Hc Vin qun Y B mn Khoa Ngoi bng

Bnh hc

Ngoi khoa bng

Nh xut bn qun i nhn dn H Ni - 2008

Li gii thiu Gio trnh l ti liu khng th thiu c trong vic ging dy v hc tp, khng nhng mang li tnh thng nht, chnh quy trong ging dy m cn gip sinh vin hc tp ch ng, pht huy kh nng t tm ti, nghin cu. phc v cho vic dy v hc cc bnh ngoi khoa bng ngy cng tt hn, nm 1997 b mn Ngoi bng bin son cun Bnh hc ngoi khoa bng. Hin nay s pht trin nhanh chng ca khoa hc k thut mang li nhiu tin b mi trong y hc. Chng ti bin son gio trnh ny khng nm ngoi mc ch cp nht cho bn c nhng kin thc mi, m bo tnh kinh in, tnh hin i, tnh thc t ca gio trnh. Bin son ln ny trn c s cun Bnh hc ngoi khoa bng Hc vin Qun Y- NXB QND 1997, c tham kho cc ti liu trong v ngoi nc gn y. Cc tc gi chn lc nhng kin thc kinh in v c b xung nhng kin thc mi, vit thng nht theo kiu bi ging ngoi khoa. Gio trnh vit cho i tng l sinh vin y khoa, cc bc s tr mi ra trng, do vy kin thc c trang b l c bn, cha chuyn su, mc ch l trang b cho sinh vin nn tng tt nht hnh ngh v tip tc hc ln cc mc cao hn. y l mt c gng ca tp th gio vin B mn Ngoi bng, nhng chc chn vn khng trnh khi nhng thiu st nht nh, mong c s gp ca bn c. Chng ti xin trn trng gii thiu cun sch vi hc sinh i hc, cc bc s tr mi ra trng v xin cm n Nh xut bn Qun i nhn dn, Ban bin tp v xng in Hc vin Qun y gip B mn hon thnh cun sch ny.

H Ni ngy

.. thng .. nm 2008

Gim c hc vin qun y

PGS.TS Nguyn Tin Bnh

Ch bin

: GS.TS. Phm Gia Khnh TS. Nguyn Vn Xuyn Th k bin son: TS. Sn H 2

Bin tp

Cc tc gi
TS. Hong Mnh An TS. ng Vit Dng TS. Triu Triu Dng PGS.TS. TRn Minh o TS. Sn H PGS.TS. L Trung Hi GS.TS. Phm Gia khnh PGS.TS. Nguyn Vn Khoa PGS.TS. V Huy Nng PGS.TS. Nguyn Cng Thnh TS. Nguyn Vn Xuyn: Gim c bnh vin 103 - Hc vin Qun y. Ch nhim khoa phu thut bng Bnh vin 103 - Hc vin Qun y. Ch nhim khoa ngoi nhn dn Bnh vin Trung ng qun i 108 Ph gim c Bnh vin 198 B Cng An. Ph ch nhim b mn ngoi bng- Hc vin Qun y Ph gim c Bnh vin 103- Hc vin Qun y. Nguyn gim c Hc vin qun y, Nguyn ch nhim b mn ngoi bng- Hc vin Qun y. Trng phng k hoch tng hp Bnh vin 103 - Hc vin Qun y. Trng phng o To Hc Vin Qun y. Ch nhim khoa Phu Thut Bng Bnh vin Trung ng qun i 108 Ch nhim b mn Ngoi bng- Hc vin Qun y. Ph ch tch hi Hu mn- i trc trng hc Vit Nam.

Mc lc
* Li gii thiu 1. i cng thot v bng.

2. Thot v bn. 3. Thot v i. 4. Thot v nght. 5. Thot v sau m 6. Cc thot v him gp. 7. S bng 8. Vim phc mc 9. Thng lot d dy t trng. 10. Hp mn v. 11. Cc khi u lnh tnh ca d dy. 12. Chy mu do lot d dy - t trng 13. iu tr ngoi khoa bnh lot d dy t trng. 14. Ung th d dy. 15. Vim rut tha cp. 16. Tc rut 17. Lng rut. 18. Xon i trng Sigma. 19. U rut non 20. U lnh tnh i trng 21. Ung th i trng 22. Ung th trc trng 23. Sa trc trng 24. Nt k hu mn 25. Bnh tr 26. p xe quanh hu mn- R hu mn 27. Si ng mt ch 28. Vim ti mt 29. Chy mu ng mt 30. p xe gan 31. K gan 32. iu tr ngoi khoa tng p lc tnh mch ca 33. Vim ty cp 34. Ung th ty 35. Chn thng bng kn 36. Mt s bnh cp cu ngoi khoa tr em 37. Phu thut ni soi

i cng thot v bng

GS.TS.Phm Gia Khnh 1. nh ngha v phn loi: 1.1. nh ngha: Thot v bng l s ra khi v tr bnh thng ca cc tng trong bng ng thi ko theo l thnh ca phc mc qua 1 l thot v. Nhng l ny thng l nhng l t nhin ca c th c lp y bng t chc m hoc c thn kinh mch mu i qua nhng cng c th l nhng l mc phi do mt qu trnh bnh l hay chn thng gy nn. Cn phn bit thot v bng vi sa ni tng, vi s bng v l tng. Sa ni tng l s ln ra ngoi ca mt c quan m khng c phc mc thnh bao ph (v d: Sa trc trng, sa t cung .v.v..). S bng l s sa li ca cc c quan i qua tt c cc lp c ca thnh bng, nm ngay di da, trong trng hp ny khng c bao thot v. L tng l cc c quan trong bng qua tt c cc lp ca thnh bng tip xc vi mi trng bn ngoi. 1.2. Phn loi: C nhiu cch phn loi thot v bng: 1.2.1. Thot v trong v thot v ngoi: - Thot v trong l s sa li ca cc tng (thng l rut non) qua mt l t nhin hay mc phi trong bng. V d thot v qua khe Winslow, qua l c honh... cc thot v ny thng gy nght v thng pht hin c trong khi m. - Thot v ngoi l s sa li ca cc tng qua 1 l ca thnh bng. 1.2.2. Theo nguyn nhn: C th chia 2 loi: - Thot v bm sinh: xy ra do tn ti mt l t nhin ca c th, thng xut hin ngay sau khi hay lc nh tui. - Thot v mc phi: xy ra do 1 im yu ca thnh bng do mt qu trnh bnh l hay chn thng. 1.2.3. Theo v tr gii phu: Do c im cu to gii phu ca c th c mt s im yu ca thnh bng, thng xy ra thot v. Cc thot v thng gp l: Thot v bn, thot v i, thot v rn. Cc thot v v tr t gp l: thot v ng trng gia, thot v bng bn, thot v tht lng, thot v ngi, thot v l bt v thot v y chu. 1.2.4. Theo mc :

C thot v hon ton v khng hon ton, cc mc ny ty thuc vo thi gian v qu trnh hnh thnh ca bao thot v. 1.2.5. Thot v hi phc v khng hi phc: Thot v hi phc (hay cn gi l thot v phc v) l thot v m cc tng trong bao thot v c th tr v v tr bnh thng trong bng; cn thot v khng hi phc (thot v khng phc v) thot v m cc tng khng th tr v v tr bnh thng c do qu trnh dnh gy nn. Cn phn bit thot v khng hi phc vi thot v nght. Trong thot v nght cc tng khng tr v v tr bnh thng c do b tht nght l hay c ti thot v. 1.2.6. Thot v c bin chng v khng bin chng: Thot v c th xy ra n thun hoc km theo mt s bin chng. Cc bin chng thng gp nht l thot v nght, nhiu khi thot v nght li l triu chng u tin ca bnh. 2. Bnh nguyn v bnh sinh: Nguyn nhn gy thot v bao gm nhng nguyn nhn ton thn v ti ch: - Nguyn nhn ton thn: Cc yu t thun li nh: tui, gii, th trng v c bit l nhng nguyn nhn lm tng p lc trong bng. - Nguyn nhn ti ch l nhng c im v cu to gii phu nhng vng thng xy ra thot v. l nhng im yu ca thnh bng. Nhng im yu ca thnh bng thng xy ra thot v bng l: vng ng bn, vng nn ca tam gic Scarpa, ng trng gia bng, ng bn nguyt ca Spigel, vng tam gic Jean-Louis Petit, vng t gic Grynfelt v vng l bt... Bnh sinh ca thot v l mt qu trnh phc tp, song c th ni iu kin ch yu pht sinh thot v l mt qu trnh khng ph hp lu di gia s tng p lc trong bng vi s chng ca thnh bng. Hc thuyt v s pht sinh ca thot v l do s thiu khuyt v cn c ca thnh bng do bm sinh v mc phi khng gii thch c mt cch y v bnh sinh v bnh nguyn ca thot v. Nhiu trng hp c s thiu khuyt ca cu to thnh bng song khng c thot v. y vai tr quan trng trong c ch pht sinh bnh l cc yu t lm tng p lc trong bng. 3. Cu to ca mt thot v: 3.1. L thot v: L thot v xy ra ch yu ca thnh bng. Ch yu ny l do thn kinh, mch mu hay mt c quan no i qua thnh bng hoc c mt khe h gia cc lp c v cn m cc tng trong bng qua l ny ra ngoi. Hnh dng ca l thot v c th l hnh trn hay tam gic hoc l mt khe. Kch thc ca l c th t lt mt ngn tay, c khi ng knh trn 10cm. 3.2. Bao thot v:

Bao thot v l l thnh ca phc mc li ra ngoi qua l thot v, cha ni dung ca thot v. N c th l bm sinh do qu trnh khng lin ca phc mc (v d: thot v bn bm sinh do tn ti ca ng phc tinh mc) hoc cng c th l mc phi do s hnh thnh dn dn trong qu trnh b bnh. Hnh dng ca bao thot v th khc nhau, c th l hnh trn, hnh tr hoc hnh qu l. Bao thot v c 3 phn: c, thn v y. C bao thot v l ch hp nht ni tip gia l v thn ca bao, c chiu di khc nhau thu theo kch thc ca bao thot v. Ni dung ca bao thot v c th l bt k mt tng no trong bng. Nhng thng gp nht l rut non v rut non l c quan di ng nht, sau l mc ni ln v i trng... Khi cc tng trong bng xung bao thot v khng c phc mc bao ph hay ch c ph mt phn (v d bng quang, manh trng, niu qun...) gi l thot v trt. T l thot v trt gp khong 2,5 n 4,5% trong tt c cc loi. 4. Triu chng v chn on: Trong thi k u, cc triu chng thng khng in hnh, dn dn cc triu chng xut hin c lin quan n khi lm vic nng. Khi xut hin mt khi phng vng thot v. Bnh nhn cm thy au tc, kh chu vng thot v. i khi c ri lon tiu ho nh bun nn v nn, chng bng v to bn. Quan trng nht l khm thc th: thy mt khi phng vng thot v, c th ch thy khi gng sc (ho, rn, chy, nhy). Hnh dng ca n c th khc nhau: hnh trn hay bu dc hoc hnh qu l... kch thc c th nh nhn k mi thy, c khi rt to. Mt c im khi khm l nu nn bp, khi phng c th nh li v nhiu khi mt hon ton. Khi c th cho ngn tay vo tn c v l ca bao thot v. Chn on thot v thng khng kh. Ch yu da vo triu chng: khi phng xut hin mt vng im yu ca thnh bng, khi ny c th nh li hoc mt i khi nm ngh hay nn bp. 5. Bin chng ca thot v: 5.1. Thot v nght: l s chn p t ngt cc tng trong bao thot v l hoc c ti thot v Thot v nght thng xy ra sau khi tng p lc t ngt trong bng (vc vt nng, ho hay rn mnh...). Triu chng ca thot v nght thng in hnh. Bnh nhn thy mt khi phng vng thot v khc vi ln trc', ln ny khi phng khng th nn b li c, km theo au d di, c th bun nn hay nn, nu n mun th xut hin cc triu chng ca tc rut c hc.

Thot v nght l bin chng nng nht v c hai nguy him: hoi t rut do thiu mu nui dng v tc rut do b tht. V vy trong thot v nght cn c iu tr ngoi khoa sm. Mc ch ca iu tr ngoi khoa l tm ch tht v gii phng n, x tr cc thng tn ca tng b tht v cui vng l hi phc li thnh bng (ni xy ra thot v) cho vng chc. 5.2. ng phn: ng phn l hin tng cc quai rut trong bao thot v cng to, cha y phn, thc n v hi. ng phn l bin chng hay gp trong thot v khng hi phc . N thng tin trin dn dn. Triu chng du tin l to bn ri bao thot v to dn. Tip theo l cc triu chng ri lon tiu ho: bun nn, nn, bng cng chng. Khc vi thot v nght, ng phn trong bao thot v khng c hin tng chn p cc mch mu mc treo v thnh rut. iu tr cn c tht tho, nu iu tr bo tn khng c th m. 5.3. Vim bao thot v: Thng xut pht t vim cc c quan trong bao thot v, nh vim rut tha, vim phn ph, vim rut non... qu trnh vim c th tin trin cp tnh hoc mn tnh. 5.4. Chn thng bao thot v: Cc tng trong bao thot v c th b v do chn thng, i khi t pht (rt him). Chn thng cc tng trong bao thot v c th do tng p lc t ngt trong bng, c th do chn thng thnh bng hay chn thng trc tip bao thot v. 5.5. D vt trong bao thot v: Cc d vt nm trong ni dung ca bao thot v nh cc d vt trong rut, trong bng quang. Cc d vt trong rut thng l cc th m bnh nhn nut phi nh kim bng, nhn, xng... hoc si mt hay giun... Cc d vt trong bng quang thng l si. Chn on d vt trong bao thot v thng l tnh c trong khi m, nhng i khi bit trc do s ch , khai thc bnh nhn ca thy thuc. V iu tr: C nhiu trng hp cn phi m ly b d vt. 5.6. Ung th bao thot v: Rt him gp. C th ung th xut pht t bao thot v hoc ni dung ca bao thot v. Cng c th ung th bt ngun t t chc v c quan xung quanh c v bao thot v hoc ni dung ca n. 6. Tin trin v tin lng: Thot v bng thng tin trin t t. Nhng do qu trnh thc y dn dn ca cc tng trong bao thot v, lm bao thot v ngy mt to ra. Thot v bng l bnh khng nguy him, tr khi c bin chng nght. Tuy vy thot v bng lm hn ch kh nng lao ng v bnh nhn khng th lm 8

c vic nng, chy nhy hay i xa. Do phn ln thot v bng cn c iu tr ngoi khoa. 7. iu tr: iu tr thot v bng ch yu bng ngoi khoa. Chng ch nh m gp rt t trong cc trng hp: - Chng ch nh tuyt i: trong cc trng hp nhim trng cp tnh, c cc bnh nng km theo (lao phi, u c tnh, cc bnh tim mt b...). - Chng ch nh tng i: khng nn m nhng tr yu, di 6 thng, nhng ngi gi c bnh mn tnh v ph n c thai trong nhng thng cui. iu tr bo tn rt him c p dng ch trong cctrng hp chng ch nh ca m x. Phng php thng dng nht l bng gi. Nhc im ln nht ca phng php ny l tn thng cc c quan v t chc ch b p, gy teo c v t chc do p thng xuyn. V vy c thot v c th t to thm. Bng gi gy x dnh t chc xung quanh v lm thot v hi phc tr thnh thot v khng hi phc, ngoi ra cn lm ri lon dinh dng da. Nhc im ch yu ca bng gi l khng phng c thot v nght. Mc ch ca iu tr ngoi khoa l ct b bao thot v sau khi buc c ti thot v v lm vng chc thnh bng bng cch khu cc cn c vng , i khi c tng cng bng cc vt liu nhn to. iu tr ngoi khoa thng mang li kt qu rt tt.

THOT V bn
TS. Sn H Thot v bn l tnh trng mt tng trong bng ri khi v tr, chui qua ng bn xung bu v l loi hay gp nht trong tt c cc loi thot v thnh bng ni chung. Ch yu gp nam gii, him thy n gii. 1. S lc v phi thai, gii phu vng bn: 1.1. S hnh thnh ng phc tinh mc: (xem hnh 1). nam gii khi cn l bo thai, t thng th t, mm tinh hon cc di thn bo thai nm 2 bn ct sng bt u di chuyn xung bu. n thng th 9 ca thai nhi, tinh hon nm trong bu. Nhng trng hp qu trnh tinh hon di chuyn xung bu khng din ra, tinh hon nm trong bng gi l tinh hon lc ch, cn tinh hon nm trong ng bn c gi l tinh hon n. Khi tinh hon chui qua ng bn, n ko theo c l phc mc thnh xung, to nn ng phc tinh mc. tr s sinh ch c 20-25% chu trai, ng phc tinh mc c bt li, cn li a s sau khi , ng phc tinh mc mi c bt kn v n tui trng thnh ch cn li mt di x trng. Nu ng phc tinh mc cn tn ti khi tr ln s to ln mt ng hm, qua cc tng chui xung bu gi l thot v bm sinh. Khng phi cc trng hp cn ng phc tinh mc cng u b thot v bm sinh m ngi ta thy rng: tr mi t b thot v, mc d t l cn ng phc tinh mc cao, tr 1-2 thng tui cng t gp thng th n khi tr mt vi tui mi b thot v, c ngi ti tui trng thnh mi xy ra thot v bm sinh. Ngc li c ngi ng phc tinh mc tuy khng c x bt li, nhng n cui i vn khng c thot v. 1.2. Gii phu ng bn ng bn l mt ng hm to nn bi cn c ca thnh bng trc. ng bn di khong 6 cm tng ng vi 1/2 trong ca ng ni t gai mu n mt im cch gai chu trc trn 1 cm v pha trong. C 2 l bn: - L bn nng (cn gi l l bn trong). - L bn su (cn gi l l bn ngoi). Mt trong ca vng bn c ng mch thng v, thng ng mch rn v dy treo bng quang i l phc mc thnh mt trong ca ng bn nh ln v to thnh 3 h bn (xem hnh 2). H bn ngoi nm ngoi ng mch thng v v l ni thng xy ra thot v cho ngoi m tuyt i a s l thot v bm sinh. H bn gia nm gia ng mch thng v vi thng ng mch rn v l ni xy ra thot v trc tip. 10

H bn trong nm gia thng ng mch rn v dy treo bng quang, ni c c thng to rt chc pha ngoi nn t khi xy ra thot v v l ni c th xy ra thot v cho trong nhng rt him. ng bn l mt khoang vng bn c to nn bi nhiu lp cn c, phc mc. T ngoi vo trong gm cc lp: da, t chc di da, cn kt hp gm 2 l nng v su, cn c cho ln, c cho b, c ngang, mc ngang, lp m trc phc mc v phc mc. 2. Phn loi thot v bn 2.1. Theo v tr gii phu 2.1.1. Thot v cho ngoi - Tng thot v chui ra h bn ngoi, vo l bn su, theo ng phc tinh mc xung bu. Tuyt i a s thot v cho ngoi l bm sinh. C bao thot v nm pha ngoi ng mch thng v. Ti thot v nm trong bao th thn g tinh. giai on mun bao thot v xung tn bu. 2.1.2. Thot v trc tip - Tng thot v chui ra h bn gia v nm pha trong ng mch thng v. - y l thot v mc phi (khng bao gi c thot v bm sinh v tr ny). C bao thot v nm pha trong ng mch thng v. Bao thot v rt him khi sa xung bu. - Ti thot v nm ngoi bao th ca thng tinh. 2.1.3. Thot v cho trong - Tng thot v chui ra h bn trong. Loi ny rt him gp (khng cp n trong bi ny). 2. 2. Theo nguyn nhn 2.2.1. Thot v bm sinh: - Do cn tn ti ng phc tinh mc (hon ton hay mt phn ) - Bao gi cng l thot v cho ngoi v thng gp nht trong tt c cc loi thot v thnh bng. - Hay gp tr em v v thnh nin. - Sau phu thut t ti pht. Thng gp 1 bn. - Ti thot v nm trong bao th thng tinh. - Hay gp bin chng thot v nght. 2.2.2. Thot v mc phi - Do cn c thnh bng yu, nho, trong khi p lc trong bng li tng cao(v d: ngi thng phi mang vc vt nng, hoc c bnh mn tnh nh vim phi, vim ph qun mn tnh, kh ph thng hoc to bn, b i. - Thng gp ngi gi v thng c 2 bn. - Tng thot v chui ra h bn gia v hu ht l thot v trc tip. - Ti thot v nm ngoi bao th thng tinh. 11

- Rt t b nght do ti thot v hnh nn ct, c bao thot v thng rt rng. Tuy nhin sau m hay ti pht. 2.2.3. Theo mc tin trin ca thot v bn i vi thot v cho ngoi ty theo v tr ca ti thot v m c chia thnh: - Thot v th chm: tng thot v mi chui ra l bn ngoi. - Thot v k: tng thot v nm trong ng bn. - Thot v bn - mu: tng thot v chui ra khi l bn nng n gc bu. - Thot v bn - bu: tng thot v xung tn bu v tip gip vi tinh hon. Cc thot v bn him gp: - Tng thot v nm gia mc ngang v phc mc thnh. - Tng thot v nm gia c ngang bng v c cho b. - Tng thot v nm gia c cho b v c cho ln. 3. Gii phu bnh Ging vi cc loi thot v khc thnh bng, thot v bn c 2 phn chnh: - Ti thot v: gm c thn, c v y ti thot v. - Cc tng trong bao thot v: tt c cc tng trong bng ( loi tr gan ) cn li u c th chui vo bao thot v v thng gp l: rut non v mc ni ln, him gp hn l: manh trng, rut tha, i trng sigma, i trng ngang, bng quang. - Cc lp gii phu ca thot v trc tip bao gm: + Da v t chc di da, cn nng, cn c cho ngoi, cn ngang, bao thot v. Bao thot v ca thot v trc tip gm 2 lp: phc mc v cn ngang ngoi. - Cc lp gii phu ca thot v cho ngoi bao gm: + Da v t chc di da, cn nng, cn c cho ln thuc cung i, cn kt hp phn tip theo ca mc ngang, bao thot v cng vi t chc lin kt ca thng tinh. Bao thot v c dy, mng khc nhau c th phu tch ra khi m ri tnh mch thng tinh. Tuy nhin nhng trng hp thot v lu ngy, phu tch bao thot v tch khi cc thnh phn ca thng tinh rt kh khn. 4. Triu chng Mi loi thot v bn c c im lm sng ring, di y l triu chng ca thot v bn cho ngoi. 4.1. Triu chng c nng: Ngi bnh thng n khm v c khi phng vng bn, khi phng to ra khi i li, lao ng nng nhng nm ngh th mt i hoc t tay y ln c, tnh trng ton thn vn bnh thng. 4.2. Triu chng thc th: C khi phng vng bn vi c im: - Khi phng trn np ln bn, chy dc theo chiu ca ng bn (nu l th thot v bn- mu, bn - bu khi phng s xung thp hn lm bu to ln mt bn nhng v tr xut pht im vn trn np ln bn). - Khi phng mm, khng au, cng to hn khi bnh nhn rn mnh. 12

- Nu tng thot v l rut th g vang, s nn nghe thy ting c ch ca nc v hi, cn nu l mc ni th g c. - Dng tay nn y ln khi phng mt i. Nhng khi bnh nhn rn hoc ho th khi phng li xut hin theo hng chch t trn xung di v t ngoi vo trong - L bn nng rng, c th t lt u ngn tay hoc rng hn. S nn c cm gic khi rut chm vo u ngn tay khi lun ngn tay vo l bn nng v bo bnh nhn ho hoc rn mnh. Ngoi ra cn khm pht hin: Tnh trng trng lc c, cc d tt bm sinh km theo nh: tinh hon n, trn dch mng tinh hon. Ch cn khm k c hai bn so snh v c trng hp thot v xy ra c bn tri v bn phi. 5. Chn on: 5.1. Chn on xc nh: Nhn chung chn on thot v bn khng kh lm. Khi tng thot v ln xung d dng th cc triu chng k trn u r, d chun on. Tuy vy cn g c trng hp chn on kh khn v d nhm vi mt s bnh l khc. 5.2. Chn on phn bit: 5.2.1. Khi thot v cn cao: * Nang nc thng tinh: Khi nang nc thng thng vi bng, s nn khi phng nh li hoc mt i nn d nhm. Tuy nhin vi nang nc thng tinh, khi s nn khi phng nh li mt cch kh khn hoc khng r rng, c tnh cht ca mt khi dch thng cng nhng mm mi v nm dc theo thng tinh.. * Tinh hon n: - Khi phng nm ng bn, khng s thy tinh hon cng b n. - Khi phng c ranh gii r, mt chc, nn khng b li hoc mt i v c bit khi bp c cm gic rt au nh bp vo tinh hon bn kia. * Vim hch bn: - Khi phng vng bn sng, nng, au. - C hi chng nhim khun ton thn, st, bch cu tng cao. * Thot v i: - Khi phng nm di np ln bn. - Nn, bp c th nh li. - Ch yu gp ph n. 5.2.2. Khi thot v xung ti bu: * Trn dch mng tinh hon: - Da bu cng bng, c du hiu 3 ng (du hiu sng v). - Khng s c mo tinh hon v khng bu c mng tinh hon. - Soi n pin: nh sng xuyn qua khi dch mu hng nht v c khi m c ca tinh hon. 13

* Gin tnh mch thng tinh: - S bu to v sa thp hn bn i din, c cm gic nh bi giun di tay. Thng gp bn tri. Du hiu Curling (dng tnh). * U tinh hon: - Tinh hon l mt khi chc. - C nhiu hch vng bn * Lao tinh hon: - Tinh hon thng mm, nho. - Khi s nn tinh hon, bnh nhn c cm gic rt au. - C cc triu chng ca nhim c lao. 5.2.3. Chn on phn bit thot v cho ngoi vi thot v trc tip: * c im ca thot v trc tip: - Hay gp ngi gi thnh bng yu v thng gp c hai bn. - L thot v rng, tng thot v ngoi rut v mc ni ln c th l manh trng, bng quang thm ch c niu qun cng chui vo bao thot v. - Tng thot v chui ra theo hng t trong ra ngoi t sau ra trc: cn c, mc ngang mng v b y li ra pha trc, do dng mt ngn tay t vung gc vi da y khi phng vo d dng. - Dng ngn tay lun vo khi thot v v s c ng mch thng v p pha ngoi khi phng v cm gic s c mt trong ca xng chu. - Thot v trc tip t b nght v khi thot v hnh nn ct m y rng c bao thot v rng l ni cc tng chui ra. Tuy nhin sau m d ti pht. - Khi m ti thot v nm ngoi bao th thng tinh. * c im ca thot v cho ngoi: - Hay gp tr em v v thnh nin.Thng gp mt bn, thng l bn phi. - Ti thot v chui dc theo ng bn, theo chiu t ngoi vo trong, t trn ngoi xung di. Khi chui qua l bn nng thot v c hnh ging qu l. - Khi m ti thot v nm trong bao th thng tinh hay b nght. Tuy nhin sau m t ti pht. 6. Tin trin v bin chng: Thot v bn nu khng m th ngy cng to, nh hng t nhiu ti i li, sinh hot, lao ng ca bnh nhn v c th gp nhng bin chng nguy him nh: - B nght (xem bi thot v nght). - Vim dnh tng thot v vi bao thot v, do cc tng thot v kh y ln v d nhm trong chn on. - Chn thng khi thot v lm tn thng tng trong bao thot v. 7. iu tr: Hai phng php iu tr: Khng m (eo bng) v phu thut. 7.1. eo bng 14

y l phng php tm thi khng cho khi rut sa xung v ch i phu thut. Tuy vy i vi tr nh, nh eo bng lm cho khi thot v khng sa xung to iu kin cho ng phc tinh mc c bt li, cn c pht trin v c th khi. Nu khng khi n tui 7- 8 tr ln s m. Vi ngi gi yu hoc b bnh mn tnh nng nh suy tim mt b, kh ph thng, hen c chng ch nh m th eo bng lin tc, phng thot v nght. * Nhc im: - Khng gii quyt c nguyn nhn gy thot v m cn c th p cc tng v t chc ti ch gy vim dnh ti ch, lm cho thot v hi phc thnh khng hi phc. 7.2. Phu thut: L phng php chnh iu tr thot v bn nhm 2 mc ch: 7.2.1. Tm khu c ti v ct ti thot v: - Khu c ti l bn cng cao cng tt nhng phng khu, buc vo ng dn tinh. - Ct ti thot v, trng hp dnh nhiu, ti thot v dnh vo thng tinh, tinh hon khng bc c th phi ln mt trong ra v khu m ly thng tinh (ln bao thot v). 7.2.2. Ti to thnh bng: y l th m quan trng nhm trnh ti pht. C nhiu phng php m khc nhau. nhng d phng php no th thnh bng cng c ti to trn 2 bnh din (su v nng). Xc nh mt phng php phi cn c vo cch khu 2 bnh din nh th no? Thng tinh u so vi 2 bnh din c ti to? Bnh din su l khu cn kt hp vi cung i, bnh din nng l khu 2 mp cn c cho ln vi nhau. Trn c s ta c th chia ra 3 nhm phng php: * Nhm thng tinh nm trc 2 bnh din c ti to. i din l phng php Halstedt. * Nhm thng tinh t gia 2 bnh din m in hnh l phng php Bassini v phng php Shouldice (xem hnh 3a,b,c). * Nhm t thng tinh sau 2 bnh din nh phng php Forgue, Kimbarovski v Spaxkukovski. Hin nay 4 phng php c p dng rng ri l: Forgue, Kimbarovski Bassini v Shouldice. Phng php Shouldice phc hi theo 3 lp: mc ngang, lp nng v su bng ng khu vt i v, t l ti pht thp c nhiu phu thut vin a dng. 7.3. S dng vt liu tng hp: y l mt hng k thut mi. Ngi ta c th tin hnh m m hoc m ni soi t tm vt liu tng hp (vicryl, methylen ) l mnh ghp nhn to di phc mc lm bn vng thnh bng vng thot v. t mnh ghp nhn to c th m m hoc bng phu thut ni soi. 8. Cc tai bin, bin chng sau m: 15

8.1. Cc tai bin trong m: - Ct phi ng dn tinh c th dn ti v sinh, nu ct hai bn teo tinh hon.Tn thng cc tng trong bao thot v - Chy mu do ct phi ng mch thng v, ng mch i. 8.2. Bin chng sau m: - Chy mu: Do cm mu khng tt mu chy xung bu lm cho bu cng to, ph n v thm tm. - Ph n vng bu thng do ti to l bn nng hp, lu thng mu b hn ch. - V sinh do khi ti to li thnh bng tht phi ng dn tinh, hoc lm tn thng ng mch hai bn dn ti teo tinh hon. - Nhim trng vt m: Toc vt m dn n ti pht.

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thot v i
TS. Sn H Thot v i l tnh trng cc tng trong bng chui qua ch yu y tam gic Scarpa xung mt trc i. ng i khng c sn, n ch hnh thnh khi xy ra thot v i. Thot v i l thot v mc phi, ch yu gp n v t l nght rt cao (53-65%). 1. Gii phu bnh l: ng i c hnh thnh bi vng yu ca thnh bng. y l mt khoang ca vng i (khoang mch: ng, tnh mch i v mch bch huyt). Phn trong yu, cc tng c th chui qua. Khoang ny c gii hn bi: - Pha trc l cung i. - Pha sau l mo lc v dy chng Cooper. - Pha ngoi l tnh mch i. - Pha trong l dy chng Gimbernat. Khi m thot v i v tr ny phi ch : pha ngoi c ti c tnh mch i v pha trn c ti c ng mch thng v v nhnh ni ng mch thng v vi ng mch bt. 1.1. Cc v tr khc rt him gp (xem hnh 4): 1.2. Phn loi thot v: Ty theo mc thot v ngi ta chia lm 2 loi: - Thot v khng hon ton: Tng chui xung tam gic Scarpa ra trc i nhng ang nm di cn sng. - Thot v hon ton: Tng chui qua l bu dc v nm trc cn sng. 2. Nguyn nhn bnh sinh: Thot v i ch yu gp ph n , nht l ngi cha nhiu ln. Ngi ta cho rng c thnh bng b yu do mang thai nhiu ln, mt khc khi khung chu co gin cht t. l hai yu t chnh lm cho cc cn, dy chng vng tam gic Scarpa b yu d gy thot v. V vy thot v i l do mc phi ch khng phi do bm sinh, rt t gp tr em. 3. Triu chng lm sng: 3.1. Triu chng c nng: - Bnh nhn thy khi phng i, khi ny lc c lc khng v thng xut hin khi i li nhiu. au tng khi dui chn. - i khi thy ph 1 chn v chiu. - Cc biu hin khc nh tc nh, kh chu vng bn, i t c ch hn. 3.2. Triu chng thc th: Nhn thykhi phng nh gc trn trong ca tam gic Scarpa vi c

17

im: - C hnh trn hoc bu dc khng to lm v nm di np ln bn. - Khi phng mm, khng au. - C th nn nh li c hoc lm khi mt i, nhng khng d dng nh thot v bn. - G vang hoc nghe ting c ch nu l rut chui xung. - Bt mch: ng mch bn pha ngoi khi phng. Ch : Triu chng c nng t th hin r, thot v i li hay b nght, nn nhiu bnh nhn n trong tnh trng cp cu m khng bit mnh c thot v. Do khi gp bnh nhn n b tc rut c hc m khng r nguyn nhn phi ngh n c th do thot v i. 4. Chn on phn bit: 4.1. Thot v bn: - Thot v i ch yu ph n. Khi phng thng c kch thc nh. - Khi phng ca thot v i di np ln bn ( di cung i ). Khi phng ca thot v bn trn np ln bn. nhng bnh nhn bo vic xc nh cung i gp nhiu kh khn. Khi phi k mt ng t gai mu n gai chu trc trn gi l ng Malgaigne. Thot v i: khi phng di ng Malgaigne, thot v bn th khi phng trn ng ny. 4.2. Vim hch bn: - St, sng, nng, , au ti ch. - Xt nghim mu: bch cu tng, Neutro tng. 4.3. p xe lnh: - Khi phng l cht dch t li. - Khi phng pha ngoi ng mch i v dch lao t ct sng theo c tht lng chu xung i. 4.4. Khi phng tnh mch: - Khi phng cng to ln khi rn, khi ho hoc khi i li, n cng mt i tuy nhin c c im: - Km theo gin tnh mch chi di. - Khi phng mm n nh li nhng khi b tay khi phng li xut hin nhanh. - Dng mt ngn tay pha di ch phng th khi phng nh li nhng nu ngn tay pha trn th khi phng li to dn ra. Nu khi phng khng xp c cn phn bit vi: - U m: Khng au, khng y vo bng c. - Gin tnh mch chi di: bao gi cng km gin tnh mch dc sut chi di t trn xung di, d b xp hn khi nm. - Ti phng ng mch vng bn hoc nang vng bn. 5. iu tr: Phu thut l phng php iu tr trit , cn eo bng ch l bin php 18

tm thi phng bin chng, p dng cho nhng bnh nhn gi yu khng c kh nng m c. - ng m c th tam gic Scarpa dc theo mt trc khi phng v ln trn cung i. - C th m theo ng thot v bn, t pha trn cung i. Tm ti thot v, khu c ti v ct ti thot v ri ti to thnh bng. 5.1. K thut: Rch da: Rch i hay bn? Nu i, rch thng qua cung i n ngay trn khi thot v s thy cung i di v cn c cho to trn. - Bc tch ti thot v: Tch lp x m n c ti thot v. - Ct cung i : C thot v s l ra. - M ti thot v kim tra tng thot v v y ln bng. - Khu xuyn c ti thot v. - Ct ti thot v di ch buc v nh vo thnh bng. 5.2. Khu phc hi thnh bng: - Khu dy chng Cooper mo lc vi cc c cho b, c ngang v cn c cho ln. 5.3. Trong trng hp thot v i nght: - Mun ct b ti thot v phi ct cung i. C th i t pha trn bng xung hoc ng rch thp i. - M ti thot v - Gi quai rut nght ngoi. - Phu tch cn thn c thot v trn cao. - Bc l nhn r rnh nght. Kim tra on rut pha trn v pha di nght, nu rut cn tt th y tr li vo bng. Ct b khi rut hoi t. - Phc hi thnh bng: Khu dy chng Cooper vi c ngang, c cho b v cn c cho ln bt kn vng i li. Cn ch khi khu khng khu vo cc mch mu bn cnh nh tnh mch i, ng mch thng v, ng mch bt

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Thot v nght
PGS.TS.Nguyn Vn Xuyn

1. i cng Thot v nght l tnh trng c quan trong ti thot v b p, tht nghn li c ti, dn ti ri lon tun hon v cui cng l hoi t t chc. y l mt bin chng nguy him nht ca tt c cc loi thot v thnh bng, i hi phi chn on v x tr cp cu kp thi. Thot v nght hay gp trong thot v bn nght 1. Nguyn nhn v c ch bnh sinh. Cho ti nay nhiu tc gi gii thch nguyn nhn ca thot v nght di nhiu kha cnh khc nhau: 1. Do p lc trong bng tng t ngt (v d: nng vt nng, ho mnh.), lm cho tng chui qua l thot v nhanh, t ngt nn dn ti nght. 2. Do l thot v hp, cn c l thot v chc, t n hi nn d b nght hn l l thot v to,tng ln xung d dng. 3. Do c mt quai rut mi chui qua l thot v trong lc c mt quai rut khc chui xung. 4. Do quai rut trong ti thot v b gp khc nhiu v b quay theo trc ca n. 5. Mt s tc gi chng minh rng: nhu ng rut ca quai n bao gi cng tng, ng thi li c s gp khc ca quai rut nn lm cho dch v hi ng li.V ng nhiu lm cho p lc trong lng quai n tng cao, dn to v p c quai i. 6. Nhiu tc gi cng tha nhn cc yu t k trn v gii thch nh sau: p lc trong quai n tng kh mnh hoc rt mnh lm cng c l thot v vn t n hi. Hin tng trn s gy mt kch thch au n, do au m lm tng phn x co c thnh bng, chnh co c li lm cho l thot v hp thm v dn ti tnh trng khng ph hp gia c ti th b m khi lng rut nm tro ng bao thot v li ln nn dn ti nght. II. Gii phu bnh l iu nguy him v thng gp nht l rut b nght. Quai rut b nght tn thng nhiu hay t l ph thuc vo: S tht hp ngay l thot v (mc tht hp). Thi gian b nght lu hay mi. Quan st mt quai rut b nght ta thy: 20

1. Phn rut tng ng vi vng tht ca l thot v b tn thng sm nht v nng nht, vng l thot v cng b th tn thng cng nng v cng sm. Tn thng quai n bao gi cng nng. 2. Phn rut nm trong bao thot v hoi t nhanh hay chm ph thuc vo 2 yu t: a. Nu tnh mch mc treo b p trc, trong khi ng mch cn cung cp mu phn no cho t chc rut th: - Rut hoi t mun hn. - Quai rut gin to. - Lc u quai rut mu thm, sau chuyn dn sang mu tm. - Thnh dy do ph n. - Lng rut tch nhiu dch v c bao thot v cng c dch mu hng. - n lc c ng mch cng b tc lm cho rut hoi t tng im, tng m ri hoi t hon ton. Hoi t bao gi cng t nim mc trc, sau n c v thanh mc. b. Trng hp c ng mch v tnh mch b tc ngay t u th: - on rut b nght c mu trng nht, chng hoi t. - Dch t thm ra lng rut v bao thot v. - i vi cc on rut nm trong bng th t thng ging nh trong tc rut c hc. 3. Mc treo ca quai rut nght b ph n, dy v iu nguy him hn l tnh mch b tc, khng nhng phn b nght m c lc ln cao hn thm ch ln ti gc mc treo. Khi m cp cu, vic nh gi t thng ca quai rut c ngha rt quan trng. Ngi phu thut vin phi tr li cho c cu hi on rut cn c kh nng hi phc c na khng? quyt nh thi x tr. Mun vy trong nhiu trng hp phi c thi gian ch i, trc ht phi p huyt thanh m, phong b novocain 0.25% gc mc ttreo, i 15-20 pht nu thy: Rut khng c nhu ng. Vn mm nho, mu sc khng hng tr li. ng mch mc treo khng p. Quai rut nh vy khng cn kh nng hi phc na, phi ct on. Ngoi ra cng cn lu : C trng hp rut tuy hng tr l, vn nhu ng nhng c nhng hoi t nh. Trng hp trn nu vn bo tn th cc hoi t nh s thng, gy vim phc mc, rt nguy him cho bnh nhn. 4. Nght ngc chiu. L do hai quai rut chi vo bao thot v kiu W. Khi b nght, quai rut hoi t li nm trong bng, vic chn on kh khn, ngay lc m cng d b st nguy him.

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5. Nght mt phn ca thnh rut: Ch mt phn ca thnh rut b nght, cn lng rut vn lu thng c. III. Triu chng Ly in hnh rut non b nght trong thot v bn: 1. Triu chng c nng. au d di, t ngt vng thot v, au tot m hi khin bnh nhn phi n vin, c khi b chong v au. Nhiu bnh nhn c th cho ta bit: Trc vng au vn c khi phng, lc xut hin, lc mt i hoc t tay n ln c. Nay khi phng au v khng t y ln c na. Nn, b trung i tin, biu hin ca tc rut c hc. 2. Triu chng thc th - Ti vng thot v thy c khi phng: Cng chc. Khng y ln c. Rt au khi ta s nn G c. - Cc triu chng ca tc rut c hc: Chng bng,. Du hin rn b. Ton thn: Mt nc v in gii do nn nhiu. - X-quang: C mc nc v mc hi trong bng. Bnh nhn n sm, triu chng au l ch yu, nhng nu n mun sau 6 12 gi th cc triu chng tc rut cng r. IV. Cc th lm sng C nhiu cch phn chia. 1. Theo din bin ca bnh a) Th ti cp: Hay gp ngi c khi thot v nh, quai rut b tht nghn hon ton ngay t u, triu chng ton thn nng n nhanh chng. Nn nhiu Tru mch. Nu khng c cp cu sm s t vong trong 36-40 gi. B) Th bn cp: Khi thot v thnh thong li au, cng to dn, lc u khng y ln c nhng nu nm ngh, bnh nhn c gng cng t y ln c. t lu sau, hin tng trn li ti din. Cn m trnh b nght cp tnh.

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c) Th tim tng: Thng ngi gi v do mc ni l chui xung, triu chng c nng khng r lm, bnh nhn c lc au tc nhng chu ng c, c nn hoc bun nn. Nhng ri s qua i kh d dng, bnh nhn li sinh hot bnh thng. 2. Theo cc tng thot v b nght. Rut non - rut gi - manh trng - rut tha - i trng ngang - i trng xch ma - bng quang - cc phn ph ca n. 3. Theo v tr ca thot v. - Thot v bn nght: Chim t l cao 50-75% so vi tng s thot v nght v thot v bn gp nhiu hn cc loi khc. - Thot v i nght: Trong tt c cc loi thot v th thot v i d b nght nht, c t l rt cao 50-60%. ( So vi cng loi) - Thot v rn. - Thot v vng tht lng. - Thot v c honh. - Thot v ng trng gia. - Thot v l khuyt hng ca mc treo. - Thot v bt. - Thot v ngi. - Thot v y chu. V. Din bin ca bnh 1. Nu khng c iu tr sm, bnh nhn s t vong trong bnh cnh: - Tc rut c hc vi mi din bin ca n. - Vim phc mc ton th do rut hoi t, thng vo bng. C trng hp rut cha b thng, mi ch hoi t nim mc v mt phn ca c nhng vn b vim phc mc v vi khun theo dch tit, xuyn qua thnh rut vo bng. 2. Khi thot v t ln c nhng y ch l may mn v khng chc chn. VI. Chn on 1. Chn on xc nh. Da vo: - au t ngt d di vng thot v. - Khi thot v phng to au v khong y ln c. - C triu chng ca tc rut c hc. Tuy vy mt s trng hp vic chn on thot v nght rt kh khn, nht l thot v trong bng hoc cc vng khc rt him gp. Nhng trng hp trn, bnh nhn thng c m vi chn on tc rut c hc, cn nguyn nhn th sau khi m mi c sng t hon ton 2. Chn on phn bit. Ty theo v tr ca thot v nght m chn on phn bit cho ph hp. 23

Thot v bn v thot v i nght l 2 loi hay gp, ta phi chn on phn bit vi: a. Vim tinh hon cp. - Tinh hon rt au. - Khi au ny c danh gii r v cch bit vi thnh bng. - C hi chng nhim khunc ti ch v ton thn. - Khng c hi chng tc rut v khng c bnh cnh cua thot v bn trc . b. Vim hch bn: - C hi chng nhim khun, c sng, nng, , au ti vng bn. c. Cc tc rut c hc khc khng do thot v nght. d. Trn dch mng tinh hon nh nhi, phi c phng php khm thch hp phn bit tr au thc s hay khc v s hi. VII. iu tr Thot v nght l loi cp cu ngoi khoa, c th p dng cc phng php iu tr sau: 1. Bo tn. Nu bnh nhn n rt sm, ta c th y khi thot v nght ln v theo di. Vi tr nh, iu kin n sm, ton thn cha c nhim c, cch tin hnh l: - Tim thuc an thn, gim au theo liu thch hp. - Ngm na ngi chu b vo chu nc m, ch 15-20 pht, khi thot v c th t ln c. - C th dng tay xoa nh khi thot v nhng khng c nn th bo phng v tng bn trong. - Khi tng ln c th vn phi theo di st phng rut hoi t th pht gy vim phc mc. 2. Phu thut. L phng php iu tr chnh nhm mc ch: - Gii phng nhanh tng thot v b nght, thiu mu. - Khu c ti v ct ti thot v. - Phc hi thnh bng. Cn lu : - Khng c tt quai rut vo bng khi cha c quan st kt lun chnh xc tnh trng quai rut b nght. - Phi nh gi ng kh nng on rut cn hi phc c khng. - Ch ton thn v c hi sc b p nc v in gii.

24

Thot v sau m
GS.TS.Phm Gia Khnh

I - nh ngha. Thot v sau m l tng chui ra ngoi qua vt m c, n khc vi cc thot v thnh bng khc ch: Khi khot v khng c phc nc thnh bao ph m trc tip ngay vi t chc x ca vng m.

II. Nguyn nhn C thot v sau m l do ng khu cn c ca thnh bng khng lin c, hai mp vt m b toc rng ra, ch c lp t chc x so mng hoc da che ph vt m. Cc yu t lm vt m khng lin tt l: 1. Nhim khun lm toc vt m

Thng gp nhng vt m nhim khun trong cc trng hp: - M cc vt thng thu bng - ng m ca cc loi vim phc mc - ng m ca vim rut tha cp c m 25

- M cc tng d nhim khun nh i trng, tiu trng.v.v. v

2. i vi cc ng m vo bng: M ng trng gia t b nhim khun nht cc ng m ngang ct c nhiu, vt m km lin hn, d nhim khun v hay gy thot v sau m. Ngi ta cng thy rng nhng vt m khu t lp th t l thot v sau m t hn so vi nhng vt m c khu nhiu lp. 3. C th bnh nhn suy nhc gi yu vt m kh lnh 4. Do cn c thnh bng b cng nn vt m lnh km, chm v d: Sau m bng, rut bao gi bng cng chng do lit, hoc sau m b ho nhiu. 5. Do k thut : Khu khng ly c cc lp cn, buc khng cht, mp cn cn dn cch sau khi buc. III. Gii phu bnh l. 1. Vng thot v (l thot v). - ngay vng so c - Hnh bu dc hoc trn

26

- B ca l thot v do cn c b x ho to nn, lp phc mc thnh b dnh v x ho dc theo chu vi ca l thot v, cn b mt ca l thot v th khng c phc mc ch c tng dnh vo vng so x.

2. Ti thot v: C kch thc v hnh dng khc nhau, ty theo tng trng hp, thng c nhiu ng ngch cng c khi khng hnh thnh ti thot v. 3. Lp hc ngoi khi thot v. Ch l lp so x mng v chnh cng l ti thot v, lp ny c lc ch c da, t chc di da cng vi vt so gia nhng so cng b gin rng v mng. 4. Ti thot v: Ch yu l rut. IV. triu chng. Chn on thot v sau m thng d dng. Thy khi phng ngay ng m c, khi phng to r khi bnh nhn rn, nhng n th xp li ngay, s c cm gic tng thot v ngay di tay v lp so x mng nhng khi th tay th khi phngli xut hin hoc ch rn nh li ra. V rut dnh vo lp so, vo h l thot v nn khng y hon ton vo trong bng c.

27

- S c b ca vng thot v d dng b x v chc

V. iu tr: M l ch yu. 1. Bc tch tng dnh vo vng so c v bc dc theo b ca vng thot v. 2. Ti to thnh bng nhng si ch khng tiu, m bo kt qu nht thit phi khu, ko hai lp cn c vo vng thot v st vi nhau. t yu cu ny nhiu lc phi lm th thut chuyn vt cn, hin nay trng hp vng thot v qu ln khng th lm th thut chuyn vt cn c th mt s tc gi dng cc mng li cht do bt ch khuyt hng thnh bng. M ti to li thnh bng cho nhng bnh nhn thot v sau m khng phi lc no cng d dng, kt qu cng cn hn ch c bnh nhn phi m nhiu ln v vy cn ch : ngi c gi yu khng nn m ch eo bng gi khng cho khi thot v li ra. - V vt m trc b nhim khun lu ngy, do m li cng rt d b nhim khun l lm tht bi cuc m. V vy phi xem xt k vt m cn nhiu khun tim tng na khng, thng phi da vo: 28

- Kt qu xt nghim mu: BC, CTBC, mu lng. - T lc lnh vt m c n lc m li phi t 6 thng n 1 nm. Nu bnh nhn c nhiu vt m (thng do vt thng chin tranh th nn ch sau 2 - 3 nm mi m li). 3. Nn m di gy m ni kh qun v phi trnh lm tn thng cc quai rut dnh vo vng m c.

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Cc thot v him gp
GSTS. Phm Gia Khnh Thot v bng bn. Thot v bng bn xy ra vng bao c thng to, nhng v tr hay gp nht l ng bn nguyt ca Spigel Thot v bng bn rt him gp. Theo Rn, nm 1949 mi thu thp 120 ca c thng bo trn ton th gi, trong 2/3 l thot v nght. 1. Bnh nguyn v bnh sinh: Nhng yu t pht sinh ra thot v bng bn l: bnh bo, qu trnh vim nhim ca thnh bng, s ri lon thn kinh phn b c v c im cu to gii phu vng ny. 2. Gii phu bnh l: Ngi ta phn bit 3 loi thot v bng bn: 2.1. Thot v bm sinh: Do c ca thnh bng khng pht trin. 2.2. Thot v bao c thng to: Do khng c l sau ca bao v khi b chn thng d b t c thng to gy thot v. 2.3. Thot v ng Spigel: Thot v xy ra gc ngoi ca cung Douglas (cn c gi l "thot v ng bn nguyt ca Spigel") gia ng ni gia rn v gai chu trc trn, b ngoi c thng to, trong vng m cc si c ca thnh bng chuyn thnh cn, nhng i khi n c th thp hn hay cao hn. y l thot v thng gp nht v in hnh nht (xem hnh 5). Thot v Spigel thng nm trong chiu dy ca thnh bng. N c th i qua lp c ngang, c cho b v dng li cn c cho ln (thot v k). Him hn n c th to thnh mt l v i qua tt c cc lp c ca thnh bng ri nm ngay di da (thot v di da). Ni dung bao thot v thng l mc ni, rut non, i trng, him hn l manh trng, bng quang, d dy, vi trng, tinh hon... V tr chnh xc ca c ti thot v thng kh xc nh, v n hay thay i. L ca c ti thng l l ca thn kinh, mch mu, b ngoi c thng to, im m mt nhnh ca ng mch thng v chui qua cn ngang. 3. Triu chng v chn on: 30

Triu chng c bn ca thot v bng bn l cm gic au tc vng thot v. Khi ti thot v to th thy r mt khi phng gia ng ni t gai chu trc trn vi rn ( b ngoi c thng to) vi tnh cht ca mt ti thot v ni chung (Khi phng xut hin khi gng sc, nh hoc mt i khi nm ngh). Chn on trong nhiu trng hp khng kh khn. Nhng vi trng hp thot v b v thot v k th chn on kh. Khng him trng h p chn on nhm l vim rut tha, nhng bnh l v thn v gan. Nhiu khi ch chn on c trong khi m. 4. iu tr: Thot v bng bn ch c th iu tr bng phu thut: Rch da trn khi thot v theo hng cho xung di, vo trong. Sau khi phu tch v ct bao thot v th phc hi thnh bng theo tng lp: khu phc mc v cn ngang, khu c cho b, khu cn c cho ln v khu da. Thot v tht lng. Thot v tht lng l s i ra ca bao thot v thnh bng sau bn, qua cc khe khc nhau gia cc lp c v xng vng tht lng. 1. Nguyn nhn - bnh sinh: Cc khe h ca thnh bng sau thng c hnh thnh ch i ra ca thn kinh v mch mu. Nhng i khi c th l kt qu ca mt chn thng hoc mt qu trnh pht trin khng ng ca cn c vng ny. Nhng nguyn nhn pht sinh ca thot v tht lng th c nhiu, Borchardt chia thot v tht lng ra: thot v bm sinh, thot v do chn thng, do bnh l v thot v t pht. Thot v bn tri gp nhiu hn bn phi. 2. Gii phu bnh: Thot v tht lng c th xy ra hai ni: vng tam gic Jean-Louis petit hoc t gic Grynfelt. (xem hnh 6 v hnh 7). Thot v thng xy ra tam gic Jean-Louis petit nhiu hn. Bao thot v i qua khe h ca cn ngang vo trong tam gic Jean-Louis petit. Tam gic ny c gii hn bi c lng to, c cho ln v pha di l mo chu. T gic Grynfelt c gii hn bi pha trn l c rng sau di v xng sn 12, pha di l c vung tht lng v c cho b. Hnh dng kch thc ca t gic Grynfelt thay i theo chiu di ca xng sn 12. Khi xng sn 12 di th t gic Grynfelt i khi khng c hoc ch l mt khe, nhng khi xng sn 12 ngn th kch thc ca t gic ny s to ln. Thot v tht lng c th c ti m ni dung ca n thng l rut non, mc ni. Nhng n c th khng c ti khi ni dung ca thot v l mt u m, i trng ln, i trng xung v thn. 3. Triu chng v chn on: 31

Triu chng c bn ca thot v tht lng l c mt khi phng mt bn tht lng, khi phng ny c kch thc thay i ty theo t th v mc gng sc ca bnh nhn. Thot v tam gic Jean-Louis petit, ti thot v thng nm ngay di da. Cn thot v t gic Grynfelt, v trn n thng l c lng to hay c cho to nn ti thot v thng khng nhn thy r rng. Chn on thot v tht lng thng khng kh, khi thy mt khi phng vng tht lng, mt i khi nm nghing sang bn i din hay nm sp. Khi phng li xut hin khi bnh nhn quay sang bn i din. Chn on X quang cng gp phn quan trng. Chn on kh khn nht l trong thot v khng hi phc, c bit ni dung ca thot v li l mc ni. Khi d chn on nhm l u m. 4. iu tr: iu tr thot v tht lng ch c th bng phu thut. - Rch da thng ng trn khi thot v n mo chu. - M bao thot v v kim tra ni dung bo thot v. Nu ti thot v c cung th ct b ti sau khi tht c ti, nu khng c cung th khu kn c ti bng mi ti. Khu kn l thot v: khu theo gii phu ca vng. Thot v ngi. Thot v ngi i ra mt sau ca khung chu v i qua khuyt hng ln hoc b, i t chu hng b n mng. Papon l ngi u tin thng bo v thot v ngi, vo nm 1750. Thot v ny thng gp n v xng chu ph n rng hn v kch thc ca l ngi rng hn. Bn phi gp nhiu hn bn tri. 1. Gii phu bnh l: (xem hnh 8). 1.1. Thot v trn c thp: Xy ra nh khuyt hng ln, trn c thp, mch mu v thn kinh hng nm pha trong, bao thot v nm di c mng to. 1.2. Thot v di c thp: Xy ra y khuyt hng ln. C thp l mp trn ca l thot v, pha di l dy chng hng cng. Pha ngoi l mch mu v thn kinh thn trong, ng mch hng v thn kinh hng to (Sciatique). 1.3. Thot v di gai: Xy ra trong khuyt hng b, gia dy chng hng cng ln v b, pha trong ca ng mch thn trong.

