ni tn thng ca mch mu. Trong lc , chng phng thch ra nhng cht ha hc
li ko cc tiu cu khc li. Chng my chc, cc tiu cu kt dnh li v hnh thnh mt nt
chn tm thi. Sau , tiu cu phng thch ra serotonin, mt loi ha cht lm cho mch mu
co tht v hp li lm gim lng mu chy ra bn ngoi qua vt thng. Trong lc cc hin
tng ny xy ra, m b tn thng phng thch ra 1 cht kt hp vi calci v nhng yu t
ng mu khc trong huyt tng hnh thnh cht hot ha prothrombin. Cht hot ha
ny chuyn dng prothrombin (l mt cht c trong huyt tng do gan sn xut) thnh
thrombin (l mt loi enzyme). Thrombin sau kt hp vi fibrinogen to ra nhng phn
t di v mnh c gi l fibrin. Cc phn t fibrin kt hp vi nhau hnh thnh mt ci li
bt gi cc hng cu v tiu cu lm nn cho khi mu ng.
H TUN HON HOT NG NH TH NO

Trong qu trnh hot ng lin tc ca mnh, tim bp trung bnh hn 100.000 ln mi ngy
tng mu i hng nghn dm trong cc mch mu nui sng tng t bo mt trong hng t
t bo ca c th. mi nht bp, tim tng i khong 74 milli lt mu. ngi ln, tim trung
bnh p khong 72 nht mi pht, nh vy mi pht c khong 5,3 lt mu c tng i, mi
gi l 318 lt, mi ngy l 7.631 lt mu c tng i. Trong lc tp th dc, con s ny c th
tng ln gp 5 ln.
CHU CHUYN TIM

Chu chuyn tim l mt chui nhng s kin xy ra ti tim trong mt nhp p hon chnh ca
n. Mi mt chu chuyn tim chim khong 0.8 giy. Trong thi gian ngn , mu i vo tim, di
chuyn qua cc bung tim, sau c tng i ra khp cc khu vc ca c th. Mi mt chu
chuyn tim c chia ra lm 2 th. Hai tm nh co khi hai tm tht dn v sau th 2 tm tht
s dn ra khi 2 tm nh co. Pha co, c bit l tm tht, c gi l th tm thu, pha dn c
gi l th tm trng. Chu chuyn tim bao gm th tm thu v th tm trng ca c tm nh ln
tm tht.
DOPING MU
tng cng sc do dai ca mnh trc mi cuc thi u, mt s vn ng vin dng n
mt k thut c gi l doping mu. Th thut ny c thc hin bng cch rt bt mt
lng hng cu i. Sau khi mu b rt i, c th s p ng li bng cch nhanh chng sn xut
ra nhng hng cu khc thay th cho lng hng cu b ly i. Sau , mt vi ngy trc
khi thi u, ngi ta s tim ngc li lng mu rt ra vo c th.
Hiu qu ca vic ny l to ra hng cu nhiu hn do lng oxy trong mu cng nhiu hn.
Doping mu c th lm tng kh nng ca vn ng vin ln 10%.
Tuy nhin, th thut ny khng nhng khng hp php m cn nguy him. N c th lm suy
yu dng tun hon cng nh gy ra triu chng ging nh cm cm. Do thay v h tr
thm cho kh nng ca vn ng vin th n li lm hn ch nhng kh nng .
Qu trnh ny khi u khi mu b kh oxy (mang mt lng oxy rt nh) quay tr v tm
nh phi qua tnh mch ch. Cng lc , mu c oxy ha di chuyn t phi n tm nh
tri qua 4 tnh mch phi. Van nh-tht m ra v khi dng mu chy vo cc tm nh n cng
chy mt cch b ng vo cc tm tht. Cc van bn nguyt ng li ngn mu khng chy
t tm tht ra ngoi cc ng mch. Khi cc tm tht y khong 70%, nt xoang s gi i mt
xung ng lan truyn qua tm nh n nt nh tht. Tm nh co bp v tng khong 30% lng
mu vo cc tm tht.
Nt nh tht lm cc xung ng chm li trong mt thi gian ngn gip tm nh c thi gian
hon thnh qu trnh co li ca mnh. Xung ng ny sau i qua b nh tht, cc nhnh v
mng Purkinje n mm tim. Qu trnh co li ca cc tm tht c khi u t v tr ny,
p lc trong cc tm tht c gia tng mt cch nhanh chng v cc van nh tht ng li (gy
ra ting "bm" nghe c bng ng nghe) ngn khng cho mu chy ngc tr v tm nh.
Khi p lc trong cc tm tht tng cao hn p lc trong mu cc ng mch ln xut pht t
tim, cc van bn nguyt s m ra v mu s c tng ra khi cc tm tht. Mu b kh oxy
tm tht phi c bm ln phi qua cc ng mch phi, mu c oxy ha s ri tm tht
tri i n nhng phn cn li ca c th qua ng mch ch.
Khi tm tht co (th tm thu), cc tm nh dn (tm trng) v c y mu tr li. Khi tt
cc mu c tng i khi tm tht, cc van bn nguyt s ng li (gy ra ting tc nghe
c qua ng nghe) ngn nga dng mu chy ngc tr v tim. Cc tm tht tr nn trng
rng v ng li trong mt thi gian ngn. Khi p lc trong tm nh tng vt qu p lc trong
tm tht, van nh tht s m ra v mu s chy vo tm tht bt u mt chu chuyn tim
mi.
Tm li, trong mt chu chuyn tim, na phn trn ca tim (cc tm nh) nhn mu v mt na
phn di (cc tm nh) bm mu. Na phn bn phi ca tim (nh phi v tht phi) nhn v
bm mu b kh oxy, na phn bn tri (nh tri v tht tri) nhn v bm mu c oxy
ha.
HUYT P

Khi tm tht co, n tng mu ra khi tim i n cc ng mch ln v n hi lm chng dn ra
khi mu chy qua. p lc ca mu chng li thnh trong ca cc mch mu c gi l huyt
p. p lc ny cn thit gip cho mu chy n khp ni trong c th v quay ngc v tim.
Huyt p ln nht nhng ng mch ln v gn tim nht. Do cc thnh mch c tnh n hi
nn cc ng mch c kh nng phn hi li v bo ton hu ht p lc ca mu khi n c
tng ra khi tim. Khi mu i n nhng mch mu t n hi hn - nhng tiu ng mch, sau
n mao mch, tiu tnh mch v tnh mch - huyt p s gim xung. Khi mu quay tr v
tm nh phi qua tnh mch ch, p lc gn nh bng 0.
Khi tim co v dn trong sut chu chuyn tim th huyt p cng tng v gim trong mi nhp p.
Huyt p tng cao hn trong th tm thu (tht tri co) v gim thp hn th tm trng (tht
tri gin).
Huyt p c o bng n v milimet thy ngn (mmHg) bng my o huyt p. Gi tr huyt
p ghi nhn c thng l c ly t ng mch cnh tay. p lc tm thu c ghi nhn
trc, sau mi n p lc tm trng. Trung bnh, mt ngi trng thnh tr tui c
huyt p o c vo khong 120 mmHg i vi huyt p tm thu v 80 mmHg i vi huyt
p tm trng (c vit l 120/80 v c c l "mi-hai-trn-tm"). Ty thuc vo tui
tc, gii tnh, cn nng, v nhng yu t khc, huyt p bnh thng c gi tr thay i t 90
n 135 mmHg i vi huyt p tm thu v 60 n 85 mmHg i vi huyt p tm trng. Bnh
thng th huyt p cng gia tng theo tui.
O HUYT P
Nhn vin y t o huyt p ca bnh nhn bng mt thit b c bit c gi l my o huyt
p (sphygmomanometer). Thit b ny bao gm mt vng bng cao su, mt ci bng dng
bm bng tay v mt my dng c gi tr huyt p.
Vng cao su c bao va kht xung quanh cnh tay ca bnh nhn ngay pha trn khuu tay.
Sau , ngi o huyt p s t ng nghe ln ng mch cnh tay mt trong ca cnh tay
ngay pha trn cng tay nghe nhp mch p.
Vng cao su c bm cng phng ln bng cch bp bng cho n khi dng mu chy vo
cnh tay b ngng li v khng cn nghe hay cm thy nhp mch p na. Sau p lc vng
cao su s c gii phng t t. Khi mt lng mu nh bt u chy qua c ng mch b
chn p ta s nghe thy c mt m nh qua ng nghe. p lc ca vng cao su c c vo
thi im nghe c ting ng u tin c ghi nhn l huyt p tm thu.
Khi p lc ca vng cao su c gii phng nhiu hn na, ting nhp p tr nn ln hn v
du hn. Khi ng mch khng cn b p na v mu chy t do th ting ng s bin mt. p
lc ca vng cao su ghi nhn c vo thi im ting nhp p cui cng nghe c c gi
l huyt p tm trng.
Hnh ty l mt khi m thn kinh nm u ca ty sng v sn ca s kim sot nhng c
ng ngoi chng hn nh th v nhp tim. trong hnh ty c 2 trung tm iu khin tim
mch l trung tm kch thch v trung tm c ch. Nhng trung tm ny gi nhng xung thn
kinh n tim iu ha nhp tim.
H thn kinh t ch l mt phn ca h thng thn kinh c nh hng n nhng c quan ni
tng nh tim, phi, d dy, v gan. Chc nng ca n l ngoi {, iu ny c ngha l nhng c
ng m n iu khin xy ra m khng cn c s can thip ca thc. H thn kinh t ch
c chia ra lm 2 phn: h giao cm v h ph giao cm. H ph giao cm hot ng ch yu
khi c th ang trng thi bnh thng v ngh ngi, h giao cm hot ng ch yu nhng
lc c th b stress hoc cn nng lng.
Trung tm kch thch hnh no gi mt xung thn kinh i theo nhng dy giao cm n tim
lm tng nhp tim v tng lc co bp. Trung tm c ch gi xung thn kinh i theo nhng
dy ph giao cm n tim lm gim nhp tim. Nhng trung tm ny hot ng p ng li
vi nhng thay i ca huyt p v nng oxy trong mu thng l do tp th dc, tng thn
nhit v stress v cm xc. Nhng thay i trn c nhn bit nh cc cm th quan nm trn
ng mch cnh v cung ng mch ch.

Cc cm th quan ng mch cnh nhn bit c s gim huyt p, nhng cm th quan
trn cung ng mch ch cm nhn c s gim nng oxy trong mu. C 2 loi cm th
quan ny gi nhng xung thn kinh i dc theo nhng dy cm gic n trung tm kch thch,
v trung tm ny s gi nhng xung thn kinh i dc cc dy thn kinh n nt xoang ca tim
lm tng nhp tim. Khi huyt p v nng oxy trong mu tr v mc bnh thng th trung
tm c ch s gi nhng xung thn kinh n nt xoang n lm chm nhp tim li v mc bnh
thng.
S TRAO I GIA CC MAO MCH V CC M CA C TH
Cc ng mch, tiu ng mch, tiu tnh mch v tnh mch ch c mt chc nng duy nht l
vn chuyn mu i t tim ra ngoi hay t ngoi tr v tim. S trao i cht - oxy, CO2, cht
dinh dng v cht thi - gia mu v dch k din ra qua cc mao mch. Nhng s di chuyn
ny thay i khc nhau trong 3 cch: khuych tn, lc v thm thu.
Khuych tn l hin tng cc phn t di chuyn t khu vc c nng cao hn (cha nhiu
phn t loi hn) n khu vc c nng thp hn (cha t phn t loi hn). Hin
tng khuyc tn xy ra v cc phn t c nng lng t do, c ngha l chng lun lun chuyn
ng. y l trng hp c bit ca nhng phn t kh vn chuyn ng nhanh hn nhng
phn t cht lng v cht rn. Oxy v kh carbonic di chuyn qua li gia mao mch v dch k
bng s khuych tn. Khi mu i qua mao mch, oxy c ch bi hemoglobin trong hng cu
c s lng ln hn nn di chuyn n dch k xung quanh c s lng oxy t hn c
cc t bo nhn ly. Ngc li, CO2 c nng nhiu hn trong dch k nn di chuyn vo cc
mao mch c chuyn i. S trao i kh gia mu v dch k c gi l s h hp ni ti
(internal respiration).
Hin tng lc l cch di chuyn ca nc v cc cht tan trong nc xuyn qua mng t khu
vc c p lc cao hn n khu vc c p lc thp hn. Khi mu i vo cc mao mch n c p
lc o c l 33 mmHg trong khi p lc ca dch k ch khong 2 mmHg. Do , thng qua
hin tng lc, huyt tng v cc cht dinh dng nh amino acid, glucose, v vitamin i
xuyn qua thnh cc mao mch n cc dch k xung quanh.
S thm thu l hin tng khuych tn ca nc i qua mng bn thm (l mt loi mng ch
cho php mt vi cht qua c m thi). N di chuyn t khu vc c nhiu hn n khu vc
c t hn. Lin quan trc tip n hin tng ny l p lc thm thu, l khuynh hng ca mt
dung dch ko nc i vo dung dch . Gi tr ca p lc thm thu c tnh bng lng
cht ha tan c trong dung dch. Nu lng cht ha tan c trong dung dch cng ln th lng
nc c trong dung dch cng nh. Dung dch c cha mt lng ln cc cht ha tan s c
p lc thm thu ln v nc s c khuynh hng b ko vo dung dch nhiu hn.
u tn tip gip vi tiu tnh mch ca cc mao mch, ngay trc khi chng kt hp li
to thnh cc tiu tnh mch, p lc thm thu cc mao mch cao hn dch k do s hin
din ca albumin v mt s phn t protein ln vn cn nm li nh mt cht ha tan trong
mu. Dch k c p lc thm thu thp hn v do n s b ko vo cc mao mch v c
mang i.

Hnh nh s thm thu: nc i t ni c nhiu n ni c t nc hn

S TRAO I CA MAO MCH TRONG PHI
Sau khi mu i ht cc m ca c th, trao i oxy v cht dinh dng ly CO2 v cc cht
b th n quay tr v tim. Mu b kh oxy tr v tm nh phi qua tnh mch ch, sau i
vo tht phi. Ti y n s c bm ln thn ng mch phi, sau thn ng mch phi
s chia ra lm 2 nhnh ng mch phi phi v ng mch phi tri mang mu b kh oxy
i vo mi bn phi.
Ti phi, cc ng mch tip tc chia nhnh ra thnh nhng ng mch nh hn ri sau
thnh nhng tiu ng mch nh hn na. Cui cng, nhng tiu ng mch nh nht s phn
nhnh ra thnh cc mao mch. Nhng mao mch phi ny bao xung quanh cc ph nang, l
nhng ti kh ca phi. S trao i oxy v kh CO2 ti phi xy ra xuyn qua thnh ca cc ph
nang v gn cc mao mch.
S trao i kh ny xy ra da trn nguyn tc khuch tn. Kh trong cc ph nang c nng
oxy cao. Mu trong cc mao mch phi c nng CO2 cao. Do , theo nguyn tc khuch
tn, oxy ti cc ph nang s di chuyn vo cc mao mch trong khi CO2 trong cc mao mch
s di chuyn ngc li vo cc ph nang.
Sau khi c oxy ha, mausex chy t cc mao mch sang cc tiu tnh mch, chng kt hp
vi nhau thnh nhng tnh mch ln dn. Cui cng, mu ri khi phi qua 2 tnh mch phi
ln v c mang n tm nh tri c bm ngc tr li vng tun hon h thng mt
ln na. S di chuyn ca mu t phi tr v tim l mt hin tng kh c bit trong c th v
y l ln duy nht m cc tnh mch li c mang mu c oxy ha.
VNG TUN HON GAN - TNH MCH CA
Mt vng tun hon c bit khc na l vng tun hon gan - tnh mch ca, mt nhnh ca
vng tun hon h thng. vng tun hon ny, mu i t cc c quan ca b my tiu ha v
t lch chy qua gan trc khi i thng v tim.
Cc mao mch dn mu n d dy, rut non, rut gi, ty v lch chy vo 2 tnh mch ln l
tnh mch mc treo trng trn v tnh mch lch. Hai tnh mch ny hp vi nhau thnh tnh
mch ca mang mu i vo trong gan.
Khi vo gan, tnh mch ca chia nhnh ra hnh thnh cc mao mch c gi l cc
xoang. Cc xoang ny ln hn nhng mao mch bnh thng khc. Thnh ca chng c tnh
thm cao hn, cho php cc protein v t bo mu i vo v ra d dng. y l tnh cht rt
quan trng v mu i vo gan t cc c quan thuc h tiu ha c cha mt lng ln cc cht
dinh dng.
Khi mu chy t t qua cc xoang trong gan, mt s cht dinh dng c ly ra khi mu v
cha trong gan c s dng sau hoc chuyn thnh nhng cht khc cn thit cho c th.
T cc xoang, mu chy vo cc tnh mch gan tri v phi, sau i i vo tnh mch ch di v
cui cng i vo tm nh phi.
t khi gp hin tng mu chy hon ton t h tiu ha n tim. Bnh thng th mu t cc
ng mch v cc mao mch v chy vo cc tnh mch. vng tun hon gan-tnh mch
ca khng c s tham gia ca ng mch m cc mao mch kt hp li to thnh cc tnh
mch, sau chia nh ra thnh cc mao mch ri kt hp thnh cc tnh mch tr li. Vng
tun hon ny l cn thit mu c th c gan iu chnh. Cc cht dinh dng c th
c bo qun hoc thay i v khi cc cht c th gy c (nh ru v thuc) c th
chuyn thnh nhng cht t gy hi hn trc khi mu tr v tim v phn cn li ca vng tun
hon.
2. SINH L MU

1. KHI LNG.
Mu l t chc lng, lu thng trong h tun hon. Trong 1 kg th trng, c 75 - 80ml mu. Tr
s sinh c 100ml mu /kg cn nng, sau khi lng mu gim dn. T 2 -3 tui tr i khi
lng mu li tng dn ln, ri gim dn cho n tui trng thnh th hng nh. Mt ngi
trng thnh, bnh thng mu chim 7 - 9% trng lng c th. Mt ngi nng 50kg c
khong 4 lt mu. Ngi ta c th xc nh khi lng mu chnh xc bng nhiu phng php
khc nhau: phng php tim cc cht c mu vo mu, cht ny t b lc ra khi thn, phn
hu nhanh v khng c hi hoc dng cc cht ng v phng x nh du hng cu.
Khi lng mu tng ln sau khi n, ung, khi mang thai, khi truyn dch... Khi lng mu gim
khi c th ra nhiu m hi, nn ma, a chy, chn thng c chy mu bn trong hoc bn
ngoi c th ... Nu khi lng mu tng ln trong c th, dch t mu s vo khong gian bo
ca da v cc m, sau nc c bi xut dn theo nc tiu. Nu khi lng mu gim
trong c th, dch t khong gian bo vo mu lm cho khi lng mu tng ln. Trong nhiu
trng hp mt mu cp din (mt mu cc tng ln, cc xng ln, mt mu ng ng
mch ...) khi lng mu b gim t ngt, c th khng c kh nng t b tr; nu khng cp
cu kp thi, c th s khng sng c.
2. THNH PHN.
Mu gm hai thnh phn: th hu hnh (huyt cu) v huyt tng. Cc th hu hnh ca mu
l hng cu, bch cu v tiu cu, chim 43 - 45% tng s mu, ch s ny c gi l
hematocrit. Hng cu l thnh phn chim ch yu trong th hu hnh. Huyt tng chim 55 -
57% tng s mu. Huyt tng cha nc, protein, cc cht in gii, cc hp cht hu c v
v c, cc hocmon, cc vitamin, cc cht trung gian ho hc, cc sn phm chuyn ho ... Huyt
tng cha ton b cc cht cn thit cho c th v ton b cc cht cn c thi ra ngoi.
Huyt tng b ly mt fibrinogen th c gi l huyt thanh.
3. CHC NNG SINH L[ CA MU.
Mu c rt nhiu chc nng , di y l nhng chc nng c bn ca mu:
3.1. Chc nng dinh dng.
Mu mang trong mnh ton b cc cht dinh dng nui c th. Cc cht dinh dng c
a t ngoi vo qua ng tiu ho. Ngoi ra bch cu cn vo lng ng tiu ho nhn cc
cht dinh dng theo kiu "m bo" v "thc bo", ri li vo lng mch mang thm mt phn
cc cht dinh dng cho mu.
3.2. Chc nng bo v.
Mu c kh nng bo v c th khi b nhim trng nh c ch thc bo, m bo v c ch
min dch dch th, min dch t bo. Mu cng c kh nng tham gia vo c ch t cm mu,
trnh mt mu cho c th khi b tn thng mch mu c chy mu.
3.3. Chc nng h hp.
Mu mang 0xy t phi ti t bo v m, ng thi mu mang cacbonic t t bo v m ti
phi.
3.4. Chc nng o thi.
Mu mang cc cht sau chuyn ho, cht c, cht l ti cc c quan o thi (thn, b my
tiu ho, phi, da ) thi ra ngoi.
3.5. Chc nng iu ho thn nhit.
Mu mang nhit phn "li" ca c th ra ngoi thi vo mi trng hoc gi nhit cho c
th nh c ch co mch da.
3.6. Chc nng iu ho cc chc phn c th.
Bng s iu ho tnh hng nh ni mi, mu tham gia vo iu ho ton b cc chc phn
c th bng c ch thn kinh v thn kinh - th dch.
4. C TNH CA MU.
Mu c tnh hng nh. Tnh hng nh ca mu c nh gi qua cc ch s sinh l, sinh ho
ca mu. Cc ch s ny, trong iu kin sinh l{ bnh thng l rt t thay i hoc ch thay i
trong mt phm vi rt hp. V vy chng c coi nh l mt hng s. Kim tra cc ch s sinh
l, sinh ho ca mu l mt vic lm v cng quan trng v rt cn thit nh gi nhng ri
lon chc nng ca c th.

3. RI LON LM SNG MU

1. Thiu mu.
Thiu mu l gim Hb trong mu di mc bnh thng. Theo W.H.O ngi b thiu mu l
ngi c hm lng Hb mu gim:
< 13gHb trong 100ml mu (i vi nam)
< 12g Hb trong 100ml mu (i vi n)
< 14g Hb trong 100ml mu (i vi tr s sinh)
Thiu mu l do mt mu, do mu b hu nhanh hn trong c th hoc do tu xng gim sn
xut.
- Thiu mu do mt mu cp tnh hoc mn tnh.
- Thiu mu do suy nhc tu v b nhim x, nhim c (cht c ho hc cng nghip, chin
tranh).
- Thiu mu do thiu acid folic, thiu vitamin B12 hoc thiu yu t ni v ct b d dy vim
teo d dy, vim lot d dy- t trng.
-Thiu mu do thiu st, do thiu dng.
- Thiu mu do thiu cc yu t kch thch tng sinh, tng trng hng cu erythropoietin (suy
thn, gan mn tnh).
- Thiu mu do tan mu, do i sng hng cu qu ngn. Mt s bnh ca hng cu do mng
hng cu km bn d v nh bnh thiu mu c hng cu hnh li lim, bnh thiu mu c
hng cu hnh cu (kch thc hng cu rt nh, hnh cu).
2. a hng cu.
- a hng cu th pht do sng vng ni cao, do suy tim, do bnh ng h hp... y l a
hng cu do thiu oxy cc m.
- a hng cu tht s do tu xng tng sn xut hng cu (c km theo tng bch cu v tiu
cu). Hu qu l qu ti chc nng tun hon, nht mu tng, ri lon tun hon mao mch.

4. SINH L CM MU V NG MU

1. CM MU.
Cm mu l mt qu trnh sinh l, sinh ha tng hp nhm chm dt hoc ngn cn s mt
mu ca c th khi mch mu b tn thng hoc b t. Cm mu c thc hin nh cc c
ch: co mch, s hnh thnh nt tiu cu, ng mu, co cc mu, tan cc mu ng v s pht
trin m x trong cc mu ng ng kn vt thng.
nh gi khi qut chc nng cm mu, cc nh lm sng thng s dng hai xt ngim: xc
nh thi gian chy mu (s b nh gi cc yu t ca thnh mch v tiu cu), xc inh thi
gian ng mu (s b nh gi cc yu t gy ng mu ca huyt tng). Thi gian mu chy
theo phng php ca Duke l 3 pht. Thi gian mu ng theo phng php ca Milian l 7
pht.
1.1. Co mch.
Ngay sau khi mch b tn thng, mch mu b co li do tnh n hi ca thnh mch. Co mch
cn c thc hin nh c ch thn kinh v thn kinh-th dch. Nhng kch thch gy au t
ni tn thng, nhng cht trung gian ho hc c gii phng khi au gy phn x co c trn
thnh mch. ng thi lc ny ti ni tn thng, tiu cu b v ra, gii phng serotonin gy co
mch ti ch.
1.2. S hnh thnh nt tiu cu.
Ti ni tn thng, t bo ni mc hoc thnh mch tn thng l si collagen, tiu cu
bm vo nhng ni ny v b hot ho. Khi tiu cu b hot ho, cc protein trong n c rt
mnh v gii phng ra cc yu t lm hot ho cc tiu cu bn cnh, lm cho chng dnh vo
nhau to nn nt tiu cu bt kn ch tn thng (nu l cc tn thng nh). Hng ngy c th
ta phi chu hng trm vt rch rt nh ni mao mch do sang chn. Nh c chc nng ny m
c th trnh c s chy mu mao mch.
1.3. S hnh thnh cc mu ng.
Tiu cu gii phng ra cc yu t gy co mch v gy ng mu, to ra cc mu ng b sung
cho nt tiu cu bt kn ch tn thng (nu l cc tn thng ln hn). ng mu pht
trin nhanh trong vng 1-2 pht. Nhng cht hot ho gy ng mu c gii phng do t
chc v mch mu b tn thng, nhng cht do tiu cu gii phng v nhng cht gy ng
mu ca huyt tng c hot ho, pht ng mt qu trnh ng mu. Nu vt thng
khng qu nng, sau 3-6 pht cc mu ng hnh thnh bt kn vt thng. Sau 20 pht n 1
gi, cc mu ng co li lm cho cc mu vng chc hn.
Sau khi cc mu ng hnh thnh, vi gi sau cc nguyn bo si xm nhp, bin cc mu ng
thnh m x trong 1-2 tun l, nu l cc mu ng nh v vt thng nh. Nu l vt thng
ln, tn thng rng, mu mt nhiu, c th khng t bo v c, cn phi c s can thip
kp thi.
2. NG MU.
Trong mu v trong cc m c cha khong 50 cht c nh hng ti qu trnh ng mu. Cc
cht kch thch qu trnh gy ng mu gi l cc cht gy ng mu. Cc cht li c ch qu
trnh gy ng mu gi l cc cht chng ng mu. Mu c ng hay khng ng l ph thuc
vo s cn bng gia cc cht gy ng mu v cc cht chng ng mu. Bnh thng mu
trong c th khng ng l do cht chng ng mu chim u th. Khi mu, mch mu b tn
thng, khi mu ly ra ngoi c th, cc cht gy ng mu c hot ho v tr nn u th,
ng mu c thc hin.
2.1. nh ngha.
ng mu l mt qu trnh chuyn mu th lng sang th c, m thc cht l chuyn
fibrinogen dng ha tan thnh fibrin dng khng ho tan.
2.2. C ch ng mu (cc giai on ca qu trnh ng mu).
ng mu c din ra theo mt c ch rt phc tp. y l mt qu trnh hot ho v hot
ng ca cc enzym vi mc ch l to ra fibrin. Thng thng ngi ta chia qu trnh ng
mu ra lm ba giai on:
Giai on hnh thnh phc hp prothrombinase.
Giai on hnh thnh thrombin.
Giai on hnh thnh fibrin.
2.2.1. S hnh thnh phc hp prothrombinase.
Khi ng cho c ch ng mu l s hnh thnh phc hp prothrombinase. y l mt c ch
rt phc tp (c l l phc tp nht ) v ko di nht ca qu trnh ng mu. Qu trnh c
xy ra khi c chn thng thnh mch v m, khi c chn thng mu, khi c s tip xc ca
mu vi t bo ni mc tn thng hoc vi si collagen ca mch mu, vi cc m khc ngoi
ni mc hoc vi bt kz vt l no.
S hnh thnh phc hp prothrombinase theo hai c ch ngoi sinh v ni sinh. C ch ngoi
sinh xut hin nu c chn thng thnh mch hoc cc m k cn. C ch ni sinh xut hin
nu c chn thng mu hoc mu ly ra ngoi c th t lng mch. Trong c hai c ch ni
sinh v ngoi sinh c mt lot protein huyt tng (c bit l a
2
-globulin) ng vai tr rt quan
trng, l cc yu t gy ng mu ca huyt tng. Hu ht cc yu t ny l cc enzym
dng khng hot ng. Khi chuyn thnh hot ng, chng gy ra cc phn ng ho sinh lin
tip nhau ca qu trnh ng mu. Cc yu t ny c k hiu bng ch s Lam phn bit
vi cc yu t ca tiu cu c k hiu bng ch s rp.
Yu t I: fibrinogen
Yu t II: prothrombin
Yu t III: thromboplastin ca m
Yu t IV: ion Ca
++

Yu t V: proaccelerin
Yu t VII: proconvertin
Yu t VIII: globulin A chng a chy mu (antihemophilic globin-AHG).
Yu t IX: globulin B chng a chy mu (plasma thromboplastin component-PTC).
Yu t X: Stuart-Prower
Yu t XI: globulin C chng a chy mu (plasma thromboplastin antecedent-PTA).
Yu t XII: Hageman
Yu t XIII: n nh fibrin (fibrin stabilizing factor-FSF).
- S hnh thnh phc hp prothrombinase theo c ch ngoi sinh.
M b tn thng gii phng yu t III, phospholipid t mng t bo m. Yu t X c hot
ho (X
a
) nh yu t III, yu t VII
a
(yu t VII c hot ho nh yu t III), ion Ca
++
v
phospholipid. S hnh thnh phc hp prothrombinase t yu t X
a
c s tham gia ca yu t
V
a
(yu t V c hot ho nh thrombin), ion Ca
++
v phospholipid. Yu t V
a
lm tng hot
tnh ca yu t X
a
. Phospholipid ng vai tr l cht nn cn ion Ca
++
lm cu ni gia cc yu
t. Thrombin trong trng hp ny c tc dng iu ho.
- S hnh thnhphc hp prothrombinase theo c ch ni sinh.
Mu b chn thng, mu tip xc vi collagen hoc b mt vt l th lm hot ho yu t XII v
gii phng phospholipid tiu cu. Yu t XII
a
chuyn yu t XI thnh yu t XI
a
(c s tham gia
ca yu t Fletcher v Fitzgerald). Yu t XI
a
chuyn yu IX thnh yu t IX
a
(c s tham gia ca
yu t tiu cu). Yu t X c hot ho c s tham gia ca yu t VIII
a
(yu t VIII c hot
nh thrombin), yu t IX
a
, ion Ca
++
v phospholipid. S hnh thnh phc hp prothrombinase t
yu t X
a
c s tham gia ca phospholipid, yu t V
a

(yu t V c hot ho nh thrombin) v
ion Ca
++
. S hnh thnh phc hp prothrombinase theo c ch ni sinh chm hn rt nhiu (1-6
pht) so vi c ch ngoi sinh (15 giy).
Prothrombinase c hnh thnh t c ch ni sinh hoc ngoi sinh hoc ng thi c hai c
ch ni sinh v ngoi sinh. iu ny chng t hot tnh ca prothrombinase l ph thuc vo s
hot ho ca cc yu t tham gia vo qu trnh ny.
2.2.2.S hnh thnh thrombin
Prothrombin l a
2
-globulin, do gan sn xut, c trng lng phn t 68700, nng trong mu
bnh thng l 15mg/100ml mu. Khi phc hp prothrombinase hnh thnh n s chuyn
prothrombin thnh thrombin. Giai on ny cng cn s c mt ca ion Ca
++
. S hnh thnh
thrombin t prothrombin l rt nhanh, c tnh bng vi giy.
2.2.3. S hnh thnh fibrin.
Fibrinogen l mt protein do gan sn xut, trng lng phn t 340000, nng trong mu
bnh thng l 100-700mg/100ml mu. Bnh thng fibrinogen rt kh vo dch k. Khi thnh
mch tng tnh thm (m b vim) th fibrinogen vo dch k v b ng li do cc yu t gy
ng mu cng vo dch k.
Thrombin sau khi c hnh thnh chuyn fibrinogen thnh fibrin n phn. Cc fibrin n
phn t trng hp thnh fibrin dng si. Mt mng li fibrin hnh thnh v c n nh
nh yu t XIII. Giai on ny cng c s tham gia ca ion Ca
++
. Cc t bo mu c gi li
trn li fibrin v to nn cc mu ng. Chnh mng li ny dnh vo v tr tn thng ca
thnh mch ngn cn s chy mu.
Bn cht ca mu ng l hnh thnh li fibrin t fibrinogen nh thrombin. Chnh v vy cc
nh ngoi khoa s dng thrombin (dng tm, gc hoc bt...) cm mu khi phu thut,
c bit l cm mu cc xng xp.
2.3. S co cc mu ng.
Sau khi cc mu ng hnh thnh, n bt co li v r ra huyt thanh (huyt tng b ly mt
fibrinogen th c gi l huyt thanh).
Tiu cu c vai tr quan trng cho s co cc mu ng. Tiu cu c tc dng gn cc si fibrin
li vi nhau v n nh vng chc fibrin. Tiu cu bm trn li fibrin, khi n co rt n lm cho
li fibrin co theo, ng thi vi s gii phng yu t 8 ca tiu cu lm cho cc mu ng co
cng mnh hn. Co cc mu ng cn c s tham gia ca thrombin, ion Ca
++
. Cc mu ng lc
ny rt bn vng, gi cho cc mp ca thnh mch tn thng khp li gn nhau to iu kin
thun li cho lin vt thng.
2.4. S tan cc mu ng.
Trong huyt tng c pasminogen (profibrinolysin). Cc m tn thng, ni mc tn thng v
vi khun gii phng ra cht hot ho plasminogen. Khong mt ngy sau khi cc mu ng,
cht ny chuyn plasminogen thnh plasmin. Plasmin l mt enzym lm tiu fibrin v c
fibrinogen lm tan cc mu. V l do ny m c th gy ra chy mu th pht rt nguy him, cn
phi c phng. Ti vim, nu vi khun lm tiu fibrin i th c th s lm cho vi khun
lan rng v hng ro fibrin bo v b ph v. Song cng nh c ch ny m trong c th c
hin tng t tiu fibrin lm khai thng nhiu mch mu nh b tc nghn.


5. CU TO - CHC NNG CA HNG CU

I. CU TO
1. HNH DNG V KCH THC.
Hng cu trng thnh, lu thng trong mu l t bo khng c nhn. iu kin t nhin, n
c hnh a lm hai mt, ng knh khong 7,2mm, b dy ngoi vi l 2,2mm, trung tm l
1mm
Th tch mt hng cu l 83mm
3
(83femtolit). Nh c tnh n hi tt m hng cu d dng
thay i hnh dng khi i qua cc mao mch. Din tch b mt hng cu ln (do c hai mt lm),
v vy khi hng cu bin dng mng hng cu khng b cng v v ra. Nu tnh din tch ton b
mng hng cu trong c th cng li, c th ln n 3000m
2
.
2. THNH PHN.
T l thnh phn ca hng cu
% Cc thnh phn
67,00 Nc
28,00 Hemoglobin
0,30 Lipid cc loi (lecitin, cholesterol)
2,00 Nhng cht khc c cha nit (enzym, protein,
glutation)
0,02 Ur
1,20 Cc cht v c (K
+
)
Hng cu c mt cu trc c bit vi nhiu thnh phn khc nhau. N gm mt nn do protein
v lipid to nn. a s lipid u kt hp vi protein to thnh lipoprotein. Trong nn cn c
glucose, clorua, phosphat... Nn v mng chim 2 -5% trng lng hng cu. Gia cc mt ca
nn c hemoglobin. Hai thnh phn quan trng nht ca hng cu c nghin cu nhiu l
mng hng cu v hemoglobin. Mng hng cu mang nhiu khng nguyn nhm mu.
Hemoglobin l thnh phn quan trng trong s vn chuyn kh ca mu.
3. S LNG.
Ngi trng thnh, mu ngoi vi c 3,8 x 10
12
hng cu/lt (i vi n); 4,2 x10
12
hng
cu/lt (i vi nam). Tr mi sinh, ngy u s lng hng cu rt cao (5,0 x10
12
hng
cu/lt). Sau , do hin tng tan mu, s lng hng cu gim dn. Tr em di 15 tui c s
lng hng cu thp hn ngi trng thnh 0,1 - 0,2 x 10
12
hng cu/lt. S lng hng cu
n nh tui trng thnh.
S lng hng cu tng ln sau ba n, khi lao ng th lc, sng trn ni cao 700 - 1000m,
khi ra nhiu m hi, i nhiu, a chy, bng mt huyt tng, trong bnh a hng cu, bnh
tim bm sinh.... S lng hng cu gim lc ng, khi ung nhiu nc, cui kz hnh kinh, sau
, i lu ngy, ni c phn p oxy cao, cc loi bnh thiu mu, suy tu, nhim c, chy
mu trong, chy mu do vt thng...
4. QU TRNH SINH HNG CU
4.1. Ngun gc v cc giai on pht trin ca hng cu
Nhng tun u ca thai nhi hng cu c nhn c l thai gia sn xut. T thng th hai tr
i gan, lch, sau l hch bch huyt cng sn xut ra hng cu c nhn. T thng th 5 ca
kz pht trin thai, tu xng bt u sn xut hng cu v t tr i, tu xng l ni duy
nht sinh ra hng cu. Sau tui 20 cc tu xng di b m ho, cn tu xng xp nh xng
sng, xng sn, xng c, xng chu sn xut hng cu. V vy tui gi d b thiu mu
hn.
T bo tu xng l t bo gc vn nng c kh nng duy tr ngun cung cp t bo gc v pht
trin thnh t bo gc bit ho to ra cc dng khc nhau ca t bo mu (theo thuyt mt
ngun gc). T bo gc bit ho sinh ra hng cu c gi l n v to cm ca dng hng
cu: C.F.U.E (Colony forming unit erythrocyt). Sau cc t bo dng hng cu tri qua cc giai
on sau y.
Tin nguyn hng cu (proerythoblast)
Nguyn hng cu a kim( normoblast a kim) Nguyn hng cu a sc (normoblast a
sc) Nguyn hng cu (normoblast) Hng cu li (reficulocyt) Hng cu trng thnh
(erythrocyt)
Nhn ca nguyn hng cu mt i khi nng hemoglobin trong bo tng cao > 34%. Hng
cu chnh thc khng c nhn xuyn mch ri b tu xng vo h tun hon chung. Hng cu
li cng c kh nng vo mu nh hng cu trng thnh nhng t l rt thp ch chim 1%
tng s lng hng cu mu ngoi vi, khong 1-2 ngy sau hng cu li tr thnh hng cu
trng thnh. Hng cu sng trong mu khong 120 ngy (ngi da trng), gn 120 ngy
(ngi Vit).
H thng enzym ni bo hng cu lun lun tng hp ATP t glucose duy tr tnh n hi
ca mng t bo, duy tr vn chuyn ion qua mng, gi cho st lun lun c ho tr 2, ng thi
ngn cn s oxy ho protein trong hng cu. Trong qu trnh sng, h thng enzym gim dn,
hng cu gi ci, mng hng cu km bn v d v.
Mt phn hng cu t hu trong mu, cn i b phn hng cu b hu trong t chc vng - ni
m ca lch, gan, tu xng. Hemoglobin c gii phng ra b thc bo ngay bi cc i thc
bo lch, gan, tu xng. i thc bo gii phng st vo mu v n c vn chuyn di
dng ferritin. Phn porphyrin ca hem trong i thc bo c chuyn thnh sc t bilirubin
gii phng vo mu, ri qua gan bi tit theo mt.
4.2.Cc nguyn liu cn thit cho qu trnh sinh hng cu
to thnh hng cu, trong c th c hai qu trnh song song: s to thnh t bo hng cu
v s tng hp hemoglobin. y l nhng qu trnh rt phc tp, i hi nhiu nguyn liu nh
protein, cholin, thymidin, acid nicotinic, thiamin, pyridoxin, acid folic, vitamin B12, Fe
++
, nhiu
enzym v cht xc tc cho qu trnh tng hp ny.
Vitamin B12 v acid folic rt cn cho qu trnh tng hp thymidintriphosphat, mt trong nhng
thnh phn quan trng ca DNA. Thiu vitamin B12 v acid folic s lm gim DNA, t bo s
khng phn chia v khng trng thnh c.Lc ny cc nguyn hng cu trong tu xng c
kch thc ln hn bnh thng, c gi l nguyn bo khng l. T bo to ra l v lng DNA
khng nhng lng RNA li tng dn ln hn bnh thng, t bo tng tng hp
hemoglobin hn v cc bo quan cng nhiu hn. Cc hng cu trng thnh s c hnh bu
dc khng u, mng mng hn v i sng s ngn hn (ch bng 1/3 - 1/2 thi gian ca hng
cu bnh thng).
Vitamin B12 qua ng tiu ho kt hp vi yu t ni (t bo vin tuyn d dy bi tit).
Phc hp ny gn vo receptor mng t bo nim mc hi trng v vitamin B12 c hp thu
theo c ch m bo. Vitamin B12 vo mu, d tr gan. Nhu cu vitamin B12 l 1 - 3 mg/24h.
Trong khi s d tr vitamin B12 ca gan c th gp 1000 ln nhu cu ca c th trong mt
ngy.
Thnh phn th hai khng km phn quan trng l st. St c hp thu theo ng tiu ho
vo mu. Trong mu, st c kt hp vi mt globulin l apotransferrin to thnh
transferrin vn chuyn trong huyt tng (v st lin kt vi globulin rt lng lo). St c vn
chuyn ti cc m c bit: t chc vng - ni m v gan. Ti y, st c gii phng ra v
c t bo hp thu.
Trong bo tng, st kt hp vi mt protein l apoferritin to thnh ferritin l dng d tr
st. Mt lng nh st c d tr dng hemosiderin trong t bo. c tnh duy nht ca
transferrin l n gn rt mnh vi receptor mng t bo nguyn hng cu. Trong t bo,
transferrin gii phng st vo ty lp th. Ti y din ra qu trnh tng hp hem. Mi ngy mt
ngi trng thnh cn 1mg st. Ph n cn st nhiu gp i so vi nam gii v b mt mu
qua mu kinh nguyt. St b thi hng ngy qua phn v m hi.
St c hp thu rut nh apoferritin do gan sn xut, bi tit theo mt vo t trng.
Apoferritin gn vi st t do hoc vi st ca hemoglobin, myoglobin to thnh
transferrin.Transferrin gn vo receptor t bo nim mc rut, ri vo mu. St c hp thu
rt chm v rt t, mc d st c n vo theo thc n l kh nhiu. Khi apoferritin trong c
th bo ho st th transferrin khng gii phng st cho cc m v cng khng nhn st t rut,
hp thu st b ngng li.
Khi c th tha st, gan gim sn xut apoferritin lm cho apoferritin trong mu v mt gim v
cng lm gim hp thu st. Trong trng hp n qu nhiu st, st vo mu nhiu dn n lng
ng hemosiderin trong cc t bo vng - ni m, gy c hi cho t bo ny.
4.3. S iu ho qu trnh sinh hng cu
S lng hng cu mu ngoi vi c iu ho hng nh nhm cung cp oxy cho t bo
hot ng. S tng trng v sinh sn ca cc t bo gc c kim sot bi cc protein kch
thch tng trng, v d nh interleukin 3.
Cc t bo gc bit ho n lt mnh li chu s kch thch tng trng ca cc cht gy bit
ho, m cc cht ny li c rt nhiu c quan nh thn, gan... sn xut khi chng b thiu
oxy.
Bnh nhn b thiu mu do mt mu, b gim chc nng tu xng khi b chiu x, nhng ngi
sng vng ni cao c nng oxy trong khng kh thp hn bnh thng, bnh nhn b suy
tim, cc bnh v phi c gim trao i kh phi... u gy ra thiu oxy cc m lm cho qu
trnh oxy ho cc m b gim i.
Khi cc m b thiu oxy chng sn xut ra erythropoietin. Erythropoietin l mt glucoprotein c
TLPT l 34000. Bnh thng 80-90% erythropoietin l do thn sn xut, cn li l do gan sn
xut. Mt s m khc cng sn xut erythropoietin, nhng khng ng k. V vy chng ta c
th gp bnh nhn thiu mu do suy thn mn tnh. Khi thn v gan thiu oxy, erythropoietin
s c sn xut sau vi pht hoc sau vi gi.
Erythropoietin do thn sn xut dng cha hot ng gi l erythogenin. Nh kt hp vi
mt globulin (do gan sn xut) erythogenin chuyn thnh erythropoietin hot ng.
Erythropoietin c tc dng: kch thch qu trnh chuyn C.P.U.E thnh tin nguyn hng cu v
kch thch chuyn nhanh cc hng cu non thnh hng cu trng thnh.
5. SC BN HNG CU
Mng hng cu l mt mng bn thm. Nc c th qua mng hng cu khi p xut thm thu
bn trong v bn ngoi hng cu khc nhau. Ngi ta xc nh sc bn hng cu bng dung
dch mui NaCl nhc trng c nng khc nhau t 0,02% mt ( phng php Hamberger).
Hng cu trong dung dch mui NaCl nhc trng b trng to ln v v ra do nc t dung
dch mui vo trong hng cu.Khi hng cu v, hemoglobin gii phng vo dung dch v lm
cho n c mu hng. Mt s hng cu bt u v trong dung dch mui NaCl nhc trng
0,44%. Nng mui NaCl 0,44% c gi l sc bn ti thiu ca hng cu. Ton b hng cu
v ht trong dung dch NaCl nhc trng 0,34%. Nng mui NaCl 0,34% c gi l sc
bn ti a ca hng cu.
Sc bn ca hng cu gim trong bnh vng da hu huyt, tng ln sau ct lch.
6. TC LNG HNG CU
Mu c chng ng, t trong ng nghim, hng cu lng xung di, huyt tng ni ln
trn. iu xy ra l do t trng ca hng cu (1,097) cao hn t trng ca huyt tng
(1,028). Khi c qu trnh vim din ra trong c th lm hm lng cc protein mu thay i, cn
bng in tch protein huyt tng thay i, in tch mng hng cu cng b bin i theo,
hng cu d dnh li vi nhau hn v lm cho n lng nhanh hn.
Nh vy tc lng mu cng cao th qu trnh vim ang din ra trong c th cng mnh. Ch
s tc lng hng cu l chiu cao ct huyt tng tnh bng mm trong 1h, 2h v 24h.
7. HEMOGLOBIN
7.1. Cu trc ca Hemoglobin.
Hemoglobin (Hb) l 1 protein mu, phc tp thuc nhm chromoproteid mu , c nhm
ngoi l hem. Hb l thnh phn ch yu ca hng cu, chim 28% v tng ng vi 14,6g trong
100 ml mu. TLPT ca Hb l 64.458.
Hb gm 2 phn: hem v globin. Mi phn t Hb c 4 hem v 1 globin. N c to thnh t 4
di n v. Mi di n v l 1 hem kt hp vi globin.
Globin c cu trc l cc chui polypeptid. ngi ln, 4 chui polypeptid ging nhau tng i
mt: 2 chui a v 2 chui b. Cc di n v lin kt vi nhau bng lin kt yu: lin kt ion, lin
kt hydro, to nn cu trc bc 4 ca phn t Hb (hnh 3.2). chui polypeptid ca mi di
n v c 1 hc cha hem. Trung tm ca phn t Hb c 1 hc rng gi l hc trung tm (hnh
3.3). Hc trung tm tip nhn phn t 2,3 diphosphoglycerat (2,3 DPG) v s kt hp ca hc
trung tm vi 2,3 DPG c vai tr iu ho i lc ca Hb vi 0xy.
Thnh phn th 2 ca Hb l hem. Sc t hem thuc loi porphyrin l nhng cht c kh nng
kt hp vi nguyn t kim loi. Hem ngi l porotophyrin IX kt hp vi Fe
++
. Hem c 4
nhn pyrol lin kt vi nhau bng cu ni menten (-CH=). Vng porphyrin c gn cc gc
metyl (-CH
3
) v tr 1, 3, 5, 8; cc gc vinyl (-CH=CH
2
) v tr 2,4; cc gc propionyl (-CH
2
- CH
2
-
C00H) v tr 6,7. Fe
++
gn vi nh pha trong ca nhn pyrol bng hai lin kt ng ho tr v
hai lin kt phi tr v vi globin qua gc histidin (hnh 3.4).
Porphyrin l ph bin trong th gii sinh vt. Porphyrin kt hp vi Mg
++
to thnh cht dip
lc ca thc vt.
Hem c th kt hp vi nhiu cht khc nhau. Nu hem kt hp vi globin th to thnh Hb.
Nu hem kt hp vi albumin, NH
3
, pyridin, nicotin... to nn cht gi l hemochromogen. Hem
phn ng vi NaCl trong mi trng acid to ra chloruahem (hemin). Phn ng ny c s
dng trong php y.
7.2 Cc loi hemoglobin ngi.
Hemogobin khc nhau phn cu to globin. Hb ca thai nhi l HbF. Globin ca HbF gm hai
chui a v hai chui g. Hb ca ngi ln l HbA. Globin ca HbA gm hai chui a v hai chui b
(v tr th 3 ca chui b l glutamin c thay bng threonin chui g). Hb ca bnh nhn mc
bnh thiu mu c hng cu hnh li lim l HbS (HbB) v tr th 6 ca chui b l valin c
thay bng glutamin. Loi hng cu ny rt d v khi qua mao mch nh. HbC v HbD l cc Hb
bnh thng gp mt s chng tc ngi Chu Phi.
C nhiu phng php nh lng Hb, k c cc phng php khng chy mu. Bnh thng
ngi Vit c Hb l 14,6g (i vi nam) v 13,3g (i vi n) trong 100ml mu. m s lng
hng cu v nh lng Hb l nhng xt nghim quan trng trong nh gi s thiu mu, thiu
mu ng sc (gi tr hng cu =1), thiu mu u sc (gi tr hng cu >1) v thiu mu nhc
sc (gi tr hng cu <1).
7.3. Chc nng ca hemoglobin.
- Hemoglobin kt hp vi oxy to thnh oxyhemoglobin (Hb0
2
). Kh nng kt hp lng lo v
thun nghch to iu kin cho vic Hb nhn oxy phi ri vn chuyn n m gii phng oxy
cho t bo. Oxy kt hp vi Hb phn Fe
++
ca hem.
Mi Hb c 4 hem, mi hem c 1Fe
++ .
Nh vy v mt l thuyt mt phn t Hb c th kt hp
bo ho vi 4 phn t oxy. Thc t trong c th iu ny rt kh xy ra v khng bao gi c s
bo ho 100% Hb0
2
. S kt hp gia oxy vi Fe
++
xy ra nh sau: Khi mt phn t oxy gn ti
Fe
++
(do oxy khuych tn t ph nang vo mu, t mu vo trong hng cu) th cng mt lc
xy ra hai mi lin kt: Fe
++
-0
2
- v Fe
++
-N
+
- (nit ca nhm imidazol). Lc ny oxy mang in tch
m v nhn in t ca nit. Fe
++
lc ny tr thnh mt acid yu. V mt l{ do no m khng
c mi lin kt Fe
++
-N
+
-, lc ny oxy khng lin kt vi Fe
++
m li nhn in t ca Fe
++
, Hb
chuyn thnh methemoglobin, lm cho Hb mt kh nng vn chuyn oxy. Imidazol nh hng
trn b mt hem l nguyn nhn to ra mi lin kt Fe
++
-N
+
- .
S kt hp v phn ly Hb0
2
chu nh hng ca p0
2
,

pC0
2
, pH, nhit mu.
- Hemoglobin kt hp vi carbonic to thnh carbohemoglobin (HbC0
2
). y cng l mt phn
ng thun nghch. S kt hp xy ra m, s phn ly xy ra phi. Carbonic kt hp vi Hb
nhm amin ca globin nn gi l phn ng cc carbamin. Carbonic c vn chuyn dng
HbC0
2
khng nhiu, ch chim 6,5% tng s C0
2
vn chuyn trong mu.
- Hemoglobin kt hp vi carbonmonocid to thnh Carboxyhemoglobin (HbC0). HbC0 rt bn
vng v khng cn kh nng vn chuyn oxy v i lc ca Hb vi C0 rt cao, gp 210 ln i lc
ca Hb vi 0
2
, thm tr C0 cn y c 0
2
ra khi Hb0
2
. Khi ng c C0, cn cho th 0
2
phn p
cao ti to li oxyhemoglobin
- Hemoglobin c tnh cht m. H m hemoglobin l mt trong cc h m quan trng ca
mu, l h m HHb/KHb v h m HHbC0
2
/KHb0
2
.
Kh nng m ca Hb l ng k v hm lng Hb trong mu kh cao v chim khong 35%
dung tch m ca mu.
- Trong qu trnh chuyn ho Hb, c th to ra sc t mt. Sc t mt khng c chc nng sinh
l{ nhng n l cht ch th mu i vi cc nh lm sng, n cho ta bit mt c mt u, qua
nh gi chc nng gan mt.
II. CHC NNG
1. Chc nng vn chuyn kh oxy v carbonic.
Hng cu vn chuyn kh oxy t phi n m v vn chuyn kh carbonic t m n phi nh
chc nng ca hemoglobin.
Mt khc C0
2
m sau khi khuych tn vo trong hng cu th ti y din ra qu trnh C0
2
+
H
2
0 H
2
C0
3
nh men xc tc carboanhydrase (men ny c nhiu trong hng cu). Sau H
2
C0
3

phn ly H
+
+ HC0
3
-
. Nh hiu ng Hamburger m HC0
3
-
c khuych tn rt nhiu t trong
hng cu chuyn sang huyt tng to ra dng vn chuyn C0
2
quan trng nht ca mu
(C0
2
c vn chuyn di dng HC0
3
-
). Nh vy hng cu ng vai tr quan trng bc
nht trong s vn chuyn C0
2
dng HC0
3
-
ca huyt tng.
2. Chc nng iu ho cn bng acid - base ca mu.
Chc nng ny do h m hemoglobinat m nhim. ng thi vi h m ca Hb, hng cu
cn to ra HC0
3
-
trong qa trnh vn chuyn C0
2
, nn n to ra h m bicarbonat
HC0
3
/H
2
C0
3
,

h m quan trng nht ca mu.
3. Chc nng to nht ca mu.
Hng cu l thnh phn ch yu to nht ca mu, nh nht m tc tun hon, nht
l tun hon mao mch, hng nh. Tc tun hon hng nh l iu kin thun li cho s
trao i vt cht gia t bo v mu. Khi nht ca mu thay i s gy ra thay i tc
tun hon v lm ri lon trao i vt cht ca t bo.


6. TIU CU

Trong tu xng c nhng t bo nhn khng l (40-100mm). Cc t bo ny c bit ho t
t bo gc vn nng.
T bo c nhn rt to, nhiu thuz, a dng vi nhim sc th phn b khng u. Bo tng
nhiu, mu nht, c nhiu ht rt nh mu xanh l. T bo nhn khng l cho gi tc di
chuyn. Cc gi tc ny b teo li, tch ra, t on thnh tiu cu lu thng trong mu. Nh
vy, tiu cu (thrombocyt) l mt phn bo tng ca t bo nhn khng l, l mt t bo
khng hon chnh, khng c nhn, rt a dng, bo tng tm nht c ht mu xanh, rt kh
m v d v khi ly ra khi c th
Tiu cu c kch thc 2-4mm, th tch 7-8mm
3
. Bnh thng c 150-300 x 10
9
tiu cu
trong 1 lt mu ngoi vi.
Tiu cu c cu trc mng glycoprotein, lp ny ngn cn tiu cu dnh vo ni mc nhng li
d dnh vo ni thnh mch tn thng c cht collagen l ra. Mng tiu cu cng rt d dnh
vo cc vt l. Khi bm vo vt l, chng li c th t bm vo nhau thnh tng m. Tiu cu
cha actomyosin, thromstbohenin nn tiu cu c kh nng co rt. Tiu cu co rt mnh s b
v ra v gii phng serotonin gy co mch, cc phospholipid v cc yu t gy ng mu tham
gia vo qu trnh gy ng mu.
- Yu t 1 l yu t c kh nng chuyn prothrombin thnh thrombin. V bn cht yu t 1 gn
ging yu t V ca huyt tng.
- Yu t 2 l yu t c tc dng y nhanh fibrinogen thnh fibrin khi c mt ca thrombin.
- Yu t 3 l mt phospholipid c hot tnh ca thromboplastin.
- Yu t 4 l yu t c hot tnh ca antiheparin to iu kin thun li cho giai on u ca
qu trnh ng mu.
- Yu t 5 l serotonin c kh nng gy co mch v c kh nng lm mu ng ti ch.
- Yu t 6 l mt protein c tc dng lm dy thnh mch v lm gim tnh thm thnh mch.
- Yu t 7 l antifibrinolysin, cht c tc dng ngn cn phn ng lm tan cc mu.
- Yu t 8 retractozym l mt yu t c tc dng lm co cc mu ng.
- Yu t 9 l mt cht lm n nh fibrin.
Vi c im chc nng trn y, tiu cu tham gia vo qu trnh cm mu, c xem nh
l mt hng ro bo v s mt mu. Tiu cu cng c kh nng gn ln vi khun to iu kin
thun li cho qu trnh thc bo c d dng. Ngoi ra tiu cu cn c tc dng khc na nh
lm h huyt p, chc nng min dch v chc nng sn xut cc enzym hu protein.
S sn xut tiu cu c iu ho bng s lng tiu cu nh c ch do cc yu t trong
huyt tng kim sot. Tiu cu b tiu dit lch. i sng tiu cu cha c nghin cu
y , ngi ta cho rng n sng trong mu khong 9-11 ngy.
S lng tiu cu tng ln khi lao ng, khi n ung, khi b chy mu, bnh a sinh mn tnh th
tu bo, bnh Hodgkin, bnh Vaquez. S lng tiu cu gim trong nhim c, nhim x, xut
huyt di da, nim mc, suy tu, bnh Biermer, bnh Werlhoff.

7. BCH CU

1. HNH DNG V S LNG.
Bch cu l cc t bo c nhn, hnh dng v kch thc rt khc nhau tuz tng loi. Bch cu
khng phi ch lu thng trong mu, m n cn c mt nhiu ni trong c th: bch huyt,
dch no tu, hch bch huyt, cc t chc lin kt...
Thnh phn bch cu rt phc tp, gm nhiu cht hu c v v c. Bo tng ca bch cu
cha nhiu st, calci, lipid (cholesterol, triglycerid v acid bo). Cc lipid ny lin quan ti vai tr
chng nhim trng ca bch cu. Bch cu cha nhiu lipid c xem nh tin lng tt chng
nhim trng (Boyd,1973). trong bch cu cn c nhiu acid ascorbic, ht glycogen. Ht glycogen
nhiu ln trong qu trnh tiu ho v mc bnh i tho ng. Bch cu c mt h thng
enzym rt phong ph (oxydase, peroxydase, catalase, lipase, amylase) v mt s cht dit
khun.
Trn mng t bo bch cu c rt nhiu th th lin quan ti chc nng ca bch cu. Da vo
cc th th ny, nh cc k thut hin i, ta c th phn loi c bch cu v theo di cc
giai on pht trin ca bch cu.
Trn b mt lympho bo c h thng khng nguyn ph hp t chc. Mc d mt s khng
nguyn c mt trn t bo ca nhiu m, nhng chng li b pht hin d dng trn lympho
bo. Do tt c khng nguyn ph hp t chc ch yu ca ngi c k hiu l HLA
(humanlymphocyt antigen). Tt c HLA hp thnh h thng khng nguyn ph hp t chc ca
ngi, cn gi l h thng HLA, chia thnh 5 nhm. Nhm HLA-A, nhm HLA-B, nhm HLA-C,
nhm HLA-D v nhm HLA-DR. Di cc nhm ny c rt nhiu phn nhm c t tn. H
thng khng nguyn HLA di truyn v rt c { ngha trong p ng min dch thi ghp.
Trong 1lt mu ngoi vi c 7,0 x 10
9
bch cu (i vi nam) 6,2 x10
9
bch cu (i vi n), nhn
chung vo khong 5,0 x 10
9
n 9,0 x 10
9
bch cu (i vi ngi trng thnh). Tr s sinh c
s lng bch cu rt cao: 20,0 x10
9
bch cu/1lt mu ngoi vi. Lc mt tui cn 10,0 x
10
9

bch cu/1lit mu. T 12 tui tr i s lng bch cu tr v n nh bng ngi trng
thnh.
S lng bch cu tng ln khi n ung, khi lao ng th lc, thng cui ca thi kz mang thai,
sau khi . c bit s lng bch cu tng ln khi nhim khun, bnh bch cu. Mt s
hormon v mt s tinh cht m cng lm tng s lng bch cu nh: hormon tuyn gip,
adrenalin, estrogen, tinh cht gan, tinh cht lch, tu xng. S lng bch cu gim khi b
lnh, khi b i, khi gi yu, suy nhc tu, nhim virus, nhim c, nhim trng qu nng, hoc
iu tr bng cc hormon corticoid, insulin ko di...

2. PHN LOI BCH CU.

V mt i th, vi k thut kinh in, da vo hnh dng, kch thc t bo, hnh dng nhn,
s bt mu ca ht trong bo tng. Ngy nay nh k thut hin i cn pht hin c cc
th th b mt t bo bch cu v.v...; ngi ta c th phn loi bch cu thnh bch cu ht
(bch cu a nhn) v bch cu khng ht (bch cu n nhn). Bch cu a nhn c chia
lm 3 loi: trung tnh, a acid v base. Bch cu n nhn c chia lm 2 loi: monocyt v
lymphocyt. ngi bnh thng, t l cc bch cu trong mu ngoi vi nh sau:
Bch cu ht a acid (E): 2,3%
Bch cu ht a base (B): 0,4%
Bch cu monocyt (M) : 5,3%
Bch cu ht trung tnh (N): 62,0%
Bch cu lymphocyt (L): 30,0%
Cc nh lm sng thng gi t l % cc loi bch cu mu ngoi vi l cng thc bch cu ph
thng. Cng thc thay i khi n ung, khi lao ng, khi c kinh nguyt, khi c thai trn 4 thng,
khi . Tr s sinh c ti 70% l bch cu a nhn, t thng th 3 tr i ch cn 35% l cc bch
cu a nhn (lc ny ch yu l lympho bo). Cng thc bch cu dn n nh n sau tui dy
th mi bng ngi trng thnh.
Ngy nay nh k thut cao chng ta c th phn loi bch cu mt cch chi tit hn vi mc
ch tm hiu chc nng ca tng loi bch cu phc v cho nghin cu khoa hc, chn on v
iu tr. Tuy vy vic xc nh cng thc bch cu ph thng v s lng bch cu vn c coi
l xt nghim thng quy ca bnh vin v n vn cn gi tr thc tin. ng thi vi xc nh
gi tr tng i (l t l % ca tng bch cu), cc nh lm sng cn xc nh gi tr tuyt i
(s lng tng loi bch cu c trong 1lt mu). Ch s ny rt cn cho s tin lng bnh.
Bch cu a nhn trung tnh (N) tng >70% trong cc trng hp nhim khun cp, qu trnh
lm m, vim tnh mch, nghn mch, nhi mu c tim, nhi mu phi. N cn tng trong co
git ng kinh, a protein vo trong c th, chy mu phc mc nh. ng thi vi N tng cn
c bch cu a (stab) tng.
- Bch cu a nhn trung tnh gim <60% trong cc trng hp nhim trng ti cp, nhim virus
kz ton pht, st rt, cng lch, nhim c, suy nhc tu.
- Bch cu a nhn a acid (E) tng nh v thong qua gp trong hi phc sau nhim trng, kh
c protein. E tng lin tc trong cc bnh giun sn, d ng, bnh cht to keo.Bch cu a
nhn a acid gim trong sc, trong hi chng Cushing, trong giai on iu tr bng corticoid.
- Bch cu a nhn a base (B) tng trong mt s trng hp vim mn tnh ko di, vim hi
phc. B cn thay i trong mt s trng hp nhim c.
- Bch cu n nhn monocyt (M) tng trong nhim trng, bnh bch cu, nhim virus. M gim
trong mt s trng hp nhim c.
- Bch cu n nhn lymphocyt (L) tng do tng sinh trong nhim khun mn tnh, nhim virus,
giai on lui bnh ca nhim trng.

3- I SNG CA BCH CU.

Nh phn loi phn trn, bch cu c chia ra thnh 3 dng: dng bch cu ht, dng
monocyt v dng lymphocyt. Ba dng bch cu ny c sinh ra t t bo gc vn nng trong
tu xng.
Dng bch cu ht: t bo gc pht trin qua nhiu giai on tr thnh myeoblat
promyelocyt myelocyt metamyelocyt bch cu a nhn trng thnh. T myelocyt, bch
cu chia thnh ba loi bch cu a nhn (bch cu ht) khc nhau: bch cu ht trung tnh, bch
cu ht a acid, bch cu ht a base.
Dng lymphocyt: t bo gc vn nng pht trin qua nhiu giai on bit ho v c "x
l" cc m c bit ri thnh lympho trng thnh d tr trong cc m bch huyt lu
thng mu cc m m bch huyt v.v... chu kz xy ra lin tc.
Dng monocyt: t bo gc vn nng pht trin qua nhiu giai on bit ho thnh monocyt.
Cha bit chnh xc thi gian sng ca bch cu trong mu l bao lu v bch cu c mt khp
mi ni. Bch cu vo cc c quan ri t cc c quan quay tr li mu. Thi gian bch cu c
mt trong mu chng qua l thi gian vn chuyn bch cu t ni sn xut n ni s dng. V
vy thi gian sng ca bch cu trong mu l rt ngn.
Nu ngng sn xut bch cu t ngt (bng cch chiu tia g) trong 3 n 6 ngy u mu
ngoi vi khng cn bch cu a nhn trung tnh. Thi gian bch cu sng trong mu khang 4-5
ngy. Thi gian bch cu sng c trong v ngoi mch khong 8-12 ngy. Thi gian bch cu tn
ti trong tu xng khong 4-8 gi. Kh c th xc nh chnh xc thi gian sng ca bch cu
monocyt v n lun lun qua li gia cc m. Thi gian lu thng ca monocyt trong mu
khong 10-20 gi. Thi gian sng ca monocyt trong cc vim di hn bch cu a nhn trung
tnh. Lympho bo vo h tun hon lin tc qua ng ngc. S lng lympho bo trong ng ngc
vo h tun hon chung trong 24 gi thng l gp nhiu ln s lng lympho bo mu mt
thi im. iu chng t thi gian lympho bo sng trong mu l rt ngn (24h). Bch cu
lympho t c quan bch huyt vo mu, t mu ti m, t m li vo c quan bch huyt, ri
li vo mu... chu kz c th din ra lin tc.
Bch cu b tiu dit khp mi ni trong c th khi b gi ci, nhng ch yu l trong lng ng
tiu ho, phi v lch. Bch cu (c bit l cc i thc bo, bch cu ht trung tnh) b tiu
dit cc vim, cc vng v cc din ca c th d b vi khun t nhp nh da, phi, nim
mc.

4. C TNH CA BCH CU.

Bch cu c nhng c tnh chung sau y:
4.1. Xuyn mch.
Bch cu M v N c kh nng thay i hnh dng, xuyn qua vch gia cc t bo ti nhng
ni cn thit.
4.2. Chuyn ng theo kiu a mip.
Bch cu M v N c kh nng chuyn ng bng chn gi (theo kiu amip) vi tc :
40mm/min.
4.3. Ho ng ng v nhit ng ng
C mt s cht do m vim sn xut, do vi khun to ra hoc nhng cht ho hc a t ngoi
vo c th thu ht bch cu ti (ho ng ng dng tnh) hoc xua ui bch cu ra xa hn
(ho ng ng m tnh). Tng t, vi nhit cng nh vy, bch cu cng c nhit ng ng
dng tnh v m tnh. Cc c tnh ny ch yu l ca bch cu M v N.
4.4. Thc bo.
Bch cu M v N c kh nng thc bo, m bo. Nhng iu kin thun li cho thc bo l:
+ B mt ca vt rng v x x.
+ Khng c v bc. Cc cht t nhin trong c th c v bc l protein, cc cht ny y t bo
thc bo ra xa nn kh thc bo. Cc m cht, cc vt l khng c v bc v thng tch in
rt mnh nn chng d b thc bo.
+ Qu trnh opsonin ho. Cc khng th (c sn xut trong qu trnh min dch) gn vo
mng t bo vi khun lm cho vi khun d b thc bo.
S thc bo c thc hin nh sau:
Bch cu tip cn vt l, phng chn gi bao vy vt l, to thnh mt ti kn cha vt l. Ti
ny xm nhp vo trong t bo, tch khi mng t bo to ra mt ti thc bo tri t do trong
bo tng. Ti thc bo tip cn lysosom v cc ht khc trong bo tng v xut hin hin
tng ho mng. Cc enzym tiu ho v cc tc nhn git vi khun c trt vo ti thc bo
x l vt l. Ti thc bo tr thnh ti tiu ho. Sau khi tiu ho, cc sn phm cn thit cho
t bo c gi li, cc sn phm khng cn thit s c o thi ra khi t bo bng qu
trnh xut bo.
Tnh thc bo ca bch cu khng phi l v hn. Mt bch cu ht trung tnh c th thc bo
5-25 vi khun th cht. i thc bo c kh nng thc bo mnh hn nhiu. N c th thc bo
ti 100 vi khun. Khi nghin cu chc nng thc bo ca bch cu, ngi ta thng s dng
"ch s thc bo" nh gi chc nng ny.
Bch cu c mt khp ni trong c th cho nn vi khun t nhp bng bt kz ng no
cng b tiu dit. c bit bch cu trn gi nhng ni quan trng ca c th m vi khun d
xm nhp vo nh: da, nim mc, cc hc t nhin, phi, ng tiu ho, gan, lch. Tuy vy c
mt s vi khun b bch cu "nut" nhng khng "git" c nh mycobacteria, salmonella,
listera ... Nhng vi khun ny n nu ri nhn ln trong i thc bo. Bch cu N v i thc
bo cn cha nhng cht git vi khun. Mt s vi khun khng b tiu ho bi cc enzym ca
lysosom v chng c v bc bo v, hoc c cc yu t ngn chn tc dng ca cc enzym tiu
ho nhng li b cht bi cc cht git vi khun. Cc cht git vi khun l cc cht oxy ho mnh
nh superoxid (0
2-
), hydrogenperoxid (H
2
0
2
), ion hydroxyl (0H
-
). Ngoi ra enzym
mieloperoxydase ca lysosom cng c kh nng git vi khun v n lm tan mng lipid ca vi
khun.

5. QU TRNH VIM.

Khi vim, c tnh ca m b thay i nh sau:
- Gin mch ti ch lm cho lu lng mu tng ln.
- Tng tnh thm mao mch gy ph n.
- ng dch k v dch bch huyt do fibrinogen v cc yu t gy ng mu thot vo.
- Tp trung nhiu bch cu N v i thc bo.
- Cc t bo ca m trng phng ln.
M b thng tn do bt kz mt nguyn nhn no (vi khun, chn thng, ho cht, nhit
v.v...) s gii phng histamin, bradykinin, serotonin, prostaglandin, cc yu t gy ng mu.
Lympho bo T hot ho gii phng ra lymphokin. Mt s cht trn hot ho i thc bo v
cng vi mt s sn phm khc do t bo tn thng v vi khun to ra gy ho ng
dng tnh vi bch cu N v i thc bo. Bch cu bm mch, xuyn mch v di chuyn ti
vim.
S ng dch k v bch huyt to ra mt bc tng bo v ngn cch gia vng vim v vng
lnh. S tp trung ca bch cu (i thc bo ti trc: sau vi pht, bch cu N ti sau: sau vi
gi) l mt hng ro th hai. ng thi vi s tp trung ca bch cu, t bo vim sn xut ra
cc globulin, cc sn phm phn hu bch cu vo mu, theo mu ti tc ng ln tu xng
lm tng sn xut bch cu (sau mt, hai ngy). Do qu trnh tng sn xut bch cu cho nn
trong mu s c nhiu bch cu non hn bnh thng (bch cu a).
vim hnh thnh mt ci hc cha xc vi khun, bch cu N, i thc bo, t chc hoi t gi
l m. M nhiu s b v thot ra ngoi hoc vo cc xoang, cc tng rng ca c th. Nu hng
ro bo v km, vi khun s lan rng vo cc c quan, c khi vo c mu. mu cng c i
thc bo v bch cu N sn sng tiu dit chng. Trong nhiu trng hp c th khng t bo
v c mnh cc triu chng nhim khun tng ln dn v cn phi c iu tr kp thi.

6. BCH CU A NHN A ACID .

Bch cu E c kh nng thc bo v ho ng ng rt yu nn khng quan trng trong nhim
trng thng thng. nhng ngi nhim k sinh trng (KST), s lng bch cu E tng cao v
chng ti cc nhim k sinh trng. Bch cu E gii phng ra cc cht git KST: men thu
phn t cc ht ca bo tng, oxy nguyn t, cc peptid v.v... Bch cu E cng tp trung nhiu
cc c phn ng d ng (tiu ph qun, da v.v...). Trong qu trnh tham gia vo phn ng d
ng, dng bo v bch cu B gii phng ra cc cht gy ha ng ng dng tnh vi bch
cu E. Bch cu E c tc dng kh c l cc cht gy vim do dng bo v bch cu B gii
phng ra. Bch cu E cng c th c tc dng thc bo chng qu trnh lan rng ca vim.

7- BCH CU A NHN A BASE.

Bch cu a nhn a base c th gii phng heparin, histamin, mt t bradykinin v serotonin.
Ti vim cc cht trn cng c dng bo gii phng ra trong qu trnh vim. Dng bo
v bch cu B ng vai tr quan trng trong phn ng d ng v khng th IgE gy phn ng d
ng c kh nng gn vo mng dng bo v bch cu B. Khi gp khng nguyn c hiu phn
ng vi khng th lm cho cc t bo ny b v ra v gii phng heparin, histamin, bradykinin,
serotonin, enzym thu phn lysosom v nhiu cht khc. Cc cht trn gy ra d ng.

8. BCH CU LYMPHO.

Bch cu lympho c chia thnh hai loi: lympho bo B v lympho bo T. Chng u c chung
ngun gc trong bo thai l cc t bo gc vn nng. Cc t bo ny s bit ho hoc c "x
l{" thnh cc lympho bo trng thnh. Mt s t bo lympho di tr tuyn c v c "x
l" y nn gi l lympho bo T (Thymus). Mt s t bo lympho khc c "x l" gan
(na u thi kz bo thai) v tu xng (na sau thi kz bo thai). Dng t bo lympho ny
c pht hin ln u tin loi chim v chng c "x l" bursa fabricicus (cu trc ny
khng c ng vt c v) nn c gi l lympho bo B (ly t ch bursa).
Sau khi c "x l{" cc lympho bo lu thng trong mu ri d tr m bch huyt, ri li
vo mu v.v... chu kz tip din nhiu ln. Chc nng chnh ca lympho bo l: lympho bo B
chu trch nhim v min dch dch th. Lympho bo T chu trch nhim v min dch t bo.
Hai chc nng ca hai loi t bo ny c mi lin quan cht ch vi nhau.
8.1. Chc nng ca lympho bo B.
Trc khi tip xc vi khng nguyn c hiu, cc clon lympho B ng yn trong m bch huyt.
Khi khng nguyn xm nhp vo, cc i thc bo thc bo khng nguyn v gii thiu (trnh)
khng nguyn cho cc lympho bo B v lympho bo T. Cc lympho bo T h tr c hot ho
cng gp phn hat ho lympho bo B. Cc lympho bo B c hiu vi khng nguyn c hot
ho, ngay lp tc tr thnh cc nguyn bo lympho. Mt s nguyn bo bit ho tip thnh
nguyn tng bo l tin thn ca tng bo plasmocyt. Trong cc t bo ny c mng ni bo
tng c ht tng sinh. T bo phn chia rt nhanh: 9 ln phn chia trong khong 10 gi v
trong 4 ngy u mt nguyn tng bo sinh ra ti 500 t bo. Cc tng bo sinh khng th
globulin vi tc rt nhanh v mnh. Mi tng bo sn xut khong 2000 khng th/1giy.
Cc khng th vo h tun hon. S sn xut khng th ko di vi ngy hoc vi tun cho n
khi tng bo b cht.
Trong qu trnh thc hin chc nng min dch, mt s nguyn bo lympho sinh ra mt lng
kh ln t bo lympho B mi ging nh t bo lympho B gc ca clon v c b sung thm
vo s t bo lympho gc ca clon. Cc t bo ny cng lu thng trong mu v cng c tr
trong m bch huyt. Khi gp li cng mt khng nguyn chng s c hot ho mt ln na,
l cc t bo nh. S p ng khng th ca cc t bo lympho B ny din ra nhanh v mnh
hn rt nhiu so vi nhng t bo lymphpo gc ca clon c hiu. iu ny gii thch ti sao
p ng min dch nguyn pht (tip xc khng nguyn c hiu ln u) li chm v yu hn
so vi p ng min dch th pht (tip xc vi cng mt khng nguyn ln th 2).
8.2. Chc nng ca lympho bo T.
Khi tip xc vi khng nguyn c hiu do i thc bo gii thiu, cc t bo lympho T ca m
bch hyt tng sinh v a nhiu t bo lympho T hot ho vo bch huyt ri vo mu. Chng
i khp c th qua mao mch vo dch k ri tr li bch huyt vo mu mt ln na. Chu kz
c tip din nh vy hng thng hoc hng nm.
T bo nh ca lympho bo T cng c hnh thnh nh t bo nh ca lympho bo B. p
ng min dch t bo th pht l to ra lympho bo T hot ha mnh hn, nhanh hn p ng
min dch t bo nguyn pht. Trn b mt ca mt lympho bo T c hng trm ngn v tr
receptor.Cc khng nguyn gn vo receptor c hiu trn b mt t bo lympho T cng ging
nh gn vi khng th c hiu do lympho bo B sn xut ra.
Cc lympho bo T c chia thnh lympho bo T h tr, lympho bo T gy c v lympho bo T
trn p. T bo lympho T h tr chim 3/4 tng s t bo lympho T v c chc nng iu ho
h thng min dch. S iu ho ny thng qua lymphokin m quan trng nht l interleukin.
Nu thiu lymphokin ca lympho bo T th h thng min dch s b t lit. Interleukin 2, 3, 4, 5,
6 c tc dng kch thch to cm bch cu ht, bch cu M v lm tng chc nng thc bo ca
cc t bo ny. Interleukin 2, 4, 5 kch thch tng sinh, tng trng t bo lympho T gy c t
bo v lympho bo T trn p. Cc interleukin, c bit l interleukin 4, 5, 6 kch thch rt mnh
t bo lympho B v lm tng cng chc nng min dch dch th. Ngoi ra, interleukin 2 cn c
vai tr iu ho ngc dng tnh i vi t bo lympho T h tr lm cho p ng min dch
mnh ln gp bi.
Lympho bo T gy c t bo c kh nng tn cng trc tip cc t bo, c kh nng git cht vi
khun, i khi git c chnh bn thn c th mnh. Do c ngi gi n l t bo git t nhin
(Native Kill cell, thng vit tt l NK). Cc receptor trn b mt t bo git c kh nng gn
cht vo vi khun hoc t bo c cha cc khng nguyn c hiu. T bo git gii phng
perforin (bn cht l mt protein) to ra nhiu l trn mng t bo b tn cng. Qua l ny,
cc cht gy c t bo c bm t t bo git sang t bo b tn cng, lm cho t bo b git
tan ra. T bo git c th git lin tip nhiu t bo khc m vn c kh nng tn ti hng
thng. T bo git c tc dng c bit ln cc t bo c cha virus, v tnh khng nguyn ca
virus trong t bo rt hp dn t bo git. T bo git cng c vai tr quan trng trong s ph
hu t bo ung th, nht l t bo cc m ghp.
Lympho bo T trn p c kh nng trn p t bo lympho T h tr v t bo lympho T gy c
t bo. Chc nng ny l iu ho hot ng ca t bo, duy tr s p ng min dch khng
qu mc, v p ng min dch qu mc s gy tc hi cho c th. V vy t bo lympho T trn
p v t bo lympho T h tr c gi l t bo lympho iu ho. C ch iu ho ca t bo
lympho T trn p i vi t bo lympho T h tr l c ch iu ho ngc m tnh. Lympho bo
T trn p cng c kh nng c ch tc dng ca h thng min dch tn cng vo t bo cc m
c th (hin tng dung np min dch).

8. CHNG NG MU

1. Cc yu t trn b mt ni mc. - S trn nhn ca ni mc ngn cn s hot ho do tip xc
b mt ca h thng gy ng mu.
- Lp glycocalyx (bn cht l mucopolysaccarid) hp ph trn b mt ni mc, c tc dng y
tiu cu v cc yu t gy ng mu cho nn ngn cn c s hot ho h thng gy ng
mu.
- Thrombomodulin l mt protein ca ni mc c kh nng gn vi thrombin lm bt hot
thrombin. Ngoi ra phc hp thrombomodulin-thrombin cn c tc dng hot ho protein C
ca huyt tng, m protein C hot ho s ngn cn tc dng ca yu t V
a
v yu t VIII
a
.
2. Cc yu t trong huyt tng.
- Antithrombin.
Sau khi cc mu ng c hnh thnh i b phn thrombin c hp ph trn b mt si
fibrin (fibrin c gi l antithrombin I). Phn cn li ca thrombin c kt hp vi
antithrombin III lm cho thrombin mt hot tnh sau 12-20 pht. Tc dng trn y lm gii hn
cc mu ng trnh cho s ng mu lan rng. Ngoi ra cn c antithrombin IV c tc dng
phn hu thrombin, antithrombin V hn ch tc dng ca thrombin trn fibrinogen.
- Heparin.
Heparin (cn c gi l antithrombin II) l mt cht c hiu qu chng ng rt mnh v n c
nhiu c ch rt phc tp va ngn cn s hnh thnh thrombin va gy bt hot thrombin.
Heparin l mt polysaccarid kt hp tch in m kh mnh, bn thn n hu nh khng c tc
dng chng ng mu. Nhng khi n kt hp antithrombin III to nn phc hp heparin-
antithrombin III th li c tc dng chng thrombin v cng mnh, mnh hn hng trm, hng
nghn ln antithrombin III. Do ch cn s c mt ca heparin th thrombin b bt hot ngay
v ng mu khng xy ra. Phc hp heparin-antithrombin III cn lm bt hot cc yu t IX, X,
XI v XII cho nn cng chng c s ng mu.
Heparin do rt nhiu t bo ca c th sn xut, c bit l dng bo khu tr cc m lin kt
quanh mao mch c th. Chng tp trung vi mt cao quanh mao mch gan v phi. Bnh
thng dng bo bi tit mt lng nh heparin v heparin ny c khuch tn vo h tun
hon cng vi mt lng nh heparin ca bch cu ht a base thng xuyn chng c
cc mu ng hnh thnh mao mch (c bit l mao tnh mch). V vy heparin c dng
lm thuc bo v chng ng mu trong lm sng.
- a
2
-macroglobulin.
a
2
-macroglobulin c trng lng phn t 360.000, n c kh nng kt hp vi cc yu t gy
ng mu v lm bt hot chng, nhng tc dng chng ng mu ca n yu hn rt nhiu
ln so vi heparin.
- Coumarin.
Coumarin l cht a t ngoi vo c th lm gim s tng hp ca cc yu t II, VII, IX v X,
do ngn cn c s ng mu trong c th. Coumarin l cht cnh tranh vi vitamin K, m
vitamin K l cht rt cn thit cho qu trnh tng hp cc yu t II, VII, IX v X. Vitamin K l loi
vitamin tan trong du dng iu tr thi gian ng mu ko di do thiu vitamin K.
3. Chng ng mu ngoi c th.
- ng hoc bnh cha mu c trng silicon, ngn cn s hot ha do tip xc b mt ca yu
t XII v tiu cu, v vy mu khng ng.
- Heparin c s dng trong v ngoi c th u cho hiu qu chng ng mu rt cao.
- Cc cht lm gim ion Ca
++
nh kalioxalat, amonioxalat, natricitrat do to ra calcioxalat,
calcicitrat nn c tc dng chng ng mu rt tt.
- Mui trung tnh nh natriclorua vi nng cao cng lm bt hot thrombin nn chng c
ng mu.
- Bo qun mu nhit thp (4
0
C-6
0
C) lm ngng hot ng cc enzym gy ng mu nn
mu cng khng ng.

9. HUYT TNG

Huyt tng l phn lng ca mu, chim 55-56% th tch mu ton phn. Huyt tng l dch
trong, hi vng, sau khi n c mu sa, v hi mn v c mi c bit ca cc acid bo.
Huyt tng cha 92% l nc, cn li l cc cht hu c v cc cht v c. Huyt tng b ly
mt fibrinogen th gi l huyt thanh.
Mt s ch s vt l ca mu:
nht ca huyt tng: 2,0-2,5
nht ca mu ton phn: 4,7 (i vi nam); 4,4 (i vi n)
T trng ca huyt tng: 1,028
T trng ca huyt cu: 1,097
T trng ca mu ton phn: 1,057
p sut thm thu ca mu: 7,6 atm
pH ca mu: 7,36.
1. PROTEIN HUYT TNG.
Protein huyt tng l nhng phn t ln, c trng lng phn t cao, v d trng lng phn
t ca albumin: 69000, ca fibrinogen: 340000 v.v...
Protein ton phn: 68-72 g/l. y l phn ch yu ca nhng cht cha nit. Bng cc phng
php hin i, ngi ta c th tch protein huyt tng ra thnh hng trm thnh phn nh
khc nhau. Thng thng protein huyt tng c cc thnh phn c bn sau y:
Albumin: 42g/l
Globulin: 24g/l
T l albumin/globulin: 1,7.
a
1
globulin: 3,5g/l
a
2
globulin: 5g/l
b globulin: 8g/l
g globulin: 7,5g/l
Fibrinogen: 4g/l.
Protein huyt tng c cc chc nng chnh sau:
- Chc nng to p sut keo ca mu:
Cc phn t protein u mang in. Trong mi trng huyt tng c pH=7,36; chng mang
in m v dng proteinat. Do c nhng du in tch khc nhau mt ngoi, nn c kh
nng gi nc nhiu hay t quanh phn t. V vy protein huyt tng gi c nc
trong lng mch. Lc gi nc to nn p sut keo. Thnh phn quan trng nht ca protein
huyt tng l albumin. Cc protein ni chung hay albumin ni ring u do gan sn xut v
a vo mu. Khi gim chc nng gan, protein huyt tng gim, nc khng c gi li
trong mch m vo khong gian bo, gy ra hin tng ph (ph do thiu protein huyt
tng). Trong nhiu trng hp iu tr, mun gi nc trong lng mch duy tr huyt p
v khi lng mu lu hnh ngi ta thng truyn dch c cha cc hp cht hu c c phn
t lng cao (c p lc keo cao).
- Chc nng vn chuyn.
Cc protein thng l cc cht ti cho nhiu cht hu c v v c v d nh lipoprotein,
Thyroxin binding prealbumin, Thyroxin binding globulin...
- Chc nng bo v.
Mt trong nhng thnh phn quan trng ca protein huyt tng l cc globulin min dch:
IgG, IgA, IgM, IgD, IgE (do cc t bo lympho B sn xut). Cc globulin min dch c tc dng
chng li cc khng nguyn l xm nhp vo c th. Thng qua h thng min dch, cc globulin
min dch bo v cho c th.
- Chc nng cm mu. Cc yu t gy ng mu ca huyt tng, ch yu l cc protein do gan
sn xut.
- Cung cp protein cho ton b c th.
2. CC CHT HU C KHNG PHI PROTEIN.
Nhm ny rt a dng v thng c chia lm hai loi: nhng cht c v khng cha nit.
Nhng cht hu c khng phi protein, c cha nit:
Ur: 300mg/l
Acid amin t do: 500mg/l
Acid uric: 45mg/l
Creatin, creatinin: 30mg/l
Bilirubin: 5mg/l
Amoniac: 2mg/l
Cc cht hu c khng phi protein, khng cha nit:
Glucose: 1g/l
Lipid: 5g/l
Cholesterol: 2g/l
Phospholipid: 1,5g/l
Acid lactic: 0,1g/l
a s cc lipid huyt tng u gn vi protein to nn lipoprotein, trong lipid gn vi a
1
globulin (25%), vi b globulin (70%).
Ngoi nhng cht c bn trn, trong huyt tng cn c nhng cht c hm lng rt thp
nhng li c vai tr v cng to ln i vi cc chc phn c th nh: cc cht trung gian ho
hc, cc cht trung gian chuyn ho, cc hormon, cc vitamin v cc enzym.
3. CC CHT V C.
Cc cht v c thng dng ion v c chia thnh hai loi anion v cation. Cc cht v c
gi vai tr ch yu trong iu ho p sut thm thu, iu ho pH mu v tham gia vo cc
chc nng ca t bo.
- p sut thm thu.
n v o p sut thm thu l OsMol, tng ng vi 22,4 atm. Thng dng l mOsMol.
mOsMol l p sut thm thu ca 1/1000 Mol trong 1 lt nc. Bnh thng p sut thm thu
ca mu l 300-310 mOsMol. p sut thm thu ch yu do Na
+
v Cl
-
quyt nh (95%), ngoi
ra cn c mt s cht khc nh: HCO
3
-
, K
+
, Ca
++
, HPO
4
--
, glucose, protein, ur, acid uric,
cholesterol, SO
4
--
...
p sut thm thu gi nc v tr cn bng. Thay i p sut thm thu lm thay i hm
lng nc trong t bo v gy ra ri lon chc nng t bo.
Trong thc hnh vic xc nh p sut thm thu t nng Mol l phc tp, cho nn ngi ta
thng o h bng im tnh ra mOsMol. Mt nng 5,35 mOsMol lm h bng im
0,01
0
; p sut thm thu l 5,35 mOsMol.
- Cn bng ion.
Cc ion (anion v cation) trong huyt tng l cn bng in tch. o nng ion bng
Equivalent (Eq). Eq l ng lng mt ion bng trng lng Mol chia cho ho tr (Eq=1000
mEq).
Cn bng ion c vai tr quan trng i vi chc nng t bo, vi cn bng acid base mu...
Nng ca cc ion trong huyt tng l:
Cl
-
: 3650 mg/l, 103 mEq/l
HCO
-
: 1650 mg/l, 27 mEq/l
Protein: 70000 mg/l, 15-18 mEq/l
HPO
4
--
: 5-106 mg/l, 3 mEq/l
SO
4
--
: 45 mg/l, 1 mEq/l
Acid hu c: 45 mg/l, 5 mEq/l
-------------------------------------------------------------------
+ 155 mEq/l
Na
+
: 3300 mg/l, 142 mEq/l
K
+
: 180-190 mg/l, 5 mEq/l
Ca
++
: 100 mg/l, 5 mEq/l
Mg
++
: 18-20 mg/l, 1,5 mEq/l
Cc thnh phn khc 1,5 mEq/l
----------------------------------------------------------------------
+ 155 mEq/l
S cn bng ca cc ion trong huyt tng c thc hin nh cc c ch: khuch tn, tnh
in, cn bng Donnan, vn chuyn tch cc ca t bo, c ch siu lc, ti hp thu v bi tit
tch cc ca thn ...
HUYT TNG
Huyt tng l phn lng ca mu, chim 55-56% th tch mu ton phn. Huyt tng l dch
trong, hi vng, sau khi n c mu sa, v hi mn v c mi c bit ca cc acid bo.
Huyt tng cha 92% l nc, cn li l cc cht hu c v cc cht v c. Huyt tng b ly
mt fibrinogen th gi l huyt thanh.
Mt s ch s vt l ca mu:
nht ca huyt tng: 2,0-2,5
nht ca mu ton phn: 4,7 (i vi nam); 4,4 (i vi n)
T trng ca huyt tng: 1,028
T trng ca huyt cu: 1,097
T trng ca mu ton phn: 1,057
p sut thm thu ca mu: 7,6 atm
pH ca mu: 7,36.
1. PROTEIN HUYT TNG.
Protein huyt tng l nhng phn t ln, c trng lng phn t cao, v d trng lng phn
t ca albumin: 69000, ca fibrinogen: 340000 v.v...
Protein ton phn: 68-72 g/l. y l phn ch yu ca nhng cht cha nit. Bng cc phng
php hin i, ngi ta c th tch protein huyt tng ra thnh hng trm thnh phn nh
khc nhau. Thng thng protein huyt tng c cc thnh phn c bn sau y:
Albumin: 42g/l
Globulin: 24g/l
T l albumin/globulin: 1,7.
a
1
globulin: 3,5g/l
a
2
globulin: 5g/l
b globulin: 8g/l
g globulin: 7,5g/l
Fibrinogen: 4g/l.
Protein huyt tng c cc chc nng chnh sau:
- Chc nng to p sut keo ca mu:
Cc phn t protein u mang in. Trong mi trng huyt tng c pH=7,36; chng mang
in m v dng proteinat. Do c nhng du in tch khc nhau mt ngoi, nn c kh
nng gi nc nhiu hay t quanh phn t. V vy protein huyt tng gi c nc
trong lng mch. Lc gi nc to nn p sut keo. Thnh phn quan trng nht ca protein
huyt tng l albumin. Cc protein ni chung hay albumin ni ring u do gan sn xut v
a vo mu. Khi gim chc nng gan, protein huyt tng gim, nc khng c gi li
trong mch m vo khong gian bo, gy ra hin tng ph (ph do thiu protein huyt
tng). Trong nhiu trng hp iu tr, mun gi nc trong lng mch duy tr huyt p
v khi lng mu lu hnh ngi ta thng truyn dch c cha cc hp cht hu c c phn
t lng cao (c p lc keo cao).
- Chc nng vn chuyn.
Cc protein thng l cc cht ti cho nhiu cht hu c v v c v d nh lipoprotein,
Thyroxin binding prealbumin, Thyroxin binding globulin...
- Chc nng bo v.
Mt trong nhng thnh phn quan trng ca protein huyt tng l cc globulin min dch:
IgG, IgA, IgM, IgD, IgE (do cc t bo lympho B sn xut). Cc globulin min dch c tc dng
chng li cc khng nguyn l xm nhp vo c th. Thng qua h thng min dch, cc globulin
min dch bo v cho c th.
- Chc nng cm mu. Cc yu t gy ng mu ca huyt tng, ch yu l cc protein do gan
sn xut.
- Cung cp protein cho ton b c th.
2. CC CHT HU C KHNG PHI PROTEIN.
Nhm ny rt a dng v thng c chia lm hai loi: nhng cht c v khng cha nit.
Nhng cht hu c khng phi protein, c cha nit:
Ur: 300mg/l
Acid amin t do: 500mg/l
Acid uric: 45mg/l
Creatin, creatinin: 30mg/l
Bilirubin: 5mg/l
Amoniac: 2mg/l
Cc cht hu c khng phi protein, khng cha nit:
Glucose: 1g/l
Lipid: 5g/l
Cholesterol: 2g/l
Phospholipid: 1,5g/l
Acid lactic: 0,1g/l
a s cc lipid huyt tng u gn vi protein to nn lipoprotein, trong lipid gn vi a
1
globulin (25%), vi b globulin (70%).
Ngoi nhng cht c bn trn, trong huyt tng cn c nhng cht c hm lng rt thp
nhng li c vai tr v cng to ln i vi cc chc phn c th nh: cc cht trung gian ho
hc, cc cht trung gian chuyn ho, cc hormon, cc vitamin v cc enzym.
3. CC CHT V C.
Cc cht v c thng dng ion v c chia thnh hai loi anion v cation. Cc cht v c
gi vai tr ch yu trong iu ho p sut thm thu, iu ho pH mu v tham gia vo cc
chc nng ca t bo.
- p sut thm thu.
n v o p sut thm thu l OsMol, tng ng vi 22,4 atm. Thng dng l mOsMol.
mOsMol l p sut thm thu ca 1/1000 Mol trong 1 lt nc. Bnh thng p sut thm thu
ca mu l 300-310 mOsMol. p sut thm thu ch yu do Na
+
v Cl
-
quyt nh (95%), ngoi
ra cn c mt s cht khc nh: HCO
3
-
, K
+
, Ca
++
, HPO
4
--
, glucose, protein, ur, acid uric,
cholesterol, SO
4
--
...
p sut thm thu gi nc v tr cn bng. Thay i p sut thm thu lm thay i hm
lng nc trong t bo v gy ra ri lon chc nng t bo.
Trong thc hnh vic xc nh p sut thm thu t nng Mol l phc tp, cho nn ngi ta
thng o h bng im tnh ra mOsMol. Mt nng 5,35 mOsMol lm h bng im
0,01
0
; p sut thm thu l 5,35 mOsMol.
- Cn bng ion.
Cc ion (anion v cation) trong huyt tng l cn bng in tch. o nng ion bng
Equivalent (Eq). Eq l ng lng mt ion bng trng lng Mol chia cho ho tr (Eq=1000
mEq).
Cn bng ion c vai tr quan trng i vi chc nng t bo, vi cn bng acid base mu...
Nng ca cc ion trong huyt tng l:
Cl
-
: 3650 mg/l, 103 mEq/l
HCO
-
: 1650 mg/l, 27 mEq/l
Protein: 70000 mg/l, 15-18 mEq/l
HPO
4
--
: 5-106 mg/l, 3 mEq/l
SO
4
--
: 45 mg/l, 1 mEq/l
Acid hu c: 45 mg/l, 5 mEq/l
-------------------------------------------------------------------
+ 155 mEq/l
Na
+
: 3300 mg/l, 142 mEq/l
K
+
: 180-190 mg/l, 5 mEq/l
Ca
++
: 100 mg/l, 5 mEq/l
Mg
++
: 18-20 mg/l, 1,5 mEq/l
Cc thnh phn khc 1,5 mEq/l
----------------------------------------------------------------------
+ 155 mEq/l
S cn bng ca cc ion trong huyt tng c thc hin nh cc c ch: khuch tn, tnh
in, cn bng Donnan, vn chuyn tch cc ca t bo, c ch siu lc, ti hp thu v bi tit
tch cc ca thn ...


10. NHM MU V AN TON TRUYN MU


1. NHM MU.
S hiu bit v khng nguyn nhm mu l v cng cn thit cho cng tc truyn mu. Truyn
mu c p dng t lu trong cp cu v iu tr. Khi truyn mu gp nhiu tai bin rt
nguy him, mc d truyn mu ln u.
Ngy nay chng ta hiu rng nguyn nhn tai bin l do s c mt cu khng th t nhin
trong c th. Cc khng th ny chng li cc khng nguyn vi tnh min dch cao c trn b
mt hng cu.
Trn b mt hng cu ngi c nhiu khng nguyn khc nhau ngi ta tm c khong
30 khng nguyn thng gp v hng trm khng nguyn khc nhng u l khng nguyn c
tnh min dch yu, thng ch dng nghin cu gen. Cc khng nguyn xp thnh h thng
cc nhm mu AB0, Rh, Lewis, MNS
s
, P, Kell, Lutheran, Duffy, Kidd... Trong s ny c hai h
thng nhm mu AB0 v Rh ng vai tr c bit quan trng trong truyn ma.
1.1. H thng nhm mu AB0.
Nm 1901, Landsteiner pht hin ra hin tng: huyt thanh ca ngi ny lm ngng kt
hng cu ca ngi kia v ngc li. Sau ngui ta tm c khng nguyn A v khng
nguyn B, khng th a( chng A) v khng th b ( chng B).
Khng nguyn A v B c mt trn mng hng cu; khng th a v b c mt trong huyt tng.
Khng th a s lm ngng kt hng cu mang khng nguyn A, khng th b s lm ngng kt
hng cu mang khng nguyn B.
Do c th c trng thi dung np vi khng nguyn bn thn, nn trong huyt tng khng bao
gi c khng th chng li khng nguyn c trn b mt hng cu ca chnh c th . T h
thng nhm mu ABO c chia lm 4 nhm: nhm A, nhm B, nhm AB v nhm O. K hiu
nhm mu biu th s c mt ca khng nguyn trn b mt hng cu.
C th nhm mu A c khng nguyn A trn b mt hng cu v c khng th b (chng B) trong
huyt tng .
C th nhm mu B c khng nguyn B trn b mt hng cu v c khng th a (chng A) trong
huyt tng
C th nhm mu AB c khng nguyn A v B trn b mt hng cu v khng c khng th a v
b trong huyt tng.
C th nhm mu 0 khng c khng nguyn Av B trn b mt hng cu, trong huyt tng c
c khng th a v b.
Ngi ta cng bit rng cc khng th a v b l nhng khng th xut hin t nhin trong huyt
thanh. S phn b cc khng nguyn, khng th thuc h thng nhm mu AB0 nh sau:
Genotypes Nhm
mu
Khng
nguyn
Khng th T L %
Ngi da
trng
Ngi Vit
00
0A hocAA
0B hoc BB
AB
0
A
B
AB
-
A
B
A v B
a v b
b
a
-
47
41
9
3
43
21,5
29,5
6


Nhm A c chia thnh hai phn nhm A
1
v A
2
. V vy s lng nhm mu tr thnh 6
nhm: A
1
, A
2
, B, A
1
B, A
2
B v 0. Mt s ngi c khng nguyn A
1
, c khng th chng A
2
. Mt
s ngi c khng nguyn A
2
, c khng th chng A
1
. Cc khng th ny yu nn t gy nguy
him, nhng trong thc t c th gy tai bin nghim trng khi truyn nhm mu A
2
nhm
tng l nhm mu 0 v nhm mu A
2
B nhm tng l nhm B cho bnh nhn nhm mu B.
Cc khng nguyn thuc h ABO do mt locus kim sot vi 3 alen AB0 trong A v B l tri.
Vic pht hin ra cu trc khng nguyn nhm mu thuc h AB0 lm thay i quan nim
trc y cho rng: khng nguyn A l sn phm trc tip ca gen A, khng nguyn B l sn
phm trc tip ca gen B. Ngi ta cho rng tham gia hnh thnh khng nguyn nhm mu
trong h AB0 c cc h gen Hh v h thng gen AB0. Cc h thng gen ny di truyn c lp.
Ngi c nhm mu 0 ch c gen H m khng c gen A v B nn khng c enzym bin cht H
thnh khng nguyn A hoc B, do ch c cht H chim ton b b mt hng cu. Ngi c
nhm mu A c c gen H v gen A nn c enzym bin cht H thnh khng nguyn A do trn
b mt hng cu c c cht H v c khng nguyn A. Vi s gii thch tng t, ngi c nhm
mu B, trn b mt hng cu c c cht H v khng nguyn B. Ngi c nhm mu AB, trn b
mt hng cu c c cht H, khng nguyn A v khng nguyn B.
i b phn ngi l c gen H. Mt s t ngi khng c gen H (c th ng hp t hh), khng
c cht H trn b mt hng cu. Ngi khng c gen H, d c gen A hoc gen B th cng khng
c khng nguyn A hoc khng nguyn B, v cc khng nguyn ny ch xut hin t cht H. Khi
th mu bng k thut ngng kt, ngi khng c gen H u c ghi nhn l nhm mu O,
nhng h (c th ng hp t hh) c th to ra khng th chng H khi truyn mu ca ngi
nhm mu O tht s (c cht H) v th c th gy tai bin. Ngi c nhm mu ny c gi l
nhm mu O Bombay.
a s ngi (80%), khng nguyn nhm mu cn c mt trong cc dch tit: nc bt, dch v...
Ngay sau khi ra i, khng th c nng rt thp. T thng th 2 tr i, khng th tng dn
ln v cao nht t 8 -10 tui, sau gim dn tr v bnh thng tui trng thnh ri gim
dn theo tui tc. Khng th l g globulin, hu ht l IgM, sau l IgG. Ging cc khng th
min dch khc IgM v IgG cng do cc lympho bo sn xut.
1.2. H thng nhm mu Rh.
Nm 1940 Landsteiner v Wiener nhn thy: nu ly hng cu kh Macacus Rhesus gy min
dch cho th th huyt thanh min dch th ngoi vic gy ngng kt hng cu kh cn gy
ngng kt hng cu ngi. Lc u xp nhng ngi c hng cu b ngng kt bi huyt thanh
ny vo nhm Rh
+
nhng ngi c hng cu khng b ngng kt vo nhm Rh
-
. Nhng sau ny
thy h thng khng nguyn Rh khng n gin nh vy. Trong h thng Rh c nhiu khng
nguyn, phn ln chng c tnh phn ng cho v sinh min dch yu. Do khng th khng
gy ngng kt mnh nh h thng AB0.
Khng nguyn h Rh phn b tha tht trn b mt hng cu. C 3 loi khng nguyn chnh:
khng nguyn D (Rh
0
), khng nguyn C (Rh'), khng nguyn E (Rh''). Ch c khng nguyn D c
tnh khng nguyn mnh v c tnh sinh min dch cao. V vy khi c khng nguyn D th c
gi l Rh
+
. Nhng nhm mu khc thuc h Rh u c tnh khng nguyn rt yu, t c ch
nh Rh
1
, Rh
2
, Rh
z
, Rh
y
, rh. T l Rh
+
ca ngi da trng l 85%, ngi M da en l 95%, ngi
Phi da en l 100%, ngi Vit l 99,92%. Ni mt cch khc l t l Rh
-
ca ngi Vit l 0,08%
gn nh khng ng k.
Khng nguyn h thng nhm mu Rh l di truyn, cn khng th chng Rh ch xut hin c
th Rh
-
khi c min dch bng hng cu c khng nguyn D (Rh
+
). Khng th ny thng l
IgG. Nu mt ngi Rh
-
, cha h c truyn mu Rh
+
bao gi th vic truyn mu Rh
+
cho h
s khng bao gi xy ra phn ng tc th no. Tuy nhin sau khi truyn mu Rh
+
t 2-4 tun
sau, lng khng th chng Rh tng i cao gy ngng kt hng cu Rh
+
ca ngi
cho vn tn ti trong mu ngi nhn. Phn ng ny chm v rt nh. Sau 2-4 thng truyn
mu Rh
+
, nng khng th chng Rh trong mu ngi Rh
-
mi t ti a. Nu truyn mu Rh
+

cho nhng ngi ny ln th 2, c th gy ra tai bin truyn mu nng, chng km g tai bin
nh h AB0. Sau vi ln truyn mu Rh
+
cho ngi Rh
-
, ngi Rh
-
tr nn rt mn cm vi
khng nguyn Rh, tai bin khi truyn mu l cc kz nguy him. l l{ do ti sao ta phi cn lu
ti ngi c truyn mu nhiu ln. Cn phi xc nh nhm mu h Rh cho h, s rng
h l ngi Rh
-
.
Trng hp th hai l ngi m Rh
-
, b Rh
+
. a tr c di truyn Rh
+
t b. Hng cu Rh
++

ca thai sang mu m. Ngi m s c qu trnh to khng th chng Rh, cc khng th ny qua
nhau thai lm ngng kt hng cu thai. Nu ngi m c thai ln u th c th ngi m cha
sn xut khng th gy nguy him cho thai nhi. Khong 30% s thai th hai Rh
+
c triu
chng tng nguyn hng cu bo thai, vng da hu huyt v t l mc bnh tng dn ln v
triu chng bnh cng nng hn cho nhng thai sau.
Nhiu ngi b Rh
+
d hp t, do c khong 25% s con ci l Rh
-
. V vy sau khi a con
trc b vng da hu huyt, tng nguyn hng cu, khng nht thit a tr sau cng b bnh
ny. Nhng a tr mc bnh tng nguyn hng cu bo thai thy cc m sinh mu u tng
sinh hng cu; gan, lch to ra v sn xut hng cu kz bo thai. Hng cu ny xut hin nhiu
trong mu. Tr thng cht do thiu mu nng. Nu sng st tr thng thiu tr tu, tn
thng v no vn ng do lng ng bilirubin trong cc neuron. Cng c th khng th chng
Rh cn tn cng mt s t bo khc ca c th.
Trng hp th hai m ta cn lu { trn y chnh l ngi ph n c tin s sy thai, non,
con c tng nguyn hng cu bo thai, vng da hu huyt. Nhng ngi ny nu cn truyn
mu, phi xt nghim nhm mu Rh. Ngi ta s rng ngi m ny mu Rh
-
v trong mu
c khng th chng Rh. Nu truyn mu Rh
+
cho h th s c tai bin rt nguy him xy ra.
ca thai v sn phm phn hu hng cu Rh 1.3. Cc h thng nhm mu khc.
Trong cc h thng nhm mu cn li th h Kell chim v tr hng u. Khng nguyn Kell rt
nguy him. Nm 1947 ngi ta pht hin tai nn do khng nguyn ny gy ra, t v sau
tai nn do khng nguyn ny vn c theo di.
Khng nguyn F
y
a thuc h Duffy cng c quan tm. 1950 ln u tin Mollison pht hin
khng th chng F
y
a trong huyt tng bnh nhn b tan mu c truyn mu nhiu ln.
Trong vng 20 nm ngi ta miu t nhiu trng hp tng t. Nm 1951 c mt tai
bin cht ngi do F
y
a.
Khng nguyn S thuc h MNS
s
c th gy ra min dch sau truyn mu v xut hin tai nn tan
mu.
Nhng khng th lnh c hiu t nhin nh khng th chng Le
a
, Le
b
(thuc h Lewis), M, N,
P ch gy ra phn ng mt nhit nht nh v khng nguy him.
2. TRUYN MU.
Trong thc hnh truyn mu, ngoi nhng qui nh v nhng xt nghim pht hin cc virut ly
theo ng mu, v k thut bo qun... chng ta cn phi thc hin ng qui tc v nhm
mu, qui tc c bn l: khng khng nguyn v khng th tng ng gp nhau trong mu
ngi nhn. i vi h thng nhm mu ABO, tho mn qui tc trn l phi truyn cng nhm.
Da vo khng th bit ca huyt thanh mu (antiA, antiB, antiAB) ngi ta xc nh chnh
xc khng nguyn A v B trn b mt hng cu. ng thi vi vic xc nh nhm mu thuc h
ABO, cn phi lm cc phn ng cho: trn hng cu ngi cho vi huyt thanh mu ngi
nhn v ngc li trn hng cu ngi nhn vi huyt thanh mu ngi cho. Cc phn ng trn
khng c hin tng ngng kt hng cu th mu mi c truyn.
C mt s tc gi ngh rng, m bo an ton tuyt i, tt nht l truyn mu t thn.
i tng c ly mu lc kho mnh v c bo qun trong ngn hng, khi cn th ly
chnh mu ca h truyn cho h. Hin nay cha c iu kin k thut bo qun mu c
lu (c bit l cc nc ang pht trin) cho nn iu ny cha thc hin c. khc phc
tai bin truyn mu v tnh trng ly nhim bnh qua truyn mu, cc nh khoa hc nghin
cu sn xut ra mu nhn to lm dch truyn thay th mu. Song phm vi ng dng mu
nhn to cha c rng ri v gi thnh cn qu t.
Trong trng hp cn truyn mu m li khng c mu cng nhm, ngi ta c th truyn theo
mt qui tc ti thiu: khng xy ra ngng kt hng cu ca ngi cho trong mu ca ngi
nhn. Nu xy ra tai bin ny th ch cn truyn nhm 2ml mu c th gy cht ngi do
tc mch, ri lon trao i kh ca mu, tan mu, suy thn cp... Nh vy c th truyn mu
khc nhm, nhng bt buc phi theo s sau

Nhm O truyn c cho nhm A,B v AB. Nhm A v B truyn c cho nhm AB. Nhm AB
khng truyn c cho nhm O, A v B. Trong trng hp truyn mu khc nhm nh vy, ch
c truyn khong 250ml mu (mt n v mu), vi tc rt chm. Tai bin do truyn mu
rt kh xy ra v khng th trong mu ngi cho ngay lp tc b pha long trong mu ca ngi
nhn do nng khng th rt thp. Cc khng th ny sau s b cc enzym phn gii.
Tuy vy, ngy nay nh s hin mu nhn o c ph cp nn s truyn mu theo qui tc ti
thiu t c ng dng.
i vi h thng Rh, khng th chng Rh ch hnh thnh ngi Rh
-
khi c min dch bng
hng cu Rh
+
. T l Rh
-
ca ngi Vit li rt thp, cho nn thc t ngi ta ch { hai trng
hp cn xt nghim nhm mu h Rh l ngi c truyn mu nhiu ln v ngi ph
n c tin s xy thai, non, con c hi chng vng da hu huyt. Vic xt nghim nm
mu h Rh cng da trn khng th ca huyt thanh mu tm khng nguyn. Nu ngi cn
c truyn mu l Rh
+
th truyn mu Rh
+
hoc Rh
-
u c. Nu ngi cn c truyn
mu l mu Rh
--
. th nht thit phi c truyn mu l Rh

11. RI LON C CH CM MU

Cm mu l mt c ch rt phc tp, cho nn nhng ri lon ca c ch cm mu tht s l
nhng hi chng gy nhiu tr ngi cho vic chn on, iu tr ca cc thy thuc. Chng ta
c th gp ri lon c ch cm mu do nhng nguyn nhn sau.
- Ri lon chc nng gan s dn n ri lon c ch cm mu, v gan l c quan hu nh sn
xut ton b cc yu t gy ng mu v chng ng mu.
- Thiu ht vitamin K dn n gim cc yu t II, VII, IX v X v vy gy ri lon c ch cm mu.
- Bnh a chy mu (hemophilia) do thiu cc yu t VIII (hemophilia A), yu t IX (hemopilia
B), yu t XI (hemophilia C). y l nhng bnh di truyn.
- Suy v nhc tu lm gim tiu cu gy ri lon c ch cm mu.
- Huyt khi.
Cc mu ng hnh thnh bt thng trong lng mch gy nghn mch (thrombus) hoc cc
mu ng hnh thnh bt thng u trong h tun hon ri bong ra tri t do trong lng
mch ti ch mch nh hn th dng li v gy tc mch ti (emboli). Ri lon c ch ng
mu gy huyt khi l mt bnh l nng nht l hyt khi ti ng mch vnh, ng mch no,
ng mch thn, ng mch phi sau l ng mch chi v cc c quan khc.
Nguyn nhn ca huyt khi l b mt lp t bo ni m b x x do x va ng mch, do
nhim trng (thp tim, nhim trng mu), do chn thng... pht ng qu trnh ng mu.
Hin nay ngi ta thng dng catheter a cc cht hot ho plasminogen ca m vo
vng huyt khi iu tr.
- ng mu ri rc trong lng mch mu nh c xut hin do rt nhiu nguyn nhn khc
nhau. Khi m b cht hoc tn thng n gii phng thromboplastin vo mu v to ra nhiu
cc mu ng lm tc phn ln cc mch mu nh ngoi vi. ng mu ri rc cn gp trong
shock nhim khun. Vi khun hoc c t ca vi khun, nht l ni c t (endotoxin) s hot
ho qu trnh ng mu gy tc, nghn mch v y tnh trng shock nng thm.
- Nhim trng hoc nhim c gy hu fibrin lm chy mu. Cng c nhiu trng hp bnh
thng c ch cm mu rt cn bng nhng khi c s can thip phu thut vo c th th ri
lon c ch cm mu mi xut hin, gy chy mu ko di.
- Cu trc thnh mch b bin i, thnh mch km bn rt d gy chy mu.


BI 2. SINH L CO C
12. S CO C

I- HIN TNG C HC CA CO C.
Khi c co: v th tch khng thay i nhng gim v chiu di v tng chc ca c.
C co, c th rt ngn chiu di ti 2/3 (sinh l{ bnh thng ch co ngn 1/3) Dng phng
php c k{ (myographe) ghi th c co (mt u c phi c nh). Tuz tn s kch thch, ta
ghi c cc dng co c sau: - C co n gin: Tn s kch thch <10 ln/ sec. - C co cng: +C
co rng ca: Tn s kch thch >10 ln/sec v < 20ln/sec +C co cng: Tn s kch thch >20
ln/sec v < 100ln/sec - Co c n gin: - Mt kch thch n l, c s p ng bng mt co c
n nht, nhanh v ngn. l co c n gin. - Cng kch thch phi ti ngng, c mi
co. Cng di ngng c khng co.
Cng kch thch trn ngng m cng mnh th c p ng cng ln, l do s lng si c
c huy ng cng nhiu. Nhng ti mt lc m cng c tng th bin co c khng
tng nata c cng kch thch ti a. Cc giai on ca c co n gin:
a- Giai on tim tng: l thi gian t lc kch thch ti lc c bt u co chng 0,01sec.
b- Giai on c co: tip ngay giai on tim tng-chng 0,04sec.
c- Giai on gin c: chim khong 0,05 sec. C co v gin u l qu trnh tch cc v c s bin
i l ho c. Ton b thi gian c co n gin chng 0,1 sec.
- Nu c mt, thi gian gin c ko di. l trng thi c co cng (chut rt). 2- C co cng.
Nu ta kch thch lin tip ln c c cng nh nhau, th c c hin tng tp cng.
- Nu khong cch gia hai kch thch ln hn thi gian ca c co n gin, v ngay sau giai
on gin c trc, th ta c lot c co n gin nhng bin cao dn; l tp cng kch
thch.
- Nu khong cch gia hai kch thch nh hn thi gian ca mt c co n gin th c co cng:
l hin tng tp cng co c. Hai trng hp xy ra:
a- Trng hp 1: Kch thch sau tc ng vo giai on gin ca chu kz trcta c th c co
rng ca . n mt lc c khng th co ngn c na th ng biu din i ngang ln sng.
b- Trng hp 2: Kch thch sau tc ng vo giai an co ca chu kz trc th th l ng
i ln khng gn sng ta gi l c co cng phng. II- HIN TNG HO HC V NHIT HC
CA CO C. Thnh phn ca c gm: H2O, glycogen, lipid, protein, cht v c.
- Na+, K+ l cation nhiu nht (dng ion). - Ca++, Mg++ cng nhiu v dng hp cht.
- Phospho dng kt hp: phosphagen (phosphocreatin), ATP, Hexoza photphat.
- Protein ca c tng: c sc t h hp l myoglobin v mt s men.
-Trong t c c protein l: actin, myosin , tropomyosin v troponin. Tropomyosin v troponinc
tc dng iu ho co c..
1- Hin tng ho hc. Nhiu tc gi nghin cu hin tng ho hc trong c co v i ti kt
lun: a- Giai on ym kh: Mt lot phn ng ho hc to ra acid lactic. Xung ng thn
kinh gy ra s phn gii ATP to ra nng lng. Phn ng u tin l phn gii
phosphocreatin (PC) thnh H3PO4 v creatin, gii phng nng lng dng ti lp tng phn
ATP. Cng lc l phn gii glycogen xy ra chm vi s tham gia ca 1 s men .
to gluce to nng lng, tuy chm, nhng cung cp nng lng (60%) kp thi cho c co khi
thiu oxy (t gluceacid lactic cho 2 ATP; t glycogen acid lactic cho 3ATP) Kt qu l PC v
ATP c ti lp v xut hin acid piruvic (nu lng oxy) hoc acid lactic (nu thiu
oxy).Acid lactic vo mu gan. 1/5 acid lactic c oxy ha n giai on cui cng l CO2 v
H2O. Nng lng c to ra gip cho 4/5 acid lactic cn li ti tng hp thnh glycogen, ri li
chuyn ho cho nng lng. b- Giai on i kh: T mt phn t gluce oxy ho to 38ATP . T
mt phn t glycogen oxy ho to 39ATP. Hin tng nhit hc ca co c. C hot ng, gii
phng nng lng thc hin cng c hc, song c 70% nng lng pht ra di hnh thc
nhit. Trong lc ngh ngi, c vn sn xut nhit v tiu th oxy. Nng lng ny bo ton
cu trc t bo v duy tr in th mng (nu thiu oxy nng lng gim 1/2). Vic sn nhit
trong co c chia nhiu giai on:
- Nhit ban u gm:
+ Nhit co c.
+ Nhit hot ho v duy tr.
+ Nhit gin c.
- Nhit phc hi: khng mnh, nhng ko di : v gi tr n ln gp 1,5 ln nhit ban u.

13. SINH L C VN

I- CU TRC. C vn chim khong 50% khi lng c th. Mt c c hng triu si c gn vi
nhau. S co c l tng hp ca co cc si c hp thnh.
1- Khung:
L t chc lin kt, chia nhiu khoang trong c cc si c.
T chc lin kt dy hai u c v ho vo gn bm vo xng.
Mi khoang li c vch ngn thnh nhiu nh bc si c, chy ngang sut si c.
2- Si c:
Hnh tr, di 5-60mm, ng knh 10-100mm.
Mi si c l mt t bo c mng lin kt bao bc gi l mng si c (sarcolemme), st mt
trong mng c mt hay nhiu nhn hnh bu dc.
Xung quanh nhn l nguyn sinh cht c ht.
Trong mi si c c nhng t c (myofibrille) nm song song theo chiu dc c.
Bao quanh mi si c l h thng ng (T) ng ny thng ra ngoi si c.
Ngi ta phn ra hai loi c:
- C : t t c, nhiu c tng.
Trong c tng c nhiu myoglobulin. C co chm nhng rt chc.
- C trng: co nhanh nhng chng mt.
* C vn c 2 vn: dc v ngang:
- Vn dc: do xp xp t c chy dc, song song.
- Vn ngang: do cu trc ca t c to ra.
Nhng vn trn to ra a sm v a sng (1 t c di 20mm c khong 10.000 a sm v a
sng).
* a sm: c vng sng ngang l vng H.
* a sng: c di Z gia chy ngang. Di Z qua tt c t c v bm vo mng si c. (a sm
v a sng to thnh vn ngang).
- a sm v hai na a sng to ra n v co c: Sarcomer.
- C tng ch c vai tr dinh dng. Trong c tng, ngoi nhn cn c nhiu mytochondrie
lm nhim v chuyn ho.
- a sm thuc cu trc d hng (anisotrope)gi l a A.
- a sng thuc cu trc ng hng (isotrope) gi l a I.
- a A: phn t ch yu l myosin, mp.
- a I: phn t ch c actin, mnh. Actin t di Z i ra v xen k vo myosin.
3- H thng T.
Quanh si c l cu trc mng, hnh ti v ng (h thng ng: sarcotubular system) gm h
thng T v li c tng. H thng T tip lin vi mng si c v thng vi dch ngoi bo.
Trn c xng: ch ni a A v a I c hnh 3 trc (Triad) ch ni ca h thng ng ngang
(Transverse system) v h thng ng dc (longitudinal system).
Chc nng ca h thng T: dn truyn in th hot ng t mng t bo ti tt c si trong
c.
Li c tng ti b tn cng (Triad) cha Ca
++
lin quan ti c ch co c.
4- S phn phi thn kinh ca c.
Cc si trc ca nron vn ng sng trc tu sng i trongcc dy thn kinh vn ng, khi
n c, chia thnh nhiu nhnh, mi nhnh i vo mt si c.
Phc hp: t bo thn kinh, si thn kinh, si c to nn n v vn ng.
Ch tip xc gia thn kinh-si c gi l tm vn ng.
Mng bc ca si thn kinh (neurilemme) ho vo mng si c (sarcolemme), ch c si trc
xuyn qua mng si c v to ra rt nhiu nhnh trong khi nguyn sinh cht to ra tm thn
kinh-c.
Cc nhnh thn kinh khng i qua gii hn ca tm vn ng v khng tip xc trc tip vi
tng t c.
Ch :
- i khi cnh tm vn ng, c t chc tng t thn kinh giao cm.
- t c cn c thn kinh cm gic, im xut pht l thoi c nm xen k gia cc si c. Thoi
c c vai tr trong iu ho trng lc c v c cm gic trong co, gin c.
II- NHNG C TNH CA C VN.
C vn c hai c tnh: n hi v hng phn.
1- Tnh n hi-trng lc c.
- C gin ra di tc ng ca lc, v co v v tr c khi lc thi tc dng.
Gia lc v gin c c tng quan hyperbon (lc u c gin nhiu; sau lc tng, nhng
gin c gim dn-khng tng ng).
- Tnh n hi c gii hn, nu qu gii hn, c khng co tr li trng thi ban u. Theo
Buchthal: nu gin qu 40% th c khng tr v trng thi c.
- Bnh thng (ngh ngi) c vn trng thi co trng lcnh c b phn thoi c.
2- Tnh hng phn-co c.
C nhiu tc nhn kch thch vo cc s co.
- Kch thch sinh l: l cc xung thn kinh t TKTn c.
- Kch thch nhn to:
+ C hc: kim chm, kp, ct v.v...
+ Ho hc: acid, kim, mui v.v...
+ Nhit hc: nng, lnh v.v...
+ Kch thch bng dng in (in mt chiu, hoc cm ng) dng ph bin v: tc dng nhanh;
cng , thi gian xc nh c v khng gy tn thng t chc.
- C c tnh hng phn gin tip tc l kch thch vo dy thn kinh chi phi c, c s co.
- Loi tr mi thn kinh ti c ri kch thch trc tip vo cc co: l tnh hng phn trc
tip ca c.

14. SINH L C TRN

I- MT S C IM CA C TRN.
1- C:
Si c trn l t bo di t 50-100mm ( ng vt c v), nhn hnh gy gia t bo. C
tng gia, t c xung quanh, kha vn khng r.
C trn thng ghp li thnh mt t chc, hnh thc khc nhau:
- B nh (c chn lng).
- m mng trn (thnh mch mu, bch huyt, ph qun, niu o, ng tit ca tuyn.
- B cho (thng tng rng: t cung, bng quang, ti mt).
- Hnh vng trn (trong c tht).
- Mng mng (c tim).
2- Thn kinh chi phi:
C trn chu s chi phi ca h thn kinh thc vt, gm nhng si ring l hoc tp trung thnh
m ri.
- C nhng tn cng thn kinh ch tip xc vi mt s si c trn. C nhng c li chu nh
hng ca cht trung gian ho hc.
- Thn kinh: giao cm, ph giao cm (catecholamin, acetylcholin) chi phi.
- Chnh si c trn quyt nh tnh cht ca p ng( do cc receptor si c)
Th d: acetylcholin lm gin c trn mch mu, nhng li co c trn rut...
II- S CO CA C TRN.
1- Mt c im quan trng l c trn co rt chm.
C trn p ng vi kch thch: c hc, ho hc, in (ch p ng vi dng in mt chiu,
dng cm ng khng tc dng), kch thch c hc (ch p ng vi kch thch t ngt).
Kch thch ho hc c th gy hng phn hay c ch.
Th d: histamin: gin mch, co c ph qun v rut.
Serotonin: co mch.
Pilocarpin: co ng t
Atropin: gin ng t.
Eserin: tng tc dng ca acetylcholin (do c ch cholinesterase).
Ecgotamin: hu giao cm (do c ch a receptor).
Vic ghi th co c thng c tin hnh on rut c lp cho thy:
- Thi gian co rt di: 3 sec n vi pht.
- Giai on tim tng: 0,2 n 0,8 giy.
2- Tnh t ng.
Thy co c t pht ca tng rng c lp-tng ny nui trong dung dch dinh dng (Ringer-
Locke, Tyrode) 37
0
C.
Khi cc tng ny mt ht lin h thn kinh, n vn c ng.

BI 3. SINH L H TK THC VT
15. GII PHU H THN KINH THC VT


H thn kinh thc vt c cc trung tm nm tu sng, thn no, vng di i
(hypothalamus), mt s vng v bn cu i no, h limbic.
Thng th h thn kinh thc vt hot ng trn c s cc phn x tng. Cc tn hiu cm gic
i ti hch thc vt, tu sng, gy ra p ng phn x ln cc tng. Hoc cc kch thch t bn
ngoi tc ng vo cc th cm th ngoi vi, t y nh hng ti thn kinh trung ng, vng
di i, thn no v gy ra cc p ng phn x ln cc tng iu h hot ng cc tng.
H thn kinh thc c chia thnh hai h l: h giao cm v h ph giao cm.V v tr, cu to
ca hai h ny c khc nhau, chc nng ca chng tri ngc nhau, nhng thng nht trong
mt c th ton vn, lm cho c th thch nghi vi hot ng sng.
C hai h u c c im cu to chung l: 1- Trung khu, 2- Neuron, 3- Hch.
1.1- H giao cm.
1.1.1- Trung khu.
Trung khu ca h giao cm phn b sng bn cht sm tu sng lin tc t t tu lng 1 n
t tu tht lng 2.
1.1.2- Neuron- c 2 neuron:
- Neuron trc hch hay tin hch, thn neuron nm sng bn cht sm tu sng (trung khu).
Axon ca chng i theo r trc ca tu sng cng vi dy thn kinh tu v c bao myelin
(hnh.....).Ngay sau khi ra khi t sng, si giao cm i theo nhnh thng trng ti hch ca
chui gia cm. T y si c th i theo mt trong ba con ng sau: 1.To sinap vi neuron
nm trong hch . 2. i ln trn hoc i xung di to sinap trong mt hch khc ca
chui hch. 3. Hoc i xa hn trong chui hch, ri qua cc si giao cm v tn cng hch
trc sng.
- Neuron sau hch (hu hch), thn nm hch cnh sng hay hch trc sng, axon di,
khng c bao myelin. Si sau hch i n cc c quan c thn kinh chi phi.
Mt s si hu hch giao cm quay tr li dy thn kinh tu qua nhnh thng xm mi t
tu (hnh ).Con ng ny gm cc si C i ti c vn, cc mch mu, tuyn m hi, c
dng lng. Ngi ta tnh rng c khong 8% cc si thn kinh ti c vn l cc si giao cm,
chng t chng c vai tr quan trng trong dinh dng c vn v lm gin mch c.
Cc si giao cm khng phn b nh cc si thn kinh tu bt ngun t cng mt t tu sng.
V d: cc si giao cm xut pht t t tu D1 thng i ln theo chui hch ti u, t t
D2 ti c, t t D3, D4, D5, D6 ln ngc, t t D7, D8, D9, D10 v D11 ti bng, t t D12,
L1 v L2 ti chi di.
S d c s phn b thn kinh giao cm ti tng nu trn l ph thuc vo v tr hnh thnh nn
tng lc cn bo thai. V d: tim nhn nhiu si giao cm xut pht t t sng c ca bo thai.
Tng t nh vy, cc tng trong bng nhn cc si giao cm t cc on thp ca ngc v
phn ln rut l xut pht t khu vc ny.
1.1.3- Cc hch giao cm, c hai loi:
- Cc hch giao cm cnh sng: phn b thnh hai chui nm st hai bn ct sng, trong chui
hch giao cm c cc hch quan trng l hch c trn, hch c gia, hch c di. Hch giao
cm c di gom vi hch giao cm t ngc 1 to thnh hch sao.
T hch giao cm c trn, si hu hch i ti c quan vng u.
T hch giao cm c gia, si hu hch i theo cc dy thn kinh s no s IV, VI chi phi c
vn nhn; c nhnh i ti tim v nhnh i ti tuyn gip, thc qun.
T hch sao, si hu hch c nhnh chi phi c quan vng c, c nhnh i trong thnh phn
dy thn kinh tim di, c nhnh n chi phi cc c quan trong lng ngc.
- Cc hch giao cm trc sng l hch xa ct sng, c 3 hch: hch m ri dng, hch mc
treo trng trn v hch mc treo trng di.
T hch m ri dng v hch mc treo trng trn cc si hu hch i n chi phi cc c
quan vng bng nh d dy, gan, rut non.
T hch mc treo trng di, cc si hu hch i ti chi phi cc c quan vng chu nm trong
thnh phn dy tng di v dy thn kinh rut.
Cc si giao cm tin hch tn cng tu thng thn th i thng t sng bn cht xm tu
sng m khng dng v to synap u c. Ti thu thng thn, chng tn cng trc tip
cc neuron bin i thnh cc t bo bi tit adrenalin (80%) v noradrenalin (20%). V mt
bo thai hc th cc t bo c ngun gc l m thn kinh v tng t nh neuron hu hch giao
cm. Chng c cc si thn kinh th s v chnh cc si ny bi tit cc hormon nu trn.
1.2- H ph giao cm
1.2.1- Trung khu
Trung khu h ph giao cm phn b ba ni: no gia, hnh- cu no v sng bn cc t cng
ca tu sng (hinh....)
1.2.2- Neuron: c hai neuron trc hch v sau hch
- T cc neuron no gia xut pht cc si ph giao cm trc hch nm trong thnh phn
dy thn kinh s no s III
- T cc neuron hnh - cu no xut pht cc si ph giao cm trc hch, nm trong thnh
phn dy thn kinh s no s VII, IX, v X (hnh...). C khong 75% s si ph giao cm l nm
trong dy X v i n ton b c quan bng. C th l cc si ca dy X i ti chi phi tim,
phi, thc qun, d dy, ton b rut non, na u rut gi, gan, ti mt, tu, tuyn v thng
thn v phn trn ca niu qun.
Cc si ph giao cm i trong dy thn kinh s no s III i ti chi phi c co ng t, cc c
th mi ca mt.
Cc si ph giao cm trong dy thn kinh s no s VII i ti tuyn l, tuyn di hm , tuyn
mi.
Cc si ph giao cm trong dy thn kinh s no s IX i ti chi phi tuyn mang tai.
Cc si ph giao cm trc hch xut pht t cc neuron cc t tu cng (S1-S3) i trong
dy thn kinh chu, chi phi i trng xung, trc trng, bng quang v phn di ca niu
qun.
Cc si thn kinh trc hch ph giao cm thng di, c bao myelin
-Neuron sau hch ph giao cm c axon ngn t 1mm n vi mm i trong thnh tng hoc
gn tng v chi phi tng . Si trc neuron sau hch ph giao cm khng c bao myelin.
1.2.3- Cc hch ph giao cm:
Cc hch ph giao cm nm thnh tng hoc gn tng v to synap gia neuron trc hch
v neuron sau hch.
Ngoi h giao cm, ph giao cm, trong h thn kinh thc vt cn c h hu giao cm
(metasympathicus) hay l h thn kinh rut (Nozdrachev et at., 1980; Scracherd et al., 1997).
H hu giao cm nm trn thnh ng tiu ho, gm c m ri Auerbach v m ri Meissner.
m ri Auerbach nm gia lp c vng ( trong) v lp c dc ( ngoi). m ri Meissner
nm lp di nim mc. H thn hu giao cm l mt mng li neuron, trong c nhiu
neuron dn ng (pace-marker), do m bo cho li neuron c th tip tc hot ng
khi chng b tch ri hon ton khi s chi phi ca trung ng. i n li neuron ny c cc
si giao cm, ph giao cm v cc si t khp ni trn thnh rut. T li neuron c cc si
chy n cc c trn v tuyn ca ng tiu ho.
Chc nng ch yu ca h hu giao cm l iu ho vn ng, iu ho vn chuyn cc ion v
nc, cng nh ng vai tr trong hot ng ch tit cc enzym. Ngoi acetylcholin v
noradrenalin, trong h hu giao cm cn c nhiu cht dn truyn (transmiter) v nhiu cht
iu bin (modulator) nh sau:
- Adenosin v purin
- g- aminobutyric acid (GABA)
- Vasoactive interstinal polypeptid (VIP)
- Somatostatin
- Dinorphin v enkephalin
- Gastin
- Galanin
- Serotonin
- Bradykinin
- Substance P
- Choleystokinin (CCK 8)
- Bombesin
- Neuropeptid Y
- Calcitonin
1.3- Cc trung khu cao cp ca h thn kinh thc vt.
Ngoi no gia, hnh- cu no, tu sng cn c mt s cu trc thn kinh khc tham gia vo
chc nng thc vt.
C th l:
- Th li (formatio reticularis) thn no. V d 2/3 trn (rostalis) ca th li hai bn hnh tu
l trung khu giao cm gy tng hot ng tim, co mch gy tng huyt p. 1/3 di (caudalis)
ca th li vng gia hnh tu (quanh mm bt lng) l trung khu ph giao cm c tc dng
dng lm hot ng ca tim, gy gin mch, h huyt p. Ngoi tc dng ca dy thn kinh X
( nu trn), trung khu gim p cn c tc dng c ch trung khu tng p v xung ng cn
theo b li gai lng bn (reticulo - spinalis dorsolateralis trast) n c ch cc neuron trc
hch ca dy thn kinh giao cm chi phi tim mch tu sng.
- Cc trung khu thc vt trong tiu no (cerebellum): do tiu no lin h qua li vi cc cu trc
ca thn kinh trung ng k c v no, nn ngoi chc nng phi hp v iu ho vn ng,
tiu no cn tham gia mt s phn x thc vt. Trong lm sng, bnh nhn b tn thng tiu
no thng quan st c ri lon cc chc nng thc vt nh ri lon chc nng dinh dng,
chc nng tim mch, ri lon thn nhit v chuyn ho . C ch gy ra nhng ri lon l do ri
lon mi quan h chc nng gia tiu no vi vng di i v th li l nhng cu trc thn
kinh c vai tr quan trng trong iu ho cc phn x thc vt.
- Cc trung khu trong hypothalamus, trong th vn (corpus
striatum): hypothalamus l trung khu thn kinh thc vt cao cp di v:
+ Cc nhn phn trc vng di i c lin quan vi chc nng ca h ph giao cm. Kch
thch vo vng ny gy ra cc phn x thuc ph giao cm nh lm chm nhp tim, tng nhu
ng rut, co ng t...
+ Mt s nhn phn gia vng di i c lin quan vi chc nng dinh dng v chuyn ho
vt cht.
+Cc nhn phn sau vng di i c lin quan n chc nng giao cm. Kch thch vo vng
ny gy ra chc nng giao cm nh tng hot ng tim, tng huyt p ng mch, gim nhu
ng rut, gin ph qun ...
+ Cc nhn vng gia, trc v sau vng di i u tham gia vo c ch iu nhit.
- Mt s trung khu thuc h limbic.
Mt s vng thuc h limbic tham gia mt s phn x thc vt k c h giao cm, ph giao cm
thng qua th li v vng di i. V d h limbic tham gia phn ng cm xc nh s hi,
t v, sinh dc v.v.. u nh hng ti tim mch, h hp, c dng lng v.v...
- Vng trn ca bn cu i no c nhng si lin hp ni vi vng trn vi cc vng khc ca
v no ng thi cng c nhng si lin h vi h limbic, vi i th, vi vng di i, vi th
vn, th li, qua m nh hng ti chc nng thc vt. Ngoi ra vng nh cng c nhng
si lin h vi th vn, vng di i v i th tng t nh trn m nh hng ti chc nng
thc vt. Nhng cu trc thn kinh nu trn c chc nng iu ho hot ng cc trung khu
thc vt nm pha di chng v phi hp cc phn x thc vt vi cc phn x vn ng trong
ton b c th.

16. CHC NNG CA H THN KINH THC VT

1- Chc nng chung ca h thn kinh thc vt ni chung l iu ho cc qu trnh chuyn ho
vt cht, iu ho hot ng ca cc c quan ni tng cng nh ca chnh h thn kinh trung
ng. Trong iu ho chc nng ca cc c quan thng c s tham gia ca c hai h thn kinh
giao cm v ph giao cm.
Ph thuc vo trng thi chc nng ca cc c quan m h thn kinh thc vt c th gy nh
hng iu chnh hoc nh hng pht ng nu c quan c tnh t ng v hot ng lin tc
th cc xung ng truyn n t cc dy thn kinh giao cm hoc ph giao cm ch c th tc
ng lm tng hoc lm gim hot ng ca cc c quan . nh hng ca h thn kinh thc
vt vi c quan trong trng hp ny gi l nh hng iu chnh.
Nu c quan khng hot ng lin tc v c hng phn di nh hng ca cc xung ng
truyn n n theo cc dy thn kinh giao cm hay ph giao cm th nh hng trong trng
hp ny l nh hng pht ng.
nh hng ca h thn kinh giao cm v ph giao cm ln cc quan trong c th c tm tt
trong bng...
Bng .........tc dng ca h thn kinh thc vt ln cc c quan trong c th.
C quan tc dng ca giao cm tc dng ca ph giao
cm
Mt- ng t
- C th mi
gin (co c tia)
gin nh (nhn xa)
co (co c vng)
co rt (nhn gn)
Tuyn mi
- nc mt
- mang tai
-di hm
D dy, tu
co mch v bi tit nh kch thch bi tit,tng
th tch v tng nng
cc enzym
tuyn m hi bi tit nhiu (cholincsgic)
Bi tit m hi lng bn
tay,chn
tng tit m hi
Tim mch
C tim
gin (b2)
tng nhip, tng lc co
gin
gim nhp, gim lc co
Phi tiu ph qun
mch mu
gin
co va
co
gin
Rut- co tht
Lng rut
Tng trng lc (co)
gim nhu ng, gim
trng lc
gin
tng nhu ng v
trng lc c
Gan ti mt, ng
mt
gii phng glucoza
gin
tng nh tng hp
glucozen
co
Thn gim lc v gim tit
renin
khng c tc dng
Bng quang
- c detrusor
- C tam gic
gin nh
co
co
Gin
Dng vt Xut tinh Cng
Tiu ng mch
- Da
-Tng bng
Co
Co
Co (a adrenergic)
khng c tc dng
- C vn Gin (b2) adrenergic)
Gin (choninergic)
mu
- ng mu
Glucoze, lypit
tng khng tng
Chuyn ho c s
Bi tit ca tuyn
thng thn
Hot ng tm thn
C dng lng
C vn
T bo m
tng ti 100%
Tng
tng
Co (choninergic)
Tng phn gii glucoze
Tng phn gii m
Khng tc dng
Kt lun: Qua bng ny chng ta c th thy kch thch giao cm gy kch ln mt s c quan
ny nhng li gy c ch ln mt s c quan khc. Cng tng t nh vy, h ph giao cm c
tc dng kch thch ln mt s c quan v li gy c ch ln mt s c quan khc
Thm na, trong khi giao cm kch thch mt c quan th ph giao cm i khi li c ch c
quan y chng t l c lc hai h ny tc ng i lp nhau. Tuy nhin, phn ln cc c quan
thng do mt h chi phi mnh hn l do h kia.
2- Tc dng ca h giao cm v ph giao cm ln mt s c quan c bit
2.1- Tc dng ln mt
C hai h giao cm, ph giao cm iu ho ng m ng t v iu chnh tiu c ca nhn
mt. Kch thch giao cm lm co cc si c kia gy gin ng t cn kch thch pha giao cm
gy co cc c vng mng mt lm ng t co li. Dy ph giao cm chi phoi ng t b kch
thch khi c qu nhiu nh sng vo mt. Phn x c ng t ny c tc dng bo v vng mc
khi b nh sng kch thch qu mc. Khi thiu nh sng th dy giao cm b kch thch gy co c
tia lm m rng thm ng t vvng mc thu nhn thm nh sng.
Thay i tiu c ca nhn mt th hu nh hon ton do h ph giao cm chi phi kch thch
ph giao cm lm cho co cc c th mi lm gim sc cng nn nhn mt tr ln li hn (phng
ln) khin cho ta nhn r vt gn.
2.2- Tc dng ln cc tuyn
Cc tuyn mi, nc mt, nc bt v nhiu tuyn ca ddy b kch thch mnh bi h ph
giao cm v gy ra tng tit.
Cc tuyn tiu ho ming v d dy chu kch thch ca h ph giao cm rt mnh v gy tng
tit, cn cc tuyn rut non v rut gi ch yu chu s chi phi ca cc yu t ti ch, khng
do h thn kinh thc vt.
Kch thch giao cm c tc dng trc tip lm trc tip lm bi tit nhiu men,song n li gy co
mch n tuyn nn lm gim bi tit v lng
Kch thch giao cm lm tng tit m hi nhng kch thch ph giao cm li khng c tc dng
ny.cc si giao cm n tuyn m hi lng bn tay, lng bn chn l si adrenergic, cn cc si
giao cm n cc tuyn m hi khc l si cholinergic.
Hn na cc tuyn m hi li b kch thch bi tnf trc vng di i nucleus supraopticus v
n. Preopticus) c tc dng iu hop qu trnh thi nhit (trung khu ph giao cm). Phn ln cc
neuron vng ny tng xung ng khi nhit tng v gim xung ng khi nhit gim. Kch
thch vo vng ny s quan st thy hin tng tng thi nhit nh gin mch ngoi vi tng tit
m hi nn s bi tit m hi c th c coi l thuc chc nng ca h ph giao cm.
Cc tuyn nch cng chu kch ca h giao cm qua si adrenegic thng qua s iu ho ca
trung tm giao cm trung ng
2.3- Tc dng lnd dy rut
ng d dy, rut c h thn kinh ni tng chi phi. Tuy nhin h giao cm v ph giao cm c
tc dng ln hot ng c hc ca d dy rut. Kch thch ph giao cm lm tng hot ng ca
ng tiu ho nh lm tng nhu ng rut, gin cc c tht vng nn lm cho thc n qua ng
tiu ho nhanh. Bnh thng th cc chc nng ca ng tiu ho t ph thuc vo h giao cm
tuy nhin khi kch thch mnh giao cm li gy ra c ch nhu ng v lm cc c tht vng, hu
qu l lm gim s vn chuyn thc n trong ng tiu ho v i khi cn lm gim c bi tit
dch
2.4- Tc dng ln tim
Kch thch giao cm lm tng hot ng tim (tng hng phn, tng dn truyn, tng lc co bp,
tng tn s v tng dinh dng c tim). Kch thch ph giao cm th tc dng ngc li ngoi tr
tng dinh dng tim.
2.5- Tc dng ln mch mu vng i tun hon phn ln mch mu, c bit l mch ca cc
tng trong bng v mch ca ra b co li khi kch thch giao cm. Kch thch ph giao cm
khng c tc dng r rt ln vn mch, nhng n gy gin mch mt vi ni, v d bng
mt. Trong mt vi trng hp kch thch b2 giao cm gy gin mch nht l khi dng thuc
lm lit tc dng co mch ca a giao cm (thng th tc dng co mch ca a giao cm mnh
hn nhiu so vi tc dng ca b giao cm)
2.6- Tc dng ln huyt p
Huyt p ph thuc vo hai yu t l sc bm ca tim v sc cn ca mch mu. Kch thch giao
cm lm tng c hai yu t ny nn lm huyt p tng mnh
Kch thch ph giao cm lm gim sc bm ca tim nhng hu nh khng c tc dng g ln sc
cn ca mch nn ch gy h huyt p nh. Xong nu kch thch mnh h ph giao cm th c
th lm tim ngng p hon ton v lm mt huyt p.
2.7- Cc tc dng ln cc chc nng khc
Kch thch giao cm c tc dng c ch ln cc ng trong gan, ti mt niu qun, bng quang
cn kchd thichd ph giao cm th li c tc dng kch thch tng hot ng cc c quan trn.
Kch thch giao cm lm tng chuyn ho nh lm tng gii phng gluccoze t gan vo mu nn
glucose huyt tng, tng phn gii glucogen gan v c, tng trng lc c, tng chuyn ho
c s v tng hot ng tm thn.
C h gioa cm v ph giao cm u tham gia vo qu trnh hot ng tnh dc nam v n.

