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Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi

Bin chng chnh ca si tit niu I. i cng 1. Si tit niu l mt bnh l ngoi khoa thng gp, hay ti pht trong si niu qun chim t l 20 25% si tit niu ni chung. y l mt cp cu c tr hon (ng v gc iu tr si niu qun) v si rt d gy ra cc bin chng trong c cc bin chng dn n t vong nu khng c x tr kp thi. y l mt loi si nguy him nht trong cc loi si ng tit niu do nh hng n niu qun, chc nng thn v ton thn. 2. Si niu qun phn ln do si thn di chuyn xung (80%). Do qu trnh di chuyn, si c th ri xung bng quang v t i ra ngoi hoc c th dng li cc on hp sinh l ca niu qun nh on b thn niu qun, on niu qun bt cho ng mch chu, on niu qun trong thnh bng quang. 20% si niu qun cn li hnh thnh ti ch do cc nguyn nhn khc nhau gy cht hp niu qun: Vim nhim(lao), d dng niu qun (niu qun phnh to, tch i). 3. V v tr ca si thng gp on 1/3 di (70 75%), cn li (25 30%) gp 1/3 trn hoc 1/3 gia. 4. Si niu qun thng gy bin chng sm vi ng tit niu trn. Khi si tit niu 1 bn v chc nng thn bn i din c th b tr c th t khi xy ra bin chng. Nhng khi chc nng thn bn i din khng cn b c hoc si niu qun c 2 bn th c th dn n nhng bin chng nguy him. 5. C nhiu bin php iu tr si niu qun nhng khi c bin chng th bt buc phi tm mi cch ly si ra. II. Cu to niu qun: 1. Niu qun l ng dn nc tiu c cu to chnh: 1

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


1) Lp c dc ngoi. 2) Lp c vng trong. 2. S co gin c l tc dng chnh ca nhu ng thun chiu ca niu qun t b thn xung bng quang. 3. p lc ca niu qun tng dn t 1/3 trn (12 mmHg) n 1/3 di (40mmHg) c tc dng y dng nc tiu xung, chng hin tng tro ngc nc tiu t bng quang, niu qun on thp ngc dng ln thn. III. Sinh l v gii phu bnh si niu qun. 1. Si niu qun cn tr ng dn lu nc tiu, d tc hon ton hay khng hon ton vn gy hin tng ng nc tiu trn si. 2. Hinmann 1934 theo di th nghim thy: 1) Gy tc niu qun bng cch buc niu qun 1 bn, sau 2 tun ct thn bn i din, tho g niu qun buc th thn phc hi, vt th nghim vn sng. 2) Gy tc niu qun, 3 tun sau ct thn bn i din, tho g niu qun buc, chc nng thn phc hi 50%. 3) Gy tc niu qun, 4 tun sau ct b thn bn i din, tho g niu qun buc th thn khng phc hi, vt th nghim khng sng st. 4) Nhng thng tn gii phu bnh tc niu qun xut hin rt sm: 7 ngy: nc ti thn, gin cc ng gp, c ch hoi t. 14 ngy: cc ng ln xa, ln gn u c phn ng tng 28 ngy: 50% vng tu thn b thoi ho, cu thn qu

x collagen lm ri lon nhu ng b thn niu qun. sn, k tu thn cha cc fibroblast, t bo n nhn, i thc bo. Cc mao mch vng tu th co tht, ng thi cc mao mch cu thn b xp li. 8 tun: nhu m thn b dn mng 1 cm. 3. Thng tn n lp c s gy cht hp niu qun. 2

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


4. Cc bin chng chnh ca si niu qun: IV. Vim nhim: vim i b thn, vim thn k. ng nc tiu-nhim khun: thn nc, thn m. Thiu niu, v niu. Chn on si niu qun: 0) Tui: thng gp tui 30 50. 1) Gii: Nam/n = 2/1. C s lin quan gia gii v tnh cht si ( nam hay

1. Dch t:

gp si canxiphosphat, canxi oxalat, n hay gp si phosphat amoniaco magnesi) 2) iu kin sinh hot: Ch n nhiu canxi, phosphat, oxalat d hnh Kh hu nng, kh, hn ch lng nc tiu bi tit cng thnh si. d hnh thnh si. 3) Yu t di truyn cng c nhc ti trong 1 s bnh cnh v si cystin, si canxi 4) Nhng bnh mn tnh nm lu v bin chng ca nm lu cng d hnh thnh si. 2. Lm sng 1) C nng: Cn au si niu qun: + au qun tht lng tng cn d di ko di vi pht ti hng gi, kh ct cn au nu khng c iu tr thuc gim au. + Cn au xut hin sau khi bnh nhn i li, vn ng nhiu, lao ng nng. Cn au du i khi c ngh ngi. + V tr: Vng h tht lng, lan xung di theo ng i ca niu qun tn ht nhiu v tr khc nhau tu vo v tr 3

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


si: Si 1/3 di niu qun: lan xung bu. Si 1/3 gia niu qun: lan xung h chu. Si 1/3 trn: lan dc xung tinh hon cng bn. + Nguyn nhn: Do co tht vim ph n niu qun. + au m cng tc vng tht lng khi c ng niu qun b thn. i mu: i nc tiu hng hay (t gp), c th i i rt, i but: khi si niu qun v tr st bng Hi chng sau phc mc: Trong cn au bnh nhn c mu vi th (< 100000 hng cu/ml nc tiu). quang gy kch thch bng quang. th c nn, bng chng. 2) Ton thn: Khi cha c bin chng th cha c biu hin g c bit. 3) Thc th : Khi c cn au ca si niu qun, c th thy au co C th chm thn, bp bnh thn (+). V vng h tht lng au tng. Xt nghim mu: cng c tht lng, co cng na bng, bng chng.

3. Cn lm sng: + Cng thc mu: hng cu bnh thng, bch cu tng cao, a nhn trung tnh tng cao (>75%). Tc lng mu tng: Khi c nhim khun. + Ho sinh mu: c th thy cc nguyn nhn gy ra si: Ca tng, oxalat tng. + Nu nhim khun huyt: xt nghim c vi khun trong mu. + Ure, creatinin tng cao: c suy thn cp/t cp ca suy thn mn. Xt nghim nc tiu:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


+ T bo: Hng cu (+++), bch cu (+++), t bo biu m ng niu (+++) + Protein vt (<1g/24h). + Vi khun nc tiu(+) (> 10000/ml): thng gp E.Coli 60 80%, lin cu, t cu vng Proteus cc chng. ng s nht l trc khun m xanh. Xquang h tit niu khng chun b thng nghing: + Pht hin si niu qun tr cc trng hp si urat, acid uric. Hnh nh cn quang ca si nm trn ng i ca niu qun, hnh thoi 2 u hng ln trn v xung di. + Trn phim nghing thy si nm sau ct sng v chn on phn bit vi si ti mt vi ho, hch vi ho + Bng thn to. Siu m: Kch thc thn to hn bnh thng, bao thn dy. i b thn gin nh, niu qun trn si gin, vng v tucn phn bit r v m ng u, khng ch hoi t. Siu m pht hin si niu qun l hnh tng m c bng cn ngay c si urat, acid uric, nhng siu m kh pht hin si niu qun 1/3 gia v hi cc quai rut v xng chu. Chp niu tnh mch: + Xc nh v tr si trn ng i ca niu qun, khng b st si khng cn quang. + nh gi chc nng thn thng qua mc bi tit ca thn theo thi gian + Hnh thi i b thn, thn. + Mc gin ca niu qun, i b thn trn v tr ca si. + Pht hin cc d dng ca si. Chp niu qun b thn ngc dng: cng c gi tr chn on si, tc niu qun nhng t dng do c th gy bin chng nhim khun. 5

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


* Nh vy qua cc bc thm khm trn ta c th s b chn on c si niu qun v v tr ca n trn niu qun. iu quan trng l pht hin ra n c bin chng hay cha c thi x tr ph hp. V. Cc bin chng chnh ca si niu qun: 1) Bin chng do nguyn nhn tr: 1) Nhim khun nc tiu: Khi tr, nc tiu rt d nhim khun, vi khun hay gp l vi khun ng rut v ng s nht l trc khun m xanh. Cc triu chng km theo triu chng ca si niu qun: + i c, mc ph thuc vo mc nhim khun. + Ton thn c th c st, khng st. + Xt nghim thy c tr bch cu, t bo m trong nc tiu, vi khun. 2) Vim thn - b thn: bi ring. 3) Ap xe thn. Cc triu chng ca vim thn b thn nhng nng Siu m: hnh nh cc ap xe li ti khp thn hoc c iu tr nh vi vim thn, b thn. Ton thn c hi chng nhim khun nhim c iu tr: hn nhiu. th gp 1 vi to 4) Nhim khun huyt: l mt bin chng nng. nng. Trong mu c vi khun khi nui cy. + Hi sc thn: Truyn Lasix, huyt thanh ngt. Theo di lng nc tiu khi truyn. + Hi sc ton thn : Ci thin tnh trng huyt ng, theo di CVP. 6 A. Cc bin chng trc m:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


+ Khng sinh mnh dit vi khun G(-). + M cp cu ly si.(?) 5) Vim thn k, x teo thn. Huyt p cao. Siu m: thn teo nh hn bnh thng. Doppler mu, chp ng mch thn chn lc: gim X tr : Nu thn bn i din tt: ct b thn v niu

mch mu trong thn. qun bn tn thng. 6) Vim nhim thnh niu qun: niu qun vim nhim lm t chc niu qun dy ln, x ho, cht hp niu qun. 7) Thng thnh niu qun: gy d nc tiu. D ra ngoi: vim ty sau phc mc. D vo trong: gy vim phc mc nc tiu. X tr: phu thut ly si, khu phc hi hay ct

on, ni tn tn niu qun. 8) Vim quanh thn. 9) Ap xe quanh thn: Hu qu nng, d li m : phu thut dn lu ap xe quanh thn hoc ct thn nu khng cn kh nng bo tn. 2. Bin chng do cht tc 1) Thn nc: bi ring. 2) Thn nc nhim khun. 3) Thn m: bi ring. 4) Suy thn cp v niu: bi ring. 5) Suy thn mn tnh c 2 bn. 6) Tng huyt p: Si niu qun vim thn cp/mn, nc b thn tng huyt p (?). iu tr : iu tr tng huyt p v ly si niu qun. B. Cc bin chng trong m:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


1) Lm rch phc mc to 1 l thng t ngoi vo trong bng. 2) Lm thng cc tng trong bng: t trng, i trng. 3) Chy mu: Do lm rch cc mch mu nh quanh niu qun v tiu khung. 4) Ct t ng mch v tnh mch thn. 5) Rch tnh mch ch. C. Cc bin chng lu di: 1) Cht hp niu qun do khu qu k, lng ng niu qun b hp li 2) R nc tiu t niu qun do on cht hp niu qun pha di hn si cha gii quyt trit . 3) Suy thn khng b tr. Tuy gii quyt nguyn nhn nhng thn khng phc hi c.

Vim thn, vim i b thn, vim thn k I. i cng 1. Si niu qun lm cn tr lu thng, ng nc tiu, nhim khun ng tit niu c th ngc dng ln nhu m thn (m lin kt k thn ng thn gy vim cp hay mn tnh). 2. Vim i b thn cp tnh vi bnh cnh lm sng rm r nh hng n chc nng bi tit ca thn, nht l si niu qun 2 bn hay si niu qun 1 bn v si thn 1 bn. 3. Nu bnh c pht hin sm ngay t t cp tnh u tin, iu tr nguyn nhn kp thi (ly si niu qun) tn thng vim i b thn s khi, chc nng, hnh th thn c th hi phc hon ton. 4. Nu bnh ko di khng pht hin ra nguyn nhn si niu qun, sau nhiu t vim i b thn cp tnh, phn ng vim x tng ln s tr thnh vim i b thn mn

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


tnh, chc nng v hnh th thn t c kh nng phc hi tt cho d ly c si niu qun. 5. Cc vi khun gy bnh thng l vi khun G(-) nh E.Coli, Klebsiella, Proteus theo nc tiu ngc dng lan ln thn. Cc vi khun G(+) nh lin cu khun, t cu c th gy vim i b thn theo ng mu hay ng k cn t gp hn. II. Gii phu bnh vim i b thn vim thn cp: 1. Nim mc i b thn vim ph xung huyt, ri rc c ch lot chy mu. i b thn dn nh mt trng lc gy ng, nc tiu c (nhiu hng cu, bch cu, t bo biu m i b thn, vi khun). Vng v thn phn ng vim ph cp, cc gai thn, thp thn cc m k ng thn , thm nhim nhiu bch cu a nhn trung tnh, lympho, i thc bo. Vng tu thn cng c thng tn nh v thn. 2. Thn ph n sng to, bao thn nguyn vn nhng d mn nt. 3. Thn trng bch mt bng nhn, khng hng cng m ging nh m tuyn gip. Phn nhu m thn x ho ch yu t k thn vi s thm nhim cc t bo lympho bch cu a nhn. Vim i b thn thn mn tnh do si niu qun ni ring hay si tit niu ni chung u c mc gin i b thn, nim mc i b thn x dy cng cc gai thn teo mng. Cc ng thn cng gin hay xen k nhng ch tht hp x ho nim mc ng thn , trong lng ng thn cha cc th cast dng keo. Nhu m thn mng khng phn bit vng v v tu thn. X ho c th tin trin ti quanh cu thn v cc tiu ng mch. 4. Vim thn k mn tnh l hu qu ca qu trnh vim ng tit niu do si. III. Triu chng: 1) Cn au si niu qun : 9 1. C nng:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


au qun tht lng tng cn d di ko di vi pht ti hng gi, kh ct cn au nu khng c iu tr thuc gim au. Cn au xut hin sau khi bnh nhn i li, vn ng nhiu, lao ng nng. Cn au du i khi c ngh ngi. V tr: Vng h tht lng, lan xung di theo ng i ca niu qun tn ht nhiu v tr khc nhau tu vo v tr si: + Si 1/3 di niu qun: lan xung bu. + Si 1/3 gia niu qun: lan xung h chu. + Si 1/3 trn: lan dc xung tinh hon cng bn. Nguyn nhn: Do co tht vim ph n niu qun. au m cng tc vng tht lng khi c ng

niu qun b thn. 2) i mu: i nc tiu hng hay (t gp), c th i mu vi th (< 100000 hng cu/ml nc tiu). 3) i c: nc tiu sm mu do cc t bo nim mc i b thn vim long thi theo nc tiu, do nhim khun. Mc ph thuc nhiu vo mc nhim khun, vi khun. 4) i rt, i but: khi si niu qun v tr st bng quang gy kch thch bng quang. 5) Trong cn au bnh nhn c th c nn, bng chng. 2. Ton thn: Biu hin tnh trng nhim khun nhim c rm r: St cao dao ng 38,5 - 39C m khng thnh cn Ton thn suy st nhanh, mi kh, li bn, chn n mt Nu bnh tin trin nhanh chng c th gy ure mu v ko di trong nhiu ngy. mi (au st khng dt). cao, thiu niu, v niu, ph do suy thn. 3. Thc th: 10

