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B Y t

Bnh hc v iu tr ni khoa
(kt hp ng - ty y)
(Sch o to bc s y hc c truyn)

M s: D.08.Z.24 Ch bin: PGS. TS. Nguyn Th Bay

Nh xut bn y hc H ni - 2007
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Ch o bin son V Khoa hc & o to, B Y t

Ch bin PGS.TS. Nguyn Th Bay

Nhng ngi bin son PGS. TS. Phan Quan Ch Hiu ThS. Ng Anh Dng PGS. TS. Nguyn Th Bay BSCKII. Nguyn Th Lina

Tham gia t chc bn tho ThS. Ph Vn Thm

Bn quyn thuc B Y t (V khoa hc v o to)

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Li gii thiu
Thc hin mt s iu ca Lut Gio dc, B Gio dc v o to v B Y t ban hnh chng trnh khung o to bc s y hc c truyn. B Y t t chc bin son ti liu dy - hc cc mn c s, chuyn mn v c bn chuyn ngnh theo chng trnh trn nhm tng bc xy dng b sch chun v chuyn mn m bo cht lng o to nhn lc y t. Sch Bnh hc v iu tr ni khoa kt hp ng - Ty y c bin son da trn chng trnh gio dc ca i hc Y Dc Thnh ph H Ch Minh trn c s chng trnh khung c ph duyt. Sch c cc nh gio giu kinh nghim v tm huyt vi cng tc o to bin son theo phng chm: kin thc c bn, h thng; ni dung chnh xc, khoa hc, cp nht cc tin b khoa hc, k thut hin i vo thc tin Vit Nam. Sch Bnh hc v iu tr ni khoa kt hp ng - Ty y c Hi ng chuyn mn thm nh sch v ti liu dy - hc chuyn ngnh bc s y hc c truyn ca B Y t thm nh vo nm 2006. B Y t quyt nh ban hnh l ti liu dy - hc t chun chuyn mn ca ngnh Y t trong giai on 2006-2010. Trong qu trnh s dng, sch phi c chnh l, b sung v cp nht. B Y t xin chn thnh cm n cc cn b ging dy B mn Khoa Y hc c truyn, Trng i hc Y Dc Thnh ph H Ch Minh ginh nhiu cng sc hon thnh cun sch ny, cm n PGS. TS. Nguyn Nhc Kim; PGS. Nguyn Vn Thang c, phn bin cun sch c hon chnh, kp thi phc v cho cng tc o to nhn lc y t. V ln u xut bn, chng ti mong nhn c kin ng gp ca ng nghip, cc bn sinh vin v cc c gi ln xut bn sau c hon thin hn.

V Khoa hc v o to B Y t

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LI NI U
Bnh hc v iu tr l hai mn hc c tm quan trng c bit mang tnh quyt nh trong ngh nghip ca mi ngi thy thuc. p ng kp thi yu cu ca sinh vin v hc vin v cng hng ng vic bin son sch gio khoa trong d n Gio dc i hc ca i hc Y Dc TP.HCM ca B Y t, chng ti bin son cun Bnh hc v iu tr ni khoa kt hp ng - Ty y ny. Trong thi i bng n thng tin nh hin nay, vic tip cn vi nhng tin b khoa hc k thut khng kh, gip chng ta bit rng s tin b mnh m trong lnh vc chn on ca y hc hin i, s ra i ca nhng thuc mi gp phn lm cho iu tr ni khoa khng ngng pht trin, tuy nhin ngi ta cng nhn nhn rng y hc c truyn c mt vai tr nht nh i vi cc bnh mn tnh v nhng phng php t dng thuc y hc c truyn (YHCT) n khng dng thuc nh chm cu, dng sinh, xoa bp bm huyt, tp luyn, cch n ung h tr cho iu tr v phng bnh mt cch tch cc v hiu qu. Quyn Bnh hc v iu tr ni khoa kt hp ng - Ty y c hnh thnh t vic hiu chnh, b sung, sa cha gio trnh bnh hc v iu tr kt hp a ra ging dy nhiu nm ti Khoa Y hc c truyn i hc Y Dc TPHCM, b sung thm mt s bi mi cng nhng ni dung t cc kt qu nghin cu v bnh hc kt hp v ng dng iu tr bng YHCT trong nhng nm gn y. Ni dung sch c phn thnh 31 bi tng ng vi 31 bnh in hnh ca bnh hc ni khoa ph bin, hay gp trong lm sng thuc v cc phn: tim mch, h hp, bnh l xng khp. Chng ti (ch bin v tp th cc tc gi) c gng th hin tnh kinh in, tnh hin i v tnh thc t trong vic bin son sch gio khoa ny, qua chng ti tham kho nhiu t liu ca nhiu tc gi trong v ngoi nc, chng ti xin trn trng cm n cc tc gi . D ht sc c gng, nhng thiu st l iu kh trnh khi, rt mong nhn c kin nhn xt v ng gp ca cc bn sinh vin - hc vin, cng qu ng nghip quyn sch ngy c tt hn Chn thnh cm n Ch bin PGS.TS. Nguyn Th Bay

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HNG DN CCH S DNG SCH


p ng nhu cu o to v t o to ca sinh vin, hc vin, sch Bnh hc v iu tr ni khoa kt hp ng Ty ybao gm: Phn mc lc Phn ni dung Phn index Mi bi hc c: Mc tiu Ni dung bi hc Phn cu hi n tp (t lng gi) c gi v hc vin c th chn bi hc t mc lc v tham kho index tra cu t ng mun tm. Ty thuc vo yu cu hc tp ca mi i tng, mi bi hc c nhiu mc tiu cho hc vin chn la, t nhng ni dung bt buc phi bit, n nhng ni dung cn bit v nn bit dnh cho sinh vin, n nhng phn trin khai rng hn tin cho vic tham kho dnh cho hc vin sau i hc, cui mi bi hc c bi tp gip cho vic t lng gi cho qu trnh t hc . Mi ni dung trong bi hc, chng ti bin son theo trnh t song song ng y v Ty y, bnh danh l h thng bnh danh y hc hin i (YHH). Phn i cng lun c nh ngha, c im dch t hc ca bnh v phn loi theo c YHH v y hc c truyn (YHCT), trong cc khi nim v t ng YHCT c gii thch nhm gip hc vin lin h v kt ni vi cc phn khc trong bi hc d dng hn. Phn nguyn nhn v c ch bnh sinh ca YHCT da vo cc triu chng YHH ca bnh, tm hiu c ch bnh sinh ca YHCT sinh ra cc triu chng y ri tng hp li chn ra nhng c ch bnh sinh tng ng, nhng nguyn nhn gy bnh ph hp v cc biu hin l nhng th lm sng YHCT. Phn iu tr, ch nu nguyn tc iu tr theo YHH v iu tr theo YHCT t dng thuc n khng dng thuc, n cc kinh nghim dn gian thng s dng. Thay mt cc tc gi Ch bin PGS.TS. Nguyn Th Bay

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MC LC
Li gii thiu Li ni u 3 5

Hng dn s dng sch


Tng huyt p Thiu mu c tim X m ng mch Vim ph qun cp v mn Hen ph qun Cc ri lon vn ng ca thc qun Vim d dy Lot d dy t trng Ri lon hp thu H chng i trng kch ng Vim gan mn X gan Si mt Nhim trng tit niu Si tit niu Chng suy sinh dc nam (impotence) Bnh vim sinh dc n Thiu mu Bnh i tho ng Bnh bo ph Chng rng tc (alopecia) Bnh long xng Tai bin mch mu no PGS. TS. Phan Quan Ch Hiu PGS. TS. Phan Quan Ch Hiu PGS. TS. Phan Quan Ch Hiu PGS. TS. Nguyn Th Bay PGS. TS. Nguyn Th Bay ThS. Ng Anh Dng ThS. Ng Anh Dng ThS. Ng Anh Dng ThS. Ng Anh Dng ThS. Ng Anh Dng ThS. Ng Anh Dng ThS. Ng Anh Dng PGS. TS. Nguyn Th Bay PGS. TS. Nguyn Th Bay PGS. TS. Nguyn Th Bay ThS. Ng Anh Dng PGS. TS. Nguyn Th Bay PGS. TS. Nguyn Th Bay PGS. TS. Nguyn Th Bay PGS. TS. Nguyn Th Bay ThS. BS. Ng Anh Dng PGS. TS. Nguyn Th Bay PGS. Phan Quan Ch Hiu

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9 34 53 63 86 110 120 127 144 165 174 192 214 223 241 252 271 300 327 367 380 383 399

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Lit mt nguyn pht Bi no Vim a dy thn kinh iu tr au thn kinh ta theo YHCT Hi chng suy nhc mn tnh (CFS) Vim khp dng thp Thoi ho khp Thng phong - Goutte

BSCK II Nguyn Th Li Na BSCK II Nguyn Th Li Na PGS. TS. Phan Quan Ch Hiu PGS. TS. Phan Quan Ch Hiu PGS. TS. Phan Quan Ch Hiu PGS. TS. Nguyn Th Bay PGS. TS. Nguyn Th Bay PGS. TS. Nguyn Th Bay

420 429 440 469 482 497 520 538

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Bi 1

TNG HUYT P

MC TIU 1. Nu c nh ngha v nhng yu t dch t hc ca bnh tng huyt p. 2. Trnh by c nguyn nhn v c ch sinh bnh tng huyt p theo l lun y hc c truyn. 3. Chn on c 3 th lm sng tng huyt p theo y hc c truyn. 4. Trnh by c nhng nguyn tc iu tr tng huyt p theo y hc hin i v y hc c truyn. 5. Trnh by c phng php iu tr tng huyt p (dng thuc v khng dng thuc ca y hc c truyn). 6. Gii thch c c s l lun ca vic iu tr tng huyt p bng y hc c truyn.

1. I CNG 1.1. nh ngha Tng huyt p l mt hi chng lm sng do nhiu nguyn nhn khc nhau gy nn, ni ln tnh trng gia tng p lc mu trong cc ng mch ca i tun hon. Theo OMS, ngi ln c huyt p (HA) bnh thng, nu huyt p ng mch ti a < 140 mmHg (18,7 kpa) v huyt p ng mch ti thiu < 90 mmHg (12 kpa). Tng huyt p khi huyt p ng mch ti a 160 mmHg (21,3 kpa) v huyt p ng mch ti thiu 95 mmHg (12 kpa). Huyt p ng mch ti a cn gi l huyt p tm thu, huyt p ng mch ti thiu cn gi l huyt p tm trng. 1.2. Phn loi 1.2.1. Da theo nh ngha Tng huyt p gii hn khi tr s huyt p trong khong 140/90 < PA < 160/95 mmHg 9

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Tng huyt p tm thu khi huyt p ng mch ti a (PAs) ln hn 160 mmHg v huyt p ng mch ti thiu (PAd) nh hn 90 mmHg. Tng huyt p tm trng khi huyt p ng mch ti a (PAs) thp hn 140 mmHg v huyt p ng mch ti thiu (PAd) cao hn 95 mmHg. 1.2.2. Da vo tnh trng bin thin ca tr s huyt p Tng huyt p thng xuyn, c th phn thnh tng huyt p c tnh v tng huyt p lnh tnh Tng huyt p cn: trn c s huyt p bnh thng hoc gn bnh thng, bnh xut hin vi nhng cn cao vt, nhng lc ny thng c tai bin. Tng huyt p dao ng: con s huyt p c th lc tng, lc khng tng (OMS khuyn khng nn dng thut ng ny v nn xp vo loi gii hn v tt c cc trng hp tng huyt p u t nhiu dao ng). 1.2.3. Da vo nguyn nhn Tng huyt p nguyn pht (khng c nguyn nhn), ngi cao tui. Tng huyt p th pht (c nguyn nhn), phn ln tr em v ngi tr tui. 1.3. c im dch t hc chu u v Bc M t l ngi ln mc bnh t 15 - 20%. Theo mt cng trnh ca Tcherdakoff th t l ny l 10-20%. Vit Nam t l ngi ln mc bnh tng huyt p l 6 - 12%. Bnh tng huyt p nguyn pht l bnh ca thi i vn minh. C l tng huyt p nguyn pht ch gp loi ngi. Bnh ny c lin quan n: + Tui: tui cng cao th cng nhiu ngi bnh huyt p cao. Nu la tui tr s ngi c bnh huyt p cao chim t l 1-2% th ngi cao tui t l mc bnh tng n 18,2-38% (thm ch n 50,2%). Trn 40 tui s ngi huyt p cao gp 10 ln so vi khi di 40 tui. + S pht trin cng nghip: th v ni c nhp sng cng thng, t l mc bnh tng huyt p cao hn. Tng t, cc nc pht trin c mc sng cao v thnh th t l mc bnh tng huyt p nhiu hn nng thn. Tng huyt p l bnh gy nhiu tai bin: + Trong tui t 50-60 tui: vi huyt p tm trng 85mmHg, t l t vong l 6,3%. Vi huyt p tm trng ln hn 104 mmHg, t l t vong l 15,3%. 10

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+ Php, nguyn cu ca F.Forette (1968-1978) cho thy t l tai bin mch no ngi huyt p cao gp i (20,6%) ngi c huyt p bnh thng (9,8%). T l nhi mu c tim l 27,8% (so vi ngi bnh thng 7,8%) nhiu gp 3 ln. + M, cng trnh nghin cu do Q.B. Kannel ch o, tin hnh trn 5209 i tng, v theo di lin tc trong 18 nm chng minh: ngi huyt p cao nguy c tai bin mch no cao gp 7 ln so vi ngi huyt p bnh thng, tui cng cao nguy c cng ln. Tr s HA ti a tng thm 10 mmHg th nguy c tai bin mch no tng thm 30%. + Nht Bn, nghin cu ca K. Isomura trong 10 nm (1970-1980) cho thy: 79-88% nhng ngi tai bin mch no l nhng ngi c bnh tng huyt p. 2. NGUYN NHN 2.1. Theo y hc hin i Ty theo nguyn nhn, c th chia ra: tng huyt p th pht v tng huyt p nguyn pht. tr em v ngi tr, phn ln l tng huyt p th pht. ngi cao tui, phn ln l tng huyt p nguyn pht. 2.1.1. Tng huyt p th pht Loi ny chim 11-15% tng s trng hp tng huyt p. Nguyn nhn thn (chim khong 5-8%): vim cu thn cp, vim cu thn mn mc phi hoc di truyn; thn a nang, nc b thn, u tng tit renin; bnh mch thn (3-4%). Nguyn nhn ni tit: cng aldosteron nguyn pht (0,5-1%), ph i thng thn bm sinh, hi chng Cushing (0,2-0,5%), u tu thng thn (0,10,2%). Tng calci mu, bnh to u chi, cng gip... Nguyn nhn khc (khong 1%): hp eo ng mch ch, nhim c thai nghn, bnh a hng cu, nguyn nhn thn kinh (toan h hp, vim no, tng p lc ni s...). 2.1.2. Tng huyt p nguyn pht Khi tng huyt p khng tm thy nguyn nhn gi l tng huyt p nguyn pht. Loi ny chim t l 85-89% trng hp tng huyt p (theo Gifford v Weiss). Phn ln tng huyt p ngi trung nin v ngi gi thuc loi nguyn pht. C nhiu yu t thun li lm xut hin bnh tng huyt p nguyn pht. 11

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Yu t di truyn: bnh thng gp nhng gia nh c huyt p cao hn l nhng gia nh c huyt p bnh thng. Yu t bin dng: nh tha cn, x m ng mch, ch n nhiu mui. Yu t tm thn kinh: tnh trng cng thng thn kinh. Yu t ni tit: thi k tin mn kinh, dng thuc nga thai 2.2. Theo y hc c truyn Tm hiu cc ti liu ca YHCT ni v bnh tng huyt p ca y hc hin i (YHH) l iu khng n gin. Tng huyt p l danh t bnh hc YHH v khng c t ng ngha trong bnh hc y hc c truyn (YHCT). T ng ngha d gp gia YHH v YHCT l cc triu chng (v d: au u vi u thng, mt ng vi tht min). 2.2.1. Cc chng trng thng gp trong bnh tng huyt p Cc triu chng c nng thng gp (nu c xut hin) v c m t trong cc ti liu gio khoa ca mt tnh trng tng huyt p kinh in gm: mt, nhc u, ri lon th gic, hoa mt, chng mt, tai, chy mu cam. Theo bo co ca S Nghin cu cao huyt p Thng Hi (Trung Quc) phn tch trn 550 trng hp tng huyt p: au u chim t l cao nht (74,8%), k n l tim hi hp (52,18%). Ngoi ra c th c cc biu hin khc l nhng hu qu trc tip ca tng huyt p; l nhng tnh trng thiu nng mch vnh, tai bin mch mu no, lit bn thn. Nh vy, c th tm tt cc triu chng c nng thng gp trong bnh l tng huyt p gm: Hoa mt, chng mt: YHCT xp vo chng huyn vng hay cn gi l huyn vng. au u: YHCT xp vo chng u thng, u trng, u trng da vo nhng biu hin khc nhau ca n. nh trng ngc, hi hp: YHCT xp vo chng tm qu, chnh xung. au ngc gi l tm thng, hoc km kh th th c gi l tm t, tm trng. Hn m, lit na ngi: YHCT xp vo chng trng phong. 2.2.2. C ch bnh sinh Qua vic phn tch c ch bnh sinh ton b cc chng trng thng gp ca YHCT trong bnh l tng huyt p, c th bin lun v c ch bnh sinh theo YHCT nh sau: 12

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Nguyn nhn ca bnh l ny theo YHCT c th l Do tht tnh nh gin, lo s gy tn thng 2 tng can, thn m. Do bnh lu ngy, th cht suy yu; thn m, thn dng suy (thn m suy h ha bc ln, thn dng suy chn dng nhiu lon trn). Do m thp ng tr gy tr tc thanh khiu. m thp c th do n ung khng ng cch gy tn hi t v hoc do thn dng suy khng kh ha c nc lm sinh m. S phn chia ny c tnh tng i v gia cc nguyn nhn (theo YHCT) v cc th bnh c mi lin h vi nhau nh can m h c th dn n can dng vng (can dng thng xung), thn m h lu ngy dn n thn dng h hoc nh thn dng h c th gy nn bnh cnh m thp.
THT TNH
(gin, lo s, stress)

TH CHT YU BNH LU NGY

N UNG KHNG NG

Error!
Can dng vng Can m h Thn m h Thn dng h m thp

Dng thng cang

H ha bc ln

Chn dng nhiu lon trn

Lm tc tr thanh khiu

HUYN VNG U THNG TM QU CHNH XUNG

Hnh 1.1. S bnh l bnh tng huyt p theo YHCT

3. CHN ON 3.1. Chn on theo y hc hin i 3.1.1. Triu chng lm sng Bnh nhn tng huyt p thng khng c triu chng (tr khi h c t tng t bin, tr s huyt p 220/110 mmHg). Nhng triu chng chc nng ca tng huyt p li l nhng triu chng khng c hiu nh mt mi, au u vng gy nh mch p, nng phng mt, chy mu cam, au ngc, kh th, ri lon th gic v ting ni. 13

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Tri li, c nhng triu chng lm sng lm gi cho vic tm kim nguyn nhn ca tng huyt p + au khp khing cch hi gi cho teo hp ng mch ch. + Mc ru ( ph n), d bm mu gi cho hi chng Cushing. + Tng huyt p ko di hoc tng t, ra nhiu m hi, au u tng cn, cn hi hp, lo lng, run ry, nn i, mt ti gi cho u ty thng thn. + Gim kali mu, yu c, vp b, tiu nhiu, lit, tiu m gi cho cng aldosteron nguyn pht. + au vng hng gi cho nhng bnh ca thn v mch mu thn. 3.1.2. Lm th no xc nh chn on o huyt p lp li nhiu ln, nhiu ni khc nhau, nhiu thi im khc nhau, vi k thut thc hin ng. Holter huyt p rt tt trong trng hp nghi ng. 3.1.3. Phi lm g sau chn on tng huyt p C 3 vn phi gii quyt sau chn on tng huyt p: + Tng huyt p th pht hay nguyn pht? + c nh hng trn nhng c quan no? giai on tng huyt p? + C yu t nguy c i km? tr li 3 cu hi trn, cn ch : + Hi bnh, khm lm sng. + Nhng xt nghim cn lm sng: Xt nghim thng thng ca tng huyt p: xt nghim mu thng quy; BUN - creatinin; K+ mu; cholesterol, HDL, LDL, triglycerid; ng huyt; o EKG; phn tch nc tiu. Xt nghim cn nn lm khi c nghi ng v nguyn nhn gy tng huyt p (da trn bnh s, khm lm sng v cc kt qu ca nhng xt nghim trn). Chp X quang tim phi (hp ng mch ch). Dexamethason suppression test (hi chng Cushing). Lng metanephrin v vanillylmandelic acid trong nc tiu (u ty thng thn). Chp ng mch thn c cn quang (IVP), chp ct lp thn, ng mch (bnh mch mu thn). 14

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o nng renin hot ng huyt tng (cng aldosteron nguyn pht hay bnh mch mu thn). 3.1.4. Phn loi tng huyt p Theo WHO: huyt p bnh thng ngi ln l + Huyt p tm thu (HATT) <140 mmHg v/hoc + Huyt p tm trng (HATTr) < 90mmHg. Tng huyt p l tnh trng huyt p ng mch tng cao bn b, ni r hn l o thy cao trn mc bnh thng t nht trong 2 k cch nhau 1 n nhiu ngy, mi k o 2-3 ln cch nhau 2-20 pht, vic o huyt p c tin hnh ng theo nhng quy nh cht ch v my o huyt p, cch o huyt p v chun b bnh nhn. Phn loi mc huyt p mi theo WHO/ISH 1999, c p dng cho nhng i tng khng s dng thuc chng tng huyt p.
Bng 1.2. Phn loi mc huyt p theo WHO/ISH 1999
Hng Ti u Bnh thng Bnh thng cao THA gii hn THA 1 (nh) THA 2 (trung bnh) THA 3 (nng) THA tm thu n c HATT (mmHg) <120 <130 130-139 140-149 140-159 160-179 180 >140 HATTr (mmHg) <80 <85 85-89 90-94 90-99 100-109 110 <90

Khi HATT v HATTr khc nhau th huyt p c xp vo no cao nht. Theo hng dn ca WHO/ISH 1999 v tng huyt p, nhm mc ch xp loi nguy c v lng gi tin lng, bnh nhn tng huyt p c phn thnh 4 nhm d dng cho vic la chn phng php iu tr, bao gm: Nhm nguy c thp (nguy c c s c tim mch nng trong 10 nm di 15%). Nhm nguy c trung bnh (nguy c c s c tim mch nng trong 10 nm t 15 - 20%). Nhm nguy c cao (nguy c c s c tim mch nng trong 10 nm t 20 - 30%). 15

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Nhm nguy c rt cao (nguy c c s c tim mch nng trong 10 nm trn 30%).
Bng 1.2. Bng xp loi nguy c v lng gi tin lng ca bnh tng huyt p
Yu t nguy c khc v bnh s ca bnh Khng c yu t nguy c khc 1-2 yu t nguy c >3 yu t nguy c hoc tn thng c quan ch hoc tiu ng Tnh trng lm sng i km Rt cao Rt cao Rt cao Cao Cao Rt cao Thp Trung bnh Huyt p (mmHg) Trung bnh Trung bnh Cao Rt cao

+ Yu t nguy c: Yu t dng xp loi nguy c: 1. Tng HATT v HATTr ( 1, 2, 3) 2. Nam >55 tui 3. N > 65 tui 4. Ht thuc l 5. Ri lon lipid huyt (cholesterol TP > 6,5mmol tc > 250mg/dl) 6. Tin cn gia nh b bnh tim mch sm 7. Tiu ng 8. Ung thuc nga thai. Yu t nh hng xu n tin lng: 1. HDL-C gim, LDL-C tng 2. Tiu albumin vi th trn ngi b tiu ng 3. Ri lon dung np ng 4. Bo bu 5. Li sng tnh ti 6. Fibrinogen tng 7. Nhm kinh t x hi nguy c cao 8. Nhm dn tc nguy c cao 9. Vng a l nguy c cao. 16

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+ Tn thng c quan ch (giai on II theo phn loi c ca WHO): Dy tht tri (in tm , siu m, X quang) Tiu m v/hoc l tng nh creatinin huyt (1,2 - 2mg/dl) Hp lan ta hoc tng im ng mch vng mc Siu m hoc X quang c bng chng mng x va. + Tnh trng lm sng i km (giai on III theo phn loi c ca WHO): Bnh mch no: nhn no, xut huyt no, cn thiu mu no thong qua Bnh tim: nhi mu c tim, au tht ngc, iu tr ti ti mu mch vnh, suy tim Bnh thn: suy thn (creatinin huyt >2mg/dl), bnh thn do tiu ng Bnh mch mu ln ngoi vi c triu chng lm sng i km Bnh y mt: xut huyt hoc xut tit ng mch vng mc, ph gai th. 3.2. Chn on theo y hc c truyn 3.2.1. Th can dng xung (th m h dng xung) Trong th bnh cnh ny tr s huyt p cao thng hay dao ng Ngi bnh thng au u vi nhng tnh cht Tnh cht au: cng hoc nh mch p V tr: nh u hoc mt bn u Thng km cn nng phng mt, hi hp trng ngc, ngi bt rt Mch i nhanh v cng (huyn). 3.2.2. Th thn m h Triu chng ni bt trong th ny, ngoi tr s huyt p cao l Tnh trng u oi, mt mi thng xuyn au nhc mi lng m Hoa mt chng mt, tai, u nng hoc au m Cm gic nng trong ngi, bc rc, thnh thong c cn nng phng mt, ng tm phin nhit, ng km, c th c to bn Mch trm, huyn, sc, v lc. 17

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3.2.3. Th m thp Triu chng ni bt trong th bnh l ny: Ngi bo, tha cn. Li dy, to Bnh nhn thng t than phin v triu chng au u (nu c, thng l cm gic nng u) nhng d than phin v t nng chi di Thng hay km tng cholesterol mu Mch hot. 4. IU TR, D PHNG V THEO DI Mc tiu ca iu tr v d phng bnh tng huyt p l gim bnh sut v t sut bng phng tin t xm ln nht nu c th. C th l lm gim v duy tr HATT <140mmHg v HATTr <90mmHg hay thp hn na nu bnh nhn dung np c. ch li ca vic h huyt p l ngn nga c tai bin mch mu no, bo tn chc nng thn v ngn nga hoc lm chm din tin suy tim. Phng php thc hin bng iu chnh li sng n c hoc i km vi thuc iu tr. Chin lc iu tr c ra nh sau: Nhm nguy c cao v rt cao: iu tr ngay bng thuc. Nhm nguy c trung bnh: theo di huyt p v yu t nguy c khc t 3-6 thng. Nu HATT 140mmHg hoc HATTr 90mmHg th dng thuc. Nhm nguy c thp: theo di huyt p v yu t nguy c khc t 6-12 thng. Nu HATT 150mmHg hoc HATTr 95mmHg th dng thuc. Vic iu tr tng huyt p cha c bin chng bao gm trc tin v lun lun l nhng iu chnh v sinh hot n ung, k mi n vai tr ca thuc v nht l ch ton b v nguy c cc bnh l mch mu. 4.1. iu tr khng dng thuc Mc tiu kinh in l gi c huyt p di ngng 160/90mmHg m khng gy ra nhng kh chu (lm cho bnh nhn t chi cch iu tr). Mc tiu cng l lm cho ngi bnh thay i thi sng nhm lm gim nguy c cc bnh mch mu. Cng cn c mc tiu lm gim hoc chm vic dng thuc, iu ny i khi c th t c hoc lm tt hn vic tr liu bng thuc, bao gm: gii hn Na+, vn ng th lc, cn 18

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nng l tng, gim ru, b thuc l, c ph; gim cholesterol mu hoc tiu ng, cung cp thc n c nhiu potassium v calci, kim sot tnh trng stress, hn ch Na+. c nhng cng trnh nghin cu chng minh vic king hon ton mui lm n nh cc trng hp tng huyt p nng. Trong thc t, cch ny khng p dng c, do bnh nhn cn bit nhng ngun thc n ch yu c nhiu mui hn ch s dng (kh, mm, chao, sa, fomat, tht mui). Vi mc n mn 5-8g NaCl/ngy: + nhng bnh nhn huyt p cao th nh: tr s huyt p cao ti a gim 6,3%, huyt p ti thiu gim 6,6% (t 139,9/93,9 cn 130/87,7 mmHg o t th ngi). + nhm bnh nhn m tr s huyt p cao khng t xung c na, th ch n gim mui nh trn cng gim c tr s huyt p ti a xung 5,2%, huyt p ti thiu gim xung 3,7%. + Trong c 2 nhm, cc bnh nhn u chu ng tt hn nhng gng sc th lc. S bnh nhn phi dng thm thuc gim dn sau tng nm (27% sau 1 nm, 16% sau 3 nm v 6% trong nm th 5). 4.1.3. Hot ng th lc thng xuyn C th lm gim huyt p trung bnh (l tng l 1 gi/ngy): i b, chy chm, bi li hoc p xe, ty theo thch v sc ca bnh nhn. Nhng bi tp thch hp ca phng php dng sinh nh th gin, th 4 thi c k mng, gi chn v nhng ng tc xoa bp vng u mt cn c p dng u n. Mc tiu l thi quen ny phi c a vo cch sng ca ngi bnh. Ring vic iu tr bng chm cu s c trnh by v gii thch c th phn sau, phn iu tr c th cho tng th lm sng YHCT. 4.1.4. Gi cn l tng Ch ny bt buc ngi tha cn. Cch duy nht l ch n gim calo (phi gii thch r cha c thuc no gip lm gim cn c). Cn ch sau t n gim cn thng c tnh trng tng cn nhiu sau . 4.1.5. Hn ch ru 4.1.6. B thuc l Cn bit b thuc l khng lm gim huyt p (ngc li cn c th tng cn sau ngng thuc l). Tuy nhin, cn khuyn khch bnh nhn b v hn ch c bin chng trn mch mu. 19

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4.1.7. Vic iu chnh cholesterol/mu tng v ng/mu tng l bt buc v lm gim bin chng mch mu. 4.2. iu tr dng thuc 4.2.1. Theo y hc hin i Thuc iu tr tng huyt p thng c dng l nhng nhm sau: + Nhm c ch calci + Nhm chng cao huyt p trung ng + Nhm c ch men chuyn + Nhm c ch alpha () v beta () + Nhm gin mch c tc dng trc tip + Nhm li niu Trong c 4 loi thuc c khuyn s dng trong tng huyt p v: + Dng mt ln trong ngy + C hiu qu + Tc dng ph lm phi ngng iu tr l 25% a. Thuc li tiu c chng minh tnh hiu qu hn tt c cc loi khc. N lm gim huyt p nh cc loi khc, hn na n cn c dng nh iu tr c bn ca tt c cc th nghim chng minh vic iu tr tng huyt p; lm gim t sut, t l t vong bnh tim mch v t l t vong chung. Cc cng trnh nghin cu rt ng tin cy chng minh li tiu c tc dng tt trong tng huyt p va ( ngi trng thnh v ngi cao tui) trong cc th lm sng tng tm thu v tm trng hoc ch tng tm trng. Tp hp tt c cc cng trnh li, ta chng minh c vic gim tr s huyt p lm gim ng k nguy c chy mu no, suy tim v suy thn. Vic gim nguy c suy mch vnh t thy r hn, nhng li rt c ngha ngi cao tui. Thuc li tiu nn dng (thng l phi hp trong 1 vin): Thiazid: tng thi K + Anti aldosteron: gim K + Phi hp: aldactiazin (loi ny thng gy gim K + hn l tng K +). Chng ch nh: suy gan nng, suy thn mn ( lc cu thn < 30ml/mm). 20

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b. Thuc c ch beta ( - bloquants) c chng minh bng cc nghin cu ng tin cy v mt hiu qu trn t sut, t l t vong do bnh tim mch v t l t vong chung (nh thuc li tiu). Hiu qu ny so vi thuc li tiu trn bnh nhn cao tui c km hn cht t: + C tc dng h p: c nhng loi m tc dng ko di 24h p ng c yu cu iu tr n liu. + C ch: cho rng thuc kha mt phn h thng renin angiotensin aldosteron bng tc dng trn th th beta kim sot tit renin. Sau khi gim tm thi cung lng tim, cc thuc c ch beta lm gim khng lc ngoi vi... + Chng ch nh: suyn, COPD, vim tc mch chi di, suy tim bt hi, tiu ng l thuc insulin. c. c ch men chuyn Tc dng h p nh cc loi thuc trn. N cha c nghin cu xc nh hiu qu trn t sut, t l t vong nh cc loi thuc trn v n c lu hnh trong thi k m khng c mt nghin cu no vi placebo cho php. Cn nu dng thuc lm chng th cn s lng bnh nhn rt ln. Tr captopril ung 2 ln/ngy, cn cc loi khc dng 1 ln/ngy. C ch: ct t vic chuyn t angiotensin I sang angiotensin II (gy co mch), ct t tit aldosteron (gi li Na+). ng thi lm gim s ph hy bradykinin (degradation ny c thc hin bi men chuyn)==> bradykinin tng trong mu ==> lm gin mch. Kt qu l lm gim khng lc ngoi vi. Tc dng ph: ch yu l ho khan (c l do bradykinin tng trong mu), rt thng gp nu c yu t kch thch ph qun v/hoc ngi cao tui. Nhng tc dng ph khc c lin quan n vic dng thuc trn ngi bnh c mt nc, c bit ang iu tr vi thuc li tiu. d. i khng calci Tc dng h p nh cc loi trn. Cng khng nghin cu t sut, t l t vong nh nhm c ch men chuyn v cc l do nu trn. C 2 loi chnh: + Dihydropyridines (nifedipin): loi khng nh hng trn nhp tim hoc lm tng nhp tim. + Loi lm gim nhp tim: diltiazem. 21

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C ch: gim Ca++ vo trong cc t bo c trn thnh mch mu, dn n gin mch v cui cng l gim khng lc ngoi vi. Tc dng ph ch yu: ph 2 chi di, au u. y l do tc dng gin ng mch m khng km gin tnh mch (thng gp khi dng adalat hn nhm tildiem hay verapamil). Cch s dng thuc: quyt nh s dng thuc trong iu tr huyt p cao l mt quyt nh nng n, bi v sau rt c th quyt nh ny s b ngng li. Quyt nh ny phi c nu sau khi lm ton b bilan nh trn v sau khi p dng cc ch sinh hot, n ung. chc chn rng n cng kt hp vo ton b cch iu tr. L tng l dng mt ln trong ngy v vic chn la ty thuc ch nh v chng ch nh. Hiu qu ca vic tr liu ch c xc nh sau vi tun iu tr. Cc cng thc cn quan tm: + Chn beta + li tiu: kinh in v rt hiu qu. + c ch men chuyn + li tiu: rt hp l v nhm li tiu hot ho h thng renin v nh vy lm mnh thm nhm c ch men chuyn (IEC), ngc li IEC tng hot bi tnh trng gim Na+ mu. + Chn beta + khng calci: thng dng trn tng HA c bnh mch vnh. 4.2.2. Theo y hc c truyn Yu cu p ng c nhng nguyn tc iu tr sau: H p: r nhu. An thn: to nhn, tho quyt minh. Li tiu: trch t, m , ngu tt. Bn thnh mch: hoa he. a. Th can dng xung Php tr: + Bnh can, ging nghch. + Bnh can, tc phong (nu l cn tng huyt p). Nhng bi thuc v cng thc huyt s dng: + Bi Thin ma cu ng m: thin ma 8g, cu ng 12g, hong cm 10g, chi t 12g, tang k sinh 12g, h th 10g, trng 10g, phc linh 12g, ch mu 12g, thch quyt minh 20g, ngu tt 12g 22

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V thuc Thin ma Cu ng Hong cm Chi t Tang k sinh H th trng Phc linh ch mu Thch quyt minh Ngu tt

Tc dng Ngt, cay, hi ng, bnh, thng thanh, ging trc, tn phong, gii c Ngt, hn: thanh nhit, bnh can, trn kinh ng, hn: t ph ha, thanh thp nhit ng, hn: thanh nhit t ha, li tiu, cm mu ng, bnh: b can thn, mnh gn ct B huyt, thm tinh Ngt, n, hi cay: b can thn, mnh gn ct Ngt, nht, bnh: li thy, thm thp, b t, nh tm Cay, ng, hn: thng huyt, iu kinh Tr st cao, n khng tiu, thanh nhit Chua, ng, bnh: b can thn, tnh i xung

Vai tr Qun Qun Thn Thn Thn Thn Thn T T T Thn - T - S

+ Bi Linh dng cu ng thang: linh dng gic 4g, trc nh 20g, cu ng 12g, sinh a 20g, bch thc 12g, tang dip 8g, phc thn 12g, cc hoa 12g, bi mu 8g, cam tho 4g
V thuc Linh dng gic Trc nh Cu ng Sinh a Bch thc Tang dip Phc thn Cc hoa Bi mu Cam tho Lng can, tc phong Ngt, hi lnh: thanh nhit, lng huyt Ngt, hn: thanh nhit, bnh can trn kinh Ngt, ng, hn: sinh tn dch, lng huyt ng, cht, chua: nhun gan, dng huyt, lim m, li tiu Ngt, mt: thanh nhit, lng huyt Ngt, nht, bnh; li thy, thm thp, b t, nh tm Ngt, mt: tn phong nhit, gii c, ging ha ng, hn: thanh nhit, tn kt, nhun ph, tiu m Ngt, bnh: b t, nhun ph, gii c Tc dng Vai tr Qun Qun Qun Thn Thn Thn T T T S

+ Cng thc huyt s dng gm: hnh gian, thiu ph, can du, thn du, thi kh, phi dng, ni quan, thi dng, bch hi, n ng. b. Th thn m h Php tr: + T m, ghm dng. + T b can thn. Nhng bi thuc v cng thc huyt s dng: 23

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+ Bi thuc h p (xut x 30 cng thc thuc): thc a 20g, ngu tt 10g, r nhu 20g, trch t 10g, m 20g, to nhn 10g, hoa ho 10g.
V thuc Thc a Ngu tt R nhu Trch t M To nhn Hoa he Tc dng Ngt, hi n: b thn, t m, b huyt Chua, ng, bnh: b can thn, tnh i xung ng, hn: bnh can, tim dng, an thn Ngt, nht, mt: thanh t thp nhit bng quang Ngt, hn: li tiu, thanh ph can phong nhit, thm bng quang, thp kh Ngt, chua, bnh: dng tm, an thn, sinh tn, ch kht ng, bnh: thanh nhit, lng huyt, ch huyt Vai tr Qun Qun Thn T T T T

+ Bi thuc Lc v a hong hon gia quy thc: thc a 32g, hoi sn 16g, sn th 8g, n b 12g, phc linh 12g, trch t 6g, ng quy 12g, bch thc 8g. Bi ny thng c s dng khi tng huyt p c km triu chng au ngc, au vng tim
V thuc Thc a Hoi sn Sn th n b Phc linh Trch t Tc dng Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Chua, sp, hi n: n b can thn, sp tinh, ch hn Cay, ng, hi hn: thanh huyt nhit, tn huyt, cha nhit nhp doanh phn Ngt, nht, bnh: li thy, thm thp, b t, nh tm Ngt, nht, mt: thanh t thp nhit bng quang Vai tr Qun Qun Thn T T T

+ Bi thuc b can thn: h th 10g, thc a 15g, hoi sn 15g, ng quy 12g, trch t 12g, si h 10g, tho quyt minh 10g
V thuc H th Thc a Hoi sn ng quy Trch t Si h Tho quyt minh B huyt, thm tinh Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Dng can huyt Ngt, nht, mt: thanh t thp nhit bng quang Bnh can, h st Thanh can, nhun to, an thn Tc dng Vai tr Qun Qun Qun Thn T T T

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+ Cng thc huyt s dng: thn du, phc lu, tam m giao, can du, thi xung; gia gim: thn mn, ni quan, bch hi, a th huyt. c. Th m thp Php tr: ha m tr thp. Bi thuc v cng thc huyt s dng: bi thuc h p (xut x 30 cng thc thuc), gm: Thc a R nhu M Hoa ho 20g 20g 20g 10g Ngu tt Trch t To nhn 10g 10g 10g

5. PH LC - CNG TRNH NGHIN CU TC DNG IU TR CA BI THUC H P 5.1. Kt qu nghin cu v ha thc vt 5.1.1. Kt qu nh tnh mt s hp cht hu c Dch chit ton phn tr h p c cha: saponin, glycosid, flavon. Dch chit ton phn tr h p khng c cha anthraquinond, alcaloid, coumarin v tinh du. Kt qu nh tnh cc hp cht hu c c trong dch chit ton phn tr h p bng phng php sc k: + Hp cht hu c trong dch chit ether du ha: nhm hp cht hu c khc vi alcaloid, flavon, saponines, tinh du, coumarin, anthraquinon. + Cc hp cht hu c trong dch chit etyl acetat ca tr h p: sau khi tch bng phng php sc k trn ct silic v nh tnh trn tm SKLM, chng ti c c 9 phn on vi Rf tun t l 0,82; 0,72; 0,70; 0,65; 0,55; 0,50; 0,45 trong dung mi ca SKLM, ether du ha; AcOEt (50;50). C 2 phn on khng cho phn ng vi cc loi thuc th thng thng. Nhng phn on ny u cho phn ng dng tnh vi flavon v khng cho phn ng vi anthraquinon, alcaloid, tinh du v coumarin. 5.1.2. Kt lun chung v nghin cu thnh phn ha hc ca bi thuc Dch chit ton phn tr h p c cha: saponin, glycozid, flavon. Dch chit ton phn tr h p khng c cha anthraquinon, alcaloid, coumarin v tinh du.

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c mt s hp cht hu c hin din trong cc v thuc khng c trong ch phm tr h p m cc v thuc nu trn cu thnh. 5.2. Kt qu nghin cu c tnh ca tr h p c tnh cp din ca thuc: thuc dng vi liu rt cao nhng khng gy ng c cp, khng xc nh c liu LD50. c tnh trng din ca tr h p: thuc khng gy c khi dng di ngy Thuc khng lm gim cn sc vt th nghim khi dng di ngy. Thuc khng lm thay i ng k s lng hng cu, bch cu. Thuc khng nh hng n chc nng gan. Thuc khng lm thay i cu trc gan, thn. S khc bit gia 2 nhm khng c ngha thng k (P>0,05; =8). 5.3. Kt qu nghin cu dc l thc nghim ca tr h p nh hng ca thuc trn huyt p mo: tc dng h p r rt liu 2g/kg, tc dng h p chm (sau 15 pht), h t t v ko di n 100 pht. S sai bit c ngha vi tin cy 95% (P = 0,05; =7). nh hng ca thuc trn nhp tim (tim c lp): thuc lm chm nhp tim, gim nh co bp c tim cc nng 1/50, 1/10 (sai bit c ngha vi tin cy 95%; =9). Khi ngng tim, thy tim cht th tm trng. nh hng ca thuc trn vn ng t nhin ca sc vt th nghim: thuc khng nh hng trn vn ng t nhin ca sc vt th nghim. Sai bit khng c ngha thng k (=38; P>0,05). nh hng ca tr h p trn m hnh kho st tc dng li tiu: lng nc tiu bi tit trung bnh c 2 nhm khng khc nhau. S khc bit gia 2 nhm khng c ngha thng k (P>0,05; =38). Khng c s khc nhau ng k v s bi tit ion trc v sau khi ung thuc. S khc bit khng c ngha (P>0,05; =18). 5.4. Kt qu dc l lm sng ca tr h p (gm 68 nam; 29 n) nh hng ca thuc trn tr s huyt p ca ngi tng huyt p: Thay i tc thi tr s huyt p sau khi dng thuc: + Tr h p c kh nng h c huyt p ngay t gi u. Tc dng ny xut hin r rt 2 giai on (I v II) ca tng huyt p. Sai bit nhm tng huyt p giai on III khng c ngha (P> 0,05;=3).

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+ Tuy nhin mc h huyt p khng nhiu. nhm tng huyt p giai on I: tr s huyt p h c l 18mmHg huyt p tm thu v 5 mmHg huyt p tm trng; nhm tng huyt p giai on II: tr s huyt p h c l 7mmHg huyt p tm thu v 3 mmHg huyt p tm trng. Thay i tr s huyt p khi dng thuc di ngy: + Tr h p n nh c huyt p giai on I v II ca bnh tng huyt p. Sai bit c ngha thng k (P = 0,05; 1=44; 2=47). + Tr s huyt p c n nh r nht sau ngy th 5. Thay i tr s huyt p sau khi ngng thuc: sau khi ngng thuc, khng thy c hin tng ny ngc ca huyt p. Din bin thay i tr s huyt p trong 90 ngy dng thuc (trn 9 bnh nhn tng huyt p nh v trung bnh): thuc c kh nng gi huyt p n nh trn nhng trng hp tng huyt p nh v trung bnh. Sai bit c ngha (P=0,05; =8). 5.5. Nhng tc dng dc l lm sng khc nh hng ca thuc trn s bi tit nc tiu: tr h p khng lm thay i natri v clo trong mu v nc tiu, trc v sau khi dng thuc. Sai bit khng c ngha (P >0,05; =90). nh hng ca thuc trn nhp tim ca bnh nhn: + Trn 97 bnh nhn dng thuc, tr h p khng lm thay i nhp tim (s sai bit ca cc kt qu khng c ngha thng k). + Thuc dng sau 10 ngy khng lm thay i cc men gan, sai bit khng c ngha (P>0,05; =96). nh hng ca thuc trn cc triu chng chc nng: + Sau khi dng thuc, c cm gic d chu, c cm gic mt trong ngi. + Thuc c mi v d ung. + Khng c bt k tc dng ph no. 5.6. Kt lun chung v tc dng ca tr h p Chng minh c mt mt ca ngha b m ghm dng ca YHCT. ng dng vo iu tr bnh tng huyt p nh v trung bnh cho c 3 th lm sng YHCT.

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T lng gi I. Cu hi 5 chn 1:chn cu ng 1. T l ngi ln mc bnh tng huyt p Vit Nam

A. 1-2% B. 3-5% C. 6-12% D. 12-16% E. 16-20%


2. T l ngi trn 40 tui mc bnh tng huyt p

A. Cao gp 2 ln ngi di 40 tui B. Cao gp 4 ln ngi di 40 tui C. Cao gp 6 ln ngi di 40 tui D. Cao gp 8 ln ngi di 40 tui E. Cao gp 10 ln ngi di 40 tui
3. T l tng huyt p th pht trong tng s trng hp tng huyt p

A. 0,5% B. 1% C. 3-4% D. 5-8% E. 11-15%


4. Yu t khng lin quan n tng huyt p

A. S tch tui B. i sng cng thng C. Ung ru D. Di truyn E. Tnh trng tha cn
5. Theo YHCT, n ung khng ng cch gy tng huyt p theo c ch

A. T v b tn thng, khng vn ha c thy thp nn sinh m B. Lm chc nng t sinh huyt b tn thng, can huyt h nn can dng xung
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C. Lm chc nng t, thn m b tn thng, khin h ha bc ln D. n nhiu thc n cay nng lm can dng thng xung E. Lm thn dng h dn n chn dng nhiu lon trn
6. Triu chng lm sng gp trong tng huyt p th can dng xung

A. au u nh hoc mt bn u, mch huyn sc v lc. B. au u nh hoc mt bn u, au cng nh mch p C. au nng u, au m c u D. Hoa mt, chng mt, u oi, mt mi thng xuyn E. Hi hp, trng ngc, mch hot
7. Triu chng lm sng gp trong tng huyt p th thn m h

A. au u, hoa mt, chng mt, mch hot B. au u, hoa mt, chng mt, mch huyn sc C. au u, hoa mt, chng mt, ng tm phin nhit D. Thng than t nng h chi, au lng E. Hi hp, trng ngc, bt rt, au cng u nh mch p
8. Triu chng lm sng gp trong tng huyt p th m thp

A. au cng u nh mch p B. Ngi mt mi, mch huyn sc v lc C. au nng ngc, li dy nht, mch hot D. Cm gic nng trong ngi, bc rc, mch hot E. au u d di, chng mt, mch nhanh v cng
9. Nguyn tc iu tr tng huyt p th can dng xung

A. Ha m tr thp B. T m ghm dng C. T b can thn D. Dn ha quy nguyn E. Bnh can ging nghch
10. Nguyn tc iu tr tng huyt p th thn m h

A. Ha m tr thp B. S can l kh C. T b can Thn


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D. Dn ha quy nguyn E. Bnh can ging nghch


11. Nguyn tc iu tr tng huyt p th m thp

A. Ha m tr thp B. T m ghm dng C. T b can thn D. Dn ha quy nguyn E. Bnh can ging nghch
II. Cu hi nhn qu 1. a. Trong hi chng can dng xung, c du hiu run ry, co git bi v b. Can dng xung l do can huyt h, nay can huyt km nn khng nui dng c cn A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai 2. a. Trong hi chng can dng xung, c du hiu run ry, co git bi v b. Can dng xung c th dn n can nhit ng phong A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai 3. Trong bi thuc h p (gm thc a, ngu tt, r nhu, toan to nhn, m , trch t, hoa ho) cha chng can dng xung a. Hai v thc a, ngu tt cng tng tu vi nhau, bi v b. Hai v ny cng c tnh i xung nn lm cho dng ging A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai 30

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D. Nu a sai, b ng E. Nu a sai, b sai 4. Trong bi thuc h p (gm thc a, ngu tt, r nhu, toan to nhn, m , trch t, hoa ho) cha chng can dng xung a. V r nhu lm qun, bi v b. R nhu c tc dng bnh can tim dng A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai 5. Trong bi Thin ma cu ng m cha chng can phong ni ng (gm thin ma, cu ng, hong cm, chi t, tang k sinh, h th ch, trng, phc linh, ch mu, tho quyt minh, ngu tt) a. Hai v thin ma, cu ng tng tu vi nhau, bi v b. C hai u c tc dng thng thanh ging trc A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai 6. Trong bi Thin ma cu ng m cha chng can phong ni ng (gm thin ma, cu ng, hong cm, chi t, tang k sinh, h th ch, trng, phc linh, ch mu, tho quyt minh, ngu tt) a. Ba v tang k sinh, trng, ngu tt tng tu vi nhau, bi v: b. C 3 v u b can thn A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai 7. Trong bi Thin ma cu ng m cha chng can phong ni ng (gm thin ma, cu ng, hong cm, chi t, tang k sinh, h th ch, trng, phc linh, ch mu, tho quyt minh, ngu tt) 31

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a. V phc linh lm t, bi v b. Phc linh c tnh nh tm an thn A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai 8. Trong bi Linh dng cu ng thang cha chng can phong ni ng (gm linh dng gic, trc nh, cu ng, sinh a, bch thc, tang dip, phc thn, cc hoa, bi mu, cam tho) a. Hai v trc nh, cu ng cng tng tu vi nhau, bi v b. C hai u c tc dng trn kinh tc phong A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai 9. Trong bi Linh dng cu ng thang cha chng can phong ni ng (gm linh dng gic, trc nh, cu ng, sinh a, bch thc, tang dip, phc thn, cc hoa, bi mu, cam tho) a. Hai v sinh a, bch thc u lm thn, bi v b. Hai v u c tc dng sinh tn A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai 10. a. Trong phng huyt iu tr chng thn m h (gm thn du, phc lu, tam m giao, can du, thn mn, thi xung), chm b huyt phc lu bi v b. B huyt phc lu b thn thy theo nguyn tc con h b m A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai 32

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D. Nu a sai, b ng E. Nu a sai, b sai 11. a. Trong phng huyt iu tr chng thn m h (gm thn du, phc lu, tam m giao, can du, thn mn, thi xung), chm t huyt thi xung thanh can ho, bi v b. Chm huyt ny theo nguyn tc m thc t con A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai 12. a. Trong phng huyt iu tr chng thn m h (gm thn du, phc lu, tam m giao, can du, thn mn, thi xung) chm b huyt thn mn thanh tm ho, bi v b. Chm huyt ny theo nguyn tc con h b m A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai

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Bi 2

THIU MU C TIM

MC TIU 1. Nu c nh ngha v nhng yu t dch t hc ca bnh thiu mu c tim. 2. Trnh by c nguyn nhn v c ch sinh bnh thiu mu c tim theo l lun YHCT. 3. Chn on c 5 th lm sng thiu mu c tim theo YHCT. 4. Trnh by c nhng nguyn tc iu tr thiu mu c tim theo YHHD v YHCT. 5. Trnh by c phng php iu tr thiu mu c tim (dng thuc v khng dng thuc ca y hc c truyn). 6. Gii thch c c s l lun ca vic iu tr thiu mu c tim bng YHCT.

1. I CNG 1.1. nh ngha Bnh c tim thiu mu c xem l hu qu ca tnh trng x m ng mch vnh tim (xem bi x m ng mch). Tnh trng teo hp ng mch vnh ng k, ng thi vi nhng ri lon c ch iu ha co tht v gin n mch vnh l nhng yu t hnh thnh nhng triu chng rt phong ph ca bnh. 1.2. c im dch t hc Bnh c tim thiu mu l nguyn nhn ch yu nh hng n t l t vong v t l bnh tt trn ngi sau tui 40. T vong do bnh tim mch chim khong 40% trn tng s t vong. Thng k cho thy c khong 800.000 trng hp nhi mu c tim mi, 450.000 trng hp nhi mu c tim ti pht v 520.000 t vong/nm. Bnh c tim thiu mu tc ng rt ln n chm sc y t ca mt nc. Ti M, nm 1989, bnh c tim thiu mu c 56 triu t khm bnh, 455 triu ngy hn ch lm vic, 184 triu ngy nm vin v mt 23 triu ngy 34

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cng. Bnh thiu mu c tim hin ng hng th 3 v loi bnh phi nm vin ngn ngy (sau sinh v chn thng). chn on v iu tr bnh c tim thiu mu rt tn km. 2. NGUYN NHN, BNH SINH 2.1. Theo y hc hin i 2.1.1. Nhim m x mch L nguyn nhn trong 90% cc trng hp. 2.1.2. Nhng nguyn nhn khc (10%) Tn thng thc th ng mch vnh tim. Vim ng mch vnh do giang mai, vim quanh nt ng mch, tc mch vnh do cc mu t xa n. V c ch bnh l bnh c tim thiu mu c lin quan cht ch n s cn bng ca 2 yu t cung cp v nhu cu oxy ca c tim. Do , nhng yu t thun li sau c th c tm thy trong bnh l ny nh: Khi s cung cp oxy cho c tim khng : thiu mu nng. Khi nhu cu s dng oxy gia tng: tng huyt p, ph i tht tri, hot ng th lc t ngt gia tng 2.2. Theo y hc c truyn Bnh thiu mu c tim c th xut hin vi bnh cnh au ngc (vi rt nhiu mc khc nhau) hoc khng c biu hin lm sng (bnh c pht hin tnh c trong khi khm, iu tr mt bnh l khc). Nh vy, c th tm tt cc triu chng c nng thng gp trong bnh l c tim thiu mu gm: Nhng triu chng c th gp trong bnh l x m ng mch (xem bi x m ng mch). au ngc cn gi l tm thng; nu km kh th th c gi l tm t, tm trng, hung hip thng. Qua vic phn tch c ch bnh sinh ton b cc chng trng thng gp ca YHCT trong bnh c tim thiu mu, c th bin lun v c ch bnh sinh theo YHCT nh sau: Nguyn nhn ca bnh l ny theo YHCT c th l: Do tht tnh nh gin, lo s, gy tn thng 2 tng can v thn m. Do bnh lu ngy, th cht suy yu, m (huyt) v dng (kh) suy, h ha bc ln, nung nu dch thnh m, m ha gp li gy bnh.

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Do m thp ng tr gy tr tc kinh mch, m thp c th do n ung khng ng cch gy tn hi t v


THT TNH
(gin, lo s, stress)

TH CHT YU BNH LU NGY

N UNG KHNG NG

Error!
Can m h Thn m h Thn dng h m thp

H ha hun t tn dch

Lm tc tr kinh mch

TM THNG TM TRNG HUNG T M THP

Hnh 2.1. S bnh l bnh c tim thiu mu theo YHCT

3. CHN ON 3.1. Chn on theo y hc hin i 3.1.1. Suy mch vnh mn a. Khi no th ngh n vic tm kim suy mch vnh mn? Nhng yu t nguy c: nhng ngi au ngc, c nguy c thiu nng vnh (bng 2.1)
Bng 2.1. Nhng yu t nguy c ca tim mch
Yu t nguy c Tui tc Di truyn Ni dung bnh Trong tui t 45 - 60 tui: nguy c thiu mu tim tng 2 ln khi gi i 10 tui Tin cn gia nh c nhi mu c tim hoc t t ==> nguy c thiu mu tim tng gp 1,5 ln Tin cn gia nh c nhi mu c tim hoc t t + THA ==> nguy c thiu mu tim tng gp 3,1 ln Phng nga

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Thuc l

Nguy c thiu mu tim tng 1,4 ln nu ht 5 iu/ngy 2,1 ln nu ht 5 - 10 iu/ngy 2,4 ln nu ht 10 - 15 iu/ngy 2,8 ln nu ht > 20 iu/ngy T l t vong do bnh tim mch tng 1,7 ln nu ht 1 - 14 iu/ngy 2,6 ln nu ht > 25 iu/ngy

Gim c 50-70% nguy c nhi mu c tim sau 5 nm ngng ht Gim 50% t t sau 1 nm ngng ht

Tng cholesterol mu

Nguy c bnh tim thiu mu tng gp 4 ln nu cholesterol: 1,8 - 2,8 g/l

C gim c 1% lng cholesterol ton phn th gim c 2-3% nguy c NMCT Gia tng c HDL tng ng vi gim nguy c bnh mch vnh

Tng huyt p

Nguy c bnh tim thiu mu tng theo mc trm trng ca bnh Gp 5,4 ln nu HA TT: 130-190mmHg Gp 3,3 ln nu HA TTr: 90-110mmHg

Lm gim c 1mmHg ca huyt p ti thiu s lm gim 2-3% nguy c NMCT Lm gim nguy c xut huyt no Cha r Gim cn lm gim c 3555% nguy c bnh tim thiu mu

Tiu ng Bo ph

Nguy c bnh tim thiu mu gp 2,8 ln nu c bnh tiu ng Nguy c bnh tim thiu mu tng gp i nu cn nng vt qu 120% cn nng l tng (y khng phi l yu t nguy c c lp m thng qua tng huyt p, cholesterol mu cao) Khng phi l yu t nguy c n ng. Ch l yu t nguy c ph n Yu t ny thng kt hp vi nhng yu t nguy c khc. Do khng th nh gi nguy c ca n ring l c Vai tr ca n c tnh 2 mt: Thng kt hp vi tng huyt p L yu t bo v nhi mu c tim (NMCT)

Tng triglycerid mu Tng acid uric mu Ru

Nu dng 1 ly ru vang/ngy lm gim 35-55% nguy c NMCT Nu ti lp trng thi vn ng s lm gim 35-55% nguy c NMCT

Trng thi t vn ng Thuc nga thai ung

Nguy c t vong do bnh tim mch l 1,9

Nguy c NMCT tng gp 4 ln k t sau 1 thng s dng Nguy c ny s tng ln gp 39 ln nu c km ht thuc > 20/ ngy

Estrogen sau tt kinh

Cung cp oestrogen sau mn kinh lm gim 44% nguy c nhi mu c tim

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au ngc + in hnh: au ngc vi cc tnh cht co tht hoc cm gic nng nh b . au tng khi c ng, khi gng sc (lm ngi bnh s khng dm c ng). + V tr au: sau xng c, lan ln hm, vai, tay. + au ngc c th bt u t t v ch ko di khong vi pht. + Khng in hnh au c cm gic chn, tc ngc (lm bnh nhn chm hoc ngng bc). V tr khng in hnh hm hoc tay. C v nh au khng tng khi gng sc v khng gim vi nm ngh. C mt chu k kh r rt: nh cao ca triu chng ny l 4 gi sau khi thc dy (thi im m noradrenalin cao nht trong ngy). Ch : ty theo mc ca tnh trng lo u, ca nhng yu t nguy c ca XMM, m chng ta thy cn thit hay khng thc hin cc xt nghim cn lm sng xc nh. Kh th: trong nhiu trng hp kh th ch xut hin n c v l triu chng ch yu (c xem nh tng ng au ngc). Nhng trng hp khng c triu chng lm sng: + Nhng trng hp bnh mch vnh ang c iu tr: l nhng ngi m chng ta mun kim tra hu qu ca vic iu tr (nh lm cu ni, nong rng mch vnh). Thng lm phim mch vnh (coronarographie). + Nhng trng hp c bnh ng mch (ng mch chu hay ng mch no). y l nhng ngi c nguy c t vong rt cao do thiu nng vnh. V vy, lut bt buc trn nhng ngi ny trc khi tin hnh phu thut phi tin hnh xc nh c suy mch vnh? ( trnh tai bin phu thut). b. Xc nh suy mch vnh mn bng cch no? Chn on suy mch vnh c khi khng phi d dng, cn da vo nhng yu t sau: + au ngc. + Nhng yu t nguy c: phi, di truyn, ht thuc, t vn ng th lc, bo ph, tng huyt p, stress, ch n nhiu m, tiu ng. + Khm lm sng (mc ch ch yu): Loi b nhng nguyn nhn him ca suy mch vnh nh hp van ng mch ch, thiu mu nng Tm ra thm x m ng mch c phm n nhng vng c th khc nh khng bt c mch chn, m thi ng mch cnh, ng mch di n, huyt p 2 bn khng ging nhau. 38

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Chn on khch quan suy mch vnh bng cc nghim php: + in tim, in tim gng sc (c th lm holter/24 gi): Kt qu in tim (trong tnh trng ngh): him khi bt thng, sng T o ngc (vi iu kin phi rt r); T m, nhn v tp trung vo mt vng mch mu c th (Vd, D2, D3, aVF). Trong cn au cp (c gi tr quan trng): nu in tm (EKG) bnh thng th c th loi b thiu mu c tim; nu ST chnh xung: chc chn c thiu mu c tim. Kt qu EKG gng sc (quan trng nht): nu ST chnh xung, ln hn 1mm, trn 2 chuyn o tng xng, th rt c ngha. Trn bnh nhn c au ngc: ==> do thiu mu c tim. Trn bnh nhn khng c au ngc: ==> c th c suy mch vnh. Khi kt qu (+) sm xut hin trn nhng gng sc nh (cha cao) nh ST chnh xung rt su hay xut hin trn nhiu chuyn o hoc nu c ri lon nhp tim km theo trong nghim php gng sc th gi thuyt v mch vnh tc nghn l rt ng tin cy v nn ngh n nghim php chp cn quang ng mch vnh tim (coronarography). Kt qu EKG holter (vi mt vi loi my, ta c th phn tch chnh xc ST, o c tn s v di ca cc on ST chnh/24 gi): c gi tr nhiu trong nh gi hiu qu tr liu thiu mu c tim, gi tr t hn cho chn on, thng cho dng tnh gi nhiu v c nhiu nguyn nhn nh hng n ST. Chp nhp nhy c tim (vi thallium 201 = ng v phng x) kch hot vi dipyridamol. Kt qu nghim php nhp nhy vi thalium 201: nghim php ny tt hn EKG gng sc (nht l c gi tr nh v tn thng rt r), thallium l cht tng t nh K v c phn b cc t bo c ti mu. Nu c vng nhi mu ==> trn hnh s c l khuyt. Nu vng c tim ch c nui bi mt mch mu b teo hp ==> kt qu c th bnh thng lc ngh ngi, nhng s bt thng lc gng sc. Nu nghim php gng sc khng th thc hin c, c th thay th bng chch dipyridamol (y l thuc gin ng mch mnh) ==> hnh nh tng ti mu vng c tim bnh thng. Trong khi , vng ti mu bi ng mch b teo hp khng c hnh nh tng ti mu hoc hnh nh gim ti mu (do hin tng cp mu sang vng lnh). Tuy nhin phng php ny vn cn mt s bt li: gi thnh t, kt qu cho hnh nh p thng him, chuyn gia cn t. + Siu m tim: suy mch vnh mn thng cho kt qu bnh thng trn siu m tim. c nhiu nhm nghin cu dng siu m tim gng sc, siu m tim vi dipyridamol, siu m tim vi dobutamin. T nm 1993, nhng k thut ny khng cn dng nhiu trong chn on thiu mu c tim. Ngc li, siu m tim quy c c gi tr xc nh tnh trng tm tht tri. 39

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nhy v c hiu ca cc test ny khng phi 100%, do ch c ch nh trn nhng ngi v mt lm sng ngh nhiu n thiu mu c tim (khng nu ch nh cho nhng ngi au ngc khng in hnh v hon ton khng c yu t nguy c ca x m ng mch v s gp (+) gi rt cao. b. Phi thc hin xt nghim g khi nghi ng c suy mch vnh mn? ng huyt lc i, ng huyt sau khi n. Bilan m: cholesterol, HDL, LDL, triglycerid. Nhng quan trng hn c l cn xem xt c lm mch vnh (coronarographie) hay khng?. y l xt nghim gip chn on dng tnh c suy mch vnh mn hay khng gip quyt nh ch nh gii phu ti lp tun hon tim? Thng thng ta c th iu tr trc trong 3 trng hp sau: + au ngc gim ch cn nhng cn tha tht xut hin trong nhng gng sc khng thng thng. + Kt qu ch dng tnh trong nhng giai on gng sc sau cng. + Nu bnh nhn khng c triu chng au ngc. Vn ny cng r hn nu bnh nhn cng ln tui. Ngc li ch nh mch vnh (coronarography) cao khi: + au ngc lm nh hng n nhng sinh hot thng ngy ca bnh nhn. + Kt qu dng tnh ngay vi nhng gng sc nh. + Suy gim chc nng tht tri. Vn ny cng r hn khi bnh nhn tr. 3.1.2. Co tht mch vnh/thiu mu c tim mn a. Khi no ngh n co tht mch vnh/thiu mu c tim mn Khi c au ngc in hnh m khng c gng sc (khi ng) hoc khi th nhanh: + in hnh l xut hin ban m, khong 4 gi sng. + Thnh thong lo u, hi hp vo cui cn. + Dng trinitrin gim au ngay. + Trn in tim: ST chnh ln nhng chuyn o tng ng vi mt vng ti mu. + Mch vnh : dng methergin thy du co tht. Bnh cnh ny nu xut hin: + ngi khng c nguy c x m ng mch ==> co tht mch vnh. Tin lng tt. 40

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+ ngi c nguy c x m ng mch ==> co tht mch vnh trn nn x m ng mch. b. Lm cch no chn on co tht mch vnh/thiu mu c tim mn Xc nhn c thiu mu c tim khi: + EKG (ch gi tr trong cn) ==> ST chnh ln v quan trng l s bin mt khi cn qua i. + EKG gng sc t c gi tr lm xut hin du bt thng (nu khng c nn x m ng mch). + Holter 24h: rt hiu qu v bt gp lc ln cn r rng. Xc nhn c co tht mch vnh: + Khi dng nhm c ch calci: du hiu au ngc mt hon ton. + Mch vnh vi methergin (R): xut hin du co tht. c. Phi lm nhng xt nghim cn lm sng g? l: mch vnh . 3.1.3. Thiu mu c tim cp khng c hoi t (au ngc khng n nh) Thc t, khng c gii hn r rng gia au tht ngc n nh vi au tht ngc khng n nh; cng nh khng c gii hn r rng gia au tht ngc khng n nh vi nhi mu c tim. S phn chia nh trn ca chng ti nhm gip hc vin theo di v ng x d dng hn trong thc t lm sng. a. Khi no ngh n thiu mu c tim cp khng c hoi t (au ngc khng n nh) Nhng cn au tht ngc xut hin vi mc thng xuyn. Chng xut hin trong nhng hot ng gng sc khng ln v thm ch c trong lc ngh (au tht ngc khng n nh gn). Nhng cn au tht ngc xut hin vi mc thng xuyn hn. Chng xut hin trong nhng hot ng gng sc khng ln, ko di hn v khng p ng vi thuc gin mch vnh tc dng nhanh (au tht ngc nng). b. Lm cch no chn on thiu mu c tim cp khng c hoi t (au ngc khng n nh) in tim: on ST chnh xung. Vic xc nh s tr nn d dng hn nu bnh nhn c tin cn v bnh mch vnh hoc c nhng yu t nguy c ca bnh l thiu mu c tim. Mch vnh : Vic chn on xc nh c th rt kh khn khi cc triu chng lm sng v in tim khng in hnh. Tht s rt kh chn on phn bit vi 41

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vim mng ngoi tim cp, nhi mu phi, cng nh trng hp au ngc do nguyn nhn ngoi tim. Ngoi ra, cng tht s kh phn bit c gia au ngc khng n nh v trng hp nhi mu c tim cp khng c sng Q (nhi mu di ni tm mc). Trng hp ny thng dng cc xt nghim v men tim chn on phn bit. c. Phi thc hin nhng xt nghim cn lm sng g? EKG khng quan trng trong trng hp ny. EKG gng sc l chng ch nh (cng nh vi nghim php vi persantin). Cc xt nghim men tim: CPK, CPK-MB, SGOT, SGPT, LDH, troponinetest. Mch vnh : rt quan trng v nh hng rt ln vo iu tr. 3.2. Chn on theo y hc c truyn Da vo nguyn nhn v c ch bnh l YHCT, bnh l thiu mu c tim theo YHCT c th c biu hin di nhng th lm sng sau y: 3.2.1. Th kh tr huyt au vng tim tng cn (tha tht hoc lin tc). Cht li tm hay c im huyt. Mch trm, t, sc. 3.2.2. Th can thn m h au ngc (nu c) thng c tnh cht hoc co tht, hoc nhi nh kim m. Ngi d b kch thch, cu gt. Tnh trng u oi, mt mi thng xuyn. au nhc mi lng m . Hoa mt chng mt, tai, u nng, au m . Cm gic nng trong ngi, bt rt, thnh thong c cn nng phng mt, ng tm phin nhit, ng km, c th c to bn. Mch trm, huyn, sc, v lc. 3.2.3. Th m thp au ngc (nu c) thng c tnh cht nh c mt vt nng chn trn ngc, thng km kh th. Ngi bo, tha cn; li dy, to. 42

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Bnh nhn thng than phin v triu chng t nng chi. Thng hay km tng cholesterol mu. Mch hot. 3.2.4. Th tm t h au ngc (nu c) thng c tnh cht m . Trng ngc, hi hp, ng t, hay m, hay qun. Mt mi, gy yu, n km, bng y, i tin lng. Li nht bu, mch t nhc. 3.2.5. Th tm thn dng h Ph n, au vng ngc, hi hp. S lnh, thch ung nc m, au bng, tiu chy, nc tiu trong, t hn, tay chn lnh. Li nht, tm xm, mch v lc. Nu nng hn, tm dng h thot s c thm triu chng: ra m hi khng ngng, chn tay quyt lnh, mi xanh tm, th nh yu, li tm xm, mch nh, h mun tuyt. 4. IU TR KT HP V THEO DI 4.1. Suy mch vnh mn Vic iu tr bnh suy mch vnh mn phi m bo nhng nguyn tc tr liu sau: Chng nhng yu t nguy c ca x m ng mch. Lm gim s tiu th O2 ca c tim. Chng tnh trng to mng x va. Ti lp tun hon mch vnh (revascularisation). 4.1.1. Phng chng nhng nguy c ca x m ng mch Ngng ht thuc l (di mi dng): cng vic ny i hi ch ca bnh nhn v cc phng tin h tr (cho tng c nhn; tm l tr liu cho c nhm). n nh tnh trng tng huyt p (xem bi tng huyt p). iu tr tng cholesterol mu. Khi cholesterol TP > 200 mg% v LDL > 130 mg%. 43

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Nu LDL > 130 - 160 mg% v c < 2/5 yu t nguy c ==> iu tr bng tit ch (nhiu cht x + tri cy) (xem bi x m ng mch). Nu LDL > 130 - 160%: c >2/5 yu t nguy c: ==> tit ch + thuc. Nu LDL > 160%: c < 2/5 yu t nguy c: ==> tit ch + thuc. NB: tit ch gim cholesterol l sa i ch n t nhiu cht bo no sang bo khng no. Thuc YHH v YHCT iu tr gim cholesterol mu (xem bi x m ng mch). 4.1.2. Lm gim s tiu th O2 ca c tim S tiu th O2 ty thuc nhp tim, co bp ca c tim, khng lc ca huyt p khi tim co (huyt p ng mch), khng lc ca tm trng (huyt p tim tri cui tm trng). Thuc YHH hoc thuc YHCT u phi lm th no p ng c yu cu ny. YHCT c nhng bi thuc tham gia vo c ch ny qua vic lm gim huyt p (xem bi tng huyt p). YHH c 3 nhm thuc phc v cho yu cu ny gm: chn beta, nhm khng calci, dn xut nitrit. Chn beta: rt hiu qu v lm gim nhp tim, gim co c tim, gim huyt p tm thu. Do , loi ny c chng minh phng nga tt t vong sau nhi mu c tim. Nhm khng calci: c tc dng lm gim co c tim, gim huyt p. Cn ch nhm nifedipin v lm tng nhp tim, c kh nng lm tng nguy c thiu mu. Thuc hay dng l tildiem (diltiazem), isoptin (verapamil). C th phi hp gia chn beta v nhm khng calci v rt hiu qu chng au ngc nhng c bt li l lm chm nhp tim nhiu. Nhm dn xut nitrit: dng t 100 nm tr au tht ngc v gim c p lc lm y tht tri v nh th lm gim ti tm trng. Loi nhanh: dng di li hoc xt (spray). Loi iu tr cng c: c cc dng dng ngoi da (khng c dng 24/24, nn b ra lc ng), dng thuc ung LP. Dng phi hp vi chn beta trong suy mch vnh rt tt. Cnh nhm ny c nhm molsidomin (corvasal (R)) 6 - 12mg/24h chia 3 ln. C ch ging nh nhm dn xut nitrit. Vic nh gi da trn kt qu nhp tim chm r rng hoc c ch c nhp tim nhanh tng trn 115 ln/pht khi lm nghim php gng sc. Cng c th kim tra hiu qu vi EKG gng sc ==> nghim php gng sc ko di hn v lm c nhng bc cao hn ca nghim php gng sc. 4.1.3. Chng tnh trng to mng x va Aspirin liu thp 75 - 100 mg: rt thng dng. c chng minh lm gim tn sut nhi mu c tim. 44

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YHCT tuy cha c nghin cu v tc dng dc l ny nhng c kinh nghim qu vi nhm thuc hot huyt, kh nh: an sm, o nhn, hng hoa, ch mu. Nhng dc liu nh ngu tt, ngh th c tc dng gin tip thng qua tc dng h cholesterol mu (xem bi x m ng mch). 4.1.4. Ti lp tun hon mch vnh (thuc lnh vc ngoi khoa) Angioplastie coronaire. Pontage aorto coronaire. 4.2. Co tht mch vnh/thiu mu c tim mn Trong cn au cp ngi ta thng kt hp thuc vi chm cu, bm huyt. 4.2.1. Dng thuc Hai nhm thuc YHH c hiu qu trong au ngc do co tht mch vnh tim. Khng calci liu cao: Adalat (R) 40 - 80mg/24h. Tildiem (R) 240 - 480 mg/24h. Isoptil (R) (Vrapamil) 240 - 480 mg/24h. Nhm dn xut nitrit: S dng nhm tc dng nhanh trong cn au cp. S dng nhm tc dng chm (khi khng calci km hiu qu). i vi thuc YHCT, hin nay ch ghi nhn nhng bo co v thuc ca Trung Quc c s dng; ch yu l nhng dc liu c tnh cht hot huyt, kh mnh. Theo cc ti liu th ti Trung Quc c bo ch cc loi thuc phun sng tm thng th hn (ch yu thnh phn c cha nhc qu, hng ph), thuc phun sng tm thng th nhit (ch yu cha n b, xuyn khung.) c tc dng khng km nitroglycerin. Ngoi ra, cn c nhng bo co v s dng thuc dng tim (an sm IM, IV; xuyn khung IV; nhn sm; mch mn IV). 4.2.2. Dng chm cu Cc huyt thng dng: chin trung phi hp ni quan, c khuyt, gin s, tc tam l. Dng theo kinh nghim: + Day bm im gia ng ni 2 huyt tm du v quyt m du bn tri trong 1-2 pht. + Bm mnh huyt ni quan phi hp bnh nhn th su. 45

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Ngoi cn, nu c du hiu gi ca x m ng mch vnh tim th cch iu tr s nh phng php iu tr suy mch vnh mn. 4.3. Thiu mu c tim cp khng hoi t (au tht ngc khng n nh) Thiu mu c tim cp khng hoi t (au tht ngc khng n nh) phi c iu tr v theo di trong mt n v sn sc tch cc (ICU) v tim mch v bao gm chng thiu mu c tim, chng to mng x va v phng php ti lp ti mu. 4.4. Nhng phng php YHCT iu tr bnh l c tim thiu mu Tc dng tr liu ca nhng phng php YHCT, ngoi vic p ng nhng yu cu tr liu ca bnh l c tim thiu mu, cn ch n tng trng chung ca c th, gii quyt nhng ri lon thc vt km theo. 4.4.1. Th kh huyt tr Php tr: hnh kh hot huyt. Nhng bi thuc v cng thc huyt s dng: + Bi thuc gm: qua lu nhn 20g, c h 12g, o nhn 12g, v chanh gi 12g. + Cng thc huyt s dng gm: ni quan, tm du, chin trung; chm loa tai: huyt tm, thn mn, giao cm. 4.4.2. Th thn m h Php tr: t m ghm dng, t b can thn. Nhng bi thuc v cng thc huyt s dng: + Bi thuc h p (xut x 30 cng thc thuc) gm: thc a 20g, ngu tt 10g, r nhu 20g, trch t 10g, m 20g, to nhn 10g, hoa ho 10g.
V thuc Thc a Ngu tt R nhu Trch t M To nhn Hoa he Tc dng Ngt, hi n: b thn t m, b huyt Chua, ng, bnh: b can thn, tinh i xung ng, hn: bnh can, tim dng, an thn Ngt, nht, mt: thanh t thp nhit bng quang Ngt, hn: li tiu, thanh ph can phong nhit, thm bng quang thp kh Ngt, chua, bnh: dng tm, an thn, sinh tn, ch kht ng, bnh: thanh nhit, lng huyt, ch huyt Vai tr Qun Qun Thn T T T T

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+ Bi thuc Lc v a hong hon gia quy thc gm: thc a 32g, hoi sn 16g, sn th 8g, n b 12g, phc linh 12g, trch t 6g, ng quy 12g, bch thc 8g. Bi ny thng c s dng khi tng huyt p c km triu chng au ngc, au vng tim.
V thuc Thc a Hoi sn Sn th n b Phc linh Trch t Tc dng Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Chua, sp, hi n: n b can thn, sp tinh ch hn Cay, ng, hi hn: thanh huyt nhit, tn huyt, cha nhit nhp doanh phn Ngt, nht, bnh: li thy, thm thp, b t, nh tm Ngt, nht, mt: thanh t thp nhit bng quang Vai tr Qun Qun Thn T T T

+ Bi thuc b can thn gm: h th 10g, thc a 15g, hoi sn 15g, ng quy 12g, trch t 12g, si h 10g, tho quyt minh 10g.
V thuc H th Thc a Hoi sn ng quy Trch t Si h Tho quyt minh B huyt, thm tinh Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Dng can huyt Ngt, nht, mt: thanh t thp nhit bng quang Bnh can, h st Thanh can, nhun to, an thn Tc dng Vai tr Qun Qun Qun Thn T T T

+ Cng thc huyt s dng: thn du, phc lu, tam m giao, can du, thi xung, thn mn, ni quan, bch hi, a th huyt. 4.4.3. Th m thp Php tr: ha m tr thp. Nhng bi thuc v cng thc huyt s dng: Bi thuc h p gia o nhn, hng hoa (xut x 30 cng thc thuc) gm: thc a 20g, ngu tt 10g, r nhu 20g, trch t 10g, m 20g, to nhn 10g, hoa ho 10g, o nhn 12g, hng hoa 8g.

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V thuc Thc a Ngu tt R nhu Trch t M To nhn Hoa he o nhn Hng hoa

Tc dng Ngt, hi n: b thn t m, b huyt Chua, ng, bnh: b can thn, tnh i xung ng, hn: bnh can, tim dng, an thn Ngt, nht, mt: thanh t thp nhit bng quang Ngt, hn: li tiu, thanh ph can phong nhit, thm bng quang thp kh Ngt, chua, bnh: dng tm, an thn, sinh tn, ch kht ng, bnh: thanh nhit, lng nguyt, ch huyt Ngt, ng, bnh: hot huyt Cay, m, hot huyt

Vai tr Qun Qun Thn T T T T T T

4.4.4. Th tm thn dng h Php tr: n thng tm dng (tm dng h), hi dng cu nghch (tm dng h thot). Nhng bi thuc y hc c truyn c th s dng: + Lc v hi dng m + Hi dng cp cu thang. + Sinh mch tn. Nhng bi thuc v cng thc huyt s dng: + Bi thuc Lc v hi dng thang: nhn sm 8g, ph t (ch) 8g, ng quy 12g, an sm, nhc qu 6g, nhc thung dung 12g, ba kch 12g
V thuc Nhn sm Ph t ng quy an sm Nhc qu Nhc thung dung Ba kch Tc dng Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn Cay, ngt, rt nng: b mnh mn ha, kin t Ngt, cay, m: b huyt, hnh huyt ng, lnh: hot huyt, kh Cay, ngt, rt nng: b mnh mn ha, kin t, dn thuc Ngt, mn, m: n b thn dng, nhun trng Cay, ng, m: n thn dng Vai tr Qun Qun Thn T T, s T T

+ Bi thuc sinh mch tn gia v: nhn sm 40g, mch mn 40g, ng v t 7 ht, hong k 12g, cam tho 6g. 48

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V thuc Nhn sm Mch mn Ng v t Hong k Cam tho

Tc dng Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn Ngt, ng, lnh: nhun ph, sinh tn dch Mn, chua, m: lim hm, c tinh Ngt, m: b tm kh, thng dng kh ca t Ngt, m: b t th, b trung kh

Vai tr Qun Thn T T S

+ Bi thuc Hi dng cu cp thang: ph t ch 4g, can khng 4g, nhc qu 4g, nhn sm 12g, bch trut 8g, phc linh 8g, ng v t 10 ht, trn b 4g, cam tho nng 2g.
V thuc Ph t Can khng Nhc qu Nhn sm Bch trut Phc linh Ng V T Trn b Cam tho Tc dng n trung tn hn, hi dng cu nghch n trung tn hn, hi dng cu nghch Cay, ngt, rt nng: b mnh mn ha, kin t, dn thuc Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn Ngt, ng, hi m: kin t, to thp, cm m hi Ngt, bnh: li tiu thm thp, kin t, an thn Mn, chua, m: lim hm, c tinh Cay, m: ha kh, tiu m Ngt, m: b t th, b trung kh Vai tr Thn Thn Thn Qun T T T T S

+ Cng thc huyt s dng: n trung, c khuyt, kh hi, quan nguyn, cao hoang, ni quan. 4.4.5. Th tm t h Php tr: b ch tm t. Nhng bi thuc y hc c truyn c th dng gm: + Bi thuc Quy t thang gia v: phc thn 3g, toan to nhn 3g, long nhn 3g, nhn sm 3g, hong k 3g, bch trut 3g, ng quy 3g, vin ch 3g, i to 2 qu, mc hng 1,5g, cam tho 1g, ut kim 4g

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V thuc Phc thn Toan to nhn Long nhn Nhn sm Hong k Bch trut ng quy Vin ch i to Mc hng Cam tho Ut kim

Tc dng Tit tm nhit, bnh n tm thn Ngt, chua, bnh: dng tm an thn, sinh tn dch B huyt, kin t Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn Ngt, m: b tm kh, thng dng kh ca t Ngt, ng, hi m: kin t, to thp, cm m hi Ngt, cay, m: b huyt, hnh huyt ng, m: b tm thn, an thn Ngt, bnh: b t v, iu ha tnh nng ca thuc Hnh kh ch thng, kin t Ngt, m: b t th, b trung kh Cay, ng, n; vo t, can: hnh kh, hnh huyt, ph , gii ut

Vai tr Qun Qun Qun Thn Thn Thn T T T T S T

+ Cng thc huyt s dng: n trung, c khuyt, t du, cch du, thi bch, phong long, ni quan.

T lng gi I. Cu hi 5 chn 1: chn cu ng 1. Yu t khng phi l nguyn nhn ca bnh c tim thiu mu

A. Nhim m x mch B. Tng huyt p C. Vim ng mch vnh do giang mai D. Vim nt quanh ng mch E. Tc mch vnh do cc mu ng
2. Yu t khng tham gia vo c ch bnh c tim thiu mu theo YHCT

A. Bnh lu ngy lm m (huyt) suy h, h ha hun t tn dch sinh m, gy tc tr B. Th cht suy h dn n thn dng h, chn dng nhiu lon trn gy bnh. C. n ung khng ng cch sinh m lm tc tr kinh mch
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D. Gin, lo s gy can thn m h khin h ha bc ln hun t tn dch sinh m E. Gin d lm can kh ut kt gy tc tr kinh lc
3. Yu t khng phi yu t nguy c ca thiu nng vnh

A. Tui tc (mi tui) B. Thuc l C. Di truyn (gia nh) D. Tiu ng E. Tng cholesterol mu
4. Trn bnh nhn nghi ng thiu mu c tim, c in tim bnh thng, cn lm xt nghim g chn on

A. in tim gng sc B. in tim holter C. Chp nhp nhy c tim kch hot vi dipyridamol D. Siu m tim E. Cholesterol, HDL, LDL, triglycerid
5. Bnh nhn c triu chng au ngc khng n nh (angor instable), phi lm xt nghim g?

A. in tim B. in tim gng sc C. in tim holter D. Siu m tim E. Men tim: CPK, CPK-MB, SGOT, SGPT, LDH
6. Triu chng lm sng gp trong thiu mu c tim th kh tr huyt

A. au ngc nh c vt nng B. au ngc m , hi hp, kh th C. au ngc, cht li tm hoc c im huyt D. au nhi ngc nh co tht, ng tm phin nhit E. au ngc d di, t hn, ngi lnh
7. Triu chng lm sng gp trong thiu mu c tim th can thn m h

A. au ngc m , bng y, i tin lng B. au ngc, au nhi, cu gt, mch trm sc v lc C. au ngc, tha cn, mch hot D. Hi hp, kh th, on kh, au nng ngc
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E. au vng ngc nh c , kh th, t tay chn


8. Triu chng lm sng gp trong thiu mu c tim th m thp

A. au ngc nh , mch trm v lc B. au nhi ngc, au co tht, ngi bt rt C. au nng ngc, mt mi, i tin lng D. au ngc, hi hp, hoa mt, chng mt, t hn E. au nng ngc, bo bu, li dy nht
9. Triu chng lm sng gp trong thiu mu c tim th tm t h

A. au ngc nh , mch trm v lc B. au nhi ngc, au co tht, ngi bt rt C. au nng ngc, mt mi, i tin lng D. au ngc, hi hp, hoa mt, chng mt, t hn E. au nng ngc, bo bu, li dy nht
10. Triu chng lm sng gp trong thiu mu c tim th tm thn dng h

A. au ngc d di, li tm, c im huyt B. au ngc d di, li tm, xm, t hn C. au ngc d di, bt rt, cu gt, to bn. D. au ngc m , mt mi, i tin lng E. au nng ngc, li dy nht, mch hot
II. in vo ch trng 1. Khi no ngh n vic tm kim suy mch vnh mn

A. . B. . C. . D. . 2. Khi no ngh n co tht mch vnh/thiu mu c tim mn A. . B. . 3. Nguyn tc tr liu YHH suy mch vnh mn A. B. C. D.
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Bi 3

X M NG MCH

MC TIU 1. Nu c nh ngha v nhng yu t dch t hc ca bnh nhim m x mch. 2. Trnh by c nguyn nhn v c ch sinh bnh nhim m x mch theo l lun YHCT. 3. Trnh by c nhng nguyn tc iu tr nhim m x mch theo YHHD v YHCT. 4. Trnh by c phng php iu tr v phng bnh nhim m x mch ca y hc c truyn. 5. Gii thch c c s l lun cu vic iu tr nhim m x mch bng YHCT.

1. I CNG X m ng mch l nguyn nhn dn u gy t vong v tn tt cc nc pht trin. Mc d bnh kh ph bin, nhng mt vi tnh cht c bn ca bnh vn cha c hiu bit y . Atherosclerosis, tn gi ca bnh ni ln tnh trng tch t ca m (athere, gruel, cho) lm thnh trong ca mch mu b dy ln (sclerosis: dy cng). Bnh khng xut hin trn tt c cc ng mch ca c th. Thng thng n xut hin ng mch ch bng, k n l ng mch vnh tim trc khi tn cng n cc ng mch chu v ng mch no (cc ng mch cnh ngoi, ng mch v, ng mch nch khng bao gi thy x m d cha r l do). Ch nhng bin chng ca bnh mi lm thy r bnh: trong mt thi gian di, tin trin ca x m ng mch rt yn lng, khng triu chng v n thun ch l nhng thay i v gii phu. Nhng sang thng trn di dn trong lng ng mch lm dng mu chy chm li, to nn tc nghn mch a n nhng hi chng thiu mu cp v mn. Nhng bin chng ca x m ng mch gm (bng 3.1): 53

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Bng 3.1. Nhng bin chng ca x m ng mch


ng mch Mch vnh tim au tht ngc Nhi mu c tim (NMCT) t t Suy tim Di n ng mch cnh H thng ng mch ty thn nn ng mch no ng mch thn Suy thn Huyt p cao ng mch mc treo Thiu mu mc treo Nhi mu mc treo ng mch chi di Khp khnh cch hi Thiu mu nui chi di cp tnh Cp mu di n Cn thiu mu no thong qua Tai bin mch mu no do thiu mu nui Bin chng

2. NGUYN NHN V DCH T HC 2.1. Theo y hc hin i Cho n nay, bnh x m ng mch vn cha r c nguyn nhn. Ngi ta nhn thy c nhiu yu t tham gia vo s hnh thnh bnh l ny. Nhng nghin cu dch t hc tin hnh trong vng 35 nm gn y xc nh c nhng yu t thc y qu trnh pht trin bnh. Chng c gi di tn l nhng yu t nguy c (c th tham kho thm bng nhng yu t nguy c trong bi thiu mu c tim, trang 30-32). Tuy nhin, gip nh hng x tr, cn ch u l yu t nguy c ca x m ng mch gii phu v u l yu t nguy c ca nhng bin chng ca x m ng mch. Yu t nguy c ca nhng bin chng ca x m ng mch: th hin mi lin quan gia yu t phi nhim (exposed) v bin chng: ==> ta c th d kin rng nu tc ng trn yu t ny s lm gim nhanh tn s xut hin bin chng y (v d: ht thuc v bin chng mch vnh).

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Yu t nguy c ca x m ng mch gii phu: th hin mi lin h nhn qu gia yu t phi nhim (exposed) v s pht trin v mt gii phu ca mng x va: ==> ta c th d kin rng nu tc ng trn yu t ny s lm gim t t tn s xut hin bin chng y (v d: tnh trng tng cholesterol mu v tng atherom ==> bin chng mch vnh). Do , d nguyn nhn ca bnh x m ng mch cha r nhng vi nh ngha tm thi v nguyn nhn (yu t m khi gim s dn n s gim bt tn thng gii phu XMM hoc tn sut bnh) v yu t nguy c (yu t m s hin din gia tng s dn n s gia tng tn thng gii phu XMM hoc tn sut bnh). 2.1.1. Tng cholesterol mu c xp vo nhng nguyn nhn ca x m ng mch C mt mi lin quan trn khp th gii gia con s trung bnh cholesterol mu trong mt quc gia, s pht trin v mt gii phu ca x m ng mch v tn sut cc bnh tim thiu mu trong quc gia y. Nhiu nghin cu cho thy vic lm gim cholesterol mu, d vi phng tin no cng lm chm s pht trin x m ng mch v cui cng l gim t l t vong cc bnh mch vnh.
Bng 3.2. Gi tr cholesterol i hi mt s tr liu
Tui 20 - 29 30 - 39 > 40 Cholesterol ton phn 2g/l = 5,16mmol/l 2,2 g/l = 5,68mmol/l 2,4 g/l = 6,19mmol/l

Cholesterol di chuyn trong mu bng cch gn vo cc protein to thnh cc lipoprotein. C hai nhm lipoprotein chnh: Nhm t trng thp LDL (low density lipoprotein): trong nhm ny chuyn ch ch yu l apoprotein B. y l dng m cholesterol c mang n cc t bo ==> Nu LDL hay apoprotein B cng cao, nguy c XMM cng ln Nhm t trng cao HDL (high density lipoprotein): nhm protein chuyn ch ch yu l apoprotein A1. y l dng m cholesterol d tha c mang ra khi cc t bo. Do nu HDL hay apoprotein A1 cng cao nguy c XMM cng thp. 2.1.2. Tng huyt p c xp vo nguyn nhn XMM XMM ch thy xut hin trong nhng vng chu nh hng ca p lc ng mch cao: ngi ta khng thy XMM trong cc tnh mch saphene 55

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hoc ng mch phi (tr khi tnh mch saphene trong tnh trng ng mch ha hoc c tnh trng tng p ng mch phi). Tnh trng huyt p cng tng, tnh trng pht trin gii phu ca XMM cng nhiu v bin chng XMM cng ln. Hin nay cha c chng minh r rng gim huyt p lm gim s pht trin XMM, nhng chng minh c mi quan h gia gim huyt p v gim bin chng thiu mu no v thiu nng vnh. 2.1.3. Ht thuc l c xp vo nhng nguyn nhn ca nhng bin chng ca XMM Tn s ca NMCT, t t, vim tc ng mch chi di mn tnh u tng mt cch ng k vi s kin ht thuc l. Khng thy c mi lin h gia ht thuc l v s pht trin gii phu ca XMM. 2.1.4. Nhng yu t nguy c ca bin chng XMM t mnh m hn Tnh trng gim vn ng th lc Stress Bo ph Tng triglycerid (TG) mu Dng thuc nga thai ung 2.1.5. Nhng yu t nguy c rt ln ca XMM nhng khng c cch nga Phi nam Tui Yu t di truyn 2.2. Theo y hc c truyn X m ng mch l bnh l rt ph bin: nh trn nu, phn ln mng x va khng gy ra triu chng v rt nhiu trng hp khng bao gi c biu hin triu chng lm sng. Trong khi nhng bnh danh YHCT ch yu c da trn nhng triu chng chc nng khi bin chng ca bnh xut hin. Da vo nhng c s l lun YHH v YHCT, c th bin lun v c ch bnh sinh bnh l XMM theo YHCT nh sau:

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Tht tnh (gin, lo lng) (stress ko di)

Tin thin bt tc, bnh lu ngy

n ung khng ng

Can m h

m (huyt) h

Dng (kh) h

m thp

H ha hun t tn dch

m ho

Tc tr kinh mch

C th ni rng nhim m x mch theo YHCT, d do nguyn nhn no, cng u gy bnh thng qua c ch m thp. m thp (c th ha ha hoc khng) s lm tc tr kh huyt lu thng trong kinh mch. Ty theo tnh trng tc tr kinh mch xy ra u m biu hin lm sng s l: + tm vi triu chng tm thng, tm trng (xem bi c tim thiu mu). + kinh lc m xut hin triu chng t, au, yu lit (xem bi tai bin mch mu no). + can, thn gy chng huyn vng, u thng (xem bi tng huyt p). 3. IU TR KT HP V THEO DI i vi bnh l x m ng mch, phng bnh l yu t quan trng hng u. Vic phng bnh cn phi thc hin t lc cn tr v sut cuc i, ch yu l loi tr nhng yu t nguy c. 3.1. Tit ch Ch n nhiu rau xanh, tri cy ti l ngun cung cp sinh t, ion K+, Mg++, cc cht anti oxydant. Cn quan tm n sinh t E (l mt cht anti oxydant rt c li cho phng x m ng mch): sinh t E c nhiu trong thc n tho mc v trong cc loi du nh du mng la m, du hng dng, du bp Cht x ngoi tc dng chng to bn cn c tc dng gi li cholesterol trong lng ng tiu ha, hn ch s hp thu cholesterol vo mu, lm gim LDL, VLDL, triglycerid trong mu. 57

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Do c nhiu loi tng m trong mu khc nhau, ngi thy thuc cn ch n nhng ch tit ch ph hp.
Bng 3.3. Bng phn loi ri lon bin dng m trong mu
Cholesterol >2g/l LDL > 130mg% Tng triglycerid mu Tng cholesterol mu Tng m trong mu phi hp

1,5 g/l = 1,71mmol/l

Tit ch gim cholesterol l sa i ch n t nhiu cht bo no sang bo khng no


Bo no Sa v cht ch bin t sa M ng vt n Rau Tri cy C Thc n nng Du: liu, hng dng, u nnh Yaourt C th dng margarin t hng dng S hn Heo B, b Du u phng Sa, b, pho mt C Du hng dng King Trng > 2 trng/tun Bo khng no

Ch lm gim m (dnh cho bnh nhn tng lipid huyt)


King Bnh m Bnh nng Khoai ty u H Lan Bp Go Bt Thc ung c ng, xir Ru Trng ming c ng Tri cy kh Tht heo Tht cu Tht b Tht vt C hi C mi Pho mt (tr yaourt) Chui Nho Gim

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Ch n lm gim triglycerid: King: thc n ngt, bnh ga-t, s-a, xi-r, chocolat, ru 3.2. Thay i cch sng Cng nhm loi b nhng yu t nguy c nh: B ngay thuc l. Gi thi tm thn thch hp, lc quan, trnh cng thng thn kinh (xem bi thi tm thn trong cuc sng - dng sinh v hc thuyt m dng ng hnh). Phi hp vi ch n: thit lp ch vn ng th lc u n/ngy, nht l ngi cao tui. Nguyn tc ca ch tp luyn ny l dng nhiu c t u i bt dng c tim. Thc hin nhng bi tp dng sinh u n (xem bi th gin - th 4 thi - nhng bi tp cc t th nm, ng). 3.3. iu tr tch cc, ng n nhng bnh c lin quan iu tr bnh tng huyt p, tiu ng (xem phn bnh l tng huyt p, tiu ng). iu tr gim cholesterol mu bng thuc.
C ch Nhm fibrat Tc dng Tc dng ph Ch nh Liu dng Lipanthyl 100300mg/ 24h - Lipur (R) (gemfibrozil) 900mg/24h - Ciprofibrat Lipanor (R): 100mg/24h - Bezafibrat, befizal (R): 400600mg/24h Nhm c ch HMG -CoA reductase Gim 30% cholesterol, rt hiu qu trong tng cholesterol mu gia nh - au c - Tng transaminases v CPR - Tng nh tc dng cc thuc chng vitamin K Tng cholesterol mu n thun Simvastatin Zocor (R) Lodals (R) 10-20mg/24h Pravastatin Vasten (R) Elisor (R) 10-40mg/24h

20% - Lm tng tc Tng lipid c ch tng Gim thuc huyt (nht dng hp cholesterol cholesterol, chng vitamin K l khi gim 40% TG gan cholesterol > - Tng creatinin 2,8 g/l) - Tng transaminase

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Nhm resin (dng v tc dng ph h tiu ho, dng phi vi hp nhm 2) Ngh

Chelation cc Gim Tng 15% - To bn acid mt c cholesterol cholesterol - RLTH cha gia nh - Gim tc dng cholesterol cc thuc chng vitamin K, digital v kch t gip

Cholestyramin Questran (R) 3-6 gi /24h

Thng mt, li V cay ng, Ngi m h gim tnh n mt, m khng tr cholesterol Quy kinh can t: th khng nn dng ph c huyt, huyt tch, kim sang. Tc dng st trng, khng khun, sinh c v ch huyt Tc dng ph v chua ng, huyt, hnh tnh bnh, khng (sng), b can thn, mnh gn c; ct (chn) vo 2 kinh can, thn Li tiu; H cholesterol, Thanh nhit, gii h huyt p. c st trng, V cay, tnh n, cha bng i hi c, vo 2 trng tch, huyt u, l. Ty kinh can v v khiu, thng tiu nht, hch phi, tiu m, y trng Phm m h ni nhit, thai sn ch dng, hi ming

6-8g

Ngu tt

12-16g

Ti

4-8g

T lng gi I. Cu hi 5 chn 1: chn cu ng 1. Bnh l no khng do bin chng ca x m ng mch (XMM) trn tim

A. au tht ngc B. Nhi mu c tim (NMCT) C. Tng huyt p


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D. t t E. Suy tim
2. C ch bnh nhim m x mch theo YHCT

A. Can m h gy ni nhit B. Huyt h sinh huyt nhit C. Huyt h sinh huyt D. Kh h sinh kh tr E. m thp
3. Ch n no khng c li cho bnh XMM

A. Nhiu rau B. Nhiu tri cy C. Nhiu c D. Nhiu du phng E. Thc n nng


4. Dc liu no c tc dng lm h cholestorol trong mu

A. Sinh a B. Cc hoa C. C xc D. Trch t E. Hoa i


5. Ngh l v thuc c tc dng

A. Lm lnh so, lnh vt lot B. H cholesterol mu C. St trng D. Nhun gan mt E. C 4 cu trn u ng


Cu hi 5 chn 1: chn cu sai 1. lm gim m trong mu, cn king

A. Bnh m B. Khoai ty
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C. Tri cy kh D. Thc n ung c ng E. Yaourt


2. lm gim cholesterol trong mu, cn king

A. Trng B. Tht heo C. Tht b, b D. Sa E. C


3. lm gim triglycerides trong mu, cn king

A. Du hng dng B. Bnh ga-t C. Chocolat D. Thc n ung c ng E. Ru


4. iu tr XMM, tt nht

A. Phng bnh B. n ung ng cch C. Thay i cch sng D. iu tr bnh c lin quan E. Dng thuc h cholesterol mu
5. Cng dng ca c xc

A. An thn B. H huyt p C. Li tiu D. H cholesterol mu E. Cha au khp


6. Cng dng ca ngh

A. Khng khun B. Kch thch tiu ha C. Nhun gan mt D. Lm lnh vt lot E. St trng
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Bi 4

VIM PH QUN CP V MN

MC TIU 1. Nu c nh ngha v nhng yu t dch t hc ca bnh vim ph qun cp v mn. 2. Trnh by c nguyn nhn v c ch sinh bnh ca bnh vim ph qun cp v mn theo l lun YHH v YHCT. 3. Chn on c 9 th lm sng ca bnh vim ph qun cp v mn theo YHCT. 4. Trnh by c nhng nguyn tc iu tr ca bnh vim ph qun cp v mn theo YHH v YHCT. 5. Trnh by c phng php iu tr ca bnh vim ph qun cp v mn (dng thuc v khng dng thuc ca y hc c truyn). 6. Gii thch c c s l lun ca vic iu tr bnh vim ph qun cp v mn bng YHCT.

1. I CNG 1.1. nh ngha Vim ph qun cp (VPQC) l tnh trng vim nhim cp tnh nim mc cy kh ph qun. Thng tin trin t nhin ht, hoc cui cng sau iu tr s lnh hn bnh v hot ng h hp hon ton tr li bnh thng. Vim ph qun mn tnh (VPQM) l mt bnh c lin quan vi s tip xc lu di vi nhng cht kch thch ph qun khng c th, i i vi s tng tit nim dch cng mt s thay i v cu trc ca ph qun. V mt lm sng, c coi l VPQM khi bnh nhn c ho khc ko di t nht 90 ngy trong mt nm v trong 2 nm lin tc. Ho khc c loi tr l khng do cc bnh khc nh lao, gin ph qun, p - xe, bi phi v.v (Lancet, 1965). nh ngha trn ch nu c mc ti thiu khi u ca VPQM, v VPQM bao gm nhng trng thi bnh l nng nh khc nhau, t ho khc m gim, n nhng t suy h hp thng xuyn m tin lng cng khng km nguy him

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nh nhi mu c tim (Bourgeois, 1979). iu ny ni ln tnh cn thit ca s pht hin v phng tin trin xu. 1.2. c im dch t hc 1.2.1. Vim ph qun cp C th gp VPQC mi la tui, nhng ch yu l tr em v ngi cao tui. Thng gp VPQC khi tri lnh hoc khi thay i thi tit t ngt. VPQC chim1,5% cc bnh n bnh vin v 34,5% cc bnh ca c quan h hp (Votral.B. E). 1.2.2. Vim ph qun mn Thng gp VPQM ngi trung nin v cao tui. Bi nh hng nhiu n VPQM, t l mc bnh cao r rt cng nhn cc cng trng nhiu khi bi, dn thnh ph mc bnh cao hn nng thn, ngoi tr trng hp nhng ph n nng thn nu nng trong nh bp thiu thng thong, khng ng khi, cht t to nhiu bi bm; min ni t l thp hn ng bng. Vit Nam: t l VPQM l 4,7%, v chim hn 1/2 tng s ngi mc cc bnh v h hp (Phm Khu v CS). Trong mt iu tra khc ngi trn 60 tui, t l VPQM ln ti 19,6%. V thi tit, ma lnh lm tng s ngi mc VPQM: ti Scotland t vong l 45% do VPQ mn xy ra trong 3 thng lnh u nm (thng k 1956 - 1963 Crofton, Douglas). 2. NGUYN NHN - BNH SINH V GII PHU BNH 2.1. Nguyn nhn
Yu t Vim ph qun cp (+) Mycoplasma pneumoniae Vi khun () Cc loi vi khun khc, thng l th pht, bi nhim sau nhim siu vi hoc nhim lnh Vim ph qun mn (+++) Hemophilus influenza 13,5% (+++) T cu vng 15,5% (+++) Ph cu 13,5% (++) Proteus hauseri 12,2% (++) Pseudomonas aeruginosa 9,6% (++) Escherichia coli 9% (+) Klebsiella pneumoniae 1,9% (++) Streptococus pyogenes 6,4% () Trc khun Gram (-) (Voisin, 1976)

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Virus

(+++) RSV Syncytial Virus)

(Respiratory Para.

Virus ch l nguyn nhn ban u to iu kin cho vi khun pht trin v sau Cc loi virus nh: Influenza, Rhinovirus (Voisin) (++) nhim khng kh, kh quyn, hi c cng nghip l iu kin thun li gy bnh (+++) Khi thuc l: tc nhn ch yu bn cnh vi khun (+++) Ma lnh, nhim lnh

(+++) Adenovirus, influenza virus

(+) nhim khng kh: bi Ha hc (+) Hi c: SO2, NO2, NO3. clo, amoniac.s (+) Khi thuc l (+) Khng kh qu kh, qu m, qu lnh (+++) Nhim lnh t ngt (+) L yu t c tnh cch thc y bnh sinh: VPQC ngi hen, ph Quincke, m ay

Vt l

(++) Kt hp gia hen v VPQM (++) VPQM trn c a d ng (+) Thiu ht globulin min dch

D ng

Di truyn

(-)

(+) Bt thng v gen: mt thng bng gia h thng protease v khng protease

2.2. Bnh l gii phu 2.2.1. Vim ph qun cp Ty thuc v tr qu trnh vim xm ln ti cy ph qun m VPQC c th c chia ra vim kh ph qun, vim ph qun cp nhng ph qun c thit din ln, trung bnh v nh. Tn thng ca nim mc ph qun b ph n, sung huyt, cc mch mu gin to c lp dch nhy, m bao ph, bch cu a nhn xm nhp, t bo biu m b bong ra, c ch b lot, cc tuyn nhy cng phng v tng tit. C c lon sn v tng sn t bo biu m lng (cilia cells). Cc hot ng bo v ca nhung mao ph qun, thc bo, bch huyt b ri lon v vi khun c th xm nhp vo cc ph qun thng vn v trng, tip tc gy ra s tch t nhng mnh vn t bo hoc dch r nhy m, c th gy tc nghn ng th, c th gy xp tiu phn thy hoc phn thy. Theo thi gian qu trnh hi phc din ra th cu trc ca nim mc c phc hi hon ton. Phn x ho, d c gy suy h hp nhng cng rt cn thit cho tng xut cc dch tit ph qun. C th c tc kh do s ph vch ph qun, do tit dch b ng li v trong mt s trng hp do s co tht ca cc ph qun. 65

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2.2.2. Vim ph qun mn a. i th S phn b tn thng khng phi bao gi cng i xng 2 phi, c mt s tn thng ch khu tr ph qun ln. C hnh nh vim nhim v tc nghn: s tc nghn thng xy ra cc ph qun c khu knh t 1/2mm n 3mm do qu trnh dy x v s hnh thnh cc nt nhy. b. Vi th H thng ph qun bao gm nhiu loi ln nh khc nhau, kch thc v cu trc khc nhau. Ty thuc vo v tr tn thng v giai on tin trin ca bnh m s xut hin ng thi hoc n l cc triu chng lm sng nng nh khc nhau. Cc ph qun ln: + Tng sinh v ph i cc t bo hnh i (goblet cells). Bnh thng t l ca t bo hnh i i vi t bo lng (ciliary cells): 10-20%. Trong bnh l VPQM, t l trn c th tng 80-90%. + Lp m ph n, lp di nim mc dy ln bi s tng sn cc tuyn nhy. + Vo giai on sau, vim nhim lan to vi s thm nhp ca cc t bo vim lm hy hoi t bo c trn v cc t bo sn. + Do s tng sinh v ph i cc t bo hnh i nn cc ph qun ln tng tit cht nhy. Thnh phn cht nhy thay i, nht tng lm nh hng nhiu n hot ng ca lp nhy lng. Triu chng ho m s l triu chng ch yu, ty mc nng nh, ty loi vi khun, ty giai on vim nhim, qu trnh tng sn ca tuyn tit cng nh phn ng ca lp nim mc ni chung m ta s c cc loi ho khc khc nhau. Cc tiu ph qun: + Cc tiu ph qun tn, ph qun h hp c cc tn thng x quanh ph qun, ph n nim mc v s c mt cc cc nhy, cc c trn dy ln a n tng sc cn kh o. + Triu chng c bn l tr ngi lu thng khng kh, biu hin bng kh th vi nhng mc nng nh khc nhau. Giai on u kh th khng thng xuyn v c th phc hi c bng luyn tp. Triu chng c hiu l thm d chc nng thy hi chng tc nghn vi nhng ri lon v phn phi do qu trnh thng kh b tr ngi.