17. CC CHT DN TRUYN V RECEPTER THUC
H TK THC VT


1- Cc cht dn truyn H thn kinh thc vt c cc cht dn truyn cha trong cc tn cng
ca si giao cm v ph giao cm. Cc si tn cng cha acetylcholin c gi l si
cholinergic, cc si tn cng cha noradrenalin c gi l si adrenergic.
Cc si tin hch ca h giao cm v ph giao cm u l si cholinergic. Ngc li cc si hu
hch ca h giao cm hu ht l si adrenergic tr cc si chy n tuyn m hi, c dng lng
v mt s mch mu l si cholinergic.
Nh vy cht dn truyn tt c cc si tn cng ph giao cm u l acetylcholin, cn phn
ln cht dn truyn tn cng si giao cm hu hch l noradrenalin. Cc cht truyn t ny
s tc ng ln cc c quan khc nhau gy ra hiu ng ca giao cm hay ca ph giao cm
ln c quan .
Cc tn cng thn kinh ca h thc vt, c bit l ca h ph giao cm cng ging nhng nh
hn l cc tn cng thn kinh- c ca c vn. Song cc tn cng giao cm hu nh khng tip
xc trc tip vi cc t bo p ng ca c quan m n chi phi, c trng hp chng li tn
cng m lin kt nm ngay di t bo m chng tc ng. ni m si ny n gn t bo
p ng, ngi ta thy c cc on phng to v chnh ch phng ny c cc bc nh cha
noradrenalin hay acetylcholin.
Ngoi ra, trong cc on phng cn c nhiu ty lp th (mitochondrie) cung cp ATP to
nng lng dng cho sinh tng hp noradrenalin hay acetylcholin.
Khi in th hot ng lan ti cc si tn cng th qu trnh kh cc lm tng tinh thm ca
mng vi ion calci. Ion calci t ngoi vo trong si tn cng. Ion calci c tc dng lm cc bc
cha cht truyn t ho hc chuyn dch ti gn mng ti tn cng, ri tip xcvi mng v
ho mng, sau ph v cc bc v gii phng cc cht truyn t ho hc ra ngoi khe sinp.
Lng cht truyn t ho hc c gii phng t l thun vi lng ion calci i vo trong ti
(Ganong,1989).
Acetyicholin c tng hp cc tn cng ca cc si cholinergic, phn ln qu trnh tng hp
xy ra trong bo tng si trc, bn ngoi cc bc nh, sau Acetylcholin c vn chuyn
vo trong cc bc, c d tr li nhiu trong . Phn ng tng hp xy ra nh sau:
Cholinacetyltransferase
AcetylcoA + cholin Acetylcholin
Sau khi c gii phng, acetylcholin tn ti m vi giy, sau phn ln b men
acetylcholinesterase (gn vi collagen v glycosaminoglycan) m lin kt ti ni phn gii
thnh ion acetat v cholin ging nh iu xy ra cc sinap thn kinh- c. Cholin c vn
chuyn tr li vo trong si thn kinh c ti tng hp thnh acetylcholin (hnh...)
Qu trnh tng hp noradrenalin bt u bo tng ca si adrenegic, nhng c hon
thnh bn trong cc bc nh. Qu trnh din ra nh sau:
Ngun gc ca catecholamin (adrenalin v noradrenalin) l acid amin tyrosin. Tyrosin b
hydroxyl ho nh men hydroxylase thnh DOPA, ri DOPA c vn chuyn vo bn trong cc
bc nh. Ti y DOPA b kh carboxyl nh men decarboxylase to nn dopamim. Sau
dopamim b hydroxyl ho thnh noradrenalin. Ring tu thng thn noradrenalin c
chuyn t li ni sinh cht vo ty lp th (mitochondrie), 80% cht ny c metyl ho
to thnh adrenalin nh c s xc tc ca men phenylethanolamin N- methyl transferase,
men ny ch c tuyn tu thng thn v t chc no (hnh....)
Sau khi c gii phng, noradrenalin c ly i bng ba con ng:
- Ti nhp vo cc tn cng thn kinh nh c ch tch cc (khong 50-80%)
- Khuych tn vo cc dch k bao quanh (phn ln s noradrenalin cn li)
- B cc enzym phn gii nh monoaminoxydase (MAO) c tn cng thn kinh hoc catechol -
o methyltrasferase (COMT) c m.
Noradrenalin c gii phng trc tip vo m ch c tc dng trong vi giy, chng t s ti
nhp v khuych tn ca n xy ra nhanh. Tuy vy noradrenalin v adrenalin do tu thng
thn gii phng vo mu vn cn tc dng chng no chng ti m v ri b enzym COMT ph
hu, (ch yu l gan). Khi c gii phng vo mu, adrenalin v noradrenalin vn cn tc
dng mnh trong 10- 30giy v tc dng gim dn sau 1 n vi pht.
2- Cc receptor.
Cc cu trc nm mng sau sinap tip nhn cc cht truyn t thn kinh c gi l cc
recepter. Recepter tip nhn noradrenalin v adrenalin c gi l adrenoreceptor. Receptor
tip nhn acetylcholin c gi l cholinoreceptor. gy tc dng ln c quan p ng,
acetylcholin, noadrenalin hay adrenalin trc ht phi gn vi cc receptor c hiu t bo
p ng. Receptor thng nm mt ngoi mng t bo, l mt protein xuyn sut theo chiu
dy ca mng t bo. Khi cht truyn t gn vo receptor th cu trc ca phn t receptor b
bin i v dn n b kch thch hoc c ch t bo bng cch:
-Kch thch hay c ch t bo p ng bng cch thay i tnh thm ca mng: phn t protein
receptor l mt phn to nn mng t bo nn khi cu trc khng gian ca n b thay i th
gy ng hoc m cc knh ion v do lm thay i tnh thm ca mng i vi ion. V d:
knh ion Na
+
v knh ion Ca
++
thng c m ra v lm cho cc ion ny vo t bo nhanh,
nhiu, gy kh cc mng v kch thch t bo. Trtong trng hp khc th knh ion K
+
hoc
knh ion Cl
-
li ck m. Ion K
+
i ra hoc ion Cl
-
i vo t bo gy ra c ch t bo. mt s
t bo khc th cc ion i vo gy ra tc dng trc tip ngay ln hot ng ca t bo. V d
nh ion Ca
++
i vo t bo gy co c trn.
-Tc ng ln cc enzym bn trong t bo: mt c ch tc dng khc ca receptor l kch thichd
hay c ch mt enzym hay mt cht ho hc khc trong t bo. Enzym thng gn vo u
th vo bn trong t bo ca phn t protein receptor. nhiu lai t bo khi adrenalin gn
vi receptor th lm tng hot tnh ca enzym adenylcyclase c trong t bo dn n to
thnh nhiu AMP vng. AMP vng li gy nhiu hot ng khc ca t bo. Hiu ng do AMP
vng gy ra ph thuc vo b my chuyn ho ca lai t bo . Nh bit c c ch ny
ngi ta hiu c ti sao mt cht truyn t ca h thn kinh thc vt li c th gy c ch
c quan ny nhng li kch thch c quan khc. Tc dng kch thch hay c ch l ph thuc
vo bn cht protein receptor trn mng t bo v vo hiu qu ca s thay i cu trc khng
gian ca phn t ny khi n b gn vi cht ho hc truyn t. Chnh v vy m tc dng trn
ca cht truyn t ca thn kinh cc c quan khc nhau th khc nhau.
2.1- Cc adrenorecetor
Khi nghin cu v thuc c tc dng ging noadrenalin. (thuc tng cng giao cm) ln cc c
quan cho thy c hai loi adrenoreceptor l a receptor v b- receptor. b- receptor li c
chia thnh b1 receptor v b2 receptor. a - receptor c t bo c trn mch mu ngoi vi,
mch mu c quan ni tng. b1 receptor c c tim, nt xoang, nt nh tht, c trn tht
vng. b2 receptor c c trn thnh mch vnh, mch mu c vn, c Reissessen ph
qun, c trn thnh ng tiu ho, c trn t cung, bng quang, ti mt... . a - receptor ch kt
hp vi noradrenalin, cn adrenalin kt hp vi c 3 loi: a, b1 v b2- receptor.
Hiu qu gy ra khi noradrenalin v adrenalin kt hp vi a - receptor l co mch mu ngoi vi
v mch mu c quan ni tng. Hiu qu gy ra khi adrenalin kt hp vi b1 receptor l tng co
bp c tim, tng dn truyn nt xoang v nt nh tht, cn hiu qu gy ra khi adrenalin kt
hp vi b2- receptor l gin mch mu mch vnh, mch c vn, gin c Ressessen ph
qun v c trn ng tiu ho, c trn thnh t cung, c bng quang, c ti mt. Adrenalin v
noadrenalin do tu thng thn tit ra cng c tc dng ln cc a - receptor v b- receptor
nhng hi khc. Noradrenalin ch yu kch thch cca - receptor, nhng cng c kch thch yu
ln cc b- receptor. Adrenalin th kch thch c hai a v b- receptor mnh nh nhau. Do tc
dng ca noradrenalin v adrenalin ln cc c quan khc nhau ph thuc vo loi receptor c
cc c quan . Nu mt c quan ch c ton l b- receptor th adrenalin s c tc dng kch
thch mnh hn.
2.2- Cc cholinoreceptor c hai loi:
M- cholinoreceptor (receptor muscarinic) v N- cholinoreceptor (receptor nicotinic). Receptor
M c tt c t bo c chi phi bi cc neron hu hch ph giao cm cng nh cc t bo
c chi phi bi cc si hu hch giao cm bi tit acetylcholin. Receptor N c synap gia
neuron tin hch v neuron hu hch ( thn neuron hu hch) ca c h giao cm v ph giao
cm cng nh mng si c ch tm vn ng.
Receptor muscarinic li c chia lm hai loi: M
1
cholinoreceptor v M
2
- cholinoreceptor.
Khi acetylcholin gn receptor M
1
s gy kh cc mng sau synap, ngha l gy hng phn cn
vi gn vi receptor M
2
s gy ra tng phn cc mng sau synp ngha l gy c ch.
Nh vy cng mt cht dn truyn c th gy ra cc hiu ng khc nhau i vi cc c quan
khc nhau trong c th, iu ny l ph thuc vo cc receptor c quan . V d
acetylcholin c tc dng c ch hot ng ca c tim (v c M
2
cholinoreceptor), song li c tc
dng gy hng phn i vi c trn ca ng tiu ho (v c M
1
cholinoreceptor) adrenalin lm
tng hng phn c tim, gy co mch ngoi vi (ni c a receptor) nhng li c ch c trn ca
rut v gy gin mch mu c vn mch mu no (ni c b2- receptor).
Vic nm vng tc dng c hiu ca cc cht dn truyn ln cc lai receptor khc nhau c
ngha rt quan trng cho php s dng ng cc thuc iu tr trong lm sng. V d trong
trng hp cc c ressessen ca ph qun b co tht (cn hen ph qun) th pah dng
adrenalin tc ng ln cc b2- receptor mi t c hiu qu mong mun hoc trng
hp tru tim phi dng adrenalin tc ng ln b1- receptor cn trong trng hp tru mch
li phi dng noadrenalin lm trng huyt p v cht ny ch tc dng ln a receptor gy co
mch ngoi vi lm tng sc cn ngoi vi dn n huyt p c tng ln.

18. TC NG CA THUC LN H TK THC VT

1- Cc thuc nh hng ln c quan p ng adrenergic. 7.1.1- Cc thuc lm tng cng tc
dng ca cc adrenergic: Nu tim noradrenalin vo tnh mch th gy ra tc dng ln ton c
th.
V th noradrenalin gi l thuc ging giao cm hay thuc adrenergic.Adrenalin, ephedrin,
methoxamin v.v... l nhng thuc ging giao cm khi tim noradrenalin, hay adrenalin vo c
th c thi gian tc dng ngn t 1 n 2 pht, cn nhng thuc ging giao cm khc th c
thi gian tc dng ko di t 30 pht n 2 gi.
Mt s thuc tc dng c hiu ln a- adrenoreceptor nh: phenylephrin...
Cn isoproteronol, albuterrol ch tc dng ln b - adrenoreceptor.
1.2- Cc thuc km hm hot tnh adrenergic.
Hot tnh adrenegic c th b chn li nhiu khu:
- Thuc ngn chn s tng hp v tch tr noradrenalin tn cng thn kinh, thng dng l
reserpin.
- Thuc c ch gii phng noradrenalin t cc tn cng thn kinh. Cht in hnh l gunitidin,
Xylocholin, oknid, oktadin.
- Thuc c ch b - adrenoreceptor: Propanolon c ch tt c b - adrenoreceptor cn thuc
metoprolol ch c ch b1 adrenoreceptor.
- Thuc c ch a- adrenoreceptor: Ergotamin, Ergotoxin.
- Thuc c ch s dn truyn qua hch thc vt: Hexamethonium.
2- Cc thuc nh hng ln c quan p ng cholinergic.
2.1- Thuc c tc dng ph giao cm (muscarinic).
Tim acetylcholin vo tnh mch khng gy ra tc dng ging nh khi kch thch dy ph giao
cm v acetylcholin b ph hu ngay trong mu v trong cc dch trc khi kp n cc c quan
p ng. Tuy nhin c mtt s thuc khng b ph hu nhanh th c th gy ra tc dng ca ph
giao cm. Chng c gi l cc thuc ging ph giao cm, thng dng l Pilocarpin,
methacholin, chng tc ng trc tip ln cc receptor cholinergic loi muscarinic.
Cc thuc c tc dng ging ph giao cm cng c c tc dng ln cc c quan p ng vi cc
si cholinorgic ca si giao cm. V d hai thuc trn c th gy bi tit m hi, gy gin mch
mt s c quan ngay c cc mch mu khng c si cholinergic.
2.2- thuc tc dng tng tc dng ca ph giao cm (thuc khng cholinesterase). Mt s
thuc khng c tc dng trc tip ln c quan p ng cholinergic nhng li lm tng tc dng
ca acetylcholin cc tm vn ng: neostigmin, pyridostigmin, ambenonium. Cc thuc ny
c ch enzym cholinesterase, do lm cho acetylcholin c gii phng ra chm b phn hu,
kt qu l tc dng ca acetylcholin ln c quan p ng c ko di.
2.3- Thuc c ch hot tnh cholinergic c quan p ng (thuc khng muscarin): Atropin,
homtopin v Scopolamin c ch tc dng ca acetylcholin ln cc receptor muscarinic cc c
quan p ng cholinergic. Tuy nhin cc thuc ny khng nh hng ti cc receptor nicotinic
neuron hu hch hay c vn.
3- Thuc kch thch hay c ch neuron hch thc vt.
3.1- Thuc kch thch hch thc vt.
Tim acetylcholin c th kch thch neuron hch thc vt c hai h , v vy ng thi gy ra c
hiu ng giao cm trn ton b c th. Cht nicotin kch thch cc neuron hch ging nh
acetylcholin, v mng neuron hch cng c receptor vi nicotin. Do thuc ny cn gi l
thuc loi nicotinic. Thuc acetylcholin v methacholin c c tc dng nicotinic v muscarinic,
cn Pylocarpin ch c tc dng muscarinic m thi.
Do nicotin tc dng kch thch neuron hch, c h giao cm v ph giao cm nn gy co mch
mnh cc tng bng v chi ng thi li gy ra hiu ng ph giao cm nh lm gim hot
ng ca d dy rut, c khi cn lm gim c nhp tim.
3.2- Thuc c ch hch thc vt.
Nhiu cht nh tetraethyl, ammonium hoc nhm cc cht carare: D tubocurarin, diplacin.
Hoc nhm hexonic: hexonic. pentamin, afonat.
Cc thuc trn c ch dn truyn xung ng t neuron tin hch sang neuron hu hch chng
c tc dng c ch ng thi ln c hch giao cm ln hch ph giao cm. Chng ch yu c
dng c ch giao cm ( cc du hiu c ch giao cm thng che lp c ch ph giao cm)
thuc c ch hach thng s dng iu tr bnh nhn cao huyt p, nhng ngi ta t dng vo
mc ch ny v kh kim sot tc dng ca thuc.


19. CUNG PHN X V CC PHN X THC VT

Cc phn thc vt l cc phn x c thc hin vi s tham gia ca cc neuion thuc h thn
kinh thc vt. Cng ging nh phn x ng vt, cung phn x c 5 khu: (1) th cm th, (2)
ng hng tm, (3) trung khu, (4) ng li tm, (5) c quan p ng.
Th cm th nhn cm kch thch c th l ngoi vi (exteroreceptor) hoc bn trong c th
ni th cm th (enteroreceptor).
ng hng tm l cc si cm gic, thng l chung vi ng hng tm ca cung phn x
ng vt
Trung khu: sng bn cht xm tu sng, thn no, v bn cu no (xem mc 2)
ng li tm: qua hai neuron (tin hch v hu hch)
C quan p ng: c trn, cc tuyn, mch muv.v.. cc phn x thc vt c chia thnh phn
x thc vt chnh thc, phn x thc vt ti ch v phn x thc vt axon:
*Phn x thc vt chnh thc l cung phn x c s tham gia ca 5 khu nu trn. V d:
- Phn x thc vt ca h tim mch gip cho iu ho huyt p v nhp tim. Mt trong cc phn
x do p sut: khi huyt p tng cc recetor p sut (baroreceptor) quai ng mch ch v
xoang ng mch cnh b kch thch: Tn hiu t cc ni ny truyn v thn no v c ch trung
khu giao cm lm gim xung ng ti tim v mch mu, lm tim p chm v yu lm mch
gin ra, kt qu l HA tr v mc bnh thng.
- Phn x thc vt ca h tiu ho: phn trn ca ng tiu ho v trc trng ch yu chu s chi
phi ca cc phn x thc vt. Cc xung ng t mi v ming (khu gic, v gic) c truyn
v nhn m h, nhn li hu, nhn nc bt hnh no. Cc nhn ny li pht xung ng
theo cc dy ph giao cm ti cc tuyn nc bt , tuyn d dy gy bi tit dch ngay c khi n
thc n cha ti ming. Khi phn xung y trc trng, trc trng cng, cc kch thch t trc
trng truyng v on tu cng v cc tn hiu phn x c truyn qua cc dy ph giao cm
ti phn xa ca i trng lm n nhu ng mnh y phn ra ngoi.
- Mt s phn x thc vt khc:
Khi bng quang cng, xung ng c truyn v on tu cng v gy phn x co c bng
quang gin c tht trn, do y nc tiu ra ngoi.
Cc phn x sinh dc bt u t cc kch thch tm l no v kch thch t c quan sinh dc.
Cc xung ng ny i ti ddoanj tu cng, nam gii s gy ra cng cng dng vt (ph giao
cm), sau l gy xut tinh (giao cm).
* Phn x thc vt ti ch (local rlex) l phn x c thc hin bi cc neuron nm trong
cc hch thc vt.
Trong s cc phn x thc vt ti ch c cc phn x sau:
- Phn x tng tng l phn x c pht sinh khi kch thch vo mt tng no th gy xut
hin phn ng mt tng khc. V d. Kch thch vo cc c quan khoang bng, gy ra phn
x ngng tim.
-Phn x tng c l phn x pht sinh khi kch thch vo c quan ni tng th gy ra co c vn. V
d, kch thch vo phc mc (vim phc mc) gy ra co c thnh bng.
- Phn x tng da l phn x pht sinh khi kch thch cc c quan ni tng th phn ng xut
hin da. V d khi rut v d dy b au th gy ra phn ng ni da g v dng lng (co c
chn lng), hoc gy ra bi tit m hi.
- Phn x da tng l phn x pht sinh khi kch thch dath phn ng xut hin c quan ni
tng hoc gy ra phn ng cc mch mu, trn c s phn x da tng, ngi ta p dng
phng php iu tr nh chm nng hoc lnh da chng au cc c quan ni tng. C
ch ca phn x ti ch nh sau:
Ti hch thc vt c hai loi t bo: t bo b xung.
DogelI v t bo DogelII. t bo DogelI l t bo cm gic, c si nhnh hng v nim mc, da,
c , ni tngv.v...Chng tip nhn cc kch thch c hc, ho hc, nhitv.v... Cc si trc ca t
bo DogelI truyn xung ng n t bo DogelII ( hch thc vt). T t bo DogolII, xung ng
c truyn theo si trc n c quan b chi phi v gy ra p ng.
* Phn x axon l phn x ch din ra axon m khng c s tham gia ca hch v trung khu
thc vt. Khc vi phn x thc chnh thc v phn x thc vt ti ch trong phn x axon
khng c si truyn hng phn t neuron th cm sang neuron tc ng, m neuron ch truyn
rrong phm vi mt axon. Phn x axon ch pht sinh trong trng hp si thn knhau hch chia
nhnh, trong mt nhnh n chi phi mt c quan ny, mt nhnh khc i ti chi phi mt
c quan khc. Do khi kch thch mt nhnh ca axon, hng phn s truyn t nhnh ny
sang nhnh khc v gy ra p ng ni kt thc nhnh . V d kch thch da gy ra gin
mch.

BI 4. SINH L TIU HA
20. CHC NNG GAN

Gan l mt trong nhng c quan ln nht ca c th, l c quan c tnh cht sinh mng. gan
din ra nhiu qu trnh chuyn ha phc tp v rt nhy cm vi tnh trng hot ng chung
ca c th.
1- Cc chc nng chuyn ho ln ca gan.
1.1- Chuyn ho glucid.
Gan l c quan quan trng d tr glucid v iu ho ng mu.
- So snh nng glucose trong mu tnh mch n v i ca gan, ngi ta thy nng
glucose mu tnh mch ca lun thay i: tng khi tiu ho, gim lc khng tiu ho. Cn
nng glucose trong mu tnh mch trn gan lun gi mc n nh 0,8-1,2g/lit.
-T Th k XIX, Claurd-Bernard lm th nghim ra gan nh sau: ng c lp gan ra khi c
th con ch, ra gan bng dung dch sinh l{ cho n ht glucose trong nc ra. em gan
trong t m 38
o
C sau 2 gi, ly gan em ra li thy c glucose. Cn khi ct b gan, ri lon u
tin l h ng huyt nghim trng v con vt b t vong nhanh chng.
-T nhng th nghim trn v nhiu th nghim khc ngi ta xc nh, gan l c quan tng
hp v d tr glucid ca c th. Khi lng ng mu n nh 0,8-1,2g/lit (4,4-6,6mmol/l), gan
tng hp glycogen t glucose v cc ose khc d tr.
Khi ng mu gim, gan li phn ly glycogen thnh glucose a vo mu duy tr ng
mu.
-Gan l c quan duy nht trong c th chuyn ho galactose v fructose. Khi ri lon chuyn
ho 2 cht ny gan, s gy ra bnh galactose v Fructose niu.
-Gan cn c kh nng tn to glucid t cc acid amin sinh ng, acid bo, glycerol, acid lactic.
-Qu trnh oxy ho glucid gan cng rt mnh m, do nhit gan lun cao hn cc c
quan khc.
1.2- Chuyn ho protid.
Gan c xem l c quan d tr protid ca c th.
+ Gan tng hp ti gn 50% tng lng protid do c th tng hp, gan sn xut 100% albumin ,
# 80% globulin v fibrinogen, nhiu yu t ng mu v nhiu men quan trng ca c th. Do
khi suy CN gan s lm gim protein mu (nht l albumin) v thiu mt s men quan trng,
dn n ph thiu dng v ri lon chuyn ho cht, ri lon c ch ng mu.
+ gan c qu trnh chuyn amin rt mnh, nn to ra c nhiu loi acid amin. Gan c hai
loi men chuyn amin quan trng l GPT (glutamat-pyruvat-transaminase) v GOT (glutamat-
oxaloaxetat-transaminase).

a. glutamic + a. pyruvic
GPT


a cetoglutaric + alanin

a.glutamic + a. oxaloacetic
GOT
a cetoglutaric + aspartic
Khi nng acid amin mu gim, gan gii phng chng vo mu. Cn khi tn thng t bo
gan, cc men ny tng ln trong mu, c bit l GPT.
+ Qu trnh kh amin gan cng rt mnh di s xc tc ca enzym desaminase, gii phng
NH
3
v to nn acid a cetonic.

gan NH
3
c tng hp thnh ur, cht t c hn, qua chu trnh ocnitin.
1.3- Chuyn ho lipid.
Gan l c quan ch yu chuyn ho lipid. Cc acid bo n gan phn ln c tng hp thnh
tryglycerid, photpholipid, cholesterol este. T cc cht ny gan tng hp nn lipoprotein v a
vo mu vn chuyn n cc t chc, t bo ca khp c th. Gan l ngun cung cp ch
yu Lipoprotein huyt tng.
Loi protein Kch
thc
Thnh phn Ngun
gc
Protein Choles
terol TD
Cholesterol
este
Trigly
cerid
Phos-
pholipid
Chylomicron 75-
100
2 2 3 90 3 Rut
VLDL 30-80 8 4 16 55 17 Gan,
rut
IDL 25-40 10 5 25 40 20 VLDL
LDL 20 20 7 46 6 21 VLDL
HDL 7,5-10 50 4 16 5 25 Gan,
rut
Trong cc lipoprotein nu tng VLDL v LDL l c nguy c va x /mch; tng HDL c tc dng
ngn nga va x /mch.
Gan c cc yu t hng m nh cholin, methionin, betain, glycin ..., khi thiu cc cht ny lm
m trong gan lu ngy dn n x gan.
Gan c kh nng tng hp cc acid bo t glucid v protid.
2- Chc nng chng c.
Gan c xem l hng ro chn ca c th, ngn cc sn phm c hi thm nhp vo qua
ng tiu ho, ng thi lm gim c tnh v thi tr mt s cht cn b do chuyn ho
trong c th to nn.
Gan chng c bng hai cch:
2.1- C nh v thi tr
mt s cht kim loi nng nh ch, thu ngn, thch tn ... v cc cht mu nh BSP (Bromo
Sulpho Phtalein) n gan, c gi li khng bin i g v o thi ra ngoi theo ng mt.
Da vo tnh cht ny ca gan, ngi ta dng cht BSP nh gi chc nng thi c ca gan,
gi l nghim php BSP.
2.2- Bng cc phn ng ho hc
y l hnh thc chng c c bn ca gan. Cc cht c t ng tiu ho hp th vo (nh
indol, scatol ...) v cc cht c do n ung, cc sn phm chuyn ho cht trong c th to nn
,v.v... c gan bin thnh cht khng c hoc t c hn ri o thi ra ngoi theo ng
thn hoc ng mt.
Trong cc loi phn ng ho hc kh c ca gan, th phn ng to ur t amoniac l quan
trng nht.
Amoniac l cht c vi c th, n c to nn qua qu trnh to amin, c bit no v ng
tiu ho. Phn ln amoniac c gan tng hp thnh ur-cht t c hn, qua chu trnh ocnitin,
c s xc tc ca men c hiu l OCT (Ocnitin Carbamyl Transferase). Men OCT ch c gan,
khi hu hoi t bo gan, men OCT s tng ln trong mu.
Khi thiu nng gan, amoniac khng c chuyn thnh ure m ng li trong t chc s gy
nhim c, c bit c cho t chc no, c th dn n hn m do tng amoniac mu.
3- Chc nng to mt (Xem bi dch mt).
4- Chc nng ng mu v chng ng mu.
Gan d tr vitamin K v sn xut ra nhiu yu t ng mu, gm fibrrinogen (yu t I),
prothrombin (yu t II), proaccelerin (yu t V), proconvectin (yu t VII), yu t chng a chy
mu A (yu t VIII), yu t christmas (yu t IX). Do khi suy gan thng b ri lon ng mu.
Gan cng to nn mt lng ln cht c tc dng chng ng mu l heparin.
5- Chc nng to mu v d tr mu.
T thng th ba n cui thi kz thai nghn, gan l c quan chnh sn xut hng cu ca bo
thai.
Sau khi a tr ra i, tu xng m nhn chc nng sn xut hng cu cho c th. Lc ny
gan l ni sn xut cc protein cn thit cho s tng hp hng cu nh globin, cc lipoprotein,
phospholipid; d tr mt lng ln vitamin B12, acid folic v st di dng ferritin.
gan c h thng xoang mch rng ln, bnh thng cha # 500ml mu v gan c th cha ti
2 lt mu. Lng mu ny s c huy ng vo tun hon khi cn thit.

21. SINH L TIU HA I CNG

Tiu ho l mt qu trnh sinh l phc tp din ra trong ng tiu ho bin i cc cht thc n
t nhng dng phc tp, c hiu v khng ho tan thnh nhng dng n gin, khng c
hiu, ho tan v hp thu vo mu, bch huyt.
1.1- nghi ca s tiu ho.
* ngha to hnh.
Nh tiu ho v hp thu cc cht-c bit l protid, lipid, glucid, nc v mui khong m c
th c nguyn liu cu to nn cc t chc.
* ngha cung cp nng lng.
Cc cht thc n ch yu l glucid v lipid hp thu vo c th, c oxy ho to nng lng
cho hot ng sng ca c th.
* ngh a iu tit v chuyn ho.
Trong thc n c cc sinh t, nc v mui khong l nhng cht cn thit cho s iu tit hot
ng ca cc c quan v cc qu trnh chuyn ho vt cht trong c th.
1.2- Cc hin tng ca qu trnh tiu ho.
Qu trnh tiu ho bao gm cc hin tng sau:
1.2.1- Hin tng c hc.
Do cc lp c ca ng tiu ho co bp, c tc dng nghin nt, nho trn thc n vi dch tiu
ho v chuyn thc n dc theo ng tiu ho.
1.2.2- Hin tng bi tit.
Cc tuyn ca nim mc ng tiu ho hoc cc c quan lin quan n tiu ho (gan, tu) tit ra
cc dch tiu ho (nc bt, dch v, dch tu, dch mt, dch rut) trong c cc men tiu ho
v nc cn thit cho qu trnh thu phn cc cht dinh dng ca thc n.
1.2.3- Hin tng ho hc.
l phn ng ho hc k tip nhau trong ng tiu ho c xc tc bi cc men c hiu,
bin i thc n t cc dng phc tp thnh cc dng n gin.
Cc men tiu ho c nhiu, c gom thnh ba nhm sau:
- Men tiu ho protid: protease.
- Men tiu ho lipid: lipase.
- Men tiu ho glucid: cacbohydrase.
Trong nhng men ny c nhiu men vn dng cha hot ng (tin men) v trung tm hot
ng ca chng b che khut. Trong nhng mi trng c iu kin ph hp, trung tm hot
ng ca men c bc l, tin men bin hnh men hot ng v c th tip xc vi c cht
thu phn chng.
1.2.4- Hin tng hp thu.
Dc theo ng tiu ho cc cht dinh dng dng n gin c hp thu qua nim mc vo
mu. Ni hp thu ch yu l rut non.
1.3- S iu tit hot ng tiu ho.
Cc hin tng tiu ho k trn c iu tit bi hai c ch c bn l c ch thn kinh v c
ch thn kinh-th dch.
1.3.1- C ch thn kinh:
*- Phn x khng iu kin.
Thc n tc ng trc tip ln cc th cm th c hc v ho hc nim mc ng tiu ho gy
ra nhng phn x bin i tit dch v co bp c trn ca ng tiu ho.
*- Phn x c iu kin.
Phn x c iu kin v tiu ho hnh thnh trong qu trnh sng ca c th, do tip xc nhiu
ln vi cc loi thc n quen thuc v a thch. Do ch cn ngi, nhn, thm ch ch nghe ni
v loi thc n xut hin cc phn x nh tit nc bt, tit dch v, co bp d dy.v.v...
*- Phn x phc tp.
Thc t khi n ung, thc n khng ch tc ng ln cc th cm th c hiu
nim mc ng tiu ho v gy ra phn x khng iu kin, m mi, hnh dng, mu sc ca thc
n ting va chm bt a .v.v... cn tc ng ln nhiu c quan nhn cm khc v gy ra nhng
phn x c iu kin tiu ho. S kt hp phn x khng iu kin v c iu kin khng th
tch ri nhau, Pavlov gi l phn x phc tp.
Trung khu ca cc phn x tiu ho l mt phc hp thn kinh t tu sng n th li, v no
limbic v v no mi, do hnh vi c lin quan ti tiu ho tr nn tinh vi v c thc, tc l
c v no iu khin.
1.3.2- C ch th dch.
Trong qu trnh tiu ho cc cht thc n cng vi mt s thnh phn ca dch tiu ho kch
thch t bo ni tit nim mc ng tiu ho lm tit ra cc cht tng t hormon, gi l cc
cht hormon tiu ho. Nhng cht ny trc tip vo mu, tr li c quan tiu ho, kch thch
hoc c ch cc hot ng bi tit, co bp v hp thu ca c quan ny.

22. TIU HO MING

Ming l on u ca ng tiu ho, c chc nng tip nhn thc n, nghin x nho trn thc
n vi nc bt bin thnh vin nut. Trong qu trnh mt phn tinh bt chn c bin
i bc u.

T trung khu nc bt cc si ly tm (l cc si thn kinh thc vt) truyn xung ng ti cc
tuyn nc bt. Cc si ph giao cm t nhn nc bt trn theo dy Thng nh (nhnh ca
dy VII) ti chi phi tuyn nc bt di hm, di li. Cc si t nhn nc bt di theo
dy tai (nhnh ca dy IX) ti chi phi tuyn mang tai. Cc si giao cm xut pht t cc hch
giao cm c.
Kch thch si ph giao cm lm tng tit nc bt nhiu cht nhy v men, cn cc si giao
cm lm tng tit nc bt long.
- C ch PXCK. Nhiu khi ch cn trng thy, ngi thy hoc nghe ni n cc mn n ngon v
a thch tit nc bt, l nc bt tm l.
*- C ch thn kinh- th dch.
Khi hot ng, tuyn nc bt bI tit ra cht hormon Kallikrein, lm xc tc chuyn cht
Kininogen (c sn trong mu) thnh cht Bradykinin, theo s sau:

Mt s sn phm chuyn ho (CO
2
, histamin...) c tc dng gy gin mch tng tit nc bt.
Ngoi ra s bi tit nc bt cn ph thuc vo tnh cht ca thc n. Thc n kh, toan, kim,
chua, cay c tc dng lm tng tit nc bt.
*Kt qu tiu ho ming.
Tiu ho ming l giai on bin i s b ban u: thc n b nghin x, nho trn vi nc
bt quyn thnh vin nut. Trong cc cht protid v lipid cha c phn gii, ring mt
phn nh tinh bt chn c men amylaza phn gii thnh maltoza. Song thi gian thc n lu
ming rt ngn, 15-18 giy, nn s phn gii khng ng k v cha c hin tng hp
thu.

1- Hin tng c hc khi tiu ho ming.
Hin tng c hc khi tiu ho ming gm nhai, nut.
1.1- Nhai.
Nhai l mt phn x khng iu kin (lc cn b), khi ln ln ngi ta nhai tuz . Khi nhai hai
hm rng p vo nhau nghin nt thc n, lm tng din tip xc ca thc n vi nc bt.
Li vn ng trn thc n vi nc bt v y cc mu thc n vo mt nhai ca rng.
1.2- Nut.
Nut l mt phn x gm nhiu ng tc y thc n t ming xung d dy.
Giai on tu , ngi ta ch ng ngm ming, li nng ln y vin thc n (vin
nut) ra pha sau.
Giai on tip theo l t ng: li g ng ng ln mi, tiu thit ng ng vo kh
qun, thanh mn khp, ming thc qun nh ln v m ra, hu khp li y vin nut vo thc
qun. thc qun, thc n c sng nhu ng ca thc qun y qua tm v xung d
dy.Thi gian ny ch mt 10-20 giy, vi nc ch trong 1 giy.
V phn x nut l t ng nn khi n phi nhai k khi b nghn.
Trung khu nut v trung khu h hp hnh no hot ng c ch ln nhau, th th khng nut
v nut th khng th. Do khi n khng nn ci ni trnh b sc, nghn. Trong lm sng
khi bnh nhn hn m, ngi ta dng phn x nut thm d chc nng ca hnh no.
2- Hin tng bi tit ho hc ming.
Dch tiu ho ming l nc bt, do cc tuyn nc bt sn xut ra.
ngi c 3 cp tuyn nc bt ( hai bn) l tuyn mang tai, tuyn di hm v tuyn di
li.
2.1- thnh phn nc bt.
Nc bt l dch lng, khng mu, hi nhy, c nhiu bt, pH=6,0-7,4, cha hn 99% nc cn
li l mt s cht hu c v v c.
- Cht hu c ch yu ca nc bt l men amylase (cn gi l ptyalin), cht nhy (mucine),
men kh trng lysozym v lng rt t men maltase. Nc bt khng c men tiu ho lipid v
protid.
- Cc cht v c ca nc bt c cc mui Na, K, Ca, photphat, bicacbonat... Khi kim ca
nc bt tng th mui bicacbonat canxi v photphat ta li to nn cao rng. Lng nc bt
ngi trong 24 gi khong 1,5 lt.
2.2- Tc dng ca nc bt.
Nc bt c tc dng tiu ho v bo v.
*- Tc dng tiu ho ca nc bt, gm:
- Tm t v ho tan mt s cht thc n d nhai, d nut.
- Nho trn v quyn cc cht thc n thnh vin nut. - Men amylase nc bt bin tinh bt
chn thnh ng dextrin, maltriose v maltose. nc bt c t men maltase bin maltose
thnh glucose.
*- Vai tr bo v ca nc bt, gm:
Tm t nim mc ming, gip cho khi kh ming, lm d dng cho ng tc nut v pht m.
Lm sch v st trng ming nh men lysozym. Trung ho mt s cht toan, kim v cc cht c
tc dng kch thch mnh nh cay, chua, ng .v.v... bo v nim mc ming.
Bi tit mt s cht c nhp vo c th, nh cht kim loi nng (Pb, Hg...), vi rt di .v.v..
2.3- iu ho bi tit nc bt.
Nc bt c bi tit lin tc, nhng tng ln trong ba n, nh c iu ho bi c ch
thn kinh v thn kinh-th dch.
*- C ch thn kinh theo phn x khng iu kin (PXKK) v phn x c iu kin (PXCK).
C ch PXKK l khi ta n, thc n kch thch vo cc th cm th c hc v ho hc nim mc
li ming. Cc xung ng i trong cc si cm gic i trong thnh phn ca cc dy thn kinh
li, dy li hu v dy thanh qun trn v trung khu nc bt hnh no v tu sng.

23. TIU HO D DY

D dy l mt ti cha thc n. Ti y thc n ch yu c x l v mt c (c nho trn
vi dch v) bin thnh th h c gi l v trp v c tng qua mn v tng t xung t
trng. Trong mt s cht thc n c phn gii bc u.

1- Hin tng bi tit v ho hc d dy.
Hin tng ho hc d dy l hin tng phn gii mt s cht thc n t nhng dng phc
tp, thnh nhng dng n gin hn, di tc dng ca men tiu ho dch v do cc tuyn d
dy tit ra.
1.1- Phn vng bi bi tit dch v.
Cc tuyn bi tit dch v c cu to bi ba loi t bo, mi loi c chc nng ring.
- T bo chnh (t bo thn tuyn) bi tit men tiu ha.
- T bo ph (t bo c tuyn) bi tit cht nhy v bicacbonat.
- T bo ba (t bo vin) bi tit HCl v yu t ni.
Do t l phn b ca cc loi t bo cc vng khc nhau ca d dy khng u nhau, nn
thnh phn dch v tng vng cng khng ging nhau. Cn c vo ngi ta chia d dy ra
lm ba vng (hnh 1):
- Vng I-Vng hang-mn v. Cc tuyn ca vng ny nhiu t bo ph, nn tit ra nhiu cht
nhy, c t pepsin, cn HCl th hu nh khng c.
- Vng II-vng thn v v y v. vng ny khng c t bo ph, m ch c t bo chnh v t
bo ba, cho nn dch tit khng c cht nhy, ch c HCl v pepsin, c bit l vng b cong b.
- Vng III-vng tm v, ch c t bo ph, nn dch tit ch c cht nhy v bicacbonat m khng
c HCl v pepsin.
Ngoi ra, ton b t bo nim mc b mt d dy tit ra cht nhy ho tan v khng ho tan.
Dch v l dch hn hp ca cc vng ni trn.
1.2- Tnh cht v thnh phn dch v.
Dch v l dch lng, trong, hi nhy, c cha 0,3-0,4% HCl nn rt acid. pH dch v tinh khit l
0,8-0,9, khi c ln thc n dch v t 1,5-4,5 tuz tnh cht v s lng thc n.
S lng dch v ngi trong 24 gi l 2,0-2,5 lt. Thnh phn dch v cha 98-99% nc, cn
li l cc cht hu c v v c.
- Cc cht hu c gm: cc men tiu ho protid v lipid cht nhy, yu t ni sinh, histamin,
mt s hormon tiu ho (gastrin, somatostatin...), mt s protein v cc cht cha nit...
- Cc cht v c gm c cc mui Na
+
, K
+
, Ca
++
, Mg
++
, Cl
-
... quan trng nht l HCl v NaHCO
3
.
Nng HCl ton phn ca dch v l 160mEq%, trong c 40mEq dng t do.
1.3- Tc dng ca dch v.
Dch v c nhiu tc dng, song c th gom thnh 4 nhm tc dng chnh nh sau:
1.3.1- Tc dng ca men tiu ho.
- Men tiu ho protid: pepsin l men tiu ho protid d dy, do t bo chnh tit ra di dng
tin men (cha hot ng) l pepsinogen. Trong mi trng acid ca d dy (do HCl quyt
nh) pepsinogen c bin thnh pepsin hot ng.
Pepsin thu phn cu ni peptid bn trong phn t protid m nhm -NH thuc acid amin c
nhn thm, bin protid thnh cc on polypeptid ngn hn (nh albumose, pepteose,
pepton).
Ngy nay bng phng php sc k{ v in di ngi ta pht hin c 5-7 loi pepsin c hot
tnh khc nhau v chia thnh 2 nhm l pepsinogen I v pepsinogen II. C mt lng nht nh
pepsinogen ngm vo mu v thi qua nc tiu, gi l unopepsinogen. Mc thi qua nc
tiu song song vi mc bi tit n d dy. Do trong lm sng ngi ta thng nh lng
pepsin nc tiu v uropepsinogen niu nh gi s bi tit n d dy.
Pepsin thng tng cao trong bnh vim-lot d dy, nht l pepsinogen I.
- Renin (chymosin, presure), cn gi l men ng sa, c tc dng chuyn cht caseinogen thnh
casein v kt hp vi Canxi to thnh cht nh vng sa. Men ny quan trng vi tr em, ngi
ln n rt t tc dng.
- Men lipase d dy l men tiu ho lipid. Men ny hot ng tt mi trng kim. V d
dy c mi trng toan, nn lipase d dy hot ng yu, ch c tc dng thu phn nhng lipid
nh tng ho (nh lipid ca sa, ca lng trng) bin chng thnh acid bo,
monoglycerid v glycerol.
Lipase d dy cn cho tr em ang b sa. Ngi ln men ny c tc dng khng ng k.
1.3.2- Tc dng ca HCl.
HCl l thnh phn v c c nhiu vai tr quan trng trong tiu ho.
- To mi trng acid cho s hot ho v hot ng ca men pepsin.
- Lm trng protid to iu kin cho vic phn gii n d dng.
- Kch thch nhu ng d dy, tham gia vo c ch ng tm v v ng m mn v.
- C tc dng st trng chng ln men thi d dy.
- Tham gia iu ho bi tit dich v, dch tu, dch mt v dch rut thng qua s kch thch bi
tit cc men tiu ho ca d dy-rut.
HCl c sn xut theo mt c ch c bit, c s tham gia ca men anhydrase cacbonic v
bm proton.
S tng quat ca qu trnh to acid HCl trong t bo ba nh sau:
CA, Bm proton
CO
2
+ H
2
O + NaCl -------------------=> HCl + NaHCO
3

Hnh 2. S minh ho s sn xut HCL t bo ba
Dy X v cc cht acetylcholin, c bit l histamin kch thch s bi tit HCl rt mnh thng qua
th th-H
2
. in nay trong lm sng c thuc c ch bm proton l omeprazol v cc thuc
khng th th H
2
, nh cimetidin (tagamet) c tc dng gim tit axit rt hiu qu.
1.3.3- Tc dng ca cht nhy v bicacbonat.
Cht nhy do cc t bo ph v t bo nim mc b mt d dy sn xut, c hai loi cht nhy-
loi ho tan trong dch v v loi khng ho tan cng bicacbonat to nn mt mng dai ph kn
ton b nim mch d dy v hnh t trng. C hai loi cht nhy cng bicacbonat c tc dng
trung ho acid, che ch bo v nim mc d dy khi s ph hu ca acid v pepsin.
Khi s bi tit cht nhy v bicacbonat b ri lon, kh nng bo v nim mc b gim, to iu
kin thun li cho vim lot d dy-t trng pht trin.
c bit l xon khun Helicobacteur Pylori khu tr ph hu lp cht nhy khng ho tan, lm
cho yu t acid t do tc dng ph hu nim mc d dy.
Cc thuc dng trong Iu tr, nh aspirin, salyxylat, corticoid gy ri lon lp cht nhy khng
ho tan, do tn thng nim mc d dy vim, lot.



1.3.4- Tc dng ca yu t ni (intrinsic factor).
Yu t ni (yu t Castle) do nim mc d dy vng y tit ra, l cht cn thit cho vic hp
thu vitamin B12 rut non. Vitamin B12 l cht cn thit cho qu trnh to hng cu. Khi b
vim teo d dy, s thiu yu t ni dn n c th khng hp thu c vitamin B12 gy ra
bnh thiu mu c tnh, trong mu ngoI vi c tin nguyn hng cu (Megaloblast). iu tr
bnh ny bng cch tim vitamin B12 cho bnh nhn (ung khng c tc dng).
1.4- iu ho bi tit dch v.
Ngoi lc tiu ho dch v c bi tit mt lng nh, gi l dch v c s. Khi ta n ung dch v
s tng cng bi tit do c ch phn x thn kinh v thn kinh -th dch. Qu trnh trc
y c Pavlov chia ra 4 giai on, ngy nay thng nht chia thnh 3 giai an hay 3 pha.
1.4.1- Giai on u (pha u).
St trc ba n v khi ang n.
Khi ta cha n, mi ngi, nhn hoc nghe ni v loi thc n a thch th d dy bi tit dch
v. l dch v tm l{ v c bi tit theo c ch PX CK.
Khi n, thc n trc tip kch thch vo nim mc ming gy tit dch v theo c ch PX Khng
K. ng thi mi, hnh dng thc n, ting nhai.v.v... tip tc kch thch vo cc phn tch quan
gy bi tit dch v theo c ch PXCK. C hai c ch ny quyn vo nhau khng th tch ri v
c Pavlov gi l phn x phc tp.
S bi tit dch v khi thc n mi n ming c th c chng minh bng th nghim l d
thc qun ch (th nghim ba n gi). Trong th nghim ny, thc n nut qua ming li b
ri ra ngoi qua l d thc qun ch khng vo c d dy. Tuy vy, dch v vn tit qua l d
d dy.
1.4.2- Giai on d dy (pha d dy).
Thc n ti d dy kch thch vo vo TCT c hc v hoa hc nim mc d
dy, xung ng t cc TCT s truyn v trung khu n ung hnh no v tu sng.

Hnh 2. S c ch thn kinh-th dch iu ha bi tit dch v.
.T hn no , xung ng theo dy X (dy thn kinh ph giao cm), ti chi phi cc t bo tuyn
d dy, gy tng tit dch v nhiu men v acid.
.T trung khu thn kinh giao cm phn b cc t lng 4-10, c cc si giao cm i ra qua
m ri dng, ri theo dy tng n tuyn d dy kch thch tng tit nhiu cht nhy v
bicarbonat.
ng thi cc nhnh ca dy X v HCl ca dch v cn kch thch cc t bo ni tit ca d dy
lm tit ra cht gastrin v histamin. Cc cht ny s kch thch d dy bi tit dch v nhiu HCl
v men. Do vy s bi tit dch v giai on ny l theo c ch thn kinh-th dch (hnh 2)
2.4.4- Giai on rut (pha rut).
Thc n xung ti t trng (HCl v sn phm protein) kch thch nim mc t trng tit ra cht
enterogastrin. Cht ny vo mu ri quay tr li kch thch nim mc d dy bi tit dch v
(ging tc dng ca cht gastrin).
Nim mc d dy cn bi tit ra cht gastron v nim mc t trng bi tit ra cht
enterogastron l cc hormon c ch bi tit dch v.
Nh vy dy X l dy thn kinh quan trng trong vic iu ho bi tit dch v. Trong c th, dy
X li ph thuc rt nhiu vo tnh trng ca v no. Trong trng thi stress (lo bun, au kh,
cng thng qu mc hay ko di...) s lm tng trng lc dy X, gy tng tit dch v mnh v
ko di s dn n vim- lot d dy.
2- Hin tng c hc d dy.
D dy c nhiu hnh thc c ng gm ng m tm v, c ng c chu kz, ng m mn v v
c ng trng lc.
2.1- ng m tm v
Bnh thng tm v ng. Khi thc n t thc qun dn xung st tm v, y m tm v v vin
nut ri vo d dy, sau tm v li ng.
2.2- C ng i ca d dy.
Khi khng c thc n, d dy c nhng sng co bp nh nhng v tha. Sau khong 1 gi cc
sng tng mnh lm ta c cm gic i v hi au bng.
2.3- C ng c chu k (hay nhu ng ca d dy).
Khi i d dy xp li. Khi thc n vo d dy lm d dy gin ra va cha phn thc n ri
vo v p lc trong d dy tng ln. Sau khi n xong d dy xut hin nhng sng nhu ng
bt u t vng tm v, lan theo b cong ln v b cong nh, xung ti mn v. Do s co bp
nh vy m thc n c chuyn theo hai bn thnh d dy xung vng mn v. Nhng mn v
ng kn, nn thc n li quay ngc ln theo ng gia ca d dy. Cc sng nhu ng c
ni tip, cch nhau 20-30 giy, lm thc n c trn vi dch v thnh khi nhuyn sn st gi
l v trp v c dn xung vng hang-mn v.
2.4- ng m mn v.
Khi d dy khng c thc n, mn v h m. Khi bt u n, dch v tm l tit ra, t dch v lt
qua mn v xung t trng. t trng HCl ca dch v kch thch ngc lm ng mn v. Thc n
vo d dy, HCl tit ra ngy cng nhiu, n mc no HCl kt hp vi nhu ng d dy kch
thch mn v m ra, tng mt t thc n xung t trng. t trng HCl ln trong thc n li
kch thch ngc ln lm ng mn v. Cho n khi HCl t trng c cc cht kim
trung ho, cc yu t t d dy li kch thch lm mn v m. C nh vy v trp c tng tng
t xung t trng cho ti ht.
Hot ng ng-m ngt qung ca mn v nh vy gip ngi ta n thnh ba nhng tiu
ho, hp thu c ngy.
Thi gian thc n lu li d dy lu chng ph thuc vo tnh cht v s lng ca n.
+ Glucid qua d dy nhanh nht, sau 2-3 gi.
+ Protid qua sau 4-5 gi.
+ Lipitd qua chm nht, sau 5-7 gi.
+ Nc qua d dy ngay khi ti n.
Tuy nhin s ng m mn v cn ph thuc nhiu yu t v chu s chi phi ca h thn kinh
v thn kinh-th dch, c bit v no. Nhng cm xc m tnh (bun ru) lm mn v tht li,
nhng cm xc dng tnh (vui v) lm mn v m nhanh.
2.5- S iu tit co bp ca d dy.
D dy c kh nng co bp t ng, nh c cc m ri thn kinh nm ngay trong thnh d dy
(Meissner v auerbach).
Trong c th s co bp ca d dy chu s chi phi ca h thn kinh thc vt. Cc si ph giao
cm i trong thnh phn ca dy thn kinh ph v, c tc dng kch thch co bp d dy. Cn cc
si i trong thnh phn ca dy tng th c ch co bp v lm gim trng lc c trn thnh
d dy.
Mt s yu t th dch nh m, protid, acid c tc dng kch thch nim mc t trng tit ra
secrectin v CCK, l cht c ch s vn ng ca d dy.
V no c nh hng r rt ln s co bp ca d dy. Trong trng thi hng phn thc n qua
d dy nhanh hn, cn trong trng thi s hi, lo bun thc n xung rut chm hn.
*- Kt qu tiu ho d dy.
Thc n sau khi tiu ho d dy c bin thnh mt cht nhuyn gi l v trp. Trong 10-
20% protid c phn gii thnh cc polypeptid ngn hn. Mt phn lipid nh ho c
phn gii thnh monoglycerid, v acid bo. Cn glucid hu nh cha c tiu ho, v d dy
khng c men tiu ho glucid.
Do vy s tiu ho d dy cng ch l bc chun b thm cho cc giai on tiu ho tip theo
rut non.


24. TIU HO RUT NON

Tiu ho rut non l giai on quan trng nht ca ton b qu trnh tiu ho, bi v:
- rut non c nhiu loi dch tiu ho (dch tu, dch mt, dch rut), trong c nhiu men
tiu ho vi hot tnh cao c kh nng phn gii thc n thnh cc cht n gin c th hp thu
c.
- Nim mc rut non c cu trc c bit v nhng phn ng sinh hc tinh vi, phc tp gip cho
vic hp thu cc cht dinh dng mt cch ch ng v chn lc.
1- Hin tng bi tit v ho hc rut non.
rut non cc cht thc n c phn gii ti mc n gin nht nh tc dng ca cc dch
tiu ho: dch tu, dch rut, dch mt.
1- Dch tu.
Dch tu do cc t bo cu tuyn tu ngoi tit sn xut v c vo khc hai ca t trng
qua phnh Vater, c c Oddi.

1.1- Tnh cht v thnh phn ca dch tu.
Dch tu l mt cht lng, nhn, khng mu c phn ng kim r, pH l 7,8-8,4. ngi lng
dch tu trong 24 gi khong 1,5-2,0 lt.
Thnh phn dch tu c hn 98% l nc, cc mui v c: Na
+
, K
+
, Ca
++
. Mg
++
, Cl
-
, HCO
3
-
... v cc
cht hu c ch yu l cc men tiu ho protid, lipid v glucid, cng nhiu cht protein, hormon
tiu ho, cht nhy v cc cht khc.
1.2- Tc dng ca dch tu.
Tc dng ca dch tu chnh l do cc men tiu ho cha trong n quyt nh.
* Tiu ho protid. Cc men tiu ho protid ca dch tu khi mi sn xut u dng tin men
cha hot ng l trypsinogen, chymotripsinogen, procarboxypeptidase. Khi ti t trng, nh
s tc ng ca entrokinase (mt men ca rut) trypsinogen c bin thnh trypsin hot
ng. Ngay sau trypsin li tc ng ln cc men khc: chymotrypsinogen, procarbo-
xypeptidase v kinanogen bin chng thnh cc men hot ng.

- Trypsin cht t lin kt peptid bn trong phn t protid m c nhm CO- thuc acid amin
kim; cn chymotrypsin chuyn cht t cc lin kt peptid bn trong phn t protid m c
nhm CO-thuc acid amin thm.
Sn phm ca hai men ny ch yu l cc on peptid ngn hn (oligopeptid).
- Carboxypeptidase tc dng vo lin kt peptid ngoi cng u C-tn, tch mt acid amin ra
khi chui peptid. Trong Carboxypeptidase A i lc vi a.amin thm; Carboxypeptidase B i
lc vi a.amin kim.
Ni chung cc men tiu ho protid ca dch tu c hot tnh mnh, chng phn ct 60-80%
protid thnh cc on peptid ngn v acid amin.
* Tiu ho lipid.
rut nh c dch mt tt c cc cht lipid thc n u c nh ho, cc men tu c th thu
phn ti 95% lng lipitd thc n cc dng n gin.
-Lipase tu hot tnh mnh, thu phn gn ton b TG nh ho thnh mnglycerid,
glycerol v acid bo.
-Tu ba tit Pro Phospholipase. Vo trong rut n c men trypsin hot ho thnh
Phospholipase. C nhiu loi Phospholipase khc nhau, trong
Phospholipase A (gi l lecithinase) l nhiu nht v hot tnh mnh nht.
-Cholesterolesterase thu phn cholesteroleste v cc steroid thnh cholesterol t do, acid bo
v sterol.
Tiu ho glucid.
Cc men tiu ho glucid ca tu hot tnh rt mnh, thu phn ti # 80% lng glucid thc n.
- Men amylase tu thu phn c tinh bt chn v sng thnh dextrin, maltose.
- Men maltase bin maltriose v maltose thnh glucose.
Trong trng hp b bnh vim tu, ung th tu ... amylase c tng cng bi tit gy tng
amylase mu.
Tm li dch tu c vai tr rt ln trong qu trnh tiu ho rut non. Khi thiu dch tu s gy
ra ri lon tiu ho nghim trng, c th thiu cht dinh dng, trong phn cn nhiu cht
thc n cha c tiu ho ht, c bit l lipid v protid.
1.3- iu ho bi tit dch tu.
Dch tu bi tit lin tc, nhng tng mnh khi tiu ho do c ch thn kinh v thn kinh-th
dch iu ho (hnh 2).
1.3.1- C ch thn kinh iu ho bi tit dch tu l c ch PXCK v PXKK. Trung khu phn x
bi tit dch tu nm sng bn cht xm tu sng D4-D12 (trung khu giao cm), hnh no
(dy X, trung khu ph giao cm), v c vng di i, h limbic.
Kch thch dy X (dy ph giao cm) gy tit dch tu khng nhiu, nhng giu men. Kch thch
cc si giao cm chi phi tuyn tu lm tng lng dch tu nhng t men, nhiu bicarbonat.
* C ch thn kinh-th dch iu ho bi tit dch tu c Bayliss v Starling pht hin u tin
t nm 1902. HCl v cc sn phm thu phn protid, lipid n rut kch thch nim mc t trng
tit ra cht secretin v cholecystokinin-pancreozymin (CCK-PZ). Cc cht ny vo mu ti
tuyn tu, kch thch tit dch tu .

Ngoi secretin gy tng tit dch tu nhiu cht nhy v bicarbonat, cn tit ra cht CCK-PZ c
tc dng kch thch tit dch tu nhiu men.
Trong c th hai c ch thn kinh v thn kinh- th dch kt hp vi nhau iu ho bi tit dch
tu v chu nh hng r rt ca v no.
1.2- Dch mt.
Mt do cc t bo gan sn xut lin tc. Trong lc tiu ho mt c thng xung t trng
qua phnh Vater, cng mt ch vi ng tu. Ngoi lc tiu ho, mt c d tr ti mt, ti
mt b hp thu nc v c c c t 6-10 ln.
1.2.1- Thnh phn v tc dng dch mt.
Mt l cht dch lng, hi nhy, trong, c mu vng ti (mt gan) hoc c mu cnh gin (mt
ti mt), pH kim nh =6,8-7,4. S lng mt ngi bnh thng khong 0,8-1,0 l/24 gi.
T l cc cht mt gan v mt ti mt c khc nhau, nhng u cha cc cht: nc, cht v
c (Na
+
, K
+
, Cl
-
, HCO
3
-
...), cc cht hu c (acid mt, sc t mt-bilirubin, phospholipid,
cholesterol ...), trong acid mt v bilirubin l thnh phn c trng ca dch mt.
Dch mt khng cha men tiu ho, nhng c vai tr quan trng i vi qu trnh tiu ho
rut, cht duy nht ca dch mt c tc dng tiu ho l acid mt.
* Acid mt: Mt ngi c 4 loi acid mt c to t cht cholesterol. Lc u t bo gan to
cc a.mt t do, gm a.Cholic, a.Chenodeoxycholic, a.deoxycholic v a.lithocholic, l cc acid
khng tan trong nc v khng c hot tnh sinh hc. Sau chng c to thnh cc a.mt
lin hp l a. glychocholic, a. glychochenodeoxycholic, a. glychodeoxycholic v a.
glycholithocholic; hoc a. taurocholic, a. taurochenodeoxycholic, a.taurodeoxycholic v a.
taurolithocholic .
Acid mt lin hp l cht hot tnh b mt v c tnh kh mnh. Trong mi trng kim ca
dch mt, cc acid mt tn ti di dng mui vi ntrri hoc kali, nn thng vn c gi l
mi mt.
* Tc dng chnh ca a. mt (ca dch mt):
- Mui mt lm nh ho lipid, tng din tip xc ca lipid vi lipase v tng hot tnh ca men
lipase.
- Mui mt to Micell gip ho tan cc sn phm thu phn lipid v cc vitamin tan trong du
hp thu chng c d dng.
- Mui mt kch thch tng tit cc men tiu ho ca dch tu, dch rut, ng thi hot ho
chng.
- Mt to mi trng kim rut, kch thch nhu ng rut, c ch hot ng ca vi khun ln
men thi phn trn rut non.
Khi tc mt, mt khng xung rut s dn n ri lon tiu ho v hp thu mt lot cht dinh
dng-c bit l i vi lipid.
Sau khi tham gia tiu ho hp thu cc cht phn trn ca rut non, cc a.mt lin hp xung
hi trng b vi khun rut kh ho, to thnh cc a.mt t do v 95% c ti hp thu vo tnh
mch ca v gan, to chu trnh rut-gan acid mt, c vai tr quan trng iu ho sn xut
mt gan.
* Bilurubin:
Bilirubin l sn phm oxy ho ca Hb, c to ra cc t chc lin vng, nhiu nht l lch,
tu xng v gan. cc t chc lin vng ngoi gan to ra bilirubin t do (hay bilirubin gin
tip-BI: bilirubin indirect).
BI khng tan trong nc, trong mu BI phi kt hp vi albumin vn chuyn, chng khng
qua c mng lc cu thn, nn bnh thng trong nc tiu khng c BI.
BI-albumin theo mu ti gan, c t bo gan thu nhn v lin hp vi acid glucuronic c
men xc tc l glucuronyl transferase, to thnh bilirubin-glucuronic (bilirubin lin hp, hay
bilirubin trc tip- BD: bilirubin direct), tan c trong nc. Sau BD v phn nh BI c
a vo vi qun mt, theo ng dn mt xung rut. rut BD b vi khun rut kh ho
thnh mesobilirubin, ri urobilinogen. Mt phn hai cht ny c ti hp thu vo tnh mch
ca v gan, c t bo gan ti s dng, lin hp v vo dch mt , xung rut to nn chu
trnh rut-gan ca bilirubin. Gan bnh thng, trong nc tiu khng c mesobilirubin v
urobilinogen.
Phn urobilinogen cn li trong rut tip tc c bin thnh stercobilinogen, ri stercobilin
v thi theo phn, to mu c trng ca phn.
Khi tng hm lng bilirubin mu s gy hong n (vng da, vng nim mc). nh lng
bilirubin gp phn chn on nguyn nhn gy hong n.
-Thiu mu tan huyt: tng c BI,BD; vng da,vng mt, nc tiu v phn vng.
-Gim kh nng thu nhn BI ca t bo gan: Tng BI, gim BD, nc tiu bnh thng.
-Ri lon lin hp bilirubin: BI tng, BD gim, nc tiu bnh thng.
-Ri lon gii phng bilirubin t t bo gan: lc u tng BI,BD, nc tiu vng, phn bc mu;
sau BI tng mnh hn.
-Tc ng n mt: tuz v tr tc trong hay ngoi gan m c tng BI,BD, nc tiu vng km
theo phn gim mu, bc mu.
1.2.2- C ch iu tit dch mt.
* C ch bi tit mt do gan.
- C ch thn kinh. Thc n ti nim mc ng tiu ho kch thch cc b phn th cm gy
phn x bi tit mt.
- C ch thn kinh-th dch.
Cc mui mt xung rut c ti hp thu phn ln vo mu, theo tnh mch ca v gan, kch
thch cc hch thc vt trong gan gy tng to mt.
HCl ca dch v xung rut, kch thch nim mc t trng tit ra secretin v CCK-PZ, cc cht ny
theo mu ti gan, kch thch gan sn xut mt.
* C ch bi xut mt t ti mt.
- C ch thn kinh. S co bp ca ti mt do thn kinh thc vt chi phi. Thn
kinh ph giao cm (dy X) lm co c ti mt, gin c c ti mt v c tht Oddi, mt c y
xung t trng. Thn kinh giao cm, ngc li lm gin c ti mt, co c Oddi, mt c gi
trong ti mt.
Khi tiu ho, c phn x co bp ti mt tng mt xung rut. Nu ri lon s phi hp ca h
giao cm v ph giao cm s gy ra ri lon vn ng ng mt, dn n nhng cn au qun
mt.


Hnh 3. S c ch TK-TD Iu ho ba xut dch mt
- C ch thn kinh-th dch.
HCl ca dch v v cc sn phm tiu ho rut, kch thch nim mc t trng tit ra cht
cholecystokinin-pancreozymin c tc dng co bp ti mt, gin c Oddi tng mt xung t
trng.
Cht m, lng trng, sulfat Mg c tc dng kch thch bi xut mt kh mnh.
1.3- Dch rut.
Dch rut do tuyn Liberkuhn v Brunner nim mc rut tit ra.
1.3.1- Thnh phn v tc dng ca dch rut.
Dch rut l dch lng, nhn, hi c, kim nh pH=7,8-8,3, s lng 1,0-2,0lit/24 gi.
Thnh phn dch rut c 98-99% nc, nhiu cht cc cht v c v cht hu c gm cht nhy,
cc men tiu ho, protein, acid amin, cc t bo bch cu v c cc mnh biu m rut.
Dch rut c cc loi men tiu ho protid, lipid v glucid. Cc men ny c phn b vng
glycocalyx v ngay trn mng vi nhung mao rut. Chng thc hin giai on cui cng ca qu
trnh tiu ho, bin cc cht dinh dng cn li rut non thnh cc phn t n gin v hp
thu chng.
* Nhm men tiu ho protid.
- Aminopeptidase tch acid amin u-NH
2
ra khi chui peptid thnh acid amin t do.
- Dipeptidase phn ct dipeptid, tripeptidase phn ct tripeptid thnh cc A. amin.
- Nuclease v nucleotidase thu phn cc acid nhn.
- Men enterokinase c tc dng bin trypsinogen thnh trypsin.
- Men mucinase thu phn cht nhy (mucin).
* Men lipase : c 3 men lipase, phospholipase v cholesterolesterase tc dng ging cc men
cng tn ca dch tu, chng tiu ho nt phn lipid cn li.
* Nhm men tiu ho glucid.
- Amylase rut phn gii tinh bt chn v sng thnh ng maltose, maltriose.
- Maltase bin maltose, maltriose thnh glucose.
- Lactase bin lactose thnh glucose v galactose.
- Sacarase bin sacorose thnh glucose v fructose.
1.3.2- iu ho bi tit dch rut.
Dch rut c bi tit ch yu bi cc phn x ti ch di kch thch c hc v ho hc ca
cc cht thc n.
Cc cht hormon tiu ho nh secretin, enterokrinin, duokrinin, ... do chnh nim mc rut tit
ra c tc dng tng cng bi tit dch rut.
2- Hot ng c hc ca rut non.
2.1- Cc loi c ng ca rut non.
S co bp ca c trn thnh rut non to nn 3 loi c ng.
*- C ng lc l: l do c dc tng bn ca rut co, lm cho on rut a qua bn ny, ri li
qua bn kia.
*- C ng co tht tng on : l do c vng tng on ca rut co, chia rut ra lm nhiu
khc nh. C ng ny vi c ng lc l c tc dng nho trn thc n
vi dch tiu ho rut.
*- Nhu ng rut : l do s kt hp co c vng v c dc ca rut to nn cc sng co bp bt
u t vng hnh t trng, ri lan dc theo rut. Sng nhu ng c tc dng p thc n v y
chng chuyn mt chiu t trn xung di dc theo ng tiu ho, gip cho vic tiu ho v
hp thu cc cht dinh dng.
Khi vim rut, hay n phi cht c-l rut b kch thch to ra sng phn nhu ng (ngc vi
sng nhu ng) s gy ra nn ma.
2.2- iu ho hot ng c hc ca rut non.
S c ng ca rut c tnh cht t ng do cc m ri thn kinh ni ti rut (Auerbach v
Meissner) chi phi. Trong c th, c ng ca rut cn chu s chi phi ca h thn kinh thc
vt.
Cc si ph giao cm (thnh phn cu dy X) lm tng nhu ng rut, cn si giao cm (thnh
phn ca dy tng) lm gim nhu ng rut. Do khi au bng (do co tht d dy, co tht
rut) ngi ta dng atropin c ch dy X c tc dng gim au.
Cc cht thc n cng kch thch nhu ng rut, nht l cht thc n th (bnh mz en, rau qu
...).
Ngoi ra di tc ng ca cc sn phm tiu ho, nim mc rut tit ra nhiu cht hormon c
tc dng lm tng nhu ng rut nh villikinin, duokinin, gastrin, CCK-PZ ...
ng vt bc cao v ngi, c ng ca rut cn chu nh hng ca v no.
3- Kt qu tiu ho rut non.
Qua qu trnh tiu ho ming, d dy v rut non, thc n c bin thnh cht c sn st,
nhuyn l dng chp. Trong :
- Protid c thu phn gn hon ton v thnh acid amin.
- Lipid gn ton b bin thnh A. bo, glycerol, MG v mt s cht khc.
- Glucid hn 90% thu phn thnh glucose, galactose v fuctose .
Tt c cc cht ny c kh nng hp thu c. Cn mt t li tinh bt, cht x (xellulose) v
phn nh cht gn, dy chng ... cha c tiu ho s c a xung rut gi. Thi gian
thc n qua rut non l 6-8 gi.

25. HP THU THC N RUT NON

Hp thu rut non l s xuyn thm ca cc cht dinh dng t t hc rut vo mu v bch
huyt ngang qua lp t bo nim mc rut c cu trc tinh vi v theo nhng c ch rt phc
tp.
Tt c cc on ca ng tiu ho u c kh nng hp thu, nhng ngi v ng vt bc cao
s hp thu rut non l quan trng nht v cc l do sau:
- Nim mc rut non c cu trc c bit to nn din tch hp thu rt ln.
- Cc cht dinh dng rut non, qua qu trnh tiu ho sn sng dng hp thu c.
Chnh nh s hp thu rut non m c th nhn c cc cht dinh dng cn thit p ng
cho hot ng sng ca mnh.
1.1-S lc cu trc b my hp thu rut non.
Nim mc rut non c nhiu np nh ln l van rut. Trn mt van rut c cc np gp nh hn
gi l nhung mao. Nhung mao c ph mt lp lin bo hnh tr-l t bo hp thu, trn b
mt mi t bo c 1500-4000 vi nhung mao (cn gi b bn chi). Do cu trc nh vy nn din
tch ca nim mc rut tng ln nhiu ln, t ti 500m
2
.
Trn mt v khe gia cc vi nhung mao c cc siu nhung mao an cho nhau to nn h thng
li 3 chiu gi l glycocalyx, c vai tr ln trong qu trnh tiu ho hp thu rut.
Di lp lin bo l t chc lin kt, trong c mng li thn kinh, cc mao ng mch v
mao tnh mch ni vi nhau to nn mng li dy c. gia nhung mao c ng bch mch,
cc ng ny i ra ngoi nhung mao gom vo cc bch huyt rut.
1.2- C ch hp thu cc cht rut non.
* Vn chuyn th ng: gm khuch tn n thun, khuch tn c cht mang v siu lc. Loi
c ch ny c vai tr ng k.
* Vn chuyn tch cc: thuc loi vn chuyn tch cc th pht, cn s c mt ca ion Na
+
.
Loi c ch ny c vai tr ch o.
* Thc bo (phagocytose), m bo (pinocytose): vai tr khng ng k.
(Xem li bi vn chuyn vt cht qua mng t bo).
Nhiu cht c hp thu nh s kt hp ca cc c ch trn.
* Dy chuyn tiu ho hp thu.
Ugolev nu ra (1970): qu trnh tiu ho hp thu cc cht dinh dng rut non din ra theo
mt dy chuyn lin tc, nhanh chng v c hiu qu. Cc men tiu ho thuc dch tu v dch
rut b tr glycocalyx theo hng t lng rut ti mng vi nhung mao theo mt trt t nht
nh. i phn t cc cht thc n b cht nh dn trn ng di chuyn ti mng vi nhung
mao. Trn mng vi nhung mao, cc men tiu ho mng thc hin giai on thu phn cui cng
v chuyn giao trc tip sn phm thu phn cho h cht ti c hiu. Do lm tng hiu qu
gn ni, gim bt s cnh tranh trong qu trnh hp thu, v trnh hin tng khuch tn ngc
cht hp thu vo lng rut. Do hp thu cc acid amin v ng n to ra t oligopetid v
oligosaccarid vi tc nhanh hn s hp thu cc ng n v acid amin a vo rut di
dng t do.
Trong hi chng gim hp thu c s ri lon cu trc vi nhung mao v vng glycocalyx.
1.3- Hp thu cc cht rut non.
1.3.1- Hp thu glucid.
Glucid c hp thu di dng monosacarid (ng n). Sn phm glucid c 3 loi
monosacarid chnh, l glucose, galactose v fructose.
- Glucose v galactose c hp thu t lng rut vo t bo theo c ch vn chuyn tch cc
th pht (secondary active transport) cng vi ion natri. ng n v Na
+
c gn ln v tr
tng ng ca protein mang, lc protein mang s thay i cu hnh khng gian, chuyn
ng thi hai cht co t bo, ri li quay ra thc hin vng vn chuyn mi. T trong t bo
glucose v galactose c khch tn vo h mch mu. Khi thiu ion Na, s hp thu ng n
s b gim nhiu thm ch b ngng hon ton.
C ch ny khng b ri lon trong bnh tiu chy. Dng dung dch orezol, l dung dch mui
ng iu tr bnh tiu chy gip cho s hp thu ng v mui rut c tt.
- Fructose c hp thu t lng rut vo t bo v t t bo vo mch mu u theo c ch
khch tn c cht mang.
1.3.2- Hp thu protid.
Protid c hp thu di dng cc acid amin, ch yu theo c ch vn chuyn tch cc th
pht cng ion natri. C 5 loi protein mang trong hp thu cc acid amin, hnh thc hot ng
ca cc protein mang cng tng t nh trong hp thu glucose. Nng lng cho qu trnh vn
chuyn ny cng ph thuc vo th nng chnh lch ca ion Natri. Protid ng vt hp thu tt
hn protid thc vt.
T bo nim mc rut non ca tr nh c kh nng hp thu protein nguyn dng (native
protein), l cc gmm globulin t sa m. Khi tr ln ln, kh nng ny dn b gim v mt
hon ton ngi ln. Mt s ngi cn kh nng ny l c s ca d ng thc n.
1.3.3- Hp thu lipid.
Lipid thc n c thu phn thnh monoglycerid, acid bo, cholesterol t do v glycerol. 30%
glycerol v acid bo mch ngn (nh hn 12 C) c khuch tn thng vo t bo nim mc, ri
vo mu tnh mch.
Cn li acid bo mch di, choleserol t do v monoglycerid c hp thu vo t bo nim
mctng phc hp micell do mui m to nn. Trong t bo nim mc rut cc cht ny li
c tng hp thnh triglycerid, cholesterol este v photpholipid, ri cng vi protein to nn
cht chylomicron (loi lipoprotein nh nht), cht ny c khch tn vo h bch mch.
1.3.4- Hp thu cc vitamin.
*- Cc vitamin tan trong nc: vitamin nhm B, C, PP ... ch yu hp thu theo c ch khuch
tn. Ring vitamin B12 c hp thu do vn chuyn tch cc, cn s c mt cu yu t ni ca
d dy.
* cc vitamin tan trong du: gm vitamin A, K, D, E hp thu cng cc sn phm lipid, cn s c
mt ca mui mt (trong phc hp micell).
1.3.5- Hp thu cc cht mui khong.
Cc cht mui khong khc nhau c c ch hp thu khc nhau.
- Cc ion dng ho tr mt nhiu nht l Na
+
, K
+
c hp thu theo c ch vn chuyn tch
cc th pht v khch tn.
- Cc ion ho tr dng hai ch yu hp thu theo c ch tch cc rt phc tp, nhiu nht
l Ca
++
v Fe
++
.
- Cc ion m ch yu c hp thu th ng theo cc ion dng.
- Mt s ion m t c hp thu nh sulfat, photphat, citrat ... v mt s cht
khng c hp thu: oxalat, fluosur ... Ngi ta dng cc loi mui ny lm thuc ty (nh
sulfat Mg ...).
1.3.6- Hp thu nc.
Nc c hp thu do khch tn theo chnh lch p lc thm thu.
Hng ngy c khong 8-10 lt nc c a vo ng tiu ho gm 1,5-2,0 lit do n ung v 7-8
lit do cc ng tiu ho bi tit ra. ng tiu ho c kh nng ti hp thu ti 99% lng nc ni
trn trong mt ngy m, ch c 0,12-0,15 lit nc o thi ra ngoi theo phn. Phn cui i
trng c kh nng hp thu nc kh mnh. Do phn ng lu i trng s d gy to bn.
1.4- Cc ng hp thu.
T nim mc rut non, cc cht c hp thu theo hai ng:
14.1- ng tnh mch ca.
Cc cht nc, acid amin, monosaccarid, 30% glycerol v acid bo mch ngn sau khi hp thu s
vo mao mch nhung mao. Cc mao mch ny gom li thnh cc tiu tnh mch ri tp trung
li theo tnh mch ca v gan. gan cc cht qua qu trnh chuyn ho phc tp, ri theo tnh
mch trn vo tnh mch ch di.
1.4.2- ng bch mch.
Khong 70% cc sn phm thu phn lipid v cc vitamin tan trong du, sau khi hp thu qua t
bo nim mc rut vo mao bch mch nhung mao, ri gom v cc hch bch huyt thnh
rut, ri v b Pecquet. T y chng i theo ng ngc, vo tnh mch di n tri vo
tun hon chung.
1.5. iu ho hp thu.
1.5.1-.C ch thn kinh.
-Thn kinh ph giao cm: lm tng nhu ng rut, gin mch tng hp thu.
-Thn kinh giao cm lm gim nhu ng rut, co mch gim hp thu.
1.5.2. C ch th dch.
Cc hormon villikrinin, duokrinin, gatrin, CCK... vi mc khc nhau lm tng hp thu.

BI 5. SINH L SINH DC
26. SINH L SINH DC N

1- C IM CU TRC, CHC NNG CA BUNG TRNG V T CUNG:
Gm: bung trng, vi trng, t cung, m o, m h, tuyn tit nhy v tuyn v.
1.1- Bung trng:
L tuyn va ngoi tit (SX trng) v ni tit (tit HM SD n).
Non cp II phn chia thnh non trng thnh (c 1n NST: 22NST thn v X).
1.2- Nim mc t cung. c 2 lp:
- Lp NM nn st c t/c, khng t/i trong CKKN. M nn nui dng t si n hi.
- Lp NM chc nng. Thnh M c nhiu si n hi.
Lp NM c/nng c tuyn bi tit nim dch v b bin i theo CKKN.
Nu th thai, NM chc nng s tn ti.
2- CC HORMON BUNG TRNG
2.1- Estrogen:
* Ngun gc:
- Lp o trong ca nang tit na u CKKN. - na sau CKKN do hong th tit.
- Khi c thai, do nhau thai tit.
- V thng thn tit t (t androgen).

* BC ho hc:
Estrogen l Steroid c 18 C, tng hp t cholesterol, c 3 cht chnh:
b-Estradiol, Estrion, Estradiol
* Tc dng:
- Lm X/hin v bo tn c tnh SD th pht n.
- Vi t cung:
+ P/trin NM t cung trong CKKN.
+ Ptrin c t/c khi c thai.
+ Tng co bp t/c khi mang thai.
+ Tng lu lng mu n t/c.
+ Tng nhy cm ca c t/c vi oxytoxin.

tng tit dch nhy, kim, qunh gip tinh trng di chuyn vo t/c.
- Vi tuyn v:
Ptrin ng tuyn, lp m v m m.
- Vi m o: sng ho TB m o.
- Vi vi trng: tng nhu ng, tng h/ TB lng rung trng di chuyn vo t/c.
- Vi chuyn ho:
+ CH protid: tng t/h ADN, ARNm,protein c.
+ CH lipid: tng lng m d/d nh ngc, mng to dng n, gim cholesterol mu
+ CH mui nc: nng cao tch Na+
+ CH Ca++ v xng:
. Tng hot tnh TB to xng.
. Tng hp thu Ca++ rut.
. Tng ng Ca++ xng.
- Vi nam: n/ cao estrogen lm gim p/trin tinh hon v ngng SX t/trng.
* iu ho bi tit:
N/ cao LH k/t bung trng BT estrogen v ngc li.


. Tng p/t v ct ho sn lin hp u xng di ( mnh hn testosteron).

2.2- Progesteron:
* Ngun gc:
Do hong th Btit na sau CKKN.
Nhau thai v 1 t do v tthn BT.
* B/C ho hc:
L steroid 21 C

* Tc dng:
- Trn t cung:
+ KT NM t/c p/trin na sau CKKN.
+ KT cc tuyn NM t/c p/trin, b.tit dch, glycogen.
+ KT cc mch mu p/trin.
+ C co bp t/c (td an thai).
- Trn Vi trng: tng tit dch v cung cp cht d/d cho trng th tinh.
- T/v: tng sinh TB nang v pt bc t/v.
- C rng trng.
+ Tng thoi ho protein.
+ Tng thn nhit ( na sau CKKN- thn nhit tng 0,5oC)
+ Nng cao tng gi Na+ ng ln xa.
* iu ho bi tit:
Do GnRH, LH v FSH .
3- CHU KZ KINH NGUYT
3.1- N: l s chy mu c chu k NM t/c di t/d ca HM bung trng v tuyn yn.
CKKN l khong thi gian gia 2 ngy chy mu u tin ca 2 chu k k tip (28 ngy).
3.2- Cc giai on ca CKKN:
* G nang t (hay G tng sinh):
- Tuyn yn:
Di nh hng ca GnRH, T.Y bi tit FSH v LH tng dn.
- Hin tng rng trng
* G bi tit (hay G hong th t).
- Vo 2 ngy cui g/
Thi gian xoa kinh (mu chy) 3-4 ngy, khong 40ml mu v 35-40ml dch
4- DY TH V MN KINH
4.1- Dy th:
- im nh du: c KN u tin, #13-14 tui (Nam tinh trng p/t, #15-16 tui).
- Tuyn SD bt u tng h/ v c kh nng sinh sn.
- c tnh SD th pht xut hin: c, xng, b phn SD ngoi p/t...
- D con n rng, tuyn v p/t, v n to...
- Tng tit GnRH FSH, LH tuyn SD hot ng.
4.2- Mn kinh
- L mc chm dt hot ng sinh sn n (45-50 tui).
- Khng cn k/n lm nang trng chn, nang trng thoi ho.
- Lng estrogen, progesteron gim n mc c s.
- Khng c kinh nguyt.
- Du hiu SD th pht gim, RL thc vt RL vn mch cn bc ho, Tm l thay i...
5. QA TRNH TH THAI V MANG THAI
5.1- Th thai:
-Trng (non) vi t cung (tn ti 24-48h). -T/trng fng vo m o, d/c 3-4mm/min; ch vi
T.tr sng st qua 2-3 ngy.
Trng gp t/t #1/3 ngoi vi trng.
Ch c 1 tt kho nht gp v bm vo trng, tit enzym Hyaluronidase tiu a. Hyaluronic.
Mng trc t/t ho tan, gf cc enzym tiu lp protein quanh trng.
1 T/t chui vo trng v th tinh.
NSTca trng v t/t to b NST hon chnh (2n = 46NST):
nu t/t X phi XX = con gi;
t/t Y phi XY = con trai.
Phi va phn chia, va di chuyn vo t cung (mt 3-4 ngy).

.6Phi d/c xung t cung lm t (vo ngy th 7). Cc t bo l nui hnh thnh v p.trin, n
su vo NM t cung.
T bo l nui v NM t/cung tng sinh nhanh rau thai v mng thai.
NM t/c tit dch rt nhiu cht dd, NM n to gi l mng rng.
Thai nhn cht dd qua mu rau thai t cui tun th 8.
Rau thai c CN: v/c cht dd, tit hormon v chuyn cc cht o thi t thai mu m.
5.3- Cc hormon rau thai:
* HCG (Human chorionic gonadotropin):
do rau thai bt t ngy th 8, cao nht tun 10-12, ri gim dn v ht sau .
+ BC l protein, TLPT: 39.000.
+ T/D ging LH:
- Duy tr v KT hong th tit est. v pro.
- K/t TB Leydig tit testo., p/t SD nam v di chuyn tinh hon xung bu.
LS: - N dng chn on sm c thai
- Nam dng iu tr tinh hon n.
* Estrogen:
Hong th: 4 thng u, sau rau thai tit, n/ tng dn, gn s thai gim.
T/D: lm n rng t/c, n to v, pt ng tuyn v, n rng b phn SD ngoi.
* Progesteron:
Hong th: 4 thng u, sau rau thai tit, cao gp 10 ln bt, cao nht vo thng cui.
T/D: - pt NM t/c, nui dng phi.
- gim co bp T/C
- tng tit dch ng dn trng, nui dng v hng trng di chuyn vo T/C.

* c ch LH c ch rng trng.
* HCS (Human chorionic somatomammotropin):
do nhau thai tit, TLPT 38.000.
N/ cao nht trc khi .
T/D: - tng tng hp protein
- tng g/p a.bo t do t c th m.
* Relaxin: do rau thai SX cui tkz c thai.
T/D: lm mn c t cung; gin dy chng khp mu, khp cng chu... s thai.
5.4- Nguyn tc chn on sm c thai
Da vo c mt HCG l HM c hiu ca rau thai, td nh LH, bi tit t ngy th 8 - thng th
4, thi qua n.tiu.
C cc nghim php sinh hc v min dch hc:
- Nghim php sinh hc: Gallimainini, Friedman-brouha, Ascheim-Zondek...
- Xt nghim min dch dng Kth khng HCG (nghim php Qiuck stikct).
5.5- Cc bin php trnh thai:
* Dng cho n:
-Thuc tch thai: gm Progesteron (chnh) v estrogen c ch tit LH v FSH C rng trng.
- t thuc dit tinh trng.
- Mng ngn m o.
- Dng c t/c.
* Dng cho nam:
- Xut tinh ra ngoi m o, Bao cao su.
* Dng cho c nam v n:
- Tnh ngy rng trng (PP Ogino Knaus).
- nh sn nam, nh sn n.
HT
7- SINH L CHUYN D V BI TIT SA
7.1- Sinh l chuyn d:
Do bin i HM v c hc t cung
- Progesteron lm C co bp t/c, estrogen lm tng co bp. T thng th 7 estrogen vn tip
tc tng, cn progesteron li gim dn, do lm tng co bp ca c t/c
- oxytoxin: lm tng co bp t/c (gn ngy tit cng nhiu)

- Yu t c hc: c t/c gin ti a, c xu hng co li. Khi thai xung c t/c, gy fx tit oxytoxin
tng co bp t/c gy s thai.
au l do c t/c co p gy thiu mu.
au khi s thai l do cng c t/c, c y chu hoc tn thng vng m o.
7.2- Bi tit v bi xut sa:
- Trc khi , estrogen, progesteron C tit sa. Sau 2 HM ny gim thp.
Prolactin pht huy t/d lm tuyn v tng hp v bi tit sa.
- Mt nm v to fx tit oxytoxin co c trn nang tuyn y sa vo ng sa v sa chy ra.
Thnh phn sa: nc, cht bo, lactose, casein, khng th...
5-HOT NG SD N
Bt u t tui dy th, c nhu cu tnh dc v k/nng sinh .
m vt cu to bi th hang, th xp, m LK-c c nhiu hc mu.
Kch thch tnh dc: tm l v ti ch.
Khi giao hp, m vt cng, tuyn Bertholin tit cht nhy lm trn...

27. SINH L SINH DC NAM

1.C quan SD nam gm tinh hon, dng vt v mt s tuyn ph thuc.
2.CHC NNG CA TINH HON
C 2 CN: ngoi tit v ni tit.
2.1- Chc nng sinh tinh trng:
Mi tinh hon c # 900 ng sinh tinh.
1ng s/tinh di 50cm ni SX tinh trng.
Thnh ng s/t gm TB dng tinh (tinh nguyn bo) v TB Sertoli.
Tinh nguyn bo bit ho tinh trng.
TB Sertoli gn nhau = lp c T/D bo v TB dng tinh.
Tinh nguyn bo typ A p/chia 4 ln to 16 TB ln (typ B) v/c vo khoang gia 2 TB Sertoli
thnh tinh bo I (c 46 NST).
- Tinh bo I p.chia tinh bo II (c 23NST).
Sau 2-3 ngy Tinh bo II p/chia nguyn nhim thnh tin tinh trng (23 NST).


- T.gian to 1 tt 74 ngy, c 2 loi tt mang 1 loi NST gii tnh X hoc Y.


- Th tinh: XX con gi; XY con trai.
- T/t trng thnh gm: u, c v ui.
Cc u cha hyaluronidase phn hu lp cemen gia cc TB v men thu phn t/t
xm nhp trng.
* S thnh thc ca tinh trng:
T ng sinh tinh, tt mo tinh ng ti tinh trng thnh v c k/nng th tinh.
TB Sertoli v TB b/m mo tinh b/tit cht d/dng v men cn cho s t/thnh ca tt.
T/t kho d/chuyn vi tc : 1-4mm/ph.
Mi trng thun li: pH kim, t/tnh.
T/t sng ng SD n t 1-2 ngy.
* iu ho SX tinh trng:
+ H bng hormon:
- GnRH, FSH v LH
- FSH: lm p/trin ng s/tinh v TB Sertoli tit cht dinh dng.
- LH: tng sinh TB Leydig tit testosteron.
- Testosteron: p/chia tinh nguyn bo to TT
- GH: cn cho SX tinh trng.
+ Cc yu t khc:
- V no, h limbic: nh hng SX tt qua Hypothalamus.
- Nhit : t/t c SX n/ thp hn n/ c th 1-2 .
C Dartos ( bu) co gin theo n/ mt...
ng dng bo qun t/t n/ -175oC.
- Tia X, fng x, virut quai b lm tn thng TB u dng tinh
- pH, Khng th mu...
- Ru, ma tu lm gim SX t/trng.
2.2- CHC NNG NI TIT CA TINH HON.
Tinh hon tit testosteron v inhibin.
2.2.1- Testosteron
- Ngun gc:
TB Leydig tit
Tit tun th 7, n sau sinh: ngng.
T tui dy th: tit n ht i.
T androgen v thng thn.
- B/C: l steroid 19C, c nhm OH C17.

- Tc dng ca testosteron:
* Thi k bo thai:
+ Lm bit ho trung tm hng dc vng di i theo gii tnh nam
+ Lm p/trin c quan SD ngoi.
+ KT di chuyn t/hon t bng xung bu.
* T tui dy th:
+ Lm p/trin c quan SD (n to 8-20 ln).
Lm xut hin c tnh SD ph ca nam.
Cng FSH d/dng ng s/ tinh v p/trin tt
* T/D ln CH.
. Tng t/h protein, pt h c xng (dng lm thuc tng ng ho v doping).
. Xng: tng t/h khung xng, p/trin v ct ho sn lin hp u xng di, tng h/ TB
to xng, tng chiu dy v lng ng calci trong xng tng sc mnh xng.
- Tng CHCS 15%, tch mui, nc.
- Tng s lng hng cu (nhiu > n)
- Gy nam ho trn n.
* iu ho bi tit:
Thi k u ca bo thai do HCG, t/k trng thnh do LH.
2.2.2-Inhibin:
Do TB Sertoli tit.
- B/C ho hc: l polypeptid,
TLPT: 25.000 -1000.000.
- T/D: iu ho SX t/trng qua c ch iu ho ngc (-) FSH khi t/t SX qu nhiu.
3- DY TH V SUY GIM SD NAM:
3.1- Dy th:
L mc nh du kh nng sinh sn.
- Tinh hon hot ng bi tit HM v SX tinh trng.
- Xut hin c tnh SDc th pht.
- Tui dy th: 13-16.
3.2- Suy gim sinh dc:
Hot ng SD t tui dy th n ht i, song v gi c gim.
1/3 nam gii > 60 tui bt lc SD.

BI 6. SINH L THN

28. QU TRNH TO NC TIU

c c nc tiu, thn c ba qu trnh: siu lc tiu cu thn, ti hp thu v bi tit
tch cc tiu qun thn.
1. QU TRNH SIU LC.
Qu trnh siu lc thc hin tiu cu thn. Qa trnh ny l mt qu trnh th ng, lc nc
v cc cht ho tan trong nc t huyt tng mao mch cun mch sang khoang bao
Bowman qua mng siu lc. Nh vy, mun c dch siu lc ( dch lc, nc tiu u) , cn phi
c hai yu t c bn l mng siu lc v p lc lc.
Mng siu lc v p lc lc quyt nh s lng v thnh phn cc cht dch siu lc.
1.1. Mng siu lc.
Mng siu lc cn gi l mng tiu cu thn. Mng ny ngn cch gia huyt tng mao mch
cun mch v dch siu lc trong khoang bao Bowman. Mng c ba lp: lp t bo ni m mao
mch, lp mng nn v lp t bo biu m (l trong) bao Bowman.
Lp t bo ni m mao mch lng trn lp mng y. Trn t bo ny c nhng l thng gi l
ca s (fenestra). ng knh ca s ny l 160 A
0
.
Lp mng nn l mt mng li cc si collagen v proteoglycan, c to ra cc l nh cc
ng knh 110 A
0
. Cc l ny tch in m (do cu trc ca proteoglycan).
Lp t bo biu m bao Bowman l mt lp t bo biu m c chn (tua) mi t bo c rt
nhiu chn bm ln mng nn. Gia cc tua nh ny c cc khe nh (slit-pore) c ng knh
khong 70-75 A
0
. Trn siu cu trc, cc l ny khng phi thng trc tip m trn b mt
chng c mt mng bt siu mng
Mng siu lc c rt nhiu lp nh vy nhng li l mt mng sinh hc c tnh thm chn lc
rt cao. Kch thc phn t v s tch in m ca cc phn t quyt nh kh nng thm
ca n qua mng siu lc:
Cht ho tan Trng lng phn t Kh nng thm qua
Inulin 52000 1,000
Cc protein phn t nh 30.000 0,500
Albumin 69.000 0,005
Inulin c trng lng phn t nh nn thm qua 100%. Albumin c trng lng phn t ln, li
tch in m nn ch thm qua c 0,5%. Cc t bo mu, ng nhin l khng th qua c
mng siu lc. V vy trong dch siu lc khng c cc t bo mu, khng c cc hp cht hu
c c phn t lng cao trn 70.000. Cc protein phn t lng thp c th thm qua mng
siu lc, nhng rt t, v vy hm lng ca n trong dch siu lc ch l 0,03%, c ngha l n ch
bng 1/240 hm lng protein huyt tng. Do c s chnh lch v hm lng protein gia
huyt tng v dch siu lc (chnh lch din tch m) nn trong dch siu lc s c nng ion
Cl
-
v HCO
3
-
cao hn 5% so vi huyt tng gi cn bng in tch m (cn bng Donnan).
Nhn chung, tr nhng thnh phn m t trn y khng qua c mng siu lc, cn li
gn nh ton b cc cht trong huyt tng v dch siu lc c nng ngang nhau v dch
siu lc c p sut ng trng so vi huyt tng.
1.2. p lc lc: FP (filtration pressure).
p lc lc l p lc tc ng ln huyt tng ca mao mch cun mch, y nc v cc
cht ho tan trong nc sang khoang bao Bowman. p lc lc c to nn bi s tng hp
ca cc p lc mu mao mch cun mch , p lc keo ca huyt tng mao mch cun mch
v p lc trong khoang bao Bowman.
p lc mu mao mch cun mch: GP (glomerular pressure). Mao mch cun mch c p lc
mu rt cao, cao nht trong cc h thng mao mch, thng thng l 60mm Hg. y l ng
lc c bn nht to ra p lc lc. Ap lc ny y nc v cc cht ho tan trong nc t mu
mao mch cun mch vo khoang bao Bowman.
p lc keo ca huyt tng mao mch cun mch: GCP (glomerular colloid osmotic pressure).
GCP c to nn nh cc hp cht hu c phn t lng cao, c bit l cc protein huyt
tng. Cc cht ny c kh nng gi nc li cho huyt tng. GCP ng mch n l 28mm
Hg (y l p lc keo ca mu), ng mch i l 36mm Hg (v nc thot vo khoang bao
Bowman) nn p lc keo ng mch i cao hn p lc keo ng mch n. GCP trung bnh
ca mu mao mch tiu cu thn l 32mm Hg.
p lc trong khoang bao Bowman: CP (capsular pressure). y l p lc ca dch siu lc nm
trong khoang bao Bowman to nn, cn gi l p lc trong bao. p lc ny y nc t khoang
bao Bowman tr li huyt tng mao mch cun mch. p lc ny bng 18mm Hg. Nh vy p
lc keo ca huyt tng mao mch cun mch v p lc trong bao l ngc chiu vi p lc
mu mao mch cun mch.
Mun c dch siu lc th FP phi ln hn 0, ngha l GP phi ln hn tng GCP + CP v cng
thc p lc lc l:
FP = GP-(GCP + CP)
= 60 - (32 + 18)
= 10 (mmHg)
Tng lng dch siu lc trong 24 gi l rt ln, trung bnh l 170-180l. V vy vic nghin cu
nh gi chc nng lc ca tiu cu thn l v cng quan trng i vi cc nh lm sng c
bit l cc nh gy m-hi sc.
Ngoi FP ra, nh gi chc nng lc ca tiu cu, ngi ta cn xc nh mt s ch s nh
sau:
Phn s lc ca tiu cu:FF (filtration faction) l t s (%) gia dch lc (ml) v lng huyt
tng qua thn (ml) trong mt pht: bnh thng t s ny bng 19-21%.
GFR
FF=--------------
RPF
H s lc ca tiu cu (filtration coefficient), k hiu l Kf. H s lc Kf l s ml dch siu lc c
trong mt pht, khi p lc lc l 1mm Hg, bnh thng Kf=12,5ml/min. mmHg.
Mc lc cu thn: GFR (glomerular filtration rate). Mc lc cu thn cn gi l lu lng lc cu
thn. GFR l s ml dch siu lc c trong mt pht. N c tnh bng tch ca h s lc vi p
lc lc ca tiu cu.
GFR = Kf x FP = 12,5 x 10 = 125ml/min.
Ngi ta cng xc nh GFR bng h s thanh thi ca inulin (h s thanh thi ca inulin bng
125ml/min).
1.3. Nhng yu t nh hng ti qu trnh siu lc.
- C ch t iu ho mc lc cu thn ca b my cn tiu cu.
C ch t iu ho mc lc cu thn l c ch iu ho ngc ng thn-tiu cu
(tubuloglomerular feed bach mechanism). y l c ch iu ho ngc vn mch gy gin
ng mch n v co ng mch i v u l c ch iu ho ngc m tnh.
Khi lu lng lc cu thn gim th tc dng dch qua ng thn b chm li. Hin tng ny
lm cho tng cng ti hp thu ion Na
+
v Cl
-
nhnh ln quai Henle. Nc tiu i qua ng
ln xa s c nng ion Na
+
v Cl
-
gim hn bnh thng. Cc t bo macula densa nhn cm
c s gim nng ion Na
+
v Cl
-
trong dch lng ng thn khi cc cht ny qua chng. Cc t
bo macula densa cho nhng tn hiu m thng qua n lm gin ng mch n v kch
thch t bo cn tiu cu gii phng renin.
Khi gin ng mch n, lu lng tun hon qua thn (RBF: renal blood flow) s c tng
ln, lm tng p lc lc v nh vy s tng mc lc cu thn. Chc nng lc ca tiu cu thn
tr v bnh thng.
Khi t bo cn tiu cu gii phng renin, n s tham gia vo mt trong nhng khu quan trng
xc tc cho qu trnh chuyn angiotensinogen thnh agiotensin II. Angiotensin II lm co ng
mch i (v t bo c thnh ng mch i rt mn cm vi angiotensin II). ng mch i co, s
lm cho p lc mu trong mao mch cun mch tng. Lu lng lc cu thn tng ln v chc
nng lc ca tiu cu thn tr v bnh thng.
Hai c ch gin ng mch n v co ng mch i nhm mc ch t duy tr mc lc cu thn
hng nh, mc d huyt p ng mch c th thay i trong mt phm vi kh rng t 75-
160mm Hg.
- C ch iu ho ca h thn kinh giao cm.
Cc tn cng thn kinh giao cm c phn b ti tn t bo c trn thnh ng mch n v
ng mch i ca tiu cu thn. Cc t bo ny cng c nhng th th nhn cm i vi cc
cht trung gian ho hc ca h thn kinh giao cm. V vy khi h thn kinh giao cm b hng
phn hay b c ch, cc cht trung gian ho hc h thn kinh giao cm tng ln nhiu hay t
trong phn ng thch nghi ca c th i vi mi bin i ca mi trng, s lm cho lu lng
tun hon qua thn bin i (dng mu thn bin i). Khi lu lng tun hon qua thn thay
i th mc lc cu thn cng b thay i theo v nh vy, chc nng lc ca tiu cu s c
duy tr trng thi sinh l{ bnh thng.
- S bin i p lc lc khi c s bin i ca huyt p ng mch, p lc keo ca huyt tng
v p lc trong bao (trong thn).
Trong tt c cc trng hp c huyt p ng mch gim (shock, mt mu, suy tim v.v...) dn
n gim p lc mu mao mch cun mch v lm gim p lc lc. p lc lc gim th lu
lng lc cu thn gim. Khi huyt p ng mch gim xung ch cn 40-50mm Hg th v niu.
Nhng khng phi trng hp tng huyt p no cng lm tng p lc lc. Mt s trng hp
tng huyt p do co mch, mc d huyt p ng mch tng rt cao, nhng lu lng lc cu
thn li rt gim, v c co ng mch n, lm gim dng mu thn. Tri li, c mt vi trng
hp c gim huyt p ng mch, nhng do gin ng mch n, lm tng lu lng tun
hon thn, nn vn cn lu lng lc cu thn. Nh vy, huyt p ng mch, dng mu thn
c mi lin quan cht ch vi mc lc cu thn.
Khi b bng, b ra nhiu m hi (do lao ng trong mi trng nng m), b nn ma hoc a
chy, c th b mt rt nhiu nc, p lc keo ca mu tng rt cao dn ti mc lc cu thn
gim.
Bnh nhn b bnh vim ng thn, si thn v niu qun gy cn tr ng dn nc tiu
lm tng p lc trong thn v lm gim lu lng lc cu thn. Ngi ta nhn thy rng khi p
lc trong thn ln n 30-40mm Hg th p lc lc bng khng v c th s v niu.
- S bin i cu trc mng siu lc.
Khi mng siu lc bin i v cu trc do rt nhiu nguyn nhn khc nhau, chc nng bnh
thng ca mng siu lc khng cn na. Tnh thm ca mng siu lc tng lm cho mc lc
cu thn tng, tnh thm ca mng siu lc gim lm cho mc lc cu thn gim. ng thi khi
tn thng mng siu lc, dch siu lc s c hng cu, c protein lm cho nc tiu c hng
cu (i ra mu), c protein (i ra protein).
2. QU TRNH TI HP THU.
Qu trnh ti hp thu c thc hin ng thn. Trong qu trnh ny ton b cc cht cn thit
cho c th u c ti hp thu tr li mu. C nhng cht c ti hp thu hon ton, c
nhng cht c ti hp thu mt phn hoc phn ln, c nhng cht khng c ti hp thu v
l cht khng cn thit cho c th. Ti ng thn c c c ch vn chuyn tch cc v khuch
tn th ng.
Khi cc cht t lng ng thn c hp thu vo dch gian bo.T dch gian bo cc cht (nc
v cc cht ho tan trong nc) vo mu theo s chnh lch p lc thu tnh v p lc keo: ti
mao mch ng thn c p lc keo l 32mmHg, p lc thu tnh l 13mm Hg. Nh vy p lc gi
nc li l 32 - 13 = 19 (mmHg). Ti dch gian bo c p lc keo l 15mm Hg, p lc thu
tnh l 6mmHg. Nh vy p lc gi nc l 15-6 =9 (mmHg). Thc t s chnh lch p lc gia
mu mao mch ng thn v dch gian bo ng thn l 19 - 9 = 10 (mmHg). Nh c p lc ny m
nc v cc cht ho tan trong nc c chuyn t dch k vo mu mao tnh mch ng thn,
ri theo tun hon chung i khp c th.
Nu c chc nng lc m khng c ti hp thu, con ngi khng tn ti c. Mt v d n
gin l nc c lc trong 24 gi l 170-180l, nhng nc c o thi chnh thc theo
nc tiu l 1,5 lt, gn nh ton b nc c ti hp thu.
2.1. Ti hp thu ng ln gn.
Nhn chung c khong 80% cc cht v nc c ti hp thu ng ln gn. V vy khi ra khi
ng ln gn vo quai Henle, nc tiu vn ng trng mc d mt rt nhiu nc v
ion Na
+
.
- Ti hp thu glucose.
Glucose c ti hp thu hon ton theo c ch vn chuyn tch cc ng ln gn khi nng
glucose mu thp hn ngng glucose ca thn. Khi nng glucose mu cao hn ngng
glucose ca thn (>1,7g/l) th glucose khng c ti hp thu hon ton, mt phn glucose c
trong nc tiu, mc d ng ln gn c kh nng ti hp thu glucose cao hn khi nng
glucose bnh thng trong mu.
- Ti hp thu HCO
3
-
.
HCO
3
-
c ti hp thu ch yu ng ln gn, c mt phn ng ln xa. S ti hp thu
HCO
3
-
theo c ch vn chuyn tch cc, c lin quan cht ch vi carboanhydrase (C.A), cng c
mt phn HCO
3
-
c ti hp thu theo c ch khuch tn th ng.
Trong lng ng ln gn: HCO
3
-
+ H
+
H
2
CO
3

CO
2
+ H
2
O.
CO
2
khuch tn vo trong t bo ng ln gn v CO
2
+ H
2
O
CA
HCO
3
-
+ H
+
. ion H
+
c vn
chuyn tch cc vo lng ng ln cn HCO
3
-
c chuyn vo dch gian bo cng vi Na
+
. Nh
vy HCO
3
-
theo c ch vn chuyn tch cc khng phi chnh HCO
3
-
m thng qua s khuch tn
ca CO
2
c to thnh t HCO
3
-
.
Trong 24 gi c 4000 mEq HCO
3
-
b lc vo dch siu lc, nhng ch c 1-2 mEq HCO
3
-
b thi
ra ngoi. C ti 99,9% HCO
3
-
c ti hp thu.
- Ti hp thu protein v acid amin.
Protein phn t lng nh v acid amin c ti hp thu hon ton ng ln gn theo c ch
vn chuyn tch cc. Protein gn trn mng nh v c chuyn vo trong t bo theo c ch
"m bo". Cc protein trong "ti" b cc enzym thu phn thnh acid amin. Cc aid amin ny
c vn chuyn qua mng y vo dch gian bo theo c ch khuch tn c cht mang. Cc
acid amin t do trong lng ng ln c vn chuyn tch cc nh cht ti c hiu qua mng
nh.
- Ti hp thu K
+
, Na
+
v Cl
-
.
Ion K
+
c ti hp thu hon ton ng ln gn theo c ch vn chuyn tch cc. Ion Na
+

c ti hp thu ti 65% theo c ch khuch tn c gia tc mng nh, vn chuyn tch cc
mng y v mng bn. Ion Cl
-
c ti hp thu theo gradient in tch.
- Mt s gc sunfat, phosphat, nitrat... c ti hp thu theo c ch vn chuyn tch cc.
- Ti hp thu nc.
Nc c ti hp thu l hu qu ca ti hp thu cc cht c lc thm thu cao: Na
+
, K
+
, Cl
-
,
HCO
3
-
... Nu a cc cht c lc thm thu cao vo mu, sau n c lc qua tiu cu, cht
ny t c ti hp thu, n s b o thi ra ngoi gy ra c ch li niu thm thu.
- Ti hp thu ur.
Khi cc ion c ti hp thu, c bit l cc ion c tnh thm thu cao nh Na
+
, lm cho nc
c ti hp thu theo. Nh vy nng ur trong ng ln gn s cao hn nng ur trong
dch gian bo. V vy ur khuch tn vo dch k, ri vo mu, theo gradient nng ti 50-
60%.
2.2. Ti hp thu quai Henle.
Quai Henle c hai nhnh: xung v ln ngc chiu nhau. S cu to ca hai nhnh cng khc
nhau. Nhnh xung v phn u nhnh ln mng. Phn cui nhnh ln dy. Phn u nhnh
ln c tnh thm Na
+
, ur, nhng khng thm nc. Na
+
c ti hp thu th ng vo dch
gian bo. Phn cui nhnh ln khng ti hp thu th ng Na
+
m li vn chuyn tch cc Na
+
.
Dch gian bo quanh quai Henle rt u trng, nht l vng chp quai Henle, c bit l vng
tu thn. Nh hin tng trn m nc c ti hp thu th ng nhnh xung, v nhnh
xung c tnh thm cao i vi nc v ur, nhng li khng cho Na
+
thm qua.
Nc tiu i vo quai Henle vn l ng trng, nhng cng i xung quai Henle, n cng u
trng, chp quai l u trng nht. Chnh s u trng ny lm cho Na
+
la d ti hp thu
phn ln. nhnh ln Na
+
c ti hp thu nn nc tiu s ng trng ri nhc trng v
Na
+
c vn chuyn tch cc.
Ti ng ln xa nc tiu rt nhc trng, mc d qua quai Henle n b ti hp thu rt
nhiu nc. Kh nng ti hp thu ca quai Henle rt ln ti 25% Na
+
v 15% nc.
2.3. Ti hp thu ng ln xa.
ng ln xa l phn cui ca nephron, do s ti hp thu y ph thuc vo hai yu t c
bn th nht l nhu cu ca c th, th hai l s lng v cht lng nc tiu qua n.
- Ti hp thu nc
Nc tiu qua y l nc tiu nhc trng, trung bnh c mt pht c 20ml nc tiu qua
ng ln xa. Trong 20ml ny, thc t ch cn 2ml ho tan vt cht c trong nc tiu.
S cn li 18ml khng tham gia vo ho tan vt cht, phn nc ny c gi l nc "khng
tham gia thm thu". Phn nc ny cn c ti hp thu ch yu ng ln xa v mt phn
ng gp. Ti hp thu nc theo c hai c ch ch ng v th ng, nhng ch yu l vn
chuyn tch cc. S vn chuyn nc theo c ch ch ng nh tc dng ca ADH. ADH l
hormon ca hypothalamus, c d tr thuz sau tuyn yn v vo mu theo nhu cu ca c
th. ADH tc ng ln t bo ng ln xa v ng gp tng cng ti hp thu nc. C ch
ca ADH l thng qua AMP vng hot ho enzym hyaluronidase trong phn ng thu phn acid
hyaluronic m rng l mng trong qu trnh vn chuyn nc. Nh c ch ti hp thu nc
nn nc tiu qua ng ln xa v ng gp c c c li.
- Ti hp thu Na
+
.
Na
+
c ti hp thu mng nh theo c ch khuch tn c cht mang v theo c ch vn
chuyn tch cc mng bn v mng y. S ti hp thu Na
+
theo c ch vn chuyn tch cc l
nh tc dng ca aldosteron. Aldosteron l hormon ca tuyn v thng thn (lp cu sn
xut) c tc dng l tc ng ln t bo ng ln xa lm tng cng ti hp thu Na
+
. C ch
tc dng ca aldosteron l ln s tng hp protein ca t bo ng ln thng qua hot ho h
gen. Protein va c tng hp l protein ti v protein enzym tham gia vo vn chuyn tch
cc Na
+
.
- Ti hp thu HCO
3
-
.
S ti hp thu HCO
3
-
theo c ch vn chuyn th ng v tch cc nh ng ln gn. Song
y s vn chuyn ny c mi quan h cht ch vi s i thi ion H
+
.
3. QU TRNH BI TIT TCH CC.
Khi so snh hm lng cc cht c trong dch siu lc v trong nc tiu chnh thc chng ta
nhn thy c rt nhiu cht c mt trong nc tiu chnh thc nhng li khng c trong dch
siu lc.
Mt s cht c nng rt thp trong dch siu lc, nhng trong nc tiu chnh thc li c
hm lng rt cao. iu ny ch c th gii thch l ng thn, trong qu trnh to thnh nc
tiu, vn chuyn mt s cht t mu vo lng ng thn, hoc t bo ng thn sn xut mt
s cht chuyn vo nc tiu thi ra ngoi. Chc nng bi tit tch cc c thc hin
ch yu ng ln xa v c mt phn ng ln gn.
3.1. S bi tit H
+
.
Qu trnh bi tit H
+
l mt qu trnh c lin quan ti nng CO
2
mu. CO
2
khuch tn qua
mng t bo ng ln, trong t bo c phn ng CO
2
+ H
2
O H
2
CO
3
H
+
+ HCO
3
-
. H
+
c
vn chuyn qua mng t bo vo lng ng ln. Ion H
+
c bi tit, ng thi Na
+
c ti
hp thu. H
+
trong ng ln s c kt hp vi ion phosphat, vi NH
3
, vi cc gc acid hu c
yu hoc vi cc gc khc thi ra ngoi. H
+
cn kt hp vi HCO
3
-
to ra H
2
CO
3
CO
2
+
H
2
O. CO
2
li vn chuyn vo trong t bo to ra HCO
3
-
hp thu vo mu.
3.2. S tng hp v bi tit NH
3
.
Trong t bo ng ln c qu trnh kh amin ca glutamin (chim ti 60%) to ra NH
3
. NH
3

d dng khuch tn qua mng t bo vo lng ng ln. y NH
3
c kt hp vi H
+
to
thnh NH
4
+
thi ra ngoi.
3.3. S bi tit K
+
.
Ion K
+
b ti hp thu hon ton ng ln gn. N c bi tit ra ng ln xa theo c ch
vn chuyn tch cc nh tc dng ca aldosteron. Aldosteron c tc dng ng thi ti hp thu
Na
+
v o thi K
+
.
3.4. S bi tit cc cht khc.
T bo ng ln xa cn bi tit phenol, acid hippuric, P.A.H, creatinin, cc acid mnh, cc sn
phm ca thuc a t ngoi vo, cc cht c l khc do qu trnh chuyn ho to ra hoc
xm nhp t bn ngoi bng nhiu ng khc nhau.
Ba qu trnh siu lc, ti hp thu v bi tit tch cc nhm mc ch to ra nc tiu. Nhng s
lng v cht lng nc tiu nh th no li l hu qu ca qu trnh iu ho cn bng ni
mi ca thn.


29. SINH L THN

Trong c th thng xuyn c nhng cht cn c o thi ra ngoi. y l nhng cht c
sinh ra do qu trnh chuyn ho, nhng sn phm do s phn hu t bo v m gi ci, cc
cht c l bng nhiu ng khc nhau xm nhp vo c th.
Nhng cht trn nu khng thi ra ngoi s lm mt tnh hng nh ca ni mi. V vy chng
c mu vn chuyn ti c quan bi tit. Phi o thi kh carbonic, mt phn nc. B my
tiu ho o thi cc cht cn b ca thc n, nc, cc mui v c, cc cht c, l theo phn.
H thng da o thi nc, mui v c theo m hi. Thn o thi cc sn phm chuyn ho
protid nh ur, acid uric, creatinin v cc cht c cha nit khc, cc sn phm chuyn ho
khng hon ton ca glucid, lipid nh acid lactic, cc th cetonic cc mui v c, cc cht in
gii, cc cht c, l do c th to ra trong qu trnh chuyn ho, trong qu trnh kh c hoc
a t ngoi vo bng cc ng khc nhau v cui cng l nc. Nh vy, thn l mt c
quan quan trng nht ca h bi tit. Mt chc nng thn con ngi khng th tn ti c.
Trong mt ngy m thn thi ra ngoi:
Nc: 1,2-1,5lt.
Cl
-
: 6-10g.
Na
+
5-6g.
K
+
2-3g.
Ca
++
, Mg
++
0,1-0,2g.
Sulfat: 3-15g.
phosphat: 1-5g.
NH
3
0,6-0,8g.
ur 20-30g.
Creatinin 1-1,5g.
acid uric 0,1-2g.
GII PHU V M HC THN
Hai thn nm hai bn ct sng, ngoi phc mc, h tht lng. Nu b dc thn t pha ngoi
v nhn vo mt ct thy thn c chia lm hai vng r rt: vng v (mu ) v vng tu
(mu trng). Vng v cn c chia thnh hai vng nh hn l vng v ngoi v vng v
trong (cn gi l vng cn tu). Vng tu cng c chia thnh hai vng nh hn l vng tu
ngoi (cn gi l vng cn v) v vng tu trong. S phn chia ny c lin quan ti chc nng c
bn ca nephron: nephron ngoi v nephron trong (cn gi l nephron cn tu).
T chc thn gm cc n v thn (ng sinh niu), cc ng gp v ng ni, b my cn tiu cu,
cc mch mu, thn kinh thc vt cng cc t chc lin kt.
1. N V THN.
n v thn (cn gi l nephron) l n v cu trc - chc nng thn. Mi thn c khong hn
mt triu n v thn. Mt n v thn c hai phn: tiu cu thn v tiu qun
Tiu cu thn (tiu th Malpighi) l mt th hnh cu ng knh 200mm, gm bao Bowman v
cun mch. Bao Bowman l mt ci bc c hai lp, m ly cun mch. Gia hai lp l khoang
Bowman, trong khoang cha dch siu lc (nc tiu u). Khoang Bowman thng trc tip vi
ng ln gn. Ming bao rt hp l ni i vo v i ra ca ng mch. ng mch n (nhnh
ca ng mch thng) sau khi vo bao Bowman n chia ra khong 50 mao mch chy song song
v c nhng ch thng sang nhau, to nn mt mng li mao ng mch(cun mch) nm
gn
trong bao Bowman. Sau cc mao ng mch tp trung li thnh ng mch i ra khi tiu
cu. Thng thng ng mch i nh hn ng mch n.
Tiu qun (c ngi cn gi l ng thn) c ba phn khc nhau: ng ln gn, quai Henle v
ng ln xa. ng ln gn c ng i rt quanh co, un khc. Thnh ng l mt lp t bo
biu m hnh lp phng. Mt t do ca t bo c nhiu lng xp theo hnh bn chi. Trong t
bo c nhiu ty lp th. ng ln gn c ng knh 50 mm, di 15 mm. Tip theo ng ln
gn l quai Henle. Quai Henle hnh ch U, nm su trong vng tu. Nhnh xung mng v nh
hn nhnh ln. Thnh quai Henle l mt lp t bo biu m dt. ng ln xa l on cui ca
nephron. ng i cng un ln quanh tiu cu thn. C mt phn st vo ng mch n,
ng mch i v tiu cu to nn b my cn tiu cu. Thnh ng ln xa l mt lp t bo
biu m hnh lp phng, mt t do ca t bo khng c lng.
Chiu di mt nephron l 35-50mm. Nu cng chiu di ca ton b nephron hai thn, c th
ln ti 70-100 Km, cn din tch mt trong ca chng l 5-8m
2
.
Trong qu trnh to thnh nc tiu, ng gp (tip theo ng ln xa) cng l thnh phn kh
quan trng, v n c chc nng tng cng ti hp thu nc. Do ng gp cng c xp vo
thnh phn ca ng sinh niu.
V mt chc nng ngi ta chia nephron ra lm hai loi: nephron v v nephron tu (nephron
cn tu). Nephron v chim 70% c tiu cu nm vng v ngoi, quai Henle nm vng tu
ngoi. Cc nephron ny thin v chc nng bi tit. Nephron tu chim 30% c tiu cu nm
vng v trong v quai Henle rt di nm su trong vng tu trong. Cc nephron ny thin v
chc nng ti hp thu. Bnh thng ch cn 25% s nephron hot ng m bo cho chc
nng ca c th. Tuz tng iu kin c th m ta thy cc nephron v hay nephron tu hot
ng mnh hn 2. B MY CN TIU CU.
B my (hay phc b) cn tiu cu gm phn ng ln xa tip gip vi ng mch n v ng
mch i ca tiu cu v mt phn ca tiu cu. Cu trc c bit ny ch yu cc nephron v
gm cc t bo sau y.
- T bo macula densa.
y l cc t bo ca ng ln xa, st vo ng mch n v i. Cc t bo ny hp v cao
hn cc t bo khc. Nhn t bo st v mt t do. Mt t do ca t bo c nhiu lng. B my
Golgi v cc bo quan rt pht trin trong t bo ny. T bo Macula densa va l cc t bo
nhn cm va l cc t bo ch tit, sn xut ra cc cht vo mu ng mch n, ng
mch i v nc tiu.
- T bo cn tiu cu (t bo ht).
T bo cn tiu cu nm xung quanh ng mch (c bit nhiu xung quanh ng mch n).
Cc t bo cn tiu cu tip xc trc tip vi cc t bo ni m ca ng mch vo tiu cu
thn. T bo cn tiu cu kh a dng, nguyn sinh cht c nhiu si fibril. c bit trong t
bo c rt nhiu ht (nn cn gi l t bo ht). Trong ht c renin khng hot ng.
- T bo lacis.
Cc t bo ny nm ri rc phn gia cc t bo ng mch n, ng mch i ca tiu cu,
gia cc t bo ng ln xa v tiu cu. Cc t bo ny c tnh thc bo (hnh 8.3).
3. H MCH MU.
Sau khi ra khi tiu cu thn, ng mch i chia thnh h mao mch th hai chi phi ton b
tiu qun. Cc mao mch ny sau khi chuyn t ng mch sang tnh mch, tp trung v cc
tnh mch ln ri vo tnh mch thn. Mng mao mch quanh tiu qun c p lc mu thp
(18-13-10mm Hg), to iu kin thun li cho hp thu ng thn. Ring cc nephron tu cn c
h mch thng, h mch ny chy song song vi quai Henle, ng vai tr quan trng trong chc
nng ti hp thu ca cc nephron tu.
Do chc nng ca cc nephron khc nhau nn s cung cp mu cho tng vng thn cng khc
nhau. 80-90% mu l cung cp cho vng v, 10-15% cho vng tu ngoi, ch c 3-5% cho vng
tu trong. iu ny chng t cc nephron v c nhu cu oxy ln hn rt nhiu so vi cc
nephron tu. Cc t bo nephron v khng c kh nng thoi bin ym kh nh cc t bo
nephron tu v vy, khi lu lng tun hon qua thn gim th vng v d b ri lon chc nng
hn vng tu.
4. H THN KINH.
H thn kinh thc vt (c bit l h giao cm) c cc tn cng chi phi ti h mch mu thn.
V vy h thn kinh giao cm c kh nng iu ho c lu lng tun hon qua thn.

30. IU HA CHC NNG THN

Chc nng thn c iu ho bng c ch phn x thn kinh v thn kinh th dch.
1. CC PHN X THN KINH-TH DCH.
1.1. Phn x t th th thm thu.
Th th thm thu l cc t bo thn kinh v cc tn cng thn kinh nhn cm c hiu s bin
i ca p sut thm thu dch ngoi bo. Nh vy cc th th thm thu ny nm hai ni:
ngoi vi v trung ng. ngoi vi, chng c b tr khp trong m lin kt, thnh mch (c
bit ca cc m gan, lch, tu, phi, c tim...), t th th ny xung ng hng tm i theo
ng cm gic ti vng di i. trung ng (vng di i), vng gn nhn trn th v
nhn cnh tht, l mt cu trc thn kinh m cc t bo c c tnh th th thm thu. Nhng
th th ny b kch thch khi p lc thm thu tng v b c ch khi p lc thm thu gim (ch
yu l s thay i nng Na
+
dch ngoi bo).
Khi th th thm thu b kch thch (c ngoi vi v trung ng), xung ng hng phn s kch
thch nhn trn th v nhn cnh tht lm gii phng ADH (vasopresin), kch thch thuz sau
tuyn yn tng cng bi tit ADH. ADH vo mu s lm tng ti hp thu nc ng ln xa v
ng gp. ng thi cc xung ng hng phn t th th thm thu (ngoi vi v trung ng)
n cc trung khu dinh dng thuc h Limbic v vng di i cho cm gic kht nc. Khi
ung nc c hp thu t rut vo mu. Nh nhng c ch trn m nc c gi li trong
c th v lm gim p lc thm thu.
Trong trng hp p lc thm thu gim, cc th th thm thu khng hng phn, ADH t c
sn xut v bi tit, ung t nc, nc trong c th b thi ra ngoi theo ng niu lm cho
p lc thm thu tng ln
1.2. Phn x t th th th tch.
Th th th tch c phn b m lin kt thnh mch phi, thn, xoang ng mch cnh,
c bit l thnh tm nh tri. Cc th th ny rt nhy cm vi s thay i th tch dch ngoi
bo v khi lng mu lu hnh.
Khi th tch dch ngoi bo gim, khi lng mu lu hnh gim, s kch thch ny gy hng
phn cc th th th tch. Xung ng hng tm truyn v vng di i lm bi tit hormon
gii phng CRH vng di i (nhn trn th). CRH kch thch tuyn yn gii phng ACTH c tc
dng lm tng tng hp v bi tit aldosteron tuyn v thng thn. Nh aldosteron m Na
+

c tng cng ti hp thu ng ln xa v ng gp. ng thi khi Na
+
mu tng ln lm
tng bi tit ADH. Nc c gi li nh Na
+
v do tng hp thu t rut v thn. Th tch mu
c khi phc
S tng hp v bi tit aldosteron cn do c ch renin-angiotensin-aldosteron (vng R.A.A). Khi
khi lng mu lu hnh gim (lu lng tun hon qua thn gim), c ch tit renin c
pht ng v aldosteron s lm tng ti hp thu Na
+
, gi nc lm tng khi lng mu lu
hnh (nh nu mc 3: thn iu ho huyt p)
Ngoi ra aldosteron cn c bi tit khi nng K
+
mu tng. Trng hp ny hay gp l do
thiu oxy t bo lm cho knh vn chyn Na
+
, K
+
b ri lon dn n K
+
t ni bo vo mu. Do
aldosteron tng nn Na
+
c ti hp thu lm tng th tch dch ngoi bo. C ch ny thng
gp trong suy tim.
S iu ho th tch dch ngoi bo v p lc thm thu dch ngoi bo cn c m bo nh
cc c ch siu lc ca thn. Nu lu lng tun hon qua thn tng th p lc lc tng v mc
lc tiu cu tng lm tng lng nc tiu, v ngc li lu lng tun hon gim th s gim
lng nc tiu.
Trong c th ton vn hai loi phn x t th th thm thu v th tch thng l chi phi ln
nhau v lin quan ch yu ti hai thnh phn rt c bn ca dch ngoi bo l nng Na
+
v
hm lng nc. iu ho cn bng nc c lin quan cht ch ti iu ho cn bng Na
+
v
ngc li.
1.3. Cc phn x thn kinh.
H thn kinh trung ng c nh hng r rt ti s iu ho chc nng thn.
- Nu kch thch vo mt s vng ca v no, ta c th lm tng hay lm gim s lng nc
tiu.
- Ngi ta thnh lp c phn x c iu kin gim s lng nc tiu do au. Nhng tc
nhn kch thch c iu kin, m kch thch gy au, i km theo sau chng, gy nn gim bi
tit nc tiu. Phn x ny l c s tham gia ca h thn kinh trung ng.
- H thn kinh thc vt (c bit l h giao cm) c vai tr rt quan trng trong s iu ho
mc lc cu thn. H thn kinh thc vt c th iu ho lm tng hay gim lu lng tun
hon qua thn. Lu lng tun hon quan thn thay i th s thay i mc lc cu thn v lm
thay i lng nc tiu.
Cc phn x thn kinh trn y, ch yu nhm iu ho dng mu thn. Khi dng mu thn
c iu ho th s iu ho c mc lc cu thn.
Nh c ch phn x thn kinh v thn kinh th dch, thn trc tip tham gia iu ho cc
chc phn c th, lm cho c th thch nghi c vi mi bin i ca mi trng, gi vng
cn bng ni mi.

31. MT S NGHIM PHP THM D CHC NNG
THN

1. PHNG PHP THANH THI
T phng php thanh thi creatinin ca Rehberg (1926), hoc phng php thanh thi ur
ca Moler Mehntosh v Van Slyke (1928), ngy nay ngi ta tm c nhiu cht th thch
hp cho vic thm d tng phn chc nng thn: inulin, creatinin, ur, P.A.H, Cr 51, E.D.T.A ...
Nm 1928, Van Slyke nhn thy trong mt iu kin nht nh (s bi niu>2ml/min), lng
mt cht c bi tit trong nc tiu (U.V) t l thun vi nng cht c trong mu (P),
hay:

Trong :
U: (mg%) cht c trong nc tiu
V: (ml/min) lng nc tiu/min
U.V: (mg/min) lng cht c o thi/min
P: (mg%) nng cht c trong mu
C: (ml/min) lng huyt tng c lc sch mt cht/min
Hng s C c Van Slyke gi l thanh thi. thanh thi (clearance) l lng huyt tng
tnh bng ml cha mt cht trong mt n v thi gian b lc sch cht .
Nu nhn hng s C vi nng cht c trong huyt thanh, th bit c lng cht
c o thi ra ngoi trong mt n v thi gian.
Nh vy ch trong mt iu kin c bit, mt cht ch i qua thn mt ln b loi tr hon
ton, th thanh thi mi tng ng c lng huyt tng qua thn. iu ny rt kh xy
ra trong c th. V th, y l mt khi nim tru tng, nhng ta vn c th hiu v ng dng
c.
V d, trong mt pht c mt lng cht c bi tit ra 75ml huyt tng v iu ny ta
cng c th cho: trong mt pht c 1/2 lng cht c bi tit ra 150ml huyt tng.
Nh th, khi nim lc sch c hiu mt cch d dng hn.
Trong nghin cu thm d chc nng thn, ngi ta c gng tm cc cht th c tnh cht:
- B o thi m khng ti hp thu.
- Khng c.
- Khng b cc b phn khc ca c th bi tit v chuyn ha.
- Khng tch lu thn.
Hin nay c hai phng php vn c dng:
- Cc cht c trong c th (ni sinh): ur, glucose, creatinin, acid amin, mt s cht in gii ...
- Cc cht a t ngoi vo (ngoi sinh): inulin, manitol, PAH ...
2. MT S CH S NG DNG
2.1. Ch s nh gi chc nng lc.
nh gi chc nng lc thng qua h s thanh thi ca cht ch lc qua cu thn, m khng b
ti hp thu v bi tit thm ng thn, nh cht inulin.
U.V
----- = C (const )
P
C inulin =120-125ml/min.
2.2. Ch s nh gi chc nng ti hp thu.
Thng nh gi kh nng ti hp thu ca ng thn thng qua h s thanh thi ca cht sau khi
lc qua cu thn, mt phn c ti hp thu tr li, nh ur v so vi C inulin.
C inulin - C ur = V huyt tng cha ur ti hp thu. Thng thng C ur = 75% C inulin.
2.3. Ch s nh gi Chc nng bi tit tch cc.
nh gi chc nng bi tit tch cc thng qua h s thanh thi ca cht sau khi lc, khng b ti
hp thu m cn c bi tit thm ng thn nh PAH, PSP.
C
PAH
= 655ml/min; C
PSP
= 450ml/min.


BI 7. SINH L CC DCH C TH
32. CC DCH CA C TH

1. DCH NI BO V DCH GIAN BO
Mt c th trng thnh, bnh thng c khong 25 lt dch nm trong cc t bo (chim 45%
trng lng c th), gi l dch ni bo, c khong 9 lt dch nm xung quanh cc t bo, thuc
t chc gian bo (chim 15% trng lng c th), gi l dch gian bo. Dch gian bo l mi
trng sng ca t bo nn cn c gi l ngoi mi ca t bo.
Thnh phn cc cht ca dch ni bo v gian bo l:
Cc cht v ch s

Dch ni bo

Dch gian bo

Na
+
10 mEq/l 142 mEq/l
K
+
140 mEq/l 4 mEq/l
Ca
++
0,0001 mEq/l 2,4 mEq/l
Mg
++
58 mEq/l 1,2 mEq/l
Cl
-
4 mEq/l 103 mEq/l
HCO3
-
10 mEq/l 28 mEq/l
PO4
3-
75 mEq/l 4 mEq/l
SO4
2-
2 mEq/l 1 mEq/l
Glucose 0-20 mg/dl 90 mg/dl
Acid amin 200 mg/dl 30 mg/dl
Lipid (Cholesterol ,
Phospholipid , triglycerid)
2-95 g/dl 0,5 g/dl
pO2 20 mmHg 35mmHg
pCO2 50mmHg 46mmHg
Protein 16g/dl 2g/dl
pH 7,0 7,4
Dch gian bo cha kh y thnh phn cc cht dinh dng nui t bo. Dch ni bo
duy tr hot ng sng, pht trin v thc hin cc chc nng ca t bo. Nhn chung c nhiu
cht c thnh phn tng t nhau gia dch ni bo v dch gian bo. Song cng c mt s cht
khc nhau c bn v hm lng gia dch ni bo v dch gian bo. V d nh dch ni bo cha
mt lng protein, K
+
, Mg
+
, phosphat, sulphat ln hn nhiu so vi dch gian bo. C s khc
nhau v hm lng cc cht gia hai bn mng t bo (trong v ngoi mng t bo) l do c s
vn chuyn (th ng v ch ng, c bit l ch ng) cc cht qua mng. Dch gian bo cn
cha cc cht sau chuyn ho do t bo o thi, ri t dch gian bo, cc cht ny vo mu v
c chuyn ti cc c quan o thi ra ngoi. R rng l dch gian bo lm nhim v trung
gian v cng quan trng gia dch ni bo v huyt tng.
1.1. S trao i nc gia huyt tng v dch gian bo.
S trao i nc v cc cht ho tan trong nc gia huyt tng v gian bo ph thuc vo:
p lc keo v p lc thu tnh gia hai khu vc ny. Thnh mao mch l mt mng bn thm
ngn cch huyt tng v gian bo
- Ti mao ng mch:
p lc mu mao mch( p lc thu tnh) : 30 mmg Hg
p lc keo ca huyt tng : 28 mmg Hg
p lc thu tnh dch gian bo :-3 mmg Hg
p lc keo ca dch gian bo : 8 mmg Hg
p lc lc l : ( 30-28 ) +( 3+ 8 ) = 13 mmg Hg
-Ti gia mao ng mch v mao tnh mch:
p lc thu tnh mu mao mch : 17 mmg Hg
p lc keo ca huyt tng : 28 mmg Hg
p lc thu tnh dch gian bo : -3 mmg Hg
p lc keo ca dch gian bo : 8 mmg Hg
p lc lc l : (17 - 28 ) + ( 3 = 8 ) = 0 mmg Hg
- Ti mao tnh mch:
p lc thu tnh mu mao mch : 10mmg Hg
p lc keo ca huyt tng : 28mmg Hg
p lc thu tnh dch gian bo : -3 mmg Hg
p lc keo ca dch gian bo : 8 mmg Hg
p lc lc l : (10 - 28 ) + ( 3 + 8 ) = -7 mmg Hg
trong nc b lc sang dch gian bo vi 1 lc l 13 Qua y ta nhn thy rng ti mao ng
mch: nc v cc cht ho tan mmHg, ti vng gia mao mch gn nh khng c hin tng
lc, cn ti mao tnh mch: nc v cc cht ho tan trong nc b ti hp thu tr li mu vi
mt lc lc l - 7mmHg. p lc ti hp thu nh hn nhiu so vi p lc lc nhng vn c kh
nng a 9/10 lng dch b lc ra tr li mch v s lng mao tnh mch bao gi cng nhiu
hn v c tnh thm cao hn mao ng mch. 1/10 lng dch cn li s i theo mao mch
bch huyt.
1.2. Compliance dch gian bo.
T chc dch gian bo c hai thnh phn c bn: dch gian bo v mng li acid hyaluronic.
nh gi chc nng dch gian bo, ngi ta a ra khi nim Compliance dch gian bo.
Compliance dch gian bo l t s gia s bin thin th tch dch gian bo( D
V
) v s bin thin
p sut dch gian bo(D
P
) :
Compliance dch gian bo = D
V
dch gian bo/D
P
dch gian bo
Bnh thng nu s bin thin D
P
l 1 mmHg th s bin thin D
V
l 300 ml. Dch gian bo c p
sut -7mmHg khi V dch gian bo tng, p dch gian bo cng tng. Nhng nu V dch gian bo
tng di 30% th p dch gian bo tng khng ng k nn Compliance vn tng cao. Khi V dch
gian bo tng trn 30% th p dch gian bo tng ln mt cch t ngt lm cho Compliance dch
gian bo gim. S tng t ngt p dch gian bo ng vai tr quan trng l ngn cn nc t
huyt tng khng trn vo dch gian bo (chng ph n).
Mng li acid hyaluronic khong gian bo cng vi cc cht khc to nn hn hp gel (gel
gian bo). Gel gian bo c kh nng hp thu nc v trng ln to ra p sut trng (Welling
pressure). P lc trng ( hay p lc gel gian bo ) bng +7mmHg. Nh vy p lc gel gian bo
i lp vi p sut dch gian bo. p sut dch gian bo lun lun lm cho khong gian bo xp
li, cn p lc gel gian bo li lm cho khong gian bo gin ra. Th tch gel gian bo tng ln l
do hydrat ho, lm cho p lc gel gian bo gim. Khi th tch gel gian bo tng n 30% th p
lc gel gian bo bng 0. p sut gel gian bo ng vai tr chng li dch t do (chng ph n).
Compliance dch gian bo l mt ci van iu chnh s trao i dch th gia mu v m. Nu
th tch mu tng th dch c vo khong gian bo, nu th tch mu gim th dch t khong
gian bo vo mu. ng nhin gii hn iu ho ny ch l 30% th tch dch gian bo (khong
2 - 2,5l). Vt qu gii hn ny c th s khng t iu chnh c; hoc l b ph n hoc l b
mt nc.
2. DCH BCH HUYT
2.1. Thnh phn v s lng dch bch huyt.
Dch bch huyt l dch lu thng trong h bch huyt. Dch ny l dch khong gian bo vo h
thng bch huyt. Mt phn ln rt quan trng ca dch bch huyt xut pht t mao bch
mch ca mao trng. T y bch huyt c gom vo cc hch bch huyt, ri vo b
Pecquet, sau theo ng ngc, vo tnh mch di n tri, v tnh mch ch trn, ri
vo tm nh phi.
C khong 2/ 3 tng s dch bch huyt l xut pht t h thng bch mch ca gan v ca
rut. Cn 1/3 tng s dch bch huyt l xut pht t h thng bch huyt khc ca c th. Bn
cht ca dch bch huyt l dch gian bo nn hm lng cc cht c trong dch bch huyt gn
ging dch gian bo. Ring dch bch huyt ca gan hm lng protein rt cao: 6g/dl (gp 3 ln
so vi dch gian bo), dch bch huyt ca rut c hm lng protein 3- 4 g/dl ( gp khong 2
ln so vi dch gian bo).
c bit dch bch huyt ca rut c hm lng lipid rt cao (v 70% lipid sau qu trnh tiu ho
rut c hp thu theo con ng ny), c bit l sau khi n. Lipid trong h bch huyt
dng lipoprotein. Do c s pha trn dch bch huyt ca gan, rut v cc m nn dch bch
huyt trong ng ngc cha lipid khong 2g/dl, protein: 3-5 g/dl. Lympho bo vo mu qua h
bch huyt nn trong dch bch huyt c nhiu t bo lympho. Ngoi ra cng cn c mt s
cht c kch thc ln hoc vi khun sau khi i qua vch gia cc t bo ni mc mao bch
mch, vo c h bch huyt. Nhng phn t ny b gi li hch bch huyt v b ph hu
ti y.
S lng dch bch huyt khng nhiu, i b phn nm trong ng ngc, h thng bch huyt
gan v rut. Trung bnh c khong 120ml dch bch huyt vo trong h thng tun hon trong 1
gi. Dch bch huyt c vai tr b xung mt s thnh phn quan trng cho mu nh protein,
bch cu lympho, lipid v mt lng dch.
2.2. S lu thng ca dich bch huyt (ng lc ca dch bch huyt).
- V mt cu to, cc mao bch huyt c to nn bi t bo ni m mao mch bch huyt.
Lp t bo ny xp ln nhau lin tip to nn cc van nh khin cho dch gian bo v cc thnh
phn dch gian bo ( k c cc thnh phn c kch thc ln khng hp thu c vo h mao
tnh mch) c th qua h thng van ny vo lng mao mch bch huyt. cho mao mch bch
huyt khng b xp li cc t bo ni m mao mch bch huyt c cc dy neo vo cc t bo
m lin kt xung quanh.
- Mao mch bch huyt c tnh thm cao hn mao tnh mch nn nc v cc cht ho tan
trong nc thuc dch k d hp thu vo mao mch bch huyt mc d s chnh lch p lc
gia dch gian bo v dch bch huyt l rt thp.
- Dch bch huyt c hm lng protein cao hn nhiu so vi dch k nn nc t dch k d
vo dch bch huyt do chnh lch p lc keo.
- Cc t bo ni m mao mch bch huyt c cha cc si actomyosin nn chng c th co bp
theo nhp. Cc t bo c trn thnh mch bch huyt co cng to ra ng lc thc y s di
chuyn ca dch bch huyt.
- Khi mch p, khi co c, khi vn ng cc phn khc nhau ca c th, hoc khi c cc vt
p ln cc m t ngoi c th cng lm cho tc dng dich bch huyt tng cng lu thng.
- p lc mu tnh mch di n tri thp hn p lc dch bch huyt trong ng ngc cng lm
cho dng dch bch huyt t ng ngc d vo h tun hon v lm tng lu thng bch huyt,
c bit khi c tng thng kh phi.
3.DCH NO TU
3.1. S to thnh dch no tu.
Dch no tu cha trong cc no tht, cc b cha quanh no, cc khoang di nhn. Cc
khoang c ni thng vi nhau v c p lc dch no tu hng nh. Trong qu trnh pht trin
bo thai, h thn kinh trung ng t mt ng thng b gp khc li mt s ni, trong c
on gp khc gia no tht III v tiu no, gia tiu no v hnh no.
nhng on gp khc ny cc mch mu ca mng nui xon xut li to thnh nhng m
ri mch. Dch th c siu lc v vn chuyn qua m ri mch ny, to thnh dch no tu
vo cc no tht, ri t cc no tht qua cc l Magendie, Luschka, Monro vo khoang
di nhn. Ngoi ra dch no tu cn c sn xut t mng ng ni tu, mng nhn v mt
phn do t bo no bi tit qua cc khoang quanh mch i vo trong no.
Khoang quanh l phn gia mng nui v thnh mch. M no khng c h bch huyt cho nn
cc protein thot ra t mao mch vo dch gian bo theo khoang quanh mch n khoang di
nhn v c ti hp thu vo tnh mch qua cc nhung mao ca mng nhn. Khoang quanh
mch c vai tr nh h bch huyt, v vy c mt s cht t no c th qua khoang quanh mch
i vo mu.
3. 2. Thnh phn dch no tu
Dch no tu l mt dch trong, khng mu , c s lng t 60 - 100 ml, c t trng 1,005, c ch
s khc x l 1,334 - 1,335, pH = 7,3- 7,4, c p lcl 10 - 15 cmH
2
O ( khi nm ), 15 - 20
cmH
2
O (khi ngi).
Thnh phn dch no tu l:
Protein : 15 - 22 mg/dl
Cholesterol : < 1mg/dl
D tr kim : 10 - 27 mEq/dl
Glucose : 50 - 75 mg/dl
Ure : 20 - 50 mg/dl
Acid bo : 43mg/dl
Acid uric ton phn : 14 mg/dl
Phosphat : 9mg/dl
Calci : 5 mg/dl
NaCl : 70mg/dl
Bch cu lympho : 1 -3 BC/1mm
3
So vi huyt tng ngi ta nhn thy nng Na
+
dch no tu tng ng vi huyt tng
trong khi nng Cl
-
cao hn khong 15% v nng K
+
cao hn khong 40%.
3.3. Chc nng ca dch no tu.
T bo no c mu nui trc tip , v vy vai tr trao i cht dinh dng ca h thn kinh
i vi dch no tu l th yu. Dch no tu c chc nng quan trng nht l m cho no
b trong hp s cng. T trng ca no v dch no tu l tng ng nn no nh c tri
ni trong dch no tu. Khi c mt chn thng vo hp s s lm cho ton b no chuyn
ng ng thi, nn trnh c tn thng no.
Bn cnh , dch no tu cn ng vai tr b cha iu ho, thch nghi vi nhng thay i th
tch ca no hoc ca mu tng hoc gim. Vic nghin cu vai tr chc nng cng nh cc
thnh phn v c tnh ca dch no tu c nghi rt ln i vi lm sng. S thay i tnh
cht, thnh phn dch no tu, chc chn c lin quan n bnh l ca no b. Nghin cu v
p lc dch no tu cng cho php chn on, tin lng v iu tr bnh. Bnh thng khi p
lc dch no tu cao hn p lc mu trong xoang tnh mch 1,5mmHg th van s m v dch no
tu vo mu. Cc van ny chnh l cc nhung mao ca mng nhn c chc nng hp thu dch v
hot ng nh mt ci van khng bao gi cho mu ngc tr li dch no tu. Khi u no, chy
mu no vo dch no tu, vim mng no... p lc dch no tu c th tng ln v gy t vong.
3.4. Hng ro mu no
Hng ro mu no thc cht l mt ci chn sinh hc gia mu v dch no tu, gia dch no
tu v m no. C nhng cht d dng i qua, li c nhng cht khng vt qua c hng ro
mu no. iu ny chng t hng ro mu no c tnh thm chn lc rt cao vi mc ch bo
v v dinh dng cho t bo no, t bo quan trng vo bc nht ca con ngi.
Nhn chung, hng ro mu no c tnh thm cao vi nc, CO
2
, O
2
v cc cht ho tan trong
lipid nh ru, cc cht gy m; t c tnh thm i vi cc cht nh Na
+
, Cl
-
, H
+
v hu nh
khng thm i vi protein v cc hp cht h c c phn t lng cao. Cc khng th, cc
thuc khng ho tan trong lipid khng thm c vo dch no tu v nhu m no. V vy c
mt s thuc khng c hiu qu trn no b khi a vo mu nhng li c hiu qu rt cao khi
a vo dch no tu.
Hng ro mu no c hai chc nng chnh: chc nng bo v v chc nng iu ho dinh
dng. Hng ro mu no ngn cn khng cho cc cht c l t mu vo m thn kinh.
nh gi chc nng bo v, ngi ta a ra ch s : h s thm.
H s thm l t s gia nng cht trong m/ nng cht trong mu.
H s thm gia mu v dch no tu l t s gia nng cht trong dch no tu/ nng
cht trong mu ng mch.
H s thm gia dch no tu v m no l t s gia nng cht trong m no/nng cht
trong dch no tu.
Thng thng cc cht i t mu vo dch no tu, t dch no tu vo m no c h s <1. Cn
cc sn phm chuyn ho i t m no vo dch no tu, t dch no tu vo mu th c h s
>1.
Chc nng iu ho dinh dng l duy tr tnh hng nh ca mi trng cho t bo no hot
ng. Chc nng ny biu hin h s phn phi mt cht no .
H s phn phi ca mt cht l t s gia hiu nng cht trong ng mch v tinh mch
/ nng cht trong dch no tu hoc l t s gia hiu nng cht trong ng mch
v tnh mch/ nng cht trong m no.
Cn phi ch rng hai chc nng bo v v dinh dng l c lin quan mt thit vi nhau.
Nh chc nng bo v m m thn kinh khng b cc cht c l xm nhp v qua mi iu
ho c tnh hng nh v mt l ho ca m thn kinh.
4. DCH NHN CU ( THU TINH DCH ).
Dch nhn cu l dch nm trong nhn cu, gi cho nhn cu lun cng ra. Dch nhn cu nm
pha trc, hai bn thu tinh th v nm sau thu tinh th, trc vng mc. Dch nhn cu
lun lun c to ra v cng c ti hp thu. S cn bng qu trnh bi tit v hp thu ca
dch nhn cu c tc dng iu ho th tch v p lc dch nhn cu.
Dch c to ra do u nh ca th mi bi tit, tc 2 - 3ml/min. Dch chy qua ng t n
tin phng, vo gc gia gic mc v mng mt qua mng li i vo knh Schalemn ri vo
tnh mch ngoi nhn cu. Knh Schlemn l mt tnh mnh ni vi tnh mch ln hn, thng
ch cha thu tinh dch (cn gi l thu tinh mch). p lc nhn cu bnh thng khong 12 - 20
mmHg. Trong bnh Glaucoma (thin u thng), p lc nhn cu c th ti 60 - 70 mmHg v
gy m rt nhanh c khi ch vi gi. Dch nhn cu l trong sut. Trong qu trnh sng, do ri
lon chuyn ho nn n c th c, vn c gy ra du hiu om m, rui bay... lm gim
th lc.



33. CC DCH KHC CA C TH



34. THN IU HA CN BNG NI MI

Thn c mt vai tr v cng quan trng l bng chc nng bi tit nc tiu trc tip tham
gia vo iu ho tnh hng nh ni mi.
1. THN IU HO CN BNG ACID - BASE CA MU.
Trong qu trnh sng c th lun to ra cc sn phm lm bin i tnh hng nh ca ni mi.
Trong c cn bng acid-base. Ngi ta nhn thy rng phn ng iu chnh pH mu ca thn
c mun hn nhng li rt c hiu qa. S iu ho c thc hin mt cch hon ho vai
tr ca thn trong s bi tit H
+
, ti hp thu HCO
3
-
, tng hp v bi tit NH
3
.
1.1. Bi tit H
+
Trong iu kin sinh l, thn o thi khi c th phn tha cc acid do chnh c th to ra
trong qu trnh chuyn ho m phi khng th m nhim c.Thng thng nc tiu thi
ra ngoi c phn ng acid, pH ca n bng 4,5 v nng H
+
t do ti 800 ln cao hn huyt
tng. Nng H
+
trong nc tiu vo khong 0,03m Eq/l. Bnh thng hai thn
thi 0,03-0,06 mEq H
+
/24h.
Nh trnh by trn, H
+
c to ra do qu trnh CO
2
+ H
2
O to thnh H
2
CO
3
(c enzym
carboanhydrase xc tc). Sau H
2
CO
3
phn ly thnh H
+
v HCO
3
-
. H
+
c vn chuyn qua
mng t bo, c mt phn nh H
+
khuch tn qua mng t bo vo lng ng ln, c s trao
i vi Na
+
cho Na
+
ti hp thu cng HCO
3
-
vo dch gian bo
S bi tit H
+
c lin quan cht ch vi cc h m ca ng thn: h m phosphat, h m cc
acid hu c yu (creatin, acid citric, acid lactic, cc b oxy acid bo). Trong h m phosphat
l quan trng nht. Vi h m phosphat khi pH mu bng 7,36 trong mu c 80% phosphat
tn ti dng HPO
4
--
v 20% dng HPO
4
-
. Trong nc tiu, khi pH nc tiu =6,8 th nng
cc ion ny ngang nhau, cn khi pH nc tiu=4,5 th trn 99% phosphat tn ti dng H
2
PO
4
-
.
Nh vy trong qu trnh to thnh nc tiu acid xy ra hin tng: HPO
4
--
+ H
+
H
2
PO
4
-

(H
2
PO
4
--
b siu lc cu thn. Mt phn t gam phosphat b o thi s ko theo l 0,8mEq H
+

ra nc tiu (hnh 8.5).
Vi h m cc acid hu c yu th b oxy acid bo l chim u th. Trong mu chng ch yu
tn ti dng anion (A
-
). Trong nc tiu khi pH=4,5 th 80% b oxy acid bo dng t do l
mt phn t trung tnh (AH). Khi o thi 1 phn t gam b oxy acid bo s ko theo 0,45 mEq
H
+
ra nc tiu. Phn ng ny din ra nh sau: A
-
+

H
+
AH (A
-
b siu lc tiu cu).
Nh vy trong qu trnh to thnh acid c s kt hp ca H
+
vi cc h m ca ng thn, hoc
lm gim ho tr ca cc anion, hoc chuyn anion thnh phn t trung tnh. Phn tha cation
tng i b ti hp thu vo mu (thng l Na
+
). S to thnh H
+
trong t bo ng ln lm
xut hin HCO
3
-
v n s hp thu vo mu cng vi Na
+
.
1.2. Ti hp thu HCO
3
-
.
HCO
3
-
l cht kim ch yu ca huyt tng. N cn c ti hp thu khi o thi acid v b o
thi khi pH mu kim. Bnh thng khi pH nc tiu=4,5 th HCO
3
-
c hm lng qu thp (ch
c vt). Trong 24h c khong 400mEq HCO
3
-
b siu lc, m ch c 1-2mEq HCO
3
-
b thi ra ngoi.
Ngha l 99,9% HCO
3
-
c ti hp thu. S ti hp thu HCO
3
-
c lin quan rt cht ch vi
enzym carboanhydrase (carboanhydrase nm pha mng nh t bo ng ln gn). C mt
phn HCO
3
-
c khuch tn vo dch gian bo, cn i b phn HCO
3
-
khng phi c vn
chuyn trc tip qua mng t bo m thng qua s khuch tn d dng ca CO
2
vo t bo ng
ln.
CO
2
l lng ng ln do to ra t H
2
CO
3
(H
2
CO
3
H
2
O + CO
2
) m H
2
CO
3
c to thnh trong
lng ng ln t HCO
3
-
+ H
+
H
2
CO
3
(HCO
3
-
b lc tiu cu). C mt phn CO
2
t dch gian bo
khuch tn vo t bo. trong t bo c qu trnh c bn CO
2
+ H
2
O -> H
2
CO
3
(c enzym
carboanhydrase xc tc). H
2
CO
3
phn ly thnh H
+
v HCO
3
-
. Chnh HCO
3
-
c to ra trong t
bo ng ln mi c hp thu vo dch gian bo ri vo mu (hnh 4). Nu tim vo c th
cc cht c ch enzym carboanhydase (v d nh acetasolamid) th nc tiu c rt nhiu HCO
3
-
. Trong trng hp ny ta li thy HCO
3
-
c ti hp thu cn H
+
li c o thi. Trong iu
kin ngh ngi bnh thng nc tiu gn nh khng c kim HCO
3
-
.
1.3. Tng hp v bi tit NH
3
.
Thn c mt chc nng rt quan trng l to ra NH
3
. Trn c s o thi NH
3
thn mt ln na
li o thi acid. Nng NH
3
mu ng mch thn rt thp, v d l 1 th trong mu tnh mch
nng ca n kh cao, l 2-3 cn c bit nng cht ny trong nc tiu ln n 100 ln
cao hn. Theo cc tc gi NH
3
c to ra t bo ng ln l do qu trnh kh amin rt mnh
ca cc tin cht l: glutamin, alanin, histidin, glycin, leucin, methionin, lysin ... Trong
glutamin l quan trng nht (hnh 8.6). 60% NH
3
c to ra t glutamin. NH
3
sau khi c to
thnh d dng khuch tn qua mng t bo (NH
3
d ho tan trong lipid) vo lng ng ln do
chnh lch phn p. Trong lng ng ln n kt hp ngay vi H
+
to ra NH
4
+
v dng
NH
3

o thi ra theo nc tiu l dng kt hp NH
4
Cl (Cl
-
c phn ly ra t NaCl trong lng
ng ln) y cng l mt c ch na c lin quan ti bi tit H
+
ca thn. Trong 24 gi c
40-60mEq NH
4
+
c o thi ra ngoi theo nc tiu.
Ngi ta phi tha nhn rng mt trong nhng chc nng quan trng nht ca thn l iu
chnh cn bng acid-base ca mu. Nu pH mu tng (nhim kim), thn s gim bi tit H
+
,
gim ti hp thu HCO
3
-
, gim tng hp v bi tit NH
3
; nc tiu kim. Nu pH mu gim
(nhim acid), thn s tng bi tit H
+
, tng ti hp thu HCO
3
-
, tng tng hp v bi tit NH
3
;
nc tiu rt acid. V vy, thn m bo cho pH mu hng nh.
2. THN IU HO CN BNG NC-CC CHT IN GII CA MU.
Thn iu ho cn bng nc-cc cht in gii ca mu, chnh l iu ho cn bng th tch-p
sut thm thu dch ngoi bo. Trong c th, thc cht khng th tch ring r gia cn bng
nc v cn bng cc cht in gii. Hai mi cn bng ny ph thuc v chi phi ln nhau. Nu
thn iu ho c cn bng nc th thn mt phn iu ho cn bng cc cht in gii.
Nu thn iu ho c cn bng cc cht in gii th thn mt phn iu ho cn bng
nc.
Cc qu trnh siu lc, ti hp thu v bi tit tch cc l th hin s iu ho cn bng nc -
cc cht in gii mu cu thn.
2.1. iu ho cn bng cc cht in gii.
- Ion Na
+
.
Na
+
l ion chim u th, n chim gn 90% tng s cc cation dch ngoi bo v quyt nh p
sut thm thu dch ngoi bo. Na
+
c a v c th theo ng n, ung, iu tr. N c
thi ra ngoi theo phn, theo m hi, theo nc tiu, trong quan trng nht l theo nc
tiu.
y l mt s cht c lc v ti hp thu so snh.