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Khi c cn au ca si niu qun, c th thy au co C th chm thn, bp bnh thn (+) nu km theo nV vng h tht lng au tng. cng c tht lng, co cng na bng, bng chng. c, m thn. *Cc triu chng trn thng hay gp ti din, nhng ln sau nng hn. 4. Cn lm sng: Xt nghim mu: + Cng thc mu: hng cu bnh thng, bch cu tng cao, a nhn trung tnh tng cao (>75%). + Tc lng mu tng. + Ho sinh mu: c th thy cc nguyn nhn gy ra si: Ca tng, oxalat tng + Nu nhim khun huyt: xt nghim c vi khun trong mu. + Ure, creatinin tng cao: c suy thn cp/t cp ca suy thn mn. Xt nghim nc tiu : + T bo: Hng cu (+++), bch cu (+++), t bo biu m ng niu (+++) + Protein vt (<1g/24h). + Vi khun nc tiu(+) (> 10000/ml) : thng gp E.Coli 60 80%, lin cu,t cu vng Proteus cc chng. ng s nht l trc khun m xanh. Xquang h tit niu: + Pht hin si niu qun tr cc trng hp si urat, acid uric. Hnh nh cn quang ca si nm trm ng i ca niu qun, hnh thoi 2 u hng ln trn v xung di. + Bng thn to. Siu m: Kch thc thn to hn bnh thng, bao thn dy. i b thn gin nh, niu qun trn si gin, vng v 11

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


v tu cn phn bit r v m ng u, khng ch hoi t. Siu m pht hin si niu qun l hnh tng m c bng cn ngay c si urat, acid uric, nhng siu m kh pht hin si niu qun 1/3 gia v hi cc quai rut v xng chu. Chp niu tnh mch khi ht t vim cp tnh: + Xc nh v tr si trn ng i ca niu qun, khng b st si khng cn quang. + nh gi chc nng thn thng qua mc bi tit ca thn theo thi gian + Hnh thi i b thn, thn. + Mc gin ca niu qun, i b thn trn v tr ca si. + Pht hin cc d dng ca si. IV. Chp niu qun b thn ngc dng: cng c gi tr Din bin: chn on si, tc niu qun nhng t dng. 1. t vim i b thn cp: nu chn c khng sinh nhy cm hiu lc tt c th tin trin 5 7 ngy: hin tng vim ph n ng tit niu gim, nu si niu qun khng gy tc hon ton, niu qun c lu thng c mc vi lu lng nc tiu tng dn bnh nhn s gim dn au, h st v s qua t nhim khun cp tnh. 2. Tnh trng vim i b thn mn tnh vi si niu qun l hu qu ca bnh l si khng c iu tr ng, s coi nh bnh nhn c si, khi du cn au ri b qua, ngay c cc trng hp sau khi iu tr si niu qun giai on mun c bin chng. Vim i b thn thn mn tnh vn c th nhng t bng pht cp tnh khi bi nhim tng thm, lm suy gim dn chc nng thn v gin i b thn. V. Vim i b thn 2 bn.

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Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


1. Vim i b thn cp 2 bn: u do si hay vim i b thn cp 1 bn v thn i din l thn bnh l (m si tit niu c, vim thn , teo thn ..) cc triu chng biu hin bng cn au si niu qun, st cao, ng thi thiu niu, v niu, ure, creatinin tng. 2. Vim i b thn mn tnh 2 bn: do si niu qun hai bn hay 1 bn si, 1 bn nhim khun ngc dng i b thn khng c si. Biu hin tnh trng vim ng tit niu trn v suy Ton trng chung suy gim, nim mc nht, c th ph thn mn tnh vi mc khc nhau. kn o hay r rt, mt mi, chn n, ng ming do ure, creatinin tng. Cc xt nghim sinh ho thay i nhiu: ure, creatinin cc cht in gii mu Na+, K+ tng v toan ho. Mc lc cu thn gim, h s thanh thi ure, creatinin u gim. Xt nghim mu hng cu gim < 3000000 hay thp hn na thiu mu nhc sc , bch cu tng, a nhn trung tnh v lympho tng. VI. Xt nghim nc tiu c y du hiu vim ng iu tr tit niu. 1. Nguyn tc l iu tr tnh trng vim i b thn cp do si niu qun trc v gii phng sm niu qun khi b tc si. 2. C th: 1) Gim au : Atropin, papaverin, morphin, dolargan. Li tiu nh (khng dng Lasix l thuc li tiu mnh).

2) Khng sinh:

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Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Ch xt nghim vi khun v khng sinh th mt tnh cp cu ca vim i b thn cp c th tin hnh iu tr (thuc dit vi khun G(-)): + Vi vim i b thn nh v trung bnh c th dng: Cephlosporin ung (Cefalexin), Augmentin. + Vi vim i b thn nng c th dng: Cefotaxim + C th iu tr: Erythromycin v Biseptol 0,48gx 2vin/24h. iu chnh khng sinh sau khi c xt nghim vi khun v khng sing . Lu dng cc khng sinh t c vi thn trong trng hp c suy thn (trnh dng gentamycin, streptomycin). t iu tr 5 7 ngy phi dt im: Ct cn au qun thn, ht st, ht nhim khun tit niu, lng nc tiu tng, ton trng n nh, nu khng n nh nhng ngng khng sinh tin hnh cc chn on b sung ( chp UIV) bnh cnh lm sng li ti din phi tnh n vic can thip phu thut sm: m niu qun ly si v t thng niu qun tt hn cc bin php can thip khc. 3) Tm v loi b si niu qun v cc nguyn nhn khc gy ra si niu qun: Khi tnh trng vim i b thn cp n nh: chp UIV nh gi si niu qun, si tit niu v nh hng chc nng thn. Si nh < 1cm, trn nhn: + 1/3 trn, gia niu qun: t thng niu qun y si ln thn, tn si thn ngoi c th (tn si qua da). + 1/3 di niu qun: ni soi si niu qun ly si hay tn si ngoi c th. + Nu c s khng c trang b chuyn bnh nhn v cc trung tm tit niu. Bnh nhn khng c iu kin chuyn vin, m niu qun ly si sm. 14

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Si > 1cm x x c dng niu qun: nn phu thut ly Lm cho si tt xung bng quang. n nh, ung nhiu nc lc, nc hoa qu (nu c v niu B nc, in gii bng ng tnh mch nu c mt Nu c suy thn: ch n nht, gim m. si lp li lu thng niu qun/m ni soi. 4) Ch dinh dng hp l: th king rau qu v hn ch nc). nhiu nc. 3. Kt qu iu tr vim i b thn thn cp tt l: sau m hay can thip sm si niu qun v ng tit niu c ly ht, cc xt nghim t bo hng cu (-), bch cu (-). 4. iu tr vim i b thn thn mn i vi 1 thn niu qun c si: kh nng hi phc chc nng thn l rt hn ch, nhng chc nng thn i din s b tr hon ton nn th trng chung v cht lng cuc sng vn m bo. 5. Vim i b thn mn tnh 2 bn sau khi can thip si niu qun tit niu 2 bn khng lm vim i b thn thn nng thm nhng tnh trng suy thn t c kh nng hi phc (nht l cc trng hp suy thn giai on III IV) tin lng xu phi iu tr bng lc mu chu k. Thn nc I. i cng 1. Thn nc l hu qu ca rt nhiu nguyn nhn gy tc ng dn niu, trong do si niu qun l mt trong nhng nguyn nhn ph bin, bnh c th cp hay mn tnh. 2. Si niu qun l 1 cn tr dng nc tiu d tc hon ton hay khng hon ton gy ng nc tiu v nhim khun ng tit niu do cht hp.

15

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


3. V tr cht hp: Thng gp 1/3 gia (ngay st trn ng mch chu), 1/3 di (st bng quang).Trong qu trnh vim nhim cc thng tn vim x vim mc, di nim mc n c thnh niu qun s gy cht hp ngay ti ch si niu qun. 4. Khi si tc khng hon ton: nc tiu c, thn to t. Khi si tc hon ton: thn to cng, nhu m thn gin mng c khi nh mng nilon thnh 1 bc cha ng nc tiu (500 530 ml). 5. Thn cng to nc dn n s hu hoi v cu trc lm suy chc nng thn. Nu gii phng tc nghn sm th chc nng thn c hi phc 1 phn hay hon ton. Nu l tc hon ton trong vng 1 tun l th thn b suy kh hi phc. Do vy trn lm sng cn pht hin sm v x tr sm bin chng ny ca si niu qun. 6. Thn nc n thun theo logic khng th c, nhng trn lm sng cc trng hp thn nc tiu trong, xt nghim khng c vi khun nn danh t thn nc vn c gi tr thc t. 7. Trng hp thn nc km theo nhim khun s dn n m thn. 8. Trong iu tr thn nc phi quan tm bo tn thn ngay c giai on 3, 4. II. Triu chng lm sng: tu thuc vo tnh cht tc nghn (cp hay mn), v tr tc (thp hay cao, 1 hay c 2 bn, c km nhim khun hay khng). 1. Bnh nhn c bnh s si niu qun (c cc triu chng ca si niu qun trong tin s hoc ng thi vi cc triu chng ca nc thn nu cp tnh). 2. C nng:

16

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


1) Hi chng tc nghn ng tit niu trn do si niu qun: au vng tht lng do thn nc c c im khc vi au vng tht lng do si niu qun n thun: au m lin tc, au nhiu v m. Cng tc nhc nhi rt kh chu, chn n, ung nhiu. au lm mt kh nng vn ng v lao ng. m , thm ch

Mt s trng hp ch au tht lng

khng au do si niu qun nh, trn, c th lu thng nc tiu tng t ri li vim tc niu qun, niu qun v thn gin to dn. Cng c khi au xut hin khi rn i biu hin s pht ngc dng bng quang-niu qun. 2) i nhiu, hay i v m, t trng nc tiu thp (nu nc di ngy). 3) Cc triu chng c nng khc ca si niu qun 3. Ton thn: Ton trng vn bnh thng, c th gai st 37 38C do bi nhim (thn nc nhim khun). Nu cc trng hp thn nc 2 bn, ton trng suy sp hn: gy, da kh, ph, thiu mu, chn n, mt mi, khng mun vn ng i li v au cng tc c 2 bn tht lng. i t Tng huyt p: tng nh hoc trung bnh do thn tng tit Renin hoc do gi nc, gi mui. a phn khi loi b si niu qun th huyt p tr li bnh thng, 1 s trng hp tng cao phi ct b thn mi iu chnh c. Suy thn cp. Suy thn mn tnh c 2 bn: trng hp thn nc c 2

bn ko di. + Hi chng ure mu cao: + Hi chng thiu mu: da xanh, nim mc nht, mch nhanh. + Ph. + i t. 17

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


+ Trng hp nng (suy thn giai on cui khng hi phc): kh th toan huyt, xut huyt, i lng, chng bng, v niu: hn m, t vong. 4. Thc th: C tht lng ph n, ty s vo rt au. Thn to nh khi u vng tht lng, t au c khi bnh

nhn t s thy, thy thuc pht hin: Thn to cng, mm cn n hi, n vo khi thn bnh nhn au tc: chm thn(+), bp bnh thn(+). C phn ng thnh bng ti ch tht lng thnh bng. i khi c nhng trng hp vim tc niu qun gim i, si di chuyn c, nc tiu lu thng c, thn li b i. III. Triu chng cn lm sng i mu i th hay vi th. Nhiu bch cu, bch cu a nhn thoi ho: nu c Ly nc tiu em cy tm vi khun (nc tiu gia 1. Xt nghim nc tiu:

nhim khun nc tiu. dng/chc ht bng quang, thng i): > 100000 vi khun /ml:nu nhim khun nc tiu. Lm khng sinh . Protein niu(+): c vim thn, b thn km theo. Hng cu bnh thng, trong nhng trng hp a hng 2. Xt nghim mu: cu do thn nc sn xut nhiu erythropoietin th hng cu mu tng, bch cu hi tng. Tc mu lng tng nh. Cc xt nghim sinh ho gii hn bnh thng nu l

si niu qun 1 bn thn bn i din b tr. Xt nghim sinh ho c nhiu bin i tu mc thn nc v suy thn: ure, creatinin tng, ri lon nc in gii Na+, K+ tng, toan ho mu, d tr kim gim, pH mu thp. IV. Chn on hnh nh: 18

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


1. Chp h tit niu khng chun b: Bng thn to. Pht hin si niu qun 1 bn hay 2 bn (93 - 95%) tr

trng hp si urat. Khi thn to qu c th y niu qun, si v pha i din trng vi ct sng kh nhn thy si, hoc nhm chn on si niu qun bn khng c thn to. 2. Siu m: nh gi tnh trng nhu m thn, niu qun, mc L phng tin chn on tt si niu qun ngay c si nc. urat, nhng kh pht hin si 1/3 gia v vng rut v khung chu. Phn bit vi bnh thn c nang. Thy chc nng thn bn c si b gim, mt: 3. Chp UIV: + Bng thn bn tc thng m nt hn. + i b thn gin rng. + Niu qun phnh, gin ngon ngoo. nh gi chc nng thn thn bn i din. Khi c si niu qun 1 bn thn bn i din s b tr. Trong cc trng hp ny thn bn c si ngm thuc km hay khng ngm thuc cha hn l thn mt chc nng. Cn theo di nhng phim chp chm sau 60 90 120 pht nh gi c chc nng v hnh th i b thn nc. Cc trng hp si niu qun 2 bn cng phi chp UIV chm nh gi c ng chc nng v hnh th thn. Nu 2 thn khng ngm thuc trong cc phim chp chm 120 180 pht s kh khn cho thi x tr. Chp ng v phng x vi 99mTcDTPA cho php nh gi ng chc nng thn tng bn khi UIV khng ngm thuc.

