396

CHNG 6
NI TIT

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

397


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















1.1. Di truyn
T type 1 phi hp cao vi s gia tng thng xuyn ca khng nguyn HLA, KN
HLA u th phi hp vi T type 1 thay i ty theo chng tc, HLA B8, B14,15,
B18, Cw3, DR3 v DR4 gp bnh nhn T chng tc da trng, trong khi HLA
Yu t khi pht:
- Nhim khun
- Thc n
Yu t thc y
- Nhim khun
- Thc n
Nhy cm di truyn
Phn ng t min
T lm sng
Khng c phn ng t
min
Thuyn gim
Hai giai on pht trin T type 1:
- G1: To p ng t min hng nh vi TB o ty, biu hin bi s xut
hin cc t khng th GAD65, IAA, ICA, IA-2 (n c hay phi hp)
- G 2: Tin trin t p ng t min vi TB o ty sang T type 1.

Ngun: TCYTTG - 4.2002

398
DR3, DR4 c lin quan vi T th 1 chu , chu Phi v chu M Latinh. HLA DR3
hoc DR4 gp 95% T type 1 so vi 45-50% nhm chng chng tc da trng.
Nghin cu nhng cp sinh i ng hp t gi rng nh hng di truyn T
type 1 t gp hn l type 2. Ch c 30% nhng cp sinh i ging ht nhau b T
type 1 s pht trin thnh bnh. iu ny cng gi rng yu t mi trng lin
quan n bnh sinh T. Ngc li, cp sinh i ging nhau ca T type 2 d xy
ra trong vng nm u tin b bnh nhiu hn l anh ch em rut.
1.2. Yu t mi trng
T type 1 l hu qu ca s nhim trng, nhim c lm tn thng ty, h thng
min dch tn cng v ph hy t bo bta ty. Yu t mi trng kt hp vi tn
thng chc nng t bo o ty bao gm virus (quai b, rubella, virus coxsackie
B4), tc nhn c ha hc (nitrophnyl-urea c cho chut), v cc cht c hy
hoi t bo khc nh hydrogen cyanide t bt sn h hng hay t c sn.
1.3. Yu t min dch
1.3.1. Min dch th dch
Khng th lu hnh chng li nhng t bo o ty c tm thy phn ln bnh
nhn T type 1 ngay lc c chn on (60 - 90%) ri gim. Cng c nghin cu
cho rng t KT khng t bo tiu o (ICA: islet cell autoantibody) c pht hin
trong 5 tun u sau khi khi bnh 85-90% T th 1. Ngoi ra > 60% KT khng
insuline c tm thy trc khi iu tr insuline (autoantibody to insuline: IAA).
Ngoi ra cn c KT khng Tyrosine phosphatase IA-2 v IA2.
Ngoi ra, phn ln KT khng t bo o trc tip chng li Glutamic Acid
Decarboxylase (GAD hay GADA), mt loi men nh v trong t bo bta ca ty. C
s ging ht gia thnh phn protein ca virus coxsackie cha chui 24 amino acid
tng ng vi GAD65.
1.3.2. Min dch t bo
Cng ng vai tr trong bnh sinh T type 1: ngi ta nghin cu trn chut
BB v nh vo KT n dng cho thy ri lon TB lympho lin quan n T type 1
(gim lympho T c ch, v tng t lympho T gip /lympho T c ch). Nhng
nghin cu rt gn y gi rng bnh l min dch ca o ty bt u nhiu nm
trc khi chn on lm sng; tin trnh min dch xy ra chm v tip tc.
Cc yu t khc ngoi liu php min dch c th nh hng n din tin t nhin
ca suy t bo trong T type 1
Bng 1: Cc yu t nh hng n T
Yu t Tc dng
Tui Tui cng tr th lng insulin ni sinh cn li cng thp
Cc t khng
th
Bnh nhn c ICA + th tc ph hy TB cng nhanh. Cc t khng
th khc t c gi tr tin on hn.
khng
insulin
Bnh nhn T type 1 thng c bng chng ca khng insulin;
y c th l mt yu t thc y s mt b chuyn ha.
Gii Mt s nghin cu cho thy nam gii bnh din tin nhanh hn
iu tr T iu tr mnh T lm chm tc gim sn xut insulin.
2. T type 2
2.1. Yu t di truyn

399
Yu t di truyn l tri c gi sau khi nghin cu cc cp song sinh ging
nhau, nu mt ngi mc T th 100% ngi cn li cng mc T.
2.2. Yu t mi trng
Tui, bo ph, tnh ti l yu t nguy c d a n bnh T. T type 2 bo
ph nht l bo bng, tnh ti thng c s thiu lin kt insuline vi th th v sau
th th trong ni bo, kt qu l mt p ng vi insuline.
Ngoi ra T type 2 thng xy ra qun th c nguy c cao khc nhau, bao gm
khng insuline, gia tng bt thng m m, tng VLDL, nh tng insuline khi i
v sau n, tng HA (trong hi chng chuyn ha).
S khng insuline trong T type 2 l hu qu ca nhiu c ch bnh sinh khc
nhau. Phn ln c ch ny c l do hu qu ca ri lon chuyn ho nh tng
glucose mu, tng acide bo khng - ester ho. Mt khc nhng nghin cu gn y
trn qun th tin i tho ng, thy rng s khng insuline m c xy ra rt
sm trong qu trnh pht trin ca bnh. Insuline receptor kinase, phosphatase lin
quan ti hot ng insuline, cht chuyn vn glucose v tng hp glycogene.
Ri lon chc nng t bo trong T type 2: c 5 ri lon:
1. Ri lon tit Insulin:
- Gim p ng ca insulin i vi glucose: mt pha sm.
- Ri lon tit insulin theo nhp: ri lon pha dao ng chm. S tit insulin
sinh l gm 2 loi dao ng: dao ng nhanh (mi 8-15, khng lin quan glucose),
dao ng chm (mi 80-120, lin quan cht ch vi nng glucose).
2. Bt thng chuyn ha prinsulin: trong T type 2 t proinsulin v cc sn phm
chuyn ha trung gian / insulin: tng.







3. Gim khi lng t bo .
4. Lng ng amyloid (amylin) ti o ty. Gp trong 90% trng hp T type 2.
Xy ra sm gy mt dn khi lng t bo o ty, nht l t bo .
5. Vai tr ca c cht th th insulin 2 (IRS 2: Insulin Receptor Substrate 2), NF-kB,
ri lon chc nng ti th, stress oxy ha.
IV. TIU CHUN CHN ON I THO NG
chn on T, hin nay ngi ta dng tiu chun chn on mi ca T chc
Y t Th gii (TCYTTG) nm 1998 v c xc nh li 2002. Chn on xc
nh T nu c mt trong ba tiu chun di y v phi c t nht hai ln xt
nghim hai thi im khc nhau:
1. Glucose huyt tng bt k trong ngy 200 mg/dl (11,1 mmol/l), km ba
triu chng lm sng gm tiu nhiu, ung nhiu, st cn khng gii thch c.

2. Glucose huyt tng lc i 126 mg/dL (7mmol/l) (i c ngha l trong
vng 8 gi khng c cung cp ng).
Endopeptidase
Proinsulin
Des 64,65 Proinsulin
Des 31, 32 Proinsulin
Insulin
C peptide

400
3. Glucose huyt tng hai gi sau ung 75g glucose 200 mg/dl
(11,1mmol/l) khi lm nghim php dung np glucose bng ng ung (OGTT).
Giai on trung gian:
+ Ri lon glucose mu i (IFG: Impaired Fasitng Glucose): khi
glucose mu i Go (FPG) 110 mg/dl (6,1 mmol/l) nhng < 126 mg/dl (7,0 mmol/l).
+ Ri lon dung np glucose (IGT: Impaired Glucose Tolerance): khi
glucose mu 2 gi sau OGTT (G2) 140 mg/dl (7,8 mmol/l), nhng < 200 mg/dl (11,1
mmol/l).
- Go < 110 mg/dl (6,1 mmol/l): glucose i bnh thng.
- Go 126 mg/dl (7,0 mmol/l): chn on tm thi l theo di T (chn on
chc chn l phi iu kin nu trn).
nh gi kt qu khi lm nghim php dung np glucose bng ng ung:
- G2 < 140 mg/dl (7,8 mmol/l): dung np glucose bnh thng.
- G2 140 mg/dl v < 200 mg/dl (11,1 mmol/l): ri lon dung np glucose
(IGT).
- G2 200 mg/dl (11,1 mmol/l): chn on tm thi l T.
Lu : TCYTTG cn s dng glucose mao mch chn on T (cn lu n
tnh chnh xc ca my o dng huyt mao mch); trong khi Hi T Hoa K
(ADA) ch s dng glucose huyt tng tnh mch trong chn on T.
Bng 2: Tiu chun chn on T v cc ri lon glucose mu khc (theo TCYTTG -
1999)
Nng glucose mmol/L (mg/dL)
Mu ton phn Huyt tng
Tnh mch Mao mch Tnh mch Mao mch
T:
+ Go 6,1 ( 110) 6,1 ( 110) 7,0 ( 126) 7,0 ( 126)
+ G2 10,0 ( 180) 11,1 ( 200) 11,1 ( 200) 12,2 ( 220)
IGT:
+ Go (nu c)
v
< 6,1 (< 110)
v
< 6,1 (< 110)
v
< 7,0 (< 126)
v
< 7,0 (< 126) v
+ G2 6,7 ( 120) 7,8 ( 140) 7,8 ( 140) 8,9 ( 160)
v < 12,2 (< 220)
IFG:
+ Go v 5,6 ( 100)
v
< 6,1 (< 110)
5,6 ( 100)
v
< 6,1 (< 110)
6,1 ( 110)
v
< 7,0 (< 126)
= 6,1 (= 110) v
< 7,0 (< 126)
+ G2 (nu o) < 6,7 (< 120) < 7,8 (< 140) < 7,8 (< 140) < 8,9 (< 160)


401
CHIN LC CHN ON I THO NG THEO WHO 2002





















Bng 3: CC GIAI ON LM SNG CA T
Glucose mu
bnh thng
Tng glucose mu
T
Giai
on

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

+ Khim
khuyt tit
insulin u th

Cc type c
bit khc

T thai
nghn

Go (mmol/l) Glucose mu bt k (mmol/l)
Khng triu chng
h
7,8 7,8-11,1
Khng triu
chng 11,1
< 6,1 6,1 Go <
7
7
XN li Go XN li
Bnh
thng
RL Glucose
i
XN li Khng
XN na
6,1 Go <
7
11,1
7
I THO NG
11,1 Nghi ng T
11,1
G2
7,8-11,1 RLDNG G2
7,8-11,1
RLDNG
7,8 nh gi thm
7,8
C tr
chng
11 1

402
V. PHN LOI I THO NG
Sau y l bng phn loi ca Hi i tho ng Hoa K (ADA) nm 2004
Bnh T gm 2 th loi chnh l T type 1 v type 2.
1. T type 1 (t min v v cn)
i tho ng type 1 c trng bi s hy hoi t bo bta ca o Langherhans
ty (t min hoc v cn) v thiu ht gn nh tuyt i insuline, v th d b nhim
toan ceton nu khng c iu tr.
Tui khi bnh thng gp nht la tui nhi ng v thiu nin, tuy vy cng c
th gp la tui 90.
Thng c yu t t bm di truyn v c lin quan n mt s yu t mi trng
(nhim virus trong thi k bo thai, c t...).
Thng c phi hp vi mt s bnh t min khc nh bnh Basedow, vim tuyn
gip Hashimoto, bnh Addison.
c trng bi s hin din khng th khng GAD 65, khng th khng t bo o
ty (ICA) hay khng th khng insulin IAA, khng th khng tyrosine phosphatase
IA-2, IA-2((85-90% trng hp). mt s ngi (c bit ngi chu v chu
Phi) ngi ta khng tm c bng chng ca hin tng t min v c phn
loi l "type 1 v cn". Tc ph hy t bo bta rt thay i, c th chm ngi
trng thnh gy nn T th LADA (Latent Autoimmune Diabetes in Adults).
i tho ng th LADA (theo Diabetes 12.2005): > 10% ngi > 35 tui, 25%
ngi <35 tui.
- Tn khc ca T LADA: T type 1 tim tng, T ph thuc insulin tin trin
chm, T ph thuc insulin khi pht chm, T type 1 tin trin chm, T type
1,5, T t min tim tng ngi tr (LADY-like), T t min khng cn insulin
lc chn on, T LADA type 1 v type 2, T type 2 bo ph c t khng th,
T t min ngi trng thnh vi suy chm t bo ((ADASP: Autoimmune
Diabetes with Slowly Progressive -cell failure).
- Tiu chun chn on LADA
1. 30 tui
2. C s hin din ca t nht 1 trong 4 t khng th: ICA, GAD65, IA-2, IAA.
3. Khng cn iu tr bng Insulin trong vng 6 thng sau khi c chn on.
- Ngay lc chn on T LADA c ri lon chc nng TB v th c quan im
s dng insulin ngay t lc mi c chn on. Hu ht bnh nhn LADA u cn
Insulin trong vng 6 nm k t lc c chn on, mt s trng hp cn insulin
sau 12 nm. S hin din ca cc t khng th cng nhiu th tc ri lon t bo
(xy ra cng nhanh: 2 t khng th ri lon t bo trong vng 5 nm; LADA
ch c ICA + hay GADA + ri lon t bo xy ra mun hn (12 nm), LADA
khng c s hin din ca t khng th hay ch c IA-2 + chc nng t bo
khng b nh hng v vn c bo tn 12 nm sau khi c chn on.
2. T type 2
Thng gp nht. c trng bi ri lon hot ng hay tit insulin: thay i t
khng insulin chim u th vi thiu insulin tng i n khim khuyt tit insulin
chim u th km khng insulin hay khng.
Thng khng c chn on trong nhiu nm v mc tng glucose mu khng
trm trng, nhiu trng hp c ch pht hin tnh c. Thng xy ra ngi ln
tui >40 tui, nhng i khi cng xy ra tr nh, c tnh gia nh.

403
a s trng hp c km bo ph v bn thn bo ph li lm trm trng thm tnh
trng khng insulin. Nhiu bnh nhn khng c xem l bo ph da trn nhng
tiu chun kinh in nhng li c s tch t m nhiu vng bng.
Him khi nhim toan ceton ngoi tr khi c stress hoc nhim trng.
Nng insulin mu bnh thng hoc cao trong trng hp khng insulin chim
u th; hoc nng insulin gim trong trng hp c khim khuyt kh nng tit
insulin.
C yu t gia nh r (c l do di truyn). Cc yu t nguy c ca T type 2 bao
gm: tui ln, bo ph, t hot ng th lc, tng huyt p, ri lon lipid mu, tin s
gia nh T, tin s b T thai nghn v thuc mt s nhm chng tc c nguy c
cao mc T.
3. Cc tp c bit khc: bao gm
- Gim chc nng t bo bta do khim khuyt gene: MODY1 n MODY 6. T
th MODY (Maturity-onset diabetes of the young): do khim khuyt 1 gene lm gim
chc nng t bo bta gy gim tit insulin. Thng xy ra sm (trc 25 tui), c
trng bi ri lon tit insulin, trong khi hot ng insulin khng b nh hng hoc
nh hng khng ng k. vi tng glucose mu mc nh. Loi thng gp nht
l MODY 3 do t bin NST 12 yu t nhn t bo gan (HNF1 alpha).
- Gim hot tnh insulin do khim khuyt gene: khng insulin tp A, T th teo
m, hi chng Rabson Mendenhall...
- Bnh l ty ngoi tit: bnh ty x si, vim ty, chn thng/ct b ty, ung th,
x kn ty, bnh nhim sc t st...
- Bnh ni tit: hi chng Cushing, to u chi, pheochromocytoma, u tit glucagon,
cng gip, u tit somatostatin, u tit aldosterone...
- T do thuc, ha cht: Vacor, pentamidin, acid nicotinic, corticoid, hormon tuyn
gip, thuc ng vn giao cm bta, thuc ng vn giao cm alpha, li tiu
thiazide, Dilantin, interferon alpha...
- Nhim khun: Rubella bm sinh, Cytomegalovirus...
- Cc th khng thng gp ca T qua trung gian min dch: t khng th khng
th th insulin, hi chng ngi cng...
- Mt s hi chng di truyn i khi kt hp vi T: hi chng Down, tht iu vn
ng Friedrich, hi chng Klinefelter, hi chng Turner, ma vn Huntington, hi
chng Lawrence-Moon-Biedel, lon dng trng lc c, porphyria, hi chng
Prader-Willi, hi chng Turner, hi chng Wolfram...
4. T thai nghn
T thai nghn (TTN) l tnh trng ri lon dung np glucose mu vi cc mc
khc nhau, khi pht hay c pht hin u tin khi c thai; d dng insulin hay
ch tit thc iu tr v ngay c khi T vn cn tn ti sau khi sinh. nh ngha
ny khng loi tr tnh trng ri lon chuyn ha glucose xy ra trc hay xy ra
cng lc khi c thai m khng c nhn bit trc .
VI. CN LM SNG
1. Glucose huyt tng tnh mch
Lc i, hoc bt k hoc 2 gi sau lm nghim php dung np glucose mu bng
ng ung; c gi tr nh nu trn phn chn on.
2. Insuline mu

404
Thp, i khi ch cn vt T typ 1; ngc li tng hoc bnh thng hoc hi
thp T typ 2.
3. Nng C-peptide
C-peptide l thnh phn cu ni hai chui A v B ca phn t proinsuline do tu sn
xut. Proinsulin Insulin + C peptide. C peptide gip nh gi nng d insulin ni
sinh.
4. HbA1c
Khi glucose mu tng th tp trung glucose trong hng cu tng, dn n t
HbA1c cng tng. HbA1c cho php nh gi nng glucose mu trung bnh trong 2
thng trc .
5. Fructosamine
nh lng tng th protein gn glucose (c bit l albumine). Tr s bnh thng l
1 - 2.5 mmol/l, thay i tu theo phng php nh lng. Tr s Fructosamine phn
nh nng glucose mu trung bnh trong hai tun trc.
6. Cc xt nghim min dch - di truyn
- Di truyn: c th pht hin c cc khng nguyn HLA-DR3 v/hay HLA-
DR4, HLA-DQ, HLA-DRB (14,15), HLA-DR/DQ.
- Yu t min dch th dch: KT khng t bo tiu o (ICA): du ch im rt
quan trng trong hot ng min dch ca T type 1. KT khng insuline (IAA). KT
khng Tyrosine phosphatase IA-2 v IA2(. KT khng Glutamic Acid Decarboxylase
(GAD65 hay GADA65).
7. Bilan v bin chng hay bnh phi hp
- Ctone niu: c ch nh trong trng hp T mt b nng, nht l khi
nghi ng c b nhim toan cetone, thng (+) trong hn m nhim toan ctone
type 1 hay type 2 mt b nng do mc mt s bnh phi hp.
- o in tim, chp phim phi, soi y mt, chp ng mch vng mc, siu
m doppler hoc chp ng mch chi di nu nghi ng c x va gy hp, bilan
v lipide, XN chc nng thn (ur, cratinine mu, albumine niu vi th, protin
niu).
- o in c EMG, trc nghim thm d bnh thn kinh t ng h tim
mch, Holter o HA v mch 24 gi.
VII. CHN ON
Bng 5: Cc c im chnh ca T type 1 v type 2 (theo TCYTTG 2002)
c im Type 1 Type 2
Tui khi pht in hnh < 35 > 35
Yu t t bm di truyn t Nhiu
Cc t khng th chng li TB

C (90-95%) Khng
Vc dng Bnh
thng/gy
Bo ph
Insulin/C-peptide huyt tng Thp/khng c Cao
c im chuyn ha chnh Thiu insulin Hi chng chuyn ha vi
km nhy cm insulin
iu tr insulin p ng Cn liu cao

405
Cc thuc kch thch tit insulin Khng p ng p ng
1. Chn on T type 1
Khng c bn ci l:
- Khi u tui tr < 40 tui.
- Glucose mu tng theo tiu chun chn on ca TCYTTG nh ni trn.
- Du lm sng rm r: tiu nhiu (tng sinh niu thm thu), ung nhiu, n
nhiu, gy nhiu, v suy kit (asthnie).
- Tnh trng gim insuline tuyt i d a n nhim ctone v nhim toan-
ctone nu khng iu tr (C-peptide <0,2ng/ml). Trc khi gim insuline tuyt i,
nng nh lm sng ph thuc vo tit insuline cn c xc nh bng cch
o insuline mu hoc C-peptide.
- Khng th khng o (+), v KT khng th khng GAD (+).
- iu tr ph thuc insuline.
- Bin chng vi mch l thng gp.
- Lin quan n yu t HLA
2. Chn on T type 2
Lm sng, bnh nhn T type 2 c triu chng lm sng r xy ra sau tui 40, i
khi c th xy ra sm hn. Du lm sng thng khng rm r nh type 1, nhng
cng c th l tiu nhiu, ung nhiu, n nhiu (thng c yu t lm d nh stress,
nhim trng...), ri lon th gic c bit l du do tng glucose mu nh ri lon
chit quang, hoc l c bin chng v mch mu v thn kinh. Trong nhng
trng hp ny tng glucose mu thng phi hp vi glucose niu v chn on
d dng khng cn thit lm trc nghim chn on qu phc tp. i khi hon ton
khng c triu chng, v chn on phi cn n cc xt nghim cn lm sng mt
cch c h thng (30-50% T type 2 khng c pht hin).
Bng 6: Bng phn bit T type 1 v T type 2 ca Nhm d kin T quc gia
Hoa K (NDDG), v ca V. Fattorusso v O. Ritter (c phn ging nhau) nu ln vi nt
c th ring gia 2 th nh sau
T type 1 T type 2
T l mc bnh 10 - 20%
Khi u c hiu tui tr <40 tui
Khi u thng cp
Gy
Tit insuline rt thp
Nng insuline HThanh rt thp hoc bng 0
Th th insuline him khi b tn thng.
Hn m do nhim toan ctone

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

C HLA-DR3 v DR4
C khng th khng o, KT khng GAD
C tin s gia nh 10% trng hp
80 - 90%
Thng khi u >40 tui
Khi u khng r rng.
Bo ph hay khng bo
Binh thng hoc gim t
Tng hoc bnh thng hoc gim t.
Thng b tn thng th th.
Hn m tng thm thu
(Rt him nhim toan ctone)
Bin chng mch mu ln
Tit thc, vn ng hay tit thc+ S.U.,
Metformine hay insuline
Khng lin quan n HLA.
Khng c KT khng o
C tin s gia nh 30% trng hp

406
30-50% xy ra tr sinh i ging nhau
Tin s nhim siu vi, nhim c
100% xy ra tr sinh i ging nhau
Khng c.
VI. BIN CHNG
1. Bin chng cp
Bin chng cp c hiu bnh nhn T type 2 l tng thm thu do tng glucose
mu, h glucose mu, nhim toan lactique; T type 1 l nhim toan cetone.
1.1. Tng thm thu do tng glucose mu (HHS: Hyperglycemic Hyperosmolar
State)
Thng xy ra ngi gi. Gim chc nng thn v ri lon kht thng gp
ngi gi, cng lm tng cng v tnh trm trng bin chng ny. Hn m vi
thm thu HT > 340 mOsm/Kg nc, khng c nhim toan ceton. Lm sng tin
trin nhanh, mt nc, st v ri lon thc (sng s, hn m, co git ng kinh).
Mt nc ni v ngoi bo, ch yu ni bo. Th nhanh, nng, nhng khng c mi
cetone.
CLS: - Glucose mu tng >8g/l (44 mmol/l), c th t n 20g/l, nhng lun lun >
7g/l, Natri mu tng rt cao (>150mmol/l); Kali c th bnh thng hoc gim do
iu chnh glucose bng insuline, cetone niu (-). Thng c suy thn chc nng,
ur lun trn 1,5 g/l.
- pH mu bnh thng, d tr kim khng thay i
- C nhiu cch tnh tng thm thu:

hoc
1.2. H glucose mu
L triu chng ng ngi, nht l bnh nhn gi T type 2 iu tr bng
sulfonylureas. Nu bnh nhn T c bin chng thn kinh t ng lm mt p
ng tit catcholamine, lm che du triu chng h glucose mu nn bnh nhn
cng nh thy thuc khng cnh gic c. H glucose mu bnh nhn T gi
l ngun gc ca tai bin mch mu no hoc mch vnh, cng tng t sut T,
ngay c du h glucose mu mc va nhng nu lp li nhiu ln cng rt nguy
hi v khng hi phc.
1.3. Nhim toan acid lactic
Xy ra bnh nhn T type 2 ln tui, thng c tn thng suy t bo gan, hoc
suy thn, v thng do iu tr bng Biguanide. Him gp
1.4. Nhim toan cetone i tho ng (DKA: Diabetic Ketoacidosis)
Gp bnh nhn T type 1, type 2 him. Tin triu c th rt kn o: mt mi,
chn n, nn ma. au vng thng v, c hiu theo tht lng. Tiu nhiu v kht
nc nhiu, nc tiu c cetone > ++ l triu chng bo ng, ngay c khi khng c
triu chng lm sng. C vi trng hp nhim toan cetone nng xy ra trong vi
gi, hoc vi ngy, v tc xut hin l yu t chnh gip tin lng.
Du lm sng r vi kh th do nhim toan: th nhanh 25 l/ph, kh th 4 th ca
Kussmaul. Ri lon thc, thng thng khng c du thn kinh khu tr v Babinski
(-). C du mt nc ni v ngoi bo. Ri lon tiu ho (nn ma, au bng nhiu,
i chy cng lm mt in gii). Hi th c mi acetone, h nhit thng gp. Dn
ng t.
Cn lm sng: glucose niu (++++) v cetone niu (+++).
(Na 2) + G mmol/L >320 mOsm/Kg nc (Na +K
+
) 2 + G + Ur > 340 mOsm/Kg nc

407
- ECG: phi thc hin mt cch h thng ngay khi bnh nhn mi vo vin,
nh gi bin sng T v xem c bt thng v dn truyn tim tng ng vi kali
mu
- Glucose mu: 3 - 5g/l.- Th ceton trong HT rt cao
- HCO
3
-
gim < 10 mEq/l, pH gn 7,0 hoc thp hn (BT: 7,30)
- Ri lon kali mu: gi u bnh thng hoc tng, nhng gim nhanh trong
3 gi sau. V th theo di in tim u n l cn thit.


