AI HO C HU

TRNG AI HOC Y KHOA

B MN NI











BNH LY HOC NI
KHOA





















Hu - 2008






LI NI U

Thc hin ch trng ca i hc Hu, c s nht tr ca Ban Gim Hiu Trng i
hc Y khoa Hu, B Mn Ni tin hnh ph bin gio trnh in t Y khoa ln u tin. y l
mt phng tin thng tin ph bin nht v thch hp cho cc i tng sinh vin, hc vin
khp mi ni c th tham kho cc bi ging ni khoa. y cc bi ging c chn lc, tp
trung vo mt s ni dung c bn nht. Mt s hnh nh v s ca bi ging do s khng
c a vo. Qu c gi c th lin h tham kho cc phn chi tit tp gio trnh hon chnh
ca B Mn Ni hoc vi cc trng phn mn lin h.
Chng ti cng xin lu vic sao chp mt phn hoc ton b tp bi ging ny ngoi
mc ch hc tp cn c s ng ca n v ch qun hoc tc gi.
Chn thnh cm n s quan tm v hp tc cng nh rt mong s gp ph bnh ca qu
c gi .


TM. Ban ch nhim B Mn Ni kim Ch bin
PGS.TS. Hunh vn Minh
hvminh@dng.vnn.vn
hvminhdr@yahoo.com

1
CHNG I
TIM MCH

THP TIM
Mc tiu
1. Nm c cc du chng lm sng v cn lm sng ca thp tim.
2. Vn dng chn on v iu tr thp tim.
3. Nm c tm quan trng ca phng thp s cp v th cp.
Ni dung
I. I CNG
1. Thp tim: l mt bnh vim nhim ton th, biu hin nhiu c quan m ch yu l
khp v tim, bnh c nhng c im sau:
- L hu qu chm ca vim ng h hp trn do liu cu tan huyt nhm A.
- Xut hin thnh tng t cch nhau hng thng, hng nm c khi c chc nm.
- C ch sinh bnh nghing v t min.
- Thng tn van tim c th mn tnh, tin trin a n suy tim.
- Phng bnh thng hiu qu.
2. Dch t hc
- Tui tr: 5 -15 tui.
- Ma lnh m lm d vim hng.
- Sinh hot vt cht: bnh thng gp cc nc chm pht trin, c iu kin sng
thp.
- Bnh xy ra sau vim hng do lin cu, hoc nhim lin cu nhng khng c triu
chng, bnh d ti pht nht l bnh nhn thp tim c.
II. BNH NGUYN, C CH SINH BNH
1. Bnh nguyn
Lin cu tan huyt nhm A l vi trng gy bnh do hin tng qu mn sau nhim lin cu.
Nu cn c vo phn loi theo Protein M th c khong 60 type khc nhau, lin cu gy vim
hng thuc type 1, 2, 4, 12. T l mc bnh khong 30%.
2. C ch sinh bnh
- Cha r, nghing v t min. C s tng t gia khng nguyn ca lin cu v
khng nguyn tim (mang khng th chng liu cu v tim, protein M, khng nguyn
glycoprotein c bit ging protein ca van tim).
- Khng th (KT) c hiu: Khng th chng tim, chng t bo no, KT chng
Glycoprotein, Antistreptolysin O. Cc khng th ny tng t tun th 1 n tun th 4 ca
bnh.
- C a di truyn: D mc bnh, c nguy c ti pht ko di sut i.
III. GII PHU BNH
Thng tn tin trin
1. Giai on u: Gy ph m lin kt, thm nhim t bo thoi ha dng fibrin, c th hoi
t (c tim).
2. Giai on sau
- C ht Aschoff nm gn mch mu, ht ny c cu to:
2

Ht Aschoff trong c tim: T bo c tim ln, nhiu nhn, c mt s t bo c nhiu ht nhn

+ Trung tm l mt vng hoi t dng fibrin, sau n mt vng t bo dng biu m vi
nhng t bo khng l nhiu nhn ngoi cng l t bo a dng nht l lympho v tng bo.
+ Nhng nt ny tn ti nht l mng trong tim gy ra cc nt so van tim v ct c ca van
tim.

-Thng tn tim: c th c 3 lp cu to tim v m lin kt.
- Mng trong tim: Thng tn van hai l 40%. Van 2 l kt hp van ng mch ch
40%. Van ng mch ch n thun 10-15%. Van dy x cng cun li gy h, van dnh cc
mp li gy hp.
- C tim: Gin cc si c tim, vim x, thm nhim t bo a nhn dng Aschoff.
- Mng ngoi tim: Tn thng c hnh thi si khng c hiu hay phn ng vim
dng fibrin v thng c dch mu vng khong 50-200ml, c khi mu , c.
- Tn thng m lin kt: Vim thoi ha dng fibrin.
+ Tn thng khp: tit dch fibrin, v trng, khng n mn mt khp.
+ Thng tn no: Gp th vn gy ma git.
+ Thng tn da: l cc ht Meynet cn gi l ht Aschoff ngoi da.
IV. TRIU CHNG HC
1. Lm sng: Thay i nhiu ty c quan b tn thng v trm trng.
1.1. Khi pht
- St cao t ngt du nhim c nu biu hin vim khp l chnh.
- St t t, st nh khng r nu vim tim l chnh.
1.2. Khp: in hnh l vim cc khp ln l chnh vi sng - nng - - au hn ch c
ng, di chuyn hi phc nhanh chng trong vng 2 - 3 tun, nht l khi c iu tr, khi hon
ton khng li di chng khp, cc khp thng gp l: khp vai, khp gi, khuu, c
tay, c chn, c khi khng vim khp in hnh, mt s trng hp khng c biu hin
khp.
1.3. Tim: Vim tim l biu hin nng nht ca thp tim, l biu hin duy nht c li thng
tn quan trng vnh vin v gy t vong. C th gy vim c 3 lp cu to ca tim:
- Vim mng ngoi tim
+ au vng trc tim.
+ C khi nghe c ting c mng ngoi tim.
- Vim c tim
+ Ting tim m
+ Suy tim: nhp tim nhanh, ting nga phi, ngoi tm thu, cng c khi nhp tim rt chm, lon
nhp. Bloc nh tht cc cp.
- Vim mng trong tim: Hay gp l cc ting thi tm thu mm do h van 2 l v
hoc ting thi tm trng y tim do h van MC.
1.4. Nhng biu hin khc
3
- Thn kinh:
+ Ma git: l nhng c ng khng t , nhanh bin ln chi, c, mt. Trng lc c
gim, xut hin mun v thng gp n.
+ Vim no v vim dy thn kinh cng c th gp.
- Ngoi da
+ Nt di da (ht Meynet) ng knh vi milimt n 1cm thng thy mt dui ca cc
khp ln, mt chc, khng au, du hiu vim thng xut hin mun.

Hnh nh ht di da (hnh 1) v ban vng (hnh 2, 3)

+ Ban vng: vng cung khng thm nhim, thay i nhanh, gp thn v gc chi.
- Thn: Vim thn tng : c protein niu nh, huyt niu vi th. Cng c khi gp vim cu
thn cp lan ta.
- Phi v mng phi: Trn dch mng phi, ph phi xung huyt mt hay hai bn.
- Bng: au bng c khi nhm vi rut tha vim.
2. Cn lm sng
2.1. Biu hin phn ng vim cp trong mu
- VS tng cao thng >100 mm trong gi u.
- Bch cu tng 10.000 - 15.000/mm
3
ch yu a nhn trung tnh.
- Fibrinogen tng: 6 - 8 g/l; Tng (alpha 2 v gamma Globulin).
- Creactive Protein (CRP) dng tnh.
2.2. Biu hin nhim lin cu
- Cy dch hng tm lin cu: Thng dng tnh, ngoi t vim ch 10 % dng
tnh.
- Khng th khng lin cu tng trong mu > 500 n v Todd/ml.
- Antistreptokinase tng gp 6 ln bnh thng.
2.3. in tim: Ri lon dn truyn nh tht, PR ko di. C cc ri lon nhp: Ngoi tm thu,
bloc nh tht cc cp.
2.4. X quang: Bng tim c th bnh thng hoc ln hn bnh thng, nu vim c tim thy
du tr tun hon phi, bng tim ln.

4

Hnh nh XQ tim ca bnh nhn 8 tui b vim c tim do thp tim (trc v sau iu tr)
V. TIN TRIN V BIN CHNG
1.Th thng thng: Lm sng ci thin rt nhanh.
- Triu chng khp gim sau 24-48h, PR cn ko di sau vi ngy, VS cn tng sau 2
- 3 tun.
- Tt c cc triu chng thng mt sau 2 thng.
2. Th nng
- Thp tim c tnh
+ Gp tr nh < 7 tui.
+ Vim tim ton b c bit l vim c tim cp hoc no, thn, phi.
+ St kn o, au khp t.
+ iu tr t kt qu.
- Th tin trin
+ Tin trin chm hn.
+ C s ni tip cc t cp v t lui bnh.
+ Lun b di chng trm trng tim (van tim).
3. Th di chng: Thng mng trong tim:
- Van hai l: Tn thng nhiu nht gy h hp van 2 l sau 2 nm.
- Van ng mch ch: Hp h van ng mch ch, h MC n thun cn hp th
him.
- Van 3 l: rt him gp, thng kt hp vi cc van khc.
4. Vim mng trong tim nhim khun: bin chng nng, Osler hay gp h cc van hn l
hp.
5. Ti pht: Hay gp bnh nhn khng d phng thp tim tt.
VI. CHN ON
1. Chn on xc nh: Kh khn trong t thp u tin, da vo cc tiu chun ca Jones.
1.1. Tiu chun chnh
- Vim tim.
- Ban vng.
- Vim khp.
- Nt di da.
- Ma git.
1.2. Tiu chun ph
- St
- au khp
- PR ko di
- VS tng, bch cu tng, C Reative Protein-CRP (+)
- Tin s thp hay b bnh tim sau nhim lin cu.
1.3.Tiu chun mi b nhim liu cu
5
- Tng dn nng khng th khng lin cu.
- Va b bnh tinh hng nhit (Scarlatine).
Khi chn on thp tim phi c 2 tiu chun chnh, hoc 1 tiu chun chnh + 2 tiu chun
ph v mi b nhim lin cu.
1.4. Siu m Doppler tim
- Siu m 2 bnh din v M-Mode c th thy trn dch mng tim, cc bin i cc van tim,
mc ri lon chc nng tim v tng p phi.
- Siu m Doppler v Doppler mu: Pht hin h van 2 l, van MC, cho php nh gi mc
h.

H van 2 l trn Doppler mu, van 2 l dy ng khng kht trn 2D

H van ng mch ch trn Doppler mu 2D v ph i tht tri trn siu m 2D

Hp van 2 l trn Doppler mu 2D, trn Doppler lin tc (o din tch van 2 l-MVA=1,2cm
2
)
v hp van 2 l trn siu m 2D
2. Chn on phn bit
2.1. Vim a khp dng thp: Vim nhiu khp nh, bin dng khp, teo c, cng khp bui
sng, tin trin ko di.
2.2. Vim khp do lu cu: Vim thng mt khp, thng khp gi, dch khp c vi khun.
2.3. Lao khp: Thng trn c th suy kit, st dai dng, thng sau lao phi, khp thng
gp: khp hng, ct sng lng.
2.4. Lupus ban : Ban hnh cnh bm ngoi da, bin i mu da, au nhiu khp, thng
tn thn nng, tn thng mng phi, bng v nhiu c quan.
6
2.5. Vim mng ngoi tim, c tim do virus: Bnh tin trin rm r, cp tnh, st cao, c mng
ngoi tim, ri lon nhp tim, ri lon dnc truyn c bit l blc nh tht hon ton, c th t
vong, i vi th thng thng thng khi hon ton khng li di chng.
VII. TIN LNG: Ph thuc vo tn thng tim.
- Nu khng tn thng tim trong t u hoc vim tim nhng tim khng to, chn on v
iu tr sm, d phng y , khng ti pht th tin lng tt, 90% phng c bin chng
tim.
- Nu tn thng tim t u khng d phng y theo phc th tin lng xu i
nhiu.
- Theo Fridberg v Jones: 10 - 20% bnh sau t thp tim u s tr thnh tr tn ph. T
vong sau 2 - 6 nm.
- S cn li sng n tui trng thnh:
- 65% bnh nhn sinh hat bnh thng.
- 25 % sng sc khe gim st nhiu v l gnh nng cho gia nh v x hi.
VIII. KT LUN
- L bnh gp ngi tr, nguyn nhn do lin cu.
- Bnh cnh a dng.
- Chn on ban u kh, khi chn on c th tim b tn thng.
- Din bin kh lng, d phng sut i ni ln tm quan trng ca thp tim tc ng ln
tim c bit l bung tim tri.

7
BNH HP VAN HAI L

Mc tiu
1. Nm vng cc triu chng lm sng v cn lm sng ca bnh hp van hai l.
2. Nm c cc th lm sng ca bnh hp van hai l.
3.Nm vng cc phng tin iu tr ni khoa bnh hp van hai l.
4. Nm vng ch nh iu tr ni khoa, iu tr ngoi khoa v phng nga cc bin chng
Ni dung
I. I CNG
Hp van hai l l mt bnh van tim mc phi kh ph bin nc ta, chim khong
40,3% cc bnh tim mc phi. Bnh c pht sinh loi ngi t khi bt u sng thnh
tng qun th do iu kin sinh sng thp km, cht chi thiu v sinh d gy ly nhim bnh.
T 1887 Bouillaud ri Sokolski m t v bnh. n 1920 Duckett Jones (Hoa k)
nghin cu bnh ny v n 1944 ng mi cng b by tiu chun chn on bnh. Cng vo
nhng nm ny Cutter v Levine Phillipe (Hoa k) tm cch phu thut hp van hai l, ti Anh
Souttar cng m c hp van hai l. Giai on ny bnh hp van hai l l bnh tim mch
ph bin nht, gy tn ph v t vong nhiu. T nm 1944 vic pht minh ra Penixillin dit
cc loi lin cu v c bit to ra loi Penixillin chm (Benzathyl Penixillin) c tc dng
phng nga bnh ny do n nay cc nc pht trin nh Thy in, H lan v c
bnh thp tim gn nh mt hn.
Tuy vy, cc nc chm pht trin bnh ny cn ang ph bin. Bnh hay gp tui
lao ng 20 - 30 tui, t l bnh hp hai l rt cao khong 60 - 70 %, t l t vong n 5%.
Bnh c nhiu bin chng phc tp v a n tn ph v t vong. Bnh gp n nhiu hn
nam (2/1) v nng thn mc nhiu hn thnh th.
II. BNH NGUYN V C CH SINH BNH
Tu theo tui, ch yu do thp tim (99%) i vi tui tr, mt s nguyn nhn khc
nh bm sinh, Carcinoid c tnh, lupus ban h thng, vim khp dng thp c nhng
nghin cu cn cho l do virus Coxsackie gy ra. Tc nhn gy bnh ch yu l do lin cu
khun tan huyt nhm A gy vim hng v gy tn thng tim. S d lin cu hng gy
bnh thp tim m khng vo cc c quan khc l do i qua bch mch gia hng v tim. Cu
trc bo thai hc cng cho thy c ng ni mch mu v thn kinh gia tim v c.
Nm 1976 Taranta (Hoa k) chng minh c c ch bnh sinh trc tip ca c t
lin cu khun ln tim. Cc khng th khng tim xut hin bnh nhn thp tim c vim tim,
c c cc phn ng khng nguyn cho gia cc cu trc tim v lin cu nhm A. C ch
sinh bnh c th c ghi nhn nh sau:
- Lin cu khun nhm A xm nhp vo c th gy vim hng ng thi sinh ra
nhng c t. Ngoi ra, trong m tim, ngi ta cng tm thy nhng cht c cu trc min
dch ging protein M v vy cc khng th hnh thnh cng chng lun li cc van tim.
- Hin tng t min cho nhm ln gy vim tim v vim khp. Vim tim c th t khi
nhng sau 2 nm n c th li di chng van tim, c 3 bnh nhn th c 1 bnh nhn b di
chng van tim nh dy dnh x gy hp h van tim.
III. TRIU CHNG HC
1. Lm sng
1.1. Ton thn: Nu mc bnh trc tui dy th, bnh nhn km pht trin th cht gi l ln
hai l (nanisme mitral). Nu xy ra sau tui dy th tr pht trin gn nh bnh thng.
1.2. C nng
- C khi pht hin tnh c bi khm sc khe hng lot mc d bnh nhn khng c
triu chng c nng no ngay c khi gng sc.
- C khi bnh nhn i khm v kh th, ho v khc ra mu, hi hp nh trng ngc,
nut nghn do tm nh tri ln chn p vo thc qun nht l khi gng sc.
8
1.3. Du chng thc th: Nghe tim l ch yu, bnh nhn nm nghing tri, c th nghe khi
nm nga, hoc c khi phi bnh nhn lm ng tc gng sc. Hp van hai l in hnh
thng nghe c cc du chng sau tu theo tn thng van, bnh l phi hp hay bin
chng ca hp van 2 l:
- Ting T
1
anh mm (do van x dy p vo nhau).
- Rung tm trng (RTTr) mm do van hp lung mu b tng mnh xung tht tri va vo
cc ct c v cu c tht tri b vim dy x cng, vi ha hoc RTTr mt khi van hp rt
kht, van v t chc di van dy, vi ha, dnh vi nhau.
- T
2
mnh y tim do tng p lc ng mch phi van MC v MP ng khng cng lc
to nn T
2
tch i (van MP ng mun hn van MC).
- Ting thi tin tm thu gia tim hay mm do lung mu i qua ch hp mu cn li
nh tri, nh tri bp y mu xung tht tri; nhng khi b rung nh hay nh tri gin th
khng cn nghe ting thi tin tm thu na.
- Ting clc m van hai l mm hoc trong mm. Ting ny ch c khi van cn mm.
- Khi p lc ng mch phi tng cao tht phi gin nhiu lm gin vng van MP gy ra
ting thi tm trng van MP gi l ting thi Graham - Steel.
Cng c nhng trng hp hp van hai l khi khm bnh khng nghe c g m nh
cc bin chng (suy tim phi, rung nh, tc mch) v nh cn lm sng nht l siu m tim
gi l hp van hai l cm.
2. Cn lm sng
2.1. in quang: C 2 t th thm d trong hp van 2 l:
- T th thng:
+ Bn phi: Tm nh tri to ln sang pha phi thng c 3 giai on.
Giai on 1: Nh tri to to thnh 2 cung song song vi b trong l nh tri, b ngoi l nh
phi.
Giai on 2: Nh tri to ln ra ct cung nh phi, to thnh hai cung ct nhau.
Giai on 3: Nh tri to ln ra ngoi to thnh 2 cung song song m cung ngoi l nh tri v
cung trong l nh phi (ngc vi giai on 1).
+ Bn tri: c 4 cung ln lt l cung MC, cung MP, cung tiu nh tri, cung di tri vi
mm tim hch ln (tht phi ln).
Rn phi: m, to nn 2 bn bng tim hai khong m rng v ranh gii khng r. Hai ph
trng m do huyt, c th thy c ng Kerley B. Nu khi c tnh trng tng p lc
MP ch ng th thy vng rn phi m v vng ra phi rt sng.
- Trn phim nghing c ung bart: thc qun b chn p 1/3 gia. Mt khong sng trc
tim hoc sau xng c (tht phi ln).

Hnh nh XQ tim phi thng: Bn tri c hnh nh 4 cung, bn phi c hnh nh 3 cung; trn
phim nghing c barit nh tri chn thc qun 1/3 gia
2.2. in tm
9
- Giai on u cha hp kht hoc cha nh hng nhiu trn cc khoang tim: in tim cn
bnh thng.
- Giai on sau: dy nh tri vi P (0,12s hoc P hai pha, pha m ln hn pha (+) V
1
.
Trc in tim lch phi v dy tht phi.
Ngoi ra cn c th thy tnh trng ri lon nhp nh ngoi tm thu nh, nhp nhanh nh, rung
nh l hay gp hn c. C th c blc nhnh phi khng hon ton.

in tm hp van 2 l: Nhp xoang, trc hng phi,

=85
0
, dy nh tri (D
1
, V
1
), tng
gnh tht phi (V
1
, V
3
R, V
4
R)
2.3. Siu m tim
L phng tin chn on xc nh chnh xc hp van hai l nht l khi hp van hai l trn
lm sng khng pht hin c. Siu m cn cho php ta nh gi van v t chc di van c
dy khng ta c quyt nh thay van, nong van hay sa van.
Trong hp n thun
- Kiu mt bnh din: Van l van trc v sau dnh vo nhau nn di ng song song cng
chiu, cc l van dy ln. Van c dng hnh cao nguyn hay giy trt tuyt. dc tm
trng EF b gim. Nu hp kht dc tm trng c th gim <15 mm/s. ng knh nh
tri tng. ng knh tht phi tng, vch tht phi dy. C th thy c du tng p MP
gin tip.
- Siu m 2 chiu: Xc nh c s di ng ca van, do kch thc bung tim ng
thi o c din tch l van.

Hnh nh siu m M-Mode v 2D ca hp 2 l
- Siu m Doppler c th pht hin c hp van hai l c kt hp vi cc tn thng
khc c thi x tr thch ng. ng thi o p lc ng mch phi, theo di p lc
ng mch phi trc v sau iu tr.
10

o din tch van 2 l (MVA) qua siu m 2D v Doppler lin tc (PHT)
2.4. Tm thanh c ng
Kt hp vi in tm nh gi mc hp ca van da vo khong Q - T1 v khong
T2 - CM. Nu Q - T1 cng di v T2 - CM cng ngn th hp van hai l kht, hin nay thm
d ny t s dng do c siu m tim
2.5. Thng tim
Thy c s chch lch p tm trng gia nh tri v tht tri, du hiu c trng ca hp
hai l. Hin nay, siu m tim c tnh cht quyt nh nn t s dng phng tin ny. Ngi ta
ch s dng khi c bnh l tim phc tp phi hp (him).
IV. CHN ON
1. Chn on xc nh
Da vo cc tiu chun lm sng v cn lm sng, nh m t trn. Quyt nh nht vn l
du nghe tim v siu m tim.
2. Chn on phn bit
- Rung tm trng trong hp van 3 l: RTTr trong mm, T
1
khng anh. in tim c dy
nh phi, khng c du dy tht phi. Siu m tim l quyt nh chn on.
- U nhy nh tri (Myxoma): nghe rung tm trng thay i theo t th. Khng c T
1

anh. Bnh nhn thng hay c ngt. Chn on da vo siu m tim.
3. Chn on giai on
C 4 giai on ca hp hai l
- Giai on 1: Khng c triu chng c nng k c khi gng sc. Khm lm sng pht hin
tnh c.
- Giai on 2: C hi chng gng sc r: Kh th, hi hp, nh trng ngc, ho hoc ho ra
mu, cha c biu hin suy tim.
- Giai on 3: C kh th nhiu, c suy tim phi nhng iu tr c hi phc.
- Giai on 4: Hp van 2 l c suy tim nng, iu tr khng hi phc.
4. Chn on th
4.1. Th n thun: c th dung np tt, bnh nhn cha c du hiu c nng v thng pht
hin bnh tnh c.
- Th in hnh: Nh m t trn v khi khm lm sng, X quang, in tim c th chn on
c.
- Hp van hi l cm: Bnh nhn c th c hoc khng c triu chng c nng. Nghe tim
khng thy cc du hiu c trng cc hp van hai l. Th ny i hi tm cc bin chng ca
hp van hai l v cn lm sng nht l siu m tim gip chn on.
- Th tin trin: thng l nhng trng hp hp van hai l khp hay rt kht. Bnh nhn vo
vin vi cc bin chng nng n. Ri lon nhp, hen tim, ph phi cp, tc mch vv...
4.2. Th phi hp
- Hp hai l phi hp h van hai l: phi phn bit h hai l l chnh, hp l ph hay ngc
li. Nu h van hai l l ch yu: nghe TTT mnh mm tim ting thi to, lan xa, s c rung
miu tm thu, T
1
khng anh. Rung tm trng nh, X quang, siu m, in tim c dy gin
11
tm tht tri v nh tri. Ch yu siu m tim nh gi c mc h hai l c bit l vi
siu m Doppler.
- Phi hp vi bnh van ng mch ch.
+ Hp van hai l phi hp h ng mch ch: ngoi hp van hai l cn nghe ting thi tm
trng lin sn III bn tri v lin sn II bn phi lan xung dc b c tri, in tim c
dy tht tri, siu m doppler tim cho php chn on.
+ Hp hai l kt hp hp ng mch ch: ngoi triu chng hp van hai l cn nghe thm
ting thi tm thu lin sn III bn phi v lin sn II bn phi lan ln 2 bn ng mch
cnh km s rung mu.
Chn on in tim c dy tht tri tm thu, X quang v siu m tim cho php chn on.
- Hp van hai l kt hp bnh van 3 l:
+ Hp hai l kt hp h 3 l: nghe TTT trong mm tim hoc ngay mi c. ting TTT mnh
ln khi ht vo su v nn th, c th s gan to v p theo nhp p ca tim. Tnh mch c
p. Phi thng sng hn.
+ Hp van hai l kt thng lin nh: Hp hai l kt hp thng lin nh gi l hi chng
Lutembacher. Chn on xc nh nh siu m tim v thng tim.
Hp van hai l c th cn phi hp vi cc bnh l tim mch khc nh tng huyt p nhng
him gp
5. Chn on bin chng
Hp van hai l thng c 4 nhm bin chng sau:
5.1. Ri lon nhp tim
- Ri lon nhp xoang thng l nhp nhanh. Ngoi tm thu nh, cn nhanh trn tht.
- Cung nh v rung nh l nhng bin chng nng n ca HHL. T nhng ri lon nhp tim
nay c th gy ra bin chng tc mch ngoi vi v cng lu s dn n suy tim phi.
5.2. Tc mch: C 2 c ch tc mch:
- Tc mch vng i tun hon: Do mu nh tri chm lu chuyn xung tht tri
nn mu d ng. Nu cc ri lon nhp nhanh nh rung nh, nhp nhanh trn tht to iu
kin thun li hnh thnh cc mu ng. Sau khi nhp tim chm li cc mu c a xung
tht tri v vo i tun hon gy tc mch no, chi, thn, mc treo vv...
- Tc ng mch phi: Do cc mu ng c hnh thnh t cc tnh mch ngoi bin,
vo tht phi gy tc ng mch phi. Hoc c th do p lc phi tng trong hp hai l nn c
th hnh thnh cc mu ng ti ch gy tc ng mch phi.
5.3. Nhim trng
- Nhim trng ti phi do mu ng mch phi l mi trng pht trin cho vi trng:
C th vim phi lan ta, vim phi khu tr.
- Nhim trng ti tim c th gy ra vim ni tm mc bn cp Osler. Bin chng ny
him gp nhng khi xy ra th tin lng xu v iu tr kh v c th tht bi.
5.4. Suy tim
- C th c cn hen tim ph phi cp hay gp khi gng sc hoc ban m. Do mu ng
trong phi nhiu ban m thn kinh ph giao cm hot ng mnh nn lm dn mch, thot
huyt tng vo ph nang gy ph phi.
- Suy tim phi. y cng l bin chng ng thi cng l giai on cui cng ca
bnh. Nu khng c iu tr trit . Cc bin chng trn c th xy ra khi bnh nhn gng
sc v tinh thn, th cht v nhn mt nhim trng da, phi. c bit ph n c thai, lc
chuyn d hay thi k kinh nguyt.
VI. IU TR
1. iu tr ni khoa
Ch c tc dng tt khi hp van hai l mc nh v trung bnh. Nu hp kht, vi din tch l
van <1.5 cm2 th iu tr ngoi khoa mi c tc dng.
1.1. iu tr suy tim
12
1.1.1. Ch sinh hot n ung
Hn ch lao ng nng, n lt, iu tr phng thp ti pht, phng nga Osler.
1.1.2. Li tiu
Khi c th tng khong 2 kg so vi trc.
Furosemid 40 mg x 1-2 vin/ngy.
Trong cn suy tim cp c th dng Lasix 20 mg tim tnh mch chm. Ch khi dng li tiu
cn dng thm kali (nn cho loi mui K+ hu c tt hn v c, nh K+, Mg++ aspartate bit
dc Panangin) phng h kali mu, d ng c Digital.
1.1.3. Digital
t c tc dng trong suy tim do hp hai l, ngay c khi c suy tim phi. Digital c tc dng tt
trong suy tim do hp hai l c bin chng rung nh ngn nga cc cn rung nh c nhp tht
nhanh, lm nng thm tnh trng suy tim, c th dng liu ngm chm. Digital 0,25 mg x 1
vin/ ngy trong 5 ngy, ngh 2 ngy ri dng li. Hoc Digital 0,25 mg x 1 vin / ngy trong
3 ngy, ngh 3 ngy ri dng li.
Khi iu tr Digital cn lu du chng ng c Digital nh:
- Bnh nhn nn ma, au bng, m mt, nhn i, i cu phn lng.
- Ngoi tm thu tht nhp i hay c tnh.
- Hoc nhp tim tng vt ln (trong khi ang dng Digital) hoc chm li vi Blc nh tht cc
cp, hoc nhp b ni.
- Nu xut hin cc triu chng trn nn ngng Digital v cho tng cng thm Kali bng
ng tnh mch hoc ng ung, ch b sung thm Mg++.
1.1.4. Cc thuc gin mch
- c s dng nhiu trong nhng nm gn y. Thuc gin mch c th iu tr lin tc, ko
di. Thuc gin mch c tc dng gim tin gnh, hu gnh gip cho suy tim hi phc tt.
- i vi suy tim trong hp hai l tt nht l nhm Nitrat v dn xut nht l khi hp hai l c
tng p lc ng mch phi, ph phi mn tnh v cp tnh. Risordan LP 20 mg x 1-2 vin /
ngy, hoc Imdur (mononitrate Isosorbid) 60 mg x 1/2 - 1 vin / ngy.
1.2. iu tr phng tc ng mch h thng
- Tc mch c th: ng mch no, ng mch mc treo, ng mch ngoi v, ng mch
lch, ng mch thn, ng mch vnh.....
- Bin chng tc mch gia tng bnh nhn hp van hai l c bin chng rung nh v suy tim,
c bit khi mi xut hin rung nh.
- Hp van hai l c bin chng tc mch nhiu hn h van hai l. 20-60% tc li ln th hai
sau tc ln th nht trong 6-12 thng nu khng c d phng hu hiu bng cc thuc
chng ng.
- iu tr tc mch cng sm cng tt:
+ Heparin 10.000 - 20.000 UI / ngy x 5 - 10 ngy. C th dng Heparin c trng lng phn
t thp c bit i vi tc mch no. Sau dng cc thuc khng ng loi khng Vitamin
K nh Sintrom, Previscan, Dicoumarin gi u 48-72 gi trc khi ngng Heparin duy tr t
Prothrombin cn khong 30-35% hoc IRN 2,5-3 l tt nht.
+ Sau khi chuyn rung nh v nhp xoang bng thuc hoc sc in, nong van hai l l phng
php d phng tc mch ti pht tt nht. Hoc nhng bnh nhn khng c iu kin nong
van, phu thut s van, thay van c th ung thuc d phng tc mch ko di nhiu nm
liu thp 100 - 500 mg / ngy bng Aspirin (aspegic 100mg), dipiridamole vv...
1.3. iu tr d phng
- Phng thp ti pht bng Benzathylpenixilin 1,2 triu n v mi 15-20 ngy, tim bp su
sau khi th test.
- Ngoi ra phng bi nhim phi hoc Osler bng khng sinh Penixilin nhanh hoc
Erythromycin 0,5g trc cc can thip nh nh rng, x nht ngoi da vv... Khi c du hiu
13
vim tnh mch chi di c th phng tc ng mch phi bng cch t li lc tnh mch
ch di.
2. iu tr ngoi khoa
iu tr phu thut van hai l c nhiu tin b. Nong van hai l bng tay hoc bng dng
c hoc bng bng (catheter baloon).
2.1. Nong van hai l bng bng
a ng thng qua ng tnh mch i i vo nh phi, xuyn qua vch lin nh vo nh tri
nong van 2 l bng bng. K thut ny c thc hin ti Vit Nam. Phng php ny
c ch nh cho bnh nhn tr tui <40, hp van hai l n thun, van cn mm mi, t
chc di van cha h bin nhiu, khng c cc mu ng nh tri hoc tiu nh. Bin
chng ca phng php ny l chc thng thnh tm nh tri gy ra trn mu mng ngoi tim
cp, gy chn p tim cp.
2.2. Nong van hai l kn (close mitral commissurotomy)
- Bng tay hoc dng c: thc hin nhng bnh nhn: c din tch l van hai l hp <1.5
cm2, van cn mm hoc x ho, cha c vi ho nhp xoang hay rung nh, nhng khng c
tin s tc mch, khng c bnh van ng mch ch, hoc h van hai l (nu h van hai l
nh <2/4 th khng chng ch nh), tui < 40, khng b bi nhim phi hoc thp tim ang
tin trin, khng b Osler.
- Kt qu sau nong c 5-10% trng hp ht triu chng hp van hai l, triu chng tng p
lc ng mch phi gim dn v tr v bnh thng. Mt s bnh nhn nong van hai l khng
kt qu hoc thp tim ti pht gy dnh li cc mp van phi nong li ln 2 nhng kt qu
thnh cng thp hn v t l t vong cao hn 10 ln lc ban u.
- Bin chng khi nong van v sau khi nong
+ Suy tim v ri lon nhp sau phu thut
+ St
+ Hi chng sau nong van
+ Trn dch mng ngoi tim
+ Tc ng mch no thong qua.
+ H van hai l sau khi nong thng gp nhng bnh nhn b vi ho van h bin nhiu t
chc di van.
+ Ngng tim khi ang nong
+ Hen tim, ph phi cp
+ Lon nhp tim (ngoi tm thu tht, nh, rung cung nh, nhp nhanh kch pht trn tht v
tht, rung nht)
+ Osler gy t dy chng, sa van hai l
2.3. M tim h
Cn c tim phi nhn to
- Sa van hai l: phu thut vin c th m rng hoc thu hp vng van hai l, ct b phn b
si lot, vi ho hoc ly cc mu ng nh, tht, v cc l thng trn mt l van khu ni
cc tr c v dy chng b t. Bnh nhn khng phi thay van nn gim c nguy c min
dch thi ghp, gim nguy c vi ho, tc mch nn vic chng ng n gin hn thay van,
gim nguy c vi ho, tc mch nn liu php chng ng n gin hn.
- Phu thut thay van: c ch nh trong cc trng hp
+ hp van hai l t chc van x dy vi ho nng
+ Hp kt hp h van hai l nng hay h van hai l n thun.
+ Si lot van do Osder
- Cc loi van thng dng thay van hai l
+ Van Starr-Edwards: c lng gi qu bng bi, khi tht bng bi chuyn ng ln pha nh
ng van nh tht.
+ Van SCDT-Custer l dng van Starr ci tin.
14
+ Van Magovevu-cromt l van Starr ci tin
+ Van Kuy-Suzuki thay bng bi bng a phng, c nhiu u im v huyt ng hn dng
van bi, khi phu thut thay van t l t vong thp hn, gim qu trnh to cc mu ng van
v quanh van, l van nhn to mi nht c ci tin t van Starr. Vi hnh dng v cht liu
khc nhau nh Titanium, Teflon, Pyrolytic-carbon, Silastic, Polyproline.... to c nhiu
loi van khc nhau:
+ Cuged-ball
+ Starr-Edwards: 7 loi. Smeloff-custer: 2 loi: Braald-custer, Cuged-disc
+ Beall c 5 loi: Kay-Shiley, Kay Suzuki, Starr-Edwards, Cooley-Cutter, Tilting disc.
+ Bjork-Shiley c 3 loi
+ Lalehei-kaster: 4 loi
Tng cng c 27 loi van nhn to
- Van hai l sinh hc: Phc hi mt cch c bn huyt ng, khng b nhim khun, khng
to cc mu ng, khng b thng t vng van sau thi gian di phu thut, v vy n m ra
trin vng pht trin sau ny.
2.4. Bin chng sau khi thay van
Ngoi cc bin chng nh nong van cn c thm cc bin chng.
- t t trong khi phu thut
- t t do hot ng ca van b ri lon.
- Dnh kt Fibrin, sau vi ho ti van v quanh van mn.
- Osler do vi khun v nm.
- Abces quanh vng van.
- H quanh vng van hai l.
- Block nh tht cp cao hoc bloc b His (do ct cc tr c)
- Hp hoc h MC th pht sau thay van hai l
- Gim kh nng b p tun hon khi gng sc.
- Kh iu tr bng phng php sc in, to nhp khi cn thit.
iu tr nong van hai l hay phu thut tim kn hay h cn tip tc iu tr phng thp, phng
Osler, iu tr chng ng, suy tim th mi ko di cuc sng ca bnh nhn.
15
TNG HUYT P
Mc tiu
1. Nm vng kin thc c bn v tng huyt p, mt bnh tim mch ph bin hin nay.
2. Nm vng phn loi, cc bin chng ca tng huyt p cng nh cc c ch sinh bnh
tng huyt p
3. Nm vng cc nhm thuc v tc dng dc l, ch nh v tc dng ph trong iu tr
tng huyt p.
4. Vn dng c phc iu tr tng huyt p trong thc tin lm sng
Ni dung
I. I CNG
1. Dch t hc
Tng huyt p (THA) l triu chng ca nhiu bnh, nhiu nguyn nhn nhng c th
l mt bnh, bnh tng huyt p, nu khng tm thy nguyn nhn. cc nc Chu u - Bc
M t l tng huyt p trong nhn dn chim 15 - 20% ngi ln. C th nh sau: Benin
14%- Thi lan: 6.8%- Zaire:14%- Chile: 19-21%, Portugaise: 30%, Hoa k: 6-8%. Nhn
chung t l rt thay i. Vit Nam, t l tng huyt p chung l 11,8% (B Y T Vit Nam,
1989). T l ny gia tng ng quan tm v trc 1975 t l ny min Bc Vit nam ch c 1-
3% (ng Vn Chung). Ti BVTW Hu nm 1980 t l THA trong s cc bnh ni khoa ch
c 1% nhng 10 nm sau, nm 1990, tng n 10%. Thng k gn y nht ca Vin Tim
Mch ti Min Bc Vit Nam cho thy t l THA l 16,3% (2002).
2. nh ngha
T chc Tng huyt p Th gii (TCYTTG) v U ban Quc gia Cng lc Hoa k,
Hi Tng huyt p Vit nam u thng nht mt ngi ln b tng huyt p khi huyt p tm
thu trn hoc bng 140mmHg v hoc huyt p tm trng trn hoc bng 90mmHg.
nh ngha ny n gin nhng vn c nhc im l tr s huyt p khng hon ton n
nh v huyt p thay i theo tui, gii...
3. Mt s nh ngha mi THA
3.1. THA tm thu n c: i vi ngi ln, huyt p tm thu c xu hng tng v huyt p
tm trng c xu hng gim. Khi trung bnh ca huyt p tm thu >140 v huyt p tm
trng <90, bnh nhn c phn loi l tng huyt p tm thu n c. chnh huyt p (
tm thu - tm trng) v huyt p tm thu d bo nguy c v quyt nh iu tr.
3.2. THATT n c ngi tr tui: Tr em v ngi tr, thng l nam gii, s phi hp
ca s gia tng nhanh chng v chiu cao v s rt n hi ca mch mu lm tng s khuch
i bnh thng ca sng p lc gia ng mch ch v ng mch cnh tay to nn HA tm
thu rt cao nhng huyt p tm trng v huyt p trung bnh bnh thng. Huyt p ng
mch ch tuy vy cng bnh thng. iu ny c th da vo s phn tch sng mch.
3.3. THA tm trng n c: Thng xy ra ngi trung nin, IDH thng c nh
ngha khi huyt p tm thu < 140 mmHg v huyt p tm trng ? 90 mmHg. Mc d huyt
p tm trng thng c cho l yu t tin lng tt nht v nguy c bnh nhn tu <50.
Mt s tin cu v tng huyt p tm trng n c cho thy tin lng c th lnh tnh tuy
vy vn ang cn tranh lun.
3.4. THA o chong trng v hiu ng o trng: Mt s bnh nhn HA thng xuyn
tng ti bnh vic hoc phng khm bc s trong khi HA hng ngy hoc o 24h li bnh
thng. Tnh trng ny gi l THA o chong trng, cho d mt thut ng khc t mang
tnh c ch hn l THA phng khm hoc bnh vin n c . T l hin mc THA o
16
chong trng l 10%-30% chim mt t l khng phi khng ng k trn nhng i tng
THA. THA o chong trng tng theo tui v t l ny < 10% THA 2, 3 khi o ti
phng khm. THA o chong trng c th l khi u ca THA thc s v c th lm tng
nguy c BTM mc d khng phi nghin cu no cng tr li nh th. Nghi ng THA o
chong trng khi HA o ti phng khm tng hoc khng tr khi khng c tn thng c quan
ch. Nhng ngi THA phng khm n c c nguy c tim mch thp hn nhng ngi
va THA phng khm v THA 24 gi.
3.5.Tng huyt p n du ( masked hypertension) hoc THA lu ng n c: Thng t gp
hn tng huyt p o chong trng nhng kh pht hin hn, l tnh trng tri ngc -
huyt p bnh thng ti phng khm v THA ni khc, v d ti ni lm vic hay ti nh
(tng HA 24 gi n c). Nhng bnh nhn na c tn thng c quan ch nhiu hn v
nguy c cao hn nhng i tng huyt p lun lun bnh thng
3.6. Tng huyt p gi to: Trong mt s lng nh bnh nhn ln tui, cc ng mch nui
c ngoi bin tr nn cng nn bng cun phi c p lc cao hn nn li. ng mch cnh
tay hay ng mch quay vn bt c d bng cun c bm cng (du Osler dng
tnh). Khi nghi ng, o huyt p ni ng mch quay c tin hnh xc nh.
3.7. H huyt p t th ng: c nh ngha l s gim huyt p tm thu ti thiu 20
mmHg hoc huyt p tm trng 10 mmHg trong vng 3 pht khi o t th ng. Nu mn
tnh, s gim huyt p c th mt phn do s suy gim h thn kinh t ng n thun, suy
gim a h thng v mt s trng hp khng c h thn kinh t ng. Nhng bnh nhn ny
khng ch c gim huyt p t th ng m tng huyt p trm trng trong t th nm nga
trong m.
II. BNH NGUYN V C CH SINH BNH
1. Bnh nguyn
1.1.Tng huyt p nguyn pht: chim gn 90% trng hp b tng huyt p (theo Gifford -
Weiss).
1.2. Tng huyt p th pht
- Bnh thn: Vim cu thn cp, vim cu thn mn hai bn do mc phi thn a nng,
nc b thn, u thn lm tit rnin, hp ng mch thn...
- Ni tit
+ Bnh v tuyn thng thn, hi chng Cushing, hi chng Conn, u sn xut qu
tha cc Corticosteroid khc (Corticosterone, desoxycortisone), sai lc trong sinh tng hp
Corticosteroid.
+Bnh ty thng thn, u ty thng thn (Pheochromocytome).
- Bnh tim mch: Bnh hp eo ng mch ch, vim hp ng mch ch bng cho
xut pht ng mch thn, h van ng mch ch.
-Thuc: Cc Hormone nga thai, cam tho, carbenoxolone, A.C.T.H. Corticoides,
Cyclosporine, cc cht gy chn n, cc IMAO, cht chng trm cm vng...
- Nhim c thai nghn.
- Cc nguyn nhn khc: Bnh cng gip, bnh Beri-beri. Bnh Paget xng, bnh
a hng cu, hi chng carcinoid, toan h hp, tng p s no...
2. Mt s yu t lm d (thun li): c xem nh c lin quan n tng huyt p nguyn
pht tuy vn cn bn ci l
- Yu t di truyn, bnh tng huyt p c tnh gia nh.
- Yu t n ung, n nhiu mui, n t protit, ung nhiu ru, ung nc mm t
Ca
++
, Mg
++
, K
+
. Trong ni bt v c tha nhn l s lin quan gia ion Na+ v tn sut
17
bnh tng huyt p. Ion Na
+
lm tng huyt p qua trung gian gia tng th tch mu v nht l
qua s co tht mch mu.
- Yu t tm l x hi, c tnh trng cng thng (stress) thng xuyn.
3. C ch sinh bnh ca tng huyt p nguyn pht
Tng huyt p ng mch thng km theo nhng bin i v sinh l bnh lin quan
n h thn kinh giao cm, thn, renin-angiotensin v cc c ch huyt ng, dch th khc.
3. 1.Bin i v huyt ng
- Tn s tim tng, lu lng tim tng dn, thi k u c hin tng co mch phn
b li mu lu thng t ngoi vi v tim phi do sc cn mch mu cng tng dn. Tim c
nhng biu hin tng hot ng b tr v dn n dy tht tri. Huyt p v sc cn ngoi
bin ton b tng dn. Lu lng tim v lu lng tm thu cng gim, cui cng a n suy
tim.
- Trong cc bin i v huyt ng, h thng ng mch thng b tn thng sm c
ton b. Trc kia ngi ta ngh ch c cc tiu ng mch b bin i co mch lm gia tng
sc cn ngoi bin. Hin nay, ngi ta thy cc mch mu ln cng c vai tr v huyt ng
hc trong tng huyt p. Chc nng t c bit n ca cc ng mch ln l lm gim i
cc xung ng v lu lng mu do tim bp ra. Do thng s v n hi ng mch
(compliance artrielle) biu th tt kh nng ca cc ng mch. S gim thng s ny cho
thy cng ca cc ng mch ln, l din bin ca tng huyt p ln cc ng mch v v
lu di s lm tng cng tim dn n ph i tht tri. ng thi vic gia tng xung p
(hyperpulsatilit) ng mch a n s h hng cc cu trc n hi sinh hc
(bioelastomeres) ca vch ng mch.
- Ti thn, tng sc cn mch thn, gim lu lng mu ti thn chc nng thn suy
gim tuy trong thi gian u tc lc cu thn v hot ng chung ca thn vn cn duy tr.
- Ti no, lu lng vn gi c thng bng trong mt gii hn nht nh thi k
c tng huyt p r.
- Khi huyt p tng, sc cn ngoi bin tng th tch huyt tng c xu hng gim
cho n khi thn suy th tch dch trong mu tng c th tng a n ph.
3.2. Bin i v thn kinh:
thi k u nh hng ca h giao cm biu hin s tng tn s tim v s tng lu
lng tim. S hot ng ca h thn kinh giao cm cn biu hin lng Catecholamine
trong huyt tng v dch no ty nh adrenaline, no-adrenaline, tuy vy nng cc cht
ny cng rt thay i trong bnh tng huyt p.
- H thn kinh t ng giao cm c iu khin bi h thn kinh trung ng hnh
no-ty sng v c hai h ny lin h nhau qua trung gian cc th cm p lc. Trong tng
huyt p cc th cm p lc c iu chnh n mc cao nht v vi ngng nhy cm cao
nht.
3.3. Bin i v dch th
- H Renin-Angiotensine Aldosterone (RAA): Hin nay c chng minh c vai
tr quan trng do ngoi tc dng ngoi vi cn c tc dng trung ung no gy tng huyt p
qua cc th th angiotensine II . C tc gi chia tng huyt p nguyn pht da vo nng
renine cao, thp trong huyt tng, c s t l nghch gia nng renine-angiotensine II
trong huyt tng v tui.
- Angiotensine II c tng hp t angiotesinegne gan v di tc dng renine s
to thnh angiotesine I ri chuyn thnh angiotesine II l mt cht co mch rt mnh v lm
tng tit aldosterone. S phng thch renine c iu khin qua ba yu t: -p lc ti mu
thn - lng Na+ n t ng ln xa v h thn kinh giao cm. S thm d h R.A.A, da
18
vo s nh lng renine trc tip huyt tng hay gin tip phn ng min dch v
angiotensine II, nhng tt nht l qua tc dng ca cc c ch men chuyn.
- Vasopressin (ADH): c vai tr kh r rng trong c ch sinh bnh tng huyt p c
tc dng trung ng gim huyt p (qua trung gian s tng tnh nhy cm thn kinh trung
ng i vi phn x p t xoang ng mch cnh v quai ng mch ch) tc dng ngoi vi
co mch (trc tip v qua hot ha cc si Adrenergic).
- Cht Prostaglandin: tc dng trung ng lm tng huyt p, tc dng ngoi vi lm
gim huyt p.
- Ngoi ra cn c vai tr ca h Kalli-Krein Kinin (K.K.K) trong bnh tng huyt p
v mt s h c vai tr cha r nh: h Angiotensine trong no v cc encephaline, h cng
dopamine bin i hot ng th cm p lc. Mt c ch iu ha lin quan n cc th th
Imidazolique trung ng v ngoi bin c ghi nhn t nhng nm 80 vi s xut hin
thuc huyt p tc dng ln th cm Imidazole gy dn mch.
3.4.C ch sinh bnh ca tng huyt p th pht:
Ty vo nguyn nhn gy bnh.
III. TRIU CHNG HC
1. C nng
a s bnh nhn tng huyt p khng c triu chng g cho n khi pht hin bnh.
au u vng chm l triu chng thng gp. Cc triu chng khc c th gp l xong, hi
hp, mt, kh th, m mt... Khng c hiu. Mt s triu chng khc ca tng huyt p ty
vo nguyn nhn tng huyt p hoc bin chng tng huyt p.
2.Triu chng thc th
2.1. o huyt p: l ng tc quan trng, cn bo m mt s quy nh.
- Bng cun tay phi ph c 2/3 chiu di cnh tay, b di bng qun trn khuu
tay 2cm. Nu dng my o thy ngn nu dng loi l xo phi iu chnh 6 thng 1 ln.
- Khi o cn bt mch trc. Nn bm n khong 30mmHg trn mc p lc lm
mt mch (thng trn 200mmHg) x xp nhanh ghi p lc khi mch ti xut hin, x xp
ht. t ng nghe ln ng mch cnh tay, bm nhanh bao hi n mc 30mmHg trn p lc
ghi, x chm t t vi tc 2mmHg trong 1 giy (hay mi nhp p). Huyt p tm
trng nn chn lc mt mch (pha V Korottkoff). tr em v v ph n c thai nn chn
pha IV Korottkoff.
- Nu o li ln 2 cn ch 30 giy. Nu lon nhp tim phi o li ln 3 v ly trung
bnh cng ca cc tr s.
- Phi o huyt p nhiu ln, trong t nht 2 ngy lin. o huyt p c chi trn v chi
di, c t th nm v ng. Thng thng chn huyt p tay tri lm chun.
2.2. Du hiu lm sng
- Bnh nhn c th bo ph, mt trn trong hi chng Cushing, c chi trn pht trin
hn c chi di trong bnh hp eo ng mch ch. Tm cc biu hin x va ng mch trn
da (u vng, u m, cung gic mc..).
- Khm tim mch c th pht hin sm dy tht tri hay du suy tim tri, cc ng
mch gian sn p trong hp eo ng mch ch. S v nghe ng mch pht hin cc
trng hp nghn hay tc ng mch cnh trong ng mch ch bng...
- Cn lu hin tng (huyt p gi) gp nhng ngi gi i ng, suy thn do
s x cng vch ng mch lm cho tr s huyt p o c cao hn tr s huyt p ni mch.
C th loi tr bng cch dng th thut Osler hay chnh xc nht l o huyt p trc tip.
19
Mt hin tng khc cng ang c c gng loi tr l hiu qu o chong trng bng
cch s dng phng php o lin tc huyt p 24 gi.
- Khm bng c th pht hin ting thi tm thu hai bn rn trong hp ng mch
thn, phng ng mch ch hoc khm pht hin thn to, thn a nang.
- Khm thn kinh c th pht hin cc tai bin mch no c hoc nh.
3. Cn lm sng: Cn n gin, mc ch nh gi nguy c tim mch, tn thng thn v
tm nguyn nhn.
3.1. Billan ti thiu (theo T chc Y t th gii)
Mu: Kali mu, Cratinine mu, Cholesterol mu, HDL- C, LDL-C, Triglycerid,
ng mu, Hmatocrite, Acide Uric mu. Nc tiu: Hng cu, Protein. Nu c iu kin
nn lm thm, soi y mt, in tim, X quang tim, siu m...
3.2. Cc xt nghim hay trc nghim c bit
i vi tng huyt p th pht hay tng huyt p kh xc nh.V d: Bnh mch
thn:cn chp U.I.V. nhanh, thn , trc nghim Saralasin. U ty thng thn
(Pheochromocytome): nh lng Catecholamine nc tiu trong 24 gi, trc nghim
Rgitine.
Cc ngng HA p dng chn on THA theo cch o.
HATT ( mm Hg) HATTr (mm Hg)
o HA ti phng khm/ bnh vin 140 90
o HA lu ng 24 gi * 125 - 130 90
- Ban m 130-135 85
- Ban ngy 120 70
o HA ti nh (t do) 135 -135 85
(*) o chnh xc hn HA vn phng c bit nh gi hiu qu h HA nh iu tr,
l do l khng c hin tng c chong trng v cc yu t nhiu tc ng ngy cng nhiu
sau mi ln . Cho d mt s u im s c th t c nu gia tng s ln o HA vn
phng ln, o HA i li 24 gi trc nhn sut qu trnh iu tr c th c khuyn khch
trong mt vi trng hp vo thi im chn on hoc thm thot sut qu trnh iu tr.
IV. CHN ON
1.Chn on xc nh: Cn phi chn on sm v ng n bnh THA. Ch yu bng cch
o huyt p theo ng cc quy nh nu trn. Tuy nhin iu quan trng l nn t chc
nhng t khm sc khe khm xt ton din nhm pht hin sm nhng trng hp tim
tng hoc cha c triu chng.
2.Chn on giai on tng huyt p: c nhiu cch phn giai on, trong phn giai on
ca TCYTTG chi tit v thch hp hn.
2.1.Theo T.C.Y.T.T.G (1996) chia lm 3 giai on. Hin nay phn giai on ny ch c tnh
cch tham kho.
- Giai on I: Tng HA tht s nhng khng c tn thng thc th cc c quan.
- Giai on II: C t nht mt trong cc bin i cc c quan sau:
+ Dy tht tri: Pht hin bng lm sng, X quang, in tim, siu m.
20
+ Hp lan ta hay tng vng cc ng mch vng mc (giai on I v II y mt ca Keith-
Wagener-Baker).
+ Thn:Anbumine niu vi th, Protein niu, ur hoc cratinine mu tng nh.(1.2-2 mg%)
+ C hnh nh mng va x ng mch trn siu m hoc X quang ( ng mch ch, ng
mch cnh, ng mch chu hoc ng mch i)
- Giai on III: C du hiu chc nng v thc th do tn thng cc c quan ch:
+ Tim: suy tim tri, cn au tht ngc, nhi mu c tim.
+ No: tai bin mch no thong qua, xut huyt no, tiu no hoc thn no. Bnh no THA.
Lon thn do mch no (vascular dementia)
+ y mt: xut huyt vng mc xut tit c hay khng c ph gai th (giai on III v IV)
cc du hiu ny l c bit ca giai on c tnh (giai on tin trin nhanh).
Cc biu hin khc thng gp giai on III nhng khng c hiu lm ca tng
huyt p.
+ Thn: creatinine huyt tng tng r (> 2mg%), suy thn.
+ Mch mu: phng tch, bt tc ng mch, tc ng mch ngoi bin c triu chng r.
Tng HA c tnh hay tin trin nhanh l mt hi chng gm c:
- Huyt p ti thiu rt cao trn 130mmHg.
- y mt giai on III v IV theo Keith-Weigener.
- C bin chng thn, tim, no.
- Bnh nhn tr tui di 40.
- Tin trin nhanh, t vong trong vng 2-3 nm.
2.2. Phn loi theo y ban Cng lc Quc gia Hoa k ( 2007)
Phn loi huyt p Huyt p tm thu (mmHg) Huyt p tm trng (mmHg)
Bnh thng
Tin tng huyt p
Tng huyt p giai on 1
Tng huyt p giai on 2
< 120
120 - 139
140 - 159
> 160
v < 80
hoc 80 - 89
hoc 90 - 99
hoc > 100
2.3. Xp loi THA theo T chc Y t th gii ( WHO) v Hi THA th gii (ISH) (2003),
Hi Tng huyt p Vit nam v Hi Tng huyt p Chu u ( 2007): y l phn loi c p
dng rng ri nht ti nc ta v nhiu nc trn th gii.
Xp loi HA tm thu
(mmHg)
HA tm trng
(mmHg)
Ti u
Bnh thng
Bnh thng cao
< 120
< 130
130-139
< 80
< 85
85-89
THA nh (giai on 1) 140-159 90-99
THA va (giai on 1) 160-179 100-109
THA nng (giai on 2) 180 110
3. Phn loi tng huyt p
3.1- Theo tnh cht:
- Tng huyt p thng xuyn:nh tng huyt p lnh tnh v tng huyt p c tnh.
21
- Tng huyt p giao ng, huyt p c lc cao, c lc bnh thng.
3.2- Theo nguyn nhn: Gm
- Tng huyt p nguyn pht (v cn).
- Tng huyt p th pht.
V- TIN TRIN V BIN CHNG
1. Tim: Suy tim v bnh mch vnh l hai bin chng chnh v nguyn nhn gy t vong cao
nht i vi tng huyt p. Dy tht tri l bin chng sm do dy c tim tri. i ph sc
cn ngoi bin nn gia tng sc co bp lm cng tim tng ln v vch c tim dy ra. Dn dn
suy tim tri v vi kh th khi gng sc, hen tim hoc ph phi cp sau chuyn sang suy
tim ton b vi ph, gan to, tnh mch c ni. Xquang v in tim c du dy tht phi.
Suy mch vnh biu hin bng cc cn au tht ngc in hnh hay ch c lon nhp.
in tim c ST chnh xung di ng thng in cc chuyn o tim tri, r hn
chuyn o gng sc; khi bin chng nhi mu s xut hin sng Q hoi t.
2. No: tai bin mch no, thng gp nh nhn no, xut huyt no, tai bin mch no
thong qua vi cc triu chng thn kinh khu tr ch ko di, khng qu 24 gi hoc bnh no
do tng huyt p vi l ln, hn m km theo co git, nn ma, nhc u d di.
3. Thn
- Va x ng mch thn sm v nhanh.
- X thn gy tnh trng suy thn dn dn.
- Hoi t dng t huyt tiu ng mch thn gy THA c tnh.
- giai on cui thiu mu cc b nng thn s dn n nng Renin v
angiotensine II trong mu gy cng aldosterone th pht.
4. Mch mu
- Tng huyt p l yu t sinh va x ng mch, to iu kin cho s hnh thnh va
x ng mch.
- Phng ng mch ch, bc tch. Him gp nhng bnh cnh rt nng n d a n
t vong.
5. Mt: khm y mt rt quan trng v l du hiu tt tin lng.
Theo Keith- Wagener-Barker c 4 giai on tn thng y mt.
- Giai on 1: tiu ng mch cng v bng.
- Giai on 2: tiu ng mch hp c du bt cho (du Gunn).
- Giai on 3: xut huyt v xut tit vng mc.
- Giai on 4: ph lan ta gai th.
VI. IU TR
1. Nguyn tc
1.1. Mc tiu
- a huyt p tr v tr s sinh l n nh.
- Ngn nga cc bin chng.
- Ci thin cc bin i bt thng cc ng mch ln.
Do phi gii quyt 3 vn :
+ iu tr nguyn nhn tng huyt p; Ct b u ty thng thn, ct b thn teo, thng ng
mch b tc...
+ iu tr triu chng tng huyt p: Bng phng php ni khoa khng dng hoc dng
thuc hoc phu thut (v d ct b mt s dy thn kinh giao cm).
22
+ iu tr bin chng ca tng huyt p: Mc tiu chung ca iu tr l nhm a huyt p v
tr s bnh thng hay di tr s 140/90mmHg. Tn trng huyt p sinh l ngi gi.
1.2. Nguyn tc chung: Cn lin tc, n gin, kinh t v c theo di cht ch.
2. Phng php iu tr
2.1. Tit thc v sinh hot
Hn ch mui di 5gNaCl mi ngy, hn ch m, cc cht bo ng vt, king ru,
thuc l, ch c. Trnh lao ng tr c cng thng, lo lng qu , nn tp th dc nh, i b
th gin, bi li.
2.2.Thuc
Cn nm vng c ch tc dng, tc dng phi hp cc loi thuc iu tr tng huyt p
v cc tc dng ph khi s dng trc mt v lu di. C 3 nhm thuc chnh:
- Li tiu
+ Thiazide v dn xut
c ch ti hp th Na
+
v Cl
-
trong ng ln xa nh Hydrochlorothiazide (Hypothiazide)...
vin 25mg ngy ung 2 vin. Chlorthiazide vin 500mg ung 2 vin/ ngy l nhng loi c
dng rng ri trong tng huyt p. Ngoi ra cn c Chlorthalidone (Hygroton) vin 50mg-
100mg x 1ln/ngy v Metolazone (Diulo) 2,5mg-5mg x 4ln/ngy hay mi 2 ngy/ln v tc
dng ko di.
Tc dng ph thiazide: Tng acid uric, tng cng mu, gim Kali mu, li tiu Thiazides t
tc dng khi tc lc cu thn di 25ml/pht, lm tng LDL cholesterol v gim HLD
cholesterol.
+ Li tiu quai Henl
Cng lm h Kali mu, nhng khc nhm thiazide l tc dng nhanh v ngn, ph thuc
liu.Thng dng l Furosemide (Lasix) vin 40mg x 1-2vin/ngy c ch nh khi suy thn
nng, cn tng huyt p cp tnh nhng v lu di tc dng khng hn nhm Hypothiazide.
Cc loi khc trong nhm cn c Edecrine (Acide ethacrynique), Burinex (Butnamide). Tc
dng ph tng t Thiazide nhng liu cao c c tnh ln tai.
+ Li tiu xa gc Gi Kali, gm c 2 nhm nh:
- Nhm khng Aldosterone nh Spironolactone (Aldactone)vin 25-50mg x 4ln/ngy.
Canrnone (Phanurane) c hiu lc i vi nhng trng hp cng Aldostrone, thng
dng phi hp thiazide.
- Nhm th 2 l nhm c tc dng trc tip nh Amiloride (Modamide), Triamterene
(Teriam) loi ny thng phi phi hp vi cc nhm khc v tc dng thi Na yu. Tc dng
ph: v nam, bt lc ri lon kinh nguyt.
+ Li tiu phi hp
C th trnh c tnh trng gim Kali trong mu, loi ny phi hp mt loi Aldosterone v
mt loi thiazides nh Aldactazine, Moduretic, Ditriam..
- Loi chn giao cm
Tc dng c ch Renin, gim ng c tim, gim hot ng thn kinh giao cm trung ng, c
nhiu nhm. Chn lc tim, khng chn lc tim v loi c tc dng ging giao cm ni ti
hay khng c. Thng dng c propranolol (Avlocardyl, Inderal) l loi khng chn lc, khng
c tc dng giao cm ni ti (ASI) vin 40mg dng 1-6vin/ngy. Tc dng ph: Lm chm
nhp tim, ri lon dn truyn nh tht, lm nng suy tim, co tht ph qun, hen, hi chng
Raynaud, h ng mu, ri lon tiu ha, mt ng, d ng hoc tc dng di khi ngng iu
tr (gy ra cn au tht ngc, nhi mu c tim cp).
- Cc thuc c ch men chuyn
23
c ch s to thnh angiotensine II, ngoi ra cn c tc dng:
- Tng cng hot ng h Kali-Krine-Kinine ngn cn s phn hy bradykinine.
- Kch thch s tng hp Prostaglandine. Do sau cng a n dn mch.
Ch nh: Tng huyt p cc giai on, k c loi tng huyt p rnine cao v thp.
Tc dng ph: t c tc dng ph ngoi ri lon v thm n, nga, ho khan, lu khi phi
hp li tiu gi Kali, thuc chng vim, chng Steroid.
Chng ch nh: Khi tng huyt p c hp ng mch thn hai bn hoc ch c mt, ph n c
thai.
C 3 nhm chnh
- Captopril (Lopril, Captolane) vin 25-50mg liu 50mg/ngy.
- Enalapril (Renitec) vin 5-20mg, liu 20mg/ngy.
- Lisinopril (Prinivil, Zestril) vin 5-20mg, liu 20mg/ngy.
Hai nhm sau cng c tc dng ko di v khng c nhm Thiol t tc dng ph nn c a
thch hn.
- Thuc c ch Canxi
Ngn cn s i vo t bo ca ion Ca
++
. c ch lung Ca
++
chm ca knh Ca
++
ph thuc
in th. Tc dng ny t l vi nng v hi quy khi c ion Calcium. C hai ni tc dng.
- Trn mch mu: s gim lung Ca
++
a n s dn c v lm dn mch. iu ny lm
gim sc cn ngoi bin v ci thin dn n cc mch mu ln.
- Trn tim: lm chm nhp tim cn bng t nhiu phn x nhp nhanh th pht v gim s co
bp c tim.
Cc tc dng ny ty vo loi c ch Ca
++
c s dng. Loi 1-4 dihidropyridine c tc
dng chn lc mnh i vi mch mu, cn Verapamil v Diltiazem tc dng ln c hai ni.
Cc loi c ch Ca
++
tc dng tt i vi tng huyt p renine thp (ngi ln tui) c th:
+ Nhm 1-4 Dihydropyridine: Nifedipine (Adalate) vin nhng 10mg-20mg LP, liu 2
vin/ngy.
+ Diltiazem (Tildiem) 300mg LP, liu 1 vin/ngy.
+ Verapamil (Isoptine) 120-240 LP, liu 1-2 vin/ngy.
Tc dng ph chim 10-20% trng hp. Thng thng l nhc u, ph ngoi bin, phng
mt. Him hn l h huyt p th ng, mt, xong, ri lon tiu ha, hi hp, pht ban, bun
ng v bt lc. Cc loi Verapamil, Diltiazem c th gy ri lan dn truyn nh tht, nhp
chm. Khng c dng c ch Canxi khi c thai, i vi Verapamil v Diltiazem khng
dng khi c suy tim, blc nh tht nng nhng cha t my to nhp.
- Thuc tc dng ln thn kinh trung ng
C nhiu loi nhng hin nay t dng do c nhiu tc dng ph d c hiu qu.
- Anphamethyldopa (Aldomel, Dopegyt): H huyt p do to ra anpha-methylnoadrenaline
lm hot ha cc c quan th cm giao cm no, do c ch trng lc giao cm. Vin
250mg hoc 500mg, liu t 500mg n 1,5g trong 24 gi. c s dng khi c suy thn. Tc
dng ph: h huyt p th ng, thiu mu huyt tn, bt lc, suy gan.
- Reserpine vin 0,25mg liu 2-6 vin/ngy. Tc dng ph h huyt p th ng, thiu mu
huyt tn, bt lc, suy gan, hin nay t dng.
- Clonidine (Catapressan): Tc dng ln vng hnh ty cng trng lc giao cm h huyt
p. Vin 0,150mg liu 3-6 vin/ngy. Cn lu phi ngng thuc t t nu khng s lm
huyt p tng vt ln. Tc dng ph: Trm cm kh ming, to bn, ri lon tnh dc.
- Cc thuc tc dng trung ng khc: Guanabenz, Guafacine, Tolonidine, Hyperium.
24
- Thuc dn mch
- Prazosin (Minipres): Tc dng c ch cm th anpha sau tip hp nn c hiu lc tt. Vin
1mg dng liu tng dn t 1-2 vin - 10 vin/ngy nu cn. Tc dng ph: chng mt, ri lon
tiu ha d kch ng, tiu kh, h huyt p th ng, nht l vi liu u tin.
- Dihydralazine (Nepressol) vin 25mg, liu t 1-4 vin/ngy. c dng khi c suy thn, c
nhiu tc dng ph. Nhp tim nhanh, gi mui nc, hi chng gi luput ban , vim a dy
thn kinh ngoi bin khng dng khi c suy vnh, phng ng mch ch bc tch, thng c
ch nh trong tng huyt p c suy thn.
- Minoxidil (Loniten) tc dng rt mnh, ch dng khi tng huyt p khng cc loi khc,
suy thn mn; t dng hin nay.
3. iu tr c th
3.1. nh gi THA theo mc nguy c ca T chc y t Th Gii v Hi tng huyt p Th
Gii (ISH) nm 2003, 2007.
Theo cc bc sau:
* nh gi cc yu t nh hng n tin lng, bao gm:
+ Yu t nguy c ca bnh tim mch:
- Mc huyt p tm thu v tm trng (1-3).
- Nam > 55tui.
- N > 65 tui.
- Ht thuc l.
- Cholesterol ton phn > 250mg%.
- Tiu ng.
- Tin s gia nh b bnh tim.
+ Yu t khc nh hng xu tin lng:
- HDL-C gim.
-LDL-C tng.
-Albumine niu vi th bnh nhn tiu ng.
-Ri lon dung np Glucose.
-Bo ph.
-Li sng tnh ti.
-Fibrinogene mu tng.
-Nhm kinh t x hi cao.
-Nhm dn tc nguy c cao.
- Vng a l nguy c cao.
+ Tn thng c quan ch: nh giai on II ca tng huyt p theo phn ca t chc y
t th gii trc y bao gm: c dy tht tri, tn thng y mt, c prtin niu,...
+ Tnh trng lm sng i km: nh giai on III theo theo phn ca t chc y t th gii
trc y bao gm: suy tim tri, suy vnh, suy thn, suy tun hon no.
3.2. Phn loi nguy c gip tin lng bnh
Bng 1:
THA I THA II THA III
Khng c yu t nguy c
(YTNC)
Nguy c thp Nguy c trung bnh Nguy c cao
25
1-2 YTNC Nguy c trung bnh. Nguy c trung bnh Nguy c rt cao
3 YTNC hoc tn
thng c quan ch hoc
tiu ng.
Nguy c cao. Nguy c cao Nguy c rt cao
Bnh tim mch i km Nguy c rt cao Nguy c rt cao Nguy c rt cao
i vi tng huyt p nguy c thp v trung bnh cn theo di thi gian ri nh gi li huyt
p v yu t nguy c, p dng cc bin php khng dng thuc. i vi nhm nguy c cao v
rt cao cn iu tr thuc ngay phi hp vi khng dng thuc.
* p dng phc iu tr theo c nhn. C th tm lc theo s di (trang sau):
- Trong iu tr 2 loi thuc, loi th 2 c chn vn trong 4 nhm thuc bc 1. Nu tht
bi, sau khi cn nhc cc kh nng khng iu tr, liu lng cha thch hp... th c th
xt n vic phi hp thm loi th 3 nh loi dn mch hay cc loi khng adrenergic trung
ng
- Ch nh chn lc thuc theo phng php iu tr tng c nhn bnh nhn (ca Hi ng
quc gia v tng huyt p ca Hi Tim mch Hoa k JNC VI ).
+ Li tiu: Ngi gi, da en, ph n tin mn kinh, c ri lon nhu m thn.
+ Chn bta: Ngi tr, da trng, nam gii bnh nhn cng giao cm, hot tnh renine cao,
bnh mch vnh, bnh nhn b glaucom v au na u.
+ c ch men chuyn: Tng huyt p nng, khng iu tr, hot tnh renine cao, suy tim
hay suy thn, ri lon tnh dc, tng lipt mu, i ng, tng acide urc mu.
+ c ch canxi: ngi gi, da en, bnh mch vnh, i ng. Bo ph tng huyt p khng
kim sot c bng chn bta th pht sau cng aldosterol nguyn pht, bt lc, tng lipt
mu v tng acide urc mu.
+ Khng adrenergique ngoi bin: Bnh nhn tr b trm ut, hen suyn, bnh phi tt nghn,
i ng tng lipit mu.

X tr THA theo phn nguy c tim mch

Nhng yu t nguy
c, tn thng c
quan v bnh cnh
lm sng
Bnh
thng
Bnh
thng
cao
THA 1 THA 2 THA 3
Khng c yu t
nguy c
Khng iu
tr HA
Khng
iu tr
HA
Thay i li
sng vi
thng ri
dng thuc
nu HA
khng gim
Thay i li
sng vi tun
ri dng
thuc nu
HA khng
gim
Thay i li
sng+ dng
thuc ngay
C 1-2 yu t nguy
c
Thay i
li sng
Thay i
li sng
Thay i li
sng vi tun
ri dng
thuc nu
HA khng
gim
Thay i li
sng vi tun
ri dng
thuc nu
HA khng
gim
Thay i li
sng+ dng
thuc ngay
26
C 3 yu t nguy
c, hi chng
chuyn ho, tn
thng c quan
ch hoc i tho
ng
Thay i
li sng
Thay i
li sng
Thay i li
sng+ dng
thuc
Thay i li
sng +dng
thuc
Thay i li
sng+ dng
thuc ngay
i tho ng Thay i
li sng
Thay i
li sng+
xt dng
thuc
Thay i li
sng+ dng
thuc
Thay i li
sng+ dng
thuc
Thay i li
sng+ dng
thuc ngay
C tnh trng lm
sng i km hoc
bnh thn
Thay i
li sng +
dng thuc
ngay
Thay i
li sng+
dng
thuc
ngay
Thay i li
sng+ dng
thuc ngay
Thay i li
sng+ dng
thuc ngay
Thay i li
sng+ dng
thuc ngay





* iu tr cn tng huyt p cp tnh
Cn phi dng loi h huyt p bng ng tnh mch nh:
27
- Nitroprussiate de Na (Nipride) chuyn tnh mch liu 0,5-2mg/pht (10mg/gi) c chn
dng trong hu ht cn tng huyt p. Tc dng ph: ng c Thiocyanate.
- Nitroglycerine chuyn tnh mch dng bnh nhn c suy vnh cp khi khng chng ch
nh, liu 5 - 10mg/pht.
- Labetalol (Trandate) loi c ch c anpha v bta giao cm, dng tt nhng bnh nhn
nhi mu c tim cp, chuyn tnh mch 1-2mg/pht.
- Anpha Methyldopa hay clonidine chuyn tnh mch.
- Cc loi c ch men chuyn: Captopril 25mg ngm di li.
- Thng phi hp thm Lasix chch tnh mch.
VII. D PHNG
1. D phng cp I
i vi nhng ngi cha b tng huyt p cn lu vn sinh hot hng ngy nht l cc
thi quen c hi sc khe phi khm nh k pht hin tng huyt p hay cc bnh lin
quan. Trong i tng ny ch n nhng ngi c yu t nguy c mc bnh cao cho d
nhng ln u cha pht hin THA nhng cn trao i tuyn truyn phi hp d phng
cng nhn vin y t tuyn trc.
2.D phng cp II
i vi ngi tng huyt p, cn phi cht ch hn na trong ch n ung, ngh ngi
theo di huyt p u n v c k hoch iu tr ngoi tr theo di tin trin, tc dng ph
ca thuc. Cn ch yu t kinh t trong iu tr v y l mt liu trnh lu di, tn km.
VIII. TIN LNG
Tin lng bnh nhn thng ph thuc vo:
- Tr s huyt p: Tr s huyt p cng cao th t l t vong cng ln.
- Cc bin chng: L yu t tin lng gn rt quan trng nht l khi c bin chng.
- V tin lng xa: Cholesterol mu c v tr quan trng v d a n x va ng mch
vnh, nhi mu c tim sau ny.
- Vn iu tr cng gi vai tr ng k, tin lng kh quan nu iu tr sm, ng cch,
c theo di lu di.
IX. KT LUN
Tng huyt p l mt bnh chn on xc nh d nhng vn cn phc tp v bnh nguyn,
c ch, vic iu tr c nhiu tin b nhng khng trnh khi nhng tc dng ph ng k.
Bnh nh hng ln n sc khe con ngi. V vy tng huyt p l vn ln ang c
nc ta v th gii quan tm. Trong iu tr tng huyt p cn ch phi hp iu tr bnh
nguyn v c bit l cc yu t nguy c.


28
SUY TIM
Mc tiu
1. Nu c cc nguyn nhn suy tim.
2. Trnh by c cc triu chng lm sng v cn lm sng.
3. Vn dng c trong chn on suy tim.
4. Hc thuc cc thuc s dng iu tr suy tim
5. Nm vng cc phc iu tr suy tim
Ni dung
I. I CNG
1. nh ngha: Suy tim l trng thi bnh l, trong c tim mt kh nng cung cp mu theo
nhu cu c th, lc u khi gng sc ri sau c khi ngh ngi.
Quan nim ny ng cho a s trng hp, nhng cha gii thch c nhng trng hp
suy tim c cung lng tim cao v c trong giai on u ca suy tim m cung lng tim cn
bnh thng.
2. Dch t hc: Ti chu u trn 500 triu dn, tn sut suy tim c lng t 0,4 - 2% ngha
l c t 2 triu n 10 triu ngi suy tim. Ti Hoa K, con s c lng l 2 triu ngi suy
tim trong 400.000 ca mi mi nm. Tn sut chung l khong 1-3% dn s trn th gii v
trn 5% nu tui trn 75. Ti nc ta cha c thng k chnh xc, nhng nu da vo s dn
70 triu ngi th c n 280.000 - 4.000.000 ngi suy tim cn iu tr.
II. NGUYN NHN
1. Suy tim tri: Tng huyt p ng mch, h hay hp van ng mch ch n thun hay phi
hp, nhi mu c tim, vim c tim do nhim c, nhim trng, cc bnh c tim, cn nhp
nhanh kch pht trn tht, cn cung ng nh, rung nh nhanh, cn nhp nhanh kch pht tht,
blc nh tht hon ton, hp eo ng mch ch, tim bm sinh, cn ng ng mch, thng lin
tht.
2. Suy tim phi: Hp van 2 l l nguyn nhn thng gp nht, tip n l bnh phi mn
nh: Hen ph qun, vim ph qun mn, lao x phi, gin ph qun, nhi mu phi gy tm
ph cp. G vo ct sng, d dng lng ngc, bnh tim bm sinh nh hp ng mch phi, t
chng Fallot, thng lin nh, thng lin tht giai on mun, vim ni tm mc nhim trng,
tn thng van 3 l, ngoi ra mt s nguyn nhn t gp nh u nhy nh tri. Trong trng
hp trn dch mng ngoi tim v co tht mng ngoi tim, triu chng lm sng ging suy tim
phi nhng thc cht l suy tm trng.
3. Suy tim ton b: ngoi 2 nguyn nhn trn dn n suy tim ton b, cn gp cc nguyn
nhn sau: bnh c tim gin, suy tim ton b do cng gip trng, thiu Vitamine B1, thiu
mu nng.
III. C CH BNH SINH
Chc nng huyt ng ca tim ph thuc vo 4 yu t: Tin gnh, hu gnh, sc co bp c
tim v nhp tim.






1. Tin gnh: l ko di ca cc si c tim sau tm trng, tin gnh ph thuc vo lng
Sc co bp
Hu gnh
Tn s tim
Cung lng tim Tin gnh
29
mu dn v tht v c th hin bng th tch v p lc mu trong tm tht th tm trng.
2. Hu gnh: hu gnh l sc cn m tim gp phi trong qu trnh co bp tng mu, ng
hng u l sc cn ngoi vi, hu gnh tng th tc cc si c tim gim; do th tch tng
mu trong th tm thu gim.
3. Sc co bp c tim: Sc co bp c tim lm tng th tch tng mu trong th tm thu, sc co
bp c tim chu nh hng ca thn kinh giao cm trong c tim v lng catcholamine lu
hnh trong mu.
4. Tn s tim: Tn s tim tng s tng cung lng tim, tn s tim chu nh hng ca thn
kinh giao cm trong tim v lng Catcholamine lu hnh trong mu. Suy tun hon xy ra
khi ri lon cc yu 1,2 v 4, suy tim xy ra khi thiu yu t 3.
Trong suy tim, cung lng tim gim, giai on u s c tc dng b tr
- Mu li tm tht lm cc si c tim b ko di ra, tm tht gin, sc tng mu mnh
hn nhng ng thi cng tng th tch cui tm trng.
- Dy tht do tng ng knh cc t bo, tng s lng ti lp th, tng s n v co c
mi nh du bt u s gim st chc nng co bp c tim. Khi cc c ch b tr b vt
qu, suy tim tr nn mt b v cc triu chng lm sng s xut hin.
5. C ch b tr trong suy tim
5.1. B tr ti tim
Gin tm tht: L c ch thch ng u tin trnh qu tng p lc cui tm trng ca tm
tht. Khi tm tht gin ra s lm ko di cc si c tim v theo nh lut Frank-Starling s lm
tng sc co bp cc si c tim nu d tr co c vn cn.
Ph i tm tht: Tim cng c th thch ng bng cch tng b dy cc thnh tim nht l trong
cc trng hp tng p lc trong bung tim. Vic tng b dy cc thnh tim ch yu i
ph vi tnh trng tng hu gnh v ci thin th tch tng mu b gim trong suy tim .

Hnh : T bo c tht bnh c tim ph i v suy tim. S kch thch tng trng dn n s
khc bit v hnh thi hc ca t bo c.
5.2. B tr ngoi tim
30
- Kch thch h thn kinh giao cm: Khi c suy tim h thn kinh giao cm c kch
thch, lng catecholamine t cc u tn cng cc si giao cm hu hch c tit ra nhiu
lm tng sc co bp ca c tim v tng tn s tim. Cng giao cm s co mch ngoi vi nh
da, c, thn v cc tng bng u tin ti mu cho no v tim.
- Kch thch h Renin-Angiotensin-Aldosteron: Tng hot ha giao cm v ti mu ti
thn s kch thch b my cnh cu thn ch tit nhiu renin v lm tng nng renin trong
mu. Renin s hot ha Angiotensinogen v cc phn ng tip theo tng tng hp
Angiotensin II. Chnh Angiotensin II l cht co mch mnh, ng thi li tham gia kch thch
tng hp Noradrenalin u tn cng cc si thn kinh giao cm hu hch v Adrenalin t
ty thng thn. Cng chnh Angiotensin II cn kch thch v thng thn tit Aldosteron lm
tng ti hp thu Natri v nc ng thn.
- H Arginin-Vasopressin: suy tim giai on mun, vng di i- tuyn yn c
kch thch tit ra Arginin-Vasopressin (ADH). ADH lm tng thm tc dng co mch ngoi
vi ca Angiotensin II v lm gim bi tit nc ng thn. C 3 h thng co mch b tr ny
nhm duy tr cung lng tim, nhng lu ngy chng li lm tng tin gnh v hu gnh, tng
nc v Natri, tng cng v mc tiu th oxy c tim, to nn vng xon bnh l lm tim
ngy cng suy thm.
- Nhng yu t khc: Trong suy tim nhm c gng hn ch vic co mch khu tr hay
ton thn qu mc, cc cht gin mch khc cng c gia tng sn xut nh: Bradykinin,
Prostaglandin (PGI2,PGE2), Endothelin v c bit l yu t li niu nh ANP , m ngy nay
ch yu l BNP c xem l yu t quan trng trong vic chng ri lon chc nng tht tri,
lm ci thin tnh trng suy tim.
IV. PHN LOI SUY TIM
4.1. Suy tim cp v suy tim mn
Biu hin ca suy tim ty thuc vo tc din tin v thi gian hin tng tch t
dch m k xy ra. Nhn chung nu bnh tim gc din tin chm, cc c ch b tr c thi
gian hot ha, bnh nhn c kh nng iu chnh ph hp vi tnh trng thay i cung
lng tim. Nu bnh l gc din tin nhanh hoc km yu t thc y suy tim, kt qu c th
l ti mu c quan khng hoc sung huyt cp tnh. Ging tnh mch dn lu v tht b
nh hng, gy ra mt b tim t ngt km theo gim cung lng tim v khi pht cp tnh
cc triu chng.
31
Trong suy tim mn, c ch thch nghi c hot ha mt cch t t v tim ph i dn. Nhng
thay i ny cho php bnh nhn iu chnh v dung np hin tng gim cung lng d dng
hn. Khi suy tim tri xy ra t t, tim phi to ra p lc cao hn p ng vi tnh trng khng
lc mch mu phi cao; trng hp khng lc mch mu phi tng cp tnh ti mc tng t c
th gy nn bnh cnh suy tim phi cp. Bnh nhn suy tim mn c th t c tnh trng b
tr nhng sau c th mt b cp tnh nu c yu t thc y.
4.2. Suy tim phi v suy tim tri
Suy tim thng ch b mt bn nu khi u t ngt (v d: Trong NMCT). Kh nng cha
mu ca h tnh mch bn tri nh hn h tnh mch ton thn bn phi, v tng p lc tnh
mch cng nh cc triu chng km theo ca suy tim tri xy ra khi c s tch t dch tng
i t hn. Mc d qu trnh bnh ban u c th ch lin quan n mt tht, nhng v sau
thng c hai tht u b suy, nht l khi tht tri b tn thng trc. C hai tht c chung
vch lin tht v nhng thay i sinh ha khng ch gii hn bung tht b tn thng m
nh hng n bung tht bn kia. Thm vo , do c bn bung tim nm trong khoang
mng ngoi tim, khi kch thc ca bt k bung no tng ln t ngt, bung tim i din s
b chn p v p lc y tht tng ln (iu ny c nh ngha nh l s ph thuc ln
nhau gia cc bung tht). Suy tim tri thng gy suy tim phi, nhng suy tim phi n c
(V d: Thng lin nh, tm ph mn) him khi gy suy tim tri nu khng c mt bnh l tim
tri ring km theo (V d: Bnh mch vnh vi thiu mu cc b hoc NMCT). cc bnh
nhn b suy tht tri, tim phi suy c th lm gim cc triu chng h hp (kh th khi gng
sc, kh th khi nm, kh th v m) thng c trong suy tim tri .
4.3. Suy tim cung lng cao v suy tim cung lng thp
Phn ln trng hp suy tim thng km theo tnh trng cung lng thp, gy ra nhng
thay i tun hon ngoi bin (co mch), bao gm biu hin u chi lnh, m v xanh tm;
thiu niu; p lc mch thp v chnh lch oxy gia mu trn tnh mch v mu ng
mch thng ln. Suy tim cung lng cao, vn t gp hn, thng kt hp vi trng thi tng
ng tun hon (thiu mu, nhim c tuyn gip, c thai, bnh xng Paget, d ng tnh
mch). Cc tnh trng ny thng lm khi pht suy tim trn nn mt bnh l tim c sn.
Khng ging nh tnh trng suy tim cung lng thp c tnh trng co mch, trong suy tim
cung lng cao bnh nhn c tnh trng gin mch, da m, phng v mch ny mnh.
chnh lch oxy gia mu ng mch v mu trn tnh mch bnh thng hay gim nhng
thng cao hn mc ca bnh nhn suy tim cung lng thp. Mc d ch s tim thng cao
32
hn bnh thng (<4l/pht/m
2
), ni chung ch s ny thp hn trc khi khi pht suy tim v
r rng khng p ng nhu cu oxy tng cao .
4.4. Suy tim pha trc v suy tim pha sau
Tng p lc trong h thng dn mu vo mt hay hai tht (suy tim pha sau), cung lng
tim tng mu i khng (suy tim pha trc), hoc phi hp c hai tnh trng trn gii thch
triu chng lm sng ca suy tim. Suy tim tri gy suy tim phi l mu hnh quan trng ca l
thuyt suy tim pha sau. p lc tm trng tht tri, nh tri v tnh mch phi tng nh
hng dy chuyn lm tng p lc pha sau dn n tng p lc ng mch phi, cui cng
gy suy tht phi v tng p lc tnh mch h thng. Ngoi hu qu sung huyt tnh mch cc
c quan, suy tim pha sau c th gy gim cung lng tim km ti mu c quan km (suy
tim pha trc). Suy tim pha trc c th l gii nhiu triu chng lm sng trong suy tim,
nh l ln do gim ti mu no, mt mi v yu do gim ti mu c vn, v gi mui, gi
nc vi sung huyt tnh mch th pht do gim ti mu thn. Tnh trng gi mui v nc
li lm tng th tch dch ngoi bo v cui cng dn n cc triu chng sung huyt ca tim,
vn do tch t dch nhiu c quan v m ngoi bin.
C ch gy c suy tim pha trc v suy tim pha sau hin din a s bnh nhn b suy
tim mn tnh. Tuy nhin, qu trnh sinh l bnh, nhng bt thng huyt ng hc v tnh
cht khi pht (v d: NMCT cp, thuyn tc phi cp) ca bnh nguyn c th quyt nh
kiu suy tim no chim u th. Trong giai on u, suy tim c th c cung lng tim bnh
thng lc ngh ngi. Tuy nhin khi b stress, v d nh khi hot ng th lc v giai on c
tng nhu cu chuyn ha, cung lng tim khng th tng ln mt cch bnh thng, lc
cu thn gim xung v cc c ch gi mui v nc thn c hot ha. p lc y
tht cng nh p lc trong nh v h thng tnh mch pha sau tm tht b nh hng c th
tng mt cch bt thng trong giai on stress. iu ny c th gy ra s thm dch v cc
triu chng ca sung huyt m trong khi vn ng. Trong nhng giai on sm nh vy, ngh
ngi c th c tc dng li tiu v mt i triu chng nhiu bnh nhn suy tim nh; hot
ng th lc qu mc v lp i lp li s lm xu hn tnh trng huyt ng c iu
chnh v thc y n suy tim .
4.5. Suy tim tm thu v suy tim tm trng
Triu chng c nng v thc th ca suy tim c th do bt thng chc nng tm thu dn
n tim gim co bp tng mu (suy tim tm thu) hoc bt thng chc nng tm trng cu c
33
tim dn n bt thng v y tht (suy tim tm trng). Gim y tht tri do ri lon
chc nng tm trng gy gim th tch nht bp v cc triu chng ca cung lng tim thp,
trong khi tng p lc y dn n cc triu chng ca sung huyt phi. V vy, mt s c
trng ca suy tim (v d: Tht tri mt kh nng cung cp cung lng v pha trc p
ng nhu cu ca c vn khi vn ng, ng thi duy tr p lc y tht bnh thng) c th
ban u l do ri lon chc nng tm trng, v c th xy ra mt s bnh nhn c chc nng
tm thu tht tri bnh thng. Khng c d liu chnh xc no v tn sut ca ri lon chc
nng tm trng dn n suy tim, vi cc chc nng tm thu bnh thng. Tuy nhin nhiu
nghin cu chng minh rng c n 40% bnh nhn trong s cc bnh nhn c chn on
lm sng suy tim c chc nng tm thu tht tri bo tn, v nhiu ngi trong s cc bnh nhn
ny c bng chng ca ri lon chc nng tm trng. Mt vi yu t c th lm tng nguy c
ri lon chc nng tm trng trong trng hp chc nng tm thu tht tri bnh thng.
Nhng yu t lin quan vi ri lon chc nng tm trng tht tri
- Bnh ng mch vnh
+ Thiu mu c tim
+ So v ph i th pht sau nhim trng c tim
- Ph i tht tri
- Bnh c tim gin
- Qu ti th tch
- Gia tng hu ti
- X ha c tim
- Hn ch y
+ Vim mng ngoi tim co tht
+ Bnh c tim tc nghn
+ Bnh thm nhim c tim (v d: amyloidosis)
Biu hin lm sng chnh ca suy tim tm thu l do cung lng tim v pha trc khng
; hu qu chnh ca suy tim tm trng lin quan n s gia tng p lc y tht v p
lc tnh mch pha trc tm tht, gy ra sung huyt phi hoc sung huyt tnh mch h thng
hoc c hai. Suy tim tm thu gy ra do suy chc nng co bp c tim mn tnh sau hoi t c
34
tim do nhi mu trc v s gim sc co bp c tim cp tnh trong thiu mu cc b c
tim. Mt khc, suy tim tm trng cc bnh nhn b bnh ng mch vnh trc tin l do
gim n hi ca tht v tng cng do m c tim bnh thng, n hi b thay th bi
m so x khng cng gin (v d: Vng NMCT) cng nh do gin tm trng ca c tim
bnh thng b gim cp tnh trong giai on thiu mu c tim thong qua. Suy tim cc bnh
nhn b bnh ng mch vnh thng l kt qu ca s kt hp gia ri lon chc nng tm
thu v tm trng .
V. CHN ON
1. Suy tim tri
1.1. Triu chng lm sng
- Triu chng c nng:
C 2 triu chng chnh: Kh th v ho. Kh th l triu chng thng gp nht. Lc u kh
th khi gng sc, v sau tng cn, c khi kh th t ngt, c khi kh th tng dn; ho hay
xy ra vo ban m khi bnh nhn gng sc, ho khan, c khi c dm ln mu.
- Triu chng thc th:
- Khm tim: Nhn thy mm tim lch v pha bn tri, nghe c ting thi tm thu nh
mm do h van 2 l c nng.
- Khm phi: Nghe c ran m 2 y phi. Trong trng hp cn hen tim c th nghe
c nhiu ran rt, ran ngy.
- Huyt p: HATT bnh thng hay gim, HATTr bnh thng.
1.2. Cn lm sng
- X quang: Phim thng tim to, nht l cc bung tim tri, nh tri ln hn trong h 2 l, tht
tri gin vi cung di tri phng v dy ra, phi m nht l vng rn phi.
- in tm : Tng gnh tm trng hay tm thu tht tri. Trc tri, dy tht tri.
- Siu m tim: Kch thc bung tht tri gin to, siu m cn cho bit c chc nng tht
tri v nguyn nhn ca suy tim tri nh h van ng mch ch...vv.
1.3. Thm d huyt ng: Nu c iu kin thng tim, chp mch nh gi chnh xc mc
nng nh ca mt s bnh van tim.
2. Suy tim phi
2.1. Lm sng
2.1.1. Triu chng c nng: kh th nhiu hay t ty theo mc suy tim, kh th thng
xuyn, nhng khng c cn kh th kch pht nh suy tim nh suy tim tri. Xanh tm nhiu
hay t ty nguyn nhn v mc ca suy tim phi.
2.1.2.. Du chng thc th: Ch yu l mu ngoi bin vi gan to, b t, mt nhn, n au
tc, iu tr tch cc bng tr tim v li tiu gan nh li, ht iu tr gan to ra gi l gan n
xp, nu gan b mu lu ngy gan khng nh li c gi l x gan tim vi gan b sc,
mt chc. Tnh mch c ni, phn hi gan tnh mch c (+) t th 450. p lc tnh mch
trung ng v tnh mch ngoi bin tng cao.
- Ph: Ph mm lc u 2 chi di v sau ph ton thn, c th km theo c trng,
trn dch mng phi. Tiu t 200-300ml/ 24gi.
- Khm tim: Ngoi cc du hiu ca nguyn nhn suy tim, ta cn nghe nhp tim nhanh, c
khi c ting nga phi phi, thi tm thu van 3 l do h van 3 l c nng hu qu ca dn
35
bung tht phi. Huyt p tm thu bnh thng, huyt p tm trng tng.
2.2. Cn lm sng
- X quang: Tr trng hp suy tim phi do hp van ng mch phi c c im l phi sng,
cn li cc nguyn nhn suy tim phi khc trn phim thng phi m, cung ng mch phi
gin, mm tim hch ln do tht phi gin. Trn phim nghing tri mt khong sng sau xng
c.
- in tm : Trc phi, dy tht phi.
- Siu m tim: Tht phi gin to, tng p ng mch phi.
- Thm d huyt ng: Tng p lc cui tm trng tht phi, p lc ng mch ch thng
tng.
3. Suy tim ton b: Bnh cnh suy tim phi thng tri hn. Bnh nhn kh th thng
xuyn, ph ton thn, tnh mch c ni t nhin, p lc tnh mch tng cao, gan to nhiu,
thng c c trng, trn dch mng phi, huyt p tm thu gim, huyt p tm trng tng,
Xquang tim to ton b, in tm c th dy c 2 tht.
VI. PHN SUY TIM
1. Theo Hi Tim Mch New York: thng dng nht hin nay.
Chia lm 4 : 1: Bnh nhn c bnh tim nhng khng c triu chng c nng, hot ng
th lc vn bnh thng. 2: Cc triu chng c nng ch xut hin khi gng sc nhiu, hn
ch hot ng th lc. 3: Cc triu chng c nng xut hin ngay c khi gng sc nh, lm
hn ch hot ng th lc. 4: Cc triu chng c nng xut hin thng xuyn k c khi
bnh nhn ngh ngi.
2. Phn suy tim mn theo Trn Trinh & V nh Hi: t x dng hin nay
- Suy tim 1: Kh th khi gng sc, ho ra mu, khng ph, gan khng to.
- Suy tim 2: Kh th khi i li vi vn tc trung bnh, khi i phi ngng li th,
ph nh, gan cha to hoc to t, 2cm di b sn. Phn hi gan tnh mch c (+) t th
45
0
.
- Suy tim 3: Kh th nng hn hoc gim i, ph ton, gan > 3cm di sn, mm,
phn hi gan tnh mch c (+) t th 450, iu tr gan nh li hon ton.
- Suy tim 4: Kh th thng xuyn, bnh nhn phi ngi dy th, gan > 3cm di
b sn, mt chc, b sc, iu tr khng p ng hoc nh li t.
3 . Chn on suy tim theo tiu chun Framingham: tiu chun mi c ch x dng gn
y nhng kh p dng trn lm sng,
Tiu chun chnh Tiu chun ph
- Kh th kch pht v m hoc kh th
t th nm.
- Tnh mch c ni.
- Ran m phi.
- Tim to.
- Ph phi cp.
- Ting nga phi T
3
tim.
- Ph c chn.
- Ho v m.
- Kh th khi gng sc.
- Gan ln.
- Trn dch mng phi.
- Dung tch sng gim 1/3 so vi ti a.
- Nhp tim nhanh >120 ln/pht.
36
- p lc tnh mch tng (> 16cm H
2
O).
- Thi gian tun hon >25 giy.
- Phn hi gan tnh mch c (+).
- Gim 4,5kg/ngy iu tr suy tim.
Chn on xc nh suy tim khi c: 2 tiu chun chnh hoc 1 tiu chun chnh km
theo 2 tiu chun ph.
4. Phn suy tim theo Hunt SA
Suy tim l mt hi chng ca nhiu bnh l khc nhau, c th tin trin khng ngng. iu tr
suy tim cng thay i theo tng giai on tin trin ca bnh. Do , t nm 2001, Hunt SA
v cng s phn suy tim ra lm nhiu giai on: A, B, C, D.
- Giai on A: Bao gm nhng bnh nhn c nguy c suy tim (V d: Tng huyt p, i tho
ng, Hi chng chuyn ho...) nhng cha c tn thng thc th trn tim v cha c triu
chng c nng suy tim.
- Giai on B: L mc tin trin ca giai on A, bnh nhn c tn thng thc th ca tim
nhng cha c triu chng c nng hay triu chng thc th ca suy tim.
- Giai on C: Nng hn, bnh nhn c tn thng thc th ca tim, tin s hay hin ti c
triu chng c nng ca suy tim.
- Giai on D: L giai on nng nht, suy tim khng tr, kh th khi ngh d dng thuc
ti a, cn nhng bin php iu tr c bit nh my tr tim, ghp tim. . .
VII. IU TR SUY TIM
1. Cc thuc iu tr suy tim.
1.1. Digitalis
c a vo s dng iu tr suy tim t lu, hin gi vn cn c s dng rng ri. N
c c tnh sau:
- Tng sc co bp c tim.
- Lm chm nhp tim.
- Lm gim dn truyn trong tim.
- Tng tnh kch thch c tht.
* Ch nh
Digital c ch nh r rng trong suy tim tr c rung nh. Tuy nhin nu l nhp xoang th
vai tr ca n vn cn b tranh ci. Ngoi ra ch nh khc ca n l trong cc lon nhp trn
tht nh rung nh, cung nh, nhp nhanh trn tht kch pht kiu Bouveret.
* Chng ch nh
Tuyt i khi c nhim c digital.
Cc chng ch nh khc:
- Bloc nh tht 2 v 3 khng c my to nhp.
37
- Trng thi tht cng kch thch nng.
- Bnh c tim nghn.
- Thiu oxy.
- H kali mu.
Digital t c li v thm ch c th cn nguy him khi: nhi mu c tim cp (ngoi tr nu c
cn rung nh nhanh), suy tim nhp chm khng c my to nhp, suy tim giai on cui, tm
ph mn, vim mng ngoi tim co tht, suy tim c cung lng tim cao, cc bnh tim do qu
ti chuyn ha nh nhim thit huyt t, nhim bt.
* Giao thoa thuc
Cc thuc sau c th lm tng nng digoxin: erythromycin, tetracycline, quinidine,
amiodarone, verapamine.
Trong iu tr suy tim mn c hai loi hay c dng l digoxin v digitoxin nhng v
digoxin tc dng nhanh, thi nhanh do t hiu qu iu tr nhanh trong khi kh gy ng
c nn c a dng hn. Lu l digoxin thi qua thn v digitoxin thi qua gan v th nu
suy thn nn dng digitoxin trong khi suy gan th nn dng digoxin. ph n c thai
digitoxin qua c hng ro nhau thai trong khi digoxin th khng. Trn thc t khng c mt
phc no hon ton ng cho mi bnh nhn. Liu iu tr ty theo nhy cm ca ngi
bnh vi thuc theo nguyn tc l ngi gi hoc l suy tim vi tim dn rt ln, ngi bnh
gy th phi gim liu thuc. Ni chung liu thng thng iu tr tn cng l digoxin
0,25mg (2 ln / ngy trong vng mt tun sau tr v liu duy tr l1/2 - 1 vin / ngy, ung
cch nht hoc l thm ch c th ung hng ngy khng ngh ty theo i tng. i vi
digitoxin bt buc phi ngh chng hn ung 3 ngy ngh 3 ngy do thi gian na i di.
Vng iu tr ca thuc: digoxin mu 1- 2,5ng/ml, digitoxin mu 15- 35 ng/ml. Tuy nhin i
vi tr em vng hiu qu xung quanh 3 (1ng/ml khi iu tr phi theo di cc triu chng ng
c c thi x tr kp thi.
1.2. Ch ngh ngi v tit thc
Ch hot ng ca ngi bnh ty thuc vo mc suy tim. Khi c suy tim nng phi
ngh ngi tuyt i ti ging bnh. n nht l cn thit di 2gam mui /ngy nu suy tim
I v II, di 0,5gam/ngy nu suy tim II,IV.
1.3. Thuc li tiu
Vn c coi l ch o trong iu tr suy tim tr. Vi suy tim nh th li tiu thiazide liu
va phi cng p ng tt phi hp vi ch n nht. Khng nht thit phi cho sm
thuc li tiu quai tr phi khng c p ng vi Thiazide. Liu thuc Thiazide 25mg (1-4
vin / ngy, Trofurit 40 mg (2-3 vin/ ngy. Hai loi ny l li tiu thi mui cho nn phi
cho tng t mui kali km theo (1-2g/ngy). Khi tnh trng tr nng c th phi hp tng
t vi li tiu gi kali tc dng ng ln xa (Spironolactone) v lc hay c cng
aldosterone th pht.
1.4. Thuc dn mch
* Cc dn cht nitrate
c s dng rng ri nhm gim triu chng h hp (kh th) ca suy tim. Liu khi u
nh sau tng t t nhm trnh tc dng ph nh au u. Liu iu tr i vi Isosorbide
dinitrate khong 120mg/ngy. Tng t c th dng mononitrate, trinitrine dn, molsidomine.
* Cc cht dn ng mch C tc dng ci thin tnh trng cung lng thp. Hydralazine hiu
qu nhng nhc im phi dng liu cao kh thc hin (12 - 16 vin chia 4). Prazosine c
tc dng cng tt nhng b yu i kh nhanh chng sau . Ni chung ngy nay cc thuc ny
t c s dng.
* Cc thuc c ch men chuyn
38
lm ci thin r rt tin lng ca bnh nhn b suy tim. N khng nhng ci thin triu
chng m cn ci thin c c tin lng sng. Nguyn tc s dng phi tun theo nhm
trnh tai bin do thuc c th xy ra nht l nhng bnh nhn ang c dng li tiu. Liu
khi u nh (6,25mg/ngy vi Catopril) sau tng ln ti liu 50 - 150mg/ngy ty theo
trng hp.
1.5. Cc thuc c ch beta
Trc kia c xem nh chng ch nh. Tuy nhin gn y chnh thc a vo iu tr
suy tim. Cc loi thuc sau c chp nhn rng ri: metoprolol, bisoprolol v nht l
Carvedilol. S dng thuc ny theo nguyn tc l cho khi suy tim n nh (khng dng
trong suy tim cp), liu nh tng dn. Vi Carvedilol vin 12,5mg liu khi u 1/4-1/2
vin/ngy.
1.6.Cc cht c ch phosphodiesterase (Amrinone, Milrinone, Enoximone)
C ch tc dng l tng lng AMPc t c hai tc dng:dn ng mch v tng co bp c
tim khng l thuc vo cc th th (. Thuc c dng trong suy tim vi biu hin suy huyt
ng nng sau khi dng dopamin v dobutamin khng c hiu qu.
2. iu tr theo th loi suy tim
2.1.Suy tim cp
Bng 1. Cc bin php x tr trong suy tim cp
1. Bin php chung An thn bng morphin
2. iu chnh cc yu t lm d Lon nhp, thiu mu, tng huyt p
3. iu chnh thiu oxy Th oxy, h hp h tr nu cn.
4. iu tr c hiu Thuc: li tiu, gin mch,tng co bp c tim, bng
ni ng mch ch, phu thut: thay van, ng l
thng bm sinh.

Bng2. Cc thuc dng trong iu tr suy tim tri cp.
Thuc C ch Tc dng sinh l Hiu qu iu tr
Li tiu
*Furosemide 40-80mg tim TM

Li tiu

Gim tin gnh

Chng ph phi
Dn mch
*Morphin 5-10mg TM, TB,
TDD.
*Trinitrin:10-150(g/pht truyn
tnh mach hoc cc dn cht
nitrat dng ngm, ung.
*Nitroprusside: 25-150(g/pht

Dn tnh mch
Dn tnh mch



Dn tiu ng
mch v tnh mch

Gim tin gnh
Gim tin gnh



Gim tin gnh v hu
gnh

Chng ph phi
Chng ph phi



Chng ph phi v
tng lu lng tim
Tng co bp c tim
*Dobutamine: 250-750(g/pht
*Dopamine: 100-600(g/pht


*Digital(lanatoside C,
digoxine)1 ng tnh mch

Ging giao cm

Ging giao cm



Tng co bp tim

Tng co bp tim, gim
hu gnh (liu thp),
tng hu gnh (liu
cao).

Tng lu lng tim

Tng lu lng tim,
tng huyt p (liu
cao).
Chng ph phi lm
39
c ch bm
Na-K ATPase
Tng co bp tim, gim
tin gnh v hu gnh.
gim p lc phi.
2.2.Suy tim mn tnh
* Cc mc tiu iu tr suy tim mn

S 1: Thi x tr suy tim mn
Phc iu Tr Suy Tim (Theo M. KOMAJDA v Y. GROSGOGEAT)
Giai on suy
tim (NYHA)
Phng php kinh in Phng php thay th
I Khng iu tr Khng iu tr
II - Hn ch th lc
- Ch n king mui
- Digital
-Digital + Li tiu Thiazid
- Hn ch th lc
- Ch n king mui
- Li tiu? c ch men chuyn?
- Li tiu + CMC hoc
Li tiu + Dn mch
III - Digital + Li tiu quai.
- Digital + Li tiu + Dn mch
- Li tiu + CMC hoc Dn mch +
Digital ? hoc
- Li tiu + CMC hoc Dn mch +
thuc tr tim?
- Chn bta?
- Ghp tim.
IV - Digital + Li tiu + Dn mch +
Thuc tr tim mi
- Ghp tim


Phc iu tr suy tim theo cc giai on ABCD ca Hi Tim mch Hoa k




40



TL: Jessup M et al. N Engl J Med 2003; 348: 2007 - 2018

Phc iu tr suy tim phn xut tng mu gim theo Hi Tim mch Hoa k

T TL L : : M Ma an nn n D DL L. . H Ha ar rr ri is so on n s s P Pr ri in nc ci ip pl le es s o of f I In nt te er rn na al l M Me ed di ic ci in ne e 1 17 7
t th h
e ed d M Mc cG Gr ra aw w H Hi il ll l, ,
2 20 00 07 7



41

SUY MCH VNH
Mc tiu
1.Nm c nguyn nhn chnh gy bnh mch vnh.
2.Nm c triu chng, cch chn on.
3.Nm c cc th lm sng ca cn au tht ngc
4.Nm vng nguyn tc iu tr, cc phng tin ni ngoi khoa iu tr suy vnh.
Ni dung
I. I CNG
1.1.i cng:
Bnh mch vnh l mt bnh rt thng gp trong s cc bnh tim cc nc pht
trin. C ch bnh sinh ca suy mch vnh l do lng ng m lp di ni mc cc ng
mch vnh. Tnh trng x va tin trin dn dn lm hnh thnh cc mu ng gy thuyn tc
trong lng mch. Bin chng ch yu ca bnh mch vnh l gy cn au tht ngc, nhi
mu c tim v t t.
1.2.Dch t hc ca BMV:
au tht ngc v nhi mu c tim chim khong 6% n ng >50 tui. chu u hng
nm c thm khong 0,3-0,6 % ngi mc bnh. V t l t vong th mi nm c khong 120-
250 ngi cht / 100.000 ngi dn cc nc cng nghip pht trin. T l ny tng ln vi
tui: 800 - 1000 ngi cht /100.000 la tui 65 - 74 i vi nam gii, 300/100.000 i vi
ph n cng la tui (Vademecum clinique 1988).
Vit nam cha c thng k ton dn nhng cc thng k ti cc bnh vin ln cho
thy bnh nhn b bnh mch vnh hu ht tui 50 tr ln. Nm 1996 thnh ph H ni c
khong 200 bnh nhn BMV nhp vin cn thnh ph H ch Minh c khong 400 bnh
nhn.
II. BNH NGUYN
2.1.Bnh mch vnh: l nguyn nhn ch yu.
- a s l do x va mch vnh.
- Khng phi do x va: co tht mch vnh, vim mch (vim nhiu ng mch dng
nt, lupus ban , bt thng bm sinh).
2. Bnh van tim: Bnh van ng mch ch: hp, h van ng mch ch do x va v giang
mai.
3. Bnh c tim ph i:
Hai nhm nguyn nhn sau ny c th gy suy mch vnh c nng trong ng mch
vnh khng c hp.
III. C CH BNH SINH
3.1. C tim v oxy
S tiu th oxy c tim: ph thuc vo:
+ Tn s tim
+ S co bp c tim.
+ Sc cng trong thnh tim: Sc cng ny ph thuc vo p lc trong bung tht v th
tch tm tht.
S gia tng mt trong cc yu t trn s lm gia tng s tiu th oxy c tim. Ni cch
khc s tiu th ny t l theo:
42
-Tn s tim x p lc ng mch tm thu
-Tn s tim x p lc ng mch tm thu x Thi gian tng mu.
3.2. D tr vnh: gm 2 thnh phn: d tr vnh v dng mu vnh.
- D tr vnh (reserve coronaire): D tr vnh c thc hin bng cch ly oxy ca c
tim, hu nh ti a trng thi c bn. D tr lu lng vnh c kh nng gia tng n 300 -
400% tr s c bn. S thch nghi v gia tng nhu cu oxy thng km theo s gia tng song
song ca lu lng vnh. Lu lng vnh ph thuc vo: p lc ti mu v sc cn vnh do
kh nng dn mch di ngoi tm mc.
- Dng mu vnh (flux coronaire): thng ly mu ti a k tm trng. Do kh nng
dn cc mch mu ni tm mc rt yu, v vy khi c gim lu lng vnh s ti mu s xy
ra ch yu di ni mc.
3.3. Kh nng vn mch ca ng mch vnh: ph thuc vo
- Yu t co tht mch
+ Sc bp k tm thu: quan trng i vi tht tri hn tht phi.
+ Cu c bt qua mt ng mch vnh thng tm mc.
+ Kch thch th th alpha, c ch th th bta vi Dopamine liu trn 15mg/kg/ph qua
trung gian noradrenaline, trc nghim lnh, dn xut ca lo mch - thromboxane A
2
-
prostaglandine F - Neuropeptide Y.
- Yu t dn mch
+ Cc cht bin dng do TMCT: adenoside, lactate, ion H
+
, CO
2
, bradykinine.
+ c ch th th alpha - kch thch th th bta vi dopamine liu di 5mg/kg/ph - cc
th th i giao cm kch thch i giao cm qua trung gian acetylcholine, c ch calci, dn
xut nitr - prostacycline - prostaglandine E, EDRF (yu t dn ni mc) - VIP (peptid rut
dn mch: vasodilatator intestinal peptid).
3.4. Tnh trng thiu mu c tim (TMCT)
Xut hin khi c s mt cn bng gia cung cp oxy v nhu cu oxy c tim.
- C ch: c th do hu qu
+ Gia tng nhu cu oxy (thiu mu th pht): khi gng sc s gia tng tiu th oxy c
tim c thc hin qua s gia tng tn s tim, HA tm thu v s co bp c tim. Trong trng
hp hp MV c ngha (>70% ng knh ng mch vnh), lu lng vnh khng th p
ng vi s gia tng nhu cu oxy s a n TMCT.
+ S gim t ngt lu lng vnh (thiu mu nguyn pht): tng ng vi s co tht
mch vnh m khng c tn thng mch mu, tuy vy cng c th xy ra trn mt ng
mch vnh b hp t trc.
Cn au tht ngc xy ra khi nhu cu oxy ca c tim vt qu kh nng chu cp ca h
thng mch vnh. au l biu hin trc tip ca thiu mu cc b c tim v s tch ly cc
cht chuyn ha do thiu oxy. Mt khi c tim thiu mu cc b, pH gim trong xoang vnh,
mt kali t bo, tng sn xut lactat, xut hin cc bt thng ECG, chc nng tht xu i.
Cc yu t xc nh tiu th oxy c tim l nhp tim, s co bp c tim, p lc tm thu. Khi c
tng mt hoc l nhiu yu t ni trn cng vi tnh trng dng mu vnh gim th s to ra
cn au tht ngc.
3.5. Hu qu TMCT:
- V bin dng: tit lactate.
- V huyt ng: ri lon s th gin, gim co dn tht v sau l gim s co bp.
- V ECG: xut hin ri lon s ti cc.
43
- V lm sng: xut hin cn au tht ngc.
III. GII PHU BNH
Mt hoc nhiu ng mch vnh b hp do mng x va. C nhng vng hoi t v x
trong c tim, thng thng khu tr trong lp di ni tm mc. Tht tri c th ph i.
IV. TRIU CHNG
4.1. Triu chng c nng: l cn au tht ngc vi c im sau:
V tr: sau xng c.
Hng lan: xung mt trong cnh tay, tn cng ngn nhn v ngn t ca tay tri, tuy
nhin n c th lan ln vai ra sau lng, ln xng hm di, ln c.
Tnh cht au: c th m h kiu nh c g chn ngc, co tht hoc nh c vt g nng
p ln ngc khng xc nh chnh xc v tr au. Lu l nhng ngi m t im au
chnh xc vng mm tim, au nhi nng thong qua th thng khng phi l au tht ngc
do suy vnh.
Thi gian: au ngn v ko di khng qu vi pht.
au thng khi pht sau gng sc, gim v mt khi ngh ngi hoc l dng thuc gin
vnh. Lnh cng l yu t d gy khi pht cn au.
4.2.Triu chng thc th
Trong cn c th chng c g tuy nhin c th c tng tn s tim v tr s huyt p, nghe
c th c thi tm thu gia v cui tm thu do lon chc nng c nh v thiu mu cc b.
4.3.Triu chng ECG:
in tm trong cn au ngc c ch cho chn on, cho thy cc bin i xy ra
trong cn suy vnh nh ST chnh xung l in hnh, ngoi ra i khi thy ST chnh ln, ri
lon nhp nht l ngoi tm thu tht. Ngoi cn khi ngi bnh ngh ngi ECG thy bnh
thng trong 30% trng hp ngi bnh c au tht ngc in hnh.
Bng 4.1.Phn loi cn TN ca Hi Tim mch Canada (CSS)
Vn ng khi pht cn TN Hn ch hot ng thng ngy
I Gng sc ko di Khng
II i b > 2 khu nh Nh
III i b < 2 khu nh Nhiu
IV Ti thiu hoc lc ngh Nng
V. CHN ON
5.1. Chn on xc nh
5.1.1. Chn on lm sng:
Da trn bnh cnh au ngc c trng nh m t trn xy ra khi gng sc v gim
bt khi ngh ngi. C th khng nh chn on bng theo di ECG thy hi phc tr v bnh
thng cc bin i do thiu mu cc b hoc bng dng test iu tr th vi nitroglycerin
di li thy bin mt cn au trong vng 1-3 pht. Nu khng thy gim au nhanh vi
nitroglycerin c th khng phi au tht ngc do suy vnh hoc l dng nng nht ca suy
vnh l nhi mu c tim.
5.1.2. Chn on cn lm sng
5.1.2. 1. in tim gng sc: gip chn on sm, d hu v theo di iu tr.
44
- K thut: dng xe p lc k hay thm ln, tng dn cng mi 30W i vi xe p
hoc dng biu Bruce i vi thm ln. Cn c chuyn vin theo di ECG v HA lin tc
khi tin hnh. nhy ca phng php: 60% v c hiu 80% trong pht hin mch
vnh. T l t vong di 0,01%.
- Ch nh:
+ Chn on cn au tht ngc n nh hay cn au ngc khng in hnh.
+ Bilan ngi tr c nhiu nguy c bilan b bnh mch vnh n nh c hay khng
iu tr.
+ nh gi hiu qu ca iu tr TMCT
+ nh gi kt qu phu thut mch vnh hay sau nong mch vnh, bilan sau nhi mu
c tim vo ngy th 10-15.
+ nh gi chc nng ca mt s bnh van tim (tr hp van ng mch ch).
+ nh gi chc nng ca suy tim cn b.
- Tiu chun nh gi da vo nhiu yu t nh: ST chnh xung v nm ngang trn
1mm hoc i xung trn 0,08 mm sau phc b QRS; ST chnh ln (him gp); thi gian gng
sc; cng ti a t c; xut hin cn T in hnh; in tm bin i trong hay sau
trc nghim gng sc; huyt p v tn s tim; mc t tn s tim theo l thuyt; xut hin
lon nhp khi lm test v/ hoc c du suy tim tri.
Kt qu test gng sc gn lin vi tui v gii ngi bnh (kh kt lun ph n <55
tui, dng gi >20% ngi < 40 tui trong khi gim cn < 10% ngi > 60 tui).
5.1.2.2. o in tim Holter trong 24 gi: Gip chn on bnh mch vnh im lng, chn on
v theo di cn TN Prinzmetal hoc s gia tng kch thch tm tht.
5.1.2.3. ng v phng x
- Nguyn tc: Kho st s ti mu c tim vng bng cch so snh s phn b cht
ng v phng x Thalium 201 vo c tim khi ang gng sc v sau mt thi gian ti ti
mu khi ngh ngi.
- ch li v hn ch: Nhy hn trc nghim gng sc (80%), c hiu hn (90%) cho
php xc nh vng b thiu mu, nh gi chc nng c tim. Gii hn ca phng php:
dng tnh gi nu c block nhnh tri, gi thnh cao.
- Chp bung tht bng phng x: bm tnh mch cht Technium. C th nh gi s co
bp tng vng v ton b tht tri cng nh chc nng tim tri.
5.1.2.4. Siu m tim v Doppler
* Siu m 2 chiu: nhm mc ch:
+ Phn tch s hot ng tng phn nh gim co bp, khng co bp thm ch ri lon co
bp khu tr, tim bt thng thn chung ca ng mch vnh nh calci ha.
+ Tnh ch s co hi tht tri nhm nh gi chc nng tht tri ton b.
+Vi Doppler gip chn on h van 2 l do thiu mu c tim, p lc mch phi. Cc
bin i v s lm y tht, nh gi lu lng ng mch khi gng sc v ngh ngi.
* Siu m tim gng sc: gip chn on khi thy bt thng vn ng thnh tim cho
nhy cm chn on > 90% nu hnh nh tt.
5.1.2.5.Chp mch vnh:
Bm cht cn quang chp ton b h mch vnh v bung tht.
i vi h mch vnh c gi tr nh gi mc , v tr tn thng mch vnh cng
nh tnh trng ti mu, phn b mch mu, calci ha ng mch, cc bt thng bm sinh.
45
i vi bung tht nhm phn tch s co bp tng phn, chc nng tht tri, ch s tng
mu v h 2 l do thiu mu c tim.
Chp ng mch vnh l phng tin quyt nh nh gi nng ca bnh mch
vnh cng nh chn on khi cc phng tin thm d khc khng cho php xc nh suy
vnh. C th ni chp mch vnh l xt nghim khng th thiu c i vi bnh l mch
vnh c bit khi cn thit phi can thip ngoi khoa, tuy vy y l k thut tn km v i
hi chuyn khoa c kinh nghim.
5.1.2.6.Chp nhp nhy c tim bng Thallium 201 hoc Technitium 99: c nhy 70-90%
v c hiu 60-90% nhng t tin.
5.2. Chn on phn bit
5.2.1. au vng trc tim do ri lon thn kinh thc vt: thng gp trn thc t lm sng
nht l tui tr. au thng mm tim, khng c khi pht khi gng sc m l khi ngh
ngi. Cn au c th ko di hng gi, hng ngy. Ngoi ra c th km thm cc triu chng
ri lon thn kinh thc vt khc.
5.2.2. au do bnh ct sng - xng sn: vim khp, vim thn kinh lin sn. Khm n
au khu tr, au khng c lan.
5.2.3. au do bnh ng tiu ha
-au do co tht thc qun cng sau xng c, c km kh nut, . i khi lan ra hai cnh
tay v cng gim bt sau khi dng nitroglycerin. Chp thc qun cho php chn on chnh
xc.
5.2.4. Hi chng tro ngc d dy - thc qun: gy cm gic nng sau xng c, nng ln
khi nm nga, du bt sau khi dng cc thuc khng acide.
VI. CC TH LM SNG CN AU THT NGC:
6.1. au tht ngc n nh: cn au xy ra khi gng sc.
6.2. au tht ngc khng n nh
- Mi khi pht cn au tht ngc nng (< 2 thng) v/hoc xy ra 3 cn/ngy.
- au khi ngh ngi hoc l ch khi hot ng rt nh nhng.
- Cn au tht ngc tng tin: thuc loi n nh nhng gn y nng hn, au ko di
hn, hay xy ra hn v xy ra vi gng sc nh hn trc.
Bnh nhn c mt trong 3 tiu chun trn c gi l c cn au tht ngc khng n
nh (Harrson 2005).
6.3. Co tht vnh: cn c gi cn au tht ngc Prinzmetal. Xy ra trn mch vnh hon
ton bnh thng hoc l c mng x va gy hp gn v tr ca co tht. au tht ngc c
tnh tng t nhng m trm trng hn v xy ra in hnh khi ngh ngi cng vi hnh nh
on ST chnh ln rt cao trn ECG. Lu l co tht vnh c th gy nn nhi mu c tim
cng nh cc ri lon nhp c tnh. Chn on xc nh da trn chp ng mch vnh c
tim TM Methergin (ergonovine).
6.4. Thiu mu cc b c tim yn lng: c pht hin bi ghi Holter hoc l trc nghim
ECG gng sc ch yu xy ra nhng ngi c thiu mu cc b c tim c triu chng. Ghi
nhn c bin i ST-T nhng v triu chng mc d c bnh mch vnh.
6.5. Nhi mu c tim: Xy ra khi tc mt hoc nhiu nhnh ca mch vnh. Nhi mu c
tim (NMCT) l s hoi t thiu mu nng v h thng c tim vi din tch tn thng 2cm.
6.5.1. Triu chng lm sng: au ngc tng t nh l cn au tht ngc tuy nhin cng
mnh hn nhiu v ko di hn (> 30 pht), t thuyn gim khi ngh ngi v khi dng
nitroglycerine. Tuy nhin c 25% nhi mu c tim im lng v mt lm sng.
6.5.2. Triu chng cn lm sng:
46
6.5.2.1. in tm thng thng
Nhi mu c sng Q: ST chnh ln, T o ngc, sng Q hoi t.
Nhi mu khng c sng Q: ST chnh xung, bin i dai dng ST-T m khng c xut hin
sng Q.
6.5.2.2. Men: tng CPK, CPK-MB, GOT, LDH, Troponin T.
6.5.3.Chn on NMCT
Theo T chc Y t th gii NMCT c chn on xc nh khi c hai trong 3 du hiu
sau: cn au tht ngc bin i, thay i ECG theo tin trin ca bnh v s gia tng men tim.
Mt s trng hp khng th chn on xc nh NMCT m ch c th c NMCT.
Thng th c triu chng lm sng in hnh rt gi nhng m thiu bng chng khch
quan trn ECG v men. Nu lm sng nghi ng nhiu th c th l NMCT nh. Trc mt
bnh nhn nam gii >35 tui, n gii >50 tui c au ngc th phi xem xt c NMCT hay
khng. Phi chn on phn bit vi au do vim phi, tc ng mch phi, vim mng ngoi
tim, gy xng sn, co tht thc qun, phnh tch ng mch ch v nhng tnh hung gy
bnh cnh au bng cp tnh do bnh trong bng.
6.5.4. Bin chng
6.5.4.1. Ri lon nhp: ngoi tm thu, rung tht, nhp nhanh tht, bloc nh tht...
6.5.4.2. Suy tim: c chong hoc khng.
6.5.4.3. Phnh thnh tim.
VII. IU TR
7.1. Nguyn tc iu tr
7.1.1 Ci thin cc yu t nguy c
y l bin php hng u c gi tr v t tn km, p dng c cho cc i tng
giu/ngho nhng i hi s quyt tm v cng tc ca bnh nhn. C th nh thay i li
sng, ch n ung gim m, tp luyn th dc nh: i b, bi li, i xe p, trnh stress.
Theo di, khm bnh, xt nghim lipid u n, lm trc nghim gng sc hng nm.
7.1.2. iu tr cn nguyn
Nu bit c. V d: iu tr x va ng mch bng cc thuc gim m, iu tr phu
thut vi cc tn thng van tim bm sinh hay mc phi.
7.2. Phng tin
7.2.1. iu tr ni khoa
Bng cc thuc nh: dn xut nitrs, molsidomine, chn bta, c ch calci, c ch knh
kali, chng ngng tp.
7.2.2.Nong ng mch vnh qua da (Angioplastie coronaire transluminale percutane)
(PTCA)
X dng mt catheter a vo M vnh qua da xc nh mc hp mch vnh, sau
s x dng mt bong bng nh, ng knh 2-4mm bm ln v tr b hp, c xem kt
qu khi nng c trn 50% so vi khu knh trc, t l thnh cng thng t n 90-95%
trong giai on u tin.
7.2.3.Phng php phu thut cu ni ch - vnh (Pontage aorto-coronaire)
Phng php c thc hin bng cch ghp tnh mch hin trong hoc ng mch v
trong vo v tr mch vnh b tn thng. T vong phu thut khong 1-4%, phng php ny
ci thin d hu v triu chng ca bnh nhi mu c tim.
7.3. iu tr c th:
7.3.1. iu tr cn au tht ngc gng sc
47
7.3.1.1.iu tr ct cn au tht ngc gng sc
- Nn p dng ngay trc khi vo vin v p dng cng sm s c tc dng ngn nga
bin chng xu xy ra.
- Ngh ngi, trnh gng sc.
- Dng cc dn xut Nitrs ngm di li (Natirose vin 0,75mg) c th lp li sau 5
pht hay bm Natispray liu 0,4mg lp li sau 5 pht nu cn, nu khng gim sau 15 pht
cn phi xem xt c phi cn au tht ngc khng n nh hoc nhi mu c tim khng.
7.3.1.2.iu tr lu di cn au tht ngc gng sc:
*Cc loi chn bta
Tr khi c chng ch nh, y l thuc iu tr chn lc cn au tht ngc gng sc,
iu tr hu hiu khi nhp tim ngh ngi t 50-60/ph v khi gng sc di 100/pht. Khi u
bng liu thp, tng dn liu ln khi khng c bin chng. C th:
- Propranolol (Avlocardyl vin 40mg) loi khng chn lc, khng c hot tnh giao cm
ni ti, liu 2-4 vin chia 2 ln mi ngy.
- Atenolol (Tenormine) vin 50-100mg, loi chn lc ln tim nhng c hot tnh giao
cm ni ti, liu 50-100mg, ngy 1 ln.
- Metoprolol (Lopressor) vin 100mg hay Seloken vin 100-200mg, chn lc ln tim,
khng c hot tnh giao cm ni ti, liu 50-100mg/ngy 1 ln.
- Acebutolol (Sectral) vin 200-400mg, chn lc ln tim, c hot tnh giao cm ni ti,
liu 400mg/ngy ch dng 1 hay 2 ln (khi u 200mg/ngy chia 2 ln).
Nu khng p ng cn xem c c ch co tht ng mch vnh trong cn, ch l
khng bao gi ngng t ngt iu tr chn bta v d c nguy c ri lon nhp, nhi mu c
tim v t t.
*Cc dn xut Nitrat
Thng c s dng u tin v phi hp vi 1 loi thuc khc (nh chn bta v hay
chn calci) gm:
- Nitroglycerine (vin hay bm xt) rt t chng ch nh (ngoi tr bnh c tim tc
nghn) v t tc dng ph (thng gp l h huyt p, nhc u).
- Cc dn xut Nitrat n, i hoc Nitrat dng vin hay dng dn.
Hin tng dung np (tolerance) vi cc dn xut Nitrs hay gp vi liu cao, ko di.
Hin tng gim i, nu tn trng khong trng Nitrat, ngha l khng ung Nitrat sau 18h v
khng dn t 20 gi v 8 gi sng, iu ny gii thch s quan trng phi hp vi chn bta
hoc c ch calci c bit bnh nhn c cn au tht ngc ban m.
C th:
- ng ung:
+Trinitrine (Lnitral) nang 2,5 mg v 7,5mg liu: 2 nang/ngy chia 2 ln.
+Isosorbide dinitrate nh: Langoran nang 20-40mg hay 80mg LP. Liu 40-80mg/ngy.
Risordan vin 10-20mg liu 40mg/ngy chia 2,3 ln. Risordan LP vin 20-40mg liu
40mg/ngy.
+ Hay 5- isosorbide mononitrate nh: Monicor LP 20mg ngy ung 2 nang.
+ Molsidomine (Corvasal) khng phi l dn xut Nitrs nhng c tc dng tng t,
ngoi ra cn c tc dng chng ngng tp tiu cu. Bit dc: Corvasal vin 2-4mg, liu 1/2 -
1vin. ch li ca nhm ny l khng c hin tng dung np.
- ng dn: nh Cordipath liu 5mg, dn vo bui sng v bn ngc, nn dn ngt
qung, ch dn vo ban ngy.
48
*Thuc c ch canxi
Nu chng ch nh chn bta (nh suy tim mt b, ri lon dn truyn nh- tht, hen
ph qun, hi chng Raynaud) th ngoi cc dn xut Nitrat v Molsidomine, vic s dng
cc loi c ch calci l thuc la chn nht l trong cn au tht ngc hn hp hay co tht
mch vnh.
C th:
- Diltiazem (Tildiem) vin 60mg hay Bi-Tildiem vin 90-120mg liu 2 vin/ngy trc
khi n hay vin 90mg chia 2 ln/ngy.
th nng: 180mg/ngy chia 3-4 ln, chng ch nh: suy nt xoang, bloc nh tht 2,
3 khng t my to nhp, suy tim tri, c thai. Tc dng ph: nhp chm xoang, bloc nh
tht, ph chi di, suy nhc, bun ng, ri lon tiu ho.
- Nifedipine (Adalate) vin 10mg. Liu 2 nang mi ngy khi n, th nng c th dng 3-
4 nang ngy. Chng ch nh: c thai, tc dng ph, phng mt, nhc u, ph chn, au
bng, h huyt p, nhp nhanh.
- C th phi hp c 2 loi trong th nng hoc khng nong mch vnh c nh:
+ Tenormine 80-100mg/ngy + Adalate 3 nang/ngy hay Monicor LP 1 nang/ngy. Khi
phi hp chn beta v Diltazem cn theo di tn s tim v ri lon nhp xoang.
+ Hoc Seloken 100-200mg/ngy + Corvasal 4mg 3 ln/ngy + Adalate 1 nang 4
ln/ngy. Nitriderm TTS. 5mg dn t 20 gi n 8gi.
+ Hoc ngoi l th khng: Pexid vin 100mg 1 vin/ngy trong 3ngy + sau 2
vin/ngy cn theo di cht ch v tc dng ph nhiu nh: xong, tn thng gan, thn kinh.
*Cc thuc khc
- Thuc hot ho knh kali (Nicorandil) tc dng dn ng mch v tnh mch vnh v
c ngoi bin. Khng gim co bp tim v khng c hin tng khng tr.
- Amiodarone tc dng chng lon nhp v chng thiu mu cc b. Lu tc dng ph.
- Trimetazidine.
- Gim au v an thn.
7.3.1.3.Phng php can thip
-Nong v t stent (gi ): da vo kt qu chp mch v c chng minh c s thiu
mu bng nghim php gng sc thallium. Chng ch nh khng nhiu ngoi tr hp thn
chung ng mch vnh tri hoc ng mch vnh vi ho.
-Bc cu ni ng mch ch - vnh: khi bnh nhn c triu chng lm sng, nong vnh
tht bi km hp ti pht, tn thng nhiu nhnh nht l thn chung vnh tri km suy chc
nng c tim nng.
7.3.2. iu tr cn TN Prinzmetal
- Trong cn: Nitroglycerine hay 1 nang Adalate ngm t t khi nm.
- Tip theo cn phi iu tr bng c ch calci, heparine, dn xut nitrate liu cao, khng
dng c ch bta.
Ch : Chng ch nh phi hp Tildiem vi Cordium hay Tildiem vi Isoptine.
7.3.3. iu tr cn au tht ngc khng n nh
Cn nm ti trung tm hi sc tim mch. Nu
- Nu do co tht (ban m, ngh ngi) cn cho Nitrat v c ch calci.
- Nu do cn TN gng sc tng dn hay nng ln: cho chn beta, Nitrat v/hay c ch
canxi.
C th:
49
- Ngh ngi, monitoring, Oxy.
- Theo di lm sng, in tm v sinh ha (CPK).
- An thn: Tranxene 15-30mg/ngy.
- Chng au: Morphine 1/2 -1ctg di da hoc tnh mch nu dn xut Nitrs khng p
ng.
- Dn xut Nitrat: chuyn lin tc bng bm in nh Risordan liu 2-5mg/gi hay
Lenitral liu 1mg/gi hay Corvasal, khng nn chuyn qa 48 gi.
- c ch calci: Tildiem 3-4 vin/ngy.
- Chn beta: nu khng do c ch co tht mch vnh c th cho Acebutolol 200-400mg/
ngy
hoc Tenormine 80-100ng/ngy.
- Heparine chuyn lin tc 400-800 v/kg hoc heparin trng lng phn t thp
(Enoxaparin 1mg/kg tim di da 2 ln/ngy).
- Aspirine 250-300mg/ngy.
Nu khng p ng d iu tr phi hp nitres + c ch bta + c ch canxi th can
thip mch vnh cp.
7.3.4. iu tr thiu mu c tim im lng
- Cn tng cng iu tr chng au tht ngc.
- Lp bilan mch vnh.
7.3.5. iu tr nhi mu c tim
Nhi mu c tim l mt bin chng trm trng ca suy mch vnh hoc thiu mu c
tim. Vic iu tr phi thc hin ti trung tm hi sc tim mch.
Mc ch iu tr l gim au, hn ch ti a s lan rng vng nhi mu, phng nga v
iu tr ri lon nhp v cc bin chng c hc.
C th:
- Nhp vin ti trung tm sn sc tng cng tim mch theo di lin tc.
- t mt ng truyn tnh mch cp cu x tr thuc.
- iu tr tiu si huyt sm vi streptokinase, APSAC, hay cht hot ha plasminogene
m (tPA) c th gim thiu din tch nhi mu v t vong, hn ch ri lon chc nng tht
tri. nhng i tng thch hp, tiu si huyt cn cho cng sm cng tt ti cc n v
tng cng hoc trung tm chm sc mch vnh. Bnh nhn c ch nh cho trong vng 3
gi sau khi xut hin triu chng th kt qu tt hn c, tuy nhin cho php s dng thuc <12
gi sau nhi mu. Bin chng bao gm xut huyt, ri lon nhp do ti ti mu, v trong
trng hp x dng vi streptokinase c th c d ng. Thuc chng ng (aspirine v
heparine) bt u cng lc vi thuc tiu si huyt. Chp mch vnh tip theo thng ch
nh cho nhng bnh nhn b au ngc ti din hoc trc nghim gng sc dng tnh trc
khi ra vin. bnh nhn chng ch nh tiu si huyt, cn thc hin nong mch vnh sm
m bo lu lng vnh. cc trung tm c can thip mch vnh th nong mch vnh thng
c a chung hn tiu si huyt.
- Kim sot cn au: Morphine sulfate 2-4 mg TM mi 5-10 pht cho n khi ht au
(nu cc triu chng ph xut hin th thuc i khng l naloxone 0.4-1.2mg TM); h huyt
p (nu nhp tim chm x tr bng atropine 0.5mg TM, nu khng c th cn nhc chuyn
dch).
50
- Nitroglycerine 0.3 mg ngm di li nu HA tm thu trn 100mmHg; nu vn cn
au ngc cn cho TM nitroglycerine (bt u vi 10microgam/pht, tng dn n mc ti a
200 microgam/pht, theo di cht ch bng monitor).
- Oxygen 2-4 lt/pht bng xng mi, nhm duy tr nng bo ha O2 >90%.
- An thn nh (V d: Diazepam 5 mg ung x 4ln / ngy).
-n nh chng to bn: Dng cc cht nho phn Vd. docusate sodium 100-
200mg/ngy)
- Chn bta: c tc dng gim tiu th O
2
c tim, hn ch din tch nhi mu, gim t l
t vong. Thuc c tc dng tt trong trng hp tng huyt p, nhp tim nhanh, au tht ngc
tn ti. Lu chng ch nh khi suy tim, HA tm thu <95 mmHg, nhp tim < 50 ln/pht,
bloc nh tht hoc tin s hen ph qun. Cho TM v d metoprolol 5mg / 5-10 pht cho n
liu tng cng 15mg sau cho ng ung metoprolol 25-100mg x 2 ln/ ngy.
- Thuc chng ng/ thuc chng ngng tp tiu cu:
Bnh nhn sau khi c dng tiu si huyt thng c tip ni chng ng bng
aspirine v heparine, thi gian bt u ty thuc loi tiu si huyt. Trong trng hp khng
th dng tiu si huyt c th cho aspirin 80-325mg/ngy v liu thp Heparin 5000 v tim
di da hoc tim tnh mch / 12 gi. Liu heparin hu hiu (thi gian PTT gp i thi gian
chng) sau duy tr bng thuc chng ng ung c khuyn co x dng nhng bnh
nhn suy tim nng, c cc mu ng tm tht chn on bng siu m, hoc c vng ri lon
vn ng ln do NMCT trc.
- Cc thuc c ch men chuyn: gim t vong nhng bnh nhn ri lon chc nng
tht tri khng c triu chng sau NMCT (ch s tng mu di 40%) v c th cho nhng
bnh nhn huyt ng n nh. Vd: captopril 6.25mg liu tt u tin sau tng ln 50mg
ung 3ln / ngy.
VIII. D PHNG
Gm cc bc tin hnh mt cch c h thng:
8.1. Xc nh yu t nguy c
Thu thp ng thi cc thng tin v cc yu t nguy c phi hp cho php nh gi ton
b mc rng nguy c mang tnh c th ca ng mch vnh c li khuyn c hiu.
8.2. Li khuyn c hiu
Dnh cho c ngi cha b v c ngi b ri
- Ht thuc: b hon ton thuc l. Nguy c ht thuc li ln hn khi c nhiu yu t
phi hp. Vic d phng cn ch c bit nu l nam gii.
- Huyt p: cn c ch iu tr theo di cht ch nhng trng hp mc bnh d ch
mi giai on u tin hoc ch tng huyt p gii hn.
- Tng cholesterol mu: cn ch khi cholesterol mu tng trn 220 mg% vi s
khuyn dng ch n c bit cng nh cn phi c khm xt v iu tr thuc khi tng
trn 260mg%.
-Tng cng luyn tp v hot ng th lc nhiu hn. Vic gim cn s lm gim r
cc yu t nguy c.
- i tho ng: iu tr lin tc, c theo di cht ch mt trung tm chuyn khoa l
s chn la thch hp cho bnh nhn.
-Thuc nga thai ng ung: hn ch x dng.


51
BNH C TIM

Mc tiu
1. Nm c nguyn nhn, c c ch bnh sinh 3 nhm bnh c tim khc nhau,
ch yu vo bnh c tim dn l nhm bnh thng gp nc ta.
2. Nm ca triu chng lm sng v cn sng cc bnh c tim dn gip vn dng
trong thc hnh lm sng.
3. Chn on phn bit c ba loi bnh c tim.
4. Bit vn dng iu tr cc loi thuc theo cc tnh hung cng nh bin chng ca
tng bnh c tim.
5. Bit r cc bin php phng nga cc bnh c tim.
Ni dung
I. NH NGHA
Theo bo co ca Lc lng c nhim T chc Y t th gii (TCYTTG): Bnh c
tim l bnh gy tn thng c tim m nguyn nhn thng khng bit r. Bnh thng
khng lin quan n cc bnh nh tng huyt p, bnh tim bm sinh, bnh van tim, bnh ng
mch vnh hay bnh mng ngoi tim.
II. PHN LOI
C 3 loi da vo c ch sinh bnh
- Bnh c tim dn n hay sung huyt (Dilated cardiomyopathy)
- Bnh c tim hn ch (Restrictive cardiomyopathy)
- Bnh c tim ph i (Hypertrophy cardiomyopathy)
y l cch phn loi thng dng nht hin nay da vo khi nim ban u ca Goodwin v
c TCYTTG cng nhn.
Ngoi ra cn c cch phn loi theo nguyn nhn l bnh c tim tin pht v bnh c tim th
pht nhng hin nay t dng. Bnh c tim tin pht cn c tn gi l bnh c tim, cn bnh
c tim th pht gi l bnh c tim c hiu ngha l cc bnh c nguyn nhn r rng hoc
l hu qu ca bnh ca cc c quan khc.
III. DCH T HC
Bnh c tim c m t u tin t nm 1957 v pht hin khp th gii. Tuy vy
ty theo c im chng tc, vn ha, a l ca tng quc gia m tn xut ca cc bnh rt
khc nhau. Bnh c tim dn l nhm bnh gp hu ht cc ni trn th gii, cn bnh c tim
hn ch l bnh him gp nht. Bnh c tim ph i chim t l trung bnh. Bnh c tim dn v
ph i gp cc nc vng chu v Thi bnh dng. Trong khi bnh c tim hn ch li
gp cc vng chu Phi, Nam M, Trung M v mt s vng ti n .
T l mc bnh c tim gin ti Thy in c c tnh l 10/10.000 dn/ nm. Ti
Trung quc trong mt nghin cu ti mt nh my trn 60.000 cng nhn ghi nhn 65
ngi b, trong c 52 ngi b BCT dn v 4 trng hp b BCT ph i. Ti Chandigarh
Chu Phi 3,7% trng hp m t thi c bnh c tim. Trong 38 trng hp pht hin th 28 ca
b BCT dn, 9 ca b x ha c tim ni tm mc, 1 ca b bnh c tim, ph i.
i vi bnh c tim ph i th t l chnh xc cha bit r v d nhm ln cc bnh khc.
Trong khi bnh c tim hn ch hu nh gp cc nc nhit i. Uganda 14%
trng hp t vong suy tim l do x ha c tim- ni tm mc. Nigeria l 10%.
nc ta, hin nay cha c t l ton dn; tuy nhin nhiu tc gi ghi nhn t l
BCT dn chim a s v gy nguy c t vong rt cao.
52

BNH C TIM GIN

I. NH NGHA
Bnh c tim dn l hi chng dn tht tri vi s gia tng khi lng tht ch yu l
tht tri vi ri lon chc nng tm thu hay tm trng m khng c tn thung nguyn pht
mng ngoi tim, van tim hay thiu mu c tim.
Trn lm sng bnh c tim dn c biu th qua s dn hai tht, tht tri nhiu hn
tht phi, do s tr trong bung tht, l ngun gc cc cc mu ng gy tc mch.
V gii phu bnh, l s x ha k c tim, cc t bo c ph i v thoi ha khng
c hiu.
II. NGUYN NHN: Thng iu tr bng cch loi tr.
1. Mt s yu t c ra nh: Nhim trng (entrovirus), dinh dng, ng c (ru), tng
HA, tn thng vi tun hon vnh, min dch, sau sinh.
2. Chn on bnh c tim dn v cn: Ch xc nh khi loi tr cc nguyn nhn bit c.
III. SINH L BNH
1. S dn tht v gim co bp: a n s gim ch s tng mu v s gia tng th tch cui
tm trng. iu ny s lm gim s lm rng tm nh, lm tng p lc nh tri v p lc cui
tm trng ca tht tri. giai on u, nhp tim nhanh b tr vi s gim th tch tng mu
tm thu nhm duy tr lu lng tim (Q = FxV). V sau s xut hin gim lu lng tim, s
gia tng p lc mao mch phi (OAP) v sau cng l s gia tng p lc mao mch phi v suy
tht phi.
2. S gim p lc ti mu thn: a n s kch thch h renine - angiotensine -aldostrone.
iu ny lm gia tng th tch mu nhng gy s co mch ngoi bin. S thiu mu di ni
tm mc thng gp do s gim d tr vnh.
VI. LM SNG
1. Hi bnh
1.1. Tin s
- Tin s c nhn v iu tr hin ti hay trc y.
- Gia nh.
1.2. Triu chng c nng:
- Mt mi, kh th cc mc .
- Ph ngoi bin, au ngc, hi hp, tin s thuyn tc ngoi bin hay no.
2. Khm lm sng
- Tim: Nhp tim nhanh, huyt p ng mch bnh thng hay thp, mm tim lch tri, ting
T3, T4, thi tm thu h hai l v/hay h ba l, cc du hiu ca suy tht phi.
- Phi: Ran m phi, trn dch mng phi.
V. CN LM SNG
1. X quang phi: Tim to vi s gia tng t l tim/lng ngc, du xung huyt phi, trn dch
mng phi.
53

X quang bnh c tim gin: Tim tri ln ton b, phi huyt
2. in tim: Nhp nhanh xoang, bt thng khng c hiu on ST-T, ph i tht tri, bloc
nhnh tri khng hon ton hay hon ton, bt thng nh , sng R gim bin . i khi
c sng Q d nhm hoi t c tim, ri lon nhp nh v nhp tht.

Cc ri lon nhp trong bnh c tim gin: Blc nhnh, blc nh tht hon ton v rung tht
3. Sinh ha: Ion : gim Natri mu, suy thn chc nng, CPK bnh thng.
4. Siu m tim vi Doppler tim
4.1. Siu m 2 bnh in v TM: Dn cc bung tim nht l tht tri, gim ch s co hi, gim
co bp ton th vch tim, c khi khng co bp d nhm suy mch vnh, c th thy cc mu
ng v trn dch mng tim.
4.2. Doppler tim: Tm du h 2 l (c nng), du h 3 l hay h ng mch phi, s ri lon
chc nng tm trng, nh gi cung lng tim.

Siu m Doppler tim: Cc bung tim gin ch yu tht tri, h van 2 l v 3 l
5. Cc phng php thm d c bit:
54
5.1. Chp nhp nhy c tim: Phn s tng mu gim.

Chp bung tim phng x, gim phn sut tng mu tht tri
5.2. Thng tim: cho php nh gi p lc bung tim, s hot ng cc bung tim, cc van tim.
Sinh thit c tim ch cn khi mun tm nguyn nhn.
5.3. Holter nhp, trc nghim gng sc, kch thch tim.
VI. TIN TRIN
1. Bin chng: Suy tim ton b, rung nh, nhp nhanh tht v t t, tc mch ngoi bin v
no b, phi.
2. T l sng trung bnh: 6 thng n 3 nm sau khi xut hin cc triu chng, 20% bnh nhn
c din tin thun li hn.
VII. CHN ON PHN BIT
- Bnh c tim thiu mu tin trin.
- Bnh c tim do tng huyt p tin trin.
- Bnh van tim, c bit l h van hai l nng.
- Bnh c tim tc nghn.
Ni chung, bnh c tim dn nguyn pht c chn on khi loi tr sau khi loi tr tt c
cc nguyn nhn dn tht tri, c bit l bnh mch vnh nng hay h van tim nng.
VIII. HNG IU TR
1. Bin php chung
2. iu tr thuc: kt hp thuc c ch men chuyn kt hp vi chn bta v li tiu c
nh gi cao, ko di s sng cn ca bnh nhn b bnh c tim gin.
3. iu tr bin chng: nh ph phi cp, chong tim, rung nh, ri lon nhp tht.
4. Ghp tim.

BNH C TIM PH I TC NGHN

I- NH NGHA: Bnh c tim tc nghn c tim (BCTTN) l s ph i tt c hay mt phn
lm tc nghn ng tng mu k tm thu. Th ph i vch tim thng gp nht v l
nguyn nhn do tc nghn bung y tht tri.
II- NGUYN NHN: Cha r.
1. Di truyn: Theo nhim sc th tri chim 55% trng hp, c th do:
- Ri lon hot ng cc catecholamines.
55
- S gia tng lu di calcium t bo gy ra s ri lon chc nng c tim v mch mu.
2. Trong 45% trng hp: bnh xy ra n c v khng r nguyn nhn do (2/3 nam gii).
3. i khi bm sinh khng c ngun gc gia nh.
III- SINH L BNH
1. Chc nng tm thu tht tri: ri lon v gim hot ng tng mu tht tri, qua c 2 gii
thch:
- Gradient trong tht tri l hu qu ca s lm rng sm tht tri tng ng. 75% lung
mu tm thu c tng ra 1/3 u k tm thu. S di chuyn van 2 l ra trc (SAM) ch l
hu qu s xon vn ca bung tht tri.
- S di chuyn ra trc van 2 l (hiu qu Venturi) do s gia tng tc qua mt bung y
c th tch thu nh.
2. Ri lon chc nng tm trng tht tri: a n
- Nhng bt thng v s dn n v s lm y tht tri.
- Cc ri lon trn c th ci thin vi cc thuc c ch canxi (Verapamil).

Khi u tm thu Thi k tm thu sm Gia tm thu
S di chuyn l van ra pha trc trong k tm thu bnh c tim ph i
IV- CHN ON XC NH TH THNG THNG BCTTN
1. Hon cnh pht hin: Xy ra ngi tr, tui trung bnh: 25 - 30 tui, khng THA, ph i
vch khng i xng
1.1. Khm h thng: (nghe tim) v bnh nhn thng chu ng tt trong mt s na trng
hp.
1.2. Du hiu chc nng: (khng c hiu) pht hin bng hi bnh.
- Kh th, gng sc, hi hp, nhp nhanh, au ngc khng in hnh xy ra khi gng sc.
- Hi bnh gip xc nh v tin s c nhn gia nh (t t, tui cht b m). C th pht
hin nhng du hiu gi nh: au tht ngc (30%), ngt, xu (25%) nhng ph phi, ri
lon nhp t gp hn.
2. Khm thc th
- Huyt p bnh thng.
- S vng trc tim c du chm mm, lch tri.
- Nghe tim: thi tm thu (90% ca) kiu tng mu gia k tm thu, vng gia tim lan ra
mm, cng thay i theo thi gian, gia tng khi gng sc, ngoi tm thu tht, khi lm
nghim php Valsalva, gim khi ht vo, cc ting tim bnh thng, c T4 thng. C thi
ton k tm thu do h 2 l vi cng gim khi ht Nitrite d Amyle hay khi lm th thut
Valsalva.
56
3. in tim: Khng c du c hiu.
- Nhp tim: thng l nhp xoang, ngoi ra cn gp rung nh (5-10%), ri lon nhp tht.
- Ph i tht tri (60%), c khi 2 tht.
- Ph i vch tim: sng Q thanh mnh (< 0,04), su (50%) V5, V6, D1, aVL.

in tim: Tng gnh tht tri, sng Q su d nhm nhi mu c tim (nhng khng ri lon
kh cc v ti cc tht)

i khi c sng Q rng, gi nhi mu, d iu tr nhm khi c cn au tht ngc.
- Ri lon ti cc thng gp vi ST chnh xung, sng T m tnh.
- Ri lon dn truyn: bloc khng hon ton nhnh tri, bloc phn nhnh tri trc.
4. X quang ngc
- Tim bnh thng nhng khi bng tim ln cn tm du h 2 l vi dn nh tri. ng mch
ch nh, m, khng b canxi ha.
5. Tm thanh : c gi tr hn ch. C th gip iu tr phn bit thi tm thu tng mu vi
thi 2 l. Gip tm ting nga phi v ting T2 tch i nghch l.
6. Siu m tim
6.1. Siu m 2 bnh din: gip xc nh.
- Tnh cht ph i: m bt thng trong vch, phn b ca ph i, tn thng phi hp
vi tht phi.
- C ch tc nghn: lch b phn van 2 l, xon vn bung tht tri.
- Kch thc bung tim (nh tri dn).
- Ch s co hi bnh thng hay gia tng.
- Tnh trng van tim: s di chuyn van 2 l ra trc.
- Mng ngoi tim bnh thng.
- Chuyn ng ra trc van 2 l k tm thu (S.A.M).
- S ng li sm gia k tm thu ca van MC kiu cnh bm. Tuy vy, 3 du ny
khng thung xuyn v khng c hiu.
57

Hnh nh du SAM trn siu m M-Mode
6.2. Doppler tim.
- Doppler mu: cho thy s gia tng tc trong bung tng mu tht tri gia k, du h 2
l phi hp.
- Doppler mch: cho thy nhng bin i c bit ca s lm y tht tri.
- Doppler lin tc: c gi tr cao v cho php xc nh gradient ti a trong bung tht tri, l
d 2 l v p lc ng mch phi.

Hnh nh Doppler xung dng chy ti bungtng mu tht tri tng chnh p tht tri-ng
mch ch (du hiu tc nghn)
6.3. Cc xt nghim c hiu khc
- h tr cho iu tr trc m hay khi c nghi ng tn thng vnh phi hp nh k thut
thng tin, chp mch vnh.
- o in tim lin tc 24-48 gi Holter.
- in tim khuch i cao tm in th chm.
- in tim gng sc khi hp qu kht.
- ng v phng x bng Thallium, IRM... t dng.
V- TIN TRIN
- Suy tim tri.
- Ri lon nhp: rung nh, ngoi tm thu nh, ngoi tm thu tht, nhp nhanh tht.
- Bin chng khc xen k vo: vim ni tm mc, tai bin thuyn tc.
- t t do cn nhp nhanh, nghn bung tht, chim 2-3%.
VI- TH LM SNG C BIT
58
1. Bnh c tim ph i khng c gradient trong tht tri v cn phi s dng cc trc nghim
dc l, da vo tin s gia nh iu tr.
2. Bnh c tim ph i mm: c tin lng nh hn, gp nam gii tui trung bnh 35, c
sng T m, su khng l trc vng tim.
3. Bnh c tim ph i ngi THA ln tui.
- THA trc y khng c tin s gia nh b bnh c tim tc nghn, tin lng kh hn nu
iu tr sm.
VII- CHN ON PHN BIT
1. Lm sng
- Hp van ng mch ch: da vo c im ting tim v siu m.
- H 2 l: hay kt hp bnh c tim tc nghn, da vo Doppler iu tr.
-Xa hn: vi thng tht, hp phi.
2. ECG. Cn phn bit sng Q suy vnh, nu cn chp ng mch.
3. Siu m
- Khi c ph i tht tri, siu m cn tm nguyn nhn (THA, hp ch).
- C th c s phi hp bnh c tim tc nghn v bnh tim THA.
VII- HNG IU TR
- Thuc: chn bta, c ch canxi,disopyramide, amiodarone.
- iu tr phu thut.
- iu tr bin chng nh ph phi cp, rung nh, lon nhp tht.
-Khng sinh d phng.

BNH C TIM HN CH

I- NH NGHA: Bnh c tim hn ch l mt triu chng lin quan n tr ngi lm y
tht vi bt thng chc nng tm trng (s dn c tim) do bnh ni tm mc, di ni mc
v c tim.
II- NGUYN NHN
1. X ha ni mc c tim l nguyn nhn thng gp ca bnh c tim hn ch vng nhit
i. Bnh Loeffler: hay gp Chu u. Cn phi phn bit 3 giai on qua sinh thit c tim:
giai on hoi t sm, giai on thuyn tc v giai on x ha mun.
2. Cc nguyn nhn khc: bnh nhim kt, nhim huyt t, bnh sarcoidose, x cng b, bnh
glycogen, K, chiu x, thi ghp.
III- BIU HIN LM SNG
1. Hi bnh
- Tin s (d ng, i xa...)
- Triu chng: suy nhc, kh th gng sc, suy tht phi, ph c chng.
2. Lm sng: o HA, nhp nhanh xoang thng xuyn, pht hin cc du hiu suy tim (P) (d
nhm vim mng ngoi tim co tht) v du suy tim (T).
IV- CN LM SNG
1. X quang lng ngc: bng tim ln, va phi, trn dch mng phi, cc du hiu dn nh,
xung huyt phi.
59

Bng tim khng ln, cc tm nh ln, phi huyt
2. ECG: Du dy tht (P), tht (T), bin i on ST-T, c th c gim in th ngc vi
thnh tim dy trn siu m tim.

in tim bnh c tim hn ch: Blc nhnh phi hon ton, bin sng cc chuyn o
gim ngc vi thnh tim dy trn siu m tim

3. Sinh hc: CTM: c bch cu i toan tng trong x ha ni mc-c tim. nh lng st
huyt thanh, ferritin. Bilan min dch (x cng b).
4. Siu m tim vi Doppler tim.
4.1. Siu m tim hai bnh din v TM.
- X ha ni mc-c tim: hnh nh cht mm tim tri v / hay tht phi, dn nh, dn TM, cc
mu ng trong bung tim.
-nh gi tnh trng tht, chc nng tim, van v mng tim.
60

Nh tri ln, tht tri kch thc bnh thng (dy), gim chc nng tm trng
4.2. Doppler tim: pht hin h 2 l v cc van khc, ri lon chc nng tm trng nh bt
thng nh dn, dn n tim ca tht.
5. Cc xt nghim c bit khc nh: Thng tim, chp mch, sinh thit c tim, Holter...
V- CC TH BNH C TIM TC NGHN C BIT KHC
1. X ha ni mc c tim: bnh Chu Phi v bn nhit i, tn thng x ha u mm
tim, sau lan ra, bnh cnh lm sng ty theo v tr tht b tn thng.
2. Vim ni tm mc Loeffer: vng n i, bnh nhn tr, tng bch cu i toan, biu hin suy
tim 2 tht v thuyn tc, siu m cho thy dy vch tim khu tr, van 2 l lch ra sau, dn nh,
h van nh tht.
VI- TIN TRIN
1. Chung: V tm thu nng, ri lon nhp nh v tht, thuyn tc.
2. Cho tng bnh: Ammylose: t vong trong 6 thng khi iu tr. Sarcoidose: suy tim, t t.
X cng b: bnh c tim tri, tng p phi. Loeffler: nng.
VII- CHN ON PHN BIT
1. Vim mng ngoi tim co tht.
2. Bnh c tim dn.
3. Bnh c tim ph i.


61
Bng 1: CHN ON PHN BIT BNH C TIM
Bnh c tim dn Bnh c tim hn ch Bnh c tim ph i
Triu
chng
- Suy tim sung huyt, T >
P
- Mt
- Thuyn tc phi v ton
th
- Kh th, mt
- Suy tim sung huyt, bn P
- Cc du hiu ca bnh h
thng: thoi ha bt, st
- Kh th, au ngc
- Mt, ngt, hi hp
Triu
chng
thc th
- Tim to va (rt to
- C T3 v T4
- H van nh tht, nht l
2 l
- Tim to nh(va
- T
3
hay T
4

- H van nh tht, du hiu (p
lc TM khi ht vo (du
Kussmaul)
- Tim to nh
- Rung tm thu mm, mch
ng mch cnh 2 th.- T4
hay gp
- Ting TTT/ vi th thut
Valsalva
X
quang
lng
ngc
- Tim to va (rt to, nht
l tht tri
- Tng p phi
- Tim to nh
- Tng p TM phi.
- Tim to nh (va
- Nh tri ln
in
tim
- Nhp nhanh xoang
- Ri lon nhp nh v tht
- on ST-T bt thng
- Ri lon dn truyn tht
- in th thp
- Ri lon dn truyn tht
- Ri lon dn truyn nh & tht
- Nh tri ln
- Ph i tht tri.
- Bt thng on ST-T
- Bt thng sng Q
- Ri lon nhp nh & tht
Siu m
tim
- Tht tri dn & r/lon
c/nng
- Vn ng bt thng
van 2l tm trng th
pht sau s lm dn bt
thng v p lc lm y
bt thng
- Gia tng dy thnh tht tri
v khi lng tht
- Khoang tht tri bnh thng
hay thu nh
- Chc nng tm thu b/thng
- Trn dch mng tim
- Ph i khng i xng
vch
- Hp bung y tht (T)
- Vn ng bt thng ra
pha trc (SAM) van 2 l
- Tht tri bnh thng hay
nh
Thm
d y
hc ht
nhn
- Dn tht tri v ri lon
chc nng
- Tm nhun c tim vi Fe
201

- Tht tri c k/thc bnh
thng hay nh
- Chc nng tm thu bnh
thng
- Tht tri bnh thng hay
nh
- Gia tng sc co bp tim
- Ph i khng i xng
vch
Bng 2: DU HIU SIU M TRONG BNH C TIM
-(Bung TT
- dy vch TT
- S co bp TT
++ ( )

- ()
- () hay
+ ()
+ () hay

+ ()
hay - ()
Ghi ch: ++: gia tng, -: gim, (: bnh thng
VIII. IU TR
1. iu tr bnh c tim dn
1.1. Bin php chung
- Ngh ngi khi c nhng cn suy tim (T).
- Ch n king mui.
62
- B ru, cc thuc ng c tim v gim co bp tim.
1.2. iu tr thuc (ngoi cn ph phi) kt hp vi loi dn mch v li tiu.
* Thuc c ch men chuyn
L nhm c xem c hiu qu nht v gim t vong do suy tim tri (giai on III v IV
NYHA).
* Phi hp Dihydrazine-dn xut Nitrs
C th dng nhng kh chu ng v phi dng liu cao.
* Chng ng bng khng vitamin K
Khi khng c chng ch nh, c dng trong trng hp dn bung tht nng vi s bin
i chc nng co bp tim, cc mu ng trong bung tht, tin s tc mch.
* Nhiu phc iu tr ang nh gi nh
- Thuc dn mch kt hp vi thuc tng co bp tim.
- Chn beta: cn s dng ti bnh vin vi iu kin khng c chng ch nh, tim cng
kch thch v nn dng liu thp sau tng dn.
1.3. iu tr bin chng
- Ph phi cp.
- Chong tim: dng thuc tng co bp tim (nhm kch thch (: Dobutamin, Dopamin)
- Rung nh: Digital v/ hay amiodarone. Thuc chng lon nhp nhm IA v IC khng c
dng.
- Ri lon nhp tht: amiodarone.
1.4. Ghp tim
1.5. iu tr nhng bnh c tim dn thng gp
- Bnh c tim do nghin ru: cai ru, iu tr suy tim ton b kinh in, n giu vitamine
nhm B. Ch c t bnh nhn sng c trong vng 3 nm nu khng cai ru v iu tr kp
lc.
- Bnh c tim chu sinh: iu tr nh bnh c tim dn chung..Lu khuyn ngng sinh
trnh ti pht.
2. iu tr bnh c tim tc nghn (Bnh c tim phi i)
2.1. Chng ch nh cc bin php sau:
- Gng sc, th thao nng (t t).
- Digital.
- Dn xut Nitrat (tr khi c suy mch vnh phi hp) v cc loi dn ng mch n thun.
- Isoproterenol v cc loi cng giao cm (Dopamine, dobutami).
2.2. Phng tin
* Thuc
Khng thay i t l t t.
+ Chn bta
Propranolol (Avlocardyl 160-320 mg/ngy) c th gim triu chng 30-35% cas.
+ c ch canxi
Verapamil (Isoptine 360 mg/ngy): ci thin triu chng khi khng p ng chn bta, nhng
c nhiu bin chng (h HA, ri lon nt xoang, bloc NT...), v vy ch dng bnh vin.
+ Disopyramide (Rythmodan)
C li v lm gim lon nhp, gim co bp nn gim tc nghn.
63
+ Amiodarone (Cordarone)
Gim du hiu c nng dng khi cc loi thuc trn tht bi hay khi lon nhp tht nng.
* iu tr phu thut
- Phu thut ct c tim vch lin tht phn y.
- Thay van 2 l: khi phu tht trn khng tt, t l t vong do m 5-8%, kt qu gn 90% t 6
thng n 1 nm, lu di ch 70% trong 5 nm.
2.3. Ch nh
* Bnh c tim tc nghn khng triu chng ngi tr
iu tr bng chn (hay verapamil c ch nh khi:
- Tin s gia nh t t.
- Ph i tht tri, r.
- Nghn co bp trong bung tht tri.
Cn theo di lm sng mi 3 thng v siu m mi 6-12 thng.
* Bnh c tim nghn mch nng c triu chng ngi tr
- iu tr ni khoa l ch yu (chn (va /hay verapamil).
- Phu thut cn bn n khi p lc trong bung tht tri trn 50mm tnh trng c bn.
* Bnh c tim ph i bnh nhn THA ln tui
- Mc ch iu tr l phi kim sot THA, gim khi lng tht tri.
- iu tr ni khoa l chnh, dng thuc liu tng dn, theo di p ng bng siu m.
2.4. iu tr bin chng
* Ph phi cp
Dng li tiu, chn Beta (celiprolol, propranolol) v /hay Verapamil.
* Rung nh
Sc in, digital, chng lon nhp loi I.C, Amiodarone, khng vitamin K (ch dng khi rung
nh mn tnh v nh tri gin).
* Lon nhp tht
iu tr thng t hiu qu, c th dng amiodarone n thun hay phi hp chn (v
Verapamil.
* Khng sinh d phng
Khi p dng cc th thut ngn nga vim ni tm mc nhim khun.
3. iu tr bnh c tim hn ch
3.1. iu tr khng c hiu
Khng dng li tiu v dn mch. Digital ch cho khi rng nh. To nhp: khi ri lon nhp
chm trm trng. Chng ng khi c cc mu ng, tc mch.
3.2. iu tr c hiu
* Sarcoidose
Corticotd.
* X cng b
Corticoid v hay c ch min dch.
* Nhim thit huyt t
Trch mu. C li nu thc hin sm. Thuc desferoxamine gip lm gim nhim st c tim.
* iu tr ngoi khoa
64
Khi iu tr ni khoa tht bi. Ct lc lp ni mc b x v thay van tim b nh hng ca
bnh. C ch trn mt s ngi bnh
* Ghp tim
IX. PHNG NGA BNH C TIM
1. Bnh c tim dn
Vic phng bnh hn ch do nguyn nhn cha r. Tuy vy nguyn nhn nhim trng, nhim
virut chng ta c th quan tm iu tr. i vi bnh c tim c hiu nh bnh c tim chu
sinh hay nghin ru th c th ngn nga bng cch gio dc v li sng, nng cao sc khe.
2. Bnh c tim ph i
Do bnh c tnh di truyn nn cn qun l cc trng hp mc bnh.
3. Bnh c tim hn ch
Cn pht hin sm tr di 15 tui qua bch cu acid khng ht.



65
VA X NG MCH
Mc tiu
1.Nm vng mt s gi thuyt v c ch bnh sinh v cc yu t nguy c va x ng
mch.
2.Vn dng c cc triu chng lm sng v cn lm sng trong chn on va x
ng mch.
3.Nm vng nguyn tc iu tr, cc phng tin iu tr chnh.
4.Bit vn dng cc bin php c th c bit l cc thuc iu tr lipid mu trong x tr
v d phng x va ng mch
Ni dung
I. I CNG
T chc Y t th gii nh ngha: Va x ng mch l s phi hp cc hin tng
thay i cu trc ni mc ca cc ng mch ln v va, bao gm s tch t cc b cc cht
lipid, cc phc b glucid, mu v cc sn phm ca mu, m x v cn lng acid, cc hin
tng ny km theo s thay i lp trung mc.
Ni chung va x ng mch l hin tng x ha thnh ng mch bao gm cc ng
mch trung bnh v ng mch ln. Biu hin ch yu l s lng ng m ti lp bao trong
thnh ng mch gi l mng va.
Va x ng mch c pht hin cc xc c Ai cp t 50 nm trc Cng
nguyn. VXM gy ra 2 bin chng nguy him l nhi mu c tim v tai bin mch no.
cc nc cng nghip 50% t vong do tim mch trong nguyn nhn VXM chim 50%.
Ti M ngi trn 60 tui c 88% VXM, ngi gi hn th khng ngi no khng b
VXM. Va x ng mch c hnh thnh t khi cn tr: nghin cu trn 300 lnh M tui
trung bnh 22 cht trong chin tranh Triu tin, khi m t th thy 77% b VXM vi mc
nhiu hay t. nc ta cha c s liu ton dn.
II. NGUYN NHN- C CH BNH SINH
2.1. C ch bnh sinh
2.1.1. Nhc li cu to thnh ng mch
Thnh ng mch cu to bi 3 lp ng tm t trong ra ngoi nh sau:
- lp o trong hay lp ni mc: ch c mt lp duy nht cu to bi cc t bo ni mc
nm trong khong di khng c t bo v ngn vi trung mc bi lp n hi trong.
- lp o gia hay lp trung mc to thnh bi nhng t bo c trn, si collagen v
elastin, gii hn ngoi mc bi lp n hi ngoi.
- lp o ngoi hay ngoi mc l lp m lin kt c cc mch mu nui.
2.1.2. Qu trnh pht trin VXM
Mng va x ng mch c to thnh do s dy ln ca cc thnh ng mch bao
gm mng li m si bao bc chung quanh bi lp m pht xut t khong di ni mc
ca bao trong. Mng VXM gp ch yu cc thn ng mch ln (MC bng, m vnh,
chu i, cnh v ch xung) c bit hay nhng vng xoy mu nh nhng ch un cong
hay ch i.
Mng VXM xut hin sau nhiu nm vi nhng c ch m ngy nay dn dn c
bit r hn:
- Giai on u do ri lon huyt ng ti ch (hin tng xoy mu) lm bin i cu
trc bnh thng ca lp trong. Tn thng xut hin sm nht l tnh trng ph n khng c
m, v sau mi xut hin cc t bo n m di dng cc t bo c ht, t li thnh m di
66
t bo ni m. Giai on ny thnh mch b ri lon to iu kin cho lng ng lipid. Tip
theo l s hnh thnh nhng vt m trn b mt ni mc.
- Giai on hai, mng va n thun xut hin. Mng va dy gia c vng hoi t nm
trong mt v x. Vng hoi t cha rt nhiu acid bo v cholesterol. Mng va x tin trin
rt nhanh lm cho ng mch hp dn.
- Giai on sau cng l s bin i thnh mng va gy bin chng lm tc nghn khu
knh ng mch v tai bin thiu mu cc b. Hin tng ch yu ca qu trnh pht trin ny
l s lot ca lp o trong, ngha l lp t bo ni mc b x rch, mu s chy vo qua ch
lot to nn cc mu t. S rch ca ni mc gy nn s dnh ca tiu cu, xut pht ca
nghn mch, v to thnh cc tc, cc tc s bao ph ch lot. y l khi u ca cc bin
chng v sau. Cc mng va x pht trin ngy cng nhiu, cc mng canxi gn lin nhau, t
chc x pht trin nhiu hn gy bt tc ng mch.

Hnh 1: Tin trin ca mng x va v nhng bin chng ca n
2.1.3. Nhng gi thuyt bnh sinh VXM
C nhiu gi thuyt cp nhng cha hon ton sng t.
2.1.3.1.Gi thuyt p ng tn thng thnh ng mch: Lp ni mc chu nhiu tn thng
khc nhau nh s gia tng cholesterol cao mn tnh hay do chn thng, thuc, vi khun,
min dch d ng, t min. Ni mc khi b tn thng s lm cho n bo gn vo ni mc, di
chuyn xuyn qua ni mc v chuyn thnh i thc bo. i thc bo c kh nng bt gi
cc ht lipid, nht l LDL bin i. S hin din ca i thc bo lm gia tng tn thng
lp ni mc.
2.1.3.2.Gi thuyt t bo: s xm nhp vo thnh ng mch ca bch cu n nhn mt kh
nng thc bo lm tn thng hoc kch thch pht trin cc t bo c trn, i thc bo, t
chc lin kt, pht trin nhng vng tn thng t gy VXM nh thuyt tn thng
nu.
2.1.3.3. Gi thuyt v ti lp th: Cc men ti th t bo thnh mch c th gy thoi ho v
tch t m t bo c trn nht l men cholesterol ester hydrolase.
2.1.3.4. Gii thuyt n dng: ti ni tn thng ni mc ng mch sn sinh nhng dng
isozyme kch thch pht trin t bo c trn ca thnh mch ging c ch to u lnh tnh, sau
l qu trnh to va x.
2.1.3.5. Gi thuyt v tng lipid: y l gi thuyt c nhiu ngi cng nhn nht v:
-C th gy XVM trn thc nghim ng mch vi ch n nhiu m v cholesterol.
- Nhng ngi c nng lipid mu cao hay b VXM hn nhng ngi bnh thng
67
thnh phn cu trc ca mng VXM ch yu l lipid.
Ngoi ra hin nay nhiu tc gi cn a ra gi thuyt mi v c ch bnh sinh x va
lin quan n vai tr nhim trng nh Helicobacter pylori, Clamydia pneumonia,
Cytomegalovirus.
2.2. Cc yu t nguy c XVM
2.2.1.Tng lipid mu:
Hu ht cc kho st dch t hc u xc nhn tng cholesterol mu l nguy c chnh
VXM v l nguyn nhn bnh tim mch thiu mu. Tuy nhin nguy c ph thuc vo loi
lipoprotein chuyn ch cholesterol. LDL Cholesterol c vai tr quan trng i vi bnh sinh
VXM. C th ni rng bt k s gia tng LDL cholesterol mc no trong mu u c
nguy c gy VXM. Lipoprotein (a) hay Lp(a) cng l yu t nguy c cao khi vt qu 0,3
g/l.
Chylomicron hnh nh t c ngha trong vic gy XVM mt phn v n hin din c
trong iu kin sinh l, mt phn ngi ta him thy s gia tng VXM song song vi s gia
tng chylomicron.
HDL Cholesterol ngc li l yu t chng x va cao v chng vn chuyn cholesterol
v gan trong iu kin thnh ng mch qu tha cholesterol, do cn gi chng l nhng
cholesterol tt.
2.2.2. Cc yu t nguy c khc:
- THA: L YTNC rt cao, nht l i vi cc mch mu no. HA cao lm tng sinh t
bo c trn lm dy trung mc ng mch v lm gia tng cht elastin, cht keo v
glycosaminoglycans. p lc do HA cao to ra cng lm d v mng x va cng nh lm gia
tng tnh thm ni mc i vi cholesterol.
- Ht thuc: cng l YTNC chnh, nguy c mch vnh tng gp i ngi ht thuc,
nht l nhng ngi ht 40 iu/ ngy.
- i ng: l nguyn nhn gy ri lon lipid, nn d gy XVM.
-Bo ph, t hot ng.
-Stress.
-Cc thuc nga thai.
III. PHN THEO SINH L BNH TN THNG NG MCH
3.1.Theo tn thng ng mch
- I: Bin i chc nng ni mc. Tn thng ny lin quan n lng cholesterol
cao v cc yu t nguy c.
- 2: Bong lp ni mc. Lin quan n ri lon lipid, thuc l, tiu ng.
- 3: nh hng n c trung mc, mng si c th din tin nng gy nt v. Lin
quan n ri lon lipid, huyt p cao v di truyn.
3.2. Theo tin trin VXM ca Stary: gm c 8 giai on
- Stary 1: Ch c i thc bo cha nhiu ht lipid.
- Stary 2: Di m xut hin.
- Stary 3: Lipid xut hin ngoi t bo ni mc.
- Stary 4: lng ng nhiu lipid ngoi t bo.
- Stary 5: thng tn va x. T bo c trn di chuyn v tng sinh trong mng.
- Stary 6: thng tn c huyt khi hoc xut huyt.
- Stary 7: thng tn vi ho. Lng ng canxi, vi ho v mnh vn t bo.
68
- Stary 8: Mt s v tr tn thng thay th bng cht keo to thnh thng tn si ho.
III. TRIU CHNG HC
Din tin triu chng lm sng thng tri qua 3 giai on:
- Giai on tim tng: cha c biu hin lm sng
- Giai on lm sng: c cc triu chng thiu mu c quan in hnh
- Giai on bin chng cc c quan do s thiu mu cc b gy ra.
Triu chng thng ph thuc vo cc c quan b tn thng.
3.1.VXM ch
Hay gp theo th t l gc ng mch ch, ng mch ngc, ng mch ch bng nht
l ni phn chia ng mch chu.
Triu chng:
- au tht ngc nu c tn thng XVM vnh.
- Nu tn thng ng mch ch: cc triu chng lm sng l triu chng h van ng
mch ch hay hp ng mch ch hoc phi hp.
- Bc tch ng mch ch: nu nng c trng thi au tht ngc d nhm nhi mu c
tim nhng khng p ng thuc dn mch vnh tr Morphine.
3.2. VXM bng
Giai on u nh ch c ri lon tiu ha v sau au bng v m, sau n.
- Khi nng hay hp nng: c th gy xut huyt hay thng d dy,hoi t mc treo, rut.
- Khm c th pht hin ng mch ch phnh gin v bin chng nng ln v gy trn
mu bng, t vong.
- Chn on cn phi hp siu m, siu m Doppler v nht l chp ng mch ch
bng.
3.3. VXM no
Biu hin sm l tnh trng thiu mu vi xong, tai, ri lon tr nh, mau qun; v
sau l ln, khng tp trung c, mt ng. Bin chng nng n l tc mch mu no gy lit
na thn, ri lon ngn ng, ri lon thc hay xu hn l hn m.
3.4. VXM vnh
Vi cc biu hin ca suy vnh mn, hay cp tnh nh nhi mu c tim
3.5. VXM thn
Thiu mu thn lu ngy lm x ha, THA do hp ng mch thn. Xc nh chn on
cn da vo xt nghim nc tiu, siu m, chp mch thn hay sinh thit thn.
3.6. VXM chi di
Tn thng gp hu ht cc ng mch tr ng mch mu bn chn t gp hn. Triu
chng thiu mu chi thng gp vi: t lnh hai chn, cn au cch hi, HA hai chn chnh
lch hay khng bt mch c bn tc mch. Bin chng v sau c th gy hoi t. Chn
on cn da vo siu m Doppler, chp ng mch.
Phn XVM theo Fontaine c 4 giai on:
+ Giai on 1: Khng c biu hin triu chng lm sng
+ Giai on 2: c cn au cch hi gm hai mc :
- 2a: ng knh i b trn 100m
-2b: ng knh i b di 100m
+ Giai on 3: cn au cch hi xut hin khi ngh ngi.
69
+ Giai on 4: hoi t cc u chi.
3.7. VXM ni khc: Him gp hn nh:
- ng mch thi dng: gy nhc u nh bnh Horton hay Migrain.
-ng mch y mt: gy ri lon th gic
-ng mach h khu no tuyn yn: gy i tho nht
-ng mch ty: gy i tho ng
IV. CHN ON
Chn on da vo nhiu du chng v kt qu thm d cn lm sng khng c mt tiu
chun r rt. C th:
- Cc ri lon c nng do thiu mu cc b c quan hoc ngoi bin.
- S hin din ca nhng yu t nguy c.
- Tnh trng ng mch ngoi bin.
- Kt qu xt nghim: soi y mt, xt nghim bilan lipid, chp ng mch cn quang,
siu m doppler.
V. IU TR
5.1. Nguyn tc iu tr
C 3 mc ch chnh
- iu tr cc yu t nguy c chnh: ri lon lipid, i tho ng, tng huyt p, thuc
l trc khi c cc triu chng (phng bnh s cp) hoc sau khi c cc triu chng (phng
bnh th cp).
- iu tr cc bin chng va x ng mch (VXM) s cp v th cp (iu tr chng
ngng kt tiu cu)
- iu tr c hiu tn thng
Mt s nguy c phi hp song song cn iu tr nh: iu tr thay th hocmon trong tin
mn kinh, ch n king trong bo ph, tng hot ng th lc
5.2. iu tr c th
5.2.1. Thay i cc yu t nguy c (YTNC)
Mt s YTNC caVXM c th tc ng nhm ngn chn s tin trin hoc lm gim
dn XVM: ngng ht thuc, kim sot HA, n nh ng mu, trnh dng ru qu nhiu,
tp th dc u n nht l kim sot s ri lon lipid mu. Nhiu nghin cu cho thy s
iu tr c kh nng gim c ngha ng k cc bin chng tim mch, tuy nhin t c tc
dng gim thiu cc mng VXM.
5.2.2. Thuc c ch men chuyn v thuc chn bta
Nhiu nghin cu cho thy hai thuc ny c th gim nguy c nhi mu c tim v bnh
tim do thiu mu cc b ni chung. V d thuc c ch men chuyn gim t 14 n 28% bin
c tim mch; thuc chn bta gim t l t vong sau nhi mu c tim 20%, gim ti pht nhi
mu 25% v gim t t 30%.
5.2.3. iu tr tng lipid mu
iu tr va x ng mch l mt iu tr ton din bao gm nhiu bin php ni v
ngoi khoa, tuy vy mt trong nhng mc tiu c bn vn l thoi trin mng va x c s
lng ng lipid, gim i cc thnh phn lipoprotein mu c hi.
5.2.3.1.Phn loi tng lipid mu theo Friedrickson
L phn loi thng dng nht, kinh in. C 5 th:
- Loi 1: tng ch yu chylomicron, t TG/CT > 2.5.
70
- Loi 2: chia lm 2 th: th IIa: tng LDL-C vi t TC/TG >2.5 v th IIb: tng c
LDL-C v HDL-C, t TG/TC hoc TC/TG <2.5.
- Loi 3: t gp, tng IDL-C, t TG/TC< 2.5.
- Loi 4: tng VLDL-C, t TG/TC > 2.5
- Loi 5: him, tng c chylomicron v VLDL-C.
Trong cc th trn th cn iu tr l IIa, IIb v th IV do nguy c gy va x ng
mch cao.
5.2.3.2.Thuc gim lipid mu
Gm 4 nhm chnh:
- Nhm 1:l cc cht bt gi mui mt. Tc dng chnh l gim LDL-C. y l nhng
resin trao i ion gn vi mui mt trong rut non lm gin on s lu hnh mui mt trong
chu trnh gan rut v kch thch s chuyn cholesterol thnh mui mt trong gan. iu ny s
kch thch s to thnh cc th th LDL do s lm gim LDL huyt thanh. ng u nhm
l cholestyramine (Questran), gim cholesterol 15-30% v triglycerid t 5-15% vi liu dng
4-16 g/ngy. Colestipol liu 5-20 g/ ngy. Tc dng ph: to bn, y bng, bun nn.
- Nhm 2: cc fibrate c tc dng tng hot tnh lipoprotein lipase lm gia tng qu trnh
thoi bin VLDL-C v IDL-C do gim triglycerid. u im l HDL -C gia tng khi x
dng fibrate. Tc dng ph bao gm ri lon tiu ho, gia tng to si mt. Thuc thng dng
nh fenofibrate (Lipanthyl) lm gim CT (15-30%) v TG (15-30%), liu t 100-300mg/
ngy. Gemfibrozil 600 mgx 2ln/ngy hoc Clofibrate 500mg x 2-3 ln/ngy.
- Nhm 3: c acid nicotinic v dn cht. Tc dng khi dng liu cao. C tc dng gim
s to thnh VLDL trong gan do gim HDL. Nicotinic acid gim CT (5-15%) v TG (15-
30%) v lm gia tng c HDL-C. Thuc thng dng l probucol (Lurselle) liu 0.3-0.6g/
ngy. Tc dng ph:phng mt, tng dng mu, tng acid uric mu, ri lon tiu ho, c
cho gan. Cn theo di chc nng gan khi iu tr. Phng mt c th khng ch bng aspirin.
- Nhm 4: l cc statin, lm gim CT >30-50 % v TG 15-50%. y l nhm thuc c
tc dng mnh h cholesterol mu. C ch tc dng l c ch men HMG CoE reductase lm
ngn cn qu trnh chuyn ho to cholesterol ni bo. c ch qu trnh ny s lm gia tng
tng hp th th LDL do s lm gim cholesterol huyt thanh. Thuc thng dng l
Fluvastatine liu 20-40mg/ngy, Lovastatine 10-80mg/ngy, Pravastatin 10-40mg/ngy,
Simvastatin 5-40 mg/ngy. Tc dng ph bao gm kh tiu, bn, au bng, co rt v c th
c vi gan nn cn theo di men gan.
5.2.3.3.Vic chn la thuc
Cn cn c vo s gia tng thnh phn lipid l ch yu.
- Nu tng CT: u tin l cc resine, statin ri n cc fibrate hoc nicotinic acid. C th
phi hp resin vi statin hoc resin vi nicotinic acid
- Nu tng TG: u tin l cc fibrate ri n nicotinic acid. C th phi hp fibrate v
resin hoc nicotinic acid v resin
- Nu tng c CT v TG: u tin l fibrate ri n statine, nicotinic acid. C th phi
hp resin vi nicotinic acid hoc fibrate vi resine hoc resine vi statin.
Vic iu tr tng lipid mu thng phi ko di nhiu thng nhiu nm v chi ph cao
nhiu tc dng ph nn cn phi cn nhc. Ngoi vn iu tr cc yu t nguy c rt quan
trng vic x dng thuc phi lm th no t c mc chun nh CT phi gim di
200mg% v hoc TG di 200mg%.
5.2.3.4.Thuc chng oxy ha
Nh cc vitamine A, C, E, du gan c.
71
5.2.4. Thuc dn mch
Papaverine 0.04g X 2-4 vin/ ngy, Hydergine 3-6mg/ ngy, Tegretol 100mgX 3-6 vin/
ngy. Ngoi ra cn c nhiu ch phm tng t c th p dng Vastarel, Fonzylane, Praxilen,
Torental, Sermion, Trivastal, Cervoxan.
5.2.5. iu tr ngoi khoa
Phu thut ly b cc nghn hoc nong ng mch bng bng kt hp t stent, bt cu
qua ch tt.
5.2.6. Phng nga cc mu ng
Cc mu ng to thnh trn mng VXM lm cho tin trin bnh nhanh v gy ra cc
bin chng nh mch vnh. Aspirin c hiu qu trong phng nga ti pht NMCT cp, liu
dng 100mg/ ngy n thun hoc phi hp dipyridamol (Persantine) liu 75-150 mg/ ngy.
VI. D PHNG BNH VXM
Chia ra 2 mc d phng, tin pht v th pht.
6.1. D phng tin pht
Nhm d phng sm k c khi mi sinh:
- Bo m ch sa m, trnh cc thc n lm tng lipid nh ng v tinh bt.
- Gim mui trong ch n nhm lm gim tng huyt p. m bo ch n nhiu
rau qu, nn n nhiu c ti. Khng ht thuc l.
- C ch luyn tp d phng bo ph. Tp th dc ty theo mc u c tc dng
chng tng lipoprroteine c hi.
- Sinh k hoch trnh tng cn sau sinh.
6.2. D phng th pht: yu t nguy c gy bnh nh thuc l i tho ng, tng
huyt p. Gim stress, tng cng hot ng th lc.
- Theo di v iu tr cc bin chng ti cc trung tm u n c theo di nhm trnh
ti pht.

72
CC THUC CHNG LON NHP TIM
Mc tiu
- Trnh by uc nh ngha ca ri lon nhp tim
- Nm vng c cch phn loi cc thuc chng lon nhp
- Nm vng c mt s thuc chng lon nhp tiu biu.
- Nm c ch nh iu tr.
Ni dung
I. NH NGHA
Ri lon nhp tim l s ri lon hot ng in sinh hc ca tim v ba mt:
- S to thnh xung ng
- S dn truyn xung ng
- Phi hp c hai mt trn
II. PHN LOI
Thuc chng lon nhp tim c chia lm 4 nhm theo phn loi ca Vaughan-William.
- Nhm I: c tc dng n nh mng t bo ngha l c ch dng Natri nhanh qua mng t bo
vo lc kh cc. Trong nhm ny chia lm 3 phn nhm:
+ Nhm Ia: ng u l quinidine, c tc dng gy t mng, lm ko di thi k tr
hiu qu v in th ng. Thuc c tc dng c ch co bp tim.
+ Nhm Ib: c tc dng gy t mng nh hn. Ngc li, c tc dng rt ngn thi k
tr hiu qu v in th ng. t c ch s co bp tim. i din l Xylocaine.
+ Nhm Ic: c c 2 tc dng trn nhng khng thay i thi k tr v in th ng.
i din l flecaine.
Cc thuc chng lon nhp nhm I






73

- Nhm II: l thuc c ch cc th th giao cm bta, gim nng catecholamine. C tc
dng c ch co bp tim. ng u l propranolol. Nhm ny c 2 tiu nhm: nhm chn lc
ln tim v nhm khng chn lc ln tim, trong c thuc c tc dng giao cm ni ti v
thuc khng c tc dng giao cm ni ti.
- Nhm III: ng u l amiodarone. C tc dng ko di thi k tr v in th ng thng
qua tc dng c ch knh kali ra khi t bo. t lm gim s co bp tim.
- Nhm IV: nhm c ch knh canxi chm vo trong t bo. c ch c s dn truyn ln t
ng. Lm gim s co bp tim. ng u nhm l verapamil.
Ngoi ra cn c mt s thuc c tc dng chng ri lon nhp tim nhng cha phn loi chnh
thc vo nhm ca Vaughan-Williams. l digital v ATP.
III. NHNG THUC CHNG LON NHP CHNH
1. Quinidine: nhm Ia ca Vaughan-Williams, hin nay t dng v tc dng ph nhiu.
Liu lng: quinidine sulfate tr em 30-60mg/kg/ngy chia lm 4 ln; ngi ln: 300-
600mg/ngy chia lm 4 ln. Loi tc dng chm c liu tng cng tng t.
Bi tit: qua gan.
Tng tc thuc: amiodarone, cimetidine, verapamil lm tng nng quinidine trong mu.
Phenyltoine, phenobarbital, rifampicine lm gim nng quinidine trong mu. Quinidine
cn lm tng nng digital khong 50%, cng nh tng tc dng ca warfarine.
c tnh: chn n, nn, bun nn. Gy lon nhp khong 15% ngi ln trong c xon
nh v ngt.
2. Disopyramide (Rythmodan): nhm Ia ca Vaughan-Williams
Liu lng: ngi ln 300-1000mg/kg/ngy, chia lm 4 ln.
Bi tit: 50% qua thn v 50% qua gan.
Tng tc thuc: atenolol, erythromycine lm tng nng disopyramide. Tng tc dng ca
warfarine v tng c tnh ca lidocaine.
Tc dng ph: kh ming, b tiu, nhn m, to bn, lm suy tim nng do gim co bp tim,
gy lon nhp.
Tc dng ph cc thuc chng lon nhp

74
3.Lidocaine (Xylocaine): nhm Ib ca Vaughan-Williams.
Liu lng: liu tn cng bng ng tnh mch 0.5-1.0 mg/kg/ln. C th lp li sau 5-10
pht khi c kt qu, liu ti a l 5mg/kg. Liu duy tr: 20-50microg/kg/pht, gim liu nu
dng thuc trn 24 gi.
Bi tit: qua gan.
Tng tc thuc: thuc c ch bta, cimetidine lm tng nng lidocaine. Phenyltoine,
phenobarbital, rfampycine v isoproterenol lm gim nng . Tng c tnh lidocaine khi
dng phi hp disopyramid.
Tc dng ph: ch yu ln h thn kinh nh co git, d cm, mt cm gic v ngng h hp.
4. Flecaine: thuc nhm Ic
Liu lng: ngi ln ung 200-400mg/ngy.
Bi tit: 50% gan v 50% thn.
Tng tc thuc: amiodarone, cimetidine lm tng nng thuc trong mu. Propranolol lm
tng nng c hai trong mu. Tng nng digital khong 50%.
Tc dung ph: cc biu hin thn kinh nh run, dau u, d cm, gim i khi gim liu. Lm
gim co bp tim nn khng dng khi c suy tim. C tc dng gy lon nhp tim nu dng
bnh nhn c tn thng c tim.
5. Propranolol: nhm II ca Vaughan-Williams
Liu lng: ung 2-5mg/kg/ngy chia lm 4 ln. ng tnh mch 0.1-0.2mg/kg/liu trong 5
pht. C th lp li sau mi 6 gi.
Bi tit: qua gan.
Tng tc thuc: cimetidine, furosemide, quinidine lm tng nng thuc. Phenyltoine,
phenobarbital, rifampicine lm gim nng trong mu.
Tc dng ph: lm chm nhp tim, tng bloc tim, tng suy tim, co tht ph qun, lm tng
ng mu, c th trm cm, lit dng.
6. Amiodarone: nhm III ca Vaughan-Williams.
Liu: ung tn cng ngi ln 10mg/kg chia 2 ln / ngy trong 10 ngy sau gim liu
duy tr 5 mg/kg/ ngy trong 2 thng ri gim li na liu.
Tng tc thuc: amiodaron lm tng tc dng ca warfarine khong 100%, digoxine 70%,
quinidine 33% v procainamid 50%. Thuc lm tng nng ca flecaine, phenyltoine. C
tc dng hp ng vi thuc c ch bta, chn canxi nn khng dng phi hp cc loi ny
khi c suy tim.
Tc dng ph: rt t. C th gy vim phi, lng ng kt mc mt, ri lon chc nng ti
gan, tuyn gip, xm da nu iu tr lu di.
7. Adenosine: thuc khng nm trong phn nhm Vaughan-Willams nhng c tc dng chng
lon nhp tim tt nn c tc gi xut nhm VI. (Digital c xut nhm V)
Liu lng: chch tnh mch nhanh liu 50-250microg/kg. C th nhc li sau 5-15 pht.
Bi tit: tc dng cc ngn, ch di 10 giy.
Tng tc thuc: dipyridamol, diazepam lm tng nng adenosine. Theophyliine v
quinidine lm gim nng thuc. Adenosine c th c tc dng hp dng vi verapamil.
Tc dng ph: kh th, au ngc, nn nhng gim nhanh.