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2.3. Bnh sinh 2.3.1. Nhu m phi Vim tiu ph qun a n vim ph nang. Ty theo mc tc nghn cc tiu ph qun s c hin tng kh ph nang hay vi xp phi (micro atelectasis). Trong VPQM kh ph nang chim u th r rt thy bn ca phi. Triu chng ch yu biu hin l kh th, r rt v thng xuyn hn v s tp luyn cho hi phc lc ny tr nn kh khn v chc nng h hp; ngoi hi chng tc nghn, cc ri lon v vn chuyn kh xut hin, suy h hp dn hnh thnh. 2.3.2. Tim mch Cc tiu ng mch phi cng b nh hng bi qu trnh vim. Hay xy ra hin tng huyt khi lm tc mch. Tnh trng huyt khi ti cc ng mch phi thng l nguyn nhn t vong ca VPQM. Tim: c ph i tht phi, ph thuc trng thi tng p lc ng mch phi v trng thi ny li do thiu oxy v suy h hp.
Bng 4.1. Phn loi ph qun v cc biu hin bnh l khi tn thng
Loi ph qun Cu trc Tn thng gii phu Biu hin lm sng Thm d chc nng Ln Trung bnh (tiu ph qun) Nhiu tuyn v sn cng Tng sn tuyn tit Ho khc Cha c Nhiu c Co tht, tc, xp Kh th tng lc Hi chng tc nghn, ri lon thng kh Tng t vch ph qun Hy hoi Kh th r v dn thng xuyn Ri lon vn chuyn kh Nh

2.4. Nguyn nhn bnh sinh theo YHCT Vim ph qun l bnh danh ca YHH v khng c t ng ngha trong YHCT. T ng ngha d gp gia hai nn y hc l m t cc triu chng trn lm sng (th d nh: ho vi khi thu, kh th vi ho suyn, st vi pht nhit v.v). 2.4.1. Cc biu hin lm sng thng gp trong VPQ cp v mn Cc triu chng c nng c m t trong bnh VPQ cp v mn thng bao gm: ho, st, khc m. Ty thuc vo din bin v bin chng ca bnh 67

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m c th c thm triu chng mt ting, kh th. Cc triu chng nu trn c y hc c truyn (YHCT) khi qut trong cc chng khi thu, tht m, ho suyn, m m. Khi: c ting ho m khng c m. Thu: c ting m kh kh, c c m khng c ting ho. Biu hin bnh l thng khi cng c ho khan khng c m, nhng cng thng khi c ho v m km theo nn gi chung l chng khi thu. Ho: cn gi l chng p khi. Sch Thin kim phng m t chng ny c c l do bnh lu nm, c nhiu m kh kh trong c, khi th rt ln thnh ting; khi pht ra chng ny l nm khng c. Suyn: th gp, th cp bc, hi a ln th nhiu a xung th t. Thc t cho thy, chng suyn c khi pht ra n c, nhng chng ho th lun km chng suyn. Trong bnh cnh VPQC, VPQM m chng ta nu trn y c th hiu kh th xy ra l do m ng v tc nghn nn gi chung l chng ho suyn. m m cng c s khc nhau: + m th do dnh, thuc cht trc, thuc v m. + m th lng long, thuc cht thanh, thuc v dng. Trn thc t thng gi chung l m m v cng l mt loi (u t tn dch ca n ung m ho ra). 2.4.2. Nguyn nhn bnh sinh theo y hc c truyn Nguyn nhn sinh ra 3 chng trn c m t do ngoi cm v ni thng. Ngoi cm: do lc dm, t kh tc ng gy bnh. + Gy chng khi thu: tt c phong, hn, th, thp, to, ho u c th gy bnh. + Gy chng ho suyn: ch do phong, hn. + Gy chng m m: do phong, hn, thp. Ni thng: c nhiu nguyn nhn do ni thng m sinh ra cc chng trn. + n ung khng chng mc, t b tn thng nh hng n ph thn. + Lao nhc thng xuyn, n ung thiu thn lm t h. + Tu sc v lm t thn h. Qua vic phn tch cc chng trng YHCT thng gp trn lm sng trong bnh l VPQ cp v mn, c th bin lun v nguyn nhn bnh sinh theo YHCT nh sau: 68

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Do ngoi cm lc dm xm nhp vo c th, phong hn xm phm lm cho ph kh vt tc khng tuyn thng dn n ho khan, khn ting hoc mt ting, hoc gy nn tnh trng ngoi t ng tc ph, ph kh ut khng tuyn ging c gy st, ho, tr em c cnh mi php phng. Do v kh suy yu, lc dm t kh nhn c hi xm nhp qua b mao nh hng n ph; nu phong hn b ngoi th gy st, au u, khng ra m hi, ho c m v kh kh th kh; phong n phm ph th st cao, c m hi, ho nng tc hng sn; ha nhit bc bch ph gy chng st cao, ho nng ra m vng hoc dnh mu, kh kh c c. Do bnh lu ngy, th cht suy yu, thn m h dn n thn dng h. Thn m h lm kh cn tn dch khng nui dng ph, hn na thn m h, h ha bc ln cng thiu t chn m lm tn thng ph m gy ra chng ho khan, t m; nu h ha bc lm tn thng ph lc th trong m c ln mu. Thn dng h lm nh hng n t dng sinh m ng tc gy chng kh suyn, ho c m v kh kh nng. Do n ung khng iu ha, khng y , tr con sinh chng Ph cam do ut nhit lm tn thng ph sinh chng ho m kh th, quy khc, trng bng i cu phn sng, ngi ln th tn thng t lm cho tinh hu thin b suy gim khng cung cp nui dng ph kh, nh hng n chc nng tc ging kh sinh ra chng m trc v kh th, ph kh h cng nh hng n sc khng bnh ca c th (v kh) lm cho tu l tha h l c hi cho ngoi t tip tc xm nhp gy bnh, to nn vng lun qun bnh l tip din khng ngng Tu thuc vo nguyn nhn, vo giai on din tin bnh sinh, bnh l VPQ cp hoc mn s c biu hin cc th lm sng YHCT nh: nhm thc chng gm: phong hn, phong nhit, kh to, m thp, m nhit; cc bnh cnh ny c th thy xut hin trong c vim ph qun cp v mn tnh. Nhm chng h gm: ph m h, ph kh h, ph t h, ph thn dng h thng xut hin trong vim ph qun mn v giai on bin chng l bnh phi tc nghn mn tnh v tm ph mn. 3. CHN ON 3.1. Chn on theo y hc hin i 3.1.1. Vim ph qun cp a. Triu chng lm sng Vim ph qun nhim khun cp tnh thng c nhng triu chng i trc ca mt s bnh nhim khun h h hp trn nh s mi, n lnh, st 69

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nh, au lng, au c v vim hng. Ho thng l bo hiu s khi pht ca vim ph qun. Ho lc u l ho khan khng m, nhng sau vi gi hay vi ngy c th thy khi lng nh m nht, v sau m nhiu ln v c dng nhy hoc nhy m. m cha ton m khin ngh n s nhim khun chng lp. Trong trng hp bnh nng nhng khng gy bin chng th st cao 38o8C ko di n 3-5 ngy, sau cc triu chng cp tnh s bin i; ho tip tc trong vi tun, ho dai dng ko di khng ht khin ngh n vim phi bin chng, c th c th c kh th do tc nghn kh o. Thng thy cc bin chng nng nhng bnh nhn c bnh v h hp mn tnh. nhng trng hp ny VPQC c th dn n suy h hp cp. b. Cn lm sng: X quang phi o chc nng h hp o kh mu ng mch Xt nghim huyt hc 3.1.2. Vim ph qun mn a. Triu chng c nng Ho l triu chng bao gi cng c t trn 2 nm, ho thng xuyn hay ho tng t di. Ho nhiu ln trong ngy, hay ho vo bui sng, ho tng cn nng nhc v y thng l l do lm bnh nhn n khm. Khc m: giai on u c th t, thng xut hin ng thi vi ho; s lng v mu sc ty thuc vo loi vi khun, mc nng nh v ty giai on vim nhim. Kh th: khng hng nh. C th kh th lc gng sc, khi nm hoc kch pht, i khi ging hen do tnh trng ph qun co tht. b. Triu chng thc th Giai on u, nu khng c bi nhim nghe phi c th thy bnh thng. Giai on sau c th thy lng ngc cng, bin h hp gim. + Nu c kh ph nang, g trong, r ro ph nang gim nht l nh phi. + y phi c th thy ran ngy, ran rt i khi c ran m. C th c ngn tay di trng. + Tim mch: T2 vang ng mch phi, nghe thy ting nga phi khi c suy tht (P) km gan to, phn hi gan - tnh mch c (+), ph chi di, tiu t. 70

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c. Cn lm sng X quang phi: + Giai on u gn nh bnh thng. + Giai on tin trin bnh: Triu chng vim nhim: 2 y m m khng r ranh gii, ta bng, khng thun nht. Xng sn nm ngang, khong lin sn gin rng. Triu chng tim mch: thn ng mch phi gin to, tht (P) to. Ni soi ph qun: rt quan trng. Ni soi cho php: + Xc nh tnh trng vim nhim cc ph qun ln. + Mt s trng hp c co rt thnh sau kh qun. + Qua ng soi: ht m th vi khun v t bo hc lm sinh thit xc nh m hc v chn on loi tr cc loi khi u. Thm d chc nng: gip nh gi nng nh ca bnh, pht hin ri lon tc nghn v chn on xc nh bnh phi tc nghn. + Chn on xc nh bnh phi tc nghn: FEV1/ (F) VC < 70% Mc tc nghn: Nh: 60% < FEV1 < 80% Va: 40% < FEV1 < 60% Nng: FEV1 <40% + Chn on giai on COPD theo GOLD 2003:
Giai on COPD O I II III IV FEV1/FVC 70% < 70% < 70% < 70% < 70% FEV1 so vi d on 80% 80% 80% > FEV1 50% 50% > FEV1 30% < 30%

Tng dung tch cn chc nng: nh gi bng cng thc th tch cn/ tng dung tch phi. Gim th tch th ra ti a giy: nghim php dc l ng hc cho php chn on phn bit gia hen v vim ph qun mn co tht. Cc kh mu ng mch: p lc ring phn O2 trong mu ng mch (PaO2), bo ho oxyhemoglobin (SaO2). 71

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giai on mun, c hi chng gim O2 mu v tng CO2 vi toan h hp. Xt nghim huyt hc, do thiu O2 mu nn c tnh trng a hng cu tng bch cu v tng tc lng hng cu khi c bi nhim. in tm : + Trc QRS xoay phi (> +110o). + R cao V1, S su V5 V6. 3.1.3. Cc bin chng ca vim ph qun mn Tm ph mn Nguyn nhn ca tm ph mn l do tng p lc tun hon phi v c ch bnh sinh l s co tht ca h thng mch mu tiu tun hon (do phn x t v i vi trng thi thiu O2 ph nang, thng gi l phn x Von Euler) lu ngy dn n tr ngi tm tht (P). Tm ph mn l mt triu chng quan trng ca VPQM, chng t bnh din bin n giai on nguy him, bnh nhn cn c qun l chu o. nh ngha ca WHO gi tm ph mn cn c trn gii phu hc: c s ph i r rng ca c tim. Nhng nu ch i c du hiu trn th bnh thng b coi l qu mun. Tiu chun lm sng i vi nhng triu chng nh: ting nga phi, nhp tim nhanh, gan to, phnh tnh mch cnh, ph chi di cng c nhiu nh lm sng bn ci cha thng nht thi im no gi l bt u c tm ph mn, l do l t cu trc tim bnh thng n khi c dy tht r rt, hot ng cng nh hnh thi c tim c nhng thay i dn trong qu trnh lu di. Ty quan im, mi nh lm sng c th ly mt thi im trong qu trnh xc nh tm ph mn. K thut thng tim ra i, o c p sut ng mch phi l c s bit chc ngay t giai on tim phi bt u qu ti. Giai on ny, thy thuc c th c tc ng tt nht cho tim v phi ca bnh nhn. Tuy nhin khng phi ni no cng thc hin c k thut thng tim. khc phc iu ny, cc nh lm sng ngh c th dng mt s tiu chun chn on gi l c kh nng mc. Sau y l xut ca Chiche 1970: Du hiu bo ng d c kh nng mc tm ph mn: + Vim nhim ph qun tng t. + Tm ti thng xuyn hay tng lc. + Gy st km mt nc. + L m km bun ng ban ngy. + Nhp tim nhanh. 72

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Cc nguy c c th mc tm ph mn: C 3 mc : Loi A (cha c tng huyt p phi): SaO2 bnh thng, PCO2 gia 45 v 55mm, th tch hng cu bnh thng. Loi B: huyt p phi c th 30 - 50 mmHg v c kh nng mt b khi thy SaO2 gim di 0,92 (92%), PCO2 gia 55 - 7mmHg, d tr kim tng, s lng hng cu tng. Loi C: chc chn c tng huyt p phi v thng c suy tim phi: SaO2 gia 0,51 v 0,53 (51 - 53%), PCO2 tng 9,31 - 13,3Kpa (70 - 100mmHg), d tr kim trn 30mEq, th tch hng cu tng. Cn c vo cc du hiu tng i n gin trn, c th d on tnh trng huyt p tiu tun hon v qua s hnh thnh tm ph mn. Kh ph thng. Gin ph nang. 3.2. Chn on theo y hc c truyn 3.2.1. Nhm chng thc a. Phong hn: thng gp trong cc bnh vim ph qun, hen ph qun, vim thanh qun... ca YHH. Ho, kh kh (kh suyn), m trng, ming khng kht (phong hn phm ph lm ph kh mt tuyn ging). Chy nc mi, ngt mi. S lnh, pht st (phong hn bao b lm ut ph v (b mao)). Ru li mng, mch ph. b. Phong nhit: thng gp trong cc bnh vim ph qun cp, mn, hen ph qun, vim thanh qun, vim phi, p xe phi giai on u... ca YHH. Ho m c vng, ming kh (do tn dch b mt) Ming kht, hng au,... St, ra m hi, nc mi c, cht li , mch ph sc (phong nhit phm vo ph v). c. Kh to (to nhit): thng gp cc bnh vim ph qun cp, vim hng hoc bnh nhim khun... ca YHH Ho khan, hay ho t m m m dnh, mi kh, hng kh. St, nhc u, ngi au mi (to ut phn ph v). u li kh, mch ph sc (tn dch gim st). 73

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d. Th m: theo YHCT gm 2 loi m nhit v m thp. Thng hay gp bnh vim ph qun mn tnh, p xe phi, vim thanh qun cp,... ca YHH. m nhit: + Ho m vng c dnh, kh th, au ngc (m nhit lm ph b tr ngi mt kh nng tuyn ging). + Hng kh, ru li vng: m nhit gy ra ming ng, mch hot sc (gy ra cc chng nhit lm mt tn dch). m thp: + Tc ngc, ho, hen, suyn, m d khc (m thp lm ph kh khng tuyn ging). + Nn, lm ging (m lm v kh nghch). + Ru li dnh, mch hot (m thp bn trong). 3.2.2. Nhm chng h a. Ph kh h: thng gp nhng bnh hen ph qun mn tnh, tm ph mn tnh,... ca YHH. Ho, kh th, ting ni nh nh yu, cng vn ng cc triu chng bnh cng tng ln (ph ch v h hp). Hay t ra m hi (ph hp vi da lng, nn ph kh h dn n v kh khng cht ch). Da mt khng vinh nhun lm sc mt trng bch ra (kh h th huyt h). Kh h cn biu hin mt mi, li m, mch h nhc. b. Ph m h: thng gp nhng bnh hen ph qun, vim ph qun mn tnh, lao phi, thi k hi phc ca bnh vim phi, vim mng phi do lao, vim thanh qun mn tnh... Ho khan, hay t m, m dnh, nga hng, ting ni khn, mch nh, cht li , t ru (ph m h, tn dch b gim). Nu m h nng, tn dch b gim st nhiu dn n h ha bc ln gy st v chiu, hai g m , kht nc, trong m c ln mu, cht li , ru t, mch t sc. c. Ph t h Ho lu ngy c nhiu m, d khc (ph h mt chc nng tuyn ging, t h vn ha thy cc d dang sinh ra m). n km, bng y, a lng (t kh h vn ha tht thng). Mt mi v lc. Ph, ru li trng, cht li m, mch t nhc (thy thp nh tr). 74

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d. Ph thn dng h Triu chng ging nh chng ph kh h km thm nhng triu chng ca thn dng h nh au lng mi gi, lit dng, tay chn lnh, s lnh, tiu tin nhiu ln, mch trm t nhc. Ho, m nhiu, ngc sn y trng, ming kht m khng mun ung nc, nn. Lng v tay chn lnh, hoa mt, chng mt, th ngn, hi hp, li bu, ru li trng trn. 4. IU TR V CHM SC 4.1. iu tr 4.1.1. Th phong hn Php tr: pht tn phong hn v ha m (tn hn tuyn ph, n ph tn hn). Cc v thuc thng dng l: ma hong, ta t, bch ch, ct cnh... Cc bi thuc thng dng l: Hnh t tn, Ch thu tn, T t ging kh thang. Nhng bi thuc v cng thc huyt s dng: + Bi T t ging kh thang: bn h 12g, hu phc 8g, tin h 8g, chch tho 4g, nhc qu 4g, t t 16g, ng quy 12g, sinh khng 3 lt, trn b 8-12g.
V thuc T t Sinh khng Nhc qu Hu phc Trn b Tin h ng quy Bn h ch Cam tho Tc dng Cay, m, vo t ph: pht tn phong hn, kin v, ch nn, ha m, ch khi, l kh, an thai (ht: c thn, gii c, st trng) Cay, hi nng, vo ph, t, v: pht tn phong hn, n v, ch nn, ch t, ha m, ch khi, li thy (v) Cay, ngt, i nhit, vo can thn: b mnh mn ha, kin t, tr dng, cu nghch ng, cay, m; vo: t v, i trng: hnh kh ha m, tr nn, n trung to thp Cay, m; vo: v ph: hnh kh, bnh v, ha m, to thp ng, cay, hi lnh; vo t, ph: pht tn phong nhit, h m, ging kh Ngt, cay, m; vo tm, can t; dng huyt, hot huyt Cay, m; vo t, v, bnh kh, ha m, to thp, ging nghch, ch nn, ch khi Ngt, bnh; vo 12 kinh: b trung kh, ha hon, gii c Vai tr Qun Thn Thn T T T T - S T T - S

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+ Bi Ch thu tn (Y hc tm ng): kinh gii 16g, bch b 16g, t uyn 16g, trn b 8g, bch tin 16g, cam tho 6g, ct cnh Phn tch bi thuc
V thuc Kinh gii Ct cnh Trn b T uyn Bch b Bch tin Cam tho Tc dng Khu phong gii biu Tuyn ph ging kh Kin t ch khi Ha m ch khi Ch khi ha m Ch khi ho m n trung, ha v Vai tr Qun Thn Thn T T T S

+ Cng thc huyt s dng gm: i chy, phong tr, phong mn, lit khuyt, n trung, phong long. 4.1.2. Th phong nhit Php tr: pht tn phong nhit, s phong thanh nhit, tr m (thanh nhit tuyn ph). Cc v thuc thng dng cha l: l du ti, bc h, hoa cc,... Cc bi thuc thng dng cha nh: Ngn kiu tn, Ma hnh thch cam thang, Tang cc m, V kim thang. Nhng bi thuc v cng thc huyt s dng: + Bi Tang cc m gia gim: tang dip 20g, ct cnh 16g, cc hoa 10g, cam tho 8g, hnh nhn 16g, l cn 16g, lin kiu 12g, bc h 8g.
V thuc Tang dip Bc h Cc hoa Lin kiu Hnh nhn Ct cnh L cn Cam tho Tc dng Ngt, ng, hn; vo can, ph, thn: pht tn phong nhit, thanh can, minh mc, thanh ph ch khi Cay, mt; vo ph, can: pht tn phong nhit Ngt, ng, tnh hi hn, vo ph, can thn: pht tn phong nhit, thanh can minh mc, ging ha gii c ng, lnh; vo m, i trng, tam tiu: thanh nhit, gii c, tn kt, gii cm tr phong nhit ng, m; vo ph, i trng: thng ph, bnh suyn, nhun trng, thng tin, n ph ng, cay, hi m; vo ph, kh m ch khi, tuyn ph li hu hng, bi nung gii c Ngt, hn, vo ph v: thanh nhit, sinh tn, li niu, thanh ph nhit, ch khi, thanh nhit, ch nn Ngt, bnh; vo 12 kinh: b trung kh, ha gii c Vai tr Qun Thn Thn Thn T T T S

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+ Cng thc huyt s dng gm: i chy, phong tr, phong mn, lit khuyt, n trung, phong long, khc tr, hp cc. 4.1.3. Th kh to Php cha: thanh ph, nhun to. Cc v thuc thng dng l: t t, l h, thin mn, sa sm, mch mn,... Cc bi thuc thng dng l: Tang cc m, Thanh to cu ph thang... Nhng bi thuc v cng thc huyt s dng: + Bi Hong lin gii c thang (dng khi mi mc bnh): hong lin 30g, hong cm 20g, hong b 20g, chi t 20g. Phn tch bi thuc
V thuc Hong lin Hong cm Hong b Chi t Tc dng ng, lnh, thanh nhit, to thp, gii c, t tm ha v t ha trung tiu ng, lnh, thanh ph nhit, lng huyt, t ha thng tiu ng, lnh, t tng ha, thanh thp nhit h tiu ng, lnh, thanh nhit t ha tam tiu, dn nhit i xung.

Vai tr
Qun Qun Qun Thn, s

Bi Thanh to cu ph thang: tang dip 20g, a giao 8g, thch cao 16g, mch mn 12g, nhn sm 5g, hnh nhn 6g, cam tho 8g, t b dip 8g, ma nhn 8g.
V thuc Nhn sm Tang dip T b dip Thch cao M en Mch mn A giao Hnh nhn Cam tho Tc dng Ngt, hi ng, m; vo ph t: i b nguyn sinh, ch huyt, sinh tn Ngt, ng, hn; vo can, ph: pht tn phong nhit, thanh can, minh mc, thanh ph, ch khi ng, bnh; vo ph v: thanh ph ch khi, thanh v, ch nn Ngt, cay, hn; vo ph v, tam tiu: thanh nhit, ging ha, tr phin, ch kht Ngt, bnh; vo t, ph, can, thn: nhun h, li niu, ch nn Ngt, hi ng, hi lnh; vo ph, v, tm: h st, nhun ph sinh tn Ngt, bnh; vo ph, can, thn: t m, dng huyt, b ph nhun to, ch huyt, an thai ng, bnh; vo ph, i trng: thng ph, bnh suyn, nhun trng, thng tin, n ph Ngt, bnh; vo 12 kinh: b trung kh, ha hon, gii c Vai tr Qun Thn Thn Thn Thn, t Thn Thn T S

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Cng thc huyt s dng: i chy, phong tr, phong mn, lit khuyt, n trung, phong long, khc tr, hp cc. 4.1.4. Th m nhit Php tr: thanh ha nhit m v nhun to ha m (tuyn ph ha m nhit, thanh ph ha m). Cc bi thuc thng dng: Nh trn thang gia thm bi mu, tri mu; Tiu hm hung thang; Sinh lch t i to t ph thang; Nhun ph thang; T m thanh ph thang; Bch hp c kim thang; Bi mu qua lu thang... + Bi Bch hp c kim thang: sinh a 12g, thc a 18g, bch hp 12g, mch mn ng 12g, bi mu 10g, thc dc 10g, huyn sm 8g, ct cnh 8g, sinh cam tho 10g Phn tch bi thuc
V thuc Bch hp Mch mn Huyn sm Sinh a Thc a Bi mu Thc dc Ct cnh Sinh cam tho Tc dng Nhun ph ch khi thanh nhit Thanh tm nhun ph ch khi T m ging ha, lng huyt gii c Thanh nhit lng huyt B huyt dng m, b thn Nhun tm ph, ha m, ch khi Lim m dng huyt ch thng Thng ph kh, tiu m, dn thuc i ln T ha gii c, iu ha cc v thuc Vai tr Qun Qun Thn Thn Thn T T T, s T, s

4.1.5. Th m thp Php tr: to thp ha m ch khi, n ha thp m. Cc v thuc thng dng: ht ci trng, bn h ch, trn b, t t, ct cnh, bch tin... Cc bi thuc thng dng l: Nh trn thang, Lc qun t thang, L trung ha m hon... + Bi Nh trn thang gia v: trn b 10g, thng trut 8g, bn h 8g, bch trut 12g, phc linh 10g, cam tho 10g, hnh nhn 12g, sinh khng 6g.

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Phn tch bi thuc


V thuc Trn b Bn h Phc linh Bch trut Thng trut Cam tho Hnh nhn Sinh khng L kh ha m Ging kh nghch, tiu m thp Kin t, li thp Kin t, tp thp, ha trung To thp, kin t n trung, ha v Ch khi, bnh suyn, nhun trng Ging nghch ha m Tc dng Vai tr Qun Qun Thn T T S T T

+ Bi Lc qun t thang: nhn sm 10g, cam tho (chch) 6g, bch trut 9g, trn b 9g, phc linh 9g, bn h 12g. c dng khi t h khng ch c thp, khng vn ha c thy cc, dch ngng t li m thnh m. Phn tch bi thuc
V thuc Nhn sm Cam tho Bch trut Trn b Phc linh Bn h Tc dng i b nguyn kh, kin t, dng v n trung, ha v Kin t, to thp L kh ha m Thm thp kin t Ging kh nghch, tiu m thp Vai tr Qun S Thn T Thn T

+ Cng thc huyt s dng gm: t du, ph du, thn du, tc tam l, hp cc, tam m giao. 4.1.6. Th ph kh h Php tr: b ch ph kh. Cc v thuc thng dng: ng sm, bch trut, hong k,... Cc bi thuc thng dng l: Bo nguyn thang, Ngc bnh phong tn, Qu chi gia hong k thang,... + Bi Ngc bnh phong tn gm: hong k, bch trut, phng phong 79

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Phn tch bi thuc


V thuc Hong k Bch trut Phng phong Tc dng B kh, c biu Kin t, b trung tiu Pht biu, tr phong Vai tr Qun T Thn

+ Bi Bo nguyn thang gm: nhn sm, hong k, nhc qu, cam tho. Phn tch bi thuc
V thuc Nhn sm Hong k Nhc qu Cam tho Tc dng i b nguyn kh ch kh, c biu Tr dng, tn hn n trung, ha v Vai tr Qun Qun Thn S

4.1.7. Th ph m h Php tr: t dng ph m, t m, ging ha. Cc v thuc thng dng: sinh a, huyn sm, a ct b, ngc trc, an b, bch hp... Cc bi thuc thng dng l: Nht m tin, Lc v hon + Bi Nht m tin gia gim gm: bch thc 8g, a ct b 4g, sinh a 8g, cam tho 3g, mch mn 12g, thc a 20g, tri mu 4g.
V thuc Mch mn Sinh a a ct b Bch thc Tri mu Cam tho Tc dng Ngt, hi ng, hi lnh; vo ph, v: h st, nhun ph, sinh tn ng, hn, vo tm, can, thn: thanh nhit, lng huyt, dng m, sinh tn Ngt, hi ng, tnh hn; vo can, thn, ph: thanh ph nhit, ch khi, cha can ut ha gy huyn vng; iu tr ct chng, ra m hi ng, chua, lnh; vo can, t, ph: lim m, dng huyt, li thy ng, lnh: t thn, b thy t ha, h thy, ch kh Ngt, bnh; vo 12 kinh: b trung kh, ha hon, gii c Vai tr Qun Thn Thn T T S

+ Cng thc huyt s dng: thi uyn, thin lch, tam m giao, ph du, thn du. 4.1.8. Th ph t u h Php tr: kin t, ch ph. 80

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Cc v thuc thng dng l: ng sm, phc linh, d, bch trut,... Cc bi thuc thng dng l: Sm linh bch trut tn, B trung ch kh thang... + Bi Sm linh bch trut tn: bch trut 8g, ht sen 8g, sa nhn 8g, bin u 8g, nhn sm 8g, sn dc 8g, ct cnh 8g, phc linh 12g, d 12g, chch tho 4g
V thuc Nhn sm Bch trut Bch linh Bch bin u Hoi sn Sa nhn d Ht sen Ct cnh Cam tho Tc dng Ngt, hi ng; vo ph t: i b nguyn kh, ch huyt, sinh tn Ngt, ng, m; vo t, v: kin t to thp, ch hn, an thn Ngt, bnh; vo tm, t, ph, thn: li niu, thm thp, kin t, an thn Ngt, hi m; vo t v: ha trung, h kh, b t v; ch t l, phin kht, au bng Ngt, bnh; vo t, v, ph, thn: b t, ch t, b ph, sinh tn, ch kht, bnh suyn, sp tinh Cay, m; vo t, thn, v: hnh kh, iu trung, ha v Ngt, lnh; vo t v ph: kin t, tr thp Ngt, sp, bnh; vo tm, t, thn: c tinh, ch t, b t, dng tm ng, cay, hi m; vo ph: kh m, ch khi, tuyn ph, li hu hng, bi ung, thi c Ngt, bnh; vo 12 kinh: b trung kh, ha hon, gii c Vai tr Qun Thn Thn Thn Thn T T T T S

+ Cng thc huyt s dng gm: thi uyn, thin lch, trung ph, kh hi, n trung, tam m giao, ph du, thn du, t du, mnh mn, phc lu. 4.1.9. Th ph thn dng h Php tr: n thn np kh, b ph kh Cc v thuc thng dng ph t ch, nhc qu, ng sm, hong k... Cc bi thuc thng dng l: Hu quy n gia gim, Bt v qu ph gia gim,... + Bi Hu quy m: thc a 32g, nhn sm 8g, nhc qu 4g, trng 12g, cam tho 4g, hoi sn 16g, k t 8g, ph t ch 2g, sn th du 8g.

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V thuc Ph t Qu Thc a Hoi sn Sn th n b Phc linh Trch t

Tc dng i nhit, c c, cay, ngt: hi dng cu nghch, b ha tr dng, trc phong hn thp t Cay, ngt, i nhit hi c: b mnh mn tng ha Ngt, hi n: nui thn dng m, b thn, b huyt Ngt bnh: b t v, b ph thn, sinh tn ch kht Chua, sp, hn n: n b can thn, sp tinh ch hn Cay, ng, hi hn: thanh huyt nhit, tn huyt, cha nhit nhp doanh phn Ngt, nht, bnh: li thy, thm thp, b t nh tm Ngt, nht, mt: thanh t thp nhit bng quang

Vai tr Qun Qun Qun Qun Thn T T T

+ Cng thc huyt s dng gm: thi uyn, thin lch, trung ph, quan nguyn, kh hi, n trung, tam m giao, mnh mn, ph du, thn du, t du, phc lu. 4.2. Tp luyn dng sinh c ch nh trong nhng trng hp vim ph qun mn. C th t tp luyn mi ng tc dng sinh khng hn ch v ty theo sc khe ca c th, nhng cn nht l cc ng tc sau: Luyn th su. Luyn th ra ti a: th 3 th, thi chai. Luyn th: th 4 th v c k mng. Xoa tam tiu.

T lng gi Cu hi 5 chn 1: chn cu ng 1. Nhm nguyn nhn no sau y c tnh quyt nh gy bnh VPQ mn

A. Di truyn + d ng B. Vt l + d ng C. Ha hc + vi khun D. Virus + vt l E. Vi khun + d ng


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2. Hnh nh vim nhim v tt nghn trong VPQM thng xy ra

A. Ph qun ln B. Tiu ph qun C. Nhu m phi D. Tiu ng mch phi E. Kh ph qun


3. Cc du hiu: vim nhim ph qun tng t, tm ti thng xuyn hay tng lc, gy st km mt nc, l m km bun ng ban ngy, nhp tim nhanh bo ng c th mc

A. Vim ph qun mn B. Kh ph thng C. Tm ph mn D. Suy h hp cp E. Vim phi tc nghn


4. Bi thuc Nh trn thang (gm: trn b, bn h, phc linh, cam tho) c th ch nh iu tr vim ph qun mn th

A. Th phong nhit B. m thp C. T h D. Kh to E. Ph m h


5. Bi Lc qun t thang (gm: nhn sm, bch trut, phc linh, cam tho, trn b, bn h) dng ch nh vim ph qun mn th

A. Phong nhit B. Phong hn C. Kh to D. T h E. Thy m


6. Bi thuc T t ging kh thang (gm: bn h, hu phc, tin h, chch tho, nhc qu, t t, ng quy, sinh khng, trn b) c ch nh iu tr vim ph qun th

A. Phong hn B. m thp
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C. T h D. Th thp E. Thy m
7. Bi thuc Ch thu tn (gm: kinh gii, bch b, t uyn, trn b, ct cnh, cam tho, trong v kinh gii) c tc dng v vai tr

A. Tuyn ph ging kh: vai tr qun B. Ch ho ha m: vai tr qun C. Khu phong gii biu: vai tr qun D. Tuyn ph ging kh: vai tr thn E. Khu phong gii biu: vai tr thn
8. Th bnh no sau y v mt triu chng hc xut hin c trong VPQ cp v VPQ mn

A. Phong hn B. Phong nhit C. m thp D. Kh to E. Thy m


9. Bi thuc Tang cc m (gm: tang dip, ct cnh, cc hoa, hnh nhn, l cn, lin kiu, bc h, cam tho) thng ch nh iu tr VPQ mn th

A. Phong nhit B. Th thp C. Kh to D. m thp E. Thy m


10. Nguyn nhn no sau y lm tn thng ph, lm kh tn dch m sinh ra cc chng: ho khan khng c m, hoc c t m dnh, mi hng kh, st, nhc u, u li kh, mch ph sc

A. Phong hn B. Th thp C. To ha D. Tu sc v E. Tht tnh ut nhit


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11. V hong cm trong bi Hong lin gii c thang (gm: hong lin, hong cm, hong b, chi t) c ch nh iu tr th kh to thng gp trong VPQ cp nhm vo tc dng

A. T tm ha, t ha trung tiu B. T ha, thanh thp nhit h tiu C. Thanh nhit t ha tam tiu D. Thanh ph nhit, t ha thng tiu E. Thanh to tuyn ph
12. V mch mn trong bi thuc bch hp c kim thang (gm: thc a, bch hp, mch mn, bi mu, thc dc, huyn sm, ct cnh, cam tho) c ch nh iu tr VPQ mn th

A. m thp B. m nhit C. Kh to D. Phong nhit E. Ph m h


13. V hong k trong bi thuc Bo nguyn thang (gm: nhn sm, hong k, nhc qu, cam tho) ch nh iu tr VPQ mn th ph kh h) c vai tr v tc dng

A. B kh, kin t: vai tr qun B. Kin t, b trung: vai tr thn C. ch kh, c biu: vai tr qun D. ch kh, c biu: vai tr thn E. B kh, kin t: vai tr t

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Bi 5

HEN PH QUN

MC TIU 1. Nu c nh ngha v c im dch t hc bnh hen ph qun. 2. M t c nguyn nhn, bnh sinh, ca hen ph qun theo y hc c truyn v y hc hin i. 3. Nu c cc th lm sng ca Hen ph qun theo YHH v YHCT. 4. Trnh by c vic iu tr Hen ph qun theo YHCT. 5. Gii thch c c s l lun ca vic iu tr hen ph qun theo YHCT.

1. I CNG 1.1. nh ngha 1.1.1. nh ngha ca OMS (1974) Hen ph qun (HPQ) l bnh c nhng cn kh th do nhiu nguyn nhn khc nhau, km theo du hiu lm sng tc nghn ton b hay mt phn ph qun, c th phc hi c gia cc cn. Tnh trng tc nghn do tng t ngt nhng cn tr ng h hp c lin quan hoc khng lin quan n c ch min dch. 1.1.2. nh ngha ca Hi Phi hc M (1975) Hen ph qun l bnh c c im tng tnh phn ng ng h hp do nhiu nguyn nhn. 1.1.3. nh ngha ca Charpin (1984) Hen ph qun l mt hi chng ca nhng cn kh th v m, hi chng tht nghn v tng tnh phn ng ca ph qun do nhiu yu t kch thch v c bit do acetylcholin.

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1.1.4. nh ngha ca chng trnh Quc gia gio dc HPQ M (1991) Hen ph qun l mt bnh h hp c 3 c im: Hi chng co tht. Vim ng h hp. Tng tnh phn ng ng h hp. Vy c th nh ngha hen ph qun l: Mt hi chng biu hin bng nhng cn kh th rt kch pht, xut hin t ngt, kh th th th ra, thng v ban m, km theo ting th rt do ph qun co tht, ho v khc m nhy dnh; c th hon ton hi phc sau . V phng din chc nng c biu hin hi chng tc nghn, mt s tng hot tnh ton b cc ph qun khi chng b cc yu t kch thch khc nhau tc ng, c bit l cc cht trung gian tit cholin. 1.2. c im dch t hc 1.2.1. Tnh hnh mc bnh Hen ph qun hay gp nhiu nc, mi la tui. T l hen ph qun trung bnh chim 5 - 6% dn s, trong 5% ngi ln v 10% tr em di 15 tui. tr em di 15 tui: t l hen con trai l 1-2%, con gi l 0,5-1%. V tui bt u mc hen: nam gii 90% mc trc 35 tui v 80% trc 15 tui. Trong khi n 75% l trc 35 tui v ch c 40% trc 15 tui. S nam gii mc hen sau 35 tui chim 10% tng s bnh nhn v n l 25%. Vit Nam t l ni chung l 6% cho c tr em v ngi ln. Theo Phm Khu (1980) thng k vi hn 14000 ngi trn 14 tui, t l mc bnh hen l 1,7 %; 10000 ngi cao tui, t l l 2,3%. Theo L Vn Thi (1986): t l hen gp l 5,1% thnh ph; 3,3% nng thn ng bng v 1,7% nng thn min ni. Qua nhiu thng k thy rng tnh hnh mc hen ang c xu hng tng ln. 1.2.2. L do xu hng tng bnh hen V s bnh nhn thc t c tng ln. V nhu cu chm sc sc khe cao hn.

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Do bn thn vic iu tr hen, cc thuc cha ngy nay tuy c tt hn nhng cng c nhiu phn ng ph hn. Ti hi ngh quc t Boston nm 1990 c nu kh nng ca mt s nguyn nhn sau y: + Do nhim mi trng. + Do s dng ba bi thuc, ha cht. + Nhp sng cng thng, stress. + Kh hu nng v m. + Do yu t sai lm trong chn on. Theo Woolcock (1989), mt chuyn gia hen hc ngi Australia cho rng trong cc cn nguyn mc hen th kh hu c nh hng rt r rt. Cng theo tc gi nhn nh chnh xc hn v dch t hc bnh hen hin nay c 3 vn cn nn tm hiu l: s bnh nhn mi mc bnh hng nm, tnh cht nguy kch ca bnh v cc yu t nguy c. 1.3. Phn loi hen ph qun Da vo nguyn nhn gy bnh: + Hen ngoi lai. + Hen ni ti. Da vo tnh cht ca cn hen: + Mc hen. + Bc hen. 1.4. Quan nim ca YHCT v hen ph qun Da trn cc biu hin v triu chng hc, cn kh th ca hen ph qun cng c miu t trong cc chng hen suyn, ho suyn ca YHCT. Sch Y hc chnh truyn ni: Suyn l ni v hi th, th gp gp, khi nng th h ming so vai. Hen ni v m thanh pht ra t c hng, c ting c ca pht ra khi th. Nhng thng thng hay gi chung l chng hen suyn hoc chng ho suyn. Trong chng suyn c suyn thc do c t kh xm nhp v suyn h do c nguyn kh h suy m sinh ra bnh. Chng hen: khi ht th kh ra vo sinh ra ting kh kh, c ca hoc rt. Trong hen c hen hn do c dng kh h suy li cm phi ngoi t v hen nhit do c m nhit tc tr. Chng hen khi pht ra thng km theo c chng suyn, nhng chng suyn khi pht ra c th khng km theo chng hen. 88

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2. NGUYN NHN V C CH SINH BNH 2.1. Nguyn nhn C hai nhm nguyn nhn gy HPQ: 2.1.1. Hen ph qun khng do d ng Di truyn Ri lon tm thn Ri lon ni tit Gng sc Aspirin v thuc chng vim khng steroid. 2.1.2. Hen ph qun do d ng a. Hen ph qun d ng khng nhim trng Bi sinh hot: bi nh, bi ng ph Phn hoa cy, c Lng v Biu b lng sc vt (ch, mo, nga) Thc phm (trng, c, sa) Thuc (penicillin, piperazin). b. Hen ph qun d ng nhim trng Vi khun (t cu, lin cu, ph cu, Klebsiella, Neisseria) Virus (Arbovirus..) Nm mc (Aspergillus, Cladosporiom.). Nhim khun hay gp nht l nhim virus t nh, l yu t thun li hnh thnh hen v tnh d b kch thch ph qun khi trng thnh. HPQ
Khng d ng Khng nhim trng D ng

Nhim trng (typ IV)

Typ I

Typ III

Hen ph qun d ng thuc 3 loi typ I, III, IV (theo cch phn loi ca Gell v Coombs)

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Phn loi hen ph qun (ADO, 1986) Di truyn Ri lon ni tit Khng d ng Ri lon tm thn Gng sc Aspirin Sng n Typ I Khng nhim trng Hen ph qun (bi nh, phn hoa) Typ III D ng Nhim trng (typ IV) (lin cu, t cu, ph cu, Klebsiella, Nisseria), nm, mc,

2.2. C ch sinh bnh 2.2.1. Yu t tng mn cm bnh nhn hen ph qun, ph qun thng c tnh mn cm mnh hn so vi ngi khng mc bnh, tc l d phn ng bt thng hn khi gp mt kch thch c hiu (d nguyn) hoc khng c hiu. Trong lm sng ngi ta chia ra 2 loi hen ch yu: Ngoi lai: thy r do mt khng nguyn bn ngoi gy nn. Ni ti: khi khng chng minh c r do khng nguyn bn ngoi gy nn, v trong hen ni ti, nng IgE bnh thng hoc thp, bnh xut hin ngi ln, thng tui trung nin, bnh mang tnh cht mn tnh vi nhng cn lin tc, t c tin s d ng c nhn v gia nh. a. C ch gy HPQ ca yu t tng mn cm Khng th trong hen gi l reagin (k hiu l IgE - mt globulin min dch): IgE do lympho B v tng bo tng hp, nhng hot ng p ng di s kim sot ca lympho T h tr v cc lympho c ch. Khi tip xc khng nguyn, phc hp IgE - khng nguyn s hnh thnh v gn vo b mt cc t bo a base, ch yu l dng bo v i thc bo; mt lot phn ng s xy ra, cc ha cht trung gian s hnh thnh, histamin, cc yu t ha ng ng a eosinophil gy co tht ph qun v tp trung cc t bo a eosin. Cc ha cht trung gian gy vim s sinh ra ph n v thm nhim cc thnh ph qun. Cc cht c v cc yu t hot ha tiu cu s gy tn thng cc t bo biu m. 90

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Cc ha cht trung gian gy phn ng c nghin cu nhiu l histamin, cc yu t ha ng ng, cc prostaglandin v leucotrien (sinh ra do chuyn ha ca acid arachidonic t mng t bo), yu t hot ha tiu cu v cc kinin.
KHNG NGUYN
IgE khng th Dng bo mt ht v gii phng Arachidonic acid metabolisme

Histamin

Yu t ha ng ng

Leucotrien

Co tht c ph qun (tc th)

Thm nhim bch cu i toan

Vim thnh ph qun, co tht c ph qun (mun)

S c ch p ng vi khng nguyn ht vo

Trong nhng nm gn y, xu hng chung cho hen l mt bnh do vim. Do nhiu nguyn nhn, t bo biu m b tn hi gy thm nhim bch cu v lm tng tnh d b kch thch ca ng th. Bn thn ca s co tht ph qun cng l hu qu ca qu trnh vim cc t bo biu m. b. C ch tc nghn ng th Trn cn nguyn tng mn cm v vim nhim nu trn, ph qun phn ng bng co tht v gy nn tc nghn lu thng khng kh trong ng th, n l c im ch yu ca cn hen. C 3 yu t c bn to nn trng thi ny: Co tht ph qun. Ph n nim mc ph qun. Lp tc do tng tit cc cht nim dch ph qun. C trn ph qun co tht l hin tng quan trng nht trong cc nguyn nhn gy cn hen c chng minh trn thc nghim cng nh m t thi. Co tht, lp tc, ph n nim mc l biu hin c th nht ca ph qun mn cm, to nn s tr ngi cho lu thng khng kh, nguyn nhn gy cn kh th ca bnh hen. C 3 hin tng li c th mt i sau nn c s hi phc gn nh hon ton ca chc nng h hp sau cn hen. c. C ch t yu t vim Vai tr ca vim ph qun c nhiu tc gi chng minh (tha c quc t Mariland 1992). Tho c ny cho rng cng l mt nguyn nhn 91

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gy tc nghn ng th ngoi yu t co tht. Cc t bo vim gm mastocyt, cc bch cu, cc i thc bo, bch cu n nhn, cc lympho bo, tiu cu v biu m hp thnh cht dch nhy, trng thi ny c chng minh qua k thut ra ph qun - ph nang v sinh thit ph qun. Phn ng vim c th phc hi nhng cng c th gy tn thng vnh vin, do iu tr vim l mt hng quan trng cha hen ph qun. 2.2.2. Cc yu t khc ngoi tng mn cm a. Yu t di truyn Nhiu tc gi nghin cu thy bnh nhn hen thng c ngi trong gia nh cng mc hen hoc cc biu hin d ng khc. Theo Williams, khong 50 % bnh nhn hen c tin s d ng gia nh so vi 12% ngi khng hen. b. Kinh nguyt v sinh n Theo Rees (1967) c ph n mc hen tui dy th, sau ny hng thng li thy cn hen 7-10 ngy trc khi hnh kinh v khi c mang th bnh hn; tuy nhin bnh nhn hen khng c cn nguyn d ng th khng thy r nh hng ca sinh . c. C ch thn kinh C ch thn kinh trong hen c cp qua nhn xt bnh nhn hen c th phn ng khng c hiu vi nhiu nguyn nhn khng phi l min dch (v d: nhim khun hoc khi ht phi cc cht kch thch). Ngoi ra cc stress tm l cng c th lm pht sinh cn hen. d. Cc yu t kch thch gy cn hen Vi c ch nu trn, c rt nhiu kch thch c th khin cn hen xut hin: Cc d nguyn: c rt nhiu d cht c nu l cn nguyn gy hen, ph bin nht l: bi nh, phn hoa, bo t nm, lng sc vt nui trong nh nh (ch, mo, th, chut lang, chut bch,...). Ngoi ra thc n nh trng, c, sa v thuc nht l aspirin v cc loi khng vim non steroid cng kch thch gy hen. Nhim khun: nhim virus t nh l yu t thun li hnh thnh hen v tnh d b kch thch ph qun khi trng thnh. 2.3. Biu hin lm sng theo y hc hin i 2.3.1. Triu chng cn hen in hnh ngi ln Cn hen thng xy ra v m, nhiu khi c bo trc bng nhng triu chng: nga mt, chy nc mt, nga mi, ht hi, ho khan hoc nng bng, tc ngc nh c vt g chn vo lm ngi bnh phi ngi dy v cn kh th bt u. Nhp th chm, kh th tri th th ra gy nn nhng 92

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ting rt, kh kh, c ca m chnh ngi bnh v nhng ngi ng gn cng nghe thy. Kh th nh vy lm ngi bnh phi h ming th, t tay vo thnh ging thnh gh. Cm gic thiu khng kh lm ngi bnh i m ca ht khng kh. Trong cn ngi bnh rt mt nhc, da xanh nht, tot m hi, ting ni ngt on. 2.3.2. Yu t lm xut hin cn hen Thay i thi tit nht l thay i nhit mi trng t nng m sang lnh. Ht phi mt d nguyn, mt cht kch thch (khi bi, hi ho cht), mt mi nng. 2.3.3. Triu chng thc th Khm lm sng: g ngc vn trong, rung thanh bnh thng, r ro ph nang gim. C 2 ph trng c nhiu ran rt, ran ngy, nhp th o ngc, th th ra nghe thy di gp 2, 3 ln th ht vo. X quang phi: trong cn hen lng ngc cng, ph trng tng sng, rn phi m (do mu li cc ng mch), cc xng sn nm ngang, khoang lin sn gin rng, c honh t di ng. 2.3.4. Din bin ca cn hen Lm sng: cn hen c th ko di t 5-10 pht, na gi hoc vi gi v kt thc bng vi ting ho bt ra m trng trong nh ht trai nhy dnh. Ngi bnh ht kh th ng li c, sng hm sau thc dy ngi bnh cm thy gn nh bnh thng. Xt nghim m: trong m c nhiu t bo i toan, nhiu tinh th Chartcot -Leyden, nhiu vng xon Crushmann. Xt nghim mu: c tng t bo i toan (trn 400 t bo/mm3) du hiu ny khng hng nh v t c gi tr ngi Vit Nam. Cc kh mu: trong cn trung bnh c gim oxy nh, khng c tng thn. Nu cn hen ko di, thng kh ph nang b ri lon v tng thn xut hin. o chc nng h hp: FEV1 sau FEV1 trc 200ml v 12% (ATS) [ 15% (BTS)]

FEV1 sau FEV1 trc FEV1 trc

Qua cn cp chc nng h hp tr v bnh thng.

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2.3.5. Triu chng lm sng ngoi cn hen Sau cn trung bnh: h hp tr li yn tnh vi gi sau, ch cn thy ri rc vi ran rt ran ngy khi nghe phi. Sau cn nng ran rt cn tn ti vi ngy sau. Nu cn hen xut hin v ko di v ban m th ban ngy cn mt, nht l khi gng sc. Thm d chc nng h hp, c ri lon thng kh. Mt hi chng tc nghn th hin bng chng th ra ti a trong mt giy gim v h s Tiffeneau gim (nhiu hay t ph thuc chng hen lu nm hay mi mc, nng hay nh). H s Tiffeneau ngi bnh thng l 85% - 75%, ngi hen nng l 60% - 50% hay thp hn na. Tnh trng mn cm ca ph qun i vi acetylcholin: c s tng mn cm ph qun ngi hen i vi acetylcholin thp <1000mcg (bnh thng = 10000mcg). 2.3.6. Cc th bnh lm sng YHH a. Hen ngoi lai hay hen d ng Thng bt u tr em hay ngi tr, c tin s d ng r rt, c d nguyn c hiu, nng globulin min dch IgE trong mu cao. Thng p ng tt vi tr liu gii mn cm c hiu. Tin lng lu di tng i kh quan, t vong trong cn him. b. Hen ni ti hay hen nhim trng Thng bt u tui trung nin 35-40 tui. Cn hen thng xut hin sau t nhim trng h hp, gia nhng cn kh th vn tn ti, khng c tin s d ng, p ng km vi cc bin php iu tr, tin lng d dt, cht c th xy n v cn hen lin tc hay bin chng suy tim, gin ph nang, tm ph mn. c. Hen kh th lin tc y l th hen nng, thng thy ngi b hen lu nm, c nhiu t bi nhim, cng c khi do dng qu nhiu cc thuc cng giao cm (adrenalin, isopromalin) v cc amin c tc dng cung giao cm (ephedrin). Cn ho ko di 2-3 ngy lin lm bnh nhn phi ngi lun rt mt nhc. T mt chng c nng, hen rt mau chng c cc tn thng thc th nh x phi, gin ph nang. d. Hen c tnh L mt tnh trng rt nng, ko di, khng p ng vi cc iu tr thng thng, hay xy ra ngi hen lu nm, c lin quan n nhim trng h hp, i khi do sai lm v iu tr; c bit do lm dng thuc cng giao cm (di dng tim chch hoc kh dung), lm dng cc thuc an thn lm c ch cc trung khu ho. Cc cc m c lm tc nghn cc ph qun nh gy: 94

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Kh th nng, nhp th nhanh 20-30 ln/pht, mt mi tm ti, v m hi. Huyt p c th hi tng thong qua, nhp tim tng nhanh, i khi xy ra try mch. Khng ho, khng khc m ra c, r ro ph nang gn nh mt hn. Xt nghim cc kh trong mu: c suy h hp cp, bo ha O2 mu ng mch (SaO2) gim, p lc CO2 trong mu ng mch tng, c th c toan h hp. iu tr ng cch ngi bnh c th qua khi. C mt s trng hp t vong do nght th, try mch hay do xut huyt tiu ha. 2.4. Nguyn nhn v bnh sinh theo y hc c truyn 2.4.1. Nguyn nhn Cm nhim ngoi t thng l phong, hn t. n ung lnh. n qu nhiu cht chua, mn, ngt, ung nhiu ru, tch nhit, thng m, ho m thnh cht ng sinh bnh. Lao nhc thi qu. Mc bnh lu m t cn n phc trong ph lc hoc sinh nhiu m nhit gy tc tr: + Nu v thng n ung sng lnh, hn ngng ng t sn bn trong li cm nhim phong hn t th s sinh ra chng hen hn. + Nu v m nhit tch bn trong, li cm phi phong t m pht bnh th gi l hen nhit. + Nu t kh xm nhp, bn trong li sn c hn m ngng ng ut li, kh nghch ln, bnh n gp rt, h ming so vai th gi l thc suyn. Nh vy thc suyn ch yu l do m, thng gp phi phong hn hoc to nhit tri ma xm nhp kch thch gy bnh. + Nu nguyn kh h sn, thm m m ngng ng, lm thn khng np kh sinh ra h suyn m khng cn phi c t kh lc dm mi pht. Nh vy h suyn ch yu do h, vn ng lao ng mt cht l suyn tng. 2.4.2. Bnh sinh Theo Trn Tu Vin i Thanh vit trong Y hc thc ti tr lun v chng hen: Hn t xm nhp nm sn ph du. 95

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m m c kt t sinh ra ph. Trong ngoi cng ng, khi c iu kin phong hn th thp to ha lm tn thng l pht cn ngay. Ngoi lc dm, nu ung ru, n lnh, lao ng vt v, nhp phng qu nhiu cng c th pht cn c. Khi pht cn th kh lnh ph du, cng vi m m ti ph, cng da vo nhau, ngn lp cc ca ng thng iu ph kh khng cho th ht, rng sc th ht th pht ra ting kh kh. Theo Ni kinh, mi xung ngc ln u thuc v ha, hi th ngn gp m lun lun khng hi th gi l suyn. Suyn th cp bc y l do kh b ha ut m m m nhy dnh ph v. Hn t xm phm, m m ng bn trong quyt lnh thi m, kh b ut, hn t cng lm b b ph khiu, kh ca 2 kinh th dng minh v thi dng l phn biu ca ph, ngc ln hung cch m sinh ra thc suyn. Ngi c tinh huyt h km, m h, h ha bc, kh ha khng tr v ngun a ngc ln. Thng thng th ph pht kh ra, thn np kh vo, nhng v thn h, khng thc hin c chc nng b tng do li long ha bc ln dn n ph b thng lm cho th ra ht vo gp rt; ha khng b thy c ch, dng khng b m lim np li, do nguy c m vong dng thot cht trong chc lt. D l hen hay suyn bnh lu ngy cng tn thng ph - t - thn sinh ra ph m h, ph kh h, t kh h, t dng h, thn m h v thn dng h. 3. CHN ON 3.1. Chn on theo y hc hin i 3.1.1. Lm sng Da vo triu chng ca cn hen in hnh chn on cn hen. Da vo cc triu chng c nng v thc th chn on ngoi cn v bin chng. 3.1.2. Cn lm sng ang cn hen nu soi X quang lng ngc thy hai ph trng qu sng, cc khoang lin sn gin rng, xng sn nm ngang v c honh 2 bn b y xung thp. Gia cc cn hay ngoi cn cc triu chng lm sng ln X quang ni trn khng cn, tuy nhin c th lm mt s th nghim nh nghim 96

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php gng sc, nghim php dng acetylcholin vn pht hin c tnh trng tng hot tnh cc ph qun. Thc hin cc chn on cn lm sng khc chn on nguyn nhn v bin chng (nh da vo chc nng h hp). 3.1.3. Chn on hen ph qun khi Qua cn cp chc nng h hp tr v bnh thng. p ng c ngha vi thuc gin ph qun ng ht hoc 2 tun corticoid ng ton thn (prednison 30 - 40mg/ngy), hoc 6 tun corticoid ng ht. FEV1 sau FEV1 trc 200ml v FEV1 sau FEV1 trc FEV1 trc Chn on bc hen:
Bc hen I II III IV FEV1 hoc PEF (%) 80% 80% 61 - 79% 60% dao ng sng - chiu < 20% 20 - 30% > 30% > 30%

12% (ATS) [ 15% (BTS)]

dao ng PEF =

PEF chiu - PEF sng (PEF sng + PEF chiu)/2

3.2. Chn on theo y hc c truyn 3.2.1. Chng hen Ch chng ca hen l kh th, khi th c ting c ca (rt, kh kh), khi c cn kh th n khng nm c, phi ngi th. Trong lm sng chia lm 2 loi: a. Hen hn Ngi lnh, sc mt trng bch Ngc y tc m trong long, c bt, d khc Khng kht, thch ung nc nng i tin phn nho nt 97

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Cht li nht, ru li mng trng trn Mch trm khn. b. Hen nhit Bun bc kh chu Ru li thng vng c i tin to Mch hot sc Nu do m h ha vng th cht li sm Nu c kim ngoi cm th lnh, au mnh, pht st, kht nc; biu hin chng lnh bn ngoi, nng bn trong. 3.2.2. Chng suyn Ch chng ca suyn l th gp a. Thc suyn: Phong hn: Ngc y tc Ho, m nhiu v long Pht st au u n lnh, m hi Khng kht nc Ru li trng nhn Mch ph hot To nhit Phin nng Ho, au ngc Kht nc, hng au m nhiu, c, kh khc Cht li , ru mng Mch sc b. H suyn Ph h: Th ngn hi km theo ho 98

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Ting ni yu Tinh thn u oi Li nht Ngoi ra cn c chng: tn dch kh ro, ngi nng, hng vng tc, t m hi, sc mt tng lc, li , mch vi nhc. Thn h: Nu thn m h suyn: + Ho, kh th + au hng + Mt , vt v + Lng bn tay chn nng + Mch t sc. Nu thn dng h suyn: + n lnh + Vn ng l suyn xut hin v tng ln + Sng mu bn chn + Tay chn lnh + Mch vi hoc trm nhc. Triu chng bo nguy: + Kh nghch ln, th gp vt v + Chn lnh, m hi u + i tin lng + Mch ph i m khng c lc. 4. BIN CHNG 4.1. Nhim trng phi Thng xy ra ngi hen lu nm: bnh nhn c st, kh th khng ch th th ra m c th ht vo, m c, t bo i toan c thay th bng t bo a nhn trung tnh, cn hen thng ko di. 4.2. Gin ph nang Trong cn hen, cc ph qun hp li, do khi ht vo th cc c h hp can thip vo nn thng c sc cn; th th ra (th ng) khng kh khng ra ht nn li lm ph nang n ra, lu ngy cc ph nang mt dn tnh n hi, n ra ri khng co li c nn khng kh b ng, oxy vo phi t, 99

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dioxyd carbon khng ra c gy tnh trng thiu oxy v tng dioxyd carbon. y l tnh trng suy h hp mn. 4.3. Suy tim phi Mch mu ca ph nang co li c khi b tc lm cn tr tiu tun hon. Trong nhiu nm tim phi gin dn v to ra; bnh nhn c mi thm, gan to, ri i n suy tim khng hi phc. 5. D phng V TIN LNG Hin nay vic xc nh trong tng lai xa ca mt ngi hen ph qun cn kh, song nh gi tng lai gn cn da trn: 5.1. Lm sng Tn sut cn hen: s cn hen trong mt khong thi gian quan st cho ta khi nim v d kin tin trin ca cn hen; cn hen cng gn nhau tin lng cng xu. 5.2. Ph dung k Th tch th ti a/giy v h s Tiffeneau. Cc ch s ny cng thp th hen cng nng. Tnh nhy cm cholinergic: ngng acetylcholin cng thp th hen cng nng. S hi phc nhng ri lon tc nghn di nh hng ca cht kch thch giao cm: p ng vi isoproterenol cng trn vn th tin lng cng tt. Th tch cn: th tch cn cng tng l hen cng nng. iu kin mi trng sinh sng v cng tc. 6. IU TR 6.1. Nguyn tc v mc tiu iu tr iu tr hen ph qun thng c 3 mc tiu: iu tr tn gc lm cho bnh khi hon ton: nu pht hin c cc nguyn nhn gy bnh c th iu tr tn gc, tuy nhin vic lm ny rt kh v hen ph qun thng do nhiu nguyn nhn phi hp, rt t khi ch c nht mt nguyn nhn, do vy bnh c th tm khi mt thi gian di ri li ti pht. iu tr triu chng ko di: + Gin ph qun: dng thuc kh dung. 100

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+ Cc thuc tc ng ln trn cc hin tng vim nhim v bi tit. + Cc phng php tp luyn nh luyn th; tp vt l nh: bi li, tm nc sui nng v.v. iu tr ct cn hoc cp cu cn hen ph qun. Ngoi ra cn ch : + iu tr bin chng + iu tr d phng ln cn hen: c hiu: loi b d ng nguyn, gii mn cm. Khng c hiu: cromoglycat disodique, dipropionat. Bin php b sung: vn ng liu php, tm l tr gip, chng nhim trng, liu php kh hu v nc sui. Phng bnh: hen ph qun l loi bnh l c yu t th tng nn vic phng bnh thng rt kh khn, tuy nhin hn ch c th cha sm cc bnh l ng mi hng, tp th dc thng xuyn, gi mi trng sng trong sch t bi bm, thong mt. 6.2. iu tr theo y hc c truyn 6.2.1. Hen hn Php tr: n ph, tn hn, tr m, nh suyn. Cc bi thuc: + Bi X can ma hong thang gia gim X can 6g, sinh khng 4g, khon ng hoa 12g, bn h ch 8g, ma hong 10g, t tn 12g, ng v t 8g, i to 12g. Phn tch bi thuc
V thuc Ma hong Qu chi Thc dc Bn h T tn Ng v t X can Can khng Khon ng hoa Cam tho Tc dng Pht hn, gii biu, bnh suyn Pht hn, n kinh, gii biu iu ha danh v Ging kh nghch, tiu m thp Tn phong hn, khai khiu Lim ph, sp tinh, ch thn, sinh tn dch Thanh nhit gii c, tiu m n trung, tn hn Nhun ph, h kh, ho m, ch khi n trung ha v Vai tr Qun Thn Thn T T T T T T S

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+ Bi thuc T t ging kh thang: t t 12g, hu phc 8g, qut b 8g, qu chi 18g, bn h ch 8g, ngi cu 12g, ng quy 10g, gng 4g, tin h 10g, i to 12g, bn h ch 12g, ng v t 16g, cam tho 4g, hnh nhn 8g.
V thuc T t Sinh khng Nhc qu Hu phc Trn b Tin h ng quy Tc dng Cay, m; vo t ph: pht tn phong hn, kin v, ch nn, ha m, ch khi, l kh, an thai Cay, hi nng; vo ph, t, v: pht tn phong hn, n v, ch nn, ch t, ha m, ch khi, li thy Cay, ngt, i nhit; vo can, thn: b mnh mn ha, kin t, tr dng, cu nghch ng, cay, m; vo t v, i trng: hnh kh, ha m, tr nn, n trung to thp Cay, m; vo v ph: hnh kh, bnh v, ha m, to thp ng, cay, hi lnh; vo t ph: pht tn phong nhit, h m, ging kh Ngt, cay, m; vo tm, can, t: dng huyt, hot huyt Vai tr Qun Thn Thn T T T T, S

Chm cu: chm b cc huyt thin t, chin trung, phong mn, nh suyn, lit khuyt, tam m giao, phong long, tc tam l. Cu cc huyt cao hoang, ph du, thn du Chm loa tai: bnh suyn, tuyn thng thn, giao cm, thn mn, ph. 6.2.2. Hen nhit Php tr: thanh nhit, tuyn ph, ha m, bnh suyn. Bi thuc nh suyn thang: ma hong 6g, hong cm 12g, tang bch b 20g, hnh nhn 12g, trc lch 20g, cam tho 4g, bn h ch 8g. Phn tch bi thuc
V thuc Ma hong Hnh nhn Bn h ch Tang bch b Trc lch Cam tho Hong cm Tc dng Pht hn, gii biu, bnh suyn Ha m, ging nghch, ch khi Ging kh nghch, tiu m Thanh ph nhit, ch khi, h suyn Thanh nhit n trung, ha v Thanh ph nhit Vai tr Qun Thn Thn T T S T

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Chm cu: chm t cc huyt trung ph, thin t, chin trung, nh suyn, ph du, xch trch, thi uyn, phong long, hp cc. 6.2.3. Thc suyn a. Phong hn Php tr: li ph, khai khiu, ging kh, nh suyn. Cc bi thuc: + Bi thuc Tiu thanh long thang: ma hong, qu chi, t tn, bn h, can khng, thc dc, ng v t, cam tho. Phn tch bi thuc
V thuc Ma hong Qu chi Can khng T tn Bn h ch Ng v t Hnh nhn Thc dc Cam tho Tc dng Pht hn, gii biu, bnh suyn n kinh, thng mch n trung, tn hn Tn phong hn, khai khiu Ging kh nghch, tiu m Lim ph, ch khi, sp tinh, sinh tn dch Ha m, ging nghch, ch khi Hot huyt, iu ha doanh v n trung, ha v Vai tr Qun Qun, thn T T T T T T S

Bi thuc Tam ao thang (nu v ngoi cm phong hn xut hin cc chng au u, khng c m hi m ho ra m trng th dng) gm: ma hong 20g, hnh nhn 20g, cam tho 10g Phn tch bi thuc
V thuc Ma hong Hnh nhn Cam tho Tc dng Gii biu, pht hn, bnh ph suyn Li ph, h kh n trung, ho v Vai tr Qun Thn T

Bi Ma hnh thch cam thang (nu v m ha ng tc ph khiu m sinh chng suyn th dng ma hong 10g, hnh nhn 20g, thch cao 40g, cam tho 12g) 103

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V thuc Ma hong Thch cao Hnh nhn Cam tho

Tc dng Cay, ng, n: khai thu l, lm ra m hi, li tiu tin V ngt, cay, tnh hn; vo 3 kinh ph, v, tam tiu: thanh nhit, ging ha, tr phin, ch kht ng, m; vo ph, i trng: thng ph, bnh suyn, nhun trng, thng tin, n ph Ngt, bnh; vo 12 kinh: b trung kh, ha gii c

Vai tr Qun Thn T S

b. To nhit Php tr: thanh kim, ging ha. Bi thuc T bch tn, gm: tang bch b, a ct b, ngnh m, cam tho Phn tch bi thuc
V thuc Tang bch b a ct b Ngnh m Cam tho Tc dng Thanh ph nhit, ch khi, h suyn Thanh nhit Ha trung, kin t n trung, ha v Vai tr Qun Thn, t Thn S

6.2.4. H suyn a. Ph m h Php tr: t m, b ph, nh suyn. Bi thuc Sinh mch tn gia v: ng sm 16g, sa sm 12g, mch mn 12g, ngc trc 8g, ng v t 6g, bi mu 12g
V thuc Nhn sm Mch mn Ng v t Hong k Cam tho Tc dng Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt, sinh tn Ngt, ng, lnh: nhun ph, sinh tn dch Mn, chua, m: lim hn, c tinh Ngt, m: b tm kh, thng dng kh ca t Ngt, m: b t th, b trung kh Vai tr Qun Thn Thn T S

Chm cu: chm b ph du, cao hoang du, chin trung, thn du, t du, quan nguyn. b. Ph kh h Php tr: b ph, c biu, ch kh, nh suyn. 104

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Cc bi thuc: + Bi thuc Ngc bnh phong tn gia gim: hong k 12g, t t 12g, phng phong 8g, bch trut 12g. Phn tch bi thuc
V thuc Hong k Bch trut Phng phong T t B kh, c biu Kin t, b trung tiu Pht biu, ch ng phong Pht tn phong hn, ha kh, ha trung Tc dng Vai tr Qun Thn Thn T

Bi thuc Qu chi hong k thang gm qu chi 8g, hong k 8g, bch thc 8g, ng sm 16g, i to 12g, ng v t 12g, gng 4g Phn tch bi thuc
V thuc Qu chi Hong k Bch thc ng sm i to Ng v t Gng Tc dng Thng huyt mch, n kinh B kh, c biu Lim m, dng huyt, ch thng B t, kin v, ch kh B t, ch v, dng tm Lim ph, ch khi, sp tinh, sinh tn dch n trung, tn hn, thng mch Vai tr Qun Qun T Thn T T S

Chm cu: cu cc huyt nh trong ph m h. c. T h Php tr: kin t, ch kh. Bi thuc Lc qun t thang: bch trut 12g, trn b 8g, ng sm 16g, bn h 8g, phc linh 12g, cam tho 6g Phn tch bi thuc
V thuc ng sm Phc linh Bch trut Trn b Bn h Cam tho Kin t, thm thp Kh n, kin t, to thp Kin t, l kh, to thp, ha m Ging kh nghch, tiu m thp ch kh, b trung, ha v Tc dng B t, kin v, ch kh, sinh tn dch Vai tr Qun Thn Thn T T S

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Chm cu: cu cc huyt t du, ph du, v du, quan nguyn, thn du, tc tam l. d. Thn dng h Php tr: n thn np kh. Bi thuc Kim qu thn kh hon: can a hong 20g, n b 7g, hoi sn 10g, qu chi 4g, trch t 7g, ph t 4g, phc linh 7g, sn th 10g Phn tch bi thuc
V thuc Ph t Qu chi Can a hong Hoi sn Sn th n b Phc linh Trch t Tc dng B ha, tr dng, trc hn t n kinh, thng mch, tn hn B thn, dng m, b huyt B ph thn, sinh tn ch kht n b can thn Thanh huyt nhit Li thy thm thp, b t, nh tm Thanh t thp nhit Vai tr Qun Qun Qun Thn Thn T T T

e. Thn m h Php tr: t m, b thn. Cc bi thuc: + Bi thuc T quy m: thc a 20g, phc linh 10g, sn th 10g, hoi sn 10g, k t 10g, cam tho 6g Phn tch bi thuc
V thuc Thc a Cu k t Sn th Hoi sn Phc linh Chch tho B huyt, b thn Nhun ph, b thn n b can thn, sp tinh, ch hn B ph thn, sinh tn, ch kht Li thy thm thp, b t, nh tm n b t v, iu ho cc v thuc Tc dng Vai tr Qun Qun Thn Thn T S

+ Bi thuc Lc v gia gim (cn gi l Bt tin thang): thc a 16g, trch t 8g, hoi sn 12g, n b 8g, sn th 8g, ng v t 8g, phc linh 8g, mch mn 8g

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Phn tch bi thuc


V thuc Thc a Hoi sn n b Phc linh Trch t Mch mn Ng v t Sn th T m, b thn B t, c thn, sinh tn, ch kht Thanh huyt nhit Li thy, thm thp, kin t Thanh t thp nhit Thanh tm, nhun ph, ch khi Lim ph, ch khi, sp tinh, ch thn, sinh tn dch n b can thn, sp tinh ch hn Tc dng Vai tr Qun Qun T Thn T T T Thn

Chm cu. + Thn dng h: quan nguyn, kh hi, thn du, mnh mn, ph du, chin trung. + Thn m h: chm b cc huyt trn v thm tam m giao, thi kh.

T lng gi Cu hi 5 chn 1: chn cu ng 1. Trn lm sng triu chng no sau y xut hin s bo hiu tin lng xu ca bnh hen

A. St, ho nhiu B. Kh th C. V m hi D. Cn hen cng gn nhau E. Ho khc m c c


2. Triu chng khc nhau c trng gia lnh ho v nhit ho l

A. Tnh cht kh th, kh kh B. Tnh cht ho C. Tnh cht m D. Tnh cht m hi E. Tt c cc tnh cht trn
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3. Triu chng no sau y m t trong h suyn th ph m h

A. Ting th v ting ho ngn gp, cp bc B. Ting ho, th gp, t m hoc khng c m C. Ting th v ting ho ngn gp, m nhiu long D. Ting th kh kh, ho khc khc khng hi, t m E. Ting th, ting ho ngn gp, hi hp
4. Bi thuc Tam ao thang (gm ma hong, hnh nhn, cam tho) c ch nh iu tr chng

A. Lnh ho B. Nhit ho C. Thc suyn do phong hn D. Thc suyn do ni hn E. H suyn


5. Bi thuc nh suyn thang (gm: ma hong, hnh nhn, cam tho, hong cm, tang bch b, trc lch, bn h ch) thng c ch nh iu tr

A. Lnh ho B. Nhit ho C. Thc suyn D. H suyn E. C B v C u ng


6. V thuc nh lch t trong bi thuc i to t ph thang (gm: nh lch t, i to iu tr chng thc suyn) c tc dng

A. T ha, thanh ph nhit B. Thanh to, tuyn ph C. T ha, gii c, nh suyn D. Tiu m, h kh, bnh suyn E. Thanh t ph nhit, nh suyn
7. V thuc hong k trong bi thuc Ngc bnh phong tn (gm: hong k, phng phong, t t, bch trut) c tc dng

A. B kh, c biu: vai tr qun B. ch kh, nh suyn: vai tr qun


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C. B ph, nh suyn: vai tr qun D. B ph, c biu: vai tr thn E. ch kh, nh suyn: vai tr thn
8. V thuc bch trut trong bi thuc Lc qun t thang (gm bch trut, trn b, ng sm, bn h, phc linh, cam tho) dng ch nh iu tr hen ph qun th t h c tc dng v vai tr

A. Kin t, l kh, ho m: vai tr qun. B. Kh n kin t, to thp: vai tr qun C. Kin t, thm thp: vai tr qun D. Kin t, l ho m: vai tr thn E. Kh n kin t, to thp: vai tr thn
9. Bi thuc Ma hnh thch cam thang (gm: ma hong, hnh nhn, thch cao, cam tho) c dng iu tr hen th

A. Thc suyn B. H suyn C. Lnh ho D. Nhit ho E. C thc suyn ln lnh ho


10. Bi thuc Sinh mch tn gia v (gm: ng sm, mch mn, sa sm, ng v, ngc trc, bi mu) ch nh iu tr h suyn th

A. Ph m h B. Ph kh h C. T h D. Thn m h E. Tm ph kh h

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Bi 6

CC RI LON VN NG CA THC QUN

MC TIU 1. Phn loi c cc nhm ri lon vn ng thc qun. 2. Gii thch c c ch bnh sinh ca cc ri lon vn ng thc qun trn c s sinh l ca nhm c vng thc qun v vi sinh thc qun. 3. Phn bit c cc nhm triu chng chc nng c th ca cc nhm ri lon vn ng thc qun. 4. Gii thch c c ch bnh sinh ca cc chng kh nut, co tht thc qun v Globus pharyngeal cng php tr tng ng theo y hc c truyn. 5. Nhn thc c cc nhm ri lon vn ng c hc ca thc qun lun n gia mt bnh l c tnh.

1. NH NGHA Cc ri lon vn ng ca thc qun l nhm bnh chng lin quan n chc nng vn ng ca thc qun, bao gm cc nhm bnh l ca c vng thc qun v c trn vch thc qun m triu chng ch yu thng l kh nut (dysphagia) au ngc v nn ma (regurgitation). 2. NHC LI SINH L v GII PHU CA THC QUN Thc qun c 2 chc nng chnh: Chuyn thc n t ming n d dy. Ngn chn s tro ngc thc n t d dy ln thc qun trong chc nng th hai s c m trch bi 2 c vng vn lun ng li trong khi nut. H thng c vng ca thc qun gm c vng trn v c vng di. C vng trn gm c co tht Crico pharyngeus v Inferior pharyngeal, vn l nhng c vn c iu khin bi cc neuron vn ng di, nhng c vn ny khng c trng lc cng nh khng b chi phi bi cc dy thn kinh c ch. Do s ng li ca c vng trn l do tnh n hi ca chnh n v 110

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tnh trng lc ca dy thn kinh iu khin n (neuron kch thch) trong khi s m ra ca n li do s thay i v tr ca Larynxsuprahyoid C vng di l c trn c iu khin bi h thng thn kinh ph giao cm, bao gm cc si kch thch v si c ch. S ng li ca c vng di l do bi trng lc ca n v c iu ho bi h thng ph giao cm kch thch trong khi s m ra ch p ng vi h ph giao cm c ch. Cc cht dn truyn thn kinh ca si kch thch l acetylcholin, trong khi ca cc si c ch l VIP v nitric oxyd. Ngoi ra chc nng ca c vng di cn c b sung bi nhm c vn ca honh cch m. Vai tr ch yu ca c vng di l ngn chn s tro ngc thc n t d dy ln thc qun. Do ta cng cn bit nhng yu t sau y c nh hng ti n: + Nhng yu t gy th gin: d dy trng hi, cht bo, thuc l, tr, c ph, c-ca, beta adrenergic agonist, dopamin, cholecystokinin, secretin, VIP, calcitonin gene related peptid, adenosin, nitrat. + Nhng yu t gy co tht: M2 muscarinic receptor angonist, alpha adrenergic agonist, gastrin, subtance P, prostaglandin F2 . 3. PHN LOI 3.1. Nhm ri lon vn ng c vn thc qun 3.1.1. Lit hu hng (oropharyngeal paralysis)
Hnh 6.1. C vng di thc qun

Nu ch lit nhm c hng th bnh nhn s c triu chng kh nut v tro ngc thc n, nc bt ra khi ming. Trong khi lit hu (pharyngeal paralysis) th kh nut, tro thc n ung ra mi v ho sc (do thc n chy vo kh ph qun). Nu c thanh qun cng b nh hng th bnh nhn s khn ting, cn nu ch lit c Suprahyoid bnh nhn s khng nut thc n c (paralytic achalasia). Nguyn nhn ni chung l do cc bnh nhc c nng, bnh vim a c, vim a dy thn kinh hoc di chng ca tai bin mch no v bnh nhn thng cht v cc bin chng ca vim phi ht.

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Hnh 6.2. Lit thanh qun

Hnh 6.3. Kh nut do lit

3.1.2. Cricopharyngeal Bar Do c vng trn khng gin ra trong khi nut nn bnh nhn c cm gic nh thc n chn dnh ngang c hng v trn X quang s thy hnh nh mt thanh chn vch sau hu (phaynx), 95% bnh nhn c triu chng kh nut. Nguyn nhn c th s x ho c crico pharyngeal. Phu thut crico pharyngeal myotomy c ng dng ch tr khi bnh nhn b chng tro ngc thc qun (gastro - oesophageal reflux). 3.1.3. Globus pharyngeus Cm gic nh c mt khi u ngang hng nhng bnh nhn li khng kh nut. Triu chng ny thng xy ra ph n c ri lon cm xc v nhng bnh nhn ny cng thng c km vim thc qun tro ngc. Nhng kt qu chp X quang cng nh in c vn bnh thung. 3.2. Nhm ri lon vn ng c trn thc qun 3.2.1. Chng Achalasia Chng ny l do ri lon c trn thc qun trong c vng di thc qun s khng gin n khi nut cng vi s co tht khng nhu ng ca thn thc qun Chng ny chim t l 0,4 - 0,6 trn 100.000 dn, tui thng gp t 20 - 40 tui. Trong trng hp ny c vng di thc qun s khng gin n ng mc khi nut v nhu ng bnh thng ca ton b thc qun s b thay th bi nhng co tht bt thng. Da vo nhng co tht bt thng ny, ngi ta phn ra 2 loi: Classic achalasia: c c im nhng sng co tht bin nh xy ra cng mt lc. 112

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Vigorous achalasia c c im l nhng sng co tht bin ln khi ng cng mt lc v lp i lp li tng t nh trong chng co tht thc qun lan to (diffuse esophaeyngeal spasm). C ch bnh sinh y l s mt i nhng neuron c ch nm trong vch thc qun v trong c vng di. Bnh c th l tin pht khng r nguyn nhn (primary idiopathy) hoc th pht do ung th d dy, lymphoma, bnh Chagas, hi chng gi tc rut mn tnh c ngun gc thn kinh, nhim siu vi trng, vim d dy tm nhum eosin (esosinophylic gastroenteroitis). a. Triu chng lm sng Kh nut: xy ra sm vi c thc n c v lng, r nht l khi n vi vng hoc khi xc ng. C th dng ng tc Valsalva gip d nut au ngc xy ra nhiu hn trong th Vigorous. Nn ma v vim phi ht. Cn nh rng chng Achalasia thng i sau mt vim thc qun tro ngc, do vi mt bnh nhn b chng nng rt sau xng c ko di, sau ht v xut hin triu chng kh nut l mt gi n chng Achalasia. Ta c th s dng cc phng php sau y chn on chng Achalasia: b. X quang lng ngc: X quang lng ngc khng sa son s khng thy ti hi d dy m i khi li thy mt khi hnh ng nm bn cnh ng mch ch. Nu c ng thc n trong thc qun, X quang s cho thy mc nc, mc hi. Trn hnh nh X quang vi cht cn quang barium: thc qun gin n vi hnh m chim hoc ui chut v i khi l hnh nh mt ch nang trn c honh. Nu bnh din tin lu th thc qun s c hnh nh nh mt i trng Sigma.

Hnh 6.4. Achalasia

Hnh 6.5. C vng di thc qun/Achalasia

Hnh 6.6. Thc qun/ Hnh 6.7. Tro x cng b ngc thc qun

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Trn X quang s khng cn thy nhng nhu ng bnh thng 2/3 di thc qun v c thay bng nhng co tht bt thng trong th Vigorous. Phn cui cng ca thc qun ging nh m chim. c. o p lc ca thc qun bng Manometry: cho thy p sut c bn trong c vng di bnh thng hoc tng, trong khi nut c vng di s khng gin n hoc gin n km hoc chm v c im ny khng thay i. thn thc qun c s tng trng lc khi ngh, ngc li khi nut th nhng sng nhu ng bnh thng s b thay bng nhng sng co tht khi u cng mt lc vi bin hoc nh hoc ln v lp i lp li.

Nu cho bnh nhn dng mecholyl (mt cht agonist vi th th muscarinic) s gy tng p lc thc qun a n au ngc v nn ra thc n. Ngc li cholecystokinin vn l cht c ch c vng di thc qun th li gy co tht a n cc triu chng ca Achalasia. c. Ni soi thc qun: gip loi b cc Achalasia th pht, nht l ung th d dy. d. iu tr chng Achalasia nguyn pht: thng l gii quyt triu chng, bao gm: Nitroglycerin 0,3 - 0,6mg ngm di li trc khi n hoc lc au ngc. Isosorbid dinitrat 2,5 - 5mg ngm di li hoc 10 - 20mg ung c tc dng di v dng trc khi n. Nifedipin 10 - 20mg ngm di li hoc ung trc khi n. 114

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Tim c t botulinum vo c vng di thc qun qua ni soi. C hc: dng qu bng cao su nong c vng di, nu c kinh nghim c th t ti 85% hiu qu. Tuy nhin xut huyt v thng thc qun c th xy ra. Gii phu: th thut lc b lp c trn bn ngoi nim mc ca Heller (extranucosal mystomy). Tuy nhin hai phng php ni trn s a ti vim thc qun tro ngc v teo hp d dy 3.2.2. Co tht thc qun lan to Vi c im l nhng sng co tht khng nhu ng s a ti vic thc qun tro ngc v teo hp d dy; sng co tht bin ln, ko di v lp i lp li, chng c khi pht cng mt lc v c th xy ra t nhin hoc ngay sau khi nut. C ch bnh sinh l s thoi ho ri rc dc theo ng i ca h thn kinh ph giao cm c ch trn vch thc qun. Nguyn nhn ca n c th khng r, c th lin quan n s xc ng v tui; c th phi hp vi nhng bnh collagen, bnh l thn kinh do tiu ng, cc vim thc qun hoc cc thuc anticholinergic. Chng co tht thc qun c th tin trin thnh chng Achalasia. a. Triu chng lm sng: au ngc v/hoc kh nut v lun lun lin quan n nhng t co tht. au ngc thng xy ra lc ngh nhng c th do nut hoc xc ng, cn au t sau xng c lan ra sau lng hoc 2 bn ngc v 2 tay hoc ln hm v ko di t vi giy n nhiu pht nh cn au ca thiu mu c tim. Kh nut vi c thc n c v lng. b. Trn X quang vi barium: thc qun s c hnh nh xon cun, hnh nh sng ln tn vch thc qun, hnh nh nhng ti gi hoc hnh nh ci vn nt chai hoc thc qun phnh ra 2 bn trong khi c vng di vn m ra bnh thng. c. Trn Manometry: cho thy nhng co tht khi u cng mt lc vi bin ln, ko di v lp i lp li ( 2/3 di thc qun), v s ri lon ny c tnh cht nh k nn phi kt hp cc k thut khc nh:

Hnh 6.8. Co tht thc qun lan to

Nut thc n lnh s gy au ngc nhng khng gy co tht.

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Nut thc n cng hoc dng eadrophonium s gy au ngc hoc ri lon vn ng thc qun. d. iu tr ch yu l gii quyt triu chng bng thuc nh: nitroglycerin isosorbid hoc nifedipin ung trc ba n. 3.2.3. Hi chng thc qun do x cng b y l s teo lp c trn thc qun a n gim vn ng ca 2/3 di thc qun v c vng di. Triu chng ch yu l kh nut vi thc n c v c bit l vi thc n lng khi nm. Mt s trng hp s c cm gic nng rt sau xng c v nn ra thc n do vim thc qun tro ngc m chnh iu ny s tng thm chng kh nut do hnh thnh s x thc qun. Chn on bng X quang c sa son s cho thy cc sng nhu ng ca thc qun u bin mt cn c vng di th co li, i khi cn thy nhng hnh nh lot v teo hp trn thc qun. Manometry cho thy cc sng co tht 2/3 di thc qun gim bin p lc ca c vng di lc ngh th yu nhng s gin khi nut th bnh thng. Nhng bt thng v vn ng thc qun cng c th gp trn ngi c hi chng Raynaud. 4. Theo y hc c truyn Theo quan nim ca YHCT, cc chng kh nut (dysphagia), au ngc (chestpain) v nn (regurgitation) trong cc th bnh Achalasia nguyn pht v co tht thc qun lan to u ph thuc phm tr cc chng cch, tm thng, u m yu t khi pht khng nm ngoi yu t can kh tht iu. c bit cc triu chng ca globus pharyngeus (tng ng vi chng mai hch kh ca YHCT) cng c cng mt c ch bnh sinh ni trn. Do php tr ca YHCT trong trng hp ny s l s can, l kh, ch thng vi mc ch: An thn, chng lo u bng cc v thuc: phc linh, si h. Chng co tht c trn tiu ho (i khng acetylcholin) bng cc v: bch thc, cam tho. Bi thuc in hnh trong trng hp ny l Tiu dao tn (Ho t cc phng) gm: si h, bch thc, phc linh, ng quy, bch trut, chch cam tho.

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V thuc Si h Bch thc Phc linh ng quy Bch trut Chch tho (cam tho)

Dc l ng, hn; vo can, m, tm bo, tam tiu: t nhit, gii c, thng ng, chua, lnh; vo can, t, ph: dng huyt, li thu, lim m Ngt, nht, bnh; vo tm, t, ph, thn: li niu thm thp, kin t, an thn Ngt, cay, m; vo tm, can, t: dng huyt, hot huyt Ngt, ng, m; vo t v: kin t, to thp, ch hn, an thn Ngt, bnh; vo 12 kinh: b trung kh, ho hon, gii c

Liu 12g 12g 12g 12g 12g 8g

Vai tr Qun Thn T Thn T T, S

(Phn gii thch tnh v quy kinh, qun thn t s xin xem sch Bnh hc kt hp tp I)

Ngoi ra nn gia thm trn b hoc ch xc, mc hng, inh hng, th l nhng dc liu c tc dng chng co tht c trn tiu ho l kh, khoan hung v thng kh thng tiu.

T lng gi 1. Cc nhm ri lon vn ng thc qun bao gm A. Ri lon vn ng c trn v c vn B. Achalasia v chng co tht thc qun lan to C. Achalasia v globus pharyngeal D. Achalasia v hi chng thc qun do bnh x cng b E. Achalasia v chng lit hu hng 2. C ch bnh sinh ca hi chng crico pharyngeal bi nhim l A. Lit c hu (pharyngeal) B. Lit c hyoid C. Co tht thc qun D. Co tht c vng di E. Co tht c vng trn

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3. C ch bnh sinh ca chng Achalasia A. Co tht thc qun B. Co tht thc qun v c vng trn C. Co tht thc qun v c vng di D. Lit c hu E. Lit c hyoid 4. Triu chng no sau y khng c trong chng Achalasia A. au ngc B. Kh nut thc n c C. Kh nut thc n long D. Nng rt sau xng c E. Nn ra thc n 5. Triu chng kh nut i km vi thc n tro ra mi gp trong A. Achalasia B. Hi chng thc qun do x cng b C. Co tht thc qun lan to D. Lit c hu E. Lit c hng 6. Chn on phn bit gia Achalasia v co tht thc qun lan to bng manometry s da trn A. Cc sng co tht ca thn thc qun B. Cc chng co tht ca thn thc qun khi nut C. S tng nhu ng ca thn thc qun D. S xut hin cc sng co tht vi bin ln E. S co tht ca c vng di khi nut 7. C ch bnh sinh ca cc chng globus pharyngeal theo YHCT l A. Can kh thng xung B. Can v bt ho C. Can m khuy tn D. Can m thp nhit E. Can ho thng vim

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8. Trong bi thuc Tiu dao (gm: si h, ng quy, bch thc, bch trut, bch linh, cam tho) v si h lm qun v c tc dng A. Lim can m B. Bnh can dng C. S can, gii ut D. S can tit nhit E. Ho gii biu l 9. V thuc no sau y c th gia gim thm trong bi Tiu dao (gm cc v: trn b, ch xc, mc hng) vi mc ch l kh, khoang bng v thng kh thng tiu: A. i hong B. ch tr nhn C. Bch u khu D. inh hng E. Mt dc 10. Vi php tr l s can, l kh, ch thng, ngoi bi thuc Tiu dao, ta c th dng bi A. Hng sa lc qun B. iu ho can t C. Thng t yu phng D. Hong k kin trung E. B trung ch kh

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Bi 7

VIM D DY

MC TIU 1. Phn loi c cc bnh vim d dy theo tnh cht m hc, v tr v c ch bnh sinh. 2. M t c cc c im m hc ca vim d dy mn. 3. Lit k c cc phng php iu tr thch ng vi cc loi vim d dy cp cng nh mn. 4. Phn tch c mc ch iu tr ca bi thuc Hong k kin trung thang trn cc th vim d dy mn. 5. Nhn thc c vim d dy mn typ B n cha mt nguy c ung th ho.

1. I CNG Vim d dy hay vim nim mc d dy l mt nhm bnh mang tnh cht vim ca nim mc d dy bao gm nhng khc nhau v hnh nh lm sng, c im m hc v c ch gy bnh. Thng thng nhng phn loi v vim d dy u t nn mng trn: Tnh cht cp hay mn ca lm sng Hnh nh m hc S phn b theo v tr C ch bnh sinh 2. BNH HC 2.1. Theo y hc hin i 2.1.1. Vim d dy cp a. Phi hp vi Helicobacter Pylori (HP) Khi u ca s nhim HP l s tng acid dch v tm thi v sau khong 1 nm s l tnh trng gim acid. 120

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Bnh nhn thng c nhng kh chu vng thng v nhng phn ln l khng triu chng. Nn nh rng khng phi lc no ni soi v sinh thit cng tm thy c HP. b. Do nhim cc vi sinh vt khc Vim ty d dy (phlegmonous gastritis) vi s tm nhum, t bo vim lan to khp vch d dy, s hoi t m v hnh nh nhim trng ton thn m vi sinh vt gy bnh c th l Streptococcus, Staphylococcus, Proteus, Hemophilus hoc E. coli; i tng d b nguy c thng l nhng bnh nhn b suy gim min dch. Vic iu tr phi ch trng n bi hon nc in gii, tim truyn khng sinh v nu khng hiu qu phi ct b ton b d dy. Ngoi ra siu vi Herpes simplex v Cytomegalovirus cng c th gy vim cht d dy (erosive gastritis) trn nhng ngi b suy gim mim dch. 2.1.2. Vim d dy mn Vi hnh nh m hc l s tm nhum t bo lm ba v tng bo, s phn b v tr vim c tnh cht ri rc khng u. V din tin, khi u hin tng vim ch xy vng nng v su ca nim mc d dy, sau s tin ti hy hoi cc tuyn ca d dy v cui cng s c hnh nh bin d cc tuyn v teo i. a. Da vo hnh nh m hc ta c Loi vim nng: l giai on khi u, hin tng vim ch gii hn lp lamina propia vi s tm nhum ca t bo vim v ph n cc tuyn d dy. Loi vim teo: l bc pht trin k tip vi hin tng tm nhum s tri di ti lp nim mc su v phn b t hang v ln n thn v y d dy. y s c s ri lon cu trc v hy hoi cc tuyn d dy. Teo d dy: l giai on cui cng m cu trc cc tuyn d dy s bin mt, trong xen k vi m lin kt l ri rc mt t t bo vim. V i th nim mc d dy tr nn mng v c th thy c cc mch mu khi ni soi d dy. Cc tuyn d dy s chuyn dng thnh cc tuyn nim mc rut non vi nhng goblet cell v l yu t tim n cho vic ung th ho. b. Cc loi vim d dy mn Vim d dy type B (antral predominant, HP gastritis, environmental gastritis): loi ny rt thng gp, ngi tr bnh ch nh hng n vng hang v nhng ngi gi li lan to ton b d dy. T l vim 121

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ny s gia tng theo tui k t khi bnh nhn b nhim HP (chim 78% ngi trn 50 tui v 100% ngi trn 70 tui), thi gian qu ca hin tng vim t khu tr n lan to trung bnh l 15 - 20 nm. Nguyn nhn ch yu ca bnh l do HP. Hnh nh m hc cho thy s tm nhum dy c ca lympho v tng bo lp lamina propia v s thm nhp bch cu a nhn vo lp biu b cng nh lun lun tm thy HP trong giai on vim nng. Ngoi ra, ngi ta cng c th tm thy khng th khng t bo thnh v khng gastrin. Vim d dy do HP mn s a n vim teo d dy: nhiu im hoi t, teo d dy v gy d sn tuyn nim mc d dy cng nh chnh s iu tr bng cc thuc c ch s tit HCl s pht trin thm hin tng teo d dy v lm tng nguy c ung th, adenocarcinoma (nguy c ny cao gp 3 - 6 ln ngi c huyt thanh (+) vi HP). Do chn on xc nh nn sinh thit cc vng nghi ng vim. Tuy nhin, v c ch bnh sinh gia loi vim d dy typ B vi adenocarcinoma r nn khng c iu tr c hiu cho loi vim d dy ny. Ngoi ra s nhim trng vi HP lin quan n bnh lypophoma, t bo lympho B mc thp m vic iu tr bng khng acid s khin loi lympho ny thoi trin. Vim d dy typ A (body predominant, autoimmune, chronic atrophy): loi ny t gp hn, tn thng vim thng nh v vng y v thn d dy, bnh thng phi hp vi thiu mu c tnh (pernicious anemia). V phng din min dch hc, ngi ta thy c s lin quan gia bnh vim d dy typ A, bnh thiu mu c tnh v mt s bnh t min khc da trn nhng d liu huyt thanh hc sau y: + Khng th chng t bo thnh c trong 90% huyt thanh ngi b thiu mu c tnh v trong 50% huyt thanh ngi b vim d dy typ A. + Huyt thanh ca nhng ngi c h hng vi bnh nhn thiu mu c tnh c vim teo d dy v v acid dch v, c khng th chng t bo thnh vi tn sut cao hn ngi bnh thng. + Trong iu tra v huyt thanh hc ca mt qun th ngi ta nhn thy khng th chng t bo thnh c mt trong: 20% trng hp ngi trn 60 tui, 20% trng hp bnh nhn suy tuyn ph gip, bnh Adisson v bch bin; khong 50% ngi thiu mu c tnh c khng th chng tuyn gip; khong 30% ngi b bnh tuyn gip c khng th chng t bo thnh. 122

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+ Huyt thanh c khng th chng ni yu t (intrinsic factor) th c hiu vi typ A hn so vi khng th chng t bo thnh v chng cng c mt trong 40% trng hp bnh nhn b thiu mu c tnh. Ngoi ra ngi ta cn tm thy c ch min dch qua trung gian t bo c tham gia trong c ch gy vim nim mc vim d dy typ A v bnh nhn thiu mu c tnh. Triu chng lm sng v sinh ha l hu qu ca s v acid dch v v thiu mu do ri lon hp thu B12 (thiu mu i hng cu v cc ri lon thn kinh). Ngoi ra cn c tnh trng tng gastrin/mu (> 500 pg/ ml) tng ng vi hi chng Zolinger ellisson v tng sinh t bo ECL a n Carcinoid tumor do tnh trng v acid dch v. Khng c iu tr c hiu cho loi bnh ny. Vim d dy tm nhum lympho bo (lymphocytic gastritis): y l loi vim d dy vi s tm nhum dy c cc t bo lm ba lp thng b v tng bo lp Lamina propia. Bnh nhn khng c triu chng lm sng, i khi bnh phi hp vi Celiac - sprue. Ni soi thy np gp nim mc dy ln ph y nhng nt nh c ch lm gia (varioliform gastritis). Hiu qu ca vic iu tr bng corticoid v cromoglycat vn cn ang bn ci. Vim d dy tm nhum bch cu i toan (eosinophylic gastritis): tn thng vng Antrum vi hnh nh tm nhum t bo i toan t nim mc n lp c. Bnh nhn thng au bng, nn i v c th b tc nghn vng mn v, i km vi cc biu hin ca mt bnh d ng v tng bch cu i toan trong mu. iu tr bng glucocorticoid a n kt qu kh quan. Vim d dy tm nhum bch cu ht (granulomatous gastritic): tng ng nh bnh Crohns c gy lot d dy, ngoi ra cc nhim trng do Histoplasmosis, Candida, giang mai v lao cng c th gy nn bnh ny. Chn on xc nh bng sinh thit v t bo hc. Bnh Menetrier: ton b nim mc vng thn v y d dy tr nn ph i v ngon ngoo do s tng sinh t bo nhy (foveolar hyperplasia) thay th cho t bo chnh l t bo thnh, cn lp lamina propia th cha cc t bo vim mn tnh. Tuy nguyn nhn cha c bit r nhng s lm dng cc yu t gy tng trng nh TGF - cng c th lin quan n din tin ca bnh. Triu chng lm sng l: au vng thng v, chn n, bun nn v st cn, c hin tng mu ln trong phn do lot cht nim mc d dy, i khi bnh pht trin thnh lot hoc ung th d dy. Ngoi ra do hin tng mt protein qua ng d dy nn bnh nhn s gim albumin mu v ph. 123

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Chn on bng ni soi v sinh thit su loi b ung th d dy hoc u t bo lympho, hi chng Zolinger ellisson, vim d dy (kt hp vi b sung m) do Cytomegalo virus, Histoplasmosis, vim d dy do bnh giang mai v sarcoidosis. iu tr bng thuc khng cholinergic s lm gim s mt protein. Nu c lot nn iu tr nh lot d dy. Nu khng p ng nn ct b ton b d dy. 3. BNH HC THEO Y HC C TRUYN Cc triu chng trong vim d dy mn typ B th nng v th vim teo khng nm ngoi cc th lm sng kh tr, t v h hn ca chng v qun thng (xem bnh hc III). Trong trng hp vim d dy mn typ B ta c th dng php tr n trung kin t vi mc ch kch thch bi tit dch v v iu ha nhu ng d dy rut. Bi thuc c th l Hong k kin trung (Kim qu yu lc) gia gim gm: hong k, cam tho, bch thc, cao lng khng, can khng, i to, thc a
V thuc Hong k Cam tho bc Bch thc Tc dng Ngt, m: b kh, thng dng kh ca t Ngt, m: b t th, b trung kh Chua, ng, lnh: ch thng, lim m Liu 12g 12g 12g Vai tr Qun Thn T

Gia: cao lng khng 6g, can khng 6g, i to 5 qu, thc a 20g. Phn tch bi thuc (xem lot d dy - t trng - Sch bnh hc v iu tr tp III). Ngoi ra, vi vim d dy tm nhum lm ba cu (lymphocytic gastritis) v bch cu i toan (eosinophilic gastritis) trong c ch t min ng vai tr nht nh cng c th dng bi thuc trn vi l do: Hong k c tc dng iu ha min dch, thc y chuyn ho protid. Cam tho bc c tc dng c ch min dch (do c ch men 5 reductase ca cortisol) a n ko di tc dng ca cortisol. Thc a c tc dng c ch min dch nhng khng c ch hot ng ca v thng thn.

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T lng gi 1. C ch bnh sinh ca bnh vim d dy no sau y khng lin quan n yu t min dch? A. Vim d dy typ B B. Vim d dy typ A C. Bnh Menetriez D. Vim d dy tm nhum bch cu lm ba E. Vim d dy tm nhum bch cu eosin 2. Hnh nh m hc ca vim nng trong vim d dy l A. S tm nhum t bo vim B. S ph n cc tuyn d dy C. S hu hoi cc tuyn d dy D. S bin d cc tuyn d dy E. S ri lon cu trc tuyn d dy 3. Hnh nh m hc ca vim teo trong vim d dy l A. S tm nhum t bo vim B. S ph n cc tuyn d dy C. S hu hoi cc tuyn d dy D. S bin d cc tuyn d dy E. T bo vim ri rc 4. Hnh nh m hc ca teo d dy trong vim d dy l A. S tm nhum t bo vim B. S ph n cc tuyn d dy C. S hu hoi cc tuyn d dy D. S bin d cc tuyn d dy

E. S ri lon cu trc tuyn d dy


5. Phng php iu tr cho vim d dy typ B l A. Cc thuc trung ho acid dch v B. Cc thuc i khng H2 receptor C. Cc thuc c ch ln proton H + D. Cc khng sinh nhy cm vi HP

E. Ct d dy
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6. Phng php iu tr cho vim d dy typ A l A. Cc thuc trung ho acid dch v B. Cc thuc i khng H2 receptor C. Cc thuc c ch ln proton H + D. Ct d dy E. Vitamin B12 7. Phng php chn on ti u cho cc loi vim d dy l A. Huyt thanh hc B. Ni soi v sinh khit C. X quang c chun b D. Urea label breath test E. o acid dch v 8. Phng php chn on ti u cho cc loi vim d dy mn typ B l A. Sinh thit v huyt thanh hc B. Ni soi v sinh thit C. X quang c chun b D. C.L.O test E. o acid dch v 9. Bi thuc Hong k kin trung (gm: hong k, bch thc, cam tho bc, cao lng khng, i to), c hong k lm qun v A. C biu, lim hn B. Kin t kh, thng dung C. B kh, li thu D. B trung kh, ch thng E. n kin t v 10. Bi thuc Hong k kin trung thang c th gia thm dc liu no gia tng tc dng c ch min dch ca n A. Si h B. Ng v t C. i to D. Thc a E. Cu k t 126

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Bi 8

LOT D DY-T TRNG

MC TIU 1. Trnh by c c ch bnh sinh ca lot d dy-t trng theo YHH. 2. Trnh by c c ch bnh sinh ca chng v qun thng theo YHCT. 3. Lit k v gii thch c c ch tc dng ca cc dc phm dng trong iu tr lot d dy-t trng. 4. Lit k v gii thch c cng dng ca cc nhm thuc v cng thc huyt dng trong cc th lm sng ca chng v qun thng.

1. NH NGHA Lot d dy-t trng l s mt cht ca nim mc d dy-t trng. Lot d dy-t trng l mt bnh kh ph bin, vi chng 5 - 10% dn s c vim lot d dy-t trng trong sut cuc i mnh v nam gii hay gp gp 4 ln n gii (ti Bc Vit Nam t l mc bnh c tnh 5 - 7% dn s), thng gp 12% - 14% trong cc bnh ni khoa v chim 16% trong tng s cc ca phu thut trong mt nm. Ngoi ra nh ni soi, ngi ta cn pht hin khong 26% bnh nhn b lot d dy-t trng m khng h c triu chng au cng nh khong 30 40% bnh nhn c au kiu lot d dy-t trng nhng li khng tm thy lot. Lot d dy-t trng c nhng t tin trin xen k vi nhng thi k n nh m chu k thay i ty ngi. Hng nm trung bnh c khong 50% ngi b lot c t au phi iu tr v trong t tin trin c th c nhng bin chng nguy him nh chy mu, thng, hp... v d c phu thut cp cu t l t vong vn cao (khong 22%). Cc iu tra v dch t hc cn cho thy mi lin quan gia lot d dy t trng vi hi chng Helicobacter Pylori, trong khong 30 - 60% ngi b lot t trng v 70% ngi b lot d dy c s hin din ca HP 127

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Sau cng, tuy lot d dy-t trng khng phi l mt bnh kh cha nhng t l ti pht li rt cao, thng k cho thy t l ti pht ca lot t trng l 80% trong vng 1 nm v lot d dy l 50% trong vng 5 nm. 2. C CH BNH SINH 2.1. Theo y hc hin i Lot d dy-t trng l kt qu ca s mt cn bng gia mt bn l yu t ph hy nim mc d dy - t trng v mt bn l yu t bo v nim mc d dy - t trng Yu t ph hy nim mc Yu t bo v nim mc

Lot d dy - t trng = Trong

Yu t ph hy nim mc: HCl v pepsin. Yu t bo v nim mc: cht nhy, HCO3. Hng ro nim mc d dy Theo nhng nguyn nhn gy hot ho yu t ph hy nim mc d dy-t trng c th k n: S cng thng thn kinh do cc stress tm l ko di gy nn trng thi cng ph giao cm m kt qu s gy tng tit HCl v tng co bp c trn d dy. S hin din ca xon khun Helicobacter Pylori (HP) s hy hoi t bo D nim mc t trng (l t bo tit somatostatin c tc dng c ch tit gastrin), qua s gy tng tit HCl. Ngc li, nhng nguyn nhn lm suy gim yu t bo v nim mc d dy li l: S cng thng thn kinh do cc stress tm l ko di s lm cc t bo nhy nim mc d dy gim bi tit HCO3. Ru v cc thuc gim au chng vim non steroid ngoi vic thng qua c ch ti khuych tn ion H + cn c ch s tng hp prostaglandin do ng thi va lm tng tit HCl va hy hoi t bo nim mc d dy cng nh lm gim s sinh sn t bo nim mc d dy. Corticoid v cc dn xut ca n qua c ch gim tng hp glucoprotein (mt thnh phn c bn ca cht nhy) s lm gim yu t bo v nim mc d dy. 128

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Vai tr ti mu ca h mao mch d dy-t trng i vi s bn vng ca hng ro nim mc d dy. Theo s x va h mao mch d dyt trng (kt qu t hin tng sn sinh cc gc t do) s lm cn tr s ti mu nim mc d dy c dng gii thch cho c ch vim d dy mn tnh cng nh gii thch l do ti sao c nhiu lot to v bt tr ngi c tui. S hin din ca xon khun Helicobacter Pylori (HP) nim mc d dy-t trng s sn sinh ra NH3 va cn tr s tng hp cht nhy va lm bin i cu trc phn t cht nhy t dng hnh cu sang dng hnh phin mng, khin cho lp cht nhy d b tiu hy bi pepsin. Ngoi ra chnh Helicobacter Pylori (HP) cn tit ra protease, phospholipase, c t 87 KDA protein v kch thch tit interleukin gy tn thng trc tip ln t bo nim mc d dy. Yu t th tng: nhm mu O c tn sut lot cao hn cc nhm mu khc, iu ny c l lin quan n s u tin kt hp gia nhm O v HP, s lin quan gia HLAB5 antigen vi tn sut lot t trng. Vai tr ca thuc l trong vic c ch tit HCO3 ca tuyn ty, gia tng s thot dch v vo t trng ng thi to nn cc gc t do gy tn hi n nim mc d dy. 2.2. Theo y hc c truyn Bnh lot d dy-t trng vi biu hin lm sng l au vng thng v cng vi mt s ri lon tiu ha c xp vo bnh l ca t v vi bnh danh l v qun thng m nguyn nhn c th l: Nhng cng thng tm l ko di nh gin d, ut c, khin cho chc nng s tit ca tng can (mc) b nh hng, t cn tr ti chc nng ging np thu cc. Nhng cng thng tm l ko di nh lo ngh, toan tnh qu mc cng nh vic n ung i no tht thng s tc ng xu ti chc nng kin vn ca tng t v nh hng xu ti chc nng ging np thy cc ca v. Trn c s , thi tit lnh hoc thc n sng lnh m YHCT gi l hn t s l yu t lm khi pht cn au. Trong giai on u, chng v qun thng thng biu hin th kh ut (tr), ho ut hoc huyt ; nhng v sau do kh suy, huyt km m chng v qun thng s din tin theo th t v h hn.

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Gin d, ut c

Lo ngh, toan tnh

n ung tht thng

S TIT CAN HN T V

KIN VN T

V KH UT TR

Ha UT

HUYT

T V H HN

3.CHN ON 3.1. Theo y hc hin i 3.1.1. Triu chng lm sng Ni chung cc triu chng c nng v du hiu lm sng ca bnh lot d dy-t trng thng ngho nn, ch trong nhng t tin trin bnh nhn mi c au vng thng v, ri lon tiu ha. a. Nhng cn au vng thng v Ko di t 15 pht - 1 gi, c th khu tr bn (T) nu l lot d dy hoc bn (P) nu l lot t trng. Cn au c th lan ra vng hng sn (P) hoc c th chi ra sau lng (nu lot thnh sau d dy). Cn au c tnh chu k v tr nn au dai dng lin tc nu l lot lu ngy hoc lot x chai. Cn au thng xut hin lc i, v m v gim ngay sau khi ung sa hoc dung dch antacid nu l lot t trng; thng xut hin sau khi n hoc t thuyn gim vi antacid nu l lot d dy. Cn au c tnh cht qun tht hoc nng rt, hoc nng n m . 130

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Trong cn au, khm c th pht hin thy vng thng v khng khi s nn. b. Nhng ri lon tiu ha To bn: rt thng gp. Nn ma, bun nn thng xy ra trong trng hp lot d dy nhng t xy ra trong lot t trng nu khng c bin chng. Bnh nhn n vn ngon ming nhng c cm gic chm tiu, thng l nng, trng bng hoc hi, chua sau cc ba n. 3.1.2. Du hiu cn lm sng chn on lot d dy-t trng , ngi ta c th dng phng php: Gin tip: nh ht dch v cho thy c tng HCl t do 2 gi sau khi kch thch d dy trong trng hp lot t trng. Ngc li tnh trng v acid dch v sau khi kch thch bng pentagastrin gi n mt kh nng ung th d dy nhiu hn. Trc tip: nh X quang d dy - t trng vi nhng hnh nh trc tip nh hnh chm, hnh hoc cng mt on hoc i khi l mt ti Hawdeck vi 3 mc baryt, nc, hi cng vi nhng hnh nh gin tip nh tng trng lc, tng nhu ng. Ngoi ra trong nhng trng hp lot t trng cn c hnh nh du ch chun hoc tampon ca toa xe la (tampon du wagon). Tuy nhin nhng lot di 0,5cm s khng th thy c v ngc li nhng lot ln hn 3cm cn phi ngh n mt ung th. Tuy nhin chnh xc nht vn l ni soi d dy - t trng bng ng mm (fibroscope) v sinh thit lot chn on phn bit vi lot ung th ha (97% trng hp) c 8% lot c v lnh tnh trn X quang nhng li c pht hin l c tnh nh ni soi. Ngoi ra, hin nay vi quan nim v vai tr ca Helicobacter Pylori trong bnh sinh lot d dy-t trng (hin din 80 - 100% trong nhng lot khng do steroid hoc non steroid), ngi ta cn chn on s nhim HP bng cc test chn on nhanh nh: Rapid urease test campylobacter like organism, nui cy mu sinh thit d dy hoc 13C hoc 14C labelled urea breath test v chn on bng huyt thanh min dch.

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Cc test chn on nhim HP


Loi TEST 1. Urease 13C hoc 14C labelled urea breath 2. Qua mu sinh thit - Rapid urease test - C.L.O. test 2. M hc 3. Cy 4. Huyt thanh 70 - 90% 90 - 95% 95% Cn n ni soi v thuc nhum c bit Cn n ni soi, nn dng cho trng hp khng thuc Khng phn bit mi nhim hay nhim t lu 90 - 98% Cn n ni soi nhy cm 90 - 95% LI khuyn n gin, dng theo di

3.1.3. Bin chng Thng thng trong nhng t tin trin, mi t au c th ko di vi ngy hoc 2 - 3 tun l ri t nhin ht. Nhng cng c khong 10 - 20% trng hp thng xy ra cc bin chng nh: Xut huyt tiu ha: chim 15% trng hp thng gp trong lot t trng v ngi trn 60 tui, lc bnh nhn t nhin c cm gic kh chu, mt mun xu, kht nc, v m hi lnh, du hiu shock, i khi nn ra mu v sau mi i cu ra phn en. Khong 20% bnh nhn s khng c nhng biu hin nh trn. Thng: khong 6 - 7% trng hp hay xy ra trong lot t trng nhng t l t vong t hn thng d dy 3 ln. C th thng vo mng bng t do vi biu hin: + au nh dao m vng hng sn (P). + Lc u mch v huyt p cn n nh nhng bnh nhn th nng, sau xut hin trng thi shock vi du hiu vim phc mc. + Khm bng thy c du hiu co c khng ti ch, vi gi sau au lan ta khp bng, c khi chi ln 2 b vai, 2 c thng bng ni r ln, s nn thy c du hiu bng g. + Bnh nhn nn ma v khng trung tin c. + Thm trc trng khi chm vo ti cng Douglas rt au. + Chp X quang bng khng chun b cho thy trn kh mng bng km lim hi trc gan hoc trn gan. + Sau 12 gi bng cng trng, bnh nhn ri vo trng thi nhim trng, nhim c. Lc c can thip cng v ch, thng th bnh nhn s cht sau 3 ngy. 132

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Ngc li trng hp thng vo mng bng c vch ngn thng kh chn on, hay xy ra cc trng hp lot mn tnh, biu hin bng nhng triu chng v du hiu ca mt p xe di c honh (T) do thng t d dy vo thu tri gan hoc du hiu ca mt vim ty do thng t t trng vo ty hoc thm ch l l r gia d dy v rut gi. Hp: chim khong 1 - 2% bnh nhn. C th nh khu mn v, gia d dy hoc t trng. Nguyn nhn c th do co tht, vim v ph quanh lot hoc co rt do ln so, vim quanh tng. Lc ny au thay i tnh cht v tr nn lin tc, bnh nhn thng nn ra thc n hm trc. Khm bng thy c du hiu c ch, sng v lc i. Ht d dy lc i s c c mt lng dch d dy khong 50 - 100ml ln nhng mnh vn thc n. X quang v ni soi s gip xc nh v tr v nguyn nhn hp. Ung th ho: t khi xy ra cho lot t trng trong khi 90% lot d dy b cong nh u c kh nng ho ung th. Cc du hiu nghi ng c tnh l: + Du hiu lm sng v X quang vn cn tn ti sau nhiu tun l iu tr. + au tr thnh lin tc. + Lun lun c du hiu n mu trong phn. + V acid dch v. Nhng chn on xc nh vn l ni soi v sinh thit. 3.2. Theo y hc c truyn Chng v qun thng c chia lm 4 th lm sng sau y: 3.2.1. Kh ut (tr) Vi triu chng au thng v tng cn lan ra hai bn hng sn km hi, chua, to bn. Yu t khi pht cn au thng l nng gin, cu gt. Tnh tnh hay gt gng, ra li , ru li vng nhy, mch huyn hu lc. 3.2.2. Ho ut Vi tnh cht au d di, nng rt vng thng v, nn ma ra thc n chua ng, hi th hi, ming ng, li sm, mch hng sc. 3.2.3. Huyt au khu tr vng thng v cm gic chm chch, cht li tm hoc c im huyt , mch hot. Nng hn th i cu phn en hoc nn ra mu bm. 133

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3.2.4. T v h hn Hay gp lot d dy-t trng mn tnh, ti pht nhiu ln hoc ngi gi vi triu chng au vng thng v mang tnh cht m lin tc hoc cm gic y trng bng sau khi n. Yu t khi pht thng l ma lnh hoc thc n tanh lnh lm au tng. Triu chng i km l chn n, bun nn, phn c lc lng, st, nhy nht, li nht bu, ru li trng dy nht, mch nhu hon v lc. 4. IU TR 4.1. Theo y hc hin i Nhm mc ch: Lm lnh lot. Loi b xon khun Helicobacter Pylori. Phng chng ti pht. Theo di v pht hin trng thi ung th ha. Vic iu tr ni khoa lot d dy-t trng bao gm mt ch n ung hp l v thuc nh sau: 4.1.1. Ch n ung Cho n nay, vic thc hin ch n ung gm cc thc n mm, khng gia v, nhiu tri cy khng ch g cho vic lm lnh lot cng nh ch n sa v kem cng khng lm cho tnh trng lot xu hn. Do tt nht bnh nhn nn trnh nhng thc n no gy au hn hoc gy ri lon tiu ho xu hn; ng thi bnh nhn phi king c ph, ru v c bit l thuc l. 4.2.2. Thuc iu tr a. Nhm antacid: c th nh maalox vi liu s dng 30ml ung sau ba n t 1 - 3 gi v trc khi ng, thi gian iu tr nn ko di t 1 - 2 thng. Cc thuc thuc nhm ny cng c tc dng ngn nga ti pht nhng cn ch cc antacid c th gy tiu chy (do c Mg) hoc to bn (do c Al) hoc hi chng Milk - Alkali (do c cha calcium carbonat) hoc gy nhim c thn kinh trn ngi suy thn do c cha Mg v aluminium. b. Sucralfat: c tc dng bao ph lot v gn kt vi pepsin, nn dng 1g trc ba n 1 gi v trc khi i ng hoc dng 2g x 2 ln/ngy. Thuc c tc dng ngn nga ti pht.

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Cn ch : thuc gy to bn (2 - 3%)v c th gn kt vi thuc khc nu dng chung. Ngoi ra khng nn dng thuc cho ngi suy thn. c. Misoprostol: c tng hp t prostaglandin E1 c tc dng kch thch tun hon nim mc d dy, ng thi cn thc y s tng hp prostaglandin, kch thch s bi tit cht nhy bicarbonat. Liu thng dng l 200mg x 4 ln/ngy. Thuc c hiu qu trong lot d dy-t trng do non steroid, tuy nhin thng gy phn ng ph l tiu chy (30%), co tht v xut huyt t cung. d. Nhm H2 receptor antagonist Cimetidin: vi liu s dng 300mg x 4 ln/ngy hoc 400mg x 2 ln/ngy hoc 800mg ung vo lc i ng. Thuc c tc dng ph l chng androgen liu cao, gim chuyn ho gan v tng men transaminase. Ranitidin: vi liu s dng 150mg x 2 ln/ngy hoc 300mg ung vo lc i ng. Thuc t c tc dng ph hn cimetidin. Famotidin: ung 1 ln 40mg vo lc i ng. Nizatidin: ung 1 ln 300mg vo lc i ng. Cc thuc trn dng trong mt liu trnh t 4 - 6 tun v nu dng 1/2 liu tiu chun lin tc trong 1 nm th c th ngn nga c s ti pht n 70% trng hp. e. Nhm c ch bm proton (H+ K+ ATPase) Omeprazol 20mg ung 1 ln vo bui sng. Lansoprazol 30mg ung 1 ln vo bui sng. Nhm ny c tc dng ph lm gim men gan, thng thng hiu qu ti a ca thuc xy ra trong 2 gi v ko di n 72 gi. Liu trnh iu tr c th ko di t 4 - 8 tun (c hiu qu lm lnh lot d dy so vi nhm H2 receptor antagonist). f. Mt s tc gi khc cn s dng n cc dc phm c tc dng kch thch s tng hp glucoprotein, phosphorlipid v prostaglandin E2, I2 nh carbenoxolon hoc teprenon (selbex) 50mg vi liu ung 1 vin/3 ngy ung sau mi ba n. Cn ch l thi gian iu tr lot d dy thng di hn iu tr lot t trng v bt buc phi kim tra lot bng ni soi v sinh thit. Nu kch thc lot sau 3 thng iu tr m vn khng nh i th phi ngh n ung th ho (70%). g. i vi nhng trng hp lot c nhim HP, lot ti pht nhiu ln, lot c bin chng chy mu th cc thy thuc ni khoa s phi s dng n nhng phc sau y: 135

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Triple therapy vi bismuth subsalicylat 2 vin x 4 ln/ngy kt hp vi amoxicilin hoc tetracyclin 500mg x 3 ln/ngy v metronidazol 250mg x 3 ln/ngy. Thi gian iu tr l 2 tun kt hp vi nhm H2 receptor antagonist hoc nhm c ch bm proton. Thuc c hiu qu ti 91% trng hp nhng hin nay ch cn 63% do c tnh trng HP khng vi metronidazol. Thuc gy bt li nh tiu chy, vim rut kt gi mc (30% trng hp). New-triple therapy vi omeprazol 20mg x 2 ln/ngy kt hp clarithromycin 250mg x 2 ln/ngy v metronidazol 500mg x 2 ln/ ngy, ung trong 1 tun, t gy phn ng ph nhng t tin hn. Ranitidin bismuth citrat 400mg x 2 ln/ngy ung trong 4 tun v clarithromycin 500mg x 3 ln/ngy ung trong 2 tun. Phc ny hiu qu 85% nhng thuc c v kh chu, gy a chy. Quadruple therapy vi cng thc colloidal bismuth subcitrat + tetracyclin + metronidazol + famotidin hoc omeprazol hoc ranitidin vi liu trnh 1 - 2 tun s c hiu qu lm sch HP t 89 - 97% trng hp trong liu s dng ca: + Colloidal bismuth subcitrate l 108mg x 4 ln/ngy. + Tetracyclin 500mg x 4 ln /ngy. + Metronidazol (hoc tidinazol) 500mg x 2 ln/ngy. + Omeprazol 20mg x 2 ln/ngy. i vi cc tn thng do non steroid th phi s dng n misoprostol (200mg x 4 ln/ngy) hoc famotidin (40mg x 2 ln/ngy) hoc liu cao ca omeprazol. Ngoi ra gim bt s tn thng nim mc d dy ta c th dng celecoxib hoc rofecoxib nhng phi thn trng v thuc c kh nng gy suy thn v ng mu. 4.3. Theo y hc c truyn 4.3.1. S can l kh Bi thuc tiu biu l: Si h s can, Tiu dao gia ut kim, iu ha can t, Hng cc b ngh vi mc ch an thn, chng co tht c trn tiu ho v chng tit HCl dch v hoc trung ho acid. C th trong chng v qun thng th kh ut (tr) ta c th dng bi Tiu dao gia ut kim vi liu lng nh sau:

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V thuc Si h Bch thc Phc linh ng quy Bch trut Sinh cam tho Ut kim

Tc dng ng, hn; vo can, m, tm bo, tam tiu: t nhit, gii c, thng ng, chua, lnh; vo can, t, ph: dng huyt, li thu, lim m Ngt, nht, bnh; vo tm, t, ph, thn: li niu thm thp, kin t, an thn Ngt, cay, m; vo tm, can, t: dng huyt, hot huyt Ngt, ng, m; vo t v: kin t, to thp, ch hn, an thn Ngt, bnh; vo 12 kinh: b trung kh, ho hon, gii c Cay, ng, n vo t, can: hnh huyt, ph , hnh kh gii ut

Liu 8g 8g 10g 8g 8g 8g 6g

Vai tr Qun Thn T Thn T T, S Thn

Ngy ung 1 thang. Nu bnh nhn lo lng, gt gng nn bi thm si h, phc linh hoc gia thm toan to nhn sao en 10g. Nu cn au mang tnh cht qun tht ko di nn bi thm bch thc, cam tho. Nu c triu chng lm ging, bun nn bi thm bch trut. Nu c cm gic nng rt, cn co nn bi thm ng quy, gia i to 3 qu, b ut kim. Hoc dng bi:
V thuc Hng ph Cc tn Xng b M Ngh vng Tc dng Cay, n: iu kh, thng kh, khai ut ng, hn: thanh nhit, gim tnh m cc v thuc Cay, n: trng v: kch thch tiu ho, thuc b iu kh, thng kh, khai ut Ngt, mt: li tiu, ch khi, tr m Cay, ng, m: tr lot d dy, li mt, lnh so Liu 8g 12g 8g 12g 6g Vai tr Qun T, s Thn T Thn

Ngy ung 2 thang Nu bnh nhn au nhiu bi thm hng ph 16g. 137

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Nu au km theo cm gic nng rt th bi m 20g. Nu c cm gic y trng, hi, chua bi thm xng b 12g. Chm cu: chm t nhng huyt trung qun, li cu, hnh gian, thi xung, thn mn
Tn huyt Trung qun Li cu Hnh gian Thi xung Thn mn C s l lun M huyt ca v Lc huyt ca can Hunh ho huyt ca can Du th huyt ca can (m thc t con) Du th huyt ca tm (m thc t con Tc dng Cha chng au trng bng T can kh thc Bnh can Bnh can Bnh can

Dng sinh: dng phng php phnh tht bng. 4.3.2. Thanh ha, tr ut Bi thuc tiu biu l: Hng cc b ngh hoc Ha can tin hp vi T kim hon, Thanh cao m vi mc ch chng co tht, chng tit HCl, khng sinh khng vim bng c ch lin thnh mch hoc c ch leucotrien. C th trong chng v qun thng th ho ut c th dng bi Hng cc b ngh nhng tng liu m 20g hoc gia thm gia thm bi mu 16g, nhn trn 20g, chi t 12g, b cng anh 20g. Chm cu: chm t nhng huyt ni nh, hp cc, ni quan.
Tn huyt Ni nh Hp cc Ni quan C s l lun Hunh ho huyt ca kinh t Nguyn huyt ca i trung Giao hi huyt ca tm bo v m duy Tc dng Thanh t ho t v Thanh nhit, t ho Cha chng bt rt, tm phin

4.3.3. Hot huyt tiu ch huyt Vi mc ch chng sung huyt v cm mu ngoi tc dng chng co tht v chng tit HCl d dy. Bi thuc tiu biu l bi Hng cc b ngh hoc Tiu dao gia ut kim hoc T vt o hng. Tt c gia c mc, trc bch dip sao en. C th trong chng v qun thng th huyt , nn dng bi Tiu dao gia ut kim hoc Hng cc b ngh nhng tng liu ut kim hoc khng hong 12g, c mc (sao en) 12g, trc bch dip (sao en) 12g. 138

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Chm cu: chm t thi xung, huyt hi, hp cc. Nu bnh nhn xut huyt tiu ha c km ri lon huyt ng hc nn x tr cp cu bng YHH
Tn huyt Thi xung Huyt hi Hp cc C s l lun Du th huyt ca can (m thc t con) Huyt c hiu ca huyt Nguyn huyt ca i trng Tc dng Bnh can Hot huyt Thanh huyt nhit

4.3.4. n trung kin t Bi thuc tiu biu l bi Hong k kin trung vi mc ch kch thch tit dch v, iu ha nhu ng d dy rut, ci thin tun hon nim mc d dy, kch thch tng hp glucoprotein v prostaglandin E2, I2.
V thuc Hong k Can khng Cam tho chch Hng ph Bch thc Cao lng khng i to Dc l Ngt, m: b kh, thng dng kh ca t Cay, m: tr dng, cu nghch, tr hn ch thng, ch nn, ch huyt Ngt, m: b t th, b trung kh Cay ngt ng, bnh: s can, l kh, ch thng ng, chua, hi hn: dng huyt, lim m, li tiu, nhun gan Cay, nng: n t v Ngt, m: b trung ch kh, ho hon dc tnh Liu 10g 6g 8g 8g 8g 6g 3 qu Vai tr Qun Thn Thn Thn T Thn T

Gia i hi 4g, ch tr nhn 8g, bch u khu 4g, tho qu 0,6g; ngy dng 1 thang. + Nu bnh nhn mt mi, chn n lm ging th bi hong k 16g, cam tho chch 12g. + Nu bnh nhn y trng bng, tiu lng th bi thm can khng 8g, cao lng khng 8g. Chm cu: n chm hoc cu nhng huyt quan nguyn, kh hi, tc tam l, thi bch, phong long, t du, i , thiu ph.

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Tn huyt Quan nguyn Kh hi Tc tam l Thi bch Phong long T du i Thiu ph

C s l lun Ca ca nguyn kh, nguyn dng B ca kh Hp huyt ca v Nguyn huyt ca t Lc huyt ca v Du huyt ca t Ho huyt ca t Hunh ho huyt ca tm

Tc dng B nguyn kh B nguyn kh Kin v Kin t (nguyn, lc) Kin t (bi du) Kin t (con h b m)

Dng sinh: dng phng php xoa trung tiu.