Qua bng trn ta thy ch tnh ring Na
+
v Cl
-
vt qu tng s lng tt c cc cht b ti
hp thu cn li. S ti hp thu Na
+
cc ng thn khc nhau l khc nhau. ng ln gn, 60-
80% Na
+
b siu lc c ti hp thu theo c ch khuch tn v vn chuyn tch cc, nhng ch
yu l vn chuyn tch cc. Tc hp thu l 76 x 10
-7
mEq/cm
2
.gy.
S ti hp thu y cn ph thuc vo lu lng cu thn, p lc keo- thm thu, p lc thu
tnh gia lng ng ln - dch gian bo - mu. c bit n ph thuc vo tnh trng h thng
vn chuyn tch cc Na
+
v s hp thu H
2
O cc nephron v hay nephron tu.
Ti quai Henle, Na
+
c ti hp thu theo c ch vn chuyn tch cc phn ln lm cho dch
gian bo u trng gy ra hin tng ti hp thu th ng nc phn xung. Nu tnh v s
lng th s ti hp thu Na
+
v H
2
O phn ng ln xa t hn nhiu so vi ng ln gn 5 - 6
ln. Na
+
gn nh khng ti hp thu th ng y v s cn ca t bo ng ln xa kh cao i
vi s chuyn ng ca Na
+
. Ti y Na
+
c hp thu ngc gradient nng v s iu ho
nng Na
+
mu c quyt nh y ti hp thu Na
+
phn ng ln xa thc s mi mang
{ ngha iu ho v s hp thu Na
+
l theo nhu cu c th. Hn th na ng ln xa l phn
cui ca nephron. Na
+

c khuych tn c cht mang mng nh v vn chuyn tch cc
mng bn v mng y vo dch gian bo nh hormon aldosteron.
Nng Na
+
ni mi quyt nh s iu ho ti hp thu Na
+
ng ln xa theo c ch phn x
thn kinh-th dch. Thc ra khng ch aldosteron c tc dng lm tng ti hp thu Na
+
m cn
c cc hosmon DOC, glucocorticoid cng c tc dng tng ti hp thu Na
+
, nhng km hn
nhiu.
Tc dng tng ti hp thu Na
+
ca aldosteson mnh hn DOC ti 20-25 ln, mnh hn cortisol
ti 40 ln. C tc gi cho rng aldosteson cn tc ng ln c ng ln gn, quai Henle v ng
gp tng ti hp thu Na
+
. C th tc dng ca aldosteron l hot ho h gen tng hp ln
protein vn chuyn Na
+
. C mt s cht khng sinh nh actenomycinD, puromycin c ch tng
hp protein s lm gim tc dng ca aldosteron.
- Ion K
+
.
Mi ngy ngi ta cn 70-100 mEq K
+
trong thc n. Thc t n gn nh b thi ra qua nc
tiu hon ton. C 700-800 mEq K
+
b siu lc tiu cu,v ch c 10% tng s K
+
siu lc l b
thi ra ngoi.Phn K
+
siu lc cu thn, n c ti hp thu gn nh hon ton ng ln
gn. Nu trong khu phn n m thiu K
+
th c th K
+
c ti hp thu ng ln xa v ng
gp. Ti hp thu K
+
ti cc phn ca ng thn l qu trnh vn chuyn tch cc nh cu trc nm
pha mng nh v y ca t bo ng ln gn.
S bi tit tch cc K
+
t bo ng ln xa thc s l mt c ch iu ho v cng quan trng,
n quyt nh nng K
+
dch ngoi bo. Bi tit K
+
ng ln xa l nh vai tr ca aldosteron.
Aldosteron ng thi ti hp thu Na
+
th bi tit K
+
. C ch vn chuyn tch cc ny nh mt
protein vn chuyn c hiu. S iu ho nng K
+
mu l ph thuc vo aldosteron. V vy
cc phn x thn kinh th dch c nh hng ln s bi tit ca aldosteron s nh hng ln
iu ho nng K
+
ma. ng thi ngi ta cng thy khi nng K
+
cao trong mu th
Aldosteron cng c bi tit v K
+
b bi tit ra ng ln xa.
- Ion Ca
++
v Mg
++
.
Bt kz mt thay i no ca nng Ca
++
mu u ko theo nhng thay i tng ng s o
thi n thn. Ngi ta thy lng Ca
++
c hp thu rut tng ng vi lng Ca
++
b
thi ra thn. Tng Ca
++
trong khu phn n th Ca
++
nc tiu tng v ngc li. Trong c ch
iu ho c mi lin quan gia hp thu Ca
++
rut v o thi Ca
++
thn. i vi Mg
++
cng
thy tng t. Ngoi o thi Mg
++
theo nc tiu cn thy o thi Mg
++
theo phn (1%) . Sau
qu trnh siu lc thy c khong 60 - 70% Ca
++
, Mg
++
c ti hp thu cng vi nc ng
ln gn, c khong 10% Ca
++
, Mg
++
c ti hp thu ng ln xa. Cc ion ny cng c th
c ti hp thu c quai Henle khi cn.
Cc t bo ng ln xa cng c kh nng bi tit ion Ca
++
v Mg
++
iu ho nng cc ion
ny trong mu. S ti hp thu, bi tit Ca
++
, Mg
++
ng thn ph thuc vo chnh cc cht ny
trong mu, ph thuc vo cc hormon iu ho nng Ca
++
, phosphat mu:, PTH hormon cn
gip trng lm tng, cn calcitonin hormon gip trng lm gim o thi Ca
++
qua nc tiu.
Ngoi ra s iu ho nng Ca
++
, Mg
++
mu ca thn cn ph thuc vo cn bng acid - base
ca mu, ph thuc vo cc c ch hp thu Ca
++
, Mg
++
rut, c ch to xng v mt s c
ch khc.
Tng nng Ca
++
mu (cp din hay trng din ) u lm ri lon chc nng thn. Khi suy thn
th nng Mg
++
mu thng tng ln. Thiu Mg
++
c th gy tch lu calci trong c th do gim
o thi Ca
++
thn v tng hp thu Ca
++
rut.
-Ion Cl
-
.
Cl
-
chim u th anion dch ngoi bo. Ti hp thu Cl
-
lin quan n ti hp thu Na
+
. Ti hp
thu Cl
-
theo c ch th ng do gradient in tch. C th Cl
-
cn c vn chuyn tch cc
ng ln xa.
- Ion phosphat.
Sau khi b siu lc, ion phosphat c ti hp thu ng ln gn khong 80%. Ti hp thu
phosphat theo c ch vn chuyn tch cc. H thng cht vn chuyn phosphat nm gn mng
nh. Ti ng ln xa ion phosphat li c o thi. S o thi ion phosphat nhiu hay t lin
quan cht ch vi PTH. PTH l hormon tuyn cn gip trng c tc dng lm gim ngng
phosphat ca thn, v th phosphat tng nc tiu v gim trong mu. Phosphat c huy
ng t xng vo mu duy tr nng phosphat mu hng nh. Do phosphat t xng
vo mu nn ko theo Ca
++
tng trong mu v lm tng Ca
++
trong nc tiu. Hin tng trn b
gim i di tc dng ca calcitonin, GH v vitamin D.
-Ion sulphat.
S ti hp thu ion sulfat ng ln gn v ng ln xa theo c ch vn chuyn tch cc.
Thn iu ha nng ion sulfat mu bng c ch ti hp thu ion ny nhiu hay t ng thn
sau khi n lc ra tiu cu thn.
2.2. iu ho cn bng nc.
Bng c ch siu lc v ti hp thu nc, thn iu ho cn bng nc trong c th.
Trong 24h tiu cu thn lc ti 170 - 180l nc, nhng ch c 1,2 - 1,5l nc c thi ra
ngoi. Gn nh ton b nc c ti hp thu. Khong 80% nc c ti hp thu ng
ln gn, 5% nc c ti hp thu quai Henle, 15% nc c ti hp thu ng ln xa v
ng gp. S ti hp thu nc ng ln gn v quai Henle ch yu ph thuc vo ti hp thu
cc cht c lc thm thu cao v d nh Na
+
. S ti hp thu nc ng ln xa v ng gp ph
thuc vo ADH . ADH l mt hormon ca vng di i, c d tr thuz sau tuyn yn. ADH
vo mu theo c ch phn x thn kinh- th dch theo nhu cu ca c th. ADH tc ng ln t
bo ng ln xa v ng gp lm tng cng ti hp thu nc.
C ch tc dng ca ADH l thng qua cht truyn tin th 2 l AMP
v
hot ho enzym
hyaluronidase. y l enzym tham gia vo phn ng thu phn acid hyaluronic trn mng t
bo trong c ch vn chuyn nc. S ti hp thu nc ng ln xa gi mt vai tr rt quan
trng trong s iu ho cn bng nc. Th tch dch ngoi bo c nh hng r rt ln c ch
iu ho cn bng nc ca thn. Nu lng nc trong c th cao th thn s hn ch ti hp
thu nc ng ln xa v nc tiu s nhiu hn bnh thng. Ngc li nu lng nc
trong c th thp th thn s tng cng ti hp thu nc ng ln xa v nc tiu s gim
hn bnh thng. Nu v mt l{ do no m thiu ht ADH th nc khng c ti hp thu
ng ln xa v ng gp nn lng nc tiu nhiu, nc tiu nhc trng khng c ng
(i tho nht). Ngi ta cng gp i tho nht do thiu ht enzym tham gia vo c ch ti
hp thu nc ca ADH, mc d lng ADH vn bnh thng trong c th.
3. THN IU HO HUYT P.
Thn iu ho huyt p thng qua b my cn tiu cu. Khi huyt p gim, khi lu lng tun
hon qua thn gim, t bo ht ca b my cn tiu cu tng tit Renin. Renin c bn cht cu
trc l mt glucoprotein, bn cht chc nng l mt enzym, tc ng ln mt c cht c trong
mu v bch huyt do gan sn xut l angiotensinogen (bn cht l a
2
- globulin, c 14 acid
amin), chuyn angiotensinogen thnh angiotensin I (10 acid amin). Di tc dng ca convertin
enzym (CE), mt enzym ca phi, angitensin I chuyn thnh angiotensin II (8 acid amin).
Angiotensin II l mt cht c hot tnh sinh hc cao, c kh nng gy co mch v kch thch qu
trnh tng tng hp v bi tit aldosteron. Aldosteron lm tng ti hp thu Na
+
ng ln xa
lm tng Na
+
mu v gi nc. Chnh v hai tc dng ny m angiotensin II lm cho huyt p
tng ln
Trong lm sng ta c th gp bnh tng huyt p do vim thn mn tnh, do cht hp ng
mch thn. Da theo c ch tng huyt p do angiotensin, ngi ta s dng cc thuc c
ch enzym chuyn, ngn cn qu trnh to angiotensin II.
4. THN IU HO SINH SN HNG CU.
Thn l mt trong nhng c quan sn xut erythropoietin tham gia vo qu trnh sn sinh
hng cu trong tu xng.
Khi thiu mu, lng oxy mu gim tc ng ln thn (t bo b my cn tiu cu v mt s
t bo khc) lm cho cc t bo ny sn xut ra yu t kch thch to hng cu ca thn
(erythrogenin). ng thi lng oxy mu gim kch thch gan sn xut mt globulin. Globulin
ny di tc ng ca erythrogenin to ra yu t kch thch to hng cu ca huyt tng l
erythropoietin, mt glucoprotein c hot tnh sinh hc cao. Erythropoietin tc ng ln cc
t bo tu xng sinh ra tin nguyn hng cu v tc ng chuyn nhanh hng cu non thnh
hng cu trng thnh vo mu (s 8.8). Trn lm sng ta c th gp thiu mu trn bnh
nhn vim thn mn tnh.
Bn cnh qu trnh sinh sn hng cu, thn cng cn sn xut ra cht c ch s to hng cu
khi mu tha oxy. Nh vy s bo ho oxy mu c vai tr quan trng trong s iu ho sinh sn
hng cu ca thn.
5. THN IU HO QU TRNH CHNG NG MU.
Cc t bo b my cn tiu cu sn xut ra urokinase. Urokinase l mt cht c kh nng hu
fibrin nn kch thch qu trnh tan cc mu ng. V vy n c ng dng trong iu tr, trong
lm sng. Thn cn l c quan d tr heparin nn n c th c ch qu trnh ng mu.




PHN 2. SINH L BNH Y HC

35. I CNG SINH L BNH
NGUYN HU M
Lch s pht trin ca loi ngi l lch s u tranh vi thin nhin, trong c cuc u tranh
vi bnh tt v cht chc. Khoa hc y hc dn dn trng thnh trong cuc u tranh ny.
hn mt th k nay, cng vi s tin b ca khoa hc, y hc pht trin rt mnh, nhng
thng tin v y hc n mc m mi ngi kh c th nm bt ht c, vic chuyn khoa
ho tht s l cn thit, khng th trnh c. Do , xu hng chuyn khoa sm lm
cho hc vin v c ngi thy thuc ngy nay c th lm vo nguy c l bit tht su trong mt
phm vi tht hp. chnh l trnh nguy c ny, ngay t bc u, cn trang b cho ngi thy
thuc tng lai nhng nguyn l chung nht ca bnh l hc, tc l sinh l bnh hc. Sinh l
bnh hc (hay gi tt l sinh l bnh) gii thiu cho h nhng quy lut chung ca hot ng c
th khi b bnh, ca cc qu trnh bnh l{ in hnh, nhng khi nim ln v y hc h t tm
ly hng i ca mnh trong rng rm bnh l{.
I. NH NGHA V NI DUNG
Sinh l bnh l mn hc nghin cu v nhng quy lut hot ng ca c th b bnh trong
nhng trng hp bnh l c th, ri t rt ra nhng quy lut hot ng ca cc qu trnh
bnh l{ in hnh v cui cng tm hiu nhng quy lut hot ng ca bnh ni chung.
C th, sinh l bnh nghin cu :
Nhng nguyn nhn v iu kin gy bnh, c ch pht sinh, pht trin v kt thc ca cc qu
trnh bnh l.
Nhng bin i bnh l v chc nng ca cc h thng, c quan v t chc.
Nu c th bnh thng hot ng theo cc quy lut c tm hiu trong sinh l hc, th trong
iu kin bnh l{ n cng tun theo nhng quy lut nht nh. Nhng hin tng bnh l d
mun hnh mun v song mt s lm vn c th xp vo nhng qu trnh bnh l{ in hnh nh
vim, st, nhim khun, vv ... C nhng quy lut c hiu m s hiu bit v n s gip i su
vo bn cht ca bnh, ngha l hiu bnh l g phng bnh v cha bnh cho ngi.
Sinh l bnh m ni dung ch yu l y hc thc nghim d mi hnh thnh t gia th k 19
nhng n nay tr thnh mt mt khoa hc bao trm ln nhiu mn khc, v nh theo li
C-lt Bec-na (Claude Bernard) th n tr thnh mt khoa hc cao hn, cn thit hn, rng
hn v chung hn.
Ni dung ca mn sinh l bnh gm c 2 phn ln :
sinh l bnh i cng nghin cu v nhng khi nim chung (khi nim v bnh, bnh nguyn
v bnh sinh, vv ...) v nhng qu trnh bnh l{ in hnh (ri lon chuyn ho, vim, st, u
nhim khun vv ...).
sinh l bnh b phn nghin cu quy lut hot ng ca tng c quan, h thng b bnh (mu,
tun hon, h hp vv ...), nghin cu nhng ri lon chc nng trong tng bnh c th.
II. VAI TR CA SINH L BNH TRONG Y HC
Cng nh cc mn y hc c s khc, sinh l bnh c mt a v quan trng trong y hc.
1.Sinh l bnh l c s ca y hc hin i : C-lt Bec-na nh gi y hc thc nghim l
c s ca y hc hin i, m y hc thc nghim li chnh l ni dung ch yu ca sinh l bnh.
Lch s loi ngi tri qua nhiu thi k vn minh c i trong y hc cng c nhng
thnh tu nht nh nh y hc Trung Quc, n , Ai Cp, vv...; nhng nhng nn y hc c i
ny gp b tc , khng pht trin c l v khng c c s vt cht, khng c thc nghim
m li i su vo nhng l lun tru tng , duy tm , thn b. S pht trin ca y hc hin i -
cn gi l Ty y ngy nay c lin tc v mnh m chnh l nh c s thc nghim. Ngay
nh trong tro lu y hc hin i trn th gii, ni no thng tr mt hc thuyt tru tng,
gio iu th nn y hc cng b tr tr. Tri li, nc no m y hc thc nghim pht trin th
nc , y hc t c nhng thnh tu huy hong nht, c nhng cng hin ln nht cho
loi ngi.
Ni mt cch c th hn na, sinh l bnh khng nhng l c s ca y hc hin i m cn c
s trc tip ca lm sng : c th ni, mt phn quan trng ca sinh l bnh l sinh l bnh lm
sng. Ngoi ra, sinh l bnh , nh nu trn, cn lm nhim v tng hp cc thnh tu ca
cc cng trnh, phn tch, tm hiu cc quy lut bnh l trong nhng bnh c th.
2.sinh l bnh l l lun ca y hc. T ch nghin cu quy lut hot ng ca tng bnh c
th, nghin cu quy lut hot ng ca tng h thng, c quan b bnh, ri n quy lut ca
cc qu trnh bnh l{ in hnh, mn sinh l bnh tm cch khi qut ho tm hiu quy lut
ca bnh ni chung, nh quy lut hot ng ca cc yu t gy bnh. n mc cao nht, con
ngi c th i su tm hiu bn cht ca bnh l g v ch c th, con ngi mi khng ch
c bnh tt.
3. Cui cng, sinh l bnh cn soi sng cng tc d phng v iu tr, v y mi l mc ch
chnh, mc ch cui cng ca mn sinh l bnh. Ch c hiu r nguyn nhn v iu kin gy
bnh , c ch pht sinh, pht trin ca bnh th mi lm tt cng tc phng bnh cng nh
cha bnh. Khng nhng cn bit r nguyn nhn v iu kin gy bnh mi phng tt
c bnh m cn cn phi c nhng quan im ng n v mi quan h gia nguyn nhn
v iu kin cng nh gia con ngi vi mi trng (trong c x hi) th cng tc d phng
mi chu o c. Trong cng tc iu tr, nh nhng cng trnh nghin cu sinh l bnh thc
nghim v iu tr thc nghim m rt nhhiu vn c gii quyt : vn bnh sinh ca
bnh i tho ng tu c gii quyt nh th nghim ct tu, t ngi ta iu tr
c kt qu bng insulin. Trong 3 phng php iu tr (bnh nguyn, bnh sinh v triu chng)
th hai phng php trn tt hn c. Bit c nguyn nhn gy bnh m tiu dit ngay t
u, l iu l{ tng, song ng tic l ngy nay cn nhiu bnh vn cha r nguyn nhn.
ngay nh phng php iu tr triu chng, mc d mang nng tnh i ph cng cn phi c
sinh l bnh soi sng ch l cn nm bnh sinh ca triu chng th cho thuc mi khng
sai nguyn tc iu tr. Th d trong st , nu hiu l mt phn ng bo v ca c th th
khng phi bao gi cng dng thuc gim st.
III. V TR CA SINH L BNH TRONG Y HC
Sinh l bnh quan h mt thit vi mt s mn nh sinh l{ hc, sinh ho hc, gii phu bnh
hc, v c bit l y hc lm sng.
Mun hiu c sinh l bnh , phi nm vng sinh l hc, v mi ri lon u xut pht pht
t hot ng bnh thng v ch khi bit r gii hn ca nhng hot ng ny th mi hiu u
l bnh l{. Nhng vic hiu r u l gii hn ca nhng hot ng bnh thng khng phi bao
gi cng d dng v kh nng thch nghi ca c th l rt ln, lai lun lun thay i.
Sinh l bnh lin quan cht ch vi sinh ho hc. Sinh ho hc nghin cu qu trnh chuyn
ho trong c th kho mnh, cn sinh l bnh li i su vo nhng ri lon chuyn ho trong c
th b bnh. Hn th na, sinh ho hc hin i pht hin cc c ch bnh sinh mc
men, phn t.
Sinh l bnh v gii phu bnh lin quan mt thit vi nhau, ti mc Anh, M ngi ta gp
hai mn l mt, di danh t bnh l{ i cng. Hai mn hc dng hai phng php khc
nhau nghin cu cng mt i tng chung : c th b bnh. Chnh nhng thay i v hnh
thi (i th v vi th) lm sng t nhng thay i v chc nng, l c s vt cht trn
c xy dng nhng gi thuyt v cc c ch bnh l.
Nhng mi quan h mt thit nht ca sinh l bnh vn l vi lm sng. trong gio dc y hc,
c th ni sinh l bnh l cu ni gia cc mn y hc c s v y hc lm sng. N tng hp cc
mn y hc c s (sinh l, sinh ho, gii phu bnh, vv ...) chun b cho hc vin vo lm sng
bng cch gii thiu cho h nhng quy lut hot ng ca c th b bnh, nhng phng chm
y hc v y t ng n. Da vo nhng quy lut v phng chm , hc vin c th i vo
rng rm lm sng m khng s lc hng. Nhng chnh lm sng li l ni p dng thc t
nhng iu hc trong sinh l bnh, lm sng cn l ni xy ra bit bao nhiu vn cha
bit cn c gii thch, c nghin cu. Nh vy, lm sng bao gi cng l ngun cung cp
ti liu cho sinh l bnh nghin cu, phn tch, tng hp, vi kt qu nghin cu tr li phc
v cho lm sng, hiu r bnh hn. Nu nh trong qu trnh y hc hin nay, mn sinh l bnh
c ging trc mn bnh l hc l hc vin hiu c nhng quy lut chung trc khi i
vo nhng ci ring, th khi hc mn bnh l hc lm sng li soi sng, cng c nhng khi nim
, quy lut hc trc . l khng k v mt nghin cu, pht trin y hc th lm sng bao
gi cng l hn th vng ca mi gi thuyt c xy dng trong sinh l bnh v bao
gi cng vn l ngun ti tm ti khoa hc. Nh I. Pp-lp ni rt ng : Vn cui
cng ca s tm hiu bnh tt vn thuc v lm sng.
Tm lai, da vo ti liu thc nghim, sinh l bnh xy dng mt c s l lun khoa hc
cho y hc lm sng; ng thi da vo nhng nhu cu thc t, lm sng nu vn cho sinh l
bnh nghin cu v kim tra, nh gi nhng kt qu rt t thc nghim trn ng vt.
IV. PHNG PHP TRONG SINH L[ BNH
Phng php trong sinh l{ bnh ch yu l phng php thc nghim , ngha l xut pht t
nhng quan st khch quan mt hin tng bnh l{, ng trn quan im duy vt m ra gi
thuyt thch hp v cui dng dng thc nghim chng minh xem gi thuyt c ph hp
vi thc t khng. Mun s dng tt phng php thc nghim th cn c mt u c khoa
hc, ngha l tnh c lp trong l lun, khng c thin kin, cn c nghi nh khoa hc song li
tin tng tuyt i vo quyt nh lun khoa hc (tc l s lin quan tuyt i v cn thit gia
cc hin tng).
T trc ti nay, c rt nhiu phng php thc nghim , nhng tuz i tng v mc ch
nghin cu m c th dng phng php ny hay phng php khc.
1. Phng php gii phu - lm sng : theo phng php ny, ngi ta gy ng vt mt
m hnh thc nghim ging nh ngi, ri tng thi gian, hi sinh con vt quan st s tin
trin ca bnh. Phng php ny cho mt hnh nh ng, st thc t, ch khng phi tnh nh
khi m xc ngi bnh. Phng php ny gn y pht trin mnh vi knh hin vi in t v
ho hc t bo.
Mt hn ch ca phng php ny l ch n cho mt hnh nh tng i tnh v ti ch ca
mt hin tng ng, din bin lin tc, d lm cho ngi quan st ch nhiu ti nhng thay
i ti ch m coi nh, thm ch qun mt nhng thay i ca ton thn trong bnh l.
2. Phng php phn tch (cn gi l phng php th nghim cp tnh, phng php c quan
c lp) l phng php nghin cu chc nng ca tng c quan tch ri khi c th v cho thy
nh hng ca nhng kch t nht nh trn c quan (th nghim tim ch c lp, tai th c
lp vv...). Mc d c nhiu cng hin i vi y hc, phng php phn tch c mt s nhc
im : thng gy ra tn thng trn c th, kch thch tng c quan ring bit mt cch nhn
to, tin hnh nghin cu di iu kin gy m, thi gian quan st li ngn vv... nn thng
khng lt t c ht bn cht ca qu trnh bnh l mt cch y v c h thng. Ngoi ra,
phng php phn tch khng tr li c cu hi khi mt c quan thay i hot ng th nh
hng ca n i vi cc c quan khc nh th no. Cui cng, c quan c lp hot ng c
th khc hn khi n trong c th ton vn.
3. trnh nhng bt tin k trn, ngi ta dng phng php tng hp, tn trng s
nguyn vn ca c th con vt th nghim m ch nh gi mt chc nng, qua nhng cht
c a vo hoc thi ra. Th d nh gi chc nng ca thn bng cch phn tch nc tiu
v mu. Phng php ny tn trng c th nh mt khi ton vn, song khng gii quyt c
vn l phn no ca c th quyt nh nhng thay i m ngi ta thy. N ch cho
nhng ch s chung chung. Tuy nhin vi nhng tin b mi ca khoa hc nh s dng ng v
phng x, phng php ny c th cho nhng kt qu chnh xc hn, c hiu hn, th d s
dng it 131I thm d chc nng tuyn gip.
4. Hin nay, ngi ta dng phi hp c hai phng php phn tch v tng hp. Th d, trong
chuyn ho, nu phng php tng hp cho bit kt qu chung v chuyn ho ton c th, th
phng php phn tch s cho bit chi tit qu trnh trong tng c quan mt bng cch
phn tch mu vo v mu ra c quan , v su hn na l trong cc t bo nh th no.
Phng php th nghm trng din ca Pap-lp cng c coi nh mt phng php phi
hp : c quan cn c nghin cu c t vo mt v tr d quan st bng phu thut, ch
trnh ct dy thn kinh
n c quan , ch cho con vt hon ton hi phc ri mi tin hnh th nghim. Phng
php th nghim trng din cho php quan st c nh hng ca nhng c quan khc ln c
quan . Trong d dy nh ca Pp-lp, ngi ta c th theo di nh hng ca thn kinh, ca
tnh trng chung ton c th nh st, nhim khun i vi hot ng ca d dy. Ngy nay, vi
vic x dng rng ri ng v phng x, phng php phi hp pht trin mnh m.
5. Ngoi ra, tm hiu qu trnh bnh l{, ngi ta cn dng phng php bnh l hc so
snh : so snh qu trnh bnh l loi ng vt khc nhau tm ra nhng im ging v khc
nhau. Nghin cu phn ng vim nhng loi ng vt trn bc thang tin ho, Mt-nhi-cp
i ti kt lun :hin tng thc bo l hin tng ph bin nht, chung nht cc loi ng
vt c trnh pht trin khc nhau.
Ni tm li, vi phng php khoa hc, vi k thut chnh xc v vn dng rng ri khoa hc
c bn (ton, l, ho), mn sinh l bnh gp phn lm cho y hc t mt ngh thut (v khng
c quy lut nht nh) tr thnh mt khoa hc chnh xc (c quy lut r rng), t nhng hiu
bit c tnh cht kinh nghim thnh mt l lun chnh xc.

36. KHI NIM V BNH

( NGUYN HU M )
Mun tin hnh tt cng tc phng v cha bnh, ngi thy thuc cn c mt khi nim
ng v bnh.
Vy bnh l g ? Cu hi ny c t ra k t khi loi ngi c mt trn tri t ny. Khi
nim v bnh c xy dng dn trong qu trnh pht trin ca nn y hc v l kt qu ca
cuc u tranh lin tc, quyt lit gia ch ngha duy tm v ch ngha duy vt trong bnh l
hc. Quan nim v bn cht ca bnh lun lun thay i, tuz theo pht trin ca khoa hc
ni chung v nn y hc ni ring trong tng thi k. Rt nhiu nh ngha v bnh c a
ra, di y ch nu mt s nh ngha tng i chnh xc v khoa hc, nn c vn dng
mt cch rng ri, c bit l nhng khi nim v bnh cuat th k XIX v XX.
I. BNH L HC T BO
Th k XIX, trn c s pht hin t bo, Vic-sp (Virchov) ra hc thuyt bnh l t bo :
theo Vic-sp, bnh l mt qu trnh ti ch, do tc dng trc tip ca nguyn nhn gy bnh
i vi t bo, t chc. Chnh tn thng t bo gy ra bnh. Theo tc gi, bnh s xut hin
khi no v ch no c tc dng ca nhn t gy tn thng. V cng theo tc gi th khng
phi ton b c th phn ng i vi nhn t gy bnh, m ch l nhng t bo , nhng c
quan ring bit tham gia vo qu trnh bnh l.
Vi quan im trn, Vic-sp v trng phi ca ng m t t m nhng bin i v hnh
thi trong mt s qu trnh bnh l{ c bn (vim, u, teo, ph i, vv... ).
Bnh l hc t bo l hc thuyt khoa hc u tin nhm gii thch bn cht ca bnh : hc
thuyt ny p tan quan im thn b v tru tng v ngun gc ca bnh. Ngoi ra, v bnh
hnh thi hc, hc thuyt ny cng lm phong ph thm ni dung bnh l hc.
Song sau ny, hc thuyt bnh l hc t bo tr ngi nhiu cho s pht trin ca bnh l
hc. Theo Vic-sp, ch cn i su nghin cu nhng s thay i v hnh thi ca t bo l c
th nhn thc c bn cht ca bnh. Song trong thc t lm sng, c nhiu bnh, c bit l
trong thi k u thng khng thy tn thng t chc t bo r rt km theo, ch yu li l
ri lon chc nng. ngoi ra c nhiu trng hp nhng s thay i v hnh thi li khng phi
l nguyn nhn gy bnh , tri li ch l hu qu ca mt bnh pht sinh v ang pht trin.
Ngoi ra quan nim bnh nh mt qu trnh ti ch, Vic-sp ph nh tnh thng nht ca
c th, coi nh vai tr ca h thn kinh trong bnh l hc.
Tm li, hc thuyt bnh l hc t bo duy vt ch xut pht t thc t khch quan, song
khng bin chng, ch l duy vt my mc, siu hnh v khi xem xt tch ri s vt, c lp cc
hin tng.
Hin nay, mt s thy thuc cn chu nh hng ca Vic-sp , c th l au u cha y,
nng v iu tr ti ch, nh v iu tr ton thn, nng v thuc men k thut, nh v iu tr
ton din, cha ch { y ti yu t tinh thn, ti sinh hot ca bnh nhn. H cha bnh
ch khng phi cha ngi bnh.
II. HC THUYT STRESS
Theo Xilai (Selye), bt c mt kch thch mnh no ca ngoi mi tc ng trn c th u c
th gy ra mt trng thi cng thng (Stress), mt chui phn ng khng c hiu kt hp vi
nhau thnh hi chng thch ng chung. Hi chng ny bao gm 3 thi kz : sau phn ng bo
ng l th kz khng, k n l thi kz kit qu.
Phn ng bo ng bao gm 2 giai on k tip nhau : giai on sc v giai on chng sc.
Trong thi kz khng, kch thch vn tip tc, nhng hin tng tn cng v phng ng vn
xen ln nhau, c th ng vin c mt h thng phng ng trong ch yu l tin yn v v
thng thn. C th s hi phc nu h thng phng ng vng chc ; Tri li n kh nng
phng ng yu t v kch thch bnh l tip tc pht huy tc dng, bnh s pht sinh.
Trong thi kz kit qu (suy sp) kh nng thch ng gim dn ri mt v c th s cht. Trong
thi kz ny, nhng ri lon chc nng v chuyn ho cn bn nh trong giai on sc, song
nghim trng hn.
Bnh sinh hc ca hi chng thch ng chung c gii thch nh sau :
Kch thch t ngoi mi tc dng ln c th.
Vng di th b kch thch.
xung ng c dn ti tin yn c tc dng gii phng ACTH.
ACTH lm gii phng mt lng ln cocticoit ng.
cocticoit ng tng thoi bin protein, ng thi gim tng hp protein t chc ton c
th, song ni kch thch tc ng (th d vt thng) li thy tng tng hp protein, tn dng
nhng sn phm thoi bin k trn tng cng sc khng ti ch (th d hn gn vt
thng). ngoi ra cc cocticoit ng cn hu hoi t chc bch huyt v gii phng vo mu
ngoi vi mt lng ln khng th nhm tiu dit nhn t gy bnh (nu l trng hp nhim
trng. Sau giai on thoi bin l giai on tin bin ( t chc ton c th cng nh ni b
kch thch ) cho ti khi c th phc hi hon ton. trong giai on tin bin , cocticoit ng
thi khng tng, by gi n lt STH v cocticoit khong tng mnh m.
tng tit cocticoit ng hn ch tit STH v aldosterol.
khi tng tit cocticoit ng chm dt thy STH v aldosterol tng tit, c tc dng tng qu
trnh tin bin bo tng.
Bnh thng th hot ng ca hai h thng cocticoit (ng v khong ) hip ng v cn
bng nhm bo v c th, m bo s hng nh ca ni mi . Theo
Xi-lai mt cn bng v hip ng ny s sinh ra bnh gi l bnh thch nghi : bnh do ri lon
ca kh nng thch nghi. Theo tc gi, tnh nh tuz loi kch thch, tuz tm quan trng ca kch
thch v tuz thi gian kch thch m tng tit cocticoit ng hoc cocticoit khong l ch yu.
Song nu hormon ny vo mu qu nhiu, hay ni ng hn nu cocticoit ng qu nhiu so
vi cocticoit khong v nht l trng hp ngc li th c th pht sinh bnh thch nghi. Ri
lon thch nghi c th pht sinh trong giai on phn ng bo ng , trong giai on thoi bin
hoc trong giai on tin bin. Khi nhiu cocticoit ng th vt thng lu lnh v qu trnh
pht trin t chc b ngn cn . tri li khi tha cocticoit khong th cht keo hnh thnh nhiu ,
t chc lin kt pht trin nn sinh ra nhng chng nh vim nt quanh ng mch, vim khp
dng thp , huyt p cao, x cng ng mch thn, vv... (iu tr cc bnh ny bng cocticoit
ng hoc ACTH thy c tc dng tt r rt).
Nhng cng trnh ca Xi-lai ng gp nhiu cho y hc. u im ca hc thuyt Stress l
nu ln c qu trnh thch ng phng ng ca c th khi mc bnh v nhng thay i ca h
thng ni tit khi c mt kch thch mnh tc ng ln c th, Xi-lai nhn mnh nhng quy
lut chung khng c hiu v qu trnh pht sinh v pht trin ca bnh. Ngoi ra cn cho thy
r tc nhn kch thch gy bnh , ngoi ng thn kinh cn qua h thng ni tit : nhng phn
ng ni tit khng c hiu c th gy ra nhng qu trnh bnh l khc nhau. Hc thuyt Stress
khng nhng to ra mt c s l lun vng chc cho vn iu tr bng hormon m cn
gii thch c hiu qu ca phng php iu tr khng c hiu .
Tuy nhin hc thuyt Stress vn cn mt s mt hn ch nh :
coi nh hot ng ca h thn kinh cao cp , s thng nht ton vn ca c th , Xi-lai khng
thy r h ni tit tuy rt quan trng song ch l khu trung gian trong qu trnh iu tit thn
kinh do quan nim c ch thch ng phng ng mt cch gin n , phin din.
Khng thy r mi tng quan gia c th v mi trng trong cc iu kin bnh l.
Qu nhn mnh ti vai tr ca h ni tit ti mc coi nh, thm ch ph nhn rt nhiu hin
tng thch ng khng c hiu khc .
Thay th kt lun, c th nu ra y nhn xt ca Ptrp : Hc thuyt Stress mc d sng
t nhiu im v hot ng trong c th khi b bnh , song v qu cng iu vai tr ca h
thng ni tit , ly ci b phn gii thch ci ton b, nn Xi-lai khng thy r c th l
mt khi thng nht ton vn, c lin h mt thit vi ngoi mi di nh hng ca v no.
III. HC THUYT FROI (FREUD)
Cn gi l thuyt phn tm, thuyt tinh thn c th. Hc thuyt ny cho rng yu t tm l l
nguyn nhn ch yu gy ra cc bnh. Froi chia tm l{ con ngi ra lm 3 thnh phn :
ci n l ci v thc gm nhng bn nng. theo Froi bn nng l phn quan trng nht trong
i sng tm l ca con ngi, l thc cht ca tm l{ con ngi, l ci ch o , iu khin
ton b cc hot ng thc ca con ngi, i khin t tng v hnh vi ca con ngi. Froi
gn cho bn nng tnh dc nhng kh nng v hn. Froi em quan h tnh dc bao trm ln
ton b cc quan h khc.
ci ti l tt c cc hot ng ca con ngi nhm tho mn nhng bn nng.
ci siu ti hay ci ti l{ tng (cn gi l lng tm, { thc) l s rng buc ca x hi
(phong tc, tp qun, lun l{, d lun, php lut,vv... ) i vi con ngi. Ci siu ti chn p
ci bn nng, khng cho n t do hot ng.
Gia ci n v ci ti l{ tng lun lun c xung t, chng i ln nhau. Cc bn nng
b chn p, song khng mt i m vn tim tng , hot ng v iu khin hnh vi ca con
ngi, hoc do b chn p m sinh ra cc bnh tm thn. Nh vy bnh ch l sn phm ca mt
cuc xung t tm l{ trong { thc chn p bn nng. theo Froi, th phn ln nhng xung
t trong ni tm ca chng ta gy ra bnh tm thn l thuc bn nng sinh dc v x hi c
nhng quy lut kht khe v hnh vi sinh dc y. V khng c li thot cho nhng bn nng b
chn p , c bit l bn nng sinh dc s tm cch biu hin thnh nhng hin tng tm thn
fnh ni but ming, tnh lng qun, mng m, thm ch nhng hin tng bnh l{ nh Isteri,
suy nhc tm thn, vv... t , cch cha bnh, theo Froi l phi tm cch gii phng nhng
bn nng b chn p bng nhng phng php phn tch tm l.
Lc u Froi bn nng nh l mt c ch nhm tho mn mi nhu cu v do cc kch thch
bn trong gy nn, nh vy nguyn l dc vng l ng lc ch huy mi hot ng v phng
din tm l chng no ngoi mi khng chng i li. Song v cui i tc gi li thay i quan
nim cho rng mi ng lc trong tim thc c bn c th quy v 2 bn nng : bn nng sng
ch huy mi hot ng m bo s sinh tn ca con ngi, k c vic duy tr ging ni v bn
nng cht nhm ph hoi mi hot ng sng . Froi cho rng hai bn nng lun chng i
vi nhau trong sut i sng con ngi, lc ci ny thng, lc ci kia thng. bn nng sng to
ra sc kho, cn bn nng cht to ra bnh tt.
Hc thuyt ca Froi hin rt thnh hnh cc nc t bn, cho rng tt c mi bnh tt u
do nguyn nhn tm thn gy ra. Hc thuyt ny c dng gii thch c ch bnh sinh ca
nhiu bnh nh u c tuyn v l do s cha hay do b tht tnh, hen ph qun ngi con
l do s mt tnh cm ca ngi m. Thm ch hc thuyt cn dng gii thch nhng hnh
ng n cp , git ngi l biu hin bnh l ca bn nng cht ch khng phi do t chc x
hi gy ra.
Hc thuyt Froi c phn ng trong nh gi vai tr quan trng ca nhng xung t tm l
trong qu trnh pht trnh pht sinh bnh tm thn, hoc vai tr quan trng ca bn nng sinh
dc trong mt s trng hp bnh l.
Song hc thuyt ny ch yu da trn quan st bn ngoi v suy din nn i ti nhng
quan nim tru tng nh { thc, tim thc, ci ti, ci siu ti, vv... v do mang
tnh cht duy tm thn b. Tri vi hc thuyt Pap-lp dng phng php khch quan nghin
cu hot ng ca h thn kinh cao cp, hc thuyt Froi dng phng php ch quan phn tch
tm l{ tm ra nguyn nhn gy bnh, tc l bn nng b chn p. Hc thuyt Froi tch
chc nng ra khi cu to, tch cc qu trnh bnh l ra khi nhng thay i v hnh thi, v
sinh l bnh. Hc thuyt ny ph nhn s thng nht gia c th v ngoi mi , ph nhn
tc ng to ln ca ngoi mi i vi hot dng ca c th, ph nhn c s vt cht ca thc,
vv...
Li dng hc thuyt Froi, giai cp thng tr cc nc t bn xuyn tc ngun gc ca
bnh tt, th d h ru rao rng bnh tm thn khng phi do lao ng v iu kin sinh hot
gy ra m ch l hu qu ca ri lon tm thn, hoc nhng cng nhn b chn thng khi sn
xut khng phi do thiu st ca ch bo v lao ng m l tm thn ca h c vn ,
khng phi l nhng ngi bnh thng.
IV. HC THUYT THN KINH
Trng phi Nga, vi nhng nh bc hc ni ting nh Set-s-np, Bt-kin, Pap-lp c
nhiu ng gp soi sng bn cht ca bnh, v ra hc thuyt thn kinh ca bnh. Set-s-
np nu bn cht phn x ca cc qu trnh thn kinh ; Bt-kin ly hc thuyt thn kinh lm
nguyn tc gii quyt bnh.nhng t tng ny c pht trin thm mt bc trong hc
thuyt hot ng thn kinh cao cp ca Pap-lp. theo hc thuyt ny, ni mi v ngoi mi l
mt khi thng nht m trong hot ng ca thn kinh cao cp chi phi kh nng thch ng
ca c th i vi ngoi mi. Pap-lp bo v nguyn tc quyt nh lun trong ngun gc
gy bnh v ch r trong mi bnh c 2 qu trnh song song tn ti : qu trnh bo v sinh l
v qu trnh hu hoi bnh l{.
Hc thuyt thn kinh ca trng phi Nga c u im l nhn nhn vn mt cch ton
din hn nhng hc thuyt trc . N tip thu mi tin b ca khoa hc ni chung v ca y
hc ni ring, nht l nhng thnh tu ca cc cng trnh nghin cu v thn kinh trung ng
ca Pap-lp.
Song sau ny, nhng hc tr ca Pap-lp qu cao, thm ch tuyt i ho vai tr ca v
no, coi nh l khu quyt nh mi hot ng ca c th, cho rng t thn kinh c th sinh ra
mi th bnh, v phn x bnh l{ l c s duy nht ca s pht trin bnh. chnh quan nim
phin din hn ch vic nghin cu pht trin cc hng khc trong y hc mt thi gian di
(nh thn kinh thc vt, ni tit, sinh ho thn kinh, vv...).
V. NHNG IU CN CH TRONG MT KHI NIM V BNH
1. Bt c bnh no cng do nguyn nhn nht nh gy nn.
Song ngy nay, trong y hc cn nhiu bnh cha r nguyn nhn. Do trnh khoa hc cn
hn ch, cha pht hin c nhng yu t bt thng ca ngoi mi gy ra nhng thay i
ca ni mi, lm cho bnh pht sinh. Cng mt kch thch c th l bnh l{ i vi ngi ny
song li l bnh thng, sinh l{ i vi ngi khc , l do tnh phn ng ca c th chi
phi.
Nhng nguyn nhn gy bnh thng tc ng trn c th trong nhng iu kin lao ng
v sinh hot nht nh. Nhng nhn t bnh l ca ngoi mi (c gii, vt l, ho hc, sinh vt,
vv... ) phi thng qua hon cnh x hi, quan h x hi nht nh mi pht huy c tc dng
trn c th ngi. iu kin lao ng v sinh hot khc nhau , ch x hi khc nhau c mt
ngha quan trng i vi qu trnh pht sinh v tiu dit ca bnh tt. Trong ch XHCN,
khng cn hin tng ngi bc lt ngi, i sng tinh thn v vt cht cng nh iu kin
lao g ca nhn dn c ci thin khng ngng, do bnh tt v t vong gim rt nhanh,
sinh v tui th ca con ngi tng r rt.
2. Bnh c tnh cht mt cn bng mi.
S hng nh ca ni mi l kt qu ca mt cn bng sinh l{, nh s lng hng cu trong
mu ngoi vi l biu hin ca s cn bng gia 2 qu trnh to v hu hng cu. Khi c th b
bnh, vn c mt trng thi cn bng ch khng phi mt cn bng nh mt s tc gi vn
thng ngh, song trng thi cn bng ny khc vi cn bng sinh l v c tnh cht km bn
vng. thc vy, khi nhn t gy bnh tc ng ln c th th c th c mt phn ng bo v
p li nhm duy tr trng thi hng nh ca ni mi b ri lon. trong mi qu trnh bnh l,
lun lun xy ra 2 hin tng gn lin vi nhau v nh hng ln nhau : hin tng hu hoi
bnh l (m Pap-lp gi l bnh thc s) v hin tng phng ng sinh l. th d trong qu
trnh vim, ri lon chuyn ho v tn thng t chc nh hng khng tt ti qu trnh hot
ng ca c th, gy ra nhiu ri lon chc nng, thm ch uy hip s an ton ca c th. Song
song vi hin tng ph hoi , c th cn ng vin c mt h thng phng ng thch ng :
xung huyt ng mch, tng bch cu, xuyn mch, sn sinh khng th, thc bo, tng sinh,
vv... Cn nhn mnh l bt c mt kch thch no, ngay t u cng gy ra phn ng phng ng
ca c th chng li nguyn nhn gy bnh,ng thi hn gn tn thng, phc hi hng nh
ni mi. chnh cuc u tranh ny to ra mt cn bng mi, song cn bng ny khng ko di
m thng thay i theo hng phc hi v cn bng c cn bng sinh l- hoc nu yu t
gy bnh thng th bnh ngy mt nng dn ti t vong. Nh vy thy r tnh cht km bn
vng ca cn bng mi.
Trong mi bnh, ngi thy thuc phi thy r u l tn thng, l bnh tht s cn phi
tiu dit v u l bin php sinh l ca c th cn phi tng cng gip c th chng li
bnh tt mt cch ch ng. Nghin cu k c ch thch ng ca c th l mt vn quan
trng tin hnh tt cng tc phng bnh v cha bnh. Nu sc chng ca c th tt,
bnh s nh hoc khng pht sinh, do thy r phng chm ly d phng l chnh c c
s khoa hc vng chc. Tuy nhin phn bit 2 loi hin tng tn thng v phng ng
trong nhiu trng hp khng phi d dng v n gin.
Trong khi ngoi mi lun thay i m ni mi i hi mt trng thi hng nh tng i, c
th lun phi thch ng vi nhng thay i ca ngoi mi. ng trc s thay i mnh m ca
ngoi mi, c th phi huy ng nhng c ch thch ng mnh m, thm ch c th dn ti mt
tnh trng bnh l m Xi-lai gi l bnh thch nghi. Thc ra, khi lm bnh, kh nng thch ng
vn cn, song r rng l b hn ch. Nh khi c th b st, kh nng iu ho nhit ca c th
vn cn, ngi b st ra ngoi lnh vn cn phn ng tng sinh nhit, song phn ng khng
mnh m nh khi kho.
3. Bnh l mt cht lng mi
Trong qu trnh bnh l, bn cnh nhng thay i v s lng (nh tng nhit trong st, gim
s lng hng cu trong thiu mu,vv... ) cn c nhng s thay i v cht lng. th d quan
nim v bn cht ca u c m ch da vo hin tng t bo tng sinh, khng thy s thay i
v cht ca t bo u c (c im cu to, sinh ho, vv...) th l mt thiu st nghim trng.
hoc trong thiu mu, ngoi gim s lng hng cu, cn thy nhiu thay i v cht ca hng
cu (thay i v kch thc, hnh dng, mu sc,vv... ) V chnh nhng thay i v cht l
nhng yu t quan trng trong chn on v tin lng bnh. th d protein niu c khi l triu
chng n c, duy nht trong thi gian di ca bnh vim cu thn mn tnh, hoc bnh vim
cu thn cp khi v lm sng , nc tiu v cn bn tr li bnh thng, song vn cn
protein niu dai dng tuy nh, nh vy vn cha ht bnh (bnh chuyn sang th mn tnh).
Qua phn tch trn, thy r bnh l mt cht lng mi.
4. Bnh hn ch kh nng lao ng.
Ring i vi con ngi l mt ng vt cao cp sng c t chc thnh x him lao ng l
mc ch ca cuc sng, cho nn cn ch ti c im bnh hn ch kh nng lao ng. Ngoi
bn nng sinh tn nh mi sinh vt, con ngi cn lao ng ci to mi trng sng ca
mnh, ch ng thin nhin, nhm nng cao i sng. Do r rng l bnh lm gim hoc
mt kh nng lao ng.
Cn c vo nhng { trnh by trn y, c th nh ngha bnh nh sau :
Bnh l s ri lon i sng bnh thng ca c th, do nh hng ca nhng tc nhn ph
hoi khc nhau, s ri lon y dn ti mt cn bng mi km bn vng, hn ch kh nng thch
nghi ca c th i vi ngoi mi v gim kh nng lao ng ca con ngi.
Mt quan nim nh vy s gip nhiu cho cuc u tranh phng chng bnh tt. Tin tng
vo quyt nh lun khoa hc, ta s tch cc nghin cu pht hin cc nhn t gy bnh
(nguyn nhn v iu kin), mnh dn tn cng vo ci khng bit, trnh i vo con ng duy
tm, thn b.
Hiu bnh l mt cn bng mi km bn vng s quyt nh thi ca ngi thy thuc l
tm mi cch hn ch nhng hin tng hu hoi bnh l{, ng thi tng cng nhng hin
tng phng ng sinh l{, hng s tin trin ca bnh v cn bng sing l.
Nhn r kh nng thch nghi ca c th b hn ch khi mc bnh s gip cho ngi thy thuc
phng bnh bng cch khuyn khch rn luyn thn th, tng l an ton hot ng ca mi c
quan v c rn luyn sc chu ng, kh nng thch nghi cao hn so vi ngi t luyn tp.
Trong cha bnh, ngi thy thuc cng tm cch bo v kh nng thch nghi ca c th n
mc ti a, hn ch v trnh nhng kch thch qu mnh vt qu kh nng thch nghi ca c
th.
Cui cng, nhn r bnh lm gim kh nng lao ng l mt nguyn l{ c bn cho vic phng
v cha bnh. bnh khng nhng lm gim kh nng lao ng ca mt con ngi m cn c
th ca c mt tp th ngi. Cho nn cng tc phng bnh phi c bit ch ti nhiu bnh
d nh , t gy cht song nhiu ngi mc phi. trong cha bnh,c gng bo tn, nht l
nhng c quan, chc nng c lin quan nhiu ti lao ng : th d trong phu thut bn tay,
phi c gng bo tn ti mc ti a ngn ci ngn tay c tm quan trng dc bit.
Ni tm li, mt quan nim ng hay sai v bnh s quyt nh thi ca ngi thy thuc
trong cng tc hng ngy ca mnh cng tc u tranh chng li bnh tt.

37. QU TRNH BNH L

( NGUYN HU M )
I- CC GIAI ON CA QU TRNH SINH L BNH
Bnh tt l mt qu trnh thng din qua 4 giai on:
- Giai on bnh (nung bnh).
- Giai on tin chng (khi pht).
- Giai on ton pht.
- V giai on kt thc.
1. Giai on bnh:
Giai on bnh bt u t lc nhn t gy bnh tc ng ln c th ti khi triu chng
bnh l{ u tin xut hin.
Trong giai on ny, kh nng thch ng ca c th cn mng, nn cha pht sinh ri lon,
c th hot ng hu nh bnh thng. Nu sc khng mnh, tiu dit c nhn t gy
bnh th bnh s khng pht sinh.
Giai on nung bnh di hay ngn l ty loi bnh: c khi ch trong nhy mt (dng in
mnh), c khi v pht (mt liu thuc c mnh), vi ngy (bnh si t 6- 13 ngy), vi thng
(bnh di t 1-2 thng) thm ch c khi hng nm (bnh hi). Ngoi ra, i vi tng bnh, giai
on bnh khng c nh khi di khi ngn :thng hn t 7- 28 ngy, quai b t 2-30 ngy,
un vn t 1- 40 ngyGiai on bnh dao ng nh vy l ph thuc vao:
- S lng mm bnh xm nhp vo c th nhiu hay t, c tnh mnh hay yu, thi gian
tit ra c t nhanh hay chm, ni mm bnh xm nhp c gn ni c tr ca mm bnh khng
(th d: bnh di khi b ch di cn vo mt thng giai on bnh ngn hn khi b cn vo
chn), ng truyn bnh (th d bnh bch hu th hu c th bnh ngn hn hon ton
da, th mt)
- Tnh phn ng ca c th mnh hay yu, kh nng th bnh cao hay thp, tnh min dch,
kh nng sn xut khng th mnh hay yu
Giai on bnh khng c gi tr v mt lm sng, song v dch t hc li rt quan trng :
mt s ln bnh, bnh nhn bi tit ra mm bnh v c kh nng truyn bnh cho ngi xung
quanh ngay trong giai on bnh. Giai on bnh cn l cn c :
- Bao vy dch.
- Cch ly v theo di nhng ngi tip xc vi bnh nhn.
- Chn on bnh, tm ngun ly bnh, xc nh khng gian v thi gian ly bnh.
2. Giai on tin chng:
Giai on ny bt u t lc triu chng bnh l{ u tin xut hin ti khi bnh ton pht.
Giai on ny di hay ngn ty theo tng bnh. C bnh khi pht t t, nng dn nn nh
thng hn, ho g, c bnh khi pht t ngt nh cm, vim mng no Trong giai on tin
chng, mm bnh tng sinh rt mnh (trong nhiu bnh, kim tra mu bnh nhn thng thy
c vi sinh vt), kh nng thch ng b han ch, tnh phn ng ca c th thay i, nn bt
u pht sinh mt s ri lon nh, ch yu l nhng s thay i ca hot ng thn kinh cao
cp v thay i chuyn ha nhit: bnh nhn cm thy st, mt mi nhc u, au mnh, s
gi, ng ming, bing n, nn e, i to hoc a lng; ni chung cha c triu chng g c bit
gip ta chun on ngay ra bnh. l mt tr ngi ln cho vn pht hin sm phng
bnh tt, nht l v mt ly truyn, l thi k ly mnh nht, nh trong cc bnh do virut.
Trong giai on tin chng, i khi c th xut hin mt vi triu chng c hiu ca bnh:
th d trong giai on tin chng ca si, bnh nhn thng hay chy nc mt, s mi, ho, st
v nim mc ming xut hin nhng chm trng nh ta c th chun on c bnh.
Trong giai on tin chng, nu sc khng mnh, bnh c th kt thc giai on ny.
Nu kh nng thch ng km. bnh s tin vo giai n ton pht.
3. Giai on ton pht:
Thng ti giai on ny, cc triu chng chnh ca bnh mi xt hin y , r rt. Chun
on quyt nh ch yu gai on ny. Giai on ton pht c th bt u t t (thng hn,
lao k). Hoc t ngt (vim phi, st hi quy). Nhiu bnh nhim trng c mt giai on
ton pht nht nh: vim phi trong 9 ngy, si trong 8- 10 ngy, st pht bang trong 13-16
ngy. Tri li c mt s bnh nht l cc bnh mn tnh, khng c k hn nht nh: st rt, hi,
giang mai.
Trong cc bnh nhim trng , nu giai on tin chng l giai on ca nhng triu chng
nhim trng nhim c ton thn, l giai on thng mi trong mu th sang giai on ton
pht, mm bnh t nhp vo nhng ni tng nht nh ty theo hng tnh ca n: th d
trong vim gan truyn nhim th virut t nhp vo gan, trong bi lit th virut t nhp vo t
bo vn ng ca sng trc V th, trong giai on ton pht bn cnh hi chng nhim
trng nhim c ngy cng nng ta thy xut hin thm nhng triu chng tn thng b phn
c tinh cht c hiu ca tng bnh.
Giai on ton pht l giai on m bnh c th gy bin chng. y l giai on nguy him
nht ca bnh v thng cht trong giai on ny.
Da vo tnh cht v thi gian din bin ca bnh, ngi ta thng phn bit ba th bnh:
a) Th cp tnh: ko di t vi ngy ti 2-3 tun, triu chng r rt, d pht sinh bin chng,
trng hp ny thng gp trong mt s bnh truyn nhim cp tnh (thng hn, t dch)
b) Th bn cp tnh: ko di t 3-6 tun, triu chng cng kh r song li km phn c lit
(vim mng trong tim).
c) Th mn tnh: Ko di trn 6 tun, din bin t t, c th k tc th cp tnh, triu chng
thng khng r rt, song nu c bnh tin trin, c th gy ra nhng hu qu tai hi (giang
mai, hi, i ng..).
Cn ch l mt bnh cp tnh c th tr nn mn tnh; tri li, mt bnh mn tnh i khi
li c biu hin cp tnh: th d l amip cp tnh iu trn khng tt c th tr thnh mn tnh v
khi sc khng ca c th gim (lao lc qu , n ung tht thng), l mn tnh c th
gy ra mt t cp tnh
Ty theo mm bnh (c tnh, s lng mm bnh xm nhp vo c th) v sc chng
ca c th, c th pht sinh nhiu th lm sng khc nhau:
a) Th in hnh r rt: Th bnh thng gp, bnh tin trin qua cc giai on in hnh,
pht sinh nhng ri lon chc nng v tn thng thc th r rt song vn cn kh nng hi
phc c (do sc khng ca c th cn tt).
b) Th khng in hnh : (th nh, th ct) trong trng hp ny, sc chng ca c th
chim u th. Khng c nhng ri lon chc nng v tn thng thc th nng. Th khng
in hnh thng xut hin nhng c th c cht t min dch hoc khi mm bnh c c
tnh yu xm nhp vo c th vi s lng t. Th d trong st rt khng in hnh, st nh
khng thnh cn r rt, bnh nhn ch n lnh, mt mi, vng u. Nhng bnh nhn c
tim chng thng mc th nh, khng in hnh; th khng in hnh, th nh, th ct l
nhng bnh c gi tr quan trng v phng din dch t v nhng th ny kh pht hin hoc
b coi nh, v bnh nhn mc th ny thng vn i li c, do l ngun ly bnh d dng.
c) Th ti c: (th c d ng, th qu mn, th c tnh): thng xy ra nhng bnh nhn
mn cm sn i vi mm bnh (bch hu, l th c), pht sinh nhng ri lon chc nng v
tn thng thc th cc t chc v ni tng rt nng, nhiu khi khng hi phc c. Bnh
thng din bin qua cc giai on in hnh.
4. Giai on kt thc:
Ba kh nng c th xy ra:
- Khi bnh.
- Chuyn sang th mn tnh.
- Cht.
Khi bnh: c th nhanh (vim phi) hoc ko di (thng hn, lao). Giai on lui bnh l
giai on nhng phn ng min dch bo v ca c th bt u chim u th, cc ri lon chc
nng v tn thng thc th bt u hi phc, th cn bng gia c th v ngoi mi dn dn
n nh v mm bnh dn dn b tiu dit v o thi ra khi c th. Qu trnh hi phc lm
sng thng xy ra sm hn qu trnh hi phc t chc.
Khi bnh c nhiu mc :
Khi hon ton khi:
. Ht cc triu chng lm sng.
. Ht cc tn thng thc th.
. Khng cn mang mm bnh v khng cn bi tit ra mm bnh (nu l bnh nhim trng).
Th d: khi l trc trng phi t 3 tiu chun: khng i ng ra mu nhy , phn
thnh khun, ht au bngsoi trc trng thy nim mc i trng bnh thng, khng c
lot, c trt, c m xut huytCy phn khng cn thy trc khun l.
- Ch khi lm sng n thun, nhng cn ri lon chc nng v tn thng thc th. Th d,
bnh vim gan truyn nhim, bnh nhn ht vng da, n thy ngon, ht y bng v au
bng, gan ht sng song nhng chc nng gan qua cc xt nghim vn cn b ri lon.
- Khi v lm sng, khi c v ri lon chc nng v tn thng thc th , song cn bi tit ra
mm bnh (nu l bnh nhim trng). Th d, bnh nhn thng hn sau khi tr thnh ngi
lnh, mang trng hng thng,hng nm.
Trng hp cn mang trng sau khi khi bnh c 3 loi:
+ Cn mang mm bnh, nhng c mim dch (bch hu, thng hn): c th khng mc
bnh ln th 2 song c kh nng truyn bnh cho ngi xung quanh.
+ Cn mang mm bnh nhng khng c mim dch, c th mc bnh ln th 2 (cm).
+ Cn mang mm bnh v sc th bnh li tng so vi trc y (nh vim qung), loi ny
rt d mmc bnh li
Ti pht. C nhng trng hp triu chng bnh l{ ht (khi lm sng), song v mt
nguyn nhn no bnh tr li ging ht ln trc: hin tng ny gi l ti pht. Cn phn
bit ti pht v ti nhim: ti nhim l vi sinh vt t nhp ln th 2 vo c th v gy bnh cn
ti pht l bnh xut hin ln th 2 tuy khng b nhim trng thm. Nhiu bnh nhim trng c
ti pht. C hai loi ti pht:
- mt s bnh, ti pht l mt giai on tt yu ca qu trnh tin trin ca bnh; th d
trong st hi quy, c 3- ngy li ln mt cn st ko di 3- ngy, loi ti pht ny phc thuc
vo qu trnh sinh sn ca mm bnh, thng c coi l giai on bnh.
- Song mt s ln bnh khc, ti pht khng phi l hin tng tt yu, thng khi c khi
khng, do nhiu nguyn nhn chi phi:
+ Do mm bnh cn n nu trong c th, khi gp c hi tt, mm bnh tng c tnh v gy
ti pht (st rt, thng hn).
+ Do c ch d ng: trong c th khng cn khng nguyn vi sinh vsstj, song c th trng
thi mn cm, khi gp mt kch thch khng c hiu (th d b lnh), cng c th gy ti pht
(nh trong vim cu thn).
II. QU TRNH CHT
A- SINH L BNH CA QU TRNH CHT
Khi kh nng thch ng ca c th hon ton mt, khi c th khng cn kh nng tip tc
hot ng, con ngi s cht. Cht c th chia lm 2 loi:
- Cht sinh l{, thng xy ra ngi cao tui, l kt qu ca s tiu hao dn mn ca c
th.
- Cht bnh l, l mt trong nhng phng thc kt thc ca bnh tt.
Cn c vo cc ti liu hin i, ngi ta phi ti 140-150 tui mi cht (c trng hp sng
n 248 tui ), song ch c mt s t ngi sng ti tui , cn i a s l cht non, cht do
bnh tt, c bit l cc nc t bn v thuc a.
Nguyn nhn trc tip gy ra cht l lm tim hoc h hp nh ch hot ng. Cht c th
xy ra t ngt hoc t t.
Cht l kt thc ca sinh mnh, song khng phi h cht l tt c cc chc nng trong c th
u nh ch mt lc m mt s b phn no vn tip tc hot ng trong mt thi gian
ngn na: sau khi cht rut vn tip tc co bp, tc v mng tay vn tip tc mc, tim
pilocapin vo mch mu ngn tay vn gy c tit m hiDo thy r cht l c mt qu
trnh: trong qu trnh cht, hot ng ca h thn kinh trung ng nh ch sm nht: trc
tin l v no sau ti gian no, trung no, hnh ty v ty sng. Ni chung nhng b phn
ca h thn kinh trung ng hnh thnh sm nht th cht mun nht. Sau khi h hp nh ch,
c th thy tim cn hot ng yu t, thoi thp.
Trc khi cht, thng c thi kz hp hi, ko di ti vi gi ti vi ngy. c im ca thi
kz ny l h thn kinh trung ng v cc chc nng qyuan trng ca c th b ri lon nng n:
h hp lon nhp (khng u, cch qung), ri lon hot ng tim, thn nhit gim, hn m,
phn x mt dn(H1)
Qu trnh cht c th chia lm 2 giai on:
a) Cht lm sng: c im ca giai on ny l tim ngng p, mt phn x, h thn kinh
trung ng b c ch nghim trng (do ri lon chuyn ha nng n, d tr nng lng kit
qu), song cc t bo thn kinh, c bit l t bo v i no cha b tn thng, nu kp thi
cp cu c hy vng cu sng c. Giai on cht lm sng thng ko di ti 5-6 pht. Trong
thc t, khi mt mch cnh coi nh cht lm sng.
b) Cht sinh vt tip theo cht lm sng. c im ca thi kz ny l cc t bo thn kinh
b tn thng khng hi phc, trc tin l v i no sau l cc trung khu cp thp.
B - HI SINH
Phng php hi sinh l mt phng php khoa hc du tranh chng ci cht: nh c
phng php ny, ngi ta c th khi phc c cc chc nng quan trng ca c th lm
vo thi kz hp hi hoc cht lm sng. Ni chung, phng php ny c kt qu tt trong
nhng trng hp cht nhanh (sc, chy mu nng, ngt cp din) v cc c quan quan trng
(no, tim, gan, thn ) cn tng i tt, tri li, rt t tc dng i vi cc bnh mn tnh gy
ra nhiu ri lon chc nng quan trng, c bit no, tim ,gan, thn, phi Cu ngi hp
hi d hn ngi cht lm sng. Nu thi gian cht lm sng qu 6 pht, kh m cu
sng c (v trong v i no pht sinh nhng tn thng khng hi phc c ). Do
cng tc hi sinh phi ht sc khn trng, trnh th tng giy pht, chun b tht chu o, nm
vng k thut (v 1 thiu st nh c th c mt nh hng tai hi)
Qua nhiu cng trnh nghin cu, gn ay ng ta sng to ra phng php hi sinh tng
hp bao gm : h hp nhn to, truyn mu ng mch, bp tim.
a) H hp nhn to. Dng phng php ni kh qun bm oxy (hoc khng kh) vo phi vi
mt p lc nht nh lm cho phi gin ra, c tc dng kch thch trung khu h hp mt cch
phn x. n gin hn c th dng phng php h hi thi ngt.
b) Truyn mu ng mch. Truyn mu vi mt p lc cao (180-200 mmHg) vo ng mch,
ngc chiu mu chy (hng v tim). Mu vi p lc cao c th vo ti ng mch vnh, khi
phc c dinh dng c tim, ng thi kch thch th th thnh ng mch vnh v t tim,
c tc dng thc tnh s hot ng ca tim, phi mt cch ph x. Sau khi huyt p hi phc,
tim co bp tt, by gi mi truyn mu vo tnh mch d tim c y mu thi kz tm
trng, c tc dng tng cng hot ng ca tim.
c) Bp tim: C tc dng kch thch tim, thc tnh s hot ng ca tim.
Phng php hi sinh tng hp, p dng trong thc t em li nhiu kt qu tt, nu
c tin hnh kp thi. Nu ngng tim t ngt, ch cn bp tim kp thi, c c oxy th rt
tt, cn truyn mu ng mch th nhiu khi khng cn thit.
Trong qu trnh hi sinh, yu t thi gian v cng quan trng:
- T khi ngng tim n khi bp tim tt nht l di 3 pht, c th hi phc hon ton.
- 4-6 pht: bnh nhn hi phc c song tri qua 4-5 thng nh ngn.
- 6-10 pht: bnh nhn khng th sng c, ngng h hp, tun hon c th hi phc
c. Bnh nhn t th, mch v huyt p tr li bnh thng, nhng bnh nhn khng tnh
m c m man ri cht.
- 10-30 pht: h hp hi phc, mch huyt p khng hi phc, nhng tim c th p li, yu
t mt thi gian ri ngng hn.
- Sau 30 pht: tim khng c kh nng p li.
C- QU TRNH HI PHC
Tun hon no c khi phc c tc dng ci thin chc nng h thn kinh trung ng. Khi
chc nng hnh ty c khi phc, h hp t ng xut hin. Hng phn t trung khu h hp
hnh ty lan ti trung khu vn mch, c tc dng ci thin tun hon. Ngoi ra, h hp t ng
sm cn c tc dng khi phc chc nng cc trung khu cao cp: h hp hi phc mun thng
gy ra t vong.
H thn kinh trung ng hi phc theo th t sau: cc trung khu hnh ty (h hp, vn
mch) hi phc u tin ri ti trung no (phn x ng t i vi nh sng). Sau v c khi
sau phn x gic mc mi hi phc phn x ty sng. Dn dn hi phc cc trung khu di v
no, sau mi ti tiu no v cui cng l v i no. Hot ng thn kinh cao cp hi phc
tun theo nhng quy lut nht nh: phn x khng iu kin hi phc trc sau mi ti
phn x c iu kin t nhin, ri ti phn x c iu kin nhn to. Ni c ch hi phc mun
nht. Khi chc nng v i no hi phc, cc chc nng ca c th c ci thin nhanh
chng.

38. MIN DCH BNH L
NGUYN HU M


Min dch bnh l (Danh t do Guy A. Vosin ra, 1953) bao gm :
- Ri lon chc nng min dch
- Tng mn cm c hiu
- Phn ng c min dch
- Tng mn cm khng c hiu
I. RI LON CHC NNG MIM DCH
Hai trng hp c th xy ra :
- Thiu nng min dch
- Ri lon thc th ca chc nng min dch
1. Thiu nng min dch
a) Trong thc nghim, ngi ta gy trng thi thiu nng min dch bng nhiu cch :
- Ct b tuyn c khi mi
- Chiu x ton thn
- Dng cc thuc c ch min dch
- Dng huyt thanh khng lympho
b) Trn lm sng, thiu nng min dch thng gp trong cc trng hp sau y :
- Gim gammaglobulin mu, c th do :
+ Mc phi, gp trong nhim x nng, nhim c thuc chng phn bo, thuc c ch min
dch, c th mt ko di mt lng rt ln protein (nh trong hi chng thn h).
+ Bm sinh, hay gp tr em, biu hin bng mt qu trnh nhim khun lin tip. Xt
nghim mu thy gim phn ln, hoc hu nh ton b gammaglobulin, bnh nhn khng c
kh nng tmh hp khng thkhi c kch thch khng nguyn, song nhng biu hin ca min
dch t bo (nh phn ng Tubeculin, phn ng ghp vv... ) vn tn ti. Tr thng cht do
nhim kun nu khng c khng sinh.
- Bnh Hodgkin : v mt min dch thy gim hoc mt tng thi tng mn cm mun (do gim
dn t bo lympho), trong khi s hnh thnh khng th c bn khng thay i.
2. Ri lon chc nng min dch
Ch yu gp trong lm sng. Nh bit, cu trc ca khng th globulin min dch ging
nhau ch chng u c n v cui cng gm 4 chui a
peptit : 2 chui nng H v 2 chui nh L, ni vi nhau bng nhiu cu ni disulfua.
Trong mt s trng hp bnh l t gp, c th tng hp nhng globulin bt thng (gi l
lon globulin) : hoc ch gm cc chui nh (bnh u tng bo, cn gi l a u tu, bnh
Kahler), hoc ch gm cc chui nng (gamma hoc alpha), hoc tng hp nhng globulin phn
t lng rt ln (bnh macroglobulin mu Waldenstrom).
II. TNG MN CM C HIU
Phn ng min dch thng c tnh cht bo v ca c th chng lai s xm nhp ca nhng
cht l c hi i vi c th. Tuy nhin trong mt s trng hp, c th pht sinh trng thi
ngc hn li : nhng ln tip xc sau vi khng nguyn dn ti tnh trng tng mn cm (cn
gi l d ng) vi nhng hu qu bnh l c hi. C mt s ngi c th b tng mn cm i vi
cc cht hoc tc nhn bnh thng v hi. Hin tng ny l do mt c ch min dch.
Trng thi tng mn cm c th c chia thnh 2 loi :
1. Tng mn cm do khng th lu ng
Nhng khng th c sn trong th dch c th gn vo mt c quan, t chc v khi tip xc li
vi khng nguyn c hiu s gy ra nhng ri lon trm trng, xut hin rt sm gi l tng
mn cm th dch hoc tng mn cm tc th (cn gi l d ng th dch hoc d ng tc th).
2. Tng mn cm khng do khng th lu ng m do mt tnh cht dc bit ca t bo
lympho b thay i mt cch c hiu do tip xc trc kia vi khng nguyn. Trong hin
tng ny, khng c s tham gia ca khng th lu ng v khng nguyn cn c vo tn
bn trong t bo gy mn cm. Do , hin tng xy ra chm hn gi l tng mn cm
mun hoc tng mn cm t bo (d ng mun, d ng kiu t bo, d ng kiu Tubeculin).
Hai hin tng tng mn cm ny khng tch ri nhau hon ton.
Ngoi ra cn c hin tng tng mn cm khng c hiu m cht pht hin khc hn cht
gy mn cm.
A. TNG MN CM TC TH
Bao gm :
- Phn ng qu mn (cn gi l phn v)
- Hin tng Arlhus
- Hi chng bnh huyt thanh
1. Qu mn thc nghim
a) Nhng biu hin ca phn ng qu mn. Phn ng qu mn c th l ton thn hoc ti
ch, ch ng hoc th ng.
+ Qu mn ton thn : sc qu mn. Phn ng qu mn do Ri-chet v Portier khm ph ra
nm 1902. Hai tc gi tm cch gy cho ch quen vi mt cht c ly t hn b: h dng mt
liu di lng gy c, tim vo tnh mch ch, hon ton khng thy ri lon g. Nhng 27
ngy sau, cng mt liu nh vy, tim tnh mch, thy pht sinh ngay lp tc nhng tai bin
trm trng, dc bit l tru tim mch, lm cho con vt cht kh nhanh.
Phn ng qu mn c nhng c im sau y :
- Nhng biu hin qu mn ch pht sinh sau khi tim li cng cht (tnh cht c hiu)
- Gia 2 ln tim cn c mt khong cch t nht l 7 n 10 ngy (thi k bnh, cn thit
cho c th tng hp c mt lng khng th gy phn ng qu mn)
- Bn cht ho hc ca khng nguyn c th khc nhau, song nhng biu hin qu mn khng
thay i i vi mt loi ng vt
- Trng thi qu mn c th truyn th ng bng cch tim huyt thanh ca ng vt mn
cm cho ng vt bnh thng.
- Nhng biu hin bnh l c th gim khi dng nhng cc cht khng histamin.
Phn ng qu mn pht sinh khi trng lc c thay i t ngt v mnh m. cc loi ng
vt khc nhau, bng lm sng c khc nhau l do cc c quan c c trn mn cm khc nhau
i vi s tn cng : chut lang, c trn ph qun c bit mn cm v du hiu ch yu
l co tht ph qun (sau khi tim khng nguyn, thy nhanh chng pht sinh kh th, xanh tm,
giy gia ri cht, khi m thy phi khng xp do ph qun b co tht), a s cc loi ng vt
khc, c trn ca h tun hon c bit mn cm (co tht ng mch phi th, co tht tnh
mch trn gan ch) do ri lon huyt ng hc ni ln hng u : gim lng mu tnh
mch v tim phi, dn ti gim huyt p v tru tim mch, c th gy cht. Nhng biu hin ca
sc qu mn ngi tng t nh ng vt (c bit l ch) : thng xuyn c gim p
thm vo c nga v ni my ay ton thn, nn ma v i khi kh th kiu hen. Ngi
bnh c th cht do tru mch nu khng iu tr kp thi.
+ Qu mn tai ch. Th d in hnh ca phn ng qu mn invitro ny l hin tng Schultz
Dale: trong dung dch Ringer c oxy, mt ph tng tch ri c nhiu c trn (hi trng, sng
t cung) v ra k cho ht hn mu, ca mt chut lang c mn cm, khi thm v git
khng nguyn dng gy mn cm, thy cc c trn ca ph tng co tht li (hnh 2).
Invivo, c th gy phn ng qu mn ti ch bng cch tim mt lng nh khng nguyn :
in hnh l tim trong da khng nguyn , thy nhanh chng pht sinh ban v ph n tm
thi, do gin mao mch v tng tnh thm (nh trong phn ng dng tnh i vi Penixilin).
+ Qu mn th ng. Tt c cc phn ng k trn u c th truyn th ng bng cch tim
huyt thanh ca mt con vt mn cm vi cho mt con vt bnh thng, v sau tuz cch
tim li khng nguyn c th pht sinh qu mn ton thn (sc qu mn) hoc qu mn ti ch,
cng c y cc c im ca qu mn ch ng.
b) c ch ca qu mn. Phn ng qu mn din bin qua 4 giai on :
- Giai on 1 : gy mn cm ng vt, mn cm c th ch ng (con vt t n sinh ra khng
th) hoc b ng (con vt nhn khng th do con vt khc sn sinh ra).
- Giai on 2 : tim li khng nguyn c hiu, khng nguyn ny s kt hp vi khng th
c gn sn vo t bo bia (t bo mastocyt, t bo a kim ch, tiu cu th) v hnh
thnh phc hp khng nguyn khng th c tc dng c.
- Giai on 3 : cc phc hp ny tc ngln cc t bo bia v pht sinh mt lot phn ng
men, gy gii phng histamin v cc cht trung gian ho hc khc.
- Giai on 4 : cc cht c gii phng ny tc ng ln cc c quan v t chc, gy ra cc biu
hin lm sng ca phn ng qu mn .
Cc cht trung gian ho hc gy phn ng qu mn bao gm : histamin, serotonin (5-
hydroxytryptamin,5-HT), Slow reacting substance (nguyn vn ngha l cht tc ng chm,
SRS-A), brandykinin, heparin. Quan trng nht l histamin v nhiu l do :
- cc loi ng vt, sc qu mn v sc do histamin biu hin rt ging nhau.
- Phn ng qu mn gii phng mt lng quan trng histamin.
- Nhng cht gi l gii phng histamin, tc ng bng mt qu trnh khng phi l min dch,
gy ra nhng ri lon rt ging phn ng qu mn.
- Cui cng, nhng cht khng histamin c tc dng bo v rt tt i vi nhim c histamin
cng nh i vi sc qu mn.
ng ch { l cc cht trung gian ho hc c gii phng nhiu hay t l tuz loi ng vt.
ngi, khng nh l ph qun, t chc phi v bch cu ca ngi mn cm v s gii
phng histamin sau khi tip xc vi khng nguyn. ng thi vi histamin, cht SRS-A cng
c gii phng gy co tht ph qun nh, m tc dng ny khng chu nh hng ca cc cht
khng histamin.
2.D ng tc th ngi.
ngi, t thy hin tng qu mn ton thn (sc qu mn), tr mt vi trng hp tai bin
do iu tr (c bit l Novocain, Penixilin, Streptomycin,vv... ) tronh cng thy cn c mi
tim chun b v gia hai ln tim cng cn c thi gian nht nh.
a) c im ca d ng tc th ngi.
- Tai bin c tnh cht khu tr hn, ti mt khu vc nh ph qun, da, nim mc, vv... m biu
hin ch yu l xung huyt. phi c hen ph qun, da c vim d ng, ni my ay, l sn
vv... , mu c ban chy mu, gim bch cu, tiu cu, vv...
- Xy ra bt thng v ch thy ngi (rt kh gy ng vt) v tuy cng tip xc vi khng
nguyn nh nhau, thng ch c mt s ngi d mc v c th di truyn cho i sau. Yu t
th a v di truyn rt quan trng (t l con b nhiu hn nu c b ln m u b).
- Khng nguyn thng l yu, xm nhp t t, theo ng t nhin (h hp, tiu ho).
- Khng th thuc loi c bit : reagin d ng (IgE) khng th pht hin bng cc phn ng
invitro v nht l khng bao gi kt ta vi khng nguyn trong dung dch ho tan.
b) Hnh nh lm sng ca d ng tc th ngi.
Phn ng c c im l xy ra rt sm, ngay sau khi tip xc vi khng nguyn, bt u rt
t ngt, n tng cn ri qua i khng li mt du vt g. Tuy nhin, tnh cht ny ch r
nht khi tim khng nguyn ln hai, cn khi tip xc t nhin vi khng nguyn, cc hin tng
xy ra sm mun khc nhau, tuz thuc vo thi gian cn thit khng nguyn thm c qua
da hoc nim mc (h hp, tiu ho).
Trong cc trng hp c phn ng, nhng hin tng gin mch, xut tit, ph n, ban v
nga, vv... u l nhng th hin gii phu chng t c s gii phng v c tc ng ca nhng
cht trung gian ho hcnh trong qu mn ton thn.
c) Cc cht gy d ng. Thng gi l d nguyn (alecgien hoc reagien) c rt nhiu loi khc
nhau. Hay gp nht trong d ng h hp l cc loi bi trong nh, cc phn hoa, vv... C th l
nhng khng nguyn t k sinh trng, vi khun, cc protein c trng lng phn t cao hoc
mt s cht n gin trong thc n, c bit l thuc (khng sinh, sulfamit, novocain,vv... ) c
l c vai tr hapten kt hp vi protein ca t chc tr thnh khng nguyn.
Trong d ng th dch, hay c tnh trng a d ng do cc cht gy d ng u c cng mt loi
hapten.
D ng thuc. Mt s thuc khi vo c th b phn ho thnh cc thnh phn c kh nng gn
vo cc protein ca c th. Cc thnh phn ny c tnh cht ging nh l cc hapten v phc
hp hapten protein c th tr thnh khng nguyn. C th phn bit hai loi d ng thuc, tuz
theo c ch phn ng bng dch th hay phn ng kiu t bo. Ngi ta ch nhiu n d ng
do penixilin.
Khi vo c th, penixilin b phn ho thnh hng chc nhm khc nhau, v cc nhm ny c
th tr thnh cc hapten. Nhiu khi kh xc nh c trckhi tim l ngi bnh c b d ng
penixilin hay khng , khng t trng hp xy ra ngi khng c phn ng khi lm th
nghim penixilin trong da song khi tim li gy tai bin.
Ngoi penixilin, ngi ta cn thy hu ht cc thuc khng sinh u c th gy d ng.
Phn ng qu mn cn c th do nhiu thuc khc gy ra : procain, vitamin (B1, B12 ...) ,
sulfamit, vv...
Mt s thuc khc c th gy tn thng huyt cu m hu qu l thiu mu tan mu tuyt
bch cu ht, ban chy mu gim tiu cu. Thiu mu c th do quinidin, phenaxetin, axit
paraamino- salixylic, quinin vv... Ban chy mu gim tiu cu l mt bin chng ph bin ca
vic dng thuc (sedormid quinidin, quinin, aspirin, digitoxin,vv... ). Trong huyt thanh bnh
nhn thiu mu tan mu, cc thuc k trn c kh nng gn vo b mt hng cu v huyt
thanh ca bnh nhn c th ngng kt hng cu. Hng cu c th tan v nu c thm b th,
cn trong huyt thanh ngi bnh ban chy mu gim tiu cu, thy c khng th gn trn b
mt tiu cu v phn ng vi thuc.
B. TNG MN CM MUN
1.Nhng c im ca tng mn cm mun.
Trong nhng iu kin nht nh, hoc t nhin (nhim khun, tip xc vi mt s ho cht
c bit) hoc nhn to (min dch ho thc nghim vi cc khng nguyn protein, thng kt
hp vi tr cht Freund ton phn), s tip xc vi khng nguyn khng to ra khng th, song
li gy mt phn ng min dch c bit gi l tng mn cm mun . Phn ng ny pht hin
bng tim khng nguyn vo trong da, phn ng ti ch bt u t gi 4 6 v th hin r nht
sau 24 gi. Ch c th truyn mn cm bng t bo lympho, dng huyt thanh khng c tc
dng. Nhng c im ny phn bit tng mn cm mun vi tng mn cm tc th.
Ngoi ra, tng mn cm mun cn c nhng c im sau y :
- Thm nhim t bo n nhn (i thc bo v lympho) tp trung thnh m quanh mch
mu v dy thn kinh.
- Tng mn cm mun cn c th gy nn do cc khng nguyn ca vi khun hoc virut, trong
mt s trng hp do protein tinh khit, c khi do c nhng cht c trng lng phn t thp
(nhng hapten s tr thnh khng nguyn sau khi kt hp vi protein ca da hoc huyt
thanh).
- Phn ng c tnh cht c hiu ch pht hin vi khng nguyn dng gy mn cm,
song cng c th mn cm cho vi nhng protein c tnh cht khng nguyn tng t (th d
albumin g v vt).
- Tng mn cm mun vn pht sinh bnh nhn gim hoc khng cn gammaglobulin trong
mu.
C th ngi rt mn cm i vi tng mn cm mun. Tng mn cm mun l nguyn nhn
ca nhiu bnh , c bit l cc bnh d ng ngoi da. Ngoi ra, tng mn cm mun cn gy ra
loi tr mnh ghp v mt s bnh t min.
2.Tng mn cm mun thc nghim
Ngi v chut lang l hai loi ng vt rt r gy v rt r pht hin tng mn cm mun .
Trc khi tim , dung dch khng nguyn thng c nh tng ho trong tr cht freund
ton phn .
Thng tim vo trong da gan chn mt liu khng sinh rt thp . Trng thi tng mn cm
mun xut hin sau mt thi gian t nht l 5 ngy. cc hch khu vc , thy pht sinh nhiu s
thay i quan trng trong t bo : vng gn v pht trin v cha nhiu t bo a pirnin (t
mc ti a vo ngy 4 ) .
Ct b cc hch khu vc vo ngy th 3 s c ch mn cm chut lang . S tn ti ca h
lympho ph thuc tuyn c t ra cn thit to ra tng mn cm mun : ct b tuyn c khi
mi , mt s loi ng vt c tc dng c ch phn ng ny.
3. Pht hin tng mn cm mun.
a) Invivo : phng php thng dng nht l tim khng nguyn vo trong da (0,1 ml). phn
ng da bt u t gi th 6, t mc ti a sau 24 gi v i khi sau 48 gi. l mt phn
ng va c ban , va c thm nhim. Nhng phn ng mnh c th gy hoi t trung tm
song khng bao gi gy chy mu. ngi ta phn bit d dng phn ng ny vi tng mn cm
tc th, pht sinh rt nhanh sau 15 n 30 pht, thm ch ngay sau khi rt kim tim).
b) Invitro : trng thi tng mn cm mun, biu hin nh sau c ch di tn i thc bo,
hin tng lymphoblast ho, hin tng t bo, vv...
- c ch di tn i thc bo :ly t bo lympho ca mt con vt mn cm khng nguyn ,
em cy vi s c mt ca khng nguyn , ri ly i thc bo ca mt chut lang bnh
thng cho tip xc vi mi trng cy k trn, thy c hin tng c ch di tn i thc bo
(bnh thng sau 24 gi, i thc bo di chuyn ra khi ng mao dn, to thnh mt thm t
bo m ngi ta c th o c din tch).
Hin tng c ch di tn i thc bo ch gp trong tng mn cm mun : y, t bo
lympho mn cm tc ng thng qua mt yu t gi l MIF (migration inhibitory action, tc
l yu t c ch di tn), yu t ny xut hin trong dch cy t bo lympho sau khi tim khng
nguyn vo.
- Hin tng lympho blast ho. (cn gi l chuyn dng lympho bo) : nu thm khng
nguyn vo mi trng cy t bo lympho ca mt con vt trong trng thi tng mn cm
mun, thy nhng t bo ny c s thay i :xut hin nhng t bo ln a pyronin, trong
tng hp protein, N v ADN tng v hot tnh phn bo cao. Hin tng ny gi l blast ho v
t mc ti a sau 4 ngy. thm i thc bo vo mi trng cy t bo lympho, thy mc
blast ho tng .
4. Tng mn cm mun do nhim trng (cn gi l d ng nhim trng)
C nhiu bnh nhim trng trong c hin tng tng mn cm mun i vi vi khun hoc
i vi mt s thnh phn ca vi khun. Ni bt ln hng u l bnh lao : tng mn cm
tubeculin gp a s cc loi ng vt sau khi b nhim trng t nhin hoc thc nghim.
Ngoi bnh lao, tng mn cm mun cn gp trong nhiu bnh nhim trng khc : bruxela, lin
cu khun, thng hn, giang mai, mt s bnh do virut(quai b,vv... ), nhim nm, vv... Trong
a s bnh nhim trng, tng mn cm mun khng nh hng r rt ti din bin ca qu
trnh bnh l. Trong mt s trng hp khc, nh trong bruxela v c bit l lao, tng mn
cm rt mnh v c nh hng su sc ti qu trnh bnh l.
a)D ng lao : trong lch s nghin cu tng mn cm mun, chnh cc tnh trng d ng i
vi vi khun c nghin cu trc tin, in hnh l phn ng tubeculin v hin tng Cc.
- Phn ng tubeculin : trong phn ng ny, ngi ta tim vo da 0,1 ml tubeculin gi (cht ny
c ly khi un si v lc mt m nui cy vi khun lao) hoc tubeculin tinh ch PPD cc
m khc nhau, tuz theo mc mn cm ca i tng.
chut lang gy bnh lao t 4 8 tun, khi tim tubeculin vo da, 24 n 48 gi sau thy
mt thm nhim vim ti ch, nu liu lng v mn cm chut s b st, cc tn thng
lao c s pht trin thm. Tim tnh mch, chut s b st sau 1 2 gi cao nht vo gi th
6 v ko di khong 10 gi, ng thi c phn ng ni tn thng song khng c nhng biu
hin tc th kiu qu mn.
ng ch { l tim cho chut lang cha b nhim trng d nhiu ln cng khng c tai bin g.
-Hin tng Koch : y l mt hin tng c bn c tm qu trnh c bit. M u cho rt
nhiu cng trnh nghin cu v tng mn cm trong cc bnh nhim trng . Nh bc hc Koch
tim vo da mt chut lang bnh thng mi trng cy trc khun lao v trong nhng ngy
sau ni tim , khng thy g khc thng .
Ti ngy 10 14 ch vim ni cc, lot nhanh, ko di, hch trong vng sng ln, vi khun lan
trn theo ng bch huyt v lm cho chut cht.
mt chut lang gy lao trc 4 6 tun, khi tim trc khun ln th 2, ti ni tim
thy phn ng khc hn, ngay ngy th nht hoc ngy th hai thy mt phn ng vim
rng v bu mu, sang ngy th t pht sinh hoi t , ng vy, bong ra, nhng hch trong
vng khng sng, chng t trc khun ca ln bi nhim b loi tr, khng lan trn c v
da ca chut lang nhim lao phn ng khc hn so vi da chut lang bnh thng . Dng trc
khun cht, thm ch dng tubeculin gi cng t kt qu tng t.
- nh hng ca tng mn cm i vi tn thng t chc th hin rt r trong bnh lao,
hn hn so vi cc bnh nhim trng khc .
Hoi t ch yu gp trong lao . ngi , hoi t thng xuyn gp , ngay c nhng lao tim
cng thy hoi t .
Nhiu s kin nu bt vai tr ch yu ca tng mn cm trong hnh thnh hoi t lao :
Trong lao thc nghim , hoi t lao ch pht sinh sau mt thi gian ng thi vi tng
mn cm .
Nhng yu t g tng cng mn cm cng ng thi tng din tch hoi t : th d , bc trc
khun cht bng du paralin thy mn cm tng r rt ng thi hoi t cng tng .
Mc tng mn cm i vi lao thay i tuz loi ng vt :
Nhng loi mn cm yu (chut nht , chut cng ) thng t thy hoi t v tri li ngi -
mn cm nht i vi lao thy hoi t rt ph bin.
Nh vy, mi lin quan gia tng mn cm v hoi t r rng.
5. Tng mn cm mun do tip xc
Mt hnh thc p ng min dch kiu t bo l phn ng da tip xc vi cc ho cht khng
c i vi da : l nhng bnh vim da do tip xc. Trong cc bnh ny hay thy ban ,
mn nc, nga, v t chc hc , nt ni bt l thm nhim bch cu n nhn kh tr quanh
cc mch mu v lan ti vng biu b. gia ln tip xc u tin v ln tip xc th hai vi ho
cht, cng cn phi c mt thi gian tim tng t nht l 5 ngy. c th pht hin trng thi tng
mn cm bng cch th nghim da (cn gi l test da) thng thng v phn ng dng tnh
th hin rt r sau 24 48 gi.
Rt nhiu cht c th gy vim da do tip xc. Vi s pht trin ca ho hc, s cht ny ngy
cng tng. bnh ngoi da do tip xc ngy nay l mt loi bnh ngh nghip ph bin nht. Cc
ho cht c th c trng lng phn t thp, chng c kh nng gn vo cc protein, c bit l
protein ca biu m t mt aapten bin thnh mt khng nguyn hon ton. ng ch { l
cng trong iu kin nh nhau, ch c mt s cng nhn ho cht b vim da do tip xc, iu
ny ni ln vai tr ca t bm c nhn trong sinh bnh hc.
6. Vai tr ca tng mn cm mun trong ghp
T lu ngi ta bit vai tr ca cc phn ng min dch trong hin tng loi thi c quan
v t chc ghp. nhiu cng trnh nghin cu cho bit min dch trong ghp pht sinh theo
c ch tng mn cm mun.
Thm nhim bch cu n nhn ni ghp ch c th truyn min dch ny bng t bo
lympho mn cm, cc t bo lympho cc hch khu vc pht sinh nhiu s thay i
(lymphoblast ho)vv...
7. Vai tr ca tng mn cm mun trong bnh t min
C in, ngi ta cho rng mt c th khng bao gi c kh nng sn xut khng th chng
li nhng t chc ca chnh mnh. Ngy nay, ngi ta thy rng khng hon ton nh th. M
c th c th phn ng li vi khng nguyn ca chnh mnh. Ti sao c th khng nhn ra cc
t chc ca chnh mnh, li gy ra cc tn thng thc th v ri lon chc nng, tc l bnh t
min ? Bn kh nng hnh thnh t khng nguyn trong c th c th xy ra :
a) Phn ng t min do mt dung np t nhin. trng hp ny xy ra vi cc t chc tuyn
gip, tinh trng, myelin, nhn mt,vv... Trong c th, cc t chc ny vn tn ti t thi kz bo
thai, nhng v tr bit lp, khng c mu ti nn khng tip xc vi h thng t bo c thm
quyn min dch. Nu v mt nguyn nhn no (chn thng, m x,..) dn ti s tip xc
ny chng s b coi nh mt khng nguyn l. cc t bo c thm quyn min dch cha h
gp chng nn chng li t khng nguyn t nhin ny: hnh thnh cc t bo lympho mn
cm v t khng th chng li cc t khng nguyn ny, gy ra tn thng thc th v ri lon
chc nng, v bnh t min pht sinh.
b) T chc c th bin cht tr thnh l i vi c th. Do tc ng ca cc yu t
bnh l (nhim trng, chn thng, phng x,vv... ) mt s t bo t chc c th b tn thng
v thay i cu trc, tr thnh l i vi c th. By gi, c th s hnh thnh cc t bo
lympho mn cm v t khng th chng li t khng nguyn ny gy ra hi chng t min dch
trong cc bnh bng, phng x, nhim c, nhim trng, vv...
c) Vi khun lt vo c th c cng khng nguyn vi t chc ca c th. Trong trng hp
ny, khng th khng vi khun ng thi khng c t chc ca c th c cng khng nguyn vi
vi khun gy bnh. T khng th loi ny xut hin trong c ch bnh thp tim : cht hexozamin
c trong polyosit ca lin cu khun tan mu nhm A cng c trong glucoprotein van tim, nn
khng th khng lim cu khun cng khng lun c van tim, gy ra tn thng van tim.
d) Ri lon b my kim sot min dch , gp trong lm sng (thiu mu tan mu mc phi,
luput ban , nhc c nng,vv... ) thy cc khng nguyn trong cuc vn bnh thng, do
c th ngh rng, b my kim sot min dch b ri lon ti mc khng th nhn ra nhng
khng nguyn ca chnh mnh, nn phn ng vi chng. Theo Burnet, trong iu kin bnh
thng, mt s clon (dng) t bo vn c kh nng chng li cc khng nguyn ca bn thn.
vo cui thi k bo thai, cc khng nguyn ny b loi ra khi c th, hoc b b my kim sot
min dch c ch hot ng. Ngi ta gi l clon cm. Trng hp b my kim sot min
dch b suy yu, cc clon cm khng b km hm na , chng thc tnh, sn sinh mnh m s
gy p ng min dch kiu t bo hoc th dch, tnh trng t min ny c th c th cng mt
lc gy tn thng nhiu c quan, t chc khc nhau (th d bnh luput ban ri rc).
Ngoi ra, tuyn c, chi phi b my kim sot min dch, cng gi vai tr quan trng trong
vic loi tr cc clon cm. Thc t, trong nhiu bnh t min thy tuyn c khng c bnh
thng.
Cui cng, v c ch cc tn thng t min, mt cu hi c t ra : do khng th lu
ng hay do t bo mn cm gy ra ?
Vai tr ca khng th. Khi nim c in ny cho rng khng th gn vo khng nguyn c
hiu, vi s c mt ca b th gy nn tn thng t bo t chc.
Vai tr ca t bo mn cm. khi nim ny, mi m hn, nhn mnh ti vai tr ca duy nht
ca t bo mn cm c hiu trong pht sinh tn thng t min:
- hnh nh t chc hc tng t nh trong mn cm mun m c im l thm nhim t bo
n nhn.
- tn thng t chc v mc tng mn cm mun thng song song.
- Ngoi ra c th gy cc tn thng t min bng cch truyn cc t bo lympho ng vt
mn cm.
Vai tr ca c khng th v t bo mn cm.
Trong thc t, c hai yu t u c tc dng, hoc ring r, hoc tc ng qua li (c th hip
ng hoc i khng).


39. BNH SINH HC

NGUYN HU M

I. I CNG
Bnh sinh hc l mn hc nghin cu c ch pht sinh, pht trin v kt thc ca bnh.
Bnh nguyn hc v bnh sinh hc c lin quan cht ch vi nhau : bnh nguyn hc tm hiu
bnh do au m c, cn bnh sinh hc nghin cu bnh tt xy ra nh th no, tm hiu xem
nhn t gy bnh tc ng ln c th nh th no, qu trnh bnh l din bin ra sao, tun theo
quy lut g ?
Trong cng tc iu tr nu ta bit c c ch bnh sinh th c th ngn chn sm nhng
pht trin xu ca bnh , hn ch c tc hi.
* Vai tr ca yu t bnh nguyn trong qu trnh bnh sinh :
yu t bnh nguyn c vai tr khc nhau trong cc bnh :
a) Yu t bnh nguyn ch tc dng trong thi gian ngn, c tc dng khi ng, sau qu
trnh bnh sinh t n pht trin. th d trong bng do la yu t nhit ch tc ng trong
mt thi gian ngnv gy ra tn thng t chc nghim trng, nhng tn thng ny li gy ra
c mt chui phn ng phc tp (sc bng, nhim c, nhim trng, suy mn,vv...) to iu
kin cho bnh pht trin, mc d nguyn nhn ban u ht tc dng.
b) Yu t bnh nguyn c th tn ti trong sut qu trnh bnh sinh vi cc tnh cht khng
thay i v ng vai tr quyt nh trong qu trnh ny, lm cho ngi bnh cht nhanh chng
nh khi b in git, nhim c nng, vv...
c) Ngoi ra nguyn nhn gy bnh c th tn ti trong c th trong sut qu trnh bnh l,
song tc ng ca n thy i tuz theo trng thi ca c th. Th d trong bnh thng hn, vi
khun Samonella l yu t gy bnh, pht sinh nhim khun huyt lc ban u, sau hnh
thnh min dch, gy hin tng d ng tun th 3, cui cng vi khun khu tr ti mt v
khng cn kh nng gy bnh cho chnh ngi d na nhng vn c th reo rc bnh cho ngi
khc.
Vai tr ca yu t bnh nguyn cn ph thuc vo ng vo c th ca yu t gy bnh :
i vi mt s bnh mm bnh c th vo c th theo nhiu ng khc nhau, gy ra nhng
bnh khc nhau. Th d bnh thng hn c th mt, th mi, th da, th hu vi nhng c
im bnh l khc nhau.
Kinh nghim thng ngycho bit : ngoi yu t bnh nguyn, bnh pht sinh hay khng,
din bin th no, kt thc ra sao, vv... ch yu ph thuc vo sc chng , tnh phn ng ca
c th.
Ni dung ca bnh sinh hc bao gm nhiu vn quan trng :
- Bnh pht sinh v pht trin ch yu thng qua c ch phn x
- Vn ton thn v ti ch trong bnh sinh
- Quan h nhn qu v khu chnh trong bnh sinh
- C ch phc hi sc kho
- Nhng nguyn tc chung v iu tr, iu tr bnh sinh
II. VAI TR CA TNH PHN NG TRONG BNH SINH
Tnh phn ng l kh nng p ng ca c th i vi mi kch thch bnh thng hoc bnh
l. Ngoi nhng c tnh do i trc truyn li, tnh phn ng cn bao gm cc c tnh c th
hnh thnh trong cuc sng. Do nhng c th khc nhau, tnh phn ng thng khc
nhau. Bnh pht sinh hay khng , din bin ra sao, kt qu nh th no ch yu ph thuc vo
tnh phn ng ca c th. Cn phi thy r : i tng ca thy thuc khng phi l bnh tt
m l bnh nhn c th. C nghin cu k tnh phn ng ca c th mi hiu c c ch bnh
sinh v kh nng hi phc ca c th khi b bnh, to iu kin tt cho cng tc phng v cha
bnh.
Rt nhiu yu t nh hng ti tnh phn ng ca c th :
- yu t thn kinh
- yu t ni tit
- yu t gii tnh
- yu t mi trng
A - NH HNG CA THN KINH
1. nh hng ca thn kinh cao cp : thn kinh cao cp c nh hng r rt ti tnh phn ng
ca c th.
a) tuz theo trng thi ca v no (hng phn hoc c ch) qu trnh bnh l c th c nhiu s
thay i. Th d trong s do truyn nhm nhm mu c th xy ra mt cch im lng bnh
nhn gy m su (v no b c ch), tri hn vi cc yu t m xy ra bnh nhn tnh.
b) lai thn kinh cng nh hng su sc ti tnh phn ng. Nhng ngi thuc loi thn kinh
yu thbt c mt cm gic au nh, khc thng no trn mi b phn ca c th (nhng ci
mi ngi thng xuyn gp nhng khng ) thng qua t m th v tm l lo lng, tng l
mnh mc bnh nghim trng. V th nhng cm gic nh y khng nhng khng mt i li
c duy tr, cng hng mnh thm ln, gy ra nhng triu chng bnh l. triu chng
c hnh thnh ny li thng qua tm l bnh hon ca t m th thnh mt vng lun qun,
dn ti nhng ri lon sinh l thc s, y l c ch pht sinh ca lonn thn kinh chc nng.
Cao hn, cc ri lon ny c nhn ln bi tng tng hoang ng v bn th v gy ra v
s nhng triu chng bnh tt c o, kz d nh : bng nhin cm, m, ic, lit 2 chn, ln
ln vt v, co un kch ng, vv...
Mt s ngi thuc loi thn kinh mnh nhng khng thng bng cng d c hnh vi bt
thng trong cuc sng cng nh khi c bnh. Thc t chng minh : i khi do nhng xc
cm bt pht m ngi ta c th ni hoc lm nhng vic m khng bao gi h t cho php
mnh lm khi bnh tnh, ri li hi hn khi cn cm xc qua.
Vi nhng ngi thuc loi thn kinh mnh khi b bnh, m au lu, v no b suy yu do lo
lng, nhng lo lng suy tng ny cng thm bnh c sn lm cho bnh cng nng thm.
c) Li ni v t tng cng nh hng r ti tnh phn ng ca c th. Mt li ni v thc
cng c th gy rab hoc lm bnh nng thm. Pap-lp ni : Li ni i vi con ngi l
mt kch thch tht s, c iu kin nh tt c cc kichs thch khc ... c bit nhng cu ni
khng cn nhc ca nhn vin y t v bnh nhn u c th nh hng n tm thn ca h.
N tc ng trc tip n tm thn bnh nhn , Th d trc mt mt bnh nhn ni v mt
bnh nhn khc cng bnh nhng cha khng khi. Cho nn trnh gy thm bnh, cc nhn
vin y t cn phi thn trong khi trao i v chuyn mn vi nhau v phi tun th cc quy
nh tm l{ i vi tng bnh nhn.
trnh gy cho bnh nhn nhng chn thng tm thn , nhn vin y t phi bit tin hnh
kp thi tm l liu php vi bnh nhn. bng nhng bin php n gin nht nh an i, thuyt
phc, ng vin, ngi thy thuc c th lm cho bnh nhn an tm, tin tng s khi bnh,
chu ng c cc chn thng tm thn v t mnh u tranh cho bnh chng khi. Trong
mt s trng hp, tm l liu php li c tc dng hn c thuc men k thut. Theo
Platnp, tm l{ liu php rt c hiu qu i vi mt s bnh ri lon chc nng do nguyn
nhn tm thn. Trong iu tr, kt hp nhng cht khng lin quan (thng gi l thuc gi) vi
li ni thuyt phc thy c nh hng tt ti din bin ca nhiu bnh : ht au u 59%
bnh nhn, ht say sng 58% bm, ht lon thn kinh chc nng 34% bnh nhn, vv...
Tm l liu php cn thit i vi tt c cc chuyn khoa. Ngi thy thuc d rt gii chuyn
mn song khng hiu tm l bnh nhn v khng bit cch tc ng n n th kt qu iu tr
nht nh b hn ch. Ngi thy thuc lun nn nh rng trc mt h l mt bnh nhn m
tm thn mc t nhng ang b tn thng v v vy nhng li ni thiu thn trng ca
ngi thy thuc v ngay c s i ging v nhng c ch thiu suy ngh c th li mt du
vt khng phai m. Do mt s trm ngm chm ch v mt ci lc u m chiu chng hn
khi c cc phim X-quang , c cc phiu xt nghim, nhng t ni ra bnh nhn khng hiu
(ni thm) ... u c th lm cho bnh nhn lo ngi.
Xc cm tm l l mt nguyn nhn gy bnh. Cch y hn 4000 nm, cc sch y hc c ca
phng ng vit tht tnh l ngun gc ca bnh tt (tht tnh l 7 loi tnh cm : vui,
gin, yu, ght, ham mun, u t, khip s) v gii thch : tnh cm mt thng bng lm ri
lon kh cht, t gy ri lon sinh l{ c th. Danh y Tu Tnh tng cha nhiu bnh khng
cn thuc m ch cn cha mo bng li ni cng khi, iu chng minh y hc dng m
th cha bnh ngay t rt xa xa. ngy nay nhiu nc tin tin p dng phng php
m th thi min vo nhiu lnh vc y hc.
d) khi mc mt bnh cp tnh (nhim trng, nhim c cp) thot tin pht sinh c ch ton b
v no : bnh nhn t phn ng i vi kch thch bn ngoi, phn x c iu kin gim st. Qu
trnh c ch c tnh cht t v ca v no gii phng cc trung khu thc vt di v v tng
cng h thng di th tin yn v thng thn, dn ti : mt mt qu trnh hng phn
nhng trung khu thc vt c dn truyn theo ng giao cm v ph giao cm ti cc ni
tng iu ho chc nng ; mt khc h tin yn v thng thn tit ra nhng hormon
(ACTH, cocticoit ng v khong) tc ng ti phn ng vim, vv... Trong trng hp bnh
qu nng, qu trnh c ch lan ti cc trung khu di v lm suy yu mi chc nng khng
ca c th (c ch bnh l).
2. nh hng ca thn kinh thc vt
Khi thn kinh giao cm hng phn, chuyn ho c bn tng, thc bo tng, sn xut khng
th c hiu b c ch song sn xut khng th khng c hiu tng.
Khi thn kinh ph giao cm hng phn, sn xut khng th c hiu tng, tri li sn xut
khng th khng c hiu b c ch, thc bo gim, cc hng ro bo v (nh hch bch huyt )
tng cng hot ng.
B - NH HNG CA NI TIT
Tnh phn ng ca c th chu nh hng su sc ca h thng ni tit, ch yu l tin yn v
v thng thn. Theo Xi-lai bt c mt kch thnh mnh no ca ngoi mi tc ng ln c th
u c th gy ra mt chui phn ng khng c hiu kt hp vi nhau thnh hi chng thch
ng chung m c s hot ng l ni tit, c th l hormon ca tin yn v v thng thn
(xem bi khi nim v bnh)
Khi b kch thch mnh, trung tm di th tit ra mt s hormon thn kinh (cn gi l yu t
gii phng) nhng hormon ny c dn ti tin yn bng ng mu, thuz trc tin yn bt
u tng tit ACTH, hormon ny kch thch v thng thn gy tng tit coctisol. Sau tin
yn tng tit STH, dn ti tng tit aldosterol.
1. Vai tr ca ACTH v coctisol
Coctisol c vai tr chng vim v chng d ng.
a) chng vim :
- coctisol c ch mi nhn t ca qu trnh vim d l vim do vi khun, d ng hay mt
nguyn nhn ho hc khc.
- coctisol hn ch phn ng i thc bo, c ch s pht trin ca t chc lin kt, t chc
ht, gim tnh thm thnh mch, gim ph n v tit dch, hn ch s hnh thnh ca mao mch
tn to.
- tuy chng c vim nhng coctisol khng ngn nga c nhng tn thng hoi t do
mn bnh gy ra.
b) chng d ng :
- coctisol khng ph hu nhng khng th c tim vo c th, v ch trc tip c ch qu
trnh min dch ch ng.
- Coctisol gy thoi bin cc t chc bch huyt , gy tan v cc t bo lympho v tng bo,
c ch phn ng tng bo v c ch hot ng thc bo. v th s lng tng bo v
gamma globulin gim trong cc t chc bch huyt v t chc vim, dn ti hn ch tng hp
khng th.
Qua s phn tch trn, thy r coctisol mt mt hn ch cc phn ng d ng ton thn v ti
ch (chng d ng), mt khc lm suy yu sc chng ca c th (chng vim). Do nhng tc
dng trn, coctisol rt c hiu qu vi nhng bnh vim nhim d di, nhng bnh d ng,
nhng th tng mn cm ca cc bnh nhim trng. Tri li coctisol ch ng hn ch khi c th
suy kit, khi mn bnh khng c khng sinh c hiu, vv... Dng liu cao i vi ngi v ng
vt c th tng kh nng mc bnh i vi nhiu loi vi khun.
2. Vai tr ca STH, DOC v aldosterol :
Tc dng ca STH i lp vi ACTH v coctisol.
- STH tng cng qu trnh vim, kch thch t chc lin kt tng sinh, qua c tc dng
chng nhim trng. Khc vi DOC (desoxycocticosteron), STH cn c tc dng chng hoi t.
- STH tng cng s pht trin ca tng bo trong cc t chc bch huyt, tng tng hp
globulin v khng th.
DOC v aldosterol c tc dng iu ho chuyn ho nc, in gii (gi NA, thi K). tc dng
ca aldosterol mnh hn DOC. Tri vi coctisol, hai hormon ny u tng cng phn ng vim
(tng sinh t bo x non ca t chc ht, pht trin mao mch v tng cng phn ng tng
bo).
C - NH HNG CA GII TNH
Mt s bnh hay gp nam gii (lot d dy, t trng, nhi mu c tim, u c phi). Tri li
n gii hay gp nhng bnh nh vim tuid mt, u c v, Isteri, vv...
D - NH HNG CA TUI
Mi tui li c nhng c im phn ng ring i vi bnh tt. tnh phn ng ca c th
yu khi cn nh, tng ti tui dy th v gim lc tr v gi. Do bnh thng chia lm bnh
ca tr s sinh, bnh ca tr em, bnh ca tui dy th, bnh ca tui thanh nin v bnh ca
ngi gi.
1. Tnh phn ng ca tr s sinh v ang b.
- h thng thn kinh, c bit l thn kinh cao cp cha pht trin y , nn cn st loi
tui ny rt mnh (d gy co git) song chng lui.
- Cc h thng hng ro chng nhim trng (da, nim mc, hch bch huyt) cha kin ton.
- Trong mu khng c hoc c rt t khng th t nhin. khi tr ln ln, nhng khng th t
nhin ny xut hin dn trong mu v a tr cng dn ra khi trng thi khng phn ng.
Tui s sinh khng th sn xut khng th ngay c khi gy min dch ch ng (tim chng) ; tr
s sinh ging nh tnh trng ngi khng c gamma globulin trong mu. nguyn nhn chnh l
v tr s sinh khng c tng bo (trong tu xng v hch bch huyt) l nhng t bo sn
xut khng th. Tuy nhin tr s sinh c th thy khng th t mu m truyn sang qua nhau
thai trong thi kyd bo thai. Nhmg s gamma globulin ny gim dn trong 3 thng u. T
thng th t tr i, trong c th bt u c phn ng tng bo, lc khng th bt u
c sn xut trong c th tr em.
- Ngoi ra hot ng thc bo tr s sinh ni chung cn yu.
- Ngoi trng thi khng phn ng ca ton thn, da ca tr s sinh v tr ang b cng
khng c tnh phn ng. V th tui ny, nhng phn ng d ng ngoi da thng khng r
rt. Phn ng vim ngoi da tui ny cng yu, nn thng c xu hng b nhim trng m
mu mi khi b nhim t cu khun hoc lin cu khun qua da, v qu trnh phn ng vim
ngoi da cc hch bch huyt hu nh khng c do tui ny khng c phn ng vn mch
v h thn kinh cha pht trin.
Nhng c im ca tnh phn ng ca tr s sinh v ang b c nh hng r rt ti bnh
tt ca la tui ny:
- tr t mc si, rubeon, vv... v c khng th ca m truyn sang. T thng th 4-5-6 tr i,
cc khng th t m mt dn, ng thi tr cha c min dch t nhin ch ng nn bt u
c kh nng mc bnh.
- V tnh phn ng yu nn trn lm sng, mt s bnh la tui ny khc vi ngi ln ,
thng khng in hnh. c bit nhng bnh nh si, ho g, bch hu, nhim trng mu, vv...
tr di 2 tuoo thng tin trin rt nng v t l cht cao hn so vi tr ln.
2. Tnh phn ng tui thanh nin
Khi ln ln, tnh phn ng c tng cng theo s pht trin v kin ton ca h thng
thn kinh , ca cc hng ro t v (da, nim mc, hch bch huyt ) v ca c kh nng sn xut
khng th. triu chng lm sng tui thanh nin thng r rt, in hnh , nhiu khi d di
nhng li c kh nng phc hi mau chng.
3. Tnh phn ng ca ngi gi
Khi v gi, tnh phn ng li gim v h thn kinh, h thng hng ro phng ng , kh nng
sn xut khng th, hot ng thc bo u gim. tui ny bnh thng tin trin khng r
rng, khng in hnh, khng d di nhng thng nng, phc hi chm, t l cht cao.
E - NH HNG CA NGOI MI
Mi trng bn ngoi nh hng su sc ti tnh phn ng ca c th nh nh sng, tia x,
nhit , thc n, cht c, vv... v c bit i vi con ngi l hon cnh x hi.
Ai cng bit nhim lnh lm gim sc chng ca c th i vi nhim trng ; sc chn
thng thng d pht sinh v din bin nng nhng thng binh b nhim lnh.
Nhng ho cht gy nhim c ko di cng lm thay i tnh phn ng ca c th. Nghin
ru gy vim d dy, x gan, do lm gim sc chng ca c th i vi s xm nhp
ca vi khun, d pht sinh bnh.
Nhng tia nh sng hay tia x lm thay i tnh phn ng : tia t ngoi vi liu lng thch
hp c tc dng tng cng sc chng ca c th i vi nhim trng, tri li liu ln c th
gy bng.
* Dinh dng v sc chng ca c th :
Tnh trng dinh dng nh hng su sc ti tnh phn ng ca c th. Trong lch s nhn
loi, i v dch thng i i vi nhau, nh t v bnh dch cng vy. Dinh dng y lm
tng sc chu ng ca c th i vi nhim trng, nhim c. Tri li dinh dng km, khng
cn i u lm gim sc chng ca c th.
1. Vai tr ca protein.
Trong dinh dng , yu t quan trng c bit i vi sc chng ca c th l protein. C
th ni d tr protein trong c th l hng ro t v chng li nhm trng (Madden v
Whipple). Trong thc nghim , ng vt n thiu protein thng d pht sinh nhng nhim
trng t nhin (vim phi, pe, nhim trng mu, vv... ) Trn lm sng, nhng ngi b ph do
thiu protein thng d pht sinh nhng bnh ng h hp, v nhiu bnh khc. nhng bnh
nhn tr em gy cm syt dinh dng hay b bi nhim, vi nhng bnh nhn suy kit, truyn
mu v huyt tng cho kt qu tt. Nh bit, protein n vo l ngun cung cp nguyn liu
(axit amin ) tng hp khng th; ngoi ra thiu protein trong dinh dng cn lm gim hot
ng thc bo.
2. Vai tr ca vitamin
n ung y vitamin lm tng sc chng d ca c th i vi bnh tt, c bit i vi
nhim trng .
a) Vitamin A. thiu vitamin A, sc chng t v ca cc nim mc b gim st, v thiu
vitamin A gy lon sn biu m v lm ri lon qu trnh oxy ho ca biu m. ngi thiu
vitamin A hay b vim hng , vim tai gia, nhim trng ng kh qun trn, vim phi, vv...
b) Vitamin nhm B lm tng sc chu ng ca c th i vi nhim trng v chng c vai tr
quan trng trong qu trnh chuyn ho t bo oxy ho trong c th, nh hng ng thi ti
sc ln, ti chc nng tit dch ca d dy, ti trng lc c rut, ti chc nng to mu, ti
chc nng h hp ca h thng thn kinh, vv... trong thc nghim tim virut bnh st vng vo
no chut, l chut c n vitamin nhm B sng 76,4%, cn l chng ch sng c 16,7%.
c) Vitamin C : thiu vitamin C lm gim r rt sc chng ca c th i vi nhim trng v
vitamin C cn thit cho qu trnh oxy ho v qu trnh hi phc ca chuyn ho t bo. trong
c th b nhim trng, phn ng oxy ho t bo thng tng cng nn tiu th vitamin C rt
nhiu, v th thiu vitamin C l mt c im ca bnh tuyn nhim. thiu vitamin C cn c ch
hot ng thc bo v hn ch kh nng min dch (gy teo t chc lympho, dn ti gim sn
xut khng th).
d) Vitamin D cng tham gia mt phn vo sc khng chng nhim trng v vitamin D duy tr
th cn bng ca qu trnh dinh dng v cc qu trnh oxy ho trong t bo.
3. suy dinh dng v c im lm sng bnh nhim khun.
nhng bnh nhn suy dinh dng, thiu protein, thiu vitamin, tnh phn ng v sc chng
ca c th gim st. Cho nn thng c nhng c im lm sng sau y :
- Nhit khng cao lm, c khi khng st, ngay c nhng bnh cp tnh nh cm, vim phi,
nhim trng mu, vv... C khi thay i hn chu kz bnh nh trong st rt, st hi quy, vv...
- Phn ng bch cu yu, c th khng c.
- Hiu gi ngng kt nhng phn ng huyt thanh c hiu thng thp,thm ch phn ng
m tnh v sn xut khng th gim. khng thy gan , lch sng mt cch r rt trong nhim
trng mu, thng hn, st rt, vv...
- Lm sng bnh thng khng r rt, khng in hnh, bnh hay tin trin nng, ko di, d
ti pht, t l cht cao.
- ch dng thuc iu tr nguyn nhn gy bnh m khng ch p dng nhng bin php
tng sc chng ca c th (tip t protein, vitamin, l liu php, min dch liu php, vv...),
kt qu s hn ch.
Mt khc ngi ngi suy dinh dng v tnh phn ng yu nn t mc nhng bnh pht sinh
ch yu theo c ch d ng nh hen ...
III. BNH PHT SINH V PHT TRIN CH YU
THNG QUA C CH PHN X
Kch thch bnh l tc ng trn c th trc tin gy tn thng t chc, ri lon chuyn
ho v ri lon chc nng ti ch b kch thch. ng thi, kch thch bnh l{ cn tc ng ln
cc th th v thng qua c ch phn x gy ra mt chui phn ng ton thn phc tp. Th
d khi b thng nng ngoi tn thng ti ch , cn pht sinh mt trng thi suy xp t ngt
ton b cc chc nng quan trng ca c th (sc) : h thng thn kinh trung ng hng phn,
sau b c ch (lc u l c ch bo v, sau l c ch bnh l ). huyt p gim, mch
nhanh yu, h hp nng v nhanh, thn nhit gim, gim cm gic, gim phn x, thiu niu
thm ch v niu, vv... Nu kp thi tc ng trn cung px (phong b Novocain, tim morphin,
thuc lit thn kinh, vv...) thy cc ri lon trn gim hoc trnh c sc.
Ngoi c ch phn x khng iu kin, bnh cn c th pht sinh theo c ch phn x c iu
kin. Sau nhiu ln kt hp vi kch thch bnh l, , mt kch thch khng lin quan (c iu kin
) c th gy ra bnh. Trong thc nghim, da vo c ch phn x c iu kin, ngi ta c th
gy nhim c morphin, long no, vv... bng cch tim cho ch dung dch sinh l. Trn lm sng,
phn x c iu kin bnh l c th gy ra mt s qu trnh bnh l (co tht ng mch vnh,
au qun gan, qun thn, vv...)
C ch thn kinh th dch l mt khu quan trng trong qu trnh iu tit cc chc nng
ca c th. Gia h thn kinh v h ni tit c mt mi quan h mt thit ; ng vt cao cp
v ngi, mi tng quan gia v no, di th, tuyn yn v thng thn c vai tr v cng
quan trng trong bnh sinh hc. C h thng chi phi kh nng thch ng phng ng ca c
th, chi phi cc phn ng khng c hiu ca c th i vi tc ng ca bt c mt kch thch
bnh l{ no. Nh vy, c ch phn x - c ch bnh sinh ch yu thc hin bng 2 con ng
kt hp cht ch vi nhau : ng thn kinh th dch.
Gia v no v ni tng c mi quan h qua li mt thit c Bu-cp chng minh v pht
trin thnh hc thuyt v no ni tng. Nh bit, bnh thng v no trong trng thi
hng phn nn c tc dng cm ng m tnh i vi cc trung khu di v, tc l iu tit , km
hm hot ng ca cc trung khu ny. tri li, khi v no trong trng thi b c ch , trung khu
di v c gii thot, do pht sinh hng phn hn lon (cm ng dng tnh) v gy ra
nhiu ri lon thc vt : co tht mch mu, ri lon phn tit v vn ng d dy rut, ri lon
ni tit, ri lon chuyn ho, vv... Nu ri lon thn kinh ch l tm thi th cc chc nng s
dn dn hi phc, tri li, nu ri lon thn kinh ko di, hot ng ca cc ni tng thay i
v khng ngng truyn nhng xung ng bnh l ln trung khu thn kinh, kt qu l tng cng
mi quan h gia v no v trung khu di v, gy ra mt vng xon bnh l lm cho bnh tip
tc pht trin. Bnh l hc v no ni tng ly nguyn l{ ny lm c s. Bnh huyt p cao,
bnh lot d dy t trng v mt s bnh khc c th pht sinh, pht trin theo c ch ny .
phc hi li chc nng ca v no v trung khu di v (iu tr bng gic ng) trong mt s
trng hp thy c hiu qu tt.
IV. VN TON THN V TI CH TRONG BNH SINH HC
1. Quan nim sai lm :
Trong y hc, cn tn ti xu hng chia bnh ra lm bnh ton thn v bnh ti ch. chu nh
hng ca Vic-sp, cc tc gi ny cho rng bnh ch l mt qu trnh ti ch do tc ng trc
tip ca cc nhn t bnh l. T qu trnh ti ch chuyn sang ton thn, h cho l do tc
ng ca nhn t gy bnh trn din t bo rng ln hn.
Quan im trn sai v nguyn tc v ph nhn tnh thng nht ca c th. Ngoi ra khng
c bnh no hon ton l ti ch, cng khng c bnh no hon ton l ton thn. nhng bnh
thot nhn cho l ti ch (vim, u c, vv... ) song trong thc t qu trnh bnh sinh l thuc vo
trng thi ton thn, ng thi nh hng su sc ti ton thn ; tri li nhng bnh thot nhn
th thy ch ri lon ton thn (phn ln cc bnh truyn nhim) song thc t mt s c quan
, t chc no c nhng thay i v cu to v chc nng quan trng.
2. Bnh l mt phn ng ton thn m biu hin ti ch l ch yu.
Qu trnh bnh l ti ch ph thuc vo tnh trng ton thn, ng thi nh hng su sc
ti ton thn.
a) Ton thn nh hng ti ch : tuz theo tnh phn ng ca c th, mt bnh c th din
bin khc nhau nhng bnh nhn khc nhau, do c cu : khng c hai bnh nhn hon
ton ging nhau. Th d phn ng vim ph thuc nhng yu t : tui (ngi gi phn ng
vim yu hn thanh nin), tnh trng dinh dng ca c th (khi i n vim d nng), tnh
min dch (vim d di c th c mn cm sn), h vng ni m (vim nng hn khi h ny
b c ch ), h ni tit (c bit l tin yn v v thng thn), h thn kinh trung ng (h
thn kinh cng bit ho, phn ng vim cng r rt v phong ph).
Mi ngi u r, ton thn kho mnh th sc chng ti ch cng tt hn, do
nhn t gy bnh kh xm nhp vo c th hoc nu vo c th cng nhanh chng b o
thi ra ngoi. Th d vt thng chng lnh nu ngi bnh c n ung y , hoc
ngi c min dch tt th vi khun khng xm nhp vo c th c. Theo quan im ca y
hc phng ng c truyn th cha bnh c bn l lm cho c th b bnh vng ln, khc
chng c mi nhn t gy bnh, l thm nhun mi lin quan gia ton thn v ti ch.
b) Ngc li, qu trnh bnh l ti ch c th nh hng su sc ti ton thn. Ni chung, mt
qu trnh bnh l ti ch vi mt cng nht nh c th gy ra nhng thay i v cu to v
chc nng xa ni b bnh. Th d bng nng c th gy ra mt chui phn ng ton thn phc
tp, thm ch pht sinh sc : ri lon thn kinh trung ng (hng phn ri c ch), huyt p
gim, mch nhanh yu, th nng nhanh, mu c, ri lon tit niu (thiu niu hoc v niu),
vv...
kt lun , ta thy r bnh l mt phn ng ton thn m biu hin ti ch l ch yu.
Nhng qu trnh c gi l ti ch thc t ch l mt b phn quan trng ca mt h thng
phn ng phc tp, ch l biu hin ti ch ca mt bnh ton thn, do khng th tch ri
ti ch v ton thn m phi thng nht mt cch bin chng. Cho nn trong chc bnh, cn
phi bit kt hp cha ti ch v cha ton thn, song ng tic l khng t thy thuc hay mc
khuyt im l thng lng qun ton thn m ch ch ti ch.
V. QUAN H NHN QU V KHU CHNH TRONG BNH SINH
Nhng bnh phc tp thng din bin qua nhiu khu, tip ni nhau theo mt trnh t nht
nh v c lin quan mt thit vi nhau. Chnh bnh sinh hc nghin cu v c ch bnh sinh
ca cc khu cung xnh mi tng tc gia chng vi nhau. Th d lin cu khun gy vim
hng, ri t c th gy vim mng trong tim, m hu qu l h van v hp van. Nhng thay
i v cu to ca tim dn ti nhng ri lon tun hon mu trong tim. Lc u c tim cn
mnh, b p c, song dn dn mt b, tim b suy, dn ti mu tnh mch m hu qu l
ph v trn dch, ri lon chuyn ho v chc nng ton thn, v c th din bin lm cho bnh
ngy mt nng.
Cho nn trong qu trnh bnh sinh, nguyn nhn ban u gy ra nhng hu qu nht nh,
nhng thay i ny li tr thnh nguyn nhn ca nhng ri lon mi v cc ri lon ny li c
th dn ti cc hu qu khc vv... Kt qu l mt qu trnh bnh l khng ngng pht trin v
bnh ngy mt nng.
c bit quan trng l trong nhiu qu trnh bnh l, nhng khu sau tc ng li khu trc
lm cho bnh nng thm. Th d trong sc chn thng nng gy ri lon thn kinh trung ng
nghim trng (hng phn ri c ch) m hu qu l thiu oxy do ri lon tun hon (suy mch
cp), thiu oxy li tng cng trng thi c ch thn kinh trung ng khin ri lon tun hon
v h hp thm nng, vv... C nh vy khu n tc ng ln khu kia lm cho sc din bin
nng thm , to ra vng xon bnh l lm cho sc khng hi phc (hnh 1).
Nhim v ca ngi thy thuc l thy r mi quan h nhn qu gia cc hin tng bnh
l{, nh gi ng nhng thay i y v kp thi pht hin nhng thay i ch yu ngha l
nhng khu chnh trong qu trnh bnh sinh. iu ny rt quan trng c mt cch iu tr
thch ng (iu tr bnh sinh ), kp thi ngn chn vng xon bnh l khi xy ra v mt khi
xy ra th phi kp thi ct t., ph v vng xon, tr b cc ri lon v phc hi cc chc
nng . Th d trong suy tim, trng tm iu tr l phc hi sc co bp c tim kt hp vi ch
ngh ngi gim bt gnh nng i vi c tim b suy. hoc trong sc, trng tm iu tr l
phc hi lng mu lu thng bng cch truyn dch. Trong nhiu trng hp, phi tm cch
tc ng ln nhiu khu cng mt lc, in hnh l trong sc, phi tm cch tc ng ln nhiu
khu : ri lon thn kinh, ri lon tun hon, ri lon h hp, ri lon chuyn ho, vv...
VI. C CH PHC HI SC KHO
Trong c ch phc hi sc kho, chc nng thch ng phng ng c mt { ngha v cng
quan trng. c th con ngi c nhiu hnh thc phng ng chng li bnh tt.
- Sn sinh khng th (trong bnh nhim trng)
- Phn ng thc bo
- Chc nng gii c ca gan
- o thi cc nhn t gy bnh, cc c t ra ngoi (nn, nc tiu, phn, m hi, nim dch,
vv... )
- T bo tng sinh hn gn tn thng t chc.
- Chc nng b p
* Chc nng b p
y l mt hnh thc phng ng ph bin rt quan trng trong qu trnh phc hi sc kho .
trong thc nghim, ct b 2 tuyn thng thn chc chn s gy cht trong thi gian ngn,
song nu ch li 1/10 th tch ca mt tuyn, con vt vn sng. Hoc ct b hon ton tuyn
gip gy ph nim, song nu li 0,2% th tch tuyn , thy con vt vn bnh thng.
Trn lm sng, chc nng b p th hin rt r :
- Khi mt bn phi b bnh , phi lnh tng cng hot ng m bo nhu cu v oxy ca
cc c quan, t chc.
- Khi mt bn thn b bnh, thm ch ct b mt thn, thng khng thy pht sinh nhim
c ure v thn lnh tng cng hot ng b p.
Hot ng thch nghi b p lm nn iu rt kz diu trong trng hp nh bc hc Pat-
xt : nm 46 tui, ng b chy mu no bn cu no phi. thot c cn bnh cc kz nguy
kch ny, ng ra sc rn luyn v sc kho ca ng dn hi phc. ng li tip tc nghin cu
khoa hc v sau c hng trm pht minh trong c 3 pht minh v i to nn nhng cuc
cch mng trong y hc. ng mt nm 75 tui. Khi m t thiu, ngi ta thy bn cu i no
phi ca ng b teo hon ton, khng hot ng c na. Nh vy, vi ngh lc phi
thng, vi vic rn luyn bn b, Pat-xt tip tc lm vic vi na b c cn li v hng
trm pht minh ra i t na b c !
Qua s phn tch trn y, thy r chc nng phng ng c vai tr v cng quan trng trong
qu trnh phc hi sc kho. Song ch qun rng khng phi tt c cc hin tng thch ng
phng ng u c li i vi c th, i khi cn c hi nu qu mc. Th d :
- Nn ma c tc dng thi tr cht c, song mn ma qu nhiu c th gy mt nc v
in gii nghim trng.
- St c tc dng tng cng thc bo v sn sinh khng th, song st cao s nh hng
khng tt ti chc nng thn kinh, tun hon, chuyn ho, vv...
* Trng thi c ch :
Trong c ch khi phc sc kho, hin tng c ch c mc ca h thn kinh trung ng
l mt phn ng phng ng chng li nhng kch thch qu mnhh ko di, trnh cho t bo
thn kinh, c bit l v i no khi b tiu hao qu . Trong cng tc iu tr, nhng bin
php c tc dng tng cng c ch bo v c ng dng nhm khi phc chc nng v
i no v cc trung khu cp thp. Ngi ta dng phng php iu tr bng gic ng c tc
dng tt i vi mt s bnh (bnh lot, huyt p cao, vv...)pht sinh do tc dng ca cc kch
thch bnh l{ gy ra suy nhc t bo thn kinh. Gic ng sinh l{ cng nh gic ng nhn to
(nu gn ging gic ng sinh l) theo Pap-lp c tc dng bo v t bo v no : trnh tiu hao
qu mc, ng thi khi phc nng lng mt, do thc y qu trnh khi phc chc
nng thn kinh b suy yu, khin cho c th chng lnh bnh.
VII. NHNG NGUYN TC CHUNG V IU TR
Mt phng php iu tr hp l phi nhm tr b nguyn nhn gy bnh (c bit trong
bnh nhim trng) tng cng kh nng thch ng phng ng ca c th, v cui cng thanh
ton hoc hn ch c nhng hu qu ca bnh (ri lon chc nng v tn thng t chc).
Cha bnh thng thng bng thuc. Nhng khi cn thit phi tin hnh phu thut mi gii
quyt c bnh. Ngi ta cn iu tr bng cc phng php vt l (l liu php). Ngoi ra cn
cn phi ch ti vn sinh hot vt cht (c bit l dinh dng) v tinh thn (tm l liu
php) ca ngi bnh . tt nhin bnh nhn c ngh ngi thoi mi th bnh mi chng khi.
Ngi ta phn bit 3 loi iu tr :
a) iu tr nguyn nhn : nhm tr b nguyn nhn gy bnh. Th d dng khng sinh trong
iu tr cc bnh nhim trung c tc dng tiu dit vi khun gy bnh. Song c nhng bnh
khng iu tr nguyn nhn c v khng r nguyn nhn hoc nguyn nhn gy bnh ch tc
ng mt thi gian ngn, sau bnh vn tip tc pht trin (sc, bng, vv... )
b) iu tr bnh sinh : nhm tng cng kh nng thch ng phng ng ca c th, pht hin
nhng thay i ch yu trong qu trnh bnh sinh, tm c khu chnh trong vng xon bnh
l{ ph v. Th d trong sc nng phi gii quyt tnh trng thiu oxy do ri lon tun hon v
h hp gy ra mi lm cho bnh nhn thot sc c. hoc mun gii quyt tnh trng mu
v ph bnh nhn suy tim cn phi hi phc sc co bp ca c tim, vv... iu tr bnh sinh c
mt tm quan trng c bit v i hi mt c s l lun vng chc.
c) iu tr triu chng : nhm au u cha y, c tc dng nht thi.


40. BNH CN HC

( HONG DUNG )

Bnh cn hc (hay bnh nguyn hc) l thuyt nghin cu v cc nguyn nhn gy bnh v
c iu kin pht sinh bnh tt. Bnh cn hc gii p ngun gc pht sinh bnh tt, bnh do
yu t g gy nn, do bnh cn hc l mt vn c bn ca y hc. Khi nim v bnh cn
hc khng phi d dng thng nht gia 2 quan im duy vt v duy tm trong lch s Y hc,
nn chng ta cn i su nghin cu v xc inh mt quan im ng n v khoa hc. Hiu r
nhng yu t c bn trong bnh cn hc mi sng t c { ngha cc bin php d phng v
iu tr bnh tt v mi thy c kh nng to ln ca cng tc d phng trong y hc cch
mng.
Con ngi lun sng v tip xc vi ngoi cnh, trong nhng iu kin sinh hot v mt
ch x hi nht nh, cho nn bnh tt pht sinh ph thuc vo cc yu t c bn sau y:
1. Nguyn nhn v iu kin gy bnh: l nhng yu t hin nhin quyt nh s pht sinh
bnh a s trng hp.
2. c im ca c th: vi mt s bnh c th, ngoi cc nguyn nhn, iu kin bnh pht
sinh cn ph thuc vo nhng c im c th ca con ngi (tnh phn ng ca c th di vi
bnh tt, th tng, di truyn).
3. iu kin v hon cnh x hi: cng l nhng yu t quan trng nh hn ti s pht sinh
ca bnh tt.
Cc yu t ny thng lin quan cht ch vi nhau trong tng trng hp c th, c th yu
t ny hay yu t khc ni bt ln hng u. Cng c th xp chung l nhng nguyn nhn v
iu kin gy bnh v iu kin hon cnh x hi cng nh nhng mm bnh, iu kin hon
cnh ngoi mi u l cc nguyn nhn, iu kin bn ngoi v c im c th l nhng
nguyn nhn, iu kin bn trong, s xut hin bnh tt trong cc trng hp ny khng chu
nh hng ca cc nguyn nhn, iu kin bn ngoi.
I. VAI TR CA NGUYN NHN V IU KIN
GY BNH TRONG BNH CN HC
A- NGUYN NHN GY BNH
L nhng yu t quyt nh s pht sinh bnh tt v quyt nh c im ring ca tng
bnh. Trc khun lao l nguyn nhn gy bnh lao vi nhng c im ring ca bnh;
plasmodium l nguyn nh gy bnh st rt vi nhng c im ring ca bnh, ch khng
phi l nguyn nhn gy cc bnh thng hn, t Cho nn mi bnh u c nguyn nhn ca
n. Tuy nhin, hin nay vn cn nhng bnh cha xc nh c nguyn nhn (ung th, bnh
bch cu, mt s bnh tm thn).
Ngi ta phn bit:
1. Nguyn nhn bn ngoi: l nhng mm bnh, nhng yu t ngoi mi tc dng ln c th
v gy bnh ung nh:
- Yu t c hc: chn thng, tai nn.
- Yu t vt l: bng, qu nng, qu lnh, dng in, thay i p sut t ngt
- Yu t ha hc: cht c, ha cht
- Yu t sinh hc: cc vi sinh vt (vi khun, virut), nm.
- Yu t x hi: iu kin, hon cnh sinh hot, t chc v tm l x hi.
2. Nguyn nhn bn trong: tui tc, th tng v di truyn. Trong thc t bnh c th do
nhiu nguyn nhn gy nn hoc c nguyn nhn nhng khng nht thit pht sinh bn tt khi
khng c iu kin thch hp. Mt khc,, cng c th nguyn nhn l yu t duy nht quyt
nh s pht sinh bnh tt (mt s bnh truyn nhim gy nn do cc vi sinh vt c tnh
mnh). Do phi lun cnh gic vi quan im nguyn nhn n thun.
Thuyt nguyn nhn n thun ra i t khi Pasteur tm ra vi khun l nguyn nhn ca
mt s bnh. L mt hc thuyt duy tm cc oan v bnh cn hc, cho rng h c nguyn
nhn (vi khun) l nht nh c bnh. Hc thuyt ny ch ch trng ti nguyn nhn, cha ch {
ng mc vai tr ca cc iu kin gy bnh, coi nh kh nng thch ng, phng ng ca c th
v tc ng qua la gia c th v ngoi mi. Vi quan im ny, trong iu tr ch yu l tiu
dit nguyn nhn (vi khun); mi ch iu tr bnh m cha quan tm ti ngi bnh, khng
ch ti hon cnh lao ng, sinh hot, tmt tnh cm ca bnh nhn cng nh cha ch {
ti cc bin php nng cao sc khng, chng ca c th ngi bnh nn cha pht huy
c hiu lc to ln ca iu tr ton din. ng thi hc thuyt ny cn gy 1t tng tiu
cc trong cng tc d phng bnh tt.
B- VAI TR CA IU KIN GY BNH
TRONG BNH CN HC
iu kin gy bnh l nhng yu t lm cho bnh d pht sinh v pht trin. Nh nguyn
nhn pht sinh bnh lao phi l trc khun lao nhng bnh lao thng xut hin thun li khi
iu kin dinh dng km, lao lc qu , nhim lnh Nhng yu t ny l nhng iu kin
gy bnh, c tc dng lm gim sc khng ca c th, lm cho nguyn nhn pht huy tc
dng v gy thnh bnh.
Ni chung, iu kin khng th thay th c nguyn nhn cng nh khng nht thit phi
co iu kin trong qu trnh pht sinh bnh. Bnh vim phi c th pht sinh khi khng c cm
lnh, thiu dinh dng, mt mi v mt s iu kin khc, khi b tc ng bi cc ph cu
khun c tnh rt mnh. Nhng cng c trng hp iu kin ca cc bnh ny ng thi li
c th l nguyn nhn ca mt s bnh khc, nh n ung thiu km l iu kin thun li
trong pht sinh bnh, ng thi li l nguyn nhn chnh ca bnh suy dinh dng, thiu sinh
t
Cn cnh gic vi quan im iu kin n thun .Thuyt ny cho rng cn nhiu iu kin
kt hp li c th gy c bnh m khng cn c nguyn nhn c hiu. Cho rng nguyn
nhn c hiu nh vi khun thng c sn ngoi mi, khng th trnh c, nn ch cn s
tp hp cc iu kin l lm cho bnh xut hin. Quan im ny mang nhiu tnh cht tiu
cc v hon ton sai lm v a ra rt nhiu iu kin, khng ci no ph, khng ci no chnh.
Tng iu kin tch ring ra, cng nh nhiu iu kin kt hp li cng khng th quyt nh
c bnh m ch lm cho bnh d pht sinh di tc dng ca mt nguyn nhn c hiu:
khng c trc khun lao, nht nh khng c bnh lao mc d c y cc iu kin thun li
(lao tm, lao lc, n ung thiu km). Dit mui, chng t, tr ht plasmodium khng thy
xut hin bnh st rt vng nu khng c nguyn nhn truyn bnh t ni khc ti.
Hc thuyt ny lm cho ngi thy thuc qun mt nhim v hng u trong d phng v
iu tr bnh tt l phi tm ra c nguyn nhn chnh, iu tr nguyn nhn v iu tr ton
din m ch i vo iu tr chung, khng c hiu, tr ngi rt ln cho s pht trin Y hc.
C- MI LIN QUAN GIA NGUYN NHN
V IU KIN GY BNH
Gia nguyn nhn v iu kin c mt mi quan h cng lc rt r rng. Nguyn nhn vi
c tnh mnh c th n c gy bnh nhng nu kt hp vi cc iu kin xu bnh li cng
pht sinh d di v nghim trng. Nguyn nhn vi s lng v c tnh khng mnh lm
nhng gp cc iu kin kt hp (n ung km, mt m qu sc, i, lnh) lm cho bnh d
pht sinh; ngc li nu vo cc iu kin c th tt (th lc khe mnh,sc chng tt,
dinh dng y ) li c tc dng ngn nga bnh rt hiu lc.
Song thng thng, nguyn nhn bao gi cng pht huy tc dng trong nhng iu kin c
th nht nh. iu kin c tc dng lm gim sc chng ca c th, do tng cng kh
nng gy bnh ca nguyn nhn, lm cho bnh d pht sinh ng thi nh hng ti qu trnh
pht trin v kt thc ca bnh. Trong thc t lm sng mt s trng hp iu tr nguyn
nhn c kt qu tt, nhng nu bnh nhn lm vo nhng iu kin xu, bt li (b nhim
lnh, dinh dng km, chn thng tinh thn) bnh c th tr thnh nng, din bin nghim
trng hoc pht sinh nhng bin chng nguy him c th dn ti t vong.
Hiu r mi quan h mt thit gia nguyn nhn v iu kin ta phi ph b kt cu v
nh vy c th tin hnh cng tc d phng v iu tr vi nhiu bin php:
- Hn ch nguyn nhn, tiu dit cc mm bnh l bin php c hiu nht nhng kh thc
hin trit .
- Hn ch cc iu kin thun li lm cho bnh d pht sinh, pht trin: ci to thin nhin,
ci thin di sng vt cht, tinh thn, ci to v sinh hon cnh, ci thin n ung, gii quyt
hp l vn n ung v ngh ngi Cc bin php ny rt phong ph, c th ty ni, ty lc
tin hnh cng tc d phng v iu tr c hiu lc cao.
- Nng cao sc chng ca c th: rn luyn th lc, n ung, ngh ngi tt, n nh t
tng, tim chng phng bnh
Nh vy, kh nng phng bnh rt ln, c rt nhiu bin php ngn nga bnh tt, bo v
sc khe, bo m nng sut lao ng v nng cao tui th ca con ngi. V cng t ,
ra quan im d phng l chnh v iu tr ton din, m ra mt trin vnh v cng to
ln v kh nng con ngi trong cc cuc u tranh vi bnh tt. V ngi thy thuc khng
phi ch u tranh chng bnh tt m mun bo v sc khe cho con ngi mt cch c hiu
lc cn phi tham gia vo u tranh ci to thin nhin, ci thin i sng vt cht, tinh thn
cho con ngi cng nh u tranh ci to x hi na.
II. VAI TR CA CON NGI V C IM C TH
TRONG BNH CN HC
Nguyn nhn v iu kin phi tc dng trn c th con ngi mi gy c bnh. Trong
thc t, c khi cng b tc ng bi nguyn nhn trong hon cnh v iu kin nh nhau,
nhng ch c mt s ngi mc bnh, c ngi bnh nng, c ngi bnh nh hn, mt s
khc li khng mc bnh. l do c th khng p ng li bng nhng bin php khc nhau,
ph thuc vo tnh phn ng ca tng c th v ph thuc vo nhng c im c bit ca
tng c th (th tng v tnh di truyn).
1. Tnh phn ng ca c th: l kh nng p ng c co th i vi cc kch thch bnh
thng v bnh l{. i vi kch thch bnh l, mi c th c bin php p ng khc nhau,
ngi tr khe, phn ng thng mnh hn ngi gi yu. Tnh phn ng ca c th chu
nh hng ca nhiu yu t: th lc, tui tc, gii tnh, thn khinh- ni tit v mt s yu t
ngoi cnh nh thi tit, nhit , dinh dng tc dng trn c th.
2. Th tng: ngi cng nh ng vt, u c nhng im c th v hnh thi v th
cht gi l th tng. T y hc c i ti nay, ngi ta phn bit nhiu loi th tng ca ngi
da vo nhng du hiu phong thi bn ngoi hoc da vo nhng cu to bn trong c th,
tn ti tng i lu di v quyt nh s khc nhau c bn gia con ngi. Theo quan nim
hin i, th tng l yu t bn trong c th, l tng hp cc c im v hnh thi v chc
nng ca c th da trn c s ca tnh di truyn v quyt nh tnh phn ng ca c th i
vi bnh tt. C th ni tng l c s vt cht ca tnh phn ng.
C th phn bit 2 loi th tng:
a) Th tng cu trc (constitutio) da vo cu trc chc phn v hnh thi ca c th: th
tng a-stnic pht chnh v chiu cao; th tng hyper- stnic pht chnh v chiu ngang; th
tng giao cm, ph giao cm
b) Th tng d mc bnh (diathesis) l trng thi c th c phn ng c o i vi cc kch
thch bnh thng v c khuynh hng d mc bnh ny hay bnh khc. Diathesis l mt khi
nim khng c th, khng phi l bnh tt nhng sn sng mc mt s bnh khi c iu kin
thch hp, thng gp tr em:
- Tng xut tit: vim nim mc xut tit tr em, c im l d b cc bnh ngoi da (l,
chc, eczema) v gim sc chng vi nhim khun. Nguyn nhn c th l do tng tnh
mn cm ca c th, v c th l ngun gc cc bnh d ng, t min sau ny
- Tng co git: c nhng cn co git v co cng c lin quan n nhng ri lon cc mui
khong v tnh hng phn ca thn kinh- s. Khi co git, nng Ca mu gim, nng P v c
tng, chc phn tuyn cn gip tng v c thiu ht sinh t C.
- Tng thymus-hch: hay b vim amidan, vim mi hng, vim tai, ni hch, d c phn ng
tng bch cu n nhn.
Ni chung, th tng khng phi l trng thi c nh, vnh vin m c th bin i do nh
hng cc yu t ngoi cnh, ngh nghip, hoc khi iu tr tch cc. S pht sinh v pht trin
bnh tt trong trng hp ny c th ngn nga c bng cc bin php phng bnh, ci
thin v thay i iu kin, hon cnh cng nh cch sng ca bnh nhn.
Hc thuyt ni tng l mt hc thuyt duy tm, cho bnh pht sinh l do th tng quyt
nh, t cc zen di truyn c nh gy nn, do ngi bnh l nhng ngi mang sn cc zen
bnh l v thuc nhm ngi cha hon chnh nh vy, nhn dn v ngho i m mang bnh,
cng nhn mc bnh ngh nghip, b tai nn, bnh dch cng l do th tng bnh l ch khng
phi do ch x hi, v sinh phng bnh km hoc bo h lao ng km gy ra. Thuyt ny
cn l c s cho t phn bit chng tc; ngi da en thuc chng tc h ng, thuc nhm
ngi khng hon chnh nn d mc bnh hn ngi da trng. V nh vy, th tng l nguyn
nhn bn trong, quyt nh bnh tt nh mt nh mnh ch khng th trnh thot, t dn
n quan im tiu cc u tranh, chu ng s phn, cho nn hc thuyt ny cn c tnh phn
ng chnh tr.
3. Yu t di truyn: cng l nguyn nhn bn trong ca bnh tt. Bnh c th truyn t b
m cho con ci qua cc zen bnh hoc ch truyn nhng yu tbm di truyn
(praedispositio),trong trng hp ny cc yu t di truyn ch lm nhim v hnh thnh c a
tao iu kin cho bnh pht sinh khi c yu t bn ngoi ph hp (bnh huyt p cao, bnh i
tho ng).
III. VAI TR CA YU T X HI TRONG BNH CN HC
Bnh tt ngi thng pht sinh trong nhng iu kin lao ng v sinh hot x hi nht
nh nn yu t x hi c mt { ngha v cng quan trng trong s pht sinh bnh tt, cng nh
trong d phng v ngn nga bnh tt.
1. Hon cnh x hi to ra nhng yu t bnh l c bit ca con ngi.
Ta thng ni mt s bnh no l con ca mt ch x hi nht nh, nh vy yu
t x hi c coi nh l nguyn nhn ca mt ss bnh c gi l bnh x hi. Mt ch
dung tng nhng hin tng n chi, try lc, nn mi dm s ny sinh ra nhiu loi bnh hoa
liu nh giang mai, lu v bnh x ke. cc nc chm tin, mc sng thp, iu kin v sinh
km, sinh hot thp th bnh au mt ht, bnh giun-sn ng rut, bnh gan-mt ph bin
vi t l mc bnh rt cao. Bnh ngh nghip do nhim c cc ha cht tng nhanh cc nc
cng ngh pht trin mnh
2. Yu t tm l x hi cng l mt nguyn nhn gy bnh quan trng:
S khc nhau c bn gia ngi v ng vt l lao ng sng to v li ni, v do hot ng
thn kinh cao cp ngi pht trin cao nn yu t tm l x hi c th l mt trong nhng
nguyn nhn chnh gy bnh, hoc lm cho bnh d pht sinh v pht trin. Vai tr ca yu t
tinh thn, tm l (chn thng tm l{, lo bun day dt, xc cm qu ) c cng nhn
trong mt s bnh: bnh lon thn kinh chc nng, bnh cao huyt p, bnh lot d dy-t
trng, bnh u nng gip trng, bnh tm thn Cho nn mt s bin php phng v cha
bnh nh gii quyt thc mc n nh tinh thn (tm l niu php), an dng ngh ngi, iu tr
bng gic ng (thy min liu php) c tc dng bo v v phc hi chc nng iu chnh ca
v no i vi cc chc phn c th t c nhiu kt qu thc t trn lm sng.
i vi ngi thy thuc v c nhng ngi quanh bnh nhn, li ni c mt { ngha v cng
quan trng. Pavlov cho li ni i vi con ngi l mt kch thch tht s, mt kch thch c iu
kin nh tt c cc kch thch bnh l khc. Tc ng ta cng c cu li ni c th git ngi,
ngc li li ni c th lm ngi ta sng li c. Trn thc t li ni khng ng ch ca
thy thuc, ni khng cn nhc nhng nguy c ca bnh, thi chn nn bt lc lm cho bnh
nhn lo s cho tnh mng ca mnh, hoc li ni nng ny, bc tc, thiu tn trng, thiu quan
tm ca thy thuc cng lm bnh nhn lo ngh, bun phin, lm cho bnh din bin tr thnh
nghim trng v i khi dn ti nhng hu qu tai hi khn lng. Ngc li thi thy thuc
tn tm, vui v, c nhng li ni nh nhng, an i ng vin, thuyt phc ngi bnh yn tm
iu tr tin tng s khi bnh v gp phn u trang gii quyt bnh tt th cng tc iu tr s
c tin hnh tt, bnh tt thuyn gim do ngi bnh bit t theo di, bo co nhng din
bin cn thit, thc hin tt nhng yu cu ca iu tr ( tp vn ng, lao ng nh nhng, n
ng v ung thuc ng quy nh ) nn thng em li kt qu iu tr kh quan. chnh l
do ngi thy thuc s dng tt tm l{ liu php, mt khu quan trng trong iu tr ton
din , v c mt quan nim khoa hc bin chng v bnh cn hc, khng ch nhn thy nguyn
nhn gy bnh m phi thy c con ngi trong cc iu kin sinh hot x hi iu tr c
ngi bnh ch khng phi ch iu tr bnh tt
3.Yu t x hi l nhng iu kin gy bnh thc t cho con ngi:
Nhng nguyn nhn gy bnh thng thng qua nhng iu kin sinh hot x hi ( vt cht
v tinh thn ), hon cnh v quan h x hi nht nh mi pht huy c tc dng trn c th
con ngi .
min Bc trc y v min Nam nc ta hin nay sng trong ch thc dn kiu c v
mi, i a s nhn dn lao ng b p bc bc lt, i sng kh cc thiu thn, mng li y t
v sinh khng c pht trin rng ri phc v cho ng o qun chng, ch bo h lao
ng khng c ch , cc t nn x hi c khuyn khch nn bnh tt d pht sinh, lan
rng v t l t vong ti cc nh thng b th tng vt mt cch khng khip, tui th trung
bnh gim rt thp. Ngi m v tr em khng c bo v nn pht sinh nn hu sinh v
dng, nhiu nhng nui dng c rt t khin cho c th ngi m suy nhc, gim
nng sut lao ng, d mc cc bnh sau khi sinh n (bnh hu sn) ; tr em th kh nui, qut
quo, si mn do nh hng ti sc kho chung ca dn tc. Cc bnh dch pht trin
rng ri v ph bin : dch hch, dch t, dch u ma, dch vim mng no, dch st nh kz,
vv... git hi hng triu ngi dn lao ng.
Ngi thy thuc phi thy r yu t x hi trong bnh cn hc. Di ch XHCN, i sng
vt cht v tinh thn khng ngng c ci thin, bi tr cc t nn x hi, cc h tc, xy dng
i sng mi trt t v sinh, tn trng cc ch bo h lao ng, sinh c k hoch, bo v
b m v tr em, xy dng tt nh tr mu gio, trng hc, vv... chnh l to nhng yu t
thun li gip cho con ngi d phng v u tranh tiu dit bnh tt, nng cao sc kho v
tng nng sut lao ng x hi. Mng li y t trong nhn dn pht trin mnh n tn cc
x, v trong qun i, cng tc v sinh phng dch cng c thc hin c h thng nhm bo
v sc kho, nng cao sc chin u cho ton qun. chng ta cn tn dng v nng cao hiu lc
ca cc t chc . Tuy rng hin nay cc t chc cha tht c hon ho, nhng chng ta
cng thy c kh nng to ln ca cng tc d phng bnh tt mt cch ton dinv hiu
ngha ca phng chm d phng l chnh ca y hc cch mng. Nh vy trong tng lai
khng xa, con ngi c th y li mt s bnh tt ra khi i sng ca nhn loi, tuy nhin
cuc u tranh vi bnh tt cng vn phi lin tc v hon cnh, iu kin sng, ch mi
xut hin th mt s bnh tt mi li ny sinh. Nh vy, nm c khi nim khoa hc, ng
n, ton din v bnh cn hc chng ta mi c th ch ng , tch cc trong cng tc d
phng, iu tr bnh tt.