32

Bao thot v trt xung theo thn kinh hng, trong t chc bao quanh dy thn kinh, v c th chn p dy thn kinh gy cm gic au d di, c khi gy lit chi di do chn p dy thn kinh bt. C ba loi thot v trn, bao thot v c th tt xung n gia i v c th thp hn. 2. Triu chng v chn on: Thng bnh nhn c cm gic au vng thot v. Theo M.A.Vaxiliev, nu vch mt ng t gai chu sau trn n nh mu chuyn ln, th im au ca thot v trn c thp im ni 1/3 trn v 2/3 di ca ng ny. Trong thot v di c thp im au thp hn 3- 4 cm. Khi thot v nh ra ngoi, cn chn on phn bit vi u m, p xe lnh. 3. iu tr: iu tr thot v ngi ch c th bng phu thut, k thut m ty thuc vo loi thot v. Rch da theo mt ng cho, song song vi c mng to, t gai chu sau di n b sau ca mu chuyn ln. Trong thot v ngi nght, thng i ng bng, hoc phi hp vi ng mng. Khi ct l ti thot v phng tn thng ng mch mng. M bao thot v, kim tra ni dung ri y vo bng. Phu tch bao thot v n l thot v. L thot v c khu kn bng cn c vng xung quanh. Thot v l bt. Thot v l bt xy ra ng bt hay ng di mu. l mt ng x c di 2-3 cm, i cho xung di ra trc v vo trong, thng gia khoang chu hng b vi phn trc trong ca i, i qua phn trn ca l bt (xem hnh 9). Thot v l bt tng i him gp (1/15.000 cc loi) thng b hai bn. Phn ln pht hin trong trng thi nght. Thot v bt thng gp ph n ng tui, gy, rt t khi gp nam gii. iu ny c gii thch l kch thc ca l bt v ng bt ca ph n ln hn, thm vo l sau ng bt ca ph n th phc mc b ko cng v di hn. 1. Gii phu bnh: ng bt c 2 l: L sau trong chu hng b c hnh bu dc, bc quanh n pha di l cung x ca cn c bt trong. l nguyn nhn lm thot v l bt hay b nght. L ny di h bn trong, gia b ca bng quang v ng mch rn, n c ph bi phc mc thnh v t chc t bo di phc mc. L trc th i, c gii hn di bi di di mu v c che ph bi c lc. 33

Thn kinh bt, ng mch bt v tnh mch bt i trong ng bt v xp theo th t t trn xung di. Pochard phn bit 3 loi thot v l bt: 1.1. Thot v k: Bao thot v mi nm trong ng di mu. 1.2. Thot v sau c lc: Bao thot v i ra khi ng, hoc mi ra khi l ngoi hay xung thp hn, gia 2 b c bt ngoi nm ngay di c lc. 1.3. Thot v trc c lc: Bao thot v i vo gia c lc v c khp nh, c th nm ngay di cn i hoc trong t chc di da. C ti thot v th l trong ca chu hng b, thng hp v thng sau v ngoi b mch thn kinh, nhng cng c th trong. Ti thot v thng mng v nh, ni dung hay gp l rut non, i khi l mc ni, manh trng, him hn l bng quang, phn ph, bung trng. 2. Triu chng v chn on: Triu chng khc nhau ty theo mc ca thot v: - Khi thot v cn trong ng bt th khng c ti phng, triu chng quan trng l du hiu Howship-Romberg: au theo ng i ca thn kinh bt, au mt trong i lan theo khp hng, khp gi v i khi xung ngn chn. Cng au khc nhau, c khi au d di nh au dy thn kinh, au tng ln khi vn ng. Chi di t th gp v quay ra ngoi. - Khi bao thot v ra khi ng bt th c th nhn thy khi phng. Engliach khuyn nn pht hin ti thot v bng cc bin php sau: . Ch quan st th tch v hnh dng ca i, n c th dy ln bn au, hoc h di mu v np bn th hin khng r. . Khm trong t th ng, chn gp, ti phng th hin r hn v mt i khi chn dui. . i khi g trong, l quai rut v chn on c xc nh. Khm ti ch bng cch s nn su di cung i v thm trc trng, m o c th s thy l sau ca ng bt v trong nhiu trng hp c th chn on chnh xc trc khi m v la chn mt phng php m thch hp. 3. iu tr: iu tr thot v l bt ch c bng phu thut . ng m c th tin hnh i, bng, hay phi hp. - ng i: rch ra theo chiu dc di 5-6 cm, song song vi tnh mch hin. Qua c lc v c khp th tm bao thot v theo thn kinh v mch mu bt. Ct b bao thot v. ng kn bao thot v bng cch khu cc cn c vng thot v. 34

- ng bng: thng p dng trong trng hp thot v nght, khi ct vng nght th ct pha di v trong trnh tn thng mch mu. - ng phi hp: gip cho phu thut tin hnh d hn. C th bt u bng ng bng hoc ngc li t ng bn. thot v y chu Thot v y chu i qua cc im yu ca c honh y chu. N c th xy ra mt trong 3 l: hoc gia b trong ca c nng hu mn, hoc khe gia c nng hu mn v c ngi ct, hoc khe gia c ngi ct vi xng ct (hnh 10). Nhng c im v cu to gii phu ca y chu vi s hnh thnh nhng ngch ca phc mc l yu t hnh thnh thot v ny. Nguyn nhn thng l do bm sinh, him hn l mc phi. Thot v y chu c th phi hp vi sa sinh dc hoc sa trc trng, s sa ny c th l tin pht hay th pht. n gp nhiu hn nam. 1. Gii phu bnh l: 1.1. n: - Thot v gia: bao thot v c th: ra trc - thot v m o (efytrocele). - Thot v sang bn: bao thot v c th: ra trc- thot v sau mi ln, ra sau: thot v y chu sau (xem hnh 11). 1.2. nam: - Thot v gia: bao thot v ch ra pha sau (thot v hu mn) thot v trc rt him gp. - Thot v bn: bao thot v c th: . Ra trc: thot v y chu trc. . Ra sau: thot v y chu sau. Thot v gia pht trin theo ngch trc trng hay m o, n thng khng c c ti v t khi b nght. Thot v bn i n di da ca y chu, trc n thng l u m, thot v thng c ti, c v c th gy nght. Ni dung ca bao thot v c th l rut non, i trng, mc ni, vi trng, bung trng v bng quang. 2. Triu chng v chn on: Triu chng ca thot v y chu rt khc nhau ty theo v tr ca n. chn on bnh ny, trong bt k trng hp no au y chu m khng gii thch c bng nhng bnh hu mn, trc trng v c quan sin h dc th phi ngh n thot v y chu v phi khm xt y chn on. Mun chn on chc chn cn khm m o, trc trng, bng quang v chp X quang rut c thuc cn quang. 35

Thot v sang bn ra trc n i n mi ln, cn phn bit vi thot v i. Trong thot v y chu th mi ln dy hn v c th xc nh v tr bao thot v gia m o v ngi bng thm khm m o. Thot v y chu sau c th tm thy b di c mng to v khi d nhm vi thot v ngi. phn bit cn khm l thot v. Trong thot v y chu khng hi phc d nhm vi mt khi u, ngay c trong khi m. l l do lm tn thng cc ni tng trong khi m. 3. iu tr: 3.1. i vi thot v bn: Rch da song song vi ngnh ngi mu trn khi thot v. Qua t chc m, h ngi trc trng (thot v sau) hoc c v cn y chu (thot v trc). Gii phng bao thot v ln tn c ti, ct b v buc c ti thot v. Khu bt l thot v bng nhiu lp vi mi ch ri. 3.2. Thot v gia: Phc tp hn nhiu, nhn chung, bao thot v khng c c thng phi hp vi sa sinh dc hay sa trc trng. 3.2.1. n: i vi thot v m o (thot v y ti cng Douglas) ng rch c th: - ng bng: khi thot v to, c bin chng dnh. - ng y chu: khi l thot v nh, c cung ph n bo c tui v yu. - Hoc phi hp: khi thot v rt to, khng c cung, thc s l s y chu trc. - Phu tch ct b bao thot v v khu cng c cc cn c vng thot v. 3.2.2. nam: i vi thot v y chu phi hp vi sa trc trng. - Th bng: treo trc trng. - Th y chu: m ct bao thot v. Sau khu gp c mu ca c nng hu mn.

36

S bng
PGS.TS. Nguyn Vn Xuyn 1. i cng - nh ngha: s bng l tnh trng tng chui ra ngoi qua vt m c, khc vi cc thot v thnh bng ch: khi tng khng c phc mc thnh bao ph m trc tip ngay vi t chc x ca vng m; khng c cc thnh phn ca thot v nh c ti, ti thot v. - C hai loi s bng: s bng do chn thng, vt thng, vt m v s bng t pht hay bm sinh. - S bng khc vi li ph tng l cn c lp da thnh bng che ph tng. - Phn bit vi thot v sau phu thut: l tnh trng tng chui ra ngoi qua vt m c m vn c phc mc thnh bao bc, to nn ti thot v, c th c c ti hoc khng c. 2. Nguyn nhn 2.1. S bng do vt thng, chn thng, vt m: - S bng do tai nn: chn thng, vt thng gy t rch phc mc, cn c thnh bng. - S bng sau phu thut: do ng khu cn c ca thnh bng khng lin c, hai mp vt m b toc rng ra, ch c lp t chc x so mng hoc da che ph vt m. Cc yu t lm vt m khng lin tt l: + Nhim khun lm toc vt m: thng gp nhng vt m nhim khun trong cc phu thut vt thng thu bng, cc loi vim phc mc, vim rut tha cp c m, hoc phu thut cc tng d nhim khun nh i trng, tiu trng + i vi cc ng m vo bng: m ng trng gia t b nhim khun nht, cc ng m ngang (ct c nhiu) km lin hn, d nhim khun v hay gy thot v sau phu thut. Ngi ta cng thy rng, nhng vt m khu t lp th t l thot v sau m t hn so vi nhng vt m c khu nhiu lp. + C th bnh nhn suy nhc, gi yu vt m kh lnh

37

+ Do cn c thnh bng b cng nn vt m lnh km, chm (sau phu thut bnh nhn b trng bng do lit, b ho nhiu. + Do k thut: khu khng ly c cc lp cn, buc khng cht, mp cn cn dn cch sau khi buc. 2.2. S bng t pht - S bng s sinh: do ngng pht trin ca thnh bng trc thi k bo thai, gm l tng rn, nhng khuyt nh cn c ng trng gia trn rn, bao cn c thng to, cc c cho. - S bng tr em: do ci xng, bng tr nn nho v phnh ra ch ng trng, lm cho hai c thng to b cch xa nhau. Ngoi ra, cn do bnh bi lit gy thoi ha mt s c thnh bng trc, lm cho thnh bng phng ln (nht l khi khc), s nn thy thnh bng nho hon ton. - S bng ngi ln: do bnh nho c ngi gi, bi lit, ph n sinh nhiu ln, ngi bo bu. C nhng ch c b tch xa nhau, cng ngy cng rng c th n 8 - 10 cm. 3. Gii phu bnh l - V tr: s bng ngay vng so c, hnh bu dc hoc trn, c th rt to hoc nh ty theo cn c vt m b tch ri nhiu hay t. - B ca vt m c b tch ra do cn c x ho dn to nn, lp phc mc thnh b dnh v x ho dc theo chu vi, cn b mt th khng c phc mc ch c tng dnh vo vng so x. - Vng s bng c kch thc v hnh dng khc nhau, ty theo tng trng hp, thng c nhiu ng ngch. - Lp bc ngoi: ch l lp so x mng, lp ny c lc ch c da, t chc di da cng vi vt so gia nhng so cng b dn rng v mng. - Tng : ch yu l rut, c th l mc ni ln.

38

Phc mc thnh C thnh bng

Quai rut

Da v t chc di da

Hnh s bng 4. Triu chng - Chn on s bng thng d, thy khi phng ngay ng m c, khi phng to r khi bnh nhn rn, nhng n th xp li ngay, nhng khi th tay th khi phng li xut hin hoc ch rn nh li ra, s c cm gic tng ngay di tay v lp so x mng. V rut dnh vo lp so, nn khng y hon ton vo trong bng c. - S c b ca vng s bng d dng, thy b x v chc. 5. iu tr phu thut - Bc tch tng dnh vo vng so c: bc dc theo b ca vng s bng, ct lc phn x so (ly ht t chc x nhng tit kim ti a t chc cn), ch bo v cn lnh thnh bng. - Ti to thnh bng: m bo kt qu cn phi khu, khu bng ch khng tiu, ko hai lp cn c ca vt m c vo st vi nhau che kn l khuyt hng. ng bng phi khu tng lp ch chc chn, tht cht nt ch; t yu cu ny, c th phi lm th thut chuyn vt cn bng cch to cc mt li cn thnh bng hai bn. Trng hp vng s bng khuyt hng qu ln, khng

39

th lm th thut chuyn vt cn c, mt s tc gi dng cc li cht do (mesh) v ch khuyt hng thnh bng. - Phu thut ti to li thnh bng cho nhng bnh nhn s bng ln l mt phu thut kh khn, t l thnh cng hn ch, i khi phi phu thut li nhiu ln, nht l nhng ngi gi yu, khuyt hng thnh bng ln, vt m c b nhim khun lu ngy v tim tng; nn khi phu thut li cn ch : + nh gi nguy c nhim khun vt m da vo lm sng v cc xt nghim. Nu nhim khun vt m, th coi nh phu thut tht bi. + Thi gian t lc lnh vt m c n lc phu thut li, phi t 6 thng n 1 nm. Nu bnh nhn c nhiu vt m bng (do vt thng chin tranh), th nn ch sau 2 - 3 nm mi m li. + Nn phu thut di gy m ni kh qun, trong phu thut phi trnh lm tn thng cc quai rut dnh vo vng m c.

Vim phc mc
PGS.TS .
Nguyn Vn Xuyn

1. Mt s c im gii phu, sinh l ca phc mc lin quan n bnh l v iu tr: 1.1. Gii phu: 1.1.1. Cc l phc mc: - Phc mc thnh. - Phc mc tng. - Cc np phc mc: Mc treo, mc chng, mc ni. 1.1.2. Khoang phc mc:

40

L khoang ln ca c th, c 75 - 100 ml dch vng, trong, trn cc tng trt ln nhau. Trong 1 ml dch phc mc c 2000 - 2500 t bo gm ch yu l t bo trung biu m v t bo limpho. Khoang phc mc nam gii hon ton kn, cn n gii thng vi bn ngoi qua l ca loa vi trng. Khoang phc mc c 2 ti: - Ti nh (hu cung mc ni) c tin nh v khe Winslow, qua y ti nh thng vi ti ln. - Ti ln: c tng trn v tng di mc treo i trng ngang. Tng trn c chia lm hai khu (khu phi v khu tri) bi mc chng lim. Tng di cng c chia lm hai khu bi mc treo tiu trng v c mc treo i trng chu hng y ln chu hng b.

Hnh nh gii phu khoang phc mc

1.2. Chc nng sinh l: 1.2.1. Chc nng c hc: - Treo, chng, gi cc tng trong bng. - Cc tng khng dnh v trt ln nhau c l nh dch phc mc. 1.2.2. Chc nng bo v: - Mc ni ln to nn mt hng ro c hc v sinh hc chng nhim khun. 41

- Dn ng dch bng vo ni thp (ti cng Douglas ). - Sc ht ca c honh trong mi nhp th lm tch t dch di c honh 1.2.3. Chc nng trao i cht: Phc mc c din tch ln tng ng vi din tch da ca c th (1,5 - 2 2 m ) v c cu trc nh mt mng thm phn. - Hp thu cc protein huyt tng, cc cht keo, nc in gii, tinh th, c t vi khun, cc cht c ng knh di 30 Angstron..... - Bi xut: cc cht in gii, nc, protein huyt tng .... vo khoang phc mc. 1.2.4. Cm gic phc mc: - Phc mc thnh nhy cm vi cc kch thch trong bng. - Phc mc tng ch nhn cm c cm gic ni tng. - R mc treo nhy cm vi s co ko. 2. Phn loi vim phc mc: 2.1. Theo nguyn nhn sinh bnh: 2.1.1. Vim phc mc nguyn pht: Khi trong bng c m, gi mc m khng c tn thng tng. Cc vi khun xm nhp vo bng theo ng t nhin hoc ng mu. Hay gp vim phc mc nguyn pht trn bnh nhn s gan c chng, vim phc mc do ph cu hoc lin cu khun tr em. 2.1.2. Vim phc mc th pht: C cc nguyn nhn l: * T ng tiu ho: - Bin chng ca vim phc mc rut tha cp l nguyn nhn hay gp nht, c th vim phc mc mt th, hai th, ba th.

42

Hnh nh vim rut tha cp

- Thng d dy t trng: do lot hoc do K.

Hnh nh thng lot mt trc hnh t trng

- Thng hi trng do bnh thng hn, ni thng l cc mng payer, bin chng thng thng xy ra vo tun th 2 ca bnh. - Vim ti tha Meckel b thng hay gp tr em nhiu hn ngi ln. - Hoi t rut non: l hu qu ca nhiu bnh l khng c chn on v x tr kp thi: nght rut, xon rut, lng rut, nhi mu mc treo tiu trng, vim rut hoi t....... - Thng v hoi t i trng: do cc nguyn nhn nh K i trng, l amip, l trc khun, ti tha, xon manh trng hoc i trng chu hng ..... * Bnh l gan, mt, ty: - Vim phc mc mt: thng gp sau tc mt do si v giun lm cho ti mt, ng mt hoi t v thng, dch mt chy vo bng gy vim phc mc. - Thm mt phc mc: khi tc mt, ng mt ch v ti mt b dn to, thnh cng mng, dch mt thm ra bng. - Vim ti mt hoi t: ti mt b vim (do si hoc khng do si) lm m v hoi t lan ra xung quanh gy vim phc mc. - p xe gan v m hay gp l p xe gan amip b v.

43

- Vim ty cp nht l th hoi t. * Bnh l sn ph khoa: - Vim phn ph, vim m vi trng v p xe loa vi trng v. - Thng t cung do no thai, ph thai khng ng k thut. * Chn thng v vt thng bng gy thng tng rng: D dy, rut non, i trng, ti mt, ng mt, bng quang. * Sau m cc c quan bng (vim phc mc sau m). C th do: - Nhim khun ngay trong lc m do khng tun th ch v trng tuyt i (t gp). - Khng ly ht v ra k cc cht bn trong khi m vim phc mc - X r ming ni, ng khu (rt hay gp). * Tai bin ca mt s th thut: Chc ht m p xe gan, p xe rut tha, chp mt qua da, tht tho hoc soi i trng gy thng v i trc trng . 2.2. Theo tc nhn gy bnh: 2.2.1. Vim phc mc do nhim khun: Vi khun ym kh, i kh, hoc vi khun i kh kt hp vi ym kh xm nhp vo bng. - Theo ng mu. - T mt nhim trng trong bng ( p xe). - Thng, v cc tng rng. 2.2.2. Vim phc mc ho hc: - Do dich v axt trong giai on u ca thng d dy t trng. - Dich ty trong vim ty cp. - Phn su trong thng rut bo thai. 2.3. Theo din bin: 2.3.1. Vim phc mc cp tnh: Hay gp trong ngoi khoa, i hi phi can thip phu thut cp cu. 2.3.2. Vim phc mc mn tnh: Gp cc loi nh lao phc mc, vim phc mc dnh, vim phc mc ho nang bc rut ..... 2.4. Theo mc lan trn ca tn thng phc mc: 2.4.1. Vim phc mc ton th: Khi ton b bng (tng trn v tng di mc treo i trng ngang, mc ni ln) c dch bn, m, gi mc, 2.4.2. Vim phc mc lan to: Khi nhiu vng trong mt tng ca bng c m, gi mc, dch bn, qu trnh vim c xu hng lan sang cc vng khc ca bng, nu khng c m sm s chuyn thnh vim phc mc ton th. 2.4.2. Vim phc mc ti ch (vng):

44

Khi dch bn, m, gi mc ch mt vng ca bng, qu trnh vim c khu tr li, nu c v bc th gi l p xe: p xe di c honh, p xe gia bng v p xe chu hng b.
Cc pxe trong bng

2.5. Theo c im ca dch tit: C cc loi: thanh dch, thanh t huyt, t huyt m, m, mt, ty, mu. 3. Gii phu bnh l: 3.1. Tn thng cc l phc mc: - L tng dy ln, ph n v tng sinh cc mch mu, c gi mc bm dnh, quai rut chng cng hi. - Mc treo v mc ni ln vim dy. - Phc mc thnh tn thng chm hn. 3.2. Dch trong bng ty theo nguyn nhn c th l: - Dich c khng mi. - Dch m mi thi. - Dich mt trong vim phc mc mt - Dch ty trong vim ty cp - Dch tiu ho c ln mnh thc n. 3.3. Tn thng ca cc c quan l nguyn nhn gy vim phc mc: C th thng, v, rch, hoi t, vim m hoc cng dn qu mc 4. Triu chng: 4.1. C nng: 4.1.1. au bng: 45

Lin tc, khng thnh cn, au tng khi vn ng, nn, bnh nhn nm im t th t chn, cn trong Tc rut c hc au thnh cn v c lc du i. 4.1.2. Nn v bun nn: Thng gp nn khan, nu giai on mun rut lit, ng nhiu th nn nhiu, khc vi Tc rut c hc gp nn thc nn tho, nn xong au bng. 4.1.3. B trung i tin: Thng gp b trung tin nht l vim phc mc mun, nhng c khi bnh nhn li i tin phn lng. B trung i tin khng r rng nh trong Tc rut c hc. 4.2. Thc th: 4.2.1. Chng bng: Gp r cc bnh nhn n mun, tr em v ngi gi, bng thng chng u v cn i hai bn. 4.2.2. Co cng thnh bng: - Nhn thy bng khng tham gia nhp th, cc th c thng bng ni r. - Khi s nn bng, tay c cm gic nh s trn mt vt cng, r rt v in hnh l co cng nh g, c th thy phn ng thng bng l mc thp hn. - Co cng thng xuyn lin tc. 4.2.3. Cm ng phc mc: Pht hin bng du hiu Blumberg dng tnh. Co cng thnh bng v cm ng phc mc l nhng triu chng lm sng quan trng nht v c ngha quyt nh cho chn on vim phc mc cp. 4.2.4. G c vng thp: Ch xut hin r khi trong bng c nhiu dch xen gia thnh bng v cc quai rut. 4.2.5. Mt ting nhu ng rut: Giai on u nghe nhu ng rut tha v yu, giai on mun th mt hn. 4.2.6. Thm trc trng: Thm m o: l du hiu khng th b qua c trong vim phc mc nht l khi cc triu chng trn thnh bng khng r. Thm trc trng thy ti cng Douglas cng phng v au, in hnh l thy ((ting ku Douglas)). 4.2.7. Chc d: Do Solomon thc hin nm 1906, v tr chc d l im gia ca ng ni gai chu trc trn n rn hoc rn n u mt sn sn 10. Frink 1940 dng 200 ml huyt thanh sinh l bm vo bng khi chc d v gi l phng php chc d ((t)). y l bin php chn on lm sng sau cng. Hin nay c th chc d bng di hng dn ca siu m cho kt qu chnh xc cao v hn ch tai bin.

46

Khi chc d c dch bn, m l c vim phc mc, nu chc khng ra dch cng khng loi tr c. 4.2.8. Chc ra bng: Phng php ny do Root thc hin nm 1 964 p dng chc ra khi chc r cho kt qu m tnh. y l 1 phng php chn on b tr cho kt qu tt nhng bnh nhn nng, gi, tm thn, hn m m khng c kh nng xc nh c nhng triu chng lm sng v cc xt nghim cn thit. Kt qu dng tnh nu c trn 500 bch cu a nhn trung tnh /1ml dch ra l c vim phc mc cp, hoc khi dch ra c ln dch tiu ho, dch mt, dch ty . 4.3. Ton thn: 4.3.1. Tnh trng nhim khun: - Bnh nhn th nhanh nng, cnh mi php phng, mi kh, li bn, b trng, th hi, nm im, biu hin ((v mt vim phc mc)) (facies peritoneal) - St cao lin tc 39- 40 nhng vn c cm gic gai lnh. - Mch nhanh 100-120ln/pht, huyt p ng mch t thay i. 4.3.2. Tnh trng nhim c nu bnh nhn n mun: - L m, ni nhm, lc tnh, lc m, c khi lo u, ht hong, da xanh, ti nht, nhn nheo, mt hc hc mt thm qung. - Thn nhit thp, tt nhit . - Mch nhanh nh, kh bt, huyt p tt thp, kt. - Thiu niu hoc v niu. 4.4. Triu chng cn lm sng: 4.4.1. X quang: Chp bng khng chun b t th dng hoc na nm na ngi cho thy: - Bnh thng: thy r b ngoi c tht lng chu hai bn v thy r b di gan v bng gan. - Cc hnh nh chung ca vim phc mc: + Bng m ton b. + Quai rut dn cha y hi do lit rut. + Thnh rut dy v dch xen vo gia hai quai rut cnh nhau. + ng sng hai bn bng mt i hoc b ngt qung. - Cc hnh nh tn thng ring bit. + Lim hi di c honh trong thng tng rng. + Bng gan to trong p xe gan. + Mc nc, mc hi trong tc rut. 4.4.2. Siu m: Cho bit hnh nh c dch trong bng, hi trong lng rut dn v hnh nh bnh l ca mt s nguyn nhn vim phc mc. 4.4.3. Xt nghim mu: - Bch cu tng cao c th ti 15 -20.000/mm3, cng thc BC chuyn tri

47

- Ri lon in gii: thiu ion natri, kali, canxi - o cc thng s pH, pHC02, cc kim thy mu nhim toan chuyn ho. - Xt nghim ur v creatinin trong mu v nc tiu cng vi s lng nc tiu 24 gi nh gi tnh trng suy thn cp v tin lng kt qu iu tr. 5. Chn on: 5.1. Chn on xc nh: Da vo cc triu chng lm sng l chnh. 5.1.1. Hi chng nhim khun: St cao, mch nhanh, v mt vim phc mc, bch cu tng cao, cng thc bch cu chuyn tri. 5.1.2. Hi chng vim phc mc: au bng lin tc, co cng thnh bng c cm ng phc mc, du hiu Blumberg (+), g c vng thp, thm trc trng thy ti cng Douglas cng phng v au (ting ku Douglas), chc d hoc chc ra bng thy dch c hnh nh X quang ca vim phc mc. 5.2. Chn on nguyn nhn: Cn da vo: - Triu chng au u tin nht l v tr au. - Ni au nhiu nht. - Ni thnh bng co cng nhiu nht. - Bnh s v din bin ca bnh. 5.3. Mt s trng hp chn on kh: - Tr nh: kh khai thc bnh s v kh khm bng. - Ngi gi: thnh bng nho nht l ph n cha nhiu ln, hoc c bnh thn kinh tm thn l ln. - Ph n c thai hoc mi sinh. - Bnh nhn ang c iu tr khng sinh. - Bnh nhn sau m, thng st, lit rut, c dng khng sinh v thuc gim au. - Bnh nhn c dng thuc gim au tuyn trc hoc nghin ht. - Cn phn bit vim phc mc cp vi gy xng chu, mu t sau phc mc, chn thng ct sng tu sng v..v..... 6. iu tr: 6.1. Nguyn tc iu tr: Vim phc mc cp tnh th pht ch nh m l tuyt i, m cp cu cng sm cng tt, iu tr phu thut phi kt hp vi hi sc ngoi khoa trc, trong, sau m. 6.2. Hi sc ngoi khoa tch cc trc, trong , sau m: 6.2.1. Hi sc: - Bi ph nc v in gii. 48

- Hi sc tim mch nht l ngui gi v c bnh l tim mch. - Hi sc thn: t Sonde bng quang theo di nc tiu, nh gi tnh trng thiu v v niu. - Th oxy. 6.2.2. Chng nhim khun: Nn dng khng sinh ph rng liu cao v kt hp khng sinh, dng thm metronizadon, truyn tnh mch vi liu 2,5 mg/kg th trng. Vic s dng khng sinh tt nht l theo khng sinh . 6.2.3. H st: - Bng cc bin php c hc: Chm lnh, chm . - Bng thuc h st. 6.2.4. t sonde d dy v ht dch d dy chng chng: 6.2.5. Nui dng bng ng tnh mch, cho ng tiu ho ngh hon ton: 6.3. iu tr phu thut: 6.3.1. Mc ch: - Loi b nguyn nhn vim phc mc. - Thanh ton tnh trng nhim trng ca bng. 6.3.2. V cm: Gy m ni kh qun c gin c. 6.3.3. ng m: Phi rng ri t c cc yu cu: D kim tra x tr thng tn, lau ra bng thun li, sau m vt m t nhim trng. Nn chn ng trng gia trn di rn. 6.3.4. nh gi thng tn: - Mc lan trn ca vim phc mc, m, gi mc. - Xc nh nguyn nhn ca vim phc mc cn c vo dch bng, c quan b tn thng. 6.3.5. X l nguyn nhn gy vim phc mc: Ty theo nguyn nhn m c chin thut x tr thch hp, ch yu nhm mc ch cu sng tnh mng bnh nhn: ct rut tha trong vim phc mc rut tha, khu l thng d dy trong vim phc mc do thng d dy..... 6.3.6. Lau ra bng: Ty theo mc lan trn ca vim phc mc m c th lau hoc lau v ra bng. Ra bng bng thanh huyt mn ng trng m, c th pha thm betadine (dung dch it hu c). cc bnh nhn gi yu v nng cn thc hin lau ra bng khn trng, nhanh chng. 6.3.7. Dn lu vng thp ca bng: - Nhm mc ch cho dch bn tip tc chy ra ngoi sau m, v c th theo di bin chng sau m.

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- Dn lu thng c t vng thp ca bng: ti cng Douglas, di gan 6.3.8. ng bng: ng bng mt lp cn c phc mc, da h, sau 1- 2 tun c th khu da k II 6.4. Lm sch bng sau m: i vi cc trng hp vim phc mc ton th mun nng nht l vim phc mc phn m vic lau ra bng thc hin trong m khng trit c th ngi ta c th p dng cc phng php lm sch bng sau m nh: ti ra phc mc, bng m, oxy cao p hoc p dng kt hp cc phng php vi nhau. 6.5. Bin chng sau m: - Nhim khun vt m: c th vim ty, mng m, p xe hoc toc vt m. - Vim phc mc li do dch m cn tn ti v lau ra khng sch, dn lu khng ht, nguyn nhn ca vim phc mc cha gii quyt c trit , x r ng khu, ming ni. - p xe tn d trong bng: c th p xe di c honh, ti cng Douglas hoc gia cc quai rut. - Tc rut sm sau m xy ra trong thi k hu phu - Tc rut mun sau m. - S bng sau m.

Thng lot d dy - t trng

TS. Sn H 1. i cng: Thng lot d dy - t trng ( DD - TT ) xp th 4 trong cc bnh l cp cu ngoi khoa bng sau vim rut tha cp, tc rut v vim ty cp. Thng lot l bin chng nng n v trm trng ca bnh lot. Nu chn on mun v khng x tr kp thi, bin chng ny s e do tnh mng bnh nhn, t l t vong ti 2,5 - 10%, bnh nhn gi yu c th n 30%.

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1.1. V la tui: Thng lot DD - TT c th gp bt k la tui no t tr s sinh n ngi cao tui nhng hay gp la tui lao ng t 30 - 50 tui. 1.2. V ma: Thng lot DD - TT hay gp ma ng xun, y l khong thi gian giao thi, chuyn ma v l thi k bt pht ca bnh lot DD - TT. 1.3. V gii: a s thng lot DD - TT gp nam gii, t l nam/n : 9/1. 2. Nguyn nhn: 2.1. Lot d dy- t trng mn tnh. y l nguyn nhn hay gp nht, chim 90%- 95%. Lot t trng thng l ch yu, lot d dy thng t gp hn 2.2. Lot ming ni: Thng do lot ming ni sau ct d dy hoc ni v trng, him gp. 3. Gii phu bnh l: 3.1. L thng: Thng ch c mt l thng, rt t khi c hai hay nhiu l thng. L thng trn nn mt lot x chai hoc trn lot non cn mm mi. 3.1.1. Thng lot t trng: V tr : a s mt trc t trng. L thng c hnh van hoc hnh trn. Kch thc l thng to nh khc nhau. B lot thng thng nhn, mm mi xung quanh ph n nh. Tuy nhin b lot c th x chai cng nhng mn lm t trng co rm, sau khi khu d gy hp lng t trng. Mt trong l thng thng rng hn mt ngoi, do y ca lot b bo mn nn gy thng hoc do thng t trc c gi mc, mc ni ln hay ti mt bt vo. 3.1.2. Thng lot d dy: V tr: a s b cong nh, t gp mt sau d dy. Kch thc l thng d dy thng to hn t trng v c ng knh cng rt khc nhau. L thng trn nn lot c th mm mi (lot non) hoc x chai. 3.2. Tnh trng bng: bng sch hay bn ph thuc vo bnh nhn n sm hay mun, c hp mn v hay khng, thng gn hay xa ba n. Trong bng thng c hi v dch d dy. Dch trong bng khi mi thng cn sch, c mu l c hoc mu vng nht, khi c ln dch mt.Trng hp thng bnh nhn hp mn v, dch trong bng c mu en, bn, c khi ln baryte do bnh nhn mi c chp cn quang d dy. Khi bnh nhn n mun dch d dy nhim khun, cc quai rut v xung quanh l thng c gi mc. 4. Triu chng lm sng: 4.1. Triu chng c nng: 4.1.1. au:

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au t ngt, d di nh dao m vng thng v, au lm bnh n hn phi gp ngi li, khng dm th mnh. Sau au lan nhanh khp bng, km theo c cm gic nng rt. au lan ln vai phi, ln ngc hoc ra sau lng. au lin tc, khng c lc no cm thy d chu. Thng thng giai on sm bnh nhn khng nn, ch nn khi thng c km theo chy mu hoc giai on mun. 4.1.2. B trung i tin: Triu chng ny bao gi cng c, nhng khi pht hin c th mun , c vim phc mc. 4.2. Triu chng thc th: 4.2.1. Nhn: Bng khng tham gia nhp th, cc mi c thng bng ni r. 4.2.2. S nn: - S nn vng thng v thy co cng thnh bng, c cm gic nh s vo mt tm g, gi l co cng nh g. Co cng thnh bng l triu chng khch quan ngoi mun ca thy thuc v bnh nhn. y l triu chng bao gi cng c khi mi thng v l triu chng lm sng quan trng nht trong chn on thng lot d dy t trng. - S nn au khp bng tuy nhin au nht vn vng thng v, c cm ng phc mc pht hin bng du hiu Blumberg (+). 4.2.3. G: - G vang vng trc gan do kh len vo khoang gia gan v thnh bng trc. - G vng thp c, nht l vng h v v hai h chu do dch bng ng vng thp trong t th nm. 4.2.4. Nghe: - Giai on u nhu ng rut gim, giai on mun c vim phc mc th nhu ng rut mt . 4.2.5.Thm trc trng hoc m o ti cng Douglas cng phng, n au chi, in hnh c ting ku Douglas. 4.2.6.Chc d bng: Trong trng hp cc triu chng lm sng khng r nhng bnh nhn qu yu, c dng thuc gim au hay ang trong tnh trng s c, hn m m X quang khng c lim hi th c th chc d hoc chc ra bng chn on. 4.3. Ton thn: - Lc mi thng c biu hin sc do au, thng xy ra trong 5 -10 pht u. Bnh nhn c biu hin ht hong, mt ti nht, v m hi, tay chn lnh. - Bnh nhn lc u khng st, nhng giai on mun th st do nhim khun phc mc. Nu n mun ngoi biu hin nhim trng cn c nhim c

52

r, st cao 39- 40 , mch nhanh trn 100L/pht, c v mt vim phc mc: mi kh li bn, mt hc hc, hi th hi. 4.4. Tin s d dy t trng: Bnh nhn thng d dy c tin s vim lot d dy t trng chim t l 70- 80% cc trng hp. Tuy nhin c khong 20%- 30% trng hp thng khng c tin s v thng l du hiu u tin ca bnh lot d dy t trng, gi l " thng lot cm". 4.5. Tru chng cn lm sng: 4.5.1. X quang: Chiu hoc chp bng khng chun b t th ng c th thy lim hi di vm honh hai bn hoc mt bn. Thng thng thy lim hi bn phi v vm honh phi cao hn vm honh tri. Thng lot d dy- t trng ch c khong 80% c lim hi, a s do thng mt trc. Tuy nhin nu chp X quang khng c lim hi nhng lm sng r cng c ch nh m gii quyt nguyn nhn. tng t l c lim hi, c th chp bm hI d dy bng cch bm 800 - 1200 ml khng kh qua sonde d dy, sau soi di mn hnh tng sng hoc chp bng tm lim hi. 4.5.2. Siu m bng: Trong nhng nm gn y siu m bng c p dng rng ri trong cp cu. Hnh nh siu m trong thng lot DD-TT c th thy hi hoc dch t do hoc c c hi v dch t do trong bng. 4.5.3. Soi bng cp cu cc c s c trang b my ni soi c th tin hnh soi bng cp cu va chn an va ng dng phu thut ni soi khu l thng d dy t trng. 4.5.4. Chp ct lp vi tnh: Chp ct lp vi tnh c th thy nhng hnh nh hi v dch t do trong bng. 4.5.5. Xt nghim: Xt nghim mu nh gi tnh trng nhim trng khi bch cu tng v cng thc bch cu chuyn tri. nh lng ur v creatinin nh gi tnh trng suy thn trong nhng trng hp vim phc mc nng. Lm in gii cn thit cho vic hi sc trc, trong v sau m. 5. Din bin: Thng d dy t trng c th din bin theo hai kh nng sau: 5.1. Vim phc mc cp tnh ton th: Dch d dy qua l thng chy vo bng. Trong nhng gi u l dch v trng c tnh cht axt. Sau 12 - 24 gi vi khun pht trin (s chuyn sang giai on vim phc mc hu trng). Nu mun na bnh nhn s c trng thi nhim trng nhim c nng, ur huyt tng cao, suy thn dn n hn m, suy a tng. 5.2. Vim phc mc khu tr (apxe): 53

Dch d dy chy ra c mc ni ln, ti mt, cc tng ln cn vy bc, khu tr li thnh mt p xe di honh bn phi. Bnh nhn c triu chng mt mi, st cao dao ng, khm c cc triu chng in hnh ca p xe di honh phi, xt nghim bch cu tng, chp XQ c hnh nh ca p xe, siu m c long m ranh gii r. 6. Chn on: 6.1. Chn on xc nh: Chn on thng lot d dy t trng da vo cc triu chng sau: - au t ngt d di nh dao m vng thng v. - Co cng thnh bng m in hnh l bng cng nh g, c cm ng phc mc pht hin bng du hiu Blumberg (+). - X quang c hnh nh lim hi di honh l du hiu c hiu ca thng tng rng. - Nu bnh nhn c tin s vim lot d dy t trng th chc chn l thng lot DD-TT. 6.2. Chn on phn bit: 6.2.1. Vim rut tha cp v vim phc mc rut tha: + au bng khu tr h chu phi, sau lan ra khp bng nu vim phc mc. + XQ khng c lim hi. + Siu m c hnh nh ca vim rut tha cp. 6.2.2. Vim ty cp: + im sn tht lng bn tri au (im Mayo- Robson). + Amylaza mu hoc nc tiu tng. + Amylaza trong dch ra bng tng. + XQ khng c lim hi. 6.2.3. Vim phc mc do p xe gan v: + au h sn phi, st cao, gan to au, + Dch chc d bng l m mu socola khng thi. + Siu m c p xe. + XQ c gc sn honh m t nhng khng c lim hi. 6.2.4. Vim phc mc mt: + au d di lin tc nht l na bng bn phi + C tin s si mt, xt nghim mu Bilirubin tng 6.2.5. Thng tng rng khc: +Thng rut non do thng hn +Thng ti tha Meckel +Thng i trng do l, ti tha, ung th, 7. iu tr: 7.1. Phng php bo tn bng ht lin tc: 54

Cn gi l phng php Taylor, c tc gi p dng t nm 1946. Hin nay ch p dng nhng ni khng c iu kin phu thut ch i chuyn v tuyn sau, cn nhng ni c iu kin phu thut th t sonde d dy ht dch c ngha hi sc tch cc chun b m cp cu. 7.2. iu tr ngoi khoa: 7.2.1. Nguyn tc: - M cp cu sm x tr nguyn nhn, lau ra v dn lu vng thp ca bng, kt hp hi sc ngoi khoa trc, trong, sau m. 7.2.2. Khu l thng n thun: c Mikulicz p dng u tin nm 1880. Ch nh: p dng cho nhng trng hp lot thng t trng khng c bin chng,hoc thng d dy m khng c kh nng ct on, ngi cao tui, gi yu khng chu c phu thut ln, khi bng bn, vim phc mc khng th p dng phu thut trit cn, vi mc ch nhm cu sng tnh mng bnh nhn. L thng c khu kn lp trong ton th bng ch tiu, lp ngoi bng mt ng khu dc song song vi trc ca d dy bng cc mi khu thanh mc- c. u im ca khu l thng l nhanh, k thut n gin, khng mt mu, t c bin chng sau m. Hin nay khu l thng t trng kt hp iu tr ni khoa sau m c p dng tng i ph bin. Nhc im l khng iu tr c nguyn nhn gy lot m ch gii quyt c bin chng thng. 7.2.3. Khu l thng qua ni soi Hin nay, mt s c s iu tr c th tin hnh phu thut ni soi khu l thng, lau ra bng v dn lu bng sau lau ra. Ch nh khu l thng qua ni soi cho cc tr ng hp thng lot t trng, bnh nhn n sm, th trng cho php, phu thut vin c kinh nghim m ni soi, c s iu tr c y phng tin cn thit phc v cho phu thut ni soi trong iu kin m cp cu.
7.2.3 Khu l thng kt hp ni v trng:

- Ch nh: sau khi khu l thng c nguy c hp mn v. Thng lot, km theo hp mn v m khng th ct on d dy cp cu hoc to hnh mn v. - u im: K thut n gin, gii quyt c lu thng d dy- rut, trnh c s ng d dy. - Nhc im:T l lot ming ni cao, v c ch tit a xt gy lot vn cn tn ti. Khi m ct li d dy, phu tch kh khn hn (Degastro gastrectomie)

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7.2.4.Dn lu l thng - Phng php Newmann thc hin nm 1912. - Ch nh: Bnh nhn n vin qu mun, vim phc mc nng, bng qu bn hoc l thng ln x chai, mn nt, khng c ch nh ct on d dy cp cu, khu s c nguy c x bc. Phng php ny khi p dng cn ht sc cn nhc, l phng php c la chn sau cng. - K thut: Qua l thng t mt ng thng nh sonde Malecot hoc sonde Petzer vo d dy hng xui xung pha mn v, khu vi kn chn sonde, qun mc ni vo quanh chn sonde, khu c nh d dy bng 3 mi ch p l thng vo thnh bng. 7.2.5. Ct on d dy cp cu: - Ct on d dy cp cu do thng c Ketly thc hin ln u tin nm 1902. y l phu thut va iu tr trit cn va gii quyt c bin chng thng. - Ch nh: Thng lot t trng c bin chng hp mn v, xut huyt tiu ho. Cn thng lot d dy hin nay a s cc tc gi ch trng ct on d dy cp cu trong iu kin c th thc hin c. - Cc iu kin ct on d dy cp cu: + Thi gian : n sm trc 6 gi k t khi thng. + bng sch, thng xa ba n: khng c m, gi mc, vim phc mc + Th trng bnh nhn cho php gy m, khng c bnh nng km theo, tui khng qu cao v cng khng qu tr. + Phu thut vin c kinh nghim ct on d dy. + iu kin k thut v trang thit b: Gy m m bo tt trong m v c iu kin hi sc sau m, c mu truyn v m bo c s vt cht cho cuc m. 7.2.6. Khu l thng v ct dy X: - Ch nh: Lot t trng thng, khng p dng cho lot d dy. - iu kin : Bnh nhn n sm, khi bng tng i sch. - K thut: Khu kn l thng, lau ra bng sch trc khi ct khi ct dy X. C th p dng cc k thut nh ct thn dy X kt hp vi phu thut dn lu nh ni v trng, tao hnh mn v hoc ct dy X siu chn lc khng km theo phu thut dn lu d dy. C th p dng phng php Taylor - Hill: khu l thng kt hp ct thn dy X phi v ct dy X tri siu chn lc.

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Hp mn v
PGS.TS. Nguyn Cng Thnh PGS.TS. Nguyn Vn Xuyn 1. i cng: - Hp mn v l hi chng do nhiu nguyn nhn vi biu hin chung l tnh trng lu thng thc n, dch d dy xung t trng gp kh khn hoc nh tr hon ton. Hu qu dn n d dy b dn to, dch v thc n ng d dy sau 6 gi vn cha lu thng ht. Trong cc nguyn nhn th hay gp nht l ung th hang mn v d dy, th hai l lot x chai bin dng hnh t trng, cc nguyn nhn khc thng t gp. - Hi chng hp mn v nu khng c iu tr kp thi s nhanh chng dn n ri lon chuyn ha nc, in gii, ton thn suy kit do lu thng d dy- rut b nh tr. Vic iu tr ch yu bng ngoi khoa v phi coi y l mt phu thut cp cu c tr hon nhng trc khi m phi bi ph nc, in gii, nng cao th trng bng truyn mu, m cho bnh nhn, nht l nhng trng hp hp nng. 2. Nguyn nhn: 2.1. Bnh d dy t trng : 2.1.1.Lot t trng: Trc y l nguyn nhn hay gp (5-15%), do lot to, x chai gy bin dng v cht hp. Hin nay, do nhng hiu bit mi v c ch bnh sinh v quan im iu tr bnh lot nn hp mn v do lot gim ng k (2-5%). 2.1.2.Ung th hang- mn v d dy: T l ung th vng hang mn v rt hay gp trong ung th d dy, t 20- 60%. Khi u si cng thnh d dy b thm nhim lm hp lng hang- mn v, tnh trng hp din ra tng dn theo s pht trin ca khi ung th. 2.2. Cc nguyn nhn khc 2.2.1. d dy: - U lnh tnh vng mn v, thng l polip mn v, hang v tt xung gy bt mn v. - Sa tt nim mc d dy qua l mn v - Teo c hang v - Hp ph i mn v - Hch trong bnh Hodgkin

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- So bng d dy do ung axit, kim. 2.2.2.Ngoi d dy: - T chc ty vng lc ch vng mn v. - U ty xm ln mn v, t trng. - Vim dnh quanh t trng do vim ti mt, sau m ct ti mt... 3. Sinh l bnh: Hp mn v c th do hp c nng v vim nhim, ph n, co tht, kh nng p ng vi iu tr ni khoa tt. Trong trng hp hp thc th nh lot t trng to, x chai hoc ung th thng phi iu tr ngoi khoa. in hnh, hp mn v din bin theo hai giai on: 3.1. Giai on tng trng lc: D dy tng trng lc, tng co bp khi b cn tr lu thng. Trn lm sng bnh nhn xut hin kh tiu, nn sm sau n. Khi bnh nhn c nhn n, dng khng sinh, b dch, in gii...cc hin tng vim nhim, ph n gim dn. 3.2. Giai on mt trng lc: Khi hp mn v lu, khng c iu tr s dn n hu qu d dy b dn to cha nhiu dch v thc n ng, nn xut hin sau n nhiu gi, dn ti tnh trng mt nc, in gii, ri lon cn bng kim toan do gim Cl- nhiu hn K+ trong mu, tng d tr kim trong mu v tng bi tit K+ trong nc tiu. Khi hp mn v, bnh nhn khng n ung c kt hp vi nn nhiu dn ti mt nc, lm gim khi lng lu thng tun hon trong mu dn ti tnh trng suy thn, tng ur mu. Nn v khng n ung c ko di dn ti th trng gy st, ri lon dinh dng, thiu mu v gim Albumin trong mu. 4.Triu chng: 4.1. Giai on u: 4.1.1. Lm sng: - au bng: Thng au sau ba n, au vng thng v, tnh cht au khng c g c bit, au gim i sau khi nn. - Nn: Xut hin sm sau khi n, c khi nn ra thc n ca ba n trc cng dch d dy mu xanh en. - Bnh nhn c cm gic y bng, m ch, kh tiu - Ton thn cha bin i, cha c tnh trng mt nc v ri lon in gii. - Ht dch d dy vo bui sng sm khi cha n thy: hin tng tng tit > 100ml/2h (bnh thng 40- 60ml/2h), c th thy cn thc n ba trc cng dch d dy ng. 4.1.2. X quang: Chp d dy c ung barit : dch ng ln barit trong d da nhiu. D dy co bp nhiu v mnh nht l vng hang v, ng nh, thuc vn qua mn 58

v c v mn v vn m do nhng co bp c gng ca d dy. Hin tng tng sng nhu ng xut hin tng t, xen k l hnh nh d dy gin . 4.1.3. Ni soi: Giai on ny thng thy d dy ng nh, mn v ph n, l mn v co tht, a ng soi hi kh nhng vn qua c. Hnh nh lot tin trin vi b g cao, y lot khot su, cc lp nim mc n . Nu ung th th thy khi u si nh cn tr lu thng d dy. 4.2. Giai on tin trin: 4.2.1. Lm sng: * Du hiu c nng: - au: au xut hin mun hn, 2- 3 gi sau n, n vo au tng. au tng cn lin tip nhau. Bnh nhn khng dm n, mc d rt i. - Nn: cng ngy nn cng nhiu. Nn ra dch ng trong d dy mu xanh en, c thc n ca ba mi ln vi thc n ca ba trc cha tiu. Sau nn bnh nhn ht au, cho nn c khi v au m bnh nhn phi mc hng nn. * Ton thn: Ngi gy, da kh, mt nc, mt mi. Do nn nhiu, n ung t nn th trng bnh nhn gy st nhanh, i t v to bn. * Thc th: - Du hiu lc c ch lc i (+): lc bng s nghe c ting c ch nh lc mt chai nc, do dch v v thc n ng d dy. - Du hiu Bouveret (+): Trong mi cn au hoc khi kch thch vng thng v sau p lng bn tay ln s thy cm gic tng t sng nhu ng d dy tng co bp t tri sang phi. - Bng lm lng thuyn: vng thng v cng trng, vng bng di lp kp, g khng vang, hai gai chu v mo chu nh cao. 4.2.2. X quang: - Hnh nh tuyt ri: Cho bnh nhn ung barit, khi chiu theo di di mn hunh quang thy thuc ri t t qua lp dch t ng trong d dy ging nh tuyt ri. - D dy hnh y chu: gin to, y sa thp di mo chu. - D dy hnh 3 mc: di l baryt v thc n c, gia l dch ng v trn l hi d dy. - Sng nhu ng nhiu v mnh trong giai on tng trng lc, chng t cc lp c d dy cn tt. giai on mt trng lc, d dy co bp t hoc khng co bp. - ng d dy: Sau 6-12 gi, nu chiu hoc chp li, s thy thuc cn quang nm ng li kh nhiu d dy, hnh d dy gin to, thuc cn quang khng qua mn v. Hnh t trng v t trng khng hin ln trn cc phim hng lot. Nu giai on ny khng c iu tr, bnh s din bin nhanh v dn ti giai on cui. 59

4.2.3. Ni soi: Ni soi thc hin sau khi ra sch d dy. Trn hnh nh ni soi thy: D dy ng, nhiu dch nu c cn thc n. D dy gin, vng hang, mn v ph n, l mn v tht nh. Trng hp hp mn v do lot t trng, ng soi kh qua c ch hp xung pha di. Nu hp mn v do ung th hang v c th thy hnh nh u si, nham nh, d chy mu... 4.3. Giai on cui: 4.3.1. Lm sng: * C nng: - y bng, chng bng, n ung m ch kh tiu. - au : au lin tc nhng nh hn giai on trc. - Nn : t nn hn, nhng mi ln nn ra rt nhiu dch ng v thc n ba trc, c khi 2-3 ngy trc. Cht nn c mi thi. Bnh nhn thng phi mc hng cho nn. * Ton thn: Tnh trng ton thn suy sp r rt. Bnh nhn biu hin mt nc: th trng gy, mt hc hc, mt lm su, da kh t nhn nheo, c khi l m v ur huyt cao, c trng hp co git v canxi trong mu thp. Trong giai on ny cn phi xc nh s thiu ht ca nc v in gii bi ph thch hp. * Du hiu thc th: - D dy gin to, xung qu mo chu, c khi chim gn ht bng, bng chng khng ch ring thng v m ton bng. - Lc c ch lc i (+) r. - D dy mt ht trng lc, khng cn co bp, mc d kch thch cng khng c mt du hiu phn ng no na, Bouveret (-). 4.3.2. X quang: - Cc hnh nh tuyt ri, d dy hnh chu li cng r rt. D dy khng cn sng nhu ng, hc nu c th ch rt yu. Sau 12 - 24 gi hay hn na baryt vn cn ng d dy kh nhiu, c khi vn cn nguyn. - Khi chp: D dy hnh y chu, sa xung mo chu, c ba mc r. 4.3.3. Ni soi: Ni soi DD - TT giai on ny d dng xc nh hp mn v vi cc du hiu: D dy gin to, ng nhiu dch, nim mc vim , mn v cht hp hon ton, ch thy mt l nh, khng th a ng soi qua c, ng soi phi y su gn ht vo hang - mn v. 5. Nhng ri lon v th dch: Nhng nm gn y, cc nh lm sng quan tm nhiu ti nhng ri lon v th dch v coi y l mt vn quan trng nh gi tin lng bnh. Kt qu phu thut xu hay tt, mt phn ln l do nhng ri lon ny nhiu hay t, 60

nng hay nh v phng php iu tr trc khi m c thch hp v khn trng khng. 5.1. Mu: Bnh nhn hp mn v n ung km, khng hp thu c nn thng b gim protein mu, thiu mu nhng c th hng cu vn cao do mu c, Hematocrit thng tng. 5.2. in gii: Bnh nhn hp mn v nn nhiu gy ra nhng ri lon in gii: - Clo gim nhiu - Natri gim nhng t hn. - Kali gim t. Kali ch yu trong t bo, cho nn xt nghim mu khng chnh xc. - D tr kim mu tng . - Nit trong mu tng nhiu do: t l clo trong mu h thp; i; thn b tn thng v kim mu. 5.3. Nc: Nc mt do nn, phn ln c thay th bng nc trong khu vc ni bo, cho nn khi lng nc ngoi t bo hu nh bnh thng. Mt phn clo v kali cng t khu vc ni t bo chuyn qua. Nu t bo mt nc nhiu hn in gii dn n tnh trng u trng trong t bo. 5.4. Nc tiu: Thiu niu v trong nc tiu t l clo, natri h thp. 6. Chn on: 6.1. Chn on xc nh: - Triu chng c nng: au bng vng thng v, nn ra thc n c phi mc hng nn, nn xong d chu, m ch y bng kh tiu. - Triu chng thc th: du hiu lc c ch khi i (+); du hiu Bouveret (+). - Triu chng X quang: hnh nh tuyt ri, d dy hnh chu, ba mc, sau 6 gi d dy vn cn barit ng. 6.2. Chn on phn bit: 6.2.1. Bnh co tht tm v: Nghn c sc lng X quang: thc qun pha trn gin to, di cht hp ging hnh c ci, hnh bt tt, khng c ti hi d dy. Ni soi thy ng thc n trong thc qun. Thc qun gin to, tm v cht hp, co tht lin tc nhng nim mc mm mi. Khi soi phi ch c tm v m ra mi a ng soi xung d dy c. 6.2.2. Hp t trng:

61

Nguyn nhn do lot, u hay do ti tha t trng. Ty theo v tr ca tn thng gy hp m c cc biu hin khc nhau. - Trn bng Vater: ging nh hp mn v. - Di bng Vater: + Nn nhiu, nn ra dch mt vng. + Ton thn suy sp nhanh. + X quang xc nh c ch hp, trn l t trng gin rng. + Ni soi xc nh r v tr hp v tn thng gy hp. Sinh thit c th xc nh loi thng tn. 6.2.3. Vim teo vng hang v: Thng km theo lot b cong nh, kh iu tr ni khoa. Chn on phi da vo ni soi: vng hang v x teo, co nh. X quang: hang v co nh, gp khc. 6.2.4. Hp ph i c mn v: Xut hin tr s sinh, sau vi tun bnh thng s xut hin nn nhiu dn n ri lon ton thn. X quang: mn v ko di nh si ch, trn l d dy gin to. 6.2.5. Tc rut cao: Tc rut c hc cao: ch yu au, nn nhiu. X quang: mc hi, mc nc vng trn rn. 6.2.6. Nguyn nhn thn kinh: - Lit d dy do thn kinh: d dy khng co bp, mt nhu ng. - Tng p lc ni s: nn nhiu, nn lin tc, au u, mt m, ri lon thc, ph gai th. 6.2.7. Vim ti mt: Khi ti mt vim do si, ti mt cng to do tc mt. Cc cn au tng ln ng thi nn nhiu, nn tng dn. C ch nn c th do co tht c mn v, Si ti mt ln mn v, vim xung quanh vng ti mt, mn v t trng lm cn tr lu thng. 6.2.8. Bnh l ty: - Vim ty mn tnh. - U u ty, u bng Vater. Biu hin lm sng vi triu chng hp mn v c tc mt, tc ng Wirsung. 7. iu tr: Trc ht phi phn bit l hp c nng hay thc th. Hp mn v c nng ch cn iu tr ni khoa bng khng sinh, truyn dch, cc thuc chng co tht, cn hp mn v thc th phi iu tr ngoi khoa. Trc khi m phi bi ph nc, in gii v cung cp nng lng cho bnh nhn. 7.1. Chun b bnh nhn trc m: c ngha quan trng Bi ph nc, in gii da vo in gii .

62

Nui dng ng tnh mch bng truyn m, mu, m, v tr lc... cn c vo lm sng v cc xt nghim, tin hnh c trc v sau m. Phi ra d dy tht sch bng sonde Faucher, nht l trc m. 7.2. iu tr ngoi khoa: 7.2.1. Mc ch Mc ch chnh l phu thut gii quyt tnh trng hp v c th ng thi cha trit cn. Tt nht l m ct on d dy, nu bnh nhn n vin sm, tnh trng ton thn cho php, chun b tt th ct on d dy. Nu bnh nhn n mun, yu, tnh trng ton thn khng cho php nn ni v trng. 7.2.2. Cc phng php phu thut * Ct on d dy, lp li s lu thng tiu ha theo kiu Billroth I hoc Billroth II. Nu hp mn v do lot nn ct 2/3 d dy, cn do ung th nn ct ton b , 3/4, 4/5 d dy theo nguyn tc m ung th. * Phu thut ni v trng: Ch nh cho nhng trng hp : - Hp mn v giai on mun. Ngi gi v tnh trng suy kit. - Lot t trng su m khng c kh nng ct d dy c. Phu thut gii quyt c hp mn v, nhng nguyn nhn gy hp vn cn nht l K d dy. * Ct dy thn kinh X km theo ni v trng, ct hang v hoc to hnh mn v: Ch p dng cho hp mn v do lot hnh t trng, c th ct thn dy X, ct chn lc kinh in, hoc chn lc cao (siu chn lc). Hin nay t p dng. Hin nay p dng phu thut ni soi trong iu tr hp mn v do K hang v trong cc trng hp ct on d dy trit cn hoc s dng ni soi bng vi mc ch chn on.

63

Cc khi u lnh tnh ca d dy

TS. Hong Mnh An

1. i cng: Khi u lnh tnh ca d dy l mt bnh him gp, kh chn on, chim khong 5% ca cc khi u d dy. Trong nhng nm gn y do s pht trin v hon thin ca k thut chp X quang d dy, ca phng php ni soi tiu ho, cc khi u lnh tnh ca d dy c pht hin nhiu v sm hn. Mus G.D. v Bardosanhitzo X.V. trong thi gian t nm 1980 -1982 m 448 ca bnh v d dy, trong c 4 ca u lnh tnh (1%) gm 3 ca polip v 1 ca u m. Petrop V.P. theo di 293 bnh nhn c m ct on d dy t nm 1974 n 1982 gp 46 bnh nhn l polip d dy. Gropova G.V. trong 15 nm (1965-1981) iu tr ngoi khoa cho 286 bnh b polip d dy. Vin 103 trong hng ngn trng hp cc bnh l v d dy c m, cc khi u lnh d dy thng gp cng l polip. 2. Phn loi: C 2 loi 2.1. Theo t chc hc: 2.1.1. U lnh tnh biu m (Epithelium) thng l u tuyn. - U mt nhm tuyn hnh thm hoc lan to (bnh Mnetrier). - U tuyn trong hi chng Zollinger - Ellison. - U tuyn nh (typ Gladular - khng tng gastrin mu). - U tuyn Brunner. 2.1.2. U lnh tnh khng phi biu m m xut pht t t chc lin kt. Theo Chimofiv N.S. chia ra: - T trung m: c u c, u x, u x- c, u thn kinh, u m, u xng, u xngsn, u tng bo (plasmocytome), ty lc ch.