T lng gi 1. Hu qu ca cc stress tm l ko di s khng gy nn A. Tng co bp c trn d dy B. Tng tit HCl C. Gim bi tit HCO3 D. Gim sn nim mc d dy E. Khng cu no ng 2. Vai tr ca Helicobacter Pylori trong c ch gy lot d dy-t trng khng phi l A. Hy hoi t bo D nim mc d dy B. Bin i cu trc phn t cht nhy C. Gim tng hp glucoprotein ca cht nhy D. Tit cc men, c t v interleokine E. Cn tr s tng hp cht nhy 3. C ch tham gia gy lot no sau y khng do ru, khng do cc thuc gim au chng vim corticoid, non steroid v thuc l A. Cn tr s ti mu nim mc d dy B. Tng tit HCl qua c ch ti khuch tn ion H + C. Gim sn t bo nim mc d dy do c ch tng hp prostaglandin 140

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D. c ch tit HCO3 ca tuyn ty E. Gim tng hp glucoprotein 4. Trong c ch bnh sinh ca chng v qun thng, ri lon cng nng ch yu xy ra tng ph no? A. Can B. T C. V D. Trng E. Tam tiu 5. Tnh cht no sau y khng thuc cn au ca mt lot d dy-t trng mi mc? A. C chu k B. Dai dng v lin tc C. Xut hin lc i, v m D. Gim au sau khi ung sa hoc cht kim E. Lin quan ti ba n 6. Du hiu no sau y khng thuc du hiu nghi ng ca mt lot d dy ho ung th A. Du hiu lm sng v X quang tn ti sau nhiu tun iu tr B. au tr thnh dai dng lin tc C. Lun lun c mu n trong phn D. Hnh nh nim mc d dy mt mm mi trn X quang E. Trng thi v acid dch v 7. chn on s sch xon khun HP sau mt t iu tr lot d dyt trng, ngi ta khng da vo: A. Rapid vrease test B. Huyt thanh min dch C. Nui cy mu sinh thit D. C.L.O test E.
14

C Labelled urea breath test

8. Triu chng no sau y khng c trong th kh ut (tr) A. chua B. To bn 141

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C. Cu gt D. Mch huyn E. Lnh au 9. Triu chng no sau y khng c trong th ho ut A. au nng rt B. Nn thc n chua ng C. Mi li l lot D. Li sm E. Ming ng hi 10. Triu chng no sau y khng c trong th huyt A. au cm gic nh kim chm B. Cht li tm C. Mch hot D. Nn ra nc trong E. i cu phn en 11. Triu chng no sau y khng c trong th t v h hn A. au m , lin tc B. y trng bng sau n C. Tiu chy phn nhy nt D. Tri lnh au tng E. au bng v m 12. Tc dng ph no sau y khng c trong khi s dng lu di cc thuc trong nhm antacid A. Tiu chy B. Long xng C. Nhuyn xng D. To bn E. Hi chng Milk - Alkali 13. Thuc no sau y c hiu qu cao trong lot d dy-t trng do s dng cc thuc chng vim gim au non sterod A. Antacid B. Misoprostol 142

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C. Sucralfat D. H2 receptor antagonist E. c ch bm proton 14. Tc dng dc l no sau y khng c trong php s can, l kh A. An thn B. Tng tit HCO3 C. Chng co tht c trn tiu ho D. Chng tit HCl E. Trung ho acid dch v 15. Tc dng dc l no sau y khng c trong php thanh ho tr ut A. Chng co tht B. Chng tit HCl C. Khng vim bng c ch bn thnh mch D. Khng vim bng c ch c ch leucotrien E. Tng cng tun hon nim mc d dy 16. Tc dng dc l no sau y khng c trong php n trung kin t A. Kch thch tiu ho B. Kch thch tit dch v C. Tng tit HCO3 ca t bo nim mc d dy D. iu ho nhu ng d dy rut E. Ci thin tun hon nim mc d dy

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Bi 9

RI LON HP THU

MC TIU 1. Trnh by c cc triu chng lm sng trong hi chng ri lon hp thu. 2. Phn loi c cc c ch ca ri lon hp thu. 3. Trnh by c c ch bnh sinh ca hi chng ri lon hp thu theo quan im ca YHCT. 4. Trnh by c cc triu chng c nng, du hiu lm sng v xt nghim gip chn on 18 nguyn nhn a n ri lon hp thu. 5. Trnh by c 2 th lm sng ca hi chng ri lon hp thu theo YHCT. 6. a ra c cc phng php iu tr cho18 nguyn nhn gy ra ri lon hp thu. 7. Trnh by c tc dng dc l ca cc php tr theo YHCT.

1. NH NGHA Mt bnh l c chn on l ri lon hp thu khi lng m hin din trong phn vt qu 14g mi ngy Trong hi chng ri lon hp thu, ngoi biu hin ton thn nh st cn, mt mi, huyt p thp cn c nhng du hiu lm sng cc h khc nh: Tiu ho: au bng, snh bng, vim li, vim li, tiu chy. Sinh dc, tit niu: i m, tng ur mu, v kinh, gim ham mun tnh dc. Huyt hc: thiu mu, chy mu t nhin. C xng: au nhc trong xng, tetani, t tay chn. Thn kinh: cc bnh l thn kinh ngoi vi. 144

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Gic quan: qung g, nhuyn gic mc. Da lng: chm, ban xut huyt, vim da tng sc t. 2. C CH BNH SINH 2.1. Theo y hc hin i C nhiu nguyn nhn a ti ri lon hp thu, sau y l mt s phn loi: 2.1.1. Do hp thu khng y a phn m sau phu thut ct d dy. Men lipase thiu hoc b bt hot do cc bnh ca ty tng hoc hi chng Zollinger - Ellisson. 2.1.2. Do gim nng mui mt/rut Cc bnh gan. Lon khun ng rut. Gin on tun hon gan rut ca mui mt trong bnh Crohn hoc phu thut ct ileum. Lm dng thuc neomycin, calci carbonat, cholestyramin. 2.1.3. Do gim b mt hp thu Phu thut ct b rut hoc ni bypass. Phu thut ni thng d dy - hi trng (gastro-ileotomy). 2.1.4. Do tc h bch dch ca mc treo rut Bnh intestinal lymphangiectasy. Lymphoma trong bng. 2.1.5. Do ri lon h tim mch Vim mng tim co tht. Suy tim huyt. Suy tun hon mc treo rut. 2.1.6. Do tn thng nim mc rut Do nguyn nhn vim nhim: bnh Crohn, amyloidosis, scleroderma, lymphoma, vim rut do tia x, vim rut tng eosinophil, tropical sprue, 145

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bnh thng hn, bnh collagen, mastocytosis, dermatitis herpestiform.

bnh

Sprue,

bnh

Whipple,

Do ri lon di truyn hoc chuyn ho nh: celiac sprue, thiu men saccharidase, bnh hypogammaglobulin, abeta lipoprotein, bnh harnup, bnh Cystinuria v Monosaccharides malabsorption. 2.1.7. Do bnh ni tit Bao gm cc bnh: i tho ng, thiu nng ph gip trng, u nng tuyn gip, suy tuyn thng thn. 2.2. Theo y hc c truyn Khi nim v hi chng ri lon hp thu thuc phm tr chng h t v h lao m nguyn nhn c th do tin thin bt tc; hoc hu thin tht iu (do m thc hoc do ni thng) khin thn ho khng h tr cho t th; hoc t dng t n khng lm trn chc nng thng thanh ging trc a n h li thanh cc. V lu di tinh kh ng tng u cng kit m sinh ra chng h lao.
Tin thin bt tc Hu thin tht iu

Thn (ho)

T (th)

Ging trc

Thng thanh

H li thanh cc

Can Mt m, v kinh, co rt, vp b

Thn au trong xng, i m, yu mi 2 chn

Tm Hay qun

Ph Mt mi, on kh, da lng kh

T Tht teo, chn tay, bi hoi

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3. CHN ON NGUYN NHN V IU TR RI LON HP THU THEO YHH 3.1. Do hp thu khng y trong cc bnh gan mt Ngoi c im tiu phn m (steatorrhea), bnh nhn cn c nhng bnh l v xng nh osteomalacia (nhuyn xng) do thiu ht vitamin D v calci. 3.1.1. Chn on tiu phn m Nhum phn bng dung dch Soudan III. o lng m/phn: nu lng m > 14g/ngy l bt thng. Ung 14C triolein v o bnh l.
14 14

CO2/hi th /6h; nu lng

C triolein < 3,5% l

3.1.2. Chn on thiu ht vitamin D v calci/mu o nng vitamin D, calci v phosphat trong mu. Hng iu tr: cha bnh nguyn nhn, b sung vitamin D v calci bng ng chch. 3.2. Ri lon hp thu sau ct d dy (phng php Bilroth 1 v 2) Ngoi triu chng tiu phn m bnh nhn cn c triu chng thiu calci, thiu mu do thiu Fe v B12, tnh trng lon khun ng rut do thiu HCl. Hng iu tr: S dng cc men ty. Xc nh tnh trng lon khun ng rut bng cch cy dch hng trng, nu c >105 khm vi khun/1ml dch th iu tr bng khng sinh thch hp. B sung st, vitamin B12 v calci bng ng tim. 3.3. Do gim din tch hp thu ca rut Thng gp sau phu thut ct b on ileum hoc ileocecal. Ngoi triu chng tiu phn m, st cn, mt mi, ph dinh dng, bnh nhn cn c nhng du hiu lm sng do thiu ht cc loi vitamin v cc nguyn t vi lng. Hng iu tr: Bo m ch n 2500calo/ngy ch yu l ng v m, hn ch m < 40g/ngy. 147

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Cung cp cc loi vitamin, cc nguyn t vi lng v cc acid bo cn thit. S dng cc thuc chng co tht nh loperamid 2mg x 2 ln/ngy hoc cholestyramine 1/2 gi ung vo cc ba n nga tiu chy. S dng cc thuc chng tit HCl nh H2 antagonist hoc omeprazol (vi liu iu tr nh lot t trng) ngn cn tc dng bt hot dch ty ca HCl. S dng octreotid (mt cht ng phn ca somatostatin tc dng lu di) lm gim tiu chy vi liu 0,1mg, tim di da, ngy 1 ln. Bo m dinh dng bng ng truyn trong 6 thng u sau khi m. 3.4. Do lon khun ng rut T cc tn thng nh hp, l r, Blind-loop, ti tha hoc t cc nguyn nhn lm gim vn ng rut nh i ng, x cng b, gi tc rut nguyn pht. Hu qu ca lon khun ng rut l gim nng mui mt trong rut, phn hy B12 v cc protein b bn chi rut, lm tn thng cu trc nhung mao rut v phn hy cc men maltase, sucrase ca rut. Phng php chn on nhm mc ch: Chn on thiu men maltase, sucrase bng test hi th vi lactose hoc 14 C xylose. Chn on lon nhim khun ng rut bng cch cy dch t trng hoc hng trng nu > 105 khm VT/1ml dch l dng tnh. Hng iu tr: S dng khng sinh thch hp lin tc 2 - 3 tun mi thng v tip tc cho n khi xt nghim bnh thng. 3.5. Hi chng gi tc rut nguyn pht C th do bnh l thn kinh c ni tng hoc do th pht sau cc bnh collagen, amyloidosis, i ng, suy tuyn ph gip, bnh Chagass, ung th phi t bo nh, ti tha hng trng do phng php gii phu Bypass rut hoc do lm dng cc thuc narcotic v nhm chng trm cm 3 vng (tricyclic). Bnh nhn ngoi cc du hiu nh gin thc qun, gin d dy, cn c nhng triu chng do ri lon vn ng rut nh nn i, au chng bng, to bn xen k tiu chy v nhng cn tc rut m khng tm thy nguyn nhn c hc. Nhng xt nghim c th gip chn on nguyn nhn do cc bnh collagen, amyloidosis hoc bnh Chagas l sinh thit rut non. 148

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Hng iu tr: Gii quyt triu chng bng cisaprid 5 - 10mg x 3 ln/ngy. 3.6. Tropical sprue Chim t l 5 - 10% dn s vng nhit i (Nam n, Phi Lut Tn ) C th do suy dinh dng hoc nhim trng nhim c. Triu chng l biu hin ca thiu Fe, B12, folat, tiu phn m, gim hp thu xylose (cho bnh nhn ung 25g D. xyclice, nu sau 2 gi lng xylose trong mu < 30mg hoc sau 5 gi lng xylose < 4g trong nc tiu l bt thng). Chn on xc nh khi: Tropical sprue ch c chn on (+) khi khng tm thy s hin din ca bo t hoc dng bo ca cc loi k sinh trng trong 3 mu phn xt nghim. Sinh thit: + Thay i cu trc ca cc nhung mao rut. + S tp trung cc bch cu n nhn lp lamina propia. Nhng ngi c triu chng tiu chy ko di km theo nhng du hiu ca suy dinh dng (malabsorption) vn tng sng nhng vng nhit i nh Nam n, Phi Lut Tn v qun o Caribean. Hng iu tr: Sulfonamide hoc tetracyclin. Acid folic. Dng lin tc trong 6 thng, cc triu chng s c ci thin t 1 - 2 tun. 3.7. Sclero derma Do gim vn tnh rut a n lon khun kt hp vi tn thng thnh rut v thiu mu nim mc rut. Triu chng ch yu l tiu phn m chim 1/3 trng hp ngoi cc biu hin sang thng da. Sinh thit rut non cho thy c hin tng ho si quanh tuyn Brunnel. Hng iu tr: Cisaprid 10mg x 3 ln/ngy ung. Erythromycin 500mg x 4 ln/ngy ung chng lon khun rut cho n khi cy phn bnh thng. 149

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3.8. Ri lon hp thu do bnh AIDS Vi biu hin nhim khun rut v sarcom kaposi rut non. Triu chng chnh l: tiu phn m, ri lon hp thu xylose v gim Zn /mu. iu tr bng cch gii quyt triu chng, iu tr tiu chy bng octreotid 0,1mg tim di da, ngy 3 ln. 3.9. Do tc h bch mch rut non 3.9.1. Bnh Whipple Vi biu hin au khp, au bng, a chy, st cn, tiu phn m, st, tng sc t da, hch ngoi vi sng to, suy tim, vim ni tm mc, vim mng b o kt mc, l ln, tn thng cc dy thn kinh s no, gim albumin mu v thiu mu m nguyn nhn l do trc khun Gram (+) Tropheryma whippelii. Chn on xc nh: Sinh thit rut non cho thy i thc bo nhum PAS (+) cha trc khun T. Whippelii cng vi s hin din trc khun trong mu mu c cy.

Hng iu tr: S dng bactrim liu cao trong 1 nm nhng t l ti pht rt cao 40%, trong trng hp ti pht, c bit nhng bnh nhn b l ln c th s dng n chloramphenicol. 3.9.2. Intestinal lymphoma Loi nguyn pht xy ra nam gii > 50 tui. Bnh nhn b suy dinh dng vi: Triu chng lm sng v sinh thit ging nh celiac sprue. 150

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au bng + st. Tc rut. Chn on xc nh: Sinh thit rut non cho thy lp lamina propia tm nhum bi cc t bo ging lymphoma v tng bi tit IgA. Hng iu tr: Gii phu hoc x tr. Bnh nhn sng t 4 thng - 4 nm; cht v thng rut, chu mu, tc rut. 3.10. Do mt protein qua ng rut Mt protein qua ng rut do nhng c ch sau y: Do nim mc rut b vim lot: vim lot i trng, ung th t bo tuyn d dy - rut, bnh Menetriez, lot d dy-t trng. Do nim mc rut b tn thng: celiac spue. Do ri lon dng bch dch a n tt nghn: cc nguyn nhn gy ph i hch bch huyt trong bng. Vim tht mng ngoi tim, suy tim huyt, suy tun hon mc treo, bnh valve tim bn phi. Chn on xc nh: Ph ton thn gia albumin v globulin/mu m khng c bnh thn hoc gan i km. Gim lympho bo trong cc nguyn nhn gy cn tr dng bch dch. Da vo s bi tit albumin c gn ng v phng x 125I hoc 51Cr, nu bi tit qua phn > 2% hoc > 4% trong 24 - 48 gi l bt thng. o lng 1 antitrypsin bi tit theo phn (nu > 2,6mg/1g phn l bt thng) nhng khng c dng nh gi cc tn thng d dy bi v 1 antitrypsin s b phn hu trong mi trng acid. Hng iu tr: cha bnh nguyn nhn. 3.11. S khim khuyt chc nng nim mc rut 3.11.1. Bnh Crohn Hu qu l ri lon tun hon gan rut ca mui mt, l mt tnh trng lon khun ng rut cng nh lm tn thng nim mc rut v thnh rut a n mt protein qua rut. Triu chng ch yu l tiu phn m, h calci mu, h B12 v albumin trong mu. 151

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Chn on xc nh: sinh thit hi trng cho thy nhng granulomatous (u ht). Hng iu tr: bng sulfasalazin, glucocorticoid v c ch min dch nh imuran. 3.11.2. Chronic non-granulomatous ulcerative jejunoileitis Vi triu chng au bng, st, st cn, tiu chy, tiu phn m v gim albumin mu. Chn on xc nh: sinh thit hng - hi trng (ileo jejunum) cho thy nhng du hiu nh bnh Crohn v Celiac sprue. Hng iu tr: iu tr bng glucocorticoid. 3.12. Vim rut do x tr Tnh trng a chy v suy dinh dng c th xy ra sm hoc mun sau vi nm x tr. Chn on xc nh: tiu phn m 10 - 40g/ngy, sinh thit rut non cho thy gin n h bch dch v lacteal trong lp lamina propia, cc nhung mao c hnh nh di trng (hnh nh ca intestinal lymphansiectasy). Hng iu tr: tr sinh, men ty, glucocorticoid, opium v king c thc n c cha gluten. 3.13. Eosinophilic enteritis Tn thng nim mc rut vi triu chng thiu st, tiu phn m, gim ALB mu v d ng mt s thc n. Tn thng lp c trn: X quang cho thy s dy cng, mt v mm mi ca d dy v rut cng hnh nh hp mn v. Tn thng lp thanh mc: c chng vi nhiu bch cu eosin trong dch c trng. Chn on xc nh: sinh thit: tm nhum cc bch cu eosin lan to hoc thnh di cc lp lamina propia v di nim mc. 152

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C s tng IgE trong huyt thanh. Hng iu tr: Nu tc rut phi gii phu v dng corticoid. 3.14. Cc bnh vim da a n ri lon hp thu (tiu phn m) C th k n vy nn, vim da dng chm v vim da dng Herpes. Chn on xc nh: Sinh thit cho thy cc nhung mao rut b dt. Tng HLA A1 v B8. Hng iu tr: Sulfure cha bnh ngoi da, cha chng tiu phn m ch bng ch n king cht gluten. 3.15. Cc bt hng sinh ho hoc di truyn 3.15.1. Celiac sprue Bnh thng xut hin ngi chu u vi nhng triu chng: st cn, y trng bng, tiu chy, tiu phn m, ngoi ra mt s bnh vim da dng Herpes v sau s pht trin thnh celiac sprue. Tuy cha bit nguyn nhn nhng c 3 yu t lin quan r rt n bnh: Cht gliadin l mt thnh phn ca gluten (hin din trong la m, go) s gy tn thng nim mc rut d c a vo ng trc trng.
Herpesti

Celiac Sprue

Yu t t nhim vi s hin din ca khng th IgA antigliadin v antiendomysial. Ngoi ra vic iu tr bng prednisolon trong 4 tun s lm thuyn gim mc d bnh nhn vn tip tc s dng cc thc phm c gluten. Yu t di truyn: bnh xut hin trn nhng ngi c HLA - DQ2.

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Hnh nh sinh thit A. Bnh thng; C. Celiac sprue ( iu tr); B. Celiac sprue (trc iu tr); D. Intestinal lymphangiectasia

Chn on xc nh: Da vo: Sinh thit cho thy cc nhung mao rut ngn hoc bin mt, gim sn cc ct nhung mao, tn thng b mt biu b v tm nhum bch cu n nhn. Ri lon hp thu xylose. Nhng biu hin lm sng sinh ho v sinh thit s ci thin sau khi king n thc phm c cha gluten. Hng iu tr: 80% s p ng tt vi ch n king gluten, nu khng kt qu c th do suy ty, lot hng hi trng, collagenous, sprue v intestinal lymphoma. Vic s dng glucocorticoid hoc 6 - mercaptopurine vn cn bn ci. Bin chng: Tin trin thnh cc khi u tn sinh ng tiu ho hoc lymphoma rut non, c bit l nhng trng hp khng p ng vi ch n khng c gluten. Tin trin thnh bt tr hoc collagenous sprue vi tin lng rt xu.

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3.15.2. Systemic mastocytosis Chn on xc nh: Sinh thit cho thy lp lamina propia tm nhum mastocyt. Test xylose (+). Test schilling (+). 30% trng hp a ti ri lon hp thu. Hng iu tr: cha tiu chy bng H1 v H2 antagonist cng vi cromolyn. 3.15.3. Thiu ht men lactase C th nguyn pht hoc th pht sau cc bnh Tropical sprue, bnh Crohn, nhim khun rut, nhim Giardiase, thiu beta lipoprotein, Cystic fibrosis, vim lot i trng. Bnh c triu chng sau khi dng sa s y trng bng, au qun bng v tiu chy. Chn on xc nh: Test hi th o nng hydrogen sau khi ung 50g lactose. Hng iu tr: 70% p ng ng vi ch king sa v ch phm t sa. 30% khng p ng v c km hi chng rut gi kch ng. 3.16. Ri lon hp thu th pht do cc bnh ni tit v chuyn ho Nn cha theo nguyn nhn. 3.17. Carcinoid syndrom do c ch tng tit serotonin Bnh ny gy tiu chy, tiu phn m. Hng iu tr: Methyl sergid 8 - 12mg/ngy. 3.18. Gin h bch dch rut non Vi hi chng ph (c khi ch 1 chn b ph), trn bch dch vo xoang bng (chylous ascite) v a chy. Chn on xc nh: Sinh thit: gin n h bch mch v lacteal lp lamina propia nhung mao rut c hnh di trng. Sinh ho: gim ALB, IgG, IgA, IgM, transferin, xeruloplasmin.

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Huyt hc: a phn m 40g/ngy, gim calci mu, gim B12, gim lymphocyt, tng bi xut 131 iod labelled AlB/phn. Hng iu tr: Ch n t m (medium chain fatty acid). 4. CHN ON V IU TR CC TH LM SNG CA hi chng RI LON HP THU THEO YHCT 4.1. T bt kin vn Triu chng: ngi mt mi, chn n, i chy sng phn, sc mt nht nht km ph dinh dng, cht li nht bu, mch nhu hon. Php tr: kin t tr vn, nhm mc ch + Kch thch tiu ho bng cch tng tit dch v nh trn b, sa nhn. + iu ho nhu ng v trng lc rut gim au bng, tiu chy nh: ng sm, bch trut, cam tho bc, sa nhn. + Gip tiu ho cc carbonhydrat: hoi sn. Bi thuc tiu biu: T qun hoc Sm linh bch trut tn. Phng dc: T qun gia hoi sn, d sao.
V thuc Bch trut ng sm Phc linh Trn b Sa nhn Hoi sn sao d sao Chch cam tho Dc l Ngt, ng, m; vo t v: kin t, to thp Ngt, bnh: b dng t v Ngt, nht, bnh; vo tm, t, ph, thn: thm thp, kin t ng, cay, m: ho m, to thp, hnh kh, ho v V cay, m: hnh kh, ho thp, n trung, ch t Ngt, m: ch kh, dng m, b t ph Ngt, hi lnh: kin t, thm thp Ngt, bnh; vo 12 kinh: b kh, hon trung, gii c Liu 12g 12g 8g 8g 6g 12g 12g 6g Vai tr Qun Thn Thn Thn Thn Thn Thn T, S

+ Nu bnh nhn b ri lon hp thu do cc nguyn nhn lm gim vn tnh ca rut nh i ng, x cng b, hi chng gi tc rut mn tnh th nn b cam tho bc v tng liu ng sm, bch trut ln 20g. + Nu bnh nhn b ri lon hp thu do cc thiu men lactase hoc sucro isomaltase nn tng liu hoi sn, d sao ln 30g.

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+ Nu bnh nhn b ri lon hp thu do cc bnh Crohn, do nhim x, do eosinophilic enteritis, vim da, Celiac Sprue v mastocytosis th nn tng cng cc thuc c ch min dch nh cam tho bc ln 40g. 4.2. T thn dng h Triu chng: thng bt u a chy, au bng t sng sm, phn tanh sng, bng trng y, tay chn lnh, mch trm t nhc. Php tr: n b mnh mn tr t th nhm mc ch + Kch thch hot ng ca v thng thn, gip tng sinh tit v pht trin cc t bo bn chi (brush cell) rut non nh ph t ch, cam tho bc. + iu ho nhu ng rut v trng lc rut nh ng sm, bch trut, ph c ch. + Tng bi tit dch v v li mt nh nhc u khu, can khng, ng v t. + Chng ln men y hi nh ng th du. + Bi thuc bi thuc c cha tinh du nn c tc dng khng khun ng rut. Phng dc: Ph t l trung + T thn thang
V thuc Ph t ch Nhn sm Can khng Bch trut Ph c ch Ng th du Nhc u khu Ng v t Cam tho sao Tc dng Cay, ngt, rt nng: n b mnh mn Ngt, hi ng, bnh: b nguyn kh, nguyn dng Cay, m: tr hn, tr dng Ngt, ng, m; vo t v: kin t, to thp Cay, ng: b mnh mn tng ho Cay, ng, m, hi c: n trung, ch t Cay, m, hi c: n t sp trng Chua, mn, m: n b ng tng Ngt, bnh: b trung kh, ho hon dc tnh Liu 8g 12g 6g 12g 12g 6g 6g 6g 6g Vai tr Qun Thn Thn Thn Thn Thn Thn Thn T

+ Bi thuc ny thch hp cho vic iu tr cc ri lon hp thu do lon khun ng rut (bacterial over growth ), do bnh Whipple. + Nu ri lon hp thu do cc bnh min dch nh Crohn, x tr, eosinophylic enteritis, systemic mastocytocis nn tng liu ph t ch 20g, cam tho bc 40g. 157

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+ Nu ri lon hp thu sau ct b d dy hoc gim b mt hp thu (do ct b rut) nn gim hoc b cc thuc gy bi tit dch v nh can khng, nhc u khu.

T lng gi 1. Triu chng tiu ho no sau y khng do ri lon hp thu a n A. au bng B. Snh bng C. Vim li D. To bn E. Tiu chy 2. Triu chng huyt hc no sau y khng do ri lon hp thu a n A. Thiu mu huyt tn B. Thiu mu thiu B12 C. Thiu mu thiu st D. Chy mu t nhin E. Ban xut huyt di da 3. C ch bnh sinh ca ri lon hp thu trong hi chng Zollinger Ellisson l do A. Lon khun ng rut B. Thiu ht men lipase C. Bt hot men lipase D. Gin on tun hon rut ca mui mt E. Gim nng mui mt trong rut 4. C ch bnh sinh gy ri lon hp thu trong bnh Crohn l do A. Tc h bch dch mc treo rut B. Tn thng nim mc rut C. Gim b mt hp thu ca rut D. Thiu ht men lipase E. Bt hot men lipase

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5. C ch bnh sinh gy ri lon hp thu trong bnh Sprue l do A. Tn thng nim mc rut B. Thiu ht men lipase C. Bt hot men lipase D. Lon khun rut E. Gim nng mui mt trong rut 6. Trong chng h t, ri lon cng nng thuc tng no l chnh A. Thn B. T C. Tm D. Ph E. Can 7. chn on triu chng tiu phn m (steatorrhea) ngi ta dng phng php A. o nng vitamin B12 trong nc tiu B. Secretin test C. o nng 14 CO2 trong hi th sau khi ung 14 C triolein D. o nng 14 CO2 trong hi th sau khi ung 14 C xylose E. o nng H2 trong hi th sau khi ung 50g lactose 8. Trong ri lon hp thu sau ct d dy, tnh trng no sau y xy ra do thiu HCl A. Tiu phn m B. Thiu calci mu C. Thiu mu thiu st D. Thiu mu thiu B12 E. Lon khun ng rut 9. Trong ri lon hp thu do lon khun ng rut, men tiu ho no sau y s b thiu ht A. Lipase B. Amylase C. Maltase D. Saccharidase E. Peptidase 159

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10. chn on thiu ht men sucrase ngi ta dng phng php no A. o nng 14 CO2 trong hi th sau khi ung 14C xylose B. o nng 14 C trong hi th sau khi ung 14 C triolein C. o nng H2 trong hi th sau khi ung 10g lactulose D. o nng H2 trong hi th sau khi ung 50g lactose E. Cc phng php trn 11. Chn on xc nh lon khun ng rut l khi cy dch hng trng cho thy A. < 105 nhm vi trng/1ml dch B. 105 nhm vi trng/1ml dch C. < 104 nhm vi trng/1ml dch D. < 103 nhm vi trng/1ml dch E. < 102 nhm vi trng/1ml dch 12. Hi chng gi tc rut nguyn pht do lm dng cc thuc no sau y A. Tr sinh B. Calcicarbonat C. Cholestyramin D. Thuc chng trm cm 3 vng E. Tt c cc thuc trn 13. Chn on xc nh bnh Tropical sprue l khi bnh nhn c A. Thiu mu thiu st B. Thiu mu thiu B12 C. Thiu mu thiu folat D. Tiu phn m E. Nng 14 CO2 trong hi th u gim khi ung 14 CO2 triolein v C. xylose
14

14. Chn on ri lon hp thu do x cng b bng sinh thit rut non cho thy A. Lp lamina propia tm nhum i thc bo cha cc glucotrotein nhum PAS (+) B. Ho si quanh tuyn Brunnel

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C. Lp lamina propia tm nhum cc t bo ging lympho v tng bi tit IgA D. Cc u ht E. Cu trc nhung mao bnh thng, t bo biu b cha u khng bo 15. Chn on xc nh ri lon hp thu do bnh Whipple bng sinh thit rut non cho thy A. Lp lamina propia tm nhum i thc bo cha cc glucotrotein nhum PAS (+) B. Ho si quanh tuyn Brunnel C. Lp lamina propia tm nhum cc t bo ging lympho v tng bi tit IgA D. Cc u ht E. Cu trc nhung mao bnh thng, t bo biu b cha u khng bo 16. Ri lon hp thu trong bnh Intestinal lymphoma c th c chn on qua sinh thit rut non vi hnh nh cho thy A. Lp lamina propia tm nhum i thc bo cha cc glucotrotein nhum PAS (+) B. Ho si quanh tuyn Brunnel C. Lp lamina propia tm nhum cc t bo ging lympho bo v tng bi tit IgA D. Cc u ht E. Cu trc nhung mao bnh thng, t bo biu b cha u khng bo 17. Bnh l no sau y khng gy mt protein qua rut A. Vim tht mng ngoi tim B. Suy tim huyt C. Cardiac tamponade D. Suy tun hon mc treo E. Cc cu trn 18. Chn on ri lon hp thu trong bnh Celiac sprue da vo A. Ri lon hp thu lactose B. Ri lon hp thu xylose 161

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C. Ri lon hp thu triolein D. Ri lon hp thu maltose E. Ri lon hp thu saccharose 19. Chn on ri lon hp thu do thiu men lactase da vo A. o nng 14 CO2 trong hi th sau khi ung 14 C xylose B. o nng 14 C trong hi th sau khi ung 14 C. triolein C. o nng H2 trong hi th sau khi ung 10g lactulose D. o nng H2 trong hi th sau khi ung 50g lactose E. Cc phng php trn 20. Triu chng no sau y khng xut hin trong th lm sng t bt kin vn A. Ph dinh dng B. i chy sng phn C. Chn n D. Ng canh t E. Mch nhu hon v lc 21. Triu chng no sau y khng xut hin trong hi chng t thn dng h A. Ng canh t B. Phn tanh sng C. Bng y trng D. Tay chn lnh E. Mng tinh 22. Tc dng dc l no sau y khng thuc php kin t tr vn A. Tng tit dch v B. iu ho nhu ng rut C. iu ho trng lc rut D. Gip tiu ho tinh bt E. Kch thch v thng thn 23. Bi thuc T qun gia hoi sn, d nn bi thm v no nhm mc ch lm tng vn tnh ca rut A. ng sm, bch trut 162

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B. Hoi sn, d sao C. Cam tho bc D. Phc linh E. Cc v trn 24. Bi thuc T qun gia hoi sn, d nn bi thm v no thay th cho s thiu ht men lactase A. ng sm, bch trut B. Hoi sn, d sao C. Cam tho bc D. Phc linh E. Cc v trn 25. Bi thuc T qun gia hoi sn, d nn bi thm v no c tc dng c ch min dch A. ng sm, bch trut B. Hoi sn, d sao C. Cam tho bc D. Phc linh E. Cc v trn 26. Tc dng dc l no sau y khng thuc php tr n b mnh mn, tr t th A. Kch thch hot ng v thng thn B. iu ho hot ng nhu ng rut C. Tng tit dch v D. Gip tiu ho carbonhydrad E. Chng y hi 27. Bi thuc Ph t l trung v T thn thang (gm ph t ch, ng sm, bch trut, can khng, cam tho bc, ph c ch, ng th du, nhc u khu, ng v t) nn bi thm v no c tc dng c ch min dch A. Ph t ch, cam tho bc B. Can khng, nhc u khu C. Ng th du, ph c ch D. Bch trut, ng sm E. Ng v t, ng sm 163

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28. Bi thuc Ph t l trung v T thn thang (gm ph t ch, ng sm, bch trut, can khng, cam tho bc, ph c ch, ng th du, nhc u khu, ng v t) nn bi thm v no trong trng hp ri lon hp thu do ct b rut A. Ph t ch, cam tho bc B. Can khng, nhc u khu C. Ng th du, ph c ch D. Bch trut, ng sm E. Ng v t, ng sm 29. Bi thuc Ph t l trung v T thn thang (gm ph t ch, ng sm, bch trut, can khng, cam tho bc, ph c ch, ng th du, nhc u khu, ng v t) c th dng c trong ri lon hp thu do gim vn tnh rut v do tc dng dc l ca cc v thuc A. Ph t ch, cam tho bc B. ng sm, bch trut C. Ng th du, nhc u khu D. Can khng, cam tho bc E. Ng v t, cam tho bc 30. Bi thuc Ph t l trung v T thn thang (gm ph t ch, ng sm, bch trut, can khng, cam tho bc, ph c ch, ng th du, nhc u khu, ng v t) nn b cc v no nu dng trong ri lon hp thu do ct b hng - hi trng (ileocecal) A. Nhc u khu, can khng B. Cam tho bc, ng th du C. Ph t ch, cam tho bc D. ng sm, bch trut, ph c ch E. Ph t ch, ng sm, ng th du

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Bi 10

HI CHNG I TRNG KCH NG


(IRRITABLE BOWEL SYNDROM)

MC TIU 1. Lit k c nhng yu t c lin quan n vic khi pht hi chng i trng d kch ng. 2. Trnh by c c ch bnh sinh ca hi chng ny theo YHCT. 3. Lit k c nhng tiu chun hng n chn on hi chng i trng d kch ng. 4. Trnh by v phn tch nhng bin php cn thc hin chn on xc nh hi chng i trng d kch ng. 5. Trnh by nhng th lm sng ca chng i trng d kch ng theo YHCT. 6. Lit k tc dng dc l ca nhm thuc trong iu tr hi chng ny theo YHH. 7. Lit k tc dng dc l ca cc php tr hi chng ny theo YHCT. 8. ra c mt php tr thch hp cho tng th lm sng.

1. NH NGHA Hi chng i trng d kch ng l mt ri lon vn ng ca d dy rut c biu hin bng s thay i thi quen i cu cng vi au bng m khng h pht hin c mt tn thng thc th no. L mt hi chng kh ph bin cc bnh nhn trong tui 30 - 40, t l 10 - 22% dn s, chim khong 25 - 50% s bnh nhn n khm ngoi tr cc chuyn khoa tiu ha vi t l n mc bnh gp 2 ln nam gii 2. C CH BNH SINH 2.1. Theo y hc hin i Ngi ta khng tm thy mt tn thng thc th no i trng ca bnh nhn, ngoi tr mt tnh trng ri lon vn ng i trng. iu c bit l ngi ta nhn thy hi chng i trng d kch ng c lin quan n: 165

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Tng cm gic nhn thc ni tng do ri lon iu ho cm gic nhn thc gia vng trn trc v v khu - hi m truc. Mt trng thi ri lon nhn cch: trm cm, u lo, lon thn kinh hysteria hoc lm dng tnh dc xy ra trong 80% trng hp. S tng nng prolactin/mu, c bit ph n trong chu k kinh nguyt. Mt trng thi cm ng c bit i vi cholecystokinin. 2.2. Theo y hc c truyn Nhng khi nim v hi chng i trng d kch ng thuc phm tr chng phc thng, trng mn, xn tit, b kt v tm hy m yu t khi pht thng do tnh ch tht iu a n can kh ut kt khin cho cng nng ging np v truyn tng ca v trng b ri lon hoc thc y tm ha vng ng a n hi hp bt an. Lu ngy, phn do lo u hoang mang v bnh tt, phn do n ung king khem khng ng cch khin cho tm t kh huyt lung h
TNH CH THT IU

CAN MC

V TRNG

TM HO

TRNG MN, PHC THNG, XN TIT, B KT

TM HY

LO U, M THC THT THNG

TM T LNG H

3. CHN ON 3.1. Theo y hc hin i Nn ngh n hi chng i trng d kch ng nu mt bnh nhn lin tc trong 3 thng lun lun c nhng triu chng hoc nhng t ti pht ca: 166

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Cn au xut hin h v (25%) hoc thng v (10%) vi tnh cht qun tht hoc m , hoc cm gic kh chu bng, m n s gim sau khi i cu. To bn (<3 ln/tun) hoc tiu chy (>3 ln mi ngy vi s lng di 200ml v thng gia tng khi c cng thng tm l hoc n mt thc n no 3) hoc i cu ra nhng cht nhy hoc c cm gic mt, trn nng hu mn khi i cu v i khng ht phn. Trng bng, y hi. 25 - 50% bnh nhn c ri lon tiu ho, nng rt sau xng c, bun nn, nn ma. ng trc mt bnh nhn nh vy, ngi thy thuc cn phi loi b: Nhng triu chng khng ph hp vi hi chng i trng d kch ng nh trong phn c mu, st cn, st, au bng hoc tiu chy xy ra trong m. Tnh trng lactose intolerance (bng hydugenheath test) hoc s lm dng cc cht sorbitol, fructose v cafein. Mt bnh chng tiu ho no khc nh: cc bnh vim i trng mn tnh, ung th i trng, sigmoid volvulus, megacolon, abdominal angina, ischemic colitis, idiopathic pseudoobstruction, ng phn i trng, nhim Giardiase lamblia v bnh ngoi h tiu ha nh Endometriosis. Tnh trng ng c porphyrin cp tnh hoc ng c ch nu to bn c au bng. ng thi phi: + Ch trng thi trm cm hoc ri lon cm xc c hay khng bnh nhn. + Truy tm thm cc bnh l khc nu qua khm thc th pht hin c mt du hiu lm sng no khc. + Thc hin mt s cc xt nghim thng quy sau y: Cng thc mu. Ni soi trc trng Sigma (trn nhng ngi 40 tui v nhng bnh nhn c tiu chy). Soi phn tm KST ng rut, ht m v bch cu, kho st chc nng tuyn gip, tuyn ph gip trn ngi b to bn v sinh thit i trc trng nu bnh nhn b tiu chy l chnh.

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Nhng bng chng chng li chn on mt hi chng i trng kch ng l: Thiu mu Tc lng mu tng C bch cu hin din trong phn Khi lng phn nhiu hn 200ml/ngy 3.2. Theo y hc c truyn Cc hi chng i trng d kch ng c phn lm 2 th lm sng sau y: 3.2.1. Can kh ut kt Vi triu chng lo u, xc ng hay than th nhiu v bnh tt km vi triu chng bng y trng sau khi n, au bng vi cm gic qun tht v gim sau khi i xong, bnh nhn thng to bn hoc xen k vi tiu chy v tiu chy nu c thng xy ra sau khi n phi mt s thc n. Cc t ti pht thng xy ra khi gp phi nhng stress tm l. Khm thng thy ru li vng, ra li , mch huyn 3.2.2. Tm t lng h Mt mi, v lc, mt ng hoc thng hay chim bao mng m. Bnh nhn thng km n, bng y chng ngay sau khi n, thng xuyn au bng m m h km i tiu phn nhy nht khng thnh khun. n thc n no khc l cng c th lm khi pht cn au. Thng s lnh, khm thy li nht bu, ru nht, tay chn lnh, mch nhu t. 4. IU TR 4.1. Theo y hc hin i To c mt tm l hp tc cng nh xo b nhng hoang mang, lo s ni ngi bnh bng cch gii thch cho h bit v bnh tt ca h: iu tr nhng ri lon tm thn nh: trm cm, anxiety - disorder, hysteria. Chn cho bnh nhn mt ch n ung ph hp, khng lm khi pht cn au cng nh khng king khem n mc gy thiu dinh dng (denutrition). 168

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Dng dc phm gii quyt triu chng, c th nh sau: + Nu au l triu chng ni bt, c th s dng nhm chng co tht nh: Dicyclomin 10mg - 20mg x 3 - 4 ln/ngy. Hoc cimetropium bromid 50mg x 3 ln/ngy. C th ung trc ba n 30 pht vi nhng cn au khi pht sau khi n. + Nu tiu chy l triu chng ni bt, c th s dng: lomotil 2,5 - 5mg mi 4 - 6 gi hoc nhm tricyclic chng trm cm nh desipramin 50mg x 4 ln/ngy s c th ci thin c triu chng au bng v tiu chy. Cc thuc chng trm cm kiu selective serotonin reuptake inhibitor cha c chng minh r rng. + Nu to bn l triu chng ni bt c th s dng cc dc phm dn xut t psyllium. + Kt hp vi ch n nhiu rau (tr bp ci, legumes), ng cc, tinh bt. King cc thc n ngt, nc ung c gas. + Nu triu chng hi hp, lo u l chnh nn s dng cc loi benzodiazepin chng lo u. V gn y dc phm leuproreline (mt cht ng phn ca luiteinising hormon - releasing hormon) cng nh fedotozin (cht ng phn ca Kappa opoid) v aloseton hoc octreotid (serotonin receptor antagonist) ang c nghin cu, c xem l c ci thin ng k cc triu chng ca IBS (hi chng rut gi d kch ng). 4.2. Theo y hc c truyn 4.2.1. S can, kin t (th can, vn t) Dng phng php ny vi mc ch: + An thn. + Chng co tht c trn tiu ha. + Kch thch tiu ho. Bi thuc tiu biu: Tiu dao tn, Si h s can thang C th trong trng hp can kh ut kt ta c th dng bi Tiu dao gia gim

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V thuc Si h Bch trut Bch linh Bch thc Hong cm Bc h Trn b Gng ti Ut kim Ch xc Cam tho bc

Tc dng ng, hn: s can l kh, gii ut Ngt, ng, m: kin t, to thp, an thn Ngt, nht, bnh: thm thp, kin t, an thn ng, chua, lnh: dng huyt, lim m ng, lnh: thanh thp nhit, ch t l Cay, mt: thanh tit can nhit Cay, ng, m: l kh, iu kinh Cay, hi m: ho t v Cay, ng, n: hnh kh gii ut ng, chua, hn: tiu tch, tr b B trung kh, ho hon dc tnh

Liu 12g 12g 12g 12g 12g 8g 6g 6g 6g 6g 8g

Vai tr Qun Thn Thn Thn Thn Thn Thn Thn Thn Thn T

Ngy dng 1 thang. + Nu bnh nhn lo lng, d xc ng bi si h 20g, bch linh 20g. + Nu bnh nhn au nhiu bi bch thc, cam tho mi th 20g. + Nu y chng bng, to bn nn gim bch linh 6g, gia ch thc 8g. + Nu tiu chy nhiu nn bi bch trut 20g. Chm cu: chm t ni quan, thn mn, thi xung, thin xu; chm b can du, trung qun, tc tam l.
Tn huyt Ni quan Hnh gian Thiu ph Thin xu Can du Trung qun Tc tam l C s l lun Giao hi huyt ca tm bo v mch m duy Hunh ho huyt ca can Hunh ho huyt ca tm M huyt ca i trng Bi du huyt M huyt ca v Huyt c hiu ca vng bng Tc dng Cha chng bt rt, tm phin Bnh can mc Thng tin, nhun h T can m Cha phc thng tr b mn

4.2.2. Kin t, dng tm Dng phng php ny vi mc ch: + An thn, chng lo u. 170

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+ Tng cng chuyn ho glucid, protid, cha mt mi. + iu ho nhu ng rut gi. Bi thuc tiu biu: Quy t thang
V thuc To nhn Phc thn Hong k Bch trut Nhn sm ng quy Mc hng Vin ch i to Dc l Ngt, chua, bnh: dng tm an thn, sinh tn dch Tit tm nhit, bnh n tm thn Ngt, m: b tm kh, thng dng kh ca t Ngt, ng, hi m vo t v: kin t, to thp, cm m hi Ngt, hi ng: b tm kh, thng dng kh ca t Ngt, n, hi cay: b huyt, hnh huyt Hnh kh ch thng, kin t ng, m: nh tm, an thn Ngt, bnh: b trung, ch kh, ho hon dc tnh Liu 8g 8g 12g 12g 16g 12g 6g 8g 12g Vai tr Qun Qun Thn Thn Thn T T T T

Chm cu: chm b t du, v du, tc tam l, tam m giao, ni quan, thn mn
Tn huyt T du V du Tc tam l Trung qun Tam m giao Ni quan Thn mn C s l lun Du huyt ca t Du huyt ca v Huyt c hiu ca vng bng M huyt ca v M huyt ca i trng Giao hi huyt ca tm bo v mch m duy Du th huyt ca tm Kin t Kin v Cha phc thng, tr b mn Thng tin, nhun h Cha chng bt rt, tm phin Ging ho Tc dng

+ Chm b: thn mn, ni quan 15 pht. + Cu b hoc n chm: t du, v du, tc tam l, trung qun, tam m giao mi huyt 5 pht.

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T lng gi 1. Yu t no sau y khng lin quan n vic khi pht hi chng i trng d kch ng A. Trng thi tm l B. Lon thn kinh chc nng C. Ch n ung D. Nng prollactin mu E. Cholescystokinin 2. Theo c ch bnh sinh ca YHCT, tng ph no s b ri lon cng nng trong chng i trng d kch ng

A. Can t thn
B. Tam can thn C. Tm can t D. Can ph thn E. Ph t thn 3. Triu chng no sau y khng c trong tiu chun hng ti chn on hi chng i trng d kch ng A. Phn nhy mu B. au bng C. To bn D. Tiu chy E. Trng bng 4. Phng php cn lm sng no sau y l khng cn thit trong chn on loi tr hi chng i trng d kch ng A. Soi phn tm KST ng rut B. Chp X quang i trng C. Cng thc mu D. Ni soi i trng - trc trng E. Sinh thit i trc trng 5. Triu chng no sau y khng c trong th can kh ut kt A. Lun xc ng B. y trng bng sau n C. To bn xen k tiu chy D. Tiu chy lc m sng E. Gim au bng sau khi i cu 172

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6. Triu chng no sau y khng c trong hi chng tm t lng h A. au bng m h m B. i tiu phn nhy nht C. Cn au khi pht do thc n D. Bng y chng sau n E. Gy m, st cn trm trng 7. Phng php iu tr no sau y khng dng cho bnh nhn b hi chng i trng d kch ng A. Liu php tm l B. Ch n ung hp l C. Gii quyt triu chng D. iu tr hi chng ri lon tm thn E. Ngh ngi tuyt i ti ging 8. Vi bi thuc Tiu giao gia gim trong th can kh ut kt, nu bnh nhn vn cn au bng, ta s tng liu A. Bch trut, phc linh B. Bch trut, ch thc C. Sinh khng, ut kim D. Bch thc, cam tho E. Si h, hong cm 9. Vi bi thuc Quy t gia gim trong th tm t lng h, nu bnh nhn vn cn y trng bng, ta s tng liu A. Long nhn, i to B. ng sm, bch trut C. Hong k, ng quy D. Phc linh, phc thn E. To nhn, mc hng 10. Vi bi thuc Quy t thang gia gim trong th tm t lng h, nu bnh nhn c hi chng trm cm i km ta c th cho thm A. Phc thn B. Hong k C. ng sm D. Vin ch E. Nhn sm

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Bi 11

VIM GAN MN tnh

MC TIU 1. Trnh by c c ch bnh sinh ca vim gan mn tnh do virus v vim gan t min. 2. Trnh by c c ch bnh sinh ca bnh vim gan mn tnh theo YHCT. 3. Trnh by c cc triu chng lm sng v cn lm sng chn on nguyn nhn vim gan mn tnh. 4. Trnh by c 4 th lm sng ca bnh vim gan mn tnh theo YHCT. 5. Lit k c cc phng php iu tr ca cc th lm sng vim gan mn tnh do siu vi v do t min. 6. Trnh by c tc dng dc l ca cc php tr bnh vim gan mn tnh theo YHCT.

1. NH NGHA Vim gan mn tnh l mt bnh bao gm mt lot nhng ri lon gan c nguyn nhn v mc trm trng khc nhau, trong hin tng vim v hoi t lin tc ko di trn 6 thng 2. PHN LOI Trc y da vo tnh cht khu tr hoc lan ta ca tn thng gan m ngi ta phn thnh 3 loi: Vim gan mn tnh tn ti (persitent hepatitis). Vim gan tiu thy (lobular hepatitis). Vim gan hot ng (active hepatitis). Nhng hin nay s phn loi li da vo: Nguyn nhn. Trng thi m hc (grade). Din tin (stage). 174

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Trong theo nguyn nhn c th c: Vim gan mn tnh do virus: virus vim gan B (HBV), virus vim gan D (HDV), virus vim gan C (HCV) hoc virus vim gan G (HGV). Vim gan mn tnh t min hoc khng r nguyn nhn (cryptogenic). Theo trng thi m hc:
Hnh nh m hc 1. Hoi t quanh khong ca (gm hoi t gm nhm (PN) v hoc hoi t bc cu (BN)) Mc Khng c PN nh PN va PN nng PN + BN trung bnh PN + BN nng Hoi t nhiu thu 2. Hoi t trong thy im 0 1 3 4 5 6 10

Khng c Nh Trung bnh Nng

0 1 3 4

3. Vim khong ca

Khng c Nh Trung bnh Nng

0 1 3 4

4. Ho si

Khng c Lan to quanh ca Ho si bc cu X gan

0 1 3 4 22

Theo din tin: Da trn s ho x, trong x gan c nh ngha l nhng di x bao quanh nhng nt ch m gan v cu trc tiu thy gan thay i

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Theo :

im 0 1 2 3 4

Tn thng Khng c hoi t ho si Ho si quanh ca nh Ho si quanh ca trung bnh Ho si bc cu X gan

Do so snh gia phn loi mi v c, hin nay ngi ta c s ng nht nh sau:


GRADE STAGE Khng hoc nh Nh Nh, trung bnh, nng

Vim gan mn tnh tn ti Vim gan mn tnh tiu thy

t hoc nh Nh hoc trung bnh

Vim gan mn tnh tin trin Nh, trung bnh, nng 3. C CH BNH SINH CA VIM GAN MN tnh 3.1. Theo y hc hin i

Trong phm vi bi ny chng ti khng cp n vim gan mn tnh do thuc, ch xin nhn mnh mt iu l khng phi tt c cc phn ng ph no gan do thuc cng u gy nn vim gan mn tnh. Chng ch c gi l vim gan mn tnh do thuc khi c nhng phn ng biu hin s tng mn cm nh st, ni mn, au khp, tng BC eosinophil (ch xy ra 25% trng hp) v cho d c biu hin hnh nh m hc nh th no i na th cng lun lun c hnh nh hoi t v gan ho m. 3.1.1. Vim gan mn tnh do virus i vi vim gan virus B s c 90% i tng nhim cp t lc s sinh v 1% i tng nhim cp t tui trung nin chuyn sang mn tnh. i vi vim gan virus C s c 50 - 70% i tng t nhim cp chuyn sang mn tnh. Tt c cc hnh nh m hc - sinh ho v lm sng s tr nn r rng v trm trng khi virus vim gan B, C v D ang trong giai on sao chp m di truyn (replicate) tng ng vi giai on chn on huyt thanh cho thy c HBeAg (+); HBV-DNA (+), HCVRNA (+), HDV-RNA (+) u tng. giai on ny cc hnh nh m hc s l hoi t v vim quanh khong ca, hoi t trong thy, ho si vi cc mc t trung bnh ti nng 176

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Ngc li nu vo giai on khng sao chp (non replicated) m di truyn th hnh nh m hc, lm sng v sinh ho thng nh, c khi bnh nhn ch trong trng thi ngi lnh mang bnh. c bit trong vim gan B s chuyn i t giai on sao chp xy ra khong 10% - 15% trng hp mi nm. 3.1.2. Vim gan t min Ngc li trong vim gan t min, hin tng vim v hoi t t bo gan xy ra lin tc a n s x ho v suy t bo gan. S tn cng min dch qua trung gian t bo m y tnh c hiu ca gan (t bo gan tr nn l antigen i vi t bo min dch) c khi pht sau khi dng thuc hoc b nhim mt loi virus no . Nhng bng chng sau y cho thy vim gan t min l mt loi bnh ri lon min dch qua trung gian t bo: S c mt ca tng bo v cytotoxic lympho trong gan. S c mt cc t khng th trong mu, yu t dng thp v tng globulin trong mu. C mt trong cc bnh ri lon min dch khc cng xut hin nh vim tuyn gip, vim khp dng thp, vim cu thn, thiu mu huyt tn min dch, Sjgren. S c mt cc khng nguyn tng hp m nh HLAB1, B, DRW3 - DRW4. Thng p ng tt vi corticoid. T bo lympho tr nn rt nhy cm vi protein ca mng t bo gan. Mt kim sot c ch iu ha min dch trn cc lympho bo gy c. Tuy nhin cc phn ng t min khng phi xy ra trong bt k lc no nn c th nhm vim gan t min vi vim gan khng r nguyn nhn. 3.2. Theo y hc c truyn Bnh vim gan mn tnh c YHCT khi qut trong phm tr cc chng hong n, hip thng i cng vi cc ri lon tiu ho m nguyn nhn c th do: Cm phi thp nhit t khin cho can kh ut kt khng s tit c m m sinh ra vng da. Do n ung khng iu , lao lc qu mc kt hp vi ung ru khin cho cng nng tiu ha ca t v b ri lon thp, thp ng lu ngy a n nhit, thp nhit ut kt sinh ra chng hong n.

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THP NHIT T

TU C

N UNG

LAO LC

Ut kt HIP THNG CAN

S tit T V Vn ho S tit

THP NHIT

HONG N

HONG N

4. CHN ON 4.1. Theo y hc hin i 4.1.1. Vim gan mn tnh do virus Biu hin lm sng c th t nh n nng nh mt mi, vng da dai dng hoc tng t. Ring trong vim gan mn tnh do virus C biu hin lm sng thng l m v ch tr nn nng trn nhng bnh nhn c nghin ru, c bnh nhim sc t st hemochromatosis hoc thiu 1 antitrypsin. Ngoi ra, nu trong vim gan mn tnh do virus B thng c cc triu chng ngoi gan do c ch phi hp khng th khng nguyn virus B nh vim khp, vim cu thn, vim nt a ng mch v vim mch mu kiu leukocytoclastic th trong vim gan mn tnh do virus C thng c cc triu chng ngoi gan khng do phc hp min dch nh hi chng Sjgren, liken phng, ri lon chuyn ha forpyrin biu hin da mun. V mt cn lm sng th SGPT tng t 100 - 1000UI v lun cao hn SGOT (ring vim gan mn tnh do virus C hoc khi vim gan virus B mn chuyn thnh x gan th ch s SGPT thp hn SGOT). Phosphotase tng nh hoc bnh thng. Bilirubin tng 3 - 10mg%. Albumin mu gim, thi gian prothrombin ko di xy ra trong giai on cui hoc nng. V sau cng chn on vim gan mn tnh do loi virus no, ta cn ch n mt s huyt thanh chn on sau y: 178

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+ chn on virus B ta dng n: HBsAg, IgG AntiHBC, HBeAg, HBV-ADN. + chn on virus vim gan C ta dng n: anti HCV, HCV-ARN. + chn on virus vim gan D ta dng n: anti HDV, HDV - ARN, HBsAg. Ngoi ra trong vim gan mn tnh do virus C cn c khng th anti LKM1 (anti kidney - liver microsomal) cng nh nhng bnh t min dch hoc hyper globulin li cho phn ng dng gi vi anti HCV v trong vim gan mn tnh do virus D cng c khng th anti LKM3. 4.1.2. Vim gan mn tnh do t min Thng xy ra ngi tr hoc ph n trung nin, hi chng lm sng gm c mt mi, kh chu, chn n, mt kinh, mn trng c, au khp, vng da. i khi li c vim khp, tn thng da kiu macula papular eruption hoc erythema nodosum, vim i trng, vim mng phi-mng tim, thiu mu, tng ur mu. Du hiu cn lm sng thng i i vi hnh nh m hc, trong : Transaminas dao ng t 100 - 1000UI. Bilirubin tng 3 - 10mg%. Phosphotase alkalin tng nh. globulin > 2,5g%. RF (+). Khng th khng nhn (ANA) dng tnh. Albumine v taux de prothrombin gim khi bnh din tin nng. Ngoi ra ngi ta cn phn bit: + Vim gan t min typ I: hay xy ra ph n tr c hyperglobulin v ANA (+). + Vim gan t min typ II: chia lm 2 typ nh IIA: xy ra ngi tr vi hyperglobulin, anti KLM1 (+) cao v p ng tt vi corticoid (hay gp chu u v Anh). IIB: xy ra ngi ln tui, vi globulin mu bnh thng, nhng anti KLM1 (+) thp, thng phi hp vi nhim virus vim gan C v p ng vi interferon. + Vim gan t min typ III: vi ANA (-) v anti KLM1 (-), ng thi c khng th tun hon chng li khng nguyn gan ho tan (solube liver antigen). 179

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4.2. Theo y hc c truyn 4.2.1. Can ut, t h Thng gp trong vim gan mn tnh tiu thu hoc giai on vim gan mn tnh tn ti chuyn sang vim gan mn tnh tin trin vi nhng triu chng au tc nng vng hng sn phi, ming ng, n km, ngi mt mi, i tin phn nho, cht li nht, ru li trng mng, mch huyn. 4.2.2. Can m h Thng gp trong vim gan tn ti hoc giai on thuyn gim sau vim gan mn tnh tin trin. Triu chng gm c: hi hp, ng t, lng bn tay bn chn nng, st m 37o5 n 38o, kht nc, hng kh hay gt gng, li , to bn, nc tiu vng, mch huyn t sc. 4.2.3. Can nhit, t thp Thng gp trong vim gan mn tin trin vi cc triu chng: ming ng, chn n, bng y trng, ming kh nht, au nhiu vng gan, da vng xm, tiu tin vng, li ru vng mch huyn. 5. TIN LNG 5.1. i vi vim gan B mn tnh Thi gian sng st sau 5 nm v sau 15 nm l: 97% v 77% nu l th tn ti. 86% v 66% nu l th hot ng. 55% v 40% nu l th hot ng km x gan. V c bit nng khi c bi nhim virus D (nhim thm HDV trn nn vim gan mn tnh). Ngoi ra nhng trng hp vim gan th tn ti c th din tin thnh x gan n 20% trng hp trong khong thi gian t 1 - 13 nm. 5.2. i vi vim gan C mn tnh Qua theo di 10 - 20 nm s c 20% din tin thnh x gan. Tin lng s xu i trn ngi nghin ru, nhim thm virus vim gan B, bnh nhim sc t st (hemochromtosis) thiu 1 antitrypsin, tui gi thi gian mc bnh lu, tn thng m hc din tin v genotyp ca virus (1b). Sau cng mt vim gan virus C d nh vn c th din tin thnh ung th gan sau nhiu thp nin vi t l t 1 - 3%. T l t vong sau 10 - 20 nm theo di ca ngi vim gan virus C mn tnh vn khng khc bit so vi ngi nhim virus vim gan C mn tnh. 180

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5.3. i vi vim gan t min Khi bnh tr nn nng th t l t vong trong 6 thng l 40%. 6. IU TR 6.1. Theo y hc hin i 6.1.1. i vi vim gan virus B S dng interferon: hin nay c 3 ch phm interferon 2A (roferon A), interferon 2B (roferon A) v interferon N (Wellferon). V mt tc dng, chng c 2 c ch: + C ch dit virus: khi kt hp vi receptor c bit b mt t bo gan, n s phng thch ra mt men ni bo 2,5 oligo adenylat synthetase, chnh men ny s hot ho ribonuclease ph hy mARN ca virus. + C ch min dch: gia tng s bc l protein b mt mng t bo HLA class I, c ngha l lm thc y s thi loi cc t bo gan b nhim virus, lm gia tng hot tnh t bo dit (killer cell), lm trng thnh t bo gy c ng thi ngn chn procollagen typ III l cht thc y gan ho si. Mt liu trnh 16 tun INF tim di da vi liu 5 triu n v/ngy hoc 10 triu n v/ln trong mt tun s lm chuyn i giai on sao chp (replicate) ca siu vi B cng vi nhng ci thin v mt m hc trong 35% trng hp, ng thi c khong 20% trng hp c anti HBe v nu iu tr sm c th lm mt HBsAg trong 80% trng hp. Ring SGPT tr v bnh thng thnh 2 pha: pha u gim nh ri tng cao v sau tr v bnh thng (do s hoi t ca t bo gan b nhim virus). Thuc thng gy nhng phn ng ph nh cm, ri lon cm xc dng kch ng hoc trm cm, rng tc, gim tiu cu v bch cu, ni mn, tiu chy, t u chi. Cc triu chng ny c th tiu mt khi ngng thuc hoc gim liu nhng vim tuyn gip t min th khng. Ngoi ra, gn y ngi ta ang th nghim mt s thuc mi trong iu tr vim gan mn tnh do virus vim gan B nh sau: + Nhm nucleosid ng phn m qua qu trnh phosphoryl ho n s tng tranh vi nhng acid nhn c bn trong chui ADN ca virus vim gan B. C th k n lamivudine, famciclovir, ganciclovir trong lamivudin c th ngn chn men sao chp ngc chuyn i HBV - ARN thnh ra HBV - ADN ca virus vim gan B. y l mt loi bit dc ung vi liu 100mg/ngy c dung np tt c trn bnh nhn b x gan c trng. Thuc ch gy phn ng ph l nhc u, bun nn v mt mi. 181

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+ Mt liu trnh 12 thng s lm mt HBeAg n 33% trng hp v lm xut hin anti HBe n 20% trng hp, ng thi bnh thng ho men gan (40%), ci thin hnh nh m hc (50%) v lm chm din tin x gan (20%). Trong nhng trng hp khng chuyn i HBeAg trong nm u, vic iu tr tip tc bng lamivudin s lm tng t l chuyn i ny n 27% trong nm th hai v 44% trng hp trong nm th ba. + Cng nh INF , lamivudin s lm SGPT tr v bnh thng thnh 2 pha (khong 25% trng hp), khi ngng lamivudin khong 20 - 30% trng hp c SGPT tng cao tr li gp 2 - 3 ln, iu chng t l HBV ti sao chp tr li. + Ngoi ra t iu tr bng lamivudin cng a n t bin YMDD (tyrosin-methionin-aspartat-aspartat) trn HBV ADN polymerase vi t l 30% nm th nht, 38% nm th hai v 50% nm th ba. nhng bnh nhn ny SGPT v HBV ADN s tng v tn thng m hc s xut hin nhng khng trm trng hn so vi nhng bnh nhn vim gan B mn tnh c p ng min dch bnh thng. iu chng t HBV t bin YMDD ny khng c ng lc cao. Tuy nhin nhng bnh nhn suy gim min dch loi HBV t bin YMDD ny s a n suy gan. Hin nay ch c adefovir dipivoxil ang c th nghim trn loi HBV t bin YMDD ny. + Nhm iu ho min dch gm thymosin (cht chit xut ca thymus) vi c ch tc dng l tng hot chc nng ca T cell v interleukin 2, c ch s sinh sn ca virus mc du c nhiu tc dng ph.
Tiu chun chn la thuc dit virus vim gan B
HBeAg(+), HBV ADN SGPT tng Hnh nh m hc c trng Cn p ng min dch Mt p ng min dch Nhim tui trng thnh (chu u) Nhim tui thiu nin (chu ) Bnh gan cn b Bnh gan mt b Vim gan virus B mn tnh typ hoang d Vim gan virus B mn tnh t bin precore Khng p ng vi IFN INF c c c Khng c Khng c Khng c Khng Khng Lamivudin c c c c c c c c c c c

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6.1.2. i vi vim gan tnh C INF: vi liu 3 triu n v/ln x 3 ln/tun x 6 thng s lm ci thin men gan (50% trng hp) v lm mt HCV ARN (30% trng hp), s thuyn gim men gan thng xy ra sau 3 thng u iu tr (85 - 95% trng hp) v xung u (tuy nhin t l ti pht ln ti 90%). Nhng bnh nhn t p ng vi iu tr bng INF n c l: HCV genotyp 1b, thi gian mc bnh lu, mt p ng min dch, HCV quasispecies diversity cao v nhim huyt sc t. Hin nay, ngi ta ang s dng loi interferon tc dng ko di (gn vi polyethylenglycol). Nhng kho st gn y cho thy liu mi tun mt ln ca n c hiu qu tng ng nh liu 3 ln/mi tun ca INF hoc tng ng vi li iu tr kt hp gia INF thng thng vi ribavirin. INF kt hp ribavirin IF (2A, 2B) 3 triu v/ln x 3 ln/tun Ribavirin 1000mg-1200mg (vi ngi di hoc trn 75kg) S t kt qu gp 2 ln so vi iu tr bng interferon n c v s p ng vn cn tip tc sau nu: Nng virus thp (<2 triu copi/1ml). Khng phi l HCV typ 1b. Tui di 40, gan t ho si. L ph n. c bit vi trng hp HCV khng phi l typ 1b v nng virus thp, s p ng c th t n 95% v ch cn iu tr trong 6 thng. Cc phn ng ph ca li iu tr kt hp ny tng t nh interferon cng thm thiu mu huyt tn, nga, nght mi, gy bnh Goutte v khng c dng cho ngi suy thn, ph n mang thai. 6.1.3. i vi vim gan virus D Liu trnh INF 9 triu v x 3 ln/tun x 12 thng s ci thin lm sng v chuyn i HDV ADN trong 50% trng hp, tuy nhin sau s ti pht hon ton. Cc loi thuc khng virus khc cha chng minh c hiu qu. Vim gan virus D mn tnh giai on cui c gii quyt bng ghp gan. 183 6-12 thng

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6.1.4. i vi vim gan mn t min 80% trng hp p ng vi glucocorticoid nhng khng ngn nga c vic din tin ti x gan, liu dng l 60mg prednison/ngy, sau khi t kt qu h liu xung dn trong 1 thng v duy tr liu 20mg/ngy. Hoc c th dng 30mg/ngy kt hp vi azathioprin 50mg prednison/ ngy, sau khi t kt qu h liu prednison xung cn 10mg/ngy. Cch iu tr ny ko di trong 18 thng v lm gim cc tc dng ph ca prednison t 66% xung khong 20%. Cch dng ny ch p dng cho vim gan t min nng vi cc du hiu mt mi, chn n, vng da s c ci thin trong vi tun; cc du hiu sinh ho nh ALB, BIL, globulin s tr v bnh thng sau vi thng. S thay i hnh nh m hc s ci thin t 6 thng - 2 nm. Cn iu tr lin tc 1 nm - 1,5 nm, d t l ti pht c l 50% th cng vn tip tc nh c. Ngi ta nhn thy nu tip tc s dng azathioprin sau khi ngng corticoid c th lm gim t l ti pht. Nu iu tr tht bi v bnh din tin ti x gan th nn ghp gan. 6.2. Theo y hc c truyn Vic iu tr vim gan mn gm 3 phng php sau y: 6.2.1. Thanh nhit tr thp Thuc thanh nhit tr thp c dng vi mc ch: + H st: nh c flavon trong hong cm c tc dng c ch men polypheno - loxidase gy st trong bnh l t min. + Li mt v tng mt nh c acid chlorogenic v 6,7 dimethyl coumarin c trong nhn trn hoc magi silicat c trong hot thch. + Li tiu v bo v t bo gan: nhn trn. + Tng kh nng min dch ca c th: phc linh. Bi thuc tiu biu l: Nhn trn ng linh tn v Hong cm hot thch thang. C th: + Trong chng can nhit t thp ta dng bi: Nhn trn ng linh gia gim
V thuc Nhn trn Bch trut Phc linh Tr linh Trch t Qu chi Tc dng ng, lnh: thanh nhit, li thp, thoi hong Ngt, ng, hi n: kin v, ho trung, to thp Ngt, nht, bnh: li thu, thm thp, b t, nh tm Li niu, thm thp Ngt, nht, mt: thanh t thp nhit bng quang Cay, ngt, m: tn hn, hnh huyt, li thu Liu 20g 12g 12g 8g 12g 6g Vai tr Qun Thn Thn Thn Thn T

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Nu do vim gan virus nn tng liu bch trut v phc linh ln 20g, thm dip h minh chu 50g. Nu do vim gan t min nn tng liu ng sm 30g, gia thm cam tho bc 30g. + Hoc Hong cm hot thch thang gia gim
V thuc Hong cm Hot thch i phc b Phc linh Tr linh u khu Kim ngn hoa Mc thng Nhn trn Cam tho bc Dc l ng, lnh: t ph ho, thanh thp nhit Ngt, lnh: thanh nhit, li thp Cay, ng m: thng tin, li thp Ngt, bnh: li thp Ngt, bnh: li thu, b m ch kht Cay, m: hnh kh ho thp Ngt, lnh: thanh nhit, gii c ng, hn: li tiu, thng huyt mch ng, lnh: thanh nhit, li thp Ngt, bnh: b t v, nhun ph, thanh nhit, gii c, iu ho cc v thuc Liu 12g 12g 12g 8g 8g 8g 16g 12g 20g 4g Vai tr Qun Qun Thn Thn Thn Thn T T T T, s

Nu c nng st, vng da nn tng liu hong cm, hot thch ln 20g. Nu vng da hoc tng transaminase nn tng liu nhn trn ln 30g. 6.2.2. S can kin t Dng php s can, kin t vi mc ch: + Kch thch tiu ho thng qua tc dng tng hot tnh ca men ty nh bch trut, phc linh, trn b v.v .. + Bo v t bo gan: si h, ng quy, i to, glyciridin ca cam tho. + iu ho chc nng: bch trut. + Min dch: si h, ng sm, bch trut, glucid ca bch thc. + Khng virus vim gan: si h. Bi thuc tiu biu: Si h s can thang hoc Si thc lc qun. C th: + Trong chng can ut t h ta dng Si h s can thang gia gim 185

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V thuc Si h Bch thc Ch thc Xuyn khung Hu phc Cam tho bc ng quy i to

Dc l ng, hn: t nhit, s can gii ut, gii c, thng Chua, ng, lnh: ch thng, lim m ng, cay, hi lnh: ph kh, tiu tch, tr b mn Cay, m: hot huyt, hnh kh ng, cay, m: hnh kh, tiu tch Ngt, bnh: b trung ch kh, ho trung V ngt, m: b huyt, hot huyt Ngt, bnh: b trung ch kh, dng huyt, an thn, ho hon dc tnh

Liu 12g 8g 6g 8g 6g 6g 8g 8g

Vai tr T Thn Thn Thn Thn Thn Thn Thn

Nu cm gic au tc nng vng gan lm bnh nhn kh chu nn tng thm liu bch thc, cam tho 12g, xuyn khung 10g, ch thc 10g, hu phc 10g. Nu bnh nhn b vim gan mn tnh do cc bnh t min tng liu bch thc, cam tho bc ln 20- 30g. Nu vim gan mn do virus nn gia thm dip h minh chu (ch rng ca) 50g c ch men ADN polymerase ca virus vim gan B; tng ng quy, i to ln 20g. + Hoc Si thc lc qun gia gim
V thuc Si h Bch thc Bch trut ng sm Phc linh Cam tho bc Trn b Bn h ch Tc dng ng, hn: t nhit, s can gii ut, gii c, thng Chua, ng, lnh: ch thng Ngt, m: kin t, li thp Ngt, bnh: b trung, ch kh Ngt, bnh: li thp Ngt, bnh: b trung, ch kh, ho trung Cay, ng, m: l kh, iu trung Cay, n: h kh nghch, tiu m Liu 12g 12g 12g 12g 8g 6g 6g 8g Vai tr T T Qun Thn Thn T Thn T

Nu bnh nhn chn n, ngi mt mi, i tin phn mu th gia thm bch trut, ng sm mi th 10g, phc linh 12g. 186

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Nu lm ging, bun nn th gia thm trn b, bn h ch 10g. Nu vim gan mn do virus nn gia thm dip h, minh chu 50g c ch men ADN polymerase ca virus vim gan B. Nu vim gan mn do bnh t min th tng liu bch trut, ng quy, ng sm, cam tho bc ln 20- 30g. Nu vim gan mn tnh do dng thuc hay ru th tng liu cam tho bc, bch trut ln 20-30g. 6.2.3. T dng can m Dng php t dng can m vi mc ch: + An thn: cho n trinh t, h th . + Bo v t bo gan chng thoi ho m: do bretain ca cu k t. + Tng chc nng min dch ca c th: glucocid ca bch thc, spolysaccharid ca k t. + H st: sa sm. Bi thuc tiu biu: Nht quan tin gia gim (nht l trong chng can m h). + Trong chng can m h ta dng Nht quan tin gia gim
V thuc Sa sm Sinh a N trinh t Mch mn Bch thc K t H th ch Tc dng Ngt, hi hn: dng m, sinh tn, ch v Ngt, ng, lnh: lng huyt, sinh tn, nhun to An thn Ngt, ng hi lnh: dng m, sinh tn, ch v, nhun trng Chua, ng, lnh: ch thng, lim m Ngt, bnh: t b can thn, sinh tinh huyt Ngt, ng, hi m: dng huyt, ch tinh Liu 12g 12g 12g 12g 12g 12g 12g Vai tr Qun Thn Thn T T T T

Nu vim gan mn tnh do virus nn tng liu bch thc ln 20g, k t 30g; thm dip h minh chu 50g. Nu vim gan mn tnh do ru nn tng liu k t ln 30g.

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T lng gi Trong giai on virus vim gan sao chp m di truyn (replicat) chn on huyt thanh no sau y s dng tnh A. HBsAg B. HBeAg C. AntiHBe D. AntiHBg E. AntiHBs 2. Trong giai on virus vim gan sao chp m di truyn (replicat) hnh nh m hc no ca vim gan s khng hin din

A. Hoi t quanh khong ca B. Vim quanh khong ca C. Hoi t trong thu D. Gin n cc xoang gan E. Ho si
3. Chng c no sau y khng chng t vim gan t min l mt loi bnh do ri lon min dch A. S c mt ca cc t khng th trong mu B. p ng tt vi glucocorticoid C. Vim cu thn do ng phc hp khng th - khng nguyn D. C mt HLA B1, B8, DRW4, DEW4 E. C mt cytotoxic lympho T trong gan 4. Trong c ch bnh sinh chng hong n hip thng, ri lon cng nng ch yu xy ra tng ph no

A. Can - thn B. T - thn C. Tm - t D. Can - t E. Tm - thn


5. Trong vim gan mn tnh do virus C, cc triu chng s tr nng khi bnh nhn c

A. SGPT tng 100UI B. Mt mi C. Nghin ru


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D. Chn n E. au vng gan


6. Trong vim gan mn do virus giai on cui hoc nng, xt nghim cn lm sng cho thy

A. SGPT tng 200UI B. Phosphatase alkalin tng gp ri ln bnh thng C. Bilirubin tng 3mg% D. globulin tng E. Albumin mu gim
7. chn on xc nh vim gan mn tnh do t min, ngi ta da vo kt qu xt nghim no sau y

A. Transaminase tng 1000UI B. Bilirubin tng 10mg% C. Phosphatase alkalin tng gp 2 ln bnh thng D. globulin tng 2,5g% E. Khng th - khng nhn (ANA) (dng tnh)
8. Triu chng no sau y khng c trong th can ut t h ca chng hong n hip thng

A. au tc vng gan B. St m C. i tin phn nho D. Ngi mt mi E. Mch huyn


9. Triu chng no sau y khng c trong th can m h ca chng hong n, hip thng

A. St m B. Mt ng C. i tin phn nho D. Lng bn tay, bn chn nng E. Kht nc


10. Triu chng no sau y khng c trong th can nhit t thp ca chng hong n, hip thng

A. Da vng xm B. au tc vng gan C. Bng y trng


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D. Kht nc ung nhiu E. Chn n


11. Ch nh iu tr vim gan mn tnh do virus B bng interferon khng t ra khi bnh nhn c

A. HBeAg dng tnh B. HBV ADN dng tnh C. SGPT tng 1000UI D. Bnh gan cn b E. C trng
12. Ch nh iu tr vim gan mn tnh do virus C bng interferon khng t ra khi bnh nhn c

A. SGPT bnh thng 1,5 ln B. HCV ARN dng tnh C. Tn thng m hc mc nh D. Bnh gan mt b E. Tn thng m hc mc trung bnh
13. C ch tc dng no sau y khng thuc interferon

A. Hot ho ribonuclease B. Thc y s thi loi t bo gan b nhim virus C. c ch men ADN polymerase D. Gia tng hot tnh killer cell E. Ngn chn procollagen typ III
14. Tc dng dc l no sau y khng nm trong php tr thanh nhit tr thp

A. Li mt v tng mt B. Bo v t bo gan C. H st D. c ch ADN polymerase (ca ch rng ca) E. Tng kh nng min dch
15. Tc dng dc l no sau y khng thuc php tr s can kin t

A. Kch thch tiu ho B. Li mt v tng mt


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C. Bo v t bo gan D. iu ho chc nng min dch E. Khng virus vim gan


16. Tc dng dc l no sau y khng thuc php tr t dng can m

A. An thn B. Chng thoi ho m gan C. iu ho chc nng min dch D. iu ho vn tnh rut E. H st
17. Bi Si h s gan thang (gm si h, bch thc, ch thc, xuyn khung, hu phc, cam tho bc, ng quy, i to), s phi bi thm v no trong iu tr vim gan t min

A. Bch thc, cam tho bc B. Si h, hu phc C. Xuyn khung, ch thc D. ng quy, i to E. Hu phc, ch thc
18. Bi thuc Nht quan tin (gm sa sm, sinh a, n trinh t, mch mn, bch thc, k t, h th ch) nn bi thm v no trong iu tr vim gan mn tnh do ru

A. Sa sm B. Cu k t C. Bch thc D. H th E. Mch mn


19. Bi thuc Nhn trn ng linh (gm nhn trn, bch trut, phc linh, tr linh, trch t, sa tin, ng sm, d), nn bi thm v no trong iu tr vim gan mn tnh do virus

A. Bch trut, phc linh, dip h minh chu B. ng sm, cam tho bc, trn b C. Sa tin, d, mc hng D. Nhn trn, trch t, hong cm E. Sa tin, cam tho bc, hong lin

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Bi 12

X GAN

MC TIU 1. Trnh by c c ch bnh sinh ca 4 loi x gan: do ru, do virus, do mt, do tim. 2. Trnh by c c ch bnh sinh ca hi chng x gan theo YHCT. 3. Trnh by c triu chng lm sng v du hiu cn lm sng ca 4 loi x gan. 4. Trnh by c cc th lm sng hi chng x gan. 5. Trnh by c hng x tr 4 loi bin chng ca x gan: c trng, xut huyt, hn m gan v vim phc mc nguyn pht. 6. Trnh by c tc dng dc l ca 3 php tr hi chng x gan theo YHCT.

1. NH NGHA X gan l mt bnh l c nhiu biu hin lm sng phn nh mt tn thng nhu m gan khng hi phc, bao gm s ho si lan to phi hp vi s thnh lp ca o nhu m gan tn sinh. Nhng hnh nh ny l kt qu t: S hoi t t bo gan. S sp h thng vng ni m nng . S ng cc m lin kt. S ri lon h mch mu. S tn to nhng nt nhu m gan. Din tin bnh l ny c th coi nh l con ng chung cuc ca bt c loi tn thng gan mn tnh no. Hnh nh lm sng ca x gan s phn nh mc trm trng ca tn thng hn l nguyn nhn ca cc bnh a ti x gan. Trong : S mt chc nng ca khi t bo gan s a ti vng da, ph, ri lon ng mu v hng lot cc ri lon bin chng khc. 192

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S ho si v xo trn cu trc mch mu s a ti tng p lc tnh mch ca v cc bin chng ca n. Trong khi c trng v bnh cnh no gan l kt qu t s suy t bo gan v tng p lc tnh mch ca. Hin nay, cch phn loi x gan c l hu ch nht l kt hp gia nguyn nhn v hnh nh m hc theo nh cch phn loi sau y: X gan do ru. X gan sau hoi t hoc sau vim gan virus. X gan do mt. X gan do tim. X gan do chuyn ho, di truyn hoc thuc. X gan do cc nguyn nhn khc. 2. C CH BNH SINH 2.1. Theo y hc hin i 2.1.1. Bnh gan do ru v x gan Thng thng mt ngi ung ru hn 10 nm vi liu lng hn 250ml ru cc loi mi ngy u c kh nng a n x gan. Trong cho thy t 10 - 15% nhng ngi nghin ru s mc bnh x gan. Bnh x gan do ru thng din tin lm 3 giai on: Gan m: gan to, vng, chc, t bo gan gin n bi nhng khng bo m y nhn t bo gan sang mt pha. S tp trung m trong t bo gan l do s h hi c ch oxyd ho m, s tng thu nhn v s ester ho acid bo, gim s tng hp v bi tit lipoprotein. Vim gan do ru: hnh nh thoi ho v hoi t t bo gan vi nhng t bo hnh qu bng, s tm nhum t bo lympho v bch cu a nhn. Cc bch cu a nhn bao quanh cc t bo gan c cha th mallory (hyalin). Ngoi ra cn c s ng si collagen quanh t bo trung tm tiu thy gan v vng quanh khong ca. X gan: cng vi s tip tc ung ru v hu hoi t bo gan. Cc nguyn bo si xut hin v kch thch s to thnh collagen. Nhng vng m lin kt hnh chn vt xut hin quanh khong ca v vng cn trung tm tiu thu gan s ni kt v bao ly nhng khi nh t bo gan v chng s thoi ho to thnh nhng nt nhu m gan. Lc gan s nh li, xut hin nhng nt u v tr nn cng. Mc d x gan do ru l mt bnh din tin mn tnh nhng nu c iu tr thch ng v b hn ru vn c th chm dt bnh bt k giai on no. 193

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2.1.2. X gan sau khi nhim virus (x gan sau hoi t) Thng k cho thy 1/4 s ngi mang mm bnh virus B, C v 15% nhng ngi b nhim virus vim gan lc cn tr s din tin n x gan. Lc ny gan thu nh kch thc, cu trc m hc gan b o ln v c thay th bng nhng o t bo gan b tch ri bi nhng di si dy v rng. 2.1.3. X gan do mt nguyn pht X gan do mt nguyn pht l bnh l ri lon min dch thng phi hp vi cc hi chng Calcinosis, Raynaud, lon vn ng thc qun, x cng u chi, telangiectasy, SICCA (kh mt v ming), vim tuyn gip min dch v Renal tubular acidosis, i tho ng typ I v suy gim IgA. Khong 90% tm thy IgG khng th khng ty lp th (AMA) c tc dng ngn chn hot tnh men pyruvat dehydrogenase, ketodehydrogenase v ketoglutarat dehydrogenase. Nng khng th IgG cao v cc cryo protein cn lm hot ho h thng b th (80 - 90%). Ngoi ra ngi ta cn tm thy khng nguyn ph hp m lp II lp biu b ca ng mt. Tt c nhng yu t trn thc y mt tnh trng vim v hu hoi cu trc ca gan. V hnh nh m hc c 4 giai on: Vim hy hoi khng nung m ng mt trong gan, ti vng ca ca ng mt nh u b tm nhum bi cc t bo vim dy c cng vi hin tng ho si a n mt. S tm nhum gim nhng c hin tng tng sinh cc ng mt nh. Gim s lng ng mt lin thy, mt t bo gan, ho si lan rng quanh khong ca. S pht trin cc nt t bo gan tn to ln v nh. 2.1.4. X gan do tim Suy tim phi vi s truyn ngc p lc mu ln tnh mch ch di v tnh mch gan a n sung huyt ti gan, cc xoang gan gin n v mu. Tnh trng sung huyt v thiu O2 lu di a n hoi t t bo gan trung tm tiu thy v sau cng l ho x t vng trung tm lan to ti khong ca. 2.1.5. Bnh Wilson y l bnh di truyn theo gen lit, khin cho s chuyn ho cht ng bi men ceruloplasmin b ri lon a n ng cht ng trong gan v mt s c quan khc. 2.1.6. Hemochromatosis C th do di truyn lin quan n khng nguyn ph hp m HLA -A6 hoc hu qu bnh thalassemia v sideroblastic anemia, gy ng st trong gan, tim, ty v mt s c quan khc. 194

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2.1.7. Porphyria cutanea tarda (PCT) S thiu ht men uroporphyrin decarboxylase a n ng porphyria trong gan. Ngoi ra c th do b nhim mt s ho cht nh hexachlorobenzen, Di-tri chlorophenol v 2, 3, 7, 8 tetrachlorodibenzo - p - dioxin. 2.2. Theo y hc c truyn Chng x gan c trng thuc phm tr chng trng v hong n theo YHCT m nguyn nhn c th do: Cm th thp nhit t nh hng ti chc nng s tit ca gan. Can kh khng s tit khin cho t v khng vn ho thy cc a n thp v nhit. Thp nhit ut kt a n hong n. Thp nhit ut kt lu ngy lm tn hao kh huyt ca t v khin cho cc chc nng ca t v nh: + Ging np thy cc. + Vn ho thy cc, thu thp. + Thng thanh ging trc. + Thng nhip huyt. + Ch c nhc, t chi. Cc chc nng trn u b tn thng a n chn n, y bng, nn ma, tiu phn sng, ph, c trng, chy mu, gy st cn v.v.. Ngoi ra cn phi k n nguyn nhn m thc tht thng v ung ru cng trc tip lm tn hi n cng nng t v.
n ung tht thng Tu c Thp nhit t S tit T v Vn ho Thp nhit Can

Hong n

Chn n, y bng

Tiu phn sng

Trng thng

C nhc teo nho

Chy mu

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3. CHN ON 3.1. Theo y hc hin i 3.1.1. X gan do ru Bnh gan m thng khng c triu chng v kh nhn bit. Vim gan do ru thng chn n, bun nn, mt mi, st cn, cm gic kh chu trong bng v vng da; st 390C gp trong 1/2 trng hp; gan to, au; lch to gp trong 1/3 trng hp, c du sao mch. Nng hn c th l c trng, ph, xut huyt v bnh cnh no gan. X gan: triu chng lm sng c th m , kn o trong 40% trng hp, thng thng bnh nhn chn n v suy dinh dng a n st cn, teo c, vng da ngy mt tng dn, xut huyt tiu ho, c trng v bnh cnh no gan. Khm gan c th c triu chng gan to hoc bnh thng hoc nh, ngoi ra cn c nhng du hiu vng da, lng bn tay son, mng tay mt knh ng h (clbbing finger), lch to, thiu mu, c trng v hoc ph ton thn. n ng c triu chng v to, teo tinh hon, rng lng. Ph n b ri lon kinh nguyt. Xt nghim cn lm sng cho thy: + SGOT tng nh trong giai on gan m, i khi c tng phosphatase alkalin v bilirubin. + Trong giai on nng hn SGOT tng 300 UI. SGOT SGPT C du hiu thiu mu, tng nng lch v thiu mu huyt tn. Thi gian prothrombin ko di. ALB mu gim, globulin mu tng (do s kch thch h vng ni m), i khi c tng amoniac mu. Bt dung np glucose. Gim natri v kali mu do hin tng cng aldosteron. nh gi tin lng mt ngi x gan do ru, ngi ta thng dng ch s:
4,6 x [ (prothrombin control) tim + total Bil m/l ] Disriminant fraction = 17 > 32

>2

Nu t s cng cao tin lng cng xu v t l sng st sau 5 nm khng qu 50%. 196

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3.1.2. X gan sau nhim virus Vi du hiu lm sng ca tng p ca r rng nh c trng, lch to, tng nng lch, xut huyt do v, gin tnh mch thc qun v bnh cnh no gan. 75% trng hp bnh nhn cht trong khong 1 - 5 nm do xut huyt, bnh cnh no gan hoc ung th gan. Xt nghim cn lm sng cho thy: SGOT SGPT <1

globulin tng. Trong giai on nng hn, c th gp albumin mu gim v prothrombin time ko di. Chn on nguyn nhn da vo test huyt thanh (xem bi vim gan mn). 3.1.3. X gan do mt nguyn pht nhng trng hp pht bnh c triu chng, 90% trng hp gp ph n tui 35 - 60. u tin nga lng bn tay, bn chn, mt mi. Sau nhiu thng, nm vng da xut hin, da tr nn sm mu nhng vng phi ra nh sng. Tnh trng tiu phn m v ri lon hp thu a n: + Thiu vitamin D vi triu chng au xng do nhuyn xng hoc long xng. + Thiu vitamin A vi triu chng qung g. + Thiu vitamin E vi triu chng vim da. + Cng vi tnh trng suy t bo gan v tng p ca. Bnh nhn ch sng t 5 - 10 nm k t khi c triu chng u tin ca bnh. Xt nghim cho thy: + Phosphatase alkalin tng gp 2 - 5 ln so vi tr s bnh thng. + 5 nucleotidase tng, glutamyltranspeptidase tng. + Tng lipid mu v xut hin lipoprotein X. + Bilirubin ton phn tng 30mg%. + Transaminase tng 150 - 200VI. 197

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Chn on xc nh: + 90% AMA dng tnh vi hiu sut > 1:40 + Nu AMA (-) nn lm thm xt nghim tm: Khng th khng protein E2. Khng th khng nhn ANA. Khng th khng c trn ASM. 3.1.4. X gan do tim Gan to v au, cm gic au vng h sn phi, nhng thng thng du hiu suy tim che m du hiu ca gan. Trong trng hp suy tim do h van 3 l s c triu chng gan p theo nhp. C trng v ph thng thng do suy tim a n. Xut huyt tiu ho t gp nhng bnh cnh no gan rt thng gp. Cng vi thi gian suy tim ko di, gan tr nn to cng khng cn au. Du hiu cn lm sng khng c th, ch cho thy c tng nh bilirubin, tng phosphatase alkalin, SGOT tng cao v tm thi trong nhng tnh trng shock gan, prothrombin time ko di. Chn on xc nh da trn gan to, chc cng vi cc bt thng cn lm sng ca mt bnh gan mn tnh trn mt bnh nhn b bnh van tim, vim tht mng ngoi tim hoc tm ph mn tnh. Cng cn chn on phn bit vi bnh Budd - Chiari vi du hiu gin tnh mch xoang gan v sung huyt thu trung tm (trn sinh thit gan) m khng c bnh l suy tim phi. y l bnh thuyn tc tnh mch gan hoc tnh mch ch di do: + Bnh a hng cu Rubra Vera. + Hi chng Myelo proliferative. + Bnh i huyt sc t kch pht ban m. + Cc ri lon tng ng mu v vic dng thuc nga thai. + S xm ln bi cc khi u t thn hoc t gan. + X tr gan, thuc chng ung th v mt alkaloid pyrrolidizin c trong dc tho ca YHCT. 3.1.5. Bnh Wilson Nn ngh n nhng bnh nhn di 40 tui b vim gan mn tnh hoc x gan m khng tm thy nguyn nhn no khc. 198

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S chn on da trn: Bnh nhn c bnh gan, bnh thn kinh hoc mt ri lon tm thn m nguyn nhn khng xc nh. Anh ch em rut c ngi b bnh Wilson. Vng Keyser-Fleischer trn gic mc. Nng ceruloplasmin/mu <20mg%. Tng transaminase mu ko di, khng gii thch c. Chn on chc chn khi sinh thit gan cho thy hnh nh vim gan lan to cng vi s xut hin nhng nt x (macronodular cirrhosis) v nng ng (Cu) trong gan > 250g%. 3.1.6. Bnh hemochromatosis Khong 50% bnh nhn s din tin ti x gan v 30% din tin ti ung th gan. Bnh c biu hin: + Gan to (95%). + Tng sc t da (90%) vi mu en ca kim loi. + i tho ng (65%). + Bnh khp (25- 50%). + Suy tim, lon nhp tim (15%). Ngoi ra cn c nhng biu hin ca suy tuyn sinh dc (hypogonadism) suy thng thn, suy gip v ph gip. Cc xt nghim gip chn on nh: + St huyt tng: 180 - 300 g%. + Total iron binding capacity: 200 - 300g%. + Transferin saturation: 50 - 100%. + Serum ferritin: 900 - 6000g/l. 3.1.7. Bnh porphyria cutanea tarda Bnh biu hin bng nhng sang thng da nh mn, bng nc nhng vng da phi ra nh sng, sau chuyn thnh nhng mng trng hoc tng sng ho, tng sc t hoc nhng sang thng nh x cng b. Chn on xc nh da trn s xut hin porphyrin trong nc tiu (nc tiu sm en). 199

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3.2. Theo y hc c truyn 3.2.1. Th can ut t h Vi triu chng mt mi, chn n, tc nng vng gan, bng trng y hi, i tin phn nt, ru li mng, mch huyn t (thng gp trong giai on x gan cn b). 3.2.2. Th t thn dng h Mt mi, n km, bng trng, chn ph, tiu t, i ngoi phn long, sc mt vng ti, li nht bu, mch trm t. 3.2.3. Th m h thp nhit Sc mt vng sm, chy mu da nim mc, c trng, chn ph, st hm hp, phin to, hng kh, tiu t, cu to, li kh, mch huyn t sc (thng gp trn nhng bnh nhn x gan, c ri lon in gii v suy t bo gan nng). 3.2.4. Th kh tr huyt Vi triu chng au tc 2 bn mng sn, bng trng ni gn xanh, ngi gy, mi li tm, mch t (thng gp trong th x gan c tng p lc tnh mch ca). 3.2.5. Thy kh tng kt C trng pht trin nhanh, kh th, mch huyn sc. 4. IU TR 4.1. Theo y hc hin i Nguyn tc: Cha bnh nguyn nhn. Gii quyt bin chng. 4.1.1. Cha bnh nguyn nhn a. X gan do ru Ch n ung: + Nu khng c nghi ng bnh cnh no gan nn cho n 1g m/kg th trng/ngy v t 2000 - 3000 calo/ngy, kt hp thm a sinh t. + Ngng ung ru hon ton. 200

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+ Thn trng khi dng nhng thuc li tiu, an thn, paracetamol (< 2g/ngy), aspirin v tt c nhng thuc c chuyn ho ti gan v bi tit theo ng mt. Thuc: + Tim B1 liu cao cho bnh nhn c hi chng Wernick - Korsakoff. + Prednison 20 - 40mg/ngy trong 4 tun ch dng cho nhng bnh nhn c bnh cnh no gan hoc ch s Discriminant fraction > 32 m khng c xut huyt tiu ho hoc nhim trng trc . b. X gan do nhim virus Ch tp trung gii quyt bin chng, c bit l vn nhim trng. c. X gan do mt nguyn pht Ghp gan l phng cch ti u nht d sau AMA vn dng tnh vo khong 25% trng hp v tn thng m hc vn cn ko di trong 5 nm. Ursodiol (10 - 15mg/kg/ngy) cho thy c ci thin men gan v phosphatase alkalin. Dng cholestyramin 8 - 12g/ngy lm gim nga v gim cholesterolemia. n t m gim triu chng tiu phn m. Tim vitamin A v D, b sung cht km nu qung g khng p ng vi vitamin A. B sung calci v vitamin D trong nhng bnh l ca xng [nn dng 25 (OH) D3 hoc 1,25 (OH)D3]. d. X gan do tim Cha bnh tim e. Bnh Wilson Loi b ng (Cu) ra khi gan bng D.penicillamin 1g/ngy, ung lm nhiu ln trong ngy v iu tr sut i. Ngoi ra khng nn n s, chocolat, gan, nm v ht d v c cha cht ng. f. Bnh hemochromatosis Trch mu mi 500ml/mi tun lin tc trong 1 - 2 nm cho n khi transferin tr v bnh thng. Sau tip tc mi 3 thng trch mu 1 ln hoc trch mu mi tun 1 ln kt hp vi tim truyn dexferoxamin. g. Porphyria cutanea tarda Khng ung ru, khng s dng estrogen hoc thuc c cht st (Fe). 201

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Trch mu 450ml/1 - 2 tun. Hoc chloroquin 125mg x 2 ln/tun. 4.1.2. Gii quyt bin chng a. C trng v/hoc ph Vi t l 60% trn ngi b x gan v l nguyn nhn gy thiu O2 mu (hi chng gan phi) v gy nguy c vim phc mc nguyn pht. Mc ch ch cn lm gim: 0,5 kg/ngy ngi c trng. 1 kg/ngy ngi c c c trng v ph. Cc bin php gm: Ngh ngi tuyt i trn ging trong t th nm nga. Hn ch mui (2g mui n/ngy, ch ung khong 1 lt nc/ngy trnh h natri mu). Thuc li tiu: spironolacton 25 mg x 4 ln mi ngy, sau mi vi ngy tng thm 100mg cho n khi t liu ti a 400mg/ngy. Nu khng hiu qu nn kt hp thm furosemid 20 - 80mg/ngy. Chc tho bng 1, 5 lt - 2 lt/tun, nn dng khi c nguy c bnh nhn b ri lon thng kh do c trng qu to. Hai liu php trn y cn theo di huyt ng hc v ion mu, nc tiu ngn nga nguy c gy bnh cnh no gan v hi chng gan thn. Truyn albumin nhng coi chng nguy c gy xut huyt do v gin tnh mch thc qun. Phu thut ni sid to sid porto - caval shunt hoc peritoneo - venous shunt. b. Vim phc mc nguyn pht (spontaneous bacterial peritonitis) Vim phc mc nguyn pht vi hi chng st, n lnh, au khp bng, c phn ng thnh bng hoc i khi ch thy vng da nng ln v bnh cnh no gan. Chn on xc nh bng cch chc d dch mng bng cho thy: Bch cu > 500 con/1l dch vi 50% l bch cu a nhn. Cy vi trng thng gp cc loi trc khun Gram (-) rut, him gp hn l cc loi Pneumococci v trc khun Gram (+). Nu BC > 10.000 con/1l dch, cy ra nhiu loi vi trng th c th l vim phc mc th pht. 202

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Ngoi ra cn c tnh trng monomicrobial nonneutrocytic bacterascite: cy dch mng bng thy c vi trng nhng bch cu neutro < 250 con, loi ny thng gp bnh gan c din tin khng nng lm. iu tr: cefotaxim 2g/ngy trong 10 - 14 ngy. Tuy nhin mt liu trnh ngn ngy (5 ngy) cng cho kt qu tng t. Tuy nhin do t l ti pht cao, 70% trong vng 1 nm nn cn phi phng nga bng: Ciprofloxacin 750mg/1 ln mi tun. Norfloxacin 400mg/ngy. Hoc bactrim dng 5 ngy/tun. C th lm gim t l ti pht n 65%.
Qua chc d mng bng cn xc nh: - T bo - Cy vi trng v nhum Gram - nh lng albumin (nu hiu s gia ALB mu v Alb/ascit < 1,1g% => ascit do tng p lc tnh mch ca)

Dch mng bng ALB

Hn ch natri < 2g/ngy Hn ch nc < 1 lt/ngy nu Na+ < 120mEq/ l - To shunt h ca gan qua TM cnh - To shunt TM ch v xoang bng

Nu nhum Gram c kt qu hoc bch cu > 250 trong mm3 c th ngh ti vim phc mc nguyn pht (80-85% l E. coli, Streptococcus v Klebsiella)

Spironolacton 100mg/ngy tng 400mg/ngy hoc hn cho n khi Na+/niu > K+/niu Cefotaxim 2g IV 8 - 12h/10J Theo di ion , bun, creatin trong mu v nc tiu iu tr theo kt qu cy (nu cy c nhiu VK th chn on l VPM th pht) Thm furosemid, hydrochorothiazid Khng p ng

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c. V gin tnh mch thc qun V gin tnh mch thc qun l yu t gy t vong cao nht ngi x gan (50% ch sng c 2 tun v 10% ch sng c 1 nm). X tr cp cu: Tim truyn vasopressin 0,1 - 0,4UI/pht, nu trn nhng bnh nhn c thiu mu c tim nn kt hp nitroglycerin tim mch hoc isosorbid dinitrat ngm di li va gim phn ng ph va tng tc dng ca vasopressin. Tim tnh mch 1 liu somatostatin 250g v sau tip tc tim truyn tnh mch somatostatin vi tc 250g/gi (c th s dng mt cht ng phn vi somatostatin l octreotid vi tc tim truyn tnh mch 25g - 50g/gi). S dng baloon tamponad loi sengstaken blakemore (3 lng ng) hoc minesota (4 lng ng). Ni soi thc qun x ho v tht bi gin tnh mch. Phng nga: propanolol 20mg - 40mg chia lm 2 ln/ngy v c th tng ln 160mg/ngy (duy tr nhp tim ch bng 25% nhp bnh thng l c). Phng php ny c th kim sot c 30% tai bin xut huyt. S NH GI LNG MU MT V LNG DCH CN BI HON TRONG V giN TNH MCH THC QUN
Chn on bng ni soi thc qun, d dy, t trng

Tht tnh mch gin hoc x ho

Sau khi kim sot c

- Octreotid (50-100g/) - Somatostatin (250g/) Hoc vasopressin tim truyn 0,1 - 0,4V/pht (+ nitroglycerin)

iu tr duy tr Tht bi 1. Tip tc tht hoc x ho TM Khng kim sot uc t vn ni shunt Transjugular Intrahepatic Porto 2. Dng propanolol hoc nadol ( nhp mch khi ngh hoc gim 25n% p lc TM gan) GHP GAN

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d. Bnh cnh no gan Vi cc mc ri lon thc t ri lon tc phong, nhn cch, tr nh n hn m su cng vi du rung vy bn tay (flapping tremor).
4 GIAI ON LM SNG CA BNH CNH NO GAN Giai on I Tnh trng thc Sng khoi hoc trm cm, hi lm ln, ni x xo, ri lon gic ng L m, lm ln Lm ln nhiu, ni khng hiu c, ng g Hn m, c p ng vi kch thch au nhng s mt dn Du rung vy +/ No Sng 3 pha

II III IV

+ + -

Sng 3 pha Sng 3 pha Sng delta

X tr bng cch: Loi b protein ra khi ch n ca bnh nhn. Xc nh nhng yu t tham gia nh xut huyt tiu ho, ri lon nc in gii, thuc an thn, nhim trng, to bn v.v... v phi iu chnh ngay. Thuc: + Lactulose sirop (30 - 60ml/gi) hoc lactulol (10 - 20ml/ngy) sao cho bnh nhn phi i tiu chy. + Neomycin 0,5g - 1g x 4 ln/ngy (c th s dng metronidazol). + Vic s dng men thc y chuyn ho NH3 thnh ur (dc phm ornithin carbamin transferase) levodopa, bromocryptin, cc cht ng phn keto ca cc acid amin cha c nh gi l c hiu qu. + Trong trng hp hn m do benzodiazepin c th dng flumazenil lm cht i khng. e. Hi chng gan thn L mt tnh trng suy thn trn bnh cnh x gan m khng tm thy mt tn thng thc th no thn. Nguyn nhn a n hi chng ny tng t nh bnh cnh no gan. C th mt s mt cn bng trong chuyn ho acid arachidonic gy ra ri lon ny. Chn on da vo tnh trng t nhin: 205

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Bnh nhn v niu (<50ml nc tiu /24h). Huyt p tm thu < 90mHg. Na+ niu <5mmol/l. Creatinin mu > 1,5g/100ml. d ngng thuc li tiu v bi hon nc in gii y .

Mt s trng hp c p ng vi vic truyn albunmin, nhng cch iu tr tt nht l ghp gan. 4.2. Theo y hc c truyn 4.2.1. S can kin t Mc ch (xem bi vim gan mn tnh). + Kch thch tiu ho thng qua tc dng tng hot tnh ca men ty nh bch trut, phc linh, trn b v.v.. + Bo v t bo gan: si h, ng quy, i to, glyciridin ca cam tho. + iu ho chc nng gan: bch trut. + Min dch: si h, ng sm, bch trut, glucid ca bch thc. + Khng virus vim gan: si h. C th trong chng can ut t h dng bi Si h s can hoc Si thc lc qun. Phng dc: Si h s can thang gia gim
V thuc Si h Bch thc Ch thc Xuyn khung Hu phc Cam tho bc ng quy i to Tc dng ng, hn: t nhit, s can gii ut, gii c, thng Chua, ng, lnh: ch thng, lim m ng, cay, hi lnh: ph kh, tiu tch, tr b mn Cay, m: hot huyt, hnh kh ng, cay, m: hnh kh, tiu tch Ngt, bnh: b trung ch kh, ho trung V ngt, m: b huyt, hot huyt Ngt, bnh: b trung ch kh, dng huyt, an thn, ho hon dc tnh Liu 12g 8g 6g 8g 6g 6g 8g 8g Vai tr T Thn Thn Thn Thn Thn Thn Thn

+ Nu cm gic au tc nng vng gan lm bnh nhn kh chu th nn tng thm liu bch thc 12g, cam tho 12g, xuyn khung 10g, ch thc 10g, hu phc 10g. 206

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+ Hoc: Si thc lc qun gia gim:


V thuc Si h Bch thc Bch trut ng sm Phc linh Cam tho bc Trn b Bn h ch Tc dng ng, hn: t nhit, s can gii ut, gii c, thng Chua, ng, lnh: ch thng Ngt, m: kin t, li thp Ngt, bnh: b trung ch kh Ngt, bnh: li thp Ngt, bnh: b trung ch kh, ho trung Cay, ng, m: l kh, iu trung Cay, n: h kh nghch, tiu m Liu 12g 12g 12g 12g 8g 6g 6g 8g Vai tr T T Qun Thn Thn T Thn T

+ Nu bnh nhn chn n, ngi mt mi, i tin phn nt th gia thm bch trut, ng sm mi th 10g; phc linh 12g. + Nu lm ging, bun nn th gia thm trn b, bn h ch mi th 10g. 4.2.2. n trung hnh thy Mc ch: + Li tiu: do trch t, phc b, phc linh v thng qua tc dng tng cardiac output v lm tng lu lng mu ti thn ca ph t ch, hong k. + Kch thch tiu ho thng qua s bi tit dch v ca qu chi, can khng, xuyn tiu, hu phc. + Ci thin chuyn ho protein gan, gim amoniac mu, bo v t bo gan ca hong k, ph t ch, phc linh. C th trong chng t thn dng h dng bi Ph t l trung gia gim
V thuc Ph t ch Qu chi Can khng Phc linh Hu phc Trch t i phc b Xuyn tiu Hong k Tc dng Cay, ngt, rt nng: tr dng, n b mnh mn Cay, ngt, m: tn hn, hnh huyt, li thu Cay, m: tr dng, tr hn, ch thng, tr u th Ngt, nht, bnh: kin t, li niu, thm thp ng, cay, m: hnh kh, tiu tch Ngt, nht, mt: thanh t thp nhit bng quang Cay, ng m: thng tin, li thp Cay, nng: n trung, ch thng Ngt, m: b kh, thng dng kh ca t Liu 12g 6g 6g 12g 6g 12g 12g 6g 12g Vai tr Qun Thn Thn Thn Thn Thn Thn Thn Thn

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+ Nu bnh nhn ph nhiu, mt mi, kh th c th tng trch t, i phc b 20g, hong k 20g. + Nu mt mi ch tng hong k 20g. 4.2.3. T m li thp Mc ch + Li tiu: trch t, bch trut, phc linh, r c tranh. + Bo v t bo gan bng tc dng c ch min dch nh thc a. + Tng chuyn ho m ti gan nh: an sm, trch t, phc linh, bch trut. + Cung cp cc acid amin nh hoi sn. + Cm mu: thc a. + H st: n b. C th trong chng m h thp nhit dng bi Lc v a hong gia gim
V thuc Thc a Sn th Hoi sn Phc linh an b Trch t Bch trut ng quy a ct b Bch mao cn Tc dng Ngt, hi m: dng huyt, b thn m Chua, hi m: n b can thn Ngt, bnh: b ph thn, sinh tn, ch kht Ngt, nht, bnh: kin t, li niu, thm thp Cay, hi lnh: thanh huyt nhit, tn huyt Ngt, nht, mt: thanh t thp nhit bng quang Ngt, ng, hi m: kin t to thp Ngt, cay m: dng huyt, hot huyt Ngt, lnh: lng huyt, thanh ho Ngt, hn: lng huyt, ch huyt Liu 12g 8g 12g 8g 8g 8g 12g 8g 12g 20g Vai tr Qun Thn Thn Thn Thn Thn Thn Thn Thn

+ Nu biu hin xut huyt khng thuyn gim th b trch t; tng thc a 40g, bch mao cn 40g. + Nu c st cao th tng liu n b v a ct b 20g; gia thm sinh a 20g hoc tng thc a 40g. 4.2.4. Cng h trc thy Mc ch + Li tiu mnh: khin ngu, cn b, hi to, i kch, nh lch. + Ty x: khin ngu, i hong, hc su. 208

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C th: trong chng thu kh tng kt dng bi Thp to thang


V thuc Nguyn hoa Cam toi i kch i to Tc dng Tnh m, c c: trc thu, tiu m, gii c ng, lnh, c c: trc thu m tam tiu, tn kt tiu thng ng, lnh, c c: trc thu m tng ph Ngt, bnh: b trung, ch kh, ho hon dc tnh Liu 4g 4g 4g 10 qu Vai tr Qun Thn Thn T, s

Nu khng thuyn gim dng bi Thin kim i phc thy


V thuc Khng hong Khin ngu Cn b Hi to Qu tm nh lch Tc dng Cay, ng, m: hnh huyt, kh ng, lnh: cng trc thu m V mn, tnh hn: li thu nhuyn kim ng, mn, lnh: thanh nhit, li thu, tit Cay, ngt, m: thng kinh hot huyt, li thu Cay, ng, lnh: trc thu, tiu m ph v bng quang Liu 4g 10g 12g 10g 6g 12g Vai tr Qun Thn Thn Thn

+ Nn kim tra ion khi dng thuc cng h trc thy ko di. 4.2.5. Hnh kh ho Mc ch: gin mch, chng s ngng tp tiu cu gy tnh trng thuyn tc trong h tnh mch ca nh xch thc, xuyn khung, hng hoa, o nhn, an sm, nga trut. C th: trong chng kh tr huyt th dng bi Cch h trc thang
V thuc o nhn Hng hoa ong quy Xch thc an sm Tam lng Nga trut Hng ph ch Ch xc Tc dng ng, ngt, bnh: ph huyt, hnh , ph trng h tch t Cay, m: ph huyt, cha trng h tch t Dng can huyt, hot huyt ng, chua, hi lnh: hnh huyt ng, hi hn: hot huyt, ho , tiu tch, ph thng ho tch t ng, bnh: ph huyt, khu , cha trng h tch t Cay, ng m: ph huyt, khu , hnh kh, ch thng ng, ngt, bnh: s can l kh ng, chua, lnh: ph kh, tiu tch Liu 12g 8g 12g 20-30g 12g 8g 8g 8g 8g Vai tr Qun Qun T Thn Qun Qun Qun Thn Thn

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T lng gi 1. Du hiu lm sng no sau y khng phi l hu qu ca s mt chc nng khi t bo gan

A. Vng da B. C trng C. au vng gan D. Lit dng E. Sao mch


2. Du hiu cn lm sng no sau y l hu qu ca s mt chc nng khi t bo gan

A. Tng SGOT B. Ko di thi gian prothrombin C. Tng globulin mu D. Tng SGPT E. Tng gamma glutamyl transferase
3. Du hiu lm sng no sau y l hu qu ca tng p lc tnh mch ca

A. Lch to B. Ph 2 chn C. Xut huyt di da D. Lit dng E. V kinh


4. Trong c ch bnh sinh ca chng trng v hong n, ri lon cng nng ch yu nm tng

A. Tm B. Can C. T D. Ph E. Thn
5. c im cn lm sng ca x gan do ru l

A. Ammoniac mu tng cao B. Albumin mu gim nhiu


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C.

SGOT SGPT

>2

D. Thi gian prothrombin ko di E. Gamma globulin tng cao


6. c im cn lm sng ca x gan do mt nguyn pht l

A. Transaminase tng B. Bilirubin tng +++ C. Albumin mu gim D. Prothrombin time ko di E. Amoniac mu tng
7. X gan do tim c t ra khi ngoi du hiu x gan c trng bnh nhn cn c triu chng

A. au vng h sn phi B. Kh th C. Suy tim phi D. Ph ton thn E. Gin tnh mch di li
8. Triu chng no sau y khng gp trong th can ut t h

A. Chn ph B. Chn n C. Tc nng vng gan D. i tin phn nt E. Bng trng


9. Triu chng no sau y khng gp trong th t thn dng h

A. S lnh B. Chn ph C. Bng trng D. Hot tinh E. Tay chn lnh


10. Triu chng no sau y khng gp trong th m thp h nhit

A. C trng
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B. Chn ph C. St hm hp D. Sc mt trng nht E. Chy mu da nim


11. Triu chng no sau y khng c trong th kh tr huyt

A. au tc hng sn B. Bng trng C. Ngi gy D. Mi li tm E. Mch khn


12. Ch nh dng corticoid cho ngi x gan do ru khng c t ra khi bnh nhn c

A. Bnh cnh no gan B. Amoniac mu tng C. Ch s driscriminat fraction > 32 D. Xut huyt tiu ho E. Tt c trng hp trn
13. ngn nga nguy c gy bnh cnh no gan v hi chng gan thn trong khi s dng thuc li tiu, cn phi theo di

A. Cn nng mi ngy B. Lng nc vo ra mi ngy C. Ion mu v nc tiu D. Lng m trong ch n mi ngy E. Du tnh mch c xp mi ngy
14. ngn nga bnh cnh no gan xy ra sau khi xut huyt do v gin tnh mch thc qun, phng php no sau y khng cn thit

A. n nh huyt ng hc B. Tht tho phn C. S dng lactulose D. S dng ornitin carbamin transferase E. S dng neomycin
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15. Chn on hi chng gan thn khng da vo

A. Na+ niu < 5mEq/24h B. HA tm thu < 90mmHg C. Creatinin mu tng D. V niu E. C trng tng nhanh
16. Tc dng dc l no sau y khng c trong php tr n dng hnh thu

A. Li tiu B. Ty x C. Ci thin chuyn ho protid gan D. Bo v t bo gan E. Kch thch tiu ho


17. Tc dng dc l no sau y khng c trong php tr t m li thp

A. Li tiu B. c ch min dch C. c ch virus vim gan B D. Tng chuyn ho m ti gan E. Cm mu


18. Tc dng dc l no sau y c trong php tr hnh kh ho

A. Li tiu B. Ty x C. Chng ngng tp tiu cu D. Cm mu E. Ci thin chuyn ho protid gan

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Bi 13

SI MT

MC TIU 1. Trnh by c c ch bnh sinh ca 3 loi si mt theo YHH. 2. Trnh by c c ch bnh sinh ca si mt theo YHCT. 3. M t c cc triu chng ca si mt theo YHH v YHCT. 4. Lit k cc ch nh iu tr si mt theo YHH. 5. Phn tch cch cu to bi thuc YHCT iu tr si mt theo dc l c truyn v dc l hc hin i.

1. NH NGHA C ch v s bi xut mt: mt trong gan l mt dung dch ng trng vi thnh phn in gii nh huyt tng. Trong khi mt trong ti mt li khc vi mt trong gan do cc ion clo v bicarbonat c hp thu qua lp biu b ca ti mt. Thnh phn ca mt gm 82% l nc, 12% l acid mt, 4% l lecithin v cc phospholipid cn cholesterol khng este ho ch chim 0,7%. Nhng thnh phn cn li nh bilirubin kt hp, cc protein (IgA, cht chuyn ho ca cc hormon, nhng protein c chuyn ho gan) nhng cht in gii, cht nhy v nhng cht chuyn ho ca thuc. Acid mt trong gan v trong ti mt cn gi l cc acid mt s cp nh cholic v chenodeoxy cholic vn c tng hp t cholesterol trong gan, c kt hp vi glycin v taurin. Trong khi cc acid mt th cp l deoxycholat v lithocholat vn l cc acid mt nguyn pht b chuyn ho bi cc vi khun trong rut. Ngoi ra cn c mt acid mt th pht l ursodeoxycholat vn l mt d phn ca chenodeoxycholic. Trong mt thnh phn mt bnh thng, t l kt hp vi cholesterol ca glycin v taurin l 3:1. S ho tan ca cholesterol trong mt s tu thuc vo t l gia acid mt v lecithin cng nh nng ca cc thnh phn lipid c trong mt. Chnh s thay i cc yu t ny s a n s thnh lp si mt.

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Vai tr ca acid mt khng nhng gip cho s bi xut cholesterol theo ng mt d dng m cn cn thit cho s hp thu cht m vo trong rut, thc y s lu thng dng mt trong gan cng nh s chuyn ch cc mui in gii v nc rut non v rut gi. Chu trnh chuyn ho ca acid mt tu thuc vo dng tun hon gan rut. Phn ln cc acid mt hp thu qua c ch chuyn ch ch ng cui hi trng, t chng s theo h tnh mch ca v gan, c hp thu ti t bo gan, ri uc ti kt hp v ti bi tit. Trung bnh mi ngy s c mt lng mt t 2 - 4g chu chuyn theo vng tun hon gan - rut khong 5 ln m trch vic tiu ho cht m v ch tht thot theo phn khong t 0,3 0,6g/ngy. Tuy nhin vi tc sn xut mt gan ti a l 5g/ ngy th vic tht thot mt qua phn trong nhng bnh l ca rut (v d nh bnh Crohn) nht nh s a n bnh l tiu phn m.
Cholesterol Bnh thng

Tng hp 0,5g acid mt mi ngy Acid mt >4mM Hng trng Na 0,5g acid mt i trng Hi trng

S bi xut acid mt vo rut cn tu thuc vo chc nng ca ti mt v c vng Oddi vi c ch iu ho ca mt hormon l cholecystokinin (CCK) vn c bi xut t nim mc t trng p ng cho vic tiu ho cht m v cc acid amin trong thc n, tc dng CCK l: Gy co bp ti mt. Gin c vng oddi. Tng s bi tit mt ca gan a n s thc y mt bi xut vo t trng. Si mt gp rt nhiu cc nc phng Ty. Ring ti M chng xut hin khong 20% n gii v 8% nam gii trong tui 40. Tnh trung bnh nm c khong 1 triu trng hp mi. Ring v loi si sc t (vi thnh phn chnh l calcium bilirubinat) li thng xut hin cc nc Vin ng v c lin quan mt thit vi bnh l nhim trng ng mt. 2. C CH BNH SINH 2.1. Theo y hc hin i 2.1.1. Si cholesterol (80%) Loi si thnh cholesterol monohydrat chim 50% m c ch c th l do: 215

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S siu bo ho thnh phn cholesterol trong dch mt: hu qu ca s mt cn i ca cc men hn ch tc tng hp cholesterol gan (tng hot men hydroxymethyl glutaryl co-enzym A, gim hot men 7 O.H.ase v 7 hydroxylase). S to nhn ca cholesterol monohydrat a n s ng cc tinh th cholesterol khi u cho vic ln dn ca khi si, trong c s mt cn bng t l gia yu t gy nhn si l mucin v yu t chng gy nhn si l apolipoprotein AI , AII. S gim vn tnh ca ti mt. 2.1.2. Mt bn Mt bn l mt cht nhy ng c gm cc tinh th cholesterol, lecithin, tinh th cholesterol monohydrat, calcium lilirubinat, si mucin v cht nhy. S hin din ca chng ni ln: ang c bt thng trong s bi tit v thi tr thnh phn mucin trong dch mt. ang c hin tng to nhn ca cc thnh phn trong dch mt. Qua theo di 96 bnh nhn c mt bn bng siu m, ngi ta nhn thy: 18% bin mt v khng xut hin li trong thi gian 2 nm. 60% bin mt ri li ti xut hin. 16% pht trin thnh si mt. 6% xut hin cn au qun mt. C 2 tnh trng lin quan n s thnh lp si cholesterol v mt bn: Thai k: c bit l trong 3 thng cui c s thay i thnh phn ca lng mt tham gia tiu ho (bile acid pool) v kh nng chuyn ch cholesterol ca mt khin cho hin tng siu bo ho cholesterol xy ra ng thi vn tnh ca ti mt cng gim a n ng mt. Ngi ta nhn thy trong thai k mt bn xut hin n 30% trng hp v si mt xut hin n 12% trng hp. Tuy nhin, chng li c th bin mt mt cch t nhin sau khi sinh n. Ch n gim cn nhanh 520 Kcalo/ngy trong 16 tun c th xut hin si mt (10 - 20%). 2.1.3. Si sc t (20%) Si sc t c thnh phn chnh l calcium bilirubinat, trong khi cholesterol chim t l di 20%. C ch hnh thnh si sc t l do s c mt qu nhiu s lng bilirulin khng kt hp trong dch mt. S c mt bilirubin khng kt hp ny (mono 216

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v digluconat) l do bi cc enzym ni gluronidase hoc c th do thu phn ancalin, m nhng tnh trng ny c th xy ra trong qu trnh nhim trng mn tnh

iu c bit l si sc t rt thng gp ngi chu v cng thng phi hp vi nhim trng ung mt

2.2. Theo y hc c truyn Si mt (ti mt v ng mt) vi cc triu chng au lin sn phi, bun nn, nn ma v cc ri lon tiu ho hoc thm ch l vng da, thuc phm tr chng can kh thng v hong n m nguyn nhn c th l do n ung tht iu hoc do ri lon chc nng vn ho ca t trc a n ri lon cng nng s tit ca can m, t m trp b ng m sinh ra thp, thp ut kt sinh ra nhit (trng hp bin chng thnh vim ng mt); ng thi ri lon cng nng s tit ca can a n can kh ut kt gy au v can kh honh nghch khin cho v kh bt ging np gy nn ma, hi.