41. SINH L NHIM TRNG

NGUYN HU M
Qu trnh nhim trng ch trng thi ca c th t khi vi sinh vt gy bnh (vi trng, rickettsia,
virut hoc k{ sinh trng) vo c th ti khi c th phc hi hoc cht.
Qu trnh nhim trng chu nh hng ca nhiu nhn t:
- c tnh v s lng mm bnh vo c th.
- Tnh phn ng ca c th (kh nng min dch tui, th lc, dinh dng, trng thi thn kinh,
ni tit, nhng bnh mc v hin ang mc v.v).
- Ngoi mi: Hon cnh thin nhin v hon cnh x hi.
Vi sinh vt l nguyn nhn gy ra bnh, cn tnh phn ng ca c th v nh hng ca ngoi
mi l iu kin lm cho bnh pht sinh.
Nhim trng xy ra khi mt cn bng gia nhng bin php chng ca c th v nhng yu
t gy bnh ca mm bnh. S mt cn bng ny do:
- Mm bnh bin i.
- Hoc sc khng suy sp.
- Hoc do c hai yu t.
Trong thc t, mm bnh c th tn ti trong c th, sogn khng phi lc no cng gy bnh.
Bnh sinh hc ca qu trnh nhim trng chu nh hng ca nhiu nhn t:
- Mi tng quan gia mm bnh v c th.
- Kh nng gy bnh ca mm bnh
- Yu t thn kinh
- Yu t ni tit
- Yu t d ng
- Yu t dinh dng v.v
A - TNG QUAN GIA MM BNH V C TH
Ba trng hp c th xy ra :
1. Mm bnh tn ti trong c th song khng gy ra mt ri lon bnh l no.
Trong trng hp ny, c th nhim trng khng mc bnh v ch l mt cha mm bnh
n thun ( ngi lnh mang bnh), rt nguy him i vi xung quanh c bit l nhng ngi
mang trng sau khi mc bnh v nhng ngi mang trng c km theo du hiu vim nhng
ni mm bnh tn ti ( th d nhng ngi lnh mang trng bch hu hoc mng no cu khi
bnh thm vim hng th rt nguy him v phng dien dch t).
2. Nhim trng th tim:
Trong trng hp ny, c th b nhim trng c mt vi s thay i trong qu trnh hot
ng. Mm bnh sinh sn v pht trin trong c th song kh nng thch nghi ca c th cn
mnh nn bnh cha pht sinh v nhn bn ngoi c th vn khe mnh. Trong c th,
pht sinh mt chui phn ng phng ng (thc bo, sn sinh khng th, o thi mm bnh ra
ngoi); ngoi ra, trong ni tng pht sinh ri lon chc nng v tn thng thc th tinh
vi, song c th vn khng c nhng du hiu lm sng r rt. Nhim trng th tim thng gp
nhng ngi khe mnh khi c dch cm, bch c, bi lit
3. Bnh nhim trng (hay qu trnh nhim trng) mm bnh tc ng trn c th, khng
nhng gy ra nhiu ri lon sinh l trong c th, m cn lm suy yu kh nng thch nghi ca c
th i vi ngoi mi, gy ra nhiu ri lon chc nng v tn thng thc th su sc biu hin
ra ngoi bng nhng triu chng lm sng r rt.
Ty theo vi th (c tnh v s lng mm bnh vo c th) v i th (tnh phn ng, sc th
bnh ca c th), c th pht sinh nhiu th lm sng khc nhau:
a) Th in hnh r rt: Th thng gp, bnh tin trin qua cc giai on in hnh (nung
bnh, khi pht, ton pht, kt thzc). Ri lon chc nng v tn thng thc th r rt song c
th vn c kh nng hi phc c.
b) Th khng in hnh (th nh, th ct): Trong trng hp ny phn ng t v cu c th
chim u th. Khng c nhng ri lon chc nng v tn thng thc th nng. Th khng in
hnh thng gp c th c chzt t min dch, hoc khi mm bnh c tnh yu, hoc vo
c th vi s lng t. Th khng in hinh, th nh ,th ct c ngi dch t nhng bnh nhn
c tim chng thng mc th nh, khng in hnh. Trong st rt khng in hnh, st
rt nh, khng thnh cn r rt, bnh nhn ch n lnh, mt mi, vng uTh khng in
hnh, th nh, th ct c { ngha v dch t hc quan trng v nhng th ny kh pht hin hoc
b coi nh v bnh nhn mc th ny thng vn i li c, do ngun ly bnh d dng.
c. Th ti c (th c d ng, th qu mm, th c tnh) thng gp nhng bnh nhn phn
ng mnh, mn, cm sn i vi mm bnh (bch cu, l th c v.v) Trong th ti c, pht
sinh nhng ri lon chc nng v tn thng thc th nghim trng khng tin tin trin qua
cc giai on in hnh.
B- KH NNG GY BNH CA VI SINH VT
Ph thuc vo nhng yu t sau y:
1. Ni vo ca mm bnh
Nh bit mm bnh vo c th mi loi bnh mt khc bng nhng ng khcnhau, do
thng phn bit: Bnh ng tiu ho bnh ng h hp, bnh ng mu.
i vi mt s bnh, mm bnh c th vo c th bng nhiu ng khc nhau. Th d: Trc
khun bch hu qua nim mc hu, mi, mt da v.vgy ra nhng th lm sng khc nhau (th
mt, th mi, th hu, d dav.v.v
2. Kh nng gy bnh cu vi sinh vt.
Vi sinh vt l nguyn nhn gy ra bnh v chng no vi sinh vt cn tn ti v sinh sn trong c
th th bnh vn tip tc din bin. Do trong nhng bnh nhim trng cng phi tiu dit
mm bnh bt kz giai on no ca bnh v thuc khng sinh l mt bin php v cng quan
trng trong cc giai on ca bnh nhim trng.
Cng mt loi vi sinh vt nhng kh nng gy bnh mi chng loi mt khc
Do tnh i lp ca mt s vi sinh vt, cho nn khi mt loi sinh vt b tiu dit nhng vi sinh vt
i lp s c iu kin sinh sn v gy ra nhiu bnh.
Th d: Khi trc khun coli rut b thuc khng sinh dng qu mc tiu dit, t cu khu
rut c th gy i lng.
S lng vi sinh vt xm nhp vo c th nh hng ti qu trnh bnh ti mc nng nh
ca bnh, ti th bnh v.vMun gy c bnh cn phi c mt s lng vi sinh vt nht nh
(liu nhim trng). Mc d c min dch sau khi mc bnh hoc sau khi tim chng ngi ta
vn c th mc bnh ln th hai nu s lng vi sinh vt vo c th nhiu.
c tnh ca vi sinh vt bao gm hai yu t
- Kh nng tit c t
- Kh nng sinh sn trong cc t chc.
Hai yu t trn mi vi sinh vt mt khc. V d: trc khun un vn, thng sinh sn nhng
vt thng phn mm dp nt v c kh nng tit ra c t rt mnh, cn vi khun bnh than
sinh sn mu rt d dng, song kh nng tit ra c t li rt yu.
Phn loi theo c ch bnh sinh (nhim trng, nhim c) ch c gi tr tng i. Tht ra,
trong bt c bnh nhim c t no( bch hu, l ) u c yu t nhim trng phi hp;
ngc li, bt c mt bnh nhim trng no ( nhim trng mu, bnh than) t nhiu u c
nhim c km theo.
C nm c c ch bnh sinh mi tin hnh tt cng tc d phng v iu tr. i vi hai
bnh bch hu v un vn, c ch ch yu l do c t, song cn c vai tr ca vi sinh vt, cho
nn iu tr ch yu bng huyt thanh khng c t, song vn phi km thm khng sinh dit
vi khun gy bng v ngn nga vi khun bi nhim. i vi nhng bnh nhn nhim trng l
ch yu, trong iu tr phi nhm dit vi khun song khng c qun gii c.
3. c tnh ca vi sinh vt gy bnh :
a) Hng tnh ca vi sinh vt a s vi sinh vt c xu hng tn ti v sinh sn nhng t chc
nht nh v mm bnh gp nhng iu kin thun li nht. Hin tng ny gi l hng
tnh. Th d trc khun un vn c hng tnh i vi t chc c, vi rt bi lit c hng tnh
i vi t bo vn ng sng trc ca ty sng.
b) Do hng tnh trong bnh nhim trng, thng ni bt ri lon v tn thng mt s ni
tng nht nh. Do hng tnh c hiu, cho nn bn cch nhng triu chng nhim trng
nhim c ton thn ni ln phn ng ca ton b c th trc s tn cng ca mm bnh,
trong bng lm sng ca bt c bnh nhim trng no cng thng ni bt ln nhng ri lon
v tn thng mt s ni tng nht nh. Nhng triu chng ny c tnh cht c hiu i vi
tng bnh, tri li hi chng nhim trng nhim c ton thn l mt hi chng chung cho
nhiu bnh. Th d: un vn gy co cng c, bch hu hay c mng gi hng
c) Nh vy, lm sng bnh truyn nhim thng bao gm hai hi chng ln : hi chng nhim
trng- nhim c ton thn v hi chng tn thng v ri lon b phn. Nu trong chun
on phn bit phi da ch yu vo hi chng tn thng v ri lon b phn ( c tnh cht
c hiu) th trong tin lng bnh phi da ch yu vo hi chng nhim trng nhim c
ton thn v trong nhiu trng hp cht ca bnh nhim trng khng phi do tn thng b
phn m do nhim c ton thn qu nng.
C- VAI TR CA DI TH TIN YN- V THNG
THN TRONG QU TRNH NHIM TRNG
Nhng nm gn y, ngi ta chng minh vai tr ca hocmon trong qu trnh nhim trng
v mim dch, c bit l hocmon ca h tin yn v thng thn. Khi b kch thch, trung tm
di th tit ra mt s hocmon thn kinh( cn gi l yu t gii phng ) c dn ti tin yn (
qua ng mu) gy tng tit ACTH, STH
1. Vai tr ca ACTH v coctizon: chng vim v d ng
a) Chng vim:
Hn ch phn ng i thc bo v hot ng thc bo.
c ch s pht trin ca t chc lin kt- t chc ht.
Gim tnh thm ca thnh mao mch, gim ph n v tit dch.
Hn ch s hnh thnh mao mch tn to.
b) Chng d ng: hn ch sn xut khng th v c ch min dch.
Khng ph hy nhng khng th tim vo c th, v ch trc tip c ch qu trnh min dch
ch ng.
Gy thoi bin cc t chc bch huyt, gy tan v t bo lympho v tng bo, c ch phn
ng tng bo v c ch hot ng thc bo. Kt qu l gim tng hp khng th.
Do nhng tc ng trn, ACTH v coctizon rt c hiu qu i vi nhng bnh vim nhim d
di, nhng bnh d ng, nhng th tng mn cm ca bnh nhim trng. Tri li, coctizon ch
nh hn ch khi c th suy kit, khi mm bnh khng c khng sinh c hiu
2. Vai tr ca STH v aldosteron:
Tc dng i lp ca ACTH v coctizon:
Tng cng phn ng vim, kch thch t chc lin kt tng sinh, do c tc dng chng
nhim trng.
Tng cng s pht trin tng bo trong cc t chc bch huyt, tng tng hp khng th.
D-VAI Tr CA H THN KINH TRONG
QU TRNH NHIM TRNG
1. Vai tr ca v no:
a) i vi qu trnh nhim trng: khi mc mt bnh nhim trng nhim c cp tnh, thot tin
thng pht sinh c ch ton b v no: bnh nhn t phn ng i vi nhng kch thch bn
ngoi, cc phn x c iu kin suy yu, bnh nhn mt mi, th thn, mt kh nng lao ng
qu trnh c ch c tnh cht t v ca v no gii phng trung khu thn kinh thc vt lp di
v v tng cng h thng di th- tin yn- v thng thn dn ti:
Mt mt, qu trnh hng phn nhng trung khu thc vt c dn truyn theo ng giao
cm v ph giao cm dn ti cc ni tng diu ha chc nng.
Mt khc, h tin yn- v thng thn t nhng hocmon tc ng ti phn ng vim (ACTH v
coctizon, STH v aldosteron)
c ch v no c tc dng bo v, trnh cho t bo v no khi b kit qu (do tiu hao qu
nhiu nng lng) nhng bnh nng, v no b c ch su gy ra trng thi mt mi, I khi
km theo m sng, vt v. V no b c ch qu mc, hot ng thn kinh cao cp mt hn :
l trng thi hn m.
Trng hp bnh qu nng, qu trnh c ch lan xung c lp di v,c ch cc trung khu thc
vt quan trong, c bit gy lit trung khu vn mch v bnh nhn c th cht v try tim mch.
b) i vi phn ng min dch: ( hot ng thc bo, tng hp khng th). V no tc ng ti
qu trnh min dch thng qua h thng di th- tin yn- v thng thn v nhng trung khu
thn kinh thc vt di v.
2, Vai tr ca lp di v
a) Vai tr ca h thng di th- tin yn- v thng thn:
trnh by trn, h ny mi khi tng cng hot ng ( do tc nhn gy bnh kch thch ) s
tit ra nhiu loi hocmon: ACTH v coctizon, STH v aldosteronh ny chi phi phn ng t-
ng bo ( tng bo tng sinh) do chi phi s tng hp khng th. Tc dng ny khng c
hiu v coctizon, STH ch tc ng ti s pht trin ca tng bo ch khng trc tip tham gia
tng hp khng th c hiu nh khng nguyn.
b) Vai tr ca thn kinh thc vt:
Trong qu trnh nhim trng, thn kinh thc vt thng trong trng thi hng phn do:
V no b c ch gii phng cc trung khu di v.
Ngoi ra, vi sinh vt v c t kch thch trc tp cc trung khu thc vt v cc synp ca thn
kinh giao cm v ph giao cm.
Xung ng bnh l t cc trung khu thc vt c cc dy thn kinh giao cm v ph giao cm
dn ti cc ni tng, gy ra nhiu ri lon v tn thng ni tng.
Ngay trong thi kz nung bnh, thn kinh giao cm tng cng hng phn, ti thi kz khi pht
li tng hn na. Thn kinh giao cm tng cng hot ng trong bnh nhim trng (chuyn ha
c bn tng, thn nhit tng, tim p nhanh, ng mu tng) c { ngha phng ng quan
trng.
Giai on sau, thn kinh giao cm hng phn : mch chm li, huyt p gim, m hi ra nhiu
khi c th bt u hi phc chuyn ha c bn v thn nhit gim. Trong mt vi bnh (vim
phi, st pht ban ) nhng s thay i ny pht sinh t ngt v c th gy ra trng thi kch
bin: cc triu chng c v nng thm, c th gy try tim mch song sau th ht st ngay,
tnh to li v i gii nhiu. i vi c th suy yu, ngi gi, cn kch bin c th gy cht.
Ri lon thn kinh thc vt nng c th gy ra mt s hi chng nguy him (hi chng c tnh)
nh: try tim mch i lng nhim c tr em, hi chng st cao ti nht tr em, ri lon
tun hon no Trong try tim mch hi chng c tnh xut hin t ngt, pht trin nhanh,
hay gp bnh nhn b thng hn, bch hu, cm, st cao tr em Bnh nhn bng nhin rt
mt ngi lm v thu i, mch rt nhanh, yu, huyt p tt, mi v ngn tay, ngn chn tm li,
lnh, tim khng c triu chng g c bit.
Hi chng c tnh thng gp trong nhiu bnh nhim trng v thng l nguyn nhn gy cht.
-VAI Tr CA YU T D NG TRONG
QU TRNH NHIM TRNG.
D ng c mt { ngha quan trng trong bnh sinh hc qu trnh nhim trng : yu t d ng
thng lm cho bnh tin trin nng hn, nhiu khi triu chng ca d ng lm thay i c lm
sng in hnh ca bnh, ln t c nhng ri lon do chnh mm bnh gy ra. l do c th
trong trng thi mn cm, thng p ng mt cch mnh m, d di trc s tn cng ca
mm bnh.
Trng thi mn cm c th xy ra trong hai trng hp:
a) trng thi mn cm c sn t trc khi c th b nhim trng:
Do c th trc kia tip xc vi mm bnh ny (d ng c hiu) hoc mc mt bnh
khc (d ng khng c hiu) cng c trng hp khi virut mi xm nhp vo c th c th
gy mn cm ngay trong nhng ngy u. Trong trng hp ny lm sng bnh s thay i v
km thm nhng triu chng d ng ngay t thi kz u, thi kz khi pht. Trng hp ny
thng gy ra nhng th qu mn, nhng th c tnh, c t (bch hu, l, si )
b) Trng thi mn cm hnh thnh trong qu trnh nhim trng: do chnh mm bnh gy ra (d
ng c hiu) hoc do vi sinh vt bi nhim, vi sinh vt th xut sinh ra (d ng khng c hiu).
Trng hp ny l d ng th pht, triu chng ca d ng xut hin trong qu trnh tin trin
ca bnh.
So vi d ng c hiu th vai tr ca d ng khng c hiu trong c th b nhim trng tng
i quan trong hn, v d ng khng c hiu hay gp hn, hnh thnh rt nhanh. Hn na d
ng khng c hiu c th gy ra mt cch d dng nh trc khun coly l mt vi sinh vt
thng xuyn c trong c th. Trn c s ny, hin nay gii thch c mt s triu chng
v bin chng do c ch d ng khng c hiu: vim thn, vim rut, chy mu
Zdracpxki nhn mnh cn ch mt s bnh nhim trng t n rt nh (v c tnh ca
mm bnh yu) song c th tr thnh rt nng, v vi sinh vt ca bnh lm tng tnh cm
ng ca c th i vi nhng vi sinh vt bi nhim, th xut. Nhng vi sinh vt th xut ny tuy
bn thn c tnh yu song c th gy nhng tn thng rt nng mt c th mn cm.
E-VAI Tr CA YU T DINH DNG TRONG NHIM TRNG
Trong lch s nhn loi, i v dch thng i km nhau, nh t v bnh dch cng vy.
Dinh dng y lm tng sc chu ng ca c th vi nhim trng nhim c. Tri li, dinh
dng km gim sc chng ca c th.
1. Vai tr ca protein:
Trong dinh dng, yu t quan trng bc nht i vi sc khng ca c th l protein. C tc
gi ni d tr protein trong c th l mt hng ro bo v chng nhim trng . Trong thc
nghim, gy bnh ph thng hn hai l chut thy mt l ch n rau cht ti 24%trong khi
l c n protein t l cht gim r rt (42%). Trn lm sng, nhng ngi b ph do thiu
protein d mc bnh h hp v nhiu bnh khc, nhng bnh nhn tr em suy dinh dng hay
b bi nhim; vi nhng bnh nhn suy kit, truyn mu hoc huyt tng em li nhiu kt
qu tt. Nh bit, khng th c tng hp t nhng axit amin n vo, do khi c th thiu
proterin, sc chng d ca c th gim.
2. Vai tr ca vitamin:
Vitamin l mt thnh phn quan trng ca men, do n ung thiu vitamin thy sc chng
ca c th gim, c bit r trong bnh nhim trng.
- Vitamin A: khi thiu vitamin A, sc chng t v ca nim mc gim, d gy vim hng, vim
tai gia, vim phi, nhim trng ng kh qun trn.
- Vi tamin nhm B:Tng sc chu ng ca c th i vi nhim trng v c vai tr quan trng
trong chuyn ha t bo, ng thi nh hng ti sc ln, ti chc nng tit dch ca d dy, ti
trng lc c rut, ti chc nng to mu, chc nng h hp ca t chc thn kinh
Thiu vitamin nhm B cn lm yu hot ng thc bo ca bch cu a nhn.
- Vitamin C: tng sc chng ca c th i vi nhim trng v vitamin C cn thit cho qu
trnh oxy ha trong t bo.Trong c th th nhim trng, phn ng oxy ha t bo thng tng
nn tiu th nhiu vitamin C, do thiu vitamin C l mt c im ca bnh nhim trng
Thiu vitamin C thng hn ch sn xut khng th, c ch hot ng thc bo.
- Vitamin D:cng tham gia mt phn vo sc chng i vi nhim trng v vitamin D duy tr
th cn bng ca qu trnh dinh dng v cc qu trnh oxy ha t bo.
3. Suy dinh dng v c im lm sng bnh nhim khn :
bnh nhn suy dinh dng (thiu protein, thiu vitamin) tnh phn ng ca c th gim, cho
nn c nhng c im lm sng sau y:
- Nhit khng cao lm, c khi khng st, ngay c nhng bnh cp tnh nh cm, vim phi
nhim trng huyt... C khi thy i hn chu kz nhng bnh nhn st rt, st hi quy...
- Phn ng bch cu yu, c khi khng c.
- Hiu gi ngng kt trong cc phn ng huyt thanh c hiu thng thp, c trng hp phn
ng m tnh v tng hp khng th giam.
- Gan lch khng sng r rt.
- Lm sng bnh thng khng r rt, khng in hnh, bnh thng tin trin nng, ko di, d
ti pht, t l t vong cao.
- Ch dng thuc iu tr nguyn nhn n thun m khng ch p dng nhng bin php
tng cng sc chng ( nh dinh dng, min dch liu php, l liu php... ) kt qu s hn
ch.


42. RI LON CN BNG AXIT BAZ

NGUYN HU M
Vn cn bng axit-baz khi qut m ni l vn ca ion H
+
.
Bnh thng cc qu trnh chuyn ho trong c th sinh ra cc axit, ch yu l axit cacbonic, axit
sulfuric, axit photphoric, vv... Khi phn ly, cc axit ny gii phng ra cc ion H+ t do (quyt nh
pH ca ni m) trong c th lun c xu hng tng ln, c th gy ra trng thi nhim toan.
duy tr nng H+ cc khu vc ni v ngoi bo trong phm vi ph hp vi iu kin sng v
hot ng ca t bo, cc axit ny lun lun c trung ho, thi th bng nhiu c ch linh
hot, phc tp. Kt qu l pH mu ngi bnh thng lun c duy tr trong mt phm vi
n nh rt hp : 7,35 7,45.
Khi pH di 7,35 pht sinh nhim toan v khi pH trn 7,45 pht sinh nhim kim. Khi pH ti
di 6,8 v trn 7,8 th cuc sng nh ch.
I. IU TIT CN BNG AXIT-BAZ
Nh nu trn , pH mu rt n nh , do c mt h thng iu tit rt chnh xc , rt nhy ,
bao gm : cc h thng m ca mu , thng kh phi , chc nng thn .
A - CC H THNG M CA MU .
H thng m ph bin nht bao gm mt axit yu vi mui ca axit vi mt baz mnh .
Th d H
2
CO
3
v NaHCO
3

HCl + NaHCO
3
NaCl + H
2
CO
3

(axit mnh) (axit yu)
NaOH + H
2
CO
3
NaHCO
3
+ H
2
O
(kim mnh) (kim yu)
Nh c h thng m , pH khng thay i hoc thay i rt t, so vi lng axit hay baz thm
vo. H thng m ca mu bao gm :
<!--[if !supportLineBreakNewLine]-->
H thng m quan trng nht l h thng bicacbonat axit cacbonic , v cc qu trnh chuyn
ho trong c th to ra mt lng ln CO
2
, do nhiu bicacbonat c to ra , lm cho h
thng ny c tm quan trng c bit .
pH mu = pK H
2
CO
3
+ log [ <!--[if !vml]--><!--[endif]--> bicacbonat/axit cacbonic]= 7,4
Nu [HCO
3
-
] gim hoc [ axit cacbonic+ tng pH s gim v pht sinh nhim toan . Tri li , nu [
HCO
3
-
+ tng hoc [axxit cacbonic] gim , pH s tng v pht sinh nhim kim . khi pht sinh
nhim toan hoc nhyim kim , thy pH c phc hi nhanh chng do s thay i kp thi ca
v kia ca t l : l nhim toan hoc nhim kim c b p . nu s thay i qu ln , vt
kh nng b p ca c th , s pht sinh nhim toan mt b ( pH gim ) hoc nhim kim mt
b ( pH tng ).
Ion bicacbonat lun lun c hng cu v thn b sung theo c ch :
Anhidraza cacbonic
CO
2
+ H
2
O -----------------------------> H
2
CO
3
---------> HCO
3
+ H
+
H
+
sinh ra trong phn ng c cc m khc trung ho .
Cc axit sinh ra trong qu trnh chuyn ho caccht trong c th u b trung ho theo phn
ng :
H
+
A
-
+ HCO
3

-
---> A
-
+ H
2
CO
3
-----> H
2
O + CO
2
(axit mnh) (thi qua thn) (axit yu) (thi qua phi)
B THNG KH PHI
Thng kh phi chu s iu tit ca pH , pCO
2
v pO
2
, trong pH v pCO
2
c tc dng mnh
nht . C hai yu t ny u nh hng ti cn bng axit baz . Thng kh phi duy tr cn
bng axit baz bng cch iu p lc CO
2
ph bo , do iu ho c nng H
2
CO
3
ho
tan trong mu (hnh 1) . Trung khu h hp rt nhy cm i vi nhng s thay i rt nh ca
pH huyt tng v p ng bng cch tng thng kh phi mi khi pht sinh khuynh hng
nhim toan . Nh vy , axit cacbonic tha c o thi v pH c n nh . Tri li , khi nng
axit cacbonic mu gim , thng kh s gim , c tc dng gi CO
2
li , nhm ti lp cn bng
axit - baz . Trung khu h hp rt nhy cm i vi s thay i ca pCO
2
.
Bn cht ho hc ca iu tit h hp cn bng axit baz trong mu c th tm tt nh sau :
CO
2
+ H
2
O ---> H
2
CO
3
---> H
+
+ HCO
3
-

Khi nhim toan chuyn ho , b p bng tng thng kh phi , phn ng s i t phi sang tri
v khi nhim kim chuyn ho , b p bng gim thng kh phi , phn ng s i t tri sang
phi .
C - VAI TR CA THN
Trong nc tiu , c tt c cc axit (v baz ) c trong huyt tng . Do mi khi chc nng
lc cu thn gim nghim trng , u pht sinh nhim toan.
Ti ng thn, Na
+
c ti hp thu di dng bicacbonat nh c men anhydraza cacbonic ( c
trong t bo ng thn ) men ny c tc dung tng hp axit cacbonic t CO
2
v H
2
O . Trong lc
Na c ti hp th di dng bicacbonat , cc axit c o thi , hoc nguyn vn (1ion H
+

trao i vi mt ion Na
+
) hoc di dng mui amn sau khi kt hp vi mt phn t NH
3
do
t bo thn tng hp .
Mu ti thn c phn ng kim nh ( pH 7,4 ) cn nc tiu cui cng c phn ng toan (pH 6),
do phtphat dibazic Na
2
HPO4 (c tcdng kim ) bin thnh photphat mnbazic NaH
2
PO
4

(c tc dng toan ).
Qua s phn tch trn y , thy r thn loi tr ti a axit , ng thi tit kim ti a d tr
baz , do thn chng li trng thi nhim toan rt c hiu qu ( Hnh2 v hnh 3 ).
Tm li , qu trnh chuyn ho cc cht trong c th sn sinh ra CO
2
, cc axit ( photphoric ,
sunfuric vv...), lm cho nng ion H+t do lun lun tng ln trong c th , c th gy ri lon
cn bng axit baz nu c axit sinh ra khng kp thi c trung ho v thi tr .
Nh cc h thng m ca mu ( c bit l h bicacbonat / axit cacbonic ) tc dng tc th v
t hiu qu ti a sau 10- 15 pht , pH ca mu khong thay i hoc thay i rt t.
S phn ng ca phi ( tng hoc gim thi tr CO
2
) xy ra lp tc ngay sau khi pH mu thay
i v t hiu qu ti a sau 12- 24 gi.
Cc axit ny sau khi b cc m trung ho c thi qua thn (bng cc c ch thi axit v to
amoniac) Khi ri lon cn bng axit-baz ko di, b p ch yu do thn m nhim. Trng
thi b p ny chm xut hin song c hiu qu c bn v lu di.
II. RI LON CN BNG AXIT-BAZ
C th xp thnh 4 loi :
nhim toan h hp
nhim kim h hp
nhim toan chuyn ho
nhim kim chuyn ho
Ngoi nhng ri lon n thun k trn, trong bnh l ph bin hn nhiu l nhng ri lon kt
hp .
Cc ri lon cn bng axit-baz v mt triu chng hc , ni chung ngho nn, khng c hiu
v phn ln cc biu hin lm sng li l ri lon ca cn bng nc, in gii v ca nhng hi
chng dch th khc.
Chn on ch yu da vo xt nghim sinh ho (pH v d tr kim) (hnh 4)
iu tr ch yu l tr b nhng nguyn nhn gy ri lon.
A NHIM TOAN H HP
nhim toan h hp (cn gi l nhim toan hi) l hu qu ca trng thi CO
2
trong mu.
1. Nguyn nhn gy nhim toan h hp :
c ch trung khu h hp do gy m su, ngi qu nhiu CO
2
, tim mocphin, thuc nh.
Lit c h hp : bnh bi lit, c mu gim, vv...
Tc ng h hp do d vt, vt l, co tht u.
Gim din tch h hp, vim phi, ph qun ph vim, x phi, kh thng phi, hen, trn kh v
trn dch mng phi, vv...
2. C ch b p trong nhim toan h hp :
- Vai tr ca h m : tng nng bicacbonat ngoi bo nhm phc hi gi tr bnh thng ca
t l [HCO
3
-
] / [H
2
CO
3
].
- Vai tr ca phi : CO
2
mu tng v pH mu gim kch thch trung khu h hp gy tng thng
kh phi , c tc dng tng cng o thi CO
2
, nhm phc hi li t l [HCO
3
-
] / [H
2
CO
3
].
- Vai tr ca thn : t bo ng thn tng o thi ion H
+
ng thi tng ti hp thu bicacbonat ,
ngoi ra thn cn tng o thi Cl
-
, tng tng hp NH
3
bi xut NH
3
v Cl
-
di dng NH
4
Cl .
Nh vai tr ca thn nhim toan chm dt v cn bng axit-baz c ti lp.
3. Lm sng : biu hin lm sng duy nht l h hp tng.
B NHIM KIM H HP
Nhim kim h hp (cn gi l nhim kim hi) l hu qu o thi qu nhiu CO
2
do tng
thng kh phi.
1. Nguyn nhn gy nhim kim h hp
Trung khu h hp hng phn mnh, cm xc mnh, nhim c cc dn xut ca axit salicylic,
vv...
Trng thi st gy tng cng thng kh phi, c tc dng tng thi nhit.
Nhit bn ngoi tng gy tng thng kh phi.
Ln cao gy tng thng kh phi m bo lng oxy cho c th.
2. C ch b p trong nhim kim h hp :
Vai tr ca phi : th nng do CO
2
mu gim v pH mu tng nhm phc hi CO
2
, trng hp
nhim kim h hp nng c th pht sinh ngng th.
Vai tr ca h thng m : ion H
+
t t bo vo mu c tc dng ngn cn pH mu ng sang
pha kim. C ch b p quan trng tip theo l h thng m protein proteinat huyt
tng . trong mi trng kim , protein tc ng nh mt cht toan s phn ly , tch ion H
+

ng thi hp thu ion Na
+
do cng hn ch trng thi kim ho mu.
Vai tr ca thn : thn gim o thi ion H
+
ng thi tng o thi HCO
3
-
cng vi Na
+
(do
nc tiu c phn ng kim) Kt qu l [HCO
3
-
] mu gim ng thi [H
2
CO
3
+ tng, v pH c
phc hi. Ion Cl
-
o thi theo nc tiu gim r rt v b gi li trong mu , thay th cho ion
HCO
3
b o thi ra ngoi.
3. Lm sng
Lc u, h hp tng (gy nhim kim ), v sau khi nhim kim, h hp gim, thm ch nh ch .
phn ng kim gy gim ion ho Ca ngoi bo , c th pht sinh co git.
Nu dch ngoi bo kim tnh, oxy kt hp vi Hb d dng song tch khi Hb chm hn so vi
bnh thng, do trong nhim kim nng c th pht sinh thiu oxy t chc (gy nhim toan
chuyn ho ). Ngoi ra khi pCO
2
mu gim, cc mch mu gin ra gy gim khi lng mu lu
thng (do mu v gim huyt p), gy thiu oxy t chc, dn ti nhim toan chuyn ho,
trng thi ny c th coi nh mt phn ng b p ca c th i vi nhim kim h hp.
C NHIM TOAN CHUYN HO
Cn gi l nhim toan c nh. y l loi ri lon cn bng axit-baz ph bin nht, v nghim
trng nht . ch yu do tha axit, i khi do mt baz.
1. Nguyn nhn gy nhim toan chuyn ho
Tng sinh axit (th xetonic , axit lacic, axit pyruvic,vv... ), gp trong :
i n, i tho ng, vv... Trong nhng trng hp ny, c th thiu gluxit hoc khng s
dng c gluxit (do thiu insulin ) nn axetyl CoA khng vo vng Krebs c, do tng sinh
th xetonic, c th thiu nng lng m d tr c huy ng , tng cng thoa bin cn dn
ti tng sinh th xetonic.
Thiu oxy (m ln, st, thiu mu nng, chy mu nghim trng, tru tim mch, suy tim, suy h
hp, mt nc nghim trng, vv... )
b) axit. Gp trong bnh thn (suy thn cp, suy thn kinh).
Suy thn kinh : gim s lng tiu cu thn hot ng gy axit trong mu.
Suy chc nng thi H
+
ca ng ln xa.
Suy chc nng ti hp thu HCO
3
-
ca ng ln gn.
nhim toan chuyn ho cn c th do mt nc nghim trng hoc ri lon huyt ng hc
nng n gy suy thn cp (thiu niu, v niu) dn ti ng cc sn vt axit.
c) Mt Na
+
: thng gp trong ri lon tiu ho, c bit l i lng, tc rut, l d rut v
ty,vv... Mt dch tiu ho gy mt nc v in gii khu vc ngoi bo m hu qu l thiu
niu, lm cho nhim toan thm nng, mt khc ri lon tiu ho gy trng thi thiu dinh
dng dn ti tng xeton mu.
Ngoi ra nhim toan chuyn ho cn do lm dng thuc li niu, thuc ty, vv... gy ra, ch yu
do mt Na
+
v mt nc.
Trong bng rng, nhim toan chuyn ho cn do do mt Na nghim trng vt bng.
d) Thuc axit ho : dng nhiu thuc axit ho nh NH
4
Cl , CaCl
2
, KCl, ngay c huyt thanh
mn ng trng (dch truyn vo cha 154 mEq/l Cl) gy ng Cl
-
trong dch ngoi bo
(nhim toan tng Cl
-
mu , c bit khi c suy thn).
2. C ch b p trong nhim toan chuyn ho :
a) Vai tr ca h thng m . Cc ion H
+
tng trong mu c trung ho bng cch kt hp vi
cc ion HCO
3
-
to ra H
2
CO
3
, mt axit yu do c tc dng phc hi pH.
H
+
ngoi bo tng vo trong t bo thay th Na
+
v K
+
t bo ra ngoi , ng thi HCO
3
-
t t
bo ra huyt tng kt hp vi H
+
mi tng. Nh vy tng *HCO
3
-
+ dn ti tng t l
[HCO
3
-
] / [H
2
CO
3
] khin cho pH huyt tng ng sang pha kim.
b) Vai tr ca phi : pH mu gim kch thch trung khu h hp gy tng thng kh phi, dn
ti tng o thi CO
2
: H
2
CO
3
--> H
2
O + CO
2
, kt qu l H
2
CO
3
huyt tng gim, khin cho
HCO
3
-
kt hp vi H
+
to H
2
CO
3
v axit ny phn ly , CO
2
li c o thi qua phi,vv...
c) Vai tr ca thn : thn tng o thi H
+
ng thi tng hp thu HCO
3
-
.
3. Du hiu lm sng v cn lm sng :
Phn ng toan hn ch s phn ly HbO
2
t chc v gy tr ngi cho s hnh thh HbO
2
phi,
dn ti gim oxy mu v thiu oxy t chc.
Trong nhim toan h hp, lc u thy tng hot ng ca tim (mch nhanh, tng lu lng
mu, tng huyt p). song khi c nhim toan chuyn ho kt hp thy hot ng ca tim gim.
Di nh hng ca nhim toan chuyn ho, chc nng ca c tim b c ch sm hn. ng
ch l ri lon nhp tim rt ph bin trong nhim toan chuyn ho : tim p nhanh, P-Q ko
di, tc nh tht, ngoi tm thu, thm ch rung tht, vv...
Trong nhim toan chuyn ho, thy lng nc tiu gim do tun hon thn gim : di nh
hng ca nhim toan thy mch thn co li, ng thi huyt p ng mch gim , hot ng
ca c tim gim hn ch tun hon thn. Gii quyt c trng thi nhim toan thy lng
nc tiu hi phc.
D NHIM KIM CHUYN HO
Cn gi l nhim kim c nh. Do c ch mt ion H
+
hoc do tng (tuyt i hoc tng i )
cc baz ca c th.
1. Nguyn nhn gy nhim kim chuyn ho :
Truyn nhiu dch kim (Natri lactat, natri xitrat, natri bicacbonat,vv... ) gy tng nng
bicacbonat ngoi bo.
Mt mt lng ln dch v : dch v cha nhiu ion H
+
v Cl
-
; Do nhim kim chuyn ho gp
trong nn ma, ht dch d dy, hoc ra d dy nhiu ln.
Mt nhiu K
+
(nhn n lu ngy, khng c tip t y K
+
, u nng v thng thn,vv... ) :
khi c th thiu K
+
, cc t bo ca ng ln xa s o thi nhiu H
+
thay th K
+
theo c ch :
H
2
O + CO
2
--> H
2
CO
3
--> H
+
+ HCO
3
-

Do mi khi 1 ion H
+
c thi tr th li c mt phn t HCO
3
-

c to ng thn v
khuych tn vo mu, do pht sinh nhiu kim ho hc.
- Tng tit glucococticoit hoc iu tr bng cocticoit, thy K
+
t bo thot ra ngoi, ng thi H
+

t ngoi vo trong t bo, nh vy nng H
+
mu gim, gy tng pH mu.
2. C ch b p trong nhim kim hoa hc:
a) Vai tr ca h thng im. C ch b p u tin nhm phc hi pH din bin nh sau:
B
+
+ HCO
3
-
+ H
+
m ---> B. m + H
+
+ HCO
3
-
Tip theo l tc dng ca h thng m protein huyt tng: trong mi trng kim, cc
protein phn ly nh cc axit, tch cc ion H
+
.
H
+
t bo vo trong huyt tng, ng thi Na
+
v K
+
ngoi bo vo trong t bo, khin cho pH
mu khng ng sang pha kim.
b) Vai tr ca phi : Nhim kim chuyn ho gy th nng, nhm khi phc t l
c ch b p ny t quan trng v pCO
2
tng li kch thch trung khu h hp, gy tng thng kh
phi, dn ti tng o thi CO
2
.
3. Du hiu lm sng v cn lm sng:
Nhim kim chuyn ho t c nghin cu v t gp v khng nguy him lm i vi c th do
c b p tt. Nhim kim chuyn ho thng gy th nng, co git do Ca
++
mnh, ri lon
tm thn ( mt nh hng, thm ch m sng ).
D RI LON KT HP CN BNG AXIT BAZ
Nhng ri lon kt hp cn bng axit baz ph bin hn cc ri lon n thun rt nhiu v
thng l i khng, do kh chun on hn nhiu, ch yu phi da vo hi bnh chnh
xc v theo di k bnh nhn v cc xt nghim lm sng t gip ch hoc khng gip ch g c.
Th d, trong nn ma ko di, thy nhim kim chuyn ho (do nn ma lm mt H
+
v Cl
-

mu) kt hp vi nhim toan chuyn ho (do nn ma gy thiu dinh dng dn ti tng
xton mu).


43. RI LON CHUYN HA GLUCID

( NGUYN HU M )
I. CHUYN HO GLUXIT
A - I CNG
Gluxit l thnh phn chnh ca thc n v l ngun nng lng chnh ca c th ngi. Di
dng glucoprotein v mucopolysaccarit, gluxit tham gia to thnh cht c bn ca t chc lin
kt, mng t bo,vv... Hng lot cht sinh vt hc (hormon, men, vitamin, khng nguyn, khng
th, vv... )u c cha gluxit.
Trong gluxit , glucoza l loi ng quan trng nht v mt sinh l. Trong t bo, glucoza c
th bin i theo nhiu chiu hng khc nhau sau y :(H1)
- Chuyn thnh glucogen d tr.
- Thoi bin cung cp nng lng cho c th.
- Tng hp lipit v protein.
- Tng hp mt s ng cn thit cho c th (riboza, desoxyriboza,vv... )
Nhng s bin i k trn ch c th thc hin c sau khi gluxit vo bn trong t bo v
c photphoryl ho di tc dng ca men hexokinaza tr thnh glucoza -6- photphat. Do
glucoza -6- photphat l mt hp cht c bn trong chuyn ho ca glucoza.
B - IU HO NG MU
Gm nhiu c ch phc tp, ni bt ln l vai tr ca gan v h thng ni tit, ngoi ra cn c
cc yu t l ho v vai tr ca h thng thn kinh.
1. Vai tr ca gan.
Gan c vai tr rt quan trng trong iu ho ng mu v gan tng hp glycogen d tr, tn
to glucoza, ng thi thoi bin glycogen gi cho nng ng mu lun lun hng nh.
ng vt sau khi ct b gan thy ng mu gim khng phc hi. (H2)
2. vai tr ca h ni tit :
Bao gm 2 h thng i lp nhau
- H thng lm gim ng mu : insulin.
- h thng lm tng ng mu , phc tp hn, bao gm nhiu hormon (H3).
- Insulin : hormon duy nht lm gim ng mu , do t bo beta tu o tit ra, c tc ng
trn :
- chuyn ho gluxit : insulin lm cho glucoza qua mng t bo d dng, hot ho men
hexokinase (bin glucoza thnh glucoza-6-photphat ) v mt s men tiu ng khc
(photphofructokinaza, pyruvatkinaza,vv... ) c ch men glucoza-6-photphataza (do hn ch
glucoza-6-photphat bin thnh glucoza ), hot ho men glycogen synthetaza (tng tng hp
glycogen).
- Chuyn ho lipit : tng tng hp triglyxerit t gluxit , ng thi gim thoi bin triglyxerit .
- chuyn ho protein : lm cho axit amin t mu qua mng t bo d dng v tng tng hp
protein (cung cp nng lng v hot hoa smen tng hp protein ).
C ch gim ng mu ca insulin c th nh sau :
- gim glucoza t gan vo mu, do gim thoi bin glycogen (c ch men glucoza-6-
photphataza ), ng thi gim tn to glycogen t protein.
b) h thng tng ng mu : bao gm nhiu hormon.
- Adrenalin : hot ho men photphorylaza gan v c do bin glycogen thnh glucoza, gy
tng ng mu.
- Glucagon : do t bo alpha tu o tit ra, c ch tc dng nh adrenalin (song khng c tc
dng vi men photphorylaza c).
- ACTH v glucococticoit ; tng to glycogen t axit lactic, tng tn to glycogen t protein (do
hot ho men fructoza-1,6-diphotphataza), c ch men hexokinaza ( do hn ch phn ng
phtphyl ho glucza ni bo ) hot ho men glucza -6- phtphtta (do tng to glucza
t glucza -6-pht pht) .
- Ngoi ra ,cn phi k ti tc dng tng ng mu ca S T H v thyrxin m c ch cha
tht sng t .
3 .Vai tr ca h thn kinh :
- Kch thch giy ph giao cm thy ng mu gim ( do tng tit insulin ),tri li kich thich
dy giao cm thy ng mu tng (do tng tit catcholamin ). Khi xc cm mnh thy ng
mu tng v tit sinh ng niu .
II. RI LON CHUYN HO GLUXIT .
C th xp thnh 7 loi :
-Ri loi tiu ho v hp th gluxit .
-Ri lon tng hp v thoi bin glycgen .
-Ri lon chuyn ho trung gian gluxit .
-Tng ng mu .
-Bnh i tho ng .
-Gim ng mu .
-Cc ri lon khc : pentza niu ,fructza niu, galactoza niu .
A- RI LON TIU HO V HP THU GLUXIT
Do thiu men tiu ho gluxit ( c bit l amylaza tu ), nn a ng khng bin thnh
n ng , do khng hp th c v pht sinh i gluxit.
Ri lon hp thu gluxit cn gp trong ri lon phtphoryl ho glucza thnh rut : trng
hp ny gp trong vim nim mc rut , nhim c phloridzin , monoiodoaxetat ( c tc dng
c ch men hexokinaza ). Glucoza khng bin thnh glucoza -6- phtphat nn khng hp thu
vo mu c .
B - RI LON TNG HP V THOI BIN GLYCOGEN .
a)Tng thoi bin glycgen do hng phn h thn kinh trung ng : xung ng thn kinh theo
ng giao cm , c dn ti kho d tr glycogen v kch thch thoi bin glycogen. Ngoi ra ,
hng phn h thn kinh trung ng cn tng cng chc nng tu thng thn, tin yn, tuyn
gip, kt qu l tng thoi bin glycogen.
Trong lao ng nng, c tiu th nhiu glucoza , cng thy glycogen tng cng thoi bin.
b) Gim thoi bin glycogen : lon chuyn ho glycogen . Do thiu men thoi bin glycogen
(gluccoza -6 - photphataza , amylo -1 , 6- glucozidaza , photphorylaza vv...) , nn pht sinh
ng glycogen mt s c quan (gan , thn , c ) . Bnh di truyn , t gp .
c) Gim tng hp glycogen : gp trong thiu oxy, do gim nng lng d tr ATP, cn thit
cho tng hp glycogen. Khi thiu glycogen, c th phi s dng ti lipit d tr, thm ch c
protein t chc , bo m nng lng cn thit cho s hot ng bnh thng ca c th.
C RI LON CHUYN HO TRUNG GIAN GLUXIT
Nhiu nguyn nhn dn ti ri lon chuyn ho trung gian gluxit.
1.Thiu oxy, gp trong suy h hp, suy tun hon, thiu mu, vv... Thoi bin k kh chim u
th so vi thoi bin a kh, do axit pyruvic v lactic tng, gy nhim toan chuyn ho ng
thi gim ATP.
2.ri lon chc nng gan. Do axit lactic khng ti tng hp c glucoza hoc glycogen, gy
tng axit lactic trong mu (nhim toan).
3.thiu vitamin B1 : gy ri lon oxy ho pyruvic v sinh t ny l mt thnh phn ca coenzym
TPP tham gia vo qu trnh kh cacboxyl, bin axit pyruvic thnh axetyl CoA , do gy ng
axit pyruvic v lactic. Ri lon oxy ho axit pyruvic gy gim tng hp axetylcholin, m hu qu
l ri lon dn truyn xung ng thn kinh, axetyl CoA gim hn ch qu trnh thoi bin a
kh ca glucoza. Nh bit, glucoza l ngun cung cp nng lng ch yu i vi t chc
thn kinh, do ri lon chuyn ho gluxit gy ri lon chc nng h thn kinh : mt cm gic,
vim dy thn kinh, lit, vv... Ngoi ra ng axit pyruvic gy nhim c i vi h thn kinh.
Khi thiu sinh t B, cn thy pht sinh ri lon vng pentoza photphat, c bit l s hnh
thnh riboza : ri lon ny l do thiu men transetolaza chi phi s hnh thnh riboza, coenzym
ca men ny l TPP (B1).
D TNG NG MU
Tng ng mu pht sinh khi nng ng mu trn 120 mg%. tng ng mu c th do
nhiu nguyn nhn gy ra.
1. Tng ng mu do n : xy ra khi n nhiu ng. Loi tng ng mu ny thng c
ng dng nh gi trng thi chuyn ho gluxit. Ngi bnh thng sau khi ung mt ln
100 n 150 g ng, thy nng ng mu tng, t mc ti a 150 170 mg% sau 30
45 pht. Sau , ng mu bt u gim v sau 2 gi th tr v bnh thng, sau 3 gi th c
hi gim so vi bnh thng.
2. Tng ng mu do xc cm. Di tc ng ca yu t cm xc, lung xung ng theo
ng giao cm c dn ti tuyn thng thn v tuyn gip, gy tng tit adrenalin v
thyroxin c tc dng tng thoi bin glycogen.
3. Tng ng mu do hormon . pht sinh do ri lon chc nng cc tuyn ni tit. C th do
tng tit cc hormon tng ng (adrenalin v glycogen, ACTH v gluco cocticoit, STH, thyroxin,
vv... ).
4. tng ng mu do gy m. c bit gy m t vv morphin gy kch thch trung khu giao
cm, lm cho tuyn thng thn tng tit adrenalin.
5. tng ng mu do thiu insulin. Loi ny n nh nht v biu hin r nht. Trong thc
nghim c th gy thiu insulin bng cch ct b tu (tuy nhin trong trng hp ny thiu
insulin li kt hp vi ri lon tiu ho), hoc tim alloxan cho con vt (cht ny ch gy tn
thng cho t bo tu o).
D BNH SINH I THO NG
Bnh i tho ng l mt bnh m c im ch yu l tng ng mu v ng niu
mn tnh do thiu insulin tuyt i hoc tng i.
1. Nguyn nhn gy bnh.
Trc y, ngi ta inh ninh rng i tho ng l do tu o. song trong thc t lm
sng, nhng ngi b bnh ny, khng phi bao gi cng thy tn thng ti tu. Thng k
998 trng hp i tho ng c m xc, Ben nhn thy bnh mc lc cao tui th t l tn
thng tu rt thp, th d bnh nhn di 20 tui th 100% c tn thng tu, t 20 46
tui : 79%, t 40 60 tui : 48%, cn bnh nhn 60 tui tr ln ch c 33,5% c tn thng
tu.
Mt thng k khc cho thy i tho ng n thun tng i t gp m hay thy kt hp
vi cc ri lon ni tit khc. thng c thy mt trng hp i tho ng n thun th
thy n 2 trng hp i tho ng c km theo u nng tuyn gip., 5 km theo u nng
thng thn v 20 kn theo u nng tuyn yn. M xc bnh nhn i tho ng th tn
thng thc s tu ch chim 25% tng s bnh nhn . 50% lai thy t bo beta tng tit,
cn li 25% th hon ton khng thy tn thng g (Hpman).
Trong thc t, bnh sinh i tho ng rt phc tp . hai trng hp c th xy ra l :
a) bnh pht sinh do nguyn nhn ty : thiu nguyn liu tng hp insulin, tnt thng mch
mu tuyn ty, nhim trng, nhim c, u, vim tuyn ty,vv... l thiu insulin tuyt i.
b) bnh pht sinh tuy t bo beta hot ng bnh thng, i khi cn tng tit insulin v do
nhiu nguyn nhn ngoi tu gy ra , hn ch tc dng ca insulin. l thiu insulin tng
i.
Thiu insulin tng i c th do tng tit cc hormon tng ng mu , ch yu l STH,
ACTH, v gluco cocticoit. Nhng hormon ny gy bnh i tho ng khng nhng ng vt
m cn gp trong iu tr khi tim ACTH v coctisol (c bit khi chc nng t bo beta gim
sn). bnh ny xy ra khi tin yn v v thng thn tng cng hot ng (chim t l 33
40% trong tng s bnh nhn b bnh to cc). Khi chc nng tin yn gim hoc khi ct b tin
yn, thy nhng triu chng ca bnh i tho ng gim r rt. bnh nhn c u v thng
thn, sau khi ct b u, thy bnh i tho ng chm dt. U tu thng thn cng gy i
tho ng, v sau khi ct b u ny cng thy ht bnh.
Nhng s kin trn ay chng t l bnh i tho ng khng ch do thiu insulin m cn
do tng tit hormon tin yn, thng thn, c bit khi chc nng t bo beta gim sn. Do
c th quan nim bnh i tho ng l mt bnh do ri lon cn bng ni tit. Vi khi nim
ny, c th a ra nhng bin php iu tr bnh sinh thch hp : ct b u tin yn, v hoc li
thng thn, c ch chc nng cc tuyn ni tit, vv...
Bnh i tho ng cn do insulin tng cng phn hu di tc dng ca cc men
insulinaza.
Ngoi ra, phi k ti khng th khng insulin, c tc dng trung ho, kt hp v phong b
insulin . Ngi tim insulin di ngy thy trong mu c khng th khng insulin; nhng bnh
nhn ny phi dng liu insulin rt cao so vi nhng bnh nhn khc. l bnh i tho
ng khng insulin.
Ni tm li , nguyn nhn gy i tho ng rt phc tp, cho nn cn quan nim i tho
ng l mt hi chng ch khng phi mt bnh.
2. Bnh sinh i tho ng
Trong bnh i tho ng, cc loi chuyn ho u pht sinh ri lon, c bit l chuyn
ho gluxit v lipit , to ra mt bng lm sng kh phong ph.
ng ch { l nhng triu chng ch yu ca bnh i tho ng (ng mu tng, lipit
mu tng , nhim toan) khng phi l hu qu trc tip ca thiu insulin m do tng , tuyt i
hay tng i , cc hormon khng insulin, khi thiu insulin : khi ct b tuyn yn hoc tuyn
thng thn, thy thiu insulin khng gy ra cc triu chng k trn, hoc ri lon chuyn ho
trong bnh i tho ng c th pht sinh tuy lng insulin vn bnh thng , c khi cn tng
nu cc hormon khng insulin tng.
a) ri lon chuyn ho gluxit. Khi thiu insulin, tc vn chuyn glucoza mu vo t bo
gim. (H4)
Trong t bo , hot tnh men hexokinaza gim km hm phn ng photphoryl ho glucoza
ni bo, gy gim glucoza-6-photphat . hot tnh men hexokinaza gim do do thiu insulin v
chnh cng do thiu insulin , glucococticoit tng tit c ch men ny. glucoza-6-photphat
gim hn ch s dng glucoza ni bo ; c th : gim tng hp glycogen (t glucoza ), gim
oxy ho trc tip glucoza vo vng pentoza photphat., gim thoi bin k kh v a kh glucoza ,
gim tng hp axit bo, protein v mt s ng cn thit cho c th.
Gim glucoza-6-photphat c b p bng tng tn to glucoza v glycogen (t axit amin )
do tc dng ca gluccocticoit, khi thiu insulin, glucococticoit tng tit c tc dng hot ho
men fructoza-1,6- diphotphataza, kt qu l tng thoi bin glycogen.
Tiu glycogen vhim u th so vi tn to, lm cho glucoza t gan vo mu nhiu , gy tng
ng mu , mt trong nhng triu chng chnh ca bnh i tho ng . khi ng mu
vt ngng thn s pht sinh glucoza niu, ko theo c nc (a niu thm thu) ; bnh nhn
kht do c th mt nc nghim trng (c th ti 5 10 lit trong 24 gi, thm ch hn na), do
ung nhiu. T bo khng s dng c glucoza nn trung khu i b kch thch, bnh nhn
n nhiu , nhng vn khng b c nng lng b mt, nn gy.
Ngoi ra khi thiu insulin, men pyruvic kinaza khng c hot ho hn ch tng hp axit
pyruvic (t axit photphoenoinpyruvic), dn ti gim axit oxaloaxetic, lm cho axetyl CoA khng
vo vng Krebs c : gim tng hp nng lng, c bit ATP, dn ti gim tng hp axit bo,
protein,vv... Khng vo vng Krebs, v khng c tng hp thnh axit bo, axetyl CoA khng
cn con ng no khc l tng tng hp cholesterol v cc th xetonic. (H5)
Glucoza mu l ngun cung cp nng lng duy nht i vi t chc no, c bit l v no,
nn khi thiu insulin, no trong trng thi i gluxit, , ngoi ra, t chc no hp thu oxy cng
vi glucoza, do khi gim hp thu glucoza, oxy vo t chc no cng t i, kt qu l t chc
no va thiu gluxit, va thiu oxy, khin cho v no b c ch su sc.
b) ri lon chuyn ho lipit. Khi thiu insulin thy :
- Gim tng hp axit bo do thiu nng lng (vng Krebs b hn ch)v thiu NADPH2 (do
vng pentoza photphat b hn ch)
- gim tng hp triglyerit do thiu axit bo v thiu alpha glyxerophotphat, mt sn vt
photphoryl ho ca chuyn ho gluxit.
- Ngoi ra khi thiu insulin, qu trnh lipit phn tng cng, do tng tit cc hormon khng
insulin (c tc dng hot ho men triglyxerit-lipaza t chc ), khin cho nhiu axit bo t t
chc m vo mu c oxy ho cc t chc, nhm cung cp nng lng b p cho
glucoza. Tng lipit phn lm cho c th gy st, tng lng axit bo t do huyt tng, ti
gan cc axit bo t do huyt tng ti tng hp glyxerit gy nhim m gan.
- Nh phn tch trn, khi thiu insulin, axit oxaloaxetic gim nn axetyl CoA sn vt oxy
ho ca axit bo khng vo vng Krebs c cung cp nng lng, buc phi tng tng
hp th xetonic v cholesterol. Th xetonic tng cao gy nhim c t bo , c ch cc men, c
ch chc nng h thn kinh trung ng, thm ch gy hn m i tho ng . tng tng hp
cholesterol dn ti x cng mch, c th gy nhi mu c tim, vim x thn, chy mu y
mt,vv...
c) ri lon chuyn ho protein
Trong bnh i tho ng, tng hp protein gim do :
- Thiu insulin , cc axit amin t mu qua mng t bo kh.
- Thiu nng lng do vng Krebs b hn ch, km hm tng hp protein.
- Ngoi ra, thiu insulin khng hot ho c h men tng hp protein.
- Khi thiu insulin, glucococticoit tng tit tng thoi bin protein , tng tn to glycogen
(t axit amin ).
Nh vy, tng thoi bin ng thi gim tng hp protein gy ra cn bng N m. Tim
insulin s nhanh chng phc hi chuyn ho bnh thng ca protein. (H6)
Ri lon chuyn ho protein trong bnh i tho ng c ch qu trnh to hnh, lu
lnh vt thng, khng th gim, hn ch sc chng ca c th vid nhim trng,vv...
d) Hn m i tho ng , ch yu do th xetonic tng mnh. Tuy nhin trong mt s
trng hp, th xetonic mu tng nhiu song vn khng pht sinh hn m i tho ng . Do
ngoi vai tr tng th xetonic cn phi k n mt s yu t khc.
- thiu insulin gim mc s dng glucoza, do hn ch nng lng gii phng, nh
hng su sc ti hot ng bnh thng ca v no. Ngoi ra nh phn tch trn, t chc
no hp thu oxy cng glucoza, do khi gim hp thu glucoza, oxy vo t chc no cng t i,
kt qu l t chc no thiu oxy , gp phn gy ra trng thi hn m.
- Ngoi ra, trng thi mt nc v in gii nghim trng (do a niu) cng l mt yu t
ng k trong bnh sinh hn m i tho ng.
E GIM NG MU
Pht sinh khi ng mu di 80 mg%. c rt nhiu nguyn nhn dn ti gim ng mu .
1. Lao ng th lc vi cng cao, huy ng c mt lng ln glycogen d tr gan
v c, ng thi khng c tip t lng thc y , kp thi (trng hp chin u c lit).
2. cung cp gluxit thiu hoc ri lon tiu ho v hp thu gluxit.
3. Tn thng t bo gan (vim gan, x gan,vv... ) hn ch chc nng to glycogen d tr.
4. tim mt lng ln insulin, vi mc ch iu tr (sc insulin trong iu tr bnh tm thn.)
5. u ty (tng sn t bo beta ty o) gy tng tit insulin m hu qu l gim ng mu.
6. gim tit cc hormon tng ng mu nh thyroxin, adrenalin, glucococticoit (bnh
Addison). Trong bnh Addison, ng mu gim km theo tng K+ mu, gim Na+ mu do
thiu nng v thng thn. Ch { bnh nng rt nhy cm vi nghim php cm th insulin.
7. gim thoi bin glycogen. Gp trong ri lon chuyn ho glycogen ( trnh by trn).
8. i tho ng do thn. Do nhim c phloridzin, monoiodoaxetat, c ch men
hexokinazakhieens cho glucoza khng c ti hp thu v o thi theo nc tiu, gy gim
ng mu .
c bit mn cm i vi thiu glucoza l h thn kinh trung ng m t bo khng c d tr
glycogen. Thiu glucoza dn ti thiu oxy . khi gim glucoza mu ko di, t bo thn kinh
thy pht sinh nhng tn thng khng hi phc, , bt u l ri lon chc nng v no, sau
l no gia .
Khi ng mu gim, c th c gng b p bng cch tng tit hormon tng ng mu
(adrenalin, glucococticoit, vv... )
Khi ng mu gim 80 50 mg%, thy tim p nhanh (do tng tit adrenalin), cm gic i
(do hng phn trung khu n vng di th khi ng mu gim ), ri lon h thn kinh trung
ng (mt mi, d b kch thch,vv... ).
Khi ng mu gim di 50 mg%, v no pht sinh c ch, ng thi di v pht sinh
hng phn, gy ra nhiu ri lon : ri lon th gic, bun ng, lit nh, ra m hi nhiu , bt
tnh, h hp chu kz, co cng ri co git, pht sinh trng thi hn m.
F FRUCTOZA NIU GALACTOZA NIU PENTOZA NIU
y l nhng ri lon chuyn ho gluxit bm sinh, do thiu men c hiu nn mt s gluxit
khng c chuyn ho theo bnh thng v c o thi theo nc tiu.
Bnh frutoza niu do thiu men fructokinaza (lm cho frutoza khng bin thnh frutoza
photphat) hoc fructoza-1-photphoaldolaza (lm cho chuyn ho frutoza dmh li giai on
glucoza -1-photphat).
Bnh galactoza niu do thiu men galactoza-1-photphat uridin transferaza khin cho
galactoza-1-photphat khng chuyn ho c , galactoza mu tng, gy ra galactoza niu.
Bnh pentoza niu do thiu men L. NADP-xylitol dehydrogenza (lm cho L. xyluloza khng
bin thnh xylitol c).

44. RI LON CHUYN HA LIPID

( NGUYN HU M )
Lipit l ngun d tr nng lng ln nht ca c th ( ngi bnh thng, lipit c th chim
ti 40% th trng). lipit cn tham gia vo cu trc t bo (mng bo tng), c bit l t chc
thn kinh v ni tit. Gn y ngi ta thy r t chc m khng phi ch l ni d tr m,
mt kho d tr nng lng th ng : m thc s l mt t chc sng, mt c quan c hot
ng rt mnh, c thi gian bn thoi ho ch vo khong 5 9 ngy, trong t chc m cc qu
trnh chuyn ho (gluxit, lipit , protein, vv... ) din bin mnh m.
Trong c th c nhiu loi lipit khc nhau song ch yu l 3 nhm :glyxerit, photpholipit,
steroit.
I. CHUYN HO LIPIT
A TIU HO V HP THU LIPIT
lipit do thc n cung cp c tiu ho v hp thu ch yu ti phn trn ca rut non. (Hnh
1)
triglyxerit lu thng trong mu di dng chylomicron, lm cho huyt thanh sau khi n m
trng c nh sa, trng thi ny ko di vi gi, sau men lipoprotein lipaza trong mu
(c heparin ho) lm trong dn huyt tng bng cch thu phn triglyxerit ca
chylomicron thnh axit bo v glyxerol.
B LIPIT TRONG MU
Lipit mu do nhiu ngun ti : lipit mi hp thu t ng tiu ho vo, lipit iu t kho d tr
ra, lipit mi c tng hp a v kho d tr, lipit em i s dng,vv...
Lipit lu thng trong mu dng kt hp : triglyxerit di dng chylomicron, axit bo t do
huyt tng (ABTDHT) kt hp vi albumin .
C CHUYN HO LIPIT
1. Ti gan. ABTDHT chuyn ho theo 3 ng khc nhau :
- Mt phn nh c oxy ho hon ton thnh CO2.
- Mt phn nh khc bin thnh th xeton, ri c mu vn chuyn ti mt s t chc
oxy ho v gii phng nng lng.
- Phn ln cn li c este ho thnh triglyxerit (60 70%) v phn nh (10 20%) thnh
photpholipit v cc steroit (ch yu l cholesterol). Triglyxerit sau khi to ra c d tr mt
phn trong gan, phn cn li kt hp vi protein, cholesterol v photpholipit ni sinh to
ra beta lipoprotein vo mu . Nh vy triglyxerit thc n vn chuyn trong mu di dng
chylomicron cn triglyxerit ni sinh d dng beta lipoprotein.
2. Cc ABTDHT vo c vn chuyn ho theo hai ng :
Oxy ho cung cp mt phn nng lng cho c.
3. Trong t chc m, ABTDHT ch yu i theo con ng este ho thnh triglyxerit v d tr
, cn con ng o ho ABTDHTch l th yu. Nhng nguyn liu cn thit tng hp axit
bo v triglyxerit ch yu do chuyn ho glucoza cung cp, ATP, NADPH, pentoza,vv... (H2).
Trong nhng t chc m vng pentoza din bin mnh (t chc m ) qu trnh tng hp m t
gluxit th hin r hn so vi nhng t chc m vng ny din bin yu (t chc gan).
Tng hp v thoi bin triglyxerit trong t chc m chu nh hng su sc ca ng mu ;
khi ng mu tng thy tng hp triglyxerit tng v thu phn triglyxerit gim (dn ti gim
ABTDHT). Tri li, khi ng mu gim hoc glucoza khng c s dng y (trong bnh
i tho ng ), thy tng hp triglyxerit gim v thu phn triglyxerit tng (gy tng
ABTDHT). T thy r l n nhiu gluxit s gy bo ph (th d v ng vt bng ng cc) v
khi thiu gluxit c th s huy ng m, gy gim d tr m, c th gy st.
l kt qu ca mt cn bng gia hai h thng sinh m v tiu m (Hnh 3).
1. h thng sinh m.
Bao gm : glucoza, insulin, prostagladin, axit nicotinic. Vai tr ca glucoza trnh by trn,
insulin l hormon ch yu chi phi tng sinh m :
- tng sinh m t gluxit cung cp nguyn liu cn thit cho tng hp axit bo v triglyxerit
(axetyl CoA, alpha glyxerophotphat, ATP, NADPH2,vv... ).
- ngoi ra insulin cn tc dng trc tip gip ABTDHT thm qua mng t bo.
ng thi, insulin (v c prostagladin, axit nicotinic) c tc dng hn ch tiu m bng cch
hn ch men tiu m triglyxerit lipaza t chc (xem s ).
2. h thng tiu m :
Bao gm nhiu hormon : catecholamin, ACTH, glucococticoit, STH, glucagon, hormon tuyn
gip, vv... C ch tc dng tiu m phc tp, ch yu l gin tip hot ho men tiu m
triglyxerit lipaza t chc : cc hormon ny hot ho men adenylcyclaza t chc c tc dng bin
ATP thnh AMP vng l yu t cn thit hot ho men triglyxerit lipaza c tc dng thu
phn m, gii phng ra cc axit bo t do. (H4)
Ngoi ra, khi hot ng ca h giao cm tng (lao ng nng, gim ng mu , rt, xc cm
mnh, vv... ) catecholamin (ch yu l noradrenalin) s tng tit c tc dng tng cng tiu
m.
II. RI LON CHUYN HO LIPIT
Bao gm nhiu loi :
- Ri lon tiu ho v hp thu lipit
- Ri lon vn chuyn lipit trong mu tng lipit mu
- Ri lon chuyn ho lipit trong t chc
- Nhim m v thoi ho m
- Ri lon chuyn ho trung gian lipit
- Ri lon chuyn ho cholesterol
A RI LON TIU HO V HP THU L
Thiu mt v lipaza ty gy ri lon tiu ho v hp thu lipit, lng m trong phn tng gy
chng phn m.
Ri lon hp thu axit bo cn do trong c nhiu mui Ca v Mg v cc axit bo kt hp vi cc
mui ny to thnh nhng cht khng ho tan.
Qu trnh tng hp triglyxerit trong nim mc rut cn c s tham gia ca alpha
glyxerophotphat mt sn vt photphoryl ho ca chuyn ho gluxit. Do thiu cocticoit
khong (c bit l aldosterol, nh trong bnh Addison) lm cho c th mt Na+ nn nh
hng ti qu trnh photphoryl ho v hp thu m.
Tn thng biu m rut non (do nhim trng, nhim c,vv... ) thiu vitamin A (m bo hot
ng bnh thng ca biu m rut), thiu vitamin nhm B (tham gia vo qu trnh photphoryl
ho ), thiu vitamin nhm C (lin quan ti chc nng v thng thn ) u gy ri lon hot
ng men tham gia qu trnh tng hp triglyxerit trong nim mc rut, do hn ch hp thu
lipit .
thiu lipit ko di (trn 3 4 thng) gy ra nhiu triu chng bnh l : vim da, rng tc, chm
ln, mt kh nng sinh sn,vv... l do c th thiu nhng axit khng no cn thit i vi
hot ng bnh thng c c th m t chc khng t tng hp c (tnh hnh tng t nh
khi c th thiu nhng axit amin cn thit), c bit l axit linolenic, axit linoleic, axit
arachidonic. Nhng axit ny c nhiu trong du thc vt. tim hoc cho n nhng axit ny thy
cc ri lon k trn mt : nhng axit bo ny c vai tr quan trng trong qu trnh oxy ho kh,
c tc dng gim cholesterol mu, cn thit cho tng hp cholesterol este.
B RI LON VN CHUYN LIPIT TRONG MU . TNG LIPIT MU
Thnh phn lipit trong mu rt phc tp, ch yu l triglyxerit , photpholipit v cholesterol . lipit
mu mc tng i hng nh (800 850 mg%) l nh s cn bng gia cung cp (do n,
tng hp t gluxit, iu t t chc m vo), v tiu th (do s dng v vn chuyn). C th tm
tt trong s sau :
Da theo s ny, thy r lipit mu c th pht sinh trong nhng trng hp sinh l v bnh
l sau :
- Tng lipit mu do n
- Tng lipit mu do
- Tng lipit mu do huy ng
1. tng lipit mu do n:
Tng lipit mu bt u 2 3gi sau khi n nhiu m, t mc cao nht sau 4 -6 gi v ti gi
th 9 th tr v mc bnh thng.
Mc v thi gian tng lipit mu ph thuc vo nhiu yu t : loi m (du thc vt hp
thu nhanh hn m ngvt), thi gian m thot khi d dy, cng nhu ng rut, lng
mt bi tit, hot tnh men lipaza ty v rut, lng lipit mu lc u,vv...
Khi lipit mu tng, d c n thm m lipit mu cng khng tng bao nhiu, hin tng t
iu chnh lipit mu l do lipit mu tng c ch hp thu lipit rut, hot ho chc nng c
nh m ca t chc phi, kch thch h li ni m gy tng tit cc hormon (tin yn) v
heparin Ch cn mt khu trong dy chuyn c vn l gy ri lon qu trnh t
iu chnh lipit mu .
2. tng lipit mu do :
Khi gim hot tnh men lipoprotein lipaza do tng cht c ch men ny (protamin, axit mt,
NaCl) hoc do gim tit heparin (nh trong bnh x va ng mch) thy gim thu phn
triglyxerit (di dng chylomicron) gy tng lipit mu .
Trong bnh thn h, tng lipit mu l do cc cht c ch tiu m ; ngoi ra trong bnh ny
albumin huyt tng gim (do protein niu nghim trng) do gim kh nng kt hp vi
ABTDHT, kt qu l qu trnh tiu m b c ch v tng lipit mu . tng lipit mu sau khi chy
mu cng pht sinh theo c ch ny. tim albumin cho bnh nhn thn h thy hin tng
tng lipit mu chm dt.
3. tng lipit mu do huy ng
Do triglyxerit t chc m c huy ng nhiu khin cho ABTDHT tng.
Tng lipit mu do huy ng c th do nhng nguyn nhn sau gy ra : d tr glycogen gim
(i n), trng thi cng thng (stress), lao ng nng, giao cm hng phn, tng tit hormon
(catecholamin, ACTH, STH, thyroxin,vv... ), i tho ng (glucoza khng c s dng, lipit
tng thoi bin, lipit mu tng ti 1000 2800 mg/100ml ).
Tim glucoza gy tng ng mu c tc dng tng tng hp triglyxerit t chc m do
hn ch tiu m v chm dt hin tng tng lipit mu do huy ng.
4. hu qu ca tng lipit mu :
Tng lipit mu dn ti tng tng hp photpho lipit beta lipoprotein v cholesterol trong gan ,
khin cho cc cht ny tng trong mu.
Tng lipit mu lm tng ng mu v photpholipit trong beta lipoprotein c tc dng tng t
thromboplastin t chc.
C RI LON CHUYN HO M TRONG T CHC M BO PH, GY.
T chc m khng phi ch l ni d tr m . tht th, trong t chc m cc qu trnh
chuyn ho khc (gluxit, protein ,vv... ) din bin mnh m.
Nhng nguyn liu cn thit tng hp axit bo , v triglyxerit ch yu do thoi bin
glucoza cung cp : ATP, NADPH, axetyl CoA, alpha glyxerophotphat,vv...
Tng hp v thoi bin triglyxerit trong t chc m chu nh hng su sc ca ng mu .
C ch t iu chnh qu trnh tng hp v thoi bin triglyxerit ch l mt khu trong h
thng phc tp iu chnh chuyn ho lipit . nh bit, h thn kinh v h ni tit nh hng
su sc ti chuyn ho lipit . ri lon cc h thng dn ti 2 hu qu : tch m qu nhiu
(bo ph) hoc tri li : gy.
1. Bo ph : c th do
- n nhiu (gluxit, lipit ) li t vn ng
- Gim s dng m
- Tng tng hp m t gluxit
a) bo ph do n :
vng di th sau, c trung khu n kh tr nhn bng bn, chi phi cm gic thm n :
ph hu trung khu ny, con vt khng chu n v s cht i. Cng vng di th sau c trung
khu no kh tr nhn bng gia, xung ng c tnh cht c ch c dn ti nhn bng bn,
ph hu nhn bng bn thy con vt n rt d, nhanh chng bo ph. Loi bo ph thc nghim
c gy ra chut cng, chut nht, mo v kh. 24 gi sau khi ph hu trung khu no, cn
nng ca chut cng tng 15% v sau vi tun, tng gp 10 ln so vi l i chng.
ngi cng c th gy trng thi bo ny sau vim no , chn thng vng di
th,vv... bnh nhn sau khi khi bnh n rt nhiu , tng cn nhanh, tch m khp c th nhng
thn kinh , tr tu li gim st.
Trung khu no c th th i vi glucoza : khi glucoza mu gim s c ch trung khu no, do
trung khu n hng phn; tri li khi glucoza mu tng trung khu no hng phn s c ch trung
khu n. tt c cc yu t gy gim ng mu n nh (nh khi chc nng ty o tng ) u
gy hng phn trung khu n, dn ti bo ph (nu t vn ng c).
Hot ng ca trung khu n cn chu nhiu nh hng ca cc xung ng hng tm t cc
th th ngoi v trong ti, bo hiu nhng thay i trong chuyn ho. Nhng th th ca ng
tiu ho c mt tm quan trng c bit : kch thch v gic (gia v) c th gy hng phn trung
khu n. hng phn trung khu n cn pht sinh theo c ch phn x c iu kin.
b) bo ph do gim s dng m. Nh nu trn, vng di th tc ng n huy ng m
thng qua thn kinh giao cm v mt s hormon . loi bo ph ny c th do ri lon chc nng
vng di th sau (gy trong ng dp , chn thng, vim no) hoc do gim hng phn thn
kinh giao cm. trong lm sng, sau chn thng vng tu sng c th pht sinh tch m vng
do giao cm b tn thng chi phi. ch, ct t r trc thn kinh tu (trong c si giao
cm) v hu chui hch giao c mt bn thy pht sinh bo ph cng bn.
nhoi ra khi gim chc nng mt s tuyn ni tit (tin yn, thng thn, tuyn gip,vv... )
cng thy pht sinh bo ph. Hi chng bo ph sinh dc do tn thng vng di th c ch
tuyn yn, gim chc nng tuyn sinh dc. Trong bnh ny m tch phn di bng, khung
chu, mng, mt trong v phn trn i. Ngi b hon cng c th b bo tng t. Ring
ngi b suy tuyn gip th bo cn i hn. Nu dng m nh du th thy, nhng ngi
ny hot ng ca t chc m gim, thi gian bn thoi ho c th ko di ti 90 ngy (bnh
thng l 5 9 ngy).
c) bo ph do tng trng hp m t gluxit : nh nu trn, insulin lm tng xm nhp v s
dng glucoza trong t bo. Do tng tng hp m . ng thi insulin cn gim thu phn m
bng cch c ch men adenylcyclaza . ngoi ra insulin cn lm cho ABTDHT qua mng t bo d
dng vo t chc m. Nh vy insulin tng tit s gy bo ph.trong hi vhng gim ng
mu , (do u ty o) thy bo ph pht sinh nhanh chng.
Ngoi insulin , qu trnh tng hp m t gluxit cn chu tc dng ca prolactin, trng thi bo
ph n trong thi k cho con b c th do tng tit prolactin.
d) Hu qu ca bo ph
kh nng lao ng s gim, m bc quanh cc ph tng , nht l tim, lm suy yu cc c quan
: bnh nhn d b x va ng mch, i tho ng, vv... Cho nn mi c cu : tht lng cng
di th i cng ngn !
2. Gy.
Do nhiu nguyn nhn gy ra :
- Thiu cung cp
- Tng s dng
- Ri lon thn kinh, ni tit.
a) gy do thiu cung cp.
Ch yu l do i n trong thi k chin tranh , ph n trong thi k cha hay nui con,
giai cp b bc lt trong x hi TBCN, thuc a. Trong bnh l, gy cn gp trong ri lon tiu
ho nh nn, i lng, ct on d dy, rut, vv...
b) do tng s dng nh trong nhim trng ko di, u c, lao ng nng nhc (b i chin u
cng thng, hnh qun vt v, vv... ) gy cng c th do hai nguyn nhn trn kt hp : lao ng
th lc nng song thiu bi dng thch ng, trng hp ny kh ph bin trong tc chin.
c) do ri lon thn kinh, ni tit
nh trn ni, vng di i th chi phi cm gic chn n hay thm n, do khi vng ny
b tn thng, c th gy cm gic chn n v c th gy i. ri lon thn kinh cao cp cng c
tc dng c ch trung khu n : bnh lon thn, bnh tm thn, xc cm m tnh (bun b, tht
vng, chn nn, lo lng,vv... ) c th lm cho bnh nhn chn n v gy i.
trong bnh Basedow, c th gy nhanh do chuyn ho c bn tng ; trong bnh i tho
ng m d tr c em ra x dng nn bnh nhn cng gy st nhanh chng. bnh nhn
thiu nng tuyn yn ch cn da bc xng, c teo v yu, s thc n, cam chu i, c th suy
kit dn ri cht.
i khi c th gy trng thi gy ti mt khu vc nht nh do cng giao cm ti ch : th d
c ngi ch gy u, cn thn bnh thng. Trong thc nghim kch thch dy giao cm mt
bn c gy tiu m khu vc mt cng bn (teo na mt).
d) Hu qu ca gy : khng k trng hp gy do mt bnh thc th th trng thi gy lm
gim nng lng d tr ca c th, ngi gy km chu ng, km bn b v d lm vo tnh
trng t thc (t tiu protein ca bn thn) khi c th cn nhiu nng lng.
D NHIM M V THOI HO M
Nu m c mu dn ti c quan , t chc khng c tiu th, li t bo, s pht sinh
nhim m : nhim m kt hp vi thay i cu trc bo tng v thnh phn protein bo
tng gy thoai ho m.
Nhim m thng gp gan v khi c tn thng gan s pht sinh thoi ho m.
Mc d hin nay pht hin rng hu ht cc t chc u c kh nng oxy ho hon ton
axit bo v t chc m l mt t chc hot ng rt mnh , song vai tr ca gan trong chuyn
ho lipit vn gi vai tr qu trnh bc nht. C th trong tng hp v oxy ho cc axit bo , tng
hp triglyxerit, photpholipit , cholesterol, cc lipoprotein v sn xut th xeton.
Cc lipit do n, hoc t chc iu ti hoc c tn to t gluxit u qua gan c oxy
ho, hoc c chuyn vn ti d tr. (H5) theo s ny th lng m trong gan l kt qu
ca s cn bng gia lng m n v i.
Khi m tn ti lu trong t bo gan, song cha nh hng n chc nng gan th c th c
tnh trng nhim m gan.
Nhim m gan c th do nhng nguyn nhn sau gy ra : (hnh 6)
1. Do n nhiu m : khi n nhiu m , cc chylomicron d b cc t bo gan gi li, dn ti
nhim m gan.
2. Do tng huy ng m . axit bo ti gan nhiu ti tng hp triglyxerit, gy nhim m gan,
tng t trng hp n nhiu m . tt c cc trng thi kch thch ko di h thn kinh giao
cm hoc tng tit catecholamin (Stress, thiu mu, thiu oxy ,vv... ) u dn ti nhim m gan,
v u gy gim glycogen gan v tng huy ng m . trng hp c th i n, i tho ng
tu (do thiu insulin , glucoza khng c s dng) trng thi thiu nng lng tng huy
ng m ti gan v n ti nhim m gan. Tng tit hormon tin yn (STH, FMS) thng thn
(cocticoit) thc y qu trnh huy ng m cng l nguyn nhn gy nhim m gan.
3. Do m khng ra khi gan : triglyxerit ra khi gan di dng beta lipoprotein ho tan trong
nc (H7). Cc thnh phn a nc ca beta lipoprotein hn protein v photpholipit c xp
ngoi, tip xc vi nc, cn cc thnh phn khng a nc nh triglyxerit , cholesterol th
c xp trong, trnh va chm vi nc. Do m beta lipoprotein ho tan c trong
nc. Qua s phn tch trn y, thy r khi c th thiu photpholipit, triglyxerit khng ra khi
gan c v gy nhim m gan. Thnh phn ca photpholipit ch yu gan (lecxithin ) l cholin
s km hm tng hp lecxithin, gy nhim m gan . thc n thiu methionin cng nh thiu cc
cht hng m khc (inositol, axit nhn, lipocain,vv... ) s c ch to photpholipit, cng dn ti
nhim m gan.
4. Do nhim c gan. Cn nhn mnh rng cc yu t nh n nhiu m , tng huy ng m ch
gy nhim m n nh v ko di khi ng thi pht sinh ri lon m ra khi gan , tiu m v
axit bo. l trng hp tn thng t bo gan , km theo ri lon men (c bit l CoA,
cytocromoxydaza, succinoxydaza), by gi, nhim m gan chuyn thnh thoi ho m gan.
l c ch bnh sinh thoi ho m gan do nhim c ru, clorofoc, CCl,vv... trong thoi ho
m gan do nhim c , khng nhng m gan nhiu m cn pht sinh ri lon vn chuyn m ra
khi gan . h hp t chc gan gim l yu t bnh sinh qu trnh gy thoi ho m gan do
nhim c.
thoi ho m gan gy ri lon chc nng gan v khi din bin cp c th dn ti bnh teo gan
vng cp, din bin kinh c th dn ti x gan teo. Nghin ru l nguyn nhn ch yu gy
nhim m gan , dn ti x gan, sau nghin ru l i tho ng.
E RI LON CHUYN HO TRUNG GIAN LIPIT . TNG XETON MU
Gan l c quan ch yu to ra th xetonic. T gan vo mu, th cetonic c oxy ho kp
thi trong vng Krebs t chc c vn, thn, phi cung cp nng lng nn xeton mu bnh
thng khng qu 2 4 mg% v thng khng thy trong nc tiu. Ngoi ra, mt phn th
xetonic (axit axetoaxetic) c th ti tng hp axit bo vi s c mt ca NADPH2 .
Lng xetonic hnh thnh trong c th ph thuc vo nhiu yu t.
- Cng tng hp th xetonic gan , cng ny li l thuc vo lng m v axit bo
ti gan , tc oxy ca axit bo,
- Hot tnh ca men deacylaza gan.
- Cng ti tng hp axit bo.
- Cng oxy ho axetoaxetyl CoA vo vng Krebs l thuc vo din bin bnh thng v tc
ca chuyn ho gluxit. Do mi c cu m chy trong ngn la ca ng.
Qua s phn tch trn thy r ri lon chuyn ho trung gian lipit dn ti tng th xetonic
mu v xeton niu (c th ti 40 mg%).
Khu bnh sinh ch yu gy tng xeton mu l tng axetyl CoA c th do tng tng hp cht
ny hoc do qu trnh oxy ho cht ny trong vng Krebs b hn ch. (do li trong mu ).
Tng axetyl CoA c th do nhng nguyn nhn sau gy ra :
a) Trong thc n c nhng cht to xeton nh m , axit amin to xeton (phenylalanin, leuxin,
isoleuxin) ng ch { l mun trnh xeton mu nn dng cc thc n chng xeton : glucoza l
cht chng xeton ch yu, tip t glucoza s hn ch huy ng m ti gan , m bo (vi s c
mt ca insulin ) oxy ho cc th xetonic . mt s cht khc cng c tc dng chng xeton ,
nhng cht ny c th chuyn thnh glycogen d tr gan (nh glyxeryl) mt s axit trong
vng Krebs, mt s axit amin vv...
t chc thiu gluxit (i n, lao ng th lc nng, st, thi k sau m,nhim c tuyn
gip,vv... ) trong cc trng thi bnh l{ ny, c th thiu gluxit huy ng m d tr ti gan ,
gy tng thoi bin axit bo, m hu qu l tng tng hp axetyl CoA v th xetonic.
b) Ri lon chuyn ho axit pyruvic thnh axit oxaloaxetic. Nh trong bnh i tho ng
hu nh ton b axit pyruvic bin thnh axetyl CoA.
c) Ri lon vo vng Krebs ca axetyl CoA . nh khi c th tch nhiu kim loi kim v amoniac
: nhng cht ny tch axit oxaloaxetic ra khi vng Krebs bng cch bin axit ny thnh axit
asparaginic. Ngoi ra cc cht k trn cn c th tch axit alpha xetoglutaric ra khi vng Krebs
bng cch bin axit ny thnh axit glutamic. Trong trng hp ny, axetyl CoA khng vo c
vng Krebs do tng tng hp th xetonic.
d) Ri lon tng hp axit bo t axetyl CoA khi c th thiu biotin hoc i tho ng. Tng
axetyl CoA t axit pyruvic, ri lon vo vng Krebs ca axetyl CoA v ri lon tng hp axit bo
t axetyl CoA u dn ti hu qu : tng tng hp th xetonic.
E RI LON CHUYN HO CHOLESTEROL
2 trng hp c th xy ra :
- Gim cholesterol mu
- Tng cholesterol mu
1. gim cholesterol mu : c th do nhng nguyn nhn sau gy ra
a) Thc n thiu cholesterol
b) Nhim khun v nhim c gy tn thng gan , hu qu l gim tng hp cholesterol, c
bit l cholesterol este.
c) Tng phn hu cholesterol trong c th.(nhim c tuyn gip) hoc tng o thi qua
ng tiu ho (i lng).
Gim cholesterol mu gy ri lon dn truyn xung ng thn kinh v cholesterol l mt
thnh phn cu to mng t bo. ngoi ra cn pht sinh thiu nng ni tit v cholesterol l
nguyn liu tng hp cc hormon steroit ca tuyn thng thn v sinh dc.
2. tng cholesterol mu : gp trong nhng trng hp sau :
a) Do n : trc kia ngi ta cho rng n nhiu thc n c hm lng cholesterol cao (trng,
no, gan,vv... ) s dn ti tng cholesterol mu . song thc t li rt kh gy tng cholesterol
mu do n. c th l cholesterol trong thc n kch thch t bo mast tit ra heparin v cht
ny hot ho men lipaza c tc dng phn gii cholesterol.
b) Nhng yu t ni sinh : c th l axit axetic leuxin, valin, cn etylic,vv... nhng cht ny
cng nh gluxit, protein, m chuyn ho thnh axetyl CoA tr thnh cholesterol.
c) Tng huy ng m d tr (ng thi cholesterol cng ra theo) gy trong hng phn thn
kinh giao cm, xc cm mnh, trng thi Stress. thn kinh giao cm hng phn bin dehydro
cholesterol thnh cholesterol. Cng c th do nhng xung ng thn kinh tc ng ti s
tng hp cholesterol gan.
d) Ri lon tng hp axit bo v th xetonic t axit axetoaxetic. Trong trng hp ny thy
tng hot tnh men tham gia vo tng hp cholesterol beta oxy beta- methyl glutaryl CoA.
e) Gim oxy ho gp trong thiu oxy cc loi, thiu nng tuyn gip, vv... km hm oxy ho
cholesterol.
Tng cholesterol mu ko di c th gy ra mt s ri lon sau :
a) bnh nhim sc vng m c im l ng cholesterol v cholesterol este t chc (da,
gn,vv... ) gy tng sinh t bo lin kt, mu vng y l do trong thnh phn cu to c sc
t lipocrom cholesterol c th ng xng s, hm di, xng chu (bnh Schuler
Chistian). ngf gi, c gic mc l do bnh nhim sc vng.
b) cholesteatose : ng cholesterol v cholesterol este cc c quan nhu m, c bit gan
. trong trng hp ny ,beta lipoprotein v cholesterol t do xm nhp vo t bo gan gy x
gan.
c) X va ng mch : trong bnh ny , cholesterol ng trong lp di ni m ca ng
mch ch, cc ng mch ln, ng mch vnh.
Ngay t 1913, N. Ahitcop nu vai tr ch yu ca cholesterol trong bnh x va ng
mch. Trong thc nghim cho ng vt (ch, th, g,vv... ) n nhiu cholesterol thy c th gy
c va x ng mch. Trong lm sng nhng bnh c cholesterol mu cao (i tho ng ,
bo ph, thn h nhim m,vv... ) thng hay b x va ng mch km theo. Nhn xt chung
l dn tc no nhiu m ng vt th hay b x va ng mch.
Tuy nhin, cholesterol mu tng khng phi l nguyn nhn tt yu v duy nht gy ra va x
ng mch, c nhiu trng hp cholesterol mu tng song khng b x va ng mch , tri
li, cholesterol mu bnh thng song vn b x va ng mch.
Rt nhiu yu t c th gy x va ng mch :
- Trng thi cng thng thn kinh ko di: y l yu t gy bnh qu trnh nht. X va ng
mch gy nhiu nht nhng ngi lm vic tr c v t gy nht cng nhn v nng dn. ri
lon chuyn ho lipit ph thuc vo mc cng thng ca h thn kinh trung ng. nghin
cu nng cholesterol mu cc ngh s trc v sau khi biu din, thy tng 100% so vi
bnh thng. hc vin khi thi cng thy nh vy. ng thi thy gim nng lexithin alpha
lipoprotein v tng beta lipoprotein. M xc 300 lnh M cht trong cuc chin tranh xm lc
Triu Tin thy c 70% b x va ng mch sau mt nm chin u cng thng.
- Ri lon chuyn ho lipit, n nhiu lipit (c bit l cholesterol, cc axit bo no,vv... )
- t lao ng chn tay, lm cho va x ng mch d pht sinh, di nh hng ca cc yu t
thn kinh v n nhiu.
- yu t thnh mch. Trng thi thnh mch ch yu ph thuc vo chc nng ca h t chc
lin kt, vi tui hot tnh ca t chc lin kt gim v x va ng mch d pht sinh. C th
ni trng thi thnh mch l mt yu t gy bnh quan trng .
- nghin thuc l : nhng ngi nghin nng thy b x va ng mch nhiu gp 3 ln so vi
nhng ngi khng nghin.
- yu t tui : x va ng mch thng gp ngi c tui.vv...
V bnh sinh ca x va ng mch, c 3 im cn ch :
- lipit mu bnh thng v thnh ng mch bnh thng khng b x va ng mch.
- Lipit mu bnh thng song thnh ng mch b tn thng : b x va ng mch
Tm li nhiu yu t c th gy x va ng mch , ch yu l :
- Tn thng thnh ng mch. (xy ra trc khi c lng ng lipit )
- n qu nhiu lipit (c bit l cholesterol ) li t vn ng.
- Ri lon chuyn ho lipit.

45. RI LON CHUYN HA NC IN GII

( NGUYN HU M )
I. CHUYN HO NC, IN GII
Nc c vai tr rt quan trng trong vic tham gia cu to t bo v t chc, k c vic duy tr
hot ng bnh thng ca c th. Trong thc nghim thy chut cht kht nhanh hn cht i
: c th nhn i hon ton trn 30 ngy nhng khng c nc , c th s cht sau vi ngy. C
th mt 10% nc lm vo tnh trng bnh l, mt 20 25% nc c th cht.
Trong c th, cc cht in gii c mt vai tr v cng quan trng : duy tr p lc thm thu,
cn bng axit-baz , chi phi tnh chu kch thch thn kinh c,vv... ri lon in gii nh
hng nghim trng ti hot ng ca c th, thm ch c th gy cht.
A PHN B NC V CC CHT IN GII TRONG C TH.
Nc chim 70% th trng v phn b khng ng u trong cc c quan, t chc. Nhn ton
b c th, ngi ta chia thnh 2 khu vc cha nc:
Khu vc trong t bo chim 50% th trng.
Khu vc ngoi t bo chim 20% th trng. Khu vc ny li chia thnh 2 phn : huyt tng
(chim 5% th trng) v dc gian bo (15%).
Gia 2 khu vc trong v ngoi t bo c mng t bo ghn cch. Mng t bo c tnh thm
la chn : cho nc v cc cht hu c phn t nh (axit amin, glucoza,vv... )i qua, v khng
cho cc cht c phn t ln (protein, SO
4
2-
, PO
4
3-
, vv...) i qua. Do c im , s phn b cc
cht trong v ngoi mng t bo rt khc nhau.
dch gian bo v huyt tng b ngn cch vi nhau bi thnh mao mch. tnh ca mng
ny l khng cho qua protein nhng cho qua tt c cc cht in gii.
thnh phn cc cht hu c trong cc dch gian bo, dch gian bo v huyt tng c nhng
im khc nhau :(H1)
dch gian bo v huyt tng khng c nhng khc bit quan trng v thnh phn in
gii,chng cha phn ln NaCl. Lng Na
+
dch gian bo v huyt tng ln hn lng Na
+

trong t bo nhiu. Tri li chng cha t K
+
hn t bo nhiu. huyt tng cha nhiu Na
+
, K
+

hn dch gian bo, nhng t Cl
-
hn. huyt tng cha 70g protein /lit, trong khi dch gian
bo ch cha rt t.
dch t bo cha rt t Cl-, Na
+
, tri li cha nhiu ion K
+
, photphat v protein .
B TRAO I NC V IN GII QUA MNG T BO
Mng t bo c vai tr v cng quan trng trong hot ng ca t bo, tham gia trc tip vo
mi qu trnh chuyn ho ca t bo.
Mng t bo c cu to bi lipoprotein, trn mng t bo c l nh (ng knh 5,5 8,0
A
o
) cho cc cht c th qua mng theo cch khuch tn thng thng. mt trong ca
mng t bo c h thng men v c th c cc cht vn chuyn trung gian (bn cht cha r)
vn chuyn tch cc cc cht i ngc bc thang nng ( l h thng bao gm ATPaza, ATP
v cht chuyn trung gian ).
S trao i nc v in gii qua mng t bo rt phc tp, cn nhiu im cha r. (H2)
Tng qut m ni, bnh thng mt trong t bo tch in m, nn c cc ion tri du qua
v y cc ion cng du, cc ion nhiu ho tr nh protein, HPO
4
--
, SO
4
--
l nhng ion khng
khuch tn c v b gi trong t bo. cc ion Cl
-
, HCO
3
-
khng vo c bn trong v chng
cng du vi mng t bo. tuy nhin ring vi Cl
-
th trong iu kin hot ng in tch ca
mng t bo thay i th lc Cl
-
c th vo trong t bo cngvi Na
+
. Ion K
+
trong t bo c
th ra dch gian bo d dng (vn chuyn th ng); cn khi t ngoi vo trong t bo do ngc
vi bc thang nng nn s xm nhp c kh khn v phi vn chuyn tch cc (trong qu
trnh ny c tiu th ATP). V ion Na
+
, mng t bo khng ch thm ring i vi K
+
m cn c
i vi Na
+
(ng thi km theo c vn chuyn ng, axit amin vo trong t bo ) cn khi t
trong t bo ra ngoi ngc vi bc thang nng, Na
+
cng nh K
+
c vn chuyn tch cc
nh bm Na K
Bm Na K khi hot ng t bo tng th ATPaza s c hot ho. Nh tc dng ca mt loi
men kinaza c bit diglyxerit (c trong thnh phn ca mng) s c photphoryl ho cho axit
photphatidic. Axit ny c to thnh mt trong mng t bo,s kt hp vi Na thnh Na
photphatidic. Hp cht ny sau khi tan trong lipit ca mng t bo s khuch tn ra ngoi mng,
n b men photphataza (ca mng) thu phn gii phng ra Na v photphat v c (H
3
PO
4
).
Nh vy Na
+
c vn chuyn ra khi t bo.
Tm li ,cc ion qua mng t bo tng i kh khn , phc tp , chm chp v tiu hao
nng lng. Cn nc th qua li rt d dng, cho nn s trao i nc v in gii y ch
yu v thc cht l qu trnh di chuyn nc gia trong v ngoi t bo. nc vn chuyn qua
mng t bo l do s chnh lch p lc thm thu gia 2 khu vc : bn no p lc thm thu
cao (ch yu l do nng Na
+
quyt nh) th nc s di chuyn v bn : u trng ngoi
bo gy mt nc t bo, tri li nhc trng nhoi bo gy ngm nc t bo.
C TRAO I NC V IN GII QUA THNH MAO MCH
Cn bng huyt tng v dch gian bo ph thuc vo nhng yu t sau :
1. Tnh thm thnh mch
l mng ngn cch cho php mi phn t nh qua, tr nhng phn t nh protein (khng
tuyt i v tuz ch, do dch gian bo vn c mt t protein ). V vy m cc cht in gii
hai bn thnh mch khng chnh lch nhau nhiu.
Tnh thm thnh mch chu nh hng ca nhiu yu t : thn kinh vn mch, trng thi dinh
dng thnh mao mch,vv... Trong bnh l thiu oxy , thiu vitamin, nhim toan nh hng ti
ni tit v cc cht trung gian ho hc, vv... c th thay i tnh thm thnh mch .
2. p lc thm thu v p lc keo trong mu v dch gian bo
S vn chuuyn nc trong v ngoi lng mch l do cn bng gia p lc thm thu c xu
hng y nc ra ngoi v p lc keo (ch yu do albumin chi phi) ht nc t ngoi vo. c
th tm tt hot ng ca hai lc nh sau : (H3) nc ra khi lng mch phn mao ng
mch v vo phn mao tnh mch.
Ngoi ra c mt s nc gian bo v theo ng bch huyt. vai tr ca thnh mch c
coi nh mng bn thm m hot ng c th minh ho trong hnh.
3. yu t thn kinh th dch.
Ch yu do ADH v aldosterol.
ADH do nhn trn th v nhn gn no tht vng di th tit ra v c d tr hu yn. S
tit ADH chu nh hng ca p lc thm thu ca mu : tng p lc thm thu huyt tng ,
thng qua cc th cm th vng di th (ch phn chia ca ng mch cnh trong) v mt s
c quan, t chc khc (gan, phi , ty, vv... ) gy tng tit ADH , do tng hp thu nc c tc
dng phc hi p lc thm thu huyt tng (nh khi ung nhiu nc , truyn nhiu dch,vv...
). Cng thng qua cc th th thm thu , gy gim tit ADH do ti hp thu nc gim c
tc dng phc hi p lc thm thu huyt tng.
Ngoi cc th th thm thu cn c cc th th th tch ( nh phi) c tc dng chi phi s
tit ADH : dn nh tri, thng qua dy X gy c ch tit ADH, tri li mu ti nh tri gim s gy
tng tit ADH. Ngoi ra tng tit ADH cn gp trong mt s trng hp : au, s, vn c, tim
morphin, chy mu,vv... S tit ADH cn thc hin thng qua c ch phn x c iu kin, ni
ln vai tr ca no b.
Aldosterol . y l hormon chnh ca cn bng nc, in gii., c tc dng ti hp thu Na
(mnh gp 30 ln so vi DOCA) v thi K (mnh gp 5 ln so vi DOCA) on xa ng thn.
Khi Na mu tng , aldosterol gim tit c tc dng tng o ti Na. tri li khi Na mu gim ,
aldosterol s tng tit, c tc dng tng ti hp thu Na.(hnh 4)
Nhng yu t nh hng ti s tit aldosterol :
Tng tit :
Thiu Na
Tha K
Gim khi lng mu lu thng
Chn thng
Xc cm
ACTH
STH
Hormon hu yn
Gim tit :
Tha Na
Thiu K
Tng khi lng mu lu thng
kch thch dy X
dn nh phi
tng catecholamin
nhng cht khng aldosterol
Hin r l renin c tc dng kch thch tit aldosterol : khi huyt p gim, renin tng tit
dn ti tng angiotensin Iic tc dng kch thch v thng thn tng tit aldosterol. Tri li khi
huyt p tng, renin gim dn ti gim tit aldosterol. Trong mt s hi chng lm sng thy
renint tit, kt hp vi tng tit aldosterol (mt mu, suy tun hon do , x gan, vv... ).
Vic iu tit aldosterol cn nh nhng th th th tch thnh ng mch cnh, ng mch
ln gn tim, tm nh,vv...
Trung tm kht l nhn bng gia vng di th : trong thc nghim nu ph hu nhn ny
thy con vt khng chu ung nc v chu cht kht.
II. RI LON CHUYN HO NC, IN GII
Trong lm sng, hai loi ri lon chuyn ho nc v in gii thng kt hp vi nhau, v
ri lon chuyn ho nc gy ra nhng thay i v nng cc cht in gii trong cc dch
ca c th, v tri li nhng ri lon chuyn ho in gii gy ra s phn phi li nc trong c
th phc hi cn bng thm thu. Song tin phn tch, ta s cp ring r 2 loi ri lon
ny.
A RI LON CHUYN HO NC
Nhng thay i v nc trong c th c chia lm 2 loi ln :
a) Mt cn bng nc n thun : bao gm 4 hi chng
mt nc khu vc ngoi bo
tng ngm nc ngoi bo
mt nc khu vc t bo
tng ngm nc t bo
b) Mt cn bng nc kt hp (cn gi l lon ngm nc ) bao gm 4 hi chng:
mt nc ton b
tng ngm nc ton b
mt nc ngoi bo kt hp tng ngm nc t bo
mt nc t bo kt hp tng ngm nc ngoi bo
1. Mt nc ngoi bo : trong trng hp ny c th mt in gii v mt nc ngoi bo , gy
gim th tch nc ngoi bo .
a) nguyn nhn gy mt nc ngoi bo :
Mt nc u trng (mt nc nhiu hn mt mui) gp trong :
Ra m hi nhiu (tri nng, st cao, lao ng nng,vv... ) c th mt ti 14 lit/24 gi (vi 35 g
NaCl).
Trong bnh i tho nht , bnh nhn o thi my lng nc tiu rt long (c khi ti 10
14 lit trong 24 gi).
Khi tip t nc khng trong khi c th vn tip tc mt nc (qua da, phi thn,vv... ) l
trng hp bnh nhn bt tnh , suy mn, khng ung c nc hoc khng gi c nc
ung vo, vv...
Trong cc trng hp k trn, c th mt nc nhiu hn mt mui gy ra trng thi u
trng ngoi bo, gi nc t bo ra ngoi bo (gy mt nc t bo ) cho ti khi cn bng
thm thu gia 2 khu vc c ti lp.
Mt nc ng trng (mt nc v mt mui tng xng vi nhau) gp trong ri lon tiu
ho, nn ma (ch yu mt Cl), i lng (ch yu mt Na), d ng tiu ho,vv... trong nn ma
v i lng nng c th mt i 15% tng lng Na, 28% tng lng Cl, 22% tng lng dch ngoi
bo. Tr nc bt v m hi l nhng dung dch nhc trng, cn cc dch tiu ho khc c
tnh cht ng trng, nn khng c di chuyn nc gia hai khu vc.
Mt nc nhc trng khi mt mui nhiu hn mt nc. l trng hp suy thng
thn (bnh Addison, mt nc v mui nhng ch tip t nc ng thi khng b xung mui
,vv... ). Trong loi mt nc ny , do nhuc trng ngoi bo, nc t khu vc ngoi bo vo
trong t bo (gy tng ngm nc t bo ) nhm lp li cn bng thm thu.
du hiu lm sng v cn lm sng : mt nc ngoi bo dn ti gim khi lng mu lu
thng, nh hng su sc ti ton b cc chc nng ca c th.
Ri lon huyt ng hc : huyt p gim, mch nhanh, yu, lu lng tim pht gim, vv...
Ri lon tit niu : thiu niu, v niu (suy thn cp).
Ri lon thn kinh : thiu mu no dn ti nhiu hu qu nghim trng (t chc no thiu oxy ,
thiu cc cht dinh dng, vv... )
Ri lon tiu ho : gim tit dch , gim co bp, gim hp thu, vv...
Tuz mc nng nh ,mt nc ngoi bo c th chia lm 3 :
1 : (khi mt khng qu 4 litng nc i vi mt ngi nng 70 kg) bnh nhn cm thy mt
mi, da kh, nhn nheo, thiu niu , huyt p gim.
2 : (khi mt 4 -6 lit nc ) cc triu chng k trn nng hn, ngoi ra cn pht sinh ri lon
thn kinh (gim lao ng tr c v chn tay, au u, chng mt,vv... )
3 : (khi mt 6 10 lit nc ) bnh nhn sc mt xm li, mi hin, mt hm li, trong trng
thi v tnh cm v sng s. Huyt p di 90 mmHg, thng c nn lm cho trng thi mmt
nc thm nng.
iu tr : trong mt nc ngoi bo , c th va mt in gii va mt nc. Do nguyn tc
iu tr l tip t dung dch NaCl (ung hoc tim) ng trng hoc u trng (khi mt mui
nhiu ) phc hi th tch nc ngoi bo v p lc thm thu ngoi bo . Thi truyn dch
khi thy ht cc triu chng k trn (da kh, huyt p gim, mch nhanh, thiu niu,vv... ).
2. Mt nc t bo :
Mt nc t bo pht sinh do mt nc (khc vi mt nc ngoi bo va mt nc, va
mt in gii) hoc do t mui trong c th. C hai nguyn nhn ny u gy tng p lc thm
thu ngoi bo (u trng ngoi bo ), lam fcho nc di chuyn t khu vc t bo ra ngoi bo
gy mt nc t bo.
Mt nc t bo thng kt hp vi mt nc ngoi bo.
a) nguyn nhn gy mt nc t bo :
Cung cp nc thiu (st cao, sau khi m ng tiu ho, vv... )
Chc nng thn gim, khng o thi y cc cht in gii, c bit l Na (vim cu thn,
suy tim mt b, vv...)
u nng thng thn (tng tit aldosterol v DOCA) c tc dng gi Na trong c th, c th gp
trong vi ngy u sau khi m ln.
i nht (do thiu ADH ) gy mt nc t bo in hnh.
Tt c cc nguyn nhn k trn u dn ti hu qu l tng Na ngoi bo (u trng ngoi
bo) lm cho nc di chuyn ra ngoi gy mt nc t bo.
b) Du hiu lm sng v cn lm sng :
Tuz mc nng nh, mt nc t bo c th chia lm 3 :
1 : mt khong 75 lit i vi ngi nng 70 kg. Ngoi cm gic kht du hiu sm nht v
quan trng nht ca mt nc t bo khng c du hiu no khc.
2 : mt 4 4,5 lit nc. Kht nhiu, suy nhc, ming v li kh, kh nut do thiu nc
bt, thiu niu, kh nng lao ng vn cn. St l du hiu ton thn quan trng nht v c
bit l ca mt nc t bo, tip t y nc thy st lui ngay.
3 : mt 5 10 lit nc. Cc triu chng k trn nng hn, kh nng lao ng (tr c v chn
tay) gim st, pht sinh nhiu ri lon thn kinh v tm thn (ng g, vt v, v cm, chut rt,
ng lm, o gic, hn m,vv... ). Tt c cc triu chng ny l do mt nc t bo, c bit l t
bo h thn kinh trung ng nhy cm nht i vi ri lon chuyn ho nc.
c) iu tr
Mt nc t bo l do u trng ngoi bo, do nguyn tc iu tr l gii quyt trng thi
ny. hp l nht v n gin nht l cho bnh nhn ung dung dch glucoza ng trng (hoc
tim ), tuyt i khng c dng NaCl, ngay c dung dch ng trng v gy mt nc t bo
(do dch tim vo cha nhiu Na 154 mEq/l nhiu hn dch ngoi bo 142 mEq/l).
Thi iu tr khi ht kht, ht st, ht cc triu chng ri lon thn kinh,vv...
3. Mt nc ton b :
a) nguyn nhn :
Ra m hi nhiu : c th mt ti 14 lit / 24gi khi tri rt nng, li lao ng nng (b i hnh
qun, chin u ma h).
Trong bnh i nht , bnh nhn o thi mt lng ln nc tiu.
Tip t nc khng trong khi c th vn mt nc qua da, phi, thn (trng hp bnh
nhn bt tnh, suy mn , khng ung c nc ,vv... ).
Trong cc trng hp trn, c th mt nc nhiu hn mt mui, gy ra trng thi u
trng ngoi bo , gi nc t bo ra ngoi bo, gy mt nc t bo, v pht sinh mt nc
ton b.
b) Du hiu lm sng v cn lm sng : trong mt nc ton b, cc triu chng ca mt nc
ngoi bo (huyt p gim, mch nhanh, yu, thiu niu , da kh,vv... ) kt hp vi nhng triu
chng ca mt nc t bo (kht, st, ri lon tm thn , thn kinh,vv... )
c) iu tr : trc tin phi gii quyt mt nc t bo, tt nht l dng dung dch glucoza ng
trng (ung hoc tim) nhm cung cp nc , phc hi p lc thm thu ngoi bo nc
tr li t bo, m bo hot ng bnh thng ca t bo. khi ht kht v ht cc triu chng
khc, s dn dn b xung dung dch NaCl ng trng nhm gii quyt mt nc ngoi bo.
4. Tng ngm nc t bo :
Hi chng ny ni ln trng thi nhim c nc ca c th. Tng ngm nc t bo n
thun rt t gp trong thc t lm sng, thng kt hp vi tng ngm nc ngoi bo, gy
tng ngm nc ton b.
a) nguyn nhn :
Suy thng thn gy mt Na, do pht sinh nhc trng ngoi bo gy ngm nc t bo.
chnh trng thi ny gy ra nhng ri lon tiu ho v thn kinh trong bnh Addison : tip t
NaCl thy bnh nhn hn.
Tt c cc trng hp mt nc v mt mui nu ch tip t nc m khng ng thi b xung
mui u gy ra nhc trng ngoi bo m hu qu l tng ngm nc t bo.
Nc ni sinh tng : trong mt s bnh cp tnh nng , nht l khi c st , thoi bin t bo
tng mnh, do nc ni sinh tng (bnh thng l 300 ml/24gi), c khi tng n 10 16 lit,
lm cho t bo trn ngp nc .
b) Du hiu lm sng v cn lm sng :
Ri lon tiu ho thng ni bt ln hng u. Lc u bnh nhn ch thy chn n v bun
nn, chn n hon ton , c th chn ung. Nu tng ngm nc t bo nng, c th bnh nhn
s nn ma (du hiu c gi tr).
Ri lon thn kinh . t nh ti nng c chut rt, au dy thn kinh, au u , ri lon tm
thn, co git, hn m, vv...
vv...
c) iu tr :
nu do tip t qu nhiu nc (hoc glucoza ng trng ) th thi tip t nc trong vi ngy
cho ti khi xut hin cm gic kht, by gi li tip t nc, t mt.
Nu do mt mui nhiu , tip t NaCl u trng phc hi p lc thm thu.
Nu do nc ni sinh tng , dng hormon sinh dc nam hn ch thoi bin protein, ng
thi tng tng hp protein.
5. Tng ngm nc ngoi bo : nc khong gian bo gy ph v trn dch ( nc cc
h thanh mc)
a) nguyn nhn gy ph : c ch gy ph kh nhiu, c th xp vo 2 loi ln
C ch thn
C ch mao qun
a) c ch thn :
Chc nng lc ca cu thn gim song ti hp thu ca ng thn vn bnh thng, th d trong
vim cu thn, ri lon tun hon (suy tim mt b).
hoc tng ti hp thu do tng tit aldosterol sau m, iu tr dng nhiu hormon hu yn,
hormon v thng thn.
b) C ch mao qun :
tng p lc thm thu : huyt p mao mch tng v tc mu chy gim lm cho nc d
thm qua thnh mao mch vo khong gian bo. thng gp trong xung huyt tnh mch (suy
tim mt b, x gan tng huyt p gnh, vv... ) (hnh 3)
gim p lc keo huyt tng : khi protein huyt tng gim nhiu (c yu l gim albumin )
thy ph xut hin , thng gp trong thn h nhim m (protein niu nghim trng), i n,
cc bnh tiu hao, x gan,vv...
tng tnh thm thnh mao mch : gp trong vim , thiu oxy, nhim toan, nhim c, tng
histamin mu ,vv... c im ca loi ph ny l dch ph cha nhiu protein (4 5 g% v hn
na). ngoi ra cn phi k ti :
gim sc khng t chc : trong mt c th bnh thng, mi t chc c mt sc khng (i p)
nht nh . trong nhng iu kin ging nhau, dch thm vo t chc lng lo d dng hn l
thm vo t chc c. Khi sc khng ca t chc gim (trng hp teo t chc, gim cht to
keo ca t chc khi i n, vv... ) thy pht sinh ph.
Ri lon tun hon bch huyt : mt phn dch gian bo tr v mu qua ng bch huyt, nn
khi tc mch bch huyt s pht sinh ph (ph chn voi).
Trong thc t lm sng ph thng do nhiu yu t kt hp gy ra, trong c mt yu t l
ch yu. th d trong ph tim, yu t bnh sinh ch yu l tng p lc thu tnh (do gim sc co
bp c tim), phc hi c sc co bopd ca tim, thy ph gim hoc mt. Phn loi ph
thng da vo nguyn nhn : ph tim, ph gan, ph thn, ph do vim, ph do i, ph d
ng,vv...
Hin nay, vai tr ca aldosterol trong ph c khng nh : trong tt c cc loi ph, khi
ph tng th nng aldosterol mu v nc tiu tng.khi ph gim, nng aldosterol gim.
Do trong iu tr, cn hn ch mui nghim ngt hn hn ch nc.
b) Du hiu lm sng v cn lm sng : khi lng nc khong gian bo khng qu 1 2 lit,
biu hin lm sng ca ph khng r, l trng thi trc ph , vi nhng du hiu nh tng
cn nng, khuynh hng mu long, gim nng protein huyt tng ,vv... Khi nc nhiu,
ph th hin r. ng ch { l khi ph ton thn, theo di cn nng cho ta bit mc ca ph
mt cch chnh xc.
Ph v trn dch nh hng khng tt ti hot ng ca t chc : dch ph chn p t chc,
gy ri lon tun hon ti ch, do nh hng khng tt ti chuyn ho ca t bo. t chc
ph km dinh dng nn d b nhim trng. Ph ko di gy tng sinh t chc lin kt . Nu
dch ph u trng s pht sinh mt nc t bo (kht, st). Nu dch ph nhc trng s
pht sinh nhim c nc . ri lon cn bng in gii trong ph c th gy ra ri lon cn bng
axit-baz. Tuz theo v tr, ph c th gy nguy him cht ngi (ph phi cp, ph thanh qun,
vv... ).
c) iu tr ph . Ch yu l phi iu tr nguyn nhn gy ph. Ngoi ra c th kt hp mt s
bin php nhm gii quyt trng thi nc, king mui, rt dch ph, li tiu, vv...
6. Tng ngm nc ton b
C hai khu vc t bo v ngoi bo u nc, ch yu do tip t nc qu nhiu ng thi
thi tr nc b hn ch gy ra nhc trng ngoi bo v tng ngm nc ton b.
a) nguyn nhn :
Trong v niu, bnh nhn c ung tht nhiu i c , kt qu l nhc trng ngoi bo.
Trong mt s bnh , bnh nhn ung nhiu nc song i gii t, hoc n t mui (vim thn,
suy tim mt b) hoc mt mui nhiu (bnh Addison), hoc trong nn ma v i lng tr em
gy mt mui (v mt nc) nghim trng, song bnh nhn ch ung nc nhiu. Kt qu l
pht sinh nhc trng ngoi bo, gy tng ngm nc ton b.
Truyn dch qu nhiu sau khi m (c khi ti 7 10 lit sau 24 gi) gy li tiu cng dn ti
ngm nc ton b.
b) Du hiu lm sng v cn lm sng : nhng du hiu tng ngm nc t bo (ri lon tiu
ho, thn kinh , vv...) kt hp nhng du hiu tng ngm nc ngoi bo (ph, trn dch, tng
khi lng mu lu thng, ph phi, vv... )
c) iu tr : ch yu l thi ung nc hoc ung rt t trong vi ngy. tin lng tt nu cc
triu chng k trn gim, c bit nu xut hin cm gic kht.
7. Mt cn bng nc kt hp :
Thng thng, ri lon cn bng nc xy ra c hai khu vc : t bo v ngoi bo. 4 trng
hp c th xy ra :
Mt nc ton b ( trnh by trn).
Tng nhm nc ton b ( trnh by trn).
Tng ngm nc ngoi bo kt hp vi mt nc t bo : trng hp ny c th gp bnh
nhn suy tim khng king mui ; mui gy u trng ngoi bo lm cho t bo mt nc.
Trong iu tr, cn hn ch mui.
Mt nc ngoi bo kt hp tng ngm nc t bo. Trong trng hp ny, c th mt mui
nhiu hn mt nc, do pht sinh nhc trng ngoi bo, gy tng ngm nc t bo.
Gp trong suy thng thn (cn cp tnh), nn ma, i lng, vv... bnh nhn ch ung nc
khng tip t mui km theo. iu tr bng NaCl thng em li kt qu tt.
B RI LON CHUYN HO IN GII
Nh nu trn, ri lon chuyn ho nc v in gii lin quan cht ch vi nhau. Cn bng
in gii l do cc ion Na
+
, K
+
, Cl
-
v HCO
3
-
m nhim chnh. ay ch cp n 2 ion Natri v
Kali, cn 2 ion kia s ni ti trong bi ri lon cn bng axit-baz.
1. Ri lon chuyn ho Na :
Na l ion ch yu ca dch ngoi bo . Na c mt vai tr v cng quan trng i vi hot ng
bnh thng ca c th, quyt nh p lc thm thu , chi phi cn bng axit-baz, vv... Yu cu
hng ngy ca c th l khong 5 10g NaCl i vi ngi ln. chuyn ho Na chu s iu ho
ca hormon v thng thn (aldosterol v DOCA).
ng ch { l khi Na mu gim , tng lng Na ca c th c th gim, khng i hoc tng.
a) Na mu gim :
Nguyn nhn gy gim Na mu c th xp thnh 3 loi :
Na mu gim do c th mt Na : trng hp ny , tng lng Na trong c th gim thc s.
Gp trong :
+ mt nc ngoi bo : ra m hi nhiu , nn ma, i lng nng, vv... Trong tt c cc trng
hp ny, c th mt nc ng thi mt mui, song do ung nhiu nc nn Na mu gim.
+ ch king mui ko di.
+ suy thng thn gy gim tit aldosterol, m hu qu l Na ra theo nc tiu
Na mu gim do mu long : trong trng hp ny tng lng Na ca c th v c bn khng
thay i, gp trong
+ bnh nhn v niu hoc thiu niu li ung nc nhiu nn Na mu gim .
+ suy tim mt b. Chc nng lc ca cu thn gim ng thi ch king mui cng lm cho
Na mu gim.
Na vo trong t bo do nhc trng ni bo. Gp trong trng hp t bo mt K
Du hiu lm sng v cn lm sng :
nhiu Na mu gim do mu long : ngoi hi chng tng ngm nc t bo cn ghp thm hi
chng tng ngm nc ngoi bo, gy tng ngm nc ton b.
Nu Na mu gim do mt mui, ngoi hi chng tng ngm nc t bo cn ghp thm hi
chng mt nc ngoi bo.
b) Na mu tng gy mt nc t bo . trong trng hp ny , cng nh gim Na mu , tng
lng Na ca c th c th gim, khng i hoc tng.
Nguyn nhn gy tng Na mu c th th xp thnh 4 loi :
C th mt nc nhiu hn mt mui. Gp trong mt nc u trng (ra m hi nhiu, i
nht, i tho ng , vv... )
Tip t nhiu mui.
Gim o thi mui qua thn do gim lc hoc tng hp thu Na. Mt trong nhng nguyn nhn
ph bin nht v quan trng nht gy tng Na mu l tng ti hp thu do tng tit aldosterol
tin pht (bnh Cushing) hoc th pht (do suy tim, suy gan )
Nc ngoi bo vo trong t bo do ri lon chuyn ho trong t bo gy ra trng thi u
trng ni bo , kt qu l gi nc ngoi bo vo trong t bo, gy tng Na mu.
Du hiu lm sng v cn lm sng :
Nu Na mu tng do mt nc, ngoi hi chng mt nc t bo cn ghp thm hi chng
mt nc ngoi bo, gy mt nc ton b.
Nu Na mu tng do tip t nhiu mui, ngoi hi chng mt nc t bo cn ghp thm hi
chng tng ngm nc ngoi bo.
2. Ri lon chuyn ho Kali :
K l cht in gii ch yu ca t bo, 98% tng lng K ca c th trong t bo, dch ngoi
bo ch cha 2%. Mi ngy khong 4g K vo trong c th v c o thi ch yu qua thn (s
o thi ph thuc vo qu trnh ti hp thu Na v hot ng to H
+
ca ng thn)
K c mt vai tr quan trng trong vic duy tr p lc thm thu , trong cc loi chuyn ho,
duy tr tnh chu kch thch ca si c , nht l c tim, vv... Do thiu K s nh hng su sc
ti cu to v chc nng ca t bo.
Mun cho c th hot ng bnh thng cn 2 iu kin :
Nng t bo bnh thng, ni ln tng lng K ca c th y .
Nng ung th mu (tc K ngoi bo) bnh thng.
Lng K mu ni ln lng K trong khu vc ngoi bo, ngha l mt phn rt nh (2%) ca
tng lng K trong c th . tuy nhin, gi tr triu chng hc ca n li rt ln. Ytc tte l mi
thay i (tng v gim ) K mu u u nh hng su sc ti dn truyn xung ng thn kinh
v co c. ng ch { l nng K mu khng cho ta bit mt cch chnh xc tnh hnh chuyn
ho K trong c th. Nng K mu ph thuc v th tch nc ngoi bo (mu c, mu long).
Thng thng ngi ta cho rng nng K mu gim gim 1 mEq/l tng ng vi mt 100
400 mEq lng K ton phn. Tri li, nng K mu tng 1 mEq/l tng ng vi mt 100 200
mEq lng K ton phn. Trn y ch l mt cch c lng i khi.
a) K mu gim :
Nguyn nhn gy gim K mu ch yu l do c th mt K, ngoi ra cn do tip t thiu K.
Mt theo ng tiu ho : nn ma, i lng, ht d dy, ra d dy lin tip, vv...
Mt K theo ng thn : tt c cc trng hp a niu u c th gy mt K (truyn qu nhiu
dung dch mn , ngt, dung dch li tiu, vv...)
Tng tit aldosterol tin pht hoc th pht u gy gim K mu
Tip t K thiu
ng ch { c th thiu K c th khng gy gim K mu, c khi K mu bnh thng , thm ch
cn tng, cn K mu gim bao gi cng do thiu K.
Du hiu lm sng v cn lm sng :
Ch yu l ri lon thn kinh c : nh bit, K chi phi kh nng hng phn thn kinh c ,
tc ng trn dn truyn xung ng thn kinh (tham gia tng hp axetylcholin v hu
cholinesteraza) v tham gia tng hp ATP.
C vn : du hiu u tin l cm gic mt mi v gim trng lu c. Nu thiu K nghim
trng c th pht sinh lit ton b c vn : c t chi v c thn b lit u tin, c th lit h
hp, lit nho kemd theo gim hoc mt phn x gn.
C tiu ho : thiu K nghim trng c th gy tc rut do lit, cng d dy, nh hng su sc
ti vn chuyn thc n.
H tim mch : in tim c nhng thay i ng ch { nh ST h thp ; T thp, ng in, hai
pha hoc m tnh ; ln sng U ln hn ra (c th gp 7 ln bnh thng).
nh lng K mu gip ch nhiu cho chn on v tin lng.
b) K mu tng :
trong lm sng, K mu tng t gp hn K mu gim. Nu K mu gim thng khng phi l
trng hp cp cu th K mu tng c tnh cht cp cu v c nguy c ngng tim.
Nguyn nhn gy tng K mu
Tip t nhiu K : bnh nhn suy thn, tip t thc n c nhiu K thng gy tng K mu
.truyn mu d tr nhiu, c bit mu lu trn 10 ngy, cng dn ti tng K mu do trong
huyt tng ca mu d tr c nhiu K t hng cu thot ra.
Gim o thi K : suy thn (v niu hoc thiu niu r rt) v suy tim gy K trong mu . do
dng mui K cho nhng bnh nhn ny c th gy nguy him ngay c vi liu va phi. suy
thng thn (bnh Addison ) mi khi pht sinh mt t cp tnh li thy K mu tng .
K t t bo thot ra : gp trong nhiu trng hp nh nhim toan, bng rng, vt thng c
hu hoi c nghim trng, tan mu t, nhim c cp nng,vv... ng ch { l K mu tng th
hin r nu ng thi pht sinh thiu niu hoc v niu, th d trong sc (chn thng, bng) K
mu tng r rt do K t t bo thot ra kt hp vi thiu niu do gim khi lng mu lu
thng.
Du hiu lm sng v cn lm sng :
Ni bt ln hng u l ri lon hot ng tim . in tm c tm quan trng c bit trong
chn on tng K mu : du hiu u tin ca tng K mu va phi (6 7 mEq/l) l s thay i
ln sng T (T cao, cn i, tng i hp, nhn) ; v sau PQ ko di , QRS tng , bin ca P v
R c th gim i cht, ST h thp, tip theo dn truyn trong tm nh v nh tht ri lon
thm nghim trng : P rng v dt, P ln vi T ng trc. PR v QRS ko di. Tng K mu
nghim trng (13mEq/l) gy chn tm tht dn ti rung tht v ngng tim ( th tm trng).

46. RI LON CHUYN HA PROREIN

( NGUYN HU M )
I. I CNG V CHUYN HO
Chuyn ho protein c { ngha v cng quan trng i vi c th sinh vt : protein l thnh
phn ch yu ca mi t bo t chc ngi v ng vt. Cc men, cc hormon cn thit cho s
sng cng nh cc cht cn cho vn chuyn cc cht khc (vitamin, hormon, st, ng,vv... )
hay cc cht bo v c th (khng th ) cng u l protein.
Bt c protein no cng u do trnh t kt hp khc nhau ca 22 loi axit amin c bn, m
i vi con ngi th 7 th hon ton ph thuc vo t nhin , ngha l c th khng t tng
hp c : isolxin, lxin, lysin, methionin, treonin, tryptophan, v valin.
Protein ca thc n c tiu ho rut thnh cc axit amin, axit amin qua tnh mch gnh
ti gan, vo h thng tun hon chung. Mt khc, cc protein ca cc t chc cng khng
ngng thoi bin, a cc axit amin vo mu. Tt c cc axit amin do tiu ho thc n (ngun
gc ngoi sinh) v do thoi bin protein t chc (ngun gc ni sinh) hp li thnh mt ngun
axit amin s dng chung cho mi nhu cu ca c th. Mi t chc ca c th ly trong
ngun axit amin trn nhng axit amin thch hp tng hp thnh cc protein ring ca mnh
(hnh 1).
ng ch { l protein vi cu trc v cng phc tp c c im l mang theo tnh cht c
bit ca tng loi, tng ging v thm ch tng c th.
1.Cn bng Nit
Vi ngi cng nh ng vt cao cp, ngun cung cp N duy nht l protein ca thc n,
nhm p ng hai nhu cu :
- Ti to li nhng cht thoi bin xy ra trong qu trnh chuyn ho ca c th.
- To ra nhng phn t protein mi cho c th trong thi kz c th ang pht trin , c thai,
hoc cho con b.
Bnh thng, lng N n vo bng lng N o thi ra (ch yu qua nc tiu) : hin tng
ny gi l cn bng N. Cn bng dng hay m ph thuc vo lng N o thi t hn hay nhiu
hn lng n vo.
a) Cn bng N dng. Trong trng hp ny, N o thi t hn so vi N n vo. cn bng N
dng gp trong nhng trng hp c th ang ln, c thai, thi kz li sc sau khi m. Ngoi
ra cn gp khi tng tit cc hormon tin bin (STH, hormon nam,vv... ) hoc dng nhiu cc
hormon ny trong iu tr. Nhng hormon ny c tc dng tng cng tng hp protein so vi
thoi bin. Insulin gip cho axit amin thm qua mng t bo d dng, ng thi hot ho men
tng hp protein, ngoi ra insilin cn hn ch tn to glucose t protein , do gim thoi bin
protein.
b) Cn bng N m. trong trng hp ny, N o thi nhiu hn so vi N n vo. cn bng N
m pht sinh khi i n, protein niu, bnh nhim trng, chn thng, bng, m ln, vv...
Ngoi ra cn gp khi tng tit cc hormon thoi bin (ACTH, cortisol, thyroxin,vv... ) hoc khi
dng nhiu hormon ny trong iu tr.
2.Chuyn ho axit amin :
a) Kh amin : ng vt, qu trnh kh amin bao gi cng l kh amin oxy ho, to thnh axit
alpha xtonic v NH3 . y l mt phn ng hai chiu : ngc vi phn ng kh amin l phn
ng amin ho, ngha l tng hp axit amin t axit alpha xtonic v NH3 .
Phn ng kh amin chu nh hng ca mt s yu t : men aminooxydaza, oxy, vitamin C,
PP, B2,) thy phn ng kh amin b km hm, gy tng o thi axit amin theo nc tiu, gim
tng hp ure.
b) Trao i amin : trong phn ng ny, mt axit amin chuyn gc amin ca n cho mt axit
alpha xtnic, bin axit ny thnh mt axit amin v axit amin mt gc amin tr thnh mt
axit alpha xtnic. S trao i amin c thc hin nh tc dng xc tc ca cc men trao i
amin (transaminase) m coenzym l pyridoxal photphat (vitiamin B6), ph bin nht v hot
ng mnh nht l men GOT v GPT. Hin nay, c bit l tt cae cc axit amin trong thin
nhin u c th trao i amin c, tuy nhin vi mc khc nhau. Mnh nht l axit
glutamic v axit aspatic, alanin,vv... Thiu vitamin B86 gy ri lon trao i amin.
c) Kh Cacboxyl : y l mt phn ng kh phr bin cc t chc ng vt to ra nhng
amin tng ng. Men xc tc phn ng ny l decacboxylaza cng c coenzym l pyridoxal
photphat. Men decacboxylaza ca axit amin rt ph bin cc vi khun ng rut. Do
rut c nhiu sn phm kh cacboxyl : histamin t histidin, tyramin t tyroxin, serotonin t 5-
hydroxytryptophan, vv... Mt phn cc sn phm ny c hp thu qua mng rut. Cc amin l
nhng cht rt c.
Trong iu kin bnh thng, cc amin to thnh c kp thi kh amin oxy ho, nh men
aminooxydaza to thnh NH3 v aldehyt. Ngoi ra cc amin cn b trung ho bng cch kt
hp vi protein.
Tng lng amin trong t chc v trong mu xy ra trong trng hp tng hoati tnh men
decacboxylaza, gim hot tnh men aminooxydaza hoc ri lon kt hp amin vi protein.
Ngoi ra, tng amin cn gp trong thiu oxy v hu hoi t chc. Trong cc qu trnh bnh l, c
c ch phn ng kh amin oxy ho, chuyn thnh axit amin ch yu c thc hin bng con
ng kh cacboxyl dn ti tng amin.
3.Sn vt cui cng ca qu trnh thoi bin protein.
a) S phn ca NH3. NH3 t do rt c i vi c th, c rt t trong mu.NH3 to thnh c
kp thi kt hp vi axit glutamic tr thnh glutamin. Glutamin khng c m l dng vn
chuyn NH3 trong mu. glutamin c to thnh hu ht cc t chc, cn s xc tc ca men
tng hp glutamic v ATP. Glutamin c mu vn chuyn ti gan v thn, glutamin thu
phn thnh axit glutamic v NH3 vi s c mt ca men glutaminaza, NH3 c gii phng bin
thnh ure hoc o thi qua nc tiu di dng mui amoni.
Ure c to thnh gan, t NH3, ri vo mu, c vn chuy ti thn o thi ra
ngoi. Do gan l c quan ch yu to thnh ure, thn l c quan o thi ure nn trong lm
sng thng nh lng ure trong cc bnh gan v thn. Qu trnh to ure qua 3 giai on. qu
trnh ny c th b o ln do ri lon hot ng men c tnh cht di truyn.
- Acgiosucxinat niu m c im l tng axit amin niu v tinh thn thiu nng do thiu men
acgiosucxinaza.
- Amoniac mu tng do thiu men tng hp cacbonyl photphat m men OCT (ocnitin
cacbamyl transferaza); trong bnh ny thy glutamin tng o thi theo nc tiu.
- Xitrunin niu : trong trng hp ny xitrunin mu c th tng gp 50 ln so vi bnh thng
sau 24 gi. C th c th o thi ti 15 g xitrunin. Nguyn nhn l do thiu men tng hp axit
acgino sucxinic.
Hot tnh ca cc men tng hp ure pht sinh ri lon trong bnh gan (vim gan, x gan),
gim protein huyt tng, c ch phn ng photphoryl oxy ho. Trong mu, NH3 tng gy
nhim c. Mn cm nht vi NH3 l t chc thn kinh.
b) S phn ca axit uric. Axit uric l sn phm thoi bin duy nht ca baz purin. Phn ln
axit uric ngi c o thi qua thn. Nc tiu v cc dung dch ca c th ngi lc no
cng c axit uric mc d khng c purin trong thc n hoc khi i n. mt khc, ch n
nhiu purin (nh cc ph tng gan, thn,vv... ) lm tng ba xut axit uric trong nc tiu. Do
, c th cho rng axit uric c 2 ngun gc : ni sinh v ngoi sinh.
Trong bnh l{, axit uric mu tng trong vim thn , bnh bch cu, c bit trong bnh Gt
(Goutte). Trong bnh ny axit uric ng li trong sn, bao khp, gn, i khi gp c da, c,
thn, gy au n, vim cc khp b mo m, mt chc nng v cui cng bnh nhn cht v x
thn. Mui urat c th lng ng ng tit niu v to thnh si.
V c ch bnh sinh, c th k n my nguyn nhn sau :
- Tng hp qu nhiu axit uric do
Tng cng tng hp trc tip qua inosin, hypoxanthin ti axit uric (trong gt thng thng).
Tng cng tng hp qua axit inosinic, axit guanilic, guanin, ri xanthin. Con ng ny thy
trong bnh gt th pht vi cc bnh v mu (h bch cu cp).
Ri lon men nh ri lon c ch phn hi c ch ca cc nucleotit, c hnh thnh i vi
men amido transferaza trong khu chuyn PRPP thnh PRA, hay khi thiu men bm sinh
chuyn hypoxanthin thnh axit inosilic (men hypoxanthin guanin photphoribozyl transferaza).
- n nhiu purin qu (cc cht c nhiu axit nhn).
- Ri lon thn khng o thi c urat. (x thn).
Hin nay trong iu tr, ngi ta s dng nhng thuc lm gim ti hp thu axit uric ti ng
thn nhng tt hn c l dng thuc c ch men xanthin oxydaza khng cho chuyn thnh axit
uric na. Xanthin trong mu tng nhng n d dng c o thi do n d ho tan hn.
4.Tng hp protein :
Nh nhng cng trnh ca Watson v Crick (gii thng Nobel nm 1962) m vai tr ca axit
nucleic trong sinh tng hp protein c xc nh. ADN trong nhn t bo ng vai tr ci
khun sn c v di truyn v sau m th t cc axit amin ca mi protein ring bit c k
hiu bng th t cc b ba nucleotit trong mi gen ADN. K hiu ny s c ARN thng tin
(hay mARN) sao chp li, a n ni tng hp l cc ribosom trong bo tng. nguyn liu
xy dng l cc axit amin c mt loi ARN khc (ARN ho tan hay sARN) vn chuyn ti
ribosom v xp theo ng trnh t quy nh, sau chng c ni vi nhau bng cc dy
ni peptit. Nh vy mi gen quyt nh cu trc ca mt loi protein v iu kin cn thit
qu trnh tng hp protein din bin bnh thng l s cung cp y v cn xng cc loi
axit amin cng nh s ton vn ca h thng thng tin, tc l ADN v ARN (hnh 2). Nhng
cng trnh nghin cu ca Jacob v Monod (1968) cho thy l gen cu trc cn b chi phi bi
gen iu ho na. Theo khi nim v operon m cc tc gi tm thy trn vi khun , th ngi ta
c th kt lun rng , nhiu gen cu trc c lin quan vi nhau nm cnh nhau v ch khi hot
ng khi c mt gen khi ng ( Gen operateur ) nm k trn cng mt th nhim sc khi
pht . Gen khi ng cng vi cc gen cu trc trc thuc hnh thnh mt operon . S hot
ng ca n v nay li tuz thuc xo mt gen iu ho , c nhim v thc y vic tng hp
mt cht c ch (represseur) . Cht ny , khi kt hp vi gen khi ng , s c ch c n v
operon khng hot ng . Di tc dng ca mt c cht hay mt sn phm chuyn ho , cht
c ch mt tc dng v operon c gii c ch s hot ng v cc cht do cc gen cu trc
ch huy s c tng hp . n lt cc sn phm mi c tng hp s lm gim c cht hay
s lm mt tc dng gii c ch l operon li b gen iu ho c ch tr li . Qu trnh c nh
vy din i din li v cc protein c hnh thnh theo nhu cu ca c th sng .
5. Vai tr ca protein huyt tng rt quan trng :
- Gi nht ca huyt tng , cn thit i vi mu , vi s hot ng ca bch cu , vi
tnh thm mao mch, vv...
- Gi vng p lc keo, rt cn cho vic m bo chuyn ho nc, in gii c bnh
thng.
- Vn chuyn cc cht khng tan trong nc vi chc nng nh cc cht d ho tan.
- vai tr i vi min dch v sc khng khng c hiu (khng th ..).
- ng mu : trong huyt tng c nhiu yu t ng mu.
- vn chuyn cc hormon v cc men. Mt khc cn bit l cc men c bn cht l protein v
bn thn cc hormon l dn xut ca protein .
- L cc cht m c vai tr quan trng trong duy tr pH mu. vv...
II. RI LON CHUYN HO PROTEIN
Bao gm :
- Ri lon tiu ho v hp thu protein.
- Ri lon thnh phn protein huyt tng.
- Ri lon tng hp protein t bo v t chc.
- Ri lon chuyn ho trung gian axit amin.
- Ri lon giai on cui ca chuyn ho protein.
A - RI LON TIU HO V HP THU PROTEIN
Ri lon tit dch ca d dy, ni chung khng nh hng su sc ti qu trnh chuyn ho
protein. Qu trnh tch cc axit amin ng tiu ho din bin c khc, tuz thuc loi axit amin.
th d : tyrosin v tryptophan bnh thng c tch ngay trong d dy, cn cc axit amin
khc phi vo ti rut non mi c tch ra. Ri lon tch tyrosin v trypyophan pht sinh
trong trng hp thiu dch v v ct on d dy.
Ri lon hp thu axit amin pht sinh trong vim v ph nim mc rut non.
Trong t bo, d ch thiu mt loi axit amin cn thit cng gy ri lon tng hp protein,
ng thi gy tng tng i cc axit amin khc vi hu qu l cc sn vt trung gian ca cc
axit amin ny.
Tng hp axit amin pht sinh ri lon khng nhng do thiu axit amin cn thit m cn do ri
lon t l gia lng cc axit amin cn thit a vo c th. Cc axit amin cn thit cho vic
tng hp cc hormon, cc cht trung gian ho hc, cc cht c hot tnh sinh vt.
C th thiu cc axit amin cn thit khng nhng gy ra ri lon chuyn ho protein ni
chung m cn nh hng su sc ti tng hp nhng protein ni ring, gy ra nhng ri lon
c hiu.
Th d :
- Thiu tryptophan ko di gy c tu tinh th chut nht, gim nng protein huyt
tng tr em.
- Thiu lysin gy bun nn, chng mt, au u, v b ting ng kch thch.
- Thiu acginin gy c ch to tinh trng.
- Thiu histidin gy gim nng hemoglobin.
- Thiu methionin gy thoi ho m gan, do thiu nguyn liu tng hp lexithin vv...
B THAY I CA PROTEIN HUYT TNG
Trong bnh l{, thng pht sinh nhng thay i ca protein ton phn cng nh ca tng
loi protein ni ring.
1.Thay i ca protein ton phn.
Danh t protein ton phn bao gm tt c cc loi protein c trong mu, khng k cc
protein ca huyt cu b loi b. Protein ton phn bnh thng t 7,1 8,3 % (phng
php Gornall).
Trong nhng trng hp bnh l khc nhau, tuz thuc vo th bnh, giai on bnh m c
th thy protein tng, gim, hoc khng thay i.
ng trc mt trng hp tng hoc gim protein mu, cn xc nh c tnh trng mt
nc hoc tng ngm nc mu, do gy sai lc kt qu hay khng ? Khi tng lng nc
mu, protein mu s gim gim tng i, cn khi mt nc th thy tng tng i. Trong c
hai trng hp ny, lng protein tuyt i khng thay i.
Gim protein mu thng bao gi cng gn lin vi gim albumin mu v tng protein mu
thng km theo tng globulin mu. tng tuyt i albumin n nay cha gp. Gim albumin
mu thng c b p bng tng globulin mu (nu h vng ni m hot ng tt) gi
vng p lc keo. Tri li, tng globulin thng c b p bng gim albumin.
a) gim protein ton phn.
Gim protein huyt tng c th l du hiu gim protein ton c th v protein huyt tng
phn nh tng lng protein ca c th. Ngi ta tnh c rng gim 1g protein huyt
tng l gim 30g protein t chc. Tuy nhin, c trng hp c th mt protein nghim
trng song protein huyt tng vn bnh thng.
Gim protein huyt tng ch yu l gim albumin. Nhng nguyn nhn gy gim protein
huyt tng c th l ri lon tng hp protein, tng thoi bin protein, c th mt protein.
- Ri lon tng hp protein : do cung cp thiu, ri lon tiu ho v hp thu (bnh ng
rut), khng tng hp c (thiu vitamin, c th suy kit do nhim trng, nhim c ko
di,vv... ) .Tng hp protein gim khi pht sinh ri lon chc nng cc c quan to protein, c
bit l trong bnh gan (vim gan, x gan). Thy gim nng albumin, fibrinogen, brothrombin
huyt tng. ngoi ra, gim tng hp protein huyt tng cn gp trong nhng bnh di truyn
(rt him) nh gim albumin mu, gim fibrinogen mu, gim globulin mu, vv...
- Tng thoi bin protein. Trong tt c cc bnh c tng thoi bin protein nh st, nhim
trng, i tho ng, u nng tuyn gip, u c, vv... u thy gim protein huyt
tng.ng ch { l bnh nhn gy xng , phi bt ng thng pht sinh cn bng N m.
- Tng mt ra ngoi, gp trong chy mu, vt thng, ri lon tiu ho : nn ma , i lng;
protein niu (trong thn h nhim m) ; tng thm thnh mao mch, vim, xung huyt tnh
mch (bng nc trong suy tim, tng huyt p gnh) ; vt thng chy m lu ngy, c bit l
apxe phi (bnh nhn c th mt ti 200g mi ngy v bnh nhn khng th no khi c
chng no trng thi mt protein khng c pht hin ra v gii quyt tt.)
- Thot huyt tng rng ln , c bit trong bng rng : trong bng (din su, ln), ni
ln hng u l hin tng gim protein r rt, tc v mc gim protein l thuc vo
din bng. Trong bng nng, protein c th gim ti 3,38 g% v ngay c khi vt bng lnh,
owr a s bnh nhn bng nng, protein huyt tng cng cha hi phc. Mt trong nhng
nguyn nhn ch yu gy gim protein huyt tng l mt protein qua vt bng, do tng thm
thnh mch, thot huyt tng ra ngoi (trong 24 gi c th thot ra 3 lt huyt tng hoc
hn), albumin thot ra ngoi nhiu hn globulin do phn t lng nh hn.
- Gim protein huyt tng th hin r trong trng thi suy mn do thng tch. Trong chin
tranh, gim protein huyt tng thng binh thng do nhiu yu t kt hp gy ra : trng
thi cng thng v mt mi khi hnh qun chin u (gy tiu hao protein ), thc n tip t
khng u, chy mu nhiu, lnh ko di, nhim trng ,vv... dn ti gim protein huyt tng,
nh hng su sc ti din bin ca vt thng.
Gim protein huyt tng gy ra nhiu hu qu :
- Gim protein huyt tng dn ti gim p lc keo ca mu, gy ra ph. Ph ch xut hin khi
lng protein huyt tng gim r rt (c khi di 2,4 g%), v trong bnh sinh ca ph, ngoi
tc dng ca p lc keo do protein huyt tng m nhim, cn nhiu yu t khc tham gia.
Trong thc t, cho n theo mt ch thiu protein thy nng protein huyt tng vn
bnh thng tuy c ph xut hin ; tri li c trng hp protein huyt tng gim song khng
c ph km theo, hoc protein huyt tng gim rt thp song mc ph li va phi.
- Gim protein huyt tng gy ri lon vn chuyn nhiu cht : cation (Ca++, Mg++,vv... ),
hormon (thyroxin...) bitiamin (c bit nhm B), bilirubin v nhiu cht khc, do gy ra mt
lot cc ri lon chc nng : ni bt ln hng u l thiu vitamin. Nhng biu hin sm ca
gim protein huyt tng l ri lon hot ng men chuyn ho gluxit, lipit, v protein; trc
tin l gim hot tnh men kh amin, chuyn amin, v tng hp axit amin (c bit r gan),
nh hng ti tng hp protein gan v cc c quan khc. hot tnh men to ure gim, nn
ure mu gim, NH3 mu tng.
- Khi thiu haptoglobin mt loi alpha 2-globulin gy ri lon kt hp v vn chuyn
hemoglobin (do hng cu b hu, gii phng ra) , khin cho hemoglobin b hu, gii phng theo
nc tiu.
- Gim tng hp cc yu t ng mu (fibrinogen, brothrombin,vv... ) gy ri lon ng mu.
- Thiu transferin mt loi beta 1-globulin gy ri lon vn chuyn st.
- Gim tng hp gamma globulin (khng th ) d gy nhim trng v nhim trng nng.
b) Tng protein ton phn
thng l tng tng i (s lng tuyt i khng tng ) do mu c, hu qu ca mt nc
nghim trng (nn ma, i lng ra m hi, vv... ), trong trng hp ny tng khng nhiu lm,
khong 10% v cao nht l 12%.
Tng tuyt i thng do tng gamma globulin (khng th ), gp trong cc bnh nhim trng.
Ch { l tng globulin mu c th pht sinh nhm b p thiu albumin , nh trong x gan,.
Tng globulin mu ng thi gim albumin dn ti gim h s albumin / globulin ca mu (bnh
thng l 2 n 2,5).
2. Thay i cc thnh phn protein huyt tng.
Bnh thng, thnh phn protein huyt tng ngi Vit Nam c th tm tt trong bng
sau :
Trong bnh l, t l cc thnh phn protein huyt tng c th thay i.
a) Albumin gim trong tt c cc trng hp gim protein huyt tng nh gim tng hp do
cung cp khng (i n), do tn thng c quan (x gan), tng thoi bin (nhim trng ),
mt ra ngoi (bnh thn, ri lon tiu ho, vv... ).
b) Alpha globulin tng trong tt c cc trng hp vim cp cng nh mn, trong hoi t t
chc (nhi mu) hay trong mt s bnh chuyn ho (thn h nhim m, nhim bt). Thnh
phn ny lm tng nht ca mu v tng tc lng mu.
c) Beta globulin t thay i m ch thy tng khi tng m trong mu nh bnh x mch, tc
mt, thn h nhim m, vv... Cn trnh nhm ln tng beta globulin thc s vi tng gi do
tng gamma globulin c tc c i st beta globulin (IgA v IgM) (hnh 3).
d) Gamma globulin tng trong tt c cc trng hp c tng khng th nh nhim trng ,
min dch , mn cm , x gan, u tng bo, vv...
Cn ch bn cnh s tng gim tuyt i cn c s tng gim tng i. Mt thnh phn
tng hay gim thc s s lm cho cc thnh phn khc c v gim hay tng v t l phn trm.
Bnh thng c mt t l cn i gia cc thnh phn protein huyt tng lm cho chng
kh t kt ta : l cn bng keo. Khi t l ny mt cn bng, huyt tng d b ta , th d
nh khi thm mui kim loi nng chng hn. l nguyn l{ ca nhiu phn ng huyt thanh
(Takata-Ara, Mac Lagan Weltmann, Wunderley, vv... ) thng dng thm d bnh gan, tuy
khng c hiu.
C RI LON TNG HP PROTEIN.
Nh nu trn, nhng iu kin cn thit qu trnh tng hp protein din bin bnh
thng l s cung cp y v cn xng cc loi axit amin cng nh s ton vn ca h thng
tin tc l ADN v ARN. Nu thiu mt trong hai iu kin th s pht sinh ri lon tng hp
protein v s lng hoc cht lng.
Ri lon tng hp protein c trnh by trn. sau y cp ti nhng ri lon v cht
lng. Tt c cc ri lon tng hp protein v cht lng u lin quan ti s thiu st ca
ADN trong nhn t bo, do thng gp trong nhng bnh bm sinh v di truyn.
Qua tm tt rt n gin qu trnh sinh tng hp protein trn y, thy r mt t bin c
th xy ra :(hnh 4)
- gen cu trc lm cho cu trc ca chui polypeptit, ca phn t protein, ca men tng hp
ra b thay i .
- gen iu ho lm cho cu trc ca kho hm b thay i , hoc khng hm, hoc khng m
d di tc dng ca cht cm ng.
- gen khi ng lm gen ny khng chu nh hng ca kho hm, dn ti tng hp men
khng iu ho, v t chc.
Trng hp cu trc ca protein b thay i, c th ni rng t bin gen cu trc l
nguyn nhn gy ra bnh. Nu cu trc ca phn t protein khng thay i song s lng
protein gim r rt c th ngh ti t bin gen iu ho.
Ri lon tng hp v cht lng c th pht sinh :
- Do sai st ca mt gen gy thiu mt men tng ng khin cho c th thiu hn mt sn
phm, ng thi ng mt sn phm chuyn ho trong c th.
- Do sai st ca gen khin cho c th tng hp mt sn phm khc thng. in hnh cho loi
bnh ny l bnh lon hemoglobin v lon globulin (paraprotein).
1.Ri lon tng hp protein do thiu men gy ng mt sn phm , ng thi thiu hn
mt sn phm khc :
Nh bit, tt c cc qu trnh chuyn ho trong c th u chu s chi phi ca yu t di
truyn. Mi qu trnh chuyn ho gm mt chui phn ng , mi phn ng thc hin c do
hot ng xc tc ca mt men nht nh.Cu to v chc nng ca men li do cc gen nht
nh chi phi. t bin mt gen gy ra ri lon tng hp protein men, do km hm mt
phn ng ho hc nht nh, c th nh hng ti mt lot cc qu trnh sinh ho khc. l
c ch di truyn ca nhiu bnh di truyn c xp vo loi bnh l men.
Cc chng ca mt qu trnh chuyn ho c th m t n gin nh sau : cht A bin thnh
cht D sau khi qua cc chng B v C. nhng phn ng ho hc thc hin c l nh cc
men a, b, g, hnh thnh di tc dng ca cc gen a, b, g. Nu mt trong nhng gen b t
bin, th men tng ng s thay i v cu trc v chc nng, hoc men khng c tng
hp v by gi phn ng do men chi phi b km hm, b chn li. chn c th pht sinh
bt k chng no ca qu trnh chuyn ho . th d chn xy ra chng B --> C kt qu l :
- Gim hnh thnh sn vt ca phn ng (C) v nhng sn vt tip theo (D).
- C cht ca phn ng b km hm (B) v tin thn ca n (A) li trong c th.
- Thay i hng ch yu ca phn ng l tng sn vt bnh thng c rt t (x, y, z).
Gim hot tnh men l c s bnh sinh ca cc bnh v men, c tnh cht di truyn. S pht
sinh chn trong qu trnh chuyn ho axit amin l yu t gy ra mt s bnh di truyn. th d
chn trn ng chuyn ho ca phenylalanin v tyroxin .
2.Ri lon tng hp protein do sai st ca gen iu khin khin cho c th tng hp mt sn
phm .
in hnh cho loi bnh ny l bnh lon hemoglobin v lon globulin.
a) bnh lon hemoglobin (Hb)
Trong phn t Hb ca ngi bnh thng c 4 chui polypeptit v 4 phn t hem (H5). Cc
chui polypeptit khc nhau v thnh phn axit amin , chui a (c 141 axit amin ), cc chui b, g,
v d mi chui c 146 axit amin . mi phn t Hb gm 2 i polypeptit ging nhau. Tuz thuc
vo s kt hp ca cc chui polypeptit, Hb ca ngi c chia thnh 3 loi :
- Hb A1 (k hiu l 22) gm 98% Hb ca ngi trng thnh.
- Hb A2 (k hiu l 22) ch chim 2% ton b Hb ca ngi ln.
- Hb F (k hiu l 22) ch thy tr s sinh v bnh thng mt i khi a tr ln ln.
Tt c cc loi Hb u cha 2 chui alpha v ch khc nhau i th 2 (H5).
Hin nay r l trong nhiu bnh thiu mu di truyn c s thay i v cu to ca phn t
Hb , trong mt axit amin nht nh trong mt chui polypeptit c thay th bng mt axit
amin khc . th d trong bnh thiu mu hng cu hnh lim, , c t bin gen quyt nh cu
to chui ca phn t Hb , GAG b thay th bi GUG, dn ti s thay i ca axit glutamic mang
in m v tr 6 bng valin trung tnh. Kt qu to ra HbS bt thng.
Khng phi tt c cc bnh lon di truyn u do s thay i v tr ca mt axit amin trong
phn t Hb, nh khi HbF tn ti qu lu, s pht sinh thiu mu hng cu bia. Trong bnh ny,
t l HbF c th chim ti 15 100%.
Trong bnh lon Hb hng cu rt d b v, do cu trc thay i nn kh nng
kt hp oxy cng gim v hng cu thng bin hnh nh hng cu hnh li lim vi HbS.
Hin nay ngi ta pht hin ra trn 40 th lon Hb khc nhau (bng

Tn Hb bt
thng


v tr axit
amin


ng l l


b thay bi


M boston


a 58


Histidin


Tyrosin


M norfork


a 57


glyxin


Axit asparaginic


I


a 16


Lyxin


Axit asparaginic


G. Chinese


a 30


Axit glutamic


Glutamin


S


b 6


Axit glutamic


Valin


C


b 6


Axit glutamic


Lysin


E


b 26


Axit glutamic


Lysin


D


b 121


Axit glutamic


Glutamin

b) cc protein bt thng:
Nh bit, cu trc ca khng th (globulin min dch ) ging nhau ch chng u c n
v cui cng gm 4 chui polypeptit : 2 chui nng v 2 chui nh ni vi nhau bng nhiu cu
ni disulfua.
Trong mt s trng hp bnh l rt t gp, c th tng hp nhng globulin bt thng, (gi
l lon globulin ) hoc ch gm nhng chui nh, hoc ch gm cc chui nng (ca IgG hoc
IgA), hoc tng hp nhng globulin phn t lng rt ln (gi l macroglobulin).