64

- T ni m: u mu, u bch huyt, u ni m (endothelioma), dn tnh mch d dy, phnh mch ca d dy, dn mch phnh v. - U dng nang: u nang nhy nim mc (mucocell), u nang h nim mc, u nang dng da (derasoida). - U hn hp: l loi u c - tuyn nh vng (ban vng), u thm nhim, bnh m bo lnh tnh dy X, u ht (sarcoid, Crohn), u giang mai, u lao. 2.2. Theo v tr gii phu: - U nim mc: thng l u tuyn, polip (polip tng sn, polip tn to, polip trung tnh, polip gia nh, polip thm nhim si...). - U thnh d dy: l nhng u xut pht t t chc lin kt. 3. Mt s u lnh tnh d dy thng gp: 3.1. Polip d dy: Polp d dy c chn on trc m ln u tin bi V.P Obrasov (1912), l loi u lnh tnh thng gp nht ca d dy. Do pht trin ca ni soi d dy nn polip ngy cng c pht hin nhiu. Theo Grigorian A.V. v cng s 1970, t l pht hin polip d dy trn m t thi l 1,1%. Theo Rosch W. l 0,33%. Cng theo cc tc gi trn t l polip d dy trong ni soi l 4-5%. Theo Richward D. Rosin polip gp ch yu hang v, chim ti 60%, trong polip tng sn chim 65 - 90% cc polip tuyn. Polip d dy thng pht trin trn nn vim d dy teo t. Hnh th ngoi ca polip rt khc nhau, hnh trn hay bu dc, c kch thc t 0,5-5 cm. Thng c chn rng, i khi c cung. Nu chn di, polip di ng c th xung n mn v gy hp. B mt thng nhn, i khi ging nh supl. Mu sc rt khc nhau t nht n sm, d chy mu. V tr thng vng hang v hay mn v, him hn tm v hay y d dy. S lng thng l 1, c khi nhiu. Tin trin ca polip c khuynh hng c tnh ho. Nhiu ngi cho polip d dy nh l mt bnh tin ung th. V vy khi pht hin polip d dy cn phi ct b bng ni soi hay qua m d dy, nhiu khi phi ct on hay ct b ton b d dy. Bin chng thng gp ca polip d dy l chy mu v ung th ho. 3.2. U thn kinh: (chim 5-10%) Xut pht t t chc thn kinh, thng nht l m ri Auerbach. Theo Hortolomei v Burghole chia ra 3 th: U ht thn kinh, u x thn kinh, u soan (Schwannome). U soan thng hay gp nht, ng hng th hai sau polip. U c hnh thnh bi s qu sn ca nhng t bo v thn kinh. i khi xut hin trong mt bnh cnh chung ca bnh Recklinghausen. U thng rt to, pht trin t b cong b d dy. Tin trin c th lm lot lp v gy chy mu v c kh nng ung th ho di th sarcoma. 65

3.3. U c (chim 16%): Pht sinh t lp c vng v c dc ca d dy. Thng tin trin rt chm. Khi u c th pht trin ra ngoi, dnh vo cc c quan ln cn, nhng nhiu khi rt t do, c th v do hoi t v chy mu vo trong bng. Khi u cng c th pht trin vo trong lng d dy, nim mc c th b lot gy chy mu. Nu u gn mn v gy hp mn v. ng ngi nht l ung th ho (myosarcoma), chim ti 10% trong tt c cc sarcoma ca d dy. 3.4. U m: Xut pht t lp di nim mc. Kch thc rt khc nhau, c th nh bng ht u, c khi nng ti vi kilogram. Ging nh c, n c th pht trin ra ngoi (u m di thanh mc) v pht trin vo trong (u m di nim mc). Loi u t gp hn v thng c nhiu u, loi th hai hay gp v thng c chn rng. Bnh thng pht trin khng c triu chng, tr khi khi u pht trin vo trong lng d dy lm cn tr lu thng thc n. thng l l do bnh nhn n khm bnh. Ngoi cc u trn, cn c th gp cc u lnh tnh khc nh u x, u mch mu, u bch huyt nhng rt him gp. 4.Triu chng: 4.1. Triu chng c nng: Cc triu chng c nng thng t, nhng khi khi u to th xut hin nhiu triu chng, nhng khng c triu chng no c hiu. Bnh nhn thng n khm vi cc triu chng sau: au bng vng thng v, thng khng au d di, khng c tnh cht chu k. Kh tiu, chn n, hoc cm gic y bng. Nu khi u to gn mn v th c triu chng hp mn v, hoc gn tm v th c triu chng kh nut. 4.2. Triu chng thc th: Thng ngho nn, t khi s thy u. Nhng nu u to th c th s thy vi tnh cht ca mt khi u lnh tnh: u di ng, mt nhn, ranh gii r. 4.3. Ton thn: Thng t thay i, nhng i khi ngi gy st khi khi gy ri lon tiu ho v n ung. 4.5. X quang: 4.5.1. Nguyn tc: - Phi kt hp gia soi v chp d dy nhiu t th khc nhau. - Soi v chp d dy khi y thuc mt na, y hon ton v khi bi xut ht. - C th bm hi hoc ung thuc sinh hi. 66

4.5.2. Hnh nh X quang thng gp: - Ni chung hnh nh khi u lnh tnh c nhng c im sau: hnh u n, thun nht, thnh d dy mm mi, np nim mc bnh thng, khng b co ko do khi u, rt di ng khi soi. - Hnh mt khi u: l hnh khuyt (t th nghing) hnh trn sng hn (trong t th thng). Cn ch phn bit vi d vt d dy. 4.5.3. Mt vi hnh nh c bit: - U thnh d dy: khng c hnh khuyt, m l hnh chn p, cn phi phn bit vi u ngoi d dy. - Hnh khi u b lot gia: c hnh cng cua (t th nghing) v hnh huy hiu (t th thng). Tm li, X quang d dy c th chn on c khi u lnh tnh d dy, nhng khng chnh xc. Theo Mus G.D. v Bardosahitzo K.V. s trng hp trong chn on X quang v sau m l 75%. 4.5.4. Ni soi L phng php chn on hnh thi c gi tr v c th nhn thy khi u v lm sinh thit cho mt chn on kh chc chn. Nhng chn on ni soi cng b hn ch khi khi u thnh d dy pht trin ra ngoi. Kt qu m tnh gi ca ni soi l 1,36% n 60% (Balalukin A.S., Rozanov I.B., Hemonek). Theo Mus G.D. chn on ph hp gia ni soi vi t chc hc sau m l 77,92%. Chn on t chc hc trc m vi sau m ph hp l 85%. 4.5.6. Siu m d dy nc: Bnh thng, siu m c th bit c thnh d dy dy hay mng. Khi cho bnh nhn ung nc, siu m s nhn thy r rng hn dy thnh d dy khi c mt mi trng khc lm i snh. Nhng u pht trin trong thnh d dy lm cho thnh dy c dy hn hn nhng vng khc. 5. Chn on: Chn on cc khi u lnh tnh d dy trc m ch yu da vo X quang v ni soi sinh thit nim mc d dy. Cc phng php trn mi ch l chn on gin tip, ngay c sinh thit nim mc khng phi bao gi cng chnh xc. Kt qu chn on chnh xc ch c sau khi xt nghim t chc hc bnh phm sau m. 6. Tin trin: U lnh tnh d dy thng tin trin rt chm: - Khi khi u to c th nh hng n n ung v lu thng ca d dy. - Khi u c th b lot, hoi t gy chy mu vo trong bng hay trong d dy.

67

- Tt c cc khi u lnh tnh ca d dy u c khuynh hng pht trin c tnh ho. V vy khi pht hin u lnh tnh d dy cn phi iu tr ngoi khoa. 7. iu tr: - Cc khi u lnh tnh d dy iu tr bng ngoi khoa vi sinh thit tc th c th ct on d dy hoc ct ton b d dy cng vi khi u lnh tnh. - i vi polip c chn nh c th ct t qua ni soi tiu ha. La chn phng php no l ty thuc vo nguyn nhn ca khi u, tnh cht v v tr ca n khi c biu hin c tnh ho th phi iu tr trit cn.

Chy mu do lot d dy - t trng

PGS.TS. Nguyn Vn Khoa 1. i cng: - Chy mu do lot d dy t trng l mt cp cu thng gp, chim t l cao so vi cc nguyn nhn chy mu ng tiu ho. Theo Edelmann gp 66,6% cc trng hp. - Khi c biu hin chy mu ng tiu ho, thy thuc cn xc nh c phi t d dy t trng hay do nguyn nhn khc? Trc ht phi coi y l mt cp cu ni khoa, ch m cp cu khi chy mu nng m iu tr ni khoa khng kt qu. 2. Nguyn nhn v iu kin thun li: 2.1. Nguyn nhn: Xy ra nhng lot mi hoc lot c. 2.1.1. Chy mu nhng lot non (lot mi). - Tin s au ngn, cn au t d di, c chu k. - Hnh nh X quang d dy t trng cha c hnh nh bin dng t trng v rt kh tm c ng thuc. - Ni soi chn on xc nh. - Chy mu c kh nng t cm c, tin lng tt . 2.1.2. Chy mu t lot d dy - t trng mn tnh : - Tin s au vng thng v lu nm, au lin tc, mt chu k, t p ng vi iu tr ni khoa. - Trn phim X quang chp d dy t trng thng c ng thuc r hoc hnh nh bin dng t trng. - Ni soi chn on xc nh. - Chy mu t c kh nng t cm, nu c cng ch tm thi. 2.2. iu kin thun li: 68

- Thay i thi tit. - Cm cm. - B chn ng mnh tinh thn. - Dng cc thuc nh hng ti d dy - t trng nh aspirin, corticoid, nonsteroid... 3. Gii phu bnh l: 3.1. lot: 3.1.1. V tr: - Lot t trng: hay gp chy mu hn lot d dy. Lot thng mt sau, lot x chai, y n su vo thnh sau, cn lot mt trc thng chy mu t v t cm d. - Lot d dy: thng gp b cong nh, mt sau d dy, hang v, phnh v ln, cc lot x chai, y su, n thng vo thnh d dy lm tn thng cc mch mu ca thnh d dy nn thng chy mu ln. 3.1.2. lot mn tnh: - Hnh nh i th: lot thng co rm gy bin dng hnh t trng hoc co ko d dy, lot c th thng vo ty, gan, ti mt v c mc ni dnh vo. - Hnh nh vi th: lot cha su, c phn ng vim r, nhiu khi lot khot thng vo cc lp ca thnh d dy- t trng. 3.1.3. lot non: - Hnh nh i th: Nhn t ngoi ch thy mt ch nht mu, s ch thy c im gn cng, khi m d dy kim tra thy mt lot nh, mm, xung quanh nim mc ph n, c th mu ang chy r r t y lot. - Hnh nh vi th: lot cn nng cha n su vo cc lp ca thnh d dy trng. 3.2. Thng tn chy mu: - lot n thng vo mch mu, gy chy mu d di, c khi phun thnh tia. - Chy mu thnh, mp lot, nim mc mp vim n, r r chy mu, thng chy t, dai dng v t cm. - Chy mu t nim mc xung quanh lot, thng do vim cp tnh hoc sau khi ung cc loi thuc nh hng ti d dy. 4. Triu chng: 4.1. Lm sng 4.1.1.Du hiu bo trc: - Bnh nhn chy mu do lot d dy - t trng khi khai thc bnh s thng c cc du hiu sau: + au nng rt vng thng v. + Ton trng mt mi, hoa mt, chng mt sau mi nn ra mu v a phn en. 69

- Tuy nhin cn lu mt s trng hp xy ra t ngt khng c du hiu bo trc. 4.1.2. Ton thn: Thng biu hin tnh trng mt mu v ty mc mt mu m c nhng biu hin khc nhau. + Mt mu t, chy r r, ton thn t thay i. + Mt mu nhiu, cp tnh th tnh trng ton thn c ri lon r : - Hoa mt chng mt, da xanh, nim mc nht, chn tay lnh, kht nc, v m hi, c khi ht hong vt v. - Mch nhanh, nh kh bt, huyt p tt nu mt mu nhiu. 4.1.3. Triu chng c nng: - Nn ra mu. - i ngoi phn en. 4.1.4. Triu chng thc th : - BN nn ra mu, cht nn thng ln mu cc, mu nu sm hoc nh nh , ln thc n v dch d dy mu hng. - BN i ngoi phn en, tnh cht phn thng nt, lng, mu en nh b c ph, c mi thi khm. - Tnh trng bng thng chng nh do trong d dy v rut cha mu 4.2. Cn lm sng: 4.2.1.Xt nghim mu: Hng cu gim, huyt sc t gim, hematorit gim, hng cu li tng, ty mc mt mu m th hin cc mc khc nhau. 4.2.2. Ni soi d dy- t trng: L phng php chn on tt nht, va xc nh c nguyn nhn, v tr tn thng va nh gi c tnh trng chy mu, nguy c chy li v c th tin hnh cc k thut cm mu qua ni soi. Phn loi ca Forrest 1977 c ci bin: F1: lot ang chy mu (1a: chy mu ang phun thnh tia, 1b: chy r r. F2: lot cm mu, chy mu gn y (2a: l mch mu, u mch mu nh ln gia nn lot, 2b: trong lng lot c cc mu ng bm, 2c: y lot c nhng chm en khc mu) F3: khng thy du hiu chy mu, lot ngng chy mu, trong d dy- t trng khng cn mu, lot nhn thy r, y trng xung quanh vin hang 5. Chn on: 5.1. Chn on xc nh: 5.1.1. chn on xc nh nguyn nhn chy mu do lot d dy t trng. Trc ht cn da vo khai thc bnh s c th c hai kh nng: - Bnh nhn c tin s au d dy t trng c th c chn on bng X quang v c iu tr ni khoa trc , thm ch c ln chy mu tiu ho trn. - C th bnh nhn khng c tin s, m chy mu tiu ho ln ny l 70

triu chng u tin. Ngoi ra c th tin hnh mt s bin php sau chn on nguyn nhn: * t ng thng d dy- t trng: thy mu tip tc chy ra, nu mu ti chng t ang chy mu, nu mu sm mu th c kh nng mu ngng chy. * Chp X quang d dy t trng cp cu : Hin nay t p dng v c th gy nhiu nguy him cho bnh nhn do phi di chuyn, phi ung thuc cn quang hn na kh thy c tn thng lot khi ang chy mu. Nu p dng cn phi ch : - Ch chp khi huyt p ti a trn 90 mmHg. - Di chuyn bnh nhn nh nhng, khng thay i t th t ngt. - Nn chp t th nm Trendelenburg, u cao. - Cho ung baryte long s lng khong 40-50 ml. - Khng s dng k thut p bng c gng tm lot * Soi d dy t trng cp cu : cho thy v tr ca chy mu, tnh cht tn thng ca lot chy mu, phn loi Forrest, nh gi c mu ngng chy hay cha v c th tin hnh iu tr chy mu. Ni soi ang c ng dng rng ri chn on v iu tr chy mu do lot d dy t trng. * Chp ng mch chn lc ng mch vnh v : t c ch nh, c th p dng nu ni soi tiu ha khng tm ra nguyn nhn, k thut ny gip thc hin tc mch chn lc cm mu. 5.2. Chn on phn bit. 5.2.1. Chy mu do nguyn nhn ngoi d dy t trng: - Chy mu ng h hp trn : chy mu mi, chy mu rng ming ri nut vo sau nn ra. - Chy mu do gin v tnh mch thc qun trong tng p lc tnh mch ca, hay gp do x gan c trng: mu thng chy t, mu ti, khng ln thc n v dch d dy, thng chy mu mc nng gy nguy him tnh mng. - Chy mu ng mt: trong tc mt do si hoc giun, mu chy r r ko di, a phn en nhiu hn nn ra mu, nn ra mu ng hnh thi bt ch (du hiu Foldari). - Chy mu ng tiu ha di : vim rut non, u rut non, ung th i trc trng, vim i trc trng xut huyt, polip i trc trng, tr, l, - Khi huyt : Mu c bt, c ui khi huyt. - Do n ung cc cht c mu ging nh mu ri nn ra (tit canh). - Chy mu do mt bnh ton thn: do st xut huyt, nhim khun nng, suy thn cp, cao huyt p, nhim c ch, ln hu c. - Bnh mu : xut huyt gim tiu cu v cn, bch cu cp, cng lch, Hemophilie. 71

5.2.2. Chy mu d dy t trng khng do lot: - Vim d dy : c th gp vim trt nim mc d dy, ni soi thy nhng vt lot trt nng chy mu. Vim d dy do cc lai thuc corticoid, nonsteroid v vim ton b nim mc d dy chy mu. - U d dy: a s l ung th biu m tuyn d dy, ngoi ra c th gp u mch mu (angioma), u thn kinh b lot. Phn ln chy mu r r t khi u i khi c th gp chy mu d di do lot ung th hoi t vo mch mu d dy. - Mt s nguyn nhn khc: vim lot ming ni, ti tha t trng, hi chng Mallory-Weiss, sau chn thng s no nng, sau bng nng... 5.3. Chn on mc chy mu: 5.3.1. Da vo khi lng mu mt: - Chy mu nh di 500 ml . - Chy my va t 500- 1000 ml. - Chy mu nng trn 1000 ml. 5.3.2. Da vo lm sng v xt nghim: Ch tiu Ton trng Mch quay HA max Hng cu Hb Hematocrit Nh Cha thay i <100 l/pht >100 mmHg >3 T/l > 100 g/l > 30% Va C th sc 100- 120 l/pht 90- 100 mmHg 2- 3 T/l 80- 100 g/l 20- 30% Nng Sc mt mu r > 120 l/pht < 90mmHg <2 T/l < 80 g/l < 20%

6. iu tr: 6.1. Nguyn tc chung: Trc ht phi cm mu, bi ph khi lng mu mt, hi sc chng sc, kt hp iu tr triu chng. - Vi cc trng hp chy mu t: Cn iu tr ni khoa v theo di st, c ch nh th iu tr ngoi khoa. - Trng hp chy mu nng, iu tr ni khoa khng kt qu phi m cp cu. 6.2. Cc phng php iu tr: 6.2.1. iu tr ni khoa. * Ch nh: Chy mu do lot cha c bin chng, chy mu ln u, chy mu mc nh v trung bnh, tn thng c xc nh bng ni soi l nhng lot non, va, cha gy hp v cha c du hiu thoi ha c tnh hoc c bnh l ton thn, ph n c thai. * Mc ch: - iu tr ni khoa c th lm mu ngng chy a bnh nhn ra khi tnh trng thiu mu cp tnh. 72

- Nhiu trng hp iu tr ni khoa gip cho bnh nhn n nh hn to iu kin cho phu thut c thun li. * Ni dung ca iu tr ni khoa. - Bt ng, th oxy h tr, t sonde d dy theo di. - Cho cc thuc cm mu, gim tit, an thn, tr tim, tr lc. - Truyn mu v cc dch thay th phc hi khi lng tun hon, tt nht l mu ti. - Phng php ra d dy bng nc lnh c th pha adrenalin, nhit lnh s lm nim mc d dy se li v lm mu ngng chy. 6.2.2. Ni soi can thip : Khng p dng trong chy mu do lot c phi hp thng, hp mn v hoc do ung th d dy chy mu. - Qua ni soi cp cu ngui ta c th t in, laser, tim x cm mu lot ang chy bng adrenalin 1/10.000, polidocanol 1- 3% hay cn tuyt i xung quanh lot hoc cnh mch mu. Ngoi ra cn s dng keo sinh hc hoc clip kp cc mch mu ang chy. - Bng ni soi ngoi vic xc nh c thng tn lot chy mu cn c th cm mu cc trng hp: lot ang chy mu (F1), lot cm mu nhng cc mu ng c kh nng bong ra tip tc chy nhng bnh nhn gi yu c cc bnh l ton thn km theo hoc ph n c thai. Tuy nhin phng php c nhng hn ch l kh cm mu nhng lot to, x chai v tn thng mch mu ln. 6.2.3. iu tr ngoi khoa: * Ch nh m cp cu: - Chy mu nng, chy mu ko di m iu tr ni khoa tch cc khng kt qu, xc nh tn thng ang tip tc chy mu (Forrest 1). - Chy mu ti pht sau khi iu tr ni khoa n nh c vi gi n vi ngy, xc nh tn thng ang tip tc chy mu (Forrest 1), lot x chai th ch nh m cp cu. - Chy mu trn bnh nhn c bin chng hp mn v, thng hoc lot c kh nng ung th ha. - Tui trn 50, c tin s lot d dy nhiu nm, iu tr ni khoa khng khi hoc khng c iu kin iu tr ni khoa. * Cc phng php: - Ct 2/3 d dy: y l phng php kinh in, c bn, hay p dng iu tr chy mu do lot d dy t trng, va ct b c lot va iu tr c nguyn nhn gy lot. - Khu cm mu y lot km theo ct dy thn kinh X, c th ni v trng hoc to hnh mn v: p dng cho lot non hnh t trng hoc lot cp tnh.

73

- Khu cm mu lot km theo tht cc cung mch n d dy: p dng cho nhng bnh nhn qu gi yu khng sc chu ng mt phu thut ko di. - Ct dy X km theo ct hang v ly i lot chy mu.

IU TR NGOI KHOA

bnh LOT D dY - T TRNG

PGS.TS. Nguyn Vn Xuyn Bnh lot d dy - t trng iu tr ni khoa l ch yu, iu tr ngoi khoa c ch nh khi iu tr ni khoa tht bi hoc c bin chng. Ngy nay nh nhng hiu bit thu o v su sc v c ch bnh sinh (vai tr ca xon khun H Pylori trong bnh sinh ca lot), nh c nhiu thuc tt (thuc khng th th H2 v thuc c ch bm proton) c s dng trong lm sng cho nn vic iu tr ni khoa mang li nhiu kt qu tt, dn dn thu hp bt nhng ch nh iu tr ngoi khoa. 1. C s ca cc phng php iu tr ngoi khoa: 1.1. Bi tit dch v: Nim mc d dy c ba vng: 1.1.1. Vng tm v: C cc ng tuyn n bi tit cht nhy (mucin). 1.1.2. Vng thn v: Ngoi bi tit ra cht nhy cn c hai loi t bo: + T bo chnh: tit pepsinogene. + T bo thnh: tit axit chlohydric. 1.1.3. Vng hang v: C cc ng tuyn nhiu nhnh tit cht nhy v cc t bo G tit gastrin. Nh vy nim mc d dy bi tit hai loi cht c chc nng khc nhau: - Loi cht bo v nim mc d dy: cht nhy.- Loi cht gy lot: Axit chlohydric v pepsinogen. + Pepsinogen mun gy lot phi chuyn thnh pepsin iu kin pH l 6, pepsin tiu hy protein gy lot khi pH l 3,5. + Gastrin l cht ni tit t bng ng mu kch thch thn d dy tit axit chlohydric. 1.2. Vai tr ca dy thn kinh X: Cc si thn kinh X chi phi d dy c hai nhim v: - Vn ng: lm d dy co bp v lm mn v m. 74

- Bi tit: kch thch t bo chnh tit pepsinogen v t bo thnh tit axit, cc si i vo vng hang v kch thch t bo G bi tit gastrin. bi tit gastrin ngoi s kch thch ca dy thn kinh X cn do s va chm ca thc n vo nim mc vng hang v, s cng dn ca hang v, kim tnh ca dch v. 1.3. toan ca dch v: Pepsin mun gy lot phi c mt ca HCl, cn gastrin gy lot bng cch kch thch bi tit HCl. Dragstedt ni: ((khng c axt th khng c lot)). 1.4. Vai tr ca vi khun Helicobacter Pylori (HP): Warren v Marshall (1982) pht hin ra xon khun H.Pylori c nhiu trong nim mc d dy, tn thng rch nim mc l ni nhiu nht. Xon khun H.Pylori gi vai tr l nguyn nhn chnh lm lch lc mi cn bng hng nh ni mi gia Somatostatin - Gastrin - Axit. C ch sinh bnh l do vi khun tit ra men Protease ph hy lp nhy bo v nim mc d dy, lot l kt qu ca s mt cn bng gia h thng sinh lot (H.Pylori v axit ) v h thng bo v (cht nhy..) Qu trnh vim lot do H.Pylori bt u bng nhng t vim lot cp, tn thng n su vo nim mc, h nim mc, lu dn hnh thnh nhng lot mn tnh . T l nhim HP cc bnh nhn lot rt cao (85 - 100%), iu tr dit H.Pylori bng khng sinh s nng cao t l khi bnh v gim t l ti pht. 2. Ch nh iu tr ngoi khoa: 2.1. Cc ch nh tuyt i: 2.1.1. Thng lot d dy t trng: Bnh nhn n cp cu vi bnh cnh lm sng: - au t ngt d i nh dao m vng thng v. - Co cng c thnh bng, bng cng nh g. ' - C tin s lot d dy - t trng. - X quang c hnh nh lim hi. 2.1.2. Chy mu d dy - t trng nng: - Phi xc nh c chy mu l do lot d dy - t trng. - Phi iu tr ni khoa tch cc, truyn b mu m vn tip tc chy mu c nguy c e da tnh mng bnh nhn. 2.1.3. Hp mn v thc th: - Nn nhiu, nn ra thc n cha tiu ca ba trc. - Lc c ch lc i, bng lm lng thuyn. - X quang: Thc n lu thng chm, ung barit chiu c hnh nh tuyt ri, chp th d dy hnh y chu, c ba mc. 2.1.4. Lot d dy nghi ung th ha: Cc lot d dy bnh nhn ln tui, c bit l lot phn ngang v gc b cong nh. Cc lot d dy c lon sn, d sn, hoc km theo vim teo nim mc d dy. 75

2.2. Cc ch nh tng i (c bn lun): Cc cn c tho lun: 2.2.1. Bnh nhn c iu tr ni khoa mt cch c bn, c h thng, c k hoch, thi gian, ng phc m khng c kt qu: Vic iu tr bao gm cc giai on: - Giai on tn cng t 4 - 6 tun: + C ch lm vic, ngh ngi thch hp v nn iu tr ni tr ti bnh vin. + Ch n: nn king gia v, ru, bia . + Dng cc nhm thuc: thuc bng se nim mc, thuc gim tit, thuc tng cng sc bn nim mc, thuc trung ha dch v, thuc khng sinh, thuc c ch bm proton... - Giai on duy tr 12 thng: iu tr ngoi tr, ch lm vic nh, n king gia v, dng thuc gim liu dn. nh gi kt qu iu tr ni khoa: Sau hai nm iu tr c h thng thy ht triu chng, chp X quang v soi d dy khng cn thy lot l c kt qu. Nu thy au lin tc, cc triu chng khng thuyn gim, nh hng n sinh hot cng tc hoc au dng thuc khng khi l khng kt qu, nn cn nhc iu tr ngoi khoa. 2.2.2. Tui i: Tr em, thanh nin di 30 tui v ngi trn 60 tui th ch nh m cn d dt v thn trng. 2.2.3. Tui bnh: Khng nn m khi bnh nhn mi mc bnh. 2.2.4. Ngh nghip: Cn nhc ch nh i vi ngi lm vic nng. Nu sau ct on d dy m khng cn kh nng tip tc lm ngh ca mnh hoc chuyn ngh khc th vic ch nh cng phi thn trng. 2.2.5. V tr lot: Lot b cong nh nn c ch nh m. 2.2.6. Tnh cht lot: - lot x chai iu tr ni khoa c h thng khng co skt qu v au nhiu Nu lot c cc bin chng: chy mu nhiu ln hoc thng lot c khu l thng m iu tr ni khoa sau m khng kt qu th iu tr ngoi khoa. 2.2.7. Dch v: Loi tng toan, tng tit th iu tr ni khoa kh khn. 2.2.8. Ton thn:

76

Khng nn m khi bnh nhn mc cc bnh mn tnh nh x gan, lao phi hoc bnh thn kinh tm thn. 2.2.9. iu kin sinh hot, v tr a l v hon cnh kinh t ca bnh nhn: 3. Cc phng php phu thut: Mc ch ca vic iu tr phu thut khng phi ch n thun ct b lot m vn chnh l phi loi b nguyn nhn gy lot. 3.1. Phu thut ni v - trng: Wollfler, phu thut vin ngi c lm u tin vo ngy 28/9/188l iu tr cho mt bnh nhn hp mn v do K d dy, n nm 1884 Rygydier dng iu tr cho mt bnh nhn hp mn v do lot t trng. 3.1.1. Mc ch: - Lm cho dch v v thc n tiu thot nhanh chng khng b ng lu d dy. - Dch t trng qua ming ni trung ha toan dch v. - Thc n khng i qua lot t trng. 3.1.2. u im: - y l phu thut n gin, khng bt buc gy m ni kh qun (c th gy t ti ch c), khng cn truyn mu, trang b va phi. - L phu thut nh nhng, khng gy nhiu tai bin, t l t vong thp. 3.1.3. Nhc im: - T l lot ming ni kh cao (15 - 25%). - li lot c th gy chy mu hoc K ha. - Phn nim mc tit axt vn cn, lot kh lin so 3.1.4. Ch nh: - Khi hp mn v, ton thn yu khng ct on c. - Khi lot qu su m kh, nu ct d dy s c tai bin. - Phi hp vi phu thut ct thn hai dy X trnh ng d dy. 3.2. Phu thut ct on 2/3 d dy: 3.2.1. Lch s: Ngy 9-4-1879 Pean p dng u tin cho mt bnh nhn K mn v, sau bnh nhn cht, 10-1880 Rygydier ct on cho bnh nhn K d dy bnh nhn ny cng cht. Thng 1- 1881 Billroth ct on d dy cho mt bnh nhn lot t trng c hp mn v bnh nhn sng. 3.2.2. Mc ct: - Pha di: ly di mn v 1- 2cm. - Pha trn: pha b cong nh ni m ng mch vnh v i st vo d dy, cn pha b cong ln l ni ht cc nhnh ngn ca ng mch v mc ni phi. Nh vy s b i 60 - 80% d dy gm: hnh t trng, mn v, hang v, v mt phn thn d dy (bao gm ton b phn d dy kch thch tit axit v mt phn thn d dy ni trc tip tit axit).

77

3.2.3. Cc phng php lp li lu thng lin tc ng tiu ha :

Hnh 1: Cc phng php khu ni d dy - rut - Kiu Billroth I: Ni mm d dy cn li vi t trng: Phng php thng dng l ni din ct ca mm d dy cn li c ng hp bt vi din ct ca mm t trng (Pan l879). u im ca phng php ny l hp sinh l v thc n i qua t trng, kch thch phn x tit dch tiu ha tt, nhng i hi t trng phi mm mi, t chc khu ni, trnh cng ko. Phu thut ny c th p dng cho lot b cong nh, lot mn v hoc hnh t trng st mn v. - Kiu Billroth II: Ni mm d dy cn li vi quai u hng trng: c th ni trc i trng ngang hoc xuyn qua mc treo i trng ngang (truc khi ni phi ng vi mm t trng bng phng php Mayo hoc ng mi ri). + Nu nguyn c din ct ca mm d dy m ni l phng php Polya (1911). + Nu ng bt din ct v pha b cong nh (khong l/3) ri ni l kiu Hofmeister - Finsterer (1888). Kiu ny c u im so vi kiu Polya l ming ni nh hn do t gy hi chng dumping v hi chng quai ti. 3.2.4. u im: - L phu thut trit v loi b c nguyn nhn gy lot (ly b phn ln cc t bo tit axt vng thn v v ly b ht cc t bo tit axt nm hang v). - T l lot ming ni thp (1- 2%). 3.2.5. Nhc im: - L phu thut c nhiu kh khn v k thut. 78

- Tai bin, bin chng sau m c t l cao. - T l t vong sau m 0,5 - 2%. - D dy cn li b nh hng ti dinh dng ton thn. 3.3. Phu thut ct dy thn kinh X: Nm 1922 Latarjet tin hnh u tin. Nm 1943 Dragstedt nu thnh l lun khoa hc v p dng rng ri. 3.3.1. Ch nh: - Ch p dng vi lot t trng, hin nay t thc hin. - Cho nhng bnh nhn tr, b lot t trng m iu tr ni khoa khng kt qu, nu ct d dy s c nhiu di chng. - Bnh nhn gi yu khng sc chu ng phu thut ct on d dy. - lot qu nh, ct d dy khng cn thit v l phu thut qu ln, hoc lot to su di gn DII hoc thng vo ty, ct d dy s nguy him. 3.3.2. Cc phng php: - Ct thn kinh X ton b l ct thn hai dy thn kinh X khi chui qua l c honh. Mc ch: nhm ngn cn giai on thn kinh ca qu trnh bi tit dch v lm gim tit gastrin v gim p ng ca t bo trc kch thch ca gastrin. Khi ct thn hai dy thn kinh X th d dy thng b lit v ng. Nn ngi ta thng kt hp lm cc phu thut dn lu d dy nh: - Ni v - trng. - Ct hang v. - M rng mn v (pyloroplastie). u im ca phu thut ct thn hai dy thn kinh X l d dy vn nguyn vn, t bin chng trong m v thi k hu phu. T l t vong thp (0,5 - 1%). Nhng c nhc im nh: chng bng sau m, lit d dy rut, a chy gp 15 - 20%, xut hin lot mi hoc lot c khng lnh.

79

Mc ct

- Ct dy thn kinh X chn lc: L ct dy X tri di ch chia ra nhnh gan v ct dy X phi di ch chia ra nhnh tng. Phu thut ny vn phi lm thm phu thut dn lu d dy v ct tt c cc nhnh chi phi vng hang v ch huy co bp ca d dy.

Nhnh gan

- Ct dy thn kinh X siu chn lc (chn lc cao) l ct cc nhnh thn kinh i vo thn v (ch huy cc t bo tit Pepsinogen v HCl) li cc nhnh chn ngng chi phi hang v mn v (vn ng ca d dy). y l mt phu thut nh nhng, t l t vong thp (0,2 - 0,3%) bin chng sau m t v nh, khng c di chng sau m, khng phi lm phu th ut dn lu. Nhng c t l lot ti pht sau m dao ng cao t 0-20% v t c tc dng vi lot x chai, hp mn v.

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4. Tai bin, bin chng sau ct 2/3 d dy: 4.1. Tai bin: - Thng tn ng mt v cung gan . - Ct ri bng Vater. - Tn thng lch. 4.2. Bin chng sm: 4.2.1. Chy mu sau m: - C th chy mu ming ni hoc trong bng. - Triu chng ca mt mu cp: da nim mc nht, u chi lnh, mch nhanh, huyt p tt, hng cu, huyt sc t, Hematocrit u gim. - Chy mu trong bng: c th do tn thng lch hoc tut ch, tht lng cc cung mch d dy. Khi pht hin chy mu trong phi m li cm mu. - Chy mu ming ni d dy - hng trng: do lng ch khu cm mu mt ct d dy, rut. Khi chy mu, ngoi cc triu chng mt mu cp, c th thy mu ti chy qua sonde d dy hoc bnh nhn nn ra mu ti. iu tr bin chng ny bng cch ra d dy bng nc m hoc lnh, khi khng kt qu phi t vn m li sm khu cm mu. 4.2.2. Tc ming ni: - Bnh nhn nn nhiu v nn lin tc dch xanh en, ton thn suy sp nhanh, vng thng v phng ln, bng di lp kp. Nu tc sm vo ngy th 3 - 4 thng do ph n th ch cn ra nc m 2- 3 ln trong mt ngy. Nu xy ra mun hn vo ngy 6 -7 tr i thng do vim dnh hoc k thut khu ni khng tt. iu tr: thng phi m li gii quyt nguyn nhn.

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4.2.3. R mm t trng: - L bin chng nng n gp trong ct on d dy kiu Billrothth II Thng xy ra vo th 4 - 7 sau m, c ba loi r: - R gy vim phc mc ton th: phi m t dn lu t trng v lau ra bng - R gy vim phc mc khu tr (p xe di c honh): phi m dn lu p xe hoc chc ht m p xe. - R ra ngoi khng gy vim phc mc: phi ht lin tc cho kh dch ti ch, nh git axt lactic long hng ngy, c th nht nhau thai vo ng r km theo nui dng ng tnh mch tht tt. 4.2.4. X r ming ni: t gp, c th gy vim phc mc ton th, p xe di c honh hoc to thnh ng r t thot ra ngoi qua vt m. 4.2.5. Vim ty cp: Do ng dp t chc ty hay ng tit ca ty hoc khu vo ng ty khi ng mm t trng biu hin sc nng: mch nhanh, huyt p tt, amylaza mu tng cao. 4.3. Bin chng mun v di chng sau m: 4.3.1. Bin chng ti ch: * ming ni: - Vim ming ni: bnh nhn lun c cm gic nng bng vng trn rn. - Lot ming ni: Gp t 1 - 3%, iu tr ni khoa t kt qu, cn phi m ct li d dy hoc ct dy thn kinh X. Nguyn nhn ca lot ming ni c th do sai st k thut: ct d dy khng 2/3. - Lng rut: hng trng chui vo lng d dy gy nn bnh cnh ca Tc rut cao. * mm d dy cn li: - Vim mm d dy cn li. - K mm d dy cn li. * quai rut: - Hi chng quai ti: do quai ti qu di thc n dn vo gy ng lm cho bnh nhn c cm gic tc nng vng h sn phi, kh chu, nn ra dch mt vng ng, nn c th nh, chp X quang thy quai ti dn v thuc ng . iu tr bng cch ni quai ti vo quai i (phu thut Braun). 4.3.2. Bin chng v di chng c nng: - Hi chng d dy b: bnh nhn cm gic y, tc bng khi n, khng n c nhiu, phi n nhiu ba trong ngy.

82

- Hi chng dumping: do thc n b tng nhanh t d dy xung rut no n lm cng dn hng trng mt cch t ngt. Hi chng ny thng xut hin sau khi va mi n xong c bit n thc n ngt hoc sau khi n chng 5 - 10 pht v biu hin nh sau: + Triu chng v tiu ha: bnh nhn c cm gic cng tc vng trn rn, bun nn v nn, si bng au qun c khi i a chy. + Triu chng thn kinh thc vt: mt bng, v m hi, tai, nhc u ht hong hoc mt xu, mch nhanh, huyt p h, cc ri lon trn mi ln ko di chng 20 - 30 pht, nm ngh th , sau mt thi gian bnh nhn thch ng dn dn v khi hn hoc ko di. D phng v iu tr bng cch: n nhiu m, t bt, khng nn ung khi ang n, n lm nhiu ba nh, sau n ngh t 15 - 20 pht. C th dng thuc khng histamin hoc thuc chng co tht. iu tr ngoi khoa nhm mc ch lm chm bt lu thng ming ni d dy - rut. 4.3.3. Bin chng v di chng ton thn: - Thiu mu: thiu mu nhc sc do thiu st v B12 v vy sau ct on d dy phi khuyn bnh nhn dng b xung cc mui st v B12. - St cn ko di sau ct on d dy. - Ri lon dinh dng: thiu cc vitamin nn bnh nhn d b vim li, li vic hp thu km cc cht m, m, ng lm cho bnh nhn gy yu, mt mi v khng cm thy thoi mi. - Gim kh nng lao ng, kh nng sinh dc nam gii. - Lao phi. - Suy nhc thn kinh: bun nn, trm cm hoc kh tnh hay cu gt. 5. Tai bin, bin chng trong ct dy thn kinh X: 5.1. Cc tai bin trong khi m: 5.1.1. Tn thng lch: - Do ng tc qu mnh khi ko cng d dy, ko van... nht l nhng trng hp c vim dnh quanh lch lm lch b rch v. X tr: phi ct lch hoc khu bo tn ty theo thng tn ca lch. 5.1.2. Thng thc qun: - Gp khi tch cc nhnh thn kinh nh i st thnh thc qun m ng tc thiu thn trng. X tr: phi khu l thng, ch sau m cn ht dch d dy lin tc v theo di phng bc ch gy vim phc mc cp. 5.1.3. Thng d dy: - Hay gp trong m ct dy thn kinh X siu chn lc khi phu tch nhnh thn kinh qu st thnh d dy. - X tr : khu l thng. 5.2. Cc bin chng sau m: 5.2.1. Lit d dy: 83

y l mt bin chng t gp nhng rt nng, do mt trng lc ca d dy, gy ri lon cn bng nc, in gii nng. Lit d dy thng xut hin sau m t ngy th 3-15 vi cc biu hin: nc, nn, bng chng cng, bnh nhn ht hong, v m hi, mch nhanh, huyt p h, xt nghim mu thy h cc cht in gii, ur mu tng, nhim kim chuyn ha. iu tr bin chng ny bng cch bi ph nc in gii, iu chnh thng bng kim toan, chng sc nu c v t ng thng d dy ht dch tch cc. 5.2.2. Chng bng: Thng gp khi ct thn hai dy thn kinh X cc triu chng xut hin sm ngay sau khi bt u n ung, sau ba n bnh nhn thy tc bng, chng bng, hin tng ny c th s gim dn v mt sau vi thng. 5.2.3. Hoi t thnh d dy do thiu mu: y l bin chng him gp trong phu thut ct dy thn kinh X siu chn lc. V tr b hoi t thng thy b cong nh v vng y d dy. Bin chng ny xut hin vo ngy th 2 - 6 sau m vi triu chng au bng d di vng thng v, c bnh cnh lm sng thng v vim phc mc. 5.2.4. a chy: C th do cc nguyn nhn sau: - Gim bi tit dch d dy qu mc to iu kin thun li cho vi khu n rut pht trin. - Gim cc men tiu ha tit ra t ty, gan mt. - Ri lon c ch ng m mn v ca d dy, lm thc n xung rut qu nhanh Vic iu tr cn ch gi gn ch n ung thch hp, king m, cc cht bt v thc n d ln men. a chy c th nh dn v ht sau 6 thng n 1 nm. 5.2.5. Lot li sau m: C th do cc nguyn nhn sau: - Ct dy thn kinh X khng , khng ht v khng ng k thut. - Vic dn lu d dy khng tt gy ng. - Vic ch nh ct dy thn kinh X khng ng, nh trong mt s bnh lot do nguyn nhn ni tit (hi chng Zollinger - Ellison). Bin chng ny thng xut hin sau m 12 thng vi cc triu chng ca lot. Vic iu tr lot ti pht u phi m li, c th phu thut ct 2/3 d dy hoc ct li nhng nhnh dy thn kinh X b b st. 5.2.6. Ri lon vn ng ti mt v ng mt: Ch yu l hin tng dn ti mt, ng mt v gim co bp ca ti mt. C hin tng ny l do ct mt nhng nhnh thn kinh ph giao cm chi phi vn ng ca ti mt. y l nguyn nhn hnh thnh si mt cc bnh nhn sau ct ton b thn hai dy thn kinh X.

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Ung th d dy
PGS.TS. Trn Minh o PGS.TS. Nguyn Vn Xuyn 1. i cng: Ung th d dy l loi ung th hay gp nht trong ung th ca ng tiu ho. Trn th gii hng nm c khong 600.000 n 700.000 trng hp ung th d dy mi c pht hin (Parkin 1988). T vong 25.000- 35.000 ngi mi nm. Ti Vit Nam t l mc bnh nam gii l 19,3/ 100.000, n 9,1/ 100.000. La tui thng gp 40 60. Chn on sm ung th d dy c ci thin nh k thut ni soi ng mm c sinh thit . Phng php iu tr duy nht c hiu qu l phu thut, kt qu sau m ph thuc vo nhiu yu t trong yu t chn on sm l quan trng nht. 2. Nguyn nhn v iu kin thun li: 2.1. Nguyn nhn: n nay vn cha c mt s hiu bit y , r rng. 2.2. Cc iu kin thun li - Tui: ung th d dy thng gp nhng ngi trn 40 tui, trung bnh trn 60. - Gii: nam nhiu hn n, vi t l 2/1. - Tnh cht gia nh, c nhng gia nh nhiu ngi cng mc bnh ung th d dy. - Nhm mu: ngi c nhm mu A c t l ung th d dy cao hn cc nhm khc, K d dy gp nhiu thnh ph hn nng thn, ngi hay ht thuc l, ung ruu mnh, n thc n xng khi cha Cacbua. - Cc tn thng tin ung th: Vim d dy th teo, d sn, lon sn, polip d dy. - Lot d dy: lot lnh tnh d dy c kh nng thoi ho thnh ung th. - Tnh trng v toan hoc thiu toan d dy km theo thiu mu c tnh, c t l mc ung th 18 ln nhiu hn bnh thng. - Xon khun H. Pylori c vai tr quan trng trong s pht trin ca ung th d dy. - Ung th mm d dy sau ct on d dy trong bnh lot. 3. Gii phu bnh. 3.1. V tr: - Vng hang mn v chim t l t 70-80 %. - Vng b cong nh chim t l t 10- 15%. - Vng tm, phnh v 3- 5%. - Vng b cong ln: t gp

85

3.2. i th: - Th u si: Khi u si mc n, pht trin vo trong lng d dy, thng thng c lot v hoi t gia. - Th lot: Thng l nhng lot to, b cng khng u ni cao, y g gh, d chy mu, c nhng n tht nh si ln. - Th thm nhim: t gp hn 2 th trn, tn thng nhim cng mt vng d dy, nim mc d dy vng ny bnh thng hoc vim. C th nhim cng ton b thnh d dy lm d dy bin thnh mt ng cng, y l hnh thi c bit gi l ung th t d dy (linite plastique). 3.3.Vi th: 3.3.1. Ung th biu m tuyn(Adenocarcinoma): Chim t l 95%. - Ung th bit ho, hay cn gi carcinoma in hnh. + Kiu b, t bo xp thnh b di. + Kiu nang nh: T bo tuyn t tp thnh nang nh gia c mng nhy. + Kiu ng - b, t bo xp thnh b xen ln hnh ng. - Ung th t bo khng bit ho: + Loi ch nhy . + Loi khng ch nhy . + Ung th loi teo t d dy . 3.3.2. Ung th t chc lin kt, t gp. 3.4. Pht trin v di cn: 3.4.1.Theo chiu su thnh d dy: Lp nim mc, h nim mc, lp c, thanh mc,y l c s phn loi ung th d dy sm (Early gastric cancer) v ung th d dy tin trin(Advanced gastric cancer). 3.4.2. Theo b rng nim mc d dy: Bt u t v tr tn thng lan ra xung quanh. Tnh cht tn thng ny c Borrmann nu ra lm c s cho ct d dy. 3.4.3. Theo h thng bch huyt: - Xm ln n cc hch lympho quanh d dy, di cn n cc nhm hch dc theo cc b mch chnh ca d dy trong bng v xa hn l cc hch trn n tri (Hch Troisier), nch tri (hch Irish). - Hip hi nghin cu ung th d dy Nht Bn phn loi di cn hch bch huyt gm 16 nhm: Nhm 1 : bn phi tm v Nhm 2 : bn tri tm v Nhm 3 : dc b cong nh Nhm 4 : dc b cong ln Nhm 5 : trn mn v Nhm 6 : di mn v Nhm 7 : dc ng mch vnh v 86

Nhm 8 : dc ng mch gan chung Nhm 9 : quanh ng mch thn tng Nhm 10: vng rn lch Nhm 11 : dc ng mch lch Nhm 12 : trc v sau cung gan Nhm 13 : trc v sau u ty Nhm 14 : dc ng mch i trng gia Nhm 15 : gc mc treo rut Nhm 16 : quanh ng mch ch bng Mi chui hch lympho tng ng vi mt vng ca d dy c chia lm ba chng: + Chng nng (N1): dc hai b cong gm nhm 1,2,3,4,5,6. + Chng gia (N2): dc ng mch thn tng v cc nhnh, g m 7,8,9,10,11,12. + Chng su (N3): gm 13,14,15,16. 3.4.4.Theo ng mu: ti cc tng nh gan ,phi, xng, no . 3.4.5. Di cn vo khoang bng n phc mc thnh, ,mc treo rut, bung trng (U Krukenberg), ti cng Douglas (mng Blumer).

Hnh 1 : Cc nhm hch bch huyt ca d dy

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Hnh 2: Cc nhm hch bch huyt ca d dy 4. Phn loi ung th d dy: 4.1. Phn loi theo mc tn thng: - Ung th d dy sm (Early Gastric Cancer): L loi ung th m tn thng mi ch lp nim mc, hoc di nim mc, c hay khng di cn hch limpho. Loi ung th ny c tin lng rt tt. - Ung th d dy tin trin (Advanced Gastric Cancer): L nhng tn thng ung th lan sang lp c, thanh mc hoc xm ln sang t chc xung quanh, tin lng loi ung th ny rt xu.

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4.2. Phn loi theo TNM: Hip hi ung th Hoa K (AJCC 1997) phn loi theo h thng TNM nh sau: - T : U nguyn pht ( primary tumor ) : + Tx : Khi u nguyn pht khng th nh gi + To : Khi u nguyn pht khng chng minh c + Tis:Ung th ti ch (in situ), khi u trong biu m cha xuyn qua mng y. + T1: Khi u xm ln lp nim mc v lp di nim mc . + T2: Khi u xm ln lp c hoc lp di thanh mc . + T3: Khi u xm ln lp thanh mc (phc mc tng), cha xm ln vo t chc xung quanh . + T4: Khi u xm ln t chc xung quanh . - N: Hch bch huyt vng (regional lymph nodes) + Nx : Cc hch vng khng xc nh c tn thng . + No : Khng c di cn vo hch vng + N1 : C di cn vo 1 n 6 hch vng + N2 : C di cn vo 7 n 15 hch vng + N3 : C di cn vo trn 15 hch vng - M : Di cn xa ( distal metastasis ) + Mx : Di cn xa khng th xc nh c + Mo : Khng c di cn xa + M1 : C di cn xa Phn giai on: + Giai on 0 : Ung th khu tr lp biu m nim mc d dy. Tis,No,Mo. + Giai on I: Ung th khu tr vng nim mc d dy: IA: T1,No,Mo IB : T1,N1,Mo. + Giai on II : Ung th di cn ti cc hch chng nng (N1). T1,N2,Mo. T2,N1,Mo. T3,No,Mo. + Giai on III: Ung th ra khi d dy, lan ti cc hch chng nng v gia (N1, N2) IIIA :T2,N2,Mo. T3,N1,Mo. T4,No,Mo. IIIB : T3,N2,Mo. + Giai on IV : c di cn xa khi vng d dy. T4,N1,Mo. T1,N2,Mo

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T2,N3,Mo. T3,N3,Mo. T4,N2,Mo. T4,N3,Mo. Mi T, Mi N ,M1. 4.3. Phn loi theo Borrmann: mi tn thng theo Borrmann tng ng vi hnh nh khc nhau ca Xquang v ni soi. y chnh l hnh nh siu m - ni soi (Echoendoscopy) ca ung th d dy. - Borrmann I: tn thng dng polip, dng nm. - Borrmann II: lot c b nh cao. - Borrmann III: lot c thnh thm nhim. - Borrmann IV: thm nhim lan to. - Borrmann V: khng xp loi c.

Hnh 3: S phn loi giai on ca Borrmann. 5. Triu chng : 5.1. Triu chng lm sng 5.1.1. Giai on sm: Tng ng vi T1 trong bng xp loi TNM. Lm sng ngho nn, khng c hiu: - au bng vng thng v khng c chu k (khc vi lot) - n ung km, chn n. - Ton trng khng thay i, thm khm bng khng pht hin g. 5.1.2. Giai on tin trin: Tng ng T2- T4 + Triu chng c nng:

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- au bng vng thng v, au khng c chu k, au tng ln sau khi n. - Nn v bun nn y l du hiu khi c hp mn v do khi u gy ra. - Chn n, y bng, kh tiu i khi gp nhng bnh nhn c cm gic khng thm n. + Triu chng ton thn: - Gy st cn nhanh, ngy cng thy r. - Thiu mu biu hin da xanh nim mc nht. + Triu chng thc th: - Khi u bng: S thy khi u vng thng v, ty theo tnh cht ca khi u m c th s thy khi u c ranh gii r di ng, hoc khng. Khi u vng hang mn v khi cha c xm ln ra xung quanh th s di ng d dng. - Mng cng: Thng l tn thng dng thm nhim cng, hoc xm ln ra t chc v c quan xung quanh, s nn thy khng c ranh gii r rng. 5.1.3. Giai on mun: - au r rt, lin tc, au nhiu pha sau lng khi xm ln vo tu. - Th trng suy kit, da xanh xao vng vt do thiu mu nng. - Khm bng thy khi u to chim ht vng trn rn, ranh gii khng r rng, b mt g gh, n chc, khng au nhiu. - Hp mn v r nu ung th hang mn v, hp tm v nu ung th vng tm v d dy. - C chng xut hin, ph thiu dng. - Vng da, vng mt (tc mt do K xm ln, di cn cung gan). - Di cn hch limph xa: + Hch h thng n tri ( hch Troisier ). + Hch nch tri ( Hch Irish). + Khi u bung trng (u Krukenberg ) . 5.2. Cn lm sng: 5.2.1. X quang: - Phi chp Xquang c ung barit l chnh , kt hp cht ch Xquang vi lm sng, khi chn on phi da vo c im thng tn tn ti thng xuyn trong mt ln chp nhiu phim v trong nhiu ln chp cch xa nhau. - Hnh nh X quang: + Hnh nh th lot: Mt ng thuc ln, rng, khng su, b nham nh, c th thy hnh thu knh l lot ln gia khi u li vo trong lng d dy. Nu ung th th lot mt d dy phi chp i quang kp. +Hnh nh th u si: hnh khuyt c nh, b nham nh, khng u, ch m ch nht, thnh cng do khi u chim ch li vo trong lng d dy.

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+ Hnh nh th thm nhim: hnh mt on b cong cng thng xuyn di hay ngn, mt tnh cht mm mi, nu chiu Xquang thy hnh tm vn ni trn mt sng . C th thy hnh mt on thng ni cao hn (hnh cao nguyn) hay lm xung (hnh ln) so vi b cong nh. i khi thy mt on hoc ton b d dy b co rt, teo nh v thun di hnh ng cng. Vng trc mn v do thm nhim to nn hnh nh chp nn hoc mn v cng m rng ra.

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5.2.2. Ni soi v sinh thit: Ni soi d dy l phng php chn on chnh xc nht, xc nh c v tr thng tn, loi tn thng, mc xm ln v sinh thit cho chn on xc nh. * Hnh nh tn thng ung th d dy sm: Theo Borrmann c 3 loi: I: u li, tn thng li ln trn b mt nim mc d dy. II: dng b mt (superficial), tn thng nm trn b mt, ranh gii khng r, cht nng nim mc d dy. III: tn thng dng h, lot nng, hi li cao. * Hnh nh tn thng ung th d dy giai on tin trin: + Th u si: u li vo trong lng d dy + Th lot: lot r, y nham nh, b li lm khng u. + Th thm nhim. Ngoi ra, cn s dng cc phng tin phi hp vi ni soi chn on nh: Ni soi c quay phim, siu m ni soi. xc nh chnh xc mc tn thng c bit l ung th d dy giai on sm. 5.2.3. Siu m: C gi tr trong vic xc nh dch c trng trong bng, kim tra cc tng xung quanh hoc h thng hch lympho di cn, khi di cn gan, u di cn bung trng , ng vai tr quan trong khi nh gi kh nng phu thut. Siu m- ni soi (echoendoscopy) gip cho chn on bnh v xc nh mc xm ln thnh d dy ca ung th. 5.2. 4. Chp ct lp vi tnh: Cho thy khi u chon ch trong lng d dy, dy thnh d dy, cc hch di cn v cc khi u th pht ty, gan, bung trng, 5.2.5. Xt nghim: - Xt nghim mu : Hng cu, HST, hematocrit gim khi c xut huyt tiu ha. Ri lon in gii khi c hp mn v nn nhiu. - Mt s xt nghim nh xc nh nng khng nguyn ung th phi CEA (Carcino- embryonic antigen); phn ng ng cng huyt thanh, gen c ch ung th p53, u tng cao trong ung th d dy, nhng khng c hiu, ch c gi tr theo di tin trin v tin lng kt qu phu thut cng nh ti pht ung th sau m. 6. Chn on : 6.1. Chn on xc nh: 6.1.1. Chn on ung th d dy sm. Rt kh chn on ung th d dy sm, khi c cc du hiu lm sng gi th phi tin hnh ni soi c sinh thit tn thng nghi ng. 94

6.1.2. Chn on ung th d dy tin trin: - Lm sng: au vng thng v khng c chu k, y bng, m ch, kh tiu, gy st cn nhanh, thiu mu, s thy u thng v. - X.quang: Cn chp X.quang, chp hng lot, c th phi chp i quang kp mi thy c tn thng. C th thy hnh khuyt, ng thuc, nhim cng mt on b cong nh d dy. - Ni soi sinh thit: Thy cc tn thng th u si, lot, thm nhim. 6.1.3. Chn on ung th d dy mun: Thng d, da vo lm sng, hnh nh Xquang d dy, ni soi- sinh thit. Ngoi ra cn phi da vo siu m nh gi xm ln v di cn gan, chp Xquang lng ngc xc nh di cn phi. 6.2. Chn on phn bit:
6.2.1. Lot d dy t trng:

au c chu k, lin quan n ba n, au ko di nhiu nm. K hng s thy u thng v. Ch yu da vo ni soi c sinh thit.
6.2.2. Vim d dy:

au ngay sau n, nht l n cc thc n chua cay nng, ung rucm gic bng rt ngay di mi c v vng thng v. Ni soi thy nhng lot cht nng, np nim mc sng n rc. Nu vim teo nim mc d dy ni soi thy cc np nim mc teo, hang v co rt, c cc m vim ri rc, cn sinh thit c chn on xc nh. 6.2.3. Polyp d dy: Lm sng kh xc nh v khng c triu chng c trng, c th pht hin qua chp d dy thng thng, hoc i quang kp. Ni soi cho hnh nh trc tip : polyp c cung di thng lnh tnh, polyp c cung ngn, u to, nhiu mi sn si th cn phi nghi ng thoi ha c tnh, nn sinh thit xc nh. 6.2.4. Vim ty mn tnh: Cn au thng ko di, c nhng t tri ln thnh cn. Chp d dy v ni soi khng thy tn thng.Siu m ty c th thy hnh nh si ty hay hnh nang gi ty. 6.2.5. Mt s u lnh tnh khc d dy: U thn kinh(Schwannome); u c trn(Leiomyome), thng khng c triu chng lm sng c hiu. Xquang ch thy hnh nh mt khi u chn vo lng d dy. Ni soi khng thy tn thng nim mc, i khi phi s dng cc k thut : siu m, chp ct lp vi tnh chn on. 6.2.6. Cc khi u ngoi d dy: U gan; u i trng ngang; u ty; u mc treo ; u rut non... 7. Bin chng :

95

7.1. Thng d dy: Thng do hoi t t chc ung th nht l th lot, hoc lot ca ung th, hoi t t nim mc ra thanh mc. Thng gp thng v tr b cong nh, mt trc ca d dy. 7.2. Chy mu: C th do tn thng mch mu d dy nhng lot hoi t ca khi ung th hoc mu chy r r t t chc ung th b hoi t. 7.3. Hp mn v: thng do u vng hang mn v. 7.4. Hp tm v: thng do u vng tm v, phnh v ln. 8. iu tr 8.1. iu tr ngoi khoa: 8.1.1.Phu thut trit (Radical operation): - Ct bn phn cc di d dy:ly b i 3/4 , 4/5 hoc di tm v d dy cng vi khi u, mc ni ln, no vt hch bch huyt theo tng chng. Ct trn u t nht 6 cm, di mn v 2cm, tt nht sinh thit tc th m bo din ct khng cn t bo ung th. Thng p dng cho ung th vng hang mn v, b cong nh. - Ct bn phn cc trn d dy (phu thut Sweet) : Ly b 1/3 hoc 1/2 phn trn d dy v phn di thc qun bng cng mc ni ln v no vt hch bch huyt, phc hi li s lu thng tiu ha bng ming ni thc qun - d dy. Thng p dng cho ung th tm v, phnh v ln. - Ct ton b d dy : ly b ton b d dy, mc ni ln, no vt hch bch huyt. + Ct d dy ton b theo yu cu : tc l ty theo v tr ca khi u, m bo nguyn tc ct d dy trong ung th t nht trn khi u 6cm, m yu cu phi ct ton b d dy. c ch nh phn ln trong iu kin hin nay, thng p dng cho ung th vng thn v. + Ct d dy ton b theo nguyn tc: tc l bt k khi u to nh v tr no u phi ct ton b d dy. Hin nay t c ch nh. + Ct ton b d dy m rng: ct ton b d dy kt hp ct b cc tng, c quan b xm ln, di cn nh gan,lch, ty, i trng, bung trng 8.1.2. Phu thut tm thi: (Palliative operation) - Ni v trng: khi ton thn v ti ch khng cho php phu thut trit cn nht l khi c hp mn v. - M thng d dy nui dng theo phng php Fontan, Witzel, p dng cho hp tm v m khng ct c ton b d dy, cc trn d dy hoc ni v- trng. - M thng hng trng nui dng theo phng php Fontan, Witzel, Roux en Y, p dng cho hp mn v m khng ct c cc di d dy, ton b d dy hoc ni v- trng. 8.1.3 Nhng k thut mi trong iu tr ung th d dy :

96

- Ni soi d dy : + Ph hu t chc ung th vi kch thc nh giai on u. + Ct di nim mc ly b khi ung th vi kch thc khi u < 2cm. - Phu thut ni soi bng, bao gm : + Ct d dy qua ni soi (laparoscopic wedge resection- LWR) + Ct nim mc trong lng d dy qua ni soi bng (Intragontric mucosal resection IGMR) - Phu thut Ni soi ct on d dy (Laparoscopy- Assisted Distal Gastrectomy LADG)

8.2. Cc phng php iu tr h tr: 8.2.1. Ho tr liu: mang tnh cht b tr, cc ha cht c dng l : 5- fluorouracil (5- FU), Adriamycin, Mitomycin C, Methotrexat trong c s dng nhiu v ph bin l 5-FU. 8.2.2.X tr : t c tc dng, thng dng 25 gray, hin nay c th s dng kt hp phu thut, x tr v ho tr liu. 8.2.3. Min dch: - Thng dng khng nguyn n (Anticorps monodoneur), tuy nhin kt qu cha r rng, ngoi ra cn dng cc loi thuc c tc dng tng min dch nh: Levamison, Aslem, Interferon. 8.2.4. Thuc y hc c truyn : tam tht, l u

97

Vim rut tha cp

PGS.TS Nguyn Vn Khoa

Vim rut tha cp (VRTC) l bnh cp cu bng ngoi khoa thng gp nht. Bnh gp mi la tui, nam cng nh n, nhng nhiu nht la tui 20-30. Bnh cnh ca VRTC rt a rng, phong ph, nhiu bin chng khng lng trc c. M cng mun bin chng cng nhiu v t vong c th xy ra. V vy VRTC cn c chn on sm v m sm. 1. Bnh sinh Nguyn nhn ca VRTC c gii thch theo nhiu quan im khc nhau. - Bnh cn v bnh sinh ca vim rut tha cp ni chung vn cha c nghin cu y , c nhiu thuyt gii thch khc nhau. - Cc thuyt gii thch chnh l: 1.1. Thuyt nhim khun Gii thch do nhiu loi vi khun xm nhp vo thnh rut tha gy vim, song mt s nghin cu khng phn lp c vi khun rut tha trong thi k u ca qu trnh vim. V vy, hc thuyt trn cn gii thch c iu kin vi khun xm nhp vo rut tha. 1.2. Thuyt ri lon vn ng: Cho rng vai tr quyt nh ca vim rut tha cp l s ri lon nhu ng, mt trng lc c v do b ng phn lm tn thng nim mc rut tha to iu kin cho vi khun xm nhp vo rut tha. Song thuyt ny khng gii thch c nhiu trng hp rut tha vim khng ng phn. 1.3. Thuyt ri lon thn kinh vn mch: L thuyt c gii thch nhiu nht trong nhng nm gn y. Theo n th c s ca vim rut tha cp l do s co mch ca chnh rut tha do tc ng ca thn kinh v kt qu l ri lon dinh dng to iu kin cho vi khun xm nhp pht trin gy nn vim rut tha cp. 1.4. Ngoi ra cc tc gi cn a ra thuyt d ng v thuyt lin quan n vai tr ca dinh dng trong vim rut tha cp. 2. Phn loi VRTC C nhiu cch phn loi: 2.1. Theo mc tn thng ca rut tha chia ra: 2.1.1. VRTC th xung huyt (th xut tit). * Hnh nh i th bng c nhiu dch v dch mu trong Rut tha mt v trng ng. Mch mu tng sinh, thanh mc mt bng 98

 Lng rut tha c dch c. * Hnh nh vi th: Thnh rut tha ngm dch ph n. Nhiu bch cu a nhn xm nhp. Nim mc c nhiu hoi t. Cc mch mu dn, tng sinh. 2.1.2. VRTC th mng m (vim ty) : * bng c dch c vng h chu phi: Rut tha sng to, c t gi mc bm trn thanh mc. Mc ni ln n quy t h chu phi. Mch mu dn to, mc treo vim ph n. * Hnh nh vi th thy: Thnh rut tha dy ph n. Nim mc rut tha hoi t, c ph hy ht lp c, thng nh thanh mc, c fibrin bt li. Nhiu bch cu a nhn trung tnh xm nhp, quy t tng m.