N UNG THT IU

S tit V CAN S tit M THP NHIT T BNH LU NGY

3. CHN ON 3.1. Theo y hc hin i 3.1.1. Triu chng lm sng Cn au qun mt (biliary colic) vi cm gic au d di hoc tc nng vng thng v hoc h sn phi vi hng lan ln gia hai vai hoc vai phi. Cn au thung khi pht kh t ngt, ko di t 30 pht n 5 gi, sau du dn hoc bin mt rt nhanh. Mt t au qun mt nh th thng ko theo cm gic m, cng tc vng h sn c ngy hoc hn. Bun nn, nn ma thng xy ra trong cn.

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St hoc n lnh trong cn au cn phi ngh n cc bnh chng c th c nh vim ti mt, vim ng mt trong gan, vim ty Nhng cm gic m h nh y bng, ri lon tiu ho, hi, si bng, c bit l sau khi n thc n c m, khng nn ln ln vi cn au qun mt. Nhng triu chng trn khng c hiu cho si mt, trong khi cn au qun mt cn c th xy ra bi mt ba n thnh son sau khi nhn i qu lu hoc thm ch c th xut hin sau mt ba n thng. 3.1.2. Xt nghim chn on a. Sinh ho Bilirubin tng Phosphatase alkamin tng C hai ch s trn u gi si ng mt ch. b. Siu m Siu m gan mt cho kt qu rt chnh xc k c mt bn (t l dng gi v m gi vo khong 4% v 2%). Ngoi ra cn nh gi c chc nng bi xut ca ti mt. c. X. quang Thng ch pht hin khong 10 - 15% si cholesterol c kt hp v 50% si sc t, nhng vn dng chn on vim ti mt trng kh (emphysematous). Oralcholecystoquaphy c ch trong s kho st cc nhnh mt v vn ng ca ti mt, ngoi ra cn c th xc nh kch thc v s lng si mt. Radio pharmaceutical 99mTc labeled N. Substituted Iminodiacetic acid (HIDA, DIDA, DISIDA) dng xc nh mt tnh trng vim ti mt cp, thng dng chn on cc bnh v ti mt khng phi l si mt v kt hp vi CCK kho st vn tnh ca ti mt. 218

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3.2. Theo y hc c truyn 3.2.1. Th kh tr au vng h sn phi m hoc qun tng cn km bun nn, nn ma v cc triu chng ri lon tiu ho khc nh y bng, si bng, hi xy ra sau n, ru li trng mng, mch huyn. 3.2.2. Th thp Triu chng nh trn nhng km theo vng da, ru li vng dy nht, mch huyn hot. 4. IU TR 4.1. Theo y hc hin i Ursodeoxycholic acid vi liu 8 - 10mg/kg/ngy c th gim c 50% trng hp si khng cn quang vi kch thc di 10mm trong thi gian t 6 thng - 2 nm; thnh cng n 70% si khng cn quang, cn di ng c kch thc di 5mm. Tuy nhin t l ti pht t 30 - 50% trong thi gian t 3 - 5 nm. Shork wave km vi thuc lm tan si c hiu qu v an ton vi nhng si khng cn quang c kch thc di 2mm v ti mt cn hot ng tt. Tuy nhin t l ti pht l 30% sau 5 nm. 4.2. Theo y hc c truyn Mc ch: 219

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+ Li mt: tng cng s bi tit dch mt nh kim tin tho v cht 6 dimethoxy coumarin ca nhn trn v paratolyl methyl carbinol ca ut kim. + Tng mt: lm gin c vng Oddi nh: nhn trn, ut kim (curcumin). + Co bp ti mt: chi t. Dng bi thuc theo hng hnh kh, gii ut v thng lm li thp, gm:
V thuc Kim tin tho Chi t Nhn trn Ch xc Ut kim ng, lnh: thanh nhit li thp ng, chua, lnh: ph kh tiu tch, hot huyt, ch thng Ph kh tiu tch, hot huyt, ch thng Tc dng V ngt, mn, tnh hn, vo can, m: thng lm li thp v thanh nhit Liu 40g 12g 12g 8g 8g Vai tr Qun Thn Thn T T

Trong : + Theo th kh tr, ta c th gia thm hng ph, mc hng mi th 8g tng tc dng l kh ch thng. + th thp c th gia thm i hong 8g tng tc dng ho thp. Ngoi ra vic s dng mt ngan (vt xim) trong vic iu tr si mt cholesterol cn ang nghin cu.

T lng gi 1. C ch no sau y khng tham gia trong qu trnh to si mt cholesterol

A. S siu bo ho thnh phn cholesterol trong dch mt B. S to nhn ca cholesterol monohydrat C. S mt cn bng trong bi tit v thi tr mucin trong dch mt D. S nhim trng ng mt E. S gim co bp ca ti mt
2. C ch no sau y khng tham gia trong qu trnh to si mt sc t

A. S nhim trng ng mt B. S siu bo ho thnh phn bilirubin khng kt hp


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C. S gim co bp ca ti mt D. S gia tng t l mucin trong dch mt E. S gia tng t l apolipoprotein trong dch mt
3. C ch bnh sinh ca si mt theo YHCT l

A. Can kh ut B. V kh bt ging C. Thp nhit can m D. Ri lon cng nng s tit ca can m E. Ri lon cng nng s tit ca can
4. Triu chng no sau y thng xy ra trong cn au qun mt

A. y bng B. hi C. Si bng D. St E. Bun nn


5. K thut cn lm sng no sau y tin li v chnh xc cho vic chn on si mt

A. Siu m B. X quang khng sa son C. Chp ti mt cn quang D. o bilirubin mu E. o phosphatase alkalin


6. K thut cn lm sng no sau y gip nh gi chnh xc kch thc v s lng si mt

A. Siu m B. X quang bng khng chun b C. Chp ti mt cn quang D. Ni soi mng bng E. Radio pharmacertical
7. Ursodeoxycholic acid c ch nh cho si mt:

A. Khng cn quang, khng di ng, nh hn 0,5mm B. Cn quang, di ng, nh hn 1cm


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C. Khng cn quang, khng di ng, nh hn 1,5cm D. Khng cn quang, i ng, nh hn 0,5cm E. Cho cc loi si khng cn quang
8. Shork wave kt hp vi ursodeoxycholic c ch nh cho si mt

A. Khng cn quang, khng di ng, nh hn 0,5mm B. Cn quang, di ng, nh hn 1,5cm C. Khng cn quang, khng di ng, nh hn 1,5cm D. Khng cn quang, i ng, nh hn 0,5cm E. Cho cc loi si khng cn quang
9. Trong bi thuc cha si mt (gm: kim tin tho, nhn trn, chi t, ch xc, ut kim) v kim tin tho lm qun v c tc dng

A. Li thp, thng lm B. Li thp, thoi hong C. Li thp, thanh nhit D. Ph kh, tiu tch E. Hot huyt ch thng
10. Trong bi thuc trn, v thuc no sau y c c hai tc dng li mt v tng mt

A. Kim tin tho B. Ut kim C. Nhn trn D. Chi t E. Ch xc

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Bi 14

NHIM TRNG tit niu

MC TIU 1. Nu c nh ngha v cc yu t nguy c gy nhim trng tit niu. 2. Nu c cc loi vi khun thng hin din trong nhim trng tit niu. 3. Trnh by c 2 c ch xm nhp ca vi khun trong nhim trng tiu v phn tch c cc yu t to thun cho nhim trng tit niu. 4. Trnh by c c ch bnh sinh ca nhim trng tit niu theo YHCT. 5. Nu c 6 tiu chun chn on xc nh nhim trng tit niu bng phng php cy nc tiu. 6. Trnh by c cc th lm sng ca nhim trng tit niu theo YHCT. 7. Nu c 7 nguyn tc trong iu tr nhim trng tit niu v phn tch c c s l lun iu tr nhim trng tit niu theo YHCT.

1. I CNG Nhim trng tit niu c 2 loi: Nhim trng cht c cha ng (tc l nc tiu) vi ngha l c s hin din ca vi trng trong nc tiu vi mt cao. Nhim trng vt cha ng (tc l vim nhu m thn hay ng tit niu trn hoc di). Nhim trng tit niu bao gm c nhim trng vt c cha ng ln vt cha ng. Trong 2 yu t (s hin din ca vi khun v vim ng tit niu) th s hin din ca vi khun l ch yu. Bnh thng, trong iu kin t nhin c t nht 3 c ch bo v chng nhim trng ca h tit niu: + Dng nc tiu y tri, loi b vi trng xm nhp ngc dng.

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+ Nim mc bng quang trong trng thi bnh thng c yu t nim mc (muscular factor) c ch s sinh sn ca vi trng. + Nc tiu vi pH acid v thm thu cao cng c ch s sinh sn ca vi trng. 1.1. Phn loi Nhim trng ng tit niu thng c phn lm 2 loi: Nhim trng ng tit niu di gm bng quang, niu o, tin lit tuyn. Nhim trng ng tit niu trn gm vim i b thn, p xe thn v quanh thn. Hai loi trn c th xy ra cng lc hoc c lp, c th c triu chng hoc khng, trong nhim trng bng quang v niu o l nhim trng nng (nim mc), cn nhim trng i b thn v tin lit tuyn l nhim trng m. Tiu chun chn on nhim trng ng tit niu l i tiu ra vi khun vi s lng 105 khm vi trng trong 1ml nc tiu (ly gia dng). Tuy nhin vi s lng 102 - 104 khm vi trng trong 1ml nc tiu ly bng phng php chch ht bng quang trn xng mu hoc qua ng thng hoc trn bnh nhn ang t ng thng tiu cng xc nh chn on l nhim trng ng tit niu. S nhim trng ng tit niu ti i ti li cn c phn lm 2 loi: Ti pht l s nhim trng tit niu tr li do cng mt dng vi khun sau khi kt thc mt liu trnh iu tr. Ti nhim l s nhim trng tr li bi mt dng vi khun khc sau khi kt thc mt liu trnh iu tr. Trong s ti pht xy ra trong 2 tun sau khi kt thc mt liu trnh iu tr thng l do hu qu ca mt nhim trng tin lit tuyn hoc thn cha c gii quyt xong hoc mt nhim trng m o hoc rut cha c ch ng mc (ring ph n). 1.2. c im dch t hc Nhim trng tit niu l bnh thng thy nht trong niu hc. T l nhim trng tit niu thay i ty tng qun th: ti phng khm t l ny l 3,5% i vi ngi ln v 1,6% i vi tr em; trong mi trng ni tr ca bnh vin c khoa tit niu t l ny l 24%, cn chnh ti khoa tit niu t l ny l 78%. Loi nhim trng mc phi trong cng ng: y l loi nhim trng rt thng gp ph n, c tnh khong 6 triu ngi/nm. n, t l ny l 224

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1% - 3% v cn tng ln khi c hot ng tnh dc hoc dy th. Theo thng k, ngi ta nhn thy s song hnh gia i ra vi trng vi hi chng niu o cp nh i kh, i lu, mt i. Hi chng ny t xy ra n ng di 50 tui nhng li rt thng gp ph n tui t 20 - 40. Ngoi ra, i ra vi trng l triu chng rt thng gp ngi cao tui (40% - 50%). 1.3. Quan nim nhim trng tit niu theo YHCT Cc y gia YHCT gi tiu tin nh git au but, tiu tin t m i lin lin, bng di cng cng au lan n rn l hin tng chung ca chng lm. Ngoi ra chng lm cn ni n hin tng tiu tin ra si hoc nh ct nh, hai khi nim ny cng ln vo nhau. C 5 chng lm l thch lm (si), kh lm (tiu tin sp tr thng nh git cha ra ht), huyt lm (tiu ra mu), cao lm (i ra cht nhn c nh m), lao lm (tiu nh git khng dt). 2. NGUYN NHN, BNH SINH 2.1. Nguyn nhn gy bnh c th gy nn nhim trng tit niu phi c 2 iu kin: vi khun lt c vo trong ng tit niu v nhng thng tn tn tr cho vi khun sinh sn. Yu t quyt nh: nhng vi khun gy bnh. 2.1.1. E. Coli Chim 80% trong cc nhim trng tit niu khng do th thut niu khoa, khng do bt thng gii phu hc h niu v khng do si. 2.1.2. Cc trc khun Gram (+) Cc trc khun Gram (+) nh: Proteus, Klebsiella, Enterobacter chim t l nh trong cc nhim trng tit niu th pht. Tuy nhin s c mt ca chng cng vi vi khun Serratia hoc Pseudomonas li gi n cc yu t tham gia nh si, bt thng cu trc h tit niu cng nh t l ti pht thng cao. 2.1.3. Loi cu trng Gram (+) Cc loi cu trng Gram (+) nh: Staphylococcus saprophyticus chim 10 - 15% nhim trng tit niu cp thiu n, Enterococcus thng gp trong vim bng quang cp ph n. Ngoi ra Enterococcus v Staphylococcus aureus thng gy nhim trng tit niu ngi c si thn hoc c lm th thut niu khoa gn y cng nh s phn lp c Staphylococcus

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aureus trong nc tiu cng gi n nhim trng tit niu thn do Bacteriemia. Thng thng c khong 1/3 ph n c hi chng niu o cp nhng nc tiu li cha t vi trng hoc v trng, trong s c n 3/4 ph n i ra bch cu (i ra m) v 1/4 khng c triu chng no c. nhng ph n i ra bch cu c th c trng hp cy nc tiu vi s lng 102 - 104 khm vi trng vi cc loi thng gp nh E. coli, Saprophyticus, Proteus, Klebsiella; nhng cng c trng hp ch c hi chng niu o cp cn nc tiu th hon ton v trng. Trong trng hp ny nn i tm cc vi trng gy bnh qua ng tnh c nh Chlamydia trachomatis, lu cu v Herpes simplex virus. 2.1.4. Vi khun Ureaplasma Vi khun Ureaplasma urealyticum v Mycoplasma honimis c th gp trong vim tin lit tuyn v i b thn. 2.1.5. Adenovirus Adenovirus gy vim bng quang xut huyt tr em v thiu nin, c th pht trin thnh dch nhng khng quan trng trong vic gy nhim trng tit niu. 2.1.6. Mycobacterium Mycobacterium tuberculosis gy lao h tit niu chim 15% trng hp lao ngoi phi. Hi chng ny gm: i kh, i mu, au vng eo lng, tuy nhin cng c th khng biu hin triu chng no c, phn tch nc tiu cho thy 95% c i mu v i m. Do khi bnh nhn c i mu v i m, cy vi trng (-) cng vi pH nc tiu acid th nn ngh n lao h tit niu. Lc nn chp h niu c sa son (IVP) cng vi cy nc tiu vo 3 bui sng lin tip s chn on xc nh n 90% trng hp. 2.1.7. Candida albicans Nhim trng ng tit niu do Candida albicans thng t cc th thut niu khoa. chn on nn cy nc tiu ly t ng thng tiu hoc t cn nc tiu bng quang. S hin din ca Candida trong phng php cy nc tiu gia dng c th l do nhim bn. Nhim trng tit niu do Candida c th a n hoi t nh thn v tc ng tiu. 2.2. C ch xm nhp ca cc vi trng gy bnh Vi khun xm nhp vo gy bnh theo 3 ng: ng dch th tc ng mu, ng bch dch. 226

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ng ngc dng nh t niu o vo bng quang, t niu qun ln thn. ng trc tip qua ng thng tiu, th thut ni soi... Trong ng xm nhp ca vi khun ngc t di ln l con ng thng hay thy nht trong nhim trng ng tit niu. Nhng loi vi khun ca rut thng tr li m o, ming l tiu, vng quanh m h ca phi n, niu o trc ca nam v n, sau di chuyn vo trong bng quang gy thng tn v thng ngng y. Nhng nhim trng vn c th pht trin ln ng niu qun v thn. Trong khi nhim trng i b thn do ng mu thng xy ra nhng bnh nhn b suy kit do bnh mn tnh hoc nhng bnh nhn ang dng thuc c ch min dch. 2. 3. Yu t thun li ph n tr, yu t to thun li cho s nhim trng tit niu l khong cch gia hu mn v l tiu qu gn (4cm), s s m trong khi giao hp v s thay i vi khun ch bnh thng do s dng mng chn m o v thuc dit tinh trng. n ng vim v ph i tuyn tin lit tuyn, c bit nhng ngi n ng mc bnh ng tnh luyn i cng d dng nhim trng ng tit niu. Ngoi ra nhng ngi b nhim HIV vi CD+4 T cell di 200/l huyt tng cng d dng nhim trng tit niu. Thai k: t l nhim trng tit niu xut hin t 7 - 8% trong thai k, trong khong 20 - 30% i ra vi trng m khng c triu chng v s a n vim i b thn. C ch l do gim trng lc c trn niu o, bng quang v van ni niu qun - bng quang. Tc nghn ng niu do ph i tuyn tin lit, si, bu hoc so. Ri lon chc nng bng quang do thn kinh nh tn thng ty sng, tabes, x cng ct bn teo c hoc i ng. Nhng bnh nhn ny thng b ng nc tiu, kt hp vi tnh trng tng calci niu do nm lu a n thnh lp si niu cng vi thng phi t thng tiu nn rt d b nhim trng tit niu. Hi lu bng quang - niu qun (vesicoureteral reflux) do bt thng ng niu v mt gii phu hc, trong trng hp ny tin hnh chp cn quang bng quang niu o trong lc i i (voiding cystoureterocpraphy). 2.4. c lc ca vi khun E. coli v proteus vi nhng tua fimbriae gip bm vo cc th th ca biu b h niu. E. coli cn c cc P. pilus v Gal - Gal pilus bm vo cc thnh phn digalactosid v glycosphingolipid trn t bo biu b ca ng niu. 227

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Ngoi ra cc vi khun cn tit ra cc hemolysin v aerobactin i khng li khng th ca huyt thanh. 2.5. Yu t di truyn S lng v loi tip th th trn cc t bo biu b ng niu c vai tr quan trng trong s xm nhp ca vi khun. C nhiu thnh phn antigen ca nhm mu hin din ng thi trn b mt hng cu v trn b mt biu b h niu. Error!
Yu t quyt nh Yu t tn tr

Vi khun sinh bnh ( nhim trng)

khng yu Nhim c c th, thn

Ngc dng Hn lon thn kinh c ng tiu

ng nc tiu B tc ng tit niu

Thng tn

- Chn thng
- Si - Bu - Chy in

ng xm nhp

Mu

Bch dch nhim trng

Bch dch - mu

ng tiu trc tip

- Da, mn nht - H hp: vim bch hu, phi - Rut: vim rut non, rut gi - Xng: vim ty sng - Rng hm mt: su rng, vim li - B phn sinh dc: vim vi, vim tin lit tuyn

Th thut v phu thut niu khoa

- Xm nhp thng - R r - Ming niu qun lc ch

Hnh 14.1. S tm lc nguyn nhn nhim trng tit niu 2.6. Nguyn nhn bnh sinh theo y hc c truyn Nhim trng tit niu vi hi chng niu o cp thuc phm tr chng lm theo YHCT m nguyn nhn khng ngoi cm nhim thp nhit t. Biu hin lm sng u tin l nhit lm. Nhit ut kt ha ha s gy nn bc huyt gi l huyt lm. Thp nhit ut kt lu ngy s to nn si niu gi l thch lm. Chng lm ko di lu ngy hoc tr i ti li nhiu ln gi l lao lm.

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THP NHIT T

PH BNG QUANG

THP NHIT UT KT

NHIT LM

THCH LM

HUYT LM

LAO LM

Hnh 14.2. S c ch bnh nhim trng tit niu theo YHCT

3. CHN ON 3.1. Chn on theo y hc hin i Chn on lm sng nhim trng tit niu: nhng biu hin lm sng ca nhim trng tit niu l vim ng tit niu v nhim c. Nhim c gy st, mt mi; vim ng tit niu di lm i but, i nhiu ln, i mu; vim ng tit niu trn v thn sinh au lng, i m hoc protein niu. Cc biu hin lm sng ca nhim trng tit niu thng khng gip cho chn on cng nh nh v c ch nhim trng l ng tit niu trn hay di. C nhiu bnh nhn i ra vi trng m li khng c du hiu lm sng no c. Cng nh c nhng ngi c i ra vi trng v c hi chng niu o cp th khong 2/3 l nhim trng ng tit niu di v 1/3 l nhim trng ng tit niu trn. ph n c triu chng i kh v i rt th ch 60 - 70% trng hp l c i ra vi trng. Theo kinh in, chn on xc nh l nhim trng tit niu th s lng khm vi trng cy c trn mt mu nc tiu ly gia dng phi hn 105 khm/1ml nc tiu. Tuy nhin: + Nu ph n c triu chng i ra m (bch cu): s lng khm vi trng cy c trn mt mu nc tiu ly gia dng ch t 102 - 104 khm vi mt trong cc dng nh E. Coli, Kleb v Proteus hoc S. Saprophyt cng chng t l nhim trng tiu. 229

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+ ngi nhim trng tiu khng triu chng nu 2 mu nc tiu cy gia dng c s lng 105 khm vi trng cng mt dng vi trng th chc chn khng phi l nhim bn. + S lng khm vi trng cy c t mu nc tiu ly i b thn v niu qun d di 105 khm/1ml cng vn khng nh c l nhim trng tit niu. + Chc ht nc tiu t bng quang trn xng mu cy c vi trng cng c th chn on (+) bt k s lng khm vi trng nhiu hay t. + S lng khm vi trng cy t mu nc tiu ly bng ng thng d ch 102 khm vi trng/1ml cng c chn on (+). Ngoi ra nhng k thut pht hin s tng trng ca vi khun nh Photometry, Bioluminescen sau 1 - 2 gi cng cho kt qu chnh xc n 90%. S hin din ca bch cu trong nc tiu l mt du hiu hng c trong nhim trng tit niu c triu chng. S vng mt ca bch cu trong nc tiu l mt iu khng th c trong nhim trng tiu. Ngoi ra ngi ta c th dng leucocyt esterase dipstick thay th cho vic soi tm bch cu trong nc tiu. Tiu tin ra m (c bch cu trong nc tiu) m cy vi trng m tnh th nn ngh ti vi trng Trachomatis, Urealyticum, lao v nm. Ngoi ra tiu tin ra m cn gp trong si niu, bt thng h tit niu v mt gii phu hc, calci ha thn, hi lu bng quang - niu qun, vim thn m k v thn a nang. Sau y l cc th lm sng ca nhim trng tiu. 3.1.1. Vim bng quang Vi triu chng i kh, i dt v mt i cng vi au trn xng mu, nc tiu c v mi khai. 30% c i mu, khi c st > 3805 C nn ngh n vim i b thn cp. Chn on xc nh bng phng php cy, ph n thng s lng khm vi trng ch khong 102 - 104 /1ml v soi knh hin vi sau khi nhum Gram thng m tnh. Trong trng hp ny nn khm niu o v m o v kho st dch tit (ch n cc vi khun hay gy bnh h sinh dc). 3.1.2. Vim i b thn Vim i b thn pht trin nhanh t vi gi n vi ngy, st 390C vi rt run, nn ma, tiu chy, au c, mch nhanh, au gc sn sng, nc tiu c bch cu hoc tr bch cu.

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Chn on xc nh bng phng php cy hoc soi tm vi trng bng phng php nhum Gram trn mu nc tiu khng ly tm. Ngoi ra c th c i mu, tuy nhin nu i mu ko di phi ngh n si, bu hoc lao h niu. Ngoi tr trng hp c hoi t nh thn hoc tc nghn ng niu, cc triu chng trn s p ng vi khng sinh sau 3 ngy, tuy nhin triu chng i ra bch cu v vi trng vn cn dai dng cng nh trong vim i b thn nng, st vn cn ko di d dng khng sinh thch hp. Hin nay vn cha c phng php chnh xc no chn on phn bit gia nhim trng tit niu trn v di (thn v bng quang). Phng php Fairley qut ra nc tiu ring bng quang v 2 niu qun th tn km v phc tp. Phng php tm antibody coating bacteria trong nc tiu khng nhy cm v khng chuyn bit. S gia tng C. reactive protein gp trong giai on cp ca vim i b thn nhng cng c th gp trong bnh l ni khoa khc 3.1.3. Vim niu o Thng ch gp ph n vi 30% c triu chng i kh, mt i v i m... cy nc tiu c th (+) hoc (-). Nu bnh nhn c mt bnh cnh lm sng m , khng i mu, khng au trn xng mu v ko di 7 ngy th nn khm tm du hiu vim c t cung v nn ngh n C. trachomatis, lu, Herpes simplex virus. Nu bnh nhn c triu chng i mu, au trn xng mu, bnh din tin cp tnh trong 3 ngy v tin cn c nhim trng tiu nhiu ln trc y th ngh n nhim E. coli. 3.1.4. Nhim trng tiu do t ng thng Khong 10 - 15% do cc vi khun Proteus, Pseudomonas, Klebsiella serratia v nguy c nhim s tng 3 - 5% mi ngy. Yu t thun li l n gii, c bnh i km, thi gian t thng tiu ko di, cch t lin tc hay gin on, cch chm sc khi thng tiu v khng sinh phng nga ng hay sai. Vi khun i ln bng quang theo ng ngoi ng v trong ng thng tiu, cc vi khun ngoi ng thng l cc vi khun cng sinh, trong khi cc vi khun trong lng ng thng l cc vi khun gy bnh, chng s sng bn di lp biofilm trong lng ng, to ra cc protein v cc mui chng li khng sinh cng nh s thc bo ca bch cu. Du hiu lm sng rt kn o v rt t, 1 - 2% trng hp gy bacteriemia. 231

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3.1.5. Vim tuyn tin lit bnh nhn tr, nguyn nhn thng l do mc phi t cng ng (community acquired) vi cc vi khun nh E. coli, Klebsiella; trong khi bnh nhn ang t ng thng tiu, vi khun gy bnh thng l trc khun Gram (-) v Enterococcus. Triu chng lm sng l st, n lnh, i kh, tin lit tuyn sng v au khi s nn. chn on xc nh nn cy hoc nhum Gram tm vi khun trn mu nc tiu ly u dng v gia dng, tin lng ni chung l tt. Ngc li vim tuyn tin lit mn tnh thng xy ra la tui trung nin vi triu chng lm sng rt ngho nn ngoi tr du hiu i ra vi trng ti i ti li nhiu ln. chn on xc nh nn cy hoc nhum Gram tm vi khun trn mu nc tiu ly c sau khi xoa bp tuyn tin lit. 3.1.6. p xe thn v quanh thn Khong 75% xut pht t vim i b thn. Thng c yu t nguy c tham gia nh si thn (20 - 60%), cu trc h tit niu bt thng, tin cn chn thng thn v i tho ng. Triu chng lm sng gm rt run (50%), au vng eo lng lan xung hng v i. Nhng yu t khin ngh n p xe thn v quanh thn l st ko di 4 -5 ngy trn 1 bnh nhn b vim i b thn, c si thn, cy nc tiu thy c nhiu loi vi trng hoc v trng. Lc nn tin hnh siu m thn hoc CT. Scan bng c chn on thch hp. 3.1.7. Bin chng Hoi t nhu m thn thng xy ra trn nhng bnh nhn c bt thng mch mu thn hoc tc nghn ng niu vi nhng yu t tham gia nh i tho ng, au sn sng, st n lnh v suy thn cp. Chn on xc nh da vo hnh nh chic nhn (ring shadow) trn hnh chp h tit niu c chun b (pyelography). 3.2. Chn on theo y hc c truyn 3.2.1. Nhit lm Ngoi cc triu chng i kh, i rt, mt i, bnh nhn cn c st, mch hng sc hoc hot sc, li ru vng, au h v chi nn, nc tiu sm c, mi khai nng. 3.2.2. Huyt lm Vi cc triu chng i kh, i au, nng rt ng tiu v c mu trong nc tiu km vi st, mch hot sc hoc nhu sc, li thm hoc c im huyt. 232

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3.2.3. Lao lm Ngi mt mi, au m 2 bn tht lng, tiu lt nht, nc tiu ri r, tiu xong au ngm h b (thng gp trong vim mn hoc ph i tuyn tin lit) hoc thng xuyn i c, i dt, li ru vng mng, mch t sc v lc. 4. IU TR 4.1. Nguyn tc iu tr Cc phng php cy nc tiu, nhum Gram v cc k thut chn on khc phi c thc hin trc khi iu tr. Khi c kt qu cy phi da vo khng sinh iu tr. Xc nh cc yu t tham gia gii quyt trit . Thuyn gim triu chng lm sng khng c ngha l sch vi trng. Sau mt liu trnh iu tr phi nh gi l thnh cng hay tht bi. Nu c nhim trng li, phi xc nh l cng dng vi khun hay khc dng, thi gian ti pht l sm (2 tun sau khi ngng iu tr) hay mun. Sau iu tr, s ti pht xy ra sm v cng mt dng vi khun th c th l c cng lc mt nhim trng ng tiu trn cha c gii quyt xong hoc mt nhim trng khc m o. Trong khi , s ti pht mun thng l ti nhim mt dng vi khun mi. Nhim trng tit niu mc phi trong cng ng v mi b ln u tin thng nhy cm vi khng sinh. Vi bnh nhn b nhim trng tit niu ti i ti li, gn y c ln nhp vin hoc c lm th thut niu khoa th c th do nhn vi cc loi khng sinh. 4.2. iu tr c th theo y hc hin i 4.2.1. Vim bng quang cp Ngi ta c th dng 1 liu duy nht mt trong cc loi thuc sau y: Trimethoprim 400mg, sulfamid 2g, fluoroquinolon, amoxicillin 3g (tuy nhin v 80% vim bng quang cp l do E. coli v E. coli nhn vi amoxicillin trong 1/3 trng hp nn phng php ny t hiu qu). Liu 1 ln duy nht nn dng cho nhng bnh nhn c th theo di c sau iu tr. Ngoi ra, ngi ta c th dng cc loi thuc ni trn vi liu trnh 3 ngy lin tc. Tt nht nn theo liu trnh 7 - 14 ngy c bit n bnh nhn c biu hin vim i b thn, nhng bnh nhn c bt thng cu trc h niu hoc c vi trng nhn thuc.

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ph n nhim trng tit niu do C. trachomatis nn dng doxycyclin 100mg x 2 ln ung/7 ngy. 4.2.2. Vim i b thn cp ph n nu nhim trng tit niu khng km theo si hoc bt thng cu trc niu o th nguyn nhn thng do E. coli nn iu tr bng cephalosporin th h III trong 14 ngy v nn dng ng tim tnh mch trong nhng ngy u. Nu sau 72 gi vn khng c p ng hoc nhim trng tit niu ti pht sau khi ngng liu trnh th phi tm kim thm nhng yu t tham gia. Nu tm khng ra th cng phi iu tr thm 2 - 6 tun na. 4.2.3. Nhim trng tiu c cc yu t thun li tham gia (complicated) nhng th bnh nh nn ung ciprofloxacin cho n khi c kt qu khng sinh . nhng th bnh nng, thng l vim i b thn cp v nhim trng mu, nn nhp vin v s dng thuc bng ng tim truyn. Nn s dng PNC hoc ceftriaxon cng vi aminoglycosides cho n khi c kt qu khng sinh v tip tc iu tr t 1 - 3 tun. 4.2.4. Nhim trng tiu trong thai k Vim bng quang: iu tr t 3 - 7 ngy bng amoxicilin nitrofurantoin, cephalosporin. Sau khi ngng iu tr phi cy li nc tiu v mi thng mi cy cho n khi sinh xong. C th dng khng sinh phng nga nh nitrofurantoin trong sut thai k. Vim i b thn: nn nhp vin v s dng khng sinh nh cephalosporin hoc PNC qua ng tim truyn. i ra vi trng: nu khng c triu chng nn dng khng sinh qua ng ung trong 7 ngy. * Ch : vic iu tr nhim trng tit niu c hiu qu cao nht v trit nht cn phi tm kim cc yu t thun li tham gia vo, c bit l cc bt thng v cu trc h tit niu. Tuy nhin, cc phng php nh gi h tit niu nh PIV, PUR, voiding cystoureterography ch nn thc hin nhng ph n hay b nhim trng tit niu ti pht, c tin cn nhim trng tit niu t nh, c si hoc i mu khng au v trn tt c n ng. 4.3. Tin lng Vim bng quang thng ti nhim hn ti pht, nu ti pht thng kt hp vi vim i b thn. 234

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Vim i b thn cp him a n suy thn chc nng hoc bnh thn mn tnh. N thng ti pht hn ti nhim. i ra vi trng khng triu chng nu khng c bnh l khc i km th khng gy tn thng thn. Nhim trng tit niu trong thai k c kh nng gy non hoc h thai. 4.4. Phng nga ph n c hn 2 ln nhim trng tit niu trong 6 thng nn t vn d phng. Ung nhiu nc sao cho mi ngy c th tiu c trn 2 lt. i tiu trc khi i ng, sau khi giao hp, bt k lc no cm thy mt tiu. Khng dng mng chn m o v thuc dit tinh trng nga thai m nn chuyn sang phng php khc. Sau khi giao hp nn s dng mt trong cc khng sinh sau y: trimethoprim 150mg, bactrim 80/400mg, cephalexin 250mg, nitrofurantoin 50 hoc 100mg. Lin tc s dng mt trong cc loi khng sinh theo liu trnh sau y: trimethoprim 250 mg mi ti, trimethoprim v sulfamethoxazol 40/ 200mg mi ti, trimethoprim v sulfamethoxazol 40/200mg x 3 ln/tun, cephalexin 250mg mi ti, norfloxacin 200mg mi ti. Vi nhng ngi vim tin lit tuyn hoc trc v sau gii phu tin lit tuyn hoc ph n c thai vi nc tiu c vi trng khng triu chng c th dng ngy 1 ln hoc 3 ln/1 tun vi 1 trong 2 khng sinh sau y bactrim 80/400 mg, nitrofurantoin 50mg. 4.5. iu tr theo y hc c truyn 4.5.1. Th nhit lm Php tr: thanh nhit li thp vi mc ch: + H st vi cc dc liu nh hot thch, cam tho. + Li tiu nh c mch, bin sc, mc thng, sa tin t. + Khng khun t cu vng, Proteus, Enterobacter nh: chi t, i hong, cam tho. Bi thuc s dng: + Bi thuc Bt chnh tn: hot thch 12g, c mch 12g, bin sc 12g, mc thng 8g, chi t 12g, i hong 8g, sa tin t 12g, cam tho bc 8g.

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V thuc Mc thng Bin sc C mch Hot thch Sa tin t Sn chi i hong Cam tho

Tc dng ng, hn: ging tm ha, thanh ph nhit, li tiu, thng huyt mch ng, bnh, khng c: li tiu, thng lm, st trng ng, lnh: thanh nhit, li tiu Ngt, hn, vo kinh v, bng quang: thanh nhit, li tiu Ngt, hn, khng c: li tiu thanh can phong nhit, thm bng quang thp kh ng, hn: thanh nhit t ha, li tiu cm mu ng, hn: h v trng tch tr, t huyt phn thc nhit, h huyt, ph trng h Ngt, bnh: b t v, nhun ph, thanh nhit gii c, iu ha cc v thuc

Vai tr Qun Thn Thn Thn Qun Qun T S

4.5.2. Th huyt lm Php tr: thanh nhit gii c lng huyt ch huyt vi mc ch: + H st: hot thch, sinh a. + Li tiu: mc thng, m trc dip. + Khng khun: cc loi vi khun gy bnh t cu E. coli, Proteus, Herpes simplex th cn dng cc v nh: ng quy, chi t, tiu k, trc bch dip. + Cm mu nh: chi t, ngu tit, b hong, tiu k, trc bch dip. Bi thuc s dng: + Bi thuc Tiu k m (T sinh phng): sinh a 40g, tiu k 20g, hot thch12g, mc thng 12g, b hong sao 20g, m trc dip 12g, ngu tit 30g, ng quy 20g, chi t 12g, trc bch dip 20g. Phn tch bi thuc
V thuc Tiu k Sinh a Hot thch Mc thng B hong sao m trc dip Ngu tit sao ng quy Chi t sao Trc bch dip Tc dng Hi ng, lnh: lng huyt, ch huyt, gii c, tiu ung Ngt, ng, lnh: lng huyt, thanh nhit, t m ging ha sinh tn nhun to Ngt, lnh: thanh nhit li thp ng, lnh: ging tm ha, thanh ph nhit, thng tiu tin Ngt, bnh: hot huyt khu , thu sp, ch huyt, li tiu Ngt, lnh: thanh tm, tr phin nhit Cht: thu sp ch huyt Ngt, m: dng huyt, hot huyt Ch huyt ng mt: lng huyt, ch huyt Vai tr Qun Qun Thn Thn Thn Thn T T T T

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Gia thm i hong 6g tng tc dng cm mu (do tng fibrinogen). 4.5.3. Th lao lm Php tr: t m, thanh nhit, tr thp, vi mc ch: + Khng vim + h st: thc a, n b, tri mu. + Li tiu: phc linh, trch t. + Khng khun: t cu vng, Proteus v.v. nh: n b, tri mu, hong b. Bi thuc s dng: bi Lc v tri b (gm: thc a 40g, hoi sn 16g, n b 20g, trch t 8g, sn th 16g, phc linh 12g, hong b 20g, tri mu 20g). Ngoi ra c th gia thm kim ngn 20g, lin kiu 20g.

T lng gi Cu hi 5 chn 1: chn cu ng 1. Trc khun E. coli thng xut hin trong cc nhim trng tit niu

A. Bnh nhn l ph n B. Bnh nhn t thng tiu C. Bnh nhn c si thn D. Bnh nhn c bt thng gii phu hc h niu E. Bnh nhn hay b ti nhim
2. S c mt cc trc khun Gram (+) trong nhim trng tit niu khng gi n

A. Bnh nhn c km si thn B. Bnh nhn c bt thng cu trc h niu C. Bnh nhn thng hay b nhim trng tiu ti pht D. Bnh nhn c hi lu bng quang niu o E. Cc cu trn u sai
3. Nhim trng tit niu ph n ngoi triu chng i ra m, cy nc tiu nhiu ln u v trng, cn phi ngh iu g trc tin

A. Nhim trng tit niu do Candida B. Lao h niu


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C. Vi khun gy bnh qua ng tnh dc D. Nhim trng tit niu do adenovirus E. Nhim trng tit niu do E. coli
4. Ngh n lao h tit niu khi bnh nhn ngoi i mu, i m, cy nc tiu m tnh cn c thm

A. T trng nc tiu cao B. pH nc tiu kim C. pH nc tiu acid D. pH nc tiu trung tnh E. m niu dng tnh
5. Khi nghi ng nhim trng tiu do Candida, nn cy mu nc tiu

A. Sau khi xoa nn tin lit tuyn B. Ly t ng thng tiu (sonde) C. Chc ht bng quang D. u dng tiu E. Gia dng tiu
6. Trong nhim trng tit niu, c ch xm nhp ca vi khun t ng di thng xy ra

A. Ph n B. n ng C. Bnh nhn c si thn D. Bnh nhn b suy kit E. Bnh nhn ang dng thuc c ch min dch
7. ngi ph n tr, yu t no sau y khng to thun cho s nhim trng tit niu

A. Khong cch qu gn gia l tiu v hu mn B. S lan truyn qua hot ng tnh dc C. Do s dng thuc nga thai ung D. Do s dng mng chn m o E. Do s dng thuc dit tinh trng

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8. Trn mt bnh nhn b tn thng thn kinh bng quang, yu t no sau y khng to thun cho s nhim trng tit niu

A. S thuyn tc tnh mch do nm lu B. S t ng thng tiu thng xuyn C. S ng nc tiu D. S d thnh lp si tit niu E. S mt trng lc c trn niu o, bng quang
9. Theo YHCT chng huyt lm trong nhim trng tit niu l do

A. Kh huyt tr B. H ho vng ng C. T bt nhip huyt D. Ho nhit t tm dn xung tiu trng E. Thp nhit ut kt
10. Chn on nhim trng tit niu bng phng php cy nc tiu s khng chnh xc khi

A. S lng khm vi trng (VT) < 105/1ml nc tiu ly t i b thn B. S lng khm VT > 105/1ml nc tiu ly u v gia dng C. S lng khm VT < 105/1ml nc tiu trn mt bnh nhn tiu m D. S lng khm VT > 105/1ml nc tiu ly qua chc ht bng quang E. S lng khm VT > 105/1ml nc tiu ly gia dng
11. Triu chng no sau y khng c trong th lao lm

A. i rt B. i au C. i c D. i mu E. i khai
12. Triu chng no sau y khng c trong 2 th nhit lm v huyt lm

A. i rt B. i au C. i mu
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D. i c E. i ra du m
13. Nhim trng tit niu ti pht sau 2 tun thng do

A. Bt thng cu trc h niu B. Bt thng mch mu thn C. Tt nghn ng niu nh: si, u, ph i tin lit tuyn D. Th trng suy kit E. Mt nhim trng khc m o hoc i b thn
14. Thi gian trung bnh cho mt liu php khng sinh trong nhim trng tit niu l

A. 1 - 3 ngy B. 3 - 5 ngy C. 5 - 7 ngy D. 7 - 14 ngy E. 14 - 21 ngy


15. Khng sinh no thng dng d phng nhim trng tit niu ti pht

A. PNC B. Amoxicilin C. Bactrim D. Kanamycin E. Doxycyclin


16. Vi bi thuc Bt chnh tn (gm: hot thch, c mch, bin sc, mc thng, chi t, i hong, sa tin t, cam tho bc) c th tng liu 2 v no trong trng hp c i mu

A. Hot thch, c mch B. Bin sc, mc thng C. Chi t, i hong D. Sa tin t, cam tho bc E. Cam tho, hot thch

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Bi 15

SI tit NIU

Mc Tiu 1. Trnh by c nh ngha, c im dch t hc v quan nim ca YHCT v bnh si tit niu. 2. Trnh by c nguyn nhn, bnh sinh ca bnh si tit niu theo YHH v YHCT. 3. Nu c ni dung chn on 3 th lm sng ca si tit niu theo YHCT. 4. Trnh by c nguyn tc iu tr ni khoa, ch nh iu tr ngoi khoa, php tr v bi thuc iu tr cc th lm sng bng YHCT. 5. Phn tch c cc bi thuc, phng huyt p dng iu tr ba th bnh lm sng ca si tit niu.

1. I CNG Bnh thng trong nc tiu c cc cht ha tan nh calci, phosphat, oxalat nhng vi nng thp. Khi nng cc cht trn cao vt qu ngng, trong iu kin l ha nht nh nu gp nhng yu t thun li th s to thnh si tit niu. Si tit niu bao gm: si thn, si niu qun, si bng quang, si niu o. 1.1. nh ngha Si tit niu l mt bnh thng gp v hay ti pht ng tit niu do s kt thch ca mt s thnh phn trong nc tiu iu kin l ha nht nh. Si gy nghn tc ng tit niu m hu qu c th dn n nc thn v hu hoi t chc thn, gy nhim khun v gy au, nh hng n sc khe v tnh mng ca ngi bnh. 1.2. c im dch t hc Si tit niu l bnh ph bin trn th gii, tuy nhin s phn b khng ng u. Bnh t gp chu Phi, cn chu M t l trung bnh l 20 ngi/10000 ngi mi nm. 241

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Tui mc bnh trung bnh t 35 - 55 tui, tuy nhin thi im mc bnh khc nhau tu theo loi si. Tui mc bnh trung bnh i vi si calci l 48,7; si amoni magne phosphat l 46,7; si acid uric l 59,4 v cystein l 27,9. Nam mc bnh gp 3 ln n, tuy nhin t l bnh thay i theo thnh phn ho hc ca si, trong khi nam gii b si calci nhiu (88% so vi 58% n gii) th n gii b si amoni magne phosphat nhiu hn (38% so vi 8,8% nam gii). tr < 5 tui hay gp si amoni mange phosphat, trn 5 tui hay gp si calci oxalat. Theo GS Ng Gia Hy Vit Nam si thn chim 40%; si niu qun chim 28,27%; si bng quang 28,3%; si niu o 5,4% trong tng s bnh nhn b si ni chung. Si tit niu nam nhiu gp 2 ln n, gp nhiu tui trn 30. Vit Nam si amino magne phosphat chim t l cao km theo nhim khun. 1.3. Quan nim ca y hc c truyn v si tit niu Si tit niu c m t trong chng thch lm ca YHCT (thch lm: tiu ra si) Thch lm l mt trong chng 5 chng lm c YHCT gi l chng ng lm, l: nhit lm, huyt lm, thch lm, cao lm, lao lm. Nhng vin si ln gi l thch lm, si nh gi l sa lm. Chng trng ca thch lm: bng di au co cng, mt bn thn lng au qun, au lan xung bng di v b phn sinh dc, tiu tin au but kh i, nc tiu c khi vng c c khi ra mu, c khi ra ln si ct. Nguyn nhn do thp nhit nung nu h tiu khin ngng kt trong nc tiu m gy bnh. 2. NGUYN NHN, BNH SINH 2.1. Nguyn nhn S pht sinh v hnh thnh si c nhiu ngun gc khc nhau, c bit l n tu thuc vo tng loi si cng nh khng ch mt nhm nguyn nhn no m l s phi hp ca nhiu yu t: t ch n ung n cc bnh tt trong c th ang c v n yu t di truyn phi hp to nn si niu. C 3 nguyn nhn c quan tm sau y: Cc cht ho tan trong nc tiu nh calci, phosphat, oxalat, urat vt qu ngng (cao hn nng ha tan). Khi pH nc tiu toan ho hoc kim ho: toan ha (pH<6) th d kt tinh si urat v si acid uric; kim ha (pH> 6,5) th d kt tinh si oxalat v phosphat. 242

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Yu t di truyn: i vi si cystin v si acid uric yu t di truyn ng vai tr quan trng, si cyatin xut hin bnh nhn kiu gen ng hp t, ngi ta nhn thy nhng trng hp si calci trong mt s ngi cng dng h, ngoi ra yu t cng calci niu thng to ra si c kh nng di truyn kiu a gen. Nguyn nhn to thnh si vi iu kin l: trong nc tiu hin din c yu t lm nhn si (t bo, m t bo bong ra t i b thn b vim). 2.2. Yu t thun li Nhng yu t thun li cho s hnh thnh si niu: Nhng ngi c bnh l d dng ng niu. Nhng ngi nm bt ng lu ngy. Ung t nc. Ngi c bnh long xng, bnh Goutte. 2.3. C ch sinh bnh Trong qu trnh bo ha, nc tiu tri qua 3 giai on t thp n cao: Giai on cha bo ha: trong cc tinh th c ha tan. Giai on trung gian: trong cc tinh th ch kt tinh lc c mt cht khi xng hnh thnh mt nhn d cht. Giai on khng bn: trong cc tinh th kt tinh t nhin t mt nhn d hay ng cht. Ngoi c ch chung nu trn mi loi si cn c c th ring nh: + Si acid uric xut hin khi s chuyn ha purin tng do ch n hay do nguyn nhn ni sinh v khi pH nc tiu < 5,3. Vi pH bnh thng nc tiu bnh nhn cha mt hn hp acid uric v urat, khi pH h acid uric t ha tan s kt ta trong khi urat d ha tan li gim i r rt. + Si amoni magne phosphat c hnh thnh khi bnh nhn tit lng calci phosphat v amoni kh ln km theo s tng pH nc tiu ln > 7,2. S d pH nc tiu tng l do nhim khun v vy si ny cng c gi l si do nhim khun. 2.4. Nguyn nhn sinh bnh theo y hc c truyn Ngi xa cho rng si tit niu c nguyn nhn chnh l do nhit h tiu. Ni kinh cho rng: t thp lm m li, m ha ha, ha sinh nhit h tiu lm chng kit nc tiu, cn lng li m thnh thch. 243

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Tu Tnh gii thch: si niu do thn kh h lm thy ha mt iu ha, ha ca tm i xung h tiu chng kh nc tiu m thnh thch (v nh cn kt y ni khi un nu lu ngy vy). Thn m h sinh ni nhit, ni nhit lm h hao tn dch cho nn i tiu t. Thp nhit h tiu: thp t, nhit t xm phm h tiu (vim ng tit niu), nhit kt bng quang lm h hao thy dch, cn lng kt li sinh si. Bnh tt nm lu bt ng, kh huyt tr, thy dch km c lu thng, cn c iu kin kt lng m thnh si. Nh vy, nguyn nhn sinh chng thch lm l: + Thp nhit h tiu. + Kh huyt tr. + Thn h. 3. CHN ON 3.1. Biu hin lm sng au: au t ngt, d di vng bng v eo lng, au lan xung h b, thng hay xut hin sau chy nhy hoc lao ng nng i mu: i mu u bi, cui bi hoc ton bi; du hiu tiu tc gia dng. Nn hoc bun nn trong t au. 3.2. Khm n im niu qun thy au. 3.3. Cn lm sng Xt nghim nc tiu thy vi khun, t bo, cn. Chp phim X quang c th thy hnh nh vin si (tuy nhin mt s si khng cn quang). Siu m cho bit v tr, kch thc vin si. 3.4. Chn on v tr si Si i b thn: t c triu chng lm sng, thng c pht hin do nhn mt ln khm kim tra sc khe c X quang. Si niu qun: + C cn au in hnh t ngt v d di. 244

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+ im au niu qun (+). + Nc tiu c mu. Si bng quang: + Tiu rt, tiu khng ht, tiu tc gia dng. + Tiu mu. Si niu o: + Gp nam gii: tiu but, dng tiu nh hoc gi git. + Thm khm qua trc trng rt au. 3.5. Chn on phn loi si C 5 loi si thng gp: Si calci: chim 60 - 80% cc loi si, si calci rt cn quang. Si phosphat: chim 5 - 15% cc loi si, si phosphat cn quang. Si acid uric: chim 10 - 20%, khng cn quang. Si xystin: chim 1 - 2%, t cn quang. Si carbonat: t cn quang. 3.6. Chn on phn bit Si niu c cn au qun thn cn c chn on phn bit vi: Tc rut: tc rut khng c triu chng bnh ca ng tit niu, au ton bng, bng trng, quai rut tng hi, b trung tin. Vim rut tha: khng c biu hin bnh l ng tit niu, au nh h chu phi, st nh, bch cu tng. Si ty, si ti mt: cn khm k, st cao, vng da. U b thn, u niu qun: au t t, cn chp ct lp phn bit. 3.7. Chn on theo y hc c truyn 3.7.1. Th thp nhit (tng ng vi si tit niu c vim nhim km theo) au t eo lng lan xung i v b phn sinh dc ngoi. Tiu tin vng sn, c, nng rt ng tiu, tiu nhiu ln, c th i tiu ra si. Gai st hoc n lnh. Ming kh kht. 245

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Li , ru vng. Mch sc. 3.7.2. Th kh huyt tr (tng ng vi si niu i ra mu) Khi i tiu thy au tc v nng trc m nang, tiu tin mu ti, i tiu khng ht. Nc tiu va c mu va c. Li c im huyt. Mch khn. 3.7.3. Th thn h (tng ng si tit niu c bin chng) Tiu t, c c m, bnh m , st ko di. Ngi mt mi, bng trng hoc ph thng, sc mt trng bch. Li nht bu, ru trng dnh. Mch t sc v lc. 4. IU TR 4.1. Nguyn tc chung Gim au (khi chn on c th). Khng sinh chng vim nhim khi cn thit. Thay i pH nc tiu; ung nhiu nc (>2 lt/ngy). Ch n ung ph hp. Ch nh phu thut khi vin si ln iu tr ni khoa khng kt qu, si c bin chng iu tr ni khoa nhm gii quyt nguyn nhn v c ch to si, c tc dng hn ch ti pht si, gim bt cc ch nh ngoi khoa v trnh cc bin chng khc ngoi thn. 4.2. iu tr theo y hc c truyn 4.2.1. Th thp nhit Php tr: thanh nhit, bi thch, tr thp, li niu. Phng dc: + Bi thuc nam kinh nghim dn gian 246

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Kim tin tho Ut kim Trch t

40g 16g 10g

Sa tin t Ngu tt

20g 10g

+ Bi c phng: Xch o tn gia v gm: sinh a 12g, trc dip 16g, mc thng 16g, cam tho tiu 10g, sa tin t 10g. Gia thm: kim tin tho 20g, k ni kim 10g. Sc ung ngy 1 thang. Phn tch bi thuc:
V thuc Sinh a Kim tin tho Trc dip Mc thng Cam tho Sa tin t K ni kim Tc dng Ngt, lnh, vo can thn: b thn, dng m, thanh nhit, dng huyt Mn, bnh: vo thn bng quang. lm tan si Ngt, nht, hn; vo kinh tm, tiu trng: thanh tm ha, li niu ng, hn; vo thn, bng quang: ging ha, li tiu tin, thng huyt mch Ngt, bnh: thanh nhit gii c, iu ha v thuc Ngt, hn: thanh ph kh, thm kh bng quang Ngt, bnh; vo kinh ph, t: tiu thy cc, l t v, cha tiu mu, mn nht Vai tr Qun Qun Thn Thn T, s T T

4.2.2. Th kh huyt tr Php tr: l kh hnh tr, thng lm bi thch. Phng dc: + Bi thuc nam o nhn Ngu tt Kim tin tho K ni kim Bch mao cn Sc ung ngy 1 thang + Bi thuc c phng Huyt ph trc thang (gm: ng quy 12g, sinh a 8g, o nhn 8g, hng hoa 8g, ch xc 6g, xch thc 8g, si h 8g, cam tho 4g, xuyn khung 8g, ngu tt 8g). 247 8g 8g 20g 8g 16g Ut kim Ch xc Sa tin t d Ngu tt 8g 6g 12g 12g 8g

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Gia thm: kim tin tho 20g, hn lin tho 20g. Sc ung ngy 1 thang. Phn tch bi thuc:
V thuc Kim tin tho o nhn Hng hoa ng quy Xch thc Ch xc Xuyn khung Ngu tt Si h Hn lin tho Cam tho Tc dng Mn, bnh; vo thn, bng quang: tn kt; lm tan si mt, si niu Ngt, ng, bnh; vo kinh can, thn, t: hot huyt, thng lm Cay, m; vo kinh can t: tn ph , hnh huyt Ngt, cay, m; vo kinh tm, can, t: hnh huyt hot huyt ng, hn; vo kinh can, t, ph: hot huyt, hnh huyt, ch thng ng, bnh; vo kinh, can, ph, t: l kh, ha trung Cay, n; vo kinh ph, i trng: khu phong, hot huyt, ch thng ng, bnh; vo kinh can, thn: b can thn, hnh kh xung ng, lnh; vo can, m, tm, tam tiu: t nhit, gii c, thng Ngt, chua, lng; vo can, thn: b thn, ch huyt l, tiu mu Ngt, bnh; vo can, m, t, v: kin t v, iu ha cc v thuc Vai tr Qun Qun Qun Thn Thn T T T T T T, s

4.2.3. Th thn h Php tr: b thn, li niu, thng lm. Phng dc: + Bi thuc nam kinh nghim dn gian Dy t hng C mi M 30g 30g 16g Th phc linh T gii Ht sen 20g 30g 30g

Sc ung ngy 1 thang. + Bi c phng: T sinh thn kh hon gia v (T sinh phng) (gm: ph t 8g, thc a 16g, hoi sn 12g, sn th 12g, n b 12g, phc linh 12g, trch t 8g). Gia thm: kim tin tho 20g, sa tin t 16g. Tn bt lm hon, ngy ung 30g.

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Phn tch bi thuc


V thuc Kim tin tho Ph t Thc a Hoi sn Sn th n b Phc linh Trch t Sa tin t Mn, bnh: lm tan si Ngt, c, rt nng: b ha, tr dng, trc hn thp Ngt, m; vo kinh thn, can, t: b thn, b huyt Ngt, nht, bnh; vo kinh t, v: b t v ph thn, sinh tn Chua, hi n; vo kinh thn, bng quang: b thn sp tinh ng, hn; vo thn, can, m: thanh huyt nhit, tn huyt Ngt, bnh; vo kinh can, thn, t: li thy thm thp, b t, nh tm Ngt, mt; vo kinh thn, bng quang: thanh t thp nhit bng quang, li thy Ngt, hn; vo kinh thn, ph, bng quang: thanh ph, thm kh bng quang Tc dng Vai tr Qun Qun Qun Thn Thn T T T T

5. PHNG BNH Gii quyt nhng d tt trn ng niu. Phng v tr bnh long xng. Trnh cc thc n c cha nhiu cc cht calci, phosphat, oxalat Ung nhiu nc hng ngy (trn 2 lt). Gi v sinh, chng vim nhim ng niu.

T lng gi 1. Si niu thng gp nht v tr A. Si niu qun trn B. Si niu qun di C. Si bng quang D. Si thn E. Si niu o 2. Nguyn nhn gy si niu (chn cu sai) A. Cc cht ha tan trong nc tiu nh calci, phosphat vt qu ngng 249

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B. Khi pH nc tiu toan ha C. Khi pH nc tiu trung tnh D. Vim nhim ti i b thn E. Yu t di truyn 3. Yu t thun li gy si niu (chn cu sai) A. Bnh l d dng ng niu B. n nhiu tht c C. Nm bt ng lu ngy D. Ung t nc E. Bnh l long xng, Goutte 4. Si niu c hnh thnh do nhim khun A. Si amoni magne phosphat B. Si calci C. Si urat D. Si cystein 5. Si niu c tnh cht khng cn quang A. Si calci B. Si phosphat C. Si acid uric D. Si cystein E. Si carbonat 6. Chn on si niu cn chn on phn bit (chn cu sai) A. Tc rut B. Vim rut tha C. Vim d dy t trng D. Si tu, si ti mt E. U b thn, u niu qun 7. Bnh si niu vi triu chng: au t eo lng lan xung i v sinh dc ngoi, tiu vng sn, c, gai st hoc n lnh, li ru vng mch sc thuc th bnh A. Thp nhit B. Kh huyt tr 250

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C. Thn h D. Can ut t h E. Bng quang h hn 8. Bnh si niu vi tiu au tc, cm gic nng trc m nang, tiu mu ti, tiu khng ht, li c im huyt mch khn A. Thp nhit B. Kh huyt tr C. Thn h D. Can ut t h E. Bng quang h hn 9. Bnh si niu vi tiu t, c, c m, m ko di, ngi mt mi, bng trng hoc ph thng, sc mt trng, li nht bu, ru trng dnh, mch t sc v lc A. Can ut t h B. Bng quang h hn C. Thn h D. Kh huyt tr E. Thp nhit

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Bi 16

CHNG SUY SINH DC NAM (Impotence)

MC TIU 1. Trnh by c c im gii phu h thn kinh v mch mu tip liu cho b phn sinh dc nam. 2. Phn loi v phn tch c cc nguyn nhn ca s suy sinh dc nam. 3. Trnh by c ch bnh sinh ca chng lit dng v di tinh theo YHCT. 4. Trnh by cc phng php thm khm lm sng v cn lm sng chn on nguyn nhn ca s suy nhc sinh dc nam. 5. Lit k v trnh by c cc tc dng dc l ca ty dc iu tr chng suy nhc sinh dc nam. 6. Trnh by c cc tc dng dc l ca cc php tr chng suy sinh dc nam theo YHCT.

1. NH NGHA Suy sinh dc nam l mt hi chng kh ph bin, chim 52% dn s nam tui t 40 - 70 (Boston), trong ngi n ng khng th t c s cng dng , s xut tinh hoc c hai. Mt ngi n ng b ri lon chc nng tnh dc thng than phin v nhng tnh trng nh mt ham mun, khng th khi pht hoc duy tr s cng dng, khng th xut tinh hoc xut tinh sm hoc khng th t c khoi cm Suy sinh dc nam c th l th pht do bi mt bnh h thng, do bi s lm dng cc loi thuc hoc b mt bnh l h sinh dc, tit niu v ni tit hoc ch do bi tm l. c th hiu r hn c ch cng nh phng php iu tr ca bnh bt lc, chng ta nn c mt ci nhn ton cnh v c ch sinh l v bnh l ca bnh bt lc. 252

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2. C CH CA S CNG DNG Bnh thng dng vt c phn b bi 3 loi si thn kinh sau y: Si somatic dn truyn cm gic xut pht t dorsal nerve ca dng vt, truyn lung cm gic t da dng vt v quy u vo n nhng hch r lng S2 - S4, qua dy thn kinh pudendal, trong nhng si truyn lung cm gic t quy u l free ending nerve. Trong khi si vn ng dn truyn xung ng t ty sng v v no v.v... s khi u t S3 - S4 theo thn kinh pudendal n nhm c hang v hnh hang cng vi nhng si giao cm hu hch phn b n ph tinh hon, thng tinh, ti tinh, c vng trong ca bng quang iu ha s co tht ng b nhp nhng ca cc cu trc ny trong lc xut tinh. Si ph giao cm tin hch xut pht t S2 - S4 bng qua thn kinh chu i n tng chu (plexus) pelvic. Si giao cm xut pht t vng xm inter lateral medio ca T11 - L2 i dc theo chui hch giao cm cnh ct sng n m ri h v trn, n thn kinh h v i vo m ri chu pelvic. Nhng si thn kinh thc vt sau khi phi hp vi nhau trong m ri pelvic s i n dng vt theo thn kinh cavernous dc theo mt sau bn ca prostate trc khi xuyn qua c sn chu ngay bn ngoi niu o, cch xa niu o mng n cho ra mt vi si i vo th xp ca dng vt, trong khi nhng si cn li i vo th hang v dc theo nhng nhnh cui ca ng mch pudendal v tnh mch hang. Ngoi vai tr ca ty sng p ng li kch thch cng dng bng s m cn c vai tr quan trng ca no b trong vic iu ho cc kch thch thng qua phn x ty: + Cc lung kch thch do tng tng, do nhn, do ngi, do nghe, do thy thng qua v no, thalamus, rhiencephalic v limbic s i n vng medial preoptic anterior hypothalamus, vng ny s tc ng nh mt trung tm iu phi m kt qu cui cng s gy nn cng dng. + Trong khi phc hp amygdaloid (amydaloid complex) ca no li c tc dng ngc li. Mc du h ph giao cm l yu t khi pht ca s cng dng nhng s chuyn dng ca dng vt sang th cng cng li l hin tng ca mch mu. Trong tnh trng mm (bnh thng), cc ng mch, tiu ng mch v cc khong xoang trong th hang ca dng vt u co tht li di tc ng ca thn kinh giao cm, trong khi nhng tiu tnh mch gia xoang v dense junica albuginea (xung quanh th hang) li m ra t do.

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S cng cng ch c th bt u c s gin n cc c trn ca cc khong xoang, iu ny s a ti s gin n ca xoang v gim khng lc ngoi vi s lm tng nhanh lung mu i qua ng mch th hang v ng mch pudendal. Chnh s gin n ca cc h xoang s chn p ln trn tiu tnh mch v din tch mt trong ca dense tunica albuginea gy mt tnh trng tc nghn tnh mch. Kt qu l s tng p lc bn trong cc h xoang s gy nn s cng cng. S cng dng xy ra khi trng lc ca cc xoang do thn kinh giao cm gy ra b i khng bi ph giao cm (xut pht t S2 - S4) bi v chnh n kch thch tng hp v phng thch ra nitric oxyd t ni b cc mch mu, mt cht dn truyn thn kinh non adrenergic, non cholinergic, a n s gin n cc c trn ca h xoang. Ngoi ra ngi ta cn tm thy cc neuro peptid nh V.I.P hoc calcitonin - gene - related peptid trong cc m xoang c kh nng gy cng phng dng vt trong khi nor - epinephrin c tc dng ngc li. Nu thn kinh ph giao cm c vai tr ch yu trong vic cng dng th h giao cm li c vai tr trong s xut tinh v phng tinh: Di s iu ho ca h adrenergic th cc ph tinh hon, thng tinh, ti tinh y tinh dch i vo niu o vng prostat. S ng ng thi c bng quang cng vi s co tht ca cc c hang v hnh hang s phng tinh ra ngoi. Nu s cng dng v phng tinh l mt hin tng thuc v c ch sinh l th s khoi cm ch l mt cm gic tm l xy ra trong giai on co tht nhp nhng ca c y chu. N c cm nhn nh l mt cm gic khoan khoi v c th xy ra ngay c khi khng c cng dng hoc xut tinh. Cui cng l s xu ca dng vt (sau khi xut tinh) c l l do hot tnh trng lc ca h mch mu c khi phc (do vai tr u thng ca h giao cm trn h c trn mch mu) s gim dng mu n dng vt v gy nn s lm rng cc khong xoang. 3. C CH BNH SINH V S SUY SINH DC NAM 3.1. Theo y hc hin i Thng thng chng suy sinh dc nam (impotence) c phn loi nh sau: 3.1.1. Mt ham mun Nguyn nhn c th do thiu ht androgen, do ri lon tm l, do dng hoc lm dng thuc gy nghin. S thiu ht androgen c th o lng c bng lng testosteron v gonadotrophin/huyt tng trong khi tnh trng gim nng tuyn sinh dc (hypogonadism) li a n s khng xut tinh do gim tit tinh dch t ti tinh v prostat. 254

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3.1.2. Khng cng dng Do gim testosteron: rt t gp nhng d chn on v iu tr, tuy nhin s gim n mc gii hn ca testosteron li khng phi l nguyn nhn ca s khng cng dng. Do tng prolactin mu a n c ch sn xut LHRH lm gim testosteron v gonadotropin, nguyn nhn c th l: + Khi u tuyn yn. + Do s dng cc thuc gy tng sn xut prolactin nh oestrogen, lm dng phenothiazin hay reserpin (2% - 5% trng hp). Do thuc: + Cc thuc chng androgen nh: H2 receptor antagonist c tc dng lm tng prolactin. Hoc spironolacton, ketoconazon, finasterid (5 - reductas inhibitor) dng cha chng ph i prostat s ng thi lm gim ham mun v ri lon phng tinh (10 - 12% trng hp). + Cc thuc chng tng HA nh clonidine, methyldopa, quanadrel (qua tc dng lit giao cm trung ng hoc ngoi vi) blocker, thiazid. + Cc thuc chng cholinergic. + Cc thuc chng trm cm loi IMAO v tricylic do tc dng lit giao cm v chng cholinergic. + Cc thuc antipsychotic. + Cc thuc an thn, chng lo u. + Ru, methanon, heroin, thuc l. Bnh dng vt: + Peyronies. + Chng cng au dng vt. + Chn thng. Bnh thn kinh: + Tn thng thy thi dng trc. + Bnh ty sng. + Ri lon thn kinh cm gic: tabes dorsalis, bnh dorsal root ganglia. + Gii phu radical prostatectomi, cystetomy, rectosigmoid. + Diabetic autonomic nevropathy hoc polyneuropathy. + Hi chng Shy - Dragg. 255

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Bnh mch mu: + Hi chng Lerich (aortic occlusion). + Tc nghn hoc hp ng mch pudendal v cavernous do x m ng mch. + Tn thng ng mch do chiu tia x tr vng chu. + R r tnh mch (venous leak). + Bnh ca khong xoang. 3.1.3. Xut tinh sm Thng do lo u, ri lon cm xc v.v... t khi do thc th. 3.1.4. Khng xut tinh Phng tinh ngc: do gii phu c bng quang hoc do diabetes. Thiu ht androgen. Do thuc: guanethisin, phenoxybenzamin, phentolamin, sertralin. 3.1.5. Khng khoi cm Thng do tm l nu bnh nhn vn c ham mun v vn cn cng dng c. 3.1.6. Khng xu c (priapism) Thng phn bit c vi s cng dng t nhin l priapism khng h c cng phng quy u. Nguyn nhn ca priapism c th khng bit nhng cng c th phi hp vi bnh hng cu lim, bnh bch cu mn granulocyt do tn thng tu sng hoc do tim cc thuc gin mch vo dng vt. 3.2. Theo y hc c truyn Chng bt lc thuc phm tr ca chng di tinh, to tit v lit dng, dng nuy m c ch khng nm ngoi phm vi ca 2 chng thn m h v thn dng h. Thn vi chc nng tng tinh (ch yu l tinh sinh dc), nu do v lo lng cng thng hoc t tng n chuyn tnh dc qu mc th hu qu s l mng tinh, to tit m bnh cnh lm sng thng biu hin cc th tm thn bt giao hoc tng ho vng ng. Ngc li nu do v cm nhim thp nhit t qua ng sinh dc tit niu th triu chng biu hin s l tinh t xut sau khi i tiu hoc l thp trc. 256

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Nu bnh ko di lu ngy s a n thn kh bt c vi triu chng hot tinh: tinh t xut khi lin tng n chuyn tnh dc hoc khi gng sc hoc a n chng dng nuy, lit dng m bnh cnh lm sng thng biu hin di th tm t lng h hoc mnh mn ho suy.
Ni nhn (lo lng t tng) Ngoi nhn (thp nhit t)

THN M

TO TIT MNG TINH

HOT TINH (thn kh bt c)

THP TRC

DNG NUY LIT DNG

4. CHN ON 4.1. Theo y hc hin i 4.1.1. Bnh s Trc mt bnh nhn than phin v chng suy sinh dc nam nn hi bnh nhn than phin v loi suy sinh dc nam no, v tin s ca bnh i tho ng, cc bnh l v thn kinh ngoi vi hoc cc ri lon chc nng bng quang, v chng khp khing cch hi, thi gian cng dng ban m (nocturnal penile-time) trung bnh ko di 100 pht/m (thng xy ra trong thi k REM ca gic ng). 4.1.2. Khm thc th Khm dng vt tm cc mng ho x mt lng dng vt (thng gp trong bnh peyroni). + Khm tinh hon v h thng lng, v: nu tinh hon < 3,5cm nn ngh ti hypogonadism nu thy v to hoc rng lng nn ch ti tnh trng tng prolactin.

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+ Khm h ng mch bng cch tm ting thi ng mch bng, s ng mch dng vt, do HA tm thu ng mch dng vt. HA ti a ca dng vt Nu t s HAM HA ti a ca cnh tay (th nm) < 0,6

Th nn lm siu m Doppler chn on C th kt hp Doppler vi siu m c phn gii cao sau khi tim alprostadil vo dng vt nh gi lu lng mu qua ng mch th hang. Nn tm tinh trng trong nc tiu sau giao hp nu nghi ng c hin tng phng tinh ngc. Nu bnh nhn than phin v chng di tinh, hot tinh: nn khm k tinh hon, ph tinh hon v thng tinh tm khi u do lao, lu; ng thi ly cht tit t niu o sau khi xoa bp prostat hoc tht nitrat bc cy tm vi trng sau lao, lu. V h thn kinh: nn khm tm cm gic dng vt, nh gi trng lc c vng, khm phn x hnh hang bng cch bp mnh quy u v nhn xt s co tht c vng hu mn, khm lc c ngn chi, phn x gn xng 2 chn, o cm gic rung, cm gic v tr, s m, au v c th lm in c phn x hnh hang. Sau cng l o nng testosteron, LHRH, prolactin nu nghi ng c thiu nng tinh hon hoc tng prolactine mu. 4.2. Theo y hc c truyn 4.2.1. Tng ho vng ng Vi biu hin ng t, hi hp, u chong vng, dng vt hay cng, hay mng tinh hoc to tit, ming kh, li , au eo lng, mch huyn sc. 4.2.2. Tm thn bt giao u vng, hi hp, tinh thn bi hoi, mng tinh hoc to tit, hay qun, cm gic bc ho mt, hng kh c ro, lnh 2 chn, tiu ngn, mch t sc. 4.2.3. Thn kh bt c (thn kh bt tc) Thng au lng, ng t, chng mt, tai, tinh t xut ra khi ngh n chuyn tnh dc hoc khi gng sc, hoc tinh long, tinh t, s lnh, tay chn lnh, sc mt trng, t hn, tiu trong di, mch trm nhc. 4.2.4. Thp trc Kht nc, ming ng, ru li vng nhy, nc tiu , tinh chy ra sau khi tiu hoc mi sng thy c cht nc c u dng vt (triu chng 258

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ny rt r khi n nhng thc n cay nng hoc ung nhiu ru, c ph hoc thc khuya). Ring chng dng nuy hoc lit dng thng c biu hin di 2 th lm sng sau y: a. Tm t lng h: hay s st, a nghi, thng xuyn hi hp, mt ng hoc mng m, hay qun, ngi mt mi, sc mt vng ti, n km bng y, tiu lng, li nht bu, mch t nhc. b. Mnh mn ho suy (thn kh bt tc): au lng, ng t, chng mt, tai, s lnh, tay chn lnh, sc mt trng, t hn, tiu trong di, mch trm nhc. 5. IU TR 5.1. Theo y hc hin i iu tr chng suy sinh dc nam theo YHH thng tp trung vo 2 hng sau: Mt ham mun. Hoc/v ri lon cng dng. V thng c chia thnh nhng phng php sau y: Tm l liu php. Thuc: qua ng ung, tim vo th hang, thm qua niu o, qua da. Gii phu. C hc liu php. 5.1.1. Thuc ung a. Testosteron: thuc ch c tc dng gy ham mun v ch c hiu qu trn bnh nhn gim nng tuyn sinh dc (hypogonadism). Liu s dng 25mg 1 ln tim bp. Nu dng lu nn theo di kch thc tin lit tuyn, chc nng gan v lipid mu. b. Bromocryptin: ch c hiu qu trn chng bt lc do prolactin trong mu cao. Liu ti a mi ngy l 5mg - 7,5mg. Ring i vi nhng bnh nhn b prolactin trong mu cao do u tuyn yn (1 - 2%) nn xt nghim gii phu bnh. c. Yohimbin: l indol alkaloid, c tc dng i khng 2 adrenergic receptor. Thuc c hiu qu trn chng bt lc do tm l hoc do ngun gc ng mch giai on sm. 259

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Liu s dng 5mg, ngy ung 3 ln. Thuc c hiu qu t 33 - 62% trng hp. Tc dng ph ca thuc thng l chng mt, hi hp, cng thng, mt ng, bun nn, nhc u, co c. d. Trazodon: l mt loi thuc chng trm cm c tc dng h tr serotonin trung ng v lit giao cm ngoi vi. Liu thng dng 50mg ngy dng 1 - 3 ln, thuc c tc dng ci thin s cng dng (trn 60% trng hp). Tc dng ph ca thuc thng l bun ng, tng huyt p, h huyt p t th, bun nn, cng dng ko di. e. Apomorphin: l mt opiat alcaloid, c tc dng h tr dopamin, tc dng tt nht trn chng bt lc do tm l hoc lit dng do c hc mc nh. Liu dng 0,25 - 1mg qua ng ngm hoc tim di da, hiu qu t 60 - 80%. Tc dng ph ca thuc thng l bun nn, ngp, h huyt p, l , mt mi. f. Phentolamin: c tc dng h tr adrenergic. Liu thng dng 50mg ngm di li, hiu qu trong 68% trng hp. Tc dng ph ca thuc thng l nght mi, chng mt hoc ngt, nng rt nu rng. g. Sildefanil: c tc dng c ch chn lc v cnh tranh vi C. GMP typ 5 specific PDE2. Thng thng s cng dng c c l nh s hot ho ca C.GMP (thng tin bc hai ca nitric oxyd) qua lm th gin c trn ca cc khong xoang v C. GMP s b phn hy bi C. GMP typ 5 specific PDE2. Bng s c ch v bt hot ny m sildefanil c tc dng gy nn s cng dng. Tuy nhin v n ch t hiu qu khi c s kch thch v mt tm l hoc trong lc giao hp, do nn dng trc khi giao hp khong 1 gi. h. Arginin: l mt tin cht ca nitric oxyd. Liu thng dng 1400mg, 2 ln mi ngy, hiu qu 40% trng hp. Ngoi ra mt s thuc i khng vi morphin nh naloxon (naltrexon) vi liu dng mi ln 50mg hoc thuc chng trm cm nh fluoxetin hoc moclobemid cng c tc dng tng t. i. Ngoi ra trong trng hp xut tinh sm, ngi ta s dng cc thuc antipsychotic nh thioridazin (melleril) vi liu 25mg mi ln. 260

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5.1.2. Thuc tim vo th hang c ch nh nhng bnh nhn c lu lng ng mch bnh thng v c ch ng tnh mch hang bnh thng, ngha l nhng bnh nhn bt lc n thun do tm l hoc thn kinh l i tng tt nht do phng php ny. Phng php ny c chng ch nh tuyt i vi nhng bnh nhn c bt thng v hemoglobin, ri lon ng mu, bnh peyroni, priapism, lon tm thn nng v chng ch nh tng i trn nhng ngi gim th lc, bo ph v h huyt p t th. Trong thp nin 1980 vi s pht hin ra alprostadil, mt cht tng hp PGE1 c tc dng gy th gin c trn qua C.AMP. Ngi ta ghi nhn tc dng ca n trn 75% trng hp v c th t ti 85% hiu qu nu kt hp vi phentolamin hoc c th l ti 92% nu kt hp thm mt cht th ba l papaverin. Thng thng alprostadil vi liu 1,25 - 2,5g s c tc dng trn lit dng do tm l hoc thn kinh v liu 5 - 10g c hiu qu trn lit dng do c ch mch mu. Tc dng ph ca thuc thng l: au ti ch tim (34%). Gy cng dng ko di t 4 - 6 gi v thm ch gy priapism (trong trng hp ny dng thuc antidot l pseudoephedrin 60mg). Gy x cng th hang a n cong dng vt. 5.1.3. Thuc qua ng niu o Thuc s dng y l alprostadil vi liu 50g. 5.1.4. Thuc qua ng da Thng t t c s cng cng hon ton, loi ny gm c: Glyceryl trinitrat c tc dng trn lit dng do tm l v thn kinh. Mrinoxidil dung dch 2%, liu ti a 1ml (0,28mg). Papaverin dng gel 7,5%, 15%, 20%. 5.1.5. Gii phu Mc ch l gii quyt nhng chng suy sinh dc nam do bnh Peyronie gm cc phng php: Gn dng vt gi. 261

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Tht tnh mch trong trng hp r r tnh mch. Sa cha h mch mu dng vt. Nh chng ta bit, bnh Peyroni l s x ho, collagen ho lp tunica albuginea bao quanh th hang (kt qu t s phc hi qu mc.. sau mt chn thng dng vt). Kt qu trn dng vt xut hin nhng mnh x gy au khi cng dng v thm ch lm bin dng dng vt. Vic iu tr ni khoa nh ung colchichin, vitamin E hoc tim ln sang thng nhng cht nh interferon, verapamil hoc cortison ch t c mt t kt qu. Do mc ch l gii phu y l lc i nhng mng x hoc trong trng hp nng l gii phu gn dng vt gi. Trong khi phng php mch mu c ch nh cho nhng trng hp nh r r tnh mch (pht hin qua cavernosometry v graphy). Ring trong trng hp suy ng mch (pht hin qua Duplex Doppler Ultrasound v chp ng mch pudendal chn lc) phng php gii phu l ni ng mch thng v di vo ng mch lng dng vt Cui cng l phng php gn dng vt gi chn ch nh cho nhng bnh nhn tht bi cho tt c cc phng php. C 2 cch p dng phng php gn dng vt gi: Phng php Nonhydraulic s dng mt que cng gn vo dng vt. Phng php Hydraulic s dng nhng cylinder. B phn ny gm c mt my bm gn vo trong bu di, mt ti cha nc d tr gn vo trc bng i v 2 cylinder t vo 2 th hang. 5.1.6. Dng c c hc Gm mt ng ht chn khng (vaccum) v mt bng cao su tht gc dng vt dng hn ch s tr v tnh mch lng dng vt ca mu. Phng php ny thng c dng cho nhng lit dng do tn thng mch mu v i ng. 5.2. Theo y hc c truyn i vi chng di tinh, to tit, php tr ca YHCT gm nhng ni dung sau y: 5.2.1. An thn, nh tm, c tinh Nhm mc ch chng lo u v c ch giao cm trung ng. Bi thuc tiu biu: an thn nh ch thang gia gim. C th trong chng tng ho vng ng, tm thn bt giao, ta c th dng cc v thuc sau: 262

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V thuc Si h Tho quyt minh Phc linh Vin ch Long ct Khim thc Lin nhc

Tc dng ng, hn: thanh tit can ho ut kt, t tng ho vng ng Mn, bnh: thanh can, ch thn Ngt, bnh: an thn ng, m: nh tm, an thn Ngt, sp, bnh: trn kinh, an thn, sp tinh Ngt, cht, bnh: ch thn sp tinh Ngt, bnh: ch thn c tinh, dng tm an thn

Liu 12g 16g 8g 8g 16g 12g 12g

Vai tr Qun Thn Thn Thn Thn Thn Thn

Nu trng hp bnh nhn b to tit do xc cm hoc hng phn qu mc c th thay lin nhc bng lin tm 12g. 5.2.2. n b thn dng, np kh c tinh Phng php ny nhm mc ch c ch giao cm ngoi vi gy gin c trn mch mu n dng vt, gy trng thi ham mun tnh dc v sinh tinh nh tc dng ca testosteron hoc cung cp arginin (tin cht ca nitric oxyd). Bi thuc tiu biu: Hu quy hon gia gim, c th trong chng thn kh bt c, ta c th dng
V thuc Ph t ch Nhc qu Thc a Hoi sn Sn th K t ng quy trng Th ty t Cao ban long Kim anh t Khim thc Lin tu Tc dng i nhit, c c, cay, ngt: hi dng cu nghch, b ho tr dng, trc phong hn thp t Cay, ngt, i nhit hi c: b mnh mn tng ho Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Chua sp, hi n: n b can thn, mnh gn ct Ngt, bnh: t dng can thn, sinh tinh huyt Cay, ngt, n: dung huyt, Ngt, n, hi cay: b can thn, mnh gn ct Ngt, cay, n: b can thn, ch tinh tu, mnh gn ct V mn, m: b ng tng, h lao Chua, cht, bnh: c tinh, sp niu Ngt, cht, bnh: ch thn sp tinh Ngt, sp: thanh tm, c thn sp tinh Liu 8g 12g 12g 8g 6g 12g 12g 12g 8g 20g 30g 30g 5g Vai tr Qun Thn T T T T T T T T T T T

5.2.3. Thanh nhit li thp Phng php ny nhm mc ch s dng khng sinh thc vt cha nhim trng niu sinh dc.

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Bi thuc tiu biu: Thy lc n (gm: khim thc v kim anh t), c th trong bnh cnh thp nhit c th dng:
V thuc Hong b nam B cng anh Kh sm T gii Khim thc Kim anh t Tc dng ng, lnh: thanh thp nhit ng, ngt, hn: li thp, thng lm, thanh nhit, gii c ng, mt: li thu ng, bnh: phn thanh, kh trc Ngt, cht, bnh: ch thn sp tinh Chua, cht, bnh: c tinh, sp niu Liu 12g 20g 10g 16g 30g 30g Vai tr Qun Thn Thn Thn T T

Tt nht nn iu tr bng khng sinh ca YHH. Ring i vi chng lit dng, dng nuy php tr ca YHCT s tp trung vo phng php. 5.2.4. n thn np kh Bi thuc tiu biu: Hu quy hon vi mc ch c ch giao cm ngoi vi lm gin c trn mch mu nui dng vt, gy trng thi ham mun tnh dc v sinh tinh ng thi cung cp arginin (mt tin cht ca nitric oxyd) gy gin c trn mch mu, c th trong chng mnh mn ho suy (thn kh bt tc).
V thuc Ph t ch K t Thc a Hoi sn ng quy trng Th ty t Nhc qu Cao ban long Cp gii Tc dng i nhit, c c, cay, ngt: hi dng cu nghch, b ho tr dng Ngt, bnh: t dng can thn, sinh tinh huyt Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b thn dng m, b ph thn Ngt, n, hi cay: b can thn, mnh gn ct Ngt, n, hi cay: b can thn Ngt, cay, n: b can thn, ch tinh tu Cay, ngt, i nhit hi c: b mnh mn tng ho V mn, m: b ng tng, h lao Mn, m: ch tinh, tr dng Liu 8g 8g 12g 8g 8g 12g 8g 4g 12g 08g Vai tr Qun Thn Thn Thn Thn Thn Thn Thn Thn T

5.2.5. n b tm t n b tm t nhm mc ch bi dng th lc v cung cp nhiu acid amin trong c arginin (mt tin cht nitric oxyd). 264

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Bi thuc tiu biu: Quy t thang, c th trong trng hp tm t lng h ta c th s dng


V thuc Long nhn To nhn Phc thn Hong k Bch trut Nhn sm ng quy Mc hng Vin ch i to Cao ban long Cp gii Thc a B huyt, kin t Ngt, chua, bnh: dng tm an thn, sinh tn dch Tit tm nhit, bnh n tm thn Ngt, m: b tm kh, thng dng kh ca t Ngt, ng, hi m vo t v: kin t, to thp, cm m hi Ngt, hi ng: b tm kh, thng dng kh ca t Ngt, n, hi cay: b huyt, hnh huyt Hnh kh ch thng, kin t ng, m: nh tm, an thn Ngt, bnh: b trung, ch kh, ho hon dc tnh V mn, m: b ng tng, h lao Mn, m: ch tinh, tr dng Ngt, hi n: nui thn dng m, b thn, b huyt Dc l Liu 12g 8g 8g 12g 12g 16g 12g 6g 8g 12g 20g 8g 12g Vai tr Qun Qun Qun Thn Thn Thn T T T T T T T

T lng gi 1. Si somatic vn ng xut pht t r lng S3 - S4 s phn b n

A. C vng trong ca bng quang B. C hnh hang C. Niu o mng D. Th xp ca dng vt E. Ti tinh
2. Si giao cm hu hch xut pht t vng xm ca T11 - L2, sau khi i n tng pelvic phi hp vi si ph giao cm s khng phn b n

A. C vng trong bng quang B. C hnh hang


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C. Ti tinh D. Th hang dng vt E. Th xp dng vt


3. C ch ca s cng cng dng vt l do:

A. S co tht ca cc tiu ng mch v cc xoang ca th hang B. S gin n ca cc tiu tnh mch gia xoang v dense tunica albuginea C. S gin n ca cc c trn tiu ng mch v cc xoang D. S gin n ca cc tiu ng mch, cc xoang, tiu tnh mch gia xoang E. S co tht c hnh hang - hang
4. Thnh phn no sau y khng gy nn s gin n cc c trn mch mu

A. Nitric oxyd B. VIP C. Calcitonin gene - related peptid D. Norepinephrin E. Non adrenergic non cholinergic
5. Nguyn nhn ca s mt ham mun khng do

A. Hypogonadism B. Thiu ht androgen C. Ri lon tm l D. Lm dng thuc gy nghin E. Finasterid


6. Nguyn nhn ca s khng cng dng do tng protactin mu

A. Cc thuc gy nghin B. Cc thuc chng cholinergic C. Cc thuc chng trm cm D. Phenothiazin E. Cc thuc c ch giao cm trung ng tr reserpin v methyldopa
7. Nguyn nhn ca s khng cng dng do bnh l thn kinh khng xp loi vo

A. Bnh Peyronie
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B. Tn thng thu thi dng trc C. Tabes Dorsalis D. Bnh i ng E. Gii phu Prostate
8. Nguyn nhn ca s khng cng dng do bnh l mch mu khng xp loi vo

A. Hi chng Lerich B. X m ng mch pudendal C. X m ng mch cavernous D. B. Peyronie E. R r tnh mch gia xoang hang
9. Nu bnh nhn khm v l do khng cng dng c, ta khng cn phi khai thc iu g trong bnh s

A. Tin cn v bnh i ng B. Tin cn v mt stress tm l ko di C. Tin cn s dng thuc D. Thi gian cng dng ban m E. Tin cn v mt bnh l thn kinh
10. Nu bnh nhn khm v l do mt ham mun, ta khng cn khai thc iu g trong bnh s:

A. Mt stress tm l ko di B. Mt bnh l ri lon cm xc, lo u C. Mt bnh l tai mi hng D. Tin cn i tho ng E. Tin cn s dng thuc
11. Trn mt bnh nhn b chng bt lc, lc khm thn kinh khng cn phi khm

A. Vn ng t ch 2 chn B. Phn x hnh hang C. Phn x gn xng 2 chn D. Cm gic nng 2 chn E. Cm gic su 2 chn
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12. Trn mt bnh nhn b chng bt lc ta khng cn phi lm

A. Khm h thn kinh 2 chn B. Kho st tinh trng C. Khm h thng lng, tinh hon D. Khm h mch mu chu, dng vt E. Khm phn x hnh hang
13. Theo y hc c truyn, mng tinh hoc to tit l hu qu ca

A. Thn m h B. Thp trc C. Thn kh bt c D. Dng nuy E. Lit dng


14. Triu chng no sau y khng c trong th tng ho vng ng

A. Ng t B. Hi hp C. Dng vt hay cng D. Khng ham mun E. Mng tinh


15. Triu chng no sau y khng c trong th tm thn bt giao

A. Mng tinh, to tit B. T hn C. Tinh thn bi hoi D. Bc ho mt E. Lnh 2 chn


16. Triu chng no sau y khng c trong th thn kh bt tc

A. au eo lng B. T hn C. Hot tinh D. Ng canh t E. Chn tay lnh

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17. Triu chng no sau y khng c trong th tm t lng h

A. S st B. Hay qun C. Bng y D. Cu gt E. Tiu lng


18. Testosterol ch c hiu qu trn chng bt lc do

A. Prolactin mu tng B. Gim nng tuyn sinh dc C. Hi chng Lerich D. Chng cng au dng vt E. B. Peyronie
19. Bromocryptin c hiu qu trn chng bt lc do

A. Gim nng tuyn sinh dc B. Do ng mch C. Do i ng D. Prolactin mu tng E. Do tabes dorsalis


20. Yohimbin c hiu qu trn chng bt lc do

A. X m ng mch pudendal, cavernous B. Hi chng Lerich C. Tabes dorsalis D. Diabetic autonomic neuropathy E. R r tnh mch th hang
21. C ch tc dng ca sildefanil l

A. Hot ho nitric oxyd B. c ch s phn hy C.GMP C. c ch s phn hy C.AMP D. Hot ho C.GMP E. Hot ho s phn hy C.AMP
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22. Ch nh tt nht cho phng php tim thuc vo th hang dng vt l

A. Bt thng trn Doppler v siu m phn gii cao B. Hi chng Lerich C. X m ng mch pudendal, cavernous D. Diabetic autonomic neuropathy E. Chn thng ty sng
23. Tc dng dc l no sau y khng c trong php n b thn dng np kh

A. c ch giao cm ngoi vi B. Cung cp tin cht nitric oxyd C. Bnh tnh dc tnh D. Gy ham mun E. Sinh tinh

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Bi 17

BNH VIM SINH DC N

MC TIU 1. Nu c nh ngha, c im dch t hc v quan nim v vim sinh dc n theo YHCT. 2. Nu c nguyn nhn, bnh sinh, cc biu hin lm sng ca vim sinh dc n theo YHH v YHCT. 3. Chn on c cc th lm sng ca vim sinh dc n theo YHCT. 4. Trnh by c nhng nguyn tc v cc phng php ng dng iu tr vim sinh dc n theo YHH v YHCT. 5. Trnh by v gii thch c c s l lun ca vic iu tr vim sinh dc n bng YHCT.

1. I CNG 1.1. Khi nim Vim sinh dc n l loi bnh ph khoa thng gp (trong c c bnh thuc nhm bnh x hi ly truyn ch yu qua tip xc tnh dc v nhim cc loi vi khun thng thng do c hi). cc nc ang pht trin, 3 bnh vim nhim ng sinh dc do vi khun (lu, nhim Chlamydia v giang mai) nm trong s 10 n 20 bnh mc cao nht gy nh hng n ch s sc khe v sinh sn hng nm cho ngi ph n do cc bin chng nh vim vi trng, v sinh, thai ngoi t cung v t vong chu sinh. Cc tc nhn gy bnh ph bin nht l lu cu, Chlamydia trachomatis, xon khun Trepomenema pallidum, Trichomonas vaginalis, nm Candida albicans, cc virus. Ngun ly ch yu l nhng ngi trng thnh c tip xc giao hp, nhm nguy c ly lan cao l gi mi dm. ng ly: ly truyn qua ng sinh dc, tuy nhin vn c th ly qua khi dng chung dng c, o qun

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1.2. nh ngha c im lm sng khi u bng tnh trng vim nim mc c quan sinh dc n, gy vim ti ch, sau lan theo chiu di b phn sinh dc v gy bnh ton thn. Triu chng chung l c nhiu huyt trng. Vim sinh dc phn lm 2 hi chng lm sng chnh: Vim sinh dc di gm: vim m h, vim m o, vim c t cung. Vim sinh dc trn (vim tiu khung) gm: vim t cung, vim phn ph. 1.3. Quan nim vim sinh dc n theo y hc c truyn Cc biu hin ca vim nhim b phn sinh dc n nm trong phm vi m t ca chng i h. i c ngha dy tht lng qun, h c ngha phn di. Theo ngha rng (Ni kinh): i h l bnh pht sinh phn di lng qun, bao gm tt c cc bnh thuc kinh i, thai, sn. Theo ngha hp: i h dng ch mt cht dch do, nht, chy t trong m o ra lin min khng dt, thng hay gi l kh h hay huyt trng. Trong phm vi ny mun trnh by chng i h c biu hin l c cht dch tit ra t m o ngi ph n trong tnh trng vim nhim b phn sinh dc bao gm tt c cc tn c phn loi theo mu sc, tnh cht ca dch tit nh sau: bch i, hong i, bch dm, bch bng, thanh i, bch trc, xch i, hc i, xch bch i, ng sc i. 2. NGUYN NHN, BNH SINH V BIU HIN LM SNG THEO y hc hin i 2.1. Vim sinh dc c h thng do vi trng lu 2.1.1. Nguyn nhn Do vi khun Neisseria gonorrhrea (lu cu), thuc nhm Gram m, do Neisser tm ra nm 1879. Vi khun di chuyn tng hi bm vo nim mc ca b phn sinh dc. Lu cu rt yu, cht rt nhanh nhit thng, n ch pht trin c mi trng c m, nhit thch hp, nhiu kh CO2 v giu cht dinh dng. i sng khong 4 gi v c 15 pht li phn chia mt ln. 2.1.2. Dch bnh hc Khong 99% bnh ly truyn do giao hp gia nam v n, ph n mang mm bnh c kh nng ly truyn bnh qua nhiu thng, nhiu nm. 2.1.3. Sinh bnh hc Bnh khi u bng tnh trng vim cp ca niu o, vim tuyn Bartholin v nim mc m o, c t cung. Vi khun lu xm nhp vo 272

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nim mc b phn sinh dc, gy phn ng vim ti ch, ko theo bch cu a nhn thc bo nn lm tit ra m niu o, m o. Sau vi trng lan theo ni mc t cung, gy vim t cung, vim phn ph. Ni mc t cung ph, sung huyt, nhng tnh trng bnh l thng t thuyn gim v m, c th t thot ra ngoi qua c t cung. M c th t thot ra khi vi trng, vo bng gy vim phc mc vng chu, t m vi chu. Nhng do vi trng lu l vi trng n lan trong lp nim mc nn v sau vi trng d b bt kn, m hoc nc, hu qu l v sinh.
Vi trng Error! lu, neisseria, gonorrhea

Trichomonas vaginalis

Nm

Tp trng

Vim sinh dc n

Vim niu o, vim tuyn bartholin

Vim nim mc m o, c t cung

Vim ni mc t cung Cp Mn

VIm phn ph

Cp

Mn

Bin chng Vim vi trng V sinh Thai ngoi t cung T vong chu sinh

2.1.4. Triu chng v chn on Triu chng c nng: st, au vng chu, tiu gt, tiu nhiu ln, tiu t. Triu chng thc th: tuyn Bartholin vim , c m, huyt trng nhiu, dch c nh m, nim mc m o vim . Thm m o: m o, t cung, hai phn ph rt au, i khi c bc m lm phng ti cng Douglas. Xt nghim: + Cng thc mu: bch cu tng vi t l a nhn trung tnh tng. + Soi ti dch m o: nhum Gram c vi trng lu (song cu trng). + Cy trng: c vi trng lu. 273

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2.1.5. iu tr Nguyn tc: iu tr ng, sm v liu, lun iu tr c cho ngi chng hoc bn tnh. Thuc khng sinh: procain penicillin hoc tetracyclin, clarithromycin (nu d ng). 2.2. Vim sinh dc do nhng nguyn nhn khc 2.2.1. Vim m o v c t cung do Trichomonas vaginalis a. Sinh bnh hc Bnh thng pH m o acid, pH = 4,5 - 5 (do vi trng Doderlein bin i glycogen t bo m o thnh acid lactic. Khi pH m o b kim, d b Trichomonas xm nhp. T l nhim bnh chim khong 25% s ph n c vim sinh dc, ph n v sinh km, thng ly qua giao hp. b. Triu chng t nga rt m o, t au khi giao hp. Huyt trng nhiu, long, vng hi xanh, c bt, hi. Nim mc c t cung v m o c nhiu nt lm tm. c. Chn on Soi ti dch m o: tm c Trichomonas bi trong git dung dch sinh l. Nhum Gimsa. d. iu tr: metronidazol (flagyl), hiu qu 95%. 2.2.2. Vim m o v c t cung do nm Candida albicans a. Sinh bnh hc: nm Candida bnh thng tm thy trong ng tiu ha, cc hc t nhin v c s bnh qun gia cc tp khun sng cng sinh, khng gy bnh. Nu dng khng sinh ba bi hoc corticoid, c th gim sc khng th nm Candida s tng trng v gy bnh. T l nhim bnh l 10% tng s vim sinh dc, thng xy ra bnh nhn tiu ng, dng khng sinh nhiu b. Triu chng Nga m h, m o nhiu. Huyt trng mu trng c, c, ln cn. Nim mc m o sng , ph n c cn trng nh sa bm vo c t cung hoc thnh m o. 274

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c. Chn on Soi ti vi KOH 10%: 40 - 80% cc trng hp thy si t nm v bo t nm. Nhum Gram: 70 - 80% trng hp thy si t nm v bo t nm. d. iu tr: mycostatin t m o, ung 500000 n v mi ln 1 vin, 3 ln/ngy x 14 ngy 2.2.3. Vim m o, c t cung do tp trng a. Sinh bnh hc: loi t cu chim u th, ph n mang nhng chng vi khun khng gy bnh nhng khi sc khng yu do bnh nhim trng, hoc khng sinh ba bi th cc chng vi khun tng c lc v gy bnh. b. Triu chng Nga m o t, t au do giao hp. Huyt trng vng nh m, lng nhiu. c. Chn on: tm vi trng bng nhum Gram, cy trng. d. iu tr: la chn khng sinh theo khng sinh , t thuc m o. 2.2.4. Vim ni mc t cung a. Vim ni mc t cung cp Thng gp sau sinh (do st nhau hay nhim trng i), sau no thai nhim trng, do vi trng lu. Triu chng v chn on vim ni mc t cung cp: ty thuc vo triu chng ca vi trng gy bnh, tu sc khng ca bnh nhn v ty tnh trng dn lu ca bung t cung + Vim nh: st nh, c sn dch hi. + Vim nng: st cao mch nhanh, c m t t cung chy ra, c t cung vim . + Vim tc tnh mch: t cung ln, co li km, di ng t cung rt au. + Lm xt nghim: ly dch m o, cy trng chn on. + Cn chn on phn bit: Vim ni mc t cung cp do vi trng lu. Vim rut tha cp. Vim b thn. iu tr: + Khng sinh theo khnh sinh , liu cao. 275

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+ Nong c t cung, no t cung sau khi cho khng sinh. + Phu thut ngun nhim trng trong nhng trng hp iu tr bo tn khng kt qu. b. Vim ni mc t cung mn Thng l di chng ca vim cp, xy ra sau vim cp, sau xy thai hoc do c u x t cung di nim mc Triu chng lm sng: + au h v m , cm gic nng vng h v, au lng, au bng khi c kinh; tiu tin gt, but + Ri lon kinh nguyt, chu k kinh b ngn li, rong kinh. + Huyt trng nhiu, long, mu vng, hi. + V sinh, d sy thai hoc nhau tin o. + Khm: t cung nh, di ng au. iu tr: + iu tr nhng nhim trng m o, c t cung nu c. + Khng sinh thch hp. + No t cung sau khi cho khng sinh 3 ngy. 2.2.5. Vim phn ph (vim vi trng v bung trng) a. Vim phn ph cp y l bin chng ca vim ni mc t cung cp sau sinh, sau no. Triu chng: + Ging bnh cnh ca vim ni mc t cung cp, km st cao, hai bn phn ph rt au. + Huyt trng nh m, mi hi, lng nhiu. + Khm thy hai phn ph au nhng mm, khng n. iu tr: + iu tr nhng nhim trng m o, c t cung, nu c. + Khng sinh thch hp. + Phu thut nu c p xe phn ph. c im ca vim phn ph do cc loi vi trng khc (khng phi vi trng lu) l vi trng i theo ng bch huyt gy vim lp thanh mc v c vi trng, nim mc vi trng vn bnh thng nn v sau vn c nhiu kh nng sinh sn. 276

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b. Vim phn ph mn Thng xy ra sau vim phn ph cp m iu tr khng y . Triu chng: + Ging nh vim ni mc t cung mn: t cung to; hai phn ph n, dy, hi au. + Khm c khi au dnh cnh t cung (hai bn), c th c bc p xe hai bn phn ph. iu tr: + Khng sinh liu cao. + Corticosteroid, chm nng. + Vt l tr liu bng ln sng in ngn. + Phu thut nu iu tr ni khoa khng kt qu. 3. NGUYN NHN, BNH SINH V BIU HIN LM SNG THEO y hc c truyn Nguyn nhn sinh chng i h do ni nhn, ngoi nhn, bt ni ngoi nhn. Ni nhn: do tnh ch bt n, th cht suy nhc nh hng ch yu n 2 tng can v t (can kinh ut ha, t kh suy yu). Sch Ph thanh ch n khoa vit: H t kh h, can kh ut, u c th sinh ra bnh i h. Ngoi nhn: phong hn, thp nhit, m thp d xm phm vo c th khi c th ang lao thng qu gy kh huyt hao tn, nhng ch khi t nhp n phn bo lc th mi gy ra chng i h. Bt ni ngoi nhn: do n ung no say qu m giao hp, hoc dng nhiu cht cao lng m v hoc ung dng thuc kh to lu ngy tn thng ti m huyt lm dng kh b nn xung cng to thnh chng i h. Tuy rng c nhiu nguyn nhn sinh ra bnh nhng ch khi bnh t gy bnh ca bo cung lm cho mch xung, nhm b thng tn mi l nguyn nhn chnh ca cc bnh i h, nh khi chc nng t b ri lon, t dng mt kh nng vn ha c thp trc nh tr bn trong phi chy xung bo cung, lm ri lon mch xung, nhm mi pht sinh ra chng i h. Hu qu ca bnh lu ngy s nh hng ti nguyn kh lm c th suy yu c hi cho vic sinh sn, truyn ging nn cn ch v sinh b phn sinh dc, bo v sc khe lu di.

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NI NHN TNH CH CAN T

NGOI NHN PHONG HN THP NHIT M THP BO LC

BT NI NGOI NHN N UNG, PHNG DC, THUC KH TO M HUYT DNG KH MCH XUNG NHM TN THNG

I h (30 th LS)

Bch i (8 th LS)

Bng i (3 th LS)

Xch bch i (5 th LS)

Xch i (2 th LS)

Hong i (2 th LS)

i ng sc

Hc i (2 th LS)

Thanh i (2 th LS)

Bch dm (2 th LS)

Bch trc (3 th LS)

Ty thuc vo mu sc, tnh cht biu hin bnh, lm sng YHCT chia ra lm nhiu loi: bch i, bng i, xch bch i 3.1. Bch i Bch i l t dng ch mt th nht mu trng, do, ko di nh si t trong m o chy ra. 3.1.1. Nguyn nhn Do ngoi nhn: phong hn hoc thp nhit hoc m thp xm phm vo bo lc lm ri lon v thng tn n bo cung ng thi lm tn thng m kh m sinh ra bch i. Do ni nhn tht tnh, lm ri lon chc nng ca can, t, thn m sinh bnh. Do phng dc qu lm tn thng nguyn kh cng sinh bnh.

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3.1.2. Cc th lm sng a. Th t h T h nn thp th b hm xung, t tinh khng gi c to vinh huyt m chy xung cht trng nhn. Triu chng xut hin lng i nhiu, u oi, sc da vng, chn tay lnh, chn ph, tiu lng. Nu km can ut ha nhit th cht i do dnh hi, mu vng, tiu sn v au. b. Th thn h K kinh bt mch thuc thn kinh, khi thn tinh suy th i mch git xung. Triu chng xut hin lng i t, mu trong, lai rai, r r, sc mt xanh bc, tinh lc yu, u chong. Nu km thn dng suy s tiu nhiu ln, u chong, yu mi lng gi. c. Th kh ut Lng i xung khi nhiu khi t, tinh thn khng thoi mi. Ngc sn tc, au v, chng mt, hi hp. hi, nn, n t, ru li bc nhn, mch huyn hot. d. Th phong hn Lng i nhiu, mu trong nh nc, s lnh, chi lnh, tiu trong di. e. Th thp nhit Lng i nhiu, cht i nhn, mu c tanh hi, nga m h, tiu tin khng thng, chong vng, mt mi, ru li dy nhn, mch nhu. f. Th m thp Lng i ra nhiu, ging nh m. Ngi bo bu, u oi, chong vng, ngc y tc, bng nng n, n t, m nhiu, nn o, li nht, ru li trng nhn, mch huyn hot. g. Th h hn Lng i t, sc trong, ko di khng dt, sc mt xanh, tinh lc yu, chi lnh, chong vng, hi hp, on kh, ru li mng, mch tr vi. h. Th h nhit Bch i lu ngy, ming ng, hng kh au. Ng tm phin nhit, hi hp, lo s. Li hng n, khng ru. Mch h, t, sc. 279

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3.2. Bch bng Th nc nht nh nc vo go, mu trng t m o chy ra lng t, o xung nn gi l bch bng. y l chng bch i trong thi k nng. 3.2.1. Nguyn nhn Do phong hn hoc thp nhit. Nhng phn nhiu do ri lon chc nng can, t, thn. 3.2.2. Cc th lm sng a. Th thp nhit Bch i nh bng mu vng, hi; bng di au sng, lng gi mi, nng u, ming ng nht, mch hot sc. b. Th h tn Do lao tn qu nh hng ti bo lc lm nguyn kh qu h. Triu chng: bch i nhiu, lu ngy khng ht, sc mt xanh bc, li hng, ru c ng nt n. Nu t thn dng h th chn tay lnh, ng canh t, mch trm tr vi. c. Th kh ut Lo ngh nhiu, tnh ch u ut, bch i xung nhiu nh bng, sc mt xanh bc, tinh thn ut c, xy xm, mt mi, ngc tc, au hng sn, bng trng, si rut, mi lng yu sc, mch huyn sc. 3.3. Xch bch i 3.3.1. Triu chng Cht nht c, c ln ln mu trng t m o chy ra. 3.3.2. Cc th lm sng a. Th thp nhit Lng i rt nhiu, cht do dnh tanh hi thi, nng th trong m h sng au, n km, bng di trng, t nga m h. b. Th huyt V bn trong c tr nn i h trng, bng di au, hnh kinh kh, kinh n trc k, li tm thm, mch tr sc.

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c. Th kh ut Do tnh ch ut c, gin d lm tn hng tm t, huyt khng quy v kinh c nn sinh i h xch bch. Triu chng xut hin ngoi du xch bch i, bnh nhn cn than phin v tnh trng bc bi, kh ng; ng thi n ung khng ngon. d. Th h hn i h xch bch lu ngy khng bt, bng di au, m o au, chn tay lnh, sc mt xanh bc, tng trng h hn. e. Th h nhit Do m h phin nhit, ni ha thnh. Triu chng km chong vng, tm phin, mt ng, ming kh, c kht, to bn, tiu t. 3.4. Xch i Trong m o chy ra th nc dnh mu nn gi l xch i. Xch i khng phi l huyt dch, chy r r lai rai khng dt. Tht ra i h rng l thuc v kinh lu (rong kinh) xen ln vi sc trng l xch bch i h cho nn kh phn bit r. Chng bnh ny c th tng ng vi y hc hin i l rong huyt hoc kh h do bnh c tnh t cung. 3.4.1. Nguyn nhn Do thp nhit sinh ha. C th do tm ha, can ha vng ln lu ngy lm kh huyt h tn. Kh h khng nhip c huyt m gy bnh. 3.4.2. Cc th lm sng a. Th thp nhit Lng i nhiu, cht nht, dnh hi tanh, ming ng, hng kh kht, kh ng, to bn, tiu vng t, tiu au, li hng ru vng, mch hot sc. b. Th h nhit Xch i tanh hi, c. + Nu huyt h km can ha vng: c triu chng tc ngc, au hng sn, nng ny, d gin, mch huyn t. + Nu huyt h km tm ha vng: chong vng, ngc phin, ng khng yn, hng kh kht nc, li hng, cht li nt n m sng, mch h t km sc.

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3.5. Hong i i h mu vng nh nc tr, c nhn c mi hi thi. Chng ny tng ng trong phm vi kh h do nhim trng ca y hc hin i. Trn lm sng chia ra hai th bnh l kh h v thp nhit. 3.5.1. Th thp nhit Do thp nhit phm vo nhm mch, nn nhm mch khng sinh tinh ha kh c, nung nu m thnh hong i. Triu chng xut hin i h mu vng, tanh hi nng nc, m h sng au. 3.5.2. Th kh h i h vng trng, lai rai khng dt, trung kh hao tn dn, tinh lc yu km. 3.6. Thanh i i h nh mu nc u xanh, nht c chy xung t m o, mi hi thi. Tng ng trong phm vi kh h do nhim trng ca y hc hin i. Tht ra, trn lm sng thanh i khng phi tht xanh m l mu tro nhn hi pha ln mu xanh vng, kh nhn nh c. Lm sng cng chia thanh i lm hai th bnh l th thp nhit v h tn. 3.6.1. Th thp nhit Thp nhit can kinh nh tr trung tiu, chy vo bo cung, kh ut nghch tch t lu ngy thnh bnh. Triu chng: i h vng trng, pha mu xanh, hi thi, sc mt xanh vng, tinh thn u ut, au u, ngc sn y tc, n km, li hng nh sc xanh, ru li vng nht, mch huyn sc. 3.6.2. Th h tn Chng thanh i lu ngy khng gim n ni can thn u h: hoa mt, mt m km triu chng h nhit. 3.7. Hc i 3.7.1. Triu chng i h sc en nh nc u en, c th c hoc lng, trong nh nc, mi hi thi. Bnh chng ny tng ng vi chng kh h do bnh c tnh t cung ca YHH. 282

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3.7.2. Cc th lm sng a. Chng ha nhit Do nhit qu nung c gy nn bnh. Nhit ny do v ho qu vng kt hp vi ha mnh mn, bng quang, tam tiu nung nu cn kh ri bin thnh mu tro, chn on l ha nhit ti cc im th bin thnh chng hc i. Triu chng: dch huyt trng, trong hong i c xen ln sc en, dnh, nhn tanh hi, ngi bn chn nng ny, kht nc. Sc mt vng, m h sng au, tiu tin sn, au rt. b. Th thn h Lu h en l v thn suy nhc, mu en thuc thn. Triu chng: gia i h xch bch, c sc en v c mi hi. Sc mt xanh bc hi vng, g m , da kh, u chong mt hoa, st v chiu, au bng v lng gi, to bn, tiu gt, , li hng nt n, mch h t sc. 3.8. i ng sc 3.8.1. Triu chng i h l cht nha nht, c mu xanh vng, vng , trng en. Nm mu ln ln, tt c u c mi thi. Chng ny tng ng trong phm vi YHH l kh h do bnh c tnh t cung. y l chng bnh nng trm trng. 3.8.2. Cc th lm sng a. Th ng tng h Do ng tng u h, ng sc cng chy xung mt lt, l huyt sinh ra bnh. Triu chng: chng i h ng sc lu ngy khng dt, xut hin triu chng h hn nh sc mt xanh bc, s lnh, tinh thn mi mt, chong vng, yu sc, tiu lng, li nht ru li t, mch trm tr v lc. b. Th thp nhit Nu thp nhit tch t trong bo cung, chng i h ng sc chc chn hi thi c bit, km tc ngc, ng ming v c nht, bng di trng au, tiu vng c, ru li vng nht. 3.9. Bch dm Cht nc trng chy ra t m h, bnh chng ny thuc phm vi suy nhc sinh dc trong YHH. 283

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3.9.1. Nguyn nhn Theo sch N khoa ch yu, do tnh dc khng c toi ch hoc giao hp qu sinh ra. Theo sch T vn: V t tng qu dm dc, khng c toi nguyn, th dm ngoi, giao hp qu lm cho cc ng gn lng lo sinh ra chng bi xui (nuy chng) v lm thnh bnh bch dm. 3.9.2. Cc th lm sng a. Th ut ha Khi c bch dm xung, ngi nng ny bt rt. Nu bnh nh: st v chiu, li hng, ru li mng; nu bnh nng: ha thnh lm tn thng ti m kh sinh bt rt, phin nhit, hng kh kht, m nm mng giao hp; li , nt n, au; mch t sc. b. Th thn h m h lun chy ra nc tinh lin tc, sc mt ti xanh, chong u, hoa mt, hai g m , au lng gi, li nt su, mch h t. 3.10. Bch trc Cht nha c thi nh m chy ra t ng dn tiu. Chng ny thuc phm vi nhim trng ng tit niu ca YHH. 3.10.1. Nguyn nhn Do tm ha thi qu. Do bi tinh sinh thp nhit. Do giao hp khng v sinh. 3.10.2. Cc th lm sng Th thp nhit, thp c: bch trc vng, trng nh m hoc trong bch trc c ln huyt; tiu au but, mu vng c m mu. Th m h ho vng: bch trc chy xung lin tc hoc trong bch trc c ln huyt, tiu tin au, nga, tiu tin ra huyt, tm phin bt rt, ming kh to. Th thn h: bch trc lu ngy khng dt, lai rai, chy xung nh m ng, chn gi run yu, tiu tin nhiu ln, nc tiu t nhng khng au, mch tr v lc. 284

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4. IU TR BNG THUC THEO y hc c truyn i h tu thuc vo tnh cht v cch biu hin m phn ra nhiu bnh chng khc nhau, mi bnh chng li c cc th lm sng khc nhau, tuy nhin cc triu chng bnh l cng nh c s l lun cho vic iu tr li ging nhau, nh vy vim sinh dc n hay i h ca YHCT c th iu tr nh sau: 4.1. Th t h Php tr: s can, gii ut, kin t. Bi thuc s dng + Bi Hon i thang (Ph thanh ch n khoa): bch trut, ng sm, cam tho, thng trut, bch thc, si h, trn b, sa tin t, hc gii tu (kinh gii sao en).
V thuc Bch trut Si h ng sm Thng trut Bch thc Hc gii tu Trn b Sa tin t Cam tho Kin t, to thp Pht tn phong nhit, gii ut B t, kin v, ch kh, sinh tn Kin t to thp Lim m, dng huyt, bnh can Pht hn, khu phong Kin t, to thp, ha m Thanh nhit, li niu n trung, iu ha cc v thuc Tc dng Vai tr Qun Qun Thn Thn T T T T S

4.2. Th thn h Php tr: b thn, trng dng, ch tinh. Bi thuc s dng + Bi Ni b hon (N khoa tot yu): lc nhung, th ty t, nhc thung dung, hong k, qu nhc, ph t ch, tang phiu tiu, bch tt l, phc thn, sa tt l, t uyn nhung. Ung trc ba n.

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V thuc Lc nhung Tang phiu tiu Th ty t Nhc thung dung Hong k Qu nhc Ph t ch Bch tt l Phc thn Sa tt l T uyn nhung

Tc dng B thn dng, b tinh huyt C tinh, sp niu, lim hn, ch i B can thn, c tinh n b thn dng, nhun trng B kh thng dng kh ca t, tiu vim Tr m h h tiu, b mnh mn ha Tn hn, ch thng Bnh can c sp, tr thp Ch kinh qu, an tm thn Bnh can, kh thp Kh thp, ch thng, b huyt, tiu m

Vai tr Qun Qun Thn T T T T T T T T

+ Bi Cu long n (Ni kinh thp di): ng quy, bch linh, sn tra, cu k t, lin nhc, khim thc, llin hoa tu, thc a, kim anh t. Ch nh iu tr: thn h ca thanh i, bch dm, bch trc
V thuc Kim anh t Thc a ng quy Bch linh Sn tra Lin nhc Lin hoa tu Cu k t Khim thc B thn tinh, c sp T m, b thn, dng huyt B huyt, dng huyt Tr thp, li thy, b t v Tiu thc tch, hnh , ha m B t, dng tm, c tinh Sp tinh ch thn, thanh tm, ch huyt B can, thn Kin t, tr thp, b thn, sp tinh Tc dng Vai tr Qun Qun Thn T T T T T T

4.3. Th kh ut Php tr: s can, l t, gii ut, thanh nhit. Bi thuc s dng + Bi Tiu dao tn: ng quy (sao) 30g, bch linh 30g, thc dc (sao ru) 30g, si h 30g, bch trut (sao) 30g, chch tho 16g, bc h.