408
Bng 7: Tiu chun chn on nhim toan ceton T (DKA) v tng thm thu do
tng glucose mu (HHS) - (theo ADA 2004)
DKA
Nh Va Nng
HHS
G huyt tng (mg/dl) > 250 > 250 > 250 > 600
pH ng mch 7,25-7,30 7,00-7,24 < 7,00 > 7,30
HCO-3 huyt tng
(mEq/L)
15-18 10 - < 15 < 10 > 15
Ceton niu + + + t
Ceton huyt thanh + + + t
Posm huyt thanh * Thay i Thay i Thay i > 320
Khong trng anion ** > 10 > 12 > 12 Thay i
Tnh trng tri gic Tnh Tnh/ng g Sng s/hn
m
Sng s/hn
m
*: P
osm
(mOsm/kg) = 2 Na (mEq/L) + G (mmol/L)
**: Khong trng anion = Na+ - (Cl
-
+ HCO
3
-
) (mEq/L)
2. Bin chng mn tnh
2.1. Bin chng vi mch
2.1.1. Bnh l vng mc T
Nguyn nhn chnh gy m. Gm 2 giai on: bnh l vng mc T khng tng
sinh (NPDR: nonproliferative diabetic retinopathy) v bnh l vng mc T tng
sinh (PDR: proliferative diabetic retinopathy).
Bng 8: Cc giai on bnh l vng mc T
Giai on Thay i bnh hc thng gp
Thay i lu lng mu qua vng mc
Mt TB quanh mao mch vng mc Giai on tin lm sng
Dy mng y
Vi phnh mch vng mc v xut huyt dng chm
Tng tnh thm mch mu vng mc
Giai on sm:
NPDR mc nh

Xut huyt dng chm nh bng gn
Giai on trung gian: Thay i khu knh tnh mch
+ NPDR mc va Bt thng vi mch trong vng mc
+ NPDR mc nng Mt mao mch vng mc
Thiu mu cc b vng mc
+ NPDR mc rt nng
Xut huyt lan ta trong vng mc v vi phnh mch lan ta
Tng sinh mch da th
Tng sinh mch nhiu ni
Tng sinh mch mng mt
Giai on mun:
PDR
Tng nhn p do tng sinh mch

409
Xut huyt dch knh v quanh vng mc
Tng sinh x mch mu
Co ko vng mc, x vng mc, bong vng mc
+ Ngoi bin chng vi mch vng mc, ti mt cn c cc bin chng sau: ri lon
chit quang nn nhn khi t khi m, ri lon mu sc (xanh, vng), c thu tinh th,
vim thn kinh th, lit c vn nhn, glaucome (do tng sinh mch mu ti mng mt
lm ngn cn lu thng dch knh t tin phng ra hu phng)
2.1.2. Bnh l vi mch thn (bnh l thn T)
Thng xy ra ng thi vi bnh l vng mc, l nguyn nhn hng u suy thn
mn tin trin. Triu chng u th giai on sm l proteine niu xut hin sau 10-
15 nm khi bnh T, m biu hiu giai on u l albumine niu vi th.
Bng 8: Cc phng php tm sot albumin niu (theo ADA - Diabetes Care 1.2004;
NEJM 4.2002)
Giai on Mu khng theo thi gian Mu theo thi gian
Khng hiu
chnh
Hiu chnh theo C crea
NT

Qua m 24 h
g/ml mg/g g/min mg/24h
BT < 20 < 30 < 20 < 30
Alb niu vi th 20-200 30-300 20-200 30-300
Alb niu i th > 200 > 300 > 200 > 300
giai on c albumine-niu vi th, sinh thit thn s thy dy mng y mao mch
vi cc lng ng lan to trong lp gian mch cu thn. Khi cc lng ng ny c
dng nt, c gi l x ho knh-cu thn dng nt Kimmelstiel v Wilson; dng
tn thng ny t gp. Sau mt thi gian di, albumine niu tng dn v xut hin
proteine niu r, nu vt qu 5 g/24 gi. C th c gim protide mu, ph c hiu
ca mt hi chng thn h, v thng phi hp hng nh vi tng HA trm trng,
vi bnh l vng mc v thn kinh T.
2.1.3. Bin chng thn kinh T
Bng 9: Phn loi bnh l thn kinh T (theo ADA 2005):
Cm gic cp tnh
Vn dng-cm gic mn tnh
Bnh l a dy thn kinh
i xng
T ng
TK s
TK thn
TK chi
Vn ng gn gc chi (teo c)
Bnh l mt dy thn kinh
mt hay nhiu
Bnh l a dy TK hy myelin do vim mn tnh cng tn ti
nh ngha bnh l thn kinh T theo ADA 2005: S hin din ca cc triu chng
v/hoc du hiu ca ri lon chc nng thn kinh ngoi bin ngi T sau khi
loi tr cc nguyn nhn khc (Chn on bnh l thn kinh T l mt chn

410
on li tr. Thng phi hp vi bnh l vng mc, bnh l thn to thnh tam
bnh (triopathie) c hiu ca T.
- Bnh l TK cm gic cp tnh: him, xy ra sau 1 thi gian kim sot chuyn ha
km (nh nhim toan ceton) hay do thay i t ngt kim sot glucose (vim TK
do insulin). Triu chng cm gic xy ra cp tnh v ni bt, tng ln v m, khng
c du hiu TK khi khm LS.
- Bnh l a dy TK vn ng - cm gic mn tnh: cn gi l bnh l TK xa gc i
xng. Thng gp nht, > 50% trng hp. ng vai tr ch yu trong bnh sinh
lot bn chn T.
Biu hiu lm sng ch yu cm gic bng, cm gic chm chch, cm gic in
git, d cm, tng cm gic au v cm gic au su. Triu chng nng v m. Xy
ra ch yu bn chn v chi di. 50% khng c triu chng v ch c chn
on khi thm khm; c khi c biu hin lot bn chn khng au.
Khm thy mt cm gic rung (dng m thoa 128 Hz), cm gic p lc (dng dng
c si n 10g - 10g monofilament), cm gic au v cm gic nhit, mt phn x
gn gt.. Thng km cc du hiu ri lon thn kinh t ng ngoi bin: bn
chn lnh hay nng, i lc tnh mch mu chn dn, da kh, nt chai vng t .
- Bnh l mt dy thn kinh: t gp, khi pht t ngt. Tn thng TK gia (5,8%),
TK tr (2,1%), TK quay (0,6%), TK mc chung. Tn thng TK s (III, V, VI, VII) rt
him gp (0,05%). Khong 1/3 bnh nhn c biu hin chn p TK (TK tr, TK gia,
TK mc v TK gia bn tay). Bnh l teo c do T thng gp bnh nhn
T type 2 ln tui vi triu chng au nhiu, yu v teo c gn gc mt hay hai
bn.
- Bnh l thn kinh t ng (BLTKT):
S tm tt bin chng thn kinh t ng cc c quan:

Bt thng
tit m hi

Bt thng
tim mch

Ri lon
d dy-rut


Ri lon
vn mch

Bnh thn kinh
t ng

Bnh thn kinh
c


Bt thng
v ng t

Bt thng
iu ho nhit


Bt lc
2.2. Bin chng mch mu ln
Biu hin x va nhiu mch mu ln: thiu mu c tim im lng, NMCT (50% t
vong), vim tc ng mch chi di gy hoi t kh, vim xng; tc mch bn
chn; cng chn, phi ct ct chi. Tai bin mch mu no. Tc mch thn: c th
pht hin c ting thi ng mch thn; hu qu THA, suy thn.
3. Bin chng nhim trng
D b nhim trng: lao, nhim siu vi v vi trng, nht l nhim trng ng tiu dai
dng v ti pht nhiu ln nht l ng tiu thp, lm d cho vim thn b thn

411
ngc dng v suy thn. Nhim trng da v nim mc: nht t cu vng, vim m
h, vim bao qui u.., i khi chnh bi cnh nhim trng ny lm khi pht T c
sn.
4. Cc bin chng khc
4.1. Tng HA
Thng phi hp vi T, i khi c trc khi T xut hin, hoc thng thng
do bnh l cu thn, x va; tn sut gp nhiu T type 2 nht l bo ph v c
s tng quan gia bo ph v THA.
4.2. Bin chng da
Ngoi tn thng nht nhim trng, da cn c nhng biu hiu sau: vim teo dng
m biu hiu bng nhng nt m phn trung tm teo li, vng vin xung quanh tm
dn, nh v ngn tay hay chi di, d ng da do insuline, ph i m m hoc teo
m m.
4.3. Bn chn T
- Sinh bnh hc nhim trng bn chn T: 3 yu t phi hp
+ Bnh l mch mu ngoi bin (vi mch v mch mu ln).
+ Bnh l thn kinh ngoi bin.
+ Suy gim min dch: do gim chc nng TB lympho, do tng glucose mu,
do dy mng y.
- Phn loi nhim trng
+ Mc nh:
Lot b mt.
Chy m hay huyt thanh.
Hoi t khng c hay rt t.
Khng c biu hin nhim c ton thn.
+ Mc va:
Lot b mt su hn.
Thng c chy m.
Hoi t m mc trung bnh.
Vim xng tu xng c th c.
Biu hin ton thn nh: st, BC tng.
+ Mc nng:
Lot b mt hay su hn (vo m di da, xng, khp).
Chy m.
Hoi t m nng v lan rng.
Biu hin nhim c ton thn nng n: nhim toan, nhim khun
huyt.
VII. IU TR
1. iu tr i tho ng tp 1
1.1. Mc tiu iu tr:
- Lm bin mt triu chng, trnh bin chng lu di, bng cch kim sot glucose
mu tt, vi t HbA1c < 7%, kt hp iu chnh ri lon lipide, protide tt, trng lng

412
n nh bnh thng, v trnh nhim cetone. Trnh pht trin bin chng thoi ha
(hn ch bin chng cp v mn tnh).
- Trnh tai bin do iu tr (teo m m, h glucose mu) v gio dc bnh nhn bit
bnh ca h.

413
Bng 9: Mc tiu iu tr T
Mc tiu iu tr c khuyn co ca Chu Thi Bnh Dng
Xt nghim Tt Kh Xu
Go (mmol/l)
G bt k (mmol/l)
4,4 - 6,1
4,4 - 8
< 7
< 10
> 7
> 10
HbA1c < 6,2% 6,2 - 8% > 8%
Mc tiu iu tr ca ADA (Hip Hi T Hoa K)
XN B/Thng

Mc tiu phi t n
khi iu tr
Cn thay i k hoch
iu tr
G trc n (mg/dl)
G lc i ng (mg/dl)
< 110
< 120
80 - 120
100 - 140
< 80, > 140
< 100, > 160
HbA1c < 6% < 7% > 8%
1.2. iu tr tng qut v chin lc iu tr
1.2.1. Gio dc bnh nhn v bnh T: gio dc cho bnh nhn bit cch dng
thuc, tit thc v cc tai bin ca thuc nht l du h glucose mu kp thi s
tr nh dng ng nhanh hoc bo cho BS. Chuyn khoa bit hoc nhp vin
ngay.
1.2.2. Tit thc v vn ng
* Tit thc: bnh nhn T tp 1 thng l gy, nn phi tng nhu cu calo
hng ngy.
* Vn ng v tp th dc va phi, ng nhin phi hp insulin. Theo di
k glucose mu v cn thn liu insulin v d nguy c h glucose mu.
1.2.3. iu tr bng insulin
* Cc loi insulin c s dng
- Insulin thng: tc dng nhanh; nu TDD c tc dng sau 15-30 pht, tc dng ti
a sau 1 gi, ko di 4-6 gi., nn c tim trc n 20- 30 pht..
Tim bng nhiu ng (TM, TB, TDD, trong phc mc), mi cch tim c
thi gian tc dng khc nhau, dng ng tim, bt tim
- Insulin trung gian (NPH) (tc dng ko di >8 gi v <24 gi). Tc dng sau 1- 2
gi, ti a 4-5 gi.
- Insulin NPH hn hp: c trn gia insulin nhanh v insulin trung gian loi NPH.
Tn th trng l Mixtard 30 HM, Scillin 30 (Insulin ngi sinh tng hp).... Thuc bt
u tc dng sau 30 pht chch, tc dng ti a 2-8 gi, ko di 24 gi.
Mixtard 30 HM Penfill cng tng t nh vy
- Insulin tc dng trung gian c km: thi gian tc dng trong vng 6-36 gi. im
bt li l gy au ch tim, nn phi tim i v mng
- Insulin tc dng chm: khng dng trong bt tim, bt u tc dng 2gi 30 sau
chch, ti a 7-15 gi, ko di 24 gi, v d nh Monotard HM
- Insulin tc dng rt chm (ultra lente): tc dng ko di 36 gi.
- T bo bta tit insuline: mi t bo c10.000 ht hay nhiu hn, mi ht ch
200.000 phn t insulin, v insuline ch c phng thch vo mu khi glucose mu
cao sau n

414
* Cch tim v ng tim: thng thng bng ng TDD, trng hp bin chng
cp nh hn m toan ceton hoc tng thm thu th truyn TM, tim TM.
Ch : Ch c insuline nhanh l c th tim bng ng TM, cn cc loai trung gian,
chm, km th khng dng ng TM
* Cch bo qun insulin: insulin n nh nhit t 7 oC-27oC, tuy nhin tt nht
nn bo qun 4 -8 oC, khng nn tim ngay sau khi ly t t lnh ra.
* Tc dng ph insulin
.- H glucose mu
- Phn ng min dch do iu tr insulin: D ng insulin: di dng m ay. Hin nay
him gp v c loi insulin bn sinh hc hay insulin ngi.
- khng insulin.
- Lon dng m m ti ch tim: c 2 biu hin: teo m m di da; ph i m
m di da vn cn l vn kh trnh.
- Tng glucose mu mu thun: hiu ng Somogyi: qu liu insulin lm h glucose,
gy kch thch cc hormon lm tng glucose mu (catecholamin, cortisol, glucagon),
cng lm nng thm cc bin chng.
- Ph: do gi mui gi nc.
* Ch nh iu tr insulin
- T tp 1: iu tr thay th sut i
- T tp 2: iu tr tng cng hay vnh vin tu thuc vo bin chng hay bnh
phi hp
- T thai nghn
* Phc iu tr insulin
- i vi insulin nhanh: ch nh trong trng hp cp cu nh hn m toan ceton,
hn m tng thm thu (truyn TM, bng seringue chuyn hoc bm). Ngoi ra
insulin nhanh thng c ch nh khi glucose mu dao ng, kh kim sot. Tim
di da trc n 30 pht. Tim nhiu ln, hoc tim 2 mi hoc 3 mi nhanh trc
ba n, hoc phi hp thm vi insulin chm hoc hn hp vo bui ti
- i vi insulin NPH: hoc ch nh trong T m glucose mu n nh, cn tim
2mi/ngy: 1 bui sng v 1 vo bui chiu. Hoc phi hp vi insulin nhanh trong
k thut 3 hoc 4 mi tim: trung gian tim vo ti, insulin nhanh th tim sng, tra
v ti.

Nhanh Nhanh Trn (Nhanh+NPH)






8 gi 12 gi 20 gi 8 gi
Trc n Trc n Trc n
sng 30pht tra 30pht ti 30pht

415
S 1: S iu tr insulin vi 3 mi tim/ngy (2 nhanh+1 loi hn hp)



416


Nhanh Nhanh Nhanh NPH






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

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








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

- i vi insulin NPH trn ln: Loi ny c s dng theo 2 cch sau:
+ K thut 2 mi tim/ngy: tim 2 mi trn ln, chn loi trn ln ny vi mc ch
l loi nhanh lm gim nhanh glucose mu sau n, cn loi chm tc dng c ngy
(mi ban ngy) v sut trong m n sng (mi ban m).
+ K thut 3 mi: insulin nhanh tim bui sng v bui tra, mi trn ln tim vo
trc n bui ti, k thut ny hiu qu hn 2 mi.
- i vi insulin chm. K thut tim 1 mi; ch nh i vi bnh nhn T c nhu
cu insulin tng i khng nhiu lm
1.2.4. Thuc c ch min dch
iu tr c ch min dch trong T tp 1 giai on mi khi pht l mt tin b.
Mc d c vi trng hp lui bnh hoc gim nhu cu insulin, phn ln bnh nhn
biu hin khng dung np ng. Loi c ch min dch c hiu nht l KT n
dng, chng c hiu trn s sn xut t bo T. Mt vi thuc khng nhm c ch
min dch nh Probucol c xu hng lm mt gc t do, v Nicotinamide c ch s

417
tng hp Poly (ADP ribose) (mt loi men phc hi s thng tn NAD) nhm lm
suy yu t bo cung cp NAD.
1.2.5. Ghp tu
2. iu tr T tp 2.
2.1. Mc tiu iu tr:
- Kim sot glucose mu tt nh ni trn
- iu tr cc yu t nguy c phi hp (thuc l, HA. Ri lon lipid mu)
2.2. Cc phng tin iu tr:
- Gio dc bnh nhn
- Tit thc v vn ng th lc, gim cn nng.
- Thuc h glucose mu: Gm cc nhm thuc ung chng i tho ng sau:
+ Thuc tng tit insulin
Sulfamides (Sulfonyl Urase)
Metiglinide (Repaglinide) v D. phenylalanine (Nateglinide)
+ Biguanide: Tng s dng glucose m (c, t bo m).
+ c ch -glucosidase
+ Cc nhm thuc khc: cng to iu ho glucose mu tt qua c ch ti rut, v
gim tng glucose mu sau n. Hoc nhm Thiazolidinedione gip ci thin
khng insulin
2.3. p dng thc t
i vi T tp 2, nht l i vi ngi tr tui hn, tit thc v vn ng th lc
l c chn la u tin. bnh nhn c glucose mu tng nh < 200 mg/dl v
HbA1c < 8.5% nn p dng 4-6 vn ng v tit thc, nu khng ci thin c
glucose mu tt th mi s dng thuc ung h glucose mu
2.3.1. Tit thc:
* Khu phn thc n hng ngy:
- Tit thc gim calo bnh nhn bo ph (20 kcalo/kg/ngy)
- Duy tr calo bnh nhn c trng lng bnh thng (30 kcalo/kg/ngy).
- Tng calo bnh nhn gy (40 kcalo/kg/ngy)
* Tn trng cn bng tit thc gia 3 loi thc n sau
- Glucide: 50-55% (50%) khu phn calo hng ngy ( l khu phn cn
bn). Dng tri cy trong mi ba n, nhng cng hn ch. ng chm hay ng
a (loi c bt) v nhng loi c si (lgume kh) lm chm tng ng sau n v
hp thu chm. Hn ch dng ng n (hp thu nhanh). C th s dng cc cht
ngt nhn to nh ng saccharine, Aspartam
- Lipide: 30-35% (trung bnh 35%) khu phn calo hng ngy. u tin l du
thc vt
- Protide: 15% khu phn calo hng ngy.
- Ru: ung bia ru vi lng va bnh nhn T c th chp nhn
c, vi iu kin phi tnh calo/ngy (1g ru cho 7 Calo) v khng nn dng khi
bng i, d h glucose mu.
2.3.2. Vn ng, tp th dc:
Gim cn; ci thin c ng mu trong v sau khi vn ng th lc (gim
khng insulin, tng tnh nhy cm insulin ngoi bin). Gim LDL-C, tng HDL-C. Tc

418
dng c li trn tim mch. Tng kh nng ti a s dng oxy, lm chm li nhp tim
lc ngh ngi v lc gng sc, gim va phi HA
2.3.3. Cc thuc ung h glucose mu:
* Thuc c tc dng kch thch tit insulin:
- Nhm Sulfonyl Urase: Chuyn ho gan, 1/2 i khc nhau, thi theo ng mt
hay thn, lin kt proteine mu cao, nguy c h glucose mu v kch thch tu tit
insulin.
+ Tc dng ca Sulfonyl urase (S.U). S.U. c tc dng ch yu l kch thch tu tit
insulin
Hot ng ngoi tu-trn tng hp glucose ti gan, vn chuyn glucose, gii phng
glucagon
S.U gim khng insulin v gim glucose mu sau n do gim c tnh glucose,
v tng tim lc trc tip trn gan, khi glucose mu gim th t bo gan nhy cm
hn i vi insulin
S.U cn c tc dng lm tng tnh nhy cm sau th th.
+ Cc nhm thuc S.U.
* Th h I: c 1/2 i ko di: hin nay t dng
- Chlorpropamide: Diabnse 500mg/vin (thi gian 1/2 i l 36 gi)
- Carbutamide: Glucidoral, vin 500mg, Tc dng 1/2 i l 45 gi. Tc dng
ko di 24 - 60 gi. Liu dng 1/2 - 1 vin/ng, dng 1 liu duy nht.
* Th h II: gm:
- Gliclazide: Diamicron 80 mg, Prdian, Glucodex, Clazic, vin 80mg. Tc
dng 1/2 i l 12 gi. Tc dng ko di 12 - 24 gi. Liu dng 1-3 vin/ng. Dng 2
ln/ng (trc hoc trong ba n sng v trong ba n ti). i vi ngi ln tui,
gim 1/2 liu.
Diamicron MR 30 mg, Clazic SR 30mg, tc dng chm, ung 1 ln bui sng,
liu 1-2 vin/ln
- Glibenclamide: Daonil 5mg, Hmi-Daonil 2,5mg, Daonil faible 1,25mg (5
gi). Tc dng 1/2 i 6 - 16 gi. Tc dng ko di 12 - 24 gi. Liu dng thng
thng 1-2vin/ng, c th tng 3v/ng. Ung ngay trc ba n chnh. 1 - 3 ln/ng
- Glipizide: Glibnse, Minidiab: tc dng 1/2 i l 3-7 gi; tc dng ko di
6-12 gi; 5mg/vin; liu 5 - 20mg/ngy, 2 ln/ng.
* Th h III: Glimepiride (Amaryl*, Amarel*) vin 1mg, 2mg, 3mg. Tc dng 1/2 i l
5 - 8 gi. Tc dng ko di 12-24 gi, Liu dng l 1mg/ng, c th tng dn theo
bc cp 1mg, 2mg, 3mg, 4mg, 6mg, thi gian tng theo khong cch 1-2 tun; thng
thng liu 1-4 mg/ng. Ung trc ba n im tm hoc ba n chnh, ung mt
liu duy nht trong ngy.
- Glinide: c tc dng kch thch tit insulin khi glucose mu cao, nn iu ho c
glucose trong ba n, kim sot c ng mu sau n. Gm:
+ Rpaglinide (Novonorm*, Prandin*): vin 0,5mg, 1mg, 2mg; liu 4mg/ngy
chia hai, ung trc n 15 pht. Ko di 3 gi
+ D-phenylalanine (Natglinide). Starlix*, vin 60-120mg, liu 60-120mg/lnx
3 ln/ngy, cho trc n; ko di 1 gi 30 pht
* Biguanides:
a. Metformin (Dimethylbiguanide):

419
- Metformine tc dng nhanh: Glucophage, Siofor, Fordia, vin 500mg,
-Metformine tc dng chm: Glucophage retard (Metformine HCL) 850mg;
Siofor 850mg; Fordia 850mg
Glucophage cho liu u tin 500mg, 2-3 ln/ng; ung trong lc n hoc sau
khi n; sau 10-15 ngy c th thay Glucophage retard 850mg, 2 ln/ng.
- Glucinan, Stagid: liu 2-3 vin/ng, ung trong lc n.
- Tc dng: khng kch thch tit insulin, nn khng c tc dng ph h ng
mu. Tuy vy do nhiu c ch tc dng n vn lm gim tc dng ng mu lc
i, c bit l sau n; thuc c tc dng u th trn gan, gim tn sinh ng
gan, ci thin p ng sau th th, tng tiu th glucose t bo ch, iu ho
c ri lon lipde mu, gim ngng ngon ming. Ch nh u tin cho T tp 2
bo
* Thuc c ch (-Glucosidase: c ch hp thu glucose rut
a. Acarbose: Glucobay, Glucor*. Vin 50mg, 100mg. Liu cho tng dn 50 mg
(3 ln/ng, ung ngay khi bt u n.
b. Voglibose (Basen*) Th h th 2. Vin 0.2mg, 0.3mg. Liu 0.2mg, 3
ln/ng, ngay trc n
* Benfluorex: (Mediator):
- Tc dng: tc dng ging Metformine, vin 150 mg. Liu: 1-3 vin/ngy (tng
dn liu), bt u 1-2, 3 vin/ngy.
* ThiazolidineDione
- Ch nh tt trong T tp 2 khng bo c khng insulin.
- Tc dng: Tng tnh nhy cm insulin, Gim glucose, TG, tng HDL.
* Cc nhm thuc mi:
Glitazones tc dng ln th th, gim c tnh khng insulin mt cch
trc tip m ch, gim glucose mu, nhng d tng cn. Gm Rosiglitazone
(Avandia) v Pyoglitazone bt u dng ti Php nm 2000.
Avandia (Rosiglitazone maleate): liu 4mg/ngy, sau 12 tun nu cn kim sot
ng huyt tt hn, c th tng 8 mg/ngy. Dng lc i hoc no. Ch nh:
- T tp 2 khng kim sot ng huyt tt sau tit thc v tp th dc.
- Phi hp vi SU hoc metformine khi T2 c iu tr bng tit ch v
thuc SU hoc metformine m cha n nh glucose mu tt
CC trong suy tim 3-4 (NYHA), suy gan hoc bnh gan c ALT >2,5 ln BT. Tc
dng ph: ph do gi mui, nc, thiu mu, rng trng tr li trong giai on tin
mn kinh
2.3.4. iu tr insulin trong T tp 2.
* iu tr insulin tm thi (cn gi l i tho ng tp 2 cn insulin hoc vin n
insulin (insulino-ncessitant, insulinorequrant):
iu tr insulin bnh nhn T tp 2 khi:
- Triu chng nng ra, mc d c iu tr tit thc v thuc ung h glucose mu.
+ Du 4 nhiu: kht, tiu nhiu, ung nhiu, n nhiu v gy r.
+ C ctone niu (+++)
+ Tng glucose mu nhiu v trng din (>3g/l), (HbA1c >7% mc d iu
tr thuc ung ti a (gy tng c tnh ng).
- au nhiu chi di.