Dc ng hc cc thuc chng lon nhp
75

IV CH NH IU TR
- Thuc chng lon nhp Ia: thng dng iu tr lon nhp trn tht.
- Thuc nhm Ib: ch x dng cho lon nhp tht.
- Thuc nhm Ic: ch dng iu tr cc lon nhp trn tht.
- Thuc nhm II: ch yu dng cho lon nhp trn tht bnh nhn c hi chng tin kch
thch v i khi c dng phi hp thuc nhm Ia iu tr bnh nhn rung nh hay
cung nh. Tc dng km i vi lon nhp tht.
- Thuc nhm III: tc dng tt c trn tht v tht.Thng dng khi dng nhm I n c
hoc phi hp nhng tht bi.
- Adenosine: c tc dng ct cn nhp nhanh kch pht trn tht rt tt.
Tng tc cc thuc chng lon nhp

76
IN TM BNH L
Mc tiu
1. Nm vng c ch bnh sinh v in tm cc hi chng bnh l c tim.
2. Vn dng c cc tiu chun in tm trong chn on lm sng.
Ni dung
I. I CNG CC T TH IN HC CA TIM
1. V tr in hc v gii phu ca tim
Tim bnh thng c tm tht phi chim mt trc tim, cn tm tht tri nm phn tri
- bn v sau ca tim. Trc tim bnh thng i t y tim n mm tim trc tim hng t sau
ra trc xung di v qua tri. Tuy vy do nhng yu t bnh l v sinh l khc nhau, t th
in tim c nhiu thay i, nhng thay i ny pht sinh do tim quay theo 3 trc chnh.
- Trc trc - sau: i qua tm ca qu tim. Khi xoay theo chiu kim ng h, tim s t th
thng ng. Khi xoay ngc chiu kim ng h t th tim s nm ngang.
- Trc dc: i t gia y tim n mm tim. Khi xoay theo chiu kim ng h, tm tht phi
s chim ton b mt trc tim v tm tht tri s chuyn ra sau, xung di. Khi xoay ngc
chiu kim ng h, tm tht tri s chim phn ln pha trc ca tim.
Bng 1: Cc biu hin ca in tim theo t th tim
Trc xoay ca tim Chuyn o tim Biu hin in tim Biu hin in tim
1- Tim quay quanh
trc dc

- Trc tim
- D
- VR
Tht (P) ra trc
RS V5, V6
S
I
Q
III

rS, QR, Qr
Tht (T) ra trc
RS V2, V1
Q
I
S
III

2- Tim quay quanh
trc trc sau

- Chuyn o thng dng
- VL
Mm tim sang (P) SI,
RIII
QS rS
Mm tim sang (T)
RI SIII
qR, qRS
3- Tim quay quanh
trc ngang

- Chuyn o thng dng
- aVF
Mm tim ra trc
QI, Q II, Q III
qR
Mm tim ra sau
SI, SII, SIII
QS, Rs
- Trc ngang: hng t phi sang tri, i qua trung tm ca khi c tim. Nu tim quay
v pha trc, mm tim s hi xoay ra trc v y tim ra sau. Cn nu tim quay ra pha sau,
s bin i s ngc li. Thc t khi tim quay bao gi cng theo c 3 trc trn.
2. T th in hc
T th in hc tim gip ta nhn bit c s thay i ca in tm , hiu thm c
ch pht sinh v hnh dng cc sng trn cc chuyn o khc nhau. Thc t ngi ta hay xc
nh t th in tim theo Wilson. Phng thc ny cho php ta xc nh t th tim quay theo
trc hay gp trc trc sau. C 6 t th trong t th trung gian hay gp nht, tim bnh l
v phn ln cc ca dy tht tri thng c s lin quan gia t th tim v trc in tim.
Bng 2: Cc t th in hc ca tim
T th T Trc T Cc phc hp tht ging nhau
1- Nm ngang
2- Na ngang
3- Trung gian
4- Na ng
0
o
- 30
0

0
o
0
o

0
o
30
o
0
o
60
o
VL V5, V6
VL V5, V6
VL V5, V6
VL thp
VF V1, V2
VF thp
VF V5, V6
VF V5, V6
77
5- Thng ng
6- Khng xc nh
0
o
90
o
khng xc nh
VL V1, V2

VF V5, V6

II. HI CHNG DY C TIM
Khi c tim b dy ln s dn n s thay i v in sinh l v v tr ca tim do:
- Khi lng c tim tng ln.
- S xoay ca tim, s thay i v tr ca cc phn c tim b dy trong lng ngc.
Da vo s thay i c th chn on bnh tim khi c tim b dy ra.
1. Hi chng dy nh
Bnh thng 2 nh bp khng ng b. Nh phi bp trc nh tri. Phn u sng P
ni ln hot ng ca tm nh phi, phn gia sng P l hot ng 2 nh v phn cui l hot
ng ca nh tri. Khi nh phi dy s gia tng thi gian kh cc ca n ch trng ln qu
trnh kh cc ca phn cui nh tri nn chng ta ch thy s nng ln ca sng P. Tri li khi
nh tri dy thi gian kh cc s tng ln r rt v lm s khng ng b 2 nh r hn.

1. Bnh thng, 2. Dy nh phi, 3. Dy nh tri, 4. Dy 2 nh
1.1. Dy nh tri:
1.1.1. Nguyn nhn:
- Hp 2 l, thng gp nht (cn gi l P hai l).
- H 2 l, hp h van MC, tng HA.
1.1.2. Triu chng:
- Sng P rng trn 0,12 , c th lm mt c khong PQ, l triu chng c bn v sm nht.
- Sng P ch i, hai nh, khong cch 2 nh trn 0,03, nh sau thng cao hn nh trc
cc chuyn o ngoi bin. chuyn o V1, V2 c sng P 2 pha vi pha (-) > pha (+).
chuyn o thc qun bin nh tng cao gp 5 - 10 ln chuyn o ngoi bin.
- Trc sng P trn mt phng trn lch tri + 30
0
n + 45
0
.

Tng gnh nh tri: Sng P rng>0,12s, thy r D
1
D
2
v V
1
(P 2 pha, pha m>pha dng)
78
1.2. Dy nh phi
1.2.1. Nguyn nhn:
- Tm ph mn (cn gi l P ph ).
- Cn gp trong h van 3 l, bnh tim bm sinh nh t chng Fallot, thng nh...
1.2.2. Triu chng:
- P cao nhn > 2,5 mm, nu trn 3mm l chc chn, c khi ch nhn ch khng cao do trn
dch mng ngoi tim hay kh ph thng.
- Thng thy sng P cao nhn D
2
, D
3
aVF.

Tng gnh nh phi: P cao nhn D
2
, D
3
aVF v V
1
, kt hp vi tng gnh tht phi (Sng R
cao V
1
)
1.3. Dy hai nh: Phi hp hai hi chng trn, lu d chn on nhm vi blc lin nh.

Tng gnh 2 nh vi sng P va cao va rng
1.3.1. Nguyn nhn: Thng gp l do tn thng c van 2 l v van 3 l, thng nh...
1.3.2. Triu chng: Ch yu l sng P rng.
- ngoi bin: C th sng P rng v cao hoc c du dy nh tri nhng P c nh trc ln
v rng hn.
- trc tim: chuyn o V1, V2: c th gp P di 3 hnh thc:
+ Sng P hai pha kiu pha dng ln hn pha m + bin cao + nhnh ni in rng
+ hoc sng P cao trn 3mm
+ hoc sng P m rt su.
2. Hi chng dy tht
Cc biu hin chung ca dy tht l.
79
- Bin sng R cao ln do cc si c tim gia tng v s lng v di (c khi sng R
khng cao do tc ng trung ha v in hc).
- Dn truyn chm tr th pht trong tm tht lm QRS dn rng.
- Thay i trc in tim v t th in hc tim.
- Nhnh ni in xut hin mun do dy c tim lm s dn truyn t ni tm mc ra thng
tm mc chm i.
- Vng chuyn tip (RS) lch tri hay phi.
- S thay i ti cc do s mt cn i gia khi lng c tim v kh nng cung cp mu.
C 2 khi nim cn bit lin quan n s bin i ti cc, tuy rng cng c g tr
tng i. l:
- Tng gnh tm thu: l s tng gnh tht ca ng tng mu k tm thu nh trong hp
MC, hp MP. C tim dy ng tm lm on ST - T bin i ngc chiu QRS.
- Tng gnh tm trng: l s tng gnh tht do lng mu dn v tht k tm trng nh
trong h van MC, h 2 l. Khi c tim dn ra lm s bin i ti cc nh nhng hn. Sng
T thng dt, dng. on ST c th chnh xung i vi dy tht tri. Trong tng gnh tht
phi s c ri lon dn truyn trong tht.
2.1. Dy tht tri
2.1.1. Nguyn nhn: Tng huyt p, h van MC, thiu nng vnh mn tnh, hp van MC,
h 2 l, cn ng ng mch, hp eo MC.
2.1.2. Triu chng
2.1.2.1. Phc b QRS
+Chuyn o trc tim
* Phc b QRS dn rng t 0,11 - 0,12 - qu gii hn ny phi nghi c bloc nhnh
tri.
* Sng R V5, V6 > 25mm - 30mm (i vi ngi c thnh ngc mng). C khi R
khng cao do t th tim xoay phi hay tri qu mnh, khi cn xc nh mm tim t
in cc thm d.
* Nhnh ni in trn 0,45s trong 2/3 trng hp.
*Sng Q bao gi cng c mt v c xu hng su hn (dy vch lin tht tri) nhng
khng qu 1/4 chiu cao sng R i sau n, chiu rng sng Q trn 0,04.
*Sng S mt hoc rt nh, nu S r phi xem chng c phi hp bloc hay dy tht
phi hoc tim xoay tri qu mnh, hoi t...
* V1, V2 sng S di ra, t s R/S nh, i khi c dng QS.
* Vng chuyn tip dch phi.
+ Cc ch s:
* Sokolov-Lyon: SV1 + RV5 trn 35mm hoc tng s sng R+S ln nht trong cc chuyn
o trc tim trn 45mm.
* Du Shane: sng Q V5, V6 > 4mm km theo cc du hiu khc ca dy tht tri.
Trong ch s Sokolow- Lyon l ng tin cy nht; nhng lu phi trn 25 tui
mi c gi tr cao.
80

Tng gnh tht tri tm trng: Sng R cao, cc tiu chun dy tht tri, trc tri =-5
0
,
T(+) nhn, c sng q
+ chuyn o ngoi bin: trc in tim lch tri do chu nh hng ca t th in hc ca
tim.
* T th nm: chuyn o D1, aVL c dng R hay QR, R ca aVL trn 12mm Tng
R1 + S3 tng c khi trn 26mm. Ch s White-Bock:Tng i s QRS1-QRS3 trn 18mm
(bnh thng t 15mm n 18mm).
*T th ng hay na ng: D3 v aVL c dng QR hay R, sng R aVL trn
20mm. D1 v aVL c dng RS.
*T th trung gian: 3 chuyn o mu v aVL, aVF c dng R hay qR.
- on ST-T:
+ Tng gnh tm thu: ST-T c xu hng ngc chiu QRS.
+ Tng gnh tm trng: sng T lun lun (+) v nhn, ST hi lch xung cht t.
2.1.3. Cc du hiu phi hp: c th gp.
- Bloc nhnh tri khng hon ton.
- on ST-T bin i su hn.
2.2. Dy tht phi
2.1.1. Nguyn nhn: Hp 2 l, tm ph mn, h 3 l, thng lin nh, t chng Fallot, hp van
MP, thng lin tht, o gc ng mch, thn ng mch chung, tng p phi tin pht,
phc hp Eisenmenger...
2.1.2. Triu chng:
-Phc b QRS: khng dn rng qu gii hn bnh thng.
-Chuyn o trc tim:
+ Chuyn o V1, V2: du hiu quan trng l s tng bin sng R, sng R cao trn 7mm,
ch s Sokolov - Lyon: RV1 + SV5 >11mm c gi tr chn on, c khi R khng cao trong
mt s trng hp nh tm ph mn, kh ph thng, khi QRS thng c dng rS, W, QS...
Nhnh ni in mun 3% - 3,5% nu trn 5% l c bloc nhnh phi phi hp.
+ Chuyn o V5,V6: sng S su hn bnh thng, c th bng R hay dng rS.
+Vng chuyn tip: lch v V5, V6.
+ Chuyn o ngoi bin: Trc phi, gc ((110 o.
- on ST-T: C 2 kh nng:
+ Tng gnh tm thu: ST-T chuyn tri chiu QRS.
+ Tng gnh tm trng: Bloc nhnh phi.
81

Tng gnh tht phi, trc phi =120
0
, blc nhnh phi khng hon ton do tng gnh tht
phi
2.3. Dy hai tht
2.3.1. Nguyn nhn: Thng gp trong hp h van hai l c tng p phi, bnh hai l - ng
mch ch, hp van hai l c tng p phi, tm ph mn km THA, thng lin tht hoc cn
ng ng mch c tng p phi.
2.3.2. Triu chng: thng phi hp, c th gp:
- Dy tht phi chuyn o tim phi + dy tht tri chuyn o tim tri.
- Dy tht tri chuyn o tim tri + du dy tht phi chuyn o ngoi bin.
- Du hiu Katz-Watchel: tng R + S cc chuyn o trc tim >50mm.

Tng gnh c 2 tht, tiu chun dy 2 tht nhng trc in tim cn nm t th trung gian
(dy 2 tht kh ng u)
3. Bloc nhnh
3.1.Bloc nhnh tri: 90% trng hp bloc nhnh tri c km theo dy tht tri nng hay nh.
Tin lng xu v tn thng c tim nng, nhnh tri b His b t.
3.1.1. Nguyn nhn: Thiu nng vnh mn tnh, tng gnh tht do cc bnh THA, hp h
MC, hp eo MC, hoc bnh c tim ngi tr (him gp).
3.1.2. Triu chng:
- Chuyn o QRS: thng dn rng; nu bloc nhnh tri hon ton thi gian QRS > 0,12
+ V5, V6: phc b QRS c mc nh, cao nguyn hay ch i, c khi c dng rSR,
nhnh ni in mun, mt sng Q. Nu c Q phi nghi c hoi t c tim. Sng S cng mt,
nu c phi nghi tim nm ngang hoc tim xoay theo kim ng h rt mnh hoc c phi hp
bloc nhnh phi khng hon ton.
82
+ chuyn o ngoi bin: ty vo t th tim.
* Tim xoay sang tri hay gp nht (90%), hnh nh trc tip D1, aVL, gin tip
D3.
* Tim khng xoay: D1, D2, c hnh nh trc tip, D3 c hnh nh trung gian.
* Tim xoay phi: t gp; D2, D3, VF c hnh nh trc tip.
- on ST-T: Chnh v m ngc vi QRS.

Blc nhnh tri hon ton: Sng R gin rng >0,12s V
5
, V
6
V
7
, sng S gin rng, c mc
cc chuyn o trc tim phi
3. 2. Bloc nhnh phi
Ngc vi BNT, BNP d hon ton hay khng hon ton thng i n c, tin
lng tt, c th gp trn tim bnh thng.
3.2.1. Nguyn nhn: Nu l tim bnh l s c.
- Bloc nhnh phi hon ton: Thiu nng vnh ngi gi, tng gnh tht tri do THA, hp
MC, NMCT trc vch.
- Bloc nhnh phi khng hon ton: Thng gp trong tng gnh tht phi, thng nh, thng
tht, thng nh-tht, suy tim phi, hp hai l, hp 3 l, bnh tm ph cp c dn tht phi,
ngoi ra cn gp trong tm ph mn, bnh Ebstein.

Blc nhnh phi hon ton: Sng R gin rng, c mc V
1
, V
2
V
3
, trong khi R hp cc
chuyn o trc tim tri
3.2.2. Triu chng:
- Phc b QRS chuyn o trc tim: Ch yu V1, V2, V3R, V4R. C dng rsR vi R dn
rng, trt m hay c mc vi nhnh ni in i khi 6% -10%; khi c phi hp dy tht
phi th R cng cao. V5, V6 c dng QRS vi S dn rng, trt m (du hiu gin tip).
- Chuyn o ngoi bin: thng gp nht l aVR dng qR hay QR, rsR, rSR vi R hay R
dn rng trt m.
83
Ngoi ra cc chuyn o ngoi bin c th gp:
* Bloc Wilson: bloc nhnh phi c trc tri.
* Bloc him: bloc nhnh phi c trc phi rt mnh.
- on ST - T: tri chiu QRS.
BNP khng hon ton hay gp ngi tr v tr em bnh thng. Nu bnh l, bloc
nhnh (P) khng hon ton thng km theo thiu nng vnh, dy tht, tm ph cp v mn,
vim mng ngoi tim.
4. Ri lon in gii
4.1. Kali
4.1.1. Tng Kali mu: Bnh thng nng K
+
mu t 3,5 - 5,5 mEq/l. Khi nng K
+
trong
mu tng cao s c ch tnh t ng ca cc lc ch v nt. Cc du hiu in tm
thng t l rt cht ch vi m K
+
ca mu.
Biu hin chung ca tng Kali mu l:
- QT ngn li, T cao nhn.
- Bloc nh tht cc mc khc nhau, bin i QRS.
- Khi nng hn, sng P dn, dt, PQ di ra, ST chnh ln v sau cng xut hin nhp
nt, t ng tht, rung tht, ngng tim.


Tng K
+
mu : ST chnh xung, sng T cao nhn nh nc lu, QT ngn
4.2. Gim K mu: Khi K < 3,5mEq/l, in th ngh s gim v in th hot ng ko di.
Triu chng ch yu l s bin i ST-T.
- Khi K+ mu t 3,5 - 3mEq/l: cha c thay i ng k.
- Khi di 3.5mEq/l: Bin sng P cao ln, ST chnh xung, T dt, sng U cao hn.
Khi nng hn sng T ln vo sng U.
Ch : Sng U c th cao trong dy tht tri, nhim Digital, nhim Quinidin.
84

G Gi i m m K K
+ +
m m u u: : S S n ng g T T g gi i m m b bi i n n ( (d d t t) ), , s s n ng g U U c ch hi i m m u u t th h , , s s n ng g P P c ca ao o, , o o n n P PQ Q ( (P PR R) )
k k o o d d i i. .



85
RI LON NHP TIM
Mc tiu
1. Trnh by uc nh ngha ri lon nhp tim
2. Nm vng c nguyn nhn, c ch bnh sinh ca ri lon nhp tim.
3. Nm vng c triu chng hc mt s ri lon nhp thng gp.
4. Nm vng cc phng thc iu tr lon nhp tim
5. Bit cch s dng cc thuc trong tng loi lon nhp tim

Ni dung
I. NH NGHA
Ri lon nhp tim (RLNT) l s ri lon hot ng in sinh hc ca tim v ba mt
- S to thnh xung ng
- S dn truyn xung ng
- Phi hp c hai mt trn
II. NGUYN NHN V C CH SINH BNH
1. Nguyn nhn
- Cc bnh nhim khun: thp tim l nguyn nhn thng gp nht; ri n cc bnh nhim
khun khc nh thng hn, bch hu.
- Do nhim c: thng gp l cc loi chng lon nhp nh: digital, quinidine
procainamid,reserpine, thuc chn beta.
- Do ri lon in gii: nh tng hoc gim kali mu, magn mu, canxi mu.
- Cc bnh ton thn: nht l cng gip, d ng thuc, i tho ng.
- Cc bnh c tim: do nhi mu c tim, thoi ha,lao,unh th, chn thng, cc bnh tim bm
sinh nh thng tht, cn ng ng mch, t chng Fallot.
- Do ri lon thn kinh thc vt: do xc cm hoc gng sc.
- Do phu thut.
- Do di truyn.
2. C ch bnh sinh: RLNT xy ra khi
2.1. Ri lon v s hnh thnh xung ng: c th gp
- Tng tnh t ng ca nt xoang: lm ton b tri tim s p theo vi tn s nhanh nh nhp
nhanh xoang.
- Gim tnh t ng ca nt xoang: tim s p chm gp trong nhp chm xoang, nhp b ni,
- Tng tnh t ng ca ch nhp di nt xoang: l nhng ngoai tm thu.
- Ngoi ra mt s si c tim c th pht ra xung ng nh trong cn nhp nhanh tht.
2.2 Ri lon v dn truyn xung ng: khi xung ng b tr ngi lm s dn truyn b chm i
ta gi l bloc. Bloc c th sinh l khng c tn thng thc th ca c tim xy ra bt k v
tr no ca ng dn truyn nh bloc nhnh, bloc nh tht, bloc xong nh. Bloc cng ch c
th theo mt chiu t trn xung, hoc hai chiu. c bit c th gp c ch vo li trong
RLNT l mt c ch c bit gp trong ngoi tm thu, cn nhp nhanh tht hoc trn tht.
2.3. Phi hp c ri lon dn truyn xung ng v hnh thnh xung ng: c ch ny s to ra
nhng RLNT phc tp hn nh phn ly nh tht, song tm thu..
III. TRIU CHNG HC MT S RLNT THNG GP
86
1. Nhp nhanh xoang
- Nguyn nhn: xc ng, st cao, suy tim, cng gip, thiu mu.
- Triu chng hc: hi hp, nhp tim trn 80ln/ pht c khi ngh ngi v nhp gia tng khi
gng sc.
- Chn on: nh in tim vi nhp xoang tn s trn 80 ln/ pht.
2. Nhp chm xoang
- Nguyn nhn: luyn tp th dc nhiu, cng ph v do nhi mu c tim vng sau- di,
thai nghn, ung nc c nhiu gaz hoc lnh qu, do dng thuc c bit l cc thuc RLNT
lm nhp chm nh Digital, Cardizem, Verapamil, chn beta qu liu...
- Triu chng: thng khng c triu chng r, nng hn c th xong, ngt, mch quay
chm di 60l/pht. in tim: nhp xoang vi tn s di 60l/pht.
3. Ngoi tm thu: l nhng nht bp sm, ngun gc t tm nh hay tm tht, c th xy trn
tim lnh hay tim bnh l
- Nguyn nhn: thng gp trn tim bnh thng, c th khng tm thy nguyn nhn, c khi
tm thy nguyn nhn nh sau: lm dng cc cht kch thch nh thuc l, c ph, c khi xy
ra trong k kinh nguyt, c thai, c th do tc dng ph ca mt s loi thuc nh digital,
quinidine, adrenaline, isoprenaline; do tn thng c tim nh nhi mu c tim, h kali mu.
- Triu chng: cm gic hng ht, au nhi tim, ang ng git mnh hoc nghn c, hoa
mt chng mt, thong ngt. Nghe tim c th pht hin nhp khng u n l hoc nhp i
nhp ba. Nhp mch c ngoi tm thu (NTT) thng yu i hc mt.
- Chn on: nh vo in tim. Cn phn bit NTT tht hay trn tht.
+ NTT trn tht thng khng c s bin dng ca phc b QRS v on ST-T; khng c
ngh b sau nht NTT m ch c s dch nhp.
+ Ngc li NTT tht thng c s bin dng ca phc b QRS vi s bin i ST-T.
Hnh nh ngoi tm thu tht
4. Rung nh
- Nguyn nhn: bnh tim mch nh bnh van hai l l nguyn nhn hng u, nh mu c
tim, thoi ha c tim, vin mng ngoi tim, tim phi mn, hi chng WPW, cc bnh ngoi
tim nh cng gip (th nh sau hp hai l), ngoi ra c th gp trong suy gip, u ty thng
thn, i tho ng, tng ur mu, vim phi... v mt s trng hp khng tm thy nguyn
nhn.
- Triu chng: nh trng ngc, chong vng kh chu, c khi xong ngt, au ngc, kh th.
Triu chng ch quan cng r rt nu rung nh (RN) xy ra cp tnh v tn s tim nhanh.
Nghe tim c nhp tim khng u v bin , tn s, khng trng mch quay. Huyt p thng
thp, thng thay i qua cc ln o.
- Chn on: ch yu nh vo in tim. Sng P khng cn thay vo l cc sng f ln tn
tn s 350-600 ln/pht. Cc mc b QRS c thay i nht l v bin nhng ch yu l v
khong cch gia cc sng khc nhau c on di, on ngn.
87

Hnh nh ECG rung nh
5. Cung nh
- Nguyn nhn: cc bnh van tim nht l van hai l, bnh thiu mu c tim, cc bnh tim khc
nh tm ph mn, thng nh, vim mng ngoi tim... C th gp trong nhim c digital, thc
hin cc th thut hoc phu thut tim v v cn.
- Triu chng: bnh nhn thng c cm gic rt kh chu v triu chng thng rm r hn
rung nh nht l cn kch pht. Nghe tim thy tim p nhanh u 130-150 ln/pht. Tnh mch
c thng p rt nhanh hn tn s tim.
- Chn on: nh vo in tim thy sng P thay bng sng F nh rng ca tn s 250-350
ln/pht. Phc b QRS bnh thng v u nhau.
6. Nhp nhanh kch pht trn tht: thng xy ra trn tim lnh
- Triu chng: hi hp tng cn km theo kh chu tot m hi, lo lng, tiu nhiu sau cn.
- Chn on: in tim c nhp tim nhanh tn s khong 180 ln/pht u. QRS bnh thng,
sng P thng ln vo QRS, c th c ST chnh xung. n nhn cu thng ct c cn.
Hnh nh ECG nhp nhanh kch pht trn tht
7. Nhp nhanh tht: l cp cu tim mch:
- Nguyn nhn: xy ra trn tim bnh l nh nhi mu c tim, suy vnh ri n thp tim, bnh
van tim, bnh c tim, ng c digital, cc th thut trn tim v v cn.
Hnh nh ECG xon nh

- Triu chng: rm r vi au ngc, kh th, ngt, ri lon huyt ng. Nhp tim rt nhanh
trn 160 ln/ pht, mch kh bt.
- Chn on: in tim cho thy cc phc b tht nhanh, phc b tht gin rng tn s 120-160
ln/ pht. Nhp nh chm hn v phn ly vi tht.
88
8.Xon nh: l cp cu tim mch.
-Thng do nhng nhm thuc chng lon nhp nhm 1 gy ra; gim kali mu cng l yu t
thun li. Triu chng ch yu l ngt, try tim mch. in tim s thy sng kh cc bin
dng ln tn, c ch nh v ch phnh to ty theo chu k.
9. Rung tht: l cp cu tim mch v thng gy ra t t. Nguyn nhn thng do thiu mu
c tim, suy tim, ng c Digital, ng c Quinidine. Triu chng l t t. in tim c ri
lon nhp tht a dng.
10. Ri lon dn truyn nh tht (Bloc nh tht)
Da vo in tim c 3 loi:
- Bloc nh tht 1: PQ (hoc PR) ko di trn 0,20 giy
- Bloc nh tht 2: c 2 th:
+ Bloc Mobit 1 (hay Luciani-Wencbach): Khong PQ ko di ri mt dn hn sau lp li
chu k mi nh vy.
+ Bloc Mobit 2 (hay Bloc nh tht mt phn): Hai, ba.. sng P mi c mt sng QRS
- Bloc nh tht 3: Nh v tht phn li hon ton, tn s nh nhanh hn tn s tht.
Da vo triu chng c nng c th chia lm 2 nhm:
+ Bloc nh tht khng c triu chng
+ Bloc nh tht c triu chng
Triu chng gi l ngt (cn Adam-Stokes) hoc ch c xm xong.
IV. IU TR RI LON NHP
1. Mc ch
1.1. Lon nhp tim kch pht: Cn ct cn ngay.
1.2. Lon nhp tim dai dng, bn b: a v nhp xoang hoc l kim sot tn s tht trong
trng hp khng vi iu tr chuyn nhp.
2. Ch nh iu tr cp cu
2.1. Suy nng chc nng ca tht tri.
2.2. Biu hin triu chng lm sng hoc l trn ECG thy thiu mu cc b c tim.
2.3. Lon nhp khng n nh bo trc kh nng rung tht.
3. iu tr khng thuc
3.1. Xoa xoang cnh, n nhn cu
3.2. Shock in
3.3. To nhp:Ct cn nhp nhanh bng phng php vt tn s hoc l kch thch sm.
3.4. Ct b qua ng tnh mch t chc dn truyn
3.5. Phu thut
* Ti to mch mu trong bnh c tim thiu mu cc b.
* Ct lc t chc dn truyn.
* Ct lc sinh lon nhp.
* Ct b phnh tht tri.




89

4. iu tr lon nhp nh bng thuc
Mc ch Thuc C ch
Phng lon nhp Disopyramide
Flecainide
Propafenone
Amiodarone
c ch t ng nh
Ct vng vo li nt nh tht Striadyn
Verapamil
c ch
Lm nghn dn truyn nh tht
Kim sot tn s tht trong
rung nh
Digoxin
Verapamil
c ch
Amiodarone
Nghn dn truyn nh tht

5. iu tr lon nhp tht bng thuc
5.1. Phng nga trong nhi mu c tim cp
- Xylocaine
- Disopyramide
- Amiodarone
- Procainamide
5.2. Phng nga bnh nhn ngoi tr
- Mexiletine
- Disopyramide
- Propafenone
- c ch
- Amiodarone
5.3. Ct lon nhp tht
- Lidocaine
- Flecaine
- Amiodarone
Lu
- Cn thn khi dng phi hp v d khng dng amiodarone cng vi disopyramide (lm ko
di QT gy xon nh)
- Nhiu loi lm gim s co bp c tim (c bit l disopyramide, flecaine, thuc c ch. V
th phi rt thn trng khi c suy tim.
6. iu tr c th
6.1. Nhp nhanh xoang
iu tr ph thuc vo nguyn nhn. Chng lo lng, h st. Digitalis v li tiu khi c suy
tim, th oxy khi c thiu kh cp tnh, b mu khi thiu mu v khng gip khi c cng gip.
Nu nhp nhanh xoang do mt thch nghi th lc v / hay lo lng gy ra s kh chu cho bnh
nhn v sau khi loi tr tt c nguyn nhn thc th, c th cho chn bta liu thp c
th lm bt tn s tim khi gng sc. Thng dng Propranolol khi u 1/4 vin x 2 ln sng
90
v chiu sau tng liu dn nhng khng qu 1/2 vinx 3 ln/ ngy. iu tr c th ngng
khi bnh nhn c luyn tp th lc ti thch nghi.
6.2. Nhp chm xoang
Ch nh iu tr i vi nhp chm xoang kch pht, giai on cp NMCT sau di.
Atropine c th lm tng tn s tim v huyt p. Liu Atropine:1mg tim di da hoc chch
tnh mch. Nu huyt p thp c th b dch. Kh khn duy nht l khi iu tr nhng bnh
nhn c hi chng nhp nhanh - nhp chm (cn gi l hi chng nt xoang bnh l), khi
i lc cn phi t my to nhp.
6.3. Rung nh
Lu chuyn nhp thnh cng cn iu chnh yu t nguyn nhn (bnh tim gy rung nh,
cng gip...). Mc tiu iu tr nhm l chuyn nhp v xoang hoc ch lm chm tn s tht.
* Sc in
Liu 250- 300j. Hn hu mi ch nh cp cu v d nh cn ti lp nhp xoang ngay trong
tnh trng chong, ph phi cp nng, tn s tht > 200 ln/pht. Sc in l iu tr chn la
trong trng hp rung nh trn bnh nhn c hi chng tin kch thch. T l thnh cng
khong 85% trng hp.
Ch nh sc in trong trng hp rung nh mn tnh:
+ Rung nh <1nm
+ ng knh nh tri <50mm
+ Tim khng ln lm
+ Dung np huyt ng km.
* iu tr bng thuc :
Vi mc ch chuyn nhp hoc ch n gin l hm bt tn s tht.
- Nu khng c suy tim, tim khng ln c th dng Flecaine IV liu 2mg/kg chuyn trong 10
pht cho php ti lp nhp xoang trong 3/4 trng hp (rung nh mi khi pht).
- C th ti lp nhp xoang bng Amiodarone (Cordarone) vin 200mg cho liu tn cng 4-6
vin/ngy (c th ung 1 ln) trong 2 ngy u sau duy tr 1 vin/ ngy trong 5 ngy. Sau
khi ti lp nhp xoang c th iu tr duy tr bng Quinidin hoc Amiodarone. Tuy nhin ngy
nay a s dng Amiodarone duy tr.
- Trong kh nhiu tnh hung rung nh, ngi ta chp nhn ch cn lm chm tn s tht bng
Digitalis (ngoi tr hi chng WPW), khi cn c th phi hp vi Amiodarone.
- Nu nh khng c suy tim, tim khng ln, c th dng c ch beta (hoc l c ch canxi
loi lm nhp tim chm (Verapamil, Diltiazem) mt khi m nhp tim vn cn nhanh qu mc
mc du s dng digital.
- Him khi tn s tht vn khng hm c bng iu tr ni khoa, lc ny c th cn ti k
thut ph hy nt nh - tht bng nng lng tn s radio (radiofrequency) to bloc nh tht
kt hp vi t my to nhp.
Trc khi chuyn nhp rung nh mn tnh nht l bnh nhn c nguy c cao tc mch do
huyt khi bung tim (bnh van tim) cn phi s dng thuc chng ng 3 tun phng
nga tc mch sau chuyn nhp.
6.4. Cung ng nh
iu tr hiu qu nht l sc in vi nng lng thp 25-50 W sau khi dng an
thn nh. Tuy nhin ngi ta hay a dng nng lng cao hn bi l hay b rung nh sau khi
sc bng nng lng thp. ngi b cung nh sau khi m tim h hoc l cung nh ti lp
trong nhi mu c tim cp c bit l nu ang dng digitalis th nn to nhp nh vi tn s
115-130 % tn s cung nh c th chuyn nhp v xoang. To nhp nh cng c th a
91
cung nh v rung nh v lm cho kim sot tn s tht d hn. Nu nh tnh trng ngi bnh
v mt lm sng khng cho php chuyn nhp ngay th c th lm chm tn s tht bng cc
thuc c ch nt A-V nh c ch bta, c ch canxi, hay l Digitalis. Digitalis t c hiu qu
nht v i khi li chuyn cung nh thnh rung nh. Khi dn truyn qua nt A-V b hm bng
cc thuc trn th c th dng cc thuc chng lon nhp nhm I (A hoc C) hay amiodarone
chuyn nhp. Trong trng hp cung nh bin chng trong hi chng W.P.W th chng
ch nh digitalis. Mt khc nu nh ngi bnh ang c dng digitalis th nn ch vi
ngy sau (thuc c thi ra) mi sc in.
- Phng cung nh: cc thuc nh Quinidine, Flecaine, Propafenone, Amiodarone.
6.5. Nhp nhanh trn tht
* Nhp nhanh b ni, nt xoang, nh do c ch vo li :
Nu tnh trng bnh nhn tt khng c tt huyt p th c th dng cc thuc cng ph v
ct cn hiu qu trong 80% trng hp (nn nh khng c xoa xoang cnh ngi c thi
tm thu ng mch cnh). Nu vn khng c c th cho Adenosine 6-12mg tim TM hoc
Verapamil 2,5-10mg tim TM. Cng c th dng Digitalis, c ch bta. Phng php to nhp
nh hoc tht ct cn c dng khi thuc khng c tc dng. Sc in p dng khi c
thiu mu cc b c tim nng hoc l tt huyt p.
Phng nga:
- Cc thuc digitalis, c ch bta, c ch canxi hoc l nhm IA, IC.
- Phng php t b ng dn truyn bng sng nng lng tn s radio.
* Nhp nhanh nh c c ch tng tnh t ng:
C th do ng c digitalis hoc l gp trong bnh phi hoc tim nng c gim kali
hoc ang dng theophylline v cc thuc cng giao cm khc. Loi a c bit hay gp
ngi bnh ang dng theophyline. Rung nh gp trong 50-70% ngi c dng lon nhp
ny. Tn s tht khng u do c thay i mc bloc. Trong lon nhp do Digitalis hay c
dng bloc 2/1, thi iu tr l ngng Digitalis. Trong loi nhp nhanh c ch t ng khng
do Digitalis iu tr kh hn v mc ch ca iu tr l hm tn s tht (bng c ch bta,
Digitalis, c ch canxi hoc ct lc lon nhp bng sng nng lng tn s radio hay phu
thut).
6.6. Nhp nhanh tht :
Nu dung np km th sc in ngay. Nu khng sc in c th dng cc thuc chng
lon nhp sau: ty chn gia Amiodarone, Flecaine, Xylocaine, Mexiletine, Cibenzoline,
Disopyramide, mi loi thuc ny c th ct cn t 50 - 70 % trng hp. V d Xylocaine
(hay c dng nht do gi thnh r v kh an ton) liu tn cng 50-75mg TM duy tr vi
20-50microg/kg/pht. Sau khi ct cn cn iu tr duy tr bng thuc ng ung nh chn
bta, Amiodarone v cc thuc khc. Cn ch iu tr nguyn nhn, yu t thun li. Cng
c th ct cn nhp nhanh tht vo li bng kch thch in ni mc bung tim.
6.7. Nhim c digitalis:
C th gy cc ri lon nhp v dn truyn. iu tr gm ngng ngay Digitalis, cho
kali 4 - 8g /ngy ng ung hoc l TM. Cc ri lon dn truyn nh ch cn cho Atropine
0,25 - 1mg TM hoc l di da mi 3 - 4 gi, nu nng phi t my to nhp tm thi. Cc
ri lon nhp do Digitalis ni chung p ng tt vi Phenytoine tim 250mg TM, nu tht bi
c th dng Xylocaine. Hin nay c thuc khng th khng Digoxin (Digidot mi ng
80mg c th gn vi 1mg digoxin) cho d l ng c Digoxin, Digitoxin, hay l Lanatoside
C.
6.8. Ngoi tm thu nh
92
Thng lnh tnh v v triu chng khng cn iu tr. Tuy nhin nu gy nh trng
ngc nhiu hoc l khi ng nhp nhanh kch pht trn tht th c th dng an thn v thuc
c ch beta sau khi loi b cc yu t lm d (thuc l, ru, kch thch giao cm).
6.9. Ngoi tm thu tht
- V triu chng ngi khng c bnh tim: thng khng cn iu tr.
- Nu c triu chng: dng an thn, c ch beta, thuc chng lon nhp nhm I,
Amiodaron (loi thuc ty thuc vo tnh trng tim cng nh th loi ngoi tm thu). Chng
hn nu l loi ngoi tm thu nguy him (dng R/T, a dng) th phi s dng thuc tc dng
nhanh nh Xylocaine tim TM xa ngoi tm thu.
6.10. Rung tht
Phi sc in ngay (>300J). Trong lc ch i sc phi p tim ngoi lng ngc, thng
kh h tr.
6.11. Xon nh
p tim ngoi lng ngc. Isoprenalin trong trng hp xon nh trn nn bloc nh tht
cp 3 (ngy nay hay c thay th bng magie sulfat v to nhp tim). Nu nh gi xon nh
(trn nn ngoi tm thu tht) th c th cho Xylocain. iu chnh ri lon in gii nu c.
6.12. iu tr bnh xoang nh
* To nhp
* Cc thuc chng lon nhp
* Thuc chng ng (trong trng hp hi chng nhp nhanh - chm).
Ni chung tin lng nhng bnh nhn c bnh xoang nh l tt v thng khng cn
to nhp, v th to nhp ch c ch nh nhng bnh nhn c triu chng c nng (xong,
thong ngt), mt khc cng vi mc ch ci thin s dung np vi gng sc.Trong hi
chng nhp nhanh chm i khi cn ch nh thuc chng lon nhp i vi vi ri lon nhp
nhanh m cc thuc loi ny thng lm nng thm ri lon chc nng nt xoang, lc my
to nhp c l cn phng nhp chm qu mc sau tc dng ca thuc. Vi tc gi khuyn
dng chng ng phng nga tc mch h thng trong hi chng nhp nhanh chm (hnh
thnh cc mu ng trong nh tri).
6.13. iu tr bloc nh tht
C th dng Atropin (liu 0,25-1mg tim tnh mch hoc di da mi 3-4h) hoc
Isoprenaline (1-8 microg/pht) nu tn s tht qu chm trong lc ch i t my to nhp
tm thi hay l vnh vin.
Ch nh t my to nhp:
1. Nhi mu c tim:
+ Khi c bloc nh tht 3 do nhi mu thnh sau c km:
- Tn s tim < 40 ln/ pht khng c p ng vi Atropin.
- Suy tim.
- Lon nhp tht cn iu tr thuc chng lon nhp.
+ Bloc nh tht 3 hoc l Mobitz 2 do nhi mu c tim thnh trc.
+ Bloc hai nhnh.
+ To nhp vt tn s ct lon nhp tr.
2. Bnh xoang nh gy triu chng.
3. Bloc nh tht loi Mobitz 2.
4. Bloc nh tht cp 3 mn tnh c hay khng c triu chng.
93
5. Ct cn lon nhp vo li.
Phng php to nhp: hin nay dng ch yu l VVI (to nhp ch b c ch bi tht, n ch
to nhp tht) v DDD (to nhp ch kp va nh v tht n cho php thit lp li s ng vn
nh - tht).



94
VIM MNG NGOI TIM

Mc tiu
1. Nm c cc du hiu lm sng v cn lm sng ca vim mng ngoi tim c dch.
2. Nm c cc du hiu lm sng v cn lm sng ca chn p tim cp.
3. Nm c cc du hiu lm sng v cn lm sng ca vim mng ngoi tim co tht.
4. Trnh by c cc phng php ni ngoi khoa trong iu tr vim mng ngoi tim.
5. Nm c k thut chc d mng ngoi tim
Ni dung
I. I CNG
Vim mng ngoi tim (VMNT) l bnh ca mng ngoi tim (MNT). Khi c trn dch
mng ngoi tim gy p tim cp cn phi x tr cp cu nu chm s t vong nhanh. Ngy nay
nh c siu m gip cho chn on chnh xc, v sm. iu tr kp thi gim t l bin chng
xu cho bnh nhn.
II. NGUYN NHN
1. Nhim khun: lao, virus, cc vi khun khc (thng gp trong nhim trng khc)
2. Vim: thp tim,vim a khp dng thp, lupus ban
3. Phn ng d ng min dch: phn ng d ng sau m tch van tim 2 l, hi chng sau nhi
mu c tim, nhng phu thut lin quan n mng ngoi tim
4. Ung th: Nguyn pht hoc th pht nh ung th gan, ung th phi, ung th trung tht
5. Cc p xe ln cn: gan, phi, di c honh
6. Bnh tim thiu mu cc b
7. Chn thng lng ngc: gy trn mu mng ngoi tim. V ng ngc: trn dch dng chp
MNT
8. Ri lon chuyn ha: tng ur gy phn ng VMNT. Lng ng cholesterol MNT
9. Do hu qu ca iu tr: thuc chng ng, iu tr phng x di ngy lng ngc
10. Do nm.
11. Suy tim nng: bnh nhn b bnh van tim, bnh c tim c trn dch mng ngoi tim.
12. V cn.
III. VMNT C DCH IN HNH
1. Lm sng
1.1. Triu chng ton thn: Ty thuc vo nguyn nhn: c th st, chn n, mt mi, gy st.
1.2. Triu chng c nng
au ngc: rt thng gp, au lan ta khng thnh cn km cm gic p ngc tri.
Kh th: kiu nhanh nng, vt v bt an.
Kh nut: do tim vo thc qun pha sau, km theo c ho v nc.
1.3. Triu chng thc th
Nhn, s: mm tim p yu hay cm gic khng thy p.
G: din c ca tim ln.
Nghe: nhp tim nhanh, ting tim m xa xm do b cn bi mng nc. Nu dch t s nghe
ting c mng ngoi tim (khi nn th ting ny vn cn) du ny quan trng v n xc nh c
vim mng ngoi tim.
95
Trn thc t lm sng khi c trn dch mng ngoi tim s lng nhiu, c fibrin to vch ngn
khu tr lc nghe vn thy ting tim r. C th c ting c mng ngoi tim.
Cc du hiu tr tun hon ngoi vi:
Ph, gan to, tnh mch c ni, phn hi gan tnh mch c (+)
p lc tnh mch ngoi bin tng (bnh thng 8-12 cm H
2
O)
p lc tnh mch trung tm tng (bnh thng 4-7 cm H
2
O)
Mch nhanh nh, huyt p ti a gim, huyt p kp. C th c mch nghch thng
Kussmaul (khi ht vo mch nh i). Bnh thng khi ht vo mch cng nh hn lc th ra
do p lc ph nang tng cao mu v tm tht tri t. Trong VMNT do thiu nng tm trng
mu v tim tri cng t do du mch nh cng r hn.
2. Cn lm sng
2.1. in tm
- Do tn thng (ri lon chuyn ha v vim nhim) lp c tim di thng tm mc
(pht sinh ra mt dng in tn thng, biu hin bng mt vect hng t tm im tim n
trung tm ca vng tn thng; ngha l hng xung di, sang tri, v ra trc. Chiu ln
trc chuyn o ta thy ST chnh ln ng hng cc chuyn o (ri lon ti cc).
Theo Bots chia 3 giai on bin i ST-T:
+ Giai on 1: ST chnh ln ng hng cc chuyn o ngoi bin v trc tim.
Khng c hnh nh soi gng thnh i din nh trong nhi mu c tim.
+ Giai on 2: Sau 3 tun. ST h dn xung ng ng in. T dt xung v T (-).
Nhng ST vn cn chnh ln.
+ Giai on 3: Trn 1 thng. ST chnh xung v T (-) nhng khng nhn v khng i
xng nh trong bnh c tim thiu mu cc b.
- Du hiu in th giao lu (lun phin in hc): do MNT nhiu dch tim di ng mnh nh
bi trong nc. Sau mi chu chuyn tim, tim khng tr v v tr c, sau mi ln kh cc tim
v tr khc do trc QRS thay i.
- Du in th gim: tng s tr tuyt i ca Q, R, S ca 3 chuyn o mu <15 mm;
chuyn o trc tim: V
2
tng bin ( R+S)< 9 mm V
5
,V
6
( Q+R+S)< 7 mm.


Hnh nh ECG chnh ST hu ht cc chuyn o
2.2. X. Quang
- Soi: bng tim to, co bp yu.
96
- Chp X.Q: tim to b 2 bn cung di, gc honh tim hnh t. Cung tim ngn. Do
hnh tim ging nh qu bu. C th thy hnh tim 2 b (b trong l bng tim, b ngoi l
mng ngoi tim), phi sng (do thiu nng tun hon tm trng).

Hnh nh X quang ca trn dch mng ngoi tim
2.3. Siu m tim
- Cho bit s lng dch v v tr ca dch cc thnh tim quyt nh chc d mng
tim, trong dch c nhiu fibrin v c vch ha khng?
- Xem b dy ca mng ngoi tim c hng iu tr ni hoc ngoi khoa kp thi.
nh gi nhng ri lon huyt ng thng qua hnh nh p tht phi thi k tm trng.
nh gi chc nng tm trng. Thm d p lc trong tim phi. Thm d sc cng ca thnh
tim.
C th trn siu m:
+ Siu m M-mode o kch thc ca khong dch k tm tng t tnh ra d
on lng dch mng tim.
+ Siu m 2D: quan st ton b tim mt cch tng qut, xem lng dch khu tr
hay ton th
Vi 3 du hiu chnh cn nh gi:
+ Khong trng Echo mt sau ca tim.
+ Khong trng Echo gim nhiu hoc mt hn ch ni nh tri v tht tri.
+ Mng ngoi tim khng vn ng.
Ch : Lng dch: dch mng tim t 30 ml c th pht hin c. Ngi bnh thng
khe mnh c th c 50 ml DMT. Khi lng dch bao ph ton b tim nhn thy c trn
siu m 2D lng dch khong 300 ml.
Vn ng bt thng ca tim trong TDMT: du p tim trn siu m.
2.4. Chc dch mng tim
Ly dch chn on xc nh, chn on nguyn nhn c hng iu tr ng.
Khi c chn p tim cp c ch nh chc tho dch cp cu. Dch mng tim thng c 3 mu
hay gp.
+ Dch vng chanh: lao, vi rt, d ng, bnh h thng
+ M c trng-nu: nhim trng huyt, p xe v
+ Dch mu : ung th, lao, chn thng chy mu, do thuc chng ng.
3. Chn on phn bit
97
- Tim to: do bnh c tim, suy tim nng
- Cn au tht ngc: nhi mu c tim, vim phi, v.v....
Vai tr ca siu m rt hu ch trong chn on.
4. Chn on nguyn nhn
+ Da vo lm sng v xt nghim dch mng tim.
+ Cc nguyn nhn nh ni phn trn.
IV. CHN P TIM CP
1. nh ngha
L tnh trng p lc trong khoang MNT t ngt tng cao, p vo tim v ngn cn s
y mu v tm tht trong k tm trng gy thiu nng tm trng cp, thiu nng tm
thu cp ngn cn tim bp.
p lc trong khoang mng tim tng cng cn tr tim dn ra y trong th tm
trng. Do t mu v tim, huyt p v lu lng tim gim. Nhp tim tng b tr nhng
bin i ny, khi p lc trong khoang mng tim t gn 15cm nc, cung lng tim v huyt
p s gim t ngt hn na v lm sng xut hin chong. Nu p lc trong mng ngoi tim
khng c h thp (bng cch ly dch ra), bnh nhn s t vong. Ch 200ml dch hoc mu
l c th gy p tim v t vong nu nh tc hnh thnh dch nhanh.
2. Sinh l bnh
Bnh thng p lc trong khoang mng tim bng 0 hay m nh, do h tr tng sc
ht mu v tim vo k tm trng. Khi dch trong mng tim nhiu s lm thay i p lc ca
n (lng dch ln qu hoc lng dch khng nhiu nhng hnh thnh qu nhanh) p lc
khoang mng tim khi s gn bng hay bng p lc trong tim gy nn du hiu chn tim
(tim ht mu v rt kh): tng p lc tnh mch c, huyt p tt kp, mch nghch thng,
gim cung lng tim.
3. Chn on
3.1. Triu chng c nng
Khi u t ngt vi kh th d di, au ngc, vt v, da xanh ti, tot m hi.
3.2.Triu chng thc th
Tim nhanh, ting tim m (kh nghe) mch nghch thng (KUSSMAUL). Du tr
tun hon ngoi bin r (gan ln, tnh mch c ni).
Ba du hiu cn bn ca chn p tim cp l:
- Tt huyt p, huyt p gim dn cho n khi khng o c. Khi c du hiu ca
chong: lo lng, bt rt, ti nht, da lnh v m v cui cng l mt tri gic.
- p lc tnh mch tng. p lc tnh mch c th tng n 15-20cm nc. Km vi
tnh mch c ni r, gan c th ln.
- Ting tim nghe xa xm v m.
Hn na c th c mch nghch thng. Mch nghch thng l do s gim qu mc
p lc ca mch khi ht vo (bnh thng gim di 10mmHg). C th c du Kussmaul (tnh
mch c ni khi ht vo).
3.3. Cn lm sng
- X Quang: khi chn p tim cp xy ra trong trng hp khng c trn dch mng ngoi tim
trc , th trn phim X quang thng khng pht hin c du bt thng v trn dch
mng ngoi tim t hn 250ml (nhng c th gy t vong) khng pht hin c trn phim X
quang thng thng.
98
Khi chn p tim cp xy ra bnh nhn c trn dch mng ngoi tim, trn phim X
quang c th thy bng tim hnh bu, ging nh ci bao hoc bng tim hnh cu vi gc rt
nhn hp bi b di phi ca mng ngoi tim vi c honh. Mc d khng c hnh nh no
c hiu xc nh chn on trn dch mng ngoi tim nhng c th nghi ng nu bng tim to
nhanh v km vi trng phi sng.
- in Tm : in th giao lu ton b (sng P, QRS v T) gp trong trn dch mng tim
hoc chn p tim. Tuy nhin du hiu ny khng phi lun lun c. Du hiu in tm
in hnh ca chy mu trong mng tim l sng T cao nhn t ngt cc chuyn o trc
tim. Chn p tim cp do v tim c th gy ra nhp chm t ngt v phn ly in c. in th
phc b QRS thp t ngt trn in tm gi c trn dch mng tim.
- Siu m: siu m l mt phng php khng xm nhp, gip chn on sm nht v chnh
xc nht trn dch mng tim. Mt khc cng gip nhn bit tnh trng p tim.
+ Siu m M-mode: thy s thay i bt thng bung tht phi v tri theo chu k
th: khi ht vo tht phi dn rng, khi th ra tht phi nh i. Ngc li khi ht vo tht tri
b p lm nh li.
+ Siu m 2D: nhn thy c ton din dch trong khoang mng tim, du sp
tht phi, nh phi, nh tri, lng dch nhiu.
Lu c th khng c du sp tht phi khi thnh tht phi dy cng hoc c tng
p ng mch phi.
- Thng tim: du kinh in trong thng tim l p lc trong mng ngoi tim tng, p lc nh
phi v tht phi tng v bng nhau, ng dc x ni bt v mt ng dc y v p lc tht
phi cui tm trng tng bng nh phi.
4. Chn on phn bit
Suy tim phi cp c th nhm vi chn p tim, v suy tim phi cp c th cho hnh nh
X quang vi bng tim to v phi sng. Hn na c th c p lc tnh mch trung tm tng v
huyt p gim. Tuy nhin, suy tim huyt him khi gy ra mch nghch thng.
Trn dch mng tim khng gy chn p c th i km vi suy tim huyt. Trng hp
ny cng him khi c mch nghch thng v khi nghe tim c th c m thi do bnh tim hu
thp hoc do bnh tim khc.
IV. VIM MNG NGOI TIM CO THT
1. nh ngha: VMNT co tht l tnh trng MNT vim dy, c khi nhim vi, bp cht ly
tim, lm tim khng dn ra c, dn n gim th tch tm trng, ko theo gim th tch tm
thu hu qu cui cng lm cung lng tim gim.
2. Chn on
2.1. Lm sng
Ni bt hi chng tr tun hon ngoi bin vi:
- Ph, gan to chc b sc, tnh mch c ni to
- C th c c chng
- Xm da nh, nht l cc chi do lu ngy ging nh x gan, nhng khc l khng c
tun hon bng h vng trn rn (ca - ch)
- Nghe tim: ting tim thng m t, c th nghe ting c mng ngoi tim. C th c ting
ba g ( k tm trng cch ting th 2 khong 0,10s - 0,13s).
2.2. Cn lm sng
- X.Quang: tim to t, hoc khng to, b r, c th c vi ha mng ngoi tim.
- in tm : ST gim, sng T dt hoc m tnh,c th c rung nh.
99
- Siu m tim: mng tim dy. Thnh sau tht tri c th c dng st cao nguyn. Nh tri to
hn bnh thng. TM (tnh mch) ch di v TM gan gin. Doppler xung kinh in v
Doppler m gip nhn bit VMNTCT cng nh phn bit bnh c tim hn ch.

Hnh nh X quang vim mng ngoi tim co tht
- Thng tim: ng cong p lc tht (P) c dc-cao nguyn (dip-plateau). p lc tht (P)
tng c bit p lc cui tm trng, do mng tim x cng cn tr c tht gin ra (chn on
phn bit vi bnh c tim hn ch loi x chun ni mc).
V. IU TR
1. iu tr ngoi khoa
1.1. Ch nh
- Dch mu, m lu ngy.
- Mng tim dy.
- i vi VMNT co tht ty thuc vo mc dy dnh, vi ha MNT m c th
phu thut ct b ton b MNT hay m ca s.
1.2. Theo di sau m
- Nhim trng.
- Ri lon nhp.
- Cc c quan ln cn nh hng nht l trung tht, mng phi.
2. iu tr ni khoa
2.1. iu tr chung
au do vim mng ngoi tim c th gim bt bng cch cho cc thuc chng vim
khng corticoid nh Aspirine 500 mg/4 gi. Nu au ko di qu 48 gi c th x dng c
corticoid liu 1 mg/kg. Sau 5-7 ngy nu gim au c th gim liu v ngng thuc.
2.2.iu tr nguyn nhn gy bnh
* Vim mng ngoi tim do lao: dng thuc khng lao sm , mnh, phi hp t nht 3 loi
(Isoniazide 300mg/ngy, Rifamycine 600mg/ngy, Ethambutol 15mg/kg/ngy), phc iu
tr thay i ty theo tin trin v khng sinh . Thi gian iu tr c th 6-9-12 thng. Trong
trng hp tin trin co tht th phi tng cng thuc chng lao v cn nhc s dng
corticoide vi s thn trng. Corticoide cn lm bt dch nhanh khi s lng dch nhiu cho
nn c th s dng thuc ny nu chc chn thuc iu tr c hiu chng lao c hiu qu.
100
Trong trng hp nu cc triu chng khng thoi lui nhanh th phi ct b mng ngoi tim.
Liu Prednisone 1-2 mg/kg/ngy trong 5-7 ngy sau gim dn v ngng sau 6-8 tun.
* Vim mng ngoi tim do vi khun sinh m: dng khng sinh ton thn da vo khng sinh
ca cy dch mng tim kt hp khng sinh bm ti ch mng tim. Nu mng tim dy, m
c qunh cn phi dn lu phu thut.
* Vim mng ngoi tim do thp: Corticoid v Penicilline.
* Vim mng ngoi tim cp lnh tnh: c khi khng cn iu tr. C th dng Aspirine 1-3
g/ngy.
* Xut huyt mng ngoi tim: sau chn thng cn phi phu thut.
* Vim mng ngoi tim do ung th: dng ha tr liu, x tr liu, nu cn dn lu phu thut
hoc to ca s mng phi-mng tim nu ti din tit dch.
* Vim mng ngoi tim sau nhi mu: ni chung t nguy him, c th dng aspirin hoc
corticoid.
* Vim mng ngoi tim do ure mu cao: lc thn hoc chy thn nhn to.
* Chn p tim cp: chc dch mng tim.
* Vim mng ngoi tim mn tnh co tht: c th dng li tiu gim dch. Digital ch dng
khi c rung nh tn s tht nhanh. Nu do lao cn iu tr phi hp. Ct b mng ngoi tim l
bin php trit nhng cn thc hin sm.
2.3. Chc dch mng tim
* Mc ch
- L th thut quan trng nht chn on xc nh v nguyn nhn (ngay c khi
dch t)
- Tho bt dch trnh p tim trong chn p tim cp trnh ri lon huyt ng nh
hng n chc nng tim, hoc nng n hn l t vong.
Ly dch mng tim c th c 3 cch: chc bng kim v ng dn (catheter), m mng tim qua
ng xng c, ct b mng tim ton b hoc mt phn bng phu thut. Ngy nay siu m
c dng hng dn chc d rt tt v n c bit c ch trong trn dch mng tim khu
tr. Tai bin chc d: lm rch tim, ng mch vnh v phi. Trc kia nguy c tai bin chc
d l 20% nhng ngy nay vi s tr gip ca siu m t l ny ch cn < 5%. Chc d mng
tim c th gy bin chng hoc l chng c ch ci thin huyt ng trong nhng trng
hp sau:
- Trn mu mng tim do chn thng do tc trn mu nhanh mc du ang chc ht.
- Lng dch t hn 200ml.
- Trn siu m khng c trn dch pha trc tim.
- Trn dch c vch ngn.
- Cc mu ng v fibrin lm y khoang mng tim v trung tht sau phu thut.
Chc d s c t nguy c nu nh thy dch thnh trc > 10mm trn siu m. C mt bin
chng c th xy ra tuy l him gp sau khi x tr p tim l gin tht t ngt v ph phi
cp. C ch c th do tng lung mu tnh mch phi trn nn tng lon chc nng tht tri c
sn.
K thut chc dch mng tim: bnh nhn nm u cao 30-45
o
dn dch v pha trc v
di. Tin m bng Atropin v thuc an thn gim au (VD: Dologan). Gy t ch chc bng
Xylocaine 1-2%. Trnh chc vo: gan, c tim, phi, b mch b di cc xng sn, ng
mch v trong.
101
- Dieulafoy: chc vng trc tim, nu c hng dn bng siu m th y l v tr chc hay
c dng.
K thut: u tin xc nh im chc. u d siu m t 3-5cm cch b c tri nh v ni
dch gn vi u d nht cng nh ch nhiu dch nht. o trn siu m khong cch t da
cho ti khoang mng tim c dch. Xc nh ng i ca kim chc thng qua gc ca u d
siu m. Dng kim nng c 16-18 chc trnh b di xng sn, khi thy dch y su thm
2mm ri rt kim li ng thng trong khoang mng tim.
- ng Marfan: chc di xng c, ng chc ny c a thch v trnh c mng
phi, trnh tn thng mch vnh.
K thut: st trng da vng chc sau dng kim c 16-18 chc vo khong gia mi c v
b sn tri. Mi kim hng ti mm xng b vai, kim y t t di p lc m. Khi thy
dch th rt kim ra v lun catheter vo. C th khu c nh catheter rt dch nhng ln
sau.
Khi lng dch dn lu < 50ml/ngy c th rt ng dn lu v theo di bng siu m. V nguy
c nhim trng nn nu khng thc s cn thit th rt ng dn lu sau 24h.
Chng ch nh chc:
- Phnh tch ng mch ch
- Nhim trng da vng chc
- Rch c tim
- Ri lon ng mu nng
Bin chng:
- Rch ng, tnh mch vnh
- p tim
- Chc thng rch bung tim
- Suy tht tri v ph phi cp
- Chy mu
- Lon nhp tim
- Trn kh mng phi
- Tt huyt p
Ch : Lng dch ly ra t t trnh thay i p lc t ngt lm thay i t th ca tim.
Nu p tim cp cho ly dch nhanh. Sau khi ht dch xong cn bm t kh vo khoang mng
tim, s lng bng 2/3 hoc 1/2 lng dch ly ra.
+ Sau chc d:
- Ly mu dch xt nghim: sinh ha, t bo, vi trng v cy ng thi lm khng sinh
iu tr.
- o li HA, mch, nhp tim, khm li gan: lng dch ly ra ci thin ngay triu chng c
nng. HA khng cn kt. gan nh li, nhp tim chm hn.
- o li .T.: Bin in th cc sng in tim cao hn ht hnh nh in th giao lu
(nu trc khi chc d c).
- Cho bnh nhn nm theo di phng cc tai bin nh: d dch vo trung tht, trn kh mng
phi, ri lon nhp tim.v.v....
- Nn cho bnh nhn i chp li X.Q. tim: xem bng tim nh li, xem mng ngoi tim c dy
mc no c hng iu tr ni hay ngoi khoa kp thi cho bnh nhn
- C iu kin siu m tim li cho bnh nhn nh gi chnh xc hn v lng dch v dy
ca mng ngoi tim sau khi chc d mng tim. S. khng phn bit c dch MNT do
102
vim, do chn p trn mu hay dng chp nhng phn bit c: c si fbin, cc mu, hay
K mng tim di cn thy cc khi di cn trong mng tim c dch.



103
BNH TIM BM SINH
Mc tiu
- Lit k c nhng bnh tim bm sinh gp ngi ln
- Trnh by c nguyn nhn ca bnh tim bm sinh
- Trnh by c triu chng v cch chn on cc bnh tim bm sinh
- Nm vng v vn dng c cc ch nh v cc phng tin iu tr ni ngoi khoa
trong iu tr bnh tim bm sinh ngi ln.
Ni dung
I. I CNG
Bnh tim bm sinh l nhng d tt tim v mch mu ln to nn do nhng bt thng trong
bo thai thng th 2-3 ca thai k, vo giai on hnh thnh cc mch mu ln t ng tim
nguyn thy. T l chng 5% tr s sinh theo ti liu Php, M, Vit nam hin cha c
mt thng k no.
II. BNH NGUYN
2.1. Cc bnh ngi m mc phi trong thi k thai nghn: Nhim siu vi ch yu l bnh
o ban (Rubella), hi chng Rubella thng c ic, c thy tinh th, u b v c th phi
hp vi cn ng ng mch, hp van ng mch phi, thng lin tht.
2.2. Cc yu t di truyn c hoc khng ri lon nhim sc th nh mc tim bm sinh trong
hi chng Marfan, lch khp hng, hi chng Down, bin d n gene cng c cp n
trong di truyn mang tnh gia nh ca bnh thng lin tht, thng lin nh, o ph tng...
2.3. Gn y ngi ta pht hin nhng b m nghin ru m mang thai c th sinh ra tr
c d tt bm sinh gi l hi chng ru i vi bo thai, gm u b, mt ti h, trn g, hm
nh, chm pht trin thai nhi, thng lin tht, thng lin nh...
III. S B PHN LOI
Shunt tri-phi, phi-tri hoc khng c Shunt
1. Loi Shunt tri - phi: l loi tim bm sinh khng c tm. Mu chy t bn tri c p lc
cao sang bn phi c p lc thp hn. Tuy nhin lu ngy do tng p lc ng mch phi
nng n c th o shunt lc ngi ta gi l hi chng Eisenmenger. Trong nhm ny hay
gp thng lin nh, thng lin tht, cn ng ng mch.
2. Loi c Shunt phi - tri: Thng l nhng d tt gy tng p lc khoang tim phi lm mu
t phi sang tri gy trn ln mu ng mch v mu tnh mch pht sinh tm, tm xut hin
khi Hb > 5g/100ml v bo ha O
2
< 70%, y l bnh tim bm sinh gy tm. Cc bnh
thuc nhm ny nh t chng Fallot, tam chng Fallot, Ebstaine.
3. Loi khng c Shunt: l d tt bm sinh trong tim hay trn cc mch mu ln nhng khng
c shunt nh hp eo ng mch ch, hp di van ch hay phi...
IV. BNH TIM BM SINH C LUNG THNG TRI-PHI
1. Thng lin nh
L bnh tim bm sinh thng gp nht (15-20% trng hp). Dng n thun ch chim
khong 20% trong tng s cc trng hp thng lin nh. T l n /nam vo khong 2/3. Nu
khng iu tr bng phu thut tim h th kt cc dn ti suy tim nng n.
1.1. Th lm sng
- L th pht: nm trung tm cn gi l cn l Botal. L hnh trn hoc bu dc, i khi
ko di hoc l dng ca s. ng knh trung bnh vo khong 20-30mm.
- L xoang tnh mch nm trn hoc di:
104
+L trn ch vo ca tnh mch ch trn, loi ny hu nh lun km bt thng tr v tnh
mch phi khng hon ton (trc tip vo nh phi hoc l phn thp ca tnh mch ch
trn).
+ L phn vch thp: ko di ti tn tnh mch ch di (l xoang vnh).
- L tin pht: him gp hn nhng loi trn. L thng nm phn y ca mng trc l
xoang vnh. N c th n thun hoc l phi hp vi li phu l vch van hai l.
1.2. Sinh l bnh:
y l loi c lung thng chiu tri phi do p lc nh tri cao hn. ln ca shunt tu
thuc vo kch thc ca l v sc cn tiu ng mch phi. Mc du lu lng shunt ln
nhng p lc ng mch phi khng tng hoc l tng t. Qu ti th tch lm gin bung tim
phi v mch mu phi. Ngc li bung tim tri cng nh ng mch ch kch thc li
nh. V sau tiu ng mch phi b tn thng (vim tng sinh ni mc, thuyn tc) s lm
tng sc cn a ti tng p phi v th tch shunt gim. Cui cng khi p lc bung tim phi
tng qu s lm o shunt v ngi bnh s c tm.
1.3. Triu chng chn on:
1.3.1. L th pht: trong 90% trng hp s nghe c ting thi tm thu kiu tng mu
van ng mch phi. Ting thi lan dc b tri xng c nhng cc i lin sn 2 hoc 3
cnh c tri. Ting thi c c tnh cng va phi, m sc m nhng cng c th c m
sc th mnh ging ting thi gp trong hp van ng mch phi. Ting T2 tch i c nh
theo chu chuyn h hp. Trong trng hp tng p phi nng c th nghe c ting thi tm
trng do h van ng mch phi. Hnh nh Xquang ni bt cc du chng gin tim phi v
ng mch phi. in tm hay c trc QRS lch phi v nht l hnh nh bloc nhnh phi
hay gp th khng hon ton. Siu m l phng tin chn on rt hu hiu, trn hnh nh
siu m hai bnh din cho thy tht phi tng kch thc do qu ti th tch tm trng. N
cho thy trc tip hnh nh khuyt vch lin nh v vi siu m mu thy lung shunt qua
vch, siu m cn quang thy vng ra trong nh phi nu shunt tri phi v trong trng hp
o shunt c th thy cht cn quang qua tim tri.
Thng tim: c hai triu chng sau cho php khng nh chn on
- ng thng chy t nh phi sang nh tri d (7-8 ln/10).
- Nng Oxy nh phi giu hn trong tnh mch ch.
Ngoi ra thng tim cng cho php nh gi p lc ng mch phi, o lu lng ca shunt,
o sc cn ng mch phi.
Tin trin
Tu thuc vo ng knh l thng tc l lu lng shunt. Tui th trung bnh 35-40 tui.
Bnh nhn lu ngy s tin trin suy tim phi, lon nhp (hay c rung nh), khi p lc nh phi
tng hn bn nh tri s lm o shunt v c tm. Lu c 14-66% thng lin nh t ng l
thng.
1.3.2. L tin pht: chim 20 % cc trng hp thng lin nh. Tui th trung bnh thp hn
(30 tui), phu thut kh hn.
Lm sng ngoi triu chng ca thng lin nh cn c thi tm thu mm do bt
thng van hai l. in tm trc tri trong khi li c bloc cnh phi. Thng tim c thng
lin nh thp cng nh thy dng mu chy ngc ln nh do h hai l. Siu m Doppler cng
cho php chn on tng t.
1.3.3. Thng lin nh phi hp tr v bt thng tnh mch phi: hay gp tr v bt thng
tnh mch thu trn phi hoc gia phi vo phn tn ca tnh mch ch trn (dng sinus
venosus).
Thng tim chp mch cho php chn on rt tt.
105
1.3.4. Hi chng Lutembacher: phi hp hp hai l v thng lin nh.
2. Thng lin tht: l loi tim bm sinh hay gp nht chim 20-30% cc bnh tim bm sinh.
Nu tnh chung c cc bnh tim bm sinh c thng lin tht phi hp n chim 50%. y l
loi tim bm sinh c shunt tri phi (dng n thun).
2.1. Gii phu bnh hc: c nhiu v tr thng lin tht.
- Hay gp nht l thng phn mng.
- cao v pha trc di van ng mch phi.
- cao pha sau di l vch ca van ba l.
- Thp nm phn c ca vch lin tht.
Tht tri c th thng vi nh phi (khng thc s l thng lin tht), thng phi hp vi bt
thng van 3 l.
2.2. Sinh l bnh: do p lc tht tri cao hn p lc tht phi cho nn s c shunt tri phi qua
vch lin tht. ln ca shunt tu thuc vo kch thc l thng v sc cn tiu ng mch
phi. tr em ng knh l thng >1,2cm2 /m2 c th (hoc >1/2 l van ng mch ch) th
khng cn chnh p gia hai bung tht v cho th tch shunt ln nu sc cn phi thp to
tng p phi cung lng . L thng c th t ng theo thi gian hoc l shunt s gim
(hay ci thin lc 2 tui) do tng ng knh l van ng mch ch. Trong loi thng lin tht
phn c l thng s nh i k tm thu.
Sc cn tiu ng mch phi tng ln c th do cc yu t sau:
- Tng p phi hu mao mch: to nn do mu v nh tri qu nhiu trong khi van hai l ng
v khi m thot mu khng kp to hp c nng van hai l.
- Tnglu lng phi sau ny c hu qu dy cc si c lp o gia cc mch mu nh (giai
on I), tng sinh ni mc (giai on II), thoi ho hyalin v x ho (giai on III), hoi t
gin khu tr (giai on IV). Lu lng shunt s gim theo nhng p lc ng mch phi vn
tng.
Sinh l bnh s khc nu c hp ng mch phi (bm sinh hoc mc phi do thch
nghi th pht) cho bnh cnh gn ging t chng Fallot.
Ngi ta chia cc nhm thng lin tht chnh nh sau:
- Thng lin tht l nh, c shunt tri phi p lc ng mch phi bnh thng, y l bnh
Roger.
- Shunt ln l to, sc cn tiu ng mch phi bnh thng hoc tng t.
+ Nhm II a: p lc ng mch ph tm thu < 70% p lc h thng.
+ Nhm II b: p lc ng mch phi tm thu > 70% p lc h thng.
- Nhm III: tng p phi v tng sc cn phi nng, shunt tri phi nh, c th c shunt hai
chiu nh. Khi o shunt gi l hi chng Eisenmenger.
- Nhm IV: phi bo v (hp ng mch phi van hoc phu), ranh gii vi t chng Fallot
(ngoi tr shunt tri phi).
2.3. Triu chng chn on
- Lm sng: triu chng c nng thay i tu theo nhm thng lin tht cng nh tui ngi
bnh m c th v triu chng hoc l kh th. Tr em c th chm ln, bin dng lng ngc.
Khm c thi ton tm thu to c rung miu (khng phi lun vy), m sc th rp cc i lin
sn 4 cnh c tri lan mi hng. Ting T2 phi bnh thng hoc l mnh tch i. Ngoi
ra cn c th nghe ting thi tm thu kiu tng mu do tng lu lng phi nghe thy
khong lin sn 2-3 cnh c tri, rung u tm trng do hp van hai l c nng nghe c
mm tim. Khi tng nng sc cn tiu ng mch phi ting thi s gim cng hoc l
mt, khng cn nghe thy ting rung tm trng mm.
106
- X quang: c th c hay khng thy bng tim ln tri ln bn tri cng nh tnh trng gin
ng mch phi.
- in tm : dy tht tri, nh tri, khi c tng p phi c th thy du dy tht phi.
- Siu m doppler: cho php thy c l thng lin tht cng nh lung shunt qua l thng,
nh gi c ln ca shunt cng nh tnh trng tng p lc ng mch phi.
- Thng tim chp mch: chp bung tht tri cho php thy chnh xc thng lin tht. Ngoi
ra thng tim cn cho bit c p lc ng mch phi cng nh sc cn tiu ng mch phi,
lu lng shunt.
3. Cn ng ng mch
3.1. Gii phu: v tr ca ng bt ngun t ng mch ch trc eo vo ng mch phi tri
i khi ch phn nhnh ng mch phi. Him khi vo ng mch phi phi. ng knh
tr em di 7-10 mm rng 5-7mm, ng cng c th c hoc khng to ln theo tui.
3.2. Sinh l bnh: ng ng mch to shunt tri phi. Nu shunt ln p lc ngang bng hai
bn h tun hon. Tng p nh tri v tnh mch phi gy co tht tiu ng mch phi phn x
trong thi gian di c th hi phc lm gim bt lu lng shunt. Lu ngy sc cn tiu ng
mch tng thc th khng hi phc v tin ti o shunt hoc l mt shunt.
Trong mt s him trng hp c tng p phi cng nh tng sc cn phi ngay do
bt thng cu trc bo thai ca tiu ng mch phi.
3.3. Triu chng chn on:
- Lm sng: thng pht hin tnh c khi khm sc kho bi bnh thng dung np tt. Nghe
tim l c bn chn on vi ting thi lin tc vng h n tri. tr b m i khi ch
nghe ting thi tm thu.
Nu shunt ln c th nghe ting rung tm trng do hp c nng van hai l, hiu p
ng mch tng.
- X quang: bng tim thng bnh thng, trong trng hp shunt ln tht tri c th gin.
- in tm : bnh thng nu shunt nh hoc hnh nh dy tht tri nu shunt ln.
- Thng tim: cho php khng nh chn on khi ng thng t ng mch phi vo ng
mch ch thnh hnh ch phi, tuy nhin thng khng cn thit.
- Siu m doppler mu: cho php nhn thy ng thng cng nh shunt, nh gi lu lng
shunt cng nh p lc ng mch phi.
3.4. Tin trin:
- Suy tim: tu thuc vo lu lng shunt v p lc ng mch phi. Bnh cnh suy tim tri
sau suy tim ton b tr nhanh vi iu tr tr tim.
- Vim ni tm mc nhim trng trn thnh ng: nng n kh iu tr. C th lm phnh ng
lm phu thut kh khn.
- Phnh ng: c nguy c v.
3.5. Th lm sng:
- Cn ng ng mch tr b: thi tm thu vi ting T
2
mnh van ng mch phi. Chn
on c th kh phn bit vi thng lin tht. Nu nh c tng hiu p, ng mch ch gin
cng nh tng m mch phi loi ny thng lm suy tim sm v cn phi c can thip
phu thut sm.
- Cn ng ng mch c tng p phi mnh: kh th, c th tm (nht l chi di), hay nhim
trng phi, du suy tim nng, bin dng lng ngc, chm pht trin th lc.
Nghe tim khng cn ting thi lin tc, T2 rt mnh i khi c thi tm trng do h
van ng mch phi c nng.
107
X quang tim ln, cung ng mch phi phng trong khi ngoi vi phi sng lc tng
sc cn tiu ng mch phi v shunt nh.
in tm tng gnh tm trng tht tri phi hp tng gnh tm thu tht phi (do
lu lng shunt ln hoc sc cn phi ln).
Thng tim ngoi vic chn on v o p lc ng mch phi cn cho php phn nh
c c ch ca tng p lc (do tng lu lng hay tng sc cn phi).
- Dng phi hp: hp eo ng mch ch, thng lin tht, hp ng mch ch.
4. Phnh xoang Valsalva
Ti phnh Valsalva thng tim tng v c pht hin tnh c. Tuy nhin c nguy c v ti
phnh v vim ni tm mc nhim trng.
4.1. V: thng nhn mt ng tc gng sc v gy au ngc d di, tnh trng chong v
kh th d di. Thng thng ti phnh v vo tht phi v him khi v vo nh phi. Khm
tim c ting thi lin tc cng mnh nm vng thp b tri xng c v du hiu ngoi
vi ca h van ch. X quang v in tm cho thy du hiu qu ti c hai tht. Thng tim
phi thy shunt tri phi ln tng nh hoc tht cng nh cho bit mc tng p phi. Siu
m Doppler cng cho php chn on v phnh Valsalva. Tin trin t vong nhanh chng
trong vng vi tun hoc vi thng v suy tim.
Nu v ti phnh vo mng tim c th lm trn mu mng ngoi tim, v vo nh tri
to ting thi lin tc nhng khng c shunt, v vo tht tri gy h van ng mch ch.
Chn on phn bit vi d ng mch vnh, d ch ph.
4.2. Cc bin chng khc: nhim trng ti phnh c th cng lm v. Khi ti phnh ln v
pha vch lin tht c th lm cho ri lon dn truyn.
V. BNH TIM BM SINH C LUNG THNG PHI - TRI
1. T chng Fallot
L d tt bm sinh phi hp bao gm 4 chng sau:
- Hp ng mch phi.
- Thng lin tht.
- ng mch ch lch sang phi.
- Dy tht phi ng tm.
Lm sng tm ngn tay chn di trng, tr em khi mt hay ngi xm, kh th ngt co
git. Nghe c thi tm thu cng mnh th rp khong lin sn 3 cnh c do hp ng
mch phi. Ting T2 gim cng hoc l mt.
X quang bng tim bnh thng nhng c hnh i hia, cung gia tri lm, cc ng
mch phi nh v trng phi sng.
in tm c dy tht phi v nh phi.
Siu m cho thy ng mch ch ci nga, thng lin tht phn mng, dy tht phi
cng nh kho st van ng mch phi v thn nhnh ca n.
Thng tim chp mch cho php chn on cc bt thng trong d tt bm sinh ny.
2. Bnh Ebstaine
L bt thng bm sinh him gp ca van ba l. L vch v l sau dnh nhau v ch
tch nhau 1/3 di. Chng lm thnh l van di thp bt thng, nh vy to bnh cnh
tht b nh ho.
- Phn tht b nh ho co bp cng lc vi nh v th cn tr qu trnh lm y mu. L van ba
l hp hoc l h. Kt qu l tr tun hon thng ngun ca van ba l, nu c phi hp
108
thng lin nh th s c shunt phi tri, nu vch lin nh bnh thng th c tr tnh mch
ngoi vi (gan ln, tnh mch c ni, c chng).
- Nghe tim c cc ting tim tch i do bloc cnh phi hon ton, thnh phn T1 ca van ba l
m sc kim loi. Hay gp ting thi tm thu do h van ba l c im l dch sang tri so vi
bnh thng lm nhm h hai l.
- X quang c bng tim ln lm cho c th nhm trn dch mng ngoi tim. in tm c
lch trc phi dy nh phi v hnh nh bloc cnh phi.
- Siu m M-mode thy van ba l ng chm 0,04-0,12s so vi van hai l, siu m hai bnh
din thy bm thp van ba l.
- Thng tim chp mch cho thy tnh trng nh ho tht cng nh o p lc bung tim phi.
- Tin trin thay i, i sng trung bnh 13 nm. Nu qua khi thi k nin thiu c th sng
30-40 nm. Nguyn nhn t vong do tai bin mch no, suy tim phi, ri lon nhp.
5.3. Phc hp Eisenmenger: c m t ln u tin vo nm 1897 khc vi t chng Fallot.
Tm mun, bao gm cc d tt sau:
- Thng lin tht cao.
- ng mch ch xut pht t ch thng lin tht c th c ci nga.
- Dy tht phi.
- Gin ng mch phi.
in tm : Thng dy 2 tht. Xquang: Tr nh tim to v rn phi m.
Hin nay ngi ta xp tt c cc bnh tim bm sinh c Shunt tri-phi nhng o Shunt
phi-tri gi l hi chng Eisenmenger.
VI. BNH TIM BM SINH KHNG SHUNT
1. Hp eo ng mch ch
- Lm sng: thi tm thu cnh c tri cng va phi, khng c rung miu nhng lan ra sau
lng r, huyt p tng v mch ny mnh chi trn, huyt p thp v mch yu chi di.
- in tm , Xquang: Dy tht tri mnh hay va ty hp eo ng mch ch gn hay xa l
van ng mch ch, tht tri ln va phi vi gin ng mch ch phn trn xng n tri
km theo du gm mn xng sn (ng mch lin sn gin).
- Siu m-Doppler: Thy c v tr, kch thc ca hp, dng chy tng tc qua ni hp
v du nh hng ca hp eo ng mch ch (gin tht tri....).
- Thng tim, chp mch: p lc tht tri tng, p lc ng mch ch tm thu tng cao phn
trn hp nhng bnh thng ng mch bn. Chp mch cho bit v tr hp, mc gim
ca tun hon bn ca ng mch lin sn, ng mch v trong.
Ngoi hp eo ng mch ch cn gp hp di van ng mch ch bm sinh do tn ti mt
mng di ch cn ng tng mu tht tri.
2. Hp van ng mch phi: Chim 7% bnh tim bm sinh gm hp van, hp di van, hp
phu, v phi hp:
- Lm sng: thi tm thu mnh van ng mch phi km rung miu, T2 nh hoc mt, tm
mun.
- in tm , Xquang: dy tht phi chn lc, thn ng mch phi gin v phng, ln tht
phi, gim mch mu c 2 trng phi (phi sng).
- Siu m-Doppler: Cho bit th hp van, di van, phu hay phi hp, tht phi dy, tc
mu qua van ng mch phi tng cao, chnh p qua ch hp tng.
109
- Thng tim, chp mch: thy chnh p lc gia tht phi v ng mch phi tng (p lc
bung tht phi tng cao trong khi thp ng mch phi). Chp mch cho thy hp, cht cn
quang i qua ch hp van.
VII. IU TR
1. Thng nh
Phn ln thng nh khng dn n suy tim. chnh p lc gia 2 bung nh khng cao do
thng nh cng khng b bin chng vim ni tm mc nhim trng. Do thng khng
cn phi dng khng sinh d phng khi nh rng, cha rng hoc lm th thut ngoi khoa.
1.1. Ni khoa
Ch c vai tr tng i nht l khi cha c ch nh phu thut nh:
- iu tr bi nhim phi.
- iu tr ri lon nhp khi c rung nh, nhp nhanh kch pht trn tht.
- iu tr suy tim.
- iu tr phng chng tc mch.
ng l thng lin nh bng ng thng a mt dng c gi l d i a vo l thng
bt l mt th thut c cc nh ni tim mch thc hin.
1.2. Ngoi khoa
Bng phu thut tun hon ngoi c th, ng l thng lin nh bng cch khu trc tip
hay bng ming v tng hp. Thng nh c th t ng vi tn sut t 14-66%. Do khng
nn phu thut tui di 1 tui tr khi c bin chng suy tim hoc tng p phi khng kim
sot c.
Ch nh phu thut: tui phu thut thay i c tc gi cho nn m tui i hc t 3- 5, hoc
c th m tui t 15 -20 tuy vy nhn chung ch nh phu thut thng nh thng khng
khn cp nh thng tht v bin chng tng p phi thng xy ra mun hn. C nghin cu
cho ngi ln tui mi pht hin cng nn m. Ch nh thng thng nht khi:
- Lu lng dng mu phi/ lu lng dng mu ng mch h thng >1.5/1
- Cha i shunt (nng O2 bo ha ng mch (92% hoc sc cn MP < 15 n v
Woods/m
2
c th).
Khng phu thut khi: p lc ng mch phi o bng Doppler gn bng p lc mch
h thng, lung thng rt t v 2 chiu, bo ho O
2
lc ngh di 92% v gim hn khi
gng sc.
2. Thng lin tht (TLT)
V ni khoa ni chung cn iu tr cc bin chng ca TLT nh suy tim, bi nhim
phi, vim ni tm mc nhim trng. Phu thut tr s sinh thng c t vong cao 10-20% so
vi tr ln 2%. Thng lin tht cng c th t ng, cc trng hp nng lu d chuyn
sang hi chng Eisenmenger kh khn khi phu thut.
2.1. Thng tht c l thng nh, shunt nh
Khng c ch nh ngoi khoa v bnh nhn thch nghi tt. Ch cn d phng nhim
trng ni tm mc. Tuy vy TLT l nh c km h van ng mch ch (hi chng Laubry -
Pezzi) cng nn xt m sm.
2.2. Thng tht ln, shunt tri - phi ln (thng lin tht nhm II)
Chim 50%. Ni khoa gip iu tr cc bin chng hai khi bnh nhn khng c ch nh
phu thut. iu tr ch yu ngoi khoa vi tun hon ngoi c th, bng cch dng ming v
nhn to. Nguy c t vong t 1-2% trong th nh v < 10% trong th nng. Tai bin phu
thut thng gp do tn thng b His gy bloc nh tht hay bloc nhnh.
110
Ch nh: nn t vn sm tui t 2 -10, ch s p lc ng mch phi/ p lc ng mch
ton th (0.75 km theo suy tim cn phu thut ngay. Nu suy tim n nh khi iu tr ni
khoa
Ngoi hai nhm mu lm sng trn cn hai nhm c bit khc t gp hn:
- Nhm III vi s tng p phi nng, gn vi hi chng Eisenmenger nhng shunt tri-phi
vn cn d rt yu. Khng c ch nh phu thut.
- Nhm IV vi hp van hay phu MP (Thng lin tht c bo v phi) gn vi t chng
Fallot, nhng shunt tri - phi vn cn d rt yu. Cn phu thut nu dy tht phi r.
3. Cn ng ng mch (COM)
Tt c bnh nhn COM nu khng t ng c cn ch nh phu thut do c nhiu
nguy c nu khng gii quyt nh: vim ni tm nhim trng, suy tim tri, tng p phi, vi
ho ng ng mch.
3.1. Ni khoa
tr s sinh v cn b c th dng indometacine (Indocid) 25mgx 1-2 vin/ngy 1
thng lm ng li ng ng mch do thuc c ch tc dng co tht ca Prostacycline. C tc
gi s dng Aspirine cng c kt qu. Nu khng c kt qu phi phu thut. Ngy nay c th
bt ng ng mch bng dng c khng cn phu thut.
3.2. Ngoi khoa
Bng th thut ct buc hay nt l thng nu l thng ng knh di 5mm v tr 8kg.
p dng phu thut vi tui t 1-2 tui nhng c th ln hn nhng cha i shunt. T l
nguy c t vong khi phu thut t 1-2% do suy tim, Osler.
Theo Kirklin tt c CM c triu chng hoc tr khng ln d iu tr ni khoa tch cc
c th phu thut bt k tui no.
- Cn ng ng mch vi shunt ln v tng p phi nh:
iu tr ngoi khoa: Ct buc. Nguy c t vong cao hn so vi nhm trn.
- Cn ng ng mch vi shunt nh v tng p lc phi nng.
iu tr: Ch nh phu thut cn xem xt k.
Nu sc cn p lc phi trn 10 v/m
2
, khng cn ch nh phu thut. Nu sc cn mch
phi thp hn nhng ng ng mch ngn, vi ho nhiu nn phu thut tim h trnh v ng
mch khi kp trong phu thut kn.
4. T chng Fallot
- Ni khoa: iu tr ch c tnh tm thi, lm bt cc triu chng chun b cho phu thut.
Gim s tng mu tht phi bng cc thuc c ch bta nh Propanolol 40mg x1vin ung.
Cho thuc chng ng hay chng ngng tp tiu cu nh Aspirine 0.25g/ ngy. Tr s sinh c
tun hon phi khng c th chuyn Prostaglandine E1 gi ng ng mch m. Tt c
tr c dung tch hng cu cao cn cho thm vin st ung. Chng cn thiu Oxy kch pht:
cho nm u thp gi - ngc, O
2
, Morphine 0.01-0.1 mg/kg TB, truyn Natri bicarbonate.
- Ngoi khoa: c th phu thut tm thi hoc phu thut sa cha. Tui l tng phu
thut sa cha (v l thng tht bng mnh ghp v sa cha hp MP) l 2 tui. chm
tui ln s c nhiu bin chng sau m. Tnh trng tht tri v kch thc ng mch phi l
nhng yu t quan trng gip quyt nh k thut ny.
V phu thut tm thi c hay k thut thng dng l Blalock - Taussig (ni h n tri v
nhnh tri MP) v Blalock - Taussig c bin ci (ni bng ng Gore- Tex). Khng thc hin
phu thut Blalock - Taussig tr nh di 6 thng tui hoc MP c ng knh <3mm v
d b thuyn tc.
111
Cn gii phu sm khi triu chng c nng ngy cng tng hoc th tch hng cu khong
65%. T l t vong khong < 5% i vi Blalock v 10% i vi iu tr tn gc. K thut
Blalock ch cho kt qu tt trong khong 50% trng hp trong vng 10 nm.
5. Hp ng mch phi
- Ni khoa: t c tc dng. c coi va khi chnh p lc tht phi/ MP ti a 50-80
mmHg, nng khi chnh p ti a >80 mmHg. Can thip cng chm cng hp nng hn do
ph i vng phu. C th p dng phng php nong van thay cho phu thut m. Hin nay
ch nh nong bng qua da nhng c gi tr cao nu tui nh. y l phng php iu tr la
chn, hu nh khng c t vong.
- Ngoi khoa: ch p dng khi khng nong van qua da c. Phu thut to van ng mch
phi hai l c km theo hay khng sa cha phu phi. Khi c suy tim phi t l t vong cao
trn 14%.
6. Hp eo ng mch ch
Ngoi khoa: Cn t vn phu thut ngay khi bnh nhn cn chu ng c. Tui l
tng l t 10 -15 tui, v sau nguy c cao do b x va phi hp. Nguy c t vong di 5%.
Phu thut bng cch ni tn hoc bt cu ni bng ng nhn to.
7. Phc hp v hi chng EISENMENGER
-Ni khoa: iu tr bin chng suy tim: O
2
, tr tim, li tiu...
-Ngoi khoa: khng c ch nh phu thut ngoi tr thay tim.




112
VIM NI TM MC NHIM KHUN
Mc tiu
1. Trnh by nguyn nhn, c ch bnh sinh ca vim ni tm mc nhim khun.
2. Trnh by cc triu chng lm sng, cn lm sng v tiu chun Duke trong chn on
VNTMNK.
3. Nu cc th lm sng, nguyn tc iu tr vim ni tm mc nhim khun.
Ni dung
I. I CNG
1.1. nh ngha
Vim ni tm mc nhim khun (VNYMNK) l bnh nhim trng mng trong tim, tn
thng ch yu l cc van tim, nhng lp ni mc ca cc mch mu ln cng b tn thng
trong bi cnh lm sng chung. Bnh do nhiu tc nhn gy bnh v nhiu ng vo khc
nhau cui cng khu tr ni tm mc, tn thng vi c trng l lot v si nht l cc van
tim, ng hng u l van 2 l ri n van ng mch ch. Van 3 l t gp hn v thng trn
c a c bit (chch Hroine bng ng tnh mch).
1.2. Dch t hc
1.2.1.Vim ni tm mc nhim khun a s xy ra bnh nhn b nhim khun, tui thng
gp < 50, nam nhiu hn n, 60 - 80% bnh nhn c tin s b bnh tim trc ch yu l
bnh van tim, 30% do thp; VNTMNK hay gp van hai l dn ti van ng mch ch, 10 -
20% do bnh tim bm sinh. V d: bnh cn ng ng mch, thng lin tht, t chng Fallot,
hp MC; 10 - 30% sa van hai l. Cc bnh tim thoi ha cng l c s a n vim ni tm
mc c bit l hp van MC vi ha ngi gi, him hn ph i vch khng i xng, hi
chng Marfan, hp van ng mch ch do giang mai v 20 - 40% khng c bnh tim t trc.
1.2.2.Vim ni tm mc nhim khun bnh nhn chch ma ty: thng gp nam tr tui
khng c bnh tim, da thng l ngun ly nhim, van 3 l thng hay b tn thng hn c.
1.2.3.Vim ni tm mc bnh nhn mang van nhn to chim 10-20%, a s l nam gii,
van MC thng b hn van 2 l, tn thng thng cnh van trn ng khu van nhn to
vi vng van. Bnh thng xy ra trong tun u hay trong nm u sau phu thut (chim 1-
2% trng hp), t l mc bnh gim cn 1% trong nhng nm tip theo.
II. NGUYN NHN V C CH SINH BNH
2.1. Vi khun gy bnh
a s trng hp vi khun gy bnh l lin cu, thng l lin cu nhm D, t nhy cm
vi Pnicilline thng thng. Lin cu tan huyt (gy tan huyt b phn) v lin cu tan huyt
(li rt nhy cm vi Pnicilline, ngoi ra cn gp vim ni tm mc do lin cu (hin nay, t
cu l vi khun cng hay gp nht l do nhim trng huyt sau no ph thai (loi ny thng
nng, t l t vong cao do khng khng sinh). Ngoi ra cng c th gp vim ni tm mc
do trc trng Salmonella, Brucella.
2.2.ng vo
Bng 1: Nguyn nhn v ng vo ca vi khun trong vim ni tm mc nhim trng
ng xm nhp Tn thng Vi khun
Rng, ming Nh rng, U ht dnh lin cu Lin cu
Tai mi hng Vim hng, vim tai, ct
Amygdale, vim xoang
Lin cu D, lin cu
Tit niu Thng tiu, soi bng quang, m
tit niu
Lin cu D, t cu vng, trc
khun Gr (-)
113
Ph khoa Ph thai, sinh , vim ni mc
t cung
T cu, lin cu D
Da Bng, bnh v da T cu
Tiu ha Vim ti mt, U tiu ha Lin cu D, lin cu, t cu
ng thng T cu
Shunt chy thn nhn to Trc khun Gr (-), t cu
Dng ma ty Trc khun Gr (-)
M tim Nm
2.3. C ch sinh bnh
2.3.1. Tn thng ni mc
nh v ca vi khun trong tn thng ni tm mc theo l thuyt thng nm v tr
i din tn thng ni mc theo nh lut Venturi.




Hnh 1.Hiu qu lut Venturi v inh v ca vi khun
2.2.2. Vi khun
S c nh v s tng sinh ni vi khun ty thuc vo:
- sc khng vi khun t nhin ca huyt thanh: tnh bo v ca b th
- s him c ca vi khun Gram (-) do s nhy cm t nhin i vi b th.
- s hin din nhng khng th ngng kt lm to nn nhng m vi khun
- c tnh kt dnh c th do s tham gia ca nhng cht slime do mt s vi khun tit ra
nh t cu vng.
T cu vng -> lin cu khun tan huyt -> Pseudomonas aeruginosa
2.2.3. Cc biu hin min dch
Ph thuc vo:
- thi gian nhim trng
- s tn ti ca ngun kch thch khng th.
III. GII PHU BNH
Ngi ta phn bit 2 th ch yu sau y:
1. Vim ni tm mc cp c tnh
114
Tin trin nhanh, xut hin trn mt ni tm mc lnh, th ny nng n, thng gy t
vong nhanh v trong bi cnh nhim trng huyt. Tn thng gii phu bnh l lot, n mn,
sau cng l thng cc van, c th t cc dy chng, lot si c th gy nn p xe mt s
ph tng nh gan, lch, thn. Th ny c gi l c tnh v trc khi c khng sinh t vong
l 100%.
2. Vim ni tm mc bn cp nhim khun Jaccoud-Osler
L tn thng lot si xy ra trn cc bnh van tim, tim bm sinh c trc. Vi khun
gy bnh c pht hin nh cy mu hoc gii phu t thi vi cy m ni tn thng.
Trc khi c khng sinh, y l mt bnh nng, t vong 100%, nhng t khi c khng sinh t
l t vong c gim nhng vn cn l bnh nng.
IV.TRIU CHNG HC
4.1. Triu chng lm sng
4.1.1. Giai on khi u
Thng bt u vi st khng r nguyn nhn trn bnh nhn b bnh tim, v vy nu
bnh nhn c mc bnh tim m st khng r nguyn nhn trn 10 ngy, km suy nhc c
th, km n, xanh xao phi ngh n vim ni tm mc bn cp nhim khun (Osler). Thm
d chn on bng cch:
- Tm ng vo ca vi khun.
- Xt nghim nc tiu tm protein v bch cu niu.
- Cy mu nhiu ln, khng nn cho khng sinh lm cy mu tr nn m tnh.
- i khi bnh c th bt u bng tai bin mch mu no vi lit na ngi hay nhi
mu ph tng.
4.1.2. Giai on ton pht
Thng sau vi tun cc triu chng r dn:
- St v suy nhc: St dao ng km rt run hoc st kiu ln sng, nhit 39-400
xen k nhng t khng st do phi cp nhit mi 3 gi mt ln, st thng km da xanh,
thiu mu, gy.
- Nghe tim: Bnh tim t trc thng khng thay i. Theo th t thng gp l bnh
h van ng mch ch, h van hai l, hp van hai l, bnh van 3 l v van ng mch phi
him gp hn. Bnh tim bm sinh c th gp nh cn ng ng mch, thng lin tht, hp
ng mch phi, hp di van ng mch ch, hp eo ng mch ch, t chng Fallot.
- Ngn tay di trng rt c gi tr chn on trn bnh tim c st nhng du hiu ny
thng mun, ngoi ra xut huyt di da, nim mc cng c th gp.
- Lch to: 2- 4cm di b sn, rt c gi tr chn on nht l khi phi hp vi bnh
tim c st.
- Thn: kinh in l i mu i th hay vi th, Protein niu gp trong 70% trng hp.
- Cc du chng khc: Tc cc ng mch nh:
+ Tc mch no gy lit na ngi.
+ Tc mch chi gy au chi, da xanh ti, lnh.
+ Tc mch lch gy au h sn tri, lch to nhanh.
+ Tc mch mc treo: au bng.
+ Tc mch thn: au tht lng d di, i ra mu, thng v niu phn x trong 3 gi
u.
+ Nhi mu phi: au ngc, ho ra mu, kh th.
+ Vim mng no m, xut huyt mng no.
115
+ Tc mch kt mc mt.


Hnh 2. Cc biu hin lm sng ca vim ni tm mc
4.2. Cn lm sng
Cng thc mu: Thiu mu, bch cu tng.
Mu lng tng.
Lm in tm , chp X quang phi.
Soi y mt: Tc ng mch vng mc.
Lm cn Addis.
Protein niu.
Ur mu thng tng > 0,5g/lt.
in di Protein: globulin tng.
Cy mu: Lm 9 ln trong 3 ngy lin tip, lc nhit tng cao v trn nhiu mi
trng khc nhau.
116
Siu m tim: Hin nay c coi l xt nghim c nhy chn on cao, ngoi ra cn
cho php theo di tin trin ca bnh. Vi k thut siu m 2 bnh din ngi ta c th xc
nh c s hin din ca tn thng si trn cc van tim, siu m c th pht hin c t
dy chng hay thng van tim. Nu thy tn thng si th chn on chc chn mc d cy
mu (-), nhng khng thy tn thng si khng loi tr chn on.

Hnh 3. Du hiu si (VEG) trn siu m tim

V. CHN ON XC NH
p dng tiu chun chn on lm sng ca Duke nm 1994.
5.1. Hai tiu chun chnh
5.1.1 Cy mu dng tnh
- Vi khun c hiu phn lp c trong hai ln cy mu ring bit
- Cy mu dng tnh tn ti
5.1.2. Bng chng tn thng ni tm mc
- Siu m dng tnh
- H van mi xut hin
5.2. Su tiu chun ph
- Yu t thun li: c bnh tim, dng thuc ng tnh mch
- St > 38C
- Biu hin van tim: tc mch, phng mch, xut huyt, du hiu Janeway.
-Biu hin min dch: vim cu thn, nt Osler, du Roth, yu t thp.
-Bng chng vi sinh hc: cy mu dng tnh nhng khng c cc tiu chun chnh,
du huyt thanh hc nhim khun cp.
-Siu m tim: c du VNTMNK nhng khng c cc du hiu chnh.
5.3.Vn dng chn on
5.3.1. Tiu chun bnh l
+ vi khun: cy mu hoc c nt si gy tc mch hay p xe trong tim
+ tn thng gii phu bnh: si, p xe trong tim c m hc xc nh
5.3.2. Tiu chun lm sng
c chn on xc nh VNTMNK khi c:
- 2 tiu chun chnh, hoc
117
- 1 tiu chun chnh v 3 tiu chun ph, hoc
- 5 tiu chun ph
VI. TH LM SNG
6.1. Vim ni tm mc nhim trng bn cp cy mu m tnh
Vim ni tm mc nhim trng bn cp cy mu m tnh khi cy mu lin tc 9 ln
trong 3 ngy trn nhiu mi trng khc nhau u m tnh, nhng c th tm thy vi khun
trn cc tn thng khi gii phu t thi.
c im ca vim ni tm mc bn cp nhim trng cy mu m tnh l:
- Hay gp trn nhng bnh nhn b tn thng van ng mch ch.
- Thng km theo cc bin i ni tng.
- Thng km thiu mu, gim bch cu, tng globulin.
- Bnh thng nng, t l t vong cao mc d iu tr tch cc. Ti sao cy mu m tnh
? cha r nguyn nhn, nhng c my nhn xt sau:
+ Trong lch c s nang ha ca vi khun.
+ Mt s bnh nhn km theo st pht ban, Lupus ban ri rc.
+ (globulin thng tng.
6.2. Th lin cu nhm D
Thng gp trong 10-15% trng hp, bnh hay xut hin sau nhim trng sinh dc-tit
niu, bnh p ng vi Peniciline liu cao kt hp vi Gentamycine, bnh c xu hng hay
ti pht.
6.3. Th do t cu
- Nhim trng da, tit niu v sinh dc.
- Thng gp tn thng trn van 3 l.
- Lm sng biu hin suy tim khng hi phc.
- T l t vong cao mc d iu tr tch cc.
6.4. Th thn
Chim 8-12% trng hp.
Biu hin lm sng vi i mu, Ur mu cao, ph v tng huyt p, tin lng xu.
6.5. Vim ni tm mc bn cp trn bnh tim bm sinh
Thng hay gp l t cu.
6.6. Vim ni tm mc trn phu thut tim kn hoc h
Biu hin sm 3-5 ngy sau phu thut, thng gp l t cu v cc vi khun khc.
VII. NGUYN TC IU TR
7.1. iu tr ni khoa
Ch yu x dng khng sinh v thng thng ty theo khng sinh m iu tr.
7.2. iu tr ngoi khoa
Ty theo tnh trng huyt ng hc m ch nh can thip.
7.3. iu tr d phng
V trng tuyt i cc dng c phu thut, cc dng c thm khm hoc bng khng
sinh cho cc bnh nhn c bnh tim mc phi hoc bnh tim bm sinh khi c can thip th
thut hay phu thut.
118
VIII. TIN TRIN V TIN LNG
Khi cha c khng sinh t l t vong 100%, t khi c khng sinh tin lng c kh hn
nhng t l t vong cn cao 20-40%. Tin lng bnh ph thuc vo cc yu t sau:
1. Tui ln >70.
2.Khng tm thy ng vo ca vi khun.
3.Suy thn.
4.Biu hin thn nng, tc mch hay suy tim sm.
5.Th cy mu m tnh.
6.Ti pht sau 2 thng tuy iu tr tn gc.
Tin trin: Thng khi trong cc trng hp iu tr sm. Tuy nhin di chng ca bnh
nh vim thn mn vi tng Ur mu, tai bin mch no vi lit na ngi, tin lng cn
ph thuc vo bnh tim c trc v mt s trng hp t vong do suy thn hay tc mch.
IX. IU TR VIM NI TM MC NHIM KHUN
9.1. iu tr ni khoa
9.1.1. iu tr tit cn: ch yu bng khng sinh.
9.1.1.1.Cn x dng khng sinh dit khun, sm liu cao, lin tc, ko di, s dng nhng
khng sinh cng lc trong c vai tr ca cn lm sng gip chn la thuc ph hp. Cn
xc nh s nhy cm vi khun da vo khng sinh qua vic xc nh nng c ch ti
thiu (Minimum Inhibitory Concentration = MIC), nng ti thiu dit khun (Minimum
bactericidal concentration = MBC) ca khng sinh v kh nng dit khun dn c hoc phi
hp.
9.1.1.2.Lin cu (Streptococci) nhy cm vi Penicilline G c MIC 0.1ug/ml: dng mt
trong nhng phc sau:
+ Phc A: PNC G 12-18 triu v/ ngy, tim TM cch 4 gi mt ln trong 4 tun.
+ Phc B: PNC G nh phc A kt hp Gentamycine liu 1 mg/kg tim TM mi 8
gi, c hai loi dng trong 2 tun.
+ Phc C: Ceftriazone 2g tim TM hoc TB 1 ln/ ngy , trong 4 tun.
+ Phc D: Vancomycin liu 15 mg/kg tim TM mi 12 gi trong 4 tun.
- Lin cu nhy cm PNC c 0.1 ug/ml< MIC< 0.5ug/ml:
+ Phc E: PNC G 18 triu v/ ngy, tim TM cch 4 gi mt ln trong 4tun. Phi
hp Gentamycine 1 mg/kg tim TM mi 8 gi trong 2 tun u.
+ Hoc dng phc D nu bnh nhn d ng PNC.
9.1.1.3.Trng cu khun (Enterococci) hoc lin cu khun nhy cm Penicilline c MIC
0.5ug/ml hoc Streptococci viridans bin th dinh dng:
+ Phc F: Penicilline G 18-30 triu v/ ngy hoc Ampicilline 12 g/ ngy tim TN
cch 4 gi mt ln. Phi hp vi Gentamycine 1 mg/kg tim TM mi 8 gi. Dng c hai loi
trong 4-6 tun.
+ Phc G: Vancomycine 15 mg/kg tim TM mi 12 gi . Phi hp Gentamycine nh
phc F. C hai loi dng trong 4-6 tun.
9.1.1.4.T cu cn nhy vi Methicilline bnh nhn c van tim t nhin:
+ Phc H: Nafcilline hoc Oxacilline 2 g tim TM mi 4 gi trong 4-6 tun. C th
kt hp hoc khng vi Gentamycine 1 mg/kg tiem TM mi 8 gi trong 3-5 ngy u.
+ Phc I: Cefazolin 2 g, tim TM mi 8 gi, trong 4-6 tun, c kt hp hoc khng
vi Gentamycine nh trong phc H.
119
+ Phc J: Vancomycine 15 mg/kg tim TM mi 12 gi trong 4-6 tun c hoc khng
kt hp vi Gentamycine nh phc H.
9.1.1.5.T cu khng vi Methicilline hoc Corynebacterrium van t nhin.
Phc K: Vancomycine nh phc J, c hoc khng c phi hp vi Gentamycine
nh phc H i vi t cu nhng dng tip tc Gentamycine t 4-6 tun vi
Corynebacterium.
9.1.1.6.Vi bnh nhn c van tim nhn to:
+ Streptococci hoc Enterococci: phc F hoc G.
Do Streptococci: PNC hoc Vancomycine trong 6 tun kt hp Gentamycine trong 2
tun u hoc lu hn.
Do Enterrococci: PNC hoc Vancomycine, phi hp vi 1 loi aminoglucoside trong 6-
8 tun.
+T cu cn nhy cm Methicilline: phc H.I hoc J trong 6-8 tun, kt hp
Gentamycine trong 2 tun u v Rifampicine 300mg ung mi 8 gi trong 4-6 tun.
+ T cu khng Methicilline: phc J trong 6-8 tun, phi hp gentamycine trong 2
tun u v Rfampicine 300mg ung mi 8 gi trong sut liu trnh.
9.1.1.7.Vi vi khun nhm HACEK:
Phc L: dng phc C.
- Mt s trng hp c bit:
+ C th dng Cephalosporine th h khc thay th Cefazoline.
+ Streptomycine c th thay th Gentamycine vi liu 7.5 mg/kg TB mi 12 gi.
+ Khi cha c kt qu cy mu: Nu khng c van tim nhn to: dng khng sinh theo
phc F hoc G. Nu c van tim nhn to: phc K. Nu c tim chch ma tu: phc J.
+ Kt qu cy mu m tnh: nu p ng lm sng tt: tip tc iu tr nh trn . Nu
khng p ng lm sng sau khi iu tr c 7-10 ngy: dng phng php nui cy c
bit hoc di ngy hn, tm thm cc mm bnh khc nh Brucella, Leigiolla, Chlamidia,
Rickettesia, nm... ng thi p dng phc iu tr phi hp c 3 loi khng sinh:
Vancomycine+Gentamycine+Rifampicine. Nu sau 3 tun vn khng phi ngng khng
sinh v lm li bilan chn on.
9.1.2. iu tr ng vo vi khun v iu tr cc bin chng.
9.2. iu tr ngoi khoa
Ch nh:
- Suy tim nht l do tn thng van ch hoc van tim nhn to.
- T chc si c kch thc ln > 10 cm.
- H van tim nng d khog c suy tim.
- Tn ti nhim trng ko di d dng khng sinh thch hp 8-10 ngy.
- Tai bin mch no ti din nhiu ni.
- p xe vch tim hoc p xe vng van ng mch ch.
- VNTM ti pht sau 6 thng.
- Tn thng vng xoang Valsalva hoc vng nh tht.
- Vim ni tm mc do nm.
- Trn van tim nhn to th sm sau thay van < 2 thng.
9.3. D phng
120
Cn phi thm khm h thng rng ming hoc tai mi hng. Ch cc i tng c
nguy c cao nh thay van tim nhn to. Trit tit khun cc dng c phu thut.

121
CU HI NH GI
1. Nguyn nhn v c ch bnh sinh ca thp tim
2. Tiu chun chn on thp tim
3. iu tr v phng bnh thp tim
4. Triu chng lm sng v cn lm sng ca hp van hai l
5. Chn on hp van hai l
6. iu tr hp van hai l
7. Phng php o huyt p v xp loi tng huyt p theo t chc y t th gii
8. Bin chng ca tng huyt p
9. iu tr v d phng tng huyt p
10. Chn on suy tim tri v suy tim phi
11. Cc thuc iu tr suy tim
12. Phc iu tr suy tim
13. Cc th lm sng cn au tht ngc.
14. Triu chng v phn loi cn au tht ngc
15. iu tr cn au tht ngc khng n nh v nhi mu c tim
16. Chn on v iu tr bnh c tim gin
17. Chn on v iu tr bnh c tim ph i
18. Chn on v iu tr bnh c tim hn ch
19. Nu c ch hnh thnh v pht trin ca x va ng mch?
20. Vai tr ca cc yu t nguy c tim mch trong s hnh thnh v pht trin ca x va
ng mch?
21. Ch nh iu tr ri lon lipid mu
22. Phn loi cc thuc chng lon nhp tim
23. Ch nh iu tr cc thuc chng lon nhp theo nhm
24. Du chng ECG ca dy tht tri v phi
25. Du chng ECG ca bloc nhnh
26. Du chng ECG ca ri lon in gii
27. Nguyn nhn ca ri lon nhp tim. Nu cch thc x tr ri lon nhp tim theo nguyn
nhn v cc phng thc iu tr ri lon nhp tim.
28. iu tr cc ri lon nhp nhanh: rung nh, cung nh, nhp nhanh kch pht trn tht. nhp
nhanh tht.
29. iu tr ri lon nhp chm: hi chng nt xoang bnh l, bloc nh tht.
30. Chn on v iu tr vim mng ngoi tim c dch
31. Chn on p tim cp
32. Chn on vim mng ngoi tim co tht
33. Chn on v thi iu tr thng lin nh
34. Chn on v thi iu tr thng lin tht
35. Chn on v thi iu tr cn ng ng mch
36. Nu tiu chun chn on vim ni tm mc ca Duke nm 1994.
37. Nu cc phc iu tr lin cu khun v t cu.
38. Ch nh iu tr ngoi khoa trong vim ni tm mc.
122
TI LIU THAM KHO

1. Nguyn Ph Khng (1996), Lm sng Tim mch, NXB Y hc.
2. Bi ging Ni khoa Trng i hc Y khoa Hu (1998).
3. Alain Combes (1999), Tim mch hc, Nh xut bn Y hc.
4. Phm Nguyn Vinh (1999), Siu m tim v bnh l tim mch tp I v II, NXB y hc.
5. Phm Nguyn Vinh v cs. (2002), Bnh hc Tim mch Tp I, Nh xut bn Y hc.
6. Schland Robert (2001), S tay chuyn khoa tim mch tp 1 v 2, NXB y hc tp 1 v 2.
7. Emanuel Golberger (1990), Cp cu tim mch hc, Nh xut bn y hc.
8. Brauwald E.(1998), Heart disease.
9. Topol J. Eric (2000), Textbook of cardiovascular disease.
10.Guide pratique des urgences cardilogiques (1992), Medicorama.
11. Hurst' s THE HEART (2002), Robert C. Schlant, R. Wayne Alexander.
12. HARRISON'S- Principles of Internal Medicine (2005)

123
CHNG 2
TIU HA
LOT D DY T TRNG
Mc tiu
1. Trnh by c c im dch t hc, c ch bnh sinh v cc yu t nguy c gy bnh.
2. Trnh by c cc triu chng v bin chng lot.
3. Chn on v nu c cc phc iu tr lot.
I. DCH T HC
Tn sut bnh tin trin theo thi gian v thay i ty theo nc, hoc l theo khu vc.
Cui th K 19 Chu u, lot d dy thng gp hn, v ph n. Gia th k 20, tn sut
lot d dy khng thay i, nhng lot t trng c xu hng tng, v hin nay t l lot t
trng /lot d dy l 2/1, v a s gp nam gii. C khong 10-15% dn chng trn th gii
b bnh LDDTT. Anh v c l 5, 2-9, 9%, M l 5-10%, Hu l 10,8%. Hin nay c
khong 10% dn chng trn th gii b LDDTT.
II. BNH SINH
1. Pepsine: c tit ra di dng tin cht pepsinnogene di tc ng ca acid HCL bin
thnh pepsine hot ng khi pH <3, 5 lm tiu hy cht nhy v collagen.
2. S phn tn ngc ca ion H
+
: tin trnh lot c khi pht do tng tit HCL do lng t
bo thnh qu nhiu hoc qu hot ng, do lng dch v c bn hoc sau kch thch rt
gia tng, s phn tn ngc v s i vo ca ion H+ lm thng tn thnh d dy v gy ra
lot; do lm trung ha ion H+ lm gim t l lot rt nhiu. Nguy c lot cng cao khi
s tit acid cng nhiu.
3. Yu t bo v ca nim mc d dy
3.1. Hng ro nim dch: chng li s tn cng ca ion H+, yu t chnh l lp nim dch
giu bicarbonate to bi glycoprotine c cha cc phospholipides khng phn cc, nm trn
b mt ca lp gel ny c tnh nhy n hi. Khi pepsine ct chui peptide phng thch cc
tiu n v glycoproteines; chng lm mt tnh cht nhy n hi ny. Cc ion H+ xm nhp
vo lp nhy, nhng chng b trung ha bi bicarbonate. Nhng khi pH<1, 7 th vt qu kh
nng trung ho ca n v ion H+ n c lp nim mc d dy v gy ra lot.
3.2. Lp nim mc d dy: tit ra glycoproteines, lipides v bicarbonate, chng c kh nng
loi b s i vo bo tng ca ion H+ bng 2 cch: trung ha do bicarbonate, v y ion H+
vo khong k nh bm proton H+- K+ - ATPase.
3.3. Lp lamina propria: ph trch chc nng iu ha. Oxy v bicarbonate c cung cp
trc tip cho h nim mc bi cc mao mch c rt nhiu l h, m cc t bo ny rt nhy
cm vi toan chuyn ha hn l s thiu kh. Mt lng bicarbonate y phi c cung
cp cho t bo nim mc ngn chn s acid ha trong thnh d dy gy ra bi ion H+
xuyn qua hng ro nim mc ny.
4. Vi Khun H.P: gy tn thng nim mc d dy t trng ng thi sn xut ra amoniac lm
mi trng ti ch b acid gy ra lot. HP sn xut men urease lm tn thng nim mc
d dy; n cng sn xut ra proteine b mt, c ho ng ng (+) vi bch cu a nhn trung
tnh v monocyte. N cn tit ra yu t hot ho tiu cu, cc cht tin vim, cc cht
superoxyde, interleukin 1 v TNF l nhng cht gy vim v hoi t t bo v cui cng gy
124
lot. HP cn sn xut ra cc men protease, phospholipase lm ph hu cht nhy nim mc d
dy to iu kin acid v pepsin tn cng vo thnh d dy t trng.
III. BNH NGUYN
1. Di truyn: cho rng lot t trng c t tnh di truyn, tn sut cao mt s gia nh v lot
ng thi xy ra 2 anh em sinh i ng non, hn l d non.
2. Yu t tm l: hai yu t cn c l nhn cch v s tham gia ca stress trong lot.
Th tm thn nh hng ln kt qu iu tr, lot cng thng xy ra ng c nhiu san
chn tnh cm, hoc trong giai on cng thng tinh thn nghim trng nh trong chin tranh.
3. Ri lon vn ng: l s lm vi d dy v s tro ngc ca t trng d dy. Trong
lot t trng c s lm vi d dy qu nhanh lm tng lng acid ti t trng. Ngc li trong
lot d dy s lm vi d dy qu chm, gy tr acide d dy.
4. Yu t mi trng
4.1. Yu t tit thc: khng loi tr lot phn b theo a d l c s ng gp ca thi quen
v n ung. Nh Bc n n nhiu la m lot t hn min Nam n ton go. Tht vy
nc bt cha nhiu yu t tng trng thng b lm gim lot. Cafine v calcium l nhng
cht gy tit acide; ru gy tn thng nim mc d dy.
4.2. Thuc l: lot d dy t trng thng gp ngi ht thuc l, thuc l cng lm xut
hin cc lot mi v lm chm s lnh so hoc gy khng vi iu tr do c ch yu t
tng trng ca nim mc d dy t trng (epithelial growth factor). C ch gy lot ca
thuc l vn hon ton cha bit r c th do kch thch dy X, hy nim dch do tro ngc
t trng d dy hoc do gim tit bicarbonate.
4.3. Thuc
- Aspirin: gy lot v chy mu, gp d dy nhiu hn t trng, do tc dng ti ch v ton
thn. Trong d dy pH acide, lm cho tinh th aspirin khng phn ly v ha tan c vi m,
nn xuyn qua lp nhy v n mn nim mc gy lot. Ton thn do Aspirin c ch
Prostaglandin, lm cn tr s i mi t bo nim mc v c ch s sn xut nhy d dy v
t trng.
- Nhm khng vim nonsteroide: gy lot v chy mu tng t nh Aspirin nhng tnh acid
yu hn nn khng gy n mn ti ch.
- Corticoide: khng gy lot trc tip, v ch lm ngn chn s tng hp Prostaglandin, nn
ch lm bc pht li cc lot c, hoc ngi c sn t tnh lot.
4.4. Hlicobacter Pylori (HP): c Marshall v Warren pht hin nm 1982, HP gy vim
d dy mn tnh nht l vng hang v (type B), v vim t trng do d sn nim mc d dy
vo rut non, ri t gy vim hoi t v lot. 90% trng hp lot d dy, v 95% trng
hp lot t trng c s hin din HP ni lot.
IV. TRIU CHNG HC
Trong lot d dy t trng triu chng lm sng chnh l cn au lot v hi chng
lot, trong c nng l ni bc cn triu chng thc th thng ngho nn, hoc l khi c
bin chng nh xut huyt, hp mn v, thng, hoc ung th ho.
1. Lot d dy
1.1. Triu chng: au l triu chng chnh c nhiu tnh cht.
125
- au tng t mi t ko di 2 - 8 tun cch nhau vi thng n vi nm. au gia tng theo
ma nht l vo ma ng to nn tnh chu k ca bnh lot. Tuy nhin cc biu hin lm
sng ca vim vng hang v xy ra trc lot c th lm mt tnh chu k ny.
- au lin h n ba n, sau n 30 pht - 2 gi; thng au nhiu sau ba n tra v ti hn
l ba n sng.
- au kiu qun tc, au i him hn l au kiu rt bng. au c lm du bi thuc
khng toan hoc thc n, nhng khi c vim km theo th khng hoc c th lm au
thm.
- V tr au thng l vng thng v lan ln trn dc theo xng c hay vng trc tim. Nu
lot nm mt sau th c th au lan ra sau lng. Ngoi ra c th au bt k ch no trn
bng.
Mt s trng hp lot khng c triu chng v c pht hin khi c bin chng.
1.2. Lm sng: ngho nn, c th ch c im au khi ang c t tin trin, trong lot mt
trc c th c du cm ng nh vng thng v. Trong t lot c th st cn nh nhng ra
khi t au s tr li bnh thng.
1.3. Xt nghim: Cc xt nghim sinh ha t c gi tr trong chn on:
- Lu lng dch v c bn thp (BAO)
- Lu lng sau kch thch (MAO) bnh thng hoc gim trong lot loi 1. Trong lot loi 2
v 3 s tit dch v bnh thng hoc tng. Trong lot d dy km v toan cn ngh n ung
th.
- Chp phim d dy baryte v nht l ni soi cho thy c hnh nh lot thng nm hang
v, gc b cong nh, i khi thy thn d dy hay tin mn v.
2. Lot t trng: xy ra ngi ln vi mi la tui. Tuy nhin, nhn chung n xy ra trc
60 tui. Nam = 2 n v thng c yu t gia nh.
2.1. Triu chng: au l c trng ca lot t trng thng r hn lot d dy, v y khng
c vim phi hp. Cc t bc pht rt r rng. Gia cc k au, thng khng c triu chng
no c. au xut hin 3 - 4 gi sau khi n v ko di cho n ba n tip theo, to thnh nhp
ba k, hoc au vo m khuya 1 - 2 gi sng. au i v au kiu qun tht nhiu hn l au
kiu nng ran. au thng v lan ra sau lng v pha bn phi (1/3 trng hp) v thng
km thm a chua. Cng c 10% trng hp khng au, c pht hin qua ni soi hoc do
bin chng v 10% trng hp lot lnh so nhng vn cn au.
V nhp iu th au lot t trng thng nhp nhng v c tnh chu k hn l au do lot d
dy.
2.2. Xt nghim: Trn 90% lot nm mt trc hoc mt sau ca hnh t trng cch mn v
2 cm. i khi 2 lot din gi l Kissing ulcers. Ni soi cho hnh nh lot trn, l hay
gp nht, lot khng u, lot dc v lot hnh mt ct khc di salami t gp hn.
S tit acid d dy thng cao bt thng. Ni soi v phim baryte, cho thy ng
thuc thng nm theo trc ca mn v trn hai mt hoc hnh nh hnh t trng b bin
dng.Trong trng hp lot mn tnh x ha, hnh t trng b bin dng nhiu, cc np nim
mc b hi t v lot lm mn v b co ko, hoc hnh t trng b chia ct thnh 3 phn to
thnh hnh cnh chun. Mt hnh nh bin dng khng i xng lm dn np gp y ngoi
v teo np gp y trong to thnh ti tha Cole lm cho l mn v b lch tm. Ni soi c
th nhn ra d dng lot do y mu xm sm c ph mt lp fibrin, i khi c che
126
y bi cc np nim mc b sng ph, cc lot dc kh phn bit vi mt lot ang lnh
so, trong trng hp ny bm bleu de mthylene n s nhum fibrin c mu xanh.
nh lng acid v gastrin c ch nh nu nghi ng 1 s tit bt thng do u
gastrin, mt s ph i vng hang v, cng ph gip hoc suy thn.
2.3. Xt nghim tm HP:

XT NGHIM HP
1. Xm nhp:
- Nhum: Giemsa, Hematoxylin eosine, Genta,
Warthin Starry
- Urease test: Clotest
- Cy: Vi i kh
2. Khng xm nhp:
- Huyt thanh chn on (ELISA)
- Test th (C13,14)
- PCR



NhimH. pylorie
Vimb mt d dy mn tnh
Bnh lot
da t trng
Vimb mt
d dy mn
U lympho
Vimteo dd
mn tnh
K d dy
Nhiu tun-nhiu thng
Hng nm - hng chc nm
DIN TIN CA VIM LOT D DY T TRNG DO HP



127

HNH HNH NH N NH N I SOI LO I SOI LO T T
T T TR TR NG (TT) NG (TT)
Lo Lo t t su su, ,
nhi nhi u u
lo lo t t d d c c




Hnh nh lot d dy
v
V. CHN ON
1. Chn on lot d dy: t ra khi lm sng c cn au lot in hnh xc nh bng chp
phim d dy baryte v bng ni soi. in hnh l ng thuc khi lot b ca d dy. V
ni soi d nhn ra ming lot y ca n ph mt lp fibrin mu trng xm, b u hi nh
ln do ph n hoc c bao quanh bi cc np nim mc hi t. iu quan trng l phi xc
nh bn cht ca lot bng sinh thit phn bit vi ung th th lot v lot ung th ha.
128
2. Chn on lot t trng: Gi bng cn au lot in hnh t trng, thng xy ra
ngi tr tui, c nhm mu O. Xc nh bng ni soi v phim baryte, cho thy ng thuc
thng nm theo trc ca mn v trn hai mt hoc hnh nh hnh t trng b bin
dng.Trong trng hp lot mn tnh x ha, hnh t trng b bin dng nhiu, cc np nim
mc b hi t v lot lm mn v b co ko, hoc hnh t trng b chia ct thnh 3 phn to
thnh hnh cnh chun. Mt hnh nh bin dng khng i xng lm dn np gp y ngoi
v teo np gp y trong to thnh ti tha Cole. Ni soi c th nhn ra d dng lot do y
mu xm sm c ph mt lp fibrin.
3. Chn on phn bit
3.1. Vim d dy mn: au vng thng v m h, lin tc, khng c tnh chu k, thng au
sau n, km chm tiu y bng. Chn on da vo ni soi sinh tit c hnh nh vim d dy
mn vi tm nhun t bo vim n nhn, x teo tuyn tit.
3.2. Ung th d dy: Thng xy ra ngi ln tui, au khng c tnh chu k, ngy cng
gia tng, khng p ng iu tr lot. Cn ni soi sinh thit nhiu mnh cho hnh nh ung th
d dy.
3.3. Vim tu mn: C tin s vim tu cp nht l ung ru mn, c th km i chy mn
v km hp thu. au thng lan ra sau lng vng tu. Xt nghim men amylase mu
thng tng 2-3 ln. Siu m v chp phim X quang thy tu x teo c si, ng tu dn.
3.4. Vim ng mt ti mt mn do si: Tin s si mt, lm sng c cn au qun gan,
nhim trng v tc mt. Chn on da vo siu m v chp ng mt ngc dng cho hnh
nh si, ti mt x teo.
VI. BIN CHNG
Thng gp l chy mu, thng, x teo gy hp, thng bt hay t do, lot su km
vim quanh tng, t bit lot d dy lu ngy c th ung th ha.
1. Chy mu: thng gp nht nhng kh nh gi tn s chnh xc. Khong 15-20% bnh
nhn lot c mt hoc nhiu ln chy mu; lot t trng thng chy mu (17%) so vi d dy
(12%), ngi gi chy mu nhiu hn ngi tr. Bin chng chy mu thng xy ra trong
t lot tin trin nhng cng c th l du hiu u tin.
Chn on da vo ni soi cn thc hin sm khi ra khi chong. Tn sut ti pht l 20%,
tin lng tt nu chy mu t ngng trong vng 6 gi u. Nguy c ti pht cao >50% nu:
+ Chy mu t tiu ng mch to thnh tia.
+ Mch mu thy c nn lot
+ Chy mu ko di >72 gi.
2. Thng: lot n su vo thnh d dy hay t trng c th gy thng. y l bin chng th
nh sau chy mu (6%), n ng nhiu hn ph n. Lot mt trc hoc b cong nh th
thng vo khoang phc mc ln, lot mt sau th thng vo c quan k cn hoc hu cung
mc ni.
- Triu chng: thng khi u bng cn au d di kiu dao m l du vim phc mc
v nhim trng nhim c. Chp phim bng khng sa son hoc siu m c lim hi di c
honh nht l bn phi.
3. Lot xuyn thu dnh vo c quan k cn: thng l ty, mc ni nh, ng mt, gan,
mc ni ln, mc treo i trng, i trng ngang thng gp l lot mt sau hoc lot b cong
ln. Cc lot ny thng au d di t p ng vi iu tr, lot xuyn vo ty thng au ra
sau lng hoc biu hin vim ty cp, lot thng vo ng mt chp ng mt hoc siu
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m c hi trong ng mt hoc baryte vo ng mt. Nu r d dy - i trng gy i chy
phn sng v km hp thu, cn iu tr phu thut.
4. Hp mn v: thng gp nht khi lot nm gn mn v. Gy ra do lot d dy hoc t
trng hoc phn ng co tht mn v trong lot d dy nm gn mn v, hp c th do vim ph
n mn v.
- Triu chng: Nng bng sau n. Ma ra thc n c > 24 gi. Du c ch d dy lc i v
du Bouveret. Gy v du mt nc.
- Chn on hp mn v: bng
+ Thng d dy c dch >100ml.
+ Phim baryte d dy cn tn ng baryte >6gi.
+ Phim nhp nhy, chm lm vi d dy >6 gi khi thc n c nh du ng v phng x
Technium 99.
+ Xc nh c nng hay thc th bng nghim php no mui ko di, sau 1/2 gi v 4 gi:
nu sau 1/2 gi >400ml, v sau 4gi >300ml l thc th, nu <200ml l c c nng, hoc lm
li no mui sau 3 ngy chuyn dch >100ml l thc th.
5. Lot ung th ha: t l lot ung th ha thp 5-10%, v thi gian lot ko di >10 nm.
Hin nay ngi ta thy rng vim mn hang v nht l th teo, thng a n ung th ha
nhiu hn (30 %), cn lot t trng rt him khi b ung th ha.
VII. IU TR
1. iu tr ni khoa
1.1. Ch n ung v ngh ngi: Ngh ngi c th xc v nht l tinh thn trong giai on c
t au lot. Trong giai lot tin trin cn n ch n lng v thc n kim tnh nh cho
sa, trnh cc thc n kch thch cay nng nh tiu t. C bia ru v nht l thuc l v lm
chm lnh so v d gy lot ti pht. Thc t hin nay chng minh thc n t quan trng
ch cn n u trnh nhn i gy tng tit acide. n ph ban m hoc trc lc i ng gy
tit acide ban m, nn cn chng ch nh. Thuc l c chng minh c hi gy tng tit
acide, chm lnh so v lm tng ti pht.
- Tm l liu php: cn gii thch bnh nhn yn tm v hp tc trong iu tr. Nu bnh
nhn qu lo lng c th cho thm an thn: Diazepam, Ttrazpam, Chlodiazepate
1.2. Thuc iu tr lot c chia lm cc nhm sau
* Thuc khng toan: Bicarbonate natri v calci khng c dng na do tc dng di v lm
tng calci mu gy si thn. Ngi ta thng dng kt hp hydroxyde nhm v magn
gim tc dng gy bn ca nhm v gy i chy ca magn; tuy nhin chng cng to cc
mui phosphate khng ha tan lu ngy gy mt phospho (tnh cht ny c khai thc
iu tr tng phospho mu trong suy thn). Cc bit dc thng l Maalox, Gelox, Alusi,
Mylanta c thm Simticon l cht chng si bt lm gim hi trong d dy, Trigel c phi
hp thm cht lm gim au, Phosphalugel c trnh by di dng gel nn c tnh cht
bng nim mc v gi li trong d dy lu hn; liu dng 3-4g/ngy.
* Thuc khng tit: l cc thuc lm gim tit acid dch v qua nhiu c ch khc nhau do
khng th th H2, khng choline, khng gastrine v khng bm proton ca t bo vin thnh
d dy.
- Thuc khng choline: t lu l nn tng ca iu tr lot n c tc dng c ch dy X, gim
tit trc tip do tc ng trc tip ln t bo vin v gin tip bng hm sn xut gastrin, s
130
tit pepsine cng b gim. c ch dy X cn lm gim nhu ng d dy: gim co tht thn v
hang v lm gim au, lm chm lm vi thc n c. Hiu qu tt ca khng choline trn cn
au c xc nh, nhng tc dng trn s lnh so th cn bn ci, thuc c in trong
nhm ny l atropin ngy nay t c dng v c nhiu tc dng ph vi liu iu tr 1mg/ng,
thng gy kh ming, snh bng, tiu kh. Chng ch nh trong tng nhn p, u x tin lit
tuyn. Hin nay thuc khng choline c vng 3, v pirenzpine chn th th muscarine chn
lc M1 trn t bo vin, nn khng c tc dng trn co tht c trn v s tit nc bt nn
c ch nh rng ri. Pirenzpine lm nhanh s lin so trong lot d dy v t trng. Trong
hi chng Zollinger Ellison phi hp pirenzpine v Khng H2 rt c hiu qa ln s tit acid
hn l dng mt mnh khng H2. Thuc bit dc l Gastrozpine, Leblon.
- Thuc khng H2: c ch s tit acid khng ch sau kch thch histamine m c sau kch thch
dy X, kch thch bng gastrine v c th nghim ba n.
+ Th h 2: Ranitidine (Raniplex, Azantac, Zantac, Histac, Lydin, Aciloc...) Vin 150mg,
300mg, ng 50mg.
Cu trc hi khc vi cimtidine do c 2 nhnh bn nhn imidazole nn liu tc
dng thp hn v t tc dng ph hn, tc dng li ko di hn nn ch dng ngy 2 ln. Hiu
qu cao hn cimtidine trong iu tr lot d dy t trng v nht l trong hi chng Zollinger
Ellison. Tc dng ph rt t trn androgen nn khng gy lit dng.
Liu dng 300mg/ng ung 2 ln sng ti hoc mt ln vo bui ti nh cimtidine.
+ Th h 3: Famotidine (Pepcidine, Servipep, Pepcid, Quamatel, Pepdine). Vin 20mg, 40mg;
ng 20mg. Tc dng mnh v ko di hn ranitidine nn ch dng mt vin 40mg 1 ln vo
bui ti.
Cc tc dng ph cng tng t nh i vi Ranitidine.
+ Th h th 4: Nizacid (Nizatidine), vin dng nang 150mg, 300mg, liu 300mg ung 1 ln
vo bui ti. Tc dng v hiu qu tng t nh Famotidine.
- Thuc khng bm proton: l th th cui cng ca t bo vin ph trch s tit acide
chlorhydride, do thuc c ch bm proton c tc dng chung v mnh nht.
+ Omeprazol (Mopral, Lomac, Omez, Losec). Vin nang 20mg, 40mg; ng 40mg. Liu
thng dng 20mg ung 1 ln vo bui ti. Thuc tc dng rt tt, hiu qu ngay c nhng
trng hp khng H2. Hiu qu lnh so i lot t trng sau 2 tun l l 65%, i vi lot d
dy l 80 - 85%. Thuc tc dng rt nhanh sau 24 gi c ch 80% lng acide dch v.
Liu trnh i vi lot t trng thng thng l 2 tun, lot d dy l 4-6 tun.
Liu gp i dnh cho nhng ngi p ng km hoc hi chng Zollinger Ellison th dng
liu cao 160-320mg/ ngy.
Tc dng ph vi trng hp nh bn, nn ma, nhc u, chng mt, i khi c
ni m ay v nga da. ngi gi c th c l ln, hoc o gic, cc triu chng ny gim
khi ngng thuc. V mu, c th c gim bch cu, tiu cu, v him hn l thiu mu huyt
tn.
Chng ch nh: ph n c thai v cho con b.
+ Esomeprazole (Nexium): ng phn t tuyn ca Omeprazole c thi gian bn hu lu hn,
thi gian c ch tit acid ko di 10-14 gi nn c tc dng c ch tit Acide v dch v ko
di v n nh hn, nn c th dng ngy 1 ln. Vin 20mg, ngy x 2 vin.
+ Lanzorprazol (Lanzor, Ogast) vin 30mg, liu 1-2 vin ung chia 2 hoc vo bui ti.
131
Tc dng v ch nh tng t nh Omeprazol.
+ Pantoprazole (Inipomp, Pantoloc) vin 20mg, ng 40mg. Liu 40mg/ng.
+ Rabeprazole (Pariet, Ramprazole, Barole) vin 20mg. Liu 40mg/ng. Thuc c tc dng
ko di nn tc dng c ch tit acid tt hn v n nh hn.
- Thuc khng Gastrin
Proglumide (Milide) l thuc i khng gastrin. N lm gim tit acide khi tim
gastrin, nhng khng lm gim khi tim histamin, c ch nh trong iu tr lot c tng
gastrin mu v nht l trong u gastrinome.
* Thuc bo v nim mc
- Carbnoxolone (Caved s, Biogastrone): l dn xut tng hp ca cam tho, kinh nghim
dn gian xa dng iu tr lot d dy. N lm tng sn xut nhy v ko di tui th
ca t bo nim mc, tc dng kp ny ging nh PGE2, c th do lm chm thoi ha
prostaglandine. Ngoi ra carbnoxolone lm c ch hat ng ca pepsine, n cng c tnh
cht khng vim.
Carbnoxolone lm nhanh s lnh so lot d dy v nht l n cha trong nang tan
chm cng hiu qu trong lot t trng. Tuy nhin x dng ca n cn hn ch do tc dng
ph ging nh aldosterone: gi mui v ph, h Kali mu, cao huyt p. Do khi dng cn
theo di trng lng, huyt p v in gii .
- Bismuth (Peptobismol, Trymo, Dnol): trc y cc mui bismuth natri hp thu nhiu gy
ra bnh no do bismuth nn khng cn c dng trong iu tr. Hin nay bismuth sous
citrate (C.B.S) do khng hp thu v trong mi trng acide kt hp vi protine ca m hoi
t t lot, to thnh mt phc hp lm acide v pepsine khng thm qua c. sc vt th
nghim, n cng bo v nim mc chng li s n mn ca ru v ca aspirine.
Trnh by: vin 120mg, ngy 4 vin chia 2 ln sng ti trc n.
Khng nn dng thuc nc hoc nhai v thuc lm en rng v li.
- Sucralfate (Ulcar, Kal, venter, sulcrafar): l thuc phi hp gia sulfate de sucrose v mt
mui nhm. Cng nh sous nitrate de bismuth trong dung dch acide n gn vo b mt lot
mang in tch (-) kt hp vi in tch (+) ca thuc, lm thnh mt lp m, gip chng li
s phn tn ngc ca ion H+. Hn na n cn hp ph pepsine v mui mt, lm bt hot
chng, cho nn c dng iu tr vim d dy do tro ngc dich mt. Trong iu tr lot
d dy t trng, n lm gim au nhanh v lm lnh so tng ng nh Cimtidine. Mc d
hp th t nhng cng khng nn dng trong trng hp suy thn nng, v n cha nhiu
aluminium. Ngoi ra n cn gy bn v do tnh hp ph ca n lm ngn chn hp thu cc
thuc nh tetracycline, phnytoine.
- Prostaglandine E2 (Cytotec, Minocytol) c nhiu c ch tc dng: c ch tit acide, kch
thch tit nhy, tng tit bicarbonate v lm tng ti mu cho lp h nim mc d dy. Vin
200g; liu 400-600g/ngy. Tc dng ph gy au bng v i chy.
* Thuc dit H.P: ch yu l cc khng sinh:
- Nhm Bta-lactamine nh Pnicilline, Ampicilline, Amoxicilline, cc Cphalosporines.
- Nhm cycline: Ttracycline, Doxycycline.
- Nhm macrolides: Erythromycine, Roxithromycine, Azithromycine, Clarithromycine.
- Nhm Quinolone nh Levofloxacine, Moxifloxacine.
132
v nhm imidazoles: Mtronidazole, Tinidazole, Secnidazole...
- Nhm Bisthmus: Nh trymo, denol, Peptobismol.
2.3. p dng iu tr
* Lot d dy
Trong trng hp khng tng toan tng tit: thng ch yu ch dng thuc bo v
nim mc. V d: Ulcar gi 1g, ngy 3 gi, ung 30 pht -1 gi trc n v 1 gam trc khi i
ng, c th dng thm an thn nh Tranxne 5mg ti ung mt vin.
Nu c nhim H.P th p dng pht iu tr hin nay l phi hp 3 thuc dit H.P
nh sau: Bismuth + Ttracycline + Mtronidazole hoc Bismuth + Amoxicillin +
Metronidazol. Tuy nhin c mt s trng hp khng vi Ttracycline v
Metronidazole (40-50%), nn ngi ta thch phi hp Bismuth + Clarithromycin +
Tinidazole. Trong thi gian 6 - 8 tun, t l lnh so 80-85%.
Trong trng hp c tng toan tng tit p dng pht iu tr tng t nh lot t
trng nhng thi gian 6 - 8 tun.
Theo di iu tr: rt quan trng trong iu tr lot d dy sau 3 - 4 tun iu tr cn
kim tra ni soi v sinh thit, sau 3 thng, ri 6 thng v hng nm trong 5 nm u. Cn
sinh thit nhiu mnh trn nhiu vng v nhiu vng khc nhau (8 -12 mu). Nu c d sn
cn tch cc kim tra li sau khi iu tr tch cc 3 tun. Nu c lon sn hoc c hnh nh ung
th cn phu thut.
* Lot t trng: a s u c tng toan v tng tit nn thng p dng pht phi hp: 1
khng tit mnh + 1 bo v nim mc. V d: 1 khng H2 mnh nh Ranitidin, Famotidine
hoc Omprazole + Sucralfate, c th l Ranitidine 300mg hoc Famotidine 40mg ung chia
2 ln sau n hoc mt ln khi i ng + Sucralfate 3g ung 3 ln trc n 30 ph v 1gr trc
lc i ng.
Trong trng hp c H.P, cho thm thuc dit H.P nh trong lot d dy, thi gian
cho khng sinh thng l 2 tun. Kt qu mt s pht iu tr 3 thuc nh sau:
- Bismuth (480mg/ng)+Tetracycline 1, 5g/ng (hay Amoxicillin)+Mtronidazol (1, 5g/ng) x 2
tun lnh bnh l 85%.
- Ranitidin (300mg/ng)+Amoxicillin (1, 5g/ng)+Metronidazol (1, 5g/ng) x 2 tun, sau
tip tc dng Ranitidine thm 2 tun, t l lnh bnh l 89%.
- Omprazol (40mg/ng) + Clarithromycine (0, 5g/ng) + Tinidazol (1, 5g/ng) x 1 tun,
lnh bnh l 93, 2% hoc Omeprazol (40mg/ng)+Clarithromycine (0, 5g/ng)+Amoxicilline (1,
5g/ng) x 1tun, lnh bnh l 90%.
Trong mt s vng t l khng cao ngi ta p dng pht 4 thuc nh sau:
Bismuth+Tetracycline (hoc Amoxicilline)+Metronidazol+ Omeprazole v c th rt ngn
thi gian iu tr xung 2 tun. hoc dng cc thuc mi cha b khng nh Rifabutin, dn
cht ca Rifamycine vin 300mg, liu 600mg/ngy; hoc Levofloxacin, vin 500mgli
2v/ngy ; hoc Nitrofurantoin vin 100mg, liu 3 vin/ngy.

3. iu tr ngoi khoa
3.1. Phu thut ct 2/3 d dy: vi lot d dy sau khi iu tr tch cc 6 tun m lot khng
thay i hoc trong trng hp c lon sn th cn phu thut ct b 2/3 theo kiu Bilroth
hoc Pan loi tr lot cng nh loi b vng tit gastrine v acide.
133
Trong lot t trng, phu thut rt hn ch, ch dng cho lot bt tr. Cc ch nh phu
thut chung: l lot bin chng chy mu cp nng khng cm c bng phng tin ni
khoa, lot gy bin chng hp mn v kht v thc th, lot thng hoc lot xuyn thu vo
ty gy vim ty cp ti pht nhiu ln.
Cc bin chng phu thut bao gm
Hi chng Dumping: thng xut hin na gi sau khi n vi au thng v, bun
nn, chong vng, hi hp, v m hi, mt l do lm y t trng qu nhanh, do thc n u
trng, c ch bnh sinh phc tp do nhiu nguyn nhn:
- Gim th tch do cn bng li p lc thm thu u trng.
- Phn x thc vt, gii phng hormon vn mch nh serotonin, bradykinine, V.I.P.,
gy ra do cng dn rut. Cn phn bit vi h ng mu xy ra chm 1-2 gi sau n do tit
qu nhiu insulin v hp thu mt lng ln ng. iu tr ch yu l n c nhiu ba nh, t
ng v sa, dng pectine lm chm vi d dy.
Hi chng quai ti: sau phu thut do ng thc n v nht l mt trong quai ti
lm vim thng biu hin bng au v ma ra mt.
Suy dng: do nhiu nguyn nhn:
+ Do ct b d dy qu nhiu gy thiu dch v v n qu t v d dy qu nh.
+ Km hp thu th pht do thiu mt, ty.
+ Ln men vi trng trong quai ti v hng trng. Ngoi ra cn thiu st, B12,
Folate, long xng nhuyn xng, d nhim trng nht l lao.
Bin chng xa l do tro ngc t trng d dy gy vim ming ni, ri d sn v lon
sn nim mc gy ra ung th ha thng 10-15 nm sau.
3.2. Phu thut ct b dy X
Gip loi b pha u ca s tit, lm gim tit ban m v lm gim lng tit acid do
gastrine.
* Ct thn d dy: ct on vo bng quanh thc qun, cng c th ct bng ng ngc.
Phu thut ny thng gy ra ri lon vn ng cn b sung bng ni v trng hoc chnh hnh
mn v gip lm vi d dy. Cc hu qu c th c sau phu thut ny l:
- Hi chnh Dumping v tro ngc mt ty.
- i chy v ri lon mt ty do mt iu chnh thn kinh.
- Bezoard do ri lon lm vi d dy v gim tit dch v.
* Ct dy X chn lc: ch ct cc si i vo d dy thng km chnh hnh mn v.
* Ct dy X siu chn lc: ch ct nhnh dy X i vo y v v gi li nhnh Latrjet iu
hnh hang v, nn bo ton c chc nng hang mn v nn t gy ra bin chng.
3.3. Mt s ch nh c bit
- Trong lot mn v + tng toan: ct dy X + lot + xt nghim m hc.
- Trong lot kp: ct dy X + ct hang v.
- Lot ti pht sau phu thut: ty theo cch phu thut trc.
+ Sau ct d dy lot ti pht t trng hoc hng trng.
+ Sau ct dy X, thng lot ti pht ch c.
134

VIM D DY
Mc tiu
1.K cc nguyn nhn gy vim d dy cp v mn.
2.Chn on c cc th vim d dy cp v mn thng gp.
3.iu tr tt mt s th bnh vim d dy thng gp.
Ni dung
I. I CNG
Vim d dy l bnh m triu chng lm sng c khi rm r nhng c khi rt nh
nhng, m thm. Chn on cn c ni soi v sinh thit, iu tr c khi n gin nhng c khi
cn nhiu kh khn.
Da vo nguyn nhn, ngi ta chia vim d dy lm 2 th: vim d dy cp v vim
d dy mn. Chn on bng t chc hc v s phn b v gii phu ca d dy.
V m hc, chn on vim d dy da vo phn loi ca Sydney cn c trn tnh
trng tn thng ca tuyn tit ca d dy.
II. VIM D DY CP
1. Nguyn nhn
- Ru: Gy vim d dy cp i khi gy chy mu, c gi l vim d dy do n mn.
Thng xy ra khi ung ru mt lng ln trong mt thi gian ngn.
- Thuc khng vim khng steroides (NSAIDs), Aspirin. (Hnh 1)
- Stress
- Ung phi cht n mn (thng l cht kim)
- Virus: CMV, Herpes.
- Vi khun: Lin cu alpha tan mu, Clostridium septicum
- Tng ur mu
- Phng x.
2. Cc th vim d dy
2.1. Vim d dy chy mu hay vim d dy n mn
L nguyn nhn hay gp ca chy mu tiu ha cao nhng t khi nng. S n mn i
khi hon ton m thm. Ni soi cho thy n mn nhiu , c th lan n ton b nim mc
d dy hoc ch khu tr thn, hang v hay phnh v d dy. Nim mc tr nn rc nh
b chy rn nhng c khi gn nh bnh thng.
V m hc, s n mn ch ph hy n lp nim mc, khng lan n lp c nim do
khng nh hng n cc lp mch mu di nim mc. Cc thng tn thng hi phc
hon ton. y l c trng ca loi vim ny. Bt k lc no, ngi ta c th tm thy nhng
b n mn c nhng biu hin nhng giai on tin trin hay hi phc khc nhau. C th
gp thng tn nn phng hay np gp nim mc. Gia cc n mn l vng mt biu m
v thot qun tng hay lan rng va lp h nim mc (Lamina propria). Nu tin trin ko
di, s n mn c th lan n lp h nim mc to nn lot cp khi chy mu tr nn trm
trng hn.
135
Nguyn nhn hay gp l do dng thuc khng vim khng Steroide, c bit l
aspirin: mi trng acide dch v, aspirin khng ion ha d c hp th bng s
khuch tn th ng. Vo mi trng trung tnh ca biu m nim mc d dy, aspirin
bin thnh dng acide ion ha, ph hy t bo v to ca m cho hin tng lot do acide.
Khi dng km vi bicarbonate natri, aspirin khng gy tn thng nim mc d dy v
khng b ion ha, v do khng c hp th d dy hoc khi aspirin c bc bi
mt nang, n s i qua khi d dy v c hp th rut non. Ngoi ra Aspirin v cc
AINS khc cn ngn cn tng hp prostaglandine (l yu t bo v nim mc d dy cng
nh kch thch tit acide v pepsin d dy) v vy lm thng tn nim mc d dy.
Phenylbutazol v Indomethacine l 2 thuc d gy vim d dy nht.
Ru cng l nguyn nhn gy vim d dy cp chy mu nht l khi ung mt
ln nhiu trong thi gian ngn, m trc y khng ung.
Tng p tnh mch ca cng l mt yu t lm d cho chy mu d dy.
Cc stress th pht nghim trng nh bng, nhim trng, chn thng, phu thut,
sc, suy h hp, suy thn, suy gan cng thng gy vim hay lot cp. Bnh nguyn trong cc
trng hp ny cha c hiu r ht c l do gim lng mu n nim mc d dy dn n
hoi t nh nim mc.
Lm sng: Bnh nhn c th kh chu nh vng thng v, chm tiu, snh bng
ngay sau n, hi, bun nn, nn mu km i cu phn en. i khi khng c triu chng.
Chn on tt nht nh soi d dy ngay lc c chy mu v nu khng cc thng tn c th
lnh v bin mt. X quang vi k thut i quang kp c th pht hin c cc vt n mn
cn ny.
2.2. Vim d dy cp phi hp vi Helicobacter pylori (HP): Nhim H.P c th xy ra d
dy c sn tng tit acide hay trn d dy bnh thng. Nhim H.P cp l tin cho vim
d dy mn hot ng. Triu chng lm sng ch biu hin vi cm gic kh chu nh vng
thng v, nng tc hay i khi n chm tiu.
III. VIM D DY MN
1. Xp loi
- Vim d dy mn do ho cht: Tro ngc dch mt, dch kim t rut, cc NSAID
- Vim d dy c hiu: Vim d dy tng Eosine (u ht tng bch cu a acide, vim d dy
rut tng bch cu a acide)
- Vim d dy u ht: Crohn, lao, Histoplasma, giang mai, sarcoidose, d vt, nhim k sinh
trng, v cn.
- Bnh d dy ph i: Bnh Mntrier, gi lymphoma d dy, hi chng Zollinger-Ellison.
- Bnh d dy sung huyt (tng p ca): khng phi vim d dy tht s (Hnh 2)
- Vim d dy khng c hiu:
+ Nhm khng n mn: (vim d dy t min type A, vim d dy do mi trng type B,
vim d dy mn c lin quan n HP).
+ Nhm n mn: vim d dy lympho, vim d dy dng thy u.
Cc t bo vim xm nhp ch yu l limpho v tng bo, mt t bch cu a nhn v
bch cu a acide. Thng tn lp nng ca vng tuyn tit ca nim mc d dy c th lan
xung su, gy d sn, gim sn v teo t bo.
2. Cc th vim d dy mn hay gp
136
Ngi ta chia lm hai loi vim d dy mn chnh, ngoi ra cn c cc biu hin bt
thng khc d dy hoc do tn thng th pht hoc khng do vim mn tnh.
2.1.Vim d dy mn type A
Vim vng thn v y d dy, c yu t t min. Bao gm vim d dy nng, vim
d dy dng teo(Hnh 3) v teo d dy. Vim d dy ny thng km thiu mu c tnh. S
xut hin khng th khng t bo thnh v khng yu t ni gi cho yu t bnh sinh ca c
ch t min. Loai ny gp khong 20% ngi trn 60 tui. Triu chng ngho nn, vim
dng teo km v toan, thiu mu v nguy c ung th d dy. Chn on bng ni soi v sinh
thit.
2.2. Vim d dy mn type B (vim d dy vng hang v, vim d dy do H.P): chim 80%
(Hnh 4)
Vim hay xy ra vng hang v, gp a s ngi tr. H.P c nh trn cc phc hp
ni kt lm v cc cu ni lin bo v tit dy c cc cht nhy trung tnh. Cc t bo b
bong ra l lp di nim mc. ng thi protese ca vi khun H.P lm gia tng s
khuch tn cc ion H+ gy ph v glycoprotein lm gim tnh nhy trn lp nim mc. Loi
vim d dy ny c th dn n vim teo d dy hoc teo hn d dy, nang bch huyt d dy,
u limpho t bo B d dy (MALT). Dch v c cung lng acide thp s dn n nhim trng
v nguy c ung th.
Chn on bng ni soi v sinh thit, test nhanh urease thc hin trn cc mnh sinh
thit nim mc d dy hoc test th ur v xt nghim tm khng th khng H.P trong mu
(ELISA) hay cy tm HP.
Lm sng ch c triu chng kh chu vng thng v, n kh tiu.
S phn loi trn c khi khng phi hon ton r rng, ngi ta cn phn type AB ch
thng tn lin quan c thn v hang v d dy.
2.3.Vim d dy do tro ngc (Hnh 5): Thng do tro ngc dch mt t t trng vo d
dy gy vim ng tuyn mn v, vim vng tin mn v. Lm sng triu chng t rm r, Bnh
c th kt hp vi lot d dy.
2.4. Bnh d dy tng p ca (bnh d dy xung huyt)
Tht s khng phi l mt phn ng vim, v khng tm thy s thm nhim cc t bo
vim lp nim mc cng nh lp h nim ca d dy. y ch l mt bin chng, hu qu
ca bnh l tng p ca hay do x gan. Nhng trng hp lm trit tnh mch trng thc
qun qua ni soi, thng dn n xung huyt d dy phn ng sau .
Qua ni soi, chng ta c th thy nim mc d dy v dy ln, xut huyt thnh
tng m nh trong nim mc, to thnh mng li hay dng khm.
IV. PHN LOI SYDNEY
Da vo tn thng tuyn vi vim c hay khng c teo tuyn, phn loi ny a ra
cc hnh thc tn thng v tn gi ng ngha nh sau.

Loi vim d dy Nguyn nhn Tn ng ngha
Khng teo tuyn

Helicobacter pylori (HP)

Vim d dy nng, vim hang v lan to,
vim hang v mn tnh, vim d dy nang -
k, vim d dy tng tit, vim d dy tp B
137
C teo tuyn
-Vim d dy t min

-Vim d dy teo nhiu




T min

H. pylori
Yu t mi trng


Vim d dy tp A, vim thn d dy lan
to, vim d dy km thiu mu c tnh
Vim d dy tp B, AB.
Vim d dy do mi trng, vim d dy d
sn tuyn, vim d dy teo tuyn, vim d
dy dng rut tin trin
Cc th vim c hiu
Do ho cht

Do tia x
Vim dng limph

Khng nhim trng
+ Dng u ht

+ a acide

- Cc nhim trng khc


-Kch thch ho hc,
NSAIDs, mt
Tn thng tia x
Thuc, t min, v cn.
Gluten

BnhCrohn,Sarcoidosis,
u ht Wegener, cc cht
t bn ngoi
Nhy cm thc n

Vi khun khng phi HP
Virus.
K sinh trng.
Nm

Vim d dy phn ng, vim d dy tro
ngc

Vim d dy dng thu u
Vim d dy km bnh Celiac

U ht

D ng

Vim ty, Giang mai.
CMV.
Anisakiasis
Candida albican

V. IU TR
1. i cng iu tr
Vim d dy l tn gi chung cho cc bnh l d dy do tn thng nim mc d dy
c hiu hoc khng c hiu. Mt cch phn loi c cc nh lm sng v gii phu bnh
thng dng d l da vo cc tn thng c gi tn theo cc c im v m bnh hc, vi
khun v v tr tn thng ca d dy.V vy, cch iu tr c th hn v kh chnh xc hn.
Mc ch iu tr l bo v t bo, hi phc s tit acide tr li bnh thng, loi b
nguyn nhn, hn ch bin i lm teo nim mc d dy gp phn ngn nga ung th.
2. iu tr vim d dy cp.
2.1.Vim d dy do n mn
2.1.1. Vim d dy do ru v thuc khng vim
y l nguyn nhn hay gp do ung mt lng ru ln, do dng thuc khng vim
khng corticoides v c corticoides.
iu tr bao gm
138
- Chm dt nguyn nhn cng sm cng tt.
- m bo th tch tun hon c hiu qu bng dch truyn, nhn n v nui dng bng
ng ngoi ming.
- Ra d dy cm mu bng cch dng nc mui ng trng lnh ha Adrenalin.
- Thuc khng tit: Cimetidine hoc Ranitidine, hoc Omeprazole tim tnh mch.
- Thuc trung ha Acide.
- Thuc bng nim mc: C th dng Sucralfate dng gel, hoc Misoprostol (cytotec 600g -
800 g /ng.
- Truyn cc cht gy co mch nh Vasopressine hoc Sandostatin khi chy mu nng.
- Cm mu bng laser, nhit hoc quang ng.
- iu tr d phng cho cc trng hp phi dng thuc khng vim: Dng khng H
2
hoc c
ch bm proton H
+
.
2.1.2. Vim d dy do ha cht
Tc nhn gy vim c th l cc kim mnh nh KCl, hoc st, hoc Cocaine. iu tr
trong cc trng hp ny l ;
- Gim au, nhn n, nui dng bng ng tnh mch.
- Hi sc tim mch, h hp.
- Nu c vim x gy hp th c ch nh phu thut ni d dy rut.
2.1.3.Vim d dy do chn thng thc th
t gp nh sau t ng thng d dy, sau iu tr cm mu d dy bng ni soi, bng
laser, nhit ng. iu tr bng nhn n, truyn dch, bng nim mc d dy v khng tit.
2.1.4.Vim d dy do x tr
Vim hang v, tin mn v. Tn thng c th su lm thng, chy mu hoc hp.
iu tr bng cc thuc bng nim mc, khng tit v ngng x tr.
2.1.5. Vim d dy do thiu mu
L biu hin ca bnh ton thn nh trong bnh Scholein- Henoch, nhim CMV. iu
tr bng thuc bng nim mc v khng tit, thuc dit virus.
2.1.6. Bnh d dy xung huyt
Gp trong tng p tnh mch ca ca bnh x gan.
iu tr ch yu bng thuc chn giao cm nh Propanolol, hoc Nadolol 60mg- 80
mg/ng sao cho mch cn 3/4 so vi trc khi dng.
2.1.7. Vim d dy do nhim trng
Nguyn nhn thng gp l lao, CMV, Candida Albican, Histoplasmosis, bnh Crohn.
iu tr c hiu bng khng sinh, khng nm, thuc dit virus. Trong trng hp nng th c
th phu thut.
2.2.Vim d dy cp khng do n mn phi hp nhim HP cp hoc mn. iu tr thuc dit
HP gm Omeprazole (40mg/ng) phi hp Amoxicillin (2 gr/ng), Clarytromycine(1gr /ng)
trong 7- 10 ngy. C th km thuc bng nim mc nh Bismuth.
3. iu tr vim d dy mn
139
3.1.Vim d dy mn khng do n mn hay gp:
3.1.1.Vim d dy mn type A
y l vim d dy vng thn, thng l vim teo nim mc, thng phi hp vi
cc bnh t min khc nh vim tuyn gip t min, suy thng thn, x ng mt tin
pht.
iu tr: cha c iu tr c hiu, thng dng cc thuc trung ha acide, vitamin C,
st, vitamin B12, corticoides. Cn theo di din tin dn n ung th d dy.
3.1.2.Vim d dy mn type B
Tn thng vng hang v d dy gp trong 80% trng hp v rt quan trng, n
cn c gi l vim d dy do HP. Cn iu tit cn hn ch hin tng teo tuyn xy ra.
iu tr khng tit phi hp khng sinh dit HP.
3.1.3.Vim d dy type AB
Tn thng c hang v v thn d dy.
iu tr bao gm thuc khng tit, khng sinh, bng nim mc, Vitamin B12, st
ci thin tnh trng thiu mu.
3.1.4..Vim d dy do tro ngc
Vim d dy vng mn v gp sau ct 2/3 d dy. iu tr bao gm thuc thay i
thnh phn dch mt nh Cholestyramin phi hp sucralfate v Cizapride hoc
Metoclopropramide lm y nhanh thc n ra khi d dy.
3.1.5.Vim d dy ph i: (bnh Mntrier): t gp
Cn gi l vim d dy lympho, tn thng lan rng c d dy ch yu b cong ln.
iu tr bng khng Cholin, khng tit, Tranexamic acide (Frenolyse), corticoides v
Ortreotide km khng sinh nu c thm nhim HP, hoc km thuc dit virus nu c nhim
CMV. Trng hp nng, c th phi ct d dy ton phn.
3.2.Vim d dy mn do n mn: t gp, Tn thng nim mc d dy dng thu u vi cc
nt nh c n mn trung tm gp vng hang v thn d dy, cn gi l vim d dy dng
lympho. Bnh ny c tng IgE trong mu gi cho nguyn nhn min dch. Bnh p ng
vi Cromoglycate 80- 160mg/ng.
3.3.Vim d dy th gi u lympho: Thng phi hp tn thng lot hoc vim c ng hoc
to thnh m limph ( MALT : mucous Associated limphome Tissuse) trong trng hp
nhim HP.
iu tr: Nu c bng chng c HP th phi dit tn gc bng khng tit, khng sinh
3.4.Vim d dy i toan: Him gp. Do cc ht bch cu i toan to thnh cc polype nh
vng hang v cn c gi l u t bo quanh mao mch.
iu tr bng Prednisolone l thuc chn lc, liu 10-15mg/ng, cc tn thng s thoi
trin sau vi ba ngy.

140

H1. Vim d dy n mn do NSAIDs H2. Bnh d dy tng p ca: Hnh khm, cc chm



H3. Vim d dy mn vng thn H4. Vim d dy mn do HP: HP(mi tn)
(tp A) c teo tuyn l r mch mu

H5. Vim mn v do tro ngc dch mt

141
VIM NG MT - TI MT CP
Mc tiu
1. Trnh by c c ch bnh sinh ca cc loi si mt.
2. Nu c cc c im lm sng v cn lm sng ca vim ng mt ti mt cp
3. Trnh by c cc bin chng cp v mn ca vim ng mt ti mt cp.
4. Trnh by c cc phng tin iu tr ni khoa vim ng mt- ti mt cp

I. I CNG
Vim ng mt ti mt cp (VMTMC) l mt cp cu ni - ngoi khoa thng gp, c th
c bin chng nng thm ch t vong nu khng c chn on v iu tr kp thi.
VMTMC nc ta c cc c im dch t hc v c ch bnh sinh khc vi cc nc u
M. Vic iu tr v theo di i hi s phi hp ni - ngoi khoa.
II. DCH T HC
VMTMC nc ta ch yu l do giun hoc si mt, trong 95% l si ng mt ln.
Si mt l bnh ng hng th hai trong cc bnh gan mt nc ta sau cc bnh vim gan.
Hin nay t l do giun a gim rt nhiu.
Si mt cc nc u M th ch yu l do si ti mt (90%) m thnh phn ch yu l si
Cholesterol. Php, t si mt ngi ln khong 10-15%. Ty u v Nam M t l ny
l 10-30%. Nht Bn si mt chim t l 5%, ch yu l si sc t mt.
III. BNH NGUYN
1. Vim ng mt ti mt cp khng do si
1.1. Giun chui ng mt.
1.2. Nhim khun huyt: thng do E. Coli, thng hn.
1.3. Chn p ng mt: do cc khi U ng mt, u u ty, hch chn p.
1.4. Th thut thm d ng mt: Ni soi ng mt, ct c vng Oddi.
2. Vim ng mt ti mt cp do si: si cholesterol, si sc t mt.
IV. C CH SINH BNH
1. C ch to si Cholesterol
Bnh thng, t bo gan tng hp cc axit mt v bi tit cholesterol vi t l 1 gam cho mt
lt mt. Cholesterol ha tan trong mi trng mui mt to thnh mt dung dch. Lecithin
cng l mt thnh phn ca mui mt gip cho s ha tan ca Cholesterol.
Thng thng, t l mui mt/ cholesterol (SB/C)> 10, t l Phospholipid/ Cholesterol
(L/C)> 3; khi cc t l ny thay i: SB/C gim, L/C gim th c hin tng bo ha
cholesterol to si.
S bo ha cholesterol l tin cho s kt ta cholesterol to si v thng gp trong cc
trng hp sau:
Gim bi tit mui mt:
- Gim hp thu rut: bnh Crohn, ct on rut.
- Bo ph: bi tit mui mt c tng nhng khng tng bng bi tit cholesterol.
142
- Tui cao, dng nhiu Oestrogen.
Tng bi tit cholesterol.
- Ch n giu calo
- Oestregen, Clofibrate lm tng tng hp cholesterol.
Vai tr ca ti mt:
- Ti hp thu nc do lm cho Cholesterol d kt ta hn.
- Tit ra cht nhy lm cho Cholesterol v mui mt d kt ta hn.
2. C ch to si sc t mt: c hai tc nhn ng lu
2.1. Nhim trng: Cc vi khun, ch yu do giun mang theo khi chui vo ng mt, gy
vim nhim lm ng mt gin, nhu ng km v ng mt. Thnh ng mt ph n v
nim mc c th b bong ra. c bit cc men vi khun (Glucuronidase) s bin Bilirubin
thnh Bilirubinat d kt ta. Nhng yu t trn lc u to trong ng mt mt cht gi l
bn mt, v sau kt dn thnh si mt.
2.2. K sinh trng: Nhiu nghin cu thc nghim cng nh cc quan st khi m si mt cho
thy giun a v trng giun a lm nhn cho vic to si. Thng phi hp vi c ch
nhim trng.
V. LM SNG
1. Si ti mt
1.1. Si ti mt khng c triu chng: chim phn ln trng hp, t l gy cn au qun gan
v bin chng hng nm ch c 2%.
1.2. Cn au qun gan
1.2.1. C nng: au h sn phi lan ra sau lng hoc b vai. au t ngt ddi ngay t
u hoc tng dn, thng au lin tc vi cc cn kch pht. au tng khi th su. Nn ra
thc n, dch mt, co khi nn ra giun. au thng ko di t 15' n 3 gi.
1.2.2. Thc th
- Giai on sm triu chng thng ngho nn: bng mm, im au vng ti mt, gan
v ti mt khng c hi chng nhim trng hoc tcmt.
- Giai on mun sau 6 gi: hi chng nhim trng r, ngi gi hoc c a xu c
th c hi chng nhim c. Ti mt ln v au, h sn phi au v khng, phn ng
thnh bng nu c thm mt phc mc. C th c hi chng vng da, xut huyt,
2. Si ng mt
Khi c vim ng mt thng c 3 nhm hi chng chnh:
2.1. Triu chng do tn thng gan mt: vi cn au qun gan nh trn.
2.2. Hi chng nhim trng: St xy ra ng thi hoc vi gi sau au: St cao, rt run, c
th c biu hin nhim c nng.
2.3. Hi chng tc mt: ty thuc v tr, kch thc v thm ca vin si. C th nh
thong qua, c khi r vi nc tiu vng m, kt mc mt v da vng; t gp hn l phn bc
mu, nga. Vng da thng xut hin 1-2 ngy sau triu chng au v st.
au, st, vng da lm thnh tam chng Charcot c trng cho si ng mt.
143
VI. XT NGHIM CN LM SNG
1. Xt nghim sinh hc
1.1. Cng thc mu: bch cu tng ch yu a nhn trung tnh.
1.2. Cy mu: khi cha dng khng sinh, thng gp l E. Coli.
1.3. Xt nghim dch mt: ht dch mt bng thng t trng hoc bng ni soi: cy vi khun,
tm trng giun, sn l gan.
1.4. Bilirubin mu: tng trong tc mt, ch yu loi trc tip.
1.5. Nc tiu: sc t mt, mui mt tng, urobilinogen (-) khi tc mt hon ton.
1.6. Transaminase, Phosphatase kim, gamma GT trong mu tng khi tc mt ko di.
1.7. Phc hp Prothrombin gim, nghim php Kohler dng tnh.
2. Chn on hnh nh.
2.1. Chp bng khng sa son: thng t thy si.
2.2. Siu m bng: rt c gi tr d s dng. C th thy hnh nh trc tio ca si (tng m
mnh, c bng lng) hoc hnh nh gin tip qua hin tng gin cc ng mt.
2.3. Chp ct lp t trng: chnh xc hn i vi si ng mt nhng t tin.
2.4. Chp ng mt: Thng c ch nh l chp ng mt ngc dng c bm thuc
cn quang, c th kt hp vi ct c vng Oddi ly si, c gi tr chn on v iu tr cao.
Chp ng mt qua da: ch tin hnh khi c ch nh phu thut.
VII. CHN ON
1. Chn on xc nh
- au h sn phi km st, vng da vng mt.
- Siu m bng hoc chp ng mt cn quang.
2. Chn on phn bit
2.1. au h sn phi cn phn bit vi
2.1.1.Vim ty cp: au lin tc, c cc im au ty, Amylase mu tng, siu m bng: Ty
ln, ph n, cc ng dch, c th phi hp vi vim ng mt - ti mt do giun, si
2.1.2. p xe gan amip
St trckhi au, gan to v au, im au khi tr vng gan, thng khng c vng da vng
mt. Chn on da vo siu m v ELISA tm khng th amip
2.1.3. Lot d dy t trng
Khng st, khng vng da, au c tnh chu k, gim au sau n nh hoc ung khng toan.
Chn on bng ni soi d dy t trng.
2.1.4. Ri lon vn ng ti mt
D nhm vi si mt th khng vng da, thng gp ph n, khng st, khng vng da,
gim au t nhin. Siu m khng c giun hoc si
2.2. Vng da cn phn bit vi
2.2.1.Vim gan
144
C trng hp au nhiu d nhm vi si mt. Vng da th ht st. Bilirubin gin tip tng
cao, ALAT v ASAT tng rt cao. Siu m gip phn bit.
2.2.2.U u ty: Tc mt t t ngy cng tng, thng khng au, khng st. Chn on bng
siu m bng v nht l CT Scan
VIII. BIN CHNG
1. Bin chng cp tnh
1.1. Bin chng gan v ng mt
1.1.1. Thm mt phc mc: Tc mt lm ti mt cng to v gin mng, cc ng mt cng
cng to lm mt thm ra ngoi, vo bng. Bnh nhn au nhiu hn v lan ra ton bng.
Khm bng c phn ng thnh bng, nht l h sn phi.
1.1.2. Vim hoi t ti mt hoc ng mt ch: Thnh ti mt v ng mt ch c th b vim
dy, trn c nhng ch b hoi t. Nhng ch c th c mc ni hoc cc tng xung
quanh ti dnh bt li hoc bc vo bng gy vim phc mc, gp ti mt nhiu hn ng
mt ch, lm sng c hi chng nhim trng nhim c nng, bng ngoi khoa. Chn on
bng siu m v chp ct lp t trng.
1.1.3. p xe ng mt: nhim trng v tc mt nng, gan ln v au. Siu m pht hin cc
p xe trong gan.
1.1.4. Chy mu ng mt: Do p xe hoi t nhu m gan lm mt nhnh ca ng hay tnh
mch trong gan thng vi ng mt hoc do vim ti mt chy my. Thng hi chng tc
mt nh hoc khng r. bnh nhn thy mt mi, chong vng, hoa mt, sau i cu phn
en hoc nn ra mu, trng hp in hnh trong cht nn c cc cc mu ng hnh thi bt
ch. Chy mu ng mt thng dai dng v d ti pht.
1.2. Bin chng ton thn v cc c quan khc
1.2.1. Nhim trng huyt v chong nhim trng: Thng do vi khun Gram m. St cao km
rt run, mch nhanh huyt p ty v kp, tay chn lnh, ni vn tm, nc tiu gim. Cy mu
thng dng tnh. Tin lng nng.
1.2.2. Hi chng gan thn vi tiu t, v niu. Ur mu tng nhanh.
1.2.3. Vim ty cp: au lin tc, nn nhiu, cc im ty au, Amylase mu tng. Siu m
hoc chp ct lp t trng thy tn thng ty.
2. Cc bin chng mn tnh
2.1. X gan: do mt v vim nhim ko di v ti pht nhiu ln. Chc nng gan gim dn
v cui cng i ti x gan do mt.
2.2. Vim ti mt mn: do vim ti mt ti pht nhiu ln. nhim trng t rm r, ti mt
khng ln, c th c m qunh vng ti mt. Siu m thy ti mt teo nh, thnh dy v
thng c si.
2.3. nc ti mt: Gp trong si c ti mt hoc vim ti mt mn gy tit dch lng.
2.4. Vim x c Oddi: do si bng Vater lm vin c Oddi lu ngy lm x v lm nng thm
s cht hp ng mt.
IX. IU TR
1. iu tr
1.1. iu tr triu chng
145
* Tit thc: hn ch m, trng. Cung cp nng lng, nc v in gii.
* Chng au
+ Chng co tht
- Atropin 0, 25mg, 2-4 ng/ngy; chng ch nh trong trng hp u x tin lit tuyn
hoc tng nhn p.
- Buscopan 20mg, 2-3 ng /ngy
- Phloroglucinol (Spasfon)
+ Gim au mnh phi hp
- Dolargan 100mg tim bp hoc chuyn tnh mch 1-2 ng.
- Khng dng Morphin v gy tng co tht c vng Oddi.
* Chng nhim khun
+ Nguyn tc chung
- Khng sinh phi hp ng tim. liu cao.
- Khng sinh chn ban u c tc dng tt ln cc vi khun Gram m, k kh, sau
iu chnh theo kt qu cy mu hoc dch mt.
- iu chnh theo tnh trng chc nng thn.
- Dng ko di, t 15 -21 ngy.
+ Phng tin iu tr
- Ceftriaxone (Rocephine): 1 g/12 gi tim TM chm.
- Amoxicilline+ acid clavulanic (Augmentin): 1 g/12 gi tim TM chm
- Metronidazole (FLAGYL): 1-1, 5 g/ngy, chia 2-3 ln, ho trong glucose 5%, chuyn
TM trong 30 pht.
- Ciprofloxacin (Ciflox): 400mg/12 gi tim TM chm.
+ Mt s phc c th:
- Augmentin 1 g/12 g tim TM chm
- Ceftriaxone + Flagyl
- Ciprofloxacin + Flagyl
- Ceftriaxon + Gentamycin + Flagyl
* Vitamin K
Trong trng hp tc mt ko di, t Prothrombin gim nhiu: 5mg, 2 ng/ ngy trong 3
ngy.
2.2. iu tr nguyn nhn
* Giun a
Dng thuc lit giun sm bng
- Pyrantel palmoat (Combantrin, Helmintox): 125mg/10kg ung mt ln
- Albendazole (Zentel): 400 mg, 2 vin ung 1 liu duy nht.
146
* Do si
+ Thuc lm tan si ng ung
Ch nh i vi si cholesterol.
- ng ung
C ch: cc dn xut ca mui my c th lm tan si Cholesterol nh c ch ha tan ht
micelle ca vin si, ring i vi acid Ursodesoxycholic th c thm c ch tng cng l s
to ra giai on tinh th lng.
Tiu chun chn bnh
- Bnh nhn c cc cn au qun gan nh hoc trung bnh nhng khng c cc bin
chng nh vim ti mt cp, vim ng mt, vim ty, tc nghn ng mt.
- Si cholesterol: cn c vo tnh cht si khng cn quang trn phim x quang, tt hn
l trn chp ct lp vi tnh, si c mt nh hn hoc bng dch mt, khng c hnh nh vi
ha. Mt du chng gi si Cholesterol khc l hnh nh tri ni ca si khi chp cn quang
ti mt do trng lng ring ca si gn bng thuc cn quang.
- ng ti mt phi thng thong m bo chc nng lm y v lm rng ti mt.
- Kch thc ca si t 5-10mm, tt nht l si 5 mm.
+ Cc thuc lm tan si
- Ursodesoxycholic (URSOLVANT, URSODIOL): dng liu 10-15mg/kg/ ngy. Thn
dng ban m l thi im l s tit mui mt thp nht v s tit cholesterol cao nht.
- Chenodesoxycholic (CHENODEX, CHENODIOL): 14-16 mg/kg/ ngy. Hin nay
khng dng do liu tan si th thng gy nhiu tc dng ph nh i chy, tng men gan v
tng cholesterol mu.
- C th phi hp URSOLVANT 5mg/kg + CHENODEX 5 mg/kg c tc dng lm tan
si tt hn URSOLVANT n c v t tc dng ph.
- Thi gian iu tr trung bnh: 6 thng i vi 5 mm v 2 nm i vi si 10-15mm.
- Hiu qu: URSOLVANT lm tan si trong khong 49% i vi si di 10 mm v ch
29% i vi si trn 10 mm.
Tc dng ph: thng gp vi CHENODEX: i chy 920-40%), tng men gan, tng
cholesterol LDL (10%).
+ Lm tan si trc tip
Bm trc tip thuc lm tan si vo ti mt: Methyl Ter Butyl Eter (MTBE). t c s
dng v t hiu qu.
+ Phu thut
- Ct ti mt bng phu thut m bng hoc tt nht l ni soi.
- M ng mt ch ly si, sc ra, dn lu Kehr.
+ Ni soi
Chp ng mt ngc dng qua ni soi khng ch l phng php chn on chnh
xc si mt m cn gip phi hp iu tr ly si, gip bnh nhn trnh c phu thut m
bng c in.
- K thut:
147
+ Ni soi t trng, chp ng mt bng thuc cn quang.
+ Xc nh v tr si, nh gi kh nng c th ly qua ni soi
+ Ct c vng Oddi bng dao ct, phi hp ct v ng cm mu, kch thc on
ct ty thuc kch thc vin si, kch thc ng mt, di ca phu ng mt, thng
t 10-15mm.
+ a r Dormia hoc bng ln ng mt ch qua ming ct ko si xung t trng.
Trong trng hp kch thc si ln th c th tn si c hc trc tip ti ch trc khi ly
si.
- Bin chng
+ Bin chng sm:
Xut huyt
Thng t trng hoc him hn l thng ng mt ch.
Vim ty cp
Vim ng mt cp l bin chng nng, c th gy t vong.
Kt r Dormia bng vater.
+ Bin chng mun (sau 30 ngy)
St si
Hp th pht ming ct
Vim ti mt cp
- Ch nh
+ Si ti pht ng mt bnh nhn ct ti mt
+ Bnh nhn ln tui, nguy c bin chng do phu thut cao.
+ Si ng mt khng km theo si ti mt
+ Trong trng hp cp cu, c km theo chang nhim trng, suy thn cp, xut
huyt tiu ha, vim ty cp...
X. D PHNG
- D phng si cholesterol bng tit thc gim cholesterol, gim m bo ha, thn trng
khi dng thuc nga thai, iu tr bnh huyt tn nu c.
- Tuyn truyn, gio dc v v sinh n ung, v sinh mi trng, x l phn thi nng
thn. Khuyn khch phong tro trng v s dng rau sch. Ra tay trc khi n.
- X giun nh k mi 2-3 thng
- iu tr tt cc t nhim trng ng mt
148
VIM GAN MN
Mc tiu
1. Nm c bnh nguyn v c ch bnh sinh trong vim gan mn.
2. Khm v pht hin c cc triu chng ca vim gan mn.
3. Chn on c v bit cch d phng
4. Trnh by c cc pht iu tr vim gan mn theo tng nguyn nhn gy
bnh.
I. I CNG
Vim gan mn (VGM) l biu hin ca nhiu loi tn thng gan do nhiu loi
nguyn nhn khc nhau trong vim v hoi t t bo gan ko di > 6 thng. Th nh l th
khng tin trin hoc tin trin rt chm v khng a n x hoc ung th gan cn th nng
l th vim hoi t dn dp hoc nhiu t tin trin tn cng vo t bo gan ri cui cng
a n x v ung th ha. Vim gan mn gy ra do nhiu loi nguyn nhn thng gp l
sau vim gan siu vi nht l B, C, v B phi hp vi D v gn y l vim gan mn G; vim
gan mn t min, vim gan mn do thuc.
II. GII PHU BNH
Cc tn thng thng phi hp gia tm nhun t bo vim, hoi t v x ha.
Tm nhun t bo vim ch yu l khong ca, lm cho khong ca b dn rng ra, vim
cn xy ra quanh cc tiu thy gan, vi cc t bo gan b hoi t. Cc t bo vim tm
nhun ch yu l cc t bo vim n nhn nht l lymphocyte v plasmocyte v monocyte
Hoi t t bo gan thng l nng v lan rng, c bit l hoi t tng m nh vi ba t bo
ch tip cn vi khong ca, hoi t ny gi l hoi t kiu mi gm, rt c trng cho
vim gan mn hot ng. Mt loi hoi t khc cng thng gp l hoi t kiu cu ni, ni
lin khong ca v tnh mch trung tm tiu thy.
X v nt tn to thay i t nhiu ty theo giai on din tin ca bnh, trong giai on sau
x chim u th v lm cho cu trc gan hon ton b o ln ng thi c s xut hin ca
nt tn to, cn biu hin vim th li gim dn cho hnh nh giai phu bnh nh trong x
gan v cui cng c th b ung th ha.
III. PHN LOI VIM GAN MN
Hin nay ngi ta phn loi da vo s phi hp ca lm sng, huyt thanh hc v thay i
v m hc cho nn cho nhiu gi tr thng tin hn. Phn loi vim gan mn l da trn cc
yu t sau
- Nguyn nhn.
- Hot tnh m hc cn gi l .
- tin trin gi l giai on.
1. Phn loi theo nguyn nhn
Lm sng v huyt thanh cho php chn on c vim gan mn do siu vi, ch yu l siu
vi B, C, phi hp D, cc loi siu vi khc; vim gn mn t min gm cc tiu nhm: type 1,
type 2 v type 3; vim gan mn do thuc; vim gan mn khng r nguyn nhn gi l
Cryptogenic chronic hepatitis.
2. Phn loi theo
149
S phn chia l da vo s lng gi m hc ca hot tnh vim hoi t khi sinh thit gan.
S lng gi v nng m hc bao gm hoi t quanh khong ca v s ph v lp t
bo gan quanh khong ca bi t bo vim hoi t gi l hoi t kiu mi gm. S ni kt ca
cc hoi t ny to thnh hoi t cu ni, ni lin khong ca v mch mu trung tm, hoc
cc khong ca vi nhau. Nhiu h thng cho im mc hoi t ny, nhng ph bin nht
hin nay l bng ch s nh gi hot tnh m hc (HAI: hepatitis activity index) da trn
cng trnh nghin cu ca Schnell v Ishak. HAI l mt bng o v , n cng lng gi
x ha m hin nay c dng chia giai on bnh. N cng c dng o hot tnh
ca bnh trc v sau iu tr. Lm sng VGM chia ra 3 nh, va v nng.
3. Phn loi theo giai on
Phn loi ny phn nh giai on tin trin ca bnh, da trn mc x gan.
- Khng c x.
- X nh.
- X va.
- X nng c c x cu ni.
- X gan tht s.
4. Phn loi phi hp vi m hc: chia ra 3 loi
4.1. Vim gan mn tn ti: tm nhun t bo vim n nhn lan ta nhng cn gii hn trong
khong ca, ranh gii quanh khong ca cn nguyn vn v khng c s xm ln ca tin
trnh vim hoi t vo tiu thy gan, hoc ch c mt t x quanh khong ca m khng c x
gan. Thng l bnh nhn Khng c triu chng hoc rt nh nh mi mt, chn n, bun
nn. Thc th rt ngho ch c th gan hi ln hoc bnh thng. Men transaminases ch tng
nh v khng c hoc rt t a n x gan.
4.2. Vim gan mn tiu thy: ngoi vim khong ca, xt nghim m hc c hoi t v
vim trong tiu thy. V hnh thi hc, vim gan mn tiu thy tng t nh tin trin chm
ca vim gan cp. Ranh gii quanh khong ca vn cn nguyn vn, khng c x quanh
khong ca hoc ch hn ch, cu trc thy cn gi c v t khi chuyn qua vim gan mn
hot ng v x gan. V vy vim gan mn tiu thy c xem nh l mt th ca vim gan
mn tn ti. i khi hot tnh trn lm sng ca vim gan mn tiu thy gia tng mt cch t
nhin, hot tnh ca men transaminase tng t nh trong vim gan cp v c tn thng m
hc gan thong qua. Thut ng hin nay ca vim gan mn tiu thy l tng ng vi th nh
hoc va v giai on l khng c x hoc x ti thiu.
4.3. Vim gan mn hot ng: v lm sng c c trng ca hoi t lin tc khong ca,
quanh khong ca, vim tiu thy gan v x, mc t nh cho n nng. Vim gan mn
hot ng c bit nh l mt tin trnh tn thng gan a n x, suy v cht. c im
v hnh thi hc ca vin gan mn hot ng bao gm:
- Thm nhim dy c t bo vim n nhn trong khong ca lan rng vo tiu thy gan
(trong vim gan mn t min l plasmocyte).
- Hy hoi t bo gan quanh tiu thy lm ph v hng ro t bo gan quanh khong ca
(hoi t kiu mi gm).
- Vch x bao quanh khong ca v lan rng t khong ca vo trung tm lm c lp t bo
nhu m vo trong mt m v bao ly cc ng mt.
- C s ti to nhu m gan thnh lp th hoa hng, b gan b dy ra v ti to (nt tn to)
150
Bng 1: Ch s hot tnh m hc ca Schnell- Ishak trong vim gan mn
Hnh thi m hc nng Ch s
1. Hoi t quanh khong ca,
bao gm hoi t mi gm v
hay cu ni
Khng
PN nh
PN va
PN ng k
PN va+ BN
PN ng k+ BN
Hoi t nhiu thy
0
1
3
4
5
6
10
2. Hoi t ni tiu thy Khng
Nh
Va
ng k
0
1
3
4
3. Vim khong ca Khng
Nh
Va
ng k
0
1
3
4
4. Si x Khng
Lan rng khong ca
X cu ni
X gan
0
1
3
4
Tng s 22
IV. TRIU CHNG
1. Lm sng
Triu chng khi u c th biu hin nhng t rm r nh trong vim gan cp (1/3 trng
hp), phn cn li thng m thm lm phn ln bnh nhn khng nhn bit c, thng ch
biu hin bi triu chng c nng chung l mi mt, cm gic nng tc vng h sn phi,
nhiu lc c au c, au khp hoc nhiu lc ch c cm gic nhc mi chung chung. Trong
nhng t tin trin, cc triu chng thng phong ph v rm r hn vi st, vng da vng
mt, nc tiu vng hoc sm mu, au c v au khp v nht l au tc vng gan v nga.
Khm thy gan ln va, cng chc n au tc, vng da vng mt, hng ban v dn mch hnh
sao. C th c lch ln 30% nht l khi c tng p ca, km thm c bng; hch ln 15-
20% thng l hch nch v hch c.
Cc biu hin ngoi gan c th gp: ban da, vim tuyn gip t min Hashimoto, vim mch,
vim cu thn, hi chng Sjogren, vim i trc trng lot chy mu, thiu mu, chy mu do
gim tiu cu.
Giai on sau khi c bin chng x gan cc biu hin vim thng gim dn thay vo
l cc triu chng ca x gan vi bng v suy gan l ni bt; hoc cc triu chng ca ung th
gan vi gan rt ln, cng c nhiu khi u ln nhn.
151
2. Xt nghim
2.1. CTM: BC v HC thng gim c th gim lun c TC, VS thng tng cao.
2.2. Chc nng gan: thay i nhiu.
- Bilirubin tng c trc tip v gin tip.
- Men transaminase thng tng gp >5 ln bnh thng.
- Gammaglobulin tng nhng albumin gim, t A/G rt thp.
- T prothrombin gim, yu t V gim.
- Phosphatase kim tng.
2.3. Min dch
- HBsAg(+), ADN virus, ADN polymerase v HBeAg(+) trong vim gan mn hot ng B.
- Anti HVC v HVC-RNA (+) trong vim gan mn virus C.
- KT- khng nhn, KT-khng c trn, KT- khng ti lp th (+) trong vim gan t min.
2.4. Sinh thit gan: l mt xt nghim cn thit gip chn on nguyn nhn v giai on,
trm trng ca vim gan mn cho hnh nh vim hoi t xm nhp tiu thy gan vi hoi t
mi gm, hoi t cu ni, hoi t mng xen ln vi t chc x pht trin nhiu khong ca
xm nhp tiu thy v cc nt tn to trong giai on sau.
V. CHN ON NGUYN NHN
1. Vim gan siu vi
1.1. Vim gan mn B: trong thi k lui bnh c khong t 1-10% bnh nhn vn mang virus,
nguy c mang mm bnh mn c lm d bi tnh trng suy gim min dch trc .
Nhim bnh t s sinh thng im lng nhng c n 90% c nguy c chuyn thnh mn,
trong khi nhim bnh tui thiu nin khi c min dch, th biu hin lm sng vim
gan cp r hn nhng ch c 1% tr thnh mn tnh. Mc tn thng gan rt thay i t
nh, va v nng; mc tn thng m hc lin quan n trm trng ca bnh. Mt
nghin cu c theo di ko di 5 nm cho thy thi gian sng cn 97% trong VGM tn ti,
55% trong vim gan mn hot ng.
Ngoi tn thng m hc, s nhn ln ca virus cng rt quan trng trong vn tin
lng, ngi ta chia vim gan mn ra lm 2 pha da trn s ch im nhn ln ca virus
(HBeAg, HBV- DNA), c s hin din ca khng nguyn nuclocapside ni bo (HBcAg).
Trong pha t nhn i virus, khng c mt ca HBeAg v HBV- ADN nhng c anti HBe,
khng c mt ca HBcAg ni bo, pha ny rt t ly nhim, v tn thng gan t. Bnh nhn
c pha nhn ln virusk c khuynh hng nng, trong khi bnh nhn khng c pha nhn
ln virus, thng l vim gan nh hoc va hoc ngi lnh mang bnh. S chuyn t nhin
t vim gan mn c nhn ln sang vim gan mn khng nhn ln hng nm l t 10-15%.
Tn thng gan do nhim virus B mn khng phi trc tip gy ra do virus, m lin h n
phn ng min dch chng li t bo gan do cc khng nguyn ca chng, nht l HBcAg.
Lm sng ca vim gan mn siu vi B rt thay i t nhim khng triu chng cho n rt
nng n thm ch t vong do suy gan. Khi bnh a s thng m thm, ch mt s t biu
hin nh mt vim gan cp. cc triu chng thng gp l mt mi, vng da tng t, km
chn n, v sau xut hin cc triu chng ca x gan v tng p ca nh ph, bng, chy mu
nht l t tnh mch trng thc qun, ri lon chy mu ng mu, bnh no gan, lch ln.
152
cc triu chng ngoi gan gn ging nh vim gan siu vi cp do s lng ng cc phc hp
min dch Ag-Ab nh au khp, vim khp, ban da, vim cu thn, vim mch.
Xt nghim
- Men transaminase tng t 100- 1000 v trong SGPT tng nhiu hn, nhng khi c x
gan th SGOT chim u th hn.
- Phosphatase kim tng va. Bilirubin tng gp 3-5 ln bnh thng.
- Albumin mu gim.
- T prothrombin gim nht l trong giai on nng y cng l yu t tin lng.
- Cc cht ch im l HBeAg v anti HBe, HBV- DNA, HBsAg, anti HBc thng (+).