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V thuc Si h Bch thc Ut kim ng quy Bch trut Bch linh Cam tho

Tc dng ng, hn, vo can, m, tm bo, tam tiu: t nhit, gii c, thng ng, chua, lnh, vo can t, ph: dng huyt, li thy, lim m Cay, ng, n vo t, can: hnh huyt, ph , hnh kh gii ut Ngt, cay, m vo tm, can, t: dng huyt, hot huyt Ngt, ng, m; vo t, v: kin t, to thp, ch hn, an thn Ngt, nht, bnh; vo tm, t, ph, thn: li niu thm thp, kin t, an thn Ngt, bnh; vo 12 kinh: b trung kh, ha hon, gii c

Vai tr Qun Thn Thn Thn T T T, s

+ Bi Trm hng ging kh (Chng tr chun thng): trm hng, chn ging hng, h kinh ct, nhn sm, long m tho. Ch nh trong kh ut ca bch bng
V thuc Trm hng Nhn sm Chn ging hng H kinh ct Long m tho Hng hong X hng Nh hng Tc dng Ging kh, b nguyn dng, h m i b nguyn kh, ch huyt, sinh tn dch Tr kh, tr m Thng kh, b thn, trng dng Thanh can, tr thp nhit Gii c, st trng Khai khiu, thng kinh lc iu kh ha huyt Vai tr Qun Qun Thn T T T S T

4.4. Th thp nhit Php tr: thanh nhit, ho thp. Cc bi thuc s dng + Bi Long m t can thang: long m tho 20g, trch t 12g, sa tin t 12g, mc thng 12g, sinh a 12g, si h 12g, ng quy 12g, sn chi 12g, hong cm 12g, cam tho 6g. Ch nh cho thp nhit ca bch i v thanh i

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V thuc Long m tho Hong cm Chi t Si h Sa tin t Trch t Mc thng ng quy Sinh a Cam tho

Tc dng ng, hn: t can m thc ha, thanh h tiu thp nhit ng, hn: t ph ha, thanh thp nhit ng, hn: thanh nhit t ha, li tiu, cm mu Bnh can, h st Ngt, hn: thanh ph, can, thm bng quang thp nhit Thanh thp nhit bng quang, thn ng, hn: ging tm ha, thanh ph nhit, li tiu tin, thng huyt mch Dng can huyt Ngt, ng, hn: sinh tn dch, lng huyt Bnh, ngt: b t v, nhun ph, thanh nhit, gii c, iu ha cc v thuc

Vai tr Qun Qun Qun Thn Thn T T Thn Thn S

+ Bi Gia v nh diu tn: hong b 10g, thng trut 12g, ng quy 12g, quy bn 15g, ngu tt 10g, phng k 12g, t gii 6g. Ch nh cho thp nhit ca bch bng
V thuc Hong b Thng trut ng quy Quy bn Ngu tt Phng k T gii Tc dng T tng ha, thanh thp nhit h tiu n trung ha m Dng huyt, hot huyt T m, tim dng Hnh huyt, tn , li thp Thanh thp nhit huyt phn, li thy tr thp Thm thp, li niu, kin t Vai tr Qun Qun Thn T T T T

+ Bi Tam b hong (N khoa chun thng): hong lin (sao) 12g, hong cm (sao) 12g, hong b (sao) 12g, sn chi 8g. Ch nh cho thp nhit ca xch i
V thuc Hong lin (sao) Hong cm (sao) Hong b (sao) Sn chi Tc dng Thanh nhit to thp Lng huyt, thanh thp nhit T m, thanh nhit to thp Hnh huyt, gim au Vai tr Qun Thn Thn T

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+ Bi thuc Tam b hong (nh trn) gia thm si h 16g, nhn trn 12g. Ch nh cho thp nhit ca bch trc. + Bi Bt tin m (Sn khoa pht mng): th phc linh, bch linh, trn b, ng quy, kim ngn hoa, xuyn khung, i hong Ch nh cho thp nhit ca xch bch i
V thuc Th phc linh Bch linh Trn b ng quy Kim ngn hoa Xuyn khung i hong Cam tho Tc dng Li thp, thanh nhit Tr thp, li thy, b t v Kin t, l kh to thp B huyt, hot huyt, iu kinh Thanh nhit gii c Hnh kh, hot huyt, gim au H tch tr iu ha v thuc Vai tr Qun Qun Thn Thn T T T S

Bi Gii c t vt thang (Y hc nhp mn): hong cm, hong lin, hong b, sinh a, chi t, dng quy, bch thc, xuyn khung, thc a. Ch nh trong thp nhit ca i ng sc
V thuc Hong cm Hong lin Hong b Sinh a Chi t ng quy Bch thc Xuyn khung Thc a Tc dng Thanh thp nhit, gii c Thanh can nhit, to thp, gii c Thanh nhit to thp h tiu B m, thanh nhit lng huyt Thanh nhit lng huyt t ho B huyt, dng huyt Lim m, dng huyt, bnh can Hnh kh, hot huyt, ch thng T m dng huyt, b thn Vai tr Qun Qun Qun Thn Thn T T T T

4.5. Th m thp Php tr: ho m to thp. Bi thuc s dng: 289

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Bi Lc qun t thang gia v: nhn sm 12g, bch linh 8g, bch trut 8g, cam tho 4g, trn b 8g, bn h ch 8g, khim thc 12g, lin nhc 12g, kim anh t 12g.
V thuc Nhn sm Kim anh t Bch linh Bch trut Cam tho Trn b Bn h ch Khim thc Lin nhc i b nguyn kh C tinh, sp niu Li niu thm thp, b t Kh n, kin t, to thp Cam n ch kh, b trung ha v Kin t, to thp, ha m Bn h, ging kh nghch, tiu m thp B thn, kin t, c tinh, sp niu C tinh, b t, dng tm Tc dng Vai tr Qun Qun Thn Thn S T T T T

4.6. Th h hn Php tr: thng dng, ha v, ch tinh. Bi thuc s dng: + Bi C chn thang (ng vin phng): si h 20g, chch tho 6g, ng sm 12g, can khng 8g, trn b 12g, hong cm 12g (sao ru), qu hoa 8g, ut l nhn 8g, ph t 8g.
V thuc Can khng Ph t ng sm Si h Trn b Hong cm Qu hoa Ut l nhn Chch tho Tc dng n trung, trc hn, hi dng, thng mch B ha, tr dng, trc phong hn thp B t, kin v, ch kh Pht tn phong nhit, gii ut Kin t, l kh, ha m Gii c, tiu thng Khai ut, gii c Khai ut, l kh n trung, iu ha cc v thuc Vai tr Qun Qun Thn Thn T T T T S

Th h hn trong xch i: Php tr: thng dng ch kh n trung. Bi thuc s dng: 290

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+ Bi B trung ch kh thang (ng vin phng): hong k (chch mt) 8g, ng sm 8g, quy thn (sao ru) 8g, chch tho 6g, bch trut (sao) 16g, trn b 8g, thng ma 6g, si h 8g, sinh khng 8g, i to 2 qu
V thuc Nhn sm Hong k Trn b Si h Thng ma Bch trut Bch linh ng sm Quy thn Chch tho Tc dng Ngt, hi ng, bnh; vo t, ph: i b nguyn kh, ch huyt, sinh tn Ngt, m, vo t ph: B kh, thng dng kh ca t, ch hn, li thy Cay, ng, m, vo t ph: hnh kh, bnh v, ha m, tr thp ng, hn, vo can m, tm bo, tam tiu: t nhit, gii c, thng Cay ngt, hi ng vo ph, v, i trng: thanh nhit, gii c, thng Ngt, ng, m; vo t v: kin t, to thp, ch hn, an thn Ngt, nht, bnh vo tm, t, ph, thn: li niu thm thp, kin t, an thn B trung ch kh, sinh tn, ch kht B huyt, hot huyt, nhun to, thng kinh B trung, iu ha cc v thuc Vai tr Qun Thn Thn Thn Thn T T T T S T T, s

Sinh khng n trung, tiu m, hnh thy, gii c i to B t, ch kh, dng v, sinh tn, iu ha doanh v

Th h hn trong xch bch i c th dng bi thuc trn gia thm long ct, mu l, hi phiu tiu. 4.7. Th h nhit Php tr: t m, thanh nhit Bi thuc s dng: + Bi Si cm t vt thang (Ha t cc phng): sinh a 20g, ng quy 8g, xuyn khung 12g, bch thc 12g, si h 12g, hong cm 8g. Ch nh trong h nhit ca bch i
V thuc Sinh a ng quy Xuyn khung Bch thc Si h Hong cm Tc dng B m, thanh nhit, lng huyt B huyt, hot huyt, iu kinh Hnh kh, hot huyt, gim au Lim m, dng huyt, bnh can Pht tn phong nhit, gii ut Gii c, tiu thng Vai tr Thn T T T Qun Qun

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+ Bi t vt gia cm lin thang: ch nh trong h nhit ca thanh i. + Bi C kinh hon (Y hc nhp mn): hong cm 16g, bch thc 16g, quy bn 16g, xun cn 12g, hong b 8g, hng ph 7g. Ch nh trong h nhit ca xch bch i v xch i.
V thuc Hong cm Bch thc Quy bn Xun cn Hong b Hng ph Tc dng Thanh nhit, ch huyt, c kinh Ch ha tim dng, lim m Ch ha tim dng, lim m Thanh nhit, ch huyt, c kinh Thanh nhit, ch huyt, c kinh iu kh, th ut Vai tr Qun Thn Thn Qun Qun T, s

+ Bi Thanh tm lin t m: thch lin t 10g, bch linh 8g, chch k 8g, ng sm 12g, mch mn (b li) 8g, hong cm 8g, a ct b 8g, chch tho 4g, sa tin t 4g, ng quy 8g, b hong (sao) 8g. Ch nh trong h nhit, m h ha vng ca bch trc.
V thuc Thch lin t a ct b Hong cm Phc linh Sa tin t Mch mn ng sm Chch k ng quy B hong Chch tho Tc dng Thanh tm ho, giao tm thn Ging ph ha, thoi h nhit, ch o hn Thanh thp nhit, lng huyt gii c L kh ha m Thanh nhit li thy Thanh tm nhun ph, tr phin nhit B t ch kh sinh tn B kh, c biu, tiu c B huyt dng huyt Thanh nhit, hot huyt n trung, ha v Vai tr Qun Thn Thn T T T T T T T S

4.8. Th phong hn Php tr: n tn hn t. Bi thuc s dng Bi Ng th du gia v (Chng tr chun thng): ng quy 16g, nhc qu 8g, ng th du 8g, n b 12g, bn h 8g, mch mn 12g, phng phong 8g, t tn 8g, can khng 4g, phc linh 12g, mc hng 8g, chch tho 6g, co bn 4g 292

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V thuc Co bn Ng th du Nhc qu Can khng n b Bn h Mch mn Phng phong T tn Phc linh Mc hng ng quy Chch tho Tn phong hn t

Tc dng n trung, tn hn, gii ut B ha mnh mn, dn ha quy nguyn, tr hn tch n trung, trc hn, hi dng, thng mch T phc ha, bnh t ha Ha m, ging nghch, tr thp Thanh tm, nhun ph, ch huyt Pht biu, tr thp Tn phong, hnh thy kh, khai khiu Hnh thy li thp nhit Hnh kh, kin t, khai ut, gii c B huyt, hot huyt, iu kinh n trung, iu ha cc v thuc

Vai tr Qun Qun Qun T T T T T T T T T S

4.9. Th h tn Php tr: n b c sp. Bi thuc s dng: + Bi K t n (Ph khoa bt t): lc gic sng, thch xng b, long ct, ch tr nhn, ng quy, bch linh, vin ch, hoi sn
V thuc Lc gic sng Long ct ch tr nhn ng quy Thch xng b Bch linh Vin ch Hoi sn Tc dng B tinh huyt, tn , tiu vim Thu lim, c sp n thn t dng, sp niu B huyt, iu kinh Khai khiu, ha m, gii c, tn phong Hnh thy, li thp Ha m, tn ut B t v, ch ph, b thn Vai tr Qun Qun Thn T T T T T

Bi K t n s dng cho th h tn trong bch bng, thin hng l t h. + Bi T m a hong hon (Chng tr chun thng): ng v t, mch mn, ng quy, a hong, thung dung, sn th, hoi sn, cu k t, cc hoa, ba kch. Lng bng nhau, tn bt lm hon. 293

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Dng tr h tn trong thanh i, thin hng can thn h.


V thuc Cu k t ng quy a hong Sn th Hoi sn Mch mn Ng v t Nhc thung dung Cc hoa Ba kch B can, thn B huyt, dng huyt T m, b huyt B can thn, sp tinh, thng khiu Sinh tm, kin t Thanh tn nhun ph, ch huyt Thanh nhit lng huyt, nhun to n b thn dng, nhun trng Thanh nhit gii c n thn, trng dng Tc dng Vai tr Qun Qun Thn Thn T T T T T T

4.10. Th huyt Php tr: ha thng huyt. Bi thuc s dng: + Bi o nhn tn (Chng tr chun thng): o nhn 8g, n b 8g, ngu tt 12g, trch lan 10g, xch thc 12g, ng quy 12g, ng sm 12g, bn h 8g, qu tm 4g, xuyn khung 10g, sinh a 12g, b hong 8g, cam tho 6g, gng 6g
V thuc o nhn ng quy Xuyn khung Sinh a Ngu tt Xch thc ng sm n b Trch lan Bn h B hong Qu tm Gng Cam tho Tc dng Ph huyt , trc , nhun to B huyt, hot huyt, iu kinh Hnh kh, hot huyt, gim au T m, b huyt Hnh huyt tn , tiu ung, li thp Thanh nhit, lng huyt, iu kinh B t, kin v, ch kh, sinh tn Li thy, ha thp Thanh nhit gii c Ging kh nghch, tiu m thp Hnh huyt, ch thng Tn hn n trung n trung, iu ha cc v thuc Vai tr Qun Qun Thn Thn T T T T T T T T T S

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4.11. Th ha nhit Php tr: tit ha. Bi thuc s dng: + Bi Li ha thang (Ph thanh ch n khoa): i hong 12g, bch trut 20g, bch linh 12g, sa tin t 12g, hong lin 12g, chi t 12g, tri mu 8g, sinh thch cao 20g, vng bt lu hnh 12g
V thuc i hong Hong lin Chi t Bch trut Bch linh Sa tin t Tri mu Sinh thch cao H tch tr trng v Thanh nhit t ha, gii c Thanh nhit t ha, ch huyt Kin t, to thp, li thy Hnh thy, li thp nhit Li thy, tr m Thanh nhit, ch kht, nhun to Thanh nhit, tr thp Tc dng Vai tr Qun Qun Thn T T T T T

4.12. Th ng tng h Php tr: b h c sp. Bi thuc s dng: + Bi V phong tn (Gin d phng): ng sm (sao), ng quy, bch trut (sao), xuyn khung, phc linh, qu nhc, m cc. Thm go 100 ht.
V thuc ng sm ng quy Xuyn khung Bch trut Phc linh Qu nhc M cc Tc dng B t, kin v, sinh tn dch B huyt, hot huyt, iu kinh Hnh kh, hot huyt Kin t, to thp, lim hn Tr thp, li thy Thng huyt, tr hn tch Kin t Vai tr Qun Qun Thn T T T T

4.13. Th ut ha Php tr: thanh nhit, tit ha, khai ut. 295

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Bi thuc s dng: + Bi Hong lin thanh tm m (T th lng thang): hong lin, sinh a, quy thn, ng sm, si h, phc thn, to nhn, vin ch, lin nhc, chch tho. Cc v u c lng bng nhau 6 - 8g, sc ung.
V thuc Hong lin Sinh a Si h ng quy ng sm Phc thn Vin ch Lin nhc Chch tho Tc dng Thanh nhit, t ha, gii c Thanh nhit lng huyt Thanh nhit, gii ut B huyt, hot huyt, iu kinh B t, kin v, sinh tn dch Ch kinh qu, an tm thn Ging kh, ha m Thanh tm, kin t iu ha cc v thuc Vai tr Qun Thn Thn Thn T T T T S

5. IU TR BNG CHM CU 5.1. Nguyn tc iu tr iu tr triu chng. B h. 5.2. Cch chn huyt Chn huyt trn mch nhm, mch c v 3 kinh m chn. Huyt ch: i mch, bch hon du, kh hi, tam m giao. + Nu thp nhit: hnh gian, m lng tuyn. + Nu thp hn: quan nguyn, tc tam l. + Nu h chng: B t: t du, thi bch, phong long. B thn: thn du, thi kh, phi dng. 5.3. K thut chm Thp nhit: chm t khng cu. m thp: chm bnh b, bnh t. H chng: chm hoc cu b. 296

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T lng gi 1. T i h nhm ch A. Cht dch do, nht chy ra t m o ph n B. Chng trng vim nhim b phn sinh dc n, sinh ra cht dch chy ra t m o ph n C. Loi bnh pht sinh di tht lng bao gm c cc bnh thuc kinh, i, thai, sn D. Tn thng gi ca b phn sinh dc n cng vi bo cung E. C 4 cu trn u ng 2. Triu chng lng i t, mu trong, lai rai, r r, sc mt xanh bc, tinh lc yu, u chong: l biu hin ca bch i biu hin trong th A. T h B. Thn h C. Kh ut D. m thp E. H hn 3. Triu chng lng i nhiu, cht i nhn, mu c, tanh hi, nga m h, tiu khng thng, chong vng, mt mi, l biu hin ca bch i trong th A. T h B. Thn h C. Kh ut D. m thp E. Thp nhit 4. Triu chng cht nc trng chy ra t m h, lin tc l m t chng A. Bch dm B. Bch trc C. Bch i D. Bng lu E. Bch bng

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5. Chm t cc huyt: i mch, bch hon du, hnh gian, m lng tuyn nhm ch nh iu tr chng i h c biu hin lm sng th A. m thp B. Thp nhit C. Kh ut D. Kh tr E. Huyt 6. Bi thuc Dch hon thang (gm: hoi sn, hong b, bch qu, khim thc, sa tin t), thng ch nh iu tr i h th A. m thp B. Thp nhit C. H tn D. Kh ut E. Kh tr 7. Bi thuc Bt tin m (gm th phc linh, trn b, kim ngn, i hong, bch linh, ng quy, xuyn khung) thng ch nh iu tr xch bch i th A. Huyt B. Kh ut C. Huyt h D. Huyt nhit E. Thp nhit 8. Bi thuc Tam b hong (gm: hong lin, hong cm, hong b, sn chi) thng ch nh iu tr xch i th A. Huyt B. Kh ut C. Kh tr D. Thp nhit E. m thp 9. Bi thuc K t n (gm: lc gic xng, long ct, ng quy, vin ch, thch xng b, ch tr nhn, bch linh, hoi sn) thng c ch nh iu tr bch bng th A. Huyt h B. Kh ut 298

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C. H tn D. Huyt E. m thp 10. Bi thuc T gii phn thanh m (gm: t gii, dc, ch tr nhn, thch xng b) trong t gii c tc dng v vai tr A. Thm thp, li niu, kin t, vai tr qun B. Thanh nhit, tr thp, kin t, vai tr qun C. Thm thp li niu, vai tr thn D. Thanh nhit tr thp, vai tr thn E. Thng khiu, li tiu tin

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Bi 18

THIU MU

MC TIU 1. Nu c khi nim v thiu mu theo YHH v YHCT. 2. Trnh by c nguyn nhn v bnh sinh gy thiu mu. 3. Gii thch c c s chn on thiu mu theo YHH v YHCT. 4. Trnh by c nguyn tc iu tr thiu mu v cc bin php phng bnh. 5. Trnh by c cc phng php v cc bi thuc, phng huyt ng dng iu tr thiu mu. 6. Phn tch c c s ca cc phng php dng thuc v khng dng thuc ng dng vo iu tr thiu mu.

1. I CNG 1.1. Khi nim v thiu mu Mu l mt dch th lu thng tun hon trong c th, bao gm t bo mu v huyt tng. T bo mu gm hng cu, bch cu v tiu cu, trong hng cu l yu t trc tip lin quan n s thiu mu. Hng cu ngi c tui th trung bnh l 120 ngy, trong iu kin sinh l bnh thng v s lng hng cu n nh, c s cn bng lin tc gia s lng hng cu b cht v s lng hng cu c sinh ra. Thiu mu ch xy ra khi s cn bng b ph v: hng cu b ph hy nhiu hoc c sn sinh ra qu t. Hng cu b ph hy nhiu c th do chy mu hoc tan mu nghim trng; trong c hai trng hp, c ch bnh xy ra ngoi vi cn ty xng vn tm cch b tr, thiu mu ch xut hin khi ty xng khng cn kh nng b c na. Hng cu sn sinh khng cng c th do hai c ch: ty xng khng sinh c hng cu, hoc sinh c mu nhng km cht lng khng c hiu lc.

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Trong hng cu c cha huyt cu t (hemoglobin), chc nng ca hng cu ch yu l do huyt cu t m nhim. Nhim v ch yu ca huyt cu t l vn chuyn O2 v CO2 , nng huyt cu t trong hng cu l 32 - 38g/dl, trung bnh ngi Vit Nam t 20 - 23,6mmol/l. 1.2. nh ngha Thiu mu l s gim st lng huyt cu t lu hnh trong h tun hon v mi hu qu ca thiu mu u lin quan n t l huyt cu t. Nng huyt cu t trung bnh v th tch trung bnh ca mi hng cu khc nhau ty tng hi chng thiu mu, do vy lng huyt cu t cng khc nhau i vi cng mt s lng hng cu. Theo T chc Y t Th gii nh ngha: thiu mu xy ra khi mc huyt cu t lu hnh ca mt ngi no thp hn mc ca ngi khe mnh cng gii cng tui v cng sng trong mt mi trng. V i th: thiu mu l mt hi chng bnh l do nhiu nguyn nhn gy ra lm cho tng lng hng cu lu thng trong mu gim di mc bnh thng, lm cho mu khng cung cp O2 cho t bo. Bnh thng ngi ln: hng cu nam l 4200000 210000 n 3800000 160000 Th tch trung bnh ca hng cu: MCV = 90 femtolit (fl) Nng huyt sc t trung bnh t 32 - 38g/dl Gi l thiu mu khi c t nht 2 trong 3 iu kin sau: Th tch hng cu gim di mc bnh thng Nng huyt sc t gim di mc bnh thng S lng hng cu/mm3 gim di mc bnh thng 1.3. Phn loi thiu mu Nguyn liu to ra hng cu ch yu l protein v nguyn t st. pht trin hng cu cn n cc cht ph tr vi nhng liu lng thch hp nh vitamin B12, acid folic. Ngoi ra s to ra hng cu cng cn n vitamin B6, B2, C, E v cc nguyn t vi lng nh ng, mangan, cobalt, km Nh vy nu thiu cc yu t trn trc tip hoc gin tip s sinh ra thiu mu. Khuynh hng chung khi phn loi cc trng thi thiu mu thng cn c vo:

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Nng huyt sc t trong hng cu: xc nh l u sc, ng sc hay nhc sc. Th tch ca hng cu: xc nh loi hng cu l to, nh hay trung bnh. C nhiu cch phn loi thiu mu nhng ngi ta thng phn theo 2 cch da vo hnh thi, mu sc v da vo sinh l bnh ca thiu mu. 1.3.1. Da vo hnh thi v mu sc ca hng cu Loi ny ch yu cn c vo th tch trung bnh ca hng cu (MCV) v nng huyt cu t trung bnh ca hng cu (MCHC), thng c 3 loi thiu mu: Thiu mu nhc sc, hng cu nh: thng thng l do thiu yu t st nn c biu hin lng huyt cu t gim r rt lm cho kch thc hng cu nh (MVC < 80fl; MCHC <32%). Thiu mu ng sc, hng cu bnh thng: MCV bnh thng t 80 100Fl, MCHC a s mc bnh thng tc 32 - 36%, MCH mc bnh thng (huyt sc t gim song song vi hng cu, gi tr hng cu lc no cng =1, khng c thay i th tch hng cu, nng huyt sc t trung bnh trong hng cu bnh thng). Loi thiu mu ny thng gp trong: + Xut huyt cp. + Tn huyt cp. + Vim nhim kinh nin. + Suy ty. Thiu mu u sc, hng cu to: huyt sc t gim t hn so vi hng cu, gi tr hng cu > 1. MCV>100fl, MCHC>36%. Loi thiu mu ny ch yu do thiu vitamin B12 hoc acid folic. Trong mu thy hng cu khng l, hng cu to, mt vi hng cu c nhn, th tch hng cu trung bnh > 120m3. 1.3.2. Da vo sinh l bnh Loi ny ngi ta phn ra 3 loi nh: Thiu mu do tng ph hy hng cu: cn gi l thiu mu tn huyt do bm sinh v nhng nguyn nhn khc, hng cu c hnh dng khc thng, MCV bnh thng, MCHC bnh thng hoc hi tng. + Nguyn nhn do bn thn hng cu: c th do d tt ca bn thn hng cu nh: hng cu hnh cu di truyn, hng cu hnh bu dc c tnh gia nh, hng cu hnh gai bm sinh hoc mc phi, 302

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phospholipid ca mng hng cu khng bnh thng, bnh do thiu ht men trong chuyn ha, huyt cu t khng n nh, s thiu ht cc dy globin, bnh thalassemia vng bin v.v + Nguyn nhn ngoi hng cu: Do s dng ha cht (nh: ch, thch tn), hoc do nc c cn trng hay rn c cn phi. Do nhim trng nng, nhim k sinh trng st rt, nhim virus. Do phng rng hoc tn thng h tun hon. Do cng lch. Do nguyn nhn min dch, bt ng nhm mu ABO, bnh t min, truyn mu khng ph hp. Thiu mu do gim sn sinh hng cu: + Do suy tu xng: chc nng to mu ca ty xng b suy yu do ty b hu hoi hoc thiu yu t kch thch, hng cu gim ngy cng nng, hng cu li rt him hoc mt hn. + Do thiu nguyn liu to mu: nh thiu st, protein, vitamin B12, acid folic. Nguyn nhn: v hp thu khng , hp thu km hoc do nhu cu tng, do mt mu qu nhiu. Thiu mu do mt mu: bao gm mt mu cp v mn tnh. + Do mt mu cp tnh: hnh dng hng cu bnh thng, ng sc, ng bo. + Do mt mu mn tnh: thng km theo thiu st nn phn nhiu l thiu mu do thiu st thuc loi thiu mu nhc sc. Hai cch phn loi trn u c cc u im ring, do trn lm sng thng vn dng phi hp b sung cho nhau gip chn on v iu tr d dng, nh vy d theo cch phn loi no thiu mu cng lin quan n nguyn liu to mu l st, vitamin B12, acid folic, protein v.v. (c do mt mu hay do gim sn sinh hng cu) v c lin quan n cc yu t bm sinh hay bnh l lm tng ph hu hng cu. 1.4. c im dch t hc Tt c cc loi thiu mu nu trn u c hin din Vit Nam nhng mc xut hin bnh c t l khc nhau. Thiu mu nhc sc do thiu st: theo thng k ca Vin Huyt hc v Truyn mu Trung ng th thiu mu do giun mc chim 30%, do lot d dy 15,17%. 303

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Trong mt cuc iu tra thc t, cc tc gi pht hin 50% nng dn b nhim k sinh trng ng rut, trong ch yu l giun mc. Thiu mu do tan mu: cng gp kh nhiu. Theo s liu ca Vin Bo v sc khe tr em Trung ng, s tr b bnh huyt cu t chim 49%. Thiu mu tan mu cng c gp ngi ln, a s l tan mu t min c khng th t sinh vi nghim php Coombs dng tnh ph hp vi cc ti liu quc t. Thiu mu do dinh dng: + V mt dch t hc, thiu st l nguyn nhn ch yu gy thiu mu do dinh dng; sau l thiu acid folic, vitamin B12 v protein. + Tnh trng thiu mu do dinh dng rt ph bin trn th gii, nht l cc nc ang pht trin, c tnh c t 500 triu n 1 t ngi b bnh, thng l ph n v tr em. Tnh trng thiu mu do dinh dng rt ph bin Vit Nam, nht l tr em v ph n c thai. Theo Vin Nghin cu nhi khoa 1989, t l thiu mu do dinh dng tr em v ph n nh sau: s trung bnh thiu mu tr di 3 tui ng bng l 35%, min ni l 49,5%; ph n c thai thnh ph l 37% v nng thn l 41,7%. 1.5. Quan nim v thiu mu theo y hc c truyn Ni n mu l ni n mt dch th c mu lu thng tun hon gip cho hot ng trong c th, tng ng trong YHCT ni n huyt. iu ny cn c chng minh khi m t v mt triu chng hc ca thiu mu nh: xanh xao, mt mi, gim gng sc, nim mc nht nht, li l, bun nn, chn n. cng c m t trong cc chng huyt h, h lao do kh huyt h Tuy nhin, YHH v YHCT c hai h thng l lun khc nhau. V mt lm sng triu chng thiu mu cng biu hin tng t chng huyt h, nhng khi bnh nhn c huyt h cha hn l c thiu mu. Huyt l mt trong 5 dng vt cht gip cho c th sng hot ng l: tinh, kh, thn, huyt v tn dch. Huyt c to ra bi tng t v tng tm: t bin ha cc cht tinh vi ca thc n ung thnh ra tinh v tm kh ho mt phn tinh ra thnh sc gi l huyt. Trong hot ng ca c th, kh v huyt l hai dng vt cht lun ng hnh, tr lc, v chc nng lun quyn vo nhau, huyt hu hnh cn kh th v hnh, huyt th tnh m kh th lun ng, huyt c kh mi lu thng c, kh c huyt mi c ni nng ta v gi gn. C hai yu t ny trao i tc dng v nng ta vo nhau gip nui dng cng nh mi hot ng ca c th, nn khi biu hin triu chng huyt h c ln triu chng ca kh.

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Huyt c sinh ra ti nhun cc kinh lc, chu lu khp ton thn, gip nui dng c th, gip vinh nhun da lng v gip cho cc tng ph hot ng. Mt nh huyt m trng c, tai nh huyt mi nghe c, ngn tay v bn tay nh huyt mi cm nm c, chn nh huyt mi i c, cc tng nh huyt mi thu rt li v tng tr c, cc ph nh huyt mi tit c. Sau giai on vn hnh, huyt li c tr v tng tr can. T va c vai tr sinh ra huyt, va c vai tr iu khin huyt ng v tr ca n (thng nhip huyt), nu huyt khng ng ch l xy ra chng xut huyt nh: khi huyt (ho ra mu), th huyt - u huyt (i ra mu), khc huyt, tha huyt (nh ra huyt), t nc (chy mu mi), no nc, mc nc, nh nc, x nc, thit nc, i nc, hn huyt, tin huyt, niu huyt, huyt v.v. Nh vy vic sinh ra huyt v hot ng ca huyt c lin quan trc tip n hot ng ca cc chc nng t, tm v can; gin tip c lin quan n ph v thn, v ph tng tr cng nh iu khin hot ng ca kh, thn np kh v h tr hot ng kh ho thc n ung ca t cng nh chu trch nhim v nguyn m v dch cht cho ton c th ni chung trong c huyt. Do khi c ri lon v chc nng cc tng nu trn l c nh hng n huyt, v ngc li khi c ri lon v huyt th cng c kh nng nh hng n mt trong cc chc nng ca cc tng ni trn. 2. NGUYN NHN V C CH SINH BNH CA THIU MU 2.1. Theo y hc hin i 2.1.1. Thiu mu nhc sc a. Nguyn nhn Thiu mu nhc sc do thiu st: c 4 nguyn nhn chnh + Do cung cp thiu st: nh tr b thiu sa m, tr n khng ng v cht dinh dng, thiu thc n ngun ng vt, n bt qu nhiu ko di, thiu dinh dng, tr non hoc thiu cn, ngi m trong thi gian c thai v cho con b b thiu st + Do hp thu st km nh b mc cc bnh mn tnh ng tiu ha, tiu chy ko di, b hi chng km hp thu, b ct d dy, b bnh coeliaque.. + Do b mt qu nhiu st nh chy mu mn tnh, chy mu tiu ha, b bnh k sinh khun ng rut nh giun mc, Schistosome. + Do nhu cu st cao trong cc giai on pht trin c th nhanh tr em m cung cp st khng kp thi, ph n c thai nhiu ln v sinh lin nhau. Thiu mu nhc sc khng do thiu st: trong mu thy hng cu kch thc bnh thng hoc to, t khi gp hng cu nh, gi tr hng cu gim 305

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nhiu hoc t, nng st huyt thanh cao c khi > 35,8mol/l; thng gp trong: + Ri lon chuyn ha huyt sc t trong mt s trng hp nhim c, c th thiu m hoc thiu vitamin B6. + Bnh thiu mu vng bin Thalassemia. + Ri lon v hormon nh thiu nng gip trng. b. Sinh bnh hc ca thiu mu nhc sc Sinh bnh hc ca thiu mu nhc sc do thiu st: mt trong nhng thnh phn quan trng cn thit cho s thnh lp hng cu l lt. St kt hp vi protoporphyrin III to thnh phn t Hem, 4 phn t Hem kt hp vi 1 phn t globin to thnh hemoglobin. Nu thiu st s gy thiu mu nhc sc. + S hp thu st: st c hp thu phn trn ca b my tiu ha, ch yu t trng v hng trng, khi thiu st trm trng st c hp thu c i trng. S hp thu st tng ln khi d tr st gim, khi thiu mu, khi c thai, khi hnh kinh v khi cho con b. Ngc li s hp thu st gim khi truyn mu, tim cht st..v..v. Nhiu yu t lm thun li cho s hp thu st nh: tht, gan, c lm tng hp thu st ngun gc thc vt; tng t acid ascorbic, acid clohydric kh Fe+++ thnh Fe ++, ion ha st khng Hem, lm tng hp thu st. Ngc li, nhiu yu t lm gim s hp thu st nh: sa, lng trng, phomat lm gim hp thu st ngun gc thc vt. Tr to thnh tanin lm cho st khng tan; cng nh phosphat, carbonat, oxalat to thnh cc phc hp st ln kh tan nn kh hp thu. Hu ht st trong c th di dng kt hp: st Hem v st khng Hem. St Hem gm st cha trong huyt sc t (hemoglobin), myoglobin v trong mt s enzym. St khng Hem gm st vn chuyn v d tr: St vn chuyn gn vi mt protein gi l transferin hay siderophylin sn xut t gan. Transferin c vai tr vn chuyn st ti c quan s dng, nht l c quan to hng cu v thu hi st gii phng ra t hng cu b ph hy. Transferin tham gia iu ha hp thu st, st hp thu d hn khi bo ha transferin thp v ngc li. S tng hp transferin gim trong trng hp thiu protein nng. Ngoi transferin cn c cc protein gn st khc nh lactoferin, feritin, nhng khng c vai tr vn chuyn st. St d tr chim 30% st ton b c th, khong 600 - 1200mg ngi ln, 35 - 50mg tr s sinh c d tr gan, lch, ty xng. 306

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Hai dng st d tr ch yu l hemosiderin v feritin. Hemosiderin khng ha tan, hu nh c nh ngay c khi c nhu cu, cn feritin ha tan trong nc d huy ng. Lng feritin huyt tng rt t, song phn nh chnh xc s d tr st t chc c th. + S thi st: lng st thi ra ngoi c th hng ngy khong 14g/kg th trng; mt phn theo phn, mt v cc t bo rut bong ra; phn khc mt qua nc tiu, m hi v cc t bo bong ra t da, nim mc, mng, tc; i vi ph n, st cn mt qua chu k kinh 0,8 - 1mg/ngy v nu kinh nguyt nhiu c th mt ti 1,4 mg/ngy. Nh vy lng st mt i hng ngy l: 0,4 - 0,5mg i vi tr di 1 tui. 0,8 - 1mg i vi ngi ln nam gii. 1,6 - 2mg (c th nhiu hn) i vi ph n. + Biu hin lm sng ca thiu mu thiu st thiu mu nhc sc l tnh trng thiu mu mn tnh, xut hin t vi thng cho n vi nm, do thiu st. Lng huyt cu t gim nn kh nng vn chuyn oxy ti t chc thiu, nh hng ln nhiu c quan b phn. Tun hon tim mch: mt, hi hp, nh trng ngc, r nht lc hot ng. Nghe tim c m thi tm thu c nng dc b tri xng c, nu thiu mu mn nng ko di c nguy c suy tim, ngi gi d bc l cn au tht ngc khi c x m ng mch km theo. Thn kinh: nhc u, chng mt, tai, ng g. H hp: th nhanh nng. Tiu ha: n chm tiu, ri lon tiu ha ko di nh kh nut, d dy c biu hin nh vim d dy, teo nim mc d dy v gim toan dch v. Da, nim mc, lng tc, mng: da xanh, nim mc nht nht, thiu mu nng nim mc c th trng bt, li mt gai, li b vim kh lnh, mng chn tay nht nht, bt hoc lm, c kha d gy, mng mt bng, da kh nga, tc d rng. C xng khp: au c, au xng - khp xng. Sinh dc: nam: bt lc; n: kinh t, v kinh. Ngoi ra thiu mu thiu st c th l biu hin u tin ca mt ung th d dy - rut. + Cn lm sng ca thiu mu thiu st: c im ca thiu mu thiu st l thiu mu nhc sc v hng cu nh. Hng cu nh khi th tch trung bnh ca hng cu di 80fl, v nhc sc khi nng trung bnh huyt cu t ca mi hng cu gim di 30%. 307

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T l huyt cu t gim nhiu, nhng hng cu t khi gim xung di 2,5 triu mi mm3. Do s tng hp huyt cu t gim nn protoporphyrin t do hng cu tng trn 700g/l. Protoporphyrin tng rt sm t khi thiu st cn rt nh. T l st huyt thanh gim di 500g/l kh nng gn st ton phn tng nn ch s bo ho transferin di 16%. Feritin huyt thanh gim: nh lng feritin c gi tr phn nh ng tnh trng d tr st ca c th, c s song song gia lng st huyt thanh vi mc d tr st trong c th, khi thiu st lng feritin huyt thanh gim di 12g/l. Trong mu ngoi vi, hng cu li v tiu cu c s lng bnh thng, bch cu bnh thng, sc bn hng cu bnh thng. Ty : tng cc hng cu c nhn, chim u th l cc tin nguyn bo hng cu a base; ngoi ra s bin mt hemosiderin trong ty xng l c trng ca thiu mu do thiu st. Thiu mu nhc sc khng do thiu st: + Ri lon chuyn ha huyt sc t trong nhim c, trong trng hp c th thiu m v vitamin B6: s thiu cc acid amin cn thit, lm cho thiu nng lng ko di gy ra thiu mu, thng trong thiu mu do thiu protein thng ln trong thiu st v acid folic phi hp... + Hi chng Thalassemia: c xp vo nhm thiu mu tan mu di truyn nhng vng sinh ca hng cu ngn ngy v giai on tan mu cp him c thy trn lm sng. Do vic tng hp sai chui globin ( hoc ) ca phn t HbA ngi ln dn ti mt cu trc Hb thiu st v gy nn qu trnh tng hp Hb khng thch hp hng cu, hnh thnh nn nhng hng cu nh nhc sc. y l nhm bnh huyt sc t ngy cng tr nn phc tp c nhiu nhng yu t d nguyn: hnh thc ng hp t ca Thalassemia, trng thi d hp t v s phi hp ca gien Thalassemia vi nhng gien gy bnh Hb khc, nhng ri lon di truyn v nhng ri lon Hb trong thi k thai nhi. Hi chng Thalassemia c xp loi n gin l: nng, trung bnh v nh, c vt vi nhng hnh nh lm sng l kt qu ca s kt hp khng ng nht gia cc gen thiu st nhim sc th s 16 v s 11. Nhng thiu st c th nh hng n s tng hp globin nhng mc khc nhau v c nhng c ch bnh khc nhau c xp da trn s thiu ht mt phn hay ton b gien, nhng bt thng do mt on, thiu on hoc chuyn on t nhng gien c cu trc bnh thng. 308

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2.1.2. Thiu mu u sc, t bo to a. Nguyn nhn: Ch yu do thiu vitamin B12 hoc acid folic, hoc c hai. Thiu acid folic: ngoi tr nhng ri lon hp thu thiu acid folic hay folat thng do n king khng thch hp (c bit nhng ngi trung nin, nghin ru, thiu n hoc bnh do chn n) hoc do tng nhu cu s dng trong bnh c tnh, c thai, st cao, nhim khun v.v Thiu folat thng phi hp vi thiu st nhiu hn l thiu B12, c thy trong hi chng ri lon hp thu, c thai v bnh c tnh ng rut - d dy vi nhng chy mu kn o. Thiu vitamin B12 + Ch n khng thch hp: ngi n chay. + Thiu yu t ni bao gm: thiu mu c tnh trong bnh Addison; thiu yu t ni bm sinh; do phu thut ct d dy . + S phn ly phc hp B12 v yu t ni: vi khun pht trin mnh trong bnh ti tha, x cng b, bnh Whipple. + Bnh ng rut: bnh km hp thu mn tnh nhit i hi trng tn b nh hng; bnh Crohn; ct b trn 60cm rut hi; sn + Cc nguyn nhn khc: thiu dch ty nng, nhc gip, dng thuc b. Sinh bnh hc ca thiu mu u sc t bo to Acid folic c phn b hu ht cc m c th, c bit l gan. Cc dn cht ca acid folic tham gia vo chuyn ha mt s acid amin, base purin, pyrimidin ca acid nucleic, thiu acid folic lm cho s phn chia t bo b chm li nht l nhng t bo i mi nhanh nh t bo mu gy thiu mu. Cc t bo c th ngi khng tng hp c acid folic m c th c cung cp acid folic qua thc n. Acid folic c nhiu trong tht, gan, thn, trng, men mc v hu ht cc rau xanh sm mu. Vitamin B12 bao gm cc cht gi l cobalamin. Vitamin B12 c trong tt c cc t chc ca c th, nhng tp trung ch yu gan v thn. Vitamin B12 rt cn thit cho tng hp acid amin v tng hp mch ADN trong s phn chia t bo. Thiu viatmin B12 lm s phn chia t bo chm li, c bit cc t chc nhanh nh t chc to mu gy nguy c thiu mu. Vitamin B12 c tng hp do cc vi khun ch yu l vi khun rut. ngi s tng hp ny khng cho nhu cu c th m phi c b sung qua thc n. Ngun thc n c vitamin B12 gm tht nht l tht b, gan, sa, trng. Vitamin B12 tng i bn vng vi nhit. 309

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c. Biu hin lm sng v cn lm sng ca thiu mu u sc t bo to Khi do thiu acid folic: + Ni bt nht l: da xanh, nim nht nht, ngi bnh mt mi, chng mt, km hot ng, lao ng yu, kh th khi gng sc. + Triu chng v tiu ha nh chn n, bun nn, hay nn, tiu chy, vim ming, vim li - li mt gai, gan to. + Triu chng v thn kinh nh mt mi, run tay chn, chng mt, tng trng lc c. + i vi ph n c thai: thiu mu do thiu acid folic d b sy thai, non, cn nng tr thp, d tt thai, nhau bm bt thng d c nguy c tai bin sn khoa. + Cn lm sng: biu hin lng hng cu gim, huyt sc t gim, hng cu khng u, th tch hng cu trung bnh >100fl, hng cu li gim thp. XN ty thy nhiu nguyn hng cu khng l. V ha sinh acid folic huyt thanh gim di 3g/ml, folat hng cu < 100g/ml. Khi do thiu vitamin B12: + Thiu mu t t, da xanh, nim nht nht. + Ri lon tiu ha nh chn n, hay nn, tiu chy, vim li, gan c th to + Ri lon thn kinh nh nh mt mi, chng mt, ri lon cm gic su, au mi, run tay chn 2.2. Nguyn nhn bnh sinh thiu mu theo y hc c truyn 2.2.1. Nguyn nhn bnh sinh a. Bnh nng lu ngy tn thng tng ph Bnh lu ngy do lc dm hoc tht tnh lm cho chc nng tng ph b tn thng nh t h khng vn ha thy cc to ra tinh ra huyt; tm h khng kh ha c tinh ra thnh sc gi l huyt; ph h lm cho kh suy km, huyt khng vn hnh, huyt khng kch thch c to huyt mi; thn h khng np kh hoc thn m h s nh hng n cc dch cht trong c th trong c huyt Cc chc nng tng ph ni chung b h suy s nh hng n vic to mi cc thnh phn vt cht gip cho hot ng c th bao gm c tinh, kh, huyt, thn v tn dch 310

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b. n ung khng y Dinh dng km nh hng n cng nng hot ng ca t, v. Vt cht c bn to thnh tinh, kh, huyt, thn, tn dch ch yu l t thc n, nu n ung thiu thn, ngun cung cp khng y , kh huyt khng c ngun sinh ha, lu ngy sinh huyt h, h lao.. c. Mt mu qu nhiu + Bnh bin t ngoi cm n ni thng sinh ha, ha nhit vng hnh bc huyt lm chy mu nh trong khi huyt, th huyt, x huyt, tin huyt, v.v + B chn thng ng dp mt nhiu mu. + Kinh nguyt qu nhiu, hoc rong kinh rong huyt lu ngy. d. Tin thin bt tc Bm sinh tinh, kh, huyt.. khng y l do: Khi th thai cha m tui gi, sc yu, tinh huyt km. Khi th thai, ngi m n ung thiu thn hoc lao tm, lao lc thi qu hoc b mc cc bnh mn tnh. Dinh dng thai nhi km hoc khng ng cch. Tin thin bt tc ch yu l do thn. Thn tng tinh, tinh tin thin gp phn thng qua thn kh h tr cho t vn ha thy cc thnh tinh hu thin, tinh hu thin li b sung lm mi ha khng ngng tinh tin thin gip cho hot ng ca thn. Khi thn kh suy yu nh hng dy chuyn n vic sinh huyt. Ngoi ra thn li l ch phn m ca c th, ch v huyt dch nn khi thn h tt nhin s nh hng n huyt. Tin thin bt tc, hu thin tht dng u dn n thn h, thn h tt s dn n huyt h. e. Cc nguyn nhn khc Lao nhc qu li km thm n ung thiu thn lm tn thng c kh ln huyt. Lao tm qu lm tn thng m huyt. Sinh nhiu hao kh tn huyt hoc phng dc qu cng dn n kh h huyt suy. Trng tch: bnh giun sn tch t, thng l bng, lu ngy cng dn n tn thng t v gy nn nao, bng lc au lc khng, sc mt a vng, mi li nht nht. 311

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2.2.2. Biu hin lm sng ca thiu mu theo y hc c truyn Huyt l mt trong nm dng vt cht gip c th hot ng v nui dng cc kh quan, nu huyt h s xut hin cc triu chng c th quy vo 2 nhm nh: a. Tng ph tht dng Tng ph tht dng thng biu hin ra sc mt, mi, mng tay chn nht nht, km ti, chng mt, xy xm, tay chn t mi, hi hp, mt ng, da tc kh, i tin to kt. Tm ch huyt, can tng huyt nn khi c huyt h biu hin lm sng ch yu l hai tng tm v can: tm huyt bt tc c biu hin hay hi hp, mt ng, hay mng m, thn ch bt an; can huyt bt tc th sc mt ti nht, chng mt, tai, hai mt kh, nhn vt khng r hoc qung g, tay chn t mi, mng tay chn kh d gy. Trong mi quan h gia cc cng nng sinh huyt, to huyt v hot ng ca huyt lng trong mi quan h ca ng hnh tng sinh - tng khc, cc biu hin lm sng c th c thm cc triu chng do ri lon dy chuyn cc chc nng thn, ph, t b. Huyt h kh tr Trong vic to ra huyt phi nh c kh, khi huyt dch c to ra kh nng ta vo huyt m vn hnh chu lu trong ton thn. Nu huyt h kh khng cn c ch nng nh nn cng h theo, do khi huyt h thng km theo kh h v trn lm sng khng ch biu hin triu chng ca huyt m c c triu chng ca kh nh: ht hi, th ngn, hay th di, ting ni yu t, mt mi, m hi. 3. CHN ON 3.1. Chn on thiu mu 3.1.1. Lm sng: ph thuc nhiu vo tnh trng thiu mu v kh nng thch nghi ca c th Da xanh, nim mc nht nht, r nht l lng bn tay v nim mc di li. Mng tay, u ngn tay kh t. Lng tc kh, d gy, d rng. Ngi mt mi, tay chn yu, tinh thn r. St nh c th thy trong thiu mu nng.

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Kh th khi gng sc v c khi c lc ngh ngi gp trong thiu mu nng. Tim p nhanh, nht l khi gng sc, thiu mu nhiu s xut hin m thi tm thu nghe c mm tim v van ng mch phi. 3.1.2. Cn lm sng a. Kim tra mu thng thng Lm huyt : gm tm c lng hng cu, bch cu v tiu cu Lng hng cu: bnh thng ngi ln: nam: 4200000 210000; n: 3800000 160000 nh lng huyt sc t: rt cn thit tnh lng huyt sc t trung bnh ca mi hng cu Huyt sc t bnh thng ngi ln: nam 14,6 0,60; n 13,2 0,55g/dl. nh lng hematocrit gip kim tra s lng hng cu, khng th c thiu mu nu hematocrit cao hoc bnh thng. Hematocrit bnh thng nam 43%, n 39% . b. o ch s hng cu MCV (th tch trung bnh ca hng cu): bnh thng 85 - 95fl, o ch s ny xc nh loi hng cu to, nh hay trung bnh. MCH (lng huyt sc t trung bnh ca hng cu): bnh thng nam 34, 6pg v n 35pg (2,18 - 2,2fmol). MCHC (mean corpuscular hemoglobin cocentration - nng huyt sc t trung bnh) bnh thng 32 - 38g/dl xc nh l u sc, ng sc hay nhc sc. c. Kim tra ch s hng cu li Hng cu li l nhng hng cu non mi c ra mu, sau 24 - 48 gi, hng cu ny mt li v tr thnh hng cu thng, do trn phin nhng hng cu li chng t n mi trong tu ra trong vng 48 gi. Bnh thng hng cu li trong mu c t l 0,7 0,21% nam v 0,9 0,25% n so vi hng cu ni chung. Trn 1% l tu ang tng sinh hoc ang phc hi hng cu, thp hn 0,5% l dng hng cu khng sinh sn c. Hng cu li tng nhiu trong cc trng thi thiu mu nng nhng tin lng ang tt, mu ang c hi phc, cc c quan to mu cn kh nng.

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3.2. C s l lun bc u chn on thiu mu


c im huyt Thiu mu bnh sc, kch thc HC bnh thng hoc to, hi phc c Thiu mu bnh sc, kch thc HC bnh thng hoc to, khng hi phc c Thiu mu nhc sc, c hoc khng c km theo kch thc hng cu nh, khng hi phc Thiu mu nhc sc, c hoc khng c km theo kch thc hng cu nh, hi phc c D on bnh sinh Hng cu b ph hy qu nhiu Gim sinh hoc lon sinh hng cu khng phi do tng hp huyt cu t Lon sinh hng cu do tng hp huyt cu t khng tt Kt hp mt mu gn y kh nhiu v thiu st. Thiu mu tan mu c ri lon tng hp huyt cu t Mt st do tan mu mn tnh trong huyt qun Mt st ang c iu tr Thiu mu nhc sc, kch thc hng cu to, khng hi phc c Kt hp ri lon tng hp huyt cu t v mt nguyn nhn khc lm ri lon sinh sn hng cu nhlng st huyt thanh v siderophilin ton phn, ty Thng tin cn Tm triu chng tan mu, tm nguyn nhn mt mu cp Tm hiu lm sng ca vim, suy thn, suy gip, ty , tnh trng cc dng t bo khc nh lng st huyt thanh v siderophilin ton phn trong mu Tm du hiu ca tan mu Tm du hiu ca mt mu nh lng st huyt thanh v siderophilin ton phn

3.3. Chn on thiu mu thiu st Ngoi nhng biu hin nu trn, c im thiu mu thiu st c: Khi pht m thm bng mt v xanh xao tng dn. Mt mi, t hot ng, chng mt, tai. Kh th khi gng sc. Mng tay chn nht nht, bt hoc lm, c kha, d gy. Li b vim, mt gai li. Thng c nhng ri lon v tiu ha khi thiu mu ko di nh kh nut, vim d dy, teo nim mc v gim toan dch v. Tr em khi thiu st thng chm pht trin c th, gy. c im ca thiu mu thiu st l hng cu nh, nng huyt sc t hng cu gim < 30g/dl, huyt sc t trung bnh < 28 picogram v th tch hng cu gin < 80 femtolit. St huyt thanh gim < 500g/l, khng c hemosiderin trong ty xng. 314

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nh lng ferritin c gi tr phn nh ng tnh trng d tr st ca c th, khi thiu st lng feritin huyt thanh gim < 12g/l. 3.4. Chn on phn bit cc loi thiu mu nhc sc Cc thiu mu gim sc hng cu nh khc nh trong bnh thiu mu vng bin l bnh bm sinh bi tnh trng ri lon trong tng hp cc chui a peptid ca hemoglobin m biu hin lm sng rt hay thay i v i t nhng th khng c biu hin n cc th nng vi thiu mu lch to v ri lon v pht trin (hp s hnh thp, v mt hi chng Down); cn lm sng c cc hng cu nh hn s lng bnh thng, huyt cu t t khi gim di 9g/100ml, hemosiderin vn c mt trong ty xng, t l st huyt thanh v kh nng ton phn c nh st th bnh thng. Thiu mu phi hp vi mt nhim khun: thiu mu gim sc nh v kch thc bnh thng, t l st huyt thanh gim, kh nng ton phn c nh st gim, hemosiderin trong tu xng bnh thng. Thiu mu nguyn bo st: cc nguyn bo st l nhng hng cu cha nhng ht st khng to huyt cu t. Trong nhng thiu mu nguyn bo st vic s dng st tng hp huyt cu t b ri lon, do thiu mu t nhiu gim sc r v trong mu ngoi vi c mt s hng cu nh cng tn ti vi hng cu bnh thng, tng sinh ty dng hng cu tng i r, nhng s lng hng cu li trong mu ngoi vi khng tng, t l st huyt thanh bnh thng hay tng nh. Cc bnh v huyt cu t: chn on bng in di huyt cu t. 3.5. Chn on theo y hc c truyn Da theo cc biu hin lm sng hoc ri lon chc nng tng ph hoc huyt h kh tr , YHCT phn thnh cc th bnh lm sng sau: 3.5.1. Tm huyt h Hi hp hay qun, tm phin lo lng bt an. Mt ng, gic ng khng su, hay mng m ni m. Chng mt, hoa mt. Sc mt khng ti, mi li nht nht. Mch t sc. 3.5.2. Can huyt h Sc da kh sm, xanh nht hoc vng bng, nng th da trc vy nhn nheo. Mng tay chn nht nht, kh, d gy. 315

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Ming mi v cht li trng, nht nht. Th trng gy cm, tay chn t di hoc gn mch co rt. au tc hng sn. Hai mt kh rt, qung g hoc nhn vt l m, hoa mt tai. Mt ng, hay m, d s hi. Ph n hnh kinh t, nht mu hoc hnh kinh mun, b kinh, sau khi hnh kinh au bng, thiu sa hoc khng th thai. Mch huyn t. 3.5.3. Tm t h Tu thuc vo giai on bnh m c cc triu chng lm sng ph hp nh: do u t qu lm tm huyt ngm ngm b h hoc sau khi bnh nng ko di, chm sc khng tt lm nh hng n t lm cho s ha sinh kh huyt b gim st, tm huyt h lm tm kh h c th nh hng n c t dng . Tuy nhin khi c tm t u h s xut hin: Hi hp, hay qun, hoa mt, chng mt. Km n, mi mt. Mt ng. Sc mt a vng, li nht nht. C th c kinh nguyt khng u n hoc xut huyt di da. Mch nhc. 3.5.4. T thn dng h Thn th n lnh, tay chn lnh. Km n, trng bng. Tiu phn nho hoc tiu chy ko di, hoc i tiu ra nguyn thc n, hoc ng canh t. Tiu tin khng thng li. Ton thn ph thng. Lng gi mi lnh. n ng c ri lon cng dng hoc di tinh. Ph n khng th thai. Cht li bu, nht, ru li trng trn. Mch trm tr, t nhc. 316

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3.5.5. Kh huyt u h Sc da xanh xao nht nht. Hi hp, hoa mt, chng mt. Mt mi yu sc, thiu hi, bing ni. Mt ng. T ra m hi. Li nht bu. Mch t nhc. 4. IU TR 4.1. Nguyn tc 4.1.1. Theo y hc hin i a. Nhng iu cn ch trc khi quyt nh iu tr Khng c mt phng php iu tr chung cho cc loi thiu mu: + Mi loi thiu mu c mt cch iu tr khc nhau. + Khng nn bt u iu tr thiu mu ch da vo s lng hng cu. Khng iu tr thiu mu khi cha c chn on xc nh v cha r nguyn nhn: + Thiu mu khng l mt bnh m l triu chng ca nhiu loi bnh, trong nhiu trng hp tnh nghim trng ca thiu mu l nm nguyn nhn gy nn thiu mu, th d cng l thiu mu thiu st nhng nu do dinh dng th d c thiu mc nng qua iu tr b sung st cng c hiu qu tt; ngc li nu do ung th d dy gy xut huyt mn tnh cng thiu st mc nh iu tr b sung st tuy bnh c gim nhng che mt cc du hiu khng pht hin ung th kp thi dn ti hu qu nghim trng. + iu tr thiu mu khng phi l trng hp cp cu (ngoi tr mt mu cp do chn thng). Cn lm cc xt nghim chn on xc nh, v chn on nguyn nhn. + Thn trng trong cc ch nh truyn mu, st, hoc vitamin B12 s gy kh khn trong vic tm nguyn nhn. + Khng nn vi cho thuc b v thuc chng thiu mu. b. Nguyn tc iu tr Nhm vo nhng nguyn nhn trc tip gy thiu mu. Bin php phng chng thiu mu: 317

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+ Cn tch cc chng nhim mi trng, lm v sinh mi trng nng thn gim nhim k sinh trng ng rut, kim sot cht ch thuc tr su. + Trin khai cc k hoch chm sc sc khe ban u c s. + Gio dc v dinh dng hp l. + iu tr sm cc bnh mn tnh ng tiu ha, cc bnh giun sn. + Pht hin sm cc tt di truyn. + Trnh dng thuc iu tr bnh mt cch trn lan bao vy. 4.1.2. Nguyn tc iu tr theo y hc c truyn a. Kin t ha v T v l ngun sinh ha ca huyt dch, n ung c iu , cng nng vn ha ca t v bnh thng th kh huyt thnh, do b huyt trc ht cn phi kin vn t v. Cc bi thuc thng dng bao gm: T qun t thang, T vt thang, ng quy dng huyt thang. b. ch kh, sinh huyt Kh l ngun ng lc thc y tinh ha thnh huyt, theo cc t liu kinh in huyt v kh u quan trng nhng phi b kh trc b huyt, m dng u l c bn v cn yu nhng nn dng dng trc t m. Trn thc t dng thuc thng theo nguyn tc kh nng sinh huyt dng thuc b huyt gia thm thuc ch kh, nhng phng thuc thng dng nh quy t thang, ng quy b huyt thang. Thuc b kh thng dng gm hong k, nhn sm, ng sm, bch trut, hong tinh, sn dc, i to phi hp thuc dng huyt nh ng quy, bch thc, a giao, thc a. c. B thn, sinh huyt Thn l ngun gc ca tin thin, ch tng tinh, tinh sinh ty, ty ha huyt. Ngoi ra mnh mn l ni t hi ca nguyn kh, l gc ca 12 kinh, l ngun ca sinh ha, cng l ng lc thc y sinh huyt. Khi iu tr chng huyt h cn kt hp b thn sinh tinh ch tu. Cc phng thuc thng dng gm: th ty t, nhn sm, nh tin n. Cc v thuc b thn thng dng gm c: lc nhung, lc gic giao, quy bn, ba kch thin, ta dng, dm dng hoc, th ty t, nhc qu, thc a, cu k t, t h sa d. Tn sinh huyt Huyt dch vn hnh chu lu ton thn gip nui dng, nu v l do no s vn hnh ny b tc nghn s sinh ra tr, kh huyt ngng tr nh hng n tt c tng ph k c c quan to huyt m sinh chng huyt h. Trong trng hp ny vic iu tr s l tn sinh huyt, cc bi thuc thng dng gm: o hng t vt thang, B dng hong ng thang, Huyt ph trc thang. Cc v thuc trc thng dng nh ng quy, xuyn khung, an sm, tam tht, n b, hng ph. 318

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e. Gii c sinh huyt Cc bnh do ni thng hay do ngoi cm lc dm, bnh lu ngy tch nhit ha ha, rt d lm hao tn phn m a n huyt h. Trong trng hp ny vic iu tr cn phi thanh nhit gii c, cc phng thuc thng dng bao gm: T gic a hong thang, Tam hong thch cao thang, Nhn trn cao thang, Ng v tiu c m, Thanh vinh thang 4.2. iu tr c th 4.2.1. iu tr chung khi c thiu mu a. Nhng bi thuc hoc mn n dng trong thiu mu ni chung Nhn sm 10g, i to 10 qu sc ly nc ung: tr thiu mu do mt mu. Thc a 12g, ng quy 10g, bch thc 10g, xuyn khung 6g, sc ung. Tang thm 50g, cu k t 20g, sc nc ung. Sinh a 30g, mch mn 12g, cu k t 12g sc ly nc ri em nu vi huyt g hoc vt thnh canh, nm gia v n dng trong thiu mu do thiu st hoc ngi th trng m h. Xng c d 1-2 on p gip, i to 20 tri (b ht), go np 50 - 100g nu thnh cho n. Long nhn 5g, ht sen 10g, np 100g nu cho n. Mng heo 2 b, u phng 50g, i to 10 tri cng nu chn n trong trng hp thiu mu c c gim bch cu v tiu cu. G c 1 con, ng trng h tho 10g cng hm chn n. b. Bnh l vim nhim min dch mn tnh gy thiu mu Vim gan mn gy thiu mu: bi thuc Nhn trn cao thang gia gim (gm: nhn trn 20g, nhn sm 10g, thc a 30g, bch thc 10g, ng quy 10g, chi t 15g, i hong 10g, cam tho 5g).
V thuc Nhn trn Nhn sm Thc a Bch thc ng quy Chi t i hong Cam tho Tc dng Thanh li thp nhit, thoi hong i b nguyn kh, ch huyt, sinh tn T m, b thn, b huyt, sinh tn T m, dng huyt, lim hn, ch huyt B huyt, dng huyt Thng li tam tiu, li thy T nhit trc , thng li i tin B trung, ho v Vai tr Qun Qun Qun Thn Thn T T S

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Nhim trng nhim c mn tnh hoc cc bnh l vim nhim do min dch gy thiu mu: dng bi Thanh dinh thang gia gim (t gic 5g, sinh a 20g, bch thc 10g, ng quy 10g, huyn sm 8g, mch mn 8g, an sm 5g, ngn hoa 10g, lin kiu 10g, hong lin 8g, lin t 10g, i to 3 tri).
V thuc T gic Sinh a i to ng quy Bch thc Mch mn Huyn sm an sm Ngn hoa Lin kiu Hong lin Lin t Tc dng Thanh tm ha, lng huyt, gii c T m, thanh nhit, b huyt Kin t, b huyt B huyt, dng huyt B huyt, lim hn T m, thanh nhit, b ph Thanh nhit lng huyt, sinh tn dch Hot huyt, kh Thanh nhit, gii c Thanh nhit, gii c, tn kt Thanh nhit, gii c, thanh tm Thanh tm b t Vai tr Qun Qun Thn, S Thn Thn T T T T T T T

4.2.2. Th kh huyt h Thng gp trong hi chng suy nhc mn, cc bnh mn tnh ko di. Php tr: b kh huyt. Bi thuc thng dng: Bt trn thang.
V thuc Nhn sm Thc a Hong k Bch trut ng quy Bch thc Phc linh Xuyn khung i to Cam tho Tc dng B tm kh, i b nguyn kh, ch huyt, sinh tn B thn, dng m, b huyt B kh, thng dng kh ca t, ch hn, li thy Kin t to thp, cm m hi B huyt, hnh huyt B huyt, cm m hi, gim au Kin t, thm thp, li thu, an thn Hnh kh hot huyt, khu phong, ch thng Kin t, b huyt B t th, b trung kh, ho v Vai tr Qun Qun Thn Thn Thn Thn T T T S

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Phng huyt:
Tn huyt n trung Quan nguyn Kh hi Thn mn Cch du Cao hoang Tc tam l Tam m giao C s l lun M huyt ca tm bo Hi ca 3 kinh tc tam m B ca kh Nguyn huyt ca tm Hi huyt ca huyt Huyt ca bng quang, ch ca thn minh Hp huyt ca v Giao hi ca 3 kinh m chn Tc dng B tm kh B nguyn kh B kh B tm iu kh, b huyt B huyt, gn gi huyt cho dng iu trung kh T m

4.2.3. Th tm huyt h Php tr: t m, dng huyt. Bi thuc thng dng: Quy t thang gm nhn sm 8g, bch trut 16g, hong k 16g, ng quy 12g, long nhn 16g, toan to nhn 12g, phc thn 12g, vin ch 8g, mc hng 8g, cam tho 8g
V thuc Phc thn Toan to nhn Long Nhn Nhn sm Hong k Bch trut ng quy Vin ch Mc hng Cam tho Tc dng Tit tm nhit, bnh n tm thn Ngt, chua, bnh: dng tm, an thn, sinh tn dch B huyt, kin t Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn Ngt, m: b tm kh, thng dng kh ca t Ngt, ng, hi m: kin t, to thp, cm m hi Ngt, cay, m: b huyt, hnh huyt ng, m: b tm thn, an thn Hnh kh, ch thng, kin t Ngt, m: b t th, b trung kh Vai tr Qun Qun Qun Thn Thn Thn T T T S

+ Nu tnh trng huyt h dn n m h, tm m h dn n thn m h, c th dng bi thuc Hu thin lc v phng (gm: thc a 20g, ng quy 12g, nhn sm 8g, an sm 6g, vin ch 6g, to nhn 6g).

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V thuc Thc a ng quy Nhn sm an sm To nhn Vin ch

Tc dng B thn, dng huyt, b m B huyt, hot huyt, dng huyt i b nguyn kh, ch huyt, sinh tn Hot huyt, kh Dng tm an thn, sinh tn dch B tm thn, an thn

Vai tr Qun Thn T T T T

Phng huyt:
Tn huyt Tm du Quyt m du Tam m giao Ni quan Thn mn Cch du Huyt hi C s l lun Bi du huyt ca tm Du huyt ca tm bo Hi huyt ca 3 kinh m Lc huyt ca tm bo Nguyn th huyt kinh tm Hi huyt ca huyt B ca huyt Tc dng iu tr Dng tm an thn B tm T m, thanh nhit nh tm nh tm, an thn B huyt B huyt

4.2.4. Th can huyt h Php tr: b can huyt. Bi thuc thng dng: B can thang hoc T vt thang + Bi t vt thang: thc a 30g, ng quy 15g, bch thc 20g, xuyn khung 12g
V thuc Thc a ng quy Xuyn khung Bch thc Tc dng Ngt, hi n: b thn, dng m, b huyt Dng can huyt ng, cht, chua: nhun gan, dng ph Cay, n: hot huyt, ch thng, hnh kh, khu phong Vai tr Qun Thn T T

+ Bi thuc Lng a thang gm: a giao, bch thc, thc a (hay sinh a), a ct b, huyn sm, mch mn.

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V thuc Thc a Bch thc A giao a ct b Huyn sm Mch mn

Tc dng Ngt, ng, n: sinh tn dch, dng m, b huyt ng, cht, chua: nhun gan, dng ph Ngt, bnh: t m, dng huyt, b ph, nhun to Ngt hn: lng huyt, t ha ng, mn, hi hn: t m, ging ha, tr phin, nhun to Ngt, ng, mt: nhun ph, sinh tn

Vai tr Qun Qun Thn Thn T T

4.2.5. Th tm t h Php tr: b ch tm t. Bi thuc thng dng: Quy t thang hoc Bt trn thang gia gim. Bi Bt trn thang: nhn sm 12g, bch trut 12g, phc linh 12g, cam tho 6g, thc a 12g, xuyn khung 12g, ng quy 12g, bch thc 12g
V thuc Nhn sm Thc a Bch trut ng quy Bch thc Phc linh Xuyn khung Cam tho Tc dng B tm kh, i b nguyn kh, ch huyt, sinh tn B thn dng m, b huyt Kin t to thp, cm m hi B huyt, hnh huyt B huyt, cm m hi, gim au Kin t, thm thp, li thu, an thn Hnh kh, hot huyt, khu phong, ch thng B t th, b trung kh, ho v Vai tr Qun Qun Thn Thn Thn T T S

Phng huyt:
Tn huyt n trung Quan nguyn Kh hi Thn mn Chi chnh Thi uyn Thin lch C s l lun M huyt ca tm bo, hi ca kh Hi huyt ca 3 kinh tc tam m B ca kh Nguyn huyt ca tm Huyt lc ca tiu trng Nguyn huyt ca ph Huyt lc ca i trng Tc dng iu tr B tm kh B nguyn kh B kh B tm B tm ph B ph B ph

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4.2.6. Th t thn dng h Php tr: n b thn dng, tr t th. Bi thuc: Hu quy m gia gim (gm: thc a 25g, hoi sn 12g, sn th 12g, cu k t 12g, th ty t 12g, lc gic giao 12g, nhc qu 6g, ng quy 10g, ph t ch 6g, nhn sm 12g, chch cam tho 6g).
V thuc Ph t Qu Thc a Hoi sn Sn th K t Nhn sm trng Sn th Cam tho Tc dng i nhit, c c, cay, ngt: hi dng cu nghch, b ha, tr dng, trc phong hn thp t Cay, ngt, i nhit, hi c: b mnh mn tng ha Ngt, hi n: nui thn dng m, b thn, b huyt Ngt bnh: b t v, b ph thn, sinh tn ch kht Chua, sp, hi n: n b can thn, sp tinh, ch hn Ngt, bnh: b can thn, nhun ph to, mnh gn ct i b nguyn kh, ch huyt sinh tn Ngt, n, hi cay: b can thn, mnh gn ct n b can thn, sp tinh, ch hn Ngt, bnh: b t v, nhun ph thanh nhit gii c, iu ha v thuc Vai tr Qun Qun Qun Qun Thn Thn Thn Thn T S

Phng huyt:
Tn huyt Thn du Tam m giao Mnh mn Trung cc C s l lun Du huyt ca thn lng Giao hi huyt ca 3 kinh m chn c hiu dng cha chng chn ha h, b mnh mn tng ha M huyt ca bng quang Giao hi ca tc tm m v nhm mch Tc dng iu tr ch thy, trng ha km cha chng au lng T m Bi nguyn, b thn Li bng quang, iu tr ri lon tiu tin iu huyt tht bo cung, n tinh: iu tr di tinh Can du Thi xung Du huyt ca can lng Du th huyt ca can B can huyt Thanh can ha, cha chng u chong mt hoa

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T lng gi Chn cu ng nht 1. Thiu mu l tnh trng gim

A. Lng hng cu trong mu B. Lng huyt cu t C. Din tch hng cu D. 02 trong mu E. C02 trong mu
2. Nguyn nhn thiu mu do gim sinh hng cu

A. Nhim trng B. Nhim k sinh trng st rt C. Cng lch D. Bt ng nhm mu E. Suy ty


3. Nguyn nhn thiu mu khng phi do tng ph hy hng cu

A. Bnh Thalassemia B. Suy ty C. Cng lch D. Bnh t min E. Truyn nhm nhm mu
4. Xt nghim dng trong thiu mu nh gi chc nng ty

A. MCV B. MCH C. MCHC D. HC li E. Huyt sc t


5. Triu chng ca thiu mu th tm huyt h

A. Hoa mt, chng mt, hi hp hay qun B. au tc hng sn C. Hoa mt, bng mt, b kinh
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D. Hoa mt, bng mt, mt mi, n km E. Hoa mt, chng mt mng tay chn kh, d gy
6. Triu chng thiu mu ca ngi thn dng d

A. Hoa mt, chng mt, au tc hng sn B. Hoa mt, chng mt, xut huyt di da C. Hoa mt, chng mt, tay chn lnh, ng canh t D. Hoa mt, chng mt, thiu hi E. Hoa mt, chng mt, kinh nguyt khng u
7. V nhn trn trong bi thuc Nhn trn cao thang iu tr thiu mu do vim gan mn (gm cc v: nhn trn, nhn sm, thc a, bch thc, ng quy, chi t, i hong, cam tho) c tc dng

A. Thanh nhit li thp: vai tr t B. Thanh nhit li thp: vai tr qun C. Thanh nhit li thp: vai tr thn D. B huyt, dng huyt: vai tr thn E. B huyt, dng huyt: vai tr qun
8. V hong k trong bi thuc Bt trn iu tr thiu mu trong cc hi chng suy nhc mn (gm: nhn sm, thc a, hong k, bch trut, ng quy, bch thc, phc linh, xuyn khung, i to, cam tho) c tc dng

A. B kh, kin t, li thy: vai tr qun B. B kh, kin t, li thy: vai tr thn C. B kh, hnh huyt, thm thp: vai tr qun D. B kh, hnh huyt, thm thp: vai tr thn E. B kh, hnh huyt, thm thp: vai tr t
9. V thc a c tc dng

A. T m b thn, c tc dng dng huyt, sinh tn: vai tr thn B. T m b thn, dng huyt sinh tn: vai tr qun C. T m b thn, hot huyt: vai tr thn D. T m b thn, hot huyt: vai tr qun E. T m b thn, hot huyt: vai tr t

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Bi 19

BNH I THO NG

MC TIU 1. Trnh by c nh ngha i tho ng (T) v cc khi nim ri lon dung np glucose. 2. Nu c c im dch t hc ca i tho ng (T). 3. Trnh by c nguyn nhn, bnh sinh ca T typ 1 v typ 2. 4. Trnh by c c s chn on T theo YHH v chn on 2 nhm bnh cnh lm sng T theo YHCT. 5. Trnh by c c cc bin chng cp v mn tnh ca T. 6. Nu c nguyn tc v ng dng vo iu tr T typ 2. 7. Trnh by c cc phng php khng dng thuc, cc phng huyt, cc bi thuc v cc kinh nghim dn gian vo iu tr T theo YHCT. 8. Phn tch c c s l lun ca vic ng dng iu tr ny.

1. i cng 1.1. nh ngha i tho ng l bnh mn tnh, c yu t di truyn, do hu qu t tnh trng thiu insulin tuyt i hay tng i. Biu hin c trng ca bnh l tnh trng tng ng huyt cng vi cc ri lon v chuyn ha ng, m, m, khong cht. Cc ri lon ny c th a n cc bin chng cp tnh, cc tnh trng d b nhim trng v lu di s gy ra cc bin chng mch mu nh v mch mu ln 1.2. Phn loi i tho ng 1.2.1. i tho ng typ 1 (trc y cn gi l i tho ng ph thuc insulin) c trng bi phn ln l tnh trng thiu ht insulin th pht do s ph hy cc t bo tiu o Langerhans bng c ch t min xy ra trn cc 327

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i tng c h gen nhy cm, mt s trng hp khc l do s mt kh nng sn xut insulin khng r nguyn nhn. S thiu ht insulin s dn ti tng ng huyt v acid bo s gy ra tnh trng a niu thm thu v nhim ceton. Bnh nhn thng gy do mt nc, do m m v m c b ly gii. a s bnh xut hin t thi nin thiu hoc thanh thiu nin, nhng cng c th xy ra bt c tui no. Bnh c tnh l thuc insulin. 1.2.2. i tho ng type 2 (i tho ng khng ph thuc insulin) Loi ny chim 80% tng s bnh nhn i tho ng, c c ch bnh sinh a dng, c trng bi tnh trng tng ng huyt mn tnh v kt hp vi bo ph trong 60 - 80% trng hp. Bnh thng xut hin sau tui 30, phn ln bnh nhn c mt giai on b mp ph. Bnh c lin quan n yu t di truyn v stress. Vic iu tr i khi cng dng insulin nhng khng phi lun lun, m thng l s dng cc sulfamid. 1.2.3. i tho ng thai k i tho ng thai k c nh ngha nh mt ri lon dung np glucose, c chn on ln u tin trong lc mang thai. nh ngha ny khng loi tr trng hp bnh nhn c i tho ng t trc khi c thai nhng cha c chn on, p dng cho mi trng hp vi mi mc ca ri lon dung np glucose d dng insulin hay ch cn tit ch n thun trong iu tr v ngay c khi ng huyt tip tc tng sau khi sinh. Sau khi sinh 6 tun bnh nhn s c nh gi li xp vo cc nhm i tho ng, hoc ri lon ng huyt lc i, hoc ri lon dung np glucose, hoc bnh thng. Trong a s trng hp, thai ph s tr li bnh thng sau khi sinh, tuy nhin mt s bnh nhn c th c ri lon dung np ln sinh sau, 30 - 50% bnh nhn sau ny s c i tho ng thc s hoc typ 1, hoc typ 2. i tho ng trong thai k chim t 3-5% s thai nghn. Chn on i tho ng trong thai k quan trng v nu p dng iu tr tt v theo di thai nhi k trc khi sinh c th lm gim t l t vong v bnh l chu sinh. Thai ph b i tho ng trong thai k cng tng kh nng b m v cao huyt p. 1.2.4. i tho ng cc typ c bit khc y l loi i tho ng th pht gp trong cc trng hp: Bnh ca tuyn ty: vim ty mn, ung th tuyn ty, gii phu ct b ty. Bnh ca tuyn yn: bnh khng l, cc i u chi. Bnh tuyn gip: cng gip trng. Bnh tuyn thng thn: hi chng Cushing. 328

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Nhim sc t st. Do dng thuc: corticoid, thuc nga thai, li tiu thiazid, diazoxid. U no, vim no, xut huyt no. 1.3. c im dch t hc T l mc bnh tiu ng rt khc nhau bi n ph thuc vo cc yu t: a l, chng tc, la tui, mc sng, thi quen n ung sinh hot v tiu chun chn on. 1.3.1. T l mc bnh tiu ng cc nc Chu M: 5 - 10 %. Ring M, theo cuc iu tra c bn sc khe quc gia, nm 1993 c khong 7,8 triu ngi c chn on l i tho ng, tn sut cho mi la tui l 3,1%, trong i tho ng typ 1 khi bnh trc 30 tui chim khong 7% tng s bnh nhn, phn ln cn li l i tho ng typ 2, khong 1 - 2% i tho ng th pht hoc kt hp vi bnh khc. Chu u: 2 - 5%. ng Nam : 2,2 - 5%. Singapore: 8,6%. Vit Nam: H Ni: 1,1% (1991); thnh ph H Ch Minh 2,52% (1992) v 4,5% nm 2001. Trn phm vi ton cu, t l mc bnh i tho ng typ 2 theo c lng nm 1994 thay i t di 2% vng qu Bantu Tanzania v Trung Quc, cho n 40 - 45% sc dn da Pima ti M v dn Micronesia Naru. S khc bit ny do hu qu ca s nhy cm v di truyn v mt s cc yu t nguy c c tnh x hi nh cch n ung, mp ph, t vn ng. T l mc bnh ton b (prevalence) i tho ng trn 20 tui: trn th gii chim 4,0 - 4,2%; cc nc pht trin: 5,8 - 8%; cc nc ang pht trin: 3,2 - 4,2%; trong i tho ng typ 2 chim 80% tt c cc trng hp i tho ng (tui < 65) v 80% ca s ny c km theo bo ph. S ngi b i tho ng typ 2 tip tc gia tng, nu nh nm 1995 l khong 135 triu ngi trn ton th gii, th nm 2000 l 160 triu v nm 2015 d on s c 300 triu ngi mc bnh. T l t vong ng hng th ba sau ung th v tim mch, hng u trong cc bnh ni tit.

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Dch t hc v bin chng ca n

T typ 2 c chn on

20% c bnh l vng mc

> 50% c bnh tim mch T typ 2 khng c chn on 9% c bnh l thn kinh ngoi bin 8% c tn thng t bo cu thn

Hnh 19.1. Cng ng 300 triu ngi mi mc T typ 2

1.3.2. Cc yu t nguy c gy bnh i tho ng Bo ph, tng huyt p, x cng ng mch. Di truyn, nhim virus, xut hin vi cng mt s bnh t min. Thi quen t vn ng, n nhiu thc n giu nng lng; s dng nhiu cc cht kch thch nh ru, thuc l. Ph n sinh con trn 4kg hoc b sy thai, a i. S dng cc thuc: corticoid, nga thai; li tiu nhm thiazid, diazoxid. 1.4. Cc khi nim trung gian Cc khi nim trung gian l mun ni ln khong trung gian gia ng huyt bnh thng v i tho ng. C 2 khi nim l: ri lon dung np glucose IGT (impaired glucose tolerance) v ri lon ng huyt lc i IFG (impaired fasting glucose). Thut ng ri lon dung np glucose: dng ch nhng ngi c ng huyt 2 gi sau khi ung 75g glucose 140mg/dl v < 200mg/dl. Thut ng ri lon ng huyt lc i IFG: dng ch mc ng trong huyt tng lc i b ri lon trong khong: glucose huyt tng lc i 110mg/dl (6,1 mmol/l) v < 126mg/dl. Nng glucose huyt tng lc i = 110mg/dl c coi l gii hn cao ca mc bnh thng. 330

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IFG v IGT l nhng yu t nguy c cho i tho ng typ 2 do mi quan h ca chng vi s khng insulin v bn thn chng khng lin quan trc tip n bin chng tim mch trong i tho ng nhng n gi vai tr yu t nguy c do s phi hp mi lin quan gia cc ri lon ny v hi chng khng insulin nh ni trn. ngn chn i tho ng, iu quan trng l pht hin cc ri lon dung np glucose v bo ph chn on sm v c quyt nh iu tr ph hp 1.5. Quan nim ca y hc c truyn v bnh T Trong y vn ca y hc c truyn (YHCT) khng c bnh danh i tho ng nhng nhng triu chng lm sng ca i tho ng nh: kht nc nhiu, ung nhiu, tiu nhiu, cm gic i, thm n, gy, t b d cm ngoi da, m mt, cng c YHCT m t trong mt s chng trng nh tiu kht, h lao, ma mc..v..v.. 1.5.1. Chng tiu kht Theo mt s t liu nh: sch Ni kinh, T vn chng k bnh lun: n nhiu cht bo ngt sinh mp ph, cht bo sinh ni nhit, cht ngt gy trung mn, kh tro ln sinh chng tiu kht. Sch Ngoi i b yu nu: Kht m ung nhiu nc, tiu nhiu, nc tiu ngt l do thn h sinh chng tiu kht. Ngoi ra cng sch Ngoi i b yu khi ni n nguyn nhn cn nu: Can kh ut kt, ut tr sinh nhit, ha to, thng m sinh ra ming kht, ung nhiu, hay i. Cc y gia i ng Trung Quc cn nhn mnh thm: Tnh ch tht iu, n nhiu cht bo ngt tch nhit, thng m sinh chng tiu kht, ni nhit ha ha tip tc thiu t chn m lm cho kht nhiu, n nhiu, gy nhiu, tiu nhiu nc tiu ngt l chng tiu kht. Nh vy trn cc biu hin lm sng triu chng ca T cng biu hin tng t nh m t trong chng tiu kht ca YHCT, tuy nhin khi bnh nhn c y triu chng ca tiu kht cha hn l c tng ng trong mu hay bnh T. Quan nim bnh tiu kht l do m h v to nhit, hai nguyn nhn ny tc ng nhn qu vi nhau lm tiu hao tn dch ph v v m tinh thn. Tu thuc vo c a, vo nguyn nhn v cc yu t thun li khc c th gy bnh thng tiu trung tiu hoc h tiu m cc biu hin triu chng theo YHCT nh nu trn c th gp trong c i tho ng v i tho nht... Trong qu trnh pht trin bnh tt, ngi xa cng cho l bnh thng hay chuyn bin, cn phi bit phng cha cn thn. Trng Trng Cnh tng nu bnh tiu kht c th chuyn bin thnh chng ph nuy. Ch bnh 331

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nguyn hu lun cng ni bnh c th pht ra hoi th hoc l ngoi da hoc ph thng. Lu H Gian th cho rng phn nhiu kim thm ic, lng tai, m mt, m, mn l, rm sy, chn tay b t lit... 1.5.2. Chng h lao Do nhiu nguyn nhn nh tin thin bt tc, n ung khng chng mc, lao tm, lao lc qu ... lm tn hi m dng, kh huyt; m h sinh ni nhit, nhit tch ha ha li thng m sinh ra cc chng kht nc, nng ny bt rt, gy rc, da kh t b, ming li l... 1.5.3. Chng ma mc Ma mc (t b) l da chi th hoc mt b phn no trn c th khng c cm gic na. Bnh chia lm 2 mc: + T (ma) l mc nh l c phu bt nhn (da c khng nhn bit c cm gic), song c lc cng cm thy c do kh lu hnh. + B (mc) mc nng l khng bit au nga, do chn kh khng n ni c. y l mt biu hin ca ri lon cm gic ca y hc hin i. V nguyn nhn gy ra chng ma mc: bnh lu ngy c v kh b thng phong, dinh huyt b thng hn, c nhc b thng thp ri n kh h khng vn hnh tt hoc kh tr gy b tc, hoc kh huyt h da c khng c nui dng tt, hoc c huyt cht trong mch, hoc ha nhit tch t sinh m, hoc m thp tr gy kh h huyt tr.v..v... C ch sinh bnh: t b c lin quan n dinh v kh huyt. Ni kinh vit: dinh kh m h th da khng c cm gic, v kh h th khng vn ng c (dinh kh h tc bt nhn, v kh h tc bt dng). 2. NGUYN NHN V BNH SINH CA I THO NG 2.1. Nguyn nhn 2.1.1. i tho ng typ 1 Nguyn nhn khng r: mt s trng hp T typ 1 khng c nguyn nhn, bnh nhn ny b thiu insulin trm trng v d b nhim ceton acid nhng khng c bng chng t min. Nguyn nhn di truyn: th bnh ny c yu t di truyn rt r, thiu cc yu t t min vi t bo beta, khng kt hp vi nhm HLA, bnh nhn c lc cn insulin sng st c lc khng. Ngoi ra s thiu st acid amin (acid aspartic) v tr 57 ca chui DQ d mc bnh T typ 1 hn nhng ngi c acid amin ny. 332

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Yu t thun li pht ng bnh: + Cc yu t mi trng c tc ng khi ng hot tnh min dch gy bnh c th l nhim virus (Coxackie B, quai b..), nhim trng, hoc mt khng th ni sinh do cc tn thng m do c cht (nh thuc dit chut). + Stress. 2.1.2. i tho ng typ 2 nh hng ca di truyn v mi trng: nh hng ca yu t di truyn ln bo thai rt mnh, da trn cc quan st sau + T l anh ch em sinh i cng trng cng b T typ 2 l 90 - 100%. + Bnh nhn T typ 2 thng c lin h trc h cng b T. + C s khc nhau rt nhiu v t l mc bnh T gia cc chng tc, cc sc dn khc nhau. + Mp ph v thiu vn ng l 2 yu t quan trng nh hng n t l cao ca bnh T typ 2 dn thnh th v dn nhp c vo cc nc pht trin. + n nhiu m nht l m bo ha ca ng vt. nh hng ca s pht trin lc bo thai v thi nin thiu: + Cc bo thai nm trong mi trng chuyn ha ca m b T hoc T trong thai k cng kch thch s trng thnh ca t bo beta v tng sinh o ty. + n thc n hp th nhanh v ung nhiu nc ngt, t vn ng. 2.2. C ch bnh sinh 2.2.1. Bnh sinh i tho ng typ 1 Khi cc triu chng lm sng xut hin th a s t bo tuyn ty b ph hy. C ch bnh sinh lin quan n yu t nguy c nhim virus nh virus quai b, si, Cosackie B4. Qu trnh vim nhim t bo tuyn ty c din tin nh sau: khi u phi c gen nhy cm; sau , s nhim virus c tnh cch pht ng gy bnh. Nhim virus s gy mt tnh trng vim tuyn ty (insulitis), qu trnh ny s hot ha t bo lympho T v thm nhim tiu o ca tuyn ty. Cc t bo lympho T c hot ha s lm thay i b mt ca t bo tuyn ty, lm n tr thnh vt l i vi h thng min dch c th. Ngay lp tc s xut 333

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hin p ng min dch qua trung gian t bo. Cc khng th c t bo ny s c to thnh v ph hy t bo beta tuyn ty. Nh vy, c ch bnh sinh ca i tho ng typ 1 lin quan n h thng khng nguyn HLA, DR3, DR4, B8, B15. Khng nguyn B8 rt ng ch v lin quan nhiu n cc bnh t min nh Basedow, suy thng thn, bnh nhc c. Ngi ta cng m t khng th chng mng t bo trn ngi b i tho ng th tr nhng khng r chnh nhng khng th t min ny sinh ra bnh hay n ch sinh ra do khng nguyn xut hin t ty tng b vim. 2.2.2. Bnh sinh i tho ng typ 2 Ngi ta nhn thy rng c 3 ri lon cng song song tn ti trong c ch bnh sinh ca i tho ng typ 2 l: Ri lon tit insulin. S khng insulin m ch. S tng sn xut glucose c bn ti gan. Trn ngi bnh thng, duy tr hng nh v glucose tu thuc vo s tit insulin, s thu np insulin m ngoi vi v c ch s sn xut insulin t gan v rut. Sau khi n, glucose s tng ln trong mu v ty s tng tit insulin, cc yu t ny s tng s thu np glucose m ngoi vi (ch yu l c) v ni tng (gan - rut) nhng li c ch s sn xut glucose t gan. Nu c khim khuyt ti t bo beta, c v gan c th s xy ra ri lon dung np glucose, ni cch khc ri lon dung np glucose l hu qu ca s khim khuyt trong s tit insulin hoc khng vi tc dng ca insulin ti m ch. S khng insulin ti m l yu t bnh sinh quan trng trong i tho ng typ 2 Gan l v tr khng insulin u tin trong trng thi nhn i. Tng sn xut glucose t gan l yu t chnh lm tng ng huyt lc i. Sau khi n: c tng ng huyt v tng tit insulin. V tr khng insulin trong giai on ny ch yu nm c. Khi bnh nhn i tho ng typ 2 c ng huyt lc i tng cao, tng sn xut glucose t gan cng gp phn lm tng ng huyt thi im sau hp thu.

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Error!

Bnh thng

Gen

khng insulin

ENVIRONMENT

Gim tit insulin - Gen i tho ng - Gen khng insulin - cell function genes - Besity genes I THO NG TYP 2 - Ch n - t vn ng - Nhim c

Ngoi ra nhng ngi ln tui, nht l nhng ngi b bo ph, kh nng tng hp protein ca t bo rt km nn khng tng hp c receptor bt gi insulin (receptor bn cht l protein), do tuy tuyn ty ca nhng ngi ny vn sn xut insulin bnh thng nhng khng c tc dng a ng vo trong t bo. 2.3. c im lm sng 2.3.1. i tho ng typ 1 i tho ng typ 1 l i tho ng ph thuc insulin, chim t l 10 - 15% bnh i tho ng ni chung. i tho ng typ 1 c 2 th 1A v 1B. Typ 1A: hay gp tr em v thanh thiu nin, chim 90% t l bnh ca typ 1, lin quan n h thng khng nguyn HLA. Typ 1B: chim 10% ca bnh typ I, thng kt hp vi bnh t min thuc h thng ni tit, gp nhiu ph n hn nam gii, tui khi bnh tr: 30 - 50 tui. c im lm sng ca i tho ng typ 1: + Bnh thng khi pht di 40 tui. + Triu chng lm sng xy ra t ngt, rm r, st cn nhiu. + Nng glucagon huyt tng cao, c ch c bng insulin. + V tnh trng thiu insulin tuyt i nn d b nhim ceton acid, rt p ng vi iu tr insulin. 2.3.2. i tho ng typ 2 L i tho ng khng ph thuc insulin. 335

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Thng khi pht t tui 40 tr ln. Triu chng lm sng xut hin t t, hoc i khi khng c triu chng. Bnh c pht hin mt cch tnh c do khm sc khe nh k, th trng thng mp. Nng insulin huyt tng bnh thng, hoc ch cao tng i, ngha l cn kh nng duy tr ng huyt n nh. Nng glucagon huyt tng cao nhng khng c ch c bng insulin. Bnh nhn thng b hn m tng p lc thm thu. i tho ng typ 2 khng c lin quan n c ch t min v h thng khng nguyn HLA. Yu t di truyn chim u th i vi i tho ng typ 2. S phn tch v cy chng h cho thy bnh i tho ng c th di truyn theo kiu ln, kiu tri hoc kiu a yu t trong cng mt gia nh. Nh vy khng th quy nh mt kiu di truyn duy nht bao gm ton th hi chng tiu ng. Ch ring i vi phenotyp gia tng ng huyt hoc gim dung np i vi cht ng ngi ta m t n 30 kiu ri lon di truyn. Th d: c hai anh em sinh i cng trng, tui > 40, t s tiu ng ng b xy ra l 100% v tui < 40 l 50 %, chng t nh hng di truyn u thng trong bnh tiu ng ng tui. 2.4. Nguyn nhn, bnh sinh theo y hc c truyn Da theo c ch bnh sinh ca YHCT sinh cc triu chng lm sng tng ng vi m t ca YHH, c th tng hp nguyn nhn bnh sinh T theo YHCT nh sau: Do n qu nhiu cht bo ngt bao gm c ung ru qu : n ung qu nhiu cht bo ngt, li ung nhiu ru c thc n ln ru u tch nhit ri ha ha trung tiu. Ha nhit s thiu t tn dch lm cho m h, m cng h nhit cng tch sinh ra cc chng kht, ung nhiu vn khng ht kht, gy nhiu. Do tnh ch: tinh thn cng thng, cm xc m tnh ko di lm cho thn tn ha ha hoc do ng ch cc ut cng ha ha. Ha sinh ra thiu t phn m ca ph tng. Do ung nhiu cc thuc an thch (thuc tng hp t ha cht nh tn dc) lm cho thn thy b kh kit, do sinh ra kht nhiu v i tiu tin nhiu. Do bnh lu ngy: bnh lu ngy lm cho m h, m h sinh ni nhit, nhit tch li ha ha li tip tc tn thng chn m sinh ra chng nng 336

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ny, bt rt, kht nc, gy kh hoc ha nhit sinh ra m, m lu nin gy nn thp tr sinh ra chng t b, d cm ngoi da. Do tin thin bt tc hoc do phng dc qu : lm cho m tinh h tn, tc ng dy chuyn tn hi cc m tng nh thn m, can m, tm m, ph m, v m..v..v.
Ung ru + n nhiu bo ngt Bnh lu ngy Ung Error! thuc nng Tnh ch Phng dc qu Tin thin bt tc

TCH NHIT HA HA CHN M HAO TN

V m h Tiu nhiu, kht, gy

Ph m h Tiu nhiu, kht nhiu, ung nhiu

Thn m h Tiu nhiu, gy, m mt

m thp T b, tiu nhiu

TIU KHT, H LAO, MA MC

Hnh 19.2. Nguyn nhn v c ch bnh sinh theo YHCT

3. CHN ON 3.1. Theo y hc hin i 3.1.1. Tiu ch chn on mi bnh i tho ng (1) Mt mu ng huyt tng bt k 200mg/dl kt hp vi cc triu chng lm sng ca tng ng huyt. (2) ng huyt tng lc i 126mg/dl (sau 8 gi khng n). (3) ng huyt tng 2 gi sau khi ung 75g glucose 200mg/dl. 3.1.2. Triu chng lm sng Thng biu hin bi nhm triu chng: Kht nc v ung nc nhiu. Tiu nhiu hay cn gi l a niu thm thu. n nhiu. St cn. 337

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S xut hin cc triu chng trn l do tnh trng thiu insulin dn n hu qu tng p lc thm thu mu, lm nc ni bo ra ngoi bo khin lu lng tun hon tng v tng tc lc vi cu thn. Mt khi lng ln nc tiu c thi ra cng glucose l do glucose mu vt qu ngng thn. Ngoi ra cng tng thi qua ng niu ion K + v Na +. Hu qu gy mt nc ni bo v ngoi bo, lm ri lon in gii, kch thch trung tm kht nn bnh nhn ung nhiu. Lng glucose mt qua ng niu khong trn 150g/24 gi s gy cm gic i v bnh nhn phi n nhiu m vn st cn. Ngoi triu chng trn, ngi bnh cn c th b kh da, nga ton thn v m mt thong qua. 3.1.3. Xt nghim cn lm sng a. ng huyt Theo tiu ch chn on mi c WHO cng nhn nm 1998, cc loi ng huyt th chn on xc nh bao gm: ng huyt tng lc i: t nht phi th 2 ln lin tip khi i, ly mu tnh mch. + ng huyt tng lc i <110mg/dl: bnh thng. + ng huyt tng lc i >126 mg/dl, hoc > 7mmol/l (sau 8 gi khng n): chn on tm thi l i tho ng (chn on xc nh cn nn lm thm mt ln na). + ng huyt tng 110mg/dl v < 126mg/dl = ri lon ng huyt lc i. ng huyt tng bt k: chn on xc nh i tho ng khi ng huyt tng bt k > 200mg% kt hp vi cc triu chng lm sng ca tng ng huyt. ng huyt tng sau 2 gi lm nghim php dung np glucose: + ng huyt tng 2 gi sau khi ung 75g glucose < 140mg/dl = dung np glucose bnh thng. + ng huyt tng 2 gi sau khi ung 75g glucose 140mg/dl v < 200mg/dl: ri lon dung np glucose. + ng huyt tng 2 gi sau khi ung 75g glucose > 200mg/dl: chn on tm thi l i tho ng, chn on xc nh khi lp li mu th ln 2 kt qu nh trn b. ng niu Khi ng huyt bnh thng v chc nng lc ca thn bnh thng s khng c s hin din ca ng trong nc tiu. 338

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Khi ng huyt vt qu 160 - 180mg/dl (8,9 - 10,0mmol/l) s c ng xut hin trong nc tiu v ngng thn b vt qu. Mt khc, cng c th lng ng huyt bnh thng, nhng ngng lc ca thn gim v ng cng s hin din ngoi nc tiu nn mt s tc gi khng dng xt nghim ng niu. Tuy nhin, xt nghim tm ng trong nc tiu va n gin li r tin, nn nu chc nng thn ca ngi bnh bnh thng cng c th dng theo di kt qu iu tr hoc gip tin lng din tin ca bnh. c. Th ceton huyt thanh Bnh thng: 0,5 n 1,5mg%. Trn ngi b tiu ng, s hin din ca th ceton trong mu vi nng cao chng t c th ang thiu insulin trm trng. d. Huyt sc t kt hp vi glucose (glycosylated hemoglobin) Bnh thng huyt sc t trong ty cha kt hp vi glucose. Khi hng cu c phng thch vo mu, cc phn t huyt sc t s gn vi glucose theo qu trnh glycosyl ha (glycosylation). Nng huyt sc t kt hp glucose t l vi ng huyt v c gi l glycosylated hemoglobin. Bnh thng lng huyt sc t kt hp vi glucose chim khong 7%. Khi c bnh tiu ng, c th tng n 14% hay hn. C 3 loi huyt sc t kt hp glucose chnh AIA, AIB, A1C, gp chung li thnh HbA1 Huyt sc t A1C tng trong trng hp tng ng huyt mn tnh v c lin h n tnh trng chuyn ha ni chung nht l cholesterol. Trn bnh i tho ng n nh lng huyt sc t kt hp glucose s tr v bnh thng sau 5 n 8 tun. Trn bnh i tho ng khng n nh lng huyt sc t kt hp vi glucose s cao v song song vi lng cholesterol mu tng cao. Trn bnh nhn c ng huyt tng cao, nu iu tr tch cc gim c ng huyt th huyt sc t kt hp vi glucose s ch thay i sm nht sau 4 tun. 3.2. Chn on theo y hc c truyn Nh trnh by trn, cc biu hin lm sng YHCT ca i tho ng l khng c trng ch mang tnh nh hng cho cc th lm sng, nn chn on xc nh T cn kt hp th ng huyt lc i, khi mc ng huyt tng km vi cc triu chng sau y s c chn on: 3.2.1. i vi th khng c kim chng hoc bin chng C biu hin chung l m h ni nhit nh kht, ung nc nhiu, n nhiu mau i, ngi gy da kh, mm kh, thn li thon , ru li mng hoc vng, mch hot sc hoc t sc. Trong c cc th: 339

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Th ph m h: + Kht nhiu. + Ung nhiu nc. + Hng kh. + Li , t ru. + Tiu nhiu. + Mch sc. Th v m h: + n nhiu, mau i. + Tng gy. + Kht nc. + Li , ru vng, li l. + Mch hot sc. Th thn m h: + Tiu nhiu v tiu m nhiu ln. + Kht nc. + Li khng ru. + M mt. + Lng bn tay bn chn nng. + Mch t sc l th thn m h. + Nu chn tay lnh, mt mi, ngi gy, mch t hon v lc l th thn dng h. Th m thp: + Tng bo bu. + T b, d cm ngoi da. + Tiu nhiu. + Li b, ru nhy nht. + Mch hot sc. 3.2.2. i vi th c kim chng (hoc bin chng) Ngoi ra, ngi thy thuc YHCT cn ch n nhng du chng km theo v bin chng sau y quyt nh chn la hoc gia gim vo cch iu tr v chm sc bnh nhn. 340

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Chng hi hp, mt ng: do m h lm tn dch tn thng, tinh thn mt mi, mt ng, hi hp, hay qun, tiu bn, d sinh l lot trong ming, li ru vng, mch t sc Php tr: ch kh dng huyt, t m thanh nhit. Chng u vng mt hoa: + Nu l m h dng xung: chng mt, tai, au cng u, au nng hn lc tinh thn cng thng, nng ny d gt, mm ng, hng kh, li ru vng, mch huyn. + Nu l m trc: vng u, bun ng, ngc bng y tc, n t bun nn, li nht ru nht, mch hot. Trng v to thc: chng nht, lot l thng hay ti pht, kh khi, rng li sng au, li ru vng, mch sc. Php tr: thanh nhit gii c. Chn tay t di: mt mi, c teo, chn tay t di i khng vng, li nht ru mng vng, mch t sc. Php tr dng m thanh nhit, b huyt thng lc. Ho khan: ho khan t m, ng tm phin nhit, st m v chiu, ra m hi trm, li t ru, mch t sc. Php tr: dng m thanh nhit, nhun ph ch khi. 4. BIN CHNG 4.1. Bin chng mn tnh ca bnh tiu ng Bnh nhn b tiu ng c th b rt nhiu bin chng lm th trng suy sp. Trung bnh cc bin chng xy ra khong n 20 nm sau khi ng huyt tng cao r rt. Tuy nhin cng c vi ngi khng bao gi b bin chng hoc bin chng xut hin rt sm. Mt bnh nhn c th c nhiu bin chng cng mt lc v cng c th c mt bin chng ni bt hn tt c. 4.1.1. Bin chng mch mu ln X cng ng mch thng gp trn ngi b tiu ng, xy ra sm hn v nhiu ch hn so vi ngi khng bnh. X cng ng mch mch mu ngoi bin c th gy tnh trng i cch hi, hoi th v bt lc n ng. Bnh ng mch vnh v tai bin mch mu no cng hay xy ra. Nhi mu c tim th khng au c th xy ra trn ngi b tiu ng v ta nn ngh n bin chng ny khi bnh nhn b tiu ng thnh lnh b suy tim tri. V vy phi lm EGC nh k v Doppler mch mu pht hin sm sang thng. 341

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4.1.2. Bin chng mch mu nh Sang thng xy ra nhng mch mu c ng knh nh c tinh lan ta v c hiu ca tiu ng. nh hng ch yu ln 3 c quan: bnh l vng mc, bnh l cu thn v bnh l thn kinh. C ch bnh sinh ca sang thng mch mu nh cha r. C s tham gia ca ri lon huyt ng hc nh tng hot tnh ca tiu cu, tng tng hp thromboxan A2 l cht co mch v kt dnh tiu cu to iu kin cho s thnh lp vi huyt khi. Ngoi ra s tng tch t sorbitol v fructose cc m, s gim nng myonositol cng lm cho sang sang thng mch mu trm trng hn. Cui cng tnh trng cao huyt p cng lm nng thm bnh l vi mch vng mc v thn. Sang thng c m t ca mch mu nh l s dy ln ca mng y mao mch v lp di ni mc ca cc tiu ng mch. Nng hn na l s bin mt ca cc t bo chu b bao quanh v nng mch mu. Tn thng ny hay gp trong bnh l vng mc v thn. Cc sang thng m hc u tin xy ra sm, nhng cc biu hin lm sng ch xut hin khong 10 n 15 nm sau khi bnh khi pht. a. Bnh l vng mc Thay i c bn: thay i sm nht vng mc l cc mao qun tng tnh thm. Sau nhng mao qun b nghn tc to nn cc mch lu dng ti hay hnh thoi. Sang thng mch mu km theo s tng sinh t bo ni mc mao qun v s bin mt ca cc t bo chu b (pericytes) bao quanh v nng mch mu. Ngoi ra cn c hin tng xut huyt v xut tit vng m. Sang thng tng sinh: ch yu do tn to mch mu v ha so. C ch kch thch s tng sinh mch mu khng r, c gi thit cho rng nguyn nhn u tin l tnh trng thiu oxy do mao qun b tc nghn, 2 bin chng trm trng ca sang thng tng sinh l xut huyt trong dch th v bc tch vng m gy ra m cp tnh. Thng sau 30 nm b tiu ng hn 80% bnh nhn s c bnh l vng mc, khong 7% s b m. Mun pht hin sm cc sang thng u tin ca vng mc phi dng phng php chp ng mch vng mc c hunh quang th nhng sang thng vi mch lu s pht hin kp thi iu tr sm phng nga din tin ca bnh l vng mc. b. Bnh l thn y thng l mt trong nhng nguyn nhn gy t vong ca bnh tiu ng. C 4 loi sang thng c m t trn knh hin vi: Tnh trng x ho vi cu thn. Tnh trng x cng ng mch ti v ng mch i khi vi cu thn.

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Glycogen, m v mucopolysaccharides ng quanh ng thn. vi cu thn, ngi ta c th thy 2 loi sang thng: + Nhng m trn cht hyalin, phn ng PAS dng tnh xut hin gn b ngoi vi cu thn. + Mng c bn ca cc mao qun dy ln, phn trung m cng tng sinh. Tuy nhin khng c s lin quan mt thit gia sang thng vi th v triu chng lm sng. C th khi lm sinh thit thn c sang thng nhng trn lm sng chc nng thn hon ton bnh thng. Mt khc, nu trn lm sng c bin chng thn, ngi ta c th ngh l c thay i vi th. Hi chng Kimmelstiel Wilson bao gm ph, cao huyt p, tiu m v suy thn trn bnh nhn b tiu ng. Tiu m > 3g/24 gi l du hiu xu. a s cc bnh nhn b bin chng thn ng thi c thay i y mt nhng nhiu bnh nhn c thay i y mt li khng c triu chng r rng ca bnh thn. Thi gian bn hy ca insulin ko di trn ngi suy thn, c ch ca n cha c bit r. 4.1.3. Bin chng thn kinh Bin chng thn kinh nh hng ln mi c cu ca h thn kinh c l ch tr no b. Bin chng gy nhiu kh khn cho bnh nhn d t khi gy t vong. Tham gia vo c ch sinh bnh do ri lon chuyn ha dn ti gim myoinositol v tng sorbitol, fructose trong dy thn kinh. Ngoi ra cn c thiu mu cc b do tn thng vi mch dn n thoi bin myelin dy thn kinh v gim tiu th oxy. Bin chng thn kinh hay gp bnh nhn tiu ng l: Vim a dy thn kinh ngoi bin: thng b i xng bt u t u xa ca chi di, t nhc, d cm, tng nhy cm v au. au thng au m , hoc au trong su, c khi au nh in git. Khm thng sm pht hin mt phn x gn xng c hiu l mt phn x gn gt Achille, mt cm gic rung v xng. Vim n dy thn kinh cng c th xy ra nhng him: triu chng c tay rt, bn chn rt hoc lit dy thn kinh III, IV, VI, bnh c th t ht. Bnh nhn cn c th b au theo r thn kinh. Bin chng thn kinh dinh dng (hay thc vt) cn gi bin chng thn kinh t ch nh hng ln cc c quan nh:

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+ Tim mch: tng nhp tim trng thi ngh ngi: 90 - 100 ln/pht, gim huyt p t th (huyt p tm thu t th ng gim > 30 mmHg). + Tiu ha: mt hoc gim trng lc ca thc qun, d dy, rut, ti mt. Bnh nhn nut kh, y bng sau khi n; tiu chy thng xy ra v m, tng t khng km theo au bng, xen k vi to bn. + H niu sinh dc: bin chng thn kinh bng quang lm gim co bp v lit bng quang, bt lc nam gii. + Bt thng tit m hi: gim tit m hi na phn thn di v tng tit phn thn trn, tay v mt, nht l khi ng ti v sau khi n cc cht gia v. + Ri lon vn mch: ph ngoi bin mu bn chn. + Teo c, gim trng lc c . 4.1.4. Bin chng nhim trng C a tiu ng rt d b nhim trng bi v kh nng thc bo gim do thiu insulin dn ti gim sc khng ca c th. Nhim trng mn nht ngoi da thng do Staphylococcus aureus gy ra. Nhim nm Candida albicans b phn sinh dc dc hay k mng tay v chn. Nhim trng tiu thng do vi trng Gram m E. coli gy vim bng quang, vim i b thn cp hoc mn, vim hoi t gai thn. Vim phi do vi trng Gram m hay gp; ngoi ra cn gp do vi trng Gram dng, vi trng lao. 4.1.5. Lot chn bnh tiu ng Thng do phi hp bin chng thn kinh, bin chng mch mu v bin chng nhim trng. Vi trng gy nhim trng chn thng t khi mt loi vi trng m thng phi hp cc loi vi trng Gram dng, vi trng Gram m v vi trng k kh. 4.2. Bin chng cp tnh ca bnh tiu ng 4.2.1. Hn m do nhim ceton acid a. Sinh bnh hc Tnh trng hn m ny l hu qu ca s thiu insulin tng i hay tuyt i km theo s gia tng nhiu t ca cc hormon chng insulin nh glucagon, cortisol, catecholamin, hormon tng trng Thiu insulin: tng glucose huyt. 344

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Glucose khng vo c t bo c v t bo m. S sn xut glucose ni sinh tng ln, gan tng s thy phn glycogen v tng s tn sinh ng phng thch glucose vo mu. Ngoi ra, gan tng s phng thch glucose cng cn do tng glucagon, tng cortisol trong mu v gia tng cc cht cn cho s tn sinh ng n gan (nh acid amin, lactat, glycerol). Tng glucose huyt a n ri lon nc v in gii. Tng glucose huyt -> tng p lc thm thu ngoi bo -> nc t ni bo ra khong ngoi bo -> lc u tng th tch huyt tng -> tng lng mu n vi cu thn -> tng lng glucose lc qua vi cu thn -> a niu thm thu. Tnh trng a niu thm thu ny tuy gii hn phn no s tng glucose huyt nhng gy kit nc, mt K +, mt Na +. Tng th cetone huyt: + Thiu insulin, cc men gan hng v s thnh lp th ceton. M b thy phn thnh acid bo nhiu hn. Tng glucagon s kch thch men carnitin acyl transferase gip cho acid bo i vo ty th (mitochondrie) c oxyd ha. + Ceton l nng lng c th c s dng bi c tim, c vn, thn. ngi thng n c th c ch s ly gii m m, c l do kch thch s tit insulin. S c ch ly gii m m ny khng c trong tnh trng nhim ceton acid. Nng th ceton khi tng rt nhiu so vi s s dng v tng nhanh huyt tng n 100 - 300mg% (bnh thng di 5mg % sau 12 gi nhn i). + Th ceton gm ch yu acid hydroxybutyric v acid aceto acetic l acid mnh s gy c toan bin dng. Lng d tr kim HCO3 trong mu s gim v khi kh nng b tr b vt qu pH mu s gim. + Bnh nhn s c nhp th su Kussmaul tng thi CO2. Tng thi cc acid cetonic qua thn di th mui natri v kali. c toan nng c th a n try tim mch do gim co bp c tim, gim trng lc mch mu, gim s cm th ca c tim vi catecholamin ni sinh. Thoi bin cht m v tng acid amin trong mu: + Gim insulin v tng cc hormon chng insulin trong huyt tng. Th d cortisol s gia tng s thoi bin cht m. + Thy phn m c: alanin (acid amin chnh ca s tn sinh ng) t c dn n gan. C gim thu np cc acid amin c nhnh (valin, leucin, isoleucin). S thoi bin m ny lm K + t ni bo ra ngoi bo nhiu. 345

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b. Nguyn nhn gy bin chng hn m Trn bnh nhn thiu insulin tuyt i: xy ra tiu ng tr trn 83% trng hp khi bnh nhn thnh lnh ngng insulin. Trn bnh nhn thiu insulin tng i: khi c mt trong nhng nguyn nhn sau y thm vo: + Nhim trng (50% trng hp): nhim trng h hp trn (tai, ming) p xe ming, vim phi, vim i b thn cp, vim ng mt, nhim trng huyt. + Nhi mu c tim. + Vim ty cp, thng d dy - t trng. + Thai k (tng nhu cu insulin t thng th t). + Cng gip trng. + M. + Chn thng (c th hay tinh thn). Cc trng hp trn u lm tng cortisol, glucagon, catecholamin. c. Triu chng lm sng v cn lm sng Thi k nhim ceton: + Nu cha bit bnh nhn c tiu ng, hi bnh s s c gy nhanh, 2 - 3 ngy nay km n, nn, tiu nhiu, ung nhiu, mt. + Trong nc tiu: ng niu > 20g/l, c ceton trong nc tiu. + Mu: tng ng huyt, gim d tr kim 18 < HCO3 < 25mEq/l, pH mu bnh thng. Nu iu tr ng, din tin tt rt nhanh. Nu bit c bnh tiu ng, theo di nc tiu thy bt u c nhim ceton, s tng nhiu insulin nhanh cho n khi ht ceton trong nc tiu. Nu khng ht, cho bnh nhn nhp vin. Thi k nhim ceton acid nng (thi k c toan bin dng do nhim ceton nng): + Ri lon tri gic, l m, hn m. + Th su nhp Kussmaul. + Hi th c mi ceton. + Du kit nc ngoi v ni t bo: da kh, mt hm su, tnh mch c xp, h p huyt, gim cn, kh nim mc ming, gim trng lc nhn cu, nu c kch xc nn tm sang thng ni tng nh nhi mu c tim, vim ty cp. 346

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+ Nn ma, au bng. + Nhit h di 360C. + Khi khm nn hi: trng hp xut hin cc triu chng, thi im xut hin v trm trng ca triu chng nn, i ngoi, cc thuc dng trc khi nhp vin nh li tiu, corticoid ch pht hin du chng ri lon nc in gii v h K + mu. + Triu chng cn lm sng (th ngay ti ging bnh): Trong nc tiu: glucose niu > 20g/l; ceton nc tiu (+) mnh. Trong huyt tng: ceton mu (4+) vi huyt tng cha ha tan, cetones mu (2+) vi huyt tng ha tan. Cc xt nghim khc.

pH mu < 7,20; d tr kim HCO3- < 10mEq/l. Th ceton mu 100 - 300mg%. Glucose huyt tng < 6g/l. Nu > 6g/l phi nghi ng bnh nhn truyn glucose hoc c suy thn. K+ mu rc khi iu tr c th bnh thng tng hoc gim. D sao bnh nhn vn mt K +. Nu K+ mu gim th s mt K+ rt trm trng, ta cn iu tr ngay t u. Na+ c th bnh thng, tng hoc gim. Dung tch hng cu, m huyt tng do gim th tch huyt tng Ur huyt tng, mt phn do thoi bin cht m, c th do suy thn chc nng.

d. Din tin Theo di din tin: + Mi gi: nhp th, nhp tim, p huyt, nc tiu, ng niu, ceton niu. + o in tim (ECG). + Mi 4 gi: pH mu, HCO3 mu, ng huyt, ion . Theo di bin chng: + Trong nhng gi u tin bnh nhn c th b try tim mch, nhim toan nng, h K+ mu, h ng huyt nn phi truyn nc ngay. + Ph no b. + Bnh nhn hn m nng v nm lu c th b xp phi, lot da, nhim trng tiu. 347

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4.2.2. Hn m do tng p lc thm thu mu y l bin chng cp tnh thng xy ra trn bnh nhn b tiu ng ng tui khng ph thuc insulin. Bnh xy ra ngi trung nin, ngi gi c ng huyt cao ko di km vi tnh trng kit nc m bnh nhn khng th ung s nc cn thit b li. Bnh nhn thng sng mt mnh, b tai bin mch mu no, trc c dng li tiu, corticoid hoc lm thm phn phc mc. a. Triu chng lm sng v cn lm sng Triu chng ton pht s khng xy ra cho n khi th tch mu gim trm trng lm gim lng nc tiu. Bnh nhn hn m hoc ri lon tri gic. Run c, kinh git. C hi gng. C du kit nc trm trng c ni bo ln ngoi bo. Cn lm sng: + Glucose huyt > 10g/l. + Na+ mu > 150mEq/l. + Cl mu > 110 - 115mEq/l. + K+ mu gim. p lc thm thu mu tng n 350 - 450mobm/l (bnh thng 300 mobm/l). Ta c th tnh gn ng p lc thm thu mu nh sau: + Na mEq/l x 2 + 5,5 (i vi mi 100mg% glucose huyt). + Nu Na = 160 mEq/l; glucose huyt 100mg%. + p lc thm thu mu s l: 160 x 2 + 5,5 x 1000/100 = 375 mobm/l Th cetones khng c hay dng tnh t. Dung tch hng cu tng, m huyt tng. Trong nc tiu: ng cao, Na+ thp, K+ cao. T l t vong > 50%. 4.2.3. Hn m do h ng huyt Thng do bnh nhn dng insulin hoc sulfamid h ng huyt qu liu. Dng thuc m khng n hoc chm gi n, hot ng nhiu ngoi chng trnh. 348

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a. Triu chng lm sng v cn lm sng Triu chng lm sng: + H ng huyt cp tnh: bnh nhn cm thy bun nn, chng mt, nhc u, m hi, hoa mt, ni ngng, l m, tim p nhanh. Nu cho 10 - 20g glucose triu chng s ht, nu khng bnh nhn s i vo hn m, c th km theo kinh git. + H ng huyt t t v nng: bnh nhn nhc u, ri lon tri gic, m mt hay ngp, ngi yu, ni kh v ngh kh, bun ng, ng lu, dn dn a n mt tri gic, hn m, nhit c th thp. Ngoi ra bnh nhn c th b git c, kinh git, ng kinh, c nhng cm gic k l hoc nhng c ng bt thng nh ma git... Cn lm sng: glucose huyt < 40mg% (< 0,4g/l). b. iu tr Tim tnh mch dung dch ng u trng 30% 50ml (25g) bnh nhn s tnh li trong giy pht, rt him khi tnh sau 1 gi. Hoc c th tim glucagon 0,5mg di da hoc tim bp, hoc tim tnh mch lp li mi 15 pht. Khi tnh li cho bnh nhn n ng. Nu h ng huyt do dng sulfamid th cn theo di lu n 3 ngy. Thc ra l mt bin chng ca iu tr, nu bnh nhn c hng dn k, theo di k, c th nga c bin chng ny. Tuy nhin trong trng hp phc tp nh tiu ng kt hp vi x gan hoc trn bnh nhn suy kit, sinh bnh l hc ca h ng huyt tr nn phc tp hn nhiu. 4.2.4. Hn m do acid lactic tng cao trong mu Xy ra trn bnh nhn ln tui, iu tr bng biguanides (phenformin) km thm yu t suy h hp cp, suy tim, kch xc, nhim trng huyt do vi trng Gram m, vim ty cp, ung nhiu ru. a. Triu chng lm sng v cn lm sng Bnh khi u mau, hn m tht s, bnh nhn c nhp th Kussmaul. Th mu: + pH mu < 7, d tr kim gim. + Acid lactic mu 10 - 20mEq/l (bnh thng 1mEq/l hoc 9mg%). + Acid pyruvic mu tng gp 3 - 4 ln bnh thng (bnh thng = 0,214mEq/l).