19

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Nu chc nng thn < 5% th chc nng lc ca thn khng cn. 4. CTscanner: cc trng hp cha r rng. V. Chn on mc thn nc: Da trn lm sng v chn on hnh nh ch yu l siu m v UIV, chia 4 : 1. 1: thn to hn bnh thng, thn gim tit thuc (chm sau 15 pht), i b thn gin r hnh chu, nhu m thn dy hn 10mm. 2. 2 : thn to r rt 12x10cm, thn gim tit thuc ( chm sau 30 pht), i b thn m gin hnh chm nho (ng knh 2cm), nhu m thn 10 5mm. 3. 3: thn to r rt 15x12 cm, thn gim tit nhiu ( chm sau 45 pht) i b thn m hnh qu bng bn (>2cm) nhu m thn 5 3 mm. 4. 4: thn to r rt, chc nng thn gim nhiu, khng tit thuc (chm sau 60 pht), khng thy hnh i b thn, nhu m thn di 3mm hoc khng o c. VI. X tr : 1) Nhanh chng chn on v x tr khn trng thn nc. 2) Loi b yu t gy tc: ly si niu qun. 3) Chng nhim khun sm, chnh xc v tch cc nu khng thn nc s chuyn sang thn m gy hu hoi nhu m thn, hu hoi ton b thn. 4) Chng ri lon cn bng nc, din gii: chng mt nc, tru mch trong trng hp c i nhiu trn 2,5l/24h bng cho ung v truyn tnh mch bng dung dch thch hp. 5) Cha suy thn bng ch n gim m hoc lc mu ngoi thn. 6) Ch nh ngoi khoa ng. 20 1. Nguyn tc:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2. iu tr ngoi khoa: Ch kh nng bo tn, ht sc hn ch ct b thn. a. Phu thut bo tn thn: khi chc nng thn cha b mt hon ton (bao gm c trng hp UIV bi tit chm 60 120 pht), nhu m thn cn dy 3 5 mm, nc tiu c vi khun N < 10 4 /ml. Thn nc 1 2: tn si ngoi c th, ni soi niu qun, m ly si, phc hi lu thng niu qun n thun hay t thng niu qun. Thn nc 3 4: m ly si niu qun, phc hi lu thng vi ng thng niu qun hay dn lu thn m bo an ton cho phu thut. Trng hp c cht hp niu qun thc s (khi phu thut thm d niu qun ng thng 8 Ch khng thng) c th ct on hp niu qun ni tn tn trn ng thng niu qun, hay dn lu tm thi v chuyn bnh nhn n cc trung tm ngoi khoa tit niu. Si niu qun hai bn cn nh gi ton trng, cn nhc can thip c 2 bn trong 1 ln m. b. Ct thn ch c ch nh trong cc trng hp thn nc 4 (20 25%) v khi thn mt ht chc nng ch cn l ti cha nc tiu, thn bn i din b tr hon ton. Thn m I. i cng: 1) Si niu qun l 1 cn tr dng nc tiu d tc hon ton hay khng hon ton gy ng nc tiu v nhim khun ng tit niu do cht hp. 2) V tr cht hp: Thng gp 1/3 gia ngay st trn ng mch chu, 1/3 di st bng quang. Trong qu trnh vim nhim cc thng tn vim x vim mc, di nim mc 21

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


n c thnh niu qun s gy cht hp ngay ti ch si niu qun. 3) Khi si tc khng hon ton: nc tiu c, thn to t. Khi si tc hon ton: thn to cng, nhu m thn gin mng c khi nh mng nilon thnh 1 bc cha ng nc tiu (500 530 ml). 4) Thn m l tnh trng si niu qun tc gy ng v nhim khun nc tiu do qu mun khng iu tr. II. Gii phu bnh: Thn m thng to chc, t khi teo nh. Khi m c th thy i b thn gin rng cha y m trng, c nh nc vo go, nh sa, i khi c mu nu nh sa chocolate do hoi t chy mu ln m. Nhu m thn b ph hu, cc ng thn cng gin mng thnh nhng hc cha y m. Lp v thn dy x ho bao bc nhng m to nh khc nhau, v cc lp m xung quanh dnh vo v thn. Hoi t nhu m thn c th khng hon ton nhng do apxe ri rc nn lm hng thn, bnh nhn sng ch yu vi thn bn i din. III. Triu chng lm sng: 1. Bnh nhn c bnh s si niu qun vi nhng cn au qun tht lng v nhim khun nhiu t. 2. C nng: au tht lng tri ln cng tc, khng n ng c. i nc tiu c nh nc vo go hay nh sa. Cc triu chng ca si niu qun km theo. Th trng gy st, da xanh, thiu mu st cao rt run

3. Ton thn: 39 - 40C kh iu tr. Tng huyt p: tng nh hoc trung bnh do thn tng tit Renin hoc do gi nc, gi mui. a phn khi loi b si niu qun th huyt p tr li bnh thng, 1 s trng hp tng cao phi ct b thn mi iu chnh c. 22

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Suy thn cp. Suy thn mn tnh c 2 bn: trng hp thn nc c 2

bn ko di. + Hi chng ure mu cao. + Hi chng thiu mu: da xanh, nim mc nht, mch nhanh. + Ph. + Trng hp nng (suy thn giai on cui khng hi phc): ting c mng tim, kh th toan huyt, xut huyt, i lng, chng bng: hn m, t vong. 4. Thc th: Khm thy thn to cng, chc, rt au t di ng (nh 1 u thn) khc vi thn nc (thn cng mm, c th di ng c). C tht lng ph n ty do thm nc tiu, m ra Phn ng thnh bng vng tht lng. Xt nghim mu: quanh thn. 5. Cn lm sng: + Hng cu gim, bch cu tng ch yu l a nhn trung tnh v lympho. + Tc lng mu cao. + Ure mu, creatinin mu bnh thng hay tng nh (do thn bn i din b tr), c th tng cao nu c suy thn. Xt nghim nc tiu: + Bch cu thoi ho nhiu, hng cu (+++) + Vi khun: E. coli hoc Proteus s lng N >10 4 /ml. Xquang h tit niu khng chun b: c vng tht lng Siu m: niu qun i b thn gin to, cha dch m, bng thn to v si niu qun. m m khng ng u, nhu m thn mng. Pht hin

23

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


si niu qun. nh gi mc thn m: nh vi thn nc: 4 . Chp UIV: + nh gi chc nng thn bn c si: gim hoc mt: bng thn bn tc thng m nt hn, i b thn gin rng, niu qun phnh gin ngon ngoo. + nh gi chc nng ca thn bn i din. IV. Th lm sng: 1. Th bn cp hay mn tnh: tnh trng nhim khun khng nng (nh st cao), i tiu c tng t nhng ton thn suy sp, gy, da xanh thiu mu. Hng cu, hematocrite thp, bch cu tng cao, tc lng mu cao. 2. Th c khi vng tht lng to, chc, au cn phn bit vi khi ung th thn. 3. Th suy thn ure huyt cao: thn m nc 2 bn. V. Thi x tr: 2) Nhanh chng chn on v x tr thn nc. 3) Loi b yu t gy tc: ly si niu qun. 4) Chng nhim khun sm, chnh xc v tch cc nu khng thn nc s chuyn sang thn m gy hu hoi nhu m thn, hu hoi ton b thn. 5) Chng ri lon cn bng nc, in gii: chng mt nc, tru mch trong trng hp c i nhiu trn 2,5l/24h bng cho ung v truyn tnh mch bng dung dch thch hp. 6) Cha suy thn bng ch n gim m hoc lc mu ngoi thn. 2. iu tr phu thut: a. Nguyn tc: Thn m l tnh trng nhim khun ng tit niu Ct thn c ch nh. 24 trn rt nng. 1. Nguyn tc:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


C khi phi bo tn v thn bn i din l thn bnh l, ch ly si niu qun v dn lu thn m. b. Phu thut bo tn thn: khi chc nng thn cha b mt hon ton (bao gm c trng hp UIV bi tit chm 60 120 pht), nhu m thn cn dy 3 5 mm, nc tiu c vi khun N < 10 4 /ml. Cc trng hp thn m nhim khun cp hay nhim khun huyt, i tho ng, suy thn, th trng bnh nhn suy sp e do tnh mng trong cp cu th ch dn lu thn iu tr ni khoa ri nh gi li tnh trng ton thn, chc nng 2 thn, s can thip trit sau. a. Ct thn m l 1 phu thut kh, cn chun b bnh khi m trnh cc tai bin lm thng tn cc tng hay mch mu.

Suy thn cp I. i cng 1. Si niu qun l 1 trong nhng nguyn nhn gy thiu niu, v niu suy thn cp sau thn. 2. Thiu niu khi lng nc tiu < 400ml/24h, v niu khi < 100ml/24h. 3. Suy thn cp sau thn do si niu qun hay gp si niu qun 2 bn (hoc si thn 1 bn, 1 bn l si niu qun). 4. Si niu qun 1 bn nu v niu thng l thn bn i din bnh l, tuy nhin si niu qun 1 bn gy v niu cng c gp trong y vn gi l v niu phn x. II. Sinh bnh hc: 1. Si gy vim tc niu qun cp tnh ng qu mc thn, trong tnh trng gin i b thn c trc, to phn x ngng bi tit ca thn. Thc cht suy thn cp do si

25

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


niu qun (si tit niu) l suy thn cp sau thn nhng chnh ti thn cng c s thng tn. 2. Nhim khun tc ng ln tnh cht bnh l ca si niu qun lm tng nguy c suy thn cp. 3. Ri lon nc in gii: Na+ tng, K+ tng. 4. Ri lon toan kim: ure mu tng, creatinin mu tng, d tr kim gim, pH mu gim. III. Triu chng: 1) Bnh nhn c bnh s si niu qun (thn), cn au tht lng nhiu ln nhng bnh nhn c din bin bt thng: nhim khun tit niu, hay sau khi i xa, lao ng mt mi gy suy thn cp. 2) au vng tht lng d di hn km theo au bng, bng chng, bun nn, nn nhiu. 3) i t dn n mc ch c 200ml/ngy, hay khng c nc tiu. 4) Thn to. 2. Ton thn: Suy sp nhanh, mt mi, chn n, ng ming, bnh Nim mc nht thiu mu. Tun hon ri lon: nhp tim tng, huyt p cao. Th nhanh nng. Cc triu chng din ra rm r tin trin nhanh trong 2 C th ph phi cp. nhn khng mun n, s ung nc, da kh mt nc. 1. Nhm cc triu chng ca si niu qun:

3 ngy: l m, hn m, vt v. 3. Cn lm sng: 1) Xt nghim mu: Hng cu< 3 triu, bch cu tng cao, mu lng tng cao.

26

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Trong cc trng hp thiu niu, v niu do si niu qun thng ure mu cao gp 2 3 ln bnh thng (> 30mol/l). Ri lon nc in gii nht l K+ >5mEq v trn in tm c ST chnh, km ri lon toan chuyn ho. 2) Xquang h tit niu: si niu qun 1 bn hoc 2 bn hoc 1 bn si niu qun 1 bn si thn. Bng thn to. 3) Siu m: thn to i b thn gin, pht hin si niu qun v bt thng ca thn bn i din. IV. Tin trin v tin lng: 1. V niu 5 7 ngy: iu tr c kh nng phc hi tuy nhin ph thuc theo tnh trng nhu m thn dy hay mng, si niu qun tc hon ton hay khng hon ton. 2. Ngoi 7 12 ngy: iu tr t c kh nng hi phc, t l t vong cao, v nhim khun v hoi t nhu m thn, x ho tin trin sau khi iu tr ly si. V. iu tr: 1) Bi ph thng bng nc, in gii, kim toan. 2) Li niu. 3) H huyt p: thuc chn beta, thuc c ch men chuyn. 4) Khng sinh: Dng khng sinh ph rng khng c vi thn: cephalosporin 3, metrronidazole, fluoroquinolon perflacin tim tnh mch. 5) Phu thut gii quyt nguyn nhn do si. 6) Chy thn nhn to nu cn. 7) Ch n ung, sinh hot hp l. 2. Phu thut: 1) Can thip sm nu ure, creatinin cha qu cao, in gii mu bnh thng: t ng thng JJ, iu tr ni khoa n nh, can thip si niu qun sau. 27 1. Nguyn tc:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2) Nu ure qu cao (>30mmol/l), K > 5mEq/l, bnh nhn ph: lc mu cp cu v can thip sau khi h K, ure, creatinin mu. 3) Phu thut: Gy t ti ch hoc gy t tu sng l tt nht. Ly si dn lu thn l ch yu hoc kt hp ly si niu qun mt hoc c 2 bn, ch m bo lu thng niu qun. Sau m bi ph thng bng nc, kim toan. Theo di hi chng sau m si ngy th 5 7:

+ Tnh trng mt nc v in gii nng + Tnh trng nhim khun sau m: nhu m thn tip tc hoi t nn chc nng thn khng hi phc. + Bi ph khi lng tun hon nhng bnh nhn vn i t, ph tng ln, sau 2 tun mi tin lng c. Kt hp chy thn nhn to trong cc trng hp ure mu Theo di cc ch s nh gi kt qu iu tr v > 30mmol/l, K > 5mEq/l, ph: 1 2ln/tun. tin lng: ure, creatinin mu, ure, creatinin nc tiu, cc thng s kim, pH mu, in gii mu, nc tiu. Cc bin php iu tr si tit niu I. Ni khoa: 1) Gim au: Atropin, papaverin. visceralgine 2) Chng nhim khun: theo khng sinh 2. iu tr thc th. 1) Nguyn tc: mc ch l gip hn si niu qun di chuyn xung bng quang ri ra ngoi. Ung nhiu nc. Truyn huyt thanh. Li tiu nh (khng dng Lasix l mt li niu mnh c 1. iu tr triu chng:

th gy v thn). 28

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


II. Chng vim. iu tr bng th thut: ng dng ch nh trn lm sng thng chia ng tit niu thnh 2 khu vc ch yu: 1. ng tit niu trn:1/3 trn niu qun+ i b thn: bi si thn. 1) Tn si ngoi c th: Ch nh: + Si c ng knh < 2cm. + Hn ch vi si c ng knh > 2cm: phi tn 2 3 ln, kt qu thp hn. + Rt hn ch vi si san h, si qu ln: rt t kt qu. Chng ch nh: + Si qu rn: si cystin, si acid uric. 2) Ly si thn qua da: C th p dng cho mi loi si nhng hay gy bin chng: chy mu, nhim khun 3) Phu thut: a. Ch nh: Si gy bin chng: Si trn thn hoc ng tit niu d dng. Si trn thn bnh l: u thn, lao thn. Si trn bnh l ton thn: tng huyt p, bnh mu X tr cc bin chng hay cc trng hp khng x l c + nc, m thn, chy mu thn.

ca cc phng php trn. b. Phng php: M ly si + kim tra lu thng ng tit niu. M ly si + t ng thng dn lu thn khi c nguy M ct thn khi thn b hu hoi ht chc nng. M v to hnh ng niu (ct, ni).

c tc, hp ng niu.