2.1.3. VRTC th hoi t: * bng c dch m (Tp trung nhiu h chu phi, ti cng Douglas) - Mc ni ln n h chu phi cng b vim. - Rut tha sng to, nhiu gi mc bm. * Tn thng vim gy hoi t lm cho rut tha b thng. Vng hoi t thng thy phn ui, hoc thn rut tha. 2 1.4. Th hoi th: - Him gp, do vi khun k kh gy nn, c hoi t kh hoc hoi t t. - bng nhiu dch thi - Rut tha thi ra, ng mu vng a (nh mu l a)- hoi t t. Hoi t kh: rut tha c mu tm en ton b, t dch. 2.2. Theo v tr ca rut tha: C th gp cc v tr khc ngoi v tr bnh thng h chu phi nh: - VRT sau manh trng - VRT h chu b. - VRT gia cc quai rut. - VRT di gan - VRT h chu tri Trong cc v tr bt thng trn th sau manh trng l thng gp hn t (1015%) 2.3. Theo th a: C cc th - VRTC tr em - VRTC ngi gi.

99

- VRTC ph n c thai 3. Triu chng Lm sng ca VRTC rt a dng, trng hp in hnh thy: 3.1. Triu chng c nng: 3.1.1. au bng: au l triu chng u tin v sm nht. - au c th bt u h chu phi, nhng c nhiu bnh nhn u tin au thng v hoc quanh rn v mt s v tr khc mt thi gian sau, au mi khu tr h ch phi. - Tnh cht au: m , lin tc, tng dn. Cng c lc au thnh tng cn nhng gia cc cn au khng khi hn. - Ni chung tn thng cng nng th au cng tng ln tuy nhin tr em v ngi gi tnh tng xng c lc khng r rng. 3.1.2. Nn v bun nn: Triu chng ny lc c, lc khng v khng c trng. 3.1.3. B trung i tin: y cng l triu chng thng gp tuy nhin khng c hiu v c bnh nhn khng b trung i tin. Ngc li c bnh nhn a lng. 3.2. Triu chng thc th: 3.2.1. Ton thn: C hi chng nhim khun thng l mc nh hoc trung bnh: mi kh li bn, st thng 37,50C- 38,50C nu st 390C- 400 C thng l rut tha vim c bin chng. 3.2.2. Ti ch. Khm bng s thy: * Phn ng c vng h chu phi: y l triu chng rt c gi tr. Phi khm k v so snh 2 bn. Rt kh xc nh khi khm ngi bo, ngi gi, v ph n cha nhiu ln. Nhng bnh nhn ny phn ng c thng khng r rng. * C im au khu tr: - Thng thy au khu tr im Mac-Burney (im gia ng thng ni rn vi gai chu trc trn bn phi). - im Clado: im gp nhau b ngoi c thng to bn phi vi ng lin gai chu trc trn. - im Lanz: im ni 1/3 gia vi 1/3 ngoi bn phi ca ng lin gai chu trc trn (im niu qun gia bn phi). 3.2.3. Mt s du hiu - Schotkin- Blumbeng (+): n t t vo h chu phi bnh nhn thy au, t ngt b tay ra bnh nhn thy au tng ln r. - Rowsing (+): dn hi i trng tri gy au vng h chu phi. - Sitkovski (+): Cho bnh nhn nm nghing sang tri gy au 100

h chu phi. - obrasov (+): Du hiu p manh trng rut tha, r khi vim rut tha sau manh trng. 3.3. Cn lm sng: 3.3.1. Xt nghim mu: BC tng, nht l bch cu a nhn trung tnh, cng thc bch cu chuyn tri. Thi k u BC tng va phi, khi c bin chng BC tng cao, c lc ti 20.000/mm3 3.3.2. Siu m: C gi tr chn on cao, chnh xc 80 - 90%. Tuy nhin phi lm t m c k thut v c u d ph hp. Hnh nh VRTC trn siu m: ng knh rut tha > 0,8 cm, hnh nh bia bn mt ct siu m ngang rut tha, hnh nh ngn tay eo gng mt ct siu m dc rut tha, dch quanh rut tha, h chu phI, p u d siu m h chu phi au.

Hnh bia bn

Hnh ngn tay eo gng. Hnh 1:Hnh nh siu m VRTC

4. Cc th lm sng khc 4.1. Theo v tr khng in hnh: 4.1.1. VRT sau manh trng: L th lm sng bt thng thng gp nht do v tr rut tha thay i. Do rut tha nm st sau manh trng, i khi nm ngoi phc mc nn c nhng c im ring v triu chng v din bin ca bnh. - Triu chng nn hu nh khng c. - C thnh bng h chu phi vn mm trong mt thi gian di. - C im au sau trn mo chu phi.

101

- Nu vim lan ti t chc sau phc mc th bnh cnh lm sng rm r hn: st cao 390C - 400C, n au ton b vng tht lng phi nn d nhm vi vim ty quanh thn phi bi nhng nguyn nhn khc. 4. 1.2. VRT chu hng b (tiu khung). - au vng h v. - Bnh nhn c cm gic mt i ngoi kiu l v mt tiu. i lc nc tiu cng c hng cu (v khi vim kch thch trc trng, bng quang). - Thm trc trng m o c im au chi ti cng Douglas. 4.1.3. VRT gia cc quai rut. - au vng quanh rn. - au thng c triu chng bn tc rut. V vy khi mt bnh nhn c bn tc rut km theo st phi ngh ti VRTC. 4.1.4. VRT h chu tri. - Cc triu chng ca VRTC u th hin h chu tri. - Khi nghi ng o ngc ph tng phi kim tra v tr ca gan, tim, nu 2 c quan trn o ngc th rut tha nm bn tri. 4.1.5. VRT di gan. - au v phn ng c vng h sn phi, c hi chng nhim khun nn d nhm vi vim ti mt cp. - Du hiu Rowsing (+): Dn hi t h chu tri bnh nhn au h chu phi, gip cho chn on phn bit. Du hiu Rowsing dng tnh cho php ngh nhiu ti VRTC nhng nu m tnh th cng cha c php loi tr. 4.2. Theo c a: 4.2.1. VRT tr em. + Thng gp tr trn 4 tui. + Lm sng thy c c im sau: - Tr st cao mch nhanh. - Triu chng nn v bun nn: gp nhiu. - V tr au cao hn bnh thng. - Tin trin nhanh, thng dn n vim phc mc ton b, nhim trng, nhim c nng. 4.2.2. VRT ngi gi. + Triu chng thng ngho nn. - au m h chu phi, c bnh nhn ch thy tc nng vng h chu phi - Khng c st hoc st nh. - Phn ng c vng h chu phi khng r rng. + Chnh v c im trn, bnh nhn thng n khm mun trong bnh cnh vim phc mc, p xe rut tha hoc khm thy khi chc h chu phi d nhm ti cc khi u khc vng manh trng. 4.2.3. VRT ngi c thai.

102

+ Ph n c thai, 4 thng u t cung cha to lm nn triu chng vim rut tha cha khc bit r rt. Tuy nhin giai on ny cn phn bit vi tnh trng thai nghn v v cha ngoi d con. + T thng th 5 tr i, nht l 2 thng thng cui t cung to v y manh trng ln trn v ra sau, c bng cng b dn nn cc triu chng cng thay i: - au cao hn, thng vng h sn phi. - Phn ng c nh hoc khng r, v c t cung che khut nn vim chm lan ti thnh bng trc, mt khc do c ang b dn nn co yu i. - Bnh nhn nm nga, ly ngn tay y nh t cung t bn tri bnh nhn au bn phi. - Cn khm k chn on phn bit vi vim b thn ngi c thai.

Hnh 2: Cc v tr vim rut tha: (1) trc hi trng; (2) sau hi trng; (3) gn nh; (4) trong tiu khung; (5) di manh trng; (6) cnh i trng

5. Tin trin v bin chng: Nu VRTC khng c m s dn ti: 5.1. Vim phc mc ton b. Thng gp sau 6 - 24h Do rut tha b v, m chy lan khp bng. Lm sng th hin: - Hi chng nhim trng nhim c r ton thn 103

- Bnh nhn au khp bng. - B trung i tin v chng bng do lit rut - Phn ng c thnh bng. VPMRT c nhiu mc khc nhau v c th din bin theo nhiu hnh thi khc nhau 5.2. p xe rut tha (Vim phc mc khu tr) + Rut tha vim b v m nhng c mc ni, cc quai rt bao bc li.S kt dnh ca rut v phc mc to nn mt hng ro ngn cch khng cho m lan ra ni khc v m c khu tr trong phm vi nht nh. Hay gp h chu phi do rut tha sau manh trng cn him gp hn l p xe rut tha gia cc quai rut, trong tiu khung, hoc di gan. + V lm sng thy: - Bnh nhn vn au v st cao. - S h chu phi thy mt khi vi c im: . Pha trong c b r rt, Pha ngoi lin tip vi mo chu. . Khng di ng. . Mt nhn, cng, n au. . Nu mun c th thy hin tng ty ph n ngoi da, khi p xe tr nn mm hn. - Xt nghim mu: BC tng cao, chuyn tri r. + p xe rut tha c th v vo bng gy vim phc mc hoc v ra ngoi gy r manh trng. 5.3. m qunh rut tha. + Do sc khng ca bnh nhn tt, vim khng nng lm, rut th cha ha m th s kt dnh ca quai rut v mc ni to nn mt khi chc gi l m qunh rut tha th hin trn lm sng: - au v st gim dn. - h chu phi s nn thy c m hoc mng (mas) chc tay, khng di ng, khng c gianh gii r rt, s nn b mt khng nhn, au t. - Xt nghim mu: BC dn dn tr li bnh thng. + m qunh rut tha l bin chng nh nht ca VRTC. m qunh c th tin trin theo 2 hng: - Nu sc khng tt, kt hp iu tr khng snh m qunh s tan dn. - Cng c th t m qunh tin trin thnh p xe rut tha hoc vim phc mc rut tha. 6. Chn on: 6.1. Chn on xc nh: + C 4 yu t c bn, gi tr nht gip chng ta chn on xc nh l: - au khu tr vng h chu phi. - C phn ng c vng h chu phi.

104

- im Mac Burney au - C hi chng nhim trng mc nh. + Mt bnh nhn in hnh c 4 yu t trn, chn on d. Tuy nhin vim rut tha cp rt a dng, khi khng cc triu chng in hnh, ngi thy thuc phi: - Khm k pht hin thm cc triu chng khc c thm t liu khch quan. - Khm nhiu ln so snh mc tin trin ca cc triu chng hoc kt hp vi hnh nh siu m ca VRTC. 6.2. Chn on phn bit. Nhiu bnh ni v ngoi khoa u c th nhm vi VRTC, cn chn on phn bit. 6.2.1. Cn au qun thn phi. - au vng bng phi nhng lan xuyn xung bn, bu. - C ri lon tiu tin: i but, i dt. - Nc tiu c HC v BC. - Chp XQ khng chun b c lc thy hnh cn quang niu qun phi hay bng quang. 6.2.2. Vim phn ph n gii. - Thng au c 2 h chu. - C kh h (dch chy ra m o). 6.2.3. Xon u nang bung trng phi. - au dt ngt d di hn. - C lc khm thy khi u rt au. - Cn thm khm m o d xc nh. - Khi m: Thy dch hng phi kim tra ngay bung trng. 6.2.4. Cha ngoi d con bn phi b v. - Bnh nhn c chm kinh v triu chng thai nghn. - C triu chng chy mu trong. - Thm m o: cng Douglas phng, au v c mu theo tay. - Trng hp cha ngoi d con v ng kn, nhim khun, vic chn on phn bit rt kh khn, ch khi m mi xc nh c. 6.2.5. Vim c tht lng chu bn phi. - au vng h chu phi. - C hi chng nhim khun. - Triu chng c bit: chn phi lun co, khng dui c. p xe rut tha sau manh trng, lm vim c c tht lng chu, cng lm cho chn bnh nhn cng t th co. V vy khng c ch quan dng li vi chn on vim c, trnh b st ng tic 6.2.6. Lng rut hi manh trng. 105

- au tng cn h chu phi hoc cao hn. - Ri lon i tin, phn c nhiu mu. - C bng vn mm. - Khm thy h chu phi rng v nhiu khi thy bi lng. 6.2.7. Vim i trng co tht. - Ri lon i tin: au bng tng cn, gia cc cn bnh nhn khng cn cm gic au. Phn thng nt, c th km theo nhy mi. - au dc theo khung i trng, c th khm thy thng i trng. - Bnh thng ti pht nhiu ln. 6.2.8. Vim d dy cp. - au vng thng v, y bng, hi. - C phn ng vng thng v, cc vng khc vn mm. - Khng c im au khu tr. 6.2.9. Vim ty cp. - Bnh nhn au nht vng thng v nhng c th lan khp bng trong c h chu phi. - Bng chng, n im sn - sng lng tri au. - Xt nghim Amylase mu tng. * Khi VRTC v gy vim phc mc cn phn bit vi cc nguyn nhn khc nh thng lot d dy - t trng, thng ti tha... * Nhiu bnh ni khoa khc cng d nhm nhng t gp hn nh: - Lao hi - manh trng. - Bnh Crohn. - Vim ti bt Meckel. - Vim phi thy tr em. - Thng hn. - Vim ti mt. - p xe mt di gan. 7. iu tr. chn on vim rut tha cp th phi m cp cu cng sm cng tt, C th m m theo k thut kinh in, hoc m ni soi. Nguyn tc chung ca m m l: 7.1. Vim rut tha cp cha c bin chng. - M bng theo ng Mac-Burney. - Ct b rut tha. - Lau sch h chu v ng bng theo tng lp. - C dn lu hay khng l do phu thut vin quyt nh. 7.2. Vim phc mc ton b. - M bng theo ng trng gia trn v di rn hoc ng trng bn phi 106

- Ct b rut tha - Lau ra sch bng. - Dn lu Douglas v h chu phi. 7.3. p xe rut tha. + M cp cu c tr hon, rch da v cn c theo ng Roux. - Chc d, rch thnh p xe, dn lu m. - Tuyt i khng tm cch ct rut tha, khng lm m thng vi bng + Gn y phng php chc ht m di hng dn ca siu m c kt qu tt ang c p dng. 7.4. m qunh rut tha. - y l trng hp duy nht khng m ngay. - V iu tr dng khng sinh ph rng v theo di st. - Su thng sau, khi m qunh tan c th m ct rut tha (nu BN au li). 8. Bin chng sau m. 8.1 Bin chng sm: 8.1.1. Chy mu: - Chy mu trong bng do tut ch buc ng mch mc treo rut tha. - Chy mu thnh bng gy t mu vt m do cm mu khng tt. 8.1.2. Vim phc mc sau m: Do r phn gc rut tha, hoc do sai st k thut lm thng apxe vi khoang bng trong m dn lu apxe rut tha. 8.1.3. Apxe tn d trong bng: thng do lau bng khng sch, dn lu khng tt nht l sau m vim phc mc rut tha. 8.1.4. Nhim khun vt m: c th vim ty, mng m, apxe, hoc toc vt m lm l cc quai rut. 8.1.5. R manh trng ra ngoi. 8.1.6. Tc rut sm sau m. 8.2. Bin chng mun. 8.2.1. Tc rut mun sau m: do dnh hoc dy chng, xon rut. Tc rut mun sau m c th xy ra bt c lc no, c trng hp sau 30- 40 nm. 8.2.2. Thot v hoc s bng sau m: vng vt m.

107

Tc rut
PGS.TS L Trung Hi Tc rut l s nh tr lu thng cc cht cha trong lng rut. L mt cp cu bng ngoi khoa hay gp ng hng th hai sau vim rut tha cp. T l t vong chung t 3 - 5%. 1. Nguyn nhn v phn loi: 1.1. Tc rut c hc: Tc nhn gy tc rut l mt cn tr vt cht (mt nguyn nhn c hc) chim 95 - 97% trong s tc rut. 1.1.1. Tc rut do bt: tin trin chm, vt gy tc c th : - trong lng rut: bi giun a, b thc n (mng, hng xim, ht hoa qu ), si mt. - thnh rut: u lnh tnh, ung th, lao, vim, so, d dng bm sinh, bnh Crohn, hp ming ni do m c. - ngoi rut: u x t cung, u nang bung trng, u sau phc mc, u mc treo rut, dnh rut. 1.1.2. Tc rut do tht: tin lng nng, do nguyn nhn gy tht p mch mu gy hoi t rut. - Xon rut (mt quai hay ton b rut). - Lng rut (rut ln li v lng vo quai rut ln cn). - Thot v nght. - Tc rut do dy chng. 1.2. Tc rut c nng: Do ri lon hot ng ca h thng thn kinh iu khin cc nhu ng rut 1.2.1. Tc rut c nng do lit: Do tn thng thn kinh (nhu ng dc): do vim phc mc, lit rut sau m, mu t sau phc mc, ri lon chuyn ho, tn thng ty sng... 1.2.3. Tc rut c nng do co tht: Do tn thng thn kinh gy tng co tht, song rut vn khng c nhu ng nh trong ng c ch, Alcaloid, tn thng thn kinh trung ng. 2. Gii phu bnh: 2.1. i th: - bng c dch, quai rut gin to, cng gn ti ch tc quai rut cng gin to. - Ch tc l ni tip ni gia quai rut trn cng to v quai rut di xp. 2.2. Vi th:

108

Rut trn ch tc mi u huyt nh, sau chy mu di nim mc v trong lp c c du hiu nhi mu, nim mc v tuyn rut b thoi ho ri hoi t tng mng. 3. Sinh l bnh: Tc rut gy nn 2 loi ri lon: ri lon ti ch rut v ri lon ton thn. 3.1. Ri lon ti ch rut: - Sau khi c tc rut, quai rut pha trn ch tc s gin to do b dch v hi. - Trong tc rut giai on u dch tiu ha tit ra tng ln, nhng kh nng hp thu li gim. - Do mu v ri lon tun hon thnh rut s lm thiu xy thnh rut, tng tnh thm thnh mch v lm tng thm dch vo trong lng dch v vo khoang phc mc. Nu tc rut cng lu lng dch thot khi thnh mch cng ln, cng c nhiu quai rut gin. 3.2. Ri lon ton thn: + Pht trin nhanh chng ca cc vi khun trong rut dn n tnh trng nhim c: Do rut gin to lm gim trng lc c thnh rut v gim nhu ng rut dn n ng lm cho vi khun pht trin mnh v tnh trng nhim c. + Mt nc v in gii, mt huyt tng: Do ng dch trong lng rut v tng tnh thm thnh mch s dn n mt nc, in gii v mt huyt tng. Ngoi ra nn lm tng mt nc, mt in gii. Nu tnh trng mt nc, in gii v huyt tng ko di cng v i tnh trng nhim c s dn n sc do gim khi lng mu lu hnh. + Ngoi ra do ri lon tun hon v thiu xy thnh rut s dn n gim sc sng thnh rut v hoi t, thng gy nn vim phc mc.

109

S c ch bnh sinh ca tc rut Tc rut Rut gin to Gim trng lc c thnh rut Ri lon tun hon thnh rut Gim ti hp thu

Gim nhu ng rut

Thiu oxy thnh rut

Ph n

dch trong lng rut

ng

Gim sc sng thnh rut Hoi t

Tng tnh thm thnh mch Mt huyt tng

Mt nc in gii

Vi khun pht trin Nhim c Vim phc mc

Thng

Sc

3. Triu chng 3.1. Lm sng: 3.1.1. Triu chng c nng: - au bng tng cn (lin quan n cc t nhu ng rut). y l triu chng xut hin sm v c gi tr. Trong tc rut do xon hay nght thng au d di. - Nn thng xut hin sm trong tc rut cao, cng nn ph thuc vo v tr tc rut. - B trung i tin l triu chng c gi tr chng t s nh ch lu thng trong lng rut. 3.1.2. Triu chng thc th: - Bng trng, c th thy ni hn cc quai rut.

110

- Du hiu rn b: L du hiu chng t nhu ng rut c tng cng chng li tr ngi. y l du hiu quan trng c gi tr chn on xc nh tc rut c hc v chn on phn bit vi tc rut c nng. - S nn bng c th thy bi giun hoc khi lng. - G vang - Nghe thy tng nhu ng rut. - Thm trc trng: c th thy bng trc trng rng, c th s thy u hoc c mu mi theo tay trong lng rut. - Cn khm l thot v, so m c. 3.1.3. Triu chng ton thn: Ph thuc vo cng cn au, tnh trng mt nc v mc nhim c nng hay nh. Trng hp c nght, xon rut th sc thi bnh nhn thay i nhanh chng, v m hi, da nht. 3.2. Cn lm sng: 3.2.1. Xt nghim mu: - Tnh trng mu c do mt dch. - Ri lon in gii: Cl- gim, Na+ v K+ gim), - Tng ur mu. 3.2.2. X quang: - Chp bng khng chun b t th ng: bng c hnh nh mc nc hi l du hiu quan trng ca tc rut c hc. Hnh dng, v tr, s lng cc mc nc hi cho bit v tr tc rut tiu trng hay i trng. Ngoi ra thy bng m, vin cc quai rut dy chng t c dch trong bng. - Dng cc thuc cn quang ng ung hay tht baryte pht hin thm v tr v nguyn nhn tc rut. 3.2.3. Siu m: Hnh nh quai rut gin, tng hoc mt nhu ng, c dch trong bng. 4. Chn on: 4.1. Chn on tc rut c hc: - au bng tng cn. - B trung i tin. - Bng c du hiu rn b. - X quang c hnh nh mc nc - hi. 4.2. Chn on v tr tc rut. + Tc rut non (tc cao): tin trin cp tnh rm r, au v nn nhiu, b v trng va, c th suy sp nhanh. X quang c nhiu mc nc - hi gia bng, c va phi, chn rng (b rng ln hn b cao), thnh mng xp hnh bc thang t h sn tri n h chu phi. Nu chp nghing thy mc nc hi trc ct sng. + Tc rut gi (tc thp): tin trin bn cp, au nh, nn t v mun, b v trng nhiu. X quang c t mc nc- hi dc theo khung i trng, c to, 111

chn hp (b cao ln hn b rng), thnh dy; chp nghing thy cc mc nc hi sau ct sng; tht baryte thy thuc dng li rut gi. 4.3. Chn on nguyn nhn theo la tui - Nh nhi: thng l tt khng c hu mn, teo rut bm sinh, tc rut phn su, phnh i trng. - Tr b (4 - 12 thng): lng rut. - Tr ln (4 - 12 tui): Tc rut do giun, ht hoa qu. - Ngi ln (20 - 40 tui): Tc rut sau m, thot v nght, xon rut. - Ngi gi: K i trng, xon i trng sigma, tc rut do b thc n. 4.4. Chn on phn bit: - Nhng bnh khng phi cp cu ngoi khoa: + Cn au qun thn + Cn au qun gan + Cn au do vim d dy cp + Nhim trng, nhim c thc n - Nhng bnh ngoi khoa cp tnh: + Vim rut tha cp + Vim phc mc + Xon u nang bung trng, cha ngoi d con + Vim ty cp + Vim ti mt cp hay vim ng mt do si, giun 5. Th lm sng 5.1. Tc rut cp tnh. Thng l do xon rut hay tc rut cao. Cc triu chng xut hin sm, r v nng, ton trng suy sp nhanh, tin lng nng. 5.2. Tc rut bn cp. Thng do tc rut thp, tc rut do bi giun. Triu chng biu hin nh hn, ton trng khng b suy sp nhanh. Khi trung tin c cc triu chng tc rut mt i 6. iu tr : Vic iu tr nhm 2 mc ch : - iu tr cc ri lon ton thn do tc rut gy nn. - iu tr phu thut gii quyt nguyn nhn gy tc. 6.1. iu tr ni khoa - Truyn dch, bi ph nc v in gii. - Khng sinh. - t xng d dy ht dch. - t xng hu mn, bng quang. 6.2. iu tr phu thut: Mc ch: Gii quyt nguyn nhn tc, phc hi lu thng rut. - M ni kh qun, m bng ng trng gia trn di rn. 112

- Kim tra gc hi manh trng: nu xp l tc rut non, nu gin l tc rut gi. - Xc nh v tr tc. - Gii quyt nguyn nhn gy tc: + Do dy chng: ct b dy chng. + Do d vt trong lng rut (nh b thc n, giun ...) m ch lnh ly v khu li. +Do lng rut: tho lng v c nh. +Do thot v nght: gii phng tng nght v ti to thnh bng. +Do xon i trng Xichma: g xon v c nh. + Phu thut ct on rut: khi rut b hoi t. + Phu thut dn lu khi iu kin khng cho php: Dn lu ngoi: gy mt nc, mt in gii. Dn lu trong: bng cch ni tt.

113

Lng rut
TS.V Huy Nng 1. i cng - Lng rut l mt cp cu bng ngoi khoa thng gp, do mt on rut ln li v chui vo lng ca on rut k cn, l nguyn nhn ca tc rut c hc m c ch va do bt va do tht. - Lng rut c th gp bt c la tui no, nhng gp nhiu nht l la tui 4-9 thng, trong hai nm u i t l chim ti 80% cc trng hp. - Lng rut gp b trai nhiu hn b gi t 2 ti 4 ln - Bnh gp quanh nm nhng nhiu nht l ma ng xun, ma c t l nhim khun ng h hp cao. Bnh t gp tr suy dinh dng, a s gp tr bo tt, b bm. - T l ti pht sau tho lng khng m l 8-12%. Sau phu thut tho lng t l ti pht l 0-3%. - T vong sau m lng rut gim ng k cng vi thi gian, nguyn nhn t vong sau m ch yu l vim phi v st cao co git. - V lm sng thy bnh din bin rt khc nhau hai loi tui: 1. Tr di 24 thng tui, bnh biu hin cp tnh, din bin nhanh, tin lng nng theo tng gi. 2. Tr ln: biu hin bn cp hoc mn, i khi cp tnh, nhng din bin khng nhanh chng v nng nh tr cn b. 2. Lng rut tr cn b 2.1. Nguyn nhn, bnh sinh: Nguyn nhn lng rut cp tnh tr em vn cha r, c mt s cch gii thch v bnh sinh: - Do s mt cn i gia kch thc ca hi trng v manh trng: Tr em 4 thng tui kch thc hi trng v manh trng gn bng nhau, t 4-12 thng tui manh trng pht trin to nhanh hn. - Manh trng v i trng ln di ng khng dnh hoc dnh lng lo vo thnh bng sau. Mt s trng hp lng rut cp tnh c khi im l ti tha Meckel, polip, u rut non, bi giun,... - Vim hch ca mc treo: tr cn b van Bauhin nh vo trong lng i trng, cc nang bch huyt phong ph, khi vim sng to s cn tr nhu ng ca rut non ang tng. - Vim hch bch huyt mc treo c lin quan ti nhim virus. Ma hay gp lng rut trng vi thi gian nhim khun ng h hp cao, nht l nhim Adenovirus, Enterovirus...

114

- Vng hi manh trng l ni giao tip ca hai lung sng nhu ng ngc chiu nhau, nhu ng xui chiu ca hi trng v nhu ng ngc chiu ca i trng v pha manh trng. 2.3.Gii phu bnh l 2.3.1.i th Khi ct ngang khi lng chng ta thy c ba ng: - ng ngoi: l on rut tip nhn - ng gia: - ng trong: on rut b lng - u khi lng: im xung thp nht ca on rut b lng, u khi lng c th i xung i trng, i trng xung hoc i trng sigma thm ch sa ra ngoi hu mn). - C khi lng: ni khi im ca lng rut. 2.3.2. Tin trin: Tin trin ca khi lng: on rut tip nhn chn p ln thnh ca on rut b lng, mc treo cng vi cc mch mu b li cun vo trong lng on rut di, b tht nght li c khi lng dn n tc rut c hc. Do tht nght mch mu, on rut lng nhanh chng b tn thng dn n hoi t. 2.3.3. Cc hnh thi lng rut: c xc nh bi im khi u ca lng rut v v tr rut b lng. - Lng rut hi - i trng: Chim 75% cc trng hp. im khi u l on cui ca hi trng, sau hi trng chui vo i trng, hng v pha hu mn. Van Bauhin nguyn ti ch (lng rut xuyn van), hoc to nn u ca khi lng (lng rut hi manh- i trng). - Lng rut hi hi trng n thun: t gp, 15% . - Lng rut i - i trng: rt t gp (di 10%). - Lng rut tha vo manh trng: cc k him gp. - Lng rut phc tp l s kt hp ca cc th nu trn. 2.4.Triu chng Thng gp nhng chu b 6- 12 thng tui, b bm, khe mnh. 2.4.1. C nng - au bng cn: gp 75% cc trng hp, biu hin bng khc tht tng cn, l triu chng sm v ni bt nht. Cn au bng t ngt, d di, tr n ngi, xon vn, hai chn p lung tung, cn au nh thc tr dy ban m, ban ngy lm tr phi ngng mi hot ng, b chi, b b. Cn au xut hin v mt i t ngt, mi cn au ko di 5-15 pht. Cc triu chng c th ti din ngay sau , tr yu dn, mt l, khong cch gia cc cn au ngy cng ngn i. - Nn: chim 65%. Xut hin ngay t cn au u tin, lc u nn ra thc n sau nn ra dch xanh hoc vng. 115

- i tin ra nhy mu: gp 95% cc trng hp y l du hiu biu hin mun. I ra mu xut hin c th ngay t cn au u tin khi lng cht kht, kh tho hoc xut hin mun sau 24 gi. a s cc trng hp mu ln nhy, c th hoc nu, i khi c vi git mu ti chy ra hu mn, dy ra t. Trong nhiu trng hp mu ch c pht hin khi thm trc trng c nhy mu theo gng. - B trung i tin nu khi lng gy tc hon ton, tuy nhin khi rut khng tc hon ton bnh nhn vn i tin c. y l tnh hung d lm cho chn on nhm, nht l c mt s bnh nhn a chy sau khi lng rut xut hin. 2.4.2. Thc th - S thy khi lng: gp 85-95% cc trng hp, thng h sn phi, trn rn khi lng nm ngang, cn h chu tri c hnh vnh cung. Lc bnh nhn du cn au, bng thng mm, s thy khi lng l mt khi di, di ng, chc, mt nhn, au khi n, nm dc theo v tr ca khung i trng. C th khng s thy khi lng do nm su di b sn phi, lng ti gc gan hoc khi bng cng chng do tc rut n mun. - H chu phi rng (du hiu Dance) do manh trng di chuyn ln trn. - Thm trc trng thy nhy mu theo tay v dnh gng biu hin ca xut huyt rut. Nh li ca Mondor nu l lng rut c tm s thy mu phn. C trng hp thm trc trng s thy u khi lng nu lng rut xung thp ti tn bng trc trng. - Sau 48h c cc triu chng ca tc rut c hc. 2.4.3. Ton thn Giai on sm t thay i. Giai on mun thng mt l, t hot ng, biu hin mt nc, in gii, nhim khun nhim c, nhit tng cao. 2.4.4. X quang * Chp bng khng chun b t c gi tr trong chn on, c th thy mt s du hiu gi : - Mt m m di gan hoc vng thng v tng ng vi v tr khi lng. - Khng c hi h chu phi do manh trng di chuyn ln cao hn - Cc biu hin ca tc rut: Mc nc, mc hi, in hnh khi bnh nhn n mun. - Lim hi do rut hoi t b thng. * Chp bng c tht baryte vo i trng bao gi cng c cc hnh nh c hiu ca lng rut: hnh y chn, hnh cng cua, hnh mc cu, hnh huy hiu hoc hnh m thoa. Chng ch nh: tc rut n mun 48h, vim phc mc, thng rut. * Chp bng c bm kh vo i trng, cc hnh nh ca lng rut c ng in hnh nh bm baryte, y l th thut an ton, d p dng. 2.4.5. Siu m - Siu m l phng php tin cy v chnh xc chn on lng rut. 116

- Hnh nh khi lng: Mt ct ngang: Khi lng l hnh trn, bu dc c ng knh trn 3cm vi vng trung tm tng m v vng ngoi vi gim m Mt ct dc: Khi lng c hnh nh ca mt bnh Sandwich gm 3 lp: gia l mt lp tng m v hai lp gim m hai bn. - V tr khi lng: khung i trng hoc nm ngoi. - Siu m Doppler mu: l phng php tin lng v ch nh phu thut hay tho lng, cn c vo dng chy ca mu trong on rut lng , nu khng c dng chy ca mch mu mc treo b chn p trong on rut lng (c du hiu thiu mu rut) th phu thut. 2.4.6. Chp ct lp vi tnh : hnh nh tc rut non : quai rut trn ch lng gin, di xp. t c p dng tr em 2.5. Chn on 1.5.1. Chn on xc nh - Trng hp n sm da v phng trnh Fevre chn on : au bng d di tng cn + Khi lng = Lng rut au bng d di tng cn + Nn+ Thm trc trng c mu = Lng rut au bng d di tng cn + Hnh nh Xquang hoc siu m c hiu = Lng rut - Trng hp n mun: da vo phng trnh Ombredan: Triu chng tc rut hoc vim phc mc+ ra mu nhy hu mn= lng rut. 1.5.2. Chn on phn bit - Mt s trng hp c a mu: bnh a chy mu, l, polip i trc trng v rut non, tr, sa trc trng, vim i trc trng xut huyt, vim rut hoi t. - Mt s trng hp c nn: vim mng no, vim hng, vim ph qun... - Trng hp c khi: tc rut do bi giun. - Vim rut tha cp, vim d dy cp, vim ti tha Meckel. 2.6. iu tr 2.6.1. Tho lng bng bm hi. Ngy nay vic tho lng bng hi ang c s dng ph bin thay cho tho lng bng Baryt. Vit Nam tho lng bng hi c tin hnh t 1964 v t nm 1973 tc gi Ng nh Mc nghin cu c h thng v ton din. Tc gi sn xut my tho lng c van iu khin p lc nhm phng bin chng v i trng trong khi tho lng. Hi c bm vo trc trng, theo di sao cho p lc khng vt qu 80cm H2O (tr di 6 thng) v di 120 cm H2O (tr ln hn 6 thng), trong thi gian 3 pht. T l tho lng thnh cng nu bnh nhn n sm trong 24 gi u l 90% cc trng hp. 117

Cc tiu chun cho bit tho lng c: Xquang: Hi t manh trng a vo on cui hi trng, manh trng v i trng ln tr li v tr bnh thng Lm sng: Ht au, ht nn, ng yn, a phn vng. Cn phi cnh gic vi cc trng hp lng kp hi hi - i trng. Tuy thuc cn quang hoc kh sang rut non nhng lng hi hi trng vn cn. 2.6.2. Tho lng bng nc: Hirschsprung- 1876 bo co mt lot bnh nhn c tho lng bng p lc nc. Ngy nay phng php tho lng bng nc c th tin hnh phng siu m. Dung dch c dng: nc, nc mui sinh l hoc dung dch Ringer. Dung dch c lm m bng nhit c th, bm vo trc trng qua ng Foley s 10 18F vi p lc 100mmHg. Theo di kt qu bng siu m, du hiu thnh cng l: khng cn hnh nh ca khi lng ng thi thy nc v bt kh t manh trng trn vo on cui hi trng. T l thnh cng 50-89%. Phng php ny c u im: bnh nhi khng b nh hng bi tia X. 2.6.3.Tho lng bng baryte: Nm 1913 Ladd s dng phng php chp i trng c bm thuc cn quang chn on lng rut. Sau ny cc tc gi c, M, Php s dng nh mt phng php iu tr lng rut, hin nay t c p dng iu tr. Khng nn p dng khi lng rut sau 24h. Ch nn coi l mt phng php chn on, khng nn coi l mt phng tin iu tr, tho lng bng tht baryte ch nn coi l mt may mn trong qu trnh tin hnh chn on. Bc ng baryte tht cao hn mt bn 80- 100cm, theo di bnh nhn qua mn hunh quang nht l khi thuc n u khi lng, p lc duy tr khng qu 5 pht. Tiu chun tho lng thnh cng: baryte a vo hi trng (du hiu bn pho hoa), hi trng v manh trng tr v v tr bnh thng, lm sng ht au, ht nn, a phn vng. 2.6.4. iu tr ngoi khoa - Vo gia th k XVII Paul Barbette m t bnh lng rut v gi m tho lng. Nm 1871 Jonathan Hutchinson m tho lng thnh cng trng hp u tin. - Ch nh: Khi lng rut c chng ch nh tho lng bng kh hoc khi tho lng bng kh khng c kt qu. - V cm: gy m ni kh qun. - ng m: ng trng gia trn v di rn d dng kim tra x l ct on rut khi cn.

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- K thut tho lng: Khi thy khi lng dng tay nn nh nhng t di ln trn, ngc chiu nhu ng rut, y li dn khi lng. Nu kh khn nn p huyt thanh m hoc phng b Novocain mc treo v ch i. Khi phi ct on rut lng b hoi t nn ni rut ngay hay a ra ngoi l ty thuc tnh trng ca rut v bng: + Nu bng khng vim phc mc v quai rut cn tt nn ni rut ngay. + Nu bng vim phc mc nn dn lu hai u rut ra ngoi. - Ct rut tha v c nh hi trng vo manh trng, mang trng vo thnh bng bn phi khng phi l mt nguyn tc bt buc trong lng rut cp tr cn b. 3.Lng rut tr ln 3.1. Nguyn nhn a s lng rut tr ln c nguyn nhn thc th: - Manh trng v mt phn i trng phi di ng. - Polyp, bi giun, u rut non hoc u i trng. - Tn ti ti tha Meckel. 3.2. Lm sng au bng khng d di nh lng rut tr cn b. Nn hay gp. a nhy mu t l khng cao gp khong 44%. S thy khi lng gp khong 89%. Nhn chung triu chng au bng v khi lng xut hin 1-2 ngy, thnh tng t, sau ht au, khi lng bin mt, t khi bnh nhn c biu hin tc rut hon ton. 3.3. Cn lm sng Chp khung i trng c tht baryte hoc bm hi cho du hiu c hiu ca lng rut. Tuy nhin i khi khng bt c hnh nh lng rut v khi lng lng lo, rt d b tho di p lc trc khi kp quan st thy, do vy siu m trong cn au c gi tr chn on cao. 3.4. Chn on - Chn on xc nh: Lm sng: au bng cn, s thy khi lng. X quang, siu m , CT scanner. - Chn on phn bit vi tc rut do giun. 3.5. iu tr Lng rut tr ln a s c nguyn nhn thc th, d ti pht, thng hay gp lng rut hi- manh- i trng, nn m tho lng, c nh hi trng vo manh trng, manh trng vo thnh bng bn phi v ct rut tha ng thi phi ch tm nguyn nhn gii quyt: ct ti tha Meckel, polip, u ...

119

xon i trng sigma

PGS.TS.Nguyn Vn Khoa 1. i cng: - Xon i trng sigma l mt cp cu bng ngoi khoa. Bnh thng gp ngi cao tui, t l nam nhiu hn n, lm sng c triu chng ca tc rut thp. - Chn on ch yu da vo triu chng lm sng v X quang. 2. Nguyn nhn: Xon i trng sigma thng gp nhng bnh nhn c iu kin thun li v do cc nguyn nhn sau: 2.1.V gii phu: - i trng sigma di do bm sinh hoc do hu qu ca mt s bnh khc. - R mc treo i trng sigma ngn do bm sinh hoc do vim nhim gy nn 2.2. Do to bn lu ngy, nm lu hoc nhng ngi mc bnh tm thn. 3. Gii phu bnh l: 3.1. i th: - Khi m vo bng thy i trng sigma dn rt to, ty theo mc v thi gian b xon m m hnh nh tn thng thnh rut khc nhau. C khi rut b thm tm, rut c th hoi t khi m mun. - Chiu xon ca i trng sigma c th cng chiu hay ngc chiu kim ng h. 3.2. Vi th: Cc tn thng do xon i trng sigma c th c xung huyt, xut huyt nim mc, nghn cc mch mc treo, hoc hoi t hon ton thnh rut. 4. Triu chng: 4.1. C nng: - Bnh nhn xut hin au bng tng cn vng di rn. - Thng c bun nn v nn km theo. - B trung i tin. - Khai thc tin s thy bnh nhn thng b to bn mn tnh i khi c biu hin ca bn tc rut. 4.2. Thc th: - Nhn: bng trng lch, khng u, cng to bn phi nhiu hn, t khi c du hiu rn b. - Nghe: nhu ng rut khng tng.

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- G vang do quai rut chng hi. - S, nn thy mt khi cng dn bng. - Trn quai rut chng c tam chng Von Wahl: khng c sng nhu ng, g vang, nghe khng c ting nhu ng. - Thm trc trng: bng trc trng rng, i khi c th s thy mt nt xon cao, n vo rt au. Lun ng nelaton qua trc trng ln cao c cm gic tc nghn. 4.3. Ton thn: - Nu xon i trng sigma n sm th tnh trng ton thn khng nh hng. - Nu mun bnh nhn s suy sp do rut b hoi t, gy nn tnh trng vim phc mc phn, tin lng rt nng. 4.4. X Quang: - Chp X quang bng khng chun b thy mt quai rut n c, gin cng to hnh ht c ph, mt lm quay xung h chu tri. Quai rut gin nm bt cho t h chu tri sang h sn phi, y c mc nc. - Tht baryte vo i trng qua hu mn thy bng trc trng gin to, c hnh m chim. 5. Din bin v cc th lm sng: 5.1. Din bin: - Xon i trng sigma khng hon ton c th t tho xon, khng phi iu tr phu thut nhng d b ti pht. - Nu xon hon ton khng iu tr sm v kp thi th quai rut xon b tn thng ngy cng nng, c th dn n hoi t v thng gy vim phc mc phn, tin lng rt nng. 5.2. Cc th lm sng: - Th ti cp tnh: au t ngt, d di, quai rut xon 360 , rut nhanh chng b hoi t, vim phc mc, nhim c, ton thn suy sp nhanh. - Th cp tnh: m t nh trn. - Th bn cp: cc triu chng khng rm r, bnh nhn thng khng n vin hoc n rt mun. - Th ti pht: Thng ti i, ti li nhiu ln. 6. Chn on 6.1. Chn on xc nh: - Lm sng: triu chng tc rut thp. - X quang: hnh nh quai rut gin hnh ht cafe nm t h chu tri n h sn phi, hnh m chim, 6.2. Chn on phn bit: 6.2.1. Xon manh trng: - t gp, chn on kh, Chp X quang bng khng chun b thy mt quai

121

rut gin nm bt cho t h chu phi sang h chu tri, hnh ht c ph lm li quay v h chu phi. - Tht baryte, chp thy tc trn cao vng i trng ln ty mc son. 6.2.2. Ung th i trc trng: - Tin s c au bng tuy nhin au khng c tnh cht cp tnh v d di nh trong xon i trng. - i ngoi phn nh, dt, c mu mi. - Bng chng u. - X quang tht baryte, chp khung i trng c hnh u nham nh, ni soi sinh thit chn on xc nh. 6.2.3. Lng rut: - Thng s thy bi lng d dng. - Thm trc trng c mu theo tay. - Chp khung i trng cn quang c hnh lng rut. 7. iu tr: 7.1. iu tr bo tn: + Ch nh: - Bnh nhn n sm, bit chc quai rut khng b hoi t. - Nhng bnh nhn trn 60 tui, xon ln u. + Cho bnh nhn nm t th gi- ngc, qua soi trc trng y ng thng cao su mt cch nh nhng ln cao. Khi ng thng vt qua nt xon s c hi x ra, sau c nh ng thng vo hu mn tho hi v phn ra ngoi, chun b cho m phin. 7.2. iu tr phu thut: + Ch nh: Ch nh m cp cu nu nh khng tho xon c hoc biu hin ca tc nght, hoi t ca rut xon. + Thi x tr trong m: - Khi m bng, nu quai rut cn tt th nh nhng tho xon ngc chiu vi chiu xon, ct on i trng sigma a ra ngoi, m khu ni th hai. - Nu i trng sigma c nguy c hoi t th ct on rut m khng tho xon, a ra ngoi lm hu mn nhn to. - Nu rut hoi t v thng th sau khi ct on rut lm hu mn nhn to phi ra sch bng, t dn lu c h thng bm ra bng hng ngy. nhng bnh nhn ny t l t vong cao do tnh trng vim phc mc phn rt nng.

122

Cc khi u rut non v mc treo

TS. SnH 1. i cng: Cc khi u rut non chim t l 1- 6% cc khi u ng tiu ho ni chung v 2- 6,5% cc khi u rut. Trong 30% s bnh nhn c khi u rut non l lnh tnh, cn li 70% l c tnh. Theo Vn Tn (2000) trong 10 nm ti bnh vin Bnh Dn m 67 trng hp u rut non: u lnh chim t l 23%, u c tnh - 77% gm c: u c c trn- 40%, u c lym pho- 38%, u biu m tuyn c tnh - 17%, u carcinoid l 4%. Cn li l u lnh c: u c trn, u tuyn, u m, u mu. Trong s cc khi u lnh tnh, u c v u m hay gp hn c chim t l trn 30%, t gp l polip, u x, u mu v u thn kinh.Trong cc u c tnh, sarcoma chim t l 45% cc u rut non, trong 65% cc khi u ny l c tnh. Ung th rut non chim t l 3 - 15% cc khi u rut non. 2. U lnh tnh: Cc khi u lnh tnh rut non c ngun gc t t chc biu m v t chc lin kt c c im pht trin vo trong lng rut v ra pha ngoi thanh mc. Cc khi u pht trin vo trong lng rut thng khng ln, cn khi u pht trin ra pha ngoi thanh mc thng c kch thc v trng lng rt ln. Adenoma l nhng u biu m n c, dng polip pht trin vo trong lng rut. Polip rut non thng c tnh. U t t chc lin kt thng gp nhiu hn c l u c, loi u ny thng khu tr hi trng, i khi tin trin thnh sarcoma. Ngoi ra cn u m, u x, u mu, u bch mch, u thn kinh rt him gp. Bnh cnh lm sng cc u lnh tnh rut non ph thc ngun gc t chc pht sinh, v tr khu tr, kch thc, s lng khi u. Nhiu bnh nhn c u lnh tnh rut non khng c biu hin lm sng, ch tnh c pht hin c trong khi m. Cc khi u pht trin ra pha thanh mc c kch thc rt ln, chn p cc c quan bn cnh. Cc khi u pht trin vo trong lng rut thng gy tc rut, au bng cn, chng bng. Nu u hng trng thng au khu tr vng rn hoc vng bn tri rn. U hi trng, au vng h chu phi. U c thng bin chng chy mu t, u mch mu thng thy phn ln mu. U pht trin vo lng rut c th gy xon hoc lng rut vi bnh cnh lm sng ca tc rut c hc. U m tin trin lm sng vi c im hay gy lng rut. Cn li cc u c kch thc ln hoc c cung c th gy xon rut.

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Khm thc kh pht hin cc u lnh tnh tr khi khi u ln, s thy khi khm bng hoc thm trc trng, m o. X quang trong trng hp u pht trin vo lng rut c th thy hnh khuyt hoc dng thuc cn quang. iu tr cc u lnh tnh rut non bng phu thut ct on rut, khi u c bin chng tc rut th chin thut x tr ph thuc mc tn thng ca tc rut v ton trng bnh nhn. 3. Cc khi u c tnh: 3.1. Ung th rut non: Ung th v sarcoma rut non trong thc t lm sng gp rt t. Tr nhng u do carcinoid, chng ch chim t l 1- 3% cc u c tnh ng tiu ho. U c th pht chim t l 29%. U c tnh rut non gp ch yu la tui trn 40, a s l nam gii. U thng gp on u hng trng hoc on cui hi trng. 3.1.1. Gii phu bnh l: * i th: Ung th rut non v i th c 2 dng, u pht trin vo trong lng rut v ra pha ngoi thanh mc. Loi pht trin ra pha ngoi thanh mc thng c vng x cng c dng hoa sp l, polip hoc lot v dn dn lm hp lng rut. Loi pht trin vo lng rut gy nhim cng thnh rut theo b mc treo. * Vi th: adenocarcinoma ung th lin bo tuyn, di cn vo h bch huyt sm, di cn xa ti gan, phi, thn, xng, mc ni. * Lm sng: Bnh cnh lm sng thi k u ca ung th rut non tin trin m thm, khng r rt thay i tht thng ph thuc v tr kch thc v t chc hc ca khi u. au bng cn ngn, khng c im au khu tr r rt. Ri lon tiu ho v c, y bng, kh chu, i ngoi to, lng xen k nhau, bun nn hoc c nn. n ung chm tiu, chn n, gy st cn nhnh. Giai on mun tin trin rm r hn, au bng cn tng ln, tng nhu ng rut, nn nhiu, nhim trng nhim c tng ln, c trng hp trn c s lit rut, ri lon tiu ho t ngt chuyn sang hin tng tc rut c hc cp tnh au bng d di, nn, b trung i tin cn phi m cp cu. C th c bin chng khc nh: thng, chy mu, * Chn on: Ung th rut non giai on u tin trin thm lng. V vy chn on thng mun do vy kh nng phu thut trit rt kh khn. Do cn phi lu nhng tin triu ca bnh mc d kh phn bit vi cc ri lon tiu ho khc. Thng ch nh m khi c bin chng. Kinh nghim ca cc tc gi chn on ng trc m ch t khng qu 15%. Chn on da trn triu chng lm sng vi hnh nh X quang, soi ng mm, chp ng mch chn lc. * iu tr: 124

U lnh tnh rut non iu tr ngoi khoa cng sm cng tt. U nh n c c th ct b kiu hnh chm. U ln ct on rut, nu nhiu u sau sinh thit tc th, t c chin thut ph hp. Nu u c tnh th ct rng ri k u trn v di khi u 6cm, kt hp ct b mc treo cng vi h thng hch bch huyt. Khi c di cn xa, xm ln rng khng th ct c th ni tt gii quuyt tnh trng tc rut. iu tr ho cht kt hp sau m. 3.2. Sarcoma rut non: Khc bit vi ung th, Sarcoma thng gp ngi tr, ch yu nam gii. Sarcoma thng c kch thc ln, pht trin ra pha ngoi thanh mc,dng hoa sp l, di cn sm. Vi th dng lymphosarcoma, t chc t bo sarcoma dng hnh trn v gin phn. 3.2.1. Lm sng: Bnh cnh lm sng sarcoma rut non giai on u khng r rt. au bng , st cn, st. i ngoi phn lng. Thiu mu t gp hn hn u c tnh c ngun gc t t chc biu m. giai on mun s thy khi u ln di ng. Khc vi ung th, sarcoma t khi tc rut v t chc sarcoma thng mn nt v d thng. 3.2.2. Chn on: Khi u nh bnh cnh lm sng ngho nn, nhng khi s nn thy th khi u ln, c dng hoa sp l, di ng. C th da trn hnh nh Xquang chn on, chp ng mch chn hoc ni soi bng. Cn phn bit vi lao rut non, bnh Crohn, ung th i trng, u sau phc mc, 3.2.3. iu tr: Ct b rng ri khi u k u cng on rut tn thng cng vi mc treo. Tin lng ph thuc vo giai on bnh, iu tr trit cn t l sng sau 5 nm khong 35- 40%. 4. Cc khi u mc treo rut non: Khi u mc treo thng gp la tui 20 - 40, n gp nhiu hn nam. Cc khi u lnh tnh mc treo tin trin thm lng, chng tnh c c pht hin bi bnh nhn s thy hoc khi thm khm ca thy thuc. Trong mt s trng hp c mt vi triu chng nh au rt m h v c du hiu ri lon tiu ho. i khi au lan xuyn ra pha b vai v ct sng. U c tnh thng c triu chng gy st cn, ton trng mt mi, chn n, thiu mu. 4.1. Chn on: Chn on u mc treo rt phc tp. khi u di ng thng s thy vng rn. G c trn vng c u (du hiu Tillaux) hoc g c quanh u (vng Caturna). loi tr bnh l c quan khc cn thm trc trng m o, chp thn ngc dng. 4.2. iu tr:

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iu tr u v nang mc treo rut non bng phu thut, bao gm ct khi u cng vi on rut c mch mu mc treo nui dng. U c tnh ct b u cng mc treo, ct on rut ti t chc lnh. 5. u Carcinoid v hi chng carcinoid: Nm 1897 Kultschitzky miu t ln u tin v c im t bo c pht hin nim mc ng tiu ho c nhn ln hnh cu, mng mng v c nhiu bo quan nguyn sinh cht, c gi l t bo Kultrski. Thut ng "carcinoid" c S.Oberndofer a ra nm 1907 v cho rng theo tin trin lm sng u ny l dng lnh tnh tuy nhin theo cu trc GPBL n khng khc Adenocarcinoma. Tri qua thi gian rt di ngi ta khng tm c ngun gc khi u. Nm 1928 P. Masson chng minh cc khi u carcinoid pht sinh t s tng sn trong phn chia t bo Enteroxomatin. U carcinoid l cc u dng ni tit sinh ra t cc t bo a crm c mt ri rc khp ni trong thnh rut. Carcinoid him gp vi t l 0,08 - 0,65 cc trng hp. Hay gp nht rut tha (60- 90%), tip n hi trng,t trng, hng trng, trc trng thm ch gp ty, phi, tinh hon. Carcinoid gp nam v n. Trc y rt lu ri ngi ta cho rng: carcinoid tin trin lnh tnh. Ngy nay vi kinh nghim lm sng cho thy, n c kh nng di cn. Carcinoid rut tha rt t di cn, tuy nhin carcinoid hi trng di cn gp 65% - 75% cc trng hp c carcinoid. Thng gp nht di cn n gan, hch bch huyt. Nhng nm gn y ngi ta ch n hi chng carcinoid do trong mu c hm lng serotonine c tng hp bi cc t bo Enteroxomatin v vai tr ca cc cht trung gian chuyn ho khc nh kinin, proglandin, katecholamin, histamin (I. X. Derizanov- 1985). 5.1. Lm sng: a s cc bnh nhn carcinoid c tin trin lm sng khng in hnh, thng khng chn on c trc m. Carcinoid rut tha c tin trin lm sng nh vim rut tha cp hoc mn. Ch khi m ct rut tha hoc sau soi t bo ca rut tha ct mi c chn on chnh xc. Bnh nhn Carcinoid rut non thng c triu chng au cn vng na bng phi, i ngoi phn lng, chng bng v c du hiu bn tc rut Phng php duy nht iu tr carcinoid l phu thut ct b khi u. Carcinoid rut tha chim t l 90% cc khi u tin pht rut tha v chim gn 1/2 tt c cc khi u carcinoid ng tiu ho. Carcinoid rut tha thng nm phn ui rut tha c hnh o van vi kch thc to va phi, mt chc, c mu vng. Bnh thng gp ngi tr, ngc li ung th rut tha hay gp ngi gi ( chim t l 0,2-0,5% ung th ng tiu ho). Do bnh cnh lm sng u carcinoid rut tha tin trin thm lng v khng in hnh cho nn carcinoid rut tha ch xc nh c trong v sau m ct rut tha. Khi ct b rut tha cng vi mc treo l phu thut trit cn, cn trng hp khi

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carcinoid nm gc rut tha xm ln vo manh trng th phi ct na i trng phi. Tin lng sau phu thut trit cn tng i tt. Khong 10% bnh nhn vi u carcinoid c "hi chng carcinoid". H chng ny c cc biu hin: da mn , a chy, co tht ph qun v van tim bn phi b lng ng collagen. S d c cc triu chng y l do cc u carcinoid gii phng ra mt s hot cht, ng l phi gi li gan, nhng li i thng vo tun hon chung. Trong hu ht hi chng carcinoid, serotonin c sn sinh ra vi khi lng ln, chnh n l nguyn nhn ca hin tng a chy. Mt lot cc hot cht khc c th tham gia vo hi chng Carcinoid, k c cc peptid lm dn mch thuc dng tachykinin nh cht substance P. Neuropeptide K v neurokinin A. Cn nhiu cht khc cng c ghi nhn trong vic to ra cc bnh cnh a dng ca hi chng Carcinoid: histamin, catecholamin, polypeptid ty, gonadotropin mng m, gastrin, glucagon, prostaglandin, ACTH, v calcitonin. 5.2. Xt nghim: Mt s u carcinoid c pht hin bng chp x quang. Gi tr hm lng ca 5 - hydrocxyindoleacetic acid (5 - HIAA) tng cao trong nc tiu l du hiu gi tr chn on hi chng carcinoid. C th dng nghim php pentagastrin chn on: khi tim pentagastrin s c nng serotonin v cht P trong huyt thanh tng cao. 5.3. iu tr: Tt c cc u carcinoid pht hin c rut non, mc treo, phc mc u phi c ct b. Nu c di cn mc treo, tuy khi u chnh ct b th 6 thng sau cn phi m kim tra li. Nu khi u gy tc rut th d tn thng trng c v ((khng hy vng)) cng nn c gng ct ly b ht v tin trin ca u rt chm. Trong mt s trng hp phi ct gn ht rut, sau nui dng qua ng tnh mch. Nu c di cn gan khu tr, nn c gng ct b t chc di cn. Nu di cn gan m khng ct b c c th iu tr tm thi bng gy tc ng mch gan hoc truyn ho cht vo ng mch gan. Doxorubicin c p ng ttvi t l 20%. Nu phi hp Fluorouracil, doxorubicin (adriamycin), cyclophosphamid v treptozicin s cho t l p ng l 30%. C th iu tr hi chng carcinoid bng phi hp nhiu thuc khc nhau nhm gim tc dng ph ca cc hot cht. C th dng phenothiazin, corticosteroid, thuc chng th th histamin H1 v H2.. Somatostatin c tc dng c ch gii phng mt s peptid hornon. 5.4. Tin lng: U carcinoid pht trin chm, ko di hng thng hng nm. T l sng 5 nm sau m ct u carcinoid rut non khong 70%; Thm ch 40% bnh nhn c di cn xa khng cn kh nng phu thut v 20% bnh nhn c di cn gan c th sng c 1 nm hoc lu hn. Theo thng k thi gian sng trung bnh sau 127

khi c pht hin sm bng m bnh hc l 14 nm v t khi xut hin triu chng ca carcinoid l 8 nm.