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+ Cl gim, K+ tng, Na+ tng. Khong trng anion tng Bnh thng khong anion l: (Na+) - (Cl + HCO ) = 10 - 20mEq/l hoc 9mg%. 3 b. Thi x tr: chuyn ngay bnh nhn vo cc trung tm cp cu chuyn khoa. 5. IU TR I THO NG 5.1. Mc tiu Cc mc tiu ny p dng cho c i tho ng typ 1 v typ 2, tu thuc vo mi loi c th c thay i t nhiu. Lm gim bt cc triu chng: + Lm sng: ung nhiu, nu c tiu nhiu. + Cn lm sng: a ng huyt v mc gn bnh thng nht, ng niu m tnh (vi ngi ln tui phng h ng huyt khi dng thuc liu cao, hoc c km theo cc nguyn nhn gy h ng huyt nh khng n c, c suy gan hoc suy thn, tng trng qu km). t c cn nng hp l gn vi hng s sinh l, i vi i tho ng typ 2 c bo ph cn lm gim cn. Lm chm xut hin cc bin chng, trnh cc bin chng nguy him nh hn m tng ng huyt, suy thn, hoi t chi do tc mch, vim vng mc..v.v. Nng cao cht lng i sng ngi bnh. 5.2. Nguyn tc iu tr iu tr c hiu qu i tho ng cn c s ng gp ca nhiu chuyn ngnh, chuyn khoa; cn c s phi hp ca nhiu phng php nh: 5.2.1. Chng trnh hun luyn bnh nhn Chng trnh ny nhm cung cp cho bnh nhn: Cc kin thc cn thit v bnh i tho ng: + Bnh thc t c th ca h h t lm ch bnh tt ca mnh. + bnh nhn c th phi hp tt vi thy thuc trong iu tr v chm sc. Cc k nng cn thit : + Nhn bit cc bin chng nguy him nh h ng huyt, nhim trng bn chn v cch phng. 350

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+ Bit cch t theo di ng huyt, ng niu (nu c iu kin). + Bit cch n ung hp vi bnh tt ca mnh. + Bit s dng insulin (i vi bnh nhn T typ 1). + Bit li ch ca rn luyn c th v cch thc hin sao cho ph hp vi tnh trng bnh ca mnh. Bnh i tho ng s c iu tr ti u khi bnh nhn c thng tin y . Chng trnh hun luyn bnh nhn cn nhn mnh ti kha cnh thc hnh v vic iu tr bao gm: Ch n. K thut theo di ng huyt v ng niu. Hot ng th lc v thi tm thn trong cuc sng. Dng thuc. 5.2.2. Ch dinh dng hp l Thc n c nhiu glucid lm cho ng huyt tng nhiu sau khi n, thc n c nhiu lipid d gy x va ng mch ngi i tho ng. V th iu c bn trong ch dinh dng ca bnh nhn i tho ng l phi hn ch glucid trnh tng ng huyt sau khi n v hn ch n lipid nht l cc acid bo bo ha Tt c bnh nhn i tho ng, khng k i tho ng typ 1 hay 2 u phi tun th ch n gim glucid Khong 10% bnh nhn i tho ng typ 2 p dng ch n gim glucid tt gip n nh ng huyt lu di hay tm thi m khng cn phi dng thuc. Nhu cu v nng lng: ngi bnh i tho ng cng c nhu cu nng lng ging nh ngi bnh thng, cng tng hay gim thay i tu theo: + Tui: tui ang ln cn nhiu nng lng hn ngi ln tui. + Theo loi cng vic nng hay nh. + Theo th trng: mp hay gy.

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Mc lao ng Tnh ti Va nng 30Kcalo/kg 35Kcalo/kg 45Kcalo/kg

Nam

N 25Kcalo/kg 30Kcalo/kg 35Kcalo/kg

Khi cn tng th trng: cho thm 300 - 500Kcal/ngy Khi cn gim th trng: tr i 500Kcal/ngy

T l cc loi thc n: + Glucid 45 - 50%. + Protid 15 - 20%. + Lipid 35%. Trong cc sch v dinh dng v iu tr, v cc sch chuyn khoa i tho ng ngi ta lp ra cc thc n vi cc mc nng lng khc nhau (tham kho thm) trnh s nhm chn dnh cho bnh nhn kh tun th ch n king, lm sao ng vt qu qu thc n cho php, c bit l qu glucid. Ngi ta cng chia thc n thnh tng loi c hm lng glucid khc nhau: + 5% glucid (gm a s cc loi rau xanh). + 10% glucid. + + 20% glucid. Ngi bnh i tho ng c th n: + Khng hn ch cc loi thc n c 5% glucid. + Hn ch i vi cc loi 10% - 20% glucid. + King hay hn ch tuyt i cc loi ng hp thu nhanh (mt, ko, bnh ngt, nc ngt, tri cy kh). + Cn m bo vitamin, cc yu t vi lng (st, iod) v si x... cc loi ny thng c nhiu trong rau ti, v tri cy, go khng gi k... c tc dng chng to bn; gim tng ng huyt, cholesterol, triglycerid sau ba n. + Cc cht to v ngt: m bo khng dn ti hin tng chn n ngi gi c th dng cc cht to v ngt. Cc cht ny thng c ngt cao hn nhiu ln so vi ng thng dng l sucrose, mt s cht b ph hy khi un nng, mt s cht c d v ng, c dng ph bin hin nay c saccharin, aspartam... Cc cht ny khng cung cp thm nng lng hoc rt t khng ng k, c th c dng thay th cho ng glucose.

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Thay i ch n l quan trng vi tt c mi loi i tho ng k c vi bnh nhn km dung np ng: + Cc mc tiu ca iu tr bng ch n khc nhau ty thuc vo:

Typ tiu ng. Tnh trng bo ph. Lng m bt thng trong mu. C cc bin chng ca tiu ng. ang c iu tr ni khoa. V c theo s thch, kh nng ti chnh v yu cu ca bnh nhn.

+ Cc mc tiu ca calo t ra cn phi t c v gi vng cn nng l tng, gim calo ch t ra khi bnh nhn qu bo. + Gi vng thnh phn v thi gian n l quan trng, nht l i vi bnh nhn dng mt ch insulin hoc thuc sulfamid h ng huyt c nh. + Thnh phn mn n: thnh phn dinh dng ti u cho ngi tiu ng khng c nh. S quan tm khng ch v thc n nh hng ti ng huyt m cn lm gim x va ng mch v cc bin chng mn tnh khc.

Hydrat carbon (55 - 60%): l cht ch yu cung cp calo n vo. Thc n c lng ng cao phi hn ch nhng vn phi c cn bng ba n. Protein (10 - 20%): cung cp bilan nitrogen v tng trng. i vi cc bnh nhn c bin chng thn phi gii hn lng protein. M (25 - 30%): phi ht sc hn ch. Lng cholesterol n vo phi di 300mg v m bo ha phi thay bng nhiu loi m khng bo ha. Thc n c si 25g/1000Kcal c th lm chm s hp thu ng v gim tng ng sau khi n. Thc n c cha si gm u, rau, thc n c cha keo, cm, c th lm gim ng ng thi h cholesterol ton b v lipoprotein t trng thp (LDL). Cc cht ngt nhn to c th dng thay ng trong nc ung v mt s thc n. Aspartam v saccharin gip lm gim lng ng n vo m vn gi c ngon ming.

+ Cn hn ch ru:

Ru c ch hnh thnh glycogen gan v c th lm h ng huyt bnh nhn dng insulin hoc thuc h ng huyt.

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Ru lm tng triglycerid cp v mn, lm ri lon chuyn ha cht sulfamid. Ru c cha ng cng c th gy tng ng huyt. Ru lm thng tn h thn kinh nng hn.

Y hc c truyn cng rt ch n vn tit ch trong iu tr tiu kht:

Hn ch cc cht cao lng m v; gim n cc cht cay, bo, ngt. Nn n nhiu cht hoa qu rau xanh, gi u, b, ng, nn ung nc tr xanh hng ngy. Gim m trnh n tr, hi t v, khng c li cho ngi bnh. Tuyt i king ru v thuc l, v ru tnh n v cay pht tn vo c th lm hao thm tn dch vn c trn bnh nhn, do lm tng bnh v d gy bin chng.

5.2.3. Rn luyn c th hay phng php tp luyn cho ngi bnh i tho ng Khi dng phng php ny cn ch v n va c li li va c hi. ngi bnh thng: vic s dng ng tng ln khi c bp hot ng, ng s c cung cp do c iu ha sn xut ng gan. Cn bng ny c insuline iu chnh. ngi i tho ng: khi tp luyn ng huyt tng ln r rt v tnh trng nhim ceton c th xy ra khi bnh tiu ng khng c kim sot tt, hoc s h ng huyt c th nng do lng insulin a vo nhiu hoc insulin tit ra do tc dng kch thch ty ca thuc ung h ng huyt. Mt k hoch n cn trng v c nh mc l rt cn thit khi bnh nhn ang c iu tr insulin ng thi vi vic tng hot ng hay th tp luyn nng. Tp luyn nng c th hi cho bnh nhn i tho ng; tng nguy c bin chng mn nh tim mch, thn kinh v vng mc. phng cn nh gi tnh trng tim mch trc khi cho ch tp luyn v sn sc cn thn khi tp luyn. Rn luyn c th c tc dng tt, nhng cn c s phn bit gia i tho ng typ 1 v i tho ng typ 2, ngi bnh c th tham gia hu nh tt c mi hot ng th dc th thao. Nhng luyn tp phi ph hp vi tui tc sc khe v s thch. + Nn tp nhng mn rn luyn s do dai, dai sc nh i b, i xe p, bi li hn l nhng mn i hi th lc cao nh nng t + Nn tp theo nhm (dng sinh, thi cc quyn) c th ng vin v kim tra gip ln nhau. 354

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+ Bi tp nn nh nhng lc u, v sau tng dn, trnh qu sc v nn c s theo di ca thy thuc. Trc khi tp cn ch : + nh gi s kim sot ng huyt. + Bnh nhn c hay khng c cc bin chng ca i tho ng. + Khm tim mch, lm in tm gng sc nu cn. + Khm bn chn: nh gi bnh l thn kinh, nh gi tnh trng tun hon ngoi bin nu c. + Khm mt, nu c vim vng mc tng sinh phi i cho n khi iu tr n nh. Rn kuyn c th i vi i tho ng typ 1: trng hp ny s khng ci thin ng k mc ng huyt nhng vn c tc dng tt nh: + Lm gim VLDL, LDL v tng HDL cholesterol. + Ci thin hot ng tim mch. + Gim huyt p. + Lm tinh thn sng khoi. Rn kuyn c th i vi i tho ng typ 2: Trong i tho ng type 2, rn luyn c th c tc dng iu chnh ng huyt thng qua c ch lm gim tnh trng khng insulin. Tc dng tt ca rn luyn c th i vi i tho ng type 2 l ci thin kim sot ng huyt do: + Lm gim s tha cn. + Lm gim s khng insulin v tc dng tt nh i vi i tho ng typ 1. Bnh nhn i tho ng typ 2 nu ch iu tr n thun bng ch dinh dng th khng phi lo lng v vic h ng huyt xy ra khi tp luyn, nhng nu iu tr bng cc sulfamid gim ng huyt th cng cn ch tnh trng h ng huyt vn c th xy ra, nu khng ch tun th cc quy nh dng thuc hay n ung. YHCT trong bnh ny khuyn ngi bnh tp dng sinh nh nhng, th gin, i b vn ng nh nhng mi ngy. Tuyt i gi c th khng b chn thng xy xt ngoi da. 5.2.4. Thi tinh thn trong cuc sng T to cho mnh cuc sng thoi mi c v th xc ln tinh thn, trnh khng tc gin thi qu, cng thng qu lm can kh ut kt, ut tr sinh nhit ha to thng m s sinh ra kht nhiu, hay i; hoc vui mng thi 355

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qu, thn tn sinh nhit thiu t chn m, lo ngh nhiu hi t, lo s nhiu hi thn... 5.2.5. iu tr dng thuc Gm iu tr bng insulin, hoc thuc ung h ng huyt sulfonylure. La chn thuc phi cn nhc cn thn ti tc dng ph c th tn hi ti vic iu tr bnh v lm nng ln cc bin chng ca tiu ng. Nhng vic iu tr l bt buc khi c ch nh chc chn. Phi theo di ng huyt nhiu ln khi thay i liu lng hoc ngng (gin cch) bt c loi thuc no. Dng thuc lm gim ng huyt i vi T typ 1, cn n chuyn gia v ni tit c iu chnh ng huyt bng insulin v cc ch theo di nghim nht trong iu tr v phng trnh cc bin chng. i vi T typ 2: dng phc iu tr sau:
Khng dng thuc (dinh dng, rn luyn c th) ng huyt khng kim sot n tr liu (iu tr cc bin chng km theo nu c):

Sulfonylurea Biguanid c ch -glucosidase Insulin ng huyt khng kim sot

Tr liu phi hp:


Sulfonylurea + biguanid Sulfonylurea + insulin Sunfonylurea + c ch -glucosidase Kch thch cell tit insulin

Thuc sunfonylurea c ch khng insulin Tng nhy cm ca m ngoi vi i vi insulin Thuc biguanid Gim s thm n

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5.3. iu tr c th Tu thuc vo lng ng huyt, tu thuc vo giai on biu hin v bin chng ca bnh m c quyt nh chn la cch phi hp thuc. 5.3.1. Khi bnh nhn c lng ng huyt 6,5mmol/l (120mg/dl) v 7mmol/l (126mg%/dl) Ch n: tit ch cc loi thc n cung cp ng. Tp luyn theo thi quen v s thch nh i b, bi li, nh cu, tp dng sinh, thi cc quyn, khiu v. phng cc bin chng. Theo di ng huyt thng xuyn: sau khi p dng cc ch theo di ng huyt mi tun 1 ln t nht 2 tun lin tip (nu n nh sau mi thng) nh gi s n nh ca ch iu tr thch hp cha, nu lng ng huyt vn cha tr v mc bnh thng th cn ch ch n nghim ngt hn trc khi ngh ti vic dng thuc dng thc n nh ung cc loi tr dc tho thay cho nc thng nh: tr kh qua, da di, v sa t, cam tho nam 5.3.2. Khi bnh nhn c ng huyt 126mg/dl hoc 7mmol/l v 180mg/dl c chn on l i tho ng typ 2, cha c bin chng Ch n: tit ch cc loi thc n cung cp ng. Tp luyn. phng cc bin chng. Theo di ng huyt thng xuyn. Dng thuc. a. i vi th khng c kim chng hoc bin chng Php tr: dng m thanh nhit. Nhng bi thuc v cng thc huyt s dng: + Bi thuc 1: bi thuc nam kinh nghim (gm: kh qua 65g, l a 35g). Bi thuc c GS Bi Ch Hiu cu to theo kinh nghim ca dn gian v nghin cu ghi nhn tc dng h ng huyt c trn thc nghim ln lm sng trn bnh nhn T typ 2 cha c bin chng c ng huyt 120mg 140mg%. Bi thuc c tip tc nghin cu 2 dng thuc l vin nn v tr, dng tr thng dng v ph bin hn c dng nh mt loi thc phm ung hng ngy cho ngi b T gip n nh ng huyt khi a c ng v mc bnh thng. 357

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+ Bi thuc 2: bi Tri b a hong hon gia v (gm: sinh a 20g, tri mu 12g, hoi sn 20g, hong b 12g, sn th 10g, mch mn 12g, n b 12g, sa sm 12g, phc linh 12g, ng v t 4g, trch t 12g): phng thuc ny c b c t, kim tr tam m, tr m h ha vng triu nhit, l phng thuc dng m thanh nhit mnh m. Phn tch bi thuc
V thuc Sinh a Hoi sn Mch mn Sa sm Sn th n b Phc linh Trch t Tri mu Hong b Ng v t Tc dng T m, thanh nhit, b can thn Sinh tn, ch kht B ph m, dng v, sinh tn Dng v, sinh tn Thanh t can ha T Thn, t ha Thm thp, ha t Thanh t nhit Thanh t nhit ha Thanh t nhit ha Lim ph t thn, sinh tn, lim hn Vai tr Qun Qun Thn Thn T T T T T T T

Ngoi ra, theo ti liu Trung dc ng dng lm sng (Y hc vin Trung Sn) do GS Trn Vn K lc dch c nu: Nc sc sinh a c tc dng h ng huyt r trn sc vt thc nghim c ng huyt cao, cng c th lm cho ng huyt bnh thng ca th h thp. Nc sc tri mu c tc dng khng khun mnh trn cc loi trc khun thng hn, trc khun ng rut, t cu khun v tc dng h ng huyt trong th ph v to nhit. Nc sc sn th c tc dng c ch t cu vng, trc khun l v h ng huyt trn thc nghim. Ng v t trn thc nghim c tc dng tng chc nng ca t bo min dch; gia tng qu trnh tng hp v phn gii glycogen, ci thin s hp thu ng ca c th. + Bi thuc 3: Hong lin hon (gm: sinh a 40g, thch cao 12g, th hong lin 30g) c tc dng dng m thanh nhit. Phn tch bi thuc: 358

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V thuc Sinh a Hong lin Thch cao

Tc dng T m ging ha, lng huyt sinh tn, nhun to Thanh t nhit ha Thanh nhit lng huyt

Vai tr Qun T Thn

b. i vi th lm sng biu hin ph m h r Php tr: dng m, nhun ph. Nhng bi thuc v cng thc huyt s dng: + Bi Tri b a hong hon gia v (gm: sinh a 20g, tri mu 12g, hoi sn 20g, hong b 12g, sn th 10g, mch mn 12g, n b 12g, sa sm 12g, phc linh 12g, ng v t 4g, trch t 12g, gia thm thch cao 40g): ch tr bi ny l thin v ph v nhit qu lm tn hao tn dch. + Bi Thin hoa phn thang (gm: thin hoa phn 20g, sinh a 16g, mch mn 16g, cam tho 6g, ng v t 8g, go np 16g). Phn tch bi thuc:
V thuc Thin hoa phn Sinh a Mch mn Cam tho Ng v t Go np sao Tc dng Sinh tn dch, h ha, nhun to T m ging ha, lng huyt, sinh tn, nhun to B ph m, sinh tn Gii c trng v, iu ha cc v thuc Lim ph, t thn, sinh tn, lim hn Dng v, tr t Vai tr Qun Qun Thn S T T

+ Bi Bch h gia nhn sm thang (gm: thch cao 30g, tri mu 12g, ngnh m 8g, cam tho 6g).
V thuc Thch cao Tri mu Ngnh m Cam tho Tc dng Thanh nhit phn kh ca dng minh Gip thch cao t m thanh nhit ph v ch v, bo v tn dch Gii c trng v, iu ha cc v thuc Vai tr Qun Thn T T, s

c. i vi th lm sng thin v v m h r Php tr: dng v, sinh tn. 359

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Nhng bi thuc: + Bi Tri b a hong hon gia v (gm: sinh a 20g, tri mu 12g, hoi sn 20g, hong b 12g, sn th 10g, mch mn 12g, n b 12g, sa sm 12g, phc linh 12g, ng v t 4g, trch t 12g) Gia thm hong lin 16g. + Bi Tng dch thang gia gim (gm: huyn sm 20g, sinh a 20g, mch mn 16g, thin hoa phn 16g, hong lin 16g, i hong 8g).
V thuc Huyn sm Sinh a Mch mn Thin hoa phn Hong lin i hong Tc dng Mn, hi ng, hn; vo ph, v, thn: thanh nhit, lng huyt, t ha, gii c, sinh tn dch, tn kt Ngt, ng, hn; vo tm, can, tiu trng, thn: thanh nhit, lng huyt, dng m, sinh tn Ngt, hi ng, hi lnh; vo ph, v: nhun ph, sinh tn, li niu Ngt, chua, hn; vo ph, v, i trng: sinh tn ch kht, ging ha, nhun to, bi nung, tiu thng ng, hn; vo tm, can m, i trng, v: thanh nhit, to thp, thanh tm Vai tr Qun Thn Thn Thn, T T

d. i vi th lm sng thin v thn m h, thn dng h Php tr: t m, b thn, sinh tn dch (cho thn m h); n b thn, sp niu (cho thn dng h). Nhng bi thuc: + Bi Tri b a hong thang gia gim (gm: sinh a (hoc thc a) 20g, k t 12g, hoi sn 20g, sa sm 8g, sn th 8g, thch hc 12g, n b 12g, thin hoa phn 8g). + Bi Bt v qu ph gia gim (gm: thc a 20g, tang phiu tiu 12g, hoi sn 20g, kim anh t 12g, n b 12g, khim thc 8g, trch t 12g, sn th 8g). e. i vi th m thp Php tr: ha m, ging trc. Bi thuc: + Bi Bn h bch trut thin ma thang (gm: bn h 10g, trn b 6g, bch trut 20g, phc linh 6g, thin ma 6g, cam tho 4g). 360

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Phn tch bi thuc


V thuc Bn h Bch trut Phc linh Trn b Thin ma Cam tho Kin t, to thp Kin t, l kh, tr thp Kin t, l kh, to thp, ha m Ha m tc phong n trung, ha v Tc dng Tiu m thp, ging kh nghch Vai tr Qun Thn Thn Thn T S

f. i vi th c kim chng (hoc bin chng) Dng cc ch n v tp luyn nh i vi th khng c kim chng. Hi hp mt ng do m h, tn dch tn thng: + Php tr: ch kh, dng huyt, t m thanh nhit. + Bi thuc: Bi Thin vng b tm n (gm: sinh a 30g, ng v t 6g, nhn sm 6g, ng quy 15g, huyn sm 6g, thin mn 15g, n sm 6g, mch mn 15g, phc thn 6g, b t nhn 15g, vin ch 6g, to nhn 12g, ct cnh 6g, chu sa 6g).
V thuc Sinh a Huyn sm an sm ng quy ng sm Phc linh B t nhn Vin ch Thin mn Mch mn Ng v t Toan to nhn Ct cnh Chu sa Tc dng Ngt, ng, hn: dng m, dng huyt ng, mn, hi lnh: thanh nhit, dng huyt, gii c, ging ha ng, lnh: hot huyt, kh Ngt, cay, m: b huyt, hnh huyt Ngt, bnh: b dng t v Ngt, bnh: b t th, nh tm, li thy Ngt, bnh: b huyt, kin t, an thn ng, m: b tm thn, an thn Ngt, lnh: thanh tm nhit, ging ph ha Ngt, ng, lnh: nhun ph, sinh tn dch Mn, chua, m: lim hn, c tinh Ngt, chua, bnh: dng tm an thn, sinh tn dch ng, cay, m: iu ha cc v thuc Ngt, lnh: an thn, trn kinh, dn thuc vo tm Vai tr Qun Qun Thn Thn Thn Thn Thn Thn T T T T S S

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Chng u vng: + Php tr: bnh can tim dng (m h, dng xung); ha m, ging nghch (m trc). + Nhng bi thuc: Bi Thin ma cu ng m (gm: thin ma 9g, thch quyt minh 18g, cu ng 12g, tang k sinh 12g, hong cm 9g, sn chi 9g, ngu tt 12g, ch mu 9g, trng 12g, phc thn 9g): dng trong trng hp bnh can, tim dng.
V thuc Thin ma Cu ng Hong cm Chi t Tang k sinh H th trng Phc linh ch mu Thch quyt minh Ngu tt Tc dng Ngt, cay, hi ng, bnh: thng thanh, ging trc, tn phong, gii c Ngt, hn: thanh nhit, bnh can, trn kinh ng, hn: t ph ha, thanh thp nhit ng, hn: thanh nhit t ha, li tiu, cm mu ng, bnh: b can thn, mnh gn ct B huyt thm tinh Ngt, n, hi cay: b can thn, mnh gn ct Ngt, nht, bnh: li thy, thm thp, b t nh tm Cay, ng, hn: thng huyt, iu kinh Tr st cao, n khng tiu: thanh nhit Chua, ng, bnh: b can thn, tnh i xung Vai tr Qun Qun Thn Thn Thn Thn Thn T T T Thn, t, s

Chng nht, lot l thng hay ti pht, kh khi, rng li sng au: + Php tr: thanh nhit gii c. + Nhng bi thuc: Bi Ng v tiu c m (gm: kim ngn 20g, huyn sm 15g, cc hoa 20g, h kh tho 15g, b cng anh 15g). Phn tch bi thuc:
V thuc Kim ngn hoa Huyn sm Cc hoa H kh tho B cng anh Thanh nhit, gii c T m, ging ha, lng huyt, gii c Thanh nhit, gii c, tn phong Thanh can ha, tn ut kt Gii c, tiu vim, thanh nhit Tc dng Vai tr Qun Thn T T T

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Chn tay t di, mt mi, c teo, u chn tay t di i khng vng: + Php tr: dng m, thanh nhit, b huyt, thng lc. + Bi thuc T vt ng ng thang: Sinh a Bch thc K huyt ng Nhn ng ng 20g 12g 12g 10g ng quy Xuyn khung Lc thch ng Cu ng 10g 10g 10g 10g

Khp xng au nhc, bp tht mi r, t b: + Php tr: thanh nhit, sinh tn, thng lc, ho dinh. + Bi thuc: Bch h nhn sm gia qu chi. Ngoi ra, i vi loi i tho ng c ng huyt cao trong mu, c hin din ng trong nc tiu v nhiu bin chng nn kt hp vi cc chuyn gia ni tit hc theo di v iu tr cho bnh nhn. 5.3.3. iu tr bng chm cu Thn trng khi s dng chm cu trn bnh nhn i tho ng, cn v trng ng cch trc v sau chm, hn ch cu. Th chm: c th chn cc huyt sau: + Kht nhiu: ph du, thiu thng. + n nhiu: t du, v du, tc tam l. + Tiu nhiu: thn du, quan nguyn, phc lu, thy tuyn. Nh chm: + Ung nhiu: ni tit, ph, v. + n nhiu: ni tit, v. + Tiu nhiu: ni tit, thn, bng quang. Chm cch nht hoc hng ngy, lu kinh 15 - 30; hoc dng kim nh hon gi kim 3 ngy, i bn. Mai hoa chm: g dc bng quang kinh 2 bn ct sng t ph du n bng quang du, kch thch va, mi ln 5 - 10, g cch nht hoc hng ngy. 5.3.4. Kinh nghim dn gian n gin tr tiu ng Bi thuc kinh nghim: kh qua 55g, r 25g, l a 20g. Cng thc trn c nghin cu t thc nghim n lm sng, vi liu lng trn c th dng mi ngy cho bnh nhn i tho ng c km theo bin chng nhim trng tiu, vim hng mn. 363

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Kt qu nghin cu ghi nhn bi thuc c tc dng h ng huyt i vi bnh nhn c ng huyt lc i > 120mg% nhng di < 190mg% sau 4 tun dng thuc. Ngoi ra i vi bnh nhn c lng ng cao hn c th phi hp vi cc thuc h ng huyt ca Ty y, khi ng huyt n nh tip tc dng, khng ghi nhn tc dng gy h ng huyt. Nhng kinh nghim dn gian khc: B ao: 100g nu si, gi nt vt nc ung thng xuyn hng ngy. Rau cn ty: 100g nu si, gi nt vt nc ung ngy 2 ln. Rau ng t n cm hng ngy. C ci 5 c, go t 150g; c ci nu chn vt ly nc cho go vo nu n thng xuyn. Tri kh qua 250g, tht 100g: nu canh n. Ty heo 250g, hoi sn 120g, thin hoa phn 120g: ty heo gi nt trn vi bt thuc. V trng r du, go np rang phng, mi th 50g, sc ung hng ngy.

T lng gi Cu hi 5 chn 1 : chn cu ng 1. Nguyn nhn no sau y sinh T theo YHCT

A. Do n nhiu cht bo, ngt tch nhit ha ha thiu t chn m B. Do thn ch tht iu, ng ch cc ut ha ha thiu t phn m ca ng tng C. Do tin thin bt tc hoc thin qu suy, m tinh hao tn D. Do ho nhit lu tch li, c th sn c m h E. C 4 cu trn u ng
2. Ho nhit lu tch lu ngy, nu gp c th c thin qu suy d sinh T th

A. Ph- i trng thuc thng tiu B. T-v thuc trung tiu C. Thn thuc h tiu D. Thn m h
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E. C th c 3 th ph, t, thn
3. Triu chng c trng ca T th v m h l

A. Kht nhiu, ung bao nhiu vn khng kht B. Kht nhiu v i tiu nhiu C. Thm n, n nhiu m vn gy kh D. n nhiu, ung nhiu v kht nhiu E. n nhiu, ung nhiu, kh tiu
4. V thuc ng v t trong bi Tri b a hong hon gia v (gm sinh a, hoi sn, sn th, n b, phc linh, trch t, ng v t, tri mu, hong b, mch mn, sa sm) c tc dng

A. Lim ph, t thn: vai tr thn B. Lim ph, sinh tn: vai tr thn C. Lim hn, sinh tn: vai tr t D. Lim ph, t thn, sinh tn lim hn: vai tr thn E. Lim ph, t thn, sinh tn, lim hn: vai tr t
5. V thuc huyn sm trong bi thuc Ng v tiu c m (gm kim ngn, cc hoa, huyn sm, h kh tho, b cng anh) c vai tr v tc dng

A. Thanh nhit, lng huyt, gii c: vai tr qun B. Thanh nhit, lng huyt, gii c: vai tr thn C. T m, ging ho, lng huyt, gii c: vai tr thn D. T m, ging ho, lng huyt, gii c: vai tr qun E. T m, ging ho, lng huyt, gii c: vai tr t
6. V thuc huyn sm trong bi Tng dch thang (gm: sinh a, huyn sm, mch mn, thin hoa phn, hong lin, i hong), iu tr tiu kht th v m h c tc dng v vai tr

A. Thanh nhit, lng huyt, sinh tn, ch kht: vai tr qun B. T m, nhun huyt, sinh tn: vai tr qun C. T m, nhun huyt, sinh tn: vai tr thn D. T m, thanh nhit, nhun to: vai tr t E. Nhun h, sinh tn, ch kht: vai tr thn
7. Bi thuc thin vng b tm n (gm: sinh a, nhn sm, huyn sm, n sm, phc thn, vin ch, ct cnh, ng v t, ng quy, mch mn, b t nhn, to nhn, chu sa) c ch nh iu tr T th 365

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A. Ph m h B. V m h C. Thn m h D. C kim chng hi hp mt ng E. C kim chng u chong mt hoa


8. Huyt thiu thng thng c chn iu tr T th c triu chng no sau y tri hn

A. Ph m h vi kht nhiu B. V m h vi thm n nhiu C. Thn m h vi tiu nhiu D. V m h c kim chng kht E. Thn m h c kim chng kht
9. Bi thuc dng m thanh nhit (gm: sinh a, thch cao, th hong lin) v th hong lin c tc dng

A. T m, ging ha: vai tr t B. Thanh nhit, lng huyt: vai tr t C. Thanh nhit, t ha: vai tr t D. Thanh t nhit, trit c: vai tr t E. Thanh t nhit ha: vai tr thn
10. Bi thuc ng v tiu c m (gm: kim ngn, cc hoa, b cng anh, huyn sm, h kh tho) ch nh iu tr T c kim chng

A. To, kh kht, tiu t sn B. D y bng, bun nn, to bn ra mu C. m h tiu bn sinh l nht, li , ru vng D. L lot hay ti pht, rng li sng au, li E. C th ch nh c 4 trng hp trn

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Bi 20

BNH BO PH

MC TIU 1. Nu c nh ngha, c im dch t hc v cc phng php nh gi bo ph. 2. Trnh by c nguyn nhn, bnh sinh v phn tch c sinh bnh hc ca bo ph theo YHH. 3. Trnh by c chn on bo ph cng cc nguy c v bin chng ca n. 4. Nu c cc nguyn tc v cc phng php phi hp trong iu tr bo ph. 5. Trnh by c ng dng iu tr 4 th lm sng bo ph theo YHCT. 6. Phn tch c cc bi thuc p dng iu tr bo ph.

1. I CNG 1.1. nh ngha Bo ph l tnh trng d tha khi m, l mt hi chng c trng bi s tng tuyt i ca khi m, hay ni cch khc l mt s lm pht ca d tr nng lng, ch yu l triglycerid di dng m m. Bo ph l mt tnh trng bnh l a yu t. C s lin quan cht ch gia bo ph v tnh trng dinh dng qu mc m khng hp l. Cc cng trnh nghin cu ngy cng chng minh rng bo ph l mt yu t lm tng t l bnh tt, tng t l t vong, gim nng sut lao ng. 1.2. c im dch t hc Bo ph l mt bnh v dinh dng thng gp v c nhiu hng gia tng khp mi ni trn th gii, nht cc nc cng nghip pht trin c ti 20% dn s b bo ph. Tn sut thay i theo: 367

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Tui: 2% lc 6 - 7 tui; 7% lc tui dy th v cao nht xut hin la tui 50. Tuy nhin ngy nay ngi ta ghi nhn t l ngy cng tng cng ng tr em. Gii: thng gp n gii nhiu hn nam gii, tn sut 25% gii n v 18% gii nam. a d: c nhng vng bo ph gp nhiu hn vng khc, ngay trong mt nc cng vy, nh Php t l min ng nc Php l 33% cn min Ty ch c 17% v Paris l thp nht. iu kin kinh t x hi: bo ph c lin quan n ch dinh dng, phong cch sng. 1.3. nh gi bo ph Khi c th mp, cn nng tng ln tc khi m cng tng ln. nh gi bo ph ch yu l nh gi s gia tng ca khi m. Cn nng l tng: l cn nng ph hp vi la tui, gii, so vi chiu cao. Cn nng l tng thay i tu theo chng tc, a l v l mt hng s sinh l ch ph hp trong nhng iu kin nht nh. Cc phng php nh gi cn nng: Cc phng php nhn trc hc: + o np da vng c tam u bng dng c c bit: nu kt qu > 20mm nam v > 25mm n l c bo ph. + o chu vi vng eo (ngang qua rn) chia cho chu vi vng i (ngang hng ch i to nht) tnh t l c lng s phn b m trong c th. T l 1 i vi nam v 0,8 i vi n l c bo ph. Cng thc Lorentz c xc lp qua nhng cng trnh nhn trc hc, cc thng k nhiu nm ca cc hng bo him y t
Cn l tng = chiu cao (cm) 100 chiu cao (cm) 150 (N = 4 nam v = 2,5 n) N

Ch s khi c th (hay cn gi l ch s Quetelet): Body Mass Index (BMI): c tnh bng cn nng (kg) chia cho bnh phng chiu cao (m). BMI bnh thng nam l 23 - 25 (trung bnh 25); n l 18,7 - 23,8 trung bnh l 21 theo WHO. BMI > 27 l bo ph, v BMI > 30 l bo ph bnh l. Vit Nam theo Vin Dinh dng H Ni: BMI = 19,72 2,81 cho nam v = 19,75 3,41 cho n 368

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1.4. Quan nim ca YHCT v bo ph Theo YHCT hnh th con ngi phn thnh 3 loi l: ph, cao v nhc (nhn hu ph, hu cao, hu nhc). Gii thch 3 loi th tng ngi nu trn nh sau: Quc nhc kin, b mn gi, ph. Quc nhc bt kin, b hon gi, cao. B nhc bt tng ly gi, nhc. Bnh bo ph theo YHCT khng lin quan n th trng ph, cao, nhc nu trn, m ni n tnh trng mp vt qu mc bnh thng thng do nguyn nhn n ung khng cn i (khng qun bnh) hoc sau khi mc cc bnh ni thng sinh ra. 2. NGUYN NHN, BNH SINH 2.1. Nguyn nhn a s bo ph l tin pht v c lin quan n di truyn, nm 1995 tm c gen gy bo ph (M). 2.1.1. Di truyn Khong 69% ngi bo ph c cha hoc m bo ph; 18% c cha v m u bo ph; ch c 7% l bo ph m cha m c cn nng bnh thng. Phn nh gia vai tr ca di truyn v vai tr ca dinh dng tht s cn cha r. 2.1.2. Ni tit Tn thng vng h i gy n nhiu: vng h i c vai tr iu ha n ung, vai tr ca nt leptine - neuropeptide Y (NPY) NPY l mt neuropeptid t vng h i, l cht kch thch n mnh nht. S tit cht ny c iu ha mt phn bi leptin c ch s tit NPY. Leptin l mt hormon do m m tit ra, thng tin cho vng h i v mc khi m, do n l mt ch im. Trong mt s trng hp ngoi l bo ph gia nh, ngi ta cng ghi nhn t bin gen leptin v th th ca n. Suy sinh dc gim gonadotropin hormon gy hi chng mp ph - sinh dc (Babinski - Froehlich). Suy gip. Cng v thng thn (Cushing). 369

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U ty tit insulin, thng l u lnh, mp l do insulin lm h ng huyt i phi n nhiu. 2.1.3. Do cc bnh him gp Hi chng Laurence - Moon - Biedl - Bardet. Hi chng Prader - Willi. 2.2. Sinh bnh hc ca bo ph Bo ph ch xy ra khi c s mt qun bnh gia cung cp thc n v tiu tn nng lng, khi s cung cp nng lng vt tri hn s tiu hao nng lng lm cho cn cn thu - chi nng lng lun mt cn i theo chiu hng tch t li v ng. Hay ni mt cch khc hn l s mt cn i trong cch n ung v s chm tr trong chuyn ha nng lng. 2.2.1. Mt cn i trong cch n ung n qu mc cn thit v thc n t thay i, qu nhiu cht bo, t thc n loi sinh nhit nhanh (protid). Nguyn nhn ca s mt cn i ny c th do mt ri lon ti h i: trung tm ch huy cm gic i - no, mt s gim tit serotonin m hu qu l lm mt cm gic no. 2.2.2. Chm tr trong chuyn ha nng lng Nguyn nhn ch yu l t hot ng th lc. Tuy nhin 2 yu t ni trn biu hin vi nhiu mc khc nhau: y nh trng hp ngi n nhiu v chuyn ha gim. Khng y l trng hp ngi n t, nhng chuyn ha li chm tr nhiu. 3. CHN ON 3.1. Chn on theo y hc hin i 3.1.1. Chn on xc nh Bo ph c xc nh khi BMI > 27. Bo ph c xc nh khi cn nng > 20% cn nng l tng l thuyt (cng thc Lorentz). Nhm nhn din c s pht trin nh hng ca bo ph i vi: + C, xng, khp: long xng, bin dng xng khp, thoi ha khp. 370

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+ Tim mch: tng HA, vim tc ng mch chi di. + H hp: suy h hp, vim ph qun mn, hi chng Pickwick. nh gi bo ph: + nh gi bo ph qua ch s BMI nh sau:
BMI I II III IV 25-30 31-35 36-40 > 40 Lm sng Tha cn Bo ph nh Bo ph va Bo ph nng

+ Xc nh kiu bo ph: Kiu nam: m m tp trung na trn c th: c, vai, tay, bng. Kiu n: m m tp trung phn di c th: eo, mng, i. Cn lm sng: thc hin nhm mc ch chn on cc nguy c trn bnh nhn bo ph. Cc xt nghim thng quy bao gm: + Cholesterol mu (ton phn, HDL, LDL), triglycerid mu. + Chc nng gan. + Chc nng thn. + ng huyt, acid uric, phosphokinase. Nghim php tng ng huyt nu c nghi ng 3.1.2. Chn on phn bit Ph: + Do suy tim, do hi chng thn h, do x gan cn c vo bnh cnh lm sng. + Ph chu k khng r nguyn nhn: c lin quan n chu k kinh nguyt, yu t tm l v thay i s cn trong ngy. Hi chng Cushing: + Lp m khu tr mt - c - thn ch khng ng u. + Lng cortisol mu bui sng (8 gi) thng cao do cng thng thn chc nng c ch c bng nghim php Nugent, chu k tit cortisol trong ngy vn bnh thng tc khng tng vo bui chiu. + U m: khng tng cn, khi m khu tr, bin dng (phi phu thut). 371

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3.2. Chn on theo y hc c truyn 3.2.1. Bo ph th m thp nhit Th trng mp, chn tay nng n. Ngc bng y kh chu. hi, nut chua. Chng mt, nng u. Tiu t, mu vng sm; n mau i, ming kht, thch ung mt. Cht li , ru vng dy. 3.2.2. Th can vng, t suy Th trng mp bu, bng to trng y, ngc nng. Tiu tin rt t. i tin khng d chu. Chng mt. 3.2.3. Th v nhit, trng to Th trng bo mp. n nhiu mau i. Kht nc hay ung. Chng mt, mt . i tin to kt. 3.2.4. Th can thn m h Th trng bo mp. Chn tay thng trng, yu sc. Chng mt hoa mt. tai, lng mi. Cht li ti. Mch huyn hot. 4. BIN CHNG 4.1. Tng nguy c t vong Do cc bin chng chuyn ha: i tho ng, tng lipid mu. 372

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Do bnh thng din tin nng trn ngi bo ph nh: + Trong ngoi khoa: nguy c khi gy m, hu phu (vim tnh mch, bi nhim). + Trong ni khoa: nhim khun nng. + Trong sn khoa: sinh kh. 4.2. Bin chng chuyn ha Chuyn ha glucid: c tnh trng khng insulin, tng tit insulin pht hin qua test dung np glucose b ri lon, d dn n bnh i tho ng. Chuyn ha lipid: triglycerid mu thng tng trong bo ph, tng VLDL. S tng lipoprotein c lin quan n ri lon chuyn ha glucid ni trn lm cho gan sn xut nhiu VLDL hn. Cholesterol mu t khi nh hng trc tip bi bo ph, nhng nu c tng cholesterol trc th d lm tng LDL, HDL thng gim khi triglycerid tng. Chuyn ha acid uric: acid uric mu thng tng c l c lin quan n tng triglycerid mu. Tng acid uric mu nng thm khi n king, cn ch n tng acid uric t ngt khi iu tr lm gim cn, c th gy cn Goutte cp tnh do thoi ging protid. 4.3. Bin chng tim mch Bn thn bo ph l mt nguy c cho cc bnh tim mch: Cao huyt p: c s lin quan cht ch gia bo ph v tng HA, tn sut cao HA tng trong bo ph bt k l phi nam hay n. HA gim khi lm gim cn. Suy mch vnh (au tht ngc, t t, nhi mu c tim): thng gp ngay c khi khng cng thm cc yu t nguy c khc (i tho ng, tng lipoprotein mu, cao HA). Suy tnh mch: do c hc, nht l n, d a n ri lon dinh dng chi di (lot cc gin tnh mch). Cc bin chng tim mch khc: suy tim tri th pht do bo ph hoc do tng HA v suy mch vnh; suy tim phi trong trng hp c suy h hp (kh th gng sc rt thng gp), tai bin mch mu no, x va ng mch. 4.4. Bin chng phi Gim chc nng h hp do nguyn nhn c gii (di ng km ca lng ngc), gim thng kh ph nang ti a gy ra gim oxy m v tng CO2 mn tnh. 373

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Trng hp nng gy hi chng Pickwick (hi chng kh th khi ng): ng g ng gt ban ngy, nhc u bui sng, tng hng cu, tng CO2 trong mu, thng gp trong cc trng hp bo ph nng, c mt cn nng gii hn m di mc hi chng ny ny mt i v ti xut hin khi cn tng trn ngng . 4.5. Bin chng xng khp cc khp chu lc cao nh u gi, khp hng, ct sng tht lng d b thoi ha. Thng tng t l hoi t do thiu mu u xng i tng ln. Thot v a m, trt t sng gy au lng, au thn kinh ta. Long xng. 4.6. Bin chng ni tit i tho ng khng ph thuc insulin (do tng insulin th pht do nhiu nguyn nhn: do tc dng ca - endorphin, hoc do gim s lng v cht lng th th insulin ngoi bin, kch thch t bo do n nhiu glucid). ng huyt c th gim khi gim cn. Chc nng ni tit sinh dc: gim kh nng sinh sn; chu k kinh ko di khng phng non, rm lng 4.7. Bin chng khc Da: nhim trng da cc np gp, nht l nhim nm. Cc nguy c ung th ha: tng t l ung th v v ni mc t cung do chuyn dng t m m v cc androgen thnh oestrogen, gy tng oestrogen tng i. ph n: hi chng bung trng a nang. Khi phu thut: gy m c nhiu nguy c. nh hng tm l x hi. 5. IU TR 5.1. Nguyn tc iu tr 5.1.1. Nguyn tc chung iu tr phi lu di, t c s gim cn, khng cn nhanh v nhiu m phi p ng c vi sc khe v nhu cu ca bnh nhn, mc tiu l t c cn nng hp l. 374

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Cn c nh trng lng mong mun, c th khc vi trng lng l tng v tc phi t c trng lng ny. Nn phi hp nhiu phng php: gim cung cp calo, p dng cc bi tp th lc, iu tr ni khoa, i khi cn phi iu tr bng phu thut i vi mt s trng hp c bit. Cc phng php tu thuc vo bn cht bo ph, cc yu t nguy c phi hp v yu cu. Khi ch nh iu tr dng thuc bt buc phi tht thn trng trc cc bnh nhn c bo ph lu, n nh, khng bin chng cng khng c yu t nguy c, khng tin s gia nh v chuyn ha. Ch nh iu tr khn cp khi c tng HA, suy tim, suy h hp, trm cm hoc khi c nhng xung t cm xc cp tnh. Cn theo di u n khi iu tr (thng l mi thng) c th iu chnh iu tr. 5.2.2. Cc phng php iu tr a. Gim cung cp calo Gim ch cung cp ngu nhin 1/4 - 1/3 nhng khng di 1200Kcal/ ngy ti nh, st cn 2 - 3kg/thng. Ch thng ngy l: gim glucid, gim lipid v tng protid. Cn thit n 3 ba n mi ngy. Cung cp vitamin l rt cn thit. Ch ung nhiu nc. Ch n c 2 giai on: giai on mt lm gim cn, giai on hai cng c kt qu. Cn phi hp gio dc vi vic ngh ch king n. Quan trng l vic theo di (+++): phi theo di thng xuyn; st cn thng l chm v dn dn, vic theo di cho php h tr tm l bnh nhn. Khi ng biu din th trng n nh, ch nn ngh ch n king n mi nu n hu ch v kh thi. Ch n gim nng lng da trn ch s BMI:
BMI I II III IV 25 - 30 31 - 35 36 - 40 > 40 Nng lng cn thit 1500Kcalo/ngy 1200Kcalo/ngy 1000Kcalo/ngy 800Kcalo/ngy

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T l glucid l 60%, t l protid nn tng trong iu kin c th c: 1g/kg/ngy. Hn ch cht bo: tht m, cht bo bo ha, glucid hp th nhanh, mui 6g/ngy (bnh thng 10g) ung nc 1,5 - 3 lt/ngy. Trng hp nu cn phi cho 800-1000Kcal/ngy, nn cho nhp vin v phi b sung vitamin tan trong du (A,D,E,K), kali, st, acid amin. b. Cc bi tp th lc Rt hu ch mc d tiu tn nng lng kh thp, lm hn ch cc bin chng v tim mch, khp v nht l duy tr s hot ng th lc to tm l cn bng. Tuy nhin p dng s hn ch do tui tc, hoc do c cc bin chng hoc bnh i tho ng km theo. c. Cc phng php khc Tm l liu php rt cn thit, khng phi lc no cng qua trung gian bc s chuyn khoa, bn cht thc s ca nhu cu s xut hin trong lc khm bnh lp i lp li. d. iu tr bng y hc c truyn Bo ph th m thp, nhit: Php tr: thanh li m thp, tnh t ha trc. Bi thuc: bi Lm th khinh kin thang (gm: bn h 10g, bch linh 15g, trn b 3g, chch tho 3g, d 10g, trch t 10g, thn khc 10g, sn tra 10g, hoc hng 10, nhn trn 6g).
Dc liu Bn h (ch) Bch linh Trn b d Trch t Thn khc Sn tra Hoc hng Nhn trn Chch tho Tc dng Ging kh uy kch, tiu m thp Kin t, thm thp, tiu m trc thy L kh to thp, kin t Kin t, tr thp Thanh thp nhit bng quang Hnh kh, kin t, tiu thc tch Ph kh, tiu trc, ha m nhit Hnh kh, tn thp, ho trc Thanh li thp nhit n trung, iu ha cc v thuc Vai tr Qun Qun Thn Thn T T T T T S

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Phng huyt: dng php t, v kim kch thch mnh hoc in chm cc huyt nh: tc tam l, lng khu, t du, trung qun, v du, thin xu. Nh chm dng cc huyt ni tit, v, t, ty. Th can vng t suy: Php tr: kin t li thp, bnh can ha m. Bi thuc: Thanh tiu m (gm: phan t dip 12, tho quyt minh 15g, trch t 15g, d 15g, bch linh 15g, phng k 15g, bch trut 12, trn b 10g)
Dc liu Phan t dip Tho quyt minh Y d nhn Bch linh Trch t Phng k Bch trut Trn b Thanh can t ha Thanh can nhun to Kin t, tr thp Kin t, thm thp Thanh thp nhit bng quang Tn m thanh thp Kin t, to thp Ha kh, tiu m Tc dng Vai tr Qun Qun Thn Thn T T T T, S

Phng huyt: dng php t cc huyt can du, cch du, t du, v du, tam m giao, thin khu, trung qun, quan nguyn. Nh chm dng cc huyt thn mn, ni tit, i trng, v. Th trng v to nhit: Php tr: thanh v thng ph, mt huyt ha trng. Bi thuc: Thanh thng m (gm: hong lin 10g, phan t dip 10g, i hong 10g, sinh a 10g, h kh tho 12g, tho quyt minh 12g)
Dc liu Hong lin Phan t dip i hong Sinh a Tho quyt minh H kh tho Tc dng Thanh nhit gii c, t v nhit Thanh t nhit ha Thanh t nhit ha Thanh nhit, lng huyt, dng m, sinh tn Thanh can nhun to Thanh nhit li thp Vai tr Qun Qun Qun Thn T T

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Phng huyt: chm cu cc huyt trung qun, v du, tc tam l, phong long, lng khu, kh hi, thin khu. Nh chm dng cc huyt thn mn, ni tit, v, ph, tam tiu. Th can thn m h: Php tr: t b can thn, hot huyt, ha , kim tr thp trc. Bi thuc: Triu th tr chi ging m (gm: cu k t 12g, h th 12g, an sm 30g, ut kim 10, phc linh 20, tho quyt minh 15, sn tra 15, trch t 15g).
Dc liu Cu k t H th Ut kim Phc linh Tho quyt minh Sn tra Trch t Tc dng B can thn, nhun to B can thn, b huyt Hnh kh, ph , gii ut Kin t thm thp, tiu m Thanh can nhun to Ha , tiu trc, ha m Thanh thp nhit bng quang Vai tr Qun Qun Thn T T T T

Phng huyt: trung qun, v du, tc tam l, phong long, ni quan, lng khu, kh hi, tc tam l, t du (gia gim thin xu, chi cu).

T lng gi 1. Cc phng php nh gi bo ph: khng phi A. o np da c tam u nu > 20mm nam v > 25mm n B. c lng s phn b m 1 i vi nam v 0,8 vi n C. BMI > 27 D. BMI 25 E. BMI > 30 2. nh gi bo ph qua ch s BMI vi bo ph II l A. 25-30 B. 31-35 C. 36-40 D. 40-45 E. > 45 378

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3. nh gi bo ph qua ch s BMI vi bo ph III l A. 25-30 B. 31-35 C. 36-40 D. 40-45 E. > 45 4. Bin chng bo ph (chn cu sai) A. Tng nguy c trong gy m, hu phu B. Sinh kh C. Ri lon lipid mu D. Aicd uric mu tng E. Vim d dy - t trng 5. Trong iu tr bo ph, cn st cn A. 1-2kg/thng B. 2-3kg/thng C. 3-4kg/thng D. 4-5kg/thng E. 0,5-1kg/thng 6. Nng lng cn thit cho bnh bo ph I l A. 1700Kcal/ngy B. 1500Kcal/ngy C. 1200Kcal/ngy D. 1000Kcal/ngy E. 800Kcal/ngy

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Bi 21

CHNG RNG TC (ALOPECIA)

MC TIU 1. M t cc th lm sng ca chng rng tc theo YHH. 2. Trnh by c c ch bnh sinh ca Telogen effluvium, Androgenic v Areata alopecia. 3. Trnh by c c ch bnh sinh ca chng rng tc theo YHCT. 4. Lit k c cc phng php iu tr rng tc Areata alopecia. 5. Trnh by c cch cu to bi thuc Hu thin lc v phng theo dc l c truyn v dc l hin i.

1. NH NGHA Rng tc c gi l bnh l khi s tc rng trong mt ngy hn 100 si hoc s tc rng sau khi gi u mi sng hn 20 si. 2. PHN LOI CC CHNG RNG TC Nu s phn b lng v tc ca c 2 gii c quyt nh bi nng ca androgen tun hon v s lng ca androgen receptor nang lng trong tng vng c th th s sinh trng ca tc li ty thuc vo s chuyn ho trung gian ca androgen. Chng rng tc (khng cp n hi u do di truyn) ngoi vn thm m, ring n cn biu hin mt tnh trng sc khe chung hoc mt bnh l no khc. Sau y l mt s phn loi chung v chng rng tc. 2.1. Rng tc ho x (scarring alopecia) V mt vi th vng da u s c hin tng vim, ho si v mt nang lng. V mt i th da u trn lng v khng cn thy chn tc.

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y l nhng loi rng tc khng cn kh nng hi phc na. Thng thng loi rng tc ny thng l hu qu ca mt s bnh da nh: Lichen planus, Folliculitis decalvans, Cutaneus lupus hoc Linear scleroderma v him hn l bnh sarcoidosis di cn n da. 2.2. Rng tc khng ho x (non scarring alopecia) Khng c hin tng vim, ho si v mt nang lng. V mt i th tuy thn tc mt nhng chn tc vn cn, do tc s mc tr li sau khi loi tr nguyn nhn ca n. Sau y l mt s nguyn nhn, du hiu lm sng v cch x tr ca chng 2.2.1. Telogen effluvium C hin tng tc rng phn tn khp da u, n thng xut hin sau mt t st cao, nhim trng gii phu hoc mt stress tm l v nht l sau sinh (do s thay i hormon). Hin tng ny ch xy ra sau nhng stress ni trn trong khong t 6 tun n 4 thng. C th l do cc stress gy nn mt s tht nhp (asynchronization) vn l bnh thng ca chu trnh mc tc tr thnh ng nhp (synchronization) bt thng khin cho mt s lng ln si tc v ang mc (anagen) ng lot i vo giai on cht (telogen phase). Trong trng hp ny thy thuc ch nn theo di v gii thch cho bnh nhn ng thi tm kim nhng nguyn nhn khc c th do thuc hoc cc bnh lin quan ti chc nng tuyn gip. 2.2.2. Androgenic alopecia C hin tng tc tr nn ngn v mng vng gia da u, ng thi m tc - trn tht li v pha sau (r nht ph n). C ch l do tng s nhy cm ca tc i vi testosteron hoc tng nng androgen tun hon n gii (bnh thng l di 2 nanogram/ml i vi testosteron v 8000 nanogram/ml i vi dehydroepiandroserone). Nu ngi ph n c triu chng rm lng, ging tr nn trm, m vt ph i th nn nghi ng n u bung trng hoc thng thn. V mt x tr, nu khng c biu hin ca tng androgen c th bi minoxidil v hoc tretinoin, nu khng hiu qu c th cy tc. 2.2.3. Alopecia areata Thng xy ra tui 15 - 45, tn sut c 2 gii l nh nhau. C nhiu gi thit cp n yu t min dch nh:

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Bnh thng phi hp vi cc bnh t min nh bnh tuyn gip, bnh bch bin (vitiligo) v thiu mu c tnh. Tm thy s c mt ca khng th khng t bo thnh d dy v khng th khng tuyn gip. S tm nhum ca lympho T trong nang tc v quanh chn tc (peribulbar). V mt lm sng, chng rng tc c th gii hn nhng th multifocal vi nhng vng trn rng tc ng knh 2 - 5cm, ng bin r rng hoc th marginal (ch rng tc sau gy, c bit l tr con); hoc lan trn khp u (totalis); hoc ti c nhng vng c lng hoc ru m trong 10% trng hp c nhng mng tay v chn cng b bin dng nh g ln, lm xung, c vt r, c np (universalis).

Alopecia areata

Alopecia areata (universalis)

Trong trng hp ny ta c th s dng: + Bi cc thuc m c steroid vi nhng sang thng gii hn v nhng trng hp cn nh v sm. Liu trnh ny ko di n 2 thng. + Tim vo trong sang thng cc steroid i vi nhng sang thng nh v chm hi phc. Phng php ny c bit c hiu qu trong trng hp cc lng my b rng. + Bi thuc dithranol dnh cho nhng sang thng ln, chm hi phc hoc trong th totalis. Khng nn bi trn mt v thuc gy kch ng, c th dng loi 0,4% nu ch bi trong khong 1 - 2 gi/1 ln/ngy hoc 0,1% nu bi trc khi i ng v c th tng liu. Bin php ny c th ko di trong 3 thng. + Nu bnh nhn khng p ng vi dithranol, c th bi minoxidil t dung dch 2% - 5%. Bin php ny ko di lin tc t nht l 6 thng n hn 1 nm, c bit l trong cc trng hp nng. Loi ung tuy c hiu qu nhng thng gy h huyt p v mc lng mt. 382

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+ Nu khng c chng ch nh, c th dng steroid loi ung trong nhng trng hp nng, nn bt u vi liu 40mg/ngy ri iu chnh liu theo cn nng v tui. Sau 6 tun th gim liu v kt hp vi cc phng php khc. 2.2.4. Tinea capitis Do nm da ch yu l trichophyton tonsurans, sang thng c trng bi nhng vng ng vy cng vi nhng si tc gy t ngang hoc nhng vng tc gy xen k vi nhng vng ly nhy, ty bi m hoc cht tit. Trong trng hp ny nn x tr bng cch ung griseofuluine v selenium sulfit 2,5% kt hp vi gi u bng ketoconazol.

Tinea capitis

Alopecia areata

2.2.5. Tc gy, t, rng, qun queo Do cc dng c, ho cht lm tc hoc do hi chng tm l hay bt tc, cn mng tay (trichotillomania). 2.2.6. Do thuc Thng gp l do cc loi thuc nh: daunorubicin, warfarin, heparin, propil thiouracil, carbinazol, vitamin A, isotretinoin, etretinat, lithium, beta blockers, colchichin, amphetamin, thalium. 2.2.7. Cc nguyn nhn him Nh bnh Lupus (LED) vi th discoid gm nhng hng ban c vy nu bnh ang tin trin hoc nhng vng tng gim sc t da khi bnh thoi trin hoc th lan trn vi sang thng trn v tc tr nn ngn hn so vi vng khc. 383

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Hoc nh giang mai thi k th II vi nhng vng rng tc nham nh nh tm n. Ngoi ra tc c th tha v mng do cc bnh tuyn gip, bnh suy chc nng tiu thy no (hypophyse) do aids, do thiu protein, st, biotin v km. 3. CHNG RNG TC THEO QUAN NIM Y HC C TRUYN Theo YHCT, ru thuc chn m v tc l cht tha ca huyt thuc tm: Huyt t kh nhiu th tc tha v ngn. Huyt km th tc kh khan. Sau khi m dy tc rng nhiu l do huyt suy tn. Ngoi ra trong ng lao tht thng c cp n lc cc trong huyt cc th tc rng. Nu ngc li nu tc rng m da u nga l do huyt nhit. Do vic cha tr khng ngoi b dng tinh huyt. 4. IU TR CHNG RNG TC THEO Y HC C TRUYN 4.1. Chng rng tc sau khi m dy hoc sau khi sinh n Ngoi rng tc bnh nhn cn c nhng du hiu huyt km, huyt h. Do php tr y s l b m dng huyt. Bi thuc tiu biu l Hu thin lc v phng (Ln ng - Hiu phng tn phng)
V thuc Thc a ng quy Nhn sm an sm Vin ch To nhn (sao en) Dc l Ngt, hi m: b thn, dng m, dng huyt Ngt, cay, m: b huyt, hot huyt Ngt, hi ng: i b nguyn kh, ch huyt, sinh tn ng, lnh: hot huyt ng, m: b tm, thn Ngt, chua, bnh: dng tm, sinh tn Liu 40g 20g 12g 8g 4g 4g Vai tr Qun Thn thn T T T

Gia thm: b t nhn: 20g, tang thm: 20g. Trong : Thc a b thn m, ch tinh, dng huyt: vai tr qun. ng quy dng can huyt; tang thm b huyt sinh tn: vai tr thn. 384

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Nhn sm i b chn m; an sm hot huyt: vai tr t. To nhn, vin ch, b t nhn c tc dng dng tm, an thn: vai tr t s. Ngoi ra theo quan im ca YHH, i vi chng rng tc alopecia areata c nhng bng chng ca bnh l t min. Do ta c th s dng bi thuc trn v thc a c tc dng c ch min dch hoc dng bi thuc trn kt hp vi liu php corticoid v thc a s hn ch tc dng feedback ca vic iu tr bng corticoid di ngy; ng thi, ta kt hp vi cc thuc bi nh sau: + L b ao ti vt ly nc bi vo da u. + L vng nem 1 nm tay, ht m 1 thng: tt c cho vo nc go vo nu si 5 - 6 ln, b b, ly nc gi mi ngy. + L trc b phi rm, tn nh trn vi du m bi mi ngy. + V r du 40g, l trc b 40g, nu nc gi. + Ton thn cy m, l liu, c mn chu mi th 100g ngm nc vo go mt m sau nu cho chn nh, vt b b c c li, trn vi ht m em gi nh p ln ch b hi (bi thuc gia truyn ca c lng y L Minh Xun). 4.2. Rng tc do nm (tinea capitis) Dng cc v thuc: Kh phn Lu hong Thch cao nung 100g 100g 50g Thanh i Bng phin 30g 1,5g

Tt c tn thnh bt mn, trn vi du m, bi ngy 2 ln dng trong 5 7 ngy. Hoc: Kh phn Lu hong Hoc mt tng bi. 30g 30g S sng t 30g

Tn thnh bt mn, trn vi du m bi.

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T lng gi 1. Trong chng rng tc Telogen effluvium, tc rng

A. Hai bn thi dng B. Sau gy C. Gia nh u D. Ton b da u E. Bt k ch no


2. Trong chng rng tc Androgenic, tc rng

A. Hai bn thi dng B. Sau gy C. Gia nh u D. Ton b da u E. Bt k ch no


3. Trong chng rng tc Areata, tc rng

A. Hai bn thi dng B. Sau gy C. Gia nh u D. Ton b da u E. Bt k ch no


4. Trong chng rng tc Timea captitis, tc rng

A. Hai bn thi dng B. Sau gy C. Gia nh u D. Ton b da u E. Bt k ch no


5. Cc chng rng tc no sau y khng thuc loi rng tc ho x

A. Lichen planus B. Hng ban C. X cng b D. Rng tc Areata E. Bnh Sarcoidosis


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6. Cc chng rng tc no sau y khng thuc loi rng tc khng ho x

A. Telogen affluvium B. X cng b C. Timea captitis D. Alopecia areata E. Androgenic alopecia


7. Vic s dng steroid ch dng trong rng tc

A. Telogen effluvium B. Androgenic alopecia C. Alopecia areata D. Timea captitis E. Do thuc


8. Vic s dng steroid dng ung ch dng trong Alopecia areata th

A. Tng im B. Sau gy C. Khp u D. Tc, lng, ru E. Gia nh u


9. Trong bi thuc Hu thin lc v phng (gm: thc a, ng quy, nhn sm, an sm, vin ch, to nhn, sn tra) v thc a c tc dng b thn m, ch tinh, dng huyt nn lm

A. Qun B. Thn C. T D. S E. T v s
10. Bi thuc Hu thin lc v phng c hiu qu trong chng rng tc

A. Androgenic B. Timea captitis C. Telogen effluvium D. Do thuc E. Rng tc ho s


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Bi 22

BNH LONG XNG


(osteoporose)

MC TIU 1. Nu c nh ngha, c im dch t hc v quan nim ca YHCT v bnh long xng. 2. Trnh by c nguyn nhn, c ch bnh sinh ca long xng theo YHH v YHCT. 3. Chn on c long xng theo YHCT v YHH. 4. Trnh by c cc phng php ng dng iu tr long xng theo YHCT v phn tch c cch iu tr ny.

1. I CNG Xng l mt m lin kt c bit c 3 chc nng: vn ng, bo v v chuyn ha. Xng c cu to bi 2 thnh phn c bn l khun xng v cc hp cht khong Khun xng chim khi lng ln trong ton b xng gm cc si colagen, cc m lin kt khc rt giu cht glucoaminoglycin v cc t bo (to ct bo v hu ct bo). Trn cc khun bng cht hu c ny cc hp cht khong calci v phospho s c nh v lm cho xng tr nn rn chc, chu lc, chu ti. M xng lun c thay c i mi trong sut cuc i, hy ct bo ph hy phn xng c, ng thi to ct bo to nn xng mi b p li, hai qu trnh ny cn bng nhau ngi trng thnh, nhng to nhiu hn ngi tr v hu nhiu hn ngi gi. C nhiu yu t tc ng vo s iu ha qu trnh to v hu xng nh: di truyn, tui, gii, dinh dng, ni tit, s sinh sn, ngh nghip, cc thi quen trong cuc sng nh vn ng, tnh ti.

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1.1. nh ngha L hin tng tng phn xp ca xng do gim s lng t chc xng, gim trng lng trong mt n v t chc xng, l hu qu ca s suy gim cc khung protein v lng calci gn vi cc khung ny. V gii phu bnh thy cc b xng teo, mng v tha, phn v xng mng, to ct bo tha tht, khng thy cc ng dim dng xng (bordures ostoides), ty xng ngho v thay bng t chc m. 1.2. c im dch t hc ca long xng Long xng ang l vn ln i vi sc khe cng ng, trong ring long xng nguyn pht c cc chuyn gia y hc thng k nh sau:
M mi nm c khong 1,5 triu ngi gy xng do long xng, i hi chi ph ln ti 7 - 10 t la mi nm cho cc trng hp ny. Php s ph n b long xng sau mn kinh c tnh khong 4,5 triu

ngi trong 10% b tn ph.


chu u: 20% ph n tui 65 c t nht l mt hoc nhiu tn thng ct sng, xng c tay, cn u xng i v 40% trong s ny sau c th b gy xng. Hng Kng nm 1993 thng k thy c 380 trng hp gy xng trn

100000 ph n v nam gii con s ny l 200/100000. 1.3. Quan nim ca YHCT v bnh long xng Theo YHCT biu hin ca long xng cng c m t trong phm vi chng h lao, l tn gi chung ca c ng lao tht thng v lc cc. Bnh chng ny c nu trong sch Nn kinh v nh cch iu tr. Sch Kim qu yu lc em chng ny thnh ra mt thin ring, vit thm v cch phn bit mch, chng v phng dc iu tr. n thi i Kim nguyn th L ng Vin v Chu an Kh c thm kin v chng lao quyn ni thng, ng Vin s trng dng thuc cam n b trung kh v an Kh gii v thuc t m ging ha. Sau cc i sau nh Nguyn, Minh, Thanh u c sch v ni n bnh l ny. Theo sch Ni kinh: ng lao l nhn lu hi huyt, nm lu hi kh, ngi lu hi tht, ng lu hi xng, i lu hi gn (cn gi l tm lao, ph lao, t lao, thn lao, can lao). Tht thng l n no qu hi t; gin qu hi can; gng sc, mang nng qu, ngi lu ch t t tn thng thn; thn th b lnh tn thng ph; bun ru lo ngh tn thng tm; ma gi rt nng th tn thng hnh th; khip s qu khng tit ch c th tn thng ch. Lc cc l kh cc, huyt cc, cn cc, c nhc cc, ct cc, tinh cc. Nh vy, long xng l mt trong cc bnh l thuc chng h lao, l thn lao hay ct cc. 389

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2. NGUYN NHN, C CH BNH SINH 2.1. Nguyn nhn Bn cht ca long xng l do thiu st trong khu sn xut khung xng, cn cc ri lon chuyn ha calci - phospho, nht l tng calci niu ch l th pht v ch r rt nu long xng tin trin nhanh chng. Ngi ta phn bit long xng nguyn pht v th pht. 2.1.1. Long xng nguyn pht Long xng nguyn pht gp tui gi, do qu trnh lo ho ca to ct bo gy nn thiu sn xng, tui cng cao th tnh trng thiu sn xng cng tng, cho n khi trng lng ring gim trn 30% so vi bnh thng th c du hiu lm sng v coi l bnh l v vt qu gii hn sinh l bnh thng. Gp tui mn kinh do ri lon v thiu ht kch t n. 2.1.2. Long xng th pht Thy mi la tui v do nhiu nguyn nhn khc nhau: Bt ng qu lu: do bnh, do ngh nghip, nhng ngi du hnh v tr lu trong con tu Do bnh ng tiu ha, hoc do dinh dng: + Hi chng km hp thu. + Ct on d dy. + Thc n thiu calci. + Bnh Scorbut. Do c bnh ni tit: cng v thng thn (Cushing), suy tuyn sinh dc (ct bung trng, tinh hon), cng gip, to vin cc Do thn: suy thn mn (thi nhiu calci), chy thn nhn to chu k Do thuc: lm dng steriod, heparin 2.2. Nhng yu t nguy c gy long xng Yu t di truyn. Thiu st trong cu trc hoc trong tng hp cht to keo, th trng qu gy. Do dng thuc: chng co git, ha tr liu ung th, lm dng ru. Ht thuc l. Cafein: ung > 5 tch c ph 1 ngy. 390

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Bng xp loi nguyn nhn long xng theo mc xut hin


Hay gp Sau mn kinh Tui cao Suy sinh dc (ct b bung trng) iu tr bng corticoid Bt ng lu Ung th (nh a u tu xng) Thiu nin Trng nin Ri lon nhim sc th Hi chng Cushing Cng gip Bnh do ng st Him gp

2.3. C ch sinh bnh Thiu sn xng v mc nng hn ca n l long xng l hu qu ca s ph v cn bng gia hai qu trnh to xng v hy xng, y qu trnh to xng suy gim trong khi qu trnh hy xng bnh thng; nguyn nhn ca hin tng ny gii thch bng nhiu cch: Theo Albright: long xng l s mt cn bng gia suy gim ni tit t sinh dc trong khi ni tit t v thng thn bnh thng. Theo Nordin: ngi gi hp thu calci qua ng tiu ha gim, lng calci qua ng tiu ha gim, lng calci mu thp s kch thch tuyn cn gip tit nhiu parathormon, cht ny kch thch hy ct bo tng cng hot ng. Theo Frost: lo ho ca to ct bo ngi gi l nguyn nhn ch yu gy nn long xng, ngi trng thnh hai qu trnh to ct v hy ct lun cn bng duy tr cu trc bnh thng ca xng. 2.4. Phn loi 2.4.1. Long xng nguyn pht Long xng nguyn pht c chia thnh hai th: Long xng tui mn kinh: xut hin sau tui mn kinh trong vng 6 hoc 8 nm, tn thng long xng nng phn xng xp, do thng thy cc du hiu ct sng nh ln t sng, g, cng. Th ny c gi l long xng typ I. Long xng tui gi: gp c nam v n xut hin sau tui 75, tn thng long xng thy nhiu phn xng c (v cc xng di), thng biu hin bng d gy xng (c xng i, c tay). Th ny c gi l long xng typ II. 2.4.2. Long xng th pht Long xng th pht c triu chng lm sng ging long xng nguyn pht. 391

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2.5. Nguyn nhn, bnh sinh theo y hc c truyn 2.5.1. Bm sinh khng y Khi th thai, do cha m tui ln, sc yu, tinh huyt km, hoc khi mang thai khng iu dng gi gn, s dinh dng cho thai nhi km. 2.5.2. Lao thng qu Lm vic phi ng lu v nhiu, gng sc, mang nng qu, ngi lu ch t m t. 2.5.3. Dinh dng khng y Dinh dng khng y nh hng n s to tinh huyt, li cm nhim hn t lm ri lon s vn hnh kh huyt trong c th gy au tc trong xng. Tn dch, tinh, huyt bn trong c th u thuc m. V th chng m h bao gm: huyt h cng chng tn dch bn trong b kh ro, m tinh hao tn do m dch khng y , h ha bc ln nn bnh sinh s c cc biu hin sm nht l huyt h dn n kh h, thn m h dn n thn kh h. 3. CHN ON 3.1. Nhng biu hin lm sng Nhng biu hin lm sng ch xut hin khi trng lng ca xng gim trn 30%. Triu chng lm sng c th xut hin t ngt sau mt chn thng nh (ng ngi, i t ng xc nhiu) hoc c th xut hin t t tng dn. au xng: thng au vng xng chu ti ca c th (ct sng tht lng, chu hng), au nhiu nu l sau chn thng, au m nu l t pht. au tng khi vn ng i li, ng ngi lu; gim khi nm ngh. Hi chng kch thch r thn kinh: au c th km vi du hiu chn p kch thch r thn kinh nh au dc theo cc dy thn kinh lin sn, dc theo dy thn kinh i b, dy ta au tng khi ho, ht hi, nn hi nhng khng bao gi gy nn hi chng p ty. 3.2. Thm khm Ct sng: bin dng ng cong bnh thng nh g vng lng hay tht lng, g c ng cong rng (t khi l g nhn), c th li qu cong v pha trc (hyperlordose), mt s trng hp g mc nng gp v pha trc gy nn tnh trng cng lng (hay gp long xng typ I sau mn kinh). Chiu cao ca c th gim vi cm so vi lc tr tui. 392

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Nu au nhiu, cc c cnh ct sng c th co cng phn ng, khin bnh nhn khng lm c cc ng tc ci, nga, nghing, quay; ct sng trng nh cng . G hoc n vo cc gai sau ca t sng bnh nhn thy au tri ln. Ton thn: khng thy cc du hiu ton thn (nhim khun, suy sp, st cn), thng thy cc ri lon khc nhau nh ca tui gi nh bo bu, gin tnh mch chn, thoi ha khp, tng huyt p, x va mch. 3.3. Tin trin au do long xng tin trin tng t, khi tng, khi gim, thng tri ln khi vn ng nhiu, chn thng nh, thay i thi tit. Chiu cao c th gim dn, mt s trng hp lng cng gp dn khin cho cc xng sn cui gn st vi xng chu Ngi b long xng rt d b gy xng, ch mt chn thng nh c th gy nn gy c xng i, gy hai xng cng tay (Pouteau - Colles), gy xng sn hoc ln t sng chn p cc r thn kinh gy au nhiu, hoc khng i li c. 3.4. Nhng du hiu X quang 3.4.1. Nhng du hiu ca long xng Xng tng thu quang: trn tt c cc xng u thy trong sng hn bnh thng, mc nh cn thy c cu trc cc b xng l nhng hnh vn dc hoc cho. Nu long xng mc nng th cu trc b mt, xng trong nh thy tinh, phn v ngoi ca t sng c th m hn to nn hnh nh t sng b ng khung. Hnh nh thn t sng bin dng: tt c thn t sng bin dng cc mc khc nhau (hnh lm mt trn, hnh thu knh phn k, hnh chm, hnh li). Ni chung chiu cao thn t sng gim r, c th di lch mt phn, a m t thay i so vi t sng. Hnh nh ct ha v vi ha: cng vi qu trnh long xng, calci lng ng mt s dy chng, sn sn, thnh cc ng mch ln v ng mch ch to nn cc hnh cn quang bt thng. 3.4.2. nh gi mc long xng bng X quang Trn phim chp rt kh nh gi mc cn quang nhiu hay t, v n ty thuc vo nhiu yu t (in th, khong cch, cht lng phim v thuc hin hnh); do ngi ta phi s dng mt s phng php nh gi nh: o ch s Barnett v Nordin: da vo hnh nh X quang ca xng bn tay s 2 (mtacarte), o ng knh ca thn xng D v ng knh ca phn ty xng d. Ch s B v N =

Dd 100 D
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Ch s ny bnh thng l trn 45, nu gim di 45 c coi l long xng. o mt xng: long xng khi < -2. Ch s Singh. Chp u trn xng i t th thng: bnh thng thy c 4 h thng di xng, trong long xng cc h thng di xng ny b t gy, mt i t hay nhiu ty theo mc nng nh ca long xng; ch s 7 l bnh thng, ch s 1 l nng nht. 3.4.3. Xt nghim sinh ha Cc xt nghim calci mu, phospho mu, men phosphatase kim, hydroxyprolin niu u bnh thng. Nghim php tng calci mu: tim tnh mch 20ml gluconat calci 10%, ly ton b nc tiu trong 9 gi sau khi tim, nh lng s calci thi ra ri so snh vi lng calci thi ra 9 gi ngy hm trc lc cha tim. nhng ngi long xng sau khi tim, lng calci thi ra cao hn lc bnh thng 30% tr ln (v kh nng hp thu v gi calci ngi long xng km hn ngi bnh thng). Nghim php vitamin D2: cho bnh nhn ung 2 ngy lin mi ngy 15mg vitamin D2. Sau nh lng calci niu 24 gi sau, 48 gi v 5 ngy sau; bnh thng calci niu tng 50-100mg trong 24 gi u, sau tr v bnh thng. ngi long xng calci niu tng nhiu v ko di nhiu ngy sau. Nghim php cortison: trong 5 ngy mi ngy ung 25mg prednisolon, nh lng calci niu tng ngy. Bnh thng calci niu khng thay i, bnh nhn long xng c calci niu tng nhiu v ko di.

Chn on long xng:


au xng t hay nhiu ko di C hin tng gy xng t nhin Pht hin ngu nhin khi chp X quang Gim chiu cao Calci huyt, phospho huyt v phosphatase kim bnh thng Mt cht khong ch yu l ct sng v khung chu o mt xng

Cn chn on phn bit: nhuyn xng, cng cn gip, a u tu xng, di cn xng do ung th

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4. IU TR Chng h lao ly nguyn kh hao tn lm c trng. Vic iu tr ngoi s dng thuc cn phi hp cc phng php tp luyn, kh cng, xoa bp, chm cu, iu ha sinh hot hng ngy v n ung cng nh hng rt nhiu n hiu qu iu tr. 4.1. iu tr dng thuc 4.1.1. Kh huyt h Php tr: iu b kh huyt. Bi thuc: B trung ch kh thang gia gim (gm: hong k, bch trut, trn b, thng ma, si h, ng sm, ng quy, chch tho).
V thuc Nhn sm Hong k Trn b Si h Thng ma Bch trut Bch linh Tc dng Ngt, hi ng, bnh; vo t, ph: i b nguyn kh, ch huyt, sinh tn Ngt, m; vo t ph: b kh, thng dng kh ca t, ch hn, li thy Cay, ng, m; vo t ph: hnh kh, bnh v, ha m, tr thp ng, hn; vo can m, tm bo, tam tiu: t nhit, gii c, thng Cay ngt, hi ng; vo ph, v, i trng: thanh nhit, gii c, thng Ngt, ng, m; vo t v: kin t, to thp, ch hn, an thn Ngt, nht, bnh; vo tm, t, ph, thn: li niu thm thp, kin t, an thn Vai tr Qun Thn Thn Thn Thn T T

4.1.2. Thn m h Php tr: b thn, ch tinh, t m, dng huyt. Bi thuc: Lc v a hong hon gia v
V thuc Thc a Hoi sn Sn th n b Phc linh Trch t Tc dng Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Chua, sp, hi n: n b can thn, sp tinh ch hn Cay, ng, hi hn: thanh huyt nhit, tn huyt, cha nhit nhp doanh phn Ngt, nht, bnh: li thy, thm thp, b t nh tm Ngt, nht, mt: thanh t thp nhit bng quang Vai tr Qun Qun Thn T T T

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4.1.3. Thn kh h Php tr: b thn, tr dng. Bi thuc: Hu quy hon


V thuc Ph t Qu Thc a Hoi sn Sn th K t trng Cam tho Tc dng i nhit, c c, cay, ngt: hi dng cu nghch, b ha tr dng, trc phong hn thp t Cay, ngt, i nhit hi c: b mnh mn tng ha Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Chua sp, hi n: n b can thn, sinh tn ch hn Ngt, bnh: b can thn, nhun ph to, mnh gn ct Ngt, n, hi cay: b can thn, mnh gn ct Ngt, bnh: b t v, nhun ph, thanh nhit gii c, iu ha v thuc Vai tr Qun Qun Qun Qun Thn Thn Thn S

iu tr bng cc phng php khng dng thuc: + Chm cu: chm b hoc cu b cc huyt quan nguyn, kh hi, thn du, thi kh, mnh mn, tam m giao, thi xung, tc tam l. Bm huyt vng gip tch 2 bn ct sng v t du, v du. + n ung: n y cht, ch vitamin v khong cht. + Tp luyn: th dc vn ng khi u t nh n mnh dn (cho nhng ngi gi mi bt u tp) tt nht l i b (t i bch b bnh thng n i nhanh v sau chy) v bi li; ch nhng tc ng xng theo chiu dc ca c th s gip xng mau chc khe hn, ngoi ra tt c cc mn hot ng th lc u tt nh nh cu, khiu v, tp v dng sinh Luyn th gip s trao i kh tt hn, h tr cho s to lp li qun bnh gia to xng v hu xng, theo xu hng gim qu trnh hu xng v quan trng hn na qua chng c s lo ha t bo c th ni chung.

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T lng gi 1. Theo sch ni kinh m t long xng thuc A. Tm lao B. Ph lao C. T lao D. Thn lao E. Can lao 2. Theo sch ni kinh m t, ng lu hi A. Huyt B. Kh C. Tht D. Xng E. Gn 3. Nguyn nhn long xng th pht khng do A. Bt ng qu lu B. Bnh ng tiu ha C. Bnh ni tit D. Suy thn mn E. Thuc tng huyt p 4. Yu t nguy c long xng khng do A. Di truyn B. Ngi gy C. Thuc tr ung th D. Ht thuc l E. Cafein > 1 ly ngy 5. Nguyn nhn long xng theo YHCT khng do A. Thp nhit B. Bm sinh khng y C. Lao thng qu D. Dinh dng khng y E. Sng ni m t 397

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6. Cn lm sng sau nh gi long xng l sai A. o mt xng: long xng khi <-2 B. Ch s Barnett v Nordin < 35 C. Nghim php tng calci mu: lng calci thi ra cao hn bnh thng 30% D. Nghim pht vitamin D2: calci niu tng nhiu v ko di sau E. Nghim php cortison: calci niu tng nhiu v ko di 7. Trong long xng php tr thn m h A. T m dng huyt B. B thn ch tinh C. T m can thn D. T m kim dng E. B thn ch tinh

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Bi 23

TAI BIN MCH MU NO

MC TIU 1. Nu c nh ngha v nhng yu t dch t hc ca tai bin mch mu no. 2. Trnh by c nguyn nhn v c ch sinh bnh ca tai bin mch mu no theo l lun YHCT. 3. Chn on c 2 th lm sng tai bin mch mu no (trong cn) v 3 th lm sng di chng tai bin mch mu no (sau cn) theo YHCT. 4. Trnh by c nhng nguyn tc iu tr tai bin mch mu no theo YHHD v YHCT. 5. Trnh by c phng php iu tr tai bin mch mu no (dng thuc v khng dng thuc ca y hc c truyn). 6. Gii thch c c s l lun cu vic iu tr tai bin mch mu no bng YHCT.

1. I CNG 1.1. nh ngha Tai bin mch mu no (TBMMN) c nh ngha l du hiu pht trin nhanh chng trn lm sng ca mt hi chng thn kinh nng n, thng do nguyn nhn mch mu no, i khi do nguyn nhn mch mu ca cung mch mu no nm c, tin lng sinh tn cng nh tin lng chc nng ca thn kinh ty thuc vo nguyn nhn v mc lan rng ca tn thng. Nh vy, theo nh ngha ny trn lm sng, y l cc biu hin bnh l gm phn ln cc trng hp chy mu trong no, chy mu di nhn, nhn no, thiu mu no thong qua. Nhng trng hp nh tn thng hoc bnh l ca tnh mch no (vim tc tnh mch no) khng c cp trong bi ny. c im gii phu sinh l c lin quan n tai bin mch mu no. ng mch no gia (ng mch thng gy TBMMN) c 2 nhnh: 399

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Nhnh su xut pht t khong nn, chy trong rnh Sylvius. Nhnh ny d b v v l ng mch tn, phi chu hu qu ca vic tng cao huyt p. Nhnh nng phn b v l mt ngoi bn cu no. Nhnh nng thng chu hu qu t hn i vi tnh trng huyt p tng cao nh h thng vi mch ln, nhng ngc li d b nhn no v din ca chng qu rng. Cc nhnh tn cng ca cht trng khi v d sinh ra khi t trong no, thng lin quan n mt d dng mch mu no (u mch, ti phnh). 1.2. c im dch t hc Theo Hip hi Tim mch M, nm 1977 ti M c 1,6 triu ngi b TBMMN, tng ng vi s ngi mc bnh tim do thp v bng 1/2 s ngi bnh mch vnh. Theo thng k ti M, hng nm c khong 500000 trng hp TBMMN mi, phn ln xy ra sau 55 tui (Russell, 1983). Theo Kurtzke, t l bnh TBMMN mi mc hng nm l 2% cho mi la tui. Trong , 12% do chy mu trong no, 8% do chy mu di nhn, 69% do lp mch. Tc gi Wolf (1978) qua 26 nm theo di nhng ngi t 65 - 74 tui ghi nhn: + Nhn no do x va nam l 58%, n l 54%. + Nhn no do lp mch no nam l 16%, n l 19%. + Chy mu trong no nam l 5%, n l 3%. + Chy mu di nhn l nam l 10%, n l 12%. + Thiu mu no thong qua nam l 8%, n l 9%. V mc t vong do TBMMN: + ng hng th 3 trn th gii v t l t vong (sau bnh tim v ung th). Theo Russell, t l t vong giai on u l 15% v 50% bnh nhn sng st b tn ph. + Nm 1977, ti M c khong 182000 trng hp t vong do TBMMN (chim khong 1/10 tng s t vong). 2. NGUYN NHN V C CH BNH SINH 2.1. Theo y hc hin i 2.1.1. Xut huyt no X m ng mch vi tng huyt p. 400

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D dng mch mu no (nht l ti phnh). U no. Bnh v mu (bnh bch cu cp). Chn thng s no. S dng thuc chng ng. Trong nhm ny, cn ch n khi mu t trong no. 2.1.2. Nhn no X m ng mch: ti nhng ng mch c ng knh trung bnh nh ni xut pht ng mch cnh su, ng mch ct sng, nhng ni ngot ca ng mch Sylvienne. Thuyn tc ng mch no: cc tc xut pht t tim tri nh hp van 2 l, vim ni tm mc do nhim trng, rung tht Tiu ng, giang mai, vim mng no mn, thoi ha ct sng c, teo hp ng mch ct sng, vim nt quanh ng mch 2.1.3. Xut huyt mng no (di nhn) Nguyn pht: + V ti phnh ng mch y no (chim 75% trng hp). + V ti phnh ng tnh mch, v cc bu mch tiu no hoc ty sng. + X m ng mch no vi km hoc khng km tng huyt p. Th pht: + Chn thng s no (c th khng c b hp s). Ch , khng c qun chn thng sn khoa. + Bnh v mu: xut huyt gim tiu cu, bnh mu chm ng (hmophilie), bch cu cp. + Bu no, vim mng no, vim no v nhng bnh nhim trng nh thng hn, st pht ban). + Ng c (ch, CO, ru .). + S dng thuc khng ng. 2.1.4. Suy tun hon no (insuffisande circulatoire crbrale) Do x va ng mch no. Tnh trng x va ny xu thm vi bnh tng huyt p, tiu ng, giang mai. 401

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Do vim ng mch no c ngun gc nhim trng (giang mai) hoc bnh ton th (collagnoses). Do thuyn tc mch mu no (ch yu t tim). Do d dng mch mu no bm sinh v vi trng chn thng ct sng c. 2.2. Theo y hc c truyn Nhng triu chng thng gp trong TBMMN nh t ngt t ng, hn m, lit na ngi, lit mt, hoc c khi ch l mt tnh trng hoa mt, chng mt Nhng biu hin ni trn c thy trong: t ngt t ng, hn m: YHCT xp vo chng thin phong, trng phong. Hoa mt, chng mt: YHCT xp vo chng huyn vng hay cn gi l huyn vng. Lit na ngi, lit mt: YHCT xp vo chng nuy. T tay chn: YHCT xp vo chng ma mc (kh huyt tc kinh lc) c th do ngoi t hoc m thp. Qua vic phn tch c ch bnh sinh ton b cc chng trng thng gp ca YHCT trong TBMMN, kt hp vi ton b l lun ca YHH, c th bin lun v nguyn nhn l c ch bnh sinh theo YHCT nh sau: + Do ngoi nhn ch yu l phi ha nhit v sinh phong. + Do tht tnh (ni nhn) nh gin, lo s gy tn thng 3 tng t, can, thn. + Do mc bnh lu ngy (ni thng), lm c th suy yu, thn m v thn dng suy (thn m suy, h ha bc ln; thn dng suy, chn dng nhiu lon trn). + Do yu t di truyn hoc d dng bm sinh (tin thin bt tc). + Do n ung khng ng cch sinh m thp lm tc tr kinh lc. + Do chn thng gy huyt tc, kinh lc khng thng.

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NGOI NHN (nhit - phong)

TIN THIN BT TC

THT TNH (gin, lo s, stress)

BNH LU NGY TH CHT YU

N UNG KHNG NG CCH

Thn dng h

Thn m h

Can m h

T h

H ha bc ln Thp Huyt

m THNG CHN

PHONG

Thin phong, nuy chng, ma mc, huyn vng

Hnh 1. S bnh l tai bin mch mu no theo YHCT

3. BNH CNH LM SNG V CHN ON 3.1. Theo y hc hin i 3.1.1. Chy mu no Th thng gp l chy mu vng bao u do tng huyt p ngi cao tui. Khong 90% trng hp chy mu xy ra ng mch u vn, cn gi l ng mch Charcot hay ng mch ca chy mu no; 10% chy mu c 2 bn (hoc cng mt lc, hoc ch trc ch sau). a. Du hiu lm sng Tin chng: thng thng c nhc u, nht l ban m, c th ch nhc mt bn u (bn s c chy mu). C th c chng mt, tai, nng phng mt km theo. Mt s du hiu khc cn ch nh chy mu cam. C bnh nhn trong tin s b lit na ngi hoc t na ngi (30% c tin s thiu mu no thong qua). Khi u: t ngt bnh nhn ng vt ra v hn m nng ngay. Nhng cng c th bt u bng nhc u d di, thc thu hp dn v chuyn dn sang giai on ton pht. 403

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Ton pht: vi 3 hi chng + Hn m: thng hn m su v nng. + Lit na ngi: bn lit c tnh trng gim trng lc c, k c c mt. Bnh nhn nm t th u v mt cng quay v bn tn thng. Lit mt c th c xc nh bng nghim php Pierre Marie - Foix. Du hiu c nhiu gi tr l Babinski, Hoffman bn lit. Tuy nhin do c ph no nn du hiu ny c th xut hin c 2 bn. Ngoi ra c th c gin ng t bn lit. + Ri lon thc vt: bao gi cng c v thng xut hin sm. Bnh nhn c du hiu tng tit ph qun dn ti ng, ri lon nhp th (i khi kiu Cheynes -Stokes), ri lon nhp tim, huyt p tng cao, nhit lc u thp nhng v sau tng (380 - 390C), ri lon dinh dng nht l lot t th, d xy ra t ngy th 3 tr i. Nhn chung, nhng ri lon vn mch v dinh dng (nhiu m hi, ph n) xut hin nng n hn bn lit. b. Du hiu cn lm sng Mu: bch cu tng, ng huyt, ur huyt tng. Dch no ty hi hng hoc c th c hng cu khi soi vi th. Nhng ngy sau, dch no ty chuyn sang mu vng, protein trong dch no ty tng va. Cng c trng hp dch no ty bnh thng. Chp ct lp in ton (xem phn sau). c. Tin trin Ni chung, thng dn n t vong (chim khong 2/3 trng hp). T vong thng xy ra vo nhng gi u hoc cui tun u. C tc gi nu nhng ngy nguy him nht l ngy th 2 v ngy th mi. Nhng ngy u, ri lon thc vt l nguy c ch yu gy t vong. Sau ngy mi, tuy nguy him hn nhng vn c th t vong v cc bin chng, v nhim khun ng h hp, ng tit niu cng nh cc ri lon nc in gii, ri lon dinh dng. Nhng ngy sau , ni bt l nguy c tn ph vi cc di chng thn kinh nng n, di chng tm thn. 3.1.2. Khi mu t trong no a. Du hiu lm sng y l th bnh cn ch , v c th gii quyt tt bng phu thut thn kinh. Khi mu t trong no l mt th c bit ca chy mu no nhng khng thm vo nhu m no m thng ng li ti ch, gy nn triu chng gi khi u. Thng gp nht l lit na ngi.

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Hn m ngt qung; c th hn m vi ngy ri tnh, n khong ngy th 10 li hn m li; mt hai tun sau i vo hn m nng. Hn m c th xy ra vi tun sau khi lit na ngi (c trng hp ch chp chn, c trng hp khng hn m). Hi chng tng p lc trong s: cn ch ch c 1/3 trng hp c ph gai. b. Du cn lm sng in no . CT. Scan. 3.1.3. Nhn no a. Du hiu lm sng Tin triu: thng c. Ty theo v tr s b nhn m xut hin cc triu chng v gic quan, vn ng v cm gic tng ng Khi u: hn m v lit na ngi. Nu nhn no do tc mch thng din tin t t. Ton pht: c th c hn m va hoc nh, cc ri lon thc vt mc trung bnh (nhit v nhp th hi tng) v thng tn thng thu hp (nu tn thng rng s c hn m tht s). b. Tin trin Nu qua c giai on cp (nht l ngy th 2, ngy th 10), bnh nhn s phc hi dn nhng vn cn mt s di chng. 3.1.4. Chy mu no - mng no C 2 dng biu hin lm sng: chy mu t no trn vo mng no (th no - mng no) v chy mu t mng no trn vo no (th mng no - no). Th no -mng no gm 3 bnh cnh khc nhau: + Th ti cp (lt no tht): thng bt u t ngt, thc u m, nhc u ri i vo hn m su rt nhanh. + Th cp cng bt u bng chy mu no: mt tun sau, ri lon thc nng hn, xut hin cc ri lon thc vt, hi chng mng no, du hiu Babinski thng (+) c 2 bn. + Th khng y : c du hiu ca xut huyt no km thay i v mu sc v dch no ty. Th mng no - no: bnh thng bt u vi nhng cn co git ton b, ton th hoc cc b kiu Bravais - Jackson hoc vi cc triu chng

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thiu st (lit na ngi). Sau khong 1 tun nhng du hiu thn kinh khu tr xut hin r nt hn. 3.1.5. Chy mu mng no a. Du hiu lm sng Giai on khi u: t ngt au u d di ri mt thc (cng c khi khi u t t vi nhc u nhiu, nn, chng mt ri thc u m dn; cng c khi khi u vi ri lon tm thn vi l ln, kch ng). Giai on ton pht: + Ri lon thc: thng l l m, ng g. Nu c hn m th thng l nng, c th xen k trng thi kch thch vt v. t gp hn m su, km ri lon thc vt trm trng. + Hi chng mng no: nhc u, cng gy, cng ct sng, s nh sng v ting ng. + Du thn kinh: phn x gn xng c th gim hoc mt (thng l tng). Babinski thng (+) c 2 bn, t gp tn thng dy s no. Nu thy lit dy III th nn ngh n v ti phnh ng mch cnh hoc ng mch thn nn. + Ri lon thc vt nh: vch mng no, st b. Du hiu cn lm sng Xt nghim mu: ng huyt tng c th ln n 300 - 400mg% (km theo ng niu v ceton niu). + Ur huyt c th tng ti 100mg%. + Bilirubin, SGOT, CPK u c th tng. Dch no ty lc u , c nhiu hng cu, sau 10 ngy chuyn sang mu vng, c bch cu tng nh, m tng (300 - 500mg%). 3.1.6. Nhng k thut chn on mi V mt chn on i vi TBMMN, cn tm cch chn on chnh xc tnh cht tn thng (chy mu no, nhn no, khi mu t), din tch thng tn. Hin nay c nhng k thut c th gip t c mc tiu ny nh: Chp ct lp in ton (CT. Scan). Cng hng t ht nhn (MRI). Chp qut ct lp bng tia photon hoc tia positron. Chp lp lnh mch no. 406

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3.2. Theo y hc c truyn TBMMN biu hin trn lm sng phong ph, di nhiu dng v khc nhau t nhng triu chng khng c hiu nh hoa mt, chng mt, cm gic t mt phn c th cho n hn m, lit na ngi. V th, vic m t ton b cc th lm sng YHCT ca TBMMN khng tht s d dng. Thng thng, c th thy xut hin nhng th lm sng sau y 3.2.1. Trong t tai bin mch mu no a. Trng lc (trng phong lc) Bnh nhn t ngt ghi nhn da t di km cc chng u vng, au, hoa mt. Triu chng ny c th thong qua ri bin mt hoc ko di. b. Trng kinh (trng phong kinh lc) Bnh ti kinh mch: ngi bnh khng m man, tuy nhin tnh trng thc tht s cng b nh hng, c th l m, ly b, bi lit na ngi, chn tay t di, ming nhiu m di, ni nng khng tri chy, ru li trng dy, mch huyn hot. c. Trng phong tng ph Bnh cnh ny c mt c im chung l triu chng hn m v gm 2 nhm bnh chnh (ty theo tnh trng hn m xut hin t ngt hay t t): Trng ph (trng phong ph): bnh nhn m man, xut hin cc chng bi lit na ngi, ming mt mo lch, ni nng hoc m lp thanh khiu, ni khng c, i tiu tin khng nn c hoc b kt. Trng tng (trng phong tng): bnh nhn t nhin ng ra m man bt tnh. Trong nhm bnh ny li chia ra lm 2 nhm nh. + Chng b:

Dng b: bnh nhn t nhin ng ra m man bt tnh, hm rng cn cht, tay nm cht, mt , th n o, ting th kh kh, li rt li, i tiu tin u b, ru li vng nhy, mch huyn hot sc. m b: bnh nhn t nhin ng ra m man bt tnh, rng cn cht, tay nm cht, mt trng nht, mi bm, ting th kh kh, chn tay lnh, ru li trng nhy, mch trm hot.

+ Chng thot: bnh nhn t nhin ng ra m man bt tnh, hn m rt su, mt nhm, mm h, h hp yu, chn tay lnh, 2 bn tay xo ra, i sn, v m hi ng tng git hoc nhn nh du, li nht, ru li trng trn, mch vi tuyt. 407

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3.2.2. Giai on sau TBMMN (di chng ca TBMMN) giai on ny, c 2 loi di chng cn c quan tm. l di chng thn kinh (ch yu l vn ng) v tm thn. Do bnh tr thnh mn tnh v nh hng nhiu n can v thn nn triu chng YHCT trong giai on ny ch yu gm cn nuy, ct nuy, kin vong (do tinh ca thn khng nui tm). Nhng bnh cnh lm sng YHCT thng xut hin l: Can thn m h (chim a s cc trng hp): sc mt xm, mt m thng ng hng, rng kh, mng kh, gn gng cng co rt li, au ni eo lng, tiu m, to bn, ng km, than nng trong ngi, ngi d bc dc, bt rt, li bu, mch trm sc v lc. Thn m dng lng h: sc mt ti xanh hoc en xm, rng kh, mng kh, gn gng cng co rt li, au ni eo lng, tiu m, ng km, khng kht, t ung nc, s lnh, li nht bu, mch trm nhc. m thp (bnh nhn bo bu): + Ngi bo, tha cn, li dy, to. + Bnh nhn thng t than phin v triu chng au u (nu c, thng l cm gic nng u) nhng d than phin v t nng cc chi. + Thng hay km tng cholesterol mu, mch hot. 4. CHM SC V IU TR Nh trn trnh by, TBMMN biu hin trn lm sng di nhiu th lm sng khc nhau (t nhng triu chng khng c hiu nh hoa mt, chng mt, cm gic t mt phn c th cho n hn m, lit na ngi) v nguyn nhn cng c nhiu loi nn vic chm sc v iu tr cng rt phong ph. Trong gii hn ca ngi thy thuc a khoa YHCT ngy nay, c th ng dng vo iu tr nh sau 4.1. Trong t tai bin mch mu no iu tr cp cu v chm sc tch cc bnh nhn bng phng php v phng tin tr liu YHH ph hp vi tnh trng bnh nhn v nguyn nhn gy bnh. Trong giai on ny, vai tr ca nhng phng php iu tr YHCT t quan trng (c kin ngh s dng song song chm cu phc hi lit v u chm trong giai on bnh nhn cn hn m). Phng php dng thuc v khng dng thuc trong giai on ny c th c ch nh phi hp vi YHH trong trng hp trng phong kinh lc (bnh nhn khng hn m). Theo YHCT, trong giai on cp tnh ny bin php iu tr quan trng l iu tr ngn (triu chng) m khng ch n gc bnh (nguyn nhn). 408

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Bt k nguyn nhn no cng u a n tnh trng phong ng, nn cch iu tr ch yu ch l bnh can tc phong. Nhng bi thuc v cng thc huyt s dng: Bi Thin ma cu ng m Thin ma Hong cm Tang k sinh trng ch mu Ngu tt 8g 10g 12g 10g 12g 12g Cu ng Chi t H th Phc linh Thch quyt minh 12g 12g 10g 12g 20g

Bi Linh dng cu ng thang Linh dng gic Cu ng Bch thc Phc thn Bi mu 4g 12g 12g 12g 8g Trc nh Sinh a Tang dip Cc hoa Cam tho 20g 20g 8g 12g 4g

Cng thc huyt s dng gm: hnh gian, thiu ph, can du, thn du, thi kh, phi dng, ni quan, thi dng, bch hi, n ng. 4.2. Giai on sau TBMMN (di chng ca TBMMN) Trong giai on ny, vic iu tr v chm sc bnh nhn bao gm 2 mc tiu: Phc hi chc nng vn ng v tm thn. Gii quyt nguyn nhn bnh hoc bnh l km theo nh tng huyt p, x m ng mch, ri lon bin dng m, tiu ng Vic chm sc v iu tr cho mc tiu ny xin tham kho thm phn bnh hc tng ng. 4.2.1. Th thn m h Php tr: t m ghm dng, t b can thn. Nhng bi thuc v cng thc huyt s dng: + Bi thuc h p (xut x 30 cng thc thuc) Thc a R nhu 20g 20g Ngu tt Trch t 10g 10g 409

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M Hoa ho

20g 10g

To nhn

10g

+ Bi thuc Lc v a hong hon gia quy thc Thc a Sn th Phc linh ng quy 32g 8g 12g 12g Hoi sn n b Trch t Bch thc 16g 12g 6g 8g

Bi ny thng c s dng khi tng huyt p c km triu chng au ngc, au vng tim. + Bi thuc b can thn H th Hoi sn Trch t Tho quyt minh 10g 15g 12g 10g Thc a ng quy Si h 15g 12g 10g

Cng thc huyt s dng: thn du, phc lu, tam m giao, can du, thi xung. Gia gim thn mn, ni quan, bch hi, a th huyt. 4.2.2. Th thn m dng lng h Php tr: n b thn dng. Nhng bi thuc v cng thc huyt s dng: + Bi thuc Thn kh hon Bch phc linh Sn th Qu chi Ph t + Bi Hu quy m Cam tho Hoi sn Nhn sm Ph t Thc a 410 4g 16g 8g 2g 32g trng K t Nhc qu Th du 12g 8g 4g 8g 120g 160g 40g 40g Thc a n b Trch t Sn dc 320g 120g 120g 160g

Tn bt, ngy ung 8-12g.

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+ Chm cu: cu b hoc n chm cc huyt thi dng, bch hi, u duy, phong tr, thi xung, quang minh, can du, thn du, tam m giao, thi kh, phi dng, mnh mn, trung cc, quan nguyn, kh hi. 4.2.3. Th m thp Php tr: tr m, thng lc. Bi thuc s dng: dng bi thuc Nh trn thang gia v (xut x Thin gia diu phng) Bch trut Phc linh Nhn sm 40g 12g 4g Cam tho Bn h Trn b 4g 12g 4g

4.2.4. Phc hi di chng vn ng v tm thn a. iu tr bng thuc Php tr: b kh, hot huyt, kh , thng lc. Bi thuc s dng: dng bi B dng hon ng thang (gm: hong k 40g, hng hoa 7g, o nhn 6g, xuyn khung 7g, a long 7g, xch thc 6g, ng quy 8g). Ch : nhng bi thuc b m dng lu ngy s gy n tr, nh hng khng c li trn vic phc hi vn ng. Do , ty theo tnh hnh bnh nhn m ngi thy thuc c th dng thay i vi nhng bi thuc iu tr chung ca c th Phn tch bi thuc:
V thuc Hong k ng quy Xch thc Xuyn khung o nhn Hng hoa a long Tc dng Ngt, m; vo t ph: b kh, thng dng kh ca t, ch hn, li thy Cay, ngt, n: b huyt, hot huyt, nhun to, hot trng, iu huyt, thng kinh ng, chua, hi hn: tn t, hnh huyt Cay, n: hot huyt, ch thng, hnh kh, khu phong ng, ngt, bnh: ph huyt, hnh , nhun to, hot trng Cay, m: ph huyt, sinh huyt Mn, hn, vo kinh t, v, thn: thanh nhit, trn kinh, li tiu, gii c Vai tr Qun Thn T T T T S

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b. iu tr bng chm cu Phng php u chm vng vn ng (nu ch c lit) v vng cm gic (nu c km ri lon cm gic) bn i din, chm nghing kim (300), v kim khong 200 ln/pht; lin tc trong 1 - 2 pht, lu kim 5 - 10 pht. Thng thng chm 1 ln/ngy, chm 10 ngy lin tc thnh 1 liu trnh, ngh 3 - 5 ngy c th bt u liu trnh th 2 (xem Chm cu hc ). Phng php ny thng c s dng sm trong khong thi gian 6 thng k t khi b tai bin (thng khng qu 1 nm). Phng php th chm: thng s dng nhng huyt trn cc kinh dng minh ca tay v chn bn lit, phi hp vi huyt kinh in phc hi lit nh dng lng tuyn, thay i huyt mi ngy, thng phi hp vi in chm. Cn ch s dng dng in (tt nht l dng in mt chiu u) v thng in thch hp. Thi gian ca mi ln iu tr cn da vo s tip thu kch thch ca tng ngi bnh, trong tng bnh, tng lc, i vi tng loi dng in m quyt nh. Ni chung cn theo di, nh gi tnh trng bnh nhn sau khi chm ln th nht. + Nu bnh nhn khng c mt mi, mt ng....: nn duy tr thi gian kch thch. + Nu bnh nhn thy mt mi, mt ng... l do tng lng kch thch qu mnh: cn gim thi gian kch thch. Trung bnh ngy chm mt ln hay cch ngy chm mt ln: t 10 n 15 ln in chm l mt liu trnh, ngh 10 n 15 ngy ri tip tc ty theo yu cu cha bnh (xem Chm cu hc , trang 181 - 194). c. Vt l tr liu phc hi chc nng Cn thc hin tun t nhng bc sau: nh gi tnh trng chung ca bnh nhn, bao gm: + nh gi tng qut v bnh nhn: tr hay ln tui? Mc hp tc? Tnh trng tinh thn (tch cc, tiu cc)? + Tnh trng sc khe? Tnh trng bnh tt i km? Mc ? + Bnh nhn c th lm c g khi ngi, khi ng? Thng bng? + Bnh nhn khng lm c g? + Xc nh r tnh trng c lc: cn lng gi mc vn ng ca tng b phn tht c th (tay, cnh tay, cng tay, c tay, bn tay, ngn tay), vi tng loi ng tc khc nhau v cc t th nm, ngi, ng khc nhau.

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Lng gi kh nng thng bng ca bnh nhn? t th ngi? T th ng? Khi i? Lng gi v cm gic ca bnh nhn. Xc nh c th chin lc tp luyn cho ngi bnh. Xc nh mc ch u tin ca phc hi chc nng trn ngi bnh l g? Nhng chc nng no cn phi tp cho bnh nhn trong giai on u tin? Giai on k tip? Phng php thc hin: + Giai on u (rt quan trng): phc hi vn ng ng cch trong giai on ny gip hn ch mc trm trng ca nhng ri lon (mt c ch phn x chnh th bnh thng ca bn lit, khuynh hng tng co cng bn lit, ri lon cm gic bn lit lm c ch vn ng) v gp phn rt ln vo hiu qu iu tr v sau. Thy thuc cn hng dn chi tit huy ng ngi nh bnh nhn tham gia tch cc vo qu trnh phc hi sm ny.

B tr ging bnh: khng t bnh nhn nm vi bn lit st tng, tt c vt dng trong phng u pha bn lit, ngi chm sc v tp luyn cho bnh nhn ch n pha bn lit. T th bnh nhn khi nm trn ging:

Nm nghing v bn lit: u bnh nhn c gi chc chn, c hi gp, khng u b y ra sau; thn mnh t th na nga, c gi pha lng.

Tay lit: khp vai, xng b vai c ko ra trc to vi thn mt gc 90 , khuu dui, cng tay xoay nga, c tay gp v pha sau, ngn tay dui dng; tay lnh v tr thoi mi trn mnh, hoc trn gi sau lng.
0

Chn lit: khp hng dui, gi h gp; chn lnh: khp hng v gi gp (ta trn mt gi ngang vi thn).

Nm nghing v bn lnh: u bnh nhn nh trn. Thn mnh nm vung gc vi mt ging, c gi sau lng.

Tay lit: c gi mc ngang vi thn, t th dui, to vi thn mt gc khong 100 . Tay lnh: t th m bnh nhn thy thoi mi. Chn lit: c gi mc ngang vi thn, khp hng v khp gi gp. Chn lnh: khp hng dui, khp gi hi gp.

Nm nga: u bnh nhn c gi chc chn, mt quay sang bn lit, khng lm gp cc t sng c v ngc.

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Vai v tay bn lit: c gi bn di xng b vai a xng b vai v khp vai ra pha trc; dng gi tay lit t th khuu, c tay dui, cc ngn tay dng. Tay lit c th xui theo thn hoc dui thng ln qua u. Chn lit: c gi k di hng v i a hng ra trc, gi chn t th khp hng v gi gp, dng gi k trnh chn khi b ra ngoi. Chn v tay lnh t th m bnh nhn cm thy thoi mi.

Thay i t th cho bnh nhn: y l im rt quan trng. Bnh nhn phi c thay i t th mi 2 - 3 gi. Nu bnh nhn cha ch ng vn ng c tay chn, bnh nhn cn c tp th ng tt c cc khp bn lit. Tp nh nhng, u n trnh lm tn thng khp ca bnh nhn. Khi bt u c th tham gia vo tp luyn:

Nhng bi tp cn thc hin ngay trong giai on u.

Tp ln nghing sang bn lit: c th c tr gip bng cch nng chn v tay ln, nng u; ngi bnh a chn tay lnh ra pha trc sang bn lit ri ln ngi theo. Tp ln nghing sang bn lnh: bnh nhn nm nga; thy thuc gip bnh nhn nng tay v chn lit ln, a ra trc sang bn lnh. Tp vn ng vai tay (tay lnh tay lit): nm nga, ci cc ngn tay 2 bn vo nhau, ngn ci bn lit ngoi ngn ci bn lnh. Dui thng 2 tay ra trc, a 2 tay ln pha u v xung pha chn, cng xa cng tt. Tp dn trng lng ln chn lit: nm nga, 2 gi gp; ngi iu tr gip gi bn lit (nu cn). Bnh nhn nng chn lnh ln khi mt ging dn trng lng ln chn lit. Lm cu: nm nga, 2 gi gp, ngi iu tr gip gi chn lit cho khi . Bnh nhn c gng t nng mng ln khi mt ging, gi 2 bn hng ngang nhau ri nng chn lnh ln khi mt ging (nu c) ton b trng lng dn ln chn lit. + Giai on sau: giai on ny, vic phc hi tp trung vo 2 mc tiu tp luyn gip vn ng vng c b lit, ng thi tp luyn chng tnh trng co cng c.

Vic tp luyn c thc hin nhng t th khc nhau: Tp vn ng t th nm. Tp vn ng t th ngi. Tp vn ng t th ng. Tp vn ng trn m. Tp ln.

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Tp chuyn t th t nm sang qu chng tay. Tp vn ng t th qu. Tp ng ln.

Bnh nhn cn ch trong khi tp l lun phi hp cht ch vi th su. Phng nga co rt khp vai: nm nga, ci cc ngn tay 2 bn vo nhau, ngn ci bn lit ngoi ngn ci bn lnh. Dui thng 2 tay ra trc, a 2 tay ln qu u cho n khi 2 tay chm vo mt ging hoc sn nh ri a tay xung pha chn. Phng nga khuu tay, c tay v ngn tay b co rt: bnh nhn ng cnh bn, ci cc ngn tay 2 bn vo nhau. Xoay nga lng bn tay v p lng bn tay xung mt bn. Dui thng 2 tay, ng ngi v pha trc dn trng lng ln 2 tay cho ti khi khp c tay dui ti a.

Bnh nhn ngi, dng tay lnh lm dui cc ngn tay bn lit v lm dui c tay. Sau t xung mt ging cnh thn, dng tay lnh gi khp khuu bn lit dui thng v nghing ngi sang bn lit dn trng lng ln tay lit. Ci cc ngn tay 2 bn vo nhau, a 2 bn tay ln st cm, dng lc ca bn tay lm dui ti a c tay bn lit. C th ta vo m v cm v gi yn trong mt thi gian lu.

Phng nga co cng chn t th dui: nm nga, ci cc ngn tay 2 bn vo nhau, co 2 gi li v vng 2 tay qua 2 gi, ko 2 gi v pha ngc v nng u ln; sau , tr v v tr ban u. Phng nga co rt gn gt v gp ngn chn: dng mt cun bng t di ngn chn bn lit, sau ng ln, bc chn lnh ra pha trc, pha sau. C th vn vo mt ch ta nu ng cha vng.

T lng gi I. Cu hi 5 chn 1: chn cu ng 6. Nguyn nhn gy bnh TBMMN theo YHCT

A. Ngoi nhn B. Bnh lu ngy lm thn h, ha bc C. Tin thin bt tc


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D. n ung khng ng cch gy m thp, ha ha E. Chn thng


7. Yu t no gy c bnh TBMMN

A. Nhit B. Hn C. To D. Thp E. Phong


8. Triu chng quan trng phn bit trng phong lc vi trng phong kinh

A. C lit mt hay khng? B. C lit na ngi hay khng? C. C hn m hay khng? D. C khi pht t ngt hay khng? E. C co git, ng kinh hay khng?
9. Triu chng quan trng phn bit trng phong kinh vi trng phong ph

A. C lit mt hay khng? B. C lit na ngi hay khng? C. C hn m hay khng? D. C khi pht t ngt hay khng? E. C co git, ng kinh hay khng?
10. Triu chng quan trng phn bit trng phong ph vi trng phong tng

A. C lit mt hay khng? B. C lit na ngi hay khng? C. C hn m hay khng? D. C khi pht t ngt hay khng? E. C co git, ng kinh hay khng?
II. Cu hi nhn qu 1. Trong phng huyt iu tr chng can dng xung gm: hnh gian, thiu ph, can du, thn du, thi kh, phi dng; gia gim ni quan, thi dng, bch hi, n ng 416

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a. Ngi ta chm b huyt hnh gian bnh can bi v b. Hnh gian l ha huyt ca can, dng n theo nguyn tc m thc t con

A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai
2. Trong phng huyt iu tr chng can dng xung gm: hnh gian, thiu ph, can du, thn du, thi kh, phi dng; gia gim ni quan, thi dng, bch hi, n ng

A. Ngi ta chm t huyt thiu ph bnh can ging ha bi v B. Thiu ph l ho huyt ca tm, dng n theo nguyn tc m thc t con C. Nu a ng, b ng, a v b c lin quan nhn qu D. Nu a ng, b ng, a v b khng lin quan nhn qu E. Nu a ng, b sai F. Nu a sai, b ng G. Nu a sai, b sai
3. Trong phng huyt iu tr chng can dng xung gm: hnh gian, thiu ph, can du, thn du, thi kh, phi dng; gia gim ni quan, thi dng, bch hi, n ng a. Ngi ta chm b huyt thn du bi v b. Chm b huyt thn du c tc dng t m ghm dng

A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai
4. Trong bi Thin ma cu ng m cha chng can phong ni ng gm: thin ma, cu ng, hong cm, chi t, tang k sinh, h th ch, trng, phc linh, ch mu, tho quyt minh, ngu tt a. V phc linh lm t bi v b. Phc linh c tnh nh tm an thn 417

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A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai
5. Trong bi Linh dng cu ng thang cha chng can phong ni ng gm: linh dng gic, trc nh, cu ng, sinh a, bch thc, tang dip, phc thn, cc hoa, bi mu, cam tho a. Hai v sinh a, bch thc u lm thn bi v b. Hai v u c tc dng sinh tn

A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai
6. Hai v ph t, qu nhc trong bi thuc Thn kh hon v Hu quy hon a. Hai v ny u lm qun bi v b. C hai u c tc dng n b mnh mn tng ho

A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai
7. Trong bi thuc Hu quy m cha chng thn kh bt tc gm: ph t, qu, thc a, hoi sn, sn th, k t, trng, cam tho bc a. V k t dng lm thn bi v b. K t c tc dng b can thn

A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai
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8. Trong nhm huyt n b thn dng gm thi xung, quang minh, can du, thn du, tam m giao, thi kh, phi dng, mnh mn, trung cc, quan nguyn, kh hi a. Chm huyt trung cc cha chng ri lon tiu tin bi v b. Huyt trung cc l m huyt ca bng quang, chm vo b thn dng kh ho bng quang

A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai
9. Trong nhm huyt n b thn dng gm thi xung, quang minh, can du, thn du, tam m giao, thi kh, phi dng, mnh mn, trung cc, quan nguyn, kh hi a. Chm t huyt thi xung thanh can ha, bi v b. Thi xung l du th huyt ca can

A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai
10. Trong nhm huyt n b thn dng gm thi xung, quang minh, can du, thn du, tam m giao, thi kh, phi dng, mnh mn, trung cc, quan nguyn, kh hi a. Chm b huyt quan nguyn cha chng thn dng suy bi v b. Quan nguyn l ca ca nguyn kh, nguyn dng

A. Nu a ng, b ng, a v b c lin quan nhn qu B. Nu a ng, b ng, a v b khng lin quan nhn qu C. Nu a ng, b sai D. Nu a sai, b ng E. Nu a sai, b sai

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Bi 24

LIT MT NGUYN PHT

MC TIU 1. Nu c yu t dch t hc ca lit mt nguyn pht. 2. Lit k c triu chng lm sng chn on lit mt nguyn pht. 3. Lit k c nhng bnh l cn chn on phn bit vi lit mt nguyn pht. 4. Trnh by v gii thch c c s l lun ca vic iu tr.