29

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Si 2 bn: nh gi chc nng thn 2 bn ri phu thut mt bn trc hay phu thut cng lc c 2 bn. 2. ng tit niu di: 1/3 di niu qun+ bng quang + niu o. 1) Ly si qua ng soi niu qun: Dng my soi niu qun t t ngoi vo niu o, vo bng quang ri a ln niu qun cho ti v tr hn si. Lc c th ly hn si cc cch: Kp gp si. Lun si vo r Dormia ri ko ra ngoi. Tn si c hc: Ch yu p dng cho si bng quang

2) Tn si: khng qu ln (4 5cm) bng my tn si c hc hay bp tay. Tn si bng sng xung ng thu in: in cc t trc tip vo si, lm si v thnh mnh nh v ly ra ngoi. Tn si bng sng siu m, laser lm si nh v ly ra i vi si niu o, cn y si vo bng quang bng ngoi. cc phng php tn si ly si ra l ch yu. t ng soi ln niu qun ti v tr c si. t in cc Laser st hn si. My hot ng ng thi cho dng nc chy vo lin tc ra cho cc mnh vn si ri xung. 3) Phu thut: ch nh: Si gy bin chng: nhim khun ng niu nhiu, Si trn bnh nhn b hp ng tit niu di, khng Si trn bnh nhn c bnh l ng tit niu di nh nc, m thn t c my, x c bng quang, hp niu qun. bnh u x tin lit tuyn, u bng quang, ti tha bng quang, u niu qun. 30

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


3. Si niu qun 1/3 gia ngi ta hoc y si vo vo thn tn nu gn on 1/3 trn hoc gn on 1/3 di s c ly ra ngoi qua ng soi niu qun. Si thn I. i cng 1. vit nam si tit niu l mt bnh ph bin ng hng u trong cc bnh l h tit niu, trong si thn cng chim mt t l kh cao (42%). Trn th gii cng rt ph bin, nht l chu u, chu , t hn chu Phi. 2. V dch t: 1) Tui: thng gp tui 30 50. 2) Gii: Nam/n = 2/1. C s lin quan gia gii v tnh cht si ( nam hay

gp si canxiphosphat, canxi oxalat, n hay gp si phosphat amoniaco magnesi) 3) iu kin sinh hot: Ch n nhiu canxi, phosphat, oxalat d hnh Kh hu nng, kh, hn ch lng nc tiu bi tit cng thnh si. d hnh thnh si. 4) Yu t di truyn cng c nhc ti trong 1 s bnh cnh v si cystin, si canxi 3. Nguyn nhn hnh thnh si. 1) Si th pht: c hnh thnh do nguyn nhn nc tiu b tr, l hu qu ca s cht hp ca i thn hoc ch ni b thn-niu qun do bm sinh hay sau cc nhim khun (lao, giang mai). 2) Si nguyn pht: phc tp. Hay gp nht l do ri lon chuyn ho (nguyn nhn ton thn) v do vim nhim

31

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


ti thn (nguyn nhn ti ch). V d: ri lon hp th rut, cng gip, cng cn gip, ung th di cn 3) Vin si: S lng, hnh dng, kch thc a dng. Cu to: Si canxi (oxalat, phosphat), si phosphat-

amonico-magnesi. (trn thc t cc thnh phn thng cu to vi nhau to thnh si) V tr: hay gp b thn v d tn thng nn nguy him. 4. Si thn gy ra nhiu bin chng: nc, m thn, vim thn, x ho thn v c th dn n t vong. 5. Chn on ch yu da vo lm sng cn lm sng (siu m, UIV, cc xt nghim pht hin bin chng). 6. Trong nhng nm gn y c nhiu tin b trong hiu bit mi v bnh l ca si, ng thi phng php iu tr si tit niu c nhiu bin i to ln, nh c tin b trong lnh vc quang hc, siu m v laser, cc phng php iu tr ni khoa v ngoi khoa c hiu lc v y ha hn, phng php phu thut kinh in thu hp dn phm vi ch nh m thay th dn bng 1 s phng php hin i nh tn si ngoi c th, ly si thn qua da, tn si v ly si qua ng soi niu qun. II. Lm sng Mt s bnh nhn c si thn khng c biu hin lm sng m ch tnh c pht hin l si thn khi i khm 1 bnh khc. bnh nhn si thn c biu hin lm sng thng c tin s i ra si. 1. C nng: 1) Cn au qun thn: V tr:

32

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


+ au vng thn bn bnh lan xung dc theo ng i ca niu qun xung bng quang v ra tn u ngoi ca b phn sinh dc. + i khi si mt bn li kch thch gy au c 2 bn hoc gy au bn i din. Tnh cht: + Thng xy ra sau khi: lao ng, c ng qu mnh, qu sc, i li nhiu, s dng thuc li tiu qu mnh. + au d di nh dao m, ln ln. 3. i mu ton bi. 4. i m ton bi. 5. Hi chng sau phc mc: Bng chng, nn, b trung i tin (d nhm vi tc rut) 2. Thc th: Vng tht lng n au. Thn to: chm thn, bp bnh thn (+)

3. Ton thn: 2. Khi c nhim khun: st cao, mi kh, li bn, hi th hi. 3. Khi c suy thn:ph, c trng IV. Cn lm sng: 1) Xt nghim mu: Nhm mu. Mu chy mu ng Tc lng mu: tng khi c nhim khun. Ure, creatinin tng trong trng hp c suy thn. Nng Ca mu tng trong trng hp si thn Canxi. C th thy tr hng cu, bch cu trong nc tiu. Cc tinh th, pH nc tiu. Vi khun niu: xc nh c bin chng nhim khun 1. Xt nghim:

2) Xt nghim nc tiu:

khng. 33

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


3. Siu m: nhm xc nh: Hnh nh cn m ca si (k c si khng cn quang). dy nhu m thn. gin i b thn. c ch nh rng ri trong trng hp bnh nhn c

thai, hoc khi thn khng ngm thuc cn quang. 4. Xquang h tit niu khng chun b: Thng chp phim thng thy cc hnh nh cn quang ca si: cc mc cn quang gim dn tu thuc thnh phn ca si: si canxi phosphat> si oxalat > si phosphat amoniac magnesi Ring si uric v si xanthin khng cn quang. chn on phn bit gia si thn cn quang vi cc hnh nh vi ho khng thuc si thn nh: si mt, si tu, thoi ho ct sng, hch vi ho.. 5. UIV: Mc ch: nh gi hnh thi v chc nng thn. Chp phim chm 3 6 12h hoc chp nh git vi liu

thuc cn quang nhiu gp 2 ln thng thng. 6. CTscanner h tit niu. V. Trong trng hp kh chn on. Pht hin nhng tn thng phi hp nh u Cc bin chng ca si thn: Si thn gy tr nc tiu pha trn gy ra: 1. Nhim khun tit niu. 2. nc thn. 3. m thn. 4. p xe quanh thn 5. Suy thn: suy thn cn kh nng hi phc, suy thn khng cn kh nng hi phc. 6. Cao huyt p do nguyn nhn thn. 34

7. Chp niu qun b thn ngc dng: t c dng

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


VI. iu tr: phi hp gia iu tr ni khoa v ngoi khoa: iu tr triu chng: 1. iu tr ni: + Gim au: visceralgine, atropin1 ng tim bp su. + Chng nhim khun: s dng khng sinh thch hp theo khng sinh . iu tr thc th: c vai tr quan trng trong phng bnh v phng ti pht bnh. Nguyn tc: + Ung nhiu nc, s dng thuc li niu nh, chng vim nhm mc ch cc hn si nh c th ri xung v i ra ngoi. + Hn ch tng tit tinh th gy ra do ngun thc n hoc ri lon chuyn ho (thc n gim lng Ca, purin ) + Chng nhim khun, c bit l nhng loi vi khun tc ng ln ure niu (v d: proteus) + Gii quyt pH: toan ho i vi si nhim khun, kim ho i vi si acid v si cystin. + Gii quyt nguyn nhn: Ct b u tuyn cn gip. Loi b cc nguyn nhn gy ng v nhim khun (di tt bm sinh, bng quang thn kinh). + S dng cc loi thuc lm tan si (cn nhiu tranh lun). 2. iu tr ngoi khoa: Nh c tin b trong lnh vc quang hc, siu m v lazer, phng php phu thut kinh in thu hp dn phm vi ch nh m thay th dn bng 1 s phng php hin i nh tn si ngoi c th, ly si thn qua da, tn si v ly si qua ng soi niu qun. 2. Tn si ngoi c th:

35

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Nguyn tc: sng xung ng tp trung vo 1 tiu im (si thn) vi p lc cao lm v si, sau cc mnh ny c bi tit ra ngoi. Ch nh: + Tt nht si < 2cm i b thn hoc niu qun trn. + Si > 2cm: tn 2 3 pht, kt qu thp hn. + t kt qu vi si ln, si san h, si qu rn (cystin, acid urric) 3. Ly si thn qua da: Ch nh: c th ly hu ht cc loi si. Yu cu: k thut thnh tho do d bin chng: chy

mu, nhim khun. thng i trng 4. Phu thut kinh in: Ch nh: + ng bi xut b tc. + Nhim khun nng. + Suy thn v niu. + e do tnh mng bnh nhn. Phng php: + M b thn ly si b di hay mt sau b thn (i vi si b thn thng thng). + M b thn trong xoang hay m rng ng rch b di vo nhu m thn (si san h/ si b thn trong xoang). + Rch nhu m thn ly si cc i thn (i vi si san h: rch nhu m thn m rng theo dc b ngoi thn) c th kt hp vi h nhit ti ch. + Ct thn bn phn ly c si i b thn v loi b nhu m bnh l. + Ct thn ton b nu thn cm. Si h tit niu I. i cng 36

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


1. Si h tit niu l mt bnh l ngoi khoa thng gp, hay ti pht. Nam gii gp gp 3 ln n gii. Vit nam: si thn ~ 40%, si niu qun ~ 28%, si bng quang ~ 28%, si niu o ~ 5,43%. 2. Thnh phn ca si. 1) Hay gp l canxi oxalat (70 80%) > canxi phosphat > amoni magne phosphat > acid uric 2) C lin quan vi gii: Nam: hay gp l si canxi N: hay gp l si amoni magne phosphat (do nhim

khun). 3. Nguyn nhn hnh thnh si 1) Si c 2 nhm : nguyn pht v th pht Nguyn pht: ri t thn xung. Th pht: Do gen: hay gp si cystin, acid uric. Do d dng ng tit niu, ri lon chuyn ho,

2) Yu t di truyn:

ng, nhim khun. 3) a d, kh hu: Nng, nhit i (hay gp si tit niu hn vng n i). 4) Ch n: nhiu purin, oxalat, canxi. 5) nhim khun, nm bt ng lu ngy. 4. Sinh l bnh: 1) Thuyt qu mc bo ho: 2) Thuyt v yu t c ch s kt tinh 3) Thuyt v cu trc ct hu c. 4) nhim khun. 5) Thuyt hp thu cc cht sinh si. 5. din bin ca si: 1) Si nh nhn (d < 4mm) c th thot ra ngoi c qua ng tiu. 37

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2) Si thn: di ng/ khng di ng khng di ng:

+ C nh i thn gin tng ng 1 nhm nhu m thn. + C nh b thn, gy tc nghn ch ni b thn niu qun i b nhu m thn gin. Nu trng hp c nhim khun rt d hoi t nhu m thn, nhim khun huyt. 2) Si niu qun: hay gp nht on 1/3 di niu qun, nu tc 2 bn nhim khun. 3) Si bng quang: II. Thng l th pht sau u x tin lit tuyn, hp niu Tin pht: gp trong th bng quang thn kinh. Chn on: nh gi tn thng gii phu, v tr, kch thc, s lng nh gi bin chng (nh gi chc nng thn, mc nh gi mc ri lon chuyn ho, nguy c o, hp bao qui u. 4) Si niu o: t gp, tr trng hp c hp niu o. 1. Mc ch: si. suy thn (UIV, sinh ho), nh gi mc nhim khun) phng v iu tr. 2. Lm sng: 1) Tin s gi : nhiu ln i ra si. 2) C nng: Cn au qun thn: + V tr: Vng tht lng, c bit khi si di chuyn gy tc. + Tnh cht: au d di vng tht lng, lan xung di theo ng i ca niu qun v lan ra b phn sinh dc ngoi 38

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


(au c tnh cht tng cn). au tng khi vn ng, lao ng nng nhc, gim khi ngh ngi. i tiu: + V niu gp trong trng hp si niu qun 2 bn/ si niu qun gy tc bnh nhn c 1 thn. + i but: + i mu ton bi : tng khi vn ng, gim khi ngh ngi. + i c (m): trng hp c km nhim khun tit niu. Bng chng, nn ma, chn n, b trung i tin (hi chng sau phc mc: gi tc rut). 3) Ton thn: Trong giai on u khng c biu hin g c bit St: st cao rt run gp trong trng hp nhim khun, vim thn b thn. i khi c nhim khun tit niu nhng khng c st. Ph: Gp trong trng hp suy thn: ph trng, mm, n lm. 4) Thc th : Nc tiu hng hay c. Hai h tht lng cng tc, n au. Chm thn, bp bnh thn c th (+). n im niu qun au

3. Cn lm sng: 1) Xquang h tit niu khng chun b ( thng, nghing): Nhm pht hin si tit niu c cn quang (90% cc trPht hin hch vi ho, cc vi ho tiu ho, si mt, si ng hp). tu cn quang (chp phim nghing). Hnh nh si tit niu nm trn ng i ca h tit niu, sau ct sng. 2) Chp UIV nh git: 39

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Pht hin si c cn quang v khng cn quang. nh gi chc nng thn bn c si v thn bn i nh gi cc tn thng phi hp. Trng hp thn ngm thuc chm, phi chp phim chm

din.

60 120 180 pht. 3) CTscanner h tit niu. nh gi, pht hin si nh, si khng cn quang. Pht hin u ng tit niu: u nh b thn, niu qun U cn gip.