420
- Cc tnh hung cn insulin:
- Cc bnh nhim trng
- Can thip phu thut.
(Mc ch nhm trnh s mt qun bnh glucose mu do phi hp vi mt s bnh
trm trng nh nhim trng hoc can thip phu thut).
- Hoc nhng bnh nhn T tp 2 ang iu tr bng cc loi thuc lm
tng glucose (nh corticoides..)
- Hoc i tho ng thai nghn.
Trong phn ln cc trng hp ny, s s dng insulin c thc hin ti bnh
vin hay ti nh, glucose mu c theo di u n thch nghi liu insulin. Ty
p ng m bc s s quyt nh ngng insulin v tr li iu tr thuc ung chng
T.
Ch nh insulin trong trng hp ny c th n c hoc cng phi hp
vi thuc ung chng T.
- Nu insulin < 40UI, Glucophage 2 vin/ngy, bui sng v bui ti, ri 3v/ng,
insulin gim t 2-4 UI mi 2 ngy.
* iu tr insulin lu di (sau cng): c ch nh trong nhng trng hp sau:
- Bnh thn, gan, tim hoc bin chng mt, khng th tip tc iu tr cc
loi thuc ung chng T c.
- Hoc v bnh T tin trin nhiu nm, mt cn bng glucose mu trng
din. Ty khng sn xut insulin.
+ Cch s dng insulin trong T tp 2: insulin c th thay th thuc vin hoc
phi hp 2 loi insulin v thuc ung gi l iu tr hn hp. Liu insulin thch nghi
theo glucose mu. S ln tim ging nh trong tp 1.
3. iu tr bin chng i tho ng
C rt nhiu bin chng, c cp v mn, mt s bin chng v tim mch nh THA,
bnh mch vnh, thn th trnh by cc phn iu tr theo chuyn khoa. y
chng ti ch ni s v iu tr cc bin chng cp thng gp nh hn m toan
ceton, hn m tng thm thu, bin chng mn nh bin chng thn kinh
3.1. Bin chng nhim toan- ceton (acidocetose)
iu tr ny thc hin trung tm c bit, v chuyn khoa, theo di cht ch
3.1.1. Chng mt nc v cung cp mui
ti lp li dch trong lnh vc ngoi bo v tng th tch. Phi bit trng lng ca
bnh nhn trc khi b nhim toan: nu mt 10% trng lng th b lng dch
tng ng trng lng mt. V d bnh nhn 60 kg, mt 10% trng lng th
b 6 lt: 3 lt trong 6 gi u v 3 lt trong 24 gi sau, gm:
- Dung dch mui ng trng: 1 - 2 lt trong 2 gi u (Nu HA ti a < 80 mmHg,
v khng c hoi t c tim, th chuyn dch c phn t ln).
- Ri ngng thay bng dd glucose 5%, thm ch 10% nu glucose <2g/l, bao gm:
+ 2 lt trong 4 gi tip theo.
+ 3 lt trong 12 gi sau na.
3.1.2. iu tr insulin
- Insulin nhanh c th cho liu n 300 UI, v
- Liu dng: 5-10 UI/gi insulin nhanh bng seringue in. Hoc bolus 10 UI;
nu chuyn khng c th TB (trnh liu cao).

421
3.1.3. Cn bng in gii: Bicarbonat: ch nh cn thn v c nguy c h kali mu:
+ Nu tn s th > 26 l/pht.
+ pH mu gim < 7,10 mi ch nh chuyn Bicarbonate. Nu khng s
gy phn ng di kim chuyn ho mt khi ceton b chuyn ho. Kim chuyn ho
s lm thay i s trao i Kali lm tng nguy c ri lon nhp tim
Liu 500-750 ml Bicarbonate ng trng (ch khng chuyn mt mnh
Bicarbonate, m phi cho cng mui ng trng).
3.1.4. Kali: C th cung cp kali sau khi iu tr, tu theo in gii v bin i in
tim.
3.1.5. Cc iu tr khc
- Khng sinh.
- iu tr bnh nguyn.
- Ngn nga bin chng xut huyt tiu ho do thuyn tt mch.
3.2. Bin chng hn m tng thm thu
3.2.1. B dch: Mt nc do tng thm thu thng n 10 -11 lit/24, mt c ngoi
bo ln ni bo. V th cn cung cp nc khi lng ln, nhng kh v theo l
thuyt phi chuyn nc nhc trng, nhanh, phi c sn dng tc th (nc
ct v glucose ng trng), nn hon ton bnh nhn phi khoa c bit (c
nguy c v hng cu). Thc t thng dng mui ng trng: chlorure natri 0,9%,
1-2 lt trong 1-2 gi u. Sau b nhc trng 0,45%. Lng dch b c th l 6-
8 lt/12 gi u, phn cn li trong 24 hoc 48 gi sau.
3.2.2. Insulin: Tim ngay, liu thp hn liu ca nhim toan acidocetose; u tin 10-
15 UI, ri 1-2 UI mi 1/2 gi bng sringue in. Nu khng c sringue in, th
dng sringue thng cho liu 5-10 UI, lp li mi 2 gi/ln, nu glucose mu < 200
mg% th phi chuyn glucose 5% hoc dextrose 5%, nhng phi duy tr glucose mu
250-300 mg%, trnh ph no
3.2.3. iu chnh Kali mu: theo di k in gii xem c h kali khng, nu c
cho kali 10-30mmol/L
3.2.4. Hparine: cho sm trnh thuyn tc, thay i tin lng.
3.2.5. Khng sinh: iu tr nhim trng tin hoc th pht.
3.2.6. iu tr nguyn nhn.
3.2.7. Chng sc
- Thuc vn mch dobutamine 5-15 g/kg/pht, hoc dopamine 3-5 g/kg/pht.
- Chuyn plasma.
Tm li: trong 36 gi u phi t n mc ch sau:
- Glucose mu gn 250 mg%
- Nng thm thu HT gn <320 mOsm/kg nc.
- Lng NT gim gn 50 ml/gi.
3.3. iu tr bin chng thn kinh T
3.3.1. Thuc c ch Aldo-rductase:
* Sorbinil: iu tr trong 1 nm, ci thin lm sng tt, v t ra c hiu qu i vi
bnh l thn kinh mi khi pht, nhng tn thng lu, nng th kt qu hn ch.
* Torestat: cng cho kt qu tt sau 6 thng iu tr, khng c tc dng ph trm
trng.

422
3.3.2. Myo-inositol: c tng thm s dn truyn TK, nhng khng ngn chn c
s Sorbitol.
3.3.3. c ch Sorbitol-dehydrogenase: gim oxyde ha sorbitol thnh Fructose bng
cht S.0773 l mt tin dc (prodrug) c cung cp bi Geinsen v cng s, liu
100mg/kg/ngy/3ngy.
3.3.4. iu tr h HA t th
Trong thi gian u, thng thng phi sa i tnh trng gim th tch mu, phi
hp vi thuc. Thuc iu tr hiu qu nht l
- Khong-corticoid nh Fludrocortison, liu 100 - 300(g/ngy (vi thc n
nhiu mui, 2-6 g mui/ngy).
- Mtoclopramid (primperan): thuc i khng dopaminergic, liu primperan
10mg/vin x 3ln/ngy,.
- Thuc i khng th th alpha-adrenergic tin synap
+ yohimbin vin 2mg, liu 4mg x 3 ln/ngy
+ Cn thn bnh nhn c tin s TBMMN
- Dihydroergotamin: thuc co ng mch, ngoi iu tr migrain cn iu tr h
HA t th do thn kinh, do c tc dng i khng th th serotonin 5 HT2, nhng liu
cao c tc dng ng vn th th adrenergic v tc dng serotonic.
+ Tamik*, vin 3mg x 2 vin/ngy, trong khi n;
+ Seglor* nang 5mg, ikaran LP* vin 5mg, liu 10mg/ngy, chia 2
+ Khng nn phi hp bta-bloquant
- c ch bta: mt s rt t bnh nhn c tng th th bta, th propanolol
c ch nh (liu thp).
- Thuc ng vn alpha 1: Nu tht bi khi dng cc loi thuc trn, th dng
cht ng vn alpha 1 nh midodrine (gutron). Liu 2.5-4 mg mi 6 gi, thng
thng phi hp vi dihydroergotamin v cafein.
- Thuc ng vn ca somatostatin c tc dng di: i vi cc th h HA t
th kh tr, xy ra trong thi k sau n, th dng Octreotid liu 0,1-0,5 g/kg TDD vo
bui sng hoc ti
- Thuc c ch tng hp prostaglandin: nh indometacin, ibuprofen, cng c
kh nng sa i h HA t th sau n bnh nhn T.
3.3.5. iu tr lit d dy:
- Lit d dy gy bun nn, hay nn th iu tr
+ Metoclopramid (primperan), cht i khng dopamin, vin 10mg, ung 4
ln/ngy, Nhng nu d dy lit nng th phi dng ng tim v hp thu thuc ti
d dy km.
Cc thuc khc nh:
+ Cisapride (prepulside*): c th lm gia tng phng thch acetylcholine t
tng thn kinh c rut (plexux myenteric), kch thch vn ng hang v v t trng,
liu 10-40 mg trc n 30 pht
+ Dopaminobloquant: domperidone (motilium), ci thin ri lon nhp in d
dy, 20mg/vin, liu 10-40 mg/ngy, c th 80mg/ngy chia bn ln, cho 30 pht
trc n.
+ Thuc ng vn cholinergic (ging ph giao cm): bethanechol chloride
10mg, 2 ln/ngy

423
+ Cht c ch cholinesterasase: pyridostigmin bromid 1-2 mg/ngy, c th
lm gim kh ming
+ Erythromycin: kch thch th th motilin, kch thch co tht hang v sau n v
i
Nu tt c u tht bi, c th phu thut ct jujenum, v nui n qua ng rut
3.3.6. iu tr i chy T
+ Primperan, hay loperamid (imodium, 2-4mg x 4 ln/ngy). Tc dng ca loperamid
lm gim s ln i cu v cng lm tng p lc c vng hu mn lc ngh ngi
+ Hoc phi vin ti codein (30mg x 4 ln/ngy), opinium
+ Clonidin: tc dng c li trn c tng nhu ng rut v tng tit rut non, liu 0,6
mg/vin x 3 ln/ngy, gim nhu ng thy r.
+ Octreotid: 50-75 (g TDD 2-3 ln/ngy, c th lm gim s ln i cu t 6 xung 1
ln. Tuy nhin octreotide c th a n bin chng h glucose mu ti din do
gim tit cc hormon chng iu ho.
+ Diphnoxylat + atropin: lomotil 2mg-5mg, 2-4 ln/ngy, ung. Ch diphenoxylat
l thuc c s dng sau cng, v tht cn thn v d gy phnh i trng
(megacolon)
- i khi kt hp khng sinh chng nhim khun.
3.3.7. iu tr bin chng ti bng quang:
Thng gim kch thch bng quang, nu c cu bng quang, dng th thut Crede.
Nu tht bi th dng thuc ging ph giao cm nh bethanechol HCL 10mg, 2
ln/ngy, C th dng alpha-bloquant (xatral) liu cao gim khng ng
thot tiu, nhng c th gy h HA t th v ri lon phng tinh.
Nu tht bi, th phu thut ct on c bng quang lm mt s co tht ca c
vng on di nam gii.
3.3.8. iu tr bt lc
+ Thuc i khng alpha-adrenergic: yohimbin 4mg, 3 ln/ngy, c th gim
33% trng hp, v nu cn
+ Regitin v papaverin: c th tim trc tip vo dng vt, mt s c kt qu
tt, nhng d b nhim trng, hoc cng qu mc, hoc x ho..
+ Sidenafil (VIAGRA): thuc lm tng t GMP vng, gy cng dng; vin
25mg. 50mg, 100mg. Liu 25-50mg, 1 gi trc khi hot ng sinh dc
+ Caverject: l prostaglandine E1, gy dn ng mch dng vt, v dn c
trn th hang, l 10-20(g, tim vo th hang 5-20(g
+ Hoc t prothese dng vt.
3.3.9. iu tr triu chng au trong bnh thn kinh ngoi bin
- Gabapentin (Neurontin): thuc nhm chng ng kinh, co git, c cu trc gn
ging cu trc ca GABA/acid gamma aminobutyric, vin 100mg, 300mg v 400mg,
liu 300mg x 2 ln/ngy, ti a c th ti 1200mg, tc dng ti a sau 2-3 gi, na
i 5-7 gi, Thn trng khng nn dng: tr em, c thai, cho con b, suy thn, ti x
li xe
- Thuc khng trm cm 3 vng (amitriptylin, nortriptylin, desipramin): c s
dng chng au trong bnh thn kinh T t lu:
* Liu lng: Chia liu nh gim tc dng ph.
nh gi tim mch trc khi ch nh.

424
Bt u 10-25mg lc i ng c th tng liu mi tun, liu t n t 25-
150mg.
Tc dng ph thuc: m mt, thay i thi nhn thc, kh mi, bn, h
HA t th, tit m hi, ri lon sinh dc, mch nhanh, b tiu
3.3.10. iu tr lot bn chn T
- Ct lc vt thng rng.
- iu tr nhim trng
- Ti lp ti mu tt.
- Loi b sang chn
- Gim p


425
H GLUCOSE MU
Mc tiu
1.Trnh by c c ch bnh sinh v bnh nguyn ca h glucose mu.
2. Trnh by c nhng triu chng lm sng v cn lm sng lin quan n h
glucose mu.
3. Bit cch x tr v theo di bnh nhn b h glucose mu theo tng mc .
4. Bit phng thc tm kim nguyn nhn v bin php d phng h glucose mu.
Ni dung
I. NH NGHA
H glucose mu cn c gi l h ng huyt, din t nhng biu hin lm
sng v cn lm sng xy ra i vi c th ngi khi nng glucose huyt tng
tnh mch (50 mg/ dl (2,7 mmol / l).
H glucose mu l mt trong nhng cp cu ni khoa thng gp trn lm sng, l
mt trong nhng nguyn nhn gy t vong bnh nhn i tho ng s dng
insulin hoc sulfamide h ng huyt trong t l t vong 3 - 7% bnh nhn i
tho ng tp1. Tuy nhin thc t lm sng gii hn nng ng mu ni trn
c th thay i do tnh hung lm sng cp hay mn ty thuc vo tui cng nh
bnh l i km nht l bnh nhn i tho ng c thi gian mc bnh ko di.
II. BNH NGUYN
1. H ng huyt lc i km cng insulin
1.1. Phn ng insulin
- Ch n khng y v s v cht lng hoc l do qun ba n bnh nhn
i tho ng iu tr.
- Hot ng th lc qu mc: ngi khng b i tho ng lng thu nhn
glucose ca c vn (tng 20-30 ln trn mc cn bn) c b tn sinh ng
gan. iu ny l do gim insulin lu hnh do tng catecholamine do vn ng lm
c ch t bo beta. iu ha ny b gim bnh nhn ang iu tr insulin. Khi cc
ni lng ng thuc di da tip tc phng thch insulin trong qu trnh hot ng v
tng hp thu insulin nhng vng c gn gc.
- H thng iu ha glucose b tn thng bnh nhn i tho ng b bnh lu
ngy. Phn ln bnh nhn i tho ng tp 1 c s km p ng glucagon khi h
ng huyt
- Qu liu insulin. Do khng nhn r hoc do thay i nng Insulin trong l thuc
(40 UI/ ml thay th 100 UI/ ml)
- Qu liu sulfamide h ng mu, thuc c tc dng ko di (Chlopropamide c
thi gian bn hy trn 35 gi...) c bit bnh nhn c thng tn gan, thn, ngi
ln tui d c nguy c h ng huyt.
- Cc nguyn khc
+ Stress: Khi b stress (bnh tt, nhim trng, phu thut...) thng tng liu Insulin
cn bng ng mu. Khi stress chm dt cn phi gim liu.
+ Suy v thng thn (bnh Addison) gy h ng huyt v th cn gim liu
Insulin.
+ Bnh l d dy i tho ng: Bnh l thn kinh thc vt cc tng lm d dy
gim trng lc lm chm a thc n t d dy vo rut, nguy c h ng sau
n bnh nhn s dng Insulin.

426
+ Thai nghn. Nhu cu tiu th ng tng trong thai nghn v th cn gim liu
Insulin trong 3 thng u.
+ Suy thn: Lm ging ha Insulin v thuc h ng huyt b ko di.
+ Thuc dng phi hp: Bnh nhn i tho ng c phi hp thuc iu tr nh:
Allopurinol, c ch beta, clofibrate, cimetidine, thuc chng ng, hydralazine,
indomethacine, Maleate de perhexilline, miconazole, phenolbarbitale phenylbutazole,
probenecide, salycile, sulfamide chng nhim khun, IMAO.quinine, quinidine, c
ch men chuyn, disopyramide, tricycliques, propoxyphene, octreotide, tetracycline,
mebendazole, cibenzoline, stanozolol, fluoxetine, ethanol, sertaline, tromethamirne,
gancilovir, lithium, temafloxacilline.
+ H ng huyt gi (dng ln lt Insulin v cc thuc h ng huyt): lin quan
n bnh nhn c bnh l tm thn phi hp.
+ H ng huyt t min. C khng th khng Insulin. H ng huyt xy ra 3 - 4
gi sau n v c quy cho s phn ly gia phc hp min dch khng th & Insulin
lm phng thch Insulin t do... H ng huyt t min do tch ly s lng khng
th ln c kh nng phn ng vi Insulin ni sinh, c ghi nhn bnh nhn
iu tr methimazole trong bnh Basedow ti Nht Bn, cng nh mt s bnh nhn
lymphoma, a u ty, hi chng lupus, trong paraprotein v khng th phn ng
cho vi Insulin.
H ng huyt do khng th khng th th Insulin tng i him, bnh nhn ny
c thi k khng Insulin v chng gai en (acanthosis nigricans).
H glucose mu cng c ghi nhn s p ng vi iu tr glucocorticoid m
khng thy trong lc huyt tng v c ch min dch.
- H ng huyt do dng Pentamydine: Loi thuc dng iu tr nhim khun
Pneumocystic carinii bnh nhn AIDS, thuc lm tng Insulin cp do tc dng trn
t bo beta (10 - 20% bnh nhn).
- U t bo beta tuyn tu.
1.2. H ng huyt lc i khng cng insulin.
1.2.1. Cc ri lon phi hp vi gim lu lng glucose gan.
- Do mt mt s lng t bo gan nh teo gan vng cp, nhim c gan cp.
- Do ri lon cung cp acid amin n gan (chn n thn kinh, nhn i lu ngy, hi
chng uree mu cao, suy v thng thn).
-Do bt thng chuyn ha glucose tr s sinh (thiu men thoi bin glycogen,
men tn sinh glucose).
1.2.2. H ng huyt do ru
Ru (ethanol) chuyn ha ti gan nh NAD v xc tc bi ethanol dehydrogenase.
V th dng ru lu ngy lm gim lng NAD gan. y l cht cn thit trong
phn ng tn sinh ng. H ng huyt do ru do gim tn sinh ng km
gim ngun d tr glycogen ti gan. Ngoi ra insulin mu gim thun li cho tng
cetone mu v trong nc tiu.
Bnh nhn h ng huyt do ru thng km thiu vitamine B1 (Beriberi) cp v
th ngoi s dng glucose cn phi hp vi vitamine B1. Ngoi ra do hai yu t ni
trn vic s dng Glucagon trong h ng huyt do ru khng c tc dng.
Triu chng thng xy ra sau n t 8 - 12 gi. Bnh nhn trc ung nhiu
ru v s lng cng nh thi gian lm gim ngun d tr glycogen mt phn do
n ung khng y .

427
1.2.3. U ngoi tuyn tu.
Fibrosarcome sau phc mc, ung th gan, ung th thng thn, ung th thn, ung
th d dy rut, lymphoma v bch cu cp. nh lng Insulin khong 8 (U/ml vo
lc h ng huyt lc i. C l c s tit Insulin lc ch.
Khong 50 % khi u c tit peptid c trng lng phn t thp vi tc dng ging
Insulin gi l peptide hot ng ging Insulin khng b kim hm (NSILA peptide =
nonsupressible Insulinsulin like activity) bao gm human Insulin like growth factor v
mt vi cht ca somatomedine.
2. H ng huyt phn ng (h ng huyt khng xy ra lc i)
H ng huyt phn ng xay ra sau n 2 - 3 gi hoc mun hn 3 - 5 gi.
2.1. H ng huyt do thc n sau ct d dy.
y l hu qu ca cng Insulin sau ct d dy. Thc n xung nhanh sau n, hp
thu glucose nhanh lm tng ng huyt, kch thch tit Insulin lm bnh nhn chng
mt, xm xong, v m hi. (d dy trng nhanh sau n, kch thch thn kinh ph v
v sn xut hormone d dy rut kch thch t bo beta (beta cytotropic
gastrointestinal hormone). C th dng khng cholinergic nh propantheline (15 mg /
ngy 4 ln), nn n tng ba nh, hn ch ng hp thu nhanh, c th dng thuc
c ch men alpha glucosidase.
2.2. H ng huyt chc nng do thc n.
Thng gp bnh nhn mt mi mn tnh, loi u, kch thch, yu, km tp trung,
gim tnh dc, nhc u, i sau n...
2.3. H ng huyt mun.
H ng huyt sau n 4 - 5gi sau khi ung ng gi tin triu i tho ng
th 2.
III. BNH SINH H GLUCOSE MU
Khi nng Glucose mu bt u gim di mc sinh l s kch thch vng di i
kch thch tuyn yn tit ACTH (tng Cortisol) v STH (tng glucose).
Khi h glucose mu nhiu cn pht sinh cm gic thm n ng v kch thch h
li - hnh ty gy kch thch ty thng thn tit adrenaline, h ph giao cm (nhn
X), ty tng (t bo alpha) tit glucagon, d dy rut tit gastrin, secretine, kch thch
tit ADH.
Adrenaline cng glucagon lm tng thoi bin glycogene v tng tn sinh glucose ti
gan, adrenaline (cng giao cm & thn kinh thc vt: m hi, lo lng, nhp tim
nhanh)
Gastrin v secretine lm tng hp thu glucose ng tiu ha. Kch thch h i giao
cm (i bng, bun nn v nn).
Nhng triu chng trn thng xut hin sm nhng ch yu v trm trng ca h
glucose mu tc ng ch yu trn t bo no (v khng c ngun d tr glycogene)
xy ra trong vng vi pht. Thiu glucose mu ko theo gim tiu th oxy. Nhu cu
glucose t bo no khong 60 mg / pht v xy ra hn m khi cn 30 mg / pht.
Thng tn t bo no khng hi phc khi nu s thiu nng lng trm trng v
ko di. Do nhy cm v thiu nng lng ca cc vng thuc no b c khc nhau,
v th th t xut hin triu chng ca cc giai on gii phu lm sng xut hin
ln lt nh sau.
+ Giai on v no: L m, bun ng, kch thch tm thn, nhn i.
+ Giai on di v no v no trung gian: hot ng t ng, vt v, co git.