1 . I CNG 1.1. nh ngha Lit mt nguyn pht l lit ngoi bin ton b na bn mt, nguyn nhn cha r, c khi u t ngt v a phn c tin lng tt. 1.2. Dch t hc Lit mt nguyn pht l th bnh thng gp nht trong cc loi lit mt ngoi bin, cn c gi l lit Bells (Bells palsy). T l mc bnh (IR) khong 23/100000/nm hay 1/60 - 70 ngi trong sut cuc i ca h. 2. NGUYN NHN V C CH BNH SINH 2.1. Theo y hc hin i 2.1.1. Gii phu hc Nhn dy thn kinh mt (s VII) bt u t phn thp ca cu no. Sau khi vng qua nhn dy thn kinh vn nhn ngoi (s VI), dy thn kinh mt chui ra khi thn no ( rnh cu - hnh no). Sau khi ri thn no, dy thn kinh mt, c km theo dy ph Wrisberg (dy VII bis, chu trch nhim v cm gic), ng mch v m ri tnh mch, chy xuyn qua xng trong mt ng xng: vi Fallope (aqueduc de Fallope). 420

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ng xng ny c hnh ca li l cm u sng. V th, on dy thn kinh mt c chia ra lm 3 phn: hch gi (on thn kinh nm gia on 1 v 2) l ni nhn nhng si cm gic ca dy ph Wrisberg, ng thi cng l ni xut pht si thn kinh nng ln; on th 3 ca dy thn kinh mt, xut pht t thng nh (chorda tympani). Si ny sau khi chy xuyn qua hp nh, s ni vi dy thn kinh li. Dy thn kinh mt chui ra khi xng l chm, tip tc i vo vng mang tai v phn thnh 2 nhnh tn cng phn b cho cc c vng mt. 2.1.2. Sinh l hc Chc nng ca dy thn kinh mt bao gm: Chc nng vn ng: dy thn kinh mt phn b n tt c c mt (tr cc c thi dng, c nhai v c chn cnh bm) v c nh hng n thnh gic vi vic tham gia vo vn ng c ca xng e. Chc nng cm gic: dy thn kinh mt nhn cm gic ca loa tai v ng tai ngoi, vng sau tai, vi Eustache v 2/3 trc li. Chc nng gic quan: dy thn kinh mt chu trch nhim v gic ca 2/3 trc ca li (thng qua dy thn kinh li v thng nh). Chc nng vn mch v bi tit: dy thn kinh nng ln phn b n cc tuyn l (thng qua trung gian ca hch Gasser). Thng nh chu trch nhim vic bi tit nc bt ca hch di hm v di li. C ch bnh sinh ca lit mt nguyn pht cha r rng. Trc y, vai tr ca lnh c cp n qua: + C ch mch mu: do co tht nhng ng mch chy theo dy VII trong vi Fallope dn n ph v vim phn ng ca dy VII. Ph n lm dy b chn p trong khung xng ca vi Fallope. + C ch nhim trng: v nhn thy c v trong vi trng hp lit mt nguyn pht c lin quan n nhim virus. y l trng hp tn thng vim trc tip dy VII v vai tr ca lnh c cho l to thun cho s pht trin ca virus xm nhp t vng hng hu ln vng Fallope. Tuy nhin, nhng gii phu t thi ca nhng cng trnh nghin cu sau ny cho thy khng c nhng thay i ng ghi nhn, khng c nhng phn ng vim nh thng gi nh trc y. 2.2. Theo y hc c truyn Theo YHCT, lit mt ngoi bin c m t trong nhng bnh danh khu nhn oa t trng phong nuy chng. Nguyn nhn gy bnh:

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Ngoi nhn: thng l phong hn, phong nhit tha lc tu l s h xm nhp vo cc kinh dng u v mt. Bt ni ngoi nhn: do chn thng vng u mt gy huyt li cc lc trn. Nhng nguyn nhn ny lm cho kh huyt ca lc mch vng u mt b cn tr hoc b tc li, gy nn chng nuy (yu lit), c th km theo t v au (khng thng th au).

NGOI NHN (phong hn, phong nhit)

NGUYN NHN KHC (bt ni ngoi nhn)

Chnh kh suy Kh huyt khng thng lc mch vng u, mt

Huyt

KHU NHN OA T, NUY CHNG, TRNG PHONG

Hnh 24.2. S nguyn nhn v c ch bnh ca lit mt

3. CHN ON 3.1. Theo y hc hin i Bnh khi pht t ngt, triu chng lit xut hin hon ton thng trong vng 48 gi. C th au sau tai trc 1 - 2 ngy, c th km tai, thng chy nc mt sng. Lit ton b c mt mt bn, mt np nhn trn, mt np m mi; nh hng n ting ni, n ung. Mt nhm khng kn: Charles - Bell (+). Mt tr nn tr cng, mt b lch v bn lnh. Mt v gic 2/3 trc li.

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Mt nhng phn x c s tham gia ca c vng quanh mt nh phn x gic mc (cm gic ca gic mc vn gi nguyn). 3.2. Theo y hc c truyn Da vo nguyn nhn v c ch gy bnh nu trn, YHCT xp thnh 3 th bnh ch yu sau y 3.2.1. Phong hn phm kinh lc Th bnh lm sng thng xut hin trong nhng trng hp lit mt do lnh. Triu chng nh trn (phn YHH), km theo ngi gai lnh, s lnh. Hon cnh khi pht bnh t nhiu c lin quan n yu t thi tit lnh nh sau khi gp ma, ma lnh, ru li trng mng, mch ph. 3.2.2. Phong nhit phm kinh lc Th bnh lm sng thng xut hin trong nhng trng hp lit mt do nguyn nhn vim nhim. Triu chng nh trn (phn YHH), km theo ngi st, s gi, s nng, ru li trng dy, mch ph sc. 3.2.3. Huyt kinh lc Th bnh lm sng thng xut hin trong nhng trng hp lit mt do nguyn nhn chn thng hoc khi chon ch. Triu chng nh trn (phn YHH) v lun c km du au, xut hin sau mt chn thng hoc sau m vng hm mt - xng chm. 4. CHN ON PHN BIT Cn chn on phn bit vi nhng trng hp lit mt ngoi bin th pht sau: Chn thng s no: c tin cn chn thng u, c chy mu tai cng bn lit. Di chng sau gii phu vng hm mt - xng chm. Zona hch gi: km au nhc trong tai v na bn mt, xut hin cc nt nc nh vng Ram say - Hunt. U tuyn mang tai: khi u vng tuyn mang tai, khng mt v gic 2/3 trc li. U dy thn kinh s 8: du tn thng thnh gic v tin nh, khng mt v gic 2/3 trc li. 423

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Vim dy thn kinh trong hi chng Guillain - Barr: thng lit mt c 2 bn, km nhng triu chng d cm ca vim a dy thn kinh, ri lon dch no ty. 5. IU TR Do c ch gy bnh cha r nn vic iu tr ch yu l gii quyt triu chng 5.1. iu tr bng thuc 5.1.1. Th phong hn phm kinh lc Php tr: khu phong, tn hn, hot lc; hot huyt, hnh kh. Bi thuc s dng: K u nga Qu chi K huyt ng Ut kim Hng ph 12g 8g 12g 8g 8g Tang k sinh Bch ch Ngu tt Trn b 12g 8g 12g 8g

5.1.2. Th phong nhit phm kinh lc Php tr: + Khu phong, thanh nhit, hot huyt (khi c st). + Khu phong, b huyt, hot lc (khi ht st). Bi thuc s dng: Kim ngn hoa Th phc linh Xuyn khung Ngu tt 5.1.3. Th huyt kinh lc Php tr: hot huyt, hnh kh. Bi thuc s dng: Xuyn khung Ngu tt Ut kim Trn b 424 12g 12g 8g 6g an sm T mc Ch xc Hng ph 12g 8g 6g 6g 16g 12g 12g 12g B cng anh K u nga an sm 16g 12g 12g

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5.2. iu tr bng chm cu C th ni phn ln nhng trng hp lit mt ngoi bin ch cn p dng phng php tr liu bng chm cu, xoa bp v tp luyn c t kt qu cao. Cng thc huyt gm: + Ton trc, n ng, thi dng, dng bch, nghinh hng, gip xa, h quan, a thng. y l nhng huyt ti ch trn mt (thay i theo ngy). + phong, phong tr: khu phong. + Hp cc bn i din. K thut: + Phn ln l n chm (v a s trng hp lit mt l do lnh). n chm cng ng thi c ch nh trong trng hp huyt (do sang chn). Nu thuc th phong nhit phm lc mch th k thut s dng l chm t. + Trnh s dng in chm do nguy c gy co tht phi hp mt (synkinesis) v co cng mt v sau (facial spasm). Nu s dng in tr liu, ch dng dng in Galvanic ngt on. 5.3. Vt l tr liu phc hi chc nng 5.3.1. u im Bo v mt trong lc ng. Xoa bp v chm nng c mt vng lit. Tp luyn c bng ch ng tr gip v tin ti tp ch ng c khng. 5.3.2. K thut Xoa bp: + Ngi bnh nm nga, u k trn gi mng. + Thy thuc ng pha u ngi bnh. + Vut t di cm ln thi dng v t trn hng xung tai. + Xoa vi cc ngn tay khp kn, xoa thnh nhng vng nh. + G nh nhanh vng trn v quanh mt vi cc u ngn tay. Tp luyn c: ngi bnh c gng thc hin cc ng tc + Nhm hai mt li. + Mm ci. 425

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+ Hut so v thi. + Ngm cht ming. + Ci thy rng v nhch mi trn. + Nhn trn v nhu my. + Hnh 2 cnh mi. + Pht m nhng m dng mi nh b, p, u, i

T lng gi I. Cu hi 5 chn 1: chn cu ng 1. T l mc bnh lit mt nguyn pht

A. 5 - 9/100.000/nm B. 10 - 14/100.000/nm C. 15 - 19/100.000/nm D. 20 - 24/100.000/nm E. 25 - 29/100.000/nm


2. T l mc bnh lit mt nguyn pht trong sut cuc i ca mt ngi

A. 1/30 - 39 ngi B. 1/40 - 49 ngi C. 1/50 - 59 ngi D. 1/60 - 70 ngi E. 1/70 - 80 ngi
3. Du hiu quan trng chn on lit mt ngoi bin

A. Charles-Bell (+) B. Mt v gic 2/3 trc li C. Khng hnh mi c D. Np m mi m hoc mt E. Nhn trung lch v mt bn

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4. Huyt phong s dng trong iu tr lit mt nguyn pht, c chn theo nguyn tc

A. Ti ch B. Theo ng kinh C. c hiu D. Ti ch v theo ng kinh E. Ti ch v c hiu


5. T th bnh nhn trong xoa vut mt

A. Nm nga, u k trn gi mng B. Nm nghing, mt bn lit hng ln trn C. Ngi, u nga ra sau D. Ngi, chng tay di cm E. Ngi, u nghing sang bn
II. Cu hi 5 chn 1: chn cu sai 1. Lit mt ngoi bin xut hin trong

A. Zona hch gi B. U dy thn kinh s 8 C. Hi chng Guillain - Barr D. U tuyn mang tai E. Chn thng s no
2. Triu chng bt buc c trong lit mt ngoi bin

A. Mt v gic 2/3 trc li B. Mt nhm khng kn C. Ming khng ngm cht c D. Khng nhn trn c E. Khng nhu my c
3. Triu chng xut hin trong lit mt ngoi bin

A. Np nhn trn m hoc mt B. Np m mi m hoc mt C. Charles - Bell (-)


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D. Np khe chy s xung bn lit E. Khng nhu my c


4. Triu chng xut hin trong lit mt ngoi bin

A. Mt nhm khng kn B. Khng nhn trn c np nhn trn m hoc mt C. Khng nhu my c D. Khng nhch mp v bn lit c E. Khng cn cht rng bn lit c
5. Nhng phng tin iu tr p dng c cho lit mt nguyn pht

A. Xoa bp B. Tp luyn c C. n chm D. in chm E. Chm nng


III. in vo ch trng 1. Trong nhm huyt iu tr lit mt nguyn pht

A. Huyt ton trc c chn theo nguyn tc .. B. Huyt h quan c chn theo nguyn tc .. C. Huyt phong c chn theo nguyn tc .. D. Huyt phong tr c chn theo nguyn tc .. E. Huyt hp cc c chn theo nguyn tc ..
2. T th ngi bnh v thy thuc trong xoa bp vng mt

A. T th ngi bnh:.. B. T th thy thuc:


3. M t k thut xoa bp iu tr lit mt

A. Vut: .. B. Xoa: .. C. G: .

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Bi 25

BI NO

MC TIU 1. Nu c nh ngha v nhng yu t dch t hc ca bi no. 2. Trnh by c nguyn nhn v c ch sinh bnh ca bnh bi no theo l lun YHCT. 3. Chn on c th lm sng theo YHCT. 4. Trnh by c nhng nguyn tc iu tr bnh theo YHHD v YHCT. 5. Trnh by c phng php iu tr bi no (dng thuc v khng dng thuc ca y hc c truyn). 6. Gii thch c c s l lun ca vic iu tr bi no bng YHCT.

1. I CNG Danh t bi no c dng ch mt nhm bnh thn kinh: Xut hin t khi sinh. Biu hin lm sng rt a dng v nng n. Nguyn nhn cng rt phong ph. Mc d bt thng v vn ng l du hiu ni bt nht, nhng rt thng gp km theo nhng sa st v tr thng minh, v pht trin tnh cm, ngn ng v nhn thc. Theo YHCT, bnh nm trong phm vi chng ng tr, ng nhuyn, nuy. 2. NGUYN NHN GY BNH 2.1. Theo y hc hin i Lm sng da vo s pht bnh trc v sau sinh khng ging nhau, c th phn lm ba loi: trc sinh, trong sinh, sau sinh.

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2.1.1. Trc sinh Nguyn nhn ch yu do thiu oxy no ca thai nhi trong t cung (da sy, xut huyt do chn thng trong thai k), trong thi k mang thai m b cm, xut huyt. Hoc m b cao huyt p, tiu ng, t, chn thng thai, tip xc cht c. Yu t di truyn c vai tr trong 10% trng hp. 2.1.2. Trong sinh Nguyn nhn do tc i, nhau chong hoc sinh kh, chn thng lc sinh gy ra thiu oxy no hoc chy mu no Sau sinh: nguyn nhn do co git ko di sau sinh, vng da, vim no, chn thng s no gy thiu oxy no hoc xut huyt no. 2.2. Theo y hc c truyn YHCT khng c t bi no. Nhng biu hin ca bnh nh yu lit, chm pht trin tr tu c xp tng ng vi chng nuy, chng ng tr, chng ng nhuyn. Theo quan nim YHCT: no l b ty, c quan h mt thit vi thn. Nu thn tinh bt tc, khng nui dng c ct ty s lm no b h rng. Can thn ng ngun, thn thy y s dng c can mc tt. Nu thn thy suy h, can mc b tht dng (do can ch cn, nn khi can b tht dng s xut hin cn suy yu). V th, nu can huyt bt tc, thn kh h u dn n no tht dng, b ty suy yu khng nhun c cn khin chn tay bt dng. ng nhin t v h cng nh hng n ngun sinh huyt, huyt khng dng c can, can tng huyt khng , a n cn tht dng gy nn chng nuy. Do n nhit c t hoc nhit khin cho ph b nhit nung nu m tn dch tiu hao. Ph khng lm trn vai tr thng iu thu o, li khng lm trn vai tr Tng ph chi quan i vi tm tng nn kh huyt khng n do cn mch ton thn khng c nui dng nhu nhun m sinh ra chng nuy. Do chn thng (bt ni ngoi nhn) gy huyt lm tc tr kinh lc sinh chng nuy.
Error!

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NGOI NHN

CHN THNG

TIN THIN BT TC

HU THIN THT DNG

Huyt h

Thn h

T h

Cn khng c nui dng

No ty thiu dng

NUY CHNG, NG TR, NG NHUYN

Hnh 25.1. S bnh bi no theo YHCT

3. TRIU CHNG LM SNG 3.1. Theo y hc hin i Ni chung, cc th lm sng ca bi no u c pht hin nh vo s chm pht trin ca tr (c th cht v tr thng minh) so vi tr cng tui. Thi gian m cha m tr pht hin c s bt thng ca tr ty thuc vo mc trm trng ca bnh, nhng thng l trong vng 12 n 18 thng tui ca tr (trong mt s trng hp c pht hin tr hn sau 2 nm khi cha m thy tr chm v kh khn khi i). Nhng du hiu lm sng c th thy trong bi no gm: Lit trung ng: rt a dng; c th lit hai chi di, lit na ngi, lit t chi. Do bnh thng xy ra tr cn nh nn du hiu sm cn ch nh ng tc khng t ch, ma vn, c co git. Sau sinh vi thng c th thy c mm, lng yu ngi khng c, c bit hai chn di rt t c ng, ng ti l co git, phn x gi gt gim. Ty theo biu hin m phn ln cc trng hp c th c xp vo mt trong nhng hi chng lm sng ring bit. Lit cng 2 chi (spastic diplegia - littles disease): y l th thng thy nht, c th km hoc khng ri lon tr tu. Mc lit rt thay i t nh (ch c yu, chm i hn tr bnh thng, tng phn x gn c h chi) n rt nng (tr khng kh nng bc i, t chi gng cng, ni kh, nut kh). Lit 2 chi th tiu no (cerebellar diplegia): ch yu lit mm, trng lc c gim, khng c xut hin nhng vn ng v nhng xut hin du lay trng mt (nystagmus), tht iu khng i xng c t chi. 431

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Lit na ngi tr em (infantile hemiplegia): bnh c th xy ra c 2 bn (double hemiplegia). Trong trng hp ny phn bit vi lit 2 chi th tiu no bng vic chi trn b nng hn chi di. Bnh c th xut hin ngay sau khi sinh (u nang bm sinh bn cu no, nhi mu no trong t cung) nhng thng xut hin trong thi k tr cn nh (sau ho g hoc sau tnh trng co git do st cao). Du lm sng thng thng l chi trn b lit nng (bn tay v ngn tay hon ton mt vn ng, tay v cnh tay co cng trc ngc), tri li chi di li b nh hn, d cng c tnh trng cng, tng phn x gn c. Bnh nhi vn bc i c, v i khi rt ng ngc nhin, i khng kh khn lm. Nu v no u th b tn thng, tr s khng ni c. Chm pht trin tr tu, tr lc km: vic chn on chm pht trin tr tu trong thi gian tr cn nh rt kh khn. Cn phi c k nng v kinh nghim khi thm khm tr pht hin mc pht trin tr tu ca tr bnh so vi tui ca tr bnh thng (ci, mt theo di nh sng di ng, ly vt, pht m tng t v ch). Cn phn bit r nhng trng hp suy gim chc nng vn ng (apraxia), cm gic (agnosia), gic quan (ic), nng lc ni (aphasia, articulatory apraxia, dyslexia) khin cho ta cm gic tr b chm pht trin tr tu (thng vic phn bit ny c kh khn v i khi cn n nhng test v tr thng minh IQ test), mt s xut hin ng kinh, in, chy nc ming, nut kh, c mt, mt t, cng. 3.2. Theo y hc c truyn 3.2.1. Th thn tinh bt tc T chi lit, teo. Pht trin th cht v tr tu km: ni khng r, thp khng kn, c, lng mm. Ru li trng, mch vi t. 3.2.2. Th can thn m h Lit hai chi di, c, gy cng, chn tay c ng chm. Khi ng chn co rt, bc khng thng. Mt, mt co ko, ni khng r. Li , mch vi sc. 3.2.3. Th m, tn h Lit t chi, c teo, mi ming kh nt, km st thp, o hn. Li ru nt, mch t sc. 432

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3.2.4. Th tc no lc Lit chi di, tr lc gim, tc rng, gn ni r mt, u. T chi quyt lnh. Cht li ti tm, mch t sp. 3.2.5. Th m thp ni tc Lit t chi, c m hng, c khi in hoc co git, km bun nn, nn ma. Ru li vng nht, mch hot sc. 4. CHN ON PHN BIT Vim a dy thn kinh: xut hin on xa thn kinh, phn b i xng, vn ng cm gic u b nh hng, in hnh u chi c cm gic mang gng hoc i tt, lit mm (nu c), phn x gim hoc mt. Vim ty: thng thy thanh nin, c ba c im ln: lit, gim cm gic, i tiu tin khng t ch. Lit do bnh c: thng pht tr khong nm tui, biu hin lm sng bng cc du hiu nh: t t xut hin t chi co mt lc v teo, phn x gn gim hoc mt, khng ri lon cm gic. C tin cn gia nh. 5. IU TR 5.1. iu tr bng thuc 5.1.1. Th thn tinh bt tc Php tr: chn tinh, ch ty, b thn kin no. Bi thuc: Hu quy hon gia gim Thc a Sn th Cu k Quy bn ng quy 5.1.2. Th can thn m h Php tr: t b can thn, tc phong, tim dng. Bi thuc: i nh phong chu gia gim (gm: xch thc 12g, bch thc 12g, a giao 12g, quy bn 12g, sinh a 12g, ng v 3g, mu l 4,5g, mch 433 15g 9g 9g 11g 15g Hoi sn Th ty t Nhung gic giao T h sa trng sao 15g 9g 12g 4,5g 15g

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ng 15g, chch tho 5g, k t hong 1 ci, mit gip 15g, chn chu 30g, a long 12g) Phn tch bi thuc:
V thuc A giao Quy bn Mit gip Sinh a Ng v t Mch mn K t hong Mu l Bch thc Xch thc a long Cam tho Tc dng V ngt, tnh bnh: t m, b huyt Ngt, mn, hn; t m, b tm thn V mn, hn: vo can, ph, t: dng m, nhun kin, tn kt Hn, ngt, ng: nui thn, dng m, dng huyt Chua, mn, n: c thn, lim ph; c tinh, ch m hi, cng gn ch kh, b ng tng Ngt, ng, mt: nhun ph, sinh tn T m huyt, tc phong Mn, cht, hi hn: t m, tim dng, ha m, c sp ng chua, hi hn: dng huyt, lim m, li tiu, nhun gan ng, lnh: thanh nhit, lng huyt Mn, hn, vo kinh t, v, thn: thanh nhit, trn kinh, li tiu, gii c Ngt, bnh: b t, nhun h, gii c Vai tr Qun Qun Thn Qun Thn Thn Thn Thn Thn, T T T S

5.1.3. Th m tn h Php tr: t m, sinh tn. Bi thuc: Tng dch thang (gm: sinh a 30g, mch ng 30g, huyn sm 15g, sn dc 15g, sa sm bc 12g, sa sm nam 12g, thch hc 30g, thin hoa phn 12g) Phn tch bi thuc:
V thuc Huyn sm Sinh a Mch mn Thin hoa phn Hong lin Tc dng Mn, hi ng, hn; vo ph, v, thn: thanh nhit, lng huyt, t ha, gii c, sinh tn dch, tn kt Ngt, ng, hn vo tm, can, tiu trng, thn: thanh nhit, lng huyt, dng m, sinh tn Ngt, hi ng, hi lnh; vo ph, v: nhun ph, sinh tn, li niu Ngt, chua, hn; vo ph, v, i trng: sinh tn ch khi, ging ha, nhun to, bi nung, tiu thng ng, hn; vo tm, can, m, i trng, v: thanh nhit, to thp, thanh tm Vai tr Qun Thn Thn Thn, t T

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5.1.4. Th tc no lc Php tr: hot huyt ha ut, tnh no thng khiu. Bi thuc: Thng khiu hot huyt thang (gm: xch thc 15g, xuyn khung 6g, o nhn 9g, nhung hu 0,15g, an sm 15g, gng kh 3g, hong k 60g). Phn tch bi thuc:
V thuc Xch thc Xuyn khung o nhn an Sm Can Khng Nhung hu Hunh k Tc dng ng, lnh: thanh nhit, lng huyt, hot huyt Cay, n: hot huyt, ch thng, hnh kh, khu phong ng, ngt, bnh: ph huyt, hnh , nhun to, hot trng ng, lnh, vo kinh tm, tm bo: hot huyt, kh , iu kinh, thanh nhit n trung tn hn Ngt, n: sinh tinh, b ty, ch huyt Ngt, m, vo t ph: b kh, thng dng kh ca t, ch hn, li thy Vai tr Qun Qun Qun Qun T Thn Thn

5.1.5. Th m thp ni tc Php tr: kin t, ha m, tc phong, tnh no. Bi thuc: Hong lin n m thang (gm: hong lin 3g, bn h ch 9g, m tinh 3g, tch thc 9g, trc nh 9g, bch trut sao 9g, thin ma 15g, phc linh 15g, xng b 3g).
V thuc Xng b Bch trut Bn h Ch thc Phc linh Thin ma Hong lin Trc nh Tc dng Cay, n: n trng v, kch thch tiu ha, thuc b Ngt, ng, hi m: kin t, to thp, cm m hi Cay, n: h kh nghch, tiu m ng, chua, hi hn: ph kh, tiu tch, ha m, tr b Ngt, nht, bnh: li thy, thm thp, b t nh tm Ngt, cay, hi ng, bnh: thng thanh, ging trc, tn phong, gii c V ng, lnh: t tm nhit, gii kh bn nhit ca thiu m Ngt, hi lnh: thanh nhit, lng huyt Vai tr Qun Qun Qun Qun Thn T T T

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5.2. iu tr khng bng thuc 5.2.1. Nguyn tc chung trong phc hi di chng Thng thng phng php iu tr khng dng thuc c s dng phc hi di chng bi no. Vic phc hi di chng khng th tch ri vi tng trng chung ca tr, do m lun lun c s phi hp gia iu tr bng thuc v khng dng thuc cho mc tiu ny. Trong iu tr di chng ca bi no khng bng thuc, cn ch n h thng k kinh bt mch v nh phn c ch sinh bnh YHCT nu, bnh bi no c quan h cht ch n tnh trng ca tin thin v h thng thn. Cc k kinh u bt ngun t h thng thn - bng quang (thin ng du, sch Linh khu c on: Xung mch l bin ca 12 kinh, cng vi i lc ca kinh tc thiu m, khi ln t bn di thn (khi vu thn h).... Thin Bn du, sch Linh khu c on: Mch nhm v c bt ngun t thn v thng vi m dng ca tri t. Nhng mch m kiu, dng kiu, m duy v dng duy xut pht tun t t nhng huyt chiu hi, thn mch, trc tn, kim mn thuc h thng thn - bng quang). Trong ton b h thng k kinh vn dng vo iu tr, cn ch c bit n mch c (xem Chm cu hc , trang 150 - 152). 5.2.2. Phng php p dng c th Tc ng n mch c: ty tnh hnh thc t, c th tc ng bng nhiu cch khc nhau (cun da, xoa vut, g mai hoa .). Huyt s dng theo di chng: Ri lon tm thn: bch hi, ni quan, thn mn, an min. Lit c, vai, lng: phong ph, phong tr, thin tr. Lit chi trn: kin tnh, kin ngung, khc tr, xch trch, lit khuyt, hp cc, lao cung, bt t. Lit chi di: hon khiu, m lng, dng lng, y trung, c t, tha sn, gii kh, dng tuyn, bt phong. Ni kh: mn, nh mn, lim tuyn, thin t, ph du.

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T lng gi Cu hi 5 chn 1: chn cu ng 1. Nguyn nhn no khng phi l nguyn nhn sinh bnh bi no theo YHCT

A. Ngoi nhn B. Ni nhn C. Bnh lu ngy D. Tin thin bt tc E. Chn thng


2. C ch bnh no khng ph hp trong bnh bi no theo YHCT

A. Bnh lu ngy lm thn h suy khin can huyt h, cn khng c nui dng B. T h khin huyt h khng dng c cn, no C. n nhit c hun t tn dch nh hng n ph tm; hu qu l kh huyt khng n c cn, mch D. Chn thng gy huyt , huyt thot lm tc tr kinh lc E. Do tin thin bt tc khin no ty tht dng
3. C ch sinh bnh bi no theo YHCT

A. T h khin m thp tr kinh lc B. n nhit t hun t tn dch sinh m lm tc tr kinh lc C. Do ni m thp lu ngy, thp nh tr sinh chng nuy D. Chn thng gy huyt , huyt thot lm tc tr kinh lc E. Do bnh lu ngy lm tn thng can thn
4. Triu chng quan trng phn bit bi no th thn kh bt tc vi th can thn m h

A. Lit 2 chi hay t chi B. C chm pht trin tr tu hay khng C. C ng kinh hay khng D. Li hay khng E. C m hng hay khng
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A. Cht li ti tm, c im huyt hay khng B. Lit t chi hay lit na ngi C. C chm pht trin tr tu hay khng D. C ng kinh hay khng E. Lit cng hay lit mm
6. Triu chng quan trng phn bit bi no th tc no lc vi th m thp ni tc

A. Tay chn c lnh hay khng B. C m nht hng hay khng C. C lit hay khng D. C chm pht trin tr tu hay khng E. Li hay khng
7. V mit gip trong bi i nh phong chu gia gim (gm: xch thc, bch thc, a giao, quy bn, sinh a, ng v, mu l, mch ng, chch tho, k t hong, mit gip, trn chu, a long) tr bi no th can thn m h, c tc dng

A. T m b tm, thn: vai tr thn B. T m b tm, thn: vai tr qun C. T m tim dng: vai tr thn D. T m dng huyt: vai tr thn E. Dng m, nhun kin, tn kt: vai tr thn
8. V an sm trong bi Thng khiu hot huyt thang (gm: xch thc, xuyn khung, o nhn, nhung hu, an sm, gng kh, hong k) tr bi no th tc no lc, c tc dng

A. Sinh tinh, b ty, ch huyt: vai tr thn B. B kh, thng dng: vai tr thn C. Thanh nhit, lng huyt: vai tr qun D. Hot huyt, kh : vai tr qun E. B kh, sinh huyt: vai tr qun
9. V xng b trong bi Hong lin n m thang (gm: hong lin, bn h ch, m tinh, tch thc, trc nh, bch trut sao, thin ma, phc linh, xng b) tr bi no th m thp ni tc, c tc dng

A. Li thy, thm thp: vai tr thn


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B. H kh nghch, tiu m: vai tr thn C. n trng v: vai tr qun D. Kin t, to thp: vai tr qun E. T tm nhit: vai tr t
10. V bch trut trong bi Hong lin n m thang (gm: hong lin, bn h ch, m tinh, tch thc, trc nh, bch trut sao, thin ma, phc linh, xng b) tr bi no th m thp ni tc, c tc dng

A. Li thy, thm thp: vai tr thn B. H kh nghch, tiu m: vai tr thn C. n trng v: vai tr qun D. Kin t, to thp: vai tr qun E. T tm nhit: vai tr t

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Bi 26

VIM A DY THN KINH

MC TIU 1. Nu c nh ngha v nhng yu t dch t hc ca nhng loi bnh l thn kinh ngoi bin. 2. Trnh by c nguyn nhn v c ch sinh bnh ca bnh l thn kinh ngoi bin theo l lun YHCT. 3. Chn on c 06 th lm sng theo YHCT. 4. Trnh by c nhng nguyn tc iu tr bnh l thn kinh ngoi bin theo YHHD v YHCT. 5. Trnh by c phng php iu tr bnh l thn kinh ngoi bin (dng thuc v khng dng thuc ca y hc c truyn). 6. Gii thch c c s l lun cu vic iu tr bnh l thn kinh ngoi bin bng YHCT.

I. I CNG Tn thng thn kinh ngoi bin l tp hp nhiu bnh l vi nhng biu hin lm sng khc nhau. Khm lm sng trong hi chng ny rt quan trng c th tm ra c nguyn nhn. Vic tm kim ny cn thit n ni cho n tn ngy nay vn pht hin thm nhng hi chng mi v lm pht trin rt nhiu cho vic iu tr. c rt nhiu hi chng c nh ngha trc y: u tin l vim a dy thn kinh (polyneuropathy) vi bnh l tn thng hai bn, i xng, c ri lon cm gic hoc ri lon cm gic vn ng. y l bnh cnh thng gp nht. Vim nhiu dy thn kinh (multineuropathy, cn c gi l multiple mononeuropathy) m biu hin ca n khng i xng. Bnh cnh ny ch yu gp trong nhng bnh l thn kinh ngoi bin c lin quan n tnh trng vim ng mch nht l vim nt quanh ng mch, bnh tiu ng, bnh porphyrin.

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Cui cng l nhng trng hp vim a r dy thn kinh m tn thng xy ra tun t thn v r thn kinh, tn thng va xa va gn. Tnh cht cp hay mn ca bnh l ny c da trn tnh trng din tin ca bnh di hay trn 6 thng. II. BNH L TN THNG THN KINH NGOI BIN THEO Y HC HIN I A. VIM A DY THN KINH Bnh l thn kinh ngoi bin ny thng gp nht v c th xut hin trong nhiu bnh khc nhau, do nhiu nguyn nhn khc nhau gy nn. 1. Vim a dy thn kinh do dng thuc Phn ln cc trng hp l tn thng si trc dn n bnh cnh ri lon cm gic, hoc ri lon cm gic - vn ng; rt him khi ch biu hin ri lon vn ng. Bnh l ny thng gp hn nhng trng hp vim a dy thn kinh (VDTK) do c cht. 1.1. Tn thng si trc Tnh cht ch yu ca bnh l bn cp v mn. Nhng du chng u tin trong phn ln cc trng hp l ri lon cm gic ngn chi, di chuyn dn v gc chi. Triu chng ni bt l t, gim cm gic; hoc him hn l au ngn chn - bn chn, sau l bn tay. Biu hin lm sng giai on u thng ngho nn gm gim cm gic au v nng lnh phn xa ca chi di v gim phn x gn gt. Gim vn ng xut hin tr nht v thng ch l du bn chn rt. Du in c c gi tr quan trng. Du chng ny lc u xut hin chi di, sau mi xut hin chi trn. Tr trng hp c bit, dch no ty thng trong gii hn bnh thng. Gii phu bnh l thn kinh - c i khi cn thit cho chn on v cung cp t liu gi v mt nguyn nhn. Ngng dng thuc s lm gim VDTK. Tuy nhin s hi phc cn ty thuc rt ln vo c a (ln tui, c bnh km theo s lm chm thi gian hi phc), thi gian, mc trm trng ca ng c thuc v vo nhng yu t c nhn cn cha c bit r. 1.1.1. Almitrin (Bismesylate d) c pht hin u tin nm 1985 bi Ghrardi R. v cng s trn nhng bnh nhn sau thi gian di dng vectarion (bnh ng h hp mn tnh). Nm 1989, Bouche P. v cng s bo co v nhng tai bin sau thi gian di dng duxil (phi hp gia almitrin v raubasin).

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Bnh cnh l VDTK th ri lon cm gic - vn ng: ri lon cm gic xut hin trc tin v nh hng n tt c cc loi cm gic (au, nhit , rung, cm gic bn th). Bnh c din tin bn cp, chm v thng c km gy ton thn. Du lit vn ng n tr hn, xut hin u tin phn xa ca chi. Chn on xc nh nh in c v gii phu bnh (cho thy bnh bao myelin ca cc si thn kinh c ng knh trung bnh v ln). Cch iu tr tt nht l phng nga: khng dng thuc trn bnh nhn c nguy c ng c thn kinh (tiu ng, suy thn, ang dng mt loi thuc c thn kinh khc), ngng ngay thuc khi xut hin triu chng t chn. 1.1.2. Dapson Rt thng dng trong iu tr phong hoc mt s bnh ngoi da (nh Acne conglobata hoc nhim Pneumocystis carinii). Thuc d gy c khi dng n liu > 400mg/ngy trong mt thi gian di. Bnh cnh l VDTK nh hng n phn xa ca cc si trc vn ng, lm xut hin du lit tin trin cc phn xa ca t chi (c th nng hn chi trn) v km theo teo c. Du ri lon cm gic thng him gp. 1.1.3. DDC v DDI y l 2 loi thuc c dng gn y iu tr nhim HIV, nht l nhng trng hp khng hoc khng dung np vi zidovudin. Bnh cnh l VDTK kiu ri lon cm gic, mc nng nh ty thuc vo liu thuc s dng. Tnh cht lm sng c bit l au kiu nng rt cc u chi. Bnh lui dn sau khi ngng thuc. 1.1.4. Disulfiram Thng dng trong iu tr nghin ru, thng gy bnh cnh VDTK kiu ri lon cm gic v au. Liu c th gy c khi trn 125mg/ngy (Palliyath SK. 1990). 1.1.5. Isoniazid Gy bnh cnh VDTK kiu ri lon cm gic, c th phng nga vi B6. 1.1.6. Lithium Thng gy VDTK th ri lon vn ng, lm lit c t chi. C th kt hp vi mt s bnh cnh no cp trm trng.

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1.1.7. Metronidazol Ch gy bin chng thn kinh nu s dng di ngy nh trong iu tr bnh Crohn hay cc trng hp nhim trng him kh. Bnh cnh lm sng l VDTK kiu ri lon cm gic km au. Ornidazol v misonidazol cng c kh nng gy VDTK nh metronidazol. 1.1.8. Nitrofurantoin: gy VDTK kiu ri lon cm gic - vn ng 1.1.9. Podophyllin Dng ngoi da tr mn cc v cc condylomes. Loi thuc ny gy VDTK th cm gic hoc cm gic - vn ng khi bnh nhn ung (t t). Bnh thng km du chng tiu ha v bnh cnh no. 1.1.10. Thalidomid 1.1.11. Vidarabin Dng trong iu tr vim gan virus B, loi ny c kh nng gy VDTK th ri lon cm gic - vn ng nng, i khi km ri lon thc vt trm trng (Chauplannaz G. v cng s 1984). 1.1.12. Vincristin Thng dng trong iu tr cc bnh c tnh. Thng l gy VDTK kiu ri lon cm gic. Du hiu sm l t cc u chi. Khm lm sng pht hin gim cm gic au, nhit v bn th phn xa ca chi v mt phn x gn c, ri lon vn ng him thy. iu tr ngoi vic ngng thuc, c th s dng nhng thuc bo v thn kinh (acide glutamique, Jackson DW. 1988) (naptidrofuryl, Lger JM. 1994). Bnh l VDTK do dng thuc ngy cng phong ph. Tham kho tp ch thn kinh hc trong 10 nm gn y cho thy c nhng gi v nhng loi thuc tr cng gip carbimazol (Lger, 1984), cimetidin (Pouget, 1986), si - r ho codobromyl (Mabin, 1988), thuc tr vim i - trc trng chy mu salazosulfapyridin (Blin 1992), piroxicam (Sangla 1993). 1.2. Tn thng t bo thn kinh Tn thng xy ra cc t bo thn kinh cm gic, do cn c gi l tn thng hch thn kinh nguyn pht. Trn lm sng xut hin n thun ri lon cm gic, xut hin trc tin phn xa ca chi, tin dn v gc chi. Tht iu. Mt phn x gn c. in c c gi tr quan trng trong chn on. 443

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1.2.1. Cisplatin Rt thng dng trong iu tr ung th. Cn chn on phn bit vi VDTK trong cc bnh cn ung th. Vic phn bit nh vo khng th anti HV (-). 1.2.2. Sinh t B6: thng gp M do dng B6 liu cao v ko di. 1.3. Tn thng bao myelin Tn thng loi ny do dng thuc t gp nht. c im lm sng l ri lon vn ng c xa v gn, mt phn x gn c sm. Dch no ty thng c m tng cao. Chn on xc nh nh vo in c v sinh thit. 1.3.1. Amiodaron Thng dng cho ri lon nhp tim. Bnh cnh lm sng l VDTK kiu ri lon cm gic v vn ng. Cc ri lon cm gic r rt hn gm t v gim cm gic u chi, tht iu, mt phn x gn c. Dch no ty thng c tng protein. Chn on xc nh bng in c v sinh thit. Hi phc chm sau khi ngng thuc. 1.3.2. Cloroquin Thng biu hin di cc bnh cnh bnh thn kinh v c (neuromyopathy). Hi phc tt sau ngng thuc. 1.3.3. Tryptophan Dng lu di loi thuc ny thng lm xut hin hi chng au nhc c v tng t bo i toan. Trong 20 - 30% trng hp c km bin chng VDTK th cm gic - vn ng v au nhc. 1.3.4. Mui vng Thng dng trong iu tr vim a khp dng thp. C th gy bnh no nhng cng c th gy nn VDTK c km au nhc. Nm 1993, Petiot P. v cng s bo co trng hp vim a r dy thn kinh do dng mui vng. 2. Vim a dy thn kinh do ng c 2.1. Ng c acrylamid Tip xc lu di loi thuc c ny c th gy VDTK loi tn thng si trc kiu ri lon cm gic - vn ng. c bit c th km tn thng thn kinh trung ng, tiu no v thn kinh thc vt

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2.2. Arsenic Ng c arsenic cp: nn ma, tiu chy, sang thng da, bnh cnh no cp, bnh c tim, gan Ng c arsenic mn: du tng qut (nh mt mi, km n, nn ma), du ngoi da (da lng bn tay - bn chn dy ln, mng c nhng sc trng, da mt sc t), VDTK kiu ri lon cm gic - vn ng (thng nh hng cm gic bn th), teo c vng xa ca chi. iu tr bng dimercaptopropanolol (BAL) hay vi penicillamin. Phi theo di nhiu thng. Trong trng hp ng c ko di, s hi phc thng khng hon ton. 2.3. N-hexan Thng xy ra trong k ngh lm sn mi, lm keo. Bnh cnh lm sng l VDTK kiu cm gic, i khi c th c ri lon vn ng. 2.4. Phospho hu c Xy ra trc y trong k ngh lm thuc st trng, hin nay thy trong k ngh nha. Bnh cnh lm sng l VDTK kiu ri lon cm gic - vn ng, thng c km tn thng trung ng vi biu hin ca tn thng thp. iu tr bng atropin ch c tc dng trn hi chng cholinergic, khng c gi tr i vi VDTK. 2.5. Ch Bnh cnh lm sng l VDTK kiu ri lon vn ng biu hin ch yu chi trn, cc cn au bng, km th trng suy gim, mt mi, gy, km n. Xt nghim mu thng c thiu mu nhc sc hng cu nh. Chn on xc nh bng o lng ch trong mu v nc tiu. iu tr vi penicillamin, EDTA. 2.6. Thallium Thng xut hin vi bnh cnh VDTK kiu ri lon cm gic km au, ri lon tiu ha, vim thn kinh hu nhn cu v tn thng thn kinh trung ng. 2.7. Ru VDTK do ru xy ra trn 40% ngi nghin ru. Bnh cnh lm sng l VDTK c ri lon cm gic v vn ng, din tin m thm. Triu chng u tin xut hin phn xa ca chi di: vp b v m, t bn chn, i mau mt, au khi bp cc c. 445

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Mt phn x gn c xut hin sau , gim cm gic vng xa. Trong th in hnh, bnh nhn thng than phin au bn chn v chn. au kiu nng rt thng xuyn, lin tc vi nhng cn au nh in git. Yu lit cc nhm c cng chn trc lm xut hin du bn chn rt. Khm lm sng c gim cm gic kiu mang tt ( chi di), kiu mang gng ( chi trn), ri lon cm gic bn th t r rt, teo c, ri lon dinh dng, gim hoc mt phn x gn c. Chn on nh vo in c; dch no ty thng bnh thng, i khi m c th tng. iu tr vi sinh t, ch n giu m, gim au vi cc thuc tricyclic. 3. Vim a dy thn kinh do thiu dng 3.1. VDTK do thiu sinh t nhm B (B1, B6, B8, B12, acid folic) Nhng trng hp bnh do thiu sinh t nhm B, c th xut hin n c hoc kt hp vi thiu m v nng lng l nguyn nhn ca nhng bnh l VDTK v bnh no cp. Trong tt c cc trng hp u c s hin din ca ri lon cm gic ch quan, ch yu biu hin phn xa ca chi nh vp b, tng cm au (nht l cm gic nng rt lng bn tay - bn chn) i khi rt d di v c bit. Khm lm sng pht hin ri lon vn mch, ri lon cm gic phn xa ca chi (c cm gic nng v su), mt phn x gn c, du vn ng biu hin r chi trn v nhm c nng bn chn lm xut hin teo c cng tay v vng mt ngoi cng chn. 3.2. VDTK do thiu sinh t PP hay niacin Thiu sinh t PP c th lm xut hin mt bnh cnh VDTK v trong trng hp nng c th xut hin bnh cnh pellagra in hnh gm tam chng: sang thng ngoi da, tiu chy, ri lon thc (o gic, l ln). Bnh cnh ch xut hin trong trng hp ch n va thiu PP va thiu tryptophan (c vai tr trong tng hp PP ni sinh). Bnh thng thy trong mt vi trng hp ung th rut non khi 60% tryptophan b bin i sang serotonin. 3.3. VDTK do thiu sinh t E (tocopherol) Bnh cnh thng xut hin chung vi s thiu ht nhiu loi sinh t khc. Bnh cnh xut hin l VDTK din tin m thm, kt hp vi lit phi hp vn ng mt, tht iu th pht do teo v tiu no v gim th lc do tn thng vng mc (trm trng thm khi c thiu sinh t A phi hp). 446

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4. VIM A DY THN KINH TRONG CC BNH CN UNG TH Nhng hi chng thn kinh cn ung th c xc nh khi c bnh c tnh kt hp, ng thi khng thy bin chng di cn, bin chng do dng thuc iu tr, do bin dng, do thiu dng hoc nhim trng. Mc d t l xut hin thp (khng n 1% cc trng hp ung th) nhng vic xc nh bnh l, vic hiu bit v nhm bnh ny c 2 li ch: V l thuyt, mt s trong nhng bnh ny c v l bnh l t min. V thc hnh, n gip hng n chn on sm ung th trong 50% trng hp. Sau vi bi bo l t, n cui th k XIX v c bit sau bo co ca Denny Brown nm 1949; Henson, Urich, Brain, Corsellis nhng nm 50 m t gii phu lm sng cc bnh l ny. Trong nhng nm 80, s pht hin khng th t min trong huyt thanh lm sng t c ch sinh bnh hc ca mt vi hi chng (De Lattre J.Y. v cng s 1991) v cho php gi n phn loi bnh da trn c s hin din hay khng ca khng th t min, tn s xut hin ca hi chng thn kinh vi bnh ung th (Dubas F. 1992).
K phi hp Vim no ty bn cp cn K Thoi ha tiu no cn K Opsoclonus myoclonus paraneoplasiques Hi chng Lambert - Eaton Bnh vng mc cn K K ph qun K ph khoa K v (neuroblastome) K phi K phi Anti canaux Ca ++ Anti retin Khng th Anti-Hu Anti-Yo Anti-Ri

C th thy rng nhng bnh c tnh trc khi c pht hin c th gy tn thng trn h thn kinh. Tn thng rt a dng v c th xut hin nhiu t trung ng n ngoi bin vi cc triu chng phong ph no, tiu no, mt Thm ch c nhng trng hp tai bin mch mu no c ngun gc ung th xy ra do ng mu ni mch. Bi ny t gii hn trong nhng bnh l thn kinh ngoi bin cn ung th. 4.1. VDTK kiu cm gic cn ung th ca Denny Brown y l dng kh ph bin. Bnh cnh lm sng gm tht iu, ri lon cm gic nht l cm gic bn th, au nhc v c th km yu t chi. Bnh cnh lm sng thng c phi hp vi vim no (ri lon hnh vi, l ln), tn thng vng thn no (lit cc c mt, ri lon tin nh). Cn ch l trong 50% cc trng hp, ngi ta khng tm ra c bnh ung th (Authier F.J., De Lattre J.Y. 1992). 447

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4.2. VDTK kiu ri lon vn ng - cm gic cn ung th Phn ln l VDTK in hnh. Him hn l nhng trng hp VDTK din tin tng t vi nhng t gim bnh ri li ti pht. VDTK trong giai on cui thng l VDTK c nhiu nguyn nhn (thiu sinh t, thiu dng, do dng thuc). 4.3. VDTK kiu ri lon vn ng bn cp Xy ra t hn, hay gp trong lymphome c tnh. 4.4. Vim nhiu dy thn kinh hoc a r dy thn kinh Guillain - Barr Cng c nu trong din tin ca cc bnh c tnh (Hodgkin). 5. VIM A DY THN KINH TRONG CC BNH THOI HA, DI TRUYN Loi ny c xp vo 3 nhm chnh: a. VDTK di truyn kiu ri lon cm gic - vn ng (neuropathies sensitivo - motrices hrditaires). b. VDTK di truyn kiu ri lon cm gic v thc vt (neuropathies sensitives et dysautonomiques hrditaires). c. VDTK di truyn kiu vn ng (neuropathies motrices hrditaires). Trong tng nhm, c nhiu typ bnh khc nhau: Nhm a: VDTK di truyn kiu ri lon cm gic - vn ng (neuropathies sensitivo - motrices hrditaires). Typ I: bnh Charcot Marie - Tooth c thoi ha myelin v ph i c. Typ II: Bnh Charcot Marie - Tooth c tn thng t bo thn kinh. Typ III: Bnh Djeurine Sottas. Typ V: Kt hp vi lit 2 chi di co cng. Typ VI: Kt hp vi teo thn kinh th. Typ VII: Kt hp vi vim vng mc sc t. Typ IV: Tng ng vi bnh Refsum. Nhm b: VDTK di truyn kiu ri lon cm gic v thc vt (neuropathies sensitives et dysautonomiques hrditaires). Typ I: Bnh Thvenard th tri. Typ II: Bnh Thvenard th ln. Typ III: Ri lon thc vt gia nh (HC Riley-Day). Typ IV: Khng c cm gic au bm sinh. 448

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Typ V: Bnh thn kinh ngoi bin bm sinh vi mt chuyn bit cc si c bao myelin ng kinh nh. 6. VIM A DY THN KINH TRONG CC BNH BIN DNG 6.1. VDTK do tiu ng Tn thng thn kinh ngoi bin l bin chng thng gp. Nhng nghin cu dch t hc gn y nht cho thy du lm sng khch quan ca bin chng thn kinh gp 13% bnh nhn tiu ng di 60 tui, 33% bnh nhn tiu ng trn 60 tui; du lm sng ch quan ca bin chng thn kinh gp 28% bnh nhn tiu ng di 60 tui, 48% bnh nhn tiu ng trn 60 tui. nh hng trn tn s xut hin bnh, ngoi yu t tui tc nu trn, cn c yu t v thi gian mc bnh tiu ng v vn kim sot bin dng. 6.1.1. Lm sng a. Th ri lon cm gic T 2 chi di, i xng, ngn chi nng hn gc chi. au d di nh chy bng, au nh xon vn su trong c. Cm gic khch quan t khi b ri lon, tr cm gic su. Phn x gn c mt, ri lon vn mch v teo c, km theo lot lng bn chn; ra nhiu m hi. b. Th ri lon vn ng - cm gic Lit i xng 2 chi di ca cc c mt ngoi v trc cng chn, lit 2 bn (bn chn r) v tin trin nhanh. Ri lon cm gic khch quan rt m h, t c ri lon dinh dng. Bnh din tin ko di v vic iu tr bnh tiu ng giai on ny thng t c hiu qu. c. Th gi bnh Tabes au ging nh trong bnh Tabes (au rt d di). Ri lon cm gic su (long chong). Mt phn x gn c. Ngoi ra, nhng bnh lit 4 chi bn cp cng c ghi nhn, hnh th lm sng ging vim a r v dy thn kinh. 6.1.2. iu tr iu tr ng mc bnh nguyn (tiu ng) c gi tr phng nga bin chng VDTK, nht l th ch c ri lon cm gic. 449

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Sinh t B1, B12 liu cao. Thuc gim au trong trng hp au nhiu, thuc gin mch t c tc dng. Ch ngn nga bin dng khp do teo c. 6.2. VDTK do porphyrin L bnh bin dng, mang tnh di truyn r rt. 6.2.1. Du chng chn on Bnh thng xut hin nhn c hi dng mt loi thuc no . Bnh xy n cp tnh trong vi gi (t khi ko di nhiu ngy): khi u vi triu chng t, au nhc c chi v thn, lit lan rng 4 chi hoc tri hn chi trn; tn thng dy s VII v cc dy vn nhn. Ri lon cm gic trong 50% trng hp, thng gc chi (nh mc o tm). Phn ly cm gic (cm gic su cn). Tn thng thc vt: thng l ri lon c vng; ri lon tim mch c th din tin tng dn. Cc ri lon thn kinh khc: ri lon tm thn (40%), cn ng kinh (20%). Biu hin khc: au bng, da d nhy cm vi nh nng. in c: tn thng si trc, nhng khng nh hng n vn tc dn truyn. Xt nghim nc tiu: trong thc hnh lm sng, ri lon chuyn ha porphyrin c th c xc nh khi nc tiu ngoi khng kh lu 24 gi: nc tiu c mu nu . C th o lng porphobilinogen trong phn. 6.2.2. Din tin T vong khong 20 - 30% do ngng tim hoc ngng h hp. Nu sng, bnh din tin 2 - 3 tun, thi gian lui bnh chm, phc hi khng hon ton. 6.2.3. iu tr Truyn hematin (lm ngng tng hp porphyrin). iu tr triu chng: gim au, an thn, ri lon tm thn, ng kinh, hi sc tch cc (trong suy h hp v ri lon tim mch). 450

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7. VIM A DY THN KINH TRONG BNH BCH HU Bnh ny cho n ny rt him gp, nhng d nhn trn lm sng, thng gp ngi ln v trong cc v dch. Bnh ch xy ra trong cc th bch hu c tnh. 7.1. Lm sng 7.1.1. Th cc b Th ny c t l cao nht, xy ra sm. Du hiu u tin l lit hng (c khi triu chng ch l ni ging mi, nut sai ng vo kh qun). Khm thy vm hu h thp v gn nh bt ng. Phn x vm hu v thanh qun gim. C khi ch lit na vm hu. C khi lit thanh qun m khng lit vm hu. Nim mc vm hu v thanh qun tr nn ti, gim hoc mt hon ton cm gic. Lit ko di thng 4 - 5 ngy (c th lu hn, nhng t khi tr nn mn tnh). 7.1.2. Th lan rng Th lan rng theo sau th lit vm hu trn, lit c mt, thng lit cc c nh hng n chc nng iu tit (khng nhn gn, khng nhn vt nh c) cn cc c co ng t vn bnh thng. Bnh c th khi t 8 10 ngy sau. 7.1.3. Th ton thn y l giai on bnh mun, theo sau th cc b. Yu hoc lit mm 2 chn, mt phn x. Ri lon cm gic nng khch quan, km theo ri lon cm gic su. Ri lon dinh dng t. Phn ng in gim. Dch no ty: m tng (40mg-200mg/l); t bo tng 10-20/mm3, a s l t bo lympho. 7.1.4. Th gi Tabes Ri lon cm gic su, Romberg (+). Cm gic nng t b tn thng. Phn x gn c mt. 451

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Nhng th lm sng nu trn u thuc dng bn cp. Tin trin ca chng ni chung chm nhng d hu thng tt. 7.1.5. Th cp tnh Tin trin nhanh, lan ton thn. Khi u lit 2 chn ri lan ln 2 tay, c thn, c, c h hp. C nhng trng hp c biu hin ging nh hi chng Landry, din tin i ln dn. T vong do tn thng hnh ty (tim p nhanh thng xuyn, th khng u hoc ngt t ngt). 7.2. Din tin Lit vm hu c th din bin theo 2 hng: hoc lnh tnh (ch khu tr ti vng hu) hoc lan rng nhanh chng nh th cp tnh. Nu lit xy ra tr (30 - 70 ngy): ch lit nhm c vn nhn. C th lit din tin qua 2 giai on: khi u lit vm hu, ri bnh khi dn. Sau 20 - 30 ngy: lit li lan rng ra ton thn. 7.3. iu tr Quan trng nht l phng nga, iu tr ng mc v kp thi bnh bch hu. Huyt thanh khng bch hu: tr em 30.000 n v, ngi ln 60.000 n v. Khi c triu chng thn kinh, vn tip tc s dng huyt thanh iu tr, nu lc khi u bnh nhn cha c iu tr y bng huyt thanh. B. VIM NHIU DY THN KINH y l bnh vim nhiu dy thn kinh lan ta, tn thng ng thi nhiu dy thn kinh cch xa nhau, tn thng khng i xng, khng ng b, biu hin bng cc triu chng au, lit v teo c. Trong giai on u, bnh ging nh vim mt dy thn kinh. Trong qu trnh tin trin, tn thng nhiu dy thn kinh ging nh trong bnh vim a dy thn kinh. Nguyn nhn gy bnh chnh xc v c ch sinh bnh cn ang c tranh lun. Cc nguyn nhn chim t l hng u l vim nt quanh ng mch v cc bnh l v mch mu, bnh tiu ng, bnh porphyrie cp, bnh phong, cc bnh v nhim c, nhim trng. Cn li mt s khc khng r nguyn nhn. V bnh sinh, hin c 3 c ch c cp: Hin tng thiu mu: c cp n trong cc bnh vim nt quanh ng mch, cc bnh v mch mu, tiu ng, bnh amylose, bnh porphyrie. 452

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Hin tng thm nhim v chn p si thn kinh: hay thy trong bnh phong. Hin tng ri lon dinh dng ti ch: xy ra nguyn pht hoc th pht sau qu trnh thiu mu v chn p. Cc yu t ti ch tn thng: phn tch c cc yu t ny rt kh 1. LM SNG 1.1. Bnh cnh chung Khi u t ngt trong vi pht n vi gi vi cc triu chng d cm, au kiu r v thn dy thn kinh, t khi xut hin cc triu chng ca dy thn kinh s no. Bnh tin trin tng dn. Triu chng vn ng xut hin: gim vn ng, gim phn x gn c. Ri lon cm gic khch quan khng r rt, xy ra chm hn du vn ng v khu tr vng thn cc dy thn kinh b tn thng. Cc dy thn kinh thng b tn thng l: thn kinh hng khoeo ngoi bn tri hoc 2 bn, thn kinh tr bn phi hoc thn kinh quay. chn on, dng phng php kch thch dng in, ghi in c. Khi c tn thng c r dy thn kinh s c phn ng tng nh m trong dch no ty. Din tin ty thuc vo nguyn nhn v tu thuc iu tr, lit c th khi hon ton hoc gim mt phn hay ngc li bnh nng dn vi thng tn ngy mt lan rng hn. 1.2. Th lm sng theo nguyn nhn 1.2.1. Vim nhiu dy thn kinh do cc bnh ca ng mch a. Vim nt quanh ng mch Bnh cn c gi l bnh Kussmaul - Maier. Nhng biu hin v thn kinh thng xut hin sau cc triu chng c bit ca bnh ny khong 4 thng (xut hin nhng ht ngoi da, khng mu sc v kh nhn nh r). Bnh nhn c triu chng au lan ta, mt mi, st, tng trng km; c triu chng cao huyt p, triu chng v thn, khp. Triu chng thn kinh: 2/3 trng hp bnh khi u 2 chi di (thn kinh hng khoeo ngoi b nhiu hn thn kinh hng khoeo trong), t khi c biu hin chi trn. Triu chng ni bt l cn au rt d di km d cm (ngc li ri lon cm gic khch quan khng r rng v b che m bi d cm), au lan theo dy thn kinh hoc au kiu r. Teo c xy ra nhanh chng, km theo l ph dinh dng, ri lon vn mch phn ngn chi, xy ra 453

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cng lc hoc trc khi lit. Lit cc dy thn kinh nh dy thn kinh da cnh tay trong. Cc dy thn kinh s no t b tn thng (nu c hay gp lit mt hoc lit thn kinh vn nhn). Din tin t nhin ca bnh phn ln cc trng hp khng kh quan. Do iu tr bng corticoid, triu chng c gim. giai on ny c khi mi thy r tnh cch lit khng i xng v lit thn dy thn kinh. Trong vim nt quanh ng mch, c khi biu hin ca th VDTK hng ln ca Landry. Cc biu hin ca vim dy thn kinh ngoi bin c th i km vi hi chng lit na ngi, hi chng mng no hoc bnh c. Xt nghim dch no ty: bnh thng hoc m tng nh (nu khng c hi chng mng no). in c cho thy c tn thng dy thn kinh ngoi bin v ti c. Sinh thit da v c s thy tn thng c hiu ca mch mu trong bnh vim nt quanh ng mch. b. Bnh vim ng mch c biu hin ging vim nt quanh ng mch Cc bnh ca cht to keo khc: Lupus ban , vim khp mn tin trin. Cc bnh ng mch khc: vim x ng mch, vim ng mch ngi gi. 1.2.2. Vim nhiu dy thn kinh do bin dng a. Bnh tiu ng Thng bnh nhn 40 - 60 tui, mc bnh tiu ng lu nm c cc biu hin bnh ng mch 2 chi di. C 3 th lm sng: Vim nhiu dy thn kinh tin trin (tn thng thn kinh i, thn kinh hng khoeo ngoi, thn kinh da i): + Gim vn ng, teo c nhanh, d cm v au. + Ri lon cm gic khch quan t. + Phn x gt gim nhiu hn gi. + Tn thng mt s dy thn kinh s no: III, V, VI, VII. + Vim au tim tin:

C hi chng au: cn au xy ra tng t v m. Cc dy thn kinh b tn thng: thn kinh ta, thn kinh i, thn kinh da - i, thn kinh lin sn, m ri thn kinh c cnh tay, thn kinh V. Gim cm gic nng lnh, mt phn x co dng lng Bnh gim khi bnh tiu ng c kim sot.

Vim cc dy thn kinh s no: him gp. Mt trng hp c ghi nhn l lit vn nhn ti i ti li v thay i bn. 454

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b. Bnh porphyrie cp Tui mc bnh 20 - 40 tui, n nhiu hn nam, c tnh cch gia nh, xut hin c cn bc pht. Khi u l d cm v au, khng c ri lon cm gic khch quan (c khi biu hin bng triu chng au bng, bnh cnh c th rt phc tp vi cc biu hin trung ng: ri lon tm thn, co git, triu chng thp). Lit c dui bn tay v ngn tay, teo c xy ra nhanh, t khi gy lit 2 chi di v khng thy tn thng cc dy s. Triu chng thiu nng tun hon ng mch: co tht mch mu vng mc, mch ngoi bin, c nhng cn au tht ngc, cn cao huyt p. Tin trin bnh chm. Tm cch chn on bng yu t gia nh v tm thy acid aminolevulinic v porphobilinogen tng trong nc tiu. 1.2.3. Vim nhiu dy thn kinh trong cc bnh v mu v cc bnh c tnh Trong bnh Vaquez do tc mch mu n nui ring dy thn kinh, cc bnh ri lon hng cu trong mu nh bnh hng cu cc i, bnh ca h vng ni mc lnh tnh hoc c tnh, thng c 2 bnh cnh: Lit 2 chi di hoc 4 chi: khi u vi mt bn, khng i xng, c cc cn au rt d di, ri lon vn ng, teo c nhiu, tn thng cc dy thn kinh s. Thng gp trong bnh bch huyt lympho bo, ung th ni tng. Vim t dy thn kinh, lit cc dy thn kinh s no V, VII, thn kinh ty sng, thn kinh quay, thn kinh tr, thn kinh ta, ging trong bnh Besnier Boeck Schaumann. 1.2.4. Vim nhiu dy thn kinh trong cc bnh nhim trng Thng xy ra cng lc hoc sau cc bnh nhim trng c lm tn thng thn cc dy thn kinh. Thng gp trong bnh thng hn, vim phi, lu, kit l, st rt, lao, giang mai. Cc nguyn nhn tn tr ca bnh: ri lon dinh dng, ung ru, ng c thuc (INH), Zona, phong. 1.2.5. Vim nhiu dy thn kinh trong cc bnh do nhim c a. Oxyd carbon Tn thng ca nhiu dy thn kinh, c khi biu hin ging vim a dy thn kinh. Tn thng c ghi nhn ni cc mch mu nui thn kinh v c hin tng xut huyt ni thn dy thn kinh. 455

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b. Nhim c barbiturat v sulfamid: t khi gp c. Cc loi huyt thanh Vim thn kinh cnh tay, thn kinh i, thn kinh hng khoeo ngoi phi, thn kinh c honh, thn kinh tr tri. 1.2. iu tr Vic iu tr ty theo nguyn nhn: Corticoid, cc thuc chng d ng, nivaquin cho vim nt quanh ng mch. Sulfon trong iu tr phong. iu tr ng mc bnh tiu ng. iu tr vi thuc khng vim thng thng, sinh t nhm B, thuc gim au, chnh hnh phng nga cc bin chng ca chi. Gi tr ca thuc gin mch cn cha r. C . VIM A R DY THN KINH Vim a r dy thn kinh (polyradiculonvrites) l danh t ch bnh l tn thng bao myelin ca thn kinh ngoi bin. Bnh c tnh cht lan ta, i xng, khng tr nhng thnh phn gn ca thn kinh ngoi bin (r trc v m ri thn kinh l vng hay b tn thng nht) cng nh dy thn kinh s no. Nguyn nhn ca vim a r dy thn kinh c rt nhiu. C 2 th lm sng chnh: cp (hi chng Guillain - Barr do Guillain G. v cng s gii thiu u tin nm 1916) v mn. 1. VIM A R DY THN KINH CP 1.1. Dch t hc T l mc bnh hng nm l 1/100.000. Tui hay gp l t 20 - 50 tui. Xut hin 2 gii ngang nhau. 1.2. Nguyn nhn Nguyn nhn ca bnh cha r rng. Ngi ta ghi nhn c trong 2/3 trng hp, khong 1 - 4 tun trc khi hi chng bnh ny xut hin, bnh nhn c mt giai on nhim virus ng h hp trn, him hn l mt hi chng tiu ha. Nhng nghin cu pht hin nhng trng hp nhim trng Cytomegalovirus v nht l Campylobacter jejuni. Him khi thy xut hin hi chng Guillain - Barr trn nhng bnh nhn nhim virus m khng xc nh c nh Zona, Varicelle, MNI (Epstein Barr) hay bnh Hodgkin, lymphome, LED, sarcoidose hay nhng ngi nhim HIV. 456

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1.3. Lm sng Hnh nh lm sng ni bt ca hi chng Guillain - Barr l tnh trng lit mm cp, mt cc phn x. Din tin bnh bao gm 3 thi k: thi k lit pht trin, thi k ng yn v thi k phc hi. Thi k pht trin ca lit khng ko di qu 4 tun. Thi k ng yn rt thay i, nhn chung t 2 - 4 tun nhng i khi ko di nhiu thng. Vic phc hi, trong phn ln trng hp, thng khi hon ton hoc gn hon ton. Triu chng khi pht c th: ch l d cm hoc ri lon cm gic kt hp vi yu lit hoc ch c yu lit c. t hn, c th thy bnh khi pht vi lit u tin gc chi hoc thn kinh s no, c bit l lit mt 2 bn. a. Lit D do khi pht cch no th ch sau vi ngy, lit cng tr nn r rng, lit c tnh cht i xng. u tin lit phn xa ca chi, sau lan nhanh n cc gc chi v thn (c khuynh hng lit hng ln). Lit c mc nng nh rt thay i: t ch lit nh n lit t chi hon ton. c tnh ni bt l lit mm, gim hoc mt phn x gn c. au nhc c, c bit l c dc sng lng, rt thng thy v kt hp vi tnh trng tng men c/mu. Lit ng u cc phn ca tay chn hoc ngn chi nng hn gc chi (nu lit gc chi nng hn th gi l th gi bnh c). Lit hai chi trn thng nh v xy ra sau hai chi di. Lit c thn, lit c bng, cc c h hp dn n tnh trng suy h hp cp i hi ngi thy thuc phi ch khm i khm li nhiu ln pht hin sm v chuyn ngay bnh nhn sang hi sc cp cu (tnh trng ny chim 15%). Lit cc dy thn kinh s no: lit dy VII (50-69%) thng lit c 2 bn Lit dy IX. X xut hin vi t l gn tng ng nh lit dy VII gy lit hu hng, lit dy thanh m 1 bn hoc 2 bn. Cc dy thn kinh s no khc t b tn thng hn. b. Ri lon cm gic Ri lon cm gic ch quan: rt r, bnh nhn c cm gic b t, c cm gic nh b chm chch, kin b. Ri lon cm gic khch quan: thng pht hin gim cm gic nhn bit t th v rung m thoa. Trong vi trng hp dn n tht iu. c. Ri lon thc vt Rt thng xuyn, t nhp nhanh xoang n ri lon nhp tim v huyt p trm trng lm tng nguy c t vong.

457

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Ri lon c trn nh b tiu, gim hoc mt cm gic i tiu, to bn thng xy ra hn. Ri lon vn mch v giao cm: ra nhiu m hi, da ti, ph n chi b lit. Trong mt vi trng hp him, ngi ta ghi nhn c du hiu Babinski (+), ph gai th v c khi l ln tinh thn. Th lm sng him (th Miller Fisher) c bo co nm 1956. y l th lm sng him gp (< 4%). Bnh cnh gm lit c vn nhn, tht iu v mt phn x gn c. 1.4. Cn lm sng Dch no ty: l xt nghim quan trng. Ri lon ca xt nghim ny ch xut hin sau 1 tun (i khi rt tr, khong tun th 4 - 6) v c th m tnh 10% cc trng hp. Kt qu quan trng chn on l phn ly m - t bo, protein khong 50mg% hoc cao hn trong khi cc thnh phn khc ca dch no ty khng thay i. in c: gip xc nh bao myelin b h hoi khi c du bt thng trong dn truyn xung ng thn kinh nh ko di thi gian tim n, gim tc dn truyn. Cng c th thy du hiu ca thoi ha si trc (th pht sau thoi ha myelin). 1.5. Din tin Nh vo nhng tin b trong tr liu m t l t vong ca Guillain Barr gim ng k t 33% xung di 5%. Phn ln cc bnh nhn phc hi hon ton v tr li lm vic bnh thng sau 3 - 6 thng. C 1/5 trng hp cn than phin yu c sau 1 nm. C th ni rng, sau 18 thng m di chng vn cn th rt t c hy vng hi phc. C khong 15% trng hp vn cn di chng v 5% l di chng nng n. Cc yu t lm tin lng tr nn xu: Bnh nhn trn 40 tui. Thi gian lit pht trin: nhanh < 7 ngy. Bnh nhn cn gip th. Thi gian lit ng yn > 3 tun. Phn ng c vi kch thch ngn chi: yu (Mc Khann G.M. v cng s 1988). Tnh trng ti pht rt him (3%) v i hi phi tm cho ra nguyn nhn. 1.6. Chn on phn bit Vim a r dy thn kinh do giang mai v bnh Lyme: ch yu da vo tnh cht khng i xng v c au, trong dch no ty c tng t bo. 458

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Cn lm xt nghim chn on giang mai (VDRL,) hoc phn ng huyt thanh xc nh c Borrelia burgdorferi. Vim a r dy thn kinh nhim xon khun Leptospira idero hemorragiae: du vim a r dy thn kinh c th xut hin sm trong thi k cp ca bnh nhng cng c khi xut hin tr trong thi k hi phc ca bnh. Du lm sng c th l tn thng mt si thn kinh (thng l thn kinh s no) r thn kinh hoc m ri thn kinh. Du hiu vim a dy thn kinh thng trm trng. Chn on xc nh bng in c (du tn thng si trc) v sinh thit (thm nhim cc monocyt). Vim a r dy thn kinh do Brucella: thng xut hin tr hn l sm. Bnh cnh c th l vim a r dy thn kinh c tnh cht khng i xng hoc tn thng thn kinh s no (VIII, VI, VII, XI) hoc tn thng mt si thn kinh. Dch no ty c tng m v t bo (ch yu l lympho bo). Phn ng huyt thanh Wright (+) Vim a r dy thn kinh do bch hu: thng th bnh ny gy lit vm hu (ni ging mi, sc thc n ln mi). Cn chn on phn bit vi bnh ny trong trng hp c bin chng mun ca bnh nhi khi 2-3 thng sau thy xut hin du vim a r dy thn kinh. Bnh thng khi pht vi lit iu tit ca mt (gy kh khn khi c v khi nhn gn). Dch no ty thy xut hin nhiu t bo lympho. 1.7. iu tr Phng nga cc bin chng do nm lu: nhim trng h hp, suy h hp cp. Thay huyt tng: nghin cu hp tc nm 1987 ca Php v M chng minh vic thay huyt thanh 4 ln cho kt qu ng tin cy (67% so vi 44% l chng). Nghin cu ny cng khuyn thay huyt tng nn khi u 15 ngy sau khi bnh khi pht. Dng liu cao immunoglobulin: ang nghin cu. 2. VIM A R DY THN KINH MN Quan nim v bnh l ny bao gm nhng trng hp vim a r dy thn kinh hoc ti pht, hoc ko di hoc khng p ng vi corticoid. Nm 1975 Dick P.J. v cng s nh ngha bnh v nm 1991 nhng tiu chun chn on c thit lp nh sau (research criteria for diagnosis of chronic inflammatory demyelinating polyneuropathy). Tiu chun lm sng: c 1/3 trng hp c bnh khi pht nh hi chng Guillain - Barr (khi pht vi lit c km hoc khng ri lon cm gic t chi, i xng). Lit ch yu cc tit on gc chi v ri lon cm gic ch yu l bn th (nhn bit t th, cm gic rung). 459

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Mt phn x gn c mt phn hay ton thn. Tn thng dy thn kinh s no. Suy h hp c th c nhng t hn th cp. Ri lon thc vt, teo c, au nhc: t gp hn. Tiu chun din tin: tin trin ko di trn 6 thng vi nhng t ti pht, mc li hoc khng p ng vi tr liu steroid. Tiu chun sinh ha: 80% c phn ly m t bo. Tiu chun in c: tc dn truyn thn kinh gim 70% vi tn thng thoi ha myelin. Nhng du chng ca blc dn truyn thng xut hin nhiu hn trong th cp. Tiu chun sinh thit: thoi ha myelin v tm nhun t bo vim. iu tr kt qu tt vi corticoid, c ch min dch, thay huyt tng v truyn immunoglobulin t ra c hiu qu 60 - 80%. III. BNH L TN THNG THN KINH NGOI BIN THEO Y HC C TRUYN 1. Nguyn nhn v c ch sinh bnh Bnh l thn kinh ngoi bin l danh t bnh hc YHH v khng c t ng ngha trong bnh hc y hc c truyn (YHCT). T ng ngha d gp gia YHH v YHCT l cc triu chng, v d: d cm, t vi ma mc, yu lit vi nuy chng (triu chng hc YHCT, trang 53 - 55). Qua vic phn tch c ch bnh sinh ton b cc chng trng thng gp ca YHCT trong bnh l bnh l tn thng thn kinh ngoi bin, c th bin lun v c ch bnh sinh theo YHCT nh sau: Do ngoi t nh phong, hn, thp gy bnh. Phong, hn, thp tha c v biu suy yu m xm nhp lm kinh lc b tc tr sinh ra chng t. Ty theo tnh cht ca t m nh c loi t kh gy bnh (phong tnh hay ng, lu b phu nn t c cm gic nh trng b; thp c tnh nng n v nh hng n phn c; hn tnh n tr v d tn thng dng kh). Do bnh lu ngy, m thc bt iu hoc phng tht khng iu lm th cht suy yu, kh b h suy. Kh h dn n v ngoi bt c, phong hn thp t d xm nhp; ng thi, kh h dn n kh tr lm huyt khng c vn hnh. Ton b c ch trn dn n kinh mch b rng, da c khng c n m v nui dng lm xut hin triu chng t. Do huyt dch khng y (sau sinh, thiu mu hoc bnh lu ngy): tn v huyt c tc dng t nhun v nhu dng c da. Tn v huyt

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thiu khin kinh lc, c, biu, b mao khng c nui dng gy nn chng t; nng s n chng nhc nuy. Do m ut ng tr gy tr tc kinh lc: m thp c th do n ung khng ng cch gy tn hi t v hoc do thn dng suy khng kh ha c nc lm sinh m.
NGOI NHN (phong, hn, thp) TH CHT YU, BNH LU NGY N UNG KHNG NG

Tn, huyt h

T kh h

Thn dng h

Kh h

m ut

B mao, c nhc khng c nui dng

Ma mc, nuy chng

Hnh 26.1. S bnh l tn thng thn kinh ngoi bin theo YHCT

2. Triu chng lm sng YHCT phn chia thnh 6 th lm sng 2.1. Phong hn thp b c im ni bt ca th bnh ny l t v au nhc c tng khi tri lnh, m thp. Bnh nhn thng thch c chm m ti ch t, au. Ngi s lnh, chn tay lnh, lng gi mi. Ru li mng trng hoc trng nht, cht li nht. Mch ph huyn khn.

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2.2. Thp nhit b Triu chng t thng xut hin chn. Ngi thy nng n km au nhc hoc c cm gic rt nng, s bn ngoi da thy nng. Li , ru vng nht. Mch huyn sc hoc t sc. 2.3. Kh h tht vn T t chi, t nhiu u chi; nhc chi ln kh khn, mt lc. Tnh trng ny s tng ln khi gp lnh (tri lnh, nhng tay chn vo nc lnh) hoc lm vic. Sc mt nht, khng bng, thiu hi, on kh, mt mi, thch nm. S gi, s lnh, n km, i tin lng, d b cm. Li nht bu, ra c du rng, ru trng mng. Mch trm nhu. 2.4. Huyt h tht vinh Chn tay t, da trng kh, ngi gy yu. Mt mi nht km chng mt, hoa mt, mt ng, hay qun. Tm qu, chnh xung. Cht li nht. Mch trm t. 2.5. m h phong ng T nhiu km run nh, c lc c cm gic nh trng b. Ngi gy kh km hoa mt, chng mt, tai. Mt ng, hay mng m. Lng gi nhc mi. Cht li ti, ru mng. Mch trm t. 2.6. m ut tr T ko di, v tr t c nh, c cm gic cng, n vo thy d chu. Km vng u, nng chi hoc c cm gic tc ngc. Cht li ti hoc c vt bm, ru nht. Mch trm sp hoc huyn hot. 462

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3. IU TR 3.1. iu tr bng thuc 3.1.1. Th phong hn thp b Php tr: khu phong tn hn, s thp trc t, n kinh thng lc. Bi thuc iu tr: Quyn b thang + Qu chi thang (gm: khng hot 8g, c hot 8g, tn cu 10g, qu chi 8g, bch thc 6g, ng quy 12g, xuyn khung 8g, tang chi 8g, xuyn (ch) 6g, hi phong ng 10g, k huyt ng 10g, sinh cam tho 6g). Phn tch bi thuc:
V thuc Khng hot c hot Tn cu Qu chi Bch thc ng quy Xuyn khung Tang chi Xuyn (ch) Nh hng K huyt ng Sinh tho Tc dng Ngt, ng, bnh, khng c: tr phong, cha t chi trn Ngt, ng, bnh, khng c: tr phong, cha t chi di ng, cay, bnh: hot huyt, trn thng Cay ngt, i nhit, hi c: tr c lnh trm hn, gii biu Chua ng, hi hn: nhun gan, dng huyt, lim m Ngt, cay, m: b huyt, hnh huyt ng, m: hnh kh, hot huyt, khu phong, ch thng ng, bnh: kh phong thp, li quan tit; cha t, au nhc Cay, ngt, tnh i nhit, c c: b ha, trc phong hn, thp t ng, cay, hi m: iu kh, hot huyt ng, bnh, kh phong, thng kinh lc Ngt, bnh: b t v, nhun ph, thanh nhit gii c, iu ha cc v thuc Vai tr ca cc v thuc Qun Qun T Qun Thn Thn T T Thn T T S

3.1.2. Th thp nhit b Php tr: thanh li thp nhit, s kinh thng lc. Bi thuc iu tr: Tam diu hon gia gim (gm: thng trut 10g, hong b 6g, ngu tt 10g, hi phong ng 10g, k huyt ng 10g, a long 6g, khng hong 9g, phng k 10g, nh hng 6g).

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Phn tch bi thuc:


V thuc Thng trut Hong b Ngu tt Phng k a long Khng hong Nh hng K huyt ng Sinh tho Tc dng Cay, ng, m vo t v: kin t, to thp, pht hn ng, hn, vo thn, bng quang: tr ha c, t m, thanh nhit to thp Chua, ng, bnh: b can thn, tnh i xung Rt ng, cay, lnh: kh phong, hnh thy, t h, tiu huyt phn, thp nhit Mn, hn: thanh nhit, trn kinh, li tiu, gii c Cay, ng, n vo t, can: hnh huyt, ph , hnh kh gii ut ng, cay, hi m: iu kh, hot huyt ng, bnh, kh phong, thng kinh lc Ngt, bnh: b t v, nhun ph, thanh nhit gii c, iu ha cc v thuc Vai tr ca cc v thuc Qun Qun T Thn Qun T T T S

3.1.3. Th kh h Php tr: b kh tr vn, hot huyt vinh chi. Bi thuc iu tr: B trung ch kh thang gia gim (gm: hong k 30g, ng sm 15g, bch trut 10g, ng quy 10g, trn b 8g, thng ma 8g, qu chi 8g, k huyt ng 12g) (xem Bnh hc YHCT , trang 172). 3.1.4. Th huyt h Php tr: dng huyt, hot huyt, xung mch, nhun chi. Bi thuc iu tr: T vt thang gia an sm (gm: thc a 20 - 24g, bch thc 12g, ng quy 12g, xuyn khung 6g, an sm 12g (xem Bnh hc YHCT , trang 264). C th tham kho bi Thn ng dng chn n (gm: thc a 10g, ng quy 10g, xuyn khung 8g, an sm 12g, hong tinh 10g, hong k 20g, qu chi 8g, bch thc 8g, k huyt ng 12g, tn cu 10g, tang chi 10g, mc qua 8g, ngu tt 8g). 3.1.5. Th m h phong ng Php tr: t m, dng huyt, hot huyt. Bi thuc iu tr: Thin ma cu ng m gia ng quy 10g, xuyn khung 8g (xem Bnh hc YHCT , trang 269)

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3.1.6. Th m ut tr Php tr: ha m, li ut, hot huyt, thng lc. Bi thuc iu tr: song hp thang gia gim. y l hp ca 2 bi thuc o hng t vt thang (xem Bnh hc YHCT , trang 263) v bi Nh trn thang, gm trn b 6g, bn h 6g, phc linh 12g, hng ph 6g. Gia thm t tn 4g (n thng tr tr), a long 6g, ngu tt 10g (dn kinh thng mch), sinh cam tho 10g. 3.2. iu tr bng chm cu Ch yu l s dng nhng huyt ti ch chi trn v chi di s thng kinh lc. Chi trn: hp cc, khc tr, kin ngung, kin tnh, ngoi quan, thi uyn, xch trch. Chi di: phong th, dng lng, cn ln, huyn chung, tc tam l, tam m giao.

T lng gi Cu hi 5 chn 1: chn cu ng 1. im khc nhau v lm sng gia VDTK v vim nhiu dy thn kinh (VNDTK)

A. C gim cm gic au hoc khng B. C gim vn ng hoc khng C. C ri lon cm gic kiu i xng hoc khng D. C ri lon thc vt hoc khng E. C km au nhc hoc khng
2. im khc nhau v lm sng gia VDTK v vim a r dy thn kinh (VRDTK)

A. C gim cm gic au hoc khng B. C gim vn ng hoc khng C. C ri lon cm gic kiu i xng hoc khng
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D. C ri lon thc vt hoc khng E. C km tn thng dy s no hoc khng


3. Bin chng quan trng nht ca VRDTK cn c bit quan tm

A. au nhc c B. Lit dy IX C. Lit dy X D. Lit c thn E. Tht iu


4. C ch gy bnh thn kinh ngoi bin trong trng hp m huyt suy h

A. m huyt h khin phong thp t tha c xm nhp B. m huyt h sinh m lm tc tr kinh lc C. m huyt h khng nui dng c kinh lc D. m huyt h sinh nhit, nhit cc sinh phong lm kinh lc tc nghn E. m huyt h lm tm huyt h suy, khng ch c huyt mch m sinh bnh
5. C ch gy bnh thn kinh ngoi bin trong trng hp kh h tht vn

A. Kh h khin phong thp t tha c xm nhp B. Kh h sinh m lm tc tr kinh lc C. Kh h sinh hn, hn lm tc tr kinh lc D. Kh h sinh hn, hn cc sinh nhit, nhit cc sinh phong lm kinh lc tc nghn E. Kh h khin v kh suy km phong hn thp t tha c xm nhp
6. Nu do phong hn thp t gy bnh VDTK, triu chng ch yu s l

A. Yu B. Lit C. T D. Tht iu E. Ri lon dinh dng


7. Nu do phong nhit t gy bnh VDTK, triu chng ch yu s l

A. Yu, lit B. T C. Yu v t
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D. T v gim cm gic E. Ri lon dinh dng


8. V bch thc trong bi Quyn b thang + Qu chi thang (gm: khng hot, c hot, tn cu, qu chi, bch thc, ng quy, xuyn khung, tang chi, xuyn (ch), hi phong ng, k huyt ng, cam tho sng) c tc dng

A. T m, dng huyt: vai tr thn B. T ha, tn huyt: vai tr thn C. Lim m, dng huyt: vai tr qun D. Thanh thp, nhit: vai tr thn E. Dng v sinh tn: vai tr qun
9. V qu chi trong bi Quyn b thang + Qu chi thang (gm: khng hot, c hot, tn cu, qu chi, bch thc, ng quy, xuyn khung, tang chi, xuyn (ch), hi phong ng, k huyt ng, cam tho sng), c tc dng

A. Pht hn, gii biu, khai tu l: vai tr qun B. Pht hn, gii c: vai tr thn C. Pht hn, gii c: vai tr qun D. Bnh suyn, ging nghch: vai tr t E. iu ha cc v thuc: vai tr s
10. V xuyn khung trong bi T vt thang gia an sm (gm: thc a, bch thc, ng quy, xuyn khung, an sm) c tc dng Hnh kh, hot huyt: vai tr thn Ha m, to thp: vai tr qun Lim m, dng huyt: vai tr thn B trung ch kh: vai tr thn H kh nghch, tiu m: vai tr thn II. Cu hi in vo ch trng 1. Ri lon cm gic ch quan (t) trong VDTK

A. B. C.

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2. Ri lon cm gic khch quan trong VDTK

A. B.
3. Ri lon vn ng trong VDTK

A. B. C.
4. Hai xt nghim cn lm sng c gi tr chn on bnh thn kinh ngoi bin

A. B.
5. Du chng thng gp dch no ty bnh VRDTK

A.

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Bi 27

IU TR AU THN KINH TA THEO YHCT

MC TIU 1. Nu c nhng yu t dch t hc ca bnh au dy thn kinh ta. 2. Lit k c nhng triu chng quan trng chn on 2 th lm sng au dy thn kinh ta theo YHCT. 3. Trnh by c phng php iu tr bnh au dy thn kinh ta (dng thuc v khng dng thuc ca y hc c truyn). 4. Gii thch c c s l lun ca vic iu tr au dy thn kinh ta bng YHCT.

I. I CNG au dy thn kinh ta c nh ngha l mt hi chng thn kinh c c im ch yu l au dc theo l trnh ca dy thn kinh ta v cc nhnh ca n; nguyn nhn thng do bnh l a m phn thp ca ct sng. au dy thn kinh ta c nhiu nguyn nhn nhng ch yu l do nhng tn thng ct sng tht lng. Nm 1928, mt nguyn nhn mi c pht hin lm thay i hn khi nim v nguyn nhn gy bnh, l thot v a m vng tht lng. Sigwald v Deroux l nhng ngi u tin m t hi chng au dy thn kinh ta (1764). Lasgue, C. E., Brissaud. E., Djeurine J. J. chng minh y l bnh au r ch khng phi au dy (1914). Wirchow m t a m, tuy cha phi r rng (1857); sau Goldnwait J. E., Middleton v Teacher tch au dy thn kinh ta do thot v a m thnh mt th ring (1911). Schomorld G (1925-51) l ngi m t rt k v cu trc gii phu ca a m (qua 10.000 ct sng). Alajouanine, Petit Dutaillis (1928-30), Mauric (1933) v Mixter v Barr (1934) m t k v lm sng v gii phu bnh ca thot v a m.

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T 1937, c hng lot cng trnh nghin cu v au dy thn kinh ta ca Glorieux (1937), Bergouignan v Caillon (1939). Trong s ny, trng phi ca De Sze c nhng ng gp rt ln.

Hnh 27.1. Dy thn kinh ta - ng i v phn nhnh

II. DCH T HC Bnh thng gp la tui 30 - 60. Nam mc bnh nhiu hn n gp 3 ln. au thn kinh ta c nhiu nguyn nhn nhng ph bin nht l thot v a m (chim 60 - 90% theo nhiu tc gi, 75% theo Castaigne.P). III. NGUYN NHN 1. Theo y hc hin i C nhiu nguyn nhn au dy thn kinh ta. d vn dng trong thc hnh ngi ta sp xp: Thot v a m: y l nhm nguyn nhn thng gp nht, chim t l cao nht trong cc loi nguyn nhn khc. Cc bt thng ct sng tht lng cng (mc phi hoc bm sinh): + Mc phi: vim nhim ti ch (do b lnh, nhim khun, nhim c, tiu ng..); thoi ha ct sng ( ngi cao tui); ung th di cn vo ct sng (K tin lit tuyn, K v, u vng chu nh, u bung trng) + Bm sinh: nhiu tc gi cho rng trc khi chn on nguyn nhn au dy thn kinh ta do cc d tt bm sinh, cn phi loi tr thot v a m v ch xem cc d tt ch l yu t thun li. 470

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Cc nguyn nhn trong ng sng: u ty v mng ty, vim mng nhn ty khu tr, p xe ngoi mng cng vng tht lng. Mt s nguyn nhn him: kh chn on, thng ch xc nh c sau phu thut nh gin tnh mch quanh r, gin tnh mch mng cng, ph i dy chng vng, r thn kinh tht lng V (L5) hoc cng I (S1) to hn bnh thng. 2. Theo y hc c truyn
1

Hnh 27.2. Thit ct dc ng sng cho thy s lin quan ca a m l lin hp (3) vi dy chng (1) v dy chng dc sau (2)

Theo YHCT, hi chng au dy thn kinh ta c m t trong nhng bnh danh ta in phong, ta ct phong. Phong trong hi chng bnh l ny nhm m t tnh cht thay i v di chuyn ca au. Mt cch tng qut, do triu chng quan trng nht ca bnh l au nn hi chng au dy thn kinh ta c th c tm hiu thm trong phm tr ca chng t hoc thng (ty theo nguyn nhn gy bnh). Nguyn nhn gy bnh: Ngoi nhn: thng l phong hn, phong nhit, hoc thp nhit tha lc tu l s h xm nhp vo cc kinh bng quang v m. Bt ni ngoi nhn: nhng chn thng (vi chn thng) ct sng (a m) lm huyt li 2 kinh trn. Nhng nguyn nhn ny lm cho kh huyt ca 2 kinh (bng quang v m) b cn tr hoc b tc li, gy nn au (khng thng th au). Ty theo bn cht ca nguyn nhn gy bnh m biu hin ca au s khc nhau. Nu bnh ko di s nh hng n chc nng hot ng ca can v thn.

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NGOI NHN (phong hn, phong nhit, thp nhit, hn thp) Chnh kh suy

NGUYN NHN KHC (bt ni ngoi nhn)

Huyt

Kh huyt khng thng kinh bng quang v m

Ta in phong, ta ct phong, t chng, thng Ko di mn tnh Chc nng can thn suy gim

Hnh 27.3. S nguyn nhn v c ch bnh au thn kinh ta

IV. TRIU CHNG HC V CHN ON AU DY THN KINH TA A. Theo y hc hin i 1. Triu chng lm sng 1.1. Triu chng ch quan au lng lan dc xung chi di 1 hay 2 bn, au m hoc d di au lan theo 2 kiu: T tht lng xung mng, xung mt ngoi i, mt ngoi cng chn ti lng bn chn, t b ngoi bn chn cho qua mu bn chn n ngn ci (r L5) Hoc t tht lng xung mng, xung mt sau i, mt sau cng chn ti gt lng bn chn, tn cng ngn t (r S1) C th km theo d cm (t, nng, au nh dao m, cm gic kin b bn chi au) 1.2. Thm khm bnh nhn Quan st bnh nhn khi i hoc ng: na ngi bn lnh h thp (vo ngi v bn 472
Mt trc Mt sau

Hnh 27.4. Khu vc cm gic ca r L5 v S1

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lnh). Khi ng chn bn au hi co ln, tay chng vo mn sn hoc u gi bn au. Quan st khi bnh nhn nm: xem c t u i, c bp chn c teo khng. Lm nhng nghim php cng dy thn kinh ta: + Nghim php Lasgue: bnh nhn nm nga, hai chn dui thng, nng gt chn bnh nhn ln cao khi ging. Chn bnh thng nng cao c ti 900, khi chn au ch ln ti 300 - 600 l bnh nhn than au lan ti tht lng. y l du hiu rt quan trng, gn nh lc no cng c; cn dng theo di din tin iu tr. + Nghim php Bonnet: bnh nhn nm nga, gp gi v pha bng v xoay khp hng vo trong, nu au: Bonnet (+). + Nghim php Nri: bnh nhn ng thng, gi thng 2 gi, t t gp ngi c chm 2 tay xung t. Nu bnh nhn than au v khng th thc hin ng tc ny (gp gi bn au), Nri (+). Nghim php lm tng p lc dch no ty: + Nghim php Naffziger: vo tnh mch c 2 bn, nu bnh nhn ku au t ct sng lan xung chn, nghim php (+). C th phi hp vi vic bo bnh nhn ho. Nghim php gy au bng cch n vo l trnh ca dy thn kinh ta: + Du nhn chung: n vo ngang gai sng L4-L5 hoc L5-S1 s gy au lan dc theo l trnh dy thn kinh ta tng ng. + Thng im Valleix: n vo nhng im trn l trnh dy thn kinh ta (nht l vng dy thn kinh ta i gn xng) s gy au theo r. Khm du cm gic: c th gim cm gic vng c th tng ng vi r thn kinh b tn thng. Khm du vn ng: + Bnh nhn ng, np mng bn bnh s thp hn bn i din. + C bp chn nho. + n mnh vo gn gt ghi nhn bn bnh lm nhiu hn bn lnh. + Yu c (ty theo r b tn thng): nu tn thng L5 s xut hin yu cc nhm c cng chn trc, dui cc ngn. Bnh nhn khng ng bng gt c v c du bn chn ri. Nu tn thng S1, xut hin yu cc nhm c mt sau cng chn. Bnh nhn khng ng bng ngn chn c. Mt hoc gim phn x gn c (tng ng vi r b tn thng). 473

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Du hiu ti ct sng: co c phn ng, ct sng mt ng cong sinh l, c th c vo ct sng t th. 2. Triu chng cn lm sng Xt nghim mu (hng cu, bch cu, cng thc bch cu, tc mu lng) v chc d dch no ty trong trng hp au thn kinh ta khng in hnh m c nghi ng n khi u trong ng sng Chp X quang ct sng quy c: + Nu c hnh nh bn l tht lng - cng bnh thng, cng khng cho php loi tr thot v a m. + Du hiu ca thot v a m: xp a m biu hin chiu cao ca khe gian t hp hn so vi khe gian t trn v di. + Du hiu c gi tr ln: hnh kp hoc h mt bn a m. Trn phim thng, h mt bn c gi tr hn hp mt bn. Nu trn phim chp nghing, hnh nh h mt bn a m vn khng mt i th rt c gi tr. Chp X quang c cn quang: c ch nh ch yu trong trng hp nghi ng au dy thn kinh ta c khi u gy chn p v gm: + Chp ty bm hi (sacco-radiculographie gazeuse): vi k thut ny, cc chng hp ng sng, cc thot v a m gia v k gia thy rt r trn phim, nhng cc thot v a m bn khng pht hin c. + Chp bao r thn kinh (radiculographie classique): cc thot v a m gia v k gia (mdianes et paramdianes) thy rt r trn phim. + Chp a m (discographie): trn phim chp thng, nghing c th thy a m b thoi ha, nhng ch c a m no gy au nhiu khi bm thuc cn quang mi ng l a m cn phu thut. Cc phng php thm d khc: + in c : ghi in c v o thi tr dy thn kinh cho php chn on v tr ca thot v a m. + Chp in ton ct lp (CT.Scan): l phng tin hin i nht c vn dng chn on thot v a m. B. THEO YHCT Y hc c truyn chia au thn kinh ta lm 2 th lm sng ch yu 1. Th cp (th phong hn phm kinh lc hoc kh huyt tr) c im lm sng: 474

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au: + au lng sau xung chn dc theo dy thn kinh to. + au d di, au tng khi ho, khi ht hi, khi ci gp c t ngt. + au tng v m, gim khi nm yn trn ging cng. + Gim au vi chm nng. + Ru li trng, mch ph (nu do phong hn). + Li c th c im huyt (nu do kh huyt tr). Bnh nhn c cm gic kin b, t cng hoc nh kim chm b ngoi bn chn cho qua mu bn chn n ngn ci (r L5) hoc gt chn hoc ngn t (r S1). Khm lm sng: + Triu chng ct sng:

C lng phn ng co cng. Ct sng mt ng cong sinh l.

+ Triu chng au r: du hiu Lasgue (+); Bonnet (+); Nri N (+). + xc nh chnh xc r no b xm phm: cn khm phn x, cm gic, vn ng, dinh dng theo bng sau:
R L5 S1 Phn x gn xng Phn x gn gt bnh thng Phn x gn gt gim Cm gic Gim hoc mt pha ngn ci Gim hoc mt pha ngn t Vn ng Khng i c bng gt chn Khng i c bng mi bn chn Teo c Nhm c cng chn trc ngoi, cc c mu bn chn, c cng chn, c gan bn chn

2. Th mn (th phong hn thp: can thn m h) y l loi thng gp trong au dy thn kinh ta do cc bt thng ct sng tht lng cng nh thoi ha cc khp nh ct sng, cc d tt bm sinh. c im lm sng: Bnh ko di, au m vi nhng t au tng, chm nng hoc nm ngh d chu: thng au 2 bn hoc nhiu r. Triu chng ton thn: n km, ng t, mt mi, mch nhu hon hoc trm nhc. 475

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V. IU TR 1. Th cp (giai on cp v cc t cp ca cc th mn tnh Th phong hn phm kinh lc hoc kh huyt tr: Nm yn trn gng cng, k mt gi nh di khoeo chn cho u gi hi gp li, trnh hoc hn ch mi di chuyn. Cng thc huyt v k thut chm cu: + Cng thc huyt: p thng im (thng l cc gip tch L4-L5, L5S1), hon khiu, y trung; kinh ct, i chung (nu au dc r S1); khu kh, li cu (nu au dc r L5). + K thut: kch thch kim mnh, c th s dng in chm kt hp vi cu nng. Thi gian lu kim cho 1 ln chm l 5 - 10 pht. + C th s dng nh chm (c bit quan trng trong thi gian cp tnh, khi xoay tr ca bnh nhn tht s kh khn) vi huyt s dng gm: ct sng tht lng (+++), dy thn kinh (++); hng, mng, hng, gi, c chn (+). Nhng bi tp vn ng tr liu au dy thn kinh ta. Ch bt u khi thc gim au (xem hng dn phn tip theo). Bi thuc s dng: Bi thuc tr thp khp (GS. Bi Ch Hiu) gm: l lt 12g, c gai leo 12g, qu chi 10g, thin nin kin 12g, c xc 10g, th phc linh 12g, si t 12g, h th 16g, sinh a 16g. 2. Th mn (th phong hn thp) Tuy mc au t hn, nhng thng p ng iu tr chm. Giai on ny, cn ch trng thm xoa bp v tp luyn. Cn ch trng tp mnh cc c vng tht lng, nhm c mng v c t u i. Tuy nhin, phi tp t t v theo sc ca bnh nhn. giai on u, ch cho tp gng c, dn dn tin ti vn ng ch ng, ri ch ng c khng. Ngoi ra, ko nn v ko ct sng cng c th em li kt qu tt. Cng thc huyt v k thut chm cu: dng cng thc huyt nh trn gia thm: thn du, thi kh, phi dng, tam m giao. i vi nhng huyt c gia thm: kch thch kim nh hoc va, thi gian lu kim cho 1 ln chm l 20 - 30 pht. Nhng bi tp vn ng tr liu au dy thn kinh hng: + Ngi bnh nm nga:

Gng c t u i. Tp c chn.

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ng tc n lng. ng tc tam gic v tam gic bin th (xem Dng sinh: bi tp t th nm).

+ Ngi bnh nm nga, hng v gi gp: tp gng c bng. + Ngi bnh nm sp:

Gng c mng. Ngng u ln, xoay u. Nhc tng chn ln, h xung. Gp, dui gi tng bn v 2 bn cng mt lc. Tay sau gy, nhc u v vai ln. a tng chn ln, h xung. ng tc cho mt tri (xem Dng sinh: bi tp t th ngi).

+ Ngi bnh qu (chng 2 tay v 2 gi):


+ Ngi bnh ngi dui thng 2 chn, hai tay v thn mnh vn ti bn chn, u ngn tay c chn vo u ngn chn. Ch khi tp: + Bt u t ng tc d, nh (gng c) tin dn n cc ng tc nng, kh hn. + Khi bt u tp mt ng tc mi, ngi thy thuc phi c mt theo di, nh gi, tr gip cho ngi bnh, trnh tnh trng qu sc. Bi thuc s dng: + Bi thuc 1: Bi thuc tr thp khp (GS. Bi Ch Hiu), gm: l lt 12g, c gai leo 12g, qu chi 10g, thin nin kin 12g, c xc 10g, th phc linh 12g, si t 12g, h th 16g, sinh a 16g. + Bi thuc 2: c hot tang k sinh gia gim, gm: c hot 12g, phng phong 8g, tang k sinh 12g, t tn 6g, qu chi 6g, ngu tt 12g, trng 8g, ng sm 12g, phc linh 12g, cam tho 8g, bch thc 12g, ng quy 12g, thc a 12g, i to 12g. Bi thuc bao gm nhng dc liu c cha tinh du, c tnh nng m, c tc dng chng vim, gim au; ng thi c nhng v thuc nng tng trng, b dng. 3. iu tr phu thut Phng php ny c t ra trong 4 trng hp: Th lit v teo c: l ch nh phu thut sm, trnh tn ph cho bnh nhn. 477

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Th ngoan c, c bit l loi au d di: sau iu tr tch cc nhiu thng (thng l 3 thng) m tin trin vn khng n nh. Th ti pht nhiu ln v ngy cng gn, lm nh hng sinh hot ca bnh nhn. Th phc tp nh km hi chng chm ui nga. VI. PHNG BNH au dy thn kinh ta tuy c nhiu nguyn nhn nhng phn ln l xung t gia a m v r thn kinh. y l im quan trng cn ch phng nga. Trong lao ng chn tay cn ch trong cc ng tc phi ci bc vc mt trng lng ln, lun c gng gi ct sng thng khi b vc. Tp th dc rn luyn c lng v tng s mm mi ca ct sng. iu tr kp thi cc bnh thoi ha ct sng c gi tr tch cc phng bnh trong au dy thn kinh ta.

T lng gi Cu hi 5 chn 1: chn cu ng 1. T l mc bnh au dy thn kinh ta

A. Nam mc bnh nhiu hn n gp 2 ln B. Nam mc bnh nhiu hn n gp 3 ln C. Nam mc bnh nhiu hn n gp 4 ln D. N mc bnh nhiu hn nam gp 2 ln E. N mc bnh nhiu hn nam gp 3 ln
2. T l bnh au dy thn kinh ta gy bi thot v a m

A. 30 % B. 40 % C. 50 % D. 60 % E. 60 %
3. Triu chng lm sng quan trng dng phn bit au thn kinh ta cp v mn (theo y hc c truyn) 478

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A. au tng v m (tri lnh) hoc khng B. au tng khi ho, ht hi hoc khng C. au gim vi chm nng hoc khng D. C cm gic t, kin b hoc khng E. au d di hoc m
4. au thn kinh ta theo kinh m

A. au mt sau chi di B. Phn x gn gt gim hoc mt C. Cm gic gim hoc mt pha ngn ci D. Teo c sinh i (c bp chui) E. Khng i c bng mi bn chn
5. au thn kinh ta theo kinh m

A. T hoc kin b mt sau chn B. Phn x gn gt gim hoc mt C. Ho hoc rn au tng D. au lng lan xung mng v mt sau chn E. n au phong th, dng lng tuyn, huyn chung
6. au thn kinh ta theo kinh bng quang

A. Phn x gn gt gim B. Cm gic gim hoc mt pha ngn ci C. Khng i c bng gt chn D. Teo nhm c cng chn trc E. au mt ngoi chn
7. au thn kinh ta theo kinh bng quang

A. au lng lan xung mng B. n au tha ph, tha sn C. au mt ngoi cng chn D. au khi i bng gt chn E. Phn x gn gt tng
8. Cng thc huyt dng trong au thn kinh ta r L5 th cp (phong hn hoc kh huyt tr) 479

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A. Gip tch L4-L5, hon khiu, u trung, kinh ct, i chung B. Gip tch L4-L5, hon khiu, u trung, khu kh, li cu C. Gip tch L4-L5, hon khiu, u trung, kinh ct, i chung, tam m giao D. Gip tch L4-L5, hon khiu, u trung, khu kh, li cu, thn du, tam m giao E. Gip tch L4-L5, hon khiu, u trung, kinh ct, i chung, thn du, tam m giao, thi kh
9. Cng thc huyt dng trong au thn kinh ta r S1 th cp (phong hn hoc kh huyt tr)

A. Gip tch L5-S1, hon khiu, u trung, kinh ct, i chung B. Gip tch L5-S1, hon khiu, u trung, khu kh, li cu C. Gip tch L5-S1, hon khiu, u trung, kinh ct, i chung, tam m giao D. Gip tch L5-S1, hon khiu, u trung, khu kh, li cu, thn du, tam m giao E. Gip tch L5-S1, hon khiu, u trung, kinh ct, i chung, thn du, tam m giao, thi kh
10. Cng thc huyt dng trong au thn kinh ta r L5 th mn

A. Gip tch L4-L5, hon khiu, u trung, kinh ct, i chung B. Gip tch L4-L5, hon khiu, u trung, khu kh, li cu C. Gip tch L4-L5, hon khiu, u trung, kinh ct, i chung, tam m giao D. Gip tch L4-L5, hon khiu, u trung, khu kh, li cu, thn du, tam m giao E. Gip tch L4-L5, hon khiu, u trung, kinh ct, i chung, thn du, tam m giao, thi kh
11. Cng thc huyt dng trong au thn kinh ta r S1 th mn

A. Gip tch L5-S1, hon khiu, u trung, kinh ct, i chung B. Gip tch L5-S1, hon khiu, u trung, khu kh, li cu C. Gip tch L5-S1, hon khiu, u trung, kinh ct, i chung, tam m giao D. Gip tch L5-S1, hon khiu, u trung, khu kh, li cu, thn du, tam m giao E. Gip tch L5-S1, hon khiu, u trung, kinh ct, i chung, thn du, tam m giao, thi kh
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II. in vo ch trng 1. Trong cng thc huyt iu tr au thn kinh ta r L5 th cp

A. Huyt hon khiu c chn theo nguyn tc . B. Huyt y trung c chn theo nguyn tc . C. Huyt khu kh c chn theo nguyn tc . D. Huyt li cu c chn theo nguyn tc .
2. Trong cng thc huyt iu tr au thn kinh ta r S1 th mn

A. Huyt thn du c chn theo nguyn tc . B. Huyt thi kh c chn theo nguyn tc . C. Huyt phi dng c chn theo nguyn tc . D. Huyt tam m giao c chn theo nguyn tc .
3. Nhng ng tc tp luyn cho bnh nhn au thn kinh ta trong t th nm nga (xin ghi theo tun t tp luyn)

A. . B. . C. . D. . E. . F. .
4. Nhng ng tc tp luyn cho bnh nhn au thn kinh ta trong t th nm xp (xin ghi theo tun t tp luyn)

A. . B. . C. . D. . E. . F. .

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Bi 28

HI CHNG SUY NHC MN TNH (CFS)

MC TIU 1. Nu c nhng yu t dch t hc ca hi chng suy nhc mn tnh.

2. Lit k c nhng triu chng quan trng ca hi chng suy nhc mn tnh. 3. Chn on c 3 th lm sng hi chng suy nhc mn tnh theo YHCT. 4. Trnh by c nguyn tc iu tr hi chng suy nhc mn tnh (dng thuc v khng dng thuc ca y hc c truyn). 5. Trnh by c phng php iu tr hi chng suy nhc mn tnh (dng thuc v khng dng thuc ca y hc c truyn). 6. Gii thch c c s l lun ca vic iu tr hi chng suy nhc mn bng YHCT.

1. I CNG 1.1. nh ngha Hi chng suy nhc mn tnh (chronic fatigue syndrome) l tn gi hin nay ca bnh l gy suy nhc kt hp vi nhiu ri lon vt l, th cht v tm thn kinh. Hi chng ny trc y 30 nm c gi vi nhiu tn khc nhau nh suy nhc thn kinh, tnh trng u ut, chronic mononucleosis, hi chng suy nhc sau nhim virus. 1.2. Dch t hc Bnh thng gp la tui 25 - 45, d bnh cng c th gp tr em v tui trung nin. N mc bnh nhiu hn nam gp 2 ln. Bnh xut hin ri rc. T l mc bnh tht s kh xc nh v ty thuc hon ton vo nh ngha bnh: suy nhc mn l triu chng khng c 482

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hiu, xut hin 20% bnh nhn n khm bnh tng qut; nhng hi chng suy nhc mn tnh th t ph bin hn. Theo CDC (Trung tm Kim sot v phng bnh - M) th hi chng suy nhc mn tnh xut hin trn 2 - 7 ngi/100.000 ngi. 2. NGUYN NHN V C CH BNH SINH 2.1. Theo y hc hin i S xut hin ca nhiu tn gi khc nhau ca hi chng bnh l ny phn nh nhiu gi thuyt cn tranh lun v nguyn nhn gy bnh. Thng nhng gi thuyt v nguyn nhn c cp xoay quanh: Nhim trng: cp n nhng loi siu vi (lymphotropic herpes virus, retrovirus v enterovirus) Nhng ri lon min dch: ngi ta quan st thy trong nhng trng hp ny c s gia tng trong mu nhng khng th khng nhn, suy gim cc immunoglobulines, nhng thay i v hot ng ca lympho bo. Nhng ri lon ni tit: nhng cng trnh nghin cu gn y cho thy trn nhng hi chng suy nhc mn tnh c s suy gim phng thch cc corticotropin - releasing factors ca no thy dn n nng trung bnh cortison trong mu ca bnh nhn thp hn ngi bnh thng. Cng theo gi thuyt trn th s bt thng v thn kinh ni tit c th c lin quan n tnh trng thiu sc lc v tnh kh, tm tnh ca bnh nhn. Tnh trng trm ut c ghi nhn 2/3 trng hp. Tnh trng trm cm ny thng thy cc bnh mn tnh. Tuy nhin, trong trng hp hi chng ny th tnh trng trm cm li xut hin rt nhiu, vt hn nhiu t l thng gp trn cc bnh mn tnh khc. V th, c ngi cho rng bnh ny c ngun gc tm l l c bn; nhng ri lon thn kinh ni tit v min nhim l th pht. 2.2. Theo y hc c truyn Hi chng suy nhc mn biu hin lm sng rt phong ph. Nhng triu chng thng gp trong hi chng ny nh mt mi, kh tp trung t tng, au u, au nhc c - khp, d cu gt, nng trong ngi, kh ng, st cn.. Nhng biu hin ni trn c thy trong tm cn suy nhc ca YHCT. Nh vy, c th tm tt cc triu chng c nng thng gp trong hi chng suy nhc mn gm: Mt mi: YHCT xp vo chng h gm kh h, huyt h, m h, dng h. 483

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Hoa mt, chng mt: YHCT xp vo chng huyn vng hay cn gi l huyn vng. au u: YHCT xp vo chng u thng, u trng, u trng da vo nhng biu hin khc nhau ca n. Nhng ri lon tm thn nh hay qun, hot ng tr c gim st: YHCT xp vo chng kin vong. Nng trong ngi, cn nng phng mt: YHCT xp vo chng pht nhit. nh trng ngc, hi hp: YHCT xp vo chng tm qu, chnh xung. Kh ng: YHCT xp vo chng tht min. au ngc: cn gi l tm thng, hoc km kh th th c gi l tm t, tm trng. Qua vic phn tch c ch bnh sinh ton b cc chng trng thng gp ca YHCT trong hi chng suy nhc mn, c th bin lun v c ch bnh sinh theo YHCT nh sau: + Do tht tnh (ni nhn): nh gin, lo s gy tn thng 3 tng t, can, thn. + Do mc bnh lu ngy (ni thng) lm c th suy yu; thn m, thn dng suy: thn m suy h ha bc ln, thn dng suy chn dng nhiu lon trn. + Do c a yu: tin thin bt tc (khng y ).
TIN THIN BT TC BNH LU NGy

THT TNH

Gin, lo s, stress

TH CHT YU

Thn dng h

Thn m h

Can m h

T h

Chn dng nhiu lon trn

H ha bc ln ( tm)

Khng dng c tm

Huyn vng, u thng, pht nhit, tm qu, chnh xung, kin vong, tht min

Hnh 28.1. S bnh l hi chng suy nhc mn theo YHCT

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3. BNH CNH LM SNG 3.1. Theo y hc hin i Bnh cnh in hnh ca trng hp suy nhc mn xut hin t ngt trn ngi trc hon ton bnh thng. C nhng trng hp bnh nhn ghi nhn c tnh trng nh cm hoc c sang chn tinh thn ngay trc (c bnh nhn xem nh l yu t khi pht). C nhng triu chng nh au u, au hng, au nhc cc hch ngoi vi, au nhc c khp, tnh trng st thng xy ra lm ngh n trng hp c nhim trng. Sau vi tun, nhng du chng khc ca hi chng bt u xut hin nh ri lon gic ng, kh tp trung t tng v trm ut. Theo SE. Straus, nm 1988, tn sut xut hin nhng triu chng ca hi chng suy nhc mn tnh c trnh by trong bng sau:
Triu chng bnh Mt mi Kh tp trung t tng au u au hng au hch ngoi vi au nhc c au nhc khp Nng trong ngi Kh ng Vn tm l D ng au bng St cn Ni ban Mch nhanh Ln cn au ngc m hi trm T l % 100 90 90 85 80 80 75 75 75 65 55 40 20 10 10 5 5 5

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Thng thng, cc triu chng rt bin thin. Ngi bnh thng ghi nhn tnh trng hot ng th lc qu sc hoc stress lm trm trng thm nhng triu chng sn c. Do tnh phong ph ca nhng triu chng trong hi chng suy nhc mn tnh m: Ngi bnh thng i khm rt nhiu ni, nhiu thy thuc (tng qut ln chuyn khoa: d ng, thp khp, tm l, chuyn khoa bnh truyn nhim.) v kt qu thng khng c nh mong mun. chn on hi chng mt mi mn (suy nhc mn), cn phi thc hin vic khm lm sng v thc hin nhng th nghim cn lm sng thng quy loi tr nhng nguyn nhn gy bnh c th ca nhng triu chng xut hin. Cn ch : cho n nay, khng c mt phng tin chn on no c th chn on c bnh l ny cng nh o lng c mc trm trng ca n. Do , khng nn thc hin nhng th nghim t tin tr trng hp nghin cu ang c tin hnh. 3.2. Theo y hc c truyn YHCT phn thnh 4 th lm sng khc nhau. Cc triu chng cng gm nhc u, kh tp trung t tng, mt ng, au nhc mnh my Tuy nhin, tnh cht ca nhng triu chng s quyt nh th lm sng YHCT 3.2.1. Th m h ha vng th ny, cc triu chng th hin qu trnh hng phn tng, c ch bnh thng. au u trong th ny c tnh cht tng cn, au d di, au cng nh mch p hoc cng, thng au nh hoc bn u. Ngi cu gt, bt rt, nng trong ngi, mt , i tin thng to, ru li kh; mch huyn, t, sc. Bnh nhn kh vo gic ng, hay ln tr trn ging, kh nm yn. Ngi bnh d vn cn lm vic c tt nhng kh nng tp trung bt u st gim. 3.2.2. Th can thn m h (tng ng vi qu trnh hng phn bnh thng, c ch gim) au u thng m , kh xc nh tnh cht v v tr, thng au c u. Ngi mt mi, mt ng, st cn. Bnh nhn thng cm thy mt nhiu hn v chiu, d cu gt, bt rt, hong ht. 486

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Kh nng tp trung t tng gim st nhiu, thng c km di tinh. Ru li kh. Mch t. 3.2.3. Th tm t lng h (tng ng vi qu trnh c ch thn kinh gim, km theo suy nhc nhiu, n km) au u thng m , kh xc nh tnh cht v v tr, thng au c u. Ngi mt mi, st cn. Ng t, d hong s, hi hp, trng ngc. Kh nng tp trung t tng gim st nhiu, hai mt thm qung. Ru li trng, mch nhu t hon. 3.2.4. Th thn dng h (tng ng vi s suy gim c 2 qu trnh, du chng suy nhc tr nn trm trng). Ngoi cc triu chng nu trn, bnh nhn cn c thm triu chng s lnh, lit dng, hot tinh, mch trm nhc. Phn ln bnh nhn vn cn c kh nng cn bng v thch ng c vi nhng yu cu cng vic, gia nh v x hi. Tuy nhin, cng c khng t nhng trng hp m ngi bnh c cm gic khng cn kh nng lm vic. Cui cng, tnh trng t c lp, tnh trng tht bi trong cng vic thng l du n cui ca bnh l mn tnh ny (du chng ny rt thng thy trong th lm sng thn dng h). Ngi bnh thng ni gin vi thy thuc v khng gip c nhiu cho tnh trng khn kh ca h. 4. IU TR Trch nhim c bn ca ngi thy thuc khi phi i mt vi hi chng suy nhc mn tnh l phi tm ra nguyn nhn bng cch khai thc bnh s tht k lng, khm lm sng ton din, s dng khn ngoan nhng xt nghim cn lm sng; v trong sut qu trnh kho st y phi lun lun thc hin vic chn on phn bit. Sau khi loi b c nhng bnh l khc, th nhng nguyn tc tr liu sau y phi c xem xt trong vic chm sc lu di hi chng suy nhc mn tnh. 4.1. Nguyn tc iu tr 4.1.1. Gii thch cn k tnh trng bnh tt cho bnh nhn Bnh nhn phi c gii thch y v bnh v c ch bnh, v nh hng ca n trn nhng mt th cht, i sng tm l v x hi. Bnh nhn thng cm thy d chu khi nhng kh chu ca h c quan tm mt cch nghim tc. 487

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4.1.2. Ti khm nh k Vic ti khm nh k rt hu ch trong vic tm ra nhng bnh tt cn n du (cha pht hin c trong nhng ln khm trc ). 4.1.3. iu tr triu chng Vic lm gim mt triu chng trong bnh l ny (d nh) cng to nn mt khc bit rt ln i vi ngi bnh. 4.1.4. Hng dn ngi bnh thay i cch sng, sinh hot Trnh nhng ba n ti nng n, trnh dng nhng cht kch thch v m. Khng nn ngh ngi hon ton: nn thc hin ngay nhng bi tp dng sinh c chng minh c hiu qu i vi nhng trng hp suy nhc, mt ng nh th gin, cc ng tc tp luyn t th nm. c nhiu trng hp c th v vic ci thin tnh trng bnh nhn (nh tnh trng sc kho th xc v tinh thn, nhng triu chng au nhc ton thn, tnh tnh cu gt, mt ng, tiu m) sau nhng kha hc dng sinh (xem bi th gin, thi tm thn trong cuc sng, dng sinh). Nn c ch lm vic tht s c th, thc t cho tng trng hp c th, nhng ni chung lm vic nh v tng dn cng cn c khuyn khch. 4.1.5. Nn trnh nhng tr liu khng hiu qu Nhng nghin cu c so snh vi l chng chng t acyclovir, tinh cht gan tim bp, acid folic, sinh t B12 u khng c gi tr. Ngoi ra, cng c nhng cng trnh cho thy vic iu tr bng immunoglobulin liu cao tim tnh mch cng khng c gi tr tr liu no. 4.2. iu tr bng y hc c truyn 4.2.1. Th m h ha vng Do tnh cht a dng ca bnh m vic iu tr cng rt phong ph. Thng thng, trong th ny du chng dng xung (ho bc) l quan trng. Du chng ny thng xut hin h thng can v tm. Php tr: s can, l kh, gii ut, an thn; t m, ging ha, tim dng, an thn. Nhng bi thuc v cng thc huyt s dng. + Bi thuc n chi tiu dao gia gim (gm: si h 12g, chi t 12g, bc h 8g, sinh khng 6g, bch thc 10g, ng quy (ra ru) 10g, phc linh 12g, n b 12g, bch trut (sao t) 8g). Gia gim thin ma 12g, cu ng 12g, thch quyt minh 12g, cc hoa 12g. 488

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V thuc Si h Chi t Bc h Sinh khng Bch thc ng quy (ra ru) Phc linh n b Bch trut (sao t) Thin ma Cu ng Thch quyt minh Cc hoa Bnh can h st

Tc dng

Vai tr Qun Thn Thn Thn Thn Thn T T T Qun Qun Thn T

ng, hn: thanh nhit t ha, li tiu, cm mu Cay, mt: gim au, pht tn phong nhit Cay, hi n: gii biu, tn hn ng, cht, chua: nhun gan, dng huyt, lim m, li tiu Dng can huyt Ngt, nht, bnh: li thy, thm thp, b t, nh tm Cay, ng, hi hn: thanh huyt nhit, tn huyt; cha nhit nhp doanh phn Ngt, ng, m: kin t, to thp, ha m, li thy Ngt, cay, hi ng, bnh: thang thanh, ging trc, tn phong, gii c Ngt, hn: thanh nhit, bnh can, trn kinh Tr st cao, n khng tiu: thanh nhit Ngt, mt: tn phong nhit, gii c, ging ha

+ Bi K cc a hong thang (gm: bch cc hoa 120g, phc linh 120g, thc a 320g, cu k t 120g, hoi sn 160g, trch t 120g, n b 120g, sn th 160g). Tn bt, lm hon, ngy dng 8 - 16g.
V thuc Thc a Hoi sn Sn th n b Phc linh Trch t K t Cc hoa trng Tc dng Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Chua, sp, hi n: n b can thn, sp tinh, ch hn Cay, ng, hi hn: thanh huyt nhit, tn huyt; cha nhit nhp doanh phn Ngt, nht, bnh: li thy, thm thp, b t nh tm Ngt, nht, mt: thanh t thp nhit bng quang Ngt, bnh: b can thn, nhun ph to, mnh gn ct Ngt, ng, hi hn: tn phong thp, thanh u mc, ging ha, gii c Vai tr Qun Qun Thn T T T Thn T

+ Bi thuc gm cu ng 12g, h kh tho 12g, chi t 12g, to nhn (sao en) 8g, long nhn 16g, l vng 20g, mung tru 12g. + Chm cu: chm t lu kim 15 pht cc huyt thi dng, bch hi, u duy, phong tr, thi xung, quang minh. 489

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4.2.2. Th can thn m h Php tr (ty thuc vo triu chng ch yu): + B thn m, b can huyt, an thn. + B thn m, b can huyt, c tinh. Nhng bi thuc v cng thc huyt s dng: + Bi thuc Lc v a hong hon gia quy thc (gm: thc a 32g, hoi sn 16g, sn th 8g, n b 12g, phc linh 12g, trch t 6g, ng quy 12g, bch thc 8g). Bi ny thng c s dng khi tng huyt p c km triu chng au ngc, au vng tim. Phn tch bi thuc:
V thuc Thc a Hoi sn Sn th n b Phc linh Trch t ng quy Bch thc Tc dng Ngt, hi n: nui thn dng m, b thn b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Chua, sp, hi n: n b can thn, sp tinh ch hn Cay, ng, hi hn: thanh nhuyt nhit, tn huyt, cha nhit nhp doanh phn Ngt, nht, bnh: li thy, thm thp, b t nh tm Ngt, nht, mt: thanh t thp nhit bng quang Cay, ngt, n: b huyt, hot huyt, nhun to, hot trng, iu huyt, thng kinh ng, chua, hi hn: dng huyt, lim m, li tiu, nhun gan Vai tr Qun Qun Thn T T T Thn Thn

+ Bi thuc B can thn (gm: h th 10g, thc a 15g, hoi sn 15g, ng quy 12g, trch t 12g, si h 10g, tho quyt minh 10g) (xem Bnh hc YHCT , trang 224). Phn tch bi thuc:
V thuc H th Thc a Hoi sn ng quy Trch t Si h Tho quyt minh B huyt, thm tinh Ngt, hi n: nui thn dng m, b thn, b huyt Ngt, bnh: b t v, b ph thn, sinh tn ch kht Dng can huyt Ngt, nht, mt: thanh t thp nhit bng quang Bnh can, h st Thanh can nhun to, an thn Tc dng Vai tr Qun Qun Qun Thn T T T

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+ Bi thuc Kim ta c tinh hon (gm: khim thc 80g, lin t 80g, mu l 40g, lin tu 80g, long ct 40g, sa uyn tt l 80g) (xem Bnh hc YHCT , trang 203).
V thuc Khim thc Sa uyn Mu l Lin nhc Tt l Long ct Lin tu Tc dng Ngt, cht, bnh: b t, ch thn, ch t, sp tinh Kinh nghim Mn, cht, hi hn: t m, tim dng, ha m, c sp Ngt, bnh: b t dng tm, sp trng, c tinh ng, n: bnh can tn phong, thng thp, hnh huyt Ngt, sp, bnh: trn kinh an thn, sp tinh v lm ht m hi Kinh nghip tr bng huyt, th huyt, di mng tinh Thn Thn T T T Vai tr Qun

+ Bi thuc gm thc a 20g, kim anh 12g, khim thc 12g, to nhn (sao en) 8g, long nhn 16g, l vng 20g, mch mn 12g, ym ra (sao) 12g, mu l (nung) 8g, mai ba ba (sao gim) 12g. Chm cu: chm b lu kim 30 pht cc huyt thi dng, bch hi, u duy, phong tr (a th huyt), thi xung, quang minh, can du, thn du, tam m giao, thi kh, phi dng, phc lu gia thm thn mn, ni quan, bch hi. Cng thc 1: thn du, phc lu, tam m giao, can du, thi xung; gia thm thn mn, bch hi, a th huyt
Tn huyt Thn du Phc lu Tam m giao Can du Thi xung Thn mn Bch hi A th huyt C s l lun Du huyt ca thn lng Kim kinh huyt ca kinh thn: b mu, b thn thy Giao hi huyt ca 3 kinh m chn Du huyt ca can lng Du th huyt ca kinh can: t t, t can ha Du th huyt ca kinh tm: t t, t tm ha Hi ca c mch v 6 dng kinh Tc dng iu tr ch thy, trng ha km cha chng au lng B thn m: cha chng o hn T m B can huyt Thanh can ha, cha chng u chong mt hoa Thanh tm ha, t tm nhit, thanh thn ch, tit nhit

Cng thc 2: thn du, phc lu, tam m giao, can du, thi xung, ni quan, thn mn 491

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Tn huyt Thn du Phc lu Tam m giao Can du Thi xung Ni quan Thn mn

C s l lun Du huyt ca thn lng Kim kinh huyt ca kinh thn: b mu, b thn thy Giao hi huyt ca 3 kinh m chn Du huyt ca can lng Du th huyt ca kinh can: t t, t can ha Giao hi huyt ca tm bo v mch m duy c hiu vng ngc Du th huyt ca kinh tm: t t, t tm ha

Tc dng iu tr ch thy trng ha km cha chng au lng B thn m: cha chng o hn T m B can huyt Thanh can ha: cha chng u chong mt hoa Cha chng hi hp, au ngc gy kh th, ngn ngc Thanh tm ha T tm nhit: cha chng tm phin

4.2.3. Th tm t h Php tr: kin t an thn (b tm t). Nhng bi thuc v cng thc huyt s dng: Bi thuc Quy t thang (gm: bch phc linh 8g, hong k 10g, nhn sm 10g, bch trut 10g, long nhn 10g, toan to nhn 4g, cam tho 2g, mc hng 2g, vin ch 4g, ng quy 4g).
V thuc Toan to nhn Long nhn Nhn sm Hong k Bch trut ng quy Vin ch Mc hng Cam tho Bch phc linh Tc dng Ngt, chua, bnh: dng tm an thn, sinh tn dch B huyt, kin t Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt sinh tn Ngt, m: b tm kh, thng dng kh ca t Ngt, ng, hi m: Kin t, to thp, cm m hi Ngt, cay, m: b huyt, hnh huyt ng, m: b tm thn, an thn Hnh kh ch thng, kin t Ngt, m: b t th, b trung kh Vai tr Qun Qun Thn Thn Thn T T T S

+ Bi Phc mch thang (gm: a giao 8 - 12g, mch mn 8 - 12g, ma nhn 8 - 16g, chch tho 12 - 20g, nhn sm 8 - 12g, sinh a 16 - 20g, i to 10 qu, qu chi 8 - 12g, sinh khng 3 - 5 lt) (xem Bnh hc YHCT , trang 352). 492

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V thuc Cam tho Nhn sm i to Qu chi Sinh khng Sinh a A giao Mch mn Ma nhn

Tc dng Ngt, m: b t th, b trung kh Ngt, hi ng: b tm kh, i b nguyn kh, ch huyt, sinh tn Ngt, bnh: b t v, iu ha tnh nng ca thuc n kinh, thng dng Gii biu, pht hn Dng m, dng huyt T m, b huyt Nhun ph, sinh tn dch Ngt, bnh: nhun trng, li niu, chng nn

Vai tr Qun Thn Thn T T T T T T

Chm cu: chm b lu kim 30 pht cc huyt a th, tm du, t du, v du, tc tam l, cch du, tam m giao, thn mn, ni quan, thi bch, phong long. 4.2.4. Th thn dng h Php tr: n thn dng, b thn m, an thn, c tinh. Nhng bi thuc v cng thc huyt s dng: Bi thuc Thn kh hon (gm: bch phc linh 120g, thc a 320g, sn th 160g, n b 120g, qu chi 40g, trch t 120g, ph t 40g, sn dc 160g. Tn bt, ngy ung 8-12g)
V thuc Ph t Qu Thc a Hoi sn Sn th n b Phc linh Trch t Tc dng i nhit, c c, cay, ngt: hi dng cu nghch, b ha tr dng, trc phong hn thp t Cay, ngt, i nhit hi c: b mnh mn tng ha Ngt, hi n: nui thn dng m, b thn, b huyt Ngt bnh: b t v, b ph thn, sinh tn, ch kht Chua, sp, hi n: n b can thn, sp tinh, ch hn Cay, ng, hi hn: thanh huyt nhit, tn huyt, cha nhit nhp doanh phn Ngt, nht, bnh: li thy, thm thp, b t nh tm Ngt, nht, mt: thanh t thp nhit bng quang Vai tr Qun Qun Qun Qun Thn T T T

+ Bi Hu quy m (gm: cam tho 4g, trng 12g, hoi sn 16g, k t 8g, nhn sm 8g, nhc qu 4g, ph t 2g, th du 8g, thc a 32g).