47. RI LON QU TRNH PHT TRIN - U C
HONG DUNG

Trong c th sinh vt sng lun din bin qu trnh pht trin t chc do cc t bo t chc gi
hoc bnh l b tiu hu v cc t bo t chc mi c ti sinh thay th.
I. I CNG
Trong c th sinh vt sng lun din bin qu trnh pht trin t chc do cc t bo t chc
gi hoc bnh l b tiu hu v cc t bo t chc mi c ti sinh thay th.
Bnh thng, mi tng quan gia hai qu trnh tiu hu v ti to ca qu trnh pht trin t
chc c iu ho bi h thn kinh trung ng , thng qua h ni tit, cc yu t th dich v
cc kch thch ho hc t nhng sn phm phn hy t bo cht. Trong trng hp bnh l qu
trnh pht trin t chc c th b ri lon vi nhiu hnh thc khc nhau:
- Ri lon theo hng nhc sinh do qu trnh d ho mnh hn qu trnh ng ho gm
cc hin tng lon dng, teo v hoi t t bo.
- Ri lon theo hng u sinh, do qu trnh ng ho mnh hn d ho nh hin tng
tng sinh ph i, hoc pht trin thnh khi u.
A - NHNG RI LON QU TRNH PHT TRIN T CHC
1. Qu trnh teo l gim khi lng t bo do khng c dinh dng y , pht sinh khi t
chc b ri lon chc nng, mt thn kinh chi phi hoc b p lu di.
2. Lon dng l qu trnh bnh l c bin i nghim trng cc qu trnh chuyn ha vt cht,
gm :
- Thoi ha thy dc khi t bo chng to, nguyn sinh cht c c ht v hc, nguyn nhn do
tn thng mng t bo v ti lp th, ri lon h hp t bo do thiu nng lng (ATP) cho t
bo.
- Thoi ha m khi nguyn sinh cht t bo ng nhiu ht m do ri lon chuyn ha gluxit
v ri lon men oxy ha lipit.
- Thm nhim glycogen do ri lon cc men tng hp v thoi bin glycogen (
GPD gan, photphorylaza c)
- Thm nhim dng tinh bt (amyloit) , l bt protein hnh thnh nhng si nh bn cht l cc
mnh ca chui nh ca globulin min dch xut hin khi c ri lon tng hp protein trong qu
trnh p ng min dch. C th l bnh di truyn hoc gp trong cc bnh l nhim khun nh
lao, vim khp, thn h
3. Tiu v thi ra t chc do cc t bo hu hoi gii phng nhiu men tiu protit ( proteaza,
cathepsin) v hot ho plasminogen thnh plasmin lm tiu t chc cht.
4. Vi ho xut hin ti ch t chc cht do t cc t bo cht gii phng men photphataza
kim iu Canxi xng vo mu gy tng Canxi-mu v lm d lng ng hoc do cc hocmon
tuyn cn gip c th gy tng Canxi dng kt hp citrat, photphat nn d gy lng ng vi
xng v sn no.
5. Ph i l hin tng pht trin t chc qu mc, t bo to ra do ARN tng lm tng tng
hp protit trong nguyn sinh cht t bo, c km c tng sinh t bo. Ngoi cc trng hp ph
i sinh l{ ( ph i tim do luyn tp), cc hin tng ph i t chc u l bnh l, t chc
tng th tch nhng cc mch mu nui dng khng tng ph hp nn thng dn ti thiu
oxy v cc ri lon khc.
6. Qu trnh pht trin thnh u do t chc khng tun theo s iu ho ca c th ma pht
trin qu mc, ngi v ng vt u c th pht trin u lnh tnh v quan trng nht l u c
tnh ( ung th ).
B.QU TRNH TI SINH
L qu trnh pht trin t chc nhm khi phc mt phn hay hon ton cc t bo b hu
hoi. Ti sinh l mt c im quan trng ca s sng, kh nng ti sinh ph thuc vo tng
loi t chc: c th rt mnh ( da, nim mc, t bo mu, tu xng ), va phi ( gan, thn,
tuyn ni tit, xng v sn ) hoc rt km ( thn kinh, c trn,li thng thn ).
1.Nhng yu t n qu trnh ti to t chc :
a) Tnh trng ti ch ca tn thng:
- Tnh trng ca t chc b tiu hu nh vt thng khng c rp nt t chc nhiu, kht ming
thng chng lnh, nn nu sch thng c khu ngay. Vt thng khng b nhim khun,
c cung cp mu y , t lp m v tnh trng thn kinh ti ch tt cng mau lnh hn.
- Vt thng c c nh, khng di ng xng gy ( b bt, bng tt ) cng chng lnh hn.
b) Tnh trng ton thn:
- Ngi n ung y th vt thng chng lnh: ngc li dinh dng km th vt thng d
nhim khun v lu khi. Trong cc cht dinh dng th protit l cn thit, nht l cc axitamin
c lu huznh nh Methionin. Nu dng cht ng v phng x S.35 Methionin tim cho con vt
c vt thng th sau vi ngy tn mt gan v vi t chc khc, ngi ta thy cht tp
trung c vt thng. Tc dng ca Methionin l gip cho s hnh thnh cht keo ( collagen )
ca t chc lin kt. Sinh t C cng rt cn t bo lin kt x non ( fibroblaste ) s dng
c S ca Methionin kt hp vi mucopolysaccarit hnh thnh si keo. Ngoi ra cn phi k
c sinh t A c tc dng trn pht trin t bo.
- Yu t ni tit : Hocmn ca h no v tuyn gip ( STH, thyroxin ) c tc dng tng cng
chuyn ho vt thng v xng gy chng lnh. Androgen v Insulin liu nh cng c tc dng
tt, ngc li ACTH, Cotison c tc dng chng li, hn ch s pht trin ca t chc lin kt
cho nn tnh trng kch ng thn kinh, tm l{ cng l nhng Stress thng binh, c th lm
vt thng lu lnh.
Cc yu t ngoi cnh khc nh nhit t 35 40
0
C, tia t ngoi c tc dng tt i vi qu
trnh ti to t chc.
2. Chuyn ho cc cht ti t chc c ti to:
Ngay 2h sau b tn thng, ti ch thy xut hin cc t bo ca t chc lin kt ( histioblaste,
histiotyte, i thc bo ), ri sau cc bch cu, cc t bo x non ( fibroblaste ). S thoi ho
ca bch cu, kch hot cc men oxy ho kh s gii phng ra cc sn phm xc tc qu trnh ti
to, bn cht ca cc nucleoprotein c tc dng tng cng phn chia gim phn cc t bo ti
to ng thi cc men lizocm hydrolaza gy tng cng phn hu gluxit, lipit, protit vng tn
thng. Tng cng phn hu gluxit l biu hin quan trng ca chuyn ho vt cht trong t
chc ti to dn n tch lu axit lactic , piruvic v nhim toan. Tng cng phn hu lipit gii
phng cc sn phm m-lipoit (lecithin, axt bo ) lm gim sc cng b mt ca t bo. Kch
hot cc men tiu protit cng dn n gii phng histamin v cc cht tng t t cc t bo b
tn thng gy dn mch, mang n mt s lng ln cc bch cu, cc sn phm xc tc qu
trnh ti to t chc v cc cht dinh dng cho t chc c ti sinh.
Vai tr h thn kinh trung ng c { ngha ln i vi ti to t chc. Ct t dy thn kinh
ngoi vi cng gy ri lon dinh dng to thnh cc vt lot v khng thnh so ko di.
II. C IM CA U C ( UNG TH )
Ung th l s pht trin sinh sn bnh l ti ch ca cc t chc, c im ch yu l cc t bo
ung th c tnh khng in hnh, pht trin khng chu s iu ho ca c th v c nhng c
tnh ring bit v sinh ho, chuyn ho vt cht, tnh khng nguyn. t bo ung th khi im l
nhng t bo bnh thng ca c th b t bin do mt nguyn nhn cha sng t gy nn
nhng bin i khng hi phc v cu to v chuyn ho vt cht, pht trin khng theo quy
lut chung m li c kh nng pht trin khng ngng v hn nh. Tuy khi u ch yu l biu
hin ti ch nhng nh hng su sc ti ton b c th nn bnh ung th c coi l mt
bnh ton thn, c tnh cht c tnh v l mt nguy c cho nhn loi v tn s lan rng, t l t
vong ngy cng cao v nht l cho n nay vn d phng iu tr bnh vn cn l mt kh
khn ln cho y hc.
A - C IM CHUYN HO CA UNG TH
Nhn chung t chc u c c mt h thng men v chuyn ho vt cht theo mt hng ring
bit khc hn t chc bnh thng.
1.H thng men ca t chc u c:
C 3 c im ch yu:
- Cc men h hp t chc ( dehydrogenaza, cytochromeoxydaza, catalaza, succino- oxydaza,
riboflavine ) u gim nn chuyn ho ch yu tin hnh theo ng k kh.
- Cc men c hiu ca t chc gim ( nh men arginaza ca t chc gan, hexokinaza c ) lm
cho kh nng bit ho ca t chc gim.
- Cc men kh, thoi bin axit amin gim r rt, ngc li cc men nucleozit, nucleotit
photphorylaza, polymelaza li tng cng c tc dng thc y qu trnh sinh tng protit to
iu kin cho t chc u pht trin.
2.Chuyn gluxit ca t chc u c:
- Tng mnh qu trnh thoi bin glycogen, ch yu theo con ng k kh nn t chc u tch
lu nhiu axit lactic. T chc u lnh trong iu kin thiu oxy cht rt nhanh, cn t chc u c
c th tn ti v pht trin trn c s qu trnh thoi bin k kh v la ngun cung cp nng
lng chnh cn thit cho tng hp protit ca khi u.
- Cn thy tng r rt hot tnh G6PD, cung cp cho t chc u mt s nng lng cn thit
pentoza photphat cn cho sinh tng hp nucleotit. Nh vy tng mnh qu trnh thoi bin
gluxit i kh v ch yu k kh cung cp mt na nng lng cho t chc u v dn ti to thnh
mt s ln cc hp cht phn t lng thp s dng cho sinh tng hp nucleotit v axit amin.
3. Chuyn ho protit ca t chc u c:
Trong t chc u c c s ri lon cn bng gia cc qu trnh tng hp v thoi bin protit,
qu trnh thoi bin gim, ngc li qu trnh tng hp mt s lng ln protit v axit nucleic
li tng mnh duy tr mc cao s phn chia cc t bo c chuyn ca u, nht l trong u
c tnh.
- Cc qu trnh kh v chuyn amin b gim hoc c ch hon ton, t chc u cn c kh nng
hp th axit amin t mi trng ln cn, to iu kin tch lu cc axit amin cn thit cho u
pht trin.
- Tng tng hp cc nucleotit t cc gc pyrimidin v purin t do cc riboza v ATP, tng sinh
tng hp ARN, ADN.
4. Chuyn ho lipit trong t chc u:
T chc u thng d pht sinh nhim m do lng axit bo khng bo ho, photpholipit,
lecithin, cholesterol u tng ging nh trong t chc bo thai.
5. Chuyn ho nc v in gii:
- Lng nc trong t chc u c rt cao : 85 90% do tng cc cht m c phn t lng
thp ( albumin ) lm tng p lc keo t chc, U cng c, pht trin cng nhanh th lng
nc cng cao.
- Cc cht in gii 1 ho tr nh Na
+
, K
+
, tng ngc li cc cht in gii 2 ho tr Ca
++
, Mg
++
,
li gim lm t s K/Ca cao hn c so vi t chc bo thai, do sc cng b mt ca t chc u
gim v tnh di ng ca t chc u tng r rt
B - C IM V PHT TRIN CA U C
1. Pht trin khng in hnh, khng bit ho c v hnh thi v chc phn to thnh cc t bo
c tnh, non tr ging nh cc t bo phi. t chc u khng cn gi cu trc v chc nng bnh
thng ca cc t bo khi im mc d pht trin trn c s mt t chc bit ho ( t bo
gan, tuyn khng cn gi tnh cht v chc nng bnh thng m u tr thnh nhng t bo
ung th non tr v a dng.
2. Pht trin rt nhanh, mnh do kt qu phn chia t bo, v nhn cc cht dinh dng, nng
lng t cc vng ln cn cung cp do c th coi u l mt t chc k sinh pht trin trn s
tiu hao ca c th. T chc bit ho cng thp th u pht trin cng nhanh, ri lon v cu
trc, chuyn ho cng su sc.
3. Pht trin xm ln : u lnh pht trin tng i chm, p, tch v t lm hi t chc xung
quanh, ngc li u c pht trin rt nhanh lm cho v bc khng kp hnh thnh v khi pht
trin th t chc ln cn b chn p, ph hoi v u c ln theo nhng ch m sc khng yu
nht ( bch huyt, k cc thanh mc ) gy di bo ung th nhng ni xa.
C ch bnh sinh ca tnh xm ln rt phc tp : c th do lng Ca
++
thp lm gim sc cng
b mt t bo nn u c c tnh di ng cao. Mt khc t chc lin kt xung quanh khi u mt
kh nng hng ro do nng cao axit lactic v cc sn vt dung gii m tch lu trong t chc
u, nn u c thng d pht trin xm ln v hu hoi cc t chc ln cn lan rng, to
thnh nhng khi u mi, hay di cn, nhng di cn ny thng i theo ng mu v bch
huyt dng li nhng ch mch tc v pht trin nn thng c di cn phi v gan. Cng
c th c di cn mt s t chc c bit do i tnh ring : ung th d dy hay c di cn
bung trng, hoc ung th phi thng di cn thng thn hay no
III. NGUYN NHN V BNH SINH CA U C
Hin nay, ngi ta pht hin trn 700 cht c th gy pht trin ung th, c chia thnh 3 loi
chnh :
1. Cc virut gy ung th :
Vai tr ca virut gy ung th c cp t lu, bnh sc-cm Rouss g mi c th truyn t
con b bnh sang con lnh bng cc cht lc khng c t bo ca t chc u, ung th da (
papillom Shoppe ) cng gy c bng cch rch da v cy vo cht lc khng c t bo ca
u ny, virut bittner t lu c coi l yu t sa gy ung th tuyn sa ca chut, ch pht
sinh chut ci mt dng nht nh mn cm, ri nhiu loi virut gy bnh bch cu c
phn lp t cc cht nghin t bo bnh. c bit cc Sc-cm v tr khc nhau chut c th
gy c bng cch tim cc cht chit xut khng t bo t t chc Sc-cm ca ngi.
Tuy rng vn phn lp cc virut gy ung th ngi cha tin hnh c nhng thuyt
virut gy ung th c c bit ch {. Ngi ta cho rng cc virut ny c th tn ti trong c
th ngi v ng vt v bnh khng xut hin trong mt thi gian di. Di nh hng ca
cc yu t gy bng khc ( tia x ion-ho cht ho hc), ca tnh phn ng c th ( di truyn,
tui v cc yu t khc, cc virut gy ung th th n ny b kch hot lc by gi ung th mi
pht trin.
2. Cc cht ho hoc gy ung th : ( hnh 1).
a) Cc cht ho hc gy ung th ngoi sinh gm :
- Nhm hydrocacbua gy ung th :
+ Cc cht thuc 3-4 benzopyren c pht hin sm nht, c dn xut . ethyl . sco
butylstyben c tnh kch dc nh estrogen.
+ Cc cht thuc 1-2 benzathracen c kh nng gy ung th mnh nht.
+ Cc cht phenanthren v dn xut cholanthren, 20- methyl- cholanthren c tc dng gy ung
th mnh, cng thc rt gn axit mt v mt cu to ho hc ging nh cc nhn sterol (
folliculin, hocmn v thng thn, axit mt, sinh t D ). Cc hydrocacbua c tc dng gy ung
th ti ch, tim di da hoc bp tht cc cht ny c th gy to thnh cc sc-cm ti ch
hoc ung th da.
Nhm amino azoic gy ung th:
Bao gm cc ho cht mu dng lm thuc nhum, c th gy ung th xa ni kch thch:
+ Cht amino azotoluen, v cc dn xut c kh nng gy ung th gan v c cc c quan
khc nh adenm phi, epithe lim tuyn gip. Dimethylamino azobenzen gy ung th gan.
+ Cc cht n gin hn : fluoren, nitrosamin gm mt s lng khng ln lm benzel v azot
c kh nng gy ung th cc ni tng d dy, thn, xoang mi v no. Cc nitrosamin khng
i xng v cc dn xut piperizin gc d vng c th gy ung th thc qun chut. Benzidin
v . naphtylamin gy ung th bng quang ch v cn c th gy ung th gan chut
Nhm thuc l v khi thuc l:
Ngi ta chng minh s lin quan gia nghin thuc l v ung th phi, cng nh ung th
h mng, thanh qun v bng quang. Thy khi thuc l c cht gy ung th loi hydrocacbua
thm nhiu vng ( benzapyren, anthracen, phenol ) ; cc kch thch c hc biu m phi v
ph qun: thch tn( asen ), kim ( nicollum ) v crm ; cui cng l hot tnh phng x ca khi
thuc. Nha hc n c t 1- 5% trng lng ca khi thuc l khi ht. T l cht do ung th ph
qun cc cng nhn th hi than nhiu hn gp 10 ln so vi nhn dn. Thch tn v crm
trong thuc l c tc dng gy ung th cng c chng minh trong thc nghim, v nhng
liu nh PO 210 ng v phng x trong thuc l c th tch lu trong c th dn n pht sinh
ung th ( hnh 2 ).
b) Cc cht ni sinh gy ung th:
Mt trong nhng hng chnh nghin cu hin nay l xc nh nhng cht gy ung th ni
sinh, c gi nh l nhng sn phm ca chun ho aminoaxit, steroit, c nhng tnh cht
chung l hiu lc gy ung th ging nhau mc d chit xut t c quan v t chc khc nhau.
Tc dng gy ung th ca cc cht ny t l khng cao lm ( 50% ) v thng c giai on tin
ko di hn so vi tc dng ca cc cht gy ung th ngoi sinh.
Cc cht loi oestrogen l thnh phn cc ni tit t sinh dc gm oestron ( folliculin ), oesvilin,
oesvilenin, oestradiol, oestriol l cc cht c cu trc loi steroit nh cholesterol, rt ging cc
hydrocacbua gy ung th, c th gy ung th cc loi chut ( ung th tuyn v, tuyn yn, t
cung, tinh hon, c trn ). Cc cht oestrogen c th gy ung th theo con ng trc tip v
gin tip. Bi oestrogen trn nim mc m o hoc trn u v c th gy phn ng tng sn
v pht sinh u c. Tc dng gin tip l ch nhng cht ny c th bin thnh cc cht
chuyn ho c hot tnh gy ung th bng cch kch hot cc th cm t bo to iu kin tng
sn t bo v lm tng cng tnh thm mng t bo do t bo t chc d mn cm vi cc
cht gy ung th khc.
Cholesterol v cc cht chuyn ho : Trong cc cht chit xut t t chc ung th ca bnh
nhn, ngi ta thy c nhng mnh rt giu cholesterol, em cht ny tim cho ng vt
gy c sac- cm ti ch. Sau t t chc ca ngi v ng vt, c trong lng trng
ngi ta tch ra c mt cht c tc dng xc tc tng hp cht m gi l carcinolipin, mang
tim di da hoc trn vo thc n cho chut cng gy pht sinh u. Trong t chc bnh nhn
cht v ung th, nng cht ny tng gp 2 3 ln t chc bnh thng. Cu trc ho hc ca
carcinolipin rt ging cholesterol. Tc dng gy ung th cn thy c axit mt.
Cc cht chuyn ho tryptophan : thy tng cao l nguyn nhn gy ung th bng quang, bnh
bch cu, sac-cm ng vt. Ri lon chuyn ho tryptophan thy c trong giai on sm ca
bnh bch cu v trong ung th bng quang do tc dng lu di ca cht nahptylamin cc
cng nhn cc x nghip nhun mu anilin. Ri lon chuyn ho tryptophan vi s tch ly trong
c th cc cht chuyn ho c hot tnh gy ung th cn thy trong cc bnh di truyn c lin
quan n tng thoi bin sinh t B6 l mt oenzim cn thit ca nhiu men chuyn ho
tryptophan. Tuy nhin tc dng yu v gi tr ca n trong pht sinh ung th ngi cn c
tip tc nghin cu, cng nh vn ti sao v trong iu kin no c th bin nhng cht
chuyn ho bnh thng thnh cc cht c kh nng gy ung th.
3. Cc tia x ion - ho : ( tia roentgen, tia , ).
ngi b chiu x ti ch v ton thn ( lm vic hoc iu tr bng quang tuyn X, ng v
phng x ) c th thy pht sinh ung th bt u bng vim da do quang tuyn ( radiodermite )
ri dn ti ung th da, bnh bch cu hoc sac- cm. Thi kz tim ca bnh c th ko di t 1
n 30 40 nm.
Nhng nn nhn bom nguyn t Nht ( Hroshima, Nagasaki ) thy tng cng t l b ung th
v bnh bch cu c cc th h sau ( hnh 3 ). Tim vo c th cht ng v phng x c th
gy ung th khc nhau d dy, da, phi khi cht ny lt vo kh qun, gan... Tia ngoi tm v
tia nng mt tri tc dng lu di cng c th gy ung th da chut cng v chut nht.
C ch tc dng ca cc cht gy ung th trn c rt nhiu l thuyt gii thch :
Cht gy ung th vo c th s kt hp vi cht m, c bit cc cht m c ng ni S -
S to thnh mt cht m mi, lm thay i hn hng chuyn ho ca t chc hoc gy tn
thng h men c hiu ca t bo, to iu kin chuyn thnh t bo ung th.
Cc cht gy ung th ( virut, cht ho hc, tia x ) ch c tc dng u tin nh mt yu t gy
bin d, lm thay i cu trc phn t ca t bo ( AND, ARN ), gy tn thng chc phn v
tnh bit ho ca t bo, to iu kin chuyn thnh t bo ung th. Cng c th tia x ion
ho ch lm ri lon h thng iu ho sinh l ca c th, to iu kin cho virut pht huy tc
dng v gy ung th.
Cc cht gy ung th ( ch yu virut, cc cht ho hc ) l thnh phn thng xuyn v cn
thit ca t bo u, xc nhp vo cc zen ca t bo v lm bin i chng ( hnh 4 ). C th
gi nh rng virut gy c ch mt phn hay hon ton cc zen bnh thng ca t chc
ng thi li kch hot cc zen b virut xm nhp, hu qu l gy bin chuyn t bo bnh
thng thnh t bo ung th.
Trong thc nghim, virut SV40 i vi t bo chut nht 3T3 th khng sinh si ny n trong t
bo r lm dung gii t bo, thot ra gy bnh nhng t bo khc m li tch hp vi ADN
ca t bo bt t bo ny tng hp ADN v cc protein cn thit ca virut, lm t bo chuyn
bin thnh t bo ung th ( hnh 5 ).
Cc cht gy ung th c kh nng bin d mnh i vi nhim sc th ca t bo do gy sn
sinh mt dng t bo vt ra khi quy lut iu ho ca ton c th. Trong cc t bo ca t
chc ung th hay c thay i v s lng cng nh cht lng ca nhim sc th ( a bi gy
nhim sc th ) ngc li, nhng bnh nhim sc th ( hi chng Down ) thng km theo
bnh c tnh v mu ( bnh bch cu ), d mc hn so vi tr bnh thng.
C ch ca s chuyn dng ung th ca t chc c thc hin theo 3 giai on :
1. Giai on to thnh cc t bo ung th tim ( t bo tin ung th hay ung th ng ). Giai
on bt u chuyn dng thng rt kh phn bit vi t chc t bo bnh thng v cc du
hiu phn ho hnh thi m mi ch c bin i tnh phn ng ca t bo gy ri lon h thng
tin di truyn ca cromozom, hoc gy bin d cc zen , ch huy s hnh thnh cu trc t bo
do tc dng ca cc nhn t gy ung th ( cng c th c sn mt s lng t bo trong trng
thi tin ung th c trn c th bnh thng ).
2. Giai on chuyn thnh cc t bo ung th chnh thc do nh hng ca cc cht gy ung
th. Lc ny tng hp men v cc cht m c tnh c hiu c quan v t chc b c ch, nh
khu cc khng nguyn trn b mt t bo b bin i, ng thi cc zen khc c gii c
ch v tip thu c tnh cht tng hp cc cht khng nguyn bo thai v d loi, to iu kin
cho t bo chuyn thnh c tnh. Thc t thy c nhng cht ch lm t bo bnh thng
chuyn thnh t bo ung th ng v nhng cht khc li c tc dng kch thch nhng ( t bo
ung th ng ) tr thnh hot ng v lm bnh pht trin ( hnh 6 ).
3. Giai on cc t bo ung th tng cng sinh sn v to thnh cc khi u thot ra khi s
kim sot ca h thng iu ho ca c th, c th do tc dng ca nhiu yu t ni mi ( ni
tit, thn kinh th tng ) v ngoi mi ( dinh dng ).
IV. NHNG YU T NH HNG N S PHT TRIN CA UNG TH
Nhiu yu t nh hng n s pht sinh v pht trin ca ung th.
1. Yu t tui tc v dinh dng :
U c thng pht sinh nhng la tui nht nh : ung th tuyn v xut hin sau 35 tui,
ung th d dy sau 40 tui con sac- cm li hay gp ngi tr tui. C tc gi cho rng tui l
thi gian cn thit ung th nung bng hoc tui gi l lc sc khng ca c th km st,
hot ng thn kinh- ni tit suy yu nn bnh d pht sinh ( hnh 7 ). Ni chung u c pht
trin ngi cng tr th bnh cng nng, c tnh cng mnh.
Dinh dng khng phi l yu t quyt nh nhng cng c nhng nh hng nht nh : n
thiu m lm ung th d pht sinh. Thiu cht methionin d gy ung th gan v methionin c
tc dng che ch cho nhu m gan.
Trong thc t ung th gan nguyn pht hay gp cc nc chm tin, i sng dinh dng
thiu thn. Tng cng n cht m, nht l cholesterol lm cho ung th d pht sinh v pht
trin lan trn. thiu sinh t B, ( riboflavin ) trong thc n dn n pht sinh nhanh chng ung
th gan chut do cc hp cht azoic, c sinh t B, gip cho ban chuyn ho cc cht azilo-
azcic thnh cc cht khng c kh nng gy ung th. Thiu sinh t A nh hng n s pht
sinh ung th phi. B sung sinh t A lm gim t l mc ung th ng vt nghin cu do tc
dng ca benzopyren.
2. Yu t di truyn v th tng :
Di truyn to iu kin thun li cho s pht sinh ung th, cc yu t di truyn kt hp vi cc
c im sinh l, sinh ho, ni tit ca c th lm gim hoc tng cng kh nng xut hin ung
th : ung th v ch pht trin mnh chng chut C3H, bnh bch cu d gy chut chng
C58, ng nhm mu A d mc ung th hn ngi c nhm khc.
Th tng c t chc lin kt yu t, giu cc yu t biu m th d pht sinh ung th hn, v
qu trnh pht trin c l do tnh trng chc phn ca t chc lin kt b suy yu. Cc qu
trnh vim nhim mn tnh ( vt xc c t cung, lot d dy, n tht bng quang, rut non ) c
th l tin ca qu trnh pht trin c tnh. Theo thuyt ( kch thch mn tnh ) th qu trnh
vim ko di lm suy yu cc phn ng thch nghi ca c th, lm suy yu chc phn ca t
chc lin kt, kch thch s phn chia t bo, lm gim kh nng bit ha ca t bo do lm
ung th d pht sinh v pht trin. Nhng khng phi qu trnh vim nhim no cng to thnh
trng thi ( tin ung th ) cng nh khng phi trng thi tin ung th no cng c chuyn
thnh ung th m cn ph thc vo s to thnh hoc tn ti trong c th mt cht nn c
bit, bn cht ho hc l nuclepprotein, cht ny c th c a vo c th dng chun
b sn ( virut, cht ho hc ), hoc c tng hp t bn thn c th ( Neimann . M.1974 )
3. Yu t thn kinh v ni tit :
Tim cc cht gy c ch thn kinh ( phenamin, amytal Na ) trc khi gy ung th thc
nghim trn ch, ung th l mt qu trnh ri lon dinh dng thn kinh c th do mt kch
thch trng din gy ra. Ung th pht trin nhanh v nng thng gp cc bnh nhn loi
thn kinh yu v mnh nhng khng thng bng, nhng trng hp ny cng d c di cn.
nh hng ca cc tuyn ni tit cng c lu {, nht l cc hocmn tuyn sinh dc : ct b
bung trng lm cho ung th v chut khng pht trin. ngi b ung th tuyn tin lit,
nu thiu hay tim folliculin th c th ngn chn c s pht trin ung th. Ph n b ung th
v, nu ct bung trng hoc tim testosterol cng c th lm ngng pht trin unh th.
4. Yu t min dch trong ung th :
Ngi ta pht hin c cc khng nguyn ung th c hiu nh khng nguyn ung th
phi ( anphal foctoprotein trong ung th gan nguyn pht, khng nguyn trn b mt t bo
lympho trong u Burkitt ) v s dng trong theo di, pht hin bnh lm sng.
Cc khng th chng ung th ang c tip tc nghin cu. C th cc khng th ny khng
c tc dng bo v v khng c vai tr quyt nh trong min dch chng ung th v c tc dng
phong b khng nguyn, cn tr cc t bo lympho T nhn bit k th, lm min dch t bo
chng ung th khng pht huy c tc dng.
Vai tr ca min dch t bo chng ung th c nhiu tc gi cp. Mt s cho rng s d
khi u d dng pht trin l do c s suy sp min dch t bo ( ct b tuyn c dng thuc c
ch min dch, thiu nng min dch bm sinh hay mc phi ), do t bo lympho T mt kh
nng cnh gic min dch, nhm tiu dit cc t bo ung th. Cho nn ngi ta cp min
dch tr liu chng ung th nhm nng cao phn ng min dch t bo bng cch : dng tnh
cht hoc nghin khi u tim cho bnh nhn , truyn bch cu ca bnh nhn leucose
mn cho bnh nhn leucose cp tnh; dng cc kch thch khng c hiu ( BCG v cc ch phm
ca n ); gy min dch bo tr bng truyn cc lympho nn cm hoc dng cc ch phm
tinh cht tuyn thymus Mc d kt qu cha nhiu nhng c mt iu chc chn l nu kt
hp min dch tr liu vi cc bin php kinh in th kt qu kh quan hn l dng cc ha cht
v chiu x n thun.
V. HU QU CA UNG TH I VI C TH
U c thng gy nhiu thay i trong ton b c th:
Ri lon v tng cng thoi bin gluxit, u th cc qu trnh phn hy trn cc qu trnh
oxyha nn trong mu huyt ng gim, protit ton phn gim, nng axit lactic tng, cc
sn phm N phi protit tng
Cc men thoi bin c hiu ca chuyn ha axitamin, nucleotit b km hm nn cc sn phm
ri lon chuyn ha axit amin ng v tng bi tit thao nc tiu ( a peptit, tyrosin,
tryptophan )
Bng nhn b nhim kim do tc dng b p ca cc yu t kim ( K
+
) tch ly trong mu v
gim nng axit cacbonic do tng cng bi tit theo ng h hp.
Tt c cc ri lon trn lm cho bnh nhn lm vo tnh trng nhim c, thiu mu v suy
mn, bnh nhn thng cht trong trng thi suy mn hoc cht do bin chng xut huyt,
nhim khun v ri lon nghim trng cc chc nng c th. Th vy thy r tuy khi u l biu
hin ch yu nhng c s lin quan cht ch gia khi u v ton b c th.
Nhm thuc l v khi thuc l:
Ngi ta chng minh s lin quan gia nghin thuc l v ung th phi, cng nh ung th
h mng, thanh qun v bng quang. Thy khi thuc l c cht gy ung th loi hydrocacbua
thm nhiu vng ( benzapyren, anthracen, phenol ) ; cc kch thch c hc biu m phi v
ph qun: thch tn( asen ), kim ( nicollum ) v crm ; cui cng l hot tnh phng x ca khi
thuc. Nha hc n c t 1- 5% trng lng ca khi thuc l khi ht. T l cht do ung th ph
qun cc cng nhn th hi than nhiu hn gp 10 ln so vi nhn dn. Thch tn v crm
trong thuc l c tc dng gy ung th cng c chng minh trong thc nghim, v nhng
liu nh PO 210 ng v phng x trong thuc l c th tch lu trong c th dn n pht sinh
ung th ( hnh 2 ).
b) Cc cht ni sinh gy ung th:
Mt trong nhng hng chnh nghin cu hin nay l xc nh nhng cht gy ung th ni
sinh, c gi nh l nhng sn phm ca chun ho aminoaxit, steroit, c nhng tnh cht
chung l hiu lc gy ung th ging nhau mc d chit xut t c quan v t chc khc nhau.
Tc dng gy ung th ca cc cht ny t l khng cao lm ( 50% ) v thng c giai on tin
ko di hn so vi tc dng ca cc cht gy ung th ngoi sinh.
Cc cht loi oestrogen l thnh phn cc ni tit t sinh dc gm oestron ( folliculin ), oesvilin,
oesvilenin, oestradiol, oestriol l cc cht c cu trc loi steroit nh cholesterol, rt ging cc
hydrocacbua gy ung th, c th gy ung th cc loi chut ( ung th tuyn v, tuyn yn, t
cung, tinh hon, c trn ). Cc cht oestrogen c th gy ung th theo con ng trc tip v
gin tip. Bi oestrogen trn nim mc m o hoc trn u v c th gy phn ng tng sn
v pht sinh u c. Tc dng gin tip l ch nhng cht ny c th bin thnh cc cht
chuyn ho c hot tnh gy ung th bng cch kch hot cc th cm t bo to iu kin tng
sn t bo v lm tng cng tnh thm mng t bo do t bo t chc d mn cm vi cc
cht gy ung th khc.
Cholesterol v cc cht chuyn ho : Trong cc cht chit xut t t chc ung th ca bnh
nhn, ngi ta thy c nhng mnh rt giu cholesterol, em cht ny tim cho ng vt
gy c sac- cm ti ch. Sau t t chc ca ngi v ng vt, c trong lng trng
ngi ta tch ra c mt cht c tc dng xc tc tng hp cht m gi l carcinolipin, mang
tim di da hoc trn vo thc n cho chut cng gy pht sinh u. Trong t chc bnh nhn
cht v ung th, nng cht ny tng gp 2 3 ln t chc bnh thng. Cu trc ho hc ca
carcinolipin rt ging cholesterol. Tc dng gy ung th cn thy c axit mt.
Cc cht chuyn ho tryptophan : thy tng cao l nguyn nhn gy ung th bng quang, bnh
bch cu, sac-cm ng vt. Ri lon chuyn ho tryptophan thy c trong giai on sm ca
bnh bch cu v trong ung th bng quang do tc dng lu di ca cht nahptylamin cc
cng nhn cc x nghip nhun mu anilin. Ri lon chuyn ho tryptophan vi s tch ly trong
c th cc cht chuyn ho c hot tnh gy ung th cn thy trong cc bnh di truyn c lin
quan n tng thoi bin sinh t B6 l mt oenzim cn thit ca nhiu men chuyn ho
tryptophan. Tuy nhin tc dng yu v gi tr ca n trong pht sinh ung th ngi cn c
tip tc nghin cu, cng nh vn ti sao v trong iu kin no c th bin nhng cht
chuyn ho bnh thng thnh cc cht c kh nng gy ung th.
3. Cc tia x ion - ho : ( tia roentgen, tia , ).
ngi b chiu x ti ch v ton thn ( lm vic hoc iu tr bng quang tuyn X, ng v
phng x ) c th thy pht sinh ung th bt u bng vim da do quang tuyn ( radiodermite )
ri dn ti ung th da, bnh bch cu hoc sac- cm. Thi kz tim ca bnh c th ko di t 1
n 30 40 nm.
Nhng nn nhn bom nguyn t Nht ( Hroshima, Nagasaki ) thy tng cng t l b ung th
v bnh bch cu c cc th h sau ( hnh 3 ). Tim vo c th cht ng v phng x c th
gy ung th khc nhau d dy, da, phi khi cht ny lt vo kh qun, gan... Tia ngoi tm v
tia nng mt tri tc dng lu di cng c th gy ung th da chut cng v chut nht.
C ch tc dng ca cc cht gy ung th trn c rt nhiu l thuyt gii thch :
Cht gy ung th vo c th s kt hp vi cht m, c bit cc cht m c ng ni S -
S to thnh mt cht m mi, lm thay i hn hng chuyn ho ca t chc hoc gy tn
thng h men c hiu ca t bo, to iu kin chuyn thnh t bo ung th.
Cc cht gy ung th ( virut, cht ho hc, tia x ) ch c tc dng u tin nh mt yu t gy
bin d, lm thay i cu trc phn t ca t bo ( AND, ARN ), gy tn thng chc phn v
tnh bit ho ca t bo, to iu kin chuyn thnh t bo ung th. Cng c th tia x ion
ho ch lm ri lon h thng iu ho sinh l ca c th, to iu kin cho virut pht huy tc
dng v gy ung th.
Cc cht gy ung th ( ch yu virut, cc cht ho hc ) l thnh phn thng xuyn v cn
thit ca t bo u, xc nhp vo cc zen ca t bo v lm bin i chng ( hnh 4 ). C th
gi nh rng virut gy c ch mt phn hay hon ton cc zen bnh thng ca t chc
ng thi li kch hot cc zen b virut xm nhp, hu qu l gy bin chuyn t bo bnh
thng thnh t bo ung th.
Trong thc nghim, virut SV40 i vi t bo chut nht 3T3 th khng sinh si ny n trong t
bo r lm dung gii t bo, thot ra gy bnh nhng t bo khc m li tch hp vi ADN
ca t bo bt t bo ny tng hp ADN v cc protein cn thit ca virut, lm t bo chuyn
bin thnh t bo ung th ( hnh 5 ).
Cc cht gy ung th c kh nng bin d mnh i vi nhim sc th ca t bo do gy sn
sinh mt dng t bo vt ra khi quy lut iu ho ca ton c th. Trong cc t bo ca t
chc ung th hay c thay i v s lng cng nh cht lng ca nhim sc th ( a bi gy
nhim sc th ) ngc li, nhng bnh nhim sc th ( hi chng Down ) thng km theo
bnh c tnh v mu ( bnh bch cu ), d mc hn so vi tr bnh thng.
C ch ca s chuyn dng ung th ca t chc c thc hin theo 3 giai on :
1. Giai on to thnh cc t bo ung th tim ( t bo tin ung th hay ung th ng ). Giai
on bt u chuyn dng thng rt kh phn bit vi t chc t bo bnh thng v cc du
hiu phn ho hnh thi m mi ch c bin i tnh phn ng ca t bo gy ri lon h thng
tin di truyn ca cromozom, hoc gy bin d cc zen , ch huy s hnh thnh cu trc t bo
do tc dng ca cc nhn t gy ung th ( cng c th c sn mt s lng t bo trong trng
thi tin ung th c trn c th bnh thng ).
2. Giai on chuyn thnh cc t bo ung th chnh thc do nh hng ca cc cht gy ung
th. Lc ny tng hp men v cc cht m c tnh c hiu c quan v t chc b c ch, nh
khu cc khng nguyn trn b mt t bo b bin i, ng thi cc zen khc c gii c
ch v tip thu c tnh cht tng hp cc cht khng nguyn bo thai v d loi, to iu kin
cho t bo chuyn thnh c tnh. Thc t thy c nhng cht ch lm t bo bnh thng
chuyn thnh t bo ung th ng v nhng cht khc li c tc dng kch thch nhng ( t bo
ung th ng ) tr thnh hot ng v lm bnh pht trin ( hnh 6 ).
3. Giai on cc t bo ung th tng cng sinh sn v to thnh cc khi u thot ra khi s
kim sot ca h thng iu ho ca c th, c th do tc dng ca nhiu yu t ni mi ( ni
tit, thn kinh th tng ) v ngoi mi ( dinh dng ).
IV. NHNG YU T NH HNG N S PHT TRIN CA UNG TH
Nhiu yu t nh hng n s pht sinh v pht trin ca ung th.
1. Yu t tui tc v dinh dng :
U c thng pht sinh nhng la tui nht nh : ung th tuyn v xut hin sau 35 tui,
ung th d dy sau 40 tui con sac- cm li hay gp ngi tr tui. C tc gi cho rng tui l
thi gian cn thit ung th nung bng hoc tui gi l lc sc khng ca c th km st,
hot ng thn kinh- ni tit suy yu nn bnh d pht sinh ( hnh 7 ). Ni chung u c pht
trin ngi cng tr th bnh cng nng, c tnh cng mnh.
Dinh dng khng phi l yu t quyt nh nhng cng c nhng nh hng nht nh : n
thiu m lm ung th d pht sinh. Thiu cht methionin d gy ung th gan v methionin c
tc dng che ch cho nhu m gan.
Trong thc t ung th gan nguyn pht hay gp cc nc chm tin, i sng dinh dng
thiu thn. Tng cng n cht m, nht l cholesterol lm cho ung th d pht sinh v pht
trin lan trn. thiu sinh t B, ( riboflavin ) trong thc n dn n pht sinh nhanh chng ung
th gan chut do cc hp cht azoic, c sinh t B, gip cho ban chuyn ho cc cht azilo-
azcic thnh cc cht khng c kh nng gy ung th. Thiu sinh t A nh hng n s pht
sinh ung th phi. B sung sinh t A lm gim t l mc ung th ng vt nghin cu do tc
dng ca benzopyren.
2. Yu t di truyn v th tng :
Di truyn to iu kin thun li cho s pht sinh ung th, cc yu t di truyn kt hp vi cc
c im sinh l, sinh ho, ni tit ca c th lm gim hoc tng cng kh nng xut hin ung
th : ung th v ch pht trin mnh chng chut C3H, bnh bch cu d gy chut chng
C58, ng nhm mu A d mc ung th hn ngi c nhm khc.
Th tng c t chc lin kt yu t, giu cc yu t biu m th d pht sinh ung th hn, v
qu trnh pht trin c l do tnh trng chc phn ca t chc lin kt b suy yu. Cc qu
trnh vim nhim mn tnh ( vt xc c t cung, lot d dy, n tht bng quang, rut non ) c
th l tin ca qu trnh pht trin c tnh. Theo thuyt ( kch thch mn tnh ) th qu trnh
vim ko di lm suy yu cc phn ng thch nghi ca c th, lm suy yu chc phn ca t
chc lin kt, kch thch s phn chia t bo, lm gim kh nng bit ha ca t bo do lm
ung th d pht sinh v pht trin. Nhng khng phi qu trnh vim nhim no cng to thnh
trng thi ( tin ung th ) cng nh khng phi trng thi tin ung th no cng c chuyn
thnh ung th m cn ph thc vo s to thnh hoc tn ti trong c th mt cht nn c
bit, bn cht ho hc l nuclepprotein, cht ny c th c a vo c th dng chun
b sn ( virut, cht ho hc ), hoc c tng hp t bn thn c th ( Neimann . M.1974 )
3. Yu t thn kinh v ni tit :
Tim cc cht gy c ch thn kinh ( phenamin, amytal Na ) trc khi gy ung th thc
nghim trn ch, ung th l mt qu trnh ri lon dinh dng thn kinh c th do mt kch
thch trng din gy ra. Ung th pht trin nhanh v nng thng gp cc bnh nhn loi
thn kinh yu v mnh nhng khng thng bng, nhng trng hp ny cng d c di cn.
nh hng ca cc tuyn ni tit cng c lu {, nht l cc hocmn tuyn sinh dc : ct b
bung trng lm cho ung th v chut khng pht trin. ngi b ung th tuyn tin lit,
nu thiu hay tim folliculin th c th ngn chn c s pht trin ung th. Ph n b ung th
v, nu ct bung trng hoc tim testosterol cng c th lm ngng pht trin unh th.
4. Yu t min dch trong ung th :
Ngi ta pht hin c cc khng nguyn ung th c hiu nh khng nguyn ung th
phi ( anphal foctoprotein trong ung th gan nguyn pht, khng nguyn trn b mt t bo
lympho trong u Burkitt ) v s dng trong theo di, pht hin bnh lm sng.
Cc khng th chng ung th ang c tip tc nghin cu. C th cc khng th ny khng
c tc dng bo v v khng c vai tr quyt nh trong min dch chng ung th v c tc dng
phong b khng nguyn, cn tr cc t bo lympho T nhn bit k th, lm min dch t bo
chng ung th khng pht huy c tc dng.
Vai tr ca min dch t bo chng ung th c nhiu tc gi cp. Mt s cho rng s d
khi u d dng pht trin l do c s suy sp min dch t bo ( ct b tuyn c dng thuc c
ch min dch, thiu nng min dch bm sinh hay mc phi ), do t bo lympho T mt kh
nng cnh gic min dch, nhm tiu dit cc t bo ung th. Cho nn ngi ta cp min
dch tr liu chng ung th nhm nng cao phn ng min dch t bo bng cch : dng tnh
cht hoc nghin khi u tim cho bnh nhn , truyn bch cu ca bnh nhn leucose
mn cho bnh nhn leucose cp tnh; dng cc kch thch khng c hiu ( BCG v cc ch phm
ca n ); gy min dch bo tr bng truyn cc lympho nn cm hoc dng cc ch phm
tinh cht tuyn thymus Mc d kt qu cha nhiu nhng c mt iu chc chn l nu kt
hp min dch tr liu vi cc bin php kinh in th kt qu kh quan hn l dng cc ha cht
v chiu x n thun.
V. HU QU CA UNG TH I VI C TH
U c thng gy nhiu thay i trong ton b c th:
Ri lon v tng cng thoi bin gluxit, u th cc qu trnh phn hy trn cc qu trnh
oxyha nn trong mu huyt ng gim, protit ton phn gim, nng axit lactic tng, cc
sn phm N phi protit tng
Cc men thoi bin c hiu ca chuyn ha axitamin, nucleotit b km hm nn cc sn phm
ri lon chuyn ha axit amin ng v tng bi tit thao nc tiu ( a peptit, tyrosin,
tryptophan )
Bng nhn b nhim kim do tc dng b p ca cc yu t kim ( K
+
) tch ly trong mu v
gim nng axit cacbonic do tng cng bi tit theo ng h hp.
Tt c cc ri lon trn lm cho bnh nhn lm vo tnh trng nhim c, thiu mu v suy
mn, bnh nhn thng cht trong trng thi suy mn hoc cht do bin chng xut huyt,
nhim khun v ri lon nghim trng cc chc nng c th. Th vy thy r tuy khi u l biu
hin ch yu nhng c s lin quan cht ch gia khi u v ton b c th.

48. RI LON IU NHIT
HONG DUNG

I. I CNG
iu ho nhit c th l mt trong nhng iu kin c bn nht tin hnh cc qu trnh
chuyn ho trong c th sng. Da vo kh nng duy tr thn nhit, ngi ta chia ng vt
thnh 2 loi:
- ng vt mu lnh (loi khng xng sng, c, ch nhi, b st) thn nhit n nh khi nhit
mi trng ngoi thay i, bin nhit.
- ng vt mu nng (chim, loi c v) thn nhit kh n nh v tng i c lp vi nhng
bin i nhit ca mi trng ngoi ng nhit hay bnh nhit. Kh nng iu ho nhit ny
c bit hon thin ngi.
Thn nhit ca ngi giao ng trong gii hn t 36,5 37
0
5) khng ph thuc vo nhit
bn ngoi v khng u nhau tuz theo cc c quan, t chc; gan bn chn, bn tay (31 32
0
5),
nch (36,2 37
0
) cao nht l gan (39
0
5), tng i n nh m ming (37,2 37
0
5) v hu
mn (36,6 37
0
2). Thn nhit c n nh nh 2 qu trnh iu ho sn nhit v thi nhit
lin quan cht ch v lun cn bng vi nhau.
1. Qu trnh sn nhit (sinh nhit)
Sn nhit ch yu do kt qu iu ho qu trnh chuyn ho vt cht to ra nhit cn
thit. Bin i qu trnh sn nhit pht sinh do ri lon iu ho ca thn kinh do kch thch t
cc b phn ni ngoi th cm, nht l do cc yu t nhit tc dng phn x n trung tm iu
ho ho hc. Trn c s thc nghim, ngi ta xc nh c trung tm iu ho nhit nm
no trung gian, 1/3 sau ca nhn sm, gm 2 phn iu ho sn nhit v iu ho thi nhit
(hnh 1)
Cc c quan ngoi vi tham gia vo qu trnh iu nhit ho hc, sn nhit bao gm tt c cc t
chc trong c th c tin hnh chuyn ho vt cht v sinh nng lng, tuy nhin b phn quan
trng nht l c v gan.
- Hot ng ca c th l ngun gc sinh nhit ch yu. Di tc dng ca nhit thp i
vi c th, hot ng rung c xut hin thng qua c ch phn x to ra mt khi lng ln
nhit (c khi sn nhit tng ti 20% so vi mc bnh thng). Khi tri lnh qu, ng vat v
ngi u tng cng vn ng duy tr thn nhit n nh.
- Qa trnh chuyn ho vt cht gan tng cng. Ct b cc si thn kinh chi phi gan s gy
ri loan cn bng nhit v gim sn nhit.
2. Qu trnh thi nhit (mt nhit)
c tin hnh bng nhiu bin php:
- Truyn nhit v khuych tn nhit chim 65%, xy ra khi nhit c th cao hn nhit mi
trng ngoi. S chnh lch cng ln th nhit mt cng nhiu. Nu nhit b mt da l
33
0
C th s thi nhit thc t s ngng li khi nhit bn ngoi t ti 33
0
C.
Bc nhit qua da (m hi) v nim mc ng h hp, chim 30% l bin php thi nhit ch
yu khi nhit bn ngoi di 33
0
C hay khi lao ng nng, hnh qun, luyn tp
- Hun nng thc n v khng kh th vo (3%), thi nhit qua phn v nc tiu (2%). Ngoi ra
qu trnh thi nhit cn ph thuc vo mt s yu t khc nhu tc vn chuyn ca khng
kh, m, qun o b dy ca lp m di da
Do nhng c th thi nhit trn, nhit c th con ngi thay i tuz theo nhit trong
phng th nghim (hnh 2). Ch ring nhit hu mn l phn nh tng i sng nhit bn
trong c th, tuy nhin bui sng sm ngy rt thng thp hn v khi lo s hay lao ng th
thn nhit c tng hn (hnh 3)
Bi tit m hi c iu ho ca cc si giao cm tit cholin phn trc hypothalamus v
chu s chi phi ca v no nn nhng xung t tinh thn, xc cm mnh u c th nh hng
r rt n s tit m hi. Nhit u rt quan trng, khi lm nng u th phn x dn
mch v tit m hi xut hin ngay mc du thn nhit cha tng (hnh 4). ngi ch cn bi
tit mt ngy chng 4 lt m hi l thi nhit lng sinh ra trong c th tng ng 2000
2500 Kcal. ng vt khng c tuyn m hi (ch) th thi nhit ch yu nh tng nc bt
v tng nhp th.
Co, dn mch ngoi vi c mt { ngha ln trong iu ho thi nhit ca c th t b mt da,
pht sinh theo c ch phn x. Cm xc mnh cng thng gy thay i vn mch.
iu ho thn nhit cn c thc hin bng ng h hp. Tuz theo s nhit lng cn c
thi ra m su v tn s h hp thay i. S m t, cc tn hiu nh sng, ting ng nu
kt hp nhiu ln vi tc dng nhit c th tr thnh nhng tn hiu c iu kin gy thi nhit
theo ng h hp.
S phn chia iu ho nhit ho hc v vt l khng ph nhn tnh thng nht ca ton b h
thng iu ho nhit v trong iu kin bnh thng hay bnh l{ cng u thy th hin mi
quan h tng h gia hai qu trnh i lp v thng nht ca iu nhit. Trong qu trnh tin
ho sinh vt, vai tr ca iu nhit ho hc (sn nhit) ngy cng gim st v { ngha ca iu
nhit vt l (thi nhit) cng quan trng c bit ngi. Tr con mi , kh nng iu nhit
vt l{ cn km, cha hon thin nn d b i thn nhit do tc dng ca nhit mi trng,
kh nng iu ho nhit ch xut hin y vo cui u nm.
Nh c s ton vn ca cc trung tm iu ho nhit cng nh ca cc cm th v ng dn
truyn thn kinh m bnh thng 2 qu trnh sn nhit v thi nhit lun cn bng nhau v thn
nhit c n nh. Ri lon iu ho nhit l mt hin tng ph bin trong bnh l lm sng,
v do nh hng mt phn ca hon cnh kh hu nc ta (x nng vi m cao) nn cn l
hin tng ph bin trong lao ng sn xut cng nh trong chin u, luyn tp qun s. Ri
lon iu ho nhit thng biu hin di 3 hnh thc: thn nhit tng, thn nhit gim v st.
II. THN NHIT TNG
Thn nhit tng pht sinh khi nhit bn ngoi qu cao hn ch qu trnh thi nhit, hoc khi
tng sn nhit khi lao ng iu kin nhit cao (lao ng gia ng nng to, trong hm
m, l cao, chin u trong cc binh chng pho, tng, ha hc, hnh qun ma h). Lc u
c th thch ng bng cch gim vn ng, hn ch sn nhit, ng thi tng cng thi nhit
bng cch tng h hp, dn mch ngoi vi, ra nhiu m hi Nhng nu yu t nhit vn tip
tc c ch thch ng bt lc thn nhit s tng cao, c th ti 41 43
0
C v pht sinh nhim
nng. H thn kinh b hng phn mnh, chuyn ho vt cht v cc chc phn c th u tng,
cc sn phm ca chuyn ho v ammoniac tng, c th mt nc v mui nghim trng c th
dn ti tru tim mch. Sau ng vt lm vo trng thi ng ch, t lit cc phn x thn kinh
v cc chc nng c ch, hn m, co git v cht.
Say nng l tnh trng nhim nng do tc dng trc tip ca tia nng (ngoi tm, hng ni) ln
nh u, gy.
III. THN NHIT GIM
Thn nhit gim pht sinh do nhit bn ngoi qu thp hoc gim phn nhit do ri lon
chuyn ho quan trng (sc, mt mu nhiu, bin chng cc bnh nhim trng.)
Thn nhit gim gy nhim lnh. Lc u c th phn ng bng cch tng cng sn nhit (tng
cc chc phn, tng qu trnh xi ho, tng hot ng c). Sau chuyn sang giai on c
ch, hot ng thn kinh gim, chuyn ho gim, chc phn cc c quan h thng u gim.
Nu nguyn nhn nhim lnh vn tip tc tc dng s pht sinh trng thi cn sinh v t lit
nghim trng h thn kinh trung ng v cc chc phn quan trng ca c th, hn m v cht
khi thn nhit gim di 25
0
C
C s ca vic p dng gim thn nhin nhn to trong lm sng c rt ra t nhng cng
trnh nghin cu nhm phc hi cc c th b bng gi. cc ng vt ng ng (ng min)
trong thi ng cc chc phn c th u gim tiu hao ti mc ti thiu, chuyn ho vt cht
gim nhu cu xi gim, tnh phn ng c th gim v thn nhit thp c coi nh mt thi
gian ngh ngi v bi dng nng lng cho ng vt. Phng php gim th nhit hay ng
min nhn to da vo cc nguyn l sau: Lm lnh c th bng cc bin php vt l{ nh:
Chm quanh c th, ngm lnh, th khng kh lnh hoc p dng mt h thng tun hon
ngoi c th lm lnh mu. Trc khi lm lnh c th, ngn nga cc phn ng kch thch
khi tc dng trc tip vi lnh bo tn nng lng d tr cho c th, c th dng cc my
gy m c iu chnh hoc dng cc thuc phong b hch v lit thn kinh nhm ng ch c
mc h thn kinh trung ng v thc vt. Trong gim thn nhit nhn to va phi (nhit
c th 32 28
0
C) hoc su di (28
0
C) c th sng vi mc tiu hao ti thiu, nhu cu xi
gim thp (hnh 5) gim nh c phn ng c th i vi thng tch cng nh i vi cc
kch thch khc nn trnh c sc, chu ng c nhng th thut trn c th yu nhc,
vt thng s no, phu thut tr em, phu thut ko di thi gian cc c quan quan trng
(tim, gan, phi.). Sau khi ngng tc dng, phi si m cho c th ti mc thn nhit bnh
thng mi cho bnh nhn tnh li.
IV. ST
St l phn ng ca ngi v ng vt cao cap i vi nhng kch thch nguyn nhn bnh l,
c im l tng nhit c th. St c coi nh mt triu chng chung nht trong cc bnh
khc nhau ch yu l trong tt c cc bnh nhim khun.
St in hnh ch thy ngi v cc ng vt bnh nhit cao cap (ch, th, chut) m h thn
kinh trung ng t mc pht trin cao v chc nng iu ho nhit hnh thnh. Tng
thn nhit trong st l s tch lu tm thi nhit lng to thnh mt mc bnh nhit mi
cao hn, c tc dng tch cc ch ng cho nn trong st c th chu ng c nhit cao
hng tun. Trong nhim nng, ngc li cc trung tm iu nhit b ri lon nghim trng
khng phi c nhit lng tha nn thn nhit tip tc tng cao v s chu ng ca c th
thng ch c vi gi.
A. NGUYN NHN GY ST.
St pht sinh do cc nguyn nhn nhim khun, do cc tc dng cc cht gy st, ngoi sinh v
ni sinh.
1. Cht gy st ngoi sinh
L cc cht gy st c bi tit t cc vi khun trong qa trn hot ng sng hoc cht. Hot
tnh gy st gn nh c sn tt c cc vi khun gy bnh v khng gy bnh, c th c vi rt.
Khng ph thuc vo tnh gy bnh v c tnh ca chng.
Bng cch chit xut ho hc c hiu t cc vi khun khc nhau, c th tch c cc cht gy
st ngoi sinh tinh khit v t c. Cu trc ho hc ca cc cht gy st ngoi sinh l m da
dng v l thnh phn cc ni c t ca cc t bo vi khun. Cht gy st ngoi sinh tinh
khit c hot tnh vi iu rt nh ngi (1micro/cn) v th (0,01 0,001micro/cn). St
th do cht gy st ngoi sinh xut hin sau mt giai on tin ngn v tng nhit gi c
vi gi cho nn hiu qu cc cht gy st thng c tin hnh trn th. Hot tnh gy st
thy ngoi c t (bch cu, lin cu tan mu) thng gy st sau mt thi gian tim ko di
3 6 gi.
Cht gy st ngoi sinh cn c tc dng gy st qua cc cu trc t bo t chc tn thng, tc
l qua s to thnh cc cht gy st ni sinh.
2. Cht gy st ni sinh
Cc t bo v t chc ca c th khc vi cc t bo vi khun l khng c sn cc yu t gy st.
Cht gy st ni sinh ch c to ra trong cc iu kin bnh l ph hp, trong cc bnh nhim
khun v c trong cc tn thng v khun v vim nhim t chc, t cc t bo b tn thng
dch d, cc m mu bin cht, cc bch cu trung tnh, cc t bo Lympho v t bo nch
trong cc phn ng d ng chm u c th l ngun gc to cc cht gy st ni sinh. c
nghin cu nhiu cht l cc cht gy st ni sinh chit t cc bch cu trung tnh trong dch di
thot t cc huyt qun b vim. Thnh phn ha hc gm cht m v 1% cht da dng, c
bit l gy st nhanh, nhit tng ngay sau 10 15 pht v khng b quen ng thu cc
B. C CH BNH SINH CA ST
1. Vai tr ca h Thn kinh trung ng v cc tuyn ni tit trong c ch pht sinh st.
- V no v cc trung khu di v c mt { ngha quan trng trong c ch ca st. Trong thc
nghim c th gy c s theo c ch phn x c iu kin ch sau 10 ln tc dng mt s
yu t v quan kt hp vi tim cht gy st ngoi sinh vi khun. Thn nhit ngi c th
tng nh hng c thi min trong cc bnh tm thn (st tm l{), trong cn histri nhit c
th c th tng ti 42
0
C. St do xc cm c th thy cc din gi, cc din vin, cc hc sinh
trong kz thi... ng vt mt v no c 2 bn, st pht sinh vi nhit tng cao hn so vi
ng vt lnh v loi tr nh hng c ch ca v no i vi cc trung khu iu nhit di
v. Trong gy m su, phn ng st gim r rt.
- Vng di th c coi nh mt trung tm iu ho nhit t ng quan trng. Tt c 3 nhm
nhn u tham gia vo s pht sinh phn ng sng. Cc nhn gia v sau ca hypothalamus
ch yu iu ho sn nhit v gi nhit lng trong c th qua h thn kinh giao cm (tng qu
trnh xy ho chuyn ho, mch ngoi vi) v qua cc phn b thn kinh xma c - xng (tng
chng lc c, co c, rng mnh). Cc nhn phn trc khi hypothalamus ch yu iu ho thi
nhit qua cc phn b thn kinh ph giao cm (dn mch), cc si giao cm thit cholin (bi tit
m hi) v cc phn b thn kinh xma cc c th (tng h hp). Tn thng hon ton
hypothalamus hoc ct thn no di hypothalamus ng vt bnh nhit b bin i thnh bin
nhit v mt kh nng gy st.
- T cc trung tm iu nhit, cc xung ng i v tu sng ri ti cc cm th thn kinh. Cc
nghin cu thc nghim ca Vceklin chng minh c ch phn x thn kinh l c ch khi
u ca phn ng st. Khi tim cht gy st cho ng vt, cht gy st trc ht kch thch cc
c quan cm th cc b, mt mt vo mu a i khp c th tc dng ln ton b h thng
cc ni th cm, ng thi tc dng trc tip ln trung tm iu ho nhit gy st. Ct b
dy thn kinh hng tm hi tim cht gy st hoc phong b Novocain trc khi tim cht
gy st phn ng r rt 8-18 gi sau st mi xut hin v 10-20gi (sau st mi t mc ti a).
Binh thng st sau mt gi v ch 10 gi sau t mc ti a. Duy tr phn ng tt trong
trng hp ny chng t nh hng trc tip ca cht gy st i vi trung tm iu nhit qua
ng mu
Cc tuyn ni tit, h tuyn yn_tuyn thng thn b kch hot bi nh hng ca cc tuyn
gy st nhng phn ng Stress ny khng tham gia vo c th pht sinh st. Trong u nng
tuyn gip thy thn nhit thng xuyn hi tng., hocmon thyroxin gy tng qu trnh oxy
ho trong t chc. bnh nhn thu nng tuyn gip trng ngc li phn ng st biu hin
khng r rt.
2. C ch ca tng thn nhit trong st;
Trc kia c quan nim rng tng thn nhit trong st l do tha nhit lng (tng sn
nhit) v tngcng cc qu trnh oxy hoa chuyn ho . Tuy nhin trong qu trnh st khng
phi u c tng sn nhit v sn nhit khng nhiu, khng phi l yu t quyt nh. Trng st
rt, thng hn, sn nhit ch tng 40_60% so vi bnh thng trong khi mt ngi kho
mnh lao ng c va phi, sn nhit c th ln ti 100_200% nhng khng st do thi
nhit mnh (th nhanh, ra nhiu m hi) b p. mt s bnh nhim khun (ph thng
hn) nhu cu oxy ch 11,1 ml/cn/pht (bnh thng 11,5ml/cn/ pht), nh vy st ch yu
do qu trnh thi nhit b c ch, c t vi khun gy ri lon cc qu trnh oxy ho v chuyn
ho nng lng trong t bo. C th kt lun c ch ca tng thn nhit l s tch lu tm thi
nhit lng do tng sn nht v c ch thi nhit.
Trong c ch pht sinh st do nhim khun c s tham gia ca cc cht gy st ngoi sinh v c
s to thnh cc cht gy st ni sinh na. Cn bnh sinh ca st c gii phng t cc tn
thng (hu hoi, t chc, bng, t mu, gy xng). Ngoi ra hot tnh gy st cn c th
thy mt s ch phm dc l, hormon, hp cht keo, muikhng phi l nhng kch thch
ch i vi cc trung tm iu nhit m c t nhng mt xch ring bit nh v no, h thn
kinh giao cm, chuyn ho vt cht, trng lc c
Bng 1: C ch ca st do cc nguyn nhn khc nhau.
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Nguyn nhn


C ch sinh bnh.



1


2



St nhim khun:

- Kch thch phn x v trc tip cc TT iu nhit bi
cht gy st ngoi v ni sinh.
c t, vi khun , vi rt
St khng do nhim khun
1. Tn thng t/c v khun
- Vt thng, m, bng
- Chy mu trong
- Nhi mu tm c , phi
- U c (d dy, gan, Leucose
- Tn thng tc do d ng
2. St do cht m
- Tim cht m l
- St thong qua tr s sinh do
hp th tha m, gim nc
3. St ni tit:
- Tng sn xut adrenalin do u
tuyn thng thn
-Nhim c tuyn gip
4. Tc dng dc l ca
- phenamin
- atrychinin
- tetrahydronaphtylamin
5. St thn kinh
- au do si niu qun, mt, nong
dn niu o
- St tm thn trong bnh tm thn
hiatri, thi min
- st do xc cm
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Kch thch phn x v trc tip cc TT iu nhit bng
cc sn phm thoi bin t chc cc cht gy st ni
sinh c to ra trong qu trnh bnh l
Kch thch cc TT iu nhit hoc to thnh cc cht
gy st ni sinh gi nh.
Tng cng cc qu trnh oxy ho gy tng sn nhit
v co mch ngoi bin vi bn ch thi nhit.
Kch thch v no, nh hng i vi chuyn ho vt
cht v iu ho vt l Tng chng lc c, xc tc
qu trnh chuyn ho kch thch trc tip cc TT iu
nhit v tng to adrenalin
Kch thch phn x cc TT iu nhit c th pht sinh
lung trong vi khun trong mu t cc t chc tn
thng.
Kch thch v no v cc TT iu nhit di v.



Di nh hng ca cht gy st, tnh cm th ca TT iu nhit i vi cc kch thch nng
gim xung (tng sn nhit v hn ch thi nhit) ngc li cm th vi cc kch thch lnh li
tng ln do ngi b st cng c th d b cm lnh.
3. Ri lon cn bng gia sn nhit v thi nhit trong st.
St thng din ra qua 3 giai on di ngn tuz theo mc v tnh cht ca bnh vim
phi, st din bin trong 6,8 ngy, thng hn 18-21 ngy lao vi st v chiu dai dng ch ht
st khi bnh tm n nh.
- Giai on tng thn nhit hay giai on st tng : C th bt u t ngt, st cao sau vi
g (Vim phi, cm) hoc tng dn trong vi ngy, thng hn, si). Trong giai on ny, thn
nhit thng tng cao hn so vi thi nhit (sn nhit ln hn thi nhit) do cc cht gy st
ngoi sinh v ni sinh kch thch phn x v trc tip trung tm iu ho nhit gy tng sn
nhit. Sn nhit tng nh cc qu trnh oxy ho chuyn ho v tng mnh ch yu c gan v
tng chng lc c v xut hin rng mnh. Rng mnh pht sinh theo c ch phn x, cc xung
ng i t da (c cc mao mch b co ti hypothalamus qua phn bn th li ri theo dy TK
vn ng ti c cho nn rng mnh khng xut hin ng vt khi b tn thng phn sau
hypothalamus gia th v v tiu no. Rng mnh thng km theo cm gic lnh, rt run, ni
gai c l do cc c trn ca chn lng co li lm lp khng kh cch nhit tng ln c ch qu
trnh thi nhit. Cn thi nhit gim l do c cc mch ngoi vi nn tr thnh nht nht v c
ch qu trnh tit m hi.
- Giai on st ng: Thn nhit duy tr mc cao do sn nhit vn tng song thi nhit cng
tng (sn nhit bng thi nhit) c cn bng nhit mc nht nh nhng vn cha thi
c nhit lng tch lu trong giai on u nn thn nhit duy tr mc cao. S xut hin
thi nhit biu hin bng cch dn cc mch ngoi vi do kch thch cc phn b thn kinh ph
giao cm nn da ti nht chuyn thnh xung huyt, nhit da tng v ht rt run.
- Giai on st lui: Thn nhit gim xung ti mc trung bnh thng sn nhit lc ny nh
hn thi nhit. Thi nhit tng mnh bng cch ra nhiu m hi i nhiu. Sn nhit c th
gim hn hoc hi tng bnh nhn st nng, thng gim thn nhit t t, nhng cng c
trng hp gim nhanh, t ngt sau vi gi . Gim thn nhit t ngt c th dn ti thiu
nng mch cp, tru mch do gim chng lc cc mch thiu mu nghim trng.
Theo mc tng thn nhit c th phn thnh:
+ St nh khi thn nhit tng trong gii hn 38
0
C
+ St va khi thn nhit tng t 38-39
0
C
+ St cao khi thn nhit trn t 39
0
C
+ St nng khi thn nhit trn 41
0
C
Trong st t khi thn nhit ln ti 42
0
C v ti gii hn thng pht sinh ri lon nghim
trng h TKT v pht sinh nhim nng, mc tng thn nhit trong cc bnh nhim khun
ph thuc vo tnh cht phn ng c th tnh cht gy st ca vi khun, tnh trng nhim c
hoc do tc dng ph hy ca c t vi khun i vi cc trung tm iu nhit c coi nh l
bin chng ca bnh nhim khun ngi gi, suy nhc thng khng thy st cng l du
hiu khng tt nh tng thn nhit qu mc.
Cc loi ng biu din nhit trong st lm sng c { ngha chn on trong hng lot
bnh nhim khun. ngi khe mnh thn nhit c th gi mc cao trong vi ngy nh
giao ng nhit trong ngy khng vt qu 1
0
C. Tnh cht giao ng ca nhit cng ph
thuc vo tng loi bnh. (hnh 8 a, b,c,d)
C- THAY I CA C TH KHI ST
Du hiu c trng nht ca st l tng thn nhit. Ngoi ra, cc bnh l c st thng km
theo nhng bin i v chuyn ha vt cht v nhng bin i chc phn hng lot cc c
quan, h thng, ph thuc vo c trng ca nguyn nhn, tnh cht ca bnh,v tnh trng
nhim c ca c th.
1. Ri lon chuyn ha trong st.
Trong st thng pht sinh ri lon chuyn ha vt cht do:
- Thn nhit tng, thng c tng ln 10C so vi bnh thng th nhu cu oxy tng 5 -10% v
chuyn ha vt cht tng 3,3%.
- Tc dng ca nhn t gy bnh: Vi khun, c t
- Tnh trng i n ca c th.
a. Chuyn ha gluxit khng thy c bin i g c hiu, ch yu l tng thoi bin glycogen v
tng ng mu do kch hot h thn kinh giao cm v tng tit adrenalin. Tng thoi bin
glycogen gan pht sinh rt nhanh sau khi tim cho ng vt mi trng nui cy vi khun hoc
cc cht gy st.
b. Chuyn ha lipit b ri lon khi gim hoc suy kit d tr glycogen gan, trong trng hp ny
sn nhit c thc hin ch yu nh qu trnh oxy ha lipit. Qu trnh oxy ha lipit khng i
ti cc sn phn cui cng s gy cc th. Xton v tng bi tit xton qua nc tiu. Khi cung
cp y cht ng trong thc nghim, hin tng Xton -niu khng thy xut hin.
c. Chuyn ha protit b ri lon trong st l quan trng nht, do:
- Tc dng ca vi khun,c t. Tuy nhin khng phi bt kz trng thi st no cng c tng
thoi bin protit. Trong mt s bnh nhim khun cp nh cm, vim hng v mt vi bnh
nhim khun mn, chuyn ha protit hu nh khng thay i, ngc li c trng hp nhim
khun thn nhit ch tng nh nhng li c thoi bin protit mnh.
- Thn nhit tng qu cao v pH toan ca t chc lm tng cng hot tnh cc men tiu protit
nn qu trnh phn gii t chc tng li lm st nng thm.
- Nhu cu nng lng ca c th i hi, do d tr glycogen gim v qu trnh oxy ha lipit ri
lon nn khi st va phi chuyn ha protit phi cung cp 15 - 20% nng lng cho c th, khi
st nng ti 30% v hn na, mt trong st thng c ri lon tiu ha v hp th protit nn
cn bng nit m tnh, cc sn phm ca chuyn ha protit tng bi tit qua nc tiu nh
NH3, creatinin, ur/
Do cn ch { n vn dinh dng bnh nhn st. Vi st nh, cho n nhiu ng, vi
st cao v ko di cho gluxit dng d hp th nht (truyn dung dch glucoza ng, u trng)
hoc chho cc axit amin thy phn b hao qu nh hng n sc khng ca c th.
Cn cho thm sinh t v trong st c tiu hao nhiu sinh t B v C.
d. Chuyn ha nc v mui b ri lon ch yu trong giai on thn nhit gi mc cao. Nc
li trong cc c quan t chc, trong cc c v trong vim (dch di). nc s dn n
ng cc t chc cc sn phm ca ci lon chuyn ha v ng cc cht mui. Bi tit nc
NaCl cng b hn ch do chc nng thn b nh hng va tng tit m hi v c cn di gii
nhiu tng thi cc sn phm chuyn ha v cc mui b ng nn nc tiu thng vng
sm.
2. Ri lon chc phm cc c quan, h thng khi st:
a. Ri lon thn kinh: ngay t trc khi thn nhit tng v giai on u ca thn nhit tng
thy c nhng ri lon thn kinh nh nhc u, mt mi, bun ng, km tp trung t tng
biu hin trng thi c ch hot ng thn kinh cao cp, ghi in no thy cc sng anpha
chm li ng thi cc phn x c iu kin cng b c ch. Nhng ri lon su sc h TKT
nh o gic, m sng, li b, hn m, mt thc, pht sinh do tnh trng nhim c hu qu
ca qu trnh nhim khun ch khng phi do nhit tng. tr em khi v no v cc trung
tm iu nhit cha hon thin thng pht sinh co dt khi st cao trn 39
0
C. Theo cc ti liu
nghin cu ca bnh vin Bch Mai c 85,5% tr em di 3 tui cao trn 39
0
C u pht sinh co
git.
b. Ri lon tun hon, mu:
- Khi st, nhp tim tng do thn kinh giao cm tng cng hng phn v tc dng ca nhit cao
trn h thn kinh t ng tim. Thng c nhit tng ln 1
0
C th mch tng t 8-10 p. Thay
i hot ng tim cn ph thuc vo tnh cht ca nhim khun: tim p chm trong thng
han, vim mng no l do tc dng c hiu ca ni c t trn h tim mch.
- Huyt p ng mch thng khng thay i, c th hi tng trong giai on u ca st do
tnh trng co mch vi. Trong mt s trng hp nhim khun nng, c t vi khun c th gy
tn thng trc tip c tim v trung tm vn mch dn ti thiu nng mch cp v try mch.
- Tc mu chy tng cng trong cc ni tng (thn, gan, no) do co tht tun hon ngoi vi,
l c s ca nguyn tc iu tr bnh huyt p cao do thiu mu thn bng gy st nhn to.
- Trong mu ngoi vi, bch cu v hot tnh thc bo ca bch cu tng. Chc phn h thng
vng ni m cng tng nn dai thc bo, cc khng th v b th u tng. Ni chung, khi st
chc phn khng min dch ca c th tng c tnh cht thch ng phng ng, ch khi st
nng cc chc phn ny mi b ri lon.
c. Ri lon h hp: H hp tng trong st do nhit mu cao v tnh trng nhim toan kch
thch trung tm h hp. Th nhanh trong st cn l mt bin php thi nhit vy l, ch yu
cc ng vt khng c tuyn chn lng(ch, th).
d. Ri lon tiu ha: Mt trong nhng triu chng thng thng ca st l hin tng chn n,
mt ngon, ming kh, li b v ng. C ch ca chn n trong cc bnh nhim khun c th
l trung tm n b c ch v phn ng phn x do nhim c, ng thi bi tit dch v, dch ty
v dch mt u gim, toan tnh dch v cng gim. Ngoi nhng ri lan phn tit dch tiu ha
cn thy c ri lon chc phn co bp ca d dy, rut nn qu trnh chuyn chc nng t d
dy c th b tr, chng lc rut cng b ri lon c th pht sinh y bng chng h v
to bn. Ri lon tiu ha v chn n trong st l nguyn nhn gy hc hc, gy v suy nhc
c th. Trn thc nghim, s dng cc thuc h nhit lm suy yu phn ng st, cng khng
loi tr c nhng ri lon trn.
e. Ri lon chc phn gan: Khi st, qu trnh chuyn ha nng lng ca gan tng, c bit qu
trnh photphoryl ha tng mnh ti 30 - 40% so vi mc bnh thng. Chc phn hng ro
chng c ca gan, chc phn tng hp protit, phopholipit, chc phn ur, sn xut fibringen
ca gan u tng cng c tnh cht thch ng phng ng. Nhng trong mt s bnh nhim
khun, nhim c nng cht c v mt s c t vi khun c th lm ri lon qa trnh
phophoryl ha nn chuyn ha nng lng ca gian gim dn ti di lon chc phn gan.
D. [ NGHA CA PHN NG ST
T trc ti nay, c nhiu quan im khng thng nht v { ngha ca phn ng st i vi
c th. Ngun gc t "St" l "februa" tc l phng tin lm cho thot khi, chng t rng t
y hc c i, st c coi nh trng thi gip c th chng nhng cht c hi. n th k
XVIII, mt s nh lm sng li cho rng st l hin tng nguy him cho i sng v c nhiu ri
lon chc phn v nhiu bin i thoi ha trong cc t bo t chc do tc dng ca nhit
cao. Do dn ti s ham thch dng thuc h nhit, tm lnh, bc t trong iu tr st. Sau
thy rng khuynh hng h nhit thng c kt thc bng s st km trng thi ca
bnh nhn to iu kin cho bnh nhn ti pht thng han. Gim thn nhit nhn to trong
iu tr cc bnh nhim khun khng loi tr c nhng bin i bnh l m cn lm mt s
ri lon tin trin nng thm. Rt nhiu th nghim trn ng vt chng t rng khi trn p
phn ng st th mt s bnh nhim khun din bin nng hn ng vt thng cht. Nhng
qun st ny thc y nhng nghin cu c hiu v vai tr ca st trong bnh l.
Met-nhi-cp nh gi st nh mt phn ng thch ng phng ng ca c th: "Vim, tng bch
cu v st hnh thnh mt th chn king c tc dng ngn cn cc nguyn nhn bnh l khi
chng xm nhp c th". Phn ng st cng nh vim c hnh thnh trong qu trnh tin ha
v c bn l nhng phn ng thch ng bo v c th.
Vai tr bo v thch ng ca st l ch: nhit tng cao nht thi kch hot cc qu trnh
chuyn ha trong t bo v to iu kin tch ly nng lng d tr nh tng cng cc qu
trnh photphoryl oxy ha ng thi tng cng hot tnh chc phn cc c quan v t bo. Khi
st, cc vi khun v c t kch hot cc men ca mu v s tng cng cc phn ng sinh ha
l c s to thnh cc lin kt giu nng lng cn thit cho s phc hi chc phn cc t bo
t chc tn thng do mt s bnh nhim khun din bin xu nu dng thuc h st (vim
phi, cm, thng hn, bch hu). Khi tim chng phng bnh, nu dng thuc h st th kh
nng min dch gim. Nhit cao cn ngn cn s sinh sn mt s virt (cm, bi lit) v ri
khun (xon khun, ph cu khun). Cng vi tng nhit , ng thi kch thch sn sinh
khng th. Cc cht gy st cn kch hot h tuyn yn - thng thn lm tng sc khng c
th i vi nhim khun. C th ni st to ra mt tin nng lng cho s tng cng cc
chc phn sinh l, sc khng min dch v s phc hi c th.
Trong y hc, ngi ta cn s dng st nhn to vi mc ch iu tr, thng dng cht gy st
ngoi sinh ly t cc vi khun t c. St iu tr liu kt hp vi iu tr c hiu c tc dng
nht trong mt s bnh: th sm ca bnh giang mai c tn thng h TKT, vi lit c tin
trin tng dn, mt s bnh ngoi da (eczema, nht), vim da khp dng thp khng c hiu,
bnh huyt p cao th c tnh. Cc cht gy st (pyrognal, pyromen) cn c hiu lc kh
qun trong iu tr so li, so co sau khi bng, cng nh trong iu tr cc tn thng do chn
thng ty sng, v tn thng dy thn kinh ngoi vi do c ch s pht trin cc si keo, c
ch to thnh so v lm mm so.
Cn ch l st cao qu mc v ko di khng c { ngha thch ng phng ng, ngc li cn
nguy him cho i sng v gy nhiu ri lon chuyn ha v chc phn nghim trng. Trong qu
trnh bnh l nhim khun - nhim c nng c th pht sinh bin chng tng thn nhit qu
mc km theo mt thc v co git ton thn thng dn ti t vong.
Thi x tr ca y sinh l phi tn trng, bo v phn ng st va phi, khng nn vi v lm
dng thuc h nhit v c th lm thay i din bin ca bnh, gy kh khn cho cng tc chn
on v iu tr bnh. Trong khi theo di tm nguyn nhn chnh ca bnh phi ch { ngn nga
cc ri lon c th do tng thn nhit v nui dng tt tng cng sc khng chng
bnh tt. Nhng trong cc trng hp st cao v ko di, ngn nga cc bin chng c hi
ca tng nhit phi dng thuc h st kt hp vi iu tr c hiu i vi nguyn nhn gy
bnh, ng thi phi ch { n iu tr ton thn, dinh dng hp l, gii quyt kp thi cc ri
lon chuyn ha v chc phn bnh chng hi phc.

49. SINH L BNH GAN

NGUYN HU M

Gan c vai tr rt quan trng trong c th v n m nhim rt nhiu chc nng, c tc gi v
gan nh mt phng th nghim tinh vi v phc tp.
Gan li v tr ca ng ca c th nn d b cc cht c ngoi tc hi.
S phn ng ca gan i vi yu t gy bnh cng khng n thun v ngoi nhu m gan, cn
c t chc vng ni m, cn c tun hon ti gan,cn c ng dn mt, nhng b phn ny lin
quan cht ch vi nhau. Lc u, c th ch c mt b phn b tn thng, nhng chng bao lu
s ko theo b phn khc vo vng bnh l{. l c im ni bt ca hot ng gan.
Mt c im na khong km phn quan trng l nu t chc gan rt d b tn thng, th n
c kh nng hot ng b v tng sinh rt mnh. Ngoi ra, trong c th cn c mt s t chc
khc cng c mt s chc nng khc cng ging nh gan (chuyn ha ca t chc thn, sinh
tng hp khng th cu t chc vng ni m). iu nay lm cho s nghin cu chc nng gan
v nh gi kt qu xt nghim thm kh khn. Thng th ch tn thng thc th gan
kh quan trng th ri lon chc nng mi r rng.
Cho nn, trong ngin cu sinh l bnh gan, cn ln lt nghin cu tng chc nng mt, nhng
nh th khng c ngha l tch ring m lun lun phi nh l chng c lin quan cht ch vi
nhau.
I. NGUYN NHN GY BNH GAN
Do chc nng gan phc tp, do gan v tr ca ng ca c th, cho nn nguyn nhn gy bnh
gan khng n thun v thng kt hp vi nhau, do kh xc nh v lm cho hnh thi
bnh phc tp kh hiu.
A- NHNG YU T GY BNH
1. Nhng yu t bn ngoi:
a) Nhim c: C th l nhim c cp nh nhim c ch, photpho, thuc m (chlorofoc),
tetraclorua CNu nng s gy hoi t nhu m gan v cht, nu nh c th hi phc hon ton.
C th l nhim c trng din nh nghin ru. Ru l nguyn nhn ch yu gy x gan
nhng nc m dn chng ung nhiu ru (nh Vit Nam di thi Php thuc). Trong
trng hp nhim c trng din, tn thng ch t mt song tch dn v cui cng s gy tn
thng khng hi phc.
b) Nhim khun: nhim khun thng tc dng bng 2 cch: tc dng trc tip ca vi khun
hay ca c t vi khun trn nhu m gan v tc dng gin tip khi tnh trng nhim khun gy
suy sp ton thn. C th nhim k sinh trng, virut hay vi khun.
- Nhim k sinh trng: k sinh trng st rt, sn l gan l hay gp nht. Vit Nam, bnh st rt
l mt trong nhng nguyn nhn chnh gy x gan.
- Nhim virut: Vit Nam, nhim virut chim mt t l kh cao (24%) trong cc bnh gan, ng
hng th 2 sau st rt. Cn cc nc khc nhim virut ng hng u. Hin nay, ngi ta
xc nh trong mu ngi vim gan do virut B c mt protein l l khng nguyn Au (Australia).
mt s ngi bnh thng cng c khnh nguyn ny, song t l trong dn s thp: 0,1%
(chu u), 3-4% (Vit Nam), 20% (chu Phi).
- Nhim khun (coli, lao, giang mai) c th gy vim gan trng din dn ti x gan.
c) Thiu dinh dng: nh hng su sc ti chc nng gan: nhng nc thiu n (chu Phi,
chu ) thy x gan ph bin tuy khng ung ru nhiu; Vit Nam, x gan do thiu dinh
dng chim 12,5%, ng hng th 4 trong cc nguyn nhn gy x gan, l do n ung qu
thiu thn, hu qu ko di ca ch thc dn. Trong chin tranh, ngay ti cc nc chu u
x gan cng tng hn bnh thng, mc d ru b hn ch, ch yu do thiu n. X gan c th
do thiu methionin, hay ni chung l nhng cht hng m gy ra nhim m gan, lu di dn
ti x gan. Ngoi ra, ngi ta cn thy nhng ngi sau khi ct on d dy, nhng ngi ri
lon tiu ha trng din cng d b x gan.
d) Nhng nguyn nhn khc: Gn y, ngi ta ni nhiu n nguyn nhn d ng. C ch ca
loi x gan do d ng cha r, c th do cht c kt hp vi protein ca gan to thnh khng
nguyn v c th sinh khng th chng li khng nguyn , gy hy hoi t bo gan dn ti x
gan. Song vn cha r rng v qu trnh mn cm c th l th pht vi tn thng do cht
c gy nn t chc gan.
2. Nhng yu t bn trong:
a) Tun hon: suy tim nht l suy tim phi v suy tim ton b, vim mng ngoi tim dy co tht
l nguyn nhn ca x gan v gy mu v thiu oxi ti gan. Nhng bnh phi trng din
(hen, x phi, dn ph qun) gy suy tim phi v gin tip gy ri lon chc nng gan. Trong
thc nghim, c th gy mu tai gan bng cch lm hp tnh mch ch di.
b) Chuyn ha: Ti gan, qu trnh chuyn ha cht xy ra mnh, khi ri lon mt cht no th
d a n ri lon chc nng gan. Thiu men G-6- photphattaza lm cho G-6-phot-phat khng
bin thnh glucoza c, gy ng glucogen ti gan (bnh Von Gierke). Khi thiu cht hng
m, s pht sinh nhim m gan. trong bn Uynxn (Wilson), c ri lon tng hp cht
xeruloplasmin- mt thnh phn glubulin trong mu lm nhim v vn chuyn ng- thy ng
tch li trong c th, gy ng c lm tn thng th vn no kt hp vi s gan v nhiu axit
amin niu.
c) Cc yu t khc:
- Ni tit. Trong bnh cng tuyn gip (bnh basedow), thng pht sinh suy gan. Gn y,
ngi ta pht hin thy tuyn yn c hocmon LMH (lipit mobilizcing hormone) c tc dng
iu m khi ni d tr rt mnh, do c th hiu ti sao ct b tuyn yn li gy nhim m
gan.
- Thn kinh. Thn kinh giao cm v giao ph cm gic chi phi vn mch v nht l cc c tht
tnh mch trn gan v tiu tnh mch gnh. Cht histamin gy co tht tnh mch trn gan, do
tng huyt p tnh mch gnh: ngi, cng nh ch, hin tng mu thy r trong sc qu
mn, do co c tht tnh mch trn gan, di tc dng ca histamin c gii phng t.
- Vai tr ca lch. Trong bnh Banti thy x gan sau x lch. C ch cha r: loi x gan ny rt
ph bin cc nc b st rt nhiu, nh nc ta, chim ti 1/3 tng s bnh nhn x gan.
B- NG VO CA CC YU T GY BNH
Yu t gy bnh c th vo gan bng nhiu ng khc nhau:
- H thng tnh mch gnh. Cc vi khun, c t vi khun. Theo thc n trong ng tiu ha, cc
sn phm chuyn ha ln men thi ra trong rut v cc cht c khc c th theo ng tnh
mch gnh ln gan. y l nh chnh, quan trng nht gy vim gan do trc khun coli,
nhim c P, x gan do ru
- H thng ng dn mt. Vi khun c theo ng dn mt ln ti gan, gy ri lon trc tip hay
gin tip chc nng gan, th d vim ng dn mt c th dn ti x gan. Nhng k sinh trng
ln nh giun, xn c th theo ng ny ln gy tc mt cp din.
- ng tun hon mu. Vi khun v cht c c th theo ng mu ti gan, gy ri lon chc
nng gan. Thoi ha m do ng c thuc m, mu gan trong nhim khun ton thn, vim
gan do virut u do nh hng ng ti c. Vi khun lao, vi khun giang mai t tim pht
lan ti gan bng ng ng mch gan.
- ng bch huyt. Nhng yu t gy bnh c th t ng tiu ha theo ng bch huyt ti
gan gy bnh, nh amip kit l gy ti m ti gan.
- ng thn kinh. Thc nghim cho thy l khi kch thch thn kinh giao cm bng, c th
gy ra chy mu ti gan v t dn ti nhng thay i t chc gan v hnh thi hc.
II. RI LON T CHC GAN
A - C IM CU TO CA GAN
Trc dy ngi ta quan nim rng tiu thy gan vi khu vc gnh xung quanh v tnh mch
trung tm gia l n v cui cng ca hot ng gan, v nhiu trng hp bnh l{ c gii
thch trn c s cu trc nh vy.Gn dy (Rapoport) v (Gotvin) cho thy tiu thy ny khng
cn l n v trung tm na m cng phn bit ti gan vi nhng v khc. n v nh nht l
n nang: n nag do nhiu t bo gan nm quy quanh mt trc gm tiu tnh mch gnh,
tiu ng mch gan, mch bch huyt, ng dn mt nh v thn kinh. Trc ny l phn nhnh
cui cng ca b mt- mch- thn kinh khong gnh. Hai ba n nang hp thnh nhm nang
vi mt bc t chc m quanh khoang ca tam gic v nhiu nhm nang hp thnh chm
nang vi khoang ca bu dc (H1). Theo quan nim ny, cc nhnh tnh mch trung tm tiu
thy mt v tr gia m li nm ngoi ra cc chm nang, nh vy mu theo ng tnh mch
gnh phn chia ti cc t bo v cc xoang cnh t bo ri thu dn v h thng tnh mch gan
cui cng vo tnh mch trn gan. V phng in phn b, cc men chuyn ha ti gan
cng phn theo tng khu vc khc nhau, do b h hi mc khc nhau ty tng khu vc
ca chng.
Quan nim trn cho php gii thch nhng khu vc xa mch mu nui dng b tn thng
trc tin khi thiu oxi, thiu dinh dng v nhng t bo quanh mch cn tn ti s c kh
nng ti sinh mnh.Cng theo quan nim trn, cc t bo gan nm cng xa trc ca n nang
cng kh b tn thng khi nguyn nhn gy bnh l nhng trn c, vi khun tin cng t
ng tnh mch gnh hay ng mch gan.
Hin tng, quan nim n nang, c a s tc gi cho l tha ng gii thich n v cu
trc v chc nng ca gan. Tuy nhin tiu thy c in, tiu thy gnh v n nang khng c
coi l nhng quan nim i lp v cu trc ca gan, m l nhng quan nim b sung cho nhau.
Do tinh cht phc tp ca chc nng gan, i khi trong gii thch ngi ta thy cn da vo
quan nim ny hoc quan nim khc mi tha ng (Bloom v Fawcett).
B- NHNG THAY I TRONG CU TRC CA GAN
1. Tn thng m gan.
Tn thng nhu m gan c th do nhiu nguyn nhn gy ra, nhng nguyn nhn ny c th
n c tc dng hoc phi hp tc dng.
Tn thng nhu m gan t ph thuc vo tnh cht ca nguyn nhn gy bnh m ph thuc
nhiu vo c lc ca chng:
- Khi nguyn nhn gy bnh rt c nh trong vim gan nng do virut, nhim c nng, thy c
tnh trng hoi t lan trn khp nhu m gan thay th bng nhng m chy mu ln trung
tm tiu thy cho nn gan khng chc m li mm, Nhng ri lon trong c th xy ra rt
nhanh chng, ging nh ct gan thc nghim: ng mu gim rt nhanh, ure mu gim, sau
4h con vt yu dn, v sau 6h th ln cn co git v cht.
- Khi c lc ca nguyn nhn khng ln lm th s hy hoi t hn. Do cha cht ngay nn c
mt s t bo ti sinh, nhng ch nhu m mt i b xp li lm cho gan nh li, ch cn li t
chc m v m, gi l gan teo vng.
- Khi c lc ca nguyn nhn km hn na thy tn thng thu hp chung quanh tnh mch
trung tm tiu thy, t chc m t b tn thng t chc x pht trin. Nhu m c ti sinh
song b hn ch bi t chc x. Nu qu trnh x pht trin nhanh chng hn qu trnh ti sinh
th gan s to ra, gi l gan x sau hoi t, Loi x gan ny ty theo qu trnh tn thng bt
u quanh ng mt (do nguyn nhn mt) th s c x gan mt, quanh tnh mch gnh th c x
gan gnh.
2. Nhim m gan.
y l mt loi tn thng gan hay gp. Bnh thng gan c t 3-8% khi lng l lipit ch yu
l m trung tnh. Khi lng m ny chim ti 10-40% th gi l nhim m gan. Trng thi bnh
l ny c th do nhiu nguyn nhn gy ra:
- Thiu cht hng m(cholin, methionin) nh bit, triglycerit ni sinh ra khi gan di
dng lipoprotein ha tan trong nc: trong cu trc phn t ca lipoprotein, nhng cht khng
ha tan trong nc (triglycerit v cholesterol) c sp xp pha trong khng tip xc vi
nc, cn cc cht ha tan trong nc (photpholipit tng hp t methionin v mt protein c
bit do gan to ra) c sp xp pha ngoi, do ch c kt hp vi photpholipit, triglycerit
ni sinh mi ra khi gan c, v khi c th thiu methionin, s pht sinh m ha gan. Trong
lm sng iu tr bng methionin thy c kt qa tt.
- Thiu oxy hoa ko di nh trong suy tim, thiu mu.
- Nhim c ko di nh ru colropoc, photpho
Cc nguyn nhn trn y, bng cch ny hay cch khc, khng cu to hoc c ch cc men
chuyn ha m ti gan. Nhim m gan thng thy kt hp vi x gan gnh ngi v i khi
dn ti x gan. chut thiu cholin, thy r nhim m gan dn ti x gan. Nh vy c th
khng nh nhim m gan l mt nguyn nhn trc tip gy x gan v x gan ny c th dn ti
c tnh tin pht gan. C l y l mt nguyn nhn gy t l x gan cao v u c tin pht ti
gan cc ni thiu n nh c nc chm tin b quc bc lt (ti chu , Phi, M latinh).
3. X gan:
y l mt bnh ph bin trn th gii v nc ta. khoa ni bnh vin Bch Mai (1959),
bnh x gan chim hng u (37.8%) trong cc bnh gan mt.
X gan l hu qu ca tt c cc bnh gan mn tnh. N c mt hnh nh duy nht v gii phu
bnh song tri li nguyn nhn khng duy nht,c khi rt kh pht hin.
V gii phu bnh x gan c hai yu t chnh:
- Hi chng tng p lc gnh.
- Hi chng suy gan.
Qu trnh x gan c nhng c im sau y:
- Xy ra trong ton b gan.
- Tin trin lu di hng nm.
- C tng t tin trin, qua mi t bnh nng hn.
- Khng c hiu trong nguyn nhn no c.
Bnh sinh ca qu trnh x gan c quan nim nh sau: Ti ni pht sinh hoi t nhu m gan,
t chc xp li, khin cho cc mch mu ca b gnh xch li gn tnh mch trung tm tiu thy,
to iu kin mu c th chy thng t ng mch gan va tnh mch gnh n tnh mch
trung tm, b qua cc tnh mch xoang (tc l cc mao mch khc khuu) cnh cc vng gan
khng b tn thng, kt qu l s cung cp mu cho nhu m gan st cnh b ri lon, c th
dn ti hoi t do thiu mu ti ch. Ngoi ra, gim oxi t chc lm cho t chc lin kt pht
trin dn ti x ha. Hoi t cc t bo gan gy ra s ti to nhu m gan. Cc cc t chc ti
to, sp xp ln xn, p cc mch mu, gp phn tng cng ri lon tun hon trong gan,
m hu qu l hoi t nhu m gan lan rng v x gan ngy mt pht trin. Qu trnh x gan tin
trin theo kiu phn ng dy chuyn: hoi t ti to ----->o ln t chc ----> thiu mu ti
ch nhu m gan ----> hoi t
Gn y, c { kin cho rng x gan do vim gan truyn nhim pht sinh theo c ch t min
dch. T bo gan b hoi t sinh ra cht protein l i vi c th. C th sn xut ra khng th
chng li khng nguyn , ngha l chng li t bo gan ca bn thn mnh. T bo mi b tn
thng li sinh ra khng th mi v qu trnh c th tip din, lm cho gan lun b vim nhim
v dn dn x ha.
C ch trn y da vo c s min dch hc pht hin ra khng th chng li t bo gan v
iu tr vim gan mn tnh vi cc thuc gim min dch thy c tc dng nht nh.
III. RI LON TUN HON TI GAN
A- C IM TUN HON TI GAN
Bnh thng, lu lng mu qua gan l 1000-2000 ml (trung bnh l 1500 ml) trong mt pht,
bng 1/2 lu lng mu ton c th. Cho nn c tc gi v gan nh qu tim th 2 ca c th.
Lng mu qua gan do 2 ngun cung cp: ng mch gan cung cp 1/4, cn li 3/4 l do tnh
mch gnh. Mu tnh mch gnh nhiu oxy hn cc tnh mch khc (cung cp 72% oxy cho gan),
gm 1/3 t lch ti v 2/3 t ng tiu ha ti. Mu ng mch v tnh mch c trn ln ti
cc xoang mu k t bo trc khi dn v tnh mch gan v tnh mch trn gan.
Do 2 ngun cung cp mu nn gan c kh nng chu ng thiu oxy hn cc t chc khc. Gan
c kh nng b p rt mnh v c th vn hot ng bnh thng ngay c khi lu lng mu
qua gan gim r rt v pht sinh thiu oxy nng: l do kh nng ti sinh v hnh thnh tun
hon bn mnh m, ngoi ra cn c kh nng tng cng s dng oxy mu ngay c trng hp
oxy mu gim nghim trng.
Nu gan bnh thng c kh nng chu ng thiu oxy ca ton thn, th tri li, khi gan b thiu
oxy nghim trng s nh hng ti tun hon chung do gan to ra cht VDM (vaso dilatator
material, cht gy gin mch) c tc dng gin mch, gy gim huyt p. Trong sc trn ch,
con vt sng lu hn nu tun hon gan c m bo. Do c { kin cho rng mt trong
nhng nguyn nhn gy gim huyt p trong sc l do gan b thiu oxy nghim trng sn
sinh ra cht VDM gy gim huyt p.
ng ch { l t chc gan khi b tn thng (vim, x) li rt mn cm vi thiu oxy. Nu huyt
p gim (trong sc, chy mu nng) d ch tm thi cng c th pht sinh gan nhng tn
thng khng hi phc. l iu m trong phu thut lun lun cn ch v m x v gy m
l nhng iu kin gy thiu oxy c hi i vi gan b bnh sn.
B- MU TI GAN
Tt c nhng nguyn nhn g lm cn tr dng mu v tim phi nh suy tim phi v suy tim
ton b, vim mng ngoi tim co tht, bnh tim phi mn tnh, tc tnh mch gan do vim, u
chn pu lm cho mu li gan. Lng mu gan c th tng gp i (t 400 ln 800
ml). Th tch gan to ra, b di c th xung ti ng rn. i khi nhp p ca tim c
truyn ti gan (gi l mch gan) nh trong trng hp h van 3 l. iu tr tt, tnh trng suy
tim kh hn, mu lu thng tt hn, gan s nh li ri li to ra khi suy tim tin trin xu i.
Do m gan khi to khi nh ty theo sc co bp ca tim, ngi ta gi l gan dn xp.
Khi gan b mu lu ngy s sinh ph v thiu dinh dng> Tnh trng thiu oxy ko di dn ti
hoi t nhu m gan xung quanh tnh mch trung tm tiu thy, gy ra trng thi bnh l gan
ht cau.
Nu qu trnh bnh l{ ny ko di hn na th t chc x pht trin, nhng nhnh mch mi
ni tip cc nhnh mch gnh quanh tnh mch trung tm tiu thy vi tnh mch gan ngoi
tiu thy, cng lm cho trung tm tiu thy thiu oxy gy thoi ha m gan.
Qu trnh x ha do mu ko di dn dn lm cho gan to ra, rn, c b sc v thng khng
u.
Cm gic au khi c mu cp l do v bc Glitxong (Glisson) b cng qu nh trong vim
gan cp; tri li, nu gan to dn, thng khng gy au v b bc ny c thi gian thch ng
dn dn ra.
C- TNG HUYT P TNH MCH GNH
Bnh thng, huyt p tnh mch gnh bng 6-10 cm ct nc, p lc ny c th tng ln 25-50
cm trong trng hp bnh l.
1. Nguyn nhn gy tng huyt p gnh:
Tng huyt p gnh pht sinh khi mu lu thng b ngn chn mt on no ca h thng
gnh, Tr ngi c th bn trong gan hay ngoi gan. chn on phn bit, ngi ta hay o
huyt p ti lch c trng cho huyt p phn trc xoang ca gan v huyt p tnh mch
trn gan phn nh huyt p sau xoang.
Tng huyt p gnh c th phn chia lm 2 nhm ln:
a) Nhm tng huyt p gnh trc xoang vi huyt p lch tng v huyt p tnh mch gan bnh
thng. Tnh trng ny c th do tc tnh mch gnh gc hay tc tnh mch lch, hay do khu
vc gnh ca mi tiu thy b chn p. Hin tng ny gp trong x gnh bm sinh, xm nhim
vng gnh bi cc t chc c tnh nh bnh tng vng, bnh saccoit (sarcoidose), hay do k sinh
trng gy tc tnh mch khu vc gnh.
b) Nhm tng huyt p gnh sau xoang vi huyt p lch v huyt p tnh mch gan u tng.
Tnh trng ny hay gp nht trong x gan. T chc x pht trin ngn cn mu t vng gnh v
tnh mch trn gan v mu phi i theo ng tt khng qua xoang; khong 1/3 s mu i tt
nh vy, cho nn t chc gan ch yu c nui dng nh ng mch gan. Mt khc cc cc
t chc ti to, nh nu trn, pht trin v chn p ln cc xoang li tng cng cn tr
mu v tnh mch trn gan. C 2 huyt p trc xoang v sau xoang u tng. Ngoi ra, cn gp
tnh trng ny trong tc tnh mch trn gan v suy tim mt b.
Trong thc t, nguyn nhn ch yu gy tng huyt p gnh l bnh gan, c bit l x gan,
trong t chc x pht trin mnh v chn p cc nhnh ca tnh mch gnh, lm cho mu
li tnh mch gnh.
2. Hu qu ca tng huyt p gnh:
a) T chc x gan d pht trin. Do trong gan, ti cc tiu thy, tun hon bn pht trin gia
nhnh tnh mch gnh quanh tiu thy v nhnh tnh mch gnh trn gan lm cho trung tm
tiu thy cng b thiu dinh dng dn ti x gan. ng thi phi nhn mnh ti vai tr chn
p cc xoang do cc cc t chc ti to (cn gi l cc nhn ti sinh pht trin v y mi l yu
t chnh lm cho t chc x pht trin. ng mch gn cung cp phn ln mu cho cc cc t
chc ti to do trong x gan ph i hay c tun hon bn hn l x gan teo.
b) Tun hon bn ngoi gan: mu tnh mch gnh tm li v tun hon chung bng ba
ng: (H2)
- ng qua tnh mch d dy ln tnh mch thc qun vo tnh mch ch trn, gy gin tnh
mch thc qun (gp 60-70% bnh nhn b x gan) v khi v gy nn ra mu (gp 25-30%
bnh nhn b x gan), thng gy cht ngi, do mu lu ng (gan suy gim tng hp mt
s yu t ng mu).
- ng qua tnh mch rn v tnh mch bng ni h thng gnh vi tnh mch ch trn, cho
nn khi c tng huyt p gnh, thy da bng tun hon bn ni xanh kh r.
- ng qua tnh mch trc trng vi tnh mch ch di gy gin tnh mch tr v khi bnh
nhn i ng, bnh nhn rn mnh, tnh mch tr b v, i ng ra mu ti. ng ch { l
bnh tr ,ngoi nguyn nhn tng huyt p gnh cn do nhiu nguyn nhn khc gy ra (to bn
lu ngy, nhiu ln).
c) Bng nc (c trng, trn dch mng bng). y l mt hu qu khng km phn quan
trng ca tng huyt p gnh.
- Bnh sinh: Kh phc tp. Ngoi tnh trng tng huyt p gnh l nguyn nhn ch yu, cn
phi k ti tnh thm thnh mch tng (m biu hin l m protein cao trong dch bng) do
tnh trng thiu oxy v nhim c ko di (hu qu ca gan suy). p lc keo trong mu gim (do
gan suy gim tng hp albumin), do nc khng c gi li trong lng mch. Ngoi ra do
gan suy khng hy c cc hocmon c tc dng gi nc nh aldosteron, ADH, hocmon sinh
dc estrogen.
- Hu qu: Bng nc to v ko di c tc dng chn p cc ni tng trong bng, hn ch s
hot ng ca c honh, gy kh th, chn p tnh mch ch di lm cho lu thng kh khn.
Ngoi ra, dch bng c th t vi lit n vi chc lit, m protein trong li cao, do nu
chc tho lin tip c th gy thiu protein quan trng trong c th, lm cho bnh nhn ngy
cng suy yu. Cho nn, ch chc tho khi hot ng cc ni tng trong bng b hn ch nhiu.
Mt khc, truyn tr dch ngay cho bnh nhn cng l mt phng php iu tr x gan.
[newpage]
IV. RI LON CHUYN HA
MY C IM CN CH
Khi nguyn cu mi lin quan gia tn thng t chc v ri lon chc nng gan, cn ch
nhng c im sau y:
- T bo nhu m gan rt d b tn thng khi thiu oxy hay nhim c, song c kh nngb p
rt mnh v ti sinh rt cao. Trong thc nghim, ct b mt thy gan ca con vt thy sau mt
thi gian ngn gan li to nh c do ti sinh rt mnh b cho ch mt i. Cho nn khi gan b
tn thng b phn (u c tnh, ti m ln), biu hin bn ngoi ca hot ng gan vn tt
hoc tng i tt v b phn lnh c gng b p v ti sinh mnh m thay th ch b hy
hoi. Tri li, khi vim, nhim c x ha thy pht sinh ri lon chc nng gan, v trong trng
hp ny hu ht nhu m gan b tn thng, d l nh.
- T bo ca t chc m (t bo Kupffer) cng phn ng trc yu t gy tn thng nhu m:
chng tng sinh rt mnh v chng lm nhim v thc bo v sn sinh khng th trc s tn
cng ca yu t bnh l{, c bit l nhim khun.
- Mt s chuyn ha xy ra gan cn thy mt s c quan v t chc khc (tt nhin mc
c khc nhau), nh thn cng chuyn ha protein, cng chng c, h vng ni m ngoi gan
cng sn sinh khng th. Cha c loi xt nghim no c tnh cht c hiu phn nh trung
thc hot ng ca gan.
- Trng thi khng ng u trong cc chc nng gan: nh chc nng tng hp protein rt b
ri lon, song chc nng kh amin li c kh nng b mnh.
Tt c nhng c im k trn lm gim gi tr cc xt nghim thm d chc nng gan v gy
kh khn cho vic nh gi kt qu cc xt nghim. Khi gan b tn thng, thng pht sinh
nhiu ri lon chc nng phc tp. cho d hiu, khi nghin cu, thng phn tch ring tng
loi, song trong thc t nhng ri lon thng kt hp vi nhau.
A. RI LON CHUYN HA PROTEIN
Gan l ni thoi bin cc protein t ng tiu ha ti (ch yu l axit amin v dipeptit) v
tng hp cc protein huyt tng. Hai qu trnh ny lin quan cht ch vi nhau qua cc phn
ng kh amin v chuyn amin to thnh nhng axit amin cn thit cho qu trnh tng hp
protein v nhng cht d tr nh gluxit, lipit. Mt phn amin c kh s chuyn thnh ure
ngay ti gan. Gan tng hp ton b albumin huyt tng, mt phn globulin v mt s yu t
ng mu (fibrinogen, prothrombin, yu t V, VI v X).
Khi gan b bnh, thng pht sinh nhiu ri lon chuyn ha protein:
1. Gim kh nng thoi bin protein:
Khi gan suy, c bit giai on cui thng thy gim kh nng cn a peptit lt t ng tiu
ha ti. a peptit l mt cht c nn khi vo trong dch no ty c th gy ra hi chng mng
no thng gp trong hn m ga n. bnh nhn suy gan cn thy axit amin tng trong mu (do
khng c kh) v nu nhiu s gy axit amin niu.
2. Gim kh nng tng hp protein:
c bit l albumin huyt thanh gim gy ph (do gim p lc keo). Trong suy gan, thng t
chc vng ni m khng b tn thng tri li tng cng sinh khng th chng nhim
khun, cho nn hay thy globulin tng, lm cho t l A/G gim thm ch o ngc. Tnh trng
ny gy thay i tnh trng keo ca huyt tng lm cho huyt thanh d b kt ta bi cc mui
kim loi nng. cng l c s ca nhng xt nghim ln bng, kt ta thng dng thm
d chc nng gan.
Cc yu t ng mu cng gim gy ri lon qu trnh ng mu d sinh chy mu nh chy
mu di da.
3. Kh nng tng hp ure b ri lon r rt:
NH
3
di dng t do rt c i vi c th, c rt t trong mu, phn ln c kt hp di
dng amin ca axit glutamic, tr thnh glutamin> Glutamin khng c v l dng vn chuyn
ca NH
3
trong mu. Glutamin c to thnh t hu ht cc t chc. Glutamin c vn
chuyn ti gan v thn, glutamin c thy phn thnh axit glutamic v NH
3
, NH
3
c
gii phng bin thnh ure gan hoc o thi qua nc tiu di dng mui amoni.
Hot tnh ca cc men tng hp ure pht sinh ri lon trong bnh gan (vim gan, x gan).
bnh nhn suy gan kh nng tng hp ure b ri lon r rt song khng thy ure mu gim m
ch thy biu hin ch amoniac tng trong mu. Amoniac l mt cht c, mn cm nht vi
amoniac l t chc thn kinh v hn m gan ch yu do nhim c amoniac. Nu cho ngi x
gan ung 10g NH
4
Cl c th gy nhim c: dy da, me man v amoniac t NH
4
Cl bt cht tng
nhanh trong mu.
Nhng ri lon tng hp protein thng l nhng du hiu u tin ca suy gan. Lc u, trong
mu xut hin cc protein bt thng (paraprotein), ri albumin huyt thanh gim, bnh nng
hn thy pht sinh ri lon tng hp ure v kh amin, cui cng amoniac v axit amin tng
trong mu.
Nhng thay i trn y ch c mt gi tr tng i v c th c gng thch nghi bng cch tng
cng hot ng b p ca cc t chc ngoi gan. Nhng thy i ch thc r rng khi suy
gan qu nng.
B. RI LON CHUYN HA LIPIT
Bnh thng, gan lm nhim v chuyn ha lipit c hp thu a ti bi ng tnh mch
gnh (glyxerol v axit bo) v ng ng mch (lipit trung tnh). gan, lipit va thoi bin va
tng hp ty theo nhu cu ca c th. Axit bo v glyxerol thoi bin cho nng lng v th
xeton (th xeton qua ng mu ti t chc c thoi bin nu c nng lng cung cp (bi
chuyn ha gluxit). Qu trnh tng hp axit bo cng nh tng hp cholesterol v cholesterol
este cng xy ra gan (gan l c quan duy nht tng hp cholesterol este v men este ha ch
c trong t chc ca gan.
Bnh thng, hai qu trnh thoi bin v tng hp lipit trng thi cn bng v ty theo nhu
cu ca c th m trng thi cn bng c s thay i.
Khi gan b bnh, chuyn ha lipit s pht sinh ri lon:
- Tch m gan do thiu cht hng m, nhim c, ch n nhiu m...
- Lng m d tr trong c th gim nhanh do thiu n (bnh nhn suy gan s m do kh tiu)
v gim tng hp m t gluxit v protein. Do bnh nhn suy gan gy nhanh.
- Lipit mu gim, cholesterol c th bnh thng hoc gim, song cholesterol este gim r rt
do gan gim tng hp men este ha.
- Ring trong tc mt, lng lipit cng nh cholesterol mu u tng: nhng cht ny bnh
thng c o thi theo mt vo rut nay b gi li, mt khc do mui mt trong mu nn
lipit d tan hn. Cho nn, kim tra nng cholesterol mu gip cho chn on phn bit gia
vng da trong gan hay ngoi gan (c bit r trong giai on v sau, tc mt lu ngy c th dn
ti suy gan gy gim tng hp cholesterol nn cholesterol mu khng tng).
- Qu trnh hp thu cc vitamin tan trong m nh vitamin A, D, E v K t rut vo cng gim r
rt, do gim hp thu m. D tr cc vitamin trong gan gim nh tin vitamin A, vitamin B
12
gy
chm ln hay thiu mu, gim vitamin K hn ch tng hp prothrombin d gy ri lon dng
mu sinh ra chy mu.
C. RI LON CHUYN HA GLUXIT
Gan l kho d tr gluxit di dng glycogen: glycogen c tng hp ti gan t nhng loi
gluxit khc nhau nh galactoza, fructoza, glucoza hp thu t ng tiu ha vo; ngoi ra
glycogen cn c tng hp ti gan t nhng sn phm thoi bin ca glucoza (axit lactic,
pyruvic), t axit amin sinh ng (alanin, glyxin) v t lipit.
Bnh thng, gan cng mt s b phn khc ca c th lm nhim v iu ha ng mu. Khi
gan b bnh cc c quan khc c kh nng b mnh, cho nn ng mu thay i khng r lm.
Ngay c thi kz cui ca bnh nhn x gan hin tng gim ng mu cng him gp.
Khi gan b bnh, chuyn ha gluxit c th pht sinh ri lon nh sau:
- Kh nng chuyn ng mi hp thu t rut vo thnh glycogen d tr gim, ng thi kh
nng chuyn ng tha thnh m d tr cng gim. do trong th nghim gy tng ng
mu, thy mt ng biu hin tng vt ri nhanh chng tt xung (H3).
- Kh nng bin galactoza thnh glycogen gim. Do sau khi ung hay tim galactoza, thy
ng ny xut hin nhiu trong nc tiu (p dng trong th nghim galactoza niu).
- Kh nng d tr ng di dng glycogen gim cho nn ngoi ba n, khi i, ng mu
c hi gim v khi nng n c th gy hn m, gp thi kz cui ca suy gan.
- Cc sn phm chuyn ha trung gian ca gluxit (axit lactic, pyruvic) tng trong mu, do gan suy
khng cn kh nng bin citamin B
1
thnh thiamin pyrophotphat (TPP) a cc sn phm
trn vo vng Krebs.
- Ngoi ra, chuyn ha gluxit khng hon ton nh hng ti chuyn ha cc cht khc (gim
tng hp protein, lipit v ure), do trong giai on cui ca suy gan thng pht sinh nhim
c axit.
D. RI LON CHUYN HA NC V IN GII
Gan c tc dng gin tip n chuyn ha nc v in gii thng qua s thay i p lc keo,
p lc thy tnh v thoi bin cc hocmon.
Gan x gim tng hp albumin, lm cho p lc ko ca huyt tng gim, khng gi c
nc trong lng mch, thot ra khong gian bo, gy ra ph.
Gan x chn p cc nhnh ca tnh mch gnh, gy tng huyt p gnh, lm cho nc thot ra
nhiu hn, ph thm nng dn ti bnh nc (trn dch bng).
Mt s hocmon c tc dng gi nc v Na, bnh thng c phn hy ti gan nh ADH ti
hp thu nc thn, aldosteron (ti hp thu Na thn ng thi ko theo nc) v xtrogen
(gi nc trong khong gian bo). Khi suy gan, cc hocmon ny khng c phn hy, do
tch li trong c th, gp phn gy ra ph v trn dch. Ngi ta thy t s Na/Cl bi tit trong
nc tiu gim. T s Na/K cng gim, tri li K/Cl tng. iu chng t K tng cng o
thi thay th Na, ph cn do hocmon sinh dc khng b phn hy v nu tim pro esteron cho
thy c hin tng gi nc. Na gi li s vo trong t bo hay dng xng v trong mu v
dch gian bo khng thy tng Na. K t bo gim do b o thi ra nc tiu thay Na.
E- RI LON CHC NNG CHNG C
Bng nhng phn ng sinh ha kt hp, gan c kh nng trung ha cht c hnh thnh trong
c th hoc t ngoi vo nh hocmon cc c t vi khun, cc cht t ng tiu ha ti, cc cht
c l sn phm ca qu trnh chuyn ha trong c th.
bnh nhn suy gan, chc nng chng c pht sinh ri lon.
1. i vi hocmon. bnh nhn suy gan, hocmon strogen khng b phn hy, nn thng
thy cc hin tng rng tc, , teo tinh hon, v n, dn mao mch, mt kch thch dc tnh
Aldosteron v ADh, nh trn nu, khng c gan phn hy gy ri lon chuyn ha nc
in gii.
2. i vi cht mu: Bnh thng khi tim cht mu bengal vo mu th chng mt gi sau, tt
c cht mu c gi li o thi theo mt, khng cn lu hnh trong mu na. Vi cht
bromosul fopthalein th sau 45 pht ch cn li trong mu di 10% cht mu. Kh nng c nh
l do h thng vng ni m (t bo kuppffer) m nhim. Khi gan suy, kh nng ny gim nn
s lng cht mu lu hnh trong mu s cn nhiu sau mt thi gian quy nh. l nguyn
tc ca xt nghim thm d chc nng gan bng mu.
3. i vi vi khun. Ngoi kh nng c nh vi khun (nh c nh cht mu), gan cn c kh
nng sinh khng th (nh h thng vng ni m) trung ha c t v chng li vi khun.
bnh nhn x gan, vng da do nhim trng hay nhim c nng, thy khng th trong mu
gim. Song c th cn c mt h vng ni m ngoi gan hot ng b, nn hin tng gim
khng th khng thc s r rt.
4. i vi cc cht c. Gan c kh nng chuyn ha cc cht c thnh cht khng c hay t
c. qu trnh gii c ny l mt qu trnh ha hp. Mt th d in hnh l qu trnh chuyn
amoniac, mt sn phn rt c ca kh amin, thnh ure l mt sn phm t c. Hoc
axitbenzoic c ha hp vi glixin cho axit hippuric khng c, o thi theo nc tiu.
l c s ca xt nghim thm d chc nng gii c ca gan bng axit henzoic: cho bnh nhn
ung 6g Na-benzoat vi 2000ml nc, ri tp trung nc tiu trong 4h sau, bnh thng phi
thu c 3g axit huppuric, nu t hn l gan suy.
5. i vi cc thuc. Bnh nhn suy gan khng ung c nhiu thuc ng, thuc an thn, d b
nhim c ru, mocphin, nicotin l do gan suy mt kh nng trung ha cc cht c
bng cch oxi ha, ha hp.
Ch nn qun l bnh nhn suy gan thng cht trong tnh trng nhim c.
F- RI LON CHC NNG TO MU
Gan l ni tch tr sn xut protein cn thit cho qu trnh to hng cu, l ni tch tr st ln
nht trong c th, gan cn l ni cha vitaminB
2
cht ny, sau khi qua ng tiu ha ti gan,
c tch a dn ti ty xng theo nhu cu ca c th. Gan cn l ni sn xut ra
nhng yu t ng mu: yu t chy mu A, B,C, prothrombin fibrinogen gan cn l ni d
tr vitamin K, cn thit cho qu trnh tng hp prothrombin.
Do , bnh nhn suy gan thng pht sinh:
- Thiu mu: do thiu protein, thiu st, thiu vitamin.
- Chy mu: do thiu cc yu t ng mu.
V. RI LON CHC NNG TO MT
V BI TIT MT
Mt chc nng quan trng na ca gan l to mt v bi tit mt. Ri lon chc nng ny gy
ra chng vng da, ri lon tiu ha v bnh si mt.
A- CHUYN HA SC T MT
Ngun gc chnh ca sc t mt l do thoi bin hemoglobin h vng ni m (ti gan v ngoi
gan). Bilirubin t do hnh thnh vo mu, m thp (0- 0,1 mg/100 ml) do sn sinh c
bao nhiu th kp thi c gan chuyn thnh bilirubin ha hp vi nhau. Bilirubin t do vo
gan c kt hp axit uridin diphotpho - glucuronic (nh men glucuronyl-transferaza) ti to
bilirubin ha hp v axit uridin diphotphat. Bilirubin ha hp c bi tit theo mt vo rut
non, y sc t mt c kh oxy thnh urobilinogen hay mnh hn na thnh
stercobilinogen (bi vi khun ng rut). Ti rut 1 phn urobilinogen ti hp thu vo mu
c gan gi li bin thnh bilirubin ha hp ri bi tit theo mt (tuy nhin mt phn rt
nh urobilinogen khng c gan gi li v c mu vn chuyn ti thn bi tit theo
nc tiu ra ngoi). l chu trnh rut -gan (hnh 4). Khi nhu m gan b tn thng
urobilinogen t rut ti khng c gan gi li ti tng hp bilirubin ha hp, do
urobilinogen s xut hin trong nc tiu. Ti rut, urobilinogen v stecobilinogen b tip tc
oxy ha to ra mui mt (hnh 5).
Bilirubin t do khng tan trong nc (do khng bi tit ra ngoi theo nc tiu), ch tan
trong dunh mi hu c (do d bilirubin t do c i tnh vi nhng t chc m, c th l vi t
chc no). Dim ny gii thch ti sao vng da do bilirubin t do hay gy nhim c no.
Bilirubin ha hp, tri li, khng c. Do qu trnh chuyn bilirubin t do thnh bilirubin ha
hp c th coi nh mt qu trnh gii c.
B- VNG DA
Vng da pht sinh khi cc sc t mt trong mu cao hn bnh thng v ngm vo t chc b
(da, nim mc) Khi bilirubin huyt thanh tng ti 2-3 mg%, thng xut hin vng mt.
C nhiu cch xp loi vng da khc nhau, thch hp hn c l xp loi theo bnh sinh: (hnh 6)
- Vng da do nguyn nhn trc gan (hay vng da tan mu).
- Vng da do tn thng ti gan (hay vng da nh m).
- Vng da do tc mt (hay vng da c hc).
1. Vng da tan mu.
Trong loi ny gan khng b tn thng. Vng do y do tng cng tan mu nn hemoglobin
c gii phng nhiu dn ti tng bilubin (hnh 7 v hnh 8).
Nguyn nhn gy tan mu c th l: k sinh trng st rt, nhim lin cu khun tan mu, xon
khun, nhim c (sulfamit phenylhydrazin), truyn mu nhm loi
c im ca loi vng da ny l bilirubin t do tng cao trong mu, nhng khng tan trong
nc nn khng o thi theo nc tiu. Do c nhiu bilirubin t do nn gan tng tng hp
bilirubin ha hp, stecobili v urobilin lm cho phn thm mu.
V mt lm sng, loi vng da ny khng c nga, khng c tim p chm v nht l khng c
nc tiu mu vng sm. S d c biu hin nh vy l do khng tch ly mui mt trong c th.
Tuy nhin khi m bilirubin t do qu cao trong mu thng gy pht sinh nhim c h
thn kinh trung ng (c ch trnh by trn).
2. Vng da do tn thng gan:
C th chia lm 2 loi:
a) Vng da bm sinh do thiu men: Rt t gp, ch yu do cu to gan khng hon chnh, cho
nn thiu men glucuronyl transferaza khng bin bilirubin t do thnh bilirubin ha hp. Do
c im ca loi vng da ny l bilirubin t do trong mu tng cao, nc tiu bnh thng
(khng c bilirubin d c vng da), phn c t stecobilin. Khi bilirubin t do qu cao trong mu,
thng pht sinh nhim c cc nhn thn kinh. Loi vng da ny gp trong bnh vng da di
truyn Gin- be (Gilbert) (hnh 9) v bnh vng da sinh l tr s sinh (tr em mi 1-2
ngy thy xut hin vng da, c th ko di 5-6 ngy).
b) Vng da do tn thng nhu m gan: Bnh sinh ca loi ny kh phc tp. Ch yu l do tn
thng nhu m gan gy thiu th pht nhng men cn thit i vi qu trnh chuyn bilirubin
t do thnh bilirubin ha hp. Do bilirubin t do tng cao trong mu, stecobilin trong phn
gim (phn nht mu) v urobili nc tiu tng. Trong loi vng da ny, thng pht sinh nhiu
ri lon chuyn ha v chc nng, nu nng c th dn ti suy gan. Ngoi ra c th km theo
vim nhng ng dn mt nh gy tc mt lm cho bilirubin ha hp tng trong mu ng thi
stecobilin trong phn cng gim. Trong vim gan, mng t bo nhu m gan tng tnh thm cng
lm cho bilirubin ha hp d thm vo mu.
Nguyn nhn gy vng da nhu m c th l:
- Nhim khun: c bit l virut vim gan, sau ti nhim khun mu, giang mai
- Nhim c: photpho, beczlo
c) Vng da do tc mt: Loi ny c nhng triu chng c hiu nht. Do tc ng dn mt, mt
khng vo rut c nn thm vo mu v trong mu thy cc thnh phn ca mt:
bilirubin ha hp, cholesterol axit mt.
V lm sng, loi ny rt vng, ngy cng vng km theo cc triu chng nhim c mui mt
(nga, tim p chm), nc tiu vng thm v tng bilirubin ha hp, phn trng bch (phn
c). Trong dch t trng thy t hoc khng c mt. Ty theo thiu mt A, B hay C m c th
phng on tc mt ch no ca ng dn mt.
Nu mt ng lu ngy, nhu m gan c th b tn thng dn dn ti suy gan, by gi trong
mu bilirubin ha hp s gim, tng bilirubin t do l ch yu.
Nguyn nhn gy vng da do tc mt c th l:
- C hc: si. giun chui ng mt, u u ty
- Vim, so, dy chng
- Co c tht Oddi.
C- BNH SI MT
Bnh rt ph bin chu u v nc ta, thng gp n gii nhiu hn (45- 50 tui).
Si mt l do mt b c c li thnh cc: lc u mt c nh bn, ri thnh nhng ht nh
trc khi thnh si. Nhng thnh phn ca mt (cholesterol, sc t mt, mui mt, canxi) u
c th tr thnh si. Si cholesterol rt ph bin. Hay gp hn c l si hn hp. ng ch { l
gia si mt, c khi thy trng giun a, trong ng mt c khi thy xc giun, rt c th giun
lm cho si d pht sinh.
S lng si mt c th t hoc nhiu: mt hai si to hoc hng trm si nh.
Trn tt c h thng dn mt, ch no cng c th c si c: trong gan (si ha ti ch),
ti mt (si ha ti ch), ng ti mt hay ng ba ng ti mt, ng gan v ng mt ch (si r
ti mt xung, tc y), ng mt ch.
Bnh sinh hc si mt rt phc tp, trong ni bt ln vai tr ca ri lon chuyn ha, mt
v nhim trng.
1. Vai tr ca ri lon chuyn ha (thuyt th dch). Thuyt ny c nhiu ngi cng nhn,
si pht sinh do s thay i thnh phn ca mt. Bnh thng c mt t l nht nh gia 3
thnh phn ca mt: cholesterol, sc t mt, mui mt, v ngi ta cho rng mui mt c tc
dng gi cho mt long. Khi t l thay i, hoc cholesterol, sc t mt tng nhiu hoc
mui mt gim, mt s c li thnh si.
a) Theo nhiu ti liu, ri lon chuyn ha cholesterol l thnh phn ch yu ca cc loi si
mt. bnh nhn si mt, thng thy cholesterol mu tng, ng thi m cholesterol
trong mt cng tng. Bnh si mt thng kt hp vi bnh x cng ng mch, bo ph, thn
h nhim mtrong thng thy cholesterol mu tng.
b) Tuy nhin , nhiu ti liu cho bit l cholesterol tng trong mu v trong mt cha
gy ra si mt. Tht vy, trong nhiu trng hp si mt, cholesterol mt khng nht thit tng
song song. Ngoi ra cholesterol mt khng lng ng ngay c khi m rt cao. l do axit
mt c tc dng ha tan cholesterol. Ch khi m axit mt gim, mi thy cholesterol lng
n. H s axit mt/cholesterol ngi bnh thng bng 25 v ngi b si mt l 2,5. Da
vo ti liu thc nghim v lm sng, mt s tc gi i ti kt lun l si cholesterol pht
sinh do thnh ti mt b tn thng hp thu mui mt dn ti gim h s axit mt,
cholesterol. Khc vi ngi ng vt c sng, ch v th, thy h s ny rt cao (100), rt
him gp cholesterol lng ng ng vt ny, ngoi ra cn thy si cholesterol ca ngi ha
tan d dng trong ti mt ca ch.
c) Trong vng da tan mu, hemoglobin gii phng ra nhiu sc t mt, nn bin chng c in
vng da tan mu l si mt.
2. Vai tr ca mt. Mt b dn dn c li (do nc b hp thu nhiu), c li nh bn ri
thnh si. Song trong thc nghim, c th gy mt song khng gy c si. Trn lm sng, u
c u ty gy mt song khng thy sinh si.
3. Vai tr ca nhim trng: Nhiu s kin nu bt vai tr ca nhim trng trong bnh sinh si
mt: si mt pht sinh sau khi b thng hn (tng i hay gp), sau nhim khun v tn
thng nim mc ti mt, ch yu do axit mt hp thu mnh dn ti gim h s axit
mt/cholesterol. Gy vim v trng thnh ti mt cng thy axit mt tng ti hp thu.
Qua phn tch trn y thy bnh sinh si mt kh phac tp: mt khng gy si mt,
phi c thm vim ti mt hay ng dn mt. Sonh trn thc t, vim h thng dn mt li l
hu qu ca si mt: c vi khun khng lan ln ng mt chng no mt cn chy xung v vi
khun cng c th t mu ti t bo gan, theo mt ti ti mt).
Si mt c th nm yn ti ch khng gy ra triu chng g c trong mt thi gian kh di, c
khi sut i, ti khi m xc mi khm ph ra.
Thng thng si khng nm yn, m di ng vo ng mt, gy ra nhng cn au d di (au
qun gan) gy vim ti mt, tc ng dn mt, vng da c gii, ngoi ra cn gy ri lon tiu
ha v ri lon chc nng c th dn ti suy gan.
IV. SUY GAN
Suy gan l tnh trng bnh l{ trong gan khng lm trn chc phn m bnh thng n m
nhim trong cp th. Do gan m nhim rt nhiu chc nng nn hki suy gan, ngoi nhng ri
lon ca bn thn cn nh hng su sc n hot ng ca ton b c th.
Suy gan c th l cp din hoc trng din. Tt c cc trng hp nhim c, nhim khun
nng, c tnh cht cp din, u c th dn ti suy gan cp din. Cn suy gan trng din l hu
qu ca nhng bnh gan ko di, trong nhu m gan b tn thng kh rng, nh hng r
rt ti cc chc nng ca gan. Khi nhu m gan b tn thng ti 50- 70% th do kh nng b p
ca phn cn li nn gan suy khng hon ton. By gi hu ht cc chc nng ca c th t
nhiu u b nh hng, c bit l chc nng ng mu, chc nng chuyn ha nc in
gii, chc nng thn kinh v chc nng tit mt.
Hn m gan do suy gan bt u t tnh trng lon thn kinh nh chn tay run ry, phn x tng,
tr khn gim, m mng, ni lp bp, co git v cui cng l m hn.
C ch hn m gan ch yu do cc ri lon chuyn ha gy ra.
1. Ni bt ln hng u l nhim c amoniac m m trong mu tng rt cao. Tuy nhin,
cng c nhiu trng hp c ri lon thn kinh m khng co tng NH
3
mu hoc khng c s
song hnh gia m NH
3
trong mu vi mc ri lon tm thn, cho nn c kin cho
rng NH
3
cha hn l nguyn nhn gy hn m gan chnh.
2. Cc sn phm c t ng tiu ha trn vo trong khi gan suy mt kh nng gii c, phn
ln cc sn phm c ny do qu trnh kh cacboxyl ca cc axit amin nh cadaverin, putresin,
ptomain
3. Glucoza mu gim do gan mt kh nng tng hp glycogen v ieu ha ng mu.
4. Ph t chc, c bit l ph no, do ri lon chuyn ha nc in gii
5. Ngoi ra, cn phi k ti yu t tng cc cht dn truyn thn kinh gi. Trong hn m gan, c
tc gi (Docsworth, 1974) nhn thy c gim dopamin v noradrenalin trong t chc no v c
tng cc dn xut bt thng ca cc cht dn truyn thn kinh. C tc gi (Fischer) cho rng
trong rut bnh nh b suy gan tch li rt nhiu cc cht dn truyn thn kinh gi. l
nhng dn xut ca chuyn ho phenylalanin v tyrosin, gi chung l phenylethylamin nh
actopamin phenylethanolamin. Bnh thng chng b gan o thi, song khi suy gan, chng s
vo mu ri tch li cc t chc thn kinh ri b hydroxy ha bi mt men khng c hiu
thay th cc cht dn truyn thn kinh tht.
Phenylalanin Tyrosin DOPA


Phenylethylamin Tyramin Dopamin


Phenylethanolamin octopamin Adrrenalin


Noradrenalin

Nu cc cht dn truyn thn kinh gi ny tch t ti t chc no, thy pht sinh hi chng tm
thn nh mt thc, run tay ly by (c l do dopamin b thay th bi octopamin ging nh
ngi b hi chng parkinson); nu tch ly t chc thn kinh ngoi vi th cc cht dn truyn
thn kinh gi ny s thay th adrrenalin, gy gim trng lc ng mch nh, m cc mch tt
ngoi vi bt mu cho ni tng, to nn hi chng suy thn bnh nhn suy gan.
Gi thuyt tng cc cht dn truyn thn kinh gi khng nhng gii thch c nhng triu
chng va k trn m cn p dng tt trong iu tr. mt s bnh nhn c iu tr bng
truyn L.Do- pa hay metaraminol thy c kt qu tt.
b) Hn m gan l tnh trng cui cng, trong cc c quan u b ri lan nghim trng. Ngoi
nhng yu t k trn, th cn rt nhiu yu t ph khc lm cho trng thi hn m d pht sinh.