Din tin huyt thanh din hinh cua vim gan ma n tin trin Din tin huyt thanh din hinh cua vim gan ma n tin trin
Thoi gian tinh b ng tu n
Thoi gian tinh b ng tu n
Nng
d
Nng
d
IgM anti-HBc
anti-HBc toan phn
HBsAg
Cp
(6 thang)
HBeAg
Man tinh
(Nm)
anti-HBe
0 4 8 12 16 20 24 28 32 36 52
Years
Din tin huyt thanh din hinh cua vim gan ma n tin trin Din tin huyt thanh din hinh cua vim gan ma n tin trin
Thoi gian tinh b ng tu n
Thoi gian tinh b ng tu n
Nng
d
Nng
d
IgM anti-HBc
anti-HBc toan phn
HBsAg
Cp
(6 thang)
HBeAg
Man tinh
(Nm)
anti-HBe
0 4 8 12 16 20 24 28 32 36 52
Years

1.2. Vim gan mn D (Delta): c pht hin nm 1977, y l loi virus c bit n ch c
th pht trin khi c s hin din ca virus B.
Bnh cnh lm sng vim gan mn D tng t nh vim gan mn virus B, nu ng nhim
th bnh cnh lm sng s rt nng nhng dng nh khng lm gia tng tin trnh a n
mn tnh, cn bi nhim ngi vim gan B mn s lm cho tn thng gan nng ra rt
nhiu.
Chn on da vo s hin din ca HDV Ag v anti HDV c 2 type IgG v IgM. S hin
din ca HDV Ag trong gan v HDV- RNA trong huyt thanh chng t c s nhn ln ca
virus. S hin din ca khng th lu hnh khng li microsome gan-thn (anti LKM: khng
liver kidney microsome) l yu t quan trng gip chn on vim gan D mn, y l la
LKM3 khc vi LKM1 trong vim gan t min.
1.3. Vim gan mn C: Trc y gi l 0A0B (khng A khng B). Din tin mn tnh sau
vim gan C l 50-70%. Ngoi ra vim gan mn sau chuyn mu 10 nm 20% a n x gan.
Ngay c cho nhng th nh v va v khng c triu chng v ch tng nh men
transaminase, sinh thit gan ch c thng tn nh v va. T l vim gan mn C cn b a
n x gan l 50%. nhng bnh nhn c anti HVC mc d khng c triu chng v men
transaminase bnh thng. Khi sinh thit gan cng c tn thng vim gan mn v c th pht
153
hin HCV- RNA lu hnh trong mu. Din tin ca VGM C thng chm v m thm. Mc
tin trin ph thuc vo nng HCV- RNA v thi gian nhim bnh.
Biu hin lm sng ca VGM. C cng tng t nh B: thng nht l mt mi, vng da t
gp. Cc biu hin ngoi gan do phc hp min dch t gp hn B ngoi tr phc hp globulin
ngng kt lnh. Tuy nhin n thng phi hp vi hi chng Sjogren, Lichen phng,
porphyrin da.
Cc xt nghim tng t VGM B, nhng men transaminase thng tht thng v t cao hn.
i Khi c cc t khng th.
- Anti - LKM1 thng(+) nh VGM t min type 2.
- Anti - C100, Anti C22/33 (+).

2. Vim gan mn t min: cng l mt bnh mn tnh trong gan b vim, hoi t, x ho
mt cch lin tc cui cng a n x gan, chim 10-20% VGM. Bnh gy ra do mt phn
ng t min chhng li cc Khng nguyn hin nay vn cha xc nh ht, 3/4 trng hp
gp ph n tr. cc biu hin t min ngoi gan cng nh cc bt thng min dch huyt
thanh cng c cho loi bnh ny.
Tin trnh tn thng gan l qua trung gian min dch t bo chng li t bo gan, trn c s
c t tnh di truyn c khi pht bi ha cht v siu vi. Cc bng chng h tr cho VGM
t min l:
- Tn thng m hc gan ch yu l t bo T c v tng bo.
- Cc t khng th lu hnh: khng nhn, khng c trn, khng tuyn gip..., yu t thp, tng
Globulin mu. - Km cc bnh t min khc: vim tuyn gip, vim a khp dng thp, huyt
tn t min, vim lot i trng, vim cu thn tng sinh, i ng, Hi chng Sjogren.
- Yu t ha hp t chc: HLA-B1 (Human leucocyte antigen), - B8, - Drw3 v - Drw4.
- Bnh p ng tt vi iu tr corticoide v thuc ch min dch.
154
Bnh cnh lm sng cng tng t nh vim gan mn siu vi. Khi bnh c th t t hoc
t ngt vi mt mi, chn n, mt kinh, mn trng c, au khp, ban da, vim i trng,
trng dch mng phi, mng tim, thiu mu, vim kt mc, kh mt, ph, lch ln.
Xt nghim: ngoi nhng ri lon sinh hc nh trong vim gan mn siu vi, y Gamma
globulin cao >2, 5g%, Yu t thp(+). Khng th khng nhn, khng ty lp th (+).
Chn on: da vo cc yu t sau:
- Khng c bnh nguyn r.
- Thng phi hp vi cc ri lon min dch khc: Lupus, PCE, Hashimoto, thiu mu huyt
tn, hi chng Sjogren...
- Hin din trong huyt thanh cc t khng th.
Ty theo cc type khng th ngi ta chia lm 3 th:
+ Type 1: thng xy ra ph n tr, Gamma globulin tng, khng th khng nhn v c
trn.
+ Type 2: thng xy ra tr em a trung hi, khng th LKM1.
+ Type 3: c khng th khng khng nguyn ha tan gan.
3. Vim gan mn do thuc: mt s thuc nht l khi dng ko di >6 thng, c th gy ra
VGM, thng gp nht l: Clormtacine, acide Tinilique, (-mthyldopa, Nitrofurantoine,
Papaverine, Oxyphnactine, Isoniaside, Amiodarone, Aspirine, Actaminophen, Vitamin A,
Methotrexate, PTU...
Cc tn thng do thuc thng l rt nng v x gan thng hin din trc khi pht hin ra
bnh.
Chn on cn da vo cc yu t sau:
- Tin s dng cc thuc c cho gan ko di.
- Din tin tt khi ngng thuc.
- Khng tm c cc nguyn nhn khc.
- Mt s xt nghim kh c hiu cho tng loi thuc: Sinh thit gan c s nhim lipide-
phospo t bo gan trong vim gan mn do Amiodacrone, KT antimitochondrie anti-M6 trong
vim gan mn do Isoniaside, Anti LKM3 trong VGM do tinilique, anti LM trong vim gan
mn do dihydralazine...
VI. CHN ON TH
1. Vim gan mn tn ti
1.1. Lm sng
- C nng: thng rt m thm v nh nhng, khng c triu chng hoc ch hi mt, chn
n, kh chu vng thng v hoc h sn phi; i khi tc nh vng gan.
-Thc th
+ Vng mt, vng da: khng c hoc rt kn o.
+ Hng ban v nt nhn khng c.
+ Gan: khng ln hoc ln nh 1 vi cm, mm ch tc nh m khng au.
+ Hch khng c. Lch khng ln. Khng c tng p ca.
155
1.2. Xt nghim
- Sinh ha
+ Men transaminase khng tng hoc ch tng nh 2-3 ln.
+ Phosphatase kim, Bilirubin, Gamma globulin khng tng hoc ch tng rt t.
+ Khng c hot tnh nhn ln ca virus.
- M hc: vim nh khong ca vi cc t bo vim n nhn, nhng khng bao gi vt qu
khong ca. B gan cn bnh thng hoc rt t b bin i. Cu trc gan cn nguyn vn.
1.3. Tin lng
Tt, khng c hoc rt t a n x gan v ung th gan.
2. Vim gan mn hot ng
2.1. Lm sng
- C nng: biu hin r nht l cc t bc pht vi st va, mt mi, chn n, au khp au
c, v nht l au tc vng h sn phi. Nc tiu m mu, nga v vng da vng mt.
- Thc th:
+ Mt thng vng nht l trong t tin trin.
+ Hng ban v nt nhn ngy cng nhiu nht l giai on khi c x gan.
+ Gan ln 3-4cm di sn, cng tc n au v sau tr thnh chc cng, b sc.
+ Hch ln t l 20%.
+ Lch ln 30%.
+ Tng p ca: thng xut hin v sau khi c x gan.
2.2. Xt nghim
- Sinh ha
+ Men transaminase thng tng > 5 ln bnh thng.
+ Phosphatase Kim v Bilirubin mu thng tng gp 3-5 ln bnh thng.
- Globulin tng > 25%.
+ T prothrombin v yu t 5 gim.
+ Hot tnh nhn ln ca virus r: ADN virus, ADN polymerase (+).
- M hc
+ Vim vt qu khong ca xm nhp tiu thy gan.
+ Hoi t dng mi gm, hoi t cu ni.
+ Hoi t m hoc mng.
+ X tng sinh, xm nhp tiu thy gan.
+ Cu trc gan b o ln.
2.3. Tin lng: xu, cui cng a n x gan v ung th gan.
VII. IU TR
1. iu tr vim gan mn virus B
156
* Mc ch ca iu tr vim gan mn virus: lm ngng s nhn ln ca virus v lm ngng
hot tnh sinh hc v m hc. C 3 mc p ng:
- p ng loi 1: ngng s nhn ln ca virus nh du bi s bin mt ca ADN virus trong
huyt thanh.
- p ng loi 2: khi s ngng nhn ln virus c ko di bi s chuyn huyt thanh HBe
(khng th khng HBe).
- p ng loi 3: ngng hon ton s nhn ln virus v s chuyn huyt thanh HBs (anti
HBs).
* Thuc
- Lamivudine: (Didoxythiacytidine, Zefflix* ca hng Glaxowellcome) thuc khng virus
Herpes v Retrovirus hiu qu trong vic c ch s nhn ln ca virus qua c ch sao chp
tng hp ca DNA virus v DNA polymerase. Vin 100mg ung ngy 1 vin, ung trong 3
thng, hiu qu lm (-) AND virus trong HT l 100%, nhng sau khi ngng thuc th 64%
dng tnh tr li. N cng lm gim HBeAg v HBsAg nhng chm hn.
Liu trnh 1 nm cng ch lm m tnh HBeAg 39% bnh nhn. Lamivudine cng c
dng trong d phng ti nhim virus B trong ghp gan bng phi hp vi Globuline min
dch khng HBsAg. Trong vim gan B phi hp vi nhim HIV dng liu 300mg/ng cho thy
rt hiu qu.
- Famciclovir: liu 1500mg/ng chia 3 ln trong 16 tun lm gim t l ng k AND virus v
hot tnh ca men transaminase sau 1 tun. S dng liu th 2: 750mg/ng trong 16 tun na
cng lm tng ng k s i huyt thanh khng HBe. N cng dng trong iu tr d phng
trong ghp gan, hoc trong trng hp khng iu tr vi Interferon.
- Adefovir: (Hepsera) vin 10mg/ ngy 1 vin dng 6 thng n 1 nm, cn theo di chc
nng thn.
- Entecavir (Baraclude): vin 0,5mg l loi nucleoside l thuc mi ra i nm 2005, thuc t
tc dng ph v t b khng, nhng t l khng cho vi Lamivudine l 7%; do khi
b khng v Lamivudine th phi dung liu gp i.
- Tenofovir (Tefovir) l li nucleotide trc y c dung iu tr HIV, nay c s
dng iu tr vim gan B, cng l thuc mi t l p ng cao ln n 90% v cng t b
khng.
Cc thuc mi ang c th nghim lm sng l Telbivudine, Clavudine.
- Interferon: Loi interferon alpha tc dng qua 2 c ch: mt l c ch RNA virus v tng
hot tnh ca men khng virus. Hai l lm gia tng p ng min dch t bo bng cch gia
tng s trnh by khng nguyn ha hp t bo loi 1 v kch thch hot ng ca lympho bo
T gip v T git. Liu 5 triu n v tim di da hng ngy hoc 10 triu n v tim
di da hoc tim bp tun 3 ln, dng trong 4-6 thng. p ng loi 2 khong 40%. p ng
tt hn bnh nhn c nng HBV DNA < 200pg/mL v bnh nhn c men transaminase
> 100-200 .v.
Tc dng ph: - Nh cm cm vi st, nhc u, mi mt.
- Thiu mu, gim bch cu a nhn, gim tiu cu.
- Tc dng ph nng hn nhng t gp v ph thuc c a l: ri lon tm
thn, ng kinh, suy hoc cng gip.
157
Interferon tc dng ko di: Peginterferon 2a (Pegasys), mi tun ch tim 1 ln, liu 90-
180mcg.
- Corticoide: cho trc iu tr Interferon trong 4 tun, v khi dng t ngt s c phn ng
di min dch vi s gia tng hy t bo b nhim virus, s gip cho Interferon tc dng tt
hn, nhng bnh nhn x gan c nguy c suy gan nng.
- Ghp gan: ch nh cho suy gan nng, nhng cng khng trnh c tnh trng vim gan ti
pht trn gan ghp (80%). iu tr interferon trc khi ghp lm chm tin trnh vim ny.
2. iu tr vim gan mn D
Ch c Interferon mi c hiu qu trong iu tr VGM D, nhng thng kh nh gi hn v
bnh nhn ny thng phi hp vi nhim HIV v VGM.C. Vi interferon alpha p ng
c ch s nhn kln ca virus l 50%, ng thi thng km theo s gim men transaminase,
v gim hot ng m hc, nhng him khi t c mt s ngng hon ton nhn ln ca
virus, v khi ngng iu tr s c s ti xut hin ca khng nguyn v ca RNA virus, cng
nh s gia tng tr li ca men transaminase. Liu interferon cao hn 10triu .v (3 ln/ tun
v ko di 6 - 12 thng.
Ghp gan cng c thc hin khi suy gan nng v cng c nguy c vim gan trn gan ghp.
3. iu tr vim gan mn C: Corticoides khng c kt qu.
* Interferon alpha l thuc iu tr hiu qa nht hin nay. N lm bin mt s tng men
transaminase sau 1-2 thng iu tr. Nhiu nghin cu cho thy interferon lm men
transaminase tr li bnh thng trong 50% trng hp, cng nh lm gim hot tnh m hc.
Liu 3 triu n v tun 3 ln tim di da trong vng 6 thng. Cn thn trng x dng
interferon khi c suy gan nng, v khi ngng iu tr s c phn ng di, v mt hot tnh
vim gan mn s lm cho gan b suy thm.
Hiu qu lu di ca vic iu tr interferon vn cha c bit ht. V sau khi ngng iu tr
3 - 6 thng th gn 1 na c hin tng ti pht. Hin nay c interferon tc dng ko di:
Peginterferon 2a (Pegasys), mi tun ch tim 1 ln, liu 90-180mcg, tc dng tt hn v t tc
dng ph hn nhng gi cn cao.
* Ribavirin: l mt cht ng vn nuclotide c ph virus rng, c th dng lm n tr liu
chng virus C, n gip ci thin v m hc v men gan t 30 n 50% bnh nhn. Tuy nhin
n lm gim lng virus khng ng k v p ng sinh hc khng duy tr c sau khi
ngng thuc. Liu dng l 1000-1200mg/ng, dng trong 6 thng.
iu tr ghp gan cng tng t nh VGM B.
2.4. iu tr vim gan t min
Ch yu l dng corticoides v thuc c ch min dch.
* Corticoides: Dng n c th cho liu 30-60mg/ng cho ngi ln trong vng 2-3 tun sau
gim liu dn, duy tr men transaminase mc bnh thng, vi liu thng thng l
10-20mg/ng.
Nu corticoide khng hiu qu th phi hp vi Azathioprine liu 50mg/ng. Liu trnh ny
hiu qu trong 80% trng hp. d n c hay phi hp vi Azathioprine cng cn ko di
t nht l 2 nm. Nu sau thi gian ny thy men bnh thng v khng cn hoi t t bo gan
th ngng iu tr v theo di. Nu ti pht th phi iu tr li nh t u. Thng t l ti
pht l khong 60-90% trng hp, do nhiu khi phi iu tr sut i.
* Ciclosporine: l thuc c nhiu trin vng hin nay ang dng iu tr trong trng hp
khng vi iu tr corticoides. Liu 5-6mg/kg, dng ko di 1-2 nm.
158
X GAN
Mc tiu
1. K cc triu chng v bin chng ca x gan.
2. Lit k cc tiu chun chn on bnh.
3. iu tr cc bin chng chnh hay gp ca x gan.
I. I CNG
X gan: tn Hy lp l kirrhose, c ngha l gan b x, do Laennec t ra t
nm1819 khi m t tn thng gan do nghin ru lu ngy, t bnh c mang tn ng
c gi l x gan Laennec.
II. NH NGHA
Theo WHO nh ngha, x gan l qu trnh tn thng gan lan ta vi s thnh lp t chc
si v o ln cu trc t bo gan ri ti to thnh tng nt nhu m gan mt cu trc bnh
thng v gim chc nng.
X gan l hu qu ca cc bnh gan mn tnh do nhiu nguyn nhn khc nhau nhng biu
hin lm sng kh ging nhau v din tin qua 2 giai on x gan cn b v mt b. Ngoi
cc triu chng chung ca n, c th km theo cc biu hin lm sng khc c trng cho
nguyn nhn gy bnh.
III. DCH T HC
Php, tn sut x gan c triu chng l 3000 /1 triu dn, trong do ru vang chim a
s.(nam: 90%-95%; n: 70%-80%); do bia: 10%, do vim gan mn virus l 10%. S ngi
ung nhiu ru:30.000/1 triu dn c nguy c x gan l 10%. Nu trung bnh ung khong
60gr ru/ngy i vi nam v 40 gr/ngy vi n trong 10 nm th nguy c x gan l 50%.
T l t vong do x gan: 300 ngi/1 triu dn/nm.
ng nam , vng Sahara chu Phi, khong 15% dn chng nhim virus vim gan B, C
ngay c khi cn nh tui, trong 25% dn n x gan.
Hoa K, t l nhim virus B t hn, thng gp ngi c nguy c cao nh ng tnh luyn
i nam, tim ma ty, vim gan C sau chuyn mu th c khong 50% dn n x gan, t l
sng sau 20 nm l 20%. Vit Nam, t l hin mc c phng on l hn 121.562 ngi/
tng s dn l 82.662.800 (trch ngun www. wrongdiagnosis.com).
IV. BNH NGUYN V GII PHU BNH (H1)
C nhiu nguyn nhn gy x gan, vn cn 1 s nguyn nhn cha bit r.
1. X gan ru
L nguyn nhn thng gp Chu u, ngi ung ru nhiu. Biu hin vi tuyn mang
tai ln, nt dn mch, SGOT/SGPT >2, GGT tng, sinh thit gan cho thy tn thng thoi
ho m t bo gan, gan vim v c nhiu t chc si x lm o ln cu trc gan. y l
loi x gan nt nh (x gan Laennec) hay x gan tiu thu.
2. X gan do nhim trng
ng hng u l vim gan B, C v hay phi hp D gy x gan nt ln (x gan sau hoi t).
y l hu qu ca vim gan mn hot ng m c khi khng tm thy s nhn ln ca virus.
Xt nghim huyt thanh cho thy mang mm bnh B, C mn: HBsAg(+), Anti-HBc(+), Anti-
159
HCV(+). Cc nhim khun khc t gp l: Brucellose, Echinococcus, Schistosomiasis,
Toxoplasmosis.
3. X gan do bin dng
3.1 Bnh thit huyt t di truyn: C tm nhun st trong gan lu ngy do ri lon chuyn ho
st. Xt nghim c st huyt thanh tng, bo ha ferritine v transferritine mu tng.
3.2. Bnh x gan ng: ng (Cu) trong gan do ri lon chuyn ho v di truyn (bnh
Wilson) hay do bnh gan mn tnh (hay gp do virus vim gan C) lm gan b suy khng
chuyn ho c ng. Khm mt thy c vng Keyser Fleischer (H2), xt nghim c Cu
huyt thanh tng.
3.3 Cc bnh t gp: Thiu 1-antitrypsin, bnh porphyrin niu, bnh tng galactose mu,
bnh Gaucher, fructose niu, .
4. X gan do ri lon min dch
4.1. X gan mt nguyn pht
y l bnh vim mn tnh ng mt nh trong gan khng nung m, gp ph n, 30t-50t,
biu hin mt mn tnh, tng Gamma- globulin IgM v khng th khng ty lp th.
4.2 Vim gan t min
Gy hy t bo gan mn tnh, thng c t cp, xt nghim mu c khng th khng c trn,
khng th khng nhn, khng th khng ty lp th.
5. X gan c hc
5.1. X gan mt th pht
Do nghn ng mt chnh mn tnh, do hp c oddi, do si.
5.2. Tt mch
Tt tnh mch trn gan trong hi chng Budd-chiari, suy tim phi lu ngy, vim mng ngoi
tim co tht.
6.X gan do thuc
Mthotrexate, maleate de perhexilene, methyl dopa, thuc nga thai, oxyphenisatin,
izoniazide,
7. Cc nguyn nhn khc cha c chng minh
Chim khong 16% trng hp x gan. C th do bnh vim rut mn tnh, i ng,
sarcoidosis.
V. C CH BNH SINH
Din tin x gan l din tin chm qua nhiu nm, nhiu khi nguyn nhn mt nhng
bnh vn tip tc tin trin do 1 vng lun qun:
1. Cc yu t min dch
Duy tr tnh trng tn thng t bo gan, c th gp cc khng nguyn(KN) chng t bo gan,
chng hng cu, chng gamma globulin c thnh lp trong din tin x gan, t gy hy
hoi t bo gan, hy hng cu, gy thiu mu v tng nguy c nhim trng.
2. Tng p ca
160
Lm gim thm s lu thng mu trong h thng ca, lm thiu mu tng i trong t bo
gan, t bo gan s nhn thiu oxy v cht dinh dng d b hoi t thm, n n x ha, so,
o ln cu trc gan lm tng p ca.
3. Xut huyt
V bt c nguyn nhn g s lm tng thiu mu t bo gan, gy hoi t v suy gan.
4. Cc thng ng tnh mch trong gan, phi:
Lm gim lng mu n gan gy thiu mu, hoi t v suy gan.
5 Cc nt tn to t mch mu
L nguyn nhn chn p ln cc mch mu lm thiu mu gan
VI. LM SNG
1. Giai on cn b
C rt t du chng c nng v thc th, pht hin nh khm iu tra sc khe, theo di
nhng ngi c nguy c cao.
Triu chng: n km ngon, kh tiu, nng tc vng thng v, gim tnh dc, ri lon kinh
nguyt. Khm c gan ln b sc mt nhn chc khng au, lch ln, c gin mch g m,
nt gin mch hnh sao, hng ban lng bn tay. Chn on bng cc xt nghim nh gi
chc nng gan v sinh thit gan khi cn thit.
1. Giai on mt b
y l giai on c nhiu bin chng. Bnh c biu hin qua 2 hi chng:
2.1.Hi chng suy gan
Chn n, n chm tiu, y bng, ri lon kinh nguyt, lit dng, v ln, teo tinh han, chy
mu chn rng, chy mu cam, chy mu di da, lng tc d rng, mng tay khum mt knh
ng h, ngn tay di trng (x gan mt), mt ngc v chi trn gy, 2 chn ph mm, da vng
nh, thiu mu, nt gin mch hnh sao ngc v lng, hng ban lng bn tay, mi , li
bng , vim thn kinh ngoi bin, gan nh li.
2.2.Hi chng tng p tnh mch ca
Khi u l du trng hi hoc i cu phn st hoc i cu ra mu, nn mu. Khm c:
-Tun hon bng h kiu ca ch trn da bng vng thng v v 2 bn mn sn
hoc quanh rn (hnh u sa). Trong trng hp bng ln chn p tnh mch ch di s c
thm tun hon bng h kiu ch- ch.
- Lch ln
- C trng th t do.
- Tr: thng l tr ni, c th chy mu.
VII. CN LM SNG
1.Hi chng tng p tnh mch ca
1.1. o p lc tnh mch ca: Bnh thng: 10-15cm nc, tng khi >25cm nc.
1.2. ng knh tnh mch ca, tnh mch lch: Bnh thng 8-11mm, khi c tng p ca th
ng knh ln hn 13mm, ng knh tnh mch lch > 11mm (o bng siu m)
1.3. Ni soi bng: Gin tnh mch phc mc, mc treo, tnh mch rn.
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1.4. Soi thc qun d dy (H3): C trng tnh mch thc qun, d dy.
1.5. Soi trc trng: C tr.
2. Hi chng suy gan
2.1. Protid mu gim, nht l albumin, globulin tng, A/G o ngc
2.2 T prothrombin gim, y l 1 yu t tin lng nng.
2.3. Cholesterol mu gim, nht l loi ester ha.
2.4. Cc xt nghim chc nng gan c hiu: Nghim php galactose niu (+), thanh thi
caffein (+).
2.5. Ri lon in gii: Natri mu tng hoc gim, kaki mu gim, natri niu gim.
2.6. NH
3
mu tng
3. Hi chng vim
3.1. Fibrinogen mu tng > 4g/l.
3.2. LDH >250v, CRP >20mg/l, VS tng: khi c x tin trin
4. Hi chng hy t bo gan
Biu hin khi c vim trong x gan tin trin vi tng ALAT, ASAT.
5. Hi chng thiu mu: Thiu mu ng sc, hoc gim 3 dng t bo mu khi c cng
lch.
6. Cc xt ngim ghi hnh
-Siu m gan: gan nh, b khng u hnh rng ca, dng nt, tnh mch ca tnh mch lch
gin, ti lp tnh mch rn, thuyn tc tnh ca.
-Chp ct lp t trng: cho hnh nh tng t siu m.
7. Sinh thit gan
Thc hin khi cn thit, khi cc xt nghim sinh ho, huyt hc, siu m cha ph hp
hay cha gi chn on.
VIII. CHN ON XC NH
Da vo cc yu t sau:
-Tin s c bnh gan mn tnh
-Lm sng c 2 hi chng tng p ca v hi chng suy gan.
-Cn lm sng: Cc xt nghim mu, siu m, hoc sinh thit gan.
IX. CHN ON PHN BIT
1. Suy dng
C tin s, bnh s b mt protein nh ct on rut, suy kit ko di, thiu n trm trng.
Xt ngim c gim protein mu nhng chc nng gan bnh thng, siu m, sinh thit gan
bnh thng.
2. Thn h: Ph tin trin nhanh, c protein niu> 70mg/kg hay > 3, 5gr/24 gi, in di
protein mu c tng globulin l ch yu, siu m v sinh thit gan bnh thng
3. Lao mng bng: Da vo tin s, bnh s c du nhim lao, bng t do hoc khu tr, au,
bng dch tit ch yu limpho, tm BK trong dch bng.
162
4. U c tnh bng: Bng dch tit, c t bo l, chn on bng chp ct lp t trng, sinh
thit khi u hay chc ht kim nh.
5. Ung th gan: C th trn gan bnh thng hoc gan x. Gan ln nhanh, cng, bng c th
l dch mu, Alpha - FP (+), DCP(+), siu m, CT, sinh thit u.
X.TIN TRIN, BIN CHNG, BNH PHI HP
1 Tin trin
m , ko di qua nhiu nm, t giai on cn b vi rt t triu chng n giai on mt b
vi triu chng lm sng r, cn lm sng in hnh v c bit c nhiu bin chng.
2 Bin chng
Nhiu v phc tp vo giai on cui
2.1. Nhim trng: Rut, bng, tnh mch ca, phi, thn.
2.1.1. Nhim trng bng
Khi pht c th gp sau vim rut, vi biu hin bng tng nhanh hn, au bng t nhin,
st. Khm bng au khi n, chc d mng bng dch bng c tng t bo > 500/mm3

v trn
50% l bch cu trung tnh, phn ng rivalta c th (+), cy c th c vi trng gy bnh.

2.1.2. Huyt khi tnh mch ca do nhim trng
Lm sng c bng tng nhanh, au bng t nhin, st, i tin ra mu. Chn on bng siu
m cho hnh nh huyt khi trong tnh mch ca.
2.2. Bnh d dy tng p ca
Nim mc d dy rc, nhng thc s khng phi vim. Dn dn, nim mc c hnh khm
v c th km theo trng tnh mch d dy. Tn thng ny hay xy ra bnh nhn c
iu tr tht tnh mch trng thc qun.
2.3. Chy mu
Da, nim mc, ni tng (do suy gan), chy mu t tnh mch trng thc qun, tr (do tng p
ca)
2.3.1. Chy mu t cc trng tnh mch thc qun, d dy, trc trng.
Do p lc tnh mch ca qu cao. Bnh khi pht t ngt vi nn mu nhng khng c triu
chng bo trc. Tnh trng chy mu c khi rt nng vi biu hin chong do mt mu, e
do tnh mng. Ni soi tiu ho cao c trng tnh mch thc qun 3 chy mu. Ngoi ra
c th chy mu trng tnh mch vng phnh v d dy, t trng, rut non (him) v chy
t cc bi tr .
2.3.2. Chy mu do gim yu t ng mu: Chy mu no, chy mu di da, nim mc.
2.4. Hn m gan hay cn c gi l hi chng no gan, l bin chng nng ca x gan
thng xy ra khi c cc yu t thun li (yu t ngoi sinh) lm suy gan nng thm hay do
tnh trng gan suy nng vo giai on cui (ni sinh).
2.4.1. Cc yu t thun li bao gm:
- n qu nhiu protid hoc chuyn nhiu m
- Xut huyt tiu ha nng
- Dng li tiu khng ng v khng theo di lm mt nc v ri lon in gii.
163
- Dng cc thuc c cho gan nh tetracycline, thuc khng lao, thuc an thn gy ng, thuc
h huyt p.
- Sau phu thut trn 1 gan x
- Nhim trng bng, rut, phi, thn, ng mt ti mt...
- Chc tho bng vi mt lng qu ln.
2.4.2. C ch sinh bnh
Yu t quan trng nht trong bnh sinh ca hn m gan l t bo gan b suy nng v hay l
do s ni mu ca h ca v ch bn trong hay ngoi gan, hu qu l nhiu cht c c hp
thu t rut khng c gan kh c c a vo tun hon chung dn n nhng bt thng
v thn kinh trung ng.
- Amoniac v glutamin: T ng tiu ha, amoniac khng c chuyn ha qua hng ro
gan c a n no gy c cho no. ngi hn m gan, trong mt s trng hp thy c
tng amoniac trong mu ng mch v cht chuyn ho ca n l glutamin cng tng trong
dch no tu v trong m no. Ngoi ra, khi kali mu gim cng kch thch sn xut amoniac
t thn.
- Cht dn truyn thn kinh gi phenylethanolamin v octopamin: ngi x gan, cc acide
bo chui ngn ( a.amin nhn thm) nh tyrosin, phenylalanin, tryptophan tng trong khi cc
a.amin chui nhnh nh valin, leucin, isoleucin th gim. Khi c mt cn bng ny, cc a.amin
nhn thm s vo c hng ro mu no lm tng phenylalanin trong no do s c ch
sn xut dopamin v cathecholamin, to thnh cc cht dn truyn thn kinh gi nh
phenylethanolamin v octopamin.
- Serotonin 5 HT (5- hydroxytryptamin): Khi tryptophan tng trong no th tin cht ca n
l serotonin cng tng gy nn cc biu hin sm ca hn m gan nh ri lon thc, ri lon
chu k thc- ng (gy triu chng ng g).
- GABA v Benzodiazepines: y l cc cht c tc dng c ch dn truyn thn kinh.GABA
ch yu c trong no (c tng hp t glutamate) thy tng ngi x gan. Khi gan suy,
di kch thch ca amoniac, mangan v ca c benzodiazepines ngoi bin, t bo thn kinh
s chuyn cholesterole thnh allopregnanolole thot khi t bo sao v gn vo cc th th
tng ng (GABA-Benzodiazepine receptor), lm tng c ch dn truyn thn kinh gy triu
chng l m.
- Thiu oxy no khi dng cc thuc gy c ch thn kinh trung ng nh barbiturate,
diazepam cng d gy nn hn m gan do tng tnh nhy cm ca no vi amoniac. Trng
hp gim CO
2
mu cng vy.
- Mangan trong mu v trong no tng gy lng ng v tn thng t bo thn kinh cng
gp phn gy hn m.
2.4.3. Triu chng
- Lm sng: Hn m gan din tin qua 4 giai on.
+ Giai an 1: Biu hin thn kinh cn nh v kn o nh mt nh hng khng gian thi
gian, l m, ng g, ci ni v c cu gt, ni nht gng, ch vit nguch ngac, tt ni kt
s b ri lon, hi th c mi gan, c th c du rung v cnh.
+ Giai an 2: Triu chng cng r thm vi du rung v cnh, tng phn x gn xng, tng
trng lc c, c du Babinski hoc tng ng.
+ Giai an 3: Hn m tht s vi mt nhn thc, mt cm gic cm gic v vn ng
+ Giai an 4: Hn m su c th km ri lan sinh thc
164
- Cn lm sng:
Ngoi cc xt nghim v bnh gan cn c
- Tng ammoniac mu nhng khng t l han tan vi nng. Bnh thng t 60-80 g.
- Ri lan v in gii v kim toan: Natri, kali mu thng gim, d tr kim tng, pCO2
gim.
- Dch no ty: tng glutamin.
- Cc xt nghim mu v sinh ho cho thy c suy chc nng gan, tng p tnh mch ca.
- in no : in th cao, i xng, sng chm delta.
- CT scan v MRI: C th c teo no vng v hay ph no.
2.4.4. Chn on:
Ch yu da vo 4 yu t chnh sau y
- Bnh nhn c tin s mt bnh gan cp hoc mn, hoc sau phu thut ni ca ch.
- C ri lan nhn thc: l ln ri hn m.
- C cc triu chng thn kinh nh tng trng lc c, tng phn x, rung v cnh, Babinski,
i khi c du ng kinh.
- in no : in th cao, i xng, sng chm..
- Cc triu chng khc: Hi th c mi gan, glutamin dch no ty tng cao.
2.5 Hi chng gan thn: L bin chng nng, t vong cao. y l suy thn cp rt nng, pht
khi trn 1 gan suy, hoc bng qu nng, hoc do dng li tiu khng ng hoc thuc c
cho thn. Lm sng biu hin tnh trng thiu niu hoc v niu, c protein niu, hng cu
niu, tng creatinin mu, natri mu gim < 130 mEq/L, thm thu nc tiu cao hn huyt
tng.
2.6. Ung th gan: Thng gp sau x gan ngoi tr x gan do tim v x gan do mt.
2.7. Ri lon ng mu: C ri lon dung np glucose (80% trng hp x gan) v i tho
ng tht s (10%) hoc ng mu gim trong suy gan nng.
2.8. Gim oxy mu v hi chng gan phi: Do c cc ni ng tnh mch trong phi.
3. Bnh phi hp:
3.1. Lot d dy t trng: Hay gp lot hnh t trng hn lot d dy, t l gp khong
11% bnh nhn x gan. c im lot thng rt t triu chng, kh lin so, d ti pht nn
c nhiu bin chng nh thng, chy mu.
3.2. Si ti mt: T l gp khong 32% n, a s si mu, t triu chng, d nhim trng.
3.3. Vim tu mn: Thng kt hp vi x gan nguyn nhn do ru.
XI. IU TR
1. iu tr nguyn nhn
Mt khi x gan xy ra ri th vn iu tr nguyn nhn tht qa kh. Loi b
nguyn nhn tc hi nh ru, c cht th vi ch n thch hp, ngh ngi, cung cp
dinh dng c th hi phc nu qu trnh x ang giai on sm. Vi nguyn nhn do vim
gan virus, iu tr nhm ci thin tn thng m hc ca gan giai on sm s lm chm
165
phn no tin trin n x gan mt b cng nh hn ch phn no bin chng ung th gan do
nguyn nhn ny.
2. iu tr triu chng
2.1. Ch n ung ngh ngi
Ch hn ch mui: n nht 0, 5g mui/ng, t m < 50g/ng, protide khong < 2g/kg/ng.
Nng lng khong 1500 - 2000 calo/ng, nc ung < 1l/ng da vo bilan nc.(c th 100g
tht/ng hoc thay bng 2 qu trng, khng qu 0, 25l sa/ng, bnh m khng mui vi b v
mayonaise, tri cy, salad, nc st c chua, khng dng sa chocolate, ko bc h) nn dng
m thc vt, hn ch hot ng th lc.
2.2. iu tr c trng
Kh khn hn so vi c trng do cc nguyn nhn khc. n nht v ngh ngi nu khng
gim bng v natri niu < 25mmol/ng th cn x dng li tiu.
- Li tiu: Thng bt u vi khng Aldosterone nh spironolactone 100-200mg/ng hoc
Amiloride 10mg- 15mg/ng hoc Triamterene. Sau 4 ngy nu p ng km th thm
Furosemide 80mg/ng hoc thiazide 50mg- 100mg/ng, nu khng p ng cn xem li ch
n, huyt p, p lc keo. Theo di: cn nng, lng nc tiu hng ngy, xt nghim in gii
mu 2 ln /1tun khi cn ang nm vin. Gim cn ti a khng qu 2 kg/ng, tiu ti a 2
lt/ng khi c ph, khi ht ph th gim liu li tiu iu tr duy tr.
- Chc tho bng: Ch nh khi c trng ln gy kh th. Chc tho tun 1 ln, mi ln ly 1
n 5 lt v phi truyn tr li mi 6g albumin lt /lt dch (c th dng Dextran hoc
polygeline).
- Dn lu kn: Dn lu mng bng vo tnh mch c qua 1 ng teflon. Dng khi bng tr vi
iu tr.
- Shunt phc mc tnh mch (peritoneovenous shunts) hoc t TIPS : Khi bng tr vi iu
tr.
3. iu tr tng p tnh mch ca
- Ni thng ca ch, t TIPS: lm gim bng nhanh nhng c nguy c gy bnh no gan, v
hiu qu khng ci thin my.
- Thuc chn giao cm : (Propanolol, Nadolol) c tc dng lm gim p lc ca, gim cc
trng tnh mch v gim cung lng tim. Thuc c dng vi liu sao cho mch cn so
vi mch ban u khi ngh ngi v khng di 55 ln/ pht.
Tuy nhin, tng p ca trong x gan l khng hi phc cho nn phng php iu tr c
chn la l ghp gan.
4. iu tr suy gan
Khng c iu tr c hiu.
- Cc thuc chuyn ha m: Cholin, Methionin, Inositol khng lm hi phc c chc nng
gan
- Cn b sung cc vitamin B, C, A, D, K, acide folic, folate v km
5. Thuc chng x
- Corticoides: Ch dng trong vim gan mn t min.
- Cc cht c ch prolyl hydroxylase nh HOE 077 cn trong th nghim
166
- Colchicin: lm ngn qu trnh x gan ru, dng 1mg/ng, 5 ngy 1 tun trong nhiu thng
cng cha thuyt phc mnh m
5. iu tr bin chng thng gp
5.1. iu tr chy mu tnh mch trng thc qun
y l mt iu tr cp cu nhm duy tr th tch tun hon, tuy nhin khi b dch qu
nhiu c th lm tng p lc ca hn, hu qu l chy mu nhiu hn v v vy nn cn
thn.
- Truyn mu ti hoc huyt tng ti. Khong 50% trng hp c th t ngng nhng
nguy c chy mu li cn cao.
- Thuc co mch: Truyn Vasopressin (Pitressin) 20 v/ 100ml dextrose 5% IV trong 10ph p
lc ca s gim sau 45- 60 pht, hoc 0, 4v/ml trong 2 gi gy co mch tng lm gim mu
trong h ca, hiu qu 80%. Thuc c tc dng ph nh thiu mu c tim v ng tiu ha, suy
thn cp, h natri mu. lm gim bt bin chng ny c th dng phi hp nitroglycerin iv
40mg/ph IV. Terlipressin c tc dng di hn Vasopressin, truyn 1mg/mi 4 gi trong 24
gi. Hin nay thuc c dng nhiu v t tc dng ph hn vasopressin l octreotide. Bm
tnh mch 25 g sau truyn 25-50 g/h trong 3 ngy. Tc dng ttt nhng gi thnh cn rt
t.
- Cm mu bng sonde Blakemore hoc sonde Minnesota. Nguy c sc vo phi v v thc
qun do lot, thng.
- Chch x: Chch tnh mch thc qun bng polidocanol trong khi ang chy mu lm x
ho v cm chy mu, sau tip tc lp li duy tr cho n khi xp ht cc tnh mch trng.
Bin chng c th gp l lot nim mc, hp thc qun, thng.
- Tht tnh mch trng qua ni soi : Tc dng iu tr ti ch tt hn chch x tnh mch. C
th lm khi tnh mch ang chy mu.
- t TIPS cp cu: L bin php sau cng v c nhiu nguy c gy hn m gan.
- Tht tnh mch trng d dy vng phnh v bng Stape gun qua m d dy mt trc. Thi
gian lm th thut ngn t bin chng, t vong thp
- Thuc khng tit d dy nh ranitidine, omeprazole dng d phng lot d dy cp do
stress v bo v nim mc thc qun do tro ngc d dy.
- Khng sinh d phng nguy c cao nhim khun d dy rut v bng: Dng Norfloxacin hay
cc quinolol khc trong giai on cp (7 ngy).
- Tho phn bng tht tho hay dng lactulose ung.
- iu tr d phng chy mu ti pht: Phi hp Nadolol vi chch x hoc tht tnh mch
trng thc qun nh k. Tuy nhin cng cha thy tng thi gian sng cho ngi x gan.
5.2. iu tr bnh d dy do tng p ca
Xc nh bng ni soi, iu tr bng thuc chn giao cm.
5.3. iu tr nhim khun bng v vim phc mc nhim khun tin pht (SBP)
Dng CefotaximeIV 6g /24h trong 5 -7 ngy. Sau 48 gi thy gim bch cu trong dch
bng, nu gim chm cn ko di thi gian dng thuc hay xt thay i thuc. D phng ti
pht bng Norfloxacin 400mg/ng, hoc Bactrim 980 mg/ng, ti thiu l 6 thng,
5.4. iu tr hi chng gan thn
167
Hn ch dch, mui, protein, kali, khng dng thuc c cho gan, thn, iu tr nhim khun
nu c, khng dng Manitol. Li tiu liu cao v thn nhn to cng t ci thin. Cc thuc co
mch nh metaraminol, angiotensin II, ornipressin t c hiu qu trn thn. Cht c ch nitric
oxide cn trong th nghim. TIPS thc hin cho Child C t hiu qu m nn t vn ghp
gan.
5.5. iu tr hn m gan.
Cc bin php bao gm: iu tr cc yu t khi pht hn m gan, gim s sn xut v hp
th nit v cc cht c khc trong rut, thuc lm thay i cn bng cc cht dn truyn thn
kinh mt cch trc tip hoc gin tip
- Ch n: Gim protein cn 20gram/ngy, 2000 calo/ngy, nn dng protein thc vt.
- Tht tho phn loi b cc Nit v Phosphat.
- Lactulose 10-30ml x 3ln /ngy hoc lactilol 0, 3-0, 5g /kg /ng.
- Neomycin 1g x 4ln /ngy x 1 tun.hoc Metronidazol 200mg x4 ln/ng x 5-7ngy.
- Duy tr nng lng v dch da vo cn bng nc v in gii.
- Ngng li tiu.
- Levodopa: thc t t dng trong lm sng.
- Bromocriptine
-Flumazenil: Tc dng i khng receptor benzodiazepine, thuc ci thin tnh trng hn m
trong khong 70% trng hp.
- Thuc tng thi amoniac qua thn: Benzoate de Sodium
- Cc acide amin nhnh: Thuc cn t.
- Bt cc nhnh ni ca- ch.
- Ghp gan.
XII. PHNG BNH
Tuyn truyn v vic x dng ru an ton trongcng ng, trnh tnh trng nghin ru,
tim phng vacxin vim gan B bt buc cho ngi c nguy c cao v vn ng ton dn tim
phng, x dng hp l mu v an ton truyn mu, thn trng khi dng thuc c cho gan,
iu tr tt cc bnh l gan mn tnh, pht hin v iu tr cc bin chng ca x gan c th
ko di thm thi gian sng cng nh tng cht lng sng cho h v gim bt tn km cho
ngn sch iu tr ca gia nh v x hi.
XIII. TIN LNG
Tin lng lu di l xu, 5% sng sau 5 nm, ph thuc bin chng. Tin lng xu khi c
vng da ko di, xut huyt, hn m gan, teo gan vng cp, nhim khun, Child C ca phn
loi Child- Pugh.
Bng 1: Thang im nh gi giai on x gan v tin lng theo ch s Child - Pugh
1 im 2 im 3im
Bnh no gan khng l ln hn m
Bng khng kn o va phi
Bilirubin < 35 mol/l 35-50 mol/l > 50 mol/l
168
Albumin > 35 g/l 28-35 g/l < 28 g/l
T Prothrombin > 50 % 40-50 % < 40 %
Child A: im 5 hay 6. Child B: im t 7-9. Child C im t 10-15.
- Ngoi ra mt s yu t khc cng gp phn tin lng bnh nh tiu cu, albumin mu,
bilirubin mu.
nh gi nng trong 24 gi u theo Cox: 4,6 x (thi gian prothrombin bnh- chng)+
bili (mg/dL)
Gan BT Gan x
M si bao quanh nt tn to
H1. M hc gan x

H2. Vng Keyser Fleischer mt
169


H3. Trng tnh mch thc qun, d dy.

170
UNG TH GAN NGUYN PHT
Mc tiu
1. K c cc yu t bnh nguyn v yu t nguy c ca ung th gan nguyn pht.
2. Trnh by c cc triu chng lm sng v cn lm sng ca ung th gan nguyn
pht.
3. K c cc phng php iu tr ngoi khoa v khng phi ngoi khoa ca ung th
gan nguyn pht
4. Trnh by c ch nh, c ch v nguyn tc iu tr ung th gan nguyn pht bng
cch tim cn tuyt i v gy tc mch bng ha cht
Ni dung
I. I CNG
ng hng th 4 trong cc loi ung th trn th gii.
Trung quc, ng nam : ng hng u nam gii.
Min Bc VN: ng th 3 trong cc loi ung th.
TP H Ch Minh: ng th 1 nam v th 5 n.
ng nam : c tn sut cao, lin quan nhim virus vim gan B.
Tin lng xu, t l sng st sau 5 nm di 3%.
Cc th t chc hc thng gp l:
Ung th biu m t bo gan (Hepato-cellular Carcinoma)
Ung th biu m ng mt (Cholangio-cellular Carcinoma).
Cc loi khc: Ung th nguyn bo gan, Angiosarcome
II. BNH NGUYN V YU T NGUY C
1. Virus vim gan B
Tn sut UTG ngi HBsAg (+) > 200 ln so vi ngi HBsAg(-).
Tn sut HBsAg UTG > 6-20 ln dn s ni chung (Chu : 60-80%).
Protein X trn genome virus B c l c vai tr trong t bin gy ung th.
Vng dch t nhim virus vim gan B cao th cng c tn sut ung th gan cao.
Gy ung th gan qua 2 c ch: trc tip v gin tip qua trung gian x gan
2. Virus vim gan C
Cc nghin cu v sinh hc phn t, s dng RT-PCR, cho php pht hin ARN
ca virus C trong 50-70% huyt thanh v trong 55-100% t chc gan nhng bnh nhn
UTBMTBG v khng c HBsAg.
90% ung th gan lin quan vi virus C xut hin trn mt nn gan x
Nhng bnh nhn ung th gan c Anti-HCV dng tnh (c hoc khng c HBsAg) thng
c cc thng tn gan nng hn (70% x gan, trong 60-70% thuc Child B hoc C) so vi
nhng bnh nhn ch c HBsAg dng tnh (50% x gan, trong 65% thuc Child A) v
gan thng c nhiu khi u hn
171
3. X gan: do bt k nguyn nhn no.
4. Aflatoxin B1: c t nm mc (Aspergillus), thng gp trong u phng mc; c chng
minh l cht gy ung th gan chut, gia cm
Vai tr sinh ung th c l qua trung gian cht chuyn ha l Epoxide gn vo cc acid nucleic
v thay i s sao m ADN.
Tng tc vi protein 53 t bin.
5. Cc yu t khc
5.1. Ru: c l thc y qu trnh sinh ung th
5.2. Ni tit t nam Androgen, thuc nga thai ung.
5.3. Ha cht (Thorotrast),
5.4. K sinh trng (Schistosoma japonicum, Sch. mansoni, clonorchis sinensis)
5.5. Thiu alpha 1-antitrypsin, thng gp cc kiu hnh ZZ v MZ.
5.6. Nhim huyt thit t (Hmechromatose), H/c Budd-Chiari.
III.TRIU CHNG
1. Triu chng c nng v ton thn
1.1. au bng: thng gp, cm gic nng tc h sn phi, lan sau lng, him khi au d
di.
1.2. Ri lon tiu ha: chn n, bun nn, nn, i chy.
1.3. St: lin tc, dao ng.
1.4. Gy st r giai on mun.
2. Triu chng thc th
2.1. Gan ln: nhn thy hoc s thy di b sn phi, cng, b mt khng u, au nhiu
hoc t, c khi c nh khng di ng theo nhp th. C khi gan ln vt qu ng gia.
2.2. Vng da: ch yu do chn p ng mt trong gan.
2.3. Bng: t hoc nhiu, c th gp bng mu, ti to nhanh sau chc tho.
2.4. Nghe: ting thi trn vng gan
3. Sinh hc
3.1. Cng thc mu: thiu mu, c bit c khi c a hng cu.
3.2. Tc lng mu tng tng
3.3. Chc nng gan: ch ri lon trong ung th gan trn nn x gan hoc khi khi U chim
trn 75% th tch gan.
Enzyme gan: Phosphatase kim, gamma GT, 5 Nuclotidase, Alpha-2 Globulin, SGOT
thng cao hn SGPT.
3.4. Cc cht ch im ung th
3.4.1. Alpha Foeto Protein (AFP)
L mt Glycoprotein do gan phi sn xut, gim 3 tun sau sinh, nng ngi
trng thnh khong 4-10 ng/ml.
172
khi AFP > 1000ng/ml: hu nh chc chn ung th gan nguyn pht.
Tng nh trong u qui bung trng, tinh hon, mt s ung th tiu ha, vim gan hoi t
AFP c i lc Lectin (AFP - L3) mi c tm ra, c hiu hn AFP nhng k thut xt
nghim phc tp.
Nu khng c iu kin nh lng, c th nh tnh AFP bng phng php min dch
khuch tn (Ouchterlony).
3.4.2. DCP (Descarboxy Prothrombin hay PIVKA-II) dng tnh 70% bnh nhn ung th
gan nguyn pht v khong 50% nhng bnh nhn ung th gan c AFP bnh thng.
3.4.3. Alpha L-Fucosidase: enzyme ny tng cao trong ung th gan nguyn pht, vi c
hiu 90% v nhy khong 75%, cng tng trong u gan lnh tnh.
4. Thm d hnh nh
4.1.Siu m
Mt hoc nhiu khi (nodule) trong gan.
Echo giu, ngho, hn hp, dng khm
X y mch mu, ng mt (bending sign), vin gim m chung quanh
Tng sinh mch mu trong u, thng c huyt khi trong tnh mch ca.
4.2. Chp ct lp t trng: mt /nhiu khi gim mt (hypodense), bt thuc khng u,
gip hng dn chc ht, sinh thit.
4.3. Chp ng mch
Xt nghim c bn tin phu, gip xc nh v tr, ti mu, kh nng ct b u qua
trung gian mt Catheter lun vo vo ng mch thn tng
Hnh nh bi tng sinh mch mu (th ng mch)
Ti mu t chc ln xn, h mch mu (th nhu m)
lung mu tnh mch v sm (th tnh mch)
5. Gii phu bnh
5.1. Sinh thit: sinh thit di s hng dn ca siu m, CT scan hoc soi bng
Sinh thit: chnh xc nhng d chy mu.
5.2. Chc ht kim nh: t bin chng, nhng chnh xc v nhy thp hn sinh thit.
IV. CC HI CHNG CN UNG TH
1. H ng mu: do t bo u tit yu t c hot tnh tng t Insulin.
2. Tng Calci mu: do u tit yu t ging hormon cn gip.
3. a hng cu: do u tit yu t tng t Erythropoietine
4. Yu t V bnh thng nghch l
V. TIN TRIN & BIN CHNG
1. Tin trin: thng l nng, tin lng xu, t vong 6-12 thng
2. Cc bin chng:
2.1.Bng ung th:
173
2.2.Vng da: chn p ng mt trong gan
2.3.Xut huyt
- Xut huyt tiu ha cao: huyt khi ca
- Phc mc: v nhn ung th
2.4.Chn p tnh mch trn gan hoc tnh mch ch di
2.5.Di cn: trong gan, phi, mng phi, xng, hch, no.
VI. CHN ON PHN BIT
1. Gan au km st
1.1. p xe gan
1.2. Sn l gan: yu t dch t + tng bch cu i toan + huyt thanh chn on
2. Vng da
2.1. Do u chn p: Gan v ti mt ln, phn bit nh siu m.
2.2. Vim gan: giai on tin vng da, SGPT tng rt cao, cc ch im huyt thanh ca virus
vim gan v thm d hnh nh.
3. U h sn phi
3.1. Vim gan mn
3.2. Kn gan, Adenome, lymphosarcome,
3.3. K gan th pht: Tm ung th nguyn pht, Alpha FP bnh thng, t chc hc
VII. IU TR
1. iu tr ngoi khoa
1.1. Phu thut ct b khi u
Phu thut ct gan vn l phng php iu tr trit nht i vi ung th gan nguyn pht.
* Ch nh
Thng ch nh phu thut c p dng cho cc bnh nhn ung th gan giai on I, II v
IIIA.
- Mt s tiu chun thng c xt trong ch nh ct gan
+ Kch thc di 5 cm
+ Mt thu
+ Khi u c v
* Chng ch nh phu thut
-Chc nng gan km do x gan
-Khi u xm ln c hai thy gan
-Khi u xm ln hoc lm tc ng gan chung
-Khi u xm ln tnh mch ch di
-Huyt khi tnh mch ca
-Xm ln hch lympho
174
-Di cn xa (thng gp l phi v xng)
Ngay sau phu thut, s ti pht khi u l c th xy ra, c khi cn ct b ln 2 hoc thm ch
ln 3. Khong cch an ton cn c ti thiu l 1 cm cch t chc u.
Vit Nam, GS Tn tht Tng thc hin t nhng nm 70, phu thut nhng u nh n
c, sau nng min dch bng LH1 cho kt qu tt. K thut ny thng p dng cho u
n c c kch thc di 5cm, tui di 70. Chc nng gan cn li l yu t chnh quyt
nh tin lng, thng ct theo thy hoc phn thy.
Nht, t vong sau m l 3 - 11%, sng trn 3 nm l 46%. Kt qu tt nht khi u
di 2cm, t l sng trn 5 nm l 60, 5%.
Php, Bismuth thc hin 35 trng hp t 1970-1984 t l sng trn 2 nm l 32%.
Thi gian sng cn ty thuc vo ch s Child-Pudg trn 3 nm l 51% cho Child A, 12% cho
B v C.
Bin chng: Cc bin chng thng gp sau m ct gan l chy mu, nhim khun, bng v
suy gan. Him hn l d ng mt.
1.2. Ghp gan
Li ch chnh ca phng php ny l loi b tt c phn ung th v cc tn thng trc n,
loi b nguy c do tng p lc ca, vn cn nguy c ti pht vim gan trn gan ghp. Kt qu
Hannover cho thy thi gian sng trn 3 nm l 15%, Pittsburgh vi u nh n c th
sng trn 5 nm l 45%.
Cc trng hp ch c mt u di 5 cm hoc c di 3 u nh hn 3 cm th tin lng sau
ghp rt tt, gn ging nh cc bnh nhn ghp tng khc do cc l do khng phi ung th.
2. iu tr khng ngoi khoa
2.1.Tim cn tuyt i qua da trc tip vo khi u di s hng dn ca siu m
Nm 1982, ln u tin Nht bn, cc tc gi Ebara M v Okuda K... nghin cu phng
php iu tr UTBMTBG bng phng php tim Ethanol vo khi u gan v thu c kt qu
kh quan. Sau c nhiu nghin cu Php, , Trung Quc...vi cc kt qu tt.
* C ch: Ethanol gy ra huyt khi ng mch trong u, t gy ra mt s hoi t ng
khi u v tnh trng thiu mu cc b khi u.
* Ch nh
- Cc bnh nhn c chn on xc nh l UTBMTBG
- S lng khi u khng qu 3 khi, tt c u l u c v bc
- Kch thc u thng nh di 5 cm, thc t kch thc tu thuc s lng khi u (1 u 12
cm, 2 u 6 cm, 3 u 4 cm).
- Phn Child-Pugh A v B; T Prothrombin trn 60%.
* Phng php
Phng tin, dng c:
- K thut tim ethanol c thc hin di s hng dn ca siu m hoc CT Scan.
- Kim tim Chiba hoc Terumo: 0, 7-0, 9 X 7-15 cm.
- Ethanol tuyt i: 99, 8 %, ng ng 5 cc.
- Lidocain 1%, thuc gim au, dng c st trng.
175
* K thut
- Xc nh khi u gan cn chc di siu m hoc CT Scan
- Xc nh v tr chc kim, gy t
- Chc kim qua da vo trung tm khi u di s hng dn ca siu m hoc CT scan
- Tim chm Ethanol vo khi u, va tim va quan st s khuch tn Ethanol ti ch
- Rt kim ra st v gan, thay ng tim c lidocain gy t v gan
- Rt kim, bng ti ch.
- Liu lng: 1-2 v tr tim/mt ln x 2 ln mi tun; Mi ln tim 2-12 cc.
Tng liu Ethanol phi tim c tnh theo cng thc Sugiura N (Nht Bn) 1983
V = 4/3 (r + 0.5)
3
.
Trong : V l tng liu Ethanol
R: bn knh khi u
Kt qu s b ca mt s nghin cu: theo nhiu nghin cu ca nhiu tc gi ngoi nc
(Livraghi, Ebara...) v trong nc (Mai Hng Bng) th kt qu rt kh quan, t l sng thm
sau 3 nm l 71% (Child A), v 41% (Child B), mt s bnh nhn sng trn 7 nm. Phn ln
bnh nhn ci thin tt v lm sng, AFP gim r, t l khi u hoi t hon ton trn siu m
l hn 60%. K thut ny cn c th gip iu tr cm mu trong trng hp v khi ung th
gan.
2.2. Phng php gy tc mch
Phng php gy tc mch c s dng ln u tin vo nm 1975 ti M. Nakamura
iu tr gy tc mch cho 200 bnh nhn ung th gan nguyn pht v cho t l sng thm 2
thng, 12 thng v 24 thng tng ng l 71%, 48, 1% v 20, 8%. Nhm gy tc mch c
phi hp vi lipiodol c thi gian sng thm di hn c ngha
* C ch
Bnh thng, gan nhn 2 ngun mu cung cp l ng mch gan v tnh mch ca, trong
cc khi u nhn mu ch yu t ng mch gan, do vic gy tc mch bng cch tim vo
nhnh ng mch chn lc nui dng khi u s gp phn gy hoi t khi u nhng khng
gin on s ti mu i vi gan lnh. Vic phi hp tc dng gy thiu mu hoi t vi tc
dng ca cc ha cht chng ung th s lm tng tc dng iu tr.
* Cc k thut gy tc mch
+ Bt tt ng mch gan chn lc bng mnh bt b gelatin, a vo nhnh ng mch nui
dng u thng qua ng mch i v ng mch thn tng.
+ Bt tc ng mch gan siu chn lc
+ Bt tc ng mch gan kt hp tim ha cht chng u (TACE), cc ho cht thng dng l
doxorubicine, cisplatin...
+ Bt tc ng mch gan bng ha du (TOCE)
Tc dng ph sau bt tt l: st, au bng, nn, bng, hn m gan, tng transaminase.
Ngoi ra c th gy bin chng tt mch ngoi gan hoc gy p xe ha.
Cc k thut ny c th lp li sau mt khong thi gian t 3-6 thng.
176
* Ch nh
+ Cc khi u gan khng phu thut ct b c
+ iu tr cp cu xut huyt phc mc do v khi u gan
+ Gy tc mch trc m lm gim bt kch thc khi u v tng thi gian sng
thm sau m.
+ Trong mi trng hp, tnh mch ca khng c c huyt khi
2.3. Cc iu tr tm thi khc
* Phng x tr liu
Trc y iu tr phng x ngoi cho bnh nhn ung th gan nguyn pht c s dng.
Nhng do kt qu hn ch nn hin nay t c ch nh. Nhng cht phng x c s dng
l I131-antiferritin, khng th n cln gn I 131-anti HCC. Hin nay chu u cng c
nghin cu iu tr tia x chn lc vo khi u vi kt qu ban du c ko di hi gian sng
thm ca bnh nhn.
* Ha tr liu
Cc ha cht thng c s dng l 5 FU, cisplatin, doxorubicin, Mitomycine C...
ng s dng phong ph: ung, tim tnh mch, tim vo dy chng trn, tnh mch ca...
* Min dch tr liu
Cc phng tin min dch thng c s dng l phng tin c ngun gc vi sinh vt
(BCG, corynebacterrium, ..), ha cht (levamizole, Isoprinosin...) hoc nhm Cytokin (IL2,
IFN-beta, IFN-gamma...). Tuy nhin khng c phng php no hon ton c hiu.
Mt s tc gi ngh tim BCG di v gan sau khi ct b khi u vi hy vng tng min
dch khng c hiu. Lai v cng s s dng phi hp Doxorubicine + IFN-alpha 2 cho thy
c gim kch hc u, gim cc bin chng so vi nhm chng.
K thut chuyn gen: a cc gen tr liu c hiu n tiu dit cc t bo c tnh nhng
khng lm thng tn t chc gan lnh. Cc vect virus nh adenovirus thng c s
dng. Cc khng th n dng phn ng vi khi u cng dc s dng phn b cc gen
n cc t bo ung th.
* Tamoxifene
S ph thuc kch dc t v s hin din ca th th ni tit trong ung th gan, gi cho s
pht trin ca u l do kch thch t, tuy nhin nghin cu s b vi Tamoxifen cho kt qu cn
tranh ci.
* Nhit tr liu
Thng dng sng cao tn (radio frequence ablation:RFA) pht ra nhit nng thng qua mt
cy kim cm sn trong lng khi u, nhit cao s gip tiu hu t bo ung th. Kt qu
bc u kh tt.
VIII. KT LUN
Ung th gan nguyn pht kh ph bin nc ta, triu chng a dng v thng khi
pht m thm, chn on phn ln giai on mun nn iu tr kh khn, tin lng thng
rt xu.
D phng ung th gan ch yu da vo tim chng phng virus vim gan B v iu
tr cc bnh vim gan mn do virus.
177
UNG TH D DY
Mc tiu
1. M t c im dch t hc bnh ung th d dy.
2. K cc yu t nguy c v c ch gy bnh ung th d dy.
3. Trnh by cc triu chng lm sng v cn lm sng ca ung th d dy.
4. Chn on ung th d dy theo phn TNM tin lng.
5. iu tr ung th biu m tuyn d dy theo tng giai on

I.I CNG
Ung th d dy ng hng u ca cc ung th ng tiu ha. Mc d t l t vong c
chiu hng gim trong sut 60 nm qua nhng t l bnh so vi cc ung th khc vn cn
cao.
II. DCH T
T l bnh ung th d dy thay i gia cc quc gia khc nhau. Nht Bn, Trung Quc,
Chil v Ireland t l mc v t l t vong c xu hng gim ng k. M, trong nhng
nm gn y, t l bnh ny gim ( nam t 28/100.000 dn xung cn 5/100.000 v n
t 27/100.000 xung cn 2, 3/100.000) t l nam/ n l 1, 7, tui trung bnh l 63. T l t
vong gim t 33/100.000 vo nm 1930 xung cn 3, 7/100.000 vo nm 1990. Nm 1996 c
khong 22.800 trng hp ung th d dy mi mc c chn on v c 14000 ngi cht.
Nht, t l ung th d dy l 69/100.000, tui trung bnh l 55, v tn sut mc bnh c lin
quan n chng tc (ngi M gc da en, da v gc Ty Ban Nha t l ung th gp 2 ln
so vi ngi M da trng). Ngoi ra, mi trng v cc cht c xem l cc carcinogene t
thc n cng c lin quan n bnh. T l ung th d dy cao tng lp dn c c i sng
kinh t x hi thp.
Ring Vit nam, c tnh hng nm c khong 10.000 trng hp ung th d dy mi mc
(s liu thng 5/2006 ngun www.vista.gov.vn).
III. UNG TH BIU M TUYN D DY
Khong 85% ung th d dy thuc loi adenocarcinomas (ung th biu m tuyn d dy),
15% l loi lymphomas-non-Hodgkin v leio-myosarcomas v cc loi u th pht t gp.
Ung th biu m tuyn d dy c chia lm hai loi: loi lan ta v loi rut non.
1. Gii phu bnh vi th
1.1. Loi rut non
L loi ung th d dy hay gp. Cc t bo tng sinh c cu trc ng dng tuyn vi c trng
l lon sn tuyn (dysplasia). Lon sn mc cao gp trong giai on tin trin cng nh
giai on im lng ko di t 5 n 15 nm. Lon sn c th xy ra trn nn vim d dy mn
teo tuyn cng nh vng c d sn rut v c hai phi hp s lm tng nguy c ca
Adenocarcinoma d dy. Ung th thng dng lot, gp hang v v b cong nh d dy v
thng c giai on tin trin tin ung th ko di. Khi u c ranh gii r, di cn theo ng
mu n gan v theo ng bch huyt n hch, t l gp ngi gi nhiu hn.
1.2. Loi lan ta:
178
y l loi ung th t bit ha hn loi rut. T bo tng sinh thm nhim thnh tng mng,
lm dy vch d dy. N pht trin khp ni d dy k c tm v lm mt kh nng gin d
dy (gi l th linitis plastica hoc th t) v c kh nng di cn xa, thm nhim phc mc v
sau phc mc, lan ta vo cc ng bch mch, xng. Loi ny thng gp ngi tr nhiu
hn ngi gi v tin lng xu hn loi rut.
Ngoi ra cn mt dng khc l Adenosquamous tin lng rt xu v tin trin rt nhanh v di
cn sm.
2. V i th
Ty su v rng ca u, chia lm ung th b mt v ung th xm nhp.
2.1. Ung th b mt:
Ch gii hn nim mc v h nim mc, cha n lp c, biu hin 3 dng:
+ Typ I: Li ln hoc dng polype
+ Typ IIa: Np nim mc ch g ln, Typ IIb: Nim mc bng phng, Typ IIc: Nim nc hi
ln xung.
+Typ III. L s o su xung nh hnh hang, c bao quanh bi nhng nt nim mc. C
trng hp phi hp gia cc loi lm cho n c tnh cht ca lot.
2.2. Ung th th xm nhp:
Vt qua lp nim mc n lp c, thanh mc. C 3 loi.
+ Ung th th si: Mt khi trn nn cng v si vo bn trong lng d dy, khng c lot
hay hoi t.
+ Ung th th lot: Cc np nim mc hi t dng li ngoi vng ph n.
+ Ung th th xm nhim: Tn thng lan ta tm nhun ton b d dy (th t)
- Ung th d dy vng tm, phnh v thng lan rng v pha thc qun ch ni d dy
thc qun. Ung th hang v thng lan xung v gy hp mn v v him khi xm ln qua t
trng. Ung th c th lan n mc ni nh, mc ni ln, lch, i trng, ty, hch vng k
cn.
- Ung th d dy thng di cn xa n phi, gan, no, xng, hch thng n (hch
Virchow), hch nch tri (hch Irish), hch quanh rn (hch Sister Mary Joseph), bung trng
(u Krukenberg), phc mc, trc trng
III. CC YU T NGUY C
1. Cc yu t nguy c c khng nh
-Lon sn d dy mc nng: Thng gp cc th vim, lot d dy mn vi lon sn
tuyn. Khong 10% c th tin n ung th d dy sau 5 n 15 nm.
-Vim teo d dy mn, d sn rut.
- Polyp dng tuyn c tnh gia nh (FAP): C lin quan n ung th.
- Adenomas d dy.
- Barrette thc qun: Gy ung th vng tm v.
- Vi khun Helicobacter pylori: Gy vim d dy mn vng hang v, vim teo tuyn d dy,
lot d dy, u limpho d dy (MALT) v ung th d dy.
2. Cc yu t c th gy ung th d dy
179
- Sau phu thut ct d dy vng hang v 15 25 nm theo di, t l ung th l 50 -70% v c
lon sn gn ming ni.
- Thiu mu c tnh ngi gi: C lin quan n vim d dy mn tp A vng thn d dy
vi s xut hin khng th khng t bo thnh v khng th khng yu t ni.
- Bnh Menetrier: C nhiu yu t gi c lin quan n ung th nhng khng phi t
polype dng tuyn..
- Hamartomas d dy.
- Thc n: Ngi ta nhn thy rng nhng ngi n nhiu v ko di cc thc n c bo
qun bng p mui, hun khi hay sy kh c nng nitrat cao thng kt hp vi ung th
d dy. Di tc dng ca vi khun Nitrat s b bin thnh nitrosamin, mt cht gy ung th.

Nitrate Nitrite Nitrosamin.
(+)
Vi khun
- n t tri cy, rau ti: Gi bi vitamin C c ch s bin i nitrite thnh nitrosamin.
Hoa k, gim t l mi mc ca ung th d dy kt hp vi gim ca nhng thng tn let
dng rut vng thp ca d dy gi rng vic dng thc n bo qun lnh lm hn ch
pht trin ca vi khun lin quan n gim t l vim, lot v ung th d dy hn l dng thc
n bo qun bng p mui hay hun khi.
- Tnh trng kinh t x hi cng c vai tr quan trng: T l ung th d dy cao cc nc c
i sng thp, kh nng nhim khun cng cao.
- Thuc l v ru cng c xem nh l yu t nguy c.
3. Yu t nghi ng:
-Polyp tng sn
-Polyp tuyn vng y v.
-Lot d dy lnh tnh.
-Nhm mu A thng d b ung th d dy hn cc nhm khc. C l nhm mu ny, kh
nng bo v ca nim mc d dy chng cc yu t gy u yu hn cc nhm mu khc.
IV. C IM LM SNG
1. giai on sm
80% thng khng c triu chng, s cn li thng c triu chng ca lot, nn bun nn,
chn n, gim khu v, au bng, xut huyt d dy, gim cn, nut kh.
2. giai on tin trin
- Du chng st cn l ni bt (60%), bun nn, nn, chn n, cm gic nng tc sau n, au
vng thng v, i khi c cn au lot, chn ru v thuc l, c th c st. Chy mu nh
v r r thng gp nht, vi biu hin thiu mu nhc sc. Hp tm v thc qun gy kh
nut i vi th ung th cao. Hp mn v, tin mn v gy au bng, nn, mt nc.
- Khm Bng: C khi bnh thng hoc c khi s c khi u hoc mng ranh gii khng r
vng thng v. C th c di cn nh s thy hch thng n tri, hch quanh rn hay gan
ln, lch ln, au xng t nhin, c trng.
180
- Cc biu hin lm sng t gp: (Du chng cn u): Gim sn ty, nhng mng sc t en
da vng nch (Acanthosis nigricans), hi chng Trousseau, vim da c, thiu mu huyt tn
vi th, sng ha tuyn b, bnh thn mng.
V. CN LM SNG
1. V mu
- Tng Fibrinogen v cc protein khc ca phn ng vim.
- VS tng va.
-Thiu mu: Gim hng cu.
- nh lng CEA (carcinogenic embryonary antigen): Tng, ch thy giai an mun trong
1/2 trng hp, c ch trong vic theo di din tin sau phu thut ct b d dy.
2. Ni soi v sinh thit (H1)
L mt tin b trong chn an ung th b mt, xc nh v tr tn thng, tnh trng lan rng
ca u, tnh trng chy mu.
3. Xt nghim t bo hc
Chi t bo nhng kh pht hin nu tn thng su.
4. Siu m bng, siu m ni soi, Scanner bng
nh gi rng, su v pht hin di cn ca ung th.
5. Xt nghim ty, chc d no ty, scanner s, sinh thit da
Khi c gi di cn.
6. X quang
- Hnh nh khuyt vi gc nhn cm vo thnh d dy trong ung th si hoc lot si
- Co rt v cng trong ung th tm nhun lan rng.
- Let hnh nm (hnh nh tam ti hay hnh li to) trong ung th th lot si.
VI. CHN ON
- Chn an cng sm nht l giai on ung th b mt th c may iu tr khi (giai on
Tis), v thi gian sng cng di. Pht hin da vo X quang v ni soi sinh thit hng lat.
Nht, hin nay pht hin sm ung th d dy n 90% trng hp so vi Hoa K l 40%. y
l giai on T1, T2 v thng t triu chng.
- Vo giai an mun, triu chng cng r v nng, c th di cn xa, iu tr rt hn ch.
- Khi ni soi, cn phi sinh thit t nht 10 mnh, vi th t cn phi sinh thit su. Trong
thi k lm so khi iu tr, cn phi sinh thit 2 t.
VII. TIN LNG
Ty thuc th m hc ca ung th, v tr ca u, s xm ln ti ch v di cn.
- Tin lng tt: Ung th d dy giai on sm (tn thng nim mc, di nim mc)
- Ung th lai rut non c gii hn r hn nn tin lng tt hn lai ung th lan ta, ung th
vng tm v v phnh v ln do chn an chm nn tin lng xu hn ung th phn thp ca
d dy, di cn phc mc tin lng xu hn.
- Phn loi theo TNM cho php nh gi v tin lng sng, nhng cn da vo ln ca u
(T), tn thng hch (N) v s xut hin ca di cn (M).
181
T1: U cha vt qu nim mc, tng ng vi ung th b mt.
T2: U n lp c.
T3: U n thanh mc.
T4: U dnh vo c quan ln cn.
N0: Khng c hch.
N1: ch c hch gn d dy, phm vi quanh 3 cm.
N2: Hach vng b xm nhp nhng c th ct b c.
N3: di cn hch lan rng: Khng th ct b c.
M0: Cha c di cn tng
M1: c di cn
Bng 1: Bng tin lng theo hip hi nghin cu ung th d dayd Nht Bn
G/ TNM Sng n 5 nm (%)
0 Tis N0M0(g/h lp mng nhy nim mc) 100
IA T1N0M0 (xm nhp n/m, h n/m) 95
IB T2N0M0 (xm nhp n lp c) 82
II -T1N2M0 (xm nhp n/m, cn trong vch)
-T2N1M0(xm nhp n/m, cn trong vch
-T3N0M0 (lan khi vch)

55

IIIA -T2N2M0 (xm nhp n c hoc lan vch)
-T3, N1-N2, M0 xm nhp n c hoc lan vch

30
IIIB T4, N0-N1, M0(dnh chung quanh) 15
IV -T4N2M0 (dnh chung quanh hoc)
-T1-T4, N0-N2, M1 di cn xa
2
VIII. CC LOI UNG TH D DY KHC
1. Lymphoma d dy tin pht (H2)
1.1. Dch t v gii phu bnh
Him gp hn lai adenocarcinoma, chim di 15% tan b ung th d dy. C khong 1/3
trng hp khng c hch. Loi ny gia tng trong sut 20 nm qua.
U lympho d dy c th nguyn pht hoc th pht, gp mi la tui, nht l sau 50 tui.
Nhim H. pylori dng nh lm gia tng nguy c pht trin lymphoma d dy c bit l loi
MALT (mucosa-associated lymphoide tissue). Hnh thi u lympho d dy a dng, u sinh ra
t cc t chc di nim mc lan vo bn trong thnh, trn mt din rng hoc to thnh mt
khi nguyn vn. nim mc c hnh nt, nim mc dy ra, i khi b n mn, khi ln
to ra u dng polype, hoc c khi lan n t trng.
1.2. Triu chng
Gy st, au thng v, bun nn v nn, thiu mu, st, chy mu, t khi thng. Lm sng s
c khi u (1/3 trng hp)
182
1.3. Chn on
Phn bit vi Adenocarcinoma d dy i khi rt kh da vo ni soi v sinh thit (i khi
phi sinh thit su). X quang khng c hnh nh no l c hiu, nhng nu phi hp thng
tn dng polype v let trt trn cng mt bnh nhn th gi cho chn an.
1.4. Di cn
Hch, gan, ty xng, lch, phc mc, tng trn c hanh.
1.5. Tin lng
Tt hn adenocarcinome, 40%- 60% bnh nhn sng c 5 nm.
Tin lng cc gioai on ca lymphoma d dy theo Ann Arbor.
-G/1:Ch d dy:T l tng i gp 26-28%
-G/2:C hch bng: 43-49%.
-G/3:C hch trn c honh.
-G/4: tn thng lan to (giai on 3v 4 l 13-31%).
2. Sarcome c trn
Chim 1%- 3% ung th d dy, c tnh bt ngun t c. Tn thng thn d dy, gy lot
v chy mu. N him khi xm nhp vo cc tng ln cn v khng di cn hch nhng c th
lan n gan v phi.
3. U carcinoid d dy
Chim 0, 3% ung th d dy. y l loi u ni tit to ra cc cht c nhiu hot tnh sinh hc
nh serotonin, histamin, somatostatin v cc kinin nhng khng gy cc triu chng phng
mt, tiu chy v cc triu chng tim phi nh trong hi chng carcinoid. Tn thng thng
lp di nim mc nhng c th lot n lp c. Tn thng nhiu ni km tng gastrin
mu.
4. U trung m khc
c tnh bt ngun t m thn kinh
5. Sarcome mch mu Kaposi
Ch yu da, ni tng c bit d dy. Biu hin di dng nt di nim mc, i khi let
c mu sm, ng knh 1-2 cm. Thng gp bnh nhn AIDS hoc bnh nhn ang
iu tr bng liu php c ch min dch.
6. U d dy th pht
Thng him, nguyn pht t mt melanome c tnh, ung th v, phi, ty, tinh hon, tuyn
mang tai. Hnh nh X quang ging vi lymphome hoc u d dy th lan to. Chn an bng
ni soi, sinh thit
IX. IU TR
1. iu tr ung th biu m tuyn d dy
1.1. Phu thut trit
L ch nh hng u, pht hin bnh cng sm th kt qu sau phu thut cng cao (t l sng
sau 5 nm l 37% Nht v 10-15%: Hoa k).
- Ct cch b khi u t nht 5 cm.
183
- Ct bn phn: Ung th b mt 1/3 di cha di cn hch th ct d dy bn phn l .
- Ct ton phn: Ung th 1/3 gia v trn ct d dy ton phn tt hn ct bn phn hoc ct
cc trn, no b hch tan b.
- Ct lch phi hp khi ung th d dy b cong ln.
- U tm v: Ct phn cui thc qun v phn u d dy.
1.2. Phu thut tm thi: Khi c di cn xa.
1.3. iu tr khng phu thut
1.3.1. Ho tr:
Ci thin c triu chng au, triu chng ton thn, lm chm ti pht. Thng dng cho
iu tr giai on ung th khng phu thut c v b sung cho iu tr phu thut. Thng
dng a ho tr liu nhng cha thy tng thi gian sng, c cho gan, tim v thn nn dng
thn trng cho ngi gi. Cc thuc bao gm:
PLF
*5-FU: 2600mg/m
2
, truyn tnh mch trong 24 gi, mi tun 1 ln trong thi gian 6 tun
Chng ch nh: ph n c thai, bch cu < 2.500/mm
3

*Cisplatin: 50mg/m
2
, truyn tnh mch trong 15 pht tun 1, 3, 5 v 8.
*Calcium folinate 500mg/m
2
, truyn tnh mch trong 30 pht mi tun 1 ln trong 6 tun.
FAMtx
*Methotrexate 1500mg/m
2
, truyn 30 pht ngh 60 pht trong ngy th nht.
*5-FU: 1500mg/m
2
, truyn trong 30pht, ngy th nht.
*Calcium folinate 15mg/m
2
, truyn trong 24gi sau khi truyn methotrexate trong ngy u,
t ngy th 2 tr i, truyn trong 6 gi.
* Doxorubicin: 30mg/m
2
, truyn trong 30pht, lp li ngy th 15 v 29.
Thuc c nhiu tc dng ph nh bun nn, st, i chy, vim thc qun, suy ty, gim bch
cu ht, nhim c c tim, rng tc, ni my ay.
1.3.2. X tr
* Dng1 liu 28- 35Gy trc tip ti y khi u hoc trn mt ct trong khi phu thut.
* Dng liu 45-50Gy, 20-30 ln, kt hp vi ho tr cho cc trng hp khng phu thut
c v c tin lng xu (di cn mng bng, xng, hch su), hoc cng vi phu thut s
lm gim au v chm s ti pht u v hn ch di cn.
Kt qu iu tr phu thut: Theo JRSGC
- C phu thut, kt qu iu tr tut i: T1, T2, hch no vt xa vng tn thng, cha c
di cn gan, phc mc. T l sng sau 5 nm l 50%.
- C phu thut, kt qu iu tr tng i: T1, T2, cha di cn, hch gn vng tn thng.
T l sng sau 5 nm l 25%.
-Khng phu thut c, kt qu iu tr tng i: T3, di cn gan, phc mc.T l sng sau
nm nm l 15%.
-Khng phu thut c, kt qu iu tr tut i: Khi u qu ln, u giai on T4N1, T4N2,
c hn 4 hch pht hin khi m bng (2%).
184
1.4. Cc bin php h tr khc:
- t stent, ct bng tia laser km cm mu vi Nd:YAG (Argon v Neodymium: Yttrium
aluminum garner) qua ni soi.
- Bi ph st, dng thuc gim au thng thng, morphin v cc dn xut ca n.
2. iu tr Lymphoma d dy v cc loi ung th khc ca d dy
2.1. iu tr lymphoma d dy.
-G/1: Ct bn phn hay ton phn km ho v x tr sau phu thut: 4 liu CHOP, phi hp
mt hay hai ln x tr 39, 6Gy. Thnh cng 80%. Nu l loi MALT lymphoma th phi hp
dit tn gc HP.
-G/ 2, 3, 4: Phu thut km ho tr liu, loi lan to sng khng qu 2 nm.
- Nu khng phu thut c: Ho v x tr: 4 liu CHOP phi hp x tr 25, 5Gy na bng
trn.
Theo di ti pht sau phu thut: Ni soi d dy trong vng 3 nm u, ch vng
bch huyt Waldeyer v y l v tr hay ti pht.
Kt qu iu tr: Sng > 5 nm l 50%
2.2. iu tr sarcome c trn
iu tr phu thut kt hp ho tr liu cho trng hp c di cn
2.3. iu tr u carcinoid d dy
iu tr bng phu thut, ho tr km Octreotide c th ci thin triu chng nhiu
bnh nhn.
2.4. iu tr u trung m khc
iu tr ch yu bng phu thut.
2.5. iu tr sarcome mch mu Kaposi
iu tr bng phu thut, tin lng rt xu.
2.6. iu tr u d dy th pht
iu tr bng ha tr, tin lng xu.

H1. Ung th d dy th lot giai on sm H2. Lymphoma d dy
185
P XE GAN
Mc tiu
1. Nm c bnh nguyn v c ch bnh sinh ca p xe gan.
2. Khm v pht hin c cc triu chng ca p xe gan.
3. Chn on v phn bit c p xe gan amp v p xe gan mt qun
4. Trnh by c cc pht iu tr pe gan theo tng nguyn nhn gy bnh.
I. I CNG
L tnh trng vim, nhim khun v nung m xy ra gan, bao gm nhu m gan v h
thng ng mt trong gan. Nguyn nhn ch yu l do amip v vi trng sinh m. V c ch
bnh sinh v ng xm nhp cng nh v tr ca abces ngi ta chia lm hai loi: abces gan
nhu m v abces gan mt qun.
ng xm nhp ca tc nhn gy bnh thng qua mt trong nm c ch sau:
- Qua ng tnh mch ca v ng bch mch, t mt vim nhim tin pht trong
bng thng l t rut nh rut tha vim, vim ti tha, thng i trng.
- Qua ng nhim khun huyt, m tiu im nhim khun tin pht l t mt
nhim khun t xa trong c th vi trng n gan qua ng mch gan.
- Nhim khun ng mt ngc dng c lm d do s tc nghn ng mt, si
ng mt, ung th ng mt, vim x cht hp c Oddi. c bit nht bnh cnh nhit i
Vit nam, thng do s di chuyn ngc dng ca k sinh trng nht l giun a.
- ng tip cn: t abces di c honh, ung th i trng, d dy thng gy vim
abces ha sau dnh v lan vo gan.
- Do chn thng: trc tip do cc vt thng h nh vt thng ho kh, hoc t khi
mu t do chn thng hoc nang gan ri bi nhim th pht.
V kch thc v s lng: thng abces nhu m, s lng abces thng t mt vi ,
kch thc c th rt ln, c th cha hng lt m. Abces mt qun s lng thng nhiu c
th hng chc , kch thc thng nh v ri rc nhiu phn thy ng knh t 0,5 n
vi cm, khong 10-20 ml m.
II. ABCES GAN AMIP
1. i cng:
L loi nguyn sinh vt (protozeaire) thuc h Entamoeba. ngi c 4 loi:
Entamoeba, Endolimax, Pseudolimax, v Dientamoeba. Ch c loi E. histolytica cn gi l
Entamoeba hot ng l gy bnh. Th E. minuta sng cng sinh khng gy bnh trong i
trng v dng kn gy ly lan bnh. Thot u amip ch sng v gy bnh i trng. Trong
mt s iu kin thun li khi c thng tn mch mu (h tnh mch ca) v bch huyt
chng c th n gan v gy ra abces gan amip. y l loi bnh thng gp cc nc
nhit i v nhit i kh hu nng m thun li cho s pht trin amip, nht l cc nc
chm pht trin v sinh km thng gy ra cc v dch l amip.
Tn sut nhim Amib Php l 5%, Anh l 3%, M l 4,17%, Trung quc l
20%. Vit nam t l ny kh cao, thng k ca Si gn trc y l 25,7%, H ni l 15%.
Bnh c th xy ra cho mi la tui, thng gp ngi tr nam gii, thng n ung ba
bi nht l la tui 20-40 tui. y l loi abces nhu m thng ch c mt vi v thng
nm gan phi, kch tht trc y khng c pht hin v iu tr sm nn thng rt ln
vi ng knh ln n hng chc cm, cha hng lt m khng hi, c mu chocolate.
2. ng xm nhp v bnh sinh:
Kn amip theo phn ra ngoi, c th tn ti 10-15 ngy. Kn khng b tiu hy bi
thuc tm v clor, trong formalin 0,5% sau 30 pht kn mi cht. Sau khi n phi kn amip
n rut non to thnh kn bn nhn, vch tan r phng thch cc trophozoites. Cc amip
186
non ny thc hng cu, thc vi trng v cc mnh thc n. Thc nghim v dch t cho thy
rng phn ln cc amip ny thuc cc zymodemes khng gy bnh (gy tn thng v xm
nhp m). Cc yu t gy xm nhp ny vn cha c hon ton bit r c th do tnh trng
ca k ch v c lc ca k sinh nh do dng corticoids, suy dng, mang thai, hoc do
phi hp vi mt s chng vi trng c th do che ch amip khi tc nhn gy oxy ha hoc
qua s trao i c cht gen.
S xm nhp lin quan n kh nng thc bo ca chng, sn sinh ra men collagenase
v mt protein gy c t bo, khng vi p ng vim ca k ch v men hy m gy ra
do kt dnh ca trophozoide vo t bo trung gian ca lectin gy ra lot thnh rut, t gy
hoi t lp h nim mc v lp c bn di to thnh thng tn lot hnh n mng tay, hoc
abces hnh cc o thng l i trng v manh trng. y t c phn ng vim cp nn
gia cc khu vc tn thng nim mc vn bnh thng, y l iu khc bit vi l trc
trng. iu ny gii thch phn nhy mu nm ring l trong khi phn trong l trc trng
ton l mu nn c mu ca nuc ra tht ca loi ng vt c mu . Tuy nhin c vi
trng hp gy nn lot ton b i trng l th lan ta hay c tnh. Thng tn mch mu
gip amip theo tnh mch vo tun hon ca hoc bch mch n gan, y n thng b
chn li cc xoang tnh mch gy ra hoi t t (liquefaction necrosis) thnh lp cc
abces gan nh sau pht trin v tp hp thnh p xe ln. Him khi amp vo tun hon
chung i n cc c quan to thnh abces phi, no, lch do amip.
3. Triu chng lm sng:
Do c im khu tr v tn thng gan ca amip thng l i trng tri, c im
dn lu ca tnh mch mc treo trng di v dng chy v gan phi ca tnh mch ny nn
phn ln cc amip thng n gan phi nhiu hn chim n 70% trng hp.
Bnh cnh lm sng gi khi tin s c amip rut nht l ang hoc mi xy ra mt
vi tun.
Giai on u (mt vi ngy u) l vim gan amip (Amebia hepatitis) vi hi chng
nhim khun lc u nh vi st nh sau tng dn tip n l gan ln v au nhng khng
c cn au qun gan. Sinh thit gan giai on ny cho thy hnh nh vim khong ca khng
c hiu. Nu khng c iu tr s chuyn qua abces gan amip vi triu chng ngy cng
r.
Giai on abces gan: thng xy ra kh t ngt vi st cao, c th km rt run 39
40
0
, v mt nhim khun, c th km bun nn hoc nn, au nhiu h sn phi thng l
lin tc th c cn tri ln. au gia tng khi th su, ho, nhng thng khng c hi chng
tc mt, tr khi abces nm t gan, khm thy gan ln nht l gan phi (70% trng hp).
Gan thng mm hoc cng, rt t khi cng; n rt au, nht l c im au khu tr thng l
au k sn 8, 9 trn ng nch trc, rung gan (+) hoc phn ng di (+). Trong trng
hp abces nm gn mt gan triu chng au thng ni bt, khi abces nm di c honh
c th c phn ng mng phi hoc bin chng abces gan amip ln phi mng phi vi hi
chng trn m mng phi, hoc biu hin ho ra mu ti em xt nghim thng c amip
hot ng. Khm phi thy c cc triu chng ca vim phi hoc hi chng trn dch mng
phi.
++ Cc th khng in hnh:
- Th vi cn au bng cp vi triu chng au ni bt c th xy ra ngay t u kh
phn bit vi cn au qun gan v abces mt qun do si hoc giun, hoc vim ty cp, thng
d dy.
- Th thiu mu suy kit: thng xy ra tr em hoc ngi gi do bnh nhn n
mun, tnh trng nung m su lm ton thn suy kit thiu mu, ph, st cao ko di.
- Th gi u: do iu tr khng y , v abces tr nn dy, tnh trng nhim khun t
rm r, gan ln c th ni g ln chc cng t au siu m c hnh nh cho hn hp hoc ho
lng trung tm c hnh nh gn ging hoi t trong ung th gan.
187
- Th bin chng: abces v vo bng gy trn m phc mc vi biu hin ca phc
mc vim, d hoc v vo mng phi, trn m mng tim c th biu hin vim mng ngoi
tim hoc chn p tim cp. R thng vi ph qun gi l phc hp gan- ph qun (complex
hpato - bronchique) vi ho ra mu nh m t trn.
4. Xt nghim:
4.1. Cc xt nghim khng c hiu:
- CTM: BC tng, a nhn trung tnh tng, abces nng ko di gy hng cu gim.
- VS: thng cao gi u 50-100 mm, sau 2 gi thng >100 mm; trc y khng c
cc phng php theo di nhy v chnh xc nh siu m, VS c dng nh mt ch s theo
di din tin v p ng iu tr.
- Men transaminase thng t b nh hng.
- Bilirubin mu thng khng cao ngoi tr th tc mt do p xe nm t gan chn
p vo ng dn mt chnh.
4.2. Xt nghim phn tm amip: T l (+) khng cao. Cn xt nghim phn vng nhy mu.
Cn xt nghim sm <30 pht nhit 37
0
vi cc tnh cht amip di ng, c gi tc v
thc hng cu (hmatophage). Hin nay c th dng PCR xt nghim tm amp trong phn
vi nhy cm v c hiu cao.
4.3. Xt nghim huyt thanh tm ch im amip: C nhiu phng php, t l (+)thng cao
>90% nh l min dch hunh quang, ngng kt hng cu, ngng kt ht latex hoc cellulose,
hin nay c hiu l bng phng php ELISA cn phn bit vi amip rut hot ng. T
khng th khng Amip >1/100.
4. 4. Cc phng php ghi hnh:
- X quang: Trc y chp bng gan xa cho hnh nh gan ln v bin chng ln
phi mng phi phi nh: Bng gan ln, c honh phi b i ln cao hoc hnh nh trn dch
mng phi phi hoc vim p xe y phi phi.

Hnh nh bng gan ln, c honh phi i ln cao trong p xe gan amp
188
- Siu m gan: l xt nghim khng thm nhp d thc hin. Rt tt pht hin theo
di din tin v hng iu tr. Rt c gi tr khi abces >2 cm. Giai on u c th c hnh
nh cho hn hp ri cho ngho, khi ha lng cho hnh nh cho trng thng c v dy.
Cn phn bit vi cc kn gan, u mu v u th gan.


Hnh nh p xe gan giai on sm qua siu m



HNH NH Siu m p xe gan

189


Hnh nh p xe gan giai on ti to nhu m



Hnh nh CT scanner p ve gan


190


Hnh nh CT Scanner nhiu p xe nh

- Chp ct lp t trng thng nhy v chnh xc hn siu m, cng cho hnh nh khi
trn hoc thun gim mt , nht l khi tim cht cn quang nhum mch cho hnh nh gim
mt cng r hn.
- Cng hng t cng cho kt qu tng t.
- Chp phim: nht l chp bng gan xa, nay t s dng c th cho hnh nh gan ln,
i c honh phi ln cao, km di ng hoc bin chng trn dch, vim, hoc abces y phi
phi i km.
- Chc ht m nay l mt th thut iu tr ph bin di hng dn ca siu m, m
khng hi thi c mu chocolate do hoi t m v mu to ra.
- Chp nhp nhy gan vi Technitium 99 cng l mt xt nghim c ch cho hnh nh
gan ln, abces vi hnh nh khuyt trn hoc thun.
- Xt nghim amip trc tip: rt kh thc hin v trong m abces thng khng c
hin din amip, ch yu nm v abces nn t l (+) rt thp.
5. Chn on:
Da vo tin s v bnh s l amip nht l ang hoc va xy ra. Chn on gi khi
c tam chng Fontan: st, gan ln v au nht l gan phi.
- Chn on t ra khi trn siu m hoc CT scanner cho hnh nh abces mt vi
nht l gan phi.
- Da vo ch im amip bng huyt thanh hc: min dch hunh quang, ELISA
dng tnh.
- Trong iu kin thiu xt nghim c hiu th da vo iu tr th c hiu vi amip
p ng tt vi metin trong vng 2-3 ngy.
6. Chn on phn bit:
6.1. Phn bit abces gan amip v abces mt qun: c tin s si ng mt hoc giun chui
ng mt. Khi bnh vi tam chng Charcot: au, st, vng da-vng mt. y tnh trng
nhim khun thng nng hn v c th km theo nhim c. Hi chng tc mt, gan thng
ln rt au nhiu ch c th c du tn thng ti mt v ng mt ngoi gan hoc tn
thng ty kt hp. Xt nghim Bilirubin mu cao ch yu l Bilirubin trc tip, phosphatase
kim tng. Siu m v scanner cho thy hnh nh nhiu abces ri rc c hai thy, thng
nh v nm dc theo ng mt, thng kt hp vi dn ng mt v hnh nh si hoc
giun. Chc ht abces c mu trng c hoc vng c, thng hi, em cy c vi trng gy
bnh.
191
6.2. Ung th gan: nht l th khi nm su c km hoi t. Trong trng hp ny bnh nhn
cng au nhiu vng gan km theo st. Khm gan nhiu lc ch thy gan ln, khng cng lm
v au, rung gan cng (+). Trong trng hp ny phn bit cn da vo hi k bnh s, siu
m gan pht hin cc hnh nh ca ung th: s lan rng ca nhn ung th, thrombus tnh
mch ca nht l siu m doppler thy lu lng mu n khi u rt tng. -Foetoprotein
hoc D.C.P v nht l sinh thit t bo hc gip chn on ung th gan. iu tr p xe gan
amp khng p ng.
6.3. Vim ti mt cp: ngi gi hoc ph n c thai phn ln khng phi do si. V tr v
quan h gan mt nhiu lc kh phn bit trn lm sng nht l khi c m qunh ti mt dnh
vo gan hoc vim phc mc khu tr. Cn da vo tin s si hoc giun chui ng mt, cn
au y thng xut hin trc c th km theo hi chng tc mt. Chn on gin bit cn
da vo siu m v iu tr th bng thuc khng amp.
7. iu tr:
iu tr abces gan amip l mt iu tr ni ngoi khoa hoc kt hp vi th thut thut
chc ht c hng dn siu m hoc CT scanner. Kt qu iu tr ph thuc vo nhiu yu t
nh: tnh trng chung ca bnh nhn, giai on pht trin v chn on bnh, tnh trng tn
thng gan giai on vim, abces giai on sm, kch thc cn nh (<6 cm), cha ha m
ht, s lng, kch thc v v tr ca cc abces.
7.1. iu tr ni khoa:
7.1.1 Bin php chung: ngh ngi, n ung cung cp nng lng v cht dinh dng, gim
au v h st nu cn.
7.1.2 Thuc:
- mtin: l thuc dit amip t chc (amip hot ng) c s dng rt lu c c tnh
khuych tn m rt tt, chit xut t cy Ipca. Thuc c c tnh tp trung cao gan, phi,
lch, thn, thi tr chm qua thn vn cn trong nc tiu 1- 2 thng sau iu tr. C ch tc
dng l chn s tng hp protein mt cch khng hi phc do s c ch di chuyn ca
Ribosome trn ARN thng tin.
Tc dng ph: bun nn, tiu chy, au c nhng tc dng ph quan trng nht l tim
mch gy vim c tim nhim c do gy ph v hoi t si c tim, gy suy tim, lon nhp tim
nguy him. Cc triu chng nhim c l nhp tim nhamh, lon nhp, au vng trc tim, v
suy tim cp, do trnh dng cho bnh nhn c bnh tim mch, cn kim tra in tim trc,
trong v sau khi iu tr. C hai loi:
- metin Chlohydrate: ng 30, 60, 40 mg. Liu 1 mg/kg dng 7- 10 ngy. Liu trnh th hai
phi sau 4 tun. p ng tt gim st sau 2- 3 ngy
- Dhydrometine l loi tng hp c c tnh thp hn mtine. Liu 1,5 mg/kg dng 10- 15
ngy. Liu trnh th hai phi sau 2-3 tun.
- Nhm Nitro- imidazole thng: l Mtronidazole (Flagyl, Klion) cng dit amip m, cn
dit amip lng rut, c ch tc dng l do kh ferrodoxin, cht kh ny phn ng vi cc
phn t ln ca vi khun dit chng. Thuc hp thu qua rut nhanh 80% sau 1 gi, thi
gian bn hy sau 8 gi. Nng cao trong mu sau 5-7 gi.
Tc dng phu: l nhc u, nn ma, chn n kh ming, c v kim kh, mt, chng
mt. cc sc vt th nghim c th gy d bin gen nn khng dng cho ph n mang thai.
Liu 25 -30 mg/kg trong 10 - 15 ngy.
- Cc imidazole khc: Tinidazole, Nimorazole, Secnidazole (Flagentyl) v Ornidazole. Cc
thuc ny c thi gian bn hy ko di nn ch cn dng ngy 2 ln, 5-7 ngy. Trong cc loi
192
ny, ch c Tinidazloe (Fasigyne) dit amip tt, cn cc loi khc km hn mtronidazole
trong iu tr amip. Vin 0,5 g liu 3 vin/ngy, ung trong 5 ngy.
- Chloroquin c nng cao trong phi gp 200 ln/huyt thanh v trong gan 400 ln/huyt
thanh. c ch tng hp DNA v ARN, lm chm s nhn i v sao chp ca ARN. C th
dng ngn nga abces gan amip khi amip rut hot ng, hoc phi hp vi metine v
Mtronidazole trong iu tr abces v c th dng lu di. Liu lng dng l 1g trong 2 ngy
u v 0,5 g trong 3- 4 tun.
- Cc khng sinh:
+ Paromomycine (Humatin) thuc nhm Amino glycoside. Liu 25-30 mg/kg trng
lng, dng 5-10 ngy.
+ Nhm Cyclines: Tetracycline, Doxycyclines.
+ Erythromycine.
Cc khng sinh ny tc dng yu trn amip nn ch dng phi hp.
- Cc thuc dit amip lng rut:
Diloxanide furoat l dn xut ca dichloroacetanide, c ch tc dng cha c bit
r rng. Liu 500 mg x 2 ln/ngy x 10 ngy.
Lodoquinol (Direxiode, Enterovioform). Liu 650 mg x 2 ln/ngy x 3 tun.
- Chc m di s hng dn ca siu m c th pht hin cc abces cn nh hoc sau khi
iu tr bng thuc abces lng ha hon tan v khng dn sch. Xc nh v tr abces sau
chc ht di s hng dn ca siu m hoc CT scanner, ra sch m sau c th bm
trc tip thuc dit amip vo abces nh dhydrometin, Flagentyl. V ht lp li nu kim
tra cn m, kt qa rt tt gim au v st rt nhanh rt ngn thi gian iu tr.
- Phu thut: nay gim dn ch c p dng cho nhng abces qu ln, hoc nm v tr
khng chc ht c.

II. ABCES NHU M DO VI TRNG:
1. Gii phu bnh:
L s nhim khun nhu m gan v s tm nhum cc t bo a nhn trung tnh v cc
ai thc bo cui cng do hoi t v t m. Abces gan nhu m do vi trng thng n c
hoc nhiu . y l bnh t gp ch yu ngi gi 60 - 70 tui.
2. Nguyn nhn v ng xm nhp vi trng:
Vi trng n gan v pht trin theo cc c ch sau:
- Qua ng tnh mch ca v bch mch t mt nhim khun trong bng: rut
tha, vim ti tha, vim phc mc.
- Qua th nhim khun huyt t mt nhim khun xa trong c th nht l t cu
vng.
- Vi trng n trc tip do cc vt thng h.
- Cc chn thng bm dp, bi nhim v abces ha.
3. Triu chng lm sng:
Thng c triu chng lm sng ca nhim khun hoc bnh l nhim khun tin
pht. Khi tnh trng vim nhim khun xy ra cc triu chng tng t nh abces gan
amip. Nhn chung abces gan nhu m thng din tin theo kiu bn cp.
4. Xt nghim:
4.1. Cc xt nghim khng c hiu:
BC v trung tnh cao, thiu mu, VS tng, phosphatase kim tng, cy mu c th xc
nh c nhuyn nhn gy bnh.
4.2. Ghi hnh: siu m v CT scanner rt c gi tr chn on abces.
193
4.3. Cy m: nh siu m c th chc m abces gip cho chn on thng l m trng c
hoc vng c, nu do k kh th m rt hi >50% do k kh. Cy m trong mi trng k kh
gip xc nh chn on >80%. Cc vi trng thng gp E.coli, Klesbsiella, Streptocoques,
Staphylocoques, Proteus v cc Bacteroides.
5. iu tr:
Ch yu bng khng sinh thch hp nht l khi xc nh c vi trng, kt hp
chc ht m hoc phu thut. Khi cha c kt qu vi trng, cn phi hp vi Cephalosporin
th h III vi Aminoglycosides v Mtronidazole.
III. ABCES GAN MT QUN:
1. i cng:
y l bnh cnh kh ph bin ng hng th hai sau abces gan amip. Si v giun
chui ng mt l hai nguyn nhn v yu t lm d thng gp nht.
2. ng xm nhp v bnh sinh:
Trong iu kin bnh thng, c vng Oddi hot ng tt, dng chy ca mt qun
trong ng mt bnh thng, trong ng mt khng c vi trng hoc s lng rt t khng
gy bnh. Trong trng hp c si ng mt gy tc nghn, tr v tng p lc dch mt
to iu kin thun li cho vi trng i ngc dng v xm nhp gy nhim khun ng mt
v cui cng c th gy ra abces gan mt qun. Thc nghim ch cho thy rng tht ng
mt ch lm p lc mt tng 7 ln, th t l nhim khun ng mt tng 20 ln. Trong giun
chui ng mt, ngoi c ch c hc nh si, giun cn trc tip mang vi trng t ng rut v
c th c k sinh trng vo ng mt nn cng lm d vim ng mt v abces mt qun.
Ngoi ra cn c cc bnh l khc nh ung th ng mt, u u ty, bnh l c vng Oddi.
Vim x cht hp c vng Oddi hoc cc bnh l him gp hn nh lot d dy t trng thng
vo ng mt, ung th i trng, ung th d dy hoc cc th thut soi chp ng mt
ngc dng, ni mt rut c th gy vim nhim ng mt. Do phn ln cc nhim
khun gy bnh l E.coli v cc loi Gr (-) ng rut v k kh: bacteroides v Clostridium.
3. Gii phu bnh:
3.1. i th:
Gan thng to c hai thy hoc u th gan tri, c th gy hin tng mt, trn
mt gan c nhiu abces c th km vim thm ti mt hoc ng mt ngoi gan. abces
thng c m mu trng c hoc mu vng c v hi c th thy si hoc giun trong
ng mt, abces thng nm dc theo ng mt kch thc nh ng knh vi cm.
Ngoi ra c th c x ng mt hoc x gan mt, vim ti mt mn.
3.2. Vi th:
Cc vim hoi t vi s hin din ca t bo a nhn trung tnh thc bo thoi ha,
mt, nghn mt nhim khun. ng mt b gin, c th c hnh nh xc v trng giun trong
abces v ng mt hoc x gan mt.
4. Triu chng:
4.1. Lm sng
4.1.1. Khi pht: khi pht t ngt, t nhin xy ra m khng c mt du hiu no bo trc
(giun chui) hoc c yu t lm d sau n nhiu du m (si ng mt) vi au, st, vng da,
vng mt (tam chng Charcot). Ton thn c hi chng nhim khun v tc mt. Gan ln ton
th v nht l gan tri. C th c km theo du tn thng ti mt vi ti mt ln, au, tn
thng ng mt ngoi gan, vim ng mt ch v triu chng ca ty.
194
4.1.2. Ton pht: nu khng c iu tr hoc khng p ng s chuyn qua giai on abces
gan mt qun thng l vo tun th hai, vi triu chng nhim khun ngy cng nng vi st
cao km rt run, c cn vng trng huyt. Tc mt ngy cng nhiu vi vng da vng mt
m.
Gan ln gia tng, n v rung gan rt au, c im au khu tr nhiu ch. in hnh l
cc im g ln trn mt gan, n rt au. Ngoi ra cn c th c ti mt ln, au hoc du tn
thng ng mt ch, ty.
4.2. Xt nghim
- CTM: bch cu v trung tnh tng rt cao c th 20.000/mm3.
- Bilirubin mu tng nht l Bilirubin trc tip, phosphatase kim tng.
- GT v men ALAT, ASAT c th tng.
- Xt nghim ghi hnh, siu m rt c gi tr pht hin s lng v v tr cc abces
ng thi gip pht hin nguyn nhn: giun, si, thng tn cc c quan khc nh ng mt
v ti mt ln, dn, thnh dy, hi trong ng mt ti mt, thng tn ty v cc bin chng
ca n. CT Scanner cng cho kt qu tng t .
- Siu m ni soi cho kt qu tt on cui ng mt ch v bng Vater, c vng Oddi.
- Chp v ni soi ng mt ngc dng: trong trng hp siu m cho kt qu
ng mt (-). y cng l mt phng tin iu tr nh: ko si bng Dormia hoc bng
Ballonnete, v tn si c hc (lithotritie), ct c vng Oddi...



Hnh nh si mt, p xe ng mt


195

Hnh nh si mt qua chp mt ngc dng
5. Chn on:
Cn t ra bnh nhn c tin s si, giun chui ng mt. Lm sng vi nhim khun
tc mt nng, gan ln au nhiu ch rung gan rt au. p ng km hoc khng p ng vi
iu tr. Chn on xc nh cn da vo siu m hoc chp ct lp t trng.
6. Bin chng v tin lng: Bin chng thng nhiu v nng c ngoi khoa v ni khoa.
6.1. Bin chng ni khoa:
- Thng gp v nng n nht l nhim khun huyt vi chong nhim khun Gram
m. Cn t ra khi st cao lin tc 39 40
0
C km rt run, tnh trng nhim khun v nhim
c nng. Gan ln rt au, tc mt nng khng p ng vi iu tr. Cn cy mu nhiu ln
xc nh vi trng gy bnh. Cn pht hin sm cc trng hp tin chong: tnh trng bt an,
ht hong v ri lon vi tun hon vi du ni vn tm, thi gian vi huyt qun (VHQ) >3",
thi gian lm y mu tnh mch ko di >5".
- Hi chng gan thn do nhim khun v tc mt nng, gy ra do bilirubin mu qu
cao gy tc ng thn (micro lithiase billiaire).
- Trn dch mng phi v mng tim.
- Vim ty cp: c th l mt bnh cnh i km
- X gan mt y l mt bin chng lu di sau nhiu t vim nhim lm hoi t x
ha gan mt.
6.2. Bin chng ngoi khoa: do iu tr chm hoc tc nghn ng mt qu nhiu lm mt
tc dng ca khng sinh. Cc bin chng ngoi khoa thng gp l:
- V abces vo bng gy vim phc mc m.
- Thm mt vo bng gy vim phc mc mt.
- Chy mu ng mt y l mt bi chng phi hp do c hc v vim nhim
thng l nng n vi nn ra mu in hnh l c hnh thi bt ch, bnh cnh xut huyt ni
gy ra bnh cnh chong phi hp xut huyt v nhim khun.
7. iu tr: y l bnh cnh nng ngoi nhim khun cn km nhim c v bin chng
ngoi khoa, do cn t trong bi cnh iu tr ni ngoi khoa v hi sc cp cu.
196
7.1. iu tr ni khoa:
- Bin php chung: cung cp y dinh dng, nng lng v cn bng nc in
gii.
- Khng sinh: cn hng n cc vi trng Gr (-) ng rut k kh, v y l bnh
cnh abces thng km theo tc nghn ng mt nn dng khng sinh ph rng nng cao
trong ng mt, thng dng bng ng tim v di ngy thng >2 tun l. Tt nht l
da vo vi trng, khng sinh v kt hp khng sinh. Cc khng sinh thng dng l:
- Pnicilline 4 - 6 triu n v/ngy
- Ampiciline 2 - 3 g/ngy
- Cc Cephalosporin th h III: Cfotaxime (Claforan) 3 g/ngy,
Ceftriaxone(Rocphin) 2 g/ng, Cefuroxime (Fortum)x 2g/ngy..
- Cc dn cht: Carbenicilline thng nhy cm vi trc khun m xanh v protus
(liu 200 mg/kg/ngy), Ureidopenicilline nh: Azlocilline, Piperacilline liu 3g/ng. Tc dng
tt vi trc khun m xanh, Proteus hemophilus, Enterocoque.
- Cc Moxalactam, Carbapenem, Monobactam.
- Nhm Aminoglycoside: thng dng Gentamycine liu 3-5 mg/kg trng lng/ngy,
hoc cc khng sinh khc: Amikacin liu 15 mg/kg/ngy; Netilmicine liu 5-7 mg/kg/ngyy.
Ch : nhm Aminoglycosides c th gy c tai trong v thn.
- Nhm Quinolone: Ofloxacine (Oflocet) liu 400 mg/ngy; Ciprofloxacine liu 15 -
20 mg/kg/ngy, Sparfloxacine : 800mg/ngy, Levofloxacine : 1g/ngy..
- Nhm Mtronidazole: nht l ng tim truyn, thng dng trong trng hp
nhim khun k kh Bacteroide liu 1,5 g/ngy.
- Gim au v chng co tht ng mt dc dng trong trng hp c si co tht
ng mt vi Spasmaverine 40 mg x 3 vin/ngy. Buscopan ng 10 mg x 2-3 ng/ngy;
Spasfon (Phloroglucinol ) ng 80 mg x 2 -3 ng/ngy; hoc gim au thuc nhm
Noramidopyrine: Visceralgin ng 500 mg x 1-2 ng/ngy. C th gy gim bch cu ht.
Visceralgine forte: phi hp Noramdopyrine (500 mg) + Tinmonium (25 mg) l mt thuc
chng co tht c trn, tim bp su hoc tim tnh mch chm trnh tt huyt p.
- Chng chong do nhim khun Gr (-) nu c. Ngoi dng khng sinh tch cc cn
chuyn dch y v dng cc thuc vn mch nng huyt p nh Dopamine, Dobutamine
(Dobutrex). Chuyn bng kin in vi liu 5-10 g/kg/pht.
7.2. iu tr ngoi khoa:
Kh thc hin v bnh nhn au trong tnh trng nhim khun nng c th c chong,
hn na y c nhiu abces kch thc nh c th nm su kh c th pht hin hoc loi
b. Phu thut cn nhm loi b cc tc nghn c hc nh giun hoc si.
Th thut qua ni soi: bng ni soi v chp ng mt ngc dng gip xc nh chn
on. Ngoi ra cn c s dng ly giun, si, x c vng i gip gii ta tc nghn c
hc.

197
VIM TY CP
Mc tiu
1. Nm c bnh nguyn v c ch bnh sinh ca vim ty cp.
2. Khm v pht hin c cc triu chng ca vim ty cp.
3. Chn on v phn bit c vim ty cp vi cc bnh tng t
4. Trnh by c cc pht iu tr vim ty cp theoth v theo tng nguyn nhn gy
bnh.

I. DCH T:
Vim ty cp (VTC) l mt bnh l cp tnh ca tuyn ty, c th thay i t vim ty
ph n, thng l nh v t gii hn, cho n vim tu xut huyt hoi t ty. Trong mc
hoi t lin quan n trm trng v biu hin ton thn ca bnh. Thut ng vim ty
xut huyt t c ngha trn lm sng, bi v mt lng xut huyt k t nhiu c th thy
trong vim ty, cng nh trong nhng ri lon khc nh chn thng ty, u ty v cng nh
trong suy tim sung huyt nng.
Tn sut vim ty thay i theo tng nc v ty thuc vo yu t nguyn nhn nh ru,
si, ri lon bin dng hoc do thuc. M c lin quan n ung ru hn l do si, VN
thng l do si v hay l giun a chui vo ng mt tu. Dch t hc da vo m t thi,
cho thy M c khong 0,5%, Php 0,35%, Nht 0,12%, n 0,55%. M Lai l loi
bnh ng hng th t trong 10 bnh x hi.

II. BNH NGUYN:
1. Bnh l ng mt: si.
2. Do ru (gy vim ty cp v mn).
3. Sau phu thut nht l phu thut bng.
4. Sau ni soi v chp ng mt ty ngc dng.
5. Chn thng vng bng.
6. Bin dng:
Tng Triglycride mu.
Tng Calci mu trong cng ph gip.
Suy thn.
Sau ghp thn.
Gan nhim m cp trong thi k mang thai.
7. Di truyn.
8. Nhim trng: quai b, vim gan siu vi, cc virus khc (Corxakie virus, Echovirus), giun
a, Mycoplasma.
9. Do thuc:
9.1. xc nh: Azathioprim, Sulfonamide, li tiu Thiazide, Furosemide, thuc nga thai
Oestrogene, Tetracycline, Valproide acide.
198
9.2. C th do thuc: Chlorthalidone, A. thacrinique, Procainamide, tng calci mu cha r
nguyn nhn, L-Asparinase
10. Bnh ri lon m lin kt km theo vim mch: Lupus h thng, vim mao mch hai t,
ban xut huyt gim tiu cu km huyt khi.
11. lot d dy t trng xuyn thu.
12. Nghn bng Vater: trong bnh Crohn, ti tha t trng.
13. ng ty chia i, ng ty chnh (Wirsung) nh trong khi ng ph Santorini to hn, do
p lc trong ng Wirsung gia tng to yu t thun li cho vim ty.
14. Cc nguyn nhn cha c xc nh.
III. GII PHU BNH:
Thay i ty theo th tn thng.
1. Th ph n: tn thng chnh y l ph n, ty thng ln v ph n sung huyt c mu
hng hoc sm; cc nang tuyn cha b ph v.
2. Vim ty xut huyt hai t: ty c nhiu m xut huyt mu hoc tm bm hoc xm
en. Cc nang tuyn b ph v trong lng cha y mu, nhng thng cc tiu o
Langerhans vn cn nguyn vn. Cc mao mch b h bin, b ph v v hoi t, xut huyt
vo bng, nht l sau phc mc, trong cc mc ni. Km theo c hoi t m vi nhng m
hoi t dng bng n hay git nn ng knh vi mm c th lan n xoang bng trn phc
mc hay mc ni nh nhng git nn c s lng ng cc th savon ha.
3. Vim ty th nung m (p xe ty): thng l hu qu nng n ca hoi t ty km bi
nhim, cc nang tuyn b hoi t, cc bch cu a nhn b phn hy thnh cc t bo m t li
thnh p xe c th nm ri rc hoc to thnh rt ln c th chim mt phn hay ht c
tuyn ty.

IV. BNH SINH:
C nhiu yu t nguyn nhn trong bnh sinh vim ty cp, nhng c ch ch yu ca
vim ty cp n nay vn cha c hon ton bit r. C nhiu thuyt c nu ra:
1. Thuyt tt nghn v tro ngc: yu t tt nghn ng dn mt ty nh do si giun, u, do
chn p t ngoi lm khi VTC hoc do kch thch tit qu nhiu dch ty nh n qu
nhiu nht l sau mt thi gian nhn i, s tc nghn ny thng km theo s tro ngc
dch rut v dch ty c hot ha khi n t trng c th km theo dch mt l nhng yu
t gy hot ha men ty. Ngi ta gy c vim ty thc nghim sc vt khi trn ln
dch t trng v dch mt vo ng ty. iu ny bnh thng khng xy ra l do p lc dnh
ty cao hn dch mt v chnh p ng ty v t trng l 12mmHg.
2. Thay i tnh thm ca ng ty: bnh thng nim mc ng ty khng thm qua phn t
>3.000 Da. S gia tng tnh thm xy ra khi dng lng Acid acityl salicyclic, histamin,
calcium v prostaglandine E2. Khi hng ro biu m c th thm qua cc phn t t
20.000-25.000 Da. iu ny cho php thot cc phospholipase A
2
, trypsin v lastase vo m
k ty gy ra vim ty cp.
3. Thuyt t tiu: cho rng cc men thy phn protide nh trypsinogen, chymotrypsinogen,
prolastase v phospholipase A c hot ha bn trong ty hn l trong lng rut. Nhiu yu
t nh ni c t, ngoi c t, nhim siu vi, thiu mu, thiu kh, chn thng c ngh
n nh l cc yu t hot ha men. Cc men hy protin nht l trypsin khng nhng tiu
199
hy m ty v m chung quanh m n cn hat ha cc men khc nh lastase v
phospholipase. Cc men khi hot ha s gy tiu hy mng t bo, gy tiu hy protin t
gy ph, chy mu m k, lm thng tn mch mu, hoi t mch mu, hoi t m, v
hoi t nhu m ty. Thm vo khi tn thng v hoi t t bo lm hot ha v phng
thch cc Bradykinin, Kalikrin v cc cht hot mch khc nh Histamin gy ra dn mch,
tng tnh thm v ph lm gim th tch tun hon nng n s gy shock li lm nng thm
tnh trng thiu kh, thiu mu thc y thm tnh trng hoi t.
Mt s tc gi khc cn cho rng, cc men ty c t hot ha ngay bn trong
tuyn ty di tc ng ca men lysosome hydrolase. Thc nghim trn men ny vi cc
zymogens pH thp lm hot ha trypsinogen.
4. Thuyt oxy ha qu mc: nm 1993 Levy a ra thuyt v oxy ha qu mc. Theo
thuyt ny V.T.C. c khi pht l do s sn xut qu mc cc gc oxy ha t do v cc
peroxydes c hot ha bi s cm ng men ca h thng microsom p450. V d do ru,
hoc mt s cung cp qu nhiu c cht, m s chuyn ha oxy l quan trng, v d cc
hydrocarbon halogene v mt s gim c ch t v chng li s oxy ha qu mc ny, do s
gim glutathion; iu ny gii thch vai tr ca mt s thc n trong VTC
Gn y ngi ta cn a ra vai tr ca min dch v cc cytokin cng nh T.N.F.
(tumor necrotizing factor) nht l trong vim ty cp hai t v cc bin chng xa ca n nh
bin chng no, phi.

V. LM SNG:
VTC thng c khi pht mt cch t ngt vi cn au bng cp, y l mt triu
chng chnh v thng gp. au c th thay i t nh n rt nng, bnh nhn khng chu
ni, au thng xuyn v c cn tri hn ln. Trong VTC do giun, khi u l au cn kiu
giun chui ng mt, khi c tn thng ty mi tr thnh au lin tc. au thng vng
thng v v quanh rn hoc h sn tri tng ng vi vng ty, au ln ngc tri hoc
ra sau lng, au tng khi nm nga v gim khi ci gp mnh ra pha trc. Nn cng l triu
chng thng gp (70-80%), bng chng do lit d dy v rut cng thng gp. au c
th lm bnh nhn vt v bt an, tot m hi hoc chong ngt.
Ton thn c hi chng nhim trng, nht l trong trng hp do giun v si, c th
xy ra ngy u hoc ngy th hai, cn trong VTC do ru, nhim trng thng n mun
sau 5-7 ngy do bi nhim. Nu l th nh (ph n) cc triu chng au v chng bng s
gim sau 2-3 ngy. Trong th nng xut huyt hoi t, cc triu chng ton thn nng n vi
hi chng nhim trng nhim c, au nng v gia tng trn 72 gi. Bng chng v au lan
rng, cc im au ph dng tnh do s lan rng ca cc dng dch vim trong bng, c
th c du phn ng phc mc v bng ngoi khoa. Ngoi ra cn c du xut huyt ni, hoc
cc mng bm tm quanh rn vng hng gi l du Cullen v Turner do s lan rng ca
xut huyt ra ngoi di da bng. Trong trng hp ny do phng thch qu nhiu cht hot
mch v tng tnh thm mao mch, gy ra gim th tch tun hon, phi hp vi tnh trng
xut huyt, nhim trng v nhim c gy ra chong vi cc triu chng mch nhanh nh,
HA thp kp, u chi lnh, ni vn tm, tr tun hon ngoi bin.
Vng da c th l do nguyn nhn ca giun hoc si hoc trong trng hp u ty b
vim ph n chn p ln ng dn mt.
Nt hng ban do hoi t m (du git nn) c th thy da bng hoc cnh tay,
nhng trn thc t t gp.
200
Triu chng phi trong VTC nng khong 10-20% bnh nhn c triu chng phi
nht l y phi tri vi ran n, xp phi hoc trn dch mng phi. Trng hp rt nng c
th c hi chng phi choc.
Khm bng: ngoi cc triu chng au ty cn c du tn thong gan mt, bng
thng chng nht l vng trc ty v du lit rut, du hiu bng ngoi khoa.

VI. XT NGHIM:
1. Amylase mu: thng bt u tng 4 - 12 gi sau cn au, in hnh l sau 24 - 48 gi.
Trong V.T.C th ph Amylase thng gim sau 3-4 ngy, bnh thng 80- 120 v Somogy,
trong V.T.C phi tng trn 3 ln tr s bnh thng. Trong V.T.C th hoi t tng phn
Amylase c th tng cao ko di 7-10 ngy, nhng trong trng hp hoi t ty qu nng n,
Amylase mu c th khng tng, hoc gim thp. Cn phn bit Amylase ca ty (Amylase
P) c trng lng phn t thp v Amylase ca tuyn nc bt (Amylase S) c trng lng
phn t ln khng th thi qua ng tiu nh trong trng hp vim tuyn nc bt.
2. Amylase niu: Amylase c hp thu v thi tr qua ng tiu, do thng tng chm
hn sau 2-3 ngy, thng cao nht vo ngy th 4-5 v ko di 5-7 ngy. T Amylase
niu/Amylase mu = 1,7-2; do trong trng hp bnh nhn n mun >96 gi sau khi khi
pht bnh cn xt nghim Amylase niu chn on hi cu.
3. H s thanh thi Amylase/Cratinine tnh theo cng thc ca Fonstan v Levis:
Amylase niu Cr. Mu
A.C.R. = -------------------- ------------- 100
Amylase mu Cr. Niu
Bnh thng A.C.R. = 3,1 1,0. Trong VTC ch s A.C.R >5.
Thng thung ch s A.C.R c hiu hn (90%) so vi amylase mu (80%). Tuy
nhin cn loi tr trng hp suy thn mn hoc nhim toan cton mu th ch s ACR c th
tng.
4. Lipase mu: thng tng song song vi amylase mu, n thng c hiu hn amylase mt
t v ko di hn nhng vic nh lng lipase mu phc tp v mt nhiu thi gian nn thc
t t p dng, gn y cc kit: Enzygnost, Liapase, Boehringer.
Bnh thng Lipase mu l 250 UI/l
5.Trypsine: nh lng bng phng php min dch phng x, bnh thng l 8 - 10 UI, hoc
nng phn ng min dch huyt thanh Trypsinogene/Trypsine bng phng php min
dch phng x gia tng.
6. Methemalbumine: sinh ra do ph v Hmoglobine xung quanh ty phng thch
Hmatine vo huyt thanh, kt hp vi Albumine. Cht ny gia tng trong vim ty xut
huyt.
7. ng mu: trong giai on u, do s phng thch ca Glucagon, nn c th lm tng
ng mu, hoc do hoi t ty hon ton lm hy o Langerhan, ng mu c th ln hn
11,0 mmol/l (200 mg%).
8. Calci mu: c gim trong vim ty nng, thng xut hin vo ngy th 2 - 3, v ko di
mt vi tun. Calci mu <2 mmol/l l tin lng nng.
201
9.Transaminase: thng tng trong vim ty hoi t, nht l do ru. Nu loi tr tng
Transaminase do gan, khi Transaminase >5 ln bnh thng, c tin lng nng.
10. Bilirubine: c th gia tng khi c nguyn nhn tt nghn do giun v si, hoc do vim, ph
n u ty, Bilirubine c th tng >42,5 mmol/l (2,5 mg%).
11. Phosphatase kim: thng gia tng song song vi tng bilirubine mu.
12. LDH: tng trong VTC hoi t, khi LDH >350 UI, th c ngha tin lng nng.
13. Albumine: mu gim trong trng c xut tit qu nhiu, khi Albumine <3 g%, cng c
tin lng nng.
14. P02 <60 mmHg, xy ra 25% trng hp vim ty hoi t, nht l trong trng hp c hi
chng suy sp h hp ngi ln.
15. CTM: bch cu trung tnh cao, nht l VTC do giun v si. Khi bch cu >16.000/mm3
cng c tin lng nng.
16. Siu m:
- Ty ln, c th ln tan b hay ln mt phn ; bnh thng b dy ty trn siu m l : u
ty 3 cm, thn ty 2,5 cm, ui 2 cm.
- B ty m, theo dng nhiu vng trn olympic (polycyclics).
- Cu trc siu m thng hi ngho hn bnh thng so vi thang xm gan v lch.
- Ngoi ra, siu m cn gip pht hin dch trong bng, nht l quanh ty, khoang trc bn
thn tri, hoc hu cung mc ni trong trng hp vim ty xut tit ; hoc chy mu nh
trong trng hp xut huyt.
Siu m cn gip chn an nguyn nhn VTC nh: Hnh nh giun hoc si, hoc cc bin
chng ca n nh abcs v nang gi ty.
17. T trng ct lp: Cho nhng thng tin nh siu m, nhng c phn gii cao hn v
khng b nh hng bi hi trong rut v thnh bng dy. Balthazar chia VTC lm 5 giai
on:
* Giai on A: ty bnh thng.
* Giai on B: ty ln ton b hay tng phn, khng c xut huyt quanh ty.
* Giai on C: vim ty v m quanh ty.
* Giai on D: c mt t dch ngoi ty.
* Giai on E: c trn 2 t dch ngoi ty.

202

Mt ct ngang Ty qua siu m: Hnh A: s mt ct ngang ty ,
HnhB: hnh nh ty qua siu m

Vim ty cp : Th ph

Vim ty th hoi t

203

Vin ty cp do giun a chui ng ty
18. X quang: thng t gi tr trong chn on vim ty cp. Trong trng hp lit rut nhiu
c th c hnh nh quai rut gc (anse dentinelle) nm trc vng tu, hoc him khi c th
thy si cn quang trong ng mt ty. Du trn dch mng phi.
19. E.C.G: i khi c bt thng v an ST v sng T gi l hi chng gi thiu mu

VII. CHN ON:
1. Chn on dng tnh: v lm sng cn ngh n vim ty khi ng trc mt bnh nhn
c cn au bng cp vng thng v v h sn tri km nn ma nhiu, ton thn c hi
chng nhim trng, bng chng nhiu, khm thy c cc im au ty r. Chn on c
xc nh, khi phi hp vi amylase mu hoc Amylase niu >3 ln bnh thng, hoc h s
thanh lc A.C.R. >5. V ghi hnh siu m hoc scanner c hnh nh vim ty.
2. Chn on nguyn nhn:
Da vo bng phn loi nguyn nhn. Cn ch n 3 nguyn nhn thng gp sau
y:
2.1. Vim ty cp do giun a chui vo ng ty mt: c tin s vim ty cp do giun, khi
bnh t ngt vi cn au bng cp kiu giun chui ng mt. Siu m c hnh nh giun a
nm trong ng mt ty. V lm sng c th gi chn on khi ct cn au nhanh bng
thuc lit giun nhanh nh Lvamisole.
2.2. Vim ty cp do si: c tin s si ng mt: tnh cht khi pht v cn au c th
ging nh giun chui ng mt, siu m c hnh nh si thng l si bng Vater hoc kt vo
c vng Oddi.
2.3. Vim ty cp do ru: thng l t cp ca vim ty mn cn da vo tin s ung
ru nht l ln ny c ung ru 6-12 gi trc .
3. Chn on gim bit:
3.1. Thng tng rng: t bit l thng lot d dy t trng. Cn da vo tin s lot vi cn
au kiu dao m, khm c du bng ngoi khoa v mt vng c trc gan. Chp phim bng
khng sa son c lim hi di c honh. y amylase mu khng cao hoc ch cao gp
2-3 ln bnh thng.
204
3.2. Vim ng mt ti mt cp: thng l do giun v si y c th l nguyn nhn do
thng phi hp vi vim ty cp. Cn da vo tin s si ng mt. Cn au qun gan,
khm thy ni bt cc triu chng v gan mt vi gan ln, ti mt ln v au, vng da vng
mt . Siu m gip pht hin ti mt ln thnh dy v si hoc giun.
3.3.Tt rut lng rut cp: thng gp tr em hoc ngi gi c bit ngi c tin s m
bng. Khi bnh vi triu chng nn, au bng quanh rn c hi chng koenig. Khm bng
c th s c vi lng, lc u m rut tng v sau gim, i cu ra nhy mu. Chp bng
khng sa son c th thy mc hi nc.
3.4. Nhi mu mc treo rut: thng gp ngi gi, tng huyt p, c du x va mch
mu, c tin s thiu mu cc b mc treo vi cn au bng sau khi n. Khi c bin chng
nhi mu th cn au bng d di, c th km theo du chong, v i cu ra mu. Chn on
da vo siu m Doppler, chp nhum mch mu mc treo hoc chp nhp nhy ng v
phng x st 58 ng mch mc treo.
3.5. Cn qun thn tri: da vo tin s si tit niu (+), ri lon bi tiu khm c cc im
au ng tit niu, xt nghim nc tiu, chp phim hoc siu m gip pht hin thn ln v
si.
3.6. Nhi mu c tim: thng gp ngi gi, c tin s cn au tht ngc, khm cc im
ty khng au. Gim bit da vo amylase mu, in tm , v cc men C.P.K, C.P.K- M.B,
Tryponin mu gia tng.

VIII. TIN TRIN V BIN CHNG:
1. Tin trin:
1.1. Th n gin (th ph): tng ng vi vim ty cp th ph n. Nu gip ty ngh ngi
bng ht dch v, chng nhim trng th s thuyn gim sau 3-5 ngy v khng li di
chng.
1.2. Th hoi t tng phn: y l th nng va tng ng vi th xut tit thng km au
v st ko di 5-7 ngy, amylase tip tc cao ko di v gim chm. Siu m c dch tit trong
bng km cc hoi t, din tin c th a n p xe hoc nang gi ty .
1.3. Th xut huyt hoi t: y l th nng, thng km theo chong do gim th tch, xut
huyt nhim trng v nhim c. Tin lng thng l rt nng t vong cao.
2. Cc yu t tin lng nng trong vim ty cp:
2.1. Cc yu t tin lng nng ca Ranson: Nm 1974 Ranson a ra cc yu t tin
lng nng trong vim ty cp ch yu p dng cho VTC do ru cn trong VTC do si ch
ph hp khong 60%.
- Cc yu t nng khi mi nhp vin:
+ Tui >55.
+ Bch cu >16.000/mm3
+ L.D.H. >350 UI.
+ ng mu >200 mg%.
+ Men transaminase >5 ln bnh thng.
- Cc yu t nng 48 gi sau khi nhp vin:
+ Ur mu tng > 0,5 g/l.
205
+ Canxi mu <60 mg%
+ Th tch huyt cu gim >10%.
+ Bicarbonate mu gim >4 meq/l.
+ PO
2
<60 mg%
+ Th tch dch t hm >6 lt.
2.2. Ch s ca Imrie: dng nh gi khi bnh nhn mi nhp vin.
- Tui >55.
- Bch cu >15000/mm3
- ng mu >10 mmol/l.
- Ur mu >16 mmol/l.
- PO2 <60 mmHg.
- Calci mu <2 mmol/l.
- Albumin mu <30 g/l.
- LDH >1,5 ln bnh thng.
2.3. Ch s SAPS (simplified acute physiology score): bao gm 14 ch s.
Tui, mch, huyt p tm thu, nhit , nhp th, lng nc tiu trong 24 gi, Ur
mu, Hct, Bch cu, ng mu, Kali mu, natri mu, d tr kim, v ch s Glasgow v hn
m.
Trong bng ch s ca Ranson th khi c >3 yu t l c tin lng nng. Trong mt
nhin cu cho thy khi <2 yu t th t vong ch <0,9%; 3-4 yu t th t vong l16% ; 5-6
yu t th t vong l 40% ; khi c >7 yu t th t vong l 64%.
Theo Momtariol a ra ch s tin lng nng trong vim ty cp hoi t th:
-Nhp th nhanh >25 ln/ph.
- C hi chng tc rut.
- C du phn ng phc mc hoc bng ngoi khoa.
- Chy mu tiu ha.
Khi c tng Ur mu v c 1 trong 4 du chng trn l c yu t tin lng nng.
3. Bin chng:
3.1. Ti ch:
- p xe ty: nhim trng nng, st cao 39 - 40o C, ko di >1 tun, vng ty rt au,
khm c mt mng g ln rt au, xc nh bng siu m hoc chp ct lp t trng.
- Nang gi ty: tnh trng chung c phn ci thin, gim au, gim st nhng khng
tr li bnh thng. Vo tun l th 2-3, khm vng ty c mt khi, n cng tc, Amylase
mu vn cn cao gp 2-3 ln, siu m c khi Echo trng, chp ct lp t trng cng c du
hiu tng t. Nang gi ty ny c th bi nhim hoc abces ha, hoc v r vo bng.
Ngai ra n cn chn p cc c quan k cn, lm tt nghn d dy, rut non, rut gi.
- Bng l do thng hoc v cc ng ty, hoc nang gi ty vo bng. Trong trng
hp vim ty xut huyt do hoi t mch mu, lm xut huyt trong bng di dng bng
mu
206
3.2. Ton thn:
- Phi: trng dch mng phi nht l y phi tri, xp phi hoc vim y phi tri,
m quan nim hin nay l do dng dich vim, hoc do T.N.F. Bin chng nng nht v h hp
l hi chng suy sp h hp ngi ln (ARDS).
- Tim mch: gim HA, hoc try tim mch l do gim th tch tun hon hoc do choc,
m nguyn nhn l do phi hp nhiu yu t, nhim trng nhim c, xut huyt, v thot
dch, thay i in tim vi ST chch xung di v T m nh trong hi chng gi nhi mu,
trn dch mng tim.
- Mu: c th gy hi chng ng mu ri rc ni mch (CIVD), nh trong trng hp
vim rut xut huyt hoi t.
- Tiu ha: vim lot d dy t trng cp, nh l mt bin chng stres do au v nhim
trng, nhim c, v thng biu hin di dng xut huyt. Thuyn tc tnh mch ca.
- Thn: bn niu hoc v niu do suy thn chc nng do gim th tch tun hon, km
theo ur mu cao, l mt yu t tin lng nng. Hoi t thn v thng thn tri l mt bin
chng t gp, do vim lan t ty. Vim tt TM v M thn l bin chng nm trong bnh
cnh chung ca vim tt mch.
- Bin chng chuyn ha: tng ng mu do nhiu yu t, nh tng sn xut
Catcholamine v Corticoide do stress, tng sn xut Glucagon trong vim ty, trong hoi t
ty lan rng l do gim tit Insuline lm hy o.
- Tng Triglycride: VTC, tng Triglycride v ru l 3 yu t c mi quan h cn
ang bn ci. Trc tin tng Triglycride thng i trc v dng nh l nguyn nhn ca
VTC, nhng sau trong VTC cng thng c tng Triglycride mu. Ngoi ra ngi thiu
Apolipoprotine C2 d b VTC, cht ny hot ha Lipoprotine lipase, gup lm sch
Chilomicron trong mu.
- H Calci mu: do lng ng calci vo nhng ch hoi t m .
- Bnh vng mc Purtscher: gy m t ngt, y l mt bin chung t gp do xut
huyt dng bng, thng nm a th v vng Macula, do tt nghn ng mch hu nhn
cu bi s ngng kt cc t bo ht.
3.3. Bin chng ngoi khoa:
- Abcs ty: vim ty nng lm hoi t ch m ty gy ra abcs, thng xut hin
vo tun l th hai. T l 5-10% trng hp VTC, thng xy ra khi bnh nhn c trn 3 yu
t nng ca Ranson, hoc cho n qu sm, soi bng sm, hoc do thng nang gi ty v i
trng, hoc do chc ht nang gi ty. Cc triu chng thng gp l st ko di, hoc st cao
giao ng, bch cu cao, ton trng suy sp.
Khm c du lit rut nht l vng trc ty, s c mng rt au hoc c cm gic bng
nhng vng tu.
Chn on xc nh bng siu m v ct lp t trng. iu tr ch yu hin nay l
chc ht phi hp vi khng sinh mnh t hiu c th gii quyt khong 50-60% trng hp
ch tr trng hp p xe qu ln hoc khng ht ht m mi cn n phu thut.
- Nang gi ty: l mt hn hp gm cht lng, m, mnh hoi t, men ty v mu
thng c hnh thnh sau 1-4 tun VTC, khc vi nang ty tht s l y khng c v
bc, to bi m ht v m si, do v cc ng ty, thng 90% l do sau VTC, 10% do sang
chn, 85% nang gi ty nm ui v thn ty, 15% nm u ty. Thng ch c mt nang,
207
nhng cng c khi c 2-3 nang, hoc nhiu hn. Triu chng thng l au m ko di, lan
ra sau lng, c th km theo st. Khm bng s c khi hoc l mng tng ng vng ty.
Xt nghim: 75% l tng Amylase mu va, chp phim bng khng sa son, hoc
nhum Baryte d dy t trng c th thy s di lch cc c quan. Siu m, v Scanner cho
hnh nh nang gi ty.
Bin chng ca nang gi ty l abces ha, v vo bng, hoc r vo c quan k cn.

IX. IU TR:
1. Ni khoa: phn ln vim ty cp l th ph (85-90%) iu tr ch yu bng phng php
ni khoa v bnh s thoi trin sau 5-7 ngy. Cc bin php thng thng l:
- Gip ty ngh ngi lm gim au v gim tit bng nhn, ht dch v.
- B nc v in gii: trong vim ty cp do bnh nhn khng n ung c, st, nn
ma, v hin tng thot dch, nn bnh nhn thng thiu nc. Trong vim tu cp th ph
cn chuyn 2-2,5 lit/ngy ch yu bng dung dch Ringer v ng ng trng. Trong
trng hp nng do hin tng tit dch vim v tng tnh thm thnh mch nn cn chuyn
dch vi s lng nhiu 3-4 lt/ngy hoc nhiu hn na, ch yu bng dung dch keo hoc
c trng lng phn t cao hoc albumin.
- Nui dng bng ng ngoi ming cho n khi cc triu chng au gim nhiu
mi bt u cho n dn, bt u l nc ng, ri h ng ri cho gim s tit dch
ty.
- Cc thuc c ch choline t hiu qu trong vic c ch tit dch ty m cn gy
chng bng v che lp du bng ngoi khoa.
- Cc thuc gim au tht s ch dng khi bin php nhn v ht dch khng lm gim
au, nhng khng dng morphin v c nguy c lm co tht c oddi, c th dng dolargan
hoc Viscralgin.
Khng sinh: trong vim ty cp do ru ch c dng chng bi nhim nn
thng c dng chm. Tri li trong vim ty cp do giun, nhim trng rt sm, nn cn x
dng khng sinh ngay t u thng l khng sinh gram (-) bng ng tim nh: Ampicillin,
Gentamycin. Trong trng hp nhim trng nng cn phi hp cphalosporin th h 3 v
quinolone th h 2; nu nhim trng nng v ko di, cn x dng khng sinh chng k kh
nh nhm Imidazole, Bta-Lactamin hoc nhm Macrolide chng k kh (Clindamycine,
Dalacine ).
- Trong vim ty cp do giun a chui vo ng mt ty nht l giai on sm khi
giun cn sng v mi chui mt phn vo ng mt ty, th vic x dng thuc lit giun c
tc dng nhanh t ra rt c hiu qu; y c xem l iu tr nguyn nhn gip lm gim au
v lm lui bnh rt nhanh.
- Trong vim ty cp do si: hin nay c th x dng phng php ni soi v chp
ng mt ngc dng gip chn on, ng thi x c vng oddi v ko hoc tn si.
- Trong vim ty cp xut huyt hoi t: thng km chong do cn iu tr tch
cc bng b dch v in gii. Nu albumin mu gim nhiu <60 g/l cn chuyn dung dch c
p lc keo nh albumin, plasmagen hoc dung dch c trng lng phn t cao nh Rhodex;
nu c xut huyt (HCgim >1 triu hoc Hct gim >10%) th cn chuyn mu. Ngoi ra cn
dng cc thuc vn mch nh dopamin hoc Dobutamine (Dobutrex).
2. p dng thc t:
208
2.1. Vim ty cp th ph:
- Nhn i: thng l 2-3 ngy cho n khi gim au nhiu th bt u cho n dn tng
t mt bng nc ng cn theo di du au bng.
- Ht dch v.
- Chuyn dch: thng thng 2-3 lt/ngy bng ringer lactate hoc bng Clorua natri v
glucose ng trng.
Trong trng hp vim ty cp do giun th cn cho thuc lit giun sm bng
lvamisole, palmoat de pyrantel hoc albendazole. ng thi x dng khng sinh sm nh
ampicilline v hay l gentamycine.
2.2. Vim ty cp th xut tit: cn tch cc ht d dy v b nc v in gii y , ng
thi tng cng khng sinh ch yu l phi hp gentamycine v cphalosporine th h 3 hoc
quinolone th h 2 hoc khng sinh chng k kh.
2.3.Vim ty cp th xut huyt hoi t: tch cc x dng cc bin php k trn, ng thi
tch cc chng chong v b lng mu mt. Nu khng p ng cn ht ra phc mc
loi b m hoi t. Vn phu thut ch hn ch khi cc bin php trn khng hiu qu.
Trong trng hp p x ty hin nay ch yu vn l chc ht di hng dn ca siu
m hoc scanner.
Vn x dng thuc c ch men ty thc t khng c tc dng. Hin nay c th
dng somatostatine loi tng hp l Sandostatine c ch tit men ty nhng vi iu kin
x dng rt sm c ch s tit men tu gip gim qu trnh vim tu liu 200-300 g tim
di da hoc chuyn tnh mch.

X. KT LUN
V.T.C l mt bnh l ni ngoi khoa thng gp. Nguyn nhn thng gp Vit
nam l do giun v si; trong khi Ty phng l do ru v si cholestrole ng mt.
Cn ch bnh l phi hp mt ty. Cn pht hin sm bng s phi hp gia lm sng, sinh
ha, v ghi hnh bng siu m hoc scanner. Ngoi bin php iu tr chung trong vim ty
cp do giun cn x dng ngay thuc lit giun v khng sinh.,.
209
UNG TH I TRC TRNG
Mc tiu
1. K c cc yu t nguy c gy ung th i trc trng.
2. Xp loi v tin lng cc giai on ung th i trng.
3. Nm vng triu chng ca ung th i trc trng.
4. Ch nh v phi hp ng cc bin php iu tr ung th i trc trng.
Ni dung
I. I CNG
Ung th i trc trng l nguyn nhn ln gy t vong cc nc Bc M, Chu u, sau ung
th tin lit tuyn, ung th v v ung th phi. Nm 1996, c khong 134 ngn trng hp
mi mc Hoa K v 55 ngn ngi t vong ng hng th hai sau ung th phi. n nm
2004, c 146.940 trng hp mi mc v 56, 730 trng hp t vong. Trn th gii, hng
nm c khong 1 triu trng hp ung th i trng mi mc. C s gia tng ng k v t l
ung th i trc trng cc nc c t l thp trc nhng nm 1950. Vi s tin b nhanh
chng ca sinh hc phn t cho nhng nhn nhn v c ch bnh sinh ca ung th i trc
trng, t t ra vn phng nga cp 1 v bnh xy ra sau mt thi gian di c s tng
tc v bin i gen v yu t mi trng, cho nn c th pht hin bnh giai on tin ung
th v ung th giai on sm iu tr lm tng tui th cho bnh nhn.
II. DCH T HC
T l bnh cao cc nc pht trin nh Bc M, c, New Zeland, v cc nc Chu u,
thp cc nc Chu , Nam M, Sahara, Chu Phi. S khc bit v a d cng cho thy c
s khc bit v v tr ca ung th i trc trng, v d nh t l ung th i trng ngi da
en tng t nh ngi da trng nhng ung th trc trng th ngi da trng li cao hn
ngi da en v nam nhiu hn n.
Nhng ngi nhp c t ni c t l ung th i trng thp n ni c t l cao cng cho thy
t l mc bnh tng nhanh hn so vi ni c. Cc nc c t l tng nhanh l , B o Nha,
tng va Anh v an Mch, t l n nh Php v Thy S.
Vit Nam, thng k nm 2005 cho thy ung th i trc trng ng th 5 sau ung th phi,
d dy, gan v lng ngc. Thng k ca bnh vin K H Ni cho thy t l mc ung th i
trc trng l 7,5/100.000 dn ( ngun www.vista.gov.vn)
V v tr, t l ung th i trng phi v i trng sigma c xu hng tng hn nhng t l
ung th trc trng th gim, iu ny phn nh s nhy cm khc nhau ca s chuyn hnh
thi ca u on gn v xa ca i trng. T l gp i trng sigma l 25%, trc trng l
20%, ch ni gia sigma v trc trng l 10%, i trng ln v manh trng chim 25%, i
trng ngang 15% v i trng xung thp nht, 5%.
Yu t mi trng ng vai tr quan trng trong s pht trin ca bnh. Trn cng mt vng,
li sng khc nhau c t l mc khc nhau, trong thc n c lin quan n bnh nh thc
phm giu m, protein, ng, t rau v si x, t yu t vi lng.
Bnh ny thng gp ngi trn 50 tui l nhiu hn.
II. BNH NGUYN V C CH BNH SINH (H1, H2)
a s ung th i trc trng thng pht sinh t cc polyp dng tuyn bm cht vo b mt
nim mc bao gm dng polyp khng tng sn, polyp tng sn hay polyp tuyn. Ch c polyp
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tuyn l c kh nng ung th hoc ung th ho. Polyp ni chung i trng gp trn 30%
tui trung nin v ngi gi nhng ch c 1% l c tnh. a s polyp khng c triu chng v
c th c mu n trong phn.
V mt lm sng, polyp tuyn tr thnh ung th ty thuc vo ln, c im m hc, v
kch thc ca chng. Ung th thng pht sinh t polyp tuyn dt, nht l loi polyp c
ng knh > 2, 5 cm. V vy khi pht hin c c polyp th ngay khi cha c bng chng l
c tnh, phi theo di ni soi nh k mi 5 nm v nhng bnh nhn ny c n 30- 50% c
th pht sinh thm nhng polyp tuyn khc v c nguy c cao hn na cho ung th i trc
trng.
III. CC YU T NGUY C
1. Ch n
Bnh xy ra cc nc pht trin, ni c i sng kinh t - x hi cao, dn thnh ph v c
lin quan n ch n giu nng lng, nhiu du tht v m cng nh ngi c tng
cholesterol mu v bnh mch vnh.
1.1. M ng vt
Ch n giu m lm tng tng hp cholesterol v acide mt gan, lm tng lng sterol
trong i trng. Vi khun trong rut s chuyn ngc cc sn phm ny thnh acide mt th
pht v cc cht c tc dng c khc trong phn. Cc cht chuyn ha sau cng ny c l
lm tn thng nim mc i trng v gia tng hot ng tng sinh ca biu m i trng qua
trung gian ca arachidonic lm tng prostaglandin gy ung th.
n nhiu tht hn s lm gia tng t l vi khun k kh trong lng rut lm chuyn i
acide mt thnh cht sinh ung th nht l ung th i trng xung v i trng sigma. C l do
s khc nhau v t l m bo ha v cha bo ha trong thnh phn tht. X dng du c c
nhiu cht Omega 3, mt loi m khng bo ha a v du olive l loi bo ha n th tt
hn dng m ng vt. Yu t nguy c ny cng cn thy ngi c tng cholesterol v
beta- lipo-protein mu.
1.2.Cht x
Nghin cu dch t hc v trn sc vt th nghim cho thy cht x trong ch n c tc
dng bo v chng li s pht sinh ung th i trng. Vai tr ca n cha c bit r, c l
do vi khun trong i trng lm ln men cc cht x to thnh cc acide bo chui ngn, lm
gim pH ca i trng, lm thay i tnh cht ca phn v c kh nng c ch cc cht gy
ung th.
1.3. Yu t gy ung th, yu t bo v chng ung th (vitamin v cc yu t vi lng)
- Fecapentaenes: L cht chuyn ha ca cc acide bo di tc dng ca vi khun i trng,
cng c vai tr quan trng trong ung th i trng.
- Tht, c nng chy: Sn phm to ra l loi acide amin c cu trc dng vng cng l yu
t gy nn ung th.
- Bia, ru cng vy, c nguy c cao gy ung th khi x dng nhiu. Ngi ta cn thy
nhng ngi lm vic trong cc xng sa cha xe hi cng c t l ung th i trng cao
gp 2-3 ln ngi bnh thng, ngi ta cng cha bit r ti sao.
- Vitamin A, C: C tc dng nh l cht chng oxy ha, c tc dng ngn nga ung th i
trng. Rau ti xanh v cc loi rau dng hoa, vitamin E, acide folic, calci, yu t vi lng
nh Selenium cng c tc dng ngn nga c ung th i trng. Tuy nhin c ch chnh
xc th cng cha hon ton bit r.
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2. S khng insulin
Hot ng th lc c lin quan ngc li. Ngi mp ph, c khng insulin vi gia tng
insulin mu s lm tng nng yu t tng trng ging insulin typ 1 (IGF-1), yu t ny s
kch thch tng sinh nim mc rut.
3.Yu t di truyn v cc hi chng
Khong 25 % bnh nhn b ung th i trc trng c tin s gia nh b bnh, gi cho yu t
di truyn c sn. C 2 nhm chnh l bnh polyp gia nh v bnh ung th khng do polyp c
tnh di truyn.
- Polyp i trng c tnh cht gia nh: C hng ngn polyp dng tuyn sut chiu di ca i
trng. Bnh do thiu ht mt nhnh ca nhim sc th s 5, thng gp sau tui dy th vo
khong 25 tui v c kh nng pht trin thnh ung th trc 40 tui. Nn ct b i trng khi
pht hin bnh polyp ny, trong khi vi cc thuc NSAIDs cng c tc dng gim s lng v
kch thc polyp nhng ch c tnh tm thi. Con chu ca cc bnh nhn ny cn phi c
ni soi theo di ngay c khi trc tui dy th v c khong 50% c nguy c pht trin cc ri
lon tin ung th. V vy phi theo di bng soi trc trng v sigma cho n 35 tui.
- Ung th i trng khng phi polyp c tnh di truyn: Gp t nht 2 th h, l loi ung th
biu m tuyn, xy ra trc 50 tui, gp i trng ln, c th phi hp vi ung th bung
trng, ung th ni mc t cung. Tin lng tt hn loi polyp.
4. Vim rut
Ung th i trng gia tng bnh nhn b vim rut mn ko di. Ung th thng pht trin
bnh vim lot i trng hn l bnh Crohn v nguy c ny tng ln t 8- 30% nhng ngi
b vim rut mn ko di trn 25 nm, nht l ngi tr vim ton b i trng. Pht hin sm
bin chng ny bng theo di sinh thit thy c hin tng lon sn tuyn.
5. Cc yu t nguy c khc
- Nhim khun Streptococcus bovis: Vi khun t trong phn gy vim ni tm mc hay
nhim khun huyt c th gy ung th i trng tim n v ung th ng tiu hoa cao m
nguyn nhn cha bit r. Ni soi tiu ha v chp X quang l cc tt sng lc.
- M thng niu o- sigma: Ung th pht trin sau phu thut t 25- 30 nm, ti ni m
nim mc sigma lun tip xc vi nc tiu v phn.
- Thuc l: Nht l nhng ngi ht lin tc trn 35 nm. Nguyn nhn cha r.
IV. GII PHU BNH (H3, H4, H5)
Ung th i trc trng a s l ung th dng tuyn, t gp hn l loi lymphoma i trng v
u carcinoide. Ung th c th ch n c 1 v tr tn thng hay phi hp vi polyp hay c
th c nhiu v tr tn thng trn c i trng.
1. i th
Cng nh ung th d dy, ung th i trng cng c 3 th.
- Ung th th si hay dng polyp. Tn thng c th rng, li ra ngoi v thng c hnh nh
nhiu nhung mao.
- Ung th th lot si: Hay gp, c hnh nh lot trn khi si.
- Ung th th thm nhim: Nhim cng v dy vch i trng m khng c lot trn nim
mc. Loi ny t gp hn nhng tin lng xu.
2. Vi th
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Phn ln ung th i trng thuc loi biu m tuyn, kh nng bit ha cao, trung bnh hay
thp. C khong 20% thuc loi biu m ch tit nhiu cht nhy, c th gp loi biu m
dng biu b vi t bo lt tng (loi ny him gp).
V. TRIU CHNG
1. Lm sng
Ung th i trc trng thng c biu hin m thm vi din tin qua nhiu nm khng c
triu chng hay ch c thay i nh v thi quen i cu. Triu chng thng c khc nhau ty
thuc v tr ca khi u.
- Ung th i trng ln : V phn tng i lng khi i qua van hi manh trng i vo i
trng phi, cho nn vi ung th i trng ln, t khi c triu chng nghn rut. Tn thng
i trng phi thng c dng lot lm mt mu m mn tnh tng t m khng c thay i
phn r rng. Bnh nhn thng c triu chng mt mi, hi hp biu hin ca thiu mu
mn, nhc sc do thiu st, c th s c khi u vng h chu phi hay di h sn
phi. V ung th chy mu tng t nn xt nghim mu n trong phn c khi m tnh.
- Ung th i trng ngang v i trng xung: Phn c hn, khi ung th pht trin n
ln, n gy hp lng i trng tng i hay hp hon ton, i khi gy thng. Lm sng biu
hin au bng tng cn kiu bn tc v tc rut.
- Ung th i trng sigma v trc trng: Thng c biu hin ca hi chng l vi i cu
phn mu, mt rn, phn b dt km biu hin thiu mu m i khi nhm vi tr c chy
mu. Khm trc trng pht hin c khi u cng, si au v d chy mu khi ng vo.
V din tin m thm nn a s c pht hin khi bnh c bin chng tc rut hay di
cn m gan l v tr hay gp.
2. Cn lm sng
2.1. Soi i trng sigma
y l th thut n gin, nhanh chng gip pht hin 2/3 n 3/4 cc trng hp ung th
trc trng v sigma khi c biu hin hi chng l. N cn gip sinh thit hoc ct b u khi c
th hoc iu tr cm mu ti ch.
2.2. Soi i trng ton b
L phng tin chn on rt tt pht hin v tr tn thng i trng.
2.3. Siu m ni soi, CT scanner
L phng tin chn on tt cc tn thng khu tr di nim mc cng nh pht hin di
cn vo cc c quan k cn, gip chn on giai on TNM.
2.4. Chp phim nhum i trng c baryte
Pht hin cc khi u c ng knh > 2 cm, vi hnh nh lot si, hnh nh hp lng i trng
khng u nh hnh li to. Trng hp khi u nh < 1cm th cn dng k thut chp
quang kp. Thng thc hin nh hng v tr tn thng gip cho ni soi c k hn.
2.5. Cng thc mu
Hng cu, Hb gim khi c thiu mu.
2.6. St huyt thanh
Gim khi thiu mu do thiu st.
2.7. CEA
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y l ch im ung th chung cho ng tiu ho nhng t nhy, thng dng theo di ti
pht u sau ct b.
VI. BIN CHNG
1.Tc rut
L du chng cng nh bin chng thng gp ca ung th i trc trng, c th tc mt
phn hay hon ton. Tc do khi u gy nn hay do chn p ca hch.
2. Thng
Thng c th xy ra ngay ti khi u hoc trn khi u c bit manh trng.
3. Chn p cc c quan ln cn
U v cc hch di cn c th gy chn p vo d dy, chn p bng quang, chn p h thng
tnh mch tng gy c trng, chn p thn kinh chi di gy au.
VII. CHN ON
Da vo
- C hi chng l, thay i hnh dng phn, hay ch c ri lon thi quen bi phn.
- C thiu mu nhc sc.
- au bng, st, st cn.
- Khm trc trng c mu dnh gng, c u.
- Soi trc trng- sigma khi c biu hin hi chng l.
- Soi ton b i trng, sinh thit xt nghim m hc, chp nhum i trng c baryte.
Bng xp loi v tin lng ca Dukes.
Cc yu t tin lng v nh gi giai on ca ung th i trc trng ty thuc vo
su ca u, s xm ln vo vch rut, hin din ca hch vng cng nh s di cn xa ca u
(TNM). Theo phn loi ca Dukes, ung th i trng c 4 giai on:
- Giai on A (T1N0M0): Tn thng nng, khng xm ln vo lp c hoc hch vng.
- Giai on B: Tn thng xm ln xung su hn nhng cha n hch vng.
B1: T2N0M0. Tn thng ch gii hn lp c.
B2: T3N0M0. Tn thng xm ln n thanh mc
- Giai on C: TxN1M0. C hch vng
- Giai on D: TxNxM1. C di cn gan, phi, xng.
Di cn ca ung th i trc trng
Theo ng tnh mch ca n gan l hay gp nht v l ni di cn u tin, him khi thy di
cn n phi no, hch thng n m thiu di cn n gan. Ngoi l l khi ung th v tr xa
trc trng, cc t bo ung th c th theo m ri tnh mch cnh ct sng n phi v hch
thng n m khng n gan qua h tnh mch ca.
Tin lng thi gian sng
Khong 50% trng hp c th sng 6- 9 thng khi pht hin c di cn gan (gan ln, chc
nng gan bt thng) hay 20- 30 thng khi c cc nt nh trong gan vi tng CEA v bt
thng trn CT scan.
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Xp loi theo TNM
* T (tumour) biu th xm nhp ca ung th vo thnh i trng, nh s t T1 n T3,
trong T1 cn nim mc trong khi T3 xuyn n thanh mc.
* N (nodule) biu th c nh hng n hch vng hay khng.
* M (metastase) c di cn hay cha.
Bng 1: Xp loi theo TNM
GIAI ON
Gii phu bnh
T % sng
khong 5 nm
Dukes TNM S
A T1N0M0 I U gii hn nim mc v h nim mc > 90
B
1
T2N0M0 II U lan n lp c 85
B
2
T3N0M0 II U lan n hay xuyn qua thanh mc 70-80
C TxN1M0 III U nh hng n hch vng ln cn 35-65
D TxNxM1 IV Di cn xa (gan, phi) 5
VIII. D PHNG CP 1
1. Ha d phng
- Aspirin v cc NSAIDs: C tc dng c ch s tng sinh t bo do c ch tng hp
prostaglandin. N lm gim nguy c ung th i trc trng v gim c t l t vong do ung
th.
- Acide folic v calci: Lm gim nguy c ung th i trc trng dng polyp tuyn.
- Ch n giu cc cht chng oxy ha nh vitamin C, A c trong tri cy, rau xanh lm
gim thp t l ung th i trc trng nht l vi ngi c tht cc polyp tuyn lnh tnh..
- Liu php thay th oestrogen dng cho ph n sau tui mn kinh cng lm gim nguy c
ung th i trc trng nh vo vic gim tng hp IGF-1.
2. Cc tt sng lc
Chng trnh sng lc ung th i trc trng vi mc ch pht hin sm trng hp ung th
b mt v khu tr nhng ngi khng c triu chng. Chng trnh sng lc ny quan trng
i vi nhng ngi trn 40 tui, c tin s gia nh b bnh th h th 1 v ngi c a
polyp dng tuyn.
- Xt nghim thng quy l khm trc trng, khm ph khoa ph n trn 40 tui v tin lit
tuyn nam gii v bng siu m. Vic lm ny thc hin mi 3- 6 thng v l phng tin r
tin.
- Mu n trong phn: Xt nghim c mt s gii hn, ch dng tnh khong 50% trng hp
ung th i trc trng v chy mu thng xy ra tng t v c khi dng tnh gi, Vvy khi
c mu n (+) th cn phi lm thm xt nghim nh ni soi trc trng hay ton b i trng
hay chp nhum i trng c baryte.
- Soi sigma- trc trng: Khi c biu hin mu n trong phn (+).
- Soi i trng ton b: Khi c ri lon thi quen tng phn.
- CEA mi 3 thng cho ngi c nguy c cao.
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Hip hi ung th Hoa K khuyn co nn lm xt nghim mu n trong phn hng nm v
ni soi sigma trc trng mi 5 nm bt u t 50 tui ngi khng c triu chng m khng
c nguy c ung th i trc trng. Ni soi i trng ton b hay chp nhum i trng i
quang kp thc hin mi 10 nm c th thay cho soi i trng sigma v xt nghim mu n
trong phn.
- Tm t bin gen c ch u APC (adenomatous polyposis coli) trong phn l xt nghim
ang c thc hin.
IX. CHN ON PHN BIT
1.U Amp i trng
Manh trng v i trng sigma l 2 ni thng gp u amp: Tnh cht lnh tnh ca u trn
phim chp nhum baryte vi biu hin u c hnh trn hay bu dc, hp ng tm, thnh u
n. Chn on bng ni soi v sinh thit, iu tr th.
2. Lao hi manh trng
Thng th pht sau lao phi. Lm sng c du nhim lao, ri lon phn dng tiu chy hay
c to bn xen k, au bng tng cn c du bn tc rut, s c mng au h chu phi,
IDR (+), phim i trng c baryte cho thy c hnh nh hp u v mt chc nng van
Bauhin, ni soi i trng cho thy c hnh nh tn thng lot c hoi t dng b u vng
manh trng.
3. Bnh crohn hi trng, i trng
Bnh c nhiu t tin trin, ko di nhiu nm, c ri lon phn km biu hin du chng
ngoi rut nh ng mt, khp, lot ming. c im trn phim nhum i trng c baryte
cho hnh nh hp nh si ch. Chn on xc nh bng ni soi sinh thit vi s hin din t
bo biu m khng l.
4. Vim lot i trc trng chy mu
Bnh t mim, thng xy ra nam gii, t 20 n 40 tui. Lm sng c st tng t trong
giai on tin trin km au khp v i cu mu ti. Ni soi cho hnh nh lot nng lan rng
ton b i trng v trc trng, sinh thit ch thy c t bo vim m khng c lon sn.
X. CC LOI UNG TH I TRNG KHC
1. Lymphoma i trng
Lymphoma i trng tin pht ch chim khong < 0, 5% ca cc th c tnh ca i trng, gia
tng hi chng Sjogren, bnh m ht Wegener, vim khp thp, lupus ban h thng, v
hi chng suy gin min dch mc phi.
Lm sng biu hin triu chng au khng c hiu, st cn, to bn v chy mu tiu ha.
Ni soi i trng cho thy tn thng khi u bit lp hay tn thng thm nhim lan ta.
Khong 50% tn thng nm hi trng, 50% c km hch c tnh. Chn on bng ni soi
sinh thit. Tin lng bnh cng xu, sng 2 nm ch c 40%.
2. U carcinoid
Thng gp nht rut tha, i khi trc trng di dng polyp khng triu chng hay c
th chy mu (25%). U carcinoid ca trc trng v rut tha t khi di cn. Cc vng khc th t
gp hn v thng gy hp v chy mu v thng di cn. Kh nng c tnh ca u carcinoid
l cao.
XI. IU TR
216
iu tr ung th i trng, trc trng ch yu l ngoi khoa. X tr v ho tr thng c tnh
cht h tr, c th x dng ng thi hay sau khi phu thut.
Hiu qu iu tr ty thuc vo giai on pht hin bnh, khi c ch nh phu thut cng nh
qu trnh theo di v iu tr b sung sau phu thut. Ngoi ra, n cn ty thuc vo mt s
yu t c nh hng n qu trnh hnh thnh ung th, thng c gi l cc yu t nguy c.
1.Phu thut
Phu thut ct b khi ung th khi pht hin l ch nh gn nh tuyt i. Ha liu php v
x tr ch mang tnh cht h tr.
1.1.Trc khi phu thut cn thc hin
- Cn ni soi ton b i trng pht hin cc ung th hay cc polype c nguy c ung th
ha cc v tr khc ca i trng.
- nh lng CEA theo di hu phu.
- Chp CT scanner: Gip pht hin nhng trng hp di cn gan nh m siu m c th b
st.
- Siu m ni trc trng: l mt k thut siu m mi, gip kho st vng chu v nh gi
giai on ung th trc trng.
Phu thut cng c ch nh ngay c khi c di cn xa, v c th lm gim cc triu chng
xut huyt, tc rut, au bng, lm cht lng cuc sng ca bnh nhn nhng ngy cn li
tt hn.
1.2. Theo di sau phu thut:
- Nhng ung th xuyn thnh, bnh nhn c yu t nguy c di truyn l i tng c t l
ti pht cao. Ung th ngay ti ming ni cng l mt nguy c khc khi vng ct khng
loi b ht cc t bo c tnh khng nhn c bng mt thng. V vy theo di sau phu
thut l bt buc.
- Khm nh k l phng php theo di hu hiu nht. Nu trc phu thut cha lm ni
soi i trng c th sau m mt vi thng cn thc hin th thut ny. Bnh nhn cn c
theo di t nht hai ln trong mt nm vi ni soi (tt nht), X quang hay siu m bng, nhng
trng hp c nguy c cao c th 3 ln mt nm. Cn theo di CEA mi 3-6 thng.
2.X tr liu
X tr vng chu c ch nh b sung sau phu thut ct b u nht l khi u xuyn thnh n
thanh mc (v u c th di cn sm n vng ny do c h bch mch rt phong ph). X tr
d trc hay sau phu thut cng phng c di cn vng chu, nhng khng ko di c
i sng cho bnh nhn mt cch ng k.
3.Ha tr liu
- Hiu qu ca iu tr ha cht mt mnh l km, v vy thng dng nh l mt iu tr b
sung cho phu thut. Hiu qu nht cho n nay vn l 5-FU mt mnh hay phi hp thm vi
mt s thuc khc. Hiu qu gim 15-20% kch thc khi u trong 50% trng hp (hiu qu
mt phn).
- Trong trng hp di cn gan, a 5-FU trc tip vo khi u qua ng mch gan hiu qu
hn truyn qua tnh mch ngoi bin, nhng t tin v cng c hn trong khi i sng bnh
nhn cng khng ko di hn.
217
- Phi hp 5-FU vi acide folinic (cn gi l yu t leucovorin hay citrovorum) ci thin hiu
qu ca 5-FU n gp 3 ln, tuy nhin c tnh cng tng ln.
* Liu lng c th
- 5-FU 425mg/m2 TM (5') + Ca-folinate 200mg/m2 TM. Dng t ngy 1-5. Ngy th 29, lp
li liu trnh. C th 6 chu k
Nhng trng hp di cn gan n thun, khng km theo cc vng khc c th c ch inh
ct mt phn gan v t l sng n 5 nm chim 20-30%.
- Phi hp phu thut vi x tr, ha liu php c nh gi tt nhng bnh nhn giai
on B hay C, xem nh l bin php tit cn trong trong hp cha c di cn. C tc gi cn
dng thm levamisol c tc dng iu ha min dch, c th lm gim kh nng ti pht 40%,
nhng khng ko di cuc sng trn 5 nm bao nhiu so vi khng dng levamisol.
4. Min dch liu php
Khng th n dng 17-1A edrecolomab (Panorex) ang c th nghim. Kt qu ca nhiu
th nghim cho thy c hiu qu tt hn so vi ha tr liu 5 FU n c hay phi hp. u
im ln nht ca min dch tr liu l n c th tip tc tiu dit nhng t bo ung th cn st
li. Hin nay ngi ta ang th nghim cho K i trc trng giai on II (DukesB2/B3). Tc
dng ph ca min dch liu php bao gm d ng vi protein ca chut, nn, bun nn, tiu
chy.
XII. PHNG BNH
- Ch n: t m ng vt, nhiu cht x (ang cn bn ci).
- Ch sinh hot, luyn tp, trnh bo ph, b thuc l, ru bia.
- Thuc: x dng Aspirin v cc thuc khng vim khng steroide khc (NSAID) t ra c
hiu qu, lm gim nguy c ung th i trc trng.
- Cc thuc khng oxyd ha nh vitamin C, E mt thi c cp n nhng khng c
bng chng c th.
- Estrogen cho ph n mn kinh c th lm gim nguy c ung th i trc trng nhng
ngi ny.
- Ch sng lc cho nhng i tng c nguy c cao (c thn nhn, c bit thn thch loi
1) mc ung th i trc trng. Hiu qu nht l ni soi i trng 2 hay 3 nm mt ln. C th
nh lng CEA mi 3 thng. n gin hn l khm nh k 3-6 thng mt ln vi thm trc
trng, m o, siu m bng. Theo di mu n trong phn c nhy v c hiu thp nn
t khi x dng d phng php ny d thc hin v t tn km.

H1. Polype khng cung, dt H2. polype c cung

218



H3. K i trng th lot H4. K i trng th si H5.K i trng th thm nhim

219
VIM RUT MN
Mc tiu
1. K c cc c im chung ca cc bnh l vim rut mn.
2. Trnh by c cc triu chng lm sng v cn lm sng ca bnh crohn v vim lot
i trng
3. K c cc bin chng ca 2 th bnh trn.
4. Bit cch iu tr bnh Crohn v vim lot i trng

I. I CNG
Cc bnh vim rut mn tnh thng gm hai bnh chnh:
Vim i trc trng chy mu (Recto-colite hmorragique) hoc vim lot i trng
(ulcerative colitis) theo cch gi ca cc tc gi Anh M.
Bnh Crohn hay vim rut tng vng.
C 2 u c cc c trng sau
- Mt tnh trng vim mn tnh rut.
- Thng gp thiu nin v ngi tr.
- Tin trin ko di, khi tng khi gim nhng khng bao gi lnh t pht.
- Bnh nguyn cha c bit r.
- Cha c phng php iu tr ni khoa tn gc.
- iu tr bng thuc khng vim, Corticoide, v c ch min dch c hiu qu khng hng
nh.
II. BNH CROHN
1. Bnh nguyn v c ch bnh sinh
Thng tn rut l hu qu ca mt s hot ha khng c kim sot ca h thng
min dch ca nim mc.
Cc yu t nhim khun v di truyn cng tham gia vo c ch bnh sinh.
2. Cc triu chng lm sng
2.1 Cc triu chng thng gp
au bng: thng gp, c v tr thay i, thng au qun dc khung i trng, c khi c hi
chng Koenig
i chy, c khi i chy ra m hoc mu, tn s thay i.
Trong cc t cp thng c suy nhc, chn n, st cn v st nh
C th phn lp mt s biu hin lm sng thng gp nht:
i chy ko di km st.
Hi chng gi rut tha (thng tn hi trng hoc hi trng-i trng phi): au h chu
phi khng r rng, mng gii hn khng r h chu phi.
Hi chng l
220
Hi chng ging bnh i trng chc nng.
Vim i trng cp nng: i chy t, thng c mu, au bng d di ton bng, bng
chng. Ton thn c st, tim nhanh, mt l. Xt nghim: thiu mu, gim albumin mu.
2.2. Cc thng tn vng hu mn - tng sinh mn: c gi tr gi chn on.
Cc vt xc (fissure) v lot cp hu mn - trc trng.
Hp x ha ng hu mn, c khi hp rt nng.
p xe v cc l d, c th c bin chng d bng quang hoc d sinh dc
2.3. Cc triu chng ngoi tiu ha
Xng khp: vim khp:vim ct sng dnh khp, vim khp cng chu.
Da, nim mc: hng ban nt, hoi th da m, hng ban a dng.
Mt: vim mng b o, lot gic mc.
Gan mt: gan nhim m, vim gan mn, vim gan u ht, si ti mt
3. Tin trin v bin chng
3.1. Tin trin: bnh tin trin thnh tng t; 90% cc t tin trin c th khng ch c
bi liu php corticoide. Trong trng hp xu, cc t cp ngy cng dy hn.
3.2. Bin chng
- Tc rut: Lng rut hp do vim v do qu trnh x ha tin trin.
- D v p xe trong bng
- Xut huyt tiu ha
4. Chn on bnh Crohn: Do khng c tiu chun c hiu nn chn on bnh cn da vo
tng th cc triu chng lm sng v cc thm d sau.
4.1. Sinh hc
- Cy phn v xt nghim k sinh trng loi tr i chy nhim khun.
- Trong t cp c tng bch cu, tc lng mu tng.
- Feritine gim, albumin gim, thiu mu hn hp (thiu cht v do vim), tng tiu cu.
- Cc xt nghim c th cho hi chng km hp thu.
4.2. Ni soi: l xt nghim c bn cho chn on, ng thi gip nh gi mc lan rng
ca thng tn: 70-80% c thng tn i trng, 20-30% ch thng tn ring bit rut non.
Thng tn nng nh sung huyt, ph n nim mc, lot apt hoc lot dc.
Thng tn tin trin su nh lot su, so x (so lot, gi polyp, hp..).
Gia cc nim mc bnh l c cc khong lnh.
4.3. T chc hc: ph n lp m, thm nhim lympho bo, lot v u ht dng biu b t bo
ln khng c hoi t b u.
4.4. Thm d hnh nh
- Chp i trng cn quang: c ch trong trng hp ni soi khng hon ton hoc c cc l
d khng pht hin c bng ni soi. Cc du hiu X quang bao gm cc thng tn lot,
gi polyp to thnh hnh nh lt , l d, hnh nh hp cc quai rut, trng hp in hnh c
hp nhiu ch cch nhau bi nhng on rut lnh b dn to.
221
- Chp ct lp vi tnh bng: trong trng hp c khi bng hoc nghi c nung m.
5. iu tr bnh Crohn
5.1. Cc phng tin iu tr
5.1.1. Cc dn xut salicylic
- Sulfasalazine: thuc c in nht trong nhm ny, cu to bi sulfapyridine gn vi acid 5
amino salicylic (5 ASA), t hp thu rut non, khi vo i trng s b cc vi khun rut phn
hy gii phng 5 ASA.
Sulfasalazine ch tc dng trong trng hp c thng tn i trng hoc hi - i trng, c
th dng trong cc t tin trin, khng hiu qu trong duy tr giai on lui bnh.
- Mesalazine l dn xut Salicylic khng c cha Sulfapyridine v dung np tt hn.
- Cc thuc khc: Asacol, olsalazine, balsalazide.
- C ch tc dng: c ch s tng trng ca t bo T, s trnh din khng nguyn ln cc t
bo T v s sn xut khng th ca t bo B. ngoi ra tc dng khng vim thng qua s c
ch cyclo-oxygenase lm gim s sn xut prostaglandin.
5.1.2. Corticoid
L mt phng tin iu tr quan trng trong cc t cp:
+ Prednisolon liu 1 mg/kg/ng trong 3-7 tun, sau gim liu theo kiu bc thang mi 10
mg cho n 1/2 liu, sau gim mi 5 mg mi tun ko di cho liu trnh 12 tun.
+Cc loi Corticoid mi: fluticasone propionate, tixocortol pivalate, beclomethasone
dipropionate, v budesonide, cc thuc ny c u im l c i lc ln cc th th corticoid
ln hn loi corticoid c in, ng thi tng s chuyn ha qua gan ln u nn t tc dng
ph ton thn hn.
Trong , Budesonide thng c s dng nhiu trong bnh crohn, thuc gi phng hi
trng v tc dng chnh ln on cui hi trng v i trng phi, vi liu dng t 6-9mg/ng.
5.1.3. Cc thuc c ch min dch
+ Azathioprine: c hiu qu r nht, c bit cc bnh nhn ph thuc Corticoid hoc
duy tr t lui bnh, cng hiu qu trong iu tr cc l d rut - da hoc d hu mn- tng
sinh mn.
Tc dng chm, triu chng bt u ci thin sau 3 thng
Tc dng ph:c ch ty, vim ty cp, vim gan cp, khng dung np tiu ha v phn ng
d ng.
+ Methotrexate cng hiu qu trong cc th l thuc Corticoid hoc khng p ng iu tr
Azathioprine, tc dng xut hin sm t thng u tin.
5.1.4. Nui dng nhn to
L iu tr tt trong cc t cp, nui dng qua ng ngoi rut hoc ng rut em li t
l lui bnh cao v tng ng Corticoid
5.1.5. Cc phng php iu tr khc
- Khng sinh:
+ Metronidazole tc dng tt trong cc thng tn hu mn tng sinh mn.
+ Ciprofloxacine (Ciflox) cng c hiu qu tng t.
222
+ Gn y clarythromycin cng c chng minh l mt phng tin hu ch trong bnh
Crohn.
- Min dch
+ Cc khng th n dng chng yu t hoi t u loi Anti-TNF v Interleukine 10 (IL 10) t
ra c kt qu rt tt trong nhiu th nng: INFLIXIMAB( Remicade).
5.2. Ch nh v chin lc iu tr bnh Crohn
t tin trin nh hoc trung bnh
- Mesalazine 4g/ng
- Sulfasalazine 3 - 4 g/ng, duy nht trong th i trng
- Metronidazole 10 - 20 mg/kg/ng hoc Ciprofloxacine 1g/ng.
- Budesonide 9 mg/ng trong th hi trng (i trng phi
t tin trin nng hn hoc tht bi iu tr ni trn
- Prednisolon 1 mg/kg/ng
- Nu tht bi, Corticoid ng ton thn 1 mg/kg/ng
t tin trin trm trng
- Corticoid ng ton thn 1 mg/kg/ng
- nui dng ton b dng ngoi rut khi suy dng nng khng sinh
- nu tht bi, Cyclosporine TM hoc phu thut
iu tr duy tr t lui bnh
- Mesalazine 2 - 4 g/ng
- nu tht bi, Azathioprine
Th l thuc Corticoid hoc th tin trin mn tnh
- Azathioprine.
- nu tht bi, Methotrexate.
- nu vn tht bi, phu thut hoc Corticoid liu thp (<10mg/ng).
Th khng Corticoid
- nui dng ng ngoi rut hoc ng rut
- nu tht bi, Methotrexate, Cyclosporine
- IL 10 hoc Infliximab.
Phng ti pht sau m
- Mesalazine 2-3 g/ng
III. VIM I -TRC TRNG CHY MU
1. Bnh nguyn: nhiu kh nng c vai tr ca cc yu t di truyn. S hot ha h thng
min dch c vai tr quan trng. Vai tr ca cc yu t nhim khun cha r rng.
2. Gii phu bnh: nh khu: ch yu trc trng v t nhiu i trng, him hn l thng
tn ton b i trng (pancolite).
3. Lm sng
223
3.1. Th thng thng: vim trc trng - i trng xich ma nh - va:
i cu nhy mu nhiu, c khi khng c phn, km mt rn, c khi c to bn.
Ton trng t thay i v khm thc th khng pht hin c g.
Thm trc trng c th thy nim mc dng lt v c mu dnh gng.
Th ny khng c bin i v sinh hc.
Chn on da vo
Loi tr vim i trng nhim khun v k sinh trng da vo cy phn v xt nghim k
sinh trng, cn lm trong t tin trin u tin.
Soi i trng -hi trng: thng tn trc trng v i trng sich ma ng nht, gii hn trn
r, phn i trng cn li v on cui hi trng bnh thng. Nim mc , dng lt , chy
mu t nhin hoc khi tip xc, thng khng c lot.
Sinh thit ton b khung i trng, c nim mc bnh ln nim mc lnh.
3.2. Cc biu hin ngoi tiu ha
Khp: au hoc vim khp, nh hng ch yu cc khp ln ca chi,
Da: thng gp nht l hng ban nt, c th c vim da m hoc lot ap t ming.
Mt: vim thng cng mc, vim mng mt v vim mng b o.
Cc thng tn khp, mt v da thng tin trin song song vi cc thng tn rut.
4. Tin trin v bin chng
4.1. Tin trin: bnh tin trin thnh tng t, gia cc t c cc t lui bnh khng c triu
chng.
4.2. Bin chng
- Dn i trng, hay i trng ln nhim c: gp trong cc t tin trin cp nng.
- Thng: thng b che lp bi Corticoide.
- Xut huyt lan ta.
- Nguy c ung th biu m i trng tng ln trong trng hp vim ton b i trng.
5. iu tr vim i trc trng chy mu
5.1. iu tr ni khoa
Ch yu da vo cc thuc khng vim dng ko di.
+ Salazosulfapyridine (Salazopyrine) v cc dn xut nh Pentasa, Rowasa v Dipentum,
dng trong cc th nh hoc dng iu tr duy tr cc i lui bnh, c ch phm dng di
dng tht vo trc trng.
+ Corticoide: trong cc t tin trin va hoc nng, lu tc dng ph khi dng ko di.
+ Tit thc hn ch ti a si c dng trong cc t tin trin
5.2. iu tr ngoi khoa
5.2.1. Ch nh
Cc t tin trin nng sau tht bi ca mt t iu tr ni khoa mnh v ngn.
Bin chng thng hoc xut huyt lan ta
224
Trong trng hp ung th hoc lon sn nng
Trong cc th mn tnh lin tc khng p ng iu tr ni khoa gy suy kit
5.2.2. cc phng php iu tr ngoi khoa
- ct i trng-trc trng km m thng hi trng
- ct i trng-trc trng km ni hi trng-hu mn
- ct i trng km ni hi trng-trc trng
225
HI CHNG KM HP THU
Mc tiu
1. Trnh by c cc triu chng lm sng v cn lm sng ca hi chng km hp thu
2. K c mt s nguyn nhn thng gp ca hi chng km hp thu

I. I CNG
Hi chng km hp thu biu hin tnh trng suy gim mt phn hoc hon ton chc
nng hp thu ca ng tiu ha. Chn on hi chng km hp thu thng khng kh khn
nhng vic chn on nguyn nhn thng phc tp.
II. TRIU CHNG LM SNG
- Gy st mc d vn cn cm gic ngon ming
- i chy
- Chng bng
- Huyt p thp: do thiu nc v suy dng.
- Cc triu chng lm sng v sinh hc ca thiu vitamin: do hu qu ca km hp thu ko di
- Thiu mu: do km hp thu st, B 12 v acide folic.
- Chy mu
- Cn tetanie: do thiu calci
- Yu c: do suy dng, h Kali mu.
- Qung g: do thiu vitamine A
- Vim a dy thn kinh ngoi bin: do thiu vitamine B12 v B1.
III. XT NGHIM
Cc du hiu sinh hc gin tip
- Thiu mu, Fe huyt thanh gim, folate v vitamin B12 gim.
- Calci mu gim
- T prothrombin gim
- Albumin mu gim
- Cholesterol mu gim
Cc thm d chc nng hp thu
- nh lng m trong phn: > 6 g/24 gi.
- Trc nghim D-Xylose: < 250 mg/l vo lc 2gi.
- Trc nghim Schilling km yu t ni < 10%.
226
IV. CC NGUYN NHN CHNH CA HI CHNG KM HP THU
Bng 1: Cc nguyn nhn thng gp ca hi chng km hp thu:
Nguyn nhn Chn on
Trc t bo rut (lng rut)
Vim ty mn, ung th ty

Tc mt, d mt
Tng sinh vi khun rut

Phim bng khng chun b, siu m hoc
chp ct lp
Xt nghim gan, siu m
Tt th, chp lu chuyn rut
T bo rut
Bnh coeliac
Thiu immunoglobulin
Nhim giardia
Bnh Whipple
Thng tn rut: bnh Crohn, ct rut, d
rut, u lympho...

Sinh thit t trng
nh lng Ig
Xt nghim k sinh trng
Tin s, bnh s
Chp lu chuyn rut, ni soi..
Sau t bo rut
Dn bch mch tin pht hoc th pht

Xt nghim hnh thi, sinh thit, thanh lc
alpha-1-antitrypsin.
1. Bnh Coeliac
L nguyn nhn thng gp nht ca hi chng km hp thu ngi ln v tr em.
Bnh do mt tnh trng bt dung np ca nim mc ng tiu ha vi cc mnh protein trong
gluten ca ng cc, nht l gliadine
Biu hin bng i chy mn tnh, hi chng thiu cc cht dinh dng (thiu mu, long
xng, au xng...), km theo mt s biu hin ngoi tiu ha nh au khp, vim da dng
hec pt, mt s biu hin t min khc.
Chn on bng ni soi v sinh thit nim mc t trng, chp lu chuyn rut non ch yu
pht hin cc bin chng nh lot hoc u lympho.
iu tr ch yu bng tit thc khng c gluten.
2. Bnh Whipple
c xem l do nhim trng loi Tropheryma whippleii.
Triu chng phi hp mt hi chng km hp thu vi cc triu chng ngoi ng tiu ha nh
vim a khp, st, cc triu chng thn kinh.
Chn on da vo sinh thit nim mc t-hng trng.
Bnh thng p ng vi iu tr khng sinh.
3. Tng sinh vi khun rut
Yu t lm d thng l bt thng gii phu rut (quai m, hp khu tr hoc ti tha i
trng) hoc bt thng chc nng (x cng b, gi tc rut mn tnh, khng c acid
chlohydric).
227
Chn on da vo tt th vi gluco.
i chy thng gim i khi iu tr khng sinh
4. Suy ty ngoi tit
Thng do vim ty mn, him hn l ung th ty, ct b ty...