428
+ Giai on no gia: co cng c, un vn, gin ng t v khng p ng nh
sng, git nhn cu.
+ Giai on trc ty no: du mt no.
+ Giai on ty no: hn m su, mt trng lc c, mt phn x gic mc.
Ch m no b ph n nht l bnh nhn i tho ng, hoi t, xut huyt, d
gy d ng. Ngoi ra mch vnh, h tiu ha v h hp xy ra mun hn v khng
thng xuyn.
IV. TRIU CHNG
1. Triu chng lm sng
Cn lu triu chng lm sng thng t tng ng vi nng glucose mu.
Triu chng h glucose mu thng xy ra khi i hoc xa cc ba n, tng ng
thi gian tc dng ti a ca thuc (insulin hoc sulfamide h ng huyt) i vi
bnh nhn i tho ng. Triu chng trn ci thin nhanh khi cung cp glucose
tc thi.
1.1. H ng huyt mc nh:
- Du ton thn: Bnh nhn c cm gic mt mi th lc ln tinh thn, bun ng,
chng mt
- V m hi (du chng rt quan trong trong giai on ny).
- Du tiu ha: i bng v co tht vng thng v, c th nn hoc a chy.
- Du tim mch: Hi hp, nhp tim nhanh hoc ngoi tm thu. Huyt p tng. au
vng trc tim km ri lon nhp hoc dng au tht ngc.
- Du thn kinh: Chut rt, d cm u chi v quanh mi, nhc u thng xuyn
hoc kch pht. Ri lon iu tit, nhn i, run lnh (d nhm do nhim trng.
- Du tm thn kinh: Ri lon nhn cch v tnh kh: kch thch, vui v, ling thong,
hoc i khi bun b hoc nng tnh.
- Du h hp: cn kh th dng hen.
Nu giai on ny pht hin kp thi v x tr n gin vi cc thc ung c cha
ng, du hiu lm sng ci thin nhanh.
1. 2. H ng huyt nng:
C th t ngt hoc xy ra trn nn cc biu hin lm sng k trn. Trong giai on
ny biu hin lm sng ch yu l du tm thn kinh.
- Tm thn kinh: Sng s, n, cn trm cm vi xu hng t st, kch ng
hoc cng kch, hoang tng, o gic, mt thc thang qua.
- Cng hm (du quan trng d nhm un vn) v du h glucose mu nng.
- ng kinh ton th hoc khu tr dng Bravais Jackson, lit na ngi, khu tr, ri
lon tiu no - tin nh: chng mt, ri lon vn ng ( nhm tai bin mch mu
no).
Giai on ny s dng glucose u trng ng tnh mch trc tip hn l cho
ng ung bnh nhn s hi phc nhanh.
1.3. Hn m h glucose mu
Khi u thng khng t ngt, km co c, co git, tng phn x gn xng, co
ng t, cng hm, nhiu m hi, km nt mt bng v hi phc sau khi
chuyn glucose sm trc khi qua giai on khng phc hi vi hn m su thng
tn no khng hi phc v t vong nu h glucose mu nng v ko di.
2. Cn lm sng: Glucose huyt tng: (50 mg/dl (2,7 mmol / l)

429
+ Triu chng lm sng v cn lm sng thng khng tng ng vi nhau.
+ ng huyt tnh mch chnh xc nhng thi gian tr kt qu thng chm v th
trong bi cnh ti cp ng huyt mao mch cng l du chng tin cy v kt qu
c tc thi. Khng nn c i kt qu ng mu tnh mch m nn lm song hnh.
V. CHN ON H NG HUYT
1. Chn on xc nh: Tam chng Whipple
+ Triu chng lm sng h glucose mu.
+ Nng glucose mu di 2,7 mmol/l (50 mg%).
+ Ci thin triu chng khi dng cc cht cha ng
2. Chn on nguyn nhn
2.1. Bnh nhn mc bnh i tho ng
iu tr vi cc thuc Insulin hoc thuc sulfamide h ng huyt tin s ghi nhn
vi ln qua li khai bnh nhn nu cn tnh, thng qua ngi nh nu bnh nhn
hn m.
Xc nh iu kin xut hin cng nh yu t thun li (qun ba n, qu liu thuc
nsulin, hot ng th lc qu mc nhng qun b nng lng, hoc s dng thm
cc thuc lm tng tim nng ca thuc h ng huyt (xem phn nguyn nhn).
Rt ra t hu qu trn cn hng dn cho bnh nhn v ngi nh ngoi gio dc
h ng huyt cn phi.
Gim liu Insulin hoc thuc vin h ng huyt.
Xem li ch dinh dng v s lng v cht lng nht l thnh phn glucide
trong cc ba n nht l nhng lc au m.
iu chnh li gi n cho hp l.
Tng ba n gia gi (ba n ph) ngoi ba n chnh.
Cn ch
+ Bnh nhn i tho ng c iu chnh ng huyt tt khng th trnh nguy
c h ng huyt.
+ H ng huyt trn bnh nhn i tho ng tr khng phi l du hiu xu,
nhng trn bnh nhn ln tui hoc c bnh l tim mch (suy vnh, tng huyt p) l
yu t nng vi nguy c khi pht tai bin tim mch (nhi mu c tim, tai bin mch
no).
+ H ng huyt thng xy ra v m gn sng cn kim tra ng mu lc 4
gi sng nu bnh nhn c cc biu hin nghi ng.
+ Hin tng Somogyi (tng ng huyt phn ng) l biu hin ca h ng
huy trc .
2.2. Bnh nhn khng mc bnh i tho ng
2.2.1. Cc xt nghim cn lm.
Chn on thng kh i hi nhiu phng tin nh lng Insuline mu, C
Peptide v cc kch t hoc cc cht khc v cc test nh sau
- Nghim php nhn n. Bnh nhn bt buc phi nm vin nhn n hon ton hoc
ch n hn ch glucide (50 g glucide, 50 g protide v 70 g lipide)
Thi gian nhn: Nhn n cho n lc xut hin triu chng h ng huyt hoc 3
ngy vi lao ng.
Xt nghim cn lm ng thi
+ ng mu mao mch v tnh mach (gi phng xt nghim) mi 4 gi cho n khi

430
xut hin du h ng..
+ nh lng insulin
+ nh lng peptide C huyt tng.
on nhn
Da vo t l insulin / glucose (I/G) theo 2 cng thc sau:
Insulin (pmol/l) / glucose (mmol/l) (20 (bnh thng).
Hoc (100 X insulin (U/ ml) / (ng mu - 30 mg%) (50 (bnh thng)
Lu : 1(U / ml = 7,17 pmol/l.
2. Test h glucose mu bng insulin nh sau
Bnh nhn cn c theo di st.
K thut: ly mu nh lng ng v peptide C vo cc thi im Gn.
Liu insulin 0,1 UI/ kg (loi insulin tc dng nhanh).
nh gi kt qu:
- H ng huyt khi ng mu di 50 mg/dl.
- Hm tit insulin ni sinh c xc nh nu peptide C huyt tng gim di 65%
g tr bnh thng.
- Khng hm hoc hm yu: u tuyn tit insulin, h ng do dng sulfamide. Khng
hm peptide C chng c c tit nulin ni sinh t ng cn phi thm d nguyn
nhn bng chn on hnh nh. Nh nh v u tit insulin bng chp CT scanner.
Chp mch chn lc ng mch mc treo trng trn. Phn tch u tuyn tit insulin
n c trong bnh cnh a ni tit th I, ch yu tr em, c th tng sn o lan
ta, khng nhn thy (nesidioblastose)
2.2.2. Chn on nguyn nhn hng n do: Cn phn bit 2 tnh hung
H ng huyt thc th v h ng huyt chc nng.
1. H ng huyt thc th
Thng xy ra khi bng i, bui sng, n mun hoc b ba, sau vn ng
qu mc. Biu hin lm sng thng nng. Cn ch n iu kin, tnh hung xy
ra cng nh yu t phi hp. nh lng ng thi glucose mu, insulin v peptide
C. C th to li tnh hung bng nghim php nhn n. C 3 tnh hung xy ra nh
sau:
1. Insulin mu, peptide C v t insulin/ glucose u tng.
U tit insulin, Kch thch tit insulin ni sinh do thuc hay khng., Sulfamide h
ng huyt, Quinine
2. Insulin v t insulin/ glucose u tng nhng peptid C thp.
Dng insulin ngoi sinh, Chng gi bnh., Nghim php phm php (manoeuvre
criminelle). Tm khng th khng insulin nu dng insulin b, heo khng c nu dng
insulin ngi.
3. Insulin thp, t insulin/ glucose bnh thng hoc thp.
C th lin quan n bnh tt, nhim c hoc do thuc,h ng huyt do u ngoi
ty (u mc treo nh v phc mc, sau phc mc, lng ngc), u gan, u v thng
thn, u biu m. Thng h ng huyt ti din, nng. Chn on d do u ln,
chp CT scanner, nh lng tng IGF2 (insulin like growth factor 2).
2. H ng huyt chc nng:
Thng xy ra 2- 4 gi sau n, Thng khng c du thn kinh cm gic. Rt him

431
khi hn m. Biu hin i cn co v m hi. Bnh nhn thng c tin s ct d
dy, ni v trng, ct thn kinh X chn lc. l h ng huyt do cng insulin
(do thc n xung qu nhanh trong rut non) cn phn bit hi chng Dumping. Cn
phi nh lng ng mu khi xy ra s c trn. Cn thc hin li test. Bnh nhn
khng c can thip bnh l d dy (thng l ph n) h ng huyt do cng
insuline hoc nhy cm qu mc i vi insuline. Phn ng thn kinh thc vt m
khng phi h ng huyt ph n lo u v trm cm.
2.3. Mt s tnh hung c bit
- Ng c ru cp: h dng huyt lun tm kim ngi hn m do ru, suy
dng.
- Nhim c gan: Glycol, tetrachlorure de carbone, annannite phalloide.
- Dng Hypoglycine (tri cy xanh vng Jamaique)
- Bnh nng: suy thn, suy gan, suy tin yn, suy thng thn cp, suy dng, suy
tim, chong nhim trng.
- S dng mt s thuc nh (acetaminophene, c ch bta, chlorpromazine +
orphenadrine, ethionamide, disopyramide, haloperidol, maleate de perhexilline,
quinine, pentamidine, propoxyphene, salicyles)...
VI. BIN CHNG V HU QU
1. Ph no sau h ng huyt: Hn m ko di mc d ng mu tr v bnh
thng km ph gai th. Ph phi cp: Do co mao mch phi.
2. Hu qu thn kinh: Bnh l thn kinh ngoi vi: teo c tun tin, phn xa ca t chi
xy ra vi tun sau khi b mt hoc nhiu cn h ng huyt nng, thng phi
hp vi d cm t chi. Thng tn sng trc ty sng c th b.
3. Ri lon tm thn kinh ko di: in, ng kinh sau h ng huyt, hi chng
parkinson, ma vn.
4. Gy hoc xp t sng: Xy ra khi c cn ng kinh nng.
Lu : Bnh nhn c tui (trn 60 tui) nht l c bnh l tim mch d c nguy c tai
bin tim mch (cn kim tra in tim nu nghi ng thiu mu c tim im lng).
Bnh nhn i tho ng, h glucose mu c th xy ra v m thng khng
nhn bit c. V vy kim tra ng mu mao mch vo lc 4 gi sng.
5. Di chng thng xuyn: l di chng ca nhng cn cp tnh, lp li v khng
nhn bit. Lit bn thn, mt ngn ng, ma vn, hi chng Parkinson. Mt tr tu
dn dn, tnh trng sa st tr tu, hi chng teo c t chi xa gc v mt phn x gn
xng.
VII. IU TR
1. iu tr triu chng
1.1. Bnh nhn cn tnh
Ung cc thc ung cha ng cho n khi ci thin triu chng.
Khng c ung cc loi ng ha hc (sacharinate de sodium, saccharineate
dammonium) dnh cho ngi i tho ng.
1.2. Bnh nhn hn m: iu tr cp cu
1.2.1.Dung dch Glucose 30% hoc 50%.
Bm trc tip tnh mch mt lng glucose nh sau
Lng Glucose = [ Trng lng (kg) X 0,2 ] X [ Gbt - Gh ]
Trong Gbt l nng glucose huyt tng cn t v d G =1 g/l, Gh l nng

432
glucose mu lc b h ng mu v d Gh = 0,2 g/l. Nh vy mt bnh nhn nng
50 kg, Lng glucose cn bm lc u l: 50 x 0,2 x (1 X 0,2) g = 8 g glucose.
Khng nn truyn nh git m phi bm trc tip tnh mch t nng glucose
mu tng nhanh v cao.
1.2.2. Glucagon (ng 1 mg)
Tim tnh mch, tim bp hoc tim di da vi liu 1 - 2 mg, c th lp li sau 10 -
20 pht (thi gian bn hu ngn). Khng s dng glucagon i tng nghin ru
nng do d tr glycogen gan km, hoc bnh nhn nhn i lu khng cn
glycogen d tr gan. Bnh nhn T tp 1 lu ngy cng t p ng vi glucagon.
1.2.3. Hydrocortisone: 100 mg.chch tnh mch
2. iu tr duy tr
+ Nu bnh nhn tnh c th n c th tip tc n nh bnh thng.
+ Nu khng n c (nn ma, khng dung np..) Truyn tnh mch Glucose 10%
theo liu 1500-200 ml/ 24 gi (150-200 gam Glucose) cho n khi nng glucose
huyt tng tr li bnh thng sau nhiu gi. Khng cho liu cao v c th ch c
kh nng dung np ti a 1.5g glucose/gi
+ Cn theo di ng mu thng da vo thi gian bn hy ca thuc gy h
ng huyt (Insuline, Sulfamide h ng huyt..), phi iu tr vt qu thi gian
tc dng ca thuc gy h ng huyt
+ Kim tra in tim c bit bnh nhn ln tui, bnh mch vnh, tng huyt p.
NHNG IU NN LM NHNG IU NN TRNH
X tr ngay Hi bnh s qu lu
Khng ch i kt qu ng mu Ch i kt qu ng mu
Bm trc tip tnh mch Chuyn tnh mch nh git
Glucose 20% Glucose 10%
Glucagon An thn nu vng vy
Theo di sau khi li Khng theo di
in tm bnh nhn ln tui Khng kim tra in tm
4. iu tr nguyn nhn
4.1. Lin quan n bnh nhn i tho ng
+ Xc nh cc iu kin xut hin: qun ba n, thc n cha t ng, dng qu
liu Insuline, hot ng th lc qu mc nhng qun b nng lng. Dng phi hp
mt thuc c tim nng lm tng tc dng thuc sulamide h ng huyt
+ Cn thay i ch th iu tr:
Thay i hoc gim liu Insuline, liu sulfamide h ng huyt
iu chnh li thnh phn nng lng lng Glucide mi ba n cho hp l.
iu chnh gi n, nn thm ba n ph gia cc ba n chnh.
+ Khng nn ch nh cc thuc Sulfamide h ng huyt cho bnh nhn trn 70
tui, nht l cc thuc c thi gian bn hy qu di (Chlopropamide).
+ Suy thn v suy gan (tng nhy cm thuc h ng huyt)
+ Phi hp mt s thuc lm tng tc dng thuc h ng huyt hoc bng cch
gim liu thuc thng ngy.

433
+ Khng p dng tiu chun cn bng ng huyt l tng nhng bnh nhn
T trn 60 tui.
+ Cn ch hin tng Somogyi gy tng ng huyt th pht vo bui sng do
h ng huyt trong m
4.2. iu tr cc bnh l gy h glucose mu
- U ty tit insuline: Phu thut,Diazoxide (ung hoc tnh mach) liu 300-1200 mg /
ngy + thuc li tiu. Octreotide tim di da liiu 100-600 (g / ngy. Ha tr liu
bng Streptozotocine- 5 fluoro uracile.Chng h ng huyt bng chuyn glucose
v iu tr thm Sandostatine.
- U ngoi ty tit insuline:Phu thut, Chng h ng huyt (kh) bng chuyn
Glucose, chuyn di da lin tc Glucagon bng bm theo nhp khng lin tc.
- Bnh nhn b phu thut ct d dy: Gio dc bnh nhn v thn nhn du hiu v
cc x tr h ng huyt.Glucagon v Glucose u trng lkun c sn nh.Chia
u nhiu ba n. Gim loi ng hp thu nhanh. Thc n phi hp protide v
glucide.
VIII. D PHNG
+ Cn gio dc h glucose mu cng nh cch s tr h ng mu cho bnh nhn
i tho ng v thn nhn ca h.
+ X tr h glucose mu cn phi cp thi, ti ch bng mi bin php c th thc
hin trc khi chuyn bnh nhn vo vin, khng nn ch i kt qu ng mu.
+ Lu tc dng h ng huyt ca mt s thuc khi phi hp.
+ Trnh t tng ng l k th i bnh nhn i tho ng
+ Phng chm KHNG N KHNG DNG THUC H NG HUYT, NU
DNG THUC H NG HUYT BT BUC PHI N cn p dng cho tt c
bnh nhn i tho ng..


434
BO PH
Mc tiu
1. Trnh by c nh ngha, bnh nguyn v sinh l bnh ca bo ph
2. Trnh by c tiu chun chn on v phn loi bo ph
3. Triu chng, cc phng php nh gi bo ph
4. Bit r cc bin chng ca bo ph
5. Trnh by c tit thc, hot ng th lc v tp th dc gim bo ph
6. Trnh by c thuc iu tr bo ph
Ni dung
I. NH NGHA: c nhiu cch nh ngha
1. Bo ph c nh ngha bng s qu ti lng m c th, c bit lin quan n
chuyn ha nng lng, ko theo hu qu xu cho sc khe.
2. Hoc gi l bo ph khi tng trn 25% trng lng c th v c nh gi da
vo kch thc v gii.
3. i a s dng cng thc BMI nh gi mc bo ph. BMI t 20-25kg/m2
c xem l tt, qu ti trng lng khi BMI >27kg/m2 v theo phn loi hin nay,
c quc t chp nhn, bo ph c nh ngha bng BMI (30 kg/ (m2). T gi tr
ny, ngi ta xem nh l s tch m qu nhiu, bi v n ko theo mt s gia tng
c ngha v bnh sut v t sut.
II. TN SUT: Bo ph cng ngy cng gia tng nht l cc nc pht trin kinh
t trn th gii; c bit trong 10 nm li y, la tui gp cao nht l >30 tui. Tn
sut bo ph ph thuc vo tiu chun chn on. Tn sut bo ph thay i tu theo
tui, gii tnh v a d, chng tc, tnh trng kinh t x hi:
- Tui: 2% lc 6-7 tui, 7% tui dy th, v cao nht tui (50 (u M).
- Gii: n gp nhiu hn nam (25% so 18%).
- a d, chng tc: min ng nc Php l 33%, min Ty 17%. Ti Nam Phi bo
ph gp cc tnh pha Nam nhiu hn cc tnh pha Bc. Trong thp k qua, t l
bo ph ca ton nc M t 25 - 33%, tng 1/3. Ph n da en tui t 45-55 tui c
t l bo ph gp 2 ln so n da trng cng tui.
chu u, gn y khong chng 15 nghin cu dch t v s qu ti trong lng
17 nc ca chu u. S s dng tiu chun chn on khc nhau tu theo
nghin cu (BMI, hoc cng thc Lorentz, hoc cng thc Broca).
- iu kin kinh, x hi c lin quan n ch dinh dng, phong cch sng:
+ Trung Quc, s tr em bo ph tng cao trong nhng nm gn y, do c
nung chiu, n ung qu mc, t khi c ch trng mi gia nh ch c mt con;
+ Singapore, tr em bo ph ti cc trng tiu hc gia tng mt cch ng k.
+ Ti thnh ph H Ch Minh, do mc sng ngy cng cao, nn s bo ph tr em
cng nh ngi ln gia tng.
Nhng ngc li ti M mc kinh t x hi thp th tn sut bo ph cao hn so vi
mc sng kinh t x hi cao.
Nhng ngi ln bo ph c khong 50-100% nguy c cht sm so ngi c BMI
khong 20-25 kg/m
2
.

435
Bng 1: Tn sut qu trng theo nhiu nghin cu khc nhau chu u.
Tn sut bo ph Nc v tui ngh/cu nh ngha qu trng
Nam N C 2 gii
Bulgarie: 35-71 tui
an mch: 18-20 tui
7 nc: 40-59 tui
- Bc u
- Nam u
- ng c
- Ty c
- H lan: 19-31 tui
- Rumani:15-65 tui
+ Thnh ph.
+ Thn qu
-Thu s: 31-40 tui
41-50 tui
>20% Broca
>20% Broca

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


>25% Broca


10%

13%
23%
14%
16%
24%

25%
22%
18%
28%






41%
14%

32%
41%
19%

III. BNH NGUYN
1. Qu ti calo: V phng din chuyn ho, bo ph do qu ti calo vt qu nhu
cu c th. Tuy nhin c s khc nhau tu c nhn trong s dng nng lng v
nhu cu c vn. C bnh nhn n nhiu nhng khng bo, l do cn cha bit, v
trong mt gia nh, cng ch dinh dng, nhng li c ngi gy k bo. iu
ny gi thng c t tnh di truyn v bo ph.
2. n nhiu: tc qu nhu cu c th thng l nguyn nhn bo ph (95%). n nhiu
do nhiu nguyn nhn:
- Thi quen c tnh gia nh: gii thch thng gp nhiu ngi bo ph trong mt gia
nh, khng ph thuc di truyn.
- Bnh tm thn kinh.
- Gim hot ng th lc m khng gim n: gp ngi gi hoc t hot ng.
3. Nguyn nhn di truyn: 69% ngi bo ph c b hoc m bo ph; 18% c b ln
m u bo ph, ch c 7% l c tin s gia nh khng ai bo ph.
Theo Mayer J. (1959) nu c b ln m u bnh thng th 7% con h s b bo
ph. Nu mt trong hai ngi bo ph th c 40% con h b bo ph. Nhng nu c b
ln m b bo ph th t l bo ph con l 80%.
Phn nh gia vai tr ca di truyn thc s v vai tr ca dinh dng cn cha r.
Di truyn c tnh tri v yu t di truyn lm cho kh nng phn chia t bo m d
dng hn.
4. Nguyn nhn ni tit: him
- Hi chng Cushing: phn b m mt, c, bng, trong khi cc chi gy nh.
- Cng insulin: do u ty tit insuline, tng n ngon, n nhiu v tn sinh m m,
tng tiu glucid.
- Gim hot tuyn gip: him, phi ch rng chuyn ho c bn c biu th
bng calori/m2 b mt da thng gim ngi bo ph. Tht vy, b mt da gia

436
tng l do tng m m, l m t tiu th oxy. Tri li, trong phn ln cc trng hp
bo ph khc, s gim chuyn ho c bn ny khng c ngun gc tuyn gip.
- Hi chng bo ph-sinh dc (hi chng Froehlich hay Babinski-Froehlich): bo ph
thn v gc chi v suy sinh dc, biu hiu thiu nin vi ngng pht dc c
quan sinh dc, c th km ri lon khc nh i tho nht, ri lon th lc v tm
thn. Theo A. Froehlich nguyn nhn do u vng di i.
- Ngi b thin: m m tng quanh hng, phn cao ca i, ging nh hi chng
bo ph-sinh dc
- Ru l ngun quan trng ca nng lng.
5. Nguyn nhn do thuc
Gn y, thuc c thm vo danh mc nguyn nhn ca cc yu t bo ph, bi
v gia tng dc liu php. Tng cn c th l sn phm ca cc hormone steroides
v 4 nhm chnh ca cc thuc kch thch tm thn:
- Khng trm cm c in (3 vng, 4 vng, c ch IMAO).
- Benzodiazepine.
- Lithium.
- Thuc chng lon thn.
Vy gii hn s dng thuc kch thch tm thn kinh phng nga tng cn, c th
lm gim liu php iu tr
IV. SINH L BNH
1. S phn b v tin trin ca khi m 2 gii
tr <15 tui, m nhiu v u th phn di v ngoi bin c th c trai v gi
ging nhau, nhng gi m nhiu gp 1,5 ln nam gii.
tui dy th: m ph n 2 ln nhiu hn nam gii. Khng bin i phn b m
cho n 50 tui. Sau 50 tui, m c xu hng cao hn v su hn trong c th.
S tin trin ny thy r nam gii tui 15-20 tui.
Sjostrom v Kvist nhn thy rng mc ng i ngang qua rn, tng ng a
L4-L5, 53% m pha trn ng ny nam gii; 46% n gii. M tng 9 - 34%
n ng v 4 - 14% n b. S phn b ny chung cho phn ln bnh nhn,
nhng trong mt s t trng hp s phn b m ny t hay nhiu tri ngc nhau.
2. Vai tr kch thch t trong c ch phn b m
- Androgen lm gim s lng t bo m phn thp c th.
- Cortisol tng th tch t bo m phn cao.
- Estrogen v c th c c progesterone lm tng th tch v s lng t bo m
Trong mt s t trng hp do tn thng sn xut v/hay l chuyn vn hormone
sinh dc, nhng nguyn nhn cn li, s nhy cm t bo m vi hormone sinh dc
l nguyn nhn chnh ca phn b m trong 2 gii. Hin tng ny l tri v di
truyn.
3. Tnh cht khc nhau ca m nam v m n gii
p ng t bo m nam v n gii khc nhau. Nhiu nghin cu ca Lafontan
cho thy rng hot ng tiu m ca (adrenergic u th trn t bo m nam gii,
hot ng chng tiu m ca (-2 adrenergic u th trn t bo m n gii. Theo
Rebuff Scrive, hot ng canzyme Lipoprotein lipase tng trong m n gii, ti
a trong thi k c thai, ti thiu khi cho con b.
4. S khng insuline trong c, m m trong qu trnh bo ph chut

437
Bo ph sc vt, di truyn hay gy nn bi thc nghim; cng nh bo ph ngi,
thng ko theo tnh trng khng insulin phi hp tng insulin mu v vi
glucose mu bnh thng hoc tng. S khng insulin ny tm thy trong thc
nghim mc t bo ch chnh ca hormon, m c, m m. Trc ht m m c
pha p ng bnh thng vi insulin trc khi insulin b khng. Kiu din tin ny
ging nhau c bo ph di truyn v bo ph do n qu nhiu.
- khng insulin bnh nhn bo ph: xem s sinh l bnh t bo ph
n khng insulin sau:

Bo ph

khng insulin

Gim bt gi glucose mc t bo
gai on sau n

Gim sinh nhit do tit thc


Lm trm trng thm qu ti trng lng

Hnh 1: S sinh l bnh t bo ph n khng insuline:
5. Tng chuyn ha c bn
ngi bo ph, khi lng gy (tc khi tht, ni hu nh c nht ca chuyn
ha c bn) l cao r so vi khi lng gy ngi c trng lng bnh thng, v
th ngi bo ph c s tiu th qu mc nng lng lin quan n chuyn ha
cn bn.
6. Gim sinh nhit do ch tit thc: Sinh nhit do ch tit thc ngi bo ph
thp hn ngi c trng lng bnh thng.
Hu qu ca hai s thay i nghch l ca chuyn ho nng lng cho thy rng
ngi bo ph, s tiu th nng lng ton th ch mc trn rt t so vi s tiu
th nng lng ton th ngi bnh thng.
7. n nhiu: Tht vy, trong chng mc no , giai on cn bng trng lng,
nng lng a vo bng nng lng tiu th.
8. Yu t di truyn t tnh ca bo ph: 1/3 bo ph do di truyn. Khng di truyn;
truyn theo gia nh c s tham gia ca yu t mi trng khong hn 1/3 trng
hp. Th 3 phn cn li l yu t mi trung khng lan truyn
9. Gne ca bo ph: Gene Leptin l mt loi protein, c m ho bng gene ob,
ch c trong m m trng. Thiu protein ny s gy bt thng chuyn ho chut
(bo ph, tng insulin, tng ng mu, gim thn nhit). Gi thuyt cho rng c l
Leptin ngn cn thi n ung qua trm hypothalamus. Nhiu nghin cu cho thy
leptin c m m sn xut nhiu nht lc i v trong qu trnh T thc nghim,
v cng tr li bnh thng trong vi gi sau khi n hoc tim insulin. iu ny cho
thy rng Leptin tc ng nh mt tn hiu chn ngy.