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V thuc Ph t Qu Thc a Hoi sn Sn th K t trng Cam tho Nhn sm Th du

Tc dng i nhit, c c, cay, ngt: hi dng cu nghch, b ha tr dng, trc phong hn thp t Cay, ngt, i nhit hi c: b mnh mn tng ha Ngt, hi n: nui thn dng m, b thn, b huyt Ngt bnh: b t v, b ph thn, sinh tn ch kht Chua, sp, hi n: n b can thn, sp tinh ch hn Ngt, bnh: b can thn, nhun ph to, mnh gn ct Ngt, n, hi cay: b can thn, mnh gn ct Ngt, bnh: b t v, nhun ph thanh nhit gii c, iu ha v thuc i b nguyn kh, sinh tn dch

Vai tr Qun Qun Qun Qun Thn Thn Thn S T T

C th s dng bi thuc gm: thc a 20g, kim anh t 12g, khim thc 12g, to nhn (sao en) 8g, long nhn 16g, l vng 20g, trng 16g, mu l (nung) 8g, ba kch 12g. Chm cu - cu b hoc n chm: thi dng, bch hi, u duy, phong tr, thi xung, quang minh, can du, thn du, tam m giao, thi kh, phi dng, mnh mn, trung cc, quan nguyn, kh hi. 4.3. Nhng phng php tp luyn dng sinh Th gin. Th su, th 4 thi c k mng v gi chn. Hng dn thi tm thn trong cuc sng: cch sinh hot ny khng nhng c gi tr trong iu tr bnh nhn m cn c ngha vi nhng ngi khe mnh (d phng cp 0)

T lng gi Cu hi 5 chn 1: chn cu ng 1. Hi chng suy nhc mn thng gp nht la tui A. < 70 B. 60 - 70 C. 45 - 60 D. 25 - 45 E. 25 494

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2. Dch t hc ca hi chng suy nhc mn A. N mc bnh nhiu hn nam gp 3 ln B. N mc bnh nhiu hn nam gp 2 ln C. N mc bnh nhiu hn nam gp 1, 5 ln D. Nam mc bnh nhiu hn n gp 3 ln E. Nam mc bnh nhiu hn n gp 2 ln 3. Nhng triu chng thng gp nht ca hi chng suy nhc mn A. Mt mi, au u, mt ng B. Mt mi, m hi trm, st cn C. Mt mi, kh tp trung t tng, au u D. Mt mi, kh ng, st cn E. Mt mi, d cu gt, trm cm 4. Triu chng no khng c trong th can ha vng A. au u d di B. Cu gt, bt rt C. au nhc mnh my D. S lnh E. Kh vo gic ng 5. Triu chng no khng c trong th thn m h A. au u d di B. Cm gic nng trong ngi C. m hi trm D. St cn E. Lit dng 6. Triu chng no khng c trong th thn dng h A. au u B. Cu gt, bt rt C. Khng mun hot ng D. Kh tp trung t tng E. Mt ng 7. Nguyn tc iu tr no khng cn thit cho hi chng suy nhc mn A. Ti khm nh k B. iu tr triu chng 495

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C. S dng nhiu cht b dng, sinh t B12 D. Hng dn thay i cch sng, sinh hot E. Gii thch tnh hnh bnh tt cho bnh nhn 8. Mung tru trong bi thuc tr th m h ha vng, c tc dng A. Chng to bn B. B dng C. An thn D. Cha au u E. H nhit 9. H kh tho trong bi thuc tr th m h ha vng, c tc dng A. Chng to bn B. B dng C. An thn D. Cha au u E. H nhit 10. L vng trong bi thuc tr th can thn m h, c tc dng A. Chng to bn B. B dng C. An thn D. Cha au u E. H nhit

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Bi 29

VIM KHP DNG THP

MC TIU 1. Trnh by c nh ngha v nhng yu t dch t hc ca bnh vim khp dng thp (VKDT). 2. Trnh by c nguyn nhn v c ch bnh sinh ca VKDT. 3. Chn on c VKDT theo YHH v cc bnh cnh lm sng YHCT. 4. Trnh by c nhng nguyn tc iu tr theo YHH &YHCT. 5. Trnh by c phng php iu tr ca tng th bnh ca VKDT theo YHCT. 6. Gii thch c c s l lun ca vic iu tr VKDT theo YHCT.

1. I CNG 1.1. nh ngha Vim khp dng thp l mt bnh mn tnh, c coi l mt bnh t min quan trng th hai trong nhm cc loi bnh t min (sau bnh lupus h thng) v l bnh quan trng nht trong nhm bnh khp do thp. 1.2. c im dch t hc 1.2.1. Tn sut mc bnh a. T l mc bnh (prevalence) Theo WHO (1992) t l mc bnh chung l 0,5 - 3% dn s th gii t 15 tui tr ln; t l ny c th ln n 5% ty chng tc nh: T l bnh thp hn 0,5% ngi Nht v Trung Quc. c bit ch 0,1% qun th ngi da en Nam Phi v 0,18% Ty Bc Hy Lp. T l mc bnh cao hn 5% qun th ngi da trng v cc b lc da Bc M. T l mc bnh theo tui 0,3% ngi di 35 tui v n trn 10% ngi trn 65 tui.

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T l mc bnh ph n cao hn hn nam gii (t l nam/n l 1/2,5). la tui di 60, t l ny l 1/5 - 6, nhng trn 65 t l ny ch l 1/2. nc ta, theo nghin cu ca cc tnh pha Bc, t l ny l 0,5% dn s v chim 20% s bnh nhn khp n iu tr ti bnh vin. b. T l mi mc bnh (incidence) Hng nm c khong 700 - 750 ngi mi mc bnh VKDT trn 1 triu dn s t 15 tui tr ln. Vim khp dng thp c th gp mi la tui nhng tp trung ti 80% vo la tui trung nin. Ngoi ra, cc yu t dch t cng nh hng n t l mc bnh nh: tnh trng kinh t, x hi, cc stress tm l, v cc trng thi c th nh thai nghn, thuc nga thai, mn kinh C th ni v mt dch t hc, vim khp dng thp l bnh ca ph n tui trung nin, v 70 - 80% bnh nhn l n v 60 - 70% xut hin la tui trn 30. 1.3. Quan nim bnh theo y hc c truyn Triu chng bnh l ca VKDT theo YHH nu trn cng c m t trong phm vi cc chng ca YHCT nh: Chng t: tam t, ng t. Lch tit phong, hc tt phong, bch h lch tit phong Chng t l mt trong nhng chng ch yu ca YHCTC, t ng m vi b, tc b tc li khng thng. T va c dng din t biu hin ca bnh nh l tnh trng au, t, mi, nng, sng, nhc, but da tht, khp xng; va c dng din t tnh trng bnh sinh l s b tc khng thng ca kinh lc, kh huyt. 2. NGUYN NHN V C CH SINH BNH 2.1. Nguyn nhn gy bnh theo y hc hin i 2.1.1. Mt s gi thuyt v nguyn nhn Nguyn nhn gy bnh cha r, c nhiu gi thit c a ra mc d tm c s hin din ca nhm khng th khng globulin min dch trong huyt thanh cng nh trong dch khp ca ngi bnh m gi chung l nhn t thp. Khng th c th l: IgM anti IgG, IgG anti IgG, IgA anti IgG. Cc khng th ny t n khng gii thch cc tn thng bnh hc. Cng v vn cha gii thch c l do sn xut v hin din ca nhn t thp nn ngi ta xp vim khp dng thp vo loi bnh t min vi s tham gia ca nhiu nhn t. 498

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2.1.2. Cc yu t tham gia a. Yu t c a: bnh c lin quan r n gii tnh v la tui. b. Yu t di truyn: bnh vim khp dng thp c tnh cht gia nh. Nhiu cng trnh nghin cu cho thy t l vim khp dng thp nhng gia nh c cha m b bnh cao hn 2 - 3 ln so vi gia nh khc; v cng cho thy mi lin quan gia vim khp dng thp v yu t khng nguyn ph hp vi t chc HLADR4. H thng HLA c mi lin h vi hng trm bnh khc nhau trong c vim khp dng thp. Trn bnh nhn, bnh vim khp dng thp c ti 60 - 70% c HLADR4, trong khi ngi bnh thng, t l ny ch l 20 - 28%. Nh vy ngi mang HLADR4 c nguy c mc bnh vim khp dng thp nhiu gp 4 - 5 ln so vi nhng ngi khng mang HLADR4. Mc d cha xc nh c v tr gen c bit dn n s pht trin bnh, nhng cc d kin ch ra rng phc hp ha hp t chc chnh (Major Histocompatipility Complex - MHC) nm trn nhim sc th th 6 l gen quan trng dn n bnh vim khp dng thp v cc polipeptid lin quan n bnh vim khp dng thp iu khin p ng min dch hoc l c s thiu ht p ng min dch thch hp i vi mt yu t gy bnh ca mi trng. c. Yu t tc nhn gy bnh C th l mt nhim khun, nhim virus. Mt loi d ng nguyn t ngoi vo hoc ni sinh. Mt enzym do thay i cu trc. d. Cc yu t thun li c tnh cch pht ng gy bnh C th suy yu do bt thng v dinh dng v ch n ung, hoc sau khi mc bnh nhim khun nng. Cc yu t tm l, cc stress, cc trng thi c th (thai nghn, mn kinh, dng thuc nga thai), cc ri loi ni tit. Mi trng kh hu lnh v m ko di. Sau phu thut. 2.2. C ch sinh bnh Nhng kin thc mi v min dch hc v sinh hc phn t lm sng t hn c ch sinh bnh vim khp dng thp. Khi u, tc nhn gy tc ng vo c th c sn c a thun li v nhng yu t di truyn d tip nhn, tc nhn ny lm thay i tnh khng nguyn ca mng hot dch khp, sinh ra khng th chng li tc nhn gy bnh, ri cng chnh khng th ny tr thnh tc nhn (khng nguyn IgG) kch thch c th sinh ra mt s khng th chng li n gi l t khng th IgM anti IgG; khng th lc u - khng nguyn IgG - v t khng th IgM 499

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anti IgG vi s c mt ca b th kt hp vi nhau trong dch khp thnh nhng phc hp khng nguyn khng th. Nhng phc hp khng nguyn khng th ny c thc bo bi bch cu a nhn trung tnh v i thc bo. Sau cc bch cu ny s b ph hy bi chnh cc men tiu th m chng gii phng ra tiu cc phc hp khng nguyn khng th nu trn. S hin din ca phc hp khng nguyn khng th v hin tng thc bo, tc ng n tt c cc hot ng sinh hc: h b th nht l t C1 n C6 hot ha h kinin, h tiu fibrin, h ng mu phi hp vi cc cytokin ca t bo lympho T sinh ra collagen v transin - stromalysin gy bin i v to qu trnh vim, cng nh sinh cc proteoglycan khp v tc ng hy xng di sn v hy sn. Cc m khp tng sinh tng hp kinin, prostaglandin, yu t hagemen l cc yu t tch cc gy nn hin tng vim. Cc bch cu a nhn trung tnh tp trung trong dch khp; cc t bo ni mc iu chnh hot ng ng mu, tiu fibrin v tit dch cng nh gii phng cc phn t dnh mch mu; cc t bo i thc bo sau khi thc bo gii phng cc cht trung gian gy nn mt hin tng vim c trng ca vim khp dng thp. Nhn mt cch tng th th lympho T l tc nhn iu hnh ch yu ca p ng min dch v cc cytokin c vai tr bn l trong iu ha cc p ng min dch trong mt khi pht vim cng nh duy tr mng hot dch ca vim khp dng thp. Ngoi ra cn c vai tr ca interleukin, interferon, nng ARN thng tin cho s tng hp interleukin tc ng n vic tng tit prostaglandin E2, thromboxan trong vim khp dng thp. 2.3. Tn thng bnh hc Tn thng bnh l u tin trong bnh vim khp dng thp l s hot ha v s thng tn cc t bo ni mc ca cc vi mch mu mng hot dch, iu gi yu t gy bnh hoc khi pht hin n mng hot dch bng ng mch mu. Tn thng cn bn ca bnh vim khp dng thp l hin tng vim khng c hiu ca mng hot dch, bao gm: Tng sinh t bo hnh lng v lp lin bo ph gy dy mng hot dch. Gin mch v ph n mng hot dch. Lng ng cht t huyt mng trn t bo hnh lng hoc di lp lin bo ph. Thm nhp nhiu lymphocyt v plasmocyt, c khi to thnh nhng m dy c gi l nang dng thp. Phn mng hot dch bm vo phn u xng ch tip gip vi sn gi l mng mu (pannus) c th xm ln vo xng gy nn cc hnh nh bo mn xng trn X quang. 500

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Cc tn thng ny tun t qua 3 giai on chnh: Giai on 1: mng hot dch ph n, sung huyt xm nhp nhiu t bo vim c bit l neutrophile. Giai on 2: hin tng ph n c thay th bng qu trnh tng sinh v ph i ca cc t bo hnh lng v lp lin bo ph. Cc t bo vim c thnh phn chnh l lymphocyte v plasmocyte. Qu trnh tng sinh ny n su vo u xng di sn gy nn tn thng xng. Giai on 3: sau mt thi gian di, t chc x pht trin thay th cho hin tng vim dn n dnh khp v bin dng khp. Tn thng bnh hc cng c th xy ra m di da, di hnh thc nt thp c bit ca bnh. Nt thp thng c khuu tay, mt lng, da u hoc ni tng nh phi, van tim. Tn thng cng c th xy ra mch mu c ng knh nh v trung bnh. Mch mu ny b vim dn ti tnh trng km dinh dng nhng vng mch mu tn cng nh u chi, sinh ra t b, au. Hin tng vim cc mch mu hin nay c coi l hin tng khi u cho cc nt thp v sau. 2.4. Biu hin lm sng v cn lm sng 2.4.1. Biu hin lm sng a s trng hp bnh bt u t t tng dn, nhng c khong 15% bt u t ngt vi nhng triu chng cp tnh. Trc khi du hiu khp xut hin, bnh nhn c th c cc biu hin nh st nh, mt mi, gy st, t cc u chi, ra m hi nhiu, ri lon vn mch, au nhc v kh c ng khp khi ng dy. Giai on ny c th di hng tun, hng thng. a. Biu hin ti khp Giai on bt u: + V tr ban u: 2/3 trng hp bt u bng vim mt khp, trong 1/3 bt u bng vim mt trong cc khp nh bn tay (c tay, bn ngn, t ngn gn); 1/3 khp gi v 1/3 cc khp cn li. + Tnh cht: sng au r, ngn tay hnh thoi, du hin cng khp bui sng thy t 10 - 20%. Bnh din tin ko di n vi tun, vi thng ri chuyn sang giai on r rt. Giai on ton pht: + V tr khp vim: bn tay 90%, c tay 90%, khp t ngn gn 80%, bn ngn 70%, khp gi 90%, bn chn 70%, c chn 70%, ngn chn 60%, khp khuu 60%, cc khp khc (hng, ct sng, hm, c n) him gp v thng xut hin mun. 501

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Tnh cht vim: i xng 95%, sng au v hn ch vn ng, t nng , c th c nc khp gi, c du hiu cng khp bui sng, au tng nhiu v m (gn sng). Cc ngn tay hnh thoi nht l cc ngn 2, 3, 4. Din bin: cc khp vim tin trin tng dn v nng dn, pht hin thm cc khp khc. Cc khp vim dn dn n tnh trng dnh v bin dng, bn ngn tay dnh v bin dng t th na co v lch trc v pha tr, khp gi dnh t th na co. b. Triu chng ton thn v ngoi khp Ton thn: gy st, mt mi, n km, da xanh nht do thiu mu, ri lon thn kinh thc vt. da v m di da: 20% trng hp bnh nhn c nhng nt thp da v m di da. l nhng ht hay cc ni ln khi mt da, chc, khng au, khng di ng v dnh vo nn xng di, kch thc t 5mm n 20mm ng knh. V tr hay gp nht l trn xng tr gn khp khuu, hoc trn xng chy gn khp gi, hoc lng ngn tay; mt sau da u; cc ni xng li di da, s lng t mt n vi ht. Nt thp thng c cng vi giai on bnh tin trin v c th tn ti hng tun, hng thng. Da kh, teo v x nht l cc chi. Gan bn tay, bn chn gin mch hng. Ri lon dinh dng v vn mch c th gy lot v khun chn, ph mt on chi, nht l chi di. C, gn v bao khp: teo c r rt vng quanh khp tn thng; nht l c lin ct, c giun bn tay, c i, cng chn. Teo c l hu qu do khng vn ng. Vim gn: hay gp vim gn achille. Bao khp: c th phnh ra thnh cc kn hot dch nh vng khoeo. Ni tng: rt him gp trn lm sng. Tim: c th c du chng vim mng ngoi tim. Phi: c th c du chng thm nhim hay trn dch, x ph nang. Hch: hch ni to v au mt trong cnh tay. Xng: mt vi, gy xng t nhin. Thn: amyloid c th xy ra bnh nhn bnh tin trin lu ngy v c th dn ti suy thn. Thn kinh: c th b vim a dy thn kinh ngoi bin. Mt, chuyn ha: vim gic mc, vim mng mt th mi; thiu mu nhc sc.

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2.4.2. Biu hin cn lm sng a. Xt nghim chung Cng thc mu: hng cu gim, nhc sc, bch cu c th tng hoc gim. Tc lng mu tng. Xt nghim nh lng haptoglobin, seromucoid v phn ng C protein c th dng tnh. b. Xt nghim min dch Nhm pht hin yu t dng thp trong huyt thanh (t khng th) l mt globulin min dch IgM c kh nng ngng kt vi globulin IgG. Nhn t thp hoc yu t dng thp l tn gi chung ca mt nhm globulin min dch tm thy trong huyt thanh v trong dch khp bnh nhn. Nhn t thp gm: IgM anti IgG, IgG anti IgG, IgA anti IgG. IgM anti IgG c th xc nh bng mt trong 2 phng php sau: Waaler - Rose: dng hng cu ngi hoc cu tin hnh phn ng. Waller - Rose (+) khi ngng kt hiu gi k 1/16 Latex: dng ht nha. Latex (+) khi 1/32. Yu t dng thp thng thy 70 - 80% trng hp v thng xut hin mun (sau khi mc bnh trn 6 thng) v n cng xut hin trong mt s bnh t min khc nh: lupus h thng, x cng b ton th, hi chng Sjogren, mt s bnh nhim trng Ngoi phn ng ngng kt, yu t dng thp cn c pht hin bng cc phng php o c Elisa v min dch phng x. Vi phng php Elisa c th pht hin c cc yu t dng thp IgM, IgA, IgG, v IgE nn nhy hn vi phng php ngng kt v t hiu ti 98%. c. Dch khp Lng mucin gim r rt, dch khp lng, gim nht, c mu vng nht. Lng t bo tng nhiu 20000mm3 nht l a nhn trung tnh. Ngoi ra cn thy xut hin nhng bch cu a nhn trung tnh m trong bo tng c nhiu ht nh, l nhng t bo thc bo nhng phc tp khng nguyn - khng th m ngi ta gi l nhng t bo hnh nho, khi t bo hnh nho chim trn 10% s t bo dch khp th c gi tr chn on vim khp dng thp. Lng b th trong khp gim. Phn ng Waaler - Rose, Latex hoc RF c (+) sm hn v cao hn so vi mu. C t bo hnh nho (ragocyte hay cell rheumatoid arthritis). 503

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d. Fibrinogen trong mu thng cao, l biu hin gin tip ca hin tng vim nhim. e. in di m: globulin v 2 glubulin tng. f. Sinh thit Mng hot dch: trong vim khp dng thp c 5 tn thng + S tng sinh t bo hnh lng ca mng hot dch. + Tng sinh ca lp t bo ph hnh lng, t mt lp pht trin thnh nhiu lp. + Xut hin nhng m hoi t ging nh t huyt. + Tng sinh nhiu mch mu tn to phn t chc m. + Thm nhp nhiu t bo vim quanh cc mch mu m ch yu l lympho bo v plasmocyt. Sinh thit hch di da: gia l mt m hoi t dng t huyt, xung quanh bao bc bi rt nhiu t bo loi lympho bo v plasmocyt. g. X quang khp giai on u ch thy sng m mm, xng mt vi khong gn khp. giai on sau c lot b xng, sn khp b hy, khong cch hai u xng hp li, b xng nham nh, trc khp b lch, khe khp hp dn ri dnh khp, khng thy tn thng khp t ngn xa. 2.4.3. D hu v tin lng Vim khp dng thp l bnh mn tnh, tin trin ko di bng nhng t cp tnh, khng tin lng c thi gian xy ra cc t cp tnh hoc ngng tin trin. Cc t ngng tin trin xy ra giai on u ca bnh nhiu hn. Phn ln bnh nhn b hn ch c ng khp nhng vn c th t sinh hot, ch 10% trng hp l tn ph. C nhiu yu t gip tin lng bnh, tuy nhin khng ch cn c vo tng yu t ring l m cn kt hp nhiu yu t nh: Tui gi Tn thng nhiu khp Tn thng trn X quang nng v sm. C nt thp di da Yu t dng thp dng tnh cao C cc biu hin ngoi khp, c bit l vim mch mu Yu t HLADR4 dng tnh 504

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Tui th trung bnh: trung bnh bnh nhn VKDT gim th t 3-7 nm, iu ny c lin quan n: Thi gian v mc bnh. Tui v gii. Phng php iu tr v liu corticosteroid s dng. 2.5. Nguyn nhn bnh sinh theo y hc c truyn 2.5.1. Nguyn nhn sinh bnh a. Nhm ngoi cm, tc l do 3 th t kh phong, hn, thp ln ln dn n xm nhp vo c th. Cc t kh ny gy ri lon s vn hnh kh huyt, lm cho kh huyt b tc, lu thng khng iu ha m sinh bnh. Cc t kh ny li b tc lu li kinh lc, c nhc, cn mch hoc tng ph gy sng, au, nhc, t bun, nng, mi mt vng c th hay cc khp xng. b. Nhm ngoi cm phi hp vi ni thng gy bnh iu kin 3 kh t phong hn thp gy bnh c l c th c v kh suy yu, hoc c sn kh huyt h, hoc tui gi c can thn h suy. c. Nhm do ni thng Do bnh lu ngy lm kh huyt h suy, hoc do tin thin bt tc lm cho kh huyt bt tc, doanh v khng iu ha m sinh bnh. Ngoi ra iu kin thun li 3 t kh xm nhp gy bnh cho c 2 th loi trn l sng v lm vic trong mi trng m thp, ngm tm thng xuyn di nc, n ung thiu cht dinh dng, lm vic mt nhc li b ma rt thng xuyn. 2.5.2. D hu v tin lng theo y hc c truyn Nguyn nhn gy ra cc chng nu trn u do ba t kh phong, hn, thp. Tri c 6 th kh m bnh l khp xng b ba th khi lm bnh, tt nhin l bnh nan tr (v phong th i nhanh, hn th vo su, m thp th t m v ng). T kh cn ngoi b phu th bnh cn nh, d pht tn thuc phn d tr. T kh thm nhp vo ni tng lm cho tng kh suy kit thuc phn bt tr. T kh vo khong gn xng, khng cn ngoi b phu cng cha vo ni tng thuc phn kh tr. Theo sch T vn, Ni kinh: chng t phm thng vo tng s cht, nu lu nin gn xng th lu khi, nu ch khong b phu th chng khi. 505

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3. CHN ON 3.1. Chn on theo y hc hin i 3.1.1. Chn on xc nh Da trn 7 tiu chun chn on ARA (Hi Thp khp hc M) 1987: 1. C du hiu cng khp bui sng ko di trn 1 gi. 2. Sng au ko di trn 6 tun, ti thiu 3 v tr trong s 14 khp (2 bn): khp ngn tay gn, bn ngn tay, c tay, khuu, gi, c chn, bn ngn chn. 3. Sng au mt trong ba v tr: khp bn ngn tay gn, khp bn ngn v khp c tay. 4. Sng khp i xng. 5. C ht di da. 6. Phn ng tm yu t thp dng tnh. 7. Hnh nh X quang in hnh. Chn on xc nh khi c t 4 tiu chun tr ln (4/7). T tiu chun 1 n tiu chun 4 thi gian ti thiu phi ko di trn 6 tun. Ring nc ta qua nghin cu Bnh vin Bch Mai, Qun Y vin 108 v mt tnh pha Bc, cc tc gi rt ra c im ca bnh vim khp dng thp nc ta nh sau: Bnh vim khp dng thp chim 20% cc bnh khp v 5% cc bnh ni khoa ni chung trong mi trng bnh vin. Bnh gp n vi t l 80 87%. La tui thng gp l 30 - 60. Du hiu cng khp bui sng gp 80 - 82% bnh nhn. Tnh cht i xng rt thng gp vi t l 90 - 100%. Cc khp b nh hng l: khp c tay 80%, khp bn ngn tay 76%, khp c chn 63%, cc khp vai v hng thng t gp hoc nu c ch giai on sau. Thay i dch khp cng ging nh ti liu nc ngoi. Nt thp ch gp trn vi bnh nhn, t l 4,6% trong khi th gii t l ny l 20 - 25%. Do vy, v chn on, c tiu chun Vit Nam 1984 c ph bin v s dng cc bnh vin pha Bc trn 10 nm nay gm 6 tiu chun: + Sng au ko di trn 2 thng t 1 khp tr ln cho cc v tr sau: c tay, bn ngn tay, khp lin t gn (2 im). + Sng au ko di trn 2 thng t mt khp tr ln cho cc v tr sau: gi, c chn, khuu tay (1 im). 506

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+ Sng au c tnh cht i xng (1 im). + Cng khp bui sng (1 im). + Phn ng tm yu t dng thp dng tnh (1 im). + Hnh nh X quang thy in hnh tn thng bn tay (bo mn, hc, hp khe khp) (1 im). Tng cng 7 im. Chn on xc nh khi c 4 im. n nm 1995, da trn thc t Vit Nam c th s dng nhng ni khng c cc iu kin lm xt nghim hoc chp X quang. Tiu chun chn on gm: 1 tiu chun chnh v 3 tiu chun ph + Tiu chun chnh (bt buc, khng th thiu): sng au ko di trn 6 tun t 4 khp tr ln trong bt buc c mt trong 3 khp tay c tnh cht i xng (khp c tay, khp bn ngn tay, khp ngn gn bn tay 2 bn). + Tiu chun ph (c th thiu hoc thay th cho nhau):

Cng khp bui sng ko di trn 1 gi. Phn ng Waater - Rose hay Latex dng tnh. Du hiu X quang cc khp bn tay c tn thng t giai on III tr ln.

Chn on xc nh khi c mt tiu chun chnh v mt trong 3 tiu chun ph. Tuy nhin tiu chun ny cn s kim nh ca thc t. 3.1.2. Chn on phn bit a. Hi chng REITER Thng gp nam: bnh nhn c vim kt mc, vim a khp kinh nin (khp hng, khp gi, khp bn t, lin t gn); tiu tin ra m, tn thng da nim. b. Vim a khp trong bnh Lupus Ban cnh bm, ban dng a. Tm thy t bo LE. Khng th khng nhn dng tnh vi hiu gi cao. Theo di lu ngy thy c bin chng nhiu ni tng. c. Thoi ha khp Giai on khng n nh, c sng, au. Gp ngi ln tui, ngi lao ng nng tay chn lu ngy. 507

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Thng xy ra khp chu lc nhiu. Khng tin trin, khng cng khp bui sng (nu c ch xy ra vi pht). X quang c hin tng m c xng v mn xng. Dch khp: t t bo, nht tng. d. Vim ct sng dnh khp Khong 90% gp nam di 30 tui, thng xy ra ct sng, hng, vai, u gi, khng c nt thp di da. e. Vim khp xy ra di dng cp tnh Cn phn bit vi thp khp cp, vim khp ln ngoi bin, di chuyn, khng li di chng (thong qua khp). Thng xy ra khong 7-15 tui, him gp trn 30 tui. Thng bin chng tim, bnh van tim. 3.1.3. D hu v tin lng Vim khp dng thp l bnh mn tnh, tin trin ko di bng nhng t cp tnh, khng tin lng c thi gian xy ra cc t cp tnh hoc ngng tin trin. Cc t ngng tin trin xy ra giai on u nhiu hn. Phn ln bnh nhn b hn ch c ng khp nhng vn c th c ng cht t c trong sinh hot. Ch 10% trng hp l b tn ph. Cc yu t tin lng xu, khng c yu t ring l no c th tin lng c bnh m cn kt hp nhiu yu t nh: Tui gi, gii n. Tn thng nhiu khp. Tn thng X quang nng v sm. Nt thp. Yu t dng thp dng tnh cao. Yu t HLADR4 dng tnh. Cc biu ngoi khp c bit l vim mch mu. Tui th trung bnh: trung bnh bnh nhn vim khp dng thp gim th t 3 n 7 nm. iu ny c lin quan n thi gian v mc bnh, tui v gii, phng php iu tr v liu corticosteroid s dng. 4. IU TR 4.1. iu tr theo y hc hin i Mc ch ca vic iu tr l nhm duy tr kh nng hot ng ca bnh nhn: gim au, duy tr chc nng khp, ngn cn bin dng khp. 508

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4.1.1. Cc mc tiu iu tr bnh VKDT iu tr triu chng: cc thuc khng vim v gim au. iu tr c bn: cc thuc chng thp khp c th ci thin c bnh DMARDs. Chnh hnh, d phng, phu thut, phc hi chc nng. iu tr cc bin chng do thuc iu tr (bin chng tiu ha, long xng, nhim trng). Gii quyt cc vn x hi, kinh t cho bnh nhn. 4.1.2. Cc bin php p dng trong iu tr a. iu tr h tr Gio dc cho ngi bnh v nhng ngi xung quanh hiu v bnh, cch tin trin, cch d phng v cch s dng thuc c coi l rt quan trng quyt nh s thnh cng hay tht bi ca vic iu tr. Cn cho bnh nhn n ung iu v ngh ngi tng giai on ngn lin quan ti cc giai on pht trin cp tnh. Tp luyn vt l tr liu, phc hi chc nng l cc bin php khng th thiu trong mi chin lc iu tr k c trc y, hin nay v sau ny. Tp luyn ngay t giai on u ca bnh. Phu thut chnh hnh sa cha cc thng tn khng th phc hi ca bnh. Gii quyt cc vn tm l, tnh cm x hi cho ngi bnh. b. Cc loi iu tr iu tr triu chng: salicylat v cc thuc khng vim khng phi l steroids (NSAIDs). Cc dc phm c sn xut ngy cng nhiu vi mong mun c tc dng khng vim cao nht m t tc dng ph nht, nhng vn cha c loi thuc no tht s an ton v nhm ny ch c tc dng iu tr triu chng chng n thun ch khng thay i c din tin t nhin ca bnh vim khp dng thp. Cc glucocorticoid: c coi nh thn dc k t khi c tng hp 1948. Nhng sau hn 30 nm s dng, t u nhng nm 80 ngi ta nhn nh c rng tc dng ca glucocorticoid i vi bnh vim khp dng thp cng ch l iu tr triu chng n thun. Nu c cng ch lm thay i rt t din tin t nhin ca bnh. Ch nh ca thuc l lm chic cu ni trong lc ch i cc thuc iu tr c bn c tc dng. iu tr c bn 509

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+ Mui vng. + Thuc chng st rt. Hai nhm thuc ny lc chn la s dng iu tr vim khp dng thp theo quan im hon ton khc vi quan nim v nguyn nhn v c ch sinh bnh hin nay, nhng v tnh an ton d s dng li c hiu qu cho nhng th nh nn vn c s dng rng ri trong iu tr vim khp dng thp giai on n nh v c bit phi hp vi cc thuc khc trong nhm. Sulfasalazin: sn xut nm 1942, hin nay ang l loi thuc c chn la u tin iu tr c bn bnh vim khp dng thp. Thuc rt c a chung Anh. D. penicillamin: c qu nhiu tc dng ph nn ch c ch nh trong cc trng hp c tin lng nng nh c nt thp, vim ng mch, yu t dng thp dung tnh cao. Cc thuc iu ha min dch: c tc dng p ng c ch min dch c th dch v trung gian t bo ca c th. T u thp nin 80, cc thuc ny c coi l cc thuc trong nhm chng thp khp c th ci thin c bnh (DMARDs) v chim mt vai tr quan trng trong iu tr c bn ca bnh, c bit l nn s dng sm ngn chn tn thng hy hoi xng v sn ca bnh vim khp dng thp nh methotrexat, azathioprin, cyclosporin A. 4.1.3. Nguyn tc chn la iu tr vim khp dng thp hin nay S dng ngay t u nhng thuc c th ngn chn c s hy hoi xng v sn c th thay i c din tin ca bnh: dng cc thuc chng thp khp c th ci thin c bnh. iu tr triu chng ng thi vi iu tr c bn v gim dn thuc iu tr triu chng khi thuc iu tr c bn c hiu qu. Cc thuc iu tr c bn c th s dng lu di nu khng c tc dng ph. Ngoi ra ngay t u c th p dng cc bin php iu tr h tr song song. 4.1.4. Hng iu tr trong tng lai Ngoi cc bin php iu tr h tr tip tc c nghin cu, cc iu tr tng lai s tp trung vo: Can thip trc tip vo cc lympho T bng cch dng vaccin i vi th th ca lympho T. Can thip vo cc khng th n dng. Ci to mi trng sng. Can thip vo gen (ADN) tc l ci thin c a ngi bnh v loi tr nguyn nhn gy bnh. 510

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4.2. iu tr theo y hc c truyn 4.2.1. Vim khp dng thp c t tin trin cp tnh (tng ng vi th nhit t ca YHCT) Php tr: thanh nhit khu phong, ha thp. Cc bi thuc: + Bi Bch h qu chi thang gia v (gm: thch cao 40g, qu chi 6g, tri mu 12g, hong b 12g, thng trut 8g, kim ngn 20g, tang chi 12g, phng k 12g, ngnh m 12g, cam tho 8g). Phn tch bi thuc
V thuc Thch cao Qu chi Tri mu Hong b Thng trut Kim ngn Tang chi Phng k Ngnh m Cam tho Tc dng Thanh dng minh kinh nhit, tr nhit thnh, phin to. n kinh thng mch Thanh nhit lng huyt, nhun to Thanh nhit gii c n trung ha m Thanh nhit gii c Tr phong thp, thng kinh lc Tr phong, hnh thy, t thp nhit n trung ha v Gii c, iu ha cc v thuc Vai tr Qun Thn Thn T T T T T T S

Nu c nt thp hoc sng nhiu: gia thm an b (12g), xch thc (8g), sinh a (20g). Bch h thang vn l bi thuc thanh nhit kh phn, nhit t thnh kinh dng minh. Dng minh thuc v, quan h vi t ch c nhc bn ngoi nn c biu hin: st, phin to, kht, m hi ra nhiu, cc khp xng c nhc sng nng , mch ph hot nn dng bi thuc ny l lc bnh i nhit, ly mch hng sc hoc ph hot; cn nu c km theo s lnh, khng c m hi hoc st m khng kht; hoc ra m hi m sc mt trng bch, hoc mch tuy hng i m n su thy h th khng dng bi thuc ny, hoc nu dng phi gia thm cc thuc dng m. + Bi Qu chi thc dc tri mu thang (gm: qu chi 8g, ma hong 8g, bch thc 12g, phng phong 12g, tri mu 12g, kim ngn 16g, bch trut 12g, lin kiu 12g, cam tho 6g).

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Phn tch bi thuc:


V thuc Qu chi Bch thc Tri mu Bch trut Ma hong Phng phong Kim ngn hoa Lin kiu Cam tho Tc dng n kinh, thng mch, gii biu Lim m, dng huyt Thanh nhit, ch kht, nhun to Kin v, ha trung, to thp Pht hn, gii biu Pht biu, tr phong thp Thanh nhit gii c Thanh nhit, gii c n trung, ha v Vai tr Qun Thn T T Qun T T T S

Nu cc khp sng au ko di, st nh, nhiu m hi, ming kh li , mch t sc. l thp nhit thng m th phng php chnh l b m thanh nhit m ph l khu phong tr thp. Vn dng cc bi thuc nu trn, b qu chi, gia thm cc v thuc dng m thanh nhit nh sinh a, huyn sm, a ct b, sa sm, mit gip, thch hc + Dng thuc p b ngoi khp sng: ngi cu, dy au xng, li h, gi nt, sao ln vi dm p hoc b ngoi khp sng. Hoc ngi cu, ru mo, gng: gi nt sao vi ru p ln khp sng. Chm cu: + Chm cc huyt quanh hoc ln cn khp sng au. + Ton thn: chm hp cc, phong mn, huyt hi, tc tam l, i chy. 4.2.2. Vim khp dng thp t mn tnh Cc khp cn sng au nhng ht , ht st, dnh khp, cng khp hoc bin dng, teo c. Php tr: khu phong, thanh nhit, tr thp, tn hn. Bi c hot tang k sinh thang (gm: c hot 12g, ngu tt 12g, phng phong 12g, trng 12g, tang k sinh 12g, qu chi 8g, t tn 8g, thc a 12g, tn giao 8g, bch thc 12g, ng quy 8g, cam tho 6g, ng sm 12g, phc linh 12g).

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Phn tch bi thuc:


V thuc c hot T tn Thc a ng quy Xuyn khung Phng phong Tang k sinh Ngu tt Tn giao Bch thc trng Qu chi Ph t Cam tho Tc dng Kh phong thp, gii biu, tn hn Tn phong hn, hnh kh, khai khiu B huyt, b thn Dng huyt, hot huyt Hnh kh, hot huyt, tr phong, ch thng Pht biu, tr phong thp Thanh nhit lng huyt, tr thp Thanh nhit, tr thp Tr phong thp, th cn hot lc Dng huyt, ch thng B can thn, mnh gn ct n kinh, thng mch n kinh, tr phong thp n trung, ha v Vai tr Qun Qun Thn Thn Thn T T T T T T T T S

Chm cu: + Ti ch, chm cc huyt quanh hoc ln cn khp sng au. + Ton thn: hp cc, phong mn, tc tam l, huyt hi, i chy. Xoa bp, vn ng: + Ti cc khp bng cc th thut, n, day, ln, vo cc khp v c quan khp. + Vn ng: va xoa bp va tp vn ng khp theo cc t th c nng, tng bc, ng vin bnh nhn chu ng v tp vn ng tng dn. 4.2.3. Vim khp dng thp giai on sm Cha tiu chun chn on vim khp dng thp: vim khp cha qu 6 thng; khp c vim, c sng, c au nhc nhng khng nng . Trn lm sng, nu triu chng bnh l khp thin v phong, hn hay thp m c cch dng thuc khc nhau. a. Th phong t au nhiu khp, au di chuyn t khp ny sang khp khc, s gi, ru li trng, mch ph 513

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Php tr: khu phong l chnh, tn hn tr thp l ph; km hnh kh, hot huyt. Cc bi thuc: + Bi Phng phong thang gia gim (gm: phng phong 12g, bch thc 12g, khng hot 12g, ng quy 12g, tn giao 8g, cam tho 6g, qu chi 8g, ma hong 8g, phc linh 8g). Phn tch bi thuc:
V thuc Phng phong ng quy Xch linh Hnh nhn Tn giao Hong cm Ct cn Khng hot Qu chi Cam tho Tc dng Pht biu, tr phong thp B huyt, dng huyt Hnh thy, li thp nhit Nhun trng, thng tin, n ph Tr phong thp, th cn, hot lc Thanh nhit gii c Gii biu, sinh tn dch Pht biu, tn phong, trc thp n kinh thng mch n trung, ha v Vai tr Qun Thn Qun T T T T Qun T S

C ngi khng dng khng hot m li dng c hot v ma hong. + Bi Quyn t thang (gm: khng hot 20g, phng phong 16g, khng hong 12g, chch tho 10g, ng quy 16g, xch thc 16g, hong k 16g). Phn tch bi thuc:
V thuc Khng hot Phng phong Hong k ng quy Khng hong Chch tho Xch thc Tc dng Pht biu, tn phong, trc thp Pht biu, tr phong thp B kh, c biu Hot huyt, ha danh n trung tn hn n trung, ha v Lim m, dng huyt, hot huyt Vai tr Qun Qun T Thn S S T

Khng hot khu phong thp trn, phng phong khu phong; khng hong ph kh thng kinh lc phong t, au vai tay; ng quy, 514

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xch thc dng huyt, hot huyt, thng kinh lc; hong k c v; cam tho iu ha cc v thuc. Hp li c tc dng ch kh ha doanh, khu phong thng thp, thng kinh hot lc. Chm cu: + Ti ch, chm cc huyt ti khp sng hoc ti huyt ln cn. + Ton thn: hp cc, phong mn, phong tr, huyt hi, tc tam l, cch du. b. Th hn t au d di mt khp c nh, khng lan, tri lnh au tng, chm nng au, tay chn lnh, s lnh ru trng, mch huyn khn hoc nhu hon. Php tr: tn hn l chnh, khu phong tr thp l ph, hnh kh hot huyt. Bi thuc gm qu chi 8g, d 12g, can khng 8g, ph t ch 8g, xuyn khung 8g, thin nin kin 8g, ngu tt 8g, uy linh tin 8g. Phn tch bi thuc:
V thuc Qu chi Can khng Ph t ch Thin nin kin Uy linh tin d Thng trut Xuyn khung Ngu tt n trung, tn hn n thn ha, kh hn thp, gim au Tr phong thp, mnh gn xng Kh phong thp, thng kinh lc, gim au Li thy, thanh nhit, kin t n trung, ha m Hot huyt, ch thng B can, ch thn Tc dng n kinh, thng mch Vai tr Qun Qun Thn, s Thn T T T T T

Chm cu: cu quan nguyn, kh ti, tc tam l, tam m giao. Chm b hoc n chm cc huyt ti ch v ln cn khp au. c. Th thp t Cc khp nhc mi, au mt ch c nh, t b, au cc c c tnh cch tr nng xung, co rt li, vn ng kh khn, ming nht, ru li trng dnh, mch nhu hon. Php tr: tr thp l chnh, khu phong tn hn l ph, hnh kh hot huyt. Bi d nhn thang gia gim (gm: d 16g, thng trut 12g, ma hong 8g, dc 8g, qu chi 8g, hong k 12g, khng hot 8g, cam tho 6g, c hot 8g, ng sm 12g, phng phong 8g, xuyn khung 8g, ngu tt 8g).

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Phn tch bi thuc:


V thuc d dc Thng trut Hong k Ma hong Cam tho Qu chi ng sm Khng hot Xuyn khung c hot Phng phong Ngu tt Tc dng Li thy, thanh nhit, kin k Thun kh, m trung tiu n trung, ha m B kh, c biu, tiu c Pht hn, gii biu n trung, ha v n kinh, thng mch B t, kin v, ch kh Pht biu, tn phong, trc thp Hnh kh hot huyt, tr phong, ch thng Tr phong thp, ch thng, gii biu Pht biu, tr phong thp B can, ch thn, cng cn, trng ct Vai tr Qun Qun T Thn Thn S Thn T T T T T T

Chm cu: + Ti ch, chm cc huyt quanh khp sng au v ln cn. + Ton thn: tc tam l, tam m giao, t du, thi kh, huyt hi. d. iu tr duy tr phng vim khp dng thp ti pht Bnh do cc yu t phong, hn thp nhn lc v kh h m xm nhp, trong c th li c sn m h m gy bnh. Khi bnh pht ra, tnh trng m h huyt nhit cng nhiu, can thn h, khng nui dng cn xng c tt l iu kin phong hn thp xm nhp m gy ti pht bnh. Do vy, khi bnh tm n, nn tip tc dng php b can thn, lng huyt, khu phong tr thp. Bi c hot tang k sinh thang gia ph t ch (xem vim khp dng thp t mn) c hot Phng phong Tang k sinh T tn Tn giao ng quy ng sm Phc linh 516 12g 12g 12g 8g 8g 8g 12g 12g Ngu tt trng Qu chi Thc a Bch thc Cam tho Ph t ch 12g 12g 8g 12g 12g 6g 6g

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Ph phng: bi Tam t thang l bi c hot tang k sinh thang b v tang k sinh, gia hong k, tc on v gng ti, dng cha vim khp dng thp bin chng cng khp, chn tay co qup.

T lng gi Cu hi 5 chn 1: chn cu ng 1. La tui v gii no c t l vim khp dng thp cao nht

A. Trung nin, c nam v n B. Trung nin, n C. T 30 n 60 tui, n D. Trn 15 tui tr ln v n E. La tui mn kinh, n
2. Yu t no l c bn v c tnh quyt nh gy ra vim a khp dng thp

A. Yu t stress v mi trng, kh hu sng v lm vic B. D ng nguyn t ngoi vo hoc ni sinh C. Sau nhim khun hoc virus v tp qun cng mi trng sng D. Yu t t min ca khng nguyn khng th E. Yu t c a v di truyn
3. Tn thng c bn ca VKDT

A. Sng khp do vim mng hot dch khp B. Hin tng vim gy gin mch v ph n mng hot dch C. Vim v x l 2 tn thng chnh D. Vim khng c hiu ca mng hot dch khp E. Mng hot dch ph n, sung huyt
4. Cc v tr khp xng no c t l vim cao nht trong VKDT

A. 90% khp khuu, c tay, bn ngn tay, t ngn gn B. 90% khp gi, bn tay, bn ngn tay, t ngn gn C. 90% khp gi, gt, c tay, bn ngn tay, t ngn gn D. 90% gi, khuu, bn tay, c tay t gn, c chn v bn chn
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E. 90% khp khuu, c tay, bn ngn tay, t ngn gn, bn chn v c chn
5. Xt nghim CLS no c hiu nht trong chn on VKDT v ch xut hin dng tnh thi gian no ca bnh

A. Waaler - Rose v Latex ngay t khi xut hin bnh B. Waaler - Rose v Latex v VS ngay giai on u ca bnh C. Waaler - Rose v Latex, sau 2 thng mc bnh D. o c Elisa v min dch phng x sau 6 thng mc bnh E. Waaler - Rose v Latex, Fibrinogen, in di m sau 6 thng mc bnh
6. c im no sau y gip chng ta tin lng c bnh nng hay nh do VKDT

A. Tui gi, gii n, tn thng nhiu khp, tn thng X quang nng v sm, c nt thp, yu t dng thp dng tnh cao, c bin chng ngoi khp B. Tui trn 15, gii n, tn thng nhiu khp; du X quang in hnh v VKDT xut hin sm, c nt thp, yu t dng thp dng tnh cao, c bin chng vim mch mu C. Tui trung nin, gii n, tn thng nhiu khp, tn thng X quang nng v sm, c nt thp, yu t dng thp dng tnh cao, c bin chng ngoi khp D. Mi la tui, n, vi m t tn thng nh cu A E. Mi la tui, vi m t tn thng nh cu B
7. Cc bin php iu tr no sau y nn c p dng cho bnh nhn VKDT hiu qu

A. Gio dc sc kho, n ung v ngh ngi ng, tp luyn ngay t giai on u ca bnh v phc hi chc nng khp; phu thut chnh hnh xng (nu cn); dng thuc c bn v c hiu l chnh, iu tr triu chng l ph B. Gio dc sc kho, n ung ng, vt l tr liu phc hi chc nng, phu thut chnh hnh xng, can thip vo gen, ci to mi trng sng v iu tr triu chng C. Gio dc sc kho, n ung v ngh ngi ng, vt l tr liu phc hi chc nng khp, dng thuc c bn v c hiu v thuc iu tr triu chng D. Gio dc sc kho, n ung y cht, vt l tr liu, dng thuc iu tr triu chng v c hiu l chnh, iu tr triu chng l ph
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E. Cn chn A v B mi ton din


8. Nguyn tc dng thuc trong iu tr chng t l

A. n thng kinh mch, hnh kh hot huyt B. Lun phi ng thi khu phong, tn hn, tr thp v xem biu hin kh no nng hn m gia gim theo thin thng C. Phi phi hp: khu phong, tn hn, tr thp, thanh nhit v b h D. n thng kinh lc, khu phong thp, hnh kh hot huyt E. C A v B mi
9. Trong nguyn tc iu tr chng t theo YHCT ngoi chm cu, dng thuc cn phi ch iu g sau y

A. Ch n cn king cht chua, cht mn, cht tanh v cht bo m ty thuc vo th bnh B. Tuyt i khng c ung ru v ru thuc dng, tr ha thiu t cht m C. Khng nn dng thuc b ngay giai on bnh mi pht v s lm cho kh huyt tr, lm t kh ct li thnh bnh kh tr D. Cu A v B ng E. C 3 cu A, B, C u ng
10. Bi thuc gm phng phong, ng quy, hong cm, xch lch, hnh nhn, tn giao, ct cn, khng hot, qu chi, cam tho dng ch nh iu tr

A. Phong t B. Hn t C. Thp t D. Nhit t E. Phong t v thp t


11. Bi thuc Bch h qu chi thang gia v (gm: thch cao, tri mu, thng trut, tang chi, ngnh m, qu chi, hong b, kim ngn, phng k), dng ch nh iu tr th

A. Phong t hay lch tit phong B. Thp t hay tch bi thng C. Nhit t hay lch tit phong, hc tt phong D. Phong thp nhit t E. Phong thp hn t
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Bi 30

THOI HA KHP

MC TIU 1. Nu c nh ngha v c im dch t hc ca thoi ho khp. 2. Trnh by c nguyn nhn v c ch bnh sinh thoi ho khp theo YHCT & YHH. 3. Trnh by c nhng nguyn tc iu tr thoi ho khp theo YHCT & YHH. 4. Trnh by c phng php iu tr thoi ho khp theo YHCT. 5. Gii thch c c s l lun ca vic iu tr thoi ho khp xng theo YHCT.

1. I CNG 1.1. nh ngha Thoi ha khp (THK) l nhng bnh ca khp v ct sng mn tnh, gy au v bin dng khp. Tn thng c bn ca bnh l tnh trng thoi ha sn khp v a m ct sng, gn lin vi nhng thay i sinh hc - c hc gii phu v bnh l phn khoang khp (gm xng di sn v mng hot dch v khoang gia cc thn t sng). Ngi ta thng coi thoi ha khp l bnh l do hu qu ca qu trnh tch tui v s chu lc tc ng thng xuyn ln khp. Thoi ha khp gy au v bin i cu trc khp dn n tn ph lm nh hng n cht lng cuc sng v cn l gnh nng cho kinh t gia nh v ton b x hi. Thoi ha khp nu c chn on sm v iu tr sm c th lm chm pht trin ca bnh, gim triu chng au n, gip duy tr cuc sng hot ng. 1.2. c im dch t hc Thoi ha khp (THK) l bnh mn tnh thng gp nht ngi trung nin v ngi c tui, xy ra mi chng tc, mi thnh phn ca x hi, tt c cc nc v ph n nhiu hn nam gii.

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Thng k ca WHO cho thy c 0,3 - 0,5% dn s b bnh l v khp th trong c 20% b thoi ha khp. M: 80% trn 55 tui b thoi ha khp. Php: thoi ha khp chim 28% s bnh v xng khp. Vit Nam: thoi ha khp chim 10,41% cc bnh v xng khp. C s lin quan cht ch gia thoi ha khp v tui tc: + 15 - 44 tui: 5% ngi b thoi ha khp. + 45 - 64 tui: 25 - 30% ngi b thoi ha khp. + Trn 65 tui: 60 - 90% ngi b thoi ha khp. V cc v tr thng b thoi ha: + Ct sng tht lng: + Ct sng c: + Nhiu on ct sng: + Gi: + Hng: + Cc ngn tay: + Ring ngn tay ci: + Cc khp khc: 31,12% 13,96% 7,07% 12,57% 8,23% 3,13% 2,52% 1,97%

Thoi ha khp l bnh l ch yu ca sn khp v a m ct sng, nhng nh hng n ton b thnh phn cu to khp nh xng di sn, bao hot dch, bao khp bnh thng xy ra cc khp chu lc nhiu nh: ct sng tht lng - c, gi, gt. 1.3. Quan nim ca y hc c truyn V biu hin bnh l ca thoi ha khp c biu hin ni chung l au c nh ti khp, tng khi vn ng, khi thay i thi tit, t, mi, nng mt vng c th tng ng, ty thuc vo v tr khp b thoi ha, cc triu chng ny c YHCT m t: Vng c vai c chng: kin bi thng. Vng lng: ton b lng l c chng tch thng, bi thng; ch tht lng l c chng yu thng. Vng tay chn ni chung c chng: th tc kin thng. Khp gi c chng: hc tt phong. 521

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Vng bn chn gm c chn v gt chn c chng tc ngn thng. Cc khp khc c chng t v lch tit phong. 1.3.1. Chng t Theo chc nng tng ph: can ch cn, thn ch ct trong iu kin c th suy yu khng nui dng c cn mch - ct tu, ng thi lm cho v kh h yu, cc t kh nhn c hi xm nhp gy bnh vi cc biu hin ti ch nh au mi cc khp, t nng tc xng khp; mi khi thay i thi tit hay ma lnh m thp, vn ng th au nhiu hn, ngh ngi thy . 1.3.2. Chng tch, bi thng Vng sng lng l ni i qua ca mch c v kinh tc thi dng. Kinh tc thi dng phn b phn nng vng lng, cc triu chng biu hin phn ny c gi l bi. Mch c i su bn trong c lin quan ct ty, cc triu chng biu hin phn ny c gi l tch. Gy bnh 2 kinh ny c th do phong hn thp cng ln ln xm nhp gy bnh, c th do hn t nhn khi v kh yu m gy bnh. C hai kinh cng ch v dng kh, nhng khi pht bnh th bnh tch c biu hin l l chng v bnh bi c biu hin l biu chng. Tch thng t c thc chng v bi chng t c h chng. + Tch thng: au dc vng gia sng lng, khng n thng ngi c, ngu nhin n thng ngi c th kh chu m cng khng duy tr t th thng lu c. Cm gic lnh sng lng. Tiu tin trong di, i chn mm yu. + Bi thng: au c mng lng, cm gic tr tr kh chu, c khi lan ta vng sau gy v b vai. 2. NGUYN NHN V C CH SINH BNH 2.1. Nguyn nhn S lo ha: theo quy lut ca t nhin, ngi trng thnh kh nng sinh sn v ti to sn gim dn v ht hn. Cc t bo sn vi thi gian tch tui lu dn s gi, kh nng tng hp cc cht to nn si collagen v mucopolysaccharid s gim st v ri lon, cht lng sn s km dn, tnh cht n hi v chu lc gim. 522

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Yu t c gii: l yu t thc y qu trnh thoi ha nhanh. Yu t c gii th hin s tng bt thng lc nn trn mt n v din tch ca mt khp hoc a m l yu t ch yu trong thoi ha khp th pht, n gm: + Cc d dng bm sinh lm thay i din tch t nn bnh thng ca khp v ct sng. + Cc bin dng th pht sau chn thng, vim, u, lon sn lm thay i hnh thi, tng quan ca khp v ct sng. + S tng trng ti: tng cn qu mc do bo ph, do ngh nghip. Yu t min dch: bc u qua cc cng trnh nghin cu nhn thy bnh nhn thoi ha sn khp v a m c nhng thay i hot ng min dch c th hin di cc dng: + Tng p ng min dch t bo. + Tng min dch th dch to nn khng th trong t chc khoang khp. + C s di truyn min dch, biu hin qua h khng nguyn ph hp t chc ngi b thoi ha sn khp c HLA.B7 v HLA.B8 tng cao hn ngi bnh thng. Cc yu t khc: + Di truyn: c a gi sm. + Ni tit: mn kinh, tiu ng; long xng do ni tit, do thuc. + Chuyn ha: bnh Goutte. 2.2. Phn loi Theo nguyn nhn, c th phn bit hai loi thoi ha khp: Nguyn pht: nguyn nhn chnh l do s lo ha, xut hin mun, thng ngi sau 60 tui, nhiu v tr, tin trin chm, tng dn theo tui, mc khng nng. Th pht: phn ln l do nguyn nhn c gii, gp mi la tui (thng tr di 40 tui) khu tr mt vi v tr nng v pht trin nhanh. 2.3. C ch sinh bnh 2.3.1. Hot ng bnh thng ca khp Cu trc bnh thng ca khp: cu trc khp xng bnh thng l sn, xng di sn, dch khp, mng hot dch v bao khp. B phn ch yu ca khp l sn khp thch ng hon ho chu ng ti trng m bo s trt ln nhau ca hai din xng vi mt h s ma st rt thp. Hot 523

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ng tt ca khp da trn s ton vn ca nhng tnh cht vt l, ha hc, c hc v s bnh thng ca cc thnh phn cu to. Sn khp khng c mch mu v khng c thn kinh, tuy vy khng phi v th m sn l mt cht tr, ngc li sn l mt t chc sng bit ha cao, c cu to bi ba thnh phn c bn gm t bo sn km mt s t nguyn bo x v mt s cht c bn. T bo sn c cc chc nng sn xut ra cc thnh phn ca m sn, cc si to keo (collagen) 40 - 50%; mucopolysaccharid v cc enzym. T bo sn khng c kh nng sinh sn v ti to. Cht c bn: cc t bo sn v si collagen c hnh thnh trong cht c bn, cht c bn ch yu l cc chondromucprotein, l mt phc hp protein, mucopolysaccharid (chondroitin sulfat, kerato sulfat), acid hyaluronic, heparin, v nguyn t vi lng, cht c bn c c tnh ht nc rt mnh (80% l nc), chondromucoprotein ch 20% nhng ng vai tr quan trng vo dinh dng m sn (bng s thm thu) v tnh cht c hc (s chu p lc) ca sn khp. Cht c bn ny c thay i vi tc nhanh (thoi bin v ti to). Nh vy, sn khp l mt khun sn gm mt mng li ba chiu c cc si collagen nm trong mt lng ln proteoglycan to thnh. Cu trc bnh thng ca a m ct sng: + a m ct sng l mt sn khp c bit gm hai thnh phn l vng x v nhn nhy. a m nm gia hai thn t sng. Vng x gm nhiu l x sn chy song song to thnh nhng vng xon t ngoi vo trong. Cc l ny an vo nhau, gia cc lp c vch ngn, cc vng x ng vai tr nh mt gim xc, phn lc v hp th lc khi chu ti v vn ng. Nm gia a m l nhn nhy c hnh cu mu trng ng knh 1,2 n 2cm, c cu to ging nh keo c v c c tnh cng phng rt mnh, nhng c tnh ny to nn kh nng chu lc v phn phi lc ca a m. + Khun sn gm mt mng li ba chiu trong c mt si collagen nm trong mt lng ln proteoglycan to thnh mt cht gel rt a nc. T chc sn v c bit l xng chu ng c lc nn ph thuc hon ton vo s duy tr tnh nguyn vn ca li collagen v nng cao proteoglycan. 2.3.2. Qu trnh sinh bnh Thoi ha khp l bnh ca ton b cc thnh phn cu to khp. y l mt bnh phc tp din tin 2 qu trnh song song. 524

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Mt l: sn thoi ha, qua sn khp ph trn b mt xng b ph hy dn cng vi thay i cu trc khp. S thoi ha sn khp gy hn ch vn ng. Hai l: hin tng vim nhng t chc cn khp. Chnh hin tng vim ny gy triu chng au, sung huyt v gim hot ng khp. Trong thoi ha khp, din tin bnh c th phn thnh 2 giai on: Giai on sm: khi hin tng qun bnh ca s thoi ha v s t sa cha ti lp cn bng trong hot ng sinh hc ca khp cn cha b ph v. Giai on ny sn ph i, tng phn proteoglycan, ht thm nc vo t chc. Cc t bo sn tng hn hp collagen proteoglycan v c cc enzym thoi ha metelloproteinase (collagen v stromelysin). Cn bng gia sn ca khun v enzym thoi ha c duy tr trong s lun chuyn xy ra mc cao hn nhiu ln so vi bng thng. l nhng phn ng ca sn sa li cu trc v cng ch l b tr tm thi a n s tng tng hp cytokin (interlukin) v tng c enzym lm thoi ha khun; sau cc t bo sn khng th thch ng ko di vi tnh trng trn; cui cng suy sp kh nng t sa cha ca sn khng cn cn bng c qu trnh thoi ha. Giai on mn tnh: hin tng qun bnh ca sn b ph v th hin bng gim ng ha (gim tng hp collagen v proteoglycan). Song song cc sn phm lin quan n s thoi ha khun sn c tip tc vo dch khp. Sn khp: proteoglycan gim v hm lng, thay i v cu trc v suy yu, v c hc m ng cho nhng tn thng thc th. T sc chu ng km i vi c hc a n s hy hoi sn. + Thay i xng: sn b hy hoi, xng khng c che ch tn thng v cc i hi v c hc, xng di sn phn ng bng cch tng sinh xng, ti to bt thng b tr mt sn, m rng im ta, thnh lp gai xng (osteophytose), xung c li, tng cng. + Phn ng vim bao hot dch: nhng mnh proteoglycan v collagen c gii phng vo dch khp vi lng tng dn, khp gi vai tr l ni trt tho nhng sn phm thoi ha ca sn: cytokin v yu t tng trng. Nhng mnh b thc bo bi cc i thc bo. Hin tng trn dn n vim nhim mn tnh bao hot dch. Nhng t bo hot dch sinh ra cytokin, c bit interleukin I) n lt n li tc ng vo sn khp v lm tng thm s tn ph sn.

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CHT C BN

Proteoglycan Si collagen typ II

Enzym + collagenase + protease T BO SN

G khi u THK

GIAI ON THK

CHUYN HA

RI LON CHUYN HA

Tng sinh t bo Collagen II Proteoglycan Cc enzym metalloprtease (collagenase stromelysin)

ng ha Collagen II Proteoglycan Cc enzym metalloprotease

C GNG T Sa CHA

SC CHU NG V C HC CA SN, HY HOI SN

Hnh 30.1. S qu trnh thoi ha sn

Cho n nay, nhiu cng trnh nghin cu cho thy interleukin I l mt cytokin gi vai tr ch yu trong hin tng tn ph sn xng vim nhim bao hot dch v ng thi l vai tr sinh bnh ch cht trong thoi ha khp. Kim sot c interleukin I trong thoi ha khp l mt vic rt quan trng. c ch uc interleukin I l chin lc khng nhng ci thin au v hot ng ca khp m cn hn ch nhng tn thng thoi ha h tr cho s sa cha v ti to sn khp. 526

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Qun bnh THOI HA KHP

THOI BIN = T Sa CHA

Cytokin, interleukin
B TR

Enzym thoi bin

Qun bnh b ph v Tng hp collagen Tng hp proteoglycan Suy yu sn khp Thc bo Phn ng tng sinh xng: b tr mt sn Vim nhim mn tnh Thoi ha khun sn to thnh sn phm Dch khp

THAY I Cu TRC Tn ph sn xng Duy tr vim nhim

Cytokin

Hnh 30.2. Qu trnh vim t chc cn khp

Vai tr ca interleukin I trong thoi ha khp:

Interleukin I l yu t ch cht ph v s qun bnh gia thoi bin v ti to cht lung sn. Do hu qu nghim trng ca nhiu nguyn nhn: interleukin I c tng sn lm thay i cn bng ca sn v gim tng hp cc thnh phn cu to ca sn khp (proteoglycan v collagen). Interleukin I lm thay i phenotyp ca t bo sn, sn sinh ra collagen typ I v X v c proteoglycan typ khc. Do khun sn mt tnh cht ban u v c cu trc bt thng, yu v c hc, d b tn thng vt l dn n vic sn b ph hy. Interleukin I hot ha hin tng d ha: lm t bo sn tng sn xut enzym thoi bin sn, lm tng s biu hin ca enzym metaloprotease (collagenase v stromelysin) v gelatinase. Interleukin I lm gim ng ha: lm gim tng hp proteoglycan v lm tng thoi bin proteoglycan trong t chc sn. Interleukin ngn cn tng hp collagen c hiu ca sn hyalin L (collagen II v XI), li kch thch collagen nguyn bo si khng c hiu ca sn (collagen I v III). Nhng thay i ny a n s sa cha khng thch hp khun sn, dn n tn thng sn dn dn. Tm li, khi interleukin 527

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I tng sn lm khi pht v duy tr qu trnh thoi ha sn. Sn tr thnh suy gim c v cht ln v lng t bo sn khp.

Interleukin I cng l yu t tiu xng: hot ha cc t bo hy xng (osteoclaste) v lm nhanh qu trnh thoi bin xng di sn. Interleukin I tham gia vo hin tng vim nhim ca khp b thoi ha: interleukin I gi vai tr ch cht trong bnh sinh ca vim. Interleukin I l ngun gc ca vim v au. T bo sn tit ra interleukin I, interleukin I li hot ha t bo sn gii phng vo dch khp nhng sn phm ca qu trnh thoi bin ca khun sn. Nhng mnh collagen v poteoglycan li kch thch cc t bo i thc bo ca bao hot dch tit ra interleukin I v duy tr vim bao hot dch. Interleukin I tc ng thc y t bo sn v t bo hot dch tng tng hp prostaglandin v interleukin VI.

Nhng hin tng nu trn lm vnh cu ha qu trnh thoi ha v vim nhim khp.

INTERLEUKIN I

Ph v s qun bnh: - tng hp cht c bn - enzym thoi ging - Thay i phenotyp: + Collagen I v II + Proteoglycan khc

Gim ng ha: - proteoglycan trong sn - Loi kh nng t sa cha - Ngn tng hp collagen /sn hyalin (collagen II v IX)

Vim nhim khp: - T bo sn -T bo hot dch Prostaglandin Interleukin VI

Hot ha hin tng d ha: Khun sn c kin trc bt thng - sn xut enzym thoi ging - enzym metaloprotease - enzym gelatinase Hot ha t bo hy xng

Thoi ging di sn Sn b ph hy S sa cha khun sn khng thch hp

Tn thng sn tun tin VNH CU HA QU TRNH THOI HA V VIM NHIM KHP XNG

Hnh 30.3. Vai tr ca interleukin trong thoi ha khp

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2.3.3. Nhng biu hin gii phu bnh ca thoi ha khp Lp lng bnh thng, lp chuyn tip b ph n v cc si collagen b tch ra. Nt b mt sn, t bo sn ph i nhn ln v ng tng chm. Nt su n tn lp xng dui sn, t bo sn t i v hot ng gim. Mt ht sn, xng tr ra. 2.4. Nguyn nhn v bnh sinh theo y hc c truyn 2.4.1. Kh huyt bt tc Bm sinh tinh huyt km do t s nui dng ca m lc mang thai khng tt, hoc do dinh dng khng ng, hoc do d tt lm nh hng n kh huyt trong c th, huyt h kh tr lm cho s vn hnh khng thng, doanh v khng iu ha... gy au nhc t mi nng c, xng, khp 2.4.2. Ni thng Bnh lu ngy lm cho can thn h, gy mt qun bnh hot ng ca s nui dng cn mch, xng - ty. Can thn m h nh hng n huyt dch, cng nh hng n s ti nhun thng xuyn cc b phn ny m gy tc, v au. S lo ha nh hng n chc nng hot ng ng tng ni chung cng l mt nguyn nhn gy nhc mi, t nng khp xng bp tht ngi c tui. 2.4.3. Chn thng Chn thng nh hng trc tip n xng, n cn mch, chn thng ng gip nh hng n huyt dch, c nhc, gy huyt v gy au. 3. CHN ON 3.1. Lm sng 3.1.1. au au v tr khp b thoi ha, au ti ch t khi lan (ngoi tr ct sng khi c chn p r v dy thn kinh). au m , ct sng c th c cn au cp. au thng xut hin v tng khi vn ng hay thay i t th. Thng xut hin tng t ko di ri gim v ht, sau li xut hin t khc sau khi vn ng nhiu. au nhiu c th gy co c phn ng.

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3.1.2. Hn ch vn ng Cc ng tc ca khp b thoi ha c hn ch, mc hn ch khng nhiu v c th ch hn ch mt s ng tc nh hn ch ng tc ch ng v th ng. Do hn ch vn ng nn c vng thng tn c th b teo. Mt s bnh nhn c du hiu ph g khp vo bui sng hoc lc mi bt u hot ng. 3.1.3. Bin dng khp Thoi ho khp khng bin dng khp nhiu nh cc bnh khp khc (vim khp, Goutte). Bin dng y do cc gai xng mc thm u xng; ct sng bin dng hnh thc g, vo, cong lm. 3.1.4. Cc du hiu khc Teo c: do t vn ng. Ting lo xo khi vn ng: t gi tr v c th thy ngi bnh thng hoc cc bnh khc. Trn dch khp: i khi thy khp gi, do phn ng sung huyt v tit dch mng hot dch. 3.2. Cn lm sng X quang c ba du hiu c bn: + Hp khe khp: hp khng ng u, b khng u. ct sng biu hin bng chiu cao a m gim, hp nhng khng dnh khp. + c xng di sn: phn u xng, hm khp, mm t sng c hnh m c, c mt s hc nh sng hn. + Mc gai xng: gai mc phn tip gip gia xng sn v mng hot dch, ra ngoi ca thn t sng. Gai xng c hnh th v m c. Cc xt nghim khc: + Cc xt nghim ton thn khng c g thay i. + Dch khp: biu hin tnh cht trn dch c gii c mu vng chanh, cc thnh phn cng tng i mc bnh thng. + Ni soi khp: ch mi soi c khp gi thy nhng tn thng thoi ha ca sn khp, pht hin cc mnh vn ri trong khp. + Sinh thit mng hot dch: thy cc hin tng sung huyt v x ha.

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4. IU TR 4.1. iu tr v phng bnh theo y hc hin i Khng c thuc iu tr qu trnh thoi ha, ch c th iu tr triu chng, phc hi chc nng v phng bnh bng cch ngn nga v hn ch cc tc ng c gii qu mc khp v ct sng. 4.1.1. iu tr ni khoa Dng cc thuc gim au v chng vim khng steroid nh aspirin, indomethacin, voltaren, profenid, felden, meloxicam... 4.1.2. Cc phng php vt l Cc bi th dc cho tng v tr thoi ha. iu tr bng tay: xoa bp, ko nn, n huyt, tp vn ng th ng. iu tr bng nc khong. S dng cc dng c chnh hnh. 4.1.3. iu tr ngoi khoa Chnh li d dng cc khp bng cch c v khot xng. iu tr thot v a m bng cch ct vng cung sau hay ly phn thot v. 4.1.4. Phng bnh Trong cuc sng hng ngy: Chng cc t th xu trong lao ng v sinh hot. Trnh cc ng tc qu mnh, t ngt v sai t th khi mang vc, y, xch, nng Kim tra nh k nhng ngi lm ngh lao ng nng d b thoi ha khp pht hin v iu tr sm. Chng bo ph bng ch dinh dng thch hp. Khm tr em, cha sm bnh ci xng, cc tt v khp (vng king, chn cong). Pht hin sm cc d tt ca xng, khp v ct sng c bin php sm, ngn nga thoi ha khp th pht. 531

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4.2. iu tr theo y hc c truyn 4.2.1. Php tr chung Phi n thng kinh lc, hnh kh hot huyt, b can thn, b kh huyt, khu phong, tn hn, tr thp. Bi thuc chung v gia gim cho tng biu hin bnh l. Bi thuc PT5 gm: l lt, cy xu h, qu chi, thin nin kin, c xc, th phc linh, si t, h th , sinh a. Phn tch bi thuc:
V thuc L lt Cy xu h Qu chi Thin nin kin C xc Th phc linh Si t H th Sinh a Tc dng n trung tn hn, h kh ch thng Tr phong thp, gim au n kinh, thng mch Tr phong thp, mnh gn ct Thanh nhit gii biu, khu phong tr thp Thanh nhit tr thp Thanh nhit gii c, ch thng B huyt B huyt, b can thn Vai tr Qun Qun Thn Thn T T T T T

4.2.2. iu tr c th a. Thoi ha vng eo lng xung ti chn (khp ct sng tht lng, khp hng, khp gi, gt chn) Bi c hot tang k sinh thang gia gim: c hot Phng phong Qu chi T tn Tn giao ng quy ng sm 12g 12g 8g 8g 8g 8g 12g Ngu tt trng Tang k sinh Sinh a Bch thc Cam tho Phc linh 12g 12g 12g 12g 12g 6g 12g

Chm cu: chm b cc huyt quan nguyn, kh hi, thn du, tam m giao. n chm cc huyt ti khp au v vng ln cn. 532

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Xoa bp: tp luyn xuyn cc khp, chng cng khp; xoa bp cc chi au, gip tng tun hon v dinh dng. b. Thoi ha cc khp chi trn, v cc t xa bn tay Bi Quyn t thang (Bch trut tuyn phng) gm: khng hot 8g, phng phong 8g, khng hong 12g, chch tho 6g, ng quy 8g, xch thc 12g, gng 4g, i to 12g, hong k 12g. Phn tch bi thuc:
V thuc Khng hot Phng phong Khng hong Chch tho ng quy Xch thc Gng i to Hong k S phong, tr thp S phong, tr thp L kh tr trong huyt, tr kh hn thp ch kh Ho doanh, hot huyt Ho doanh, hot huyt Tr hn, ch thng Doanh, v, khu phong, tr thp ch kh Tc dng Vai tr

c. Thoi ha khp vng ct sng tht lng km biu hin thn dng h Cc bi thuc: + Bi Hu quy hon gia gim (gm: ph t 4g, k t 10g, nhc qu 4g, cam tho 8g, sn th 8g, trng 12g, hoi sn 12g, cu tch 12g, thc a 16g, ct toi b 12g).
V thuc Ph t K t Nhc qu Cam tho Sn th trng Hoi sn Cu tch Thc a Ct toi b Tc dng i nhit, c c, cay, ngt: b ha, tr dng, trc phong hn thp t Ngt, bnh: b can thn, iu tr au lng Cay, ngt, i nhit, hi c: b mnh mn tng ha Ngt, bnh: b trung kh, ch thng, iu ha cc v thuc Chua, sp, hi n: n b can thn, sp tinh, ch hn Ngt, cay, m: n b can thn, mnh gn xng, cha au lng Ngt bnh: b t v, b ph thn, sinh tn ch kht ng, ngt, m: n dng can thn, tr phong thp Ngt, m: b huyt, dng m ng, m: n b thn, mnh gn xng, hot huyt Thn Thn Qun Vai tr Qun

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+ Bi c hot tang k sinh thang gia thm ph t ch 8g. Chm cu: chm b cc huyt vng tht lng nh thn du, i trng du, mnh mn, ch tht, bt liu Xoa bp vng tht lng. ng vin ngi bnh vn ng, tp nh nhng, thng xuyn trnh cng khp ct sng do dnh khp. d. Thoi ha ct sng c t cp do co cng Php tr: khu phong, tn hn, tr thp, n kinh hot lc. Cc bi thuc: + Bi Khng hot thng thp thang (gm: khng hot 10g, c hot 12g, co bn 8g, mn kinh t 10g, xuyn khung 12g, cam tho 8g, qu chi 8g). Phn tch bi thuc:
V thuc Khng hot c hot Mn kinh t Xuyn khung Co bn Cam tho Tc dng Gii biu, tn hn, khu phong, tr thp Kh phong thp, gii biu, tn hn Tn phong nhit, gim au Hnh kh, hot huyt Tn phong hn, kh phong thp n trung, ha v Vai tr Qun Qun Thn T T S

C th gia thm: ma hong, qu chi nu cn. + Bi Can khng thng trut thang gia gim (gm: khng hot 12g, can khng 6g, tang k sinh 12g, phc linh 10g, thng trut 12g, ngu tt 12g, qu chi 8g). Phn tch bi thuc:
V thuc Khng hot Tang k sinh Can khng Phc linh Qu chi Ngu tt Thng trut Tc dng Gii biu, tn hn, khu phong, tr thp Tr phong thp, thng kinh lc n trung, tn hn Li thy, thm thp n kinh, thng mch Thanh nhit, tr thp n trung, ha m Vai tr Qun T Thn T Thn T Qun

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Chm cu: a th huyt. Xoa bp: dng cc th thut day, n, ln trn vng lng b co cng. Sau khi xoa bp nn vn ng ngay. Chm ngoi: dng mui sng rang nng chm ln vng au hoc dng cn xoa bp ( u sng, qu, i hi) nhng ch xoa ln vng au, khng c ung. C th dng l ngi cu sao ru p nng ti ch hoc rang chm nng ti ch.

T lng gi Cu hi 5 chn 1: chn cu ng 1. Nguyn nhn gy nn thoi ha khp nguyn pht l

A. S lo ha, yu t c gii v di truyn B. Yu t c gii, s lo ha v chuyn ha C. Yu t c gii, di truyn v chuyn ha D. Yu t c gii, s lo ha, thm do ni tit ngi ph n E. S lo ha yu t c gii, v cc d dng, bm sinh
2. M t no sau y nu chnh xc sinh bnh hc v thoi ha khp (THK)

A. THK l bnh din bin hai giai on: giai on qun bnh ca sn do c ch t sa cha ti lp cn bng v khng xut hin triu chng, giai on: s qun bnh ca sn b ph v v xut hin cc hin tng vim v sung huyt cc t chc khp v cn khp gy au B. THK l bnh ca ton b cc thnh phn cu to khp, c 2 qu trnh song song xy ra: mt l s thoi ha ph hy dn sn khp, ph trn b mt xng lm thay i cu trc khp; hai l hin tng vim t chc khp v cn khp gy nn au, sung huyt v gim hot ng khp C. THK din bin sm nht l vim, sau x pht trin lm thay i cu trc ng thi nhng sn phm trong qu trnh vim vo khp tn ph sn xng v vim nhim c bao hot dch to thnh vng lun qun bnh l lin tc D. THK din bin tun t nh sau: t bo sn b thoi ha, cc sn phm lin quan n s thoi ha vo dch khp gy vim dnh
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khp, sn b hy hoi, xng tng sinh ti to gy tng cng v thnh lp gai xng

E. Cu B v D ng
3. Vai tr ca interleukin I trong THK

A. Ch cht ph v s qun bnh ca hot ng sn khp; hot ha hin tng d ha, ngun gc gy ra vim v au v vnh cu ha qu trnh thoi ha khp v vim nhin khp B. Ph v s qun bnh gia s thoi ho v ti to cht lng ca sn khp; hot ha hin tng d ha, lm gim ng ha; hot ha t bo hy xng, ngun gc gy ra vim v au, vnh cu ha qu trnh thoi ha v vim nhim khp C. Ph v s qun bnh ca sn khp, hot ha hin tng d ha, tham gia vo hin tng vim nhim v hy xng, vnh cu ha qu trnh thoi ha v vim nhim xng D. Ph v s qun bnh ca sn khp; lm gim ng ha, hot ha t bo hy xng, tham gia vo hin tng vim nhim, gii phng cc sn phm ca qu trnh thoi ha lm vnh cu ha s thoi ho khp v vim nhim khp E. C A v D mi ng v
4. Xt nghim cn lm sng no sau y l c trng ca thoi ha khp

A. X quang: hp khe khp; c trng di sn B. X quang: mc gai xng phn tip gip gia xng sn v mng hot dch; ra ngoi ca thn t sng C. Tc lng mu nhanh v hnh nh X quang mc gai xng D. Ni soi khp: thy tn thng thoi ho ca sn khp E. Ty thuc giai on bnh l s c A, B, D l c trng ca thoi ha khp
5. Nn chn la thi iu tr no sau y trong thoi ha khp

A. iu tr triu chng v phc hi chc nng cc khp B. iu tr triu chng, phc hi chc nng vn ng khp v phng bnh bng cch hn ch cc tc ng c gii qu mc khp v ct sng C. iu tr triu chng, phc hi cc chc nng khp v iu tr nguyn nhn
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D. iu tr triu chng, phc hi chc nng khp v ch phng bnh cng iu tr nguyn nhn E. Tt c cc cu trn u ng
6. Bi thuc Khng hot thng thp thang (gm: khng hot, c hot, co bn, mn kinh t, xuyn khung, cam tho) dng iu tr

A. Tch thng B. Bi thng C. Phong t D. Thp t E. Tch bi thng


7. Bi Hu quy hon gia v (gm: ph t, qu chi, sn th, sn dc, lc gic giao, thc a, k t, cam tho, trng, cu tch) c ch nh iu tr

A. Tch thng B. Bi thng C. Phong t D. Hn t E. Tch bi thng


8. Bi thuc PT5 bao gm l lt, cy xu h, qu chi, thin nin kin, c xc, th phc linh, si t, h th , sinh a c th ch nh iu tr thoi ho khp

A. Vng eo lng, khp hng, gi, gt chn B. Khp vai, khuy, c tay C. Ct sng c t cp do co cng D. Chi trn v t ngn xa E. Tt c cc khp

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Bi 31

THNG PHONG (GOUTTE)

MC TIU 1. Nu c nhng yu t dch t hc ca bnh Goutte. 2. Nu c nguyn nhn v c ch bnh sinh ca bnh Goutte theo YHCT & YHH. 3. Chn on c bnh Goutte nguyn pht v th pht theo YHH v cc th bnh theo YHCT. 4. Trnh by c nhng nguyn tc v phng php iu tr Goutte theo YHCT & YHH. 5. Gii thch c c s l lun ca vic iu tr Goutte bng YHCT.

1. I CNG Bnh Goutte (hay hi chng Goutte) l danh t dng ch mt nhm tnh trng bnh l gm nhiu thi k vim khp ti i ti li, tng ng vi s hin din ca cc tinh th acid uric hoc tinh th mui urat trong dch khp. Trong nhiu trng hp c th c s tch t cc tinh th ny ngoi khp nh trong thn, trong mt s m di da. C hai loi chnh: Goutte nguyn pht: c tnh cht di truyn. Goutte th pht: thng l hu qu tin trin ca mt bnh hay l hu qu ca vic s dng thuc lu ngy (nh thuc li tiu, aspirin liu thp). Tn sut xut hin: 90% trng hp Goutte nguyn pht xy ra n ng, nu ph n ch thy xy ra tui mn kinh m thi. Goutte th pht hay gp ph n mc bnh tim mch, c tng huyt p hoc nhng bnh nhn c bnh c tnh v mu (bnh au ty Kahler, bnh bch cu kinh th ty, a hng cu), b bnh thn mn hoc b ng c ch. Theo thng k chu u: bnh Goutte chim 0,02 n 0,2% dn s, ch yu nam gii (chim t l 95%), thng xut hin tui trung nin (30 - 40 tui). Vit Nam theo thng k ca Bnh vin Bch Mai: bnh Goutte chim 1,5% cc bnh v xng khp. 538

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2. NGUYN NHN V C CH BNH SINH 2.1. Theo y hc c truyn 2.1.1 Ngun gc v s chuyn ha acid uric Nguyn nhn trc tip gy ra bnh Goutte l acid uric. ngi bnh thng: acid uric trong mu gi mc c nh: nam 5mg% v n 4mg%. Tng lng acid uric trong c th l 1000mg v lng ny lun lun c chuyn ha (sinh mi v thi tr). a. Sinh mi Acid uric c to thnh t 3 ngun: Thoi bin t cht c nhn purin do thc n mang vo. Thoi bin t cht c nhn purin t trong c th (cc acid nhn ADN v ARN do s ph hy cc t bo gii phng ra). Tng hp cc purin t con ng ni sinh. Ngoi s hnh thnh acid uric t ba ngun trn cn cn c s tham gia ca cc men nuclease, xanthin oxyclase, hypoxanthin, guanin phosphoribosyl transferase (HGPT). b. Thi tr cn bng, hng ngy acid uric c thi tr ra ngoi, ch yu theo ng thn (450 - 500mg/24h) mt phn qua ng phn v mt s cng vi cc ng khc 200mg. 2.1.2. Nguyn nhn gy tng lng acid uric Tng bm sinh (bnh Lesch - Nyhan): do thiu men HGPT nn lng acid uric tng cao ngay t nh, bnh c biu hin ton thn, thn kinh, thn v khp. Bnh ny rt him v rt nng. Goutte nguyn pht: gn lin vi yu t di truyn v c a, qu trnh tng hp purin ni sinh tng nhiu gy tng nhiu acid uric. Goutte th pht: acid uric trong c th tng do + n nhiu thc n c cha nhiu purin (gan, ph tng ng vt, tht, c, nm, tm, cua), ung nhiu ru. y cng l tc nhn tc ng gy bnh c nguyn pht v th pht. + Do tng cng thoi bin purin ni sinh (ph hy nhiu t bo t chc) nh bnh a hng cu, bnh bch cu mn th ty, Hodgkin, sarcom hch, au ty xng hoc do s dng nhng thuc dit t bo iu tr cc bnh c tnh. + Gim thi acid uric qua thn do vim thn mn tnh hoc suy thn lm acid uric li gy bnh. 539

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2.1.3. C ch bnh sinh Khi lng acid uric trong mu tng cao (trn 7mg% hay 416,5mol/l) v tng lng acid uric trong c th tng th s lng ng li mt s t chc v c quan di dng tinh th acid uric hay urat monosodic. Lng ng mng hot dch gy vim khp. Lng ng thn (nhu m thn v i b thn). Lng ng cc ni tng v c quan, gy cc biu hin bnh Goutte ni ny: + Sn xng, sn khp, sn vnh tai, thanh qun. + Gn: gn Achille, cc gn dui cc ngn. + T chc di da: khuu, mt c, gi. + Thnh mch, tim. + Mt. Trong bnh Goutte, urat monosodic lng ng thnh hot dch s gy mt lot cc phn ng:

Hot ha yu t Hageman ti ch, t kch thch cc tin cht gy vim nh kininigen v kallicreinogen tr thnh kinin v kallicrein gy phn ng vim thnh hot dch. T phn ng vim cc bch cu s tp trung ti, bch cu s thc bo cc vi tinh th urat ri gii phng cc men tiu th ca bch cu (lysozym) cc men ny cng l mt tc nhn gy vim rt mnh. Phn ng vim ca mng hot dch s lm tng chuyn ha, sinh nhiu acid lactic ti ch v gim pH, mi trng cng toan th urat cng lng ng nhiu v phn ng vim y tr thnh mt vng khp kn lin tc, vim s ko di. Do trn lm sng thy 2 th bnh Goutte: Th bnh Goutte cp tnh, qu trnh vim xy ra trong mt thi gian ngn ri chm dt, ri li ti pht. Th bnh Goutte mn tnh qu trnh lng ng urat nhiu v ko di, biu hin vim lin tc khng ngng.

2.1.4. Biu hin lm sng a. Giai on nng acid uric trong mu cao v cha biu hin trn lm sng Hay gp nam lc tui dy th v n lc tui mn kinh. C th xut hin cn au qun thn (10 - 40%) do si urat trc. 540

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b. Giai on Goutte cp tnh Goutte cp tnh c biu hin bng nhng t vim cp tnh v d di ca ngn chn ci (khp bn ngn), thng xy n bt thnh lnh. Cn Goutte cp c th khi pht sau mt s iu kin thun li nh: Sau mt ba n nhiu tht ru. Sau chn thng hoc phu thut. Lao ng nng, i li nhiu, mang giy qu cht. Xc ng, cm ng. Nhim khun cp. Sau khi dng mt s thuc li tiu nh nhm chlorothiazid, tinh cht gan, vitamin B12, steroid Khong 50% bnh nhn c du hiu bo trc nh ri lon tiu ha, nhc u, mt mi, i nhiu v nng but, st nh Cn thng xy ra vo ban m, khong 2 - 3 gi sng: au nhc d di khp bn ngn chn ci, cng lc cng au nhiu, n ni ng vo tm chn mn cng khng sao chu c. Cn au ko di n sng th du dn, n m hm sau li bt u t au nh c. Mt cn Goutte cp tnh c th ko di vi ngy n vi tun. Bnh nhn c st, c th km theo rt run, nhit t 38 - 390C. St cng cao nu bnh nhn cng au nhiu. Ni khp au nhc s c du hiu vim khp cp, da lng, ph nh, c nhiu tnh mch ni ln. Ht cn, bnh nhn s nga khp, trc da, khp b cng t 1 - 2 ngy ri tr li bnh thng khng di chng. Cn cp tnh c th ti pht nhiu ln, 7% khng c cn Goutte cp ln II, nhng phn ln cn Goutte cp ln II xy ra t sau mt nm cho ti 10 nm. c. Goutte mn tnh Din tin chm, c th c hoc khng c, km theo cc t cp. Nu c cc t ny xy ra t hn, thi gian au ngn hn. Goutte mn biu hin bng du hiu ni cc u cc (tophi) v vim a khp mn tnh, do gi l Goutte lng ng. Tophi l nhng cc tinh th acid uric hoc mui urat c mng khp, sn khp, gn c, m di da. Tophi xut hin mt cch kn o, ln chm, khng di ng, cng dn, hnh th khng u, khng au nhng s hin din khp c th lm cng dn v a ti bin dng khp. Da ni tophi xut hin 541

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d b lot, r l, chy ra mt cht trng nh phn. Tophi t khi b nhim trng nhng nu bi nhim rt kh cha lnh. Bin dng khp: khp no giai on Goutte mn tnh cng u c th b tn thng c. Thng b thng tn nhiu khp mt lc v l cc khp nh ngoi bin. Khp khng au lc ngh ngi nhng au v cng khp khi hot ng. d. Bin chng ni tng Khong 1/3 trng hp bnh nhn au sau cn Goutte c cn au qun thn do c s thnh lp si urat. Mt s bnh nhn c chc nng thn thay i, din tin bnh thn rt chm. 2.1.5. Biu hin cn lm sng Acid uric mu tng. Bch cu tng Tc lng mu bnh thng hoc tng t. Dch khp c. Bch cu tng nhiu 10.000 - 70.000/mm3; phn ln l bch cu a nhn, lng mucin gim, nng glucose v acid uric tng t nh trong mu. X quang khp: + Goutte cp cha c bin i trn X quang. + Goutte mn: khong cch 2 u xng hp li, c hin tng mc thm xng u xng v c hin tng to hang trong xng. 2.2. Nguyn nhn bnh sinh theo y hc c truyn Goutte (hay thng phong) c m t nh trn nm trong phm tr chng t th hn t, thp t, hn thp t v chng lch tit phong. Nguyn nhn bnh l do ba th t kh phong, hn, thp vo tch t lu ngy trong c th, m c th li c can thn bt tc: can h khng nui dng c cn mch; thn h khng lm ch c ct ty. H nhit kt hp vi kh huyt tr do t kh tch t gy b tc lm cho khp xng sng nng au khng co dui vn ng c. au cng d di v m, tri lnh au tng, chm nng au. Nu bnh tin trin nhanh v mnh hn th gi l bch h lch tit. 3. CHN ON 3.1. Chn on xc nh Da vo biu hin lm sng v cn lm sng c acid uric tng cao trong mu. 542

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3.2. Chn on phn bit Cn Goutte cp cn chn on phn bit vi: + Cn gi Goutte: l bnh vim khp ca ngi gi, do s lng ng ca nhng tinh th calci trong dch khp, i khi cng c xy ra ngi tr v thng tn tin trin nhanh chng nhiu khp. Bnh xut hin hai phi nh nhau. Cn gi Goutte cp cng tng t nh Goutte cp nhng thng l tn thng khp to (nht l gi, cng c th thy khp c tay, c chn, mt c, ct sng lng, ngn ci chn) v thi gian au ngn hn 1-2 tun. X quang cho thy hin tng ha vi sn. Dch khp cha cc tinh th calci v gi tophi l nhng cc tinh th calci kt li thnh tng m. Bnh iu tr khng hiu qu vi colchicin. + Vim khp cp trong bnh vim a khp dng thp. + Vim khp m. + Vim khp do chn thng. + Thoi ha khp. Goutte mn tnh: cn phi phn bit tt c cc trng hp vim khp gy bin dng khp nh thoi ha khp, vim khp dng thp. 4. IU TR THEO y hc c truyn 4.1. Mc ch Chm dt cn Goutte cp cng nhanh cng tt. Nga ti pht. Nga bin chng bng cch ngn nga s lng ng ca cc tinh th acid uric hoc mui urat. Trnh cc yu t thun li cho s xut hin Goutte. 4.2. C th iu tr cn Goutte cp thng dng colchicin liu tn cng. C th dng phenylbutazon hoc indocid tng s thi acid. Nga ti pht: c th dng colchicin liu thp v dng cc thuc probenecid, allopurinol hoc sulfinpyrazon tng s thi acid uric. Ch n ung v sinh hot: 543

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+ King ru v cc thuc kch thch nh t, c ph v.v + Hn ch thc n c nhiu purin. + Ung nhiu nc (2 lt/ngy). + Trnh lm vic qu sc, trnh lnh, trnh n ung qu mc. + Khi phu thut hoc cc bnh ton thn cn ch theo di acid uric mu iu tr kp thi. 4.3. iu tr theo y hc c truyn 4.3.1. Goutte nguyn pht Y hc c truyn m t trong chng thng t hay hn t. au d di mt khp tri lnh au tng, m au nhiu khng ng c. Hn kh nhiu hay hnh bnh i xung lm cho khp xng, da tht 2 chn nng n hoc sng nhc. Php cha chung: tn hn, khu phong, tr thp v hnh kh hot huyt. a. Th hn t Php tr: tn hn lm chnh, s phong to thp lm ph v gia thm thuc n thng v tnh cht ca hn l ngng tr. Cc bi thuc: + Bi c hot tang k sinh thang gia thm cc v thuc nh ph t 8g, qu chi 8g (xem Bnh hc v iu tr II, trang 334). + Bi u thang gia gim gm: ph t ch 8g, ma hong 12g, bch thc 12g, hong k 12g, phc linh 12g, cam tho 8g. Phn tch bi thuc:
V thuc Ph t Ma hong Bch thc Hong k Phc linh L sa -k Cam tho Tc dng B ha, tr dng, trc hn t Pht hn, gii biu Lim m, dng huyt ch thng B kh, c biu Li thy, thm thp Tr m thp n trung, diu ha cc v thuc Vai tr Qun Thn Thn T T T S

+ Bi Ng tch tn gia gim

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Phn tch bi thuc:


V thuc Can khng Nhc qu Ma hong ng quy Xuyn khung Bch ch Thng trut Tn giao Hu phc Trn b Bn h Phc linh Bch thc Cam tho n l, kh hn Pht hn, gii biu Hot huyt, dng huyt Hot huyt, ch thng Trn thng, gii biu n trung, ho m Tr phong thp, th cn, hot lc To thp, kin t Kin t, l kh, ho m Ging kh, tr thp, ho m L kh, ho m Dng huyt, ch thng n trung, ho v Tc dng n trung, trc hn, thng mch Vai tr Qun Qun Thn Thn Thn T T T T T T T T S

b. Lch tit phong Nu giai on cp khp sng to, au nhc d di, co dui kh khn, pht st th dng bi Bch h qu chi thang gia v (gm: thch cao, qu chi, tri mu, thng trut, hong b, tang chi, ngnh m, phng k). Nu qua giai on cp th dng bi c hot tang k sinh gia gim (gm: c hot, phng phong, tang k sinh, t tn, tn giao, ng quy, ng sm, phc linh, ngu tt, trng, qu chi, thc a, bch thc, ph t ch, cam tho). 4.3.2. Goutte th pht Ty thuc vo th bnh chnh km theo Goutte nh thn m h, can m hoc can huyt h, t thn dng h m dng bi thuc cho thch hp nhng v thuc chnh l l sa k t 20 n 30g. Th d: Goutte th pht trn tng huyt p th can thn m h th dng nh sau Bi B can thn ng quy Thc a Si h Tho quyt minh 12g 16g 12g 12g Hoi sn Trch t H th 12g 12g 12g

Gia thm l sa k 20g - 30g 545

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Dng c v l sa k 50g sc ung di dng tr hng ngy, km thm bi thuc Lc v nu c thn m h; km thm bi thuc Bt v nu c t thn dng h .v.v.

T lng gi Cu hi 5 chn 1: chn cu ng 1. Tn sut xut hin Goutte

A. 90% gii nam, t 20 tui tr ln B. 95% gii nam trung nin, tui t 30-40 tui C. 65% gii n trung nin t 40 tui tr ln D. 65% gii nam sau khi mc bnh tim mch E. Tt c cc yu t trn u ng
2. C ch sinh ra Goutte l do lng acid uric trong mu tng cao v

A. Gim thi qua thn, lm li acid uric thn gy bnh B. Lng ng thn gy vim thn, ri suy thn, lm acid uric li gy bnh C. Hot ho yu t Hageman kch thch cc b th tin cht gy vim khp D. Lng ng mng hot dch khp hot ho cc yu t Hageman ti ch, kch thch cc tin cht gy vim, to nn phn ng vim khp E. To nn phn ng vim lm tng chuyn ho lm gim toan v y l iu kin gy ra Goutte
3. Biu hin no sau y l c trng ca cn Goutte cp

A. Ni cc u cc (tophi) v vim a khp mn tnh B. Sng khp, km theo ri lon tiu ho, st v tiu nhiu nng but C. Sng nng au d di ngn chn ci km st cao v xy n bt thnh lnh D. Khp ngn ci sng to ni cc u cc (tophi) lot, r l, chy ra cht trng nh phn E. Sng khp to c nng km st cao, nhiu khp vim cng mt lc
4. Bi thuc Ng tch tn gia gim c tc dng

A. n thng, s phong, to thp, ho m


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B. n trung, tn hn, ho m C. Tn hn, n thng, s phong, to thp D. Tn hn, trn thng, l kh, ho m E. n l, kh hn, s phong, ho m
5. V thuc ma hong trong bi Ng tch tn (gm: ma hong, bch ch, can khng, nhc qu, thng trut, hu phc, trn b, bn h, phc linh, ng quy, xuyn khung, bch thc, tn giao, cam tho) c vai tr v tc dng

A. Pht hn, gii biu: vai tr qun B. Pht hn, gii biu: vai tr thn C. Trn thng, gii biu: vai tr qun D. Trn thng, gii biu: vai tr thn E. Pht hn, gii biu: vai tr t
6. Bi Bch h qu chi thang gia v ch nh iu tr Goutte th A. Th thp t giai on cp B. Lch tit phong giai on cp C. Lch tit phong giai on mn D. Th nhit t giai on cp E. Th nhit t giai on mn 7. Bi thuc du thang gia gim (gm: ph t, ma hong, bch thc, hong k, phc linh, cam tho) dng ch nh iu tr Goutte th

A. Hn t B. Thp t C. Hn thp t D. Hn t giai on cp E. Thp t giai on cp


8. Bi thuc B can thn (gm: ng quy, thc a, hoi sn, si h, trch t, h th , tho quyt minh gia thm l sa k) c ch nh iu tr Goutte

A. Nguyn pht km tng huyt p trn can thn m h B. Th pht trn tng huyt p th can thn m h C. Nguyn pht giai on mn th can thn m h D. Nguyn pht giai on cp th can thn m h E. Th pht mi giai on th can thn m h

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p n
Bi 1 Chn cu ng 1C; 2E; 3E; 4C; 5A; 6B; 7C; 8C; 9E; 10C; 11A Cu hi nhn qu 1B; 2A; 3C; 4D; 5E; 6A; 7A; 8C; 9C; 10A; 11A; 12E Bi 2 Chn cu ng 1B; 2E; 3A; 4A; 5E; 6C; 7B; 8E; 9C; 10B in vo ch trng 1. A B C D 2. A B 3. A B C D Bi 3 Chn cu ng 1C; 2E; 3D; 4C; 5E Cu hi nhn qu 1E; 2E; 3A; 4E; 5A; 6B Bi 4 Chn cu ng 1C; 2B; 3C; 4B; 5D; 6A; 7C; 8B; 9A; 10C; 11D; 12B; 13C au ngc trn cc bnh nhn c yu t nguy c Kh th trn cc bnh nhn c yu t nguy c au thng v trn cc bnh nhn c yu t nguy c Trn bnh nhn c bnh ng mch au ngc in hnh m khng c gng sc au ngc in hnh m khng c gng sc trn nhng bnh nhn c yu t nguy c Chng nhng yu t nguy c ca x m ng mch Lm gim tiu th O2 c tim Chng tnh trng to mng x va Ti lp tun hon mch vnh

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Bi 5 Chn cu ng 1D; 2C; 3B; 4C; 5E; 6D; 7A; 8E; 9A; 10A Bi 6 1A; 2E; 3C; 4D; 5D; 6E; 7B; 8C; 9D; 10B Bi 7 1C; 2B; 3E; 4E; 5D; 6E; 7B; 8A; 9B; 10D Bi 8 1D; 2C; 3A; 4C; 5B; 6D; 7B; 8E; 9C; 10D; 11B;12 B; 13 B; 14 B; 15 E; 16 C Bi 9 1D; 2A; 3C; 4B; 5A; 6B; 7C; 8E; 9C; 10A; 11B; 12D; 13E; 14B; 15A; 16C; 17C; 18A; 19D; 20D; 21E; 22E; 23A; 24B; 25D; 26D; 27A; 28B; 29B; 30A Bi 10 1C; 2C; 3A; 4B; 5D; 6E; 7E; 8D; 9B; 10E Bi 11 1B; 2D; 3C;4D; 5C; 6E; 7E; 8B; 9C; 10D; 11E; 12D; 13C; 14D; 15B; 16D; 17A; 18B; 19A; 20A Bi 12 1C; 2B; 3A; 4C; 5C; 6B; 7C; 8A; 9D; 10D; 11E; 12D; 13C; 14D; 15 E; 16B; 17C; 18C Bi 13 1C; 2E; 3D; 4E; 5A; 6C; 7D; 8C; 9A; 10B Bi 14 1A; 2E; 3C; 4C; 5B; 6A; 7C; 8A; 9E; 10C; 11E; 12E; 13E; 14D; 15C; 16C Bi 15 1D; 2C; 3B; 4A; 5C; 6C; 7A; 8B; 9C Bi 16 1B; 2B; 3C; 4D; 5A; 6D; 7A; 8B; 9B; 10D; 11A; 12B; 13A; 14D; 15 B; 16 D; 17D; 18B; 19D; 20A; 21B; 23C Bi 17 1B; 2B; 3E; 4A; 5B; 6B; 7E; 8D; 9C; 10A Bi 18 1B; 2E; 3B; 4D; 5A; 6C; 7B; 8B; 9B 549

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Bi 19 1E; 2C; 3D; 4E; 5C; 6A; 7D; 8A; 9C; 10D Bi 20 1D; 2B; 3C; 4E; 5B; 6C Bi 21 1D; 2C; 3E; 4E; 5D; 6D; 7C; 8D; 9A; 10C Bi 22 1D; 2D; 3E; 4E; 5A; 6B; 7E Bi 23 Chn cu ng 1A; 2E; 3B; 4C; 5D Cu hi nhn qu 1D; 2A; 3A; 4A; 5A; 6A; 7A; 8C; 9D; 10A Bi 24 Chn cu ng 1D; 2D; 3A; 4C; 5A Chn cu sai 1E; 2A; 3C; 4E; 5D in vo ch trng 1. A. Ti ch B. Ti ch C. c hiu 2. A. Nm nga, u k gi mng B. Thy thuc ng pha u bnh nhn 3. A. Vut t di cm ln thi dng v t trn hng xung tai B. Xoa vi cc ngn tay khp kn, xoa thnh nhng vng nh C. G nh nhanh vng trn v quanh mt vi cc u ngn tay Bi 25 Chn cu ng 1B; 2A; 3D; 4D; 5A; 6B; 7E; 8D; 9C; 10D 550 D. c hiu E. c hiu

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Bi 26 Chn cu ng 1C; 2E; 3D; 4C; 5E; 6C; 7A; 8A; 9C; 10A Cu hi in vo ch trng 1. A. Xut hin sm phn xa ca chi, lan dn v gc chi B. Cng v gc chi, t cng gim C. Ri lon kiu i xng: mang gng, i tt 2. A. Gim cm gic nng B. Gim cm gic bn th 3. A. Yu hoc lit B. Gim hoc C. Mt phn x 4. A. in c B. Gii phu bnh l 5. A. Phn ly m - t bo Bi 27 Chn cu ng 1B; 2E; 3E; 4C; 5E; 6A; 7B; 8B; 9A; 10D; 11E in vo ch trng 1. A. B. C. D. Ti ch c hiu Theo ng kinh Theo ng kinh

2. A. Ti ch v ng kinh B. C. Theo ng kinh Theo ng kinh

D. c hiu 3. A. Gng c 4 u i B. Tp c chn C. ng tc n lng 551

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D. ng tc tam gic E. ng tc tam gic bin th F. Gng c bng 4. A. B. C. D. E Bi 28 Chn cu ng 1D; 2B; 3C; 4D; 5A; 6B; 7C; 8A; 9D; 10C Bi 29 Chn cu ng 1C; 2E; 3D; 4B; 5D; 6A; 7A; 8E; 9D; 10A; 11C Bi 30 Chn cu ng 1A; 2B; 3B; 4E; 5B; 6B; 7A; 8A Bi 31 Chn cu ng 1B; 2D; 3C; 4C; 5B; 6B; 7A; 8B Gng c mng Ngng u ln, xoay u Nhc tng chn ln, h xung Gp, dui gi tng bn v 2 bn cng lc Tay sau gy, nhc u v vai ln

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TI LIU THAM KHO


1. Ting Vit 1. Hong Bo Chu. Phng thuc c truyn. NXB Y hc H Ni, 1995 2. Trn Vn K. ng - Ty y iu tr bnh tim mch. Bnh huyt p cao, tr. 29-51, NXBTH ng Thp, 1995. 3. Phm Khu. Bch khoa ton th bnh hc. Tng huyt p, 253-256. TTQGBSTBKVN, 1991 4. nh Ninh, L c Thip. ng y s in. Tam tiu, tr.184, NXB Long An, 1975. 5. Nguyn T Siu. Hong Ni kinh T vn. NXB Thnh ph H Ch Minh, 1992. 6. Vin Y hc trung y Bc kinh. Phng t hc din ngha. NXB Y hc H Ni, 1994. 7. Bi Ch Hiu. Dc l thuc nam, NXB ng Thp, 1994 8. Hi Thng Ln ng. Hi Thng Y Tng Tm Lnh, NXB Y hc H Ni, 1997 9. Nguyn T Siu. Ni kinh T vn. NXB TP. H Ch Minh, 1991 10. Trn Vn K. Dc hc c truyn tp I,II, NXB TP. H Ch Minh, 1998 11. B mn Ni, Trng i hc Y Dc TPHCM. Bnh hc ni khoa, 1997 12. Trng i hc Y H Ni. Y hc c truyn, NXB Y hc H Ni. 13. B mn YHCT, Trng i hc Y dc TPHCM. Triu chng hc YHCT, 1997 14. Bch khoa th bnh hc, Nh xut bn T in bch khoa, NXB H Ni 2000 15. Nguyn Thin Quyn, Nguyn Mng Hng. T in ng y hc c truyn, NXB Khoa hc k thut, 1990 16. Trn Thu - Chuyn ni khoa YHCT, NXB Y hc H Ni, 1995 17. Tt Li. Nhng cy thuc v v thuc Vit Nam trg. 244, NXB Y hc H Ni

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18. B mn Sn, i hc Y Dc Tp H Ch Minh. Bi ging sn ph khoa tp 2, NXB Y hc, 1987. 19. Cc nguyn l ni khoa Harison tp 2. Vim tiu khung tr. 780, NXB Y hc, 1993. 20. Trn Ngc n. Bnh Thp khp, Nh xut bn Y hc H Ni, 1993 21. Vin Y hc Trung Y Bc Kinh. Phng t hc din ngha - NXB Y hc H Ni, 1994. 22. Nguyn Th Khnh, Phm T Dng. Xt nghim s dng trong lm sng, NXB Y hc H Ni, 1997. 23. Phm Khu. Cm nang iu tr ni khoa, NXB Y hc H Ni. 24. Nguyn Thin Quyn, Nguyn Mng Hng. T in ng y hc c truyn, Nh xut bn Khoa hc v K thut, 1990. 25. Hi Thng Y Tng Tm Lnh. Y trung quan kin tr. 36, NXB Y hc, 1993. 26. Tu Tnh. Nam dc thn hiu tr. 264 - 265, NXB Y hc, 1996. 27. Hi phc hi chc nng Vit Nam. Vt l tr liu - Phc hi chc nng bnh nhn lit na ngi do tai bin mch mu no, 362-406, Nh XB Y hc, 1995. 28. Trng i hc Y H Ni, B mn ng y. Bi ging ng y tp 2. Lit mt ngoi bin, Nh xut bn Y hc, 1979. 29. L Vn Thnh. Bnh hc thn kinh. Bnh l thn kinh ngoi bin, tr. 224-238, Nh xut bn Y hc, 1990. 30. B mn ng y Trng i hc Y H Ni. Bi ging ng y. au dy thn kinh hng, 138-141, Nh xut bn Y hc, 1979. 31. Bi Ch Hiu, Trn Khit. Bnh chng v tr liu theo YHCT kt hp vi YHH. Suy nhc thn kinh, 405 - 411, Nh xut bn ng Nai, 1989. 32. Vin Y hc Trung y Bc Kinh (lc dch: Dng Hu Nam, Dng Trng Hiu), Phng t hc din ngha, NXB Y hc H Ni, 1994. 2. Ting Anh 1. Castaigne, M. Scherrer-Crsby. Le livre de linterne-Cardiologie. Hypertension artrielle systmique, 131-159, Mdecine - Sciences Flammarion, 1991. 2. Harrison s. Principles of Internal Medicine, 14th Edition.

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3. Raj - K - Goyal. Disease of Esophagus - Motor disorder, page 1644 1645. Harrisons principle of internal medicine - Volume II 15th edition. 4. Laurences Friedman v Walter L.Peterson - Gastritis, pp. 1610 1616. Harrisons principle of Internal medicine - Volume II 14th. Edition. 5. Erik A.J.Raws - Peptic Ulcer Disease Page 27 Medical Progress 8/ 1996, Vol 23 - N08. 6. John del valde - Peptic Ulcer Disease Page 1649 - 1658. Harrisons Principle Internal Medicine. Vol 2, 14th Edition. 7. Disorder of Absorption page 1665 - 1679 Henry. J. Binder 15th. 8. Digestive disease and science 39, 1155 - 1163, 1994. 9. Chronic Hepatitis page 1696 - 1704 Jule L. Dienstag Harrisons Principle Internal Medicine, Vol 2, 14th Edition. 10. Chronic Hepatitis page 1743 - 1751 Jule L. Dienstag Harrisons Principle Internal Medicine, Vol 2, 15th Edition. 11. Recurrent UTIS in Women page 35 - 39 John. Kelly Medical Progress December, 1996, Vol 23 No 12.

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