228
CU HI NH GI
1. Bnh nguyn ca lot d dy t trng.
2. Triu chng lm sng ca lot d dy v ca lot t trng.
3. Bin chng ca lot d dy t trng.
4. Cc nhm thuc iu tr lot d dy t trng.
5. Nguyn nhn v lm sng ca vim d dy cp.
6. Cc th vim d dy mn.
7. iu tr vim d dy cp.
8. iu tr vim d dy mn.
9. Lm sng vim ng mt ti mt cp.
10. Bin chng ca vim ng mt ti mt cp.
11. iu tr vim ng mt ti mt cp.
12. Phn loi vim gan mn.
13. Triu chng lm sng v cn lm sng ca vim gan mn.
14. Chn on phn bit vim gan mn tn ti v vim gan mn hot ng.
15. iu tr vim gan mn virus B.
16. Triu chng lm sng v cn lm sng ca x gan.
17. Bin chng ca x gan.
18. iu tr x gan.
19. nh gi giai on x gan theo ch s Child Pugh.
20. Bnh nguyn v cc yu t nguy c ca ung th gan gan nguyn pht.
21. Triu chng lm sng v cn lm sng ca ung th gan nguyn pht.
22. Phng php tim cn tuyt i v phng php gy tc mch trong iu tr ung th gan
nguyn pht.
23. Nu cc loi tn thng gii phu bnh trong ung th d dy.
24. Triu chng lm sng v cn lm sng ca ung th d dy.
25. Tin lng bnh ung th d dy theo phn lai TNM.
26. Triu chng lm sng ca p xe gan amp.
27. Triu chng cn lm sng ca p xe gan amp.
28. iu tr ni khoa p xe gan amp.
29. Bnh nguyn ca vim ty cp.
30. Lm sng ca vim ty cp.
31. Xt nghim cn lm sng trong vim ty cp.
32. Bin chng ca vim ty cp.
33. iu tr vim ty cp th thng.
34. Cc yu t nguy c ca ung th i trc trng.
35. Triu chng lm sng v cn lm sng ca ung th i trc trng.
36. Phn loi ung th i trng theo Dukes.
37. Triu chng lm sng bnh Crohn.
38. iu tr bnh Crohn.
39. Lm sng v iu tr ni khoa vim i trc trng chy mu.
40. Nu cc nguyn nhn ca hi chng km hp thu.
229
TI LIU THAM KHO
1. Bch khoa th bnh hc (2002), NXB Y hc H ni.
2. Bi ging bnh hc Ni khoa (1992), B mn Ni, trng i hc Y H ni, NXB Y hc.
3. Xun Chng (1992), Bi ging bnh hc Ni khoa sau i hc. Hc vin qun Y.
4. Nguyn Th Khnh, Phm T Dng (2001), Ho nghim s dng trong lm sng, NXB Y hc
5. B. Devulder, P.Y. Hatron, E. Hachulla (2002), Medecine interne, Masson, Paris.
healing of duodenal ulcer (1990), Gastroenterology (1990).
6. Buton Combes and Steven Schenker (1992), Laboratory tests Disease of the liver.
7. Current Medical Diagnosis and treatment (2002), Lange.
8. Harrison' s : Principles of internal medicine, 16th edition, 2005.
9. Jean Claude Rambaud (2002), Trait de Gastro- enterologie, Flmmrion.
10. Lee EL, Feldman M (2002), Gastritis and other gastropathies. Sleisengers textbook of
gastrointestinal and liver disease.
11. Mark Feldman, Marvin H.Sleisenger: Gastrointestinal and liver disease, 7
th
edition, 2001.
12. Sheila Sherlock, James Dooley (2002), Diseases of the liver and biliary system eleventh
Edition.
13. Tadataka Yamada: Gastroenterology, 2005.
14. www.martindalecenter.com
15. www.en.wikipedia.org
16. www.medicinenet.com
17. www.vista.gov.vn

230
CHNG 3
H HP

PH VIM THY-PH QUN PH VIM
Mc tiu
1.Nu c cc nguyn nhn gy vim phi.
2.Nm vng triu chng lm sng, chn on vim phi thu v ph qun ph vim
3. Bit c iu tr h tr v iu tr triu chng.
4. Bit iu tr nguyn nhn gy vim phi.
5. Bit c bin php d phng vim phi
Ni dung
I. NH NGHA: Vim phi l mt bnh cnh lm sng do thng tn t chc phi (ph
nang, t chc lin kt k v tiu ph qun tn cng), gy nn do nhiu tc nhn nh vi khun,
virus, nm, k sinh trng, ha cht...
Ngi ta phn ra vim phi thy v ph qun ph vim
II. DCH T HC: Bnh thng xy ra nhng ngi c c a xu nh ngi gi, tr em
suy dinh dng, c a c cc bnh mn tnh, gim min dch, nghin ru, suy dng hay
cc bnh phi c trc nh (vim ph qun mn, gin ph qun, hen ph qun...). Bnh
thng xut hin lc thay i thi tit, yu t mi trng thun li v c th to thnh dch
nht l virus, ph cu, Hemophillus.
- cc nc kinh t ang pht trin, vim phi c xp vo hng th 4 trong cc nguyn
nhn t vong v l nguyn nhn thng gp nht gy t vong trong cc bnh l nhim trng
(Hi tho v khng sinh v khng thuc-ISAAR 2005). Khong 20-30% vim phi cn nhp
vin, v t l t vong khong 1% i vi cc trng hp iu tr ngoi bnh vin, v 5-30%
i vi cc ca iu tr trong bnh vin
- Vit Nam, cc nghin cu cho thy vim phi nhp vin thng l vim phi ngi ln
tui. T l t vong chung l 7-20% (Hi ngh khoa hc Bnh phi ton quc 2005)
III. BNH NGUYN: Do nhiu nguyn nhn gy bnh khc nhau
1. Do vi khun
Cc loi vi khun gy nn vim phi thng gp nht hin nay l: Ph cu khun,
Hemophillus influenzae, Legionella pneumophila, Mycoplasma pneumoniae.Ngoi ra cn c
cc loi vi khun khc nh Lin cu, t cu vng, Friedlander (Klebsiella pneumoniae),
Pseudomonas aeruginosa, cc vi chun k kh nh Fusobacterium, hoc l cc vi khun gram
m, thng hn, dch hch...
2. Do virus
Nh virus cm (Influenza virus), virus si, Adenovirus, u ma, bnh tng bch cu n
nhn nhim khun. M vim phi do virus 73 % nhim khun h hp- 40% do virus cm.
3. Nm: Actinomyces, Blastomyces, Aspergillus...
4. Do k sinh trng: Amip, giun a, sn l phi.
231
5. Do ha cht: Xng, du, acid, dch d dy.
6. Do cc nguyn nhn khc: Nh bc x, tc ph qun do u ph qun phi, do ng...
IV. C CH BNH SINH
Tc nhn gy bnh vo phi thng l qua ng th (khng kh, vi khun ng h hp
trn) b ht xung, gp iu kin mi trng thun li, sc khng ca c th km hoc do
c lc vi khun mnh... Hoc tc nhn gy bnh cc c quan ln cn nh mng phi, mng
tim, gan... hay n qua ng mu, bch mch v ngc li t phi c th n c quan ln
cn v vo mu gy nhim trng huyt.
Vai tr c a rt quan trng nht l ngi nghin ru, thuc l, suy dng, gim kh nng
min dch v cc bnh mn tnh phi ng gp vai tr quan trng trong bnh sinh v p
ng iu tr.
V. GII PHU BNH
1.Vim phi thy: Thng tn c th l mt phn thy, mt thy hay nhiu thy, hoc c khi
c hai bn phi, thng gp nht l thy di phi phi.
Theo s m t ca Laennec th c cc giai on
1.1.Giai on sung huyt: Vng phi thng tn b sung huyt nng, cc mao mch gin ra,
hng cu, bch cu v fibrin thot vo trong lng ph nang, trong dch ny c cha nhiu vi
khun.
1.2.Giai on gan ha : Trong mt n 3 ngy t chc phi b thng tn c mu xm
v chc nh gan, trong t chc ny c th c xut huyt.
1.3.Giai on gan ha xm: Thung tn phi c mu nu xm cha hng cu, bch cu, vi
khun v t chc hoi t.
1.4.Giai on lui bnh: Trong lng ph nang cn t dch long, c t bch cu.
2. Ph qun, ph vim: Cc thng tn ri rc c hai phi, vng thng tn xen ln vi vng
phi lnh, cc tiu ph qun thng tn nng n hn, cc thng tn khng u nhau v khi
khi thng li x.
VI. TRIU CHNG HC
1. Ph vim thy: in hnh l do ph cu.
y l nguyn nhn hng u gy vim phi thy, chim t l 60-70%, xy ra mi la tui
nhng thng gp l tr con, ngi gi, suy dinh dng, gim min dch th t l cao hn,
bnh thngxy ra vo ma ng-xun v c khi gy thnh dch, hoc xy ra sau cc trng
hp nhim virus ng h hp trn nh cm, si, herpes... hay ngi bnh hn m, nm
lu, suy kit...
1.1. Giai on khi pht: Bnh thng khi u t ngt vi st cao,rt run, st dao ng
trong ngy, c au tc ngc, kh th nh, mch nhanh, ho khan, ton trng mt mi, gy
st, chn n, mi ming c Herpes, nhng cc triu chng thc th cn ngho nn.
1.2.Giai on ton pht: Thng t ngy th 3 tr i, cc triu chng lm sng y hn,
tnh trng nhim trng nng ln vi st cao lin tc, mt mi, gy st, bing n, kht nc,
au ngc tng ln, kh th nng hn, ho nhiu, m c c mu g st hay c mu, nc tiu
t v sm mu
Khm phi c hi chng ng c phi in hnh (hoc khng in hnh) vi rung thanh
tng, n cc khong gian sn au, g c, nghe m ph bo gim, m thi ng v ran n kh
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chung quanh vng ng c. Nu thng tn nhiu th c du suy h hp cp, c gan ln v
au, c khi c vng da v xut huyt di da, tr em c ri lon tiu ha nh bun nn, nn,
bng chng.
Cn lm sng: Xt nghim mu s lng bch cu tng, bch cu trung tnh tng, tc mu
lng cao, soi ti v cy m c th tm thy ph cu, c khi cy mu c ph cu. Chp phim
phi thy mt m m b r hay khng r chim mt thy hay phn thy v thng gp l
thy di phi phi.
1.3. Giai on lui bnh:
- Nu sc khng tt, iu tr sm v ng th bnh s thoi lui sau 7 - 10 ngy,
nhit gim dn, ton trng khe hn, n cm thy ngon, nc tiu tng dn, ho nhiu v
m long, trong, au ngc v kh th gim dn. Khm phi thy m thi ng bin mt, ran
n gim i thay vo l ran m. Thng triu chng c nng gim sm hn triu chng thc
th. Xt nghim mu s lng bch cu tr v bnh thng, lng mu bnh thng, thng
tn phi trn X quang m dn. Bnh khi hn sau 10-15 ngy.
-Nu khng iu tr hay iu tr khng ng, sc khng qu km th bnh s nng
dn, tnh trng nhim trng, nhim c tng ln, suy h hp, nhim trng huyt hay c nhiu
bin chng khc nh p xe phi, trn dch, trn m mng phi,mng tim...
2. Ph qun ph vim: Bnh thng xy ra tr em v ngi gi, ngi suy kit, hn m, sau
cc nhim virus lm suy yu min dch hay c mt bnh mn tnh...
Bnh khi pht t t vi st tng dn, kh th cng lc cng tng dn n suy h hp cp,
ton trng biu hin mt nhim trng nhim c cp, nng, c th l m, m sng... khm
phi nghe c ran n, ran m, ran ph qun, ri rc c hai phi, lan ta rt nhanh, y l mt
bnh cnh lm sng va thng tn phi v ph qun lan ta.
Xt nghim mu thy bch cu tng cao, bch cu trung tnh tng, lng mu tng c bit l
phim phi thy nhiu m m ri rc c hai phi tin trin theo tng ngy.
Nu khng iu tr hay iu tr chm bnh s dn n suy h hp nng, nhim trng huyt,
ton trng suy sp v c th t vong.
VII. CHN ON
1.Vim phi thy
1.1. Chn on xc nh
- Hi chng nhim trng.
- Hi chng c phi in hnh (hoc khng in hnh)
- Hi chng suy h hp cp (c th c)
1.2. Chn on nguyn nhn: Da vo
- Din tin lm sng.
- Yu t dch t.
- Kt qu xt nghim m.
- p ng iu tr
1.3. Chn on phn bit
- Ph vim lao: Bnh cnh ko di, hi chng nhim trng khng rm r, lm cc xt nghim
v lao phn bit.
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- Nhi mu phi: C a c bnh tim mch, nm lu, c cn au ngc t ngt, d di, khi
huyt nhiu, chong.
- Ung th ph qun - phi bi nhim: Thng tn phi hay lp i lp li mt vng v cng
v sau cng nng dn.
- p xe phi giai on u.
- Vim mng phi: da vo X quang v lm sng.
- Xp phi: khng c hi chng nhim trng, m ph bo mt, khng c ran n. X quang c
hnh nh xp phi.
2.. Ph qun ph vim
2.1.Chn on xc nh
- C a suy kit, sau nhim virus, c bnh mn tnh.
- Hi chng nhim trng cp v nng
- Hi chng thng tn ph nang lan ta
- Hi chng thng tn ph qun.
- Hi chng suy h hp cp
2.2. Chn on phn bit
- Ph qun ph vin lao: Phi lm cc xt nghim v lao.
- Hen ph qun bi nhim: Tin s hen ph qun, cn kh th xy ra trc sau c hi
chng nhim trng, p ng vi cc thuc gin ph qun.
- Gin ph qun: Bnh ko di, tin s ho v khc m nhiu vo bui sng, suy h hp mn,
ngn tay hnh di trng.
VIII. BIN CHNG
Do c lc ca tc nhn gy bnh mnh, sc khng km, c bnh mn tnh, iu tr khng
ng, bnh s dn n
- p xe phi
- Trn dch, m mng phi, mng tim.
- Ph phi cp (ph phi cp tn thng ).
- Nhim trng huyt.
IX. CC TH LM SNG
1. Do t cu vng
C th tin pht qua ng th hay th pht qua ng mu (nhim trng mu), lm sng c
th ging nh do ph cu, nhng thng l di dng nhiu p xe nh phi, ph qun ph
vim, tr em thng l p xe phi v trn m mng phi gi l t cu phi - mng phi,
bnh nhiu bin chng rt nng v t l t vong cao.
2. Do Friedlander
L loi trc khun Gr (-), gy thng tn hoi t phi rt nng v nhanh gy ho ra mu
nhiu, ly nhim mnh v t l t vong rt cao.
3. Do virus
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Thng xy ra trong cc v dch nh cm, si, hay nhim virus ng h hp trn. Bnh
khi pht t ngt, hi chng c phi khng in hnh, triu chng thc th ngho nn v
khi sau 7 n 10 ngy.
4. Do nm
Thng thng tn phi c hai bn, ch yu vng gn rn phi ri lan dn ra, c khi ri rc
khp hai phi, triu chng lm sng ging ph qun ph vim, c khi huyt. Chn on nh
tm nm trong m.
5. Do k sinh trng
- Do giun a: L mt thng tn nh phi c th c ho, c t m, nhng thng tn ny
mau bin mt t nhin gi l thm nhim mau bay hay hi chng Loeffler.
- Do amip: Thung th pht sau amip gan nhng cng c khi nguyn pht ti phi, thng
tn ch yu l y phi phi st vi c honh (c khi phi tri), hi chng nhim trng va
phi, au ngc v ho ra mu hay m c mu chocolat. Cn xt nghim soi ti m tm
amip, p ng vi thuc khng amip tt.
6. Do ha cht
Thng gp nht l xng du do ht vo, triu chng lm sng xy ra 6-12 gi sau khi ha
cht vo phi, thng tn ch yu l y phi phi, c au ngc d di v ho ra mu, c st
cao. Phi iu tr sm bng khng sinh (chng nhim trng) v corticoid.
X. IU TR
Nguyn tc iu tr l sm, mnh, liu trnh v theo di din tin bnh.
1. iu tr h tr
- Ngh ngi ti ging trong giai on bnh tin trin.
-Tit thc d tiu, m bo calo, thm m v cc loi vitamin nhm B,C
- B nc v in gii v st cao, n ung km, nn, i chy...
2. iu tr triu chng
2.1.Thuc h st
Thuc h st thng c tc dng gim au. C th dng paracetamol 0,5g x 3-4 ln/ngy.
hoc l Acetaminophen, Diantalvic...
2.2. m bo thng kh
Nu c suy h hp th dng xy qua sonde mi 5-10 lt/pht ty mc (lu nu c suy h
hp mn th gim liu cn 1-2 lt /pht v ngt qung).
2.3. Cc thuc gin ph qun
Nu c du co tht ph qun c th cho thm theophyllin 100-200 mg x 3 ln/ngy.
2.4. Cc loi thuc ho v long m
- Nu ho nhiu c th dng Codein (Acodin, Neocodeon...) 100 mg x 3 ln/ngy.
- Nu m c v kh khc c th dng cc loi nh Terpin, Benzoat Natri, Eucalyptin...
hoc acetyl cystein (Acemuc, Exocemuc, Mucosolvon ... 2-3 gi/ngy, hoc 3-4 vin/ngy.
3. iu tr nguyn nhn
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y l iu tr chnh gii quyt nguyn nhn gy bnh. C th l khng sinh, thuc phi
dng sm, ng loi, liu, da vo khng sinh , khi cha c khng sinh th da vo
yu t dch t, din tin lm sng ca bnh, kinh nghim ca thy thuc, th trng bnh nhn
v phi theo di p ng iu tr c hng x tr kp thi.
3.1. Do ph cu, lin cu
Khng sinh chnh hin nay vn l: Penicilline G. 500.000-1000.000 v x 4 ln/ngy TB. Nu
nng c th tng liu v chuyn tnh mch. C th dng Cefapirine (Cefaloject) 0,5g-1g mi
8-12 gi.
Nu b d ng vi Penicilline th dng nh Macrolide nh Erythromycine tim hay ung
2g/ngy chia 4 ln hay Roxythromycine 150mg x 2 ln/ngy.
3.2. Do t cu vng
* T cu vng nhy cm Methicillin: c th dng Cefapirine hay nhm Aminoside nh
Amikacine 15mg/kg/ngy tim bp hoc nhm Fluoroquinolon nh ofloxacin chuyn tnh
mch hay ung 400mg/ngy chia 2 ln.
* T cu vng khng Methicillin
C th dng Cefalosporine th h III: nh Cefotaxime (Claforan, Cefomic) 3g/ngy chia 3 ln
hay Vancomycin 30-50 mg/kg/ngy tim tnh mch chia 3 ln.
Nu nng c th phi hp vi Amikacine.
3.3. Do Hemophillus Influenza
C th dng:
- Ampicillin 2-3g/ngy ung chia 3 ln hay TB, hoc Ofloxacin hoc Cefapirine
- Gentamycin 3-4 mg/kg/ngy TB chia 2-3 ln
3.4. Do Mycoplasma, Legionella
C th dng nh iu tr Hemophilus influenzae.
3.5. Do Klebsiella pneumoniae
Thng iu tr phi hp Cefalosporine th h III vi Amikacine.
3.6. Do vi khun k kh
- Penicilin G hay Metronidazol 1-2 g/24 gi. Hoc Cefalosporine II, III
3.7. Do ha cht
Khng sinh thng dng Pnicilin G phi hp vi Prednisone 5 mg x 6 - 8v/ngy.
Cc trng hp vim phi c bin chng phi iu tr ko di cho n khi triu chng lm
sng v cn lm sng tr v bnh thng (xt nghim nhiu ln) trnh bin chng v ti
pht.
XI. PHNG BNH
Vim phi l mt trong nhng bnh nhim trng ng h hp di ph bin nht,
ngy nay nh vo nhiu loi khng sinh mi, mnh nn t l bin chng v t vong gim
nhiu. Tuy nhin vn c trng hp xy ra thnh nhng v dch nht l do virus. phng
bnh, gim bin chng phi nng cao th trng, gi m trong ma lnh, loi b nhng yu
lm d nh mi trng khng trong sch, khng ht thuc l, phng nga v iu tr sm, tn
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gc cc nhim trng ng h hp trn, cc t cp ca bnh phi mn tnh, iu tr sm v
theo di st giai on sm ca nhim trng ng h hp, trnh ly lan.
Ngy nay c mt s vaccin ca nhiu loi virus c x dng v c mt s thuc chng
virus.

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HEN PH QUN
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, c ch sinh bnh v bnh nguyn hen ph
qun.
2. Nu c triu chng lm sng v cn lm sng cn hen ph qun in hnh.
3. Pht hin sm bin chng cn hen ph qun cp nng
4. Nu c cc phc iu tr hen ph qun theo bc v bin php phng nga.
5.Trnh by c phc iu tr cn hen ph qun cp nng
Ni dung
I. NH NGHA
Theo GINA 2006 (Global Initiative for Asthma) th hen ph qun l mt bnh l vim mn
tnh ca ph qun trong c s tham gia ca nhiu t bo v nhiu thnh phn t bo; vim
mn tnh phi hp vi tng phn ng ph qun dn n nhng t ti din ca ran rt, kh
th, cng phng lng ngc v ho c bit xy ra ban m hay na m v sng. Nhng t
ny thng phi hp vi s tc nghn ph qun lan rng nhng thay i, s tc nghn ny
thng hi phc t nhin hay do iu tr.
Nhng quan im c bn trn y gp phn tch cc vo vic nng cao cht lng
chn on v iu tr hen ph qun.
II. DCH T HC
T l mc hen tng nhanh chng nhiu nc t 1960, trung bnh 6-12% tr em di
15 tui, 6-8% ngi ln.
Theo T chc Y T Th gii (WHO), hin nay trn th gii c 300 triu ngi hen, n 2025
s tng ln 400 triu. ng nam c lu hnh hen tng vi mc nhanh nht. Malaixia
9,7%; Indonexia 8,2%; Philippin 11,8%; Thi Lan 9,2%; Singapore 14,3% ; Vit Nam
khong 5%. T l tr em tng rt nhanh cc nc khu vc ng Nam trong nhng nm
gn y.
vit Nam: T l ngi hen trong cng ng 5%, t l hen ngi ln 1980 l 2,2%, 1990 l
3,3%, 2000 l 5%, t l hen tr em: nm 2000 l 8-9%, 2004 l 11-12% (Hi ngh khoa hc
Bnh phi ton quc 2005)
thnh ph Hu, lu hnh hen ph qun nm 2000 l 4,58 (1,12% (L Vn Bng).???
III. BNH NGUYN
1.Hen ph qun d ng
1.1 Hen ph qun d ng khng nhim khun
- D ng nguyn h hp: thng l bi nh, cc loi b nh nh Dermatophagoides
ptronyssimus, bi chn m, lng mng cc loi gia sc nh ch, mo, chut, th v.v...; phn
hoa, cy c, hay bi ngh nghip trong cc xng dt.
- D ng nguyn thc phm: thng gp l tm, cua, s, hn, c chua, trng...
- D ng nguyn l thuc aspirine, khng vim khng steroide, penicillin, mt s
phm nhum mu v cht gi thc phm.
1.2. Hen ph qun d ng nhim khun
238
-Vi khun thng gp l streptococcus pyogenes, streptococcus pneumoniae,
staphylococcus aureus...
- Virus: thng gp l virus hp bo h hp, parainfluenza, cm.
- Nm: nh nm Cladosporium hay Alternaria, cc nm mc.
2. Hen ph qun khng do d ng
2.1. Di truyn: tin s gia nh, lin quan n khng nguyn ha hp t chc HLA.
2.2. Gng sc: kh th xy ra khi gng sc v nht l khi ngng gng sc.
2.3. Lnh: kh th xy ra khi b lnh, ht khng kh lnh.
2.4. Ri lon ni tit: trong thi k trng thnh, thi k trc kinh nguyt, lc mang thai,
thi k mn kinh.
2.5. Yu t tm l: tm trng lo u, xc ng, chn thng tnh cm.
4. C ch sinh bnh
Hen ph qun xy ra qua 3 qu trnh
4.1. Vim ph qun:
Khi d ng nguyn lt vo c th, kch thch to khng th IgE gn trn t bo mast, khi d
ng nguyn xm nhp c th ln th 2 tr i, d ng nguyn s kt hp vi IgE trn t bo
mast, phng thch cc cht trung gian t t bo mast to ra phn ng d ng.
Nhng t bo vim bao gm t bo mast, bch cu a nhn (i toan, i kim, trung tnh), i
thc bo ph nang, bch cu n nhn, lympho bo v tiu cu phng thch cc cht trung
gian ha hc gy vim nh histamin, srotonin, bradykinin, thromboxan, prostaglandin,
leucotrin, PAF v mt s interleukin.
Mi mt ln ln cn hen u c 2 pha, pha nhanh v pha chm. Pha nhanh xy ra ngay sau
khi t bo mast phng thch cc cht trung gian ho hc gy co tht ph qun, pha chm xy
ra sau 2-12 gi trong c s di chuyn ca cc t bo vim (di tc dng ca cc cht ho
hng ng) n ph qun gy nn vim ph qun
4.2. Co tht ph qun: do tc ng ca cc cht trung gian ha hc gy vim v vai tr ca h
thn kinh t ng gm h cholinergic, h adrenergic v h khng cholinergic khng
adrenergic.
4.3. Tng phn ng ph qun: xy ra sau khi d ng nguyn vo c th, qua tc ng ca cc
t bo gy vim.
5. Triu chng lm sng cn hen ph qun in hnh
5.1. Giai on khi pht
Cn hen ph qun thng xut hin t ngt vo ban m, nht l na m v sng; thi gian
xut hin ty thuc vo nhiu yu t nh tip xc d ng nguyn h hp, thc n, gng sc,
khng kh lnh, nhim virus ng h hp trn, ... Cc tin triu nh nga mi, ht hi, chy
nc mi, nc mt, ho tng cn, bn chn ....
5.2. Giai on ln cn
Sau , cn kh th xut hin nhanh, kh th chm, kh th k th ra, trong cn hen lng
ngc bnh nhn cng ra, cc c h hp ph ni r, tm mi, u tay chn sau lan ra mt
v ton thn. Nhp th chm, ting th rt ko di. ng xa c th nghe ting rt hay s s ca
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bnh nhn. Nghe phi c nhiu ran rt v ran ngy. Cn kh th di hay ngn ty theo tng
bnh nhn.
5.3. Giai on lui cn
Sau vi pht hay vi gi, cn hen gim dn, bnh nhn ho khc m rt kh khn, m c
qunh, c nhiu ht nh nh ht trai. Lc ny nghe phi pht hin c nhiu ran m, mt t
ran ngy. Khc m nhiu bo hiu cn hen ht.
5.4. Giai on gia cc cn
Gia cc cn, cc triu chng trn khng cn. Lc ny khm lm sng bnh thng. Tuy
nhin nu lm mt s trc nghim nh gng sc, dng actycholine, th vn pht hin tnh
trng tng phn ng ph qun.
6. Triu chng cn lm sng
6.1. Thm d chc nng h hp
6.1.1. Ri lon thng kh
- o FEV1 (th tch th ra ti a trong giy u) v FEV1/FVC (t s Tiffeneau): trong
cn gim di 80% so vi l thuyt.
- o PEF (lu lng th ra nh): trong cn gim di 80% so vi l thuyt.
6.1.2. Kh mu: o PaO2, PaCO2, SaO2, v pH mu, y l xt nghim b sung nh gi
mc suy h hp.
6.2. Cc xt nghim v d ng
6.2.1. Test da: dng phng php ly da, da l dng tnh.
6.2.2. Test tm khng th: nh khng th ngng kt, khng th kt ta thng l lgG, lgM.
6.2.3. nh lng lgE ton phn v lgE c hiu
6.3. Phim lng ngc: trong cn hen, lng ngc cng phng, cc khong gian sn gin rng,
c honh h thp, phi tng sng, rn phi m.
7. Chn on
7.1. Chn on xc nh: cn c ch yu vo
7.1.1. Tin s c nhn v d ng: nh vim mi d ng, chm, my ay, c d ng vi mt
cht no , c tip xc vi d ng nguyn trc khi ln cn hen, tin s gia nh v hen v d
ng hoc hen xy ra sau gng sc, lnh v.v...
7.1.2. Hi chng hp tiu ph qun do co tht: kh th chm, ch yu k th ra, phi nghe
nhiu ran rt, ran ngy, phim phi thy hnh nh kh ph thng.
7.1.3. Cn kh th c tnh cht hi qui, p ng tt vi thuc gin ph qun, tt phc hi ph
qun vi ng vn bta 2 dng tnh tc sau khi dng ng vn bta 2 th FEV1 tng thm >
200ml v > 15%.
7.2. Chn on phn bit
7.2.1. Hen tim: bnh nhn c tin s cc bnh van tim nh hp van hai l, h van ng mch
ch, cao huyt p, kh th nhanh, c 2 k, phi nghe nhiu ran dch, rt t ran ngy, phim
phi cho thy hnh nh dch, tm in xc minh thm nguyn nhn.
7.2.2. t cp bnh phi tc nghn mn tnh: c tin s bnh phi tc nghn mn tnh hay
tin s ht thuc l, c hi chng nhim trng, kh th nhanh, khng c tin s c nhn v
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gia nh v d ng hay hen, phi nghe ran m to ht km ran rt v ran ngy, tt phc hi ph
qun vi ng vn bta 2 m tnh.
8. PHN LOI TRM TRNG HEN PH QUN QUA TRIU CHNG LM SNG
TRC IU TR
BC 1 (TNG CN)
- Nhng triu chng xy ra < 1 ln / tun.
- Nhng t bc pht ngn.
- Nhng triu chng ban m < 2 ln / thng.
+ FEV1 hay PEF 80% so vi l thuyt
+ PEF hay FEV1 bin thin < 20%
BC 2 (DAI DNG NH)
- Nhng triu chng xy ra > 1 ln / tun nhng < 1 ln / ngy.
- Nhng t bc pht c th nh hng n hot ng v gic ng.
- Nhng triu chng ban m > 2 ln / thng.
+ FEV1 hay PEF 80% so vi l thuyt.
+ PEF hay FEV1 bin thin 20- 30%.
BC 3 (DAI DNG VA)
- Nhng triu chng xy ra hng ngy.
- Nhng t bc pht nh hng n hot ng v gic ng.
- Nhng triu chng ban m > 1 ln / tun.
- Hng ngy phi s dng thuc kh dung ng vn (2 tc dng ngn)
+ FEV1 hay PEF 60 - 80% so vi l thuyt
+ PEF hay FEV1 bin thin > 30%
BC 4 (DAI DNG NNG)
- Nhng triu chng xy ra hng ngy.
- Thng xuyn c nhng t bc pht.
- Nhng triu chng thng xy ra ban m.
- Gii hn nhng hot ng th lc.
+ FEV1 hay PEF 60% so vi l thuyt.
+ PEF hay FEV1 bin thin > 30%
9. Bin chng
9.1. Bin chng cp
9.1.1. Hen ph qun cp nng: l tnh trng suy h hp cp rt nng c th gy t vong nhanh
trong thi gian ngn. y l mt cp cu ni khoa
- Du gi hay bo trc l hi chng e da hen ph qun cp nng:
Cn hen cp khng p ng vi iu tr thng thng v nng dn
Hoc cn hen xy ra rt cp i khi trong vng vi pht.
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- Nhng du chng h hp
+ Suy h hp cp v nng: vi tm, v m hi, kh th nhanh nng, tn s trn 30
ln/pht km du co ko cc c h hp, cnh mi php phng, c bit lng ngc cng phng
v t di ng theo nhp th
+ Ri lon tri gic: lo u km vt v hay ngc li l m c th i dn vo
hn m.
+ C th th chm chng t c s suy kit c h hp v bo trc s ngng h hp.
+ Nghe phi: im lng c hai bn phi.
+ Lu lng th ra nh di 150 lt/pht.
+ PaO
2
< 60 mmHg, PaCO
2
> 45 mmHg.
+ pH mu < 7,38.
- Nhng du chng tim mch
+ Mch nhanh thng trn 120 ln/pht, mch chm l du chng rt nng bo hiu
ngng tun hon.
+ Mch nghch l lm mch gim bin trong k th vo, c th xc nh bng cch o
hiu p tm thu gia k th ra v k th vo thng trn 20 mmHg.
+ Tm ph cp vi du chng suy tim phi.
+ Huyt p c th tng lin quan n s tng PaCO2, huyt p h trong nhng trng hp
qu nng.
9.1.2. Trn kh mng phi: do v bng kh ph thng.
9.1.3. Nhim khun ph qun - phi: thng do Streptococcus pneumoniae, Haemophilus
influenza, staphylococcus aureus, mycoplasma pneumoniae, legionella pneumophila.
9.2. Bin chng mn
9.2.1. Khi ph thng a tiu thy
- Thng c kh th khi gng sc, khi lm vic nng, tm mi v u chi, lng ngc
bin dng hnh c g hay hnh thng, g vang, m ph bo gim.
- Th tch cn v dung tch cn chc nng tng, c ri lon thng kh phi hp, PaO
2

ch gim giai on sau v PaCO
2
ch tng giai on sau.
9.2.2. Suy h hp mn
- Tm v kh th: th nhanh nng, th ra mi khp cht, du hiu HOOVER.
- Suy h hp mn nghn c tng r cc th tch cn, gim cc lu lng trung bnh v
lu lng nh, suy h hp mn hn ch c gim cc th tch phi, ty theo mc suy h
hp m PaO
2
di 65 - 70 mmHg v PaCO
2
trn 43mmHg.
- Kh th cng ngy cng tng theo th t: kh th khi gng sc, kh th khi leo ln
dc hay ln cu thang, kh th khi i nhanh trn ng phng, kh th khi i chm trn
ng phng, cui cng kh th khi lm vic nh nh v sinh, ci o qun, v sau kh th khi
ngh ngi. Tm mi, u chi, mt nu nng tm ton thn.
- Triu chng suy tim phi: Trn lm sng v trn cn lm sng.
- PaO
2
gim n 70 mmHg, PaCO
2
tng 50-80mmHg, SaO
2
< 75 %, pH mu c th
gim < 7,2.
242
10. iu tr
10.1. X tr hen ph qun theo cc bc
+Bc 1 (Hen ph qun cch khong)
Trong hen ph qun cch khong, trm trng ca t bc pht cp thay i theo tng bnh
nhn v theo thi gian. Nhng t bc pht cp nng rt t gp.
Thuc s dng trong hu ht cc bnh nhn hen ph qun cch khong nh l thuc ng vn
2 kh dung tc dng nhanh, ngoi ra c th s dng cromone hay thuc khng leukotriene.
Thuc khng cholinergic, ng vn 2 ung, hay theophylline tc dng ngn c th dng xen
k vi thuc ng vn 2 kh dung, mc d nhng loi thuc ny c thi gian bt u tc
dng chm v hay l c nguy c c nhiu tc dng ph hn. Thng thng nhng t bc
pht cp nng hn hay ko di hn c th i hi s s dng mt t iu tr ngn bng
glucocorticoide ung.
Thuc Hen bc 1 Lu
Thuc chn
la
ng vn bta 2 tc dng nhanh,
kh dung
Khi cn
Thuc phi
hp
Cromone, khng leukotrien, khng
cholinergic, theophyllin,
Xen k hay phi hp
prednisolon ch dng trong t bc pht cp
nng hn hay ko di hn
Phi hp

+ Bc 2 (Hen ph qun dai dng nh)
Cn phi c s dng thuc hng ngy hon thnh v duy tr s kim sot hen
ph qun.
Tr liu u tin l thuc khng vim dng hng ngy. iu tr chn la mt loi
glucocorticoide kh dung (200 - 500 g Beclometaso dipropionaee, hay Budenoside, 1000 -
250 g fluticasone chia 2 ln/ngy).
Thuc dng xen k l theophylline thi chm, cromones, v khng leukotriene, nhng
nhng loi thuc ny km hiu qu hn glucocorticoide kh dung hay ch c hiu qu mt
s bnh nhn. iu tr lu di theophylline thi chm cn phi theo di nng theophylline
trong huyt thanh vi nng iu tr l 5 - 15 g/ml.
Thm vo iu tr u n trn, bnh nhn hen ph qun bc 2 c th s dng mt loi
thuc ng vn 2 kh dung tc dng nhanh, nhng khng c qu 3 - 4 ln/ngy.
Nhng thuc gin ph qun khc c th c s dung nh thuc khng cholinergic, ng vn
2 ung tc dng nhanh, hay theophylline tc dng ngn, mc d nhng loi thuc ny c
thi gian bt u tc dng chm v hay l c nguy c c nhiu tc dng ph hn.
Nu tr liu lu di c bt u vi theophylline thi chm, cromone hay khng
leukotriene, m nhng triu chng tn ti sau 4 tun iu tr, th glucocorticoide kh dung phi
c s dng. Glucocorticoide kh dung c th c s dng ban u thay v nhng loi thuc
khc, hay s dng km vi nhau.
Thuc Bc 2 Lu
Thuc chn la Glucocorticoide kh dung dng hng ngy
243
Thuc phi hp Theophylline chm, cromones,
khng leukotriene, ng vn beta 2
tc dng nhanh, khng cholinergic,
theophylline
Dng xen k
hay phi hp

+ Bc 3 (Hen ph qun dai dng va)
cn phi dng thuc hng ngy t c v duy tr s kim sot hen ph qun. iu tr
chn la l phi hp mt glucocorticoide kh dung (200 - 1000 g beclometasone
dipropionate, 400 - 1000 g budenoside, 250 - 500 g fluticasone chia 2 - 3 ln/ngy) vi
mt ng vn 2 kh dung tc dng di 2 ln/ngy.
Mc du phi hp glucocorticoide kh dung vi mt ng vn 2 kh dung tc dng di l c
hiu qu nht, nhng nhng bnh nhn hen ph qun dai dng va c th s dng xen k
nhng loi thuc nh theophylline thi chm, thuc ng vn 2 ung tc dng di, thuc
khng leukotriene.
Thm vo tr liu u n hng ngy, thuc ng vn 2 kh dung tc dng nhanh c th
c s dung ct cn, nhng khng c qu 3 - 4 ln/ngy. Thuc khng cholinergic kh
dung, thuc ng vn 2 ung tc dng nhanh, hay theophylline tc dng ngn c th thay th
cho thuc ng vn 2 kh dung tc dng ngn, mc d nhng loi thuc ny c thi gian bt
u tc dng chm v hay l c nguy c c nhiu tc dng ph hn.
Thuc bc 3 Lu
Thuc chn la KD hn hp glucocorticode v ng
vn bta2 tc dng di 2ln /ngy
Dng thuc
hng ngy
Thuc
phi hp
Tc
dng
di
Theophylline chm, ng vn beta ung
tc dng di, khng leukotriene,
dng xen k hay
phi hp
Tc
dng
nhanh
ng vn beta KD tc dng nhanh,
khng cholinergic KD , ng vn beta
ung tc dng nhanh , theophylline
Khng qu 3-4
l/ng
KD: kh dung
+ Bc 4 (Hen ph qun dai dng nng)
Trong hen ph qun dai dng nng, mc tiu iu tr l t c kt qu tt nht - nhng triu
chng ti thiu, cn s dng thuc ng vn 2 kh dung tc dng nhanh ti thiu, PEF tt
nht, ti thiu cn hen xut hin khong 1 ln / ngy, v tc dng ph ti thiu. Tr liu trc
tin l glucocorticoide kh dung liu cao hn (> 1000 g beclometasone dipropionate / ngy
phi hp vi ng vn 2 kh dung tc dng di 2 ln / ngy.
Thuc ng vn 2 kh dung tc dng di l thuc c chn la, nhng c th s dng
nhng loai thuc xen k nh theophylline thi chm, thuc ng vn 2 ung tc dng di,
thuc khng leukotriene. Nhng loi thuc ny c th thm vo tr liu phi hp gia
glucocorticoide kh dung liu cao vi ng vn 2 kh dung tc dng di. Thuc ng vn 2
kh dung tc dng nhanh cng c s dng khi cn. Nu cn, glucocorticoide ung c th
c s dng vi liu thp nht, tt nht ch cho mt lu duy nht vo bui sng gim
thiu nhng tc dng ph h thng.
244
Glucocorticoide kh dung liu cao c th c s dng, nhng s s dng ny khng c
chng ming r rng l gy nhng tc dng ph h thng t hn so vi s s dng mt liu
tng ng glucocorticoide ung. Nhng iu tr ny rt tn km v c th gy nn nhng
tc dng ph ti ch nh au ming. Khng c mt chng c no t nhng nghin cu
khuyn co nn s dng glucocorticoide kh dung trong hen ph qun n nh ngi ln.
thuc Bc 4 Cch dng
Thuc chn la Glucocorticoide KD liu cao + ng vn
beta2 KD tc dng di 2ln/ng
dng hng ngy
Thuc phi hp Tc
dng
di
ng vn beta2 ung tc dng di
Theophylline chm,khng leukotriene
Dng xen k
Tc
dng
nhanh
ng vn beta2 KD tc dng nhanh Khi cn
Glucocorticoide ung C th dng liu thp nht
KD: kh dung
10.2. iu tr h tr
- Liu php oxy: khi cn th oxy khong 2l/pht.
- Khng sinh: ch dng khi c bi nhim ph qun - phi.
10.3. iu tr cn hen ph qun cp nng
10.3.1. Liu php oxy: phi thc hin lin khng cn ch kt qu kh mu, cung lng cao
6l/pht nu khng c suy h hp mn, nu c suy h hp mn cung lng thp 2l/pht.
10.3.2. Thuc gin ph qun
+ Thuc kch thch bta 2: tim di da Terbutaline (Bricanyl) 1 ng 0,5mg l bin php
cp cu ban u ngay ti nh bnh nhn.
+ Khi nhp vin th dng kh dung Salbutamol, 1 ml cha 5 mg ha 4ml dung dch sinh
l qua my kh dung cho ht trong 10 - 15 pht, lp li ty din tin lm sng, 30 pht mt
ln.
C th dng Salbutamol tim tnh mch lin tc bng ng tim t ng, liu lng ban
u thng l 0,1 - 0,2 g/kg/pht, tng liu tng 1 mg/gi theo din tin lm sng.
+ Adrnaline: ch nh khi cc thuc kch thch bta 2 b tht bi; liu lng khi u
thng l 0,5 - 1 mg/gi tim tnh mch bng ng tim t ng.
+ Aminophyllin: c th kt hp, dng bng ng chuyn tnh mch vi dung dch
Glucoza 5 % lin tc vi liu lng 0,5 - 0,6 mg/kg/gi.
10.3.3. Khng sinh: c s dng khi c nhim trng ph qun - phi km theo, c th dng
Cephalosporin, Macrolid hay Fluoroquinolon .
10.3.4. Corticosteroide: Methylprednisolone (Solumedrol) 60 - 80mg mi 6 gi.
10.3.5. Th my: c ch nh khi suy h hp cp nng hay khi iu tr bng thuc b tht
bi gy suy kit c h hp, c th khi PaO2<60mmHg hay /v SaO2 < 90%
10.4. Theo di bnh nhn
245
Mc ch iu tr cn hen cp l lm th no cc triu chng gim nhanh v ci thin chc
nng h hp cng nhanh cng tt, ng thi gim ti a tc dng ph ca thuc.
Nu iu tr ban u khng c kt qu, nu PaCO
2
cn thp, th c th tip tc iu tr ti
bnh phng; nhng nu PaCO
2
tng v pH b toan ha th bnh nhn phi c chuyn n
phng hi sc thc hin thng kh h tr.
i vi hen ph qun cp nng l mt cp cu ni khoa, bt buc phi nhp vin gp vo
khoa hi sc h hp, bng xe cp cu c trang b.
10.5. Phng nga cn hen ph qun ti pht
Hin nay, GINA khuyn co nn dng Seretide trong iu tr duy tr kim sot cn hen ph
qun v ngi ta nhn thy nhng bnh nhn hen ph qun c iu tr bng Seretide rt t
b xy ra cn hen ph qun nng.
10.6. Phng trnh cc yu t bt li ca mi trng
- Trnh cc hot ng th lc khng cn thit.
- Trnh tip xc bi, khi nht l khi thuc l v cc cht kch thch khc.
- Trnh tip xc vi nhng ngi b nhim trng h hp.
- Gi mi trng trong nh trong lnh.



246
SUY H HP CP
Mc tiu
1. Trnh by c nh ngha, bnh nguyn, c ch sinh bnh suy h hp cp
2. Nu c triu chng lm sng v cn lm sng v phn giai on suy h hp cp
3. Trnh by c phc iu tr theo tng giai on suy h hp cp
4. X tr ban u ng cch theo tng mc v chuyn tuyn ng lc
Ni dung
I. NH NGHA
Suy h hp cp l s ri lon nng n ca s trao i oxy mu; mt cch tng qut,
suy h hp cp l mt s gim thc s phn p oxy trong ng mch (PaO
2
) < 60 mmHg,
phn p ccbonic trong ng mch (PaCO
2
) c th bnh thng, gim hay tng.
C 2 loi suy h hp cp
- Suy h hp cp vi thiu oxy mu km kh ccbonic.
- Suy h hp cp vi thiu oxy mu km gim kh ccbonic.
II. BNH NGUYN
1. Nguyn nhn ti phi
1.1.S mt b cp ca nhng suy h hp mn
Yu t lm d l nhim trng ph qun - phi, thuyn tc ng mch phi, trn kh mng
phi.
1.2. Nhng bnh phi nhim trng:
Chng xy ra trn phi lnh th ch gy suy h hp cp khi nhng nhim trng phi lan
rng ra nhiu thy: ph qun ph vim do vi trng m, lao k, nhim virus c tnh.
1.3. Ph phi cp
1.3.1.Ph phi cp do tim
- Tt c nhng nguyn nhn gy suy tim tri: tng huyt p lin tc hay cn tng huyt p,
suy mch vnh trong nhi mu c tim l nguyn nhn thng gp nht, hp h van ng
mch ch, h van hai l, bnh c tim.
- Hp van hai l.
- Thuyn tc ng mch phi.
1.1.2. Ph phi cp trn tim lnh: do yu t tng p lc mao qun.
- Chuyn dch qu nhiu.
- Nguyn nhn thn kinh: chn thng s no, u hay phu thut chm n thn no, vim no.
1.1.3. Ph phi cp do tn thng thc th
Trc ht phi k n cm c tnh do nhiu yu t: yu t virus, yu t c a, v nhng th
nng gp ch yu ngi b bnh tim tri, hp hai l, nht l ngi gi, n b c thai;
tr em b nhim virus nng di dng vim tiu ph qun - ph nang. t gp hn l do cht
c (hroin, oxyd ccbon, nc rn c), sc nhim trng, thuyn tc do m, cht ui, hi
chng Mendelson (ht phi dch v do ).
247
1.4. Hen ph qun e da nng, hen ph qun cp nng
1.5. Tc nghn ph qun cp
Bnh ny t gp, tr em c th do vt l, ngi ln c th do u, xp phi cp c th do t
ni kh qun.
2. Nguyn nhn ngoi phi
2.1. Tc nghn thanh - kh qun
Bnh ny do u nh u thanh qun, bu gip chm, u thc qun vng c, u kh qun; do nhim
trng nh vim thanh qun, un vn; do vt l ln.
2.2. Trn dch mng phi
t gy suy h hp cp nu trn dch t t, ch gy suy h hp cp khi trn dch cp, lng dch
tng nhanh.
2.3. Trn kh mng phi th t do
Thng do lao phi, v bng kh ph thng, v kn kh bm sinh, t pht (khng r nguyn
nhn), c th do v p xe phi lun lun km trn m mng phi.
2.4. Chn thng lng ngc
Bnh ny gy gy xng sn t gy tn thng mng phi v phi.
2.5. Tn thng c h hp
Nguyn nhn thng gp l vim sng trc ty sng, hi chng Guillain Barr km lit ln
cp Landry, un vn, rn cn, ng c thuc tr su gc phtpho hu c, bnh nhc c
nng, vim a c.
2.6. Tn thng thn kinh trung ng
Nguyn nhn thng l chn thng s no, ng c thuc, tai bin mch mu no; nhng
nguyn nhn gy nn tn thng trung tm h hp.
III. C CH SINH BNH
1. C ch gy nn thiu oxy mu
1.1. Gim thng kh ph nang
p lc kh oxy trong ph nang c xc nh bi s qun bnh gia tc mt i ca kh
oxy, chc nng chuyn ha m v tc i mi ca kh oxy bi thng kh ph nang. Nu
thng kh ph nang gim mt cch bt thng th p lc oxy trong ph nang gim ri p lc
ring phn kh oxy trong ng lch gim theo. S gim thng kh ph nang c th th pht
sau mt tn thng trung tm h hp (hn m, ng c thuc) hay mt s v hiu ha hot
ng lng ngc - phi (tn thng sng trc ty sng, tn thng c h hp hay dy thn
kinh chi phi).
1.2. S mt cn bng gia thng kh / ti mu
S km hi ha gia thng kh v lu lng mu l nguyn nhn gy nn s ri lon trao i
kh trong mt n v phi; t thng kh / ti mu gn bng 1; p lc kh oxy v kh ccbonic
trong ph nang l 100 mmHg v 40 mmHg gn bng p lc ring phn kh oxy v kh
ccbonic trong ng mch. Nu khng kh gim, t thng kh / ti mu: VA / Q bng 0 th p
lc kh oxy v kh ccbonic trong ph nang v p lc ring phn kh oxy v kh ccbonic gn
bng nhau, p lc ring phn kh oxy v kh ccbonic trong tnh mch l 40 mmHg v 45
mmHg.
248
Nu s ti mu gim, th t thng kh / ti mu c khuynh hng v hn, p lc kh trong
ph nang v trong ng mch gn bng p lc kh ht vo (PO2 = 150mmHg, PCO2 = 0).
phi, t thng kh / ti mu thay i theo vng v theo bnh l. C 3 loi bt thng ca t
ny:
- Shunt phi
Bt thng ny l s lu thng mu trong h thng ng mch khng i qua nhng vng
c h hp. Ngi ta gp shunt phi trong ph phi, xp phi.
- Hiu qu shunt
Bt thng ny tng ng vi s khuch tn ca nhng n v phi m thng kh gim, t
thng kh / ti mu gim, nhng nhng ph nang vn cn hot ng t nht giai on u
ca s thng thng vi ng h hp; thiu oxy mu l do s gim s cung cp kh oxy ca
mu tnh mch. Ngi ta gp hiu qu shunt trong ph phi, bnh phi cp, vim ph qun
cp, vim ph qun mn, trn dch mng phi.
- Hiu qu khong cht
Bt thng ny do s gim thng kh ca mt n v phi vn cn h hp c, t thng kh /
ti mu c khuynh hng v hn. S nghn hay ph hy mch mu phi (thuyn tc ng
mch phi, kh ph thng) gy nn mt khong cht thm vo khong cht gii phu.
S thiu oxy mu cng nng khi s lng ph nang khng tham gia vo s trao i kh vng
nhiu; s tng thng kh (th b) a n mt s gim kh ccbonic mu nu kh trong ph
nang khng b li trong k th ra (vim ph qun mn, hen ph qun cp nng).
1.3. Ri lon khuch tn
Mt vi bnh phi nh bnh phi k x ha lm tn thng mng ph nang - mao mch, b
dy mng ny > 0,5m nh vy s lm gim s trao i kh oxy t ph nang sang mao mch.
2. C ch gy nn s thay i kh ccbonic trong mu
p lc kh ccbonic trong ph nang v trong ng mch thay i ngc chiu vi thng kh
ph nang.
2.1. Gim kh ccbonic mu
Hin tng ny l hu qu ca s tng thng kh gy nn do thiu oxy mu.
2.2. Tng kh ccbonic mu
hu qu ca mt s gim thng kh ph nang.
IV. TRIU CHNG HC
1. Lm sng
1.1. Nhp th v bin h hp
Thiu oxy mu v/hay tng kh ccbonic mu gy nn th nhanh, tn s th khong 40 ln /
pht phi hp vi s co ko hm trn xng c v cc khong gian sn; tr em c th km
theo cnh mi php phng. Trong nhng trng hp c tn thng do lit (vim a r thn
kinh, lit 4 chi do tn thng ty sng, bnh nhc c nng...), tn s th thng gim, bin
h hp yu, bnh nhn khng ho c, do gy nn ng m gii trong ph qun.
Theo di nhp th rt quan trng v nhp th chm l du ca s ci thin trao i kh oxy
mu nhng cng c th l s suy kit c h hp nht l trong trng hp hen ph qun cp
nng.
249
Trong cc bnh thanh - kh qun c du kh th vo.
1.2. Tm
Tm l du chng ch yu, xut hin mi, u tay chn, mt hay ton thn khi hemoblogine
kh > 50g / l. T ny tng ng vi SaO2 l 85 %. Tm cng r khi hemoglobine mu cng
cao (suy h hp mn); khng thy r tm khi thiu mu nng. Tm thng phi hp vi tng
kh ccbonic mu, tm i km gin mch u chi, i khi c v m hi.
1.3. Du chng tun hon
Thiu oxy mu v tng kh ccbonic mu lm tng t catcholamine v nh vy lm mch
nhanh, gy nn nhng cn tng huyt p v tng cung lng tim, c th c lon nhp trn tht,
giai on sau huyt p c th h.
1.4. Du chng suy tim phi cp
c bit thng gp trong t cp ca suy h hp mn. Du chng chnh l: gan ln, du
phn hi gan tnh mch c (+), nng hn l tnh mch c ni t nhin ( t th 45
0
)
1.5. Du chng thn kinh tm thn
Du chng ny ch gp trong suy h hp cp nng; l trng thi kch thch, vt v, ri lon
tri gic nh l m hay hn m.
2. Cn lm sng
2.1. Kh mu
2.1.1. Bnh thng
- PaO
2
l 80 - 95 mmHg.
- PaCO
2
l 38 - 43 mmHg.
- pH mu l 7,38 - 7,43
- D tr kim l 24 - 26 mmol / l.
2.1.2. Bnh l
-Thiu oxy mu: PaO
2
c th gim ch cn 25 mmHg.
-Ri lon kh ccbonic: s a n ri lon cn bng toan kim.
-Tng PaCO
2
: a n toan h hp m s b tr l nh nhng cht m ca mu v ca m
v nh s thi ion H
+
qua thn.
Khi c tng PaCO
2
cp, c ch m lc u l huyt tng v huyt cu, sau l m v thn
can thip trong giai on 2 vo gi th 24 bng cch tng thi tr ion H
+
v ti hp thu ion
Na
+
v bicarbonate.
Toan h hp gi l cn b khi nhng cht m t bo c s dng gi cho pH khng gim.
S b tr ny c gii hn bi s gia tng bicarbonate khng qu 50 mmol/l.
-Gim PaCO
2
: a n kim h hp vi gim bicarbonate huyt tng.
2.2. Kho st tim mch
Tm in v thng tim phi, siu m Dopler tim kho st cc tn thng tim.
2.3. Phim lng ngc
Xt nghim ny cn thc hin c th pht hin nhng tn thng ch m phi, mng
phi, trung tht.
250
V. PHN GIAI ON SUY H HP CP
Bng 1: Cc giai on ca suy h hp cp
Triu chng Giai on 1 Giai on 2 Giai on 3 Giai on 4
Kh th Khi gng sc, khi
nm lng ngc di
ng c
Lin tc, lng
ngc di ng kh
khn
Lin tc, lng
ngc khng di
ng, c h hp
cn hot ng
mnh
Lin tc, cc c
h hp hot ng
yu, th nng, ri
lon h hp
Tn s th
ln/pht
25-30 khi gng
sc
25 - 30 30 - 40 > 40
< 10
Tm Khi gng sc Mi, u chi Mt, m, u chi Ton thn
M hi 0

+ + + + +
Mch ln/pht 90 - 100 100 - 110 110 - 120 > 120
Huyt p Bnh thng Bnh thng Cao Cao hay h
Ri lon thc Khng Khng Vt v L m, hn m
SaO
2
(%) 80 - 90 70 - 80 60 - 70 < 60
PaCO
2
(mmHg) 40 45 - 55 55 - 70 > 70
pH mu 7,35 - 7,40 7,30 - 7,35 7,25 - 7,30 < 7,25
D tr kim Bnh thng Bnh thng Gim Gim
VI. TIN TRIN V BIN CHNG
Suy h hp nu c iu tr ng mc th c th lui bnh hon ton. Trong qu trnh tin
trin c th bi nhim phi hay ng tiu nht l i vi nhng bnh nhn c t ni kh
qun hay t xng tiu.
Suy h hp cp nu iu tr khng kp thi th c th tin trin nng dn, bnh nhn hn m
v t vong.
VII. IU TR
1. Nguyn tc iu tr
- Lm thng thong ng h hp.
- Liu php oxy.
- t ng ni kh qun, m kh qun, h tr h hp.
- Chng nhim khun, bi nhim.
2. iu tr c th
2.1. iu tr h tr v gii phng ng h hp
* Lau ht sch mm, hng, mi
* t canuyn Mayo khi tt li
* Ht m gii, cht xut tit bng my ht
Ra ph qun, lm long m bng kh dung, bng bm dung dch natri bicarbonate 14
hay dung dch natri chlorure 9, 2 - 5 ml mi ln ri ht ra.
251
* Bi ph nc v in gii v thng bng toan-kim
m bo c s cn bng gia lng dch ra v vo hng ngy, trnh kh qunh m, cht
xut tit ph qun.
2.2. Liu php oxy
* Th oxy
Kh oxy phi qua mt bnh cha nc v c lm m bng my siu m hay bng nhng
tm c lm nng ln.
* Nhng phng tin th oxy
+ Xng mi thng c p dng
Thng dng loi ng xng m phn u c nhiu l, t khng vt qu l mi sau (chiu
di l khong cch gia mi v di tai).
Xng mi c th dng cho nhng cung lng t 1 - 6 lt / pht, thng dng trong nhng
trng hp suy h hp nh hay va.
* Ch nh
+ Th oxy nguyn cht
p dng trong rt t trng hp nh ngng tim, chy mu nng.
+ Kh th c tng cng oxy
- Nhng bnh nhn c nng kh ccbonic mu bnh thng hay gim: Tt c nhng tnh
trng thiu oxy mu th PaO
2
u gim di 65 mmHg, cho th oxy vi cung lng 4 - 6 lt /
pht bng xng mi hay trong nhng trng hp thiu oxy nng hn th s dng mt n oxy.
- Nhng bnh nhn c PaCO2 trong mu cao mn tnh: l nhng trng hp suy h hp
mn, cung lng oxy dng bnh nhn b suy h hp mn l thp khong 1 - 3 lt / pht, th
ngt qung v c kim sot nng cc kh trong mu.
2.3. t ni kh qun
* Ch nh
- Khi c tr ngi ng h hp trn nh ph n, vt thng thanh qun, hn m gy tt li.
- Khi cn gim khong cht tng thng kh ph nang, h tr h hp, cn th oxy, th my.
- Khi c tng kh ccbonic mu.
- Khi cn bo v ng h hp, phng ht sai lc.
* Phng php
C hai phng php:
+ t ni kh qun ng mi
l phng php c dng ph bin, nht l i vi tr s sinh, tr cn b v tr em . Bnh
nhn t t th nm nga, k vai cao 5-7 cm nga c ti a .
+t ni kh qun ng ming
Bnh nhn c t trong t th nh trn. Cho th oxy vi pht trc khi t ng.
Thng thng, ng khng t qu 3 ngy.
2.4. M kh qun
252
* Ch nh
Nh ch nh t ni kh qun hay khng t c ng hay khi cn t ng qu 3 ngy.
* Phng php
- M kh qun cao: d thy kh qun hn
- M kh qun thp.
2.5. Tai bin c th gp khi t ni kh qun v m kh qun
* Tai bin khi t
Chy mu, ph n thanh qun, thng kh qun, co tht thanh mn, ngng tim.
* Tai bin sau khi t
Nhim khun ni t, vim phi, lot, hoi t kh qun, r kh thc qun, tn thng dy
thanh m, xp phi, trn kh mng phi, trn kh trung tht, trn kh di da.
2.6. H tr h hp
* Dng c h tr h hp bng tay
Kh th c cung cp cho bnh nhn l kh tri.
- Loi c bng: Ambu, Canister.
- Loi c ti xp: Ranima, Drager.
* Th my
+ Ch nh
Th my c dng khi cc phng php h tr h hp thng thng khng c hiu qu.
Ba loi bnh nhn ln tng ng vi ba mc khc nhau v kh carbonic trong mu. Mi
loi bnh nhn cn mt cch thc iu chnh h hp nhn to khc nhau:
- Loi bnh nhn th nht: l loi c mt s gia tng nhiu kh ccbonic km mt s gim kh
oxy mu, gp trong t mt b cp ca suy h hp mn, th oxy phi bt u vi cung lng
thp, sau tng dn ln nhng rt chm, kh nng cung cp oxy (FiO
2
) cao nht l lc khi
u.
- Loi bnh nhn th hai: l loi ang hnh thnh s tng kh carbonic mu, bnh nhn ny c
th h hp hon ton bnh thng vi FiO
2
khong 50%.
- Loi bnh nhn th ba: l loi c mt s gim kh ccbonic mu. Hin tng tng h hp
th pht sau thiu kh oxy mu. Tuy nhin do c bnh l phi bn di, nn s tng h hp
khng ko theo mt s tng PaO
2
c. Bi vy bnh nhn nng dn dn, cng ngy n oxy
cng tr nn trm trng.
- C 5 loi my th:
+ My th to ra chu k da trn tn s.
+ My th to ra chu k da trn th tch.
+ My th to ra chu k da trn p lc.
+ My th to ra chu k da trn dng kh.
+ My th to ra chu k hn hp.
2.7. Chng nhim khun
253
Cc vi khun gy bi nhim thng l Streptococcus pneumoniae, Haemophilus influenza,
Stapylococcus aureus, Klebsiella pneumoniae, v.v..., nn phi cho cc khng sinh thch hp.

254
SUY H HP MN
Mc tiu
1. Bit c cc nguyn nhn ca suy h hp mn
2. Hiu uc c ch bnh sinh suy h hp mn.
3. Trnh by c cc triu chng lm sng v cn lm sng ca suy h hp mn.
4. Nu c cc bin php iu tr suy h hp mn va v nng.
5. Trnh by mt s bin php cn d dt trong iu tr suy h hp mn
Ni dung
I. I CNG
Suy h hp mn l mt tnh trng trong lng oxy cn thit cho c th khng th cung cp
hay s dng c khi ngh ngi hay khi gng sc.
Trong thc t, suy h hp mn c chn on khi c ri lon mn tnh cc kh mu, gim
PaO
2
v tng PaCO
2

II. BNH NGUYN
Nguyn nhn gy suy h hp mn c rt nhiu, a dng, c th b my h hp v ngoi b
my h hp.
Ngi ta phn bit 3 loi suy h hp mn: nghn, hn ch v phi hp.
1 Suy h hp mn nghn: thng gp nht
1.1. Bnh phi tc nghn mn tnh(COPD): l mt tnh trng bnh l ca vim ph qun mn
hoc kh ph thng c hn ch lu lng kh. S tc nghn ny xy ra t t c khi tng phn
ng ph qun v c th khng hi phc hay phc hi mt phn nh m thi.
1.2. Hen ph qun: nht l th tin trin ko di, nng, khng phc hi.
1.3. Nghn ng h hp trn: do u, hp do so.
2. Suy h hp mn hn ch trong v ngoi phi
2.1. Trong phi
- Di chng nng lan to 2 bn (x phi).
- Cc bnh phi k lan to gy x: do d ng thuc, cht c, sau x tr, bnh
Sarcoidose.
- Ct b phi.
- Ph phi k mn (suy tim).
2.2. Trong lng ngc
- Dy dnh mng phi, trn dch mng phi mn.
- Tim qu ln.
2.3. T bng v thnh lng ngc
- Thot v honh.
- Bng ln.
2.4. Do c v thn kinh
255
- Cc bnh c nh hng n c h hp.
- Cc thng tn thn kinh trung ng lm nh hng n c h hp: vim sng trc
tu sng, x cng ct bn teo c, vim no, tai bin mch no, bnh Parkinson...
2.5. Thng tn trung tm h hp, cc th th, ng dn truyn n trung tm.
- Trung tm: suy gip, ph nim, nhim kim chuyn ho.
- Th th: bnh thn kinh i tho ng.
- ng dn n trung tm: vim ty ct ngang, x cng ri rc...
3. Suy h hp mn phi hp
- Gin ph qun.
- Vim phi mn lan to do vi trng thng hay lao.
III. C CH BNH SINH
1. Gim PaO
2
: l ri lon khch quan quan trng nht, c gi l thiu oxy mu mn khi
PaO2 di 70 mmHg xy ra trng din trong sut thi k bnh n nh. Thiu oxy mu mn
tr nn ng ngi t mc PaO2 = 55 mmHg
1.1 Gim vn chuyn oxy:
S vn chuyn oxy n m ty thuc vo cung lng tim (Q) v vo sc cha oxy ca mu
ng mch (CaO2).
TO
2
= Q x CaO
2

Trong CaO
2
li tu thuc vo dung lng oxy tc l vo lng hemoglobin s dng c
v vo bo ho oxy.
Trong trng hp thiu oxy mu nng (PaO2 < 50 mmHg, SaO2 < 85%), CaO2 gim lm
gim TO2. Tuy nhin s gim PaO2 thng c cn bng bi s gia tng nng
hemoglobin (a hng cu th pht). Nh vy s vn chuyn oxy thng khng b nh hng
nhiu tr nhng t suy h hp cp hoc nhng lc thiu oxy mu nng nh trong gic ng.
1.2. Phn ng tng to hng cu (a hng cu th pht)
Phn ng tng to hng cu c li do cho php bo m s vn chuyn oxy y , nhng c
hi do lm tng nht mu v nh th gp phn lm tng khng lc mch mu phi dn n
tng p ng mch phi.
1.3. Tc ng mn tnh trn no
Thiu oxy mn gy bt thng v thn kinh - tm thn nh ri lon ch v tr nh, kh khn
v t duy tru tng, v hnh vi kho lo, v cc vn ng gin n
1.4. Tc ng trn huyt ng
Thiu oxy mn lm tng sc cn mch mu phi do co tht mnh, ph i tng dn c trn
thnh ng mch gy tng p ng mch phi v tng gnh tim phi. Tim b tr s tng gnh
ny bng cch tng tn s v cung lng tm thu m bo s cung cp oxy. Cn lu s
tng p phi l mt c ch thch nghi, gip chn la mt s mao mch phc v ti mu tt,
ci thin lin h thng kh/ti mu.
2. Ri lon c hc thng kh
2.1. Trong suy h hp mn nghn
256
Trong suy h hp mn nghn, th tch th ra ti a trong giy u FEV1(VEMS) gim, t s
Tiffeneau (VEMS/CV%) gim.
2.2. Trong suy h hpmn hn ch
Cc th tch phi gim, dung tch phi ton phn (CPT) gim, dung tch sng(VC) gim,
gin phi gim lm th vo kh hn.
3. Lin h thng kh-ti mu V/Q
- Tng hiu qu ni tt.
- Tng khong cht ln nhiu.
- Gim PaO2 v tng PaCO2.
4. Hot ng cc trung tm h hp
Trung tm h hp bnh nhn b suy h hp mn khng cn b kch thch bi PaCO2 cao
mn tnh, ch cn duy tr hot ng do kch thch thiu oxy mu nn khi cho th oxy liu cao
s gy c ch trung tm h hp lmPaCO2 gia tng., c th gy t vong
IV. TRIU CHNG HC LM SNG
Phi hi bnh t m mi xc nh c thi gian v trm trng kh th gng sc, ho khc,
nghin thuc l, cng nh nhim mi trng bnh nhn ang sng hay lm vic nh ht
cht c, bi.
Ngoi ra cc du chng ring ca tng bnh nguyn, cc du chng suy h hp mn c th r.
1. Tm v kh th
Tm xut hin kh SaO
2
di 85% (bnh thng trn 95%).Kh th khi thiu oxy nng
(nng t t do tin trin t nhin hay t ngt do bi nhim).
2. Ri lon hnh vi
Ri lon hnh vi xut hin khi PaCO
2
trn 50-55 mmHg c th tin trin t nhin tng dn
hay t ngt do nguyn nhn lm d nh thuc c ch h hp. Bnh nhn d kch thch, nhc
u, ri lon thc c th sng khoi hay r, c th run p cnh bo ng hn m do tng
CO
2
.
3. Du tm ph mn
Do thiu oxy v do tng kh CO
2
: tm (Ch ch r khi c km theo tng hng cu phn ng),
du hiu suy tim phi.
4. Quan trng hn l cc du chng nh, sm hn
Thng phi lu mi pht hin c, thng gp trong suy h hp mn nghn.
4.1. Th nhanh nng km lng ngc gin rng c mc ch b tr thiu oxy v gii hn s
xp cc ph qun nh do th ra su
4.2. Du co ko chng t c gia tng p lc m mng phi do nghn ng h hp.
4.3. Tng s co cc c thang, ph i cc c ny khi th vo.
4.4. Th ra mi khp cht: mc ch lm gim hiu s p lc gia ph nang v ming lm
gim bt s xp cc ph qun.
4.5. Gin lng ngc v du HOOVER (gim ng knh ngang phn di lng ngc khi ht
vo).
257
4.6. Tt thi dim chy
+ H ming thi dim chy cch trn 50 cm.
+ Chm ming thi dim chy cch 100 cm.
Nu khng tt th c nguy c suy h hp mn.
V. TRIU CHNG CN LM SNG
1. Thm d chc nng h hp
- Trong suy h hp mn nghn: c gim FEV1, FEV1/FVC
- Trong suy h hp mn hn ch: cc th tch phi gim, dung tch phi ton phn
(CPT) gim, gin phi gim, VC hay FVC gim
2. Kh mu: c gi l suy h hp mn khi PaO
2
< 70 mmHg v PaCO
2
>45 mmHg.
- Trong suy h hp mn va
+ PaO
2
cn ln hn 60 mmHg.
+ V hay PaCO
2
cn nh hn 50 mmHg.
+ SaO
2
= 90%.
+ Km pH mu v Hct bnh thng.
- Trong suy h hp mn nng
+ PaO
2
nh hn 60 mmHg.
+ V hay PaCO
2
cn nh hn 50 mmHg.
+ SaO
2
nh hn 90%.
+ Km pH thp v Hct tng.
3. Mt s thng s khc c gi tr chn on trong tm ph mn
- in tm .
- o p lc ng mch phi trc mao mch: nhy hn tm in , bnh thng t
13-18mmHg, c o trc tip v ngoi mi t cp hay bi nhim.
VI. IU TR
1. i cng
- Chnh trm trng ca suy h hp mn quyt nh s iu tr ny. Bnh nguyn d l ri
lon thng kh do nghn hay do hn ch hoc do ri lon khuch tn ph nang - mao mch ch
c vai tr ph trong iu tr.
- trm trng ca suy h hp mn c biu th ch yu bi PaO
2
, SaO
2
v PaCO
2
, ngoi
ra cn c pH mu, d tr kim, Hct.
2. iu tr suy h hp mn va
Trong suy h hp mn va, c:
- 60 mmHg < PaO
2
< 70 mmHg v hay 45 mmHg < PaCO
2
< 50 mmHg.
- pH mu, Hct bnh thng.
- SaO
2
= 90%
2.1. Bin php chung
258
- Ngng thuc l hon ton v vnh vin
- a bnh nhn ra khi mi trng b nhim khng kh t nhin hay ngh nghip.
- Loi b mi nhim trng ng h hp trn nht l xoang v rng l ngun gc thng
gy cc nhim khun i xung.
- Thay i mt kh hu tt hn.
- Gim mp ph lm gii hn kh nng thng kh.
2.2. iu tr triu chng
* Phng chng cc bi nhim ph qun - phi
- Vaccin chng cm v chng mt s vi khun d gy nhim khun
- iu tr thch hp mnh mi t bi nhim ph qun - phi, iu tr bng khng sinh thch
hp, mnh, dung np tt ti phi nh khng sinh h Macrolide: Roxithromycine [Roxid],
Rulid, 150 mg, 2 vin/ngy chia 2 ln], hay khng sinh h Cephalosporine (Cephadroxil
[Opedroxyl, Oracefal], 500 mg, 3 vin/ngy, chia 3 ln, trong thi gian trn 8 ngy.
* Tho m
- Ch yu bng vn ng liu php: v rung lng ngc tip theo l tp khc m vi c gng
ti a, tp h hp ng cch, tn dng s hp tc lc c honh v c thnh bng.
- Thuc tan nhy nh Acetylcysteine (Acemuc) 200 mg, 3 gi/ngy chia 3 ln.
- Thuc iu ho nhy nh Ambroxol (Mucosolvan), 30 mg, 3 vin/ngy, chia 3 ln.
* Thuc gin ph qun
L mt phng tin iu tr chnh, lu di, d thm d chc nng h hp c hay khng c
pht hin co tht ph qun.
-Theophylline nhanh (vin Theophylline 100mg) hay chm (vin Theostat 300 mg), 10-15
mg/kg/ngy, nu dng loi nhanh th chia 3-4 ln, nu dng loi chm th 2-3 ln.
- Salbutamol nhanh (vin Ventolin, 2 mg hay 4 mg) hay chm (vin Volmax 4 mg hay 8 mg),
0,2 - 0,3 mg/kg/ngy, nu dng loi nhanh th chia 3 ln, nu dng loi chm th chia 2 ln.
2.3. Chng ch nh
- Thuc an thn, thuc ng v gy c ch trung tm h hp.
- Mt s thuc khng c tc dng, thm ch nguy him nh Corticoid, thuc kch thch h hp
(v ch lm mt c h hp, tng kch thch), chng ng ko di.
3. iu tr suy h hp mn nng
Trong suy h hp mn nng c:
- PaO
2
< 60 mmHg v hay PaCO
2
> 50 mmHg.
- pH mu thp, Hct tng.
- SaO
2
< 90%.
3.1. Cc bin php iu tr trn c p dng trit .
3.2. Thuc ci thin trao i kh oxy
Almitrine bimesilate (Vectarion) 15 mg, 3 vin/ngy, chia 3 ln.
3.3. Liu php oxy
259
- Rt cn thit, phi duy tr PaO
2
trong khong 60-80 mmHg, cho oxy vi lu lng thp 0,5 -
1,5 lt/pht trnh c ch trung tm h hp, thng dng khong 1l/pht
-S th oxy ny phi c thc hin ng k thut: phi t xng mi hng kh su, oxy phi
qua mt bnh nc sch, c o lu lng chnh xc, theo di k, tt nht l bng kh mu,
lc u o kh mu 2ln/tun, sau 1ln/thng.
- Thi gian th mi ngy 12-15 gi/ngy mi bo m c s bnh thng ho cc yu t
chnh nh p lc ng mch phi, Hct v gim kh th gng sc.
3.4. Th my
Khi cc bin php trn khng c hiu qu
4. Mt s bin php iu tr d dt
- Corticoide: s dng trong hen ph qun nng, bnh phi tc nghn mn tnh
- Thuc tr tim: Digoxine khi c suy tim, tuy nhin d gy lon nhp .
- Li tiu: nh Furosemide c th gy nhim kim, gy c ch trung tm h hp (nhim kim
l do tng thi ion hydro v ti hp thu bicarbonat).


260
TRN DCH MNG PHI KHNG DO LAO
Mc tiu
1. Trnh by c nh ngha v dch t hc ca trn dch mng phi.
2. Phn tch c bnh nguyn ca trn dch mng phi.
3. Trnh by c triu chng lm sng v cn lm sng cc th trn dch mng phi.
4. Chn on c trn dch mng phi, chn on phn bit.
5. Trnh by c bin chng v d chng ca trn dch mng phi
6. Trnh by c cc phng thc iu tr: iu tr nguyn nhn, iu tr triu chng, iu
tr h tr v ch nh iu tr ngoi khoa trn dch mng phi.
Ni dung
I. I CNG
Trn dch mng phi (TDMP) l bnh thng gp trong cc bnh l ca b my h hp, chn
on xc nh TDMP thng khng kh lm, nhng chn on nguyn nhn mi l iu
quan trng v quyt nh hng iu tr.
Ty thuc vo nguyn nhn v din tin bnh m dch mng phi c nhiu tnh cht khc
nhau v mu sc (trong, vng chanh, c, m, mu, trng c..) v sinh ha (dch thm,
dch tit, mu...), v t bo (bch cu a nhn, lymphocyte, hng cu, t bo ni m), v vi
trng v cc tnh cht khc.
II. DCH T HC
Ngoi cc TDMP c nguyn nhn ngoi phi - mng phi, nguyn nhn do nhim trng c
mt vai tr quan trng, bnh thng xy ra ngi c c a xu, c bnh mn tnh. TDMP
chim t l kh cao so vi cc bnh ng h hp di, iu tr ni khoa nhiu lc khng
hiu qu, li nhiu bin chng v d chng lu di nh hng n chc nng h hp. Ngy
nay nh c nhiu loi khng sinh tt v mnh nn hn ch phn no t l t vong v gim nh
bin chng.
III. BNH NGUYN
Ngi ta phn bit
1.Ti Phi - mng phi
1.1. Nhim trng
Thng th pht sau cc thng tn phi (vim phi, vim mng phi, abcs phi v vo
xoang mng phi, ung th phi hoi t hoc bi nhim...) hoc t cc c quan ln cn (gan,
mng tim, trung tht).
1.2. Siu vi
Nguyn pht hay th pht
1.3. Ung th
261
Ph qun, phi, mng phi tin pht hay do di cn, Bnh BBS (Besnier - Boeck - Schaumann)
1.4. K sinh trng
Thng gp do amp (do pxe gan, pxe di c honh v vo xoang mng phi), sn l.
1.5. Thng tn ng ngc v vo mng phi gy TDMP dng trp.
1.6. D ng, Hodgkin giai on nng, bnh to keo.
1.7. Chn thng ngc, phu thut lng ngc, tai bin chc d mng phi...
1.8. Khng r nguyn nhn.
2. Ngoi phi-mng phi
Thng gp l dch thm do cc bnh l tim (suy tim), gan (x gan), thn (HCTH, suy
thn), suy dinh dng.Hoc u nang bung trng (H/C Demons Meigs), bnh t min, bnh
to keo, vim ty cp.
y ch nhn mnh n nguyn nhn do vi khun sinh m, thng gp l ph cu, lin cu,
t cu vng. E.Coli, Klebsilla pneumoniae, Actinomyces,trc khun m xanh, nu c mi thi
l do hoc phi hp vi cc loi ym kh.
Cc thng tn c th nguyn pht ti mng phi nhng thng l th pht sau cc thng
tn phi, mng tim, hoc t cc c quan khc nh gan, trung tht, abcs di c honh... hoc
t ng mu n (nhim trng huyt) hoc trn mt c a thng tn phi c sn (lao, ung
th...) ri bi nhim hoc trn dch sau trn kh mng phi.
IV.C CH BNH SINH
Bnh thng gia hai l mng phi c mt lp dch rt mng cho 2 l mng phi trt ln
nhau. Trn dch mng phi xy ra khi c tng tnh thm mao mch, gim p lc keo trong
mu, thay i p lc thy tnh, gim tun hon bch mch, xut huyt... trong c vai tr
ca vim l quan trng nht, gy dy mng phi v chn p nhu m phi,nhng lng dch
ny c th c thm tr li vo gian bo, mu, sau khi c iu tr gim vim.
Ngi ta chia ra dch thm v dch tit da vo lng Protein, men, t bo, bch cu... S
phn chia ny c gi tr trong chn on nguyn nhn v hng iu tr.
V.TRIU CHNG
1.Th t do (th ton th): Gm c 2 hi chng
1.1.Hi chng nhim trng cp
Vi st cao dao ng, th trng gy st, bing n, v mt hc hc, li bn, nc tiu t v
sm mu, s lng bch cu tng, bch cu trung tnh tng, VS tng.
1.2. Hi chng trn dch mng phi
1.2.1. C nng
- au xc ngc d di, tng ln khi ho hay th su hoc thay i t th. Nu trn dch t t
th t au hn
262
- Ho: thng l ho khan, nu km thng tn phi th i khi c m trong hoc m c m,
ho khi thay i t th.
- Kh th: Ty theo s lng dch, tc trn dch, c kh th nhanh, kh th mt phn do
st cao v au.
1.2.2. Thc th
Nhn thy lng ngc bn thng tn g cao, gian sn gin, da vng thng tn c sng ,
ph n v c th c tun hon bng h. S thy rung thanh gim, n ke lin sn rt au, g
c, v m ph bo gim hay mt, nu dch t c th nghe c ting c mng phi.
Nu trn dch qu nhiu, nht l trn dch bn tri y tim qua phi c th gy suy h hp cp
(kh th nhiu, v m hi, tm mi v u chi, nhp tim nhanh, huyt p gim)
1.2.3. Cn lm sng
- X.quang v siu m cho bit c trn dch. Xquang thng cho thy ng cong Damoiseau,
nu c km trn kh th mc dch nm ngang, nu dch t th ch c t gc sn honh.
- Chc d mng phi thy c dch m c, nhiu bch cu a nhn, t bo ni m nhiu,
protein cao, Rivalta (+), soi ti, cy v lm khng sinh tm thy vi khun sinh bnh.
Lu khi khm xt phi hi bnh s tht k, khm ton thn v cc c quan ln cn tm
tiu im nhim trng tin pht hay th pht.
2.Th khu tr
Thng gp trn dch mng phi cnh vng phi b thng tn, bnh nhn c hi chng
nhim trng cp, nhng trn dch th kh xc nh bng lm sng, m ch da vo x.quang,
siu m v chc d. Ngi ta chia ra: trn dch th trung tht, th honh, th nch, th rnh
lin thy, th c vch ngn...
VI. CHN ON
1. Chn on xc nh
Chn on trn dch mng phi thng khng kh i vi th t do, da vo lm sng,
X.quang v quyt nh chn on l chc d c dch, vi th khu tr Xquang, v siu m l
quan trng v lm sng kh xc nh.
2. Chn on nguyn nhn
Da vo mu sc,sinh ha, t bo hc v mi hi ca dch mng phi v quan trng nht l
cy dch mng phi v lm khng sinh .
3. Chn on phn bit
3.1 Vim phi khng in hnh
Da vo lm sng, Xquang v chc d khng c dch.
3.2. Dy dnh mng phi
Khong gian sn hp, Xquang c du dy dnh.
3.3. Xp phi
263
Khong gian sn hp film phi c m hnh tam gic, y quay ra ngoi, chc d khng c
dch.
3.4. p xe di c honh
y c honh ln cao, phi da vo Xquang v siu m.
VII. BIN CHNG V D CHNG
Ty theo nguyn nhn
1. Bin chng
V vo phi, ph qun gy p xe phi - khi m
D ra thnh ngc
Trn kh th pht hay phi hp.
Trn dch mng ngoi tim.
Nhim trng huyt.
2. D chng
2.1. Nu iu tr sm, ng th bnh s khi nhng li dy dnh mng phi, c khi c vch
ha mng phi.
2.2. Nu iu tr khng ng hay iu tr tr th s tn ti m cn trong mng phi lm
nhim trng ko di, gy xp phi, suy h hp.
2.3. Ty theo nguyn nhn gy bnh v p ng iu tr v phng php iu tr.
VIII. IU TR
Nguyn tc l sm, mnh, liu trnh, phi hp, v theo di din tin iu tr.
1. iu tr ni khoa
1.1. iu tr nguyn nhn
Phi cn c vo vi chun ca dch mng phi v khng sinh , nu cha c khng sinh th
da vo bnh cnh lm sng, tnh cht dch mng phi, kinh nghim lm sng yu t dch t
v din tin ca bnh.
Ch yu l khng sinh bng ng ton thn v ti ch vo mng phi.
* Khng sinh ng ton thn: Nn phi hp t nht 2 khng sinh dit khun bng ng
tim bp hay tnh mch trong cc trng hp nng, c nguy c khng thuc cao.
- Do ph cu, lin cu: Khng sinh vn c tc dng tt hin nay l
+ Pnicilline G 1-3 triu n v/6 gi tim bp, c th phi hp vi
+ Gentamycine 3-4 mg/kg/24 gi chia 3 ln nu phn ng vi Pnicillin th dng
+ Erythromycin 1500-2000 mg/ngy chia 3 ln hay Roxycillin 150 mgx 3v/ngy.
- Do t cu vng: Hu ht t cu vng khng vi Pnicillin; nn dng
+ Cefalosporine II: (Ceclor, Keflor...) liu 3-6 g/ngy chia 3 ln TB hay TM hoc
264
+ Cefalosporine III (Cefomic, cefobis, claforan, Rocphin...) liu nh trn, phi hp vi mt
thuc nhm aminoside nh
+ Amiklin 1 - 2 g/ngy tim bp (TB) hay Gentamycine. Hoc l dng
+ Vancomycine 30-60 mg/kg/ngy TB hay TM phi hp cc loi k trn.
- Do Klebsiella pneu. (Friedlander). Dng nhm aminoside nh
+ Amiklin1 - 2 g/ngy tim bp hay Gentamycine v/hay l
+ Cefalosporine III liu 3-6 g/24 gi chia 3 ln TB hay tnh mch (TM).
+ Tobramycine 3-5 mg/kg/24 gi TB hay TM.
- Do vi khun k kh:
+ Pnicillin G: liu 4- 12 triu n v/ngy TB, TM chia 4 ln phi hp vi
+ Metronidazole 250 mg x 4-8 vin/ngy v thm Gentamycine nu cn, hoc
+ Clindamycin (Dalacin C) 300-450 mg x 4 ln/ngy hoc
+ Cefalosporine III liu nh trn.
- Do Pseudomonas: Dng
+ Cefalosporine III phi hp Gentamycine hay Kanamycine hoc dng
+ Carbenicilline 70 mg/kg/8 gi TB hay TM phi hp 1 aminoside.
Nu khng tm thy vi khun th da vo bnh cnh lm sng, yu t dch t, kinh nghim
thy thuc...
* Khng sinh vo mng phi: Thc hin sau khi chc d tho dch mng phi, sc ra mng
phi bng dung dch mui sinh l, a khng sinh vo mng phi, c ch nh nht l trong
trng hp mng phi dy khng sinh khng th ngm vo c.
Khng sinh ch nh a vo mng phi thng l nhm Lactamin, Gentamycin...
1.2. iu tr triu chng
* Gim au v h st: Paracetamol 500 mg x 3 - 4 ln/ngy, hoc Acetaminophene,
Diantalvic. Nu au nhiu c th dng loi Efferalgan - Codein 2 -3 vin/ngy.
* Nu kh th nhiu tho bt dch, khng qu 500 ml/ln. Hoc th oxy qua sonde mi.
* Chng dy dnh mng phi
Prednisone 5 mg x 6 -10 vin/ ngy chia 2 ln hoc Hydrocortisone, Depersolone...
bm vo mng phi 1-2 ngy 1 ln.
1.3. iu tr h tr
1.3.1. Ngh ngi ti ging giai on bnh tin trin.
1.3.2. n nh, d tiu, nhiu m, calo v vitamin nhm B,C.
1.3.3. B nc v in gii , nht l c st cao, ly dch mng phi nhiu...
2. iu tr ngoi khoa
2.1. Dn lu mng phi ti thiu, sc ra mng phi v a khng sinh vo mng phi nht l
trng hp m qu c.
2.2. Bc tch mng phi khi c dy dnh, to vch, kn...
265
Bnh c xem l khi khi ton trng khe, n ngon, khng st,ht triu chng thc th, X
quang v chc d khng c dch, xt nghim v mu tr v bnh thng.
IX. D PHNG
Chn on TDMP thng khng kh nhng tm nguyn nhn v din tin iu tr phc tp,
c nhiu bin chng v di chng. Cc tc nhn gy bnh thng t ng h hp do phi
pht hin v iu tr sm cc nhim trng ng h hp trn, ph qun phi, nht l cc
bnh nhn c c a xu, mc bnh mn tnh...
Phi iu tr sm, mnh, y v theo di st cc bnh nhn vim mng phi c hng
gii quyt tt, phng bin chng.


266
TRN KH MNG PHI
Mc tiu hc tp
1. Trnh by nguyn nhn trn kh mng phi
2. Bit cch chn on xc nh.
3. Bit cch chn on cc th lm sng ca trn kh mng phi
4. Trnh by c v iu tr chung v iu tr triu chng trn kh mng phi
5. Bit c phng php iu tr trn kh mng phi.
Ni dung
I.I CNG V NH NGHA
1.i cng
Trn kh mng phi trn kh mng phi c Laennec m t t nm 1819 v n 1888 th
Galliard m t r rng hn. 1937 Sattler soi lng ngc thy bng kh ph b v gy trn kh
mng phi v sau ngi ta thy cc bng kh, kn kh phi v vo mng phi.
2. nh ngha
Trn kh mng phi l tnh trng kh lt vo gia 2 l mng phi lm xp phi, c trn kh
mng phi hon ton v khng hon ton.
Gm c: Trn kh mng phi nguyn pht
Trn kh mng phi th pht
II. DCH T HC
Trn kh mng phi t pht thng gp ngi tr t 20-30 tui, t l nam 4/1 so vi n.
Theo Salmeron.(1995) th t l hng nm ca trn kh mng phi l 9/100.000 dn, ti pht
>28%.
- Khong 20% trn kh mng phi l bin chng ca cc bnh nhim trng phi.
- Khong 40% trn kh mng phi do lao v (40% khng r nguyn nhn.
- 25% trn kh mng phi ti pht sau 2 nm, 50% ti pht sau 6 nm
- Thng trn kh mng phi gp trong cn hen nng
III. NGUYN NHN
C nhiu nguyn nhn gy trn kh mng phi nguyn pht hay th pht.
1. Trn kh mng phi nguyn pht
Thng gp ngi tr v nam > n = 4 ln thng do:
- V bng kh ph
- Vim ph nang do virus
- Khng r nguyn nhn
Thng xy ra ngi c tin s ht thuc l, gng sc, ho mnh, stress...
2. Trn kh mng phi th pht
267
- Lao phi
- Nhim khun ph qun - phi (20%)
- Bnh phi tc nghn mn tnh nht l kh ph thng.
- Trong cn hen ph qun
- Ung th ph qun thm nhp hay di cn mng phi.
- Bnh phi k, x phi, bi phi Silic, Sarcoidosis
- Cc bnh phi khc
3. Trn kh mng phi do chn thng, th thut thm d
- Chn thng thng lng ngc, gy xng sn lm thng phi
- Th thut chc d mng phi, sinh thit mng phi, t ni kh qun, chm cu.
- Chc tnh mch di n
- Dn lu mng phi
4. V cn
IV. C CH BNH SINH
Bnh thng p lc trong khoang mng phi l m (-3 n - 5 cm H20) khi khng kh lt vo
mng phi th s lm nhu m phi co li, lng ngc dn ra nn dung tch sng, dung tch ton
phn v dung tch cn gim...
- Mc ri lon chc nng h hp do trn kh mng phi ph thuc vo mc trn kh
(xp phi) v chc nng ca phi trc khi b trn kh - C th c trn mu mng phi sau
trn kh do thng tn dy chng gia 2 mng phi.
- Thng thng th khng kh lt vo mng phi khi th vo v thot ra khi th ra, nu th ra
m kh khng thot ra c l trn kh c van do gy nn kh th tng dn v a n suy
h hp trm trng, y lch trung tht.
- Trn kh mng phi c th gy nn do vt thng xuyn thnh ngc hay qua l tng do
thng, v ph nang, v bng kh, v p xe phi...
- Nu l d ca mng phi c bt li th trn kh s tiu dn.
- Nu trn kh mng phi xy ra trn 1 dy dnh mng phi th s gy trn kh mng phi
khng hon ton.
V. LM SNG
1. Th trn kh mng phi t pht hon ton
Thng gp ngi tr (20-30tui) vi triu chng u tin l cn au ngc t ngt d di
nh dao m, lm bnh nhn khng dm th su, ho d di v ho lm au tng ln. C th c
chong nu trn kh mng phi nhanh v nhiu, mch nhanh, nh, huyt p h, tay chn lnh,
v m hi nhp th nhanh- nng, tinh thn ht hong lo u... sau triu chng gim dn sau
vi gi, vi ngy.
Khm phi nhn thy lng ngc bn tn thng dn ln, cc khong lin sn rng, g vang
nh trng, rung thanh gim v nghe m ph vo mt ton b, c th nghe c m thi v hay
ting vang kim kh. G vang, rung thanh gim v m ph bo mt gi l tam chng Galliard.
Giai on sau c th c g c y phi do trn mu hay trn dch sau trn kh.
268
Nu trn kh mng phi nh c th triu chng c nng khng r, g vang nh phi
v biu hin suy h hp khng r rng.
2. Xt nghim cn lm sng
2.1.X quang phi chun thng, nghing
Cho thy bn trn kh mng phi lng ngc gin to, thy tng sng hn bnh thng, ton b
nhu m phi b y v pha rn phi to thnh mm ct, trung tht b y v pha i din, c
honh b y thp xung. C th thy gc sn honh tu do trn mu hay trn dch phi hp
hay mc dch nm ngang (nhiu), c khi nhn thy cc thng tn ca ch m phi gi
nguyn nhn gy trn kh mng phi.
Nu trn kh mng phi khng hon ton th ch thy 1 vng sng khu tr v thy c l
tng b dy v dnh.
2.2. Chp ct lp vi tnh
C th gip xc nh c thng tn phi di vng trn kh v gip xc nh nguyn
nhn trn kh, nhng khng phi lc no cng xc nh c.
2.3. Cc thm d khc
- Bng p lc k: Gip xc nh p lc trong mng phi nh gi l trn kh mng phi c
van hay khng, bt l d li cha.
- Soi lng ngc: Th thut ny gip nh gi kh tt thng tn ch m phi gy trn kh
mng phi nht l c ch nh khi phi dn lu mng phi v gip d phng trn kh mng
phi ti pht hay pht hin cc bng kh khc v klebs
3. Cc th lm sng
- Trn kh mng phi ton b (hon ton)
- Trn kh mng phi khu tr (khng hon ton): do c dy dnh mng phi c
- Trn kh mng phi c van: Khng kh vo mng phi nhng khng thot ra c, y l
mt th nng c th a n t vong nu khng can thip kp thi.
- Trn kh mng phi c 2 bn: Him gp, thng t vong nhanh
- Trn kh mng phi bnh nhn c suy h hp mn (COPD, Lao x...) gy suy h hp cp/
suy h hp mn dn n suy h hp mt b.
- Trn kh mng phi th im lng: thng l trn kh mng phi khu tr, nh, i km vi hen
ph qun, kh ph thng... nn ch pht hin khi chp phim phi.
VI. CHN ON
1. Chn on xc nh
Thng khng kh vi trng hp trn kh mng phi hon ton vi triu chng c nng rm
r nh cn au xc ngc t ngt nh dao m, km biu hin suy h hp cp (kh th
nhanh, nng, tm, v m hi...) hay km chong (mch nhanh nh, huyt p tt, biu hin ca
suy tim phi cp, tay chn lnh...) v tam chng Galliard. Chn on chnh l X quang. Vi
cc th khu tr, im lng th phi kt hp vi tin s., bnh l h hp, yu t lm d v quan
trng l X quang.
2. Chn on nguyn nhn
269
Thng rt kh v khong 50% trng hp trn kh mng phi l khng r nguyn nhn. Phi
da vo tin s, bnh s v triu chng lm sng cng vi cc xt nghim khc xc nh
bnh chnh gy trn kh mng phi.
a s cc trn kh mng phi l t pht v c yu t lm d nh gng sc, ho mnh, cn hen
ph qun nng, tress...
- Phi lu cc th thut thm d lng ngc nh t ni kh qun, soi ph qun, o tnh mch
di n, sinh thit phi, mng phi xuyn thnh, chc dch mng phi, dn lu mng phi...
mt s trng hp chc d, sinh thit gan, chm cu v mt s cc th thut khc.
- Chn thng lng ngc: thng gp l gy xng sn.
3. Chn on phn bit
- Khi thng phi: thng c 2 phi, khng c triu chng c nng cp tnh, m ph bo gim
ton b 2 bn, c th c biu hin suy h hp mn, xc nh chn on bng X quang..
- Kn phi: Hnh nh X quang v cn thit th ct lp vi tnh.
- Hang phi: Cn c vo tin s,bnh s v hnh nh X quang.
VII. BIN CHNG V D CHNG
1. Bin chng
- Trn mu, dch mng phi sau trn kh.
- Nhim trng m mng phi qua khng kh vo mng phi
- Suy tim phi cp, suy h hp cp
- Trn kh mng phi c van.
2. D chng
- Dy dnh mng phi
- Trn kh mng phi mn (khng hi phc)
- Trn kh mng phi ti pht sau nhiu nm
VIII. IU TR
1. iu tr h tr
- Ngh ngi ti ging trong giai on cp, cho nm t th fowler nu c suy h hp cp.
- Trnh lo u, xc ng: Phi c yn tnh, c th dng thm thuc an thn nh Seduxen
hay Diazpam, valium 5 mg x 1 - 2 vin/ngy nhng phi lu bnh nhn c suy h hp
mn.
- Khng lm vic gng sc sau cn cp
- n nh d tiu, ngng ht thuc
2. iu tr chung
- Gim au: nu au nhiu c th dng Paracetamol hay Acetamynophen 500 mg x 3 - 4 vin/
ngy.
- Gim ho: v ho c th lm au ngc tng ln hay lm kh th: dng loi c ch ho nh:
Paxeladin 3 v/ngy (khng c ch trung tm h hp).
270
Th oxy qua sond mi liu trung bnh 2-3l/1' nu c suy h hp nhng phi lu loi trn
kh c van hay khng c van.
- Khng sinh: thng trn kh mng phi s b bi nhim do vi khun t khng kh hay t ph
qun phi vo mng phi. Nn dng khng sinh ng ton thn v loi c ph khun rng
nh Cefalosporin III: 3 - 4g/24 TB hay TM.
3. iu tr trn kh
Mc ch l lm cho ch m phi dn ra, trnh suy h hp cp v xp phi. Phng php ch
yu l ht kh mng phi bng bm tim, v tr thng chn l gian sn II trn ng trung
n.
Ty theo loi trn kh m c ch nh khc nhau.
* TKMP ng: thng thng th kh t hp th tr li sau mt thi gian, nu 3 - 4 ngy sau
m lng khng gim kh th c th dng bm tim ln v kim ht, khng nn ht sm, v
ch ht t t, lng t trnh gy shock do thay i v tr cc tng hoc gim p t ngt.
* TKMP m: phi dn lu mng phi bng catheter vi p lc m, a vo lin sn II
ng trung n hay lin sn 4 - 5 ng nch trc, a ng thng v pha nh phi,
hoc dng my ht (- 20 n 40 cm H20). Sau 3 - 5 ngy th kp ng thng li: 24 - 48 gi
xem trn kh c tr li hay khng, theo di mch, nhit, huyt p v kim tra bng X quang
nh gi.
* TKMP c van: y l mt cp cu ni khoa nn phi tin hnh nhanh.
- Nu khng c iu kin th dng kim ln chc vo mng phi v tr nu ni vi dy
chuyn Serum a vo mt hnh cha Nacl 9, nhng cu dy chuyn xung 10 -15 cm.
- Nu c dng kim loi 14 - 16 Gi chc ht c qua my lin tc, p lc ht - 15
cmH2O.
4. iu tr d phng trn kh ti pht
- C th tm thng tn gy TKMP bng phng php ni soi xc nh nh m kn kh,
bt l thng l tng...
- Lm dy dnh mng phi bng keo sinh hc.
5. iu tr nguyn nhn gy trn kh mng phi
Vit Nam nguyn nhn thng gp nht l do lao, ngoi ra do nhim trng, siu vi v mt
s yu t khc do phi xc nh nguyn nhn iu tr nhm trnh TKMP ti pht hay
nng ln.
Lu trnh cc yu t lm d nh gng sc, stress, ho mch, ht thuc l.
6. iu tr ngoi khoa
Ch nh iu tr ngoi khoa khi c cc trng hp sau.
- Trn kh - trn mu mng phi do chn thng
- Trn kh - m do v p xe phi hay do lao
- Trn kh mng phi do chn thng ngc. (chn thng h, gy xng sn, d vt...)

271
P XE PHI

Mc tiu
1. Trnh by c nh ngha ca p xe phi
2. Bit c nguyn nhn ca p xe phi
3. Trnh by c c s bnh sinh v gii phu bnh
4. Bit r triu chng lm sng ca p xe phi
5. Bit ch nh c iu tr p xe phi

Ni dung
I. I CNG V NH NGHA
p xe phi l mt tnh trng nung m, hoi t ch m phi sau mt qu trnh vim cp, m
nguyn nhn ch yu l vi khunn m, k sinh trng...
Ngi ta chia ra lm hai loi
1. Nung m phi tin pht: L s nung m cp tnh vng phi cha c tn thng c.
2. Nung m phi th pht: L nung m xy ra trn mt thng tn phi c sn nh hang
lao, nang phi, ung th phi hoi t, gin ph qun.
Bnh c bit t lu, nhng s chn on c r rng hn t khi c quang tuyn X.
II. DCH T HC
C rt nhiu hi ngh v ti liu ni v p xe phi v bnh ny trc y chim t l kh cao.
Nhng k t khi c cc phng tin gip chn on nguyn nhn v nht l c nhiu loi
khng sinh mi, c hiu nn t l ny gim i nhiu. Ap xe phi chim t l 4,8 % cc bnh
phi (Chu Vn 1991), hay chim 3% cc bnh phi iu tr ni tr vin lao v bnh phi
(Nguyn Vit C 1987)
Bnh thng gp mi la tui, nhng tui trung nin c t l cao hn, bnh xy ra nhiu
hn nhng ngi c a suy kit, gim min dch, nghin ru, thuc l, i tho ng,
cc bnh phi mn tnh. Din tin bnh ty thuc vo chn on sm, iu tr ng v liu
trnh.
III. BNH NGUYN
1. Cc tc nhn gy bnh
1.1. Vi khun k kh: y l nhng vi khun thng gp nht, chim t l khong 60%
(Cameron 1980), hay 89% (Barlett 1982), d pht hin chng v hi th v m rt hi thi,
chng c th gy nn nhng p xe lan ta, bn cp v thng kt hp vi cc loi vi khun
khc nh lin cu, ph cu... Cc loi vi khun k kh thng gp l Bacteroide
melaniogenicus, Fusobaterium nucleotum, Bacteroide fragilis Peptococus,
Peptostreptococcus...
1.2. T cu vng: Thng gp tr em nh nht l tr cn b, cc triu chng lm sng nh
st cao, ri lon tiu ha (nn, chng bng...) st cn. Bnh cnh lm sng va phi va
mng phi (trn kh, dch mng phi) gy suy h hp, nhim trng nhim c nng.
272
1.3.Klebsiella Pneumoniae (Friedlander): Tin trin lan rng rt nhanh, khi huyt, bnh cnh
rt nng v nguy c t vong cao.
1.4.Nhng vi khun khc: Nh ph cu, lin cu,nhm A hay tan mu, cc vi khun Gram (-)
nh Pseudomonas aeruginosa, Hemophillus influenzae, Legionella pneumophila.
1.5.K sinh trng: Thng gp nht l amip, c th l nguyn pht nhng hu ht l th pht
sau Aaip gan, rut, thng tn thng gp l y phi, phi st vi c honh v thng km
thng tn mng phi (phn ng), m c mu chocolat nhng thng gp l mu ti. C
th t gp hn l nm.
2. Cc nguyn nhn thun li: Gy p xe phi th pht
2.1.Cc u phi, ph qun gy nghn, bi nhim hay hoi t (ung th)
2.2.Gin ph qun: Va l nguyn nhn va l hu qu ca p xe phi
2.3.Trn nhng thng tn phi c sn: hang lao, kn phi bm sinh...
3. Yu t lm d
3.1.Cc chn thng lng ngc h, t ni kh qun.
3.2.Nhng c a xu: i tho ng, suy gim min dch, suy dng nng, nghin ru...
IV. C CH BNH SINH
a s p xe phi l nguyn pht, vi khun gy ra p xe phi theo cc ng vo sau y:
1. ng kh- ph qun
Do ht vo t khng kh, cc sn phm nhim trng mi hng, rng - li, amygdal, cc phu
thut tai mi hng, rng hm mt, cc d vt ng th, trong lc hn m, t ni kh qun,
tro dch d dy... Do bnh nhn b ri lon phn x nut, khng ho v khc m c, lit
cc c h hp, c honh, tt nghn ng th gy ng...
2. ng mu
Do vim tnh mch, vim ni tm mc, gy thuyn tc,nhi mu v p xe ha, hoc t mt
tiu im xa n (nhim trng huyt) thng gy p xe nh c hai phi. (thng gp do t
cu vng)
3. ng k cn
p xe di c honh, p xe gan do amip, p xe mt qun, p xe trung tht, p xe thc qun,
vim mng phi m, vim mng ngoi tim... hay do ng bch mch.
Mt s trng hp p xe phi th pht trn mt hang phi c trc nh hang lao, kn phi
hay mt s bnh c trc nh gin ph qun, ung th phi hoi t hay u gy tc nghn ph
qun...
V. GII PHU BNH
S hnh thnh apxe phi qua giai on
- Lc u trong nhu m phi b vim xut hin mt hay nhiu vim ha m, nhu m phi b
ng c, nu iu tr giai on ny th thng tn c th phc hi hon ton. Nu khng
th cc vim ny s hoi t lan rng v kt hp li thnh mt ln hoi t v c m. y l
giai on nung m cp v p xe phi hnh thnh, c v mng bao bc. Sau thng tn
cc ph qun ln cn v bnh nhn s khc ra m, v cc t chc hoi t.
- Sau mt thi gian (khong 6-8 tun) th vim x bt u bao quanh p xe to nn nhiu
vch ngn, hoc l m s lan qua vng ln cn gy nn cc thng tn mi.
273
- Sau khong 12 tun l th v x dy v tr thnh p xe phi mn tnh, bn trong c m
ht v biu b ha t cc nhnh ph qun ln cn, nhu m ngm nhiu fibrin v nhiu t bo
lympho, c khi thng tn mch mu gy ra ho ra mu, nu thnh ph qun b ph hy nhiu
s dn n gin ph qun.
VI. TRIU CHNG HC
Do nguyn nhn no, p xe cng u din tin qua 3 giai on.
1. Giai on nung m kn
1.1. C nng: Giai on ny ch c ho khan hoc c khi khc t m. Triu chng au ngc
m , au su v tng ln khi ho hay th su, t kh th tr khi thng tn phi lan rng hay
do tnh trng nhim c nhim trng nng.
1.2. Tng qut: st cao, rt run, mt mi, chn n, gy st, v mt hc hc, nc tiu t, sm
mu.
1.3.Thc th: Thng rt ngho nn,c khi ging mt hi chng ng c phi khng in
hnh.
1.4. Cn lm sng
- Xt nghim mu thy bch cu tng, bch cu a nhn tng, mu lng cao.
- Chp phim phi c th thy mt hnh m trn hay bu dc, thng gp y phi phi hn.
2. Giai on khi m
Sau thi gian nung m khong 5-7 ngy ty loi vi khun, bnh nhn au ngc tng ln, ho
nhiu, tnh trng suy sp, hi th hi, c th c khi huyt trc ri sau au ngc v ho
nhiu ri c ra nhiu m, thng rt hi thi, s lng c khi 300-400 ml,c trng hp ch
ho ra m t, tng bi c nh hnh ng xu v ke di. Sau khi c m th ngi cm thy d
chu hn, st gim, au ngc gim dn.
3. Giai on nung m h
Sau thi gian t 3-5 ngy,tnh trng nhim trng gim dn, du c nng gim nu c iu tr
tt. Nhng thng l hi chng nhim trng ko di, th trng suy sp nhiu do m cha
c tng ra ht gy vim nhim ko di v c khi lan rng thm, do iu tr khng ng hay
sc khng xu. Biu hin suy h hp mn, ngn tay hnh di trng.
Khm phi giai on ny c hi chng hang vi ran m to ht, m phi hang v c th nghe
c ting ngc thm.Chp phim phi thy c mt hnh hang trn, b dy, c mc hi- nc.
Quan trng nht l xt nghim m tm nguyn nhn gy bnh khi cha x dng khng
sinh.
VII. CHN ON
1. Chn on xc nh
Giai on nung m kn thng kh khn v triu chng ngho nn, khng in hnh, nu c
th th ch da vo X quang v siu m.
Trong giai on c m th chn on tng i d dng hn. Ni chung chn on da vo:
- Hi chng nhim trng cp.
- Khi m nhiu (hoc m hnh ng xu), hi thi.
- Hi chng hang, quan trng l X quang phi c hnh nh mc hi - nc.
- Ngn tay hnh di trng.
274
2. Chn on nguyn nhn
Ch yu l cy m, lm khng sinh (khi cha s dng khng sinh) nu tm amip th phi
ly m c mu v em xt nghim ngay.
Lu hi k bnh s, tm yu t thun li gy bnh.
3. Chn on phn bit
3.1. Giai on nung m kn: phn bit vi
- Vim phi: c th din tin lnh hn hay c th s pxe ha.
- Cc khi u phi: c th lnh tnh hay c tnh,hi chng nhim trng khng c, c khi
huyt, lm sng, X quang v soi ph qun... gip chn on phn bit.
3.2. Giai on nung m h: phn bit
- Ung th ph qun - phi hoi t, hay cng c th l nguyn nhn ca p xe phi. Trng
hp ny th trong lng khi u hoi t khng u, khng c mc hi-nc, ni soi, sinh thit
v tm t bo l trong m xc nh.
- Gin ph qun bi nhim: Trong tin s c ho khc m ko di, chp ph qun c cn
quang gip chn on. Lu p xe phi thng l bin chng ca gin ph qun.
- Hang lao bi nhim: thng hang nm vng nh phi, b mng, ho ra mu, BK m
thng dng tnh, phim phi khng thy mc hi nc.
- p xe gan v vo phi: qu trnh bnh l l triu chng gan trc sau n phi. Siu
m, x.quang gip chn on.
VIII. TIN TRIN V BIN CHNG
Phi theo di bnh lin tc v nhit , triu chng lm sng, s lng v tnh cht ca m
khc ra, cng thc mu, tc mu lng. Phim phi phi c chp hng tun, sau 1
thng, 3 thng, 6 thng... cho n khi khi hon ton.
1. Din tin
Trc khi c khng sinh th p xe phi l bnh rt nng, t l t vong cao, nht l tr em v
ngi gi.
1.1. Ngy nay nh c khng sinh tt, c hiu nn iu tr ni khoa y c th khi bnh
hon ton. Thng thng nhit gim dn sau khi khi m, s lng m gim dn v c th
ht sau 7-10 ngy iu tr, nhng xt nghim v mu lng v c bit l x.quang th chm hn
nhiu c khi 3-6 tun sau, li x hoc khng cn di chng g trn phim phi c.
1.2. li hang tha: tn ti rt lu v c th xem nh lnh bnh nu trong qu trnh theo di
trn X quang khng c g thay i (v mng, khng c dch...)
1.3. p xe phi mn: Sau 3 thng iu tr tch cc bnh thoi trin, ht hi chng nhim trng
cp, ngng khi m, nhng bnh khng lnh hn v c tng t khi m tr li thng tn
trn phim tn ti mi hay c xu hng lan ta hay thm mt p xe khc, c du ngn tay di
trng r.
2. Bin chng
2.1. Ho ra mu nng: C th do p xe n vo cc mch mu ln.
2.2. Trn dch tng dch si hay trn m mng phi li di chng dy dnh mng phi,
gy suy h hp mn.
2.3. Gin ph qun, x phi
275
2.4. Nhim trng huyt
2.5. p xe phi mn tnh.
2.6.T vong: do bnh nng, hoc do bin chng, c trng hp t vong ngay sau khi c m
do tt ph qun v phn x co tht ph qun (sc phi)
IX. IU TR
1. Nguyn tc iu tr
iu tr p xe phi phi tun theo nhng nguyn tc sau y
+ iu tr ni khoa kp thi, tch cc, kin tr.
+ Nu c th la chn khng sinh theo kt qu ca khng sinh th p xe phi s
chng khi.
+ Ch nh m sm trc khi c cc bin chng nng nh ho ra mu nng, vim m
mng phi.
2. iu tr c th
2.1. iu tr ni khoa
2.1.1. iu tr h tr
(1) Tit thc: nhiu protide, cung cp y nng lng, c th chuyn huyt tng
ti hay kh hay lipofundin hay cc loi dung dc acide amine nh Alvesine,
Cavaplasmal...phi hp vi vitamine nhm B nh Becozyme tim.
(2) Dn lu t th: cho bnh nhn khc m v m d dng.
(3) Ht ph qun: bng ng ht mm t tn p xe ht m v cc cht m ra, y
l mt phng php dn lu tt hn.
(4) iu chnh ri lon nc v in gii: nu c thng mt nc do st cao, hay ri
lon in gii v toan kim do suy h hp cp, gp trong nhng trng hp nng.
(5) Th oxy: khi c tnh trng suy h hp cp, bng ng xng mi, cung lng cao
khong 6 lit/pht, nu c suy h hp mn th th oxy vi cung lng thp khong 2 lt/pht.
2.1.2. iu tr bng khng sinh
(1) Vi khun k kh
+ Penicilline G liu cao khong 20 triu n v/ngy, tim bp hay tim tnh mch
chia 3-4 ln hay chuyn tnh mch ho trong Glucoza 5% ri u; c th phi hp vi
Metronidazole 250 mg, 4-6 vin/ngy, chia 4 ln hay Tinidazole 500mg, 3vin/ngy, chia 3
ln, hay Metronidazole, chai, hm lng 500 mg, liu lng 20-30 mg/kg/ngy, chuyn tnh
mch cch nhau 12 gi, c hiu qu cao trn Bacteroide fragillis v Fusobacterium. Ngi ta
thng phi hp vi mt aminoside nh Gentamicine, ng, hm lng 40 mg v 80 mg, liu
lng 1-1,5 mg/kg/8 gi, tim bp hay chuyn tnh mch chm hay Amikacine (Amiklin),
chai, hm lng 250 mg, liu lng 15 mg/kg/ngy c th dng 1, 2 hay 3 ln tim bp hay
chuyn tnh mch chm.
+ Clindamycine (Dalacine), vin nang, hm lng 75 mg v 150 mg, liu lng 15
mg/kg/ngy, hoc 1 vin 150 mg cho 10 kg cn nng/ngy hoc 1 vin 75 mg cho 5 kg cn
nng/ngy, c hiu qu cao trn Bacteroide fragillis v Fusobacterium.
276
+ Cefoxitine (Mefoxin), chai, hm lng 1 g v 2 g, liu lng 1-2 g/8 gi, tim bp
hay tim tnh mch chm, c th chuyn tnh mch, c hiu qu cao trn Bacteroide fragillis
v cc vi khun k kh khc.
(2) Klebsiella pneumoniae
y l mt loi vi khun c c tnh cao, gy tnh trng nhim trng nhim c rt nng do
phi c iu tr nhanh v tch cc.
Ngi ta thng phi hp Cefalosporine th h 3 nh Cefotaxime (Claforan), chai nc, hm
lng 1 g; chai bt, hm lng 500 mg; hay Ceftriaxone (Rocephine) chai nc, hm lng 2
g; chai bt, hm lng 1 g; liu lng trung bnh 50-60 mg/kg/ngy, trong trng hp bnh
nng c th tng ln 200 mg/kg/ngy, chia 3 ln, tim bp hay tim tnh mch, c th chuyn
tnh mch. Phi hp vi aminoside nh Gentamicine hay Amikacine, liu lng nh trnh
by trn.
(3) Staphylococcus aureus
+ Staphylococcus aureus ngoi bnh vin: l loi vi khun nhy cm vi Methicilline
(MS), th ngi ta dng Cefazoline, chai, hm lng 500 mg v 1 g, liu lng 25-50
mg/kg/ngy, chia 2 hay 4 ln, tim bp, tim tnh mch trc tip hay chuyn tnh mch. Ngoi
ra c th dng Cefadroxil (Oracefal), vin nang, hm lng 500 mg, liu lng 50
mg/kg/ngy, chia 3 ln. C th phi hp vi Clindamycine (Dalacine), ng, hm lng 600
mg, liu lng 15-40 mg/kg/ngy, tim bp hay ho vi chlorure natri sinh l hay glucoza 5%
tim tnh mch chm.
+ Staphylococcus aureus trong bnh vin: l loi vi khun khng Methicilline
(MS), th ngi ta dng Vancomycine (Vacocime), chai bt, hm lng 125 mg, 250 mg, 500
mg, liu lng 30 mg/kg/ngy, tim tnh mch hay chuyn tnh mch trong 60 pht, chia 2-4
ln; hay Cephalosporine th h 3 (Cefotaxime: Claforan; Ceftriaxone: Rocephine) hm lng
v liu lng nh trnh by trn; phi hp vi Gentamicine hay Amikacine. Ngoi ra c
th dng phi hp vi Ofloxacine, vin, hm lng 200 mg, liu lng 2 vin/ngy, chia 2
ln.
(4) Pseudomonas aeruginosa
Thng dng phi hp mt loi Betalactamine nh Carboxypenicilline (Carbenicilline), liu
lng 70 mg/kg/4 gi tim bp hay tim tnh mch chm; hay Ureidopenicilline
(Mezlocilline), liu lng 35 mg/kg/4 gi tim bp hay tim tnh mch chm hay mt loi
Cephalosporine th h 3 phi hp vi mt Aminoside.
Trong trng hp khng phn lp c vi trng th nn phi hp
+ Mt Cephalosporine th h 3 phi hp vi mt Aminoside v Metronidazole.
+ Penicilline G phi hp vi mt Aminoside v Metronidazole.
+ Cephalosporine th h 3 phi hp vi mt Aminoside hay vi Vancomycine.
Thi gian iu tr tu thuc vo tnh trng bnh, trung bnh phi 4-6 tun.
(5) Amp
Phi hp Metronidazole 250 mg, 4-6 vin, chia 4 ln, hay Tinidazole 500 mg, 3 vin/ngy,
chia 3 ln hay Metronidazole, chai 500 mg, liu lng 20-30 mg/kg/ngy, chuyn tnh mch
cch nhau 12 gi, phi hp vi Dehydroemetine, ng, hm lng 20 mg, liu lng 1
mg/kg/ngy trong 10 ngy.
2.2. iu tr ngoi khoa
277
iu tr ct b phn phi b p xe c ch nh trong trng hp p xe phi chuyn sang th
mn tnh, ngha l sau 3 thng iu tr ni khoa khng c kt qu.
Ngoi ra c th m cp cu trong trng hp bnh nhn ho ra mu lin tip nhiu ln, mi
ln khong 200 ml.
278
GIN PH QUN
Mc tiu
1. Trnh by c bnh nguyn v gii phu gin ph qun.
2. Lit k c cc triu chng lm sng v cn lm sng gin ph qun.
3. Trnh by c tin trin v bin chng gin ph qun
4. Trnh by c cch iu tr gin ph qun..
5. Nu c cc bin php d phng gin ph qun.
Ni dung
I. NH NGHA
Gin ph qun l s gin khng hi phc cc ph qun nh v trung bnh km theo s lon
dng cc lp ph qun v a tit ph qun, c th do bm sinh hay mc phi, thng b bi
nhim nh k. Gin ph qun gp nam 4 ln nhiu hn n.
II. BNH NGUYN
1. Mc phi
Hin nay c xem nh l thng gp nht; nhng th ny c th khu tr hay
lan ta.
1.1. Th khu tr
- Nhng nguyn nhn gy hp ph qun mt phn: gy nn s dch tit dn n
nhim trng v ph qun b gin ra, i khi trong 2 - 3 tun l. Nhng nguyn nhn ny
thng ch c pht hin nh ni soi ph qun, trc tin l khi u c th lnh tnh hay c
tnh, c th l vt l nht l i vi tr em, c th l lao bi nhng l d hay u ht t mt lao
s nhim tin trin hay trn di chng calci ha.
- p xe phi: di chng so x hay trn mt p xe phi mn tnh.
- Aspergillose ph qun: t gp hn nhng rt c bit l c s phi hp vi nhng
biu hin tng nhy cm type I v type II (tm nhng cht kt ta khng aspergillus), c th c
tng bch cu i toan v khu tr ph qun rt gn gc, nh vy ch tn thng cc ph qun
ln cn cc ph qun trc tn cng cn tt (bnh Hinton).
1.2. Th lan ta
- Di chng ca cc bnh ph qun - phi cp nng trong thi k thiu nin:
c th b qun lc khi u hi chng a tit ph qun - phi. Si v ho g l 2 bnh thng
gp nht, nhng bnh nhim siu vi nng nht l do Arbovirus l nhng nguyn nhn gy nn
di chng gin ph qun.
- Bnh nhy nht (bnh x ty tng nhy - kn): l nhng bnh bm sinh di truyn;
trong nhng bnh ny c ri lon v tit dch do s thanh lc b chm li, gy nn nhng
nhim trng ph qun - phi ti pht dn n nhng th gin ph qun rt nng vi suy h hp
mn v cht trc thi k trng thnh.
2. Bm sinh
Gin ph qun thng l lan ta, rt t gp.
2.1. Bnh a kn phi: thng phi hp vi a kn thn, ty v gan.
2.2. Suy gim min dch
279
- Suy gim min dch th dch: Suy gim ton th hay khng c (globuline mu, suy
gim chn lc IgA huyt thanh hay ngay c ch suy gim IgA tit.
- Suy gim min dch t bo: do tn thng s thanh lc l bnh lng bt ng; bt
thng ny thng nm trong hi chng Kartagener (gin ph qun phi hp vi o ph
tng v vim xoang sng - xoang hang).
III. GII PHU BNH
1. i th
Nhng ph qun ln khng b tn thng, do ni soi khng th pht hin c; nhng tn
thng bt u phn phn nhnh th 4 v lan ra t phn phn nhnh th 8. Ph qun tn
cng b tn thng hoc b cht thng gp nht, ch m phi khng c h hp s gy nn
hi chng hn ch, gin ph qun c gi l tn cng; hoc ph qun tn cng cn thng vi
nhng ph qun xa hn, ch m phi cn c h hp, gin ph qun c gi l trc tn
cng.
Trong gin ph qun, c nhiu dng tn thng v gii phu khc nhau:
- Hnh ti, hnh bng hay hnh gi kn gp trong gin ph qun trc tn cng.
- Hnh chui ht v hnh tr gp trong gin ph qun trc tn cng.
Thng c nhng bt thng phi hp:
- Vim ph qun trong nhng vng ln cn gy nn hi chng tc nghn phi hp vi
hi chng hn ch do gin ph qun.
- Gia tng mng li mch mu h thng, nhng tiu ng mch tr nn ngon ngho,
dn mu theo chiu ngc dng do nhng ni tt ng mch - ng mch gi l ng mch
ha tc l tnh mch phi c ly mu trong ng mch phi pha bn b bt thng ng
mch ph qun.
2. Vi th
2.1. Tn thng nim mc
Di mt lp biu b gn nh bnh thng lc u, sau b d sn v cui cng b hy hoi,
c mt mng m dy ln v thm nhim trng t bo vim v nhiu mch mu c tn to
t mch mu ph qun. Trong mt vi th bnh, nhng tn thng vim vi s ph i lp
nim mc v tng tit tri ln, gy a tit ph qun trn lm sng. trong mt s trng hp
khc, lp nim mc b teo li vi s gim nhng tuyn thanh dch - nhy v x ha lin tuyn
nang, nh vy khng c s tng tit. Hai loi ny thng phi hp trn cng mt bnh nhn.
2.2. Tn thng di nim mc
M lin kt b tn thng phi hp vi s gim v s sp xp ln xn nhng si n hi v
si c; b ct on bi si collagen tn to v c hnh gi u c.
2.3. Tn thng sn
l tn thng thoi ha sn c thay th bi nhng m calci ha hy ct ha hay bi s
x ha collagen; nhng ph qun mt i ci ct nng v tnh n hi.
2.4. Tn thng ph nang
Gp phn quan trng trong ri lon chc nng h hp v trong s trao i kh oxy phi,
nhng tn thng ny rt thay i ty ngi bnh, ty v tr cng mt bnh nhn, l
vim phi li teo hay ph i, vim ph nang xut huyt, xp phi.
280
IV. TRIU CHNG LM SNG
1. Triu chng chc nng
1.1. Khc m
Gp 80 % trng hp gin ph qun.
- Thi im: nhiu nht vo bui sng, i khi ri u trong ngy.
- Lng: thay i ty theo tng bnh nhn, thng l nhiu, khong t 20 - 100 ml /
ngy,
hay c th nhiu hn trong t cp; tuy nhin c nhng th kh, khng khc m.
- Mi v: lt, mi thch cao, i khi c mi hi; nu lng s c 4 lp t trn xung
di
l: m bt, m thnh dch nhy trong, m mi nhy, m m c.
- Phn tch: t c v nhim trng thng km theo.
1.2. Ho
L triu chng thng km theo khc m.
1.3. Ho ra mu
Quan trng, gp trong 8 % trng hp, c th km theo m hay i khi n c. Ho ra mu
c th di hnh thc tia mu mu hn l en chng t c t vim hay ho ra mu c s
lng nhiu hn mu chi tng ng vi s chy mu h thng c xem nh bin chng.
1.4. Kh th
t gp, mc d mt s gin ph qun ch c chn on giai on suy h hp mn.
2. Nhng biu hin khc
2.1. Nhng nhim trng phi - ph qun cp ti pht nhiu ln
Vi st va 38o - 38o5, c 2 c im l v tr nhim trng c nh gi c bt thng
bn di, tng trng thng khng thay i.
2.2. Trn dch mng phi thanh dch - si hn l m
3. Khm lm sng
3.1. Hi bnh
Chnh xc nhng tnh hung pht hin bnh, thi gian b bnh; trn thc t, thng khng
chnh xc, c th trong thi k thiu nin bnh nhn b bnh ho g hay si nng. Hi bnh
bit tnh chu k a tit ph qun, tn sut nhng t bi nhim nht l vo ma ng v lin
quan n nhng nhim trng mi - hng (vim mi, vim xoang, vim amian); hi bnh
bit n tin s c nhn v gia nh, ht thuc l v ngh nghip hin ti v qu kh.
3.2. Khm thc th
- Khm phi: c th bnh thng ngoi t cp, c th pht hin ran ngy, ran rt, ran
m to ht. Khi b bi nhim c th nghe c ran n kh hay ran n t nh ht hay hi
chng trn dch mng phi.
- Ngn tay hnh di trng.
- Trong nhng th tin trin, c hai bin chng nng l suy h hp mn v tm ph
mn.
281
V. CN LM SNG
1. m
1.1. T bo
C nhiu t bo biu m ph qun, c nhiu bch cu a nhn trung tnh thoi ha v cht
nhy, khng c si n hi.
1.2. Vi trng: hay gp nht l Haemophilus influenza v ph cu, ngoi ra c th gp vi trng
gram m nh Pseudomonas aeruginosa; vi trng k kh; ngoi ra phi tm BK.
2. Phim phi
2.1. Phim chun
Thng c hnh m dng li i t rn n co honh; i khi c hnh nh m mt cch c h
thng nhiu nht thy gia v thy di phi; i khi c hnh nh hoa hng nh ging
nh nhng kn kh chng ln nhau, c th c hnh nh mc nc kh trong giai on m.
2.2. Chp ct lp t trng
Cho php pht hin d dng phn ln cc gin ph qun th hnh tr. Hin nay trong thc t t
chp nhum ph qun; chp ct lp t trng gip chn on chnh xc nht l nhng bnh
nhn b suy h hp mn.
3. Thm d chc nng h hp
3.1. o chc nng h hp: cho thy c s kt hp c hai hi chng hn ch v tc nghn.
3.2. Kh mu
Ch ri lon trong th nng tc l trong gin ph qun c suy h hp mn v tm ph mn,
c th c PaO2 gim, PaCo2 tng, SaO2 gim.
4. Thm d ph qun
4.1. Ni soi ph qun
xc nh nhng ph qun b vim, ng thi c th ly m kho st vi trng.
4.2. Chp nhum ph qun
t s dng t khi c chp ct lp t trng, tuy nhin vn cn thit trc khi quyt nh phu
thut; chp nhum ph qun cho thy cc loi gin ph qun sau y:
- Hnh tr hay gp nht.
- Hnh tnh mch trng hay hnh trng ht.
- Hnh bng hay ti.
- Thng c s phi hp nhiu loi gin ph qun.
- Cng gp nhiu loi in hnh nh cy cht khng c phn nhnh tiu ph qun -
ph nang, nhng ph qun b xp li trong mt on b xp phi.
- V tr: nhng ph qun thng b thng tn nm gia ph qun phn nhnh
th 4 v th 8. Trong nhng th lan ta, bnh tri nhng thy di (on cnh tim, on tn
y), thy gia v thy li. Ngoi ra c nhng th khu tr mt bn hay hai bn.
VI. TIN TRIN
1. Th nh
282
Nhng t bi nhim xy ra khng thng xuyn; bnh ch gii hn mt vng, khng lan ra
ch m phi, khng b suy h hp.
2. Th nng
Nhim trng xy ra thng xuyn, phi s dng khng sinh, sau nhiu nm tin trin s xut
hin suy h hp mn v tm ph mn; bnh nhn c th t vong sau vi nm.
3. Bin chng
3.1. Vim phi thy, ph qun ph vim, p xe phi, trn dch mng phi.
3.2. Lao phi, p xe no bnh xng khp ph i do phi, t gp.
3.3. Ho ra mu thng gp; c th m dnh mu hay ho ra mu ton s lng nhiu.
VII. IU TR
1. iu tr ni khoa
iu tr trong nhng t nhim trng ph qun - phi nh ph vim hay p xe phi.
1.1. Dn lu t th
L mt phng php iu tr rt cn thit, quan trng v bt buc phi thc hin cho bnh
nhn m c th thot ra ngoi, thc hin 3 ln /ngy, mi ln khong 10 pht.
1.2. Vn ng liu php
Rt cn thit bnh nhn c th khc m ra cng nhiu cng tt.
1.3. Khng sinh
- Ti tuyn trung ng th phi cy m v lm khng sinh chn la khng sinh
thch hp.
- Tuy nhin trong khi ch i kt qu cy m hay ti tuyn c s, theo y vn th
nhng vi trng thng gp l Streptococcus pneumoniae, Hemophilus influenza, Mycoplasma
pneumoniae, Legionella pneumophila; do phi dng ngay khng sinh, thng dng l:
+ Cfalexine, 500 mg, 3 vin / ngy chia u 3 ln c th phi hp hay khng vi mt
thuc thuc nhm Fluoroquinolones nh Ciprofloxacine (Quintor), 500 mg, 3 vin / ngy chia
u 3 ln hay Ofloxacine (Zanocin), 200 mg, 2 vin / ngy chia u 2 ln.
+ Cfadroxil (Oracfal), 500 mg, 3 vin / ngy chia u 3 ln.
+ Roxithromycine (Rulid), 150 mg, 2 vin / ngy chia u 2 ln.
- Nu nng th phi chuyn bnh nhn ln tuyn trung ng iu tr,
khng sinh phi c dng bng ng ngoi tiu ha tc l ng tim tht hay tim tnh
mch hay chuyn tnh mch. Ngi ta c th dng mt loi Cphalosporine th h 3 nh
Cfotaxime (Claforan), l 1 g, tim tht 2 g / ngy chia u 2 ln hay Ceftriaxone (Rocephine)
l 1 g, tim tnh mch 1 ln 2 g / ngy phi hp vi mt Aminoside nh Amikacine (Amiklin)
l 500 mg, tim tht 15 mg / kg / ngy 1 ln hay chia u 2 ln, nu c m hi tc l c bi
nhim vi khun k kh th phi dng thm Mtronidazol, l 500 mg / 100 ml, 3 l / ngy
chuyn tnh mch chia u 3 ln.
1.4. iu tr trit cn
Cc nhim khun tai mi hng: bng cc khng sinh thch hp.
1.5. iu tr ho ra mu
Thng kh iu tr v khng c thuc iu tr c hiu.
283
- Nu nh c th iu tr ti tuyn c s thng dng Adrenoxyl, ng 1.500 g,
3 - 4 ng tim tht chia u 3 - 4 ln.
- Nu nng th phi chuyn ngay ln tuyn trung ng, c th dng Octrotide
(Sandostatine), ng 50 g, 100 g, tim di da 3 ng loi 50 g / ngy chia u 3 ln v phi
theo di st tnh trng ho ra mu v loi ho ra mu ny rt kh cm, nu vt kh nng iu tr
ni khoa th phi hi chn vi ngoi khoa can thip phu thut cm mu.
2. iu tr ngoi khoa
2.1. Th khu tr mt bn
Ch nh phu thut l tt nht.
2.2. Th c tn thng hai bn
- Nu tn thng cn khu tr, n nh v i xng th c th ct hai bn.
- Nu tn thng khng i xng th ct mt bn chnh.
2.3. Th lan ta
Thng khng phu thut, c th ch ct nhng tn thng chnh.
Phu thut c th p dng l ct mt vng, ct don, ct mt thy hay mt l phi.
3. iu tr d phng
3.1. Tim vacxin phng nga cm cm nu c.
3.2. Nu khng c vacxin th khi b cm cm thng xy ra vo ma thu ng th phi dng
ngay khng sinh bng ng ung nh nu trong phn iu tr d phng nhim trng
ph qun - phi.
3.3. V sinh rng ming v tai mi hng.
3.4. Chuyn ngay ln tuyn trung ng khi bnh nhn c bin chng ho ra mu nng bng xe
cp cu c trang b.

284
BNH PHI TC NGHN MN TNH
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, bnh nguyn, c ch sinh bnh v sinh l
bnh bnh phi tc nghn mn tnh
2. Nu c triu chng lm sng v cn lm sng v phn giai on bnh phi tc nghn
mn tnh.
3. Chn on xc nh v phn bit c bnh phi tc nghn mn tnh
4. Pht hin sm t bc pht cp bnh phi tc nghn mn tnh
5. Trnh by c phc iu tr theo tng giai on, mc trm trng bnh phi tc
nghn mn tnh v bin php d phng
Ni dung
I. NH NGHA
Bnh phi tc nghn mn tnh (BPTNMT) l mt bnh biu hin bi s gii hn lu lng
kh, s gii hn ny khng hi phc hon ton. S gii hn lu lng kh thng xy ra t t
v phi hp vi mt s p ng vim bt thng ca phi i vi cc ht c hay kh.
BPTNMT bao gm vim ph qun mn v kh ph thng.
Bao gm vim ph qun mn, kh ph thng v hen ph qun khng hi phc.
S chn on BPTNMT cn c vo triu chng ho, khc m, kh th v hay l c tin s
tip xc vi cc yu t nguy c. S chn on c xc nh bng ph dung k. sau khi dng
thuc gin ph qun m FEV1 < 80% so vi tr s d on phi hp vi FEV1/FVC < 70%
II. DCH T HC
BPTNMT l nguyn nhn hng u ca bnh sut v t sut trn th gii. Nm 1990 theo
TCYTTG thi BPTNMT ng hng th 12 trong s nhng bnh nng. BPTNMT l nguyn
nhn t vong ng hng th 4 sau bnh tim, ung th, bnh mch mu no. Theo bo co kt
qu hp nhm t vn ca Chu Thi Bnh Dng v BPTNMT ln th VI 1 - 2/6/2002 ti
Hng Kng th ti cc nc Chu Thi Bnh Dng, t l mc BPTNMT khong 3,8%,
nhng gn y qua mt s mu nghin cu cho thy t l ln n 6,3% ngi trn 30 tui.
Theo TCYTTG v Ngn hng Th gii th t l mc bnh trn ton th gii nm 1990 l
9,34/1000 dn nam, v 7,33/1000 dn n. T l mc bnh cao nht cc nc ang ht thuc
l nhiu v ngc li.
III. NHNG YU T NGUY C
1. Nhng yu t k ch
1.1. Gnes: Yu t di truyn ng lu nht l thiu ht bm sinh 1 antitrypsine. S pht
trin sm v nhanh kh ph thng ton tiu thu
1.2. S tng p ng ph qun: nh hng n BPTNMT l khng r.
1.2. S tng trng phi: lin h vi qu trnh xy ra trong giai on mang thai, cn nng lc
sinh v s tip xc vi mi trng trong thi k thiu nin.
2. Nhng yu t tip xc
2.1. Ht thuc l: lin h rt cht ch vi BPTNMT, iu ny xy ra c l l do nhng yu t
di truyn. Khng phi tt c ngi ht thuc l u bi BPTNMT, khong 15 - 20% ngi ht
285
thuc l b BPTNMT, 85 - 90% bnh nhn b BPTNMT l do thuc l. Ht thuc l > 20 gi /
nm c nguy c cao dn n BPTNMT. Tip xc th ng vi thuc l cng c th gp phn
gy nn BPTNMT. Ht thuc l trong thi k mang thai cng l mt yu t nguy c cho bo
thai, do nh hng n s tng trng v pht trin phi trong t cung
2.2. Bi v cht ho hc ngh nghip: nhng bi v cht ho hc ngh nghip (hi nc, cht
kch thch, khi) c th gy nn BPTNMT c lp vi ht thuc l
2.3. nhim mi trng trong v ngoi nh: Vai tr ca nhim khng kh ngoi nh gy
BPTNMT khng r. nhim mi trng trong nh nh cht t, cht t chy t nu n v
hi nng l nhng yu t gy nn BPTNMT.
2.4. Nhim khun: nhim trng h hp thi k thiu nin c th gy BPTNMT thi k
trng thnh.
IV. C CH SINH BNH
1. Vim v cc yu t nguy c ca BPTNMT
S lin quan gia ht thuc l v vim c nghin cu rt nhiu. Thuc l kch hot i
thc bo v t bo thng b sn xut ra TNF v mt s cht trung gian gy vim nh IL8
v ILB4.
2. Mt qun bnh gia proteinase v antiproteinase
Thiu 1 antitrypsine l mt cht c ch mt s proteine thuyt thanh nh neutrophile
elastase lm gia tng nguy c gy kh ph thng; elastin l mt thnh phn chnh ca thnh
ph bo b hu bi neutrophile elastase. S mt qun bnh gia proteinase v antiproteinase
ni sinh c th gy nn s ph hu phi v c th xy ra do s suy gim hot tnh ca
antiproteinase do stress oxy ho, do thuc l v c th do nhng yu t nguy c khc ca
BPTNMT.
3. Nhng stress oxy ho
Trong BPTNMT c mt s mt qun bnh r rng cht oxy ha v cht chng oxy ha, trong
ch yu l cc cht oxy ha, l hydrogen peroxide (H2O2) v nitric oxide (NO). Nhng
stress oxy ha ngoi vic gy tn thng trc tip phi cn gp phn vo s mt qun bnh
proteinase - antiproteinase Nhng cht oxy ha cng xc tin vim. Cui cng nhng stress
oxy ha c th gp phn lm hp ng h hp.
V. SINH L BNH
1. S tng tit cht nhy v ri lon chc nng h hp
S tng tit cht nhy l do s kch thch cc tuyn tit cht bi nhng cht trung gian gy
vim nh leucotrien, proteinase v neuropeptides. Nhng t bo lng b d sn dng vy dn
n s suy gim h s thanh thi nhy - lng.
2. S gii hn lu lng kh th v s cng phng phi
S gii hn lu lng kh th khng hi phc, mt s t c th hi phc, do hin tng ti cu
trc, x ha v hp ng th nh. Nhng v tr gii hn ng th l tiu ph qun c khu
knh < 2mm, trong BPTNMT khng lc ng th tng gp i bnh thng. S ph hy ph
bo gy kh ph thng. S gii hn lu lng kh c biu hin bi s gim FEV1 v t
FEV1/FVC trong t FEV1/FVC gim thng l du hiu u tin ca s gii hn lu
lng kh.
3. Bt thng v s trao i kh
286
S mt qun bnh gia thng kh / ti mu l c ch ch yu do tn thng thnh ng th
ngoi vi v kh ph thng. Trong kh ph thng c s gim DLCO / L, t gy nn thiu
oxy mu. Tnh trng thiu oxy mu v tng kh ccbonic t xy ra khi FEV1 < 1.00L. Lc u
tnh trng thiu oxy mu ch xy ra lc gng sc, nhng khi bnh tin trin nng th tnh trng
thiu oxy mu xy ra lc ngh ngi.
nhng bnh nhn b BPTNMT nng, tnh trng thiu oxy gy co cc ng mch khu knh
nh v cc tiu ng mch.
4. Tng p phi v tm ph mn
Tng p phi xy ra chm trong din tin ca BPTNMT (Giai on III), sau l tm ph
mn. Nhng yu t gy nn tng p phi l s co mch, s ti cu trc nhng ng mch
phi. S co tht mch ngoi nguyn nhn do thiu oxy mu cn do s tng hp hay phng
thch NO b gim v s tit bt thng ca nhng peptides co mch nh endothelin 1. S tng
p phi v s gim h thng mch mu phi do kh ph thng c th dn n ph i tht phi
v suy tim phi.
VI. TRIU CHNG HC
1. Triu chng chc nng
1.1. Ho: ho mn tnh, thng l triu chng u tin ca BPTNMT, Lc u ho cch khong,
nhng sau ho xy ra hng ngy, thng sut c ngy, t khi ho ban m. Mt s trng
hp, s gii hn lu lng kh c th xy ra m khng ho.
1.2 Khc m: vi s lng nh m dnh sau nhiu t ho.
1.3. Kh th: l triu chng quan trng ca BPTNMT v l l do m hu ht bnh nhn phi
i khm bnh, kh th trong BPTNMT l mt loi kh th dai dng v xy ra t t, lc u
ch xy ra khi gng sc nh i b hay chy ln thang lu, khi chc nng phi b gim, kh th
tr nn nng hn v bnh nhn khng th i b c hay khng th mang mt xch n,
cui cng l kh th xy ra trong nhng hot ng hng ngy (mc o qun, ra tay chn hay
c lc ngh ngi)
2. Triu chng thc th
Khm thc th t c gi tr trong chn on BPTNMT. Nhng triu chng thng gp l
+ Tm trung tm.
+ Cc khong gian sn nm ngang, lng ngc hnh thng.
+ Du hiu Hoover (dt 1/2 c honh phi hp vi s thu li vo trong nghch l ca
y lng ngc trong k ht vo).
+ Tn s th lc ngh > 20 ln / pht, nhp th nng.
+ Bnh nhn th ra vi mi mm li vi mc ch lm chm li lung kh th ra c
th lm vi phi c hiu qu hn.
+ Nghe phi m ph bo gim, c ran wheezing.
3. Nhng tt v nhng xt nghim b sung cho chn on BPTNMT
i vi nhng bnh nhn c chn on BPTNMT giai on II v III, nhng tt v nhng
xt nghim sau y c th c s dng:
3.1. nh gi gim chc nng h hp bng ph dung k
287
Kt qu o ph dung l tiu chun vng chn on BPTNMT v theo di tin trin ca
bnh.
+ o FEV1 v FEV1/FVC.
+ Sau khi dng thuc gin ph qun m FEV1 < 80% so vi tr s l thuyt phi hp
vi FEV1/FVC < 70% chng t c gii hn lu lng kh khng hon ton phc hi.
+ FEV1/FVC l t s c nhy cm cao ca s gii hn lu lng kh v FEV1/FVC
< 70% c xem nh l du hiu sm ca gii hn lu lng kh bnh nhn b BPTNMT
trong lc FEV1 vn cn bnh thng ( 80% so tr s l thuyt).
3.2. Tt hi phc ph qun sau khi kh dung thuc gin ph qun
+ Nhng bnh nhn khng s dng thuc gin ph qun kh dung tc dng ngn trc
6 gi, thuc ng vn 2 tc dng di trc 12 gi hay theophylline thi chm trc 24
gi.
+ o FEV1 trc khi s dng thuc gin ph qun.
+ Thuc gin th qun phi c s dng di dng kh dung qua mt bu ht hay kh
dung my. Liu lng thch hp l 40g ng vn 2, 80g khng cholinergic hay phi hp
c 2 loi.
+ o FEV1 li 3 - 45 pht sau khi dng thuc gin ph qun.
+ Kt qu: Mt s tng FEV1 > 200ml v trn 12% so vi FEV1 trc khi s dng thuc
gin ph qun c xem nh l c gi tri.
5.3.Kh mu: nhng bnh nhn b BPTNMT lu nh gi tm ph mn.
5.4. Chp phim lng ngc: cho thy kh ph thng.
VII. PHN GIAI ON BPTNMT THEO TRIU CHNG LM SNG
+ Giai on 0: c nguy c.
+ Giai on I (BPTNMT nh): Ho mn tnh v khc m, thng bnh nhn khng
ch n.
+ Giai on II v III(BPTNMT va v nng): Bnh nhn thng kh th khi gng sc,
y l giai on m bnh nhn i khm bnh c chn on l BPTNMT, c th do nhim
trng h hp.
+ Giai on IV (BPTNMT rt nng): Nhng triu chng ho, khc m tip tc xy ra
mt cch in hnh, kh th nng ln v nhng bin chng c th xut hin.
VIII. PHN LOI MC TRM TRNG CA BPTNMT
Bng 1: Cc mc trm trng ca BPTNMT
Giai on c im
0: c nguy c + Ph dung bnh thng
+ Triu chng mn tnh (Ho, khc m)
I: BPTNMT nh + FEV1/FVC < 70%
+ FEV1 80% tr s l thuyt.
+ C hay khng c cc triu chng mn tnh (Ho, khc m)
II. BPTNMT trung bnh + FEV1/FVC < 70%
288
+ 30% FEV1 < 80% tr s l thuyt
50% FEV1 < 80% tr s l thuyt
30% FEV1 < 50% tr s l thuyt
+ C hay khng c cc triu chng mn tnh (Ho, khc m, kh th)
III. BPTNMT nng + FEV1/FVC < 70%
+ 30% FEV1 < 50% tr s l thuyt
+ C hay khng c cc triu chng mn tnh (Ho, khc m, kh th)
IV BPTNMT rt nng + FEV1/FVC < 70%
+ FEV1 < 30% tr s l thuyt hay FEV1 < 50% tr s l thuyt phi
hp vi suy h hp mn
IX. CHN ON PHN BIT
Bng 2: Cc chn on phn bit thng gp ca BPTNMT
Chn on Triu chng
BPTNMT + Khi pht trong khong tui 1/2 i ngi
+ Nhng triu chng tin trin chm
+ C tin s ht thuc l ko di
+ Kh th khi gng sc
+ Gii hn lu lng kh khng hi phc nhiu
Hen ph qun + Khi pht sm thng trong thi k thiu nin
+ Nhng triu chng thay i tng ngy
+ Nhng triu chng xy ra ban m
+ D ng, vim mi v hay l chm
+ Tin s gia nh hen ph qun
+ Gii han lu lng kh hi phc nhiu
Suy tim sung huyt + Ran m nh ht y
+ X quang lng ngc cho thy bng tim ln, ph phi
+ Tt chc nng h hp cho thy ri lon thng kh hn ch
+ Khng c gii hn lu lng kh
Gin ph qun + Khc m m s lng nhiu
+ Thng phi hp vi nhim trung m
+ Ran m to ht
+ Phim lng ngc hay CT scan phi cho thy c gin ph qun v vch ph
qun dy ln
X. T BC PHT CP BPTNMT
3 triu chng chnh ca t bc pht cp ca Bnh phi tc nghn mn tnh l: gia tng kh
th, gia tng m m, gia tng lng m.

289
Bng 3: Chn on mc nng ca BPTNMT
Nh Va Nng
1 trong 3 triu chng chnh, cng nh 1 trong nhng du
chng sau y: nhim trng ng h hp trn trong 5 ngy
qua, st m khng c nguyn nhn r rng, gia tng ran rt,
gia tng ho, gia tng nhp th v tn s tim 20% so vi bnh
thng.
2 trong 3 triu
chng chnh
Tt c 3 triu
chng chnh
+ Chc nng h hp: thng thng khi PEF < 100lt/pht, hay FEV1 < 1.00L chng
t mt t bc pht cp nng, tr trng hp bnh nhn b gii hn ng th nng mn tnh.
+ Kh mu: Khi PaO
2
< 60mmHg v hay l SaO
2
< 90% chng t suy h hp. Khi
PaO
2
< 50mmHg, PaCO
2
> 70mmHg v pH < 7,30 th cn phi x tr cp cu.
+ Phim lng ngc chn on phn bit.
+Tm in gip chn on ph i tim phi, lon nhp v thiu nng vnh.
+ Cng thc mu: ch yu cng thc bch cu v a hng cu c th c Hct > 55%)
+ Xt nghim m c th tm thy Streptococcus pneumoniae, Hemophilus influnzae
v Moraxella catarrahalis.
XI. IU TR
1. X tr BPTNMT n nh
1.1. Gim cc yu t nguy c
1.1.1. Ngng thuc l
L phng php iu tr c nht c hiu qu lm gim yu t nguy c. Ngng
thuc l sm bnh nhn b BPTNMT c th ci thin FEV1, tuy nhin cc ng kh mt
khi b tc nghn trm trng th s ngng thuc l t c li.
1.1.2. Thuc
* Nhng thuc thay th nicotine: dng vin, dn.
* Thuc chng trm cm: nh bupropion v nortriptyline, thng dng loi bupropion thi
chm n c hay kt hp vi cao dn nicotine.
1.2.. iu tr bng thuc
1.2.1. iu tr kt hp:
C th lm gia tng tc dng gin ph qun, s kt hp gia mt ng vn 2 tc dng ngn
vi mt khng cholinergic nhng bnh nhn BPTNMT n nh lm ci thin nhiu hn v
ko di hn FEV1 so vi s dng mt loi thuc.
S s dng mt ng vn 2 tc dng ngn, mt khng cholinergic v hay l theophylline c
th ci thin chc nng h hp.
1.2.2 Glucocorticosteroid
Trong BPTNMT glucocorticosteroid ung v kh dung t c hiu qu hn trong hen v vai tr
trong iu tr BPTNMT n nh gii hn trong nhng ch nh c bit.
1.2.3 Nhng iu tr khc
* Vaccin: chng cm v chng ph cu cha 23 type huyt thanh.
290
* Khng sinh: S dng khng sinh d phng, dng lin tc khng c hiu qu trn tn sut
xut hin nhng t bc pht cp ca BPTNMT.
* Nhng cht chng oxy ha: c bit l N-acetylcystein lm gim tn sut xut hin nhng
t bc pht cp hay c th c vai tr trong iu tr nhng bnh nhn c nhg t bc pht
cp ti pht.
* Thuc gim ho: khng dng.
1.2.4.S tp luyn
Mc tiu chnh ca s tp luyn h hp l gim nhng triu chng, ci thin cht lng sng
v lm tng s tham gia hng ngy cc hot ng v th cht v tinh thn.
1.2.5 Oxy liu php
Thng c ch nh bnh nhn BPTNMT giai on III nng, c th bng 3 phng cch
bao gm iu tr lu di lin tc, trong cc hot ng th lc v lm du cn kh th cp. Mc
tiu u tin ca oxy liu php l lm gia tng PaO
2
ti thiu l 60mmHg lc ngh v hay l
cung cp SaO
2
ti thiu l 90% duy tr chc nng sng ca cc c quan.
Oxy liu php lu di lin tc thng c ch nh trong giai on III nng nhng bnh
nhn c:
+ PaO
2
< 55mmHg hay SaO
2
< 88% c hay khng c tng kh ccbonic hay
+ PaO
2
t 55 - 60mmHg hay SaO
2
= 89%, nu c tng p phi, ph ngoi bin gi
suy tim hay a hng cu (Hct > 55%).
iu tr lu di oxy (>15gi/ngy) nhng bnh nhn b suy h hp mn c th lm gia tng
s sng st. Oxy liu php lin tc lm gim p lc ng mch phi v c th ngn nga
c s din tin ca tng p phi.
BNG TM TT IU TR MI GIAI ON BPTNMT
Giai on iu tr c khuyn co s dng
Tt c + Trnh nhng yu t nguy c
+ Tim phng cm
0 + Nh trn
I + Thuc gin ph qun tc dng ngn
II + iu tr u n vi mt hay hn thuc gin ph qun
+ Tp luyn
+ Glucocorticosteroid kh dung nu triu chng lm sng v chc nng h hp c
p ng
III + iu tr u n vi mt hay hn thuc gin ph qun
+ Tp luyn
+ Glucocorticosteroid kh dung nu triu chng lm sng v chc nng h hp c
p ng hay nu c nhng t bc pht cp
IV + iu tr u n vi mt hay hn thuc gin ph qun
+ Tp luyn
+ Glucocorticosteroid kh dung nu triu chng lm sng v chc nng h hp c
p ng hay nu c nhng t bc pht cp
291
+ iu tr cc bin chng
+ Oxy liu php lu di nu c suy h hp mn
2. X tr t bc pht cp BPTNMT
2.1. Chp X quang lng ngc
C th cn thit v qua kt qu X quang cho thy trn 23% bnh nhn nhp vin c nhng
biu hin bnh l.
3.2.Thuc gin ph qun
Kh dung thuc ng vn 2 tc dng ngn nh salbutamol v khng cholinergic nh
ipratropium c hiu qu bng nhau trn bnh nhn BPTNMT. Nhng loi thuc ny cng c
tc dng cao trn tt c tc dng ca tt c nhng thuc gin ph qun s dng bng ng
tim bao gm methylxanthines v nhng loi thuc cng giao cm. Mt s nghin cu cho
thy phi hp thuc ng vn 2 tc dng ngn vi khng cholinergic c hiu qu cao do tc
dng hip lc m khng lm gia tng tc dng ph. Ch sau liu ti a khi u thuc gin
ph qun, c th thm mt liu kh dung gin ph qun t ra c li.
2.3. S dng corticoide
Trong t bc pht cp ca BPTNMT s s dng corticoide h thng trong 2 tun l c li.
Trong 2 tun liu lng c chia nh sau: 3 ngy s dng methylprednisolone 125
mg/6 gi, sau cho prednisone trong 2 tun (60mg/ngy t ngy th 4 n ngy th 7,
40mg/ngy t ngy th 8 n ngy th 11, v 20mg/ngy t ngy th 12 n ngy th 15).
2.4. Khng sinh
Khng sinh t ra c hiu qu trong t bc pht cp bnh phi tc nghn mn tnh. Tu theo
loi vi trng thng gy nhim trng ph qun phi m s dng khng sinh thch hp.C th
s dng Cephalosporine th h 3, Macrolides, Fluoroquinolones h hp.
2.5. Oxy liu php
Trong t bc pht cp bnh phi tc nghn mn tnh v thiu kh, s s dng oxy l cn thit
v c li cho bnh nhn. Tuy nhin vn cn lu chnh l khi s dng oxy liu php s c
nguy c gy tng kh carbonic mu v suy h hp.
2.6. Thng kh p lc dng khng xm nhp
Thng c s dng cho bnh nhn ni tr b t bc pht cp bnh phi tc nghn mn
tnh. Phng php ny khng nhng lm ci thin chc nng h hp v lm gim PaCO
2
m
trong mt s trng hp c th trnh s dng t ni kh qun.
2.7. Chng ch nh
Trong iu tr nhng bnh nhn b t bc pht cp bnh phi tc nghn mn tnh, nhng
iu tr sau y khng c li: thuc tan nhy, vt l tr liu lng ngc, methylxanthines.
p dng thc t
+ Mc nh: p dng X quang lng ngc, kh dung gin ph qun.
+ Mc va: X quang lng ngc, kh dung gin ph qun, corticoid h thng, oxy liu
php, thng kh p lc dng khng xm nhp.
+ Mc nng: X quang lng ngc, kh dung gin ph qun, corticoid h thng, oxy liu
php, thng kh p lc dng khng xm nhp, khng sinh.
292
TM PH MN
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, bnh nguyn, c ch sinh bnh tm ph
mn.
2. Nu c triu chng lm sng v cn lm sng ca cc giai on tm ph mn v tin
trin.
3. Bit cch chn on bnh v giai on bnh
4. Pht hin sm t bc pht cp tm ph mn
5. Trnh by c phc iu tr v d phng tm ph mn
Ni dung
I. NH NGHA
Tm ph mn l mt s ln rng tht phi bi mt s ph i v hay l gin th pht
ca tht phi sau nhng ri lon hay bnh ca h h hp. Bnh do mt bnh bn trong ch m
phi; mt vi trng hp c th do mt bt thng ca s ch huy thng kh, mt tn thng
lng ngc v hay l h thng c h hp, hay c th do nhng bnh ca tun hon phi. Tng
p phi lun lun i trc tm ph mn trong c suy tim phi.
II. DCH T HC
Ngi ta kh xc nh tn sut ca tm ph mn; t sau 50 tui, tm ph mn l bnh tim
mch ng hng th ba thng gp nht sau bnh tim thiu mu v tng huyt p. Bnh
thng th pht sau bnh ph qun mn tc nghn. Tht vy nhng nc ht nhiu thuc l
v b nhim mi trng th vim ph qun mn v kh ph thng c tn sut cao v tm ph
mn chim 1/3 nhng trng hp suy tim. Hin nay n ng b nhiu hn n b, c l l do
thuc l.
III. BNH NGUYN
1. Bnh phi tc nghn mn tnh
Bnh phi tc nghn mn tnh l nguyn nhn chnh gy nn tng p phi v tm ph mn. S
tng p phi ch yu th pht sau tnh trng thiu oxy mu do bt thng t s thng kh -
ti mu.
2. Nhng bnh phi k
Bnh l phi k c th th pht sau bnh sarcoidose, bnh bi amian, bnh cht to keo,
nhng cng c th khng r nguyn nhn. Trong tt c nhng bnh ny c hi chng hn ch
thng kh nhng khng c hi chng tc nghn. Thm nhim vim k chn p v ph hu
nhng tiu ng mch vch, lm gia tng sc khng ca cc mch mu phi. i khi,
nhng tn thng ny phi hp vi s ng li ca nhng tiu ph qun bi mt qu trnh
vim quanh tiu ph qun.
3. Gim thng kh ph bo vi phi bnh thng
Bnh nhc c, lon dng c; g vo ct sng v qu mp ph.
4. Nhng bnh cht to keo
Trong nhng bnh cht to keo nh lupt ban h thng thng c tn thng mch mu
phi. X cng b v nhng bnh tng t v d nh hi chng CREST cng c tn sut cao
tn thng mch mu phi v din tin sang tm ph mn.
293
5. Bnh huyt khi - thuyn tc ng mch phi
5.1. Huyt khi gy nghn nhng ng mch phi c nh v tiu ng mch
Nhng huyt khi gy nghn v ti knh ho ca nhng ng mch c c nh v tiu ng
mch phi c tm thy nh sinh thit v t thit nhng bnh nhn b tng p phi c
nguyn nhn khc nhau. gii thch nhng huyt khi ti ch ny, ngi ta chng minh
c nhng tn thng ni mc ca vi tun hon phi, mt s mt qun bnh kch pht gia
hin tng ng mu v ly gii fibrine ti ch, v s hot ho ngng tp tiu cu vi tun
hon ny.
5.2. Thuyn tc ng mch phi mn gn gc
S hin din mt hay nhiu cc mu t chc ho, bt nhng nhnh ln ca ng mch phi
vi s hnh thnh t t tm ph mn. S ly gii fibrine ti ch khng lm cho huyt khi
tan ra hoc l pha trc hoc l pha sau gy bt li nhng ng mch phi gn gc, phi hp
vi mt s gim gin n ca nhng mch mu trung tm phi.
6. Bnh tnh mch phi
Nhng tnh mch phi ln c th b bt li bi nhng di cn ca ung th nh ung th v hay
phi, bi nhim trng nh lao hay histoplasmose, bi qu trnh vim c hch nh sarcoidose
hay nhng nguyn nhn khc t gp hn nh vim trung tht x ho.
7. Tng p phi tin pht
Tng p phi tin pht din tin sang tm ph mn khng do bnh tim hay bnh phi bn
di; cn gi l tng p phi khng r nguyn nhn. Tng p phi tin pht l mt bnh him.
Bnh c th gp mi la tui, nhng nhng triu chng u tin thng xut hin ngi
tr. Gn y, ngi ta xc minh c s gia tng khng th khng nhn nhng bnh nhn ny

IV. C CH SINH BNH
. Gim PaO
2
l ri lon khch quan quan trng nht, c gi l thiu oxy mu mn khi PaO
2

di 70 mmHg xy ra trng din trong sut thi k bnh n nh. Thc ra thiu oxy mu
mn ch tr nn ng ngi t mc PaO
2
= 55 mmHg v lc c th c nhng tc hi v cn
phi iu tr.
+ Phn ng tng to hng cu c li do cho php bo m s vn chuyn oxy y , Nh
vy s vn chuyn oxy thng khng b nh hng nhiu tr nhng t suy h hp cp hoc
nhng lc thiu oxy mu nng nh trong gic ng, nhng a hng cu c hi l lm tng
nht mu v nh th gp phn lm tng khng lc mch mu phi dn n s xut hin tng
p ng mch phi.
+ Thiu oxy mn gy bt thng v thn kinh - tm thn nh ri lon ch v tr nh, kh
khn v t duy tru tng, v hnh vi kho lo, v cc ri lon vn ng gin n.
+ Thiu oxy mn lm tng sc cn mch mu phi do co tht mnh, ph i tng dn c trn
thnh ng mch gy tng p ng mch phi v tng gnh tim phi. Tim b tr s tng gnh
ny cng tng tn s v cung lng tm thu m bo s cung cp oxy. Cn lu s tng
p phi l mt c ch thch nghi, gip chn la mt s mao mch phc v ti mu tt, ci
thin lin h thng kh / ti mu.
Tm ph mn xut hin sau tng p phi, nguyn nhn thng gp nht gy tng gnh tht
phi l s gia tng sc khng mch mu phi, xy ra ch yu nhng ng mch khu
knh nh v nhng tiu ng mch.
294
H thng mch mu phi bnh thng l mt vng rt d gin n, vi sc khng thp, khi
gng sc va phi, lu lng mu tng gp ba ln v ch gy nn mt s gia tng nh p lc
ng mach phi. Tuy nhin, khi d tr mch mu phi b cn i do mt s gim dn dn
din tch v tnh gin n ca h thng mch mu phi, mt s gia tng nh ca lu lng tim
c th gy nn mt s tng p phi r rng. Tnh trng thiu oxy gy co cc ng mch
khu knh nh v tiu ng mch. Ngi ta nhn thy rng toan mu (pH < 7,2) lm gia tng
s co mch phi. Trong tnh trng thiu oxy mn, nhng hu qu ca kch thch gy tng p
phi ny thng c lm nng bi s tng nhy mu lin h vi a hng cu th pht.
i ngc vi nhng hu qu ca s thiu oxy, kh carbonic tc ng trn tun hon phi qua
trung gian ca toan mu gy nn mt s co mch trc tip. S gia tng kh carrbonic lm
gim s p ng ca nhng trung tm h hp vi kch thch carbonic v gy nn s ti hp
thu bicarbonate thn.
V. TRIU CHNG HC
1. Giai on u
1.1. Triu chng lm sng ca bnh phi tc nghn mn tnh: vim ph qun mn, kh ph
thng do thuc l, hen ph qun ko di trong s phc hi ph qun km, gin ph qun,
thng xy ra nhng t bc pht cp. Sau mi t bc pht, bnh li nng thm.
Tn thng chc nng ca phi trong nhm bnh ny biu hin th tch th ra gng sc trong
giy u (FEV1) gim, FEV1/FVC gim, sc cn ng th v th tch cn (VR) tng.
1.2. Triu chng ca nhng bnh phi hn ch: nh lao x phi, gin ph nang, mp ph, g
vo ct sng, d dng lng ngc, bnh x phi lan to, dy dnh mng phi, bnh mch phi.
Tn thng chc nng ca nhm bnh ny l dung tch sng (FVC) gim.
1.3. C th phi hp nhng triu chng ca hai nhm bnh trn.
Giai on bnh phi mn tnh ny tin trin c th nhiu nm, thay i t 3 nm n 20 nm.
2. Giai on tng p lc ng mch phi
2.1. Triu chng lm sng
- Triu chng chc nng gip pht hin
+ Kh th gng sc: lun lun c
+ Hi chng vim ph qun: ho v khc m.
+ au gan do gng sc: thng m h.
- Triu chng thc th
Ngoi triu chng bnh gc, nhng triu chng v tim sm nht l ting tim th hai mnh
van ng mch phi, du Harzer t gp hn, nhp tim nhanh khng c gi tr lm, mng tay
khum mt knh ng h, c th c au gan khi mnh vo vng h sn phi.
2.2. Triu chng cn lm sng
- Phim ph
Ngoi nhng du chng ca bnh ph qun - phi gc, thng gp nht l cung ng mch
phi phng.
- Siu m
Siu m 2 bnh din cho thy gin tht phi. Siu m Doppler mu c th nh gi p lc
ng mch phi trn 35mmHg.
295
- Bilan huyt ng
o p lc tnh mch trung ng, nu tng l du chng sm ca tm ph mn.
3. Giai on suy tim phi
3.1. Triu chng lm sng
- Triu chng chc nng
Kh th cng ngy cng tng dn t kh th khi gng sc, n kh th khi leo ln dc hay
khi ln cu thang, n kh th khi i nhanh trn ng phng, n kh th khi i chm trn
ng phng, cui cng kh th khi lm vic nh nh v sinh, ci qun o, v sau kh th c
khi ngh ngi.
- Triu chng thc th
+ Triu chng ngoi bin
Gan ln v au,tnh mch c ni ln v p, ph, tm, mt li v xung huyt, o p lc tnh
mch trung ng trn 25 cm nc, ngn tay hnh di trng.
+ Triu chng tim mch
Nhp tim nhanh, c khi lon nhp hon ton, du hiu Harzer, T2 mnh v tch i van
ng mch phi.Ting nga phi phi thi k tin tm thu, ting thi tm thu van 3 l.
3.2. Triu chng cn lm sng
- Phim phi
Thn ng mch phi phng to, ph i tht phi r rng lm tim c hnh hia v trong phim
chp nghing trc tri thy mt khong sng sau xng c. Trn dch mng phi c th xut
hin.
- Tm in : c dy nh phi (P ph) v dy tht phi
- Siu m Doppler mu: o p lc ng mch phi trn 45mmHg
- Bilan huyt ng:Trong giai on suy tht phi r rt th p lc ng mch phi tng ln
trn 45 mmHg
- o cc kh trong mu: PaO
2
gim, PaCO
2
tng. SaO
2
gim v pH mu gim c khuynh
hng nhim toa h hp
- Huyt hc: a hng cu, tng hematocrite.
VI. TIN TRIN
Tm ph mn tin trin t t, gy tn thng chc nng v cu trc ca phi dn n suy h
hp tng phn ri suy h hp ton b ri suy tim phi v cui cng l suy tim ton b. Ngy
nay d c nhiu phng php iu tr hin i, nhng suy tim phi vn chim mt t l t
vong rt cao: 60 - 70% t suy tim phi ln u hay ln th hai.
S tin trin ca bnh ph thuc vo nguyn nhn gy bnh, v nht l ph thuc vo vic
ngi bnh c pht hin bnh ca mnh sm hay khng, khi c pht hin bnh ri c c
iu tr v theo di thng xuyn hay khng.
Nhng suy h hp mn nghn m nguyn nhn thng gp l bnh phi tc nghn mn tnh
do thuc l s dn n tm ph mn rt d dng. Cc t bc pht cp ca bnh phi tc
nghn mn tnh s lm nng thm tm ph mn, c trng hp ch sau 3 nm c du hiu
suy tim phi. i vi hen ph qun th hen ph qun d ng nhim khun c khi sau 5 - 10
296
nm c du hiu suy tim phi, ngc li hen ph qun d ng khng nhim khun th rt t
a n tm ph mn.
i vi suy h hp mn hn ch nh x phi do lao, nhng phi l lao x lan ta th s a
n tm ph mn, ngc li nu lao x mt phn nh th khng a n tm ph mn, nhng
nu c mc thm gin ph qun th chng b tm ph mn v lc l suy h hp mn phi
hp. Trng hp ny nu c nhim trng ph qun phi km theo th cng lm nng thm
tm ph mn.
Nu bnh nhn c theo di v iu tr tt th bnh c th n nh, c th t 10 - 20 nm
hoc lu hn na mi c bin chng suy tim, c trng hp c th chung sng vi bnh nhn
sut i.
VII. IU TR
1. Ch n ung v ngh ngi
+ Ngh ngi rt cn thit, nn lm vic nh, khi c du hiu suy tim cn gim hoc
b cc cng vic phi gng sc.
Ch n nht, t mui, c th n 1 - 2 g mui / ngy. Trong trng hp suy tim
nng, ph nhiu, ch n nht kht khe hn; mi ngy ch dng 0,5 g mui, nhng khng
ko di.
2. Liu php oxy
Ngi ta c th cho th oxy bng xng mi, oxy nn c dn qua mt bnh nc
lm m, khng nn cho th oxy 100% vi liu lng thp 1,5 - 2 lt / pht, mun c hiu qu
phi dng t nht 12 gi / 24 gi, nhng tt nht l 15 - 20 gi / 24 gi. Ngi ta cung cp oxy
th no duy tr mt PaO
2
trn 60 mmHg v SaO
2
trn 90%, nu c nh th th s gim t
l t vong v mang li cho bnh nhn mt i sng tng i thoi mi.
3. Thuc ci thin t thng kh - ti mu phi
Bismesialate dalmitrine (VECTARION).Cch dng: iu tr tn cng vi 50 mg, 1 - 2 vin /
ngy trong 3 thng, sau phi iu tr duy tr, sau iu tr tn cng, ngh 1 thng, tip tc
iu tr 2 thng. Hin nay rt t s dng.
4. iu tr suy tim
Trong tm ph mn c th c suy tim ton b, nhng ch yu vn l suy tim phi, do thuc
iu tr chnh l li tiu, sau l digitale, c th phi hp vi cc thuc dn xut nitr.
4.1. Li tiu
+ Furosemide (LASIX): 2 - 4 vin loi 40 mg / ngy, chia u; hoc loi tim 2 - 3
ng loi 20 mg / ngy, chia u.
Khi dng li tiu furosemide phi thn trng v s gy kim chuyn ho, nh vy c th c
nguy c lm nng thm suy h hp do hiu qu kch thch h hp ca kh carbonic b gim i.
+ Spironolactone (ALDACTONE): 50 mg - 100 mg (1 - 2 vin) / ngy, trong nhng
th nng c th tng ln 6 vin / ngy, chia u. thng dng Aldactazine (Aldactone
50mg+Alizide 15mg) x 2 vin/ngy
4.2. Digitale: thng hay dng digoxine, ch s dng trong suy tim cn b, cho liu nh 0,25
mg - 0,50 mg (1 - 2 vin) / ngy, khng dng khi suy tim mt b.
4.3. Dn xut nitr: nh Isosorbide mononitrate (Imdur) 60mg x 1/2 vin/ngy
4.4. c ch men chuyn: nh captopril 6,25mg/ngy hay Lisinopril 2,5mg/ngy
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Thuc li tiu v digitale, dn xut nitr hay c ch men chuyn trong trng hp ny khng
quan trng bng cc phng php ci thin thng kh ph nang nh liu php oxy.
5. Thuc gin mch
Cc thuc gin mch n nh hay ci thin ch xy ra ti a 1/3 s bnh nhn. Hiu qu ca
cc loi thuc thay i tu theo tng bnh nhn.
+ Nhng thuc c ch calci nh Nifedipine, Dittiazem c th s dng..
+ Ngoi ra ngi ta cn dng Hydralazine vi hy vng lm gim p lc tun hon, nhng
thuc ny c tc dng lm gim oxy mu, do ri lon t s thng kh - ti mu.
+ Thuc c ch th th endothelin (Bosentan): Cht endothelin 1 l mt cht gy co mch ni
sinh gy tng p phi,
Bosentan gip ci thin kh nng gng sc v huyt ng bnh nhn tng p phi, thuc
c s dng trong 12 tun, liu khi u l 62,5 mg x 2 ln/ngy trong 4 tun l u, v sau
tng liu ln 125 mg x 2 ln/ngy
+ Chuyn tnh mch lin tc prostacycline.
+ Thuc Sildenafil (Viagra) trong iu tri tng p phi th pht sau x phi:
Sildenafil lm gia tng chn lc gin mch v lm ci thin s trao i kh bnh nhn b x
phi v tng p phi.
Epoprostenol c s dng bng ng tnh mch hay Sildenafil c s dng bng
ng ung, sau khi huyt ng thay i ca bnh nhn tr li tr s bnh thng c s
dng tip theo kh dung Nitric oxide 10 - 20 ppm, h ung 50mg Sildenafil hay chuyn ti a
Epoprostenol (trung bnh 8ng/kg/ pht). Thi gian tc dng ca Sildenafil t 120 150 pht.
Cho n nay, Sildenafil l thuc chn la tt nht trong iu tr gin mch phi.
6. Corticoides
Rt c hiu nghim trong iu tr t cp, Prednisone ung 5 mg, 4 vin / ngy hay kh dung
dipropionate de beclomethasone, hay Depersolone 30 mg tim tnh mch va c tc dng
chng vim va c tc dng chng d ng va lm gim tit dch.
7. Khng sinh
Khng sinh ch dng khi c bi nhim ph qun - phi, vi khun thng gp l Streptococcus
pneumoniae, Haemophilus influenza, Moraxella catarrhalis, Mycoplasma pneumoniae,
Legionella pneumophila, Staphylococcus aureus.
- Nu nh th thuc thng dng hin nay l
+ Azithromycine: 250 mg x 2 vin / ngy, chia 2 ln trong ngy u sau 250mg x 1
vin trong 4 ngy.
+ Cefadroxil (Droxyl, Oracefal): 500 mg, 3 vin / ngy, chia 3 ln.
+ Ciprofloxacine 500mg x 3 vin / ngy, chia 3 ln.
- Nu nng thuc thng dng bng ng tim tht hay tnh mch
Mt trong cc loi Cephalosporine th h I (Cefapirine: Cefeloject = 2g/ngy chia 2 ln) II
(Cefuroxime: Zinnat = 750mgx2 hay 3 chai/ngy chia 2 hay 3 ln) III (Cefotaxime: Claforan
= 2g/ngy chia 2 ln) IV (Axepim = 2g/ngy chia 2 ln) c th kt hp vi Aminosides
(Amikacine: Amiklin = 15mg/kg/ngy, 1 hay 2 hay 3 ln) hay Fluoroquinolones
(Ciprofloxacin: 200mg x 2 l - 4 l chuyn tnh mach).
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8. Liu php vn ng
Tp th rt quan trng, lm tng gin n ca phi v lng ngc, tng thng kh ph nang,
nht l th bng c honh.
9. Loi b nhng yu t gy kch thch
Phi cai thuc l, trnh tip xc vi bi bm, cc kh c...



299
UNG TH PH QUN - PHI NGUYN PHT
Mc tiu hc tp
1. Trnh by c nh ngha, c im dch t hc v bnh nguyn ca ung th ph qun
phi nguyn pht.
2. Nu c triu chng lm sng v cn lm sng tu theo v tr khi u.
3. Nu c cc xt nghim cn thit chn on xc nh.
4. Nm c cch phn giai on ca ung th ph qun phi nguyn pht theo TNM.
5. Bit cch iu tr theo hai nhm chnh v theo TNM
Ni dung
I. I CNG
Ung th ph qun phi nguyn pht (UTPQPNP) hin nay c tn sut ang tng ln mt cch
ng s.
L nguyn nhn gy t vong do ung th hng u nam v hng th 4 n.
Bnh nguyn ch yu l thuc l.
Pht hin thng mun nn iu tr kh v vy tin lng lun lun nng.
II. BNH NGUYN
1. Gii: ung th ph qun phi gp nam nhiu hn n vi t l 6/1.
2. Tui
Bnh gp ti a nam khong 65 tui v n khong 75 tui.
3. Mi trng
Bnh thng gp cc thnh ph ln gp 3 ln so vi nng thn.
4. Nguyn nhn
4.1. Thuc l
Khi thuc l c xc nh 1 cch chc chn l nguyn nhn gy ung th ph qun phi.
90% ung th ph qun phi l do thuc l. T l ung th ph qun phi tng theo s iu
thuc ht trong ngy v s nm nghin ht. Nu ht trn 20 gi/nm th t l ny tng r rt.
Khi thuc l lm chm s thanh lc nhy lng lm tn thng nhng chc nng thc bo
ca b my h hp.
Nhng enzyme ca nim mc ph qun khng thch ng vi s tn cng ny: bin cc cht
trong khi thuc l thnh cht gy ung th.
Cai thuc l lm gim nguy c nhng khng lm mt nguy c.
4.2. nhim mi trng khng kh chung.
Khi k ngh, khi xe hi cha benzopyrene v mt s cht c nh hydrocabure a vng,
cht khc nh kim loi, cht phng x.
4.3. nhim mi trng ngh nghip.
Bi thch min, bi m hay cc cht trong k ngh nh chrome, niken, arsenic, mc in sn
phm k ngh du m, cc cht phng x.
300
Khi thuc l c tc dng hp lc gy ung th.
4.4. Mt s yu t khc.
So phi c th lm d ung th dng tuyn hn cc th khc.
III. PHN LOI
1. Phn loi theo gii phu bnh
Theo OMS ung th ph qun phi c phn thnh nhng loi sau:
1.1. Ung th dng biu b.
1.2. Ung th t bo nh khng bit ho.
1.3. Ung th dng tuyn.
+ Ung th tuyn nang bit ho cao.
+ Ung th tiu ph qun ph nang.
+ Ung th tuyn t bit ho.
1.4. Ung th t bo ln khng bit ho.
1.5. Ung th phi hp dng biu b v tuyn.
1.6. Ung th carcinoide.
1.7. Ung th tuyn ph qun.
1.8. Ung th nh ca biu b b mt.
1.9. Ung th hn hp carcinosarcome.
1.10. Sarcomes.
1.11. Khng xp loi.
1.12. Ung th trung biu m (ung th mng phi).
1.13. U mlanine.
Trong 4 loi u l thng gp.
2. Phn giai on ung th phi theo TNM (theo hip hi M trn h thng ung th)
2.1.U tin pht
To: Khng thy u
Tx: U ch pht hin sm bng t bo ung th trong cht tit ph qun.
TIS: ung th biu m ti ch
T1: U c d 3cm, soi ph qun khng thy lan n ph qun thu.
T2: Uc d>3 cm hay u khng k kch thc hoc lan n mng phi tng hoc c xp phi
hoc c vim phi nghn, c lan n ph qun thy hay cch ca ph qun 2cm. Xp
phi/vim phi nghn ch 1 phi
T3: U khng k kch thc xm ln thnh ngc hay c honh hay mng phi trung tht hay
mng ngoi tim (m khng tn thng tim, mch mu ln, kh qun, thc qun, ct sng)
Hoc u trong ph qun gc cch ca ph qun < 2cm.
301
T4: * U khng k kch thc xm ln trung tht hay tim hay mch mu ln, kh qun, thc
qun, ct sng, ca ph qun
*Hoc trn dch mng phi
2.2. Tn thng hch
No: Khng c di cn n hch
N1: di cn n hch quanh ph qun hay rn phi
N2: Di cn hch trung tht cng bn v cnh ca ph qun
N3: di cn hch trung tht khc bn, hch rn phi khc bn, hch c thang hay thng n
cng hay khc bn
2.3.Di cn xa
Mo:khng di cn xa
M1: di cn xa nh thng thn, gan, xng, no
Bng 1: Phn theo TNM
Giai on T N M
Ung th biu m n Tx No Mo
Giai on 0 TIS No Mo
Giai on I T1
T2
No
No
Mo
Mo
Giai on II T1
T2
N1
N1
Mo
Mo
Giai don IIIa T3
T1-3
N1
N2
Mo
Mo
Giai on IIIb Bt k T
T4
N3
Bt k N
Mo
Mo
Giai on IV Bt k T Bt k N M1
IV. TRIU CHNG HC LM SNG
1. Biu hin trong lng ngc
1.1.Ho
Ho thng tng ln v tn s v trm trng.
1.2. Ho ra mu
Lng nhiu hay t, chim t l 50% trng hp.
1.3. Vim ph qun phi do nghn.
U pht trin trong lng ph qun gy nghn ph qun khng hon ton lm ri lon thanh thi
nhy lng, gy tr, t d dng b vim ph qun phi thu phi tng ng.
- Vim ph qun phi do nghn c c im: vim phi khu tr, p ng chm hay khng
hon ton vi khng sinh thch hp, vim phi lp i lp li cng mt v tr.
1.4. Ting-rt khu tr
302
Ran wheezing gi nghn khu tr khng hon ton.
1.5. Xp phi
Khi c hi chng xp phi l khi ph qun b hp hon ton.
1.6. Trn dch mng phi
C th l trn dch thanh t huyt hay trn mu, c th do u lan trc tip hay do di cn, c khi
do phn ng ca xp phi.
1.7. au ngc
au c nh v dai dng chng t ung th di cn n thnh ngc, mng phi hay trung tht.
1.8. Hch ln
Hch c th rn phi, trung tht, c thang, c th din tin m thm hay gy chn p, n
mn cc ph qun, cc mch mu hay cc m ri thn kinh ln cn.
1.9. Biu hin chn p, tc nghn do u, do di cn, do hch vng
+ Tnh mch ch trn trong trung tht b chn p lm c ln ra, sau ph o khoc,
tm mt, gin tnh mch di da vai, ngc.
+ Thn kinh qut ngc tri b chn p, gy khn ging, lit dy thanh m tri (dy
thanh m phi c vng cao quanh ng mch di n nn t b chn p).
+ Thn kinh honh: cc dy thn kinh ny i dc theo trung tht trc mi bn, mt
trong hai c th b chn p, gy lit na c honh tng ng, ch pht hin nh ri phi, thy
c honh di ng ngc chiu.
1.10. Hi chng Pancoast Tobias
Ung th nh phi xm ln mng phi nh chn p cc r di ca m ri thn kinh cnh
tay, thn kinh giao cm c. Hi chng gm au vai, au cnh tay km hi chng CLAUDE
BERNARD HORNER cng bn (ng t co, sp m, hp khe mt) c khi n mn xng n.
2. Biu hin ngoi lng ngc (di cn)
3 c quan hay b di cn nht l
+ H xng gy au xng, au tri lc nm ngh, ti pht vi cc thuc gim au
thng dng.
+ H thn kinh trung ng: t l u phi di cn ln no rt cao, gy lit cc dy thn
kinh s no, lit na ngi.
+ Gan.
+ Cc di cn khc nh mng bng, thng thn, thn, ng tiu ho.
3. Hi chng h thng
Cc hi chng ny bin mt khi ung th c ct b v ti pht khi di cn pht trin.
3.1. Tng calci mu
Tng calci mu do parathormone bt thng v mt cht gy tan xng khc parathormone.
Tng calci mu gy bun nn, nn, tiu nhiu, l ln ng lm, sng s.
3.2. Hi chng tit ADH bt thng
Gy h natri mu, gim p lc keo, tng t trng nc tiu, nc tiu cha nhiu natri.
303
3.3. Hi chng CUSHING
Ung th ph qun phi tit ra cht lng t nh ACTH, thng t hot ng hn ACTH tht.
3.4. Hi chng carcinoide
Cn xung huyt da, ph mt, tng tit nc mt, tng tit nc bt, tiu chy nn, h huyt p
do 5 hydroxytryptamine (serotonine) v 5 hydroxytryptophane c tit ra trong u carcinoide
hoc ung th t bo nh khng bit ho.
3.5. V ln
Ung th t bo ln tit ra khch thch t sinh dc gy v ln.
3.6. Ri lon thn kinh c: C ch cha r, hi chng ny khng bin mt khi ung th c
ct b.
Thng gp l: hi chng nhc c, thoi ho tiu no, c khi c no v tu, hi chng thn
kinh ngoi bin.
3.7. Ngn tay di trng
3.8. Hi chng PIERRE MARIE (hi chng xng khp ph i do phi).
Xng khp ca cc chi i xng au, sng ko di. X quang thy vim v tng sinh mng
xng, thng gp u xng chy v xng mc, km ngn tay chn di trng. Bin mt
khi ung th c ct b.
3.9. Gim min dch t bo khng c hiu
Phn ng b lao (+) l mt yu t tin lng tt sng st sau m gp i phn ng b lao (-).
V. TRIU CHNG CN LM SNG
1. X quang
+ Ung th dng biu b v ung th t bo nh khng bit ho thng rn hay gn
rn, ung th dng tuyn v ung th t bo ln thng xa rn trong ch m.
+ Ung th dng biu b thng di dng khi m trn b khng u, khng ng
cht, mt bn, c th hng ha, d gy vim phi do nghn hay xp phi.
+ Ung th t bo nh khng bit ho thng di dng khi m, t ng cht, b
khng u, c xu hng lan ra xung quanh.
+ Ung th dang tuyn thng di dng khi trn, u, m, b r.
+ Ung th tiu ph qun ph nang thng di dng khi trn n c hoc nt thm
nhim lan rng mt hay hai phi.
+ Ung th t bo ln thng di dng khi trn, m, b kh r.
Cc tn thng ung th thng khng bao gi b calci ho.
2. Chp ct ln t trng
Gip xc nh chnh xc cc tnh cht ca khi m bt thng trong nhu m phi, v trung
tht, gip sinh thit di s hng dn ca CT SCANNER chn on m hc.
3. Soi ph qun
Soi ph qun bng ng soi mm gip chn on trc tip v thm d s lan rng ca ung th
bng cch chi ra ph qun v sinh thit tn thng hay sinh thit c h thng cc ph qun.
4. T bo hc
304
Kho st t bo trong m cho kt qu dng tnh trn 70%, dng tnh gi t, pht hin c
t bo ung th ngay khi hnh nh x.quang bnh thng. Do t bo hc trong m l mt xt
nghim sng lc nhm c nguy c.
5. Sinh thit hch
Hch ngoi vi d dng c sinh thit, sinh thit hch trung tht c tin hnh phng m
do bc s chuyn khoa lm.
6. Chc ht xuyn thnh bng kim nh
p dng cho nhng ung th ngoi bin, kh soi ph qun. C th chc di s theo di trn
mng hunh quang. D gy trn khi mng phi.
7. Sinh thit mng phi
Sinh thit mng phi phi tin hnh mi trng ngoi khoa. C th kho st t bo hc dch
mng phi.
8. M thm d
bnh nhn c ch nh m. Sinh thit v xt nghim gii phu bnh tc th v quyt nh
m tip tc hay khng.
9. Thm d di cn
Phi lm siu m v chp ct lp t trng mi kt lun c mt cch cht chn.
10. Thm d chc nng h hp
Ch yu l xt ch nh m v thm d kh nng phi lnh.
Nu VEMS 1/2 bnh thng v paCO2 bnh thng 40 3 mmHg th khng cn thm d
thm.
11. Cht ch im ung th
Ch xc nh c l c khi u, gip theo di din tin sau iu tr.
VI. CHN ON PHN BIT
1. Lao phi
Chn on kh khn trong nhng trng hp sau: BK m m tnh v khng tm thy t bo
ung th trong m trong 3 ngy lin, trn phim X.quang c khi m hnh trn, ng knh 2-
3 cm b r hoc mt m m. Gp cc trng hp ny nn iu tr th lao mt cch tch cc,
ng thi tm mi cch pht hin t bo ung th. Sau mt thng chm nht l hai thng nu
hnh nh trn phim r nt hn l ung th.
2. Vim phi
Sau mt thi gian iu tr vim phi, nu sc kho khng tr li bnh thng, cc tn thng
trn phim X.quang khng xo ht, lng mu vn cao... cn ngh n ung th ph qun phi.
VII. IU TR
V mt iu tr ngi ta chia ung th ph qun phi ra lm 2 nhm chnh.
1. Ung th khng phi ung th t bo nh khng bit ho.
C thi gian nhn i 100-200 ngy, gm 3 loi: ung th dng biu b, ung th dng tuyn,
ung th t bo ln.
305
1.1. Phu thut l phng php hu hiu nht, p dng cho cc giai on ung th n, giai
on 1 v giai on 2 v mt s trng hp chn lc nh T3, No, Mo hay T1, N2, Mo.
Kt qu:
- Ung th n: sng st sau 5 nm khong 60%. Theo di k v d b ti pht khong
5%/nm/ngi.
- Ung th nt n c: m ct b thu phi. Tin lng tu theo kch thc khi u,
theo hch vng v theo s bit ho ca t bo k.
Sng st sau 5 nm khong 40-60% nu kch thc < 3cm v khng c hch vng.
Sng st sau 5 nm khong 20% n < 40% nu kch thc > 3cm v c hch vng.
1.2. Khng phu thut c dng a ho tr liu v x tr liu nu khng c chng ch nh.
+ X tr liu kt qu khng tt lm, i khi khng hn bnh nhn khng c x tr liu.
- a ho tr liu
Bng 3: Kt qu mt s a ho tr liu
c im Paclitaxel
/carboplatin
Gemcitabine
/carboplatin
Paclitaxel
/Gemcitabine
S bnh nhn 308 309 312
Thi gian sng st trung bnh 7,9 thng 7,6 thng 8,4 thng
Sng st 1 nm 33% 31% 33%

Bng 4: T l sng st sau 5 nm
Tc gi v nm cng b S bnh nhn Nhm thuc iu tr sng st 5 nm
%
Arriagada et al-2004 1867 Cisplatin v hoc
Etoposide
Vinorelbine
Vindesine
Vinblastine
44,5
Winton et al-2004 482 Cisplatin- Vinorelbine 69
Strauss et al-2004 344 Carboplatin- Paclitaxel 71(4 nm)
Rosell et al- 2005 840 Cisplatin -Vinorelbine 51
2. Ung th t bo nh khng bit ho
y l loi ung th pht trin nhanh, di cn sm v nhiu ngay khi bnh c v khu tr, do
mi c gng ct b u v hiu, nn a ho tr liu v x tr liu l chnh.
2.1.Ho tr liu
Thuc c ch topoisomerase I bao gm irinotecan v topotecan. Phi hp irinotecan hay
topotecan vi ciplastin cho kt qu tt, tuy nhin c mt s tc gi phi hp etoposide vi
cisplatin hay vi carboplatin
2.2. X tr:
X tr c dng trc hoc sau ho tr liu bi bc s chuyn khoa.
306
3. iu tr triu chng v iu tr h tr cho c hai loi
- Chng au, chng nhim khun, gim ho.
- Chng chn p thn kinh: dexamethasone 20-80 mg /ngy
- Ht dch mng phi.
- Chng suy tu, chng thiu mu.
4. Phng bnh
-Tuyn truyn tc hi ca thuc l trn cc phng tin truyn thng i chng vn ng
mi ngi b thuc l
-Chng nhim mi trng trong nh, mi trng ngh nghip.


307
CU HI NH GI
1. K cc nguyn nhn gy vim phi.
2. Triu chng lm sng vim phi thy v ph qun ph vim.
3. iu tr vim phi thy.
4. Bnh nguyn ca hen ph qun.
5. C ch sinh bnh ca hen ph qun.
6. Triu chng lm sng cn hen ph qun in hnh.
7. Phn loi trm trng hen ph qun qua triu chng lm sng trc iu tr.
8. Bin chng ca hen ph qun.
9. X tr hen ph qun dai dng va.
10. X tr cn hen ph qun cp nng.
11. Nguyn nhn gy suy h hp cp.
12. Lm sng suy h hp cp.
13. Phn giai on suy h hp cp.
14. iu tr suy h hp cp.
15. Bnh nguyn ca suy h hp mn.
16. Triu chng lm sng suy h hp mn.
17. Triu chng cn lm sng nh gi suy h hp mn.
18. iu tr suy h hp mn va.
19. K cc nguyn nhn gy trn dch mng phi khng do lao.
20. Triu chng trn dch mng phi th t do.
21. Bin chng ca trn dch mng phi.
22. iu tr ni khoa trn dch mng phi.
23. Nguyn nhn gy trn kh mng phi.
24. Lm sng th trn kh mng phi t pht hon ton.
25. iu tr trn kh mng phi.
26. Nguyn nhn gy p xe phi.
27. Triu chng lm sng p xe phi.
28. iu tr p xe phi do t cu vng.
29. Nguyn nhn ca gin ph qun.
30. Triu chng lm sng gin ph qun.
31. Cc xt nghim cn lm sng trong chn on gin ph qun.
32. iu tr ni khoa gin ph qun.
33. Yu t nguy c ca bnh phi tc nghn mn tnh.
34. Triu chng ca bnh phi tc nghn mn tnh.
308
35. Phn loi mc trm trng ca bnh phi tc nghn mn tnh.
36. X tr t cp ca bnh phi tc nghn mn tnh.
37. Bnh nguyn ca tm ph mn.
38. Triu chng lm sng ca tm ph mn.
39. iu tr tm ph mn.
40. Phn loi ung th phi theo TNM.
41. Triu chng lm sng trong bnh ung th phi.
42. Cc xt nghim cn lm sng trong chn on bnh ung th phi.