4) Chp h tit niu ngc dng: nay t dng do d nhim khun. 5) Chp ng mch thn: nh gi s phn b ca ng mch thn, pht hin d dng (t dng). 6) Siu m: ch nh trong trng hp b tr cho Xquang hoc khi chng ch nh chp Xquang v UIV: c thai, v niu, suy thn. Cho hnh nh si cn m, hnh nh ng tit niu. 7) Xt nghim: xt nghim c bn: nhm mu, mu chy mu ng xt nghim chn on:tr hng cu, tr bch cu trong xt nghim tm bin chng:

nc tiu. + nh gi chc nng thn: ure, creatinin. + ri lon chuyn ho nc, in gii: phn tch thnh phn canxi, phospho, oxalat, pH nc tiu, nh lng hormon tuyn cn gip. + nhim khun: bch cu, mu lng. III. Chn on phn bit: 1) Tc rut 40 1. Cn au qun thn:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2) Vim rut tha 3) Vim phn ph 4) Vim i trng. 2. Trng hp Xquang c cn quang: 1) Hch vi ho 2) U ngoai bng. 3) Si ti mt. 4) Si tu. 3. Trng hp khng c hnh nh cn quang: 1) U b thn v niu qun. 2) si nhu m. IV. Tin trin: si h tit niu nu khng c iu tr s c rt nhiu bin chng: 1. Vim i b thn. 2. Vim thn k. 3. nc m thn. 4. Thiu niu, v niu, 5. Tng huyt p, nhim khun huyt. V. Phng bnh: 1. iu chnh ch n ung, ung nhiu nc > 1,5 l/ngy. 2. Trnh nhim khun tit niu. 3. iu chnh pH tu loi si. 4. phu thut, iu chnh d dng bm sinh, mc phi, phu thut ct b u tuyn gip, yu t ng. VI. iu tr: phn iu tr si thn, si niu qun v suy thn cp Chn thng thn I. i cng: 1. Chn thng thn trn th gii v Vit nam do tai nn giao thng v sinh hot c xu hng gia tng.

41

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2. Chn thng thn c bnh cnh lm sng thng rt phc tp do chn thng thn thng nm trong bnh cnh a chn thng (chn thng bng, ngc, v xng chu). Mt chn thng bng c th c cc triu chng che lp triu chng ca chn thng thn hoc ngc li mt chn thng thn nng c th b st chn thng bng km theo. 3. Nhng chn thng trc tip vng tht lng (85 90%) (tai nn giao thng t, xe my (65 70%), cng xe th s p vo vng tht lng, ng t trn cao, ng cu thang vng tht lng p vo vt cng) l cc chn thng mnh gy chn thng thn. 4. Nguyn nhn gin tip (5 10%) nh ng cao, cc ng tc th thao mnh lm cc tng trong bng v thn b dn mnh cng c th gy chn thng thn. 5. Chn thng thn gp nam nhiu hn n t l 3/1, gp mi la tui tuy nhin 16 45 tui chim t l cao 75 80%, tr em di 16 tui 12 14% 6. Vic chn on v thi x tr chn thng thn th ngoi vic da trn lm sng th ch yu l da trn chp UIV nh git, chp ng mch thn chn lc, chp CTscanner hoc siu m. i khi trong cp cu vic t sode bng quang cng c ngha rt ln trong chn on. 7. Thi iu tr chn thng thn trn th gii c nhiu quan im chung, trong c phu thut bo tn. II. Gii phu bnh. 1) 1: ng dp thn: L mc chn thng thn nh, dp nhu m thn di bao, khng rch bao thn, khng c t mu quanh thn, c th t mu di bao thn. Gp 70 75% cc trng hp chn thng thn v tin trin thng t khi. 1. Chatelain (1975 1982) chia thnh 4 loi:

42

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2) 2: Dp thn: Dp nhu m thn ch yu vng v km theo rch bao thn, c th lan ti tu thn thng vi i b thn gy t mu nhu m quanh thn v i mu. Gp t 15 20%. L v thn mc trung bnh , mnh v khng b tch ri v khng mt nui dng. Gy t mu quanh thn v i mu mc va, c th iu tr ni khoa c kt qu. 3) 3: V thn: V thn thnh 2 hay nhiu mnh, gy t mu ln quanh thn sau phc mc, cc thn v c th tch ri khi thn v khng cn c ti mu, cc mnh xa vi nhau v mt cp mu. Loi htng tn ny nng, gy t mu quanh thn ln v i mu nhiu (7- 10%). 4) 4: t cung thn mt phn hay ton b lin quan n n mch mu, b thn, niu qun (3- 5 %). Loi ny cn pht hin sm v m v n nguy him ti tnh mng bnh nhn v mch mu nui dng thn. 2. Moore 1989 phn 4 mc : 1) ng dp thn. 2) Dp thn nh. 3) Dp thn nng. 4) Tn thng mch mu cung thn. 3. Mc Aninch, Caroll 1989, AASTRIS 1999 chia chn thng thn thnh 5 : 1) 1: ng dp thn: chn thng thn gy ng dp t mu nng vng v di bao thn. 2) 2: Dp thn nh: chn thng thn vng v cha lan su ti vng tu thn. 3) 3: Dp thn nng: Chn thng thn vng v lan su ti vng ty thn km theo rch i b thn. 4) 4: V thn: thn v thnh 2 hay nhiu mnh, phn thn b v mt s nui dng ca cc mch mu chnh ca thn. 43

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


5) 5: Tn thng cung thn, cc ng tnh mch vng rn thn. 4. Cc cch phn loi khc: 1) Chn thng thn thng gp 1 bn, thn tri v thn phi c t l gn nh nhau, thng tn c 2 bn thn rt t gp. 2) C th gp chn thng thn bnh l mc phi hay bm sinh nh si thn niu qun, thn nc do hi chng khc ni b thn niu qun, thn a nang, thn mng nga, c bit trn 1 thn duy nht cng c t l 1 1,5%. 3) Tn thng trong cc trng hp a chn thng: chn thng thn phi hp vi cc chn thng khc (chn thng bng, gy xng) 45 60%, c bit l chn thng bng: lch, gan, mc treo, thng i trng, rut non 20 25%. III. Lm sng : 1. C nng: Sau mt chn thng vo vng tht lng hay bng: 1) au vng tht lng: Trong a s trng hp chn thng thn u biu hin au tng theo tin trin tn thng thn do khi mu t au lan ln gc sn honh, lan xung h chu (do nc au tc v co cng c vng tht lng. to, nc tiu thm ra vng quanh thn tht lng. tiu trn ra khoang sau mng bng). 2) Hi chng sau phc mc: bng chng, nn l du hiu thng gp trong chn thng thn, chng t dp thn gy t mu, nc tiu sau phc mc. Bng chng cn ko di trong tin trin ca chn thng thn v cng l triu chng lm nhm ln kh khn cho s pht hin tn thng cc tng trong bng. 44

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


3) i mu: L biu hin ca tn thng thn thng vi ng bi tit chim 85 90% s chn thng thn. i mu i th ton bi c th nh hay nng: nc tiu hng ti mu mu hay mu cc. Tuy nhin mc i mu khng buc phi tng xng vi thng tn thn v c th c mt lng mu khng t t quanh thn sau phc mc hoc cc trng hp mu cc bt tc niu qun, hoc t cung thn khng i mu. Mt s t i mu vi th: khi xt nghim nc tiu v chn on hnh nh mi pht hin c. i mu cn c ngha theo di din bin ca chn thng thn: i mu ti tip din nng ln l tip tc chy mu, mu nu sm v vng dn l c kh nng t cm mu c. i mu thng xut hin ngay sau tn thng thn nhng cng c th gp i mu ti pht sau 5 7 ngy hay sau 2 tun gp trong cc trng hp nhu m thn dp nt c th thiu mu hoi t khng th lin khi. Cc chn on hnh nh c th xc nh sm cc tn thng ny v phi can thip ngoi khoa. V nguyn tc, trc mi trng hp chn thng thn phi xem nc tiu ca bnh nhn nh gi chnh xc i mu ca bnh nhn. 2. Thc th: 1) Co cng na bng bn tn thng: do mu t kch thch sau mng bng. 2) Khi mu t tht lng: H tht lng y hn bnh thng, cng n v rt au. Nu s thy co cng vng tht lng chng t v bao thn mu chy ra quanh thn.

45

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Theo di tin trin khi mu t tht lng c ngha quan trng nh gi tin lng mt trng hp chn thng thn. Khi mu t cng tng nhanh th chng bng v co cng na bng cng r. 3. Ton thn: 1) Shock gp trong 25 30% cc trng hp chn thng thn. Xy ra khi c cc thng tn nng nh: Dp nt thn, t cung thn(12 15%) hoc cc trng hp a chn thng(15-20%). Biu hin: V m hi, tru mch, l m, huyt p tt (<90/50mmHg), chi tm lnh, CVP: 3 5 cmH2O. 2) Biu hin thiu mu cp: Da xanh, v m hi, mch nhanh, huyt p h, th nhanh nng. Xt nghim: Hng cu h, huyt sc t, hematocrit gim. IV. Cn lm sng: 1. Chp h tit niu khng chun b: c ngha nh gi c th chn thng thn. 1) Bng thn to hn bnh thng, khng nhn r b c i chu. 2) Rut chng hi, gin. 3) Tm cc thng tn khc: Gy xng sn, ct sng. 2. Siu m: 1) Mang li cc thng tin v b thn, nhu m thn, xc nh tn ti ca khi mu t, nc tiu quanh thn. Cho thy nhng hnh nh tn thng: Hnh dng thn khng bnh thng, dp nhu m thn, t mu trong v quanh thn, mt ng vin lin tc bao thn. 2) Siu m chn on cc tn thng 1, 2, 3 r vi c hiu 80 85%, 4 kh nhn nh cc tn thng mch mu. 3) Siu m Doppler mu c th pht hin cc thng tn mch mu, s cp mu hay tnh trng tc mch thn. 46

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


4) Siu m cn gip cho theo di tin trin ca chn thng thn v sau. 3. Chp niu tnh mch cp cu rt cn thit v c th thc hin theo phng php nh git tnh mch. Chatelain, Caroll, Mc Aninch cho rng y l phng php c bn c gi tr cao trong chn thng thn. 1) Mang li thng tin v thn chn thng v thn bn i din. 2) Cho bit hnh thi v chc nng ca thn tn th ng: Cc tn thng i b thn, ct ct cc i thn, hoc trn thuc cn quang ra xung quanh thn. Thn b tn thng nh, va: thy hnh nh ng thuc cn quang ti 1 vng thn nhng ng bi tit vn bnh thng Nu tn thng nng th c hnh mt hay hai i thn b tch ri, thuc cn quang trn ra xung quanh thn hoc khng thy thn ngm thuc do i b thn y mu cc, thn b dp nt hay tn thng ng mch thn. Thn cm khng ngm thuc cn quang: + i b thn y mu cc chon ch. + V hay dp thn nng. + Tn thng ng mch thn. 4. Scanner: Mang li cc thng tin chnh xc nht v cc thng tn thn, c bit l trong trng hp chp UIV thn khng ngm thuc v cc tn thng nhu m thn, cho bit mc thng tn ch nh iu tr. 5. Chp ng mch thn chn lc: L xt nghim cho bit chnh xc tn thng mch mu ch nh trong trng hp thn khng ngm thuc trn thn phim UIV, nghi ng tn thng mch thn. 47

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


V. Hnh nh: Hnh nh ct ct, hnh nh h mu v Chn on: Cn nh gi c mc a chn thng, c thng tn thn hay khng v nu c th thng tn mc no. Ngoi ra cn phi d on c xu hng din bin ca chn thng thn. 1. Trong cc trng hp in hnh c chn thng vng tht lng di sn thng thng in hnh da vo cc triu chng lm sng: 1) Sau mt chn thng vo vng tht lng hay bng. 2) i ra mu. 3) au cng tc vng tht lng. 4) Khi mu t vng tht lng. 2. Trong bnh cnh lm sng a chn th ng, cc du hiu trn c th r rng hay b che lp. Khi triu chng lm sng khng r rng, cc xt nghim cn lm sng, tt nht l CT c ngha v nh gi c tn thng chn thng thn c th. 3. i chiu tn thng gii phu theo Chatelain hay Mc Aninch nh gi mc chn thng thn c thi x tr kp thi hp l. 1) Chn thng thn nh: ng dp thn. 2) Chn thng thn va (trung bnh): dp thn nh. 3) Chn thng thn nng: dp thn nng, v thn. 4) t cung thn: rch hoc t mch mu rn thn: tnh trng shock v mt mu rt nng. Tuy nhin tn thng nh ca ng tnh mch cung thn, tnh trng bnh nhn n nh, chn on hnh nh mi c pht hin. 4. Phc chn on: i mu i th (huyt p tt < 90mmHg + i mu vi th) 48 ng thuc.

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Chp UIV:2ml/kg Vng chn thng ngm thuc bnh thng vng chn thng ngm thuc khng hon ton/thn khng hin hnh r

theo di

siu m/ctscanner/chp ng mch thn

- T mu sau phc mc ln. Nc tiu, thuc cn quang ngm ra ngoi thn. 1 phn thn khng ngm thuc. Tn thng mch mu ln ca thn Phu thut. VI. Din bin v bin chng: 1) Bnh nhn bt au, bng bt chng v c trung tin, i mu nht mu dn, sm mu ri nu vng. 2) Khi mu t khng to, t chc thn ng dp, lin so v x ho. 3) Bnh nhn tnh to dn, khng st. 2. Xu hng khng n nh: 1) au khng gim, bng tip tc chng. 2) i mu tip din: mu cc, mu ti, khi mu t tht lng tng ln, nu c truyn mu hi phc kp thi v khng sinh bnh s n nh, hoc phi chuyn cp cu can thip phu thut. 3. Chn thng nng: V nt thn hay t cung thn: i ra mu d di, khi mu t vng tht lng tng nhanh bnh nhn ri vo tnh trng shock nng, cn phi hi sc v phu thut cp cu ngay. 49 1. Xu hng n nh:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


4. Bin chng: 1) Vim ty h tht lng, vi bnh cnh lm sng nh st cao, au vng tht lng, sng n h sn tht lng. 2) au lng ko di do vim x quanh thn. 3) nc thn do vim x cht quanh niu qun sau phc mc. 4) Nhng thng tn ng tnh mch c th gy phng hoc thng ng tnh mch thn. 5) X teo thn sau chn thng gy cao huyt p. VII. Thi x tr: Trc ht phi nh gi xem bnh nhn c shock hay khng hi sc tch cc. Sau nh gi y , c th chn thng thn s cho hng x tr thch hp, ch yu da trn: + Mc i mu, tin trin ca khi mu t vng tht lng. + Kt qu ca chp UIV, siu m, scanner. 1. iu tr ni khoa: Ch nh: ch yu trong cc trng hp ng dp thn, dp thn nh: + Ton trng bnh nhn n nh, mch, huyt p, hng cu gim nh. + i mu gim dn. + Khi mu t vng tht lng khng tng hn. + UIV: Thn cn chc nng, thuc cn quang ch ng v thn. Phng php: + Bnh nhn nm bt ng ti ging, sn sc iu tr ti ging, truyn dch v mu nu cn thit. + Khng sinh chng nhim khun: phi hp nhm betalactam v nhm aminosid. + Li tiu nh (Lasix 20mg): 1 2 ng/ ngy.