438
Mt khc, chut ob/ob, cho Leptin vo s lm gim trng lng ng k. Leptin
cng iu nh s hp th thc n, ng mu, insulin mu. N lm tng chuyn
ho ton th, nhit c th v mc hot ng th lc. Hn na, Leptin cng tc
ng trn con vt bnh thng v c th lm mt i 12% trng lng c th v tt c
m ca n trong vng 4 ngy.
bnh nhn bo ph, gne ob rt gia tng. S gia tng ny t l vi trng lng c
th. ng ch l gii n gii, Leptin c tit ra vi mc b sung iu ho
hormon. Nh vy r rng rng bo ph khng phi do Leptin b gim tng hp, cng
khng phi do Leptin bt thng. Theo Catherine Le Stunff v cs, ngi bo ph,
Leptin tng 10 ln cao hn lng Leptin ngi bnh thng, v t l vi khi lng
m. S gia tng Leptin khng lm gim s ngon ming ngi bo ph, nhng tip
tc lm tng s n nhiu v cng lm tng trng, iu ny cng c cho l l l c s
khng Leptin ngi bo ph.
V. TRIU CHNG: ch yu da vo cc ch s nh gi c bo ph hay khng
1. Cng thc Lorentz tnh trng lng l tng (TLLT) ch yu da vo chiu
cao.
TLLT (nam) = chiu cao - 100 - hoc TLLT (n) = chiu cao - 100 -
Nu TLLT tng >25% l bo ph.
Hoc IC = (TLHT/TLLT) (100%. (trng lng hin thc/trng lng l tng)
Nu IC = >120% - 130%:Tng cn qu mc
Nu IC = >130% bo ph.
2. BMI: (Body Masse Index=Ch s khi lng c th): Trng lng (kg)/chiu cao
(m2).
- Theo T chc quc t v bo ph (International Obesity Task Force) 1998
Tng trng khi BMI = 25 - 29,9; Bo ph khi BMI (30,0
- Theo tiu chun chn on bo ph p dng cho ngi chu : bo ph khi BMI (25
3. o dy ca np da tam u: gia khong cch t ci tay v vai, trung bnh
16,5mm nam, 12,5mm n.
4. Bo ph c th khng c triu chng: hay c kh th gng sc, mt, kh chu
nng, ri lon tiu ho, thoi ho khp do qu ti c th (khp hng, i, ct sng
tht lng).
5. Ri lon chuyn ho lipide: tng lipoprotein (type VLDL, LDL).
6. Hu qu tm thn kinh bo ph c th trm trng: lo lng vi tng HA.
7. Gim dung np glucose mu, T th 2 (Hi chng chuyn ho).
8. Bo ph trm trng: gim thng kh phi (hi chng Pickwick), suy tim-phi.
VI. CC PHNG PHP NH GI BO PH
C nhiu phng php nh gi m m (bo ph): phng php o nhn trc
(anthropomtrique) lm sng, phng php mi bng hnh nh siu m, ngay c ct
lp c t trng (tomodensitomtrique). S chn la gia cc phng php khc nhau
ny tu thuc vo ng cnh v mc tiu nghin cu hng n.
1. Phng php o nhn trc
1.1. Ch s khi lng c th (BMI). Kt qua nh nu trn phn triu chng.

1.2. Cng thc Lorentz: tnh trng lng l tng (TLLT), cng thc ny da vo
trng lng bnh nhn tnh bng kg v chiu cao tnh bng cm nh nu trn:

439
1.3. dy ca np gp da: dy ca np gp da phn nh dy ca lp m
di da, c th o c bng mt compas Harpender hoc Holtane, c tay cm
rng, c khc s hng nh.
Cch o: tay tri cm compas, ri kp np gp da thng ng gia ngn tr v ngn
ci, thc s cho bit dy ca np da.
o dy np gp da nhiu v tr khc nhau l cn thit: cc im quanh gc cnh
tay v i, c nh u, tam u, trn b vai, trn xng chu, thng v, trung v v
h v. Ngc li, n gii, np gp da vng i v h v l dy hn np gp da
pha trn rn v cnh tay.
V d: o dy ca np da tam u gia khong cch t ci tay v vai, trung
bnh 16,5mm nam, 12,5mm n
1.4. Ch s phn b m cc np gp da (Phng php nh gi phn b m m):
nhiu ch s hoc phng php c a ra:o dy np gp da phn nh
quan trng lp m di da, ch a ra 2 ch s d o hn
- Ch s m-c ca Jean Vague
Ch s m- c cnh tay - i (CSMCCT) gm dy np gp da quanh gc cnh
tay v i, mc khc chu vi ca i cng c o cng ngang mc . CSMCCT
cho php nh gi s lng s phn b m v c gia vng c Delta v c i,
nhng khng lin quan trc tip n lp m bng.
Gi tr bnh thng ca CSMCCT n c trng lng bnh thng, l 0.76 - 0.8,
v nam gii 1.01 - 1,10. Jean Vague c th nh ngha nhiu th khc nhau v
s phn b hypergynoide, gynoide, mixte, androide, hyperandroide.
- Ch s gia dy m m-c Delta v c mu chuyn (trochantrien): ch s gia
dy m m vng Delta v pha sau mu chuyn l t nhy cm vi lp c bn
di. 0,7 nam, v 0,3 n.
1.5. o chu vi
Ch s phn b khi m phn chu vi
- Ch s cnh tay-i: o chu vi cnh tay v i phn gc l d dng thc hin.
y l ch s ng tin cy o lng s phn b m. T ca chu vi cnh tay vi
chu vi ca i gc: 0,58 nam v 0,52 n.
- Vng bng/vng mng: ch s gia chu vi vng bng/vng mng c M.
Ashwell a ra nh l mt ch s o lng ng tin cy v s phn b m. Tr s
bnh thng l 0,92 - 0,95 nam; 0,75 - 0,80 n. Bo ph nam khi VB/VM >0,95
v n >0,80. Hoc theo ATP III, vng bng nam <102 cm, n l >88 cm
2. Siu m
dy ca m m nng c th c o trc tip chnh xc bng cch t u d
thng gc vi mt da, khng p, ti im mun xc nh. K thut c th phn bit
r rng gii hn phn m, c v xng.
3. Chp ct lp t trng
Phng php ny mi c p dng gn y nh gi s phn b m. N c
th nh lng m phn b di da v quanh tng. T phn ct ngang ca
scanner, c th tnh c b mt chon ch ca m m. Li im ca phng php
ny c th xc nh b mt m m su quanh tng. Phn ct ngang qua L4-L5 s
cho php phn bit chnh xc s khc nhau v phn b m gia 2 gii. S nh gi
bng phng php ny cho kt qu ng tin cy, chnh xc, tuy nhin gi k thut
t, dng c nng n kh thc hin cc tuyn thng thng.

440
4. Impdance mtrie: o phn trm lng m ca c th hin c v lng m l
tng da vo trng lng, chiu cao, gii, t tnh ra lng m qu ti l bao
nhiu phn trm.
VII. PHN LOI BO PH
1. Phn loi theo tui: ngi ta c th phn bit 2 th bo ph:
- Bo ph xy ra tui trng thnh: (th ph i) s t bo m c nh v tng trng
l do tch t qu nhiu lipide trong mi t bo, iu tr gim glucide l c hiu qu.
- Bo ph tui tr: (th tng sn ph i) khng ch cc t bo ph i m cn tng s
lng, kh iu tr.
2. Bo ph nam gii v n gii da theo s phn b m
Bo ph nam gii (androide): thng gp nht n ng, u th phn cao c th,
trn rn, gy c, vai ngc, bng, bng trn rn.
Bo ph n gii (gynoide): thng gp ph n, u th bng di rn, hng, i,
mng v cng chn.
Bo ph thng gp l bo ph androide ph n.
3. Phn loi da theo t vng bng/vng mng (VB/VM)
o chu vi vng bng/vng mng v tr tr nh ni trong phn VI (cc phng
php nh gi bo ph). Bo ph nam khi VB/VM >0,90; bo ph n khi VB/VM
>0,85.
4. Da vo cng thc Lorentz
IC = (TLHT/TLLT) (100%. (trng lng hin thc/trng lng l tng)
Nu >120% - 130%: tng cn qu mc
Nu >130%: bo ph.
5. Da theo ch s BMI
Bng 2: Bng phn loi theo T chc quc t v bo ph (International Obesity Task
Force)1998
Phn loi BMI (kg/ (m
2
). Nguy c
Gy
Bnh thng
Tng trng
Bo ph:
II
II
III

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


Tng va
Tng r
- Bo ph va hay chung
- Bo ph nng
- Bo ph qu mc hay bo
bnh
Hin nay p dng ph hp vi c im tng vng qua nghin cu thc t cc
quc gia chu , TCYTTG chnh thc ng cc quc gia chu ly tiu chun
ban hnh thng 2/2000 lm tiu chun chn on bnh bo ph.
Bng 3: Tiu chun chn on bnh bo ph da vo BMI v s o vng eo - p dng
cho ngi trng thnh chu .
Yu t phi hp
Phn loi BMI (kg/m
2
)
S o vng eo: < 90cm (vi nam) (90cm
< 80cm (vi n) (80cm

441
Gy < 18,5
Thp (nhng l yu t nguy
c vi cc bnh khc).
Trung bnh
Bnh thng 18,5-22,9 Trung bnh C tng cn
Bo:
+ C nguy c
+ Bo 1
+ Bo 2
23
23-24,9
25-29,9
>30

Tng cn
Bo va phi
Bo nhiu

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

442
Vai tr ca bo ph trong hi chng chuyn ho: c m t trong hnh sau:















3. Bin chng tim mch: Bo ph l mt trong nhng yu t nguy c cho bnh l tim
mch nh
- Tng guyt p (THA): lin quan cht ch gia bo ph v tng HA, tn sut
THA tng trong bo ph bt k nam hay n. Huyt p gim khi gim cn. C ch
tng HA trong bo ph cha r ht, ngoi x va ng mch hay gp, cn c gi
thuyt do tng insuline mu v khng insuline, lm tng hp thu Natri ng thn
v tng tit catecholamine lm co mch.
- Suy mch vnh: thng gp, ngay c khi khng c thm cc yu t nguy c
khc nh T, tng lipide mu, tng HA.
- Cc bin chng khc nh suy tim tri, tai bin mch mu no.
4. Bin chng phi
- Gim chc nng h hp do lng ngc di ng km do qu bo.
- Hi chng Pickwick: ngng th khi ng.
- Tng hng cu, tng CO
2
mu.
5. Bin chng v xng khp
Ti cc khp chu lc cao (khp gi, khp hng, ct sng) d b au, thoi
khp.
Tn sut hoi t thiu mu u xng i gia tng.
Thot v a m, trt t sng hay gp
Cc bin chng ny tng ln ph n mn kinh.
6. Bin chng v ni tit
- Tng insuline mu v khng insuline v T th 2, do tc dng bta-
endorphine hoc gim s lng v cht lng insulin, kch thch t bo bta do n
nhiu glucide.
- Chc nng ni tit sinh dc: gim kh nng sinh sn. Chu k kinh ko di
khng phng non. Rm lng.
7. Cc bin chng khc
BO PH
Acid bo t
d
khng Insulin
Glucose mu
i tho ng type 2
Bnh tim mch
Triglyceride
HDL
Tng huyt p
Hnh 2: Vai t r o cu a be o ph t r ong hi ch ng
chuyn hoa

443
- Nguy c ung th gia tng: ung th t cung, v, i trng, tin lit tuyn.
- Bin chng tng nng ln do bo ph:
+ Gan mt: Si mt, gan nhim m.
+ Thn: tc tnh mch thn, protein niu.
+ Sn khoa: nhim c thai nghn, sinh kh, m ly thai tng.
+ Da: rn da, nm k, tng sng ho gan bn chn, bn tay.
IX. IU TR
M hnh iu tr bo ph: da vo 3 phng cch chnh sau y:
- Tit thc gim trng lng
- Tng nng lng tiu dng (Tp th dc).
- Thay i chuyn ha thc n.
Phng cch 1 v 2 bao hm tit thc v tp th dc.
1. Tit thc gim trng lng v tp th dc
Gim trng lng l mc tiu chnh iu tr, vi gim trng lng mc nh t 5%
n 10% trng lng ban u, bng tit thc v tp th dc cng ci thin lm sng
c ngha, ci thin c bnh tng HA, bt thng lipide cng nh glucose mu.
Khong 80% bnh nhn T tp 2 c tng trng hoc bo ph, nu gim trng
lng t 5% n 10% th ci thin c ngha HbA1c.
Theo Chng trinh T Phn Lan v Chng trnh Ngn nga bnh T cho
thy rng nhng bnh nhn c ri lon dung np glucose mu, nu gim trng
lng chng 7% s gim c nguy c T tp 2 chng 58%.
1.1. Tit thc gim trng lng
- Tit thc gim trng lng: l phng cch u tin v c p dng mt cch
rng ri. Cch thc chnh l tit thc gim calo, gim m v vi thc n khc c kh
nng gim sinh nng lng cho c th. Nu nng lng a vo thp hn nhu cu
sinh l, th nng lng thm vo l t m m d tr. S khc bit ln gia nhu cu
a vo v nng lng l do s i. Khi khng c thc n a vo, nng lng
c rt ra t m m d tr l 1500-3000 kcal. M c th cha 7500 kcal/kg. Vi
cn bng calo m tnh 1500 kcalo/ngy, th s lm gim trng lng c th 1 kg mi
5 ngy. Lm gim trng lng khong t 0,5-1 kg/tun l thch hp cho mt tit thc
gim trng lng.
i vi ngi ln tui va, 1200 kcalo/ngy duy tr mt > 0,5 kg/tun.
Ni chung lng calo cho mi bnh nhn tt nht phi da vo cn nng hin ti.
Tit thc gim calo khi lng calo dng 20-25 Kcalo/kg/ngy
Nh vy nu lng calo cung cp gim di 500 Kcalo/mi ngy, th s lm gim
mt trng lng khong 0,5kg/tun. Thnh cng iu tr tu vo tui bnh nhn (bo
ph thiu nin phi c iu tr rt sm) v ng lc bnh nhn rt cn cho iu tr.
i vi nhng bnh nhn c thi quen n nhiu, chp nhn hn ch thc n trong
sut cuc sng l rt kh khn.
Tit thc t m, gim thc n giu-carbohydrat v tit thc m n khng bo ho
ci thin c bnh mch vnh. Nn dng nhiu tri cy, cc loi rau, v nhng loi
ton ht, giu cht x. Nn thay th thc n c cht dinh dng thp, giu calo bng
nhng thc n c cht dinh dng cao, t nng lng
trnh cc bnh l tim mch, nn dng cc loi rau, tri cy, cc loi ton ht, c
v cc thc n c ch bin t m km luyn tp th dc.

444
Sau y l phng cch iu tr nn ca Phng php iu tr thay i li sng
vit tt l TLC (Therapeutic lifestyle Change) l mt chng trnh gm 12 tun thm
khm, sau l mi 2 tun trong vng 3 thng na c thay th mi 6 tun nhm
t mc ch l Triglyceride, HDL-C v tt NPDNGU bnh thng. Mi ln thm
khm nh gi nng LDL-C, vng bng, trng lng, nh gi vic tun th tit
thc v tp luyn th dc ca bnh nhn.
Bng 4: Thnh phn cht dinh dng trong tit thc iu tr TLC
Cht dinh dng Nhu cu cn thit
M bo ho < 7% calories ton th
M a khng bo ho > 10% calories ton th
M n khng bo ho >20% calories ton th
M ton th 25%-35% calories ton th
Carbohyddrate (ht, tri cy, rau) 50%-60% calories ton th
Cht x 20-30 gr/ngy
Protin Ti a 15% calories ton th
Cholesterol < 200 mg/ngy
Tng cng calories ton th (k c hot
ng th lc ti a 200 Kcal/ngy
Cn bng nng lng a vo v nng
lng tiu dng duy tr mt trng lng
thch hp/ngn chn tng cn
- Tit thc Cambridge (Cambridge diet)
Cung cp y yu t vi lng, gim glucide hiu qu, gim cn kh tt, khng tai
bin
- iu tr nhn i
Nguy him v phi cho nhp vin (bo ph kh iu tr). Nhn i gy d ho
m m v protein. Gim natri v c th lm tn thng gan trm trng.
1.2. Hot ng th lc v tp th dc
Hot ng th lc v tp th dc lm tng s tiu dng nng lng, l iu tr u
tin cho nhng bnh nhn qu ti v bo ph, c xem nh l yu t cha kho
trong chng trnh gim trng lng.
Mc ch tp luyn th lc nhm cc li im sau
1) Ci thin c ng mu.
2) Gim khng insulin, tng nhy cm insulin ngoi bin.
3) Gim trng lng.
4) Ci thin lipoprotein (gim triglycerid, cholesterol ton phn, LDL-
Cholesterol v VLDL, Tng HDL- Cholestrol), nn gim c x va ng mch.
5) Tc dng c li trn tim mch (tng kh nng ti a s dng oxy, lm chm
li nhp tim lc ngh ngi v lc gng sc, gim va phi HA, gim nguy c tc
mch, v gim t sut do bnh mch vnh).
Trong hot ng th lc, tn s tim khong 50% tn s tim ti a. Tn s tim
ti a c tnh theo cng thc sau: (220-tui)/2. V d bnh nhn 50 tui: 220 - 50
= 170/pht, th tn s tim cho php l 85 ln/pht.
6) Tng sc lc
7) Lm gia tng tnh do dai

445
Nh l mt chin lc gip ngi bo ph gim trng lng, d sao tp
th dc l mt phng cch tuyt ho, Tp th dc tng tiu th nng lng c th,
nhng cng ng thi tng ngon ming. i do 5 km lm tng tiu th nng lng
200 calo. Thc cht, nu nng lng tiu dng khng tng, th lm gim trng rt
kh khn bi v kh m duy tr s gim thc n a vo.
Nn gia tng hot ng th lc t t nh tp th dc 10-30 pht/ngy cho
n khi t 300 pht/tun.
Theo Surgeon Generals Report on Physical Activity and Health khuyn vi
mi la tui nn tp luyn th dc trung bnh l 30 pht/ngy nh chy nhanh 30
pht, 3 ln/tun, tuy nhin gn y ngi ta khuyn tt hn l 60 pht/ngy.
Theo Bethesda nn tp th dc khong 2 gi ri/tun, n c m, v gim
trng lng l gim c t sut T ti M.
Sau khi tp th dc xong, tc dng insulin tng v ko di nhiu gi. Di
nh hng ca insulin, gan v c thu nhn glucose v ti d tr li glycogen.
Vn ng th lc thng l i b, p xe hay bi li..
t chy 100 calories (khong 10g cht bo) phi i b 20 pht, bi hoc
nh tennis 12 pht, 8 pht p xe hoc chy b.
Tuy nhin, tp th dc khng lm tt c i vi ngi qu bo, di chuyn
c th nng n v v vy ra m hi d dng v thng au khp, ngoi ra bnh tim
mch nng cng hn ch tp luyn
Nhng cng c khng t trng hp, vi tit thc v tp th dc vn khng lm gim
trng lng v gi l bo khng cha tr c. V vy bo tr li c thng rt
chung. y l l do ngi ta dng thuc v phu thut.
2. Thuc iu tr bo ph
Sau 12 tun tit thc gim trng lng v tp luyn th dc m khng ci thin
c trng lng th dng thuc.
2.1. Thuc iu ha th th adrnergique (Diethylpropion, Mazindol, Phentermine)
hoc th th serotonine (Fenfluramine).
Tt c cc thuc u c tc dng ph, lm mt s n ngon ming, gim trng lng,
nn ch c dng sau khi cn nhc gia li v hi ca cch thc iu tr ny.
Cc thuc ny dng phi hp c kt qu tt hn l dng n c, nh phi hp
Fenfluramine vi Phentermine (noradrenergique). Tuy nhin nm 1997 v c mt
trng hp c biu hiu bnh van tim mt ph n, nn 1998 Fenfluramine v
Dexfenfluramine rt khi th trng, ch cn li Phentermine.
2.2. Thuc lm gia tng tiu th nng lng
Hormonee gip (nhm L-Thyroxin), nhng khng c tc ng thng xuyn, thng
t dng v ko di gy c ch chc nng tuyn gip hay nhim c gip.
2.3. Thuc c tc dng bin i chuyn ha cht dinh dng:
Thuc lm gim tiu ha thc n (c ch lipase) hoc bin i chuyn ha
(androgen, estrogen, GH)
Hin nay c 2 loi thuc c U Ban Thc phm v Dc phm Hoa K/FDA v
TCYTTG ch chp thun dng gim cn ko di l Siburtramine (Meridia*,
Reductil*) v Orlistat (Xenical*).
iu tr bng Reductil (10mg/vin) c th gip gim (2 kg trong vng mt thng v
4,4-6,3 kg sau 6 thng, Reductil khng gy chn n, khng gy l thuc thuc m
lm bnh nhn c cm gic mau no khin h n t hn, v vy thch hp cho nhng

446
ngi lun c cm gic mau i v thm n nhiu, Reductil cng lm gim t VB/VM,
gim lipide mu v glucose mu. Tc dng ngoi ca thuc l kh ming, to bn,
au u nh, cm gic hi hp, tng nhp tim THA mt s ngi (him). Thn
trng: khng dng cho ngi THA v c bnh mch vnh. CC: tr em, mn cm
vi thuc, c thai cho con b.
Siburtramine l loi c ch chn lc s ti thu gi c 2 loai serotonin v
norepinephrin, n lm gim ngng ngon ming (do tc dng trung ng lm cho
bnh nhn c cm gic no sm) v tng sinh nhit, gim vn tc bin dng, nn
gim trng lng.
Orlistat, c ch lipase tu, gim hp thu rut. Tc dng ph l km hp thu m,
gim cc viatmin du nh vitamin D v E, nn phi tng cng thm vitamin.

447
2.4. Thuc lm mt s ngon ming
Thi gian
tc dng
Liu lng v cch dng
Tc dng Noadrenergic
Benzphetamine 6-12 25-50mg trc n, 25-50mg/ng
Phendimetrazine 5-12 35mg trc ba n hoc 105mg/ngy,
17.5-105mg/ng
Diethylpropion 4-6 25mg trc ba n, 25-75mg/ng
Mazindol 10 1-2mg lc i ng, 1-2mg/ng
Phentermine HCL 7-24 8mg hoc 15-37.5mg trc ba n, 15-
37.5mg/ng
Phenylpropanolamine 25mg trc ba n, 25-75mg/ng
TC DNG SEROTONERGIC
Dexfenfluramine 11-30 15mg, 2ln/ng, 30mg/ng
Fenfluramine 11-30 20mg trc ba n, 60-120mg/ng
3. Phu thut: Ngoi l, ch p dng bo ph qu trm trng, e d s sng (>50%
trng lng l tng bnh nhn < 40 - 50 tui.


448
BASEDOW
Mc tiu
1. Trnh by c nh ngha, c ch bnh sinh v bnh nguyn ca bnh.
2. Nu c nhng triu chng lm sng v cn lm sng lin quan n bnh.
3. Bit cch chn on bnh Basedow.
4. Trnh by c cch iu tr bnh Basedow.
5. X tr c nhng bin chng chnh ca bnh
Ni dung
I. NH NGHA
Basedow l mt trong nhng bnh l cng gip thng gp trn lm sng vi cc
biu hin chnh: nhim c gip km bu gip ln lan ta, li mt v tn thng
ngoi bin.
Bnh Basedow mang nhiu tn gi khc nhau Bnh Graves. Bnh Parry. Bu gip
c lan ta. Bnh cng gip t min. Nh s tin b ca min dch hc, ngy cng
nhiu khng th hin din trong huyt tng ngi bnh c pht hin, v th hin
nay bnh c xp vo nhm bnh lin quan t min.
II. BNH NGUYN
Bnh xy ra mi tui, nht l tui 20 - 40 tui, u th ph n, t l nam /
n = 1/5 - 1/7 vng khng b bu c a phng. Tuy nhin, vng dch t t l
ny thp hn. Theo Volp c l lin quan n s khim khuyt ca t bo lympho T
c ch, l yu t c bn trong bnh l t min tuyn gip. Mt vi yu t ghi nhn
c th gy p ng min dch trong Basedow nh
- Thai nghn nht l giai on chu sinh (hu sn)
- Dng nhiu iod, c bit dn c sng trong vng thiu iod, c th iod lm khi pht
bnh Basedow tim tng.
- Dng lithium lm thay i p ng min dch.
- Nhim trng v nhim virus.
- Ngng corticoid t ngt.
- Ngi c HLA B8, DR3 (dn vng Caucase) HLA BW 46, B5 (Trung Quc) v HLA
B17 (da en).
- Vai tr Stress cha c khng nh.
- Lin quan di truyn vi 15% bnh nhn c ngi thn mc bnh tng t v
khong chng 50% ngi thn ca bnh nhn c t khng th khng gip trong
mu.
III. BNH SINH
C s khim khuyt ca t bo lympho T c ch (Ts, T8), cho php t bo lympho T
h tr (T H) kch thch t bo lympho B tng hp cc khng th chng li tuyn gip.
Globulin min dch kch thch tuyn gip (TSI: Thyroid stimulating immunoglobulin
hoc TSH. R Ab (Stim): khng th kch thch th th TSH) gy tnh trng nhim c
gip. Ngoi ra cn tm thy nhiu loi khng th khng thyroglobulin, khng th
khng enzyme Peroxydase gip hoc khng th khng tiu th. Ngoi ra tin trnh
vim nhim c hc mt do s nhy cm ca cc t bo lympho T c t bo
(cytotoxic T lymphocyte) hoc cc t bo git (killer cell) i vi khng nguyn hc
mt trong s kt hp vi cc khng th c t bo. Tuyn gip v mt c th c lin
quan bi mt khng nguyn chung gia tuyn gip v nguyn bo hc mt. Tuy