309
TI LIU THAM KHO
1.Bi ging Bnh hc ni khoa ca B mn Ni i hc Y khoa H Ni (2000).
2.Bi ging Bnh hc ni khoa ca Hc Vin Qun Y (1999).
3. Chu Vn - Nguyn Vn Thnh (1991), Bi ging Ni khoa Sau i hc, NXB Y hc.
4. John Muray (1995), Respiratory failure, Cecil textbook of medicine 17th edition, W.B
Sauders company.
5. Houston C.S.(1998), Cor pulmonale, The Merck manul, Merck Co Inc.
6. Nguyn nh Hng, Bch khoa ton th Bnh hc (2000).
7. Bi Xun Tm (1999), Bnh phi tc nghn mn tnh, Bnh h hp, NXB Y hc.
8. Global Initative for Chronic Obstructive Lung Disease (GOLD) (2001), National Heart, Lung,
Blood Institute.
9. D.V.Taxen (1990) , Acute respiratory failure in COPD, Intensive care manual, 3th edition,
Butterworths.
10. Bernard Lebeau (1989), Dilatation des bronches, Pneumologie, Ellipse, Paris.
11. Alfred P.Fishman, Jack A. Elias et al (2002), Bronchiectasia, Fishman's manual of
Pulmonary Diseases and Disorders, McGraw-Hill.
310
CHNG 4
THN TIT NIU

HI CHNG THN H

Mc tiu
1. Trnh by c nh ngha, c im dch t hc, bnh nguyn, c ch sinh bnh, sinh l
bnh hi chng thn h.
2. Nu c cc triu chng lm sng, cn lm sng ca hi chng thn h.
3. Nm c chn on xc nh v chn on phn bit hi chng thn h
4. Bit ch nh iu tr triu chng v c ch sinh bnh ca Hi chng thn h.
5. Bit cc kh nng xy ra v hng gii quyt sau khi iu tr corticoide.
Ni dung
I. I CNG
Hi chng thn h l mt bnh l kh thng gp trn thc t lm sng. Thut ng Thn h
c Friedrich Mller dng ln u nm 1906 ch nhng bnh thn m cc tn thng
gii phu bnh ch c tnh cht thoi ha, khng c c tnh vim. Nm 1908 Munk dng
thut ng Thn h nhim m ch mt loi bnh thn m v lm sng c ph v Protein
niu, gii phu bnh c xm nhp th m lng chit ng thn v cu thn bnh thng.
Ngy nay, nh tin b ca k thut sinh thit thn v knh hin vi in t, ngi ta thy rng
cc bin lon sinh ha ca thn h nhim m xut hin nhiu bnh khc nhau, tn thng
cu thn cng a dng mc d cc biu hin lm sng v sinh ha tng i ging nhau. Nh
vy, thn h nhim m khng phi l mt bnh n thun nh quan nim trc kia.
Hi chng thn h (HCTH) thng biu hin tn thng ti thiu cu thn hoc nhng tn
thng dy v thoi ha mng y ca mao mch cu thn.
HCTH n thun nguyn pht nhy cm vi Corticoides thng khng c tng huyt p, suy
thn v tiu mu. Mt s ln trng hp khng li di chng tui trng thnh.
II. DCH T HC
Bnh gp ch yu tr em, 90% trng hp xy ra tui di 16.
Tn sut gp 2/ 30.000 tr em, ngi ln gp t hn 2/300.000.
tr em, HCTH tin pht xy ra tr trai nhiu hn tr gi (t l nam / n l 2/1).
Tui thng gp nht tr em l 2 - 8 tui, v thng l HCTH n thun.
Ngi ln t gp hn, thng l HCTH khng n thun v xy ra c hai gii.
Theo William G. Couser khong 1/3 bnh nhn ngi ln v 10% bnh nhn tr em c
HCTH l triu chng ca mt bnh ton th, thng l i tho ng, Lupus ban ri rc
hoc Amylose thn. S cn li l HCTH nguyn pht.

311
III. NGUYN NHN
1. Nguyn pht (v cn)
1.1.Thn h nhim m: Tn thng ti thiu mt chn li biu m mng y cu thn.
1.2. HCTH do Vim cu thn (VCT)
- Vim cu thn mng.
- VCT tng sinh mng.
- VCT thoi ha tng , on.
- VCT tng sinh lan ta.
- VCT tng sinh ngoi thnh mch (VCT tng sinh hnh lim).
2. Th pht sau cc bnh
2.1.Bnh ton th
- Lupus ban h thng.
- Vim quanh ng mch dng nt.
- Ban xut huyt dng thp
- Vim a c.
- Takayashu.
2.2. Bnh c tnh
- Hodgkin.
- Bnh bch cu mn th Lympho.
- a u ty xng.
- Ung th biu m.
2.3.Nhim c thai nghn.
2.4. Cc bnh chuyn ha
-Amylose nguyn pht- th pht.
- i tho ng.
- Suy gip.
2.5. Cc bnh nhim c
- Cc mui ca kim loi nng Hg, Au..
- Thuc:Trimthadione, Paramthadione, Pnicillamine, Probncid.
- Cc d nguyn.
2.6. Nguyn nhn v mch mu
- Tc tnh mch ch.
- Tc tnh mch thn.
2.7. Nhim trng
- Vi trng: lin cu, giang mai, vim ni tm mc bn cp.
312
- K sinh trng: st rt, Bilharziose.
2.8. Bnh v mu
- Hng cu hnh lim.
2.9. HCTH bm sinh v gia nh.
IV. SINH L BNH
1. Protein niu
Protein niu trong HCTH rt nhiu, thng trn 3,5g/24 gi / 1,73 m
2
din tch c th, c th
t n 40g / 24 gi. tr em, gn y ngi ta xut prtin niu cn chn on l
1,66 g/ngy/m
2
din tch c th, nu albumin mu gim di 25 g/l. Protein niu thay i ph
thuc vo mc lc cu thn v albumin mu, v vy prtin niu c th gim trong trng hp
gim nhiu mc lc cu thn hoc gim rt r v nhanh ca albumin mu.
Protein niu c th gm ch yu l albumin hoc nhng protein c trng lng phn t nh
hn: gi l protein niu chn lc. Trong trng hp khc, protein niu cha phn ln l cc
protein huyt tng, c bit l IgG: gi l khng chn lc.
Protein niu l do cc bt thng ca hng ro cu thn m tnh thm chn lc vi cc i
phn t tr nn bt thng.
Trong mt s trng hp, chnh hng ro chn lc theo in tch ca cc i phn t b ri
lon: C nhng bin i v mt sinh ha lan ta khp cu trc cu thn, bt thng ny khng
th xc nh bng knh hin vi quang hc c. Protein niu chn lc l thng gp trong tnh
hung ny.
Trong cc trng hp khc, chnh hng ro chn lc theo kch thc ca cc i phn t b
thng tn. C cc bt thng ca cu trc cu thn, d thy bng knh hin vi quang hc. Protein
niu trong trng hp ny thng l khng chn lc.
2. Gim albumin mu.
Gim albumin mu < 30 g/l, thng gp hn l < 20 g/l.
Gim albumin mu ch yu l do mt albumin qua nc tiu, c s tng quan gia mc
protein niu v albumin mu.
Ngoi ra cn c yu t gia tng d ha ca thn i vi albumin: Albumin sau khi lc,
c ti hp thu tr li ng ln gn bi s hp thu ni bo v sau b thoi bin ti tiu
th.
C 2 c ch chnh b tr li s mt albumin qua nc tiu
+ Tng hp albumin gan gia tng.
Bnh thng gan tng hp 12 - 14 g albumin /ngy ngi ln, bnh HCTH c th gia tng
tng hp thm khong 20%. Nh vy c th thy rng s tng hp ny l khng b s
mt protein qua nc tiu.
Mt s yu t nh tui, tnh trng dinh dng km, cc bnh gan c sn t trc cng
c th hn ch s tng tng hp ny. iu ny c th gip gii thch trong mt s trng hp
gim albumin mu rt r, vi protein niu < 10 g/24 gi, trong khi mt s trng hp khc, c
protein niu ln hn nhiu, m albumin mu cn bnh thng hoc gim va phi.
+ C s chuyn vn albumin t khu vc khong k vo huyt tng.
Nhng s b tr ny cng khng y hi phc li albumin mu.
313
3. Ph
Ph l triu chng thng gp vi tnh cht ph mm, d n lm (du godet). Ph xut hin
nhng vng p lc m k thp nh xung quanh hc mt, mt c chn.
Him hn, c th lin quan n mng phi, mng bng, i khi gy kh th.
Ph l do tnh trng gi mui v nc m c ch do cc yu t sau:
+ C ch gim p lc keo huyt tng.
C ch ny lm vn chuyn nc v in gii vo khu vc k v c th dn n gim th tch
mu v t gim th mu ny tc ng, mang tnh cht sinh l, ln h thng thn kinh - ni tit
(giao cm, RAA, Arginine vasopressine) lm kch thch s ti hp thu ng thn i vi
nc v mui b tr s gim th tch mu.
+ Nhng c ch ti thn c hiu.
c to ra bi s gim albumin mu hoc albumin niu. C th gii thch s gi mui v
nc trong HCTH nh sau: S ti hp thu mui (natri) gia tng rt sm trong nhng t bo
chnh ca ng gp v c s gia tng hot ng ca bm Natri (Na
+
/K
+
/ATPase) v ca knh
Natri biu m.
4. Tng lipid mu
Bt thng ny thng c thy trong HCTH. Lc khi u, chnh tng Cholesterol mu l
chnh, tng Triglycride mu xut hin th pht sau .
Cc bt thng Lipide ny thng gp hn khi albumin mu gim < 20 g/l.
Cc Lipoprotein t trng thp (LDL), rt thp (VLDL) v loi trung gian (IDL) u tng, cc
lipoprotein t trng cao (HDL) l bnh thng hoc gim.
Theo phn loi ca Fredrickson v Lees ri lon thng gp nht l type IIa v IIb (60%), sau
l type V (30%), him hn l type III hay IV (10%). Cc bt thng lipide hi phc khi
HCTH bin mt.
C ch ca tng Lipid trong HCTH c gii thch do cc yu t sau y:
- Tng tng hp gan Lipoprotein t trng thp rt thp (VLDL):
y l c ch chnh, thng lin quan vi nng ca gim albumine mu. Khi gim p lc
keo ca huyt tng s kch thch tng hp apoLipoprotein B. Gia tng men HGM CoA
rductase, acide mvalonique, tin cht ca cholesterol v cc acide bo t do, cng c th b
nh hng.
- Gim men Lipoprotein Lipase (LPL)
ng vai tr quan trng bng cch lm gim thoi bin VLDL. Nhng acide bo t do c ch
hot ng ca LPL. S thiu ht apo C II v nhng hparan sulfate, do bi tit trong nc
tiu, cng c ch hot ng ca enzyme ny.
- Gim men Lecithin cholesterol acyl transferase(LCAT):
iu ny ng gp vo nhng bt thng v Lipide trong HCTH bng cch gim tng hp
HDL bt u t nhng VLDL.
- Mt qua nc tiu HDL v apo A1
Mt qua nc tiu HDL v apo A1 cng c ghi nhn, nhng nng ca HDL huyt
tng phn ln l bnh thng.
314
Tc ng sinh x va ca nhng bt thng Lipide ny cha c chng minh mt cch r
rng, c l v thi gian ngn trong tin trin ca HCTH.
Tng Lipde mu cng c th to thun li ngng tp tiu cu v nhng bin chng huyt khi
tc mch, lm gim p ng ca Lymph bo i vi nhng kch thch khng nguyn. Tng
Lipde mu cng c th l mt yu t ca x ho cu thn.
5. Tng ng mu.
Nhiu bt thng cm mu c quan st thy trong HCTH, l nguyn nhn gy ra tng ng
mu v nhng bin chng huyt khi tc mch. Tng ng mu trong HCTH do cc c ch
sau:
- Gia tng fibrinogen mu do tng tng hp gan.
- Gia tng cc yu t II,V,VII,VIII v X, gim cc yu t IX,XI,XII do bi tit trong
trong nc tiu v trng lng phn t thp.
- Gim hot ng tiu fibrin do gim plasminogene v tng antiplasmine (alpha 2
macroglobuline, alpha 2 antiplasmine).
- Thiu ht nhng cht c ch qu trnh ng (Prtin C, antithrombin III).
- Tng ngng tp tiu cu.
Nhng bt thng ny, kt hp vi tng Lipide mu v gim th tch mu, to thun li
xut hin huyt khi tnh mch v tc mch phi.
6. Tng kh nng b nhim trng
Dng nh l do gim gammaglobulin mu, ngoi ra cn do mt b th qua nc tiu. Chnh
nhng iu ny lm sai st ca p ng Lymph bo i vi khng nguyn.
7 Suy dinh dng v chm pht trin
Ngoi nhng tc dng ca stroide, suy dinh dng v chm pht trin do mt prtin v mt
nhng hocmn gn lin vi cht mang prtin (TBG,T3,T4, Vitamin D)
V. TRIU CHNG
1. Ph
Thng xut hin nhanh, t ngt, cng c th ph xut hin sau nhim trng nh ng
mi hng.
Tnh cht ca ph: Ph trng mm, n lm, gi du n lu, ph ton thn, khng c hin
tng vim au vng b ph. C th c dch cc mng bng, mng phi, mng tim, b
phn sinh dc.
Cc bin chng nng: ph phi, ph thanh qun thng gp tr em.
2. Triu chng nc tiu
Lng nc tiu thng t 300-400ml/24 gi.
Mt nhiu protein niu: trn 3,5gam/24 gi. C th t 3-10g/24 gi, trng hp nng c th
30-40g/24 gi.
Lng Protein tng ln lc ng, lc gng sc, c m lng chit, tr m trong nc tiu.
Lipid niu: thc cht l nhng kt ta ca Ester Cholesterol.
Ure v Creatinine niu tng.
315
3. Triu chng th dch
- Gim Protein mu rt quan trng.Protid mu di 60 g/l, trung bnh l 50 g/l.
- Albumin mu gim di 30 g/l, trung bnh 20 g/l. Albumin mu l ch s chnh xc nh
gi nng ca HCTH.
- Ri lon cc Globulin huyt thanh: 2 Globulin tng.
Globulin tng.
Globulin thng gim trong HCTH n thun,
trong HCTH khng n thun c th bnh thng hoc tng.
- Cc thay i v lipid: Cholesterol mu tng, Phospholipid v Triglycerides tng. Ri lon
Lipid trong HCTH lc khi u tng Cholesterol l chnh. Tng Triglycerides mu xut hin
th pht sau . Ri lon Lipid thng gp hn khi Albumin mu gim di 20 g/l.
- Cc triu chng khc:
+ Na
+
mu v Ca
++
mu gim.
+ Tng Hematocrit, tng hng cu chng t mu d ng.
+ Gim Antithrombin III do mt qua nc tiu, tng tiu cu v Fibrinogen.
+ Ri lon ni tt: gim Hormone tuyn gip nu hi chng thn h ko di.
VI. CHN ON
1. Chn on xc nh
1.1. Da vo lm sng v cc xt nghim thng thng.
+ Cc tiu chun chn on: da vo cc tiu chun sau y:
1. Ph.
2. Protein niu 3,5g/24 gi.
3. Protein mu <60g/l, Albumin mu < 30g/l.
4. Lipid mu tng trn 900 mg%. Cholesterol mu tng trn 250 mg% hoc trn 6,5
mmol/l.
5. in di Protein mu: Albumin gim, t l A/G < 1, Globulin: 2 tng, tng.
6. Nc tiu c tr m, tinh th lng chit.
Trong tiu chun 2 v 3 l bt buc.
1.2. Da vo cc thm d chc nng v thn:
- Hi chng thn h n thun: Cc chc nng thn bmh thng.
- Hi chng thn h khng n thun: Ri lon cc chc nng lc ca cu thn, chc nng
bi tit v ti hp thu ca ng thn.
1.3. Sinh thit thn
- C gi tr rt ln trong chn on xc nh tn thng ca HCTH.
- Gip phn loi tn thng trong HCTH mt cch chnh xc.
- HCTH n thun tr em 80% l tn thng ti thiu.
2. Chn on phn bit
316
2.1. HCTH n thun v khng n thun:
HCTH n thun: huyt p bnh thng, khng c suy thn, khng c i mu.
HCTH khng n thun: huyt p tng v/hoc suy thn v/hoc i mu. Ngoi ra, cn da
vo in di Protein niu: trong HCTH n thun Protein niu ch yu l Albumin (Protein
niu chn lc).
2.2. Ph do cc nguyn nhn khc: X gan, suy tim, ph suy dinh dng.
VII. BIN CHNG
1. Nhim trng
- Ngoi da: Vim m di da
- Phi: vim phi.
- Phc mc: vim phc mc tin pht do ph cu, nhng c th do cc vi khun khc.
- Mng no:vim mng no t gp.
- ng tit niu: nhim trng ng tit niu.
2. Cn au bng do hi chng thn h.
au bng trong HCTH do cc nguyn nhn khc nhau
- Vim phc mc do ph cu.
- Vim rut do nhim trng, c th do t cu.
- Do ph ty, ph dy chng Treitz hoc tc tnh mch ch, tnh mch thn.
3. Try mch
Gim th tch mu nng nht l khi s dng thuc li tiu mnh lm gim th tch mu t
dn n suy thn cp chc nng. Trong trng hp ny, truyn Plasma hoc cc cht c trng
lng phn t cao th c kh nng hi phc.
4. Tc mch
Mu trong tnh trng tng ng: do gim Albumin, gim Antithrombin III, do tng cc yu t
ng mu (tiu cu, fibrinogen). y l loi bin chng c in chim 5-20% ca HCTH.
Thng tc tnh mch thn, tnh mch ca, tnh mch phi.
5. Thiu dinh dng
Nu b bnh lc cn nh: tr s gim ln so vi cng la tui.
Gim min dch, d mc cc bnh nhim trng.
Suy kit.
Ngoi ra, gim Ca mu (ti hp thu Ca rut gim), ri lon chuyn ha Vitamin D do mt
Protein.
VIII. TIN TRIN, TIN LNG
1. Tin trin
C nhiu kh nng xy ra: nu p ng tt vi iu tr, HCTH c th lui bnh v khi hn
hon ton. Trong mt s trng hp, bnh ti pht nhiu t, nhiu nm lin ri lui bnh hoc
chuyn sang suy thn mn.
2. Tin lng: ph thuc vo
317
- Tui.
- Th bnh: n thun, khng n thun
- Thng tn gii phu bnh ca HCTH.
- p ng iu tr.
IX. IU TR
1. Nguyn tc
iu tr Hi chng thn h bao gm:
- Ch tit thc sinh hot.
- iu tr triu chng.
- iu tr c ch bnh sinh.
Hi chng thn h n thun nguyn pht khng c tng huyt p, suy thn v tiu mu
thng nhy cm vi Corticoides. Mt s ln trng hp khng li di chng tui trng
thnh.
i vi cc Hi chng thn h th pht sau mt bnh khc, th iu tr c bn vn l iu tr
bnh chnh, t l p ng vi Corticoides thp hn so vi Hi chng thn h n thun
nguyn pht.
2. Ch ngh ngi n ung
2.1. Hn ch mui
Hn ch mui tu thuc vo triu chng ph ca bnh.
Trong th Hi chng thn h c ph nh: hn ch mui tng i (di 2g/ngy).
Hn ch mui tuyt i (di 0,5 g/ngy) trong nhng th ph to.
2.2. Tng lng Protid
Trong hi chng thn h, nhu cu Protid tng ln do mt mt lng ln qua ng tiu, v
vy nu bnh nhn khng c tng Ure mu th cn tng lng Protid trong ch n trn 2g/
kg/ngy. Nu bnh nhn c suy thn th ch n s gim Protid theo mc suy thn.
2.3. Nc
Tu thuc vo mc ph v lng nc tiu, thng thng phi hn ch lng nc ung
vo khong 500 - 700 ml /ngy.
3. Thuc
3.1. iu tr triu chng.
- iu tr ph: Cn lu rng trong hi chng thn h, th tch huyt tng thng l
bnh thng hoc gim. V vy s dng thuc li tiu mnh c th gy gim th tch nng,
iu ny cng d xy ra khi ang gim albumin mu cng trm trng (<15g/l). iu tr li tiu
cng cn thn trng lc khi u. Cc li tiu thiazide thng c chn la u tin. Li
tiu khng lm mt Kali (Spironolacton, triamtrene, amiloride) c th dng trong trng hp
gim kali mu. Khi triu chng ph nng n v khng p ng vi iu tr li tiu mui, cc
li tiu quai c ch nh.
- iu tr tng lipid mu: trong nhng nm gn y iu tr tng lipid mu c ngh
trong hi chng thn h khi ri lon ny nghim trng. Nhm thuc c chn la y l
nhm Statine.
318
- iu tr cc bin chng:
Tu cc bin chng gp bnh nhn Hi chng thn h c tm thy, chng hn trong cc
trng hp c huyt khi cn phi c ch nh chng ng.
- Cho thm Ca, st, cc loi vitamine, khng sinh nu cn.
3.2. iu tr c ch bnh sinh.
3.2.1. Corticoides (Prednisolone) ngi ln 1mg / kg / ngy. Tr em 1,5 mg - 2 mg / ngy.
Liu tn cng 4 - 8 tun.
Liu cng c bng 1/2 liu tn cng (0.5mg/kg/ngy ngi ln) ko di t 2 - 4 tun.
Liu duy tr 5 - 10 mg/ ngy.
Thi gian ca liu trnh Corticoides thng t 4,5 n 6 thng.
3.2.2 Cc loi thuc c ch t bo.
+ Chlorambucil vin 2mg, liu 0,1-0,2 mg/kg thi gian 3 thng n 1 nm. C th phi hp
vi Corticoides.
+ Cyclophosphamide (Endoxan) vin 50mg, ng 100mg liu bt u 5mg/kg/24h iu tr
trong 12 tun.Phi hp vi Prednisolone cho kt qa tt. Lc phi hp, liu
Cyclophosphamide 2,5mg/kg/ngy trong 90 ngy.
+ Azathioprine vin 50mg ung 2-3mg/kg/ngy t 1-6 thng.
Thuc gim min dch iu tr c kt qu trong cc trng hp HCTH khng n thun, cc
trng hp khng Corticoides, ph thuc Corticoides v loi chng ch nh Corticoides.
3.3. iu tr nguyn nhn
i vi nhng trng hp hi chng thn h th pht iu tr loi b nguyn nhn l cn
thit.

319
VIM CU THN CP
Mc tiu
1. Trnh by c nh ngha, dch t hc v nguyn nhn ca vim cu thn cp.
2. M t c c ch sinh bnh vim cu thn cp
3. Pht hin c cc triu chng lm sng, cn lm sng vim cu thn cp.
4. Chn on xc nh, chn on phn bit ca vim cu thn cp.
5. iu tr c vim cu thn cp.
Ni dung
I. I CNG V DCH T HC
1. i cng
Vim cu thn cp l biu hin lm sng ca mt thng tn vim cp ca nhng cu thn,
c trng vi s xut hin t ngt hng cu niu, protein niu, ph v tng huyt p.
Hin nay, nh nhng tin b ca k thut sinh thit thn. Ngi ta u thng nht rng:
Vim cu thn cp khng ch l mt bnh n thun m l mt hi chng gi l hi chng
cu thn cp. L do l v bnh cnh lm sng thng ging nhau nhng tn thng m bnh
hc li a dng, bnh pht sinh khng ch do lin cu m c th sau nhim t cu, ph cu,
virus. Hi chng vim cu thn cp cn biu hin th pht sau cc bnh nh lupus ban h
thng, ban dng thp, vim quanh ng mch dng nt.
Vim cu thn cp c tnh hay vim cu thn bn cp hin nay c gi l vim cu thn th
tin trin nhanh. Tn gi ny c trng cho bnh l tin trin nhanh, t vong sm do suy thn
v t khi ngi bnh qua khi 6 thng nu khng c iu tr .
2. Dch t hc
2.1. T l mc bnh: t l mc bnh vim cu thn cp sau nhim lin cu khng c bit
mt cch chnh xc v nhiu trng hp bnh c gi iu tr ngay tuyn trc. Tn sut
bnh gim dn cc nc cng nghip hin i, nhng vn cn thng gp cc nc nhit
i, cc nc ang pht trin (Chu Phi, vng Carib, Chu , Nam M...).
Bnh xut hin di dng tn pht, hoc c th thnh tng v dch, c bit nhng ni i
sng v sinh km (nhng v dch Trinidad, Maracaibo, Minnesota)
2.2. Lin quan gii v tui: Bnh rt him trc hai tui, thng gp tr con t 3 n 8 tui,
tr nam thng gp hn n (t l nam/n = 2/1). ngi ln t gp hn so vi tr em.
II. CN NGUYN
Vim cu thn cp c th do nguyn nhn nhim khun hoc khng do nhim khun.
1. Vim cu thn cp do nhim khun gm
1.1. Vi khun thng gy bnh nht l lin cu tan huyt bta nhm A (group A) c coi l
mu hnh ca vim cu thn cp. Chng thng gy bnh nht l chng 12, cc chng khc
(1, 2, 4, 18, 24, 25, 49, 55, 57, 60) cng c th gy bnh nhng him gp hn, Thng chng
4, 12, 24 nu l nhim khun c hng, chng 14, 19, 50, 55, 57 nu l nhim khun ngoi
da (khc vi thp khp cp v trong thp khp cp chng lin cu no cng c th gy bnh).
1.2. Mt s vi khun khc him gp hn cng c th gy vim cu thn cp nh t cu, ph
cu, thng hn, no m cu, Klebsiella Pneumoniae,...
320
1.3. Mt s siu vi gy vim hng cp dch t, quai b, si, thy u, Epstein Barr, vim gan
siu vi B, Cyto megalo Virus (CMV)...
1.4. Nguyn nhn do nhim nm: Histoplasmose
1.5. Nguyn nhn do nhim k sinh trng: Plasmodium falciparum v Malariae, Toxoplasma
Gondii, sn mng,...
2. Vim cu thn cp khng do nhim khun
2.1. Cc bnh to keo: c bit l luput ban h thng, vim quanh ng mch dng nt,
btut huyt dng thp.
2.2. Cc bnh biu hin qu mn cm vi mt s thuc nh Penicilline, Sulfamide, Vaccine
hay mt s thc n nh tm, cua...
III. S TM TT C CH VIM CU THN CP DO LIN CU
KHUN
Khng nguyn (KN) Khng th (KT)

Lin cu tan huyt bta - AHL (antihyaluronidaza)
- ASLO (antistreptolysin O)
- ANDAZA (antidesoxyribo nucleaza)
- ASK (antistreptokinaza) lu hnh

Phc hp KN - KT

tr lng cu thn Hot tc cc b th


Lng ng cc phc hp min Phn ng vim v tng sinh nhng mao
dch ln mng y ca mao qun cu thn
qun cu thn
IV. DU CHNG LM SNG V CN LM SNG
1. Trong vim cu thn cp do nhim khun
Di y l bnh cnh in hnh ca vim cu thn cp sau nhim lin cu khun.
1.1. Lm sng
Bnh thng gp tr em v xut hin sau mt t nhim khun c hng hoc ngoi da t 7-15
ngy. Nhim khun ngoi da thng bnh di ngy hn.
1.1.1. Giai on khi pht
Thng l t ngt nhng c th c du hiu bo trc vi:
- Ton thn mt mi, st 38-39
0
C hoc nh hn.
- au vng tht lng hai bn, ri lon tiu ha, chn n, au bng, bun nn.
321
- Cng c th bnh nhn n vin v cn vim hng, vim da.
1.1.2. Giai on ton pht
- Ph: Lc u thng xut hin mt, nh nng m mt, ph c th khi nhanh, nhng cng
c th lan xung chi ri ph ton thn. Ph trong vim cu thn cp c c im:
+ Ph mm, trng, n lm li du ngn tay.
+ Ph quanh mt c, mt trc xng chy, mu bn chn.
C th ph nng vi ph ton thn nh trn dch mng phi, mng bng, ph phi cp, ph
no. Ph trong vim cu thn cp ph thuc vo ch n ung.
- i t hoc v niu: Xut hin sm, nc tiu ch c 500-600ml/24gi. Khi c thiu niu
(nc tiu di 500ml/24gi) hoc v niu (nc tiu di 100ml/24gi) l biu hin suy
thn cp.
- Tng huyt p: Tng huyt p c ti a ln ti thiu, thng r hai tun u. Trn 60%
vim cu thn cp c tng huyp p. Ph phi cp trong vim cu thn cp l tai bin thng
gp do tng huyt p, ph v suy tim tri.
- i mu: t khi i mu i th, nu c thng xut hin sm cng vi ph, nc tiu
hay sm mu (khi hng cu niu trn 300.000/pht). Thng gp hn l i mu vi th.
Hng cu mo m d v. Tr hng cu l du hiu c gi tr nht, chng t hng cu t cu
thn xung. i mu i th thng khi sm nhng i mu vi th th ko di, hng cu niu
c khi 3-6 thng mi ht.
1.2. Xt nghim cn lm sng
1.2.1. Mu: Cng thc mu c thiu mu nh, lng mu tng nhiu tun v tr li bnh thng
khi n nh.
1.2.2. Nc tiu
- Protein: 0,2 - 3g/24gi. in di protein niu c tnh khng chn lc(t alb/globulin < 1,
clearance IgG / transferin > 10%). Protein niu trong vim cu thn cp lun c v l yu t
theo di din tin ca bnh.
- Cn addis: Hng cu 100.000 - 500.000/1 pht, Bch cu 20.000/1 pht.
- Tr Hng cu l xt nghim c gi tr chn on, tuy nhin cng c t l khng gp.
1.2.3. Ur, creatinine mu
Ur mu c th bnh thng hoc tng nh v t c ngha tin lng khi khng vt qu
1g/l. Nu ur mu cng ngy cng tng dn l mt ch dn xu, creatinine mu bnh thng,
nu tng cao dn song song vi ur l mt ch dn xu.
Tt nht theo di vim cu thn cp l tnh thanh lc cu thn vi creatinine. Mc lc
cu thn di 50ml/pht l c mt tin lng d dt.
1.2.4. B th mu gim
90% bnh nhn c b th mu gim, gim thnh phn C
3
l ch yu. Sang tun th su ca
bnh mi tr v bnh thng.
1.2.5. Cc xt nghim khc
Ch yu pht hin lin cu v cc khng th nh ngoy hng tm lin cu khun, ALSO
tng hn 400 n v Todd, in tim c PR ko di.
1.2.6. Sinh thit thn
322
Ch cn thit ngi ln tui, gip chn on th gii phu bnh v gip tin lng bnh.
Trong thc t 2 xt nghim hng cu niu v protein niu cng xc nh vim cu thn
cp.
1.3. Tin trin: Vi nhiu kh nng
- Tt: l din tin thng gp ca bnh vim cu thn cp, sau 8-15 ngy bnh nhn i
nhiu, ht ph, huyt p v nc tiu tr li bnh thng. C trng hp sau 3 thng, c khi 6
thng cc triu chng trn mi tr li bnh thng. Nhng trng hp ny gi l khi chm,
t l ny t. tr em, t l khi bnh cao (85-95%) so vi ngi ln (50-75%).
- Xu
+ Vim cu thn cp th tin trin nhanh hay c tnh ch din tin vi tun hoc vi thng, c
khi dai dng hn, nhng thng t vong trong vng 6 thng,chim t l di 10%. Lm sng
khi pht nh vim cu thn cp kinh in nhng dn n suy thn cp nhanh.
+ Tin trin xu cng dn n t vong ngoi 6 thng: ph v protein niu dai dng, thng
xut hin hi chng thn h, trc y gi l vim cu thn cp bn cp, bnh dn dn suy
thn, khng phc hi.
+ Bnh din tin ko di nhiu nm vi tng t lui bnh, nhng cui cng cng dn n t
vong, hn m do tng ur mu hoc do tai bin mch no do tng huyt p gi l suy thn
mn.

TM TT S TIN TRIN CA VIM CU THN CP NGI LN



Vim cu thn cp
- Khi hon ton (60%)
- Cht trong t cp (1-2%)
(Trong vng 2-6 tun)
- Tin trin nhanh (5-10%)
(T vong trong vng 6 thng)
- Vim cu thn mn (10-20%)
(Tim tng mn tnh nhiu nm)
1.4. Cc th lm sng khc ca vim cu thn cp do nhim khun
1.4.1. Th i mu n thun:
Thng gp tr em, i mu c th n c, khng ph, khng thiu, v niu. Tin
trin ni chung tt, nhng c th ti pht.
1.4.2. Th tim mch
Thng gp ngi ln, tr, khi pht d di vi tng huyt p, ph phi, ph
no.Chn on c bn da vo xt nghim nc tiu vi hng cu niu v protein niu. Tin
trin nu khng t vong giai on u, v sau ph ko di nhiu nm.
1.4.3. Th v niu: Biu hin ca mt suy thn cp, trc y c khi khi t pht, ngy nay
vi thn nhn to t l khi bnh nhiu hn, khi nc tiu phc hi th bnh c th khi hon ton
nh cc th khc.
1.4.4. Th nh hay thong qua: c pht hin tnh c nh xt nghim mt cch c h thng,
nht l nhng bnh nhn c vim mi, vim hng, rt him chuyn sang mn tnh.
323
1.4.5. Th s sinh v tr em nh tui: Khi pht c khi d di bng cc cn co git v suy tim
cp, tuy nhin khi qua khi, tin lng thng tt hn ngi ln.
2. Vim cu thn cp khng do nhim khun
2.1. Luput ban h thng
70% lupus c vim cu thn cp c th biu hin di hai dng:
- Nh: nhng thng nng ln v iu tr bng hormon v thng thn.
- Nng: km vi vim a khp, vim a mng.
2.2. Ban dng thp
30% c vim cu thn cp biu hin vi i mu v protein niu.
2.3. Vim cu thn cp do hin tng qu mn
Nh do thuc, vacxin, din bin thng tt sau khi ngng thuc.
V. CHN ON
1. Chn on xc nh
Da trn 3 du chng lm sng, ph, tng huyt p, thiu hoc v niu v hai du
chng cn lm sng: protein niu v hng cu niu.
2. Chn on gin bit
- t cp ca vim cu thn mn da vo tin s, bnh s, ngoi ra c th siu m o kch
thc thn, nu thn nh hn bnh thng l vim cu thn mn.
-Vim cu thn cp sau nhim lin cu vi Vim cu thn cp khng do lin cu: da vo
bnh s, cy vi khun, dch mi hng, m ngoi da, khng th ALSO v cc khng th khng
lin cu khc.
VI. THEO DI V TIN LNG
Vim cu thn cp sau nhim lin cu thng gp tr em v tin lng tt hn, ngi ln
t gp nhng tin lng nng hn.
Nhn chung, tin lng thng tt nu bnh hi phc hon ton. Trong Vim cu thn cp
ngay trong t cp, c th cht do ph phi cp, suy tim, suy thn cp, nhim khun.
VII. IU TR
1.Tit thc, ngh ngi
1.1. Tit thc
- Bnh nhn thiu v v niu c tng ur, creatinine mu: lng nc vo 500-
600ml/ngy, mui 2g/ngy, Prtide 20g/ngy.
- Bnh thiu v v niu c ph tng huyt p, ur, creatinine mu khng tng: mui
0,5 - 1g/ngy, Prtide 40g/ngy.
1.2. Ngh ngi
Ngh ngi tuyt i t 3 tun n 1 thng cho n khi ht triu chng. Sau tr li hot
ng t t ngay khi cn protein niu v i mu vi th thng t 6 tun n 2 thng.
2. Khng sinh
Ch cho khng sinh khi cn tn ti du hiu nhim lin cu.
324
Cha c t liu no khng nh rng khng sinh c th ngn nga s nng ca bnh vim cu
thn cp do lin cu, khng sinh khng c tc dng ln cu thn, thng s dng l
Pnicilline 1 triu n v /ngi ln, 500.000 n v / tr em. Nu d ng Pnicilline th dng
Erythromycine 0,2 x 5 vin/ngy ngi ln hoc Tetracyline. Khng sinh dng trong 10-12
ngy.
3. Cc thuc Corticoides
Bao gm prednisolone, mthylprednisolone. Khng c tc dng trong cc th thng thng,
thm ch c hi. Nhm thuc ny c th c s dng trong cc th tin trin nhanh.
4. iu tr bin chng
4.1. Tng huyt p.
King mn, ngh ngi tuyt i.
Thuc h huyt p: Cc nhm thuc h huyt p thng c s dng hin nay l:
+Thuc c ch canxi:C nhiu thuc nh nifdipine, amlodipine, felodipine, manidipine. y
l nhm thuc thng c s dng chng tng huyt p do bnh thn hin nay.
+Thuc c ch men chuyn: nh catopril, enalapril, perindopril. L nhm thuc c xem l
c tc dng bo v thn. Cn lu tc dng ph tng kali mu.
+ Thuc c ch thn kinh trung ng: Trong nhm ny thuc thng c s dng l
mthyldopa (Aldomet)
4.2. Ph phi
iu tr nh cc ph phi khc,cho Lasix liu cao c th n 200mg tim tnh mch, Uabain,
th oxy, Morphin khi cn thit.
4.3. Ph no
Truyn glucose u trng, Mannitol.
4.4. Th v niu
Nhng ni khng c iu kin lc thn nhn to c th iu tr th Furosemid (Lasix) liu
cao hoc c th thm phn phc mc.
Tt nht cho c ph phi, no, v niu l lc ngoi thn m thn nhn to ng vai tr hng
u.
4.5. Cc triu chng khc
- Tng ur mu, creatinine mu, hn ch lng protid a vo nhng phi m bo nng
lng 1200-1600 calo/ngy chng d ha, c th cho Durabulin hoc Testosterone 25-
50mg/ngy.
- iu tr tng Kali mu bng glucose 20-30%, 300-500ml + 10-20 n v insulin truyn tnh
mch trong 1 gi n 1g30 pht hay truyn dung dch kim, hoc c th s dng Resonium
(Kayexalate) ung 30g/ngy.
Hon cc tim phng trong thi gian mc bnh vim cu thn cp v ngay c hai nm u sau
khi ht vim cu thn cp, nht l vaccin chng ho g, un vn.
Trong vim cu thn cp th thng thng iu tr i khi ch cn ngh ngi, n nht l .
Trong khi nhng th nng, ty thuc vo bin chng v c cch iu tr khc nhau. Cng cn
lu rng khi pht hin c nguyn nhn ca vim cu thn cp th vn iu tr nguyn
nhn l quan trng
325
VII. D PHNG
1. i vi vim cu thn cp sau nhim khun lin cu
- Pht hin sm cc nhim khun do lin cu: vim hng, vim Amygdals, vim
da...
- iu tr trit cc nhim khun do lin cu: khng sinh, ct amydals.
- Nng cao v sinh c nhn: b thuc l, gi m c trong ma lnh i vi vim hng,
v sinh c nhn i vi gh bi nhim.
2. i vi vim cu thn cp khng do nhim khun
- Pht hin sm cc biu hin thn trong cc bnh ton th: lupus ban h thng, ban
xut huyt dng thp.
- iu tr tt cc bnh ton th d phng tn thng vim cu thn.



326
SI H TIT NIU
Mc tiu
1. Nm c dch t, nguyn nhn v c ch sinh bnh ca si h tit niu.
2. Bit c din tin ca si v nh hng ca si i vi ng tit niu.
3. Nu c triu chng lm sng v cn lm sng ca si h tit niu.
4. Chn on c v bit ch nh cc phng php iu tr si h tit niu.
5. Bit c cc phng php iu tr ni khoa v bit cch ch nh iu tr ngoi khoa si
tit niu
Ni dung
I. I CNG
Si thn v h tit niu l bnh thng gp nht ca ng tit niu v thng gp nam gii
nhiu hn n gii. Tui mc bnh thng l t 30 - 55, nhng cng c th gp tr em (si
bng quang). Ti cc nc cng nghip pht trin, si Acide Urique c chiu hng gp
nhiu hn cc nc ang pht trin. Vit Nam, si Amoni-Magi-Phosphat (Struvit)
chim mt t l cao hn. Ch n ung khng hp l (qu nhiu m, Hydrat Carbon, Natri,
Oxalat), nhim khun tit niu hoc sng vng nng, vng nhit i,... l nhng yu t
thun li bnh si thn tit niu d pht sinh. Cc loi si Calci thng l si cn quang,
cn si Urat v Cystin thng khng cn quang.
Theo tc gi Glenn. H. Pneminger t l mc bnh si thn tit niu trn th gii vo khong
3% dn s.
II. NGUYN NHN V C CH SINH BNH
1. Cu trc ca si
Bowman v Meckel nghin cu si niu v nhn thy vin si c mt tnh cht c th
gm hai yu t:
- Cht Mucoproteine, c tc dng nh cht keo kt dnh cc tinh th vi nhau to si.
- Cc tinh th ca cc cht bnh thng c ha tan trong nc tiu, ch yu l Calci v
Oxalat. Bn cnh cc cht thng gp ny cn c cht Phosphat, Magne, Urat, Cystine.
Vai tr ca Mucoprotein trong c ch to si hin nay vn cn c bit rt t.
C th ni rng khi nc tiu b c c hoc khi pH ca nc tiu thay i, th cc cht ha
tan trong nc tiu s kt tinh li thnh cc tinh th, cc tinh th s b loi tr theo dng nc
tiu. Cn phi c cht Mucoproteine th cc tinh th mi lin kt li vi nhau to ra vin
si. Do nhiu trng hp khi th nc tiu, thy c nhiu tinh th Oxalate hay Phosphate
nhng bnh nhn khng c si thn tit niu.
2. iu kin thun li pht sinh ra si
iu kin thng xy ra nht l s c c qu mc ca nc tiu.
Trong iu kin bnh thng, nu c hai iu kin sau y th cc tinh th ha tan c th lng
ng c:
- Dung dch c yn tnh, khng b khuy ng trong mt thi gian di.
- Dung dch c cha ng cc vt l nh si ch, xc t bo, vi khun,... th vt ny c th tr
thnh nhn cc tinh th ng xung quanh to si.
327
Ngoi ra, khi dung dch c c c qu bin ha tan trn ngng bo ha th s c s kt
tinh ca cc cht ha tan.
S thay i ca pH nc tiu s lm cho mt s cht ha tan d kt tinh li c th, di tc
dng ca mt s chng loi vi trng (nh Proteus Mirabilis) c tit ra men urase lm phn
hy ure thnh amoniaque, nc tiu s b kim ha (pH> 6,5) v nh vy, cht Photsphate -
Magi s kt tinh li. Ngc li nu pH nc tiu tr nn acid (pH< 6) th s l iu kin
thun li cho urat kt tinh li.
3. Cc loi si niu thng gp
3.1. Si calcium
Chim t l t 80 - 90 % cc trng hp. Nhng nguyn nhn lm tng nng calci trong
nc tiu l
- Cng tuyn gip cn gip.
- Gy xng ln v bt ng lu ngy.
- Dng nhiu Vitamin D v Corticoid.
- Di cn ca ung th qua xng, gy ph hy xng.
Ngoi ra cn c rt nhiu trng hp c tng nng calci trong nc tiu m khng tm
thy nguyn nhn, gp trong 40-60% trng hp. Ngoi ra cng c th c nng calci trong
nc tiu cao nhng nng Calci trong mu vn bnh thng. Nng calci cao trong nc
tiu khng phi l yu t quyt nh kt thnh si niu, m n ch l yu t thun li.
3.2. Si oxalat
Chim t l cao cc nc nhit i nh nc ta, oxalat thng kt hp vi calci to
thnh si oxalat calci.
3.3. Si phosphat
Loi si phosphat thng gp l loi amoni-magn-phosphat, chim khong 5-15% trng
hp, c kch thc to, hnh san h, cn quang, hnh thnh do nhim khun, c bit l do lai
vi khun proteus.
Vi khun protus c men urase lm phn hy ure thnh amoniaque, do nc tiu s b
kim ha, nu pH nc tiu trn 7,0 th phosphat s kt ta.
3.4. Si acid uric
Acid uric d tan trong mi trng kim v d kt tinh trong mi trng acid, khi pH nc tiu
di 6. Nguyn nhn ca n thng l:
- Lng Acid uric c bi tit qu nhiu trong nc tiu.
- Nc tiu b c c qu nhiu trong trng hp mt nc do m hi khi lm vic mi
trng nng bc.
Si acid uric d xut hin khi chuyn ha cht purine tng trong c th. Cc nguyn nhn c
th lm tng chuyn ho purine:
+ Dng nhiu thc n c cha nhiu cht purine nh lng heo, lng b, tht c kh,
nm.
+ Bnh Gt (Goutte).
+ Phn hy cc khi ung th khi dng thuc ha tr liu.
328
3.5. Si Cystin:
c hnh thnh do mt khuyt tt ca vic ti hp thu ng thn ca cht Xystin
tng i t gp nc ta. Si Cystin khng cn quang.
4. L thuyt hnh thnh si

Kt th Carr m Randall Hoi t thp i thn
Cho n by gi, vn cha c mt c ch hon ton y gii thch cho vic hnh thnh
v pht trin ca cc vin si trong h thn tit niu. Nhiu gi thuyt c a ra, nhng
cc gi thuyt cng khng gii thch c ht tt c cc trng hp hnh thnh si. V vy,
vic hnh thnh si cho n by gi vn c xem l mt qu trnh do a yu t tc ng.
4.1. Kt th Carr
nhng ngi hay b si ti pht, tc gi Carr nhn thy u ca nhng ng gp, quanh
cc gai thn c nhng ht si nh, trn, cng. Cc kt th ny c cu to bi calcium
phosphate v mucopotine.
4.2. m Randall
Randall cho rng nu thp i thn bnh thng, nhn nhi th si kh kt hp. Ngc li, nu
v mt l do no , nh trong trng hp vim i b thn, thp i thn b bin th, thng
b i thn v vim, thp i thn b mn l th tinh th s b kt ta li thp i thn, to
thnh nhng m vi ha, v sau bong ra v rt xung i thn, to thnh si nh.
4.3. Hoi t ca thp i thn
Trong mt s trng hp nh i ng, nhim trng ng tit niu mn tnh hay trong
trng hp dng thuc gim au ko di, ngi ta thy c hoi t thp i thn, v ni y
chnh l nhn cho cc tinh th lng ng to thnh si.
III. DIN TIN CA SI NIU
Sau khi vin si c hnh thnh, nu si cn nh, thng vin si i theo ng nc tiu v
c tng ra ngoi. Nhng nu vin si b vng li mt v tr no trn ng tit niu, th
n s to ra, gy cn tr lu thng ca nc tiu, a n ng v dn phnh pha trn ch
tc. Lu ngy s a n cc bin chng:
- nc tiu.
- Nhim trng.
- Pht sinh thm cc vin si khc.
Cui cng s ph hy dn phn thn sn sinh ra n.
1. Nhng nguyn nhn lm cho vin si b vng li:
1.1. Hnh dng v kch thc ca vin si.
329
Mt vin si ln, sn si th d bm vo nim mc v b vng li.
1.2. Trn ng tit niu c nhng ch hp t nhin do cu trc gii phu
Vin si khng qua c cc ch hp , nhng ch hp l
- C i thn
- C b thn
- Nhng ch hp niu qun
+ Vng tht lng, c cc mch mu sinh dc (mch mu bung trng hoc tinh hon)
bt cho qua v ni niu qun thng b gp khc, nn vin si c th b vng li.
+ Vng chu hng, niu qun bt cho qua mt s ng mch nh ng mch chu,
ng mch bng quang t cung.
+ Vng st bng quang, niu qun bt cho qua ng dn tinh.
+ Phn niu qun trong ni thnh bng quang,
V vy, vin si niu qun hay b vng li cc on nh sau
- on tht lng 1/3 trn ca niu qun.
- on trong chu hng b.
- on ni thnh ca bng quang.
1.3. bng quang
C bng quang l ch hp ch yu. nam gii, c bng quang c tin lit tuyn bao bc nn
s kh qua hn ph n.
1.4. niu o
n gii niu o khng c ch hp v ngn hn nn si t b vng li hn. nam gii, niu
o c ba ch m rng ra v vin si hay lt vo . Nhng ni l
- Xoang tin lit tuyn.
- Hnh niu o.
- H thuyn gn l so.
2. nh hng ca vin si i vi ng tit niu
Nc tiu t i b thn xung bng quang nh cc nhu ng. Mun c nhu ng phi c
tun t nh sau
- S gin n ca c vng pha trc.
- S co bp ca c vng pha sau.
- S co bp ca cc c dc.
Hin tng ny phi xy ra tun t t trn xung di th nc tiu mi i c. Nhu ng
khi pht t i thn, lan xung b thn v n niu qun. Chp i thn v c b thn l cc
ni ch nhp ca cc sng nhu ng.
Khi vin si b vng li bn trong ng tit niu, n s nh hng n ng tit niu
qua 3 giai on
2.1. Giai on chng i
330
ng tit niu pha trn vin si s tng cng sc co bp tng si ra ngoi. Niu qun
v b thn pha trn vin si cha b gin n. C s tng p lc t ngt i b thn gy cn
au qun thn. Trn lm sng giai on ny bnh nhn thng biu hin bi nhng cn au
qun thn in hnh.
2.2. Giai on gin n
Thng thng sau khong 3 thng nu si khng di chuyn c th niu qun, b thn v i
thn pha trn vin si s b gin n, nhu ng ca niu qun b gim.
2.3. Giai on bin chng
Vin si nm lu s khng di chuyn c v b bm dnh vo nim mc, niu qun b x dy,
c th b hp li. Chc nng thn s b gim dn, thn nc, m nu c nhim trng, si
cn tn ti trong ng tit niu l mt yu t thun li cho vic nhim trng ti din, lu
ngy s gy vim thn b thn mn tnh v a n suy thn mn. Si niu qun hai bn c
th gy v niu do tc nghn.
IV. LM SNG
1. Si ng tit niu trn
Gm si thn, b thn, niu qun. Cc triu chng thng gp l:
- Cn au qun thn: xut hin t ngt, sau khi gng sc, khi pht vng h tht lng mt
bn, lan ra pha trc, xung di, cng au thng mnh, khng c t th gim au. C
th phn bit hai trng hp
+ Cn au ca thn do s tt nghn b thn v i thn: au h tht lng pha di xng
sn 12, lan v pha trc hng v rn v h chu.
+ Cn au ca niu qun: xut pht t h ca tht lng lan dc theo ng i ca niu qun,
xung di n h chu b phn sinh dc v mt trong i.
- Triu chng km theo hay gp l bun nn, nn ma, chng bng do lit rut. C th c
st, rt run nu c nhim trng kt hp.
- Khm thy im sn lng au, rung thn rt au. Cc im niu qun n au, c th thy
thn ln.
Ch rng khng c mi lin quan gia kch thc hay s lng si vi vic xut hin cng
nh cng au ca cn au qun thn. Mt s trng hp bnh nhn khng c triu chng
(si th yn lng), hoc ch c du khng r rng nh au m vng tht lng mt hoc hai
bn.
2. Si ng tit niu di
Gm si bng quang v si niu o.
- Si bng quang s kch thch nim mc bng quang gy tiu but, rt, tiu lu.
- Tiu tc gia dng.
- Khm n im bng quang au.
- Si niu o s gy b tiu, khm lm sng thng pht hin c cu bng quang, s nn
dc theo niu o c th thy si.
V. CN LM SNG
1. Xt nghim nc tiu
331
1.1. Tm t bo v vi trng: nc tiu c nhiu hng cu, bch cu. C th thy vi trng khi ly
tm soi v nhum Gram khi c bin chng nhim trng. Cn cy nc tiu trong trng hp
nghi ng c nhim trng.
1.2. Soi cn lng: c th thy tinh th Oxalat, Phosphat, Calci.
1.3. pH nc tiu: c nhim trng niu pH s tng trn 6,5 v vi trng s phn hy Urea thnh
Amoniac. Khi pH di 5,5 c nhiu kh nng c si Urat.
1.4. Albumin niu: nhim trng niu ch c t Albumin niu, nu c nhiu phi thm d bnh
l cu thn.
2. Siu m: pht hin si, nc ca thn v niu qun, dy mng ca ch m thn.
y l xt nghim thng c ch nh trc tin khi nghi ng c si h tit niu v n
gin, r tin, khng xm nhp v c th lp li nhiu ln khng c hi cho bnh nhn. Nhiu
trng hp si khng triu chng c pht hin tnh c khi khm siu m kim tra thng
quy hoc siu m bng v mt l do khc.
3. X quang bng khng chun b (ASP): xc nh v tr si cn quang, cho bit kch thc s
lng v hnh dng ca si. Rt c gi tr v hu ht si h tit niu Vit nam l si cn
quang.
4. Chp h tit niu qua ng tnh mch (UIV): cho bit
- Hnh dng thn, i b thn, niu qun.
- V tr ca si trong ng tit niu.
- Mc gin n ca i b thn, niu qun.
- Chc nng bi tit cht cn quang ca thn tng bn.
5. Chp X quang niu qun thn ngc dng
- Pht hin si khng cn quang.
- C gi tr trong trng hp thn cm trn phim UIV.
6. Chp X quang niu qun thn xui dng
7. Soi bng quang: thng t dng chn on si, nhng c th ni soi can thip ly si.
VII. IU TR
1. iu tr ni khoa
1.1. iu tr cn au qun thn do si
- Gim au: thng cc thuc khng vim khng Steroid c tc dng tt trong trng hp
ny, c th dng Voltarene ng 75mg tim tnh mch.
- Trong trng hp khng c hiu qu, cc tc gi phng Ty thng khuyn nn s dng
Morphin.
- Gin c trn: tim tnh mch cc thuc Buscopan, Drotaverin,...
- Gim lng nc ung vo.
- Khng sinh, nu c du hiu nhim trng, ch chn nhng loi khng sinh c tc dng
trn vi khun gram m. Cephalosporin th h 3, Quinolone v cc Aminozide thng c s
dng nhiu, cn thay i liu lng theo mc suy thn (nu c) v trnh dng Aminozide
khi suy thn (khng sinh c thn).
332
- Gii quyt nguyn nhn gy tc nghn niu qun (si, d dng ng niu gy nc). Mt
s trng hp si niu qun gy cn au qun thn khng p ng vi iu tr ni khoa th
cn ch nh can thip phu thut sm gii quyt tc nghn. Tu theo c a bnh nhn, s
lng, kch thc si v tnh trng chc nng thn tng bn quyt nh dn lu ti thiu b
thn qua da hay c th can thip ly si bng m cp cu.
Dng thuc ung lm tan si c c khng ? y l cu hi t lu c cc nh
nghin cu xem xt. Hin nay, ngi ta kt lun nh sau:
1.2. i vi hn si nh v trn lng
Nh s nhu ng ca niu qun hn si s di chuyn dn c tng ra ngoi. iu ny
din tin mt cch t nhin ch khng phi do thuc lm bo mn hn si nh mt s
ngi thng ngh. Tuy nhin thuc li tiu lm tng dng nc tiu, thuc chng vim
khng stoide lm cho nim mc niu qun khng b ph n lm cn tr s di chuyn ca si
nn c tc dng tt cho hn si chuyn ng d dng.
1.3. Ch c si acid uric l tan c di tc dng ca thuc
y l si khng cn quang thng gp cc nc phng ty. pH nc tiu thng rt acid
< 6 si s tan khi ta cho kim ha nc tiu, cch iu tr nh sau:
- Ch n: gim m, king ru, bia, thuc l.
- Cho bnh nhn ung nhiu nc trn 2 lt nc mi ngy
- Lm kim ha nc tiu bng cc loi thuc
+ Bicarbonate de Sodium 5 -10g/ ngy
+ Foncitril 4000: 1-4 vin /ngy.Loi ny c cha cc ha cht citratesodium,
citratepotassium, acid citrique, v trimthyl phloroglucinol.
Hungarie sn xut vi cc thuc nh Malurit v Magurlit tng t nh Foncitril.
Cch dng liu tn cng 3-4 vin/ngy cho n khi pH > 7 sau duy tr t 1-2 vin/ ngy v
duy tr pH nc tiu v n khi siu m thy hn si tan ht.
+ Allopurinol (zyloric)
L thuc c ch purine liu 100- 300mg mi ngy ty theo pH nc tiu dng cng vi
Foncitril cho n khi si tan ht trong trng hp si ln c khi phi dng thuc lin tc trong
nhiu tun c th gy tc dng ph nh bun nn, tiu chy, nga, ni mn da, suy chc
nng gan. Nn ung thuc sau khi n.
+ iu tr thuc phi hp
- Thuc li tiu loi thiazide s gip s ti hp thu calxi qua ng thn thng phi dng ko
di trong nhiu thng mi c kt qu nh Hypochlorothiazide (Esidrex) 1-2 vin/ngy.
- Vitamin B6 c tc dng tt trong vic chng to si oxalat (theo nghin cu Prien).
2. iu tr ni khoa sau phu thut m ly si
Vn ti pht si sau m l ht sc gay go, nhng yu t cho s ti pht si l
2.1. St si sau phu thut
L yu t duy tr nhim trng niu lm si pht trin
2.2. Tn ti ch hp trn ng tit niu.
2.3. Nhim trng niu khng iu tr dt im
333
iu cn thit l phi iu tr dt im nhim trng niu tt nht theo khng sinh thi
gian t 4-6 tun.
3. iu tr ngoi khoa
3.1. M ly si
3.2. Cc phng php khc
- Phu thut ni soi ly si.
- Tn si ngoi c th
- Ly si niu qun qua da.
4. iu tr d phng
Cho bnh nhn ung nhiu nc, trn 2,5lt / ngy ung ri u ra trong ngy.
V ch n: tu thuc vo bn cht ca si m c ch nh thch hp cho tng bnh
nhn.
4.1. i vi si Canxi
- Loi tr u tuyn cn gip.
- iu tr tt u tu xng.
- Cc bnh nhn c Canxi niu tng th c th cho dng li tiu Thiazide lm gim nng
Canxi niu di 2 mmol/l.
4.2. i vi si Oxalate
- Loi tr cc thc n giu Oxalate nh rau mung, Chocolate,...
- i vi si Oxalate c Canxi niu tng v Phospho mu gim th c th b sung Phospho:
0,5 -1 g ung.
4.3. Si Cystine
Ch n ngho cc acide amine c lu hunh.

334
BNH CU THN
Mc tiu
1. Nm c nh ngha, cc cch phn loi ca bnh cu thn
2. Chn on xc nh vim cu thn cp, vim cu thn th tin trin nhanh hay c tnh.
3. Chn on xc nh c vim cu thn mn nguyn pht, th pht.
4. Bit iu tr cc vim cu thn mn nguyn pht, th pht.
Ni dung
I. I CNG
1.nh ngha
Bnh cu thn l s thng tn chc nng hay thc th biu hin cu thn vi c im lm
sng l ph, Protine niu, tng huyt p, din tin mn tnh v thng a n suy thn mn.
Chn on bnh cu thn ch yu da vo sinh thit thn. Tin lng ca bnh tu thuc vo
nguyn nhn v tn thng m hc trn sinh thit.
2. Phn loi
C nhiu cch phn loi bnh cu thn, c th k n cc phn loi ca Hambuger 1980,
Brenner 1985 v ca Cohn 1991. Di y chng ti cp n cch phn loi n gin nht
c gii thiu bi hip hi cc gio s thn hc Php 2003, phn loi ny chia bnh cu thn
lm hai nhm chnh, tu thuc vo din tin cp hoc mn tnh ca bnh:
2.1. Cc bnh cu thn cp tnh
- Vim cu thn cp sau nhim lin cu.
- Vim cu thn th tin trin nhanh.
- Bnh cu thn do nhim c thai nghn.
- Bnh cu thn do Lupus.
2.2. Cc bnh cu thn mn tnh
- Bnh cu thn c tn thng ti thiu (thn h nhim m)
- Bnh cu thn x ho v on.
- Vim cu thn mng (trn mng hoc ngoi mng).
- Vim cu thn tng sinh mng.
- Bnh cu thn IgA (bnh Berger)
- Bnh cu thn i tho ng.
- Amylose thn.
- Hi chng Alport.
II.CC TH BNH CHNH THNG GP
1. Vim cu thn cp
Nguyn nhn do lin cu khun Bta tan mu nhm A, type 12 in hnh cho mt vim hng,
type 49 in hnh sau vim da m. Lm sng cu th thng thng xut hin sau 10-21 ngy
vim hng t ngt xut hin au vng tht lng hai bn, thiu niu, ph ch yu hai m mt,
335
mt c chn v thng c st km theo. Nc tiu t, di 500 ml/24 gi, mu nht do
nc tiu c nhiu hng cu, c mu sm khi tiu mu i th.
Tng huyt p c ti a ln ti thiu l thng gp mc va phi
Xt nghim c ASLO tng trn 400 n v Todd, Proteine niu t 0,2-3 g/24 gi, cn Addis
c hng cu t 100.000-500.000/1 pht, nhng bch cu di 20.000/ 1 pht (cn gi l tnh
trng phn ly hng - bch cu trong nc tiu). Thng thy tr hng cu, tr ht.
Tin trin thng tt: lnh bnh 75-95 % tr em v 50-70 % ngi ln.
2. Vim cu thn cp th tin trin nhanh hay c tnh
c im lm sng thng nng tin trin nhanh n suy thn thng khng hi phc. V
gii phu bnh l c s tng sinh rng ra ngai mao qun xm ln khang Bowman, bp cht
cc vi huyt qun. Bnh chim khong 1% bnh cu thn vim, c th gp bt c la tui
no, c th khi u sau mt vim hng hay vim da.
Phn loi theo cc type sau
-Type I: Lng ng IgG trn mng y + Khng th khng mng 20%
-Type II: c hiu vi s lng ng phc h min dch vi IgG v b th 40%
-Type III: Khng c lng ng min dch trn cu thn.
Du hiu lm sng ch yu l thiu niu ri nhanh chng a n v niu vi suy thn nng.
Ph kn o huyt p bnh thng hoc tng nh, trong mu i khi tng (globulin. Bnh t
vong trong vi tun n vi thng. Trong mt s trng hp him c th tr v bnh thng,
thng gp sau nhim lin cu,gii phu bnh l thy thng tn c trong v ngoi mao qun,
cc cu thn b ph hy hon ton trong vi ba ngy, trn min dch hunh quang lng ng
lan ta cht fibrin trn cc thng tn hnh lim, IgG lng ng trn mng y tng ng vi
khng th khng mng y.
3. Vim cu thn mn
Theo quan nim hin nay, vim cu thn mn sau nhim lin cu khun ch chim 10 %, cn
li l th pht sau mt bnh l khc v v cn.
3.1. Vim cu thn mn nguyn pht
l vim cu thn khng r nguyn nhn. Do thiu d kin v cn nguyn, phn loi da
trn gii phu bnh v lm sng.
3.1.1.Hi chng thn h do tn thng ti thiu
Hu qu ca mt Protein niu nhiu ch yu l Albumin, c th bt gp sau nhng thng tn
thn hon ton khc bit nhau. Thng gp l mt hi chng thn h n thun xut hin t
ngt, Protein niu nhiu, ph, gim Protit mu, tng Lipit, Cholesterol mu. Bnh xut hin
khng c mt nguyn nhn r rt, thng gp tr em, nam nhiu hn n, ngi ln th t
l hai gii nh nhau.
Thng tn ti thiu khi sinh thit thn, thy bnh thng trn knh hin vi quang hc, trn
knh hin vi in t thnh mao mch bin i xm nhp lan ta vo chn mng y ca cc t
bo hnh lim, c hin tng ho mng ca cc t bo c chn. Min dch hunh quang khng
pht hin bt k mt s lng ng no, khng c globuline min dch hay b th lng ng
trn mng y.
336
Tin trin ca bnh thng kh xc nh, tuy nhin ngi ta thy c 10% t thoi lui, 80% lui
bnh hon ton (Proteine niu di 0,10 g/24 gi, cc du hiu khc tr v bnh thng) nh
iu tr vi Corticoide sau vi tun hoc vi thng nhng c 40% trong s ti pht mt ln
trong 6 thng, 60% ti pht nhiu ln trong 1 nm, v c th ph thuc vo Corticoide, ngha
l dng thuc bnh ti pht tr li. Nu bnh khng vi Corticoide th tin lng xa s rt
d dn n suy thn.
3.1.2. Vim cu thn th mng (ngoi mng v trn mng)
Biu hin lm sng l hi chng thn h vi i mu vi th.
Thng tn gii phu bnh l bao gm cc chui ht gin on vi dng cht mng thng gc
vi thnh mao qun to nn hnh bn chi trn knh hin vi. Min dch hunh quang thy c
s lng ng ca cc IgG v b th C3. Bnh thng gp ngi ln hn tr em, tn thng
ny chim hn 50% hi chng thn h nguyn pht ngi ln ca M. Tin trin tng i
tt, bnh c th thoi lui sau vi thng, cc du hiu lm sng mt hon ton, trn sinh thit
mt cc cht lng ng, mt s khc tin trin n suy thn. Ngi ln tin lng xu hn
tr em, khong 66% bnh nhn sng st sau 10 nm khi bnh.
3.1.3. Vim cu thn tng sinh mng
L th t gp ca vim cu thn mn, lm sng bao gm protein niu, tiu mu vi th, i khi
c hi chng thn h in hnh km theo suy thn, tng huyt p, d a n suy thn mn
giai an cui.
Tn thng gii phu bnh l l tng sinh t bo m, t bo thng b ca nang Bowman (c
th c t bo ni b) to nn hnh lim, tng sinh km theo vi lng ng trong mng y to
nn hnh 2 b cn gi l tng sinh thnh. Trn min dch hynh quang pht hin c lng ng
cc b th C1 q, C4, C3, IgG i khi l IgM, c th thy khng huyt thanh C3 trong cu thn,
nng b th trong mu lun lun thp so vi cc th khc.
Tin lng xu, thng tin trin n suy thn mn, sng st sau 10 nm ch c khong 20-
50%.
3.1.4. Vim cu thn th lng ng IgA t chc m
Biu hin lm sng l cc t i mu i th ti din nhiu ln, proteine niu va phi,
khng km vi hi chng thn h, t khi dn n suy thn. Trn min dch hunh quang thy
lng ng IgA i khi c IgG ln vng m c th pht hin qua knh hin vi thng, mt s
cu thn thy thng tn on, chng cc quai mao mch dnh vo nang Bowman. Bnh sinh
cha c r, thng gp ngi tr. C th thy IgA trong huyt thanh tng nhng khng
hng nh. Khi bnh nhn c ghp thn th thn ghp cng c nhng biu hin ging nh
bnh thn c v vy ngi ta ngh c kh nng l nguyn nhn ngoi thn.
3.1.5. Vim cu thn th x cng v an
Chim 5-10% hi chng thn h tr em, v 15-20% trong hi chng thn h ngi ln,
nam hay gp hn n. Bnh nhn thng c biu hin tiu mu vi th, tng huyt p, suy thn
mn. Protein niu th ny lun lun cao v l Protein niu khng chn lc. Tn thng gii
phu bnh: trn knh hin vi quang hc thy c lng ng cht Hyalin v tn thng x ho
tng , tng on, trn knh hin vi min dch hunh quang thy c lng ng ca IgM v ca
C3 tng on.
Tin lng thng xu, a n suy thn tin trin trong 25% trng hp tr em v trong
70% trng hp ngi ln. Thng a n suy thn mn giai on cui trong vng 5 n
20 nm
3.2. Vim cu thn th pht mt bnh ton th
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3.2.1. Vim cu thn cp bnh nhn Lupus ban
Vim cu thn chim khong 70% trong lupus ban , thng gp ph n tr vi c im
hng ban da, d cm, vi ban hnh cnh bm mt, gy st, st, au khp..., xt nghim
thy c t bo Hargraves, nht l khng th khng nhn trong mu. Lm sng gm c hi
chng thn h khng c tng huyt p, thng tn khng c hiu vi s lng ng lm dy
mng y to nn vng st, th hematoxylie trong vng m. Tin lng c th suy thn v
thng khng c tng huyt p.
3.2.2. Hi chng Good Pasture hay vim cu thn th on hoi t vi vim ph nang xut
huyt
Thng gp nam nhiu hn n, khi u bng ho ra mu, hnh nh phi m hai bn khng
r rt, sau gy thng tn thn, sau vi thng gy suy thn, tng huyt p dn n t
vong. Cc ph nang vim xut huyt cha y cc i thc bo sc t st, thn hai t dng
fibrin ri dng trong ha. Ngi ta chng minh nhng thng tn ny phi hp vi t
khng th hat ng ng thi chng c ph nang v mng y cu thn.
3.2.3. Vim cu thn do ban dng thp hay ban Schonlein-Henoch
Thng tn thn chim 35% trong bnh ny. Lm sng thng c i mu, cu thn thng
tn on, Min dch hunh quang thy lng ng IgA vng m v thnh. Bnh gy thng
tn hu ht cc cu thn, tin lng xu, tin trin dn sang suy thn.
3.2.4. Bnh Amylose thn
Thng gp trong bnh Amylose ph tng, th pht sau cc bnh nhim trng hoc vim
nhim ko di nh vim xng, lao, vim khp dng thp, phong, lit hai chi di. Bnh c
th nguyn pht. Ti Vit nam cha ghi nhn trng hp no, nhng vng a trung hi c
th gp cc la tui nhiu nht t 50-60 tui.
Lm sng biu hin l hi chng thn h, c th ch c proteine niu n thun km gan lch
to, c th i mu vi th, tng huyt p t gp, dn n suy thn. V tiu ha biu hin bng i
chy, to bn, xut huyt, li to, gan to nhng chc nng gan bnh thng.
Gii phu bnh thy lng ng cc cht dng bt (amyloide) bt mu sang mu tm ng
nh vi cu trc si c hiu trn knh hin vi in t, cht ny bn cht l Protein, c tm
thy ngoi t bo, trong gian cht v thnh.
3.2.5. Bnh cu thn do i tho ng
L tn thng cu thn do i tho ng gy ra, c hin tng x cng cu thn lan ta,
biu hin ban u l dy khng u mng y mao qun cu thn vi lng ng ni b. Lm
sng giai an u l c proteine niu, c hay khng km theo hi chng thn h, i mu vi
th c xu hng chuyn sang suy thn c tng huyt p. Giai on hi chng Kimmelstien-
Wilson thng tn thnh nt gia mao qun thnh khi trn km cc thng tn cc ng
mch thn.
Theo Mogensen chia bnh l cu thn do i tho ng ra lm 5 giai on
- Giai on 1: Giai on tng chc nng v ph i, xy ra ngay khi i tho ng c chn
on, trc khi iu tr Insulin. Kch thc thn gia tng, cc cu thn ph i nhng cu trc
ca chng th bnh thng. Mc lc cu thn tng, lu lng mu qua thn tng.
- Giai on 2: C th tn ti dai dng trong nhiu nm v ko di sut i. Mc lc cu thn
c th tng. Albumine niu m tnh nhng c th dng tnh khi b stress. B dy ca mng
y cu thn tng, cht nn gian mch tng nhiu hn v nhng tn thng ny khng hi
phc.
338
- Giai on 3: l giai on bnh thn i tho ng khi u, ch xy ra 40% bnh nhn
i tho ng, ko di t 10 n 20 nm, biu hin quan trng nht trong giai on ny l s
xut hin ca Microalbumine niu (vi m niu, Protein niu vi th).
- Giai on 4: giai on bnh thn i tho ng xc lp vi protein niu thng xuyn
trn 0,5g/24gi, thng c tng huyt p, hi chng thn h. Mc lc cu thn gim trung
bnh 1ml/thng. Tn thng cu thn: x ho cu thn lan to, gm dy mng y v tng
cht nn gian mch. Trong 10-20% trng hp tn ti nhng nt bt mu bi cht PAS tch t
gian mch xung quanh cc cu thn (gi l x ho cu thn dng nt ca Kimmelstiel v
Wilson).
- Giai on 5: L giai on bnh nhn b suy thn mn giai on cui.
III. IU TR BNH CU THN
1. iu tr vim cu thn cp sau nhim lin cu
1.1. Tit thc, ngh ngi
- Bnh nhn thiu v v niu c tng ur, creatinine mu: nc vo 500-600ml, mui 2g/24h,
protein 20g/ngy.
- Bnh thiu v v niu c ph tng huyt p, ur, creatinine mu khng tng: mui 0,5 -
1g/24h, protein 40g/ngy.
- Ngh ngi tuyt i t 3 tun n 1 thng. Sau tr li hot ng t t ngay khi cn
protein niu v i mu vi th t 6 tun n 2 thng.
1.2. Khng sinh: Ch cho khi cn du hiu nhim lin cu
Pnicilline 1 triu v/ngi ln, 1/2 triu n v / tr em. Nu d ng Penicilline th dng
Erythromycine 0,2 x 5 vin/ngy ngi ln hoc Tetracyline. Khng sinh dng trong 10-12
ngy.
1.3. iu tr bin chng
- Tng huyt p: King mn, ngh ngi, thuc nh Aldomet (0,25g x 2-4 vin/ngy)
- Ph phi: Lasix liu cao, Uabain tnh mch, th oxy, Morphin khi cn thit.
- Ph no: Truyn glucose u trng, Manitol.
- Th v niu: Furosemid (Lasix) liu cao.
Tt nht cho c ph phi, no, v niu l lc ngoi thn.
1.4. Cc triu chng khc
- Tng ur mu, creatinine mu, hn ch lng protid a vo nhng phi m bo
nng lng 1200-1600 calo chng d ha, c th cho Durabulin hoc Testosterone 25-
50mg/ngy.
- iu tr tng K mu bng glucose 20-30%, 300-500ml + 10-20v insulin truyn tnh
mch trong 1 gi n 1g30 pht hay truyn dung dch kim.
Tin trin thng tt: lnh bnh 75-95 % tr em v 50-70 % ngi ln.
2. iu tr vim cu thn cp th tin trin nhanh hay c tnh
Lm sng thng nng, tin trin nhanh n suy thn khng hi phc.
-Type I: Prednisolone, vin 5 mg, 2-3 mg/Kg/ 24 gi,
339
phi hp vi Cyclophosphamid (Endoxan) vin 50 mg, 1-3 mg/kg/24 gi hoc Chlorambucil
(Chloraminophene) vin nhng 2 mg, liu 0,15- 0,2 mg/Kg/24 gi. Thi gian iu tr thuc
chng min dch t 2-4 thng.
Phi hp vi lc plasma 2-4 lit.
-Type II: Methyprednisolone 30 mg/Kg/ 24 gi tim tnh mch x 3 ln trong 2 ngy
Sau duy tr Prednisolone 1-3 mg/Kg/ ngy trong nhiu thng.
-Type III: iu tr nh type II + phi hp thm vi Heparin, cyclophosphamide (Endoxan).
Ngoi ra cn phi hp vi Heparin 5000-10.000 v trong 4-8 tun.
3. iu tr vim cu thn mn nguyn pht
3.1. Hi chng thn h
iu tr bao gm: Presnisolone 1 mg/Kg/24 gi ngi ln
1,5-2 mg/Kg/24 gi tr em
Nu p ng tt th gim liu theo bc thang c 5 ngy gim 10 mg ri duy tr gin an mi
20 - 30 mg/ 2 ngy, ung mt ln ngi ln 10 mg/ 2 ngy.
Khi c hin tng khng hay ph thuc corticoide th dng thm cyclophosphamide 2-3
mg/Kg/ 24 gi, hoc chlorambucil 0,2-0,3 mg/Kg/ 24 gi t nht trong 2 thng, phi theo di
cc bin chng v mu v cc tai bin khc.
3.2. Vim cu thn th mng (ngoi mng v trn mng)
Theo trng phi Anh, M ch nh Presnisolone liu cao 1,5-2 mg/Kg/48 gi ung mt ln
vo cc bui sng trong 8 tun thy c hiu qa tt, ngi ta c th cho thm 4 tun na hoc
phi hp vi methylpresnisolone 1g trong 3 ngy lin tc, sau 0,5mg
presnisolone/kg/ngy/thng ri 0,2 mg/Kg/ ngy chlorambucil tng cng trong 6 thng. iu
tr ny tt hn l iu tr n thun vi steroide. Khi ti pht th dng nh c, thuc gim
min dch c tc dng sau vi ngy.
3.3. iu tr vim cu thn tng sinh mng
Tin lng xu, tin trin n suy thn, sng sau 10 nm ch c 20-50%.
iu tr phi hp corticoide v thuc gim min dch vi thuc chng ng hay chng ngng
tp tiu cu.
3.4. iu tr vim cu thn th lng ng IgA t chc m
nhng bnh nhn c tn thng m hc va phi, c Protein niu trn 3g/24 gi th iu tr
Corticoides trong vng 4 dn 6 thng. Khi Protein niu khng ci thin th c th iu tr c
ch min dch nh trong hi chng thn h.
cc nc phng Ty, ngi ta dng Acide bo Omga 3 (du c) trong trng hp bnh
tin trin, hn ch s sn xut v hot tnh ca Cytokines do s lng ng ca IgA cu
thn gy ra.
Trong trng hp c tng huyt p th c ch men chuyn c u tin s dng gim
Protin niu v lm chm s tin trin ca suy thn.
Mt s thuc khc c mt s tc gi s dng trong bnh cu thn do lng ng IgA l cc
thuc chng kt tp tiu cu, Urokinase, hoc cc Globuline min dch dng liu cao qua
ng tnh mch vn cha c kt lun c hiu qu chc chn trong bnh ny.
3.5. Vim cu thn th x cng v an
340
Tin lng sng trn 15 nm chim 50%.
iu tr corticoide nh presnisolone liu thp 1/3 - 1/2 mg/kg/24 gi trong 1-2 thng, hoc
dng nh trong th mng.
Khi c ti pht c th iu tr vi cc thuc gim min dch.
4. Vim cu thn th pht mt bnh ton th
4.1. Vim cu thn cp bnh nhn Lupus ban
iu tr: Presnisolone liu cao 2-3 mg/kg/24 gi,
Thuc gim min dch Chlorambucil 0,2-0,3 mg/Kg/24 gi trong 4-8 tun c hiu qa r rt.
4.2. Hi chng Good Pasture hay vim cu thn th on hoi t vi vim ph nang xut
huyt:
iu tr cng bng corticoide 2-3 mg/Kg/24 gi trong 4-6 tun nhng p ng lm sng km.
4.3. Vim cu thn do ban dng thp hay ban Schonlein-Henoch
Bnh gy thng tn hu ht cc cu thn, tin lng xu, tin trin dn sang suy
thn. iu tr bng corticoide v gim min dch.
4.4. Hi chng Kimmelstiel-wilson
iu tr i tho ng: rt kh khn, v tnh nhy cm vi Insulin khng n nh. iu tr
bnh thn ch l iu tr triu chng, khng dng Corticoide. Khi c suy thn mn giai
on cui do i tho ng th iu tr thay th thn suy c mt s kh khn, nht l rt hay
gp cc bin chng tc mch v nhim trng trong qu trnh lc mu.
Ghp i thn - ty c ch nh trong trng hp ny, tuy kt qu rt kh quan v c hai
phng din i tho ng v suy thn nhng thc t t c thc hin v kh khn v k
thut v ngi cho.

341
BNH THN V THAI NGHN
Mc tiu
1. Bit c nhng thay i ca h thng thn - tit niu trong thai k bnh thng.
2. Nm c c bn mt s bnh l thn-tit niu thng hay xy ra trong qu trnh mang
thai.
3. Bit c cch iu tr thng thng ca cc bnh l thn tit niu xy ra trong thai k:
tin sn git, nhim trng ng tiu, suy thn cp.
4. Nm c thi x tr v tin lng trc mt thai nghn xy ra trn mt bnh nhn
ang b bnh thn mn tnh.
I. NHNG THAY I CA H THNG THN-TIT NIU TRONG THAI K
BNH THNG
1. Thay i v gii phu h thn-tit niu trong thai k
- Kch thc thn tng ln trong thai k: trn siu m v X quang pht hin chiu di ca thn
tng ln khong 1 cm so vi trc lc c thai. Kch thc ca thn v bnh thng sau khi
sinh.
- Gin i b thn v niu qun: thng c pht hin bng siu m v chp b thn, iu ny
chng t mt tnh trng nc do tc nghn ng bi niu. S nc ny thng nh, c
gi l gin i b thn - niu qun sinh l trong thai k.
Ngi ta thy rng trong thai k c mt s gim trng lc c trn ca h thng ng dn
nc tiu (c th do vai tr ca cc Hormone gin mch nh cc Prostaglandines, Estrognes
v Prolactine) cng thm vi s chn p c hc 2 niu qun do t cung ln l nguyn nhn
ca tnh trng nc ny. S ng nc tiu ny l mt iu kin thun li cho nhim
trng ngc dng, m mc ca n c th t mt nhim khun niu khng triu chng cho
n mt vim i b thn nng n. Mt s t trng hp kh him, s ng nc tiu ny c
th gy cn au qun thn.
Nhng thay i v hnh thi ca thn c th tn ti cho n 12 tun sau khi sinh. Do vy cc
thm d v hnh thi ca h tit niu thng thng (khng phi trng hp cp cu) th c
khuyn nn lm sau sinh t nht 12 tun.
2. Chc nng thn
Nhng thay i v chc nng thn cng c th xy ra trong thai k. So vi khi khng c thai,
lu lng lc cu thn v lu lng mu qua thn trong khi c thai tng ln kh sm, ngay t
nhng thng u tin ca thai k, v c th t n mc t 30 n 50% trn gi tr bnh
thng vo cui thng th 3.
Chnh tnh trng tng lu lng lc cu thn ny s lm tng thi cc cht cn b v dn n
lm gim nng Creatinine mu khong t 35 n 44% so vi gi tr bnh thng.
Nh vy, nhng ch s v sinh ho thng c xem l bnh thng ngi ph n khng c
thai th vn c th phn nh mt s suy gim chc nng thn trong thai k.
ph n c thai, mt nng Creatinine mu trn 80 mol/l (0,8 mg/dl) v nng Ur
mu trn 5 mmol/l (13mg/dl) l c th biu hin mt suy gim chc nng thn trong thai k
(theo Marshall D. Lindheimer v Adrian I. Katz).
+ Proteine niu
342
Do tng lu lng mu n thn trong qu trnh mang thai, cho nn s lm tng lng
Proteine niu thi ra. Cng mt mc tn thng thn nh nhau th trong thai k, lng
Proteine niu thi ra s tng ln gp i.
+ Chc nng ng thn
thanh thi ton phn v thanh thi tng phn i vi Urat tng ln, lm cho gi tr bnh
thng ca Urat mu gim xung. Do vy, mt nng Urat mu tng trn 5mg/dl hoc trn
298 mol/l s c nghi ng bnh l.
Mu c xu hng kim ho nh, pH = 7,42 - 7,44.
3. Thay i v th dch
Ph l triu chng rt thng gp trong thai k.
Lng nc ton b trong c th tng ln, trong mt thai k bnh thng ngi m thng
tng cn ton b khong 12,5 kg. Lng nc ton b tng khong t 6 n 9 lt, trong t
4 n 7 lt l do tng th tch khong k v huyt tng.
S iu ho thm thu ca thn thay i kh sm trong thai k, ngng thm thu ca thn
i vi s kht v i vi s tit Vasopressin u gim khong 10 mOsmol/l mi loi. Kt
qu l nng Natri mu b gim, tr s bnh thng ca Natri mu trong thai k khong 130
mmol/l. Nng trn 140 mmol/l c xem l tng Natri mu.
Tc ging ho ca Vasopressin tng gp 4 ln bnh thng do bnh nhau tit ra men
Vasopressinase, nht l trong giai on sau ca thai k.
C 2 hnh thi kt hp bnh thn v thai nghn
- Bnh thn-tit niu xy ra trn mt thai ph m trc khi mang thai cha c.
- Thai nghn bnh nhn b mt bnh l thn mn tnh.
II. CC BNH THN - TIT NIU THNG XY RA TRONG THAI K
1. Nhim c thai nghn - Tin sn git
Thng xy ra sn ph trn 35 tui v mang thai con so v vo 3 thng cui ca thai k.
Triu chng lm sng bao gm: tng huyt p, Proteine niu v ph.
Bnh sinh ca nhim c thai nghn vn cha c bit r rng, nhng hu ht cc tc gi
u nht tr rng c nhiu yu t phi hp
- Yu t di truyn: t l tin sn git xy ra nhiu hn nhng ngi cng huyt thng khi so
snh vi nhng ngi khng cng huyt thng.
- Yu t min dch: thai nghn c xem nh l 1 qu trnh dung np min dch, trong thai
nhi c cu thnh bi 50% cc t bo l t ngi b.
- Yu t th dch: nng Aldosterone v Renine huyt tng ca thai ph bnh l thp hn
thai ph bnh thng, tng nhy cm khi truyn Angiotensine tnh mch.
- Yu t mch mu: gim ti mu bnh nhau, gim trn 50% ng knh ca cc ng mch
xon nhng sn ph b tin sn git.
Tn thng m hc ca thn: ch yu xy ra cu thn, biu hin mt tnh trng Vim ni
mc mao mch cu thn. Cc cu thn ln ra v ph n, vi s xm ln ca cc t bo mng
mao mch v cc t bo ni m. Lng ng cht Hyalin dng si di ni mc. Tuy nhin,
nhum min dch hunh quang khng thy lng ng phc hp min dch. Tn thng m
hc thn ny bin mt sau khi sinh vi tun n 1 thng.
343
2. Nhim trng ng tiu trong thai k
Ph n mang thai thng b nhim trng niu khng triu chng, mt s trng hp c th
biu hin bi mt tnh trng vim bng quang hoc nng hn na l vim i b thn. Vim
bng quang nh thng b b st v nhng triu chng kch thch bng quang cng c thy
khi t cung ln gy kch thch bng quang. Vim i b thn thng c chn on nh cc
triu chng st cao, hi chng nhim trng r, au tht lng, tiu c,... triu chng thn ln
thng kh pht hin trn lm sng v s hin din ca t cung ln.
Cc sn ph nn c xt nghim nc tiu trong qu trnh mang thai trnh b st mt
nhim trng niu khng triu chng, tt nht l cy nc tiu.
3. Suy thn cp trong thai k
Trong giai on u ca thai k, suy thn cp thng lin quan n tnh trng nghn gy nn
ma nhiu.
giai on sau c rt nhiu nguyn nhn a n suy thn cp nh:
- Bnh l tan huyt vi mch + gim tiu cu.
- Suy thn cp phi hp vi gan nhim m cp trong thai k: Hi chng HELLP (Hemolysis
Elevated Liver enzymes Low Platelets) biu hin bi gim tiu cu, tan huyt vi mch mu,
tng men LDH v Transaminase.
- Hoi t ng thn cp hoc nng hn l hoi t v thn.
- Suy thn cp sau sinh: thng xy ra ngay sau sinh cho n 3 n 6 tun sau .
in hnh v hay gp nht ca suy thn cp trong thai k l hoi t ng thn cp do thiu mu
thn hoc do nhim c, thng l bin chng cu mt bong bnh nhau, t mu ln sau bnh
nhau, thai cht lu hoc tc mch do nc i. Khi s tn thng ca cc t bo ng thn
khng hi phc c th s a n hoi t v thn, c c trng bi 1 tnh trng x ho v
thn lan to khng phc hi, y l mt bnh cnh rt nng n trong thai k.
III. THAI NGHN XY RA TRN BNH THN MN TNH
Mc d cc bnh nhn b bnh thn mn tnh (bnh cu thn, suy thn mn, ghp thn,...)
thng c khuyn khng nn c thai do nhng hu qu khng tt ca tnh trng mang thai
i vi sc kho ngi m v do nh hng ca cc loi thuc ang dng ln thai nhi, nhng
trong thc t, thai nghn vn c th xy ra trn nhng bnh nhn ny.
Theo di 3425 thai k xy ra trn 2310 bnh nhn b bnh thn mn tnh t nm 1973 n
nm 1995, cc tc gi Davison JM v Lindheimer MD nhn thy cc tai bin sn khoa s tng
ln theo mc suy thn theo bng sau
Bng 1: T l tai bin sn khoa, di chng ca thai k theo nng Creatinin mu

Mc suy thn
Creatinine mu
< 1,5 mg/dl
Creatinine mu
1,5 - 3 mg/dl
Creatinine mu
>3 mg/dl
Tai bin sn khoa 26% 47% 86%
Sinh thnh cng 96% 89% 46%
Di chng < 3% 25% 53%
344
Mc suy thn vo thi im mang thai v tng huyt p l 2 yu t tin lng chnh cho
thai k. V vy, vic theo di v iu tr tch cc tng huyt p nu c l mt vic rt quan
trng trong sut qu trnh thai nghn.
i vi tng bnh l thn c th, thai nghn c nh hng nh sau
1. Bnh thn do i tho ng
Thai nghn khng lm tng tnh trng suy thn, nhng c kh nng nhim trng niu kh cao,
tng Proteine niu v tng huyt p nht l vo nhng thng cui.
2. Bnh l cu thn mn tnh
Thai nghn lm tng huyt p, nhng dung np tt nu trc khi mang thai ngi bnh khng
c tng huyt p v khng c ri lon chc nng thn.
Nhiu tc gi cho rng cc loi bnh cu thn x ho on, bnh cu thn IgA v bnh cu
thn tng sinh mng s trm trng hn khi mang thai.
3. Bnh l thn do tro ngc v vim thn thn b thn mn tnh
Nhng bnh nhn ny thch nghi tt vi vic mang thai nu khng c suy thn, tuy nhin cn
cy nc tiu nh k (mi 2 dn 3 tun), iu tr khng sinh nu cn.
4. Bnh thn a nang
Dung np rt tt nu khng c suy thn. Trong thai k cc nang gan c th tng kch thc,
tng t l b tng huyt p v tin sn git.
5. Si thn
Dung np tt, ngoi tr vic lm tng t l nhim trng ng tiu. Si c th di chuyn do
gin ng niu.
6. Thai nghn bnh nhn chy thn nhn to chu k
Vi nhm bnh nhn ny, mc d c theo di st th tai bin sn khoa vn rt cao, vi nguy c
t vong cho m v thai, phn ln l sy thai v sinh non, nu tr sinh ra c th cng c nguy c
cao v pht trin tinh thn (Susan H Hou). Do vy, vn tip tc gi thai hay khng trn nhm
bnh nhn ny thng xuyn c t ra.
7. Thai nghn nhng bnh nhn ghp thn
i vi nhng ph n b suy thn mn giai on cui th vic ghp thn l phng php tt
nht em li cho h hy vng sinh con. Tuy vy, do nhng bnh nhn ny thng xuyn phi
dng cc thuc c ch min dch v Corticoides nn vic mang thai phi c theo di k
cng bi cc nh Thn hc.
IV. IU TR
1. iu tr cc bnh thn - tit niu thng xy ra trong thai k
1.1. iu tr nhim c thai nghn - Tin sn git
- Nhp vin, theo di theo chuyn khoa sn ph.
- H huyt p: L vn quan trng nht ca iu tr tin sn git. Thng dng loi gin
mch hoc Alpha methyldopa, trnh dng thuc li tiu v cc thuc c ch men chuyn.
- Magne Sulphate: l loi thuc c in trong sn git, c tc dng lm gim tn sut cc cn
co git v d phng c cc cn co git trong sn git.
345
Cch dng: Liu ti ban u l 4g n 6g truyn tnh mch trong vng khong 15 pht, sau
truyn tnh mch 2g mi gi duy tr nng Magne mu trong khong 4 n 6 mmol/l.
Nhng trng hp nh hn, cha c biu hin sn git, c th dng ng tim bp.
- Chm dt thai k: l bin php cui cng.
D phng: Khm thai nh k, theo di k huyt p, Protein niu. i vi nhng bnh nhn
c nguy c cao th phi thm khm t nht 2 tun 1 ln, sau nu tnh trng nhim c thai
nghn vn cn th phi nhp vin theo di trong nhng thng sau ca thai k.
1.2. iu tr nhim trng ng tiu trong thai k
- iu tr bnh nhn c vi khun niu nhng lm sng khng c triu chng: dng mt t
khng sinh trong vng 7 n 10 ngy.
Bng 2. Cc khng sinh thng c s dng iu tr nhim khun niu khng triu
chng v vim bng quang trong thai k.
Khng sinh Liu lng
Ampicilline 500 mg x 4 ln / ngy
Amoxicilline 250 mg x 3 ln / ngy
Nitrofurantoin 50 mg x 4 ln / ngy
Cephalexine 250 mg x 2 ln / ngy
Amoxicilline/A. Clavulanic 250/62,5 mg x 3 ln / ngy
iu tr vim thn b thn cp
- Nhp vin.
- Dng ngay khng sinh ng tim tnh mch.
- Thng khi u bng Ampicilline hoc Cephalosporine th h 3 (Ceftriaxone,
Cefotaxime,...).
- Khi tnh trng lm sng ci thin, sau 1 n 2 tun c th chuyn sang ng ung v phi
iu tr tip tc khng sinh t nht 2 dn 3 tun na.
- Theo di v sau bng cch cy nc tiu mi 2 n 3 tun d phng ti pht.
1.3. iu tr suy thn cp trong thai k
- iu tr suy thn cp trong thai k v nguyn tc khng khc g vi iu tr suy thn cp
ngoi thai k, bao gm:
- Duy tr tt huyt ng m bo ti mu thn y .
- Thuc li tiu: ch thn trng trong nhng trng hp huyt p h.
- iu chnh ri lon in gii v cn bng toan kim.
- Lc mu ngoi thn khi cn thit: thng dng thn nhn to v thm phn phc mc khng
dng c khi c thai.
- Kt hp Ni - Sn khoa gii quyt nguyn nhn (thai cht lu, bong bnh nhau,...).
2. Thi x tr trc mt thai nghn xy ra trn bnh thn mn tnh
D phng: khuyn bnh nhn khng nn mang thai i vi nhng bnh nhn b bnh thn
mn tnh, c bit l nhng bnh nhn c suy thn mn.
346
Dng cc phng php nga thai thng thng.
Thi iu tr trc 1 thai nghn xy ra trn 1 bnh nhn b bnh thn mn tnh
- Theo di v iu tr tch cc tng huyt p, v tng huyt p v mc suy thn ti thi
im mang thai l hai yu t tin lng chnh cho thai k:
- i vi bnh nhn cha c suy thn mn: thai k c th xy ra hon ton bnh thng, tuy
nhin bnh nhn cn c theo di k trong mi trng Sn - Ni khoa, cn ch rng cc
thuc ang c dng di ngy iu tr bnh thn nh Corticoides, c ch min dch, thuc
iu tr i tho ng, mt s thuc iu tr tng huyt p c th nh hng n thai.
- nhng bnh nhn c suy thn mn th tu thuc vo mc suy thn, nhng nhng
bnh nhn ny thng khng th gi c thai, nht l khi suy thn mn nng. nhng
bnh nhn ang c iu tr thn nhn to chu k th nguy c rt cao, cho nn khng nn gi
thai.
- i vi nhng bnh nhn ghp thn
i vi nhng ph n b suy thn mn giai on cui th vic ghp thn l phng php tt
nht em li cho h hy vng sinh con. Tuy vy, do nhng bnh nhn ny thng xuyn phi
dng cc thuc c ch min dch v Corticoides nn vic mang thai phi c theo di k
cng bi cc nh Thn hc.
Cc tiu chun trc khi mang thai nhng bnh nhn ghp thn:
- Thi gian sau ghp: 1,5 nm i vi ghp thn ngi sng, 2 nm i vi ghp thn ngi
cht.
- Khng c t thi ghp no trong vng t nht 6 thng.
- Liu Prednisone < 15 mg/ ngy.
- Liu Azathioprine < 2 mg/kg.
- Liu Cyclosporine 2 - 4 mg/kg.
- Nng Creatinine mu < 2 mg/dl.
- Huyt p < 140 / 90 mmHg (c th ang dng thuc h huyt p).
- Nng HbA1C bnh thng.
- Cy nc tiu m tnh.
Tm li, cc bnh nhn b bnh thn c th mang thai v sinh con bnh thng nu cha c
suy thn v phi c kim sot huyt p k. i vi nhng ngi b suy thn th nguy c
ca thai k cng ln nu suy thn cng nng. i vi cc bnh nhn suy thn mn giai on
cui, ch nn mang thai sau khi ghp thn v phi c t di s theo di st ca cc nh
thn hc v sn khoa.



347
VIM THN B THN
Mc tiu
1. Trnh by c nh ngha, c im ca vim thn b thn.
2. Xc nh c nguyn nhn, cc yu t thun li ca vim thn b thn.
3. Nu c cc triu chng lm sng, cn lm sng ca vim thn b thn cp v mn.
4. Chn on c vim thn b thn cp,vim thn b thn mn.
5. La chn c cc bin php iu tr, d phng vim thn b thn ngi ln.
Ni dung
I. I CNG
1. nh ngha
Vim thn b thn l bnh vim t chc k ca thn, nguyn nhn do vi trng. Bnh c th
nh hng n c hai thn cng mt lc nhng cng c th ch ti mt thn, v ngay mt
thn c th khu tr mt phn thn hoc lan ta ton b thn. Bnh c th cp tnh hoc mn
tnh.
2. c im ca vim thn b thn
2.1. V nguyn nhn
Vi trng gy tn thng trc tip, ngoi ra cn c yu t thun li l nc tiu.
2.2. V gii phu bnh
Kt hp tn thng b thn, i thn v nhu m thn m tn thng nhu m l chnh.
2.3. V din bin
Vim thn b thn hay ti pht, m , nu iu tr khng dt im th vim thn b thn cp d
tr thnh mn tnh.
II. DCH T HC
Vim thn b thn l bnh l thng gp cu h thng thn tit niu. Vim thn b thn
chim 15-40% cc bnh thn v 80% l n gii, tr em ngi gi u c th b bnh. Ring
vim thn b thn cp chim khong 0,2-0,4% cc bnh trong khoa Ni chung Bnh vin
Trung ng Hu. Vim thn b thn cp thng thy xy ra la tui 20-50 tui, n nhiu
hn nam v c n 92% bnh nhn c mt hoc nhiu yu t thun li. Vim thn b thn
mn xy ra nhiu la tui 40-70 tui. Theo tc gi Nguyn Vn Xang, Vim thn b thn
mn chim 30% cc bnh thn mn tnh.
III. BNH NGUYN
1.Vi trng
Cc tc nhn gy bnh vim thn b thn ngy nay c xc nh khng ch gii hn nhm
vi khun m cn c c nm, k sinh trng, virus.
Cc tc nhn gy bnh sau c th c pht hin khi phn lp
- Escherichia Coli, Proteus Mirabilis, Enterobacter, Klebsiella, T cu vng, Pseudomonas,
Serratia, trc khun lao, Chlamidia Trachomatis, Ureaplasma Urealyticum, lu cu.
- Candida Albicans, Candida Tropicalis, Adenovirus, Cytomegalo virus (CMV).
348
ng vo ca nhim trng
+ ng ngc dng chim i a s trng hp (97%), vi khun s xm nhp t
di ln qua ng niu o. S xm nhp ca cc tc nhn gy bnh c lm d bi tro
ngc bng quang-niu qun.
+ ng mu: cha n 3% trng hp, vi khun n nh v ti thn th pht sau
nhim trng huyt.
2. Yu t thun li
2.1. Tr em: D dng bm sinh niu qun, gin b thn.
2.2. Ngi gi: U x hoc ung th tin lit tuyn.
2.3. Ph n c thai: T cung ln vo niu qun nhng thng cui gy nc b thn -
niu qun, gim nhu ng niu qun do progesterone tng.
2.4. Ngi ln: Si thn tit niu, hp niu o, tro ngc bng quang-niu qun, i tho
ng.
2.5. Cc th thut: thng tiu, soi bng quang, cc nguyn nhn trn s lm nc tiu, lm
d nhim trng v duy tr nhim trng.

VIM THN B THN CP
I. GII PHU BNH
- Thn hi ln v xung huyt, ph n t chc k ca thn.
- Xm nhp bch cu a nhn, t bo lympho t chc k.
- Cu thn, ng thn, mch thn khng hoc rt t tn thng.
- Tn thng thng khi hn hoc cng c th li so x v cc cu thn vng ny b
mt chc nng.
- Th nng c th p-xe ha gy m thn.
II. TRIU CHNG HC
1.Lm sng
1.1. Hi chng nhim trng
- Xut hin rm r, st cao rt run, st dao ng.
- Tng trng suy sp nhanh, mi kh li bn.
- Mch nhanh, huyt p bnh thng.
1.2. au
- au vng h sn lng, mt hoc c hai bn.
- Thng au m vi nhng cn au tri ln d di, c khi lan xung bng quang, i (cn
au qun thn).
- Khm c th thy thn ln, n au tc, c du chm thn.
1.3. Hi chng kch thch bng quang
- Thng gp tiu but, tiu dt, tiu kh.
349
- au vng h v, n im bng quang au.
1.4. Hi chng nc tiu: nc tiu c, tiu ra m hoc i khi c th tiu ra mu.
2. Cn lm sng:
2.1. Xt nghim mu
- Bch cu tng, a nhn trung tnh tng, lng mu tng.
- C th c nhim trng mu, cy mu dng tnh.
- Ur, creatinin mu bnh thng, nu tng cao l c suy thn cp hoc t cp ca suy thn
mn.
2.2. Nc tiu
- Nhiu bch cu, c th c tr bch cu, t bo m, hng cu.
- Vi trng thng mt loi, a s l trc khun Gram m, 80% l E. Coli.
- Protein niu khong 1g/24 gi.
2.3. X quang (khng chun b, UIV) v siu m thn tit niu
Gip pht hin cc yu t thun li: si, cc d tt bm sinh h tit niu, hnh dng kch
thc thn.
2.4. Chp ct lp t trng (TDM, CT-Scanner):
Cho thy nhng vng gim t trng, xut hin so v thn, gip chn on nhng th khng
in hnh, nh gi trm trng v tin lng.
III. TIN TRIN, BIN CHNG
1. Tin trin
- Vim thn b thn cp khng c yu t thun li: tin trin thng tt nu iu tr khng
sinh ng v liu. Cc triu chng lm sng s gim nhanh, nc tiu tr v bnh thng
sau 1-2 tun.
- Vim thn b thn cp c yu t thun li lm nghn ng tiu gy nc tiu nh si, u
x tin lit tuyn...
iu quan trng l phi loi b c cc yu t ny, v nu iu tr khng liu, khng
lu th bnh c th ti pht nhiu ln, tr thnh mn tnh a n tng huyt p, cui cng l
suy thn.
2. Bin chng
Thng do iu tr mun, c tnh vi trng cao gy tn thng thn nng, c a xu, sc
khng c th km.
2.1. Nhim trng mu, sc nhim trng
C th t vong, cy mu dng tnh cng mt loi vi trng vi cy nc tiu.
2.2. p xe thn hoc quanh thn
Chn on da vo siu m thn, CT-Scanner gip nh v chnh xc p xe.
2.3. Tnh trng khng khng sinh
Mt phn do bn cht loi vi trng a khng, mt phn do dng khng sinh khng ph
hp, khng liu v khng lu.
350
2.4. Vim thn b thn kh thng
Him, gp nhng bnh nhn i tho ng (70%), chn on da vo siu m thn thy
cc ti hi trong nhu m thn.
IV. CHN ON
1. Chn on xc nh: da vo
- Lm sng: st rt run, au h sn lng, tiu c, thn ln.
- Nc tiu: cy nc tiu trn 100.000 khun lc /ml, nc tiu nhiu bch cu.
2. Tm cc yu t thun li
- Sau t sonde tiu, c si h tit niu, ph n c thai, u x tin lit tuyn,... cc yu t ny
thng c pht hin nh X quang v siu m thn tit niu.
3. Chn on phn bit
- Vim thn b thn bn phi: cn phn bit vi rut tha vim hoc vim ti mt cp.
- ph n: vi triu chng au cn phn bit vi vim phn ph, thai ngoi t cung.
Trong cc trng hp trn phn bit ch yu da vo xt nghim nc tiu.
- Phn bit vim thn b thn cp vi t cp ca Vim thn b thn mn: da vo tin s,
thm d bng Xquang, siu m thy thn teo nh khng u hai bn, b g gh.
V. IU TR
1. Khng sinh
1.1. Chn khng sinh: Tt nht l theo khng sinh . Khi cha c khng sinh th chn
khng sinh:
- C tc dng vi vi trng Gram m, ch t l hin nay khng vi Ampicilline (25-30%).
- C tc dng dit khun, t nh huyt thanh nhanh, nng cao trong nhu m thn, o
thi ch yu qua nc tiu.
Khng sinh p ng cc yu cu trn l
+ Aminopnicillines: dng n c hay phi hp vi Acide clavulanique.
+ Aminoglycosides: n c hay phi hp vi aminopnicillines.
+ Aztronam, Cephalosporines th h 2 hoc th h 3.
+ Cotrimoxazole, Fluoroquinolones.
1.2. Thi gian iu tr
T 2-6 tun, ph thuc vo
- C hoc khng c yu t thun li, bin chng.
- C a, trm trng lm sng.
- Triu chng sinh hc v nht l thm d hnh thi.
1.3. Liu lng v cch dng
Ty trm trng c th
Dng mt loi khng sinh hoc kt hp hai loi trong nhng ngy u hoc sut liu trnh;
ng ung hoc ng ngoi tiu ha.
351
- Amoxicilline - acide clavulanique: 1,5g/ngy.
- Gentamycine 1mg/kg/8 gi.
- Aztronam: 1g/mi 12 gi.
- Ceftriaxone 2g/ngy.
- Cotrimoxazole: 960mg x 2v/ngy.
- Ofloxacine: 200mg x 2v/ngy.
2. iu tr trit cc yu t thun li
Si, u x tin lit tuyn... loi b nguyn nhn lm nc tiu.
3. Tit thc
- n nh, ung nhiu nc.
- Trng hp nhim trng nng, mt nhiu nc: phi b nc in gii bng ng tnh
mch.
4. Phng bnh
- Gio dc bnh nhn b si thn tit niu c hng phng
+ Ch n ung
+ Khm nh k, pht hin nhim trng tim tng iu tr dt im. V sinh b phn tit
niu sinh dc.
- Trnh cc th thut: thng tiu, soi bng quang khi khng cn thit.

VIM THN B THN MN
L hu qu ca nhim trng niu ko di, ti pht nhiu ln, iu tr khng dt im.
I. GII PHU BNH
1.i th
- Thn teo nh, c hai bn nhng khng cn xng hoc ch teo mt bn.
- B thn g gh, li lm khng u.
- i b thn b bin dng, co ko, mo m.
- C khi thn l nhng m hoc mt bc m.
2.Vi th
- X ha t chc k, xm nhp nhiu t bo lympho, tng bo, bch cu a nhn.
- Nhiu ng thn b ph hy, phn cn li gin rng.
- Cu thn b hyalin ha, mt hnh th bnh thng hoc b t chc x bao quanh ngoi mng
Bowman, hoc trong mng Bowman.
- Mch thn b x cng, chn p bi t chc x.
II. TRIU CHNG HC
1. Tin s: Bnh nhn thng c nhim trng h tit niu ti pht nhiu ln, c yu t thun
li lm nghn, nc tiu: si, u x tin lit tuyn, d dng ng tit niu...
352
2. Triu chng lm sng
- C th c hi chng bng quang: tiu but, tiu dt, tiu c, tiu mu.
- Khng ph, tri li c du hiu da kh, n hi gim, kiu mt nc.
- Ch ph khi c suy thn nng, dinh dng km.
- au m vng hng lng, 1 hoc 2 bn.
- Tiu nhiu, tiu m.
- Thiu mu, tng huyt p thng xut hin mun.
3. Triu chng cn lm sng
3.1. Nc tiu
- Protein < 1g/24h.
- Bch cu > 6000/pht hoc > 5/vi trng vt knh 40.
- Vi trng > 10
5
/ml.
- Kh nng c c nc tiu gim sm: lm nghim php c c thng t trng ti a <
1,018.
- Phn ly chc nng cu v ng thn: kh nng c c gim, t trng thp, nhng mc lc cu
thn bnh thng. y l du hiu sm ca vim thn b thn mn.
- Khi c suy thn
+ Hng cu, hmoglobin mu gim.
+ Ur, cratinin mu tng.
3.3. Xquang v siu m thn
Thn teo nh khng cn xng, b g gh, li lm khng u.
III. TIN TRIN
- Tin trin ni chung l chm. C khi ht vi trng trong nc tiu bnh vn tin trin.
- Thng c cc t kch pht.
- Cui cng dn n suy thn mn.Suy thn cng nhanh khi:
+ Nhiu t kch pht.
+ Huyt p tng.
+ Dng khng sinh c cho thn.
+ Khng loi b c cc yu t thun li: si, u x tuyn tin lit.
IV. CHN ON
1. Chn on xc nh: Ch yu da vo: tin s, triu chng lm sng v cn lm sng.
2. Chn on phn bit: Cn phn bit vi vim cu thn thn mn, da vo:
- Ph hay gp hn, tng huyt p xut hin sm hn
- Nc tiu: hng cu nhiu hn bch cu, khng c m trong nc tiu, lng Protein niu
nhiu hn, ch yu l Albumin.
- Thn nh nhng cn xng, b u.
353
V. IU TR
1. iu tr nhim trng
Ch yu l cc t cp hoc giai on c vi trng niu mc d khng c triu chng lm sng
nhng pht hin qua theo di t bo vi trng niu.
Dng khng sinh theo khng sinh , trnh cc loi khng sinh c thn.
2. Loi b cc yu t thun li: u, si...
3. iu tr tng huyt p, ri lon toan kim, in gii, thiu mu...
354
SUY THN CP
Mc tiu
1. Lit k c cc nguyn nhn ca suy thn cp.
2. Tp hp c cc triu chng lm sng, cn lm sng ca suy thn cp.
3. Bit r cc bin chng ca suy thn cp.
4. nh gi cc triu chng chn on xc nh, gin bit v th bnh ca suy thn cp.
5. iu tr c suy thn cp.
Ni dung
I. I CNG V DCH T HC
1.i cng
Suy thn cp l mt hi chng xut hin khi chc nng thn (ch yu l chc nng lc cu
thn) b suy sp nhanh chng, xy ra t ngt bnh nhn khng c suy thn trc hoc
bnh nhn mc suy thn mn. Mc lc cu thn c th b suy gim nng nhng c th c
hi phc hon ton mt cch t nhin hoc di nh hng ca iu tr nguyn nhn. Suy
thn cp th hin trn lm sng c trng vi v niu, nhng c nhng th bnh vn c lng
nc tiu bo tn. Gn y chn on suy thn cp da vo s gia tng cratinine mu so vi
cratinine cn bn bit: nhiu hn 50mmol/l i vi cratinine cn bn di 250 mmol/l
hoc nhiu hn 100 mmol/l i vi cratinine mu cn bn trn 250 mmol/l.
2. Dch t hc
Suy thn cp l mt hi chng tng i t gp. Trong thc t, tn sut mc bnh ny ch c
th c nh gi bng s lng nhp vin hng nm: 1 - 3% bnh nhn nhp vin hng nm.
Tin lng ca suy thn cp thng l tt nu kh nng phc hi chc nng thn tt dn. Tuy
vy, cn phi tnh n nhng yu t nguy c lm nng ca suy thn cp: bnh nguyn, ln
tui, c a suy yu, kt hp vi suy cc tng khc, iu kin iu tr (thm phn, dinh dng)
v cui cng l kinh nghim ca i ng iu tr.
II. SINH L BNH
Chc nng lc cu thn trong suy thn cp gim hoc mt hn, xy ra do cc c ch sau:
- Gim dng mu qua thn (gim th tch, sc).
- Tnh khng ca tiu ng mch i gim (dn mch sau cu thn).
- Tnh khng ca tiu ng mch n tng (co mch trc cu thn).
- p lc cu thn (nang Baoman) gia tng (tc nghn trong lng ng thn hoc trn ng bi
tit).
- Ngoi ra suy thn cp cn c th do gim tnh thm ca mch mu thn m c ch hin nay
cn cha c bit r.
III. NGUYN NHN
1. Nguyn nhn trc thn (suy thn cp chc nng)


355
Nhng nguyn nhn chnh ca suy thn cp chc nng bao gm:
Mt nc ngoi bo
- Mt qua da (m hi, bng)
- Mt qua ng tiu ho (nn ma, a chy, l d)
- Mt qua thn:
+ iu tr li tiu qa mnh.
+ a niu thm thu trong i tho ng mt b v trong hi chng ly vt tc nghn.
+ Vim thn k mn
+ Suy thng thn
Gim th tch mu tht s
- Hi chng thn h nng
-X gan mt b
-Suy tim xung huyt
-H huyt p trong cc tnh trng sc: tim, nhim trng, phn v, xut huyt.
Suy thn cp huyt ng (do thuc c ch men chuyn, c ch th th angiotensinII, Khng
vim khng stroid, c ch calcineurines)
2. Nguyn nhn ti thn (suy thn cp thc th)
2.1. Vim ng thn cp
- L nguyn nhn thng gp nht ca suy thn cp thc th (80%).
- Chim hng u l suy thn cp chc nng chuyn sang.
- Vit Nam thng l do st rt i huyt sc t, ng c mt c trm.
- Ng c bi mui kim loi nng: As, Pb, Hg.
- Huyt tn trong lng mch do truyn nhm nhm mu, nhim c quinine, nm.
- Do thuc: khng sinh (Aminosides, Amphotericine B), thuc cn quang.
2.2. Vim cu thn cp
Do vim cu thn th tin trin nhanh. Thng gp th vim cu thn hoi t v ngoi mng
trong bnh cnh vim mch hoi t, hoc vim cu thn tng sinh trong v ngoi mng trong
bnh cnh ca lupus, ban xut huyt dng thp. Ngoi ra suy thn cp do vim cu thn th
tin trin nhanh cn gp trong hi chng Goodpasture.
2.3. Vim thn k cp
- Do Vi trng: Vim thn b thn cp
- Do Nhim c thuc: Thng qua c ch min dch-d ng. Ngoi suy thn cp cn c tng
bch cu a acid trong mu v trong nc tiu, ban da, hu t bo gan.
3. Nguyn nhn sau thn (Suy thn cp tc nghn)
- Si niu qun l hng u Vit Nam
- U x, ung th tuyn tin lit
- U vng khung chu lnh hay c tnh (u bng quang, ung th t cung, c t cung, trc trng)
356
- X cng sau phc mc
- Di cn sau phc mc (him)
- Lao lm teo hai niu qun
III. DU CHNG LM SNG V CN LM SNG
V mt lm sng, suy thn cp thng din tin qua cc giai on sau
1. Giai on khi u
L giai on xm nhp, tn cng ca cc tc nhn gy bnh, din tin ty theo tng
loi, bnh nhn ng c th din bin nhanh c th dn n v niu ngay, bnh nhn sc
th din bin nhanh hay chm ty theo nguyn nhn sc v k thut hi sc lc u.
2. Giai on thiu v niu
Thiu niu khi lng nc tiu < 500ml/24 gi (hoc di 20ml / gi), c th bt u t t
hoc ngay vi ngy u khi bnh, trung bnh ko di 1 - 2 tun, khi thiu niu ko di trn 4
tun th cn xem thn b hoi t v, vim cu thn cp th tin trin nhanh, vim quanh tiu
ng mch thn, si gy tc niu qun.
V niu khi lng nc tiu < 100ml/24 gi, theo Brenner v Rector th him gp, nhng
Vit Nam th rt thng gp, thm ch nhiu ngy, chnh v nguyn nhn thiu v v niu nn
lm cho ur, creatinine tng cao nhanh trong mu.
Biu hin trong giai on ny ch yu l hi chng tng ur mu cp gm c cc triu chng:
- V tiu ha: chn n, bun nn, nn ma , to bn hoc a chy.
- V tim mch: Tng huyt p thng gp cc bnh vim cu thn, cn li l do lm dng
dch truyn gy nc, mui, tng huyt p nng, gy ph phi, ph no.
- Du thn kinh: c th kch thch vt v, hn m, co git, c khi ri lon tm thn.
- V h hp: nhp th toan kiu Kussmaul hoc Cheyne - Stokes, ph phi, nhim khun phi.
- Thiu mu: Thng xut hin sm nhng khng nng lm, khi c thiu mu nng th cn
ngh n nguyn nhn suy thn cp l do xut huyt nng ko di hoc bnh c suy thn mn
trc .
- Ph thng do ung nhiu nc hoc truyn dch qu nhiu, mt khc l ph ni sinh do
gii phng nc t hin tng phn hy t chc, t bo. Trong phn ln cc trng hp hoi
t ng thn cp th khng ph.
- Nu c du hiu vng mt, vng da l biu hin ca tn thng gan mt thng gp do
nguyn nhn Leptospirose, st rt i huyt sc t.
- Ri lon in gii: thng gp trong suy thn cp l tng Kali mu, l hin tng hy t
bo v huyt tn tng t 0,5 - 1mmol/24 gi. Cng c khi tng nhanh 1 - 2mmol/l trong t gi
cc bnh chn thng nng, nhim khun, huyt tn. Tng Kali mu rt nguy him, v mt
lm sng thng thm lng ri t ngt bc pht rung tht, ngng tim. Khi c Kali mu trn
5mmol/l cn theo di k in tim v x tr h Kali mu kp thi. Trn in tim tng Kali mu
biu hin sm l sng T cao nhn, i xng ri QRS di, PR di, Bloc xoang nh, mt sng P
ri ngng tim c hoc khng qua giai on rung tht. Trong suy thn cp tng Kali mu ny
cng nng thm do hin tng toan mu.
Toan mu l hu qu t tng chuyn ha, d tr kim gim 1 - 2 mmol/ ngy, bnh cng nng
th gim cng nhanh, d tr kim c khi gim di 10mmol/l, hin tng ny lm cho Kali
mu tng cng nhanh.
357
Mt khc, ri lon in gii trong suy thn cp cn c gim Calci, Natri, tng Mg v
Phosphate.
- Nhim trng: trong giai on v niu nhim trng l nguyn nhn hng u gy t vong
thng l nhim trng ng h hp, tit niu v ngoi da.
3 Giai on tiu nhiu
Thng bt u t 300ml/24gi sau bnh nhn tiu nhiu, thng vo ngy th 3 ca giai
on ny lng nc tiu t 1lt/ngy. Giai on ny gi l khng hong v nc tiu c khi
ti 3 - 4 lt/24 gi v d gy ri lon nc in gii nng, try tim mch, nhim trng, vim
tc tnh mch, nht l d ho c gy gy nhiu. Trong giai on ny nu iu chnh nc in
gii khng hp l th d gy t vong. Cc ch s v sinh ho trong mu ch bt u gim dn
sau vi ngy i nhiu, ngha l trong nhng ngy u i nhiu th ur mu, creatinine vn
cn tng cao v ur, creatinine niu vn cn thp. Lng ur, creatinine tng cng nhanh
trong nc tiu th s phc hi cng sm v tin lng cng tt, ng nhin l phi gim
song song cc cht ny trong mu v c nh gi chnh xc bng thanh thi creatinine
ni sinh. Gim Kali v Natri c nh gi bng in gii hng ngy b kp thi. Trong
giai on ny, t trng nc tiu thp di 1,005.
4. Giai on phc hi
Ur, creatinine mu gim dn, mc c c nc tiu tng dn, lm sng tt ln, tuy nhin
chc nng thn phc hi rt chm: kh nng c c c khi phi hng nm mi hi phc. Mc
lc cu thn phc hi nhanh hn.
IV. BIN CHNG V TIN LNG CHUNG
- Trc kia, t l t vong rt cao, c khi n 90%. Hin nay nh nhng tin b khoa hc k
thut, nht l trong lnh vc lc ngoi thn v k thut hi sc, t l t vong cn khong 50%,
T l t vong c lin quan vi:
+Bnh l nguyn nhn: sc nhim trng hoc xut huyt, suy h hp, chn thng nng,vim
tu cp, co git.
+ C a: ln tui, bnh mch vnh, suy h hp, i ng, ung th.
+ Nhng bin chng th pht ca hi sc v c bit nhim trng bnh vin (nhim trng
cathether,bnh phi), suy dinh dng
- Nhng bin chng chnh:
+ Nhng bin chng chuyn ho ring ca suy thn cp: Toan chuyn ho v tng kali mu.
Tng th mu v ph phi. Nguy c suy dinh dng.
+ Nhim trng bnh vin (do t Sonde bng quang hoc v niu ko di lm ng bi niu
mt kh nng khng)
+ Xut huyt tiu ha do lot cp
+ Nhng bin chng tim mch: Vim tnh mch, tc mch phi, nhi mu c tim, tai bin
mch mu no.
- Cc yu t tin lng ph thuc vo
+ Tui cng cao th bnh cng nng
+ Cn nguyn: nng trong vim ty cp, sau m km theo nhim trng, vim phc
mc, cc a chn thng.
358
+ Tin lng xa trong a s trng hp khng li di chng v khng chuyn sang
mn tnh, nht l ngi tr. Hn hu 2% trng hp khng lnh hn c gii thch bng s hoi
t v thn c hai bn (cn chy thn nhn to sut i, ghp thn).
V. CHN ON
1. Chn on xc nh
- Da vo du suy thn: i t, v niu, ur, creatinine mu tng cao dn, tng K mu v toan
mu.
- Da vo tnh cht cp tnh
+ Chc nng thn bnh thng trc
+ Kch thc thn bnh thng hoc ln
+ Khng c thiu mu, khng h canxi mu
2. Chn on gin bit
Cn chn on gin bit gia suy thn cp v t cp ca suy thn mn, da vo:
- Tin s bnh nhn khng c bnh thn tit niu.
- Bnh s din tin cp tnh v c nhng nguyn nhn cp tnh dn n.
- C khi rt kh phn bit v bnh nhn khng nh r tin s, thm ch khi hn m ri mi
vo vin. Cn da thm cc triu chng khc nh:
+ Thiu mu nng trong suy thn mn; thiu mu nh, va phi trong suy thn cp.
+ Tng huyt p: Trong suy thn cp thng cao va phi v t nng. Trong suy thn mn
tng huyt p c lu ngy v cc bin chng ca n trn tim, mt, mch mu kh r rng.
+ Siu m o kch thc thn thy hai bn thn teo nh trong suy thn mn. y l du hiu
chn on quan trng gin bit.
5.3. Chn on suy thn cp chc nng suy thn cp thc th
Bng 1: Phn bit suy thn cp chc nng v thc th
Ch s STC chc nng STC thc th
1. Ur mu Tng Tng
2. Cratinin mu Bnh thung hc tng t Tng
3. Ur /Creatinine mu( mol/l) >100 <50
4. F E.Na < 1% > 1- 2%
5. Na/K niu <1 > 1
6. Ur niu/ur mu >10 < 10
7. Cratinin niu/ Cratinin mu > 30 <30
8. Thm thu niu/Thm thu mu >2 <2
(FE Na:Fraction de l excretion du sodium = UNa x Pcre / P Na x U cre)
5.4 Chn on nguyn nhn ca suy thn
Cn thit phi tm nguyn nhn gy suy thn cp trn ngi bnh.
359
- Suy thn cp trc thn: Da vo cc triu chng mt nc ngoi bo (h huyt p, nhp
nhanh, np nhn da, st cn, c c mu). Da vo cc nguyn nhn lm gim th tch mu
tht s: suy tim. X gan mt b, hi chng thn h.
- Suy thn cp sau thn: Trn nhng bnh nhn ang c cc bnh l gy tc nghn: si niu
qun, cc khi u khung chu, bnh l bng quang, tin lit tuyn.
- Suy thn cp ti thn: Da vo cc triu chng chn on bnh l cu thn, ng thn,t
chc k thn hoc mch mu thn.
Bng 2: Chn on nguyn nhn suy thn cp
Triu chng Vim ng thn
cp
Vim thn
k cp
Vim cu thn
cp
Bnh l mch
thn cp
Tng huyt p O O c C
Ph O O c O
Prtin niu < 2g/l < 2g/l > 2-3g/l Thay i
Tiu mu vi th O O C O
Tiu mu i th O + + +
Bch cu niu O C O O
Nhim trng niu O + O O
VI. IU TR
Nguyn tc chung l iu tr theo nguyn nhn suy thn cp, rt khc bit ty tng nguyn
nhn trc, ti v sau thn.
1. iu tr suy thn cp chc nng.
1.1 Suy thn cp vi mt nc ngoi bo v gim th tch mu.
- iu tr cn bn suy thn cp chc nng bng hi phc li nc, th tch mu lu
thng bng in gii, mu, huyt tng cho phn ln cc nguyn nhn trc thn
- iu tr chnh bng dung dch mui ng trng 0,9%, hoc nhc trng 0,45%
bng ng tnh mch. Trong trng hp khng nng cung cp bng ng ung.
1.2 Suy thn cp chc nng vi ph.
- Suy thn cp ca hi chng gan thn cp thng him hi phc v thng t vong v
nhng hu qu ca x gan. Tuy nhin, c th th iu tr bng Albumin nu Albumin mu <
20g/l, kt hp vi li tiu quai.
- Trong trng hp hi chng thn h, nht l khi gim th tch mu ko di, vic
truyn Albumin v s dng thuc li tiu i khi l iu chnh c hiu qu v lm bin mt
ph.
- Trong trng hp suy thn cp sau suy tim c th iu chnh bng iu tr suy tim.
1.3.Trng hp c bit do thuc c ch men chuyn v thuc khng vim khng phi
steroide: Ngng thuc.
Chung cho cc suy thn cp chc nng, nng huyt p, cng nh tc dng li tiu c th s
dng cc thuc sau:
Isuprel 0,2 - 0,6mg - 1mg trong 1000ml glucose ng trng truyn tnh mch.
360
Dopamin 3 - 5(g/kg/pht cho ngi nng 50 kg truyn vi glucose 5%.
Ngoi ra c th dng cc dung dch vi phn t lng ln nh Dextran, Manitol 20% 300 -
500ml/ngy, thm ch mu v cc ch phm ca mu gi th tch mu ti cho cu
thn.
2. iu tr suy thn cp thc th
2.1. Gim mui v nc
giai on v niu, n lt hon ton, lng nc k c dch truyn v ung mi ngy khng
qu 700ml ngi 50kg.
2.2. giai on thiu niu. hoc ngay ngy u v niu, c nc ngoi bo th dng
Furosemid (Laxis, Lasilix) mi ln 120 - 160mg, tim tnh mch mi 3 - 4 gi, liu ti a c
th n 1000mg - 1500 mg/24h nhm chuyn th v niu sang th i nhiu. Furosemid
thng thay i lng nc tiu m khng nh hng n chc nng thn. Nu dng liu
lng trong ngy m vn khng c lng nc tiu th ngng dng.
2.3. Khi c tng K mu
+ Dung dch glucose 20% 500ml + 20v Insulin truyn tnh mch nhanh t 60-90 pht.
+ Resine trao i Cation nh Resonium, Kayxelat (trao i 1-2mmol K
+
/g resine): 10-15g x
2 - 3 ln/ngy.
+ Clorua calci 10% 5-10ml tim tnh mch chm 3-5 pht, khi cp cu vi in tim c bloc
xoang nh, QRS gin rng hoc K
+
> 7mEq/l.
+ Dung dch kim 14 c 5 pht th truyn 44 mmol, nu bnh ph v tng huyt p th
dng loi kim u trng 4,2 % tim tnh mch chm.
+ Nhng thuc kch thch 2 adrnergique: Nh salbutamol, lm vn chuyn kali vo ni
bo.
2.4 iu tr toan chuyn ho.
- Truyn tnh mch Bicarbonat ng trng 1,4 g% hoc trong trng hp cn thit s dng
loi m c 4,2%, 8,4%.
2.5. iu tr lc ngoi thn.
Nht l thn nhn to theo cc tiu chun ca chy thn nhn to trong quan trng l khi
c 1 trong 2 tiu chun sau: Ur >30 mmol/l, Kali mu >6 mmol/l.
3. iu tr suy thn cp sau thn
Suy thn cp sau thn cn gi l suy thn cp tc nghn. Cho nn iu tr quan trng nht l
iu tr loi b yu t tc nghn ny.
4. iu tr nguyn nhn.
Ty tng nguyn nhn iu tr nh iu tr st rt trong nguyn nhn suy thn cp sau st
rt i huyt cu t; m ly si trong suy thn cp sau si tc nghn...
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SUY THN MN
Mc tiu
1. Trnh by c nh ngha, c ch sinh bnh ca suy thn mn.
2. Xp loi cc nguyn nhn ca suy thn mn.
3. Tp hp c cc triu chng lm sng, cn lm sng ca suy thn mn
4. Chn on xc nh, chn on giai on ca suy thn mn.
5. iu tr suy thn mn trc giai on cui.
6. Ch nh cc phng php iu tr thay th thn suy
Ni dung
I. I CNG V DCH T HC
1. i cng
Suy thn mn l hu qu ca cc bnh thn mn tnh ca thn gy gim st t t s lng
nephron chc nng lm gim dn mc lc cu thn.
Khi mc lc cu thn gim xung di 50% (60ml/pht) so vi mc bnh thng
(120ml/pht) th c xem l c suy thn mn.
Suy thn mn l mt hi chng din bin theo tng giai on: trong giai on sm, lm sng
ch c mt s triu chng rt kn o, ngc li vo giai on cui biu hin rm r vi hi
chng tng ur mu. Qu trnh din bin ca suy thn mn c th ko di t nhiu thng n
nhiu nm.
2. Dch t hc
Xc nh t l mi mc, mc bnh suy thn mn l mt vn kh khn bi trong suy thn
mn giai on u ngi bnh thng t i khm bnh v t hoc khng c triu chng lm
sng. Suy thn mn trc giai on cui t c bit r v khng c ng k v khng c
theo di, nhng t l mi mc suy thn mn giai on cui cn c iu tr thay th thn suy
th ngi ta c th bit c mt cch chnh xc. Theo thng k Php t l mi mc suy
thn mn giai on cui l 120 trng hp / 1 triu dn / nm. M v Nht l 300 trng
hp / 1 triu dn / nm (s liu nm 2003).
- T l mc bnh suy thn mn c khuynh hng gia tng theo thi gian v khc nhau gia
nc ny v nc khc.
- Suy thn mn l mt bnh l xy ra ch yu ngi ln. Thng k ca Php trong s 70
bnh nhn mi mc suy thn mn giai on cui th ch c 5 bnh nhn l tr em v thanh
nin, v 65 bnh nhn l ngi ln. Suy thn mn cng c lin quan vi gii tnh, nam mc
bnh hn n hai ln (2/1). tui trung bnh ca s bnh nhn mi bt u iu tr suy thn
mn giai on cui tng dn: nm 1987 l 55 tui, nm 1998 l 61 tui.
II. NGUYN NHN
Hu ht cc bnh l thn mn tnh d khi pht l bnh cu thn, bnh ng k thn hay bnh
mch thn u c th dn n suy thn mn.
1. Bnh vim cu thn mn
Thng hay gp nht, chim t l 40%
362
Vim cu thn mn y c th l nguyn pht hay th pht sau cc bnh ton thn nh
lupus ban h thng, i ng, ban xut huyt dng thp...
2. Bnh vim thn b thn mn
Chim t l khong 30%.
Cn lu : vim thn b thn mn trn bnh nhn c si thn tit niu l nguyn nhn thng
gp Vit Nam.
3. Bnh vim thn k
Thng do s dng cc thuc gim au lu di nh Phnylbutazone, do tng acid uric mu,
tng calci mu.
4. Bnh mch thn
- X mch thn lnh tnh hoc c tnh.
- Huyt khi vi mch thn
- Vim quanh ng mch dng nt
- Tc tnh mch thn
5. Bnh thn bm sinh do di truyn hoc khng di truyn
- Thn a nang
- Lon sn thn
- Hi chng Alport
- Bnh thn chuyn ha (Cystinose, Oxalose).
6. Bnh h thng, chuyn ho
- i tho ng
- Cc bnh l to keo: Lupus
Hin nay nguyn nhn chnh gy suy thn mn cc nc pht trin ch yu l cc bnh
chuyn ho v mch mu thn (i tho ng, bnh l mch mu thn) trong khi cc nc
ang pht trin nhm nguyn nhn do vi trng, si thn tit niu vn cn chim vi t l cao
III. VI NT V C CH SINH BNH
C ch sinh bnh ca suy thn mn c gii thch trn c s l lun ca thuyt nephron
nguyn vn: Mc d tn thng khi pht cu thn, mch mu thn, t chc ng k thn th
cc nephron b thng tn nng cng thng b loi tr khi vai tr chc nng sinh l. Chc
nng ca thn ch cn c m nhim bi cc nephron nguyn vn cn li, khi s nephron
nguyn vn cn li ny khng m bo chc nng ca thn l duy tr s hng nh ca
ni mi th s xut hin cc ri lon v nc in gii, v tun hon, h hp, tiu ha, thn
kinh to nn hi chng suy thn mn.
IV. BIU HIN LM SNG, CN LM SNG CA SUY THN MN
1. Lm sng
1.1. Ph
Ty thuc vo nguyn nhn gy suy thn mn m bnh nhn c th c ph nhiu, ph t hoc
khng ph. Suy thn mn do vim thn b mn thng khng ph trong giai on u, ch c
ph trong giai on cui. Trong khi suy thn mn do vim cu thn mn ph l triu chng
363
thng gp. Bt k nguyn nhn no, khi suy thn mn giai on cui, ph l triu chng
hng nh.
1.2. Thiu mu
Thng gp nng hay nh ty giai on, suy thn cng nng thiu mu cng nhiu. y l
triu chng quan trng phn bit vi suy thn cp.
1.3. Tng huyt p
Khong 80% bnh nhn suy thn mn c tng huyt p, cn lu c tng t tng huyt p
c tnh lm chc nng thn suy sp nhanh chng gy t vong nhanh.
1.4. Suy tim
Khi c suy tim xut hin th c ngha l suy thn mn mun, suy tim l do tnh trng gi
mui, gi nc, tng huyt p lu ngy v do thiu mu.
1.5. Ri lon tiu ha
Trong giai on sm thng l chn n, giai on III tr i th c bun nn, a chy, c khi
xut huyt tiu ha.
1.6. Xut huyt
Chy mu mi, chn rng, di da l thng gp. Xut huyt tiu ha nu c th rt nng lm
ur mu, Kali mu tng ln nhanh.
1.7. Vim mng ngoi tim
L mt biu hin trong giai on cui ca suy thn mn vi triu chng kinh in l ting c
mng ngoi tim, y l triu chng bo hiu t vong nu khng c iu tr lc mu kp
thi.
1.8. Nga
L biu hin ngoi da gp trong suy thn mn giai on c cng tuyn cn gip th pht
vi s lng ng Canxi t chc di da.
1.9. Chut rt
Thng xut hin ban m, c th l do gim Natri, gim Calci mu.
1.10. Hn m
Hn m do tng ur mu cao l biu hin lm sng giai on cui ca suy thn mn. Bnh
nhn c th c co git, ri lon tm thn giai on tin hn m. c im ca hn m do
tng Ur mu mn l khng c triu chng thn kinh khu tr.
Trn y l cc biu hin lm sng chung ca suy thn mn. Ngoi ra tu theo nguyn nhn
dn n suy thn mn mi bnh nhn m c nhng triu chng tng ng nh thn ln
trong bnh thn a nang, thn nc,...
2. Cn lm sng
- Tng ur mu, cratinine mu
- Gim h s thanh thi cratinine
- Kali mu: kali mu c th bnh thng hoc gim. Khi Kali mu cao l c biu hin t cp
c km thiu niu hoc v niu.
- Calci mu, phospho mu: trong giai on u calci mu gim, phospho mu tng. Trong giai
on c cng tuyn cn gip th pht th c calci mu v phospho mu u tng.
364
- Nc tiu:
+ Protein niu: ty thuc vo nguyn nhn, khi suy thn giai on III, IV th lun c protein
niu nhng khng cao.
+ Hng cu, bch cu: ty thuc nguyn nhn gy suy thn mn.
V. CHN ON
1. Chn on xc nh: da vo:
- Du chng ca Suy thn:
+ Tng ur, cratinine mu.
+ Mc lc cu thn gim.
- Tnh cht mn ca suy thn: c 3 tiu chun:
+ Tiu chun tin s: c tin s bnh thn, trc y c tng cratinine mu.
+ Tiu chun v hnh thi: Kch thc thn gim (chiu cao < 10cm trn siu m, < 3 t
sng trn phim chp thn khng chun b).
+ Tiu chun v sinh hc: C 2 bt thng nh hng n suy thn mn:
* Thiu mu vi hng cu bnh thng khng bin dng.
* H canxi mu.
2. Chn on giai on
Theo cc Nh Thn hc Vit nam, da vo h s thanh thi cratinine, cratinine mu:
suy thn mn c chia thnh cc giai on sau
Giai on
suy thn mn
HSTT cratinine (ml/pht)
Cratinine mu
micromol / l mg / dl
Bnh thng 120 70-106 0,8 - 1,2
I 60-41 < 130 < 1,5
II 40-21 130 - 299 1,5 - 3,4
IIIa 20-11 300-499 3,5 - 5,9
IIIb 10-5 500-900 6,0 - 10
IV <5 > 900 > 10
Theo cc nh Thn hc u - M, phn loi bnh thn mn tnh thnh cc giai on
nh sau:
Giai on M t Mc lc cu thn (ml/pht/1,73m
2
)
1 C bnh thn, nhng mc lc
cu thn cn bnh thng
> 90
2 Suy thn nh 60-89
3 Suy thn trung bnh 30-59
4 Suy thn nng 15-29
5 Suy thn giai on cui < 15

365
3. Chn on nguyn nhn
Tm cc nguyn nhn gy ra suy thn mn c ngha quan trng trong chn on. Khi loi
tr c nguyn nhn th suy thn mn mc d khng hi phc nhng c th lm chm tin
trin ca suy thn mn.
Cc nguyn nhn suy thn mn bao gm: bnh cu thn mn, bnh vim thn b thn mn,
bnh mch mu thn, bnh thn bm sinh v di truyn.
4. Chn on phn bit
Cn chn on phn bit vi
- Suy thn cp: da vo bnh s - Nguyn nhn - Tin trin ca suy thn.
- t cp ca suy thn mn:a vo tin s, t l ur mu / cratinine mu (mol/l) >
100
5. Chn on bin chng
Ch n cc bin chng trn tim mch, mu, tiu ho, thn kinh, nhim trng, ri lon nc
in gii, kim toan...
6. Chn on cc yu t gy nng nhanh ca suy thn
- Tng huyt p
- Nhim khun, xut huyt tiu ho, mt nc
- Tc nghn ng bi niu
- Dng thuc c cho thn
- n qu nhiu prtin
VI. IU TR
Ty thuc vo giai on ca suy thn mn m bin php iu tr p dng c khc nhau. Hn
na cn ph thuc vo yu t kinh t, x hi nht l cc bin php iu tr thay th thn suy.
1 iu tr suy thn mn trc giai on cui.
Tng ng vi iu tr suy thn mn cc giai on I, II v IIIa, khi thanh lc cu thn cn
trn 10 ml/pht. Cc bin php ny bo tn chc nng thn cn li
1.1. Nguyn tc chung.
- Khi bnh nhn b mt bnh l thn mn tnh, d cha c suy thn hoc suy thn nh th cng
phi c theo di bi thy thuc chuyn khoa thn, nhm pht hin v iu tr cc yu t
gy nng, theo di c h thng ngi bnh tu thuc vo mc nng nh ca suy thn mn.
- Mc ch ca theo di bnh
+ Theo di liu trnh iu tr bnh thn.
+ Ngn chn s tin trin ca suy thn mn.
+ Trnh cc thuc c cho thn v iu chnh liu thuc cho ph hp vi mc suy thn.
+ iu tr cc bin chng ca suy thn mn, cc yu t nguy c tim mch, c bit l tng
huyt p v cc yu t i km.
+ Thng tin cho bnh nhn v chin lc iu tr tu theo tng bnh nhn v tng giai on
ca suy thn.
366
+ Chun b cho vic iu tr thay th thn suy giai on cui: Chng nga vim gan Virus
B, giai on IIIa c th lm ni thng ng - tnh mch.
1.2. Lm chm s tin trin ca suy thn mn
1.2.1. iu tr tt nguyn nhn gy suy thn mn.
1.2.2. Duy tr tt huyt p v lm gim Protein niu.
y l mt im rt quan trng trong iu tr suy thn mn cc giai on nh.
nhng bnh nhn ny, ch s huyt p ti u cn t c s ph thuc vo lng Protein
niu:
- Nu suy thn mn c Protein niu < 1g/24 gi th huyt p ti u s l 130/80 mmHg.
- Nu suy thn mn c Protein niu 1g/24 gi v / hoc i tho ng th huyt p ti u
s l 125/75 mmHg.
1.2.3. Cung cp Protein trong ch n thch hp.
Trng hp suy thn nh, trung bnh (ClCr t 30 n 60 ml/pht) Protid c th c cung cp
vi liu lng 1g/kg/ngy. Trng hp suy thn nng hn th Protein cung cp t 0,6 n 0,8
g/kg/ngy.
1.3. Trnh cc thuc c cho thn v thay i liu dng ph hp theo mc suy thn.
1.4. iu tr cc bin chng ca suy thn mn.
1.4.1. Cc yu t nguy c tim mch.
- Tng huyt p: duy tr tt huyt p s lm gim t l mc v t l t vong do bnh l tim
mch bnh nhn suy thn mn.
- iu tr ri lon Lipid mu:
+ Dng nhm Statine khi tng Cholesterol mu l ch yu.
+ Nhm Fibrate trong trng hp tng Triglycerid.
- Loi b cc yu t nguy c khc:
+ B thuc l.
+ iu tr tt i tho ng.
+ Gim cn bnh nhn bo ph.
1.4.2. iu tr ri lon cn bng Canxi - Phospho.
- Duy tr nng Canxi mu bnh thng.
- Phospho mu di 1,5 mmol/l.
- PTH mu di 3 ln bnh thng.
1.4.3. iu chnh cn bng kim toan.
- Thng dng mui Natri Bicarbonate, bng ng ung hoc tim truyn tu theo ri
lon nh hay nng.
1.4.4. iu tr tng Acide Uric mu
- Tn cng bng Colchicin
- D phng ti pht bng Allopurinol.
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1.4.5. iu tr thiu mu
- Mc ch ca iu tr l duy tr Hb mu 11 n 12 g/l.
1.4.6. iu tr ri lon nc in gii
- Ch n nht: c p dng trong hu ht cc bnh thn.
- Gim lng nc ung vo trong trng hp c ph.
- iu tr Tng Kali mu
2. iu tr suy thn mn giai on cui.
Khi mc lc cu thn gim di 10 ml/pht, ngoi cc phng php ca iu tr bo tn
nh trn, m bo s sng ca ngi bnh cn thit phi c cc phng php iu tr thay
th thn suy, bao gm:
+ Ghp thn.
+ Thn nhn to.
+ Lc mng bng.
III. D PHNG
- D phng cp 1: Loi tr nhng yu t nguy c dn n bnh l thn, tit niu nh ch
sinh hot c nhn, v sinh, n ung, s dng thuc c vi thn.
- D phng cp 2: Pht hin sm bnh l thn, tit niu bng thm khm lm sng, protein
niu, iu tr trit bnh l thn tit niu.
- D phng cp 3: Khi c suy thn mn. D phng ny bao gm cc bin php c
hiu: xc nh nguyn nhn, iu tr c hiu qu loi tr bnh l nguyn nhn dn n suy
thn mn, hoc nhng bin php khng c hiu: loi tr cc yu t lm tin trin nng nhanh
ca suy thn.


368
BNH THN I THO NG
Mc tiu
1. Trnh by c khi nim, dch t hc ca bnh thn i tho ng.
2. M t c ch sinh bnh ca bnh thn i tho ng.
3. Chn on xc nh, chn on phn bit bnh thn i tho ng.
4. Chn on cc giai on ca bnh thn i tho ng.
5. Trnh by cc bin php iu tr bnh thn do i tho ng.
Ni dung
I. I CNG
Bnh cu thn i tho ng l t dng ch nhng tn thng cu thn th pht do i
tho ng. Nhng tn thng cu thn ny c nhng c trng v mt hnh thi c m t
bi Kimmelstiel v Wilson t nm 1936. Tuy nhin bnh thn i tho ng ngoi tn
thng cu thn cn c nhng tn thng khc do bn thn i tho ng gy nn thn
nh tn thng ng thn hoc nhng biu hin ca hoi t i thn hoc bnh l thn kinh
bng quang do i tho ng.
Bnh cu thn i tho ng l mt bin chng in hnh ca i tho ng typ I ph thuc
vo Insulin xut hin nhng ngi c bnh l i tho ng t cn rt tr. Tuy nhin n
cng c th xut hin nhng bnh nhn i tho ng typ II, khng ph thuc Insulin.
Hn nay cc nc u M suy thn mn giai on cui do i tho ng chim t l cao
v ngy cng gia tng.
II. DCH T HC
Bnh cu thn i tho ng (c xc nh bi protein niu thng xuyn nhng ngi
c bnh l vng mc do i tho ng hoc nhng ngi c sinh thit thn v c kt qu
trong ho x - x ho cu thn) thng xut hin bt u t nm th 10 nhng bnh nhn
i tho ng ph thuc Iusulin. T l mc hng nm t nh cao nht gia nm th 15 n
nm th 20 ca i tho ng. Thi gian mc bnh i tho ng ph thuc Insuline l yu
t nguy c chnh ca pht trin bnh l thn do i tho ng cng nh bnh l vng mc
i tho ng, bn cnh tng ng huyt, tng huyt p cng l cc yu t nguy c khc
gy nn nhng bin chng thn trn bnh nhn i tho ng.
Thi gian sng bnh nhn bnh thn i tho ng l gim nhiu. Nu khng c iu tr
c hiu qu, mt na s bnh nhn l t vong sau 7 nm xut hin protein niu. T l t vong
nhm bnh nhn ny l cao gp 37 ln so vi qun th chung. Ngc li bnh nhn i tho
ng khng c protein niu th c thi gian sng gn nh bnh thng. Cng cn lu rng
phn ln nhng nguyn nhn t vong bnh i tho ng phu thuc Insulin l t gn lin
vi suy thn m thng lin quan n bnh l tim mch, c bit bnh l mch vnh.
Bnh thn i tho ng l nguyn nhn chim v tr th nht ca suy thn mn cc nc
phng ty: 25 n 50% v hn 90% l i tho ng typ 2
III. C CH SINH BNH
C ch ca bnh cu thn th pht sau i tho ng ph thuc insulin cn nhiu bn ci,
nhng nhng gi thuyt gn y th tht l th v v chng c th c nhng kt qu c li
ngn nga v hoc iu tr bnh thn i tho ng.
369
Vai tr ca nhng bt thng v mt huyt ng hc c nhn thy giai on khi u ca
bnh nhn i tho ng mi c bit gn y. S tng lc v tng p lc gii thch cho
microalbumin niu v cng c l s gin n ca gian mch c th gy ra x ho cu thn.
Nhng yu t gy ra s gia tng lc th nhiu: trc tin l tng ng mu mn tnh nhng
cng cn do tng tit nhng hormone i khng insulin (glucagon, hormone tng trng) v
nhng cht hot mch lm bin i nhng tiu ng mch n v tiu ng mch i ca thn
(c bit l PGE2 v PGI2).
S tng dng mu qua mao mch ng vai tr ch yu trong bnh l mch (vng mc v
nhng mao mch khc).
Nhng ri lon chuyn ho th pht sau tng ng mu cng tham gia vo s hnh thnh
bnh thn bng cch lm bin i cu trc phn t ca nhng thnh phn cu thn, c bit l
mng y bng cch tng qu trnh ng phn v gim qu trnh sulfate. Nhng bin i
ng chuyn ho polyol (tng sn xut sorbitol v fructose) m vai tr ca n trong s pht
trin c thu tinh th do i tho ng l chc chn, cng c th tham gia vo s hnh thnh
protein niu. N dn n kt qu tng lc cu thn i vi nhng i phn t v tch lu trong
cu thn nhng protein tun hon gy ra nhng tn thng cu thn
IV. CHN ON
1. Chn on xc nh
Chn on xc nh bnh thn i tho ng l da vo t bo hc. Tuy nhin trong phn
ln trng hp chn on dng tnh thng da vo kt hp protein niu (m thnh phn
ch yu l albumin), tng huyt p, gim mc lc cu thn.
- Albumin niu: C th c nh lng bng nhng k thut min dch c bit (min dch
phng x, ELISA...) Cho php xc nh albumin niu vi lng cn rt t trong nc tiu.
ngi bnh thng albumin c bi tit trong nc tiu khng vt qu 20-30 mg/ngy hoc
15-20 g/pht. Khi trong nc tiu c albumin t 30mg n 300mg/ngy (t 20 n 200
g/pht) gi l microalbumin niu: y l mt ch im bt thng sm thn, c gi tr
trong chn on giai on cn sm ca i tho ng trn thn. Khi albumin niu t
300mg/24gi tr ln gi l tiu albumin niu i th (tng ng vi 0,5g/24gi protein). Cn
lu rng vic bi tit albumin trong nc tiu l rt khc bit gia cc thi im trn cng
mt c th, v th cn lm xt nghim albumin niu nhiu ln nh gi.
- Huyt p: Tng huyt p l triu chng ca bnh thn do i tho ng. Tuy nhin huyt
p ng mch ph thuc vo giai on ca bin chng thn, giai on microalbumin niu
th huyt p tm thu vo ban m gim mt t v hin tng ny khng cn na khi c
albumin niu i th.
- Mc lc cu thn: Mc lc cu thn gim l mt triu chng chn on suy thn, bin
chng ca i tho ng giai on cui. Mc lc cu thn c nh gi qua h s thanh
thi creatinin. Nhng cn lu khi nh lng creatinin c th sai s do tng ng huyt.
Mt s cht khc cng c s dng nh gi h s thanh thi trong bnh thn do i tho
ng nh Inulin, cc cht ng v phng x
125
Iodothalamate,
51
Cr - EDTA.
Ngoi ba du chng k trn, nh gi c tn thng cu thn trong bnh thn i
tho ng khi chn on cn da vo:
- Thi gian mc bnh i tho ng: mc bnh nhiu nm, ph thuc Insulin.
- Nhng biu hin ca bnh mch mu vi th (nht l bnh l vng mc do i tho ng).
- bnh nhn i tho ng khi c tam chng ca bnh l cu thn km thi gian mc bnh
nhiu nm v c bnh l vng mc, kh nng c bnh thn i tho ng l ln hn 95%.
370
2. Chn on giai on
Nhng nghin cu thc nghim v lm sng (c bit nhng bnh nhn i tho ng typ
I ph thuc insulin, c theo di trong thi gian di) cho thy bnh thn i tho ng
c trng c nhng bt thng v hnh thi v chc nng rt sm, Mogensen chia thnh 5
giai on:
- Giai on 1: Giai on tng chc nng v ph i, xy ra ngay khi b i tho ng. Kch
thch thn gia tng, cu thn ph i nhng cu trc ca chng th bnh thng. Mc lc cu
thn tng, lu lng mu qua thn tng theo song song, c th tng tit albumin niu. Tng
lc cu thn gim sau vi tun hoc vi thng iu tr bng insulin, nhng kch thc thn vn
khng thay i.
- Giai on 2: C th tn ti dai dng trong nhiu nm v 60% i tho ng typ I ko di
sut i. Mc lc cu thn c th gia tng. S gia tng ny tng quan vi kch thc thn v
s kim sot i tho ng. C l s tng lc v kim sot i tho ng km l cn thit
pht trin bnh thn i tho ng. S tit albumin qua nc tiu l bnh thng nhng
c th gia tng trong nhng tnh hung stress. B dy ca mng y cu thn tng, cht nn
gian mch tng nhiu hn v nhng tn thng ny l khng hi phc.
- Giai on 3: L giai on bnh thn i tho ng khi u. Ch xy ra 40% bnh nhn
i tho ng. N ko di t 11-20 nm, s bi tit albumin niu tng thng xuyn trong
vi nm t 10-200 g/pht. S tng lc vn tn ti nhng n bt u gim khi microalbumin
niu tng. Ch s huyt p thng tng cao hn so vi ngi bnh thng. Ngi ta vn cha
bit (theo nh gi hin nay) s can thip iu tr giai on ny (kim sot tt tng ng
mu, iu tr tng huyt p) c cho php lm chm tin trin hay khng ; nhng d sao i na
th microalbumin niu cng gim mt cch ng k.
- Giai on 4: L giai on bnh thn i tho ng xc lp vi protein niu thng
xuyn trn 0,5g/24gi, tng huyt p ng mch l hng nh. Hi chng thn h thng xut
hin. Nhng bin chng khc ngoi bnh thn i tho ng cng thng gp, c bit l
bnh vng mc (thng gy m) bnh thn kinh ngoi vi v hoc thn kinh t ng. Mc lc
cu thn gim trung bnh 1ml/thng ; iu tr tng huyt p hiu qu c th lm chm s tin
trin ny.
Ngc li, ngi ta vn cha chc chn rng s kim sot ng mu nghim ngt c tc
ng n tin trin ca suy thn hay khng.
Tn thng cu thn l c trng: tn ti x ho cu thn lan to, gm dy mng y tin
trin v tng cht nn gian mch, trong 10-20% trng hp tn ti nhng nt bt mu bi cht
PAS (+) tch t gian mch ln cn cc cu thn gi l x ho cu thn dng nt ca
Kimmelstiel v Wilson.
- Giai on 5: L giai on suy thn giai on cui. Nhng bnh nhn ny chim mt phn
quan trng trong s bnh nhn c iu tr nhng trung tm lc mu ngoi thn v ghp
thn.
Khi mc bnh i tho ng khng ph thuc insulin (thng gp cao hn 10 ln so vi
nhm khc), bnh thn cng l mt bin chng thng gp, xut hin trong 20 - 40% ca
nhng bnh i tho ng typ ny; 3-8% tin trin n suy thn mn giai on cui. Trong
bnh thn i tho ng ny, khng c s tng lc cu thn.
3. Chn on gin bit
- nhng bnh nhn i tho ng ph thuc Insulin trong thc hnh khng cn sinh thit
thn khng nh chn on nu thi gian i tho ng hn trn 10 nm v c bnh l
371
vng mc do i tho ng. Ngc li, sinh thit thn l cn thit nu 2 yu t ny l khng
hi v hoc bnh cnh lm sng lm nh hng n mt bnh nguyn khc.
i chiu 2 yu t albumin niu v huyt p thng cho php phn bit gia bnh nhn i
tho ng v bnh i tho ng km tng huyt p c bin chng thn, khi i chiu 2
yu t ny bnh i tho ng c 6 tnh hung xy ra sau:
Bng 1: Cc tnh hung tng quan gia tng huyt p, albumin niu i tho ng
Albumin niu
Tng huyt p
Bnh thng microalbumin
niu
macroalbumin niu

C
I
i tho ng + tng
huyt p nguyn pht
II
i tho ng + tng
huyt p nng (1)
III
i tho ng v
tng huyt p nng
(1,2)

Khng
IV
Tt
V
Bnh thn i tho
ng giai on u
VI
Bnh thn i tho
ng
(1: C ph i tht tri ; 2: C tn thng nhiu c quan khc ca tng huyt p)
V. D PHNG V IU TR BNH THN I THO NG
1. D phng bnh thn i tho ng
- D phng nguyn pht bnh i tho ng typ 1 c th s bng mt iu tr c ch min dch bi v
y l mt bnh t min.
- Lin quan n i tho ng typ 2: cn chng lai cc yu t nguy c (tng cn qu nhiu v li sng
tnh ti).
- D phng nguyn pht v th pht bnh thn i tho ng bao gm
+ Kim sot ng mu l tng: Bnh thng ho c ng mu l u tin hng u trong
cc bin php iu tr. Bin php iu tr Insulin theo qui c (3,4 ln tim trong ngy) l thng
c p dng. iu ny lm gim nguy c bnh thn bnh i tho ng typ 1. Li ch ca
kim sot ng huyt nghim ngt trong i tho ng typ 2 c l cng c gi tr tng t.
Mc ch chuyn ho c yu cu l HbA1c < 7%. Thng thng trn bnh i tho ng c
bin chng thn iu tr gi ng huyt n nh kh khn hn so vi khng c bin chng thn.
+ iu tr chng tng huyt p c th d phng bnh thn do i tho ng hoc lm chm tin
trin ca n. bnh i tho ng typ 2 nhng thucc ch th th angiotensine II lm gim
nguy c prtin niu i th v suy thn mn. bnh nhn i tho ng typ 1, iu tr thuc c
ch men chuyn thng thng lm bnh thng huyt p cng c th c tc dng tng t.
+ Ngng ht thuc l lm gim 30% nguy c xut hin v nng ca microalbumin niu
trong c 2 th ca i tho ng.
2. iu tr bnh thn i tho ng khi khng nh.
- i vi tt c cc giai on ca ca bnh thn i tho ng, mc tiu ca iu tr l kim
sot c chuyn ho bng tit thc v liu php Insuline.Nhm thuc Biguanide l chng ch
nh trong trng hp suy thn v nhng Sulfamide h ng huyt khng c k n
na ngay khi H s thanh lc cratinin di 30 ml/pht (nguy c h ng huyt vi
Sulfamide v nhim toan vi Biguanide)
372
- nhng bnh i tho ng typ 1 cc thuc c ch men chuyn c ch nh (k c
khong 25% ngi c huyt p bnh thng) v c bng chng v hiu qu cc thuc ny
trong vic lm chm tin trin ca bnh thn i tho ng typ1.
-Trong bnh thn i tho ng typ 2, nhng cht c ch trn th th angioten sine II
(Losartan, Irbesartan) lm gim tc tin trin ca bnh thn.
- Nhng lu khi cho thuc c ch men chuyn v nhng cht c ch trn th th
angiotensine II
+ Nghin cu hp ng mch thn nhng bnh nhn i tho ng typ 2
+ Kim tra u n cc xt nghim sinh hc, trong lu n kali mu v cratinin mu.
- Mc tiu v huyt p l tng l 130/80 mm Hg hoc ngay c 125/75 mmHg nu prtin
niu trn 1g/24 gi, vi thuc c ch men chuyn hoc c ch th th angiotensine II.
- t c huyt p trong gii hn bnh thng nhng bnh thn i tho ng cn
thit phi kt hp 2, 3 thm ch 4 loi thuc h huyt p.Thuc li tiu thng kt hp vi
thuc c ch men chuyn hoc c ch th th angiotensine II v n lm tng tc dng h huyt
p v chng prtin niu. Mt ch hn ch mui va phi (6g/ ngy) c yu cu km
theo khi iu tri thuc h huyt p.
- Khi s dng khu phn n nhiu prtin c tc dng lm tng prtin niu v nh hng n
chc nng thn.Khu phn khong 0,8g prtin/kg/ngy l cn thit c p dng. Trong thc
t nguy c suy dinh dng xut hin nu khng c theo di tit thc cn thn.
- Nhng yu t nguy c trn mch mu cn phi ch v nhng bin chng tim mch gia
tng trn i tng bnh nhn ny.
3. iu tr khi suy thn mn giai on cui.
- p dng bin php iu tr lc mu thng sm hn so vi nhng suy thn mn khng phi
do i tho ng (khi h s thanh lc cratinin tnh bng cockcroft khong 15 ml/ pht).
- V l do tin trin nhanh ca bnh thn v nhng bin chng trn mch mu ngoai bin
(calci ho ng mch), vic to ng mch mu lc mu (to l d ng tnh mch) phi
c lm sm hn (khi h s thanh lc cratinin tnh bng cockcroft khong 20 -25 ml/ pht).
- Nhn chung, nhng bnh thn i tho ng iu tr bng lc mu ngoi thn hoc ghp
thn c tin lng xu hn so vi nhng bmh nhn khng phi i tho ng, ch yu v l
do bin chng tim mch.
- Tin lng sng l xu nhng bnh nhn c suy thn mn giai on cui do bnh thn
i tho ng v nhng bin chng khc km theo nh tim mch, nhim trng... Mun d
phng nhng bin chng ny cn phi can thip giai on cn sm vo cc yu t nguy c
nh tng huyt p, nc mui, thiu mu, calci ho mch mu v tng lipid mu...
- Ghp thn: Cn lu n ngi tr v c th ghp i (thn, tu) cng lc.
- Lc mu chu k: C nhng kh khn trong to l d ng-tnh mch, v bn thn bnh l trn
mch mu ca bnh i tho ng lm cc l d ng tnh mch d hng, khng hot ng
c.
- Lc mng bng: c p dng trong cc trng hp lc mu gp tr ngi.
373
BNH THN BM SINH V DI TRUYN
Mc tiu
1. Trnh by c nguyn nhn, c ch sinh bnh thn a nang ngi ln.
2. Tp hp c cc triu chng lm sng, cn lm sng bnh thn a nang ngi ln.
3. Trnh by c cc bnh ng thn v cu thn di truyn.
4. iu tr c triu chng, bin chng ca thn a nang.
Ni dung
I. I CNG
Bnh thn bm sinh v di truyn thng biu hin nhng ngi tr tui, trong s c mt
s loi bnh rt him gp. Trong nhm bnh ny thng c chia ra:
- Nhng bnh nang thn v nhng bnh gim sn thn.
- Nhng bnh ng thn di truyn.
- Nhng bnh thn ngun gc chuyn ho.
- Nhng bnh cu thn di truyn.
II. NHNG BNH NANG THN
y l mt nhm bnh thn m c im chung l tn ti nhng nang thn. Bao gm:
- Thn a nang di truyn theo kiu gen tri (Thn a nang ngi ln)
- Thn a nang di truyn theo kiu gen ln (Thn a nang tr em): t gp, thng c pht
hin ngay sau sinh hoc trc 10 tui. Tin lng rt xu, t khi sng c n tui thanh
nin.
- Nhng nang tu thn: bao gm dn phnh ng trc i thn v phc hp nhng bnh l
nang tu thn.
1. Thn a nang ngi ln
y l loi bnh nang thn gp nhiu nht so vi cc loi khc.
1.1. Dch t hc
Theo P. Barjon t l mc thn a nang ngi ln l khong 1/1250 dn.
cc trung tm lc mu v ghp thn ca cc nc Chu u, Hoa K thn a nang chim t
l 10% trong cc nguyn nhn gy suy thn mn giai on cui.
Vit Nam cha c thng k y nhng nhn chung th tn sut khng ln so vi cc
dng bnh khc.
1.2. Nguyn nhn v c ch sinh bnh
Nguyn nhn v c ch sinh bnh ca thn a nang cho n nay c nhiu im cha c
hiu r. Cn nhc li rng trong thi k phi thai thn c pht trin qua ba hnh thi ni tip
nhau: u tin l Pronephros n Mesonephron v cui cng l Metanephros. S hnh thnh
v hon chnh b my thn tit niu ny c mt m di truyn nht nh.
Furgusson nhn xt rng bnh thn a nang di truyn ngang nhau cho c hai gii nam v n
theo kiu gen thn tri mang n. Dalgard nghin cu ph h 284 bnh nhn v gia nh
khng nh tnh di truyn ca thn a nang.
374
Cc tc gi Frances A Flinter, Frederic L.Loe v Satish Kathpalial chng minh rng bnh
thn a nang ngi ln tnh di truyn c lin kt trong hu ht cc gia nh qua phc h
gen alpha globulin v gen phosphoglyxeral kinase trn nhnh ngn ca nhiu sc th 16. Tn
sut biu hin ca gen l 100% tui 80 tr ln, c ngha ngi c bn cht di truyn thn
a nang nu sng c t 80 tui tr ln th kh nng b thn a nang l 100%. Nguyn nhn
g dn n ri lon di truyn th cha bit r.
V c ch hnh thnh nang vn cn bn ci. Nhng ngi ta cng bit chc rng cc nang ny
hnh thnh t nhng thnh phn ca nphron nht l ng gp v quai Henle. Hai bt thng
c th gii thch s hnh thnh nang l:
- C nhng tn thng mng y ng thn, iu ny lm gin ng thn.
- Tng sn cc t bo ng dn n tc nghn tng phn trong lng ng thn.
1.3. Gii phu bnh
Tn thng thn thng c hai bn. Thn gia tng kch thc dn, trng lng ca 1 thn c
a nang c th nng t 2000 n 4000g. Trong thn c nhiu nang, ln nh khng u nhau,
ng knh t 0,3 - 0,5 cm.
Cc nang thn cha dch khng mu hoc c mu vng rm, mu nu en c khi c mu khi
c xut huyt trong nang hoc di dng dch keo c.
Nhng thng tn ngoi thn c th gp km trong thn a nang gm: gan a nang (30%), t
gp hn l nang lch, bung trng, tu... Nhng tn thng v mch mu cng c ghi
nhn trong 10 n 20% cu thn a nang bao gm: phnh ng mch ni s, phnh ng mch
ch. Nhng bt thng tim c th gp km theo l sa van 2 l trong 1/4 trng hp, h van
2 l, van 3 l hoc van ng mch ch.
1.4. Lm sng v cn lm sng
Tuy l mt bnh bm sinh v di truyn nhng thn a nang ngi ln thng c pht
hin tui trn di 40. i lc c pht hin mt cch tnh c qua xt nghim siu m.
1.4.1.Lm sng
Bnh khng c triu chng lm sng trong mt thi gian di. L do khin bnh nhn i khm
bnh ca bnh thn a nang c th l: cn au qun thn, au tc bng kh chu, bnh nhn t
s thy khi u bng, tiu mu, tng huyt p, i khi bnh nhn n khm ln u tin
nhng l cc triu chng ca suy thn cp hoc suy thn mn. Triu chng lm sng khi
bnh r bao gm:
- Bng to ln, tc bng kh chu.
- au vng hng, tht lng.
- i ra mu: khi bnh thn a nang c si hay khi chn thng, bi nhim nang.
- Tng huyt p: gp 75% trng hp.
- Thn ln khi khm, c tnh cht l b mt g gh, nhiu mi, thn ln thng c hai bn
nhng khng cn xng.
Ngoi ra cn c nhng biu hin lm sng khc thng kt hp l
- Nang gan: 30%
- Nang lch, tu, bung trng, phi...
- H van 2 l, 3 l, van ng mch ch
375
- Tai bin mch mu no...
1.4.2. Xt nghim cn lm sng
- Nhm xt nghim khng nh chn on:
+ Siu m thn: l bin php hu hiu nht pht hin thn a nang. C th pht hin c
c nhng nang ng knh nh hn 0,5cm. y l k thut gip chn on sm bnh thn a
nang.
+ Chp ct lp vi tnh (CT Scanne): tn km hn siu m nhiu
+ Chp nhum thn cn quang bng ng tnh mch (UIV): C th pht hin thn to. i
thn b ko di thnh hnh kiu chn nhn c khi ch 1,2 i thn b ko di. Gc i thn
vn sc ch t vt khi c vim mn tnh. Cc i ln cng b chn ln, cht hp, ko di.
+ Chp bm hi sau phc mc: pht hin c thn ln, mt thn khng u, c nhiu y g
gh thnh mi. Hin nay t s dng.
- Nhng xt nghim khc:
+ Cng thc mu: C hin tng tng tit Erythropoietin nn t gp thiu mu ngay c khi
suy thn mn.
+ Prtin niu thng c nhng khng cao.
+ Nc tiu c hng cu, bch cu khi c bin chng tiu mu, nhim trng niu.
+ X quang thn khng chun b: 10% c si thn tit niu.
+ Chc nng thn: Gim khi c suy thn.
1.5. Chn on bnh thn a nang ngi ln
1.5.1. Nhng tnh hung dn n chn on
- C a: trung nin (him khi ngi cao tui)
- Nhng bin chng ca bnh
+ Nng tc vng tht lng.
+ au tht lng
+ i mu i th.
+ Cn au qun thn
+ Nhim trng nang
- Hoc pht hin mt cch tnh c
+ Khi khm mt cch h thng
+ Khi hi tin s v gia nh.
- i khi qua nhng biu hin ngoi thn (v d: nang gan).
1.5.2. Nhng tiu chun chn on
Chn on da trn siu m thn. Siu m thn thy thn ln c hai bn vi nhiu nang ca
hai bn thn. Cn lu nhy ca siu m trong pht hin nang tu thuc vo tui ca
ngi b bnh thn a nang n khm.
Theo tc gi Ravine ngh nhng tiu chun chn on thn a nang trong khung cnh iu
tra gia nh ca mt thnh vin trong gia nh c chn on thn a nang
376
Bng 1: Chn on thn a nang theo Ravine
Tui Tiu chun siu m
Di 30 tui t nht 2 nang ti thn (1 hoc 2 bn)
T 30 n di 60 tui t nht 2 nang trong mi thn
Trn 60 tui t nht 4 nang trong mi thn
1.5.3. Chn on gin bit
Thn a nang ngi ln l nhng bnh nang thn di truyn thng gp nht ngi ln.
Bnh ny chim khong 10% nguyn nhn gy suy thn mn giai on cui cc nc chu
u. Khi chn on cn phn bit vi cc bnh nang thn khc theo bng di y
Bng 2: Cc bnh nang thn thng gp
Nhng nang thn
Loi Tui trung bnh lc
chn on
Tui b suy thn mn Tn sut
Di truyn:
- Thn a nang:
+ Theo gen tri
+ Theo gen ln
- Nhng nang vng tu thn


30-40
0-10
< 30


> 50
0-10
< 20


1/1.000
1/40.000
?
Khng di truyn:
- Nang n
- Thn bt bin
- Nhng nang thn mc phi
sau khi b suy thn mn lc
mu chu k

Ngi ln
Ngi ln
Bnh nhn lc mu

Khng suy thn mn
Khng suy thn mn
50 tui

50%
?
1/5.000
2. Nhng nang tu thn
2.1. Bnh bt bin tu thn
L bnh thng gp trong cc bnh nang tu thn. Theo Gardener t l c th t 1/500 n
1/2000 dn v chim 1/ 200 bnh nhn c bnh ng tit niu. Vit Nam cha pht hin
c.
Thn khng to, ch 30% l to hn bnh thng
Nang thn pht trin do phnh gin ng gp v nm vng nm thn hoc vng thp
Malpighi tu thn. Nang c c hai bn nhng cng c trng hp ch b mt bn. Nang
cha dch c nhiu lng ng calci nn bin chng thng gp nhiu nht l si thn, tit
niu.
2.2. Bnh x nang tu thn
L mt loi bnh thn c nhiu nang c hai bn nhng thn khng to ln m li b co nh, x
so. Triu chng lm sng l i m, i nhiu, kht, t trng nc tiu thp do c vim k
thn. Gim kh nng c c ca thn l triu chng xut hin sm nht. Tng huyt p l t
gp. C trng hp c biu hin tc , c trng hp kt hp vim vng mc sc t. Triu
chng cn lm sng nh i mu, protein niu, tr niu, bch cu niu, vi khun niu l t gp.
377
Khi c lp i lp li nhng ri lon v xt nghim nc tiu th cn tm nguyn nhn khc
hn l x nang tu thn.
Nang thn trong x nang tu thn khng c v thn, c i xng c hai bn v pht trin t
ng gp v quai Henle. Nang ch khu tr thn, khng c kt hp nang c quan khc.
Khong 50% trng hp c biu hin di truyn kiu gen ln. C trng hp c di truyn kiu
gen tri. Do x nang tu thn c rt nhiu bin th m nhiu tc gi t tiu l phc
hp nang tu thn ch nhm bnh ny.
3. Cc bnh nang thn khc
3.1. Thn nang n
Nang nm v thn, mt nang n c hoc nhiu nang n. Nang nh hn ra pha trc b
mt ca thn. Nang thng l b cha dch trong hoc mu vng rm, thnh phn ging dch
lc cu thn.Bnh thng gp ngi c tui nn d nhm vi thn a nang. Tuy nhin bnh
t c biu hin lm sng v c pht hin thng l ngu nhin qua chp X quang v siu m
bng v nhng l do khc. Khi cn chn on phn bit c th chc ht dch nang thn. Ung
th nu c th trong dch c t bo ung th hoc mu.
3.2. Bnh thn nhiu nang bm sinh
Bnh thn nhiu nang bm sinh thuc nhm lon sn thn, nang tt c cc la tui, l hu
qu ca s ri lon c ch sinh thn lm cho ton b, mt phn hoc nhiu ca mt hoc c
hai thn bin thnh mt cu trc khng thuc bt c giai on no ca s hnh thnh thn.
Bnh thn nhiu nang bm sinh khc hn vi thn a nang l khng c tnh cht di truyn v
ch thng b mt bn. Tn sut khng ln cho nn khng c t liu. Pht hin c c tr
em trong gia nh cng b. Bn cnh nang c nhng m t chc thn bnh thng, t chc
m bit ho khng y , mt s ng thn c biu m khng in hnh, c nhng c t
chc m, sn v t chc to huyt. Chn on pht hin. Chn on xc nh nh chp ng
mch thn. Vng nang thn l khng c chc nng.
V iu tr th cn kt hp ct thn khi c chn thng chy mu, nhim khun ti pht. Tin
lng ngi ln l tt, ch b c mt bn.
3.3. Thn a nang mc phi
L mt bnh cnh mi c m t trong nhng nm gn y v xut hin ch yu l nhng
bnh nhn c lc mu thn nhn to chu k trn 3 nm. Bnh nhn khng c tin s thn a
nang v mi xut hin trong qu trnh lc thn nhn to. Nang c th b v gy chy mu t
ngt. C th pht hin ung th. T l mc phi trong qu trnh lc thn nhn to nhiu ngy l
30 - 50%.
III. NHNG BNH NG THN DI TRUYN
y l nhm bnh c tn ti nhng bt thng ng thn lm gim chc nng ti hp thu
hoc bi tit ca ng thn. Thng gp la tui nh: s sinh, tr em. Bao gm:
1. Nhng bt thng v vn chuyn phosphate ti thn
Di truyn qua nhim sc th. Nhng triu chng chnh l ci xng hoc nhuyn xng,
gim phosphat mu v tng phosphate niu, canxi mu bnh thng, canxi niu bnh thng
hoc gim.
2. Nhng bt thng v vn chuyn nhng acide amin
Bao gm bnh cystin niu v bnh Hartnup.
378
-Bnh Cystin niu: c trng vi bi tit nhiu nhng acid amin lysin, arginine, ornithine,
cystin nhng ti hp thu ng thn l bnh thng. L bnh di truyn theo gen ln. Trong cc
acid amin k trn ch c cystin l c th b di dng kt tinh dn n si.
-Bnh Harnup:L bnh l bi tit nhiu acid amin loi mono-amino mono carboxylique (ch
yu l phnylalamin v tryptophane). Di truyn theo gen ln. C th gy nn nhng thng
tn da dng Pellagroid, nhng biu hin thn kinh (mt iu ho tiu no), gim tr nh.
3. Nhng bt thng ca vn chuyn glucose, i ng thn.
ng niu nhiu (5 n 100g/ngy) nhng khng tng ng mu. Nghim php dung np
glucose bnh thng. Tin trin thng lnh tnh. y l mt bnh di truyn theo kiu gen tri
hoc ln. Thng tn ng thn l phc tp bao gm gim kh nng vn chuyn glucose ng
ln gn hoc gim ngng vn chuyn.
4. i tho nht thn.
L mt ri lon c trng vi mt tnh nhy cm ca nhng t bo ng thn vi tc ng ca
arginine vasopressine (ni sinh hoc ngoi sinh). Ri lon ny c th mc phi hoc di truyn
gn lin vi mhim sc th X.
5. Nhim toan ng thn
L bnh l khng c kh nng thit lp chnh (gradient) bnh thng gia mu v nc
tiu (toan ho do ng ln xa) hoc do mt nhiu bicarbonat (toan ho ng ln gn).
6. Hi chng Fanconi
y l mt tp hp nhiu bt thng ca ng ln gn, lin quan n acid amin, Glucose,
phtpht, bicarbonat, acid urique, Kali.Triu chng bao gm ln hoc bnh nhuyn xng,
hoc km pht trin tr em, toan chuyn ho, h kali mu.
Hi chng ny c th th pht sau nhng ri lon chuyn ho (Bnh Cystinose, Galactose, ri
lon dung np Fructose, Glycogenose, Bnh Wilson) hoc v cn v i khi c tnh gia nh.
IV NHNG BNH CU THN DI TRUYN.
1.Hi chng Alport
Gm bnh l cu thn di truyn km vi ic. L bnh l di truyn di truyn theo gen tri,
gn lin vi nhim sc th X, i khi lin quan vi gii tnh (gp nhiu nam gii). Chim
5% nguyn nhn suy thn mn giai on cui chy thn nhn to cc nc u M. Bnh
thng xut hin tui 6 tu (70% trng hp), vi triu chng i mu i th, ti pht
nhiu ln hoc di dng i prtin n c hoc hi chng thn h (25%). T 30 n 50%
c km vi ic.
2.Hi chng Fabry
L bnh l di truyn gn lin vi nhim sc th X, do thiu ht men alpha - galactosidase n
tch lu nhng glycophingolipide trung tnh. Tn thng thn c th hin bng prtin
niu, i mu vi th, thng dn n suy thn mn giai on cui tui50.
V. IU TR
Trong khun kh bi ny ch gii thiu iu tr v phng bnh thn a nang ngi ln.
iu tr bnh thn a nang.
Khng c iu tr c hiu Ch yu l iu tr cc bin chng v tc ng vo nhng yu t
nguy c nu c ca bnh.
379
V phng din ngoi khoa vic chc ht nang v ct b thn a nang ch l nhng trng
hp c bit.
Trong iu tr thn a nang trc khi suy thn mn cn ch
- Khng ch huyt p tt
a huyt p ngi bnh xung di hoc bng 130/85 mmHg. Phn ln cc thuc h huyt
p l c hiu qu, tuy nhin ba nhm thuc h huyt p c chn la trong bnh thn a
nang l: c ch men chuyn, li tiu, c ch bta. Nh cc bnh thn khc, kim tra chc
nng thn u n cn thc hin khi s dng nhm thuc c ch men chuyn.
- Chng mt nc, ri lon in gii
Phi thn trng khi ch nh dng li tiu trong thn a nang v c th gy mt nc, tru
mch, mt nhiu natri, kali.
- Nu c i mu i th th cn tm nguyn nhn loi b nguyn nhn.
- X tr si thn tit niu nu c.
- iu tr kp thi cc t nhim khun tit niu, y l yu t quan trng thc y nhanh qu
trnh suy thn.
- iu tr ri lon Lipide mu nu c.
- Bin chng ca thn a nang n n suy thn mn giai on cui ph thuc vo tui v
cc yu t nguy c:
+Suy thn mn do thn a nang ph thuc vo tui
Bng 3: La tui v kh nng suy thn mn trong bnh thn a nang
Tui Kh nng suy thn mn
40 tui 2%
40 < tui 50 20 -25%
50 < tui 65 40%
Tui > 65 50 - 70%
+ Sau y l nhng yu t c gi l yu t nguy c dn n suy thn mn ca bnh thn a
nang:
* Chn on sm.
* Nam gii.
* Gne PKD1.
* Tng huyt p.
* Tng kch thc thn.
Ngy nay, c nhiu tin b quan trng trong vic nghin cu c ch sinh bnh ca
bnh thn a nang, c bit l vai tr ca Vasopressin trong vic lm tch ly AMP vng v
hnh thnh nang thn. V vy, cht i khng vi Vasopressin c s dng vi mc ch lm
hn ch s hnh thnh v tin trin ca nang thn.
Tolvaptan (OPC-41061) c chng minh c hiu qu trn lm sng trong vic
ngn nga tin trin ca cc nang thn ngi b bnh thn a nang.
380
Khi thn a nang c bin chng suy thn mn giai on cui. iu tr thay th thn suy c
cc iu lu :
-Lc mng bng cn trnh v thn a nang c thn rt ln lm kh khn cho k thut ny.
- Khi ghp thn cn phu thut ly b thn a nang trc kho ghp v l do thn a nang c
th chn p vo thn c ghp.
2. Phng bnh thn a nang
V phng bnh trong thn a nang th quan trng nht l pht hin sm, c bin php ko di
i sng cho bnh nhn v a s bnh nhn n tui 50 l c suy thn nng.
i vi cc gia nh c ngi b bnh thn a nang. Cn khm bnh v lm siu m hng
lot cho cc thnh vin trong gia nh k c tr em v ngi ln. Siu m c th pht hin a
nang trc khi c biu hin lm sng. Cn ch kt hp pht hin gan a nang v 30% bnh
nhn c gan thn a nang.
Khi pht hin c thn a nang th cn theo di v iu tr kp thi cc bin chng nh tng
huyt p, si thn v nht l nhim khun tit niu.
i vi cc thy thuc thc hnh cn ch khi bnh nhn n khm vi cc triu chng i
mu, tng huyt p, a hng cu, thn ln, suy thn... pht hin sm bnh thn a nang.
381
BNH L NG MCH THN
Mc tiu
1. Nm c phn loi cc bnh l ng mch thn.
2. M t nguyn nhn, c ch sinh bnh ca bnh l ng mch thn.
3. Tp hp c cc triu chng lm sng ca bnh l ng mch thn.
4. Phn tch gi tr ca cc xt nghim cn lm sng trong chn on bnh l ng mch
thn.
5. Trnh by c cc bin php iu tr bnh ng mch thn.
Ni dung
I. I CNG
Bnh l ng mch thn bao gm cc tn thng nh hng n ng mch thn, c th
ng mch thn c ln, cng c th mc c va v nh. Bnh c th l nguyn pht (tn
thng bm sinh) hoc th pht sau mt ri lon khc. Din tin ca bnh ng mch thn c
th cp tnh hoc mn tnh. Biu hin ch yu trn lm sng ca bnh l ng mch thn l
tng huyt p. Chn on xc nh vn cn phi da vo cc xt nghim cn lm sng, nht l
chp ng mch thn.
Tng huyt p do bnh l ng mch thn l loi tng huyt p th pht. T l mc bnh
ny vn cn kh xc nh bi v khng phi tt c nhng bnh l c thng tn ng mch
thn u gy nn tng huyt p. Trong qun th tng huyt p khng chn lc, nguyn nhn
do bnh l ng mch thn ch chim di 1%.
II. PHN LOI
Bnh ng mch thn c th c phn loi theo nguyn nhn, theo din tin bnh hoc theo
v tr tn thng ti ng mch thn. Di y chng ti ch xin cp n hai cch phn loi
thng dng l phn theo nguyn nhn v phn theo din tin ca bnh.
1. Phn loi theo nguyn nhn
Da theo nguyn nhn, bnh l ng mch thn c chia lm 2 loi
1.1 Cc bnh l bm sinh v ng mch thn
Thng gp ngi tr tui, bao gm
- Teo ng mch thn bm sinh
- Phnh ng mch thn
- Thng ng - tnh mch thn
- Sa thn v sa cung thn
- Hp ng mch ch trn ch xut pht ng mch thn
1.2. Cc bnh l tn thng ng mch thn th pht
- X va ng mch thn
- Lon sn x ho lp c ng mch thn
- Tc ng mch thn
- Bnh Takayashu
382
2. Phn loi theo din tin
Da vo din tin, bnh l ng mch thn c chia lm hai loi nhanh (cp tnh) hoc
chm (mn tnh), ch rng mt s nguyn nhn c th c din tin cp hoc mn tnh tu
thuc tng bi cnh (v d: tc mch do tinh th cholestrol).
2.1 Nhng bnh l ng mch thn cp hoc din tin nhanh
- Nhng bnh vi mch huyt khi (mao mch cu thn v tiu ng mch)
- X ho mch mu thn c tnh (mch mu trong thn ca tt c c)
- Thuyn tc do tinh th cholestrol (ng mch trong thn ca c nh)
- Vim quanh ng mch dng nt i th (ng mch c trung bnh)
- Cn x cng b cp (mch mu trong thn ca tt c c)
2.1 Nhng bnh l ng mch thn din tin theo kiu mn tnh
- Hp ng mch thn
- Thuyn tc do tinh th cholestrol
- X ho mch mu thn lnh tnh
- Hi chng khng phospholipid
- Thi ghp mn ca ghp thn
III. NGUYN NHN CA BNH L NG MCH THN
( y ch cp n cc bnh l hp ng mch thn th pht)
1. X va ng mch thn
L nguyn nhn thng gp nht ca tng huyt p do bnh l mch thn (chim 2/3 trng
hp). y l bnh l gp ngi ln sau 45 tui. Thng tn x va gy hp thng xut
hin v tr l xut pht ng mch thn t ng mch ch hoc on 1/3 u ca ng
mch thn. Nhng tn thng x va c th c tm thy nhng ng mch khc nh
ng mch cc chi, ng mch vnh, ng mch cnh...
Tin trin ca tn thng x va dn n hp ng mch thn gp trong khong 50% trng
hp, trong gn 20% l tc nghn hon ton ng mch thn.
2. Lon sn x ho lp c ng mch thn
Chim t l 25% trong cc nguyn nhn gy tng huyt p ca bnh l ng mch thn.
Thng gp l lon sn lp o gia ca ng mch. Bnh l ny gp ch yu l cc ph
n tr trc 40 tui. Thng tn trn ng mch thn thng thy on 2/3 xa gc hoc
nhng nhnh phn chia ca ng mch thn, hnh thnh lin tip nhng on hp v nhng
on gin (du hiu chui trng ht trn phim chp ng mch thn). Thng tn lon sn x
ho ny cn c th thy cc ng mch khc nh ng mch cnh, ng mch chu. Cc
loi lon sn khc nh tng sn ni mc, x ho lon sn xung quanh lp gia l rt him gp.
3. Nhng tn thng mch mu khc
C th gp nhng him ng mch thn nh phnh, huyt khi, l d ng - tnh mch,
vim ng mch, chn p t bn ngoi (do khi u bng, u tu thng thn).
383
IV. SINH L BNH
Sinh l bnh ca tng huyt p do bnh l ng mch thn c bit qua thc nghim ch
ca Goldblatte vo nm 1934: bng cch tht bt khng hon ton ng mch thn, gy nn
tng huyt p, v tng huyt p ny khng cn na khi m tht ng mch thn.
ngi c 2 loi hp ng mch thn: hp ng mch thn mt bn vi thn bn i din
bnh thng v hp 2 bn ng mch thn hoc hp ng mch thn mt bn trn 1 thn c
nht.
1. Hp ng mch thn mt bn v thn bn i din bnh thng
Khi mc hp ng mch thn khng nhiu, s gim p lc ti mu thn l va phi v
hot ng thch hp ca h thng rnin - angiotensin s iu chnh nhng ri lon huyt ng
hc ti thn, do vy c th khng c triu chng lm sng.
Khi ng mch thn hp mc nhiu, s b tr trong thn s khng bnh thng
ho c huyt ng ta thn, do vy ti mu thn s gim v kch thch h thng rnin -
angiotensin thng xuyn lm gia tng angiotensin II dn n co tht cc tiu ng mch
chung v gy tng huyt p. Ngoi ra, cn c c ch ca tng aldosterol th pht v tng gii
phng cng nh tng tc dng ca noradrenalin th pht sau hot ho h thng rnin -
angiotensin.
Tng huyt p ch xut hin khi hp mc nhiu, lm gim khu knh ng mch thn t
70 n 80%.
thn i din khng c hp ng mch, s c s gia tng p lc trong thn a n tng bi
tit natri ca thn ny (gi l natri niu do tng p lc) nhng s tit rnin ca thn ny th
gim nhiu.
thn b hp ng mch, c tng tit rnin, gim bi tit natri, tng lng Angiotensin II
trong thn lm co tht cc tiu ng mch i cu thn (c ch t iu ho) gp phn vo gi
lc cu thn ca thn hp.
Vic s dng cc thuc c ch men chuyn lm ngn cn hnh thnh Angiotensin II t lm
h huyt p ng mch. Nhng i vi thn c hp ng mch th gy ra mt tnh t iu ho,
lc cu thn gim cn i vi thn khng c hp ng mch th lc cu thn v dng
mu qua thn khng thay i hoc gia tng.
Khi hp ng mch thn lu th vic phu thut c th khng cn lm gim huyt p c
na, do c nhng thng tn cc tiu ng mch th pht sau tng huyt p nhng ni
khng hp ng mch.
2. Hp ng mch hai bn hoc hp ng mch thn trn thn c nht
Trong tnh hung ny s gim ti mu ng mch lin quan n tt c thng tn thn.
y khng c thn i din bnh thng gii hn tng huyt p v gia tng th tch. V tng
th tch mu lm gim tit renin, nn tng huyt p ph thuc mt phn vo s gia tng th
tch mu n thn.
Angiotensin II c vai tr rt quan trng trong vic gi chc nng thn. V vy, khi dng thuc
c ch men chuyn gim Angiotensin II c th dn n 1 s gim trm trng mc lc cu
thn v gy suy thn cp.
V. BIU HIN LM SNG CA HP NG MCH THN
Biu hin lm sng quan trng nht ca hp ng mch thn l tng huyt p. Vn c
t ra l trc mt bnh nhn c tng huyt p, phi phn bit y l tng huyt p nguyn
pht hay l tng huyt p do hp ng mch thn. Mt s nghin cu so snh trn s lng
384
ln tng huyt p nguyn pht v tng huyt p do hp ng mch thn cho thy khng c
triu chng quan trng no gip phn bit rch ri gia hai loi ny.
Tuy nhin, cng c mt vi d kin qua hi bnh, thm khm lm sng v theo di iu tr
bnh nhn tng huyt p m t cho php gi n mt bnh l mch mu thn gm cc
yu t sau:
- Bt u tng huyt p tui di 30 tui hoc trn 55 tui vi tng huyt p nng.
- Xut hin tng huyt p t ngt hoc tng huyt p nng ln d c iu tr tt.
- Pht hin mt ting thi tm thu vng thng v hoc cnh rn v nht l ting thi lin
tc.
- Pht hin c s suy gim chc nng thn hoc bt thng nc tiu (protein niu, i mu
vi th) trc iu tr tng huyt p.
- Khng c hiu qu khi iu tr bng thuc chn bta, li tiu, dn mch (hydralazine) v c
ch canxi.
- Suy gim chc nng thn khi dng thuc c ch men chuyn.
Trong hp ng mch thn, tr s huyt p thng l rt cao, km vi nhng biu hin xut
tit, ph gai th khi soi dy mt. Nhng tr s huyt p tng t hoc va phi cng c th thy
bnh l hp ng mch thn.
VI. XT NGHIM CN LM SNG
Chn on xc nh bnh l ng mch thn thng da vo chp ng mch thn. Hin nay
vic s dng nhng k thut nh s cho php lm gim lng dn xut iod cn quang tim
vo trong ng mch.
- Siu m Doppler mu ng mch thn: cho php nh gi c v tr hp, mc hp, s
lng ch hp, tnh trng ng mch thn trc v sau ch hp (gin, phnh, x va,...). y
l xt nghim c a chung v khng xm nhp, r tin v c nhy cng nh c hiu
tng i cao.
- Chp thn bng thuc cn quang qua ng tnh mch nh pht vi cc phim sm thi
im pht u tin v pht th nm sau tim thuc thng c s dng. Gim kch thc
thn mt bn, chm bi tit, c s tng nng chm (hnh nh rt p) l nhng du hiu gi
bnh l mch mu thn mt bn nhng t l phn trm ca dng tnh gi v m tnh gi
ca phng php ny kh cao.
- Chp thn bng ng v phng x vi cht DTPA hoc Hippuran nh du cho php nghin
cu s mt cn xng ca lc, phng php ny cng khng c nhy hn cc phng
php khc.
- o hot tnh renin huyt tng trong mu tnh mch ngoi bin: khng phi l mt xt
nghim nh hng v nhy thp (57%) v c hiu cng khng cao (66%). Rnin huyt
tng tng trong 15% trng hp tng huyt p nguyn pht v bnh thng trong hn 20%
trng hp tng huyt p do bnh l ng mch thn.
Ni chung hin nay khng c xt nghim khng xm nhp no loi tr chn on bnh tng
huyt p do bnh l mch thn, nu kt qu ca cc xt nghim ny l m tnh. Nhng du
hiu lm sng vn c gi tr gip quyt nh thc hin chp ng mch thn khng nh
tng huyt p do bnh l ng mch thn.
385
nh lng renin 2 mu mu ca 2 tnh mch thn (t l 1.5) cng l 1 bng chng c gi
tr. Nhng mt kt qu iu tr tt c th t c trong 50 n 75% trng hp khi t l ny
l di 1.5, v vy xt nghim ny cng c nhng hn ch ca n.
Ngy nay ngi ta cn lm nghin cu chp nhp nhy thn bng DPTA v hoc Hippuran
trc v sau s dng thuc c ch men chuyn. Trong trng hp hp ng mch thn ghi
nhn sau khi s dng thuc c ch men chuyn c ri lon chc nng bi tit ca thn so vi
bn thn lnh.
Trong hp ng mch thn hai bn chn on thng l kh khn. Thng bnh nhn c 1
tng huyt p rt nng kh kim sot, suy gim chc nng thn l thng gp. Suy thn cp
xy ra khi s dng thuc c ch men chuyn gip gi nhiu n hp ng mch thn 2 bn,
ch c chp ng mch thn mi cho php khng nh chn on.
Gu D. v cng s nghin cu cc phng php thm d hnh nh ca hp ng mch thn
v c kt lun v nhy cng nh c hiu ca tng phng php theo bng sau (2002)
Bng 1: NHY V C HIU CA CC PHNG PHP THM D NG
MCH THN:
PHNG PHP NHY (%) C HIU (%)
Chp ng mch thn 99 99
Chp cng hng t 97 95
CT-Scanner (c dng Captopril) 93 95
Siu m Doppler ng mch thn 86 93
Chp ng mch nh s (qua tnh
mch)
88 89
UIV phim sm 74 86
Tm li, vic chn on xc nh hp ng mch thn hu nh vn da hon ton vo cc
thm d hnh nh, trong chp ng mch thn vn gi mt vai tr quyt nh. Lm sng
ch mang tnh gi v xt nghim khng xm nhp c a chung nht cho n nay l siu
m Doppler ng mch thn.
VII. IU TR
1. Nhng bin php iu tr p dng trong bnh ng mch thn.
iu tr l tng l cha lnh tng huyt p ng mch bng cch sa cha nhng thng tn
ng mch gy ra t thiu mu thn. S iu chnh, sa cha ny c th thc hin bi can
thip phu thut hoc bi chnh hnh mch mu qua da (nong ng mch qua da). iu tr
thuc hin nay c th bnh thng ho c huyt p nhng thuc khng tc ng ln c
nguyn nhn ca bnh l ng mch thn.
1.1. iu tr thuc
Thng s dng thuc c ch men chuyn, kt hp vi thuc li tiu, thuc chn bta, cc
thuc c ch canxi i khi cng c dng.
Tng huyt p thng c kim sot tt bng vic phi hp thuc trong a s cc trng
hp. Ch rng vic dng thuc, c bit l thuc h huyt p nhm c ch men chuyn c
th lm mt tnh t iu ho ca thn, lm gim lc cu thn, cho nn cn phi kim tra chc
nng thn mt cch u n khi dng nhm thuc ny. Trong trng hp hp ng mch thn
2 bn th nhm thuc c ch men chuyn b chng ch nh.
386
1.2. iu tr phu thut
Vi mc ch loi tr tn thng ng mch hoc nhng hu qu thiu mu. C th can thip
bng cch bc tch lp ni mc, bt cu ni ng mch hoc ct trc tip on tn thng tu
theo v tr, mc tn thng cng nh tnh trng suy thn quyt nh la chn phng
php.
1.3. iu tr chnh hnh mch mu qua da
Cho php lm dn ch ng mch b hp. c s dng gn 20 nm nay, ngy cng c
p dng rng ri. u im ca phng php ny l th thut nh nhng, thi gian hu phu
ngn, kt qu rt tt.
Vic la chn bin php iu tr no thch hp cho ngi bnh cn nhc n tui ca
ngi bnh, trm trng v v tr ca ch tc, x va ng mch nhng ni khc v hu
qu nh hng ca tnh trng x va ln cc tng.
Trong trng hp lon sn mch mu thn, thng gp ngi tr, chnh hnh mch mu
hoc phu thut l cc phng php c chn la v thng cho kt qu tt, cho php cha
lnh tng huyt p.
Trong nhng trng hp x va ng mch, phu thut hoc chnh hnh mch mu cn phi
cn nhc k v nhng bin chng, nht l gim chc nng thn c, vic nh gi chc nng
thn cn li l yu t quyt nh cho chn la bin php iu tr.
2. iu tr c th ca tng nguyn nhn
2.1 Nhng bnh vi mch huyt khi.
- iu tr nguyn nhn.
- Dng huyt tng ti trong lc lc huyt tng.
- Liu php corticoid liu cao.
- Tin lng sng ph thuc vo nguyn nhn, t l t vong khong 30 - 40%.
2.2. X ho mch mu thn c tnh.
y l mt iu tr cp cu. Mc ch
- Kim sot huyt p: iu tr thng s dng
+ Nicardipin tnh mch (Loxen) 1 - 10mg/ gi.
+ Labetalol tnh mch (Trandate) 0.5 - 1 mg/ pht.
+ V c ch men chuyn bng ng ung sau khi bnh thng ho th tch.
- Kim sot th tch mu: nh gi th tch mu l cn thit
+ Trong trng hp gim th tch mu; iu chnh nhanh bng dung dch nc mui sinh l.
Chng ch nh dng cc thuc tiu.
+ Trong suy tht tri, nn s dng thuc li tiu quai.
Thng thng trong thng u tin chc nng thn b h hng (nng ln do gim ti mu)
v i khi cn lc mu. V sau chc nng thn ci thin dn v c th tr li bnh thng nu
huyt p c ch ng tt (<130/80 mmHg).
2.3. Thuyn tc do tinh th cholestrol
- iu tr triu chng l chnh (ngng chng ng, kim sot huyt p, lc mu).
387
- Liu php corticoid thngc s dng, n lm gia tng thi gian sng.
- Tin lng ni chung l xu: T vong trn 40% sau 6 thng.
2.4. Vim quanh ng mch dng nt
Vim quanh ng mch dng nt khng gn lin vi vim gan virt: iu tr bng corticoid
i khi cn cyclophoshamid hoc Azathioprine trong nhng th nng.
Trong trng hp c lin quan vi vim gan virt B: iu tr khng virut (Lamivudine) kt
hp vi corticoid.
2.5. X cng b
- Gy thng tn thn cp: Tng huyt p c tnh vi hi chng tn huyt v tng ur mu
- iu tr cp cu vi h huyt p c bit l c ch men chuyn.
2.6. Hp ng mch thn
- Hp do lon sn si x: chnh hnh mch mu thn qua da l c chn la. Cho php cha
lnh huyt p trong 70 - 90% trng hp. Hp tr li l him.
- Hp do x va: c 2 mc ch iu tr l: kim sot huyt p v bo tn chc nng thn Sa
cha li ng mch thn bng chnh hnh hoc phu thut c ch nh khi:
+ Thn kch thc > 8 cm pha c hp ng mch.
+ Tng huyt p nng, khng iu tr, vi ph phi, suy thn.
+ Hp trn 75% lng ng mch thn.
+ Hp 2 bn hoc 1 bn trn 1 thn c nht.
2.7. X ho mch mu thn lnh tnh
- Khng c iu tr c hiu, iu tr bao gm
+ iu tr tng huyt p: Cn thit kt hp 2 thuc, trong c mt c ch men chuyn
(bov thn)
+ Sa cha nhng yu t nguy c tim mch.
+ Lm chm tin trin suy thn mn: ch rng iu tr tt tng huyt p v thiu mu (nu
c) l hai yu t chnh gip cho bnh nhn gi c chc nng thn mt cch ne nh trong
thi gian di.
+ iu tr nhng bin chng ca suy thn mn.