50

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


+ Sau 10 ngy chp li UIV nh gi li kt qu iu tr ni khoa. *Trong mi trng hp iu tr bo tn, cn theo di cht bng lm sng, siu m v UIV. 2. iu tr ngoi khoa: Phu thut chn thng thn l bo tn thn v trnh cc bin chng ca chn thng thn. Ch nh phu thut chn thng thn chim 30 35%, trong phu thut bo tn chim 70 80% (Mc Aninch: 88%) Ct thn bt buc trong trng hp dp nt thn, t cung thn n mun sau 6h chim 14 17% (11,9%: Mc Aninch). 1) Ch nh can thip cp cu: Bnh nhn c du hiu shock mt mu nng. Chn thng thn nng: t cung thn, v thn nng. C thng tn cc tng khc trong bng. Chn thng 3 (theo Chatelain), 3, 4 (theo Mc Cc trng hp iu tr ni khoa khng n nh. Cc trng hp i mu ti pht nng truyn dch,

2) Ch nh can thip sm: Aninch).

truyn mu y : m cp cu tr hon 3 7 ngy sau chn thng. 3) Yu cu gy m hi sc - phu thut: Gy m ni kh qun. ng m sn tht lng theo kinh in, hoc ng Kim tra, nh gi ngay tn thng gip nt, v hay t

trng gia qua phc mc vo trc tip cung thn. cung thn, tu theo thng tn m thc hin cc th thut thch hp: + Ly mu t quanh thn, khu cm mu ng v thn. + Ct thn bn phn nu 1 cc thn b t ri.

51

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


+ Thng tn cung thn: Thng tn c th bo tn c th khu mch mu hoc ghp mch, khu b thn km dn lu b thn. + Ct thn khi v nt thn hay thng tn cung thn khng c kh nng phc hi. Khi ch nh ct thn phi nh gi chc nng thn bn i din trc v trong m. VIII. Chm sc iu dng: 1. Trng hp iu tr ni khoa: 1) Cho bnh nhn nm bt ng ti ging, gii thch cho bnh nhn v tnh trng, ng vin bnh nhn, thng nm bt ng trong 7 ngy. 2) Theo di mch, nhit , huyt p 3 gi/ln. Theo di cc xt nghim mu hng ngy, ghi vo bng theo di. 3) t sonde tiu theo di s lng, mu sc. 4) Thc hin thuc cho bnh nhn: truyn dch, khng sinh, gim au. Li tiu. 5) Lp bilan theo di lng dch vo v ra. 6) Cho bnh nhn n ung khi c trung tin. Nu c din bin xu bo ngay cho bc s iu tr. 2. Trng hp iu tr ngoi khoa: Ngoi vic theo di nh mt bnh nhn sau m ni chung, cn ch : 1) Theo di s lng, mu sc nc tiu. 2) S lng, mu sc dch qua ng dn lu. 3) i vi nhng bnh nhn khu bo tn cn bnh nhn nm bt ng sau m 7 10 ngy. Chn thng niu o o trc I. i cng: 1. Chn thng niu o l 1 cp cu ngoi khoa phi c x tr kp thi trnh cc tai bin phc tp nh b i, vim lan ty nc tiu tng sinh mn v trnh cc di chng phc tp v sau: vim niu o, hp niu o. 52

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2. V phng din sinh l niu o chia lm 2 phn: niu o trc v niu o sau. Chn thng niu o trc v sau khc nhau v: nguyn nhn, c ch chn thng, lm sng v phng php iu tr. 3. Niu o trc c vt xp bao quanh gm 2 phn: 4) Phn di ng trc xng mu: do vt xp t khi b chn thng nn niu o trc t khi tn thng on ny tr khi dng vt khi cng b chn thng trc tip: vt hang b b gy, dao ct. 5) Phn c nh: niu o tng sinh mn( y chu): chn thng niu o trc thng b dp hoc b t on ny. Khi bnh nhn ng ngi ci nga trn vt cng (ng mn thuyn, ng xoc chn trn gin gio), tng sinh mn b p gia vt cng v b di xng mu nn niu o tng sinh mn b tn thng. 4. Chn on c th tn thng ca niu o trc cn da vo chp niu o ngc dng. 5. T 1910 Marion m t t niu o trc v tin hnh phu thut khu ni niu o tn tn trong chn thng, sau Yong Davis (1926), Sabadini(1948), Cukier (1984) tin hnh phu thut khu ni t niu o trc ngay th u trong cp cu, kt qu tr thnh xu hng iu tr t niu o trc. 6. Waterhouse (1971) v Guiolleman Cukier Boccon-Gibod (1980) ch trng dn lu bng quang v soi ct trong hp niu o th sau. II. Gii phu bnh. 4) Niu o tn thng nh, nng, bm dp. C th km theo t mu vt xp. 5) Cn Buck, cn Cole(?) cn nguyn vn. 2. t niu o khng hon ton: 53 1. Dp niu o:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


4) Niu o b t 1/3 1/2 2/3 chu vi ch yu v pha tng sinh mn. 5) Vt xp b dp v. 6) Cn Cole b v, chy mu t vt xp ra tng sinh mn t di da. 3. t niu o hon ton: 4) Niu o t hon ton. 5) Vt xp b t nh ct ngang, 2 u tt xa nhau 1 2 cm. 6) Cn Cole b t toc rng. Chy mu ln t vt xp, mu t ln y chu. III. Chn on: Cn chn on c c thng tn niu o trc hay khng da vo lm sng, v chn on c mc thng tn c th ca niu o da vo chp niu o bng quang ngc dng. 1. Lm sng: thay i ph thuc vo mc thng tn. Sau mt chn thng ng ngi ci nga, bnh nhn c th ngt i 3 5 pht, khng ngi dy c, khng i li c ngay. 4) Dp niu o: au nhi vng y chu. Vn i c, nc tiu u bi, hoc chy mu ra

ming so, s lng t l biu hin c tn thng niu o. Mu chy khng t ngng, k c khi bnh nhn ly tay p vo vng b tn thng. T mu nh y chu hay khng. n vng y chu au t, khng lm mu chy ra

ming so. 5) t niu o khng hon ton: Chy mu niu o: chy mu ra ming so t nhin, khng t ngng, k c khi bnh nhn ly tay p vo vng b tn thng. 54

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Mu t di da tng sinh mn hnh cch bm, c th lan B tiu trong nhng gi u c th do phn x tng Vng y chu au cng n, bm dp, n au chi v rng 2 bn bn, bu cng to. sinh mn hay do t niu o. lm cho mu chy ra ming so. 6) t niu o hon ton: Chy mu niu o: chy mu ra ming so nhiu. Cng au cng d chy mu bnh nhn cng hong s bp cht ly dng vt tng cm mu nhng bung tay ra mu cc c th cng bi y ra nhiu hn. Mu t ln di da tng sinh mn lan rng 2 bn bn hnh Vng y chu au cng n, bm dp, n au chi. B tiu thc s, bng quang cng. cch bm v ra pha trc. Bu cng to.

2. Cn lm sng: 4) Xquang khung chu: c th thy cc tn thng xng vng y chu. 5) Chp niu o bng quang ngc dng: Bnh thng: niu o l mt ng ng u, gin t ngoi vo tn ti cng ca niu o sau, sau hi hp li ch cc c tht trc khi lan to vo bng quang. Ch c hnh nh thuc cn quang trn ra ngoi niu Hnh nh thuc cn quang ng y chu: Nu t o: Dp hoc t niu o khng hon ton. th c th t niu o khng hon ton, nu nhiu l t niu o hon ton. IV. Bin chng: 1. B tiu: Sau 2 4h bnh nhn cn tc vng h v v b i (bnh nhn mun i tiu m khng tiu c). Lc u l phn x t v do au, v sau c tht c bng quang niu o co li v bnh nhn b i thc s. 55

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2. Vim ty nc tiu tng sinh mn: R nc tiu sau 6 9h do bng quang cng qu mc. Mu v nc tiu thm trn ra, ph n vim lan ty nc tiu tng sinh mn: c th e do tnh mng bnh nhn. 3. p xe tng sinh mn: khi vim ty nc tiu tng sinh mn d iu tr khng sinh vn phc tp, c th gy bin chng p xe v r nc tiu tng sinh mn v sau rt phc tp. 4. Hp niu o trc: nhng trng hp t niu o trc hon ton hay khng hon ton cha x tr phc hi niu o ngay th sm mun niu o tn thng s x ho hp lng niu o hon ton hay khng hon ton. V. X tr: Da vo lm sng v chp niu o bng quang ngc dng. 1. Khi bnh nhn t i tiu c: nc tiu trong hay c t mu (nc tiu u bi): Theo di, khng thm d thng niu o. iu tr bo tn: chm lnh tng sinh mn, gim au, Sau 2 tun chp li niu o ngc dng ( tuyn chuyn

khng sinh. khoa)(?) nh gi kt qu iu tr v theo di, hoc nong niu o kim tra v theo di phng hp niu o v sau. 2. Khi bnh nhn khng i tiu c: 4) tuyn c s khng c chuyn khoa: B i, bng quang cng, khng chy mu niu o nhiu: thng bng quang v trng v nh nhng(?) tho nc tiu, c th t thng ti ch 1 3 ngy, gim au, khng sinh. Sau khi rt ng thng, chp niu o kim tra (hoc nong th).(?)

56

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


B i, bng quang cng, chy mu niu o nhiu: m thng bng quang (hay cystocatheter) n thun hoc kt hp t ng thng niu o. B i, bng quang cng, chy mu niu o t mu tng sinh mn: m thng bng quang, m tng sinh mn ly mu t, cm mu. Sau chuyn v cc trung tm chuyn khoa tit niu iu tr phu thut th 2 sm (3 7 ngy sau chn thng). 5) tuyn chuyn khoa: Chn thng niu o chy mu niu o (t mu tng sinh mn): chp niu o bng quang ngc dng chn on t niu o trc hon ton hay khng hon ton sau dn lu bng quang hay cystocatheter.

- Nu khng c mu t tng sinh mn t ng thng


trong 2 tun. Khu ni niu o th sau. Nu c t mu tng sinh mn: m tng sinh mn bc l vt xp, ct lc cc m dp nt cm mu, khu ni niu o th u. 3. iu tr di chng: Vim lan ty nc tiu: dn lu bng quang hay cystocatheter, rch rng tng sinh mn tho nc tiu, can thip niu o th sau. Ap xe r nc tiu tng sinh mn: dn lu bng quang hay cystocatheter, rch p xe tng sinh mn dn lu, can thip niu o th sau. Hp niu o trc: ct ni niu o tn tn theo phng php Marion Harrison(?) hay ni soi ct x niu o. t niu o sau I. i cng 57

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


1. V gii phu niu o chia lm 2 phn: niu o trc v niu o sau. Chn thng t (dp) niu o trc v sau khc nhau v: nguyn nhn, c ch chn thng, lm sng, phng php iu tr. 2. t niu o sau l 1 trong cc tai bin ca v xng chu (chim t l 10 15%). 3. Chn thng v xng chu thng trong bnh cnh a chn thng (25 30%) c shock mt mu v tn thng cc tng phi hp. t niu o sau b che lp bi tnh trng bnh nhn nng, nn kh khn phc tp c v chn on v iu tr. 4. Nguyn tc x tr ch yu l hi sc, phu thut cp cu bnh nhn thot khi tnh trng nguy kch, sau phi hp vi cc chuyn khoa xng, hi sc v tit niu gii quyt cc bin chng t niu o sau. II. Nguyn nhn , c ch v tn thng t niu o sau: 1. Nguyn nhn: v xng chu do: 1) Tai nn giao thng va chm xe c nn nhn ng p vng mng xng chu xung nn ng (70 80%). 2) Tai nn lao ng ng cao hoc b p vng mng xng chu (15 20%) 3) V xng chu theo phn loi ca Pennal v Tile 1980 cc loi v xng chu lin quan nhiu n t niu o sau v tn thng ng tit niu di l: V toc xng mu c 2 cung trc ngnh chu mu, ngi mu Toc xng mu. V xng mu 1 bn, toc khp cng chu cng bn hay bn V xng mu v gy xng chu Malgaigne. di lch khng vng (70%).

i din.