Cc khi u lnh tnh ca i trng

TS. Sn H

Trong nhng nm gn y do s pht trin ca k thut ni soi, cc khi u lnh tnh ca i trng ngy cng c pht hin nhiu. C hai loi: - U nim mc: thng gp nht l u biu m tuyn (adenopolip), chim i a s trong cc u lnh tnh ca i trng. Adenopolip gp t l 41,9% na i trng tri, 39,3% na i trng phi v 18,8% trc trng. - U thnh i trng: him gp hn nhiu, u xut pht t t chc lin kt. Thng gp l u m, u x, u c, u mch mu, u nhung mao... 1. P lp i trng: L bnh l hay gp ca i trng: t l pht hin plp i trng trong m t thi l 7 - 31%, trong ni soi l 28,2 - 33,1%. Vit Nam, t l plp pht hin trong dn chng bng ni soi Thanh Ho l 12,1%, Bnh Tr Thin l 21% v H Ni l 5%. 1.1. Gii phu bnh l: 1.1.1. i th: - V tr: thng cng cui ng tiu ho gp cng nhiu, nhiu nht trc trng v i trng Xichma (chim 70-90%). Plp c th tp trung mt on, nhng c th ri rc khp i trng. - S lng: thng l mt ( 70%), nhng c th l 2 - 3 ci hoc hng chc - Hnh th: thng l hnh trn hay bu dc, c ng knh t 1mm n vi cm. C th c cung di, rt di ng v khng c cung. Thng c mu ti. 1.1.2. Vi th: Plp t nim mc i trng bao gm mt phn tuyn xut pht t biu m, mt phn ni tip mch mu chuyn t mng m di nim mc. Lp c khng bao gi thm nhp v s hnh thnh ca t chc u, ngay c cung cng vy. 1.2. Lm sng: Biu hin lm sng ca plp i trng rt khc nhau, phn ln plp pht

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trin khng c triu trng. Theo Deyhie th 95% plp pht trin khng c triu chng. Nhng theo G.D.Grkhva, 68 ca theo di ca mnh th tt c u c triu chng. Triu chng lm sng ca plp ph thuc vo s lng, v tr, kch thc v cu to i th. Cc triu chng thng gp l: - Mu ln trong phn v chy mu ng rut: thng chy mu ti km theo phn, c khi chy mu n thun hoc chy mu t mt, ko di gy thiu mu. Mt c im na l chy mu tng t, c thi k di yn tnh. - Ri lon tiu ho: phn to lng tht thng i khi c nhy mi. au bng. - Cc triu chng km theo: c th bt u bng triu chng ca lng rut, bn tc rut. Nu plp trc trng c cung di th c th sa ra ngoi. 1.3. Chn on: Chn on polp i trng da vo: - Lm sng: triu chng ch yu l a ra mu. Thm khm trc trng bng tay c th pht hin thy nhng polip trc trng v tr cch ra hu mn khong 9 - 10 cm. - Soi i trc trng: thy polp trong lng i trng hoc trc trng di ng v ln trnh trc ng soi. - Chp cn quang khung i trng: yu cu c k thut tt. - Chp nghing c p, dng thuc lm thay i nhu ng. Chp khi thuc y, thuc t v sau khi bm hi. Chp i quang kp. Hnh nh polp l mt vt sng, b r, trn u, rt di ng thay i qua cc ln khm v cng mt ln khm khc nhau. 1.4. Tin trin v bin chng: 1.4.1. Ung th ho: S lng polp cng nhiu th t l ung th ho cng cao. Shiuya v Wolf (1975) phn tch 5786 u tuyn c loi b bng ni soi thy: - Nu s lng l 1 u th ung th ti ch l 13,8%, ung th xm ln l 8,2%. - Nu s lng l 2 u th ung th ti ch l 21,3%, ung th xm ln l 16%.A.L.Kodenbikov theo di trn 958 ca thy: Nu c 1 polp th ch s c tnh l 1/35. Nu nhiu polp th ch s c tnh l 1/3. 1.4.2. Chy mu: C th chy r r ko di gy thiu mu, hoc chy nhiu gy mt mu cp. 1.4.3. Bin chng tc rut do plp bt lng rut hoc lng rut. 1.5. iu tr: Ch c th bng phu thut.Ty theo v tr, tnh cht, s lng v s phn b ca polp m c th: - Ct b polp i trng bng ni soi hoc phu thut m bng. 129

- Ct on i trng cng vi polp. - Ct b gn ton b i trng khi manh trng khng c plip hoc c mt vi plip, ni manh vi trng trc trng (secoretoanastmos) - Phu thut Wangenstenn - 1943. - Ct b ton b i trng. 2. Bnh polip gia nh (polipose): - Trng hp a plip lan to c Menzel m t ln u tin nm 1721. Mi hn 150 nm sau, nm 1882 Criipps mi chng minh v khng nh bnh ny c c im di truyn v gp nhiu ngi trong 1 th h hoc nhiu th h trong mt gia nh. Bnh l mt dng a polip i trng v bnh di truyn mang tnh cht gia nh. Do c gi l bnh plp gia nh. Bnh gp ch yu tr em v ngi trng thnh c hai gii. Qu trnh bnh l a polip tuyn vi nhiu polip c kch c khc nhau, nm ri rc sut chiu di i trng hoc tp trung vo bt k on no ca i trng. - Bnh cnh lm sng in hnh: au bng, phn mu ln nhy, c th c st vi cc du hiu nhim trng, nhim c v d nhm ln vi vim i trng. - Chn on da trn bnh cnh lm sng kt hp vi kt qu chn on hnh nh: X quang, ni soi v kt qu sinh thit. Bnh polip gia nh tin trin lm sng thng dn n c tnh. - iu tr: Ct on i trng c polip, vi dng a polip lan to th ct ton b i trng. 3. U M: L bnh l him gp, chim khong 1-10% trong tng s u lnh tnh ca i trng. 3.1. Gii phu bnh l: U l t chc u mm mi, pht trin chm thng lp di nim mc (bn trong), c th pht trin lp di thanh mc (bn ngoi). U thng c chn rng, i khi cng c cung v gi n l u m dngplp. Kch thc ca n c th nh nh ht hoc to bng qu cam. Phn ln gp ngi trn 40 tui. Nim mc ph trn khi u thng bnh thng v khng c np gp. U c cu to bng nhng m m c kch thc khc nhau v c ngn cch bng vch x. Nu trong u m c nhiu t chc lin kt th c gi l u x m. 3.2. Lm sng: - Bnh tin trin chm, thng khng c triu chng. - Giai on sau xut hin to bn, a chy xen k, i khi c mu v dch nhy. - Nu u to, c th s thy u vi tnh cht rt di ng, mt nhn. - i khi bt u bng triu chng lng rut cp hoc mn. 3.3. Chn on: Chn on xc nh u m i trng trc m rt kh. Chn on ch yu 130

da vo X quang: mt hnh khuyt i trng. Tuy nhin cng d nhm vi mt ung th. 3.4. Tin trin v bin chng: D a n lng rut cp hay mn, c th ung th ho di th sarcoma (t gp). 3.5. iu tr: Ct on i trng vi khi u. 4. U x: U x i trng rt him gp. U pht trin thng khng c triu chng. i khi bt u bng triu chng ca lng rut. Tin trin c th b lot v pha phc mc hay vo nim mc hoc ung th ho. 5. U c: Thng pht trin t lp c trong nhiu hn lp c ngoi.Mt ca khi u th nhn. U c th pht trin lm hp lng rut v l du hiu u tin chun on. Khi u c th gy lng rut, lot chy mu v ung th ho. 6. U mch mu: Rt him gp.Triu chng thng gp nht l chy mu. C th chy mu thng xuyn, tng t, i khi chy mu d di trong khi i tin. Khi soi trc trng, i trng thy nhng bi mch mu hnh chm nho nh ln t lp di nim mc. Chun on u mu i trng trc khi m rt him. 7. Cc u lnh tnh khc: C th gp nhng rt him cc u lnh tnh khc ca i trng nh: u nhung mao, u bch huyt, u x thn kinh... Cc khi u ny pht trin khng c triu chng hoc triu chng rt ngho nn nn kh chun on c trc khi m. Khi chun on l u lnh tnh l c ch nh ct b khi u. U nhung mao l u ca cc nhung mao i trng, trn b mt ca n c bao ph bi lp t bo biu m, u thng gp on cui i trng v trc trng. U nhung mao c Rokitansky miu t ln u tin t nm 1841. Loi u ny chim t l 1,5%- 15% cc khi u i trc trng. T chc u mm mi, c mu hng ti, thng c ph mt mng mng, u khng xm ln qu lp nim mc v pht trin vo trong lng i trng. Nim mc quanh khi u khng thay i. Bnh cnh lm sng u nhung mao: phn to lng tht thng, nhy mu mi hoc xut huyt i trng. Chy mu ng rut thng xuyn dn n thiu mu, gy cm, xanh xao. C trng hp chy mu nng mt ti 1,5 2 lt dch ln mu dn n ri lon nc in gii v shock do gim khi lng mu lu hnh. U nhung mao l bnh l tin ung th do nguyn tc iu tr trit cn nh vi ung th.

131

Ung th i trng
TS. V Huy Nng
1. i cng: Ung th i trng bao gm ung th biu m tuyn v ung th biu m lin kt. -Trn th gii, ung th i trng ph bin cc nc pht trin, hay gp Hoa K, Canada, Ty u. - Vit Nam ung th i trng l bnh l hay gp, ng hng th hai trong ung th ng tiu ho sau ung th d dy, ng hng th nm sau ung th d dy, phi, v, vm. Bnh ngy cng gia tng. Theo thng k vin K H Ni: ung th i trc trng 1992: 5,1/100.000 dn, 1994: 7,5/100.000, 2003: 12,9/100.000. - Bnh gp nam nhiu hn n. - cc nc Chu u bnh thng gp tui trn 60, Vit Nam b nh thng gp tui 40-60. - Bnh tin trin tng i chm v di cn mun,tin lng kh hn so vi cc loi ung th khc. - Triu chng ca bnh ngho nn, nn thng pht hin mun. iu tr ch yu bng phng php phu thut. M sm trong giai on u t l sng trn 5 nm l 60-70%. - Cc phng php iu tr khc nh: x tr, ho tr v min dch ch c tc dng b tr tng thi gian sng thm v gim t l ti pht. 2. Bnh nguyn v bnh sinh: Hin nay cha xc nh r nguyn nhn sinh bnh, tuy nhin c nhng yu t thun li sau: 2.1. Bnh l ca i trng: - Polyp i trng ng vai tr quan trng trong nguyn nhn gy ung th i trng. Nhng polyp i trng c nguy c ung th cao gm: polyp kch thc trn 2cm, polyp khng c cung, s lng cng nhiu d sn cng cao - Ung th cng c th pht sinh trn tn thng ca cc bnh l i trng mn tnh: vim lot, l amip, thng hn, lao, . -V tr hay gp ung th l i trng Sigma v manh trng. S cn tr lu thng do on rut b gp khc l yu t thun li cho tr phn lu ngy gy hu qu vim lot mn tnh, l iu kin pht sinh ung th. 2.2. Yu t mi trng: - Ch n nhiu m, m, t cht x ng vai tr quan trng. Theo N.N.Petrov cc hot cht phn hu ca m nh: indol, scatol, piridin l cc cht gy ung th trong thc nghim v cng c th gy ung th trn ngi.

132

- Cc thc n cha cc cht c th gy ung th trn thc nghim: lc mc, tht hun khi, 2.3.Yu t di truyn: - Bnh a polyp tuyn gia nh lin quan n s t bin gen apc, bnh ung th i trng khng c a polyp tuyn gia nh lin quan ti t bin gen P53, RAS v DCC. - Ngi ta thy yu t gia nh chim 5% trong ung th i-trc trng. 3. Gii phu bnh l 3.1. V tr: Ung th gp bt k v tr no ca i trng:manh trng, i trng ln, gc gan, i trng ngang, gc lch, i trng xung, i trng sigma. C th mt v tr nhng cng c th hai hay nhiu v tr (3- 5%), v tr thng gp nht i trng Sigma v manh trng, sau l nhng ni khc. 3.2. i th: 3.2.1. Th u si: Ung th thng pht trin trong lng rut. Nhn ngoi t bin dng. Thng gy thng tn mt phn thnh rut. U thng to ln nhn nh hnh sp l, ri rc c lot, nim mc xung quanh ph n chy mu. Loi ny hay gp i trng phi. 3.2.2.Th cht hp: Ung th thng pht trin ra pha thnh rut, vng quanh chu vi, u thng nh c mu trng, lm thnh i trng x cng v lm lng i trng cht hp, hay gy tc rut. Loi ny hay gp i trng tri. 3.3. Vi th: a s l ung th biu m tuyn in hnh (90-95%). Ung th cn gi nguyn cu trc ca tuyn. Vi cc bit ho: cao, va, km. Him hn l ung th biu m khng in hnh (5%). C bit l ung th th keo hay nhy vi c im l c nhng mng ln cht nhy. 3.4. Phn loi giai on ung th: 3.4.1. Phn loi ca Dukes C.E. (1932). Astler V.B. v Coller F.A (1954) ci tin cch xp loi ca Dukes chi tit hn. Dukes Astler-Coller A B C D A B1 B2 C1 C2 C3 D Tnh trng bnh U t lp nim mc xm ln lp di nim mc, lp c di nim mc, c trn U xm ln st thanh mc U xm ln vt thanh mc U xm ln lp c, di cn hch cnh i trng U xm ln thanh mc, di cn hch trung gian U xm ln vt thanh mc, di cn hch cnh trc trng C di cn xa 133

3.4.2. Phn loi theo TNM. T: khi u nguyn pht - Tx: khng th nh gi c khi u nguyn pht. - T0: u khng r rng. - Tis: in situ, carcinoma ti ch lp nim mc. - T1: u xm ln ht lp di nim mc. - T2: u xm ln n lp c. - T3: u xm ln ht cc lp thnh rut lan n t chc xung quanh. - T4: u xm ln n c quan xung quanh. N: hch lympho - Nx: hch vng khng th nh gi c. - N0: khng c di cn hch. - N1: c di cn 1-3 hch cnh i trng. - N2: di cn trn 4 hch cnh i trng. - N3: di cn bt k hch no trn ng i ca ng mch mc treo. M : di cn xa - Mx: di cn xa khng th nh gi. - M0: khng c di cn xa. - M1: c di cn xa. Bng i chiu phn loi giai on bnh gia TNM v Dukes: TNM N0 N0 N0 N0 N0 N1 N2 N3 Bt k N Dukes M0 M0 M0 M0 M0 M0 M0 M1 A B C D

Giai on 0 Giai on I Giai on II Giai on III Giai on IV

Tis T1 T2 T3 T4 Bt k T Bt k T Bt k T

4. Triu chng 4.1 C nng: - au bng: thng gp (>80%), khng c tnh cht c hiu, thng au lm rm, khng r rng, khng d di, i khi c au qun tng cn, trung tin c th au. V tr au ty theo v tr ung th, dc theo khung i trng. - Ri lon tiu ho: to lng tht thng. a chy hay gp trong ung th i trng phi, cn to bn l du hiu ph bin trong ung th i trng tri.

134

- a ra mu: t khi c mu ti, thng mu sm mu ln vi phn, mi hi, do chy mu r r t khi u. Mt mu ko di lm bnh nhn thiu mu, hoa mt, chng mt... 4.2. Thc th: - S thy u khi bnh nhn n mun. - i khi bnh nhn n bnh vin vi nhng biu hin ca tc rut c hc thp. 4.3. Ton thn: - Thiu mu: Da xanh, nim mc nht. - Gy st cn nhanh khng r nguyn nhn. - St ko di khng r nguyn nhn. 4.4. Cn lm sng 4.4.1. X quang: - Chp bng khng chun b: c hnh nh mc nc mc hi khi tc rut thp, hnh nh lim hi khi c bin chng thng v khi u. - Chp khung i trng: c gi tr chn on + Hnh cht hp: l khe hp khng u, khng thy np nim mc bnh thng, cn gi l hnh nhn, hay gp trong K i trng tri. +Hnh khuyt khng u, b nham nh, c th ra hay trung tm, ty theo v tr ca khi u, thng tng ng vi th u si, hay gp trong K i trng phi. + Hnh ct ct: thuc cn quang dng li nh hnh ngn nn, khi ung th cht hp hon ton lng rut trong tc rut. 4.4.2. Ni soi, sinh thit: l phng php chn on sm v chnh xc. - Thy v tr, hnh nh i th ca ung th. - Sinh thit cho chn on xc nh 4.4.3. Chp CT- scanner: Gip nh gi s xm ln ca khi u vo t chc xung quanh v hnh nh di cn hch. 4.4.4. nh lng khng nguyn ung th biu m phi (CEA): L cht ch im khi u. T l bnh thng l 7,73ng/ml nu ung th itrc trng t l tng trn 10 ln. CEA c gi tr trong pht hin di cn, ti pht sau iu tr ung th i-trc trng. 4.4.5. Test khng th n Clon MoAb B 72.3 c gn phng x Radium: Chp nhp nhy kim tra di cn gan, hch, u. p dng nhng trung tm k thut cao cc nc tin tin. 5. Tin trin v bin chng. Ung th i trng khng c iu tr s cht trong vng 1-2 nm vi cc bin chng. 5.1. Tc rut: Gp khong 30-50% trng hp. Thng gp i trng tri nhiu hn. 135

5.2. Nhim trng: Tc ch ung th hay xung quanh t chc ung th c th nhim trng di hnh thi vim hay p xe. 5.3. Chy mu: Phn nhiu chy mu r r, tim tng, lm bnh nhn thiu mu xanh xao. Cng c s t cc trng hp chy mu nhiu lm bnh nhn mt mu cp. 5.4. Thng: C th thng ch c khi u, cng c th thng v tr gn khi u. Biu hin bnh cnh ca vim phc mc. 5.5. R: C th r ra thnh bng, gy r phn, cng c th r vo cc ni tng nh: r vo d dy, t trng, rut non hay bng quang 5.6. Di cn: C th di cn trc tip vo cc t chc v c quan ln cn hoc theo ng bch huyt v ng mu cc c quan xa nh gan, phc mc, phi, xng 6. Chn on. Chn on sm thng kh. Thng bnh nhn n vi mt khi u hoc bin chng ca tc rut. Mun chn on sm phi lun ngh n n khi xut hin cc triu chng c nng gi ca ung th i trng. 6.1. Chn on xc nh: Ch yu da vo chp cn quang i trng, hoc soi i trng vi sinh thit. xc nh giai on ung th. 6.2. Chn on phn bit: - Cn phn bit vi cc khi u i trng nh polyp, lao, u nm v cc u lnh tnh khc. Ngoi ra cn phn bit cc loi vim mn tnh ca i trng. Chn on phn bit cc bnh trn ch yu da vo X quang. Song nhiu khi cung kh, ch c chn on chc chn bng xt nghim t chc hc. - Cc khi u ngoi i trng: u thn, d dy, gan, mc treo, bung trng v u sau phc mc Chn on phn bit vi cc loi u ny thng d, nh phim chp cn quang i trng. 7. iu tr. iu tr ung th i trng ch yu bng phng php phu thut. Ty theo tnh trng chung ca bnh nhn v thng tn ti ch m cho php iu tr trit hay iu tr tm thi. 7.1. iu tr trit : 7.1.1. Nguyn tc: - Ct b rng ri phn i trng c khi u, m bo din ct an ton trn v di khi u. Thng ct trn v di khi u 5cm. - Ly b hch vng cng vi mc treo i trng lin quan. 136

- Ct b cc tng xung quanh b xm ln (nu c). 7.1.2. Cc phng php phu thut: Ty theo v tr ca ung th i trng, trong trng hp cha c bin chng: - Ct i trng phi. - Ct i trng ngang. - Ct i trng tri. - Ct i trng chu hng. - Phu thut m rng: ngoi vic ct b i trng, cn phi ct b mt hay nhiu tng b ung th xm ln hay di cn. Do qu trnh lin so ca vt thng i trng kh khn v c im gii phu v sinh l ca i trng (thnh i trng mng, mch mu nui dng i trng km, trong lng i trng cha nhiu vi khun ) cho nn vic khi phc lu thng ca rut ch tin hnh ngay sau khi c s chun b chu o. Cn trong cc trng hp m cp cu (ung th c bin chng tc rut, thng ) cha c s chun b cn thn th vic khu ni phc hi ng tiu ho s tin hnh ln m sau. 7.2. iu tr tm thi. Vi nhng trng hp bnh nhn n mun, th trng yu, hoc khi u qu to, xm ln n cc c quan ln cn hoc di cn xa khng th ct b khi u c th c p dng cc phu thut: - Lm hu mn nhn to pha trn khi u. - Ni thng gia on rut trn khi u vi di khi u iu tr v d phng tc rut. 7.3. iu tr b tr. 7.3.1. Ho tr v min dch liu php: Thng dng 5FU (5 Fluoro-Uracil) iu tr b tr sau m hoc kt hp vi Levamesole hay Acide Folinique cho cc trng hp c di cn xm ln. 7.3.2. X tr: t dng cho ung th i trng v d nh hng ti cc tng trong bng. 7.4. X tr mt s tnh trng bin chng:

Sarcoma i trng
Sarcoma i trng l ung th ca t chc lin kt. L bnh l him gp, chim khong 1-5% trong tng s cc u ca i trng. Bnh gp mi la tui, nhng thng gp t la tui t 20 - 40, nam gp nhiu hn n. 137

1. Gii phu bnh l. V tr thng gp l manh trng gn van Bauhin. Hin tng cht hp lng rut trong sarcoma i trng him gp hn so vi ung th. Nim mc trn khi u thng b lot hoc c s tng sinh ca polyp. Thng tn pht trin t lp di nim mc v c th lan rng khp thnh rut. C th gp cc loi sarcoma khc nhau, nh lyphosarcoma th hay gp hn c. Trn din ct ca khi u trng ging nh tht ca c v thng c hoi t vi kch thc khc nhau. 2. Triu chng lm sng. Bnh bt u khng c triu chng. V sau xut hin au bng km ri lon ti u ho nh chn n, a chy hay to bn, i khi st cao. Giai on cui th suy mn, ph v thiu mu, tuy vy triu chng thiu mu v suy mn t gp hn trong ung th. 3. Tin trin Bnh thng pht trin nhanh, trong vng 1 nm. Ngi cng tr bnh cng c tnh. Bin chng thng gp nht l s pht trin tng sinh ca khi u n cc c quan ln cn nh rut non, bng quang, t cung. Cc bin chng khc c th gp: thng, tc rut, lng rut, chy mu 4. Chn on Chn on sarcoma i trng trc khi m thng l kh. Tuy vy, bnh nhn c khi u i trng pht trin nhanh , to, au t, di ng, khng c biu hin chn p lng rut th phi ngh n sarcoma i trng, nht l ngi tr tui. X quang: ngoi tn thng nim mc cn thy mt nhu ng ca i trng. Cn chn on phn bit khi u vim, lao, u giang mai, nm.. nhiu khi nhm vi c vim rut tha cp. 5. iu tr Ch c th iu tr bng ngoi khoa: ct b i trng coa khi u v h thng bch huyt km theo. Kt qu xa v tin lng km hn so vi ung th i trng.

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Ung th trc trng

TS. V Huy Nng 1. i cng: Ung th trc trng l bnh l hay gp trong ung th ng tiu ho, ng hng th hai sau ung th d dy v chim 1,4% trong tng s ung th, chim 66% trong ung th i - trc trng. Tn thng phn ln nm phn thp ca trc trng, c th s thy c qua thm trc trng. Bnh tin trin tng i chm, di cn mun, nhng bnh nhn thng n mun do thy thuc b qua ng tc thm trc trng v chn on nhm vi cc bnh: tr, l, vim i trng. Nu pht hin sm, iu tr trit th t l sng trn 5 nm t 60-80%. Gii: t l nam nhiu hn n (3/2). Tui: gp nhiu nht la tui t 60-70 2. Bnh nguyn bnh sinh (ging ung th i trng) 2.1. Bnh l ca trc trng - Phn ln ung th trc trng xut pht t polyp trc trng, nht l bnh a polyp tuyn gia nh. - Ung th cng c th xut pht t u lnh tnh, nh u nh (papillome) - Cc bnh vim lot ca trc trng. 2.2. Yu t mi trng Ch n ung cng ng vai tr quan trng: n nhiu tht, nhiu m, t cht x gy to bn, ng phn, nim mc trc trng thng xuyn tip xc vi cc cht gy ung th: notrosamin, indol, piriddin u to iu kin cho ung th trc trng pht trin. 2.3. Yu t di truyn Bnh a polyp tuyn gia nh mang yu t di truyn s ung th ho s au vi nm. 3. Gii phu bnh 3.1. V tr: V mt ngoi khoa, ung th trc trng c chia theo 3 v tr, v c lin quan n cch thc m v ly hch: 3.1.1. Ung th trn bng (gia trc trng v i trng Sigma): - Khi u trn ti cng Douglas (phn trc trng c phc mc ph), cch hu mn 12-15cm. Ch pht hin c bng ni soi. - V gii phu th tin trin v bin chng ging nh ung th i trng Sigma. Tin trin chm v c phc mc ph, nhng hay gy hp v u pht trin hnh nhn. 3.1.2. Ung th bng:

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Thng gp nht, chim 2/3 tng s. Ung th nm trc trng di phc mc, cch ra hu mn t 4-11cm. C hai loi: - Ung th thp: nm trn hu mn sau tuyn tin lit. - Ung th nm cao: nm sau bng quang. 3.1.3. Ung th hu mn: Cch ra hu mn 3-4cm. C c im ring v t chc hc (ung th thng b th lt), tin trin nhanh. Cm th i vi tia. 3.2. i th C 3 th: th si, th lot v th vng nhn hay th chai. 3.2.1. Ung th trn bng: T chc u cng do phn ng cht m mnh, gy cht hp kiu vng nhn. 3.2.2. Ung th bng: C hai th si ra ngoi ging nh sp l v th lot c thm nhim. 3.3. Vi th. 3.3.1. bng trc trng. - Phn ln l ung th biu m tuyn (90%) - Ung th th keo hay th nhy (10%) 3.2.2. ng hu mn. - Ung th biu m lp Malpighi 3.4. Di cn ca ung th 3.4.1. Di cn theo bch huyt: Thng pht trin khi khi u lan qua thnh trc trng n t chc ngoi trc trng theo 3 ng: - ng trn: quan trng nht l theo chui tnh mch mc treo trng di. - ng gia: pht trin theo chui tnh mch trc trng gia n hch h v. - ng di: ng thi va lan theo hng ln trn, va lan n hch bn, l ng lan truyn ca ung th ng hu mn. 3.4.2. Di cn theo ng mu Rt sm, nhng t (4%), di cn xa n gan, phi, ct sng, no. 3.4.3. Di cn n cc t chc xung quanh: Ung th lan nhanh chu vi v lan chm theo chiu cao. c bit lan theo chiu su ca thnh trc trng qua nim mc, lp c, thanh mc, hch vng v lan ti cc t chc xung quanh n c quan sinh dc v tit niu. 4. Lm sng 4.1. Triu chng c nng - a ra mu l triu chng hay gp nht, thng mu ln phn hoc ln nhy mi, v thng ra trc phn. - a to xen k vi a chy tng t.

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- Thng km theo cc triu chng ca vim trc trng nh au qun, mt rn, cm gic nng v tc hu mn. - Khi n mun th phn bit dng nh v dt. - i khi bt u bng triu chng ca tc rut nht l i vi ung th trn bng. 4.2. Triu chng thc th. 4.2.1, Thm trc trng: S thy u cng, b nham nh, c th s thy mt lot. Lng trc trng b cht hp, d chy mu. Nu l Sarcoma th thy u y nim mc vo lng trc trng, trong khi nim mc cn nhn bng. Qua thm trc trng c th xc nh: v tr u, chiu cao ca khi u, hp ca lng trc trng, mc di ng ca u v tnh trng ca c tht hu mn. ph n: kt hp vi thm m o xc nh xm ln ca u trc trng v chn on phn bit vi ung th c t cung. 4.2.2. Soi trc trng: Quan trng v pht hin cc khi u trn cao m tay khng s thy c. nh gi ng khong cch ca khi u ti cc c tht hu mn chn mt phng php m thch hp. Lm sinh thit c th cho mt chn on chc chn. Nu nghi ngi th phi lm sinh thit 2-3 ln. 4.2.3. X quang Chp khung i trng cn quang hay i quang kp s thy hnh khuyt hay cht hp, b nham nh ngoi ra cn cho bit v tr ca khi u v tnh trng i trng trn khi u. 4.2.4. Siu m ni trc trng. a u r siu m vo lng trc trng. nh gi s xm ln ca u v mc di cn hch. 4.2.5. Chp CT Gip nh gi s xm ln ca u v mc di cn hch 4.2.6. Chp cng hng t C chnh xc cao nhng gi thnh t. Ngi ta t s dng 4.2.7. Siu m bng pht hin cc di cn gan v dch c chng 4.2.8. Chp phi pht hin cc di cn ln phi. 4.2.9. chp U.I.V hoc ni soi bng quang pht hin di cn ng niu. 5. Chn on 5.1. Chn on xc nh Da vo cc triu chng ca thm trc trng, soi trc trng v quan thng nht l kt qu sinh thit khi u. 141

5.2. Chn on phn bit - Phn bit vi cc bnh l: tr, l, hp trc trng do vim v cc loi bnh l vim trc trng khc (lao, giang mai, Licolas favre ). - Phn bit vi cc khi u lnh tnh ca trc trng: u tuyn, polyp - Phn bit vi cc khi u ngoi vo: ung th c t cung, ung th tuyn tin lit. 5.3. Xc nh kh nng phu thut: Quan trng l nh gi mc di cn ti ch bng cch: - Thm trc trng: xem khi u di ng hay c nh. Nu c nh th dnh vo u: pha sau thng dnh vo xng cng, trc dnh vo bng quang v tuyn tin lit, bn dnh vo niu qun. - Chp X quang ng tit niu: chp bng quang, thn thuc ng tnh mch v chp thn, niu qun, b thn ngc dng. Mc ch xc nh s di cn ca ung th n ng tit niu. 6. Bin chng v tin trin. - Nhim trng ti ch gy st cao, c th a n vim m lng lo, vng chu hng nh, hoc p xe h ngi-trc trng. - Di cn vng m ri gy au d di. - Tc rut cho khi u lm cht hp lng trc trng. - R vo cc c quan ln cn (bng quang, m o). - Xm ln vo h tit niu (niu qun, bng quang) gy ri lon tiu tin. 7. iu tr iu tr ung th trc trng ch yu bng phu thut, c th iu tr b tr sau m bng ho tr, x tr. Ty theo th trng bnh nhn, giai on bnh v tnh trng di cn ca ung th m iu tr trit hay tm thi. 7.1. iu tr trit : 7.1.1. Nguyn tc phu thut trit : - Gii hn ct: pha trn cch b trn khi u 15cm, pha di cch b di khi u t 5-7cm. Ngy nay ngi ta chng minh ct di khi u 2-3cm l ht t chc ung th. - Ly ht h thng bch huyt theo ng tnh mch tr trn n tn gc ca ng mch mc treo trng di. - Ly b rng ri cc t chc xung quanh trc trng pha trc: ph n n thnh sau m o v c th ly b thnh sau m o; nam gii n bng quang, ti tinh v nu c th ly b bng quang v ti tinh. 7.1.2. Phng php phu thut trit : - Phu thut ng trc: i vi khi u c b di cch c tht >8cm th ct b trc trng vi khi u bng ng bng n thun v ni i trng vi phn trc trng cn li. - Phu thut Qunu-Miles: Nu b di khi u cch c tht di 5cm 142

- Phu thut Babcock-Bacon: Nu b di khi u cch c tht t 5-8cm th ct b trc trng cng vi khi u v ni i trng Sigma vi c vng hu mn bc ht nim mc. - Phu thut Hartmann (phu thut trong tnh trng cp cu): Nu khi u ch tip ni gia bng trc trng v i trng Sigma th tin hnh ct i trng Sigma v on trc trng c khi u, ng li mm trc trng pha di v a i trng Sigma trn ra ngoi bng lm hu mn nhn to. Vic phc hi lu thng rut s lm th hai. 7.2. iu tr tm thi 7.2.1. Ch nh p dng trong nhng trng hp ung th n mun, th trng bnh nhn qu yu, hoc khi u di cn nhiu n cc c quan ln cn hoc di cn xa ti gan 7.2.2. Phng php phu thut tm thi Lm hu mn nhn to i trng Sigma hoc i trng ngang. 7.3. iu tr b tr 7.3.1. X tr p dng trc, trong v sau m. Ngi ta thy c kt qu tng thi gian sng thm v hn ch ti pht sau m. 7.3.2. Ho tr v min dch liu php: Thng dng 5-FU kt hp vi Levamisol hoc Acid Foninique iu tr b tr sau m.

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Sa trc trng
PGS.TS. Nguyn Vn Xuyn 1. nh ngha: Sa trc trng l tnh trng mt phn (nim mc) hay ton b thnh trc trng ln li v chui ra ngoi qua l hu mn. 2. Nguyn nhn: Nguyn nhn ca sa trc trng c nhiu, thng bnh pht sinh do mt hay kt hp nhiu yu t sau: 2.1. Tng p lc bng ko di: - Tr em: a chy, ho g, fimossis - Ngi ln: to bn, b i, l, vim i trng mn, polip, si bng quang, Fimossis - Ngi lm ngh khun vc nng 2.2. S suy yu ca cc phng tin treo gi hu mn trc trng nh c tht, c nng hu mn, cc cn c y chu, trng nho dy chng Parks, mt lin kt phn nim mc v h nim mc. 2.3. Khuyt tt v gii phu bm sinh hoc mc phi: - Mt cong sinh l trc trng, mt gc gp gia trc ca ng hu mn v trc trc trng. - i trng sigma di qu mc. - Ti cng Douglas qu su v rng, khi p lc bng tng, ti cng Douglas vo thnh trc trc trng, dn dn y trc trng ra ngoi hu mn l thot v trt (Moschcowitz- 1912). - Khng y cc cu trc gii phu c nh trc trng nht l pha sau, khng dnh vo xng cng nn di ng d dng, trt xung v sa ra. - Dong rng hu mn. - Khuyt tt hoc t rch do chn thng h thng cn c y chu, c nng, c tht hu mn v honh chu hng. - Van trc trng km pht trin,gim cn lm trc trng d sa xung. - Hnh thnh mc treo trc trng (Ripstein v Lanter- 1963). 1.4. Dinh dng: - Suy dinh dng v thiu cn nng do n ung khng y . - Thiu vitamin nhm B. 3. Phn loi: 3.1. Sa nim mc: L ch sa phn nim mc, lp c khng b sa. Bnh thng nim mc hu mn phng v ln khi i tin tng phn, sau t co ln, khi bnh l khng co ln c 144

* Theo mc sa chia lm 4 : + 1: Sa khi rn i tin, t co ln. + 2: Sa khi rn i tin khng t co, phi y ln. + 3: Sa d dng khi gng sc nh nh i b, ngi xm, ho, ht hi. + 4: Sa thng xuyn lin tc ngoi hu mn. *Theo chu vi vng hu mn: + Sa c vng chu vi + Sa mt phn chu vi: 1/2; 2/3 vng. *Theo la tui: + Sa nim mc tr em: thng l sa nim mc n thun do s lin kt gia lp nim mc v c cha c pht trin hon chnh. + Sa nim mc ngi ln: thng km theo tr hn hp, cc bi tr lin kt vi nhau to thnh vng tr ko theo nim mc trc trng sa ra gi l tr vng. (Cricular hemorrhoids). + Sa nim mc ngi gi: c th gp sa nim mc km theo tr hn hp hoc sa nim mc n thun do ri lon mi tng quan lin kt gia lp nim mc v lp c b lo ho ngi gi. 3.2. Sa ton b: C 3 lp ca thnh trc trng sa ra ngoi qua l hu mn. * Theo gii phu: - Sa trc trng n thun: cc lp ca thnh trc trng ln li v chui ra ngoi qua ng hu mn, hu mn v tr bnh thng. - Sa hu mn trc trng: ton b thnh trc trng v thnh ng hu mntrc trng ln li v chui ra ngoi. * Theo mc : chia lm 4 : - 1: trc trng ch sa khi gng sc mnh, khi rn i tin sau t co li nhanh chng. Chiu di ca on sa 3 - 5 cm, ton thn khng c nh hng g, cc than phin ca bnh nhn ch do on trc trng sa gy nn. - 2: trc trng lun sa khi i tin t co ln rt chm phi ly tay y vo, c cc vt trt nim mc, ph n nim mc, hu mn b lm vo, c tht c thay i t, ton thn bnh thng, on trc trng sa di 6 - 8 cm. - 3: trc trng sa khi gng sc nh (ho, ci, ht hi, i b, ngi xm...) v khng t co vo c. Nim mc tuyn ca trc trng b hoi t tng m mt vi ni c so, hu mn mt trng lc c tht nho. Tinh th n b c ch, nim mc chy mu, trung tin mt t ch, on rut sa di 9 - 12 cm. - 4: rut sa thng xuyn lin tc khi i b, khi ng. Nim mc tuyn b lot hoi t, thnh so, c tht mt trng lc, trung i tin mt t ch. Ri lon cm gic vng hu mn, eczema vng y chu; on rut sa di trn 12 cm. 3.3 . Sa trc trng c bin chng : - Chy mu: do lot nim mc hoc t cc bi tr.

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- Vim lot trc trng: do sa thng xuyn kh y vo nn b lot. - Tht nght: do co cng c tht dn n nght. - Tc rut: nu c rut non sa theo trc trng khi b tht nght. - V trc trng: Sau mt gng sc mnh hoc tht nght, c y ln. - Sa trc trng km theo sa sinh dc ph n: thng km theo sa m o hoc t cung - m o. - Sa trc trng km theo thot v y chu: Khi trc trng sa ko theo ti cng Douglas v rut non gy thot v hu mn (hdrocele) hay thot v trt ca y chu. 4. lm sng: 4.1. Sa nim mc: Hu mn c khi li ln nh qu c chua mu ti, c xut tit dch, cc np nim mc xp theo hnh nan hoa t trong l hu mn m ra ( nh nm qu c chua), khng c rnh ngn cch gia khi li vi ra hu mn. l do cc mi nim mc b sa li ra khi l hu mn nh kiu lp lt ng tay o li ra khi u ng tay o. Nu sa nim mc km theo tr th c cc bi tr mu tm to thnh mt vng nim mc tr. 4.2. Sa trc trng: - Bng trc trng ln ra nh hnh ng hay hnh chp, y hu mn v nh hng ra sau (thnh trc di hn thnh sau, ging nh ci ui). C nhiu vng np nim mc ng tm hnh vnh khn, hng bng t, c th c lot. - Nu sa trc trng n thun th ng hu mn v tr bnh thng, nim mc trc trng sa tip gip vi nim mc ng hu mn, y c 3 ng: ng hu mn ngoi cng, 2 ng thnh trc trng lng vo nhau. S thy rnh gia khi sa vi ra hu mn, c th lun ngn tay vng quanh rnh phn chia ny. - Nu sa hu mn trc trng: c trc trng v ng hu mn u ln ra, ng hu mn li ra tip lin vi da mp hu mn, khng c rnh phn chia, ch c 2 ng lm thnh on sa. - Nu sa trc trng km theo thot v: Thy khi phng pha trc khi sa, xc nh bng cch kp khi phng vo 2 ngn tay s thy cng ln khi gng sc (ho hoc rn), c ting c ch ca quai rut. 4.3. nh gi tnh trng tng sinh mn: Xc nh dy v trng lc c tht, c nng hu mn 4.4. Pht hin cc bnh l kt hp: - Xem c cc thot v khc phi hp khng - Khm thn kinh: xem c tn thng ty sng, dy, r thn kinh. 5. iu tr: 5.1. Sa nim mc: - Sa nim mc ngi ln thng km theo tr hn hp th p dng cc phu thut ct tr vng (xem bi tr).

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- Sa nim mc n thun ngi gi th p dng phu thut ct b nim mc sa (phu thut Delorme, phu thut Hartmann) v lm tng trng lc c tht. - Sa nim mc n thun tr em ch yu iu tr bo tn. 5.2. Sa ton b: 5.2.1. Cc phu thut qua ng bng: * Treo trc trng trc tip khng c s tr gip ca cht do nhn to: + C nh treo mt sau trc trng vo nh trc tip bng 3 mi ch khu ri (Phm Gia Khnh- BV103). + C nh vo t chc phn mm xung quanh (Verneuil- 1881). + C nh trc trng vo thnh khung chu (Pemberton - 1939) + t on trc- i trng sigma ngoi phc mc thnh bng trc bn tri (Lahaut- 1956). + C nh mt sau trc trng vi xng cng dc 2 bn ng gia (Lange- 1887). * Treo trc trng c s tr gip ca cht do nhn to: + Phu thut Orr- Loygue- 1957 (Php): dng 2 di bng ( cht do tng hp) treo 2 bn thnh trc trng vo nh. + Phu thut Ripstein- 1965 (M): dng ming Teflon lm nn khu m kn pha trc bng trc trng, c nh 2 u hai bn gia cn trc xng cng. + Phu thut Wells- 1959 (Anh): dng ming li nhn to Ivalon c nh gia vo gia cn trc xng cng ri khu hai u vo hai bn bng trc trng, h pha trc bng trc trng. *Ct i trng v i - trc trng: - Ct i trng sigma v trc trng( ct cao hoc thp), BV Mayo Anh. - Ct on i trng tri, khng ct trc trng m treo trc trng trc tip vo cn trc xng cng (Frykman- Goldberg- 1969). 5.2.2. Cc phu thut qua ng y chu: *Khu vng hu mn (Thiersch- 1891): Dng ch Perlon khu mt vng di da quanh c tht.Sau buc li t lt ngn tay. * Treo trc trng ng y chu: - Phu thut treo v c nh trc trng vo xng cng (Thomas - 1975). - Treo trc trng qua ng y chu nh tr gip ca cht do nhn to, c nh vo mt trc xng cng v hai bn trc trng (nh k thut Wells). * Ct trc trng: - Ct b hon ton on trc trng sa (Mikulicz- 1888): t dng. - Ct b nim mc trc trng sa kt hp khu gp li lp c (Delorme 1900).

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Nt k hu mn
PGS.TS. Nguyn Vn Xuyn 1. nh ngha: Nt k hu mn l mt lot nim mc da ng hu mn, nm vng lc, thng km theo s co tht ca c tht hu mn v gy ra au d di sau khi i tin. 2. Gii phu bnh: *V tr ca nt hu mn thng xy ra im yu ca hu mn l tam gic Minor. Nt lot thng n c 90% cc sau ca ng hu mn, cn li cc trc, hu nh khng b hai bn. Mt s tc gi cho l mt dng lot dinh dng. C hai loi tn thng lot: - Lot cp: Vt nt nng, hnh bu dc hay tam gic, nhng do c tht lm rm li, u trn st vng rng lc u di ra ti ra hu mn. Vt nt c mu ti, sng n. - Lot mn tnh. y thng su, c b dy, g ln, nn chc, vt nt sng n, nht nht hoc xm. Vt lot thng c hnh vt ngc, u trong nh hn, qua y lot thy c cc si c tht trong mu trng bn. T chc gn vt nt nh mnh da tha mp hu mn, nh ph i u trong lot st ng lc. * Vi th: y lot c t chc ht, t chc lin kt qu sn, thnh mch ph i, b lot c hin tng sng ho, c tht trong ti ch b vim x. 3. Nguyn nhn: C nhiu nguyn nhn v iu kin thut li c cp n - Do vim nhim hu mn: theo Oh - 1995 sau khi i tin, phn b mc kt cc np hu mn to ra amoniac phi hp vi ion Cl_ t m hi kch thch gy vim nhim quanh hu mn. Cc t bo vim sn sinh ra cc men phn hy cht keo, lm gim sc bn t chc, khi c s cng dn th nt d xut hin, nht l khi phn rn i qua s lm rch lp nim mc da hu mn to nn lot. - Do vim x c tht trong: khi c tht hu mn ph i, tng trng lc, c tht rt mnh, s co tht ca c tht trong l yu t c bn lm cho lot khng lin c. p lc hu mn lc ngh rt cao trong nt k hu mn. y l c s l lun cho phu thut m c tht trong iu tr nt k hu mn. - Do thiu mu ti ch lm lot khng lin c v gi l lot thiu mu. - Do cu trc khuyt hng ca c tht hu mn t bo thai. - Chn thng: phn rn, sau m ct tr, hp hu mn, sau khi rn . - Yu t c a.

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- lot hay nm v tr ng gia sau c Eisenhammer - 1951 gii thch do 4 l do sau: + im yu v gii phu: do s sp sp ca cc th c tht lm cho v tr ny b ko cng nhiu nht (vng tam gic Minor) + Lp da nim mc dnh cht vo cc th x chun ca lp c phc hp dc, thng hot ng theo c tht t rong, khi kch thch b ko sang hai pha tch khi ng gia. + Da v nim mc pha sau thng b lm su bi cc hc tuyn nn d yu. + Do co ko ca bi tr hay polp khi sa ra ngoi nht l khi rn. - Sau bin chng ca mt s bnh hu mn trc t rng: tr (9-10%), nga hu mn, u li (Condylome), vim trc trng, vim quanh hu mn. 4. Lm sng: - au hu mn: au nh bng rt hu mn, lm cho bnh nhn rt s i i tin. au qua 3 giai on: + Khi i tin khi phn bt u i qua hu mn. + Ht au sau vi pht. + au li tng ln d di, ri t ngt ht au. - Sau i i tin bnh nhn lau hu mn c th thy mu hoc t dch vng, nhc nhi hu mn. - au lm bnh nhn mt n, mt ng, gy cm xanh xao nh hng n ton thn v tinh thn. - Khm hu mn: a ngn tay vo kh khn do s co tht ca c tht, i khi b x cng. C khi ch banh nh hu mn bo bnh nhn rn cng thy ngay c b di ca nt lot hoc mt bi tr x ho (tr gc cng), da tha bo hiu v tr ca lot. Quan st phn bit nt lot mi hay c. - Cn phn bit nt hu mn vi cc bnh au vng xng cng ct, au trc trng, vim quanh hu mn trc trng, vim hc Morgani v c bit l nhng lot bnh hoa liu (nht l ng tnh luyn i). 5. iu tr: 5.1. iu tr bo tn: - Gim au: ngm hu mn nc m, t thuc n hu mn, phng b di ch nt, thuc gim au. - Chng nhim khun. - Chng to bn. - Ngm, v sinh hu mn sau mi ln i tin. 5.2. iu tr ngoi khoa: Nhm mc ch trit tiu s co cng ca c tht trong. - Nong hu mn: Recamier - 1892 lm gim au, mt vng lun qun bnh l. - Ct b vt nt ri khu li: Ly i nt lot v t chc xung quanh vim 149

x theo hnh chic vt hoc bu dc. - M c tht trong thng rch 2/3 c tht trong im 6 gi hoc rch bn im 3 - 9 gi (t th sn khoa). Rch da di 1cm xc nh si c tht ct bng ko hoc dao in su, khi ct xong khu li da nim mc. C th rch c b nng c tht ngoi. - Phi hp ct b vt nt v m c tht trong. - Ct m c tht trong bng ho cht: s dng nitroglycerin hoc botulin A gy lit tm thi c tht trong lm cho nt k hu mn t lin. Aloder - 1994 s dng m nitroglycerin p hu mn c tc dng lm gim p lc hu mn lc ngh, nhng c tc dng ph nhc u. Jost - 1993 s dng c t botulin A tim vo c tht trong hai bn vt lot. 5.3. Ch nh: - i vi nt mi iu tr bng nong hu mn. - Vt c ct b vt nt hoc m c tht bng phu tht, ha cht.

Bnh tr
PGS.TS. Nguyn Vn Xuyn 1. Bnh nguyn, bnh sinh: 1.1. C ch bnh sinh: Theo quan nim c in tr l dn tnh mch hu mn trc trng. Cn theo quan im hin nay bnh tr l mt biu hin ca bnh l ca b mch tr v nhng t chc quanh mch mu ny, do nhiu nguyn nhn gy ra. C ch bnh sinh ca bnh tr c gii thch theo nhiu cch khc nhau. 1.1.1. Thuyt dn tnh mch: Cho rng tr l dn tnh mch hu mn trc trng. - Dn tnh mch do tng p lc tnh mch. - Dn tnh mch do thnh tnh mch yu, thnh tnh mch c tn ti nhng im yu gi l im tr. 1.1.2. Thuyt tng sinh mch mu (Stelzner- 1963): Cho rng tr l do tng sinh mch mu hu mn, c th l tng ph i (( cc th hang)) ca hu mn trc trng, to nn cc khoang cha mu l cc ti ng mu c thch nghi v chy mu trong tr l mu ng mch mu ti.. 1.1.3. Thuyt nhim khun: 150

Cho rng ngun gc ca tr l do nhim khun, do vim cc ng tuyn hu mn trc trng ng lc (nhim khun cc ng tuyn Hermann Defosses). 1.1.4. Thuyt sa lp m hu mn (thuyt c hc Thomson - 1975): Lp m hu mn (anal cushions) bnh th ng c tc dng lt lng khp kn ng hu mn. Khi i tin, rn nhiu cc ((m)) cng v cha nhiu mu d b y ra ngoi. Nu ti din nhiu ln lm cho dy chng Parks dn, trng nho, t, bi tr sa v dn n ri lon tun hon ti ch, bnh tr xut hin vi biu hin sa v chy mu ti bi tr, sa bi tr c trc chy mu. Thuyt ny uc nhiu tc gi ng h. 1.2. Mt s cn nguyn v iu kin thun li: - Ri lon tiu ho v lu thng rut: to bn, a lng, bnh l mt rn nhiu nht l l amp, vim i trng mn. - Mt s hnh thc lao ng, th dc th thao gy mt gng sc mnh lm mt cn bng t ngt ca tun hon ti ch vng hu mn trc trng, hoc lm vic tnh, ngi nhiu, ng nhiu, t i li, vn ng. - Mt s giai on sinh l ca c th nht l ph n: hnh kinh, c thai, sau sinh , giai on ni tit. - n ung: lm dng qu mc gia v, bia, ru, c ph v cht kch thch. - D ng ti ch: do dng khng sinh, thuc chng vim, thuc t hu mn, thuc chng cm. - Vng a l: mt s vng gp nhiu ng i mc bnh tr: a Trung Hi, Bc Phi, ng Nam . - Gia nh v di truyn: c mt s gia nh nhiu ngi mc bnh tr - Cc bnh chuyn ho: bo ph, i ng, Goutte 2. Phn loi: 2.1. Theo bnh nguyn bnh sinh: - Tr triu chng l hu qu ca mt bnh c bit r: tng p lc tnh mch ca, K trc trng, ph n c thai. - Tr bnh: cn gi l tr v cn 2.2. Theo v tr gii phu: Ly ng lc lm mc chia ra: 2.2.1. Tr ni: Chn ti tr trn ng lc, nim mc tuyn ca trc trng ph bi tr. 2.2.2. Tr ngoi: Chn bi tr di ng lc, da ng hu mn (nim mc Hermann) ph bi tr. 2.2.3. Tr hn hp: C c bi tr trn v di ng lc. 2.3. Theo chu vi vng ng hu mn:

151

C th nh v bi tr theo mt kim ng h im bao nhiu gi (chiu kim ng quay) t th sn khoa hoc gi - ngc (chng mng). Thng hay gp tr ni im 2 gi (bi phi sau), 5 gi (bi phi trc), 9 gi (bi ngang tri) t th gi - ngc. 2.4. Theo mc sa: Him nay c th chia tr nh sau: - 1: l tr giai on khi u, bi tr ni ln trong ng hu mn, khi i tin hoc rn th bi tr cng to ln nhng cha li ra khi ng hu mn, d chy mu. - 2: cc bi tr to thnh bi r rt, khi i tin hoc rn bi tr li ra khi l hu mn, khi thi rn t co vo c, c chy mu hu mn. - 3: cc bi tr kh ln, sa ra ngoi khi gng sc hoc rn, khng t co vo c phi y ln. C bi tr ph, c chy mu hu mn, c th thiu mu ton thn - 4: cc bi tr ln, ngoi cc bi chnh cn c bi tr ph, sa thng xuyn nm ngoi ng hu mn. Cc bi tr lin kt vi nhau to thnh vng tr. C th c chy mu gy thiu mu mn tnh. 2.5. Theo tin trin v bin chng: 2.5.1. Tr thng; 2.5.2. Tr chy mu ko di gy thiu mu: y l bin chng hay gp nhiu bnh nhn n vin vi triu chng thiu mu nng 2.5.3. Tr c huyt khi v vim tc tnh mch tr: Do mu, chn thng bi tr, ri lon ch n ung v c bit l s co tht ca c tht 2.5.4. V bi tr: Gy t mu cp tnh ra hu mn, mu sm v au d di. 2.5.5. Tr c sa bi tr v nim mc hu mn trc trng: Bnh tr lu ngy khng c iu tr dn n sa cc bi tr. Tr sa ra ngoi ng hu mn l cc bi tin pht hoc cc bi tin pht v th pht kt hp vi nhau to thnh vng tr c nim mc trc trng cng sa. Tr kt hp vi sa nim mc trc trng thnh vng gi tt l tr vng (circular hemorrhoids) 2.5.6. Tr nght: Do tr ni sa ra ngoi, c tht co bp lm nght, ph n thiu mu nui dng dn ti hoi t, vim v chy mu. 2.5.7. Tr c ri lon chc nng c tht: - Yu c tht hu mn: do tr sa lu ngy, sa thng xuyn lm yu c tht v bnh nhn khng gi c phn, hi (trung tin mt t ch). - Tng trng lc c tht gy co tht dn ti au. Mt trong nhng bin php nh gi trng lc c tht l o p lc hu mn. 2.5.8. Tr c cc bnh km theo:

152

- Nt hu mn - Vim nhim hu mn trc trng cc hc tuyn. - p xe quanh hu mn - R hu mn. 3. Lm sng: 3.1. C nng: - i tin ra mu: thng gp, l l do bnh nhn n khm bnh. Mu mu ti (mu mao mch) cui bi phn, chy nh git hoc thnh tia nh ct tit g. - au, rt, nga, kh chu vng hu mn nht l sau khi i tin xong. - Sa bi tr ra ngoi ng hu mn khi i tin, i b hoc ngi xm lu, lc u t co ln v sau phi y mi ln v cui cng thng xuyn sa ra ngoi. 3.2. Thc th: - Thm trc trng l bt buc khi khm hu mn trc trng ni chung v khm tr ni ring, c th s thy bi tr mm, n vo xp, nh gi s b trng lc c tht hu mn v cc bnh khc. - Cho bnh nhn ngi xm rn i tin xem mc sa v chy mu ca tr. - Soi hu mn trc trng: thy bi tr mu tm, chn bi tr nm v tr no so vi ng lc, pht hin cc tn thng chn on phn bit. - Khm ton thn pht hin cc bnh khc m tr ch l mt biu hin. 4. iu tr: 4.1. iu tr ni khoa: 4.1.1. Thuc c tc dng iu ho lu thng rut: - Chng to bn bng thuc nhun trng, ch n, king t, ru, bia .... - Chng a lng. 4.1.2. Thuc n v m: - t hoc bi hu mn, c tc dng che ph, bo v nim mc bi tr, chng vim, gim ph n v bi trn cho phn i qua d. 4.1.3. Thuc lm tng trng lc, bn vng thnh mch: - Daflon, Ginkor-fort, Cyclofort 3 4.1.4. Cc thuc chng vim v khng sinh ng rut: 4.1.5. Y hc c truyn, s dng di dng:: - Cc bi thuc ung: ho hoa tn, quy t thang, b trung ch kh, t vt o hng, huyt ph trc , t ho lng huyt, thanh nhit nhun to . - Thuc ngm tr: bt tam hong (hong lin, hong b, hong ng). - Thuc bi ngoi: kh tr tn, kem bch ng n, cao sinh c (ngh, qui v, l ph dung, hong b, ngu tt) . - Chm cu: s dng cc huyt: ton trc, yn khu, ngn giao, bch hon du, trng cng, tha sn . 153

4.1.6. Th dc liu php, i tin theo np nht nh, trnh ngi lu, ngm ra hu mn nht l sau i tin. 4.2. iu tr bng cc th thut: Thng p dng cho tr I, II c chy mu. 4.2.1. Nong dn hu mn bng tay theo phng php Lord 1969. iu tr ngoi tr cho bnh nhn tr I khng c sa bi tr, kt qu tt 30 - 50% 4.2.2. Tht bi tr bng vng cao su theo phng php Barron - 1963: Qua ng soi hu mn, dng my ht bi tr v t mt vng cao su vo c bi tr s gy nght, thiu mu cc b, hoi t v rng sau 5-7 ngy iu tr ngoi tr cho tr ni I, II kt qa tt 40 - 50% 4.2.3. Tim thuc gy x ho bi tr: Khi a thuc vo t chc di nim mc s kch thch gy phn ng vim lm x ho, nim mc v h nim mc dnh chc vi nhau. Kt qu trnh xut huyt, chy mu v sa bi tr. Cc thuc s dng: dung dch Quinin ur 5%, dung dch phenol 5% pha trong du hnh nhn, cn 70%, huyt thanh nng, Aetoxisclerol (Polydocanol, ethanol), Kinurea, Anusclerol, PG 60, tiu linh tr. 4.2.4. p lnh (Lewis 1969) bng Nit lng: - Di tc dng ca nhit thp (- 1960C) gy cho cc bi tr b ho bng, hoi t lnh, x ha v teo i. 4.2.5. Tht bi tr bng ch khng ct: Kp tht tn gc bi tr, sau 5 - 7 ngy hoi t v rng. Hin nay t dng v sau tht bnh nhn rt au. 4.2.6. Tia hng ngoi (Neiger 1979; infrared thermocoagulation) Chiu tia hng ngoi vo vng bi tr lm ng c nim mc v bi tr 4.3. iu tr phu thut: p dng cho tr III, IV, tr iu tr bng cc ph ng php khc khng kt qu 4.3.1. Ct b bi tr: - Phu tch cc bi tr, tht v ct tn gc, c th ct mt bi, hai bi, ba bi S dng cho cc trng hp c 3 bi tr n l cc v tr thng gp l cc phu thut: * Phu thut Milligan - Morgan 1937( ct bi tr tn gc, ng vt m): Ct 3 bi tr v tr thng gp 3gi, 7 gi, 11 gi t th sn khoa, bt u t mp hu mn ti tn gc. Ct b bi tr v t chc ph, tht gc, ng vt m v li gia cc bi l mt cu da-nim mc. y l phng php hay c p dng. * Phu thut Parks 1956 (ct tr di nim mc): Bc tch t chc tr di nim mc, ct, tht bi tr, li vt da nim mc ph bi tr, sau m d to thnh cc vt da tha hu mn. 154

* Phu thut Ferguson 1959( Ct tr khu kn): Thc hin nh phu thut Milligan - Morgan nhng vt m c khu kn, nn d p xe v vim nhim vt m. 4.3.2. Ct b ton b vng tr: p dng cho cc trng hp tr vng, tr c sa nim mc trc trng, hu mn - Phu thut Whitehead 1882: ct b vng nim mc tr b sa, khu ni phn nim mc trc trng v da ng hu mn. y l phu thut trit trong iu tr tr, nhng gy mt mu nhiu trong m sau m c cc bin chng v di chng: i tin mt t ch (khng gi c phn, hi) so vng gy cht hp hu mn, ln nim mc gy tit dch v m t hu mn. Phng php t c p dng v b lng qun. Mt s tc gi: Buie - 1932, Toupet - 1969, Rand - 1969, Chen - 1979, Wolff - 1988,. ci tin phu thut ny khc phc cc bin chng trn v mang li kt qu tt. - Phu thut ct b vng tr vi dng c t to bnh vin 103: s dng dng c hnh tr lm nng ta, ch ta ko vng nim mc tr, dy cao su ga r cm mu tm thi vi tc dng: To ln trng m bn ngoi ng hu mn, bt kn ngn trc trng khng thng vi vng m, c im ta bc l vng nim mc tr, c im t rch ct v phu tch, c nng ga r cm mu v m bo ng knh ng hu mn c nh khi khu ni, gim t l hp hu mn. y l phu thut t chy mu trong m, thi gian m ngn, ch ng thao tc k thut ct b, to din ct trn phng, ti to li ng hu mn c tit din ph hp vi sinh l hu mn, khng gy tn thng c tht, trnh c cc nhc im ca phu thut Whitehead. Phng php m ny an ton, n gin, kt qu iu tr tt, c ng dng nhiu c s phu thut tuyn bnh vin (Nguyn Vn Xuyn - 1991). - Phu thut Longo - 1998: ct b vng nim mc tr trn ng lc v khu ni bng my (Stapling procedure), s dng my khu ni PPH (Procedure for Prolapse and Hemorrhoids). Hin nay phu thut ny ang c ng dng nhng gi thnh cao cho 1 ln phu thut v cha nh gi c kt qu xa.