449
nhin vn cha r l lm sao gy ra dng thc min dch ny.
1. Ti tuyn gip
Cc t bo lympho T tr nn nhy cm vi cc khng nguyn trong tuyn gip v
kch thch cc t bo lympho B tng hp khng th chng li cc khng nguyn ny.
Khng th trc tip chng li th th TSH mng t bo gip v c kh nng kch
thch t bo tuyn gip pht trin v tng hot hot (khng th kch thch th th
TSH). iu ny c th lin quan n di truyn nm bn di, nhng vn cha gii
thch c l do l lm th no giai on cp xy ra.
2. Ti mt
T bo lympho c t bo (Cytotoxic Lymphocyte cn gi Killer cells) v cc khng
th c t bo (Cytotoxic Antibodies) nhy cm vi cc khng nguyn chung
(Commun - Antigen) trong nguyn bo si hc mt (Orbital fibroblast), c hc mt
v t chc tuyn gip. Cc cytokin t cc t bo lympho ny c mn cm c
th gy vim nguyn bo si hc mt v vim c hc mt. Kt qu lm sng hc
mt, li nhn cu, chng nhn i, , sung huyt v ph kt mc, ph quanh hc
mt (bnh l li mt tuyn gip).
3. Biu hin da v u chi
Ph nim mt trc xng chy v thng tn quanh mng xng u cc
ngn tay v u cc ngn chn (bnh khp gip trng) cng c th lin quan cytokin
ca cc t bo lympho kch thch nguyn bo si cc v tr ny.
Ngoi ra cc triu chng ca nhim c gip trc y ngi ta cho l hu qu ca
cht catecholamine tng cao trong mu nh nhp tim nhanh, run tay m hi, co
ko m mt, nhn chm ch. nh lng nng epinephrine lu hnh trong gii
hn bnh thng, v vy c th gii thch trong bnh Basedow lm cho c th tng
nhy cm vi cc catecholamine.
iu ny mt phn do s gia tng cc th th catecholamine tim v mt s c
quan khc.
IV. TRIU CHNG LM SNG
Chia lm 2 nhm hi chng ln, l biu hin ti tuyn gip v ngoi tuyn gip.
1. Ti tuyn gip
1.1. Bu gip
Bu gip ln, thng lan ta, tng i u, mm, n hi hoc hi cng, c th
c rung miu tm thu, thi tm thu ti bu, nu bu ln c th chn p cc c
quan ln cn. Mt s biu hin ri lon vn mch vng c (, da nng, tng tit m
hi), vn c mt t l nh bnh nhn khng c bu gip ln (lin quan khng th).
1. 2. Hi chng nhim c gip.
Cc du chng ny thng t l vi nng hormon gip vi nhiu c quan b nh
hng.
- Tim mch: hi hp, nhp tim nhanh, lon nhp kh th khi gng sc ln khi ngh
ngi. cc ng mch ln, mch nhy nhanh v nghe ting thi tm thu, huyt p
tm thu gia tng (tng cung lng tim) so vi huyt p tm trng, hiu p gia tng,
trng hp nng suy tim lon nhp, ph phi, gan to, ph hai chi di.
- Thn kinh c: run r bn tay l triu chng d nhn bit v ni bt km theo yu
c. Bnh nhn thng mt mi, d kch thch thay i tnh tnh, d cm xc, ni
nhiu, bt an, khng tp trung t tng, mt ng.
Ri lon vn mch ngoi vi, mt khi khi ti, tng tit nhiu m hi, lng bn tay,

450
chn m. Phn x gn xng c th bnh thng, tng hoc gim. c bit du yu
c, teo c, du gh u (Tabouret), yu c h hp gy kh th, yu c thc qun
lm kh nut hoc ni nghn.
ngi tr tui triu chng tim mch thng ni bt, trong khi ngi ln tui u
th triu chng thn kinh v tim mch.
- Du tng chuyn ha: tng thn nhit, lun c cm gic nng, tm nhiu ln trong
ngy, gy nhanh, ung nhiu nc, kh chu nng, lnh d chu. Ngoi ra c cc
biu hin ri lon chuyn ha calci gy tng calci mu hoc hin tng long xng
ngi ln tui sau mn kinh gy bin chng, xp t sng, gy xng t nhin,
vim quanh cc khp.
- Biu hin tiu ha: n nhiu (vn gy), tiu chy au bng, nn ma, vng da.
- Tit niu sinh dc: Tiu nhiu, gim tnh dc, ri lon kinh nguyt, v sinh, lit
dng v chng v to nam gii.
- Da v c quan ph thuc: nga, c biu hin ri lon sc t da, c hin tng
bch ban lng bn tay v cc chi; tc kh, hoe, mt tnh mm mi rt d rng;
rng lng; cc mng tay, chn gin d gy.
Tuy nhin cng cn phn bit trn lm sng hai nhm triu chng ch nh iu tr
ph hp.
(1) Thn kinh giao cm: Nhp tim nhanh, run tay, tng huyt p tm thu, tng phn
x, khe mt rng, nhn chm ch, hi hp, trm cm, kch thch v lo u.
(2) Nhim c gip: Tng tiu th oxy, n nhiu, st cn, ri lon tm thn, nhp
nhanh, tng co bp c tim, gim khng h thng mch mu.
2. Biu hin ngoi tuyn gip
2.1. Thng tn mt
Thng hay gp l li mt. C 2 loi: li mt gi v li mt tht (li mt ni tit), c
th khng lin quan n mc nhim c gip hoc c lp vi iu tr. V th c
th xy ra sau qu trnh iu tr nht l phu thut hoc iu tr phng x.
(1) Li mt gi: tn thng khng thm nhim lin quan n bt thng v chc
nng do tng hot ng ca h thn kinh giao cm, tng thyroxin gy tng co ko c
nng mi lm kho mt rng ra.
(2) Li mt tht (li mt ni tit): tn thng thm nhim lin quan n cc thnh
phn hc mt gy bnh mt ni tit trong bi cnh t min trong bnh Basedow gy
thng tn c vn nhn v t chc sau hc mt. Bnh l mt thng phi hp gia
tng nng khng th khng th th TSH (kch thch). Theo phn loi ca Hi gip
trng M (American Thyroid Association) cc biu hin mt c phn nh
sau:
- 0: khng c du hiu v triu chng.
- I: khng c triu chng, c du co ko mi trn, mt ng vn gia nhn cu v
trn, gia nhn cu v mi trn (u th triu chng ny lin quan n nhim c gip,
hi phc sau khi bnh gip).
- II: ngoi cc du hiu ca I, cn c cm gic d vt trong mt, s nh sng
(Photophobie), chy nc mt, ph m mt, sung huyt v sng kt mc... (thm
nhim c v t chc hc mt, nht l t chc quanh hc mt).
- III: li mt tht s, da vo li nhn cu do tm nhun sau t chc hc mt
(tm nhun hc mt t 3 - 4mm (li nh); t 5-7mm (li va) v (8mm (li nng).
Cn lu v phng din lm sng nn da vo yu t chng tc nh gi v

451
li nhn cu bnh thng nh gi qua thc Hertel ca ngi da vng l 16-18mm,
da trng 18-20mm v da en 20-22mm..
- IV: thng tn c vn nhn.
- V: thng tn gic mc.
- VI: gim hoc mt th lc do thng tn thn kinh th.
nh gi mt cch tng i trung thc v s tm nhun sau hc mt cng nh
nh gi iu tr cn siu m nhn cu.
2. 2. Ph nim
T l gp 2-3%, thng nh v mt trc cng chn, di u gi, c tnh cht i
xng. Vng thng tn dy (khng th ko ln) c ng knh vi cm, c gii hn.
Da vng thng tn hng, bng, thm nhim cng (da heo), l chn lng ni ln,
mc tha, lng dng ng (da cam), bi tit nhiu m hi. i khi thng tn lan ta
t chi di n bn chn.
2. 3. To cc u chi
u cc ngn tay v cc ngn chn bin dng hnh di trng, lin quan n mng
xng, c th c phn ng t chc mm, ti v nhit bnh thng phn bit vi
bnh phi mn. Ngoi ra c du chng tiu mng tay (onycholysis).
Ngoi cc biu hin trn cn tm thy mt s du hiu ca cc bnh l t min phi
hp khc i km nh suy v thng thn, suy ph gip, tiu ng, nhc c nng,
trong bi cnh bnh a ni tit t min.
V. TRIU CHNG CN LM SNG
1. Xt nghim min dch
Hin din trong mu bnh nhn mt s khng th chng li tuyn gip nh:
+ Khng th kch thch th th TSH (c hiu ca bnh Basedow).
+ Khng th khng enzym peroxydase gip (TPO).
+ Khng th khng thyroglobulin (Tg), khng c hiu v c th gp trong bnh
Hashimoto.
+ Khng th khng vi tiu th (MIC)
iu ny ni ln mt s trng hp km p ng vi thuc khng gip.
S hin din cc loi khng th trn cn gp mt s bnh t min tuyn gip khc
nh Hashimoto, bu gip n, bu gip nhn, u tuyn gip vi t l thay i.
2. Xt nghim nh gi chc nng cng gip
Gia tng nng hormon gip trong huyt tng
+ T3 : (95-190 ng/ dl = 1,5-2,9 nmol/l): tng
+ FT3 : (0,2- 0,52 ng/ dl = 3- 8 pmol/ l): tng
+ T4 : (5 - 12 (g / dl = 64 - 154 nmol/ l): tng
+ FT4 : (0,9 - 2 ng / dl = 12 - 26 pmol / l): tng.
+ T T3 (ng %) /T4 (microgam %): trn 20 (nh gi bnh tin trin)
+ TSH siu nhy (0,5 - 4,5 (U/ ml): gim.
+ tp trung I131 ti tuyn gip sau 24 gi tng cao hn bnh thng, giai on
bnh ton pht c gc thot (gc chy). Lu mt s thuc khng gip cng gy
hin tng ny (nhm carbimazole). Nn nh gi vo cc thi im 4, 6 v 24 gi.
+ Test Werner thng s dng trong giai on sm, phn bit vi nhng trng
hp c tp trung iod phng x cao (bu n ho Iod, u tuyn gip c). Hin

452
nay t dng v c TSH siu nhy v chp nhp nhy tuyn gip.
+ Test TRH v test Querido (kch thch tuyn gip bng TSH): hin nay t c ch
nh.
3. Xt nghim hnh thi v cu trc tuyn gip
+ Siu m tuyn gip: tuyn gip ph i, eo tuyn dy, cu trc khng ng nht,
gim m (nhm vim tuyn gip). Siu m Doppler nng lng c th thy hnh nh
cu trc tuyn gip hn lon nh hnh nh m chy trong thi k tm thu v tm
trng vi cc mch mu gin trong tuyn gip, ng mch cnh nht l ng mch
cnh ngoi ny mnh, (ng mch cnh nhy ma). Trong nhiu trng hp khng
in hnh (khi u hoc iu tr) kh phn bit vi hnh nh ca Hashimoto.
+ X hnh tuyn gip (chp nhp nhy tuyn gip) gip xc nh phn no hnh thi
v chc nng tuyn gip vi I123 hoc Tc 99m: cht phng x tp trung ng u
ton b hai thy tuyn gip - tuyn gip ph i - gip phn bit cc thng tn ca
cc bnh l cng gip khc (bu gip c a nhn, bu gip c, vim tuyn
gip...).
+ Chp ct lp tuyn gip (CT Scanner) v MRI t c s dng trong chn on v
cu trc t khc bit so vi mt s bnh l vim tuyn gip.
+ Hnh nh gii phu bnh: Tuyn gip ln u c hai thy, tnh cht lan ta, mm
v tn sinh nhiu mch mu. Nhu m gip ph i v tng sn, gia tng chiu cao
ca t bo thng b v tha ln vch nang tuyn, to ra cc np gp dng nh
phn nh t bo tng hot ng. S lon sn nh trn thng km thm nhim t
bo lympho, iu ny phn nh bn cht min dch ca bnh v lin quan n nng
khng th khng gip trong mu.
4. Thm d thng tn mt
o li nhn cu bng thc HERTEL (i t b ngoi hc mt n mt phng tip
tuyn mt trc nhn cu): phng php n gin, thc hin nhiu ln, tr s thay
i. Hn ch ca phng php ny l khng nh gi trc tip thng tn tm
nhun sau hc mt.
- Tm kim du vim gic mc.
- Khm y mt; o trng lc nhn cu.
- Chp ct lp vng hc mt nhm pht hin sm cc bt thng hc mt, c vn
nhn, thn kinh th gic khi cha biu hin lm sng (giai on tin lm sng) v
gip phn bit cc nguyn nhn gy li mt khc.
- Siu m mt: nh gi bt thng c vn nhn v t chc hu nhn cu (c th o
c b dy ca t chc tm nhun sau hc mt)
5. Xt nghim thng tn da: Sinh thit vng ph mm trc xng chy, nhum
PAS (+) c s lng ng cht glycosaminoglycan.
6. Chp X quang xng u chi: Mng xng dy
VI. CHN ON
1. Th in hnh
Gp ph n tr vi y cc du chng lm sng nh trn.
2. Th triu chng
u th mt s c quan
Biu hin tim.
Biu hin thn kinh.

453
Biu hin c.
Nhc c nng v Basedow.
Bnh xng nhim c gip.
Biu hin tiu ha.
Basedow v nn ma.
Biu hin huyt hc.
Th v to v Basedow.
Basedow v tng cn.
3. Th lin quan nguyn nhn
Phi hp vi cc bnh l t min khc
Suy v thng thn v Basedow.
i tho ng v Basedow.
4. Cc th sinh hc
- Tng T3 ch yu.
- Tng T4 ch yu.
5. Cc th tin trin
Th in hnh : tr v bnh gip sau iu tr.
Th thoi trin t pht : 10-20%
Th cp v bn cp : trong th bn cp thng phi hp vi du gy nhiu, tiu
chy, ri lon nhp tim, c st v biu hin tm thn; th cp thng xy ra do sai
lm iu tr, c bit chun b ni khoa khng tt bnh nhn c ch nh phu thut.
Th v tnh cm (apathies): thng gp ngi ln tui, bnh cnh tri v yu c,
lit, chn n v ri lon nut. Thng chn on kh.
6. Chn on phn bit
- Teo c trong trng hp bnh c nng cn phn bit bnh c nguyn pht.
- Lit chu k gip trng thng xy ra ph n Chu , gy lit t ngt v gim kali
mu, i khi xy ra t pht, c th d phng bng dng kali v thuc c ch .
- Tim trong cng gip: khi u lon nhp c hi phc, khng p ng vi digoxin,
km tng cung lng tim.
- Khong 50% khng c bnh l tim tim tng, bnh p ng vi thuc khng gip.
- Ngi ln tui biu hin st cn, bu gip khng ln, rung nh chm v trm cm
(nng gi l cng gip v tnh cm = apathic hyperthyroidism).
- Ngi ph n tr i khi khi u vi mt kinh, v sinh.
- Hi chng cng thyroxin do ri lon albumin gia nh: do c bt thng albumin
lin kt ch yu vi T4, lin kt km vi T3, kt qu tng T4, FT4I nhng FT4, FT3
v TSH bnh thng, cn phn bit tnh trng bnh gip trong cng gip.
VII. BIN CHNG
Do c ch bnh sinh lin quan t min bnh c th hi phc t pht hoc do iu tr.
Trong qu trnh din bin bnh thng gp hai bin chng nh sau:
1. Bnh c tim nhim c gip: Thng biu hin di 2 dng
1.1. Ri lon nhp tim. a dng vi nhp nhanh xoang, ngoi tm thu, nhp nhanh kch
pht trn tht...
1.2. Suy tim cng gip

454
Cn phn bit 2 giai on: (1) Giai on u suy tim tng cung lng (nhp tim
nhanh, huyt p tng, c tim tng co bp...) v (2) Giai on sau l th bnh c tim
(ph, kh th, tim ln, ri lon nhp, suy tim, huyt p gim, chc nng co bp tim
gim...).
2. Cn cng gip cp
- Thng xy ra bnh nhn khng iu tr hoc iu tr km.
- Khi pht sau mt sang chn (phu thut, nhim trng h hp, chn thng, tai
bin tim mch, sau sinh...).
- Khi iu tr trit (phu thut, x tr liu) khng c chun b tt. Bnh cnh lm
sng vi cc triu chng:
+ St cao 40-41(, m hi, mt nc.
+ Nhp tim rt nhanh, ri lon nhp, suy tim, chong try mch.
+ Run, kch thch, thng tn c (ri lon nut), m sng, hn m.
+ Tiu chy, au bng, bun nn, nn ma, vng da.
+ C th gp cn bo gip v cm (apathetic storm) vi c trng yu c, v tnh
cm, ri lon tm thn. Chn on da vo cc d kin lm sng c gi . Nn
iu tr tch cc ngay, khng nn ch i kt qu xt nghim.
3. Li mt c tnh: (xem phn tn thng mt)
VIII. IU TR
Hin nay c nhiu phng php v phng tin iu tr bnh Bassedow. Vic chn
la phng php iu tr tu thuc vo kinh nghim ca thy thuc, iu kin y t c
s, s dung np v tun th ca bnh nhn trong qu trnh iu tr. Di y l mt
s phng php v phng tin iu tr:
1. iu tr ni khoa
1.1. Nhm thuc c ch tng hp hormone gip
- Trnh by: thng c s dng lm sng chia lm 2 loi
Carbimazole (neomercazole) 5mg, Methimazole 5mg
Propylthiouracil (PTU) 50mg, Benzylthiouracil (BTU) 25mg
- C ch tc dng:
- c ch phn ln cc giai on tng hp hormone gip
- Carbimazole c ch kh iod tuyn gip.
- PTU c ch bin i T4 thnh T3 ngoi vi.
- Carbimazole liu cao (> 60mg/ ngy) c tc dng c ch khng th khng gip
(gim trnh by khng nguyn gip, gim phng thch prostaglandin v cytokin t t
bo gip, c ch sinh sn cc gc t do t t bo T v B c bit t bo trnh by
cc khng nguyn v th lm gim khng th).
- Hiu qu tc dng: hng nh lng hormone lin quan n thi gian na i ca
T4 v do lng hormone tch tr trong tuyn gip. Hiu qu sau 1 - 2 tun, r rng
sau 3 - 6 tun.
- Liu lng thuc khng gip tng hp
- i vi nhm Thiouracil, thi gian na i khong 90 pht, c th bt u vi liu
cao chia nhiu ln, khi t bnh gip dng liu c nht bui sng. PTU 100-
150mg/6gi/ngy. Sau 4 - 8 tun gim 50 - 200mg/mt hoc hai ln/ ngy.
- i vi nhm imidazole: thi gian na i khong 6 gi, do c tc dng khng gip
trn 24 gi, dng liu c nht bui sng bt u 40mg/ ngy trong 1-2 thng sau

455
gim liu dn 5-20mg. Theo di FT4 v TSH.
- Thi gian iu tr: (tu thuc bnh nguyn v mc ch)
- Thi gian iu tr thuc khng gip t 6 thng n 15 nm hoc 20 nm.
- Tc dng ph ca thuc: tc dng ph khong 5% trng hp biu hin tng i
a dng.
- Nh: ri lon tiu ha, pht ban, ni m ay, st, au khp, mt v gic (agneusie),
vng da tc mt (ngng thuc), tng phosphatase kim.
- Tc dng ph nng nh Lupus, hi chng Lyeel, rng tc, hi chng thn h, thiu
mu, au a khp, au a r thn kinh, mt v gic.
- Gim bch cu trung tnh: khi bch cu trung tnh <1200/mm3 - phi ngng thuc
nu e do chng mt bch cu ht, v th cn theo di st.
- Mt bch cu ht (Agranulocytose): t l 0,1% (methimazole) v 0,5% (PTU)
trng hp, c xc nh khi s lng t bo bch cu di 200/mm3, trn lm
sng kh nhn bit c, cn bo trc cho bnh nhn nguy c ny pht hin v
iu tr kp thi. Ngng bt buc thuc khng gip v dng khng sinh ngay khi c
du chng ny nht l biu hin nhim trng, vim hng.
-Theo di khi s dng thuc khng gip
- Kim tra cng thc bch cu nh k.
- FT4 v TSH us
- Kim tra chc nng gan
- Mt s tiu chun c th ngng thuc khng gip
+ Dng khng gip liu rt nh sau mt thi gian khng thy bnh ti pht tr li.
+ Th tch tuyn gip nh li (kho st theo siu m th tch tuyn gip (bnh thng
18 - 20cm
3
).
+ Khng th khng th th TSH (kch thch) khng tm thy trong huyt thanh, sau
nhiu ln xt nghim.
+ Test Werner (+): tp trung I131 tuyn gip b c ch khi s dng Liothyronine
(T
3
).
1.2. Cc phng tin iu tr khc
1.2.1. c ch vn chuyn iode
Cht Thiocyanate v perchlorate c ch vn chuyn iode nhng s dng thng bt
li, ch trong mt vi trng hp c bit.
1.2.2. Iode v c
Khi phi hp lugol th cn s dng thuc khng gip trc 1- 2 gi.
Ch cn 6mg Iodur c ch tuyn gip. Khng s dng iod v c n c m cn
phi hp vi thuc khng gip phng hin tng thot c ch.
Ch nh hin nay i vi iode v c ch yu l:
+ Chun b ngn ngy trc khi phu thut ct gim tuyn gip v
+ iu tr cn bo gip.
Trc y ngi ta thng s dng iode trong nhiu thng (trn 8 thng vi 62%).
Hin nay liu trnh s dng iode trung bnh 10 -15 ngy.
Cht iopanoic acid v ipodate sodium (ipodate 500 mg/ ngy, ng ung) c tc
dng c ch T4 thnh T3 v c ch phng thch T4, sau 24 gi c ch T3.
1.2.3. Lithium

456
Thn trng bnh nhn c bnh l tim mch v ri lon chuyn ha, nht l mt
nc liu dng 300 - 450 mg / 8m gi v duy tr nng 1 mEq/l.Ch x dng khi
bnh nhn d ng vi Thionamide hoc iode.
1.2.4. Glucocorticoide
Dexamethasone liu 2 mg/ 6 gi c th c ch phng thch hormonee gip.
1.2.5. Thuc c ch ((propranolol, atenolol, esmolol)
Liu propranolol trung bnh 20 - 80 mg/ 6 - 8 gi.
1.2.6. Thuc chng ng
Rung nh chim t l t 10 - 25% bnh nhn Basedow, nht l bnh nhn ln tui.
Warfarin d gy xut huyt sau khi iu tr phng x. Aspirin c ch nh nhng thn
trng nu s dng liu cao (aspirine lm tng FT3 v T4 do gim kt hp protein).
1.2.7. An thn. Nn chn nhm barbiturate c tc dng gim lng thyroxine do gia
tng thoi bin.
1.2.8. Cholestyramine. Dng 4 mg, ngy 4 ln c th lm gim T4.
2. Phu thut ct gim tuyn gip gn ton phn
2.1. Ch nh
+ Bnh ti pht sau nhiu ln iu tr.
+ Tuyn gip qu ln.
+ Cng gip ph n c thai p ng km vi iu tr ni khoa.
2.2.Chun b trc m
Tt nht nn iu tr ni khoa t bnh gip trc khi phu thut.
2.3. Theo di sau m
Theo di mi 4 - 6 tun pht hin suy gip hoc cng gip tr li. Lu c th
c suy gip nh t hi phc trong vng 4 - 6 tun. Suy ph gip khong 3%, lit dy
thn kinh qut ngc v th i hi phu thut vin c kinh nghim.
3. iu tr Iode phng x
Dng I131 tp trung ti tuyn gip ph hy nhu m tuyn gip ti ch, hin l
phng php iu tr c chn la do hiu qu cao, kinh t v khng c phn ng
ph nghim trng, cha c bng chng cho rng iu tr iod phng x nh hng
trn bnh l mt trong Basedow hoc gia tng nguy c c tnh.
3.1. Ch nh
- C th t 35 tui tr ln
- Bnh ti pht nhiu ln - khng phu thut c
- Kh khn trong theo di (ngi ln tui)
- Suy tim
- D ng thuc khng gip
Trng hp suy tim, nhim c gip nng, tuyn gip c th tch ln (trn 100 gam),
nn iu tr t c bnh gip trc khi iu tr iod phng x.
3.2. Chng ch nh
Tuyt i trng hp thai nghn, tuy nhin cha c bng chng cho rng iu tr iod
phng x c th gy ra mt s hu qu xu t cung (nguy c bt thng bm sinh
thai nhi ph n sau khi iu tr phng x) v bung trng (phng x vo bung
trng rt thp tng ng vi liu thm d X quang).
4. iu tr mt s tnh hung c bit

457
4.1. iu tr mt trong bnh Basedow
* Th nh: cc bin php ti ch, dng nc mt nhn to cho trng hp kh mt.,
nm u cao bui ti, nh Methyl cellulose (0,5%) khi ng bo v gic mc. c
ch ( gim co ko m mt.
* Th nng: Mang knh hoc bng mt., Lm m ti ch., Khng sinh., Phu thut
khu sn mi,
* Th c tnh: Prednisolone 1,5mg/ kg/ngy chia u, 4 - 12 tun, sau gim liu
duy tr 5-10 mg/ ngy. C th dng methylprednisone 15mg/kg mi 2 tun,
azathioprine hoc cyclophosphamide hoc cyclosporine A khi corticoide tht bi.
Trch huyt tng (hin nay phng php ny khng s dng). iu tr quang tuyn
bn ngoi vo sau hc mt liu 2000 C. Gy trong 10 liu vi thi gian trong hai tun.
Can thip dn lu gim p lc ni nhn, phu thut c vn nhn. Cc bin php trn
c th gim li nhn cu 5 - 7 mm.
Gn y ngi ta x dng Colchicine v Pentoxifylline
4.2. iu tr ph nim trong Basedow
Bi ti ch 1mg betamethasone (Celestoderm) hoc fluocinolone (Synalar).
4.3. iu tr cn bo gip
y l cp cu ni tit v th cn iu tr, chm sc v theo di tch cc.
+ Thuc khng gip: Propylthiouracil (PTU) 250 - 300mg / 6 gi hoc Mthimazole
25mg/6 gi ung hoc t hu mn (trng hp khng ung c). Trng hp
nng c th tng PTU 100 mg/ 2 gi.
+ Iode: S dng hai gi sau khi dng thuc khng gip, dng thm Sodium - Iodide
1g/tnh mch/24 gi hoc dung dch bo ha potassium - Iodide 10 git/12 gi hoc
Ipodate Sodium 1g/ngy ng ung hay ng tnh mch.
+ Propranolol 40 mg ng ung hoc 1 - 2 mg ng tnh mch mi 6 gi, trong
trng hp c bnh l mch vnh i km. Hoc Verapamil 5-10mg/6 gi/ tnh mch
chm (trng hp chng ch nh c ch ).
+ Hydrocortisone - hemisucinate 50mg/6 gi ng tnh mch (do cortisol d tr b
gim v nhu cu cortisol tng trong stress).
+ Mn lnh
+ H st bng Paracetamol (khng dng aspirine)
+ B dch, in gii v ch dinh dng rt quan trng.
+ An thn v Phenolbarbital.
+ Th oxy, li tiu v Digitalis c ch nh trong trng hp c suy tim.
+ iu tr hoc ngn cn yu t khi pht.
+ Khng sinh, chng d ng, chm sc sau m.
Trng hp nng khng hiu qu iu tr ni khoa cn trch mu hoc thm phn
phc mc gim bt nng hormone gip lu hnh.
+ Kim tra thng xuyn nng kch t gip mi 3 - 4 ngy iu chnh thuc.
Phi hp PTU, iode, Dexamethasone c th lm lng T3 tr v bnh thng sau
24 - 48 gi.
4.4. iu tr suy tim
y l vn ht sc tinh t v cn nhc trc khi chn la thuc iu tr.
+ Suy tim tng cung lng: Ch yu l thuc khng gip tng hp phi hp c ch
b ta nu khng chng ch nh.