58

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2. C ch: v xng chu lm rch cn y chu gia nn niu o sau ch yu l niu o mng b ging ko, t hay di lch. 3. Tn thng t niu o sau: 1) Niu o mng thc s l ng niu o 2 2,5 cm qua cn y chu gia c c tht vn bao quanh, b t hon ton hay khng hon ton: 80%, km theo dp nt c vn. 2) V tin lit tuyn (do b p hay u xng gy chc thng) niu o tin lit tuyn cng b tn thng (510%). 3) Phi hp t niu o mng v tin lit tuyn :10 15%. 4. Phn loi: Cn c vo chp niu o bng quang ngc dng: Loi 1: niu o sau cng gin (17%). Loi 2: t niu o sau t hon ton hay khng

hon ton nhng cn y chu gia cn nguyn vn (17%). Loi 3: niu o sau b t ri cn y chu gia b x rch km theo rch tin lit tuyn v u niu o hnh cng b tn thng (66%) 5. T mu cn y chu v trong khung chu: 1) L nhng tn thng tng i trm trng do ng tnh mch chu qua cn y chu b t v cc mch mu trc bng quang, m ri Santorini, m ri tiu khung b dp t gy chy mu trn cn y chu tiu khung. Ngoi ra cn t mu sau phc mc, h thn, quang bng quang.(?) 2) Tumer Warwich nhn nh cc mc chy mu t mu ln: t mu khu tr trn cn y chu, t mu lan

59

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


rng tiu khung, t mu ln trn cn y chu tin lit tuyn sau xng mu phc mc. 6. Cc tn thng phi hp nh: Chn thng bng (thng i trng, rut non, v gan, lch, dp mc treo rut 20 25%. Chn thng ngc ngc (trn kh mng phi): gy xng 10 15%, lc da rng, dp nt phn mm t mu vng mng tht lng 3 5 %. Tn thng vng i: gy xng, dp nt phn mm. V xng chu t niu o gp trong bnh cnh a

chn thng biu hin tnh trng lm sng nng phc tp. III. Chn on: C ti 2/3 s trng hp v xng chu c tai bin t niu o sau c bnh cnh rt nng, do vy cn trc ht phi xc nh xem bnh nhn c shock hay khng, mc cc thng tn km theo, sau mi xc nh n thng tn t niu o sau. 1. Lm sng: 1) Bnh cnh a chn thng chung: a. Shock mt mu: Vt v, da nim mc nht, mch nhanh > 90, huyt p tt nhiu < 90/60, hng cu, huyt sc t, hematocrite gim chim t l cao (65 70%) i hi hi sc cp cu kp thi. Nguyn nhn: + V xng chu: mt 1,5 2 lt mu. + C v xng chu + chn thng cc tng trong bng. + V xng chu + di chuyn bnh nhn khng ng qui cch. b. Bng chng au, co cng thnh bng: do t mu sau phc mc hoc do tn thng tng trong phc mc, nn c th che lp cc triu chng tai bin tit niu (t niu o sau, v bng quang). 60

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


5) Triu chng t niu o sau v xng chu: a. C nng: - B i: bnh nhn bun i tiu nhng khi i tiu phi rn nu t niu o n thun. Trng hp bnh nhn c shock v v bng quang ngoi phc mc km theo th khi rn tiu au di rn, khng rn, khng i tiu c, mt cm gic bun tiu. Chy mu r ra ming so, au tc vng bng quang, au vng xng chu. b. Thc th: Bm tm vng xng chu. p khung chu, n trc xng mu: au tng. Bng quang cng: kh phn bit vi t mu trc bng

quang do v xng chu v v bng quang, v cc tng trong bng. Ch c t mu trc quanh ra hu mn (khng phi t Thm trc trng au c vng niu o tin lit tuyn mu hnh cnh bm) di c bng quang, c th s thy ch gy xng mu. 6) Trng hp t niu o sau km theo v bng quang th c thm cc triu chng sau: a. C nng: au vng di rn, mt cm gic bun tiu, tiu kh, tia nc tiu yu, khng rn, khng i tiu c, khi rn au lan n di rn. b. Thc th: t mt sonde bng quang (khng lu) sau bm 10 ml huyt thanh ri ht ra nu nu th tch gim nhiu: c v bng quang. Shock mt mu: trng hp v bng quang n km t c bng quang niu o, rch m o: t l t vong cao, phi c cp cu ti phng m, cm mu, tht ng mch chu trong 1/2 bn (+/-) 61

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Vim phc mc nc tiu (v bng quang trong phc mc): + au khp bng, nht l vng di rn. + Cm ng phc mc, phn ng thnh bng khng in hnh nh vim phc mc do tn thng tng trong bng. 7) Triu chng ca v tin lit tuyn: a. C nng: Nng, chy mu ming so t. B i, bng quang cng au tc, bun i tiu d di C th shock mt mu. Thm trc trng: tin lit tuyn cng to, mm. mu

nhng kh tiu do bng quang cha nhiu mu cc. b. Thc th: vng trn cn y chu, ti cng Douglas cng au. 2. Cn lm sng: 1) Xt nghim mu: hng cu gim, hematocrite gim. trng hp c vim phc mc nc tiu do km v bng

quang: bch cu tng, bch cu a nhn trung tnh tng, ure, creatinin mu tng cao. 2) Xquang: Chp bng khng chun b: hnh nh bng chng hi, bng m do t mu sau phc mc hoc c dch trong bng ca tn thng tng trong phc mc. Chp khung chu pht hin cc th v xng chu. Pht hin cc tn thng tng trong bng. Pht hin v bng quang, mu t tiu khung quanh 3) Siu m :

bng quang, mu t trong bng quang. 4) UIV: p dng trong trng hp bnh nhn khng c shock km theo. nh gi: ng tit niu trn

62

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Th bng quang niu o: nh gi tn thng v bng Bng quang bin dng, mo lch, hnh qu l, hnh quang, t niu o. git nc mt. 8) Chp niu o bng quang ngc dng: t ng thng Foley 16 18 vo niu o quy u, T th bnh nhn: nm nghing, 1 chn gp, 1 chn Bm 60 100ml thuc cn quang 30% ngc dng. nh gi: sau bm 3 5 ml nc vo bng ( v tr h thuyn) dui.

+ Niu o tn thng, thuc trn ra ngoi hon ton: t niu o hon ton. + Thuc ng xung quanh niu o: t niu o khng hon ton Khi thy hnh nh niu o bnh thng, a ng thng vo bng quang bm 100 200 ml thuc cn quang chp bng quang nh gi tn thng ca bng quang. 9) t ng thng niu o: hin nay khng dng do y l ng tc thm khm m qung c th gy chy mu, nhim khun, chuyn t t niu o khng hon ton sang t niu o hon ton. IV. Bin chng: 3. Vim ty nc tiu vng trn cn y chu, khoang Bogros, trc bng quang s ph n, thm xung bu cng mng l bin chng nng nht do b st chn on t niu o sau hay x tr khng ng nguyn tc. bnh nhn tuy c phu thut iu tr cc tn thng khc c th ri vo tnh trng Shock khng hi phc nhim khun nng ure, creatinin mu e do tnh mng. 4. Nhim khun do p xe c vng h chu nh. 5. R niu o nc tiu ph ra tng sinh mn. 63

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


6. Hp niu o sau. 7. Vim ch v xng chu. V. Thi x tr: 10) 11) Nhanh chng nh gi tnh trng mt mu v cc Chng shock mt mu: truyn cc dung dch, hoc 8. Nguyn tc: tn thng phi hp. mu bi ph ngay khi lng tun hon. Theo di huyt p, CVP. 12) 13) Bilan cc tn thng, xc nh t niu o sau. Phu thut cp cu tn thng mch mu, v tng

c rng trc, trng hp thng trc trng km theo c th khu thng v phi lm hu mn nhn to i trng xch ma. 14) Sau x tr t niu o sau v cc tn thng h tit niu phi hp. 9. X tr t niu o sau: tu thuc vo tnh trng bnh nhn, c s vt cht, kh nng ca phu thut vin. 15) Dn lu bng quang n thun: L phng php c bn. Ch nh:

+ Tnh trng bnh nhn nng. + Bc s ngoi khoa chung. Mc ch: trnh c cc bin chng nguy him t niu o sau nh ng, vim lan ty nc tiu vng y chu. 16) Dn lu bng quang + t ng thng niu o, cm mu, ly mu t, dn lu mu t iu chnh s di lch ca niu o. Mt s trng hp t niu o sau khng hon ton c th t lin ngay trn ng thng. C tc gi cn ct dy chng mu tin lit tuyn niu o(?)

64

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


iu chnh di lch tin lit tuyn, bng quang b ko ln cao. 17) Dn lu bng quang, cm mu, ly mu t, dn lu mu t, iu chnh niu o, khu ni niu o ngay thid u sm trong cp cu hay sau 3 7 ngy. ng m bng di rn qua xng mu/kt hp vi ng m qua y chu bc l trc tip on niu o mng b t, tch r v 2 pha, ct gn mp v khu ni 2 u tn tn trn ng thng. 18) X tr v bng quang: V bng quang ngoi phc mc:

+ Ct gn mp rch, thng bng quang, khu bng ch Vicryl s 1,2: lp ton b v lp ph thanh c. + Kim tra cc l thng khc, nht l cc l thng nh. + Ly ht mu cc. + Dn lu bng quang mt im lnh. V bng quang trong phc mc: + Bc tch phc mc, ct xn mp rch thng bng quang. + Khu bng quang lp ton b bng Vicryl vi nim mc ln vo trong. + Khu ph thanh c, khu che ph li phc mc. + Dn lu bng quang mt trc bng ng thng Petzer 18 20 Ch t ng gia ngoi phc mc, c nh thnh bng quang vi thnh bng. dn lu Retzius. 19) X tr di chng t niu o sau: p xe tng sinh mn: rch rng tng sinh mn, ct lc, Hp niu o sau:

dn lu, khng sinh. + Hp niu o mng n thun: 10%. + Hp niu o tin lit tuyn: 15 20%. + Hp niu o ton b: 60%. 65

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Sau 3 6 tun xng chu n nh vng, tiu kh t mu, ht nhim khun, tnh trng bnh nhn hi phc, t i li c th tin hnh kim tra xc nh di chng hp niu o sau qua chp niu o bng quang ngc dng, xui dng c thuc cn quang thy hnh nh niu o hp. Phu thut hp niu o sau: + Hp niu o mng n thun < 2cm. Ct on hp. Ni niu o tn tn. t ng thng bng quang niu o 2 tun. + Hp niu o mng > 3m/ hp niu o tin lit tuyn: Ct on x. Lng niu o hnh vo niu o tin lit tuyn theo phng php Solovop ci tin hoc a 2 u niu o ra da, phu thut to hnh niu o th 2.

U ph i lnh tnh tuyn tin lit


I. i cng: 1. U ph i lnh tnh tuyn tin lit l mt bnh thng xut hin nam gii khi tui bt u cao v tng ln song song vi tui th ca ngi dn (trung bnh 60 tui) v l loi u lnh tnh hay gp nht nam gii. 2. y l mt bnh c tn s cao th 2 trong cc bnh v tin lit tuyn din bin bt thng, kh nng p ng, phn ng i vi bnh ca tng ngi rt khc nhau. Do phi chn phng php iu tr thch hp cho tng bnh cnh lm sng c th v phi iu tr tch cc. 3. Bnh gy ra nhiu bin chng t nh n nng. 4. V dch t: Tn s mc bnh tng ln dn theo tui, c bit l khi 45 tui. 66

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Khng c s khc bit v ngun gc, chng tc, thnh phn x hi, ch dinh dng. 5. Mc d ung th tin lit tuyn v u ph i lnh tnh tuyn tin lit hay ngi cao tui v i khi cng xut hin trn cng 1 bnh nhn nhng chng khng c lin quan g vi nhau. 6. iu tr u ph i lnh tnh tuyn tin lit da vo c im ca bnh v din bin ca bnh: + iu tr ni khoa: gii quyt 1 s bin chng thng thng. + iu tr ngoi khoa, c bit l ni soi: c kt qu tt khi bnh nhn c bin chng nng. II. Gii phu bnh: 1) Lowsly (1812): tuyn tin lit gm c 5 thu: trc, gia, 2 bn, sau. 2) Mac Neal (1976): tuyn tin lit gm nhiu phn: Phn trung tm: 20% ng Wolf. Vng ngoi vi: 75% ng Wolf. L ni xut pht ca ung Vng chuyn tip: 4- 5% ng Wolf. Cng vi cc tuyn 1. Cu to ca tuyn tin lit:

th tin lit tuyn. vng chung quanh niu o gn ni l ni xut pht ca u ph i lnh tnh tuyn tin lit. Vng quanh niu o: di 1%. Vng trc tuyn: bao gm m v si c tip gip vi c

bng quang v c tht vn. 3. Gii phu bnh: V i th u ph i lnh tnh tuyn tin lt l mt khi hnh trn hay bu dc gm 2 hay 3 thu p st vo nhau pha trc v dnh cht v pha sau. Khi lng t 30 40g c khi ln hn 100g. U ngy cng pht trin ln vo ngoi vi, hng vo lng bng quang hay v pha trc trng, 67

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


c th i c vng tam gic bng quang ln. Randal phn bit c 5 hnh thi i th ca u ph i tin lit tuyn, c th nh hng n vic thot nc tiu ra khi c bng quang. M lnh tin lit tuyn c th b y ra ngoi vi to thnh mt v bao quanh u. V vy khi u c th bc tch d dng ra khi bao x. Vi s pht trin ca u ph i tin lit tuyn, niu o tin lit tuyn b ko di ra, b chn p bi 2 thu bn, ng thi b thu gia che lp. Thnh bng quang dy gp 2 3 ln bnh thng do cc th c chp bng quang b ph i. Mt trong thnh bng quang c nhiu hnh li lm mf ngi ta gi l hnh trm hnh hc. Mt s hc c th bin thnh ti tha. Cc van niu qun d mt tc dng to iu kin nc tiu tro ngc dng ln thn. Nhim khun ngc dng v suy thn l h qu cui cng trong bnh l ny, nu khng c bin php iu tr kp thi. V vi th qu trnh tng sinh ca biu m tuyn v m m to thnh nhng nhn ngy cng pht trin v s lng v kch thc. Cc nhn gm thnh phn tuyn, cht keo v si c trn vi t l khc nhau. Cc si c trn c vai tr quan trng trong biu hin bnh l ca u ph i tin lit tuyn. Thnh phn tuyn gm cc chm nang c cha cc nh bn trong. Khc vi m tin lit tuyn bnh thng, c th tm thy y cc m nhi mu, dn cc chm nang, d sn cc t bo biu m. T l gia m tuyn v m m l 22 40% v 60 80%. C th tm thy cc hnh nh tn sn biu m tin lit tuyn 1 v 2, 2 c coi nh l tin ung th. Sau cng c th tm thy 10% u ph i tin lit tuyn km theo cc ung th nh. gm nhiu nhn c cc thnh phn: 68

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


+ tuyn(m)-chm nang nhiu nh: t bo tit v t bo dt. + X. + C III. Khi u to, mm, c ranh gii r rng. Sinh l bnh: Sau 40 tui, qu trnh tng sn tin lit tuyn bt u, di nh hng ca 2 yu t: tc ng ca androgen v tui gi. Vai tr ca andrrogen rt cn hit v nu ct b tinh hon trc tui dy th s khng xut hin u ph i tin lit tuyn. Testosteron ln phm ca t bo Leydig trong tinh hon v chim 95% ton b testosteron trong c th. Nhng testosteron l mt tin hormon. V vy c hot tnh thc s trn t bo ch, testosteron phi c chuyn thnh dihydrotestosteron (dch t hc), nh me 5alpha reductase, khu tr t bo ch. dch t hc kt hp vi cc th th androgen trong nhn t bo v thng qua cc gen chuyn mnh lnh tng trng v bit ho t bo. Vai tr estrogen rt quan trng: nam gii bnh thng estrogen tn ti trong mu nh chuyn ho ngoi vi hormon 4-androstenedion ca tuyn thng thn v testoseron ca tinh hon. Trong thi k bo thai, t tun th 20, estrogen ca m v rau thai thc y qu trnh bit ho tin lit tuyn ca thai nhi. Nhiu nghin cu cho thy tui gi, testoseron trong mu gim, trong khi estrogen tng. Chnh estrogen lm tng s nhy cm ca cc th th androge, do tc ng ca testosteron t do s cng ln i vi biu m tuyn. V vy Mac Neal (1978) cho rng qu trnh tng sn ca tin lit tuyn l s thc tnh qu trnh hnh thnh t nhin ca tin lit tuyn trong 69