155

p XE quanh Hu mn- R hu mn
PGS.TS Nguyn Vn Xuyn 1. Nguyn nhn v bnh sinh: 1.1. Nguyn nhn: Nguyn nhn chnh l nhim khun do cc vi khun gy m nh: Coli, t cu, lin cu khun . 1.2. S xm nhp ca vi khun qua lp nim mc da mng ca ng hu mn: - Do chn thng (nt k, xy st, lot) - Vim bi tr, vim cc hc tuyn Morgagni. 1.3. ng xm nhp: - n bng ng mu - n do lan trn theo ng bch mch t nng vo su - Theo cc th c ca lp c dc trc trng - Theo cc mao mch ca m ri tnh mch hu mn. - Theo cc ng tuyn hu mn: c Hermann - Desfosses - 1880 m t v xc nhn. 1.4. Tin trin ca nhim khun din bin qua 3 giai on: Thuyt nhim khun hc tuyn ca p xe v r hu mn do Lockhart Mummery - 1929 xut - Giai on u: vim ty cc hc Morgagni, cc ng tuyn, to nn l r trong v t y qu trnh vim xm nhp vo cc lp ca c tht. - Giai on p xe: hnh thnh mt p xe khi im (gi l thng tn gc) khoang t bo di nim mc da hoc gia cc lp c tht, p xe ny v vo cc khoang t bo bn cnh, hnh thnh mt p xe th pht. - Giai on hnh thnh ng r: p xe v ra ngoi to thnh l r ngoi, ng r l ng hm vim mn tnh, ph bn trong l lp t chc ht do qu trnh vim mn tnh to nn. p xe quanh hu mn trc trng v r hu mn l 2 giai on (cp tnh v mn tnh) ca mt qu trnh bnh l. 2. Phn loi: 2.1. Cc pxe hu mn trc trng: cn gi l apxe quanh hu mn: - p xe di da v nim mc - p xe gia cc lp c trong thnh trc trng 156

- p xe h ngi trc trng. - p xe chu hng trc trng 2.2. R hu mn: 2.2.1. Theo tnh cht ca ng r: * R hon ton v khng hon ton: - R hon ton: c l r trong v l r ngoi thng vi nhau - R khng hon ton: ch c mt l r thng l l ngoi, cn gi l r cht. * R n gin v r phc tp: - R n gin: ng r i thng v t ngc ngch - R phc tp: ng r ngon ngoo, nhiu ngc ngch, c ch phnh to thnh hnh ti, c nhiu l m ra ngoi ra. ng r c khi i vng v m sang hai bn hu mn gi l r hnh mng nga. * R c bin chng v r khng c bin chng: 2.2.2. Theo quan h vi c tht: * R trong c tht: ng r nng ngay di nim mc da ng hu mn * R qua c tht: - R qua c tht thp - R qua c tht cao * R ngoi c tht cn gi l r trn c tht: 2.2.3. Theo bnh cn: - R thng - R c hiu - R sau chn thng 2.2.4. Theo mc ca qu trnh vim: - Cp tnh - Thm nhim bn cp - Mn tnh 2.2.5. Theo v tr ca l r trong hoc l r ngoi: - nh v tr ca l r theo chiu quay kim ng h - Na trc, na sau ng hu mn 3. Cc loi apxe hu mn trc trng: 3.1. p xe di da v nim mc: Hay gp nht, chim 50 - 60%, p xe c th nm di da hoc di nim mc ca ng hu mn v di ng lc trong c tht. * Lm sng: - au vng l hu mn nht l khi i tin, i li vn ng kh khn, khi ngi v nm ch bn lnh, nu pha trc thng gy i kh. - Khm thy da vng hu mn ty , gia mm.

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- Thm trc trng thy khi p xe cng phng nm di ng lc, n vo au chi. - p xe c th t v ra ngoi da hay v vo trong lng trc trng. * iu tr: - Rch da ngay trn p xe ch phng nht rch c phn da v nim mc vo tn p xe bc l r y , ct b b vt rch v ly b vt nt hu mn, bi tr, hc tuyn ni xut pht ca p xe. Dng khng sinh kt hp ... 3.2. p xe gia cc lp c trong thnh trc trng: - L nhim trng cc hc tuyn lan ln trn qua lp nim mc v gia cc lp c ca thnh trc trng. * Lm sng: - Bnh nhn c cm gic tc nng hoc au tc vng hu mn nht l khi co tht c tht hu mn. - Ton thn c st. - Thm trc trng thy mt khi phng mm au. * iu tr: - M ng hu mn nhn thy r p xe v rch dn lu m ngay trn thnh trc trng ng rch phi rng cho n da ra hu mn m bo dn lu c tt. Phu thut n gin nhng c hai kh khn: Trng m hp, ng tc k thut kh. D chy mu v cm mu kh. Dng khng sinh kt hp. 3.3. p xe h ngi trc trng: - Chim khong 25 - 30% cc loi p xe hu mn trc trng, m nm h ngi trc trng c th lan rng ra t chc xung quanh, hoc lan sang bn i din hnh thnh p xe mng nga hoc lan ln trn ti tn t chc chu hng trc trng. p xe thng su v c kch thc ln. * Lm sng: - au tc vng h ngi trc trng khng dm ngi, nhn thy mng bn p xe ph n, da vng h ngi trc trng ty . Thm trc trng thy bn tn thng au v c th thy mt khi phng n hi. Ton thn st cao. * iu tr: - Rch dn lu p xe di 2 - 3cm ngay nh p xe thy m tro ra di p lc, cho ngn tay vo thm d. Sau tip tc rch da ko di hng ng tm n l hu mn ngoi c tht n ni ngun gc gy p xe. Dng khng sinh kt hp. 3.4 . p xe chu hng trc trng: p xe nm trn c nng hu mn, nguyn nhn thng do nhim khun cc c quan tit niu sinh dc vng chu hng b hoc nhim khun m xa lan ti. * Lm sng: Bnh nhn trong tnh trng nhim khun nng v au su trong chu hng b, kh khn khi i tin v tiu tin. Thm trc trng thy mt

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khi phng mm cao, pha thnh bn ca trc trng. Khm bng thy vng h v cng au i khi nhm vi vim rut tha. * iu tr: Chch tho m p xe qua thnh trc trng tng t nh chch dn lu p xe Douglas. Dng khng sinh kt hp. 4. R hu mn: 4.1. Lm sng v chn on: 4.1.1. L do n khm bnh: Thng bnh nhn n khm vi triu chng: - Chy m hoc nc vng tng t cnh hu mn, ri t khi hoc sau iu tr mt thi gian li b li. - Nga dai dng vng hu mn. - i khi x hi, hoc phn qua l r ngoi - Tin s c p xe quanh hu mn trc trng c iu tr hoc khng c iu tr t v ra. 4.1.2. Khm lm sng: - Nhn: Thy nt sn si ang chy m, dch vng, hoc kh c vy, gn hoc xa l hu mn, xc nh v tr l r ngoi theo mt ng h v t th khm. - S nn: qua thm trc trng thy mt m cng chc, to nh, di ngn, n au v xc nh s b c hng i ca ng r, mc ca thng x. - Thng, thm ng r bng dng c ch nn lm trong khi m, khng nn lm trc khi m v gy au v d bin thnh ng r phc tp do que thng lc ng. - Soi hu mn: c th nhn thy mt nh li ln, hc hu mn b vim thng l l r nguyn pht. 4.1.3. Cc bin php xc nh cu trc v hng i ca ng r: * Tm l r ngoi: Quan st hnh thi l r ngoi: v tr, s lng, khong cch vi mp hu mn, b l bng mt da hay cao hn, u n hay g gh, lot hay khng lot, mu sc da xung quanh, mt , chy dch. * Xc nh l r trong (l r tin pht): p dng nh lut Goodsall S - 1900: nu k mt ng thng ngang tm hu mn t im 9 gi n 3 gi t th sn khoa: - Nu l r ngoi nm na trc ng ngang th l r trong nm v tr tng ng trn ng lc, ng r i theo hnh nan hoa vo tm hu mn v thng l ng r n gin. - Nu l r ngoi nm na sau ca ng hu mn th l r trong nm ng chnh gia sau trn ng lc (im 6 gi), ng r i theo hnh vng cung v thng l r phc tp, c th c nhiu l r ngoi. 159

- Quy tc ny c p dng trong thc t lm sng ng cho 80 - 90% s trng hp. Nesselrod - 1949 cho rng cu trc ca m ri bch mch xung quanh hu mn ra ng gp thng i quanh vng trn ng hu mn t sau ra trc theo kiu ch U, tnh trng nhim khun xut pht t cc hc tuyn, ng tuyn lan theo ng ny.

Hnh 2: nh lut Goodsall - 1900

* Bm hi, cht mu, nc qua l r ngoi xc nh l r trong: Thng bm qua l r ngoi dung dch xanh Methylen ri quan st trn ng lc, thy cht mu chy qua l r trong. * Chp X quang ng r c bm thuc cn quang: Gip cho vic chn on ng i, cc nhnh ca ng r v xc nh c r c thng vo trc trng. *. Siu m ni soi hu mn trc trng: nh gi c mi lin quan gia ng r v h thng c tht. 4.1.4. Khm xt ton thn: Nhm pht hin mt s bnh l nh: lao phi, Crohn, ung th i trc trng m r hu mn ch l mt biu hin ph. Nn lm xt nghim gii phu bnh l ng r xc nh ngun gc t chc hc l vim mn tnh hay vim c hiu. 4.1.5. Chn on phn bit: * Bnh Verneiul (bnh vim da m): L vim m cc tuyn b da vng quanh hu mn, to nn nhiu apxe nh mt din rng, lan trn di da trn cn nng. * Bnh vim m tuyn m hi (Hidradenitis suppurative): L bnh l ca tuyn m hi hnh thnh do vim m tuyn m hi cnh hu mn, khng c l r trong ng lc. * Bnh xoang lng (Pilonidal sinus): Bnh ny cng c ng r y chu, nu lun que thm thy cc l khc nhau trong vng cng ct v c th thy cc si lng trong xoang. * Bnh Crohn (bnh u ht - Granulomatous disease):

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Bnh Crohn hu mn, trc trng hay c bin chng r. Chn on phn bit bng gii phu bnh c ht xm, khng c t bo khng l v c ht hoi t b u. * R do ung th trc trng: Thm trc trng thy c u si v mu theo tay. * Cc r i trng y chu: Pht sinh do vim ti tha i trng chu hng c bin chng thng gy r ra vng quanh hu mn, phn bit bng chp Xquang ng r.Ngoi ra c th do vim xng chu , p xe tuyn tin lit. * R niu o y chu, trc trng y chu do chn thng: Thng xy ra sau mt chn thng, vt thng vng y chu. * R do lao: C thi gian mc bnh ngn (3 - 6 thng), nhiu l r ngoi, l r rng, mm, b nham nh, y nht nht, nhiu ngc ngch, da xung quanh c mu tm, c vt lot, nu c vt m th lu lin, chy dch m thng xuyn mu xm, tc lng mu cao, ang b lao c quan khc (thng l lao phi). 4.2. iu tr: 4.2.1. Nguyn tc phu thut: * Phi tm c l r trong, thng nm trn ng lc: - Da vo nh lut Goodsall - Bm xanh Methylen, hi, nc qua l r ngoi * Phi tm c ng ng r, khng c to nn mt ng gi do dng que thm, tm t l trong tm ra, phn bit c l ngoi tin pht v cc l th pht. * Ct b ng r v t chc x quanh ng r, bin ng hm thnh ng ho m l thin ton b. * Sau m phi m bo thay bng, sn sc vt m lm cho lin vt m t y ln mt, t su ra nng. * C gng bo tn chc nng c tht hu mn ti a, c th ct mt phn c tht nhng phi ct thng gc vi th c, chiu cao di 1 cm v ch mt v tr. 4.2.2. Mc tiu ca iu tr phu thut: - Khng ti pht. - Rt ngn ngy iu tr. - Nn khi mt th. - Trnh tai bin sn phn v cht hp hu mn. 4.2.3. Cc phng php phu thut: * Rch m ng r: Rch ng r theo chiu dc t l trong n l ngoi, p dng cho r trong c tht (r nng, di da v nim mc). 161

* Ct b ng r v t chc x quanh ng r: - Phng php Cabani: ch khu li mt phn nim mc v c tht, hay c p dng v bo m nguyn tc m r. - Phng php Cuno: ct l r bc tch v ko nim mc trc trng xung che ph, hin nay t dng. - Phng php Chassaignac: khu ton b ng ct t su ra nng, hin nay khng p dng v khng ng nguyn tc m r hu mn. * Tht dn ton b c tht: Sau khi ct m ng r pha ngoi v pha trong c tht , lun dy cao su hoc 7 si ch nilon qua l r ngoi v l r trong m quanh c tht ngoi, ri tht dn, dy tht s ct dn ng r, mc ch cho cc th c tht b ct t v lin li dn dn, ngoi ra cn c tc dng dn lu ng r.

162

Si ng mt ch
PGS.TS. L Trung Hi 1. i cng Si ng mt ch (OMC) l bnh thng gp nc ta. Nhng nm trc y si OMC chim ti 80-90% trong tng s si mt, Nhng nm gn y do t l si ti mt ngy cng gia tng, lm t l si OMC gim ng k, khong 50-60%. Nhn chung bnh l si ng mt ch Vit Nam rt phc tp khc vi si ng mt ch cc nc u M (ch yu l si Cholesterol v di chuyn t ti mt xung). Si ng mt ch Vit Nam thnh phn ch yu l sc t mt, nhn l xc hay trng giun a. Yu t giun ln ng mt v nhim trng ng vai tr quan trng trong c ch hnh thnh si. 2. Triu chng 2.1. Triu chng c nng 2.1.1. au vng h sn phi: - Thng au ln ln, chng mng. - au lan ln vai phi hoc ra sau lng. - Sau khi n au cng tng hn (do kch thch ng mt co bp mnh). - Cn au ko di c khi 2 - 3 gi. 2.1.2. St: - Xy ra ng thi hoc vi gi sau khi au. - St cao 39 - 400C km theo rt run v v m hi. 2.1.3. Vng da v nim mc mt: L triu chng ch yu xut hin mun hn, lc u ch vng nh cng mc mt ri dn dn vng thm c da v nim mc. C 3 triu chng: au, st, vng da (tam chng Charcot) din ra v mt i theo mt trnh t thi gian l c im ni bt ca si OMC. Nu b bnh t lu th trong tin s bnh nhn c th c nhng t au, st, vng da nh vy hoc c tin s giun chui ng mt hay m mt c. 2.1.4. Cc triu chng khc: - Nn: i km theo au. - Nc tiu t v thm mu nh nc vi, thng xut hin sm. - i khi c phn bc mu do tc mt hon ton. - Nga ngoi da do nhim c mui mt (t gp). 2.2. Triu chng ton thn

163

C v mt nhim trng: mi kh, li b bn, mt mi, gy st mch nhanh. Da nim mc vng. 2.3. Triu chng thc th - Ti mt cng to: c khi ni ln dui b sn phi nh qu trng g, s thytrn, nhn, u, n rt au, di ng theo nhp th. T l s thy ti mt cng to t 30 - 35%. - Gan to di b sn 2 - 3 khot ngn tay, n au. - im au: n im ti mt, im cnh c phi hoc c vng t ty rt au, thng c phn ng thnh bng vng h sn phi. 2.4. Triu chng cn lm sng 2.4.1. Xt nghim mu - Bch cu tng, bch cu a nhn tng. - Tc mu lng tng t 50 - 100 mm trong gi u. - Bilirubin tng cao (bnh thng di 17 micromol/l) nht l Bilirubin trc tip. - SGOT tng nh. - Ur v creatinin mu tng cao nu nh hng ti thn. 2.4.2. Nc tiu: C nhiu sc t mt v mui mt. 2.4.3. XQuang: - Chp bng khng chun b: Bng gan to, i khi pht hin c si ti mt (si Cholesterol). - Chp ng mt vi cht cn quang: Hin nay t p dng. Chp ng mt bng ng ung hoc tim tnh mch cc thuc cn quang: cho kt qu thp (40 - 50%). - Chp ng mt qua da: + Ch nh cho nhng bnh nhn tc mt m ng mt dn to. + Cho thy hnh nh ng mt, v tr v kch thc si. Ngoi ra cn c tc dng dn lu dch mt ra ngoi. T l t kt qu cao 86 - 90%. Tuy nhin cn c mt s tai bin nh: vim phc mc mt, trn mt vo mu gy sc mt v chy mu ng mt v vy phi c tin hnh c s ngoi khoa v thng ch chc trc khi m. Hin nay chc ng mt bng kim nh (kim Chiba) di hng dn ca siu m mang li hiu qu tt, t tai bin. - Chp ng mt ngc dng qua soi t trng- Oddi: cho thy hnh nh ng mt v ng ty, xc nh c v tr si, kho st vng bng Vater, phn bit ung th vng bng Vater, c th kt hp ct c vng ly si OMC. T l thnh cng khong 90-95%. 2.4.4. Siu m: L phng php c gi tr cho thy si mt (v tr, kch thc), gip xc nh c kch thc ng mt, ti mt. Hnh nh siu m in hnh ca si ng mt ch l hnh m m c bng cn nm trong ng mt ch. y l

164

phng php khng nguy him, cho kt qu ng 95% v c p dng rng ri trong chn on cc bnh gan mt. 2.4.5. Chp ct lp vi tnh: Cho thy cc hnh nh ca gan, ng mt, ti mt v ty. N c bit c gi tr trong vic pht hin cc tn thng nh gan v ty. Vi loi CT xon gip vic chn on chnh xc hn nhiu. 2.4.6. Chp cng hng t ht nhn: Gip thy r cc ng ng trong cy ng mt ty. Phng php ny c u im hn so vi chp mt ty ngc dng qua soi t trng ch l bin php khng phi can thip v khng phi s dng thuc cn quang, tuy nhin n n thun ch chn on hnh nh, khng ging nh chp mt ty ngc dng qua soi t trng c th can thip v sinh thit khi cn. 3. Din bin v bin chng Si ng mt ch c th din bin theo 2 cch: 3.1. Khi tm thi: Si ng mt ch ngoi thi k tc mt cp tnh c th n nh tm thi (mc d si vn tn ti trong OMC). Bng cc bin php iu tr ni khoa: Khng sinh, thuc chng co tht, li mt th mt s trng hp mt s lu thng: Ht au, ht st, v vng da cng gim dn ri ht hn. Thi gian n nh di hay ngn ty theo s di chuyn v tr, kch thc si v tnh trng nhim trng ng mt. 3.2. Bin chng: Nhng bin chng cp tnh gm: 3.2.1. Thm mt phc mc (hay gp): Do mt ng trn ch tc ca OMC s thm qua thnh ng mt, nht l thm qua ti mt vo bng. Khm bng thy c phn ng thnh bng nht l na bng phi. 3.2.2. Vim phc mc mt: Do v ti mt hoc thng 0MC. Thng nng, do dch mt v vi khun vo bng gy nn nhim trng phc mc. Khm thy co cng thnh bng v cm ng phc mc r. 3.2.3. Vim m ng mt v p xe gan ng mt: - Do ng mt v nhim trng gy nn vim m ng mt: dch mt en c, mi thi v ln m. - Sau hnh thnh nhiu p xe nh ri rc gan, thng gan tri. Bnh nhn c st cao, rt run, gan to v au ... 3.2.4. Chy mu ng mt: Thng do si v p xe gy lot thnh ng mt lm ng mt thng vi mch mu trong gan. Bnh nhn nn ra mu hoc a phn en nht l trong cht nn c cc mu ng hnh thi bt ch (du hiu Foldarri). Chy mu thng ko di, dai dng v thnh tng t. 165

3.2.5. Vim ty cp do si mt: Do si on cui OMC hoc si cht vo c Oddi. C Amylaza mu v nc tiu tng cao, im sn tht lng au. 3.2.6. Vim thn cp si mt (Hi chng gan thn): i t, v niu, ur v creatinin mu tng cao, vng da tng dn. Tin lng nng, t l t vong cao ti 60%. 3.2.7. Sc nhim khun ng mt: Bnh nhn c hi chng tc mt, st cao dao ng, mch nhanh nh > 120l/p , huyt p tt, cy mu c vi khun ch yu l Gram m. T l t vong cao: 50-90%. * Cc bin chng mn tnh: - Vim ng mt. - Vim ty mn. - X gan mt. 4. Chn on 4.1. Chn on xc nh: Vi cc trng hp in hnh th chn on xc nh d dng vi cc triu chng lm sng, cn lm sng nu trn, trong ch yu da vo: - au h sn phi, st cao, vng da (tam chng Charcot). - C tin s si mt. - Ti mt cng to. - Bch cu tng cao, Bilirubin mu tng ch yu l trc tip. - Siu m v chp mt ty ngc dng qua soi t trng- Oddi hoc chp ng mt qua da thy hnh nh si mt. 4.2. Chn on phn bit: 4.2.1. Ung th u ty: Khng au, khng st, vng da tng dn, vng rm, bch cu tng t hoc khng tng. X quang: khung t trng dn rng. Siu m: kch thc u ty to. Chp CT cho thy hnh nh u u ty 4.2.2. Ung th bng Vater : da vo siu m, CT- scanner hoc chp ng mt qua da. 4.2.3. Ung th ng mt: da vo siu m, chp mt qua da v CT- scanner. 4.2.4. Vim gan virut: Xt nghim mu: bilirubin gin tip tng cao, bch cu tng t hoc khng tng, SGPT, SGOT tng, marker vim gan (+). 4.2.5. Lot hnh t trng thng vo ty: Cng c th gy au d di nh trong si mt, nhng khng c st, khng c vng da, chp d dy c hnh nh lot. 4.2.6. Si ti mt: khng vng da, khng c du hiu tc mt. Siu m c gi tr chn on. 5. iu tr 166

5.1. Nguyn tc v ch nh m - iu tr si OMC l phu thut nhm ly si, to s lu thng mt rut v dn lu tnh trng nhim trng ng mt. iu tr ni khoa ch chun b cho iu tr ngoi khoa t c kt qu tt. - Thng thng vi si OMC nn m c k hoch, trc m c iu tr ni khoa gm: khng sinh, li mt, gin c trn ng mt, truyn dch, in gii. - Cc trng hp m c chun b v m trong giai on n nh th kt qu tt hn, bin chng v t vong sau m t hn. - Tuy nhin nu sau iu tr ni khoa t 24-48 gi m tnh trng nhim trng v tc mt khng th cn can thip phu thut sm. 5.1.1. Ch nh m cp cu: - Vim phc mc mt. - Thm mt phc mc. 5.1.2. Ch nh m cp cu tr hon: - Chy mu ng mt do si: iu tr ni khoa l ch yu (truyn mu, khng sinh) song nu chy mu nhiu ln hoc tnh trng bnh nhn khng n nh phi m ly si, d vt v ra ng mt. Nu do chy mu t ti mt th ct ti mt, nu do p xe gan th ct phn thu gan, nu khng r nguyn nhn th tht ng mch gan ring. - p xe ng mt do si. - Vim ty cp do si mt. 5.1.3. Vi trng hp c bin chng nng Sc nhim khun ng mt (thng b vim ng mt m nng), vim thn cp do si mt phi c hi sc tt ri m sm v ch can thip ti thiu. 5.2. Phu thut - M OMC (on trn t trng) ly si, d vt. - Ra ng mt bng huyt thanh, ch bm ra c ng mt trong gan ly si trong gan. - Kim tra s lu thng ca OMC vi t trng bng thng Benique v chp ng mt trong m. - Dn lu ng mt: thng thng dn lu OMC bng ng Kehr, nhm mc ch: dn lu dch mt nhim trng, ra Kehr sau m, chp kim tra ng mt qua Kehr sau m. Trong mt s trng hp c th khu kn OMC (khng t dn lu Kehr) nu c ni soi ng mt kim tra trong m xc nh ht si v ng mt thng tt xung t trng. 5.3. Chm sc theo di bnh nhn sau m - Theo di lng dch mt qua Kehr: S lng, mu sc, tnh cht, mi. - Theo di ng dn lu di gan.

167

- Kp th Kehr vo ngy th 7-10 sau m, nu khng au, st th chp kim tra qua Kehr. - iu kin rt Kehr: th trng kh, khng st, n ung ngon ming, dich mt trong, cp th Kehr 2-3 ngy n nh. Phim chp kim tra qua Kehr cho thy ng mt bnh thng, khng c si v d vt, thuc lu thng xung t trng tt. - Rt Kehr trung bnh sau m t 12-14 ngy. 5.4. Cc bin chng sau m 5.4.1. Chy mu sau m - Thng do cm mu khng k, hay gp nhng trng hp m li nhiu ln, phi g dnh nhiu. Theo di ng dn lu di gan: nu mu chy trn 100 ml m vn cn tip tc chy th phi m li ngay cm mu. - Chy mu ng mt do t Kehr qu lu hoc ng Kehr to c st ng mt. Phi ra ng Kehr bng huyt thanh m, nn rt Kehr sm trnh c st. 5.4.2. R mt sau m - Nu mt chy vo bng gy vim phc mc ton th phi m li lau ra bng, dn lu. - Thng mt theo ng dn lu di gan ra ngoi, sn sc tt c th s lin. 5.4.3. St si sau m L bin chng hay gp sau m khi chp kim tra Kehr hoc siu m ng mt thy cn si trong ng mt ch. Nguyn nhn thng do m cp cu ly khng ht si hoc si trong gan qu nhiu di chuyn xung. Vi cc trng hp si bn, si nh, iu tr bng bm ra huyt thanh mn nhiu ln qua Kehr. Hoc dng phng php Pribram (2/3 ete v 1/3 cn 900), vi trng hp si ln phi m li ly si. Hin nay p dng ly si st qua ng hm Kehr hoc ly si xuyn gan qua da. 5.4.4. Ngoi ra c th gp cc bin chng khc nh vim ty cp, sc nhim khun, suy gan, suy thn, r t trng v r i trng sau m r mt sau m (nht l khi m li nhiu ln, bc tch dnh kh khn). 5.4.5. V lu di hay gp si mt ti pht. 5.5. Phng php iu tr ly si bng ni soi can thip - Ly si qua ng ni soi t trng ngc dng: tin hnh ct c vng Oddi ly si ng mt chnh. Phng php ny thng c p dng cho nhng bnh nhn si mt ti pht, c th s dng cho nhng bnh nhn cha m mt ln no v nhng bnh nhn gi yu vi t l thnh cng t 70-80%. - Ly si qua da: c th ni soi ly si qua ng hm t Kehr hoc ly si xuyn gan qua da vi s h tr ca my tn si in thy lc. Phng php ny thng c p dng cho nhng bnh nhn st si sau m hoc cc bnh nhn si mt ti pht.

168

Vim ti mt
PGS.TS. L Trung Hi 1. i cng 1.1. Gii phu Ti mt hnh bu dc nm st mt di gan. Phn c ti mt tip ni vi ng ti mt, ng ny nh, thng vo b phi ca ng gan chung. 1.2. Sinh l: Ti mt c hai chc nng: chc nng cha mt v c c mt li. Bnh thng ti mt cha t 30 90 ml, khi c hin tng tc mt th ti mt cn cha nhiu hn. 2. Nguyn nhn vim ti mt 2.1. Vim ti mt do si Hay gp cc nc u, M (85%). Thng gp nhng bnh nhn bo, tui trn 40, n nhiu hn nam. Vit Nam trong nhng nm gn y, t l si ti mt gia tng ng k, chim t 22-36% tng s si mt, c lin quan n vic p dng rng ri siu m chn on v mc sng ca nhn dn ngy cng tng. 2.2. Vim ti mt khng do si Vim ti mt nhng ngi gi yu, ph n c thai, vim ti mt do vi khun thng hn, vim ti mt sau chn thng, sau m ln hoc b bng din rng. 2.3. Vim ti mt do tc ng mt ch do si (ti mt c th c si hoc khng c si) Vit nam gp ch yu do si sc t mt. Giun ln ng mt v nhim khun ng mt l nhng yu t quan trng trong vic hnh thnh si. 3. Triu chng vim ti mt do si 3.1. Lm sng: - au h sn phi thng xy ra vo ban m, lan ra sau lng v ln b vai phi. - St. - Chn n v kh tiu (30%), chng bng hi, bun nn, s m i khi i ngoi phn lng. - Khng c vng da tr khi si ti mt km theo si ng mt. - Khm: au im ti mt, du hiu Murphy dng tnh gp trong vim teo ti mt (thy thuc t tay vo im ti mt, khi bnh nhn ht vo su th bnh nhn s cm thy au). 169

- C th s thy ti mt (nht l khi ti mt b dch cng to hoc trong tc mt) 3.2. Cn lm sng: - Chp bng khng chun b: C th thy hnh cn quang trn hay bu dc vng ti mt. trn phim nghing hnh ny trc ct sng. -Chp ti mt v ng mt bng ung thuc cn quang sau ba n Boyden hay tim tnh mch, pht hin si v hnh nh ti mt ng mt - Siu m: L bin php c gi tr pht hin si v cc hnh nh tn thng ca ti mt v ng mt. Hnh nh siu m ca si ti mt l hnh tng m c bng cn, xung quanh hnh si l hnh long m (dch mt) to nn mt nn tng phn v hnh si ny di chuyn khi thay i t th bnh nhn thnh ti mt dy trn 4mm t l chn on chnh xc t 90-95%. - Chp ct lp vi tnh : gip pht hin si v hnh nh ng mt. - Mt s xt nghim khc : bch cu tng, cng thc bch cu chuyn trI, bilirubin mu tng trong nhng trng hp vim ti mt do si ng mt gy tc mt 4. Chn on 4.1. Chn on xc nh Da vo cn au qun gan, n au im ti mt, du hiu Murphy v nht l hnh nh siu m m m c bng cn nm trong ti mt. 4.2. Chn on phn bit 4.2.1. Lot d dy t trng 4.2.2. Vim rut tha cp 4.2.3. Vim ty cp 4.2.4. Cn au qun thn 4.2.5. Vim phn ph 5. Mt s th lm sng khc 5.1. Vim ti mt ngi cao tui, ph n c thai. Do sc khng km, vi khun ch yu do E. Coli v cc vi khun ng rut. Tin lng nng. 5.2. Vim ti mt do thng hn. t gp (1%), thng vi khun thng hn c th gy vim ti mt tun th ba ca bnh. 5.3. Vim ti mt sau m, sau chn thng hoc bng nng. Thng gp ngi tr. Nguyn nhn c th do nhim khun, do m t, do tro ngc dch rut vo ti mt, do ri lon ng mu hoc cc men. Cc trng hp ny chn on kh, thng da vo siu m. 6. iu tr 6.1. Nguyn tc.

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Nu vim ti mt do si th phi phu thut ct b ti mt. nhng bnh nhn cao tui cha c bin chng th c th iu tr ni khoa. 6.2. iu tr ni khoa. - Ngh ngi chm vng ti mt. - Dng khng sinh, gin c trn , li mt, an thn. 6.3. iu tr phu thut. 6.3.1. M ct b ti mt l ch nh thng thng nht, hin nay t khi m m m thng tin hnh m ni soi ct ti mt. M ni soi c nhiu u im nh: phu thut t tnh thm m cao, thi gian phc hi sau m nhanh, gy sang chn ti thiu, gim r rt au n sau m, gim bin chng nhim khun vt m v dnh rut sau m, thi gian nm vin ngn. 6.3.2. Ly si, dn lu ti mt ch khi ti mt khng vim nng v bnh nhn gi yu, suy kit nng hoc c cc bnh kt hp nh i tho ng, x gan, lao phi, bnh tim mch m khng ct b ti mt c. 6.4. Sau m. Cn ch theo di cc bin chng chy mu, hp ng mt ch, r mt sau m.

171

Chy mu ng mt
PGS.TS. L TrungHi 1. i cng Chy mu ng mt c Francis Glisson m t ln u tin nm 1654. Chy mu ng mt l mt cp cu ngoi khoa hay gp trc y. Chy mu ng mt thng do s thng thng bt thng gia ng mt vi cc mch mu (ng mch gan, tnh mch ca, hoc tnh mch trn gan) 2. Nguyn nhn 2.1. Chy mu ng mt do chn thng. Nhng chn thng gan lm v mch mu v ng mt trong gan. 2.2. Chy mu ng mt do nhim trng ng mt. Hay gp cc nc chu , Vit Nam chim 1/3 s chy mu ng mt ni chung. Do si, k sinh trng ng mt v p xe ng mt gy ph hy nhu m gan lm thng ng mt v mch mu. 2.3. Chy mu ng mt do tai bin th thut v phu thut. - Chy mu ng mt sau chc d, chp mt qua da, nong ng mt tn si xuyn gan qua da, sinh thit gan lm tn thng mch mu v ng mt trong gan (3-10%). - Chy mu ng mt sau m ly si dn lu Kehr (do ng Kehr to, cng t lu ngy, do nhim trng ng mt hoc c gng ly si trong gan). 2.4. Chy mu ng mt do cc nguyn nhn khc: - Bnh l ca gan: ung th gan, apxe gan. - Bnh l ca mch mu: do phng ng mch b v, t gp. 3. Triu chng 3.1. Lm sng: 3.1.1. Hi chng chy mu ng tiu ha trn: Ch yu l i ngoi ra phn en. Du hiu Foldarri: trong cht nn c cc mu nn hnh thi bt ch (4%) c gi tr chn on. Tnh cht chy mu thng dai dng v ti pht. 3.1.2. St nhim trng St cao 39 40 , rt run (phn bit vi chy mu d dy) 3.1.3. au h sn phi. Cn au xy ra trc mi ln chy mu. 3.1.4. Vng da. Sau t chy mu tiu ha th vng da 3.2. Cn lm sng: 3.2.1. Xt nghim. 172

- Hng cu, huyt sc t, Hematocrit gim - Bch cu tng, tc mu lng tng, ur mu tng - Bilirubin tng 3.2.2. X quang. - Chp bng khng chun b: bng gan to, phn ng gc sn honh. - Chp ng mch gan chn lc, nht l chp mch mu s ha xa nn (DSA): c gi tr chn on cc trng hp chn thng v bnh l ng mch gan. - Chp tnh mch lch ca: c th thy l r tnh mch ca - ng mt. - Siu m, chp ct lp vi tnh gip thm chn on. 4. Chn on 4.1. Chn on xc nh: - C tin s vng da tc mt - Hi chng vng da tc mt km theo chy mu ng tiu ha. - Chy mu ng tiu ha km theo st, au vng gan. - Xt nghim bch cu tng, bilirubin mu tng. - Siu m, chp CT v chp ng mch gan 4.2. Chn on phn bit: - Chy mu do lot d dy t trng : thng c tin s lot d dy t trng, ni soi chn on xc nh. - Chy mu do K d dy : thng chy mu r r, ni soi sinh thit chn on xc nh. - Chy mu do gin v tnh mch thc qun trong tng p lc tnh mch ca: c tin s st rt, vim gan vi rt, gan x, chy mu t. mu ti, ton trng nng. Bng thng c tun hon bng h, gan lch to, c trng. 5. iu tr 5.1. iu tr ni khoa: - Truyn mu, dch. - Khng sinh, thuc cm mu. - Hi sc tt. 5.2. iu tr ngoi khoa: - Phu thut m ng mt ch ly si, bm ra ng mt bng huyt thanh m, dn lu Kehr. - Tht ng mch gan, nn tht ng mch gan ring nu vn tip tc chy mu. - Chy mu do nguyn nhn ti mt: ct ti mt. - Ct gan nu tn thng khu tr mt thy gan, c phi hp p xe gan nht l thy gan tri . - Hin nay ngoi iu tr ngoi khoa c th tin hnh iu tr nt mch (TOCE) cm mu. 173

p xe gan
TS. ng Vit Dng p xe gan l hin tng c mt hay nhiu m trong t chc gan do nhiu nguyn nhn khc nhau gy nn. Vit Nam hay gp nht l p xe gan do amp v p xe gan ng mt. 1. p xe gan do amp 1.1. Bnh nguyn v bnh sinh:. - Nguyn nhn bnh l do th hot ng gy bnh ca amp (Entam oeba histolytica) gy ra, thng gp sau bnh l amp (Glack 51%). - Trong iu kin bnh thng amp sng hi sinh i trng m ch yu vng manh trng, khi sc khng ca c th gim v thnh rut b tn thng, men ca amp tit ra gy ra cc vt lot nim mc v to nn cc p xe nh thnh i trng, lm tn thng thnh mch, amp chui vo cc mao tnh mch vo tnh mch mc treo trng trn ri theo h thng tnh mch ca v gan. Do lu lng mu ca tnh mch ca phn ln vo gan phi nn trn 80% p xe gan do amp gp gan phi. Ngoi ra amp c th ln gan theo ng bch mch hay di chuyn trc tip (amp chui ra ngoi thnh rut vo bng ri b ht ln vm gan v chui qua v Glisson vo t chc gan). - Theo Roger.S v Blanc.F, amp xm nhp vo gan dng li tnh mch khong ca v sinh sn y lm tc cc nhnh ca tnh mch ny, lm cho gan b vim cng t, xung huyt lan ta dn n gan b ph n t chc v hoi t tng m, gi l m hoi t ca Palme hay cc o hoi t Crall, cc m hoi t nh tp hp li thnh m hoi t ln, thng gp mt ln v gan phi. Nu chc ht giai on ny thng thy mt cht qunh dnh mu nu , soi trn knh hin vi thy ch yu l cc t bo gan hoi t, ln hng cu, c th thy amp v khng c vi khun. Cc cht qunh dnh ny tip tc b cc men ca amp phn hy lm long dn ra v t chc gan xung quanh tip tc b vim hoi t lm p xe to ra. Nu c iu tr kp thi th qu trnh vim hoi t dng li v cht dch c th s c tiu i. 1.2. Gii phu bnh: - Theo Cornet.L, s hnh thnh p xe gan amp v mt tn thng gii phu hc qua 6 giai on: vim gan xung huyt, hoi t, sinh lot, t m, nang ha, v b u ha. - Theo Nguyn Dng Quang, s hnh thnh p xe gan qua 4 giai on: + Giai on vim: khi amp ln gan dng li cc xoang tnh mch sinh sn, gy ra nhng hoi t t bo gan, khi im ca p xe gan. + Giai on p xe hoi t: nhu m gan b hy hoi thnh mt cht qunh m

174

khi xt nghim vi th thy ch yu l t bo gan hoi t, nhiu hng cu v amp, t bch cu a nhn, khng c vi khun, l cht hoi t v khun do amp. + Giai on p xe sinh m: (p xe nhuyn ha), trong nhu m gan hnh thnh hoi t mm nhn, b khc khuu, trong cha cht dch mu nu . Khi xt nghim vi th, Letulle chia p xe thnh 3 vng: vng trung tm c nhiu t chc hoi t, t k sinh trng; vng trung gian c nhiu i thc bo v k sinh trng; vng ngoi vi l m x, mao mch gin v mt s t bo n nhn. + Giai on p xe khu tr: do sc khng ca c th, thnh p xe x cng, m c dn li, sau mt thi gian m long dn v chuyn mu vng nht. - c im ca p xe gan do amp: + Thng gp gan phi (trn 80%). + Thng l mt ln n c (trn 80%). + Thng c xu hng pht trin v pha v gan. + Cu to p xe gan: thnh ngoi l t chc gan x ha, lp trong l t chc nhu m gan ang b hoi t (amp hay sng y), cht m trong p xe thng c mu scla, khng c mi, v trng v t l soi ti m thy amp rt thp (di 15%). 1.3. Triu chng: 1.3.1. Lm sng: * C nng: - St: khi u ca bnh bao gi cng c st, thng st cao 390- 400C, c th st nng, v m hi hoc c cn rt run nn c khi nhm vi st rt. - au vng gan l triu chng xut hin sm v c gi tr. au vng gan lan xuyn ln vng b vai phi v ra pha sau lng, au tng ln khi bnh nhn ho, ht hi hay nm nghing sang phi, bnh nhn thng th nng v th bng ngc. * Thc th: - Gan to c hai chiu: b trn gan ln cao vt qu khe lin sn V ng gia n, b di xung di b sn 2 -3 cm, b thng t, mt nhn, g c v n vo au chi. - Du hiu rung gan (+) l triu chng rt c gi tr. - Du hiu Ludlow (+) (n k lin sn VIII, IX ng nch trc, gia au chi). - Khi p xe nm nng st b mt gan c th thy da vng thnh ngc tng ng b ph n v cc tnh mch di da ni r. * Ton thn: - C hi chng nhim khun, mi kh li bn, mt mi, chn n v gy st cn do tnh trng nhim c bi s hy hoi ca t bo gan v cc c t ca amp. 1.3.2. Cn lm sng:

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* Xt nghim mu: - Bch cu tng trn 10G/L, ch yu tng BC E, nu bi nhim vi khun th N tng. - Tc mu lng thng tng cao v c coi nh mt yu t theo di tin trin ca bnh v c gi tr gp phn chn on phn bit vi cc bnh khc ca gan nh ung th gan, nang gan, u mu gan. - Thi k u ca bnh do tnh trng vim gan lan ta nn c s suy gim chc nng gan, xt nghim thy men gan tng. * X quang: - Nm 1898, Loison x dng x quang chn on p xe gan: + Chp gan xa thy bng gan to + C honh b y ln cao, thng l c honh bn phi + C phn ng xut tit dch gc sn honh phi hay trn dch mng phi. + C th thy hnh nh mc nc, mc kh trong p xe gan khi p xe gan b bi nhim vi khun k kh. + Chiu x quang thy di ng ca c honh b gim. * Siu m: Cho php pht hin v tr, kch thc, th tch, s lng, tnh cht apxe, hn na cn hng dn chc ht m chn on v iu tr. Hnh nh siu m ca p xe gan l mt vng thng tn chim ch trong nhu m gan, thng c hnh trn hay hnh bu dc, cu trc m trong p xe gan ty thuc vo t chc bn trong ha m hay cha. - Giai on sm khi gan ang vim cng t, xung huyt lan ta thy mt vng tng m v cha c ranh gii r rng. - Giai on p xe hoi t: thng l hnh nh hn hp m: ch hoi t th gim m cn ch cha hoi t ang vim cng t th tng m. - Giai on p xe sinh m: hnh nh gim m ng nht, c ranh gii r so vi t chc gan lnh. - Giai on p xe khu tr: hnh nh gim m hay trng m, p xe c ranh gii r vi t chc gan xung quanh, cn phn bit vi nang gan. * Chp CT Scanner: - Xc nh c v tr, s lng, kch thc cc nh ng knh 1cm v t trng ca khi tn thng trong gan t 0 - 20HU, gp phn chn on phn bit gia p xe gan, nang gan v ung th gan. * Soi bng chn on p xe gan: Nm 1970, Kapoor O.P, soi bng chn on v hng dn chc ht m p xe gan amp. Soi bng thy c hnh dng, kch thc, mu sc ca gan, nht l cc p xe gn b mt gan, mt di thng d thy hn l cc p xe mt sau v mt trn ca gan. * ng v phng x (Scintigraphie).

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- Cht ng v phng x thng dng l: Au198 ; I131 ; Tc99. X hnh p xe gan l mt khuyt trong gan - gi l nhn lnh, kh pht hin nu apxe gan nh di 1,5 cm. Tuy nhin cng kh phn bit vi x hnh ca u gan v nang gan. * Xc nh nguyn nhn p xe do amp. - Soi ti m tm amp: t l tm thy amp rt thp: 2,5 - 15,5 % - Xt nghim huyt thanh min dch tm khng th khng amp: c nhy v c hiu cao. Cc phng php: phn ng min dch hp ph gn men (ELISA): hiu gi huyt thanh (+) trn 1/200, min dch hunh quang (IF), min dch hunh quang gin tip (IFA): hiu gi huyt thanh (+) trn 1/400, ngng kt hng cu gin tip, ngng kt latex. 1.4. Chn on: 1.4.1. Chn on xc nh: - Tam chng Fontan: au vng gan, st, gan to au. - Xt nghim mu BC E tng, mu lng tng. - Xquang: hnh nh pxe gan. - Siu m: long m ranh gii r, thng gan phi. - Chc ht thy m mu socola, soi ti thy amip. - Xt nghim huyt thanh min dch tm khng th khng amip (+). - iu tr th bng thuc c hiu c kt qu. 1.4.2. Chn on phn bit : - Apxe gan ng mt: da vo hi chng vng da tc mt, tam chng Charcot, siu m. - Ung th gan: da vo siu m, CT- scanner, xt nghim -FP, sinh thit gan. - Nang gan: khi nang gan bi nhim d nhm vi p xe gan. - Vim ti mt cp. 1.5. Bin chng. 1.5.1.V p xe vo bng: - V vo phc mc gy ra vim phc mc cp. - V vo d dy, rut non: nn ra m mu s c la. - V vo i trng gc gan, ngang: i ngoi ra m. - V vo ti mt hay ng mt. 1.5.2. V apxe vo khoang lng ngc: - V vo khoang mng phi: gy kh th, au lan ln ngc phi do trn m mng phi, chc ht mng phi phi c m mu s c la, khng mi. Hay gp khi p xe gan st vm honh phi. - V vo phi - ph qun: gy ho nhiu, khc ra m s c la, sau t khi m bnh nhn thng hn hay gy ra p xe phi. - V vo mng tim gy hi chng chn p tim, thng din bin nng, gp khi p xe gan h phn thy II, III. 177

trong bng: 1.5.3. V vo vng h thn phi: gy vim ty vng quanh thn. 1.5.4.V ra ngoi thnh bng, thnh ngc: gy ra amp da, hoi t da lan rng, kh iu tr. 1.6. iu tr 1.6.1. iu tr ni khoa: * Thuc c hiu dit amp: - Emtin: tc dng dit amp th hot ng, khng dit c th kn. Emtin thng c vi thn kinh v c tim, nn khi iu tr phi kt hp vi Vitamin B1 liu cao v Strichnin. Cn thn trng khi iu tr bnh nhn gi yu, tr em v ph n c thai. Thuc thng thi tr chm v tch lu lu trong c th nn liu s dng l 10mg/1 kg cn nng/1 t iu tr. - Metronidazole: tc dng tt vi tt c cc th ca amp nn va c tc dng iu tr bnh v phng ly nhim, thuc t c, hp thu nhanh v thi tr nhanh, liu iu tr l 30mg/1 kg/24 gi, t iu tr t 7 - 10 ngy. * Khng sinh phi hp: Vi mc ch chng bi nhim. 1.6.2. iu tr ngoi khoa: Bao gi cng phi kt hp iu tr ni khoa bng thuc c hiu v khng sinh phng bi nhim. * Chc ht m p xe di hng dn ca siu m: - L phng php hin nay c p dng ch yu v ph bin, cho kt qu tt, t bin chng, thi gian iu tr ngn, v cm ch bng gy t ti ch v nh gi c kt qu ngay sau khi chc ht. C th bm ra c apxe, chc ht m mt ln hoc nhiu ln. - Ch nh: p xe gan ho m cha c bin chng, ng knh 4cm, hoc apxe nh nhng iu tr ni khoa khng c kt qu. - V tr chc ht: cc p xe gan h phn thy V-VI-VII-VIII: khe lin sn 7,8,9 ng nch trc hay gia. Cc h phn thy II, III, IV: chc trc tip ngay di mi c, ngay trn b mt ca gan tri. * Phu thut m bng dn lu p xe gan: - Ch nh: khi p xe gan c bin chng v m vo phc mc gy vim phc mc ton th hoc khi iu tr bng cc phng php khc khng thnh cng. - Nhc im: y l phu thut ln, thi gian iu tr thng ko di, dn lu h nn hay b bi nhim v d m qua chn dn lu. * Rch dn lu p xe ngoi phc mc: - Nm 1938, Ochaser tin hnh u tin - Phng php ny ch c ch nh vi cc p xe gan nm nng st thnh bng. * Phu thut ct gan: ch nh khi p xe mn tnh thnh p xe dy gy d m ko di, iu tr bng cc phng php khc khng kt qu. 178

2. p xe gan ng mt 2.1. Nguyn nhn v c ch bnh sinh. - Si ng mt: thng gp ngi ln, do si lm tc mt v gy vim ng mt dn n lm m v to thnh apxe. - Do giun: hay gp tr em, giun t rut chui ln ng mt gy nhim khun ng mt. - Thc t thng phi hp c si v giun, ngoi ra cn mt s trng hp c nguyn nhn do tht hp ng mt gy ng dn n vim m v apxe. 2.2. Gii phu bnh l - Nhng p xe gan nh nm ri rc nhu m gan, c khi khp c gan phi v tri. - ng mt gin to, c si hoc xc giun, c th c ch tht hp. - apxe: c m long mu trng hoc vng nht, nng mi. C th thy c trng giun. 2.3. Triu chng: biu hin lm sng c tam chng Charcot: au, st, vng da din ra v mt i theo mt trnh t, thnh tng t. * C nng: - au cn h sn phi kiu cn au qun gan. - St cao 39- 40 , st dao ng, rt run. - Da nim mc vng. * Thc th: - Gan to, mt nhn, mt mm. - Du hiu Ludlow (+), rung gan (+). - Ti mt cng to do tc mt. * Ton thn: Th trng suy sp nhanh, c th c sc, suy thn. * Cn lm sng: - Xt nghim mu: BC tng, N tng, bilirubin mu tng ch yu l trc tip. - X quang: chp mt qua da hay qua Kehr thy hnh nh thuc cn quang vo cc pxe nh hnh nh nhng chm hoa bm vo cnh hoa. - Siu m: thy nhiu long m ri rc c hai thu gan. ng mt dn, ti mt cng, to c hnh nh si v giun trong lng ng mt: hnh ng ray ca giun trong lng ng mt. 2.4. Bin chng 2.4.1. V p xe vo bng gy vim phc mc 2.4.2. V apxe vo khoang lng ngc gy trn dch m mng phi, mng tim. Tin lng thng nng hn so vi v p xe gan do amp, t l t vong cao. 2.4.3. Chy mu ng mt: - Tin lng nng n, chy mu ti pht nhiu ln v dai dng, t l t vong cao sau phu thut. 179

- Do vim lan to nim mc ng mt gy chy mu hoc apxe ph hy lm thng thng ng mt vi mch mu trong gan. 2.5. iu tr ngoi khoa. -M cp cu c tr hon, gii quyt nguyn nhn tc mt, ly si, giun, dn lu dch mt nhim khun ra ngoi bng ng Kehr, bm ra ng mt tch cc, kt hp vi khng sinh liu cao, ph rng v kt hp thuc, u tin khng sinh dit vi khun Gram (-). - Khi tnh trng bnh nhn qu nng khng cho php phu thut th ch nh chc dn lu ng mt qua da di hng dn ca siu m gii thot tnh trng tc mt tm thi v bm ra ng mt. - Ch nh chc dn lu p xe ch t ra khi c p xe ln khu tr mt thy hay phn thy gan, gp gan tri.

Ung th gan
PGS.TS. L Trung Hi 1. i cng: Ung th gan gm cc ung th nguyn pht v th pht. -Ung th gan nguyn pht phn ln l ung th t bo gan(Hepatocellular Carcinoma-HCC) hoc t bo ng mt(Cholangio Carcinoma),cn ung th gan th pht l do di cn t ung th ni khc n gan.Trong bi ny ch yu ni v ung th nguyn pht ca gan. -Ung th gan nguyn pht thng gp cc nc nhit i. Vit Nam, ung th gan ng hng th ba sau ung th ph qun v ung th d dy,hay gp nht l ung th t bo gan. 2. Nguyn nhn v iu kin thun li: Nguyn nhn trc tip gy ung th gan cha r rng,c ch gy ung th c cho rng do ri lon cu trc AND ca nhn t bo.C nhiu yu t nguy c c th lm ri lon cu trc gy t bin gen nh: 2.1.Vim gan vi rt: C s lin quan gia vim gan vi rut B v C vi ung th gan nguyn pht. Vit Nam 81% bnh nhn ung th gan c khng nguyn HbSAg(+) (vim gan B) so vi nhm bnh thng l 15%. Theo H.H. Hann2004, 60% ung th t bo gan (HCC) c lin quan ti vim gan B v 25% c lin quan n vim gan C.