50. SINH L BNH QU TRNH VIM

HONG DUNG

Vim l mt phn ng phc tp ca c th i vi nguyn nhn gy bnh, mt mt ni ln tc
dng ph hoi, gy tn thng ca nhn t bnh l, nhng mt khc cng ni ln sc khng
chng ca c th nhm tiu dit nguyn nhn gy bnh, hn ch tn thng, phc hi cc
chc nng c th b ri lon.
Phn ng vim l mt trong nhng phn ng hnh thnh sm nht trong qu trnh tin ho ca
ng vt. cc ng vt cp thp nh ng vt n bo, hin tng thc bo v m bo l
bin php phng ng c bn nhm tiu dit nhng yu t l xm nhp c th ng thi cng l
bin php duy tr s sng. cc ng vt cao cp v ngi th thc bo khng phi l phng
tin c nht m cn nhiu bin php nh cc phn ng huyt qun, sn sinh khng th, tng
sinh cc t bo t chc lin ktlin h cht ch vi nhau hnh thnh mt chc nng bo v c
th v cng phong ph. H thn kinh ng vai tr quan trng y mnh cc hot ng thch
ng phng ng sinh l ca c th cho nn cc ng vt bit ho cng cao, h thn kinh cng
pht trin th phn ng vim cng phc tp.
Biu hin bn ngoi ca vim da v nim mc ngi c m t t thi c i bao gm 5 du
hiu: sng (tumor), nng (calor), (rubor), au (dolor) v tn thng chc phn
(funetioloasa) tuy nhin trong vim cc ni tng thng khng thy y cc du hiu trn.
NGUYN NHN GY VIM
Nguyn nhn gy vim rt nhiu v phc tp, c th chia lm 2 loi:
1.Nguyn nhn bn ngoi : do cc yu t.
C hc: vt thng, tai nn gy gip nt t chc, gy xng
L hc: nng hoc lnh qu, tia quang tuyn, tia x
Ho hc: cc cht axit hoc kim mnh, cc cht c, ho cht c gy hu hoi t bo t chc.
Sinh vt: cc vi khun, virut, v nm gy bnh
Thn kinh, tm l{
2. Nguyn nhn bn trong:
Do hoi t t chc, lp qun, nhi mu, chy mu trong lan rng
Trong thc t hai loi nguyn nhn ny thng kt hp vi nhau. Cng , tnh cht ca vim
cng thay i tuz theo c im ca nhn t bnh l{, iu kin pht sinh, v tnh phn ng ca
c th do biu hin lm sng ca cc trng hp vim c th thay i khc nhau.
I. NHNG RI LON CH YU CA VIM
Nhng ri lon ch yu ca vim bao gnm 3 loi hin tng ng thi tn ti v lin quan
cht ch vi nhau:
Tn thng t chc v ri lon chuyn ho.
Ri lon tun hon v vi tun hon.
Tng sinh cc t bai t chc lin kt.
A-TN THNG T CHC V RI LON CHUYN HO TI VIM
Tn thng c th xy ra ngay lc nhn t bnh l{ tc ng trn t chc (tn thng nguyn
pht), ng thi c th pht sinh mun hn do nhng ri lon tun hon ti vim v cc yu
t khc gy ra (tn thng th pht). C ch c th do yu t bnh l tc dng ln cc th cm
thn kinh ti ch gy trng thi cn sinh to iu kin thun li cho cc bin i lon dng v
hoi t. Tn thng nh hng trc nht ti siu cu trc t bo, ti cc ti lp th
(mitochondrie) v lizosom.
Tn thng cc ti lp th, i din ch yu ca cc men oxy ho- kh ca t chc do qu
trnh oxy ho v kh nng hp th oxy ca t chc gim, h s h hp cng nh hiu th oxy
ho kh trong t chc vim gim v hot tnh cc men chuyn ho b ri lon. Hu qu l
chuyn ho vt kh (gluxit, lipit, protit) b ri lon, khng tn cng bng bi tit CO
2
v H
2
O m
dng li cc sn phm trung gian v to thnh mt s lng ln cc axit hu c nh axit
lactit, axit pyruvic, axit anpha xtoglutaric, axit malic, axit bo, polypeptitChuyn ho gluxit
tng mnh theo mt s tc gi cn do tng phn hu cc polysaccarit do men amylaza vim
b kch hot, v chuyn ho thiu Oxy nn tch lu nhiu axit lactic. Trong vim qu trnh d
ho protit cng tng r rt do tng cc men tiu protit c phng thch t cc t bo v vi
khun cht. Tn thng t chc v ri lon chuyn ho cng din bin mnh do tnh trng
thiu oxy, hu qu ca ri lon tun hon ti vim.
Tn thng cc lizocom, tiu vt ca nguyn sinh cht t bo gy gii phng cc men thu phn
(hydrolaza) ca lizocom, cc men cathepsin, men tiu gluxit, lipit, protitCc lizocom ca cc
bch cu trung tnh, cc i thc bo, cc t bo nhu m ca t chc vim u c th b tn
thng, v hu qu ca n gi mt vai tr quan trng trong bnh sinh ca vim.
Tn thng t chc, tn thng cc ti lp th v lizocom ca t bo dn ti cc hu qu sau
y:
1.Nhim toan:
Do ri lon chuyn ho vt cht, cc sn phm toan tch lu ti vim tng lm tng nng
ion, ch yu l ion H
+
v gy nhim toan.
Mc ca nhim toan ph tuc vo tnh cht v cng ca vim. trung tm vim,
nhim toan biu hin r nht, nng ion H
+
c th cao hn bnh thng ti 50 ln, cng xa
trung tm vim nhim toan cng gim (hnh 1).
Vim cng nng, nhim toan cng nghim trng. Trong vim cp din, c khi pH gim ti 6,5
5,5 ; trong vim trng din thng nhim toan nh hn 7,1 6,6. Tnh trng nhim tuz theo
mc c th gy ri lon tun hon, gy dn mch, hn ch hin tng tng sinh cc t bo
t chc lin kt
2.Bin i p lc thm thu v p lc keo tai vim:
ng thi vi tng nng ion H
+
, nng cc ion khc nh K
+
, Na
+
, Cl
-
, PO
4
-
cng tng, c
bit ion K
+
tng cao nht trunh tm vim, c th ti 100 200 mg%. Nng phn t cng
tng do vim tp trung nhiu sn phm trung gian ca chuyn ho v do qu trnh d ho potit
tng cng, phn hu cc phn t ln thnh nhiu phn t nh, mt khc do thnh mch b tn
thng tng tnh thm nn cc protein huyt tng thot vo trong vim. Tt c nhng yu
t ny lm tng p lc thm thu v p lc keo trong vim, cng mnh v r nht trung tm
v gim dn ngoi vim, cng mnh v r nht vng trung tm v gim dn ngoi vi
vim (hnh 2). Tng p lc thm thu v p lc keo lm cho t chc vim c tnh cht gi nc,
v cng vi cc yu t khc to iu kin thun li cho s pht sinh ph vim.
3.To thnh v gii phng cc sn phm c hot tnh sinh vt trong vim: Mt trong nhng
phn ng c nghin cu nhiu trong nhng nm gn y l s to thnh v gii phng cc
sn phm c hot tnh sinh vt, cc mediator ni sinh ca vim trong cc t chc bi tn thng
nh histamin, serotonin, cc polypeptit h kinin, cc axit nhn v dn xut AMP, ATP
B-RI LON TUN HON V VI TUN HON TRONG VIM
Song song vi tn thng topr chc v ri lon chuyn ho ti vim cng thy c ri lon
tun hon bao gm c hin tng.
Ri lon vn mch.
Thot dch di vim.
Thot bch cu v thc bo.
Cc hin tng ny c th quan st qua knh hin vi trn cc t chc trong sut ca ng vt
mu lnh (li, mc treo rut ch, bng quang, mng chn ch). Tn thng vim gy bng
cch t vo mt ht nh tinh th mui n hoc nitrat bcDi knh hin vi, c th quan
st phng i cc hin tng dn tiu ng mch v mao mch chuyn vn lc l ca mu v
hin tng dn, mu tnh mch. Qua knh phng i ln hn, c th thy bch cu dnh vo
thnh mch, thot mch vo t chc vim.
1.Ri lon vn mch:
Pht sinh vi hnh thi 4 giai on lin tip : co chp nhong cc tiu ng mch, xung huyt
ng mch ch ng do cc tiu tnh mch v mu, tc mch.
Co chp nhong cc tiu ng mch pht sinh do cc yu t gy
vim kch thch thn kinh co mch v cc t bo c trn tiu ng mch tai vim. Hin tng
ny rt ngn, kh quan st v tc dng kch thch nguyn pht qua rt nhanh, v cc trung gian
ho hc ca phn b thn kinh giao cm, noradrenalin b hu bi monoaminooxydaza lc
tng cao trong t chc vim.
dn cc tiu ng mch v mao mch, hay xung huyt ng mch, ch ng pht sinh theo c
ch thn kinh th dch. Thn kinh dn mch b kch thch theo phn x si trc (hnh 3), ng
thi chu nh hnh ca cc sn phm c hot tnh sinh vt trong vim nh histamin,
serotorin, bradikininTng nng ion H
+
v nhim toan cng c tc dng gy dn mch. c
bit tng nng ion K
+
trong vim ti 0,5 2% cng c gi tr tng t. Tnh cht ch ng
c th hn bng tng p lc mu v tng tc mu chy, a nhiu oxy, bch c v cc
cht dinh dng ti vim, c tc dng thch ng phng ng (hnh 4).
Dn cc tiu tnh mch v mao mch tnh mch, hay xung huyt tnh mch th ng tip theo
tc dng mnh hn ca cc nhn t gy vim. C ch ch yu do tc dng mnh hn ca cc
nhn t gy vim. C th ch yu do tc dng ca cc sn phm c hot tnh sinh vt c to
thnh mt s lng ln, b li trong t chc vim gy hu hoi cc si t chc lim kt (s
chun dn, si ko ca thnh tnh mch lm cho chng dn ra, v dng mu chy chm li. S
pht sinh v pht trin ca hin tng ny cn ph thuc vo nhiu yu t chi phi:
Thn kinh c ca huyt qun b t lit lm cho thnh huyt qun mt trng lc.
nht ca mu tng do nc thm qua thnh mao mch mi lc mt nhiu.
Bc cu dt vo thnh huyt qun lm cho mu chy chm li ng thi cc huyt cu v t bo
ni m trng ln lm cho mu vn chuyn kh khn.
Nc trn vo t chc khe k gy ph, chn p vo thnh mch cc tiu tnh mch cng l tr
ngi c gii i vi dng mu.
Tng tnh ng mu trong t chc vim do hu qu ca tn thng thnh mch gy ngng t
tiu cu v giI phng cc yu t ng mu (tromboplastin, v cc yu t khc). Tng tnh ng
mu cn gy tr ngi lu thng bch mch do tc bi nhng cc nh fibrin b hu hoi.
mu v tc mch: cc mch mu dn lm dng mu chy chm dn ri li. Trc khi ngng
tun hon, cc mch mu ti vim thng pht sinh bin i hng chy qua dng mu
mt cch c o, u n vi nhp co bp ca tim. l nhng chuyn ng lc l ca mu:
trong thi kz tm thu mu chuyn vn theo hng ca dng mu li chuyn ngc t tnh
mch sang ng mch. C ch l do trong thi kz tm thu ln sng mch chy qua cc mao
mch b dn li to thnh mch mao mch, nhng sau p lc mu gim st nhanh ng thi
gp tr ngi t dng mu tnh mch nn mu b dn ngc li. Sau mt thi gian ngn, mu
li v gy tc mch, nh hng su sc ti qu trnh chuyn ho v dinh dng ti t chc
vim.
2.Thot dch di vim (hnh 5):
Dch di vim l cc thnh phn dch th v hu hnh ca mu thot khi mao mch trn vo t
chc vim. T chc vim b tng khi lng do thot dch di, gi l ph vim.
Dch di c nhiu loi: Dch di huyt thanh mu vng nht trong sut, gn ging nh dich thm,
tuy nhin dch di khc vi dch thm ch t trng dch di cao hn (1,018 v hn), nng cht
m cng nhiu hn (3g% v hn, s lng chung cc t bo cao hn (3000 t bo/mm
3
) v pH
thng xuyn v pha toan 6 7 (dch thm, pH 7,4 7,6). Dch t huyt (fibrin) l do thoI h
fibrinogen v chuyn thnh dng fibrin ngay ti vim, c th gp trong ph nang khi b bnh
vim phi tit t huyt, hoc gp trong rut non khi b bnh l. Dch r mu c to trong cc
qu trnh vim cp nghim trng trong cc mn m u ma, trong cc hin tng vim d ng.
Dch di m mu vng c, c nhiu bch cu b thoI ho to thnh cc tiu th m, thng gp
trong cc mn m u ma, trong cc hin tng vim d ng. Dch di m m mu vng c, c
nhiu bch cu b thoI ho to thnh cc tiu th m, thng gp trong cc trng hp vim
nhim khun.
Thot dch di l mt phn ng phc tp, chu nh hng ca nhiu yu t:
p lc mu trong cc mao mch khu vc tnh machj khu vc tnh mch ca t chc vim tng
to Iu kin cho cht dch thot khi mao mch vo t chc vim nhiu gp bi bnh thng.
Tnh thm ca mao mch tng, c coi l yu t quan trng nht. Qua knh hin vi In t
thy rng s thm nc v cc cht m ho tan trong huyt tng bnh thng c tin
hnh qua nhng khe h gia cc t bo ni mac huyt qun, kch thc ch 25
o
A
. Tng cng
p lc thu tnh ca mu trong cc mao mch tiu tnh mch ca t chc vim gy nn dn cc
khe h ti 80 100
0
A
, to iu kin cho nc v cc protit huyt tng thot ra ngoI d
dng gy ph vim.
Tng cng p lc kep v p lc thm thu trong t chc vim cng to iu kin gi cht dch
trong t chc vim.
Trong c ch ca t chc vim, tng tnh thm qua mao mch do nh hng ca cc sn phm
c hot tnh sinh vt nh histamin, serotomin v cc polypeptit h kinin gi mt vai tr quan
trng. Theo cc tI liu hin nay, tc dng ca cc mdiat tnh thm ch c thc hin vi
s tham gia ca cc hp cht ln cao nng ch yu l ATP do s c ch tng hp ATP bng
Cyanid trn p gn nh hon ton cc phn ng huyt qun gy nn do histamin, serotomin,
bradikinin. Trn c s cc tc gi coi ph vim nh mt phn ng tch cc ca c th c lin
quan ti s s dng nng lng. Trong thc nghim, xc nh tnh trng tng tnh thm mao
mch, ngi ta thng dn cht mu xanh Trypan: cht xanh Trypan c c tnh gn vi cc
protein huyt tng, nu em tim vo tnh mch th sau khi gy vim lng bng cch p
nc nng th s thy vng b vim thm mu xanh do cc protein c gn xanh Trypan thot
ra ngoI t chc vim.
Gi thuyt c in cho rng thnh phn m ca dch r ni ln mc tn thng ca thnh
mch c nhiu kin khng thng nht. Trong dch di fibrin, nng fibrinogen rt cao,
trong khi anbumin, glubulin li mc rt thp mc d ta bit phn t fibrinogen ln hn
cc phn t anbumin r rt v nu coi thnh ni mc nh mt cI lc n gin th khi
fibrinogen qua c tt nhin cc cht m phn t kch thc nh hn cng qua c d
dng. Nh vy trong c ch thot cc thnh phn m qua dch di cn phI k n qu trnh
siu hp th cc cht m ca bch mch, s hp th nhiu anbumin qua cc bch mch c th
to Iu kin lm tng cng nng globulin hoc fibrinogen trong dch di v trong cc giai
on mun va vim nng, cc bch mch thng b phong b bi cc ta, cc cht lng ng
ca fibrin, globulin, cc kt vn t bo Lympho.
Ph vim mc nht nh c { ngha thch ng bo v: cc cht m trong dch ph kt hp
vi cc sn phm c trong vim, trung ho cht c ca t chc thoI bin, bch cu lm
nhim v thc bo, fibrinogen to thnh mt hng ro ngn chn khng cho vi khun v c t
lan rngTuy nhin nu dch di qu nhiu c th chn p c t chc xung quanh, hn ch hot
ng c quan (trn dch mng phi, mng tim) gy nhiu hu qu tai hi.
3.Thot bch cu v hin tng thc bo:
ng thi vi hin tng thot di dch, bch cu dt vo thnh mch ri vn ng theo kiu
amp lch qua thnh mch tin ti vim lm nhim v thc bo. Thot bch cu vo t chc
cha vim bt u giai on xung huyt ng mch, t ti mc ti a trong giai on xung
huyt tnh mch v mu. Thot bch cu c th chia l 3 giai on: (Hnh 6)
Bch cu dt v b vim mt trong ni mc cc mao mch t chc vim. Trong Iu kin bnh
thng, b mt ni m che phur mt mng mng ximng fibrin st vi lp khng di ng
ca huyt tng nn cc bch cu khng tip xc vi mng ny. Khi tn thng mao mch, cc
bch cu trung tnh theo dng mu chy chm li, dt vo b, tip xc vi mng ximng
fibrin, vt qua lp huyt tng tin n khe h gia cc t bo ni mc huyt qun.
Thot bch cu qua khe h bng hot ng amp, xuyn qua mng ngoI ra khi t chc vim.
Hai hot ng trn tin hnh trong thi gian t vI pht n na gi.
Vn ng ca cc bch cu trong vim ko dI trong nhiu gi, c th ti 24 gi, c giI
thch theo c ch hp dn ho hc (chimiotaxis), tc l cc bch cu b thu ht vn ng ti
vim b hp dn bi cc cht ho hc, thnh phn ca nhng cht c hnh thnh trong
vim. Theo Metnhicp, hp dn ho hc l s hng phn ca nguyn sinh cht t bo bi mt
cht c trong vim, hng phn lan rng ra khp t bo gy phn ng vn ng, hng t bo
ti nI c nhiu cht .
Vi sinh vt, c bit l lin cu v t cu khun c tc dng hp th ho hc dng tnh mnh
nht, tc dng ny l do nhnh sn vt phn giI, c t ca sinh vt. Cc sn phm ca ri lon
chuyn ho v phn giI t chc nh histamin, polypeptit, axit nhn v dn xut u c tc
dng hp dn ho hc dng tnh. Ngc li, mt s cht c tc dng hp dn ho hc m
tnh nh quinin, chloroforme, benzolgy c ch phn ng vn ng ca bch cu cho nn
dng cc cht vi nng cao c th gy hu qu xu: tim hp qunin c th gy p-xe do
thuc khng tan t ti t chc vim.
Hin tng thot bch cu n nhn khc hn vi thot bch cu trung tnh. Qua knh hin vi
in t thy bch cu n nhn p vo thnh cc cc t bo ni mc, xung quanh cc bch cu
n nhn to thnh nhng khng bo to, t chng I qua nguyn sinh cht ca ni mc,
lm t mng nn v thot qua vo t chc vim. Qu trnh ny chm hn thot bch cu
trung tnh qua cc khe h gia cc t bo ni mc nn bch cu n nhn xut hin trong
vim chm hn.
Cc bch cu ti vim lm nhin v thc bo, gm cc bch cu trung tnh v cc bch cu
n nhn to (monpcyte). Bch cu trung tnh cn c gi l tiu thc bo i vi cc di vt
n nh vi khun cn i thc bo l cc bch cu n nhn to, v c cc t bo t chc lin
kt c nh trong Iu kin cn thit c th tr thnh lu ng, lm nhim v n nhng vt
ln, cc mnh t bo t chc b hu hoi.
Trong vim s lng cc bch cu v hot tnh thc bo ca bch cu u tng cao c tnh cht
thch ng phng ng, Hot ng thc bo ca bch cu cn chu nh hng ca nhiu yu t:
1.nh hng ca mI trng:
Nhit thch hp nht i vi vn ng v kh nng thc bo ca bch cu l 36 38
o
C
(Khlnov E.V., 1956).
Protit huyt tng, cc globulin v fibrinogen c tc dng kch thch thc bo mnh cho nn
gim protit huyt tng nh hng r rt ti kh nng thc bo ca bch cu. Chun b t
(opsonin) trong huyt thanh tI cng c tc dng kch thch thc bo.
pH ca mi trng trung tnh to Iu kin thun li cho hin tng thc bo ngc li nhim
toan thc bo b hn ch. Bch cu trung tnh trong vim m cp din vi pH 6,6 b cht co
chu ng km cn bch cu n nhn chu ng kh hn v tip tc hot ng c mI
trng: pH 5,5. Mi trng nhc hoc u trng mnh, hot ng thc bo ca bch cu
cng b hn ch, v c th b nh ch.
2.nh hnh ca thn kinh ni tit:
Xc cm dng tinh, dng cafin c tc dng lm tng cng kh nng thc bo ca bch cu,
ngc li xc cm m tnh v dng cc thuc c ch thn kinh, thuc ng (urethan, barbamil)
kh nng thc bo ca bch cu b gim r rt.
Kch thch thn kinh giao cm lm tng kh nng thc bo v kch thch thn kinh ph giao cm,
lm tng kh nng thc bo ca bch cu.
Hormn cc tuyn sinh dc, tuyn c, c bit thuyn gip cng c tc dng kch thch thc
bo. Trong thc nghim n ct b nhng tuyn ny hot ng thc bo gim r rt.
C TNG SINH CC T BO T CHC LIN KT
Hin tng t bo tng sinh din bin ng thi vi tn thng t chc v ri lon tun hon,
do tc dng kch thch ca mt s sn phm phn giI t chc v phn giI chuyn ho b ri
lon, ngoi ra bch cu cht vim cng giI phng cc cht c tc dng kch thch t bo
tng sinh.
Giai on u, hin tng tng sinh ch yu thy cc t bo ni m v lp ngoI ca huyt
qun, cc bch cu pht trin chng kp thi vi nguyn nhn gy vim. Mt khc trung
tm vim phn ng toan mch, tnh trng thiu oxy nghim trng nn hin tng tng sinh
khng th tin hnh c.
Hin tng t bo tng sinh cn ph thuc vo loi vim v t chc t bo b hu hoi nhiu
hay t. in hnh nht l vim m, khi m v, m thot ra li mt hc thiu t chc, hc
ny s dn dy ln do tng sinh cc t bo lin kt ti ch, cc histiocyte ri t bo x non
fibroblaste. Cc i thc bo thu tnh, tiu ho, lm sch cc sn phm thoI bin trong t
chc vim cn st li bng con ng tiu ho bn trong t bo. ng thi cc t bo x non
pht trin mnh t ngoi vi tin n vo trung tm vim thay th cc t chc hoi t ng
thi to mt hng ro c tc dng bo v ngn cn khng cho c t v cht c lan rng.
Nu cc t bo t chc vim b hu hoi khng nhiu lm v c kh nng tI sinh tt th tn
thng c th lnh, t chc hon ton hi phc v mt cu to v chc phn. Thnh so
thng khng gy nh hng g, nhng vi nhng tn thng rng v su c th dn ti
nhng bin chng so co tht, li, dnh lm bin dng cu trc bnh thng v ri lon chc
phn c quan, nh so dnh sau khi b vim bng, so co thn kinh, gn khp. i vi cc
tn thng qu rng v su, hoc vi cc t bo nhu m cc c quan t chc bit ho cao (tim,
no), cc t chc b hu hoi c th khng hi phc c gy nhiu hu qu nghim trng cho
i sng.
Cc ri lon ch yu trong vim thng khng din bin ring bit m pht sinh ng thi v c
lin quan cht ch vi nhau to thnh mt chui phn ng phc tp (hnh 7).
III BNH SINH CA VIM
Nhng biu hin ch yu v in hnh ca vim, c bit l vim cp l tn thng t chc, ri
lon chuyn ho, ri lon vi tun hon gy hin tng bch cu dt vo b huyt qun, tng
tnh thm cc tiu tnh mch v mao mch dn ti thot dch di, ph vim v thot bch cu.
Bt kz mt kch thch gy vim no cng lm xut hin tt c chui phn ng . t lu cc
tc gi xc nhn c mt mi lin quan cht ch gia cc biu hin c bn ca vim v cho rng,
theo nguyn tc tn thng t chc, bin i dng mu chy dn ti tng tnh thm huyt
qun v sau ti thot bch cu. Nhiu cng trnh nghin cu chng minh rng ph n t
chc v tng tnh thm huyt qun l biu hin sm nht, in hnh nht ca vim cp. Cc
nghin cu sinh ho hc v vim chng minh tht l v cn c trong quan nim coi ph vim
nh l hiu qu ca tn thng t chc v bin i l ho trong t chc vim. Khi gy vim trn
da ng vt, thy xut hin ph mc d cha thy c hin tng bin i chuyn ho nhim,
toan v tng p lc keo thm thu t chc vim, nh vy nhng bin i l ho pht sinh
mun hn s xut hin ph, l hu qu nhanh nht nhng khng phi l nguyn nhn ca ph
(Oivin IA v CS, 1954 1961, Ehrinch WD., 1956 ). Tng tnh thm huyt qun cng khng phi
l hu qu ch ca mu, tng p lc thu tnh trong cc mao mch b dn v bin i thnh
huyt qun sau trong t chc vim gy nn bi tc dng trc tip ca tn thng ( Miles
A.A,Witheim DL , 1960 ; Cotran RS 1965 ). Trong cc th nghim gy vim tai th bng sc
nhit( bng nng ) hoc bng ho cht (Xylol) thy mu c vai tr khng ln lm trong bnh
sinh ca ph vim. Dng cc cht mu (xanh Trypan, xanh Evans) to thnh phc hp vi
anbumin v theo di s thot cht mu vo khu vc da b tn thng lm ch tiu ca tng tnh
thm cc huyt qun da, th thy rng tng tnh thm cc ht qun vnh tai th biu hin kh
r trong khi cha c nhng bin i vi tun hon v lng mch vnh tai chut (Spector WG,
Willou ghby DA, 1963; Volodin VM, Tocarev C.Yu, 1965) . Trong nhng nm gn y ngi ta
ch nhiu vai tr ca cc sn phm c hot tnh sinh vt c sn sinh trong t chc vim,
c gi l cc mdiat tnh thm c bit vai tr ca cc polypeptit h kinin nh bradikinin,
kallidin.
Trong vim cp, tn thng ca vim biu hin r v sm nht l ri lon tnh thm huyt qun
v ph vim, c th chialm hai thi kz :
- Thi kz sm, ngn hn pht sinh ngay t nhng pht u sau tc dng ca cc cht gy vim
do vai tr ca histamin ni sinh dn ti bin i cc huyt qun trong t chc vim. Sertnin
tng cng v ko di tc dng ca histamin. Cng c th c lin quan c vi s to thnh kinin
ngay trong giai on ny.
- Thi kz mun pht sinh sau vi gi v mun hn tuz theo tnh cht ca kch thch, ch yu do
vai tr ca cc polypeptit h kinin. Ngoi ra cn tc dng ca tng tng hp histamin ni sinh v
bt hot catecholamin do qu trnh vim gy ra.
1. Vai tr ca histamin v serotonin:
Khi tn thng t chc, t cc t bo ln ch yu cc t bo mastocyt vng quanh cc huyt
qun , cc ht ca t bo phng ln, v v lm thot ra mi trng ngoi histamin v serotonin.
Histamin c tc dng dn cc tiu ng mch v mao mch, gy tng tnh thm huyt
qunnhng ch trong mt thi gian ngn. Thc t trong thc nghim, gy tng tnh thm
huyt qun ging nh trong vim phi dng mt lng histamin, ln gp bi nng histamin
thy trong vim v ch tc dng trong thi gian u. Serotonin gy ph da ng vt mnh hn
histamin, tng cng v ko di tc dng ca histamintrong vim chut. V cc t bo
mastocylowr ngi khng gii phng ra serotanin, mc d serotonin c tnh mn cm rt cao
i vi cc huyt qun , mt s tc gi vn cho rng serotonin c vai tr t quan trng trong
bnh sinh vim ngi.
Gii phng histamin v serotonin c coi l c ch m u, t pht sinh hng lot phn
ng dy chuyn trong vim. Qu trnh ny cn s dng nng lng ca c th nn cc ch
phm c ch qu trnh thoi bin glucozen v axit lactic ca vng Krebs hoc c ch qu trnh
photphoryl y ho (2,4 dinitrophenol, salicylat axit axtyl salicylic, phenyl butason .) c ch
mt cch hiu lc s gii phng histamin v serotonin. Cc sn phm khng histamin nh
phenergan, chlorpromazin, dimebolin, mepiramin c ch tc dng ca histamin khi c to
thnh, nhng ch c hiu lc trong cc trng hp bin i ch yu do histamin.
2. Vai tr ca lizocom v cc men lizocom:
Khi vim, lizocom ca cc t bo (t bo t chc lin kt, bch cu ht.) b tn thng gii
phng ra cc men lizocom, chur yu l cc men thu phn (hydrolaza) c chc nng phn hu
gluxit, lipit, protit, c bit cc men tiu protit c kh nng hu thc s tt c cc phn t ln
c tnh cht sinh vt (pllisaccarit, axit nhn.) . Cc men lizocom gy tng tnh thm huyta
qun theo hai ng:
- Trc tip tc dng trn ni mc v thnh huyt qun bng kch hot men colagenaza gy ph
hu cc si keo, si chun gin ca thnh huyt qun. Hoc kch hot men hyaluronidaza gy hu
axit hyaluronic l cht a ng c bn ca thnh mch, hoc cng c th do tc dng trc tip
ca men tiu protit ca lizocom
- Gin tip tc dng gy gii phng v to thnh cc mdiattnh thm:
+ Gy gii phng histaminv serotonin t cc t bo mastocyl quanh huyt qun
+ Hot ho kallicrein v to thnh cc polypeptit h kinin.
+ Hnh thnh nhm Prostaglandin c tc dng gy ri lon men v tn thng cc t bo t
chc, gy tng tnh thm huyt qun v ph c vi liu rt nh.
Prostaglandin c sn sinh t cc t chc bnh thng, t axit bo khng bo ho (axit
arachidonic chng hn)di tc dng ca men lipit oxydara. Khi tn thng t chc do cc
nhn t c gii vt l, ho hc, nhim khun, cc hin tng t tiu t chc, nht l cc phn
ng khng nguyn khng th nng Prostaglandin tng ln mt s lng ng k. S to
thnh Prostaglandin y do tng phn hu axit bo t lecithin trong mng t bo t chc tn
thng vi s tham gia ca men lizocom photphohydrolaza.
Cho nn mt trong nhng nhim v quan trng trong iu tr bnh sinh ca vim l n nh
mng lizocom, ngn nga s gii phng cc men lizocom hay phong b tc dng ca cc men
lizocom trong mi trng.
3. Vai tr ca h thng kinin trong bnh sinh ca vim
T lu ngi ta pht hin rng cc protein huyt tng di tc dng ca trypsin hay mt
men tiu protit no c th chuyn thnh nhng polypeptit c t 8-14 axit amin, gi chung l
cc kinin huyt tng. V d: bradikinindc to trong mu t anpha, globulin di nh hng
cu kallicrnin v men amino peptilaza:
Kinin c to thnh d dng v khng hi phc. Bnh thng mt s lng khng nhiu lm
kinin c sn sinh trong huyt tng nhng li nhanh chng b hu, thi gian thoi bin kinin
trong mu ngi v ng vt ch chng 30 giy. Hu kinin do tc dng ca kininaza,
(carboxypeptidaza N), c coi l hocmon iu hi tun hon cc b trong cc iu kin sinh l.
Nh vy bnh thng c mt cn bng sinh l gia cc men to kinin v hu kinin, cn bng ny
b ri lon khi c tn thng t chc gim pH hoc do tc dng cc yu t bnh l khc.
Cc kinin huyt tng gm kallidin, bradikinin v methionin- lysin- bradikinin. Tc dng ca
kinin l gy dn cc huyt qun ch yu cc tiu ng mch, tiu tnh mch v mao mch, gy
mu trong cc tiu tnh mchv tng tnh thm cc mao mch v tiu tnh mch bng cch to
thnh mt mt khe h gia cc t bo ni mc cc tiu tnh mch. Tc dng ny, bradikinin
mnh hn histamin 20-80 ln v mnh hn acetylcholinti 1000 ln. Tc dng ca kinin ni
chung cng ch ngn ngi khng lu 15-45 pht, o ch c th ti 3-4 gi. Nh vy, tc dng
ko di trong vim cn ph thuc vo s cng lc ca histamin, serotonin ni sinh, v vo s
cn bng gia to v hu kinin. Cc kinin cn c tc dng gy thot bch cu qua thnh tiu tnh
mch v gy au ph thuc vo nng bradikinin c to thnh trong t chc vim. Cm
gic au d di trong vim c c ch bng tim phng salicylat.
Mt s tc gi nhn mnh nghi ca ri lon ng mu trong bnh sinh ca vim(Hnh 9). Khi
pht sinh vim cng nh trong bt c mt stress no, tnh ng mu cng tng cng do tng
thrombo-plastin t chc v kch hot cc yu t ng mu khc, nhng ng thi hot tnh
toan fibrin cng tng do kch hot yu Hagemangay tng hot hoplasminogen. Hin tng
ng mu c h thng plasminogen plasmin gii quyt nn mu khng nghon ton
li, v cc mn fibrin ng li trong cc tiu tnh mch v mao mch gy tng tnh thm tn
thng thnnh mch v chy mu. ng thi tng plastamin cng l yu t thun li cho s
hnh thnh cc kinin. Trong vim da do tia roentgen v tia x, dng EACA vi tc dng khng
plastamin t ra c hiu lc tt.
Nguyn nhn gy tng tnh thm v chy mu trong vim do cc bch cu trung tnh vo b mt
thnh huyt qun gii phng ra cc men tiu protitlozocom gy hu hoi thnh mch v tng
cng to kinin. Trong bnh s va ng mch, s to thnh kinin l mt xch ch yu ca vim
thanh dch thnh ng mch, dng cc cht i khng bradikinin cng nh dng trasilol, EACA
vi tc dng khng kilacrein v khng plasmin l nhng thuc c hiu lc c bit. Hng u
trong nhng cht c tc dng n nh mng lizocom, ngn nga s to thnh v gii phng cc
polipeptit h kininl cc steroit chng vim, Cotison v cc dn xut ca n hin nay c dng
rng ri lm sng ni khoa v c ngoi khoa phi hp vi cc khng sinh.
IV. Vim l mt phn ng ton thn c tnh cht thch ng bo v c th
A. Vim l mt phn ng ton thn
Trong qu trnh vim tuz biu hin cc b l ch yu song tnh cht, tnh trng din bin v kt
thc ca vim chu nh hng su sc ca ton thn, ng thi phn ng vim cng gy nhiu
ri lon trong ton b c th.
1. nh hng ca ton thn i vi vim
- Tnh phn ng c th nh hng su sc n phn ng vim. Trn c th kho mnh din
bin ca vim thng kh quan hn, din bin mnh v nghim trng thng thy c th
b mn cm gy cc th bnh nng, v phn ng yu t v din bin nguy him gp trn c th
suy nhc, i n, ngi gi sc khng b suy sp.
- H thn kinh trung ng c bit l v no nh hng r rt ti bnh sinh ca vim. ng
vt mt no, phn ng vim yu v ko di. Vim vi dng ni ban v xung huyt c th gy
ngi bng cch m th l t trn da mt ng xu nng, mc du ng xu ch bnh thng.
Gy bng cho ng vt trng thi gy m thy vim din bin nng hn, hon t nghim
trng v vt bng lu lnh hn
- Cc tuyn ni tit cng nh hng r rt ti phn ng vim. Ct b tuyn gip lm suy yu
phn ng vim. Ni tit t sinh dc nh oestrgn c ch r ho tnh nen hyaonidaza. Ct b
tuyn tu hot tnh thc bo ca bch cu gim. Mt s tc gi cho rng cc corticoit ng
(cortison, hydrocortison..) c ch phn ng vim gy gim tinh thn mao mch, c ch thc
bo v to khng th, c ch hin tng tng sinh cc t bo t chc lin kt. Gn y ngi ta
dng cortison vi tc dng n nh mng lizocom, c ch s to thnh polyoeptit h kinin nn
cortison v nhng cht tng hp tng t c s dng rng ri lm sng trong iu tr vim
nht l vim d ng.
- H vng mc ni m l ni sinh sn ra khng th v cc loi thc bo, c chc nng gii c
nn khi chc nng ny b suy yu cng nh hng nghim trng ti phn ng vim.
2 nh hng ca vim ti ton b c th.
- T vim c th gay nhiu thay i chc phn nh hng su sc ti ton b c th: ri lon
thn kinh xut hin sm nht, ri ti ri lon tiu ho, tit niu, iu ho thn nhit v quan
trng nht l nhng thay i ca mu. Cc ri lon ny pht sinh do tc dng ca cc vi khun,
c t, cc sn phm ca ri lon chuyn ho v tn thng t chc t vim vo mu gy ra.
- Vim cn thng qua c ch phn x nh hng ti cc b phn khc v khi vim nng v ko
di c th suy yu dn do thiu dinh dng, sc khng gim st c th pht sinh nhng tn
thng thc th nhng quan xa (tim, gan, thn)
T mi quan h mt thit gia vim v ton thn xy dng c mt quan im khoa hc
ng n l vim l mt phn ng ton thn vi nhng biu hin cc b l ch yu iu tr
cc b phi kt hp vi iu tr ton thn trn c s iu tr ton din.
B. VIM L MT PHN NG THCH NG BO V C TH.
Phn tch nhng biu hin ch yu trong vim ta thy c 2 loi hin tng:
- Hin tng phas hoi do cc yu t gy vim xm nhp c th gy nhng tn thng t bo
t chc dn n nhng bin i chc phn nhiu hay t cc c quan trong ton b c th.
- Hin tng thch ng phng ng ng thi xut hin di nhiu biu hin: tng tit dch d,
ph vim c kh nng lin kt, c nh cc c t vi khun trong vim khng cho hp thu v
lan rng trong c th. Chc phn thc bo v tng sinh cc t chc lin kt nhm tiu dit
nguyn nhn gy vim, khi phc li cc chc nng sinh l{, hn gn tn thng t chc. T
chc ht o to thnh hng ro bo v rt mnh chng vi khun
V bn cht ca vim c nhiu thuyt gii thch nhn mnh vai tr tn thng cc t bo
t chc (Virchow), vai tr cc ri lon tun hon nguyn pht (Conheim), nhng i l ho
trong t chc vim (Shade) Hc thuyt Metnhicp trn quan im sinh vt hc c bit ch
ti { ngha thch bo v ca vim qua hin tng thc bo (Hnh 10), tng sinh cc t bo chc
lin kt v cc phn ng phng ng khc. Tt c nhng hc thuyt trn phn nh nhng mt
quan trng nhng cc b ca vim v mi hc thuyt tuy cha ton din nhng c gi tr nht
nh trong nghin cu v bnh sinh ca vim. Nhng nm gn y, trn c s cc nghin cu
mc siu t bo v phn t, cc tc gi (Policard, 1965; Schveifax, 1967) tng hp y
nhng quan im trn v khi qut bn cht ca vim nh mt phn ng ton thn ch yu c
{ ngha thch ng phng ng. Tuynhin trong cuc u tranh t v ny, tuz theo mc nng
nh ca vim v tng quan lc lng gia c th v nhn t gy vim m din bin c th
thay i, nguyn tc x tr c bn l phi hn ch tc dng ph hoi ca nguyn nhn ng thi
gip c th tng cng cc phn ng thch ng phng ng nhanh chng phc hi cc tn
thng t chc, v cc chc nng c th b ri lon.

51. SINH L BNH THIU XY
Hong Dung
Thiu oxy l mt qu trnh bn l phc tp do cc c quan bo m khng cung cp c oxy
y cho nhu cu chuyn ha bnh thng ca t bo hoc do t bo t chc v mt l do no
khng s dng c oxy.
Rt nhiu c ch tham gia vo qu trnh cung cp oxy cho t chc, nh s thng kh, kh nng
khch tn ca phi, s tun hon vn chuyn oxy bi mu, s khuch tn qua mng t bo vo
t chc v qu trnh h hp t bo cho nn khi ri lan mt khu no trong cc c ch
trn u c th dn ti thiu oxy.
I.NGUYN NHN V BNH SINH CA THIU OXY
Theo nguyn nhn v bnh sinh c th phn thnh 3 loi
A-THIU OXY DO NGUYN NHN H HP
Loi thiu oxy ny bao gm:
- Thiu oxy do tc dng trc tip ca p lc kh quyn vi cc hin tng gim p lc kh
quyn gy gim phn p O
2
trong khng kh th (khi bay ln cao, leo ni hoc sng trn ni cao,
tu v tr), gim p lc t ngt khi tho hi thng ln, hoc tng cao p lc kh quyn khi ln
su di bin, trong thng ln, tu ngm
- Thiu oxy trong cc bnh l v h hp do ri lon thng kh, khuch tn hoc ri lon ng
mu trong cc mao mch phi, cn bng h hp, tun hon trong cc mao mch phi.
THIU OXY DO GIM P
Nguyn nhn ca loi thiu oxy ny l do khi ln cao trn mc ca mt bin, p lc kh quyn
gim do p lc O
2
trong khng kh cng gim gy gim phn p O
2
trong ph bo v trong
mu ng mao mch v thiu oxy. C th tnh theo cng thc sau:
PO
2

kk
= nng O
2
trong kk .(P
kq
- 47)
- pO
2

kk
l p lc O
2
trong kh th (mmHg).
- Nng O
2
kk bnh thng bng 0,21
- P
kq
l p lc kh quyn bng 760mmHg
Bnh thng, pO
2
kk bng 0,21. (pkq - 47)= 150mmHg
Khi ln cao trn 3000m, pO
2
k =0,21. (550 - 47)= 80mmHg, do gy nn thiu oxy.
1. Bnh cao : l hin tng thiu oxy cp khi ln cao t ngt trn 3000m hoc bay cao
trn mc gii hn m khng c hoc hng bnh oxy. cao 4000- 5000 m c coi l gii hn
khng cn cung cp thm oxy ca bay. Cc du hiu bnh l xut hin ph thuc vo cao v
sc chu ng ca c th. Du hiu sm nht l cc ri lon thn kinh v ri lon ng quan: mt
mi tht thng, nhc u, gim tr nh, phn x chm chp, bun nn, ri lon th gic, thnh
gic u l nhng giu hiu nguy him, nht l vi phi cng chin u. Do c ch b p bt
lc gy tng o thi CO2, nn l loi thiu oxy km nhc thn v nhim kim hi. Tim p
nhanh, yu, c th lon nhp. Nu khng x tr kp thi, h thn kinh b c ch su sc dn ti
co git, hn m v cht. Bin php iu tri ch yu l cung cp oxy nguyn cht :
Ln cao trn 8000m- pO
2
kk = 0.21.(270- 47) : 47mmHg
Cung cp oxy nguyn cht: 1.(270-47) :223 mmHg. Nhng nu ln cao trn 10000m th d
cho oxy nguyn cht cng khng m phi c bung p lc (tu v tr, v tinh nhn tao)
Ln cao 15000m, th oxy: pO
2
kk= 1. (95- 47): 48 mmHg trng hp ny, con ngi phi sng
trong bung p lc mi trnh c tnh trng thiu oxy v v trng lng.
2. Bnh ni cao: l hin tng thiu oxy cp khi leo ln ni cao trn 600m (cc nh thm
him). Nguy him ca thiu oxy cng ph thuc vo cao v mt s yu t ph thm nh mt
mi th cht, lnh, tc dng ca tia cc tm, tia v trKhi ln cao trn 300m, cc du hiu
thiu oxy bt u xut hin: hng phn thn kinh, trng thi kch thch , khoan khoi, hay ci
niLn cao trn 4000m du hiu r rt hn, nhc u, bun nn, mt mi tht thng, km
tr nh, kh th, tm ti,h hp chu kz cao 6000m l gii hn cui cng m con ngi c
th chu ng c m khng cn c thm oxy. Cht trong bnh cao v ni cao l do t lit
trung tm h hp v c ch h TKT v cc trung khu thn kinh. bnh leo ni cn c tnh
trng nhim toan chuyn ha do cc c phi lm vic trong hon cnh thiu oxy sn sinh nhiu
axit lactic v cc axit khc.
Vi nhng dn tc sng trn ni cao th tnh trng thiu oxy mn c cc c ch thch nghi
b p gii quyt, n nh cn bng ni mi: hng cu c th tng ti 7-8 triu/mm
3
mu,
nhim kim hi c b p tng thi tr kh bicacbonat ca thn, do cung cp v s dng
oxy, oxy ca t bo c m bo v nhng ngi ny c th sng v lao ng sn xut nh
bnh thng.
B- THIU OXY DO NGUYN NHN TIM MCH V MU
1. Do ri lon tun hon ti ch hoc ton thn: tt c cc trng hp gim huyt p ng
mch, gim cung lng mu ti t chc u dn ti thiu oxy: suy tim, sc, mt mu nhiu
2. Do shunt tnh mch-ng mch: khi mt phn mu tnh mch khng c trao i kh
thng vo mu ng mch, lm gim bo ha oxy mu ng mch, gi l shunt. Cc
shunt bnh l{ thng gp: cc vng phi khng c lu thng kh (xp phi, vim phi),
cc ch thng phng ng mch, mu u mch mu, cc bnh tim bm sinh: thng lin nh, lin
tht
3. Do bnh l ca huyt cu t:
- Thiu mu c gim s lng hng cu v lng huyt cu t nh hng n vn chuyn
oxy t chc.
- Bnh huyt cu t l nhng bnh di truyn do ri lon tng hp huyt cu t bnh thng
(HbA) gy xut hin cc huyt cu t bnh l (HbS hoc HgF) lm thay i chc nng vn chuyn
oxy ca hng cu v hnh th hng cu bin dng thnh hnh lim hoc hnh bia, do d
ngng kt v tan v gy thiu mu v cc bin i nguy him cho i sng.
- Nhim c CO pht sinh khi c tng nng kh CO trong kh th trong cc trng hp lao
ng, trong nh my c kh than cha t chy hon ton, trong chin u l ct, xe tng,
pho c ln. Nng kh CO ch cn 0,1-0,2% c th gy nhim c cp, th lu di nng
thp 0,05% gy nhim c mn v nhng ri lon tm thn kinh ko di. CO t ph bo khuch
tn vo mu rt nhanh, kh nng kt hp vi huyt cu t thnh HbCO d hn ti 300 ln so
vi oxy, c nh d dng m li thot ra rt chm do gy thiu oxy nghim trng. Kt hp
HbCO ti 50% c th gy ri lon thn kinh, lit mch ngoi vi, ln ti 70% pht sinh co git,
hn m v cht. Ngoi tc dng gy thiu oxy, CO cn gy c ch h hp t bo, v nhiu bin
i chc phn c th.
- Nhim c Methemoglobin: MetHb l mt dn xut oxy ha ca hemoglobin, bnh thng
c rt t trong mu 0-0,2%, v c h men kh nn khng gy nh hng g vi c th. Trong cc
trng hp nhim c mt s cht c tc dng oxy ha Hb, MetHb c to thnh qu nhiu,
li l mt hp cht vng bn cha Fe
+++
nn khng c kh nng vn chuyn oxy v gy thiu oxy
nghim trng. Nhim c MetHb c th gp trong:
+ Nhim c cc ha cht nh kaki chlorat, nitrobeenzol, phenylhydrazin, cc hp cht c
As
+ Nhim cc cht c sn sinh khi c ri lon tiu ha ko di nh vim phi, i tt dai
dng(nitrit H2S)
Hin tng xanh tm xut hin khi lng MetHb trn 3g% mu thnh mu nu en, kh th
trm trng, tim p nhanh, yu ,paO
2
gim rt thp, c th dn ti co git ,hn m v cht.
C- THIU OXY DO NGUYN NHN T CHC
T chc khng s dng c oxy khi c ri lon h hp t bo. H hp t bo l mt qu
trnh oxy ha- kh phc tp, tin hnh nh h thng men h hp c phn thnh nhng phn
ng dy chuyn lin quan cht ch vi nhau:
+ Phn ng tch H c thc hin nh cc men tch H (dehydraza hay dehydrogennaza),
men ny d b hng nhit trn 55
o
C v b c ch bi cc loi thuc ng babiturat, trong
thnh phn c sinh t
+ Phn ng chuyn H tip sau nh cc men coenzym I v II (DPN= diphotphoric nucleotit
v TPN trihotphoric nucleotit) v thnh phn c sinh t PP, ri chuyn tip nh men
flavopretoin thnh phn c sinh t B
1
u d b cc cht Fluorua, cyanua c ch.
+ Phn ng chuyn in t nh cc men oydafa, h cytocram v cytocrom oydaza. Cc men
ny d b cc cht cyanua, As, H
2
S c ch.
Nh vy d ch mt khu trong chui phn ng ny b ri lon, qu trnh h hp t bo cng
khng thc hin c, do tuy oxy c cung cp y , t chc cng khng s dng c
oxy.
Nguyn nhn ca h hp t bo c th l:
- Thiu c cht ( thiu n, i tho ng, suy nhc) gy thiu sinh t v thiu men h
hp t bo .
- Nhim c cc cht c ch h hp t bo nh7 cc thuc ng, CO, H
2
S, As, Fluorua, cyanua,
cc cht c to ra trong qu trnh nhim khun, u c
Trong loi thiu oxy ny, pO
2
v SaO
2
vn bnh thng v v O
2
khng c s dng nn pO
2

trong mu tnh mch tng ln mt cch bt thng.
Nh vy nguyn nhn v bnh sinh rt phc tp , trong thc t cc loi thiu oxy thng kt
hp vi nhau, phi khm xt lm sng v theo di cc du hiu sinh vt y pht hin v
cung cp oxy l mt bin php tt nhng khng phi s dng vi tt ca mi trng hp m
phi ty theo tnh cht v mc , ty theo nguyn nhn m c thi x tr thch hp .
II. C CH THCH NG B P CA C TH KHI THIU OXY
Khi thiu oxy, c th ng vin mt lot phn ng b p:
1. Tng h hp v tun hon:
H hp nhanh v su pht sinh theo c ch phn x do gim paO
2
kch thch cc cm th
huyt qun t xoang ng mch cnh, quai ng mch ch v kch thch trc tip ca tng
paCO
2
. ng thi vi c ch phn x, h hp tng cng lm cho sc ht ca lng ngc tng,
mu v tim phi tng lm cho tim cng tng cng hot ng. Kt qu l tim p nhanh v
mnh, lu lng mu trong 1 pht c th tng t 4-6 ln hn so vi bnh thng, trng lc
huyt qun v tc mu chy cng tng nhm cung cp vn chuyn oxy cho t chc.
2. Thch ng ca h mu
- u tin l phn ng phn phi li mu, mu c dn ti m bo cho cc c quan quan
trng (no, tim) v mu d tr c a ra s dng thng qua tc dng tng tit adrenalin.
- Kh nng kt hp HbO
2
c tng cng tuy phn p O
2
mu gim r rt: + Khi paO
2
=
100mmHg th kt hp HbO
2
t c 94-97%
+ Khi gim ch cn 50mmHg, kt hp HbO
2
duy tr mc 80%, ch khi paO
2
gim thp
hn na kt hp HbO
2
mi gim.
- Kh nng phn ly HbO
2
cng tng cng t chc s dng Oxy d dng, do ti nng
CO
2
v cc cht axit khc ca ri lon chuyn ha tng.
- Sn xut hng cu cng tng do tnh trng thiu oxy kch thch thn tng tit erythropoetin
v kch thch chc nng to hng cu ca ty xng.
3. Thch ng ca t chc:
- T chc tn dng oxy ca mu ng mch nn h s s dng oxy t 0,3 c th tng ti 0,85
v mu tnh mch t oxy tr thnh mu tm sm.
- Chuyn ha vt cht giai on u tng nhng sau gim r rt, thn nhit cng gim c
tc dng gim bt nhu cu oxy ca c th, to iu kin phc hi cc chc phn v tng cng
sc khng ca c th vi thiu oxy.
4. Thch ng ca h thn kinh v ni tit:
- Khi thiu oxy, lc u h thn kinh hng phn sau pht sinh c ch bo v v no v
ton b h TKT, ng thi vi gim chuyn ha, gim thn nhit v gim hot ng cc chc
phn khc ca c th. Nhng nu nguyn nhn gy thiu oxy vn tip tc, h thn kinh b c
ch su sc s gu nhiu bin lon nguy him.
- Nghin cu v sinh ha hc thy trong thiu mu no c ri lon tng hp v gim lng
ATP v PC t chc no rt nhanh. ATP v PC l nhng hp cht ln cao nng cn thit cho s
chuyn giao nng lng nhn c trong qu trnh oxy ha v c s dng cho hot ng ca
t bo. Nh vy, ATP v PC gim nhanh trong giai on hng phn v li ln c xu hng hi
phc trong giai on c ch bo v; lng ARN cng gim trong giai on hng phn v tng
trong giai an c ch bo v. Nhng nu thiu oxy nng v ko di, s gim cc hp cht ln
cao nng v ARN nghim trng s dn ti hin tng thiu nng lng cho t bo thn kinh v
thng l nguyn nhn ca cht. Nhng kt qu nghin cu trn lm sng t phn no
nguyn nhn ca s mn cm cao ca h TKT i vi thiu oxy v pht hin c bn cht
ha hc ca c ch bo v cng nh vai tr phng ng ca n trong thiu oxy. Nh vy thch
ng vi thiu oxy, vai tr quyt nh l tng kh nng ti tng hp cc cht ln cao nng v tng
hot tnh tng hp axit nhn , ch yu trong t chc thn kinh. Dng Altinomixin c ch s tng
hp ARN dn ti lm tn thng cc phn ng thch ng v dn ti t vong a s ng vt
th nghim. Trn c s ra nguyn tc c bn cho d phng v iu tr nhng hu qu
ca thiu oxy bng cc bin php th nhit nhn to v s dng nhng thuc c ch TKT
lm hn ch r rt s thoai bin v tng kh nng tng hp cc hp cht ln cao nng, lm cho
c th chu ng tt vi thiu oxy.
III. NHNG RI LON C TH KHI THIU OXY
Nhng ri lon ca c th khi thiu oxy biu hin v mc c khc nhau ty theo tnh cm
th ca tng c quan t chc v cng ph thuc vo tnh cht ca tng loi thiu oxy.
A-MC CHU NG CA CC C QUAN T CHC KHI THIU OXY
Thiu oxy gy nhiu ri lon chc phn v cu trc nhiu c quan t chc, c bit l h
TKT v v no. Cc t chc t mn cm vi thiu oxy, c th cn hot ng c trong 1 thi
gian di c khi tun hon nh ch nh xng, sn, lng, ru tc
H thn kinh:
T chc thn kinh, c bit TKT chu ng km nht vi thiu oxy. nh ch tht s tun
hon v no ch 5-6 pht, thn no v hnh no 10 pht, ty sng 15-20 pht c th
pht sinh nhng hoi t t chc khng phc hi. Cc trung khu thn kinh mn cm vi thiu
oxy nht l trung khu h hp v trung khu tun hon.
Cc c quan, ni tng:
C tim rt mn cm vi thiu oxy nhng li chu ng c lu hn v tun hon vnh
thng gin ra tng cng cung cp oxy theo c ch b p. Thn v gan d b nh hng
xu v khi no v tim c u tin phn phi mu th gan v thn li lm vo tnh trng co mch
v thiu mu nghim trng.
T bo t chc:
Khi thiu oxy thng pht sinh ri lon chuyn ha t chc dn n nhim toan, tng tnh
thm thnh mao mch v cc thay i ni mi khc cng lm nng thm tnh trng thiu oxy.
Hu qu ca thiu oxy cn chu nh hng ca tui tc (tr s sinh chu ng tt nhng
ngi gi v tr em li chu ng rt km i vi thiu oxy), trng thi chc phn h TKT
(thn kinh trng thi hng phn d chtv trng thi c ch lu cht hn so vi trng thi
bnh thng), v nh hng ca bnh tt (thiu mu, bnh phi), nghin ru, gy m
suu lm c th chu ng km vi thiu oxy.
B- DIN BIN CA THIU OXY
Thiu oxy cp thng din bin qua 3 giai on:
- Giai on hng phn pht sinh khi thiu oxy cn nh: thn kinh trng thi hng phn,
sng khoi, d chu hay ci ni, chuyn ha tng mnh v h hp cng tng cng c tc dng
b p.
- Giai on c ch pht sinh khi thiu oxy vn tip tc, h TKT b c ch lc u c tnh cht
bo vphng ng, biu hin mt mi, bun ng, nhc u, tr nh gim, cc phn x gim, cc
chc nng c th u gim hot ng, chuyn ha vt cht cng gim
- Giai on kit que do c ch nghim trng h TKT gy ri lon ton b c th khi thiu
oxy nng v ko di, c th dn ti nhng ri lon khng hi phc cc c quan quan trng
(no, tim, gan, thn) v cht khi phn p O
2
mu gim ti 40-20 mmHg.

52. SINH L BNH H TUN HON

( NGUYN HU M )
H tun hon l mt trong nhng chc nng quan trng nht tham gia vo hng nh ca ni
mi. Ngi ta thng v tim nh mt ci bm ln, va ht va y mu vo h thng ng dn
kn l mch.Song bm v ng dn y khng c nh ma lun lun c th tng gim kh nng
hot ng ca chng thch ng vi nhu cu lun lun thay i ca c th. chnh l nh
s iu ho thn kinh th dch ngay h tun hon c h thn kinh trung ng. Do , c
th ni l s gp nhng r lon tun hon trong hu ht cc tnh trng bnh l ca tim , mch,
h hp v h thn kinh. ng nh Bc(Bacp) ni h tim mch l mt h thng hon b ,
mt n v chc nng , kt hp cht ch vi phi v di s kim sot thng xuyn ca h
thn kinh. Mi tn thng ca phi u nh hng ti tun hon , mi s t lit ca vn mch
s gy nguy him i vi hot ng ca tim. Nhng noi nh vy cng cha , v ri lon cc
c quan khc nh gan, thn , ni tit cng co nh hng ti hot ng ca tim mch
Trong khi nghin cu chc nng h tun hon, cn quan nim rng s hot ng ca tim , mch
c lin quan cht ch v nh hng ln nhau trong iu kin bnh thng cng nh trong bnh
l.
I.KH NNG THCH NGHI CA TIM
Khng nhng ci bm timc mt hiu xut rt cao, m cn co kh nng tng hiu xut ln
nhiu ln, gip c th p ng c nhng nhu cu bt thng c bit(xem bng di y)
H tun hon l mt trong nhng chc nng quan trng nht tham gia vo hng nh ca ni
mi. Ngi ta thng v tim nh mt ci bm ln, va ht va y mu vo h thng ng dn
kn l mch.Song bm v ng dn y khng c nh ma lun lun c th tng gim kh nng
hot ng ca chng thch ng vi nhu cu lun lun thay i ca c th. chnh l nh
s iu ho thn kinh th dch ngay h tun hon c h thn kinh trung ng. Do , c
th ni l s gp nhng r lon tun hon trong hu ht cc tnh trng bnh l ca tim , mch,
h hp v h thn kinh. ng nh Bc(Bacp) ni h tim mch l mt h thng hon b ,
mt n v chc nng , kt hp cht ch vi phi v di s kim sot thng xuyn ca h
thn kinh. Mi tn thng ca phi u nh hng ti tun hon , mi s t lit ca vn mch
s gy nguy him i vi hot ng ca tim. Nhng noi nh vy cng cha , v ri lon cc
c quan khc nh gan, thn , ni tit cng co nh hng ti hot ng ca tim mch
Trong khi nghin cu chc nng h tun hon, cn quan nim rng s hot ng ca tim , mch
c lin quan cht ch v nh hng ln nhau trong iu kin bnh thng cng nh trong bnh
l.
I.KH NNG THCH NGHI CA TIM
Khng nhng ci bm timc mt hiu xut rt cao, m cn co kh nng tng hiu xut ln
nhiu ln, gip c th p ng c nhng nhu cu bt thng c bit(xem bng di y)
Cc ch tiu ngh Tiu
ho
Lao ng
nh
Lao ng
nng
lng oxy hp th trong 1 pht(ml) 245 360 600 3120
hiu s oxy gia ng mch v tnh mch trong
100ml mu
7 8 10 13
lu lng mu trong mt pht(ml) 3500 4500 6000 24000
lu lng mu cung cp cho tim trong 1 pht(ml) 250 350 500 2000
lng mu cung cp cho h thn kinh trung ng
trong 1 pht (ml)
350 300 400 450
lng mu cung cp cho da 400 500 800 2400
lng mu cung cp cho ni tng(ml) 1200 2000 1000 800
lng mu cung cp cho thn(ml) 400 450 350 350
lng mu cung cp cho xng(ml) 900 800 2950 12000
s lng mu tun hon(ml) 3500 4000 4500 4500
s lng mu d tr(ml) 1000 500 0 0
thi gian i ht mt vng mu(pht) 1 0,88 0,7 0,2

Vi nhng con s trn, nu ta p dng cng thc tnh nng xut c tim, th t l cng xut
ca c tim khi lm vic so vi lc ngh ngi c th tng ti 20 ln. S d tim c th tng cng
hot ng nh vy l nh kh nng d tr nng lng rt ln d c th hon thnh chc
nng bm mu khi chu cu ca c th tng ln t ngt nh trong tiu ho, lao ng.st , hoc
trong nhng trng hp bnh l khc. Kinh nghim lm sngcho bit bnh tim mch,trong mt
thi gian , khng biu hin ra ngoi khng thy pht sinh ri lon tun hon , ngay c khi tim
mch b tn thng.
Tim tng cng hot ng c , ch yu l da vo c ch sau y: tng tn s tim p, dn
tim, tim ph i.
1.Tng tn s tim p:Bnh thng tim p 60-80 ci trong vng mt pht. Tuz theo nhu cu
ca c th cn nhiu mu, tn s tim p c th tng ln nhiu, c nh vy l nh nhng
c ch sau y:
Phn x Mary(maray):huyt p xoang ng mch cnh v cung ng mch ch gim(nh
trong sc, chy mu nng, mt nc nghim trng) tc ng ln th th p lc hai b phn
ny v theo ng hng tm ln trung khu tim p nhanh v tng tn s tim p nhm phc
hi huyt p .
Phn x Benbrilgio(Bainbridge):huyt p nh phi tng(suy tim phi, suy tim ton b )tc ng
ln th th p lc b phn ny ri t ln trung khu tim p nhanh lm cho tim p nhanh.
Phn x Alam-smic(alam_smirk):mu c tim khng gy ra trng thi thiu oxy, tc ng
trn on cng ca m ri tim lm cho tim p nhanh.
Phn x tng tn s tim p co tc dng tng lng mu tun hon p ng nhu cu ca c
th bt cht tng, trong diu kin mi . Song tim p nhanh ko di s c hi i vi c tim v
thi gian tm chng ca chu chuyn tim s ngn li, nh vy c tim khng c ngh y ,
ngoi ra , tun hon vnh b hn ch (v mu chy vo ng vnh ch yu vo th tm chng).
Nh vy, c tim s khng c nui dng y , ng thi ngh ngi khng m bo, nn
kh nng hot ng ca tim ngy cng mt yu i.
2. Dn tim
Mun tng lu lng , ngoi tng tn s p , tim cong c th tng sc cha ca cc bung lm
cho mu tr v tim nhiu hn, ng thi c tim tng kh nng co bp vo thi kz tm th,
ngha l tng khi lng mu mi ln tm th. Theo di X quang ngi ta thy vn ng vin
c rn luyn tt tim gin rng hn v bp cht hn so vi tim ngi bnh thng. l dn
tim sinh l{. Khi lao ng nng, c hai c ch trn u c s dng. Dn tm tht c tc dng
tt hn lac tng tn s p v th tch ca tm tht c th tng 4 ln ,trong khi tn s p chi
tng gp i vi tng qu mc co hi i vi c tim(nh phn tch pha trn)
Dn tim sinh l cn c th gp trong bnh l{, nh h van tim thi kz u, lc ny, trong thi
thi kz tm chng, mu khng nhng tm nh xung tm tht m cn ng mch
ch(trong h van ng mch ch)hay ng mch phi(trong h van ng mch phi)tr v tm
tht lm tng th tch ca tm tht, gy dn tm tht.
Dn tim bnh l{ thng gp trong suy tim khi sc co bp ca c tim gim do bnh ca h tim
mch hay do nhng nguyn nhn ngoi tim mch.Trong thc nghim c th gy dn tim t
ngt trn th bng cch truyn vo tnh mch mt s lng ln dung dch sinh l{ di p lc
cao.
Tm li, dn sinh l l mt trng thi thch nghi ca c tim tng sc cha ca bung tim ng
thi tng cng co bp nhm tng lu lng tm th va lu lng pht, tri li dn tim bnh l
l mt trng thi th ng thng gp trong suy tim, do c tim mm nhn, sc co bp gim
hn nn mu li gy dn tim.
3.Tim ph i:
Tim dn trong mt thi gian di s dn ti ph i tim: theo Sta_linh (staring) si c cng ko
cng b ko di ti mt mc nht nh th sc bp cng mnh. Nu vy, tim tng cng hot
ng ca mt thi gian di s dn dn tr nn ph i , cc si c tim to ra, cn s lng cc si
c ca tim khng thay i. Tuy nhin, cng c { kin cho rng trng lc ca c tim cng mnh
th sc bp cng kho, v nh vy tim s ph i: quan nim nh vy s gii thch c nhng
trng hp tim ph i m tim khng co dn tim trc.
Tim ph i th sc co bp ca tim tng, do tim ph i l mt c ch thch nghi quang trng
ca tim trong iu kin sinh l{ cng nh bnh l
Cng nh trong dn tim, cn phn bit hai loi ph i:
Ph i sinh l:gp nhng ngi vn ng nhiu(vn ng vin, chin s b binh).c im
ca loi ph i ny l gia trng lng ca tim trong lng ca h thng co bp ton thn vn
gi c t l bnh thng
Ph i bnh l: gp trong bnh l tim mch, khi tim phi tng cng co bp trong mt th gian
di (bnh van tim, huyt p cao).c im ca loi ph i bnh l l trng lng ca c th
tim tng khng lin quan vi trng lng ca ton th h thng c.
Ngoi ra cn c th phn bit hai loi ph i :
Ph i ng tm : khi ton b c tim ph i thng gp vn ng vin, nhng bnh nhn
u nng tuyn gip(do chuy ho c bn tng cao nn c tim phi tng cng hot ng
ngi sng trn ni cao (do khng kh long gy thiu oxy, tim phi tng cng hot ng)
Ph i khng ng tm: khi ch c mt b phn ca tim ph i, thng l ph i bnh l (so
tim phi tng cng co bp mt thi gian di )
C trng hp t ph i khng ng tm tr thnh ph i ng tm nh trong bnh van hai
l, lc u ch c ph i tim tri, dn dn pht sinh suy tim tri, gy mu tun hon, lm
cho timn phi tng co bp, dn dn cng tr thnh ph i
Tim ph i ti mc d no c th hi phc c :trong lm sng, nhng bnh nhn b huyt
p cao c triu trng ph i c tim (trn in tm , thy in th cao, trc tim chuyn
tri).Nu iu tr tt thy cc hin tng ny mt dn, ni ln qu trnh hi phc ca ph i tim
Tim ph i l mt bin php thch nghi quan trng ca tim, song tim ph i qu c th gy
ra trng thi thiu oxy c tim do khi lng c tim tng, i hi nhiu mu nui dng, song
cc mch ca c tim khng tng thm s lng, khin cho c tim dn dn suy yu (H1)
Ni tm li, khi nhu cu v mu ca c tim tng t ngt trong diu kin sinh ly cng nh bnh
l, tim c kh nng thch nghi rt cao, thng qua ba c ch:tim p nhanh, dn tim v tim ph
i. Song, nu tim phi tng cng hot ng mt thi gian di, kh nng thch nghi phi
tng cng hot ng mt thi gian di, kh nng thch nghi b kit qu, by gi s phat sinh
suy tim.
II.SUY TIM
Suy tim xy ra khi tim mt mt phn hay ton b kh nng co bp y ra khi tim mt lng
mu thch hp vi i hi ca c th.
A-NGUYN NHN GY SUY TIM
C th xp thnh hai loi: bnh h tim mch v nguyn nhn ngoi tim mch
Bnh h tim mch:
Nhim khun, nhim c: vi khun v c t vi khun tc ng trn tim gy ri lon chuyn ho
c tim, thm ch gy tn thng c tim nhanh chng hoc dn dn ti suy tim (bch cu,
vim phi, thp khp.. )
Cc bnh tim : nh suy tun hon vnh, c bnh van tim, cc ri lon nhp tim, cc bnh tim
bm sinh. Gy kh khn cho hot ng bnh thng ca tim, lm gim l lng tim, dn ti
thiu oxy. m bo oxy theo nhu cu ca c th , tim phi tng cng hot ng va lu ngy
dn ti suy tim.
Mt khc, khi thiu oxy, c tim l t chc chiu ng thiu oxy rt km, cho nn ri lon chuyn
ho k kh ti c tim cng chng dn ti suy tim
Cc bnh mch: huy p cao, d nguyn nhn no, l mt tr ngi i vi hot n ca c
tim v dn dn ti suy tim. Trong nhng trng hp huyt p gim, mun duy tr c huyt
p binh thng, cn tng lu lng bng cch tim p mnh v tng co bp, dn dn ti suy
tim.
Nguyn nhn ngoi tim mch :
nhim trng : tng chuyn ho, i hi nhiu oxy, khin cho tim tng hot ng, c th dn ti
suy tim
nhng bnh phi :(hen, kh ph nang , x phi)gy ra tnh trng cn tr tun hon ti phi v
mun y c mu qua phi, tim phi tng cng co bp ng thi trng thi thiu oxy do
bnh phi sm mun dn ti suy tim.
thiu mu buc tim phi tng cng co bp m bo nhu cu v oxy ca c th sm mun
cng dn ti suy tim ; thm vo trng thi thiu oxy do thiu mu gy ra li lm cho suy tim
d pht sinh
nhng bnh chuyn ho v dinh dng:
u nng tuyn gip gy tng chuyn ho c bn tng nhu cu v oxy do tng hot ng ca
tim(ch yu tim p nhanh)
thiu vitamin B, gy ri lon tng hp axetyl CoA t axit pyruvic, do hn ch qu trnh to
nng lng cn thit cho co c tim cng dn ti suy tim.
B-C CH BNH SINH CA SUY TIM
C ch bnh sinh ca suy tim con l mt vn rt phc tp, nhiu im cha sng t. Tuy
nhin c th phn bit ba c ch bnh sinh ch yu :
suy tim do qu ti, do tim tng cng hot ng trong mt thi gian di.
Suy tim do ri lon chuyn ho c tim
Suy tim hn hp do hai c ch trn kt hp li
Hin nay, a s tc gi cho rng ri lon chuyn ho c tim l yu t bnh sinh ch yu gy ra
suy tim . Theo Onxn(Olson), qu trnh chuyn ho c timm din ra qua 3 giai on:sn xut
nng lng, bo qun (tang tr)nng lng v s dng nng lng H
2
;nu mt trong ba khu
b ri lon, thy kh nng c bp ca c tim gim dn ti suy tim. Trong suy tim cp , ch yu
l do ri lon to nng lng cn trong suy tim mnh ch yu l do ri lon s dng nng
lng;tuy nhin, vn cn nhiu im cha r.
1. c im c tim:
Khc vi c xng, co c tim l mt qu trnh lin tc, do c tim c nhng c im sau
y:
C tim c mt h thng mao mch rt pht trin, t ra l mt mao mch cho mt si c; lng
mu cung cp chc tim nhiu gp 10-20 ln so vi c xng.
Mng t bo c tim c bit mng,to iu kin co oxy v cc cht dinh dng khuych tn
nhanh chng vo trong t bo
t bo c tim c nhiu ti lp th khng l nng cao cc men vng Krep v cytochrom C
2. Suy tim do ri lon to nng lng:
ri lon qu trnh to nng lng l hu qu ca ri lon chuy ho c tim , c bit l ri
lon chuyn ho protein, gluxit, lipit. Men, din gii, vitamin, oxy_kh. Ngoi rra trong suy tim
cn pht sinh nhng s tahy i v cu trc v chc nng ca mng t bo v ti lp th (l
nhng trung tm tng hp nng lng ca t bo):nh bit, qu trnh to ATP i hi s
nguyn vn ca ti lp th bao gm cc men vng Krp, chui h hp t bo v h thng
cytochromC(ngay thoi bin k kh gluxit cng cn t nht l 16 men tham gia). Thiu oxy man
tnh dn ti gim photphoryloxy ho cng gy ri lon to nng lng.
Cn nhn mnh ti vai tr ca gim hot tnh men (tham gia vo qu trnh oxy ho cc c cht)
trong qu tnh to nng lng tim. Gim hot tnh men y l do ri lon tng hp men,
hu qu ca vitamin(l coenzym ca nhng phn ng men quan trng nht): th d thiu
vitamin B, gy gim cocacboxylaza, cn thit to ra axetyl CoA t axits pyruvic, thiu vitamin B
s c ch men chuyn amin, thiu vitamin B gy ri lon h thng chuyn din t
3. Suy tim do ri loan s dng nng lng:
Nh bit, co c tim ch pht sinh khi ho nng c chuyn thnh c nng . Trong trng
hp suy tim do ri lon s dng nng lng , khng thy ri lon photphyl_oxy hoa v thay
i ATP trong c tim b suy tim mn tnh,nguyn nhn gy suy tim y l gim kh nng co
bp c tim do ri lon s dng nng lng. C th do:
S thay i cua actin-moin(v lng hoc cht )do nhim trng nhim c (bch cu) hoc c
tim lan rng (do ri lon tun hon vnh)
Gim hot tnh ATPaza(trong myosin) hn ch gii phng nng lng t ATP(nng lng ny
cn thit cho hot ng ca bm Na
+
v K
+
nhm duy tr s hng nh v gradien gia Na
+
v K
+

hai bn mng t bo, cn cn thit cho s hot ng ca bm Ca
+
v lm t lin kt gia
actin v moin dn ti trng thi dui c). Nhiu tc gi thy gim hot tnh ATPaza trong suy
tim thc nghim v lm sng ng thi thy kh nng co bp ca c tim. Ngoi ra, cc ion
Mg
++
v Ca
++
rt cn thit cho s hot ng ca men ATPaza (trong myosin). Do thiu Ca
++
gy
gim hot tnh ATPaza dn ti ri lon s dng nng lng v suy tim pht sinh. Thiu Ca
++
c
th do Ca
++
khuych tn kh khn trong c tim ph i, do t c dy ra, di ra v cn do nhng
s thay i v cu trc ca mng li tng c v h thng T.( chc nng ca h thng T l
gip nhanh chng truyn in th hot ng t mng t bo c vo tn tng si t c, cong
mng li tng c th c lin quan n s vn chuyn ca ion Ca
++
cn thit cho co c)
C-RI LON CH TIU HOT NG KHI TIM SUY
1. Gim lu lng:
Khi tim suy, tc l kh nng co bp c tim gim, tim khng y ht lng mu bnh thng
(60ml)vo h ng mch, do lu lng tm thu gim v b dp vo , i khi tim p
nhanh.Song nh vy, tim yu nn khng tng tn s c nhiu v cng p nhanh th sc
co bp cng gim.Lu lng pht khng tng c bao nhiu, khng m bo c nhu cu
ca c th, ng thi tim buc phi p nhanh, nn tim cng suy.
2. Tng th tch mu:
Trong suy tim , th tch mu. Mt mt, khi tim suy, co bp yu khng y dc ht mu ra khi
tim, cho nn mu tr v tim cng khng y , v mu s li h tnh mch.Mu tr nn
qua thn t, lc cu thn gim, gi mui v nc, do th tch mu tng.
Mt khc, trong suy tim, c th lun lun trong tnh trng thiu oxy, tu xng b kch thch
nn tng sinh hng cu, kt qu l th tch mu tng
3. Gim tc mu chy:
Trong suy tim, kh nng co bp gim,nn mu chy chm, c bit h tnh mch, do mu
li phi trong suy tim tri, mu li h tnh mch ngoi vi suy tim phi.
4. Thay i ca huyt p:
Nh bit , huyt p ph thuc vo lu lng tim v sc cn ngoi vi. Trong suy tim, nh trn
phn tch, lu lng tim gim do th tch mu tr v gim v lc co bp ca tim gim, ng
thi sc cn ngoi vi cng gim v co dn mch (do thiu y v tun hon chm) co nn trong
suy tim thng thy huyt p ng mch gim.
Cn huyt p tnh mch bao gi cng tng do tim co bp yu , mu chy chm, c bit h
tnh mch ngoi vi, gy mu tnh mch. Suy tim tri gy tng huyt p tnh mch phi cn suy
tim phi gy tng huyt p tnh mch ngoi vi.
5. Cng v hiu sut ca tim gim:
Cng sut ca tim(w)ph thuc vo huyt p trung bnh (P=100mmHg i vi ng mch )v
lu lng tm thu (Q): W=P.Q Khi tim suy, nh phn tch, lu lng tm thu gim, ng thi
huyt p trung bnh cng gim, kt qu l cng sut ca tim gim.
Nu mi pht c tim tiu th 30ml oxy v bit rng c 1000ml oxy tng ng vi
19600N/m(newtn)th nng lng tiu th vo co0 tim l 588N/m, Vy hiu sut ca c tim
bng 62,23/588(62,23N/m hay Jun y l cng ca ton b tim trong 1 pht), tc l bng
10%. Khi tim suy , nh phn tch trn cng sut ca tim gim, ng thi tim suy thng
p nhanh tiu th nhiu oxy hn,kt qu l hiu sut ca tim gim.
Do , khi nhu cu oxy ca c th tng ln bt thng(st, lao ng nng), th cng ca tim
suy tng rt kh khn. By gi ch cn hai bin php l tng tn s p v tng s dng oxy.
Song khi tim suy, th khng th tng tn s c nhiu v lc bnh thng tim suy p
nhanh, cn tng cng s dng oxy cng b hn ch v bnh thng tim tiu th nhiu oxy
hn cc c khc. Do , opht sinh mt vng xon bnh l lm cho suy tim thm nng.
D-RI LON CHUYN HO TRONG C TIM B SUY
Bnh thng, c tim cng nh cc c vn, co c l nh s thu phn ATP bi myosin(c hot
ATPaza cao).ATP cn dng c cung cp lu di bi qu trnh photphoryloxy ho, nhng ngay
tc khc th bi ngun photphocreatin d tr:
ADP + photphocreatin ATP + Creatin
Nhng c tim c im khc cc c vn ch n c kh nng hot ng lu di(ging nh c
cnh bay ca chim), cho nn chuyn ho nng v ua kh. Trong c tim c rt nhiu men LDH loi
H (khc vi LDH loi M c xng)gip cho n chuyn ho khng nhng axt bo, th xton
mac c lactat na. Khi thiu oxy , men LDH loi H s khng hot ng c, do c tim chu
ng thiu oxy rt km
1. Ri lon chuyn ho gluxit
Tim suy li phi tng cng hot ng nn cng d thiu oxy, do pht sinh nhiu ri lon
chuyn ho , c bit l ri lon chuyn ho gluxit:gim lng glucogen trong c tim, tng axit
lactic v pyruvic v c tim khng chuyn ho c trong iu kin thiu oxy. Ri lon chuyn
ho cc cht trong c tim dn ti nhim toan c nh m hu qu l gim d tr nng lng.
2. Ri lon chuyn ho phtphocreatin:
photphocreatin ng vai tr dy ni giu nng lng, tham gia vo co c. Photphocreatin l do
creatin c photphoryl ho c giy ni giu nng lng nh chuyn ho gluixit m ra. Nh
nu trn, trng thi nhim toan gy gim nng lng ca tim, cho nn khng c ti hi phc
photphocreatin, tc l khng c nng lng d tr tham gia vo qu trnh hi phc ATP
trong c tim suy, ngi ta thy gim creatin r rt
3.ri lon chuyn ho K
+
v Na
+
:
Cng ngy ngi ta cng thy vai tr quan trng ca ion K
+
v Na
+
khng nhng trong tnh chu
kch thch ca si c m cn trong qu trnh photphory ho AMP v ADP thnh ATP v creatin
thnh photphocreatin
Trong c tim suy, ngi ta thy gim K
+
do nhim toan, khin cho qu trnh tng hp ATP va
photphocreatin b ri lon. Nh vy, trong c tim suy , d tr nng lng giam nghim trng
hn ch su sc kh nng p ng vi yu cu ca c th, tc l tim suy.
Tm li, thiu oxy l mt u t quan trng trong qu trnh pht trin suy tim v binh thng c
tim tn dng oxy mnh hn cc c vn khc, nn khi c th thiu oxy nn s ti tng hp li
trong c tim, c bit l axit lactic. Cng do thiu oxy nn s ti tng hp ATP v
photphocreatin gim lm cho hot ng ca tim yu i.
D-C CH CA NHNG BIU HIN SUY TIM TRI V SUY TIM PHI
Nh nu trn y, trong suy tim thng thy gim lu lng tim v tng huyt p tnh
mch, do nh hng su sc ti v nhiu chc nng sinh l{. Song tuz theo suy tim tri hay
phi m biu hin cng nh c ch khc nhau.
Nhng biu hinchnh ca suy tim tri:
a) Kh th: y l biu hinthwng gp v quan trng nht. Ngi bnh thng th nng v
nhanh, c cm giac ngt, nht l sau khi gng sc(lao ng ,ln cu thang ).Kh th trong suy
tim tri l do tim tri co bp yu, khng y ht mu ,dn dn pht sinh mu phi.Mu
phi lm cho t t chc phi bt co gin ng thi cc mao mch phi cng mu gy chn p
cc ph nang,kt qu l hn ch lng khng kh, gy kh th. Ngi bnh thng hay kh th
khi nm l do t th ny gy mu phi nng nht,cho nn ngi bnh thng ngi th d
th hn. Kh th khi nm l mt triu chng thng thy khi c suy tim tri, n khi c suy tim
phi th triu chng ny gim c mu tnh mch ngoi vi nn v phi t i ngi suy tim tri
c nhng cn kh th xy ra ban m, ging nh cn hen (thng gi la hen tim) do dy X tng
cng hot ng trong gic ng, gy xung huyt phi v co tht c trn ph qun
b) Ph phi: mu phi gy tng p lc thu tnh trong mao mch phi khin nc thot vo
ph nang gy ph phi ma tnh nghe phi thy ting rn t c hai th c bit r nn phi
i khi, c th pht sinh ph phi cp . y l bin chng nguy him nht ca suy tim tri ,
thng do tim phi vn cn kho bt cht tng hot ng(do gng sc chng hn) y mt s
mu qu nhiu ln phi, ng thi trng thi thiu oxy trong t chc lm cho thnh mao
mch tng thm, kt qu l mu s o t vo ph nang gy ph phi cp , lm cho bnh nhn
cht trong trng thi ngt ti cp din nu khng kp thi iu tr. Ngi bnh giy da, lo s
lm cho tnh trng nng thm v tim phi tng co bp li cng dn mu ln phi. Cho nn trong
iu tr ngi ta lm garo chi(hoc chch mu tnh mch)d gim gnh nng i vi phi,
dung thuc tr tim phc hi co bp ca tim tri b suy, kt hp vi mocphin ngi
bnh yn tnh
c) Ph dung sinh hot gim:tnh trng mu phi lm gim tnh co gin ca t chc phi , hn
ch thng kh phi, dn ti gim ph dung sinh hot. Suy tim tri ko di c th dn ti x phi
2. Nhng biu hin chinh ca suy tim phi:
Nu nhng biu hin ca suy tim tri phn ln thuc v triu chng phi th nhng biu hin
ca suy tim phi ch yu thuc v khu vc tnh mch ngoi vi
a) Ph: trong suy tim phi do nhiu yu t kt hp li:
- huyt p tnh mch tng lm cho nc thot ra khi mch nhiu, ng thi cn tr s ti
hp thu nc t gian bo vo lng mch. y l yu t ch yu
- gim p lc keo trong lng mch do gim protein huyt tng (hu qu ca ri lon chc
nng gan)
- ng nc v mui do gim lc cu thn
b) Gim bi tit nc tiu, do lu lng mu qua thn gim, ng thi mu tnh mch thn
gy gim p lc lc cu thn, gim lng nc tiu, dn ti mui v nc, gy ra ph
c) Ri lon chc nng gan: trong suy tim phi, mu gan lng mu gan c th tng gp
i(t 400 ln 800 ml).Th tch gan to ra , b di c th xung ti ng rn. iu tr tt, tim
phc hi kh nng co bp mu lu thng d dng, gan s nh li ri li to ra khi tim suy tr
li. Do , m gan khi to khi nh tuz theo kh nng co bp ca tim(gan n xp). Dn dn v
sau, tnh trng thiu oxy do tun hon km ko di gy thoi ho m, ri qu trnh x ho pht
trin t khong xung quanh tnh mch gan,lu ngy dn ti x gan gy tng huyt p gnh v
trn dch mng bng(c trng, bng nc)
d )Xanh tm: triu chng ny hay gp ngi suy tim nng, thy r mi , mng tay c
th c th l:
-do khi lng mu lu thng gim nn huyt sc t khng c bo ho vi oxy hemoglobin
kh tng
- cc mao mch, tnh mch b dn v mu
3. Trong suy tim ton b:nhng biu hin ca suy tim phi c suy tim tri kt hp vi nhau
Tm li, tim l mt c quan c kh nng thch nghi cao song kh nng ny cng c hn v khi
gim st s dn ti trng thi suy tim. S hiu bit v c ch suy tim cho ta thy r cn phi
chn on suy tim cng sm cng tt c mt ch sinh hot v iu tr thch hp i vi
bnh nhn suy tim.
[newpage]
III. RI LON CHUYN HO CA MCH MU
Nhng ri lon hot ng cuat mch mu biu hin c th s thay i ca huyt p
Nh d bit, huyt p , lu lng v sc cn ngoi vi lin quan cht ch vi nhau, theo cng
thc LR/P=K, trong L l lu lng ca tim, R l sc khng ngoi vi, P l huyt p v K l hng
s
1.Lu lng tim:
Lu lng tim ph thuc vo th tch mu tr v v sc co bp ca c tim
a) th tch mu tr v. l lng mu do h tnh mch co tim phi. Bnh thng, n chnh
l lu lng tm thu trong lng mch, h thng tnh mch c mt vai trt quan trng, v cha
ti 65-67% ton b th tch mu, cho nn mu tnh mch s gy gim lu lng tim
b) sc co bp ca c tim. Mu tr v tim c nhiu khi tim c kh nng y mu i. C tim
bp cnh mnh th th tch mu tr v cng nh lu lng tm thu cng tng , do huyt p
ti a v ti thiu u tng
2. Sc cn ngoi vi:
l t lc m tim phi thng dy mu t tm tht tri ti tim phi. Tr lc ny ph thuc
vo:
nht ca mu:khi nht tng, th tm tht tri phi tng cng co bp mi y mu l
thng trong lng mch. Cho nn trong bnh tng hng cu thng c huyt cao. Tri li, khi
nht gim (nh trong thiu mu, mu long)thng thy huyt p gim
co gin ca thnh mch: y l yu t chnh nh hng ti sc cn ngoi vi. Khi co mch,
sc cn ngoi vi tng, huyt p tng tri li khi gin mch sc cn gim huyt p cng gim
theo. Trong bnh x cng ng mch v x va ng mch, thnh ng mch gim co bp,
cng li, do sc cn ngoi vi tng v huyt p tng ngi bnh thng, huyt p khng
thay i nhiu , do hot ng phi hp ca lu lng tim v sc cn ngoi vi: nu mt trong
nhng y t bt cht thay i, nhng yu t kia s hot ng b ngay,nn t nh hng ti
huyt p. Trong iu kin bnh k, nhng yu t trn y thay i qu ln, vt kh nng b
p, s nh hng su sc ti huyt p, gy gim hoc tng huyt p.
Vit Nam, khi huyt p ti a trn 140mm Hg v huyt p ti thiu trn 90mm Hg, c coi
l tng huyt p. Cn khi huyt p ti a di 90 mm Hg l c huyt p gim
Nu huyt p cao l mt trng thi bn l{ ko di v thng kt thc bng mt bin chng
nhuy kch th huyt p gim l mt triu chng quan trng nh no tim.. Huyt p gim thng
gp trong sc, tru tim , mch ngt. Cn huyt p cao c th l mt bnh hoc mt triu chng
gp trong nhiu bnh
A-SC
Trong tt c cc trng hp sc(cn gi l chong ), u thy huyt p gim nghim trng. y
l mt chi tiu quang trng nh gi mc v tin lng ca sc. Trng thi sc do rt
nhiu loi nguyn nhn gy ra (sc chn thng, sc chy mu, sc bng do c t, sc do
truyn mu nhm loi) song ni bt ln l sc chn thng do tnh cht ph bin v tnh cht
nghim trng ca n.
Sc chn thng l mt trng thi suy xp t ngt ca ton b chc nng quan trng ca c
th, do chn thng gy ra :
Sc do chn thng chin tranhl loi sc kt hp , bao gm nhiu yu t : tn thng nghim
trng, mt mu, nhim trng, nhim c, bng ,vv...
S mt mi qu sc, trng thi tinh thn cng thng, i kht, nng lnh qu , c th suy
nhc, vv... l nhng iu kin thun li cho sc pht sinh v pht trin .
1. cc giai on ca sc chn thng:
giai on t b p: biu hin bng hai trng thi phn ng:
trng thi t b p qu mc v tm thi (thng c gi l sc cng) m c im l s
tng cng hot ng ton b chc nng ca c th ni ln trng thi hng phn h thn
kinh trung ong
bnh nhnn trong trng thi kch thch ,vt v, ku au, da v nim mc nht nht , mch
nhanh v mnh, huyt p tng, th nhanh v su Giai on ny thng khng qu 2-30 pht
trng thi t b p kn o v tm thi (gi l sc tim ) :sc pht sinh nhng kn o, cha
biu hin r. Thng binh b thng nng son n vi huyt p ng mch bnh thng, iu
ng ch { l mch nhanh yu (100-140 p/pht),mch vn nhanh mc d c yn tnh,
tim thuc gim au. Trong sc tim, tuy vt thng nng, khi lng mu lu thng
(KLMLT)gim song nh c c ch b p, co mch nh nn HAM cn gi c mc bnh
thng, nhng tim phi lm vic gp bi b vo KLMLT gim. Do , trong sc tim, ch cn
mt chn thng ph, mt mt lng mu nh hoc x tr mun l sc nhc tr li ngay.
Tm li, khi b chn thng,c th c nhng phn ng thch ng bng cch huy ng cc lc
lng d tr b p vo cc ri lon do chn thng gy ra. Song sc cng cn li l mt
qu trnh tiu hao nng lng d tr v nu ko di s c hi, dn ti giai on th hai l giai
on mt b.
b) Giai on mt b( thng gi l sc nhc)
giai on ny biu hin s suy sp ton b cc chc nng quan trng ca c th, ni ln trng
thi c ch h thn kinh trung ng, ngi bnh nm yn,th vi ngoi cnh, vn tnh, hi
th tr li yu t, sc mt nht nht, m hi lnh dnh da, th yu, mch nhanh yu, huyt p
gim, thn nhit gim Nu khng kp thi iu tr, sc nng c th chuyn sanh sc khng hi
phc, gy cht.
c ch mt s triu chng ch yu trong sc chn thng:
Ri lon tun hon
ri lon vi tun hon. y l yu t bnh sinh ch yu chi phi qu trnh pht sinh, pht trin v
kt thc ca sc
trong sc cng, di tc dng ca Stress chn thng, catecholamin tng tit gy co c tht
trc v sau mao mch(tr tun hon vnh v no), gy thiu oxy t chc do thiu mu . Co c
tht tng sc cn ngoi vi, lm m ng thng ng tnh mch nhm dn mu cho cc ni tng
quan trng nh tim , no(hin tng ny gi l trung tm ho tun hon). Ti giai on
nhc, trng thi nhim toan chuyn ho- do thiu oxy t chc- lm cho c tht trc mao
mch khng nhy cm i vi catecholamin, trong khi khng nh hng ti c tht sau mao
mch, do mu vo mao mch d dng nhng thot ra kh, gy ra thiu oxy do thiu mu,
khin cho t chc ni tng b hoi t, c bit l hoi t rut
do hin tng mu k trn, p lc thu tnh trong mao mch tng, gy thot huyt tng.
Ngoi ra do thiu oxy, tnh thm thnh mch tng cng tng cng hin tng thot huyt
tng , thot huyt tng gy hin tng qunh muv nghn mch vi th, to iu kin
cho hoi t t chc d pht sinh
mu h thng mao mch kt hp vi thot huyt tng dn ti gim KLMLT m hu qu l
thiu oxy ton thn. C phc hi c KLMLT( bng truyn dch kt hp vi thuc dn mch),
iu tr mi em li kt qu tt
b) Thay i ca huyt p . Trong sc cng chn thng, huyt p ng mch nht thi tng,
sau gim, ri c khuynh hng hi phc ri li gim. huyt p tng trong giai on cng l
do trung khu co mch hng phn v tng tit catacholamin gy co mch (nh phn tch
trn ). ng ch { l co mch trong sc cng khng bn vng : chy mu thm khng qu 5%
tng lng mu lm cho huyt p tt ngay
ti giai on nhc, huyt p gim ch yu do gim KLMLT (nh phn tch trn ), ngoi ra
cn do suy mch cp (do trung khu vn mch b c ch)
co mch trong sc chn thng l mt c ch thch ng b p mu bnh l(ch yu h
thng gnh )pht sinh sm v thot huyt tng, pht sinh mun, dn ti gim KLMLT, co
mch c tc dng nng huyt p, to iu kin cho c th thch nghi vi hon cnh mi
thay i ca mch: trong sc cng, mch nhanh v mnh do trung khu tim p nhanh hng
phn v do tng tit catecholamin. Ti giai on nhc, mch nhanh v yu : mch nhanh do
huyt p gim, thng qua ph x Mary, kch thch trung khu tim p nhanh, cn mch yu
do gim KLMLT, tim hu nh bp rng. Mch nhanh (trn 130-140 ln /pht), yu, ngay c khi
huyt p cn tng i tt, ni ln lin lng xu. Sc cng nng mch cng yu, cng nhanh.
Mch trung thnh hn huyt p.
b)ri lon h hp: trong giai on cng, h hp nhanh v su c tc dng b p, do trung khu
h hp hng phn . Ti giai on nhc , h hp nng, nhanh hoc chm, lon nhp, c th
pht sinh h hp chu k do trung khu h hp b c ch(c ch t trn lan xung v do thiu oxy,
hu qu ca gim KLMLT). Tin lng rt xu nu suy h hp pht sinh sm
khi b sc chn thng, h hp b ri lon sm hn v nghim trng hn so vi sc mt mu v
c th sinh bnh cng phc tp hn.
c) thay i ca mu : trong sc chn thng, thng km theo mt mu, cc tc gi thy mu
c khuynh hng long do dch gian bo vo mu b vo lng mu mt i (thm ch c trng
hp hng cu gim ti 2-1,4 triu/mm
3
v huyt sc t ch cn 42-30%)
cn trong sc bng, thng thy mu c(do thot huyt tng vt bng), song thc t li l
thiu mu(do hng cu b hu t di tc dng ca nhit cao)
d) Ri lon tit niu: trong sc chn thng, lng nc tiu gim r rt , thm ch khng c
(suy thn cp), ch yu do gim KLMLT, ngoi ra cn do c tiu ng mch dn ti cu thn gy
gim lc, ng thi tng tit ADH v aldosteron gy ti hp thu nc
lng nc tiu, gi l mt ch tiu quan trng chn on, tin lng sc ng thi quyt
nh lng dch cn truyn
c trng hp, do iu tr,huyt p hi phc, song ngi bnh vn cht do suy thn cp (tn
thng ch yu l vim ng thn cp)
2. bnh sinh sc chn thng
C nhiu thuyt nhm gii thch c ch bnh sinh sc chn thng. Song hin nay, cn tn ti
hai thuyt:
thuyt mt mu v thot huyt tng
Thuyt thn kinh phn x
a) thuyt mt mu v thot huyt tng. Theo thuyt ny, sc pht sinh l do khi lng mu
lu thng gim, hu qu ca mt mu vt thng v thot huyt tng do tng tnh thm
mao mch. Trong thc t, chn thng nng thng km theo chy mu v nhiu tc gi ca
tng vic truyn mu sm vi khi lng ln trong iu tr sc chn thng.
Tuy nhin, trn c s coi sc chn thng v chy mu cp tnh ch l mt th l mt iu sai
lm. Trong chy mu nng, ri lon tun hon xy ra trc do gim khi lng mu lu thng,
ng thi cc c ch thch ng b p cn pht huy tc dng mt thi gian di. Cn trong sc
chn thng, ri lon thn kinh pht sinh trc , do hn ch cc c ch thch ng b p.
Ngoi ra, sc chn thng c th pht sinh m khng km theo mt mu hoc ch mt mu t.
Cn thot huyt tng pht sinh mun, khi c nhng ri lon tun hon nghim trng. Trong
sc chn thng, khi lng mu lu thng gim ch yu do mu bnh l{ (c bit h
thng gnh) pht sinh sm trc khi c gim huyt p
Tuy nhin, mt mu v thot huyt tng nu khng gy sc th cng lm cho sc d pht sinh
v sc thm nng
b) thuyt thn kinh phn x. Theo thuyt ny, ri lon hot ng thn kinh l yu t ch yu
gy ra sc chn thng. Chn thong gy tn ti ch, ng thi cn kch thch mnh cc th
th ti ch, lung xung ng c dn truyn ln no, gy ra mt trng thi hng phn cao
lan rng ra khp no, c tc dng tng cng cc chc nng sinh l{ nhm bo v c th( sc
cng). Ti cui giai on b p, do hng phn cao , nng lng d tr gim r rt, by gi
pht sinh trng thi c ch c tc dng bo v, trnh kit qu cho t bo thn kinh.Nu chn
thng rt nng, c ch c th lan ti cc trung khu thc vt quan trng(trung khu h hp, vn
mch)gy suy mch cp v suy h hp cp, lm cho tnh trng thiu oxy thm nghim trng
ca c th( sc nhc), c th dn ti sc khng hi phc
c) thiu oxy trong sc. Trong sut qu trnh sc, ni bt ln hng u l trng thi thiu oxy,
thiu oxy l hu qu ca ri lon tun hon(gim khi lng mu lu thng)v ri lon h hp
(suy h hp)
no_ mt t chc c trnh bit ho cao nht, mn cm nht i vi thiu oxy. ng ch { l
trong sc , fo s phn phi li mu, no v tim c cung cp nhiu mu hn cc tng khc. Khi
sc din bin mnh, trng thi thiu oxy c tnh cht ton thn, lm cho sc thm nghim
trng. Ri lon thn kinh gy ra, dn ti trng thi nhim toan chuyn ho nh hng su sc
ti hot ng ca h thn kinh cng nh cc ni tng khc
ri lon thn kinh, ri lon ni tng, ri lon chuyn ho, thiu oxy lin quan mt thit vi
nhau, to ra mt vng xoy c bnh l dn ti sc khng hi phc nu khng kp thi iu tr
B - TRU MCH
Tru mch l tnh trng suy mch cp do cc trung tm vn mch b c ch su sc dn ti gin
mch ton b, c bit l tnh mch. Khi lng mu lu thng gim, mu tr v tim t, tim hu
nh bp rng, mu khng ln c no,khin cho cc trung tm thn kinh b c ch su sc,
do ri lon vn mch thm nghim trng. Ngoi ra thiu oxy t chc gy ra ri lon chuyn
ho gluxit, lipit, protein pht sinh nhim toan. Gan thiu mu tit ra cht dn mch ( VDM, tn
tt ca vaso dilatatr material ) cch lm cho mch dn thim. mu h thng gnh hn
ch ch nng hng ro v gii c ca rut- gan, lm cho nhim c thim nng.
Try mch c th do nhiu nguyn nhn gy ra:
a) Nhim khun: tnh trng ny xy ra vo lc nng nht ca bnh, do c t ca vi khun cng
nh sn phm chuyn ha tch li gy nhim c thnh mch, trung tm vn c v c c
tim. Trong thc nghim ngi ta gy try mch bng cch tim mt liu c vi khun kit l
hoc c t vi khun bch hu, thng hn cho th, ch. Sau khi tim mt thi gian ngn,
huyt ng mch v tnh mch tt nhanh, con vt giy gia, c th cht ngay. M xc, thy
mu ni tng, c bit l bng
b) Thay i t th: Thng gp nhng bnh nhn nng, phi nm lu, do khi ng ln, mu
theo trng lng dn xung phn di c th. Bnh thng cc th th xoang ng mch
cnh v quai ng mch ch, thng qua trung tm vn mch, gy co mch, dn mu ln no,
song d8ay cc trung tm hon ng yu thch nghi khng khp, mu khng ln no, gy try
mch.
c) Chc tho nc bng: Nu tho ht dch, c th gy try mch v mch ni tng c gii
phng t ngt dn qu mc, gy gim khi lng mu lu thng, m hu qu l thiu mu
no. Do , khng nn chc tho ht v sau khi chc, nn bng cht bng ngi bnh.
d) thiu oxy: mt s ngi, khi ln ni cao hay khi th khng kh thiu oxy, c th pht sinh
try mch: gim huyt p, mch nhanh yu, ngi bnh bt tnh
C- NGT
Ngt l mt trng thi bnh l{, trong ngi bnh mt tri gic bt thnh lnh trong mt thi
gian ngn
Ngi b ngt thng c cm gic chong vng, xy sm mt my, chn tay r ri, tot m hi,
au ngc hay bng trn, mt mi bun nn ri ng vt xung bt ng, mt ti nht, ng
t dn, h hp chm. Thng ngi bnh phc hi tri gic khi c nm yn tnh sau mt thi
gian ngn.
C ch ca ngt l do v mt nguyn nhn no , mu khng ln no, lm cho no lm vo tnh
trng thiu oxy t ngt.
1. Nguyn nhn gy ngt:
a) Nguyn nhn do tim :
-Hng phn dy X. By gi tim p rt chm, khng m bo lu lng mu, nn gy thiu mu
no. Tnh trng ny thng gp khi tnh cm th ca xoang ng mch cnh qu cao hoc trong
phn x nhn cu- ph v. nhng ngi c tnh trng ny, ch cn n mnh vo c hay mt
cng c th gy ngt.
- Ri lon dn truyn nh tht cn gi l hi chng StecAdam ( Stocckes Adam ) trong trng
hp ny, tim p rt chm(30- 40 p/ pht) lm cho no b thiu mu, gy ra ngt.
- Lon nhp tim: trong cn tim p nhanh, rung tim, tim khng kh nng co bp y mu ln
no, gy ra ngt.
Ngoi ra, trong h van ng mch ch, khi lm vic nng, c th pht sinh ngt do mu dn ti
c ln no it.
b) Nguyn nhn ngoi tim:
- Cc phn x au n, s hi, phn x nim mc mi gy ri lon trung tm vn mch v
trung tm iu ha hot ng tim c th gy ngt.
- Ngt khi thay i t th( t nm sang ng) c th gp mt s ngi khng c bnh thc
th, do trng lc mch ln v phn ng thn kinh chm.
- Khi mu lu thng t tim ln no b tr ngi( bnh huyt p cao, phng ng mch no ) c
th pht sinh ngt.
c bit mt s loi bnh nhn hut p gim khng r nguyn nhn: khi ng dy, huyt o
ti a c th tt xung 40 mmHg v ti thiu OmmHg, bnh nhn chng mt v ngt.
2. Phn bit ngt v hn m, sc v try mch:
- Ngt lhc vi hn m ch l hn m cng mt tri gic, song t t, ko di v khng t hi
phc c
- Ngt khc vi sc l nhng bin i v h tim mch trong ngt xy ra nhanh chng, bt thnh
lnh v t ng hi phc. Sc thn kinh chng qua l ngt do tc nhn tm lz gy ra.
- Trong nhiu trng hp, rt kh phn bit ngt vi try mch, v c th bnh sinh ca hai
trng thi c im ging nhau l u thiu mu no. Try mch thng xy ra nhng
ngi c v bnh thng hay tht s bnh thng.
- Phn bit sc v try mch : Trn thc t lm sng, bnh cnh cng nh c ch bnh sinh try
tim mch v sc thng hay nhm ln vi nhau. C l ch tiu phn bit sc v try mch l qu
trnh din bin: try mch xy ra rt nhanh cn sc phi c thi gian bin chuyn. Trong sc
cng c try mch cp ( tc l try mch ) song ch xy ra giai on mun; tri vi try mch
xy ra t ngt, sc bao gi cng din bin qua hai giai on b p v mt b
D- HUYT P CAO
Huyt p cao l mt qu trnh bnh l ph bin trn th gii : theo thng k gn y th c ti %
dn s b huyt p cao
Vit Nam khi huyt p ti a trn 140mmHg v huyt p ti thiu trn 90mmHg c coi l
cao. Vit Nam t l huyt p cao nhng bnh nhn tim mch ti bnh vin nh sau:
- Min Bc Vit Nam : 12,3% (1962)
- Min Nam Vit Nam : 15,4% (1967)
Da theo con s huyt p ngi ta phn bit:
Tng huyt p c ti a v ti thiu: thng gp nht c gi tr nht v bnh l.
Tng huyt p ti a:c nhiu kin cha thng nht.
Tng huyt p ti thiu: hai kh nng, hoc s ti a b gim do suy tim tri, hoc s ti thiu
tng do suy tim phi.
ng ch { l: ngi bnh thng con s ti a c th tng ti 150- 170mmHg t 50 tui tr
ln.
Tng huyt p l mt triu chng ca nhu bnh. Nhng c th l mt bnh, bnh tng huyt
p, nu khng tm thy nguyn nhn. Theo mt vi liu php:
- 40% tng hut p triu chng (c nguyn nhn)
- 60% tng huyt p bnh (khng thy nguyn nhn)
Tm ra nguyn nhn tng huyt p l mt vn rt kh khn. C ch bnh sinh ca tng huyt
p c bn ci trn 100 nm nay m vn cha r rng.
1. Tng huyt p triu chng:
Nhng nguyn nhn thng gp l; bnh thn, ri lon chuyn ha, ri lon ni tit.
a) huyt p cao do bnh thn:
t lu, trn lm sng ngi ta nhn thy mt s bnh thn ( vim cu thn cp, vim cu
thn mn, vim k, hp ng mch thn ) hay c huyt p cao km theo.
Trn thc nghim, ngi ta gy c huyt p cao bng cch lm hp ng mch thn c
hai bn.
Hin nay, ngi ta chng minh c c ch bnh sinh ca tng huyt p do thn: khi thn
thiu mu, renin c tit ra nhiu s lm tng angiotensin II trong mu v gy huyt p cao.
Gn y ngi ta nhn thy c s lin quan gia tit renin v aldosteron v c kin nh gii
thch l renin gy tng tit aldosteron, do tng ti hp thu Na+ lm thay i tnh cht ca
mng t bo, gy tng tnh kch thch ca c trn v lm tng huyt p.
b) Huyt p cao do ri lon chuyn ha: trong lm sng, t lu ngi ta nhn thy huyt p
cao hay gp nhng ngi cao tui d b x va ng mch (VXDM). Trong bnh ny,
cholesterol ng trong lp di ni m ng mch ch, cc ng mch ln, ng mch vnh,
ng mch no
Ngay t N.N.Anhicp nu vai tr ch yu ca cholesterol trong bnh sinh x va ng mch:
trong thc nghim, cho ng vt (ch, th, g) n nhiu cholesterol thy c th gy c x
va ng mch. Ngi ta nhn thy cholesterol mu tng dn vi tui, song song vi t l mc
x va ng mch. Trong cc ng vt c v thy tng huyt p hay gp ngi hn l cc
ging khc, c l v bnh thng ngi m cholesterol mu (70% trong bta lipoprotein)
cao hn cc loi khc ( ch 17%, th 47%... ) nn d lng ng thnh mch v gy x va
ng mch.
Tuy nhin, cholesterol mu tng khng phi l nguyn nhn tt yu v duy nht gy x va
ng mch: c nhiu trng hp cholesterol mu tng song khng b x va ng mch, tri li
cholesterol mu bnh thng song vn b x va ng mch. C rt nhiu yu t gy ra x va
ng mch, ch yu l :
- Tn thng thnh mch (trc khi c lng ng lipit)
- n qu nhiu lipit ( c bit l cholesterol), li t vn ng.
Ri lon chuyn ha lipit do nhiu nguyn nhn gy ra, c bit l trng thi cng thng tm
thn kinh ko di (m xc 300 lnh m cht trong cuc chin tranh xm lc Triu Tin, thy c
ti 70% b x va ng mch sau mt nm chin u cng thng)
c) Huyt p cao do ri lon ni tit
t lu, ngi ta nhn thy huyt p tng trong nhiu binh ni tit, nht l bnh tuyn
thng thn . U ty thng thn ( c tng tit adrenalin ) gy tng huyt p tng cn hay c
nh, trong hi chng c sinh ( Cushing), mt triu chng quan trng l tng huyt p, song c
ch cn cha r, c l v c tng ACTH nn tng tit desoxycoctioseron. Trong hi chng Cn
(Conn) tng tit aldosteron tin pht do u v thng thn- huyt p tng c th do nhiu c
ch.
Ngoi ra, cn thy aldosteron cng nh desoxycocticosteron c tc dng trc tip ln thnh
mch gy tng huyt p, c l chng lm tng tnh cm th ca mch ngoi vi i vi nhng
cht gy co mch nh Adrenanin.
2. Bnh tng huyt p:
Trn y cp ti tng huyt p l mt triu chng ca nhiu bnh, do nhiu nguyn nhn
gy ra. Song c th l mt bnh- bnh huyt p cao nguyn pht nu khng tm thy nguyn
nhn. C th do ri lon thn kinh trung ng lm mt s iu chnh vn mch, h thng tiu
ng mch co li, gy tng huyt p.
Trn lm sng, bnh huyt p cao hay gp nhng ngi phi lo ngh nhiu, nhng ngi lm
vic tr c, hoc lm vic nhng ni nhiu ting ng. Nhng nguyn nhn gy ri lon hot
ng v no nh s hi, lo bun, chn thng tm l{ ni chung l nhng cm xc tm l c th
gy huyt p cao. Vit Nam t l b huyt p cao trong cn b l 3,4%, trong cng nhn l
2,6%, cn nng thn v min ni ch chim 1- 1,7%. Trong chin tranh s ngi b huyt p
cao tng r rt.
t ly, ngi ta thy r vai tr rt quan trng ca thn kinh trong iu ho huyt p. Trng
phi X- Vit cho rng bnh huyt p cao l do ri lon hot ng thn kinh cao cp, tc l v
no, thng qua tng di v v h ni tit, l c quan kim sot, iu ha mi qu trnh xy ra
trong c th, ng thi m bo s thng nht gia c th v ngoi m. Bnh thng v no c
tc dng kim ch tng di v. Di tc dng ca nhng kch thch t trong hay t bn ngoi
ti m cng vt qu gii hn chu ng ca t bo v no, by gi v no s lm vo
trng thi c ch, khng cn tc dng c ch tng di v v s pht sinh hng phn hn
lon, gy ra nhng hn lon hot ng ca cc ni tng, c bit l gy tim p nhanh v co
mch, dn ti tng huyt p.
Huyt p cao do ri lon thn kinh mt khi hnh thnh c th nh hng ti thn, gy thiu
mu, tng tit renin, do huyt p cng tng, to ra vng xoy c bnh l ( hnh 3)
3. Nhng hu qu ca tng huyt p:
Huyt p cao l do co mch, cho nn cc triu trng l do cc c quan b thiu mu gy ra.
Thng thy: nhc u, chng mt, chng mt, tr nh gim, khng tp trung t tng, tnh
tnh thay i, ng t, mt km- i khi c cm gic t di: kin b chn tay
Huyt p cao c th gy ra mt s triu chnghuyt p cao tng sc cn ngoi vi, buc tim tri
phi tng co bp, dn dn ph i, ri suy tim tri. Cc mch mu b x nn d v, nguy him
nht l nhi mu c tim v chy mu no, nhng bin chng ny hay gp nhng ngi cao
tui c huyt p cao

53. SINH L BNH H TIT NIU

( NGUYN HU M )

B my tit niu bao gm nhiu b phn tronh thn ng vai tr ch yu.Thn c hai chc
nng:chc nng ni tit(to renin v erithropoetin) v chc nng ngoi tit.Chc nng ngoi
tit ca thn nhm duy tr tnh trng hng nh ca ni mi,c th l thng qua bi tit nc
tiu :
-Thi tr cc cn b ca chuyn ha protein
-Thi tr cc cht c
-n nh cc thnh phn l ha ca ni mi
-iu tit cn bng axit-baz
-iu tit cn bng nc in gii
Qu trnh bi tit nc tiu thc hin c l nh c chc nng lc ca cu thn,chc nng ti
hp thu v chc nng tit ca ng thn.
m bo cho thn hot ng,lng mu ti thn kh nhiu:trng lng ca thn ch chim
5% trng lng c th song lng mu ca thn ln ti 25% lu lng tun hon ca c
th(trung bnh mi pht khong 1,2l mu qua thn).
I.NHC LI C IM CHC NNG TIT NIU
A-C IM V CU TO CA THN
Nu i t pha mao mch ca cu thn ti bao Bao-man,ln lt qua cc lp sau:
-Lp t bo ni mao mch:to thnh mt mng r (ng knh 0,1 micromet)
-Mng nn ca thnh mao mch.
-Lp t bo lt c nhiu chn xen k vi nhau (gi l t bo chn) bm vo mt ngoi mng nn
mao mch.
-Lp t bo lt n ca bao Bao-man l thnh ca bao ny cn c l tng do t bo chn to
nn.
Qu trnh lc cu thn l s khuch tn qua mang nn mao mch.
Nhng lp t bo ny bnh thng cho lt qua mi thnh phn ca huyt tng vo nang
thn,tr nhng protein c trng lng phn t ln,trn 68000.Hemoglobin(68000) qua c
cu thn, cn albumin huyt thanh(70000) b cu thn gi li.Khi cu thn b tn thng nh
trong vim cc protein mu c th ra nc tiu(protein niu).
Cnh cu thn c mt t chc gm nhng t bo rt nhy cm i vi thay i ca huyt p(gi
l b my cnh cu thn):khi huyt p gim th t bo ny tit ra men renin,men ny vo mu
gy co mch ng thi gy tng tit aldosteron nhm phc hi huyt p.
mi thn c ti 1-1,5 triu nhng dn v thn(tiu thn),lin kt vi nhau bng t chc lin
kt(cn gi l t chc khe) trong c mch mu,mch bch huyt,dch gian bo v thn
kinh.Cc tiu thn khng hot ng cng mt lc m ch tng phn mt,thay phin nhau hot
ng.Do m thn c kh nng b rt mnh nht l khi ct mt thn.Song v mt bnh l{
cng l mt kh khn,v nhng tn thng b phn ca t chc thn nhiu khi khng c biu
hin r rng kp thi pht hin.
ng mch ti thn ngn,i thng t ng mch ch vo ri chia nhnh ti cc cu thn,to ra
b mao mch ri tp trung thnh mch ra,ti ng thn li phn chia thnh mng mch bao
quanh ng thn ri mi v tnh mch,to ra h thng tun han gnh ca thn.Do trc tip
vi ng mch ch nn huyt p ti mao mch cu thn cao hn cc qua t chc khc ( bnh
thng t 65-75 mmHg),to iu kin cho qu trnh lc mach hn nhng ng thi cng lm
cho thn d chu nh hng ca s thay i huyt p.
Ngoi ra,ng ch { na l vng ranh gii gia khu vc v thn v li thn,c nhng mch ni
gia ng mch v tch mch,to ra mt h thng sn
(shunt) bnh thng khng hot ng;trong sc cc sn ny m ra cho mu chy qua nhm dn
mu cho cc tng quan trng nh tim,no(trng thi ny gi l trung tm ha tun hon),song
ng thi gy thiu mu v thn dn ti gim thm ch khng tit nc tiu(suy thn cp).
Bnh thng,mt pht c 650ml huyt tng cu thn lc c 120ml nc tiu vo nang
thn .Nh vy,tnh ra trong mt ngy,thn lc c khong 190lt.Nu khng c chc nng ti
hp thu ca ng thn ch trong chua y mt gi c th s kit nc.
B-CHC NNG LC CA CU THN
Cu thn c coi nh l mt c quan siu lc,tc l hu ht cc thnh phn ca huyt tng
i qua,ch gi li cc t bo v hu ht protein.
Nc tiu lc c cu thn l nh c p lc lc.p lc lc ph thuc vo nhiu yu t:
Pl = Pc-(Pk+Pn)
Trong :
-Pl l p lc lc,nh m c nc tiu.
-Pc l p lc cu thn tc l huyt p cu thn(bnh thng t 65-75 mmHg).
-Pk l lc ko ca mu,c tc dng gi nc li lng mch(bnh thng l 28mmHg).
-Pn l p lc ca nang thn,tc l p lc thy tnh ca nc tiu nang,p lc mu tnh mch v
t chc thn co tc dng chng li sc lc ca cu thn(bnh thng l 10 mmHg).
Nh vy Pl bnh thng khang 40mmHg.
Qua cng thc trn thy r lng nc tiu chu nh hng ca nhiu yu t.Th d:
-Khi Pn tng(nh trong suy tim ton b),thy Pl gim,do lng nc tiu gim.
-Khi Pc gim(nh trong sc,suy tim mch),cng thy Pl gim.
Ngoi yu t k trn cn c vai tr quan trng ca thn kinh v ni tit trong qu trnh iu ha
nc tiu.
C-CHC NNG TI HP THU V BI TIT CA NG THN
ng thn c hai chc nng l tai hp thu v bi tit,thc hin c l nh lp t bo ng thn
c mt h thng men phong ph.Khi mt cht men no khng hot ng,s pht sinh ri
lon chc nng ng thn.
1.Chc nng ti hp thu:
Phn ln cc cht ca nc tiu nang nh ng, nc, mui c ti hp thu gn ht trong
ng thn.ng c ti hp thu hon ton,tr khi vt ngng ca thn.C nhng cht ch
c ti hp thu mt phn nh axit amin, phosphat, sufphat, ure
Qu trnh ti hp thu nc, Na
+
,K
+
din bin qua hai giai on khc nhau:
a)Giai on u: phn u ca ng thn (ng ln gn),80% nc v Na
+
c hp thu, K
+

c hp thu gn 100%.S hp thu ca giai on ny khng chu nh hng ca cc hocmon.
b)Giai on sau: phn cn li ca ng thn (quai Henle, ng ln xa, ng gp), nc v Na
+

c hp thu theo yu cu ca c th di s iu ha ca hocmon nh:
-ADH ca tuyn yn tng ti hp thu nc nhnh xung ca quai Henle v ng gp.
-Aldosteron ca tuyn thng thn tng ti hp thu Na
+
nhnh ln ca quai Henle,ng ln
xa v ng gp, ng thi cn trao i K
+
ng ln xa.(Hnh 1)
Ti hp thu Na+ l mt c ch thch nghi ca c th trong qu trnh iu ha cn bng axit-baz
(xem ri lon cn bng axit-baz).
2.Chc nng bi tit:
Bi tit ng thn l mt hin tng ch ng, kt qu ca s hot ng tch cc ca cc t
bo ch yu on xa ca ng thn. Ngoi hot ng bi tit cc cht in gii nhm duy tr
cn bng axit baz, ng thn cn bi tit mt s cht khc nh axit hu c thm, axit hippuric,
penixilin, PSP(phenol sulfophtalein),.m c ch cha r rng.Nhng cht ny khng nhng
c lc qua cu thn m cn c bi tit ng thn nn nng cc cht ny nc tiu
cao hn trong mu.
D-MT S XT NGHIM THM D CHC NNG THN
nh gi chc nng lc,ti hp thu v bi tit ca t chc thn, ngi ta thng dng hai
xt nghim sau y:
-Xt nghim thanh thi.
-Thm d chc nng c c ca thn.
-Sinh thit thn.
-Phng php dng ng v phng x.
1.Xt nghim thanh thi.
Thanh thi l phng php thm d chc nng tng b phn ca t chc thn.
Nu mt cht trong mu c thi tr ra nc tiu vi mt m U (tnh bng mg/1) v khi
lng nc tiu trong 1 pht l V (tnh bng ml) th UV s l lng cht c thn thi tr
khi mt khi lng huyt tng C (tnh bng ml/pht). V nu P l m cht trong
huyt tng (tnh bng mg/ml) th chnh l khi lng C y m ngi ta gi l h s thanh thi
ca cht biu din bng cng thc sau :
C =
Nh vy h s thanh thi ca mt cht l khi lng huyt tng qua cu thn trong mt pht
c thn tr b han ton cht khi huyt tng chuyn vo trong nc tiu.
Trn c s nguyn l ny:
a)Mun thm d chc nng lc ca cu thn ngi ta dng nhng cht ch lc qua cu thn m
khng b ti hp thu cng nh khng c bi tit qua ng thn: nhng cht ny phi khng b
kt hp vi cc protein huyt tng, khng b nhanh chng chuyn ha.t nhng yu cu ny
l inulin, creatinin, manitol, Na hyposulfit
Vi nhng cht ny h s thanh thi bng 120ml/pht ngha l bng khi lng nc tiu nang
trong mt pht (hnh 2).Th d i vi Manitol,P=2mg/ml,U=120mg/ml v V=2ml/ pht, ta c :
C
manitol
= = 120 ml/pht
b)Mun thm d chc nng ti hp thu ca ng thn ngi ta tm h s thanh thi ca nhng
cht sau khi lc qua cu thn li c ti hp thu ng thn nh ure, glucoza, axit amin, axit
uric, phosphat.
Vi nhng cht ny h s thanh thi nh hn 120ml/pht. Th d i vi ure P=3mg/ml,
U=112,5 mg/ml v V=2ml/pht. Ta c :
C
ure
= = 75 ml/phut
c)Mun thm d chc nng bi tit ca ng thn ngi ta tm h s thanh thi ca nhng cht
va c lc qua cu thn va c bi tit qua ng thn nh PSP, axit hu c thm, axit
hyppuric, PHA, axit paraamino hippuric
Vi nhng cht ny h s thanh thi ln hn 120ml/pht.Th d h s thanh thi ca PHA bnh
thng l 650ml/pht (hnh 3)
Di y l mt s kt qu thng gp trong bnh l:
-Trong vim cu thn th cp din thy C manitol gim cn C diodrast bnh thng chng t
chc nng lc ca cu thn gim, song chc nng bi tit ca ng thn vn bnh thng.Trong
th trng din, thy C manitol v C PSP u gim chng t khng nhng chc nng lc m c
chc nng bi tit cng gim.
-Trong suy tim mt b,C inulin c th gim ti 30-35%, C PHA cng gim chng t lng mu
qua thn gim.Trong sc cng thy vy.
-Trong bnh huyt p cao, thy chc nng thn thay i qua 3 giai on:
+ Giai on u: h s thanh thi cn bnh thng do cha c thiu mu r rt ti thn.
+ Giai on hai: C PHA v diodrast gim cn C inulin vn bnh thng chng t bt u c tn
thng ng thn.
+ Giai on ba: h s thanh thi ca ng thn v cu thn u gim chng t ton b thn u
b tn thng.
2.Thm d chc nng c c ca thn
Mt c im ca t chc thn l tnh mm do:khi c nhiu nc vo c th th nc c
o thi nhiu nn nc tiu long, t trng thp (ti thiu 1003); khi t nc vo c th thid
nc tiu it, c v t trng cao (ti a 1030). Khi t chc thn b tn thng th tnh mm do
ny gim v c tnh trng ng t trng. Khi ng thn khng lm vic (tc l cng khng ti hp
thu v cng khng bi tit) th t trng bng nc tiu lc cu thn, tc la 1010. l nguyn
l ca xt nghim Phn-ha v Strao (Volhard-Straus), tin hnh nh sau:
Bnh nhn nm ti ging 24 gi trc v trong sut thi gian th nghim ch dng 500ml nc
ung cn ton n nhng thc n c.Hng nc tiu 3 gi mt ln v o t trng mi mc cao
phi t t nht l 1025.Trong suy thn t trng thp, di 1020 v c bit t trng nc
tiu cc ln ly khng khc nhau my.Tnh trng ng t trng thp l mt triu chng xu v
chng t thm gim kh nng c c.Tri li trong vim thn cp c tnh trng ng t trng
cao ngha la t trng nc tiu cacs ln ly khng chnh lch nhau my song u cao chng t
cu thn b tn thng lt qua nhiu cht hoc ng thn b tn thng nc thm tr li
qu nhiu, nn nc tiu tr nn c c.
3.Cc xt nghim khc.
chn on v tin lng chnh xc v cc bnh thn, ngi ta c th lm sinh thit thn:
quan st vi th cho php kt lun chng xc b phn b tn thng v mc tn thng.
Hin nay ngi ta cn dng cht ng v phng x a vo mu theo di thi gian mu ti
cu thn, ng thn.y l mt k thut hin i gip ta theo di mt cch chnh xc ton b
qu trnh hot ng ca thn.
II.NGUYN NHN GY RI LON TIT NIU.
Rt nhiu yu t c th gy ri lon tit niu.i c th xp thnh hai loi ln:
Nhng yu t ngoi thn.
Bnh thn.
A-NHNG YU T NGOI THN GY RI LON TIT NIU
1.nh hng ca thn kinh v thn kinh-th dch.
V no chi phi chc nng tit niu thng qua phn di v v h ni tit. Khi gy mt cm xc
mnh trn con vt thy nc tiu gim do co tht mch v thn.C th gy tng tit niu
bng phng php phn x c iu kin, c th kt hp cho nc vo d dy kt hp rung
chung; khi phn x d c thnh lp ch cn rung chung cng gy c tng tit niu.
Phn di v cng nh hng r rt ti chc nng tit niu: nhiu trng hp u no gia gy
tng tit niu, dng kim chc vo sn no tht IV hoc vo vng di th thy nc tiu tng r
rt. vng di thi (sn no tht III) c th th thm thu v khi lng: khi thiu nc th th
ny b kch thch v t xung ng c truyn ti hu yn gy tng tit ADH c tc dng
tng ti hp thu gi nc li. iu ny cho php gii thch s gim nc tiu thng gp trong
sc, chy mu, mt nc.
Thn kinh thc vt cng nh hng ti tit niu kch thch dy giao cm bng gy gim tit niu
do co mch; tri li khi ct t dy ny thy tng niu.
Hocmon tuyn yn v v thng thn nh hng su sc ti tit niu: khi aldosteron mu
tng,Na
+
b gi li, ko theo nc gy gim niu. Tri li khi thiu hocmon v thng thn
(bnh Addison) c th mt Na
+
, ko theo nc, bnh nhn c tnh trng mu c, d dn ti try
tim mch. Cht renin cu thn tit ra khi lng mu qua thn gim c tc dng kch thch tit
aldosteron, dn ti gim niu.
2.Thay i thnh phn v trng thi l ha ca mu.
Tt c nhng trng hp bnh l{ lm thay i thnh phn v trng thi l ha ca mu, nht l
nhng ri lon chuyn ha, c th lm tng mt s cht bnh thng vn c trong nc tiu
hoc lm xut hin nhng cht bnh thng khng c trong nc tiu.
Trong nhim toan c nh thy nc tiu c nhiu cht toan.Trong i tho ng ty thy
trong nc tiu c ng.Trong bnh vng da tc mt thy axit mt v bilirubin trong nc
tiu.Khi tan mu t (st rt cn, truyn mu nhm loi) thy trong nc tiu c
hemoglobin..
Ni tm li, nc tiu phn no phn nh c trng thi l ha ca mu, cho nn kim tra
nc tiu l mt phng php khng th thiu c trong khm nghim lm sng.
3.Ri lon huyt ng hc
p lc lc, nh trn phn tch, chu nh hng su sc ca huyt p hay ni cho ng hn,
ca lu lng mu qua thn.Khi lu lng mu gim trong sc,chy mu ,try tim mch ,mt
nc nghim trng thy ncs tiu gim v khi huyt p cu thn gim ti 40mmHg s pht
sinh v niu.
Ri lon tun hon quan trng nht v thng xy ra ti thn l tnh trng thiu mu v thn
do h thng sn (ni trc tip ng mch vi tnh mch)
dn n thiu niu v v niu.Tt c nhng chn thng,k c nhng chn thng tm l{ u
lm cho nhng ng thng ny hot ng ,gy gim tit niu.
Ri lon huyt ng hc ni chung hay ri lon tun hon ti thn nhng nu ko di c th gy
thiu mu t chc thn, gy ra nhng tn thng thc th nghim trng.
B-BNH THN
Bnh l thn c nhng c im sau y:
- Thn l mt c quan chu nhiu nh hng ca s xm nhp cc cht c, cc vi khun, cc ri
lon tun hon, cc ri lon nc v in gii, cc bin i sinh l ca c th nh thai nghn v
chu nh hng nhiu ca cc bnh ton thn.
- Nhng yu t di truyn u nh hng ti s hot ng ca ng thn, nhiu tt bm sinh lm
thay i chc nng ca thn.
- Nhu m thn b tn thng trong nhiu bnh v thn. T gy ra s suy sp chc nng ca
thn r nht l trong hi chng suy thn ton b.
1.Vim ng thn cp (VOTC)
Thc ra y l hoi t ng thn cp nhanh chng dn ti suy thn cp. ng ch l suy thn
cp thng do VOTC. Bnh ny c nhng c im sau:
- Tn thng tin pht v chim u th ng thn.
- Biu hin lm sng ni bt l i t, v niu v ure mu cao.
- C kh nng phc hi hon ton nu qua c giai on nguy him.
Thc ra tn thng ng thn mc khc nhau ty theo bnh nhn, song tnh trng ph v
vim khe thn thng xuyn c, ch c cu thn v cc mch mu l khng b.
VOTC do nhiu nguyn nhn gy ra:
- Thng l nhim c: cht c c th t bn ngoi ti (Hg, sunfamit, asen, cyanua, bitmut,
mt c trm) hoc nhng cht c t bn trong c th nh VOTC sau khi truyn mu nhm
loi, sau bng nng , hi chng p, chn thng dp nt nhiu, gar t qu lu
- Ngoi ra cn do thiu mu nghim trng v thn gp trong sc, try tim mch, mt nc
Lc u ch l suy thn chc nng, nu khng iu tr kp thi s gy tn thng thc th ng
thn, thm ch gy hoi t v thn, tin lng thng rt nng.
Nh bit t chc thn c mt h thng men rt phong ph khng km g gan. Theo Pit
(Piters) th c ch sinh bnh ca VOTC do nhim c l mt qu trnh c ch cc men chuyn
ha ca t bo ng thn m tc gi gi l tn thng sinh ha. Cc cht c tc ng ln
nhng men ca ng thn ta ra nhng kt hp bn vng lm cho nhng men y mt hot tnh,
dn n nhng tn thng thc th ng thn, Thn li d b nhim c hn cc t chc khc
v lng mu qua thn rt ln.
2.Vim cu thn cp (VCTC)
y l mt bnh vim khng mng m xy ra tin pht ,cp tnh v thng lan ra khp cc cu
thn. Vim mao qun bao gm hai hin tng tng sinh v xut tit u xy ra nhanh chng
cu thn .nh ngha ny nhm loi tr nhng bnh cu thn khc c vim nhng mng m
,tm thy vi khun thn v nhng bnh cu thn khc xy ra th pht sau mt s bnh nhng
ni khoa.
Bnh thng xut hin sau khi c vim nhng ch khc ca c th:3/4 trng hp xy ra sau
vim hng ,nht l vim hnh nhn c hc m nguyn nhn ch yu l lin kt cu khun ( tan
mu nhm A),1/4 trng hp cn li xy ra sau nhim trng nhng ni khc
(rng,mi,phi,da).Ngoi tc dng gy bnh ca vi khun, cn phi k ti nhng iu kin
thun li cho pht sinh bnh nh lnh,m thp,c th yu.
Hin nay ngi ta ni nhiu ti c ch d ng trong bnh sinh ca VCTC, ch yu a vo cc
nhn xt lm sng v thc nghim sau y:
- Bnh thng gp tr em sau vim hng khong 10-15 ngy(thi giai cn thit cho qu trnh
mn cm sinh khng th.
- cc bnh nhn c nhng thay i huyt thanh v mt min dch hc nh gim b th ,pht
hin c khng th chng thn v khng th chng lin cu khun.
- c bit sinh tit cho thy nhng cht lng ng gia mng c bn v nhng ni mc mao
mch (trong vim cu thn do khng th chng mng nn)
Nhng cht lng ng ny c xc ng l cc phc hp min dch gm khng nguyn v
cac globulin min dch nh IgG v IgM.
- Xt nghim gii phu bnh cho thy VCTC khng c hnh nh ca vim nhim do nhim khun
(khng thy bch cu trung tnh xm nhp ,khng phn lp c vi khun ),m c hnh nh ca
vim d ng (nhng ni mc tng sinh , tng bch cu a axit )
-Trong thc nghim ,Madughi (Masugi) nghin thn th ri tim cho vt c huyt thanh vt
chng thn th.Sau ,tim huyt thanh ny cho th lnh , vai ngy sau thy xut hin VCTC
ging nh ngi (protein niu , tr niu , i t , ur mu cao, ph,huyt p tng ) Caventi
(Cavelti) nghin thn nh ri trn vi c lin cu khun ( tan mu nhm A),sau tim cho
th lnh thy cng gy c VCTC ( y ,thn th trn vi c t vi khun tr thnh khng
nguyn i vi c th th c tim ).Theo ch xn ( Dickson) tim huyt thanh khc loi nhc
i nhc li nhiu ln cng gy c lng ng khng nguyn-khng th bn ngoi mng nn ca
cu thn th. Hyman (Heyman) dng thn th nghim vi t cht Froi (Frennd) tim vo
bng th lnh, thy gy c VCTC do ng khng nguyn khng th quanh ng ln gn.
Nhng ti liu k trn dn ti mt kt lun :
VCTC c th pht sinh theo c ch min dch.C th c th b mn cm vi khng nguyn no
, by gi phc hp khng nguyn-khng th s ti ng cc mch mu thn. B th khi gn
vo phc hp tr nn hot ha, to ra mt vim c hiu ca VCTC. Ngoi ra, cn phi k n
c ch t min: c t vi khun hay phc hp min dch khi ng li thn co th l bin i t
chc thn, to ra mt khng nguyn, by gi c th to ra khng th (t khng th) chng li t
chc thn ca chnh mnh.
L thuyt v min dch tuy c c s thc nghim, c mt ng dng thc t trong iu tr, song
cn nhiu im v c ch bnh sinh VCTC ngi vn cha c sng t. Ngoi ra cn c
nhng trng hp VCTC pt sinh khng do c ch min dch.
3.Vim cu thn mn (VCTM)
Bnh ny c nhng c im sau:
-Tn thng lan ra ton b cc cu thn.
-Tin trin ko di dn ti suy thn mn tnh khng hi phc.
VCTM thng khng r nguyn nhn, hay gp tui 10-40. Mt s t xy ra sau khi b VCTC.
Biu hin lm sng ni bt l protin niu, i ra mu, huyt p cao
4.Hi chng thn h (HCTH)
y l mt loi tn thng cu thn vi cc c im sau y:
- protein niu nghim trng (t nht l 3,5 g/24
h).
-gim protein

mu (di 50g/l), c bit l gim albumin mu (di 30g/l)
-tng globulin, c bit l haptoglobin.
Mt s triu chng kinh in ngy nay c t gi tr : ph to ton thn l mt triu chng c gi
tr song khng phi thng xuyn c, lipit mu tng, cholesterol mu tng l nhng triu chng
hay gp nhng khng c nh.
V mt nguyn nhn,HCTH c th xp thnh hai loi :
HCTH tin pht (gp 2/3 trng hp). Thng phn bit :
- HCTH n thun (cha r nguyn nhn ) thng gp la tui 2-8 HCTH in hnh, tin lng
thng l tt, c th khi hon ton. y loi bnh thn h nhim m c m t trc
y.
-HCTH ghp vo VCTC hoc VCTM : trong vim cu thn . HCTH c th ch xut hin trong mt
giai on tm thi, nhng nhiu khi, nht l ngi ln , t xut hin HCTH phi coi l mt t
tin trin cp trn mt VCTM trc cn tim tng.
HCTH c th gp trong tt c cc loi VCTM, song hu ht l nhng hi chng khng n thun,
u c km theo i ra mu , huyt p cao, iu tr kh , t c kh nng hi phc.
HCTH th pht.
-Sau mt bnh ton thn : bnh thnh h dng tinh bt, i tho ng, luput ban
-Sau mt ri lon tun hon: tc tnh mch thn, suy tim mt b
-Do nhim c, d ng, nhim khun
-V mt bnh sinh, hin nay HCTH c coi nh l mt biu hin lm sng ca tn thng cu
thn, do nhiu nguyn nhn gy ra. Tnh trng nhim m t bo ng thn do cu thn b tn
thng cho cht m thot ra ngoi
nc tiu nang qu nhiu, mt phn c ng thn ti hp thu, m ng dn trong t bo
ng thn v gy nhim m. Nh vy, tn thng u tin l cu thn m lt qua qu
nhiu , dn dn dn n nhim m ng thn.
Dng huyt thanh ngi khe mnh c nh du bng ng v phng x ri tim cho bnh
nhn thy protein nh du nhanh chng lc qua cu thn b tn thng nn cho
protein huyt tng lt qua, gy protein niu nghim trng ngi c HCTH (20-50g/l ).
M v cholesterol c gi l hin tng b p duy tr p lc ko ca mu gim do protein
niu mnh. Dng ng v phng x nh du m v cholesterol thy tc s dng m gim
do thn thiu cc men chuyn ha m nh tributyraza, lipaza, lipop-roteinlipaza (nn thy
lipoprotein tng trong mu ngi bnh).
Gn y cho HCTH cng nh vim cu thn c th pht sinh theo c ch d ng: trong thc t
lm sng iu tr HCTH bng thuc chng d ng em li kt qu tt.
C ch bnh sinh ca HCTH c th tm tt nh sau: ri lon u tin l cu thn tng thm
lipit mu lt qua qu nhiu gy nhim m ng thn ng thi protein mu lt qua gy protein
niu nghim trng dn ti gim protein mu. Ph do gim p lc keo huyt tng v cng
aldosteron th pht. Cc ri lon v protein mu, lipit mu l hu qu ca gim protein mu.
5.Vim thn k (VTK)
Cn gi l vim khe thn, vim b thn-thn, vim b thn-thn ngc dng, vim b thn-thn
theo ng mu
y l bnh tn thng thc th thn vi c im tn thng tin pht v chim u th
khe thn.
Trong vim thn k mn, chc nng cu thn c bo v lu di, chc nng ng thn v khe
thn sm b ri lon, to ra trng thi mt cn bng v chc nng gia cu thn v ng thn v
l ngun gc ca mt s c im v triu chng.
Nguyn nhn ch yu l do nhim khun trc tip t ng tit niu ngoi, gy tn thng
sinh m ti b thn ri lan ln t chc k ca thn.
Bnh hay gp ph n (80%). iu kin thun li pht bnh l khi c nc tiu (do d dng
ng tit niu, u p, si) hoc vim bng quang vi khun i ngc dng ln khu tr b
thn gy vim m, ri t vim lan ln i thn, k thn v t chc lin kt ca thn. Vim
ko di lm cho t chc lin kt v t chc x tng sinh, chn p t chc nhu m thn c bit
l ng thn b teo r rt (tri li chc nng cu thn c bo v lu di) cc ng mch cng b
x cng theo nn hn ch lu lng tun hon (gy tng tit renin dn ti tng huyt p- triu
chng hay gp trong VCT). Cui cng cu thn cng b x ha, ng thn b bp nght, thn b x
ha ton b, teo nh li, a n suy thn khng hi phc.
Chc nng ng thn gim trong VKT gy ra mt s triu chng sau y:
- Chc nng c c nc tiu gim: Triu chng sm nht c khi l triu chng duy nht trc
khi c suy thn ton b. i nhiu, t trng thp v t thay i. C khi i nhiu nh i nht,
tim ADH khng c tc dng.
- Chc nng toan ha nc tiu gim : gim ti hp thu bicacbonat, n thi gim thi tr ion
H
+
. ng ch { l ri lon thi axit trong VKT nghim trng hn so vi cc bnh khc.
- Tng o thi Na
+
theo nc tiu kh nhiu, gy ra cc th lm sng sau:
+ Mt nc, gim Na
+
mu co n mui vi s lng binh thng c th b c.
+ Mt qu nhiu Na
+
gy hi chng i tho mui l mt hi chng ch gp trong VKT.
+ Mt Na n c, khng song song vi cc ri lon chc nng khc ca ng thn (c c nc
tiu, toan ha nc tiu) to ra th bnh VTM mt mui
C nn qun VKT chim 30-50% cc nguyn nhn gy suy thn mn v l nguyn nhn hng u
gy cht do suy thn mn.
[newpage]
III-NHNG S THAY I CA NC TIU TRONG BNH L
Khi c ri lon tit niu, thng pht sinh nhng s thay i v nc tiu, v lng cng nh
v cht.
A-THAY I V S LNG NC TIU
S lng nc tiu c th tng (a niu), gim (thi niu) hoc hon ton khng c (v niu).
a niu:
a niu pht sinh khi lng nc tiu qu 2l/ngy vi lng nc vo bnh thng. Do p lc
lc cu thn tng ( nc tiu mang ra ngoi nhiu) hoc chc nng ti hp thu ca ng thn
gim (khin cho nc khng c ti hp thu y ).
a niu do nhiu nguyn nhn gy ra:
a niu do nguyn nhn ngoi thn:
- Trong bnh i tho ng , do ng mu cao, vt ngng thn, c o th ra ngoi,
ko theo nc, gy ra i nhiu.
- Trong bnh i nht, do gim tit ADH nn ti hp thu ng thn cng gim gy i nhiu.
- Ngoi ra, trong bnh huyt p cao, giai on u mch ra ca cu thn co li, gy tng p
lc lc nn i nhiu. V sau mch ti cu thn cng co nn i t.
b) a niu do nguyn nhn thn.
- Trong vim cu thn cp, giai on u khi mi c xung huyt cu thn, m cha c tn
thng thc th , do mu ti nhiu, p lc lc tng, nn i nhiu song sm chm dt.
- Trong vim cu thn b phn, hay thy i nhiu, c th do tng hot ng b p ca thn
cn li.
- Trong vim thn k mn tnh, nh trn phn tch, do t chc x pht trin chn p ng
thn v mch mu nui dng nn ng thn gim ti hp thu nn i nhiu.
2. Thiu niu v v niu.
Thiu niu pht sinh khi lng nc tiu gim di mc bnh thng (di 500ml/ngy) vi
lng nc tiu vo bnh thng v khng phi do ri lon o thi nc tiu. Cn v niu l
hon ton khng c nc tiut hoc ch c vi chc ml, c tc gi quy nh v niu l di
100ml hoc di 300ml.
Ty theo nguyn nhn c th xp thiu niu v v niu thnh my loi sau y :
a) Do bnh thn. Thiu niu thng gp trong vim cu thn do cu thn gim lc (song ng
thn vn ti hp thu bnh thng) : (hnh 4) trong ng thn cp nng c th pht sinh v niu.
V niu thng gp trong vim ng thn cp. V sinh l bnh hc, mt hin tng gn nh tri
ngc l tn thng ng thn khng gy i nhiu (do mt chc nng ti hp thu), m li gy
v niu. C ch bnh sinh ca v niu trong vim ng thn cp phc tp, c nhiu cch gii
thch
- Do ng thn b tn thng, c nhng on ng b ph hy, do nc tiu t lng ng thn
trn vo t trc k v hp thu vo mu : hin tng lan ta o ngc ca nc tiu. Trong
lm sng, c ch ny cha c chng minh c th. Nu dng c ch ch ph hp vi mt s
c t ph hy ca ng thn gn.
-Do tc lng ng thn. Nhiu yu t gy tc :
+ T bo ng thn b trng to ra.
+ Trong lng ng thn c nhiu hnh tr, nhiu mnh t bo, cc sc t, nht l khi c tan mu
nghim trng.
+ Cc tinh th sulfamit
- Do chn p ng thn. Trong ng thn cp, ph t chc k l mt tn thng sm v quan
trng. Nc tiu t lng ng thn trn vo t ch k li lm cho ph tng. Ph t chc k
chn p ng thn v cc mao qun quanh ng thn, do gim p lc lc c hiu qu cu
thn. Tuy nhin, o c (thc nghim v lm sng) thy p lc ca t chc khe thn khi v niu
khng cao hoc khng ng k.
- Do ri lon tun hon ti v thn : Theo mt s tc gi th bt c nguyn nhn no gy vim
thn u thiu mu vng v thn, do gy gim lc cu thn.
b) Do nguyn nhn ngoi thn. C th k :
- Nguyn nhn trc thn : Khi ng mch thn b u chn hay b tc mch, mu khng ti c
thn, nc tiu khng c. Tr b c tr ngi , thn li hot ng tt.
- Nguyn nhn sau thn : cn gi l v niu gi v chc nng tit niu vn bnh thng (t ra lc
u) song do c tr ngi v ng thot nc tiu (si) nn nc tiu li trong thn, chc
nng lc ca thn b hn ch. Thn nc to dn gy bnh thn nc, nhu m ca thn b chn
p teo li, chc nng tit niu mt dn.
- Nguyn nhn xa thn : Nh b sc, chy mu nng, try tim mch, mt nc nghim trng
(nm ma, i ra) lm gim lng mu ti thn, nh hng ti p lc lc, gy v niu (khi
huyt p cu thn gim ti 40mmHg).
- V niu phn x: au n qu mc (au qun gan, qun thn, chn thng nng) c th gy
v niu thng qua c ch phn x: co mch vo cu thn ng thi tng tit ADH v aldosteron
gy gim lc cu thn ng thi tng ti hp thu ng thn. Ngay nhng chn thng tm l{
nh s hi, tc gin cng c th gy v niu (v niu ch khi cho i din vi mo).
Cn phn bit v niu vi b i: trong b i, c cu bng quang) v thng bng quang s hng
c nhiu nc tiu.
V niu cp din l mt hin tng c th hi phc: t chc b tn thng c th hon ton
lnh v lm vic tt nh trc.Nc tiu bt u xut hin li vo ngy 6-12, song c khi phi
hng thng mi hi phc. Nhng ngy u, do chc nng ng thn cha khi phc hn nn
nc tiu thng hay nhc trng.
B-THAY I V CHT LNG NC TIU
Nc tiu bnh thng mu vng nht, mi hi khai, t trng l 1018, cha mt s cht chnh
nh clorua, phosphat, sulfat, ure, axits uric, creatinin v mt s t bo lt ca ng tit niu,
bng quang v mt s t tr trong. Khi c ri lon tit niu, khng nhng cc cht trn thay i
thnh phn v t l m cn xut hin nhng cht bt thng trong nc tiu nh protein niu,
huyt niu, tr niu.
1.Protein niu
Nn gi l protein niu,ng hn l albumin niu v ngoi albumin cn c cc loi protein khc:
bnh thng, khi cu thn lc, cn that ra mt t protein nhng n ng thn, hu ht c
ti hp thu ,pht hin c; vi phng php tht chnh xc ngi ta thy trong nc tiu 24h
ch c 50-1000mg protein, ch yu l protein ca nhng t bo long ra ng tit niu, mt
s t bch cu,v cht nhy do cc tuyn ng tit niu tit.
Ch c khi no lng protein trn 150mg/l mi ni l c protein niu. Tr mt vi trng hp
protein niu sinh l xy ra, cn protein niu thng l mt triu chng ca tn thng thn c
gi tr chn on v tin lng. Protein niu bnh l{ thng xuyn c, cn protein niu sinh l
c tnh cht bt thng.
a)Protein niu sinh l: c th gp ngi tr (thng la tui 10-20) khi ng lu, do t th
ng ct sng lng ln tnh mch thn tri hoc gan ln tnh mch ch di lm cho tun
hon ti thn km i, protein niu ph n c cha cng pht sinh theo c ch ny. Ngai ra,
cn c th gp protein niu bt thng nhng ngi lao ng nng, hoc mt s ngi c
h thn kinh khng vng bn, sau khi tm nc lnh, sau nhng chn thng tm l{ (bun
gin.) c ch c th l do co tht mch thn lm cho thn bt cht thiu mu.
b) Protein niu bnh l: protein niu ch coi l bnh l khi c trn 150mg/l v phi thng xuyn
c.C khi lng protein ln ti 40-50g/l 24h. Protein niu bnh l ch yu do thnh mao mch
cu thn b tn thng d lt qua nhng phn t protein hoc i khi do ng thn b tn
thng khng ti hp thu c, hoc c hai c ch phi hp (H5).
Protein niu bnh l c th do nhiu nguyn nhn gy ra:
- Nguyn nhn trc thn: Bnh thng cu thn ch nhng protein phn t lng di
70000 qua khi trong mu c nhng protein ny, th s o thi qua cu thn. Thng gp l:
Hemoglobin (phn t lng 68000) bnh thng Hb t hng cu c gii phng ra s kt hp
vi haptoglobin mt loi -2 globulin v li c ti hp thu ng thn. Do Hb ch xut
hin trong nc tiu khi vt kh nng kt hp ca Hb.
Protein Benxe gin (Bences Jones) l nhng protein bt thng (chui nh Lamda hay Kappa)
gp trong mu bnh nhn b u tng bo cn gi l bnh Kale (Kahler(, c phn t lng nh v
xut hin trong nc tiu nu m ca chng trong mu cao hn kh nng ti hp thu ca
ng thn.
Trong nhng trng hp trn, cu thn vn hot ng tt.
- Nguyn nhn ti thn: thng thng protein niu l do tn thng cu thn. C khi ch l
triu chng duy nht, n c trong mt thi gian di (bnh vim cu thn mn). Khi thnh
mao mch b tn thng, th nhng protein c phn t lng trn 70000 cng c th qua c
vo nc tiu nang. Trc tin l albumin huyt tng ri ti globulin. Nu vim cu thn
nh, thng ch c albumin niu cn trong vim cu thn nng , thy hu ht cc protein ca
huyt tng k c macroglobulin. Ngi ta c th dng t s A/G nh gi mc tn
thng ca cu thn. Khi t s ny cng thp th bnh cng nng v tn thng nng nn
globulin thot ra nhu hn.
Protein niu cn c th do ng thn c vn . Nh bit, ng thn c kh nng ti hp thu
mt phn cc protein lc qua cu thn. Kh nng ny c th gim do tn thng ng thn, hoc
do trong nc tiu c nhiu protin vt qu kh nng ti hp thu ca ng thn. C ch protein
niu trong nhim c Hg, hay khi thn thiu oxy, thiu mu cng c th do tn thng ng
thn hn ch ti hp thu protein.
2.Huyt niu
Bnh thng trong nc tiu c mt s t hng cu: nc tiu 24 gi c khong 70000 hng cu
v 322000 bch cu. Huyt niu c th quan st bng mt thng hoc phi quan st bng knh
hin vi. Khi ly tm c mt lp cn gm nhiu hng cu v lp dch trn mu trong sut: y l
c s phn bit i ra mu v i ra nc tiu mu do thc n, do thuc ung, do i ra
mu Hb
Huyt niu c th do:
- V mch mu ng tit niu nh tn thng cu thn, ng thn hay b thn hoc
ng tit niu di (bng quang, niu o). Chn on ni chy mu khng phi bao gi cng
d dng .
- Hng cu thot khi mao mch do b vim (c bit vim cu thn cp) hoc thnh mch thoi
ha.
Vic m s lng hng cu v bch cu trong nc tiu gip ta theo di s bin chuyn cua
bnh thn, nh gi trng thi n nh hay tin trin ca bnh.
Huyt niu hay ni ng hn hng cu niu, c th do nhiu nguyn nhn gy ra:
- Nu l huyt niu hon tan (ngha l nu lm xt nghim ba cc, c ba cc u ), th c th
ngh ti:
+ Si thn nu huyt niu xut hin sau khi lao ng nng (b i hnh qun, chin u)
+ Lao nu c km theo vim bng quang.
+ U c thn nhngu huyt niu xy ra lun.
+ Hoc mt bnh khc ca thn nh vim cu thn cp hoc mn
- Nu l huyt niu v cui (ch c cc th ba mu ), nguyn nhn thng bng quang (si,
lao, vim,u )
-Nu l huyt niu v u (ch c cc th nht mu ), nguyn nhn thng niu o (vim
niu o) hoc tin lit tuyn (lao ph i).
Ngoi hng cu, trong bnh ng tit niu, ngi bnh c th i ra m, tc l i ra nhiu
bch cu. i ra m c thy bng mt thng (nc tiu c, bn) hoc phi qua knh hin vi
mi thy (nc tiu khng c, vn trong). Bch cu c th b hy nh trong cc loi m khc,
bach cu c th bnh thng hoc ch hy hoi rt t.
3.Tr niu.
Tr l nhng khun ca ng thn do protein qua b ng li v gi hnh ca ng thn. Nhng
yu t nh hng ti hng thnh tr c th l :
- pH nc tiu khi pH thp, d pht sinh v lm cho protein d kt ta. Nh Hb gp pH nc tiu
thp s ng li thnh nhng tr hem-atin lm tc ng thn.
- m v tnh cht ca protein trong nc tiu : globulin d b kt ta hn albumin, cho nn
khi c glubulin niu th bao gi cng c tr.
Quan st cc tr c th phn no bit c tnh cht tn thng ti t chc thn v tr l ni
hnh thnh, theo nc tiu ra ngoi, s mang theo hnh nh ti ni .
Cn c vo thnh phn ca tr niu, c th bit c hai loi tr chnh :
- Tr khng c t bo do protein v lipit to nn.
- Tr t bo do t kt hp to nn (hng cu, bch cu, lin bo ng thn(H6)
a)Tr trong; b) Tr ht; c) Tr sp; d) Tr lin bo; ) Tr hn hp; e)Tr mu; g) Tr m; f) Tr
m; i) Tr lipoit; k) Hng cu; l) Bch cu; m) lin bo thn; n) t bo thoi ha m; o) git m;
p) git lipoit; q v r) dng tr; s) lin bo ca niu qun,bng i v niu o (theo Alpern)
IV. NHNG HU QU CA RI LON TIT NIU
A-NHNG THAY I TRONG MU
Khi thn b tn thng, nhng cht cn b cn thi s li trong c th gy tng N phi protein
mu, nhim axit, thiu mu
m N phi protein mu tng nh ure, NH
3
, creatinin trong quan trng nht l ure.
Nhim toan do cc axit trong mu khng c kp thi o thi, cc gc phosphat, sulfat tng
trong mu.
- Thiu mu: trng gp trong vim cu thn mn tnh do thiu protin to hng cu, thiu
erthopoetin (hocmon sinh hng cu do thn tng hp); ngoi ra, cn c th do cc cht c
khng c o thi li c tc dng c ch ty xng sinh hng cu.
B-PH
Ph thng l biu hin ca mt bnh thn ch yu l thn h, vim cu thn.
1. Ph trong hi chng thn h
Do nhiu yu t kt hp vi nhau gy ra. Trong bnh ny ph rt r, do mui v nc. Lng
NaCl o thi theo nc tiu 24 gi gim t 10-15g xung ti 0,1g. Thiu niu trong thn h
khng do ri lon lc cu thn. Lng mu qua thn v chc nng lc cu thn thng l
tng so vi bnh thng. Na trong c th thn h r rng l do tng tit aldosteron (tim cho
con vt cc cht khng aldosteron thy ph khng pht sinh)
Ph trong thn h cn do gim protein huyt tng dn ti gim p lc keo. Gim protein
huyt tng y do protein niu nghim trng, hu qu ca tng thm cu thn (v gim ti
hp thu protein ng thn). Trong thn h nng, 24 gi c th mt ti 60g protein (ch yu l
albumin) v nng protein c th gim 3-2% hoc thp hn. Nc thot khi mao mch dn
ti gim th tch mu lu thng, do gy tng tit aldosteron v ADH, m hu qu l nc
trong c th. Tuy nhin gim protein huyt tng n c khng gy ra trng thi ph
nghim trng v n nh gp trong thn h.
Ph trong vim cu thn
Cho ti nay, c ch sinh bnh loi ph ny vn cha hon ton sng t. nc v Na trong
vim cu thn cp, trn lm sng v trong thc nghim, l do ri lon tun hon cu thn gy
gim lc v thiu niu. Ngoi ra, thot nc cn do gim protein huyt tng, m nguyn nhn
ch yu l tng thm mao mch cu thn gy ra protein niu.
Ngoi yu t thn k trn, ph trong vim cu thn cp cn do tng thm thnh mao mch, hu
qu ca vim mao mch ton thn : trong thc t, c im ca loi ph ny l dch ph c
nhiu protein (ti 2-3%).
Trong vim cu thn cp, thy tng tit aldosteron song vai tr bnh sinh ra sao th cha r.
C-SUY THN
Cc bnh thn cui cng u dn n suy thn, ngha l tnh trng gim nghim trng thm ch
mt chc nng bi tit nc tiu ca thn, lm cho nhng cht cn o thi ra khi c th b
li trong mu gy nhim c.
Nn gi l hi chng suy thn hn l hi chng ure mu cao v :
-Ure mu khng phn nh trung thc ch nng ca thn : c trng hp thn mt 60% chc
nng song ure mu vn bnh thng ; ngoi ra, ure mu cn ph thuc vo nhiu yu t ngoi
thn.
- Ure l mt cht khng c i vi c th (t ra l vi m gp trong suy thn). Nhng cht
c i vi c th (nh phenoliindol, scatol) bnh thng t rut thm vo mu c gan
gii, c v o thi qua thn. Nhng trong bnh thn, cc c t khng c o thi, tch
li gy nhim c. Ngoi ra, tnh trng nhim c chung ton c th hn ch chc nng gii
c ca gan. Nh vy, tng ure mu chng t rng cn c nhng c cho c th khng c
o thi, v chnh nhng snh phm , ng u l phenol, mi gy c.
- Thi tr ure mi phn nh c mt phn chc nng ca cu thn, thn cn nhiu chc nng
quan trng khc.
1. Nguyn nhn gy suy thn.
C th xp thnh hai loi :
a) Suy thn do tn thng thc th. Nguyn nhn c th l :
- Bnh thn : vim ng thn cp, vim cu thn cp v kinh, vim thn k..
- Bnh ton thn : gy tn thng thn : i tho ng, huyt p cao, bnh colagen
b) Suy thn chc nng, do cc nguyn nhn ngoi thn :
- Sc, chy mu nng, try tim mch.
- Mt nc nghim trng (nn ma, i lng nng)
Nu k thi tr b cc nguyn nhn ngoi thn, thy chc nng thn c th hi phc c.
Nhng t suy thn chc nng rt d tin trin n suy thn thc th : nh trong sc, thiu
niu, v niu lc u do gim lng mu ti cu thn gy gim lc, ti giai on mt b trng
thi thiu oxi nghim trng v thn gy hoi t ng thn (tc vim ng thn cp) lm cho
thn nng thm.
Cc th lm sng ca suy thn
Trng thi suy thn c th l cp tnh hay mn tnh.
Suy thn cp tnh:
y l trng thi suy sp nhanh chng chc nng thn, c kh nng hi phc hon ton.
Triu chng ni bt l: thiu niu, v niu, ure mu tng nhanh trong vi ngy (ti 2-3-4g%)
Suy thn cp do tn thng thc th thn (vim ng thn cp, vim cu thn cp) hoc do
nhng ri lon chc nng nh hng su sc ti chc nng tit niu (sc, chy mu, try tim
mch, mt nc nghim trng)
Suy thn cp rt t khi chuyn sang mn tnh.
b) Suy thn mn tnh
y l trng thi suy sp dn chc nng thn, c c ch b p nhng khng hi phc c.
Thng thng, suy thn mn tnh l s suy sp ton b chc nng thn. Suy thn tng phn t
khi gp.
Suy thn mn tnh l mt trng thi bnh l ton thn, nh hng su sc ti ton b chc
nng ca c th , thn khng iu chnh c s cn bng v th dch v vy triu chng
rt a dng trong thi gian u: huyt p cao, gy yu, thiu mu, c th suy nhc, ri lon
tiu ha, ph Song ti thi kz cui, triu chng nh suy thn cp: thiu niu, v niu, ure mu
tng nhanh (c khi ti 7-8%). Nhng ri lon tm thn kinh (chut rt, au cc dy thn kinh
ngoi vi, ht hong, vt v, l , u m, cui cng l hn m) do tn thng ngay ti no, tng
p lc s no, ri lon in gii (Na
+
, K
+
, Mg
++
) ri lon pH.
Suy thn mn tnh l do nhng tn thng thc th ti thn. Bnh tin trin nhanh hay chm
(6-7 thng hoc 20-30 nm) ty thuc vo :
- Mc tn thng ti thn.
- Cc tai bin c th xy ra : bi nhim, ri lon tun hon, ri lon h hp.
- Ch n ung v sinh hot.
- Cch iu tr v nhng sai st v iu tr.
- Suy thn mn tnh iu tr t kt qu, ch c tc dng tm thi, v trong trng hp ny tn
thng thn khng hi phc c. Tt nht hin nay l ghp thn lnh, nhng kh khn l
ch phi tm c mt ngi cho cng gien vi ngi nhn.