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


thi k bo thai. Tht vy, tui gi, tuyn tin lit cng nhy cm vi cc androgen. S mt cn bng gia androgen v estrogen, c vai tr ca qu trnh vim v cc yu t min dch. (Estrogen tng ln kch thch s tng sn m m v biu m tin lit tuyn). Ngoi vai tr ca cc hormon cc cng trnh nghin cu thc nghim cho thy tc ng qua li gia m m v biu m tuyn, thng qua cc yu t tng trng hot ng di hnh thc cn tit (paracrin) hay t tit (autocrin). Cc yu t tng trng c tnh kch thch gm c: yu t tng trng biu b (EGF), yu t tng trng nguyn bo si bta (b-GF), yu t tng trng ging insulin (IGF). Ngc li, yu t tng trng chuyn i beta (TGF-b) c tc dng lm hm s tng sn ca tin lit tuyn. Issacs (1990) v Tenniswood (1986) cng nu mt s mt cn bng khc xy ra tui gi, gia khu vc cc t bo ang tng trng v khu vc cc t bo nh hng cht theo chng trnh (apotosis) ca m tuyn, lm cho cc t bo gc pht trin nhanh chng trong khi qu trnh cht theo chng trnh ca cc t bo bit ho chm li. Sau cng di nh hng ca nhiu loi kch thch khc nhau nh vim nhim, tinh dch tro ngc h thng min dnh di tc ng ca cc t bo lympho T bit ho c th sn xut cc loi yu t tng trng khc gy tng sn tin lit tuyn. U ph i tuyn tin lit lm cho c Detrusor qu sn, gy tc nghn c bng quang, bng quang dn cng to, ng nc tiu dn ti 2 hu qu: Nhim khun ngc dng v suy thn do tro ngc nc tiu. IV. C ch bnh l: U ph i lnh tnh tuyn tin lit gy chn p, cht hp c bng quang. 70

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


1. Giai on u (cn b): Thnh bng quang dy ln, bng quang tng co bp trnh cc tr ngi. 2. Giai on sau (mt b): thnh bng quang mng, mt kh nng co bp, cc u tn ca thn kinh ph giao cm gim dn, cc u tn tit adrenalin tng. Nc tiu ng trong bng quang. 3. p lc trong lng bng quang ngy mt tng, bng quang ngy cng mt kh nng n hi, nc tiu tro ngc ln niu qun, i b thn gy cc bin chng: B i: hon ton hay khng hon ton.(sau khi i i xong, nc tiu cn li trong bng quang 100ml) Nhim khun tit niu: vim bng quang, vim tin lit tuyn, vim mo tinh hon, vim i b thn, nhim khun huyt. V. Si tit niu(si bng quang). Ti tha bng quang. i mu. Suy thn. Chn on xc nh:

1. Hi bnh: Cc triu chng lm sng c lin quan n ng tit niu: i tho ng. Bng quang thn kinh. Hp niu o. Cc phu thut c tin hnh trc : tr, ni soi.

2. Cc triu chng c nng 1) Cc triu chng do chn p. Rn lu mi i c. i kh (da vo lu lng dng tiu), tia nc tiu yu v i ngt qung thnh nhiu t. 71

nh.

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


i rt nc tiu(i ngn chn ci) v i khng ht. i dt c ngy ln m nhng ch yu ban m. i ngt qung v cm gic lun mun i tiu. Bun tiu nhng khng nh c vi pht(i khng t 2) Triu chng do kch thch:

ch). Cc triu chng trn ngy cng tng khi: u ph i lnh tnh tuyn tin lit ngy cng to, khi c ri lon thn kinh thc vt, khi c nhim khun. 3) Cc triu chng khi c bin chng: B i hon ton, khng hon ton(cn ng nc tiu, i r, nc tiu tro ra khi bng quang b ng kinh Nhim khun tit niu (vim bng quang,vim tin lit Ti tha bng quang, si niu qun. Suy thn: ph, protein niu. khng thoi mi khi i). din. tuyn, vim mo tinh hon).

4) Da vo bng cu hi IPSS ( international prostatic system score) gm 7 mc vi 5 mc (mi mc cho t 05 im) , tng im t 0 35: i khng ht. i nhiu ln. i ngt qung. i vi. Tia i yu. i phi rn. S ln i m. Nu tng im 0 7 im: nh, ngh ngi c th ht, T 8 22: trung bnh, c th phi iu tr thuc, 23 35 im: nng, phi can thip.

72

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


5) nh gi cht lng sng ca bnh nhn lin quan hi chng ng tit niu thp: 1-2 im: cn c, 3-4 im: trung bnh, 5-6 im: khng th chu ng c. 3. Thc th: 1) Khm b phn sinh dc ngoi: pht hin cc bt thng, d dng vng sinh dc ngoi. 2) Khm vng h v: Cu bng quang: biu hin tn d nc tiu, b i 3) Khm vng tht lng 2 bn. 4) Thm trc trng nh gi tuyn tin lit: bnh nhn nm nga, bng quang v trc trng rng, a ngn tay eo gng c chm parafin v trc trng, tay kia thm khm vng h v. c im u ph i lnh tnh tuyn tin lit: Trn u, nhn, ng nht, ranh gii r. n hi, khoonfg au. Mt rnh gia. Khng thy nhn rn 2 thu. Giai on u cha c g c bit. Giai on thnh bng quang gin: lo lng, gy st, mt Giai on c bin chng: cc triu chng ca suy thn.

4. Ton thn:

ng. 5. Cc thm d cn lm sng b tr: 1) Xt nghim mu: Biu hin nhim khun: bch cu tng, bch cu da Ure, creatinin. nhn trung tnh tng. 2) Xt nghim nc tiu: vi khun niu, khng sinh . 3) nh gi lu lng dng tiu khi i tiu (nh gi kh nng co bp ca bng quang, trng lc v sc cn ca niu o) :< 10ml/s (bnh thng: 15 20ml/s) 73

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


4) nh gi khi lng nc tiu ng sau mi ln i tiu : >100ml 5) Siu m: Ch nh: trc khi phu thut, theo di ni khoa. V tr: trn xng mu hoc u d trc trng. Hnh nh:

+ Kch thc, v tr u. + nh gi lng nc tiu tn d. + tnh trng si, ti tha, si bng quang. + Tnh trng thn v si niu qun 2 bn. - o khi lng tuyn tin lit qua siu m: V(g/cm 3 =
W .H .L ( 25-30%) 2

6) Chp UIV: C gi tr trong trng hp chn on phc tp: u, si, ti Hnh nh: tha, d dng bm sinh. + Niu qun : gin, hnh mc cu. + Hnh khuyt ca u ph i lnh tnh tuyn tin lit. + Hnh nh thnh bng quang: u, ti tha + Hnh niu o, khi nc tiu ng y bng quang: chp lc i tiu v sau khi i tiu. 7) Soi bng quang: pht hin u bng quang/si bng quang khng cn quang. 8) Xquang h tit niu khng chun b: xem c si kt hp hay khng 9) Chp niu o ngc dng: nh gi bin dng ca h tit niu. Tm tt: Chn on xc nh u ph i tuyn tin lit da vo bng sau Triu chng Cc triu chng phng php k hiu Bng cu IPSS hi 74 im 0 35

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


cht lng sng cu hi L lu lng dng o trc tip Q/max tiu(Q) hoc trn ml g/cm3 my. nc tiu tn d o trc tip (R) khi lng tuyn Thm tin lit trng, m. VI. Chn on phn bit: 1) Vi ung th tuyn tin lit: y l chn on phn bit quan trng nht V lm sng khng c s khc bit: Tiu kh, tiu Thm trc trng: c nhn n c hay nhiu nhn mu, giao hp au v xut tinh mu. ln nhn cng 1 bn hay mt cn i c 2 bn, hay c tuyn tin lit l 1 khi nh dnh vo mt sau xng mu. Mt rnh gia. Khng c ranh gii r rt Th PSA ( trc khi thm tr trng): >10ng/ml. Tng nhiu Siu m: c vng gim m, ranh gii tin lit tuyn b Sinh thit qua trc trng bng kim Frazen: th 3 5 mu trong trng hp ung th tin lit tuyn di cn xng. ph hu. xc nh t bo hc: + S gim bit ho nhn t bo. + Xm ln vo cc m m: ranh gii khi u khng r rng. + Cu to hn lon ca ung th. Xt nghim PAD ( acid phosphate) tng. Tin s vim tin lit tuyn, vim mo tinh hon. 75 2) Vi vim tuyn tin lit mn tnh: trc siu 0 6 ml/s

1. Trng hp thm trc trng thy tin lit tuyn to:

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


ng: 1) Hp niu o/x cng c bng quang: Khm pht hin bng dng c. Chp niu o-bng quang ngc dng. Soi niu o-bng quang. Thm trc trng: tuyn tin lit l mt khi x, to hn Dch tit tuyn tin lit c m. iu tr khng sinh: Peflocin 400mg x 2/ngy hoc Theo di PSA bnh thng. bnh thng, mt chc, c khi au.

Noroxin 400mg x 7-10 ngy c tc dng tt. 2. Trng hp thm trc trng thy tin lit tuyn bnh th-

3) Ri lon co bp ca bng quang v c tht v cc th bng quang-thn kinh (sau tn thng /vim thn kinh ngoi vi, i tho ng, chn thng ct sng). Da vo tin s, lm sng, niu ng hc. *Bin chng: nhim khun nc tiu, tro ngc nc tiuvim thn ngc dngsuy thn; si th pht ng tit niu(nht l bng quang) VII. iu tr: Da ch yu vo mc nh hng ca u ph i tin lit tuyn ti cht lng cuc sng ca bnh nhn. IPSS 0 7 im: nh, theo di, ch i (watch full waiting) IPSS 8 20 im: trung bnh( khng c triu chng khc i km, Q. R trong gii hn bnh thng): iu tr ni. IPSS 21 35 im: nng, phi can thip 1. iu tr ni: 1) ch nh: c b i nhng cha c bin chng. 2) Nguyn tc: Dng khng sinh thch hp. Chng co tht c trn. c ch 5 reductase.

3) Ni dung: 76

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Thuc tc ng ln c trn tin lit tuyn v c bng quang: Chn .adrenergic : + Alfuzosin (Xaltral) 2,5mg x 2ln/ngy hoc Xaltral chm 5mg/ngy x 5-6 thng. +Terazosin (Hytrin) 1-2mg , thm d liu t 1-2mg x 15ngy +Canduran (Doxazosin) 2mg x 2-3 ln/ngy. +Prazosin (Minipress), Tamsulosin : hin t dng. Thuc Tho mc: +Tadenal (Pygeum africanum) 30mg x 3-4 vin/ngy. +Permison 160mg. +Evipostat. Thuc tc dng ngn cn s ph ca tin lit tuyn: + Khng androgen Dihyrotestosteron(Cyproteron): Hin khng cn c dng. + c ch 5 reductase(?): Finesterase 5mg x 6 thng- 1 nm: t hiu qu. Thuc lm gim co bp hn lon c thnh bng quang: Thuc khng sinh thch hp. probantin, ditropan Khi iu tr ni nn s dng thuc chn bta kt hp vi tho mc. Dng my lazer t chy cc t chc u. Vt l tr liu (nhit ): gim s xung huyt ca tin

lit tuyn, hu hoi t chc nhu m: dng nhit 40C chm nng 15 pht mi ngy trong 15 ngy. Ch sinh hot: + Trnh ru bia v cc cht kch thch. + Lao ng hp l, nh nhng. + Trnh cc bnh nhim khun tit niu, ch cc bnh i tho ng v cc bnh tiu ho (to bn, tr) 77

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


2. iu tr ngoi: 1) Ch inh: Tuyt i: + B i hon ton: Sau khi rt ng thng bnh nhn vn khng i c. + B i khng hon ton: lng nc tiu cn li trong bng quang sau khi i tiu >100ml. + Tiu mu. + V niu, suy thn. + Si tit niu, ti tha bng quang. + Nhim khun tit niu. + iu tr ni khoa, vt l khng khi. Tng i: + nh hng nhiu n sc kho v lao ng (mt ng ). + IPSS > 10 (21 35),cht lng cuc sng 4- 6 dim, Q<10ml/s, R>100ml. 2) Chun b m: Chun b k v tm l cho bnh nhn, khm ton Gy t tu sng hay c tin hnh hn gy m ni din kh qun. 3) Phng php: Phu thut ng trn, bc u ph i lnh tnh tuyn tin lit qua bng quang/ngoi bng quang vo tin lit tuyn. + Ch nh: Khi u > 50g. Bnh nhn c x cng khp hng. Bnh nhn c hp niu o. + 2 loi:

78

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


*Phu thut qua thnh bng quang: p dng rng ri nht khi bnh nhn bo, c u, ti tha bng quang, si bng quang. *Phu thut sau xng mu (phu thut Millin)(ngoi bng quang): cm mu thun li, ng tit niu c lu thng sm. Ct ni soi qua niu o (ct t ni soi): + Ch nh: u < 50g. bnh nhn gi yu c bnh mn tnh. + u: t gy au. t chy mu, rt ngn thi gian iu tr. Vi cc bnh nhn cn c nhu cu tnh dc hoc cha phu thut c, c th s dng cc hng php sau: + Ct ni soi 1 ng rch t c bng quang ti ni. + Nong niu o bng qu bng qua ng thng t ng vo tuyn tin lit + iu tr sng ngn (microwave) to nhit 40-45c t trong niu o tuyn tin lit chng vim, ph n. + t dng c nong(proscath) trong niu o tuyn tin lit ki cha phu thut c cho bnh nhn. Phng php iu tr hin i nht hin nay l dng Ch : u ph i lnh tnh tuyn tin lit hay gp laser t u qua theo di trn mn hunh quang. ngi gi nn hay c cc bnh ton thn i km nn phi iu tr n nh cc bnh ny ri mi iu tr u ph i lnh tnh tuyn tin lit. Sau khi iu tr u ph i lnh tnh tuyn tin lit li tip tc phi iu tr cc bnh . 3. Bin chng sau phu thut: Chy mu trong v sau mtc ng thng nhim Nhim khun. 79 khun th pht.

Nguyn c Thng Y6B7 cng n thi bc s ni tr Ngoi


Suy thn. Tn thng c tht vn: i r. Hp niu o. Hi chng ni soi: trn nc ra vo tun hon (gp

trong khi ct ni soi.

80

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