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2.2.X gan:Ung th gan thng gp bnh nhn x gan. Vit Nam 52 80% s bnh nhn ung th gan c x gan,t l ny c l 50% v M l 89%, trong a s l x gan do ru. 2.3.Cc cht gy hoi t t bo gan v x gan: -Nm mc Aflatoxin t lc, mc. -Cht c: c bit l cht c mu da cam (Dioxin) lm rng l cy.Tetraclorua carbon,cc cht mu Azo hoc nitrosamin gy c ung th gan trn thc nghim. 2.4.Ch n ung: Thc n mc, ung ru nhiu, ch n d x gan nh t m, nhiu m, t sinh t B1. 3. Gii phu bnh l: 3.1. i th: -Khi ung th mu vng nht hoc trng ni g trn b mt gan c ranh gii tng i r,xung quanh c nhiu mch mu trn nn t chc gan x hoc bnh thng. -C 3 hnh thi:Ung th th khi (thng khu tr ti mt phn gan v trn nn gan khng x), ung th th nhn (thng nhn nm ri rc v trn nn gan x, tin trin nhanh), ung th th lan to ((nh ht k, nm khu tr hoc ri rc, trn nn gan x, tin lng xu). 3.2. Vi th: Hay gp nht l ung th t bo gan(HCC) 89%, ung th t bo ng mt 3,5%. Ung th t chc lin kt ca gan (sarcoma) ch chim khong 1,5%, cn li hn hp ung th lin bo gan v lin bo ng mt l 6%. 4. Triu chng: Bnh gp mi la tui, thng t 30 - 50 tui, hay gp nam gii. 4.1. Lm sng: Cc triu chng nhn chung l ngho nn,rt kh chn on sm nu khng c cc phng tin chn on hnh nh hin i.Khi cc triu chng r thng giai on mun,tin lng nng. 4.1.1. Triu chng c nng v ton thn: -au tc vng gan lin tc. - Chn n, mt mi. - Gy st cn nhanh. - i khi c st nh,st cao khi khi u hoi t hoc p xe ha. -C th gp vng da nh do suy gan hoc khi u lm tc mt. 4.1.2. Triu chng thc th: - Gan to,mt rn chc, b mt ln nhn khng u, n tc khng au, di ng, u to nhanh i khi nghe thy ting thi tm thu trn khi u (11-29%). giai on mun c th gp: - C chng (20- 40%):dch thng ln mu. - Lch to, tun hon bng h, chn ph,vng da. 181

4.1.3. Th lm sng: * Th c khi u: -Khi u gan vi c im nu trn l triu chng u tin v ni bt. * Th ging nh p xe gan: -C gan to, au v hi chng nhim khun ton thn. * Th ging nh x gan: - C th c mt x gan t trc ,hoc hi chng x gan mt b. - Gan to, c trng, tun hon bng h. * Th chy mu trong: - Khi ung th b v do b hoi t gy hi chng chy mu trong. * Th hi chng tng p lc tnh mch ca: - C lch to, c trng,tun hon bng h,nn ra mu. * Th hn m h ng huyt: -Him gp, c th do ung th bi tit ra mt cht tng t insulin. 4.2. Cn lm sng: 4.2.1. Xt nghim mu. - Hng cu gim nh, huyt sc t gim. - Bch cu v cng thc bch cu bnh thng ( chn on phn bit vi cc bnh vim nhim ca gan). - Protein gim, t l A/G di l. - Bilirubin mu c th tng. - Transaminase tng va. - Glucose mu thp (do gim tng hp v d tr Glycogen hoc u c cha cht tng t Insulin). - Men Arginasa trong t chc gan khi ung th gim di 40 n v (bnh thng l trn 120 n v /g t chc). - Men LDH (lactico dehydrogenaza): t l LDH5/LDH1 trn l (bnh thng t l ny < l) 4.2.2. Xt nghim min dch (c ngha chn on) -- Xt nghim Alpha-Foetoprotein (AFP) l mt xt nghim c hiu. AFP l mt Glucoprotein thng ch c trong thi k bo thai. Trong ung th gan nguyn pht gp t l AFP (+) t 60 - 90%. i vi ung th gan th pht xt nghim ny m tnh. Khi AFP nh lng (trn 20 ng/ml c coi l dng tnh) trn 200 ng/ml th c gi tr chn on xc nh l ung th t bo gan. Xt nghim AFP cn c dng theo di v nh gi kt qu iu tr. - Phn ng Mantoux: thng m tnh do min dch c th gim. Theo Tn Tht Tng: t l m tnh l 58,7% v tin lng bnh khi m tnh xu hn dng tnh. 4.2.3. Cc phng php chn on hnh nh:

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- Siu m gan: l bin php hnh nh hng u trong chn on ung th gan. Siu m cho bit kch thc v v tr u (khi u c m vang tng). Hin nay c p dng nhiu, cho t l chn on chnh xc cao. Siu m cn gip hng dn cho cc bin php iu tr ung th gan (ct gan, tim dit u qua da). Tuy nhin siu m khng cho bit bn cht khi u. Siu m Doppler gip nh gi s xm ln vo tnh mch ca, tnh mch trn gan v tnh mch ch di. - Chp ct lp vi tnh (CT scaner), nht l chp ct lp vi tnh c tim cn quang: c gi tr chn on rt sm, 94% pht hin c nhng u c ng knh trn 3 cm v xc nh r rng v tr u. y l phng php tt chn on ung th gan. - Chp ng mch gan chn lc: thy cc ng mch trong gan b khi u y rong rng ra v hnh nh c hiu ca ung th gan l h mu do cc ng tnh mch dn rng lm chm lu lng tun hon qua vng ung th. Hin nay s dng chp mch mu s ha xa nn (DSA) cho thy ng mch gan nui khi u gin to, tng tc dng chy so vi cc nhnh khc ca gan, khi u tng sinh mch r rt so vi nhu m gan lnh. Phng php ny cho php chn on ng t 80-90% cc khi u di 3 cm. - Chp cng hng t ht nhn: c chn on chnh xc cao (t t l chn on chnh xc ti 97,5% vi cc u ln hn 2 cm) v nht l gip pht hin tn thng xm ln tnh mch trn gan. - Chp gan xa khng chun b: thy bng gan to, t thy phn ng mng phi.C th thy hnh nh vm honh cao. -Chp Xquang lng ngc c th pht hin thy di cn phi. -Chp tnh mch ca: thy vng gan khng ngm thuc (v mch), c hnh khuyt ct ct, song khng bit bn cht khi u. - Chp nhp nhy gan: dng phng x 131I, 198Au (gn ln t bo Kufer) hoc 75 Se (gn ln t bo ung th gan) cho php pht hin u gan kch thc t 2 3 cm tr ln (cho thy hnh khuyt), song kh phn bit cc nhn x gan vi cc nhn ung th. Phng php ghi hnh ct lp bng bc x photon n, k thut s dng khng th n dng gip chn on ung th gan vi nhy v c hiu cao hn. 4.2.4.Cc phng php khc: - Soi bng: c th nh gi c kch thc, nhn c trc tip cc u trn b mt gan. - chc sinh thit gan: nhm xt nghim m bnh hc, nht l khi nghi ng gia ung th v p xe gan. Chc sinh thit gan vi hng dn ca siu m gip tin hnh k thut thun li, t tai bin v t l chn on chnh xc cao. C th tin hnh chc sinh thit gan qua ni soi bng hoc di hng dn ca chp ct lp vi tnh. T l chn on thnh cng 90%. 5. Chn on 5.1. Chn on xc nh. 183

Da vo cc triu chng sau: - S yu mt nhanh. - Gan hi to cng. - Xt nghim AFP (+),nu nh lng AFP trn 200ng/ml th chn on xc nh l ung th t bo gan. - Siu m gan, chp CT v MRI gan. Chc sinh thit gan. -Nhng ngi c nguy c cao:vim gan virut,x gan... 5.2. Chn on phn bit. 5.2.1.p xe gan: st cao, gan to, au(tam chng Fontan),bch cu v mu lng tng, phn ng min dch hunh quang (+), AFP (-), siu m c hnh long m,chc d c m scla, iu tr bng emetin . 5.2.2.U lnh tnh ca gan: - U mu (hemangiome) l u gan lnh tnh thng gp nht. Hnh nh siu m l hnh tng m, pht hin r hn khi chp ct lp c tim thuc cn quang. Thng ch iu tr phu thut hoc lm nt mch khi c triu chng lm sng. - Nang gan: thng ch c biu hin triu chng khi nang ln hoc c bin chng (v, nhim trng, chy mu). Khi iu tr ch yu bng m ni soi ct chm nang. - Cc u khc: x gan ph i, adenome. 5.2.3.Gan tim:gan to do suy tim phi. 6. Tin trin v tin lng - Tin trin t khi c triu chng u tin n khi t vong khong 6 thng, thng cht trong tnh trng hn m gan hoc suy kit. - Di cn ca ung th gan tng i t hn cc ung th khc. - Di cn hch 20%, thng l cc hch cung gan v thn tng. - Di cn phi 15%. - Tin lng ca ung th gan rt xu, 80% l cht trc khi di cn. 7. iu tr: iu tr phu thut l phng php c hiu qu. Cc bin php khc nh ha cht, min dch hoc quang tuyn ch l h tr v tm thi. 7.1. Phu thut. 7.1.1. Ct gan: L bin php iu tr c hiu lc nht, c bit i vi nhng bnh nhn b ung th gan m khng c x gan vi thi gian sng thm lu di sau m chim t l t 50-60%. Tuy nhin v bnh nhn thng n mun nn ch c khong 20% s bnh nhn c ch nh m ct gan. C 2 phng php ct gan: - Ct gan khng c k hoch (khng in hnh): khng tnh ton n gii phu ca gan. - Ct gan c k hoch:

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+Phng php Lortat - Jacob: da vo phu tch cc mch mu cung gan v trn gan, sau ct gan. Nhc im: kh khn, mt thi gian v chy mu nhiu. +Phng php Tn Tht Tng: ct gan bng cm mu v tht ng mt trong nhu m gan sau khi bp nt nhu m gan bng ngn tay (khi c gan x th ct bng ko c bit khng lm tn thng mch mu). Trong khi ct th cung gan c cm mu tm thi.Hin nay, s dng dao siu m (CUSA) ct gan c nhiu u im: gim mt mu trong m, t tn thng t chc hn so vi phng php bp nhu m bng ngn tay, c th ly b cc khi u xm ln vo sau phc mc bng cch ph v v ht ra ngoi, bo tn ti a phn gan lnh, gim t l bin chng v t vong sau m. 7.1.2.Tht ng mch gan: L phng php iu tr tm thi, c tc dng gim ngun mu ng mch nui dng t chc ung th gan. Ch nh p dng cho cc trng hp khng cn kh nng ct gan. Tt nht l tht ng mch gan ring hoc tht ton b cc mch mu n gan. Tht ng mch gan s gy hoi t trung tm khi u, s lm gim au, u nh li, AFP gim. T l sng trn 6 thng sau tht ng mch gan l khong 28%. 7.1.3. Ghp gan: Trng hp ghp gan trn ngi u tin c tin hnh bi Thomas Starlz (1963), Vit Nam ca ghp gan u tin trn ngi c thc hin ti Hc Vin Qun Y cho bnh nhn teo ng mt bm sinh vo 1-2004 . Ung th gan nguyn pht l mt trong nhng ch nh cho ghp gan, nht l khi bnh nhn b ung th gan v c x gan mt b, vic ct b ton b gan v tin hnh ghp gan l s la chn ng n. V ch duy nht c phng php ghp gan l c kh nng cha khi c 2 bnh ung th gan v x gan. Ch nh ghp gan c t ra khi khi u c kch thc di 5 cm v ch c khng qu 3 khi u, cha c xm ln mch mu. Thi gian sng thm trn 4 nm sau ghp gan v t l sng thm m khng c ti pht ung th l ti 85% v 92%. Ghp gan t ngi cho sng i vi nhng bnh nhn b ung th gan l bin php ngy cng c p dng nhiu cc nc chu . 7.2. Cc phng php iu tr khng phu thut: 7.2.1.Phng php gy tc mch qua chp ng mch gan chn lc TACE(Transarteriall Chemoembolization),TOCE (Transcartheter Oily Chemoembolization) iu tr ung th gan. 7.2.2.Phng php ph hy u gan qua da di hng dn ca siu m: -Tim cc ha cht vo trong khi u nh cn hay ha cht khc (axit axetic ) thng c tc dng tt vi nhng khi u nh ng knh di 3 cm. - iu tr lnh (Cryotherapy) v vi sng (Microwave). iu tr bng sng tn s radio (Radiofrequency),tia laser,chm tia siu m hi t tn s cao.

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7.2.3.Ho cht: thuc chng phn bo, chng chuyn ha 5-Fluouracyl, Vincristin.(ch c 10-15% p ng) 7.2.4.X tr: -X tr t bn ngoi: Coban 60 (chiu) rt t hiu qu. -X tr ti ch:Thc hin kt hp vi phng php gy tc mch bng I131,Y90,Re188 cho kt qu ng khch l,ht au,kch thc u v AFP gim. 7.2.5.Min dch: . BCG (tim vo khi u hay tim trong da). . LH1 (ging globulin). . Levamisol.

iu tr ngoi khoa

tng p lc tnh mch ca

GS.TS.Phm Gia Khnh

Tng p lc tnh mch ca l mt hi chng do nhiu nguyn nhn gy nn Vit Nam ch yu l do s gan do vim gan virus. n nay c gn 200 phng php iu tr ngoi khoa khc nhau, nhng cha c mt phng php no iu tr c trit , m ch yu l iu tr triu chng. Tuy vy trong khong 20 nm nay nh c nhng phng php mi nh gi ng tnh trng chc nng ca gan, c bit s tin b v ngoi khoa v gy m hi sc, iu tr ngoi khoa tng p lc tnh mch ca c nhiu tin b v t c nhng kt qu nht nh. 1. Nhc li gii phu v sinh l ca tun hon tnh mch ca: 1.1. Gii phu: Tnh mch ca gm 3 tnh mch hp thnh: - Tnh mch lch: Nhn mu t lch, mt phn ca d dy v ty. Chim 1/3 tng s mu ca tnh mch ca. - Tnh mch mc treo trng di: Nhn mu 1/2 i trng tri, v trc trng. 186

- Tnh mch mc treo trng trn: Nhn mu ton b rut non, 1/2 i trng phi, mt phn ty v d dy. - Thng thng tnh mch lch hp vi tnh mch mc treo trng di thnh thn tnh mch t mc treo trng, ri cng vi tnh mch mc treo trng trn thnh thn tnh mch ca ngang nn t tht lng th nht bn phi. Tnh mch ca c ng knh khong 12 -15 mm, di 10 cm, trong phn di ng c gi tr trong phu thut ch c 4-5 cm. Trn X quang hng i ca tnh mch ca chch t di ln trn v t tri sang phi, hp vi trc ct sng mt gc 40-55 , n gan chia thnh 2 nhnh phi v tri hp vi nhau 1 gc 90-120 . Cu to tnh mch ca l nhng si c trn mng nn di p lc d b gin to. Trong lng tnh mch khng c van, v vy khi b tc th mu h thng ca c th tro ngc v h thng ch cc vng ni. Cng li dng tnh cht ngi ta c th o p lc tnh mch ca bng cch chc kim vo lch v ni thng (Shunt) gia h thng ca vi h thng ch lm gim p lc tnh mch ca. 1.2. Sinh l tun hon ca h thng ca: Mu n gan do hai ngun: 1/3 l mu ca ng mch gan, vi p lc l 110 -130 mmHg chuyn 50% oxy cho gan v 2/3 l mu ca tnh mch ca vi p lc 7-10 mmHg chuyn 50% oxy cho gan. Gia hai h thng ny c s iu chnh qua li m bo dng mu qua gan. Gan nhn s cung cp ca mu mi pht t 100-130 ml trong 100 g gan. Ring tnh mch ca lu lng mi pht l 1 lt, bng 1/4-1/5 lu lng ca tim. Tc tun hon ca tnh mch ca bnh thng l 10 cm/giy. Trong s gan tc chm li c khi ch cn 4-5 cm/giy. p lc tnh mch ca trung bnh l 10-15 cm nc, tng ng 7-10 mmHg. N thay i ty theo tnh trng sinh l ca tiu ho, giai on th, p lc trong bng v t th ca bnh nhn. 2. Gii phu bnh v sinh l bnh. Nhng thay i quan trng trong gii phu bnh v sinh l bnh ca hi chng tng tnh mch ca l: 2.1. Tun hon bn: Tun hon bn l mt ri lon bnh l quan trng trong tng tnh mch ca. C hai loi: 2.1.1. Tun hon ca ch: C 4 vng ni: - Vng ni quanh thc qun gia tnh mch vnh v ca h thng ca vi tnh mch n ca h thng ch, ri v tnh mch ch trn. y l vng ni thng gp nht do c s chnh lch cao gia p lc ca h thng ca (trn 15 187

cm nc) vi p lc ca tnh mch n (1-2 cm nc) v cng l vng ni nguy him nht do v cc tnh mch thc qun gy chy mu - Vng ni trc trng: Gia tnh mch trc trng trn ca h thng ca vi tnh mch trc trng gia v di ca h thng ch, vo tnh mch ch di. Vng ni ny biu hin cc bi tr. - Vng ni quanh rn: Gia tnh mch rn v cnh rn ca h thng ca vi tnh mch thng v v h v ca tnh mch ch di, th hin bng tun hon bng h. - Vng ni sau phc mc: Gia tnh mch Retzius ca tnh mch mc treo trng di vi tnh mch phc mc trc tip vo tnh mch ch di. 2.1.2. Tun hon ca ca. Loi ny ch gp khi tc tnh mch ca trong khi tun hon trong gan vn bnh thng. Khi cc tnh mch ph ca Sappey (tnh mch ti mt su, tnh mch mc ni, tnh mch gan-i trng, tnh mch gan-thn) tnh mch c honh, cc tnh mch ca dy chng s mang l phn mu ca h thng ca n gan. Tun hon bn gp trong 90% trng hp tng p lc tnh mch ca. Trong quan trng nht l vng ni thc qun. T l gin tnh mch thc qun v tng p lc tnh mch ca l 50-60%. Cc tnh mch ny c th v gy chy mu. T l t vong v tnh mch thc qun tin pht l 30 -70%. V vy mc ch iu tr ngoi khoa tng p lc tnh mch ca l phng v chng chy mu do v tnh mch thc qun. 2.2. C chng: C chng l kt qu ca s phi hp nhiu ri lon. Nguyn nhn gy c chng l do tng p lc tnh mch ca, tng tnh thm thnh mch, gim p lc keo trong thnh mch v do ri lon chuyn ho nc v ri lon cc ni tit t nh Aldosteron, ADH v cc hocmon sinh dc. Gn y ngi ta cho l c c ri lon lu thng ca bch huyt. C chng chim t l 30-50% trong hi chng ny. Khi nc c chng nhiu th s gy chn p cc tng trong bng, hn ch c ng ca c honh gy kh th, chn p cc tnh mch lm mu kh lu thng. V vy trong nhiu trng hp cn phi iu tr ngoi khoa. 2.3. Thay i huyt ng hc ca h thng ca. Tnh mch ca ni vi tnh mch trn gan xoang gan. Cng mu v xoang gan vi tnh mch ca c ng mch gan. Nh vy p lc xoang gan chu s chi phi ca 2 thnh phn l p lc ca tnh mch ca v p lc ca ng mch gan. Bnh thng p lc tnh mch ca v p lc xoang gan l 7-10 mgHg. p lc tnh mch trn gan l 5-8 mmHg. Ty theo v tr ca tc m p lc o c cc v tr trn s khc nhau.

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Nu tc trc xoang th p lc o c lch rt cao, trong khi p lc xoang bnh thng, c s chnh lch ln p lc o c lch v xoang. Nu tc xoang (thng trong x gan) th p lc o c lch rt cao v p lc xoang cng cao xp x khng c s chnh lch p lc ng k gia p lc lch v xoang. Da vo s thay i p lc ny ngi ta c th chn on chnh xc v tr ca tc trong gan hay tc ngoi gan, trn c s m la chn mt phng php iu tr ngoi khoa cho thch hp. 3. Bnh nguyn v bnh sinh. C nhiu nguyn nhn lm tng p lc tnh mch ca: 3.1. Cn tr dng mu t tnh mch ca v tim: 3.1.1. Tc h thng ca trc gan. * Nhng d tng bm sinh ca h thng ca: - Do teo bm sinh h thng ca, hoc tc tnh mch rn lan sang tnh mch ca. - Cn h thng van trong h thng ca, mu s cha y dn n tc. * Huyt khi do nhim trng. Thng do vim cc c quan trong bng, nh vim ng mt, vim phc mc, p xe gan, nhim trng tnh mch rn, st rt, giang mai ... * Do chn p tnh mch ca t bn ngoi: C th do cc khi u, hch gy chn p hay qu trnh vim dnh gy nn. 3.1.2. Tc trong gan: Ch yu l x gan. C hai loi: X gan do k sinh trng thng l so Schistomonias Vit Nam t gp. Trng k sinh trng bm vo thnh tnh mch ca, lm vim dy v tc tnh mch ca trong gan. X gan do nhng nguyn nhn nh nghin ri, sau vim gan hoi t... Qu trnh x, pht trin trong ca s bp nght cc mi gan v cc mch mu trong khong ca lm cn tr dng mu qua gan (tc sau xoang). 3.1.3. Tc sau gan. Do cn tr dng mu tnh mch trn gan v tim. * Hi chng Budd-Chiari: Bnh do tc tnh mch trn gan do huyt khi, mt khi u hoc mt mng ngn... * Mt s bnh l khc nh tc tnh mch ch di, vim mng ngoi tim hay suy tim phi... 3.2. Tng dng mu h thng ca: Trong trng hp ny h thng tnh mch ca khng b cn tr p lc tnh mch ca cao l do tng dng mu n nhiu (tng p lc tnh mch ca ch ng). Thng gp trong: 3.2.1. Thng ng tnh mch h thng ca:

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Nh thng gia ng mch v tnh mch lch, gia ng mch v tnh mch gan ... 3.2.2 Mt s bnh lch: Nhng bnh Saccoit (bnh Besmier-Peeck-Schaumann) bnh d sn ty ca lch v trong nhiu bnh khc. Trong thi gian gn y nhiu tc gi cho l c s thng gia ng mch v tnh mch trong nhu m lch v l nguyn nhn ch yu trong trng hp ny. Vit Nam l 18% v c th y l bnh Banti trong giai on u hay l x gan a lch Vit Nam. 4. iu tr ngoi khoa tng p lc tnh mch ca Mc ch ca iu tr ngoi khoa l: - Lm gim p lc tnh mch ca. - phng v iu tr cc bin chng: chy mu do v tnh mch thc qun v c chng. 4.1. Cc phu thut lm gim p lc tnh mch ca. Bao gm 3 nhm phu thut: - Phu thut ni thng gia h thng ca vi ch. - Phu thut to dnh gia c quan h thng ca vi ch. - Phu thut hn ch dng mu n tnh mch ca. 4.1.1. Phu thut ni thng gia h thng ca-ch: * Ch nh: Ch nh ca phu thut ny trong cc trng hp: C tin s chy mu do v tnh mch thc qun, hoc c dn tnh mch thc qun vi iu kin chc nng gan cn tt lm gim cc bin chng hn m gan sau m. * u im ca phng php ny: - p lc tnh mch ca gim ng k sau ni (trung bnh gim 7-10 mmHg). - T l chy mu ti pht thp sau ni (khong 10-20%). * Nhc im ca phng php: - T l hn m gan cao (2-50%) - Lm tn thng gan nng hn v lm gim dng mu n gan. - Phu thut phc tp. - Ph thuc vo gii phu ca mch mu. * Phn loi phu thut. Ty thuc vo s chuyn hng ca dng mu h thng ca v ch ngi ta chia lm 3 loi. - Dn lu ton b (total shunt), hay cn gi l dn lu khng chn lc. Ngha l ton b dng mu h thng ca v tnh mch ch. Cc phu thut c ng knh ming ni trn 10 mm thuc nhm ny. - Dn lu 1 phn (Partial shunt): ch mt phn mu h thng ca v h 190

thng ch. Cc phu thut c ng knh ming ni < 8 mm thuc loi ny. - Dn lu chn lc (Selactive Shunt): ch dn lu mu t tnh mch lch v tnh mch vng d dy, thc qun v h tnh mch ch. Phu thut ny hn ch cc bin chng v no. * Cc phng php: - Ni thng (Shunt) ca-ch: Thng c 3 k thut: ni tn-bn, bn-bn v hai tn- bn. Ni tn bn lm gim p lc ton b, do phng v iu tr chy mu tnh mch thc qun tt, tuy vy p lc xoang vn cao do khng c tc dng iu tr c chng. Ni bn-bn c tc dng lm gim p lc tnh mch ca v lm gim p lc c xoang do c tc dng tt trong iu tr dn tnh mch thc qun c bit trong iu tr c chng. Tuy vy ni bn-bn nguy him hn ni tn bn. Trong tng p lc tnh mch ca do x gan khi c tng p lc tnh mch ca t ngt dng mu ca tnh mch ca v ng mch gan u b cn tr ti xoang, li sn c s giao lu gia tnh mch ca vi ng mch gan ti xoang nn dng mu ny trt dn ton b v tnh mch ch di: gan mt c dng mu sinh l v dng mu nui dng lm cho suy gan nng ln. - Ni thng lch thn: C th: . Ni lch-thn bn-bn . Ni lch - thn tn-bn trung tm: sau khi ct lch ni u trung tm ca tnh mch lch vi tnh mch thn. - Ni lch - thn tn - bn ngoi vi: Nm 1967 Warren thc hin phu thut ny. Phu tch tnh mch lch xong ct i tnh mch, u trung tm tnh mch khu kn, n ngoi bin ni vi tnh mch thn. Phu thut ny lm gim bin chng v no, nhng c nhc im lm tn thng h thng bch huyt vng tnh mch thn tri trong qu trnh phu tch, v vy nhng bnh nhn c c chng nhiu khng nn lm phu thut ny. - Ni ch-mc treo trng. - Lm cu ni ca-ch: C th dng prothese ni bc cu gia 2 tnh mch: mt tnh mch ca h thng ca vi mt tnh mch ca h thng ch. - Ni thng ca-ch trong gan (Transjugular Intrahepatic Portosystemic Shunt): Rosch thc hin ln u tin trn ng vt (1969). Colapinto thc hin trn ngi vo nm 1983. Phu thut c tin hnh bng cch t mt ng thng (Stent) gia tnh mch trn gan vi 1 nhnh ca tnh mch ca trong gan m khng phi m. Ni thng ca- ch trong gan (TIPS) l loi phu thut dn lu khng chn lc, cho nn c t l bin chng no cao, song n rt c hiu

191

qu trong iu tr chy mu do v tnh mch thc qun, c bit i vi BN c ch nh ch ghp gan. 4.1.2. Phu thut to dnh gia c quan h thng ca v ch: * Mc ch ca phu thut: - Lm tng tun hon ln. - Ci thin s lu thng bch huyt. * Ch nh: - Khng c kh nng ni mch mu v gii phu nh : tc mch, v tr cc mch mu ca v ch xa nhau. - Khng c ch nh lm phu thut ni thng ca-ch. - p dng trong trng hp chng ch nh phu thut ni thng mch mu nh chc nng gan km. * u im ca phng php: - Phu thut nh nhng. - Khng c bin chng v no. * Nhc im ca phu thut: Lm gim p lc khng nhiu v phi ch c thi gian hnh thnh tun hon bn. * Cc phng php: - Phu thut Talma (1887): Lm dnh mc ni ln vo phc mc hoc thn. - Phu thut Nylander (1955): a lch ln c honh. - Phu thut Halman (1935): a lch vo thnh bng. 4.1.3. Phu thut hn ch dng mu n tnh mch ca: * Ct lch: Ct lch lm gim khi lng mu v tnh mch ca 30- 40% (Blain) do lm gim p lc trung bnh 10 cm H20. Ch nh ct lch trong cc trng hp: Hi chng Blanti giai on u, cng lch, vim tc tnh mch lch. Chng ch nh ct lch trong x gan giai on mun v ct lch giai on ny lm mt c ch iu ho p lc tnh mch ca ca lch, lm tng nguy c chy mu do v tnh mch thc qun. * Tht ng mch lch: Tht ng mch lch lm gim p lc t 5-10 cm H20. u im ca phng php ny l: Phu thut nh nhng, gi c tun hon bn, gi c c ch iu ho p lc tnh mch ca ca lch. * Tht ng mch gan (Rienkoff-1947). Tht ng mch gan lm gim dng mu n xoang gan do lm gim p lc h thng ca, c bit trong trng hp x gan. Herrick chng minh rng: ngi bnh thng, nu p lc ng mch gan tng ln 40 mmHg th p lc tnh mch ca ch tng ln 1 mmHg. Song 192

ngi x gan nu p lc ng mch gan tng ln 40 mmHg th p lc tnh mch ca s tng ln 67 mmHg. * Phu thut Peters - Womack (1961): Bao gm: ct b cong ln d dy, tht 4 cung mch: ng mch v, mn v, v mc ni phi v v mc ni tri. 4.2. iu tr c chng: C chng c th iu tr ni khoa bng cc bin php: Hn ch Na, hn ch nc, dng thuc li tiu, chc ht dch... Khi iu tr ni khng kt qu phi iu tr ngoi khoa. Cc phu thut iu tr c chng: 4.2.1. Ni ca-ch bn bn: Mc ch lm gim p lc tnh mch xoang gan. 4.2.2. Ni thng ca ch trong gan (TIPS) L th thut nh nhng thay cho 1 phu thut ln v c hiu qu lm gim c chng. N rt c gi tr cho bnh nhn nh ghp gan. 4.2..3. Dn lu nc c chng vo tnh mch (Peritoneo venous anastomosis). Laveen H.H (1974) lm dn lu dch c chng t bng vo tnh mch ch trn qua h thng catheter v van 1 chiu. Van ny hot ng khi p lc chnh lch trn 30 mm. Chng ch nh ca th thut: C chng nhim khun, vim gan SVT cp, bnhgan giai on cui, ri lon ng mu, Bilirubin huyt thanh cao trn 3 ln bnh thng. Bin chng sm: Tc Shunt hoc km hot ng, tc mch do mu cc, nhim khun, vim phc mc, tn thng tim v phi, tc mch do kh, st d ng, r dch c chng. Bin chng mun: tc shunt hoc km chc nng, vim phc mc, p xe bng, tc tnh mch trung tm, tc mch phi, nhim khun thnh bng, Tc rut do dnh. 4.2.4. C nh mc ni vo phc mc (Omentopexy): Mc ch lm tng tun hon bn v ci thin h thng bch huyt. 4.2.5. Ni thng bch huyt - tnh mch. C th ni ng ngc vi mt tnh mch no . 4.3. iu tr chy mu do v tnh mch thc qun. iu tr chymu do v tnh mch thc qun c nhiu bin php: 4.3.1. Thuc: Cc thuc thng dng v c hiu qu: Vasopressin, Somatostatin, octreotide. 4.3.2. p bng: - u im: Cm mu ngay, kt qu t 85%. C th p dng cc bnh vin a khoa nh nu c bng p. - Nhc im: - Chy mu ti pht sau ly bng. 193

- C th c bin chng nng: hoi t hoc thng thc qun. - Gy kh chu cho bnh nhn. - Ch nh: - cc c s khng c trang b hoc kh nng phu thut. - Khi cc phng php iu tr ni soi, thuc khng kt qu. - Khi dng phi d kin cc phng php khc thay th nu iu tr khng kt qu. 4.3.3. iu tr ni soi: L phng php iu tr ph bin nht. Cc phng php thng dng l: Tim x cc bi tnh mch dn hoc tht n bng vng cao su. 4.3.4. iu tr phu thut: C th p dng mt trong cc phu thut: * Cc phu thut lm gim p lc tnh mch ca. * Phu thut can thip trc tip ln tnh mch thc qun: - Phu thut Bocrema (1949): tht 2 u tnh mch sau tim glucose 60%. - Phu thut Crile (1950): khu tnh mch thc qun b dn. Cc phu thut trn hin nay t dng v l phu thut nng v kt qu km. 8 Phu thut ngn cn dng mu n thc qun, d dy: - Phu thut Tanner (1950): Ct ngang thc qun, hoc d dy sau khu ni li. - Phu thut Nissen (1954): Rapant (1956): ch ct lp c thc qun, khu cm mu tnh mch thc qun, khng m thc qun. - Phu thut Paciora (1971): Ging phu thut Rapant nhng lm tm v. - Phu thut Phemister - Humphreys (1947): Ct 1/3 di thc qun v tm, sau phc hi lu thng ng tiu ho. - Phu thut Sugiura: Phu thut ny c p dng rng ri Nht Bn c kt qu rt tt. Ch nh ca phu thut l: chy mu v tnh mch thc qun ti pht m khng c kh nng lm cc phu thut ni thng ca- ch. Ni dung ca phu thut l: Ct ngang thc qun, tht cc mch mu quanh d dy v thc qun v ct lch. 4.4. Ghp gan: Ghp gan l bin php cui cng iu tr nhng bnh nhn b bnh gan gii on cui, trong c cc bnh l nguyn nhn ca hi chng tng p lc tnh mch ca.

194

Vim ty cp
TS. V Huy Nng 1. i cng Vim ty cp l mt bnh nng, c c tnh t tiu hu cc vng trong tuyn ty, c Nicolas Kuple pht hin v m t nm 1685 qua m t thi, trong thi gian di do cha hiu r bn cht ca bnh nn vic iu tr cn gp nhiu kh khn, t l t vong cao. Hi nghi quc t Atlanta (Hoa K) 9/1992 thng nht phn loi th vim ty cp lm hai th : ph ty cp (th nh) v vim ty cp hoi t (th nng). Biu hin lm sng ca bnh a dng t nh vi cc triu chng ngho nn (vim ty cp th ph) p ng tt vi iu tr ni khoa ti nhng hnh thi nng, suy a tng v d t vong (vim ty cp th hoi t), iu tr kh khn, tin lng nng. Trong nhng nm gn y vim ty cp gia tng cc nc kinh t pht trin, vic s dng ru rng ri c nh hng ln ti bnh ny. 2. Bnh nguyn, bnh sinh 2.1.Nguyn nhn v iu kin thun li: 2.2.1 Si ng mt : l nguyn nhn hay gp nht, c Opie m t nm 1901 qua gii phu t thi. Vim ty cp do si mt kt c vng Oddi, chim 30- 75% vim ty cp. 2.2.2.Giun chui ng mt, ng ty, hay gp tr em hn ngi ln. 2.2.3.Ru, hay gp cc nc u- M. 2.2.4. Sau chn thng : - Chn thng ty trong chn thng bng kn. - Sau phu thut: cc phu thut tng trn mc treo i trng ngang u c th gy vim ty cp nht l nhng trng hp ct d dy do lot x chai thng vo ty. - Th thut: m rng c Oddi, soi mt- ty ngc dng. 2.2.5. Ri lon chuyn ha: cng gip, cn gip. 2.2.6. Nhim c, d ng mt s thuc: oestrogen, furosemid, azotioprin. 2.2.7. Yu t gia nh: trong mt gia nh c th c nhiu ngi b vim ty cp. 2.2.Bnh sinh: Bnh thng ty tit ra cc men chuyn ha m, ng, m di dng cha hot ng, khi xung n t trng mi c chuyn thnh dng hot ng. Do cc nguyn nhn khc nhau lm cho cc men ty hot ha dy chuyn ngay trong lng tuyn ty, trypsin tiu hy t chc ty, xung quanh ty v hot ha mt s men khc gy tiu hy mng t bo, tn thng mch mu, hoi t

195

t bo, t chc. Cc cht trung gian gy vim c gii phng lm gin mch, tng tnh thm v ph n. Mt s gi thuyt gii thch c ch bnh sinh: - Thuyt tc nghn ng ty v s tng tit: + Do tc nghn ng dn ty v tr c Oddi (si kt, giun, ph n sau m c tht), trong ng ty (si ty). p lc trong ng ty phi tng> 40cm nc vim ty cp mi c th xy ra. + S tng tit dch ty sau ba n thnh son gy vim ty cp. + Ru lm thay i bi tit ca ty c th dn ti tc ng ty v gy vim ty cp, lm tng nng protein trong ty, protein kt ta to si ty gy tc ng ty (Sarles 1980). - Thuyt ng dn chung: do ng ty v ng mt ch chung vo bng Vater nn khi tro ngc dch mt v dch rut vo ng ty c th gy vim ty cp. Nguyn nhn tro ngc l do tc t trng, ri lon c vng Oddi, tng p lc ng mt do giun ln hoc si kt bng Vater. - Thuyt thn kinh vn mch: ri lon vn mch ty do co tht hoc vim tc v tc h bch huyt dn n ph n ty, hoi t nhu m, vim ty cp xut hin. 3. Gii phu bnh l 3.1. Vim ty cp th ph : - i th: tuyn ty to, ph n nht nht, ti xm, cng t, lng bng v mm nh phng b novocain. Ph n lan ra cc t chc xung quanh, trong bng c t dch trong. - Vi th: ph n t chc k gia cc tiu thy, phn ng vim gii hn bn trong t chc tuyn. Xm nhp t bo vim ch yu l bch cu a nhn. Nang tuyn to hn bnh thng nhng nguyn vn, nhn t bo co li, ng nang tuyn gin rng. Kch thc ng ty chnh khng thay i, cn cc ng dn nh gin nh. Mch mu xung huyt, gin mao mch khng c huyt khi. Mch bch huyt gin cng. 3.2. Vim ty cp th hoi t: - i th: tuyn ty to, rn, c nhng hoi t mu xm en ln nhng chy mu sm mt phn ty, ton b ty hoc lan sang cc tng ln cn. Mc ni, mc treo, phc mc ph n, c nhng vt nn trng lm tm, l hin tng hoi t m. Dch bng thng c mu sm, i khi c. - Vi th: t chc ty hoi t tp trung thnh tng m hay ri rc, cc hoi t ngoi vi tuyn ph n ph hy dc cc khong lin thy. Cc tiu thy b vim, hoi t lan ti c thnh mch v bch huyt gy tc mch, xut huyt mnh l c trng ca qu trnh hoi t. ng ty b tn thng v gin. Cc o Langerhans t b tn thng tr khi hoi t ton b ty. T bo nang tuyn mt bo quan, nhn co li. 4. Lm sng 4.1. C nng

196

- au bng: hay gp (98%), c c tnh xut hin t ngt thng sau ba n ngon v ung ru. au rt d di, au lin tc tp trung thng v, lan xuyn ra sau lng v tht lng. au l do s ln th cm th ca tuyn b kch thch, do tuyn ty b ph n v chy mu. au kt thc sau nhiu ngy. - Nn: rt hay gp, xy ra sau khi au, do nn nhiu bnh nhn kit sc, mt nc, in gii. - B trung, i tin: thng giai on mun. B trung i tin lu s lm bng trng to d nhm vi tc rut. 4.2. Thc th - Bng trng: thng do n mun. Trng u, nhiu vng trn rn, khng c du hiu quai rut ni, rn b nh tc rut c hc, nghe khng thy ting nhu ng rut. - Phn ng thnh bng: thng r, c khi mnh nh co cng thnh bng v vy nn d nhm vi thng d dy t trng. i khi thy thnh bng hI cng vng trn rn. - Cm ng phc mc pht hin bng du hiu Blumberg (+) khi trong bng c dch ty nhiu nht l vim ty hoi t km theo hin tng thy phn cc cht m v tiu t chc do cc men ty (vim phc mc do dch ty). - G c vng thp khi, g vang vng quanh rn. - im sn tht lng au, bn tri cn gi l im Mayo- Robson, y l triu chng quan trng ca vim ty cp. - Du hiu Turner (+): mng tm bm mn sn. Du hiu Cullen (+): mng tm bm quanh rn. y l cc du hiu him gp nhng nu c th rt nng - Nhu ng rut nghe gim hoc mt hn. 4.3. Triu chng ton thn - Vng da gp 25%, mt phn do si, mt phn do ph n u ty gy tc mt. - Tnh trng ton thn nng nu th ti cp: da xanh nht do nhim c v thiu oxy mu, mch nhanh nh kh bt, huyt p tt, th nhanh, nng. Tnh trng sc chim 25%. - St gp 90%, st cao km ri lon tm thn kinh gp bnh nhn c hoi t ton b tuyn ty th tin lng xu. - Suy a tng: l hu qu nng n nht dn n t vong. 5. Cn lm sng 5.1. Xt nghim mu: - Amylaza mu: Men amylaza tng sm, tng cao trong mu, tng hn 3 ln bnh thng c gi tr chn on (bnh thng < 220 U/L). - Amylaza nc tiu: amylaza tng cao gi th 12-24 (bnh thng <1000 U/L) sau gim dn v tr v bnh thng sau vi ngy n 1 tun.

197

- Gim canxi, magie huyt: gp th nng. Canxi < 1,75mmol/l tin lng xu. - Bch cu tng cao,N tng, Hematocrit tng do mu c. - Ure, creatinin mu tng do suy thn. - ng mu tng do gim tit Insulin, tng tit catecholamin v glucagon. 5.2.Siu m: - Hnh nh ty: kch thc to, nhng vng hoi t rng, nang gi ty, vi ha nhu m v si ty. - Nhng dch xung quanh ty, hu cung mc ni, gia cc quai rut, rnh thnh i trng, ti cng Douglas, sau phc mc. - Pht hin giun, si ng mt, ti mt. 5.3.X quang: Chp bng khng chun b thy: - Thnh bng dy. - Gin gii hn mt quai rut st vi ty (i trng, rut non) gi l quai rut cnh v (sentinel loop). - Quai rut gin cha y hi do lit rut c nng, thnh rut dy. - Hnh vi ha hoc si ty cn quang. 5.4. CT- scanner: Ty to, ph n hoc hoi t quanh ty. Cc dch, hoi t, apxe hoc nang gi ty. 6. Din bin v tin lng: 6.1. Din bin: - dn v khi hn: thng gp th nh, tnh trng ton thn khng nng, sau vi ngy cn au dn v trung tin c, cc xt nghim mu tr v bnh thng. - Xu dn v dn n t vong: tnh trng ton thn nng dn d p dng cc bin php iu tr tch cc. Cc biu hin nh sc t nh n nng, suy a tng, din bin nhanh, t vong trong 24- 48h, thng gp th hoi t. - Dn n cc bin chng: apxe ty, nang gi ty, vim ty mn, vim ty ti pht nhiu ln, tiu ng sau vim ty cp. 6.2. Tin lng Ranson 1974 a ra 11 yu t khch quan c gi tr tin lng cc bnh nhn vim ty cp: - Tui trn 55. - BC trn 16 G/l - Glucoza mu trn 11 mmol/l - LDH (Lactatdehydrogenase) trn 350 UI/l - SGOT > 250 U/L. Trong 48 gi u: 198

- Gim hematocrit 10%, - Ure mu tng > 1,8mmol/ l, - Canxi mu < 2mmol /l, - PaO2 < 60mmHg, - Kim ha mu trn 4mEq/L. - c tnh th tch nc ng trn 6 lt. Khi c 1-2 yu t t l t vong < 1%, 3-4 yu t l 15%, 5- 6 yu t l 40%, 7- 8 yu t t vong 100%. 7. Chn on 7.1 Chn on xc nh: - Da vo cc triu chng lm sng - Xt nghim amylaza mu hoc nc tiu tng cao gp 3 ln bnh thng. - Siu m, CT- scanner thy hnh nh vim ty cp. - Khi phu thut thy hnh nh i th ca vim ty cp. - Tuy nhin bnh cnh ca vim ty cp khng c hiu, d nhm vi cc bnh khc. 7.2. Chn on phn bit: - Thng lot d dy-t trng: au t ngt d di nh dao m vng thng v, co cng thnh bng. Chp X quang bng thy hnh nh lim hi. - Tc rut c hc: au, nn b, trng, hnh nh X quang c mc hi- mc nc. - Si mt. - Vim rut tha cp . - Nhi mu mc treo trng. - Vim rut hoi t. 8. Bin chng ca bnh: 8.1. Nhim khun - Thng gp sau vim ty hoi t. Bnh nhn c st, bch cu tng cao, chc ht dch bng c gi tr chn on cao. 8.2. Apxe ty - Apxe ty thc cht l qu trnh hoi t lan rng ca t chc m sau phc mc, mc treo rut non v mc treo i trng trong khi t chc ty vn nguyn vn mc d c vim. y l mt bin chng nng. 8.3. Nang gi ty - Nang gi ty l nang c gii hn r v cha dch. Nang gi ty c th t mt i do hp thu dch qua phc mc hoc v vo ng tiu ha, xy ra trong tun u ca qu trnh hnh thnh. Nu nang gi ty khng t mt i th cn phi can thip bng phu thut. 8.4. Vim ty ti pht

199

- Vim ty ti pht xy ra mt s bnh nhn vin ty cp. Bnh nhn c nhng cn au do ty vim ti pht. Cn au ny thng nh, p ng vi iu tr bo tn trong vng 3-5 ngy. 9. iu tr 9.1. iu tr bo tn: - Chng sc: Hi phc khi lng tun hon, iu chnh huyt p, truyn dch, plasma v mu. - Duy tr chc nng h hp, nu tnh trng nng phi th my. - iu ha chc nng ngoi tit ca tuyn: + Nhn n (khng n, khng ung 3-5 ngy, c sonde ht dch d dy, truyn dch nui dng ng tnh mch ng tiu ha ngh ngi. + Gim tit ca tuyn (atropin 0,5-1%), 3-4 ln/ngy. + Thuc bantin, probantin, glucagon, acetasolamid, cimetidin, calcitonin, somatostatin, sandostatin... + Thuc khng men: Hay dng l Trasilol, tc dng lm gim tit ca tuyn ty v gim hot tnh ca cc men c bit l Trypsin. Thuc c tc dng tng t l aprotinin. Ngi ta cn dng contrical 80.000 n v 120.000 n v/24 gi, nhng hay c d ng. - Thuc cocticoid: dng cocticoid liu trung bnh trong vim ty cp nng v c sc, tt huyt p vi quan im tc dng chng sc. - Khng sinh: phng nhng bin chng, thng dng nhm cefalosporin I, II, III. - Chc ra bng: Nu ch nh ng s hi phc nhanh chng tnh trng ca bnh nhn. + V cm ; gy m ni kh qun + ng rch : di rn 4-5cm + Dung dch gm: dextroza (15g/l). Kali (4mmol/l), heparin (500 n v), khng sinh ph rng. + Cch tin hnh: a vo 2 lt trong 15 pht duy tr 30 pht trong bng sau tho ra. iu tr trong 48 gi u c th ko di n 7 ngy. 9.2. iu tr phu thut iu tr phu thut vim ty cp ngy nay gim i, n ch c thc hin nhng bnh nhn vim ty cp c bin chng. 9.2.1. Ch nh phu thut - Chn on khng chc chn, nghi ngi c bnh cp cu ngoi khoa khc ca bng, mc ch m thm d. - Gia tng cc triu chng: au, nn ko di, bch cu tng, amylaza tng trong mu v nc tiu. Mch yu, huyt p h, vng da, c phn ng phc mc v tnh trng ton thn nng. - iu tr bo tn ng nhng khng c kt qu v xut hin bin chng. - Hnh thnh nhng p-xe tuyn ty. 200

9.2.2. X l trong phu thut - Khi c vim ty cp km theo si mt, giun ng mt: m ng mt ch ly si, giun, dn lu Kehr, ra bng, dn lu hu cung mc ni v bng. - Khi c vim ty cp, khng c si mt: m dn lu ti mt gim p lc ng mt, lau ra v dn lu bng. - Phong b novocain v contrical vo bao ty v dn lu hu cung mc ni. Trong trng hp c hoi t nh, ngi ta ct hoi t v dn lu. - Phu thut ct ty ch c ch nh trong cc trng hp: Hoi t r ca u, thn, ui hoc ton b ty. Nu tnh trng bnh nhn cho php, phu thut vin c kinh nghim th c th tin hnh ct t trng ty tng; ct gn hon ton, ct bn phn tri, nu hoi t ton b th ct ty ton phn .

Ung th ty
TS. V Huy Nng 1. i cng U ty c chia lm 2 loi: u lnh v u c tnh. U lnh tnh Him gp, pht trin chm, khng di cn v c phn loi: - U biu m : Papilome, papilomatoza, Adenome. - U t chc lin kt : Lymphangiome, Hemangiome - U hn hp : Dermoid U c tnh (carcinoma) - Ung th ty gm nhiu loi, ty theo ngun gc c th phn ngoi tit hoc phn ni tit ca ty. Tuy nhin ung th ty c hiu l carcinoma ng tuyn ty (duct cell carcinoma), ung th phn ngoi tit. - Ung th ty chim 2-4% trong cc loi ung th, bnh gia tng trong nhng nm gn y. - T l t vong 5%, ng th hai trong cc nguyn nhn gy t vong ca ung th ng tiu ho sau ung th i-trc trng. 90% ung th ty cht trong nm u ca bnh v ng hng th t gy t vong trong cc loi carcinoma. - Gp nam nhiu hn n (3/2), 80% gp tui 60- 80, tui <40 him gp chim <2%. - C nhng bt thng nhim sc th hoc t bin gen nhng bnh nhn ung th ty. 2. Bnh nguyn, bnh sinh

201

Ngy nay ngi ta cha xc nh r nguyn nhn sinh bnh. Tuy nhin c 3 yu t c vai tr nguy him: nghin thuc l, nghin ru v i ng. - Nhng ngi da en c t l ung th ty nhiu hn ngi da trng. - Nhng ngi nghin thuc l tng t l ung th ty gp 5 ln so vi ngi bnh thng. Ht thuc l gy ung th thng qua vai tr ca Nitrosamine cht ny gy t bin gen. - Nhng ngi nghin ru, n nhiu tht, m gia tng nguy c ung th ty. - Ngoi ra bnh nhn tiu ng c nguy c ung th ty cao hn hai ln bnh thng, cc bnh nhn sau ct on d dy, ct i trng cng c nguy c ung th ty. 3. Gii phu bnh - Ung th ty thng gp nht l Adenocarcinoma (90%) c cu trc tuyn ca ty. Hu ht l cc t bo dng km bit ho v bit ho va. Ngoi ra cn c cc loi ung th ty khc: sarcome c trn, sarcome m, u ty bo, u lympho v nhng u him gp: u ni tit ngun gc t t bo , - Ung th thng gp u ty (70%), t hn thn v him gp ui ty. - Phn loi T, N, M: Giai on 0 IA IB IIA IIB Tnh trng T Tnh trng N Tnh trng M Tis N0 M0 T1 N0 M0 T2 N0 M0 T3 N0 M0 T1 N0 M0 T2 N1 M0 T3 N1 M0 III T4 N bt k M0 IV T bt k N bt k M1 th (Trch AJCC Cancer Staging Handbook 6 ed. New York, Springer, 2000) T: Tx: T1 : T2 : T3 : T4 : N: Nx: N0: U nguyn pht Khng xc nh c u U < 2cm ng knh U 2 6cm > 6cm U xm ln sang t chc xung quanh Hch Khng xc nh c hch Khng c di cn n hch bch huyt 202

N1: Mt nhm hch khu vc thy c khi m N2: Hai nhm hch khu vc thy c khi m N3: S thy hch trn lm sng hch bch huyt (khng phi m bng) N4: Hch bch huyt ngoi bin to ra M: Di cn xa Mx: Khng nh gi c M0: Khng c di cn xa M1: Xut hin di cn xa 4. Triu chng 4.1. Lm sng Triu chng lm sng ph thuc vo v tr ca khi u. 4.1.1.au - Chim t l 80 90% trong s cc ung th ty v hay gp hn cc ung th thn v ui ty. - au thng gp nht vng thng v (4- 6%), na bng trn (18%) v vng 1/4 bng trn tri (13%). (Theo A.R.Mossa 1980) - 15-30% s bnh nhn au khu tr tng ln khi nm v gim xung khi ngi - au 1/4 trn bng tri, thng gp ung th thn v ui ty. - au bng di trong thi gian di trc khi biu hin cc triu chng khc gi cho ta v ch ti ung th ty. - 2/3 s bnh nhn au bng 3 thng trc khi c vng da. - Bnh nhn c u bng Vater thng khng au 4.1.2.Vng da - Gp 7-30% s bnh nhn c ung th ty (J.Berk v E.Gambile.A.R.Mossa 1980) - Vng da km theo nga, l hu qu ca tc mt. - 80% - 90% bnh nhn u u ty c vng da (H.D.Gullick 1959) ch c 6% s bnh nhn u thn v ui ty. - Vng da tc mt tin trin t t, ngy cng tng dn, nu vng da c tnh cht m m khng c au l triu chng c gi tr (khc vi vng da tc mt do si). - C mt s trng hp km lch to do ung th thn v ui ty chn vo tnh mch lch. 4.1.3.St Nhit tng km theo rt run, ging triu chng ca p xe ng mt gp 10% bnh nhn c ung th u ty, nhng khng hay gp nhim khun ng mt. 4.1.4.Triu chng khc - Hay gp st cn, thng l 2 thng trc khi n gp thy thuc. - y hi, nn, chng bng, thiu mu, a chy, to bn, mt mi (t c gi tr bnh l).

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4.2. Cn lm sng 4.2.1.Xt nghim mu, nc tiu: - Bch cu tng, Amylaza mu tng. - Ht dch t trng xt nghim c th thy t bo ung th. - Bilirubin mu tng, nht l Bilirubin t do - Nc tiu c mui mt v sc t mt 4.2.2.X quang - Chp khung t trng thy khung t trng gin rng, c hnh nh chn p t ngoi vo. - Chp d dy c thay i cc np nim mc, hnh nh d dy b y sang v tr khc, cc b cong d dy thay i do b u chn p, hoc c gin rng khong trng trc d dy, hoc c hnh nh gin d dy khi c nhi mu tnh mch lch - Chp tnh mch lch ca c hnh nh chn p ca u vo tnh mch ca. - Chp mt qua da c ngha rt c bit bnh nhn tc mt, c hnh nh tc mt do u chn vo ng mt, khng c hnh si. - Chp ng mt, ty qua ni soi: phng php cho php pht hin ung th ty kch thc 2cm ng knh v n i con ng trc tip, kt hp vi sinh thit ht gip cho chn on phn bit ung th ty v vim ty mn. - Chp ng mch ty l phng php tt nht chn on trn bnh nhn nghi ngi c u ty - Chp ng mch thn tng gip xc nh xm ln ca u ty ti tnh mch ca, ng tnh mch mc treo trng trn, c gi tr tin lng kh nng phu thut. 4.2.3.Siu m - V tr hoc s lan to ca khi u - B ty khng u. - Gin ng mt ch on trong ty - Gin ng ty - Vng long m - Gin ng mt - Hnh nh cc ng mch b y U c kch thc 1,5 cm c th pht hin c trn siu m (88%) ph thuc vo k thut thm d v kinh nghim ca bc s. 4.2.4.Chp CT scanner: c th pht hin c cc u nh 1cm, c th phn bit gia ung th ty v vim ty mn 77% cc trng hp v gip xc nh kh nng c ct c ty hay khng. 4.2.5.Chp PET (Positron Emission Tomography) C gi tr chn on cc u ty c kch thc nh m chp CT v chp cng hng t khng pht hin c. 4.2.6.Chn on trong m

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5. Chn on 5.1 Chn on trong m - Quan st i th. - Sinh thit trong khi m. Nhiu tc gi cho rng, quan st i th trong khi m cng chn on ung th ty khng cn phi dng n sinh thit. 5.2. Chn on phn bit - Cc khi u ca cc tng ln cn: u gan, u ng mt, u d dy,... - Chn on phn bit gia vng da do u u ty v u bng Vater vi vng da tc mt do si: da vo tam chng Charcot. Nu u chn p ng mt, th vng da c tnh cht lin tc, c nh v tng dn. Giai on mun c th s thy u. Xt nghim c ri lon chc nng tuyn ty. 6. iu tr. 6.1. Phu thut trit - Phu thut ct t -ty (Whipple): ct 2/3 d dy, t trng, ng mt ch (on ngoi vi), ti mt, u ty, on u trung tm ca hng trng v cc hch lympho ln cn. Ni li d dy vi hng trng v ni ng mt ch, mm ty vi hng trng. T l t vong sau phu thut l 5%. T l sng 5 nm: 10 20%. - Phu thut ct ton b ty: bao gm phu thut Whipple km theo ct lch, thn v ui ty, vt hch. - Phu thut Fortner: ct ton b ty, phn trc ty ca tnh mch gnh, ng mch thn tng, ng mch mc treo trng trn, ng mch i trng gia. 6.2. Phu thut tm thi Nhng ung th ty khng c kh nng phu thut c th ch nh phu thut tm thi, nhm mc ch: - Lm nh bt vng da, nga, tc mt - Lm gim bt cn tr d dy Tin hnh ni ng mt vi ng tiu ho gii quyt lu thng ng mt, c th kt hp ni v trng nu hp t trng, mn v. Thng thng ni ti mt, hoc ng mt ch vi hng trng theo kiu ch Y hoc ch Omega (). 6.3. Cc phng php iu tr khc 6.3.1. X tr Phng php t c s dng v ty nm su v quanh ty c nhiu c quan trng yu. Ngi ta thng p dng x tr trong m. 6.3.2. Ho tr Ngi ta dung 5 FU hoc Mitomycin C hoc Methotrexate liu cao. C 10-20% trng hp p ng vi thuc nh ng khng ci thin thi gian sng thm. 6.3.3. iu tr bo tn

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Ch nh trong cc trng hp u ty c di cn xa, th trng suy kit khng cn kh nng phu thut. Ngi ta dng thuc gim au, dit hch giao cm ct cn au, kt hp dn lu ng mt qua da hoc ni soi, t gi (stent) ng mt hn ch tnh trng tc mt.