54. SINH L BNH H TIU HA

( HONG DUNG )
H tiu ha gi mt vai tr quan trng trong i sng, cho nn trong bnh l ri lon chc phn
tiu ha nh hng r rt ti cc chc phn trong ton b c th, mt khc nhng trng hp
bnh l{ cc c quan h thng khc cng c th dn ti nhng ri lon tiu ha nghim trng.
H tiu ha c 4 chc phn chnh: tit men tiu ha, co bp, hp thu v bi tit, ty theo tng
on ca ng tiu ha m c ch chc phn ny l ch yu, chc phn kia l th yu nhng
trong thc t ri lan cc chc phn trn thng kt hp vi nhau, nh hng ln nhau lm
cho qu trnh bnh l ngy cng thm phn phc tp.
Ri lon tiu ha c th xy ra bt c on no ca ng tiu ha nhng ph bin v quan
trng nht l nhng ri lon d dy v rut.
I. RI LON TIU HA D DY
D dy l ch phnh to nht ca ng tiu ha c nhim v cha ng thc n tiu ha dn.
d dy, hai chc phn tit dch v co bp l ch yu nn trong bnh l gy nhiu ri lon quan
trng hn c.
A - RI LON CHC PHN TIT DCH CA D DY
D dy tit dch v bao gm cc men tiu ha v cht nhy kim, bnh thng trng thi cn
bng vi nhau.
1.Cn bng tit dch d dy:
S lng dch v tit trong 24h bnh thng t 2000-3000ml bao gm:
- Dch toan l cc men tiu ha ca d dy, ch yu l pepsin v axit clohydric (HCl) do cc t
bo tit ra thn v y d dy tit di hnh thc tin men pepsinogen, do tc dng ca HCl
c chuyn thnh pepsin c hot tnh (hn 1). Bnh thng trong dch v c mt toan nht
nh (HCl) ton phn: 50-60 mEq/l hay 0,180-0,124% v HCl t do 45-50 mEq/l hay 0,164-
0,182% v ch tit jgi c kch thch tiu ha.
- Dch nhy kim hay d tr kim ca d dy, do cc t bo biu b b mt d dy tit thng
xuyn di dng ha tan trong dch v hoc bm cht vo nim mc d dy hnh thnh mt
mng che ch nim mc d dy trnh sc tiu ca men pepsin v HCl. Nh vy hnh thnh 2 h
thng tit dch toan v kim lun trong tnh trng cn bng v cn thit bo v nim mc d
dy cng nh duy tr qu trnh cn bng tiu ha.
Tit dch d dy c iu ha bi c ch thn kinh- th dch. C ch thn kinh do cc xung
ng t v no qua dy thn kinh X ti d dy, tc dng trc tip ln cc t bo tit pepsin v
HCl. C ch th dch do cc xung ng c tc dng gin tip mt kch t d dy Gastrin t cc
tuyn vng y, ngay t u ba n do kch thch thng qua dy X, v sau tc dng trc tip
ca thc n l cng vng y d dy.
Kch t gastrin c tc dng:
- Kch thch tit HCl vi liu rt nh (hng microgam) v mnh hn histamin 500 ln.
- Kch thch trng lc v nhu ng d dy, rut.
Hin nay ngi ta tng hp c gastrin dng trong thm d chc phn d dy, gi l
cht tng hp pentagastrin. Ngoi ra t trang cng tit mt cht c tc dng tng t gastrin
gi l secrotagogue nhng cht ny cha c phn lp r rng.
Khi tit dch qu mnh, toan tnh dch v tng ti mc pH di 2 c tc dng c ch tit gastrin
iiu ha t ng cn bng tit dch. Khi n hiu m, t trng s tit cht enterogastron c
ch tit HCl v pepsin, do n nhiu m gy lu tiu v y bng.
2.Ri lon tit dch d dy:
Ri lon tit dch thng gy thay i c s lng v cht lng ( toan) ca dch v cc mc
khc nhau.
a)Tng tit, tng toan pht sinh khi s lng dch v tng trn 50ml (ly mt ln) v toan t
do tng trn 60mEq/l hay 0,4% lc i cha n g. Tng tit, tng toan c th gp 0,5% ngi
bnh thng khe mnh, nhng ch yu l cc trng hp bnh l (hnh 2)
+ Bnh l v d dy: lot t trng thy 75% cc trng hp, lot d dy 50%, lot mn v ,vim
d dy cp.
+ Do phn x thn kinh trong vim ng mt, vim rut
+ Do cc ha cht (histamin (hnh 3), insulin, acetylcholin) v cc ni tit t ACTH, cortison.
Tng tit- tng toan gy ngng tr khi thc n trong d dy v thc n cha cht toan qu
mc khi xung t trng s gy phn x co tht lu dai mn v. Thc n ng trong d dy s
tng cng qu trnh ln men nn bnh nhn thng chua v s lng thc n nhuyn nt
chuyn qua rut gim r rt, gy gim nhu ng rut v to bn, ng thi hp thu gim gy
gim dinh dng toan thn. Tng toan cn l mt xch quan trng trong cc bnh sinh cc vt
lot d dy v t trng. Trong giai on u ca vim d dy c th thy gim tit- tng toan
(hnh 4) c th do tnh trng mt nc ca c th.
b)Gim tit- gim toan pht sinh khi toan dch v gim di 20mEq/l, c nhiu mc khc
nhau:
- Gim tit- gim toan tng i c th gp trong:
+ Cc trng hp mt nc ca c th nh st, nhim khun, i lng
+ Cc trng hp ri lon dinh dng nh i n, thiu sinh t, suy nhc c th
+ Cc xc ng tm l m tnh (lo bun, s hi, gin)
+ Bnh l vim d dy cdo tng tit cht nhy trung ha mt phn ln HCl t do (hnh 5).
- V toan pht sinh khi c tn thng nim mc d dy v cc t bo tit, c phn bit:
+ v toan gi hay khng c HCl t do nhng vn c HCl ton phn do nim mc d dy vn cn
tit axit nhng b dch nhy kt hp ht c, thng gp trong vim d dy mn.
+ V toan tht, hon ton khng c c HCl t do v ton phn do tn thng hon ton cc t
bo tit. C th gp ngi gi, ngi thiu sinh t B
1
, thiu st nhng quan trng hn l trong
vim teo nim mc d dy, ung th d dy, giang mai d dy(hnh 6).
- V dch v l trng thi nng hn do teo nim mc hon ton, c nh, khng phc hi, nh
hng n cc t bo tit HCl v pepsin.
Gim tit- gim toan, v toan, v dch v thng dn ti nhiu hu qu nghim trng ty theo
mc :
- Do thiu HCl nn pepsin khng c kch hot, khi thc n c tiu ha khng y hoc
gn nh khng c tiu ha a thng xung t trng, qua rut khng c hp thu, cn kch
thch cc th cm thnh rut gy i lng dai dng v suy dinh dng.
Thiu HCl nn s di chuyn khi thc n xung rut nhanh (do c trung ha nhanh), gy ri
lon tiu ha rut do thiu cht kch ty v khng hp thu c st ta hng cu.
B - RI LON CHC NNG C BP CA D DY
Chc nng c bp ca d dy nhm nho trn, nghin nt v vn chuyn
thc n t d dy xung rut. Vn ng c ca thnh d dy bao gm cc co bp trng lc
nho trn v gip cho sc chu ca d dy thch nghi vi th tch thay i ca ba n, v co bp
nhu ng vi cc ln sng lm nhuyn trn thc n vi dch tiu ha v chuyn thc n xung
rut. Ri lon chc phn co bp c th theo 2 hng tng cng hoc gim st.
1. Tng co bp (tng c nhu ng v trng lc)
- Nguyn nhn thng l do :
+ Thc n c tnh cht kch thch mnh nh ru, axit lactic, cht c do thc n b nhim
khun
+ Vim d dy, lot d dy.
- Tc h vi c hc hay chc phn, giai on u
Mt cn bng thn kinh thc vt, cng ph giao cm, c ch giao cm hay khi giy thn kinh
ty sng b kch thch trong bnh Tabes.
+ Tc dng ca mt s ha cht nh htamin, cholin
- Tng co bp d dy gy p lc trong d dy biu hin bng cc triu chng nh hi, chng
mt, nng m cc, au Tng co bp lm hnh nh ca d dy ngn li, nm ngang, c th thy
r qua cc nh chp X quang (H7).
2. Gim co bp (gim trng lc v c nhu ng)
- Nguyn nhn c th l:
+ Cn tr c hc lu ngy nh tc h vi do u, so hay vi vt. Nhng nguyn ny ban u gy
tng co bp nhng sau khng thng c tr ngi, c d dy dan qu mc nn pht sinh
gim co bp.
+ Mt thng bng thn kinh thc vt nh c ch giy X hoc cng giao cm. Sau khi ct c 2
dy X th c d dy mt trng lc, gim nhu ng (phu thut Dragstedt). Sau nhng phu
thut ln vng bng, d dy cng c th b dn v sa xung do t lit dy X.
+ toan ca dch v tng nn khng gy c phn x m h v.
- Gim co bp do c d dy yu, 2 thnh khng p st vo nhau, v y d dy thng sa xung
di ng xng chu. Do nhu cu ng gim nn thc n lu thng xung rut b chm li
gy ng v d dy dn cha thc n, dch th v hi, thnh rut teo i v suy yu. T
pht tng cng ln men, thi ra, gy nn lm c th mt nc v mui kim, c th dn ti
try tim mch, co git v cht.
3. Mt s biu hin khc:
Ri lon co bp d dy thng km theo cm gic au, tc rt vng thng v, hi, bun nn,
nn.
a) Cm gic au ti d dy: bnh thng nim mc d dy khng c cm gic i vi cc kch
thch c hc, ha hc hay nhit , tr trng hp cc kch thch qu mnh gy nhng tn
thng thc th d dy hoc nhng kch thch trc tip nh hng ti on cng thn kinh
nm gia nhng si c vng ca thnh d dy. Cm gic au ti d dy c th pht sinh do:
- p lc trong d dy tng co khi co gim qu mc, co bp mnh cc c (tc h vi, vim d dy
cp, trng c thc n)
- Khi cm th tnh ca d dy tng (xung huyt, vim, lot) lm cho mt kch thch bnh
thng cng gy au.
- Tc dng ca HCL trm vim lot.
au rt cng thng v pht sinh khi c tng tnh mn cm ca cc cm th thc qun khi ln
sng phn nhu ng m tm v tng cc cht ng trong d dy vo thc qun gy co tht
thc qun.
b) Hin tng hi l s y ra mt cch bt ng hi v mt phn nh cc cht ng trong
d dy hoc thc qun. Bnh thng trong d dy ch cha mt t hi kch thch vn ng d
dy. Trong trng hp bnh l, do qu trnh ln men, thi ra tng cng c th to thnh cc
kh CO
2
, CH
4
, H
2
s, NH
3
v cc cht sinh hi khc li trong d dy lm tng p lc d dy, ri do
nh hng ca co tht phn x bt thng, cc c d dy, c honh, c bng tm v m ra v
gy hi (vim, lot d dy, u c d dy)
c) Bun nn, nn:
- Bun nn l cm gic kh chu khi co bp mnh rut nhng d dy li khng co bp. Bun
nn thng km theo chy nc ming,yu t ,xanh xao, lnh cc chi, huyt p ng mch h
do hu qu ca kch thch thn kinh giao cm.
- Nn l mt ng tc phn x phc tp do kch thch cc c quan cm th d dy bi thc n
xu, gim phm cht, cc cht c v do tng tnh cm th ca thn kinh - c d dy trong cc
bnh l d dy- rut, gy nhng xung ng kch thch trung tm sn no tht IV. Trung tm
nn b kch thch do cc xung ng t d dy, thc n xu hoc phn x c iu kin do mi v
thc n khng thch hp hoc do cc cht c, c t vi khun, chuyn ha phi khi c cha,
hoc cc xung ng t cc cm th phc mc, d con, thn gan v cc c quan khc.
Nn l mt phn x c tch cht bo v c th, tng ra khi ng tiu ha cc cht c v thc
n xu, nhng nn thng xuyn dai dng trong nhim c d dy rut, ph n c thai
thng gy suy nhc, mt nc, suy sp tun hon v ri lon cc chc nng khc trong ton
b c th.
C- RI LON CHC PHN HP THU V BI TIT CA D DY
- Bnh thng chc phn hp thu ca d dy khng ng k, nhng trong bnh l chc phn
ny lm tng cng r rt nn nhng cht c do ng khi thc n trong d dy c th
thm qua thnh ca d dy gy nhim c c th. Trong vim d dy, nim mc d dy c th
tng thm mt s cht c, c t vi khun v cc sn phm c khc.
- Chc phn bi tit ca d dy c xc nh qua tc xut hin trong dch v dng dch mu
trung tnh (rouge neutre), bnh thng sau 12-15 pht. Chc phn bi tit ca d dy c
coi nh mt bin php phng ng sinh l. ch b nhim nong thy xut hin trong dch v axit
lactic. Trong qu trnh vim m mn tnh, thy c bi tit trong dch v cc sn phm c nng
azot cao. Ri lon chc phn bi tit ca d du cng l mt trong nhng nguyn nhn lm tng
cng qu trnh nhim c v suy kit trong cc trng hp bnh l nng.
D- SINH L BNH CA VIM LOT D DY
Vim d dy
Vim d dy l mt bnh ph bin trong nhn dn cng nh trong qun i thi bnh cng nh
thi chin. Lin x trong i chin II ti cc bnh vin d chin, vim d dy chim ti 7-25%
ca tng s bnh ni khoa, trong vim cp chim 4,9%.
Hnh thi din bin ca bnh:
- Th cp thng din bin rm r, cc ri lon tiu ha bin i r rt, chc phn tit dch, co
bp u b ri lon. c bit trong vim d dy thi chin, bnh nhn au rt d di, chim ti
95% cc trng hp.
- Th mn c th tng sinh ph i v c th teo (khi toan dch v gim r rt do cc t bo
tit c hiu b teo thay th bng cc t bo tit nhy, nhn i th thy cc vt nhn xp
xung).
Vim cp iu tr tt c th khi hon ton hoc c th chuyn thnh vim mn. Vim mn
thng tin trin m thm, ko di, thnh thong c t kch pht, giai on u thng l th
tng sinh sau c th din bin thnh th teo.
2. Nguyn nhn v bnh sinh ca vim d dy:
- Do n ung: n vi, nhai khng k, rng hng, n phi thc n kh tiu, i thiu, n tht
thng, rn, lnh, thiu cht lng , thiu sinh t (iu kin chin trng), sau khi n lm vic
nng ngay.
- Do cc ha cht c, thuc nh hng ti nim mc d dy nh ru, thuc l, (nicotin), axit
salicylic, aspirin, INH, PAS (iu tr lm dng), bi ch, axit bo (iu kin sn xut khng c
bo v tt), nhim khun, nhim c bi tit theo ng tiu ha (cm, lao).
- Do d ng: thc n, ha cht
- Do thn kinh: tinh thn cng thng (chin u c lit, oanh tc d di hoc cng thng trong
i sng).
Nhng yu t ny theo B-cp hoc tc dng trc tip gy tn thng nim mc d dy, hoc
thng qua nh hng ca v no lm v no khng duy tr c mi quan h bnh thng i
vi cc ni tng gy hin tng d dy co bp nhiu v mnh, tht thng nn to iu kin
pht sinh vim d dy. Cho nn trong d phng v iu tr vim d dy ch yu pht tit ch
vn n ung, hp l v v sinh, cn tit ch ru, thuc l, khng dng aspirin v cc cht
kch thch khc, cc gia v chua cay qu v loi tr cc vim trong c th. Khi cn thit cc
thuc gim au, chng co tht v cn thit bo v chc nng hot ng thn kinh cao cp .
LOT D DY - T TRNG
L mt bnh ph bin trong nhn dn cng nh trong hng ng cn b, b i ta, thi bnh
cng nh thi chin. Theo cc ti liu thng k th lot d dy ngy cng chim t l cao:
Bungari (Sofia) 17% trong tng s bnh ni khoa, Nauy, c, Anh, M 5-10% dn s mc bnh
vim v loet d dy, s ngi phi nm iu tr 0,15-0,38% dn s. Vit Nam theo thng k
ca hi ngh ni khoa 1962, lot d dy t trng cng chim t l 5-10% trong tng s cc bnh
ni khoa.
1.Hnh thi din bin ca bnh:
- Lot d dy ring bit ch gp t 16-28% trng hp trong tng s cc bnh let, thng l
lot b cong nh.
- Lot t trng l hnh thi ph bin nht (40,67%).
- Lot phi hp c d dy v t trng.
Nhn chung, bnh ko di nh hng cng tc v nng sut lao dng, ngoi ra cn c th gy
nhiu bin chng nguy him n tnh mng. Bin chng hay gp nht l chy mu d dy chim
ti 32% lot d dy v 18% lot t trng. Thng d dy c th gp 6,2% cc bnh nhn
lot, thng t trng v mn v t gp hn.
Lot d dy-t trng thi chin do tp trung t tng, sc lc li cng thng thn kinh v sc
khng gim st nn t l chy mu v thng d dy cao hn thi bnh, ng thi c nhng
triu chng khng in hnh, kh pht hin. Chn thng nh hng rt ln ti lot d dy t
trng: ngi ta thng thy triu chng lot xut hin khong 15-20 ngy u sau khi b
thng, nhng 90% l cc vt lot c pht trin nn ngi ta kt lun rng thng thng chn
thng khng gy bnh lot mi mch gy mt t tin trin trn bnh lot c hoc gy
nhng bin chng nh chy mu, thng d dy, trng hp c bit v him mi gy bnh lot
mi.
2.C ch bnh sinh ca lot d dy-t trng.
V bnh sinh ca lot d dy- t trng t trc ti nay c rt nhiu gi thuyt gii thch
nhng ti nay vn cha c hon ton sng t, cng nh ngi ta cha gy c mt mu
bnh thc nghim ging nh lot d dy- t trng ngi nn vn iu tr bnh cn gp
nhiu kh khn. Hin nay trong bnh sinh ca lot d dy- t trng c mt s yu t c ch
c bit.
a) Ri lon cn bng tit dch d dy
Qu trnh tit dch d dy bao gm hai h thng: men tiu ha HCl v pepsin c kh nng tiu
prtit v cht nhy kim c kh nng bo v nim mc d dy v hai h thng ny lun cn
bng m bo cho s tn ti v hon thnh nhim v tiu ha. Hot ng tit dch li chu
s iu ha ca thn kinh th dch cho nn hin nay ngi ta quan nim cc bnh lot d dy-
t trng l bnh ton thn m biu hin cc b d dy l ch yu. Nh vy, vt lot d dy
hay t trng c coi nh kt qu ca s tn cng ca men pepsin v HCl c tit nhiu qu
mc hoc qu sc khng ca nim mc d dy hay hng ro phng ng b gim st nn
khng bo v c nim mc d dy chng sc tiu ca HCl v pepsin (vn tit mc bnh
thng). Trn thc t cng thy trong cc bnh lot d day ch 50% trng hp c th tng
tit- tng toan cn cc bnh nhn khc vn tit dch toan bnh thng, c th do gim st sc
khng ca nim mc d dy v gim st hng ro kim bo v.
c)Ri lon tng quan gia chc phn tit dch v chc phn co bp ca d dy: cc cng trnh
nghin cu ca Pap- lop xc ng rng thn kinh chi phi hot ng tit dch v c co bp d
dy l dy X. Cc kch thch n ung (loi thc n mi v) gy nhng xung ng thn kinh ti
d dy, lm bin i ng thi chc phn tit dch v co bp d dy. Nh phng php ghi in
d dy (EGG) v o s phn tip HCl sau ba n th nghim thy : trc tin l s bin i hot
ng co bp d dy ri sau mt thi gian mi thy bin i toan dch v. Nh vy cc tuyn
tit ca d dy p ng vi kch thch thc n khng bt u lm vic ngay m c mt giai on
tim (5- 10 min v hn na). Chnh trong giai on tim ca phn tit , hoc tnh co bp d
dy tng r rt trn EGG lm sng in ln cao ti 0.7- 0.8 mV, ri sau khi khi mc HCl t
do tng dn th bin cng gim dn ti 0.2- 0.3mV chng t c s c ch hot ng co bp
ca d dy. Sau khi HCl v pepsin c tit y cho yu cu tiu ha, pH gim ti 2 th li
c s iu ha tit dch theo c ch thn kinh ni tit m bo cho hot ng nhp nhng gia
tit dch v co bp d dy. Nh vy hot ng co bp d dy v thi gian vn chuyn thc n t
d dy vo t trng ngi khe mnh cn bn ph thuc vo mc toan trong qu trnh
tiu ha. S vn chuyn thc n t d dy vo t trng cng nhanh khi bin cc giao ng
in trong EGG cng cao v ngc li, thc n xung chm khi bin cc dao ng in thp
v sau giai on tim ca phn tit l nhng t nhp nhng y dch toan d dy v thc n
nhuyn nt xung t trng.
R rng ngi bnh thng c mt mi tng quan cht ch gia chc phn tit dch v co
bp ca d dy, l c ch t iu tit, c ch sinh l nhm c ch hot ng co bp khi toan
tnh dch v cao ngn nga s vn chuyn qu nhanh cht toan d dy vo t trng, bo v
c hiu qu phn trn ca rut i vi cc tc dng tiu hy HCl v pepsin, bo v cho c nhng
ngi khe mnh c toan dch v cao chng s pht sinh vt lot t trng. C ch ny b ri
lon bnh nhn lot t trng, bin dao ng in trong EGG tng rt cao 0,8-1 mV, d dy
co bp mnh trong khi toan dch v cao, vn ny hon ton bt thng v theo mt s tc
gi l mt trong nhng mt xch ch yu trong bnh sinh ca lot t trng. V cng trn c s
ca hin tng ny, ngi ta cho lot d dy v lot t trng l 2 bnh hon ton khc nhau.
Thc t ngi ta thy bnh lot t trng t l gp nhiu hn, v nhng bnh nhn c lot d
dy v t trng phi hp, lot t trng thng xut hin trc gy tc mn v v ng d dy,
kch thch tng tit gastrin ri t gy lot d dy. Nhng ti sao c ri lon cn bng tit dch
cng nh c ri lon mi tng quan gia chc phn tit dch v co bp d dy. 3 l thuyt gii
thch c nhc n nhiu l hc thuyt v no- ni tng ca B-cp v Guc-xin:
Cc kch thch bt thng do hon cnh x hi, tm l gy ra v cc kch thch lu di t ni tng
(vim d dy, vim ti mt) lm cho v no b mt mi, c ch khng lm c nhim v iu
ha cc trung khu thn kinh di v; v v ni tng, do pht sinh nhiu xung ng bnh l
kch thch dy X gy tng tit dch v toan, gy co tht lin tc cc c trn d dy, gy thiu dinh
dng v lm gim sc khng ca nim mc d dy to iu kin hnh thnh cc vt lot
d dy hoc t trng. D dy v t trng l nhng c quan c h thng mch mu v thn kinh
phong ph nn rt d mn cm vi nhng ri lon trn hoc nh hng trc tip ti dy thn
kinh X hoc tc dng thng qua h ni tit nn thng thy cc cht ni tit: ACTH, Cortisol,
Acetylcholin tng cao trong bnh nhn lot d dy v t trng. Khi vt lot hnh thnh li tr
thnh mt ngun kch thch lin tc ln v no to thnh mt vng xoy bnh l{ v no-ni
tng-v no v bnh c th tip din.
3.Nhng yu t nh hng n bnh sinh lot d dy-t trng
a)Yu t x hi:
Nhiu yu t x hi nh hng ti pht sinh v pht trin bnh lot d dy-t trng. Vit
Nam, t l cn b v hc sinh mc bnh tng i cao (27,7%), cng nhn (13%) v nng dn t
l mc bnh thp nht, ch 4,8%, ni chung nhng ngi lm vic i hi v lao ng tr c v
tinh thn mc bnh cao hn. V gii th nam mc nhiu hn n. Nhiu bnh lot pht hin
trong v sau chin tranh. Cc cn b min Nam mc nhiu hn so vi cc cn b min Bc
(trong thi gian mim Nam b xm lc).
b)Yu t sinh hot vt cht:
nh hng r nht l ch n ung, ngoi vn khu phn thiu protein, cn k thm cc
yu t ph:
- Lm vic nng ngay sau khi n no.
- Nhai khng k, nut nhanh do thi quen, rng hng.
- n cay nhiu.
- Cm sn, c nhiu thc, thc n kh, qu cng.
- Thuc l, thuc lo (95% trong c 43% c nghin nng).
c)Yu t ni tit:
Thc t lm sng thng thy c ri lon ni tit, ch yu l trc h no-thng thn.
- Tng tit putressin v acetylcholin trong mu bnh nhn lot c th l mt trong nhng
nguyn nhn gy co tht c trn d dy, gy thiu dinh dng v lm gim sc khng ca
nim mc d dy to iu kin pht sinh vt lot.
- Tng tit ACTH, cortol gy tng tit HCl v pepsin (hoc c th gy gim tit nhy kim bo
v). Trn thc t lm sng dng ACTH, cortosol liu qu cao, c th gy lot ngi lnh, gy
cn au kch pht bnh nhn lot n nh, gy bin chng chy mu hoc thng bnh
nhn let ang tin trin. Tuy nhin vt lot thc nghim do cortisol l vt lot khng c vim
khc hn vi lot d dy trong thc t lm sng.
- Hin tng tng tit dch v khi ng mu h c th do tuyn ty tng cng hot ng
trong ung th tuyn ty, kc ny t chc ty sinh sn mt cht tng t kch t gastrin (hi
vhng Eolinger Ellison) do cc tc gi cho rng tuyn ty cng tham gia vo diu ha tit
dch d dy.
Ngoi ra cn thy ri lon cc tuyn ni tit khc c th km theo vt lot, nh trong x gan,
ri lon tuyn sinh dc, tuyn gip, tuyn cn gip(hnh 8)
d)Yu t th tng:
Nhiu vt lot c th l hu qu ca qu trnh mn cm c th i vi mt khng nguyn no
, vt lot c vng vim xung quanh ging nh hin tng Arthus trong phn v cc b v c
th gy trn ng vt thc nghim vt lot bng tim histidin liu cao. Cn thy t l lot
ngi c nhm mu O thng cao hn ngi c cc nhm mu khc.
e)Yu t thn kinh-tinh thn:
V no v hot ng thn kinh cao cp c mt vai tr trong bnh sinh lot d dy-t trng. Qua
iu tra thc t (H Vn Mo,1962) thy Vit Nam bnh hay pht sinh nhng ngi tnh
trnh thn kinh cng thng, lm vic lin min khng gi gic, mt ng lm cho v no suy
nhc, mt mi(73% cc trng hp), v do nh hng ca cc chn thng tinh thn, tnh
cm t ngt hoc lin min ko di, day dt.
Ri lon cn bng thn kinh thc vt, cn ph giao cm theo mt s tc gi cng l iu kin
thun li cho s pht sinh lot d dy-t trng v c th gy nhng cn co tht mch mu v cc
c d dy lm cho nim mc d dy d b tiu hy bi dch v (Rokitansky). Mt s tc gi khc
(Reissletz) nhn thy lot d dy-t trng xy ra nhng ngi vim mt c quan khc (vim
rut tha, vim ti mt) v vt lot l phn x ni tng kch thch theo ng thn kinh thc
vt gy tng tit dch toan v lot nhng phi trn c s mt cn bng thn kinh thc vt sn c
mi gy c bnh.
Nh vy, rt nhiu yu t nh hng n pht sinh v pht trin ca bnh lot d dy-t trng
(hnh 9), hin nay cha c phng php iu tr c hiu m ch da vo cc yu t bnh sinh
trn nhm trung ha toan dch v (Natribicacbonat), bo v vt lot (kao lanh, mui bismuth,
cam tho..), gim au v chng tit dch (atropin, than hot), chng co tht, dinh dng tt v
chng lin so (mt ong, ngh) v iu tr phu thut khi cc bin php ni khoa bt lc.
[newpage]
II. RI LON TIU HA RUT
Ri lon tiu ha rut rt quan trng v chnh rut cc thc n mi c tip tc tiu ha
mnh v c chuyn tip thnh nhng cht c kh nng hp thu nui c th.
RI LON CHC PHN TIT DCH RUT
Dch tiu ha rut gm mt, dch ty, dch rut, trong iu kin bnh l c th ch nh hng
ti mt loi dch hoc c th nh hng chung gy ri lon tiu ha v hp thu rut .
1.Ri lon tit mt:
Mi ngy ban tit chmg 500-100 ml mt do kch thch ca thc n i vi nim mc t trng.
Mt tham gia vo qu trnh tiu ha m nh mui mt (axit mt taurocholic v glycocholic kt
hp vi cc mui c tc dng lm cho axit bo v cholesteron tan trong nc, nh tng ha
cho cc men tiu m d tip xc v pht huy tc dng.
Gim tit mt hoc nh ch tit mt gp trong:
- Co tht, tc ng dn mt do giun, si, u .
- Ri lon chc phn to mt do gan suy, thiu mui mt khi ct on hi trng (tun hon gan
mt ca mui mt b gim st).
Ri lon tit mt gy nhiu hu qu:
- Tiu ha v hp thu m khng y gy i ngoi phn m, nng m trong phn ti 70-
80%.
- Thiu mt nh hng n tiu ha chung cc cht gluxit, lipit, protit v mui mt c tc dng
trung ha nng axit d dy v duy tr mi trng kim t trng to iu kin cho cc men
tiu ha hot ng.
- Axit mt c tc dng kch thch kh nng hp thu ca biu m rut nn khi thiu mt, hp thu
cht dinh dng gim r rt.
- Thiu mt, tc dng dit khun v nhu ng rut gim dn ti tng cng qu trnh ln men,
lm thi, gy y ,chng hi v to bn.
Cc sinh t tan trong m khng c hp thu (A,D,E,K).
2.Ri lon tit dch ty:
Khi ti d dy xung rut, kht nim mc d dy, kch thch nim mc t trng tit secretin v
ancreozymin c tc dng gy tit dch ty. Dch ty c tit t 200-1500 ml trong 24H, v gm
cc men chnh:
- Men tiu protit: tryipsinogen v chymotrypsinogen, di tc dng ca enterokinaza mi c
chuyn thnh trypsin v chymotrypsin hot tnh, phn hy protit thnh cc polypeptit.
Cacboxylaza, amino pepyidaza chuyn polypeptit thnh peptit v axit amin. Nucleaza chuyn
axit nucleic thnh cc nucleotit.
- Men tiu m: lipaza c hot tnh cao, chuyn m thnh axit bo v monoglycerit. Mui mt v
mui Ca tng cng tc dng ca lipaza.
- Men tiu tinh bt: amylaza, diastaza chuyn tinh bt thnh mantaza v glucoza.
Ri lon tit dch ty c th gp trong:
- Vim t trng, thng km theo gim to secretin gy gim tit dch ty. Thiu HCl, v toan
cng gy gim to secretin.
- Tc ng ty do si, u u ty.
- Cc qu trnh vim ty, tn thng tuyn do tc hoc co tht dng mu ca tuyn, c ch
thn kinh chc nng tuyn (lon dng thn kinh ng c atropin). Kch thch dy X gy gim
tit, ct t dy X gy tng tit dch ty, kch thch dy TK tng cng gy gim tit.
- Ch n ung: n nhiu tht, m gy tng tit dch ty v ngc li ch n nhiu rau gy
gim tit.
Gim dch ty gy nhiu ri lon nghim trng qu trnh tiu ha rut: 60-80% cht m, 30-
40% cht protit v c cht tinh bt cng khng c tiu ha y nn i lng dai dng, phn
c m, nhiu si c v tinh bt cha tiu ht v mi rt thi.
Vim ty cp c th pht sinh do tc t ngt ng dn dch ty, trong trng hp ng c
ru, nhim virut, chn thng hoc sau mt ba n thnh son do tit dch ty qu nhiu.
Bnh thng cc men dch ty c tit di dng tin men, ch sau khi ra khi tuyn xung
rut mi c hot ha. Nhng trong cc trng hp bnh l trn cc men ty li, hot ha
trn vo t chc ty gy hin tng t tiu hy t chc. Trong thc nghim khi a mt lng
nh tripsin vo dng mu tuyn c th gy hoi t t chc mnh do kch hot trypsinogen ty
(phn ng t xc tc), hin tng tng t c th thy c ngi thiu anttypsin (bnh
thng c trong tuyn ty). Dch ty c th trn vo mu gy gim huyt p ng mch dn ti
try mch ty c th t vong.
3.Ri lon tit dch rut (dch trng)
Trong dch rut c 3 loi men tiu ha chnh: Erepsin tiu protit; lipaza tiu m, lactaza v
invertaza tiu ng. Dch rut cn c cc kch t: kch d dy (secretagogue), kch ty
(secretin), kch mt (cholecystokinin), cht hot ha men ty (enterokinaza), cht c ch gastrin
(enterogastron) v cht nhy bo v nim mc rut.
Ri lon tit dch rut khng cn nh hng nhiu n tiu ha khi cc men ty b li, ch tr
con b c th gy ri lon tiu ha do thiu cc men tiu sa lactaza, invertaza.
Nguyn nhn ca ri lon tit dch rut thng do:
- Vim rut, cc men tiu ha v kch t u gim ngc li, cht nhy tng tit co th ti 80
ln hn bnh thng, gy i lng, phn nhy.
- mu thnh rut trong lit mch, sc; thiu mu thnh rut khi vim i trng do nhim c
ch gy co tht cc mch mu rut.
- Ct on mt phn ln rut.
Ni chung, ri lon tit dch tiu ha rut gy ri lon tiu ha v hp thu cht thc n, lu
di dn ti suy dinh dng ton thn v trng thi mt nc v mui nghim trng.
B- RI LON CHC PHN HP THU RUT
Hp thu l qu trnh vn chuyn cc cht dinh dng trong ng tiu ha qua nim mc rut vo
mu. Ti ming ch c mt s ha cht mocphin, adrrenalin, ni tit t steroit h thu c. n
d dy th c th hpt hu c mui, ng, ru nhng qu trnh hp thu tin hnh ch yu
rut khi thc n c tiu ha thnh nhng cht c trng lng phn t nh, Nhng cht
c hp thu bao gm gluxit, lipit, protit, sinh t, nc, mui nhm duy tr cn bng kim
toan, nc mui cho c th. Qu trnh hp thu i hi nim mc rut phi lnh ln vi y
cc men chuyn ha. Ri lon hp thu biu hin di 2 hnh thi:
1.Gim hp thu pht sinh do:
- Vim rut vi tn thng hoc teo nim mc rut (90%).
- Ct on mt phn ln rut, thiu dch ty, v toan, tc mt
- Ri lon chuyn ha bm sinh nh thiu men tiu gluten, tiu disaccarit, hoc khng s
gamma globulin bm sinh nn cac vi khun rut pht trin qu mnh.
Gim hp thu trc ht gy i lng, suy dinh dng, thiu sinh t, thiu mu, ci xng, ph
do i n v cc biu hin khc.
2.Tng hp thu bnh l:
Thng kt hp vi tng thm thnh rut (xung huyt ch ng hoc kch thch biu m rut),
c bit hay gp tr nh chm ln. Tng hp thu bnh l c th gy nhim c cc sn phm
khng tiu ha y ca thc n, i khi thm c cht m trng g, sa b gy mn cm c
th v pht sinh d ng.
C- RI LON CHC PHN CO BP RUT
Do rut co bp thc n c th vn chuyn nhanh hay chm, trung bnh t 1,3 n 3 gi sau ba
n th thc n ti rut non v nm ti n gi 6-7 mi y sang i trng v khong sau 24
gi cht cn b (phn) c bi tit ra ngoi.
1.Tng nhu ng rut:
Tng nhu ng rut lm cho thc n chuyn qua rut nhanh hn v pht sinh i lng. Nguyn
nhn thng do:
- Vim rut vi tn thng nim mc rut do nhim khun, nhim k sinh lm cho tnh cm th
ca thnh ruttng cng.
- tc dng ca cc kch thch bt thng nh thc n xu. sn phm ln men thi, cht c
- Lon sinh cc vi khun ng rut.
- Ri lon co bp rut trong u manh trng, vim phc mc, ri lon thn kinh (lo s, cm
ng). Trong ung th rut, t bo rut tng tit seretonin gy nhng cn co bp rut v i
lng.
Tng nhu ng rut, a lng mc nht nh c { ngha thch ng bo v v kch thch trung
tm thn kinh ph v v kch hot d dy, to iu kin rng ra khi c th cc sn vt c
khng ng ha l i lng ko di kt hp vi ri lon tit men tiu ha rut dn ti ri lon
nghim trng tiu ha v hp thu rut gy suy dinh dng, st cn, gy. Do mt noc theo
phn ln mu c, gim lng mu tun hon c th dn ti try tim mch v mt mui kim
ca dch ty, mt gy nhim toan ko theo nhiu ri lon khc na (H10). Cho nn trong iu
tr a lng, ngoi vn gii quyt nguyn nhn (chng nhim khun, chng d ng) phi chuyn
tr nc, mui (dung dch NaCl, NaHCO
3
, glucoza), chng suy dinh dng
2. Gim nhu ng rut:
Gim nhu ng rut lm thc n vn chuyn chm hoc c ch vn chuyn dn ti to bn. C
th phn loi:
- To bn co tht pht sinh do nh hng ca cc yu t c (nhim c ch), tc dng tm l
(lo ngh, bun phin), tr ngi hot ng ca rut (au do chn thng, lot thnh rut do l )
v c nhng phn x ni tng- ni tng Tt c nhng yu t ny dn ti co tht tng on
rut v gy ng phn .
- To bn trng lc pht sinh do nhng yu t to iu kin lm gim trng lc thnh rut
v suy yu nhu ng rut nh ba n ngho nn, thiu dinh dng, thc n thiu cht b,
thiu mt, thiu mui K v Ca, tiu ha qu mc. To bn c th gp khi nim mc rut gim
tnh cm th i vi kch thch (vim rut mn, ngi gi, bo ph) v trong ri lon bm sinh
nhu ng rut (bnh Hirachprung). Trong bnh ny, c ri lon phn b thn kinh thc vt m
ri Auerbach, vng rut co tht li, pha trn dn v di ra, phn b ng gy bng chng,
nn lin tc v to bn dai dng. Phn b kh rn li, cc cht c v vi khun pht trin gy
nhim c ton thn v lu ngy c th gy xa tr. cc i trng.
3.Tc rut:
Tc rut l tnh trng bnh l xy ra khi mt on rut b tc hoc khng co bp lm thc n
khng lu thng c. V nguyn nhn c th chia lm 2 loi:
- Tc c hc pht sinh khi rut b bt kn do khi u, giun, so hoc rut b xon, tht, lng
- Tc thn kinh khi cng dy X gy co tht mt on rut hoc lit dy X gy dn hn mt on
rut (bin chng hu phu).
Din bin ca tc rut thng nghim trng:
- Lc u phn trn ch tc tng cng co bp gy cc cn au d di v hin tng rn b
thnh bng. Rut b tc, thc n khng lu thng c gy xut hin cc sng phn nhu ng
lm bnh nhn nn ma, nu tc phn di c th nn ra phn.
- Nhim c cc cht c rut v mt nc, mt Cl lm cho din bin rt trm trng, cn c
th do phn x thn kinh khi rut b cng gy sc. Tc rut on cao, hu qu s nng hn,
mt nc nhiu c th gy gim lng mu tun hon, h huyt p, try mch, tng ure mu.
Bin php x tr ch yu l phi truyn dch, n inh cn bng axit baz, chng cng rut bng
ht hi v nc phn trn on tc. Nu do nguyn nhn c gii, phi gii quyt bng phu
thut.
III. NHIM KHUN, NHIM C NG TIU HA
1.Nhim khun ng tiu ha:
ng tiu ha l ni ra vo ca nhiu loi vi khun. ngi khe trong rut c mt lung vi
khun rt giu, hng ngy phn bi tit ti hng t vi khun. Nh tnh cht dit trng ca HCl v
cc men tiu ha cc vi khun khng ny n c, t gia rut non th vi khun pht trin v
t mc ti a rut gi.
- Cc vi khun ln men ch yu hot ng rut non, pH toan v tham gia vo qu trnh ln
men, tiu ha cht b (cellulose) v tng hp sinh t K. cui i trng, pH axit li cng c cc
vi khun ln men hot ng.
- Cc vi khun lm thi chim u th i trng v manh trng v pH y kim hn.
Trn c th khe mnh u tin l cc vi khun ln men. Cc hydratcacbon, cellulose b ln men,
cn cc cht m c N b lm thi ra. Cc vi khun cn tham gia tng hp mt s sinh t (K,B
2
,
axit folic). Vi khun tc ng ln sc t mt lm cho phn mu vng t gia rut gi. Khi c ri
lon vi khun, c th chn on theo mu sc phn: phn mu da cam do phn qua rut gi
qu nhanh vi khun khng kp tc dng ; phn mu xanh hay nu xanh l do bilirubin b oxi ha
thnh biliverdin (i tt tr em).
Khi ung cc loi khng sinh mnh c kh nng dit vi khun mnh nh chloromycin,
terramycin lm cho phn ln vi khun b tiu dit, ch 1-2 loi thuc s gy mt cn bng vi
khun t nhin rut, hay trnh thi lon khun, c th gp trong vim rut do t cu vng, do
enterococcus hoc i khi do nm monoliasis. Ri lon cn bng vi khun dn ti a lng ko di
v suy dinh dng ton thn.
2.Nhim c ng tiu ha:
Cht c v c tnh rut cng tng t rut non n rut gi. Bnh thng, cht m cn li
qua ng tiu ha c kh amin mi trng kim cho nhng cht nh axit paraoxyphenyl
propionic, axit paraoxy phenyl axeetic, axit indol axetic c ct thnh nhiu cht c: idol,
phenol, scatol, cresolBng cch kh cacboxyl trong mi trng toan li cho cc chtt:
histamin, tyramin, tryptamin v cc axit 2 amin nh putressin, cadaverdin. Nhng sn phm
ny thm vo mu qua gan c gii c gan. Mt mt idol v scatol c v hi bng con
ng kt hp vi axit glycuronic c sunfuronic to thnh idoxyl, scatoxyl glycuronic v idoxyl,
scatoxyl sunfuronic. Cc cht c khc cng chuyn thnh khng c theo con ng kh amin
oxy ha v c bi tit qua thn.
Khi nhng cht ny c to ra nhiu v qu trnh thi ra ko di s tr thnh gnh nng cho
gan, lm gim st chc nng chng c ca gan v gy nhim c c th. Cc cht c trn vo
mu tc dng trn cc cm th mch mu v cc trung khu thn kinh gy cc biu hin cp tnh
ca nhim c ng rut nh: gim huyt p ng mch, gim cm gic, gim thoi bin
glycogen gan, gim co bp tim, c ch h hp v c ch su sc v no dn ti hn m v cht.
Trong nhim c mn tnh, bnh nhn thy nhc u thiu mu, bin i lon dng tm c,
gim ngon ming, ri lon tiu ha do gim tit cc dch tiu ha. Nhim c ng rut
thng din bin nng tr em v c ch b p ni chung yu hn ngi ln.
IV. RI LON KHI CT B ON KHC NHAU CA NG TIU HA
Khi ct b on khc nhau ca ng tiu ha, c th khng thy hoc c nhng ri lon ty theo
mc ca bnh:
- Ct b phn tm v: dn ti mt cm gic no, gy ri lon ung nhiu v cung n, d b nn,
c cn ngt th do co tht cc c c.
- Ct b mn v (lm gastro- enterostmose) nh hng ti ton b chc phn d dy, tc
chuyn thc n chm li 3-5 ln. t anastromose cng on rut thy biu hin cng r.
- Ct b d dy ch yu dn ti ri lon chc phn cha ng v chc phn tit dch d dy, tuy
nhin c th dn c thay th on di ng tiu ha. C th xut hin hi chng Dumping:
sau khi n 20- 3- min, cm thy mt mi, bun nn, nh trng ngc, tot m hi v cm gic
nng rt mt. Hin tng ny c gii thch bng nh hng phn x khi thc n t ngt
lm dn hng trng. mt s bnh nhn m, sau khi n thy c tng ng mu do thm
nhanh cc hydrat cacbon trong rut non, ri li chuyn thnh gim ng mu phn ng do
tng ty insulin ko di.
- Ct b rut non ton b tt nhin dn ti cht, khi ct b 1/2, 2/3 v c ti 7/8 rut, i sng
ng vt vn c th duy tr c t ngy.
- Ct b rut gi (t anastomoso trc tip ileo-coecal) chuyn thc n t d dy chm li cn
t rut non li tng cng. Tuy nhin 5 thng sau khi ct on rut gi thy c c ch tit dch
tiu ha rut v suy dinh dng.
Theo A (1973) cc ri lon tiu ha u c th dn ti mt tnh trng chung l thiu nng
hay suy tiu ha. L tnh trng m d dy- rut khng m bo c s ng ha v hp thu
thc n cho c th, biu hin: ri lon tiu ha, cn bng N m tnh, gim protein mu, thiu
sinh t, suy nhc v bin i tnh phn ng ca c th.
Nghin cu tch ri tng phn khc nhau ca ng tiu ha thy suy tiu ha c biu hin r
l chng n khng tiu tr cn b m. C ch c bn l s khng ph hp gia kh nng chc
phn ca ng tiu ha vi yu cu nui dng (khng hp l) dn ti nn ma dai dng v a
lng, khng hp thu c thc n v nc, suy kit c th. C th s dng hin tng v dch
v v gim phn tit dch ty lm kiu mu ca suy tiu ha tui trng thnh. tui gi, suy
tiu ha pht sinh do gim st chc phn tit dch tiu ha v ri lon qu trnh hp thu,
thng kt hp vi hin tng t nhim c thc n v suy yu chc phn vn ng ca d
dy- rut.

55. SINH L BNH H THN KINH


( NGUYN HU M )
Theo tin ha ca sinh vt h thn kinh cng tr nn phc tp.
Trong nghin cu sinh vt hc ngy nay, quan nim phn tch c th sng thnh tng t bo, t
chc, c quan ring bit dn dn doc thay th bng quan nim v cu trc chc nng tc l
nghin cu mi n v trong mi tng tc hot ng gia n v mi trng xung quanh, th
d nghin cu t bo vi c h thng vi tun hon, dch th, vn chuyn cc cht dinh dng v
cn b, hot ng ca thn kinh v ni tit mc . Quan nim kinh in v tnh cht c
hiu cc ng dn truyn v cc khu vc i chiu (thn kinh vn ng, thn kinh cm
gic)dn dn c thay th bng mt quan nim v cu trc khng c hiu c tnh cht tch
hp v tng hp hn (h thng li, h thng trng lc c vn). Cc cu trc ny hnh thnh
nhng tp th c quan h qua li (theo c ch hng phn v c ch ln nhau, hot ng hip
ng hay i khng, c ch phn hi khi m khi dng C th ni mi cu trc, chc nng
phi thc hin c hai nhim v : hon thnh cc qu trnh duy tr hot ng ca bn thn
ng thi ng gp vo s hot ng chung ca h thng m n l thnh vin. Nh vy, thy
ngay mi lin quan mt thit gia cc cu trc chc nng v h thng cng nh gia cc h
thng v trong ton th ni chung, trong qu trnh tng tc xui ngc, hip ng v i
khng c thc hin mt cch tht hi ha. Song bnh thng hot ng ca cu trc cp
thp chu s tri phi ca cu trc cp cao hn, ng thi, thng qua c ch phn hi, cu trc
cp thp vn c tc dng i vi cu trc cp cao hn.
Qua s phn tch trn y, thy r trong bt k tn thng thn kinh no, khng phi ch thy
mt loi triu chng, hoc thiu nng, hoc u nng m thng thy phi hp c hai. Cng v
vy m vic nghin cu hot ng thn kinh trong iu kin sinh l{ cng nh bnh l tht l kh
khn v phc tp.
I. NGUYN NHN GY RI LON THN KINH
Ri lon chc nng thn kinh pht sinh do cc yu t bnh l{ tc ng trn bt c b phn no
ca h thn kinh. Nhng kch thch bnh l y gy nn nhng ri lon phn x hoc nhng phn
ng trc tip ca cc thnh phn h thn kinh.
Nguyn nhn th rt nhiu, c th xp thnh hai loi ln: nguyn nhn bn ngoi v nguyn
nhn bn trong, c lin quan mt thit vi nhau.
A- NGUYN NHN BN NGOI
C th k:
1. Yu t vt l: nhit , phng x, dng in
2. Yu t c hc: c bit l chn thng, vi cc mc khc nhau.
3. Yu t ha hc: Nghin ru, nhim c (thuc ng, thuc m)
4. Yu t sinh vt hc, virut, c bit l loi virut co nhiu i tnh vi t chc thn kinh nh virut
bi lit, vim no. c nhng loi tc ng qua c t ca chng c i tnh c bit vi t chc
y nh un vn, bch hu, nhim c tht
5. Yu t tm- thn kinh
Ngoi nhng nguyn nhn k trn gy ra nhng tn thng thc th, th cn mt s bnh ca
h thn kinh cha r nguyn nhn, song c v yu t x hi ng vai tr rt quan trng: l
trng thi lon thn. Bnh lon thn ngi l mt bnh chc nng ca thn kinh trung ng,
biu hin bng nhng ri lon hot ng thn kinh cao cp, nguyn nhn quyt nh l chn
thng v tinh thn
B- NGUYN NHN BN TRONG
C th l nhng nguyn nhn bn trong n thun hoc l hu qu ca nguyn nhn bn ngoi.
Nguyn nhn bn trong rt phc tp, v ngoi nhng nhn t thc th, phi k n nh hng
ca tui, gii tnh v di truyn c tc dng ti tnh phn ng ca hot ng thn kinh.
1. Thiu oxy no. Thn kinh l t chc rt nhy cm vi tnh trng thiu oxy trong 5-6 pht,qua
10 pht c th xy ra nhng tn thng khng hi phc c. Thiu oxy no do nhiu nguyn
nhn gy ra: gim huyt p (st, chu mauc, try tim mch), thiu mu nng, thiu oxy trong
khng kh th (ngt, ln cao, gy m) hoc do co tht ng mch no.
2. Ri lon tun hon cc b ti no. Ch yu l x cng ng mch no v tc hoc nghn
mch. Ngoi ra, u no khi pht trin gy p t chc no cng l mt nguyn nhn gy ri
lon hot ng thn kinh.
3. Ri loan ni tit v chuyn ha: Nhng khi c thay i cn bng ni tit hi mnh l d c
nh hng ca hot ng thn kinh nh trong giai on dy th, thanh nin d xc cm v d
dn ti ri lon tm thn, cng nh lc chun kinh l thi kz hay c thay i tnh tnh ph n.
Gim glucoza mu gy ra nhng triu chng l ln, ra m hi, v c th cn co git. V no
nhy cm vi gim glucoza mu cng nh i vi thiu oxy hn l vng di v (ni tp trung
cc trung khu thc vt). Thiu oxy cng nh gim glucoza mu ko di gy ra nhng tn thng
khng hi phc v no, mc d vng di v vn c th tr li hot ng bnh thng.
4. Yu t di truyn: Cng ng ngi ta cng thy trong cc bnh thn kinh, nht l bnh tm
thn, yu t di truyn ng mt vai tr quan trng. Nhng bnh di truyn v chuyn ha u
thy c km theo trng thi ngu n (nh bnh phenylxeton niu). T l b bnh lon thn
anh ch em sinh i ng hp t cao hn hn so vi tr sinh i d hp t; ngoi ra, c b m
u b lon thn th t l con mc bnh ny cao hn so vi s tr ch c b hoc m b bnh ny.
II. SINH L BNH T BO THN KINH
Nhng yu t bnh l{, tc ng trn t bo thn kinh, c th gy ra nhiu ri lon :
- Ri lon qu trnh hng phn trong t bo thn kinh.
- Ri lon dn truyn hng phn ca si thn kinh.
- Ri lon dn truyn hng phn t nron ny ti nron khc.
- Ri lon qu trnh c ch trong t bo thn kinh v trong xi-np c ch.
A - RI LON QU TRNH HNG PHN TRONG T BO THN KINH
Nhiu kch thch bnh l{, tc ng trn t bo thn kinh, gy ri lon qu trnh oxi ha t bo
thn kinh, m hu qu l gim tnh hng phn. Th d : tnh hng phn gim do lnh, do tia
phng x hoc do cc cht c gy ri lon oxi ha (cyan, sulfit, azid). Thuc ng gim tnh
hng phn mt cch su sc. Tri li, lm nng t bo thn kinh , hoc tip t oxi ti mc no
, mt s ion (xem di) c tc dng tng tnh hng phn. Tuy nhin, nng qu hoc nng
oxi cao (oxi nguyn cht) li c tc dng c ch, lm gim thm ch mt hon ton tnh hng
phn ca t bo thn kinh.
Tnh hng phn b c ch khi c ri lon thnh phn ion ca mi trng bao quanh t bo thn
kinh (mu, dch t chc) v khi c ri lon cc c ch vn chuyn tch cc cc ion ( ch yu l
K
+
va Na
+
) gia t bo v ngi bo. Khi t bo thn kinh vo trong mi trng nhc
chng, thm ch khng c Na
+
, thy tnh hng phn b c ch su sc. Nhiu cht c chuyn
ha, c ch h hp t bo thn kinh v kim hm tc dng ca bm Na
+
, K
+
cng gy gim tnh
hng phn nh trong trng hp nhim c ouabain, luminal, aminazinng ch { l bt k
tn thng no ca t bo u gy ri lon chc nng ca bm ny v gy mt K
+
( ra khu vc
ngoi bo) nhiu gp 1 triu ln so vi hng phn bnh thng ca t bo thn kinh.
Khi hng phn t bo thn kinh gim, mun kch thch c hiu qu, hoc phi tng cng
kch thch hoc phi ko di thi gian tc dng. Tn thng t bo thn kinh cn gy ko di
thi tr (tc l thi gian cn thit kch thch c hiu qu vi dng in cng gp i
ngng), ng thi gy gim tnh linh hot (t bo thn kinh khng to ra c dng in hot
ng vi tn s cao v tn s b kch thch thp hn so vi bnh thng).
B - RI LON DN TRUYN DC THEO AXON
Dn truyn hng phn dc theo axon gim khi b lnh, thiu oxy, tia t ngoi v tia ion ha,
nhim c t vi khun (bch hu, thng hn), virut (cm, bi lit), p (so).
Sau khi ct mt y thn kinh, thy on ngoi vi pht sinh thoi ha: ngi v ng vt mu
nng, qu trnh ny pht sinh rt nhanh (sau 24 gi) v sau ci ngy th lan ti on cng thn
kinh; ng thi on ngoi vi dn truyn hng phn dc theo axon gim rt nhanh, tin ti
nh ch hon ton. Nu ni c on ngoi vi vi on trung tm, thy on ngoi vi ti sinh
v chc nng c hi phc (c 24h on trung tm di ra c 0.5-2.5mm). Nu cc si ca
on trung tm khng vo trong ng ca on ngoi vi s to ra u thn kinh.
C- RI LON DN TRUYN HNG PHN T NRON NY TI NRON KHC
(Hoc ti cc c quan thu nhn nh c,tuyn).
Dn truyn hng phn trong xinap thc hin c l nh c cc cht trung gian ha hc
(axetylcholin, noadrenalin). C ch ny bao gm s to ra cc ht nh c cha cht trung gian
ha hc (th d axetylcholin). Axetylcholin vo trong khe xinp v gy kh cc mng sau xinap,
Na
+
t khe xinap vo trong nron ng thi K
+
t trong nron vo khe xinap to ra dng in
hot ng sau xinap.
Nhiu yu t gy tn thng xinap (thiu O
2
, c t vi khun, c t thn kinh), gy ri lon
to cht trung gian ha hc, hoc ngn cn cht ny vo trong khe xinap, kt qu l pht sinh
ri lon dn truyn hng phn t nron ny ti nron khc.
1. Ri lon dn truyn hng phn trong xinap tit adrenalin. Gp trong nhiu bnh nhim
trng v nhim c m hu qu l gim trng lc c v ri lon tun hon (try mch). Trong
xinap tit adrenalin m cht trung gian ch yu l noradrenalin, cht ny bnh thng c
men monoaminoaxydaza (MAO) kp thi phn hy. Nhng cht c ch men ny gy
noradrealin trong nron m hu qu l tng hng phn v tng dn truyn hng phn xinap
tit adrenalin.
2. Ri lon dn truyn hng phn trong xinap tit axetylcholin. Xy ra do cc cht c ch men
cholinestaza (eserin v a s cc hp cht ln hu c). Axetylcholin khng b phn hy, li, lc
u gy hng phn sau gy c ch (nhim c). Nh bit, nng cao axetylcholin tc
dng n mt cht trung gian c ch, do c tc dng c vi t chc thn kinh, gim su sc
tnh hng phn, tnh linh hot, gy lit c v cht do lit trung khu h hp. Trn c s , cc
cht ln hu c c s dng dit cn trng.
Trong bnh nhim c tht ri lon dn truyn hng phn nron vn ng ty sng gy lit
c. Ri lon dn truyn hng phn cn xy ra tm vn ng (xinap thn kinh- c).
Dn truyn hng phn xinap thn kinh v xinap thn kinh -c cn b phong b bi curare (d-
tubocurarin): trong trng hp ny curare tranh ch ca axetylcholin ( mng sau xinap), d
gy mm c.
3.Ri lon chc nng xinap c ch. Trong xinap c ch, cht trung gia ha hc (- aminobutyric
axit, vit tt l GABA) tc dng ln mng sau xinap lm cho K
+
t trong nron vo khe xinap,
n thi Cl
-
t khe xinap vo trong nron, gy trng thi tng phn cc mng sau xinap, c
tc dng ngn chn trng thi kh cc do cc xung hng phn gy ra.
Ri lon chc nng xinap c ch c th pht sinh do ri lon to GABA, hoc cht ny khng
vo khe xinap c, hoc do ri lon vn chuyn cc ion K
+
v Cl
-
qua mng sau xinap, do
ngn cn trng thi tng phn cc mng sau xinap. Th d. c t un vn ngn cn GABA vo
khe xinap, nn gim c ch cc nron vn ng khi kch thch dy thn kinh cm gic.
Strychnin phong b cc th th ca GABA ( mng sau xinap) (c ch tranh ch), do kch
thch yu c th gy cn co git ng vt b nhim c strychnin hoc c t un vn.
III. SINH L BNH T CHC MT LIN H THN KINH
H thn kinh chi phi hot ng bnh thng ca cc t chc bng cch tc ng trn ba mt :
chuyn ha, tun hon v chc nng. Do , khi t chc mt lin h thn kinh, s pht sinh ri
lon chuyn ha, tun hon v chc nng ti t chc , tc l pht sinh trng thi lon dng
thn kinh. Chnh nh nhng thay i v hnh thi v chc nng c quan nhn cm m ngi
ta hiu c tn thng phn thn kinh. Khi mt dy thn kinh b tn thng th bn thn n
cng nh c quan cm th m n chi phi s thay i hot ng tun theo mt s quy lut
nht nh.
1. Quy lut thoi ha ca bn thn t bo thn kinh. T bo thn kinh cng nh dy thn kinh
c th b yu t gy bnh lm tn thng, gy thoi ha. Qu trnh ph hy thay i ty theo
loi nron. Nu l nron ngoi vi, th khi l dy thn kinh vn ng, c s b lit, khi l dy thn
kinh cm gic, s mt cm gic; khi l dy thn kinh vn mch, mch khng co li na; khi l dy
thn kinh tit dch tuyn s thi tit. Ni tm lai, ty theo chc nng ca dy m c quan cm
th b chi phi s b ri lon.
Nhng nu l nron trung tm th hin tng phc tp hn, v mi nron trung tm c lin
quan vi rt nhiu nron khc to thnh nhng h thng tng tc ln nhau. N c mt chc
nng chnh, song ng thi c th hot ng hip ng hay i khng vi nhiu ci khc. Cho
nn tn thng ti nron trung tm thng to ra hai loi ri lon :
- Nhng ri lon biu hin chc nng chnh m thn kinh ph trch b mt i.
- Nhng ri lon biu hin s gii tr c ch nhng chc nng m trc y bnh thng vn b
phn thn kinh tn thng km hm.
Th d : khi tn thng b thp, th mt chc nng vn ng ty (chc nng chnh ) nhng li
tng phn x gn (do nron vn ng ngoi vi ty sng c gii tr c ch nn phc hi
tnh t ng c bn).
Quy lut thoi ha thn kinh c vn :
C vn v dy thn kinh vn ng chi phi hnh thnh mt n v hot ng m khu dn
truyn quan trng l tm vn ng.
Trong th nghim trn mo, khi mt dy thn kinh c vn b gin on, trong vng 30h u, nu
kch thch on ngoi vi thy xung ng vn c dn truyn ti c (co c). Sau , c khng
co mc d dy thn kinh vn dn truyn v ngay ti tm vn ng vn cn thy hiu th hot
ng nhng hiu th ngy cng yu dn. Nh vy chng t c thay i tm vn ng
ging nh tnh trng nhim cura (phong b tranh chp lm mt tc dng gii cc ca
axetylcholin). Sau tm vn ng cng khng p ng, ri hiu th hot ng ca dy thn
kinh gim dn, ngha l cc si thn kinh ln lt thi dn truyn xung ng.
Cui cng sau 100h, th ngay dy thn kinh cng khng p ng na v n cng b thoi ha
( Hnh 1). Sau hai tun c mt thn kinh chi phi cng khng p ng khi kch thch trc tip vi
dng inh hai chiu, tri li i vi dng in mt chiu, c vn co v d co cng. C mt thn
kinh chi phi tr nn rt nhy cm vi axetylcholin: mt liu nh bnh thng khng tc dng
by gi c th gy co c. Thnh phn ha hc ca c b thay i: 25 ngy sau ct t dy thn
kinh thy nng protein nht l myosin gim ti 14%, ATP cng gim.
Quy lut trn y ch c gi tr i vi ng vt mu nng v vi nron vn ng sng trc ty
sng m khng c gi tr khi b thp b gin on.
Nhng hin tng trn y cn gp h thn kinh thc vt, ti hch v xinap hch sau khi dy
trc hch b ct t. 40-50 h sau khi ct t si trc hch thy pht sinh ri lon dn
truyn xinap v 45-72 h sau th khng cn p ng ngoi vi khi kch thch si trc hch tuy
xung ng vn c dn truyn ti hch v cn tn ti hiu th hch (giai on tng ng
vi nhim cura). 48h sau khi ct, lng axetylcholin hch gim 46% so vi bnh thng. Cui
cng, sau 72h, si trc thoi ha, men cholinestaza khng cn, trong hch tr nn rt mn
cm i vi axetylcholin.
3.Quy lut khng thai ha ca thn kinh thc vt
Sau khi ct t si sau hch (giao cm hay ph giao cm), thy cc si c trn v cc tuyn ni,
ngoi tit b chi phi, c th ri lon chc nng mt thi gian song khng b thoi ha. Trn
ng vt, nu ct b hon ton thn kinh giao cm v ph giao cm chi phi ng tiu ha, lc
u thy c ri lon co bp d dy rut, v con vt km n, gy i, song sau 3-4 tun, nh thch
nghi dn, co bp v tit dch c phc hi, con vt n c v li ln cn. Tim mt thn kinh
chi phi vn tip tc co bp u n, huyt p vn bnh thng, khng thy hin tng thoi
ha c tim, song tim mt kh nng thch ng b p trong iu kin sinh l v bnh l. Sau khi
ct b thn kinh giao cm chi phi ng mch tht ng mch c gin ra, song sau 8 ngy l
khi phc c trng lc. Sau khi ct dy thn kinh chi phi tuyn thng thn, thy lng
adrenalin bn tuyn b ct khng khc bn lnh.
4.Quy lut tng mn cm khi mt lin h thn kinh
Nh tren ni, mt c vn mt thn kinh chi phi tr nn rt nhy cm vi axetylcholin, cht
trung gian ha hc do dy thn kinh tit ra. Hin tng tng mn cm i vi axetylcholin
xy ra rt nhanh sau khi mt lin h thn kinh.
Hin tng tng t cng thy xy ra dy thn kinh tit noradrenalin: c trn v cc tuyn
chu nh hng ca noradrenalin tr nn rt mn cm i vi cht trung gian ha hc ny sau
khi ct t si sau hch (tit noradrenalin) chi phi chung. Nu ct t si trc hch thy hin
tng tng mn cm khng mnh bng. Sau 14-16 ngy, hin tng ny t mc ti a v tn
ti mi mi nu si thn kinh khng c phc hi hoc ti sinh. Nu c trn chu tc dng c
ch ca adrenalin nh rut, thy hi tng tng mn cm khng r ngay c sau khi ct t si
sau hch.
Nguyn nhn su xa ca hin tng tng mn cm do mt lin h thn kinh cn cha r. i
vi c vn th c l ngoi tnh cm th ca tm vn ng , mng t bo c ni chung cng tr
nn nhy cm vi axetylcholin, cho nn khi c ngh vn ghi c th hiu xung. i vi c trn
th c th l do men MAO mt hot tnh, khng kh c catecholamin.Ngoi ra, c th cn do
tng th th t do cc t chc mt lin h thn kinh, lm cho cc t chc ny c nh c
mt lng ln cht trung gian ha hc so vi t chc lnh, kt qu l gy tng mn cm i vi
cht trung gian ha hc do dy thn kinh tit ra.
Hin tng tng mn cm i vi cc cht trung gian ha hc c mt { ngha lm sng quan
trng, gip ta chun on mt tn thng thn kinh. Th d mt trng hp co tht mch u
chi (bnh Rayn) tay tri c ct b hch sao tri. Bnh nhn kh hn, ang ngh ngi thoi
mi trong phng bnh. Phu thut vin nh tin hnh mt bi lm sng cho sinh vin m ng
ta gii thiu bnh nhn trc khi m v ngi bnh c dn vo ging ng ln ngi
nghe phu thut vin ln lp trong vng 15 pht: lo lng, xc cm, tot m hi, tit adrenalin v
khi phu thut vin nh gii thiu vi sinh vin kt qu tt p ca iu tr, thy tt c cc du
hiu c bnh Rayn li xut hin tay tri.
5.Quy lut tng tnh t ng c bn do mt s kim tra t trn
Trong qu trnh tin ha ca sinh vt, h thn kinh pht trin dn t thp ln cao, nhng tng
di hnh thnh trc,nhng tng trn hnh thnh sau. mi mc, c quan hay t chc c kh
nng hot ng t ng ng thi ng gp vo s hot ng chung ca c h thng. Bnh
thng, tng trn c chc nng kim tra, hn ch, iu ha s hot ng ca tng di. Th d:
c tim mi phn c c kh nng co bp vi nhp ring ca n, nhn Tawara kim sat v
ng b hot ng ca c hai tht, cao hn na l nhn Kelth-Flack cho ton b tim v bao
trm ln c l thn kinh trung ng vi dy giao cm v ph giao cm.
Trong iu kin bnh l, khi mt kim sot t tng trn, tng di c gii phng nn phc
hi v tng tnh t ng c bn, do c th gy ra nhiu ri lon chc nng. Th d, hin
tng co cng mo mt no l do nhn tin nh thot khi s kim tra ca b ngoi thp
(nhn ); hoc khi lit trung ng (thp v ngoi thp), thy phn x vn ng tng, trng
lc c tng (dn ti co cng) do nron vn ng ngoi bin c gii tr c ch nn phc
hi v tng tnh t ng c bn.
Khi mo b ct b hai bn v i no, thy nhng biu hin tc gin nh cong lng, ui quy
thng, xe mng, nhe rng, lng dng, huyt p tng (ti 200-300 mmHg), glucza mu tng,
tng tit adrenalinTnh trng ny l do mt tc dng c ch ca v no i vi trung tm cm
xc trung no. Hin tng ny lm cho nhiu ngi ngh ti gi thuyt cho rng bn nng (do
tng di v chi phi) thng xuyn b thc (do v no chi phi) chn p.
S phc hi tnh t ng c bn sau khi mt kim tra t trn l mt bin php thch ng bo v
ca sinh vt. Nh trong ngt, kh trong tm h hp hnh ty b c ch, trung tm ti ty hot
ng tr li (th c), th d trong mt thi gian rt ngn cng ko di thm nhng pht hp
hi rt qu cho cng tc hi sc. Ti tim cng vy, chnh nh tnh t ng ca nhng trung tm
di i m i khi trung tm trn b tn thng ngng hot ng, tuy c ri lon, m bo
phn no s sng.
IV. RI LON CM GIC
Gm my loi sau y: cm gic gim hoc mt, cm gic tng,d cm, cm gic au.
A. CM GIC GIM HOC MT
Ty theo v tr ca tn thng m c th mt ton b cm gic hoc ch mt mt vi loi cm
gic (mt cm gic s m, mt cm gic nng lnh, mt cm gic su, mt cm gic au).
Mt cm gic thng gp trong cc trng hp sau y:
- t dy thn kinh ngoi vi: Mt ton b cm gic.
- t r sau ty sng: mt ton b cm gic.
- Tn thng cht xm sng sau: pht sinh hin tng phn ly ri lon cm gic, c th l mt
cm gic au v nng lnh, cn cm gic s m v cm gic su.
- t ty: khi t ty hon ton, mt ton b cm gic v vn ng. Nu ch t mt bn ty,
s pht sinh hi chng Brao-x-qua (Brown Sequard): cm gic au v nng lnh bn ty lnh
mt, cn cm gic s m v chc nng vn ng bn ty t mt.
- Tn thng i th: mt ton b cm gic bn kia c th.
- Tn thng khu cm gic v i no: gim hoc mt cm gic bn kia c th, c bit l cm
gic su v cm gic s m, cn cm gic au v nng lnh th t b nh hng.
B. CM GIC TNG
Trong thc nghim, ct b v i no c th gy ra hin tng cm gic tng: ch mt v i
no, khi b kch thch au, thy phn ng phng ng tng r rt. Nh vy l do khi mt v i
no, i th- trung tm cm gic di v - c gii tr c ch.
Trong lm sng, c trng hp cm gic au tng d di, rt nh phi bng: hin tng bng
but ny pht sinh mt cch phn x, do tn thng dy thn kinh (thng l dy gia v dy
hng, hai dy ny c nhiu si giao cm), do so hoc u thn kinh kch thch on trung tm ca
dy thn kinh t.
C. D CM
Khi dy thn kinh b kch thch mt cch khc thng, bnh nhn cm thy nga, t t nh kin
b, in gitTh d, nga do nhim axit mt, t t nh kin b nhng pht u sau khi t
gar (do trng thi thiu mu ti ch kch thch on cng ca dy thn kinh)
D. CM GIC AU
au l triu chng ca nhiu bnh v thng l nguyn nhn thc y bnh nhn i tm thy
thuc. i vi nh sinh l hc, th au l mt cm gic c bit, c b phn nhn cm ring, c
kch thch c hiu, c ng dn truyn ring, cn i vi nh lm sng, au ch l mt hin
tng bt thng, phin toi,m , kh chu, kh tr b song thng li t gi tr chn on v
tin lng (Leriche)
Cng c ngi phn bit:
au sinh l{ gp ng khe mnh khi b kch thch mnh,au ngoi da,au nng.
au bnh l{ thy ngi bnh. au l mt triu chng c bn ca qu trnh bnh l, ni ln
ri lon chc nng v tn thng t chc. Nu au thng l hu qu ca bnh th, trong nhiu
trng hp n c th l nguyn nhn ca nhiu ri lon khc, nht l thn kinh.
1. Tnh cht chung ca cm gic au:
Tnh cht v cng ca cm gic au l thuc vo nguyn nhn gy au, dc tnh ca c
quan b bnh v tnh phn ng ca tng bnh.
a) Nguyn nhn gay au: Cm gic au pht sinh do nhng tc nhn ph hoi kch thch th th
au gy mt lung xung ng thn kinh, c dn truyn qua ty, ln no, qua i th ti v
no gy cm gic au.
Cm gic au c dn truyn bi hai loi dy thn kinh: loi c ng knh to c v myelin
(loi A) c tc dn truyn nhanh (cm gic au tc th) , loi c ng knh nh khng c
myelin (loi C) vi tc chm (cm gic au m v sau).
Rt nhiu nguyn nhn gy cm gic au:
- Nguyn nhn bn ngoi: nhn t c gii, vt l, ha hc
- Nguyn nhn bn trong: ri lon tun hon, u, vim, sn phm chuyn ha
Mi kch thch tc ng trn ng i ca si thn kinh dn truyn cm gic au u gy nn
cm gic nh t ngoi vi (u dy) ti: cho nn khi bnh nhn c chi b ct on vn c cm
gic au t chi mt, khi u dy thn kinh ct b vt so kch thch (gi l chi ma).
b) Ngng au: Khc vi cm gic nng lnh c ngng thay i, ngng ca cm gic au rt
hn nh. Nhng thuc gim au c tc dng nng cao ngng ca cm gic au. Khng c hin
tng cng v khng gian ca cm gic au: nu kch thch di ngng cng mt lc trn
nhiu ch khc nhau ca da th vn khng thy au.Tri li vi cm gic nng lnh, nu tc
ng trn ton b da, ngi ta c th phn bit c nhng s thay i rt nh (ti 0.008
o
C)
m bnh thng khng phn bit c (bnh thng ch phn bit ni t 0.25
o
ti 0.5
o
C.
c) Nhng yu t nh hnh ti cm gic au: Tnh trng tm l{ hay c quan phn tch trung
ng c nh hng rt r n s chu ng cm gic au : ngi c rn luyn chu au tt
hn ngi nht nht, s ch { lm tng cm gic au (v m cm thy au hn ban ngy), tri
li khi khng ch lm gim cm gic au (trong chin u c khi khng cm thy au ni b
thng) Ct b thy trn c tc dng gim au r rt.
2. au ni tng:
Bnh thng, ni tng hat ng khng nhng khng gy au m khng gy cm gic g c, i
khi cm thy m h nh tc, kh chu mt s tng rng b cng ra (d dy, bng quang, trc
trng). Trong ni tng, cng c nhiu th th i vi p lc, ha cht, nhng rt t i vi
nhit , vi au. No v phi khng c cm gic nng lnh, khng thy au khi b ct. Tri li,
co ko mc treo rut gy nn au, thm ch c th gy sc. Do t th th cm gic au ni tng
nn rt kh khu tr (H3)
Cm gic au ni tng thng do:
- Tn thng thanh mc (mng phi, mng bng, mng no, mng ngoi mch mu)
- Co tht cc tng rng (d dy, rut, niu qun,mch mu, ng dn mt)
- Cng cc tng rng (dn d dy cp)
- Co ko cc mng treo cng gy au, thm ch c th gy sc, trng hp ny c th xy ra khi
m bng.
Trong mt s bnh ni tng, cm gic au c th lan ti mt vng nht nh ca da. Nh trong
au tht ngc c th thy au phn trn tri ca ngc, lan ti mt trong tay tri, ti c, gc
hm, ti vai v lng, i khi lan ti vng bng trn lm cho d lm vi bnh ni tng bng
(H4). Hoc kch thch phn gia c honh li thy au vai, au qun thn c th lan ti bu v
bn. S hiu bit hng lan ca cm gic au t mt ni tng ti mt vng nht nh no
ca da l rt cn thit i vi ngi thy thuc, v n gip cho chun on chnh xc c quan b
tn thng. Hin tng au ni tng lan ti mt vng nht nh ca da c th gii thch nh
sau: nhng si dn truyn cm gic au ni tng v nhng si dn truyn cm gic au ngoi
cng ti mt vng ca ty, cng theo mt ng, cng s dng nhng nron trung ng (H5)
do au ni tng, v no cng cm thy au ngoi da. Cng theo c ch ny, bnh ngoi
da, c khi thy au ni tng: th d thy au bng quang c khi nht i.
Cm gic au gy ra khi n hoc kp nh c c s dng chn on bnh ni tng. Ngoi
ra, vng cm gic au lan ti,c th pht sinh co cng c phn x: th d co cng c thnh
bng khi vim mng bng, hin tng ny kh tr b ngay c khi gy m su.
Ngoai ra, cm gic au thng km theo nhiu ri lon thn kinh thc vt: gim tit dch tiu
ha, thiu niu hoc v niu, glucoza mu tng, huyt p tng, mch nhanh, tng tit hocmon
(ACTH,cortisol, adrenalin) tham gia vo qu trnh phng ng ca c th, nhm phc hi cc
chc nng b ri lon.
[newpage]
IV. RI LON VN NG
Ri lon vn ng pht sinh do tn thng bt c im no ca h thn kinh vn ng gy ra.
Vic nghin cu c tnh cht tch hp v trng lc c gip gii thch mt s hin tng
trc y tng nh l mu thun nh trong lit b thp va c lit va c trng lc c (tng
phn x gn).
Trng lc c l mt trng thi ng, trong cc c vn thng xuyn c cng ra mt
mc thch hp vi i hi ca hon cnh. Trng lc c l k qu ca mt s iu ha rt
phc tp ca cc cu trc thn kinh cc mc khc nhau m trong vng phn x gamma
ng vai tr c bn, mt s iu ha nhm m bo s hi ha ca cc chc nng vn ng
bng cch iu chnh t th v cn bng, v s chun b h c cho mi hnh thi hot ng. C
th cho rng trng lc ngh ngi ch yu l do phn x ty sng ; trng lc t th i hi s
tham gia ca tiu no, h thng li, nhn xm v v no ; trng lc c ng l do tiu no v
nhn kim sot ; cn trng lc hnh vi chu s kim st ca cc cu trc tch hp cao nh
v no, vng di th
A.IU HA TRNG LC C
Mi c vn c phn b mt nron vn ng alpha m khi b kch thch th c s co li.
trnh qu mc, hot ng ny c kim sot nhiu mc cu trc thn kinh, m trc
tin ngay ti ty sng v c.
1. Ti c v ty sng :
C ch hot ng cm th thoi c v cc cung phn x ca chng to nn mt vng phn
hi nhm duy tr chiu di thch hp c (H6) (H7). Khi c b ko cng, xung t thoi c tng v
hnh thnh phn x co ngn c li ; tri li, khi c co ngn li nhng xung y gim v c li dn
ra. Mt khc, hot ng ca dy thn kinh gamma lm co thoi c v nh hng ti thn kinh
cm th. Khi c ang b ko cng m dy gamma li b kch thch th c cng hng tc dng
lm tng hot ng km hm, hay ni mt cch khc hot ng ca dy gamma lm tng tnh
nhy ca thn kinh cm th thoi c. Hot ng ca dy gamma cn tng khi lo lng, khi b
kch thch bi yu t c hi, hay khi nron vn ng alpha tng xung c i vo hot ng.
Mi lin kt sau ny gia alpha v gamma nhm co thoi c kp thi vi c chnh (H8)
2. Ti cc cu trc thn kinh trn ty :
Cc cu trc ny c th tc ng ln trng lc c qua nron vn ng alpha (gy co c chnh )
hoc gamma (gy co thoi c )
a) H thng li.H thng li c ch vng bng gia hnh no khi b kch thch s km hm
cc c i vn hoc ng vn ty theo ch b kch thch Cn h thng li to thun i ln lm
tng trng lc c bng cc tc ng ln c 2 nron alpha v gamma hoc ch trn nron vn
ng gamma chm hn song lin tc hn.
b)Tiu no :
Ct b tiu no gy gim trng lc kh v ngi. Do m c th cho rng :
- Thy trc v cu tio no c ch trng lc bng cch km hm hot ng ca nron alpha.
- Cc phn bn thy nhng v tn tiu no c tc dng to thun i vi hot ng ca vng
gamma: khi kch thch nhng phn ny thy tng hot ng ca thoi c.
Ngoi ra mi lin h v no v tiu nothng qua h thng v-cu-tiu no v cc ng i
ngc li qua cc nhn bng bn ca i th cho thy tiu no c vai tr ch yu trong tng
quan gia 2 h thng alpha v gamma, to iu kin cho vic iu chnh lin tc trng lc
tng ng theo nhng thng tin ng o c truyn ti n (H9)
c) Nhn xm. Cc nhn xm (nhn ui, nhn v hn, nhn cu nht, vng i th) tc ng trn
trng lc c:
- gin tip qua ng v no lm thay i xung ti h thng alpha v gamma.
- Trc tip trn cc nhn ca thn no v h thng li; nhn ui c tc dng to thun i
vi nron gamma cn nhn cu nht c tc dng km hm.
d) V no. Bn cnh vai tr vn ng c thc, v no qua ng b thap tc ng trc tip
trn nron gamma d hn l trn nron alpha. Theo nhng con ng tc ng (v no- li,
v no- th vn, v no- tiu no), cc din khc nhau ca v no cng iu chnh kh nng
chu kch thch ca vng gamma v mt cch tng qut, pht huy tc dng c ch trn trng
lc c.
)Vng di th. Cc trung tm thn kinh ni tit, thn kinh thc vt trong vng tc ng ln
trng lc c nh gim khi kch thch trung tm ph giao cm, tng khi kch thch giao cm,
gim khi thn nhit tng, tng khi lnh.
A- RI LON VN NG
Ri lon vn ng c th chia lm my loi nh sau:
- Chc nng vn ng gim, lit.
- Tng ng
- Ri lon hip iu vn ng
1.Chc nng vn ng gim lit
Ty theo b phn b lit, thng phn bit:
- Lit mt chi
- Lit hai chi di
- Lit na ngi
- Lit ton thn
Ty theo nron vn ng b tn thng, lit li cn chia lm:
- Lit ngoi bin khi nron vn ng ngoi vi b tn thng
- Lit trunh ng khi khi nron vn ng trung ng b tn thng.
a) Lit ngoai bin Do tn thng nron vn ng ngoi bin (thn t bo sng trc ca ty,
dy thn kinh ngoi bin).
Trong thc nghim, c th gy lit ngoi bin bng cch ct t mt dy thn kinh ngoi bin
(dy hng chng hn). Nu dy thn kinh b ct l mt dy pha (dn truyn cm gic ln vn
ng), th ngoi ri lon vn ng cn mt ton b cm gic.
trong lm sng, lit ngoi bin pht sinh khi vim dy thn kinh, vim m ri thn kinh , t
dy thn kinh, t ty, tn thng sng trc (bnh bi lit).
Lit ngoi bin c nhng c im sau y:
- Mt vn ng ty v vn ng phn x.
- C nho (lit ngoi bin vn c gi l lit nho) c mt trng lc do khng nhn c
lung xung ng t trung khu vn ng ti.
- C teo do khong hot ng, do ri lon chuyn ha trong t chc c d mt lin h thn kinh.
- Ri lon khi chu kch thch in: dng in kch thch dy thn kinh chi phi c b lit, khng
thy c co. Dng in hai chiu kch thch trc tip c cng khng thy c co; trai li, dng in
mt chiu thy c co.
b) Lit trung ng. Do tn thng nron vn ng trung ng (to thnh b thp v ngoi
thp)
- Lit thp. C nhng c im sau y:
+ Mt vn ng ty .
+ Vn ng phn x tng: vn ng phn x (do nron vn ng ngoi bin chi phi) khng
nhng tn ti m cn tng mnh, do nn vn ng ngoi bin c gii tr c ch (bnh
thng do b thp v ngoi thp gy ra).
+ Trng lc c tng do nron vn ng ngoi bin c gii tr c ch. Khi gp hoc dui chi
b lit, ngi thy thuc thng gp mt sc khng c bit. Trng lc c tng ti mc
no s gy ra hin tng co cng (lit trung ng cn gi l lit co cng). C tng trng lc
cc c i trng (co dui) tng sc khng vi ng tc th ng v c phn x c ch t sinh.
C ch tng trng lc v co cng l do tng tnh kch thch nron gamma v nu tim procain
vo r trc co cng s mt.
- C khng teo hoc teo t :
Tnh chu kch thch in khng thay i v nron vn ng ngoi bin vn nguyn vn.
Tn thng b thp gy t lit na ngi bn kia : phn ln cc si ca b thp bt cho ch
gip gii ty v hnh ty, do tn thng bn tri gy t lit na ngi bn phi v ngc li.
Ngoi ra, ty theo v tr ca tn thng m cc th lit thp c nhng im khc nhau.
- Lit ngoi thp. Trong loi lit ny, vn ng ty vn tn ti, song kho khn, chm chp hip
iu km, bnh nhn vn ng cng nhc nh my. C hin tng cng c, c bit : khi ngh
trng lc c tng, song khi bo bnh nhn c ng khng ngng th trng thi cng c mt
dn, bnh nhn s c ng d dng hn. Nu bnh nhn thi c ng, th trng thi cng c li
xut hin. Nu thy thuc mt chi ca bnh nhn mt t th no , thy c gi t th
trong mt thi gian di. Tng trng lc ngoi thp th hin in hnh trong bnh Pakinxn
(Parkinson) c tng sc khng lin tc, km theo s c nh t th mi do tng trng lc c c
ng vn ln i vn, xy ra khi c tn thng ca nhn xm trung ng (c l do thiu cht
dn truyn dopamin). Vai tr ca h thng gamma khng r.
2. Tng ng:
Danh t tng ng ch nhng vn ng mnh khng ty do cc khu vc vn ng ca h thn
kinh trung ng b kch thch gy ra.
Tng ng c th chia lm ba loi : tng ng thp, tng ng ngoi thp, tng ng no ty.
a) Tng ng thp :
B thp b kch thch gy ra co cng v co git. c im ca co cng l : co c khng ty {, ko
di din bin c chu kz. Co cng thng do cc nhn di v no b kch thch gy ra. c im
ca co git l : t t th co, c chuyn nhanh sang th dui, ngha l hin tng xen k co dui
c. Co git thng do v i no b kch thch gy ra. Co cng c th chuyn sang co git :
trng hp ny thng gp trong cn ng kinh hoc khi cho mt dng in chy qua no
ng vt (ng kinh in ).
Co cng v co git c th gp trong nhiu bnh : chn thng no, chy mu no, c t (un
vn, bnh di), ngt, thn nhit tng, nhim c (hn m gan, hn m i tho ng)
Cc kch thch trn y gy ra mt hng phn tr h thn kinh trung ng v bnh nhn
ln cn theo c ch u th. Cc cn co git v co cng thng pht sinh v tng cng khi
bnh nhn xc cm hoc do nh hng ca cac kch thch bn ngoi (nh sng mnh, ting
ng mnh, chm mnh vo bnh nhn). Do , trnh ln cn cn phi dng thuc an
thn, thuc ng v tranh nhng kch thch c hi (k c li ni v thc).
b) Tng ng ngoi thp. B ngoi thp b kch thch thng gy ra ma git, ma vn Trong
ma vn, pht sinh vn ng khng ty , chm v thng hn ch ngn tay, ngn chn.
Trong ma git, cng l vn ng khng ty {, song nhanh hn, khng u, ch yu l cc c
mt v phn gn ca chi.
- Trng thi run c th do nhim c (nghin ru, nhim c Hg) hoc do tn thng thn
kinh (th d tn thng th vn trong bnh Pakinxon ). Run c hai th ; tnh v ng. Run tnh
pht sinh khi bnh nhn ngh ngi v khi vn ng th ht run (nh trong bnh Pakinxon).
c) Tng ng no ty- git c. Trong trng hp ny, tng si c ring bit co, song ton c
khng co. Ri lon ny thng do nron vn ng ngoi bin b kch thch gy ra.
3. Ri lon hip ng vn ng.
Hip ng vn ng do nhiu b phn m bo : tiu no, m o, ct ty sng, v i no
(thy trn, thy thi dng) nn khi mt b phn b tn thng, s pht sinh ri lon hip
iu vn ng. Bnh nhn khng b lit, vn ng ty v phn x vn cn song khng hip
iu, mt thng bng, c ng kh khn, khng thch hp, mnh qu, qu tm
Ri lon hip iu vn ng c th pht sinh khi ngh hoc khi vn ng.
Ty theo v tr b tn thng, ngi ta phn bit nhiu loi ri lon hip iu vn ng. Ngoi
nhng c im chung, mi ri lon cn c nhng c im ring. Ph bin nht l ri lon
hip iu do tn thng no.
Ri lon hip iu do tn thng tiu no.
Trong thc nghim, gy tn thng hoc ct b mt bn cu tiu no ca ng vt, thy xut
hin ri lon hip ng iu vn ng quan trng: con vt ng khng vng v ng sang bn b
tn thng. Ngoi ra, cn thy na u v na thn bn lnh tng ng: hin tng ny l do
bn bn b tn thng, trng lc c gim tri li bn lnh trng lqcj c tng.
Khi ct b ton b tiu no, con v khng i li c, tuy khng b lit: hin tng ny l do
trng lc c gim v vn ng mt hip iu.
Hai ba tun sau khi ct b tiu no, kh nng vn ng ca con vt hi phc dn do c cc b
phn khc ca h thn kinh trung ng b p.
Gim trng lc trong ct b tiu no thng gim vi cc sc khng trong cc th nghim c
ng th ng v gim sc khng tch cc trong khi di chuyn. Nh vy l c gim c trng lc
ngh ngi v tng tnh th ng ca c v gim trng lc c ng vi s mt tc dng ca ca
cc c ch duy tr t th. Hai c ch c th gii thch hin tng gim trng lc ny. H thng
gamma b c ch v mt nh hng sinh phn x ca phn bn tiu no, mt khc nron alpha
cng mt tc dng to thun ca tiu no.
Trong lm sng, bnh nhn c hi chng tiu no ng khng vng, lun lun lo o nh nh
ngi say rou. Mt bn tiu no b tn thng trong trng thi mt cn bng biu hin r v
pha no , nht l khi y bng nhn t bn lnh ti bn b tn thng. Ngoi ra, mt hi ha
gia c co ng vn v c co i vn gy ln hin tng qu tm v sai tm (tay a qu v sai
mc tiu), hin tng mt ng vn gy thin phi hp phi hp nhng ng tc s ng, hin
tng mt lin ng lm cho nhng c ch lin tip khng thc hin nhanh c. Thm vo ,
nhng c ng phc tp phi phn tch thnh nhiu th v khi lm mt c ng ty { thng l
chm tr. Nhng triu chng ni kh, ni git ging, ni bt ging cng l do thiu phi hp
ca cc c ng mi, li v thanh qun.
VI. RI LON THN KINH THC VT
Ri lon thn kinh thc vt c th pht sinh do tn thng bt c ni no ca h thn kinh.
A- TN THNG VNG DI TH
Vng di th l trung tm ca cc chc nng thc vt. Kch thch phn di ca vng di th
gy nhng phn ng thc vt, do hot ha h ph giao cm (huyt p gim, tim p chm, h
hp chm). Kch thch phn sau ca di th c tc dng tng trng lc h giao cm (huyt
p tng, tim p nhanh, h hp nhanh).
Vng di th khng ch l trung tm ca h thn kinh thc vt m cn l mt c quan ni tit :
Hin nay r vng di th tit ra 7 hocmon thn kinh (cn gi l yu t gii phng) c tc
dng iu tit hot ng ca tuyn yn,h di th- yn l mt phc hp ni tit c tm quan
trng c bit.
Khi tn thng cc nhn thc vt ca vng di th, thy pht sinh nhng ri lon thc vt
khc nhau ty theo v tr ca tn thng. Th d :
- Tn thng nhn trn th ( phn trc vng di th) gy gim tit ADH m hu qu l i
nht.
- Kch thch din nhn di th sau gy tng tit cocticosteroit.
- Tn thng di th gia gy ri lon iu ha nhit.
- Tn thng cc nhn vng bng gia gy bo ph do n nhiu, hu qu ca trung khu n c
gii tr c ch.
B- TN THNG H GIAO CM
1.Ct ton b hch giao cm gy ra nhiu ri lon chc nng quan trng :
- Dn mch gy gim huyt p.
- Tim p chm, yu.
- Tng chc nng vn ng d dy- rut.
- Gy co cng c tht bng quan, hu mn.
- Gim qu trnh O
2
, gim thn nhit, gim limpho bo
- Ct b hch giao cm c trn ( th) gy co ng t, gin mch tai.
2.Kch thch h giao cm gy nhng ri lon ngc li.
C- TN THNG H PH GIAO CM
1. Kch thch h ph giao cm. C th do:
- Kch thch trung khu X hnh ty do yu t c gii tng p lc s no (chn thng, u no).
- Kch thch on cng dy X tim v cc tng khc (nhim axit mt trong vng da do tc mt).
- Cc cht tng cng tc dng ca axetylcholin, nh ion K
+
, vitamin B, cholin, yu t nhim
trng (virut cm, trc khun thng hn)
- Cc cht cholinesteraza nh cc hp cht ln hu c. l nhng cht c thn kinh m
quc dmg trong chin tranh ha hc: trong trng hp ny axetylcholin tch trong c th gy
cht.
Ngoi ra trong lm sng, cn gp trng thi cng thn kinh ph v c tnh cht di truyn, mt
kch thch yu i vi dy X c th gy cht t ngt do ngng tim.
2.Ct b dy X (1 hoc 2 dy, c bit l ct c hai dy) c (ch, th, ngi) gy ra nhiu ri
lon rt nghim trng:
- ng vt mt dy X cht sau vi ngy n vi thng. Ct c hai dy gy cht sm hn.
- Ri lon h hp do ct t phn x t phi ti trung khu h hp (phn x Hering Breuer).
- Lit c cn ng vo thanh qun khi nut khin cho thc n vo thanh qun v phi gy
vim phi do nut.
- mu v ph phi do lit dy thn kinh co mch phi cng dn ti vim phi.
- Ri lon tiu ha do c ch vn ng dy,rut v tit dch (dch v v dch ty).
Ri lon ph giao cm tim c th do c t vi khun (bch hu, nhim c tht).
Ri lon ph giao cm cng (S2-S1) ca dy chu gp trong chn thng hoc u ca ty sng
vng hoc ca dy chu, pht sinh ri lon i tiu tin, ri lon chc nng sinh dc.
VII- RI LON HOT NG THN KINH CAO CP BNH LON THN
u tin, ngi ta nghin cu nhng hu qu do tn thng hoc ct b bn cu i no (ton
b hay mt phn), y l mt phng php th bo tuy c sng t c mt s vn . Sau
ny, Paplop dng phng php phn tch tng hp phn x c iu kin nghin cu cc ri
lon hot ng thn kinh cao cp, thy kt qu rt tt, sng t c nhiu hin tng bnh
l pht sinh trong v i no. Nhng nm gn y vi s pht trin ca in no v sinh ha
thn kinh, ngi ta cng ngy cng c iu kin i su vo cc ri lon hot ng thn kinh cao
cp.
Ch c sau khi Paplop v hc sinh ca ng dng phng php phn tch tng hp nghin cu
hot ng thn kinh cao cp, th ngi ta mi bt u hiu v gii thch c bnh lan thn
kinh chc nng (bnh lon thn) ngi.
A- BNH LON THN THC NGHIM
1. C ch pht sinh:
C nhiu phng php gy bnh lan thn, ch yu l gy trng thi cng thng qu vi
cc qu trnh thn kinh c bn v no.
- Gy trng thi qu cng i vi qu trnh hng phn: mt kch thch mnh (ting n ln, bo
lt, lc mnh bn ch ng) c th gy ra bnh lon thn.
- Gy trng thi qu cng i vi qu trnh c ch: bt con vt phi chu ng mt trng thi c
ch qu (gy c ch phn bit qua tinh vi hoc ko di thi gian trc khi cho n trong c
ch chm...).
- Gy trng thi qu cng i vi tnh linh hat ca cc qu trnh thn kinh: nh xen k nhanh
chng kch thch c iu kin dng tnh v m tnh c th gy ra bnh lon thn.
2. nh hng ca lon thn kinh i vi qu trnh pht sinh bnh lon thn
ng vt thuc loi thn kinh khc nhau th phn ng khc nhau i vi bnh lon thn: ch
thuc loi c ch v loi hng phn d b bnh, cn loi thng bng (dc bit loi khng linh
hot) kh b bnh, phi dng phng php dc bit mi gy c bnh. Loi hng phn, khi b
bnh lon thn, qu trnh c ch rt yu, cn cc phn x c iu kin m tnh mt ht, v con
vt hng phn qu . Loi c ch, khi b bnh, cc phn x c iu kin dng tnh mt ht v
con vt trng thi c ch, thi min.
3. Nhng c im ca bnh lon thn:
Bnh lon thn gy ra nhiu ri lon thn kinh
a) Gim kh nng hot ng ca t bo thn kinh: trong bnh lon thn, cng cc qu
trnh thn kinh gim, c bit l ni c ch, khin cho hng phn phi tng cng. V sau, cc
nron v no suy nhc chuyn vo trngj thi c ch su, c tnh cht bo v.
b) Ri lon thng bng gia hai qu trnh hng phn v c ch: trong qu trnh din bin ca
bnh lon thn, khi th hng phn chim u th, lc th c ch chim u th.
c) Trng thi giai on: bnh thng, t khi tnh (hng phn) n khi n (c ch), phy sinh
trng thi giai on, song khng r rt v thi gian qu ngn (vi pht ti vi chc pht). Cn khi
mc bnh lon thn, trng thi giai on c th ko di ti hng tun.
d) Ri lon tnh linh hot ca c qua trnh thn kinh. Hai trng hp c th xy ra:
- Tnh linh hot gim: bnh thng, con vt loi mnh, thng bng v khng linh hot, cc qu
trnh hng phn v c ch thay nhau mt cch chm chp (z sinh l).Trong bnh lon thn, tnh
z ny tng r rt: mt phn x c iu kin dng tnh sau nhiu ln khng cng c vn khng
tr thnh m tnh; tri li, mt phn x c iu kin m tnh, sau nhiu ln cng c vn khng
tr thnh dng tnh.
- Tnh linh hot tng: bnh thng con vt thuc loi mnh,thng bng v linh hot, cc qu
trnh hng phn v c ch thay nhau d dng, nhanh chng. Trong bnh lon thn, tnh linh
hot ny tng r rt, sau kch thch c iu kin tc dng, pht sinh phn ng mnh song chng
mt. Th d khi kch thch c iu kin nc bt tc dng, thy nc bt tit nhanh v nhiu,
song khi cng c bng thc n, thy nc bt ngng tit rt nhanh.
) Ri lon chc nng thc vt: bnh lon thn gy ra nhiu ri lon thc vt: ri lon tim
mch, h hp, tiu ha ,tit niu, lot dinh dng, vim, u cNghin cu cc ri lan thc
vt trong bnh lon thn gip thy thuc hiu r c ch thn kinh trong qu trnh pht sinh v
pht trin ca nhiu bnh ni tng.
Trn y l nhng biu hin ch yu ca bnh lon thn cp. Bnh ny din bin c th t t,
ko di hng thng, hng nm.
B.BNH LON THN NGI
Ti liu thc nghim phn no sng t c ch pht sinh bnh lon thn ngi v nhng quy
lut c bn v hot ng thn kinh ngi v vt ni chung ging nhau. Song, trong thc t,
nguyn nhn v c ch pht sinh bnh lon thn ngi phc tp hn ng vt nhiu v
ngi c h thng tn hiu th hai v sng trong hon cnh x hi. Do , khng th my mc
p dng nhng ti liu thc ngim trn ng vt cho ngi c m ch c gi tr tham kho.
Bnh lon thn l mt bnh chc nng ca trung khu thn kinh biu hin bng nhng ri lon
hot ng thn kinh cao cp, nguyn nhn quyt nh l chn thng v tinh thn.
Nhng hon cnh gay go, au kh nh tht tnh, bt ha trong gia nh, tht bi trong cng tc,
trong i sng, au yu lin min, i sng cht vt, kh khn,Sm mun u c th gy ra
bnh lon thn. Trong ch t bn, y ry p bc bc lt, cnh tranh sinh tn gay gt, khng
hong thng xuyn, tht nghip trin minthy bnh lon thn pht trin mnh, v khi mu
thun trong x hi t bn tng u thy bnh lon thn tng theo. Tri li, trong ch x hi
ch ngha, cc nguyn nhn x hi gy bnh lon thn khng tn ti, do ngi mc bnh
lon thn khng ngng gim.
Nguyn nhn gy bnh lon thn ph n v nam gii c khc: nam gii bnh thng do
chn thng trong x hi v cng tc (tht bi trong cng tc, v tr x hi thay i) cn ph
n ch yu do chnd thng trong i sng gia nh (v chng bt ha, ngi thn cht, mt
mi qu ko di do gnh nng gia nh)
Nhng chn thng tinh thn thng gy cng thng qu mc qu trnh hng phn hoc qu
trnh c ch, hoc tnh kinh hot ca cc qa trnh thn kinh. Bnh c th pht sinh mt cch
t ngt (do tc dng ca mt chn thng tinh thn qu mnh), hoc t t (do tc dng ca
mt chn thng tinh thn khng mnh lm song ko di). Bnh c th do 1, hai hoc nhiu
nguyn nhn tc ng ng thi hoc trc sau. Thng thng, bnh lon thn khng pht
sinh ngay sau khi b chn thng m dn dn, sau mt thi gian mt nm, na nm hoc lu
hn.
Bnh thng pht sinh khi gp nhng iu kin thun li:
- Gio dc khi cn nh khng tt thng to iu kin cho bnh lon thn pht sinh, di tc
dng ca nhng nhn t bnh thng khng c hi i vi ngi khc c gio dc tt.
- Lon thn kinh cng nh hng ti bnh sinh: lan thn kinh yu d b bnh lon thn .
- Nhng bnh khc ca c th (chn thng, nhim trng, nhim c) lm suy yu v no c
th to k cho bnh lon thn d phy sinh.
- Ch lao ng v ngh ngi khng hp l{, c bit thiu ng ko di, qu sc, dinh dng
km c th lm cho bnh lon thn pht sinh (do lm cho thn kinh suy yu).


56. SINH L BNH H NI TIT

V TRIU AN

Tuyn ni tit l mt t chc bit ha lm nhim v sn xut ra hocmon c mt vai tr cc kz
quan trng trong vic m bo kh nng t iu chnh v t ti to ca sinh vt.

I. HOT NG CA TUYN NI TIT
Ngun kch thch :
Lng hocmon tit ra khi cao khi thp ty theo kch thch t ngoi ti. Ngun kch thch c th
l nhng sung ng thn kinh t trung no xung thng li thng thn lm tuyn ny tit
adrenalin. Kch thch c th l hocmon nh kch t tuyn yn, ACTH, TSHi vi tuyn trc
thucc l v thng thn v tuyn gip. Ngoi ra kch thch cn c th l thnh phn ha hc
trong ni mi nh canxi mu gim s kch thch tuyn cn gip tit hocmon cn gip .
2. Tnh cht ca kch thch :
i vi mt tuyn ni tit, kch thch c th c tc dng dng hoc m tnh. Kch thch c tnh
cht dng tnh khi n tng hot ng ca tuyn nh tng ng mu s kch thch tuyn ty
tng tit insulin. Kch thch m tnh khi n lm gim hot ng ca tuyn. Tc dng m tnh ny
c vai tr rt quan trng trong c ch iu ha ni tit, thng c gi l c ch phn hi m
tnh. Thng tng m hocmon trong ni mi c tc dng c ch i vi tuyn tit ra n v
tuyn iu khin bn trn, th d tng hocmon tuyn gip trong mu s km hm s tit TFS
(ca vng di th), TSH (ca tin yn) v hocmon tuyn gip (H1), (H2).
3- Phng thc tc dng:
Hocmon c th tc dng trn mt tuyn ni tit khc v thng c gi l kch t, nh cc
kch t ca tuyn yn i vi cc tuyn trc thuc (ACTH vi thng thn, TSH vi tuyn
gip,)
Hocmon c th tc dng trc tip trn c quan cm th. C quan ny c th xa tuyn nh
ADH vi ng thn. C khi hocmon khng cn vo ni mi m tc ng ngay trn th th ti
ch nh trng hp axetylcholin thng c coi nh l hocmon ca thn kinh.
Mt hocmon, ngoi tc dng trn c quan cm th, cn c th tc ng trn mt hocmon khc.
Tc dng ny c th l hip ng, ngha l lm tng sc mnh ca nhan nh thyroxin tng tc
dng co mch ca adrenalin. Nhng tc dng cng c th l i khng,ngha l lm gim sc
mnh ca nhau, nh insulin i khng vi catecholamin, glucagon, ACTH v glucocorticoid,
TSHtrong chuyn ha gluxit v lipit. Chnh s i khng ny gia cc hocmon m bo
trng thi hng nh cua ni mi.
Ngoi ra, tc dng ca hocmon c th tng hay gim ty theo tnh cht l ha ca ni mi:
adrenalin mi trng toan gy gin mch, hoc pH kim lm tng v pH toan lm gim tc
dng ca thyroxin.
C ch tc dng:
C ch tc dng ca hocmon hin nay phn no sng t nh cc cng trnh v sinh tng hp
protein v cht 3 5 AMP vng.
Nh bit, qu trnh tng hp protein thc hin c l nh s hot ng bnh thng ca
mt n v hot ng gi l operon bao gm mt gen khi ng (operator) v nhiu gen cu
trc nm cnh nhau trn cng mt th nhim sc (H3). S hot ng ca n v ny li ty
thuc vo mt gen iu ha c nhim v thc y vic tng hp mt cht km hm (repressor),
cht ny khi kt hp gen khi ng s c ch c n v operon khng hoy ng (H4). Di tc
dng ca mt c cht (gi l cht cm ng), cht km hm mt tc dng v operon c gii c
ch s hot ng v cc cht do cc gen cu trc ch huy s c tng hp. n lt cc sn
phm mi c tng hp s lm gim c cht khin cho operon li b gen iu ha c ch tr
li. Qu trnh c nh vy din i din li v cc protein c hnh thnh theo nhu cu ca c
th (H5) Nh vy gen khi ng c hot ha bng cm ng th ng (gii km hm bng
cch hy tc dng ca cht km hm). Ngoi ra gen ny cn c th hot ha bng cm ng th
ng bi cht 3 5 AMP vng (H6).
Hin nay theo c ch tc dng, c th phn bit hai loi hocmon khc nhau:
Loi hocmon c tc dng theo c ch cm ng th ng tc qua mng t bo ch m tc ng
ln yu t km hm. Thuc loi ny c th k cc steroit sinh dc, steroit thng thn, hocmon
tuyn gip, hocmon trng thnhPhn tch trng hp glucocorticoit thy: bnh thng cc
chui AND kp trong cc th nhim sc b km hm (khng thc hin c qu trnh sao chp)
do cc cht histon; c l cc glucocorticoit kt hp vi cht histon thc y qu trnh tng
hp protein m ch yu l cc men tn to glucoza (H7)
Loi hocmon th hai c tc dng theo c ch cm ng ch ng tc thng qua AMP vng
hot ha cc men ARN polymeraza, t tng qu trnh sao chp tng hp cc protein cn
thit. Thuc loi ny c th k cc catecholamin, glucagon, ACTH, ADHTheo Wilmer, mng
t bo c nhiu loi men adenylcyclaza, mi th ng vi mt hocmon c mu vn chuyn ti
cc t chc nhng ch tc ng ln menadenylclaza thch hp c sn mng t bo ch (c {
kin cho rng adenylclaza v c quan cm th i vi hocmon ch l mt) v gy ra mt loi
phn ng dy chuyn nh sau (xem B1)
Trng hp ACTH,AMP c to ra s hot ha protein kinaza, cht ny phosphoryl ha histon,
gii km hmADN v tng hp mt protein men c hiu chi phi qu trnh chuyn ha
cholesteron thnh cortisol (H8)
Nh bit, hocmon c th chi phi cc khu ca qu trnh tng hp protein: khu sao chp
(AND chuyn thnh mARN, rARN,tARN), khu dch m (mARN chuyn thnh protein men)
C ch ph hy:
duy tr hocmon mt mc nht nh,chng thng xuyn b ph hy bng nhiu cch
a)Hocmon b trung ha khi kt hp vi mt protein: nh bit, homon c hai th: th hot
ng dng t do v th khng hot ng khi kt hp. Th d, steroit thng thn, 95% kt
hp vi mt protein c c th l transcortin, m ch c 5% l t do hot ng.
b)Hocmon c th b ph hy bi cc men c hiu: nh insulin b ph hy bi insulinlaza,
axetylcholin bi cholinesteraza.
c)Hocmon c th b gan phn hy v thn o thi ra ngoi: nh 17-hydroxysteroit, ADH,
estrogen, progesteron
d)Cht chng hocmon: l nhng cht t nhin hay tng hp c tc dng ngc li tc dng
ca hocmom. Trong c th, cc cht chng t nhin to thnh cng vi hocmon mt trng thi
cn bng ni tit nhm m bo s hng nh ca ni mi. Th d insulin v glucagon, hocmon
tuyn cn gip v cancitonin ca tuyn gip.
Nhng cht chng hocmon tng hp ngy cng c nghin cu nhiu v c p dng trong
lm sng nh spirolacton c hiu chng aldosteron, metopyron chng glucocorticoit
(cortisol)Nhng cht chng hocmon c cu trc ha hc ging cu trc ca hocmon nn
chng bm vo c quan cm th, tranh ch ca hocmon.
)Cht khng hocmon: l nhng cht do c th to nn, theo c ch mn cm: hocmon tr
thnh khng nguyn v c th sn xut ra khng th chng li n. Trong nhiu bnh ni tit,
ngi ta pht hin c nhng khng th nh vy: nh trong bnh i tho ng c khng
th chng insulin, trong bnh Addison tin pht c khng th chng v thng thn, trong
bnh Hashimoto c khng th chng thyreoglobulin
II. RI LON CN BNG NI TIT
Trc y, ngi ta thng hay ni n ri lon ca tng tuyn ni tit, nhng ngy nay, mi
lin quan rt cht ch gia cc tuyn cng nh gia thn kinh v ni tit c hiu bit su sc
hn, cho nn ngi ta ni nhiu n bnh ca nhiu tuyn. Cng do m nhng biu hin
ca ri lon ni tit trong lm sng rt phc tp. Nhng ni chung c hai hi chng ln ca tnh
trng mt cn bng trong hot ng ca tuyn hi tit l a nng v nhc nng.
A. U NNG NI TIT
l tnh trng tng cng hot ng ca tuyn.
Nguyn nhn : c th ngay tai tuyn hay t ngoi tuyn.
a). Nguyn nhn ti tuyn : do tng sinh t chc tuyn ( ph i nhu m, u lnh, ), tuyn tng
hocmon gy trng thi u nng ni tit.
b) Nguyn nhn ngoi tuyn : mt tuyn tng cng hot ng do b kch thch t ngoi toq
qu nhiu. Mt th d in hnh l hi chng Cot sinh (Cushing), trong v thng thn tr
nn ph i do tuyn yn tit qu nhiu ACTH.
c) Phn bit nguyn nhn u nng.
chun on u nng tuyn, ngoi nhng triu chng lm sng, cn c th s dng cc th
nghim thm d chc nng nh gi hot ng ca tuyn .
Nhng th nghim tnh nh gi trc tip hay gin tip lng hocmon, nhng cht chuyn ha
ca chng trong mu hay trong nc tiu. Thi d trong u nng thng thn, t chc thong
thn sn xut rt nhiu cocticit c th ng lng trong huyt tng (glucococticoit bnh
thng 12-15mg/100) hoc qua nh lng nhng sn phm chuyn ha ca chng trong nc
tiu (17-CS hoc 17-OHCS)
Trong u nng cn gip, canxi mu tng, photphat mu gim, ng thi canxi niu gim,
phophat niu tng. Khi c u nng ty th glucoza mu tng.
Nhng th nghim tnh khng cho bit ngun gc ca u nng, do ngy nay ngi ta dng
thm th nghim ng chun on nguyn nhn ti tuyn hay ngoi tuyn. Nguyn l chung
ca th nghim ny l km hm tuyn nh thm d (bng cch gim kch thch toi tuyn )
v quan st phn ng ca n. Nu l u nng ti tuyn, thy lng hocmon vn duy tr mc
cao (th nghim m tnh), chng t hot ng ca tuyn khng cn chu s iu ha bnh
thng na. Tri li, nu tuyn tng hot ng do kch thch bn ngoi, dng th nghim km
hm thy lng hocmon gim (th nghim dng tnh)
Trng hp cc tuyn ph thuc tuyn yn, khi cho vo trong c th mt lng ln hocmon
(t nhin hay tng hp) theo tc dng phn hi m tnh, hocmon s c ch tuyn yn gim
tit kch t, do tuyn trc thuc khng b kch thch t trn xung s gim tit nu l u
nng ngoi tuyn, tri li vn tng tit nh trc nu l u nng ti tuyn (H9). Bnh thng khi
tim vo c th cht triiodothyronin (hocmon do tuyn gip tit), thy m hocmon trong
mu s gim t nht l 25% sau 24h (th nghim Werner) cn trong u nng ti tuyn, m
hocmon khng gim m vn cao. Cng nh vy, khi vo c th mt cocticoit tng hp (nh
desamethanson) thy trong nc tiu gim cht 17-OOWCS- mt sn phm chuyn ha ca
coctison; tri li trong u nng ti tuyn thng thn, cht vn cao .
Nu l tuyn khng ph thuc tuyn yn (tuyn ty, cn gip) th ch cn lm thay i tnh
cht l ha ca ni mi mt cch tng ng l c th nh gi c hot ng ca tuyn
(H10). Bnh thng ,nu gy tng canxi mu bng cch tim vo trong c th mt lng canxi
ln, lp tc tuyn cn gip s gim tit, biu hin l canxi mu gim v photphat mu tng,
ng thi canxi niu tng v photphat niu gim. Song nu c u nng ti tuyn, th nghim
km hm ny s m tnh tc l hocmon cn gip vn cao trong mu. Hoc bnh thng cho n
mn, tim huyt thanh mn u trng, tim DOCA hoc tng th tch mu thy v thng thn
gim tit aldosteron, song nu c u nng ti tuyn, aldosteron mu vn cao (th nghim km
hm m tnh).
Tm li, nu tuyn tng hot ng do b kch thch th th nghim km hm s lm cho tuyn tr
li hot ng bnh thng; cn nu nh u nng do tuyn, th th nghim m tnh hoc khng
r rt.
2. Hu qu ca u nng tuyn:
a) i vi bn thn tuyn: tuyn tng cng hot ng tr nn ph i, pht sinh u, chuyn ha
ca t chc tuyn tng mnh, nh trong u nng tuyn gip, khi tim iod nh du vo trong
c th, thy cht ny nhanh chng tp trung vo tuyn v gn vo hocmon ri vo mu.
b) i vi c quan cm th: tng hocmon s gy thay i hot ng. Th d, trong u nng
tuyn gip, tng thyroxin lm tng chuyn ha c bn, trong u nng ty, tng insilin gy gim
c mu, trong u nng cn gip, thy canxi mu tng, photphat mu gim, n thi canxi
niu gim, phptphat niu tng.
c) i vi cc tuyn ni tit khc: th d u nng t bo axit ca tuyn yn gy chng cc i,
bnh i tho ng (do tng tit yu t sinh i ng), suy sinh dc (do c ch kch t sinh
dc).
3. u nng gim.
C nhng trng hp bnh nhn c triu chng bn ngoi ca trng thi u nng, song thc s
tuyn vn hot ng bnh thng. C th l do:
a) Tng nhy cm ca c quan cm th vi hocmon: th d, nhiu trng thi tng chuyn ha
c bn m khng c u nng tuyn gip, thng c gi l u nng tuyn gip gi.
b) Gim tc phn hy hocmon: lm cho lng hocmon hot ng tch li trong c th, khng
khc g trong u nng thc. Trong suy gan, do khng kp thi phn hy aldosteron,ADH,
estrogen nn hay c biu hin lm sng nh nc, rng lng, da mn
B- THIU NNG NI TIT
y l tnh trng tuyn khng tit hay tit khng hocmon cn thit cho c th hot ng
bnh thng.
1. Nguyn nhn: cng nh trong u nng ni tit, nguyn nhn gy thiu nng ni tit c th
ngay ti tuyn hay ngoi tuyn.
a) Nguyn nhn ti tuyn c th l:
- Ri lon tun hon ti tuyn: tc mch, huyt khi
- T chc tuyn b tn thng do chn thng, vim, nhim khun, nhim c, nhim phng
x
- Ri lon hot ng tuyn do suy dinh dng: nh thiu iot nhng vng cao gy thiu nng
tuyn gip, thiu n gy ri lon tuyn sinh dc (tt kinh, nhc tinh trng)
- Ri lon do qu trnh t mn cm: v nhng nguyn nhn cha r, t chc ca tuyn hay bn
thn hocmon c tit ra tr thnh khng nguyn v c th to ra khng th chng li dn ti
thiu nng ni tit. i khi do dng hocmon iu tr ly t cc sinh vt khc (ln, b) d c
tc dng song cu trc khc nhau nn gy ra hin tng mn cm cho.
b) Nguyn nhn ngoi tuyn :hot ng mt tuyn ni tit c th gim do nhng nguyn nhn
bn ngoi, th d thiu nng thng thn th pht do tn thng tuyn yn thng gp km
thiu nng cc tuyn khc (tuyn sinh dc, tuyn gip..)
Kch thch t trn xung c th ch yu l do c ch phn hi qu mnh. Trng hp ny hay
gp khi dng hocmon tng hp iu tr: nh khi dng nhiu hydrococtanxyl hay cc loi
steroit tng hp khc, m hocmon trong mu cao s c ch tuyn yn tit ACTH dn ti
gim hot ng ca v thng thn. l l{ do ti sao khng nn ngng iu tr t ngt m
phi gim liu dn dn nhm phc hi li hot ng ca tuyn.
c) phn bit nguyn nhn gy thiu nng:
Cng nh i vi u nng, chun on phn bit gia thiu nng ti tuyn hay ngoi tuyn,
ngi ta dng th nghim ng, ch yu l th nghim kch thch m nguyn l l dng nhng
kch kch bnh thng i vi tuyn v quan st hot ng thay i ca tuyn (H11a, H11b).
Nu l nguyn nhn ti tuyn (ngha l nhu m tuyn c vn ) th th nghim kch thch m
tnh, tc l nng hocmon vn thp nh c; tri li, nu tuyn b c ch do mt nguyn nhn
bn ngoi , th khi kch thch tuyn s tng cng hot ng (th nghim kch thch dng
tnh).
Trong thiu nng tuyn ni chung, th nghim tnh cho nhng kt qu hot ng ca tuyn
thp hn bnh thng, trong thiu nng ty, glucoza mu tng, trong thiu nng thng thn,
lng cocticoit trong mu v sn phm chuyn ha ca chng trong nc tiu gim.
i vi cc tuyn trc thuc tuyn yn, thng dng kch t tuyn yn tng ng. Trng hp
thiu nng tuyn gip, kch thch trc tip tuyn gip bng kch t tuyn gip, nu hocmon
tuyn gip vn thp (th nghim kch thch m tnh) th nguyn nhn l ngay tuyn gip v
tri li, nu hocmon tuyn gip tng (th nghim kch thch dng tnh), th nguyn nhn
ngoi tuyn.Nu l nguyn nhn ngoi tuyn, hai trng hp c th xy ra: hoc tuyn yn
hoc vng di th: kch thch trc tip tuyn yn bng cht TRF (yu t gii phng kch t
tuyn gip) nu hocmon tuyn gip khng tng, nguyn nhn vng di th, kch thch gin
tip vng di th bng cch gim tit hocmon tuyn gip (bng cachimazon-mt cht chng
tuyn gip tng hp), nu hocmon tuyn gap khng tng, nguyn nhn vng di th.
Nu l mt tuyn khng trc thuc tuyn yn (tuyn ty, cn gip)th s kch thch bng cch
thay i tnh cht ca ni mi. Bnh thng khi tng p lc thm thu huyt tng (bng cch
hn ch nc hoc tim huyt thanh mn u trng), thy ADH tng tit gy thiu niu. Nu
lng nc tiu khng gim (th nghim kch thch m tnh), 2 trng hp c th xy ra: gim
tit ADH hoc ng thn gim nhy cm i vi ADH (vn tit vi s lng bnh thng). Nu
tim ADH thy nc tiu khng thay i , l do ng thn gim nhy cm; tri li nu lng
nc tiu gim, l do gim tit ADH, nguyn nhn c th l do tn thng vng di th
(nhn trn th v cnh tht tit ADH), hoc tn thng ng vn chuyn ADH hoc tn
thng hu yn- kho d tr ADH.
Trong thiu nng tuyn cn gip, nu gy gim canxi mu (bng EDTA, etradiol benzoat), thy
canxi mu gim rt r v sau khng tr li nh bnh thng v tuyn khng cn kh nng tit
hocmon iu canxi d tr ra (th nghim kch thch m tnh)
Hoc trong bnh i tho ng ty th nghim gy tng glucoza mu s cho mt ng biu
din rt c trng i vi bnh y: glucoza mu tng sau khi n ko di do khng tit insulin
cn thit.
2.Hu qu ca thiu nng tuyn:
Tuyn khng hot ng s teo i, t chc x pht trin nh trong thiu nng v thng thn,
i khi lp v ny ch cn mng bng t giy bc ly li. i vi c quan nhn cm, nu l mt
tuyn th tuyn cng teo, nh gim kch dc t th tuyn sinh dc teo li v cc b phn sinh
dc km pht trin...; nu ni nhn cm l mt cht c lng nht nh trong c th th lng
cht s thay i nh trong thiu nng tuyn cn gip thy canxi mu gim v photphat mu
tng, ng thi canxi niu tng v photphat niu gim.
2.Thiu nng tuyn gi :
Cng nh u nng gi l nhng trng hp c biu hin thiu nng nhng tuyn vn bnh
thng c th l do :
a) Tng thoi bin hocmon : gy gim m hocmon trong mu, c th do c nhiu cht
chng hocmon hoc khng hocmon. Th d nh bnh i tho ng do tng hot ng ca
insulinaza hay do khng th chng insulin.
b) Gim nhy cm ca c quan cm th i vi hocmon : bnh i tho nht c th xy ra do
ng thn gim cm th i vi ADH. Bnh i ng cn c th do t chc km nhy cm i
vi insulin.
Ni tm li, ngy nay, nh nhng th nghim ng v chc nng ni tit cng vi nhng tin
b v phng php nh lng phng x min dch cc hocmon trong mu, nn chun on
chnh xc hn cc trng thi u nng v thiu nng ni tit.

SINH L BNH MU V TO MU

HONG DUNG

I CNG
C th ngi ta l mt b my hon chnh c h thn kinh bit ho cao, li c mt t chc c
bit l mu m bo s sinh tn ca c th. Nhim v ca t chc mu nhiu v phc tp,
c th xp thnh ba chc nng chnh:
1. Mu gi vai tr vn chuyn oxy v o thi kh cacbonic nh huyt cu t ca hng cu.
Ngoi ra cn lun chuyn cc ni tit t, cc cht nui dng t bo v chuyn cc cht cn b,
sn phm chuyn hoa, cht c n cc b phn bi tit o thi ra ngoi.
2. Mu c nhim v bo m s hng nh ni mi nh cc thnh phn ca mu : protein, cht
in gii, pH mu nn c s trao i u n gia mu v t chc t bo sng v pht
trin.
3. Mu c nhim v bo v c th chng bnh tt nh cc chc phn thc bo, min dch,
chng c ca cc bch cu v vai tr ca tiu cu trong duy tr cn bng ng mu.
Nh vy mu chy qua tt c cc c quan b phn, cung cp oxy v cht dinh dng, iu ha
chc nng sinh l{ ca ton b c th, lin kt cc b phn nn tham ra vo mi trng thi bnh
l{ cng nh tham gia u tranh chng mi s tn cng ca bnh tt. Cng v vy trong tt c
cc trng thi bnh l{ u c bin i v mu v chc nng to mu, nn cc xt nghim mu
c coi l thng qui, l vic trc tin phi lm gip cho chun on, theo di lm sng.
V bnh l ca mu cng nh hng n cc chc phn khc ca ton b c th.
Sinh l bnh ca h thng mu v to mu gm nhiu phn :
Ri lon khi lng mu tun hon.
Ri lon to hng cu.
Ri lon to bch cu.
Ri lon to tiu cu v cn bng ng mu.
Ri lon cc thnh phn protit huyt tng.
Cc ri lon ny c th pht sinh ring r, hnh thnh nhng qu trnh bnh l ring, hoc c th
nh hng ln nhau m ngi ta gi chung l bnh l ca c quan to mu.
RI LON KHI LNG MU TUN HON
Mu nm trong h tim mch nhng lun c s trao i gia mu v t chc cho nn trong iu
kin bnh l khi lng mu tun hon cng nh s tng quan gia hng cu v huyt tng,
thng c nhng bin i gy mt cn bng gia sc cha v khi lng dch, ta gi chung l
ri lon huyt ng hc.
ngi khe mnh khi lng mu ph thuc vo 3 yu t:
Tng lng mu ca c th bng 6- 8% cn bng ton thn, trong khi lng hng cu phi
mc bnh thng thay i t 36- 48%(hematocrit )
H tim mch k c cc kho d tr mu ( lch v gan ). l sc cha lun lun c iu chnh
duy tr khi lng mu tun hon ( bnh thng khi lng mu tun hon chim 3/4, d
tr 1/4, ca tng lng mu )
S phn b mu iu ha gia cc khu vc ( tiu tun hon, tun hon no, tun hon gnh,
di da thn, gan ).
I. THAY I BNH L CA KHI LNG MU
1. Thay i theo tui: tr con khi lng mu nhiu hn ngi ln.
Ngi ln 76,6 ml/cn
Tr con 77,1 ml/cn
Tr s sinh 84,7 ml/ cn ( Mollison )
2. Thay i thoe t th v hot ng :
T th ng l gim, th nm lm tng khi lng mu.
Nm ngh khng hot ng trong 2- 3 tun lin, khi lng huyt tng gim r rt.
3. Thay i do thai nghn :
T thng th 3, khi lng mu tng, thng th 9 tng cao nht, ch yu l tng huyt tng
nn ph n c thai khi lng hng cu gim.
II. THAY I SINH L CA KHI LNG MU
A- TNG KHI LNG MU
c chia thnh nhiu loi :
Tng song song c huyt tng c t bo mu v hin tng nht thi sau khi truyn mt khi
lng ln mu hoc sau khi lao ng nng.
Tng khi lng mu nhng gim t bo, ch tiu hematocrit gim c th pht sinh khi b bnh
thn do thiu nng chc phn lc; trong giai on c ph n ( do dch gian bo vo dng mu )
hoc sau khi tim cc dung dch sinh l v dch thay th mu. Truyn nhanh cho ng vt mi
khi lng ln dung dch sinh l c th dn ti t vong do ri lon nghim trng tun hon vi
mu tiu tun hon v ph phi cp. Trong mt s th thiu mu, suy mn v cc trng thi
gim s lng hng cu m khng c bin i tng lng mu th khi lng mu bnh thng
nhng hematocrit vn gim
Tng khi lng mu, tng t bo : c th gp cc bnh nhn tim, cc dn sng trn ni cao,
c tnh cht thch nghi b p. Tng sn xut hng cu c th l do bnh c tnh ca h to
mu( bnh nguyn hng cu c tnh ). Khi lng mu tng gp i hoc hn na do khi
lng hng cu, hematocrit tng. Trong thc nghim trn ng vt xc nh rng tng khi
lng mu n 100% cng khng gy ra bin i bnh l{ ng ch {. Khi tng n 150% v hn
na mi pht sinh ri lon tun hon nghim trng do lm cng v lm gim trng lc cc
mch mu, tnh thm thnh cc mao mch tng cng dn n mt huyt tng vo trong t
chc v cc khong thanh mc, mu ng li tr ngi hot ng ca tim.
B- GIM KHI LNG MU
Cng chia nhiu loi :
Gim song song huyt tng v t bo pht sinh nht thi do mt mu cp hoc sc khi mt
khi lng ng k mu b bnh l khng tham gia vo vng tun hon, ch tiu hematocrit
khng thay i.
Gim t bo mu, ch yu gim hng cu xut hin sau khi mt mu cp khi khi lng mu
c khi phc bng bin php huy ng dch gian bo vo dng mu, ch tiu hematocrit gim
Gim huyt tng hng cu vn bnh thng nhng b co li ( mu c ), ch tiu hematocrit
tng ti 55- 60% v hn na, pht sinh trong trng hp mt nc, i lng nhiu ln, nn dai
dng, nhim nng, mt nhiu m hi, bng rng
III. SINH L CA BNH MT MU
Mt mu l mt hin tng sinh l ph bin trong lm sng ni, ngoi khoa, c bit trong
ngoi khoa thi chin. Trong thc t, mt mu thng gp nht l phi hp vi chn thng,
v trong cc vt thng huyt qun. Kh nh gi ng mc l chy mu trong mng phi,
bng, gian bo, c xng C xng c rt nhiu mch mu nht l ngi tr v n nang :
gy xng i n thun mt 1 lt mu; gy xng nhiu mnh c nhiu c b hy hoi c th
mt ti 2 lt mu.Trong phu thut, mt mu cng c vai tr quan trng : th thut thn xng
i, ng inh, ghp xng mt ti 1,5- 2 lt mu. Chy mu ni khoa gp trong thng d dy,
hang lao, bong rau thai sm cng gy mt nhiu mu.
A- DIN BIN SAU KHI MT MU
Khi mt mu c th pht sinh nhiu ri lon, mc nng nh ph thuc vo ba yu t :
1. Khi lng mt mu :
Mt mu t, di 10% tng lng mu thng khng gy hu qu g nghim trng ( ngi cho
mu )
Mt mu t 20% tng lng mu tr nn hu qu thng phi lu {. Thng k trong chin
tranh Triu tin trn 186 thng binh c 152 trng hp mt mu trn 20% u b sc ( 81,7%
). Ni chung c vi ngi khe mnh, mt 1 ln t 1/4 n 1/3 khi lng mu rt ng lo
ngi cho i sng v huyt p ng mch gim thp gy thiu oxy nghim trng nhng nu mt
t t trong nhiu ngy mt khi lng mu nh vy li khng nguy him do cc c ch thch
ng b p ca c th pht huy tc dng.
2. Tc mu chy : tc mu chy nhanh hay chm, gy mt mu nhiu hay t ph thuc
vo v tr mt mu tnh mch hay ng mch, huyt qun ln hay nh :
Chy mu ng mch, nht l cc ng mch ln mu chy thnh tia mnh nn thng nguy
him hn mt mu tnh mch ( chy t t, nh git ). Chy mu nhiu trong mt thi gian ngn
gy ra gim huyt p t ngt tc ng nn cc th cm p lc ca thnh mch ng thi tnh
trng mt mu, thiu oxy nui dng h thn kinh v cc c quan quan trng ca c th ( tim,
gan, thn, tuyn thng thn ) cng l nhng nguyn nhn gy sc v t vong trong cc trng
hp mt mu nng
Chy mu cc tnh mch nh v nh thng khng nguy him nhng tn thng c tnh mch
ln nht l cc tnh mch gn tim cng quan trng v gy ri lon t ngt sc cha ca tim, tim
p rng c th gy phn x ngng tim v cht mc d c khi lng mu mt khng ln lm (
300- 500 ml)
3. Tnh phn ng ca c th :
Tr s sinh v tr con di 2 tui rt mn cm vi mt mu do kh nng b p ca h tim
mch v h thn kinh cha pht huy c y .
Tnh trng mn cm vi mt mu tng khi c th suy nhc, b chn thng nng, mt mi,
i, lnh, trong trng thai gy m su c khi lng mu mt ch 10- 15% cng gy nhng hu
qu nguy him.
B- C CH THCH NGHI B P KHI MT MU
Khi mt mu c th s ng vin mt chui phn ng sinh vt phc tp nhm bo v c th
mt mc nht nh :
1. Phn ng cm mu:
Tn thng huyt qun gy phn x co mch ti ch, v cc tiu cu t li thnh mt nt sinh
hc bt kn vt thng, ng thi c hin tng tng cng cc yu t ng mu, tng to
thromboplastin t chc, tng to fibrinogen gan v cc yu t khc. Kt qu l tnh ng mu
tng, c th gp 3- 5 ln bnh thng, hin tng ny xut hin ngay sau khi mt mu v ko
di 5- 8h sau, cho nn mu c th ngng chy nhng nu khng pht hin c tn thng
mch mu v c bin php phng nga th khi vn chuyn thng binh c khi ch nhng ng
tc khng nh nhng, thay i t th c th gy chy mu th pht, sc c th dn ti t
vong nu khng x l kp thi
2. Phn ng nng huyt p ( phn x tim mch ):
Do mt mu, lng mu lu thng gim, huyt p ng mch gim kch thch phn x cc th
cm huyt qun vng xoang dng mch cnh v quai ng mch ch gy tng co bp tim, mch
nhanh v mnh hn, tc mu chy cng tng cng. ng thi c hin tng tng tit
adrenalin gy co mch ngoi vi v gin cc mch no, mch vnh. Kt qu l tim tng cng
hot ng, co mch ngoi vi v mu d tr c phng ra vng tn hon nn huyt p ng
mch c nng ln tm thi iu ha hin tng mt cn bng huyt ng lc, ng thi
cng phn phi li mu bo m cung cp cho no v tim l cc c quan quan trng duy tr
s sng.
3. Phn x tng h hp : pht sinh do kch thch phn x trung tm h hp khi nng O
2
/ mu
gim v nng CO
2
/ mu tng. H hp tng cng, th nhanh v su; qu trnh trao i hi
kh v s phn ly HbO
2
, cng tng t chc d dng s dng oxy.
4. Phn ng b p khi lng mu :
Lu lng mu gim gy tng tit ADH v aldosteron c tc dng tng ti hp thu nc v mui
ti lin bo cc ng thn do lm gim bi tit nc tiu ( thiu niu hoc v niu ). ng thi
c hin tng huy ng dch gian bo vo dng mu, c thc hin thun li v lc ny p lc
mu gim thp. Trn thc t, khi mt 1 lt mu, khi lng mu c khi phc sau 8- 24h, c
khi ti 2- 3 ngy sau mi khi phc hon ton. V mi ch khi phc phn dch nn mu long,
khi lng hng cu v huyt cu t gim, hematocrit cng gim, ( l hin tng thiu mu
sau khi mt mu )
5. Phn ng tng to cc t bo mu :
Phn ng ny xut hin mun nht 4- 5 ngy sau, pht sinh do tnh trng thiu oxy mu kch
thch ty xng tng to cc t bo mu c tnh cht thch ng b p, phn ng ca ty xng
v tc ti to t bo mu ph thuc vo tnh trng ton thn, mc mt mu v s cung
cp cc nguyn liu to mu ( protit, st ) C th tr, khe mnh, mt mu khng nhiu lm,
dinh dng y thng hi phc nhanh hn. Bch cu v tiu cu i sng ngn, ti to
nhanh nn ch 8- 10 ngy s lng mu ngoi vi c th c khi phc, hng cu th phi
ti 30- 50 ngy sau, chm nht l hut cu t phi sau 2 thng mi tr li mc bnh thng.
Nh vy, nu mt mu khng nhiu lm v iu tr gii quyt kp thi, hp l th cc phn ng
b p ca c th c th n nh c tnh trng ton thn. Nhng nu mt mu nng hoc
bnh nhn vo cc iu kin hon ton khng thun li, c th dn ti sc mt mu v cc
bin c nguy hi cho i sng.
Tn thng huyt qun
Mt mu

Gim khi lng mu tun hon

Gim huyt p Gim Oxy- mu
Tim co bp yu Thiu Oxy

Kch thch th Hng phn h
cm huyt qun TKT

Tng cc phn c ch h TKT
ng b p

Hi phc Ri lon cc chc Sc MM
phn v c ch b t vong
S v bnh sinh ca mt mu

c) Sc mt mu ( sc chy mu ) :
Sc mt mu l hin tng th pht xy ra sau khi mt mu nng din bin sau mt thi gian
h huyt p ng mch, s oxy ha khng y dn ti suy sp h TKT v ri lon nghim
trng ton b chc nng c th, biu hin r nht l h tn hon. Mt mu cng nhanh, mnh
( chy mu cc ng mch, tnh mch ln ) cng nhiu ( 25- 30% v hn na ) th sc mt mu
pht sinh cng c tnh cht ph bin v din bin cng nng.
1. Cc giai on din bin ca sc mt mu : ( hnh 1 ).
Sc mt mu thng din bin theo 3 giai on ( La porte, 1965 ).
a) Giai on 1 ( ngay sau khi mt mu )
Giai on ny ph thuc vo mc mt mu v trng thi tng c th. Bnh nhn thng
trng thi vt v, kch thch nhng nu mt mu nhiu li mt l mt ti nht, chn tay lnh, c
th ngt do thiu oxy t ngt no.
Huyt p ng mch gim do gim khi lng mu tun hon, mt mu cng nhiu huyt p
gim cng r, mt qu nhiu c th gy try tim mch dn ti t vong do cc phn ng b p
khng kp thi pht huy tc dng.
Mch nhanh v mnh pht sinh theo c ch phn x, nhng nu mt mu nhiu khi lng
mu gim nhiu tim c th p yu v lon nhp,c s chun on mc ca sc.
- H hp cng tng cng, th nhanh v su. Nhp v tn s h hp c th b ri lon ngay khi
mt mu nghim trng.
b) Giai on 2 ( cn gi l giai on tim )
Giai on ny ph thuc vo kh bng thch ng ca c th. C hai kh nng :
Nu c ch thch ng b p ca c th pht huy tc dng th tnh trng bnh nhn c xu
hng hi phc dn: huyt p ng mch c nng ln, mch vn nhanh v mnh hn,
thng khng qu 120 p/ pht; h hp cng u v su hn, sc mt nht nht v chn
tay lnh, tnh to.
Nu cc im din bin xu dn i, huyt p khng tng m tip tc gim; mch yu, rt nhanh
v lon nhp; h hp ri lon v th nhanh- nng l c ch b p bt lc v sc c th
nhanh chng chuyn sang giai on nhc.
c) Giai on sc nhc :
L giai on suy sp h TKT v ton b chc nng c th, l giai on mt b c th khi pht
do mt yu t thun li: gy m su, chn thng, au n, lnh, thay i t th, vn chuyn
2. Bnh sinh ca sc mt mu :
Mt xch ch yu ca bnh sinh mt mu l gim khi lng mu tun hon v thiu Oxy mu
gy ri lon nghim trng h TKT. Cc t bo no b thiu oxy nng t hng phn nhanh
chng chuyn sang trng thi c ch su sc gy ri lon iu ha cc chc phn v c ch cc
c ch thch ng b p ca c th. Quan trng nht l ri lon h hp do hnh no v cc
trung tm h hp b tn thng v ri lon hot ng tim do huyt p ng mch gim v thiu
oxy c tim. Tnh trng ny cng lm suy sp s cung cp oxy cho t chc gy ri lon chuyn
ha nng n. Cht trong mt mu pht sinh do lit trung tm h hp v ngng tim.
Do tc dng ca catecholamin, h thng ng mch b co tht, tun hon no v vnh gin ra l
c ch bo v cho trung tm sng nh tun hon gan, thn li b co nhiu cho nn tnh trng
ny ko di cng gy nhng tn thng nghim trng trong gan, thn, rut, thng thn cng
l nguyn nhn lm cho sc kh hi phc.
H thng tnh mch xp, khng c mu, tun hon tr v tim gim nh hng ti hot ng
tim dn n ngng tim. H thng mao mch b gin nghim trng co ri lon cc c tht tiu
mao mch. Mu trong h mao mch, ch yu khu vc ni tng, cng gy gim huyt p ng
mch to thnh vng xoy c bnh l lm cho sc nng thm.
Nguyn tc ch yu ca vic iu tr mt mu l khi phc tun hon, tr li khi lng mu
mt, gi cn bng huyt p.
Trong khi x l{, m bo cm mu tt v nn cho bnh nhn nm u dc.
iu tr sm, truyn mu ngay trong hai giai on u phc hi th cn bng huyt ng
lc, phng sc v ngn nga nhng hu qu do thiu oxy gy ra. iu tr trong giai on ny l
mt thun li khng nn b qua v tc dng iu tr tng i d dng rt c hiu lc, khi
chun sang giai on sc nhc iu tr kh khn hn. Sau khi ti lp c th cn bng, tnh
trng cn khng chc chn trong mt thi gian, cn tip tc hi sc v theo di ngn nga sc
th pht, kh hoc khng cu cha c.
3. Try tun hon ( try tim mch )
Khc vi sc, l trng thi gim huyt p t ngt, c th dn ti t vong trong mt thi gian
ngn. Nguyn nhn do chy mu nhiu, nhanh v khng cm c gy thiu oxy cp (
apoploxie ) cc c quan b phn quan trng. Thiu oxy cp c th gy gin mch do thiu oxy
nui dng cc t bo thnh mch, cc mao mch b gin, nht l cc mao mch ni tng lm
ton b khi lng mu trong gy gim huyt p trm trng. Tnh trng ny lm gim khi
lng mu v tim, h thng tnh mch xp nn mc d kh nng tim cha b tn tht, tun
hon mu cng khng thc hin c. Thiu oxy cp no nn bnh nhn bt tnh ngay v cc
chc nng thch ng bo v b c ch, cc trung khu quan trng nh tun hon, h hp b tn
thng ng thi thiu oxy cp tuyn thng thn u l nhng nguyn nhn dn n t
vong sm trong mt mu cp v nghim trng.
RI LON TO HNG CU
I CNG
Cc t bo mu c sn sinh t c quan to mu. Khi cn bo thai, t tun l th ba, cc t
bo mu u tin c hnh thnh t t chc trung dip, ni to thnh mu l nhng t bo
ni mc ca huyt qun. Sau cc t chc gan, lch cng tham gia vo to mu, t thng th
t thm ty xng to mu nhng khi ra i th cc t chc trn chm dt nhim v, ch c ty
xng tr thnh c quan to mu quan trng nht ngi.
Nh vy ngi cc c quan to mu gm :
Ty xng, c quan to mu chnh l ni sn sinh 3 dng t bo mu : hng cu, bch cu ht,
tiu cu.
Lch, cc hch bch huyt ch yu to dng bch cu lympho.
H vng ni m ( SRE ) ch yu to dng bch cu mono. V h vng ni m ri rc nhiu
nitrong c th ( ty xng, gan, lch, hch ) nn ngi ta thng phn bit bch cu mono
mu, ngun gc ty xng v cc t bo t chc lin kt, cc i thc bo xut hin nhiu khi
b vim nhim cc b.
V ngun gc cc t bo mu t trc ti nay c rt nhiu l thuyt gii thch khc nhau. Ni
chung u thng nht l cc t bo mu u bt ngun t t bo gc a nng, gi l
hemohistioblaste ( huyt nguyn t chc bo ). T t bo ny s cho cc t bo gc chung cho
cc t bo mu, nguyn bo hay hemocytoblas, ri ty theo nhu cu c th bit ha thnh cc
t bo m ca tng dng t bo : proErythroblas hay tin nguyn hng cu, t bo m ca dng
hng cu; Myelobalsthay nguyn ty bo l t bo m ca dng bch cu ht; Megacaryoblast
l t bo m ca dng tiu cu;Lymphoblast hay nguyn lympho bo l t bo m ca dng
bch cu lympho; Monoblast hay nguyn mono bo, t bo m dng bch cu mono
Hng cu c sn sinh ty xng, t t bo tin nguyn hng cu, qua cc giai on :
ProErythroblast

Erythroblast

Hng cu li
( rticulocyt)

Hng cu

Cc ProErythroblas v Erythroblas kim l nhng hng cu non, t bo ln, nhn to v trn
trn, li nhim sc thanh, nguyn sinh cht bt mu xanh thm kim tnh do cha nhiu ARN,
cc Erythroblast a sc l t bo hng cu non giai on bt u c tng hp hemoglobin nn
nguyn sinh cht va bt mu xanh kim va bt mu hng do huyt sc t. Cc nguyn hng
cu ni chung ( Erythroblast ) l nhng hng cu non c nhn ch trong ty xng to mu,
bnh thng khng mu ngoi vi.
Hng cu li l nhng hng cu gn trng thnh mt nhn v nu mang nhum bng
phng php nhum sng vi cht mu xanh sng Cresyl s thy b mt t bo c nhng ht
nh xp thnh mng li. Bnh thng hng cu li c tung ra mu ngoi vi thay th
cho cc hng cu gi b hy, nn c t l 0,5- 1.5% v nh vy hng cu li l ch tiu theo di
s tng sinh ca dng hng cu.
ngi bnh thng, s lng hng cu ngoi vi c gi mc tng i hng nh t 4- 4,5
triu trong 1mm
3
mu do c s cn bng gia hai qu trnh sn xut v tiu hy hng cu. (
hnh 1 ). Nh phng php nh du hng cu bng cht ng v phng x Cr51 ngi ta xc
nh hng cu sng c trung bnh t 110-120 ngy, t khi ra khi ty xng. Cc hng cu
gi b hy nn hng ngy c s hy huyt sinh l khong 0,83% khi lng hng cu trong cc
h vng ni m, ch yu l lch, v ty xng li sn xut tung ra mu ngoi vi cng ngn y
hng cu thay th. Khi cn bng ny b ri lon s pht sinh 1 trng thi bnh l{ m ngi ta
thng gi l thiu mu.
A. QU TRNH SN XUT HNG CU
1. Chc nng sn xut cc t bo mu ca ty xng :
Ty xng gm ty vng hay ty m thn cc xng di v ty hay ty to mu ch yu
cc t chc xp ca xng dt v u cc xng di.
Ty to mu gm hai phn:
Phn m l cc mao mch v giy h rticulin to thnh t chc xp lm nn m cho cc
t bo.
Phn nhu m gm cc t bo gc cha bit ha v cc t bo m, t bo trung gian ca cc
dng hng cu, bch cu ht v tiu cu. Ngoi ra cn mt s t bo lin vng to lympho v t
bo mno.
Tt c hp thnh mt t chc thng nht, lin quan, tip xc vi nhau m ng chc
phn to mu theo c ch iu ha nhp nhng ca thn kinh v ni tit.
Tng s lng ty xng ngi ln l 2600g, tc 4,6% so vi cn nng c th, trong 1 na
l ty to mu. Thm d chc nng ty xng bng phng php chc d ( ponction )
xng c hoc mo xng chu, u trn xng chy. Cht ty c dn vo lam knh, nhum
ri m t l % cc t bo ty, gi l ty ( mylogramme ). Khi qut 1 cng thc ty gm:
Cc t bo dng bch cu 60%
Cc t bo dng hng cu 20- 25%
Tiu cu, bch cu lympho, mono, t bo lin vng 5- 10%
nh gi chc nng ca ty xng qua 1 ty , ngi ta thng da vo cc yu t :
1. T l cc t bo non, trung gian ca tng dng t bo mu tng, chng t dng t bo
c tng sinh theo yu cu ca c th. V d: cc t bo Erythroblast kim, a sc, toantng
cao trong cc trng hp thiu mu.
2. T l cc phn bo ca tng dng t bo mu: Cc t bo mu c nhn ln bng cch phn
chia t bo. Kh nng phn chia c thc hin cc t bo non, v ch yu cc t bo gn
trng thnh c lng axit nhn cao: Erythroblast a sc, toan vi dng hng cu; Ty bo,
Hu ty bo vi dng bch cu ht
3. T l BC/ HC, tc l t l gia cc t bo bch cu v hng cu. Bnh thng t l ny bng t
2-3, v bch cu i sng ngn nn sn xut phi c tng cng. T l ny gim khi cc t bo
hng cu c tng sinh trong thiu mu, ngc li t l ny tng ln trong cc trng hp
nhim khn, c tng sinh dng bch cu ht.
4. T l cc t bo non so vi cc t bo gn trng thnh trong ty xng tng cng, v d t
l cc Erythroblast kim tng cao so vi cc Erythrob-last a sc, toan c th do tnh trng thiu
st c ch s tng hp hemoglobin...
5. S xut hin cc t bo non cc dng mu ngoi vi. Bnh thng cc t bo non, nguyn
bo v cc t bo trung gian ch c trong c quan to mu. S xut hin bt thng cc t
bo ny mu ngoi vi ni ln kh nng bit ha t bo ca ty xng b gim st hoc c ch
nn c hin tng tng cng qu mc cc nguyn bo; c trong ty xng v trn ra ngoi
mu ngoi vi.
Cc t bo non cc dng c phn chia, chuyn qua cc giai on trung gian, ri trng thnh
v c a vo mu ngoi vi thay th cho cc t bo gi hoc v l do bnh l b hy. Thiu
Erythropoietin trong bnh vim thn mn, hin tng cng lch c tc dng c ch nn qu
trnh trng thnh hng cu a ra mu ngoi vi thay th cc hng cu gi, bnh l gim st
v gy thiu mu. Trong bnh thng hn, c t vi khun c ch qu trnh trng thnh dng
bch cu ht nn mu ngoi vi c hin tng gim bch cu ht
B- QU TRNH TIU HY HNG CU
Hy hng cu sinh l l s ph hy cc hng cu gi cui giai on sng. Hng cu v v gii
phng ra huyt cu t t do. Bnh thng, huyt cu t t do c gii phng khi c hy hng
cu s kt hp vi 1 globulin alpha trong mau l haptoglobulin, v nh vy hut cu t hay st (
Fe ) c gi li trong c th s dng cho tng hp cc hng cu mi; ch khi huyt hy qu
mc trong bnh l{ lm cho lng huyt cu t t do tng qu cao trong mu vt kh nng kt
hp ca haptoglobulin th mi c huyt cu t niu ( Hb t do tng qu 150mg%
).
Huyt cu t (hemoglobin) gm globin v hemedo porphyrin v Fe
2+
to thnh. Thoi bin
hemoglobin bt u ph hy vng porphyrin, heme tch khi globin oxy ha thnh hematin.
Phn c st s gii phng Fe di dng hemosiderin ( Fe
3+
) c d tr trong lch v gan s
dng trong tng hp cc hng cu mi. Phn khng c st c to thnh sc t mt, bilirubin
kt hp ( ha hp ), xung rut thnh Urobilin v Stercobilin cui cng bi tit qua nc tiu v
phn. Do khi c hy hoi nhiu hng cu trong bnh l, bilirubin t do tng cao trong mu
gy vng da, ng thi tng Urobilin nc tiu v tng Stercobilin phn cng l nhng ch tiu
phn on mc ca hy hut.
Cc hng cu b hy c phn mnh v sau b thc bo bi cc t bo vng ni m ty
xng, gan, ch yu l lch. Lch l c quan chnh tiu hy hng cu, c nhiu nhim v lin
quan ti h thng mu :
D tr mu trong cc xoang ca ty ( pulpes rouges ) ca lch.
To cc bch cu lympho v l ni sn xut cc globulin min dch.
C tc dng c ch ty xng, i lp vi kh nng sn xut t bo mu v c kh nng a ra
mu ngoi vi nhng t bo trng thnh ca ty xng.
C chc nng hy cc hng cu gi v hng cu bnh l bng cch tng hot tnh thc bo ca
cc t bo ni m lch. Trong trng hp bnh l, chc phn ny tng cng, c th hy c cc
hng cu bnh thng v c cc bch cu v tiu cu bnh thng, v c ch bnh sinh, c tc
gi cho rng do lch sn sinh ra nhng cht c nhng men tiu hy ( lisolecithin, lysin ) hoc
nhng khng th c nh vo b mt cc hng cu, lm o ln cn bng l ha ca hng cu
do hng cu d b v, d b nh hng bi cc tn thng c gii ( tr tun hon, tn
thng thnh mch ) hoc cc tn cng bnh l khc.
SINH L BNH CA THIU MU
Thiu mu l mt hin tng bnh l ph bin pht sinh khi c ri lon s cn bng gia hai
qu trnh sn xut v tiu hy hng cu, hoc do hng cu b tiu hy qu mc ( mt mu, hy
hng cu do cc nguyn nhn bnh l ), hoc do qu trnh sn xut hng cu b gim st, c ch
( thiu nguyn liu, nhim khun, nhim c nng ). Biu hin ca thiu mu l gim s lng
hng cu, huyt cu t ngoi vi, ng thi c nhng ri lon v cht lng hng cu.
1. Thay i ca hng cu v chc nng to hng cu trong thiu mu.
Khi thiu mu, hng cu khng nhng thay i v s lng m c cht lng cng c nhng
bn i, v ty xng p ng li kh mnh b p trong cc trng hp thiu mu va
phi, c x tr iu tr hp l.
A- THAY I V S LNG HNG CU
Khi thiu mu, s lng hng cu ngoi vi gim di mc bnh thng. Gim nhiu hay t mt
phn ni ln mc nng hay nh ca thiu mu. Trong cc trng hp nng, s lng hng
cu c th gim di 2.000.000 trong 1mm
3
. Huyt sc t cng gim song song vi hng cu,
trng hp nng c th gim di 50% so vi mc bnh thng.
B- THAY I V CHT LNG HNG CU
Cht lng hng cu b bin c th do cc yu t bnh l{ tc ng trc tip tn hng cu,
hoc do qu trnh sn xut b ri lon, c biu hin bng cc ch tiu :
1. Thay i ch s nhim sc ca hng cu:
Ch s nhim sc l m huyt sc t trong hng cu, th hin gi tr chc nng ca hng cu
nn c in gi l gi tr hng cu c tnh theo cng thc n gin:
hemoglobin%
CSNS = = 1
2 s u HC.2
Gii hn bnh thng ca ch s nhim sc l 0,9- 1,1. Trong bnh l, ty theo s thay i ca
ch s nhim sc c th phn bit
Thiu mu ng sc khi hng cu v huyt sc t gim tng ng, cc trng hp thiu mu
c hy hng cu va phi, t hoc khng b thiu st do Fe c gi li s dng cho ti to hng
cu.
Thiu mu nhc sc khi CSNS gim di 0,9 do hut sc t gim nhiu hn so vi hng cu,
gp cc bnh nhn suy nhc thiu protit, thiu st. suy dinh dng, hoc kh nng tiu ha
hp thu km, kh nng tng hp protit b ri lon
Thiu mu u sc khi CSNS trn 1,1. y khng phi l tha d huyt cu t, s lng tuyt
i Hb trong 1 n v th tch mu vn gim, tuy s lng Hb trong tng hng cu c tng cao
hn bnh thng, do th tch ca hng cu tng. Bnh thng mi hng cu ch cha mt lng
Hb nht nh, t l bo ha Hb ca hng cu l 33- 34%, nn khi th tch hng cu tng thi
lng Hb trong tng hng cu cng tng. Thiu mu u sc gp trong bnh thiu mu c tnh
Addison- Biermer, c hng cu bnh l mgelo t l cao trong mu ngoi vi,s lng HC gim
thng di 1- 2 triu/ 1mm
3
. V d mt trng hp thiu mu vi s lng HC 1 800 000
trong 1mm
3
, Hb 45%, c ch s nhim sc ( 45/18,2= 1,5 ) l thiu mu u sc.
y ch l mt cch tnh ton n gin, v chuyn khoa cn phi da vo nhiu yu t chnh xc
hn nh xc nh th tch ca hng cu, bo ha Hb ca hng cu, lng Hb trong tng HC
2. C kh khng u hay hin tng a c ( anisocytose ). C th phn bit : trong mu thy
xut hin mt s hng cu to hn bnh thng, ng knh 8- 10 micromt l nhng hng cu
gn trng thnh, hng cu li va c tng sinh thay th l biu hin tt thiu mu ang
c phn ng tng sinh hi phc. Nu trong mu c nhiu hng cu nh, ng knh 5- 6 hoc 3-
5 micromt, l biu hin khng tt v l nhng HC gi ci, nhng mnh v ca HC, hoc
nhng HC b teo i di tc dng ca yu t bnh l, nhng HC sn xut trong iu kin xu,
thiu nguyn liu c cc HC khng l Mgalo, ng knh trn 10micromt, gp trong bnh
thiu mu u sc Biermer.
Do ng knh hng cu bng micromt qua knh hin vi v v thnh ng biu din Prices-
jones c gi tr nht nh trong chun on thiu mu lm sng: ng biu din chuyn sang
tri do trong mu c nhiu hng cu nh, c th gp trong cc trng hp thiu mu do nhim
c, bnh vng da tan mu ng biu din chuyn sang phi l c nhiu hng cu ln, c
th gp trong thiu mu c hng cu Mgalo
3. Bin i v hnh dng hay hin tng a dng ( poikilocytose ) do mng hng cu km bn
vng nn khi dn trn lam knh hng cu mo m khng u, to thnh cc hnh dng khc
nhau: hnh qu du, bn nguyt, qu l, qu chy hoc do cc bnh l di truyn gy bin i
cu trc v hnh dng hng cu, nh hng cu hnh bia trong bnh huyt cu t F, hnh lim
trong bnh huyt cu t bnh l S.
4. Bin i v mu sc hay hin tng lon sc ( anisochromie ) biu hin bng s bt mu khc
nhau ca cc hng cu:
Hng cu nhn l nhng hng cu khng bt mu gia do thiu huyt cu t, nhc sc.
Hng cu a sc l nhng hng cu trng thnh nhng do qu trnh chuyn ha vi vng
nn vn cn tnh cht i kim trong nguyn sinh cht nh t bo non, gp trong cc trng hp
mt mu tan mu cp tnh v qu mc
5. Xut hin nhng hng cu bt thng trong mu ngoi vi.
Trong cc Erythroblast kim, a sc, toan gp trong thiu mu nng gy phn ng mnh vi ty
xng; hoc trong cc bnh nguyn hng cu c tnh.
Xut hin cc hng cu mang d tt nh th Joly, vng Cabo trong cc trng hp thiu mu
nng v c ri lon chc nng ty xng.
Xut hin cc hng cu c ht i kim trong thiu mu do nhim c c bit nhim c ch.
C- THAY I CHC NNG TO HNG CU CA TY XNG.
Khi thiu mu chc nng ca ty xng b bin i theo hai hng :
1. Tng sinh bnh thng: Ty xng thng phn ng rt nhanh v nhy trong tt c cc
trng hp thiu mu thng thng. Ta gi l thiu mu c hi phc biu hin :
Tng hng cu li 10- 20% c khi ti 50% v hn na
Bin i v cht lng hng cu t hoc khng r rt.
Bch cu ht v tiu cu cng c du hiu tng sinh nh.
2. Chc nng b ri lon hoc b c ch:
Phn ng ca ty xng yu t hoc khng xut hin, ta gi l thiu mu kh hoc khng hi
phc, hay suy ty v nh hn l nhc ty, vi nhng biu hin :
Hng cu li gim thp hoc khng xut hin.
Nhiu bin i v cht lng hang cu.
Bch cu v tiu cu gim song song vi thiu mu.
NGUYN NHN V BNH SINH CA THIU MU
Ty theo nguyn nhn v bnh sinh, c th chia thiu mu thnh ba bnh chnh: thiu mu do
tan mu; do mt mu; v do chc nng to hng cu ca ty xng b ri lon.
A- THIU MU DO MT MU
Tt c cc trng hp mt mu ni hay ngoi khoa, cp tnh hay trng din u dn ti trng
thi thiu mu vi cc mc khc nhau.
1. Thiu mu do mt mu cp din thng do nguyn nhn ngoi khoa ( vt thng, t mch
mu, gy xng,phu thut) hc bin chng ni khoa ( nn ra mu, khc ra mu, chy mu
d dy, i ra mu, chy mu cam, chy mu di da, ni tng quan trng). Ngoi nguy c
trc mt ( sc, try tim mch ), thiu mau pht sinh sau vi cc c im sau y:
Gim hng cu v hut cu t nghim trng, mu long do dch gian bo vo dng mu b
p khi lng tun hon.
Thiu mu nhc sc, ch s nhim sc gim r rt, v mt hng cu, hut cu t thng dn
ti thiu st do st trong c th ch yu dng kt hp vi huyt cu t ( chim ti 2/3 tng s
lng st trong c th, c 1lt mu cha khong 500mg st
Tng hng cu li, ty giu t bo v c du hiu tng sn dng hng cu. Hi phc cng
nhanh nu mc thiu mu khng nng ( di 20% tng lng) v trng thi ton thn tt.
Cc bin i v cht lng hng cu cng t hoc khng xut hin.
2. Thiu mu do mt mu trng din:
Pht sinh trong cc bnh l mn tnh c chy mu. t mt, ko di ( lot d dy, tr, giun mc,
dong kinh ph n). Thiu mu din bin thng ko di , mc gim hng cu, huyt cu t
khng nhiu lm, thng l thiu mu nhc sc, cng c khi ng sc. Trong mu thy tng
hng cu li, nhng t l khng cao v tc hi phc cng chm hn, bin i v cht lng
hng cu cng nhiu v r hn ph thuc vo cc bnh chnh ca bnh nhn. Bnh cng din
bin lu di cng nh hng ti th trng ton thn nht l tim v h thn kinh ( gim tr nh,
d b chong vng, ngt lm, tim c ting thi chc phn ) Gii quyt thiu mu trong nhng
trng hp ny phi song song vi iu tr bnh chnh.
B- THIU MU DO TAN MU ( DO HY HNG CU )
L loi thiu mu do hng cu b ph hy qu mc, nguyn nhn v bnh sinh rt phc tp c
th phn thnh ba yu t chnh.
1. Tan mu nguyn nhn do yu t hng cu: hay do bn thn hng cu km bn vng, d v v
b thc bo bi cc t bo h vng ni m, do ngi ta xp vo loi tan mu trong t bo
loi thiu mu ny c th gp trong cc bnh:
Bnh huyt cu t pht sinh do ri lon tng hp huyt cu t, cc b bin d to thnh cc
huyt cu t bnh l{ F,S lm thay i cu trc v hnh th hng cu, hng cu chuyn thnh
cc dng hnh bia, hnh lim nn d v, kt dnh vi nhau gy thiu mu tan mu c tnh
cht di truyn, gia nh.
Bnh vng da tan mu do hng cu hinh trn ( spherocyte ) do thiu men enolaza l men
chuyn lysophotphattidyl- ethalonamin do kh nng dung gii ng ca hng cu lm hng
cu d b hy.
Bnh vng da tan mu bm sinh do hng cu b thiu men pyruvatkinaza hoc men diaphoraza.
Bnh thiu mu tan mu do dng mt s thuc ( premaquine, sulfamid, acetalinit, l u fve
) do hng cu thiu men G.6.P.D. ( gluco- 6 photphat dehydrogenaza).
Trong cc bnh ny sc bn ca hng cu vi cc nng dung dch NaCl nhc trng gim,
i sng hng cu ngn li ch cn 40- 80 ngy hay t hn na.
2. Tan mu nguyn nhn do yu t t chc:
Do cng hot h thng li ni m ch yu l cng lch thng gp trong bnh thiu mu
tan mu c km gim tiu cu, hoc trong cc hi chng gan- lch to. Nguyn nhn c th do
tng chc phn thc bo ca lch i vi hng cu, v tng tc dng c ch ca lch i vi ty
xng. C tc gi cho rng khi cng lch c hin tng xung huyt ng hng cu do
hng cu km bn vng v d v. C th do t chc lch tit ra cc men tiu hy ( lysin
lysolecithin... ) hoc sn sinh cc ngng kt t khng y c nh vo b mt hng cu lm
o ln cn bng l ha ca hng cu lm hng cu d v do nh hng ca tn thng c gii
cng nh ca cc tn cng bnh l khc.
Loi thiu mu do hai nguyn nhn trn c xp chung vo loi thiu mu tan mu trong t
bo v hng cu b hy v thc bo trong cc t chc vng ni m.
3. Tan mu nguyn nhn do yu t dch th:
Cn gi l thiu mu do tan mu mc phi, chim mt v tr ch yu trong bnh l thiu mu
Vit Nam. Nguyn nhn v bnh sinh loi thiu mu ny rt phc tp, thng do cc yu t bn
ngoi hoc yu t min dch tc ng trc tip trn hng cu lm cho hng cu b tiu hy ngay
trong huyt qun, thng l cc huyt qun thn nn du hiu lm sng ph bin ca loi thiu
mu ny l c huyt cu t niu.
a) Cc tai nn truyn mu thng hay gp :
Truyn nhm nhm ABO: trong mu c sn cc khng th t nhin khng A, khng B, cng nh
c sn cc khng nguyn A, B... nn tan mu c th xy ra ngay tc khc hoc do khng th
mu truyn vo hy hng cu ca ngi bnh, hoc do khng th ca ngi nhn hy hng cu
ca ngi cho mu a vo. Nhm mu O nguy him l do c tng cng khng A min
dch rt mnh nn c th lm tan v hng cu A ca ngi nhn, gy tai nn truyn mu
nghim trng lm sng.
Truyn khc nhm Rh: V nhm mu RH(-) Vit Nam rt him nn tai nn ny t gp hn v
khng th khng Rh ch xut hin sau mt qu trnh min dch ngha l sau khi mu Rh (+)
tip xc vi mu Rh (-) gy kch thch h min dch th khng th khng Rh mi xut hin vi
hiu gi tng dn. Do tai nn ny ch xy ra cc bnh nhn c truyn my nhiu ln, hay
ph n sinh nhiu ln. Thng gp nht l khc nhm Rh gia m v con, gy vng da tan
mu tr s sinh do yu t Rh. Ngi m c nhm mu Rh (-) b min dch bi mu con mang
Rh (+) ca ngi b truyn cho, mu m s xut hin cc khng th khng Rh, c th gy hy
hng cu a tr khi sinh ra, hc khi xy thai, thai cht lu trong nhng thng cui, ch yu
nhng a con sau. Vit Nam v t l ngi c nhm mu Rh (-) rt t nn tai nn ny rt
him gp, Chu Phi, Chu u t l ngi mu Rh ( -) ti gn 15% nn c chng 6 a tr b
bnh trn 10 000 dn ( Bevan 1961).
Min dch hy hng cu cn c th gp khi ngi m c nhm mu O v cc con thuc nhm
mu A hoc B (5-6/1000).
Ngoi ra cn phi k cc tai nn hy huyt do truyn mu nhiu ln, do cc khng nguyn hng
cu khc: h Lewis, h Kell, h Duffy
b) Cc bnh thiu mu tan mu t nhim: do cc qu trnh bnh l thng thng ( nhim khn,
nhim c, bng) gy hy hoi v bin cht hng cu. Cc hng cu b bin cht ny c th
tr thnh khng nguyn kch thch h min dch ca c th to ra cc t khng th khng hng
cu, c th gy hy hng cu ca chnh bn thn mnh, bnh l{ ny i khi cng gy nhiu bin
c cho bnh nhn v ngy cng gp nhiu lm sng. Cc t khng th khng hng cu c
chia thnh nhiu loi:
- Cc khng th gy ngng kt hng cu hay ngng kt t (agglutinin ) hot ng nhit
4
o
C, 22
o
C, v 37
o
C, pht hin nh nghim php Coombs trc tip v gin tip
- Cc khng th gy tan mu hay tiu huyt t ( hemolysin), c th phi hp hoc khng phi
hp vi ngng kt t, hot ng cc mi trng nng 37
o
C, lnh 4
o
C, hoc axt v hot ng
c nh c b th. Cho nn theo ri s tng v gim b th trong mu c th gp phn xc
nh nguyn nhn ca tan mu.
Cc khng th ny tc dng trn khng nguyn hng cu, lm hng cu b ngng kt v tan v
trong huyt qun v chn b cho h vng ni m thc bo hng cu d dng.
c) Cc hin tng tan mu do cc yu t bn ngoi tc ng trc tip trn hng
cu:
- Nhim c cc cht ha hc trong k ngh nh phenyl hydrazinanilin, ch, benzon, phenol,
hoc n phi nm c.
- Nhim k sinh khn: st rt gy tan mu trong chu trnh plasmodium sinh sn trong hng cu
- Nhim khn, cc vi khn lin cu hy huyt B, t cu vng, vi khn ym kh, vi khn gram (-), vi
khn lm m,trong cc bnh cm, st hch, vim no
- Cc cht c trong cc qu trnh bnh l c tnh: bnh Ho gkin, bnh bch cu, bnh ung th
cc loi
Cc bnh l{ ny gy tan mu theo hai c ch:
- Tc ng trc tip ln hng cu b tn thng hoc oxy ha hemoglo-bin thnh
methemoglobin, sulfhemoglobin nn hng cu d v, mt khc cn gy nhim c ty xng
nh hng n s sn xut hng cu.
- thng qua c ch min dch, kch thch c th to ra cc t khng th khng hng cu.
c im ca thiu mu tan mu:
1. Thiu mu c tnh cht ng sc nu tan mu va phi, chuyn thnh nhc sc khi tan mu
nghim trng. S lng hng cu gim nhanh, d di ngay trong giai on u.
2. Cht lng hng cu thay i r ri: hng cu a dng, mo m khng u, c hin tng
a c, nhiu tiu hng cu v vi hng cu, do mng hng cu b tn thng, hng cu b bin
cht thoi ha. C nhiu dng hng cu bt thng do chuyn ha vi vng khi hng cu b hy
qu mc( nguyn hng cu, th Joli, vng Cabo, ht i kim). c bit trong tan mu trong t
bo th sc bn hng cu v i sng hng cu u gim.
3. Thiu mu c hi phc, hng cu li tng rt mnh 10- 20- 30 % v hn na. Tc v tnh
trng hi phc ph thuc vo mc tan mu v tnh cht ca nguyn nhn gy tan mu. Nu
c tnh trng nhim c ty xng th phn ng tng sinh yu t v hi phc chm, kh khn
hn.
4. C cc du hiu ca tan mu : tng hemoglobin t do, tng bilirurbin t do trong mu, tng
sc huyt thnh tng sc t mt trong phn v nc tiu.
5. Din bn ca thiu mu ph thuc vo nguyn nhn: tan mu trong huyt qun th din bin
thng rm r, cp tnh, cc du hiu tan mu biu hin r rt, c huyt cu t niu v gan lch
to, mm, au. Tan mu trong t bo th phn ng lng l hn, din bin mn tnh, ko di v ch
c hut sc t niu khi kch pht, cc biu hin tan mu kn o, gan lch to, rn chc v khng
au.