388
VIM NG THN CP
Mc tiu
1. Trnh by c nguyn nhn ca vim ng thn cp.
2. M t c c ch sinh bnh ca vim ng thn cp.
3. Tp hp c cc triu chng lm sng, cn lm sng vim ng thn cp.
4. Chn on xc nh, chn on phn bit ca vim ng thn cp
5. Bit cch iu tr vim ng thn cp theo tng giai on.
Ni dung
I. I CNG
Vim ng thn cp l bnh l thng gp gy nn suy thn cp, cn c gi l hoi t ng
thn cp hoc l bnh ng k thn cp. Tn thng ch yu ca bnh l ny l hoi t lin
bo ng thn, l mt bnh l nng v t l t vong cn rt cao nu khng c x tr mt cch
kp thi v c hiu qu.
II. NGUYN NHN
C rt nhiu nguyn nhn gy nn vim ng thn cp nhng tu trung c th chia lm 3 nhm
ln:
1.Hoi t ng thn sau thiu mu.
Tt c nhng nguyn nhn no m lm cho s ti mu thn gim st ko di u c th lm
cho thn thiu mu v gy nn thng tn di dng hoi t ng thn.
Nguyn nhn gim ti mu thn c chia lm 2 nhm:
1.1.Ngun gc trc thn
- Sc gim th tch mu: sau m, sau chn thng, bng, sy no thai, mt nc, mt mui.
- Sc nhim khun, nhim c.
- Sc tim.
1.2.Ngun gc ti thn
Thng gp nht l do nhng tc dng ngoi ca mt s thuc khi s dng trn mt vi c
a c bit: thuc khng vim khng phi stroids, thuc h huyt p, thuc c ch men
chuyn khi s dng bnh nhn hp ng mch thn hai bn.
2. Hoi t ng thn cp do ng c
C th trc tip ln trn t bo ng thn hoc gin tip ln c ch mch mu v t gy
thiu mu thn.
2.1.Thuc
- Cc thuc khng sinh, nht l nhm Aminosides. Trong nhm ny c nht l Nomycin,
cc loi khc t c hn nh Streptomycine, Kanamycine, Gentamycine. Cc cphalosporine
c vi thn nht l Cfaloridine.
- Cc sn phm iod cn quang.
- Cc thuc chng U: Ciplastine, Cilosporine, Interfron.
- Mt s thuc khc nh Phenylbutazone cc thuc gy m (methoxyfluzan).
389
2.2.Mt vi sc t ni sinh nh huyt sc t (Hb), sc t c (myoglobin)
2.3.Cc ho cht thng dng nh Tetsra Cloruacarbon (CCl4), cn Mtylic.
2.4.c t ca sinh vt:
- Mt c trm, c m, c chp.
- Mt cc.
3. D ng
Cn gi l vim thn k cp d ng (NIA immuuo-allergique) nguyn nhn do thuc l
thng gp: Mthicilline, Pnicilline, khng vim khng phi Stroides, thuc li tiu,
Cimtidine.
III. GII PHU BNH
Tn thng v mt vi th nhiu mc khc nhau v c bit n khng song song vi mc
nng nh ca cc biu hin lm sng. Tn thng bao gm
1. t chc k
Ph n t chc k, xm nhp t bo vim.
2. ng thn
Thng tn ng thn khng ging nhau gia cc on ca ng thn.
- Nh vi lin bo ng thn b dt hoc b dn, nht l ng ln xa.
- Trung bnh vi hoi t cc lin bo ng thn, t bo ng thn mt nguyn sinh cht v nhn.
- Nng hn hoi t tng on ng thn v c th t tng on ng thn.
Ngoi ra trong lng ng thn cn cha cc tr v xc t bo ng thn, cc sc nh Hb, sc t
mt.
3. cu thn v mch mu
Nhn chung l bnh thng. Trong giai on sm bng k thut min dch hunh quang c th
pht hin fibrin trong lng mao mch cu thn.
IV. C CH SINH BNH
Vim ng thn cp gy nn suy thn cp thng c nhiu c ch tham gia: gim lc cu thn,
tc nghn ng thn, khuch tn ngc tr li dch lc cu thn. Trong 3 c ch ny th gim
lc cu thn l c ch c bn nht.
1. Gim lc cu thn
Mt cch khi qut, gim lc cu thn l hu qu ca 3 c ch chnh sau y:
1.1.Gim dng mu thn
- Hoc do co tiu ng mch n, ngun gc l do tng Angiotensin II (gi thuyt ca
Thurau)
- Hoc do mt tnh t iu ho ti thn do tnh nhy cm ca c vng mao mch gia tng di
tc ng ca cc Catcholamin.
1.2.Gim tnh thm cu thn
- Do gim din tch lc bi co cc si c gian mch.
390
- Do gim h s thm ca mng (Kf) th pht sau tc ng ca Angiotension II hoc ca
vasopressine.
1.3.Ti phn b dng mu thn
T vng v sang vng ty do vai tr ca nhng hcmn tc dng mch, Catcholamin v
Angiotensin II, s ti mu c u tin i vi cc nphron c kh nng ti hp thu mnh.
2. Tc nghn ng thn
Do cc t bo hoi t, cc sc t lm nghn ng thn gy triu chng i t, v niu.
3. Khuch tn ngc tr li dch lc
Hoi t ng thn dn n tng tnh thm ti ch v lm cho mt lng dch lc ca cu thn
c khuch tn tr li theo cc mch mu xung quanh ng thn.
V. LM SNG V CN LM SNG
1. Lm sng
Lm sng ca vim ng thn cp biu hin l mt hi chng suy thn cp i khi km theo
vi bnh cnh ca mt vim gan cp (gp trong bnh nguyn ng c).
Tnh hung pht hin bnh vim ng thn cp rt khc nhau: thng c pht hin l
triu chng thiu, v niu, i khi c pht hin qua mt bin chng nng nh dch ngoi
bo (tng huyt p, ph phi) hoc nhng ri lon nc in gii khc hoc bnh cnh ca hi
chng tng ur mu.
Lm sng tri qua 5 giai on:
1.1.Giai on tn cng thn
Thi gian ca giai on ny ty thuc vo nguyn nhn: cp v t ngt (sc, xut huyt)
hoc chm v ko di (khng sinh c vi thn).
1.2.Giai on thiu, v niu ban u
Xut hin trong 24 n 72 gi sau . Lm sng biu hin:
- dch ngoi bo (tng cn, ph ngoi bin, kh th gng sc)
- ng cc cht azt: du hiu ton thn, ri lon tiu ho, i khi l nhng chm xut
huyt di da.
1.3.Giai on thiu v niu tht s
Thi gian thay i t 7 n 21 ngy. Lm sng ca giai on ny l hi chng tng ur mu
cp in hnh (xem bi Hi chng tng ur mu).
1.4.Giai on i nhiu
Thng xut hin khong tun th ba ca v niu, c khi sm hn, lng nc tiu tng ln
dn. Trong giai on ny i khi cn cn thit phi lc mu, nhng quan trng hn l b li
lng dch, in gii mt.
1.5.Giai on phc hi chc nng thn.
Ur, cratinine mu tr li bnh thng hoc ging vi tr s trc y cha c suy thn cp.
Ngoi ra trn lm sng ca vim ng thn cp cng cn lu nhng th vn c lng
nc tiu khng thiu v v niu, c im ca th ny l:
- Chn on thng chm.
391
- Thng tn thn thng t nng, tin lng thng tt.
- y l th thng gp khi s dng sm li tiu Furosmide v hoc dn mch.
- iu tr lc mu, dinh dng cng ging nh th v niu.
2. Cn lm sng
Ngoi nhng xt nghim tm nguyn nhn cn c nhng xt nghim xc nh suy thn cp,
bao gm:
- Tng ur, cratinin, acide urique mu.
- Ri lon nc in gii: tng Kali mu, h Natri mu, h Calci mu, tng phosphat mu l
nhng ri lon thng gp trong suy thn cp.
- Ri lon toan kim: nhim toan.
VI. CHN ON
1. Chn on xc nh da vo
- Khi pht bnh cp tnh.
- Lm sng vi thiu, v niu lc khi u v c giai on i nhiu sau .
- Xt nghim ur, cratinin, Kali mu tng dn.
2. Chn on phn bit
- Cn phn bit suy thn cp do vim ng thn cp l suy thn cp thc th vi suy thn cp
chc nng do cc nguyn nhn khc (bi suy thn cp).
- Cn phn bit th bnh thiu, v niu v th bo tn nc tiu.
- Cn chn on phn bit gia vim ng thn cp vi cc bnh l khc nh vim cu thn
cp, si tc niu qun.
VII. IU TR
Bao gm iu tr triu chng, bin chng ca vim ng thn cp (tu thuc vo giai on ca
vim ng thn cp p dng c th) v iu tr nguyn nhn
3.1.Trong giai on sm (giai on tn cng thn):
X tr ngay cc nguyn nhn gy vim ng thn cp:Loi b cht c trong nguyn nhn do
ng c.B dch, b mu trong hoi t ng thn cp sau thiu mu,bng cch:
- iu chnh ngay h huyt p bng cch truyn cc dch keo (albumin, plasma) hoc mui
ng trng.
- Cc thuc tc dng trn mch mu: dopamin liu 3(g/kg/pht ci thin dng mu thn.
3.2.Giai on i t v niu
Mc ch c bn trong giai on ny l
- Gi cn bng ni mi
- Hn ch tng Kali mu
- Hn ch tng ur mu
3.2.1 Nc
392
bnh nhn v niu m bo cn bng m ngha l lng nc vo t hn lng nc ra.
Thng thng cho khong 500ml nc k c n ln ung. Trong nhng trng hp v niu
do mt nc mt mui th phi b dch.
3.2.2 in gii v toan mu
- iu tr tng Kali mu
+ Hn ch a Kali t ngoi vo: rau qu nhiu kali, thuc dch truyn c kali
+ Loi b cc hoi hoi t, chng nhim khun.
+ Li tiu: nhm o thi nc in gii, c bit l kali, c ch nh khi khng c bng
chng c tc nghn sau thn, bt u c th d liu bng Lasix 20mg x 4 ng tim tnh mch,
c th cho liu cao 200mg - 500mg/ 24 gi.Liu rt cao c th c ch nh nh Furosmide
1000mg/24 gi bng truyn chm qua bm tim in. Ngoi furosemide c th s dng
bumtamide hoc acide etacrynic.
+ Truyn natribicacbonat
C th truyn natribicacbonat 1,4% hoc 4,2% khi ngi bnh c mt lng nc tiu nht
nh (V d 300 - 500ml). C th tim tnh mch natribicacbonat 8,4% nu mun hn ch
lng nc a vo, B Natri bicacbonat gip ci thin toan mu, t hn ch vic di
chuyn kali t ni bo ra ngoi bo.
+ Truyn glucose u trng km insulin tc dng nhanh nhm y kali vo khu vc ni bo
+ Cho Canxi tim tnh mch chm trong cc trng hp tng kali mu nng, cp cu (nht l
c biu hin tim mch).
+ C th dng cc Rsin trao i ion nh resonium, Kayexalat (30 gam/24 gi) thi kali
qua ng phn
+ Nu kali mu 6,5 mmol/l th cn ch nh lc mu ngoi thn.
3.2.3 iu tr cc ri lon in gii khc
+ Natri v clo: Natri mu h thng l do nc. Tt nht l hn ch nc. Khi Natri mu h
nhiu cn phi b Natri.
+ Canxi: Trong vim ng thn cpt khi c h Canxi mu. Nu c xut hin Ttani do
h Canxi mu c th cho Canxi clorua hoc Canxi gluconate.
3.2.4. iu tr tng ur mu
- Ch n gim m, calo t nht l 35 kcalo/kg / 24 gi, vitamin.
- Cc thuc tng ng ha prtide nh Durabolin 25mg/ngy, Testosteron 25mg/ngy.
- B sung thm vin ketosteril: 1 vin 600mg cho 5 kg cn nng/ ngy.
- Loi b cc nhim khun
- Ch nh lc mu: nn ch nh lc mu sm bng thn nhn to hoc thm phn mng
bng. Ch nh lc mu khi:
+ Kali mu 6,5 mmol/
+ Ur mu > 35mmol/l
+ Cratinin mu > 600mmol/l.
+ C biu hin toan mu.
393
3.3.Trong giai on tiu nhiu
giai on ny, tuy i nhiu nhng chc nng thn cha hi phc. Nhng ngy u ca giai
on i nhiu nng ur, cratinin mu cn tng nn iu tr tng ur mu i khi cn
ging nh giai on tiu t v v niu.Trong giai on ny, v tiu nhiu nn gy mt nc
mt in gii. iu tr nhm:
- Tip tc hn ch prtid trong thc n, ch tng prtid khi ur mu gim mc an ton
(10 mmol/l).Cho ch n ung c kali (hoa qu) khi kali mu bnh thng.
-Truyn dch hoc ung chng mt nc, mt in gii. Trong trng hp lng nc tiu
> 3lt/24 gi cn b bng ng truyn tnh mch. Lng dch b tu theo lng nc tiu.
Sau 5 - 7 ngy tiu nhiu c th hn ch dn lng dch truyn v theo di v lc ny thn
bt u chc nng c c.
3.4. Trong giai on hi phc
- Trung bnh sau 4 tun iu tr th chc nng thn bt u hi phc tt v bnh nhn c th
xut vin
- Cn theo di nh k hng thng cho n khi chc nng thn hi phc hon ton.
- Khi ur mu tr v bnh thng th tng dn khu phn prtid, m calo, vitamin m
bo hi phc sc kho tt.
3.5 iu tr nguyn nhn.
Ty thuc vo nguyn nhn gy ra vim ng thn cp.
- iu tr khng sinh trong nguyn nhn nhim khun.
- Loi b cht c trong nguyn nhn ng c.
- Ngng cc thuc khng vim khng phi stroids, thuc c ch men chuyn
Ngng cc thuc khng sinh, Cc sn phm iod cn quang, Cc thuc chng ung th:
Ciplastine, Cilosporine, Interfron, Phenylbutazone... nu nguyn nhn do thuc.
- iu tr st rt trong st rt i huyt sc t....
394
CU HI NH GI

Cu 1: Nguyn nhn ca hi chng thn h.
Cu 2: Chn on xc nh v chn on bin chng ca hi chng thn h.
Cu 3: iu tr hi chng thn h.
Cu 4: Triu chng lm sng c cn lm sng ca vim cu thn cp.
Cu 5: iu tr vim cu thn cp.
Cu 6: Cc loi si h tit niu thng gp trn lm sng nc ta (theo cu trc ha hc ca
si).
Cu 7: Triu chng lm sng ca si h tit niu.
Cu 8: iu tr ni khoa si h tit niu.
Cu 9: Phn loi vim cu thn mn nguyn pht theo tn thng gii phu bnh.
Cu 10: c im lm sng v cn lm sng ca vim cu thn mng.
Cu 11: iu tr vim cu thn mng.
Cu 12: Thay i gii phu v chc nng ca h thng thn tit niu trong thai k.
Cu 13: Triu chng v iu tr nhim trng ng tiu xy ra trong thai k.
Cu 14: Nu c im ca thai nghn xy ra trn mt s bnh l thn tit niu mn tnh
thng gp.
Cu 15: Nu nguyn nhn, ng vo v cc yu t thun li ca vim thn b thn.
Cu 16: Triu chng lm sng, cn lm sng ca vim thn b thn cp.
Cu 17: iu tr vim thn b thn cp.
Cu 18: Triu chng lm sng v cn lm sng ca vim thn b thn mn.
Cu 19: Nu nguyn nhn suy thn cp.
Cu 20: Nu 4 giai on lm sng ca suy thn cp.
Cu 21: iu tr suy thn cp thc th giai on thiu v niu.
Cu 22: Nu nguyn nhn ca suy thn mn.
Cu 23: Biu hin lm sng ca suy thn mn.
Cu 24: Chn on giai on ca suy thn mn.
Cu 25: iu tr bo tn cho suy thn mn trc giai on cui.
Cu 26: Chn on xc nh bnh thn i tho ng.
Cu 27: Chn on giai on bnh thn i tho ng theo tc gi Mogenson.
Cu 28: iu tr bnh thn i tho ng.
Cu 29: Triu chng lm sng ca bnh thn a nang.
Cu 30: Triu chng cn lm sng ca bnh thn a nang.
Cu 31: iu tr bnh thn a nang.
Cu 32: Nguyn nhn v biu hin lm sng ca hp ng mch thn.
395
Cu 33: Triu chng cn lm sng ca hp ng mch thn.
Cu 34: iu tr hp ng mch thn.
Cu 35: Nguyn nhn gy vim ng thn cp.
Cu 36: C ch sinh bnh ca vim ng thn cp.
Cu 37: Triu chng lm sng v cn lm sng ca vim ng thn cp.
Cu 38: iu tr vim ng thn cp giai on tiu nhiu.

396
TI LIU THAM KHO
1. Trn Vn Cht v cng s (2004), Bnh thn ni khoa, nh xut bn y hc, H Ni.
2. Nguyn vn Xang, th Liu (2002), Bi ging bnh hc ni khoa, Nh xut bn Y hc
3. Nguyn Vn Xang, th Liu (2002), iu tr hc ni khoa, NXB Y hc, H Ni
4. College Universitaire des Enseignants de Nphrologie (2003), Nphrologie, ellipses.
5. P.Barjon (1991), Nphrologie, Facult de Mdecine Montpellier - Nimes.
6. Therapy in nephrology and hypertension. WB Saunders Company. 1999.
7. Harrison (2005). Principle of internal medicine, 16
th
edition.
8. P. Jungers, Nguyen Khoa Man, C. Legendre (1998), L'insuffisance rnale chronique:
prvention et traitement, Mdecine-Sciences, Flammarion. Paris.
9. John T. Daugirdas, Todd S. Ing (1994), Handbook of Dialysis, Little, Brown and
Company.
10. Shubhada N. Ahya, Kellie Flood et al (2001), Renal diseases, The Washington manual of
medical therapeutics, Lippincott Williams & Wilkins, 256-274.
11. Suzane Watnick, Gail Morrison (2008), Kidney disease, Current medical diagnosis and
treatment 47
th
edition, Mc Graw Hill, pages 785-815.
11. Thomas E. Andreoli et al (1988), Renal diseases, Textbook of medicine. WB Saunders
Company 502-655.


397
CHNG 5
C XNG KHP

VIM KHP DNG THP
Mc tiu
1. M t c nguyn nhn v c ch sinh bnh ca vim khp dng thp
2. Trnh by c triu chng lm sng v cn lm sng ca vim khp dng thp
3. M t c tiu chun chn on v chn on phn bit.
4. Trnh by c cc phng tin iu tr truyn thng vim khp dng thp
5. M t c cc phng tin iu tr mi.
Ni dung
I. I CNG
1. nh ngha
Vim khp dng thp (VKDT) l mt bnh thp khp mn, t min, ch yu n. y l
mt bnh mang tnh cht x hi v thng gp, din bin ko di v di chng do n li.
2. Dch t hc
- L bnh thng gp nht trong cc bnh khp. Vit Nam t l mc bnh l 0,5%
trong nhn dn v 20% s bnh khp nm iu tr ti bnh vin. Bnh gp mi ni trn th
gii, chim 0,5%-3% dn s ngi ln (theo tc gi Trn Ngc n, hi thp khp Vit
Nam)
- 70 - 80% l n gii v 60 - 70% c tui trn 30.
- Mt s trng hp c tnh cht gia nh.
II. NGUYN NHN V C CH SINH BNH
1. Nguyn nhn: L mt bnh t min vi s tham gia ca nhiu yu t
- Tc nhn gy bnh: c th l vi khun, vi rt, d nguyn nhng cha c xc minh
chc chn.
- C a: bnh c lin quan r rt n gii v tui.
- Di truyn: bnh c tnh cht gia nh v 60-70% bnh nhn mang yu t khng nguyn
ph hp t chc HLA-DR4 (trong khi ngi bnh thng l 30%)
- Yu t thun li: sau sang chn, c th suy yu, sinh , lnh m ko di...
2. C ch sinh bnh
Lc u tc nhn gy bnh tc ng nh khng nguyn, n gi vn cha bit l khng
nguyn g, gy bnh trng dng t bo T c khng nguyn kch thch trn nhng c th
cm nhim di truyn trong giai on u ca bnh. Mt tiu nhm t bo T hot ho trong
mng hot dch sn xut nhiu cytokine khc nhau bao gm: Interferon (IFN- ),
interleukin 2 (IL2), IL6 v yu t hoi t u (TNF -), c tc dng gy vim mng hot dch
ko di, c trng ca VKDT. Kch thch thm cc t bo khc trong mng hot dch (bch
cu n nhn, t bo B, t bo mng hot dch ging nguyn bo si), bng cytokine hoc tip
398
xc trc tip vi t bo T hot ho, s dn n giai on bnh th hai ph hu nhiu hn. Cc
bch cu n nhn hot ho v t bo mng hot dch ging nguyn bo si khng ch sn
xut cc cytokine tin vim, khc nhau (c bit l IL.1 v TNF -) v cc yu t tng trng
c th lm phc tp thm tnh trng vim, m cn kch thch s sn xut cc metalloproteinase
ca cht nn v cc protease khc. Chnh nhng tc nhn ny lm trung gian ph hu cht nn
ca m khp c trng ca giai on ph hu trong VKDT.
III. TRIU CHNG LM SNG
1.Vim khp
1.1. Khi pht: 85% bt u t t, tng dn, 15% t ngt vi cc du vim cp; a s bng
vim mt khp, l mt trong cc khp bn tay (c tay, bn ngn, ngn gn), gi. Ko di
t vi tun n vi thng ri chuyn qua giai on ton pht.
1.2. Ton pht: Vim nhiu khp
- V tr: Sm l cc khp chi, tri xa gc
+ Chi trn: c tay, bn ngn, ngn gn nht l ngn 2 v ngn 3.
+ Chi di: gi, c chn, bn ngn v ngn chn.
Mun l cc khp: khuu, vai, hng, t sng c, thi dng hm, c n.
- Tnh cht: Xu hng lan ra 2 bn v i xng:
+ Sng, au v hn ch vn ng, t nng , c th c nc khp gi.
+ au tng nhiu v m gn sng, cng khp bui sng.
+ Cc ngn tay c hnh thoi, nht l cc ngn 2 v ngn 3.
+ Bin dng khp c trng xut hin chm hn: bn tay gi thi, bn tay lng lc .
2. Triu chng ngoi khp
2.1. Ton thn: St nh, da xanh, n ng km, gy, ri lon thn kinh thc vt.
2.2. Biu hin cn khp
- Ht di da: ni g ln khi mt da, chc, khng au d: 0,5-2cm thng gp trn xng
tr gn khp khuu, trn xng chy gn khp gi, s lng t mt n vi ht.
- Da kh teo, ph 1 on chi, hng ban lng bn tay.
- Teo c: r rt vng quanh khp vim, vim gn: hay gp gn Achille.
2.3. Rt him gp trn lm sng:
- Tim: Tn thng c tim kn o, c th c vim mng ngoi tim.
- Phi: Vim mng phi nh, x ph nang.
- Lch: lch to v gim bch cu trong hi chng Felty
- Xng: mt vi, gy t nhin.
Ngoi ra cn c: vim gic mc, vim mng mt, p cc dy thn kinh ngoi bin, thiu
mu nhc sc, ri lon thn kinh thc vt, nhim Amyloid c biu hin ch yu thn,
thng xut hin rt mun.
IV. CN LM SNG
Gm X quang, du sinh hc v sinh thit
399
1. X quang: Giai on u thy mt vi vng u xng. Sau l khuyt xng hay n
mn xng phn tip gip vi sn khp, ri hp khe khp. Sau cng l hu phn sn khp v
u xng gy dnh v bin dng khp.
2. Du sinh hc: Gm du vim, ri lon min dch, dch khp.
- Tc lng mu tng,
2
globulin tng, hng cu gim.
- Waaler Rose: Pht hin yu t thp trong huyt thanh. Phn ng dng tnh khi ngng kt
vi pha long huyt thanh bnh nhn t 1/32.
- Dch khp: gim nhy, tng bch cu, t bo hnh nho 10% s t bo dch khp. t bo
hnh nho l nhng bch cu a nhn trung tnh nut nhng phc hp min dch.
3. Sinh thit: Mng hot dch hay ht di da.
- Sinh thit mng hot dch thy nm tn thng: s tng sinh cc hnh lng ca mng hot
dch, tng sinh cc lp ph hnh lng, xut hin nhng m hoi t ging nh t huyt, tng
sinh mch mu tn to, thm nhp nhiu t bo vim quanh cc mch mu. Khi c t ba tn
thng tr ln c th hng n chn on xc nh.
- Sinh thit ht di da: gia l mt m hoi t dng t huyt, chung quanh bao bc bi
nhiu t bo Lympho v tng bo.
V. TIN TRIN
Bnh din bin ko di nhiu nm, phn ln l tin trin t t v tng dn. Da theo
chc nng vn ng v tn thng X Quang, ngi ta chia din bin ca bnh thnh 4 giai
on (giai on ca Steinbroker):
- Giai on I: tn thng mi khu tr mng hot dch, sng au ch phn mm, X Quang
cha c thay i, bnh nhn cn vn ng c gn nh bnh thng.
- Giai on II: tn thng nh hng mt phn n u xng, sn khp. Trn hnh nh X
Quang c hnh khuyt, khe khp hp. Kh nng vn ng b hn ch, tay cn nm c, i li
bng gy (nng).
- Giai on III: tn thng nhiu u xng, sn khp, dnh khp mt phn. Kh nng vn
ng cn t, bnh nhn ch cn t phc v mnh trong sinh hot, khng i li c.
- Giai on IV: dnh khp v bin dng trm trng, mt ht chc nng vn ng, tn ph hon
ton. Giai on ny thng gp sau 10-20 nm.
VI. CHN ON
1. Chn on xc nh: Cn phi sm iu tr c kt qu
1.1. Tiu chun ca hi thp hc M 1987: Gm 7 im, trong tiu chun t 1 - 4 phi c
thi gian t nht 6 tun, chn on dng tnh cn t nht 4 tiu chun, l
- Cng khp bui sng: ko di t nht 1 gi.
- Sng au t nht 3 nhm khp trong s 14 nhm: ngn tay gn, bn ngn tay, c tay, khuu,
gi, c chn, bn ngn chn (2 bn = 14).
- Sng au 1 trong 3 khp ca bn tay: ngn gn, bn ngn, c tay.
- Sng khp i xng.
- C ht di da.
- Phn ng tm yu t thp huyt thanh dng tnh (Waaler-Rose +).
400
- Hnh nh X quang in hnh.
1.2. Tuyn c s thiu cn lm sng: chn on c th da vo cc im sau
- Ph n 30-50 tui.
- Vim nhiu khp xa gc chi.
- Khi u t t, tin trin t nht 6 tun.
- au tri v m v cng khp bui sng.
2. Chn on phn bit
- Giai on u (< 6 tun): Cn phn bit vi:
+ Thp khp cp: da vo tui, tnh cht vim...
+ Thp khp phn ng: sau cc bnh nhim khun, khng i xng.
+ Hi chng Reiter: Vim khp, vim niu o v kt mc mt.
- Giai on sau (> 6 tun): phn bit vi
+ Thoi khp: ln tui, khng c du vim.
+ au khp trong bnh to keo nht l luput ban .
+ Vim ct sng dnh khp: nam gii, au ct sng lng, tht lng cng chu.
+ Bnh Gt: acid uric tng cao trong mu.
VII. IU TR
Kt hp nhiu bin php: Ni, ngoi, vt l, chnh hnh.
1. Th nh
S khp vim t, vn ng gn nh bnh thng (giai on I)
- Aspirine: 1-2g/ngy, chia nhiu ln.
- Chloroquine: 0,2-0,4g/ngy, tc dng c ch men tiu th.
- Thuc dn tc: cy xu h, hy thim, l lt.
- Tp luyn, iu tr vt l, in, siu m, nc sui khong...
2. Th trung bnh
Nhiu khp b vim, vn ng b hn ch (giai on II).
- Ging nh th nh nhng cn thm:
- Dng mt trong cc thuc chng vim nonsteroid: Indomethacine 50-100mg/ngy,
Diclofenac: 100 - 150mg/ngy; Piroxicam 20mg/ngy.
- C th dng Corticoid liu trung bnh.
3. Th nng
Khng i li c, vn ng cn t hoc mt ht (giai on III).
- Corticoid liu cao: dng ngn hn, bng ung hoc TM.
- Dng mt trong cc liu php: Mui vng: tng liu 1500-2000mg; D-Penicilamin:
300mg/ngy; Methotrexate: 7,5-10mg/tun; Cyclophosphamide: 1-2mg/kg/ngy. Bin php
khc nh trn.
401
4. iu tr mi
Nhng thuc mi c gii thiu sau y iu tr VKDT c th phn thnh 3 loi:
- Thuc c ch Cyclo -oxygnase tp 2 (Cox 2)
- Cc tc nhn sinh hc.
- Thuc chng thp khp lm thay i din tin bnh (DMARD: Disease Modifying Anti -
Rheumatic Drugs).
4.1. Thuc c ch Cox 2
Gn y ngi ta nhn din c t nht l 2 th ng dng ca cyclo oxygnase (Cox):
Cox - 1 l 1 enzyme bn th, c nhiu m v ch yu lin quan n vic sn xut cc
prostaglandin cn thit cho qu trnh hng nh ni mi bnh thng. Tri li, Cox -2 l 1
enzyme cm ng c tm thy cc m lnh vi nng thp, nhng tng ln r rt trong
cc m b vim v lin quan n sinh tng hp PGE2 v tr vim. V cc thuc chng vim
khng steroid (AINS) thng thng c ch vim va c nhiu tc dng ph. Do vy nhng
thuc AINS mi c ch u tin hoc chn lc trn cox-2 th c tc dng chng vim v rt t
tc dng ph, l u im ca cc loi thuc mi.
- MELOXICAM (Mobic): vim 7,5mg v 15mg, ng 15mg.
Liu hng ngy: 15mg/ngy, dng 1 ln trong ngy.
- CELECOXIB (CELEBREX) vim 100mg v 200mg.
Liu hng ngy: 100mg x 2 ln/ngy.
Tc dng ph ca cc thuc trn gm cc tc dng ph chung ca AINS nhng t l v mc
thp hn nhiu so vi cc thuc AINS c in.
Ni chung, cc AINS khng lm chm s tin trin ph hu khp trong VKDT.
4.2. Cc tc nhn sinh hc
S quan tm c tp trung nhiu vo cc tc nhn chng TNF - , 1cytokine vim ch yu c
phng thch bi cc i thc bo mng hot dch, tc ng nh 1 phn t rt quan trng, ch huy
cc loi t bo khc mng hot dch phng thch cc phn t tin vim v ph hu khp. Hai
cht nh th, c cng nhn iu tr VKDT.
- ETANERCEPT: L 1 cht nh trng hp (dimer) gm phn ngoi bo ca 2 th th TNF
ho tan (75kDa) hp nht vi phn Fc trn immuno -globulin G1 (IgG1) ca ngi.
Etanercept gn 1 cch c hiu vi 2 phn t TNF - hoc TNF - tun hon, nn chn s
tng tc ca chng vi th th TNF trn b mt t bo.
+ Ch nh: VKDT t va n nng trn bnh nhn p ng khng y vi 1 hay nhiu
DMARD.
+ Liu lng, cch dng: 25mg tim di da x 2 ln/tun dng trong nhiu thng.
+ Tc dng ph: Phn ng nh ti ch tim.
- INFLIXIMAB: 1 khng th n dng c cu to bi (vng hng nh ca khng th
ngi v cc vng thay i ca chut nhc, c dng bng ng chuyn tnh mch v kt
gn c hiu cc dng TNF - ho tan v xuyn mng.
+ Ch nh: VKDT hot ng
+ Liu lng v cch dng: 10mg/kg chuyn TM liu duy nht, hoc chia ra chuyn TM 2 ln
trong tun.
402
+ Tc dng ph: b vim phi khi dng liu thp. S bt tin khi dng 2 loi thuc trn l
tim di da v chuyn TM c th hn ch s tun th iu tr.
4.3. Thuc DMARD mi
LEFLUNOMIDE: l 1 dn cht ca isoxazole, l thuc DMARD mi nht c cng nhn
iu tr VKDT. Trong giai on khi pht bnh, t bo T CD4 hot ho, tng sinh rt nhanh
leflunomide c ch s tng sinh bng cch ngn chn t bo T sn sinh cc pyrimidine cn
thit cho s tng hp DNA mi trc khi phn bo.
- Trnh by: vim 100mg v vin 20 mg.
- Liu lng v cch dng: 3 ngy u: 100mg/ngy.
T ngy th 4 tr i: 10 - 20mg/ngy.
- Tc dng ph: Cc triu chng tiu ho, ni mn ngoi da v rng tc, hi phc c khi
ngng thuc.
ch li lm sng y ca leflunomide khi dng n c iu tr VKDT ch r rng sau
khi dng hng nm.
Phng php s dng DMARD hu hiu
Trong phng php kim t thp truyn thng, DMARD c bt u dng tng i mun
trong qu trnh bnh v sau khng c s dng 1 cch nht qun. M hnh iu tr hin
nay p dng phng php rng ca: Theo , DMARD c s dng sm sau khi khi pht
VKDT v c tip tc sut qu trnh bnh vi mc ch gi cho tnh trng mt sc ca bnh
nhn gn vi mc bnh thng. Khi tc dng ca thuc DMARD gim i, phc s c
thay i bng cch thm 1 thuc mi vo phc ang dng hoc bng cch thay thuc. Mc
ch ca phng php rng ca l t c s ci thin c bn v kt cc lu di cho bnh
nhn VKDT.
403
THOI KHP
Mc tiu
1. Trnh by c nh ngha v dch t hc ca thoi khp.
2. M t c nguyn nhn c ch sinh bnh, v gii phu bnh.
3. Trnh by c triu chng chnh v lm sng, cn lm sng v chn on thoi khp.
4. Trnh by c cc phng tin iu tr ni khoa v vt l tr liu thoi khp.
Ni dung
I. I CNG
1. nh ngha: L mt bnh mn ca cc khp k c ct sng gy au v bin dng.
2. Dch t hc
- Bnh gp mi dn tc, nam v n mc bnh ngang nhau. Tui cng tng t l cng
cao.
- Bnh vin Bch Mai H Ni: thoi khp chim 10,41% khoa c xng khp
- Php thoi khp chim 28,6% cc bnh xng khp
- M: 80% ngi > 55 tui c du X quang l thoi khp.
Thoi khp theo th t thng gp l: ct sng tht lng, ct sng c, gi, hng...
II. NGUYN NHN V C CH SINH BNH
1. S lo ho
L nguyn nhn chnh ca thoi khp nguyn pht, xut hin mun thng ngi
ln tui (>60), nhiu v tr, tin trin chm, khng nng. T bo sn gi dn, kh nng tng
hp cc cht to nn si collagen v mucopolysacharide s gim v ri lon, cht lng sn
km dn, tnh chu lc v n hi gim, hn na t bo sn ngi trng thnh khng c
kh nng sinh sn v ti to.
2. Yu t c hc
Ch yu gy thoi khp th pht, thng gp ngi tr (di 40 tui), khu tr mt
vi v tr, nng v tin trin nhanh. Yu t ny th hin bng s tng bt thng lc nn trn
mt khp, gi l hin tng qu ti. Gm:
- Tng cn qu mc do bo ph, tng trng ti do ngh nghip.
- Bin dng khp th pht sau chn thng, vim, u, lon sn lm thay i hnh thi,
tng quan ca khp.
- D tt bm sinh lm thay i din tch nn ca cc mt khp.
3. Yu t khc
- Di truyn: c a gi sm
- Ni tit: mn kinh, i tho ng, long xng do ni tit.
- Chuyn ho: bnh thng phong, bnh da xm nu.
404
4. Xu hng mi
Cc nghin cu mi nht tp trung nghin cu nh hng ca cc yu t tng
trng v ca cytokine i vi hot ng chuyn ho ca t chc sn. Hin nay ngi ta
bit r cc cytokine tin vim c bit l Interleukine 1 (IL-1) v TNF- c kh nng lm cho
cc t bo sn tit ra cht metaloproteinase nh collagenase v stromeolysine, chng lm tng
cng s tiu hu ca sn v kt qu dn n s hu sn khng hi phc. sn ngi
cytokine tc dng ch yu bng cch hn ch s tng hp hn l kch thch s phn hy cc t
bo. Tuy nhin ngi ta vn cha r yu t no khc c th kch thch t bo sn tng hot
ng phn t ca chng giai on u.
III. GII PHU BNH
Tn thng c bn ca bnh l thoi ho sn khp v a m, thay i phn xng di sn
v mng hot dch.
- i th: sn khp v a m c mu vng nu, m c, kh, mm, mt dn tnh n hi,
mng v nt rn, c th c nhng vt lot, t chc sn b ph hy l c phn xng di
sn, nhn nhy a m mt tnh cng phng m tr nn mm xp.
- Vi th: t bo sn tha tht, cc si Collagen gy, t nhiu ch, cu trc ln xn, c nhng
phn xng di sn x ho dy ln v c cc hc nh, trong cha cht hot dch. Phn tip
gip gia xng v sn mc nhng gai xng.
IV. TRIU CHNG HC
1. Lm sng
1.1. au: au khi vn ng v gim khi ngh ngi, gi l au kiu "c gii".
1.1.1. V tr: khp hoc on ct sng b thoi ho, t lan xa tr khi c chn p r v dy thn
kinh.
1.1.2.Tnh cht: au m , c th c cn cp ct sng xut hin v tng khi vn ng, thay
i t th, gim au v m v khi ngh ngi (khc au do vim). au khng km sng,
nng, , st.
1.1.3. Din bin: Thnh tng t, di ngn tu trng hp, nhng cng c th au lin tc
tng dn (thoi khp th pht), ht t c th ht au, sau ti pht t khc.
Hn ch vn ng: do au v khi hn ch nhiu thng do cc phn ng co c km
theo. Bnh nhn c th khng lm c mt s ng tc nh quay c, ci st t, ngi xm...,
mt s bnh nhn c du hiu "ph r khp" vo bui sng hoc lc bt u vn ng.
1.2. Bin dng: do mc gai xng, lch trc hoc thot v mng hot dch.
1.3. Triu chng khc
- Teo c: do t vn ng
- Trn dch khp: do phn ng xung huyt v tit dch mng hot dch, thng thy
khp gi.
- Ting lo xo khi vn ng: t c gi tr v c th thy ngi bnh thng hoc trong
cc bnh khc.
2. X quang
C 3 du hiu c bn
2.1. Hp khe khp: hp khng ng u, b khng u, ct sng thy chiu cao a m
405
gim. Hp nhng khng bao gi dnh khp.
2.2. c xng di sn: phn u xng, hm khp mm t sng c hnh m m (cn
quang nhiu) trong phn xng c thy mt s hc nh sng hn.
2.3. Mc gai xng: phn tip gip gia xng, sn v mng hot dch, mp ngoi ca
thn t sng. Gai xng c hnh th v m (khc cu xng), mt s mnh gai xng ri ra
nm trong khp hay phn mm quanh khp.
Mt s phng php chp c bit c th pht hin sm cc tn thng ca sn khp v
a m nh: chp ct lp, chp ct lp t trng, chp bm thuc cn quang vo khp, vo
a m.
3. Xt nghim khc
- Xt nghim mu v dch khp: khng c g thay i
- Ni soi khp: thy nhng tn thng thoi ho ca sn khp pht hin cc mnh gai
xng ri trong khp.
- Sinh thit mng hot dch: gin bit cc bnh khp khc.
V. CHN ON
1. Chn on xc nh
- Khi bnh: tui, tc nhn c hc, tin s...
- Triu chng lm sng.
- Du hiu X quang.
2. Chn on phn bit
Phn bit vi cc bnh khp do vim: ch yu da vo cc du vim.
VI. IU TR
Cc bin php iu tr hin nay nhm lm gim au v phc hi chc nng khp. Mc tiu
ca iu tr thoi khp vn l ng vin tinh thn bnh nhn, bo tn khp, luyn tp chng
teo c v suy gim chc nng khp. S dng thuc gim au hoc chng vim nonstroid,
tim ti ch corticoid. Phi hp ni khoa, vt l, ngoi khoa.
1. Ni khoa
1.1. Gim au
1.1.1. Aspirine
1-2g/ngy - chia nhiu ln.
Acetaminophene: 1,5 -2 g/ngy.
1.1.2. Chng vim nonstroid
- Diclofenac 100 - 150mg/ngy
- Piroxicam 20mg/ngy
- Meloxicam 15mg/ngy
- Clcoxib 100-200mg/ngy.
V nhiu bnh nhn mc bnh tui gi nn cn theo di chc nng gan thn trc v
sau khi iu tr bng thuc chng vim nonstroid, c bit i vi nhng bnh nhn dng
406
thuc ko di.
Khng dng Corticoid ton thn, khi au v sng nhiu c th dng ti ch.
1.2. Tng cng dinh dng sn
Tc dng khng chc chn nh: ni tit t sinh dc (Testosterone), thuc tng ng ha.
Philatop, cao xng...
1.3. Thuc tc dng chm
1.3.1. Glucosamine sulfate
- L hp cht sulfat ca Glucosamine aminomonosaccharide t nhin. Glucosamine,
mt thnh phn t nhin cu thnh glycosaminoglycan sn khp v dch khp. C ch tc
dng ca Glucosamine sulfat cho n nay cha hon ton sng t. Cc tc dng nh c ch
gc t do superoxide, c ch sinh tng hp nitric oxide cng l mt cch gii thch tc dng
nhanh ca thuc trn cc th nghim lm sng ngn hn. Tuy nhin trong th nghim lm
sng di hn th tc dng ca thuc c l do bin i chuyn ho ca sn khp bao gm kch
thch hot ng ng ha nh tng tng hp proteoglycan, gim hot ng d ha ca sn
khp nh tc dng trn cc enzyme metalloprotease.
- Trnh by v liu lng: vin 0,25g, gi 1,5g.
Liu hng ngy l 1,5g. Thi gian dng: nhiu nm. Thuc c an ton cao, cha thy
tc dng ph c ghi nhn.
1.3.2. Chondroitine sulfate
Tc dng bng cch c ch cc men tiu sn, nht l men metalloprotase.
- Trnh by di dng vin, liu trung bnh: 3 vin ngy.
- Thi gian dng: t nht 1-2 thng.
1.3.3. Diacetylrin hoc Diacerhin
y l mt phn t mi thuc nhm anthraquinon, c tc dng c ch sn xut
interleukin-1 v mt s men thoi ha sn. Thuc khng gim t l prostaglandin nn khng
gy tn hi n d dy.
1.3.4. Mt s loi thuc ang c th nghim
Bao gm chloroquine, Doxicycline, thuc tng hp glycoaminoglycine hoc
hyaluronate, c th tng cng s phc hi sn hoc gim s hu sn hoc bao gm c hai.
1.3.4. Liu php thay th cht nhn
Trong thoi khp c gim nng cng nh trng lng phn t ca acide hyaluronic
lm gim nhy ca dich khp. V vy tim vo khp acide hyaluronic c trng lng phn
t cao c tc dng b sung nhn ca dch khp.
- Trnh by di dng sodium hyaluronat (Hyruan) ng 200mg/2,5ml.
- Liu lng v cch dng: ph thuc khp ln, khp nh.
i vi khp gi: Tim vo khp 1 ln 1ng 2,5ml/tun, trong 5 tun lin tip.
Tc dng ph: au nh, cm gic nng khp sau khi tim.
2. Vt l tr liu
- Cc bi tp th dc cho tng v tr thoi khp.
407
- iu tr bng tay: xoa bp, n huyt, tp vn ng.
- Bng nhit: tia hng ngoi, bn nng, parafin.
- Bng nc: nc sui khong, nc nng, bi.
- S dng cc dng c chnh hnh.
Cc phng php iu tr n gin gm iu tr vt l, acetaminophene hay thuc chng
vim nonstroid c tc dng gim au hn 70% bnh nhn thoi khp giai on sm.
3. Ngoi khoa
Sa li cc d dng khp bng c v khot xng, iu tr thot v a m, lm cng dnh
khp t th c nng, ghp khp nhn to.
VII. PHNG BNH
1. Trong cuc sng hng ngy
- Chng cc t th xu trong sinh hot v lao ng.
- Trnh cc ng tc qu mnh, t ngt, sai t th khi mang, vc...
- Chng bo ph bng ch dinh dng, th dc.
- Kim tra nh k nhng ngi lm ngh lao ng nng pht hin v iu tr sm.
2. Pht hin cc d tt
Ca xng, khp, ct sng c bin php chnh hnh, nga thoi khp th pht.
3. Kim tra tr em
iu tr sm bnh ci xng, cc tt khp gi: chn cong, i vng kin, bn chn nga, g
vo ct sng.

408
BNH GT
Mc tiu
1. Trnh by c chuyn ho ca acid uric v c ch sinh bnh Gt
2. M t c triu chng lm sng v cn lm sng
3. Trnh by c tiu chun chn on.
4. M t c cc bin php iu tr cn gt cp.
5. Trnh by c cc phng tin iu tr hi chng tng acid uric mu
Ni dung
I. I CNG
- Bnh hay gp tng lp ngi c mc sng cao, t l mt s nc chu u khong
0,5% dn s, nam gp 10 ln so vi n. Vit Nam bnh gp cha nhiu song trong thp
nin gn y thy bnh tng ln r.
- Gt l mt bnh chuyn ho, c trng l c nhng t vim khp cp v c hin
tng lng ng natri urat trong cc t chc, xy ra do tng acid uric trong mu.
II. CHUYN HO CA ACID URIC
Acid uric l sn phm thoi ging ca nucleotid c base l purin. C 3 ngun cung cp
acid uric:
+ Do thoi ging acid nucleic t thc n a vo.
+ Do thoi ging acid nucleic t cc t bo b cht
+ Do tng hp ni sinh v chuyn ho purin trong c th nh cc men c hiu.
Acid uric c o thi qua nc tiu 450-500 mg/ngy v trong phn 200mg/ngy.
Khi qua thn, urat c cu thn lc hon ton, ri ti hp thu gn hon ton ng ln gn
cui cng c ng ln xa bi tit. Trong phn, acid uric c cc vi khun phn hu.
Nng acid uric trong mu theo hng s ca ngi Vit Nam l 4510mg/l (208-327
mol/l). Khi nng > 70mg/l (>416,5 mol/l) th c gi l tng acid uric mu.
Cc nguyn nhn lm tng acid uric mu:
. Tng sn xut acid uric: dng nhiu thc n c cha nhiu purin, tng thoi ging
nucleoprotein t bo, tng tng hp purin ni sinh.
. Gim o thi acid uric niu: gim lc cu thn, gim bi tit ca ng thn. i khi
gim phn hy acid uric do vi khun trong phn.
III. PHN LOI CC HI CHNG TNG ACID URIC MU V BNH GT
1. Hi chng tng acid uric mu v cn v bnh gt nguyn pht
Th ny hay gp nht chim ti 85% cc trng hp, c tnh gia nh v di truyn do ri
lon chuyn ho purin.
2. Hi chng tng acid uric mu v bnh gt ri lon men
Ni chung th ny him gp.
3. Hi chng tng acid uric mu th pht
C th xy ra do suy thn, trong mt s bnh mu, bnh ni tit...
409
IV. C CH SINH BNH
Khi acid uric trong mu tng cao, cc dch u bo ho natri urat v s xy ra hin
tng lng ng urat mt s t chc, c bit l mng hot dch khp, sn xng, gn, t
chc di da, nhu m thn v i b thn...
khp, tng acid uric mu lu ngy dn n hnh thnh cc tphi vi th trong cc th
bo ph mng hot dch, lm lng ng natri urat sn. Cc vi tinh th acid uric c th xut
hin trong dch khp v khi t c mt lng nht nh th s gy vim khp v l biu
hin ca cn gt cp tnh. Trong bnh gt, ti khp s xy ra mt lot phn ng: cc bch cu
tp trung n thc bo lm gii phng cc lysozym, cc cht ny gy vim; cc vi tinh th cn
hot ho yu t Hageman dn n hnh thnh kallicrein v kinin c vai tr gy vim khp;
hot ho cc b th v plasminogen, dn n hnh thnh cc sn phm cui cng cng c vai
tr trong vim khp.
T khi b tng acid uric mu n cn gt u tin thng phi qua 20 - 30 nm v ngi
ta thy 10 - 40% s bnh nhn gt c cn au qun thn c trc khi vim khp.
V. LM SNG
Cn gt cp u tin thng xut hin la tui 35-55, t khi trc 25 tui hoc sau 65
tui. n t xy ra trc tui mn kinh, nam tui cng tr th bnh cng nng.
iu kin thun li: nhiu khi khng r nhng c th xy ra sau ba n nhiu tht ru,
sau xc cm mnh, sau chn thng k c vi chn thng (i giy cht), sau nhim khun,
dng thuc li tiu nh thiazid, tinh cht gan, Steroid, Vitamine B12...
1. Cn gt cp tnh
Xut hin t ngt ban m, bnh nhn thc dy v au khp, thng l khp bn ngn
chn ci (60 - 70%): khp sng to, , ph, cng bng, au d di v ngy cng tng, v chm nh
cng rt au; cc khp khc c th b: c chn, gi, bn tay, c tay, khuu. Him thy khp hng,
vai, ct sng. Lc u ch mt khp sau c th b nhiu khp.
Cn ko di nhiu ngy, thng 5 - 7 ngy ri cc du hiu vim gim dn. Ht cn
khp tr li hon ton bnh thng. Trong cn c th c st va hoc nh, tc lng mu
tng, dch khp thy bch cu khong 5000/mm3 phn ln l a nhn, di knh hin vi thy
nhiu tinh th natri urat. Cn d ti pht khi c iu kin thun li.
Bn cnh th in hnh, cng c th ti cp: khp vim sng ty d di, au nhiu v
th nh kn o au t d b b qua.
2. Lng ng urat
Hnh thnh cc ht tphi di da v gy bnh khp do urat
2.1. Tphi: Thng xut hin chm, hng chc nm sau cn gt u tin. Khi xut hin th
d tng s lng v khi lng v c th lot. Tphi hay thy sn vnh tai khuu tay, ngn
chn ci, gt chn, mu bn chn, gn Achille. Kch thc t vi milimet n nhiu centimet,
hi chc hoc mm, khng di ng do dnh vo nn xng bn di.
2.2. Bnh khp do urat: Khp b cng, au khi vn ng v lm hn ch vn ng, khp sng
va, khng i xng, cng c th c tphi km theo. Trn X quang thy hp khe khp, khuyt
xng, hnh hc u xng.
3. Biu hin thn
Urat lng ng ri rc t chc k thn, b thn, niu qun.
410
3.1. Si thn: 10 - 20% cc trng hp gt, iu kin thun li l pH nc tiu qu toan, nng
acid uric cao. Si urat thng nh v khng cn quang.
3.2. Tn thng thn: lc u ch c protein niu, c th c hng cu, bch cu vi th, sau tin
dn n suy thn. Suy thn hay gp th c tphi, tin trin chm v l nguyn nhn gy t
vong.
VI. TIU CHUN CHN ON
ILAR- OMERACT 2000 cng b tiu chun mi trong chn on bnh gt
- C tinh th urate c trng trong dch khp, v /hoc:
- Tophi c chng minh c cha tinh th urate bng phng php ha hc hoc knh
hin vi phn cc, v /hoc:
- C 6/12 trng thi lm sng, xt nghim v X quang sau:
1. Vim tin trin ti a trong vng 1 ngy.
2. C hn 1 cn vim khp cp.
3. Vim khp 1 khp.
4. vng khp.
5. Sng, au khp bn ngn chn I.
6. Vim khp bn ngn chn I mt bn.
7. Vim khp c chn mt bn.
8. Tophi nhn thy c.
9. Tng acid uric mu.
10. Sng khp khng i xng.
11. Nang di v xng, khng khuyt xng.
12. Cy vi sinh m tnh
VII. IU TR
1. Ch n
- Gim cc cht c nhiu purin nh ph tng ng vt, tht, c, tm, cua... khng n qu mc.
Gim calo nu bo.
- Khng ung ru.
- Ung nhiu nc 2 - 4l/ngy nht l nc c bicarbonat.
2. Thuc
- Mc tiu iu tr
+ iu tr vim khp trong cn gt cp.
+ D phng ti pht cn gt, phng lng ng urat trong cc t chc v phng cc bin chng
thng qua iu tr hi chng tng acid uric mu.
2.1. iu tr vim khp trong cn gt cp
Dng thuc chng vim loi nonsteroid:
411
- Colchicin: tc dng cn tr thc bo ca bch cu i vi cc vi tinh th urat, l thuc tt
nht cho n nay.
Cch dng: 1mg x 3 ln trong ngy u; 1mg x 2 ln trong ngy th 2 v 1mg t ngy th 3
tr i. Liu duy tr trnh cn ti pht l 0,5 -2mg/ngy (thng 1mg) ung trong 3 thng.
Tc dng ph: tng nhu ng ng tiu ho d gy i lng; i khi gy c ch ty xng,
rng tc, tn thng ga, c ch h hp...
- Nhiu thuc chng vim nonsteroid c nghin cu s dng, kt qu thy cng tt tuy
cha bng colchicin: Phenylbutazon, Indomethacin, Naproxen, Ibuprofen, Piroxicam,
Diclofenac.
- Corticoid lm gim vim nhanh nhng ht thuc th khp vim tr li, mt khc li lm tng
acid uric mu nn khng c dng.
2.2. iu tr hi chng tng acid uric mu
Ch nh sau khi ct cn gt cp. Thuc dng lu di c th lm cho cc tphi nh li hoc
mt i, cc khp cng hoc tr li bnh thng, hn ch c tin trin xu ca suy thn,
gim cc t vim khp.
2.2.1. Thuc lm tng o thi acid uric niu
Tc dng lm gim ti hp thu ca ng thn thuc d gy si thn nn cn phi dng liu nh
ri tng dn, ng thi cho ung thm nc bicarbonat 2 - 4l/ngy.
Benziodoron (Amplivix 100mg): liu 100 - 300mg/ngy. t tc dng ph i khi c ri lon
tiu ho.
2.2.2. Thuc lm gim sinh tng hp acid uric
Allopurinol (zyloric 100mg): c ch men xanthin-oxydase l men thoi ging hypoxanthin
thnh xanthin v xanthin thnh acid uric v lm gim c sinh tng hp purin. Thuc dng
c khi c suy thn.
Liu: 200 - 300mg/ngy ung 1 ln. t tc dng ph, i khi thy ri lon tiu ho mn
da, au u, chng mt, bun ng...
2.2.3. Thuc lm tiu acid uric trong mu
Uricozym: l men urat-oxydase tc dng lm thoi ging acid uric thnh allantoin, cht ny
c ho tan gp 10 ln so vi acid uric v c d dng o thi ra ngoi qua thn.
Uricozym lm gim acid uric rt mnh.
Tim TM hoc TB 1000-2000 n v/ngy.
Trong qu trnh dng cc thuc lm gim acid uric mu, cn theo di nng acid uric mu v lng
acid uric niu iu chnh liu duy tr, gi nng trong mu < 60 mg/l.

412
VIM CT SNG DNH KHP
Mc tiu
1. M t c nh ngha v cc yu t dch t hc.
2. Trnh by c cc triu chng lm sng v cn lm sng
3. Trnh by c tiu chun chn on v chn on phn bit.
4. Trnh by c cc phng tin iu tr ni khoa, ch nh giai on cp, giai on sau cp.
5. M t c cc phng php vt l tr liu, iu tr ngoi khoa
Ni dung
I. I CNG
1. nh ngha
Vim ct sng dnh khp (VCSDK) l mt bnh vim khp mn tnh, cha r nguyn
nhn, gp ch yu nam gii tr tui, gy tn thng cc khp gc chi v ct sng, nhanh
chng dn n dnh khp, bin dng v tn ph.
2. Dch t hc
- Gp mi ni trn th gii, nhng t l mc bnh khc nhau do c lin quan n yu t
HLA - B27.
- Vit Nam: VCSDK chim khong 20% s bnh nhn khp iu tr ti BV Bch Mai,
khong 1,5/1000 nhng ngi trn 16 tui.
- Nam gii chim khong 90-95%, tui di 30 chim 80%, 3-10% c tnh cht gia nh.
II. TRIU CHNG LM SNG
1. Khi pht
- Tui mc bnh: Trn th gii: Gn 70% trc tui 30
Vit Nam: 80% trc tui 30, 60% trc tui 20
- 70% bt t t, 30% bt u t ngt, 75% bt u t khp hng 25% bt u t ct sng.
- Du hiu ban u: au vng hng, au kiu thn kinh ta, vim gn Achille... nc ta
thng bt u bng vim cc khp chi di (c chn, gi, hng) v au ct sng tht lng.
Cc triu chng ny ko di nhiu thng, nhiu nm.
2. Ton pht
Sng au, hn ch vn ng nhiu khp, teo c, bin dng nhanh. Vim khp thng c tnh
cht i xng, au tng v m.
2.1. Cc khp chi
- Hng: 90% thng bt u mt bn, sau c hai bn.
- Gi: 80% c th c nc.
- Khp c chn: 30%, c th khng li di chng.
- Khp vai: 30%, thng khi khng li di chng.
- Cc khp khc: Him gp hn nh khuu, c n, c tay, khng bao gi thy tn thng
cc khp nh bn tay.
413
2.2. Ct sng
Thng xut hin mun hn cc khp chi.
- Ct sng tht lng: 100% au lin tc v m , hn ch vn ng, teo c cnh ct sng.
- Ct sng lng: thng mun hn vng tht lng, au m , hn ch vn ng, bin dng
(g) hoc cng, teo c.
- Ct sng c: c th mun hn hoc sm hn cc on khc, bin dng hn ch vn ng.
2.3. Khp cng chu
- L du hiu sm, c hiu (ch yu trn Xquang)
- au vng cng chu, lan xung i
- Teo c mng
- Nghim php gin cnh chu (+)
2.4. Nhng biu hin khc
- St, gy st
- Mt: vim mng mt, vim mng mt th mi
Nc ngoi: chim 20 - 30% trng hp
Vit Nam: khong 3%
- Tim: 5% c ri lon dn truyn, h van ng mch ch
- Cc biu hin him gp khc:
+ X teo da
+ X phi
+ Chn p r thn kinh tu
+ Thot v bn, rn
3. Tin trin
- Xu hng chung: nng dn, dn n dnh khp, bin dng. Nu khng c iu tr sm,
ng, bnh nhn c nhiu t th xu, tn ph.
- Bin chng: suy h hp, tm ph mn, lao phi, lit hai chi do chn p tu v r thn kinh.
- Tin lng:
+ Xu: Tr tui, vim nhiu khp ngoi vi, st, gy st nhiu.
+ Tt hn: B bnh sau 30 tui, th ct sng l ch yu.
- 50% tin trin lin tc, 10% tin trin nhanh.
III. XT NGHIM V X QUANG
1. Xt nghim
1.1. Xt nghim chung: t c gi tr chn on
- Lng mu tng (90%)
- Si huyt tng (80%)
- in di Protein: Albumine gim, Globuline tng
414
- XN min dch: Waaler Rose, khng th khng nhn, t bo Hargraves phn ln m
tnh v khng c gi tr chn on.
- Cc XN khc t thay i
1.2. Dch khp: thng ly dch khp gi, dch lng v nht, lng Mucin gim, s lng t
bo tng, nht l a nhn trung tnh, Dch khp ch biu hin vim khng c hiu.
1.3. HLA-B27 (1973): Brewerton (Anh) v Schlosstein (M) nhn thy mi lin h cht ch
gia HLA B27 v bnh VCSDK. Ngi ta thy rng trong VCSDK, 75-95% bnh nhn mang
yu t ny (Vit nam: 87%), trong khi th ngi bnh thng ch c 4-8% mang HLA B-
27 (Vit nam 4%).
2. X quang
2.1. Vim khp cng chu hai bn
y l du hiu quan trng v l tiu chun bt buc chn on sm. Hnh nh vim
khp cng chu chia thnh 4 giai on:
- Giai on I: khp hp, din hi m
- Giai on II: khe hp, b nham nh
- Giai on III: hp nhiu, c ch dnh
- Giai on IV: dnh hon ton khng cn ranh gii.
Ch c vim giai on III. IV c hai bn mi c gi tr chn on xc nh.
2.2. Vim khp hng
Xut hin sm nhng khng c tnh cht c hiu nn t c gi tr chn on xc nh
- Giai on I: mt vi chm xng i
- Giai on II: hp khe khp, din m, ranh gi khng r, c th xut hin hnh khuyt xng
nh u xng v hm khp.
- Giai on III: khp hng dnh v c nhiu di x dm c chy qua ni lin u xng v
hm khp.
2.3. Ct sng
- Hnh nh cu xng: ban u xut hin vng tht lng, sau vng lng v t sng c.
- Di x chy dc ct sng
- Vim v hp a m
IV. CC TH LM SNG
1. Th theo triu chng
- Th gc chi: 40%, tin lng xu, biu hin vim cc khp hng, gi sm v nng.
- Th ct sng: Tin trin chm, bt u sau tui 30, di chng nh.
- Th khng au: Ct sng dnh dn, khng au v khng c biu hin vim.
- Th phi hp vi vim khp dng thp: c vim thm cc khp nh bn tay.
2. Th theo c a
- Ph n: nh, kn o
415
- Tr em di 15 tui: tin trin nhanh, tin lng xu, dnh v bin dng khp trm
trng.
- Ngi gi: nh, d nhm vi thoi ho ct sng.
3. Th bnh theo hnh nh Xquang
- Th khng c du hiu vim khp cng chu
- Th c cu xng pha trc ct sng
- Th c hnh nh ph hu, khuyt xng.
V. NGUYN NHN, C CH BNH SINH V TN THNG GII PHU
BNH
1. Nguyn nhn, c ch bnh sinh
Nguyn nhn cha r, khng c bng chng v min dch nhng c bng chng v vai tr
ca nhim khun.













Biu 1: C ch bnh sinh VCSDK
2. Gii phu bnh
2.1. Mng hot dch & sn khp
- Giai on u: mng hot dch tng sinh, thm nhp t bo (lympho, plasmocyte)
- Giai on sau: sn khp b lot, vim ni mc
- Giai on mun: bao khp, mng hot dch x teo, vi ho, ct ho dn n dnh khp.
2.2. Ct sng
- T chc m gia dy chng di trc ct sng v thn t sng b vim, vi ho, ct
ho, hnh thnh cu xng.
- Cc dy chng ct sng x ho, vi ho di dy chng gy dnh ct sng.
C A:
- Nam, tr tui
- HLA_B27 (+)

NHIM KHUN
- Tiu ho
- Sinh dc
- Tit niu
YU T THUN LI:
Chn thng
- V sinh km
- Dinh dng km
KHI HN
VIM KHP PHN NG VIM CSDK
KHI NHNG HAY TI
PHT
416
VI. CHN ON
1. Chn on xc nh
1.1. Tiu chun ca hi thp khp NewYork, 1966
a. Lm sng:
- Tin s hay hin ti au vng tht lng hay lng - tht lng.
- Hn ch vn ng vng tht lng c 3 t th.
- gin lng ngc gim.
b. X quang: Vim khp cng chu 2 bn giai on 3, 4
Chn on xc nh khi c mt tiu chun lm sng v mt tiu chun Xquang.
1.2. p dng thc t Vit Nam:
- Nam gii, tr tui
- au v hn ch vn ng 2 khp hng
- au v hn ch vn ng ct sng tht lng.
- Tc lng mu tng cao
- Xquang: Vim khp cng chu 2 bn giai on 2 tr ln
2. Chn on phn bit
2.1. Vi th vim khp gc chi
- Lao khp hng
- Chy mu khp trong Hemophilie
- Vim khp dng thp.
- Goutte
2.2. Th ct sng l ch yu
- Vim ct sng do vi khun (lao, t cu...)
- Tn thng ct sng trong bnh Scheuermann: au, g, khng c biu hin vim.
- D dng, di chng chn thng gy au v hn ch vn ng.
- Cc bnh c cnh ct sng: vim, chn thng, chy mu
2.3. Mi quan h gia VCSDK vi cc bnh khp c HLA - B27 (+)
- Hi chng Reiter, HLA B27 (+) 80%
- Vim khp vy nn: HLA B27 (+) cao vi th ct sng
- Vim khp mn tnh thiu nin th ct sng: HLA B27 (+) cao
VII. IU TR
1. iu tr ni khoa
1.1. Nhng thuc c tc dng tt
1.1.1. Phenylbutazone
Giai on u tim bp 600mg/ngy, sau chuyn sang ung 150-200mg/ngy. Ch
417
tc dng ph ca thuc: mu, tiu ho, da, gi mui nc, tim mch...
1.1.2. Salazopyrine
Vim 500mg, 2 - 4 vin/ngy, thuc c dng theo c ch chng cc nhim khun
tim tng (tiu ho, sinh dc), tc dng tt 50 - 70% trng hp, ung ko di nhiu thng.
1.1.3. Cc thuc chng vim khc: Indomethacine 50-150mg/ngy, Diclofnac vin 50mg ,
Profnid, Naprosyn, Piroxicam.
1.2. Nhng thuc t tc dng
- Aspirine: gim au nhng khng hn ch qu trnh vim
- Stroid: dng ng ton thn v ti ch u t tc dng, khng nn s dng trong
VCSDK.
- Chloroquine: khng c tc dng
- Cc thuc c ch min dch: Khng s dng
1.3. Cc phng php khc
Phng php dng tia x mang li nhiu kt qu kh quan.
- Dng quang tuyn X chiu vo ct sng v cc khp vim, mi ln 100r, tng liu
400-800r.
- Dng ng v phng x: radium 224 tim tnh mch mi ln t 50-200 microgam, tng
liu t 1000-1500 microgam.
1.4. Giai on cp
- Ngh ngi
- t chi t th c nng
- Chng vim khng stroid tim, ung: Phenylbutazone, Diclofenac, Profenid
- Gin c: Mydocalin, coltramyl.
1.5. Giai on sau cp
- Tp vn ng tng dn, khng gng sc trnh co cng th pht.
- Chng vim khng Stroid: Phenylbutazone, Diclofnac, Profenid...
- Gin c
- Khng sinh: Salazopyrine 0,5g 2-4 vin/ngy hoc Tetracycline 0,25g 2-4vin/ngy,
khng dng cho bnh nhn di 15 tui.
2. Vt l tr liu
2.1. Cc bin php chng dnh khp, chng t th xu
- Khi bnh ang tin trin, au nhiu, nn khp t th c nng: nm nga trn nn
cng, gi u thp, chn dui thng hi dng. Vi t th ny nu c dnh khp th bnh nhn
vn c th i li c. Tuy nhin ch c c nh trong mt thi gian ngn, khi qua
giai on cp th phi cho vn ng ngay.
- Tp vn ng cng sm cng tt, vn ng mi t th v mi thi gian, y l bin
php tt nht chng dnh khp.
2.2. Cc phng php phc hi chc nng vn ng
418
- iu tr bng nhit chng hin tng co c
- Dng nc (b bi), nc khong: bnh nhn tp luyn, nht l tp bi mang li nhiu
kt qu.
- Xoa bp, ko lin tc, th dc tr liu.
3. Ngoi khoa
iu tr ngoi khoa c ch nh phc hi chc nng vn ng khi c dnh khp vi
t th xu.
- Ct xng hoc ghp xng chnh li trc ca ct sng, ca chi.
- Thay khp gi bng cht do hoc kim loi: ghp khp hng, khp gi

419
LAO CT SNG
Mc tiu
1. M t c cc yu t dch t, c a
2. Trnh by c triu chng lm sng v cn lm sng ca tng giai on bnh: khi pht,
ton pht v giai on cui.
3. Trnh by c chn on xc nh v chn on phn bit.
4. M t c cc nguyn tc dng thuc chng lao.
5. Trnh by c cc phng php phc hi chc nng, bt ng, ngoi khoa.
Ni dung
I. I CNG
- Bnh c m t ln u tin vo cui th k 19 do mt thy thuc ngoi khoa ngi Anh
tn l Percivall Pott, nn cn gi l bnh Pott.
- Thng th pht nht l sau lao phi, vi khun lao n ct sng bng ng mu.
- Cn gp nhiu cc nc ang pht trin, bnh chim khong 2/3 cc trng hp lao
xng khp. trung tm chn thng chnh hnh TP. HCM nm 1998 c 191 trng hp lao
xng khp, trong lao ct sng chim 67,02%.
- Thng gp 20 - 40 tui, nam v n mc bnh ngang nhau.
- Tn thng on lng v tht lng chim hn 90% (t lng 8 n tht lng 2)
II. TRIU CHNG
1. Giai on khi pht
1.1. Du c nng ch yu l au
- au ti ch: au vng ct sng b tn thng, c nh mt v tr khng thay i. au
lin tc c ngy m, tng khi vn ng, i li, gim khi ngh ngi; dng thuc gim au t
hiu qu.
- au kiu r: Do tn thng chn p vo mt vi nhnh ca r thn kinh, au lan theo ng
i ca r v dy thn kinh, c lan xung vai v gy, lng lan theo dy thn kinh lin sn,
tht lng lan theo thn kinh ta. au tng khi ho, ht hi, rn mnh.
1.2. Thm khm
- Ct sng: Thy mt on ct sng cng , hn ch cc ng tc khng gin ra khi ci. C
2 bn ct sng c th co cng, g vo vng gai sau ca on tn thng thy au r.
- Ton thn: C th thy du nhim lao, c tn thng lao phi hp > 50% trng hp (phi,
mng phi, hch...).
1.3. Xquang v xt nghim
- Xquang: Rt quan trng gip chn on.
+ a m hp so vi cc on khc.
+ Thn t sng b nham nh, m phn trc v mt trn.
+ Phn mm quanh t sng m m hn.
pht hin sm tn thng cn chp ct lp, ct lp t trng.
420
- Xt nghim:
+ Cng thc mu: bch cu Lympho tng
+ Tc lng mu tng trong 95% trng hp.
+ Phn ng ni b lao (IDR) dng tnh trong 90% trng hp.
+ Chc kim cnh ct sng ht xt nghim: c th tm thy trc khun lao (BK).
- Tm tn thng lao phi phi hp: chp phi, tm BK trong m, sinh thit hch.
2. Giai on ton pht
Sau nhiu thng bnh tin trin, tn thng ph hy t sng v a m nhiu gy bin dng
ct sng, p xe v du hiu chn p.
2.1. Lm sng
2.1.1. C nng: au c nh, lin tc, c hi chng r thn kinh thng xuyn v r rt.
2.1.2. Thm khm
- Li t sng ra sau: nhn nghing thy mt t sng li ra pha sau. Dng ngn tay mit nh
dc theo cc gai sau t di ln trn s thy r du hiu ny.
- p xe lnh: c v tr khc nhau ty v tr tn thng:
+ Ct sng c: Ti p xe i ra pha trc ngay thnh sau hng, c th nhn thy khi khm
hng, hoc i xung theo cc c cnh c n hm thng n.
+ Ct sng lng: Ti p xe c th ra pha sau ni ln ngay di da.
+ Ct sng tht lng: p xe ni ngay di da vng tht lng, vng mng hoc i ra pha trc
xung bn, c khi xung ti kheo chn.
Cc p xe lnh thng mm, khng au, mt s c th v ra chy nc vng v b u li
cc vt lot v l d dai dng khng lin.
- Hi chng chn p: l hu qu xu nht ca bnh, do t sng v a m b ph hy nhiu,
di lch, ln v c xu hng trt ra pha sau chn p vo ty, ui nga. Ty v tr tn
thng, bnh nhn c cc du hiu:
+ Lit t chi: tn thng on c.
+ Lit 2 chn: tn thng on lng, tht lng trn.
+ Hi chng ui nga: tn thng on tht lng di.
Mc t ri lon cm gic, gim c lc n mc nng lit cng, ri lon c vng.
- Du hiu ton thn: gy, suy mn, st, c th lot mng do nm lu. Tn thng lao lan
rng ra cc b phn khc nh phi, mng phi, hch.
2.2. X quang v xt nghim
- X quang
+ a m b ph hy gn nh hon ton.
+ Thn t sng b ph hy nhiu, nht l phn trc to nn hnh chm, di lch trt ra pha
sau.
+ Hnh nh p xe lnh: trn phim chp thng thy hnh m quanh tn thng, c th khng
ng u, c ch vi ha m hn.
421
- Xt nghim
+ Tc lng mu tng
+ Chc kim cnh ct sng d tm thy tn thng lao in hnh.
+ Chc dch no ty chn on p ty v vim mng no tu.
3. Giai on cui
Khng c iu tr hoc c th qu suy yu: bnh nng dn, lit nng, bi nhim, lao lan
sang b phn khc nh lao mng no, lao mng tim, mng phi v cht v suy kit.
III. CHN ON
1. Chn on xc nh
Da vo cc triu chng lm sng v Xquang. chn on sm cn chp ct lp v chc
ht cnh t sng. Trong giai on ton pht chn on d v y cc du hiu, nht l
Xquang.
2. Chn on phn bit
- Vim ct sng do vi khun m (V d: t cu): Du nhim trng nng, iu kin khi pht
(nht, hu bi), Xquang khng c p xe lnh.
- Cc tn thng u: ung th, di cn, u mu... da vo cc du hiu ton thn, Xquang khng
c hnh nh p xe lnh. Nu nghi ng, tin hnh chc ht xc nh chn on.
IV. IU TR
Hin nay ch yu l iu tr ni khoa bng cc thuc chng lao kt hp vi phc hi chc
nng. Vic bt ng v phu thut c ch nh ring cho mt s trng hp.
1. Ni khoa
1.1. Nguyn tc iu tr lao khp
- iu tr cng sm cng tt.
- Phi hp ti thiu 3 thuc chng lao: Rimifon, Streptomycine, Pyrazynamide, Ethambutol,
Rifampicine trong 3 thng, sau gim bt mt loi v tip tc dng thuc t 6 - 12 thng.
- Lu vn khng thuc ng .
- Nn dng thuc mt ln trong ngy, bui sng, bng i.
- Theo di tnh trng ton thn, tn thng ti ch, tc dng ph ca thuc.
- Thc hin ch n ung, ngh ngi hp l.
1.2. Phc iu tr lao khp (theo Chng trnh chng lao quc gia)
- i vi cc trng hp lao khp mi mc:
2 thng u: Streptomycine, Isoniazide, Rifampicine, Pyrazynamide.
6 thng sau: Isoniazide, Ethambutol.
- i vi cc trng hp lao khp c (khng tr, ti pht):
2 thng u: Streptomycine, Isoniazide, Rifampicine, Pyrazynamide, Ethambutol.
1 thng tip: Isoniazide, Rifampicine, Pyrazynamide, Ethambutol.
5 thng sau: Rifampicine, Ethambutol, Isoniazide dung cch nht.
422
2. Phc hi chc nng
- Xoa bp nh nhng cc c km tp luyn ct trnh teo c cng khp.
- Sau khi ht au, ht du hiu vim bt u vn ng ct sng t t v tng dn.
3. Vn bt ng
Trc y khi cha c thuc c hiu, iu tr ch yu l bt ng t 6 thng n 1 nm.
Hin nay bt ng c chn lc, ty trng hp thi gian t 3 - 6 thng.
- Bt ng trong sut thi gian bnh tin trin nhng khng hon ton, khng lin tc. Tt
nht l dng ging bt bnh nhn c th thay i t th nhiu ln trong ngy, trnh hin
tng cng khp teo c.
- Trng hp tn thng nng ct sng c di lch nhiu e da chn p th cn b bt.
- Nhng tn thng nh, c chn on v iu tr sm khng cn bt ng bng b bt.
4. Ngoi khoa
c ch nh trong cc trng hp sau:
- Lao ct sng c nguy c chn p ty hoc p ty.
- Lao c p xe lnh ti ch hoc di chuyn xa.
5. Theo di
Hng thng trong nm u, mi 3 thng trong nm th hai v mi 6 thng trong cc nm sau:
- Tc dng ph ca thuc: lm sng, sinh hc.
- Hiu qu ca thuc khng lao c nh gi lm sng v X quang mi 2 thng.
- Tiu chun nh gi lnh bnh:
+ Ht au
+ Tng trng tt
+ Ti lp kh nng lm vic, hc tp.
+ Khng cn d m, p xe.
+ Ti sinh xng thy trn X quang.
6. Tht bi iu tr
Sau 4 thng iu tr triu chng lm sng v X quang vn tn ti.
Nguyn nhn tht bi l
- Khng thuc tin pht
- Thiu s hp tc ca bnh nhn
- Dng thuc sai
- T chc iu tr khng ng mc, kim sot iu tr km:
+ Khng thm khm lm sng
+ Thuc khng liu
+ Thi gian iu tr khng
+ Thuc cung cp khng u
423
+ Khng gii thch cn k cho bnh nhn
+ Thiu theo di y khoa u n.
+ Thiu theo di bnh nhn ngng thuc
+ B tc dng ph ca thuc m khng c pht hin
424
VIM QUANH KHP VAI
Mc tiu
1. Trnh by c nguyn nhn ca cc th vim quanh khp vai
2. Trnh by c triu chng lm sng ca cc th vim quanh khp vai
3. Nm vng triu chng X quang ca cc th vim quanh khp vai
4. Trnh by c cc bin php iu tr cc th au khp vai n thun, gi lit khp vai v
cng khp vai
Ni dung
I. I CNG
1. nh ngha
Vim quanh khp vai l mt bnh bao gm nhng trng hp au v hn ch vn ng khp
vai v tn thng phn mm quanh khp ch yu l gn, c, dy chng v bao khp. Khng
c tn thng ca u xng, sun khp v mng hot dch.
2. Nhc li gii phu
Vai l mt khp c rt nhiu ng tc, ng tc ca cnh tay ra trc, ra sau, ln trn vo
trong, ra ngoi, xoay trn; v ng tc ca ring vai: ln trn, ra sau, ra trc. V vy c 5
khp tham gia vo vn ng ca vai.
- Khp vai chnh
- Khp c - n - Khp cng vai cnh tay.
- Khp cng vai - n m bo s vn ng ca xng b
- Din trc b vai - ngc
Mt c im v gii phu ca khp vai l bao khp rt lng lo, rng, pha trn v di
c tng cng bi mt s gn c to nn bao hot dch - gn - c.
- Pha trc c c di b v gn c nh u tng cng
- Pha trn c gn c trn gai
- Pha sau c c di gai v c trn nh

II. AU KHP VAI N THUN: Hay gp nht biu hin ch yu l au.
1. Nguyn nhn
- Chn thng: chn thng mnh vo vng vai, hoc l nhng chn thng do ngh nghip,
thi quen, th thao gp ngi tr.
- Vin gn, thoi ho, vi ho phn mm thng gp ngi trn 50 tui.
- Lin quan thi tit: lnh v m.
- Mt s trng hp khng tm thy nguyn nhn.
2. Triu chng
2.1. C nng
To thnh m
cc gn c quay
ngn ca vai
425
- C th xut hin t nhin, nhng thng do khp vai vn ng qu mc hoc v chn
thng lin tip vai.
- au vai, rnh ch V ca c delta, i khi lan xung cnh tay thm ch c cng tay, mu
tay. au kiu c hc, tng khi lm mt s ng tc ca vai, kh nm nghing, nht l lc t
vo vai.
- au tng khi nng vai ln, c th hn ch vn ng kn o do au.
2.2. Thc th
- Khng c hn ch vn ng ch ng v th ng.
- Khng gim c lc
- Khi lm ng tc co cnh tay i khng th au tng.
2.2.1 Du hiu vim cc c trn gai:
- C im au chi di mm cng vai ngoi hoc ngay pha trc mm cng vai, tng
ng vi v tr tn thng ca gn.
- Lm ng tc i khng cnh tay, au tng ln.
- au khi dang tay t 70 -90 .
2.2.2. Du hiu vim gn c di gai
- im au chi khi n vo di mm cng vai pha sau, ngoi.
- au tng khi quay ngi c i khng.
2.2.3. Du hiu vim gn b di c nh u:
- Khi n vo rnh nh u, gy au phn trn - trong ca mt trc cnh tay.
- au khi gp cng tay trn cnh tay c i khng, hoc khi dang hoc hay a ra trc.
- Tin trin c th dn n t gn.
2.3 X.Quang
Hnh nh X quang cn phi c so snh 2 bn, da trn phim thng t th quay ngoi, quay
trong v trung gian.
- Khp vai ni chung l bnh thng, c th thy mt hoc nhiu im calci ho ti gn.
- Calci ho thng thy r nht khong di mm cng vai - mu chuyn ln.
3. Tin trin
3.1 Thun li: Ni chung c din tin lnh tnh, a s gim dn ri khi sau vi tun n vi
thng, thi gian ny c th nhanh hn nh iu tr, c th ti pht.
3.2 Khng thun li hay tin trin xu
- Chuyn thnh au vai cp, thm ch cng khp vai.
- c bit khi triu chng au tn ti ko di d iu tr cn phi nghi ng c t cc gn
c quay ngn, thng gp sau 50 tui. Xc nh chn on nh chp cn quang, v nu c th
c chng minh khi lm th thut ngoi khoa ni li.
- Gn b thoi ho tng dn khi khng iu tr, s dn n khp vai tui gi, c trng bi:
+ Lm sng: ngoi au khi vn ng cn hn ch vn ng khi nng cnh tay ch ng.
+ Xquang cc du hiu in hnh:
426
1. Gy mm b - cnh tay
2. Mu chuyn b mm v c cc hc nh
3. Hp khe mm cng -cnh tay
4. Gai xng
5. Hp khe cho - Cnh tay
- Khp vai tui gi chy mu: l bin chng him gp ca t cc gn quay do gi, c chy
mu trong khoang khp v ti thanh mc di mm cng -delta. Vai au dt ngt, hon ton
khng vn ng c, km vt bm tm cnh tay rt gi . Chc ht c mu, xc nh chn
on.
III. GI LIT KHP VAI
- Biu hin bng gi lit c delta do t t ngt, r, cp, m cc gn c quay.
+ Ngi ln tui (> 50 tui): Sau mt vn ng sai t th, chn thng khp vai, hoc sau
mt gng sc tc ng ln m cc gn c quay b thoi ho.
+ ngi tr: Him hn, chi th thao, sau mt chn thng mnh.
- t phn di ca c nh u ch xy ra sau 50 tui, sau gng sc trn mt gn b thoi
ho.
1 Triu chng c nng
- au d di c khi km ting lc rc khi t t ngt m cc gn quay.
- m bm tm c th xut hin sau vi ngy, phn trc trn cnh tay.
- au kt hp vi hn ch vn ng r, mt ng tc dng ch ng ca cnh tay (du hiu
ca t gn trn gai) lun lun kt hp vi t gn di gai lm mt ng tc xoay ngoi ch
ng ca cnh tay.
- au bin mt mt cch t pht hoc do iu tr, nhng khng phc hi c kh nng vn
ng. iu ny loi tr kh nng gim vn ng l do au.
2. Thc th
- Cc du hin thn kinh bnh thng c th loi tr lit thc s.
- Mt ng tc nng vai ch ng, trong khi vn ng th ng hon ton bnh thng. y
l du khch quan rt gi .
- Trng hp t gn phn di c nh u, khm thy t gn c phn trc di cnh tay,
khi gp cng tay c i khng.
3. Xquang
- Trn phim chp khp vai c c th c du gin tip ca khp vai ngi gi.
- Chp khp vai ct lp vi thuc cn quang chng t c s t m cc gn c quay, do
thy c hnh nh cn quang thng thng gia khoang khp v ti thanh mc di mm
cng - c delta.
- Chp scanner khp c th thy c cc t thng km theo.
IV. CNG KHP VAI
Biu hin ca co tht bao khp (vim bao khp co tht), bao khp dy lm gim vn ng
khp cho - cnh tay.
427
S co cng ny ca bao khp l do ri lon thn kinh dinh dng lan to, lin quan n c
xng, c, mch mu v da to nn bnh cnh au do lon dng thn kinh phn x chi
trn.
1. Nguyn nhn
Thng gp sau 40 tui, ngi c cng thng thn kinh:
- Tn thng do chn thng khp vai, bt ng b bt ko di.
- Nhi mu c tim, au tht ngc nng, vim mng ngoi tim.
- Lao phi, ung th phi.
- Lit na ngi, bnh Parkinson, u no.
- au thn kinh c - cnh tay, Zona c - cnh tay.
- Cng gip, i tho ng, goutte.
- Thuc: Phenobarbital, INH, Ethionamide, khng gip tng hp, Iode
131
.
- Cng khp vai i khi kt hp vi au do lon dng bn tay: au, ph, bin i da vi
tng xut huyt, cng khp v c to nn hi chng vai tay.
2. Triu chng
2.1. C nng
- Khi u au vai kiu c hc, c thi tng v m.
- Dn dn trong vi tun, au gim dn trong khi vai cng li ch yu l ng tc dng cnh
tay v quay ngoi.
2.2. Thc th
- Hn ch vn ng ca khp vai, c ch ng v th ng.
- Hn ch mi ng tc nhng r hn c l dng v quay ngoi.
- Nu c gng vn ng, s cm thy mt sc cn c hc v gy au, cc ng tc cn c th
lm c l nh vai tr ca din trc b vai - lng ngc.
- C th thy im au trc hoc di mm cng vai nhng khng c du vim.
2.3. Xquang
- Phim chp thng: Bnh thng hoc thy long xng, khe khp cho - cnh tay bnh
thng.
- Chp khp vi thuc cn quang: s cho thy hp khoang khp:
+ Ch cn 5-10ml trong khi bnh thng l 30- 35ml.
+ Gim cn quang khp, cc ti cng mng hot dch bin mt.
V. IU TR
1. iu tr au khp vai n thun
- Khi t nhin sau vi tun n vi thng, c th ti pht
- C th thc y nhanh qu trnh khi bnh nh iu tr:
+ Ch yu nh tim corticoid ti ch: tim vo di mm cng vai ngoi i vi gn c trn
gai, ti a l 3 ln cch nhau 15 ngy.
428
+ Cho thuc gim au, c th dng thuc chng vim nonsteroid.
+ Cho gn b tn thng ngh ngi, c th kt hp vt l tr liu n gin nh sng ngn, siu
m.
- Tin trin c th xu chuyn thnh au vai cp, thm ch cng khp vai.
c bit khi triu chng au tn ti ko di, mc d tim ti ch, cn phi nghi ng c t
m cc gn c quay ngn, rt thng gp v mt gii phu, sau 50 tui, tn thng tng dn
dn. iu ny gii thch c im t nhin l ngho triu chng, khc hn vi bnh cnh ca
gi lit khp vai, c cc du hiu t gn r rng, t ngt v mi xy ra.
S t m ny thng c xc nh nh chp khp cn quang, v nu c th c chng
minh khi lm th thut ngoi khoa khu li.
- Khi khng iu tr, gn b thoi ho tng dn, dn n khp vai tui gi (hoc t m gn
cc c quay ngn do gi) c c trng bi: ngoi au khi vn ng va phi v khng hng
nh, cn c hn ch vn ng khi nng cnh tay ch ng.
2. iu tr gi lit khp vai:
2.1. t m cc gn c quay
2.1.1. ngi tr
t m t thnh vn iu tr ngoi khoa: khu li ch t.
2.1.2. ngi ln tui
Ch nh ngoi khoa rt t nh, do tn thng thoi ho cc gn ln cn. Cho nn trc ht
phi iu tr ni khoa, bao gm:
- Tm thi bt ng tay t th dng.
- Cho thuc gim au v chng vim nonsteroid, c gng trnh tim corticoid ti ch n mc
c th, v s lm hoi t gn tng ln.
- Phc hi chc nng: vn ng liu php tch cc, nhit tr liu. iu tr ngoi khoa c th
c ch nh khi iu tr ni khoa tht bi.
2.2. t gn b di c nh u
Khng c ch nh ngoi khoa tr trng hp c bit.
3. iu tr cng khp vai
3.1. Thng t khi sau 1 - 2 nm
3.2. Qu trnh ny c th c rt ngn nh iu tr.
- iu tr thuc gim au v chng vim nonsteroid
- L liu php khi bt u ht au: vn ng th ng nh nhng kt hp vn ch ng.
- iu tr au do lon dng: Bta bloquant, calcitonine, griseofulvine t hiu qu.
3.3. iu tr ngoi khoa
Ct bao khp
429
BNH A U TY XNG
Mc tiu
1. M t c nh ngha v cc yu t dch t.
2. Trnh by c cc triu chng lm sng v cn lm sng
3. M t c chn on xc nh, chn on phn bit v chn on giai on bnh.
4. Trnh by c cc phng tin iu tr gc v cc bin php iu tr khc.
5. M t c cc yu t nh gi tin trin v tin lng
Ni dung
I. I CNG
1. nh ngha
a u tu xng l mt bnh tng sinh c tnh cht c tnh ca tng bo (plasmocyte)
ty xng v mt s c quan khc.
Tng sinh tng bo dn n:
- Tng cc globulin min dch trong mu.
- To thnh nhiu tiu xng dn n gy xng bnh l.
- Ri lon chc nng nhiu c quan: suy thn, thiu mu, tng canxi mu, cc triu chng
thn kinh...
2. Dch t
- T l mc bnh khong 3 - 4/100.000 dn; 1 - 2% cc bnh c tnh.
- Tui thng gp: > 40 ; nam > n.
- Ngi da en gp 2 ln ngi da trng v tui khi bnh sm hn.
- Nguyn nhn v bnh sinh vn cn cha r. Tuy nhin, nghin cu v dch t hc cho thy
rng liu thp phng x lm tng t l mc bnh.
II. TRIU CHNG
Do ngun gc v chc nng, tng bo c mt hu ht cc c quan, b phn trong c th,
do khi tng sinh c tnh s biu hin triu chng nhiu ni. Bnh thng bt u t t
tng dn triu chng tn mn nn d nhm vi cc bnh khc: suy sp ton thn, biu hin
xng, thn, mu, thn kinh...
1. Biu hin xng
1.1. Lm sng
- au xng (90%): v tr thng gp l vng ct sng, chu hng, lng ngc, au tng khi
vn ng v gim khi ngh ngi, v sau au lin tc, c khi thy au theo kiu p r thn kinh.
- Gy xng t nhin (50%): gy xng sn, xng n, xng c, ln v di lch t sng
gy g vo ct sng. Thng c pht hin qua chp Xquang.
- U xng: 10% bnh nhn c du hiu ny; u mm khng au ni trn nn xng, ng
knh t 0,5cm n 2cm; thng thy cc v tr nh xng s, xng n, xng c, xng
b vai, ct sng... t thy cc xng chn tay.
430
1.2. X Quang
- Tiu xng hnh hc, hang: trn xng s, xng sn, xng chu ct sng... cc
hc hnh trn hay bu dc, ranh gii r, kch thc t vi mm n vi cm, trng nh xng b
rng.
- Tiu xng mt on hay mt phn xng di.
- Khi cc hc xng nh v dy c to nn hnh nh long xng lan ta.
- Thn cc t sng bin dng (lm, dt, hnh li), c th di lch gy nn g vo.
Hin nay c th dng phng php chp phng x nhp nhy, chp ct lp t trng,
chp cng hng t pht hin sm tn thng.
2. Biu hin ngoi xng
2.1. Ton thn: Gy st, mt mi, chn n, da xanh, st dai dng ko di.
2.2. Thn: Tn thng thn gp trong 70% trng hp.
- Protein niu thng l protein nhit tn (chui nh: Bence Jones), ng vn nhit 56
0
C
v tan khi si.
- Suy thn mn.
- V niu: xut hin t ngt do globulin tng nhiu v nhanh trong mu gy bt tc ng thn.
2.3. Mu: thiu mu, xut huyt do gim tiu cu.
2.4. Thn kinh: do cc khi u chn p trc tip hay do cc globulin min dch gy tn thng.
- p ty v r thn kinh.
- Tn thng cc dy thn kinh s no.
- Vim a dy thn kinh.
- Tng p lc ni s.
- Tn thng y mt.
2.5. Cn tng canxi mu
- L , mt mi, trm cm, d nhm ln.
- Nn, ri lon nc v in gii, ri lon tri gic, hn m.
2.6. Cc biu hin khc
- D nhim khun bi nhim.
- Gan, lch, hch to.
- Ri lon tiu ha.
- Thm nhim m phi (do plasmocyte).
- Nhim Amyloid mt s b phn.
III. NHNG THAY I V HUYT HC V SINH HA
1. Tng sinh tng bo (plasmocyte)
- Chc d: cc u xng ni trn da hoc cc vng c tiu xng (trn Xquang) xt
nghim t bo s thy rt nhiu tng bo.
431
- Ty : tng bo tng cao > 15% (bnh thng < 5%). Trong mu ngoi bin t khi
thy tng bo tng.
V hnh thi, cc tng bo ny c th bnh thng, c th to nh khng u, nhn c
nhiu ht...
2. Tng gama globulin n dng
Do cc tng bo bnh l tit ra, ch yu l IgG, IgA, t thy IgD v IgE, Tng gama globulin
c th hin bng:
- Tc lng mu tng cao (tng kt dnh hng cu).
- Protid mu tng nhiu.
- in di protein huyt thanh thy gama globulin tng nhiu.
- in di min dch: tng 1 trong cc loi gama globulin min dch: IgG, IgA, IgD,
IgE...
- Nc tiu: 50% c protein Bence Jones.
3. Cc xt nghim khc
- Calci mu tng (> 105mg/l) l hu qu ca tiu xng nhiu, lan rng.
- Hng cu v tiu cu gim trong mu.
- Chc nng thn gim.
IV. CHN ON
1. Chn on xc nh: Da vo
- Lm sng: au xng, u xng.
- Xquang: tiu xng hnh hc, long xng lan ta.
- Plasmocyte tng: chc d khi u, ty .
- Xt nghim protid mu, in di, nc tiu.
2. Chn on phn bit
- Cc u xng do di cn ung th.
- Cc bnh gy tiu xng v long xng: cng cn gip, long xng sau mn kinh,
long xng nguyn pht.
- Cc bnh mu c biu hin xng.
3. Cc th bnh
- Th mt vi lan ta ging long xng (Livre v Weissenbach).
- Th khng ch v khng tit gama globulin, ch c hnh nh Xquang, khng c thay
i th dch.
- Th mt u n c.
- Th phi hp vi Leucmie.
- Th theo globulin: th chui nh, th IgM, th 2 dng phi hp.
4. Chn on giai on bnh: C 3 giai on
+ Giai on I: gm cc tiu chun: ( 1).
432
. Hemoglbin > 100g/l.
. Canxi mu < 3mmol/l (< 12 mg%).
. Xquang xng bnh thng hoc mt tn thng n c.
. in di min dch: IgG < 50g/l
IgA < 30g/l
Chui nh niu < 4g/24 gi.
+ Giai on II: gia giai on I v III
+ Giai on III: 1 trong cc tiu chun sau:
. Hemoglobin < 85g/l
. Canxi mu > 3mmol/l
. XQ: nhiu tn thng
. in di min dch: IgG > 70g/l
IgA > 50g/l
Chui nh niu > 12g/24gi
- Da vo chc nng thn:
A: Creatinin mu < 177 mol/l (<2mg%)
B: Creatinin mu > 177 mol/l (>2mg%)
- Phi hp tiu chun giai on v chc nng thn ngi ta nh gi tin lng bnh
(theo Dan.L.Longo):
IA sng trung bnh c: 61 thng
IIA, B sng trung bnh c: 55 thng
IIIA sng trung bnh c: 30 thng
IIIB sng trung bnh c: 15 thng
V. IU TR
a u ty l mt bnh gy tn thng ty xng v nhiu c quan ngoi xng do tng sinh
c tnh cht c tnh ca tng bo. Do iu tr bao gm cc vn chnh sau: au xng
v ph hy cu trc xng, tng calci mu, suy ty vi thiu mu dai dng, gim tiu cu v
gim bch cu, suy thn v nhim trng bi nhim.
Hu ht bnh nhn cn c iu tr h thng ha cht kim sot khi u v iu tr triu
chng ngn nga bin chng.
1. iu tr gc
1.1. Truyn tnh mch tng t, trong cc loi sau
- L.Phenylalanin Mustard (L-PAM, Melphalan): 8mg/m2/ngy
- Cyclophosphamide 200 mg/m2/ngy
Phi hp vi Prednisolon 25-60 mg/m2/ngy. Mi t 4 - 7 ngy, cch nhau 4 - 6 tun.
Sau c th dng bng ng ung vi liu
Melphalan: 1 - 3 mg/ngy
433
Cyclophosphamide: 1 - 2mg/kg/ngy
Prednisolone: 1mg/kg/ngy
Dng tng t 1 - 4 tun.
Thi gian iu tr ko di 1 - 2nm. Theo di cht ch v lm sng v xt nghim
iu chnh thuc.
1.2. C th dng liu cao steroid n thun truyn tnh mch
. 200mg Prednisolone cch ngy
. Hoc Methylprednisolone 1g/m2/ngy x 5 ngy
1.3. C th dng ha tr liu phi hp xen k
. Vincristin 0,4 mg/ngy x 4 ngy
. Tip: Doxorubicin 9mg/m2/ngy x 4 ngy
. Tip Dexamethason 40mg/ngy x 4 ngy.
2. iu tr khc
2.1. Chiu x vi th khu tr, tin trin chm, u ngoi ty xng
2.2. Phu thut: th u n c, gii phng chn p
2.3. Cc iu tr triu chng phi hp
- Truyn mu
- Khng sinh
- Lc mu
- Calcitonin
- Li tiu...
VI. TIN TRIN V TIN LNG
15% cht trong 3 thng, 15% cht trong 1 nm, s cn li din bin mn tnh t 2 - 5
nm.
Nguyn nhn cht: - Suy thn
- Nhim trng huyt
- S lan rng ca khi u
- Nhi mu c tim, bnh phi mn tnh
- i ng, t qu
434
LUPT BAN H THNG
Mc tiu
1. M t c nh ngha, yu t dch t
2. Trnh by c nguyn nhn v c ch sinh bnh.
3. M t c triu chng lm sng v xt nghim
4. Trnh by c tiu chun chn on xc nh v chn on phn bit.
5. Trnh by c bin php iu tr bnh lupt
Ni dung
I. I CNG
1. nh ngha: L bnh c t l cao nht trong nhm bnh to keo (60%) biu hin vim lan
ta hay ri rc t chc lin kt, nguyn nhn do t min.
2. Dch t
- Bnh gp ch yu ph n tr, t l n/nam: 8/1.
- T l mc bnh cao nht la tui 20 - 40.
- Ngi da en c t l bnh v t l t vong cao gp 3 ln da trng, t l bnh cao theo th
t: da en, Chu , da trng.
II. NGUYN NHN V C CH BNH SINH
Ngy nay c xem l bnh t min trn 1 c a c bit.
1. Bng chng v t min
- Trong th dch bnh nhn c nhiu t khng th: khng th khng nhn, khng th khng
acid nhn (AND, ARN), khng cc huyt cu (hng cu, bch cu, tiu cu). Lng b th
gim r rt trong mu (CH50, C3, C4), phn ng BW dng tnh gi, pht hin cc phc hp
min dch trong mu v t chc.
- T l Limpho B v T thay i trong mu.
- C th gy bnh trn sc vt bng phng php min dch.
- iu tr cc thuc c ch min dch c kt qu.
2. Yu t c a
- Ph n, tr tui.
- HLA-DR3 cao hn hn so vi ngi bnh thng.
- Mt s trng hp c tnh cht gia nh.
3. Yu t nguyn nhn
Nguyn nhn trc tip gy bnh cha bit r. Tuy nhin c mt s yu t sau:
- Mt s thuc c th gy bnh Lupt: Hydralazine, dihydralazine, procainamide, Acbutolol,
D pnicillamine, quinidine, Isoniazide, chlorpromazine, sulfasalazine, minocycline,
carbamazpine, interfenon v .
- Cc sn phm k ngh: Formaldhyde, isocyanate v anhydride phtalique.
- Cc cht cytokine nh interfon, yu t kch thch sinh bch cu ht, cc khng th dng
435
trong lm sng nh anti TNF.
- Tc nhn nhim trng: nh parvovirus B19.
4. Nhng xu hng mi v nguyn nhn bnh sinh ca Lupt
4.1. Xc nh nhng gen c th dn ti bnh ny
- Gen C4A lin quan n biu hin bnh Lupt.
- Thiu ht on Fc YRIIa - H131 lin quan n vim thn Lupt.
4.2. Bt thng trong t bo T hoc TCR
- T bo T bnh nhn Lupt thiu men proteinkinase A (PKA).
- S bin i protein t bo theo kiu phosphoryl ha c th lm bin i s hng nh ni
mi v thm ch lm ri lon chc nng min dch.
4.3. Hot ng qu mc ca t bo B v sn sinh t khng th l t trng ca bnh Lupt
- S tin trin ca Lupt lin quan n tng sn phm interlenkin 10.
- Tng Apoptosis tham gia vo s pht trin ca vic gim t bo v gii phng cc thnh
phn ca nhn t bo, nhng cht c th kch thch h thng min dch sn sinh ra t khng
th.
III. TRIU CHNG
1. Lm sng: Trn lm sng ch yu gp th bn cp.
1.1. Khi pht
- a s bt u t t, tng dn: st dai dng khng r nguyn nhn, au khp hoc vim khp
ging nh VKDT.
- Mt s trng hp khi pht nhanh, cc triu chng y ngay giai on u.
- C khi bnh xut hin sau nhng nguyn nhn thun li: nhim trng, chn thng, Stress,
dng cc thuc c th gy Lupt.
1.2. Ton pht: Tn thng nhiu c quan.
- Ton thn: st dai dng ko di, mt mi, gy st.
- C xng khp: au, vim, bin dng khp, lon dng c, hoi t xng.
- Da nim mc: ban hnh cnh bm mt, ban dng a ngoi da, xm da do nng, lot
nim mc ming, mi, rng tc, vim mao mch di da.
- Mu v c quan to mu: thiu mu ko di, chy mu di da, lch to, hch to.
- Thn kinh tm thn: ri lon tm thn, ng kinh.
- Tun hon, h hp: trn dch mng tim, mng phi, vim c tim, vim ni tm mc, hi
chng Raynaud, vim phi k, vim tc ng mch, tnh mch.
- Thn, gan: protein niu, t bo tr niu, c trng, ri lon chc nng gan.
- Mt: tc tuyn l (hi chng Sjogren) vim kt mc, vim vng mc.
2. Xt nghim
2.1. Cc xt nghim khng c hiu
- Cng thc mu: gim cc dng huyt cu mt phn hay ton th, gim ngoi ty:
436
+ Hng cu gim (thng thng l thiu mu huyt tn) 65%
+ Bch cu gim, ch yu l a nhn trung tnh 32%
+ Tiu cu gim 10%
- Tc lng mu tng cao 92%, si huyt tng 45%
- in di huyt thanh: Globulin tng 86%
- Tm thy phc hp min dch trong mu.
- Phn ng BW (+).
2.2. Cc xt nghim c hiu
2.2.1. T bo Hargraves (LE): l nhng bch cu a nhn thc bo nhng mnh nhn ca
t bo khc b tiu hy do khng th khng nhn xut hin trong bnh Lupt.
Ngi ta thng tnh t l % ca t bo LE so vi tng s bch cu trong mu. T l 5% th
c gi tr chn on. Trong Lupt 60% - 90% c t bo LE.
2.2.2. Tm cc khng th th dch
- KT khng nhn: c xem l dng tnh khi pha long huyt thanh > 1/32.
- KT khng DNA rt c hiu trong bnh Lupt.
- KT chng li cc khng nguyn nhn ha tan: KT khng Sm (+) trong 50%.
- KT khng hng cu, khng Limpho bo, khng tiu cu.
- B th gim trong mu.
- Gim t l Lympho bo so vi t bo B.
2.3. Sinh thit
- Sinh thit da: lng ng globulin min dch: IgM, IgG v b th thnh mt lp gia thng
b v trung b ca da (+ 70%).
- Thn: vim cu thn, dy mng y do lng ng IgG, IgM v b th.
- Mng hot dch khp: tn thng gn ging vim khp dng thp.
IV. TIN TRIN: Ty thuc th bnh
1. Th cp: Tn thng nhiu ni tng v nng, tin trin nhanh v t vong sau vi thng do
cc thng tn thn, thn kinh, phi nhim khun.
2. Th mn: t tn thng ni tng, biu hin ngoi da nh, tin trin chm, tin lng tt.
3. Th bn cp: Tin trin tng t, ngy cng nng dn. Bnh nng thm nu c thai, nhim
khun, chn thng, phu thut, Stress, lm dng thuc. Thng t vong v cc bin chng
thn, thn kinh, nhim khun. Thi gian sng trung bnh 5 - 10 nm.
4. Hi chng Sharp: l th bnh hn hp gia Lupt v x cng b, c cc du vim a khp,
hi chng Raynaud, ngn tay sng to hnh khc di ln, x hp thc qun, vim a c. Do t
biu hin ni tng nn tin lng tt hn v nhy cm vi Steroid.
V. CHN ON
1. Chn on xc nh: Da vo 11 tiu chun ca hi thp hc M, c ci tin nm 1997,
chn on xc nh khi c t nht 4 tiu chun:
- Ban hnh cnh bm mt.
437
- Ban dng a mt, thn.
- Xm da do nng.
- Lot ming hoc mi hu.
- Vim a khp.
- Vim mng tim hoc mng phi.
- Tn thng thn: Protein niu > 0,5g/24 gi hoc tr niu.
- Tn thng thn kinh: co git hoc lon thn.
- Ri lon v mu:
+ Thiu mu tan mu (tng hng cu li); Bch cu < 4000/mm3.
+ Limpho < 1500/mm3 hoc tiu cu < 100.000/mm3.
- Ri lon min dch: trong mu c
+ Khng th khng ADN hoc khng th khng Sm.
+ Nng bt thng ca IgG hoc IgM anti - Cardiolipine, hoc hin din yu t chng
ng lu hnh (anticoagulant circulant).
- Khng th khng nhn (+).
2. Chn on phn bit
- Thp khp cp.
- Vim khp dng thp.
- Bnh trong nhm to keo: x cng b, vim a c, vim nt quanh ng mch.
- Vi cc th c bit ca Lupt cn phn bit vi cc bnh c triu chng tng t: xut
huyt gim tiu cu, vim cu thn, hi chng thn h. Vim mng tim mng phi do nguyn
nhn khc.
3. Thc t Vit Nam: khi c 5 yu t sau y xut hin trn 1 bnh nhn n, tr tui th c
hng chn on Lupt
- St dai dng ko di khng tm thy nguyn nhn.
- Vim nhiu khp.
- Ban hnh cnh bm mt.
- Protein niu.
- Tc lng mu cao.
VI. IU TR
Chung cho mi trng hp Lupt: Gio dc bnh nhn trnh nhng iu c hi nh thuc l,
trnh nh nng mt tri trc tip hoc gin tip, k hoch ha gia nh, trnh lm dng thuc.
Ch nh iu tr ph thuc vo mc nng nh ca bnh:
1. Th nh
Tn thng da - khp.
- Loi thuc dng: Aspirine v khng vim nonstroid, thuc chng st rt tng hp.
+ Aspirine v AINS: ch tc dng ph nht l tiu ha, thn, thn kinh gic quan.
438
+ Hydroxychloroquine: 400mg/ngy trong nhiu nm.
Tc dng iu tr tn thng da v khp, tc dng d phng xut hin cc t mi, c kh
nng chng huyt khi.
Theo di mt u n: th lc, nhn mu sc, in vng mc .
Cc tc dng ph khc him: mt bch cu ht, bnh thn kinh c hoc bloc nh tht khi iu
tr ko di.
+ Vi iu tr nh trn, cc triu chng khp vn tn ti, c th h tr thm prednisone < 0,3
mg/kg/ ngy.
2. Th nng
Tn thng cc ni tng.
2.1. Liu php corticoide
- Trong nhng t nng: thng bt u di dng bolus.
+ Methylprednisolone 1g chuyn TM trong 90 pht (sau khi kim tra kali mu v ECG) trong
3 ngy lin tip. Sau dng ng ung.
+ Prednisone: 1mg/kg/ngy trong th tn thng nhiu tng (bnh thn tng sinh, tn thng
thn kinh lan ta, gim tiu cu hoc tan mu nng) v 0,5mg/kg/ngy trong nhng th nh
hn. Ban u liu corticoide chia thnh 2 - 3 ln trong ngy. V sau ch dng 1 ln vo bui
sng. Khi bnh c khng ch cho dng 1 ln vo bui sng. Khi bnh c khng
ch cho dng mi 2 ngy 1 ln vi liu gp i, thng c ch nh cho tr em bo v s
tng trng.
+ Liu php Corticoide tn cng c ch nh trong 4 tun.
Sau gim liu dn (gim 10% liu /mi 10 - 15 ngy).
2.2. Hydroxychloroquine c dng khi liu prednisone < 0,5mg/kg
+ Liu php corticoide duy tr (0,15 - 0,25mg/kg/ngy) thng c ch nh lu di, ph
thuc vo trm trng ban u hoc cc ti pht trc y.
2.3. Thuc c ch min dch
iu tr loi thuc ny l vn cn tranh lun, d li ch ca chng c tha nhn trong
cc bnh thn tng sinh. N p ng 2 mc ch: ci thin bnh trong nhng th khng
corticoide, cho php gim lng corticoide.
Nguy c tim tng, nht l nhim trng v sinh u lm hn ch ch nh trong mt s tn
thng tng nng. Hai loi thuc thng dng l:
- Cyclophosphamide: hin nay t dng bng ng ung v c nhiu tc dng ph, m thng
dng bng ng tnh mch gin on vi liu 0,5 - 0,8g/m2 ph thuc chc nng thn v
lng bch cu.
- Azathioprine: 2 - 4mg/kg/ngy bng ng ung.
Khc vi cyclophospharnide l khng e da chc nng sinh dc v khng chng ch nh
trong lc c thai.
- a s tc gi iu tr thuc c ch min dch phi hp vi liu php corticoide trong cc
bnh thn tng sinh v cc tn thng thn kinh trung ng khng thiu mu, c bit l
trong trng hp ti pht. Phc thng dng l: chuyn TM cyclophosphamide mi thng
trong 6 thng, ri mi 3 thng trong 2 nm. Azathioprine thi gian dng t 12 - 24 thng.
439
2.4. Cc can thip min dch khc
Ch chim mt v tr hn ch trong iu tr Lupt
- Ciclosporine A: c tc dng thun li trong mt s srie hn ch.
- Methotrexate: Kt qu khng nh trong iu tr vim khp dng thp, c li trong mt s
trng hp tn thng thn v vim c.
- Lc huyt tng: Kt qu t c tri ngc nhau trong vim thn Lupt. Li ch khng
c chng minh trong iu tr tn cng cc bnh thn nng.
- Immunoglobuline tnh mch hin nay ch dng trong mt s trng hp gim tiu cu nng.
2.5. Cc iu tr mi ang trong thi gian th nghim
- Khng th n dng chng interleukine 10.
- Th nghim Bromocriptine v ghp t bo gc trong trng hp nng v khng vi cc
iu tr khc.
VII.TIN LNG
- Tin lng bnh Lupt ban h thng c ci thin t 20 nm nay, hin nay t l sng
10 nm vt qu 90%.
- Mt s yu t c ngha tin lng nng l: nam gii, thuc chng tc da en, khi bnh
lc cn tr em, c tn thng thn, thn kinh hoc hi chng khng phospholipide phi hp.
- Nguyn nhn t vong c phn gia tng do cc nhim trng c hi, x m mch vnh tng v
cc u tn sinh, cn nhn mnh cc nguy c do s dng ko di corticoide v c ch min dch.











440
CU HI LNG GI

1. Hy nu triu chng lm sng v cn lm sng ca vim khp dng thp.
2. Tiu chun chn on xc nh vim khp dng thp ca hi khp hc M 1987.
3. Trnh by triu chng lm sng v X quang ca thoi ho khp.
4. Hy nu phng tin iu tr ni khoa thoi ho khp.
5. M t cn gt cp.
6. Hy nu iu tr cn gt cp.
7. Triu chng lm sng vim ct sng dnh khp.
8. Hy m t phng php iu tr ni khoa vim ct sng dnh khp.
9. Trnh by triu chng lm sng v cn lm sng tng giai on lao ct sng.
10. Nu nguyn tc iu tr ni khoa lao ct sng.
11. Trnh by triu chng lm sng v X quang ca au khp vai n thun.
12. Nu phng tin iu tr au khp vai n thun.
13. Trnh by triu chng lm sng v cn lm sng a u tu xng.
14. Chn on giai on bnh a u tu xng.
15. Hy nu tiu chun chn on xc nh Lupus ban h thng.
16. Trnh by phng tin iu tr th nng Lupus ban h thng.


441
TI LIU THAM KHO
1. Trn Ngc n (1999), Bnh thp khp, NXB Y hc H Ni.
2. J.M.H.Moll, V Minh c (2000), Cc bnh v khp, NXB Y hc.
3. Nguyn Minh Ni (2001), Sinh liu php vi vim khp dng thp, Thng tin y hc qun
s nc ngoi.
4. Antonio J. Reginato (2002), Goutte et autres Arthropathies microcristallines. Maladies du
systme immunitaire, du tissu conjonctif et des articulations, Principes de medecine interne.
P: 1994 - 1998. Flammarion - Paris.
5. Breva Hannahs Hahn (2002), Lupus rythmateux systmique, Principes de medecine
interne, Flammarion, Paris.
6. Bruce Gilliland ( 2002), Troubles pri - articulaires des membres, Principes de medecine
interne. P: 2016 2018, Flammarion, Paris.
7. Dan L. Longo ( 2002), Proliferations plasmocytaires: myelome multiple, Principes de
medecine interne. Flammarion, Paris.
8. Joel D. Taurog, Peter E. Lipsky ( 2002), Spondylarthrite ankylosante, Principes de
medecine interne, Flammarion. Paris.
9. Kenneth D. Brandt ( 2002), Arthrose, Principes de medecine interne, Flammarion, Paris.
10. Peter E. Lipsky (2002), Polyarthrite rhumatoide, Principles de mdecine interne,
Flammarion, Paris

442
CHNG 6
NI TIT

I THO NG
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, bnh nguyn v c ch bnh sinh
2. Trnh by c tiu chun chn on i tho ng
3. Phn loi i tho ng.
4. Trnh by c cc triu chng cn lm sng v bnh.
5.Bin chng cp v mn ca i tho ng
6. Trnh by c cch tit thc trong i tho ng
7. Trnh by c mt s loi thuc thng dng trong iu tr i tho ng
Ni dung
I. NH NGHA I THO NG
- Theo TCYTTG 1999: "i tho ng (T) l mt tnh trng ri lon chuyn ha a
nguyn nhn c trng bi tnh trng tng glucose mu mn tnh vi cc ri lon chuyn ha
carbohydrate, m, protein do hu qu ca khim khuyt tit insulin, khim khuyt hot ng
insulin hoc c hai".
- Theo TCYTTG 2002: T l mt bnh mn tnh gy ra do thiu sn xut insulin ca ty
hoc tc dng insulin khng hiu qu do nguyn nhn mc phi v/hoc do di truyn vi hu
qu tng glucose mu. Tng glucose mu gy tn thng nhiu h thng trong c th, c bit
mch mu v thn kinh.
- Theo Hi T Hoa K 2004: T l mt nhm cc bnh l chuyn ha c trng bi
tng glucose mu do khim khuyt tit insuline, khim khuyt hot ng insuline, hoc c hai.
Tng glucose mu mn tnh trong T s gy tn thng, ri lon chc nng hay suy nhiu
c quan, c bit l mt, thn, thn kinh, tim v mch mu .
II. DCH T HC
30-50% bnh nhn mc T type 2 khng c chn on.
- Tn sut bnh T trn th gii: trn th gii, T chim khong 60-70% cc bnh ni
tit. Trong nm 1995 cc quc gia c s ngi mc T nhiu nht v s ngi d on mc
T vo nm 2025 l n (19 ln 57 triu), Trung Quc (16 ln 38 triu), Hoa K (14 ln
22 triu); trong n l nc c t l tng nhanh nht.
1985: 30 triu ngi mc T; 2000: 171 triu; 2030: d bo 366 triu; trong a s bnh
nhn = 65 tui cc nc pht trin v t 45-64 tui cc nc ang pht trin.
3,2 triu ngi T t vong do bin chng T hng nm, tng ng 6 trng hp/pht
443


- Tn sut bnh T trong nc:
2002: thnh ph: 4,4%, ng bng: 2,7%, trung du: 2,2%, min ni: 2,1%.
H Ni: 1991: 1,2%, 1999-2001: 2,42%, thnh ph Hu 1992: 0,96%, thnh ph H ch
Minh: 1993: 2,52 (0,4%.
Theo TCYTTG, nm 2000 Vit nam c 791.653 ngi mc T v tng ln 2.342.879 ngi
vo nm 2030.
III. BNH NGUYN V C CH BNH SINH
1. T type 1: C cc yu t: di truyn, mi trung, min dch.















1.1. Di truyn
T type 1 phi hp cao vi s gia tng thng xuyn ca khng nguyn HLA, KN HLA u
th phi hp vi T type 1 thay i ty theo chng tc, HLA B8, B14,15, B18, Cw3, DR3
v DR4 gp bnh nhn T chng tc da trng, trong khi HLA DR3, DR4 c lin quan
Yu t khi pht:
- Nhim khun
- Thc n
Yu t thc y
- Nhim khun
- Thc n
Nhy cm di truyn

Phn ng t min

T lm sng

Khng c phn ng t min

Thuyn gim

Hai giai oan phat trin T type 1:
- G1: Tao ap ng t min hng nh vi TB ao tuy, biu hin bi s xut hin cac t
khang th GAD65, IAA, ICA, IA-2 (n c hay phi hp)
- G 2: Tin trin t ap ng t min vi TB ao tuy sang T type 1.

Ngun: TCYTTG - 4.2002
444
vi T th 1 chu , chu Phi v chu M Latinh. HLA DR3 hoc DR4 gp 95% T
type 1 so vi 45-50% nhm chng chng tc da trng.
Nghin cu nhng cp sinh i ng hp t gi rng nh hng di truyn T type 1 t
gp hn l type 2. Ch c 30% nhng cp sinh i ging ht nhau b T type 1 s pht
trin thnh bnh. iu ny cng gi rng yu t mi trng lin quan n bnh sinh T.
Ngc li, cp sinh i ging nhau ca T type 2 d xy ra trong vng nm u tin b
bnh nhiu hn l anh ch em rut.
1.2. Yu t mi trng
T type 1 l hu qu ca s nhim trng, nhim c lm tn thng ty, h thng min
dch tn cng v ph hy t bo bta ty. Yu t mi trng kt hp vi tn thng chc
nng t bo o ty bao gm virus (quai b, rubella, virus coxsackie B4), tc nhn c ha hc
(nitrophnyl-urea c cho chut), v cc cht c hy hoi t bo khc nh hydrogen cyanide
t bt sn h hng hay t c sn.
1.3. Yu t min dch
1.3.1. Min dch th dch
Khng th lu hnh chng li nhng t bo o ty c tm thy phn ln bnh nhn T
type 1 ngay lc c chn on (60 - 90%) ri gim. Cng c nghin cu cho rng t KT
khng t bo tiu o (ICA: islet cell autoantibody) c pht hin trong 5 tun u sau khi
khi bnh 85-90% T th 1. Ngoi ra > 60% KT khng insuline c tm thy trc khi
iu tr insuline (autoantibody to insuline: IAA). Ngoi ra cn c KT khng Tyrosine
phosphatase IA-2 v IA2.
Ngoi ra, phn ln KT khng t bo o trc tip chng li Glutamic Acid Decarboxylase
(GAD hay GADA), mt loi men nh v trong t bo bta ca ty. C s ging ht gia
thnh phn protein ca virus coxsackie cha chui 24 amino acid tng ng vi GAD65.
1.3.2. Min dch t bo
Cng ng vai tr trong bnh sinh T type 1: ngi ta nghin cu trn chut BB v nh
vo KT n dng cho thy ri lon TB lympho lin quan n T type 1 (gim lympho T c
ch, v tng t lympho T gip /lympho T c ch). Nhng nghin cu rt gn y gi rng
bnh l min dch ca o ty bt u nhiu nm trc khi chn on lm sng; tin trnh
min dch xy ra chm v tip tc.
Cc yu t khc ngoi liu php min dch c th nh hng n din tin t nhin ca suy t
bo trong T type 1
Bng 1: Cc yu t nh hng n T
Yu t Tc dng
Tui Tui cng tr th lng insulin ni sinh cn li cng thp
Cc t khng th Bnh nhn c ICA + th tc ph hy TB cng nhanh. Cc t khng th
khc t c gi tr tin on hn.
khng insulin Bnh nhn T type 1 thng c bng chng ca khng insulin; y c th
l mt yu t thc y s mt b chuyn ha.
Gii Mt s nghin cu cho thy nam gii bnh din tin nhanh hn
iu tr T iu tr mnh T lm chm tc gim sn xut insulin.
2. T type 2
2.1. Yu t di truyn
Yu t di truyn l tri c gi sau khi nghin cu cc cp song sinh ging nhau, nu
mt ngi mc T th 100% ngi cn li cng mc T.
445
2.2. Yu t mi trng
Tui, bo ph, tnh ti l yu t nguy c d a n bnh T. T type 2 bo ph nht l
bo bng, tnh ti thng c s thiu lin kt insuline vi th th v sau th th trong ni bo,
kt qu l mt p ng vi insuline.
Ngoi ra T type 2 thng xy ra qun th c nguy c cao khc nhau, bao gm khng
insuline, gia tng bt thng m m, tng VLDL, nh tng insuline khi i v sau n, tng
HA (trong hi chng chuyn ha).
S khng insuline trong T type 2 l hu qu ca nhiu c ch bnh sinh khc nhau.
Phn ln c ch ny c l do hu qu ca ri lon chuyn ho nh tng glucose mu, tng
acide bo khng - ester ho. Mt khc nhng nghin cu gn y trn qun th tin i tho
ng, thy rng s khng insuline m c xy ra rt sm trong qu trnh pht trin ca
bnh. Insuline receptor kinase, phosphatase lin quan ti hot ng insuline, cht chuyn vn
glucose v tng hp glycogene.
Ri lon chc nng t bo trong T type 2: c 5 ri lon:
1. Ri lon tit Insulin:
- Gim p ng ca insulin i vi glucose: mt pha sm.
- Ri lon tit insulin theo nhp: ri lon pha dao ng chm. S tit insulin sinh l
gm 2 loi dao ng: dao ng nhanh (mi 8-15, khng lin quan glucose), dao ng chm
(mi 80-120, lin quan cht ch vi nng glucose).
2. Bt thng chuyn ha prinsulin: trong T type 2 t proinsulin v cc sn phm chuyn
ha trung gian / insulin: tng.







3. Gim khi lng t bo .
4. Lng ng amyloid (amylin) ti o ty. Gp trong 90% trng hp T type 2. Xy ra
sm gy mt dn khi lng t bo o ty, nht l t bo .
5. Vai tr ca c cht th th insulin 2 (IRS 2: Insulin Receptor Substrate 2), NF-kB, ri lon
chc nng ti th, stress oxy ha.
IV. TIU CHUN CHN ON I THO NG
chn on T, hin nay ngi ta dng tiu chun chn on mi ca T chc Y t Th
gii (TCYTTG) nm 1998 v c xc nh li 2002. Chn on xc nh T nu c
mt trong ba tiu chun di y v phi c t nht hai ln xt nghim hai thi im khc
nhau:
1. Glucose huyt tng bt k trong ngy 200 mg/dl (11,1 mmol/l), km ba triu
chng lm sng gm tiu nhiu, ung nhiu, st cn khng gii thch c.
2. Glucose huyt tng lc i 126 mg/dL (7mmol/l) (i c ngha l trong vng 8
gi khng c cung cp ng).
3. Glucose huyt tng hai gi sau ung 75g glucose 200 mg/dl (11,1mmol/l) khi
lm nghim php dung np glucose bng ng ung (OGTT).
Giai on trung gian:
Endopeptidase
Proinsulin
Des 64,65 Proinsulin
Des 31, 32 Proinsulin
Insulin
C peptide
446
+ Ri lon glucose mu i (IFG: Impaired Fasitng Glucose): khi glucose mu
i Go (FPG) 110 mg/dl (6,1 mmol/l) nhng < 126 mg/dl (7,0 mmol/l).
+ Ri lon dung np glucose (IGT: Impaired Glucose Tolerance): khi glucose
mu 2 gi sau OGTT (G2) 140 mg/dl (7,8 mmol/l), nhng < 200 mg/dl (11,1 mmol/l).
- Go < 110 mg/dl (6,1 mmol/l): glucose i bnh thng.
- Go 126 mg/dl (7,0 mmol/l): chn on tm thi l theo di T (chn on chc
chn l phi iu kin nu trn).
nh gi kt qu khi lm nghim php dung np glucose bng ng ung:
- G2 < 140 mg/dl (7,8 mmol/l): dung np glucose bnh thng.
- G2 140 mg/dl v < 200 mg/dl (11,1 mmol/l): ri lon dung np glucose (IGT).
- G2 200 mg/dl (11,1 mmol/l): chn on tm thi l T.
Lu : TCYTTG cn s dng glucose mao mch chn on T (cn lu n tnh
chnh xc ca my o dng huyt mao mch); trong khi Hi T Hoa K (ADA) ch s
dng glucose huyt tng tnh mch trong chn on T.
Bng 2: Tiu chun chn on T v cc ri lon glucose mu khc (theo TCYTTG - 1999)
Nng glucose mmol/L (mg/dL)
Mu ton phn Huyt tng
Tnh mch Mao mch Tnh mch Mao mch
T:
+ Go 6,1 ( 110) 6,1 ( 110) 7,0 ( 126) 7,0 ( 126)
+ G2 10,0 ( 180) 11,1 ( 200) 11,1 ( 200) 12,2 ( 220)
IGT:
+ Go (nu c) v < 6,1 (< 110) v < 6,1 (< 110) v < 7,0 (< 126) v < 7,0 (< 126) v
+ G2 6,7 ( 120) 7,8 ( 140) 7,8 ( 140) 8,9 ( 160)
v < 12,2 (< 220)
IFG:
+ Go v 5,6 ( 100) v
< 6,1 (< 110)
5,6 ( 100) v
< 6,1 (< 110)
6,1 ( 110) v
< 7,0 (< 126)
= 6,1 (= 110) v
< 7,0 (< 126)
+ G2 (nu o) < 6,7 (< 120) < 7,8 (< 140) < 7,8 (< 140) < 8,9 (< 160)

447
CHIN LC CHN ON I THO NG THEO WHO 2002





















Bng 3: CC GIAI ON LM SNG CA T
Giai
on

Type
Glucose mu
bnh thng
Tng glucose mu
iu ha G
mu bnh
thng
RL G mu i
hoc RLDNG
T
Khng cn
insulin
Cn insulin
kim sot
Cn insulin
sng
Tp 1:
+ T min
+ V cn
Tp 2:
+ khng
insulin u th

+ Khim
khuyt tit
insulin u th

Cc type c
bit khc

T thai
nghn

Go (mmol/l)
Glucose mu bt k (mmol/l)
Khng triu chng
chng
7,8 7,8-11,1
Khng triu chng
11,1
< 6,1 6,1 Go < 7 7
XN li Go

XN li
Bnh
thng
RL Glucose
i
XN li Khng
XN na
6,1 Go < 7 11,1
7
I THO NG
11,1 Nghi ng T
11,1
G2
7,8-11,1 RLDNG G2
7,8-11,1
RLDNG
7,8 nh gi thm
7,8
C tr chng
11,1
448
V. PHN LOI I THO NG
Sau y l bng phn loi ca Hi i tho ng Hoa K (ADA) nm 2004
Bnh T gm 2 th loi chnh l T type 1 v type 2.
1. T type 1 (t min v v cn)
i tho ng type 1 c trng bi s hy hoi t bo bta ca o Langherhans ty (t
min hoc v cn) v thiu ht gn nh tuyt i insuline, v th d b nhim toan ceton nu
khng c iu tr.
Tui khi bnh thng gp nht la tui nhi ng v thiu nin, tuy vy cng c th gp
la tui 90.
Thng c yu t t bm di truyn v c lin quan n mt s yu t mi trng (nhim virus
trong thi k bo thai, c t...).
Thng c phi hp vi mt s bnh t min khc nh bnh Basedow, vim tuyn gip
Hashimoto, bnh Addison.
c trng bi s hin din khng th khng GAD 65, khng th khng t bo o ty (ICA)
hay khng th khng insulin IAA, khng th khng tyrosine phosphatase IA-2, IA-2((85-90%
trng hp). mt s ngi (c bit ngi chu v chu Phi) ngi ta khng tm c
bng chng ca hin tng t min v c phn loi l "type 1 v cn". Tc ph hy t
bo bta rt thay i, c th chm ngi trng thnh gy nn T th LADA (Latent
Autoimmune Diabetes in Adults).
i tho ng th LADA (theo Diabetes 12.2005): > 10% ngi > 35 tui, 25% ngi
<35 tui.
- Tn khc ca T LADA: T type 1 tim tng, T ph thuc insulin tin trin chm,
T ph thuc insulin khi pht chm, T type 1 tin trin chm, T type 1,5, T t
min tim tng ngi tr (LADY-like), T t min khng cn insulin lc chn on,
T LADA type 1 v type 2, T type 2 bo ph c t khng th, T t min ngi
trng thnh vi suy chm t bo ((ADASP: Autoimmune Diabetes with Slowly Progressive
-cell failure).
- Tiu chun chn on LADA
1. 30 tui
2. C s hin din ca t nht 1 trong 4 t khng th: ICA, GAD65, IA-2, IAA.
3. Khng cn iu tr bng Insulin trong vng 6 thng sau khi c chn on.
- Ngay lc chn on T LADA c ri lon chc nng TB v th c quan im s
dng insulin ngay t lc mi c chn on. Hu ht bnh nhn LADA u cn Insulin
trong vng 6 nm k t lc c chn on, mt s trng hp cn insulin sau 12 nm. S
hin din ca cc t khng th cng nhiu th tc ri lon t bo (xy ra cng nhanh: 2 t
khng th ri lon t bo trong vng 5 nm; LADA ch c ICA + hay GADA + ri
lon t bo xy ra mun hn (12 nm), LADA khng c s hin din ca t khng th hay
ch c IA-2 + chc nng t bo khng b nh hng v vn c bo tn 12 nm sau khi
c chn on.
2. T type 2
Thng gp nht. c trng bi ri lon hot ng hay tit insulin: thay i t khng
insulin chim u th vi thiu insulin tng i n khim khuyt tit insulin chim u th
km khng insulin hay khng.
Thng khng c chn on trong nhiu nm v mc tng glucose mu khng trm
trng, nhiu trng hp c ch pht hin tnh c. Thng xy ra ngi ln tui >40 tui,
nhng i khi cng xy ra tr nh, c tnh gia nh.
449
a s trng hp c km bo ph v bn thn bo ph li lm trm trng thm tnh trng
khng insulin. Nhiu bnh nhn khng c xem l bo ph da trn nhng tiu chun kinh
in nhng li c s tch t m nhiu vng bng.
Him khi nhim toan ceton ngoi tr khi c stress hoc nhim trng.
Nng insulin mu bnh thng hoc cao trong trng hp khng insulin chim u th;
hoc nng insulin gim trong trng hp c khim khuyt kh nng tit insulin.
C yu t gia nh r (c l do di truyn). Cc yu t nguy c ca T type 2 bao gm: tui
ln, bo ph, t hot ng th lc, tng huyt p, ri lon lipid mu, tin s gia nh T, tin
s b T thai nghn v thuc mt s nhm chng tc c nguy c cao mc T.
3. Cc tp c bit khc: bao gm
- Gim chc nng t bo bta do khim khuyt gene: MODY1 n MODY 6. T th
MODY (Maturity-onset diabetes of the young): do khim khuyt 1 gene lm gim chc nng
t bo bta gy gim tit insulin. Thng xy ra sm (trc 25 tui), c trng bi ri lon
tit insulin, trong khi hot ng insulin khng b nh hng hoc nh hng khng ng k.
vi tng glucose mu mc nh. Loi thng gp nht l MODY 3 do t bin NST 12
yu t nhn t bo gan (HNF1 alpha).
- Gim hot tnh insulin do khim khuyt gene: khng insulin tp A, T th teo m, hi
chng Rabson Mendenhall...
- Bnh l ty ngoi tit: bnh ty x si, vim ty, chn thng/ct b ty, ung th, x kn
ty, bnh nhim sc t st...
- Bnh ni tit: hi chng Cushing, to u chi, pheochromocytoma, u tit glucagon, cng
gip, u tit somatostatin, u tit aldosterone...
- T do thuc, ha cht: Vacor, pentamidin, acid nicotinic, corticoid, hormon tuyn gip,
thuc ng vn giao cm bta, thuc ng vn giao cm alpha, li tiu thiazide, Dilantin,
interferon alpha...
- Nhim khun: Rubella bm sinh, Cytomegalovirus...
- Cc th khng thng gp ca T qua trung gian min dch: t khng th khng th th
insulin, hi chng ngi cng...
- Mt s hi chng di truyn i khi kt hp vi T: hi chng Down, tht iu vn ng
Friedrich, hi chng Klinefelter, hi chng Turner, ma vn Huntington, hi chng
Lawrence-Moon-Biedel, lon dng trng lc c, porphyria, hi chng Prader-Willi, hi
chng Turner, hi chng Wolfram...
4. T thai nghn
T thai nghn (TTN) l tnh trng ri lon dung np glucose mu vi cc mc khc
nhau, khi pht hay c pht hin u tin khi c thai; d dng insulin hay ch tit thc
iu tr v ngay c khi T vn cn tn ti sau khi sinh. nh ngha ny khng loi tr tnh
trng ri lon chuyn ha glucose xy ra trc hay xy ra cng lc khi c thai m khng
c nhn bit trc .
VI. CN LM SNG
1. Glucose huyt tng tnh mch
Lc i, hoc bt k hoc 2 gi sau lm nghim php dung np glucose mu bng ng
ung; c gi tr nh nu trn phn chn on.
2. Insuline mu
Thp, i khi ch cn vt T typ 1; ngc li tng hoc bnh thng hoc hi thp T
typ 2.
3. Nng C-peptide
450
C-peptide l thnh phn cu ni hai chui A v B ca phn t proinsuline do tu sn xut.
Proinsulin Insulin + C peptide. C peptide gip nh gi nng d insulin ni sinh.
4. HbA1c
Khi glucose mu tng th tp trung glucose trong hng cu tng, dn n t HbA1c cng
tng. HbA1c cho php nh gi nng glucose mu trung bnh trong 2 thng trc .
5. Fructosamine
nh lng tng th protein gn glucose (c bit l albumine). Tr s bnh thng l 1 - 2.5
mmol/l, thay i tu theo phng php nh lng. Tr s Fructosamine phn nh nng
glucose mu trung bnh trong hai tun trc.
6. Cc xt nghim min dch - di truyn
- Di truyn: c th pht hin c cc khng nguyn HLA-DR3 v/hay HLA-DR4,
HLA-DQ, HLA-DRB (14,15), HLA-DR/DQ.
- Yu t min dch th dch: KT khng t bo tiu o (ICA): du ch im rt quan
trng trong hot ng min dch ca T type 1. KT khng insuline (IAA). KT khng
Tyrosine phosphatase IA-2 v IA2(. KT khng Glutamic Acid Decarboxylase (GAD65 hay
GADA65).
7. Bilan v bin chng hay bnh phi hp
- Ctone niu: c ch nh trong trng hp T mt b nng, nht l khi nghi ng
c b nhim toan cetone, thng (+) trong hn m nhim toan ctone type 1 hay type 2 mt
b nng do mc mt s bnh phi hp.
- o in tim, chp phim phi, soi y mt, chp ng mch vng mc, siu m
doppler hoc chp ng mch chi di nu nghi ng c x va gy hp, bilan v lipide, XN
chc nng thn (ur, cratinine mu, albumine niu vi th, protin niu).
- o in c EMG, trc nghim thm d bnh thn kinh t ng h tim mch,
Holter o HA v mch 24 gi.
VII. CHN ON
Bng 5: Cc c im chnh ca T type 1 v type 2 (theo TCYTTG 2002)
c im Type 1 Type 2
Tui khi pht in hnh < 35 > 35
Yu t t bm di truyn t Nhiu
Cc t khng th chng li TB C (90-95%) Khng
Vc dng Bnh thng/gy Bo ph
Insulin/C-peptide huyt tng Thp/khng c Cao
c im chuyn ha chnh Thiu insulin Hi chng chuyn ha vi
km nhy cm insulin
iu tr insulin p ng Cn liu cao
Cc thuc kch thch tit insulin Khng p ng p ng
1. Chn on T type 1
Khng c bn ci l:
- Khi u tui tr < 40 tui.
- Glucose mu tng theo tiu chun chn on ca TCYTTG nh ni trn.
- Du lm sng rm r: tiu nhiu (tng sinh niu thm thu), ung nhiu, n nhiu,
gy nhiu, v suy kit (asthnie).
451
- Tnh trng gim insuline tuyt i d a n nhim ctone v nhim toan-ctone
nu khng iu tr (C-peptide <0,2ng/ml). Trc khi gim insuline tuyt i, nng nh lm
sng ph thuc vo tit insuline cn c xc nh bng cch o insuline mu hoc C-
peptide.
- Khng th khng o (+), v KT khng th khng GAD (+).
- iu tr ph thuc insuline.
- Bin chng vi mch l thng gp.
- Lin quan n yu t HLA
2. Chn on T type 2
Lm sng, bnh nhn T type 2 c triu chng lm sng r xy ra sau tui 40, i khi c
th xy ra sm hn. Du lm sng thng khng rm r nh type 1, nhng cng c th l tiu
nhiu, ung nhiu, n nhiu (thng c yu t lm d nh stress, nhim trng...), ri lon th
gic c bit l du do tng glucose mu nh ri lon chit quang, hoc l c bin chng
v mch mu v thn kinh. Trong nhng trng hp ny tng glucose mu thng phi hp
vi glucose niu v chn on d dng khng cn thit lm trc nghim chn on qu phc
tp. i khi hon ton khng c triu chng, v chn on phi cn n cc xt nghim cn
lm sng mt cch c h thng (30-50% T type 2 khng c pht hin).
Bng 6: Bng phn bit T type 1 v T type 2 ca Nhm d kin T quc gia Hoa K
(NDDG), v ca V. Fattorusso v O. Ritter (c phn ging nhau) nu ln vi nt c th ring
gia 2 th nh sau
T type 1 T type 2
T l mc bnh 10 - 20%
Khi u c hiu tui tr <40 tui
Khi u thng cp
Gy
Tit insuline rt thp
Nng insuline HThanh rt thp hoc bng 0
Th th insuline him khi b tn thng.
Hn m do nhim toan ctone

Bin chng vi mch sm
Bt buc iu tr bng insuline + tit thc

C HLA-DR3 v DR4
C khng th khng o, KT khng GAD
C tin s gia nh 10% trng hp
30-50% xy ra tr sinh i ging nhau
Tin s nhim siu vi, nhim c
80 - 90%
Thng khi u >40 tui
Khi u khng r rng.
Bo ph hay khng bo
Binh thng hoc gim t
Tng hoc bnh thng hoc gim t.
Thng b tn thng th th.
Hn m tng thm thu
(Rt him nhim toan ctone)
Bin chng mch mu ln
Tit thc, vn ng hay tit thc+ S.U.,
Metformine hay insuline
Khng lin quan n HLA.
Khng c KT khng o
C tin s gia nh 30% trng hp
100% xy ra tr sinh i ging nhau
Khng c.
VI. BIN CHNG
1. Bin chng cp
Bin chng cp c hiu bnh nhn T type 2 l tng thm thu do tng glucose mu, h
glucose mu, nhim toan lactique; T type 1 l nhim toan cetone.
1.1. Tng thm thu do tng glucose mu (HHS: Hyperglycemic Hyperosmolar State)
Thng xy ra ngi gi. Gim chc nng thn v ri lon kht thng gp ngi gi,
cng lm tng cng v tnh trm trng bin chng ny. Hn m vi thm thu HT >
452
340 mOsm/Kg nc, khng c nhim toan ceton. Lm sng tin trin nhanh, mt nc, st v
ri lon thc (sng s, hn m, co git ng kinh). Mt nc ni v ngoi bo, ch yu ni
bo. Th nhanh, nng, nhng khng c mi cetone.
CLS: - Glucose mu tng >8g/l (44 mmol/l), c th t n 20g/l, nhng lun lun > 7g/l,
Natri mu tng rt cao (>150mmol/l); Kali c th bnh thng hoc gim do iu chnh
glucose bng insuline, cetone niu (-). Thng c suy thn chc nng, ur lun trn 1,5 g/l.
- pH mu bnh thng, d tr kim khng thay i
- C nhiu cch tnh tng thm thu:

hoc
1.2. H glucose mu
L triu chng ng ngi, nht l bnh nhn gi T type 2 iu tr bng sulfonylureas.
Nu bnh nhn T c bin chng thn kinh t ng lm mt p ng tit catcholamine,
lm che du triu chng h glucose mu nn bnh nhn cng nh thy thuc khng cnh gic
c. H glucose mu bnh nhn T gi l ngun gc ca tai bin mch mu no hoc
mch vnh, cng tng t sut T, ngay c du h glucose mu mc va nhng nu lp
li nhiu ln cng rt nguy hi v khng hi phc.
1.3. Nhim toan acid lactic
Xy ra bnh nhn T type 2 ln tui, thng c tn thng suy t bo gan, hoc suy thn,
v thng do iu tr bng Biguanide. Him gp
1.4. Nhim toan cetone i tho ng (DKA: Diabetic Ketoacidosis)
Gp bnh nhn T type 1, type 2 him. Tin triu c th rt kn o: mt mi, chn n,
nn ma. au vng thng v, c hiu theo tht lng. Tiu nhiu v kht nc nhiu, nc
tiu c cetone > ++ l triu chng bo ng, ngay c khi khng c triu chng lm sng. C
vi trng hp nhim toan cetone nng xy ra trong vi gi, hoc vi ngy, v tc xut
hin l yu t chnh gip tin lng.
Du lm sng r vi kh th do nhim toan: th nhanh 25 l/ph, kh th 4 th ca Kussmaul.
Ri lon thc, thng thng khng c du thn kinh khu tr v Babinski (-). C du mt
nc ni v ngoi bo. Ri lon tiu ho (nn ma, au bng nhiu, i chy cng lm mt
in gii). Hi th c mi acetone, h nhit thng gp. Dn ng t.
Cn lm sng: glucose niu (++++) v cetone niu (+++).
- ECG: phi thc hin mt cch h thng ngay khi bnh nhn mi vo vin, nh gi
bin sng T v xem c bt thng v dn truyn tim tng ng vi kali mu
- Glucose mu: 3 - 5g/l.- Th ceton trong HT rt cao
- HCO
3
-
gim < 10 mEq/l, pH gn 7,0 hoc thp hn (BT: 7,30)
- Ri lon kali mu: gi u bnh thng hoc tng, nhng gim nhanh trong 3 gi
sau. V th theo di in tim u n l cn thit.

(Na 2) + G mmol/L >320 mOsm/Kg
nc
(Na +K
+
) 2 + G + Ur > 340 mOsm/Kg
nc
453
Bng 7: Tiu chun chn on nhim toan ceton T (DKA) v tng thm thu do tng glucose
mu (HHS) - (theo ADA 2004)
DKA HHS
Nh Va Nng
G huyt tng (mg/dl) > 250 > 250 > 250 > 600
pH ng mch 7,25-7,30 7,00-7,24 < 7,00 > 7,30
HCO-3 huyt tng (mEq/L) 15-18 10 - < 15 < 10 > 15
Ceton niu + + + t
Ceton huyt thanh + + + t
Posm huyt thanh * Thay i Thay i Thay i > 320
Khong trng anion ** > 10 > 12 > 12 Thay i
Tnh trng tri gic Tnh Tnh/ng g Sng s/hn m Sng s/hn m
*: P
osm
(mOsm/kg) = 2 Na (mEq/L) + G (mmol/L)
**: Khong trng anion = Na+ - (Cl
-
+ HCO
3
-
) (mEq/L)
2. Bin chng mn tnh
2.1. Bin chng vi mch
2.1.1. Bnh l vng mc T
Nguyn nhn chnh gy m. Gm 2 giai on: bnh l vng mc T khng tng sinh
(NPDR: nonproliferative diabetic retinopathy) v bnh l vng mc T tng sinh (PDR:
proliferative diabetic retinopathy).
Bng 8: Cc giai on bnh l vng mc T
Giai on Thay i bnh hc thng gp
Giai on tin lm sng
Thay i lu lng mu qua vng mc
Mt TB quanh mao mch vng mc
Dy mng y
Giai on sm:
NPDR mc nh

Vi phnh mch vng mc v xut huyt dng chm
Tng tnh thm mch mu vng mc
Xut huyt dng chm nh bng gn
Giai on trung gian: Thay i khu knh tnh mch
+ NPDR mc va Bt thng vi mch trong vng mc
+ NPDR mc nng Mt mao mch vng mc
+ NPDR mc rt nng
Thiu mu cc b vng mc
Xut huyt lan ta trong vng mc v vi phnh mch lan ta
Giai on mun:
PDR
Tng sinh mch da th
Tng sinh mch nhiu ni
Tng sinh mch mng mt
Tng nhn p do tng sinh mch
Xut huyt dch knh v quanh vng mc
454
Tng sinh x mch mu
Co ko vng mc, x vng mc, bong vng mc
+ Ngoi bin chng vi mch vng mc, ti mt cn c cc bin chng sau: ri lon chit
quang nn nhn khi t khi m, ri lon mu sc (xanh, vng), c thu tinh th, vim thn
kinh th, lit c vn nhn, glaucome (do tng sinh mch mu ti mng mt lm ngn cn lu
thng dch knh t tin phng ra hu phng)
2.1.2. Bnh l vi mch thn (bnh l thn T)
Thng xy ra ng thi vi bnh l vng mc, l nguyn nhn hng u suy thn mn tin
trin. Triu chng u th giai on sm l proteine niu xut hin sau 10-15 nm khi bnh
T, m biu hiu giai on u l albumine niu vi th.
Bng 8: Cc phng php tm sot albumin niu (theo ADA - Diabetes Care 1.2004; NEJM
4.2002)
Giai on Mu khng theo thi gian Mu theo thi gian
Khng hiu chnh Hiu chnh theo C crea
NT
Qua m 24 h
g/ml mg/g g/min mg/24h
BT < 20 < 30 < 20 < 30
Alb niu vi th 20-200 30-300 20-200 30-300
Alb niu i th > 200 > 300 > 200 > 300
giai on c albumine-niu vi th, sinh thit thn s thy dy mng y mao mch vi cc
lng ng lan to trong lp gian mch cu thn. Khi cc lng ng ny c dng nt, c gi
l x ho knh-cu thn dng nt Kimmelstiel v Wilson; dng tn thng ny t gp. Sau mt
thi gian di, albumine niu tng dn v xut hin proteine niu r, nu vt qu 5 g/24 gi.
C th c gim protide mu, ph c hiu ca mt hi chng thn h, v thng phi hp
hng nh vi tng HA trm trng, vi bnh l vng mc v thn kinh T.
2.1.3. Bin chng thn kinh T
Bng 9: Phn loi bnh l thn kinh T (theo ADA 2005):
Bnh l a dy thn kinh i
xng
Cm gic cp tnh
Vn dng-cm gic mn tnh
T ng
Bnh l mt dy thn kinh
mt hay nhiu
TK s
TK thn
TK chi
Vn ng gn gc chi (teo c)
Bnh l a dy TK hy myelin do vim mn tnh cng tn ti
nh ngha bnh l thn kinh T theo ADA 2005: S hin din ca cc triu chng
v/hoc du hiu ca ri lon chc nng thn kinh ngoi bin ngi T sau khi loi tr
cc nguyn nhn khc (Chn on bnh l thn kinh T l mt chn on li tr. Thng
phi hp vi bnh l vng mc, bnh l thn to thnh tam bnh (triopathie) c hiu ca
T.
455
- Bnh l TK cm gic cp tnh: him, xy ra sau 1 thi gian kim sot chuyn ha km (nh
nhim toan ceton) hay do thay i t ngt kim sot glucose (vim TK do insulin). Triu
chng cm gic xy ra cp tnh v ni bt, tng ln v m, khng c du hiu TK khi khm
LS.
- Bnh l a dy TK vn ng - cm gic mn tnh: cn gi l bnh l TK xa gc i xng.
Thng gp nht, > 50% trng hp. ng vai tr ch yu trong bnh sinh lot bn chn
T.
Biu hiu lm sng ch yu cm gic bng, cm gic chm chch, cm gic in git, d cm,
tng cm gic au v cm gic au su. Triu chng nng v m. Xy ra ch yu bn chn
v chi di. 50% khng c triu chng v ch c chn on khi thm khm; c khi c biu
hin lot bn chn khng au.
Khm thy mt cm gic rung (dng m thoa 128 Hz), cm gic p lc (dng dng c si n
10g - 10g monofilament), cm gic au v cm gic nhit, mt phn x gn gt.. Thng km
cc du hiu ri lon thn kinh t ng ngoi bin: bn chn lnh hay nng, i lc tnh
mch mu chn dn, da kh, nt chai vng t .
- Bnh l mt dy thn kinh: t gp, khi pht t ngt. Tn thng TK gia (5,8%), TK tr
(2,1%), TK quay (0,6%), TK mc chung. Tn thng TK s (III, V, VI, VII) rt him gp
(0,05%). Khong 1/3 bnh nhn c biu hin chn p TK (TK tr, TK gia, TK mc v TK
gia bn tay). Bnh l teo c do T thng gp bnh nhn T type 2 ln tui vi
triu chng au nhiu, yu v teo c gn gc mt hay hai bn.
- Bnh l thn kinh t ng (BLTKT):
S tm tt bin chng thn kinh t ng cc c quan:

Bt thng
tit m hi

Bt thng
tim mch

Ri lon
d dy-rut


Ri lon
vn mch

Bnh thn kinh
t ng

Bnh thn kinh
c


Bt thng
v ng t

Bt thng
iu ho nhit


Bt lc
2.2. Bin chng mch mu ln
Biu hin x va nhiu mch mu ln: thiu mu c tim im lng, NMCT (50% t vong),
vim tc ng mch chi di gy hoi t kh, vim xng; tc mch bn chn; cng chn,
phi ct ct chi. Tai bin mch mu no. Tc mch thn: c th pht hin c ting thi
ng mch thn; hu qu THA, suy thn.
3. Bin chng nhim trng
D b nhim trng: lao, nhim siu vi v vi trng, nht l nhim trng ng tiu dai dng v
ti pht nhiu ln nht l ng tiu thp, lm d cho vim thn b thn ngc dng v suy
thn. Nhim trng da v nim mc: nht t cu vng, vim m h, vim bao qui u.., i khi
chnh bi cnh nhim trng ny lm khi pht T c sn.
4. Cc bin chng khc
456
4.1. Tng HA
Thng phi hp vi T, i khi c trc khi T xut hin, hoc thng thng do bnh
l cu thn, x va; tn sut gp nhiu T type 2 nht l bo ph v c s tng quan gia
bo ph v THA.
4.2. Bin chng da
Ngoi tn thng nht nhim trng, da cn c nhng biu hiu sau: vim teo dng m biu
hiu bng nhng nt m phn trung tm teo li, vng vin xung quanh tm dn, nh v ngn
tay hay chi di, d ng da do insuline, ph i m m hoc teo m m.
4.3. Bn chn T
- Sinh bnh hc nhim trng bn chn T: 3 yu t phi hp
+ Bnh l mch mu ngoi bin (vi mch v mch mu ln).
+ Bnh l thn kinh ngoi bin.
+ Suy gim min dch: do gim chc nng TB lympho, do tng glucose mu, do dy
mng y.
- Phn loi nhim trng
+ Mc nh:
Lot b mt.
Chy m hay huyt thanh.
Hoi t khng c hay rt t.
Khng c biu hin nhim c ton thn.
+ Mc va:
Lot b mt su hn.
Thng c chy m.
Hoi t m mc trung bnh.
Vim xng tu xng c th c.
Biu hin ton thn nh: st, BC tng.
+ Mc nng:
Lot b mt hay su hn (vo m di da, xng, khp).
Chy m.
Hoi t m nng v lan rng.
Biu hin nhim c ton thn nng n: nhim toan, nhim khun huyt.
VII. IU TR
1. iu tr i tho ng tp 1
1.1. Mc tiu iu tr:
- Lm bin mt triu chng, trnh bin chng lu di, bng cch kim sot glucose mu tt,
vi t HbA1c < 7%, kt hp iu chnh ri lon lipide, protide tt, trng lng n nh bnh
thng, v trnh nhim cetone. Trnh pht trin bin chng thoi ha (hn ch bin chng
cp v mn tnh).
- Trnh tai bin do iu tr (teo m m, h glucose mu) v gio dc bnh nhn bit bnh ca
h.
457
Bng 9: Mc tiu iu tr T
Mc tiu iu tr c khuyn co ca Chu Thi Bnh Dng
Xt nghim Tt Kh Xu
Go (mmol/l)
G bt k (mmol/l)
4,4 - 6,1
4,4 - 8
< 7
< 10
> 7
> 10
HbA1c < 6,2% 6,2 - 8% > 8%
Mc tiu iu tr ca ADA (Hip Hi T Hoa K)
XN B/Thng

Mc tiu phi t n khi
iu tr
Cn thay i k hoch
iu tr
G trc n (mg/dl)
G lc i ng (mg/dl)
< 110
< 120
80 - 120
100 - 140
< 80, > 140
< 100, > 160
HbA1c < 6% < 7% > 8%
1.2. iu tr tng qut v chin lc iu tr
1.2.1. Gio dc bnh nhn v bnh T: gio dc cho bnh nhn bit cch dng thuc, tit
thc v cc tai bin ca thuc nht l du h glucose mu kp thi s tr nh dng ng
nhanh hoc bo cho BS. Chuyn khoa bit hoc nhp vin ngay.
1.2.2. Tit thc v vn ng
* Tit thc: bnh nhn T tp 1 thng l gy, nn phi tng nhu cu calo hng
ngy.
* Vn ng v tp th dc va phi, ng nhin phi hp insulin. Theo di k
glucose mu v cn thn liu insulin v d nguy c h glucose mu.
1.2.3. iu tr bng insulin
* Cc loi insulin c s dng
- Insulin thng: tc dng nhanh; nu TDD c tc dng sau 15-30 pht, tc dng ti a sau 1
gi, ko di 4-6 gi., nn c tim trc n 20- 30 pht..
Tim bng nhiu ng (TM, TB, TDD, trong phc mc), mi cch tim c thi gian
tc dng khc nhau, dng ng tim, bt tim
- Insulin trung gian (NPH) (tc dng ko di >8 gi v <24 gi). Tc dng sau 1- 2 gi, ti a
4-5 gi.
- Insulin NPH hn hp: c trn gia insulin nhanh v insulin trung gian loi NPH. Tn th
trng l Mixtard 30 HM, Scillin 30 (Insulin ngi sinh tng hp).... Thuc bt u tc dng
sau 30 pht chch, tc dng ti a 2-8 gi, ko di 24 gi.
Mixtard 30 HM Penfill cng tng t nh vy
- Insulin tc dng trung gian c km: thi gian tc dng trong vng 6-36 gi. im bt li l
gy au ch tim, nn phi tim i v mng
- Insulin tc dng chm: khng dng trong bt tim, bt u tc dng 2gi 30 sau chch, ti
a 7-15 gi, ko di 24 gi, v d nh Monotard HM
- Insulin tc dng rt chm (ultra lente): tc dng ko di 36 gi.
- T bo bta tit insuline: mi t bo c10.000 ht hay nhiu hn, mi ht ch 200.000 phn
t insulin, v insuline ch c phng thch vo mu khi glucose mu cao sau n
* Cch tim v ng tim: thng thng bng ng TDD, trng hp bin chng cp nh
hn m toan ceton hoc tng thm thu th truyn TM, tim TM.
458
Ch : Ch c insuline nhanh l c th tim bng ng TM, cn cc loai trung gian, chm,
km th khng dng ng TM
* Cch bo qun insulin: insulin n nh nhit t 7 oC-27oC, tuy nhin tt nht nn bo
qun 4 -8 oC, khng nn tim ngay sau khi ly t t lnh ra.
* Tc dng ph insulin
.- H glucose mu
- Phn ng min dch do iu tr insulin: D ng insulin: di dng m ay. Hin nay him
gp v c loi insulin bn sinh hc hay insulin ngi.
- khng insulin.
- Lon dng m m ti ch tim: c 2 biu hin: teo m m di da; ph i m m di da
vn cn l vn kh trnh.
- Tng glucose mu mu thun: hiu ng Somogyi: qu liu insulin lm h glucose, gy kch
thch cc hormon lm tng glucose mu (catecholamin, cortisol, glucagon), cng lm nng
thm cc bin chng.
- Ph: do gi mui gi nc.
* Ch nh iu tr insulin
- T tp 1: iu tr thay th sut i
- T tp 2: iu tr tng cng hay vnh vin tu thuc vo bin chng hay bnh phi hp
- T thai nghn
* Phc iu tr insulin
- i vi insulin nhanh: ch nh trong trng hp cp cu nh hn m toan ceton, hn m
tng thm thu (truyn TM, bng seringue chuyn hoc bm). Ngoi ra insulin nhanh thng
c ch nh khi glucose mu dao ng, kh kim sot. Tim di da trc n 30 pht. Tim
nhiu ln, hoc tim 2 mi hoc 3 mi nhanh trc ba n, hoc phi hp thm vi insulin
chm hoc hn hp vo bui ti
- i vi insulin NPH: hoc ch nh trong T m glucose mu n nh, cn tim
2mi/ngy: 1 bui sng v 1 vo bui chiu. Hoc phi hp vi insulin nhanh trong k thut 3
hoc 4 mi tim: trung gian tim vo ti, insulin nhanh th tim sng, tra v ti.

Nhanh Nhanh Trn (Nhanh+NPH)






8 gi 12 gi 20 gi 8 gi
Trc n Trc n Trc n
sng 30pht tra 30pht ti 30pht
S 1: S iu tr insulin vi 3 mi tim/ngy (2 nhanh+1 loi hn hp)


459


Nhanh Nhanh Nhanh NPH






8 gi 12 gi 20 gi 22 gi 8 gi
Trc n Trc n Trc n
sng 30ph tra 30pht ti 30pht
S 2: S iu tr insulin vi 4 mi tim/ngy (3 nhanh + NPH)

Hn hp (nhanh+NPH) Hn hp (nhanh+NPH)








8 gi 20 gi 8 gi
Trc n Trc n
sng 30ph ti 30ph
S 3: S iu tr insulin vi 2 mi tim/ngy (2 loi hn hp)

- i vi insulin NPH trn ln: Loi ny c s dng theo 2 cch sau:
+ K thut 2 mi tim/ngy: tim 2 mi trn ln, chn loi trn ln ny vi mc ch l loi
nhanh lm gim nhanh glucose mu sau n, cn loi chm tc dng c ngy (mi ban ngy)
v sut trong m n sng (mi ban m).
+ K thut 3 mi: insulin nhanh tim bui sng v bui tra, mi trn ln tim vo trc n
bui ti, k thut ny hiu qu hn 2 mi.
- i vi insulin chm. K thut tim 1 mi; ch nh i vi bnh nhn T c nhu cu
insulin tng i khng nhiu lm
1.2.4. Thuc c ch min dch
iu tr c ch min dch trong T tp 1 giai on mi khi pht l mt tin b. Mc d
c vi trng hp lui bnh hoc gim nhu cu insulin, phn ln bnh nhn biu hin khng
dung np ng. Loi c ch min dch c hiu nht l KT n dng, chng c hiu trn s
sn xut t bo T. Mt vi thuc khng nhm c ch min dch nh Probucol c xu hng
lm mt gc t do, v Nicotinamide c ch s tng hp Poly (ADP ribose) (mt loi men
phc hi s thng tn NAD) nhm lm suy yu t bo cung cp NAD.
460
1.2.5. Ghp tu
2. iu tr T tp 2.
2.1. Mc tiu iu tr:
- Kim sot glucose mu tt nh ni trn
- iu tr cc yu t nguy c phi hp (thuc l, HA. Ri lon lipid mu)
2.2. Cc phng tin iu tr:
- Gio dc bnh nhn
- Tit thc v vn ng th lc, gim cn nng.
- Thuc h glucose mu: Gm cc nhm thuc ung chng i tho ng sau:
+ Thuc tng tit insulin
Sulfamides (Sulfonyl Urase)
Metiglinide (Repaglinide) v D. phenylalanine (Nateglinide)
+ Biguanide: Tng s dng glucose m (c, t bo m).
+ c ch -glucosidase
+ Cc nhm thuc khc: cng to iu ho glucose mu tt qua c ch ti rut, v gim tng
glucose mu sau n. Hoc nhm Thiazolidinedione gip ci thin khng insulin
2.3. p dng thc t
i vi T tp 2, nht l i vi ngi tr tui hn, tit thc v vn ng th lc l c
chn la u tin. bnh nhn c glucose mu tng nh < 200 mg/dl v HbA1c < 8.5% nn
p dng 4-6 vn ng v tit thc, nu khng ci thin c glucose mu tt th mi s dng
thuc ung h glucose mu
2.3.1. Tit thc:
* Khu phn thc n hng ngy:
- Tit thc gim calo bnh nhn bo ph (20 kcalo/kg/ngy)
- Duy tr calo bnh nhn c trng lng bnh thng (30 kcalo/kg/ngy).
- Tng calo bnh nhn gy (40 kcalo/kg/ngy)
* Tn trng cn bng tit thc gia 3 loi thc n sau
- Glucide: 50-55% (50%) khu phn calo hng ngy ( l khu phn cn bn). Dng
tri cy trong mi ba n, nhng cng hn ch. ng chm hay ng a (loi c bt) v
nhng loi c si (lgume kh) lm chm tng ng sau n v hp thu chm. Hn ch dng
ng n (hp thu nhanh). C th s dng cc cht ngt nhn to nh ng saccharine,
Aspartam
- Lipide: 30-35% (trung bnh 35%) khu phn calo hng ngy. u tin l du thc vt
- Protide: 15% khu phn calo hng ngy.
- Ru: ung bia ru vi lng va bnh nhn T c th chp nhn c, vi
iu kin phi tnh calo/ngy (1g ru cho 7 Calo) v khng nn dng khi bng i, d h
glucose mu.
2.3.2. Vn ng, tp th dc:
Gim cn; ci thin c ng mu trong v sau khi vn ng th lc (gim khng
insulin, tng tnh nhy cm insulin ngoi bin). Gim LDL-C, tng HDL-C. Tc dng c li
trn tim mch. Tng kh nng ti a s dng oxy, lm chm li nhp tim lc ngh ngi v lc
gng sc, gim va phi HA
2.3.3. Cc thuc ung h glucose mu:
* Thuc c tc dng kch thch tit insulin:
461
- Nhm Sulfonyl Urase: Chuyn ho gan, 1/2 i khc nhau, thi theo ng mt hay
thn, lin kt proteine mu cao, nguy c h glucose mu v kch thch tu tit insulin.
+ Tc dng ca Sulfonyl urase (S.U). S.U. c tc dng ch yu l kch thch tu tit insulin
Hot ng ngoi tu-trn tng hp glucose ti gan, vn chuyn glucose, gii phng glucagon
S.U gim khng insulin v gim glucose mu sau n do gim c tnh glucose, v tng
tim lc trc tip trn gan, khi glucose mu gim th t bo gan nhy cm hn i vi insulin
S.U cn c tc dng lm tng tnh nhy cm sau th th.
+ Cc nhm thuc S.U.
* Th h I: c 1/2 i ko di: hin nay t dng
- Chlorpropamide: Diabnse 500mg/vin (thi gian 1/2 i l 36 gi)
- Carbutamide: Glucidoral, vin 500mg, Tc dng 1/2 i l 45 gi. Tc dng ko di
24 - 60 gi. Liu dng 1/2 - 1 vin/ng, dng 1 liu duy nht.
* Th h II: gm:
- Gliclazide: Diamicron 80 mg, Prdian, Glucodex, Clazic, vin 80mg. Tc dng 1/2
i l 12 gi. Tc dng ko di 12 - 24 gi. Liu dng 1-3 vin/ng. Dng 2 ln/ng (trc hoc
trong ba n sng v trong ba n ti). i vi ngi ln tui, gim 1/2 liu.
Diamicron MR 30 mg, Clazic SR 30mg, tc dng chm, ung 1 ln bui sng, liu 1-2
vin/ln
- Glibenclamide: Daonil 5mg, Hmi-Daonil 2,5mg, Daonil faible 1,25mg (5 gi). Tc
dng 1/2 i 6 - 16 gi. Tc dng ko di 12 - 24 gi. Liu dng thng thng 1-2vin/ng, c
th tng 3v/ng. Ung ngay trc ba n chnh. 1 - 3 ln/ng
- Glipizide: Glibnse, Minidiab: tc dng 1/2 i l 3-7 gi; tc dng ko di 6-12
gi; 5mg/vin; liu 5 - 20mg/ngy, 2 ln/ng.
* Th h III: Glimepiride (Amaryl*, Amarel*) vin 1mg, 2mg, 3mg. Tc dng 1/2 i l 5 - 8
gi. Tc dng ko di 12-24 gi, Liu dng l 1mg/ng, c th tng dn theo bc cp 1mg,
2mg, 3mg, 4mg, 6mg, thi gian tng theo khong cch 1-2 tun; thng thng liu 1-4 mg/ng.
Ung trc ba n im tm hoc ba n chnh, ung mt liu duy nht trong ngy.
- Glinide: c tc dng kch thch tit insulin khi glucose mu cao, nn iu ho c glucose
trong ba n, kim sot c ng mu sau n. Gm:
+ Rpaglinide (Novonorm*, Prandin*): vin 0,5mg, 1mg, 2mg; liu 4mg/ngy chia
hai, ung trc n 15 pht. Ko di 3 gi
+ D-phenylalanine (Natglinide). Starlix*, vin 60-120mg, liu 60-120mg/lnx 3
ln/ngy, cho trc n; ko di 1 gi 30 pht
* Biguanides:
a. Metformin (Dimethylbiguanide):
- Metformine tc dng nhanh: Glucophage, Siofor, Fordia, vin 500mg,
-Metformine tc dng chm: Glucophage retard (Metformine HCL) 850mg; Siofor
850mg; Fordia 850mg
Glucophage cho liu u tin 500mg, 2-3 ln/ng; ung trong lc n hoc sau khi n;
sau 10-15 ngy c th thay Glucophage retard 850mg, 2 ln/ng.
- Glucinan, Stagid: liu 2-3 vin/ng, ung trong lc n.
- Tc dng: khng kch thch tit insulin, nn khng c tc dng ph h ng mu.
Tuy vy do nhiu c ch tc dng n vn lm gim tc dng ng mu lc i, c bit l
sau n; thuc c tc dng u th trn gan, gim tn sinh ng gan, ci thin p ng sau
462
th th, tng tiu th glucose t bo ch, iu ho c ri lon lipde mu, gim ngng
ngon ming. Ch nh u tin cho T tp 2 bo
* Thuc c ch (-Glucosidase: c ch hp thu glucose rut
a. Acarbose: Glucobay, Glucor*. Vin 50mg, 100mg. Liu cho tng dn 50 mg (3
ln/ng, ung ngay khi bt u n.
b. Voglibose (Basen*) Th h th 2. Vin 0.2mg, 0.3mg. Liu 0.2mg, 3 ln/ng, ngay
trc n
* Benfluorex: (Mediator):
- Tc dng: tc dng ging Metformine, vin 150 mg. Liu: 1-3 vin/ngy (tng dn
liu), bt u 1-2, 3 vin/ngy.
* ThiazolidineDione
- Ch nh tt trong T tp 2 khng bo c khng insulin.
- Tc dng: Tng tnh nhy cm insulin, Gim glucose, TG, tng HDL.
* Cc nhm thuc mi:
Glitazones tc dng ln th th, gim c tnh khng insulin mt cch trc tip
m ch, gim glucose mu, nhng d tng cn. Gm Rosiglitazone (Avandia) v
Pyoglitazone bt u dng ti Php nm 2000.
Avandia (Rosiglitazone maleate): liu 4mg/ngy, sau 12 tun nu cn kim sot ng huyt
tt hn, c th tng 8 mg/ngy. Dng lc i hoc no. Ch nh:
- T tp 2 khng kim sot ng huyt tt sau tit thc v tp th dc.
- Phi hp vi SU hoc metformine khi T2 c iu tr bng tit ch v thuc SU
hoc metformine m cha n nh glucose mu tt
CC trong suy tim 3-4 (NYHA), suy gan hoc bnh gan c ALT >2,5 ln BT. Tc dng
ph: ph do gi mui, nc, thiu mu, rng trng tr li trong giai on tin mn kinh
2.3.4. iu tr insulin trong T tp 2.
* iu tr insulin tm thi (cn gi l i tho ng tp 2 cn insulin hoc vin n insulin
(insulino-ncessitant, insulinorequrant):
iu tr insulin bnh nhn T tp 2 khi:
- Triu chng nng ra, mc d c iu tr tit thc v thuc ung h glucose mu.
+ Du 4 nhiu: kht, tiu nhiu, ung nhiu, n nhiu v gy r.
+ C ctone niu (+++)
+ Tng glucose mu nhiu v trng din (>3g/l), (HbA1c >7% mc d iu tr thuc
ung ti a (gy tng c tnh ng).
- au nhiu chi di.
- Cc tnh hung cn insulin:
- Cc bnh nhim trng
- Can thip phu thut.
(Mc ch nhm trnh s mt qun bnh glucose mu do phi hp vi mt s bnh trm trng
nh nhim trng hoc can thip phu thut).
- Hoc nhng bnh nhn T tp 2 ang iu tr bng cc loi thuc lm tng
glucose (nh corticoides..)
- Hoc i tho ng thai nghn.
463
Trong phn ln cc trng hp ny, s s dng insulin c thc hin ti bnh vin hay ti
nh, glucose mu c theo di u n thch nghi liu insulin. Ty p ng m bc s s
quyt nh ngng insulin v tr li iu tr thuc ung chng T.
Ch nh insulin trong trng hp ny c th n c hoc cng phi hp vi thuc
ung chng T.
- Nu insulin < 40UI, Glucophage 2 vin/ngy, bui sng v bui ti, ri 3v/ng,
insulin gim t 2-4 UI mi 2 ngy.
* iu tr insulin lu di (sau cng): c ch nh trong nhng trng hp sau:
- Bnh thn, gan, tim hoc bin chng mt, khng th tip tc iu tr cc loi thuc
ung chng T c.
- Hoc v bnh T tin trin nhiu nm, mt cn bng glucose mu trng din. Ty
khng sn xut insulin.
+ Cch s dng insulin trong T tp 2: insulin c th thay th thuc vin hoc phi hp
2 loi insulin v thuc ung gi l iu tr hn hp. Liu insulin thch nghi theo glucose mu.
S ln tim ging nh trong tp 1.
3. iu tr bin chng i tho ng
C rt nhiu bin chng, c cp v mn, mt s bin chng v tim mch nh THA, bnh
mch vnh, thn th trnh by cc phn iu tr theo chuyn khoa. y chng ti ch
ni s v iu tr cc bin chng cp thng gp nh hn m toan ceton, hn m tng thm
thu, bin chng mn nh bin chng thn kinh
3.1. Bin chng nhim toan- ceton (acidocetose)
iu tr ny thc hin trung tm c bit, v chuyn khoa, theo di cht ch
3.1.1. Chng mt nc v cung cp mui
ti lp li dch trong lnh vc ngoi bo v tng th tch. Phi bit trng lng ca bnh
nhn trc khi b nhim toan: nu mt 10% trng lng th b lng dch tng ng trng
lng mt. V d bnh nhn 60 kg, mt 10% trng lng th b 6 lt: 3 lt trong 6 gi u
v 3 lt trong 24 gi sau, gm:
- Dung dch mui ng trng: 1 - 2 lt trong 2 gi u (Nu HA ti a < 80 mmHg, v
khng c hoi t c tim, th chuyn dch c phn t ln).
- Ri ngng thay bng dd glucose 5%, thm ch 10% nu glucose <2g/l, bao gm:
+ 2 lt trong 4 gi tip theo.
+ 3 lt trong 12 gi sau na.
3.1.2. iu tr insulin
- Insulin nhanh c th cho liu n 300 UI, v
- Liu dng: 5-10 UI/gi insulin nhanh bng seringue in. Hoc bolus 10 UI; nu
chuyn khng c th TB (trnh liu cao).
3.1.3. Cn bng in gii: Bicarbonat: ch nh cn thn v c nguy c h kali mu:
+ Nu tn s th > 26 l/pht.
+ pH mu gim < 7,10 mi ch nh chuyn Bicarbonate. Nu khng s gy
phn ng di kim chuyn ho mt khi ceton b chuyn ho. Kim chuyn ho s lm thay
i s trao i Kali lm tng nguy c ri lon nhp tim
Liu 500-750 ml Bicarbonate ng trng (ch khng chuyn mt mnh
Bicarbonate, m phi cho cng mui ng trng).
3.1.4. Kali: C th cung cp kali sau khi iu tr, tu theo in gii v bin i in tim.
3.1.5. Cc iu tr khc
464
- Khng sinh.
- iu tr bnh nguyn.
- Ngn nga bin chng xut huyt tiu ho do thuyn tt mch.
3.2. Bin chng hn m tng thm thu
3.2.1. B dch: Mt nc do tng thm thu thng n 10 -11 lit/24, mt c ngoi bo ln
ni bo. V th cn cung cp nc khi lng ln, nhng kh v theo l thuyt phi chuyn
nc nhc trng, nhanh, phi c sn dng tc th (nc ct v glucose ng trng),
nn hon ton bnh nhn phi khoa c bit (c nguy c v hng cu). Thc t thng dng
mui ng trng: chlorure natri 0,9%, 1-2 lt trong 1-2 gi u. Sau b nhc trng
0,45%. Lng dch b c th l 6-8 lt/12 gi u, phn cn li trong 24 hoc 48 gi sau.
3.2.2. Insulin: Tim ngay, liu thp hn liu ca nhim toan acidocetose; u tin 10-15 UI,
ri 1-2 UI mi 1/2 gi bng sringue in. Nu khng c sringue in, th dng sringue
thng cho liu 5-10 UI, lp li mi 2 gi/ln, nu glucose mu < 200 mg% th phi chuyn
glucose 5% hoc dextrose 5%, nhng phi duy tr glucose mu 250-300 mg%, trnh ph no
3.2.3. iu chnh Kali mu: theo di k in gii xem c h kali khng, nu c cho kali
10-30mmol/L
3.2.4. Hparine: cho sm trnh thuyn tc, thay i tin lng.
3.2.5. Khng sinh: iu tr nhim trng tin hoc th pht.
3.2.6. iu tr nguyn nhn.
3.2.7. Chng sc
- Thuc vn mch dobutamine 5-15 g/kg/pht, hoc dopamine 3-5 g/kg/pht.
- Chuyn plasma.
Tm li: trong 36 gi u phi t n mc ch sau:
- Glucose mu gn 250 mg%
- Nng thm thu HT gn <320 mOsm/kg nc.
- Lng NT gim gn 50 ml/gi.
3.3. iu tr bin chng thn kinh T
3.3.1. Thuc c ch Aldo-rductase:
* Sorbinil: iu tr trong 1 nm, ci thin lm sng tt, v t ra c hiu qu i vi bnh l
thn kinh mi khi pht, nhng tn thng lu, nng th kt qu hn ch.
* Torestat: cng cho kt qu tt sau 6 thng iu tr, khng c tc dng ph trm trng.
3.3.2. Myo-inositol: c tng thm s dn truyn TK, nhng khng ngn chn c s
Sorbitol.
3.3.3. c ch Sorbitol-dehydrogenase: gim oxyde ha sorbitol thnh Fructose bng cht
S.0773 l mt tin dc (prodrug) c cung cp bi Geinsen v cng s, liu
100mg/kg/ngy/3ngy.
3.3.4. iu tr h HA t th
Trong thi gian u, thng thng phi sa i tnh trng gim th tch mu, phi hp vi
thuc. Thuc iu tr hiu qu nht l
- Khong-corticoid nh Fludrocortison, liu 100 - 300(g/ngy (vi thc n nhiu
mui, 2-6 g mui/ngy).
- Mtoclopramid (primperan): thuc i khng dopaminergic, liu primperan
10mg/vin x 3ln/ngy,.
- Thuc i khng th th alpha-adrenergic tin synap
465
+ yohimbin vin 2mg, liu 4mg x 3 ln/ngy
+ Cn thn bnh nhn c tin s TBMMN
- Dihydroergotamin: thuc co ng mch, ngoi iu tr migrain cn iu tr h HA t
th do thn kinh, do c tc dng i khng th th serotonin 5 HT2, nhng liu cao c tc
dng ng vn th th adrenergic v tc dng serotonic.
+ Tamik*, vin 3mg x 2 vin/ngy, trong khi n;
+ Seglor* nang 5mg, ikaran LP* vin 5mg, liu 10mg/ngy, chia 2
+ Khng nn phi hp bta-bloquant
- c ch bta: mt s rt t bnh nhn c tng th th bta, th propanolol c ch
nh (liu thp).
- Thuc ng vn alpha 1: Nu tht bi khi dng cc loi thuc trn, th dng cht
ng vn alpha 1 nh midodrine (gutron). Liu 2.5-4 mg mi 6 gi, thng thng phi hp
vi dihydroergotamin v cafein.
- Thuc ng vn ca somatostatin c tc dng di: i vi cc th h HA t th kh
tr, xy ra trong thi k sau n, th dng Octreotid liu 0,1-0,5 g/kg TDD vo bui sng hoc
ti
- Thuc c ch tng hp prostaglandin: nh indometacin, ibuprofen, cng c kh nng
sa i h HA t th sau n bnh nhn T.
3.3.5. iu tr lit d dy:
- Lit d dy gy bun nn, hay nn th iu tr
+ Metoclopramid (primperan), cht i khng dopamin, vin 10mg, ung 4 ln/ngy,
Nhng nu d dy lit nng th phi dng ng tim v hp thu thuc ti d dy km.
Cc thuc khc nh:
+ Cisapride (prepulside*): c th lm gia tng phng thch acetylcholine t tng thn
kinh c rut (plexux myenteric), kch thch vn ng hang v v t trng, liu 10-40 mg trc
n 30 pht
+ Dopaminobloquant: domperidone (motilium), ci thin ri lon nhp in d dy,
20mg/vin, liu 10-40 mg/ngy, c th 80mg/ngy chia bn ln, cho 30 pht trc n.
+ Thuc ng vn cholinergic (ging ph giao cm): bethanechol chloride 10mg, 2
ln/ngy
+ Cht c ch cholinesterasase: pyridostigmin bromid 1-2 mg/ngy, c th lm gim
kh ming
+ Erythromycin: kch thch th th motilin, kch thch co tht hang v sau n v i
Nu tt c u tht bi, c th phu thut ct jujenum, v nui n qua ng rut
3.3.6. iu tr i chy T
+ Primperan, hay loperamid (imodium, 2-4mg x 4 ln/ngy). Tc dng ca loperamid lm
gim s ln i cu v cng lm tng p lc c vng hu mn lc ngh ngi
+ Hoc phi vin ti codein (30mg x 4 ln/ngy), opinium
+ Clonidin: tc dng c li trn c tng nhu ng rut v tng tit rut non, liu 0,6 mg/vin x
3 ln/ngy, gim nhu ng thy r.
+ Octreotid: 50-75 (g TDD 2-3 ln/ngy, c th lm gim s ln i cu t 6 xung 1 ln. Tuy
nhin octreotide c th a n bin chng h glucose mu ti din do gim tit cc hormon
chng iu ho.
+ Diphnoxylat + atropin: lomotil 2mg-5mg, 2-4 ln/ngy, ung. Ch diphenoxylat l thuc
c s dng sau cng, v tht cn thn v d gy phnh i trng (megacolon)
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- i khi kt hp khng sinh chng nhim khun.
3.3.7. iu tr bin chng ti bng quang:
Thng gim kch thch bng quang, nu c cu bng quang, dng th thut Crede. Nu tht
bi th dng thuc ging ph giao cm nh bethanechol HCL 10mg, 2 ln/ngy, C th
dng alpha-bloquant (xatral) liu cao gim khng ng thot tiu, nhng c th gy h
HA t th v ri lon phng tinh.
Nu tht bi, th phu thut ct on c bng quang lm mt s co tht ca c vng on
di nam gii.
3.3.8. iu tr bt lc
+ Thuc i khng alpha-adrenergic: yohimbin 4mg, 3 ln/ngy, c th gim 33%
trng hp, v nu cn
+ Regitin v papaverin: c th tim trc tip vo dng vt, mt s c kt qu tt,
nhng d b nhim trng, hoc cng qu mc, hoc x ho..
+ Sidenafil (VIAGRA): thuc lm tng t GMP vng, gy cng dng; vin 25mg.
50mg, 100mg. Liu 25-50mg, 1 gi trc khi hot ng sinh dc
+ Caverject: l prostaglandine E1, gy dn ng mch dng vt, v dn c trn th
hang, l 10-20(g, tim vo th hang 5-20(g
+ Hoc t prothese dng vt.
3.3.9. iu tr triu chng au trong bnh thn kinh ngoi bin
- Gabapentin (Neurontin): thuc nhm chng ng kinh, co git, c cu trc gn ging cu
trc ca GABA/acid gamma aminobutyric, vin 100mg, 300mg v 400mg, liu 300mg x 2
ln/ngy, ti a c th ti 1200mg, tc dng ti a sau 2-3 gi, na i 5-7 gi, Thn trng
khng nn dng: tr em, c thai, cho con b, suy thn, ti x li xe
- Thuc khng trm cm 3 vng (amitriptylin, nortriptylin, desipramin): c s dng
chng au trong bnh thn kinh T t lu:
* Liu lng: Chia liu nh gim tc dng ph.
nh gi tim mch trc khi ch nh.
Bt u 10-25mg lc i ng c th tng liu mi tun, liu t n t 25-150mg.
Tc dng ph thuc: m mt, thay i thi nhn thc, kh mi, bn, h HA t th,
tit m hi, ri lon sinh dc, mch nhanh, b tiu
3.3.10. iu tr lot bn chn T
- Ct lc vt thng rng.
- iu tr nhim trng
- Ti lp ti mu tt.
- Loi b sang chn
- Gim p

467
H GLUCOSE MU
Mc tiu
1.Trnh by c c ch bnh sinh v bnh nguyn ca h glucose mu.
2. Trnh by c nhng triu chng lm sng v cn lm sng lin quan n h glucose mu.
3. Bit cch x tr v theo di bnh nhn b h glucose mu theo tng mc .
4. Bit phng thc tm kim nguyn nhn v bin php d phng h glucose mu.
Ni dung
I. NH NGHA
H glucose mu cn c gi l h ng huyt, din t nhng biu hin lm sng v cn
lm sng xy ra i vi c th ngi khi nng glucose huyt tng tnh mch (50 mg/ dl
(2,7 mmol / l).
H glucose mu l mt trong nhng cp cu ni khoa thng gp trn lm sng, l mt trong
nhng nguyn nhn gy t vong bnh nhn i tho ng s dng insulin hoc sulfamide
h ng huyt trong t l t vong 3 - 7% bnh nhn i tho ng tp1. Tuy nhin
thc t lm sng gii hn nng ng mu ni trn c th thay i do tnh hung lm sng
cp hay mn ty thuc vo tui cng nh bnh l i km nht l bnh nhn i tho ng
c thi gian mc bnh ko di.
II. BNH NGUYN
1. H ng huyt lc i km cng insulin
1.1. Phn ng insulin
- Ch n khng y v s v cht lng hoc l do qun ba n bnh nhn i tho
ng iu tr.
- Hot ng th lc qu mc: ngi khng b i tho ng lng thu nhn glucose ca c
vn (tng 20-30 ln trn mc cn bn) c b tn sinh ng gan. iu ny l do gim
insulin lu hnh do tng catecholamine do vn ng lm c ch t bo beta. iu ha ny b
gim bnh nhn ang iu tr insulin. Khi cc ni lng ng thuc di da tip tc phng
thch insulin trong qu trnh hot ng v tng hp thu insulin nhng vng c gn gc.
- H thng iu ha glucose b tn thng bnh nhn i tho ng b bnh lu ngy.
Phn ln bnh nhn i tho ng tp 1 c s km p ng glucagon khi h ng huyt
- Qu liu insulin. Do khng nhn r hoc do thay i nng Insulin trong l thuc (40 UI/
ml thay th 100 UI/ ml)
- Qu liu sulfamide h ng mu, thuc c tc dng ko di (Chlopropamide c thi gian
bn hy trn 35 gi...) c bit bnh nhn c thng tn gan, thn, ngi ln tui d c nguy
c h ng huyt.
- Cc nguyn khc
+ Stress: Khi b stress (bnh tt, nhim trng, phu thut...) thng tng liu Insulin cn
bng ng mu. Khi stress chm dt cn phi gim liu.
+ Suy v thng thn (bnh Addison) gy h ng huyt v th cn gim liu Insulin.
+ Bnh l d dy i tho ng: Bnh l thn kinh thc vt cc tng lm d dy gim trng
lc lm chm a thc n t d dy vo rut, nguy c h ng sau n bnh nhn s dng
Insulin.
+ Thai nghn. Nhu cu tiu th ng tng trong thai nghn v th cn gim liu Insulin trong
3 thng u.
+ Suy thn: Lm ging ha Insulin v thuc h ng huyt b ko di.
+ Thuc dng phi hp: Bnh nhn i tho ng c phi hp thuc iu tr nh:
468
Allopurinol, c ch beta, clofibrate, cimetidine, thuc chng ng, hydralazine,
indomethacine, Maleate de perhexilline, miconazole, phenolbarbitale phenylbutazole,
probenecide, salycile, sulfamide chng nhim khun, IMAO.quinine, quinidine, c ch men
chuyn, disopyramide, tricycliques, propoxyphene, octreotide, tetracycline, mebendazole,
cibenzoline, stanozolol, fluoxetine, ethanol, sertaline, tromethamirne, gancilovir, lithium,
temafloxacilline.
+ H ng huyt gi (dng ln lt Insulin v cc thuc h ng huyt): lin quan n bnh
nhn c bnh l tm thn phi hp.
+ H ng huyt t min. C khng th khng Insulin. H ng huyt xy ra 3 - 4 gi sau
n v c quy cho s phn ly gia phc hp min dch khng th & Insulin lm phng thch
Insulin t do... H ng huyt t min do tch ly s lng khng th ln c kh nng phn
ng vi Insulin ni sinh, c ghi nhn bnh nhn iu tr methimazole trong bnh
Basedow ti Nht Bn, cng nh mt s bnh nhn lymphoma, a u ty, hi chng lupus,
trong paraprotein v khng th phn ng cho vi Insulin.
H ng huyt do khng th khng th th Insulin tng i him, bnh nhn ny c thi k
khng Insulin v chng gai en (acanthosis nigricans).
H glucose mu cng c ghi nhn s p ng vi iu tr glucocorticoid m khng thy
trong lc huyt tng v c ch min dch.
- H ng huyt do dng Pentamydine: Loi thuc dng iu tr nhim khun Pneumocystic
carinii bnh nhn AIDS, thuc lm tng Insulin cp do tc dng trn t bo beta (10 - 20%
bnh nhn).
- U t bo beta tuyn tu.
1.2. H ng huyt lc i khng cng insulin.
1.2.1. Cc ri lon phi hp vi gim lu lng glucose gan.
- Do mt mt s lng t bo gan nh teo gan vng cp, nhim c gan cp.
- Do ri lon cung cp acid amin n gan (chn n thn kinh, nhn i lu ngy, hi chng
uree mu cao, suy v thng thn).
-Do bt thng chuyn ha glucose tr s sinh (thiu men thoi bin glycogen, men tn
sinh glucose).
1.2.2. H ng huyt do ru
Ru (ethanol) chuyn ha ti gan nh NAD v xc tc bi ethanol dehydrogenase. V th
dng ru lu ngy lm gim lng NAD gan. y l cht cn thit trong phn ng tn sinh
ng. H ng huyt do ru do gim tn sinh ng km gim ngun d tr glycogen ti
gan. Ngoi ra insulin mu gim thun li cho tng cetone mu v trong nc tiu.
Bnh nhn h ng huyt do ru thng km thiu vitamine B1 (Beriberi) cp v th ngoi
s dng glucose cn phi hp vi vitamine B1. Ngoi ra do hai yu t ni trn vic s dng
Glucagon trong h ng huyt do ru khng c tc dng.
Triu chng thng xy ra sau n t 8 - 12 gi. Bnh nhn trc ung nhiu ru v s
lng cng nh thi gian lm gim ngun d tr glycogen mt phn do n ung khng y
.
1.2.3. U ngoi tuyn tu.
Fibrosarcome sau phc mc, ung th gan, ung th thng thn, ung th thn, ung th d dy
rut, lymphoma v bch cu cp. nh lng Insulin khong 8 (U/ml vo lc h ng huyt
lc i. C l c s tit Insulin lc ch.
Khong 50 % khi u c tit peptid c trng lng phn t thp vi tc dng ging Insulin gi
l peptide hot ng ging Insulin khng b kim hm (NSILA peptide = nonsupressible
469
Insulinsulin like activity) bao gm human Insulin like growth factor v mt vi cht ca
somatomedine.
2. H ng huyt phn ng (h ng huyt khng xy ra lc i)
H ng huyt phn ng xay ra sau n 2 - 3 gi hoc mun hn 3 - 5 gi.
2.1. H ng huyt do thc n sau ct d dy.
y l hu qu ca cng Insulin sau ct d dy. Thc n xung nhanh sau n, hp thu
glucose nhanh lm tng ng huyt, kch thch tit Insulin lm bnh nhn chng mt, xm
xong, v m hi. (d dy trng nhanh sau n, kch thch thn kinh ph v v sn xut
hormone d dy rut kch thch t bo beta (beta cytotropic gastrointestinal hormone). C th
dng khng cholinergic nh propantheline (15 mg / ngy 4 ln), nn n tng ba nh, hn ch
ng hp thu nhanh, c th dng thuc c ch men alpha glucosidase.
2.2. H ng huyt chc nng do thc n.
Thng gp bnh nhn mt mi mn tnh, loi u, kch thch, yu, km tp trung, gim tnh
dc, nhc u, i sau n...
2.3. H ng huyt mun.
H ng huyt sau n 4 - 5gi sau khi ung ng gi tin triu i tho ng th 2.
III. BNH SINH H GLUCOSE MU
Khi nng Glucose mu bt u gim di mc sinh l s kch thch vng di i kch
thch tuyn yn tit ACTH (tng Cortisol) v STH (tng glucose).
Khi h glucose mu nhiu cn pht sinh cm gic thm n ng v kch thch h li - hnh
ty gy kch thch ty thng thn tit adrenaline, h ph giao cm (nhn X), ty tng (t bo
alpha) tit glucagon, d dy rut tit gastrin, secretine, kch thch tit ADH.
Adrenaline cng glucagon lm tng thoi bin glycogene v tng tn sinh glucose ti gan,
adrenaline (cng giao cm & thn kinh thc vt: m hi, lo lng, nhp tim nhanh)
Gastrin v secretine lm tng hp thu glucose ng tiu ha. Kch thch h i giao cm (i
bng, bun nn v nn).
Nhng triu chng trn thng xut hin sm nhng ch yu v trm trng ca h glucose
mu tc ng ch yu trn t bo no (v khng c ngun d tr glycogene) xy ra trong vng
vi pht. Thiu glucose mu ko theo gim tiu th oxy. Nhu cu glucose t bo no khong
60 mg / pht v xy ra hn m khi cn 30 mg / pht. Thng tn t bo no khng hi phc
khi nu s thiu nng lng trm trng v ko di. Do nhy cm v thiu nng lng ca cc
vng thuc no b c khc nhau, v th th t xut hin triu chng ca cc giai on gii
phu lm sng xut hin ln lt nh sau.
+ Giai on v no: L m, bun ng, kch thch tm thn, nhn i.
+ Giai on di v no v no trung gian: hot ng t ng, vt v, co git.
+ Giai on no gia: co cng c, un vn, gin ng t v khng p ng nh sng, git
nhn cu.
+ Giai on trc ty no: du mt no.
+ Giai on ty no: hn m su, mt trng lc c, mt phn x gic mc.
Ch m no b ph n nht l bnh nhn i tho ng, hoi t, xut huyt, d gy d ng.
Ngoi ra mch vnh, h tiu ha v h hp xy ra mun hn v khng thng xuyn.
IV. TRIU CHNG
1. Triu chng lm sng
Cn lu triu chng lm sng thng t tng ng vi nng glucose mu. Triu chng
h glucose mu thng xy ra khi i hoc xa cc ba n, tng ng thi gian tc dng ti a
470
ca thuc (insulin hoc sulfamide h ng huyt) i vi bnh nhn i tho ng. Triu
chng trn ci thin nhanh khi cung cp glucose tc thi.
1.1. H ng huyt mc nh:
- Du ton thn: Bnh nhn c cm gic mt mi th lc ln tinh thn, bun ng, chng mt
- V m hi (du chng rt quan trong trong giai on ny).
- Du tiu ha: i bng v co tht vng thng v, c th nn hoc a chy.
- Du tim mch: Hi hp, nhp tim nhanh hoc ngoi tm thu. Huyt p tng. au vng trc
tim km ri lon nhp hoc dng au tht ngc.
- Du thn kinh: Chut rt, d cm u chi v quanh mi, nhc u thng xuyn hoc kch
pht. Ri lon iu tit, nhn i, run lnh (d nhm do nhim trng.
- Du tm thn kinh: Ri lon nhn cch v tnh kh: kch thch, vui v, ling thong, hoc i
khi bun b hoc nng tnh.
- Du h hp: cn kh th dng hen.
Nu giai on ny pht hin kp thi v x tr n gin vi cc thc ung c cha ng, du
hiu lm sng ci thin nhanh.
1. 2. H ng huyt nng:
C th t ngt hoc xy ra trn nn cc biu hin lm sng k trn. Trong giai on ny biu
hin lm sng ch yu l du tm thn kinh.
- Tm thn kinh: Sng s, n, cn trm cm vi xu hng t st, kch ng hoc cng
kch, hoang tng, o gic, mt thc thang qua.
- Cng hm (du quan trng d nhm un vn) v du h glucose mu nng.
- ng kinh ton th hoc khu tr dng Bravais Jackson, lit na ngi, khu tr, ri lon tiu
no - tin nh: chng mt, ri lon vn ng ( nhm tai bin mch mu no).
Giai on ny s dng glucose u trng ng tnh mch trc tip hn l cho ng ung
bnh nhn s hi phc nhanh.
1.3. Hn m h glucose mu
Khi u thng khng t ngt, km co c, co git, tng phn x gn xng, co ng t,
cng hm, nhiu m hi, km nt mt bng v hi phc sau khi chuyn glucose sm
trc khi qua giai on khng phc hi vi hn m su thng tn no khng hi phc v t
vong nu h glucose mu nng v ko di.
2. Cn lm sng: Glucose huyt tng: (50 mg/dl (2,7 mmol / l)
+ Triu chng lm sng v cn lm sng thng khng tng ng vi nhau.
+ ng huyt tnh mch chnh xc nhng thi gian tr kt qu thng chm v th trong bi
cnh ti cp ng huyt mao mch cng l du chng tin cy v kt qu c tc thi. Khng
nn c i kt qu ng mu tnh mch m nn lm song hnh.
V. CHN ON H NG HUYT
1. Chn on xc nh: Tam chng Whipple
+ Triu chng lm sng h glucose mu.
+ Nng glucose mu di 2,7 mmol/l (50 mg%).
+ Ci thin triu chng khi dng cc cht cha ng
2. Chn on nguyn nhn
2.1. Bnh nhn mc bnh i tho ng
iu tr vi cc thuc Insulin hoc thuc sulfamide h ng huyt tin s ghi nhn vi ln
qua li khai bnh nhn nu cn tnh, thng qua ngi nh nu bnh nhn hn m.
471
Xc nh iu kin xut hin cng nh yu t thun li (qun ba n, qu liu thuc nsulin,
hot ng th lc qu mc nhng qun b nng lng, hoc s dng thm cc thuc lm tng
tim nng ca thuc h ng huyt (xem phn nguyn nhn). Rt ra t hu qu trn cn
hng dn cho bnh nhn v ngi nh ngoi gio dc h ng huyt cn phi.
Gim liu Insulin hoc thuc vin h ng huyt.
Xem li ch dinh dng v s lng v cht lng nht l thnh phn glucide trong cc
ba n nht l nhng lc au m.
iu chnh li gi n cho hp l.
Tng ba n gia gi (ba n ph) ngoi ba n chnh.
Cn ch
+ Bnh nhn i tho ng c iu chnh ng huyt tt khng th trnh nguy c h
ng huyt.
+ H ng huyt trn bnh nhn i tho ng tr khng phi l du hiu xu, nhng trn
bnh nhn ln tui hoc c bnh l tim mch (suy vnh, tng huyt p) l yu t nng vi
nguy c khi pht tai bin tim mch (nhi mu c tim, tai bin mch no).
+ H ng huyt thng xy ra v m gn sng cn kim tra ng mu lc 4 gi sng nu
bnh nhn c cc biu hin nghi ng.
+ Hin tng Somogyi (tng ng huyt phn ng) l biu hin ca h ng huy trc
.
2.2. Bnh nhn khng mc bnh i tho ng
2.2.1. Cc xt nghim cn lm.
Chn on thng kh i hi nhiu phng tin nh lng Insuline mu, C Peptide v cc
kch t hoc cc cht khc v cc test nh sau
- Nghim php nhn n. Bnh nhn bt buc phi nm vin nhn n hon ton hoc ch n
hn ch glucide (50 g glucide, 50 g protide v 70 g lipide)
Thi gian nhn: Nhn n cho n lc xut hin triu chng h ng huyt hoc 3 ngy vi
lao ng.
Xt nghim cn lm ng thi
+ ng mu mao mch v tnh mach (gi phng xt nghim) mi 4 gi cho n khi xut
hin du h ng..
+ nh lng insulin
+ nh lng peptide C huyt tng.
on nhn
Da vo t l insulin / glucose (I/G) theo 2 cng thc sau:
Insulin (pmol/l) / glucose (mmol/l) (20 (bnh thng).
Hoc (100 X insulin (U/ ml) / (ng mu - 30 mg%) (50 (bnh thng)
Lu : 1(U / ml = 7,17 pmol/l.
2. Test h glucose mu bng insulin nh sau
Bnh nhn cn c theo di st.
K thut: ly mu nh lng ng v peptide C vo cc thi im Gn.
Liu insulin 0,1 UI/ kg (loi insulin tc dng nhanh).
nh gi kt qu:
- H ng huyt khi ng mu di 50 mg/dl.
- Hm tit insulin ni sinh c xc nh nu peptide C huyt tng gim di 65% g tr
472
bnh thng.
- Khng hm hoc hm yu: u tuyn tit insulin, h ng do dng sulfamide. Khng hm
peptide C chng c c tit nulin ni sinh t ng cn phi thm d nguyn nhn bng chn
on hnh nh. Nh nh v u tit insulin bng chp CT scanner. Chp mch chn lc ng
mch mc treo trng trn. Phn tch u tuyn tit insulin n c trong bnh cnh a ni tit
th I, ch yu tr em, c th tng sn o lan ta, khng nhn thy (nesidioblastose)
2.2.2. Chn on nguyn nhn hng n do: Cn phn bit 2 tnh hung
H ng huyt thc th v h ng huyt chc nng.
1. H ng huyt thc th
Thng xy ra khi bng i, bui sng, n mun hoc b ba, sau vn ng qu mc.
Biu hin lm sng thng nng. Cn ch n iu kin, tnh hung xy ra cng nh yu t
phi hp. nh lng ng thi glucose mu, insulin v peptide C. C th to li tnh hung
bng nghim php nhn n. C 3 tnh hung xy ra nh sau:
1. Insulin mu, peptide C v t insulin/ glucose u tng.
U tit insulin, Kch thch tit insulin ni sinh do thuc hay khng., Sulfamide h ng huyt,
Quinine
2. Insulin v t insulin/ glucose u tng nhng peptid C thp.
Dng insulin ngoi sinh, Chng gi bnh., Nghim php phm php (manoeuvre criminelle).
Tm khng th khng insulin nu dng insulin b, heo khng c nu dng insulin ngi.
3. Insulin thp, t insulin/ glucose bnh thng hoc thp.
C th lin quan n bnh tt, nhim c hoc do thuc,h ng huyt do u ngoi ty (u
mc treo nh v phc mc, sau phc mc, lng ngc), u gan, u v thng thn, u biu m.
Thng h ng huyt ti din, nng. Chn on d do u ln, chp CT scanner, nh lng
tng IGF2 (insulin like growth factor 2).
2. H ng huyt chc nng:
Thng xy ra 2- 4 gi sau n, Thng khng c du thn kinh cm gic. Rt him khi hn
m. Biu hin i cn co v m hi. Bnh nhn thng c tin s ct d dy, ni v trng,
ct thn kinh X chn lc. l h ng huyt do cng insulin (do thc n xung qu
nhanh trong rut non) cn phn bit hi chng Dumping. Cn phi nh lng ng mu khi
xy ra s c trn. Cn thc hin li test. Bnh nhn khng c can thip bnh l d dy
(thng l ph n) h ng huyt do cng insuline hoc nhy cm qu mc i vi
insuline. Phn ng thn kinh thc vt m khng phi h ng huyt ph n lo u v trm
cm.
2.3. Mt s tnh hung c bit
- Ng c ru cp: h dng huyt lun tm kim ngi hn m do ru, suy dng.
- Nhim c gan: Glycol, tetrachlorure de carbone, annannite phalloide.
- Dng Hypoglycine (tri cy xanh vng Jamaique)
- Bnh nng: suy thn, suy gan, suy tin yn, suy thng thn cp, suy dng, suy tim,
chong nhim trng.
- S dng mt s thuc nh (acetaminophene, c ch bta, chlorpromazine + orphenadrine,
ethionamide, disopyramide, haloperidol, maleate de perhexilline, quinine, pentamidine,
propoxyphene, salicyles)...
VI. BIN CHNG V HU QU
1. Ph no sau h ng huyt: Hn m ko di mc d ng mu tr v bnh thng km
ph gai th. Ph phi cp: Do co mao mch phi.
473
2. Hu qu thn kinh: Bnh l thn kinh ngoi vi: teo c tun tin, phn xa ca t chi xy ra
vi tun sau khi b mt hoc nhiu cn h ng huyt nng, thng phi hp vi d cm t
chi. Thng tn sng trc ty sng c th b.
3. Ri lon tm thn kinh ko di: in, ng kinh sau h ng huyt, hi chng parkinson,
ma vn.
4. Gy hoc xp t sng: Xy ra khi c cn ng kinh nng.
Lu : Bnh nhn c tui (trn 60 tui) nht l c bnh l tim mch d c nguy c tai bin
tim mch (cn kim tra in tim nu nghi ng thiu mu c tim im lng).
Bnh nhn i tho ng, h glucose mu c th xy ra v m thng khng nhn bit
c. V vy kim tra ng mu mao mch vo lc 4 gi sng.
5. Di chng thng xuyn: l di chng ca nhng cn cp tnh, lp li v khng nhn bit.
Lit bn thn, mt ngn ng, ma vn, hi chng Parkinson. Mt tr tu dn dn, tnh trng sa
st tr tu, hi chng teo c t chi xa gc v mt phn x gn xng.
VII. IU TR
1. iu tr triu chng
1.1. Bnh nhn cn tnh
Ung cc thc ung cha ng cho n khi ci thin triu chng.
Khng c ung cc loi ng ha hc (sacharinate de sodium, saccharineate
dammonium) dnh cho ngi i tho ng.
1.2. Bnh nhn hn m: iu tr cp cu
1.2.1.Dung dch Glucose 30% hoc 50%.
Bm trc tip tnh mch mt lng glucose nh sau
Lng Glucose = [ Trng lng (kg) X 0,2 ] X [ Gbt - Gh ]
Trong Gbt l nng glucose huyt tng cn t v d G =1 g/l, Gh l nng glucose
mu lc b h ng mu v d Gh = 0,2 g/l. Nh vy mt bnh nhn nng 50 kg, Lng
glucose cn bm lc u l: 50 x 0,2 x (1 X 0,2) g = 8 g glucose.
Khng nn truyn nh git m phi bm trc tip tnh mch t nng glucose mu tng
nhanh v cao.
1.2.2. Glucagon (ng 1 mg)
Tim tnh mch, tim bp hoc tim di da vi liu 1 - 2 mg, c th lp li sau 10 - 20 pht
(thi gian bn hu ngn). Khng s dng glucagon i tng nghin ru nng do d tr
glycogen gan km, hoc bnh nhn nhn i lu khng cn glycogen d tr gan. Bnh
nhn T tp 1 lu ngy cng t p ng vi glucagon.
1.2.3. Hydrocortisone: 100 mg.chch tnh mch
2. iu tr duy tr
+ Nu bnh nhn tnh c th n c th tip tc n nh bnh thng.
+ Nu khng n c (nn ma, khng dung np..) Truyn tnh mch Glucose 10% theo liu
1500-200 ml/ 24 gi (150-200 gam Glucose) cho n khi nng glucose huyt tng tr li
bnh thng sau nhiu gi. Khng cho liu cao v c th ch c kh nng dung np ti a 1.5g
glucose/gi
+ Cn theo di ng mu thng da vo thi gian bn hy ca thuc gy h ng huyt
(Insuline, Sulfamide h ng huyt..), phi iu tr vt qu thi gian tc dng ca thuc
gy h ng huyt
+ Kim tra in tim c bit bnh nhn ln tui, bnh mch vnh, tng huyt p.
474
NHNG IU NN LM NHNG IU NN TRNH
X tr ngay Hi bnh s qu lu
Khng ch i kt qu ng mu Ch i kt qu ng mu
Bm trc tip tnh mch Chuyn tnh mch nh git
Glucose 20% Glucose 10%
Glucagon An thn nu vng vy
Theo di sau khi li Khng theo di
in tm bnh nhn ln tui Khng kim tra in tm
4. iu tr nguyn nhn
4.1. Lin quan n bnh nhn i tho ng
+ Xc nh cc iu kin xut hin: qun ba n, thc n cha t ng, dng qu liu
Insuline, hot ng th lc qu mc nhng qun b nng lng. Dng phi hp mt thuc c
tim nng lm tng tc dng thuc sulamide h ng huyt
+ Cn thay i ch th iu tr:
Thay i hoc gim liu Insuline, liu sulfamide h ng huyt
iu chnh li thnh phn nng lng lng Glucide mi ba n cho hp l.
iu chnh gi n, nn thm ba n ph gia cc ba n chnh.
+ Khng nn ch nh cc thuc Sulfamide h ng huyt cho bnh nhn trn 70 tui, nht
l cc thuc c thi gian bn hy qu di (Chlopropamide).
+ Suy thn v suy gan (tng nhy cm thuc h ng huyt)
+ Phi hp mt s thuc lm tng tc dng thuc h ng huyt hoc bng cch gim liu
thuc thng ngy.
+ Khng p dng tiu chun cn bng ng huyt l tng nhng bnh nhn T trn 60
tui.
+ Cn ch hin tng Somogyi gy tng ng huyt th pht vo bui sng do h ng
huyt trong m
4.2. iu tr cc bnh l gy h glucose mu
- U ty tit insuline: Phu thut,Diazoxide (ung hoc tnh mach) liu 300-1200 mg / ngy +
thuc li tiu. Octreotide tim di da liiu 100-600 (g / ngy. Ha tr liu bng
Streptozotocine- 5 fluoro uracile.Chng h ng huyt bng chuyn glucose v iu tr thm
Sandostatine.
- U ngoi ty tit insuline:Phu thut, Chng h ng huyt (kh) bng chuyn Glucose,
chuyn di da lin tc Glucagon bng bm theo nhp khng lin tc.
- Bnh nhn b phu thut ct d dy: Gio dc bnh nhn v thn nhn du hiu v cc x tr
h ng huyt.Glucagon v Glucose u trng lkun c sn nh.Chia u nhiu ba n.
Gim loi ng hp thu nhanh. Thc n phi hp protide v glucide.
VIII. D PHNG
+ Cn gio dc h glucose mu cng nh cch s tr h ng mu cho bnh nhn i tho
ng v thn nhn ca h.
+ X tr h glucose mu cn phi cp thi, ti ch bng mi bin php c th thc hin trc
khi chuyn bnh nhn vo vin, khng nn ch i kt qu ng mu.
+ Lu tc dng h ng huyt ca mt s thuc khi phi hp.
475
+ Trnh t tng ng l k th i bnh nhn i tho ng
+ Phng chm KHNG N KHNG DNG THUC H NG HUYT, NU
DNG THUC H NG HUYT BT BUC PHI N cn p dng cho tt c bnh
nhn i tho ng..