458
+ Suy tim gim cung lng.: Bn cnh thuc khng gip tng hp cn phi hp vi
thuc tr tim, li tiu, thn trng thuc c ch bta.
4.5. iu tr Basedow ph n c thai
- Chng ch nh iu tr I131
- Khng dng iod trong qu trnh iu tr, gy suy gip tre s sinh.
- iu tr ni khoa.
+ Khng gip tng hp: Ba thng u dng PTU v ba thng gia c th phu thut.
+ Propranolol c th s dng (lu suy h hp v km pht trin thai nhi nu s
dng liu cao v ko di).
Trong thi gian cho con b c th s dng PTU v thuc qua sa m khng ng k.
Thai nhi cn c theo di st trong qu trnh s dng thuc khng gip.
4.6. iu tr chng gim - mt bch cu ht
Trong qu trnh iu tr thuc khng gip tn hp thng xuyn kim tra cng thc
bch cu nu pht hin s lng bch cu ht di 1200 mm3 cn phi theo di st
do c nguy c mt bch cu ht nu bch cu di 200 / mm3. Ngng thuc khng
gip v tu mc v x dng thm Neupogen (Filgrrstim) hoc Leucomax
(Molgramostim)
IX. TIN LNG
Tin lng bnh nhn tu thuc th bnh, phng tin iu tr v theo di.

459
BU GIP N
Mc tiu
1. Bit phn bit bu c n thun v bu c dch t.
2. Hiu c cc nguyn nhn gy bu c.
3. Chn on xc nh, phn bit v chn on mc bu gip n
4. Cc bin chng ca bu gip n
5. Ch nh c iu tr bu gip n.
6. Trnh by c cch s dng iode phng bnh bu c
Ni dung
I. NH NGHA
1. Bu c dch t: cn gi l bu gip a phng hay bu gip lu hnh: Khi
nhu cu sinh l ca iode khng trong qun th dn chng, th s pht sinh hng
lot bt thng, bao gm tn thng chc nng tuyn gip va, khi thiu iode trm
trng gy ra bu c dch t hay n n dch t, gim thng minh v tng t sut
chu sinh v s sinh. Nhng bin chng ny tht s l 1 tr ngi ln cho s pht
trin ca qun chng v c nhm li thnh mt tn chung l ri lon do thiu iode.
T ngi ta nh ngha bu c dch t nh l s ph i ca tuyn gip khu tr
hay ton th trong hn 10% qun chng.
2. nh ngha bu c ri rc: l s ph i t chc tuyn gip c tnh cht lnh tnh
ton b hay tng phn khng c triu chng suy hay cng gip, khng do vim,
khng c tnh cht a phng (tc vng khng c dch t), cc yu t gy bnh
khng nh hng trong qun th chung.
Nhiu nguyn nhn khc nhau lm tuyn gip ln c l l chung cho c bu c l
t v bu c dch t.
II. DCH T HC
Bu gip n thng gp n nhiu hn nam, t l mc bnh cao mt s a
phng. Trn th gii c nhng vng a d thiu iode: nh vng ni c nguy c
bu c rt cao: vng tuyt ph, Hy m lp sn (Himalaya, Andes)
Tuy nhin ngi ta cng thy thiu iode nhng vng c bin thp, rt xa i
dng nh lc a vng Trung Phi, lc a Chu u hin nay. Khng c con s chnh
xc cho bit s lng nhn loi c nguy c pht trin ri lon do thiu iode.
Mt nh gi c xem l c th ang kim chng > 800 triu, trong c 3 triu b
n n dch t.
Ti Vit nam, theo iu tra ca B Y t (1993) v iode niu tr em 9 - 11 tui, c
94% thiu iod.
III. BNH NGUYN
1. Thiu iode: gp trong vng a d c bit nh vng ni v mt s vng nu
trn.
2. Ri lon kch thch t n: xy ra ph n dy th, c thai, tin mn kinh
3. Do cht khng gip: bp ci trng hay thuc khng gip tng hp hoc cht ngn
cn s ti iode nh Thiocyanate, Perchlorate
Sn cng gy bu c dch t, v sn c cha Glucoside cyanognique, Linamarin,
cht ny khi b thy phn gii phng cyanure, trong c th cyanure b kh c thnh
thiocyanate, m thiocyanate c ch bm iode tuyn gip v gia tng s thanh thi
iode thn, hu qu l thiu iode c th

460
4. Do bt thng tng hp KTT tuyn gip
Do thiu enzyme nh hng n s sinh tng hp KTT tuyn gip.
Do s sai lch bm sinh trong s tng hp thyroxin sn xut ra iodoprotein bt
thng.
5. Dng iode liu cao gy c ch tng hp hormon gip do hiu qu Wolff Chaikoff
(tc dng thong qua)
6. Mt iode: tiu chy ko di, hi chng thn h (gim protein ti iode), thai nghn
(tng thi iode nc tiu).
IV. C CH BNH SINH
1. Trong bu c, gim thyroxin s kch thch tuyn yn tng tit TSH gy bu gip
v tng sn xut hormon gip, y ch l hin tng b tr, phn ng cung cp
cho c th thyroxin, do tuyn gip khng b suy hay gim chc nng.
2.Nng iode trong mu v trong tuyn gip gim, lm tuyn gip ph i b tr
cng qua c ch trn.
3. Vn bu nhn cha c gii thch r rt lm, ngi ta cho rng bt u to
ton b tuyn gip v sau thu li cn mt hay nhiu nhn. C kin khc cho
rng TSH tc dng ln mt s nh nang tuyn gip, v bu dng keo l hu qu
ca bu hay ph i t bo.
V. TRIU CHNG
1. Triu chng lm sng
1.1. Triu chng c nng
i vi bu gip n thun: bnh nhn thng c tnh trng bnh gip.
i vi bu c dch t th nh hng n s pht trin c th nht l tr em,
gim thng minh, n n.
1.2. Triu chng thc th:
i vi bu gip n u: ch tnh c thy bu ln, hoc do ngi khc pht hin
c mt khi u gia c, s c ranh gii r, khng dnh vo da, khng au, mm hay
chc, di ng theo nhp nut ln xung, khi bu to c th gy chn; khng c ting
thi ti nh bu.
i vi bu gip nhiu nhn: gm nhiu khi trn ng knh t 0,5 - vi cm.
1.3. Phn bu c c tnh dch t
Kch thc bnh thng ca mi thy TG: 2,5-4cm chiu cao, 1,5-2cm chiu rng,1-
1,5 chiu dy; trng lng ca TG 10-20g.
2. Triu chng cn lm sng
- nh lng FT3, FT4 bnh thng.
Bnh thng FT4 = 0,8 - 2,4ng/dl, hoc 8 - 18pg/ml, hoc 10 - 30nmol/L.
FT3 = 0,4ng/dl, hoc 3 - 4pg/ml
Bnh thng tuyn gip tit T4 c chuyn dng thnh T3 m ngoi bin di
tc dng ca dsiodases. T3 l hormone hot ng trn th th t bo ch. V th
tt nht l o FT3, FT4, phn nh hot tnh sinh hc, v nht l FT4 nh gi trung
thc s sn xut TG, cn FT3 c hiu cho s iu ha ngoi bin.
Cn T3 v T4 ton phn t trung thc, do d b bin i bi cc yu t ngoi lai nh
hng n cht ti protein:
+ Yu t tng protein ti hay tng T4 ton phn: oestrogen, thai nghn, vim gan
nhim trng, u ty, collagenose...

461
+ Yu t lm gim T4: suy dng, gim protid mu, x gan, thuc androgene,
corticoide liu cao..
+ Yu t ngn cn s kt hp vi protein ti: hydantoin, clofibrate, hparine,
phenylbutazone.
- TSH cc nhy (TSH us) bnh thng (TSH = 0,3 - 4mUI/L).
TSH kim sot TG, s tit TSH c iu ha rt nhy bi nng hormone gip
ngoi bin qua c ch hi tc (feed back).
Dng k thut cc nhy th h II hin nay l 0,1mUI/L, th TSHus < 0,1mUI/L l
cng gip. Th h III l 0,01mUI/L th TSH us < 0,01mUI/l l cng gip.
- tp trung I131 bnh thng, tr trng hp bu n ho iode, cn lm
thm nghim php Werner loi tr cng gip.
Bnh thng tp trung I131 ti tuyn gip cc thi im 2 gi l 15%, 6 gi l
25%, sau 24 gi l 40%.
- Chp nhp nhy x hnh gip (Sintigraphie): cho bit hnh thi tuyn gip,
chc nng tuyn gip, kh nng bt gi phng x I131 hoc 99 Techntium ca ch
m gip (xt nghim ny cn thit trong ch nh bu hn): trong bu n, iode
phn b u khp tuyn gip.
- nh lng T3, T4 t do bnh thng.
- TSH cc nhy bnh thng
- tp trung I131 bnh thng, tr trng hp bu n ho iode
- Sinh thit: c khi cn thit, cho thy cc bin i lnh tnh nh trong phn gii phu
bnh.
- i vi bu c dch t hay bu c a phng, cn o iode niu/ngy, hoc t l
iode niu/cratinine niu nh gi s trm trng ca thiu ht iode:
+ Mc nh: 50 - 99 (g/ngy hoc 50 - 99 (g/g cratinine niu.
+ Mc trung bnh: 25 - 49 (g/ngy hoc 25 - 49 (g//g cratinine niu.
+ Mc nng < 25 (g/ngy hoc 25 (g/g cratinine niu.
- Siu m bit cu trc TG v th tch TG
Tui 6 7 8 9 10 11
1
2
13 14 15 16 17
V(ml)
Gii hn trn
3,5 4 4,5 5 6 7 8 9 10,5 12 14 16
Th tch ti a (gii hn trn) ngi trng thnh 18 ml.
VI. CHN ON
1. Chn on xc nh
Dch t v lm sng cng chn on.
Trng hp bu c l t, nn khm k hn v lm sng v xt nghim thm d
chc nng tuyn.
2. Chn on phn bit
2.1. Bu gip c suy gip: ch khc nhau v triu chng suy gip.
2.2. Bu gip c cng gip nh Basedow, bu gip c lm sng c du
cng gip, tnh cht c bit ca bu v cn lm sng gip cho chn on d.
2.3. Bu gip n kt hp vi ri lon thn kinh thc vt: c triu chng ging
nhau l c bu c, km d mt hay hi hp, nhp tim nhanh nhng nhp tim d tr

462
li bnh thng khi ngh ngi hay dng an thn, lng bn tay c nhiu m hi nhng
khng nng, cc XN thm d chc nng tuyn gip bnh thng.
2.4. Bu gip n ho iode: khng c du hiu cng gip, ch c tp trung
I131 cao, nhng nghim php Werner > 50%, cc XN khc bnh thng.
2.5. K tuyn gip: rt cng, c th c triu chng chn p v hch di cn, khng tp
trung I131, sinh thit loi tr.
2.6. Vim tuyn gip bn cp v mn (Hashimoto, Riedel), bu gip lan ta, c khi
nhiu nhn, cng, tc mu lng tng, (globulin tng, t khng th khng gip cao,
KT khng TPO, sinh thit t chc gip loi tr.
2.7. U ngoi tuyn gip: khng di ng theo nhp nut
VII. BIN CHNG
1. Xut huyt trong bu: bu to nhanh, au v nng, du chn p cp
2. Cng gip: thng xy ra bu nhiu nhn, bu lu nm, Basedow ha
phn tuyn bnh thng xen k gia cc nhn, thng do cung cp iode qu nhiu
(iode- Basedow).
3. Ung th ha.
4. Ring i vi bu c do thiu iode ngi m mang thai: c th nh hng n
s chm pht trin v tinh thn v th cht ca thai nhi
VIII. IU TR
1. Nguyn tc iu tr
Nhm bnh thng ha nng hormonee tuyn gip, m khng i hi tuyn gip
phi tng hot v ph i, do nu bnh nguyn:
Thiu iode th cung cp iode, khng do thiu iode, cung cp thm hormonee gip
tng hp.
Trong bu gip n do thiu iode, iu tr bng iode hay hormonee gip lm tuyn
gip nh li nhiu hay t thay i tu thuc nhiu yu t, nh thi gian xut hin
bu, kch thc bu, x ho ca bu.
Trong nhng nguyn nhn khc gy bu gip n lan to khng c,
Levothyroxine c th c dng vi mc ch nhm gim kch thc tuyn gip
2. iu tr c th
2.1. iu tr bu gip n lan to (khng c).
2.1.1. iu tr ngoi khoa
Hn ch ti a phu thut v bu gip trong trng hp ny ln l do hot ng
b, nu ct b d b suy gip, nht l him khi ch nh i vi cc bu ln lan to.
Tuy nhin can thip phu thut c th t ra trong nhng trng hp sau:
Bu gip qu ln gy chn p (kh nut, kh th, ni khn). Bu gip lu nm d
b ung th ho hoc nghi ng ung th ho. Bu nhiu nhn
V l do thm m.
Sau khi phu thut, phi thng xuyn kim tra FT4, TSH pht hin suy gip kp
thi
2.1.2. iu tr ni khoa
* i vi bu gip do thiu iode hay bu gip a phng:
Phn ln khng hoc nh hng rt t n chc nng tuyn gip, nhng nguyn
nhn chnh l do thiu iode, nn tt nht l a iode vo iu tr v d phng, Iode
c nhiu dng:

463
- Iode di dng iodur de potassium (IK) (Lugol) 1 mg mui KI/ngy, ti thiu trong 6
thng, hoc iodat de potassium (KIO
3
).
Cn theo di bin chng Iode-Basedow
Tuy nhin v c ch Feedback cn bnh thng, nn c th s dng hormonee gip
lm gim th tch tuyn gip. L. Thyroxine vin c ch nh khi:
+ Lm sng v siu m xc nh bu gip ln.
+ Nng Thyroxine gim v TSH huyt tng tng.
+ Th tch tuyn gip c nh li so vi trc khi iu tr
- Thyroxin (Levothyroxine, L-Thyroxine, Levothyrox) (T4), vin 50g, 75g, 100g,
liu tu thuc vo tnh trng bnh nhn 0.5- 2 vin/ng
Levothyroxine c 1/2 i l 7 ngy, hp thu tt, dng bui sng trnh mt ng
- Triiodothyronine (Liothyronine) (T3) vin 25 g, 1- 2 vin/ng, t dng v hp thu
nhanh, 1/2 i ngn, hiu qu ch thong qua. Khng dng bnh nhn THA, bnh
mch vnh.
ngi tr, liu bt u 100 g/ngy, v ngng khi TSH mc bnh thng-thp
Theo di cho tng liu dn t hiu qa tt, theo di bin chng cng gip
(mch nhanh, gy).
bnh nhn gi, liu khi u 50 g/ngy, cn cho liu tng dn theo di cn au
tht ngc v o in tim.
Kt qu
- Bi v c kh nng bnh tuyn gip t min tim tng, nn thn trng khng dng
thyroxine c bit khi khi TSH gii hn thp.
- bnh nhn gi, bu nhn hoc bu x ho, kh nng bu co nh li chng
1/3, bnh thng gim sau 3-6 thng iu tr, nu sau thi gian ny khng gim th
kh c hiu qu tt.
* i vi bu c l t khng do thiu iode:
Vn iu tr bng thyroxine liu nh trn, nhm gim ph i tuyn gip
* iu tr bu gip a nhn khng c.
- Phn ln bu gip a nhn khng c c th bo tn.
- Cung cp thyroxine him khi lm tuyn gip nh li.
Nu dng Levothyroxine, dng liu khi u l 50 g/ngy, c th tng dn liu,
nhng theo di TSH.
Cht cn quang hoc cc cht cha iode nn trnh v c nguy c a n cng
gip do iod (iod-Basedow) do tng sn xut hormonee gip ca cc nhn gip.
- X tr liu ngy cng c ch nh v lm kch thc tuyn nh li, v c th
ct b chn lc cc nhn t tr. Liu I131 ph thuc vo kch thc tuyn gip, v s
bt gi iode phng x. Thng khong 100 Curie/gram m tuyn. iu tr c th
lp li nu cn. Phn ln bnh nhn, kch thc tuyn gip gim khong 40-50%.
- Khi c s chn p cp xy ra, glucocorticoid hoc phu thut c th cn thit
c ch nh.
Suy gip sau x iu tr bu gip a nhn khng c t xy ra hn so sau x iu
tr Basedow. Tuy nhin khong trn 5% suy gip t min c th xy ra sau iu tr
bnh bu gip a nhn khng c.,.
IX. PHNG BNH
i vi vng thiu iode

464
C nhiu phng php b sung
1. Mui iode ha
Nng iode trn vo mui c ngh l 1 phn iode cho 10.000-100.000 phn
mui, bng cch da trn s tiu th khong 5g-10g mui/ngy, cung cp chng 50-
500g iode/ng. Hin nay dng iodat bn vng hn iodure (IK) do c tnh n nh
ca n trong vng nhit i m thp,
D phng bu c bng cch dng mui iode c kt qu tt trong mt s QG nh
Hoa k, Thu s, n , Mxico, Phn lan, Tip khc. Ti Hoa K sau 30 nm cung
cp iode d phng gim tp trung phng x vo thi im 24 gi t 40-45%
(1960) xung cn 8-30% (1990). Tuy nhin theo khuyn co ca TCYTTG (1996) v
s dng mui iode cn lu :
- Khong 20% iode b mt i t khi sn xut cho n khi s dng.
- Khong 20% iode b h bin trong qu trnh ch bin thc n
- Lng mui s dng trung bnh trong ngy l 10g.
Cch trn
Kali iodat (iodate de potassium: KIO) hoc iodure Kali (IK) 20-25 mg/kg mui,
tng ng nhu cu trung bnh l 150- 300 g/ngy.
S cung cp c nh gi tt khi nng iode trong nc tiu trung bnh t
100-200g iode/l
2. Du iode: hp th chm
- Lipiodol
+ ng ung: 1ml cha 480mg iode, liu duy nht bng 1ml, d phng 1-2 nm.
+ Tim bp: liu 0,5-1ml (1ml cha 480mg iode), d phng bu c v chng n
a phng trong 3 - 5 nm.
Tr em <1tui: liu 0.5ml, TB mng
Tr em >1tui v ngi ln TB tay, liu 1ml
3. Nuc pha iode: iode loi dung dch m c I2, IK hay KIO
3
cho vo nc ung
t nhu cu 150g /ngy.
4. Lugol: 5g I2 + 10g IK trong 100ml (hoc 6mg iode cha trong 1 git Lugol). Thi
gian tc dng ngn hn so vi loi du iode, nn cho nhiu ln trong ngy
C nhiu cch b sung iode, nhng iode ha mui l phng php c a chung
nht trong vic b sung iode qun th thiu ht iode.


465
SUY GIP
Mc tiu
1. Nu c nguyn nhn suy gip.
2. Nu c cc triu chng lm sng v cn lm sng suy gip.
3. Nu c phng php chn on suy gip.
4. Nu c nguyn tc v phng php iu tr c th suy gip.
Ni dung
I. I CNG
Suy gip (SG) l mt bnh cnh xut hin do s thiu ht hormone gip, gy nn
nhng tn thng m, nhng ri lon chuyn ha. Nhng thay i bnh l ny
c gi l triu chng gim chuyn ha (hypometabolism).
Bnh kh thng gp, t l tri n, t l bnh gia tng theo tui. T l mc bnh
khong 1% n v 0,1% nam, t l suy gip tng hn nhiu nhng vng c
bu gip a phng.
II. NGUYN NHN
1. Suy gip tin pht. Bnh xy ra do tn thng ti chnh tuyn gip, chim hn
90% cc trng hp suy gip.
1.1. Vim tuyn gip Hashimoto: y l nguyn nhn hay gp nht. Tuyn gip c
th ln hoc teo, c khi i km vi Addison v cc ri lon ni tit khc.
1.2. Tai bin do iu tr: nht l vi iode phng x, phu thut tuyn gip, ring vi
thuc khng gip tng hp, t gp hn.
1.3. Cung cp iode khng hp l (tha iode, thiu iode): suy gip do thiu iode ang
cn l vn Vit Nam.
1.4. Vim tuyn gip bn cp, vim gip sau sinh: thng xy ra sau giai on
nhim c gip trc , suy gip y ch tm thi.
1.5. Cc nguyn nhn suy gip tin pht khc: (him).
- Thiu enzyme tng hp hormne gip bm sinh.
- Cc cht khng gip trong thc n
- Lithium: iu tr bnh tm thn.
2. Suy gip th pht. Suy tuyn yn do u lnh (adenoma) tuyn yn, do phu thut
tuyn yn, hoc do tuyn yn b hoi t trong bnh Sheehan.
3. Suy gip tam cp. Do ri lon chc nnhng yn gip ti vng di i, bnh
cnh him.
4. Suy gip do khng hormone gip ngoi bin. Bnh t gp.
III. BNH HC
Suy gip tin php - Bnh ph nim (myxedema). Hay gp n, xung quanh la
tui 50. Bnh thng xut hin t t d ln vi cc triu chng ca mn kinh.
1. Lm sng: Da, nim mc b thm nhim bi mt cht dng nhy cha nhiu
polysaccarid acid ht nc, gy ph cng n khng lm.
1.1. Da nim mc
Mt trn nh mt trng, v mt v cm. Nhiu np nhn trn trng gi trc tui.
Mi mt ph, r mi di, g m hi tm, c nhiu mao mch gin, mi dy tm ti,
phn cn li ca da mt c mu vng bng.

466
Bn tay dy, cc ngn tay kh gp, da lnh i khi tm ti, gang bn tay bn chn c
mu vng (xanthoderma).
Li to, ging khn trm (do thm nhim dy thanh i), tai, nghe km (do thm
nhim vi Eustache). Khi ng ting ngy to (do nim mc mi, hu hng b ph
nim).
Da ph cng, kh, bong vy. Tc kh d rng, ui my rng, lng nch, lng mu
rng. Mng tay, chn c vch, d gy.
1.2. Triu chng gim chuyn ha
L du soi gng ca nhim c gip.
- S lnh, thn nhit gim, tay chn lnh, kh.
- Ung t, tiu t, bi tit nc tiu chm sau ung.
- Tng cn d n km
- Tiu ha: to bn ko di, km gim nhu ng rut.
- Yu c, chut rt, au c.
- Du tm thn kinh v ri lon thn kinh thc vt: trng thi v cm, th . Suy
gim cc hot ng c th, hot ng tr c, hot ng sinh dc.
Gim tit m hi.
1.3. Tim mch
- Tim chm < 60l/ pht, huyt p thp (ch yu tm thu), tc tun hon gim cc
biu hin ny do gim chuyn ha.
- Cc du thm nhim c tim, mng ngoi tim.
au trc tim hoc cn au tht ngc tht s, kh th khi gng sc. Nghe tim: ting
tim m, chm,c khi ting tim khng u.
ECG: nhp chm, in th thp cc phc b QRS, c khi ST chnh xung, sng T
dt hoc o ngc. Hnh nh in tim s tr li bnh thng sau iu tr bng
hormone gip.
X quang bng tim to, p yu. C khi trn dch mng ngoi tim, dch c nhiu protein
v cholesterol. Siu m tim gip phn bit trn dch mng tim vi thm nhim mucoid
c tim. C khi huyt p tng do x va ng mch.
1.4. Triu chng h hp
Th nng, tn s chm, p ng h hp km i vi s tng CO2 mu hoc gim
O2 mu. Suy h hp cp l mt triu chng ch yu ca hn m ph nim.
1.5. Chc nng thn
Gim chc nng thn, gim mc lc cu thn, gim kh nng thi nc khi qu ti,
do d dn n ng c nc bnh nhn suy gip nu nc t do c a
vo c th qu nhiu.
1.6. Thiu mu
C t nht 4 c ch dn n thiu mu bnh nhn suy gip:
- Gim tng hp hemoglobuline do thiu Thyroxine.
- Thiu st do mt nhiu st v rong kinh, ng thi gim hp thu st rut.
- Thiu mc c tnh: thiu mu nguyn hng cu khng l vi thiu vitamine B12.
Thiu mu c tnh thng l mt phn trong bnh cnh bnh t min gm ph nim
do vim gip mn tnh phi hp vi t khng th khng t bo thnh, i tho
ng phi hp vi t khng th khng o ty v suy thng thn phi hp vi t
khng th khng thng thn (Hi chng Schmidt)