C- THIU MU DO RI LON CHC NNG TO HNG CU
Chc nng to hng cu ca ty xng c th b ri lon do thiu nguyn liu to hng cu (
protit, st, sinh t B12, axitfolic ) hoc do ty xng b c ch do cc nguyn nhn bnh l
khc nhau.
1. Thiu mu do thiu nguyn liu to hng cu :
Thiu mu do thiu protit hay thiu dinh dng:
Nguyn nhn ca thiu protit thng do cung cp khng y : i, thiu n, nht l
nhng c th ang pht trin nh tr ang ln, ph n c thai hoc do hon cnh chin
trng tip t vn chuyn lng thc kho khn, lc rng, lc bin, t y lu ngy.
Trong bnh l thiu protit go trong cc trng hp : bnh nhn n khng c hp th km (
bnh d dy, rut) tng hp cht protit gim, ri lon ( bnh gan, ri lon chuyn ho ), tnng
cng thoi bin protit, mt protit ( st, nhim khun, bng, bnh thn v cc bnh khc.
c im ca loi thiu mu ny l:
Thiu mu nhc sc, s lng hng cu v huyt sc t gim ph thuc vo mc ca thiu
mu, thiu protit. Da v nim mc nht nht, bnh nhn c th teo c, mt mi v ph n nh.
Ty ti sinh nhanh v mnh khi thiu mu va phi.
Prott mu ton phn gim, albumin gim ganma, globulin tng, cc t bo bch cu v tiu cu
ngoi vi u gim khi thiu protit nghim trng, ko di, c th dn ti suy ty.
Cung cp y nguyn liu, bi dng n ung hp l, dung cc rhuc kch thch to mu kp
thi, c th gii quyt tt.
Thiu mu do thiu St :
St l nguyn liu tng hp huyt cu t cn thit cho s trng thnh hng cu. Qu trnh
chuyn ha st c th tm tt theo s sau :
St hu c, v c t thc n ti d dy, nh HCl in t ha thnh st c ha tr: Fe
3+
, Fe
2+
sau
c hp th qua mng rut vo mu. mu, mun vn chuyn c st phi c kt
hp vi 1 glubulin bta, vn chuyn st l transferrin( hay siderophill ) a ti d tr ti gan
di dng Ferritin v c s dng theo yu cu c th.
Thiu st c th do nhiu nguyn nhn:
- Mt mu, chy mu ra ngoi c th.
- Cung cp thiu m nhu cu cao: tr n sa b, c th pht trin, ph n c kinh nguyt, c
thai, cho con b
- Ri lon hp th st: bnh l d dy rut, ct on d dy.
- Ri lon chuyn ha st: thiu nng bung trng, thiu nng tu{n gip, bnh l{ gan
c im thiu mu thiu st:
- Thiu mu c tnh cht nhc sc, s lng hng cu, huyt cu t gim r rt, ch s nhim
sc gim, c nhiu hng cu nh v hng cu hnh nhn. Trong ty xng t l Nguyn hng
cu kim tng, t l Nguyn hng cu a sc v Nguyn hng cu gim hn.
- St huyt thanh gim hn.
- Thiu mu c ti sinh nhng tc v tnh trng ti sinh ph thuc vo s cung cp nguyn
liu v trng thi ton thn ca bnh nhn.
-Thiu mu do thiu sinh t B12 v axit folic:
- Axit folic c chuyn thnh axit folililic cn thit cho s hnh thnh cc nhn purin v
pyrimidin l nhng cht c bn cu to axit nhn
- Sinh t B12 c tc dng trong khu kt hp cc nhn purin hoc py- rimdin vi riboza hoc
desoxyriboza v axit photphoric to thnh AND v ARN.
S hp t B12 li cn c cht nhy ca d dy( gastromuco- protin = GMP ) bo v B12
trnh b hy hoi bi cc men tiu ho. Sinh t B12 t thc n, ( trc kia gi l yu t ngoi )
vo d dy kt hp vi GMP ( trc gi l yu t ni) to thnh phc hp sinh t B
12
( cn gi l
yu t chng thiu mu ), c d tr gan, c tc dng kch thch ty xng to hng cu v
trng thnh theo nhu cu ca c th.
Thiu mu do thiu sinh t B
12
c th nguyn phat hoc th pht, thng gp l thiu mu do
thiu B
12
th pht.
a) Bnh thiu mu do B12 nguyn pht, cn gi l thiu mu ac tnh Bic- men ( bnh Addison-
Biermer ). Nguyn nhn do thiu cht GMP d dt nn khng hp thu c sinh t B12. S
dng phng php khng th huznh quang c th pht hin c cc khng th khng d dy
hay khng th khng muco- protein, nn bnh ny c gii thch bng c ch t min dch,
nguyn nhn chnh cn cha sng t.
c im loi thiu mu ny:
Thiu mu c tnh cht u sc, ch s nhim sc tng trn 1,2. S lng hng cu gim rt thp
thng di 2 triu /1mm
3
, c th di 1 triu /1mm
3
, huyt cu t gim di 50% so vi mc
bnh thng.
Tong mu ngoi vi, nhng bin i v cht ca hng cu biu hin r rt, km theo c nhng
bin i v cht v gim s lng bch cu v tiu cu. c bit, xt hin trong mu nhng
hng cu khng l megalo (mgaloblas, megalocyt).
Thiu mu c tnh cht c tnh, khng hi phc do s sn xut hng cu bnh thng b c ch,
ng thi pht trin dng hng cu bnh l mgalo. S lng hng cu li gim rt thp hoc
khng xut hin.
C cc ri lon thn kinh nh gim tr nh, cung sng, ri lon phn x, lit hai chi di do tn
thng ty hoc vim nhiu dy thn kinh, nht l cc dy s no.
iu tr c hiu bng sinh t B12 liu cao, bnh c th chuyn bin tt, ngc li ko di
hoc iu tr khng hp l c th chuyn nghim trng dn ti t vong.
b) Bnh thiu mu do thiu B12 th pht, nguyn nhn thng do cung cp khng y ( tr
nui bng sa bt, thiu dng ) ri lon hp thu ( thiu GMP, trong cc bnh vim toe nim
mc d dy ), giang mai, ng th d dy, ct on d dy, ri lon hp thu rut do sn, vim
rut mn, ct mt on rut ln ) nhu cu B12 cao ( cha nhiu ln, nhim c, nhim
khun mn ) hoc trong bnh phng x
Thiu B12 th pht thng kt hp vi thiu protit v thiu st nn tnh cht thng l thiu
mu nhc sc vi nhng c im tung t nh thiu mu do thiu protit v thiu st. Thiu
mu c th hi phc tt nu kp thi iu tr bng sinh t B12 kt hp vi cung cp st v
protit, bi dng hp l cho bnh nhn.
2. Thiu mu do ty xng b c ch:
Ty xng c th b c ch tm thi hoc lu di gy trng hp nhc ty hoc suy ty, do
nhiu nguyn nhn phc tp:
Do nhim khun nng, cc c t vi sinh vt c c lc mnh tc ng ln ty xng, thng
ch c ch tm thi. C th do tc dng ca k sinh khun ( nhoc, suy ty sau st rt ).
Do nhim c cc ha cht nh ch, phenyl hydrazin, hoc cc cht c trong qa trnh bnh l
( x gan, vim thn mn ) do nhim x nng : dng quang tuyn X liu cao, bnh phng x cp
v mn tnh.
Do lon sn ty hoc ty xng b c ch, chn p trong mt s bnh c tnh: bnh bch cu,
ung th cc loi, x ha ty xng.
Do ni tit: cng lch do thiu mu km gim tiu cu; thiu Erythropoietin trong vim thn
mn; thiu bng tuyn gip, tuyn sinh dc, tuyn yn
c im ca loi thiu mu ny l: thiu mu nhc sc nng, c th u sc ( cn c tnh ),
nhiu bin i v cht lng hng cu v ti sinh chm c th khng hi phc. Do chc nng
ca ty xng b c ch nn c gim sn xut c ba dng t bo mu hng cu, bch cu v tiu
cu dn ti trng thi nhc hoc suy ty.
Phn loi trn ta thy r gi tr, v tr ca tng loi thiu mu ring bit, nhng trong thc t
thiu mu cn do nhiu nguyn nhn phc tp kt hp vi nhau, ngi thy thuc phi bit
phn tch tnh trng mu ngoi vi, chc nng ty xng, ri cng vi cc du hiu lm sng khc
xc nh c yu t bnh sinh ch yu th iu tr mi c kt qu tt. V d : thiu mu trong
bnh gan, nguyn nhn do bnh nhn c ri lon tiu ha, chn n, kh nng hp thu km;
chc nng tng hp protit gim; d tr st v sinh t B
12
gim ( thiu nguyn liu ) ng thi c
c ri lon ng mu gy hi chng chy mu do chc nng tng hp prothrombin v cc yu
t ng mu khc b ri lon ( mt mu ), chc nng gii c ca gan gim, cc cht c c th
tc ng ti ty xng ( ri lon chc nng to hng cu ). Thiu mu trong bnh thn cng do
nhiu nguyn nhn phi hp: mt protein qua nc tiu ( thiu nguyn liu ); chy mu
ng tit niu ( mt mu ); gim Erythropoietin v c nhim c ty xng do cc cht c
khng c bi tit ra ngoi ( ri lon chc nng to hng cu ).
C CH THCH NGHI B P KHI THIU MU
Khi thiu mu do gim s lng hng cu v huyt cu t c th lm vo tnh trng thiu Oxy,
s kch thch cc c ch thch ng ca c th b p li.
A- PHN NG TNG TO HNG CU
Phn ng tng to hng cu ca ty xng xut hin nhanh v nhy nht trong tt c cc
trng hp thiu mu thng thng. C ch bnh sinh l do tnh trng thiu Oxy hoc cc sn
phm hy hoi hng cu c tc dng kch thch ty xng tng hot ng. Mt khc, thiu Oxy
cn kch thch cc t bo gn cu thn sn sinh ra cht kch hng cu t ( Erythropoietin ) c tc
dng lm tng chc nng to v trng thnh hng cu ca ty xng.
Phn ng trn nhm to mt cn bng mi duy tr s sng khi no ty xng b tn thng,
c ch mnh th phn ng ny mi khng thc hin c.
B- CC PHN NG B P KHC
1. Tng tun hon: tim p nhanh v mnh, lng mu qua tim cng tng. Phn x ny pht
sinh do tnh trng thiu Oxy mu kch thch cc th cm huyt qun v do mu t hng cu,
gim nht nn lu lng mu qua tim cng tng cng.
2. Tng h hp: th nhanh v su do phn p oxy mu gim CO
2
mu tng kch thch phn x v
trc tip h hp.
Thiu oxy cn nh hng n chuyn ha t chc gy nhim toan lm cho nhp th cng
nhanh.
3. Tng tn dng oxy: khi thiu mu, ch s s dng oxy t chc c tnh theo cng thc:
= 0,3

( Ka l oxy trong mu ng mch, Kv l oxy trong mu tnh mch )
Nh vy, khi ch s ny tng, c th ti 0,85 kh thiu mu, nng oxy trong mu tnh mch s
gim, mu tnh mch thnh mu tm sm. Mt khc v bnh thng ch s s dng oxy cc c
quan quan trng nh no, tim, c rt cao ( 0,6- 0,67 ) nn khi thiu mu cc t chc ny b
e da trc tin v cc triu chng thiu oxy cng xut hin rt sm : chng mt, hoa mt,
chong vng khi ng ln ngi xung, nh trng ngc, au vng trc tim, mt mi, au nhc
c v chut rt l nhng triu chng ph bin ngi thiu mu.
Ni chung, trong thu mu phn ng b p c hiu nht v hiu lc nht l phn ng ty
xng. Trong theo di v iu tr thiu mu phi c bit ch { n phn ng ty xng, tn
trng bo v v tng cng mt cch hp l. Nu phn ng ny yu t tr thnh v hiu lc th
thiu mu s din bn nghim trng gy nhiu hu qu nguy him cho i sng.
THAY I BNH L CA BCH CU
I. I CNG V CC DNG BCH CU
Bch cu c nhim v chung l bo v c th i vi cc nhn t bnh l khc nhau, ch yu l
nhn t nhim khun. Trong c th c nhiu loi bch cu ( bch cu ht hay bch cu ty, bch
cu lympho, bch cu mono), mi loi u c th pht sinh nhng bin i bnh l{ tng sinh
hoc nhc sinh t chc vi nhng thay i v s lng v cht lng t bo.
A- DNG BCH CU HT HAY BCH CU TY
Sn sinh ty xng , cng vi dng hng cu v dng tiu cu qua cc giai on:
Nguyn ty bo ( myloblast )
Tin ty bo ( promylocyt )
Ty bo N, E, B (mylocyt N, E, B )
Hu ty bo N, E, B ( metamylocyt N, E, B )
Bch cu a N, E, B ( Stab N, E, B )
Bch cu nhn tht khc ( a nhn ) N, E, B )
T nguyn ty bo dn hu ty bo l cc t bo non ch trong ty xng. Giai on ty bo,
bo tng bt u xut hin cc ht c hiu N ( trung tnh ), kim tnh ( B ) v toan tnh ( E ).
Bch cu a l t bo gn trng thnh, xut hin mu ngoi vi l ch tiu ca s tng sinh
dng bch cu ty ( cng nh hng cu li l ch tiu theo di s tng sinh dng hng cu )
1. Bch cu ty trung tnh (N)
Cc ht c hiu trong bo tng l ht trung tnh nh nh ht bi, l cc tiu thc bo n
cc di vt nh nh vi khun, v l t bo xut hin v pht huy tc dng ngay trong giai on
u tin ca bnh nhim khun. Bch cu N c h men rt phong ph ( leucoproteaza, catalaza,
peroxydaza, photphattaza kim) v cc axit amin ( histidin, arginin, tryptophan) nn cn
tham gia vo thnh phn dch di vim, trng cho t chc b hy hoi v tham gia vo cc qu
trnh lm lnh cc tn thng t chc. Cc loi sinh t B rt cn cho to bch cu ty. Trong
gim bch cu N do thiu dng, iu tr bng sinh t B6 v axit foltc c tc dng tt.
2. Bch cu toan tnh (E)
Cc ht trong bo tng to, trn, dy c, bt mu da cam, hay mu nu gch. Bch cu toan
tnh (a axit) E c chc phn gii c sn sinh trong qu trnh bnh lmin dch (d ng)
3. Bch cu kim tnh (B)
Cc ht c hiu thng to nh khng u, nm che c nhn t bo, mu tm sm. Chc
phn ca loi bch cu ny cha c xc nh r rng. Theo mt s tc gi, bch cu B c
cha histamin v heparin. mu ngi bnh thng, hu nh khng c bch cu B (0- 0,5%) v
ch xut hin trong mt s bnh l nng hoc bnh c tnh.
Dng bch cu ty ni chung i sng ngn, ch t 8-10 ngy cho nn c sn xut trong ty
xng nhiu hn dng hng cu 2-3 ln (t l BC\HC ty xng bng 2-3)
B- DNG BCH CU LYMPHO
Cn gi l bch cu n nhn nh, c sn sinh t tuyn c khi cn bo thai v khi ra i ch
yu lch v cc hch bch huyt, qua cc giai on :
Nguyn lympho bo ( Lymphoblast )
Tin lympho bo ( Prolymphocyt )
Cc lympho ln v nh.
Bch cu lympho c mt vai tr quan trng trong cc phn ng min dch, c th tr thnh cc
lympho mn cm hay lympho cm th tiu dit cc khng nguyn l ( min dch t bo
), hoc chuyn dng thnh cc t bo tr ( lympho- plasmocytaire ) c kh nng sn sinh
gamma- globulin v khng th ( min dch dch th ).
Bch cu lympho c t men, thng thy xung quanh cc vim, nhim khun, bao quanh cc
tn thng cn st li. Trong nhim khun cp giai on u bch cu trung tnh tng v khi
bnh c nhng din bin tt mi thy tng bch cu lympho. S lng bch cu lympho
trong mu ngoi vi cao ngang vi t l % bch cu trung tnh tr em t 1- 12 tui ( 43- 45% ),
t trn 12 tui tng t nh ngi trng thnh ( 20- 30% ). i sng ca bch cu lympho di
hay ngn ty theo loi, c loi i sng rt ngn ch vi ngy nhng c loi i sng di 100-
200 ngy, c bit lympho c tr nh min dch c th tn ti nhiu nm.
C- BCH CU MONO ( M ) HAY N NHN TO
c sn sinh t h lin vng, chia thnh nhiu loi:
Bch cu mono mu sn sinh t t chc vng ni m ty xng. Bch cu mono c sn sinh
t t chc lin vng hch v lch, thng tng trong cc bnh l v hch- bnh tng mono
nhim khun, loi ny kh nng thc bo yu.
Bch cu mono sn sinh l t chc lin vng khc nhau, xut hin trong cc bnh l vim nhim
khun, c kh nng thc bo mnh nht.
Chc nng ca bch cu mono l i thc bo, n cc vt ln nh cht m l, cc t bo cht,
cc mnh t chc b phn hy v c kh nng chuyn ng kiu amip, ngoi ra cn c kh nng
truyn thng tin min dch cho bch cu lympho tip xc vi khng nguyn l. i sng ca
bch cu mono l 8- 10 ngy.
II. NHNG THAY I V S LNG BCH CU
A. THAY I S LNG CHUNG BCH CU
S lng chung ca bch cu gii hn t 5.000-9.000/mm
3
. Trong trng hp bnh l, bch
cu c th thay i theo hai hng:
1. Bch cu tng khi s lng tng trn 9000/mm
3
, l phn ng tch cc ca c th i vi nhn
t gy bnh, ch yu l nhn t nhim khn. Bch cu tng cao trn 25000/mm
3
thng thy
xut hin cc bch cu non nn c gi l phn ng dng bnh bch cu, gp trong cc trng
hp nhim khun nng. Tng cao hn na thng l bnh ca c quan to mu (bnh bch
cu).
2, Bch cu gim khi s lng gim di 4000/mm
3
, l hin tng xu do bch cu b hy
nhiu hoc ty xng b c ch gim hoc khng sn xut c bch cu, do sc khng
vi bnh tt gim.
3. Nhng nhn t nh hng n s lng bch cu:
a)Cc thay i sinh l ca c th:
- Tr s sinh s lng BC 18000- 20000/mm
3
ko di hng tun.
- Lao ng, tiu ha, cm xccng gy tng bch cu ngoi vi do tc ng ch yu trn khu
vc d tr bch cu nm trong cc xong tnh mch ca ty xng.
b) Vim, nhim khun: l nguyn nhn hng u gy thay i s lng : cc vi khun gram kch
thch gy tng bch cu ht, cc khun gram (-) li thng gy gim bch cu. Virut nh hng
ti h vng ni m nn lm tng bch cu Mono. c t vi khun thng hn thng gy gim
bch cu ht.
c) Nhim c: nhiu cht c l, ha, sinh vt khc nhau, c tc dng vi s lng bch cu: tia
phng x liu nh kch thch, mt s cht nh: Asen, benzen, pyramidon, sulfamid, chlorocitc
th lm gim bch cu v c ch ty xng. Bch cu c th hy di nh hng ca khng th
khng bch cu c to thnh khi truyn mu nhiu ln, hoc khi b d ng vi thuc, ha
cht.
d) Thn kinh, ni tit:
- Chn thng s no hoc c tn thng vng di th thng c tng bch cu r rt.
Metanhicop cn c th gy c tng bch cu bng phng php phn x c iu kin.
- Gn y ngi ta cn pht hin cht ha hc to bch cu leucopotein tng trong mu ngi
v ng vt b nhim khun, vim c tng phn hy bch cu. Bn cht v { ngha ca cht ny
cn ang c nghin cu.
B- THAY I S LNG TNG LOI BCH CU
Nhng bin i tng loi bch cu ( tng hoc gim s lng ) thng c { ngha nht nh
trong chun on, theo di v iu tr bnh. Thng theo di s lng % tng loi bch cu,
cng thc bch cu v chnh xc hn, phi quan st s lng tuyt i hay s lng tng
loi bch cu trong 1mm
3
mu.
1. Bch cu trung tnh N :
Tng trong tt c cc trng hp nhim khun cp, c vim m; c th gp 5- 10 ln so vi
bnh thng. C th tng c trong chn thng s no, nhi mu tm c, mt mu cp do tnh
trng kch thch ty xng to bch cu ht nn t l S tng nhng N ch mc bnh thng
hoc gim do bch cu N b hy qu mc hoc sn xut bch cu b ri lon.
Gim N c th gp khi dng mt s thuc ( sulfamit, atophan, pyramidon, chloroxit ) C th
gp trong mt s bnh c c ch trng thnh bch cu ht ( thng hn, si, cm ), trong suy
dinh dng, trong cc phn ng t min dch lm suy yu sc khng ca c th v d pht
sinh cc qu trnh nhim khun nng v vim hng, lot hoi t ( angina agranulocytica ). Gim
bch cu t ngt trong giai on din bin nng ca nhim c, nhim khun do ty xng b
c ch. Gim bch cu N v c bch cu Lympho trong bnh phng x cp.
2. Bch cu toan tnh E :
Tng E gp trong cc bnh nhim k{ sinh trng giun sn ng rut, t l thng trn 10%.
Trong bnh giun mc, u trng ecchinococcus gan, giun a giai on pht trin u trng, bch
cu E c th tng ti 30% v hn na. Bch cu E cn tng trong cc trng hp d ng ( hen
ph qun, st ma ) v cc phn ng d ng nhim khun do E c kh nng hp th hittamin
v cc cht tng ng gii phng trong cc giai on din bin ca bnh. Tng E cn l c
im ca bnh bch cu ty mn.
Gim E thy trong cc giai on u ca nhim khun cp cng nh trong giai on u ca
bt kz mt strees no c th do E ti ti ch tn thng lm nhim v gii c hoc do tang
hot ni tit tuyn thng thn, tng tit corticoit c tc dng c ch E ( nguyn l ca xt
ngim Thorn thm d chc nng tuyn thng thn ). Cho nn trong bnh l nhim khun,
khi E tr li mc bnh thng l du hiu tt.
3. Bch cu Lympho :
Tng tuyt i trong mt s bnh tr em : ho g, si, cm, st hch thng hn, trong mt
s bnh nhim khun mn nh hng ti h thng hch, lch ( st rt, lao, giang mai ) trong
bnh Basedow trong cc trng hp nhim khun cp, Lympho thng tng trong giai on
mun do tng, kch hot h thng min dch ca c th. ngi trng thnh, bch cu
Lympho c th tng ti trn 35%.
Gim Lympho c th tng i trong giai on u ca nhim khun cp v gim tuyt i khi
c tn thng h thng to Lympho ( bnh Lympho ht c tnh, Lympho sac- cm )
4. Bch cu Mono:
Tng bch cu Mono trn 8% gp trong mt s bnh nhim khun v virt cp ( thy u, si,
rubole, vim hng, st ban do rickettsia) tng ko di trong cc bnh vim mng trong tim,
st rt, tng Mono nhim trng, bnh do Leishmania l du hiu kch thch ng k h vng
ni m. Tng Mono trong giai on cui ca nhim khun lm nhim v thc bo v tham
gia vo phn ng tng sinh t chc lin kt lm lnh cc tn thng vim ( chuyn thnh t bo
s non )
Gim bch cu Mono trong cc bnh nhim khun, nhim c nng v nhim khun m lu
di, nhim khun huyt l du hiu h vng ni m b c ch, sc khng ca c th suy yu.
III. THAY I CHT LNG BCH CU
Cht lung bch cu thng b bin i trong cc trng hp nhim khun, nhim c nng v
trong cc bnh l c tnh.
A- CC DNG THOI HA CA BCH CU
Ht c xut hin trong bo tng ca t bo, l cc ht bt mu tm sm to nh khng u
do ng c cht m ca bo tng di nh hng ca c t vi khun, cht c, tia x
Khng bo hay cc l trng bo tng l du hiu thoi ha m, khi c nh tiu bn bng
cn, cht m b ha tan nn nhum khng bt mu nn li l hng. C th gp trong nhim
khun nng, vim p- xe m, bnh phng x
Ngoi ra cn gp mt s du hiu khc: t bo to nh khng bnh thng, nhn b ng
c(pycnose), nhn tan, v hoc phng ln mt nhim sc
B- BIN I CH S NHN CA BCH CU ( hnh 3 )
Ch s nhn l ch s tng quan gia bch cu tr v bch cu trng thnh trong mu ngoi vi
c th hin bng cng thc ca Schilling hay ch s nhn ca bch cu:
CSN = Ty Bo Hu ty boStab = 0,03- 0,08
BCN
Trong bnh l, ch s nhn c th b bin i theo hai hng :
1. Chuyn tri CSN : l tng ch s nhn trn 0,08, l biu hin tng sinh cc t bo bch cu tr,
do ty xng b kch thch tng hot ng p ng nhu cu c th. Tuz mc c th phn
bit .
Chuyn tri va phi, khi ch s nhn tng 0,08- 0,25 do cc t bo tr c tng sinh va phi,
thng ch tng Stab, mc nhim khun khng nng lm v chc nng ty xng hot ng
tt.
Chuyn tri mnh, khi CSN 0,25- 0,5 do cc t bo tr tng nhiu, mu ngoi vi xut hin nhiu
Stab, c th gp c hu ty bo, i khi c ty bo, thng l bnh nhim khun nng, chc
nng ty xng b ri lon, kh nng bit ha t bo gim st, sc khng c th cng
gim ( phn ng dng bnh bch cu )
Chuyn tri qu mnh, CSN trn 0,5- 1 hoc hn na, thng l bnh ca c quan to mu,
kh nng bt ha ca ty xng b ri lon.
2. Chuyn phi CSN :
Khi CSN gim ti di 0,02, rt t hoc khng c bch cu tr Stab l biu hin ty xng b c
ch, thng km theo gim s lng bch cu v ni chung tin lng xu. Cn c th xc nh
chuyn phi bng tnh cng thc Arneth : m ring 100 bch cu trung tnh tnh t l % cc
bch cu phn nhnh, bnh thng cc t bo mt nhnh ( Stab ) chim 2-5%, hai nhnh 35%,
ba nhnh 41%, bn nhnh 17%, nm nhnh 2%.
Chuyn phi biu hin gim t l cc t bo t nhnh v tng cc t bo nhiu nhnh, c th
xut hin cc t bo tng phn nhnh ti trn 10 nhnh, nh trong mt s bnh nhim c
nng, bnh phng x.
Ni chung, theo di ch s nhn bch cu c s dng trong lm sng, ch yu trong lm sng
ngoi khoa v trong nghin cu khoa hc nh gi tnh trng chc nng to bch cu ca ty
xng.
IV. BNH BCH CU ( LEUCOSE )
Bnh bch cu l mt bnh c tnh ca c quan to mu, l mt bnh rt him ngho, t l t
vong rt cao v t l mc bnh ngy cng nhiu. Theo thng k ca OMS, nm 1960 t l mc
bnh bch cu l 5,8 trn 10 vn dn trn ton th gii, chim 10% ca tng s t vong do cc
bnh c tnh, cao nht tui di 30. Vit Nam cha c thng k chnh xc nhng nhng
nm gn y do nh hng ca chin tranh ( v kh hin i, thuc c loi tr su dit c ca
ch ) t l mc bnh bch cu cng cao hn so vi nhng nm trc y.
A- QUY LUT DIN BIN V C IM CA BNH BC
Trong bnh bch cu cc t bo nu khng pht trin theo quy lut bnh thng m c nhng
c im ring sau:
1. Tng sn qu mc hay qu sn :
Tng sn qu mc mt dng t bo, t chc to bch cu c biu hin ph i, tng sinh lan
trn ( tng sinh qu mc dng bch cu ht th ty v ty vng u trn ngp cc t bo )
ng thi c hin tng c ch bit ha nn mu ngoi vi xut hin rt nhiu bch cu non (
bnh thng ch trong ty xng ).
Bp nght, c ch cc dng t bo khc: khi cc t bo bch cu ht tng sinh th to hng cu
b c ch, tng huyt tn nn gy thiu mu nng, dng tiu cu cng b c ch gy gim
tiu cu v hi chng chy mu ( chy mu rng, li, di da, nim mc mi, mt, vng mc,
ni tng... ) Bnh cng c tnh cc biu hin trn cng r rt.
2. D sn, sn xut khng theo quy lut bnh thng m lan trn sang cc t chc ln cn, hoc
sang cc t chc to mu khc m bnh thng khng sn xut ra dng t bo . Nh trong
bnh bch cu ty hay t chc hch, lch cng sn xut cc bch cu ht, xm nhp chn p ct
mc gy au xng, au khp; xm nhp chn p t chc thn kinh gy lit, hi chng chn p
ty sng Trong bnh bch cu Lympho ty xng trn ngp t bo lympho , t chc lympho
cn xm nhp t chc da, nm trong trung b vng mt, mi, m, gy bin dng din mo, xm
nhp nhu m phi, thnh d dy, rut gy cc u cc ri rc, gy xut huyt lot v hoi t
Lon sn, tc l sn xut nhng t bo bnh l{ khng in hnh c v hnh thi v chc nng.
Chc nng thc bo, min dch ca cc t bo gim lm gim sc khng chng ca c
th. Cc t bo thng c du hiu thoi ha, hnh dng bt thng, c khng bo, pht trin
khng ng u gia nhn v nguyn sinh cht. Cc nguyn ty bo khng in hnh c gi
l cn nguyn ty bo ( paramyloblast ) hoc nguyn ty bo nh ( micromyloblast ), c
trng hp kh xc nh l nguyn bo ca dng no nn gi chung l cc nguyn bch cu (
Leucoblast ).
B- NGUYN TC PHN LOI BNH BCH CU ( C TH PHN BIT )
Theo t chc, t bo b bnh : bnh ca t bo dng ty gi l bnh bch cu ty ( mylo-
leucose ); bnh ca t chc t bo lympho bnh bch cu lympho ( lympho- leucose )
Theo s lng bch cu ngoi vi: chia cc th tng bch cu trn 50000/ mm
3
( bnh bch cu
a sinh ), khng tng bch cu c gi l th n, ch pht hin c khi c nhng kch thch
bt thng gy tng s lng v xut hin cc bch cu non mu ngoi vi; th gim bch cu
di 4000/ mm
3
thng l th cp tnh, nghim trng.
Theo hnh thi din bin ca bnh: th cp tnh thng din bin trm trng, cht nhanh trong
vng vi thng, c khi vi tun v trong mu xut hin nhiu nguyn bo do kh nng bit ha
b c ch khng chuyn thnh cc t bo trung gian nn bng mu c khong trng bch cu
. Th mn tnh th din bin c th ko di hn hng nm v trong mu xut hin nhu loi t
bo t nguyn bo, cc t bo trung gian ti cc t bo trng thnh, s lng bch cu
thng tng rt cao song song vi din bin nghim trng ca bnh.
C- BNH SINH CA BNH BCH CU
C nhiu thuyt c xut nhng cng nh bnh sinh ca ung th, cho n nay vn cha
hon ton sng t.
1. Thuyt virt gy bnh bch cu :
Thuyt ny da trn s pht hin cc virt gy bnh bch cu g, chim, chut v mt s ng
vt c sng ( tru, b... ) c th truyn bnh bng cch tim cho ng vt lnh cht lc t chc
khng c t bo ca ng vt b bnh. Cc virt ny thng l cc virt c ARN, c th khng
gy bnh ngay m truyn qua trng hay tinh trng n i sau mi pht bnh, hoc virt xm
nhp vo trong t bo, chuyn thnh t bo ung th ng, cho n khi c mt kch thch bn
ngoi ph hp, bnh mi xut hin. Nhng ngi vic phn lp virt gy bnh cha thc hin
c, dng cht lc khng t bo ca bnh nhn khng gy c bnh bch cu thc nghim
cng nh bnh khng thy xut hin tr b sa m b bnh bch cu.
2. Thuyt tia x:
Rt nhiu nhn xt lm sng v thc nghim xc nhn bnh bch cu c th do tia X, tia x ion
ha gy ra:
Nhng ngi cng tc vi quang tuyn X, t l mc bnh bch cu cao hn so vi ngi bnh
thng. Nghin cu trn 278 bnh nhn bch cu c ti 14 ngi trc chiu tia roentgen
liu cao, v c vi tr khi cn trong bo thai.
Cc nn nhn Nht- bn ( Hiroshima, Nagasaki ), t l mc bnh bch cu rt cao vng bn
knh 1500m xung quanh trung tm n bom nguyn t ( nm 1945 ).
3. Thuyt cht c ha hc:
Ngi ta thy Benzen v mt s cht c ha hc khc xm nhp vo c th c kh nng c ch
bit ha v pht trin tng sinh c tnh cc t bo mu gy bnh bch cu ngi v ng vt.
Cng c th cc cht ny cng nh tia x ch to iu kin kch thch cc virt dng n gy
bnh v pht trin.
4. Thuyt ni sinh chuyn ha :
Thuyt ny da vo cc c s :
T bo mu c tnh c h thng men v chuyn ha khc hn vi t bo mu bnh thng,
khng c kh nng tng hp men asparaginaza cho nn d chuyn thnh t bo tng sinh c
tnh ( iu tr bng men )
Ngay giai on sm ca bnh thy c ri lon chuyn ha tryptophan. Nhng ngi b
bnh di truyn ( hi chng Down, Turner ) c ri lon tng hp, hp th sinh t B, cn thit
cho s chuyn ha trytophan cng d mc bnh ny.
Ni chung, cc nguyn nhn trn c th lm thay i cu trc ARN, AND, gy bin d zen v
cromozm, lm cho cc t bo mu pht trin c tnh v gy bnh bch cu ( cromozm 21 b
gy on 21p v c nhiu t bo tha cromozm ) .
THAY I BNH L CA TIU CU V RI LON
CN BNG NG MU
I. I CNG V DNG TIU CU.
Tiu cu c sn sinh trong ty xng, t t bo m l nguyn mu tiu cu
(Megacaryoblast), qua t bo trung gian. Mu tiu cu (Megacaryocyt), ri cho cc tiu cu.
Tiu cu l nhng t bo nh nht mu ngoi vi, hnh trn hoc hi bu dc, phn ngoi mu
hng, hp ( hyalomre ) phn gia c nhiu ht ( granulomre ) ng knh 1,5- 2 micromet, t
bo non hn mu xanh v t ht, ng knh 3- 5 micromet. S lng trung bnh trong 1 mm
3

ngi bnh thng c t 200.000- 400.000/ mm
3
, sng c t 5- 7 ngy nhng i sng chc
phn ch 2- 4 ngy.
Tiu cu c nhim v bo v c th chng nhim khun, do c tnh d bm vo cc vt l
khng bng phng, tiu cu c kh nng bm vo cc vi khun gy ngng kt hoc a n h
vng ni m tiu dit hoc c th hp thu cc khng th nn trong giai on u cc bnh
nhim khun, Megacaryocyt sinh tiu cu trong ty xng tng v khi nhim khun nng
thng gy gim tiu cu dn n nhng bin chng chy mu nguy him. Nhng chc nng
chnh ca tiu cu l tham gia vo qu trnh ng mu do nhng yu t TC gn b mt t bo
( exo- enzyme ) hoc xut hin ngay t trong lng cc tiu cu ( endo- enzyme ). Cc tc gi a
ra 9 yu t TC nhng ni chung quan nim v cc yu t TC cng c nhiu kin tri ngc
nhau, mt s tc gi cho rng mt s yu t ch l nhng cht c hp th t huyt tng
bm vo b mt tiu cu ch khng phi l nhng yu t thc s ca tiu cu. a s tc gi (
Croizat, Levol, Lejeune) cng nhn tiu cu c nhng hot tnh tham gia vo qu trnh ng
mu:
Tnh bm ( adhsivit ) bm vo b mt m nc c th lm t v c th bm vo ni mc
tn thng, do cht thrombocytozyme .
Tnh kt dnh lm vn tiu cu li vi nhau, t thnh ( metamorphose viskqueuse ). Thrombin
to iu kin thun li v heparin, dicoumarin lm tr ngi cho dnh vn tiu cu.
Tc dng co mch, co cc ng tnh mch v gin cc mao mch do hot cht ca tiu cu l
serotonin .
Tc dng to thromboplastin do cht photpholipit thc nhm cephalin, cn gi l
thrombokinaza tiu cu.
Tc dng co cc mu ng do tc dng c gii hoc men retractozym.
Trong mu d tr c vi iu kin c bo v bng silicon nhng tiu cu tn ti cng
mt mt s chc phn ca n ( gim kh nng kt dnh, gim ATP, gim thrombokinaza tiu cu
) cho nn khi cn tip t tiu cu cn phi truyn mu ti, hoc truyn mu trc tip t ngi
cho sang ngi nhn.
II. QU TRNH NG MU V VAI TR CA TIU CU
C ch ng mu ngy cng phc tp v s yu t tm thy tham gia vo qu trnh ny ngy
cng nhiu ( trn 30 nguyn t ).
A- GIAI ON CM MU HAY GIAI ON THNH MCH
Khi thnh mch b tn thng, ngay tc khc c phn ng thn kinh vn mch ti ch gy co
mch hn ch chy mu, ng thi cc tiu cu bm vo thnh ni mc tn thng to thnh
cc mu trng bt li hoc tiu cu dnh vn tit ra mt s yu t TC khi ng cho qu trnh
ng mu. ( hnh 3 )
GIAI ON HUYT TNG HAY QU TRNH NG MU CHNH THC
Giai on ny phc tp nht, tin hnh trong huyt qun vi s tham gia ca rt nhiu yu t
v qua 3 bc: ( hnh 4 )
1. To thromboplastin hot tnh :
To thrompeplastin t chc t m v photpholipit ca t chc b tn thng, c kch hot
bi cc yu t IV ( Ca
++
), VI ( axlerin), VII ( convectin ), X ( Stuart prower ). To rt nhanh, ch
vi giy- 30 giy. To thromboplastin mu t cephalin tiu cu ( thrombokinaza, yu t TC
3
) v
cc yu t chng chy mu VIII ( antihemophilic factor A), IV ( antihemophilic factor B ),XI
(antihemophilic factor C) XII ( yu t Hageman ). C tc gi gii thch tc dng ca
thromboplastin t chc s to mt lng nh thrombin ch gy dnh vn tiu cu v
chuyn yu t V ( proaxlerin ) thnh VI ( axlerin ). Qu trnh dnh vn tiu cu s gii phng
yu t TC
3
c tc dng lm bin i thromboplastinogen ( yu t VIII ) thnh thromboplastin
hat ng ( yu t III ). Cc yu t IX, XI, XII lm tng tc to thnh v yu t IV, VI, VII, X c
tc dng xc tc to thromboplastin. Giai on to thromboplastin mu ko di 5- 8 pht.
2. To thrombin ( yu t 11 ):
Thromboplastin sau khi hnh thnh s tc ng ln Prothrombin chuyn thnh Thrombin,
cn c s xc tc ca cc yu t IV, VI, VII, X v yu t TC
1
. C tc gi cho rng yu t TC
1
chnh
l proaselrin ca huyt tng m cc tiu cu hp thu vo b mt ca chng. V vai tr ca
yu t IV ( Ca
++
) cng c { kin khc nhau : c tc gi cho rng Ca
++
ch cn thit lc u trong
phn ng to thromboplastin v c th tc dng theo phn ng dy truyn trn b mt tip
xc, mt s tc gi khc li cho rng Ca
++
c l cn thit c trong cc phn ng to thrombin v
to fibrin, v cn c tc dng khng thng xuyn v khng ct ngha c vi thnh mch,
gim Ca
++
c th dn ti tng tnh thm mao mch v lm mao mch d v.
Phn ng to thrombin b c ch bi cc cht khng thrombin c 6 cht khng thrombin m
cht khng thrombin II c to thnh bi heparin. Tc dng heparin li b c ch bi yu t
TC
4
.
3. To Fibrin ( cc mu ):
Sau khi thrombin c to thnh, ngay lp tc ( 2- 5 giy ) c tc dng chuyn fibrinogen ( yu
t I ) thnh fibrin to thnh cu trc cc mu ng. Phn ng ny c thc y bi yu t XIII
( FSF, fibrinstabilizingfactor, yu t lm bn vng fibrin v c th c yu t TC
2
. Nh vy bt
u to fibrin ha tan ( monomere, tan trong ure) sau tin hnh trng hp v to ra fibrin
khng ha tan ( polymere bn vng ). n y l kt thc qu trnh ng mu.
C- GIAI ON TIU FIBRIN ( FIBRINOLYSE )
Khi cc mu ng hnh thnh, huyt thanh trc ht b giam hm trong nhng li fibrin ,
sau cc mu ng co li v gii phng huyt thanh. Quan st knh him vi in t thy
nhng m tiu cu ko nhng si fibrin, do trc kia Fuchs v Ponio cho l tiu cu tc
dng mt cch c hc, nhng ti nay nhiu tc gi thng nht do tc dng ha hc thng qua
mt yu t TC
8
hay men co cc mu retractozyme. Hin tng nytin hnh trong 30 pht
n 3 gi.
Nu cc mu c bo qun 37
0
C trong iu kin v khun, ta thy cc mu b dn i ri
bin mt, l hin tng tiu cc mu ( fibrinolyse ), phn hy men fibrin thnh cc
polypeptit, do tc dng ca men tiu fibrin ( fibrinolysin hay plasmin. Plasmin bnh thng c
sn trong huyt tng, l mt protein thuc loi btaglobulin, phn t lng 140.000, dng
khng hot ng. Plasminogen di tc dng ca cc men tiu m kinaza, mi chuyn thnh
plasmin.
Bnh thng hin tng ny khng xy ra qu mc do tc dng c bng ca cc yu t km
hm la cc khng plmin huyt thanh va c yu t TC
7

III. KHI NIM V CN BNG NG MU
Trong cc iu kin sinh l bnh thng, h ng mu v h khng ng trong trng thi cn
bng ng c iu ho bi cc c ch thn kinh v dch th. ng mu v chy mu (khng
ng )l 2 mt ca mt phn ng phng ngsinh vt bo v c th khi b chy mu lan trn,
to iu kin lm lnh vt thng do ngn chn xm nhp ca cc yu t gy bnh. ngc
li khng ng lm cho mu lun trng thi lng, ho tan c cc cc mu c to thnh
ngn nh s ng mu t pht gy tc mch, huyt khi Hai qu trnh ny khng th thiu
c trong s sng, lun b sung v cn bng vi nhau, cho nn khng th ni n qu trnh
ng mu m khng ni n h khng ng trong c th ton vn, mt tnh trng mu thun
nhng thng nht gia 2 h thng cc cht gy ng mu v cc cht khng ng u c sn
trong c th sinh vt:
-Trong mu c sn nhng cht gy ng mu t yeeus t I n XIII huy tng, cc yu t
TC.. S lnh ln ca thnh mch mu thun vi tnh cht d bm, d dnh vn ca tiu cu cng
l mt yu t chng ng trong mu cng c sn cc cht khng ng nh khng sinh
thrombin, heparin, plasmin,Flasmin ngoi tc dng tiu fibrin cn tiu mt s cht m khc,
v cc yu t ng mu tha. Nhng ngay i vi cc tnh cht ny cng c cht khng li khi
c qu nhiu mc: yu t TC
6
hm tc dng qu mc ca heprin, cc khn plasmin va yu t
TC
7
c ch tc dng qu mc ca plasmin.
C ch iu ho cn bng ong mu cn ang oc tip tc nghin cu nhng nhiu s
kin cho php ngh n vai tr ca h thn kinh: kch thch thn kinh giao cm lm mu d
ng, ngc li kch thch ph giao cm li c ch qu trnh ng mu d ng mu. Khi tha
cht ng mu (tha thrombin ) s tc dng ln c quan cm th huyt qun gy ra tng cc
cht khn ng (heparin, plasmin)theo c ch phn x. Ct t ng phn x , cht khng
ng khng xut hin. Do trong iu nguyn tc c bn l phi n nh cn bng ng mu:
khi b chy mu, ngi ta thng dng nhng cht thc y qu trnh ng mu (Ca
++
, sinh t
K). Nhng phu thut ln lng ngc-tim, ct b i trng , kh, bin chng khi sinh
mu gim ng gy chy mu nghim trongj do s phng thch nhiu men kinaza co tc dng
chuyn plasmino thnh plasmin, nn khi iu tr phi dung cht c ch hot ha plasmin (EC,
hemcapron). Ngc li trong iu tr huyt khi, tng ng th phi dng heparin hoc cc
men tiu m (strptokinaza) tng hot ho plasmin.
IV.RI LON CN BNG NG MU
Trong cc diu kin bnh l khc nhau, cn bng iing mu b ri lon theo 2 hn ch yu :
Tng ng c th dn ti huyt khi tc mch
gim ng hay cc hi chng chy mu
1.sinh l bnh cc hin tng gim ng:
Ni chun, hi chng chy mu pht sinh theo 3 c ch ch yu thiu mt hoc vi yu t ng
mu huyt tng , bnh l tiu cu tha cht khng ng hoc kch hot h tiu fibrin.
a)Cc bnh do thiu mt vi yu t iing mu:
- Bnh hemophili:hay gp nht la hemophili A la bnh di truyn do xut hin khi gum nng
yu t VIII trn 30% so vi mc bnh thng sau nhng chn thng khng ng k, phu
thut nh (nh rng, ct ami-dan.). Cc trng hp ng hp t bnh l{ thng gy chy
mu bt thng, t nhin v d cht do thiu mu nghim trng. Mt s bnh hemophili hm
gp hn:hemophili B do thiu yu t , hemophili C thiu yu t XI, bnh hageman
- bh gim prothrembin mu do suy gan, khng hp thu dc sinh t K bm sinh , i lng ko
di, bnh bch cu
- thiu yu t V,VII do bnh gan , vng da tc m, lon sinh vi khun rut, dng qu mc
dicoumol c ch tng hp cc yu t ny t sinh t K
- thiu hoc khng co fibrinogen bm sinh hoc tn hp khng y gan (th pht).
2.Bnh l tiu cu:
- gim tiu cu triu chng hay th pht (s lng TC di 100000/
mm3
c th gp trong cc
bnh co lch to ( st rt , nhim k sinh trng lihmania ), bnh bch cu, suy tu, thiu mu
khng hi phc...
- gim tiu cu nhuyn pht, bnh Vnh, din bin ko di v nhuyn nhn bnh sinh cn c
im ch sng t, tiu cu co th gim ti 3000mm
3
.
- gim tiu cu min dch do c khng th khng tiu cu, pht hin bng cc bin php ngng
kt khi co mt b th, Boyden hoc ngng kt hng cu th ng(cc hng cu gn thnh cht
tiu cu s ngng kt khi tip sc vi huyt thanh c khng th khng tiu cu ). C th gp khi
truyn mu nhiu ln, bnh ban xut hin tr s sinh(m b bnh, co khng th t sinh)
Trong cc bnh ny c th gim ti s lng tiu cu v ch yu gim cht lng tiu cu(nhiu
tiu cu non, mt cu trc,kt li tng chui)
gim tiu cu gy d mt mu v nim mc di da. Hi chng chy mu thng biu hin
tng tnh thm mao mch v gim chng lc mch mu do thiu yu t TC
3
mu chm ng,
lm chm hin tng co cc mu so thiu rtactozym tiu cu. Thi gian chy mu(theo
phng php Duke)ko di ti 10 pht v hn th na.
3. Tha cht khng ng hoc kch hot h tiu ho fibrin:
- tha heparin do iu tr qu liu, hoc tng heparin t do trong bnh phng x, sc qu mn
- can thip phu thut hoc tn thng rng cc t chc(phi , c t cung , tuyn tin
lit,)gy tng gii phng cc men fibrinnokinaz dn ti tng hot ho plasmin v chy mu
khng cm c.
cn phn bit cc hi chng do chy mu do nguyn nhn mao mch nh hi chng chy mu
di truyn (bnh Von Willebrantd)bnh xut huyt mao mch d ng (bnh Schoenlein
Henoch)do c khng th chng ni mc mch mu, hoc bnh mc phi do thiu sinh t C.
Nhng bnh ny ch chy mu ko di, d chy mu cn cc xt nghim ng mu co th t
thay i.
Bng tng hp nguyn nhn v bnh sinh ca hin tng gim ng
Yu t gy bnh C ch bnh sinh
Hemophil A
gim s lng tiu cu (bnh Verihof, phng x,
bch cu , do min dch )
tn thng lan rng nh m gan(vim gan , ng
c phtpho)
Thiu v khng tng hp c St, K( vng da tc
mt , ri lon tiu ho)
Qu liu heparin
Qu liu dicoumarin
Sc qua mn v pepton
Tn thng rng t chc, bnh k{ khi sinh ,
phu thut phi
thiu yu t VIII
Thiu cc yu t tiu cu (TC, retractozym)
Thiu thrombin,prcnveccin. Fibrinogen
Gim prothrombin, thrombin, thromboplastin mu
c ch tng hp prthmbin.VII tng heprin,
antithrombin
Tng gii phng fibrinokinaza t chc, tan fibrin mnh,
fim nng fibrinogen

B-SINH L BNH CC HIN TNG TNG NG MU
Tng dng pht sinh do 3 c ch ch yu : tng trong mu nng cc yu t thromboplin,
thrombin.. gim hot tnh cc cht chng ng t nhin (hepin. antithrombin), c ch h
tiu tiu fibrin.
1.tng ong do tng cc yu t ng mu :
- tng ng tm thi thong qua nhng ngi trong trng thi hng phn hoc au n,
khip s. Trong c th khi khng c nguy to thnh cc mu v tng ng c b p bng
kch hot h tiu fibrin,s cn bng ny ch b ri lon trong cc trng hp bnh l
-Tng ng do tng hot tnh thrmppltin dn ti bin 1 s lng ln prothrombin gy ng
mu trong lng cc huyt qun. C th gp trong cc trng hp bnh l c tn thng t chc
rng (bng, cc phu thut ln, chn thng), ng mu c th tin hnh trong lng mch v
b mt ni mc b tn thng to iu kin gy kt vn cc yu t hu hnh mu trong long
mch lm tr ngi cho vi tun hon v dinh dng t chc. C th phi hp vi tiu th qu
mc cc yu t ng mu v tn thng ni mc gy ra chy mu ri rc trong lng mch.
2.tng ng do thiu , gim hot tnh cc cht ng t nhin va c ch qu trnh tiu fibrin:
L c ch khng km phn quan trng. Trong ng mu trong lng mch khng phi l lzc no
cng dn ti to thnh cc mu , tuy nhin kt qu cui cng ca ng mu trong lng mch
thng l tng to fibrin bn vng v c ch qu trnh tiu fibrin,to iu kin hnh thnh
trng thi tin cuc mu .Nguy c ny gp cc bnh nhn x va ng mch , huyt p cao,
vim khp , vim tc ng mch.
Trong x va ng mch v bnh huyt p cao thy co c ch mnh qu trnh tiu fibrin lm
tr ngi s ho tan cc mu v ang hnh thnh dn n to nhiu cc mu gy tc nghn
mch. c m ton phn cholesterol v bta-lipoprorein mu tng cao nn phi s dng mt s
lng ln heparin t do dn n tng ng v c ch h tiu fibrin , c ch ny cng c gii
thch trong tng ng do n nhiu m.
Hin tng c ch h tiu fibrin cn c th thy cc cng nhn cc xng my nng , x
nghip thuc l , nhng ngi ln vic tr c nhiu v khi ng c ru.
Bng tng hp nguyn nhn v bnh sinh cc hin tng tng ng.
Yu t gy bnh C ch bnh sinh
Tn thng thnh mch mu
Vim lan rng, vt thng hu phu , bng
, chy mu
Ri lon chuyn ho m ,x va ng
mch, bo ph
D tha sinh t K
Ng c ru, thuc l
Kch hot yu t XII ng mu
To tha thromboplastin gim heparin t
do,tng thromboplastin, c ch h tiu
fibrin
Tng to prothrombin, thrombin
c ch h tiu fibrin


57. SINH L BNH H HP
HONG DUNG

I. I CNG
H hp l qu trnh trao i hi kh lin tc gia c th sng v mi trng ngoi. Qu trnh h
hp c chia lm hai giai on chnh :
1. H hp ngoi c thc hin nh b my h hp, ch yu l chc nng ca phi nn cn
c gi l h hp phi. Giai on ny ph thuc vo kh nng thng kh ca phi, kh nng
khuch tan kh qua mng ph bo- mao mch v tnh trng tun hon ca cc mao mch phi.
2. H hp trong gm :
- Vn chuyn kh O
2
v CO
2
di dng kt hp vi huyt cu t, nh b my tun hon v mu.
- H hp t bo c thc hin qua mng t bo di s tham gia ca h thng men h hp,
nhm gii phng nng lng cn thit c th sng v pht pht trin.
Nh vy qu trnh h hp cung cp O2 cho c th v o thi CO2 tha khng phi ch l
nhim v ring ca b my h hp m cn c s tham gia ca h tun hon, mau v chuyn
ha t chc. Nhng qu trnh ny li chu s iu tit ca h thn kinh trung ng do trong
iu kin bnh l, chc nng h hp b ri lon c th nh hng su sc ti cc chc phn
khc ca ton b c th, ngc li ri lon h thn kinh trung ng, ri lon tun hon mu
cng nh bin i chuyn ha t chc nu c th gy thiu oxi v ri lon chc nng h hp.
S iiu ha h hp c thc hin nh c s ton vn ca trung tm h hp qua cc c ch
iu ha thn kinh v th dch (hnh 1). Trong c ch iu ha phn x thn kinh, v no c mt
vai tr quan trng : ct b v no ng vt th nghim lm cho kh nng thch nghi ca chng
vi cc thay i hot ng gim, gy kh th ko di v r rt c vi lao ng rt nh. ngi,
c th t th nhanh, th chm, th nng, th su hoc ngng th trong mt thi gian nht
nh ty theo mun ca mnh, khi v no bi c ch (ng, gy m) h hp s chm v su. Cc
trng thi tm l{ u c th gy bin i h hp (xc cm, s hi, tc gin) Cc tn hiu bo
trc gi lao ng, thi u thng gy phn x tng cng h hp.
iu ha th dch ph thuc vo s thay i cc thnh phn ha hc ca mu (nng O2,
CO2, pH mu, nhit ) kch thch phn x hoc trc tip cc t bo thn kinh ca trung tm h
hp.
S vn chuyn O
2
t phi n cc t chc thc hin nh cc qu trnh kt hp v phn ky O
2
v
Hemoglobin, l mt qua trnh sinh l ch khng phi l sinh ha v hemoglobin khng b oxy ha
cng khng thay i v ha tr ca Fe trong phn hem ca hemoglobin. S kt hp v phn ly
HbO
2
chu nh hng ca p lc ring phn ca O
2
mu, pa O
2
tng to iu kin kt hp HbO
2

d dng (bnh thng kt hp HbO
2
bo ha ti 95- 97%), khi n t chc do phn p O
2

thp nn HbO
2
b phn ly v O
2
tch ra s vo trong t bo. Qu trnh ny cn chu nh hng
ca nng CO
2
mu, pa CO
2
tng c tc dng lm gim kh nng kt hp HbO
2
v tng cng
phn ly HbO
2
. Tc dng ny do tnh cht axt ca CO
2
, cng nh i vi c cc axit (axit lactic,
axetic) do thay i mi trng v pha toan lm gim kh nng kt hp v tng kh nng
phn ly HbO
2
. S vn chuyn CO
2
c thc hin di 3 dng: ha tan, kt hp vi hemoglobin
hoc kt hp vi nc thnh H
2
CO
3
di tc dng ca men anhydraza cacbonic.
II.NHNG BIU HIN CA RI LON H HP NGOI
H hp ngoi c thc hin nh cc qu trnh thng kh, khuch tn kh v tnh trng dng
mu trong cc mao mch phi. Cc qu trnh ny kin quan mt thi vi nhau cng m bo
mt nhim v: cung cp O
2
vi mc y cn thit v loi b cc kh CO
2
tha.
A-RI LON THNG KH PHI
Thng kh phi l qu trnh lun phin lin tc gia ht vo v th ra nhm duy tr mt phn p
O
2
nht nh trong ph bo v mu l 100-104 mmHg v phn p CO
2
mu nht nh 40-42
mmHg. Mc ca thng kh ph thuc vo nhu cu O
2
, s o thi CO
2
, tnh trng b my h
hp, lng ngc, cc c th v tnh trng ca h thn kinh trung ng. Ri lon thng kh c
pht hin bng cc bin php khm trc quan (quan st c ng lng ngc, nghe ting th, g,
vn ng c honh( v bng cc ch tiu khch quan (thng kh pht v thng kh ph bo, cc
khi lng v dung tch phi).
1. Nhng ch tiu nh gi thng kh phi
a) Cc ch tiu khch quan:
- Thng kh pht l tch s ca tn s h hp (13-18 ln/pht) vi lng th (300-600 ml) v
thng kh ph bo (tch ca tn s h hp vi s chnh lch gia lng th v khong cht h
hp). Thc t trao i kh ch tin hnh trong cc ph bo nn ch tiu thc s ca thng kh
phi l lng thng kh ph bo v tng hay gim thng kh c xc nh ch yu bng ch tiu
tng hay gim lng thng kh ph bo.
Dung tch chung ca phi (khi lng phi hay tng ph dung) l lng kh cha trong phi sau
khi ht vo ti a. Dung tch chung ca phi bao gm dung tch sng v dung tch cn hay lng
cn.
- Dung tch sng (ph hot dung, ph dung sinh hot) l lng kh ln nht c th ra c sau
khi ht vo ti a, trung bnh dao ng t 3,5 4,5l. Gim dung tch sng thng gp trong mt
s bnh l h hp nh trn dch, trn kh ngc, vim mng phi, co tht ph qu, hp ng kh
o, ri lon vn ng c honh v cc c th khc.
- Lng cn l lng kh cn li trong phi sau khi th ra ti a. Bnh thng lng cn chim
t 1/3-1/4 dung tch chung ca phi. Lng cn tng cng r rt trong chng ph nang,
trong vim ph qun, v cc trng thi co tht ph qun (hen), trong vim mng phi tit dch
v trn kh ngc, dung tch chung ca phi v lng vn u gim.
- Lng kh th ra ti a trong 1 giy (VEMS) v t s Tilfeneau (h s gia VEMS v dung tch
sng) gim khi c tc nghn ng lu thng kh qun.
b) Kh th: l cm gic ch quan, c i km c cm gic au n, pht sinh theo c ch phn x
c gim phan p O
2
v tng phn p CO
2
mu, hc c th l nhng tr ngi c gii ca thng kh
phi. C th phn nhiu loi:
- Kh th ph thuc vo tn s v lng th nh kh th nhanh su pht sinh khi gng sc, xc
cm, kch thch au, thiu O
2
thng c { ngha thch ng mt mc nht nh. Kh th
nhanh, nng pht sinh ch yu trong cc bnh phi do tng tnh hng phn ca cc cm th
ph bo hoc gim tnh hng phn ca trung tm h hp, l loi h hp km hiu lc. Kh th
su, chm hay kh th vo pht sinh do co hp ng kh o v ng h hp trn. Kh th
ra pht sinh khi gim tnh n hi ca t chc phi.
- Kh th ph thuc vo nhp h hp :h hp chu kz
H hp chu kz l nhp th khng u, ngt qung tng t, hay gp nht l kiu Cheynes-
Stockes biu th bng mt on ngng th ri h hp tng dn, sau li gim dn ti ngng
th, c th lp li nhiu t. Mt xch ch yu ch yu ca h hp chu kz l gim tnh hng
phn ca trung tm h hp i vi cc tc dng sinh l ca CO
2
. H hp chu kz c th gp trong
cc trng hp bnh l c thiu O
2
nng, sc, try tim, suy thn
H hp hp hi cng l mt loi h hp chu kz pht sinh do hng phn mnh trung tm h hp
hnh no lc b mt tc dng iu ha ca v no, c th c s tham gia ca cc trung
tm h hp ty sng.
Kh th c th gp trong nhiu bnh
+ Cc bnh phi lm gim phn p O
2
, tng phn p CO
2
va gim pH mu
+ Cc bnh tim mch, mu nh hmg n s vn chuyn O
2
v CO
2

+ Cc bnh ri lon chuyn ha, ri lon cn bng axit baz
Trong bnh l h hp, kh th khng phi l triu chng bt buc v cng khng phi lun l
mt bo hiu nguy him nhng trong mt s trng hp kh th l mt yu t gip cho chn
on v tin lng bnht qu. V d trong vim ph mc c tin trin,trn dch, kh th l
triu chng quan trng ni bt ln hng u. Kh th ngy cng tng theo mc nghim
trng ca bnh trong ph phi cp. Trong lao x ri c c hai bn phi cc cng nhn m than
(silicose) kh th l triu chng duy nht ko di hng nm, c khi ngh ngi. Trong bnh lao,
kh th c th gip y sinh pht hin c tnh trng suy yu chc phn h hp: cho bnh nhn
ngh ngi nm yn theo di nhp h hp, sau c ng nh nh ni mt cu di, hoC th
lm kh th xut hin t ngt. mt bnh nhn lao n nh, bt u thy kh th c th
l do bnh tin trin, ngc li kh th gim, lng h hp tr li bnh thng l du hiu
chng t bnh c b, tn thng n nh hoc trn dch t tiu
2. Cc hnh thi ri lon thng kh phi
C th phn chia lm 3 loi:
Tng thng kh: khi tn s v lng th u tng nn thng kh pht v thng kh ph qun u
tng. Tng thng kh pht sinh do kch thch phn x v trc tip trung tm h hp bi tnh
trng gim phn p O
2
, tng phn p CO
2
v tng nng ion H
+
trong mu. Tng thng kh c
th gp trong cc trng hp sinh l khi nhu cu oxy ca c th tng (lao ng, luyn tp),
trong cc trng hp tng chuyn ha (st, nhim nng, nhim toan, u nng tuyn gip),
trong cc bnh phi v tim mch mch mu giai on u b p.
Tng thng kh dn ti tng phn p O
2
mu ng mch, lu di s gy tng o thi CO
2
,
nhc thn v nhim kim hi.
- Gim thng kh: khi c tng tn s h hp nhng lng th gim (th nhanh, nng) nn hu
qu s l gim phn p O
2
v tng phn p CO
2
mu gy u thn v nhim toan hi. Gim thng
khi thng gp trong cc trng hp trung tm h hp b c ch (gy m, nhim c thuc
ng, morphin, chn thng s no), ri lon thn kinh-c h hp (bnh bi lit, chn thng
ty sng, bin dng lng ngc), trong cc bnh l phi
- Thng kh khng u: khi bn cnh nhng vng thng kh tt c vng thng kh gim, biu
hin bng ting th yu t hoc thiu hn, dn n tnh trng thiu oxy mu v bo ha oxy
nhng vng thng kh tt khng tng c bao nhiu, tri li nhng vng thng kh km li
gim r rt, kt qu l phn p O
2
v bo ha O
2
mu u gim, tnh trng ng CO
2

thng khng c hoc ch tng khng ng k do CO
2
tng o thi nhng vng th b.
B-RI LON KH NNG KHUCH TN CA PHI
Kh nng khuch tn ca phi l lng cht kh c chuyn qua mng ph bo mao mch
phi trong 1 pht vi chnh lch phn p 2 bn mng l 1 mmHg. L kh nng chuyn cc
cht kh t vng c p lc cao n vng c p lc cht kh thp hn (hnh 2).
Kh nng khuch tn chu nh hng ca nhiu yu t:
1. Din khuch tn: l b mt cc ph bo c thng kh tip xc vi cc mao mch ang hot
ng, ngi l 90 m
2
, nhng bnh thng khng phi tt c cc ph bo u hot ng do
khi lao ng kh nng khuch tn mi c s dng ti a (hnh 3)
2. Mng khuch tn: cht kh mun c khuch tn vo mu phi qua 1 lp mng ph bo-
mao mch, dy 4m gm cc lp mng ph bo, dch khe t bo, ni mc mao mch, huyt
tng, mng hng cu (hnh 4)
3. H s khuch tn: cht kh trong mi trng mu mun c khuch tn qua lp mng ph
bo- mao mch phi ph thuc vo ha tan, ha tan ca CO
2
khon 20-25 ln ln hn
ha tan ca O
2
do t gp cc trng hp gim kh nng khuch tn ca CO
2
. Cht kh c
khuch tn t vng c p lc cao n vng c p lc cht kh thp hn , nh vy h s khuch
tn ca O
2
bng s lng O
2
hp thu trong 1 pht/pO
2
ph bo- pO
2
mao mch phi, bnh
thng khong 15-25 ml/mmHg/pht.
Ri lon khuch tn c th gp cc trng hp bnh l c gim din khuch tn (vim phi,
trn kh, trn dch), lm dy mng ph bo (trng ph nang, hen, x phi) hoc lm dy
mng mao mch (x mch mu phi). Kh nng khuch tn ti a gim dn theo tui c th l
do gim s lng mao mch phi v qu trnh x ha ngi gi. Ri lon kh nng khuch tn
thng dn ti gim paO
2
v gim bo ha O
2
(SaO
2
), mu ng mch gy thiu O
2
nhng t
nh hng ti paCO
2
.
C RI LON TUN HON MAO MCH PHI
C th thay i mc khc nhau ty theo tnh cht v din bin ca bnh:
1. Tng p lc ca mao mch phi:
Bnh thng cc mao mch phi rt mng, t chc m t nn d b gin v mu. Trong bnh
l, suy tim tri gy gin mao mch v mu phi, c th dn ti tng p lc cc mao mch
phi gy tr ngi v nh hng ti tim phi; bnh hen ph qun c th gy chn p tun hon
mao mch phi, nh hng ti tim phi dn n trng thi tm ph mn.
2. Ph phi:
Bnh thng huyt p ti cc mao mch phi rt thp, ch bng 1/7 huyt p ng mch (14-20
mmHg) do y p lc keo thng ln hn p lc mu nn c tc dng gi nc khi thot
ra v lm ph nang lun kh ro. Trong cc trng hp bnh l, khi c gin mch mu, p lc
ti cc mao mch phi tng cao hn so vi p lc keo, ng thi tnh trng thiu oxy gy tng
tnh thm mao mch nn cht dch huyt tng trn vo trong ph nang gy ph phi.
3. Bin i h s thng kh dng mu mao mch phi hay h s h hp thng kh 3,5-4 lit cng
c ti mt lng mu tng ng 4-4,5 lit mu/pht, nh vy c mt s cn bng gia h
hp v tun hon. Trong trng hp bnh l, cn bng ny c th b ri lon theo hai hng:
nu mt vng phi c thng kh tt, nhng tun han mu b ri lon hoc khng c (tc
mch, huyt khi) th vng s tng ng vi mt khong cht, paO
2
v SaO
2
gim,paCO
2

tng. Ngc li, vng c mu chy qua y nhng thng kh b ri lon hoc khng c
(cc bnh l phi) s tng ng vi mt shunt v paO
2
gim nhng paCO
2
t nh hng v
cond pg thuc vo cc khu vc o thi b v kh nng khuch tn ca CO
2
.
4. Bin i thnh phn kh ca mu :
Trong cc bnh l ca phi, thnh phn kh ca mu b thay i r rt :
- paO
2
gim di mc trung bnh (100- 104 mmHg).
- Nng O
2
mu ng mch gim (bnh thng 20,3 ml/100ml mu).
- SaO
2
gim di mc bnh thng (95-97%).
- paCO
2
mu c th gim di mc bnh thng (40 mmHg) gy tnh trng nhc thn, v lm
tng pH mu, nhim kim hi hoc paCO
2
tng cao gy tnh trng u thn, gim pH mu v
nhim toan hi.
III. NGUYN NHN V BNH SINH CA RI LON
H HP NGOI
Ri lon h hp ngoi c th pht sinh do nhiu nguyn nhn khc nhau :
A. DO RI LON CHC NNG NG H HP
TRN V KH, PH QUN
Thng gp hai hnh thi bnh l chnh : vim v tc.
- Vim mi, kh ph qun: do vim nn c biu hin ph n nim mc, tng tit nim dch gy
kh th, m kch thch cc th cm nim mc h hp gy ht hi, s mi, ho mc nht
nh c th nh hng ti thng kh pht, thng kh ph bo v kh nng h hp.
- Hp, tc ng kh o, ph qun: gy ri lon thng kh, kh th vo v tc hon ton
thng gy ra hin tng ngt th, nguy him n tnh mng nu khng cp cu kp thi.
1.Ngt.
- L hin tng tc nghn hon ton ng lu thng kh o gy thiu O
2
v ng CO
2
mu,
dn ti suy sp chc nng ton b c th v cht nu khng kp thi c bin php cp cu hp
l. Ngt cp din dng vt thc nghim thng gy cht ng vt rt nhanh, t 3- 6 pht.
a) Nguyn nhn gy ngt do 3 nhn t chnh:
- Do khng kh th khng thay i ( ngt trong phng kn, sp hm )
- Do tc nghn hon ton ng lu thng kh o: tc d vt ( tr em ), ph n thanh qun,
co tht, bp c
- Do ph nang b trn ngp nc: cht d8ui, ph phi cp
b) Din bin ca ngt : thng qua 3 giai on: ( hnh 5 )
- Giai on I: ng lu thng kh o b tc nghn nn thiu O
2
ng CO
2
gy kch thch phn
x, hng phn cc trung tm h hp v vn mch, biu hin h hp nhanh v su, th th vo
ko di, nhanh v mnh, huyt p ng mch tng rt cao c tc dng b p.
- Giai on II: b p bt lc thiu O
2
v ng CO
2
nhiu gy c ch trung tm h hp, th
chm li, nng, ri nh ch, huyt p ng mch cng gim dn, tim o chm do thn kinh
ph b kch thch v h thn kinh trung ng cng b ri lon, mt thc, c th xut hin co
git ton thn, v vi a, i do h c trn b co tht bt thng.
- Giai on III: c ch su sc v kit qu cc trung tm thn kinh cc phn x mt, ng t gin,
h hp hon ton nh ch, tim p chm, yu dn, huyt p tt nhanh, tim ngng p.
Nh vy cht do ngt l hu qu ca thiu O
2
trm trng v ng CO
2
mu gy chn p cc
trung tm thn kinh , trong trng hp ny paCO
2
c th tng ti 80mmHg cho nn trong cp
cu ngt ch yu l phi lm h hp nhn to hoc thi ngt loi thi CO
2
tr b cc nguyn
nhn gy chng ngi ng h hp, cung cp O
2
nhng khng nn dng O
2
nguyn cht ngay
v s lm mt phn x th b p vi trng thi thiu O
2
.
2.Hen ph qun:
L mt bnh d ng do khng th loi reagin, gy co tht h thng ph qun m biu hin lm
sng ch yu l cc cn kh th, c bit l th th ra.
Nguyn nhn v bnh sinh:
- Do cc d nguyn c trong hon cnh sinh hot v lao ng bnh thng nh bi nh, phn
hoa, cy c, kh hu, cht t
- Do d ng sau nhim khun, thng gp sau cc bnh nhim khun ng h hp , tai-mi-
hng, c bit sau vim xoang( 60,4%)
V bnh sinh ca hen, cn ch cc yu t di truyn( c ti 51,8% con ci mc bnh do di
truyn t b hoc m), v yu t thn kinh ( hen c th pht sinh theo c ch phn x c iu
kin v thng xut hin ban m khi trung khu v no b c ch khng kim ch c cc
trung khu thc vt di v no ).
Cc ri lon h hp trong hen:
- Cn hen thng pht sinh do tc dng ca d nguyn gy kt hp khng nguyn khng th gii
phng cc cht ha hc trung gian nh histamin, bradikinin, prostaglandinkch thch cc si ly
tm ca thn kinh ph v gy co tht h c trn v ph qun, tng tit nim dch, ph n v
vim cc nim mc ph qun dn ti cc cn kh th ra, bnh nhn rt kh th nh lng ngc
b p, thng phi ngi dy c th, mt xanh tm, tit nhiu m ri, thng kh t bo
gim, dung tch sng gim, VEMS v h s Tiffeneau gim, lng cn tng. Tn s cc cn hen,
thi gian ko dica cc cn ph thuc vo tnh cht ca bnh, thng nng v cn ko di
ngi trng thnh (hnh 6).
- Hen lu ngy c th lm gim tnh n hi ca t chc phi gy tnh trng trng ph nang,
nim mc ph qu ph i gy trng thi phi b c khi bnh thng. Ph bo cng, lun p
vo mao qun, lm tr ngi tun hon phi, gy tng huyt p ng mch phi, tm tht phi
tng cng hot ng lu di c th dn ti suy tim phi c gi l tm ph mn. Cn hen
c tnh l do tc ton b cc ph qun nh c th gy suy h hp, rt nguy him nu khng cp
cu kp thi.
B- DO RI LONCHC PHN CC PH BO
Ph bo c th b tn thng, hoi t nhu m (vim phi, lao) b mt kh nng hot ng
(trng ph nang, xp phi) hoc b trn ngp cht dch (ph phi )
1.Vim phi.
L mt trng thi bnh l ph bin trong nhn dn cng nh rong qun i, chim 49,3% trong
tng s bnh h hp, 17% trong tng s cc bnh ni khoa.
a)Nguyn nhn v bnh sinh:
- Do nhim khun: ph cu, lin cu v mt s virut thng c sn trong ng h hp, di
tc dng ca cc yu t thun li (lnh, mt mi) lm gim sc khng ca c th to iu
kin cho bnh pht sinh.
- Do nguyn nhn min dch: thiu gamma- globulin loi IgA lm gim kh nng thc bo chng
nhim khun ng h hp.
- Do cc nguyn nhn thi chin: bng, hi c chin tranh, chn thng gy mu phi, gy
tc mch do nhi mu hay t chc thi nt t vt thng a ti, hoc cng c th do phn x
t cc b phn khc gy mu v ri lon tun hon phi (vt thng s no. vt thng
bng)
b) Ri lon h hp trong vim phi :
- Kh th, th nng v nhanh do t chc phi b vim, tng tit dch di phng trong ph bo gy
tng hng phn cc cm th ph bo c ch lm th th vo sm b c ch ng thi din h
hp v khuch tn kh cng gim. Hu qu l thng kh ph bo gim, dung tch sng cng gim
gy tnh trng thiu oxy.
- Mu qua vng phi b vim khng c bo ha y oxy nn bo ha oxy ca mu gim
r rt (c khi ch cn 70%). Thnh ph nang b ph n dy nn cng nh hng n kh nng
khuch tn ca phi.
- Do cc khu vc lm tng thng kh b p nn thng khng c u thn. Thiu oxy, xanh tm
v u thn r ch gp cc trng hp c km vim ph qun (ph qun - ph vim) cc ph
qun nh b vim, ph n, bt kn cc dch nhy hoc co tht cc ph qun nh.
2. Ph phi cp (OAP)
L mt cp cu ni khoa s do ph bo v cht m khe b trn y huyt tng gy ngt th.
a) Nguyn nhn v bnh sinh:
- Do bin chng ca suy tim tri, v tim phi do mt l{ do no (lo ngh, gng sc, truyn dch
nhiu, kch thch ca cht c) tng cng hot ng, tng mt lng mu qu nhiu ln phi
gy mu v thot dch vo cc ph bo.
- Do nhim c (hi te, hi c chin tranh, nitrat bc, c t vi khun) lm tn thng
mng ph bo mao mch.
- Do thn kinh: gy co tht mao mch, tng huyt p vng tiu tun hon.
b) Ri lon h hp trong OAP:
- Kh th d di v ngy cng tng do mu tip tc c tng ln phi, gy tng cng mu,
tng tnh thm mao mch phi nn dch huyt tng c trn vo trong ph nang ngy cng
nhiu. Biu hin lm sng l cc ting rn t ngy cng nhiu c 2 bn phi. Thng kh ph
bo, cc dung tch phi, kh nng khuch tn ngy cng gim r rt gy tnh trng thiu oxy
nghim trng.
- Huyt p ng mch ngy cng gim do mu b cc mao mch phi, dch huyt tng trn
vo cc ph nang nn lng mu v tim tri gim st. Thng cht trong tnh trng kh th
nghim trng, huyt p ng mch tt nhanh, vt v, ming v mi tro ra nhng dch ln bt
mu hng.
Trong cp cu ph phi cp phi nhanh chng hn ch lu lng mu t tim tng ln phi
(chch mu, garo, bm oxy p lc cao) ngn cn tit dch vo trong ph bo, ng thi phi
ci thin hot ng ca tim (tr tim), hn ch hot ng v lm gim nhu cu oxy ca c th,
lm gim cc kch thch gy phn x co tht tun hon phi (dng morphin)
RI LON CHC PHN CC PH MC
Thng gp l cc bnh vim v trn dch, trn kh ph mc.
TRN KH PH MC
Cn gi l trn kh ngc, l hin tng bnh l khi c thng kh lt vo khoang ph mc lm nh
hng ti chc nng h hp ca phi.
a)Nguyn nhn v sinh bnh:
- Ngoai khoa thng do cc vt thng lng ngc, c th chia thnh trn kh kn khi vt thng
c bt kn, p lc trong khoang ph mc thp hn p lc bn ngoi, nh vy trn kh c
hn ch , trn kh m khi khoang ph mc thng v p lc ngang vi p lc bn ngoi v trn
kh van khi p lc bn trong khoang ph mc cao hn, v khi th ra l hng c t chc bt
kn, khng kh ch vo mi ngy mt tng m khng thot ra c.
- Ni khoa, thng do lao,c th gp trong p-xe phi, ung th phi, khng kh t cc ph nang
b tn thng trn vo khoang ph mc.
b) Ri lon h hp trong trn kh ngc:
- Ph mc b trn kh s p vo phi lm gim din h hp v gy tr ngi cho hot ng ca
phi. Tnh trng ny kch thch phn x cc cm th phi v ph mc gy tng h hp b p
cho nn vi trn kh kn v hn ch, bnh nhn c th chu ng c m t nh hng ti sinh
hot (p phi trong iu tr lao)
- Trn kh nng v t ngt c th gy sc ph mc. Phi b p mnh, co nh li rn phi,
gim din h hp, khuch tn qu nhiu s dn ti kh th d di v thiu oxy nghim trng.
Cc mch mu phi b chn p nh hng n hot ng tim, huyt p ng mch, huyt p
tnh mch tng. Bnh nhn c th cht do kh th trm trng, huyt p h nhanh, phi xp,
hot ng phi lnh cng b hn ch, trung tht b chn p, tim khng hot ng c.
Hu qu ca trn kh c th l vim, trn dch thanh huyt, trn dch mu hoc m .Trng hp
nng, khi khi cn li hi chng dy dnh ph mc nh hng lu di n chc nng ca
phi.
IV. SUY H HP (SUY TH)
Cng nh vi cc c quan h thng khc, tnh trng chung ca ri lon chc nng h hp ngoi
c gi l suy h hp hay suy th. Nh vy, suy h hp l tnh trng b my h hp ngoi
khng m bo c chc nng cung cp oxy v o thi CO
2
trong cc iu kin bnh thng
v bt thng ca c th, biu hin bng bin i r rt thnh phn kh ca mu vi nhng du
hiu h hp ngoi.
1.Nguyn nhn v bnh sinh ca suy h hp:
- Do hu qu ca cc bnh l v phi v ph mc (ri lon thng kh, khuch tn)
- Do hu qu ca cc bnh nh tn thng dy thn kinh (ng c thuc ng, chn thng s
no, bnh l tim mch (suy tim), bnh l ngoi khoa (sng n, vi lp, chn thng hoc bng
lng ngc).
2.Biu hin ch yu ca suy h hp :
- Kh th l du hiu pht hin u tin, giai on u l kh th khng tng ng vi nguyn
nhn v ch xut hin khi lao ng (suy h hp tim tng). Sau kh th xut hin c khi lm
vic nh v c khi ngh ngi (suy h hp r rt).
- Bin i thnh phn kh ca mu:
+ paO
2
gim ti 92mmHg, nng, cp tnh c th di 50mmHg.
+ SaO
2
gim di 94%, nng v cp tnh gim di 70%.
+ paCO
2
tng thm 44mmHg, nng, cp tnh tng trn 80mmHg.
- Ri lon cc chc nng h hp ngoi: thng kh v khuch tn u gim, nhim toan ng
CO
2
v cc sn phm axit ca chuyn ha, xanh tm. Cui cng suy h hp c th kt hp vi
suy tim lm cho qu trnh bnh l ngy cng nghim trng.
I. I CNG
H hp l qu trnh trao i hi kh lin tc gia c th sng v mi trng ngoi. Qu trnh h
hp c chia lm hai giai on chnh :
1. H hp ngoi c thc hin nh b my h hp, ch yu l chc nng ca phi nn cn
c gi l h hp phi. Giai on ny ph thuc vo kh nng thng kh ca phi, kh nng
khuch tan kh qua mng ph bo- mao mch v tnh trng tun hon ca cc mao mch phi.
2. H hp trong gm :
- Vn chuyn kh O
2
v CO
2
di dng kt hp vi huyt cu t, nh b my tun hon v mu.
- H hp t bo c thc hin qua mng t bo di s tham gia ca h thng men h hp,
nhm gii phng nng lng cn thit c th sng v pht pht trin.
Nh vy qu trnh h hp cung cp O2 cho c th v o thi CO2 tha khng phi ch l
nhim v ring ca b my h hp m cn c s tham gia ca h tun hon, mau v chuyn
ha t chc. Nhng qu trnh ny li chu s iu tit ca h thn kinh trung ng do trong
iu kin bnh l, chc nng h hp b ri lon c th nh hng su sc ti cc chc phn
khc ca ton b c th, ngc li ri lon h thn kinh trung ng, ri lon tun hon mu
cng nh bin i chuyn ha t chc nu c th gy thiu oxi v ri lon chc nng h hp.
S iiu ha h hp c thc hin nh c s ton vn ca trung tm h hp qua cc c ch
iu ha thn kinh v th dch (hnh 1). Trong c ch iu ha phn x thn kinh, v no c mt
vai tr quan trng : ct b v no ng vt th nghim lm cho kh nng thch nghi ca chng
vi cc thay i hot ng gim, gy kh th ko di v r rt c vi lao ng rt nh. ngi,
c th t th nhanh, th chm, th nng, th su hoc ngng th trong mt thi gian nht
nh ty theo mun ca mnh, khi v no bi c ch (ng, gy m) h hp s chm v su. Cc
trng thi tm l{ u c th gy bin i h hp (xc cm, s hi, tc gin) Cc tn hiu bo
trc gi lao ng, thi u thng gy phn x tng cng h hp.
iu ha th dch ph thuc vo s thay i cc thnh phn ha hc ca mu (nng O2,
CO2, pH mu, nhit ) kch thch phn x hoc trc tip cc t bo thn kinh ca trung tm h
hp.
S vn chuyn O
2
t phi n cc t chc thc hin nh cc qu trnh kt hp v phn ky O
2
v
Hemoglobin, l mt qua trnh sinh l ch khng phi l sinh ha v hemoglobin khng b oxy ha
cng khng thay i v ha tr ca Fe trong phn hem ca hemoglobin. S kt hp v phn ly
HbO
2
chu nh hng ca p lc ring phn ca O
2
mu, pa O
2
tng to iu kin kt hp HbO
2

d dng (bnh thng kt hp HbO
2
bo ha ti 95- 97%), khi n t chc do phn p O
2

thp nn HbO
2
b phn ly v O
2
tch ra s vo trong t bo. Qu trnh ny cn chu nh hng
ca nng CO
2
mu, pa CO
2
tng c tc dng lm gim kh nng kt hp HbO
2
v tng cng
phn ly HbO
2
. Tc dng ny do tnh cht axt ca CO
2
, cng nh i vi c cc axit (axit lactic,
axetic) do thay i mi trng v pha toan lm gim kh nng kt hp v tng kh nng
phn ly HbO
2
. S vn chuyn CO
2
c thc hin di 3 dng: ha tan, kt hp vi hemoglobin
hoc kt hp vi nc thnh H
2
CO
3
di tc dng ca men anhydraza cacbonic.
II.NHNG BIU HIN CA RI LON H HP NGOI
H hp ngoi c thc hin nh cc qu trnh thng kh, khuch tn kh v tnh trng dng
mu trong cc mao mch phi. Cc qu trnh ny kin quan mt thi vi nhau cng m bo
mt nhim v: cung cp O
2
vi mc y cn thit v loi b cc kh CO
2
tha.
A-RI LON THNG KH PHI
Thng kh phi l qu trnh lun phin lin tc gia ht vo v th ra nhm duy tr mt phn p
O
2
nht nh trong ph bo v mu l 100-104 mmHg v phn p CO
2
mu nht nh 40-42
mmHg. Mc ca thng kh ph thuc vo nhu cu O
2
, s o thi CO
2
, tnh trng b my h
hp, lng ngc, cc c th v tnh trng ca h thn kinh trung ng. Ri lon thng kh c
pht hin bng cc bin php khm trc quan (quan st c ng lng ngc, nghe ting th, g,
vn ng c honh( v bng cc ch tiu khch quan (thng kh pht v thng kh ph bo, cc
khi lng v dung tch phi).
1. Nhng ch tiu nh gi thng kh phi
a) Cc ch tiu khch quan:
- Thng kh pht l tch s ca tn s h hp (13-18 ln/pht) vi lng th (300-600 ml) v
thng kh ph bo (tch ca tn s h hp vi s chnh lch gia lng th v khong cht h
hp). Thc t trao i kh ch tin hnh trong cc ph bo nn ch tiu thc s ca thng kh
phi l lng thng kh ph bo v tng hay gim thng kh c xc nh ch yu bng ch tiu
tng hay gim lng thng kh ph bo.
Dung tch chung ca phi (khi lng phi hay tng ph dung) l lng kh cha trong phi sau
khi ht vo ti a. Dung tch chung ca phi bao gm dung tch sng v dung tch cn hay lng
cn.
- Dung tch sng (ph hot dung, ph dung sinh hot) l lng kh ln nht c th ra c sau
khi ht vo ti a, trung bnh dao ng t 3,5 4,5l. Gim dung tch sng thng gp trong mt
s bnh l h hp nh trn dch, trn kh ngc, vim mng phi, co tht ph qu, hp ng kh
o, ri lon vn ng c honh v cc c th khc.
- Lng cn l lng kh cn li trong phi sau khi th ra ti a. Bnh thng lng cn chim
t 1/3-1/4 dung tch chung ca phi. Lng cn tng cng r rt trong chng ph nang,
trong vim ph qun, v cc trng thi co tht ph qun (hen), trong vim mng phi tit dch
v trn kh ngc, dung tch chung ca phi v lng vn u gim.
- Lng kh th ra ti a trong 1 giy (VEMS) v t s Tilfeneau (h s gia VEMS v dung tch
sng) gim khi c tc nghn ng lu thng kh qun.
b) Kh th: l cm gic ch quan, c i km c cm gic au n, pht sinh theo c ch phn x
c gim phan p O
2
v tng phn p CO
2
mu, hc c th l nhng tr ngi c gii ca thng kh
phi. C th phn nhiu loi:
- Kh th ph thuc vo tn s v lng th nh kh th nhanh su pht sinh khi gng sc, xc
cm, kch thch au, thiu O
2
thng c ngha thch ng mt mc nht nh. Kh th
nhanh, nng pht sinh ch yu trong cc bnh phi do tng tnh hng phn ca cc cm th
ph bo hoc gim tnh hng phn ca trung tm h hp, l loi h hp km hiu lc. Kh th
su, chm hay kh th vo pht sinh do co hp ng kh o v ng h hp trn. Kh th
ra pht sinh khi gim tnh n hi ca t chc phi.
- Kh th ph thuc vo nhp h hp :h hp chu kz
H hp chu kz l nhp th khng u, ngt qung tng t, hay gp nht l kiu Cheynes-
Stockes biu th bng mt on ngng th ri h hp tng dn, sau li gim dn ti ngng
th, c th lp li nhiu t. Mt xch ch yu ch yu ca h hp chu kz l gim tnh hng
phn ca trung tm h hp i vi cc tc dng sinh l ca CO
2
. H hp chu kz c th gp trong
cc trng hp bnh l c thiu O
2
nng, sc, try tim, suy thn
H hp hp hi cng l mt loi h hp chu kz pht sinh do hng phn mnh trung tm h hp
hnh no lc b mt tc dng iu ha ca v no, c th c s tham gia ca cc trung
tm h hp ty sng.
Kh th c th gp trong nhiu bnh
+ Cc bnh phi lm gim phn p O
2
, tng phn p CO
2
va gim pH mu
+ Cc bnh tim mch, mu nh hmg n s vn chuyn O
2
v CO
2

+ Cc bnh ri lon chuyn ha, ri lon cn bng axit baz
Trong bnh l h hp, kh th khng phi l triu chng bt buc v cng khng phi lun l
mt bo hiu nguy him nhng trong mt s trng hp kh th l mt yu t gip cho chn
on v tin lng bnht qu. V d trong vim ph mc c tin trin,trn dch, kh th l
triu chng quan trng ni bt ln hng u. Kh th ngy cng tng theo mc nghim
trng ca bnh trong ph phi cp. Trong lao x ri c c hai bn phi cc cng nhn m than
(silicose) kh th l triu chng duy nht ko di hng nm, c khi ngh ngi. Trong bnh lao,
kh th c th gip y sinh pht hin c tnh trng suy yu chc phn h hp: cho bnh nhn
ngh ngi nm yn theo di nhp h hp, sau c ng nh nh ni mt cu di, hoC th
lm kh th xut hin t ngt. mt bnh nhn lao n nh, bt u thy kh th c th
l do bnh tin trin, ngc li kh th gim, lng h hp tr li bnh thng l du hiu
chng t bnh c b, tn thng n nh hoc trn dch t tiu
2. Cc hnh thi ri lon thng kh phi
C th phn chia lm 3 loi:
Tng thng kh: khi tn s v lng th u tng nn thng kh pht v thng kh ph qun u
tng. Tng thng kh pht sinh do kch thch phn x v trc tip trung tm h hp bi tnh
trng gim phn p O
2
, tng phn p CO
2
v tng nng ion H
+
trong mu. Tng thng kh c
th gp trong cc trng hp sinh l khi nhu cu oxy ca c th tng (lao ng, luyn tp),
trong cc trng hp tng chuyn ha (st, nhim nng, nhim toan, u nng tuyn gip),
trong cc bnh phi v tim mch mch mu giai on u b p.
Tng thng kh dn ti tng phn p O
2
mu ng mch, lu di s gy tng o thi CO
2
,
nhc thn v nhim kim hi.
- Gim thng kh: khi c tng tn s h hp nhng lng th gim (th nhanh, nng) nn hu
qu s l gim phn p O
2
v tng phn p CO
2
mu gy u thn v nhim toan hi. Gim thng
khi thng gp trong cc trng hp trung tm h hp b c ch (gy m, nhim c thuc
ng, morphin, chn thng s no), ri lon thn kinh-c h hp (bnh bi lit, chn thng
ty sng, bin dng lng ngc), trong cc bnh l phi
- Thng kh khng u: khi bn cnh nhng vng thng kh tt c vng thng kh gim, biu
hin bng ting th yu t hoc thiu hn, dn n tnh trng thiu oxy mu v bo ha oxy
nhng vng thng kh tt khng tng c bao nhiu, tri li nhng vng thng kh km li
gim r rt, kt qu l phn p O
2
v bo ha O
2
mu u gim, tnh trng ng CO
2

thng khng c hoc ch tng khng ng k do CO
2
tng o thi nhng vng th b.
B-RI LON KH NNG KHUCH TN CA PHI
Kh nng khuch tn ca phi l lng cht kh c chuyn qua mng ph bo mao mch
phi trong 1 pht vi chnh lch phn p 2 bn mng l 1 mmHg. L kh nng chuyn cc
cht kh t vng c p lc cao n vng c p lc cht kh thp hn (hnh 2).
Kh nng khuch tn chu nh hng ca nhiu yu t:
1. Din khuch tn: l b mt cc ph bo c thng kh tip xc vi cc mao mch ang hot
ng, ngi l 90 m
2
, nhng bnh thng khng phi tt c cc ph bo u hot ng do
khi lao ng kh nng khuch tn mi c s dng ti a (hnh 3)
2. Mng khuch tn: cht kh mun c khuch tn vo mu phi qua 1 lp mng ph bo-
mao mch, dy 4m gm cc lp mng ph bo, dch khe t bo, ni mc mao mch, huyt
tng, mng hng cu (hnh 4)
3. H s khuch tn: cht kh trong mi trng mu mun c khuch tn qua lp mng ph
bo- mao mch phi ph thuc vo ha tan, ha tan ca CO
2
khon 20-25 ln ln hn
ha tan ca O
2
do t gp cc trng hp gim kh nng khuch tn ca CO
2
. Cht kh c
khuch tn t vng c p lc cao n vng c p lc cht kh thp hn , nh vy h s khuch
tn ca O
2
bng s lng O
2
hp thu trong 1 pht/pO
2
ph bo- pO
2
mao mch phi, bnh
thng khong 15-25 ml/mmHg/pht.
Ri lon khuch tn c th gp cc trng hp bnh l c gim din khuch tn (vim phi,
trn kh, trn dch), lm dy mng ph bo (trng ph nang, hen, x phi) hoc lm dy
mng mao mch (x mch mu phi). Kh nng khuch tn ti a gim dn theo tui c th l
do gim s lng mao mch phi v qu trnh x ha ngi gi. Ri lon kh nng khuch tn
thng dn ti gim paO
2
v gim bo ha O
2
(SaO
2
), mu ng mch gy thiu O
2
nhng t
nh hng ti paCO
2
.
C RI LON TUN HON MAO MCH PHI
C th thay i mc khc nhau ty theo tnh cht v din bin ca bnh:
1. Tng p lc ca mao mch phi:
Bnh thng cc mao mch phi rt mng, t chc m t nn d b gin v mu. Trong bnh
l, suy tim tri gy gin mao mch v mu phi, c th dn ti tng p lc cc mao mch
phi gy tr ngi v nh hng ti tim phi; bnh hen ph qun c th gy chn p tun hon
mao mch phi, nh hng ti tim phi dn n trng thi tm ph mn.
2. Ph phi:
Bnh thng huyt p ti cc mao mch phi rt thp, ch bng 1/7 huyt p ng mch (14-20
mmHg) do y p lc keo thng ln hn p lc mu nn c tc dng gi nc khi thot
ra v lm ph nang lun kh ro. Trong cc trng hp bnh l, khi c gin mch mu, p lc
ti cc mao mch phi tng cao hn so vi p lc keo, ng thi tnh trng thiu oxy gy tng
tnh thm mao mch nn cht dch huyt tng trn vo trong ph nang gy ph phi.
3. Bin i h s thng kh dng mu mao mch phi hay h s h hp thng kh 3,5-4 lit cng
c ti mt lng mu tng ng 4-4,5 lit mu/pht, nh vy c mt s cn bng gia h
hp v tun hon. Trong trng hp bnh l, cn bng ny c th b ri lon theo hai hng:
nu mt vng phi c thng kh tt, nhng tun han mu b ri lon hoc khng c (tc
mch, huyt khi) th vng s tng ng vi mt khong cht, paO
2
v SaO
2
gim,paCO
2

tng. Ngc li, vng c mu chy qua y nhng thng kh b ri lon hoc khng c
(cc bnh l phi) s tng ng vi mt shunt v paO
2
gim nhng paCO
2
t nh hng v
cond pg thuc vo cc khu vc o thi b v kh nng khuch tn ca CO
2
.
4. Bin i thnh phn kh ca mu :
Trong cc bnh l ca phi, thnh phn kh ca mu b thay i r rt :
- paO
2
gim di mc trung bnh (100- 104 mmHg).
- Nng O
2
mu ng mch gim (bnh thng 20,3 ml/100ml mu).
- SaO
2
gim di mc bnh thng (95-97%).
- paCO
2
mu c th gim di mc bnh thng (40 mmHg) gy tnh trng nhc thn, v lm
tng pH mu, nhim kim hi hoc paCO
2
tng cao gy tnh trng u thn, gim pH mu v
nhim toan hi.
III. NGUYN NHN V BNH SINH CA RI LON
H HP NGOI
Ri lon h hp ngoi c th pht sinh do nhiu nguyn nhn khc nhau :
A. DO RI LON CHC NNG NG H HP
TRN V KH, PH QUN
Thng gp hai hnh thi bnh l chnh : vim v tc.
- Vim mi, kh ph qun: do vim nn c biu hin ph n nim mc, tng tit nim dch gy
kh th, m kch thch cc th cm nim mc h hp gy ht hi, s mi, ho mc nht
nh c th nh hng ti thng kh pht, thng kh ph bo v kh nng h hp.
- Hp, tc ng kh o, ph qun: gy ri lon thng kh, kh th vo v tc hon ton
thng gy ra hin tng ngt th, nguy him n tnh mng nu khng cp cu kp thi.
1.Ngt.
- L hin tng tc nghn hon ton ng lu thng kh o gy thiu O
2
v ng CO
2
mu,
dn ti suy sp chc nng ton b c th v cht nu khng kp thi c bin php cp cu hp
l. Ngt cp din dng vt thc nghim thng gy cht ng vt rt nhanh, t 3- 6 pht.
a) Nguyn nhn gy ngt do 3 nhn t chnh:
- Do khng kh th khng thay i ( ngt trong phng kn, sp hm )
- Do tc nghn hon ton ng lu thng kh o: tc d vt ( tr em ), ph n thanh qun,
co tht, bp c
- Do ph nang b trn ngp nc: cht d8ui, ph phi cp
b) Din bin ca ngt : thng qua 3 giai on: ( hnh 5 )
- Giai on I: ng lu thng kh o b tc nghn nn thiu O
2
ng CO
2
gy kch thch phn
x, hng phn cc trung tm h hp v vn mch, biu hin h hp nhanh v su, th th vo
ko di, nhanh v mnh, huyt p ng mch tng rt cao c tc dng b p.
- Giai on II: b p bt lc thiu O
2
v ng CO
2
nhiu gy c ch trung tm h hp, th
chm li, nng, ri nh ch, huyt p ng mch cng gim dn, tim o chm do thn kinh
ph b kch thch v h thn kinh trung ng cng b ri lon, mt thc, c th xut hin co
git ton thn, v vi a, i do h c trn b co tht bt thng.
- Giai on III: c ch su sc v kit qu cc trung tm thn kinh cc phn x mt, ng t gin,
h hp hon ton nh ch, tim p chm, yu dn, huyt p tt nhanh, tim ngng p.
Nh vy cht do ngt l hu qu ca thiu O
2
trm trng v ng CO
2
mu gy chn p cc
trung tm thn kinh , trong trng hp ny paCO
2
c th tng ti 80mmHg cho nn trong cp
cu ngt ch yu l phi lm h hp nhn to hoc thi ngt loi thi CO
2
tr b cc nguyn
nhn gy chng ngi ng h hp, cung cp O
2
nhng khng nn dng O
2
nguyn cht ngay
v s lm mt phn x th b p vi trng thi thiu O
2
.
2.Hen ph qun:
L mt bnh d ng do khng th loi reagin, gy co tht h thng ph qun m biu hin lm
sng ch yu l cc cn kh th, c bit l th th ra.
Nguyn nhn v bnh sinh:
- Do cc d nguyn c trong hon cnh sinh hot v lao ng bnh thng nh bi nh, phn
hoa, cy c, kh hu, cht t
- Do d ng sau nhim khun, thng gp sau cc bnh nhim khun ng h hp , tai-mi-
hng, c bit sau vim xoang( 60,4%)
V bnh sinh ca hen, cn ch cc yu t di truyn( c ti 51,8% con ci mc bnh do di
truyn t b hoc m), v yu t thn kinh ( hen c th pht sinh theo c ch phn x c iu
kin v thng xut hin ban m khi trung khu v no b c ch khng kim ch c cc
trung khu thc vt di v no ).
Cc ri lon h hp trong hen:
- Cn hen thng pht sinh do tc dng ca d nguyn gy kt hp khng nguyn khng th gii
phng cc cht ha hc trung gian nh histamin, bradikinin, prostaglandinkch thch cc si ly
tm ca thn kinh ph v gy co tht h c trn v ph qun, tng tit nim dch, ph n v
vim cc nim mc ph qun dn ti cc cn kh th ra, bnh nhn rt kh th nh lng ngc
b p, thng phi ngi dy c th, mt xanh tm, tit nhiu m ri, thng kh t bo
gim, dung tch sng gim, VEMS v h s Tiffeneau gim, lng cn tng. Tn s cc cn hen,
thi gian ko dica cc cn ph thuc vo tnh cht ca bnh, thng nng v cn ko di
ngi trng thnh (hnh 6).
- Hen lu ngy c th lm gim tnh n hi ca t chc phi gy tnh trng trng ph nang,
nim mc ph qu ph i gy trng thi phi b c khi bnh thng. Ph bo cng, lun p
vo mao qun, lm tr ngi tun hon phi, gy tng huyt p ng mch phi, tm tht phi
tng cng hot ng lu di c th dn ti suy tim phi c gi l tm ph mn. Cn hen
c tnh l do tc ton b cc ph qun nh c th gy suy h hp, rt nguy him nu khng cp
cu kp thi.
B- DO RI LONCHC PHN CC PH BO
Ph bo c th b tn thng, hoi t nhu m (vim phi, lao) b mt kh nng hot ng
(trng ph nang, xp phi) hoc b trn ngp cht dch (ph phi )
1.Vim phi.
L mt trng thi bnh l ph bin trong nhn dn cng nh rong qun i, chim 49,3% trong
tng s bnh h hp, 17% trong tng s cc bnh ni khoa.
a)Nguyn nhn v bnh sinh:
- Do nhim khun: ph cu, lin cu v mt s virut thng c sn trong ng h hp, di
tc dng ca cc yu t thun li (lnh, mt mi) lm gim sc khng ca c th to iu
kin cho bnh pht sinh.
- Do nguyn nhn min dch: thiu gamma- globulin loi IgA lm gim kh nng thc bo chng
nhim khun ng h hp.
- Do cc nguyn nhn thi chin: bng, hi c chin tranh, chn thng gy mu phi, gy
tc mch do nhi mu hay t chc thi nt t vt thng a ti, hoc cng c th do phn x
t cc b phn khc gy mu v ri lon tun hon phi (vt thng s no. vt thng
bng)
b) Ri lon h hp trong vim phi :
- Kh th, th nng v nhanh do t chc phi b vim, tng tit dch di phng trong ph bo gy
tng hng phn cc cm th ph bo c ch lm th th vo sm b c ch ng thi din h
hp v khuch tn kh cng gim. Hu qu l thng kh ph bo gim, dung tch sng cng gim
gy tnh trng thiu oxy.
- Mu qua vng phi b vim khng c bo ha y oxy nn bo ha oxy ca mu gim
r rt (c khi ch cn 70%). Thnh ph nang b ph n dy nn cng nh hng n kh nng
khuch tn ca phi.
- Do cc khu vc lm tng thng kh b p nn thng khng c u thn. Thiu oxy, xanh tm
v u thn r ch gp cc trng hp c km vim ph qun (ph qun - ph vim) cc ph
qun nh b vim, ph n, bt kn cc dch nhy hoc co tht cc ph qun nh.
2. Ph phi cp (OAP)
L mt cp cu ni khoa s do ph bo v cht m khe b trn y huyt tng gy ngt th.
a) Nguyn nhn v bnh sinh:
- Do bin chng ca suy tim tri, v tim phi do mt l{ do no (lo ngh, gng sc, truyn dch
nhiu, kch thch ca cht c) tng cng hot ng, tng mt lng mu qu nhiu ln phi
gy mu v thot dch vo cc ph bo.
- Do nhim c (hi te, hi c chin tranh, nitrat bc, c t vi khun) lm tn thng
mng ph bo mao mch.
- Do thn kinh: gy co tht mao mch, tng huyt p vng tiu tun hon.
b) Ri lon h hp trong OAP:
- Kh th d di v ngy cng tng do mu tip tc c tng ln phi, gy tng cng mu,
tng tnh thm mao mch phi nn dch huyt tng c trn vo trong ph nang ngy cng
nhiu. Biu hin lm sng l cc ting rn t ngy cng nhiu c 2 bn phi. Thng kh ph
bo, cc dung tch phi, kh nng khuch tn ngy cng gim r rt gy tnh trng thiu oxy
nghim trng.
- Huyt p ng mch ngy cng gim do mu b cc mao mch phi, dch huyt tng trn
vo cc ph nang nn lng mu v tim tri gim st. Thng cht trong tnh trng kh th
nghim trng, huyt p ng mch tt nhanh, vt v, ming v mi tro ra nhng dch ln bt
mu hng.
Trong cp cu ph phi cp phi nhanh chng hn ch lu lng mu t tim tng ln phi
(chch mu, garo, bm oxy p lc cao) ngn cn tit dch vo trong ph bo, ng thi phi
ci thin hot ng ca tim (tr tim), hn ch hot ng v lm gim nhu cu oxy ca c th,
lm gim cc kch thch gy phn x co tht tun hon phi (dng morphin)
RI LON CHC PHN CC PH MC
Thng gp l cc bnh vim v trn dch, trn kh ph mc.
TRN KH PH MC
Cn gi l trn kh ngc, l hin tng bnh l khi c thng kh lt vo khoang ph mc lm nh
hng ti chc nng h hp ca phi.
a)Nguyn nhn v sinh bnh:
- Ngoai khoa thng do cc vt thng lng ngc, c th chia thnh trn kh kn khi vt thng
c bt kn, p lc trong khoang ph mc thp hn p lc bn ngoi, nh vy trn kh c
hn ch , trn kh m khi khoang ph mc thng v p lc ngang vi p lc bn ngoi v trn
kh van khi p lc bn trong khoang ph mc cao hn, v khi th ra l hng c t chc bt
kn, khng kh ch vo mi ngy mt tng m khng thot ra c.
- Ni khoa, thng do lao,c th gp trong p-xe phi, ung th phi, khng kh t cc ph nang
b tn thng trn vo khoang ph mc.
b) Ri lon h hp trong trn kh ngc:
- Ph mc b trn kh s p vo phi lm gim din h hp v gy tr ngi cho hot ng ca
phi. Tnh trng ny kch thch phn x cc cm th phi v ph mc gy tng h hp b p
cho nn vi trn kh kn v hn ch, bnh nhn c th chu ng c m t nh hng ti sinh
hot (p phi trong iu tr lao)
- Trn kh nng v t ngt c th gy sc ph mc. Phi b p mnh, co nh li rn phi,
gim din h hp, khuch tn qu nhiu s dn ti kh th d di v thiu oxy nghim trng.
Cc mch mu phi b chn p nh hng n hot ng tim, huyt p ng mch, huyt p
tnh mch tng. Bnh nhn c th cht do kh th trm trng, huyt p h nhanh, phi xp,
hot ng phi lnh cng b hn ch, trung tht b chn p, tim khng hot ng c.
Hu qu ca trn kh c th l vim, trn dch thanh huyt, trn dch mu hoc m .Trng hp
nng, khi khi cn li hi chng dy dnh ph mc nh hng lu di n chc nng ca
phi.
IV. SUY H HP (SUY TH)
Cng nh vi cc c quan h thng khc, tnh trng chung ca ri lon chc nng h hp ngoi
c gi l suy h hp hay suy th. Nh vy, suy h hp l tnh trng b my h hp ngoi
khng m bo c chc nng cung cp oxy v o thi CO
2
trong cc iu kin bnh thng
v bt thng ca c th, biu hin bng bin i r rt thnh phn kh ca mu vi nhng du
hiu h hp ngoi.
1.Nguyn nhn v bnh sinh ca suy h hp:
- Do hu qu ca cc bnh l v phi v ph mc (ri lon thng kh, khuch tn)
- Do hu qu ca cc bnh nh tn thng dy thn kinh (ng c thuc ng, chn thng s
no, bnh l tim mch (suy tim), bnh l ngoi khoa (sng n, vi lp, chn thng hoc bng
lng ngc).
2.Biu hin ch yu ca suy h hp :
- Kh th l du hiu pht hin u tin, giai on u l kh th khng tng ng vi nguyn
nhn v ch xut hin khi lao ng (suy h hp tim tng). Sau kh th xut hin c khi lm
vic nh v c khi ngh ngi (suy h hp r rt).
- Bin i thnh phn kh ca mu:
+ paO
2
gim ti 92mmHg, nng, cp tnh c th di 50mmHg.
+ SaO
2
gim di 94%, nng v cp tnh gim di 70%.
+ paCO
2
tng thm 44mmHg, nng, cp tnh tng trn 80mmHg.
- Ri lon cc chc nng h hp ngoi: thng kh v khuch tn u gim, nhim toan ng
CO
2
v cc sn phm axit ca chuyn ha, xanh tm. Cui cng suy h hp c th kt hp vi
suy tim lm cho qu trnh bnh l ngy cng nghim trng.

58. BNH L DI TRUYN NGI
HONG DUNG

I. I CNG V BNH L DI TRUYN NGI
Di truyn l mn hc nghin cu nhng quy lut chuyn tip, nhng c im (tnh trng) gia
cc c th cng chung ngun gc huyt thng t th h ny sang th h khc. Con chu c
nhng c im v hnh dng bn ngoi, cng nh v cu trc, chc nng bn trong c th
ging nh ng b, cha m.
Kh nng bin d, di truyn cng l mt c im ca c th sng, th h con chu cng c th
c nhng du hiu khc vi ng b, do tnh di truyn th n hoc do nh hng ca cc yu
t ngoi cnh tc ng ln c th ang pht trin.
C s ca tnh di truyn l cc yu t ni di truyn hay cc cht liu di truyn : axit
deoxyribonucleic (ADN) trong cc gen nm trn nhim sc th (chromosome ) ca nhn t bo.
cc protit c th c tng hp ribosom ngoi bo tng, cn ADN li ch yu nm trong
nhn t bo, vy lm sao truyn t c thng tin di truyn ? Caperson ra cng thc ni
ting ADN ARN protit , chng minh rng ADN khng phi l trc tip m lm nhim v ch
huy , nh hng qua ARN. Mt m di truyn c sao chp li mt cch chnh xc nhng chi
tit tinh vi nht ca cu trc thng qua ARN thng tin (mARN) c s tham gia ca h thng men
, cho nn nhng sai st ca qu trnh sao chp thng tin di truyn , tc cc bin d, xy ra mt
ln no y ri th sau ny, nhng sai st c th c sao chp li v truyn ng nh vy
cho th h sau. iu ny soi sng mt phn cho nguyn nhn v bnh sinh mt s bnh di
truyn trong y hc.
S pht trin v pht sinh cc bnh l di truyn ph thuc vo s lin quan gia 2 yu t :
- s bin d nhng yu t ni di truyn (ADN, gen, chromosome).
- Tc dng ca mi trng ngoi.
Trong s pht sinh ca bnh di truyn, mi trng ngoi c mt vai tr rt ln. nh hng ca
mi trng ngoi c th to iu kin cho bnh pht sinh, v ngc li, c th ngn tr s xut
hin ca cc du hiu bnh l ca bnh di truyn. T nhng trn, ta c khi nim :
1. Bnh di truyn chnh thc l cc bnh di truyn pht sinh do kt qu ca nhng bin i
bnh l ca cc yu t ni di truyn (ADN, gen, chromosome ). S pht sinh bnh v s xut
hin cc du hiu bnh l ph thuc cht ch vo s c mt ca cc gen b bin d nh bnh
hemophili, bnh huyt cu t, bnh lon dng sn (chondrodystrophie), bnh m mu
(daltonisme), bnh tht iu tiu no, vv...
2. Bnh di truyn do c sn nhng yu t bm di truyn (praedispositio). Trong trng hp ny,
bnh phat sinh ph thuc vo s lin quan gia cc yu t di truyn v mi trng bn ngoi ,
v kh nng xut hin cc du hiu bnh l khng nht thit phi ph thuc vo gen bin d
tng ng m mc no b bin i do nh hng ca mi trng bn ngoi. Nh bnh
i tho ng, bnh x va ng mch, bnh thng phong (Goutte hay arthritis urica) . yu t
bm di truyn ca mt s bnh no biu hin bng trng thi bin i cc phn ng bnh
thng i vi mt tc ng bn ngoi c xc nh, th d trong bnh i tho ng ,
yu t ny c biu hin bng mt phn ng khng bnh thng i vi glucoza (ng biu
hin glucoza bnh l ) mc d lc i tho ng cha pht sinh. Cho nn trong cc trng
hp ny , yu t di truyn ch lm nhim v hnh thnh c a, to iu kin cho bnh pht sinh
khi c cc yu t bn ngoi ph hp (ri lon dinh dng, thay i chuyn ho, tinh thn cng
thng, vv... ) v do bnh thng pht sinh mun trong qu trnh sng khi c quan, t chc
hoc chc nng pht trin y . Khng nn nhm bnh di truyn vi bnh bm sinh ch
bnh bm sinh b mc bnh ly truyn ngay t trong bo thai (th d bnh giang mai) hoc t
lc a tr mi sinh (lao), nhng nu ngi m b bnh mang thaic cc bin php d phng
chu o th a tr sinh ra tch khi ngi m vn bnh thng khng b ly bnh. Bnh di
truyn nht thit phi c bin d bnh l gy bin i cc cu trc phn t bn trong c th nn
cn gi l bnh l phn t (Pauling), v bnh c th bm sinh. Phy sinh ngay trong giai on
bo thai hoc tr s sinh (mt s th st mi, tha ngn, cm ic bm sinh, hemophili, vv... )
hoc c tui trng thnh (mt s bnh i tho ng , bnh thng phong, chng ma
git, vv... ).
II. NGUYN NHN V BNH SINH CA NHNG BNH L DI TRUYN
Nguyn nhn ch yu v trc tip ca bnh l di truyn l cc bin d bnh l, tc cc thay i
c tnh cht t bin cc yu t di truyn ca c th gy nn do :
1. Cc yu t l hc : tia x nh tia alpha, beta, gamma liu ln hoc liu nh nhng ko di. Tia
Rn-ghen, tia v tr, tia cc tm, siu m cng c th gy bin d ng vt.
2. Cc yu t ho hc : cc cht c ho hc nh fomalin, hydroxit, m tc nit, cc cht chng
chuyn ho nh 6MP, ame amethopterin, cc cht c chin tranh loi tr su dit c nh 2-4-
5 T, DDT,CT, thc n b nm , mc ...
3. Cc yu t sinh hc nh nhim virut (ph n c thai mc cc bnh si, st vng, herpes, ...
thng hay c con d dng)
Ngoi ra cn mt s yu t nh hng nh ri lon dinh dng : thiu mt s axit amin cn
thit, thiu sinh t, ri lon cn bng ni tit, m cm th vi cc mm (cc d tt d to c
i vi mt, no, cc chi l cc mm ca ngoi b v ng thn kinh, cn vi cc mn ca ni v
trung b th khng gy c) v mc cm th ca cc c th, ging, loi, ...
Cc bin d bnh l{ lm thay i cu trc phn t ca ADN , lm sai lch cc m di truyn, kt
qu l lm thay i mt s c im ca c th v pht sinh cc du hiu bnh l nht ng c
hiu cho tng loi bnh l di truyn nh :
- Nhng d tt ca cu trc c th v ni tng : tha ngn, dnh ngn, st mi, tt nh u, d
dng lng ngc, tim, phi , vv...
- Nhng bin i cc chc nng sinh l{ ca c th : cao huyt p, m mu, qung g bm sinh,
vv...
- Nhng bin i v chuyn ho vt cht : cc bnh di truyn v ri lon men nh phenylaxeton
niu, chng bch tng, bnh i tho ng.
Cc bin d bnh l c th nh hng ti gen (bin d gen) hoc nh hng ti chromosome
(bin d chromosome hay bnh chromosome).
III. C CH BNH SINH CA NHNG BIN I DI TRUYN CA GEN
Gen l mt on nh ADN nm trn chromosome ca nhn t bo. Mi gen quyt nh mt
tnh trng ca c th v c di truyn t th h ny sang th h khc theo nhng quy lut tinh
vi nht nh. Mi gen c coi nh mt n v chc phn ch huy s tng hp mt protit hay
men , v mi bin d ca gen u nh hng ti s lng hoc cht lng sn phm, gy thay
i cu trc ca protein, hot tnh ca men c tng hp di s kim sot ca gen . Mi
gen iu khin s hot ng ca mt hay nhiu men, t bin gen lm cc men ngng hot
ng , b chn li mt im nht nh trn dy truyn tng hp nn bin d bnh l c th lm
thay i bn cht mt sc t, tnh c hiu ca mt khng nguyn, hoc bin i kh nng tng
hp mt axit amin, mt protit c hiu no .
Jacop.F v Mono.J (1961) trn c s nghin cu chi tit s tng hp mt s men vi khun
ra mt thuyt v hot ng ca gen , tc l mi quan h gia s m v hm gen (cm ng v
chn p) trong c ch tng hp protit. S tng qut nh sau :
Cc gen cu trc c chc nng xc ng trnh t cc axit amin tng hp mt protein hay mt
men no theo mu nh. Thng thng cc gen cu trc xp thnh tng nhm (X,Y,Z),
nm u nhm gen cu trc l mt on di truyn c bit ho gi l gen khi ng O
(operator) tt c to thnh mt Operon. Mun tng hp mt s men hoc protein no phi
c mt cht cm ng l mt cht nn c hiu tng ng vi sn phm . ng thi c mt hin
tng ngc li : hin tng chn p do cc cht chn p hay cht km hm c sn trong t
bo. Cht ny b kh hot khi c mt cht cm ng trong mi trng. Do tc dng tng h
ny, Jacop v Mono xut mt loi gen gi l gen iu ho v gi thit rng nhng gen iu
ho ny kim tra s tng hp cc cht chn p trong t bo. khi gen iu ho b t bin th s
tng hp mt loi mrn hay protein s b thay i tc , ngng li gy thiu ht s lng hoc
sn xut vi tc v t chc gy thnh bnh. Nh vy, bin d bnh l c th xy ra:
- gen cu trc th c th sn phm tng hp ra s b bin i v cht, tc l thay i v cu
trc hnh thi v c chc phn ca protein, hoc thay i hot tnh sinh l ca men.
- gen iu ho th tc tng hp s b thay i gy nn bin i v s lng protein hoc
men : thiu hoc tha qu mc, sn xut v t chc , lan trn, vv...
- gen khi ng do tc dng ca cht chn p s km hm cng mt lc tc dng ca ton b
nhm gen cu trc.
A MT S BNH DI TRUYN DO BIN D GEN THNG GP
1. bnh huyt cu t (hemoglobinose)
L nhng bnh di truyn do ri lon tng hp huyt cu t bnh thng, bin d gen gy xut
hin cc loi huyt cu t bnh l{ khc nhau ( pht hin trn 50 loi huyt cu t bnh l trn
nhiu vng a d khp th gii),
- Bnh huyt cu t S : nm 1949 Pauling cng b nghin cu v mt loi huyt cu t bt
thng chit xut t hng cu cc bnh nhn thiu mu c hng cu hnh lim. huyt cu t
bnh thng ca ngi l huyt cu t A (HbA) l mt protein kch thc trung bnh , phn t
lng 66700, gm 4 bn n v l 4 chui polypeptit cun li mt cch phc tp : 2 chui alpha
v 2 chui beta. V ho hc, gia HbA v Hb bnh l S ch c mt khc nhau duy nht l : bin d
xy ra chui polypeptit 4, chui beta trong v tr axit amin th 6 l ra l glutamin c tch
in v sai st bin d nn b thay th bng valin khng tch in. S thay i ny to thnh mt
huyt cu t bnh l : HbS, cu trc thay di th hnh dng, chc nng hng cu cng b thay
i, hng cu thnh hnh lim, d b kt dnh vi nhau gy hu hng cu v c th lm tc cc
mch mu , gim phn p oxy mu gy trng thi thiu oxy nghim trng nn cn gi l bnh
thiu mu huyt tn c hng cu hnh lim.
- Bnh huyt cu t F : trong mu thai nhi v tr s sinh , hng cu mang huyt cu t F , tc l
huyt cu t bo thai gm 2 chui alpha v 2 chui gamma. Khi a tr ra i, yu cu h hp
v s tng phn p oxy mu l tn hiu thay th HbF bng s tng hp HbA, cho nn ch sau vi
tun, hm lng HbF st xung nhanh chng v tng hp HbA cng nhanh chng tng ln, n
cui nm th 2 th hu nh hon ton khng cn HbF . bin d gy c ch tng hp HbA , tng
hp chui beta b cht chn p km hm nn trong mu vn tn ti HbF vi t l cao, hng cu
c hinhd phng gia, hnh bia nn d b hu, gy thiu mu.
2. Bnh di truyn v chuyn ho .
L nhng bnh di truyn do ri lon tng hp cc men chuyn ho ca t chc. Khi cc gen
men b bin d s gy nhng bin i bnh l v s lng (thiu men) hoc cht lng (gim
hot tnh men) do cc phn ng sinh ho b c ch dn ti ri lon chuyn ho v bin i
cc chc phn ca c th. Hin nay pht hin trn 40 bnh di truyn v chuyn ho (Garrod,
1962).
- cc bnh ri lon chuyn ho phenylalanin (hnh 1)
Bnh c th biu hin nhiu khu khc nhau :
Bin d khu thiu ht men parahydroxylaza nn phenylalanin khng chuyn ho thnh
tyrosin c, li v thoi bin cho cc th phenylxeton o thi qua nc tiu gy bnh
phenylxeton niu.
Bin d cc khu thiu ht men tyrosin transaminaza gy bnh tyrosin ; thiu men
hmgentisicaza gy bnh ncpton niu ; v thiu men tyrorinaza, DOPA khng c chuyn
ho thnh sc t nn gy bnh bch tng.
Bnh i tho ng : mt s bnh i tho ng c tnh cht di truyn do bin d cc gen
tng hp insulin ca tu o gy thiu ht insulin hoc tng hp insulin khng c hot tnh.
Cc bnh di truyn do ri lon protein huyt tng : do thay i mt hay nhiu nucleotit dn
n thay i axit amin v t thay i cu trc v chc nng protein : cc bnh lon globulin
min dch (thiu albumin, thiu gamma globulin bm sinh, thiu haptoglobin, vv... ) ; cc bnh
ri lon ng mu do thiu cc yu t chng chy mu A,B, cc bnh lon fibrinogen mu, vv...
B CC KIU TRUYN BNH DI TRUYN DO BIN D GEN
Hu ht cc bnh di truyn u thuc loi bin d gen, c th truyn bnh cho th h sau bng
nhiu dng :
1. di truyn bnh l theo kiu tri : do gen bnh l l nhng gen tri nn bnh thng xut hin
vi nhng du hiu bnh l r rt biu hin ra bn ngoi. v mi i nhim sc th c nhng i
gen tng ng (i gen alen) m mt l ca b, mt l ca m. Nu ch c b hoc m b bnh
truyn gen bnh tri d hp tth phn b gia con mc bnh v con bnh thng l 1/1.
nhng con bnh thng ny nu ly v hoc ly chng bnh thng th th h sau hon ton
bnh thng. nu c hai b m u truyn gen bnh tri ng hp t th thng thai s cht
sm hoc con ci sinh ra u mc bnh nng, kh nui sng. Cng c mt s bnh di truyn tri
khng xut hin th h ny m ti th h sau na mi xut hin. Xp vo loi ny c cc bnh
teo dy thn kinh thnh gic bm sinh, cn th, tt tha ngn, ngn ngn (do khng pht trin
t gia), tt ngn xng chi (ln), bnh ma vn, ... (hnh 2)
2. di truyn kiu ln, lp. Do cc gen b bin d l cc gen ln , b ln t, che lp khi c mt gen
alen ca n nn b bnh thng biu hin yu t hoc khng biu hin ra ngoi, ngi mang
gen bnh bn ngoi c v kho mnh, cc chc phn c th t thy biu hin khc thng
nhng vn c th truyn gen bnh cho cc th h sau. S truyn bnh d hp t ny c th tn
ti lu di , ngm ngm, kh pht hin. bnh c th pht sinh mnh m khi kt hp 2 gen bnh
to thnh nhng ng hp t bnh l{. Do s kt hn cng huyt thng thng l nguyn
nhn gy nhng bin c tai hi cho th h sau. Xp vo loi ny c mt s th bnh st mi, d
tt vm hng, tt nh u, cc bnh ri lon chuyn ho, bnh vy c (tr sinh ra b cht t
ngt do thiu kh nng th ca da), c bit bnh Tay Sachs vi biu hin l tr ngu n, khng
ngi c, m, thng cht sm (hnh 3).
3. di truyn bnh l theo kiu tri khng hon ton (trung gian).
Khi i gen , mt bnh thng, mt bin d u l gen tri th 2 c tnh bnh thng v bnh l
u c th biu hin ra ngoi, nh vy bnh nhn vn tng i kho mnh d vn mang bnh.
th d cc bnh huyt cu t khi s lng huyt cu t bnh l khng qu nhiu hn so vi
huyt cu t bnh thng.
4. di truyn c lin quan n gii tnh. Do gen bnh l l gen ln v thng nm
chromosome gii tnh X. th d bnh hemophili A do bin d gen gy thiu yu t chng chy
mu A (yu t VIII). bnh thng gp nam gii vi t l 1/10000 dn. gen ln kim sot bnh
nm chromosome X nam gii l ngi mc bnh v n gii thng ch truyn bnh.
- nu n gii mang gen bnh d hp t th bnh thng khng biu hin ra ngoi , nhng kiu
di truyn vn l XXa (Xa l chromosome gii tnh mang gen bnh )v truyn bnh c cho th
h sau. Nu nam gii mang gen bnh th kiu di truyn l XaY v biu hin bnh r rt ra
ngoi.(hnh 4)
- nu ch mt b hoc m mamh gen bnh d hp t th con ci 50% s b bnh hoc mang gen
bnh , cng vi nguyn tc nam mc, n truyn, nu c hai b m cng mang gen bnh ng
hp t th 75%kh nng con ci b bnh , trong 25% con trai mc bnh r rt (XaY) v 25%
con gi ng hp t mc bnh (XaXa), 25% con gi d hp t truyn bnh (XXa). Do hn
nhn cng huyt thng gia mt nam mc bnh v mt n truyn bnh c th gy nhiu bin
c nguy him, nh hng lu di n ni ging. bnh m mu (daltoninsme) cng di truyn
theo gii tnh v hay gp nht l khng phn bit c mu vi mu xanh. Hin nay ngi ta
tnh rng c ti 60 bnh di truyn c lin quan ti gii tnh ngi, a s l cc di vt di
truyn ca mt nh bnh qung g bm sinh, chng cm ic bm sinh, vv...
IV. C CH BNH SINH CC BNH L DI TRUYN DO BIN D CHROMOSOME
Phc hp chromosome hay b nhim sc th bnh thng ca ngi gm 23 i , 22 i
chromosome thng v 2 chromosome gii tnh. XX n v XY nam. Khi phn chia gin phn
gim s, mi t bo trng v tinh trng u ch c 23 chromosome , n gii to thnh cc giao
t ng nht , u c mt chromosome X, cn nam gii to ra cc giao t c chromosome X v
Y vi tie l ngang nhau v s th thai cu thnh mt cch ngu nhin cc hp t XX hoc XY ,
iu ny gii thch s cn bng tt nhin gia 2 ging. V nh vy , cc bnh l do bin d gen
trn chromosome X thng c ngun gc t ngi m.
Khi mt yu t bnh l{ no tc ng ln chromosome th chromosome c th b bin d,
chuyn sang mt trng thi bn mi v pht sinh bin d bnh chromosome (hnh 5) . pht
hin bnh chromosome, ngi ta thng dng phng php cy t bo (c th x dng bt k
loi t bo no : tu xng, t bo mu ngoi vi, da, t bo sinh dc, vv... ) sp xp thnh b
nhim sc th pht hin nhng sai st v s lng v chn on cht lng ca
chromosome bng phng php dng thimidin 3, pht x t ng, ... Bin d chromosome c
th tc ng ti cc chromosome bnh thng hoc chromosome gii tnh.
A BIN D CC CHROMOSOME THNG
1. Bin i v s lng do khi nhim sc th phn chia nhng khng tch ri v nh vy mt
giao t s c mt nhim sc th tha trong khi giao t kia li thiu. Kt qu l c d dng v
hnh th v mc bnh vi s lng chromosome nhiu hoc t hn bnh thng. c trng hp
b phn nhim sc th tng s lng qu mcgi l a bi (nhn s t 2n ti 3n, c khi 4n hoc
hn). th d bnh b ba hay hi chng 3 nhim sc th nh bnh Down c 3 chromosome s
21. cc bnh ung th thng c b nhim sc th loi bi 50 80 chromosome.
2. Bin i v cht lng : nhim sc th rt d dng b gy, v t nhin, hoc di tc dng
ca cc yu t l ho hoc sinh hc. Khi mt nhim sc th b gyli c th gn vi bn thn n
hoc gn vi nhim sc th khc gy nhng thay i v nhim sc th sau y :
- hin tng mt on (delection) : khi nhim sc th b gy v on gy b mt i nh trong
bnh bch cu (mt on chromosome 21), bnh mo ku do b d dng thanh qun (mt
on 1 chromosome nhm B)
- hin tng chuyn on (translocation) do chuyn ch mt on chromosome ny sang mt
chromosome khc v nhp on (duplycato) do chiu di ca chromosome c tng cng
do lp thm mt on ca chromosome khc (hi chng 3 gen 21 do mt mnh ca nhim sc
th s 14 n gn thm v chromosome 21). (hnh 7)
- Hin tng o on o ngc th t trc sau ca cc gen trong chromosome , him gp
hn (hnh 8).
Cn c th gp hin tng ng nhim sc th v nhim sc th nhn (hnh 8ab) trong mi
trng nui cy di tc dng ca cc yu t khc nhau. Ni chung cc bin i ny t gp v
thng khng truyn t th h ny sang th h khc nh bin d gen m thng ch pht sinh
tng th h m thi.
3. Mt s bnh c bin d chromosome thng gp
- bnh b ba (trisomie) hoc hi chng 3 nhim sc th . hay gp nht l bnh Langdon Down
hay ngu n bm sinh, c im l thiu nng v mt tinh thn (oligophrenia), c d dng : u
to, mt ng nghch, gy phng, mt xch xa nhau, chm ln, c d hnh xng lng ngc, thay
i nt vn tay v hay c tt bm sinh tim ... Cc bnh b ba khc nh b ba 13, 15, 18 ..
thng l tr non, hoc cht ngay sau khi sinh, c nhiu d tt, d hnh , qui thai.
- bnh bch cu (leucose) l bnh c tnh ca c quan to mu, c th pht hin nhng bin i
chromosome r rt nh tha mt s cc chromosome nh (cc i 6 - 12) to thnh cc t bo
c tnh bnh l c t 56 60 chromosome. V cht lng c hin tng mt on mt trong
i chromosome 21 c gi l 21p (phyladenphia) hoc thiu hn mt chromosome 21.
- cc bnh c tnh khc thng l tha chromosome hoc a bi th : bnh Waldenstrom trong
mu c hin tng tng cc globulin cao phn t v xut hin nhiu t bo c t 60 80
chromosome vi cc chromosome ngoi l rt to , khc thng. bnh phng x cp vi nhiu
chromosome b gy v nhng ri lon cu trc chromosome khc .
B BIN D CC CHROMOSOME GII TNH
Nguyn nhn do bin d xy ra trong giai on gin phn gim s, khi cc chromosome ng
lot c phn tn cho cc t bo giao t khc nhau. Nu i chromosome khng c phn
tn ri vo mt tinh trung hoc mt trng th t bo tha mt chromosome sinh dc, v t
bo khc s thiu mt chromosome. S kt hp cc giao t bt thng ny s to thnh cc
bo thai nam hoc n bnh l c cc b chromosome bt thng. (hnh 9).
- hi chng Turner xy ra khi b nhim sc th thiu mt chromosome gii tnh, thng l
Turner n, ch c 45 chromosome : 44A, X0. McLean (1964) nghin cu trn 10000 tr s sinh
ti nh h sinh Edinbourg thy t l mc bnh l 0,4/10000 tr em gi. c im ca bnh l c
th pht trin chm, ngi ln b; c quan sinh dc km pht trin, trng thi nhi tnh, khng
c kinh nguyt v thng v sinh, tr thng minh cng chm pht trin.
- hi chng Klinefelter : xy ra khi b chromosome tha mt chromosome gii tnh, tc l c 47
chromosome vi 3 chromosome sinh dc XXY (44A,XXY). Bo thai nam nhng pht trin c th
thin v n tnh, ngi dng cao, chn tay di, da mn, ting ni thanh, c th yu nhc, b
phn sinh dc pht trin chm, c th gim xut tinh hoc v sinh, theo quy lut tr thng minh
cng chm pht trin.
- hi chng qu n hay siu n do c 3 chromosome sinh dc XXX, thng km theo thiu nng
bung trng v v sinh.
- thiu mt chromosome sinh dc kiu YO t gp v thng cht ngay ttrong giai on bo thai
hoc ch sng c my thng. Cn hin tng i nam i n l do ri lon cc gen c bit
trong cc nhim sc th gii tnh. (hnh 10)
Ni chung cc bin lon v chromosome thng khng c tnh cht di truyn r rt do bin d
ch xy ra mt s t bo hn ch v thng ngi bnh cht sm hoc v sinh.
V. NGUYN TC D PHNG V IU TR CC BNH L DI TRUYN
Cc bnh l di truyn thng c tnh cht n nh, iu tr nhng sai st trong cu trc phn t
ca cc gen v cc chromosome bin d hin vn cn l vn y hc cha th gii quyt d
dng, nhng pht hin sm v ng bnh di truyn cng to iu kin tt cho d phng v
iu tr.
Hng nghin cu hin i l lp li cn bng thng tin di truyn, c th tr bnh bng cch a
cc ADN lnh vo c th b bnh, ghp c quan , hoc tng hp cc gen nhn to thay th.
V vy trong tng lai, bnh di truyn khng cn l nh mnh m con ngi c kh nng ci
to, gii quyt cc bnh l di truyn.
Trc mt, vn d phng, iu tr bnh l di truyn c gii quyt bng nhng bin php
thc t :
1. u tin l nhng vn x hi, cn p dng rng ri v c quy m vn nghin cu v
bnh l di truyn, t l xut hin cc bnh trong tng khu vc a d trong nhn dn, tn s
bin d v cc c ch phc tp trong bin d di truyn , lm sng t cc iu kin thun li v
cc nguyn nhn gy bin d cng nh c ch bnh sinh ca bnh , tc dng ca cc gen bnh
l.
2. Pht hin nhng ngi truyn bnh d hp t c cc gen ln bin d v a s bnh di truyn
nng thng truyn bnh theo kiu ny, nn chn on bnh gp nhiu kh khn. vn tranh
kt hn gia nhng ngi cng huyt thng cng c th ngn nga c mt phn, song cng
c nhng kh nng bnh pht sinh do s phi hp ca cc gen bnh d hp t khng cng h
hng huyt thng, m cng cn d phng trnh bnh lan truyn rng ri trong nhn dn.
3. D phng cc bnh di truyn bng cch loi b cc yu t mi trng c th pht huy tc
dng ca cc gen bin d, t lm gim xut hin bnh v s pht sinh bnh di truyn ph
thuc vo kiu di truyn ca mi c th ph thuc cht ch vi mi trng ngoi. th d loi b
phenylalanin trong thc n hoc loi b galactose c th trnh c bnh phenylxeton niu v
tng galactose mu. mt s bnh di truyn nh thng phong, x va ng mch, huyt p cao,
i tho ng gii quyt bng ci thin iu kin , hon cnh sng, dng cc hormon, ci thin
dinh dng v chuyn ho, v sinh, vv... c th gim s xut hin bnh, hoc gim bt hu qu
, hn ch bin chng, ci thin chc nng, ... Tuy nhin khi ngng cc bin php trn, bnh c
th li pht trin.








HT.


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