476
BO PH
Mc tiu
1. Trnh by c nh ngha, bnh nguyn v sinh l bnh ca bo ph
2. Trnh by c tiu chun chn on v phn loi bo ph
3. Triu chng, cc phng php nh gi bo ph
4. Bit r cc bin chng ca bo ph
5. Trnh by c tit thc, hot ng th lc v tp th dc gim bo ph
6. Trnh by c thuc iu tr bo ph
Ni dung
I. NH NGHA: c nhiu cch nh ngha
1. Bo ph c nh ngha bng s qu ti lng m c th, c bit lin quan n chuyn
ha nng lng, ko theo hu qu xu cho sc khe.
2. Hoc gi l bo ph khi tng trn 25% trng lng c th v c nh gi da vo kch
thc v gii.
3. i a s dng cng thc BMI nh gi mc bo ph. BMI t 20-25kg/m2 c xem
l tt, qu ti trng lng khi BMI >27kg/m2 v theo phn loi hin nay, c quc t chp
nhn, bo ph c nh ngha bng BMI (30 kg/ (m2). T gi tr ny, ngi ta xem nh l s
tch m qu nhiu, bi v n ko theo mt s gia tng c ngha v bnh sut v t sut.
II. TN SUT: Bo ph cng ngy cng gia tng nht l cc nc pht trin kinh t trn
th gii; c bit trong 10 nm li y, la tui gp cao nht l >30 tui. Tn sut bo ph ph
thuc vo tiu chun chn on. Tn sut bo ph thay i tu theo tui, gii tnh v a d,
chng tc, tnh trng kinh t x hi:
- Tui: 2% lc 6-7 tui, 7% tui dy th, v cao nht tui (50 (u M).
- Gii: n gp nhiu hn nam (25% so 18%).
- a d, chng tc: min ng nc Php l 33%, min Ty 17%. Ti Nam Phi bo ph gp
cc tnh pha Nam nhiu hn cc tnh pha Bc. Trong thp k qua, t l bo ph ca ton
nc M t 25 - 33%, tng 1/3. Ph n da en tui t 45-55 tui c t l bo ph gp 2 ln so
n da trng cng tui.
chu u, gn y khong chng 15 nghin cu dch t v s qu ti trong lng 17 nc
ca chu u. S s dng tiu chun chn on khc nhau tu theo nghin cu (BMI, hoc
cng thc Lorentz, hoc cng thc Broca).
- iu kin kinh, x hi c lin quan n ch dinh dng, phong cch sng:
+ Trung Quc, s tr em bo ph tng cao trong nhng nm gn y, do c nung chiu,
n ung qu mc, t khi c ch trng mi gia nh ch c mt con;
+ Singapore, tr em bo ph ti cc trng tiu hc gia tng mt cch ng k.
+ Ti thnh ph H Ch Minh, do mc sng ngy cng cao, nn s bo ph tr em cng nh
ngi ln gia tng.
Nhng ngc li ti M mc kinh t x hi thp th tn sut bo ph cao hn so vi mc sng
kinh t x hi cao.
Nhng ngi ln bo ph c khong 50-100% nguy c cht sm so ngi c BMI khong 20-
25 kg/m
2
.
477
Bng 1: Tn sut qu trng theo nhiu nghin cu khc nhau chu u.
Nc v tui ngh/cu nh ngha qu trng Tn sut bo ph
Nam N C 2 gii
Bulgarie: 35-71 tui
an mch: 18-20 tui
7 nc: 40-59 tui
- Bc u
- Nam u
- ng c
- Ty c
- H lan: 19-31 tui
- Rumani:15-65 tui
+ Thnh ph.
+ Thn qu
-Thu s: 31-40 tui
41-50 tui
>20% Broca
>20% Broca

>27 BMI
>27 BMI
>20% Broca
>20% Broca
>25% BMI
>20% TLLT


>25% Broca


10%

13%
23%
14%
16%
24%

25%
22%
18%
28%






41%
14%

32%
41%
19%

III. BNH NGUYN
1. Qu ti calo: V phng din chuyn ho, bo ph do qu ti calo vt qu nhu cu c th.
Tuy nhin c s khc nhau tu c nhn trong s dng nng lng v nhu cu c vn. C bnh
nhn n nhiu nhng khng bo, l do cn cha bit, v trong mt gia nh, cng ch dinh
dng, nhng li c ngi gy k bo. iu ny gi thng c t tnh di truyn v bo ph.
2. n nhiu: tc qu nhu cu c th thng l nguyn nhn bo ph (95%). n nhiu do nhiu
nguyn nhn:
- Thi quen c tnh gia nh: gii thch thng gp nhiu ngi bo ph trong mt gia nh,
khng ph thuc di truyn.
- Bnh tm thn kinh.
- Gim hot ng th lc m khng gim n: gp ngi gi hoc t hot ng.
3. Nguyn nhn di truyn: 69% ngi bo ph c b hoc m bo ph; 18% c b ln m u
bo ph, ch c 7% l c tin s gia nh khng ai bo ph.
Theo Mayer J. (1959) nu c b ln m u bnh thng th 7% con h s b bo ph. Nu mt
trong hai ngi bo ph th c 40% con h b bo ph. Nhng nu c b ln m b bo ph th
t l bo ph con l 80%.
Phn nh gia vai tr ca di truyn thc s v vai tr ca dinh dng cn cha r. Di truyn
c tnh tri v yu t di truyn lm cho kh nng phn chia t bo m d dng hn.
4. Nguyn nhn ni tit: him
- Hi chng Cushing: phn b m mt, c, bng, trong khi cc chi gy nh.
- Cng insulin: do u ty tit insuline, tng n ngon, n nhiu v tn sinh m m, tng tiu
glucid.
- Gim hot tuyn gip: him, phi ch rng chuyn ho c bn c biu th bng
calori/m2 b mt da thng gim ngi bo ph. Tht vy, b mt da gia tng l do tng m
m, l m t tiu th oxy. Tri li, trong phn ln cc trng hp bo ph khc, s gim
chuyn ho c bn ny khng c ngun gc tuyn gip.
478
- Hi chng bo ph-sinh dc (hi chng Froehlich hay Babinski-Froehlich): bo ph thn
v gc chi v suy sinh dc, biu hiu thiu nin vi ngng pht dc c quan sinh dc, c th
km ri lon khc nh i tho nht, ri lon th lc v tm thn. Theo A. Froehlich nguyn
nhn do u vng di i.
- Ngi b thin: m m tng quanh hng, phn cao ca i, ging nh hi chng bo ph-
sinh dc
- Ru l ngun quan trng ca nng lng.
5. Nguyn nhn do thuc
Gn y, thuc c thm vo danh mc nguyn nhn ca cc yu t bo ph, bi v gia tng
dc liu php. Tng cn c th l sn phm ca cc hormone steroides v 4 nhm chnh ca
cc thuc kch thch tm thn:
- Khng trm cm c in (3 vng, 4 vng, c ch IMAO).
- Benzodiazepine.
- Lithium.
- Thuc chng lon thn.
Vy gii hn s dng thuc kch thch tm thn kinh phng nga tng cn, c th lm
gim liu php iu tr
IV. SINH L BNH
1. S phn b v tin trin ca khi m 2 gii
tr <15 tui, m nhiu v u th phn di v ngoi bin c th c trai v gi ging nhau,
nhng gi m nhiu gp 1,5 ln nam gii.
tui dy th: m ph n 2 ln nhiu hn nam gii. Khng bin i phn b m cho n
50 tui. Sau 50 tui, m c xu hng cao hn v su hn trong c th. S tin trin ny
thy r nam gii tui 15-20 tui.
Sjostrom v Kvist nhn thy rng mc ng i ngang qua rn, tng ng a L4-L5,
53% m pha trn ng ny nam gii; 46% n gii. M tng 9 - 34% n ng v 4 -
14% n b. S phn b ny chung cho phn ln bnh nhn, nhng trong mt s t trng
hp s phn b m ny t hay nhiu tri ngc nhau.
2. Vai tr kch thch t trong c ch phn b m
- Androgen lm gim s lng t bo m phn thp c th.
- Cortisol tng th tch t bo m phn cao.
- Estrogen v c th c c progesterone lm tng th tch v s lng t bo m
Trong mt s t trng hp do tn thng sn xut v/hay l chuyn vn hormone sinh dc,
nhng nguyn nhn cn li, s nhy cm t bo m vi hormone sinh dc l nguyn nhn
chnh ca phn b m trong 2 gii. Hin tng ny l tri v di truyn.
3. Tnh cht khc nhau ca m nam v m n gii
p ng t bo m nam v n gii khc nhau. Nhiu nghin cu ca Lafontan cho thy
rng hot ng tiu m ca (adrenergic u th trn t bo m nam gii, hot ng chng tiu
m ca (-2 adrenergic u th trn t bo m n gii. Theo Rebuff Scrive, hot ng
canzyme Lipoprotein lipase tng trong m n gii, ti a trong thi k c thai, ti thiu khi
cho con b.
4. S khng insuline trong c, m m trong qu trnh bo ph chut
Bo ph sc vt, di truyn hay gy nn bi thc nghim; cng nh bo ph ngi, thng
ko theo tnh trng khng insulin phi hp tng insulin mu v vi glucose mu bnh
thng hoc tng. S khng insulin ny tm thy trong thc nghim mc t bo ch
479
chnh ca hormon, m c, m m. Trc ht m m c pha p ng bnh thng vi insulin
trc khi insulin b khng. Kiu din tin ny ging nhau c bo ph di truyn v bo ph
do n qu nhiu.
- khng insulin bnh nhn bo ph: xem s sinh l bnh t bo ph n
khng insulin sau:

Bo ph

khng insulin

Gim bt gi glucose mc t bo
gai on sau n

Gim sinh nhit do tit thc


Lm trm trng thm qu ti trng lng

Hnh 1: S sinh l bnh t bo ph n khng insuline:
5. Tng chuyn ha c bn
ngi bo ph, khi lng gy (tc khi tht, ni hu nh c nht ca chuyn ha c bn)
l cao r so vi khi lng gy ngi c trng lng bnh thng, v th ngi bo ph c
s tiu th qu mc nng lng lin quan n chuyn ha cn bn.
6. Gim sinh nhit do ch tit thc: Sinh nhit do ch tit thc ngi bo ph thp
hn ngi c trng lng bnh thng.
Hu qu ca hai s thay i nghch l ca chuyn ho nng lng cho thy rng ngi bo
ph, s tiu th nng lng ton th ch mc trn rt t so vi s tiu th nng lng ton th
ngi bnh thng.
7. n nhiu: Tht vy, trong chng mc no , giai on cn bng trng lng, nng lng
a vo bng nng lng tiu th.
8. Yu t di truyn t tnh ca bo ph: 1/3 bo ph do di truyn. Khng di truyn; truyn theo
gia nh c s tham gia ca yu t mi trng khong hn 1/3 trng hp. Th 3 phn cn li
l yu t mi trung khng lan truyn
9. Gne ca bo ph: Gene Leptin l mt loi protein, c m ho bng gene ob, ch c
trong m m trng. Thiu protein ny s gy bt thng chuyn ho chut (bo ph, tng
insulin, tng ng mu, gim thn nhit). Gi thuyt cho rng c l Leptin ngn cn thi
n ung qua trm hypothalamus. Nhiu nghin cu cho thy leptin c m m sn xut
nhiu nht lc i v trong qu trnh T thc nghim, v cng tr li bnh thng trong vi
gi sau khi n hoc tim insulin. iu ny cho thy rng Leptin tc ng nh mt tn hiu
chn ngy.
Mt khc, chut ob/ob, cho Leptin vo s lm gim trng lng ng k. Leptin cng iu
nh s hp th thc n, ng mu, insulin mu. N lm tng chuyn ho ton th, nhit
c th v mc hot ng th lc. Hn na, Leptin cng tc ng trn con vt bnh thng v
c th lm mt i 12% trng lng c th v tt c m ca n trong vng 4 ngy.
480
bnh nhn bo ph, gne ob rt gia tng. S gia tng ny t l vi trng lng c th. ng
ch l gii n gii, Leptin c tit ra vi mc b sung iu ho hormon. Nh vy r
rng rng bo ph khng phi do Leptin b gim tng hp, cng khng phi do Leptin bt
thng. Theo Catherine Le Stunff v cs, ngi bo ph, Leptin tng 10 ln cao hn lng
Leptin ngi bnh thng, v t l vi khi lng m. S gia tng Leptin khng lm gim
s ngon ming ngi bo ph, nhng tip tc lm tng s n nhiu v cng lm tng trng,
iu ny cng c cho l l l c s khng Leptin ngi bo ph.
V. TRIU CHNG: ch yu da vo cc ch s nh gi c bo ph hay khng
1. Cng thc Lorentz tnh trng lng l tng (TLLT) ch yu da vo chiu cao.
TLLT (nam) = chiu cao - 100 - hoc TLLT (n) = chiu cao - 100 -
Nu TLLT tng >25% l bo ph.
Hoc IC = (TLHT/TLLT) (100%. (trng lng hin thc/trng lng l tng)
Nu IC = >120% - 130%:Tng cn qu mc
Nu IC = >130% bo ph.
2. BMI: (Body Masse Index=Ch s khi lng c th): Trng lng (kg)/chiu cao (m2).
- Theo T chc quc t v bo ph (International Obesity Task Force) 1998
Tng trng khi BMI = 25 - 29,9; Bo ph khi BMI (30,0
- Theo tiu chun chn on bo ph p dng cho ngi chu : bo ph khi BMI (25
3. o dy ca np da tam u: gia khong cch t ci tay v vai, trung bnh 16,5mm
nam, 12,5mm n.
4. Bo ph c th khng c triu chng: hay c kh th gng sc, mt, kh chu nng, ri lon
tiu ho, thoi ho khp do qu ti c th (khp hng, i, ct sng tht lng).
5. Ri lon chuyn ho lipide: tng lipoprotein (type VLDL, LDL).
6. Hu qu tm thn kinh bo ph c th trm trng: lo lng vi tng HA.
7. Gim dung np glucose mu, T th 2 (Hi chng chuyn ho).
8. Bo ph trm trng: gim thng kh phi (hi chng Pickwick), suy tim-phi.
VI. CC PHNG PHP NH GI BO PH
C nhiu phng php nh gi m m (bo ph): phng php o nhn trc
(anthropomtrique) lm sng, phng php mi bng hnh nh siu m, ngay c ct lp c t
trng (tomodensitomtrique). S chn la gia cc phng php khc nhau ny tu thuc vo
ng cnh v mc tiu nghin cu hng n.
1. Phng php o nhn trc
1.1. Ch s khi lng c th (BMI). Kt qua nh nu trn phn triu chng.
1.2. Cng thc Lorentz: tnh trng lng l tng (TLLT), cng thc ny da vo trng
lng bnh nhn tnh bng kg v chiu cao tnh bng cm nh nu trn:
1.3. dy ca np gp da: dy ca np gp da phn nh dy ca lp m di da, c
th o c bng mt compas Harpender hoc Holtane, c tay cm rng, c khc s hng
nh.
Cch o: tay tri cm compas, ri kp np gp da thng ng gia ngn tr v ngn ci,
thc s cho bit dy ca np da.
o dy np gp da nhiu v tr khc nhau l cn thit: cc im quanh gc cnh tay v
i, c nh u, tam u, trn b vai, trn xng chu, thng v, trung v v h v. Ngc li,
n gii, np gp da vng i v h v l dy hn np gp da pha trn rn v cnh tay.
481
V d: o dy ca np da tam u gia khong cch t ci tay v vai, trung bnh
16,5mm nam, 12,5mm n
1.4. Ch s phn b m cc np gp da (Phng php nh gi phn b m m): nhiu ch
s hoc phng php c a ra:o dy np gp da phn nh quan trng lp m di
da, ch a ra 2 ch s d o hn
- Ch s m-c ca Jean Vague
Ch s m- c cnh tay - i (CSMCCT) gm dy np gp da quanh gc cnh tay v
i, mc khc chu vi ca i cng c o cng ngang mc . CSMCCT cho php nh
gi s lng s phn b m v c gia vng c Delta v c i, nhng khng lin quan trc
tip n lp m bng.
Gi tr bnh thng ca CSMCCT n c trng lng bnh thng, l 0.76 - 0.8, v nam
gii 1.01 - 1,10. Jean Vague c th nh ngha nhiu th khc nhau v s phn b
hypergynoide, gynoide, mixte, androide, hyperandroide.
- Ch s gia dy m m-c Delta v c mu chuyn (trochantrien): ch s gia dy
m m vng Delta v pha sau mu chuyn l t nhy cm vi lp c bn di. 0,7 nam,
v 0,3 n.
1.5. o chu vi
Ch s phn b khi m phn chu vi
- Ch s cnh tay-i: o chu vi cnh tay v i phn gc l d dng thc hin. y l ch
s ng tin cy o lng s phn b m. T ca chu vi cnh tay vi chu vi ca i gc:
0,58 nam v 0,52 n.
- Vng bng/vng mng: ch s gia chu vi vng bng/vng mng c M. Ashwell a
ra nh l mt ch s o lng ng tin cy v s phn b m. Tr s bnh thng l 0,92 -
0,95 nam; 0,75 - 0,80 n. Bo ph nam khi VB/VM >0,95 v n >0,80. Hoc theo ATP
III, vng bng nam <102 cm, n l >88 cm
2. Siu m
dy ca m m nng c th c o trc tip chnh xc bng cch t u d thng gc
vi mt da, khng p, ti im mun xc nh. K thut c th phn bit r rng gii hn
phn m, c v xng.
3. Chp ct lp t trng
Phng php ny mi c p dng gn y nh gi s phn b m. N c th nh
lng m phn b di da v quanh tng. T phn ct ngang ca scanner, c th tnh c
b mt chon ch ca m m. Li im ca phng php ny c th xc nh b mt m m
su quanh tng. Phn ct ngang qua L4-L5 s cho php phn bit chnh xc s khc nhau v
phn b m gia 2 gii. S nh gi bng phng php ny cho kt qu ng tin cy, chnh
xc, tuy nhin gi k thut t, dng c nng n kh thc hin cc tuyn thng thng.
4. Impdance mtrie: o phn trm lng m ca c th hin c v lng m l tng da
vo trng lng, chiu cao, gii, t tnh ra lng m qu ti l bao nhiu phn trm.
VII. PHN LOI BO PH
1. Phn loi theo tui: ngi ta c th phn bit 2 th bo ph:
- Bo ph xy ra tui trng thnh: (th ph i) s t bo m c nh v tng trng l do
tch t qu nhiu lipide trong mi t bo, iu tr gim glucide l c hiu qu.
- Bo ph tui tr: (th tng sn ph i) khng ch cc t bo ph i m cn tng s lng,
kh iu tr.
2. Bo ph nam gii v n gii da theo s phn b m
482
Bo ph nam gii (androide): thng gp nht n ng, u th phn cao c th, trn rn,
gy c, vai ngc, bng, bng trn rn.
Bo ph n gii (gynoide): thng gp ph n, u th bng di rn, hng, i, mng v
cng chn.
Bo ph thng gp l bo ph androide ph n.
3. Phn loi da theo t vng bng/vng mng (VB/VM)
o chu vi vng bng/vng mng v tr tr nh ni trong phn VI (cc phng php nh
gi bo ph). Bo ph nam khi VB/VM >0,90; bo ph n khi VB/VM >0,85.
4. Da vo cng thc Lorentz
IC = (TLHT/TLLT) (100%. (trng lng hin thc/trng lng l tng)
Nu >120% - 130%: tng cn qu mc
Nu >130%: bo ph.
5. Da theo ch s BMI
Bng 2: Bng phn loi theo T chc quc t v bo ph (International Obesity Task Force)1998
Phn loi BMI (kg/ (m
2
). Nguy c
Gy
Bnh thng
Tng trng
Bo ph:
II
II
III

18,5
18,5 - 24,9
25 - 29,9
30.0
30,0 - 34,9
35,0 - 39,9
40


Tng va
Tng r
- Bo ph va hay chung
- Bo ph nng
- Bo ph qu mc hay bo bnh
Hin nay p dng ph hp vi c im tng vng qua nghin cu thc t cc quc gia
chu , TCYTTG chnh thc ng cc quc gia chu ly tiu chun ban hnh thng
2/2000 lm tiu chun chn on bnh bo ph.
Bng 3: Tiu chun chn on bnh bo ph da vo BMI v s o vng eo - p dng cho ngi
trng thnh chu .
Phn loi BMI (kg/m
2
)
Yu t phi hp
S o vng eo: < 90cm (vi nam) (90cm
< 80cm (vi n) (80cm
Gy < 18,5
Thp (nhng l yu t nguy c
vi cc bnh khc).
Trung bnh
Bnh thng 18,5-22,9 Trung bnh C tng cn
Bo:
+ C nguy c
+ Bo 1
+ Bo 2
23
23-24,9
25-29,9
>30

Tng cn
Bo va phi
Bo nhiu

Tng va phi
Bo nhiu
Qu bo
VIII. BIN CHNG CA BO PH
Nguy c ca qu ti trng lng hay bo ph l gy nhiu bnh thm ch xut hin rt sm v
gy t vong nh do thuc l.
Nhiu nghin cu cho thy rng c s tng quan rt c ngha gia bo ph dng nam v
483
cc bin chng chuyn ho nh i tho ng, tng lipide mu, bnh sinh x va, goute.
1. Cc bin chng ca bo ph
Tng cn qu mc (120% - 130% so vi TLLT) Bo ph bnh l (>130% so vi TLLT)
Tnh trng chc nng suy yu Gim tui th
Tng huyt p Vn v chn on
i tho ng Tng nguy c phu thut
Bnh ng mch vnh Bt ng
Bnh ng mt Hi chng Pickwick
Bnh Gout Vim da b mt
Ngng th khi ng
Nghn tnh mch su
Tc mch phi
Vim xng khp
Lot do p lc (t th)
N: K t cung, K v, K t sng, K bung trng
Nam: K i trng, K tin lit tuyn
2. Bin chng v chuyn ho
Chuyn ho glucide: c tnh trng khng insulin, tng tit insulin, pht hin qua nghim php
dung np glucose bng ng ung b ri lon, d dn n bnh i tho ng, v vy bo
ph l mt yu t nguy c ca i tho ng.
Chuyn ho lipid: triglyceride huyt tng thng tng trong bo ph, tng VLDL. S tng
lipoprotein c lin quan n ri lon chuyn ho 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 c triglycerid tng.
Chuyn ho acid uric: acid uric mu thng tng, c l c lin quan n tng triglycerid mu.
Cn ch n s tng acid uric t ngt khi iu tr nhm gim cn, c th gy cn Gout cp
tnh (do thoi ging protid).
Vai tr ca bo ph trong hi chng chuyn ho: c m t trong hnh sau:












BO PH
Acid bo t do
khng Insulin
Glucose mu
i tho ng type 2
Bnh tim mch
Triglyceride
HDL
Tng huyt p
484
3. Bin chng tim mch: Bo ph l mt trong nhng yu t nguy c cho bnh l tim mch
nh
- Tng guyt p (THA): lin quan cht ch gia bo ph v tng HA, tn sut THA
tng trong bo ph bt k nam hay n. Huyt p gim khi gim cn. C ch tng HA trong bo
ph cha r ht, ngoi x va ng mch hay gp, cn c gi thuyt do tng insuline mu v
khng insuline, lm tng hp thu Natri ng thn v tng tit catecholamine lm co mch.
- Suy mch vnh: thng gp, ngay c khi khng c thm cc yu t nguy c khc
nh T, tng lipide mu, tng HA.
- Cc bin chng khc nh suy tim tri, tai bin mch mu no.
4. Bin chng phi
- Gim chc nng h hp do lng ngc di ng km do qu bo.
- Hi chng Pickwick: ngng th khi ng.
- Tng hng cu, tng CO
2
mu.
5. Bin chng v xng khp
Ti cc khp chu lc cao (khp gi, khp hng, ct sng) d b au, thoi khp.
Tn sut hoi t thiu mu u xng i gia tng.
Thot v a m, trt t sng hay gp
Cc bin chng ny tng ln ph n mn kinh.
6. Bin chng v ni tit
- Tng insuline mu v khng insuline v T th 2, do tc dng bta-endorphine
hoc gim s lng v cht lng insulin, kch thch t bo bta do n nhiu glucide.
- Chc nng ni tit sinh dc: gim kh nng sinh sn. Chu k kinh ko di khng
phng non. Rm lng.
7. Cc bin chng khc
- Nguy c ung th gia tng: ung th t cung, v, i trng, tin lit tuyn.
- Bin chng tng nng ln do bo ph:
+ Gan mt: Si mt, gan nhim m.
+ Thn: tc tnh mch thn, protein niu.
+ Sn khoa: nhim c thai nghn, sinh kh, m ly thai tng.
+ Da: rn da, nm k, tng sng ho gan bn chn, bn tay.
IX. IU TR
M hnh iu tr bo ph: da vo 3 phng cch chnh sau y:
- Tit thc gim trng lng
- Tng nng lng tiu dng (Tp th dc).
- Thay i chuyn ha thc n.
Phng cch 1 v 2 bao hm tit thc v tp th dc.
1. Tit thc gim trng lng v tp th dc
Gim trng lng l mc tiu chnh iu tr, vi gim trng lng mc nh t 5% n 10%
trng lng ban u, bng tit thc v tp th dc cng ci thin lm sng c ngha, ci
thin c bnh tng HA, bt thng lipide cng nh glucose mu. Khong 80% bnh nhn
T tp 2 c tng trng hoc bo ph, nu gim trng lng t 5% n 10% th ci thin c
ngha HbA1c.
485
Theo Chng trinh T Phn Lan v Chng trnh Ngn nga bnh T cho thy rng
nhng bnh nhn c ri lon dung np glucose mu, nu gim trng lng chng 7% s gim
c nguy c T tp 2 chng 58%.
1.1. Tit thc gim trng lng
- Tit thc gim trng lng: l phng cch u tin v c p dng mt cch rng ri.
Cch thc chnh l tit thc gim calo, gim m v vi thc n khc c kh nng gim sinh
nng lng cho c th. Nu nng lng a vo thp hn nhu cu sinh l, th nng lng
thm vo l t m m d tr. S khc bit ln gia nhu cu a vo v nng lng l do s
i. Khi khng c thc n a vo, nng lng c rt ra t m m d tr l 1500-3000
kcal. M c th cha 7500 kcal/kg. Vi cn bng calo m tnh 1500 kcalo/ngy, th s lm
gim trng lng c th 1 kg mi 5 ngy. Lm gim trng lng khong t 0,5-1 kg/tun l
thch hp cho mt tit thc gim trng lng.
i vi ngi ln tui va, 1200 kcalo/ngy duy tr mt > 0,5 kg/tun.
Ni chung lng calo cho mi bnh nhn tt nht phi da vo cn nng hin ti. Tit thc
gim calo khi lng calo dng 20-25 Kcalo/kg/ngy
Nh vy nu lng calo cung cp gim di 500 Kcalo/mi ngy, th s lm gim mt trng
lng khong 0,5kg/tun. Thnh cng iu tr tu vo tui bnh nhn (bo ph thiu nin phi
c iu tr rt sm) v ng lc bnh nhn rt cn cho iu tr. i vi nhng bnh nhn c
thi quen n nhiu, chp nhn hn ch thc n trong sut cuc sng l rt kh khn.
Tit thc t m, gim thc n giu-carbohydrat v tit thc m n khng bo ho ci thin
c bnh mch vnh. Nn dng nhiu tri cy, cc loi rau, v nhng loi ton ht, giu cht
x. Nn thay th thc n c cht dinh dng thp, giu calo bng nhng thc n c cht dinh
dng cao, t nng lng
trnh cc bnh l tim mch, nn dng cc loi rau, tri cy, cc loi ton ht, c v cc
thc n c ch bin t m km luyn tp th dc.
Sau y l phng cch iu tr nn ca Phng php iu tr thay i li sng vit tt l
TLC (Therapeutic lifestyle Change) l mt chng trnh gm 12 tun thm khm, sau l
mi 2 tun trong vng 3 thng na c thay th mi 6 tun nhm t mc ch l
Triglyceride, HDL-C v tt NPDNGU bnh thng. Mi ln thm khm nh gi nng
LDL-C, vng bng, trng lng, nh gi vic tun th tit thc v tp luyn th dc ca
bnh nhn.
Bng 4: Thnh phn cht dinh dng trong tit thc iu tr TLC
Cht dinh dng Nhu cu cn thit
M bo ho < 7% calories ton th
M a khng bo ho > 10% calories ton th
M n khng bo ho >20% calories ton th
M ton th 25%-35% calories ton th
Carbohyddrate (ht, tri cy, rau) 50%-60% calories ton th
Cht x 20-30 gr/ngy
Protin Ti a 15% calories ton th
Cholesterol < 200 mg/ngy
Tng cng calories ton th (k c hot ng
th lc ti a 200 Kcal/ngy
Cn bng nng lng a vo v nng lng tiu
dng duy tr mt trng lng thch hp/ngn
chn tng cn
486
- Tit thc Cambridge (Cambridge diet)
Cung cp y yu t vi lng, gim glucide hiu qu, gim cn kh tt, khng tai bin
- iu tr nhn i
Nguy him v phi cho nhp vin (bo ph kh iu tr). Nhn i gy d ho m m
v protein. Gim natri v c th lm tn thng gan trm trng.
1.2. Hot ng th lc v tp th dc
Hot ng th lc v tp th dc lm tng s tiu dng nng lng, l iu tr u tin cho
nhng bnh nhn qu ti v bo ph, c xem nh l yu t cha kho trong chng trnh
gim trng lng.
Mc ch tp luyn th lc nhm cc li im sau
1) Ci thin c ng mu.
2) Gim khng insulin, tng nhy cm insulin ngoi bin.
3) Gim trng lng.
4) Ci thin lipoprotein (gim triglycerid, cholesterol ton phn, LDL-Cholesterol v
VLDL, Tng HDL- Cholestrol), nn gim c x va ng mch.
5) Tc dng c li trn tim mch (tng kh nng ti a s dng oxy, lm chm li nhp
tim lc ngh ngi v lc gng sc, gim va phi HA, gim nguy c tc mch, v gim t sut
do bnh mch vnh).
Trong hot ng th lc, tn s tim khong 50% tn s tim ti a. Tn s tim ti a
c tnh theo cng thc sau: (220-tui)/2. V d bnh nhn 50 tui: 220 - 50 = 170/pht, th
tn s tim cho php l 85 ln/pht.
6) Tng sc lc
7) Lm gia tng tnh do dai
Nh l mt chin lc gip ngi bo ph gim trng lng, d sao tp th dc l
mt phng cch tuyt ho, Tp th dc tng tiu th nng lng c th, nhng cng ng
thi tng ngon ming. i do 5 km lm tng tiu th nng lng 200 calo. Thc cht, nu
nng lng tiu dng khng tng, th lm gim trng rt kh khn bi v kh m duy tr s
gim thc n a vo.
Nn gia tng hot ng th lc t t nh tp th dc 10-30 pht/ngy cho n khi t
300 pht/tun.
Theo Surgeon Generals Report on Physical Activity and Health khuyn vi mi la
tui nn tp luyn th dc trung bnh l 30 pht/ngy nh chy nhanh 30 pht, 3 ln/tun, tuy
nhin gn y ngi ta khuyn tt hn l 60 pht/ngy.
Theo Bethesda nn tp th dc khong 2 gi ri/tun, n c m, v gim trng lng
l gim c t sut T ti M.
Sau khi tp th dc xong, tc dng insulin tng v ko di nhiu gi. Di nh hng
ca insulin, gan v c thu nhn glucose v ti d tr li glycogen.
Vn ng th lc thng l i b, p xe hay bi li..
t chy 100 calories (khong 10g cht bo) phi i b 20 pht, bi hoc nh
tennis 12 pht, 8 pht p xe hoc chy b.
Tuy nhin, tp th dc khng lm tt c i vi ngi qu bo, di chuyn c th
nng n v v vy ra m hi d dng v thng au khp, ngoi ra bnh tim mch nng cng
hn ch tp luyn
487
Nhng cng c khng t trng hp, vi tit thc v tp th dc vn khng lm gim trng
lng v gi l bo khng cha tr c. V vy bo tr li c thng rt chung. y l l do
ngi ta dng thuc v phu thut.
2. Thuc iu tr bo ph
Sau 12 tun tit thc gim trng lng v tp luyn th dc m khng ci thin c trng
lng th dng thuc.
2.1. Thuc iu ha th th adrnergique (Diethylpropion, Mazindol, Phentermine) hoc th
th serotonine (Fenfluramine).
Tt c cc thuc u c tc dng ph, lm mt s n ngon ming, gim trng lng, nn ch
c dng sau khi cn nhc gia li v hi ca cch thc iu tr ny. Cc thuc ny dng
phi hp c kt qu tt hn l dng n c, nh phi hp Fenfluramine vi Phentermine
(noradrenergique). Tuy nhin nm 1997 v c mt trng hp c biu hiu bnh van tim
mt ph n, nn 1998 Fenfluramine v Dexfenfluramine rt khi th trng, ch cn li
Phentermine.
2.2. Thuc lm gia tng tiu th nng lng
Hormonee gip (nhm L-Thyroxin), nhng khng c tc ng thng xuyn, thng t dng
v ko di gy c ch chc nng tuyn gip hay nhim c gip.
2.3. Thuc c tc dng bin i chuyn ha cht dinh dng:
Thuc lm gim tiu ha thc n (c ch lipase) hoc bin i chuyn ha (androgen,
estrogen, GH)
Hin nay c 2 loi thuc c U Ban Thc phm v Dc phm Hoa K/FDA v
TCYTTG ch chp thun dng gim cn ko di l Siburtramine (Meridia*, Reductil*) v
Orlistat (Xenical*).
iu tr bng Reductil (10mg/vin) c th gip gim (2 kg trong vng mt thng v 4,4-6,3
kg sau 6 thng, Reductil khng gy chn n, khng gy l thuc thuc m lm bnh nhn c
cm gic mau no khin h n t hn, v vy thch hp cho nhng ngi lun c cm gic mau
i v thm n nhiu, Reductil cng lm gim t VB/VM, gim lipide mu v glucose mu.
Tc dng ngoi ca thuc l kh ming, to bn, au u nh, cm gic hi hp, tng nhp
tim THA mt s ngi (him). Thn trng: khng dng cho ngi THA v c bnh mch
vnh. CC: tr em, mn cm vi thuc, c thai cho con b.
Siburtramine l loi c ch chn lc s ti thu gi c 2 loai serotonin v norepinephrin, n
lm gim ngng ngon ming (do tc dng trung ng lm cho bnh nhn c cm gic no
sm) v tng sinh nhit, gim vn tc bin dng, nn gim trng lng.
Orlistat, c ch lipase tu, gim hp thu rut. Tc dng ph l km hp thu m, gim cc
viatmin du nh vitamin D v E, nn phi tng cng thm vitamin.
488
2.4. Thuc lm mt s ngon ming
Thi gian
tc dng
Liu lng v cch dng
Tc dng Noadrenergic
Benzphetamine 6-12 25-50mg trc n, 25-50mg/ng
Phendimetrazine 5-12 35mg trc ba n hoc 105mg/ngy, 17.5-
105mg/ng
Diethylpropion 4-6 25mg trc ba n, 25-75mg/ng
Mazindol 10 1-2mg lc i ng, 1-2mg/ng
Phentermine HCL 7-24 8mg hoc 15-37.5mg trc ba n, 15-
37.5mg/ng
Phenylpropanolamine 25mg trc ba n, 25-75mg/ng
TC DNG SEROTONERGIC
Dexfenfluramine 11-30 15mg, 2ln/ng, 30mg/ng
Fenfluramine 11-30 20mg trc ba n, 60-120mg/ng
3. Phu thut: Ngoi l, ch p dng bo ph qu trm trng, e d s sng (>50% trng
lng l tng bnh nhn < 40 - 50 tui.

489
BASEDOW
Mc tiu
1. Trnh by c nh ngha, c ch bnh sinh v bnh nguyn ca bnh.
2. Nu c nhng triu chng lm sng v cn lm sng lin quan n bnh.
3. Bit cch chn on bnh Basedow.
4. Trnh by c cch iu tr bnh Basedow.
5. X tr c nhng bin chng chnh ca bnh
Ni dung
I. NH NGHA
Basedow l mt trong nhng bnh l cng gip thng gp trn lm sng vi cc biu hin
chnh: nhim c gip km bu gip ln lan ta, li mt v tn thng ngoi bin.
Bnh Basedow mang nhiu tn gi khc nhau Bnh Graves. Bnh Parry. Bu gip c lan
ta. Bnh cng gip t min. Nh s tin b ca min dch hc, ngy cng nhiu khng th
hin din trong huyt tng ngi bnh c pht hin, v th hin nay bnh c xp vo
nhm bnh lin quan t min.
II. BNH NGUYN
Bnh xy ra mi tui, nht l tui 20 - 40 tui, u th ph n, t l nam / n = 1/5 -
1/7 vng khng b bu c a phng. Tuy nhin, vng dch t t l ny thp hn. Theo
Volp c l lin quan n s khim khuyt ca t bo lympho T c ch, l yu t c bn trong
bnh l t min tuyn gip. Mt vi yu t ghi nhn c th gy p ng min dch trong
Basedow nh
- Thai nghn nht l giai on chu sinh (hu sn)
- Dng nhiu iod, c bit dn c sng trong vng thiu iod, c th iod lm khi pht bnh
Basedow tim tng.
- Dng lithium lm thay i p ng min dch.
- Nhim trng v nhim virus.
- Ngng corticoid t ngt.
- Ngi c HLA B8, DR3 (dn vng Caucase) HLA BW 46, B5 (Trung Quc) v HLA B17
(da en).
- Vai tr Stress cha c khng nh.
- Lin quan di truyn vi 15% bnh nhn c ngi thn mc bnh tng t v khong chng
50% ngi thn ca bnh nhn c t khng th khng gip trong mu.
III. BNH SINH
C s khim khuyt ca t bo lympho T c ch (Ts, T8), cho php t bo lympho T h tr
(T H) kch thch t bo lympho B tng hp cc khng th chng li tuyn gip. Globulin min
dch kch thch tuyn gip (TSI: Thyroid stimulating immunoglobulin hoc TSH. R Ab
(Stim): khng th kch thch th th TSH) gy tnh trng nhim c gip. Ngoi ra cn tm
thy nhiu loi khng th khng thyroglobulin, khng th khng enzyme Peroxydase gip
hoc khng th khng tiu th. Ngoi ra tin trnh vim nhim c hc mt do s nhy cm ca
cc t bo lympho T c t bo (cytotoxic T lymphocyte) hoc cc t bo git (killer cell) i
vi khng nguyn hc mt trong s kt hp vi cc khng th c t bo. Tuyn gip v mt
c th c lin quan bi mt khng nguyn chung gia tuyn gip v nguyn bo hc mt. Tuy
nhin vn cha r l lm sao gy ra dng thc min dch ny.
1. Ti tuyn gip
490
Cc t bo lympho T tr nn nhy cm vi cc khng nguyn trong tuyn gip v kch thch
cc t bo lympho B tng hp khng th chng li cc khng nguyn ny. Khng th trc tip
chng li th th TSH mng t bo gip v c kh nng kch thch t bo tuyn gip pht
trin v tng hot hot (khng th kch thch th th TSH). iu ny c th lin quan n di
truyn nm bn di, nhng vn cha gii thch c l do l lm th no giai on cp xy
ra.
2. Ti mt
T bo lympho c t bo (Cytotoxic Lymphocyte cn gi Killer cells) v cc khng th c
t bo (Cytotoxic Antibodies) nhy cm vi cc khng nguyn chung (Commun - Antigen)
trong nguyn bo si hc mt (Orbital fibroblast), c hc mt v t chc tuyn gip. Cc
cytokin t cc t bo lympho ny c mn cm c th gy vim nguyn bo si hc
mt v vim c hc mt. Kt qu lm sng hc mt, li nhn cu, chng nhn i, , sung
huyt v ph kt mc, ph quanh hc mt (bnh l li mt tuyn gip).
3. Biu hin da v u chi
Ph nim mt trc xng chy v thng tn quanh mng xng u cc ngn tay v
u cc ngn chn (bnh khp gip trng) cng c th lin quan cytokin ca cc t bo
lympho kch thch nguyn bo si cc v tr ny.
Ngoi ra cc triu chng ca nhim c gip trc y ngi ta cho l hu qu ca cht
catecholamine tng cao trong mu nh nhp tim nhanh, run tay m hi, co ko m mt,
nhn chm ch. nh lng nng epinephrine lu hnh trong gii hn bnh thng, v
vy c th gii thch trong bnh Basedow lm cho c th tng nhy cm vi cc
catecholamine.
iu ny mt phn do s gia tng cc th th catecholamine tim v mt s c quan khc.
IV. TRIU CHNG LM SNG
Chia lm 2 nhm hi chng ln, l biu hin ti tuyn gip v ngoi tuyn gip.
1. Ti tuyn gip
1.1. Bu gip
Bu gip ln, thng lan ta, tng i u, mm, n hi hoc hi cng, c th c rung
miu tm thu, thi tm thu ti bu, nu bu ln c th chn p cc c quan ln cn. Mt s
biu hin ri lon vn mch vng c (, da nng, tng tit m hi), vn c mt t l nh bnh
nhn khng c bu gip ln (lin quan khng th).
1. 2. Hi chng nhim c gip.
Cc du chng ny thng t l vi nng hormon gip vi nhiu c quan b nh hng.
- Tim mch: hi hp, nhp tim nhanh, lon nhp kh th khi gng sc ln khi ngh ngi. cc
ng mch ln, mch nhy nhanh v nghe ting thi tm thu, huyt p tm thu gia tng (tng
cung lng tim) so vi huyt p tm trng, hiu p gia tng, trng hp nng suy tim lon
nhp, ph phi, gan to, ph hai chi di.
- Thn kinh c: run r bn tay l triu chng d nhn bit v ni bt km theo yu c. Bnh
nhn thng mt mi, d kch thch thay i tnh tnh, d cm xc, ni nhiu, bt an, khng
tp trung t tng, mt ng.
Ri lon vn mch ngoi vi, mt khi khi ti, tng tit nhiu m hi, lng bn tay, chn m.
Phn x gn xng c th bnh thng, tng hoc gim. c bit du yu c, teo c, du gh
u (Tabouret), yu c h hp gy kh th, yu c thc qun lm kh nut hoc ni nghn.
ngi tr tui triu chng tim mch thng ni bt, trong khi ngi ln tui u th triu
chng thn kinh v tim mch.
- Du tng chuyn ha: tng thn nhit, lun c cm gic nng, tm nhiu ln trong ngy, gy
491
nhanh, ung nhiu nc, kh chu nng, lnh d chu. Ngoi ra c cc biu hin ri lon
chuyn ha calci gy tng calci mu hoc hin tng long xng ngi ln tui sau mn
kinh gy bin chng, xp t sng, gy xng t nhin, vim quanh cc khp.
- Biu hin tiu ha: n nhiu (vn gy), tiu chy au bng, nn ma, vng da.
- Tit niu sinh dc: Tiu nhiu, gim tnh dc, ri lon kinh nguyt, v sinh, lit dng v
chng v to nam gii.
- Da v c quan ph thuc: nga, c biu hin ri lon sc t da, c hin tng bch ban
lng bn tay v cc chi; tc kh, hoe, mt tnh mm mi rt d rng; rng lng; cc mng tay,
chn gin d gy.
Tuy nhin cng cn phn bit trn lm sng hai nhm triu chng ch nh iu tr ph
hp.
(1) Thn kinh giao cm: Nhp tim nhanh, run tay, tng huyt p tm thu, tng phn x, khe
mt rng, nhn chm ch, hi hp, trm cm, kch thch v lo u.
(2) Nhim c gip: Tng tiu th oxy, n nhiu, st cn, ri lon tm thn, nhp nhanh, tng
co bp c tim, gim khng h thng mch mu.
2. Biu hin ngoi tuyn gip
2.1. Thng tn mt
Thng hay gp l li mt. C 2 loi: li mt gi v li mt tht (li mt ni tit), c th
khng lin quan n mc nhim c gip hoc c lp vi iu tr. V th c th xy ra sau
qu trnh iu tr nht l phu thut hoc iu tr phng x.
(1) Li mt gi: tn thng khng thm nhim lin quan n bt thng v chc nng do tng
hot ng ca h thn kinh giao cm, tng thyroxin gy tng co ko c nng mi lm kho mt
rng ra.
(2) Li mt tht (li mt ni tit): tn thng thm nhim lin quan n cc thnh phn hc
mt gy bnh mt ni tit trong bi cnh t min trong bnh Basedow gy thng tn c vn
nhn v t chc sau hc mt. Bnh l mt thng phi hp gia tng nng khng th khng
th th TSH (kch thch). Theo phn loi ca Hi gip trng M (American Thyroid
Association) cc biu hin mt c phn nh sau:
- 0: khng c du hiu v triu chng.
- I: khng c triu chng, c du co ko mi trn, mt ng vn gia nhn cu v trn, gia
nhn cu v mi trn (u th triu chng ny lin quan n nhim c gip, hi phc sau khi
bnh gip).
- II: ngoi cc du hiu ca I, cn c cm gic d vt trong mt, s nh sng
(Photophobie), chy nc mt, ph m mt, sung huyt v sng kt mc... (thm nhim c v
t chc hc mt, nht l t chc quanh hc mt).
- III: li mt tht s, da vo li nhn cu do tm nhun sau t chc hc mt (tm
nhun hc mt t 3 - 4mm (li nh); t 5-7mm (li va) v (8mm (li nng). Cn lu v
phng din lm sng nn da vo yu t chng tc nh gi v li nhn cu bnh
thng nh gi qua thc Hertel ca ngi da vng l 16-18mm, da trng 18-20mm v da
en 20-22mm..
- IV: thng tn c vn nhn.
- V: thng tn gic mc.
- VI: gim hoc mt th lc do thng tn thn kinh th.
nh gi mt cch tng i trung thc v s tm nhun sau hc mt cng nh nh gi
iu tr cn siu m nhn cu.
2. 2. Ph nim
492
T l gp 2-3%, thng nh v mt trc cng chn, di u gi, c tnh cht i xng.
Vng thng tn dy (khng th ko ln) c ng knh vi cm, c gii hn. Da vng thng
tn hng, bng, thm nhim cng (da heo), l chn lng ni ln, mc tha, lng dng ng
(da cam), bi tit nhiu m hi. i khi thng tn lan ta t chi di n bn chn.
2. 3. To cc u chi
u cc ngn tay v cc ngn chn bin dng hnh di trng, lin quan n mng xng, c
th c phn ng t chc mm, ti v nhit bnh thng phn bit vi bnh phi mn.
Ngoi ra c du chng tiu mng tay (onycholysis).
Ngoi cc biu hin trn cn tm thy mt s du hiu ca cc bnh l t min phi hp khc
i km nh suy v thng thn, suy ph gip, tiu ng, nhc c nng, trong bi cnh
bnh a ni tit t min.
V. TRIU CHNG CN LM SNG
1. Xt nghim min dch
Hin din trong mu bnh nhn mt s khng th chng li tuyn gip nh:
+ Khng th kch thch th th TSH (c hiu ca bnh Basedow).
+ Khng th khng enzym peroxydase gip (TPO).
+ Khng th khng thyroglobulin (Tg), khng c hiu v c th gp trong bnh Hashimoto.
+ Khng th khng vi tiu th (MIC)
iu ny ni ln mt s trng hp km p ng vi thuc khng gip.
S hin din cc loi khng th trn cn gp mt s bnh t min tuyn gip khc nh
Hashimoto, bu gip n, bu gip nhn, u tuyn gip vi t l thay i.
2. Xt nghim nh gi chc nng cng gip
Gia tng nng hormon gip trong huyt tng
+ T3 : (95-190 ng/ dl = 1,5-2,9 nmol/l): tng
+ FT3 : (0,2- 0,52 ng/ dl = 3- 8 pmol/ l): tng
+ T4 : (5 - 12 (g / dl = 64 - 154 nmol/ l): tng
+ FT4 : (0,9 - 2 ng / dl = 12 - 26 pmol / l): tng.
+ T T3 (ng %) /T4 (microgam %): trn 20 (nh gi bnh tin trin)
+ TSH siu nhy (0,5 - 4,5 (U/ ml): gim.
+ tp trung I131 ti tuyn gip sau 24 gi tng cao hn bnh thng, giai on bnh ton
pht c gc thot (gc chy). Lu mt s thuc khng gip cng gy hin tng ny (nhm
carbimazole). Nn nh gi vo cc thi im 4, 6 v 24 gi.
+ Test Werner thng s dng trong giai on sm, phn bit vi nhng trng hp c
tp trung iod phng x cao (bu n ho Iod, u tuyn gip c). Hin nay t dng v c
TSH siu nhy v chp nhp nhy tuyn gip.
+ Test TRH v test Querido (kch thch tuyn gip bng TSH): hin nay t c ch nh.
3. Xt nghim hnh thi v cu trc tuyn gip
+ Siu m tuyn gip: tuyn gip ph i, eo tuyn dy, cu trc khng ng nht, gim m
(nhm vim tuyn gip). Siu m Doppler nng lng c th thy hnh nh cu trc tuyn
gip hn lon nh hnh nh m chy trong thi k tm thu v tm trng vi cc mch mu
gin trong tuyn gip, ng mch cnh nht l ng mch cnh ngoi ny mnh, (ng mch
cnh nhy ma). Trong nhiu trng hp khng in hnh (khi u hoc iu tr) kh phn
bit vi hnh nh ca Hashimoto.
+ X hnh tuyn gip (chp nhp nhy tuyn gip) gip xc nh phn no hnh thi v chc
nng tuyn gip vi I123 hoc Tc 99m: cht phng x tp trung ng u ton b hai thy
493
tuyn gip - tuyn gip ph i - gip phn bit cc thng tn ca cc bnh l cng gip
khc (bu gip c a nhn, bu gip c, vim tuyn gip...).
+ Chp ct lp tuyn gip (CT Scanner) v MRI t c s dng trong chn on v cu trc
t khc bit so vi mt s bnh l vim tuyn gip.
+ Hnh nh gii phu bnh: Tuyn gip ln u c hai thy, tnh cht lan ta, mm v tn sinh
nhiu mch mu. Nhu m gip ph i v tng sn, gia tng chiu cao ca t bo thng b v
tha ln vch nang tuyn, to ra cc np gp dng nh phn nh t bo tng hot ng. S
lon sn nh trn thng km thm nhim t bo lympho, iu ny phn nh bn cht min
dch ca bnh v lin quan n nng khng th khng gip trong mu.
4. Thm d thng tn mt
o li nhn cu bng thc HERTEL (i t b ngoi hc mt n mt phng tip tuyn
mt trc nhn cu): phng php n gin, thc hin nhiu ln, tr s thay i. Hn ch ca
phng php ny l khng nh gi trc tip thng tn tm nhun sau hc mt.
- Tm kim du vim gic mc.
- Khm y mt; o trng lc nhn cu.
- Chp ct lp vng hc mt nhm pht hin sm cc bt thng hc mt, c vn nhn,
thn kinh th gic khi cha biu hin lm sng (giai on tin lm sng) v gip phn bit cc
nguyn nhn gy li mt khc.
- Siu m mt: nh gi bt thng c vn nhn v t chc hu nhn cu (c th o c b
dy ca t chc tm nhun sau hc mt)
5. Xt nghim thng tn da: Sinh thit vng ph mm trc xng chy, nhum PAS (+) c
s lng ng cht glycosaminoglycan.
6. Chp X quang xng u chi: Mng xng dy
VI. CHN ON
1. Th in hnh
Gp ph n tr vi y cc du chng lm sng nh trn.
2. Th triu chng
u th mt s c quan
Biu hin tim.
Biu hin thn kinh.
Biu hin c.
Nhc c nng v Basedow.
Bnh xng nhim c gip.
Biu hin tiu ha.
Basedow v nn ma.
Biu hin huyt hc.
Th v to v Basedow.
Basedow v tng cn.
3. Th lin quan nguyn nhn
Phi hp vi cc bnh l t min khc
Suy v thng thn v Basedow.
i tho ng v Basedow.
4. Cc th sinh hc
494
- Tng T3 ch yu.
- Tng T4 ch yu.
5. Cc th tin trin
Th in hnh : tr v bnh gip sau iu tr.
Th thoi trin t pht : 10-20%
Th cp v bn cp : trong th bn cp thng phi hp vi du gy nhiu, tiu chy,
ri lon nhp tim, c st v biu hin tm thn; th cp thng xy ra do sai lm iu tr, c
bit chun b ni khoa khng tt bnh nhn c ch nh phu thut.
Th v tnh cm (apathies): thng gp ngi ln tui, bnh cnh tri v yu c, lit, chn
n v ri lon nut. Thng chn on kh.
6. Chn on phn bit
- Teo c trong trng hp bnh c nng cn phn bit bnh c nguyn pht.
- Lit chu k gip trng thng xy ra ph n Chu , gy lit t ngt v gim kali mu,
i khi xy ra t pht, c th d phng bng dng kali v thuc c ch .
- Tim trong cng gip: khi u lon nhp c hi phc, khng p ng vi digoxin, km
tng cung lng tim.
- Khong 50% khng c bnh l tim tim tng, bnh p ng vi thuc khng gip.
- Ngi ln tui biu hin st cn, bu gip khng ln, rung nh chm v trm cm (nng
gi l cng gip v tnh cm = apathic hyperthyroidism).
- Ngi ph n tr i khi khi u vi mt kinh, v sinh.
- Hi chng cng thyroxin do ri lon albumin gia nh: do c bt thng albumin lin kt
ch yu vi T4, lin kt km vi T3, kt qu tng T4, FT4I nhng FT4, FT3 v TSH bnh
thng, cn phn bit tnh trng bnh gip trong cng gip.
VII. BIN CHNG
Do c ch bnh sinh lin quan t min bnh c th hi phc t pht hoc do iu tr. Trong
qu trnh din bin bnh thng gp hai bin chng nh sau:
1. Bnh c tim nhim c gip: Thng biu hin di 2 dng
1.1. Ri lon nhp tim. a dng vi nhp nhanh xoang, ngoi tm thu, nhp nhanh kch pht
trn tht...
1.2. Suy tim cng gip
Cn phn bit 2 giai on: (1) Giai on u suy tim tng cung lng (nhp tim nhanh, huyt
p tng, c tim tng co bp...) v (2) Giai on sau l th bnh c tim (ph, kh th, tim ln,
ri lon nhp, suy tim, huyt p gim, chc nng co bp tim gim...).
2. Cn cng gip cp
- Thng xy ra bnh nhn khng iu tr hoc iu tr km.
- Khi pht sau mt sang chn (phu thut, nhim trng h hp, chn thng, tai bin tim
mch, sau sinh...).
- Khi iu tr trit (phu thut, x tr liu) khng c chun b tt. Bnh cnh lm sng
vi cc triu chng:
+ St cao 40-41(, m hi, mt nc.
+ Nhp tim rt nhanh, ri lon nhp, suy tim, chong try mch.
+ Run, kch thch, thng tn c (ri lon nut), m sng, hn m.
+ Tiu chy, au bng, bun nn, nn ma, vng da.
+ C th gp cn bo gip v cm (apathetic storm) vi c trng yu c, v tnh cm, ri
495
lon tm thn. Chn on da vo cc d kin lm sng c gi . Nn iu tr tch cc
ngay, khng nn ch i kt qu xt nghim.
3. Li mt c tnh: (xem phn tn thng mt)
VIII. IU TR
Hin nay c nhiu phng php v phng tin iu tr bnh Bassedow. Vic chn la
phng php iu tr tu thuc vo kinh nghim ca thy thuc, iu kin y t c s, s dung
np v tun th ca bnh nhn trong qu trnh iu tr. Di y l mt s phng php v
phng tin iu tr:
1. iu tr ni khoa
1.1. Nhm thuc c ch tng hp hormone gip
- Trnh by: thng c s dng lm sng chia lm 2 loi
Carbimazole (neomercazole) 5mg, Methimazole 5mg
Propylthiouracil (PTU) 50mg, Benzylthiouracil (BTU) 25mg
- C ch tc dng:
- c ch phn ln cc giai on tng hp hormone gip
- Carbimazole c ch kh iod tuyn gip.
- PTU c ch bin i T4 thnh T3 ngoi vi.
- Carbimazole liu cao (> 60mg/ ngy) c tc dng c ch khng th khng gip (gim trnh
by khng nguyn gip, gim phng thch prostaglandin v cytokin t t bo gip, c ch sinh
sn cc gc t do t t bo T v B c bit t bo trnh by cc khng nguyn v th lm gim
khng th).
- Hiu qu tc dng: hng nh lng hormone lin quan n thi gian na i ca T4 v do
lng hormone tch tr trong tuyn gip. Hiu qu sau 1 - 2 tun, r rng sau 3 - 6 tun.
- Liu lng thuc khng gip tng hp
- i vi nhm Thiouracil, thi gian na i khong 90 pht, c th bt u vi liu cao chia
nhiu ln, khi t bnh gip dng liu c nht bui sng. PTU 100-150mg/6gi/ngy. Sau 4 -
8 tun gim 50 - 200mg/mt hoc hai ln/ ngy.
- i vi nhm imidazole: thi gian na i khong 6 gi, do c tc dng khng gip trn 24
gi, dng liu c nht bui sng bt u 40mg/ ngy trong 1-2 thng sau gim liu dn 5-
20mg. Theo di FT4 v TSH.
- Thi gian iu tr: (tu thuc bnh nguyn v mc ch)
- Thi gian iu tr thuc khng gip t 6 thng n 15 nm hoc 20 nm.
- Tc dng ph ca thuc: tc dng ph khong 5% trng hp biu hin tng i a dng.
- Nh: ri lon tiu ha, pht ban, ni m ay, st, au khp, mt v gic (agneusie), vng da
tc mt (ngng thuc), tng phosphatase kim.
- Tc dng ph nng nh Lupus, hi chng Lyeel, rng tc, hi chng thn h, thiu mu,
au a khp, au a r thn kinh, mt v gic.
- Gim bch cu trung tnh: khi bch cu trung tnh <1200/mm3 - phi ngng thuc nu e
do chng mt bch cu ht, v th cn theo di st.
- Mt bch cu ht (Agranulocytose): t l 0,1% (methimazole) v 0,5% (PTU) trng hp,
c xc nh khi s lng t bo bch cu di 200/mm3, trn lm sng kh nhn bit c,
cn bo trc cho bnh nhn nguy c ny pht hin v iu tr kp thi. Ngng bt buc
thuc khng gip v dng khng sinh ngay khi c du chng ny nht l biu hin nhim
trng, vim hng.
-Theo di khi s dng thuc khng gip
496
- Kim tra cng thc bch cu nh k.
- FT4 v TSH us
- Kim tra chc nng gan
- Mt s tiu chun c th ngng thuc khng gip
+ Dng khng gip liu rt nh sau mt thi gian khng thy bnh ti pht tr li.
+ Th tch tuyn gip nh li (kho st theo siu m th tch tuyn gip (bnh thng 18 -
20cm
3
).
+ Khng th khng th th TSH (kch thch) khng tm thy trong huyt thanh, sau nhiu ln
xt nghim.
+ Test Werner (+): tp trung I131 tuyn gip b c ch khi s dng Liothyronine (T
3
).
1.2. Cc phng tin iu tr khc
1.2.1. c ch vn chuyn iode
Cht Thiocyanate v perchlorate c ch vn chuyn iode nhng s dng thng bt li, ch
trong mt vi trng hp c bit.
1.2.2. Iode v c
Khi phi hp lugol th cn s dng thuc khng gip trc 1- 2 gi.
Ch cn 6mg Iodur c ch tuyn gip. Khng s dng iod v c n c m cn phi hp
vi thuc khng gip phng hin tng thot c ch.
Ch nh hin nay i vi iode v c ch yu l:
+ Chun b ngn ngy trc khi phu thut ct gim tuyn gip v
+ iu tr cn bo gip.
Trc y ngi ta thng s dng iode trong nhiu thng (trn 8 thng vi 62%). Hin nay
liu trnh s dng iode trung bnh 10 -15 ngy.
Cht iopanoic acid v ipodate sodium (ipodate 500 mg/ ngy, ng ung) c tc dng c
ch T4 thnh T3 v c ch phng thch T4, sau 24 gi c ch T3.
1.2.3. Lithium
Thn trng bnh nhn c bnh l tim mch v ri lon chuyn ha, nht l mt nc liu
dng 300 - 450 mg / 8m gi v duy tr nng 1 mEq/l.Ch x dng khi bnh nhn d ng vi
Thionamide hoc iode.
1.2.4. Glucocorticoide
Dexamethasone liu 2 mg/ 6 gi c th c ch phng thch hormonee gip.
1.2.5. Thuc c ch ((propranolol, atenolol, esmolol)
Liu propranolol trung bnh 20 - 80 mg/ 6 - 8 gi.
1.2.6. Thuc chng ng
Rung nh chim t l t 10 - 25% bnh nhn Basedow, nht l bnh nhn ln tui. Warfarin
d gy xut huyt sau khi iu tr phng x. Aspirin c ch nh nhng thn trng nu s dng
liu cao (aspirine lm tng FT3 v T4 do gim kt hp protein).
1.2.7. An thn. Nn chn nhm barbiturate c tc dng gim lng thyroxine do gia tng
thoi bin.
1.2.8. Cholestyramine. Dng 4 mg, ngy 4 ln c th lm gim T4.
2. Phu thut ct gim tuyn gip gn ton phn
2.1. Ch nh
+ Bnh ti pht sau nhiu ln iu tr.
497
+ Tuyn gip qu ln.
+ Cng gip ph n c thai p ng km vi iu tr ni khoa.
2.2.Chun b trc m
Tt nht nn iu tr ni khoa t bnh gip trc khi phu thut.
2.3. Theo di sau m
Theo di mi 4 - 6 tun pht hin suy gip hoc cng gip tr li. Lu c th c suy
gip nh t hi phc trong vng 4 - 6 tun. Suy ph gip khong 3%, lit dy thn kinh qut
ngc v th i hi phu thut vin c kinh nghim.
3. iu tr Iode phng x
Dng I131 tp trung ti tuyn gip ph hy nhu m tuyn gip ti ch, hin l phng
php iu tr c chn la do hiu qu cao, kinh t v khng c phn ng ph nghim trng,
cha c bng chng cho rng iu tr iod phng x nh hng trn bnh l mt trong Basedow
hoc gia tng nguy c c tnh.
3.1. Ch nh
- C th t 35 tui tr ln
- Bnh ti pht nhiu ln - khng phu thut c
- Kh khn trong theo di (ngi ln tui)
- Suy tim
- D ng thuc khng gip
Trng hp suy tim, nhim c gip nng, tuyn gip c th tch ln (trn 100 gam), nn iu
tr t c bnh gip trc khi iu tr iod phng x.
3.2. Chng ch nh
Tuyt i trng hp thai nghn, tuy nhin cha c bng chng cho rng iu tr iod phng
x c th gy ra mt s hu qu xu t cung (nguy c bt thng bm sinh thai nhi ph n
sau khi iu tr phng x) v bung trng (phng x vo bung trng rt thp tng ng
vi liu thm d X quang).
4. iu tr mt s tnh hung c bit
4.1. iu tr mt trong bnh Basedow
* Th nh: cc bin php ti ch, dng nc mt nhn to cho trng hp kh mt., nm u
cao bui ti, nh Methyl cellulose (0,5%) khi ng bo v gic mc. c ch ( gim co
ko m mt.
* Th nng: Mang knh hoc bng mt., Lm m ti ch., Khng sinh., Phu thut khu sn
mi,
* Th c tnh: Prednisolone 1,5mg/ kg/ngy chia u, 4 - 12 tun, sau gim liu duy tr 5-
10 mg/ ngy. C th dng methylprednisone 15mg/kg mi 2 tun, azathioprine hoc
cyclophosphamide hoc cyclosporine A khi corticoide tht bi. Trch huyt tng (hin nay
phng php ny khng s dng). iu tr quang tuyn bn ngoi vo sau hc mt liu 2000
C. Gy trong 10 liu vi thi gian trong hai tun. Can thip dn lu gim p lc ni nhn, phu
thut c vn nhn. Cc bin php trn c th gim li nhn cu 5 - 7 mm.
Gn y ngi ta x dng Colchicine v Pentoxifylline
4.2. iu tr ph nim trong Basedow
Bi ti ch 1mg betamethasone (Celestoderm) hoc fluocinolone (Synalar).
4.3. iu tr cn bo gip
y l cp cu ni tit v th cn iu tr, chm sc v theo di tch cc.
498
+ Thuc khng gip: Propylthiouracil (PTU) 250 - 300mg / 6 gi hoc Mthimazole 25mg/6
gi ung hoc t hu mn (trng hp khng ung c). Trng hp nng c th tng PTU
100 mg/ 2 gi.
+ Iode: S dng hai gi sau khi dng thuc khng gip, dng thm Sodium - Iodide 1g/tnh
mch/24 gi hoc dung dch bo ha potassium - Iodide 10 git/12 gi hoc Ipodate Sodium
1g/ngy ng ung hay ng tnh mch.
+ Propranolol 40 mg ng ung hoc 1 - 2 mg ng tnh mch mi 6 gi, trong trng hp
c bnh l mch vnh i km. Hoc Verapamil 5-10mg/6 gi/ tnh mch chm (trng hp
chng ch nh c ch ).
+ Hydrocortisone - hemisucinate 50mg/6 gi ng tnh mch (do cortisol d tr b gim v
nhu cu cortisol tng trong stress).
+ Mn lnh
+ H st bng Paracetamol (khng dng aspirine)
+ B dch, in gii v ch dinh dng rt quan trng.
+ An thn v Phenolbarbital.
+ Th oxy, li tiu v Digitalis c ch nh trong trng hp c suy tim.
+ iu tr hoc ngn cn yu t khi pht.
+ Khng sinh, chng d ng, chm sc sau m.
Trng hp nng khng hiu qu iu tr ni khoa cn trch mu hoc thm phn phc mc
gim bt nng hormone gip lu hnh.
+ Kim tra thng xuyn nng kch t gip mi 3 - 4 ngy iu chnh thuc.
Phi hp PTU, iode, Dexamethasone c th lm lng T3 tr v bnh thng sau 24 - 48 gi.
4.4. iu tr suy tim
y l vn ht sc tinh t v cn nhc trc khi chn la thuc iu tr.
+ Suy tim tng cung lng: Ch yu l thuc khng gip tng hp phi hp c ch b ta nu
khng chng ch nh.
+ Suy tim gim cung lng.: Bn cnh thuc khng gip tng hp cn phi hp vi thuc tr
tim, li tiu, thn trng thuc c ch bta.
4.5. iu tr Basedow ph n c thai
- Chng ch nh iu tr I131
- Khng dng iod trong qu trnh iu tr, gy suy gip tre s sinh.
- iu tr ni khoa.
+ Khng gip tng hp: Ba thng u dng PTU v ba thng gia c th phu thut.
+ Propranolol c th s dng (lu suy h hp v km pht trin thai nhi nu s dng liu
cao v ko di).
Trong thi gian cho con b c th s dng PTU v thuc qua sa m khng ng k. Thai nhi
cn c theo di st trong qu trnh s dng thuc khng gip.
4.6. iu tr chng gim - mt bch cu ht
Trong qu trnh iu tr thuc khng gip tn hp thng xuyn kim tra cng thc bch cu
nu pht hin s lng bch cu ht di 1200 mm3 cn phi theo di st do c nguy c mt
bch cu ht nu bch cu di 200 / mm3. Ngng thuc khng gip v tu mc v x
dng thm Neupogen (Filgrrstim) hoc Leucomax (Molgramostim)
IX. TIN LNG
Tin lng bnh nhn tu thuc th bnh, phng tin iu tr v theo di.
499
BU GIP N
Mc tiu
1. Bit phn bit bu c n thun v bu c dch t.
2. Hiu c cc nguyn nhn gy bu c.
3. Chn on xc nh, phn bit v chn on mc bu gip n
4. Cc bin chng ca bu gip n
5. Ch nh c iu tr bu gip n.
6. Trnh by c cch s dng iode phng bnh bu c
Ni dung
I. NH NGHA
1. Bu c dch t: cn gi l bu gip a phng hay bu gip lu hnh: Khi nhu cu
sinh l ca iode khng trong qun th dn chng, th s pht sinh hng lot bt thng, bao
gm tn thng chc nng tuyn gip va, khi thiu iode trm trng gy ra bu c dch t hay
n n dch t, gim thng minh v tng t sut chu sinh v s sinh. Nhng bin chng ny
tht s l 1 tr ngi ln cho s pht trin ca qun chng v c nhm li thnh mt tn
chung l ri lon do thiu iode.
T ngi ta nh ngha bu c dch t nh l s ph i ca tuyn gip khu tr hay ton
th trong hn 10% qun chng.
2. nh ngha bu c ri rc: l s ph i t chc tuyn gip c tnh cht lnh tnh ton b
hay tng phn khng c triu chng suy hay cng gip, khng do vim, khng c tnh cht
a phng (tc vng khng c dch t), cc yu t gy bnh khng nh hng trong qun th
chung.
Nhiu nguyn nhn khc nhau lm tuyn gip ln c l l chung cho c bu c l t v bu
c dch t.
II. DCH T HC
Bu gip n thng gp n nhiu hn nam, t l mc bnh cao mt s a phng.
Trn th gii c nhng vng a d thiu iode: nh vng ni c nguy c bu c rt cao:
vng tuyt ph, Hy m lp sn (Himalaya, Andes)
Tuy nhin ngi ta cng thy thiu iode nhng vng c bin thp, rt xa i dng nh
lc a vng Trung Phi, lc a Chu u hin nay. Khng c con s chnh xc cho bit s
lng nhn loi c nguy c pht trin ri lon do thiu iode.
Mt nh gi c xem l c th ang kim chng > 800 triu, trong c 3 triu b n n
dch t.
Ti Vit nam, theo iu tra ca B Y t (1993) v iode niu tr em 9 - 11 tui, c 94% thiu
iod.
III. BNH NGUYN
1. Thiu iode: gp trong vng a d c bit nh vng ni v mt s vng nu trn.
2. Ri lon kch thch t n: xy ra ph n dy th, c thai, tin mn kinh
3. Do cht khng gip: bp ci trng hay thuc khng gip tng hp hoc cht ngn cn s ti
iode nh Thiocyanate, Perchlorate
Sn cng gy bu c dch t, v sn c cha Glucoside cyanognique, Linamarin, cht ny
khi b thy phn gii phng cyanure, trong c th cyanure b kh c thnh thiocyanate, m
thiocyanate c ch bm iode tuyn gip v gia tng s thanh thi iode thn, hu qu l thiu
iode c th
4. Do bt thng tng hp KTT tuyn gip
500
Do thiu enzyme nh hng n s sinh tng hp KTT tuyn gip.
Do s sai lch bm sinh trong s tng hp thyroxin sn xut ra iodoprotein bt thng.
5. Dng iode liu cao gy c ch tng hp hormon gip do hiu qu Wolff Chaikoff (tc dng
thong qua)
6. Mt iode: tiu chy ko di, hi chng thn h (gim protein ti iode), thai nghn (tng thi
iode nc tiu).
IV. C CH BNH SINH
1. Trong bu c, gim thyroxin s kch thch tuyn yn tng tit TSH gy bu gip v tng
sn xut hormon gip, y ch l hin tng b tr, phn ng cung cp cho c th
thyroxin, do tuyn gip khng b suy hay gim chc nng.
2.Nng iode trong mu v trong tuyn gip gim, lm tuyn gip ph i b tr cng
qua c ch trn.
3. Vn bu nhn cha c gii thch r rt lm, ngi ta cho rng bt u to ton b
tuyn gip v sau thu li cn mt hay nhiu nhn. C kin khc cho rng TSH tc dng
ln mt s nh nang tuyn gip, v bu dng keo l hu qu ca bu hay ph i t bo.
V. TRIU CHNG
1. Triu chng lm sng
1.1. Triu chng c nng
i vi bu gip n thun: bnh nhn thng c tnh trng bnh gip.
i vi bu c dch t th nh hng n s pht trin c th nht l tr em, gim thng
minh, n n.
1.2. Triu chng thc th:
i vi bu gip n u: ch tnh c thy bu ln, hoc do ngi khc pht hin c mt
khi u gia c, s c ranh gii r, khng dnh vo da, khng au, mm hay chc, di ng
theo nhp nut ln xung, khi bu to c th gy chn; khng c ting thi ti nh bu.
i vi bu gip nhiu nhn: gm nhiu khi trn ng knh t 0,5 - vi cm.
1.3. Phn bu c c tnh dch t
Kch thc bnh thng ca mi thy TG: 2,5-4cm chiu cao, 1,5-2cm chiu rng,1-1,5 chiu
dy; trng lng ca TG 10-20g.
2. Triu chng cn lm sng
- nh lng FT3, FT4 bnh thng.
Bnh thng FT4 = 0,8 - 2,4ng/dl, hoc 8 - 18pg/ml, hoc 10 - 30nmol/L.
FT3 = 0,4ng/dl, hoc 3 - 4pg/ml
Bnh thng tuyn gip tit T4 c chuyn dng thnh T3 m ngoi bin di tc dng
ca dsiodases. T3 l hormone hot ng trn th th t bo ch. V th tt nht l o FT3,
FT4, phn nh hot tnh sinh hc, v nht l FT4 nh gi trung thc s sn xut TG, cn FT3
c hiu cho s iu ha ngoi bin.
Cn T3 v T4 ton phn t trung thc, do d b bin i bi cc yu t ngoi lai nh hng
n cht ti protein:
+ Yu t tng protein ti hay tng T4 ton phn: oestrogen, thai nghn, vim gan nhim trng,
u ty, collagenose...
+ Yu t lm gim T4: suy dng, gim protid mu, x gan, thuc androgene, corticoide liu
cao..
+ Yu t ngn cn s kt hp vi protein ti: hydantoin, clofibrate, hparine, phenylbutazone.
501
- TSH cc nhy (TSH us) bnh thng (TSH = 0,3 - 4mUI/L).
TSH kim sot TG, s tit TSH c iu ha rt nhy bi nng hormone gip ngoi bin
qua c ch hi tc (feed back).
Dng k thut cc nhy th h II hin nay l 0,1mUI/L, th TSHus < 0,1mUI/L l cng gip.
Th h III l 0,01mUI/L th TSH us < 0,01mUI/l l cng gip.
- tp trung I131 bnh thng, tr trng hp bu n ho iode, cn lm thm
nghim php Werner loi tr cng gip.
Bnh thng tp trung I131 ti tuyn gip cc thi im 2 gi l 15%, 6 gi l 25%, sau
24 gi l 40%.
- Chp nhp nhy x hnh gip (Sintigraphie): cho bit hnh thi tuyn gip, chc nng
tuyn gip, kh nng bt gi phng x I131 hoc 99 Techntium ca ch m gip (xt nghim
ny cn thit trong ch nh bu hn): trong bu n, iode phn b u khp tuyn gip.
- nh lng T3, T4 t do bnh thng.
- TSH cc nhy bnh thng
- tp trung I131 bnh thng, tr trng hp bu n ho iode
- Sinh thit: c khi cn thit, cho thy cc bin i lnh tnh nh trong phn gii phu bnh.
- i vi bu c dch t hay bu c a phng, cn o iode niu/ngy, hoc t l iode
niu/cratinine niu nh gi s trm trng ca thiu ht iode:
+ Mc nh: 50 - 99 (g/ngy hoc 50 - 99 (g/g cratinine niu.
+ Mc trung bnh: 25 - 49 (g/ngy hoc 25 - 49 (g//g cratinine niu.
+ Mc nng < 25 (g/ngy hoc 25 (g/g cratinine niu.
- Siu m bit cu trc TG v th tch TG
Tui 6 7 8 9 10 11 12 13 14 15 16 17
V(ml)
Gii hn trn
3,5 4 4,5 5 6 7 8 9 10,5 12 14 16
Th tch ti a (gii hn trn) ngi trng thnh 18 ml.
VI. CHN ON
1. Chn on xc nh
Dch t v lm sng cng chn on.
Trng hp bu c l t, nn khm k hn v lm sng v xt nghim thm d chc nng
tuyn.
2. Chn on phn bit
2.1. Bu gip c suy gip: ch khc nhau v triu chng suy gip.
2.2. Bu gip c cng gip nh Basedow, bu gip c lm sng c du cng gip, tnh
cht c bit ca bu v cn lm sng gip cho chn on d.
2.3. Bu gip n kt hp vi ri lon thn kinh thc vt: c triu chng ging nhau l c
bu c, km d mt hay hi hp, nhp tim nhanh nhng nhp tim d tr li bnh thng khi
ngh ngi hay dng an thn, lng bn tay c nhiu m hi nhng khng nng, cc XN thm
d chc nng tuyn gip bnh thng.
2.4. Bu gip n ho iode: khng c du hiu cng gip, ch c tp trung I131 cao,
nhng nghim php Werner > 50%, cc XN khc bnh thng.
2.5. K tuyn gip: rt cng, c th c triu chng chn p v hch di cn, khng tp trung
I131, sinh thit loi tr.
502
2.6. Vim tuyn gip bn cp v mn (Hashimoto, Riedel), bu gip lan ta, c khi nhiu
nhn, cng, tc mu lng tng, (globulin tng, t khng th khng gip cao, KT khng
TPO, sinh thit t chc gip loi tr.
2.7. U ngoi tuyn gip: khng di ng theo nhp nut
VII. BIN CHNG
1. Xut huyt trong bu: bu to nhanh, au v nng, du chn p cp
2. Cng gip: thng xy ra bu nhiu nhn, bu lu nm, Basedow ha phn tuyn
bnh thng xen k gia cc nhn, thng do cung cp iode qu nhiu (iode- Basedow).
3. Ung th ha.
4. Ring i vi bu c do thiu iode ngi m mang thai: c th nh hng n s chm
pht trin v tinh thn v th cht ca thai nhi
VIII. IU TR
1. Nguyn tc iu tr
Nhm bnh thng ha nng hormonee tuyn gip, m khng i hi tuyn gip phi tng
hot v ph i, do nu bnh nguyn:
Thiu iode th cung cp iode, khng do thiu iode, cung cp thm hormonee gip tng hp.
Trong bu gip n do thiu iode, iu tr bng iode hay hormonee gip lm tuyn gip nh
li nhiu hay t thay i tu thuc nhiu yu t, nh thi gian xut hin bu, kch thc
bu, x ho ca bu.
Trong nhng nguyn nhn khc gy bu gip n lan to khng c, Levothyroxine c th
c dng vi mc ch nhm gim kch thc tuyn gip
2. iu tr c th
2.1. iu tr bu gip n lan to (khng c).
2.1.1. iu tr ngoi khoa
Hn ch ti a phu thut v bu gip trong trng hp ny ln l do hot ng b, nu ct
b d b suy gip, nht l him khi ch nh i vi cc bu ln lan to. Tuy nhin can thip
phu thut c th t ra trong nhng trng hp sau:
Bu gip qu ln gy chn p (kh nut, kh th, ni khn). Bu gip lu nm d b ung
th ho hoc nghi ng ung th ho. Bu nhiu nhn
V l do thm m.
Sau khi phu thut, phi thng xuyn kim tra FT4, TSH pht hin suy gip kp thi
2.1.2. iu tr ni khoa
* i vi bu gip do thiu iode hay bu gip a phng:
Phn ln khng hoc nh hng rt t n chc nng tuyn gip, nhng nguyn nhn chnh l
do thiu iode, nn tt nht l a iode vo iu tr v d phng, Iode c nhiu dng:
- Iode di dng iodur de potassium (IK) (Lugol) 1 mg mui KI/ngy, ti thiu trong 6 thng,
hoc iodat de potassium (KIO
3
).
Cn theo di bin chng Iode-Basedow
Tuy nhin v c ch Feedback cn bnh thng, nn c th s dng hormonee gip lm
gim th tch tuyn gip. L. Thyroxine vin c ch nh khi:
+ Lm sng v siu m xc nh bu gip ln.
+ Nng Thyroxine gim v TSH huyt tng tng.
+ Th tch tuyn gip c nh li so vi trc khi iu tr
503
- Thyroxin (Levothyroxine, L-Thyroxine, Levothyrox) (T4), vin 50g, 75g, 100g, liu tu
thuc vo tnh trng bnh nhn 0.5- 2 vin/ng
Levothyroxine c 1/2 i l 7 ngy, hp thu tt, dng bui sng trnh mt ng
- Triiodothyronine (Liothyronine) (T3) vin 25 g, 1- 2 vin/ng, t dng v hp thu nhanh, 1/2
i ngn, hiu qu ch thong qua. Khng dng bnh nhn THA, bnh mch vnh.
ngi tr, liu bt u 100 g/ngy, v ngng khi TSH mc bnh thng-thp
Theo di cho tng liu dn t hiu qa tt, theo di bin chng cng gip (mch nhanh,
gy).
bnh nhn gi, liu khi u 50 g/ngy, cn cho liu tng dn theo di cn au tht ngc
v o in tim.
Kt qu
- Bi v c kh nng bnh tuyn gip t min tim tng, nn thn trng khng dng thyroxine
c bit khi khi TSH gii hn thp.
- bnh nhn gi, bu nhn hoc bu x ho, kh nng bu co nh li chng 1/3, bnh
thng gim sau 3-6 thng iu tr, nu sau thi gian ny khng gim th kh c hiu qu tt.
* i vi bu c l t khng do thiu iode:
Vn iu tr bng thyroxine liu nh trn, nhm gim ph i tuyn gip
* iu tr bu gip a nhn khng c.
- Phn ln bu gip a nhn khng c c th bo tn.
- Cung cp thyroxine him khi lm tuyn gip nh li.
Nu dng Levothyroxine, dng liu khi u l 50 g/ngy, c th tng dn liu, nhng theo
di TSH.
Cht cn quang hoc cc cht cha iode nn trnh v c nguy c a n cng gip do iod
(iod-Basedow) do tng sn xut hormonee gip ca cc nhn gip.
- X tr liu ngy cng c ch nh v lm kch thc tuyn nh li, v c th ct b
chn lc cc nhn t tr. Liu I131 ph thuc vo kch thc tuyn gip, v s bt gi iode
phng x. Thng khong 100 Curie/gram m tuyn. iu tr c th lp li nu cn. Phn
ln bnh nhn, kch thc tuyn gip gim khong 40-50%.
- Khi c s chn p cp xy ra, glucocorticoid hoc phu thut c th cn thit c
ch nh.
Suy gip sau x iu tr bu gip a nhn khng c t xy ra hn so sau x iu tr
Basedow. Tuy nhin khong trn 5% suy gip t min c th xy ra sau iu tr bnh bu
gip a nhn khng c.,.
IX. PHNG BNH
i vi vng thiu iode
C nhiu phng php b sung
1. Mui iode ha
Nng iode trn vo mui c ngh l 1 phn iode cho 10.000-100.000 phn mui,
bng cch da trn s tiu th khong 5g-10g mui/ngy, cung cp chng 50-500g iode/ng.
Hin nay dng iodat bn vng hn iodure (IK) do c tnh n nh ca n trong vng nhit
i m thp,
D phng bu c bng cch dng mui iode c kt qu tt trong mt s QG nh Hoa k,
Thu s, n , Mxico, Phn lan, Tip khc. Ti Hoa K sau 30 nm cung cp iode d
phng gim tp trung phng x vo thi im 24 gi t 40-45% (1960) xung cn 8-
504
30% (1990). Tuy nhin theo khuyn co ca TCYTTG (1996) v s dng mui iode cn lu
:
- Khong 20% iode b mt i t khi sn xut cho n khi s dng.
- Khong 20% iode b h bin trong qu trnh ch bin thc n
- Lng mui s dng trung bnh trong ngy l 10g.
Cch trn
Kali iodat (iodate de potassium: KIO) hoc iodure Kali (IK) 20-25 mg/kg mui, tng ng
nhu cu trung bnh l 150- 300 g/ngy.
S cung cp c nh gi tt khi nng iode trong nc tiu trung bnh t 100-
200 g iode/l
2. Du iode: hp th chm
- Lipiodol
+ ng ung: 1ml cha 480mg iode, liu duy nht bng 1ml, d phng 1-2 nm.
+ Tim bp: liu 0,5-1ml (1ml cha 480mg iode), d phng bu c v chng n a
phng trong 3 - 5 nm.
Tr em <1tui: liu 0.5ml, TB mng
Tr em >1tui v ngi ln TB tay, liu 1ml
3. Nuc pha iode: iode loi dung dch m c I2, IK hay KIO
3
cho vo nc ung t nhu
cu 150g /ngy.
4. Lugol: 5g I2 + 10g IK trong 100ml (hoc 6mg iode cha trong 1 git Lugol). Thi gian tc
dng ngn hn so vi loi du iode, nn cho nhiu ln trong ngy
C nhiu cch b sung iode, nhng iode ha mui l phng php c a chung nht trong
vic b sung iode qun th thiu ht iode.

505
SUY GIP
Mc tiu
1. Nu c nguyn nhn suy gip.
2. Nu c cc triu chng lm sng v cn lm sng suy gip.
3. Nu c phng php chn on suy gip.
4. Nu c nguyn tc v phng php iu tr c th suy gip.
Ni dung
I. I CNG
Suy gip (SG) l mt bnh cnh xut hin do s thiu ht hormone gip, gy nn nhng tn
thng m, nhng ri lon chuyn ha. Nhng thay i bnh l ny c gi l triu chng
gim chuyn ha (hypometabolism).
Bnh kh thng gp, t l tri n, t l bnh gia tng theo tui. T l mc bnh khong 1%
n v 0,1% nam, t l suy gip tng hn nhiu nhng vng c bu gip a phng.
II. NGUYN NHN
1. Suy gip tin pht. Bnh xy ra do tn thng ti chnh tuyn gip, chim hn 90% cc
trng hp suy gip.
1.1. Vim tuyn gip Hashimoto: y l nguyn nhn hay gp nht. Tuyn gip c th ln
hoc teo, c khi i km vi Addison v cc ri lon ni tit khc.
1.2. Tai bin do iu tr: nht l vi iode phng x, phu thut tuyn gip, ring vi thuc
khng gip tng hp, t gp hn.
1.3. Cung cp iode khng hp l (tha iode, thiu iode): suy gip do thiu iode ang cn l
vn Vit Nam.
1.4. Vim tuyn gip bn cp, vim gip sau sinh: thng xy ra sau giai on nhim c
gip trc , suy gip y ch tm thi.
1.5. Cc nguyn nhn suy gip tin pht khc: (him).
- Thiu enzyme tng hp hormne gip bm sinh.
- Cc cht khng gip trong thc n
- Lithium: iu tr bnh tm thn.
2. Suy gip th pht. Suy tuyn yn do u lnh (adenoma) tuyn yn, do phu thut tuyn yn,
hoc do tuyn yn b hoi t trong bnh Sheehan.
3. Suy gip tam cp. Do ri lon chc nnhng yn gip ti vng di i, bnh cnh
him.
4. Suy gip do khng hormone gip ngoi bin. Bnh t gp.
III. BNH HC
Suy gip tin php - Bnh ph nim (myxedema). Hay gp n, xung quanh la tui 50.
Bnh thng xut hin t t d ln vi cc triu chng ca mn kinh.
1. Lm sng: Da, nim mc b thm nhim bi mt cht dng nhy cha nhiu polysaccarid
acid ht nc, gy ph cng n khng lm.
1.1. Da nim mc
Mt trn nh mt trng, v mt v cm. Nhiu np nhn trn trng gi trc tui. Mi mt
ph, r mi di, g m hi tm, c nhiu mao mch gin, mi dy tm ti, phn cn li ca
da mt c mu vng bng.
Bn tay dy, cc ngn tay kh gp, da lnh i khi tm ti, gang bn tay bn chn c mu
vng (xanthoderma).
506
Li to, ging khn trm (do thm nhim dy thanh i), tai, nghe km (do thm nhim vi
Eustache). Khi ng ting ngy to (do nim mc mi, hu hng b ph nim).
Da ph cng, kh, bong vy. Tc kh d rng, ui my rng, lng nch, lng mu rng.
Mng tay, chn c vch, d gy.
1.2. Triu chng gim chuyn ha
L du soi gng ca nhim c gip.
- S lnh, thn nhit gim, tay chn lnh, kh.
- Ung t, tiu t, bi tit nc tiu chm sau ung.
- Tng cn d n km
- Tiu ha: to bn ko di, km gim nhu ng rut.
- Yu c, chut rt, au c.
- Du tm thn kinh v ri lon thn kinh thc vt: trng thi v cm, th . Suy gim cc
hot ng c th, hot ng tr c, hot ng sinh dc.
Gim tit m hi.
1.3. Tim mch
- Tim chm < 60l/ pht, huyt p thp (ch yu tm thu), tc tun hon gim cc biu hin
ny do gim chuyn ha.
- Cc du thm nhim c tim, mng ngoi tim.
au trc tim hoc cn au tht ngc tht s, kh th khi gng sc. Nghe tim: ting tim m,
chm,c khi ting tim khng u.
ECG: nhp chm, in th thp cc phc b QRS, c khi ST chnh xung, sng T dt hoc
o ngc. Hnh nh in tim s tr li bnh thng sau iu tr bng hormone gip.
X quang bng tim to, p yu. C khi trn dch mng ngoi tim, dch c nhiu protein v
cholesterol. Siu m tim gip phn bit trn dch mng tim vi thm nhim mucoid c tim.
C khi huyt p tng do x va ng mch.
1.4. Triu chng h hp
Th nng, tn s chm, p ng h hp km i vi s tng CO2 mu hoc gim O2 mu.
Suy h hp cp l mt triu chng ch yu ca hn m ph nim.
1.5. Chc nng thn
Gim chc nng thn, gim mc lc cu thn, gim kh nng thi nc khi qu ti, do d
dn n ng c nc bnh nhn suy gip nu nc t do c a vo c th qu nhiu.
1.6. Thiu mu
C t nht 4 c ch dn n thiu mu bnh nhn suy gip:
- Gim tng hp hemoglobuline do thiu Thyroxine.
- Thiu st do mt nhiu st v rong kinh, ng thi gim hp thu st rut.
- Thiu mc c tnh: thiu mu nguyn hng cu khng l vi thiu vitamine B12. Thiu mu
c tnh thng l mt phn trong bnh cnh bnh t min gm ph nim do vim gip mn
tnh phi hp vi t khng th khng t bo thnh, i tho ng phi hp vi t khng th
khng o ty v suy thng thn phi hp vi t khng th khng thng thn (Hi chng
Schmidt)
1.7. Triu chng ni tit
- Tuyn gip: c th ln, tuy nhin a s trng hp tuyn gip b teo..
- Cc ri lon ni tit khc nh rong kinh, kinh t km chy sa hoc mt kinh - chy sa,
chy sa n thun
507
- Lnh cm.
1.8. Cc triu chng thng c trong suy gip (Theo Perlemuter v Hazard):
Triu chng gim chuyn ha: Mt mi:99%. S rt:89%. Tng cn:59%
Triu chng tim mch: Nhp tim chm:95%. Hi hp:31%. au vng trc tim:25%.
Triu chng da nim mc: Da kh:97%. Gim tit m hi:89%. Li ln v dy:82%. Rng
lng: 76%. Xanh ti: 67%. Rng tc: 57%. Ph ngoi vi:55%. Ging khn: 52%. ic: 32%.
Triu chng tiu ha: To bn dai dng: 23%.
Triu chng c bp: Chut rt (vp b) > 70%
Triu chng thn kinh: L (Lthargie): 91%. Ni chm: 91%. Gim tr nh: 66%. Ri lon
tm thn: 35%.
1.9. Hn m suy gip
L mt bin chng nng ca suy gip, him, thng ch gp x lnh, xy ra trn bnh nhn
suy gip iu tr khng y hoc khng c iu tr, vi cc yu t thun li nh: nhim
trng, phu thut, chn thng, nhim c... hoc ngng iu tr thyroxine t ngt. Tin
lng thng nng, t l t vong hn 50%. Lm sng l mt tnh trng hn m im lng km
cc du hiu sau:
- Thn nhit h, y l du hiu hng nh, nhit khong 32-350C c khi thp hn.
- Ri lon h hp, lun lun c, vi nhng t ngng th, gim thng kh ph nang.
- Cc biu hin tim mch nh nhp tim chm, h huyt p, cung lng tim gim, tim ln.
- Ngoi xt nghim hormone khng nh bnh cnh suy gip, trong t hn m suy gip
cn cho thy: in gii mu v nc tiu: Lun lun c gim natri mu, km gim clor,
gim protid mu, gy nc ni bo d dn n ph no, glucose mu c th gim, ADH
tng.
2. Cn lm sng
2.1. nh hng thiu hormone gip ln chuyn ha v t chc ngoi vi:
- Chuyn ha c bn gim di 10% so vi bnh thng
- Thi gian phn x gn gt ko di trn 320ms.
- Cholesterol mu trn 3g/l (du khng hng nh). Triglyceride tng song song vi
Cholesterol.
- CPK (cratin phosphokinaza) tng do cao iso - enzym c ca CPK tng 70UI/l.
- Thiu mu ng sc hay nhc sc, hng cu bnh thng hoc hng cu ln.
2.2. nh lng hormone gip lu hnh:
Iode ton phn (iode trong hormone) < 4(g/ 100ml.
T
4
< 3 g/dl.
FT4I gim
T
3
< 80mg/dl (< 1,2 mmol/l)
Nu ch T3 gim n c th cha v T3 c th gim do nhng nguyn nhn khng phi do
tuyn gip (hi chng T3 thp).
FT4 < 0,8(g/dl.(T4 t do).
2.3. nh lng TSH:
Nu suy gip tin pht TSH lun lun tng trn 10 (UI/ml (TSH > 20 (UI/ml khng nh chn
on): chng t tn thng tuyn gip tin pht. p ng ca TSH vi TRH rt mnh (test
ny khng cn thit nu TSH tng r).
Nu suy gip do nguyn nhn cao TSH khng tng.
508
2.4. o tp trung iode phng x ti tuyn gip
tp trung iode phng x t di 5%, 10% v 20% vo cc thi im 2h, 6h v 24h, c
khi thp hn na (bnh thng: 20%, 30%, 40% vo cc thi im trn). X hnh tuyn gip
thy hnh nh iode tp trung ri rc, khng ng cht, x hnh t ch li trong chn on v
tin lng suy gip
IV. CHN ON
1. Chn on xc nh: Khng kh i vi nhng trng hp in hnh. Cn ngh n suy
gip trc tt c nhng trng hp c biu hin nghi ng nh tuyn gip ln hoc c iu tr
iode phng x hoc phu thut gip.
1.1. Nu nghi ng suy gip tin pht: TSH l xt nghim tt nht gip chn on xc nh.
TSH bnh thng, loi tr suy gip tin pht. TSH tng r (>20(U/ml), xc nh chn on.
Nu TSH tng nh (<20(U/ml), cn nh lng FT4, nu FT4 thp: suy gip lm sng, nu
FT4 bnh thng: suy gip di lm sng (subclinical), nhng trng hp ny gip suy nh,
nhng TSH tng gip duy tr T4 bnh thng, triu chng lm sng nhng trng hp ny
khng r.
1.2. Nu nghi ng suy gip th pht: Do gi thng tn tuyn yn, TSH thng gim
nhng c khi bnh thng do cn nh lng FT4, khng nn ch da vo nh lng TSH
chn on suy gip th pht. Nhng trng hp ny nn thm d thm tuyn yn, di
i.
2. Chn on phn bit
- Tui gi: Do suy thoi c th, biu hin chm chp v tinh thn v th cht, da kh, rng
lng (nht l lng my), km chu lnh, tp trung I131 c th gim. Cc biu hin trn
cng c th c mt phn do gim hot gip.
- Suy thn mn: chn n, chm chp, ph nh, thiu mu, phn bit da vo huyt p tng,
ur, cratinin mu tng...
- Hi chng thn h: ph, thiu mu, cholesterol mu tng, phn bit da vo hi chng th
dch v nc tiu.
- Bnh Langdon Down: tr tu, tay chn km pht trin, ln nhng tr nng ng hn, da
khng kh, mt xch, mng mt c vt trng (Brushfield).
- Thiu mu, suy dinh dng: da ti, ph nh, tc lng c th rng nhng tinh thn khng
chm chp, cholesterol mu khng tng, cn xt nghim sinh ha, hormone phn bit.
- Bo ph: tng cn, nng n trong vn ng, cholesterol mu tng, nhng lng khng rng,
tinh thn bnh thng, khng s lnh, mch khng chm, th khng chm.
V. IU TR
1. Nguyn tc iu tr suy gip
1.1.Tt c trng hp suy gip u cn c iu tr ngoi tr cc th suy gip ch c biu
hin cc du sinh hc nh nh:
- Tng TSH va (< 10 (U/ml)
- T3 T4 bnh thng.
- ang thi im khng c biu hin bnh ang pht trin.
1.2.iu tr suy gip ni chung l n gin v hiu qu: ch yu da vo iu tr hormone
gip thay th.
1.3. Ngoi tr hn m ph nim, s iu tr suy gip khng nn vi vng, cn xc nh chn
on chc chn trc khi thc hin iu tr.
509
1.4. Cn gii thch cho bnh nhn s cn thit dng thuc u n v vnh vin. Ngc li
cng cn hiu rng c nhng trng hp suy gip thong qua khng cn thit phi iu tr lu
di.
1.5. S iu tr cn rt thn trng ngi gi, suy tim, suy vnh, phi bit chp nhn mt
iu tr thay th mt phn.
2. Thuc Hormone gip
2.1. Tinh cht tuyn gip (extrait thyroidien)
Thuc c ch t tuyn gip gia sc.
Hm lng: 1cg 5cg 10cg (Php)
16 32 60 325mg/ vin (M)
(Bit dc: Amour Thyroid. Thyroteric, Extrait thyroidien choay).
2.2. Hormone gip tng hp
2.2.1. Levothyroxine, LT
4

Dng thuc: vin nn, thuc nc, tim.
Hm lng ; 1 git = 5g.
Vin nn: 25 - 50 - 75 - 100 - 300(g.
Thuc tim ; 200 - 500g (100g/ml)
(Bit dc:Synthroid- levothroid, L Thyroxine - Roche, Levothyrox...)
2.2.2. Liothyronine, LT
3

Dng ung: vin nn.
Hm lng ; 5 - 25 - 50 g.
(Bit dc: Cynomel)
2.2.3. LT4 phi hp vi LT3
C nhiu phi hp vi nhng t l khc nhau gia T4 v T3 (4/1, 5/1, 7/1).
Tn chung M l Liothrix.
Hm lng: nhiu loi, thng thng nht l 100mcg LT4 / 25 mcg LT3 dng vin nn cng
c nhng hm lng khc.
(Bit dc: Euthyroid, Thyrolar, Euthyral, Thyreotoin, Thyreocomb)
Trong iu tr cn c dng D. Thyroxine. (Dextro - Thyroxine) nhng dng L Thyroxine
c a chung v tc dng mnh hn.
2.3. u nhc im ca cc loi thuc
Thi gian bn hy ca L Thyroxine khong 8 ngy, gii thch mt s n nh nng thuc
trong mu, ch cn cho ung mt ln theo gi c nh trong ngy. L Thyroxine c kh iode
ngoi bin tr thnh Triiodothyronine (T3).
Ring i vi T3 (cynomel) c dng ring l s c tc dng nhanh hn nhiu nhng nng
thuc tng t ngt sau mi ln ung gy kh chu cho bnh nhn. Thi gian bn hy ca
T3 l 48h, thuc cn dng 2-3 ln/ ngy. T3 thng ch c ch nh tm thi cho K gip
bit ha trc thm d hoc x tr liu.
Vi Euthyral (phi hp T3 v T4) thuc cng c th gy tng T3 t ngt trong mu,do
cng t c la chn trong iu tr, cn tinh cht tuyn gip (extrait thyroidien) khng c
dng na trong iu tr suy gip vi nhng t l khc nhau gia T3 v T4 kh nh gi kt
qu.
3. iu tr c th
510
Thyroxine l thuc c chn la u tin hin nay, liu thay th trung bnh 75-125(g/ngy.
Trn bnh nhn gi thng thp hn, lu bnh cn iu tr sut i.
3.1. Khi u
Nu bnh nhn tr, cn kho nn bt u liu 100g/ngy. Vi liu lng ny tnh trng suy
gip s ci thin dn, nhng phi mt nhiu tun T4 t hng nh. Triu chng gim sau vi
tun iu tr. Vi bnh nhn gi nn bt u vi liu 50g/ngy. Bnh nhn c bnh tim liu
khi u nn l 25g/ngy ng thi theo di st cc biu hin v tim trong qu trnh iu tr.
Nhng bnh nhn ny tng liu 25g/ngy mi tun cho n khi t hiu qu iu tr mong
mun
3.2.Theo di v iu chnh liu lng
3.2.1.Vi suy gip tin pht
Mc ch iu tr l duy tr TSH mc bnh thng. Cn nh lng TSH 2-3 thng sau khi
bt u iu tr. Liu thyroxine c iu chnh t 12-25g/ngy mi 6-8 tun cho n khi
TSH tr v bnh thng. Sau ch cn nh lng TSH tng nm kim sot iu tr nh
mong mun, khng nn p dng liu thyroxine cao biu hin nng TSH di mc bnh
thng, c th gy nguy c long xng, rung nh.
3.2.2.Vi suy gip th pht
Khng th da vo TSH iu chnh iu tr. Mc ch iu tr nhm duy tr FT4 t mc
bnh thng. Liu thyroxine c iu chnh mi 6-8 tun cho n khi t mc ch iu tr.
Sau theo di FT4 mi nm mt ln l kim sot bnh.
Trong suy gip th pht (hi chng Sheehan) thng km c suy thng thn, suy sinh dc
cng v suy gip, do phi cho km cho theo cc hormone thch hp. Nn cho hormone
thng thn trc phng suy thng thn cp khi cho hormone gip lm tng chuyn
ha ca c th.
3.2.3. Vi bnh nhn c bnh mch vnh
Thyroxine c th lm nng thm bnh l mch vnh ni ring cng nh cc bnh tim nh suy
tim, ri lon nhp, cn cho liu nh, tng liu rt chm theo di k tnh trng tim mch, in
tim, cho km thuc chn beta nu cn (ch cc chng ch nh). Nu vn xut hin triu
chng au tht ngc, d nh, cng nn ngng iu tr hormone gip, c th xem xt ch nh
cc bin php can thip trong iu tr mch vnh (lu phi an ton trn bi cnh suy gip).
3.3.Nhng kh khn trong kim sot suy gip
Thng do khng bng lng vi iu tr. Mt s trng hp cn phi tng liu thyroxine nh:
3.3.1. Km hp thu thuc
Do bnh ng rut hoc mt s thuc cn tr hp thu thuc nh cholestyramine, sucralfate,
hydroxyde nhm, sulfate st.
3.3.2. Tng tc vi cc thuc khc
Lm tng s thi thuc nh rifampin, carbamazepine, phenytoine hoc c ch s chuyn T4
thnh T3 ngoi bin nh amiodarone.
3.3.3. Mang thai
Nhu cu thyroxine tng trong 3 thng u. Ni chung cn tng liu thyroxine va cho m va
trnh bu gip ln cho con.
3.3.4. Chc nng tuyn gip cn li
Thng suy gim dn sau iu tr suy gip.
3.4. Suy gip di lm sng
Nn dng thyroxine trong nhng trng hp sau:
511
- C triu chng suy gip
- C bu gip ln
-Tng cholesterol mu n mc phi iu tr.
Nhng bnh nhn suy gip di lm sng cn li cha cn iu tr phi c theo di mi
nm, nn bt u cho thyroxine khi triu chng suy gip xut hin hoc TSH > 20 g/ml.
3.5. Suy gip v phu thut
Mc du suy gip c tng nguy c nhng bin chng ca phu thut nhng ni chung khng
nng. Khi cn phu thut cp cu theo yu cu ch nh c th tin hnh ngay, tuy nhin cn
cho thyroxine ngay trc phu thut, liu u tin bng ng tnh mch. Nhng trng hp
phu thut theo chng trnh c th hon li cho n khi suy gip iu tr c nhiu tun..
3.6. iu tr hn m do suy gip
Mc d him gp, nht l cc x nng, nhng hn m suy gip l mt cp cu cn iu tr
khn cp. Phc iu tr gm:
3.6.1. iu tr triu chng:
- H tr h hp ; oxy liu php, t ni kh qun, gip th, ng thi iu tr tnh trnh tru
mch mt cch tch cc. Nhanh chng xc nh chn on bng nh lng TSH, FT4 trc
khi cho thyroxine.
- Si m t t nhit phng l 22
0
C. Si m nhanh qu c th lm nng tnh trng try
mch v rung tht.
- B nc in gii, glucose.
3.6.2.Thyroxine
50-100g TM mi 6-8 gi trong 24 gi, sau 75-100g/ngy TM cho n khi ung c.
iu tr hormone thay th c tip tc sau nh thng quy khi m suy gip c chn
on xc nh. Cn theo di k v tim mch nhanh chng pht hin tc dng khng mong
mun trn tim do thyroxine.
3.6.3.Hydrocortisone
100mg tnh mch sau tim bp 50mg mi 8h trong t cp, tip ty tin trin c th
gim bt liu lng.

512
VIM TUYN GIP, UNG TH TUYN GIP
Mc tiu
1. Nu c cc loi vim tuyn gip v bnh nguyn, triu chng lm sng v cn lm sng.
2. Nu c cc loi ung th tuyn gi v triu chng lm sng v cn lm sng.
3. Nu c phng php iu tr c bn vim tuyn gip, ung th tuyn gip
Ni dung
I. VIM TUYN GIP
1.i cng
Vim tuyn gip l mt nhm bnh gy tn thng tuyn gip c th do nhim trng hoc
qu trnh vim xy ra trn tuyn gip bnh thng. Bnh cnh lm sng cn lm sng, din
tin khc nhau tu theo nguyn nhn gy bnh. Vim tuyn gip x ho c th din tin rt
nng, vim tuyn gip lympho thng dn n suy gip, vim tuyn gip bn cp lun lun
lnh hn.
2. Cc loi vim tuyn gip
2.1Vim tuyn gip cp
Bnh t gp, xy ra do nhim trng tuyn gip, vi vi khun nh: t cu vng, lin cu,
E.Coli, vi khun k kh, samonella... c khi vi c BK, vi nm nh actinomyces, c bit vi
k sinh trng nh Echinococcus.
+ Lm sng: Trng hp do vi trng thng, gy hi chng nhim trng, ti gip c biu
hin nh mt abces vi nng, , sng, au, au c th lan ln tai, chm, hm.
+ Cn lm sng: Cng thc mu c bch cu tng cao, a nhn chim u th. Siu m gip
thy vng gim m (hypoechogene). X hnh gip thy vng khng bt gi iode. Chc d
thy m. T3,T4,TSH bnh thng, khng c khng th.
2.2. Vim tuyn gip bn cp (De Quervain hoc Crile)
Nguyn nhn do virus nh virus quai b, Coxsacki, E.C.H.O, adenovirus. Bnh thng
xy ra trn ngi c HLA BW 35.
+ Lm sng: Thng c triu chng cm cm trc . Chn on da trn cc triu
chng au t gip lan ra, tuyn gip ln, ban u mt bn sau lan ra ton gip, s thy mt
tuyn gip chc, au, hch khng ln. Ton thn c st nh, au c, suy nhc. C 1/2 s
trng hp c biu hin nhim c gip.
+ Cn lm sng: Hi chng vim khi xt nghim, vi VS tng, bach cu bnh thng
hoc tng nh. X hnh thy gim hoc mt tp trung iode. Hormone gip bnh thng hoc
tng nh (phng thch do m gip b hu hoi). TSH bnh thng hoc thp. Khng c khng
th.
+ Tin trin: Thng lui bnh t nhin sau 6 tun, c khi lu ln. Cng c trng hp
gp suy gip thong qua.
2.3. Vim tuyn gip khng au (vim tuyn gip im lng)
Kh thng gp, nht l ph n sau sinh (5-7% cc trng hp thai nghn).
+ Lm sng: Bu gip chc, khng au. Du nhim c gip va, khng c li mt.
+ Cn lm sng: VS bnh thng hoc tng nh. Hin din khng th khng gip vi
chun thp. Hormone gip tng, TSH gim. X hnh gip khng bt gi iode.
+ Tin trin: Lnh t nhin sau 2-4 thng, t khi chm hn. Suy gip thong qua kh
thng gp. C th ti pht mt nhim c gip rt lu sau . Bu gip c th tn ti lu
di.
513
+ Ghi ch: Vim tuyn gip khng au rt ging vi vim tuyn gip bn cp, ch
khc nhau triu chng au, mt im khc na vim tuyn gip im lng l t min bnh. Lm
dng idoe c th gy biu hin tng t, phn bit da vo iode mu, iode niu bnh thng
trong vim gip im lng.
2.4. Vim tuyn gip lympho (Hashimoto).
L bnh t min, trn cc i tng thuc nhm HLA B8 DR3. Thm nhim gip vi
lympho v tng bo, vi nhng nang gip b ph hu bn cnh nhng nang gip tng sn.
Din tin mn tnh c th dn n suy gip.
+ Lm sng: Bu gip ln lan to, mt chc, gii hn r, khng au, hch ln cn
khng ln. Biu hin bnh gip, c khi nhanh chng dn n suy gip (suy gip ngi
trng thnh + bu gip ln = Hashimoto). C khi biu hin nhim c gip thong qua.
+ Cn lm sng: Hin din khng th khng thyroglobuline, khng th khng
microsome tuyn gip, khng th khng peroxydase. nh lng hormone gip bnh thng
hoc thp vi TSH tng. Rt him nhng c th T3,T4 tng km TSH gim trong giai on
nhim c gip. X hnh gip c hnh lm m khng ng nht. VS bnh thng hoc tng
nh.
+ Tin trin: Rt thay i, c khi tn ti bnh cnh bu gip bnh gip, c khi dn
n suy gip vi tuyn gip teo nh.
+ Lu :
- Hin din khng th khng gip khng ch ring Hashimoto, cn c trong bnh Basedow.
- T l ln suy gip ngi ln km teo tuyn gip c nguyn nhn vim gip Hashimoto m
giai on khi pht b b qua.
- Hashimoto c th phi hp vi nhng bnh khc nh suy thng thn, bung trng, i
tho ng. Hoc bnh bch bin, Biermer; hoc thng tn mt kiu Basedow (him).
2.5. Vim tuyn gip ho si (Riedel)
Bnh him, cha r nguyn nhn, tin trin nng.
+ Lm sng: Bu gip cng nh , ban u khu tr, sau lan ton tuyn gip. S x
ho lan rng n cc c c, c quan ln cn gy cm gic b cht c, kh nut, kh th.
Bnh c th phi hp x ho sau mng bng, trung tht, sau hc mt, tuyn l.
+ Cn lm sng: T3,T4, TSH bnh thng, VS bnh thng, tp trung iode phng
x gim.
+ Tin trin: T vong khng trnh khi, iu tr duy nht l phu thut, nhng kh
nng phu thut rt hn ch.
Bng 1: Phn bit cc loi vim gip
Cp Bn cp Im lng Hashimoto Riedel
au +++ +++ 0 0 0
Gip Abces Rt chc Chc Rt cht Cng nh
Du ton thn ++ ++ 0 0 0
FT3, FT4 BT BT hoc BT hoc BT hoc BT
TSH BT BT hoc BT hoc BT hoc BT
Khng th 0 0 hoc + 0 hoc + +++ 0
VS

(hoc BT BT BT
X hnh Vng lnh Khng bt iode Khng bt iode Khng ng cht Vng lnh
514
II.UNG TH TUYN GIP
1.Phn loi.
Ung th tuyn gip chim t l 1% trong s nhng trng hp t vong do ung th,
y l mt nhm bnh c tin lng rt khc nhau, ngi ta chia ra:
- Nhng ung th biu m t bo tuyn gip bao gm:
+ Ung th bit ho, tin lng tt nu iu tr ng, bnh d xut hin khi chiu x c t
tui thiu nin hoc nhim nguyn t.
+ Ung th khng bit ho tin lng rt xu.
- Nhng ung th biu m tu, pht trin t t bo C ca tuyn gip.
- C bit c lymphoma hoc ung th ni khc di cn n
1.1. Ung th tuyn gip bit ho.
T l gp cao, nht l ph n tr, tin lng tt. i khi c kh nng bt gi iode, nhng
him khi l u tit.
1.1.1. K biu m nh (carcinome papillaire)
Chim 50% cc trng hp, gp mi la tui, nhng hay gp tr em v thanh nin trc
40 tui, chiu x vng c l iu kin thun li gy K biu m nh, K lan rng theo ng
bch huyt, c khi bnh c gi ban u t mt hch di cn vng c.
X hnh u bt iode km (vng lnh).
1.1.2. K biu m nang (carcinome folliculaire)
Chim di 25% cc trng hp, hay gp la tui 40-60, di cn bng ng mu n
xng, phi, gan.
X hnh u c th bt iode khng u, im di cn cng c th bt gi iode phng x.
1.1.3. K biu m tu (carcinome medullaire)
Hoc cht m dng bt (struma amyloide), hoc cn nang (parafolliculaire), chim di 5%
cc trng hp, thng gp sau 50 tui, lan rng bng ng mu v ng bch huyt, c
khi phi hp vi cc u khc nh pheochromocytome (Hi chng Sipple), c th c tinh gia
nh.
X hnh u khng bt iode (vng lnh). Chn on da vo nh lng calcitonine huyt tng
tng, nh lng sau kch thch vi pentagatrine thy calcitonine tng rt nhiu. Khng
nguyn biu m phi (ACE) thng tng.
1.2. Ung th tuyn gip khng bit ho
K biu m khng bit ho, chim khong 20% cc trng hp, thng xut hin sau 50 tui,
t mt nt n c lan rt nhanh n vng ln cn, gy triu chng chn p. Din tin nng
nhanh trong vng vi thng.
X hnh thy u khng bt iode (nhn lnh).
S pht trin ca u b tc ng bi nng TSH trong mu, U pht trin nhanh khi TSH tng
v ngc li.
2.Chn on
Triu chng gi K gip:
+ Pht hin mt nt tuyn gip th tch tng dn, hoc mt nt c t lu, gn y
cht tng th tch.
+ Du hiu chn p c quan ln cn (hi chng trung tht).
+ Hch c hoc thng n ln dn, chc, khng au.
+ Siu m gip gip phn bit nang vi khi c.
515
+ X hnh gip: Kt qu tu thuc loi u, nu pht hin nhn lnh cn chc ht xt
nghim t bo hc, hoc sinh thit xt nghim m hc.
3.Tin lng
T l sng cn10 nm khi c iu tr nh sau:
+ 80% i vi K biu m nh.
+ 60% i vi K biu m nang.
+ Vi K biu m khng bit ho tin lng rt xu.
4. iu tr
Phu thut ct tuyn gip mt bn, khi cn khu tr, hoc ct ton phn, bc hch xm ln.
Sau phu thut cho thm iode phng x vi liu iu tr v hormone gip vi liu c ch.
i vi K gip khng bit ho cn phu thut rng, iode phng x liu cao, c th xem xt
ho tr liu tm thi.
i vi K biu m tu, sau khi phu thut ton b tuyn gip, nh lng calcitonine gip
pht hin m ung th cn li cha c ly ht.






516
I THO NHT
Mc tiu
1. Nu c sinh l v ADH.
2. Nu c phn loi i tho nht.
3. Nu c bnh hc i tho nht.
4. Nu c nguyn tc iu tr i tho nht
5. Nu c cc loi thuc iu tr i tho nhtt.
Ni dung
I. NH NGHA
i tho nht (TN) l tnh trng bnh l do mt kh nng ti hp thu nc ng thn, hu
qu ca s thiu ADH tng i hoc tuyt i dn n tiu nhiu, ung nhiu, nc tiu c
t trng thp v ung nhiu, bnh c th xy ra do km phng thch ADH (TN trung ng
hoc thn kinh) hoc do thn p ng km vi ADH (TN thn). C khong 50% trng hp
TN khng r nguyn nhn.
II. SINH L
ADH (antidiuretic hormone) c tit ra t vng di i, t n ni cha l thu sau
tuyn yn. ADH tc ng ln s iu ho nc do iu chnh s ti hp thu nc thn.
ADH ngi cn gi l arginine-vasopressin (AVP) l mt polypeptide c 8 acid amin
(octapeptide). ln arginine c thay bng lysine (LVP). ng ch trn ngi LVP cn
c th kch thch tit ACTH.
Vi thm thu huyt tng 280mOsm/kg, ADH o c trong mu l < 2pmol/l (=pg/ml),
ADH s tng ln 10-12pmol/l khi thm thu ca mu t 310mOsm/Kg. Thi gian na i
ca ADH rt ngn: 10-20 pht. ADH b phn hy nhanh chng do enzyme c quan ch ch
yu thn (2/3), s cn li c phn hy gan (1/3).
thm thu huyt tng = (natri mu +kali mu) x 2 + ure mu + glucose mu.
Tt c tnh bng n v mM/l. Tr s bnh thng: 290-300mOsm/kg
1.Tc dng sinh l: Tc dng ch yu ca ADH xy ra thn, ADH lm tit kim nc t do.
Thn lc 120ml nc/pht (hoc 172 lt/24h). Hn 85% nc c ti hp thu bt buc ng
ln gn cng vi Na
+
, nh vy cn 23,5 lt c ti hp thu do vai tr ca ADH.
Thiu ADH tuyt i chc chn s gy mt nc cp nu khng ung . Tuy nhin thc t
cho thy s tiu nhiu do thiu ADH khng vt qu 8-12 lt (1/2 ca lng 23,5 lt l thuc
ADH theo l thuyt).
2. C ch tc dng
ADH tc dng thng qua 2 loi th th V1 v V2:
+ Th th V1 lm co c trn mch mu, kch thch s tng hp prostaglandine v phn hy
glycogne gan. Tc ng ln th th ny lm gia tng phn hy phosphatidylinositol gy
nn s huy ng calci.
+ Th th V2 chu trch nhim ca tc dng vasopressin trn thn. ADH lm tng tnh thm
nc ca lp thng b ng gp. Thiu ADH s ti hp thu nc b gim dn n tiu nhiu.
C ADH th ngc li, tnh thm ca lp thng b tng r, nc c ti hp thu. Tc dng
ny xy ra do ADH gn vi th th V2.
Trn tim mch ADH tc dng ln th th V1 trn cc tiu ng mch ngoi bin lm tng
huyt p. Tuy nhin bn thn ADH li lm chm nhp tim, c ch thn kinh giao cm li lm
gim bt tc dng tng huyt p. D sao tc dng lm tng huyt p c th ni bt khi th tch
mu gim lc ADH huyt tng tng rt cao.
517
V vai tr tc dng ca th th V1, V2 cn c nhiu kin cha thng nht. Ring i vi
th th V2 mi kin u ng khi kch thch lm tng ti hp thu nc.
Vi cc th th V1 c kin cho rng V1 c tc dng lm gim p ng chng bi niu ca
AVP trn thn.
3. iu ha s tit ADH
p lc thm thu v th tch huyt tng l 2 yu t quan trng nht.
- Cc yu t kch thch s tit ADH:
+ Yu t thn kinh thc vt: xc cm, au, vn ng.
+ Cc dc cht: acetylcholine, morphine, nicotine.
+ Sc nng.
+ Cc yu t thm thu: Truyn dung dch u trng, tng p lc thm thu huyt tng,
gim th tch huyt tng.
- Cc yu t c ch s tit ADH:
+ Dc cht: Adrenaline, Alcool.
+ Lnh.
+ Yu t thm thu: Truyn dung dch nhc trng, gim p lc thm thu huyt tng.
+ Tng th tch huyt tng.
III BNH NGUYN I THO NHT
1.TN trung ng (TN thn kinh)
Cc thng tn vng di i tuyn yn gy suy tuyn yn c th l nguyn nhn gy TN,.
cc thng tn vng di i nh u s hu (craniopharygiomas) hoc cc thng tn khc
ca thn kinh trung ng do thm nhim, thng d dn n TN.
TN cng c th do chn thng, hoc do cc phu thut u di i, u tuyn yn.
TN do gia nh, l mt bnh him, do di truyn, xy ra tui nh.
TN v cn thng xut hin cui tui u th, thanh nin v tui trng thnh, bnh cnh
cng thng c s gim s lng si thn kinh cha ADH. C khong 30 -40% cc bnh
nhn c khng th trc tip neuron vng di i tit ADH.
TN do di truyn thng i km vi i tho ng, teo mt, ic, TN vi ri lon men
ca ADH lu thng do gia tng enzyme Vasopressinase xut hin lc mang thai.
2. TN thn
Bnh xut hin do thn khng p ng vi tc dng sinh l ca ADH, trong trng hp ny
ADH trong mu bnh thng hoc gia tng.
Cc bnh thn mn tnh, nht l cc bnh gy tn thng vng ty, v cc ng gp c th dn
n TN do thn.
Cc ri lon in gii: H kali mu, tng Calci mu lm gim kh nng c c nc tiu.
C nhiu loi thuc gp phn lm xut hin bnh TN do thn nh lithium, Demeclocycline,
Methoxyflurane, Amphotericin B, Aminoglycosides, Cysplatin, Rifampiciny.
Trong thai k, mt aminopeptidase t nhau thai lm tng chuyn ho AVP gy thiu AVP
dn n tiu nhiu..
3.Ung nhiu tin pht (thi ung nhiu-potomanie)
Thc cht khng phi bnh TN, bnh nhn ung nhiu do tm l. Lng nc ung c th
nhiu hn c trng hp TN tht s. Bnh thng gp trn mt c a lon thn, bnh xut
hin t t sau mt sang chn tm l. Phn bit vi TN da trn nghim php nhn kht.
518
IV. TRIU CHNG LM SNG
Cc triu chng lm sng ca TN c th xut hin t ngt, tin trin nhanh chng vi 2
triu chng tiu nhiu v ung nhiu.
1. Tiu nhiu
L triu chng chnh ca TN, lng nc tiu t 5 -10l/ ngy, c khi ln n 15 -20l/ ngy,
c khi t hn nhng c bit nc tiu long nh nc l.
2. Kht v ung nhiu
Lun lun i km vi tiu nhiu vi 3 c im kht nhiu, khng ngng, khng ht kht.
S kht nc nh thc bnh nhn dy trong m.
Ton trng bnh nhn vn tt, tr trng hp TN km s thng tn lm ph hy vng
di i - tuyn yn.
Nu bnh nhn khng th ung c (v d hn m v chn thng s no, thuc m...) c th
dn n t vong.
Cc trng hp chn thng s no hoc phu thut u c th lm xut hin bnh cnh
ny, cn theo di lng nc tiu, nng huyt tng v nc tiu bnh nhn c hn m
gip ngn nga thiu nc trm trng, do TN khng c chn on.
Rt him khi TN km ph hy trung tm kht, lm trm trng nhanh chng bnh cnh dn
n t vong.
Cc trng hp hp niu o km gy thn nc cng rt him.
V. DU SINH HC
1. Cc xt nghim thng quy
- T trng nc tiu sng sm lc i < 1,005.
- p lc thm thu nc tiu 200 mOsm/kg nc.
Nu bnh vn ung y , thng cc xt nghim sinh hc t ra vn bnh thng nh:
- Cng thc mu bnh thng, c th c mt thiu mu nh do long mu.
- in gii hon ton bnh thng (mu)
- in gii niu /24h bnh thng
Chn on xc nh phi da trn cc test ng, cc test ny va chn on ngun gc ri
lon va phn bit mt TN vi mt ung nhiu do tm l (potomanie)
2. Cc test ng hc:
bnh nhn TN, cc test ng hc nhm mt mt nh gi s hn ch nc c kch thch
tit ADH khng, mt khc nh gi s lng hormone c tit ra lm gim TN.
2.1 Nghim php nhn kht:
Cn thc hin bnh vin v tai bin nguy him c th xy ra.
Mc ch xem ADH c kh nng bi tit hay khng.
- Cho bnh nhn i tiu ht nc tiu, cn bnh nhn ri nm ngh.
- Ly mch, HA mi 15 pht, nc tiu mi 30 pht. Tip tc theo di chng no m bnh
nhn cn chu ng c, khng kh chu.
- Cc triu chng bo ng l: lo lng, cc du khi u ca mt nc nh kh nim mc,
kht nhiu, mch nhanh, nht l HA h. Phi ngng nghim php khi cn nng gim n 3%
trng lng c th.
Kt qu
ngi bnh thng:
519
Lng nc tiu gim < 5ml/ pht
T trng nc tiu (1,020 tng dn.
bnh nhn TN:
Lng nc tiu ln hn 5ml/ pht
Nng thm thu nc tiu < 200 mosm/kg H
2
O
T trng 1,001 - 1,005
2.2. Cc nghim php kch thch tit ADH
C in c test ca Carter v Robbins hoc test ci tin ca J. Deccourt hoc test nicotine,
mc ch nhm kch thch tit ADH di tc ng ca chuyn dch mui.
Cc test hin nay t dng. Hoc test chuyn dch mui u trng ng thi nh lng ADH.
TN ADH s khng tng (Robertson 1980).
Ni chung cc test ny hin nay t dng.
3. Cc test c bit va chn on va thm d iu tr
3.1 Test Chlorothiazide
Bnh thng Chlorothiazide l mt thuc li tiu lm mt NaCl. bnh nhn TN, ung
Chlorothiazide li lm gim tiu mt cch mu thun m khng lm m tnh thanh thi
nc t do. C ch cha c hiu r. C gi thuyt cho rng TN ci thin do s mt mui
ca thuc. Test ny ngy cng t dng.
3.2 Cc test iu tr c hiu
Chlorpropamide lm tng cng hot ng ca ADH ng thn.
Clofibrate v Carbamazepine c tc dng kch thch vng di i tng tit ADH. Ngi ta
o thi nc t do trong 24 gi hoc trong cc mu nc tiu ly t 3 thi k (8-14 gi, 14
gi - 19 gi, 19 gi - 8 gi) thuc s lm gim lng nc tiu, v nht l tng c c nc
tiu.
Nu thanh thi nc t do tr v m tnh mi c php kt lun thuc c tc dng tt.
Cc test ny c v tr quan trng trong vic la chn iu tr lu di sau ny cho bnh nhn.
3.3 Dng tinh cht thy sau tuyn yn:
Nhm phn bit TN do thiu ADH v TN do thn. Pitressin 5/1000/v (5 milliunits)
truyn tnh mch chm trong mt gi hoc 5 n v vasopressin tannate du tim bp s lm
gim TN do thiu ADH, nhng khng gim nu TN do thn khng tc dng ca ADH.
4. nh lng ADH bng min dch hunh quang
Nng c th bnh thng nhng khng gia tng trong nghim php nhn nc, test tng
mui.
TN do thn, nng ADH cn bn tng cao.
VI. IU TR
1. Thuc iu tr c cu trc ging AVP
1.1.Desmopressine (DDAVP)
1.1.1.Bit dc
Minirin
1.1.2.Trnh by
Thuc c trnh by di 2 dng: Dng xt mi, l cha 2,5ml. Dng chch, 4g/ml. Bo
qun +2
o
n +8
o
C.
1.1.3. Ch inh
520
y l thuc c chn la u tin trong iu tr bnh i tho nht trung ng. Ring dng
chch ch nh cho bnh nhn i tho nht trung ng nhng bnh nhn khng th dng dng
xt do kh chu hoc i tho nht sau phu thut thn kinh hoc sau chn thng.
1.1.4.Dc ng hc
Desmopressine c cu trc ging ADH t nhin. Tuy nhin so vi ADH t nhin
desmopressine c tc dng chng li s tiu tin (tc dng ln th th V2) mnh hn v ko
di lu hn, nhng cc tc dng khc ln th th V1 li t hn AVP. Sau khi chch liu 1-4g
TM ch 15-30 pht sau l c tc dng gim tiu, tc dng ko di 5-20 gi tu theo liu
lng. Vi liu cao hn (0,3-0,4g/kg cn nng) thuc c tc dng lm tng yu t VIII v
yu t von Willebrand gp 3-4 ln nng cn bn. Vi liu 0,4g/kg cn nng, thuc c tc
dng gin mch, mt ng , huyt p tm trng st v nhp tim gia tng thong qua. Bng
ng xt mi thuc ch cn cho 2 ln/ngy l .
1.1.5.Liu lng
Vi dng xt mi: Ngi ln 0,1-0,2ml (10-20g). Tr em 0,05-0,1ml (5-10g) ngy 1-2 ln.
Thng thng mi l Minirin cha 25 ln xt, mi ln xt cha 0,1ml tc l 10 g
desmopressine.
Vi dng chch: c th chch TM, bp hoc di da 1-2ln/ngy. Ngi ln: 1-4g
(0,25-1ml). Tr em trn 1 tui: 0,4-1g (0,10-0,25ml). Tr em t 1 tui tr xung: 0,2-0,4 g
(0,05-0,10ml).
1.1.6. Chng ch nh
Nhy cm vi cc thnh phn ca thuc s dng.
Mang thai, cho con b.
1.1.7. Tng tc thuc
D thuc t tc dng ln th th V1, khng nh hng nhiu ln tim mch, tuy nhin khi dng
ng thi vi cc thuc vn mch khc cng cn thn trng.
Tc dng chng tiu tin c th thay i khi dng chung cc thuc khc:
- Clofibrate, indometacine, carbamazepine, chlorpropamid: tng tc dng chng tiu
tin.
- Glibenclamide: gim tc dng chng tiu tin.
1.2. Lypressine
1.2.1. Bit dc, trnh by, dc ng hc
Diapid, trnh by di dng dung dch xt mi. L 12ml. Bo qun +2
o
n +15
o
. Thuc
tng hp c cu trc ging AVP c tc dng kch thch s ti hp thu nc phn xa ca ng
thn.
1.2.2. Ch nh
iu tr i tho nht do thiu ADH do bt k nguyn nhn no.
1.2.3. Liu lng,chng ch nh
Mt xt cho mi l mi, 3-6 ln/ngy, phi cch nhau t nht 4 gi gia cc ln xt (Mi xt
phng thch 0,12ml dung dch tc l 6/v lypressine. Mi l xt c 100 ln). Khng dng
cho ngi suy mch vnh, mn cm vi thuc, gy m vi hallogen, ph n mang thai, cho
con b.
2. Cc loi thuc ung
2.1. Chlorpropamide
2.1.1.Bit dc, trnh by, dc ng hc
521
Dabinese (Pfizer), Diabetoral (Boehring Mannheim), Chloronase (Hoechst) trnh by di
dng vin nn, hm lng 250mg/vin. Thuc thuc nhm sulfonylurease th h I lm h
glucose huyt, ring i vi i tho nht, liu lng 250-500mg/ngy thuc lm tng
thm thu ca nc tiu v lm gim s tiu tin 25-75% trn cc bnh nhn TN nng. tuy
nhin thi gian cn thuc c tc dng gim tiu rt thay i. Thuc c tc dng tng cng
hot ng ca ADH trn ng thn. Tc dng ph quan trng l h glucose mu.
2.1.2. Ch nh
i tho ng Typ 2, TN trung ng, c th dng phi hp vi DDAVP, TN thn.
2.1.3.Liu lng, chng ch nh
250-500mg/ngy. Chng ch nh trong trng hp suy gan, suy thn hoc suy gip
nng, tin s d ng vi sulfamide, ph n c thai, cho con b.
2.2. Clofibrate
2.2.1. Bit dc, trnh by, dc ng hc
Lipavlon (ICI; Avlon), Atromid (ICI), Clofibral (Negma), Normolipol (Delagrange)...Trnh
by di dng vin, hm lng 500mg. Thuc c bit ch yu dng trong iu tr tng
VLDL, LDL cholesterol, triglyceride, ngoi ra thuc cng c tc dng lm gim tiu nh
chlorpropamide nhng yu hn, c ch tc dng cha hon ton r, thuc khng c tc dng
trn bnh TN do thn. chng minh c thuc lm tng tit AVP. Tc dng ph gy au
c, yu, tng men ca c.
2.2.2. Ch nh
Tng cholesterol, tng triglyceride mu, TN trung ng
2.2.3. Liu lng, chng ch nh
500mg 3-4 vin/ngy. Chng ch nh: suy gan, suy thn
2.3. Carbamazepine
2.3.1. Bit dc, trnh by, dc ng hc
Tgrtol hoc Tegretal (Ciba-Geigy), Biston (Spofa, Tchcoslovaquie), Sirtal (Labaz). Trnh
by di dng vin, hm lng 200mg. Ch nh ch yu ca thuc l: ng kinh, au dy
thn kinh tam thoa, ngoi ra thuc cng c tc dng gp phn lm gim tiu, c ch cha
hon ton r, thuc kch thch tit ADH. Tc dng ph quan trng l c ch tu xng.
2.3.2. Ch nh
i tho nht trung ng, ng kinh, au dy thn kinh tam thoa. Do thuc c nhiu tc dng
ph v vy thuc ch nn ch nh khi cc thuc khc khng dng c.
2.3.3. Liu lng, chng ch nh
100-200mg hai ln mi ngy. Chng ch nh: D ng vi thuc, mang thai (nht l 3 thng
u), suy gan, ri lon to mu, bnh tng nhn p, ong nc tiu, cc ri lon v tim
mch.
2.4. Hydrochlorothiazide
2.4.1. Bit dc, trnh by, dc ng hc, ch nh
Dichlotride (Merck, Sharp, Dohm), Esidrex (Ciba-Geigy)...Trnh by vin 25mg. Thuc
thng c dng gip tng thi mui v nc nhng trng hp ch nh thng thng
nh ph, tng huyt p, suy tim... tuy nhin thuc c tc dng gim tiu mt cch nghch l
tt c nhng trng hp TN, tc dng ny xt hin th pht sau khi nc tiu b long
nhnh ln ca quai Henle, cng nh th pht sau khi th tch gim nh ng ln xa. Vi
liu lng tiu chun, thuc lm gim 30-50% lng nctiu tt c cc th TN, do
thuc rt hu ch khi dng h tr vi cc thuc ung khc trong iu tr TN trung ng
cng nh TN do thn
522
2.4.2. Liu lng, chng ch nh
1-5mg/kg/ngy. Khng dng thuc khi suy thn nng, ph n mang thai, cho con b, d ng
vi sulffamide, bnh gout mn, h Natri, k Kali mu.
3. Mt s nguyn tc trong iu tr
3.1. Gio dc, theo di
Gio dc bnh nhn ch ung nc khi tht s kht. Theo di thy Natri huyt tng <
130mEq/l xut hin 2 ln xt nghim chng t ung qu nhu cu tht.
3.2. Thi gian ca liu trnh
i vi TN trung ng trong phn ln cc trng hp phi iu tr sut i, ngay c nhng
trng hp nguyn nhn gy bnh c loi b, mt s rt t cc trng hp bnh c ci
thin n mc ngng iu tr, thng khng phi do AVP hi phc s tng tit m c th do
cc yu t khc nng hn nh suy thng thn, tit AVP lc ch t u c tnh, tnh trng mt
nc trm trng do ri lon c ch kht nc. Tuy nhin c nhng bo co bnh hi phc
do mi nm nn th ngng iu tr vi ngy nh gi s hi phc.
3.3. Tch cc tm nguyn nhn
Cn tch cc tm hiu nguyn nhn gy bnh bng nhiu phng tin v chn on hnh nh
hc, cc xt nghim dch no tu cng nh nhng thm d v ni tit vng di i, thu
trc tuyn yn ngay c khi hnh nh h yn bnh thng.
3.4. i tho nht ngi mang thai
Thuc duy nht c dng l DDAVP, liu dng thng cao hn mt t so vi bnh nhn
TN khng mang thai do nhau thai sn xut vasopressinase, Trong thai k chp nhn natri
mu thp hn 5mEq/l so vi ngi TN khng mang thai. DDAVP khng c tc dng ln co
c t cung. Thai k khng c dng cc thuc ung iu tr TN do kh nng gy qui thai.
3.5. Ung nhiu tin pht
iu tr ch yu gio dc bnh nhn. Thuc an thn kinh khng hiu qu i vi ung nhiu
do tm l. Hn ch ung cng lm bnh ci thin nhng kh thc hin, thc t vi nhng
bnh nhn ny cng hn ch ung, cng lm kht nhiu hn.
Dng DDAVP lm tiu t li nhng khng tc ng g trn tnh trng ung nhiu do tm l,
bnh nhn vn tip tc ung, do lun lun dn n ng c nc, hi hn l li, biu hin
trong 24-48 gi vi h Natri mu, nhc u, chng mt, lo lng, bun nn, nn, ln ln, co
git, hn m, ngay c t vong. Cn chn on chnh xc trc khi quyt nh iu tr. Nu
cn, thuc cng c th cho vo lc i ng, cn cn nhc k liu lng sao cho thuc khng
ko di tc dng n ngy hm sau, l lc bnh nhn li ung nhiu c th gy ng c
nc.

523
SUY THU TRC TUYN YN
Mc tiu
1. Trnh by s lc chc nng ca tuyn yn
2. Nm c cc nguyn nhn suy thy trc tuyn yn
3. Triu chng lm sng ca suy thy trc tuyn yn
4. Trnh by cc triu chng cn lm sng ca suy thy trc tuyn yn
Ni dung
I. I CNG
Tuyn yn l tuyn quan trng iu chnh s hot ng ca cc tuyn ni tit khc gi l
tuyn tip nhn gm tuyn thng thn, tuyn gip, tuyn sinh dc, tuyn v...
Mc khc tuyn yn c iu ha hot ng bi vng di i.
Mt s tha hoc thiu hormon tuyn yn s biu hin lm sng hc bng s tng hay gim
hot ng ca cc tuyn , y l hin tng Feed- Back. Tuyn yn c hai thy chnh, thy
trc v thy sau:
1. Thy trc: C 3 nhim v
1.1. iu chnh s pht trin c th: do STH (Somathormone, Somatotropine, Somatotrope,
hoc GH: Growth hormone) tit ra t t bo a acide. S tit STH cng c iu ha bi
cht trung gian Somatomdine hoc IGF-1 l cht c tit ra t gan, rut, ty.
1.2. iu chnh s hot ng ca cc tuyn ch: nh
- TSH: iu chnh hot ng tuyn ca tuyn gip (thyreotrope).
- ACTH: do t bo a base tit ra, iu chnh hot ng tuyn thng thn (corticotrope).
- Hormon sinh dc: LH, FSH (gonadotrope)
FSH: Follicule stimulating hormone, nam, ph trch s pht trin tinh hon, ng sinh tinh
v sn xut tinh trng. n, FSH kch thch nang trng (De Graaf) pht trin.
LH: Lutotrophin Hormone, nam, c tc dng dinh dng t bo Leydig, kch thch bi tit
testostrone. n, LH phi hp vi FSH lm nang De Graaf chn v ch tit estrogene, LH
c tc dng lm rng trng v to hong th, ch tit progestrone v estrogne.
- Hormon tit sa: PRL (lactotrope): PRL c tit gia tng khi khi c thai, cho con b, c
stress, T PRL n tng cao hn nam gn 50%. S iu ha tit PRL ch yu l do nh
hng km hm ca Dopamin. Mt s thuc i khng dopaminergique thng c dng
nh thuc tm thn, thuc bng d dy rut cng gy tng tit PRL quan trng.
Bnh thng: PRL < 25 ng/ml n., < 18ng/ml nam.
1.3. Tc dng n chuyn ha c bn nht l chuyn ha ng.
2. Thy sau
Cha ng hormon ADH (Vasopressin, Oxytocin), ADH c tit ra t vng di i
(hypothalamus).
II. NGUYN NHN: Suy tuyn yn: c th do nhiu nguyn nhn.
1. Pht trin /Cu trc
- Tn thng yu t chuyn vn
- Lon sn/bt sn tuyn yn
- Khi thn kinh s no bm sinh, encephalocele
- Rng tuyn yn tin pht
524
- Ri lon hypothalamus bm sinh (lon sn vch ngn-th, hi chng Prader-Willi, h/c
Laurence-Moon-Biedl, h/c Kallmann).
2. Chn thng.
- Phu thut ct lc
- Chiu tia x
- Thng tn u
3. Khi u
- Adenome tuyn yn
- U ngoi tuyn yn (meningioma, germinoma, ependymoma, glioma)
- Nang Rathke
- U sn s hu (craniopharyngiome),
- Hypothalamic hamarthoma, gangliocystoma
- Lymphoma, leukemia
- Meningioma
4. Thm nhim/Vim
- Hemochromatosis
- Vim tuyn yn t bo lympho
- Sarcoidosis
- Histiocytosis X.
- Vim tuyn yn dng ht
5. Tn thng mch mu
- Thiu mu tuyn yn
- Lin quan n thai nghn: nhi mu trong T, hoi t tuyn yn sau sinh (Sheehan).
- Bnh t bo Sickle
- Vim ng mch
6. Nhim trng
- Nm: histoplasmosis
- K sinh trng: Toxoplasmosis
- Lao.
- Pneumocystis carinii
III. LM SNG
1. Lm sng suy thy trc tuyn yn
Ngc li vi cng chc nng tin pht ca tin yn, thng thng l cng mt loi
hormon, trong suy tin yn thng thng l suy ton th. Biu hin lm sng u th l ri
lon tng trng, dy th, ri lon chc nng sinh dc. Ni chung biu hin lm sng ca suy
tin yn ph thuc vo loi hormone tuyn yn b thiu hoc khng c.
Thiu GH l nguyn nhn lm gim s pht trin c th.
Thiu Gonadotropin nguyn nhn ca ri lon kinh nguyt v v sinh n b v gim chc
nng sinh dc v mt dc tnh th pht nam gii.
Thiu TSH v ACTH thng pht trin sau mt tin trnh suy tuyn yn. Thiu TSH tr em
s lm chm pht trin, v c biu hin suy gip c tr em v ngi ln. Thiu ACTH s
a n suy tuyn thng thn
Thiu PRL gim tit sa.
525
Sau y l cc biu hin lm sng ca suy thy trc tuyn yn
1.1. Bnh nhi tnh
Tn ti ngi ln tui, cc triu chng tinh thn v tnh dc ca tr em, chiu cao ca ngi
bnh ph thuc vo tui ca h vo lc b suy tuyn yn. Nu pht sinh lc nh, bnh nhn s
ln, nu pht sinh tui thnh nin, chiu cao gn bnh thng hoc bnh thng.
1.2. Hi chng ph sinh dc
- Bo ph mt trc c, gy khng b.
- Mp ngc, bng v cc gc chi.
- Da mn v mm.
- Sinh dc: tr chm hoc khng pht trin th lc, thiu nin khng dy th, ngi ln,
n b mt kinh, rng lng, v sinh. n ng lit dng, b phn sinh dc tr con, b phn
sinh dc ph n t pht trin.
- Triu chng do u chn.
1.3. Bnh Simonds
-Nguyn nhn: do suy ton b tuyn yn, ch yu l do suy thy trc. Hi chng suy nhiu
tuyn do gim hormon thy trc tuyn yn
-Lm sng
+ Du chc nng: suy nhc, mi mt, thng bui chiu mt nhiu hn bui sng). Ri lon
sinh dc. Thu (lipothymie) do gim HA v gim ng mu
+ Du thc th: xanh; teo da v phn ph thuc; gim tnh cht sinh dc (lit dng, mt
kinh, mn kinh khng c phng mt); gim HA. Du hiu do u tuyn yn chn: nhc u,
nhc sau hc mt, gii hn th trng
- Cn lm sng
+ CTM: thiu mu; Glucose mu gim; Na
+
mu gim, K
+
mu tng
+ Suy thyrotrope: T3, T4 gim, TSH cc nhy gim (hoc bnh thng)
+ Suy gonadotrope: Testostrone, Oestradiol gim, FSH, LH gim
+ Suy corticotrope: Cortisone, ACTH gim, test Synacthene (ACTH) dng tnh
+ Xt nghim phn bit suy vng di i (hypothalamus) hay suy ti tuyn yn: Test TRH,
Test LH-RH, LVP, dng tnh nu nguyn nhn suy ti hypothalamus, m tnh nu nguyn
nhn ti tuyn yn.
+ o PRL huyt tng.
+ Test TRH: tim TM 200 - 400 g TRH, ri o PRL thi im 0, 30, 60, 120.
Kt qu bnh thng: PRL tng < 60 ng/ml n.
< 80 ng/ml nam.
1.4. Sheehan: hoi t tuyn yn sau sinh, triu chng nh hn rt nhiu. Khi u triu chng
ny rt nhanh sau sinh, du bo hiu l khng chy sa, lng mu khng mc (sau khi co),
hoc rng, khng c kinh tr li, khng phng mt, khng ra m hi. Cc triu chng y
thng xut hin sau mt thi gian di vi teo da, mt mu da, suy nhc vi tt c du
chng suy tin yn.
1.5. Cn lm sng
Chn on sinh ho ca suy tuyn yn cho thy cc hormone u mc thp. V d FT4 thp
vi TSH thp gi l suy gip th pht. Tng t testosterone thp m khng c gia tng
gonadotropin gi gim nng tuyn sinh dc do suy tuyn yn gim tit gonadotrophin.
526
Bng 1: Tt chn on suy tuyn yn
Hormon Tt Mu mu Din gii kt qu
GH Tt dung np insulin: iu
ho insulin
(0,05-0,15 U/kg TM)

GHRH tt: 1 g/kg TM

Tt L-Arginin 30 g TM trn
30 pht

Tt L-Dopa 500 mg ung
- o Glucose, GH:
-30, 0, 30, 60, 120 pht


- o GH: 0, 15, 30, 45,
60, 120 pht
- o GH: 0, 30, 60, 120
pht

- o GH: 0, 30, 60, 120
pht
Glucose <40 mg/dl
GH >3g/L


-p ng bnh thng nu
GH >3 g/L
-p ng bnh thng nu
GH >3 g/L

-p ng bnh thng nu
GH >3 g/L
Prolactin Tt TRH: 200-500 g TM o TSH v PRL Prolactin BT >2 g/L v
tng khi Prolactin > 200%
liu c bn
ACTH Tt dung np Insulin:
Insulin thng 0,05-0,15
U/kg TM

Tt CRH: 1 g/kg TM lc 8
g


Tt Metyrapone:
Metyrapone 30 mg/kg lc
na m

Tt kch thch ACTH:
ACTH 1-24 (Cosyntropin)
0,25 mg TB hay TM

Tt ACTH liu thp:
ACTH 1-24 (Cosyntropin) 1
mg TM.

Tt kch thch ACTH trong 3
ngy: 0,25 mg ACTH 1-24
(Cosyntropin) TM mi 8
gi/ngy
o glucose v cortisol
-30, 0, 30, 60, 90 ph


o ACTH v cortisol:
0, 15, 30, 60, 90



o 11-deoxycortisol v
cortisol lc 8 gi

o cortisol v
aldosterone 0, 30, 60


o cortisol 0, 30, 60




Glucose <40 mg/dl
Cortisol tng >7-20g/dl


-ACTH c bn tng 2-4 ln
v t ti a 20-100pg/ml
Cortisol >20-25 g/dl

-Cortisol HT < 4 g/dl n
p ng y

p ng cortisol BT
>21g/dl, v p ng
aldosterone >4 ng/dl trn c
bn
Cortisol >21 g/dl


Cortisol >21 g/dl

TSH o FT3,F T4, TSH

Tt TRH: 200-500 g TM
Tt c bn

o TSH, PRL: 0, 20,
60
FT3, F T4, TSH thp

TSH tng >5 mU/l, tr phi
hormon gip gia tng
LH, FSH LH, FSH, testosterone,
estrogen
Tt c bn

LH, FSH tng ph n mn
kinh.
527


Tt GnRH:
GnRH 100 g TM


o LH, FSH 0,30, 60
Testosteron thp khi Lh,
FSH thp.
Phn ln ngi trng
thnh, LH tng n 10 IU/l
V LH tng 2 IU/L. p ng
BT l thay i

Nhiu loi
hormon
Tt kt hp tin tuyn yn:
GHRH (1 g/kg)
CRH (1 g/kg), GnRH (100
g), TRH (200 g)
o GH, ACTH, cortisol
LH, FSH, TSH -30, 0,
15, 30, 60, 90, 120
p ng phng thch
hormone ring r hay kt hp
phi tng
2. Hi chng suy thy sau
2.1. Nguyn nhn: Do thiu ADH (do vim tuyn yn t min) hoc do tn thng vng di
i-tuyn yn.
2.2. Biu hin lm sng: l bnh i tho nht
- Triu chng lm sng: xy ra thng t ngt
+ Tiu nhiu: th tch nc tiu 8-10 lt/24 gi. Trong vi trng hp, tiu nhiu c th t ti
15-20 lt hoc khng nhiu lm, nhng hnh thi nc tiu rt c th: nht ging nh nc
la.
+ Ung nhiu: ung nhiu xy ra sau khi tiu nhiu, b s lng nc mt i do tiu
nhiu. Nu khng ung nc, bnh nhn rt kh chu, c khi c hin tng mt nc cp: st
cao, kh th, bun nn, nn, c khi m sng, v th ung nhiu trong TN c 3 c tnh c
th: khng nhn c, ung khng thy chn v ung lin tc. Ung c ngy ln m, bnh
nhn phi thc dy v kht.
Nu c gng khng ung nc vn i i nhiu, nhng li chu nh hng ca tinh cht hu
no thy, tim tinh cht thy sau tuyn yn, s gim s lng nc tiu (test iu tr bng
ADH) hoc bng dDAVP.
Thng khng nh hng th trng nhiu
+ Cc triu chng khc: mch tng nhanh, huyt p h
2.3. Cn lm sng:
+ Nng thm thu nc tiu thp < 200mosm/l
+ thm thu huyt tng tng
+ Na
+
mu tng (> 142mM/l)
+ ADH huyt tng thp
+ T trng nc tiu thp < 1,005
+ Protein niu (-), Glucose niu (-)
+ Test dDAVP: Tim tnh mch 4p hay 2p dDAVP (p < 50kg) mi 2 gi, theo di mch,
HA, th tch nc tiu, thm thu nc tiu. Nu th tch nc tiu gim v thm thu
nc tiu tng, .T.N. trung ng hoc di i
+ Test hn ch nc
Nu th tch nc tiu gim v thm thu nc tiu tng: ung nhiu tin pht.
Nu th tch nc tiu v thm thu niu khng thay i i tho nht do ADH, sau
tim dDA.V.P, nu th tch niu v thm thu khng thay i th .T.N. do thn.
528
CN LM SNG B SUNG
- XQ s no xem h yn: Hc xng hm v trn rng ra, s dy, khng u, nht l phn
ngoi. H yn c th rng ra, hoc su hn, cc ng vch khng r, mm gc yn b mng
i, c hnh mm chim.
- Scanner s no.
- o STH (GH) trong 24 gi hoc ngy hoc m mi 20 - 60 pht (v STH c tit ra theo
nhp iu ngy m.
+ o STH niu /24 gi.
+ Somatomdine, hoc IGF huyt tng..
+ o STH trong khi lm Test hm bng cch cho ung ng (HGPO),
Bnh thng STH hoc GH cn bn l < 5ng/ml, sau nghim php dung np glucose ung,
STH < 2ng/ml, nu l bnh to cc vin cc, th test hm suy yu 2 ng/ml.
+ Khm th trng: c gii hn th trng.

529
TNG HOT V THNG THN
Mc tiu
1. Trnh by c cc xt nghim chn on hi chng Cushing.
2. Nu c 5 nguyn nhn chnh ca cng aldosteron nguyn pht.
3. M t c cc xt nghim tm sot v xt nghim chn on cng aldosteron nguyn
pht.
4. M t c cc biu hin lm sng ca cng v thng thn sinh dc theo la tui.
5. Nu c phng php iu tr cc th tng hot v thng thn: bnh Cushing, cng
aldosteron nguyn pht, cng v thng thn sinh dc
Ni dung
I. HI CHNG CUSHING
S gia tng mn tnh hormon glucocorticoid do nhiu nguyn nhn khc nhau gy ra hi
chng Cushing. Nguyn nhn thng gp nht ca hi chng Cushing l do thuc. Cc
nguyn nhn khc l do ri lon tuyn yn, thng thn hoc do s tit ACTH lc ch.
Danh t bnh Cushing ch hi chng Cushing do tuyn yn tng tit ACTH.
1. Sinh l bnh
1.1. Bnh Cushing
S tng tit ACTH xy ra tng t ngu nhin gy ra s tng tit cortisol khng cn tun theo
nhp iu trong ngy. 90% trng hp bnh Cushing gy ra do u tuyn ca tuyn yn.
S tit ACTH khng th b c ch c bi nng glucocorticoid sinh l, v th d nng
glucocorticoid tng cao, ACTH vn tit ra a n s tng tit glucocorticod mn tnh, nng
ACTH cao c ngy ln m, tng t.
Ngoi ACTH, u cn c th tng tit LPH, endorphin. S tit ACTH v cortisol khng
tng thm khi c stress. Nng cortisol tng cao cng nh hng n s tit TSH, GH v
gonadotropin v gy ra nhng triu chng ton thn.
Trong bnh Cushing cng c c s tng tit androgen t tuyn thng thn, DHEA, DHEA
sulfat, androstenedion cng tng v c chuyn thnh dihydrotestosteron m ngoi vi gy
cc biu hin nam ha ph n.
1.2. Hi chng tit ACTH lc ch
Do u khng thuc tuyn yn tng hp v tit ra cc cht ACTH c c tnh sinh hc, cng c
u tit LPH, endorphin v c ACTH khng c hot tnh, c th u tit ACTH v tit CRH
hot tnh khng r. Cc u thng gy tit ACTH lc ch l: ung th biu m t bo nh
phi, u carcinoid phi, u tuyn c, rut, ty, bung trng, u ty thng thn.
S tit ACTH v cortisol trong trng hp ny thng cao hn trong bnh Cushing nhiu v
cng lin tc hn, tuy nhin cc triu chng in hnh ca hi chng Cushing li t gp v s
tng tit cortisol xy ra nhanh v bnh nhn km n, ngoi ra cn c cc biu hin khc ca
bnh c tnh.
1.3. U tuyn thng thn
U tuyn thng thn tng tit cortisol t pht, tuyn yn s b c ch v s tit ACTH gim,
do phn tuyn thng thn bnh thng bn cn li s teo. Cc nghim php gy nh
hng ln trc h khu no-tuyn yn nh c ch bng dexamethason liu cao hoc
metyparon u khng gy p ng g trn u tuyn thng thn.
U tuyn ca tuyn thng thn thng ch tit cortisol.
Ung th biu m tuyn thng thn tit nhiu loi hormon thng thn v c tin cht ca n.
2. Lm sng
530
Cc triu chng c m t y phn Triu chng hc Hi chng tng v gim hot
v thng thn: mp ph trung tm, thay i da (da teo, mng, d bm mu, vt nt da),
rm lng, tng huyt p, ri lon sinh dc, ri lon thn kinh tm l, yu c, long xng, si
thn, kht v tiu nhiu.
3. Cn lm sng
Cc xt nghim chn on hi chng Cushing.
3.1. Nghim php c ch bng Dexamethason qua m kt hp o cortisol trong nc tiu
(nghim php tm sot)
Ung 1mg dexamethason lc 23h, 8h sng hm sau o cortisol mu; ng thi tnh lng
nc tiu 24h v o lng cortisol t do trong . Nu cortisol mu gim di 3g/dL vo 8h
sng hm sau l bnh thng. Nu cortisol mu sng hm sau gim hn 5g/dL rt kh chn
on l hi chng Cushing, nu kt hp thm cortisol t do trong nc tiu bnh thng c
th loi b hi chng Cushing. Nu 2 kt qu bt thng c th chn on hi chng Cushing
sau khi loi cc nguyn nhn lm sai kt qu.
3.2. o cortisol t do trong nc tiu
Bnh thng 90-100 g trong nc tiu 24h. Tng trong hi chng Cushing.
3.3. Kho st s thay i nhp iu trong ngy
Trong hi chng Cushing c s tng tit cortisol c sng ln chiu, tuy nhin kh pht hin
tnh trng ny v c ACTH v cortisol u thng tit thnh tng t. Nu bnh nhn khng
c stress, nng cortisol huyt thanh 7 g/dL lc 24h c xem l c hiu cho hi chng
Cushing.
3.4. Nghim php c ch bng dexamethason liu thp
Ngy u hng nc tiu 24h, o cortisol t do v 17 OH corticosteroid v o cortisol mu
lc 8h. Ngy th hai v th ba cho bnh nhn ung dexamethason 0,5mg mi 6h. Ngy th ba
lng nc tiu 24h, o nh trn; 8h sng ngy th t o cortisol mu.
Bnh thng: 17 OH corticosteroid trong NT 24h < 4mg, cortisol trong NT 24h < 25g,
cortisol mu < 5g/dL.
II. CNG ALDOSTERON NGUYN PHT
1. Nguyn nhn
C 5 th bnh chnh:
- U tuyn tit aldosteron.
- Cng aldosteron v cn.
- Tng sn thng thn nguyn pht 1 bn.
- Cng aldosteron p ng vi glucocorticoid.
- Ung th biu m thng thn tit aldosteron.
2. Lm sng
Triu chng lm sng khng c hiu, bnh nhn nh cm thy yu mt; nng hn gy nhc
u, hi hp, ung nhiu, tiu nhiu, tiu m v d cm. Bnh nhn thng n khm v cc
triu chng ca h kali mu v tng huyt p.
Triu chng thc th: tng huyt p t nh n nng, y mt giai on I, II; gim kali nng
c th c h p t th khng km tim p nhanh v gim cm nhn ca th th p lc. Khi
kim mu nng c th c triu chng nh h calci mu (Chvostek, Trousseau).
3. Cn lm sng
Kali mu gim trong trng hp in hnh, Natri mu hi tng, ri lon dung np glucose.
4. Chn on
531
4.1. Tm sot
Nn tm sot cng aldosteron nguyn pht khi c h kali mu c km tng hyt p, v a s
l tng huyt p khng iu tr.
4.1.1. Kali mu
Trnh n nhiu kali v ngng thuc li tiu t nht 3 tun. 20% bnh nhn c kali mu bnh
thng hoc gii hn thp ca bnh thng.
4.1.2. nh gi h thng renin-angiotensin-aldosteron
o hot tnh renin huyt tng bt k (PRA): gim trong cng aldosteron nguyn pht.
o nng aldosteron trong huyt tng (PAC) lc 8h sng sau t nht 4h nm ngh v n
y mui vo my hm trc.
Nu PAC/PRA > 30 v PAC > 20 ng/mL: cng aldosteron nguyn pht vi nhy 90%,
c hiu 91%.
4.1.3. Nghim php Captopril
Ung 25mg Captopril sng, 2h sau ly mu th, bnh nhn t th ngi.
Bnh thng: PAC gim, PRA tng.
Cng aldosteron nguyn pht: PAC v PRA khng i. PAC/PRA > 50, PAC > 15 ng/dL.
4.2. Xc nh chn on
Dng nghim php c ch aldosteron bng NaCl ung hay truyn tnh mch xc nh
aldosteron trong nc tiu v huyt tng khng b c ch c.
4.2.1. Nghim php c ch bng NaCl ung
n mui liu cao trong 3-4 ngy, b sung KCl 40-200mEq/ngy. Ngy sau cng ly nc
tiu 24h o aldosteron, natri, creatinin. Nu Natri nc tiu > 200mEq/L v aldosteron nc
tiu > 10-14 g th gip chn on xc nh.
4.2.2. Nghim php truyn tnh mch NaCl
Nhn i qua m, nm; truyn tnh mch 2L dung dch NaCl 0,9%. Sau o aldosteron
huyt tng (PAC). Chn on xc nh khi PAC > 10 ng/mL.
III. CNG V THNG THN SINH DC
1. Nguyn nhn
1.1. Cng v thng thn
Tng sn, u tuyn, ung th biu m.
1.2. Tng sn thng thn bm sinh do thiu men
Enzyme hydroxylase P450
C21
, P450
C18
, P450
C17
, P450
C11
.
Men 3 hydroxysteroid dehydrogenase (3 HSD).
2. Lm sng
Triu chng thay i ty theo bnh l khi u t lc cn bo thai, s sinh, tr em hay ngi
ln. Thng ngh n chn on cng v thng thn sinh dc khi c tng huyt p, h kali
mu kt hp vi rm lng, thiu kinh, mn trng c v nam ha.
2.1. nh hng t bo thai
Thai nam: t triu chng, ch c ph i b phn sinh dc.
Thai n: nam ha b phn sinh dc.
2.2. nh hng trn tr nh
Sn tng trng ct ha sm nn tr ngng tng trng chiu cao sm.
B trai: da bu c nhiu np nhn, sm mu.
532
B gi: c triu chng nam ha, rm lng, c bp pht trin; da dy, nhiu m hi, mn trng
c; ging khn; m vt ln.
2.3. nh hng tui dy th
Tr nam: dy th sm, mc lng mu, dng vt ln nhng tinh hon nh, khng c tinh trng
v hot ng phng tinh.
Tr n: v khng pht trin, t cung nh, bung trng nh, khng c kinh.
2.4. nh hng trn ngi ln
Nam gii: khng c triu chng c hiu.
N gii: triu chng thay i t gim n tnh vi kinh tha, t hoc tt kinh. V teo, v sinh
(khng rng trng). Nu nng s c triu chng nam ha: mc ru mp, cm; lng nhiu hn
tay, b phn sinh dc; da nhn, ging khn; m vt ln, mi ln ph i.
3. Cn lm sng
- 17-cetosteroid trong nc tiu 24h tng. Nam > 20mg/24h (bnh thng < 5mg); n > 14
mg/24h (bnh thng < 3mg).
- Dehydroepiandrosteron sulfat trong huyt tng v trong nc tiu tng.
- Testosteron trong huyt tng v trong nc tiu tng.
IV. IU TR
1. Cushing
1.1. iu tr bnh Cushing
1.1.1. Phu tht
Phng php iu tr bnh Cushing tt nht l phu thut. i vi phu thut vin c tay
ngh cao, vi phu thut tuyn yn bng ng tip cn xuyn qua xng bm t thnh
cng n 80%, t vong him, tai bin khong 2%.
1.1.2. X tr
Chiu x vi cc ht nng c t l thnh cng 80% nhng i hi k thut rt cao nn khng
c p dng rng ri. X tr theo kiu c ch thnh cng 15-20%. Trc kia iu tr bnh
Cushing ta hay dng phng php ct b tuyn thng thn 2 bn nhng phng php ny
ch dng khi phng php trn khng thnh cng v n km hiu qu v c th a n hi
chng Nelson (u tuyn ca tuyn yn tng th tch sau khi ct tuyn thng thn 2 bn).
1.1.3. Cc thuc c ch tit cortisol
- Ketoconazol c s dng nhiu, c tc dng trn hu ht bnh nhn, t tc dng ph. Liu
hiu qu 400-500mg/ngy chia 2 ln ung. Thuc c th gy c cho gan nhng t khi nng.
- Metyparon 2g/ngy cng vi Aminoglutethimide 1g/ngy (ung chia 4 ln). Hai thuc ny
t, c th lm ri lon tiu ha v lm tng ACTH sau khi dng lu.
- Mitotan 3-6 g/ngy. p ng chm sau hng tun, hng thng; c th gy bun nn, nn,
tiu chy, bun ng, mn da, suy thng thn.
- Reserpin, Bromocriptin, Cyproheptadin, Valproat natri trc y cng c dng c ch
ACTH nhng ch mt s t bnh nhn p ng.
1.2. U tit ACTH lc ch
iu tr tn gc l ct b u, nu u c tnh v di cn xa khng th m c th dng cc
thuc k trn ngn s gia tng cortisol.
1.3. U tuyn thng thn
Ch yu l phu thut. Trng hp K biu m tuyn thng thn, nu cn st li sau m th
dng Mitotan c ch s tng hp cortisol.
533
2. Cng Aldosteron nguyn pht
2.1. U tuyn tit aldosteron
Ct b thng thn 1 bn ni c u tuyn.
Cn iu tr tnh trng h kali mu trc phu thut bng Spironolacton.
Tt hn l ct b thng thn qua ni soi.
2.2. Tng sn thng thn nguyn pht mt bn
Cng p ng tt vi iu tr phu thut nh trng hp u tuyn.
2.3. Cng aldosteron v cn
Tng huyt p khng gim sau iu tr phu thut tuy h kali mu c th ci thin, do
phng php iu tr thch hp trong trng hp ny l ni khoa:
- n lt < 100 mEq Na
+
mi ngy.
- Gi cn nng l tng, c ru, tp th dc u n.
- Spironolacton: iu tr tng huyt p, liu u 200-300 mg/ngy; gim dn n 100 mg/ngy
khi huyt p v kali mu ci thin.
- Amiloride cng c hiu qu nu bnh nhn khng dung np Spironolacton.
Nu huyt p khng gim sau khi dng liu y , c th dng thm thuc c ch calci, c
ch men chuyn hoc li tiu.
2.4. Cng aldosteron p ng vi corticoid
Glucocorticoid vi thay i liu t liu sinh l n liu dc l c th kim sot c huyt
p v tnh trng h kali. Tuy nhin Spironolacton cng c hiu qu tng t v v lu di an
ton hn glucocorticoid.
2.5. K biu m thng thn tit aldosteron
- iu tr phu thut. Nu sau phu thut cn st li t chc K th iu tr bng Mitotan.
- Nu u tit cortisol c th dng Ketoconazol.
- Nu u tit qa nhiu aldosteron c th dng Spironolacton.
3. Cng v thng thn sinh dc
3.1. K biu m thng thn
Phu thut. Nu khng thc hin c th dng Mitotan.
3.2. Tng sn tuyn thng thn
Hydrocortison liu gp 1-1,5 ln lng hydrocortison tit ra mi ngy (10-13mg) cho mi
mt vung c th. Hoc c th c lng10-26 mg Hydrocortison/ngy; hoc Dexamethason
0,5-1 mg/ngy.
Liu c chnh theo 17-cetosteroid trong nc tiu, DHEA trong huyt tng v nng
cc tin cht ca cortisol.
Nu c triu chng mt mui: Syncortyl 1 mg/kg tim bp hoc liu duy tr 9-
Fluorohydrocortison 25-50g/ngy.
534
CU HI LNG GI
1. Chn on xc nh i tho ng.
2. Chn on phn bit i tho ng typ 1 v typ 2.
3. iu tr i tho ng th 2.
4. Triu chng h Glucose mu.
5. u tr h Glucose mu.
6. Nguyn nhn bo ph.
7. iu tr bo ph.
8. Triu chng lm sng bn Basedow.
9. Triu chng cn lm sng trong bnh Basedow.
10. iu tr Basedow bng thuc.
11. Nguyn nhn v c ch bnh sinh bu gip n.
12. Triu chng lm sang v cn lm sng ca bu gip n.
13. iu tr v d phng bu gip n.
14. Nguyn nhn suy gip.
15. Triu chng lm sng, cn lm sng suy gip.
16. iu tr suy gip.
17. Triu chng ca vim tuyn gip Hashimoto.
18. Lm sng v cn lm sng ung th tuyn gip.
19. Nguyn nhn v c ch bnh sinh ca i tho nht.
20. Triu chng lm sng v cn lm sng ca i tho nht.
21. iu tr i tho nht.
22. Triu chng lm sng ca suy thy trc tuyn yn.
23. iu tr suy thy trc tuyn yn.
24. Lm sng v cn lm sng ca hi chng Cushing.
25. iu tr Cushing.
26. iu tr cng Aldosterone nguyn pht.

535
TI LIU THAM KHO
1. Le gnraliste et le diabtique non insulinodpendant (1995), ditions Frison-Roche.
2. Coeur et diabte (1999), ditions Frison-Roche.
3.G Michael Besser and Michael O Thorner (2002), Comprehensive Clinical Endocrinology,
Third Edition, Mosby.
4. Silvio E. Inzucchi (2005), The diabetes Mellitus Manual, A primary Care Companion to
Ellenberg &Rifkins six Edition, Mc Graw Hill.
5. Francis S (1997), Basic and Clinical Endocrinology, Greenspan 5
th
edition.
6. Harrison's Principles of internal medecine (1998), 14
th
edition.
7. Williams Textbook of Endocrinology (1998), 9
th
edition, Volume 2.
8. Le gnraliste et le diabtique non insulinodpendant (1995), ditions Frison-Roche
9. Nguyn Hi Thu (2000), Chn on v iu tr bnh tuyn gip, NXB Y hc.
10. Mai Th Trch, Nguyn Thy Khu (1999), Ni tit hc i cng, NXB TP H Ch Minh.
11. Endocrinology (2001), 4
th
Edition, W.B. Saunders Company.

536

CHNG 7
TNG QUT

RI LON CN BNG NC IN GII V CN BNG TOAN KIM
Mc tiu
1. Trnh by c cc c ch iu ha ca nc, in gii, toan kim trong c th
2. Chn on v xc nh c nguyn nhn gy tng Natri mu, h Natri mu, tng Kali mu
v h Kali mu.
3. Chn on c cc loi nhim toan, nhim kim chuyn ha, nhim toan, nhim kim h hp
4. Tnh v iu tr c cc ri lon nc in gii thng thng.
5. iu tr c cc ri lon toan kim h hp v chuyn ho.
Ni dung
I. NHC LI SINH L V C CH IU HA CN BNG NC IN GII
1. Phn b nc trong c th
ngi ln bnh thng, tng lng nc chim khong 60 % trng lng c th, trong
40% ni bo v 20% ngoi bo. Trong 20% dch ngoi bo th 15% trong khong k v
5% trong ni mch. Lng nc trong c th n t hn nam v gim dn theo tui. Nng
thm thu gia khoang ni bo v ngoi bo thng bng nhau (khong chng 285 mosmol/l).
Vn chuyn ca nc qua li mng t bo nh vo chnh lch p lc thm thu (osmol), trong
khi vn chuyn nc qua li mng mao mch th ph thuc vo chnh lch p lc thu tnh v p
lc keo. Cc ri lon cn bng nc ni v ngoi bo l hu qu ca s mt cn bng ca Bilan
Natri v /hoc Bilan nc.