Hnh 1 Nhng thnh phn ct b trong phu thut ct t trng ty tng

Hnh 2 Thm d khi u sau khi gii c phng t trng

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Hnh 3 Ni hng trng ty tng phng php tn-tn

Hnh 4 Ni hng trng ty tng phng php tn-bn

Phu thut ct t ty (Whipple)

Chn thng bng kn

TS. Sn H 1. i cng Chn thng bng kn l mt cp cu ngoi khoa gp c trong thi bnh v thi chin, do nhiu nguyn nhn gy nn. Nu chn on v x tr khng kp thi bnh nhn s t vong do sc mt mu nng, nhim trng nhim c bi vim phc mc mun v suy a tng, v vy cn c chn on sm v x tr hp l. Tuy nhin chn on sm c th gp kh khn do cc triu chng khng in hnh hoc b che lp trong bnh cnh a chn thng vi nhng tn thng kt hp. Do i vi mi bnh nhn c th khi b chn thng vng bng cn c thm khm lm sng ton din, t m, theo di cn thn kt hp vi cc phng tin cn lm sng xc nh c cc tng trong bng c b tn thng hay khng ? Nu c tn thng th mc no? C tnh trng shock v tn thng kt hp khng? 2. Nguyn nhn v c ch chn thng 2.1. Nguyn nhn chn thng bng kn trong thi bnh: - Tai nn giao thng l nguyn nhn hng u. - Tai nn lao ng: ng gin gio, ca my p vo bng, v bnh hi cao p... - Tai nn trong luyn tp, th dc th thao. - Tai nn trong sinh hot. Cc tng trong bng b tn thng do nhiu c ch khc nhau: . - Lc tc ng mnh, do thay i lc qun tnh, dng t ngt trong khi di chuyn vi vn tc cao. - Do tng p lc t ngt trong bng bi mt lc mnh hoc b p gia hai lc. 2.2. Nguyn nhn chn thng bng kn trong thi chin - Bom, n pho ca ch oanh tc hoc nhng loi v kh khc c sc n mnh gy chn thng bng kn do sng n, sng n gy chn thng bng kn bng hai cch : + Tc ng gin tip: lm nh, sp hm... gy cho ngi b tn thng. +Tc ng trc tip ln c th i vi nhng ngi trong tm bn 207

knh st thng m khng c vt che khut. Loi tc ng trc tip ny gy nn nhng thng tn phc tp, c tn thng cc c quan bng. - T l chn thng bng kn ca qun i Lin X trong i chin th gii ln th II l 3,8%, chn thng bng kn ca qun i M trong chin tranh Vit Nam l 9,8%. Gn y trong cuc chin Kosovo-Nam T, M s dng v kh nguyn t u ran ngho, t l chn thng bng kn s tng rt nhiu v phc tp hn. 3. Cc tn thng trong chn thng bng kn Bt c tng no trong bng u c th b tn thng, tnh cht v mc tn thng cn ph thuc vo v tr, hng v lc chn thng.Trong chn thng bng kn c th gp cc loi tn thng sau: 3.1. Tn thng tng c Chim t l t 32%- 35,5% (theo thng k ti khu vc H ni trong thi gian t thng 12 nm 2004 n thng 8 nm 2006 trong 926 trng hp chn thng bng kn c 360 bnh nhn v tng c) 3.1.1.V gan: Chn thng thng gan chim t l khong 13,5- 16% cc tn thng bng kn ni chung v ng hng th 2 sau v lch chn thng. Chn thng gan l tn thng cu trc ca gan t rch bao Glisson, tn thng nhu m n mch mu, ng mt. V gan n thun hoc c tn thng kt hp hoc nm trong bnh cnh a chn thng. Gan c th v nt, gip nt rng gy chy mu vo trong bng hoc v trong bao v nhu m, hoc b x rch khi cc dy chng treo gan. V gan vi cc mc khc nhau v theo phn loi ca Hip hi phu thut chn thng Hoa K (1994 ) chia lm 6 : - I: T mu nh di bao, <10% din tch gan Rch bao su <1cm trong nhu m gan. - II: T mu di bao 10-50% din tch gan T mu trong nhu m ng knh< 10cm. Rch su 1-3 cm trong nhu m gan, di <10cm. - III: T mu di bao rng trn 50% b mt gan hay lan thm, v. T mu trong nhu m > 10cm hay lan thm Rch su >3 cm vi chiu di > 10 cm. - IV: Rch 25- 75% thy gan hay tn thng 1-3 phn thy gan theo xp loi ca Couinaud trong cng mt thy. Tn thng tnh mch trn gan, tnh mch ch sau gan. - V: Tn thng> 75% thy gan hay tn thng >3 phn thy theo xp loi ca Couinaud trong cng mt thy. Tn thng tnh mch trn gan, tnh mch ch sau gan - VI: t ri cung gan, cc tnh mch ln ca gan. 3.1.2. V lch:

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Lch c th b v nt, v mt cc hay v di bao to thnh khi mu t ln, c th v th pht v lch 2 th. Phn loi tn thng lch theo phn ca Shackfort ci tin (4 ), hin nay ang c p dng ti Bnh vin Vit - c v Bnh vin 103. - I: Rch nh bao lch, cc tn thng nng. - II: Nt, rch hoc thng nhu m nhng khng tn thng vo mch mu rn lch. - III: Nt, rch su vo rn lch, c th tn thng cc mch mu rn lch, lch v hnh sao hay t ri 1 phn lch. - IV: Lch v nhiu mnh hoc t ri cung lch. Tn thng lch trong chn thng bng kn cn gp trong trng hp c lch bnh l nh: lch to do st rt, bnh Banti 3.1.3.V ty: Tn thng ty t gp nhng rt nng, chim t l 2% chn thng bng kn, thng km theo chn thng t trng. Ty nm su so vi cc tng khc, trc ct sng, lc chn thng phi rt mnh mi gy c tn thng. Khi ty b gip th km theo tc mch nn cc t bo ty ang tn thng nhanh chng b hoi t,dch ty chy ra lm tiu hy cc t chc xung quanh. Tn thng ty theo phn loi ca Moore (1976) chia lm 4 : - I: Dp, v ty khng c tn thng ng ty. - II: t la ui ty hoc chn thng m ty c tn thng ng ty. - III: t la u ty hay chn thng ty km theo tn thng ng ty. - IV: Chn thng khi t ty, c hay khng tn thng bng Vater. 3.1.4. V thn Thn c th b v nt, t cung thn, gip thn hoc v di bao hay v mt phn to nn khi mu t quanh thn. 3.2. Tn thng cc tng rng. 3.2.1.V d dy: V d dy sau chn thng him gp. D dy c th v khi cha y thc n. Bnh nhn trong tnh trng sc, c hi chng vim phc mc, nn ra mu hoc dch d dy ln mu chy qua ng thng d dy. 3.2.2.V t trng: V t trng thng gp trong chn thng bng v kt hp tn thng ty, c th gp tn thng trn hoc di bng Vater. Tn thng t trng theo phn loi ca Moore (1976) chia lm 5 : - I: Rch lp thanh c, khng thng. T mu mt on t trng. - II: V < 50% chu vi, t mu trn hn 1 on t trng - III: V 50- 75% chu vi t trng on DII. Hoc v 50- 100% chu vi t trng 3 on DI, DII, DIII.

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- IV: V > 75% chu vi, on DII c tn thng bng Vater hay on sau ng mt ch. - V: V nng khi t ty. T trng b t ht mch mu nui dng. 3.2.3.V, thng rut non: Tn thng c th mt hoc nhiu v tr khc nhau, hay gp l ch tip gip gia on di ng v c nh (quai u hng trng v quai cui hi trng), i khi b t la hoc rch mc treo gy chy mu vo bng. C trng hp l thng nh c bt tm thi bi b thc n hoc b mc treo nn kh pht hin. 3.2.4. V thng i trc trng: i trc trng c th v, thng, ng gip do chn thng nhiu v tr khc nhau. Tn thng i trng v vo bng gy nn n vim phc mc nng, c khi tn thng i trng mt sau cc on c nh, sau phc mc gy vim ty lan to. 3.2.5. V bng quang: Chn thng bng, bng quang cng b v do tng p lc t ngt, thng v y. Khi v xng chu, bng quang b x rch hoc mnh xng m thng, rch bng quang nc tiu chy vo bng gy nn vim phc mc. 3.3. Tn thng cc tng khc: - Tn thng c honh c th gp trong chn thng ngc - bng kt hp, nu v rng gy thot v c honh. - Tn thng cc mch mu trong bng. 3.4. Khi mu t. Chn thng bng kn do tai nn trong thi bnh c th gy nn khi mu t sau phc mc cn cc tng khc khng b tn thng. Chn thng bng kn do tc nhn sng n hay gp trong thi chin, thng c nhiu khi mu t ri rc trong cc c quan, c thnh bng. V lc chn ng c din rng. Nhng trng hp ny bnh nhn vn b mt mu, vn c hi chng kch thch phc mc, mc d khng c v tng rng. Do vy thng gp nhiu kh khn trong chn on v ch nh phu thut. Tuy nhin nu c mu t ri rc v km theo c tn thng tng th phi m. Nhng nu ch c cc mu t n thun m tin hnh phu thut s lm cho tnh trng bnh nng n v trm trng hn. 3.5. S lng c quan tn thng. - C th ch gp mt c quan b tn thng. - C th hai hay nhiu tng cng b tn thng. 3.6. Tn thng bng kt hp vi tn thng cc c quan. - Tn thng phi trong chn thng ngc bng kt hp - Chn thng s no c chn ng hoc gip no. - Tn thng bng km theo gy xng: t chi, ct sng, khung chu Bnh cnh lm sng ca chn thng kt hp hoc a chn thng nhiu khi rt phc tp vi cc triu chng suy h hp, sc mt mu, sc chn thng, 210

hn m... lm lu m cc triu chng vng bng nn d b st hoc chn on mun. 4. Triu chng lm sng Bnh cnh lm sng ca chn thng bng kn hon ton ph thuc vo tnh cht, mc ca cc tng tn thng, nhn chung biu hin lm sng vi 3 hnh thi: - Chong (shock) chn thng. - Hi chng chy mu trong bng. - Hi chng vim phc mc. Cn phi khm ton din t m pht hin ht cc triu chng khng b st mt c quan no. Nhng trng hp kh, bnh nhn cn c khm i khm li nhiu ln, cch nhau 15 30 pht. 4.1. Hi bnh: Cn xc nh hon cnh xy ra tai nn bng cch hi t m bnh nhn hoc ngi a bnh nhn nu bnh nhn hn m lm r: - C ch chn thng - T th bnh nhn khi b tai nn, hng ca lc tc ng - Thi gian t khi b nn n khi c x tr ban u, n khi nhp vin, cc x tr ca tuyn trc... - Tnh trng ton thn: - Cc ch s chc nng sng: mch, huyt p, nhp th, tri gic theo thang im Glasgow nu c hn m, du hiu thn kinh khu tr...c chn thng s no kt hp hoc cc tn thng khc kt hp. Mu sc da, nim mc. - C nn ra mu, nc tiu c mu khng ? - C au bng khng? au khu tr hay lan to ? 4.2. Khm bng: - Cn khm t m, ton din v h thng bng quan st k lng vng bng trc,vng lng, tng sinh mn nhm pht hin cc vt bm tm, t mu, sy st. S nn bng pht hin mt vng au c nh qua nhiu ln khm hoc c im au, bng co cng hoc c phn ng thnh bng, bng chng khng tham gia nhp th, c cm ng phc mc khi thng tng rng (Blumberg +), cc trng hp chy mu trong cn g c vng thp. Khm trc trng m o l mt thm khm bt buc i vi CTBK khi c mu hoc dch trong bng, ti cng Douglas phng au. Ngoi ra cn khm pht hin cc triu chng gy xng chu, xng sn ... 4.3. Chc d v chc ra bng: Chc d bng vi mc ch chn on c Solomon thc hin ln u tin nm 1906. Vi mc ch thm d v lch, t l chnh xc 76% v khng c bin chng th thut. Coleman khuyn dng kim nh c ng knh 0,5 mm v chc b ngoi c thng.C th chc d di hng dn ca siu m cho t l dng tnh cao. 211

Chc r bng dng tnh khi ht ra c mu khng ng chng t c chy mu trong bng v c coi l tiu chun vng trong chn on chy mu trong bng,hoc c th ht ra dch rut, tu, dch c ln dch mtTuy nhin chc d m tnh khng th loi tr thng tn trong bng. Phng php ny ch dng tnh trong khong 80% cc trng hp chy mu trong bng. Chc ra bng c nhy v c hiu hn, t l chnh xc t 88,5 n 100%. Nm 1964 Root tin hnh chc v ra bng: Lun qua kim mt catheter nh, qua nh git nhanh khong 500ml dung dch mn 0,9%. Th tch dung dch ny s pha long v lm tng khi lng dch trong bng. Dch ht c c mu l chy mu trong. Nu nghi ng, quay ly tm m s lng hng cu, bch cu. Chc ra bng dng tnh khi hng cu trn 100.000/ ml (chy mu trong), bch cu trn 500/ml (vim phc mc), amylaza c nng cao. 4.4. Cc phng php chn on hnh nh: 4.4.1. X quang: Chiu hoc chp bng khng chun b trong iu kin cho php. Bnh nhn a chn thng nn chp khung ch u, ct sng, phim phi thng pht hin cc hnh nh: lim hi trong thng tng rng; hnh nh vm honh tri b y ln cao, m vng h sn tri, i trng gc lch h thp, bng d dy trng hi b y lch vo trong do v lch; m vng thp do c dch t do trong bng. Phim X quang c th thy hnh nh xng gy, mt bng c tht lng chu, m bng ... 4.4.2. Siu m: Hin nay siu m c xem l phng tin u tay chn on chy mu trong bng do chn thng (kt hp vi lm sng) vi cc u im ca phng php ny nh thc hin ngay ti ging bnh, ngay c trong tnh trng nng, khng gy nguy him, au n cho ngi bnh v c th lm i, lm li nhiu ln. Tuy nhin c hn ch trong chn on v tng rng, trn c a ngi bnh qu bo... ph thuc vo trnh v kinh nghim ca ngi thc hin. Nu thc hin tt, siu m chn on c th thay th c bin php chc ra bng trong chn on chy mu trong bng. 4.4.3. Chp ct lp vi tnh ( CT- scanner): Xc nh chnh xc tn thng nhu m, cc ng v tng c, khi mu t, phn loi c mc tn thng gan, lch, thn, hnh nh chn p, c dch t do trong bng nhng t gi tr trong chn on v tng rng v chn thng ty sm . Tuy nhin phi vn chuyn bnh nhn v mt thi gian nn ch thc hin nhng bnh nhn c huyt ng hc n nh. 4.4.4. Soi bng: C th s dng trong chn on chn thng bng, nh gi quan st gan, c honh, thnh bng trc. Tuy nhin kh nng p dng cn hn ch, i hi phi gy m v kh trin khai trong cp cu nht l trng hp a chn thng

212

4.4.5. Chp ng mch chn lc: Ch nh cho cc trng hp c tn thng tng khu tr, huyt ng n nh. Tuy nhin ch nh rt hn ch. 5. Hng x tr Chn thng bng kn c tn thng tng cn phi m cng sm cng tt, nu cng mun th t l t vong cng cao. Tuy nhin khng phi ch n thun yu t thi gian m cn phi chn thi im can thip phu thut ph hp vi tng trng hp bnh nhn c th. 5.1. Hng x tr chung Nu c v tng c gy chy mu trong bng th phi m cp cu khn cp, va hi sc (quan trng nht l truyn mu) va m cm mu. Nu chn ch, ch i th mu vn tip tc chy v hi sc s khng c hiu qu. Nu c tn thng tng rng v c vim phc mc th phi m cp cu. Trng hp bnh nhn khng cn chong na th m cng sm cng tt. Nu bnh nhn ang chong nng th trc ht phi chng chong tch cc theo di st, khi chong tm thi n nh th can thip phu thut ngay (nu m trong lc bnh nhn ang chong s lm cho chong nng thm, khng hi phc). 5.2. Hng x tr ring i vi tng tng b tn thng: 5.2.1. V gan: - X tr v gan ph thuc tnh cht, c im tn thng, tnh trng bnh nhn. Hin nay nh c phng tin nh siu m, chp ct lp vi tnh kt hp vi lm sng chn on chnh xc mc v theo di tin trin ca tn thng gan. V vy c th iu tr bo tn v gan chn thng khi: bnh nhn c huyt ng n nh, khng c cc du hiu chy mu tip, tn thng gan mc nh, trung bnh ( I, II). - La chn phng php phu thut, vi nguyn tc bo tn ti a t chc gan, ch ct lc nhng t chc gip nt, c th phi ct b phn thy hoc c mt thy gan nhng cng ch tin hnh khi gip nt hon ton khng cn kh nng hi phc. Khi x tr cn ch : Cm mu bo m, tm buc cc ng mt b t, hn ch r mt. - Cc phng php x tr phu thut: + Chn gc cm mu. + t in cm mu. + Khu cm mu. + Tht ng mch gan. + Ct gan in hnh hoc khng in hnh: ct h phn thy, phn thy ... 5.2.2. Tn thng lch: - Trc y tn thng lch do chn thung, ct b lch l chnh. Tuy nhin bnh nhn sau ct lch, nht l tr em c nguy c nhim khun rt ca o do vai tr min dch ca lch khng cn. iu tr bo tn v lch chn thng khi: 213

V lch nng, nh I, II khng c tn thng phi hp khc trong bng. Bnh nhn khng c bnh l v mu, c phng tin theo di (my siu m, chp ct lp...) hi sc, phng tin m kp thi, m bo mu truyn. Phu thut vin c kinh nghim theo di, kh nng thc hin phu thut cp cu mi lc. Cc k thut bo tn lch chn thng: + Khu lch hoc khu lch c trm mc ni + Ct lch bn phn. + Dng cc cht cm mu ti ch bng s collagen, keo fibrin... + Bc lch bng li Vycryl, r Dexon. + Nhng trng hp phi ct b lch nn cy ghp lch t thn (ly khong 20 gam lch- mt lt mng, cy vo mc ni ln hoc trong bao c thng to) m bo chc nng ca lch. 5.2.3. Tn thng ty: Nguyn tc x tr: cm mu, ct lc t chc hoi t, gi li nhiu tuyn ty, dn lu tt v trit . Cn theo di chm sc nui dng tt sau m c th phi m thng hng trng nui dng ngay trong khi m. - Nu ch tn thng nhu m, ng Wirsung cn nguyn vn th khu nhu m ty, dn lu hu cung mc ni. Nu ng Wirsung b tn thng th c th : + Khu phc hi ng Wirsung. + Ct b ty (ui ty). + Ni ty - tiu ha. - Nu u ty dp nt kt hp vi tn thng t trng c th phi ct khi t ty (phu thut Whipple). 5.2.4. V d dy: Khu kn theo chiu ngang nht l vng hang v trnh hp. Cn kim tra trnh b st v thng mt sau. 5.2.5. V t trng: X tr chn thng t trng rt phc tp v ph thuc kch thc tn thng, v tr trn hay di c Oddi. Ni dung phu thut: khu t trng ch b rch v phi lm thm cc th thut gim p trong lng t trng: ni v trng; dn lu ti mt; m thng d dy, lun ng cao su qua mn v ht lin tc m thng hng trng nui dng. i khi phi ct on d dy, ct khi t ty nu tn thng ln v kt hp vi ty. D p dng bin php no th kh nng bc ch khu t trng vn c th xy ra. Do cn dn lu cnh ch khu v phi nui dng tt sau m (truyn mu v m). 5.2.6. V rut non: V rut non cn kim tra k trnh b st tn thng nht l trng hp thng nh, thnh rut bm gip nhiu, n mun nhiu gi mc ... - Nu tn thng nh th khu li.

214

- Nu tn thng rng hoc tn thng nhiu ch gn nhau th ct on rut, ni rut tn - tn hay bn - bn. 5.2.7. Thng i trng: a ch thng ra ngoi thnh bng, lm hu mn nhn to hoc khu ch thng v lm HMNT trn dng, khng khu kn k u. 5.2.8. V bng quang: - Khu li bng quang. - Dn lu bng quang trn xng mu, khng c khu kn bng quang n thun v nguy him d x bc ch khu. Sau khi x tr tn thng cc tng xong, iu ht sc quan trng l phi lau ra sch bng, cn vic t ng dn lu bng u, ch no th do phu thut vin quyt nh ty tng trng hp c th.

S x tr chn thng bng kn

CTBK BN Shock huyt ng khng n nh Khng c a ch.th + M ngay C a ch.th Ch.ra bng -Hi sc theo di Ch.ra bng + Nghi ng M Theo di tip Mu t M Theo di lm sng Khng th kh.bng do hn m Bng Nghi ng BN c huyt ng n nh C th kh.bng c Bng bnh thng

Siu m +

215

Mt s cp cu bng ngoi khoa tr em

TS. Hong Mnh An

1. Cc d tt hu mn trc trng
1.1. i cng: - D tt hu mn trc trng l cc d tt hay gp ca on cui ng tiu ho, bao gm cc loi khng c hu mn n thun hoc khng c l hu mn km cc ng r vo ng tit niu, sinh dc. - T l gp khong 1/500 n 1/1500 ln sinh, gp tr trai nhiu hn tr gi. - Trc y, t l t vong l 60 -70% hoc c nhiu bin chng. Gn y do nhng tin b trong chn on bo thai hc, c c cch phn loi d tt hp l, ch trng lm HMNT sm, trnh gy m hi sc nhi khoa c nhiu tin b lm gim t l t vong xung di 10%, t l tai bin cng gim. 1.2. Bo thai hc : T tun th 5 n tun th 8 ca phi thai bt u c s bit ha hnh thnh trc trng, hu mn v b phn sinh dc. Phn cc ui ca phi c mt vng c gi l nhp l ni chung ca rut cui pha sau v niu nang pha trc, c mt lp mng nhp che ph bn ngoi. Qua trnh bit ha din ra hai giai on: - Hnh thnh vch ngn hon ton gia niu sinh dc vi trc trng, do l phi gia ta t trn xung mu ct to ra xoang niu sinh dc phn bng v trc trng phn lng. S ngn cch ny nu khng kn hon ton s to ra ng r cao bm sinh. - Hnh thnh ng hu mn v l hu mn l s ha hp ca cc l phi trong, gia v ngoi. ng trc trng i xung gp c hu mn v tr hu mn s khai; c hu mn pht trin vng quanh to ra c tht ngoi ng hu mn v hu mn. Mng nhp v mng hu mn tan i. - Nu qu trnh tan mng hu mn v mng nhp khng thun li s xut hin d tt hu mn lc ch. Nu ng trc trng i xung khng gp hc hu mn, hoc c tn thng mch mu nui dng s xut hin teo hu mn hoc cc d tt khc... 1.3. Phn loi d tt hu mn trc trng 1.3.1. Mc xc nh - Mc gii phu: ai qung c mu trc trng (M), vng t xng mu n khuu gp ca on ni trc trng hu mn, i ngang phn gia m o ca n hoc nh tuyn tin lit nam. - Mc X quang: B trn xng mu (Pubis). im ct ha cng ct (Coccyx). 216

 ngi (Ischium). K thut chp + Chp t th Vanghensteen Rice (1930): u dc ngc, chn tri dui, chn phi co, cng chn gp 900, i gp 900 vo bng, ch hu mn bt kn nh du mt vt cn quang nh. + K thut Cremin 1970: ci tin gp c hai i vung gc vi bng, khi hai ngi chp lm mt (Ischium), trng vi ng PC v ai qung c mu trc trng, pht hin c cc tn thng d dng cng ct thai nhi. 1.3.2. Phn loi d tt * Phn loi Ladd v Gross (1934) Gm 4 kiu th: - Kiu th I: Hp hu mn trc trng. - Kiu th II: Hu mn mng. - Kiu th III: Hu mn bt kn. - Kiu th IV: Loi hai ti cng. * Phn loi Sartulli (1965) Sartulli phn loi ging Ladd v Gross nhng kiu th III li chia thnh III cao, III thp. * Phn loi Melbourn Nm 1970, trn 200 nh phu thut nhi hp Melbourn (Australia) ra phn loi mi da vo vng ai mu-trc trng chia lm 3 loi: - Loi cao: D tt v ti cng trn vng ai mu trc trng. - Loi trung gian: D tt v ti cng trng vi vng ai mu trc trng - Loi thp: D tt v ti cng nm di vng ai mu trc trng. Tm tt phn loi quc t: Hu mn mng Hu mn np Khng r Teo hu mn Teo HMTT Hp HM mng. Hp HM np. R HM tng sinh mn. Khng Trc tip R HM da. D R HM - m h. c l tt R HM - tin nh. hu mn C r R TT - tin nh. R TT - bng quang. Gin tip R TT - niu o. R TT - m o. R TT - nhp. Hp ng HM-TT. C l Teo trc trng. hu mn Khng r 217

C r Ghi nh: - Nhng d tt c tn trc trng (tr r trc trng - tin nh, r trc trng - m o thp, r trc trng - niu o hnh) u l cc d tt cao. - Nhng d tt c tn hu mn (tr teo hu mn) gi l cc d tt thp. - Cc d tt cn li (nhm tr) l d tt trung gian. 1.4. Chn on: 1. 4.1. Khng c l hu mn-khng r - Lm sng: c hi chng tc rut s sinh. Tr nn sm ngay sau khi sinh hoc sau ln cho n u tin. Bng trng cng. - Khm ti ch khng c hu mn. Tng sinh mn b bt kn hon ton. Vt tch hu mn c vng thm m, dng kim chm vo thy c phn x co tht, chng t c du tch c tht ngoi. - Gm cc loi: Hu mn mng. Hu mn np. Teo hu mn. Teo hu mn trc trng. 1.4.2. Khng c l hu mn- c r - Lm sng: tr i ra nc xanh ca phn su hoc u niu o dnh phn xu. Trng bng, nn nhng khng rm r. - Khm ti tng sinh mn c cc l r kn khng nhn thy. V c ng r thot phn, hi nn nhng ngy u khng c biu hin tc rut hon ton ngay. - Gm cc loi: + R trc tip: Tr em nam c 4 loi: Hp hu mn mng. Hp hu mn np. R hu mn tng sinh mn. R hu mn da. Tr em n c 3 loi: R hu mn-m h. R hu mn-tin nh. R trc trng-tin nh. + R gin tip: Tr em nam c 2 loi: R trc trng-bng quang. R trc trng-niu o. Tr em n c 2 loi: R trc trng-m o. R trc trng-xoang tit niu sinh dc. 1.4.3. C l hu mn - khng r - Hp ng hu mn v trc trng. - Teo trc trng. 1.5. iu tr 218

Cc d tt HMTT ni chung phi iu tr ngoi khoa, tr hp hu mn c th nong sm 1.5.1. Ch nh M cp cu (ch yu cc d tt thp): - Hu mn bt kn, khng r hoc r nh. - C l hu mn nhng teo trc trng. - Cc d tt c l r nh (r trc trng- tit niu, trc trng- m o) Cc trng hp khc m tr hon (d tt cao v hu ht d tt trung gian). L r trng thy c th nong ch tr ln. 1.5.2. Phng php m * Phu thut tm thi:lm hu mn nhn to * Phu thut trit - H bng trc trng ng bng-tng sinh mn. - H bng trc trng ng tng sinh mn. - Rch rng, ct np hu mn. - Ct ng r. 1.5.3. Bin chng - M d tt cao l phu thut rt nng, t vong cao. Ngay sau m cn phng suy th. - nh gi mch mu nui dng khng tt nn on rut a xung d b hoi t, gy vim phc mc. - V lu di d c hp hu mn, v th cn thc hin nong hu mn sau m cho tt. - C th i ngoi sn phn do chc nng c tht ngoi yu, khng trng lc cn thit. 2. Bnh dn i trng bm sinh (Megacolon, Hirschsprung) 2.1. i cng: - Nm 1886 Harol Hirschsprung (an Mch) m t u tin v bnh. Cc nghin cu tip sau ca cc nh gii phu bnh kt lun: trc trng khng c cc t bo hch l th phm gy dn to i trng. - Nm 1946 Swenson (M) lm thc nghim v sinh thit hng lot bnh phm thy c 90% bnh nhn khng c t bo hch vng ni trc trng - i trng Sigma (aganglionarie). Do vy nhiu phng php phu thut ra i. - Theo Bodian, t l gp ca bnh l 1/2000. Nam/n = 4/1 - Dn i trng bm sinh phn lm 3 loi : + Dn bm sinh : Do v hch thnh trc trng c ngay t lc . + Dn mc phi hay th pht: Tr mc bnh khng c iu tr c hiu qu t u. Tnh trng ng ko di lm cho i trng ngy cng dn to; d tt hu mn trc trng (mc bnh KST, bnh Chagas lm cho t bo hch i trng teo i ...); nhng khi u vng tiu khung chn p trc trng ko di. + Dn c nng : Trong mt s bnh thn kinh, nhc nng tuyn 219

gip, tuyn yn, ri lon nhim sc th, x ho c trn trong ... 2.1. Bnh nguyn, bnh sinh 2.2.1.Bnh sinh - on i trng trn chu s chi phi ca dy ph v. Sigma v trc trng do thn kinh ph giao cm chi phi. Cc nhnh trc hch dn truyn kch thch n m ri thnh rut lm co bp c vng, nhng li gim trng lc c tht trong, lm m hu mn. tr bnh, nhu ng rut b thay i, trc trng hu nh khng c nhu ng, i trng Sigma nhu ng gim. i trng xung nhu ng tng ln, cc on i trng khc nhu ng bnh trng. - Do tr khng t i a c, i trng b ng phn phn trn ko di lm tr b nhim c phn, n ung km, chm pht trin, thiu mu, suy dinh dng, bng ngy cng to, chn p c honh, lng ngc b hp a ti tnh trng gim h hp, vim nhim h hp. Tr cng d nhim trng ng rut, a chy ko di. 2.2.2. Bnh nguyn - Cho n nay, ngi ta vn cn cha bit c nguyn nhn v hch v v sao s v hch ch trc trng (thuyt v hch). - State v Rhbein cho rng bnh khng phi l do mt t bo hch, bng chng l c tr t bo hch pht trin sm hn m ri cng, thnh rut ch l t bo hu hch. V th phi o nhu ng rut (thuyt ny cng khng lm r c nguyn nhn) 1.3. Gii phu bnh: 1.3.1. i th: i trng ngang bnh thng, i trng tri hi gin to nhng thnh khng dy. i trng Sigma v phn trn trc trng to ra (ng knh c th t 2 n 56 ln bnh thng), thnh dy c khi qu 1cm. Di dc c to v di ra. Nim mc vim lot, chy mu, c khi b thng. on di trc trng v ng hu mn ng knh hp hn bnh thng hoc hon ton bnh thng, di t 6 - 10 cm, trng ging mt ci phu. Thc cht y l on gy nn bnh l. 1.3.2. Vi th: Gia hai lp c ca ng hu mn khng c t bo hch trong m ri Auerbach v Meissneir, cc si trc khng c bao myeline. Tnh trng trn tp trung vng v hch ni trc trng - i trng Sigma, lm mt nhu ng t ng. 1.4. Triu chng: 1.4.1. Tr s sinh (th c tnh): Din bin nng, t vong cao. * Lm sng : ging triu chng tc rut c gii . - Khng c phn su (bnh thng l 3- 6 gi, chm l 24 gi sau , nu qu 24 gi l bnh l). - Bng chng, quai rut ni, c khi ging tun hon bng h. 220

- Tr nn, c du hiu mt nc . - Chp i trng c Baryte: thuc lu i trng rt lu, thi rt chm (3 5 ngy sau). - t Sonde Nlaton 14 vo hu mn c hin tng tho cng (hi v phn su ra nhiu, bng ht chng). Song sau khi rt sonde, d tr c i a, nu chp Baryte th hm sau vn cn Baryte trong i trng. 50% trng hp nh vy l megacolon, cn 50% l tc rut khc. * Xquang: Chp khng chun b, t th ng, c nhiu mc nc - hi, khung i trng cha dn to, ng knh vn bnh thng. 2.4.2. Tr nh nhi, tr ln: Triu chng in hnh. * Lm sng : - To bn trng din. - Khng t i a c, phi tht tho, kch thch ... - Phn khng thnh khun (dt hoc nho). - Mi phn rt khm (do tch lu v khun ln men). - Thm trc trng: qua hu mn 1-2 cm thy phn. * Triu chng ca bin chng (cht 75% trc 2 tui). - a chy nhim c, nhanh chng truy tim mch (entrocolite). - Vim phi, ph qun ph vim. - Suy dinh dng: khng n c li nhim c. - Tc rut hoc bn tc rut do u phn (Fcalome) d b chn on nhm u bng hoc u nang bung trng . * Xquang: phim chp i trng c Baryte ly c ng hu mn: - Thng: i trng dn to, khng thy on hp . - Nghing: thy on hp, c hnh phu. * Sinh thit c trc trng: c Swenson coi l phng tin chn on kh chc chn nguyn nhn v hch. * o nhu ng trc trng: thy i trng ln nhu ng bnh thng; i trng ngang, i trng xung nhu ng tng; sigma dn to nhu ng km; trc trng khng c nhu ng. * o phn x c ch trc trng hu mn: khng c phn x kiu Denis Browne (1935 Denis Browne lm ngi bnh thng: hin tng cng trng bng trc trng gy dn ng hu mn, c trn trong nhng c tht ngoi th tht li). 1.5. Chn on Da vo:- Lm sng. - XQ: c hai phim thng, nghing ly t phn mm hu mn tr ln . - Sinh thit: ly c thnh trc trng, khng c t bo hch thn kinh. 221

- o nhu ng rut. 2.6. Tin trin Nu khng iu tr kp thi th ngoi bin chng vim nhim, a chy ... cn dn ti v rut, tc rut . 2.7. iu tr 2.7.1. Ni khoa: i vi tr s sinh ch yu l ni khoa chm sc (nursing). - Tht tho hng ngy nc mui 90/00 . Sonde nn a vo su, vt qua ch khng c t bo hch. - Nong hu mn hng ngy: do c trn trong l c trn b co tht lin tc, nong hu mn mi to c iu kin cho tr d i a. - Ch n nng lng. - Nu iu tr ni khng c kt qu phi lm hu mn nhn to. 2.7.2. Ngoi khoa: i vi tr ln phi iu tr ngoi khoa. - Tm thi: lm hu mn nhn to - Trit : Ct b ton b vng v hch, lp li lu thng rut. Cc phng php m: - Phng php Swenson (1948 - M): Ct on v hch v dn to, bng cch phu tch, ln ra ngoi ct pha ngoi ri khu ni tn-tn, thng cch hu mn 1,5 cm. Sau a tr li bng. - Phng php Duhamel- Grob (1956-Php): Ct trn vng v hch, loi n ra khi ng tiu ho, ni i trng lnh tn - bn. - Phng php Soave (1960-): Ct b on i trng dn v v hch, nhng li mt ng thanh c trc trng, lun on trn qua, sau 1/2 thng lin so th sa l ngoi.s - Phng php State-Relibein: (Theo thuyt khng phi v hch) Ct phn i trng dn to v ct trc trng ti a 6 - 8 cm. Ni vi rut lnh v ph phc mc ln (khu ni ngoi phc mc). 3. Tc rut tr s sinh 3.1. i cng - Thi k s sinh: Theo Swenson thi gian s sinh t 7- 15 ngy. Dellerin F. cho l 1 thng. Ferve, Marion cho l 10 ngy u. Song khong thi gian c tha nhn nhiu hn l 1 thng. - Theo Gross (1952): 40 - 50% tr s sinh b tc rut l tr non, thiu cn nng, m a i. T l t vong rt cao v n mun - Bnh l tr s sinh chn on cn kh mun v phn nhiu thy thuc c

222

s cn cha quen vi bnh l ny. Tr non cha c n nh do sc chu ng km, c mt s d tt phi hp: tim, thn; s pht trin cha hon chnh ca mt s c quan: cc yu t ng mu cha bn vng, vn mch yu, h h hp nh b, thn kinh cha hon chnh...; d vim nhim h hp do tro ngc. - a a s cc d dng tin thin gy tc rut cn c m ngay trong thi k s sinh. Vic phu thut, gy m, chm sc sau m i hi rt cao v kinh nghim chuyn su. 3.2. Bnh sinh Tc rut tr s sinh c chia lm 2 loi c nng v c hc, nhng khc vi cc la tui khc l tr b tc tin thin. 3.2.1. Tc rut c nng - Tr c tnh trng nhim trng ton thn nng: vim ty da, c lan to; vim phi; nhim trng rn. - Tr c bnh l: megacolon, v hch trc trng... 3.2.2. Tc rut c hc * Tc rut cao: ch yu l tc t trng di bng Vater do cc nguyn nhn sau: - Ni ti: Teo t trng Hp t trng T trng bt kn kiu mng ngn hon ton hoc khng hon ton. - Ngoi lai: Dy chng Ladd- Gross do rut quay cha ht. Ty nhn lm hp t trng. Hch vo t trng. Tnh mch ca bt cho trc t trng. * Tc rut di gc Treitz: do cc nguyn nhn sau: - Ni ti: Teo rut D tt bt kn hu mn (teo hu mn trc trng). Tc rut do phn su. Nt phn su. - Ngoi lai: Vim phc mc kt bc do thng rut bo thai. Vim phc mc phn su. 3.3. Triu chng 3.3.1. Mt s nt v sinh l tiu ho - Hi: C sau 6 gi. - Phn su: Sau vi gi tr a ra phn su, tr non a phn su mun hn. 80% tr c trong 24 gi. Phn c mu xanh en, qunh, dnh, thnh phn c dch tiu ho, nht l dch mt, thnh phn biu b ca da tr (sng, lng). Khi ty ether, nhum mu v soi trn knh hin vi s thy cc thnh phn ny (gi l nghim php Farber (+). 3.3.2. Triu chng lm sng: 223

Tr c hi chng tc rut s sinh gm: - Khng a phn su: Do tn thng tin thin, tc rut xy ra t thi k bo thai, hoc cng c th c nguyn nhn c hc. on rut trn ch tc dn to, on di xp. Tr sng c nh trao i cht qua nhau thai. Sau khi a tr khng a phn su hoc nu c ch l cc kt th ca nim dch mu xm (nghim php Farber (-). - Nn ra dch mt: Tr nn ngay sau khi ung nc hoc n sa ln u tin. Cht nn l nc, sa va ung. Mun hn l dch tiu ho c mu mt hoc mu ging nc phn. - Bng chng: Bng tr ngy cng to dn, cng bng, c tun hon bn h, c th vim ty quanh rn, hai bn bu hoc hai bn mi ln. 3.3.3. Thm trc trng: Dng ngn tay t hoc sonde nlaton thm trc trng khng a vo su c (nu vo c c th c hoc khng c phn xu ra). 3.3.4. X quang: Chp bng khng chun b c nhiu hnh nh mc nc - hi, ty tng loi tc m c nhng du hiu c hiu khc. 3.4. Chn on - Da vo lm sng: c hi chng tc rut s sinh. - Thm trc trng bng ngn tay t hoc sonde Nelaton s 8 thy: + Cm gic trc trng thu hp khi y ln cao, c cht nhy trng hoc tinh th xm: tc rut ngh ti nguyn nhn teo rut. + C phn su hoc phn su en tro ra: tc rut do megacolon. + Thm hu mn ch ln c 2 cm, khng c dch: tc rut do d tt hu mn trc trng. - Chp X quang c nhiu mc nc - hi, hoc c nhiu nt vi ng thnh khi. 3.5. iu tr - Tc rut c nng ch iu tr ni khoa. - Tc rut c hc phi iu tr bng ngoi khoa. ty theo nguyn nhn m c thi x tr khc nhau.

i cng v phu thut ni soi

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TS. Triu Triu Dng 1. Lch s ni soi v phu thut ni soi: 1.1. Thi k s khai: Trc Cng Nguyn, nhiu thy thuc Hy Lp, Ai Cp v La M s dng nhng chic ng nh vi mc ch ban u l nui dng cho bnh nhn cng nh dng chng tht tho. Dn dn, ngii ta nhn thy nhng chic ng c th gip chn on bnh. Lch s ghi nhn Hyppocrates (460 375 BC) l ngii tin hnh chn on qua ni soi sm nht. ng m t dng c banh trc trng c cu to v nguyn l hot ng rt ging cc dng c hin nay. M t dng c tng t cng c thy trong nhng ti liu Pompeii (Italia) cng thi k . Hn th, chng cn c s dng thm khm mi, tai, thanh qun, m o. Nhng th thut thm khm trn c tin hnh d i nh sng t nhin. Sau mt thi gian rt di, Abulkaism (980 1037 AD) v Giulio Cesare Aranzi (1530 1589) s dng gng phn chiu lm tng sng, gip nhn r nhng phn su hn bn trong. Trong sut thi gian t trc cng nguyn n th k 18, vic thm khm nhng b phn bn trong c th qua ng soi lun gp tr ngi rt ln l thiu nh sng. Philippe Bozzini (1773 1809) sng ch ra mt h thng dn truyn nh sng bao gm mt ngn nn, mt gng phn chiu thm khm trc trng v bng quang; nh sng qua mt ng vo bng quang chiu sng, cn ng soi knh th 2. Antonio J. Desormeaux (1815 1881) pht minh ra dng ng soi mi. Ngun sng l s t chy ca hn hp alcohol v turpentine, nh sng qua gng phn chiu, qua mt thu knh hi t vo ng soi gip ng thm khm niu o, bng quang, m o. Vo thi im , nng lng in c tm ra, tuy nhin Desormeaux khng p dng lm ngun sng vi l do thit k qu phc tp v tn km. 1.2. Bc t ph th nht: Pht minh c tnh t ph, tin thn ca nhng ng soi ngy nay l ca Maximillian Nitze (1848 1906). Nm 1879, ng pht minh ra ng soi bng quang vi mt h thng thu knh gm c 3 phn: 1 vt knh, 1 thu knh trung gian v 1 th knh. H thng thu knh ny cho gc nhn rng hn v phng i hnh nh. Ngun sng l mt si dy platium c t nng bng in. n nm 1885, sau khi Thomas Edison pht minh ra bng n in, Nitze thay th ngun sng (si platium) bng mt bng n in nh gn u ng soi. Nm 1901, George Kelling, phu thut vin ngii c, tin hnh soi bng quang trn ch sng; bo co c trnh by ti hi ngh Hamburg. to trng quan st c rng ri, ng bm kh tri vo bng ch bng mt kim nh xuyn qua thnh bng. Cui nm 1910, Hans Christian Jacobaues (Stockholm) cng b bo co v soi bng v soi lng ngc u tin trn ngi trong tp ch Muchener Medizinissche Wochenschift. Sau khi m thc nghim 20 225

t thi vi nhng Trocart do ng t sng ch, Jacobaues thc hin soi bng trn 17 bnh nhn b c chng v soi lng ngc 2 bnh nhn c trn m mng phi. ng bm kh tri vo bng trc tip qua Trocart. Nm 1911, Jacobaues bo co kinh nghim: 115 trng hp soi bng, 45 trng hp c bnh l; v 72 trng hp soi lng ngc, 27 trng hp c bnh l. 1.3. Bm hi bng: Cho ti u th k 20, nhiu tc gi nhn thy rng bm hi bng l yu t rt quan trng ng gp cho thnh cng ca thm khm qua ni soi, c bit l ni soi bng. Tuy nhin, vic s dng kim chc xuyn qua thnh bng c th gy ra nhiu bin chng nh chy mu; s dng cc loi kh bm trong bng c nhiu tranh ci nh kh tri, O2, CO2, helion, nitro v mi loi u c u nhc im cng nh s tin li v gi thnh khc nhau. Mt khc, duy tr p lc lun hng nh trong khoang bng l mt vn tr ngi ln gy kh khn cho qu trnh thm khm t ra mt nhu cu i hi pht trin v cng ngh. Nm 1938, Janos Veress (Hungary) s dng mt cy kim t ch chc ht dch c chng v chc ht kh dch trong khoang mng phi. Nng cy kim ny t u, tt vo trong ng khi chc qua thnh bng v nh ra ngay sau kim qua cc lp thnh bng bo v cho cc tng khi u nhn ca kim. Phng php ca Veress hin vn cn c p dng cho bm hi bng theo phng php kn ngy nay v cy kim c mang tn ng. Nm 1924, Richard Zollikofer (Thu S) ngh dng CO2 bm hi khoang bng thay v dng kh tri lc hay nitrogen trnh nguy c chy n trong bng v phc mc hp thu CO2 tt hn hp thu cc kh khc. 1.4. Bc t ph th hai: Harold H. Hopkins c 2 pht minh ht sc quan trng, c coi l nn mng cho dn my ni soi ngy nay: h thng thu knh hnh que v cp si thy tinh dn sng. Nm 1954, ng cng ngi hc tr Kapany gii thiu mt loi ng soi mm c cu to bi cc b si thu tinh ng hng, cho php dn truyn nh sng i theo trc thay i. H thng thu knh hnh que gm mt vt knh c trng nhn rng v mt lot cc thu knh hnh que bng thu tinh. Bt u gia nhng nm 60, ngi ra cho rng Kurt Semm (c) i tin phong trong lnh vc ni soi. ng ch to ra hng lot dng c gip cho vic thm khm v lm th thut qua ni soi bng. ng cng ch to ra h thng bm kh t ng gip duy tr p lc kh trong bng mc hng nh. Nh , nhiu th thut c tin hnh qua ni soi bng. 1.3. Bc t ph th ba: n nm 1985, yu t cn thiu trong h thng my ni soi phc v phu thut c pht minh. l s xut hin ca chic my quay phim c s dng chip in t ca hng Circon Corporation, kt qu ca s pht trin k thut sn xut cc linh kin vi in t trong 2 thp k trc . u camera c 1 chip silicon trong, trn con chip ny c mt vng c chia nh thnh cc phn t 226

cm nhn nh sng gi l CCD (charge coupled device). B phn ny tip nhn hnh nh t ng soi v truyn tn hiu in t qua mt ng truyn ti b phn nhn v gii m hnh nh video (video processor), v sau hnh nh c truyn ln mn hnh ti vi. 2 nm sau , Philippe Mouret (Php) thc hin ca ct ti mt ni soi u tin, khi u cho mt cuc cch mng mi trong ngnh ngoi khoa trn th gii. 2. Phng tin v dng c phu thut ni soi: Cng vi s pht trin nhanh chng ca khoa hc k thut cui th k XX, phu thut ni soi (PTNS) c nhng "yu t vt cht cn bn" thc s l mt chuyn ngnh mi ca y hc. 2.1. Camera: Trong PTNS s dng CCD (charged couple device) chip. B mt CCD chip c phn chia thnh rt nhiu vung gi l cc phn t (pixels) cm nhn nh sng. Khi mt chm photon nh sng p vo 1 phn t, mt tn hiu in t s c sinh ra v c gi ti u thu. Ti u thu, tn hiu c tng hp t cc phn t to nn hnh nh truyn hnh. CCD cng cha nhiu pixels th phn gii ca hnh nh to ra cng cao. Cc camera hin nay thng c 3 chip, mi chip nhn 1 mu ring r, v vy phn gii ca camera 3 chip cng cao hn rt nhiu so vi camera 1 chip. Tn hiu hp iu khin camera truyn n mn hnh (hoc thit b ghi) c nhiu dng nh Composite Video, tn hiu Y/C, tn hiu RGB. Tuy nhin, cc camera hin ang s dng ch yu l cc th h RGB, c kh nng truyn cc tn hiu mu ring r (, xanh da tri, xanh l cy) theo 3 knh khc nhau, sau cc thnh phn ny s c ti to li mn hnh hay u thu thnh hnh nh mu. Mt phng thc tinh vi hn trong x l hnh nh ca cc camera th h mi nht l p dng vic x l k thut s hnh nh c truyn t CCD trong u camera khin cho cht lng hnh nh trung thc hn. 2.2. Ngun sng: C 3 loi hay c s dng trong PTNS l xenon, halogen v metal halide. Do cc bng n khi hot ng c nhit rt cao nn trong ngun sng bao gi cng c mt qut gi lm mt bng n v cc thit b khc. Ngun sng ni vi ng soi bng mt cp si thu tinh, c cu to bng mt b bao gm rt nhiu cc si thu tinh rt nh dn truyn nh sng, xung quanh c bao bc bi 1 lp o bng cht do tng hp. nh sng c truyn t cp si thu tinh qua mt khp ni vo i dc theo theo ng soi qua mt h thng b si thu tinh nm xung quanh h thng thu Hopkins. S sp t ny cho php t ngun sng xa ng knh, nh u ng soi vn nh sng m khng b qu nng v c gi l h thng nh sng lnh (cold light source). 2.3. Thit b ghi hnh: 227

Nhm mc ch lu li hnh nh ca cuc m cho php phu thut vin xem li k thut m ca mnh, xem li chi tit khi c tai bin bin chng, ng thi c th s dng lm phng tin ging dy, nghin cu, trao i thng tin gia cc phu thut vin. Vic ghi hnh lin tc c thc hin bng cch ni mt u ghi bng video, u ghi CD/DVDRW hoc my tnh xch tay vo h thng hnh nh. Thit b ghi hnh hin nay c tc dng tr gip cho ging dy, hi chn t xa 2.4. My bm kh: C kh nng bm v duy tr p lc kh trong bng mt mc hng nh, gip cho trng m lun c n nh, r rng. My bm tt l my c th bm kh tc cao v t ng iu chnh duy tr p lc bng. Hin ti cc loi my bm ang s dng c tc t 20 30 lt/pht n 40 50 lt/pht. 2.5. Trocar: c chia thnh 2 loi: loi dng nhiu ln v loi dng 1 ln. Nng Trocar dng nhiu ln thng b cn (do dng i dng li). Hu ht cc Trocar dng 1 ln c b phn che ph u nng; b phn ny t ng nh ra che phn sc nhn ca nng Trocar ngay khi Trocar xuyn qua thnh bng, gi l Trocar khng sang chn. 2.6. ng soi: Hin nay c nguyn l cu to nh ng soi cng s dng h thng thu knh hnh que do Hopkins pht minh thp k 60. ng soi ny l mt ng hnh tr c bc ngoi bng thp khng r, trong l b si thu tinh dn truyn nh sng bc quanh h thng thu knh trung tm. H thng thu knh gm mt vt knh c trng nhn rng v mt lot cc thu knh hnh que bng thch anh. Th knh ca ng soi khp ni vi camera. Vt knh c th l loi nhn thng (00), hoc nghing 300, 450, 500. ng soi cng bng c nhiu c (1, 2, 3, 5, 10mm) v c th c 1 knh lm th thut. Loi c s dng thng dng nht trong phu thut l 10mm khng c knh th thut. 2.7. Dng c ni soi: V mt chc nng khng khc vi dng c m m; tuy nhin v mt hnh thi c nhng khc bit, nht l v chiu di v c nhiu b phn chi tit. chnh l hn ch chnh ca PTNS l phu thut vin phi cm nhn nh gi tn thng qua dng c. Mt dng c tiu chun bao gm b phn tay cm c th c c cu kho, c cu xoay v cui cng l hm dng c quyt nh chc nng ca dng c (dng ch to tng t nh dng c m m). Ngoi ra, dng c ni soi cn c th c b phn ni vi dao in tr gip cho qu trnh phu tch. Mt s dng c tiu biu nh: km phu tch, kp phu thut, ko phu thut, km kp clip, dng c gt tng Nng lng in, siu m trong phu thut ni soi 228

Nu mt dng in i qua m, in tr ca m s gy ra hin tng mt s nng lng b tiu ph thnh sc nng. Hu ht cc h thng dao in c nguyn tc l truyn mt dng in gia mt dng c kim loi (in cc hot ng l b phn s tip xc vi t chc) v dng in truyn tr v qua mt bn kim loi v tr khc (bn in cc tr v) truyn xung t. H thng ny gi l my dao in n cc. Dao in lng cc, ngc li ngc li nguyn l n cc, kp t chc gia 2 in cc, v vy dng in i t in cc ny sang in cc kia qua trung gian t chc (khng i qua c th). Mt dng c phu tch siu m in hnh gm c mt u dao siu m, b phn dn truyn v phn my chnh. My chnh cha ng my pht v b phn nt iu chnh bin dao ng. Li dao c tn s 55,5 KHz, c tc dng bin cht collagen thnh coagolum (lm tc cc mch mu nh). Dng c c th t v ct ng thi m khng c nguy c tai bin ca dao in. Dng c hn m sinh hc theo 2 phng php: s dng nng lng laser hoc nng lng in, sng siu cao tn c kh nng ct t t chc. 2.9. Dng c ghim ct t ng: (Stapling device) c 3 loi chnh: - Dng c ghim dng khu 2 mp t chc cnh nhau hay m bo s bn chc, khng chy mu. - Dng c ghim ct thng (Linear cutter hay gastrointestinal anastomosis GIA device) cng mt lc ghim 4 hng v ct t chc gia (mi bn 2 hng). - Dng c ghim ct trn (end to end anastomosis EEA) cng c ci tin t loi dng cho m m sang cho m ni soi. 3. Nguyn tc k thut:

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Nm 1992, Estour E. lp bn S Eustour thnh bng vi mc ch chun ho cc v tr t Trocar. Thnh bng trc c coi nh mt hnh bu dc, c chia thnh 4 phn bi mt ng dc ni mi c - rn - khp mu v ng ngang ni im 9 gi - rn - im 3 gi. Nh vy bng c chia thnh 4 gc 1/4; mi gc 1/4 li c chia thnh 3 gc nh bi cc ng knh i qua im 1 gi, 2 gi, 3 gi...; 2 vng ng tm khc cch u nhau chia bng thnh 3 vng (trung tm, gia, ngoi) ly rn lm tm. Da trn s ny, cc phu thut vin c th d dng trao i hc tp kinh nghim ln nhau. N l nguyn tc vic s dng cho thao tc cc dng c thun li d dng. Da trn v tr, tnh cht bnh l v mc tn thng, phu thut vin c th vn dng s ny t Trocar sao cho ph hp. Chng ch nh ca phu thut ni soi Cc chng ch nh phu thut ni chung, Bao gm bnh l tim phi nng, ri lon ng mu, nhim khun huyt, thot v thnh bng rt ln, chn thng bng c huyt ng khng n nh hoc phi hp vi chn thng s no c nguy c tng p lc ni s Chng ch nh tng i Ph thuc giai on bnh, tnh trng bnh, tn thng c th, iu kin trang thit b v trnh ca phu thut vin. (Tham kho trong bi vit v tng k thut c th) u im nhc im ca phu thut ni soi u im - PTNS vn da trn cc nguyn tc x tr ca phu thut kinh in. Do vy nhng phu thut vin thnh tho m m th u c th lm tt PTNS. - PTNS cho php phu thut vin tip cn d dng hn ti nhng vng m hp, su v c nhiu phu thut vin p dng thay th cho phu thut kinh in, nh phu thut Heller, phu thut ct dy X qua ng ngc, phu thut ct gan d dy, ty tng v thc qun - Thi gian m trong mt s phu thut t hn so vi m m, nht l khi so snh thi gian t Trocar vi thi gian m v ng thnh bng. - Bnh nhn t au sau m, do ng m nh, cc c quan t b sang chn. Nh vy bnh nhn khng phi dng nhiu thuc gim au cng nh nhng ri lon h hp, ri lon vn mch do au gy nn c gim thiu ti a. - Gim nguy c nhim trng hn rt nhiu so vi m m. Cc thao tc k thut ca PTNS c thc hin trong khoang kn, v trng; lung kh CO2, dng c phu thut, cc Trocar u v trng; cc tng trong bng hay lng ngc khng b phi by ra bn ngoi nh trong m m. - Thi gian nm vin ngn do bnh nhn t au, vt m lin sm, lu

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thng tiu ho tr li sm, n ung sm hn, sc kho hi phc nhanh. c bit vi cc phu thut khng c ming ni nh ct ti mt, ct thn kinh X, m thot b bn bnh nhn c th ra vin sau 2 3 ngy. - Khng c nhng bin chng ca vt so m. Trong m m, ng m d c c thc hin chu o n u cng c th c nhng bi n chng: nhim trng, h cn c thnh bng, thot v, so li ... - Vt so di l ni bn khon ln ca ngii bnh, nht l ph n tr. PTNS gii quyt c vn thm m cho ngii bnh vi ng m rt nh. Nhc im - Phi m vi gy m ton thn. Do vy ngoi nhng chng ch nh ca phu thut ni chung, PTNS cn c chng ch nh l nhng trng hp khng c gy m ton thn. - Phng php m ni soi kt hp khung treo thnh bng mc d c u im l trng m c nh m khng cn bm hi nh ng c nhc im l thit b phc tp, vng vu cn tr thao tc ca phu thut vin, gy chn thng cho thnh bng v tng nguy c nhim trng sau m (hin nay t c s dng). - Hin tng thn kh gy suy h hp v ri lon vn mch do s hp th kh carbonic, nht l trong phu thut bng. Tai bin ny khng nhiu nh ng c th xy ra khi carbonic trong khoang phc mc c p lc cao v t ngt; nguyn nhn ch yu l do s dng tc v p lc bm kh khng ph hp. - Khng ch chy mu gp kh khn v c th khng kp thi trong nhng trng hp chy mu t cc mch mu ln. - Khng c cm gic s m m xc gic nhiu khi rt quan trng trong phu thut; gip cho nh gi v nhn nh ng tnh trng bnh l. - Vi thng tn ung th che chn rt kh khn, t bo ung th d ri vi trong khoang bng hoc thm nhp vo thnh bng qua ch t Trocar. - Thi gian m ko di mt s phu thut ln nh ct i trng, ct gan, ct lch, thay thc qun - C nhng tai bin v bin chng c th ca PTNS nh tai bin do Chc kim Veress, tai bin do t Trocar, tai bin do bm hi phc mci hi phng tin k thut ng b hin i m khng phi bt c c s y t no cng c th c iu kin trang b c.

Trin vng ca phu thut ni soi Cho n thi im ny, PTNS tri qua 20 nm pht trin v c th ni PTNS t n nh cao v k thut. Hu ht cc k thut can thip bng phu thut kinh in th hin nay u c th thc hin bng k thut m ni soi. S. Eubanks v P. Schauen (1997) phn loi PTNS lm 3 nhm 1. Cc phu thut chng minh li ch hn hn so vi m m v c

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chp nhn: ct ti mt, ct rut tha, ct i trng cho tn thng lnh tnh, phu thut Heller Nissen, ct lch, ct thc qun, g dnh rut, ti to thnh bng trong thot v bn, ct chm nang gan, ct u tuyn th ng thn, ni soi chn on 2. Cc phu thut thc hin tt v mt k thut v ang c theo di nh gi kt qu: ct i trng do ung th, ct ui ty, ni v trng, ni mt rut, sa trc trng, ct d dy 3. Cc phu thut c th thc hin c nhng cha chng minh u th hn so vi m m: phu thut Whipple (ct khi t - ty), ct gan Nm 1999, khi nim m ni soi c phn thnh 2 cp khc nhau: l "k thut m ni soi c bn" v "k thut m ni soi nng cao" cho hu ht cc chuyn ngnh nh phu thut bng, phu thut tit niu, phu thut lng ngc, sn khoa, tai mi hng, phu thut thn kinh s no C nhng chuyn ngnh nh phu thut tiu ho c th m bo t 65 85% cc mt bnh ca phu thut kinh in. Trong tng lai, PTNS s cn tip tc pht trin mnh m, tuy nhin khng thay th hon ton phu thut kinh in m y l hai phng php phu thut cho phu thut vin la chn, h tr v b sung ln nhau vi mc ch duy nht l em li li ch cho ngi bnh.

Ti liu tham kho: 1. Triu chng hc ngoi khoa NXBYH - HN 1990 2. Triu chng hc ngoi khoa NXBYH - HN 2000 3. Triu chng hc ngoi khoa NXBYH - HN 2002, tp 1, 2 4. Ngoi khoa c s NXBYH HN 1999 5. Bnh hc ngoi khoa sau i hc NXBQND - HN 2002, tp 1, 2 6. Bnh hc ngoi khoa bng NXBQND - HN 1997 7. Bnh hc ngoi khoa NXBYH - HN 1985 tp 1, 2 phn bng. 8. Tai bin v bin chng phu thut HVQY 1988 9. Bch khoa th bnh hc NXBYH - HN 2003, tp 1, 2, 3 10. Ngoi khoa c s (gio trnh ging dy i hc) NXBQND H Ni 2005 11. Bnh hc ngoi khoa tiu ha NXBYH - chi nhnh thnh ph H Ch Minh 2003 12. Ngoi khoa c s - triu chng hc ngoi khoa NXBYH - chi nhnh thnh ph H Ch Minh 2004 13. iu tr ngoi khoa tiu ha NXBYH - CN thnh ph H Ch Minh 2004

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