S 1: Phn b ca nc trong c th
285 mosmol/l 285 mosmol/l
40% 15% 5%
Ni bao Ngoai bao
Khoang ke
Nimch
mmmm
chmach
Ung
Chuyn
Phi
Da
Tiu hoa
Thn
537

2. Cc c ch iu ho nc in gii, toan kim
C ch ny rt cn thit v i hi s nhy cm, chnh xc m bo tnh n nh ca
ni mi: l iu kin cn thit cho s sng. C s u tin cho s cn bng thm thu so vi
cn bng th tch ni mi. Hai mt iu ha cn bng nc in gii v cn bng toan - kim c
lin h mt thit vi nhau.
2.1. iu ha cn bng thm thu
Ch yu do c ch tit hcmn chng bi niu ADH (Antidiuretic Hormone) v c ch
kht. Kch thch tit ADH l s tng p lc thm thu v s gim th tch mi trng ngoi bo.
Trung tm kht vng di i, ti y c th th p lc thm thu, s gim th tch mi trng
ngoi bo cng kch thch gin tip trung tm kht.
2.2. iu ha th tch mi trng ngoi bo
Th tch mi trng ngoi bo ch yu do Natri quyt nh, do c ch iu ha th tch
mi trng ngoi bo ch yu do iu ha Natri ngoi bo, s iu ha Natri ngoi bo ch yu
qua trung gian Aldostrone v thn.
2.3. iu ha cn bng ion:
Ion Natri c nu trn.
Ion Kali ngoi bo c lin h mt thit vi ion Natri v pH mi trng ngoi bo. Khi
pH gim, Kali i t ni bo ra ngoi bo lm Kali ngoi bo tng v c thi nhiu ra ngoi nu
thn bnh thng, hoc li nu thn b suy, s kim ha mi trng ngoi bo c tc dng
ngc li.
Ion Canxi c iu ha nh hocmn tuyn cn gip (PTH), Vitamin D v lin quan
mt thit vi nng Phospho trong mu.
2.4. iu ha cn bng kim toan
Trong c th c cc h thng m, c kh nng gii hn s thay i ca pH mc
no gi cho pH mu c duy tr trong gii hn bnh thng, trong h m quan trng
nht l h m Bicarbonat:
H
+
+ HCO
3
-
H
2
CO
3
CO
2
+ H
2
O
H m Bicarbonat c vai tr rt ln trong iu ha thng bng kim toan ca c th v
c hai yu t ca h ny c th c iu chnh mt cch d dng: HCO
3
-
bi thn v CO2 bi
phi.
II. MT NC NGOI BO
1. nh ngha
Mt nc ngoi bo l tnh trng gim th tch ca khoang ngoi bo, gm 2 khoang k
v khoang ni mch. Do mt Ion Natri tng ng vi mt nc, cho nn Bilan Natri lun m
tnh. Nu ch mt nc ngoi bo n thun th nng thm thu ngoi bo bnh thng (285
mosmol/l) v th tch ni bo khng i (biu hin bi nng Natri mu bnh thng).
2. Nguyn nhn
2.1. Nguyn nhn mt nc ngoi thn (c trng bi Natri niu < 20 mmol/24 gi)
538

Mt qua ng tiu ho: Nn ma ko di, a chy, l d ng tiu ho, dng thuc
nhun trng,...hoc mt nc qua da, nim mc: m hi, bng din rng.
2.2. Mt nc qua ng thn (Natri niu > 20 mmol/24 gi)
- Bnh l thn: Bnh l thn k, suy thn mn giai on cui vi tit thc hn ch mui nhiu,
suy thn cp giai on tiu nhiu.
- Bnh l ngoi thn: do tc dng li tiu thm thu: i tho ng, truyn nhiu Mannitol, tng
Canxi mu, dng cc thuc li tiu, suy thng thn cp.
2.3. Mt nc vo "khoang th 3"
Do hnh thnh mt khoang dch ngoi bo: vim phc mc, vim tu cp, tc rut, v
hu c vn do chn thng.
3. Sinh l bnh
Mt nc v mt mui theo t l ng trng, cho nn s a n gim th tch dch
ngoi bo m khng c thay i v nng thm thu, khng c thay i th tch dch ni bo
(nng thm thu huyt tng v Natri mu bnh thng).
4. Chn on
Chn on xc nh da vo khm lm sng v cn lm sng:
4.1. Triu chng lm sng
- H huyt p: lc u l h huyt p t th, sau l c khi nm.
- Nhp tim nhanh.
- Sc gim th tch mu khi lng dch mt trn 30%.
- Cc tnh mch nng b xp.
- Thiu niu, v niu.
- Gim cn.
- Du vo da (Casper) dng tnh.
- Da kh, nim mc kh.
- Kht nc: c nhng khng nhiu nh trong mt nc ni bo.
4.2. Triu chng cn lm sng
Khng c xt nghim no phn nh trc tip tnh trng mt nc ca khoang dch k,
thng thy mt nc ng trng khoang ni mch: tng Protid mu (>75g/l), tng
Hematocrite (>50%) v khng c du xut huyt, c th c du suy thn cp chc nng do gim
th tch mu.
4.3. Chn on nguyn nhn
Thng n gin, ph thuc vo tng bi cnh bnh, triu chng lm sng v lng Natri
niu trong 24 gi.
- Mt nc in gii do nguyn nhn ngoi thn:
+ Thiu niu.
539

+ Natri niu < 20 mmol/24 gi.
+ C hin tng c c nc tiu: Ur niu / Ur mu > 10; Creatinine niu / Creatinine
mu > 40; thm thu niu > 500 mosmol / l.
- Mt nc, mui do mt qua ng thn:
+ Lng nc tiu bnh thng hoc tng (>1000 ml/24 gi).
+ Natri niu tng > 20 mmol/ 24 gi.
+ Nc tiu khng b c c: Ur niu / Ur mu < 10; Creatinine niu / Creatinine mu <
20.
III. NC NGOI BO
1. nh ngha
nc ngoi bo l mt s tng th tch dch khoang ngoi bo, c bit l khoang
k, dn n ph ton. nc ngoi bo thng do nc v mui (vi lng tng ng), c
Bilan Natri dng tnh.
2. Nguyn nhn
- Ba nguyn nhn thng gp nht l: suy tim, x gan, hi chng thn h.
- Cc nguyn nhn khc ti thn: vim cu thn cp, suy thn cp, mn.
- Nguyn nhn ngoi thn: suy dinh dng, gin mch ngoi bin nhiu nh trong trng hp c
l d ng tnh mch, c thai, ang iu tr cc thuc gin mch.
3. Sinh l bnh
S vn chuyn ca nc v Natri qua 2 bn mng ca mao mch tun theo qui lut
Startling. Thng thng ph l hu qu ca:
- Gim p lc keo ni mch: gp trong gim Protid mu nng. Nc v Natri i t ni mch ra
khong k s gy gim th tch lng mch.
- Tng p lc thu tnh ni mch: trng hp ny 2 khong k v khoang ni mch u tng th
tch, thng do suy tim hoc 1 tnh trng nc v mui do tn thng thn.
- Phi hp nhiu c ch: suy tim xung huyt, gim th tch mu lm thn tng ti hp thu nc,
mui tng th tch tng mu. Trong x gan: ph l hu qu ca tng p ca, v cng do gin
mch tng.
4. Chn on
Chn on xc nh ch yu da vo lm sng.
- Triu chng lm sng nc ngoi bo:
+ Ph: ph ngoi bin, trng, mm, khng au, du n lm dng tnh, c th trn dch
cc mng (tim- phi - bng) hoc khoang k phi.
+ Cc du chng ca nc lng mch: tng huyt p hoc ph phi cp.
+ Tng cn.
540

- Cn lm sng thng ngho nn: long mu (thiu mu, gim Protid mu), khng hng nh v
khng c triu chng cn lm sng no phn nh c th tch khoang k.
- Chn on nguyn nhn thng n gin bng phn tch bi cnh xut hin v triu chng lm
sng.
IV. MT NC NI BO (TNG NATRI MU)
1. nh ngha
Mt nc ni bo l gim th tch ngoi bo do bilan nc m tnh vi tng nng thm
thu huyt tng > 300 mosmol/l. S tng thm thu ny s lm cho nc t ni bo ra ngoi
bo.
Biu hin ch yu trn xt nghim l tng Natri mu.
Ch : Nng thm thu huyt tng c th c c lng theo cng thc:
P osmol = [Na
+
x 2 ] + Glucose mu = 285 mmol/l.
2. Nguyn nhn
2.1. Mt nc ni bo c tng Natri mu
- Mt nc mt b: mt nc qua da, qua ng h hp, mt qua thn nh trong i tho ng,
dng Mannitol nhiu, mt qua ng tiu ho nh tiu chy, dng thuc nhun trng.
- Cung cp nhiu Natri: trong hi sc, trong thn nhn to.
- Gim cung cp nc: ri lon vng di i tr s sinh, ngi gi, bnh nhn hn m.
2.2. Mt nc ni bo nhng khng tng Natri mu
- Tng thm thu mu th pht do ri lon cc cht c hot tnh thm thu: Glucose, Mannitol,
Ethylene glycol.
- Cc cht khuych tn t do vo t bo nh Ur, Ethanol,... s khng a n ri lon nc ni
bo.
3. Sinh l bnh
- Bilan nc vn c cn bng.
- S kht nc s iu ho lng nc ung vo v hot ng thn m bo n nh thm
thu gia 2 ngn ni v ngoi bo.
- S bi tit ADH c iu ho ch yu bi s thay i nng thm thu huyt tng, bi
th tch lng mch v bi c ch kht. Khi ADH c tit khng y , Bilan nc m tnh to
ra cm gic kht nc.
Chng ta c th gp bilan nc m tnh v tng thm thu mu trong cc trng hp:
- Mt nc qua ng ngoi thn: da nim mc, h hp.
- Mt nc qua thn do thiu ADH hoc do gim nhy cm ca thn i vi ADH.
- Ri lon trung tm kht hoc ri lon cc th th v thm thu vng di i.
4. Chn on
Chn on xc nh
541

- Triu chng lm sng
+ Thn kinh: Khng c hiu, lin quan vi mc tng Natri mu
L m, ng g.
Cm gic mt l.
Ri lon thc dng kch thch.
St.
Co git
Hn m.
Xut huyt no - mng no.
+ Kht: i lc rt d di.
+ Nim mc kh: c bit mt trong ca m.
+ Hi chng ung nhiu, tiu nhiu trong trng hp nguyn nhn do thn.
+ Gim cn.
- Triu chng cn lm sng:
+ Thm thu huyt tng > 300 mmol/l.
+ Natri mu > 145 mmol/l.
V. NC NI BO
1. nh ngha
nc ni bo l tnh trng tng th tch dch ni bo do bilan nc dng tnh phi hp
vi gim thm thu huyt tng, Natri mu gim <135 mmol/l.
2. Nguyn nhn
- Hp thu nc nhiu hn kh nng bi tit: bnh tm thn ung nhiu.
- Bi tit khng thch hp hocmn ADH (SIADH).
- Do gim bi tit nc trong x gan, suy tim, hi chng thn h,...
- Trong suy thn mn nng (mc lc cu thn < 20 ml/pht).
3. Chn on
3.1. Triu chng lm sng
+ Ri lon thn kinh: khng c hiu, lin quan n mc Natri mu: bun nn, nn
ma, chn n, nhc u, u m thc, hn m, co git.
+ Tng cn va phi.
+ Khng kht, ngc li khng thch ung nc.
3.2. Triu chng cn lm sng:
+ Thm thu huyt tng < 270 mosmol/l.
542

+ Natri mu < 135 mmol/l.
VI. TNG KALI MU
1. nh ngha
Tng Kali mu c nh ngha khi nng Kali mu trn 5,0 mmol/l. Tng Kali mu
t ngt c th e do tnh mng ngi bnh.
2. Triu chng
2.1. Triu chng tim mch
c biu hin ch yu trn in tm
- Sng T cao, nhn v i xng.
- Bt thng dn truyn trong nh (gim bin sau l mt sng P), ri lon dn truyn nh
tht (Bloc xoang-nh, Bloc nh-tht).
- Sau : ri lon dn truyn trong tht: phc b QRS gin rng.
- Nng hn: nhp nhanh tht, rung tht v ngng tim.
2.2. Triu chng thn kinh c
Thng khng c hiu: d cm u chi v quanh ming. Nng hn c th thy yu c
hoc lit khi pht chi di v tin trin dn ln.
3. Nguyn nhn
3.1. Cung cp qu nhiu Kali
Him gp ngi bnh thng, thng do iu tr Kali ng tnh mch hoc ng
ung.
3.2. Do Kali t ni bo ra ngoi bo
- Nhim toan chuyn ho.
- Tng phn hu t bo:
+ Hu c vn v dp nt c.
+ Bng nng, tn huyt nng.
+ Hu khi u t pht hoc do ho liu pht.
+ Xut huyt tiu ho nng.
- Hot ng th lc nng.
- Cc nguyn nhn do thuc:
+ c ch Bta khng chn lc
+ Ng c Digital
+ Ng c Fluor v Cyanure.
3.3. Gim tit Kali qua thn
- Suy thn cp.
543

- Suy thn mn.
- Thiu cc Corticoides khong: Suy thng thn.
- Do thuc: khng vim khng Steroide, Cyclosporine A, Heparine, c ch men chuyn, c ch
th th Angiotensin II.
4. Chn on
Tt c cc trng hp nghi ng tng Kali mu phi lm in tm , in gii . Phi chn on
sm cc ri lon dn truyn iu tr cp cu.
VII. H KALI MU
1. nh ngha
H Kali mu khi nng Kali mu di 3,5 mmol/l. N c th e da n tnh mng ca
bnh nhn v gy ri lon tim mch.
2. Triu chng
2.1. Tim mch
Chm ti cc tht do ko di thi k tr.
- Triu chng in tm tu thuc mc gim Kali mu
+ on ST lm xung.
+ Sng T o ngc.
+ Xut hin sng U.
+ Ko di khong QU.
+ Gin QRS sau th ri lon nhp trn tht hoc nhp tht (ngoi tm thu, nhp nhanh
tht, xon nh, rung tht.)
2.2. Triu chng c
- Chut rt
- au c
- Yu c, lit.
- Khi nng dn n c th hu c vn.
2.3.Triu chng tiu ho: bn (do lit rut)
2.4. Triu chng thn: gim Kali mu mn tnh nng c th l
- Biu hin mt hi chng tiu nhiu ung nhiu
- Nhim kim chuyn ho.
- Bnh thn k mn tnh.
3. Nguyn nhn
3.1.Gim cung cp Kali.
3.2. Chuyn Kali t ngoi bo vo ni bo
544

- Nhim kim chuyn ho hoc h hp
- iu tr Insulin trong i tho ng.
- Cc tc nhn kch thch Adrenergic
+ Pheochromocytome
+ Salbutamol, Dobutamin, ng c Theophylline
- Bnh lit chu k gia nh.
3.3.Mt qu nhiu Kali
- Qua ng tiu ho: tiu chy, d rut non.
- Mt qua ng thn:
+ Li tiu quai v Thiazide
+ Tng tit hcmn Steroide tuyn thng thn, cng Aldosterone nguyn pht, th
pht.
- Bnh thn k
- Bnh ng thn do nhim c: Amphotericine B, Aminoside.
4. Chn on
- Chn on xc nh: da vo nh lng Kali mu v in tm
- Chn on nguyn nhn: thng kh, phi da vo bi cnh lm sng, vo tin s bn thn,
gia nh v Kali niu,...
VIII. NHIM TOAN CHUYN HO
1. nh ngha - pH mu ng mch di 7,38.
- HCO
3
-
di 22 mmol/l.
- PCO
2
gim th pht do tng thng kh b.
2. Triu chng
- H hp: + Tng thng kh
+ Sau suy h hp khi nng
- Tim mch: + Gim cung lng tim, thn,gan
+ Lon nhp
+ Gim nhy cm vi Catecholamine
- Thn kinh: + Ri lon thc, hn m.
- Xt nghim: Tng Kali mu
IX. NHIM KIM CHUYN HO
1. nh ngha - pH mu ng mch trn 7,4
- HCO
3
-
mu trn 27 mmol/l.
545

- Tng PCO
2
th pht (b).
2. Nguyn nhn
- Cung cp qu nhiu cht kim trong iu tr.
- Ri lon bi tit cht kim ca thn.
- Do gim th tch mu, kch thch h Renin-Angiotensin: thng phi hp gim Kali mu v
cng Aldosterone th pht.
- Do cng Aldosterone nguyn pht, hi chng Cushing...
3. Triu chng
- Thn kinh: nhc u, bun ng, l ln, co git.
- Tim mch: lon nhp tht hoc trn tht, d ng c Digital.
- H hp: gim thng kh.
- Thn kinh c: Chwostek (+), Trousseau (+), yu c.
- Xt nghim: gim K
+
mu, gim Ca mu, gim Mg mu, gim Phosphat mu, pH mu trn
7,42; HCO
3
-
trn 27 mmol/l.
- Thn: tiu nhiu, kht nhiu, ri lon c c nc tiu.
X. NHIM TOAN H HP (PCO
2
trn 40 mmHg)
1. Nguyn nhn: kh ph thng, ph phi cp, gim hot ca trung tm h hp.
2. Lm sng: tm, th nhanh nng, nhc u, run chn tay, ri lon tm thn.
3. Chn on: ch yu da vo bi cnh lm sng c bnh nguyn thch hp v xt nghim ion
mu.
XII. NHIM KIM H HP (PCO
2
di 40 mmHg)
1. Nguyn nhn: Histeria, tn thng thn kinh trung ng (vim no, trng c Salisilat...) th
gng sc.
2. Lm sng: Th nhanh, su, ri lon thc.
3. Chn on: da vo xt nghim mu. Chn on phn bit gia cc th ca ri lon thng
bng toan kim c tm tt theo bng sau
Bng 1: Chn on cc dng ri lon cn bng toan kim n gin
pH mu H
+
HCO
3
-
PCO
2
Toan chuyn ho

Kim chuyn ho

Toan h hp

Kim h hp


546

SHOCK NHIM TRNG
Mc tiu
1. Pht hin c cc triu chng tin chong.
2. Theo di c bnh nhn shock nhim trng.
3. Lit k c cch phng shock nhim trng.
4. Trnh by c cc bin php iu tr shock nhim trng Gram m
Ni dung
I. NH NGHA
Shock nhim trng l mt trng thi lm sng pht sinh do s suy tun hon nhng m do
nhim trng huyt thng l Gram m. S gim tun hon cc t chc l nhiu yu t bnh l:
Sc cn ngoi bin tng.
mu trong huyt qun.
Lu lng tim gim.
Thiu kh m.
II. BNH NGUYN
C khi do vi khun Gr(+) nhng t trm trng Shock nng mc d c h HA nhng c gin
mch ngoi bin, lu lng tim bp v lu lng mu bnh thng. Trong thc t, Shock nhim
trng thng ch do Gr(-) nht l trc khun ng rut, ng u l Escherichia Coli,
Streptococcus Faecali, vi khun khc nh Pseudomonas Aeruginosa, cc Proteus, Klebsiella. Cc
vi khun Gr(-) tit ni c t gy cc phn ng bnh l v ph trch trc tip Shock.
S pht trin ca Shock nhim trng Gr(-) thng c mt s iu kin lm d nh:
C a xu, ngi gi, tr em, ngi c bnh mn tnh
S dng khng sinh ba bi chng Gr(+) dit ht Gr(+) lm tri vi khun Gr(-).
III.SINH BNH HC
1.Nhc li khi nim sinh l cn thit v sinh bnh l
1.1.Khi nim v c quan tip th v ca h trc giao cm
lm co mch ton b, k c tnh mch nhng tnh mch co t hn v c trn thnh tnh
mch mng.
lm gin mch v kch thch tim mch c v tn s ln cng .
S phn phi hai c quan ny rt khc nhau, c nhiu huyt qun, da, c v c quan
ni tng nhng t no v tim.Ngc li h nhiu tim no m t cc c quan khc.
1.2.Khi nim v cc c vng mao mch
Bnh thng cc c vng u mao mch ng li mt s mao mch. Cc mao mch
ny chu tc dng ca nhiu cht khc nhau. c bit c vng sau mao mch chu co bi
547

catecholamine (Adrenaline v Noradrenaline). C vng u mao mch m ra bi cc cht chuyn
ha toan.
1.3.Cc mch ni tc ca ng mch v tnh mch
Bnh thng cc mch ni tc ng li, nu v l do g c vng m ra nh shock nhim
trng th mu s vo mch ni a n hin tng ni tc lm cho cc m thiu mu.
2.C ch bnh sinh
ngi Shock nhim khun c hai giai on
Giai on tng vn ng (xem bng)
Nc v huyt tng ra ngoi khong k.
Cung lng tim (CO) gim do gim tun hon tr v v gim sc co bp ca c tim Sn sinh yu
t MDF (Myocardial Depressant Factor). MDF do men tiu t bo to ra vng bng b thiu
mu. Tnh cht ca suy tim l suy tim tri (tng p lc cui tm trng tri).
Bnh nhn thng c toan chuyn ha.
Nu khng iu tr ngay, nhiu tng s b suy: tim, phi, thn, gan, ng tiu ha, ty.
Bng 1: Hai giai on ca Shock nhim khun
Giai on CI RPT HA CVP MVO
2
DAVO
2
PH
Tng vn ng
(Hyperkinetique)
Tng Gim Gim
nh
Gim nh Tng Gim Tng
Gim vn ng
(Hypokinetique)
Gim Tng Gim Thay i Gim Gim Gim
CI (Cardiac index): Ch s tim.
CO (Cardiac output) S lng tim o bng phng php nhit pha long.
CVP: (Central venous pressure): p lc tnh mch trung tm.
DAVO
2
: chnh lch Oxy mu ng - tnh mch.
RPT: Sc cn ngoi vi ton b.
MVO
2
: tiu th Oxy.
Trn thc nghim ngi ta thy rng trong Shock ni c t t bo b tn thng qua 4 co ch:
Tn thng t bo do ni c t.
Bch cu phng thch ra men Lysosome (Men tiu t bo).
Hot ha h thng b th.
Ri lon chuyn ha do thiu Oxy t bo. Tn thng ca t bo ni mc, tiu cu bch cu gy:
Tng tnh thm thnh mch.lm cho nc thot ra khong k lm gim th tch mu hu hiu.
Gim tiu cu: tiu cu b ph hy s phng thch ra cc cht trung gian nh Serotonine,
Adrnaline, Thromboxan A2 gy co mch.
548

Bch cu ht gim: Bch cu b ph hy phng thch ra cc men tiu t bo v cc dn cht ca
Arachidonic qua ng b th v ng Properdine
i thc bo sn xut ra TNF v Interleukin gy gin mch nhanh, toan chuyn ha, hot ha h
thng ng mu, xut huyt ty, thng thn.
Thiu Oxy t bo gy ra:
Ri lon chc nng to Glycogen, ri lon chu trnh Krebs, ri lon to mt, tng Lactate mu.
Ni c t
Gy co tht c trn trc v sau mao mch (tc dng ln th th lm ng mu phi, bng,
thn).
Thng qua yu t Hageman (XII) lm hot ha Bradykinine l cht gin mch gy ng mu
t chc ngoi bin. Bradykinine cn lm tng tnh thm mao mch.
Ngi ta c nu ln tc hi ca Acide Arachidonic v opi ni sinh (Endorphine). Dng Imidazole
ngn cn s hnh thnh Thromboxan A2 hoc dng Prostacycline i khng vi Thromboxan A2
s khng gy c Shock ni c t. Trn ngi thn v phi l hai c quan b Shock ni c t
nh hng trc tin: gi l thn Shock, phi Shock.
Giai on u: s tit ni c t c tc dng tng t Catcholamine lng va phi nn c tc
dng ca gy co mch da, c, thn, cc tng v dn mu cho tim, thn, no ng thi kch
thch va phi lm tng lu lng tim. Giai on ny c li cho bnh nhn, tuy nhin thn v
co mch nn lng nc tiu t dn.
Giai on sau: S sn xut ni c t qu nhiu lm co qu mc cc huyt qun do tc dng ca
nht l co c vng sau mao mch, mu li trong cc mao mch khng v tim c lm gim
lu lng mu ton c th. S mu ton c th ng thi s to s thiu Oxy trong cc m,
trong t chc. Cc t bo s phn ng bng chuyn ha theo c ch k kh dn n sn xut ra
sn phm chuyn ha toan lm m rng c vng u mao mch lm mu thm trong cc mao
mch bnh thng c mu v c nhng mao mch bnh thng khng c mu. Hu qu l mu
cng ng cc mao mch dn n cng gim thm lu lng tun hon. ng thi s tr s
lm tng p lc thy tnh, nc in gii thot ra khi thnh mch. iu ny s lm lu lng
mu cng gim thm. T gy hai hu qu chnh l gim lu lng tun hon v thiu mu,
thiu Oxy m. M hai hu qu ny chnh l nh ngha ca Shock.
Cc khu trong c ch bnh sinh cng xc tc thc y cho nhau i theo mt vng ln qun
khng hi phc c do Shock nng dn, cui cng s dn n ng mu ri rc ni mch
(CIVD: Coagulation intravasculaire dissmine) thng tn lan ta ca cc mao mch v huyt
qun do thiu Oxy lm mu ng ti ch cc thnh mch do lm tiu th ht cc yu t ng
mu dn n chy mu lan ta tt c cc c quan.
IV.TRIU CHNG V CHN ON SHOCK NHIM KHUN
1.Hon cnh xut hin
Khi nim:
- Bt k nhim khun khu tr hay ton thn thng
+ ng tit niu: si, sau m.
549

+ Tiu ha: vim mt qun, vim phc mc rut tha, sau m.
+ H hp: k c m kh qun, vim phi.
+ Sinh dc: sau sinh, no ph thai.
+ Tnh mach: thm d huyt ng, truyn dch.
+ Da: lot da, lot mng, vim da.
-a s l gram m.
-Thng gp trong th thut cp cu.
-40% l nhim khun mu.
-60% Xy ra trn c a suy km.
2.Mt vi c im lm sng
2.1.Do no m cu: Shock xut hin nhanh, chy mu di da, hi chng mng no, CIVD, xut
huyt nhiu ni: no, thng thn,da nh hi chng Schwarztmann Sanarelli (do tim no m
cu cht vo tnh mch).
2.2.Do ph cu: (Nhim khun mu)
tr nh c a suy gim min dch lm sng nh no m cu. C ch l do khng nguyn v
ph cu vo mu nhiu.
2.3.Do ngoi c t
T cu: Sau vim da, chn m, vim sinh dc
Lin cu tan mu: vim hng, vim da.
2.4.Do vi khun thng hn: Lin quan ti khng sinh liu cao lm tan vi khun.
V. PHNG BNH
iu tr tch cc cc trng hp nhim trng Gram m.
Trnh s dng ba bi cc loi thuc khng sinh dit vi khun Gram dng.
VI. IU TR
1. Ti lp khi lng tun hon v iu chnh thng bng kim toan
C th truyn dch ng trng, c th km mt t dung dch Glucose cung cp nng lng.
Dung dch kim nh Natri bicarbonate.
Khi lng dch truyn c th rt ln ty nng nh.
Trong truyn dch cn theo di p ng, phng nc, suy tim. Nu c dung dch Dextran l
cht cao phn t c trng lng phn t ln, to thnh trong lng huyt qun mt lp trng lm
tiu cu khng dnh vo c v chnh n li trong lng mch lu hn.
2. Cc thuc vn mch
Hin nay ngi ta hay dng Dopamine liu 5 - 20 g /kg /pht truyn tnh mch rt chm.
Ch iu chnh toan khi x dng cc thuc vn mch.
550

Trong trng hp nhp tim nhanh th c th dng Dobutamine thay th cho Dopamine.
Vn s dng Adrenaline v Noradrenaline cn ty theo trng phi, c th phi hp
Dopamine vi Noradrenaline khi Dopamine liu > 20 g /kg /pht khi huyt p tm thu
<90mmHg hoc khi nhp tim qu nhanh >130ln/pht.
3. Khng sinh
Nguyn tc l dng sau khi cy mu v da vo khng sinh , nhng trong khi ch i khng
sinh nn dng khng sinh c ph khun rng. Phi dng liu cao nn tt nht l dng bng
ng tnh mch. (Lu bnh nhn c suy thn chc nng hoc thc th nn cn d dt vi
nhng khng sinh c cho thn nh Streptomycine, Gentamicine).
Cn nm vng loi khng sinh ang s dng, dc ng hc, ch nh, chng ch nh, tc dng
ph v tai bin do thuc.
Theo di p ng ca khng sinh, d phng khng khng sinh (vi khun khng thuc).
Thi gian s dng khng sinh phi hp l, kinh t nhng phi cht lng
Cc loi khng sinh thng c s dng trong chong nhim trng Gr (-) l:
-Cephalosporin th h III (Ceftriaxon, Cefomic.)
Hp thu tt qua ng tiu ho, thuc phn b khp c th ngoi tr dch no tu ch vo c
khong 20% thuc qua c nhau thai v sa m, thi tr qua nc tiu. Thuc tc dng tt trn
nhiu vi khun rut nh Escherichia Coli, Klebsiella, Proteus Mirabilis, Shigella, Salmonella.
Tc dng ph v c tnh: C khong 0,05% d ng ging Penicilline, ngoi ra thuc c th gy
ri lon tiu ho nh tiu chy, bun nn, nn ma, nhim nm.
Gim bch cu, tiu cu, tng men gan
-Aminoglycosides: (Streptomycin, Gentamicin, Tobramycin, Amykacin)
L thuc dit khun, thi gian bn hu tu thuc chc nng thn, khng hp thu bng ng
ung, thuc khuych tn vo phn ln cc t chc v th dch ca c th, trong ti nhu m
thn cao hn huyt tng. Thuc hp thu km mt, tin lit tuyn, khng qua hng ro nhau
thai, sa m v hng ro mu no., h thn kinh trung ng v mt.
Thuc thi tr qua nc tiu 65% sau 6 gi, 85% sau 24 gi.
Ch nh
-Nhim trng Gram m ti thn v h tit niu, nhim khun huyt.
Tc dng ph v c tnh.
-Ri lon thnh gic: tin nh b c gy chng mt, mt iu ho, rung git nhn cu, tai,
gim hoc mt thnh lc. Trng hp nng tn thng s khng hi phc.
-c vi thn: thuc thi tr, tch ly v thn v gy bnh ng thn cp. Tc dng ny thng
xy ra ngi ln tui, c bnh thn hoc mt bnh l gy mt nc.
Liu lng:
-Amikacin 15 mg/ kg / ngy chia 2 ln.
-Gentamicin 5 mg/ kg / ngy chia 2 - 3 ln / ngy.
551

Nhm Nitroimidazole: (Metronidazole)
L thuc khng khun, hp thu nhanh gn 80% sau 1 gi, nng trong huyt tng khi s dng
bng ng ung v ng tim tng ng nhau, thi gian bn hu t 8 - 10 gi. Thuc gn
vo Protein khong 20%, thuc khuych tn nhanh, mnh phi, gan mt dch no tu, thn
nc bt, tinh dch, dch m o. Thuc thm qua nhau thai v sa m.
Thuc chuyn ho qua gan, nng cao gan v mt. Thuc thi tr ch yu qua nc tiu v
c mt lng nh khi thi tr cn nguyn hot tnh nn lm cho nc tiu c mu nu.
Tc dng ph v c tnh:
-Ni my ay, nga, chn n, bun nn, c v kim loi ming, vim ming, i tin phn lng,
nhc u chng mt, gim bch cu a nhn, vim dy thn kinh v nu dng ko di c th ri
lon tm thn.
Nhm Quinolone: l thuc dit khun bao gm:
Th h 1: cc Nalidixic acide, Oxonilic acide, Pipemidic
Th h 2: (Fluoroquinolone) Norfloxacin, Ofloxacin, Ciprofloxacin, Enoxacin, Pefloxacin,
Lomefloxacin, Levofloxacin.
Th h 3: Sparfloxacin (Zagam)
Hp thu tt nhng c i lc vi kim loi nng, b c ch khi dng chung vi Fe, Canxi, v mt s
Cation. t nng cao khi dng trc n 1 gi hoc sau n 2 gi
Hp thu: thuc c hp thu nhanh v rt tt hu nh t 100% nng cao nht t trong huyt
tng sau ung 6 gi, thi gian bn hu 6 - 8 gi. Thuc c phn b khp t chc v dch nh
phi, da, c t cung, bung trng, m v dch tin lit tuyn, m. Thuc thi ch yu qua thn
(80%).
Tc dng ph v c tnh
-Ri lon tiu ho, au vng thng v, bun nn, nhc u, chng mt, ng g, o gic, l ln,
co git.
-au c, au khp, ni my ay pht ban
-Tng men SGOT, SGPT v LDH, tng bch cu i toan, gim bch cu trung tnh, gim tiu
cu.
-Tng tc dng ca Theophyllin, Warfarin.
-Zagam gy ri lon nhp tim trong trng hp QT ko di nn khng c vi Cordarone.
Chng ch nh
C thai, dang cho con b, tr s sinh, ngi gi trn 70 tui suy gan suy thn, ngi ang mc
bnh tm thn, thiu men G6 PD.
Khng nn dng khi ang li xe, ngi ang lm vic trn cao, s dng my mc.
4. Bin php khc
- Corticoide tim tnh mch liu cao chng s thm qua mng mao mch.
552

- H tr h hp bng Oxy liu cao, thng kh c hc, khai thng ng h hp trn cho bnh
nhn.
- Thuc tng sc co bp c tim.
- Huyt tng ti, mu ti c th gip cho bnh nhn khi phc lng mu, chng chy mu.
- Cui giai on II, u giai on III c dng Heparine chng ng mu nhng kh nguy
him. Hin nay ngi ta c th dng Acide Aminocaproide.
- iu tr loi b nhim trng nh ct ti mt, iu tr p xe...



553

TRNG C CP THUC TR SU GC PHOSPHORE HU C
Mc tiu
1. M t c c ch bnh sinh v cc yu t lm nng thm tnh trng ng c
2. Trnh by c cc triu chng lm sng cn lm sng.
3. Chn on xc nh v iu tr c trng c theo cc mc .
Ni dung
I. DCH T HC
Thuc tr su gc phospho hu c c s dng rng ri trong nng nghip, chng c dng
dit cn trng do tip xc trc tip hoc qua h thng ca cy c do cn trng n phi cc loi
cy c ny. Ngoi ra ngi ta cn x dng cc thuc ny dit mt s k sinh trng ngi v
sc vt nh ch, rn. Do vic pht trin v x dng cc thuc ny ngy cng ph bin, nn vic
trng c cp loi thuc ny ngy cng nhiu nc ngoi cng nh trong nc. Cc cht
phospho hu c c th gy ra cc triu chng trm trng cht ngi. Do trng c phospho
hu c l mt loi trng c nguy him v vy cn c chn on sm v iu tr kp thi, ng
v y mi trnh c t vong.
Ng c phospho hu c thng xy ra nng thn nhiu hn thnh ph v ni y thuc c s
dng mt cch rng ri, nht l nhng ngi lm nng nghip v thng xy ra v ma h nhiu
hn ma ng. Gp thanh nin nhiu hn l ph n. nhng ngi b nhim c mn
thng c nng nhim c thp hn ngi cha tng b ng c. ngi gi, ph n c thai
v c bnh mn c sn thng b ng c nng hn ngi thng.
II. C CH BNH SINH
1. i cng v s dn truyn qua synape
Khi nron b kch thch, t bo kh cc, xung ng c dn truyn theo si trc n mt tn
cng, ti y xung ng to nn mt kch thch mi lm cho cc ti cha Actylcholin chuyn
ng Brown va vo nhau v ra gii phng Actylcholin, Actylcholin i qua khe synape n tip
xc vi th th ca mng sau synape (mng t bo c...), gy kh cc ti y, v gy co c.
khe synape, sau khi gy kh cc mng sau synape, Actylcholin b Actylcholinestrase
phn hy thnh Actate v cholin mt tc dng, kt thc qu trnh kh cc.





Synape gia 2 nron Synape thn kinh-c
Hnh 1: Synape l ni tip gip gia 2 nron (t bo thn kinh), hoc gia nron vi thn kinh c.
554



Xung ng


Ti cha Actylcholin (Ach)


Ach
Phospho hu c
(-)
Acetylcholinestrase

Actylcholin Actate + Cholin


Atropin

Mng sau synape Th th


Hnh 2: S s dn truyn qua synape v cc yu t nh hng

2. C ch tc dng ca thuc tr su gc phospho hu c
2.1. C ch gin tip
Thuc tr su gc phospho hu c vo c th phi hp vi acetylcholinestrase thnh mt phc
th bn, tc phn li xem nh bng khng. Do acetylcholinestrase mt hn tc dng thy
phn Acetylcholine.
Acetylcholinestrase b bt hot ha, ch c b li do s tn to Acetylcholinestrase, s ti to
ny xy ra rt chm sau nhiu ngy, c th hng tun, thm ch hng thng.
Acetylcholine khng c Acetylcholinestrase bt hot ha, tch t li nhng ni bnh thng
n c tit ra trong trng thi b kch thch cng nh trong trng thi ngh l:
- Giao thoa ca ton h i giao cm.
- Giao thoa hch giao cm v tm vn ng
555

- Giao thoa lin thn kinh trung ng
2.2. C ch tc dng trc tip
Trn cc v tr tip th Acetylcholine. Nu thuc tr su gc phospho hu c nng cao v tc
dng ko di th c th lm cho tm vn ng thoi ha kh hi phc.
3. Kt qu tc dng ca thuc tr su gc phospho hu c
Do c ch tc dng c ch men cholinesterase khng hi phc, phospho hu c to ra 3 loi tc
dng sau:
3.1. Tc dng dng Muscarine
L kt qu tc dng kch thch ln cc giao thoa i giao cm gy ra nhng du chng hng phn
i giao cm trn cc c trn, cc tuyn, tim...H thn kinh trung ng chu tc dng ny khng
c hiu. (Kch thch hay c ch)
3.2. Tc dng dng Nicotine
L kt qu tc dng trn cc giao thoa hch giao cm v tm vn ng c vn trong quan
trngnht l c h hp. Tc dng Nicotine c tnh kch thch lc ban u, ko di mt thi gian
ngn, nhng sau li lm lit cc c quan chu nh hng khi s nhim c nng v ko di.
3.3. Tc dng trn thn kinh trung ng
C tnh kch thch ri lm lit khi cng v thi gian nhim c tng. Quan trng nht l tc
dng trn cc trung tm sinh thc.
Tc dng dng Muscarine c trung ha d dng bi Atropine, t chu nh hng ca cc
oximes.
Tc dng Nicotine chu nh hng rt t ca Atropine v Oximes tr tm vn ng, chu nh
hng rt tt ca Oximes.
Tc dng thn kinh trung ng chu nh hng kh tt ca Atropine, khng chu tc dng ca
Oximes.
4. S xm nhp-hp th-bin i v thi tr thuc tr su gc phospho hu c
Phn ln cc thuc tr su gc phospho hu c u tan mnh trong lipit, nn chng c hp th
d dng qua da v nim mc nh nim mc mt, tiu ha, h hp,chng thng c dng di
dng kh dung, sau khi pha long hng trm, hng ngn ln.
Thuc xm nhp bng mi ng
- Da, nim mc, nht l khi c sn tn thng nh dng xc gh, bn vo mt, tip xc da khi
s dng thuc
- H hp: nh ht phi hi thuc khi m bnh thuc kn, ht phi kh dung khi bm thuc
- Tiu ha: do t t hay ung nhm.
S hp th rt d dng bng mi ng k trn rt nhanh v hon ton, nhanh nht l qua ng
h hp, chm nht l qua da. Chng c th b trung ha phn no bi cht kim v Hypochlorite.
556

Trong c th chng b thoi bin bi cc men thy phn v oxy ha, nht l trong gan, nhng s
thoi bin ny rt chm. i vi cht phospho hu c phi hp vi Acetylcholinestrase, ch
thi di dng thoi bin thnh Paranitrophenol.
5. c tnh
Trong cc phospho hu c th thiophot (parathion) l c c tnh ln nht, trung bnh l mthyl
parathion (wolfatox) v nh hn l malathion. v d liu ng c ca parathion l <5mg/kg th
trng, mthyl parathion l 5-50mg/kg th trng, malathion l 50-500mg/kg th trng. c tnh
ny tng gp ln hng chc ln khi 2 th thuc c phi hp vi nhau.
III.TRIU CHNG
1. Thi gian tim tng: thay i ty theo nhiu yu t.
1.1. ng xm nhp: t nhanh n chm: h hp, tiu ha, da.
1.2. trm trng ca s nhim c: cng nng th thi gian tim tng cng ngn. V d ng c
trung bnh th cc triu chng lm sng thng xut hin sau 1 gi, nhng nhng trng hp
nng th ngn hn ch sau 15- 30 pht v trong trng hp rt nng nhiu lc ch 30 pht n 1
gi bnh nhn cht.
1.3. Th trng bnh nhn: cng nh tui thi gian tim tng cng ngn (v nng AchE thp).
Ngi gi triu chng ng c cng nng hn.
1.4. Yu t nhim mn: Ngi b ng c nh tim tng trc cng b trng c nhanh hn.
Ngi b ng c mn tnh, du nhim c nhanh v nng hn nu c nhim cp.
1.5. Bng i, ung ru: cng lm trng c bng ng tiu ha xy ra nhanh hn.
1.6. Phi hp nhiu ng nhim c: lm ngn thi gian tim tng.
2. Th t xut hin cc du chng
Du chng dng Muscarine xut hin trc tin. Du chng dng Nicotine v thn kinh trung
ng thng kh phn tch hn, xut hin chm hn. Nhng nu trng c trm trng th c 3
loi du chng xut hin ng thi.
3. Cc du chng trn cc c quan
3.1. Mt: c du Muscarine r nht, sung huyt kt mc, teo ng t c th rt mnh bng u
kim gm, nhng vn cn p ng vi nh sng, hn lon iu tit, gim p lc ni nhn. Du teo
ng t l du Muscarine rt nhy nn c th l mt trong nhng du nh gi trm trng
lc ban u, tr trng hp mt b tc dng trc tip ca tr su do thuc bn trc tip vo mt
th du ny sm v nng nhng c th du nhim c ton thn khng nng.
3.2. Da: cng l ni biu hin du dng Muscarine r, sung huyt, chy m hi.
3.3. Tiu ha: du chng dng Muscarine. Tit nc bt rt nhiu, tng tit dch tiu ha nht l
dch d dy, tng nhu ng, co tht trn tiu ha gy au qun bng, kh nut, bun nn, nn.
Nu trng c trm trng c nh hng n thn kinh trung ng th c du i tin v thc.
3.4. Du h hp: biu hin 3 loi tc dng: Muscarine, Nicotine, thn kinh trung ng.
Tc dng muscarine lm tng tit dch ph qun gy ho, tng tit m gii, bt ph qun gy kh
th, nghe ran n t to nh ht, ng thi lm co tht c trn ph qun gy kh th thm.
557

Tc dng Nicotine giai on lm lit s lm lit c h hp gy suy h hp nng. Tc dng ny
cng lm lit c li t gy tt li lm bt ng h hp.
Tc dng thn kinh trung ng giai on lit s lm lit trung tm h hp, tng cc tc dng ni
trn.
Suy h hp cp, l biu hin tt nhin ca trng c nng, l nguyn t vong chnh.
3.5. Du tun hon: cng biu hin phi hp 3 loi tc dng.
Tc dng Muscarine lm mch chm, huyt p h.
Tc dng Nicotine v thn kinh trung ng: gy cng trc giao cm v kch thch cc trung tm
iu ha tim mch, t nht l trong giai on kch thch a n mch nhanh, huyt p cao. Trong
giai on lit ca tc dng Nicotine, thn kinh trung ng, cc du chng c th ngc chiu tr
li l try tim mch.
3.6. Du c vn: biu hin tc dng Nicotine v thn kinh trung ng.
- Giai on kch thch
Rung c, tht s l rung cc th c l mt du chmg quan trng cho bit trng c kh trm
trng, cn tm k pht hin nht l c ngc, bng, cnh tay, vai v i. Cn phn bit vi rung
c v lnh.
- Giai on lit c: yu c ri n lit c, quan trng nht l c h hp lm ngng th.
Nu trng c ko di, lm tm vn ng b thoi ha th lit c s ko di rt lu.
3.7. Du thn kinh trung ng: biu hin do c 3 loi tc dng
- Muscarine v Nicotine gy thiu kh no, v tc dng thn kinh trung ng trc tip ca
phospho hu c.
- Trong giai on u l kch thch, bt an, co git.
- Trong giai on cui, gim phn x gn xng, ri mt phn x, hn m, lit cc trung tm thn
kinh sinh thc.
- St c th du chng nhim c thn kinh trung ng ca phospho hu c.
IV.TIN TRIN
1. Khng iu tr
C th t lnh nu trng c nh. Nhng nu l trng c kh nng th cc du chng s tng dn
a n hn m, suy h hp v cht.
2. C iu tr ng mc
Cc du Muscarine gim v bin mt trc, sau hai du chng Nicotine v thn kinh trung
ng cng thuyn gim dn. Nhng nu trng c qu trm trng hay iu tr chm, th ban u
cc du chng Muscarine gim, bnh nhn c th tnh li, nhng sau cc du Nicotine v thn
kinh trung ng ngy cng nng v a n suy h hp v t vong.
Nguyn nhn t vong chnh l suy h hp trong hu ht cc trng hp.
558

V. CHN ON
1. Chn on xc nh
Cn c vo hi bnh, hi thn nhn bnh nhn nht l da vo mi hi c bit ca thuc tr su
trong hi th, trong cht ma, trn o qun, da bnh nhn, da vo cc du chng lm sng c
hiu, nht l du Muscarine c phi hp hay khng vi du Nicotine v thn kinh trung ng.
Cn lm sng cn cho nhng trng hp nh, khng r loi ng c bng cch nh lng
butyrocholinestrase trong huyt tng hay Acetylcholinestrase trong hng huyt cu. Hai t l
ny gim. Tht ra, s gim hai t l ny khng phn nh trung thc, m t Acetylcholinestrase
trong cc m l t quyt nh trm trng ca s trng c: T cholinesterase gim < 30% l
ng c nh, 50% l ng c va, gim > 70% l nng.
2. Chn on trm trng
Cn c vo hi bnh:
- Th trng bnh nhn.
- ng nhim c. Nht l ng ung v bng i.
- Lng thuc xm nhp c th.
- iu kin trng c (t c, hay ng c).
- Thi gian t lc nhim c n lc c loi b thuc ra khi c th (sc d dy) v c iu
tr ng mc.
- iu tr tuyn di tt hay khng.
Ni tm li, tt c nhng iu kin no lm cho lng thuc ngm vo c th cng ln, iu tr
ng mc cng chm, cng lm trm trng tng thm.
Chn on trm trng cn cn c vo du lm sng, cc du Nicotine v thn kinh trung ng
nng th trm trng cng cao.
S gim t butyrocholinesterase v Acetylcholinesterase khng phn nh hon ton trung thc
trm trng.
Trong thc t, hi bnh nhn v khm lm sng k c th c tnh trm trng kh ng n.
2.1. Nh: du Muscarine nh hay n thun.
2.2. Va: du Muscarine nng kt hp vi du Nicotin v du thn kinh trung ng va.
2.3. Nng: du Nicotin v thn kinh trung ng nng, du muscarine c th c hay khng.
Hoc du trng c va km yu t nng do hi bnh.
3. Chn on phn bit
3.1. Ng c Carbamate: Lm sng ging ng c phosphore hu c. C ch cng ging. iu
tr bng Atropin, nhng khng dng PAM v lm nng thm tnh trng ng c.
3.2.Ng c DDT (Dichloro-Diphnyl-Trichloetan): L cht dn xut ca clorobenzen, khng
thm qua da ch thm qua nim mc tiu ha. Triu chng ng c l gy ri lon tiu ha, xut
hin 1-6 gi sau nh nn ma, a chy, au bng. Tc dng trn h thn kinh, gy nhc u, d
559

cm, run, co git, cng co git ty thuc vo nng DDT trong no. Du t nh n nng
l rung c, tng phn x, co cng ton thn, co git, suy h hp, ngng th, ngng tim v cht.
3.3. Ng c 666: L dn xut ca Cyclohexan cng gy cc triu chng nhim c ging nh
DDT, nhng thi gian tim tng ngn hn.
VI. IU TR
1. Nguyn tc iu tr
- Xc nh c cht: xc nh c phi l Phospho hu c hay khng cn da vo hi bnh
nhn, ngi nh hoc ngi chung quanh; y l loi thuc dit su b khc vi cc loi thuc
khc thng dng hin nay l thuc dit nm v thuc dit c. Tn thuc thng da vo bng
danh mc cc thuc phospho hu c thng by bn trn th trng. Mu sc, mi v v cu to
ca thuc: Thng trnh by di dng lng, c mu trng nht l khi ho vi nc c mu trng
c nh sa v c mi nng nc rt c bit, khc vi mi ca cc loi thuc st trng khc.
- Gii hn lng cht c hp thu vo c th v loi b cht c ra khi c th.
- Trung ha tc dng ca thuc c c hp thu.
- Phng thch Acetylcholinesterase khi phc th Acetylcholinesterase-Phosphore hu c.
- iu tr triu chng nhiu lc rt quan trng v c th cu sng bnh nhn nh ng kinh, tt
huyt p, ngng th bng th my.
2. iu tr c th
2.1. Loi b cht c: ty theo ng ng c
- Ty sch thuc khi da v nim mc: ci b qun o dnh thuc, lau sch thuc da, ra da tht
sch bng x phng, hay tt hn nc c pha bng Bicarbonate hay Hypochloride.
- Nu thuc dnh vo mt th ra mt tht sch.
- Nu trng c bng ng h hp th lp tc a bnh nhn ra khi vng ng c, c bnh
nhn vo khu vc thong mt, tng thng kh phi loi b thuc qua ng h hp.
- Sc ra d dy: p dng cho trng c do ng tiu ha. Mun c hiu qu v khng nguy
him, cn thc hin trong nhng trng hp sau y:
+ Sc ra cng sm cng tt. Thc hin trc 6 gi k t khi b nhim c.
+ Bnh nhn khng m.
+ Trc khi sc phi tim Atropine trc, liu thch hp vi trm trng thng l 2mg v cn
thc hin t nht l 4 pht (nu tim tnh mch) v 10 pht (nu tim bp), v khi sc d dy c
th lm tng trng thi cng i giao cm sn c v gy phn x c ch cht ngi.
+Sc d dy phi c thc hin nh nhng, trnh tng kch thch i giao cm thm. Dng
nc pha Bicarbonate, lng nc sc kh nhiu cho n khi ht mi hi. Thng c th n vi
chc lt nc sc ra d dy.
2.2. Atropine liu cao dng sm
- C ch tc dng: Atropine l thuc c ch i giao cm hiu qu nht trong trng c cp
thuc tr su gc photpho hu c.
560

Atropine c tc dng
+ i khng mnh trn cc du chng dng Muscarine biu hin cc c quan thc hnh ngoi
bin.
+ Tc dng i khng yu hn trn du chng thn kinh trung ng, trn cc du chng dng
Nicotine hch giao cm, v hon ton v hiu i vi s lit c vn do tc dng ti tm vn
ng.
- Tc tc dng: Liu trung bnh 2mg Atropine Sulfate hay Tartrate tim bng ng tnh
mch: 1 pht sau bt u c tc dng, nu tim bp hay di da th 8 pht sau, v t tc dng ti
a sau 6 pht i vi tim tnh mch v 35 pht nu tim bp hay di da.
- Thi gian v liu lng dng Atropine: Khi s trng c c xc nh, th tim Atropine
cng sm cng tt.
+ Trng c nh: D cha c du chng trng c vn tim bp 1-2mg Atropine, lp li nu cn
cch nhau 30 pht. cho n khi ht du chng Muscarine v c du no Atropine. Sau duy tr
trng thi no Atropine nh va trong 24 gi hay hn. Ch : gim liu trc, gin thi gian sau.
+ Khi trng c va: tim tnh mch 3-5mg Atropine, lp li liu 2-4mg cch nhau khong 10-15
pht cho n khi du chng Muscarine bin mt v c no Atropine nh. Sau duy tr Atropine
nh hoc va trong vng 48 gi hay hn.
+ Trng c nng: Nht l khi c kh th, co git, hoc hn m th tim tnh mch 5 n 8mg
Atropine ngay. Lp li liu 5mg cch khong 5-8 pht cho n khi ht co git v gim tit dch
ph qun v tit nc bt. Sau tr li pht iu tr trng c nng va, cho n khi ht du
chng Muscarine v c no Atropine. Duy tr trng thi Atropine va hoc nhiu trong vng 48
gi hay hn.
- p ng vi Atropine v theo di bnh nhn: Atropine liu cao dng sm ci thin r bnh
cnh lm sng, lm mt du Muscarine, ci thin thng kh phi, lm chm s lit trung tm thn
kinh nn ci thin c hn m, co git v kh th, nhng trong nhng trng hp rt nng, th
s ci thin ch nht thi. Bnh nhn sau b lit h hp v Atropine hon ton v hiu i vi
s lit tm vn ng.
i vi nhng trng hp trng c va hay nng, khi s dng Atropine liu cao, cn theo di
bnh nhn tht st iu chnh liu lng, pht hin du chng bo hiu tng trm trng
tr li, khi gim liu Atropine. Theo di st s pht hin s ti xut hin cc du chng trng c.
Trng c Atropine
+ Trng c nh: kh ming, mi, hng, gy kh nut, cm gic nng ch quan, mt phng ,
tim nhanh, kh tiu, gin ng t, lm nhn gn kh.
+ Trng c va: cc du chng trn tng nhiu c bit nhit ngoi bin tng cao, bun ng
nhiu, bn, b tiu, chng mt, bt an, ni nhiu.
+ Trng c nng: ngoi nhng du chng trn, du chng thn kinh trung ng nng, r hn
vi st cao, mt nh hng, o gic du chng tm thn, qu kch thch, ni sng chy by.
- Nguyn tc gim liu Atropine: Cn gim liu t t v theo di st cc du Muscarine ti pht
hoc xut hin du Nicotine nng; do cn gim theo kiu bc thang nh v cn gim liu trc
khi gim ln tim Atropine.
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2.3. Pralidoxime (P2AM = Pyridine 2 - Aldoxine Methiodide)
- C ch tc dng: Pralidoxime c c tnh tc dng vi phc th AchE - PHC kt hp vi
phospho hu c gip gii phng AchE t do ti hot ng. Nhng oximes cn c dng sm th
mi hiu qu. Tc dng oximes r nht trn tm vn ng.
- Tc tc dng: Tim tnh mch, P2AM c tc dng rt nhanh, yu c v rung c gim ch
sau 5-30 giy, ti a sau 5-10 pht.
- Thi gian v liu lng dng: P2AM c tim trc 36 gi. Tim tnh mch 1000-2000mg
chm (500mg/pht) c th lp li nhiu ln. Tuy nhin trong trng hp trng c nng v c
ngun phospho tch lu lu trong c th nh trong trng hp trng c qua ng tiu ho c
sc ra chm th c th dng PAM liu cao v ko di n 5-7 ngy. Trong trng hp trng c
va th liu PAM l 2 n 4 gam/ngy bng ng tnh mch chia lm 4 ln. Trong trng hp
trng c nng v c ngun tch lu th dng liu cao phi hp tim v chuyn qua ng tnh
mch duy tr liu cao ca PAM trong mu, liu thng dng l 6 n 8 gam/ngy v ko di
hng tun.
- p ng vi P2AM: du chng thuc tm vn ng p ng tt nht.
2.4. H tr h hp
- Khai thng ng h hp: ht m gii kh c du suy h hp d nh, nu t p ng iu tr th
nn t ng ni kh qun.
- Th Oxy: khi c suy h hp cung lng cao 8-10L/pht hay 3-4L/pht ty theo trm trng
(nu c suy h hp mn th th oxy cung lng thp 1-3L/pht.)
- H hp nhn to: l phng tin iu tr cn thit trong nhng trng hp nng, p ng khng
hon ton vi iu tr, suy h hp cp. H hp nhn to cn c ko di rt lu c th 2-3 tun.
Do cn phi c my th mi m bo h hp nhn to tt v ko di, cn khai thng kh qun
v cho th my ng lc v kp thi.
Cm dng Aminophylline hay thuc tng t v Aminophylline c tc dng ph l gy
nn ma, chng mt, hn lon tinh thn, co git h huyt p.
2.5. Cc bin php iu tr khc
- Chng sc: bng nhng phng tin thng l d dt khi dng cc thuc tng huyt p. Kinh
nghim cho thy nu gii quyt tt cc khu khc th vn chng sc t c t ra. Nu tt
huyt p cn b dch v cho thuc nng huyt p nh Dopamine v Dobutamine.
- Truyn dch: khng nhm thi cht c m ch nhm chng sc nu c, b lng nc mt qua
m hi, ma, tit dch v nui dng. Loi dch v lng dch truyn s thay i ty theo nhu
cu. Truyn dch cng l mt phng tin a Atropine vo c th v nui dng bnh
nhn.
- Chng co git: bt an, lo lng, c th dng thuc chng ng kinh nh diphnylhydantoine, cc
thuc an thn nh, trnh lm lit cc c quan thn kinh sinh thc. Cm dng Morphine v lm suy
h hp m thng c lm d do hi chng Muscarine..
- D phng bi nhim: nht l phi nn dng khng sinh c hot ph rng nh nhm
Cphalosporine th h 3 nh Cefotaxime, Ceftriazone liu 2-3 gam/ ngy hoc Quinolone th h
2 nh Ofloxacine hoc Ciprofloxacine bng ng chuyn tnh mch.
562

- Chng cc thc n c cha lipide nh sa v lm gi tng s hp thu ca thuc.
2.6. Theo di bnh nhn
- Theo di tht st khng nhng khi bnh nhn hn m, m ngay c khi tnh, c p ng iu tr.
- Theo di pht hin cc du chng v bin chng nng xut hin, hay cc du chng nng ti
xut hin tr li sau khi gim liu Atropine, c thi x tr kp thi.
VII. PHNG NGA
1. Qun l cht ch s phn phi v x dng thuc tr su gc phosphore hu c.
2. Ph bin rng ri cc khi nim v c tnh ca thuc cho dn chng nht l nng dn v
nhng ngi bo qun thuc.
3. Ph bin cc nt ln v iu tr xung tn tuyn di. Nht l vic sc rut v iu tr sm
bng atropine bng liu cao.
VIII. TIN LNG
Nu c iu tr sm, ng mc, th nhng trng hp nh va c tin lng tt, nhng tin
lng nhng trng hp nng vn xu, nht l c suy h hp ko di. Nhng trng hp trng
c nng v cp bnh nhn hn m v ri lon trung tm sinh thc rt sm gy t vong nhanh
lm khng kp hi sc thng l cht ti ch hay trn ng di chuyn bnh nhn n bnh vin
vi ngng tim, ngng th.
IX. KT LUN
Trng c cp thuc tr su gc photpho hu c l mt cp cu ni khoa trm trng, cn c
nh gi ng mc v trm trng, x tr, ng mc tht sm vi cc bin php loi b cht
c. Atropine liu cao, ti lp nhiu ln, P2AM liu cao v lin tc ng thi cn phi hp v h
tr h hp nhn to nht l th my ko di chng ssuy h hp v ngng th. Ngoi ra cc
bin php chng chong, ngn nga bi nhim v nui dng cng l nhng bin php h tr
quan trng gip cu sng bnh nhn.




563

BNH T MIN
Mc tiu
1. Trnh by c c ch bnh sinh bnh t min
2. Chn on c cc bnh t min thng gp.
Ni dung
I. I CNG
Bnh t min l tnh trng bnh l xy ra do b my min dch mt kh nng phn bit cc khng
nguyn bn ngoi v t khng nguyn. T khng nguyn l thnh phn ca c th, v l do no
tr thnh vt l, t khng th ca c th chng li cc t khng nguyn ny lm bnh t min
xy ra.
Cn phn bit bnh t min vi phn ng t min, phn ng t min lm xut hin cc t khng
th nhng khng gy bnh, nh cc t khng th c to sau s hoi t m gp phn loi b cc
cht phn hu.
Bnh cn c mang nhiu tn khc nhau nh: Bnh do t khng th, bnh do t cng kch, bnh
do t duy tr, bnh t d ng, bnh t mn cm, tn gi thng c dng nhiu nht l bnh t
min.
II. C CH BNH SINH
Cha c c ch no c th gii thch tt c cc trng hp bnh t min, c th c ch thay i
theo bnh.
Bnh thng cc thnh phn ca c th trong thi k bo thai tip xc vi h li ni m, sau
ny tip xc li s c nhn bit l ca c th, khng lm pht sinh khng th chng li, l
tnh dung np min dch. Tnh dung np min dch ny v lm pht sinh bnh t min trong 4
trng hp sau:
1. Trng hp 1
C s trng hp ngu nhin gia mt khng nguyn l vi mt thnh phn ca c th. C th sn
xut khng th chng li khng nguyn ny (v d vi khun) ng thi chng lun b phn c cu
trc ging khng nguyn. V d bnh thp tim, cht hexosamine c trong lin cu (tan huyt
nhm A cng c trong glucoprotein van tim, do khng th khng lin cu, khng lun van
tim.
2. Trng hp 2
Do tc ng ca nhim c, nhim khun, chn thng, mt s t bo ca c th b tn thng
v thay i cu trc tr thnh vt l, cc t bo min dch coi chng l khng nguyn l v sn
xut khng th chng li. V d vim gan virus.
3. Trng hp 3
Mt s b phn ca c th mu khng tip xc trc tip, t bo min dch khng n c, khi
chng xut hin trong mu (v d chn thng) c th s to khng th chng li, nh trong bnh
nhn mt, khi b tn thng mt bn lm xut hin khng th chng lun mt kia gy nn bnh
vim mt giao cm (ophtalmie sympathique).
564

4. Trng hp 4
Do tn thng hoc suy yu kh nng kim sot ca chnh cc t bo min dch. H thng c ch
tng hp t khng th b suy yu, do vy cc t bo min dch pht trin v sn xut khng th
chng li cc thnh phn vn vn quen thuc ca c th. V d mt s bnh ca h lin vng ni
m thng c km thiu mu huyt tn do xut hin cc khng th hng cu t sinh.
III. CC LOI T KHNG TH, HU QU CC PHN NG T MIN
1. Cc loi t khng th
Cc t khng th trong bnh t min tc ng gy bnh bng nhiu cch nh hu hoi, lm
thng tn, c khi li kch thch c quan ch gy nn nhng biu hin khc nhau. C hai loi t
khng th
- T khng th chnh: gy bnh tht s nh t khng th chng b mt hng cu, chng
bch cu, chng mng nn, chng th th acetylcholine.
- T khng th ph: i km bnh t min ch khng quyt nh s gy bnh. V d: t
khng th chng t bo thnh d dy trong bnh Hashimoto l mt t khng th khng c hiu
cho c quan bnh l gip, t khng th chng cc ht nhn, chng ti lp th, chng c tim.
2. Hu qu ca cc phn ng t min
- Tiu t bo do thc bo, b th, lympho T c t bo (thiu mu tan mu)
- Lng ng phc hp min dch ti cc m ch (lupus ban h thng)
- Vim mn vi thm nhim t bo n nhn (Hashimoto)
- Hoi t t bo, thoi ha dng t huyt (vim cu thn cp)
- Kch thch t bo (Basedow).
IV. C TNH CHUNG CA CC BNH T MIN
Vi quan nim v bnh t min nh nu trn do c s lm dng trong chn on, ngoi
vn cn c nhiu kin ngc nhau trc nhiu bnh c tht s l bnh t min hay khng ? Ni
chung hiu bit v bnh vn cn phi tip tc tm hiu thng nht. Sau y l mt s c im
ca bnh t min:
- Bnh thng gp ngi tr hoc ng tui (thng t 20 n 40 tui). Tr em v
ngi gi t gp hn. N gp nhiu hn nam. Thng c yu t di truyn, c tnh cht gia nh.
- Bnh tin trin tng t, nng dn (v vy bnh c tn l bnh t duy tr) din tin
thng phc tp, a dng t cp tnh, ti cp n nh, dai dng.
- C th tn thng ng thi nhiu c quan.
- Khng c nguyn nhn trc tip r rt. Tuy nhin bnh c th xy ra sau cc tnh hung
sau: Nhim c, nhim trng cp, mn, thai nghn, sang chn tinh thn hoc th cht, tc nhn
vt l nh chy nng, K, sau dng mt s thuc, bnh c th p ng kh tt vi mt s thuc c
ch min dch nht l corticoide.
V phng din chn on, khng c tiu chun chung cho cc bnh t min tuy nhin bnh
cnh lm sng, din tin v mt s xt nghim gi hng n bnh t min nh gim v c
565

hng cu, bch cu, tiu cu c th km tng lympho, tng tc lng mu, tng gamma -
globulin...
Chn on chnh xc da trn s pht hin cc t khng th, cng c hiu, cng chnh xc, iu
ny ch c th c thc hin cc trung tm chuyn su.
V. XP LOI
Nhng bnh t min l tp hp mt nhm bnh khng ng nht, c ch sinh bnh cha c
hiu r hon ton v s xp loi cn tranh ci. Sau y l s xp loi c nhiu ngi ng :
1. Cc bnh t min chc chn
pht hin c t khng nguyn v t khng th. Bnh c th thc nghim c, v d
bnh Lupus ban h thng, hi chng Goodpasture, bnh nhc c, vim tuyn gip
Hashimoto.
2. Cc bnh rt c th l t min
pht hin c t khng th, v d thiu mu c tnh vi t khng th chng yu t ngoi lai
v chng t bo thnh ca nim mc d dy.
3. Cc bnh c th l t min
Do cc biu hin lm sng v s ci thin sau iu tr bng c ch min dch, v d vim lot i
trng xut huyt.
4. Phn ng t min
Gm nhiu bnh, pht hin c t khng th nhng ngi ta khng r cc t khng th ny
c ng vai tr gy bnh hay ch n thun nh mt du ch im ca bnh. V d khng th
khng myeline trong bnh x cng ri rc.
VI. MT S BNH T MIN CHNH
1. Cc bnh cht to keo
1.1. Lupus ban h thng
Do cc t khng th chng cc khng nguyn nhn, nh ADN, Ro, Sm. Thng xy ra n, tr
(90%). Tn thng nhiu c quan. Da: ban hnh cnh bm mt, lot nim mc ming, rng
tc. C xng khp: vim, au c, vim nhiu khp. Thn: gy hi chng thn h. Thn kinh:
tn thng nhiu ni ca thn kinh. Tim mch: vim mng ngoi tim kh, c dch, co tht, vim
c tim, vim ni tm mc, nhi mu c tim do vim mch vnh, huyt khi mao mch. Phi:
vim phi km theo xp, x phi, vim mng phi. Huyt hc: ri lon ng mu, thiu mu, tan
mu. Tiu ha: tiu chy, thng rut, gi tc rut, vim ty cp, tng men gan. Mt: vim mch
mu vng mc gy m, vim lot kt mc, vim thn kinh th, kh mt.
1.2. Vim khp dng thp
Do t khng th khng HLA DR4, DR1, nguyn nhn khi pht c th l virus Epstein Barr.
1.3. Hi chng Sjorgen
Do t khng th chng t bo thng b ng nc bt, t khng th chng khng nguyn nhn,
gy hi chng kh (mt, nc bt, mi).
566

2. Bnh ni tit
2.1. Vim tuyn gip mn Hashimoto
Bnh do t khng th chng Thyroglobulin, chng Thyroperoxidase, vi tiu th. Thng xy ra
n, tuyn gip c th ln hay khng, thm nhim lympho. Giai on u c th c cng gip
thong qua sau suy gip, din tin chm, c th km cc bnh t min khc.
2.2. Bnh Basedow
Do t khng th TSI, TBII, TGI.
2.3. i tho ng typ 1
Do t khng th khng o Langerhans, khng glutamic acid decarboxylase, khng t bo b ta.
2.4. Mt s bnh ni tit t min khc
-Addison tin pht: TKT chng v thng thn.
-Suy cn gip tin pht: TKT chng t bo chnh ca tuyn cn gip.
-V tinh trng tin pht t min: TKT chng tinh trng.
3. Huyt hc
3.1. Thiu mu c tnh Biermer
Do TKT chng t bo thnh, TKT chng FI v TKT chng FI + Vitamin B12 gy thiu mu u
st, teo nim mc li, d dy km thm nhim lympho.
3.2. Thiu mu tan mu t min
Do TKT chng KN b mt hng cu t nhin, biu hin tan mu cp hay mn, xy ra mi la
tui. Cp, thng xy ra tr em sau mt s bnh cp nh: vim phi do Mycoplasma, Eaton,
quai b, zona, thy u, cm, vim gan siu vi... Mn, thng xy ngi ln sau cc bnh mn
nh bch cu lympho mn, lupus ban h thng, Hodgkin, nhc c, vim i trc trng chy
mu, Basedow, x gan...
3.3. Gim tiu cu t min
Do TKT chng tiu cu, bnh t gp hn, gy ban xut huyt gim tiu cu mn n c hay kt
hp mt s bnh mn nh bnh bch cu lympho mn, Hodgkin, lympho khng Hodgkin, u
tuyn c, thiu mu tan mu t min, lupus ban h thng...
3.4. Bt sn ty do t khng th chng t bo mm ty xng.
3.5. Gim bch cu do t khng th chng bch cu.
4. Thn kinh
4.1. Bnh nhc c
4.2. X cng ri rc
Do t khng th chng myeline thng xy ra ngi tr (15-40 tui) vi cc thng tn thn
kinh a dng, ri lon cm gic vn ng, tiu no, cc thng tn v mt, thng tn ty xng,
vi cc bt thng v tinh thn. Bnh din tin tng t nng dn.
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4.3. Hi chng Guillain - Barr
Vim a r dy thn kinh, cha hin r v t khnh th, gy lit ngoi bin hai chi di, dch no
ty c phn ly m - t bo.
5. Tiu ha gan mt
5.1. X gan do mt tin pht do t khng th khng Mitochondrie
5.2. Vim gan mn tn cng do t khng th chng c trn, t khng th chng lipoprotein ca
t bo gan.
5.3. Bnh Coeliakie do t khng th chng Reticuline.
5.4. Vim lot i trng xut huyt: cha tm thy t khng th.
5.5. Bnh Crohn gy hp tng on ng tiu ha nht l i trng, lm sng v cn lm sng
d ln vi lao i trng, cha tm thy t khng th.
6. Thn
6.1. Mt s bnh vim cu thn v vim ng thn k: do t khng th chng khng nguyn nhn
v khng nguyn u, khng IgG.
6.2. Hi chng Goodpasture: do t khng th chng mng nn cu thn.
7. Phi
Hi chng Goodpasture: do t khng th chng mng nn ph nang phi. Vim ph nang x ha
v cn. Bnh u ht ca Wegener, hai bnh sau ny cha r t khng th.
8. Da
Pemphigus tht s: T khng th chng cht lin bo ca thng b. Pemphigus Bot: t khng
th chng mng nn ca thng b. Vitiligo t khng th chng melanocyte.
9. Vim mch
Nh cc bnh vim ng mch thi dng, bnh u ht ca Wegener, bnh Churg Strauss, vim
nt quanh ng mch. Cc bnh ny cha r t khng th.
VII. KT LUN
Bnh t min l mt tp hp bnh phc tp m nguyn nhn gy bnh, c ch bnh sinh cn
nhiu iu cha r, do iu tr cn nhiu iu cha nh mun, trong tng lai iu tr c
hiu bng khng th n dng c nhiu ha hn.

568

LIU PHP KHNG SINH
Mc tiu
1. Trnh by c cc loi khng sinh thng s dng trn lm sng.
2. M t c c ch tc dng, dc ng hc ca tng loi khng sinh
3. Xc nh c nhng ch nh, chng ch nh, tc dng ph ca cc loi khng sinh
4. Trnh by c cc c ch, nguy c v bin php nhm hn ch khng khng sinh.
Ni dung
I. NH NGHA KHNG SINH
Khng sinh l nhng tc nhn khng khun c ngun gc t vi sinh vt, hu hiu nng thp.
Hin nay khng sinh c xem nh l nhng hp cht ha hc khng khun hoc dit khun tc
ng mc phn t, hu hiu vi liu lng thp v s dng iu tr bnh nhim trng.
II. MT S NGUYN TC KHI CH NH KHNG SINH
1. Pht hin v xc nh nhim trng
Da vo khm xt lm sng (tiu im tin pht v th pht nhim khun), cn lm sng (cng
thc bch cu), xt nghim vi khun (nhum Gram, cy mu,CRP...)
2. Tnh hung lm sng ch nh khng sinh
Cp cu, iu tr nhim trng thng thng hay iu tr d phng.
3. Chn la loi khng sinh
Hiu r c ch tc dng loi khng sinh ang s dng, tm hiu c quan b nhim khun,
loi vi khun.
5. Tnh trng ngi bnh (chc nng thn v gan)
Khi men gan >2.5 ln nng bnh thng cn thn trng cc khng sinh gy c tnh cho gan.
nh gi h s thanh thi creatinine (ml/pht)
nam = [(140 - tui) x cn (kg)] / [Ccrea (mol/l) x 0,8]
n = 0,85 [(140 - tui) x cn (kg)] / [Crea (mol/l) x 0,8]
Bng 1: Cc giai on suy thn
Giai on suy thn Creatinine (mol/l) thanh thi (ml/pht)
Giai on khi u 13 - 300 30 - 50
Giai on tin trin 300 - 600 15 - 30
Giai on sau cng 600 - 1000 < 15
Chy thn nhn to - < 10
Khi chc nng thn gim cn gim liu lng khng sinh thi qua thn.
5. Phi hp khng sinh hay dng n c (ch khng thuc)
6. ng vo ca khng sinh (ti ch, ung, tim bp, tnh mch, chuyn tnh mch...)
569

7. Theo di p ng ca khng sinh: d phng khng khng sinh v tc dng ph ca khng
sinh, bit cch x tr cc tai bin do thuc.
8. Thi gian s dng khng sinh: hp l, kinh t nhng phi cht lng.
III. PHN LOI KHNG SINH
1. Nhm beta lactamin
1.1. Phn nhm penicillin (Penicilin G, V, M, A...)
1.2. Penemes (Thienamici v imipeneme - meropenem)
1.3. Cephemes (cephalosporine th h 1, 2 v 3). Cephamycine, oxacepheme...
2. Nhm khng sinh c ph khun rng
Tetracyline
Phenicole (Chloramphenicol)
Rifamycine
Fosfomycine
3. Nhm Aminoside
Streptomycine, gentamycine, amikacine, tobramycine, netylmycine, dibekacine, isepamicine,
aminocyclitol, spectinomycine.
4. Nhm khng sinh c ph khun trung bnh
Macrolide (erythromycine, spiramycine, josamycine, midecamycine) Fusidamine.
Glycopeptide: Vancomycine v Teichoplanine
5. Nhm khng sinh c ph khun hp
Lincosamide (Lincomycine, clindamycine)
Polypeptide cyclique (Polymycine B, E, Bacitracine, Mupirocine)
6. Nhm c ch sinh tng hp vi khun
Thuc chng phong: Sisulone (Dapsone), Clofazimine (Lamprene)
Sulfamide (n thun, phi hp (sulfamide + trimethoprime)
Khng sinh ng tiu. Quinolone (th h 1, 2 v 3),
Nitrofurane
Khng sinh ng rut. 5 nitro imidazole (metronidazole, nimorozole, ornidazole, tenonitrozole,
tinidazole, secnidazole...) 8 hydroxyquinoleine: Broxyquinoline (entercine), Tibroquinol
(intetrix)
Khng lao (rifampicine, Isoniazide, ethambutol, pyrazinamide...)
IV. C CH TC DNG CA KHNG SINH
1. c ch tng hp vch t bo
Nhm Beta lactamine (penicilline, cephalosporine): c ch s lin kt ngang cui cng ca cu
570

trc Mucopeptide ca vch t bo lm vi khun d b tan.
- Vancomycine, Bacitracine: c ch hnh thnh Mucopeptide ca vch
2. c ch mng nguyn tng
- Nhm Polymycine (Polymycine B), Gramicine A: tc ng ln cu trc ha hc c bit ca
mng gy ph v mng.
3. c ch tng hp protein
- Nhm Phenicol: c ch tc ng ca peptidyl transferaza lm cn tr kt hp Aa vo chui
peptide mi sinh n v 50S ca ribosome.
- Nhm Cyline: c ch s gn ca aminoacyl tRNA vo phc hp m RNA ca n v 30S
ribosome.
- Nhm Macrolide v Lincosamide: kt hp vi tiu n v 50S ribosome
- Nhm Aminoside: bng cch gn vo protein tip nhn trn n v 30S ca ribosom lm c sai
thng tin ca RNA.
- Nhm Mupirocin (polypeptide): c ch Isolosine tRNA synthetase
4. c ch chuyn ha t bo
Bactrime: cnh tranh c ch enzyme lin quan 2 giai on ca sinh tng hp acid folic.
- Sulfonamide do c cu trc tng t nh PABA (acid para aminobenzoic) l mt cht chuyn
ha cn thit trong qu trnh tng hp acid folic gip tng hp Purine v DNA) i vo phn ng
thay cho PABA nhng khng c hot tnh sinh hc, kt qu ngn cn s pht trin vi khun.
- Trimethoprime: c ch men Dihydrofolic redutaza, men ny bin i acid dihydrofolic thnh
acid Tetrahydrofolic, mt giai on trong chui phn ng tng hp purin v DNA.
5. c ch tng hp acide nhn hoc hot ng
- Rifampin: c ch tng hp DNA (c ch RNA polymeraza ph thuc DNA)
- Nhm Quinolone: c ch tng hp DNA (c ch tiu n v A ca DNA gyraza)
- Nhm Imidazole: c ch tng hp DNA
- Novobiocin: c ch tng hp DNA
V.CC LOI KHNG SINH THNG DNG TRN LM SNG
1. Nhm Penicilline
1.1 C ch tc dng: Dit khun bng cch lin kt vi protein ca vch vi khun thng qua c
ch lin kt ngang ca vch t bo, lm tan vch do c ch thm thu.
1.2 Dng trnh by: Benzylpenicillin, penicillin G, procaine penicillin, benzathyl
penicillin, Phenoxypenicillin.
1.3. Dc ng hc
Penicillin phn b cc t chc. (thp mt, tuyn tin lit, t chc xng v dch no ty
(ngoi tr trong vim mng no).Thuc thi qua nc tiu (60 - 90% trong 6 gi). Penicilline thi
qua thn (10% lc cu thn v 90% tit ng thn v b c ch mt phn bi Probenecid. Thuc
571

qua nhau thai v c trong sa m. Thuc nhy cm vi lin cu, ph cu, lu cu, no m cu,
trc khun gram dng, xon khun (Leptospira, Giang Mai, Borrelia), vi khun k kh. Thuc b
khng t nhin vi trc khun gram m (Bacteroide, Legionella, Mycoplasma,
Mycobacterium...). khng vi t cu (85 - 95%), lu cu (15%), v ph cu.
Penicilline c ch nh trong nhim trng do lin cu, ph cu, no m cu, xon khun
(treponeme), clostridium perfingens v d phng nhim trng hoi th. Nhim trng h hp, rng
ming, tai mi hng, thn, sinh dc, da, t chc mm, ni tm mc, nhim trng mu vi cc vi
khun ni trn.
1.4. Liu dng
Penicillin G: 2 - 4 triu V / TM 4gi thng ch nh trong giang mai thn kinh.
Penicillin V: 250 - 500 mg/ ln/ ngy 4 ln.vim thanh qun do lin cu nhm A.
Benzathine penicilline 1,2 - 2,4 triu V/ 3 - 4 tun 1 ln hin x dng trong d phng thp tim,
vim cu thn, vim thanh qun do lin cu..
Procaine penicillin ; hin t dng.
Vim mng no hoc vim ni tm mc: 10 - 24 triu V / ngy, dng tnh mch ngt qung 2-4
gi ln.
2. Nhm Penicillin c ph rng
Trnh by: Aminopenicillin, Caeboxypenicillin, Uredopenicillin;
Dc ng hc: Penicilline A c khun ph rng i cu khun rut v trc khun gram m.
Thuc phn b khp cc t chc v dch c th (30% dch no ty), thi tr trong nc tiu (75%
trong 6 gi), ng mt (20%) qua nhau thai v sa m.
Ch nh: Penicilline A c ch nh vim mng no, nhim trng tai, mi, hng, phi, thn, sinh
dc, ng mt, tiu ha, ni tm mc, nhim trng huyt, thng hn, bnh Lyme, bnh
pasterella, bnh do listeria.
Ampicilline:250-500 mg/ 6 gi ng ung trong vim xoang, vim thanh qun, vim tai gia,
ng tiu.
Liu ampicilline 2 - g/ TM 4 - 6 gi nhim trng gram (-) nng
3. Dng kt hp
Nhm penicillin + c ch beta lactamase (clavulanic, sulbactam,tazobactam).
Augmentine (Amoxicilline + Acide clavulanique.) vim xoang, vim tai gia v nhim trng da.
Unasyn (ampicillin + sulbactam): k kh, vim ng h hp trn v di do gram (-), ng tit
niu, nhim trng t chc mm,
Timentin (Ticarcillin + clavulanic acid) vi khun k kh, vi khun rut, nhim trng ti t chc
mm
Zosyn (piperacillin + tazobactam) ch nh nh trn
4. Nhm Penicillin khng penicillinase
Trnh by: Methicillin, Oxacillin, Cloxacycillin, Dicloxacillin, Nafcillin..
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Dc ng hc: Penicilline M ngoi ch nh nh trn cn c ch nh i t cu cc c
quan c, khp, t chc mm, phi, sinh dc, ni tm mc, nhim trng huyt. Penicilline M hp
thu qua ng ung (ngoi tr meticilline) tc dng i vi t cu.
Tc dng ph c tnh ca penicilline v dn cht
Chong phn v, vim thn k, thiu mu, gim bch cu. Vim gan (oxacillin v nafcillin)
D ng: biu hin ngoi da (nga, ni m ay, hng ban), bnh huyt thanh (st, vim khp, hch
to, lch to, giam bch cu).Lon khun rut: tiu chy (Amocillin).
au ti ch, vim huyt khi, nhim Na, Kali. Chch Penicilline gn thn kinh ta cng gy tc
dng tng t.Bnh no cp; ri lon thc, co c, tng phn x, co git, hn m. Dng liu cao
penicillin (> 20 triu), liu cao oxacillin, cloxacillin, ticarcillin.Xut huyt khi dng > 40 triu
penicillin/ngy, carbenicillin, ticarcillin, azlocillin, piperacillin (trn 3 tun).
Liu cao Nafcillin gy gim bch cu, ticarcillin, mezlocillin v pipericillin gy gim kali kim
ha, tng men gan v c ch ngng tp tiu cu
5.Nhm cephalosporine
5.1. Trnh by v phn loi
- Th h I: cefazolin, cephalothin, cephapirin, cephradine, cefadroxyl.
- Th h II:
+ cefuroxime, cefonicid, cefamandole
+ cefoxitin, cefotetan
+ cefmetazole
+ cefuroxime axetil, cefprozyl, cefdinir, cafaclor, lobracarbef
- Th h III: cefotaxim,, ceftriaxone, ceftizoxime, cefoperazone)
- Th h IV: Cefepime
5.2. Dc ng hc
Cephalo I hp thu tt qua ng tiu ha (ch yu l cephalexine, cefadroxil, cefatrizine,
cefradine), thuc phn b khp c th ngoi tr dch no ty, thi tr qua nc tiu, thuc qua
nhau thai v sa m.
Thuc tc ng trn nhiu khun rut (Klebsiella, Escherichia coli, Proteus miabilis, shiigella,
salmonella), Haemophilus Influenzae, t cu, lin cu, bch cu clostridium perfingens, xon
khun, leptospira. khng mt vi chng ca E.coli (10%), Klebsiella (10%), P.Mirabilis
(15%), H. Influenza.
Cepha I v II c ch nh bnh nhim trng cc vi khun nhy cm ng h hp, tai mi
hng, tit niu sinh dc, xng khp, da, t chc mm, nhim trng nng ngoi tr vim mng
no.
5.3. Liu lng
Cefazolin: 1-2 g/ TM, TB/ 8 gi.
Cephalothin, cephapirin, cepharadine: 1-2 g/ TB. TM / 4 gi
573

Cefadroxyl, cephalexin, cephadrine: 500 - 1000mg/ 6 gi/ ng ung.
Cephalo II khng hp thu qua ng tiu ha (ngoi tr cefuroxime), tc dng tt hn th h I,
nhng cng khng qua mng no.
Cefuroxime 1,5 g/ TM, TB mi 8 gi. Cefonicid 1-2 g/ ngy, cefamandole 1-2 gamTM. TB/ 4-6
gi bnh l nhim trng ng h hp, vi khun k kh.
Cefoxitin 1-2 g/ TM mi 4 - 8 gi, cefotelan 1 - 3 g/ TM mi 12 gi, cefmetazole 2 gam TM / 6 -
12 gi.
Cefuroxime axetyl 250 - 500 mg/ ung mi 12 gi, cefdinir 300 mg/ ung mi 12 gi, cefaclor
250 - 500 mg/ ung mi 12 gi.
Cephalo III v IV c tc dng tt v c khun rng hn so vi th h I v II. Nng thuc trong
dch no ty bng 20% huyt tng, bn hy 1 gi, thi trong nc tiu v mt dng khng i
(60% trong 24 gi).
Cephalo III ceftriaxone 1-2 g / TB, TM mi 12 - 24 gi., cefotaxime 1-2 g/ TB,TM mi 4 - 12
gi, ceftizoxime 1 4 gam/ TB,TM 8- 12 gi, cefoperazone 2 - 4 g/TM mi 12 gi
Cephalosporine th h IV. Cefepine (500 mg - 2 gan/ TM hoc TB mi 8 - 12 gi dng trong
nhng trng hp nhim trng nng, khng, thng phi hp metronidazole nhim trng tiu
ho nng.
5.4.Tc dng ph v c tnh
Chong phn v, vim thn k, thiu mu, gim bch cu. Cephalosporine th h III c th gy
si bn v bnh gan mt v th h II gy xut huyt.
D ng (0,05%) ging penicilline Ri loi tiu ha: tiu chy, bun nn, nn ma, nhim nm,
gim tiu cu, tng men gan.
c cho thn do cephaloridine. Dng ng tnh mch c th gy au, vim huyt khi ti ch
(ch yu cephalothine), vim no km ri lon thc, co git (liu cao bnh nhn suy thn).
Gim prothrobine (d phng vi vitamine K)
6. Nhm Macrolide
6.1.Tn thuc trn th trng
Erythromycin, Dirithromycin, Propiocine, Oleandomycin, Spiramycin
6.2. C ch tc dng
Tc ng trn tng hp protein bng cch lin kt vi tiu n v 50S ribosom
6.3. Dc ng hc
Tc dng kim khun Hp thu ng tiu ha khng u. Phn b cc t chc (ngoi tr no,
dch no ty v nc tiu), thi tr ch yu qua dch mt.
Thuc tc dng i cu khun v gram m, mt vi trc khun gram m, k kh. khng t
nhin vi vi khun rut (pseudomonas, Mycoplasma hominis). khng cho vi haemophilus
influenzae (60%), cu khun rut (50 - 70%), t cu (15 - 30%), ph cu (22%), lu cu, trc
khun.
574

6.4. Ch nh
Cc bnh l thng c ch nh nh vim hng, vim xoang, vim xng, vim ph qun,
vim phi, nhim trng da (mn trng c).
6.5. Tc dng ph v c tnh
Ri lon tiu ha, au thng v, nn, tiu chy, au bng.Tn thng gan min dch d ng:
mt, vng da. tai v kch tnh mch (chuyn tnh mch).
Tng tc dng thuc chng ng, digoxin, theophyllin, khng histamin,cyclosporine (do c ch
cytochrome P450).
Erythromycine 250 - 500 mg/ mi 6 gi hoc 0,5 - 1 g/ TM mi 6 gi.
Trnh liu trn 4 gam/ ngy.
Dirithromycin 250 - 500 mg/ ung mi 12 gi
Clarithromycin 250 - 500 mg/ ung mi 12 gi
Azithromycin 500 mg ung/ ngy u ri 250 mg/ ngy trong 4 ngy
7. Lincosamide
7.1. Tn th trng
Lincomycin (lincocine), clindamycin (dalacine)
7.2. C ch tc dng
Trn s tng hp protein bng cch lin kt vi tiu n v 50S ribosom
7.3. Dc ng hc
Tc dng dit khun, hp thu ng tiu ha hon ton (clindamycine tt nht), thuc phn b
khp c th c bit xng v khp (rt km dch no ty), chuyn ha gan, thi tr qua
mt v phn, lng t hn nc tiu. Clindamycine c tc dng tt hn.
Tc dng i vi nhm k kh, lin cu, ph cu, t cu. khng t nhin i vi Haemophilus
nluenzae, lu cu, no m cu v vi khun gram m. Nhy cm khng thng xuyn i vi t
cu vng khng erythromycine v methicilline, mt s clostridiae (10 - 30%) v bacteroides
(20%).
7.4. Ch nh
Nhim trng nng c bit do t cu v vi khun k kh (ngoi tr vim mng no, nhim trng
thn v h tit niu).
7.5. Liu lng
Liu Clindamycin 20 - 30 mg / kg / ngy (chia 2 ln)
7.6. Tc dng ph v c tnh
Ri lon tiu ha, tiu chy, vim rut kt mng gi (tiu chy, co cng thnh bng, st, mt
nc v in gi, xut huyt rut).Nn, nga hu mn, vim ming, vim li, ri lon v gic.
Vim tnh mch, h huyt p, ri lon nhp tim, ngng tim (khi tim tnh mch nhanh). Thng
tn t bo gan, c quan to mu (gim 1 n 3 dng). D ng: nga, ni m ay, pht ban, hi
575

chng Lyell v Stevens Johnson.
8. Nhm cycline
8.1. Tn th trng
Tetracycline, oxytetracycline, doxycycline, minocycline.
8.2. C ch tc dng
Tc ng trn s tng hp protein bng cch lin kt vi tiu n v 50S ribosom
8.3. Dc ng hc
Thuc c tc dng kim khun, thuc phn phi t chc ni v ngoi bo (ngoi tr no, dch
no ty v khp), thuc t b chuyn ha (ngoi tr doxycycline), thi tr di dng hot tnh qua
ng mt v trong nc tiu.
Thuc hp thu khng u qua ng tiu ha, hp thu km khi dng chung aluminum hydroxide,
gim tc dng khi dng Ca, Fe.
8.4. Ch nh
Bnh Brucella, st hi quy, st Q, vim phi khng in hnh, bnh mt ht, nhim trng c
quan sinh dc, bnh ht xoi (Nicolas favre) dch hch. St rt khng chloroquine, mn trng
c. Thuc c ph khun rng. khng t nhin vi Seratia, vi khun rut, mt vi loi proteus,
Pseudomenas aeruginosa, mycobacterium. khng hin nay vi vi khun k kh (80%), trc
khun rut (75%), lin cu nhm B (50%), lin cu nhm C v G (45%), lin cu nhm A (30%),
ph cu (16%), t cu (30%), Escherichia coli (50%), Klebsiella (50%), Salmonella (25%),
Shigella (40%).
8.5. Tc dng ph v c tnh
Di ng.Ri lon tiu ha, vim ming - hu hng - thc qun,.Vim gan, suy thn, tng p ni
s.Dng Demeclocyclin gy i tho nht (c ch ADH), tng ure mu nu dng chung vi li
tiu.Gn vo xng, rng tr em gy chm pht trin xng, hng rng, vng rng.Thuc qua
nhau thai gy tc dng tng t cho bo thai. Ri lon nhp tim. Chong phn v khi dng ng
tnh mch (doxycycline), hin tng cm quang. Ri lon tin nh, nhim nm candidose tiu
ha.
9. Nhm Phenicol
9.1. Tn th trng
Chloramphenicol, Thiamphenicol. (hin khng dng ti M).
9.2. C ch tc dng
Tc ng trn s tng hp protein bng cch lin kt vi tiu n v ribosom 50S
9.3. Dc ng hc
Tc dng km khun, thuc khuch tn cc t chc v th dch (dch no ty 50%), Thuc thi
di dng cn hot tnh trong nc tiu (70% i vi thiamphenicol v 15% i vi
chloramphenicol) trong mt (5 - 6%) v trong phn (20%). Thuc qua nhau thai v c trong sa
m. Thuc khng t nhin vi pseudomonas, Acinetobacter, Mycobacterium...)
576

9.4. Ch nh
Nhim trng cp tnh ng h hp, gan mt, mng no (Haemophilus), niu o (gonococcus),
tiu ha nh do thng hn hoc salmonella, vi khun k kh.
9.5. Liu lng
12,5 - 25 mg/kg/ TM mi 6 gi, liu ti a 1 gam/ TM mi 6 gi.
9.6. Tc dng ph v c tnh
Thiu mu: Ty thuc vo liu dng v thi gian s dng, c bit ngi c suy gan, s hi phc
sau vi tun.. Bt sn ty: khng ph thuc liu dng cng nh thi gian dng, tin lng nng.
Hi chng xm: gp tr em v tr em non, nn, nhp th nhanh, tm nhanh, phn xanh, ng
lm, try mch v t vong. Dng ko di gy vim thn kinh th gic, vim thn kinh ngoi vin,
ri lon tiu ha, gy ni m ay v pht ban. Trnh khi c thai, cho con b, tr s sinh, suy gan,
thiu mu.
10. Nhm Aminoglycoside
10.1. Tn th trng
Streptomycin, gentamycin, tobramycin, amykacin, neltimycin, framycetin, sisomicin,
paromomycin, kanamycin, dibekacin...
10.2. C ch tc dng
Tc ng trn s tng hp protein bng cch lin kt tiu n v ribosome 30S.
10.3. Dc ng hc
Thi gian bn hy ty thuc chc nng thn., Khng hp thu bng ng ung. Thuc
khuch tn vo phn ln t chc v th dch ca c th, trong ti nhu m thn cao hn huyt
tng. Thuc hp thu km mt, tuyn tin lit, khng qua hng ro nhau thai, sa m v hng
ro mu no, h thn kinh trung ng, mt.Thuc thi qua nc tiu siu lc ch yu (65% sau 6
gi, 85% trong 24 gi).
- Ch nh: Nhim trng vi khun gram m ti thn v h tit niu, nhim khun huyt v vim
ni tm mc, nhim trng da, nhim trng h hp v khp xng.
10.4. Liu dng
Streptomycine: 15 - 25 mg / kg / ngy. Chia 1 - 2 ln
Amikacin: 15 mg / kg / ngy.. chia 2 ln.
Gentamycin 5mg / kg / ngy. chia 1 - 3 ln ngy.
Tobramycin 5 - 7 mg / kg / ngy. Chia 2 - 3 ln ngy.
Spectinomycin 40 mg / kg / ngy (Dng 1 ln)
10.5. Tc dng ph v c tnh
Ri lon thnh gic: tin nh b c gy chng mt, mt iu ha, rung git nhn cu, tai gim
hoc mt thnh lc, nng gy t thng khng hi phc.Yu t thun li nh l dng mt s
thuc c c tnh vi thnh gic (furosemide, vincomycin), ngi cao tui, suy thn, thai nghn
(nh hng thai nhi).
577

c vi thn: Thuc thi qua thn, tch ly v thn v gy bnh ng thn cp, thng xy ra
ngi ln tui, c bnh thn, b mt nc.
Gin c vn: Gy lit mm, nh hng c quan h hp xy ra ngi b bnh nhc c, gy m
c curate, tim thuc nhm aminoside vo mng bng, mng phi, c s dng canxi phi hp. D
ng: chong phn v.
11. Nhm Quinolone
11.1. C ch tc dng
Tc ng trn s tng hp DNA bng cch c ch DNA gyrase (tiu n v A)
11.2. Trnh by
Th h 1: Flumequin, cc acid nalidixic, oxolinic, pipemidic.
Th h 2 (fluoroquinolone): norfloxacin, ofloxacin, ciprofloxacin.
Th h 3: Sparfloxacine (Zagam)
Th h 4: Trovofloxacine.
11.3 Dc ng hc
Hp thu tt nhng c i lc vi kim loi nng, b c ch khi dng chung vi Fe, Ca v mt s
cation, nn dng 1 gi trc v 2 gi sau n. Tc dng dit khun, Thuc c hp th nhanh tt
hu nh 100%, t nng cao sau khi ung khong 6 gi, thuc phn b khp cc t chc v
dch nh phi, da, mn nc, c t cung, bung trng, m v dch tuyn tin lit, m. Thuc
thi ch yu qua ng thn 80%, thi gian bn hy t 6 - 8 gi.
11.4. Ch nh
Cc nhim khun gram dng, m v k kh (nhim trng da, tit niu, c quan sinh dc, h hp
v lao
11.5. Tc dng ph v c tnh
Ri lon tiu ha, au vng thng v, bun nn. Nhc u, chng mt, ng g, o gic l ln, co
git. au khp, au c, v to. Ni m ay, pht ban, hin tung cm quang. Tng men gan
SGOT, SGPT, v LDH, tng bch cu acid, gim bch cu trung tnh, gim tiu cu. Zagam gy
ri lon nhp tim trong trng hp QT ko di (khng c phi hp vi cordarone). Tng tc
dng ca theophylline.
11.6. Chng ch nh
C thai, ang cho con b, tr s sinh, ngi gi trn 70 tui.Suy gan, suy thn, bnh nhn b tm
thn, thiu men G6PD. Ngi li xe, lm vic trn cao, s dng my mc.
12. Nhm Nitroimidazole
12.1. C ch tc dng
Tc ng trn tng hp DNA bng cch tch lu cc cht chuyn ho c tch nh hng trn
nhiu tin trnh sinh hc
12.2. Trnh by
Metronidazole, Ornidazole, Tinidazole, Secnidazole
578

12.3. Dc ng hc
Thuc khng khun, hp thu nhanh, t nht 80% sau 1 gi, nng huyt tng khi s dng bng
ng ung v tim truyn gn ging nhau, thi gian bn hy t 8 - 10 gi. Lin kt vi protein
khong 20%. Thuc khuch tn nhanh, mnh vi nng cao phi, thn, gan, mt, dch no
ty, nc bt, tinh dch, dch tit m o. Thuc qua nhau thai v sa m.
Thuc chuyn ha qua gan, nng cao gan v mt, thp rut, t bi tit qua phn, m ch
yu qua nc tiu v c mu nu.
12.4.Ch nh
Bnh do Amibe, Trichomonas, Giardia intestinalis, vi khun k kh
12.5. Tc dng ph v c tnh
Ni m ay, nga. Chn n, bun nn, v kim loi ming, vim ming, nim li, li en, i
lng. Nhc u chng mt, c th gy vim no v co git, vim ty. Gim bch cu a nhn,
gim bch cu nu dng ko di. Vim a dy thn kinh (cm gic v vn ng). Thn trng: ph
n c thai (3 thng u), ang cho con b, bnh tm thn v thiu mu. Gy ung th sc vt th
nghim.
13. Nhm sulfamide
13.1. C ch tc dng
c ch chuyn ho acid folic bng cch cnh tranh c ch cc enzyme trong 2 giai on
sinh tng hp acid folic.
13.2. Trnh by
Sulfamides + Trimethoprime: Bactrim (Cotrimoxazole)
Sulfamide: Adiazine (sulfadiazine), sulfamide chm (fanasyl, fansidar)
13.3. Dc ng hc:
Bactrim c kh nng dit khun, hp thu nhanh v gn nh hon ton (90%), phn b khp cc t
chc nh dch no ty, tuyn tin lit, mt, tai gia, phi. Thoi bin gan, thi ra trong nc
tiu, dch mt v phn. Thuc c khun ph rng i vi vi khun ng rut (E coli, proteus,
citrobacter, salmonella, shigella, vibrio chlera, listeria, pneumocystis carinii, toxplasma gondii).
Nhy cm khng thng xuyn vi (Klebsiella, vi khun rut, lin cu, ph cu, t cu).
khng vi khun k kh, mt vi loi cu khun rut nh pseudomonas aeruginosa,
campylobacter, xon khun, leptospirose, mycoplasma...
Sulfamide: Thuc c tc dng kim khun, dung np tt bng ng ung, phn phi khp cc t
chc k c dch no ty, thi tr qua nc tiu v ng gan mt.
13.4. Ch nh
Bactrim c ch nh trong nhim trng do vi khun nhy cm h tit niu, tuyn tin lit, h
hp, tai gia, tiu ha, thng hn, vim i trng. Nhim trng do Pneumocystis carinii v do
toxoplasma gondii.
Sulfamide (Adiazine) ch nh trong nhim trng ng tiu cp do cc chng nhy cm.
Fansidar dng trong iu tr st rt khng thuc.
579

13.5. Tc dng ph v c tnh
Pht ban, nga, thng tn nim mc bong biu b dng bng nc (hi chng Lyell, hi chng
Stevens Johnson).St, gim bch cu, thiu mu, tan huyt, vim gan.Ri lon tiu ha: chn n,
bun nn, tiu chy. Thn kinh: mt, mt ng, nhc u, tai. Tit niu: tiu t, tiu mu
13.6. Chng ch nh
D ng sulfamide, thiu G6PD, suy gan, suy thn, c thai, ang cho con b, tr s sinh.
14. Nhm glycopeptide
14.1. C ch tc dng
Tc ng trn vch t bo bng cch a vo nhng tiu n v vch mi (muramyl
pentapeptide)
14.2. Trnh by
Vancomycin, teicoplanin
14.3. Dc ng hc
Vacomycine c tc dng dit khun do c ch sinh tng hp vch t bo, thay i tnh thm ca
mng t bo.Thay i s tng hp ARN ca vi khun. Thuc khng hp thu qua ng tiu ha,
phn b khp cc t chc ngoi tr dch no ty, thi ra trong nc tiu (90% trong 24 gi).
Thuc nhy cm vi t cu vng, cu khun rut, clostradium, lin cu, ph cu, no m cu, lu
cu, bch hu.
khng t nhin i vi cc trc khun gram m, mycobacter v cc vi nm.
14.3. Ch nh
Nhim trng do t cu vng khng meticilline (ngoi tr vim mng no), vim ni tm do
lin cu, trc khun rut, t cu. Ch nh khi c st ngi b gim bch cu, vim phc mc
trong qu trnh thm phn.
14.4. Liu lng
20-30 mg/kg/ngy chia 2 hoc 3 ln, chch tnh mch 10 mg/kg trn 20 pht. thi gian bn hu
c th ln n 8 ngy.
14.5. Tc dng ph v c tnh
Phn ng lin quan n tim truyn (ging nh chong phn v, ni m ay, nga). Truyn chm
(1 gam/ chuyn trn 60 pht) c tnh trn thn do liu lng cao. c cho tin nh c tai.
Gy ic v chng mt (nng huyt tng qu 80 g/ml). Gim bch cu (2%), Vim tnh
mch, cc phn ng khc (st, bun nn, lnh run, hi chng Stevens Johnson).
15. Nhm thuc khng lao
15.1. Isoniazid
+ C ch tc dng: c ch tng hp thnh phn lipid ca vch t bo vi khun
+ Dc ng hc: Thuc thu tt qua ng tiu ha, Phn b khp cc t chc k c thn kinh
trung ng. Thi trong nc tiu.
+ Liu trung bnh 15 mg/kg/ ngy, ngi ln 300 mg/ ngy, ti a 900 mg/ngy
580

+ Tc dng ph: mt ng, bt an, au c, tng phn x, co git, ng kinh. Vim gan (20%)
ngng thuc khi men tng gp 3 ln.Vim dy thn kinh ngoi bin (phi hp Pyridoxin 25 - 50
mg/ ngy) c bit ngi gi, c thai, i tho ng, suy thn, nghin ru, tm thn.
15.2. Rifampin
- C ch tc dng: Tc ng trn s tng hp DNA bng cch c ch enzyme polymerase RNA
ph thuc DNA (DNA- dependent RNA polymerase).
- Dc ng hc: Phn b khp tt chc k c thn kinh trung ng(nng 50% so vi huyt
tng), Thi ch yu qua gan v t hn nc tiu
- Liu lng:
Rifampin: 10 - 20 mg/kg (600 mg/ ngy)
Rifabutin: (300 mg/ ngy) dnh cho bnh nhn nhim HIV.
Rifapentine (600 mg/ 2 ln mt tun trong 2 thng)
- Giao thoa thuc: Thuc lm tng chuyn ha thuc chng ng, thuc nga thai, Thuc lm
gim nng mt s thuc methadone, ketoconazone, chloramphenicol, thuc h ng huyt,
thuc chng lon nhp v ciclosporine.
- Tc dng ph nh pht ban da, ri lon tiu ho, viem gan, vim thn k, tng acid uric
(rifapentine).
15.3. Pyrazinamide
- C ch tc dng: dit vi khun trong i thc bo nhng c ch khng r
Tc dng dit khun Phn b khp cc t chc k c mng no (tng ng huyt tng)
- Liu 15 - 30 mg/kg/ ngy, ti a 2 gam.
- Liu duy tr 50 - 75 mg/ 2 ln tun, ti a 4 gam
- Tc dng ph nh nn, bun nn, st, tng acid uric. Liu cao gy c tnh cho gan
15.4. Ethambutol
- C ch tc dng: tc dng kim khun nhng khng r c ch
Hp thu qua ng tiu ha, Thi qua thn 20% v qua phn 50%, thm qua mng no km.
- Liu lng: 15 - 25 mg/kg/ ngy
- Liu duy tr 50 - 75 mg/ 2 ln tun ti a 2,5 gam.
- Tc dng ph: Tng acid uric, vim thn kinh th, gim th lc, gim th trng.
15.5. Streptomycine.(xem nhm Amonoglycoside)
15.6. Mt s thuc khng lao khc
- Aminosalicylic acid (PAS)
- Clofazimine.
- Capreomycin.
- Cycloserine.
581

- Ethionamide
- Fluoroquinolones (ofloxacin 750 mg/ ngy 2 ln v ciprofloxacin 400 mg/ ngy 2 ln.).
VI. PHI HP KHNG SINH
1. Mc ch
- Gim kh nng xut hin chng khng ( khng t bin) trong iu tr lao
Nhm iu tr trong trng hp nhim nhiu loi vi khun (vim phc mc, vim ni tm mc,
ph qun ph vim, abces no...)
- Tng kh nng dit khun, nht l trng hp nhim trng nng
- Ngi bnh gim sc khng (suy gim min dch, i tho ng...)
2. Kt qu
- Tng tc dng ph
- Tc dng i khng
PNG tc ng giai on vi khun ang nhn ln, Tetracycline c ch pht trin t bo.
Khi phi hp dn n tc dng i khng nh phi hp Erythromycine + Lincomycine hoc
Clindamycine + Chloramphenicol. Hay c tc dng i khng do c cng tc ng vo mt ch.
Gim hot tnh do tng k thuc: gentamycine + Penicilline ha cng dch chuyn
(Gentamycine b mt hot tnh bi Penicilline) lm gim tc dng.
- Tc dng hip ng
c ch cc giai on khc nhau trong cng mt chu trnh chuyn ha ca vi khun.
Bactrime (Sulfamethoxazole + Trimethoprime)
Augmentine (Amoxilline + acide clavulanique) cht sau c tc dng c ch men beta lactamase
(beta lactamine khng b phn hy, pht huy tc dng.
Mi loi khng sinh tc ng vo mt trong nhng qu trnh ca tng hp vch vi khun
Khi phi hp lm tng tc dng (Ampicilline + Oxacilline, Ampicilline + Ticarcilline)
Khng sinh tc ngvo vch to iu kin cho khng sinh khc xm nhp ni bo. Phi hp
Penicilline + Streptomycine.
Oxacilline + Gentamycine (Tobramycine) iu tr t cu.
Carbenicilline hoc Ticarcilline + gentamycine iu tr Pseudomonas aeruginosa.
Cephalothine + Gentamycine iu tr Klebsiella.
3. Cch thc phi hp ( c thc nghim trn lm sng)
Nhm Penicilline + nhm Penicilline hoc cht c ch Beta lactamase
Nhm Penicilline + nhm Nitroimidazole hoc nhm Aminoglycoside
Nhm Penicilline + Aminoglycoside + Nitroimodazole hoc Lcosamide
Nhm Cephalosporine + nhm Penicilline
582

Nhm Cephalosporine + nhm Penicilline+ Licosamide
Nhm Aminoglycoside + Licosmide hoc Nitroimodazole
VII. KHNG KHNG SINH
1. C ch khng thuc khng sinh ca vi khun.
1.1 Tng ph hy hoc bin i cu trc ca thuc khng sinh
Do men (qua trung gian ca Plasmid); men betalactamaza khng nhm beta lactamine; men
cephalosporinaza khng cephalosporine; men phosphorylaza, adeylaza, acetylaza bt hot
aminoside; men acetylaza bt hot chloramphenicol.
1.2. Bin i th th ca thuc
Lm bin i protein c hiu vi thuc Ribosome lm thay i s gn vo th th ca thuc,
v th VK tr nn khng vi khng sinh (khng aminoside, Erythromycine, rifampicin,
Bactrime...)
1.3. Gim tnh thm mng nguyn tng
Do mt (khng aminoside) hoc lm thay i h thng vn chuyn mng nguyn tng (khng
Beta lactamine, chloramphenicol, quinolone, tetracycline, bactrime...) lm cho khng sinh khng
thm vo ni bo c.
1.4. Tng s to thnh mt men mi
Mt s vi khun c mang plasmid khng thuc, c kh nng to nn mt men mi c i lc
mnh hn (khng sulfonamide).
2. Cc loi khng khng sinh
2.1. khng gi
- H thng min dch ca c th suy gim (dng corticoide, tia x...)
- Vi khun ngoan c trong trng thi ngh (khng nhn ln, khng phn bo do thiu oxy, pH t
chc b thay i).
- Vt cn (do tun hon b tr) khng sinh khng thm ti vim.
2.2. khng tht s
2.2.1. khng t nhin
Do mt s vi khun bn cht khng chu tc dng ca mt s khng sinh (E.Coli khng
Erythromycin, Pseudomonas khng Penicillin...). Vi khun khng c vch nh Mycoplasma
khng chu tc dng ca khng sinh c ch qu trnh tng hp vch (penicillin, cephalosporin,
vancomycin).
2.2.2. khng thu c
Do bin c di truyn, vi khun t ch khng tr thnh c gen khng. Gen khng c th nm
trn nhim sc th trn plasmid hoc Transposon.
+ Plasmid l 1 phn t AND t sao chp nh hin din trong nguyn tng ca vi khun. Mt
Plasmid c th cha mt hoc nhiu gen khng gi l R plasmid.
Cc plasmid ca vi khun thng mang trn n cc gen cho php chng gn vo b mt nim
583

mc, to ra c t v xm nhp. Cc plasmid khng thuc c th truyn cho nhau gia cc vi
khun lm lan nhanh s khng thuc.
+ Transposon l nhng gen c kh nng di chuyn, cn gi l gen nhy, l nhng on DNA cha
gen khng, c th nhy t plasmid vo nhim sc th v ngc li hoc t plasmid ny sang
plasmid khc.
+ t bin gen: xy ra trc hoc sau khi tip xc khng sinh (ph thuc vo vic c hay khng
tip xc vi khng sinh).
t bin mt bc:
Mc khng khng ph thuc vo nng khng sinh c tip tc, c th ch sau 1 ln
t bin vi khun khng rt cao. Nng c ch ti thiu c th ln n 100(g/ml ( khng
SM, Lincomycine, INH).
t bin nhiu bc:
Mc khng lin quan n nng khng sinh sau mi ln t bin nng c ch ti thiu
cao hn ln trc (PNG, Cephalosporine, tetracycline, chloramphenicol, aminoside, sulfamide...)
Gen khng sau khi xut hin s lan truyn t th h ny sang th h khc, cng vi s phn
chia ca t bo vi khun.
3. Nguy c cho vic iu tr do vi khun khng
Gy thnh dch (thng hn);
Bnh mn tnh (bnh ng tit niu, h hp);
nhim khun bnh vin (lin quan s dng khng sinh ban u, iu tr d phng, cng tc v
trng, dng c y t nhim khun...)
VIII. D PHNG KHNG KHNG SINH
Khng nn lm dng khng sinh, ch dng khng sinh khi chc chc b nhim khun
Tng cng bin php v trng.
Cn cn nhc iu tr d phng hoc phi hp khng sinh.
Chn khng sinh theo khng sinh , c bit khng sinh c ph hp v c hiu.
Chn khng sinh khuch tn tt vo im nhim khun, ch n dc ng hc ca khng sinh.
Phi hp khng sinh hp l.
Tn trng thi gian dng thuc, cn c c s ngng thuc (din bin tt trn lm sng, s tr li bnh
thng ca cng thc bch cu, tc mu lng, CRP, X quang...)
Theo di lin tc tnh hnh khng ca vi khun x tr kp thi.

584

TIU SI HUYT, HEPARINE V KHNG VITAMINE K
Mc tiu
1. Trnh by tc dng, liu lng, ch nh, chng ch nh, cc tc dng ph v x tr ca tiu
si huyt trong iu tr bnh tim mch.
2. Trnh by tc dng, liu lng, ch nh, chng ch nh, cc tc dng ph v x tr ca
heparine trong iu tr bnh tim mch.
3. Trnh by tc dng, liu lng, ch nh, chng ch nh, cc tc dng ph v x tr ca cc
thuc khng vitamine K trong iu tr bnh tim mch.
Ni dung
I. TIU SI HUYT
1. i cng
- Tiu si huyt l s ly gii cc mu ng cha fibrine v tiu cu.
- Tiu si huyt (TSH) ch yu c x dng trong nhi mu c tim (NMCT) v thuyn
tc phi.
Cc mu ng fibrine tiu cu bao gm mt li fibrine gi cc tiu cu. S ph hu cc mu
ng cn phi ly gii li fibrine trc ht. iu ny thc hin nh plasmine l mt dn cht ca
mt tin cht bt hot gi l plasminogene. Plasminogen c hai loi: loi lu hnh di dng t
do v loi dnh vo fibrine ca cc mu ng.
Hot ho plasminogen thnh plasmine l mt qu trnh sinh l, chm, qua trung gian tPA (hot
ho plasminogen m) hoc nhanh hn nh TSH.
Cc cht TSH thng khc nhau v:
- Ngun gc: hoc xut pht t vi khun (streptokinase, anistreplase) lm cho chng c kh
nng khng gne mnh do thng chng ch nh khi x dng lin tip TSH qu gn nhau v
khi dng cn phi kt hp mt cch h thng vi corticoid. Hoc c ngun gc t cng ngh
gne nn khng c nhng bt li trn.
- Khc nhau v tnh c hiu ca plasminogen gn vi fibrine. i ny gii thch tc dng
TSH mnh hn v s tiu fibrine ton b thng yu hn (do plasminogen lu hnh t hot ho).
Tuy vy li t b tai bin xut huyt hn, c kh nng phi hp ng thi vi heparin v khng
cn theo di fibrinogen.
2. Cc cht TSH
Alteplase (Actilyse) l cht thng dng nht trong NMCT v nhi mu phi do m bo t l
nguy c xut huyt / tnh hiu qu (ti thng sut) tt nht. Cc TSH hin nay nh
retplase(rapilysine) ngoi nhng c tnh trn cn c tnh nng x dng cao hn nh chch liu
mnh trong 30 pht thay v chuyn trong 90 pht).
585

Bng 1: Mt s tiu si huyt thng dng
Tn cht TSH Ngun gc c hiu ln fibrine
ca cc mu ng
Ch nh v liu dng
Alteplase
(Actilyse)
Cng ngh gen C NMCT: 15mg TM sau
0.75mg/kg/30ph ri duy tr 0.5
mg/kg/60 ph (tng liu < 100 mg).
Nhi mu phi(NMP): 90
mg/kg/120 ph
Anistreplase
(Eminase)
Vi khun Trung bnh NMCT: 30 v/ 5 ph
Reteplase
(Rapilysine)
Cng ngh gen C NMCT: 10 v (2 liu mnh cch
nhau 30 ph)
Streptokinase
(Streptase)
Cng ngh gen Khng NMCT: 1.5 triu v/ 45ph
NMP: 100.000v/gi trong 12gi
n 24 gi
Urokinase
(Urokinase)
Cng ngh gen Khng NMP: 2.000 n 4.400 v trong 12
n 24 gi
Lu : S dng Heparine tnh mch (TM) lin tc kt hp TSH nhm trnh s ti tc cc mch
mu ti thng. Heparine dng ngay khi bt du alteplase, reteplase (1000 v/ gi) v xa hn
vi cc loi khc nh khi fibrinogen > 1g/l i vi streptokinase hoc 4 gi vi antitreplase.
Hemisuccinate hydrocortisone 100 mg TM ri 50 mg/ 6 gi c cho mt cch h thng vi
anistreplase, streptokinase v urokinase nhm trnh cc tc dng ph d ng
3. Ch nh
3.1. Nhi mu c tim
- NMCT di 12 gi vi cc tiu chun nh sau: au tht ngc > 30 pht, khng trinitrine,
ST chnh ln > 2 mm trong 2 chuyn o trc tim, > 1 mm i vi ngoi bin hoc bloc nhnh
tri.
- Mt s trng hp c th cho gia gi th 12 v gi th 24, nu cn au tht ngc v ST
cn chnh ln do kh nng NMCT din rng.
TSH m bo ti thng trong khong 70% trng hp, hn ch din nhi mu, gim s xut hin
suy tim v t vong v sau. Tuy vy phung php nong mch vnh vn u th hn TSH nht l
trong NMCT c chong. Cn kt hp h thng TSH vi aspirine v heparine.
3.2. Thuyn tc phi
- Ch ch nh trong thuyn tc phi mi xy ra < 7 ngy v c ri lon huyt ng.
- Khng ci thin d hu trung hn v di hn do nguy c tm ph mn.
TSH ci thin d hu ngn hn nhng nhi mu phi (NMP) c bin chng nh chong do tc
nghn cp mt nhnh ca ng mch phi.
586

3.3. Tc tnh mch gn
- Ch nh khng qui c: d c ci thin nhanh nhng du chng ti ch vim tnh mch,
TSH khng gim s xut hin nhng bin chng v sau (bnh tnh mch sau vim) v c nguy c
xut huyt khng b qua.
- Ch nh ch yu trong mt s trng hp tc tnh mch gn, vng ch hai, mi xy ra < 5
ngy, khng tc hoc khng bin chng NMP.
Liu tung t trong NMP v lun phi hp heparine.
3.4.Tc van nhn to
iu tr ch yu l thay van. TSH thng chng ch nh khi c tc mch no thong qua hoc tai
bin mch no. Ch ch nh khi bnh nhn c nguy c cao phu thut hoc khi ch phu thut.
3.5.Tc tnh mch trung tm
TSH ti ch vi 2 mg Actilyse.
4. Chng ch nh
Khi c chng ch nh phi chn phng n thay th TSH nh: nong van trong NMCT, ly cc
mu ng bng phu thut trong NMP. Sc in ngoi lng ngc khng phi l mt chng ch
nh ca TSH.
Bng 2: Cc chng ch nh ca TSH
Tuyt i Tng i
- Xut huyt no - mng no.
- Tai bin mch no(TBMN) kiu thiu mu,
ngay c TBMN thong qua (6 thng).
- Phu thut no - mng no (3 thng), mt (3
thng), mch mu c t dng c (2 thng), ni
tng hoc chnh hnh nng (1thng), tng qut
(15 ngy).
- Chn thng no mi xy ra.
- Xut huyt mi xut hin.
- Bnh vng mc i tho ng nng.
- Lot d dy- t trng tin trin.
- THA nng khng kim sot
- Chc ng mch hoc tnh mch trung tm
khng c p (10 ngy), sinh thit gan hoc thn,
chc mng phi hoc tu sng. Chch bp. (48
gi).
- Hi sc tim- phi ko di (xoa bp tim ngoi
lng ngc, t ni kh qun do chn thng)
- Tui > 75.
- Suy thn, suy gan nng.
- Gim tiu cu, ri lon ng mu.
- Thai nghn.
Chng ch nh i vi streptase, eminase, anistreptase: nhim lin cu mi mc, x dng
thuc < 6 thng, hen ph qun, d ng thuc.
5. Tc dng ph
- Xut huyt nng (3-4%) nht l xut huyt mng no (1%, nguy c lin quan tui) v tiu ho.
Phi ngng TSH v heparine, nu xut huyt khng kim sot phi cho aprotinine (antagosan),
acid aminocaproique (hemocaprol), acid tranexamique (exacyl). Nu cn phi chuyn mu, iu
tr tn thng xut huyt.
587

- Xut huyt nh nh chy mu cam, u mu, xut huyt ch chch.
- D ng thuc.
II. HEPARINE
Chia lm hai loi: heparine khng phn on (HKP) v heparine tiu chun c trng lng
phn t thp (HPTT).
1. Dc ng hc
1.1. c im
- Tc dng chng ng: cc HKP l nhng glycosaminoglycan, polymere trng lung phn t
cao to vi khng thrombine III thnh mt phc hp c ch s to thnh thrombine do ngn cn
cc cht hot ho ca n nh: yu t IXa, Xa, XIa (tc dng chng Xa)., c ch tc dng
thrombine (tc dng khng IIa).
Cc HPTT c to thnh do s phn on ca s ng phn HKP v su chn lc cc chui
ngn. S mt cc di heparine to ra s mt mt phn tc dng khng IIa, tc dng khng Xa vn
duy tr (t l khng IIa/Xa i t 1 trong HKP n 3 i vi HPTT). Tht vy, s c ch
thrombine cn c nhng chui di c nhim v lin kt ng thi vi thrrombine v khng
thrrombine III.
- Nhng tc dng khc ca heparine: chng vim, chng ngng kt tiu cu, hot ho tPA, c
ch s tng sinh ni mc, hot ho lipoproteine lipase, khng aldosterone, hot ho s ly gii
collagen.
2.2. Dc ng hc
- HKP: bt hot khi ung, ch cho bng ng tnh mch hoc di da, khng chch vo trong
c do nguy c t mu. Sau khi qua huyt tng, s c nh vng chc vo protein v m gii
thch li ch khi cho liu tn cngv cn phi gim liu heparine trong nhng ngy sau nhm duy
tr ngng iu tr. Heparine c thi gian bn hu 90 pht khi chch TM cho n 10 gi nu
chch di da (calciparine, chch hai ba ln mi ngy). Heparine loi tr qua gan, thi qua thn.
Heparine khng qua hng ro nhau thai do c trng lng phn t cao.
- HPTT: c nhng c tnh tng t HKP. S phn b sinh hc ti u do c nh m thp. Thi
gian bn hu ko di 4 gi ng TM, 12gi n 20 gi khi chch di da.
2. Cc loi Heparine
- HKP chch tnh mch: Heparinate de sodium: 1ml- 5.000 v.
- HKP chch di da: Heparinate de calcium (Calciparine) 1 ml: 25.000 v.
- HPTT:
+ Dalteparine (Fragmine) ng 2500, 5000 v 10.000 v khng Xa.
+ Enoxaparine (Lovenox) ng 20,40, 60, 80 v 100 mg (100mg= 10.000v khng Xa)
+ Nadroparine (Fraxiparine) ng 0.2, 0.3, 0.4, 0.6, 0.8, 1 ml(1ml= 10250 v khng Xa)
+ Reviparine (Clivarine) ng 1750 v 4200 v khng Xa.
+ Tinzaprine (Innohep) ng 0.5, 0.7 v 0.9 ml (1ml= 20.000 v khng Xa)
588

3. Ch nh
Bng 3. Ch nh v liu lng
Ch nh Liu lng
HKP D phng bnh l tc mch:
- Nguy c va.
- Nguy c cao
Calciparine TDD 5000 v 2 gi trc
ri chch mi 8 gi.
- Calciparine TDD mi 8 gi vi TCA gp
1.5 ln chng.
iu tr bnh l tc mch:
- NMCT cp.
- TBMN thiu mu
- Tc ng mch.
- ng mu ri rc ni mch
- Heparine TM:
500 v/kg/ngy +/- liu tn cng 100 v/kg
TM chuyn TM lin tc hoc gin on
(IVD/ 2gi)
- Calciparine TDD
5000 v/ kg/ngy trong 3 ln chch lin
tip.
HPTT D phng bnh l thuyn tc
- Nguy c va: chch trc mi th
nht di da 4 gi ri chch mi
ngy 1 mi.
- Nguy c cao: chch mi th nht
12 gi trc ri 1 mi/ ngy.
- Fragmine 2.500 v
- Lovenox 20 mg
- Clivarine 1750 v

- Fragmine 5000 v
- Lovenox 40 mg
- Clivarine 4200 v
iu tr:
au tht ngc khng n nh
-Fragmine 100v/kg 2 ln/ngy
- Lovenox 1mg/kg/2 ln/ngy
- Clivarine 175 v/kg 2 ln/ ngy
4. Chng ch nh
- Tuyt i: D ng Heparine, xut huyt ang tin trin nht l xut huyt no (< 2 tun) hoc
xut huyt ni tng (< 10 ngy), phu thut thn kinh- nhn khoa hoc chn thng s no nng
(< 3 tun), ri lon cm mu (bnh tiu si huyt, gim tiu cu), chch vo bp tht hoc vo
khp.
- Tng i: Hu phu, THA nng, lot d dy tin trin, dng phi hp thuc khng vim
khng steroid, aspirine, ticlopidine; vim ni tm mc nhim khun tr phi thay van c hc hoc
rung nh ; vim mng ngoi tim, bc tch ng mch, tc dng ph.
5. Bin chng v x tr
5.1. Xut huyt
- Nh: iu tr triu chng, kim sot thi gian cephalin (TCA) hoc hot ho khng anti Xa, vic
ngng heparine t khi cn thit tr khi qu liu hoc khng kim sot xut huyt c.
589

Nng: iu tr triu chng, kim sot TCA hoc hot ho khng anti Xa, ngng heparine, dng
cht i khng nu qu liu: protamine 1m TM/ 100 v heparine.
5.2. Gim tiu cu do heparine
- lin quan n cc loi heparine, thng gp vi HKP, chim 1%.
- Gim nh.
- Gim nng: triu chng nhm vi xut huyt gim tiu cu: tc mch nhiu cc mch mu
ln, trung bnh(TBMN, NMCT, thiu mu chi di...) hoc TM (TTP), thng nhiu ln d c
chng ng hiu qu, him khi xut huyt. Nng hn a n t vong > 50%.
Thi x tr: xc nh kh nng gim tiu cu bng ng nghim EDTA, ngng ngay heparine,
xc nh kh nng min dch d ng ca s gim tiu cu: tm khng th tiu cu dnh vi tiu cu
khi c heparine (lu tt m tnh khng loi b chn on). iu tr bt u vi Hirudine
(Refludan) hoc Heparinoid tng hp (Orgaran) duy tr sau bng khng vitamine K.
D phng: Khng dng heparine nu bnh nhn d ng. Thay th bng khng vitamine K liu
hu hiu vo ngy th 7 nhng trc phi khi u 1-2 ngy trc. Trong thng u cn kim
tra tiu cu mi 3 ngy.
Bng 4. c im v x tr gim tiu cu
Gim tiu cu nh Gim tiu cu min dch d ng
C ch Ngng kt tiu cu Ph hu tiu cu
Ngy Th 2 v th 5 Th 7 v th 20
c im - Va (>100.000tiu cu/ml)
- T t
- Lnh tnh.
- Khng triu chng.
- Thng gp (10%)
- R rt (< 50.000 tiu cu/pht)
- D di
- Trm trng (30% t vong)
- Thuyn tc ng-tnh mch nhiu ni.
- Him (1%)
Thi
x tr
- Tip tc heparine
- nh lng tiu cu hng ngy cho
n khi bnh thng

- Ngng ngay v xc nh v mt sinh hc
ca s d ng.
- Dng heparinoid hoc hirudine sau
duy tr bng khng vitamine K.
5.3. Cc tc dng ph khc
- Long xng v tng kali mu.
- Ni ban da.
- Tng men gan.
6. Cch cho thuc
6.1. Trc khi iu tr
Pht hin bt thung cm mu ng mu. Tm xem c suy thn, suy gan khng. D kin s thay
th bng khng vitamine K sm nu cn.
590

6.2. Trong khi iu tr
Bng 5.Theo di lm sng: tm du xut huyt. nh lng tiu cu mi 3 ngy.
Trc nghim Gii hn hiu
qu
iu chnh liu
lng
S ln lm trc
nghim
HKP TM lin
tc,

HKP TM/2 gi
TCA 1.5 - 3 ln
chng tng
ng TCA #
45-90 giy
< 1.5: tng
1000v/gi
3-4: gim
100v/gi
> 4: ngng 1 gi
sau gim 100
v/ml
- 4 gi sau khi bt
u chuyn hoc 4
gi sau khi chch
mi th 2.

HKP di da < 1.5: tng 0.05
ml/ln chch.
3-4: gim
0.05v/ln chch
> 4: b qua 1 ln
chch sau gim
0.05 ml
- tng t sau khi
thay i chuyn.
- hng ngy
HPTT iu tr Khng Xa 0.5 -1 v
khng Xa/ml
C th 10-20 v
khng Xa/kg/ngy
4 gi sau khi chch
mi th 2
HPTT d phng Khng, tr
phi
khi c suy
thn,
suy gan, xut huyt
7. Duy tr khng Vitamine K v Heparine
Cn lm sm vo ngy th 1 hoc ngy th 2. Dng liu heparine hu hiu cho n khi INR
(International Normalized Ratio) trong gii hn iu tr. INR vo gi 48- 72 sau khi bt u
khng vit K hoc sau khi chnh liu. Ngng heparine khi liu INR u tin hiu qu.
Bng 6. Mt s tnh hung x tr khi duy tr khng vitamine K/ heparine
INR TCA Thi x tr
Thch hp hoc cao qu Bnh thng, qu thp hoc
qu cao
Ngng heparine. Gim
liu khng vitamine K nu
cn
Qu thp Tng liu heparine
Tng khng vitamine K
Qu thp Bnh thng Heparine nh c
Tng khng vitamine K
Qu cao Gim Heparine
Gia tng khng vitamine
K
591

III. KHNG VITAMINE K
C hai nhm, nhm coumarine (coumadine, apegmone, sintrom, tromexane) v cc dn xut
indanedione (previscan, pindione) c tc dng c ch tng tranh vitamine K trong t bo gan.
1. Dc l hc
- Tc dng chng ng gin tip lin quan n s gim tng hp ti gan cc yu t ph thuc
vitamine K: prothrombine (II), proconvertine (VII), yu t Stuart (X) v chng hemophilie (IX)
cng nh protein C v S.
- Tc dng chng ng c nh gi qua ch s INR (international normalized ratio) gip
tiu chun ho nhng kt qu chng ng ngha l khng ph thuc vo lab xt nghim.
- Cc khng vitamine K c li l hp thu mnh qua ng tiu ho, di chuyn trong mu nh
s c nh mnh protein ri sau c chuyn ho ti gan. Nhng c im ny gii thch
nhng tng tc thng gp gia cc loi thuc khc ln khng vitamine K nh hp thu ti d
dy, c nh ln gan, thoi bin ti gan, bin i s tng hp nhng yu t ng mu nht l chu
k gan -rut ca vitamine K.
2. Cc loi khng vitamine K
Thng cc loi ny khc nhau ch yu da vo thi gian bn hu, sau n tc dng ph (d
ng vi indanedione).
Thi gian tc dng ngn cho thy c ch khi tc dng chng ng bin mt nhanh trong khi tc
dng ko di li c tc dng chng ng n nh.
Bng 7: Thi gian tc dng ca cc khng Vitamin K
Bit dc Tn gc Khi u tc
dng
Thi gian tc
dng
S ln dng mi
ngy
Coumadine Warfarine 36-72 gi 3-5 ngy 1
Apegmone Ticlomarol 36-72 gi 2-3 ngy 1
Sintrome Acenocomarol 24-48 gi 2-3 ngy 2
Tromexane Biscoumacetate
d ethyl
24-48 gi 1-2 ngy 2
Previscan Fluindione 36-72 gi 2-3 ngy 1
Pindione Phnindione 24-48 gi 1-2 ngy 2
3. Ch nh
3.1. Bnh l thuyn tc
+ Dng lin 6 thng sau khi tc mch phi hoc tc tnh mch su.
+ Tip tc trong cc trung hp: ti pht, bnh tm ph mn, bt thng ng mu do thiu
protin C.S, ATIII..
+ iu tr d phng trong b bt lu di chi di trong cc trng hp ny ch cn INR mc
va phi: 2-3.
592

3.2. Rung nh: Cho khng vitamine K lu di cn c t ra khi c nguy c tc mch trong rung
nh loi kch pht ri n mn tnh. Ch cc nguy c theo mc nh:
+ Nguy c cao: rung nh bnh van tim mc phi hoc nhn to, hoc van tim b tc ri, cc
ng nh tri, suy tim.
+ Nguy c va: rung nh xy ra nhng trng hp khng phi bnh van tim nhng c nguy
c tc mch nh: dy tht, tng huyt p, tui > 75, i tho ng.
+ Nguy c thp: Rung nh khng r nguyn do ngi tr, khng c bnh tim km theo.
Bng 8. Mc nguy c thuyn tc v iu tr
Nguy c thuyn tc iu tr Thi gian
Thp Aspirine ?
Trung bnh Khng vitamine K vi INR 2-3 Sut i
Nng Khng vitamine K vi INR 3-4.5 Sut i
Cc trng hp khc cn cho khng vitamine K trong 1 thng sau gim dn.
3.3.Van tim nhn to
Bng 9. S dng khnh vitaminK bnh nhn mang van tim nhn to
INR Loi van nhn to Thi gian dng khnh
vitamine K
3-4.5 C hc (tr nhng trng hp di y) Sut i
2-3 Van ng mch ch c hc, c cnh, nhp
xoang
Van sinh hc (v sa van) c rung nh

Van sinh hc (v sa van) c rung nh 3 thng sau phu thut
3.4. Cc nguyn nhn tc ng mch khc
- Suy tim bnh tim dn, nhm III v IV ca NYHA nht l khi c ri lon nh hoc tht.
- Phnh tht tri sau nhi mu.
- Bnh ng mch chi di (ch nh him v bn ci): vim ng mch ti thng nhng
li mch mu h lu km.
- Tai bin mch no hoc TBMN thong qua.
4. Chng ch nh
- Cho b.
- Thai nhng thng u do nguy c gy bnh no do coumarine v thng th ba do nguy c
xut huyt.
- D ng thuc.
- Xut huyt tin trin.
- Lot d dy t trng tin trin.
593

- THA c tnh.
- Phu thut thn kinh hoc phu thut mt mi xy ra.
- Tai bin mch no mi xy ra.
- Suy gan hoc suy thn nng.
4. Tc dng tng tc thuc khng vitamine K
Bng 10.Tc dng tng tc thuc khng vitamine K
Gia tng tc dng khng vitamine K c ch tc dng khng vitamine K
Gia tng s hp thu ng tiu ho cc
khng vitamine K
Gim s hp thu ng tiu ho cc khng
vitamine K
Chm nhu ng rut Thuc nhun trng.
Thuc chng lot.
Cholestyramine(Questran), than hot ho.
Gim s c nh protin khng vit K
Khng vim khng steroid
Aspirine liu cao.
Sulffamid h ng mu hoc khng sinh.
Fibrate
Acide tienilique (Diflurex)
Miconazone (Daktakin)

c ch thi qua thn
Probenecide (Benemide)
c ch thoi bin gan thuc khng vitamin
K
To nn s thoi bin gan ca khng vitamin K
Cimetidine
Allopurinol
Chloramphenicol
Ketoconazole
Barbiturique
Carbamazepine
Phenytoine (ihyan)
Meprobamate
Rifampicine
Griseofulvine
Ru
Gim s tng hp cc yu t ph thuc
vitamine K
Tng s tng hp cc yu t ph thuc vitamine
K

Suy gan nng
Khng vim khng steroid
Amiodarone
Ostrogene
Corticoid
594

Quinidine v dn xut
Gim nng vitamine K Tng nng khng vitamin K
mt
Khng sinh ung nht l tetracycline,
sulfamid
Cng gip
Thc n vitamin K
Vtamin K ung chuyn
6. Tc dng ph
6.1.Xut huyt
- Xut huyt nng (TBMN, xut huyt tiu ho, u mu c y chu hoc sau phc mc):
ngng ngay khng vitamine K, chuyn PPSB ngi (nu qu liu), chch vitamine K, duy tr
Heparine chch TM qua bm in khi INR < 1.5 vi TCA: 1.2-1.5.
- Xut huyt nh khng qu liu: INR> 5: ngng hoc gim khng vitamine K trong 24 gi ri
duy tr li vi 1/2 hoc 3/4 liu.
- Cm mu ti ch.
- Vitamine K ung nu qu liu nng INR > 8-10
6.2. Phn ng d ng vi indanedione
Him nhng nng: phn ng da, gim bch cu, gim tiu cu, bnh thn, vim gan.
6.3.Tc dng ph ca coumarine
au d dy, nn, nga, rng lng, lot ming.
6.3.Bnh no do coumarine
Xy ra ngay c vi pindione vo tun th 6 v tun th 9, l nguyn nhn teo mi, canxi ho u
xng, chm pht trin thn kinh vn ng.
7. Cch cho thuc
7.1.Trc khi cho thuc
Loi tr cc chng ch nh hoc tng tc thuc. Loi tr ri lon ng mu (INR, TCA) hoc
suy thn, suy gan, c sn nhm mu.
Bt u liu 1vin/ ngy (3/4 nu bnh nhn ln tui, nh cn, suy gan hoc suy thn va), INR
nh lng sau 48-96 gi.
7.2.Thay i liu mi 1/4 vin
nh lng INR v sau mi 48 n 96 gi cho ton b vic iu chnh liu. INR mi 48 gi khi
trong gii hn iu tr. Mi tun cho n khi n nh trong hai ln kim tra mu lin tip.
7.3. Cp bnh nhn mt phiu theo di thuc chng ng


595

LIU PHP GLUCOCORTICOIDE
Mc tiu
1. M t c i cng v glucocorticoide
2. Trnh by v dc hc lm sng phn loi glucocorticoide tng hp
3. Trnh by tc dng ca glucocorticoide
4. Trnh by ng dng lm sng ca liu php
5. Trnh by v tc dng ph v tai bin khi s dng liu php glucocorticoide
Ni dung
I. I CNG
Glucocorticoide l mt trong nhng hocmn c tng hp ti tuyn v thng thn trong
quan trng nht l cortisol. y l hocmn chuyn ha cht ng c tuyn thng thn
tit khong 15 - 30 mg /ngy vi 50% s lng c tit cao nht lc 6 - 8 gi sng. thi gian
na i huyt tng ca cortisol khong 70 - 90 pht. nng cortisol sinh l nh sau:
lc 8 gi sng: 3 - 20 g / dl (80 - 540 nmol / l) trung bnh 10 - 12 g / dl (276 - 331 nmol/l).
Lc 16 gi cn mt na so vi sng.
Lc 22 gi n 2 gi sng: di 3g / dl (80 nmol/l).
Trong Stress: tng ln 40 - 60 g / dl (1100 - 1600 nmol/l).
Liu php glucocorticoid da trn tc dng sinh hc ca cc thnh phn glucocorticoid tng hp
p dng trong lnh vc iu tr nhm mc ch khng vim, chng d ng v c ch min
dch. Corticoide dng tng hp c tc dng mnh hn so vi corticoide ni sinh. V th nu x
dng v lu di khng nhng gy nn mt s tc dng ph m cn c th gy c ch trc i -
Yn - Thng Thn, gy suy v thng thn. Liu php corticode nhm gp phn hng dn x
dng cc glucocorticoide tng hp c hiu qu.
II. DC HC LM SNG CA LIU PHP GLUCOCORTICOIDE
Cn phn bit liu php glucocorticoide ton thn trc tip hay gin tip v liu php
glucocorticoide ti ch.
1. Liu php glucocorticoide ton thn trc tip
Glucocorticoid tng hp c chia lm 3 nhm da theo thi gian tc dng sinh hc. thi gian
na i tc dng sinh hc da vo khong cch c ch v thng thn sau mt liu ca hp cht.
(1) loi tc dng ngn thi gian sinh hc na i 8-12 gi, (2) loi trung gian khong 18 - 36 gi
v (3) loi ko di 36-54 gi.
+ Thng c x dng l dn xut ca cortisol vi tc dng khng vim v tc dng corticoide
khong. Thuc hp th tt qua ng ung, tc dng sinh hc khong 90%.Cc dng 11 cto
c chuyn thnh 11 hydroxy c c tc dng. Cc t chc lin kt, da, cht hot dch u
hp thu tt cc cht ny. X dng dng ester tan trong nc dng ng tnh mch hoc tim bp
tht vi tc dng ko di hn.
596

+ Cc phn t lin kt vi proteine huyt tng: Vi liu thp. Transcortine b bo ha, khi dng
liu cao cc cht albumine dng ph thm (lin kt mnh hn). S lng dng hot ng ph
thuc vo liu v gim albumine huyt tng l nguyn nhn ca tc dng ph. Ngay c thai
nghn v x dng estrogene c th nh hng trn s lin kt proteine.
+ Chuyn ha ch yu gan v to thnh dng ester hoc glucuronide khng hot ha v thi
trong nc tiu. Chuyn ha chm trong trng hp thai nghn, x gan, tng hot gip v dng
thuc salicyl.
+ Thi gian na i huyt tng ca cc dn cht tng hp thng di hn so vi cortisol ni
sinh nhng tc dng sinh hc th khng lin quan n thi gian na i (c ch tc dng ni bo).
Bng 1: Phn loi glucocorticoide tng hp



Thi gian
1/2 i sinh
hc (gi)
Tng
ng (mg)
Tim nng
Gluco
corticoid
Tim nng
corticoid
khong
Thi gian
1/2 huyt
tng (pht)
Nhm Glucocorticoide
Tc dng ngn
Cortisol 20 1 2 90 8-12
Cortisone 25 0.8 2 80-118 8-12
Tc dng trung gian
Prednisone 5 4 1 60 18-36
Prednisolone 5 4 1 115-200 18-36
Triamcinolone 4 5 0 30 18-36
Methylprednisolone 4 5 0 180 18-36
Tc dng ko di
Dexamethasone 0.5 25-50 0 200 36-54
Betamethasone 0.6 25-50 0 300 36-54
Nhm corticoid khong
Aldosterone - 0.3 300 15-20 8-12
Florocortisone 2 15 150 200 18-36
Desoxycorticosterone
acetate
- 0 20 70 -
Prednisolone c cu trc cortisol vi cu ni i gia C-1 v C-2, lm tng tc dng
glucocorticoid v gim tc dng corticoid khong. Thm nhm alpha-fluoro C-9 lm tng tc
dng c hai, ngc li thm nhm hydroxyl hoc methyl C-16 lm gim tc dng corticoid
khong.
Dexamethasone c ni i C-1 v C-2, nhm fluoro C-9, v nhm alpha methyl C-16, c
tc dng glucocorticoid gp 25-50 ln.
597

Cu ni i C-2 v C-3, v methyl ha C-2 v C-16 ko di thi gian na i huyt tng,
2. Liu php glucocorticoide ton thn gin tip
+ Thng dng ACTH tng hp trong thnh phn C tn cng 25-39 hoc 26-39 b loi b,
c tc dng ci thin dung np.
+ Cc cht ACTH tng hp ny lm tng phng thch cc steroide thng thn, cortisol tng ti
a trong vng 30 - 60 pht i vi loi trung gian v tng sau 4 gi v ko di 24 - 36 gi i vi
loi chm.
+ Dng polypeptidique ch dng bng ng chch.
3. Cc dng khc
3.1. Tc dng ti ch
Khng gy c nu dng ngn ngy. Nhm steroid cha fluorinated (dexamethasone,
triamcinolone acetonide, betamethasone v beclomethasone) xuyn qua da tt hn nhm khng
cha thnh phn ny nh l hydrocortisone.
3.2. Glucocorticoid dng cho mt
Tn thng t min hoc v cn phn trc ca mt (mng mt, mng mch nho ca mt),
vim nhim sau phu thut hoc do chn thng s dng nhm hn ch ph n.
3.3. Glucocorticoid dng ht
Trong bnh hen ph qun v bch hu thanh qun.
3.4. Glucocorticoid ng mi
Kh dung trong vim mi d ng.
3.5. Glucocorticoid bnh khp
Dng chch vo khp (cn v trng)
II. TC DNG CA GLUCOCORTICOIDE
1. Mc t bo
+ Glucocorticoide dng t do tc ng ln th th c hiu ni bo.
+ Phc hp steroide - th th c hiu c hot ha v di chuyn vo nhn t bo, kch thch
sao chp ARN v tng tng hp proteine.
2. Mc chuyn ha
Glucocorticoide lm bilan azote m tnh bng cch tng thoi bin v c ch ng ha proteine
(ti gan tng tng hp protein v RNA). Tng thoi bin lipide thng xuyn ng thi bin i
chuyn ha protide theo hng chuyn ha cht ng (tng tn sinh ng, tng ng mu,
khng insulin ngoi bin).
Corticoide lm bilan phosphate - calci m tnh bng cch gim hp thu calci rut, tng thi
phosphate thn bng cch c ch hot ng ca to ct bo, c tc dng khng vitamine D.
Chuyn ha mui - nc b ri lon nng nhng ty thuc vo cc cht. Thng phi hp vi s
kim ha km mt kali v cng lin quan n gim khi lng c (nh hng ca c ch ng
ha v thoi bin proteine).
598

3. Mc dc ng hc
3.1. Tc dng iu tr
l cc tc dng khng vim, chng d ng v c ch min dch. Cortisol tc ng 3 mc c
bn.
- Thay i di chuyn cc thnh phn t bo n v tr vim (gim lymphocyte, gim bch cu i
toan i kim mt s thm nhp bch cu a nhn, gim s di chuyn cc t bo sn xut yu t
ha hng ng..).
- Thay i sn xut v hot ha cc cht vn mch (c ch phng thch histamine, c ch
bradykinine, gim leucotrien C, gim sn xut prostaglandine.)
- Thay i chc nng thc bo (gim kho lu hnh) v lymphocyte (gim lymphocyte T bi c
ch interleukine 2, gim lymphokin, monoki, gim sn xut khng th..). Chng nh hng trn
s tn sinh nguyn bo si, s tng hp collagen, v mucopolysacaride cng nh lm qu trnh
x ha v kt so.
- Tc dng khng vim v chng d ng thng c dng liu thp v ty loi sn phm.
- Tc dng c ch min dch vi liu cao (1 - 1,5 mg / kg i vi prednisolone)
3.2. Tc dng liu php corticoide ton thn gin tip
+ Do tc dng ca cortisol gy ra.
Tc dng gi mui v nc i khi b che du (tc dng corticoide khong do cortisol v kch
thch tit aldosterone).
Khng c tc dng c ch thng thn i vi ACTH tng hp, nhng v lu di c ch sn xut
ACTH c th xy ra.
+ Cc peptide ny kch thch to hc t (mlanogense) v lu di v c th c tc dng thoi
bin trc tip lipid v thn kinh.
III. NG DNG LM SNG LIU PHP CORTICOIDE
1. Thit lp phng thc iu tr lu di
Ngoi cc ch nh iu tr triu chng ko di (iu tr thay th trong suy thng thn cp, mn,
ph i bm sinh thng thn vi liu sinh l hng ngy ca hydrocortisone hay cortisone) vic
iu tr ko di corticoide rt quan trng cn phi m bo an ton ti a cho ngi bnh, tun
th mt s nguyn tc c bn v chn la phng thc ph hp cho tng trng hp.
1.1. Nguyn tc u tin
- Hn ch ch nh i vi tn thng m s trm trng ca tn thng da trn nguy c chp
nhn do iu tr m khng c mt phng tin iu tri tch cc v tt hn thay th.
- Cc ch nh trn lm sng:
1.1.1. Chn on v iu tr mt s bnh l v thng thn:
+ Suy v thng thn.
Suy v thng thn mn (Bnh Addison)
Suy v thng thn cp.
599

+ Tng hot v thng thn:
Chng ph i bm sinh v thng thn (s dng trong th loi bt thng v tng hp cortisol).
Hi chng Cushing (s dng sau khi ct b cc tuyn yn, thng thn iu tr)
Cng Aldosterone (s dng trong th th pht)
+ Dng trong mc ch thm d chn on: Thng x dng trong cc test dc ng hc (xem
thm d tuyn v thng thn)
1.1.2. Corticoid v s pht trin ca phi:
Pht trin phi ca bo thai i hi cortisol. V vy m x dng liu cao corticoid lm gim t l
suy h hp ngay sau sinh.Tr sinh non thng x dng betamethasone
1.1.3. Cc ri lon khng lin quan thng thn.(iu tr h tr)
1.1.4. Cc ch nh trn lm sng thng gp l:
+ D ng: ph do mch, hen, cn trng cn, vim da tip xc, d ng thuc, vim mi d ng, ni
m ay.
+ Bnh khp: Thp khp cp, vim khp mn,vim mng hot dch, vim gn c.
+ Bnh collagen: Vim nt quanh ng mch, lupus, vim a c, vima khp dng thp,
+ Vim ng mch thi dng (bnh Horton)
+ Ghp c quan (dng liu cao)
+ c ch min dch (dng liu cao)
+ Nhim trng G (-) chong (phi hp vi khng sinh)
+ Tng calci mu: tng canxi mu, carcinoma,
+ Mt: Vim kt mc d ng, vim thn kinh th.
+ H hp: hen lin tc, bnh ph qun phi tc nghn, sarcoidosis.
+ Tuyn gip: li mt trong bnh Basedow nng, Vim gip Hashimoto.
+ Bnh mu: Hogdkin, ung th mu, thiu mu huyt tn, xut huyt gim tiu cu v cn, bnh
bch cu n nhn,
+ Da: biu hin da ca bnh mu, pempigus c tnh, hng ban a dng, bong biu b cp, bnh
li ni m, hng ban nt
+ Tiu ha: vim gan mn, vim gan hoi t cp, vim i trng let
+ Bnh thn: hi chng thn h, vim cu thn cp,
+ Thn kinh: x cng ri rc.
+ Hi chng West.
+ Hi chng suy h hp cp tnh (SARD) ngi ln.
1.2. Nguyn tc th hai
+ Nguyn tc th hai l tn trng cc chng ch nh kinh in:
600

- Lot d dy t trng (liu prednisolone di 15 mg/ ngy t gy tai bin ny)
- i tho ng (khng n nh ng huyt)
- Tng huyt p (do tc dng gi mui)
- Nhim trng tin trin.
- Gim th trng r.
- Tin s tm thn.
- Cn kim tra trc khi x dng glucocorticoid vi liu dc l.
+ Hin din lao phi hay nhim trng mn tnh khc (X quang phi, IDR).
+ C ri lon dung np glucose hoc tin s i tho ng thai k.
+ C du hin tin long xng (m xng ph n mn kinh).
+ Tin s let t trng, vim d dy hoc vim thc qun.
+ C tng huyt p hoc bnh tim mch.
+ Tin s ri lon tm thn.
2. Cch thc s dng
2.1. Chn loi liu php
Thng u tin l dng trc tip hn l gin tip do nhiu l do: liu chnh xc, thch ng r, t
tc dng corticoide khong, khng tc dng kch thch hc t v lu di v c th chuyn dng
ng chch thay ng ung.
2.2.Chn ng dng
+ ng ung thng c a chung nht.
+ ng tnh mch dng trong trng hp cp cu, v dng liu tn cng ngay t u m ng
ung b hn ch.
+ ng tim bp c tc dng phn on liu trong mt thi gian, c tc dng hm ng k
nht l cc ch phm tr tnh m liu hng ngy khng th khng ch.
2.3. Nhp s dng thuc
+ Nhp x dng nhm m bo hiu qu iu tr ng thi ph hp vi nhp sinh hc ngy m
v iu ha cortisol u tin duy tr hot ng tit ca thng thn.
+ X dng mt liu bui sng loi prednisone, triamcinolone v dexmethasone hoc hai liu khi
i lm (2/3 liu) v khong 5 gi chiu (1/3 liu) loi hydrocortisone v cortisone acetate trong
ngy thng c khuyn co.
+ S iu tr khng lin tc c ngh chuyn sang dng liu i cch nht nhm gim tc
dng ph v hn ch s c ch trc i - Yn - Thng thn.
+ Hiu qu iu tr m bo trong cc trng hp thng tn trung bnh, nhng khng th m
bo i vi mt vi th vim nng v nht l ghp c quan m s iu tr i hi hng ngy.
601

2.4. Chn la thuc
+ im qua cc dn cht tng hp cortisol chng ta ghi nhn tc dng khng vim tng dn trong
khi tc dng gi mui t n. V th x dng cc dn cht khng vim cng mnh th thi
gian tc dng hm trc i - Yn - Thng Thn cng di, v lu di y l yu t nguy c tt
yu.
+ u tin chn mt trong nhng dn cht c tc dng hm yu (prednisone, prednisolone,
methylprednisolone) m tc dng khng vim m bo vi liu tng ng v dnh cc loi
khng vim mnh trong liu trnh ngn hn.
+ Cc loi cortisone, cortisol, prednisone v prednisolone qua nhau thai t. chnh nng
gia mu m v nhau thai l 10:1 i vi cortisol v prednisolone trong khi 2,5:1 i vi
betamethsone v dexamethasone.
2.5. Liu dng
+ Liu dng cn thch ng vi mc trm trng bnh l v v th c s khc bit gia mt
thng tn cp nng vi liu tn cng t 1 - 3 mg / kg/ ngy (prednisolone) hoc mt thng tn
tin trin mc va phi v th cn chn liu hiu qa ti thiu tng miligram.
3. Theo di iu tr
3.1. Theo di hiu qu iu tr
+ Cn tng liu v nhp iu tr nu cha m bo hiu qu v iu tr.
+ Trng hp t kt qu tt c th chuyn ng tim sang ung, gim liu mt cch thn trng
theo bc thang hng tun t liu ti thiu c hiu qu.
+ Liu php v lu di nn x dng cc dn cht gy hm it liu gn bng liu sinh l
+ Nhp x dng ch yu vo bui sng nhm hn ch suy v thng thn v sau.
3.2. Theo di dung np
+ Tm kim cc tc dng ph trong qu trnh iu tr. Cc tc dng ph ny c th l nguyn
nhn ca cc tai bin i khi nguy him v i hi theo di thng xuyn v cn nng, kch
thc, huyt p, nhit , da, c khp, tiu ha v phi.
+ Theo di xt nghim sinh hc ngay khi u liu trnh v nht l khi x dng liu cao nh:
Glucose mu, kali mu, ure mu, creatinine mu, triglycerides, cng thc mu (bch cu tng
khng hn l c nhim trng).
+ Cn tm kim cc tai bin do qu liu, cc tai bin do nghin c th xy ra di liu php
corticoide khi c stress hoc do gim liu qu nhanh, bnh nhn cn c bo trc v tnh
hung ny.
Mt s phng tin cung cp hng ngy cn ch hn ch ri lon chuyn ha ca
Glucocorticoid.
1. Theo di nng lng c x dng d phng tng cn.
2. Hn ch mui a vo d phng ph v tng huyt p v mt kali.
3. Cung cp kali nu cn.
4. Dng khng toan, khng tit, v/ hay dng c ch bm proton.
602

5. Thit lp thi biu x dng thuc glucocorticoide nu c. Bnh nhn x dng thuc
trong thi gian di cn c bo v trong thi k c stress cp bng cch tng liu gp i liu
hng ngy.
6. Hn ch ti thiu tnh trng long xng bng cch:
+ Thm hormone sinh dc: 0,625 -1,25 mg oestrogen vo chu k ca progesterone tr khi vn
cn t cung, testosterone thay th cho nam suy sinh dc.
+ Dng calcium liu cao: c th n 1200 mg/ ngy.
+ Dng vitamine D nu calciferol hoc 1,25 (OH)
2
vitamne D gim.
+ Dng calcitonin hoc diphosphate nu gy xng xy ra ngay c khi c iu tr nh trn
4. Ngng iu tr
+ y l mt ch nh ht sc thn trng
+ Ch c a ra nu s p ng v bnh l cho php thc hin iu . Tuy nhin trong mt
vi bin chng nng c th hng n sm hn d nh. S ngng thuc khng nn t ngt
nhm trnh hin tng nghin thuc.
4.1. Cch thc p dng
Nu s ngng thuc khng nn t ngt, gim liu c th nhanh cho n khi t c liu sinh
l, v rng corticoide cn m bo tc dng hormone (ngng nhanh cc loi corticoid gin tip,
nhng nhm c chng c v tc dng).
Tuy nhin khi t liu sinh l, suy thng thn c th b che du nu s iu tr hm, trong
mt vi trng hp hin tng tr thng thn c th cn c xc nh. V th cn nh gi
chc nng thng thn bi thm d chnh xc khng nn da vo nh gi s chuyn ha trong
nc tiu (i hi ngng iu tr trong 48 gi) m trc tin phi nh lng cortisol huyt tng
bui sng v test kch thch v i khi nh gi hon chnh hn chc nng hng v thng thn
nu nh p ng thng thn cha y .
Phc nh sau
+ Nu kho st cho thy chc nng thng thn cn m bo v cn bn cng nh ng hc,
gim liu c th kh nhanh theo bc thang hng tun, bng cch kim sot li chc nng thng
thn khi chm dt iu tr hon ton.
Bng 2. Test xc nh suy v thng thn t t
Test ni tit xc nh suy v thng thn t t
Test Khng c ch Suy v thng thn
ACTH (liu cao 250 (g) bnh thng di bnh thng
H ng mu do insulin bnh thng di bnh thng
Metyparone bnh thng di bnh thng
Kch thch CRH bnh thng di bnh thng
ACTH (liu thp 1g) bnh thng di bnh thng
603

+ Nu chc nng thng thn b ri lon, gim liu cn phi thn trng, bng cch thay th
cortisol bng hydrocortisone m bo nhu cu hocmn c bn, v theo di s phc hi trc
i - Yn - Thng Thn v trong nhng tnh hung ny i khi ngi ta hng n n chn
on tr thng thn sau iu tr v nhm n s tr liu thay th.
4.2. Theo di lu di
+ S dng glucocorticoid trn liu sinh l thi gian trn 2 tun u c th c nguy c suy v
thng thn. Tai bin thng t xy ra cc i tng x dng prednisolone di liu sinh l
(12-15 mg/m
2
da/ ngy) v thi gian di 2 tun.
+ theo di suy v thng thn ti thiu trn 1 nm sau khi ngng thuc
+ tr em nh theo di mi 3 thng (n 5 nm), tr ln mi 6 thng.
+ ngng iu tri, s theo di khng c li lng v chc nng hng v thng thn ti lp bnh
thng nhiu thng sau khi ngng iu tr hon ton.
+ cn bo trc cho bnh nhn nguy c suy thng thn c th xy ra khi gp stress v i hi
x dng hocmn trong vi ngy. v y cng c li trong s kim sot bnh thng tr li ca
trc i - yn - thng thn trong nhng thng sau khi ngng thuc.
IV. TC DNG PH V TAI BIN CA LIU PHP GLUCOCORTICOIDE
1. Do qu liu
1.1. Tai bin sm
- Ri lon tiu ha: mc trung bnh nhng cng c th nng ln bi mt t bc pht lot d
dy hay t trng, c th gy bin chng xut huyt hoc thng. (tng tit acide d dy, gim tn
sinh cht nhy, v i mi t bo v c ch prostaglandine).
- Xut huyt hoc thng rut c th gp. V th cn lu trc cc i tng nghi ng bnh l
d dy t trng.
- Ri lon tm thn kinh: Thng xy ra nhng c nhn c a c sn vi biu hin bng ri
lon gic ng, mt ng, sng khoi hoc n nhiu, c th dng m sng, hng phn, trn cm gn
nh l ln, c th gy ng kinh (gim ngng kch thch v no), chng gi u tiu no (tng p
lc ni s).
- Nguy c nhim trng: nht l khi iu tr ko di c t lm bc pht bnh l nhim trng tim
tng hoc do nhim cho vi vi khun m, lao, siu vi (lu bnh u ma, herpes, zona, si s
nng ln nu x dng corticoides) v k sinh trng (nm).
Cc tai bin trn rt kh iu tr do ty theo trm trng v thi gian x dng thuc. Ty
trng hp c th ngng thuc, Nhng i tng b nghin thuc km cn iu tr thay th cn
phi theo di i lc cn phi tng liu. Trn thc t cn theo di ti bnh vin.
1.2. Tai bin chm
- Lng ng t chc m v ri lon da- c:
Lng ng m (100 mg cortisol/ ngy trong 2 tun) dng Cushing vi qu ti m vng mt, c
v thn thng km ri lon da nh da mng, ban xut huyt, vt rn da, so gi hnh sao,
chm kt so, rm lng, c bit khi dng ACTH tng hp ko di.
604

Mn trng c thng gp tr v thnh nin, phi hp vi bnh l c do corticoide u th gc
chi, d bo cho suy sinh dc chc nng thng ghi nhn cc dn cht ca fluor.
- Ri lon xng:
Biu hin bi s mt khong cht do tr tn sinh xng gy xp ct sng v gy xng di nht
l khi dng liu cao v ko di. C th d phng chng ny bng cch dng phi hp 25 OH
Vitamine D V cch phi hp iu tri fluorure de Na v 25 OH vitamine D v canxi c hiu qu
ngi ln. Hoi t xng v trng do corticoide thng gp u xng i vi nhiu , cn
nghi ng bin chng ny trc mt au khp khng gii thch c.
- Chng chm pht trin tr em l bin chng ng lo ngi, c th xy ra ngay c liu thp
Bnh v c.
- Hin tng gi mui:
Tng cn, ph, tng huyt p v th cn c ch hn ch mui.
- Ri lon v mt: c thy tinh th sau v tng nhn p (khuynh hng u trng, lng ng
MPS trn thy tinh th).
- Ri lon ni tit v chuyn ha: Cng insulin, khng insulin, mt kali, gim kali kim ha,
bc pht i tho ng tim tng hoc lm nng i tho ng c sn.
- Suy nhc sinh dc (nam), ri lon kinh nguyt (n). Gim TSH v T3
- Tng bch cu a nhn (ngay khi khng c nhim trng), gim bch cu i toan.
- Tng ng mu.
- Vim ty cp, gan nhim m.
+ Dng corticoid bi ti ch c th gy chng teo biu b da, gim nhim sc t, chng gin mao
mch, mn trng c, vim nang lng.
2. Tai bin do ngng thuc
2.1. Hin tng di
Biu hin bng s ti xut hin triu chng ca bnh chnh gy nn. y l do gim liu nhanh,
cn phn bit vi mt t tin trin ca bnh ngay khi ang iu tr
2.2. Suy v thng thn
Thng thy khi dng liu php corticoide trc tip lin quan n tc dng hm trc i - Yn-
Thng thn do corticoide. Nht l khi x dng liu cao ko di, liu cao hn liu sinh l.
Suy thng thn d b mn cm khi c stress nhim trng, chn thng, phu thut, bin chng
cp, ngng thuc t ngt. V th d phng cn phi gim liu dn, ch yu ngang mc sinh
l v nht l theo di trc i - Yn - Thng thn v iu tr h thng khi c stress vi cortisone
hoc hydrocortisone liu gp 2 - ln so vi liu hng ngy.
2.3. Hi chng cai (syndrome de sevrage)
Cn phi theo di trc mt trng hp suy nhc xut hin khi gim liu thuc nhng khng i
km suy v thng thn, Nu iu ny khng tng ng tc dng trn tm thn kinh ca bnh
nhn i vi corticoide. Cn phi n tnh trng thng thn (inertie surrnalienne)
605

3. Tai bin do s dng ti ch
+ Khi s dng ti ch (khp, da..) cng c th gy tc dng ton thn nu dng thng xuyn v
liu ng k v cng c th gy cng cortisol v tr thng thn.
+ C th gy nhim trng ti ch (hoc nhim trng trong khp), teo hoc hoi t t chc di
da (nht l khi chch nng), phn ng vim ti ch khi x dng cc dng tinh th huyn trc
(khp, ty).
4.Tng tc gia glucocorticoide vi cc thuc khc
Bng 3. Tng tc thuc
Tng tc gia glucocorticoid vi cc thuc khc
Amphotericin B gim kali
Digitalis nhim c digitalis, gim kali
GH khng hiu qu
Li tiu mt kali gim kali
Vacin t virus nhim trng nng
nh hng glucocorticoid trn nng cc thuc khc
Aspirin gim (tng chuyn ha, thanh thi)
Coumarin gim
Cyclophosphamide tng (c ch chuyn ha gan)
Cyclosporine tng (c ch chuyn ha ti gan)
Insulin gim
Isoniazide gim (tng chuyn ha, thanh thi)
Thuc vin h ng mu gim
nh hng ca cc thuc trn nng glucocorticoid huyt tng
Khng acid gim (gim hp thu ti rut)
Carbamazepine gim (do tng hot ng Cytochrome P-450)
Cholestyramine gim (do gim hp thu corticoid rut)
Colestipol gim (do gim hp thu corticoid rut)
Cyclosporine tng (do c ch chuyn ha gan)
Ephedrin gim (do tng chuyn ha)
Erythromycine tng (do gim thi tr)
Mitotane gim km tng transcortin (nng cortisol khng ng tin cy)
Thuc nga thai tng (do gim thi tr, gim protein lin kt)
Phenolbarbital gim(do tng hot ng Cytochrome P-450)
Phenytoin gim (do tng hot ng Cytochrome P-450)
606

Rfampin gim (do tng hot ng Cytochrome P-450)
Troleandomycin tng (do ri lon thi tr)

Kt lun: Vic tn trng mt s nguyn tc lin quan n ch nh thuc glucocorticoide, theo
di v ngng x dng, bo trc cc s c xy ra, cc bin php d phng v iu tr tai bin
nhm hn ch cc tai bin ng tc xy n cho ngi bnh khi x dng liu php
glucocorticoide.
607

LIU PHP LI TIU
Mc tiu
1. Trnh by c nh ngha cc thuc li tiu v sinh l hnh thnh nc tiu.
2. Phn loi c cc nhm thuc li tiu chnh, cc c ch v ni tc dng ca chng.
3. Trnh by c cc ch nh v chng ch nh ca cc thuc li tiu.
4. Trnh by c cc tc dng ph v tai bin khi dng thuc li tiu.
Ni dung
I. I CNG
1. nh ngha
Li tiu l nhng thuc c kh nng lm tng s o thi nc thn v cc cht khc trong
nc tiu ch yu l mui Natri. iu tr li tiu nhm mc ch gim ph mi khu vc trong
quan trng nht l khoang ni mch, gy h huyt p, gim p lc mt s ph tng.
2. Qu trnh hnh thnh nc tiu
S hnh thnh nc tiu sau cng bng quang l kt qu ca mt qu trnh lc cu thn, ti
hp thu v bi tit ng thn.
2.1. Lc cu thn
Bnh thng mu n tt c cc cu thn ngi ln l 1200-1300ml/pht, tc l khong 1800
lt/24 gi v sau khi qua cu thn, 1/10 s lng mu ny c lc ra thnh dch lc cu thn hay
cn gi l nc tiu nguyn thu (gn bng 180lt/24 gi). Thnh phn ca nc tiu nguyn
thu gn ging nh trong huyt tng, ch khc l khng c mt s cht c trng lng phn t
ln nh protein v lipid. Lc cu thn l mt hin tng th ng ph thuc vo p lc mu v
p lc thy tnh nang Baoman.
2.2. Hin tng ti hp thu, bi tit ng thn
- ng ln gn: gn 50-85% Natri v gn ton b Kali c ti hp thu theo c ch ch
ng m nng lng c cung cp bi ATPase. Nc c ti hp thu th ng theo Natri nn
nc tiu y ng trng.
- Quai Henl: s ti hp thu r nt hn. Nc tiu nhnh xung quai Henl tng p lc
thm thu do s ti hp thu nc on ny nhiu hn ti hp thu Natri, v vy nc tiu y
u trng, nht l nh quai Henl. nhnh ln ca quai Henl ti hp thu Natri mnh nn
nc tiu li nhc trng.
- ng ln xa: c s ti hp thu Na
+
, Cl- v Bicarbonate. S ti hp thu qua trao i vi
ion H+ (c gii phng t t bo ng thn di tc ng ca men anhydrase carbonique) v qua
trao i vi K+ (vai tr ca aldostrone).
Mt cch khi qut, s ti hp thu Na
+
chu nh hng ca
- iu kin huyt ng ti ch v tun hon chung: nu gim dng huyt tng thn
gy nn Na
+
.
- Ni tit t: aldostrone, ADH.
608

II. PHN LOI CC THUC LI TIU
C nhiu cch phn loi cc nhm thuc li tiu theo v tr tc dng, c ch tc dng, cu trc
ho hc,... di y, chng ti gii thiu cch chia cc thuc li tiu ra 4 nhm da theo v tr tc
dng
1. Nhm li tiu gn (diurtiques proximaux): l nhm c tc dng c ch men Anhydrase
Carbonique (Actazolamide) v cc thuc li tiu thm thu (Mannitol).
Nhm li tiu ny khng dng iu tr cc tnh trng ph do nguyn nhn t thn v khng
dng iu tr tng huyt p.
2. Nhm li tiu quai: Furosemide (Lasilix) Bumetamide (Burinex) Pietamide (Eurlix), acide
tacrynic, nhm ny c tc dng c ch ti hp thu Natri nhnh ln ca quai Henl.
3. Nhm li tiu Thiazides: l nhng dn xut ca Benzothiazide v nhng li tiu nhm
Sulfamide: Hydrochrothiazide (Esidrex), Chlortalidone (Hygroton), Indapamide (Fludex). Nhm
ny c tc dng c ch ti hp thu Natri trn phn u (phn gn) ca ng ln xa.
4. Li tiu ca ng gp: gm cc thuc: Triamtrne (Teriam), Amiloride (Modamide) v cc
thuc khng Aldosterone (Aldactone) chng c tc dng chung l i khng s trao i
Natri/Kali
III. C CH TC DNG CA CC THUC LI TIU
1. C ch hp th Natri
Tt c cc t bo vn chuyn Na u c bm ph thuc Na/K ATPase trn mng. Cc bm ny
ng vai tr ch o trong vn chuyn Na. Tc dng ca chng c tm tt trong s sau

Nc tiu Mu






3Na+
Na+
2K+


Hnh 1. C ch ti hp thu Na trong ng thn


T BA O
609

Qu trnh ti hp thu Na gm 2 bc
-Na i vo t bo thng qua 1 knh c trn mng t bo pha trn u.
-Vn chuyn Na xuyn qua mng pha y nh bm Na/K ATPase.
2. C ch tc dng ca thuc li tiu quai
- NaCl c lc trong lng ng thn i vo cc t bo nhnh ln quai Henle qua trung gian 1
cht ti ng vn Na- K - 2 Cl nm mng pha u ca t bo. Nng lng cho vic vn chuyn
ny c cung cp bi Gradient in th thch hp ca Na (ngoi thp ca ni bo, in tch
m ca t bo).
- Cc li tiu quai c ch trc tip s ti hp thu ca Na, K, Cl, nh tranh chp vi v tr Cl ca
cht ti, cc thuc nhm ny cho php thi 20-25% lng Na c lc (trong ng thn). Cc
thuc li tiu ny ng thi c 1 tc dng ln o thi Canxi (c ch ti hp thu Nacl ua n c
ch ti hp thu Calci)
3. C ch tc dng ca li tiu nhm Thiazide
- ng ln xa, Na i vo t bo nh vo cht ti NaCl nm t bo pha u.
- Cc cht Thiazide c ch trc tip ti hp thu ca NaCl bng cch tranh chp v tr Cl ca cht
ti, chng kch thch 1 cch gin tip ln s ti hp thu Ca.
- Tc dng ca ca nhm thuc ny thng yu, ch cho php o thi 5- 10% lng Na c lc
(trong ng thn)
4. C ch tc dng ca li tiu gi Kali
Lin quan n phn v ca ng gp.
- Na i vo t bo qua knh Na biu m trn mng t bo. Nng lng c cung cp bi
Gradient ca Na. Sau Na c bi tit pha mng y ca t bo thng qua 1 bm ph thuc
Na- K- ATPase.
- Aldosterone lm tng s lng knh Na v s lng cc bm ph thuc Na-K-ATPase.
- Cc thuc li tiu gi Kali (nh Amiloride) c ch trc tip cc knh Na trong khi
Spironolactone i khng vi tc dng ca Aldosterone.
- Tc dng thi Na ca nhm thuc ny thp, cho php bi tit 1-3% lng Na c lc (trong
ng thn)
5. C ch tc dng nhm li tiu gn
- Mannitol li tiu theo c ch thm thu.
- Acetazolamid c ch ng ln gn v c ng ln xa men anhydrase carbonique theo phn
ng:
CO
2
+ H
2
O


H
2
CO
3


H
+
+ HCO
3
-

: cn anhydrase carbonique
: khng cn anhydrase carbonique
610

IV. CH NH CA CC THUC LI TIU
1. Cc bnh tim mch
1.1. Ph phi cp: ch nh thuc li tiu bnh l ny l cc loi li tiu nhanh, mnh (nh
Furosmid).
1.2. Suy tim ton b, suy tim phi vi ph n v trn dch.
1.3. Tng huyt p: nht l tng huyt p ngi ln tui, thuc li tiu c chn la l cc li
tiu h Thiazid, lu khi phi hp thuc li tiu vi cc nhm thuc khc gy h huyt p s
tng hiu qu ln rt nhiu.
1.4. Vim mng ngoi tim cp v mn.
2. Ni tit, sn khoa v cc bnh dinh dng
2.1. i tho nht: c ch nh s dng cc thuc li tiu mui.
2.2. Hi chng ph chu k v cn (hi chng Mach) vi triu chng tng t ngt trng lng
trong thi k kinh nguyt nh nhc u, thay i tnh tnh, to bn. Trong hi chng ny thng
gp tng aldostrone th pht nn loi Spironolactone v Triamtrne l c ch nh tt.
2.3. Nhim c thai nghn c phi hp hoc khng c vi tng huyt p: khi s dng li tiu cn
lu c th gy nhim c vi thai nhi v ngay c cho ngi m nht l cc nhm thiazid.
2.4. Tng canxi niu v cn phi hp vi si tit niu. Tng canxi niu c gim bi mt s
thiazid nh hydroflumthiazide (Lodrine) v Benzothiazide (Fovane).
3. Bnh l gan
Ph, c trng do x gan v trong mt s bnh vim gan bn cp.
4. Cc bnh l thn
Trong vim cu thn cp, vim cu thn mn tnh, suy thn cp, suy thn mn.
i vi hi chng thn h iu tr thuc li tiu phi cn thn v c th lm gim thm th tch
mu gy suy thn cp chc nng.
Nhn chung, i vi nhm bnh l thn, thuc li tiu nhm Furosmid c ch nh rng ri v t
c v tc dng nhanh, mnh nht l ch trong suy thn cp. Khi suy thn c tng Kali mu th li
tiu tit kim Kali l chng ch nh.
5. Bnh phi: Tm ph cp, tm ph mn c km suy tim phi.
6. Ph vi tng tit dch do ung th
V. LIU LNG CC THUC LI TIU CHNH
1. Li tiu thy ngn
V nhm ny gy nhiu tai bin nn ngy nay t dng. Ch cn nhng dn xut ca thy ngn hu
c l cn dng nh Novurit (Mecuropylline) ng 0,3g, liu dng 1/2 n 2 ng/ngy.
2. Loi c ch men anhydrase carbonique
Acetazolamid (Diamox, dng vin 125mg, 250mg, 500mg: liu lng 250mg-500mg/ngy.
Dichlorophenamide (DARANIDE), vin 50mg, liu lng 200mg/ngy.
611

Cc thuc trong nhm ny thng c s dng iu chnh ri lon toan kim trong suy h
hp mn, lm gim p lc nhn cu ca bnh Tng nhn p (Glaucome), trong bnh ng kinh.
3. Loi thuc li tiu mui: L nhm thuc tng o thi Natri, Kali. L mt trong nhng nhm
thuc c s dng vi mc ch li tiu nhiu nht hin nay, gm:
3.1. Cc Thiazides: l loi sulfamide li tiu v trong cu trc ca chng c gc sulfonamide.
Trong nhm thuc ny c nhiu bit dc, ch k tn mt s thng dng:
- Chlorothiazide (Diuril) vin 0,5mg, liu lng 1-2vin/ngy
- Hydrochlorothiazide (Hypothiazide) vin 25mg, liu lng 2-3vin/ngy. L loi thuc
thng c dng trong iu tr tng huyt p.
- Clopamid (Brinaldix) vin 20mg, liu lng 1-2vin/ngy
3.2. Cc thuc nhm li tiu quai (quai Henl: bao gm:
- Furosemide (Lasix - Lasilix) vin 40mg, ng 20mg: l thuc c ch nh kh rng ri v
tc dng nhanh (ung sau 45 pht, tim tnh mch sau 10 pht) v mnh.
- Acid tacrynique (Edecrine) vin 50mg, ng 50mg. Vi ng dng tnh mch, thuc
c tc dng nhanh sau 1/2 gi tim v ko di 6-8 gi.
4. Spironolactone
n thun nh Aldactone vin 50mg, liu lng 2-6vin/ngy. Liu duy tr 2 vin/ngy.
Spironolactone phi hp vi Thiazide nh Aldactazine (Spironolactone 25mg + Altizide 15mg)
liu lng 3-4 vin/ngy, liu duy tr 1-2 vin.
Cn lu hiu qu c ch aldostrone ko di nhiu ngy sau khi ngng thuc cho nn c th gy tai
bin nng n do mt nc nu liu trnh khng chm dt ng lc.
5. Triamtrne
n thun nh Teriam vin 100mg, liu tn cng 2-3 vin/ngy, liu duy tr 1 vin trong ngy
hoc 2 ngy.
Triamtrne phi hp vi Thiazide nh cyclotriam (triamtrne 150mg + cyclothiazide 3mg)
6. Amiloride
Cng l loi li tiu gi Kali bit dc Modamide vin 5mg, liu lng 1-4vin/ngy.
7. Cc nhm thuc khc c tc dng gy li tiu
7.1. Cc Corticoides: Thng c kh nng gy li tiu sau 3-4 ngy iu tr, ban u l li tiu
n thun tip theo l li tiu thm thu vi bi tit Kali v Natri c th gy gim Kali ng k.
7.2. Li tiu thm thu
- Mannitol 10-20% x 500-1000ml chuyn tnh mch trong 24 gi, c th phi hp vi mt
thuc li tiu mui hoc khng aldostrone. Thng ch nh trong ph no, thiu v niu sau
phu thut, ng c nng o thi c cht nht l thuc Barbiturate.
Chng ch nh trong suy tim, suy gan, suy thn mn tnh nng.
VI. TC DNG PH, TAI BIN CHUNG V CHNG CH NH
1. Tai bin d ng v nhim c
612

1.1. Ni mn da, nn o, y bng: thng gp do cc thuc li tiu Thiazide c gc
Sulfonamide.
1.2. Vim gan do thuc.
1.3. ic: thng do cc thuc li tiu quai: tacrynique, Furosemide.
1.4. Nhng tc dng v ni tit: do Spironolactone.
2. Cc ri lon v nc in gii
- Kim chuyn ha vi mt Kali: gp trong phn ln cc thuc li tiu tr Spironolactone,
Triamtrne.
- Gim Kali mu biu hin bng mt mi, co cng c, yu c, c th dn n hi chng
gi lit, to bn v gy cc ri lon v in tm , cc bin chng ny c th d phng bng cho
thm Kali ung nht l trong iu tr suy tim, c trng do x gan...
- Tng Kali mu c th gp khi dng ko di cc loi li tiu khng Aldostrone nh
Spironolactone, Triamtrne. Khng bao gi phi hp hai loi ny cng lc.
- Mt mui, mt nc ngoi bo trm trng v gim th tch mu cp khi dng cc thuc
li tiu nht l khi dng cc loai li tiu mnh ln quai Henl nh Furosemide, Acide
tacrynique. Trong trng hp gim th tch mu nng cn hi phc li th tch mu bng dch
truyn ng trng (NaCl 9o/oo, Glucose 5%), bng huyt tng.
- Mt nc ni bo: thng xy ra sau khi dng cc loi li tiu thm thu ko di
(Manitol u trng) nguy c dn n ri lon tri gic v hn m vi tin lng trm trng nu
khng iu tr kp thi.
- Nhc trng huyt tng: xy ra khi iu tr thuc li tiu m king mui nghim ngt
nhng li khng hn ch nc thng gp nhng bnh nhn suy tim, x gan; biu hin vi
triu chng ph, ri lon tri gic, i khi ln cn co git.
3. Cc ri lon v chuyn ha
- Tc dng tng ng huyt ca cc loi li tiu c gc Sulfonamide: do h Kali mu v
do ri lon gii phng Insuline ca t bo bta ty. Thuc c th lm nng hn bnh i tho
ng, gy ra i tho ng nhng ngi i tho ng tim tng, gy ri lon dung np
Glucoza khi s dng thuc li tiu ko di.
- Tng Acid uric mu: gy ra nhng cn Goutte khi s dng thuc li tiu mui, thuc li
tiu quai. Ngc li Triamtrne lm tng o thi Acid uric niu.
4. Tm tt cc chng ch nh
- Trong suy tim khng dng cc loi li tiu thm thu
- Trong c trng do x gan khng dng loi thy ngn v Acetazolamide.
- Trong i tho ng khng dng loi li tiu mui v Acetazolamide.
- Trong suy thn khng dng li tiu thy ngn v mui.
- Nu c tng Kali mu khng dng Spironolactone. Triamtrne.
613

CU HI LNG GI
1. Nguyn nhn v triu chng lm sng ca mt nc ngoi bo.
2. iu tr mt nc ngoi bo.
3. Chn on nc ngoi bo.
4. iu tr nc ngoi bo.
5. Nguyn nhn v triu chng lm sng ca mt nc ni bo.
6. iu tr mt nc ni bo.
7. Triu chng ca nc ni bo.
8. Nguyn nhn ca tng Kali mu.
9. Triu chng cn lm sng ca tng Kali mu.
10. iu tr tng Kali mu.
11. Triu chng lm sng v cn lm sng ca h Kali mu.
12. iu tr h Kali mu.
13. Triu chng ca nhim toan chuyn ha.
14. iu tr nhim toan chuyn ha.
15. Bnh nguyn ca sc nhim khun.
16. Triu chng lm sng sc nhim khun.
17. Bin chng ca sc nhim khun.
18. S dng khng sinh iu tr sc nhim khun nhng bnh nhn c p ng min dch bnh
thng.
19. iu tr h tr tun hon (chuyn dch, thuc vn mch) trong sc nhim khun.
20. ng xm nhp ca cc thuc tr su gc Phospho hu c.
21. Triu chng lm sng ca ng c cp thuc tr su gc Phospho hu c.
22. Chn on trm trng ca ng c cp thuc tr su gc Phospho hu c.
23. S dng Atropin v Pralidoxim trong iu tr ng c cp thuc tr su gc Phospho hu c.
24. Nu 4 trng hp trong c ch bnh sinh ca bnh t min.
25. c tnh chung ca cc bnh t min.
26. Phn nhm cc thuc khng sinh.
27. Cc c ch tc dng ca thuc khng sinh.
28. Tc dng ph v c tnh ca Penicillin v cc dn cht.
29. Nu mc ch, kt qu v cch thc phi hp khng sinh.
30. C ch khng thuc khng sinh ca vi khun.
31. D phng khng khng sinh.
614

32. Cc ch nh iu tr ca Heparin.
33. Cc ch nh iu tr ca thuc khng Vitamin K.
34. Theo di khi iu tr bng thuc chng ng Heparin v thuc khng Vitamin K.
35. Chng ch nh ca thuc Corticoides.
36. Theo di trong iu tr thuc Corticoides.
37. Tai bin do ngng thuc Corticoides.
38. Phn loi cc thuc li tiu.
39. C ch tc dng ca thuc li tiu quai.
40. Tc dng ph v tai bin khi dng cc thuc li tiu.

615

TI LIU THAM KHO
1. Alain Combes (1999), Tim mch hc, Nh xut bn Y hc.
2. Bch khoa th bnh hc (2002), NXB Y hc H ni.
3. Bi ging bnh hc Ni khoa (1992), B mn Ni, trng i hc Y H ni, NXB Y hc.
4. Xun Chng (1992), Bi ging bnh hc Ni khoa sau i hc. Hc vin qun Y.
5. Current medical diagnosis and treatment (2002), Lange.
6. Cecil textbook of medicine 17th edition, W.B Sauders company
7. Harrison (2005). Principle of internal medicine, 16
th
edition.
8. Principes de medecine interne( 2002), Flammarion, Paris.
9. Endocrinology (2001), 4
th
Edition, W.B. Saunders Company.

MC LC Trang

Chng 1. TIM MCH
1. Thp tim ..........................................................................................................................1
2. Hp van hai l .................................................................................................................7
3. Tng huyt p ................................................................................................................15
4. Suy tim ..........................................................................................................................28
5. Suy vnh ........................................................................................................................41
6. Bnh c tim ...................................................................................................................51
7. Va x ng mch ........................................................................................................65
8. Cc thuc chng lon nhp tim .....................................................................................72
9. in tm bnh l ......................................................................................................76
10. Ri lon nhp tim ........................................................................................................85
11. Vim mng ngoi tim ................................................................................................. 94
12. Bnh tim bm sinh ....................................................................................................103
13. Vim ni tm mc nhim khun ...............................................................................112

Chng 2. TIU HO
14. Lot d dy ................................................................................................................123
15. Vim d dy .............................................................................................................134
16. Vim ng mt, ti mt cp ....................................................................................141
17. Vim gan mn ...........................................................................................................148
18. X gan .......................................................................................................................158
19. Ung th gan nguyn pht ..........................................................................................170
20. Ung th d dy ..........................................................................................................177
21. p xe gan .................................................................................................................185
22. Vim ty cp .............................................................................................................197
23. Ung th i trc trng ...............................................................................................209
24. Vim rut mn ..........................................................................................................219
25. Hi chng km hp thu .............................................................................................225
Chng 3. H HP
26. Ph vim thu, ph qun ph vim ...........................................................................230
27. Hen ph qun ............................................................................................................237
28. Suy h hp cp ..........................................................................................................246
29. Suy h hp mn .........................................................................................................250
30. Trn dch mng phi khng do lao ...........................................................................260
31. Trn kh mng phi ...................................................................................................266
32. p xe phi .................................................................................................................271
33. Gin ph qun ...........................................................................................................278
34. Bnh phi tc nghn mn tnh ..................................................................................284
35. Tm ph mn .............................................................................................................292
36. Ung th ph qun phi nguyn pht .........................................................................299

Chng 4. THN TIT NIU
37. Hi chng thn h .....................................................................................................310
38. Vim cu thn cp .....................................................................................................319
39. Si h tit niu ..........................................................................................................326
40. Bnh cu thn ............................................................................................................334
41. Bnh thn v thai nghn ............................................................................................341
42. Vim thn b thn .....................................................................................................347
43. Suy thn cp ..............................................................................................................354
44. Suy thn mn .............................................................................................................361
45. Bnh thn i tho ng .........................................................................................368
46. Bnh thn bm sinh v di truyn ...............................................................................373
47. Bnh ng mch thn ................................................................................................381
48. Vim ng thn cp ....................................................................................................388

Chng 5. C XNG KHP
49. Vim khp dng thp ................................................................................................397
50. Thoi khp ................................................................................................................403
51. Bnh Gt ...................................................................................................................408
52. Vim ct sng dnh khp ..........................................................................................412
53. Lao ct sng ..............................................................................................................419
54. Vim quanh khp vai ................................................................................................424
55. Bnh a u tu xng .................................................................................................429
56. Lupt ban h thng ..............................................................................................434
Chng 6. NI TIT
57. i tho ng ..........................................................................................................442
58. H Glucose mu ........................................................................................................467
59. Bo ph ......................................................................................................................476
60. Basedow .....................................................................................................................489
61. Bu gip n ...........................................................................................................499
62. Suy gip ....................................................................................................................505
63. Vim tuyn gip, ung th tuyn gip .......................................................................512
64. i tho nht .............................................................................................................516
65. Suy thu trc tuyn yn ..........................................................................................523
66. Tng hot v thng thn .........................................................................................529
Chng 7. TNG QUT
67. Ri lon cn bng nc in gii v cn bng toan kim .........................................536
68. Shock nhim trng ....................................................................................................546
69. Trng c cp thuc tr su gc Phosphore hu c .................................................553
70. Bnh t min .............................................................................................................563
71. Liu php khng sinh ................................................................................................568
72. Tiu si huyt, Heparine v khng Vitamine K .......................................................584
73. Liu php Glucocorticoid ........................................................................................595
74. Liu php li tiu .....................................................................................................607


PHM VI V I TNG S DNG GIO TRNH

1. Gio trnh c th dng tham kho cho cc ngnh:
- Y khoa.
- Dc khoa.
- Nha khoa.
- iu dng.
- Y t cng cng.
2. Gio trnh c th dng trong cc trng:
- i hc Y khoa.
- i hc Dc.
- ai hc Rng hm mt.
- i hc Y t cng cng.
- Cao ng Y t.
- Trung cp Y t.
3. Cc t kha:
Ni khoa, bnh hc, bnh tim mch, bnh h hp, bnh tiu ha, bnh thn, bnh khp,
bnh ni tit, bnh ni khoa, bnh sinh, bnh nguyn, lm sng, chn on, iu tr.
4. Yu cu kin thc trc khi hc mn ny:
- Nm vng kin thc v ni khoa c s v l thuyt v lm sng.
- hc cc mn Y hc c bn: gii phu ngi, sinh l ngi, sinh ha, sinh l bnh
hc, gii phu bnh, dc l hc, min dch hc, ...
5. Gio trnh c xut bn:
- Nh xut bn Y hc, nm 2007.
- Ti bn ln th nht nm 2008.
CH BIN
PGS.TS. HUNH VN MINH

Ban bin tp Bnh l hc ni khoa:
Chng 1. TIM MCH
- PGS.TS. Hunh Vn Minh
- PGS.TS. Nguyn Anh V
- TS. BS. Nguyn Cu Long
- TS. BS. L Th Bch Thun
- BSCK1. Phan c Th
- ThS. BS. Hong Anh Tin
Chng 2. TIU HO
- PGS.TS. Hong Trng Thng
- PGS.TS. Trn Vn Huy
- ThS. BSCK2. Nguyn Th Xun Tnh
Chng 3. H HP
- PGS.TS. L Vn Bng
- ThS. BS. Trn Mn
- ThS. BSCK2. Phan Th Hng Dip
Chng 4. THN TIT NIU
- TS. BS. V Tam
- TS. BS. Hong Vit Thng
- TS. BS. Hong Bi Bo
Chng 5. C XNG KHP
- ThS. BS. H Vn Lc
- ThS. BSCK2. o Th Vn Khnh
- ThS. BS. Nguyn Hong Thanh Vn
Chng 6. NI TIT
- PGS.TS. Trn Hu Dng
- PGS.TS. Nguyn Hi Thu
- PGS.TS. Nguyn Th Nhn
- ThS. BS. L Vn Chi
Chng 7. NI TNG QUT
- PGS.TS. Hunh Vn Minh
- PGS.TS. Hong Khnh
- PGS.TS. Hong Trng Thng
- PGS.TS. Nguyn Hi Thu
- TS. BS. V Tam
- BS. Trn Th Phc Yn
Th k bin tp:
- TS. BS. Hong Bi Bo
- BS. Hong Anh Tin
- BS. Trn Th Phc Yn
- CN. H Th Thi Thu