467
1.7. Triu chng ni tit
- Tuyn gip: c th ln, tuy nhin a s trng hp tuyn gip b teo..
- Cc ri lon ni tit khc nh rong kinh, kinh t km chy sa hoc mt kinh - chy
sa, chy sa n thun
- Lnh cm.
1.8. Cc triu chng thng c trong suy gip (Theo Perlemuter v Hazard):
Triu chng gim chuyn ha: Mt mi:99%. S rt:89%. Tng cn:59%
Triu chng tim mch: Nhp tim chm:95%. Hi hp:31%. au vng trc tim:25%.
Triu chng da nim mc: Da kh:97%. Gim tit m hi:89%. Li ln v dy:82%.
Rng lng: 76%. Xanh ti: 67%. Rng tc: 57%. Ph ngoi vi:55%. Ging khn:
52%. ic: 32%.
Triu chng tiu ha: To bn dai dng: 23%.
Triu chng c bp: Chut rt (vp b) > 70%
Triu chng thn kinh: L (Lthargie): 91%. Ni chm: 91%. Gim tr nh: 66%.
Ri lon tm thn: 35%.
1.9. Hn m suy gip
L mt bin chng nng ca suy gip, him, thng ch gp x lnh, xy ra trn
bnh nhn suy gip iu tr khng y hoc khng c iu tr, vi cc yu t
thun li nh: nhim trng, phu thut, chn thng, nhim c... hoc ngng iu
tr thyroxine t ngt. Tin lng thng nng, t l t vong hn 50%. Lm sng l
mt tnh trng hn m im lng km cc du hiu sau:
- Thn nhit h, y l du hiu hng nh, nhit khong 32-350C c khi
thp hn.
- Ri lon h hp, lun lun c, vi nhng t ngng th, gim thng kh ph
nang.
- Cc biu hin tim mch nh nhp tim chm, h huyt p, cung lng tim gim,
tim ln.
- Ngoi xt nghim hormone khng nh bnh cnh suy gip, trong t hn m
suy gip cn cho thy: in gii mu v nc tiu: Lun lun c gim natri mu,
km gim clor, gim protid mu, gy nc ni bo d dn n ph no, glucose
mu c th gim, ADH tng.
2. Cn lm sng
2.1. nh hng thiu hormone gip ln chuyn ha v t chc ngoi vi:
- Chuyn ha c bn gim di 10% so vi bnh thng
- Thi gian phn x gn gt ko di trn 320ms.
- Cholesterol mu trn 3g/l (du khng hng nh). Triglyceride tng song song vi
Cholesterol.
- CPK (cratin phosphokinaza) tng do cao iso - enzym c ca CPK tng 70UI/l.
- Thiu mu ng sc hay nhc sc, hng cu bnh thng hoc hng cu ln.
2.2. nh lng hormone gip lu hnh:
Iode ton phn (iode trong hormone) < 4(g/ 100ml.
T
4
< 3g/dl.
FT4I gim
T
3
< 80mg/dl (< 1,2 mmol/l)

468
Nu ch T3 gim n c th cha v T3 c th gim do nhng nguyn nhn
khng phi do tuyn gip (hi chng T3 thp).
FT4 < 0,8(g/dl.(T4 t do).
2.3. nh lng TSH:
Nu suy gip tin pht TSH lun lun tng trn 10 (UI/ml (TSH > 20 (UI/ml khng
nh chn on): chng t tn thng tuyn gip tin pht. p ng ca TSH vi
TRH rt mnh (test ny khng cn thit nu TSH tng r).
Nu suy gip do nguyn nhn cao TSH khng tng.
2.4. o tp trung iode phng x ti tuyn gip
tp trung iode phng x t di 5%, 10% v 20% vo cc thi im 2h, 6h v
24h, c khi thp hn na (bnh thng: 20%, 30%, 40% vo cc thi im trn). X
hnh tuyn gip thy hnh nh iode tp trung ri rc, khng ng cht, x hnh t ch
li trong chn on v tin lng suy gip
IV. CHN ON
1. Chn on xc nh: Khng kh i vi nhng trng hp in hnh. Cn ngh
n suy gip trc tt c nhng trng hp c biu hin nghi ng nh tuyn gip
ln hoc c iu tr iode phng x hoc phu thut gip.
1.1. Nu nghi ng suy gip tin pht: TSH l xt nghim tt nht gip chn on xc
nh. TSH bnh thng, loi tr suy gip tin pht. TSH tng r (>20(U/ml), xc nh
chn on. Nu TSH tng nh (<20(U/ml), cn nh lng FT4, nu FT4 thp: suy
gip lm sng, nu FT4 bnh thng: suy gip di lm sng (subclinical), nhng
trng hp ny gip suy nh, nhng TSH tng gip duy tr T4 bnh thng, triu
chng lm sng nhng trng hp ny khng r.
1.2. Nu nghi ng suy gip th pht: Do gi thng tn tuyn yn, TSH thng
gim nhng c khi bnh thng do cn nh lng FT4, khng nn ch da vo
nh lng TSH chn on suy gip th pht. Nhng trng hp ny nn thm
d thm tuyn yn, di i.
2. Chn on phn bit
- Tui gi: Do suy thoi c th, biu hin chm chp v tinh thn v th cht, da kh,
rng lng (nht l lng my), km chu lnh, tp trung I131 c th gim. Cc biu
hin trn cng c th c mt phn do gim hot gip.
- Suy thn mn: chn n, chm chp, ph nh, thiu mu, phn bit da vo huyt
p tng, ur, cratinin mu tng...
- Hi chng thn h: ph, thiu mu, cholesterol mu tng, phn bit da vo hi
chng th dch v nc tiu.
- Bnh Langdon Down: tr tu, tay chn km pht trin, ln nhng tr nng ng
hn, da khng kh, mt xch, mng mt c vt trng (Brushfield).
- Thiu mu, suy dinh dng: da ti, ph nh, tc lng c th rng nhng tinh thn
khng chm chp, cholesterol mu khng tng, cn xt nghim sinh ha, hormone
phn bit.
- Bo ph: tng cn, nng n trong vn ng, cholesterol mu tng, nhng lng
khng rng, tinh thn bnh thng, khng s lnh, mch khng chm, th khng
chm.
V. IU TR
1. Nguyn tc iu tr suy gip

469
1.1.Tt c trng hp suy gip u cn c iu tr ngoi tr cc th suy gip ch
c biu hin cc du sinh hc nh nh:
- Tng TSH va (< 10 (U/ml)
- T3 T4 bnh thng.
- ang thi im khng c biu hin bnh ang pht trin.
1.2.iu tr suy gip ni chung l n gin v hiu qu: ch yu da vo iu tr
hormone gip thay th.
1.3. Ngoi tr hn m ph nim, s iu tr suy gip khng nn vi vng, cn xc
nh chn on chc chn trc khi thc hin iu tr.
1.4. Cn gii thch cho bnh nhn s cn thit dng thuc u n v vnh vin.
Ngc li cng cn hiu rng c nhng trng hp suy gip thong qua khng cn
thit phi iu tr lu di.
1.5. S iu tr cn rt thn trng ngi gi, suy tim, suy vnh, phi bit chp
nhn mt iu tr thay th mt phn.
2. Thuc Hormone gip
2.1. Tinh cht tuyn gip (extrait thyroidien)
Thuc c ch t tuyn gip gia sc.
Hm lng: 1cg 5cg 10cg (Php)
16 32 60 325mg/ vin (M)
(Bit dc: Amour Thyroid. Thyroteric, Extrait thyroidien choay).
2.2. Hormone gip tng hp
2.2.1. Levothyroxine, LT
4

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

Dng ung: vin nn.
Hm lng ; 5 - 25 - 50 g.
(Bit dc: Cynomel)
2.2.3. LT4 phi hp vi LT3
C nhiu phi hp vi nhng t l khc nhau gia T4 v T3 (4/1, 5/1, 7/1).
Tn chung M l Liothrix.
Hm lng: nhiu loi, thng thng nht l 100mcg LT4 / 25 mcg LT3 dng vin
nn cng c nhng hm lng khc.
(Bit dc: Euthyroid, Thyrolar, Euthyral, Thyreotoin, Thyreocomb)
Trong iu tr cn c dng D. Thyroxine. (Dextro - Thyroxine) nhng dng L
Thyroxine c a chung v tc dng mnh hn.
2.3. u nhc im ca cc loi thuc
Thi gian bn hy ca L Thyroxine khong 8 ngy, gii thch mt s n nh nng
thuc trong mu, ch cn cho ung mt ln theo gi c nh trong ngy. L Thyroxine
c kh iode ngoi bin tr thnh Triiodothyronine (T3).

470
Ring i vi T3 (cynomel) c dng ring l s c tc dng nhanh hn nhiu
nhng nng thuc tng t ngt sau mi ln ung gy kh chu cho bnh nhn.
Thi gian bn hy ca T3 l 48h, thuc cn dng 2-3 ln/ ngy. T3 thng ch c
ch nh tm thi cho K gip bit ha trc thm d hoc x tr liu.
Vi Euthyral (phi hp T3 v T4) thuc cng c th gy tng T3 t ngt trong
mu,do cng t c la chn trong iu tr, cn tinh cht tuyn gip (extrait
thyroidien) khng c dng na trong iu tr suy gip vi nhng t l khc nhau
gia T3 v T4 kh nh gi kt qu.
3. iu tr c th
Thyroxine l thuc c chn la u tin hin nay, liu thay th trung bnh 75-
125(g/ngy. Trn bnh nhn gi thng thp hn, lu bnh cn iu tr sut i.
3.1. Khi u
Nu bnh nhn tr, cn kho nn bt u liu 100g/ngy. Vi liu lng ny tnh
trng suy gip s ci thin dn, nhng phi mt nhiu tun T4 t hng nh. Triu
chng gim sau vi tun iu tr. Vi bnh nhn gi nn bt u vi liu 50g/ngy.
Bnh nhn c bnh tim liu khi u nn l 25g/ngy ng thi theo di st cc
biu hin v tim trong qu trnh iu tr. Nhng bnh nhn ny tng liu 25g/ngy
mi tun cho n khi t hiu qu iu tr mong mun
3.2.Theo di v iu chnh liu lng
3.2.1.Vi suy gip tin pht
Mc ch iu tr l duy tr TSH mc bnh thng. Cn nh lng TSH 2-3 thng
sau khi bt u iu tr. Liu thyroxine c iu chnh t 12-25g/ngy mi 6-8
tun cho n khi TSH tr v bnh thng. Sau ch cn nh lng TSH tng nm
kim sot iu tr nh mong mun, khng nn p dng liu thyroxine cao biu
hin nng TSH di mc bnh thng, c th gy nguy c long xng, rung
nh.
3.2.2.Vi suy gip th pht
Khng th da vo TSH iu chnh iu tr. Mc ch iu tr nhm duy tr FT4
t mc bnh thng. Liu thyroxine c iu chnh mi 6-8 tun cho n khi t
mc ch iu tr. Sau theo di FT4 mi nm mt ln l kim sot bnh.
Trong suy gip th pht (hi chng Sheehan) thng km c suy thng thn, suy
sinh dc cng v suy gip, do phi cho km cho theo cc hormone thch hp.
Nn cho hormone thng thn trc phng suy thng thn cp khi cho
hormone gip lm tng chuyn ha ca c th.
3.2.3. Vi bnh nhn c bnh mch vnh
Thyroxine c th lm nng thm bnh l mch vnh ni ring cng nh cc bnh tim
nh suy tim, ri lon nhp, cn cho liu nh, tng liu rt chm theo di k tnh trng
tim mch, in tim, cho km thuc chn beta nu cn (ch cc chng ch nh).
Nu vn xut hin triu chng au tht ngc, d nh, cng nn ngng iu tr
hormone gip, c th xem xt ch nh cc bin php can thip trong iu tr mch
vnh (lu phi an ton trn bi cnh suy gip).
3.3.Nhng kh khn trong kim sot suy gip
Thng do khng bng lng vi iu tr. Mt s trng hp cn phi tng liu
thyroxine nh:
3.3.1. Km hp thu thuc
Do bnh ng rut hoc mt s thuc cn tr hp thu thuc nh cholestyramine,
sucralfate, hydroxyde nhm, sulfate st.

471
3.3.2. Tng tc vi cc thuc khc
Lm tng s thi thuc nh rifampin, carbamazepine, phenytoine hoc c ch s
chuyn T4 thnh T3 ngoi bin nh amiodarone.
3.3.3. Mang thai
Nhu cu thyroxine tng trong 3 thng u. Ni chung cn tng liu thyroxine va cho
m va trnh bu gip ln cho con.
3.3.4. Chc nng tuyn gip cn li
Thng suy gim dn sau iu tr suy gip.
3.4. Suy gip di lm sng
Nn dng thyroxine trong nhng trng hp sau:
- C triu chng suy gip
- C bu gip ln
-Tng cholesterol mu n mc phi iu tr.
Nhng bnh nhn suy gip di lm sng cn li cha cn iu tr phi c theo
di mi nm, nn bt u cho thyroxine khi triu chng suy gip xut hin hoc TSH
> 20g/ml.
3.5. Suy gip v phu thut
Mc du suy gip c tng nguy c nhng bin chng ca phu thut nhng ni
chung khng nng. Khi cn phu thut cp cu theo yu cu ch nh c th tin
hnh ngay, tuy nhin cn cho thyroxine ngay trc phu thut, liu u tin bng
ng tnh mch. Nhng trng hp phu thut theo chng trnh c th hon li
cho n khi suy gip iu tr c nhiu tun..
3.6. iu tr hn m do suy gip
Mc d him gp, nht l cc x nng, nhng hn m suy gip l mt cp cu
cn iu tr khn cp. Phc iu tr gm:
3.6.1. iu tr triu chng:
- H tr h hp ; oxy liu php, t ni kh qun, gip th, ng thi iu tr tnh
trnh tru mch mt cch tch cc. Nhanh chng xc nh chn on bng nh
lng TSH, FT4 trc khi cho thyroxine.
- Si m t t nhit phng l 22
0
C. Si m nhanh qu c th lm nng tnh
trng try mch v rung tht.
- B nc in gii, glucose.
3.6.2.Thyroxine
50-100g TM mi 6-8 gi trong 24 gi, sau 75-100g/ngy TM cho n khi ung
c. iu tr hormone thay th c tip tc sau nh thng quy khi m suy
gip c chn on xc nh. Cn theo di k v tim mch nhanh chng pht
hin tc dng khng mong mun trn tim do thyroxine.
3.6.3.Hydrocortisone
100mg tnh mch sau tim bp 50mg mi 8h trong t cp, tip ty tin trin
c th gim bt liu lng.


472
VIM TUYN GIP, UNG TH TUYN GIP
Mc tiu
1. Nu c cc loi vim tuyn gip v bnh nguyn, triu chng lm sng v cn
lm sng.
2. Nu c cc loi ung th tuyn gi v triu chng lm sng v cn lm sng.
3. Nu c phng php iu tr c bn vim tuyn gip, ung th tuyn gip
Ni dung
I. VIM TUYN GIP
1.i cng
Vim tuyn gip l mt nhm bnh gy tn thng tuyn gip c th do nhim trng
hoc qu trnh vim xy ra trn tuyn gip bnh thng. Bnh cnh lm sng cn
lm sng, din tin khc nhau tu theo nguyn nhn gy bnh. Vim tuyn gip x
ho c th din tin rt nng, vim tuyn gip lympho thng dn n suy gip,
vim tuyn gip bn cp lun lun lnh hn.
2. Cc loi vim tuyn gip
2.1Vim tuyn gip cp
Bnh t gp, xy ra do nhim trng tuyn gip, vi vi khun nh: t cu vng, lin
cu, E.Coli, vi khun k kh, samonella... c khi vi c BK, vi nm nh actinomyces,
c bit vi k sinh trng nh Echinococcus.
+ Lm sng: Trng hp do vi trng thng, gy hi chng nhim trng, ti gip c
biu hin nh mt abces vi nng, , sng, au, au c th lan ln tai, chm, hm.
+ Cn lm sng: Cng thc mu c bch cu tng cao, a nhn chim u th. Siu
m gip thy vng gim m (hypoechogene). X hnh gip thy vng khng bt gi
iode. Chc d thy m. T3,T4,TSH bnh thng, khng c khng th.
2.2. Vim tuyn gip bn cp (De Quervain hoc Crile)
Nguyn nhn do virus nh virus quai b, Coxsacki, E.C.H.O, adenovirus. Bnh
thng xy ra trn ngi c HLA BW 35.
+ Lm sng: Thng c triu chng cm cm trc . Chn on da trn
cc triu chng au t gip lan ra, tuyn gip ln, ban u mt bn sau lan ra
ton gip, s thy mt tuyn gip chc, au, hch khng ln. Ton thn c st
nh, au c, suy nhc. C 1/2 s trng hp c biu hin nhim c gip.
+ Cn lm sng: Hi chng vim khi xt nghim, vi VS tng, bach cu bnh
thng hoc tng nh. X hnh thy gim hoc mt tp trung iode. Hormone gip
bnh thng hoc tng nh (phng thch do m gip b hu hoi). TSH bnh thng
hoc thp. Khng c khng th.
+ Tin trin: Thng lui bnh t nhin sau 6 tun, c khi lu ln. Cng c
trng hp gp suy gip thong qua.
2.3. Vim tuyn gip khng au (vim tuyn gip im lng)
Kh thng gp, nht l ph n sau sinh (5-7% cc trng hp thai
nghn).
+ Lm sng: Bu gip chc, khng au. Du nhim c gip va, khng c
li mt.
+ Cn lm sng: VS bnh thng hoc tng nh. Hin din khng th khng
gip vi chun thp. Hormone gip tng, TSH gim. X hnh gip khng bt gi
iode.

473
+ Tin trin: Lnh t nhin sau 2-4 thng, t khi chm hn. Suy gip thong
qua kh thng gp. C th ti pht mt nhim c gip rt lu sau . Bu gip
c th tn ti lu di.
+ Ghi ch: Vim tuyn gip khng au rt ging vi vim tuyn gip bn cp,
ch khc nhau triu chng au, mt im khc na vim tuyn gip im lng l t
min bnh. Lm dng idoe c th gy biu hin tng t, phn bit da vo iode
mu, iode niu bnh thng trong vim gip im lng.
2.4. Vim tuyn gip lympho (Hashimoto).
L bnh t min, trn cc i tng thuc nhm HLA B8 DR3. Thm nhim
gip vi lympho v tng bo, vi nhng nang gip b ph hu bn cnh nhng
nang gip tng sn. Din tin mn tnh c th dn n suy gip.
+ Lm sng: Bu gip ln lan to, mt chc, gii hn r, khng au,
hch ln cn khng ln. Biu hin bnh gip, c khi nhanh chng dn n suy gip
(suy gip ngi trng thnh + bu gip ln = Hashimoto). C khi biu hin
nhim c gip thong qua.
+ Cn lm sng: Hin din khng th khng thyroglobuline, khng th khng
microsome tuyn gip, khng th khng peroxydase. nh lng hormone gip bnh
thng hoc thp vi TSH tng. Rt him nhng c th T3,T4 tng km TSH gim
trong giai on nhim c gip. X hnh gip c hnh lm m khng ng nht. VS
bnh thng hoc tng nh.
+ Tin trin: Rt thay i, c khi tn ti bnh cnh bu gip bnh gip, c khi
dn n suy gip vi tuyn gip teo nh.
+ Lu :
- Hin din khng th khng gip khng ch ring Hashimoto, cn c trong bnh
Basedow.
- T l ln suy gip ngi ln km teo tuyn gip c nguyn nhn vim gip
Hashimoto m giai on khi pht b b qua.
- Hashimoto c th phi hp vi nhng bnh khc nh suy thng thn, bung
trng, i tho ng. Hoc bnh bch bin, Biermer; hoc thng tn mt kiu
Basedow (him).
2.5. Vim tuyn gip ho si (Riedel)
Bnh him, cha r nguyn nhn, tin trin nng.
+ Lm sng: Bu gip cng nh , ban u khu tr, sau lan ton tuyn
gip. S x ho lan rng n cc c c, c quan ln cn gy cm gic b cht c,
kh nut, kh th. Bnh c th phi hp x ho sau mng bng, trung tht, sau hc
mt, tuyn l.
+ Cn lm sng: T3,T4, TSH bnh thng, VS bnh thng, tp trung iode
phng x gim.
+ Tin trin: T vong khng trnh khi, iu tr duy nht l phu thut, nhng
kh nng phu thut rt hn ch.
Bng 1: Phn bit cc loi vim gip
Cp Bn cp Im lng Hashimoto Riedel
au +++ +++ 0 0 0
Gip Abces Rt chc Chc Rt cht Cng nh


474
Du ton
thn
++ ++ 0 0 0
FT3, FT4 BT BT hoc BT hoc BT hoc BT
TSH BT BT hoc BT hoc BT hoc BT
Khng th 0 0 hoc + 0 hoc + +++ 0
VS (hoc BT BT BT
X hnh Vng lnh Khng bt
iode
Khng bt
iode
Khng ng
cht
Vng lnh
II.UNG TH TUYN GIP
1.Phn loi.
Ung th tuyn gip chim t l 1% trong s nhng trng hp t vong do ung
th, y l mt nhm bnh c tin lng rt khc nhau, ngi ta chia ra:
- Nhng ung th biu m t bo tuyn gip bao gm:
+ Ung th bit ho, tin lng tt nu iu tr ng, bnh d xut hin khi chiu x
c t tui thiu nin hoc nhim nguyn t.
+ Ung th khng bit ho tin lng rt xu.
- Nhng ung th biu m tu, pht trin t t bo C ca tuyn gip.
- C bit c lymphoma hoc ung th ni khc di cn n
1.1. Ung th tuyn gip bit ho.
T l gp cao, nht l ph n tr, tin lng tt. i khi c kh nng bt gi iode,
nhng him khi l u tit.
1.1.1. K biu m nh (carcinome papillaire)
Chim 50% cc trng hp, gp mi la tui, nhng hay gp tr em v thanh
nin trc 40 tui, chiu x vng c l iu kin thun li gy K biu m nh, K lan
rng theo ng bch huyt, c khi bnh c gi ban u t mt hch di cn
vng c.
X hnh u bt iode km (vng lnh).
1.1.2. K biu m nang (carcinome folliculaire)
Chim di 25% cc trng hp, hay gp la tui 40-60, di cn bng ng mu
n xng, phi, gan.
X hnh u c th bt iode khng u, im di cn cng c th bt gi iode phng x.
1.1.3. K biu m tu (carcinome medullaire)
Hoc cht m dng bt (struma amyloide), hoc cn nang (parafolliculaire), chim
di 5% cc trng hp, thng gp sau 50 tui, lan rng bng ng mu v
ng bch huyt, c khi phi hp vi cc u khc nh pheochromocytome (Hi
chng Sipple), c th c tinh gia nh.
X hnh u khng bt iode (vng lnh). Chn on da vo nh lng calcitonine
huyt tng tng, nh lng sau kch thch vi pentagatrine thy calcitonine tng
rt nhiu. Khng nguyn biu m phi (ACE) thng tng.
1.2. Ung th tuyn gip khng bit ho
K biu m khng bit ho, chim khong 20% cc trng hp, thng xut hin sau
50 tui, t mt nt n c lan rt nhanh n vng ln cn, gy triu chng chn p.
Din tin nng nhanh trong vng vi thng.

475
X hnh thy u khng bt iode (nhn lnh).
S pht trin ca u b tc ng bi nng TSH trong mu, U pht trin nhanh khi
TSH tng v ngc li.
2.Chn on
Triu chng gi K gip:
+ Pht hin mt nt tuyn gip th tch tng dn, hoc mt nt c t lu,
gn y cht tng th tch.
+ Du hiu chn p c quan ln cn (hi chng trung tht).
+ Hch c hoc thng n ln dn, chc, khng au.
+ Siu m gip gip phn bit nang vi khi c.
+ X hnh gip: Kt qu tu thuc loi u, nu pht hin nhn lnh cn chc
ht xt nghim t bo hc, hoc sinh thit xt nghim m hc.
3.Tin lng
T l sng cn10 nm khi c iu tr nh sau:
+ 80% i vi K biu m nh.
+ 60% i vi K biu m nang.
+ Vi K biu m khng bit ho tin lng rt xu.
4. iu tr
Phu thut ct tuyn gip mt bn, khi cn khu tr, hoc ct ton phn, bc hch
xm ln.
Sau phu thut cho thm iode phng x vi liu iu tr v hormone gip vi liu c
ch.
i vi K gip khng bit ho cn phu thut rng, iode phng x liu cao, c th
xem xt ho tr liu tm thi.
i vi K biu m tu, sau khi phu thut ton b tuyn gip, nh lng calcitonine
gip pht hin m ung th cn li cha c ly ht.







476
I THO NHT
Mc tiu
1. Nu c sinh l v ADH.
2. Nu c phn loi i tho nht.
3. Nu c bnh hc i tho nht.
4. Nu c nguyn tc iu tr i tho nht
5. Nu c cc loi thuc iu tr i tho nhtt.
Ni dung
I. NH NGHA
i tho nht (TN) l tnh trng bnh l do mt kh nng ti hp thu nc ng
thn, hu qu ca s thiu ADH tng i hoc tuyt i dn n tiu nhiu, ung
nhiu, nc tiu c t trng thp v ung nhiu, bnh c th xy ra do km phng
thch ADH (TN trung ng hoc thn kinh) hoc do thn p ng km vi ADH
(TN thn). C khong 50% trng hp TN khng r nguyn nhn.
II. SINH L
ADH (antidiuretic hormone) c tit ra t vng di i, t n ni cha l thu
sau tuyn yn. ADH tc ng ln s iu ho nc do iu chnh s ti hp thu
nc thn.
ADH ngi cn gi l arginine-vasopressin (AVP) l mt polypeptide c 8 acid
amin (octapeptide). ln arginine c thay bng lysine (LVP). ng ch trn
ngi LVP cn c th kch thch tit ACTH.
Vi thm thu huyt tng 280mOsm/kg, ADH o c trong mu l < 2pmol/l
(=pg/ml), ADH s tng ln 10-12pmol/l khi thm thu ca mu t 310mOsm/Kg.
Thi gian na i ca ADH rt ngn: 10-20 pht. ADH b phn hy nhanh chng do
enzyme c quan ch ch yu thn (2/3), s cn li c phn hy gan (1/3).
thm thu huyt tng = (natri mu +kali mu) x 2 + ure mu + glucose mu.
Tt c tnh bng n v mM/l. Tr s bnh thng: 290-300mOsm/kg
1.Tc dng sinh l: Tc dng ch yu ca ADH xy ra thn, ADH lm tit kim
nc t do. Thn lc 120ml nc/pht (hoc 172 lt/24h). Hn 85% nc c ti
hp thu bt buc ng ln gn cng vi Na
+
, nh vy cn 23,5 lt c ti hp thu
do vai tr ca ADH.
Thiu ADH tuyt i chc chn s gy mt nc cp nu khng ung . Tuy nhin
thc t cho thy s tiu nhiu do thiu ADH khng vt qu 8-12 lt (1/2 ca lng
23,5 lt l thuc ADH theo l thuyt).
2. C ch tc dng
ADH tc dng thng qua 2 loi th th V1 v V2:
+ Th th V1 lm co c trn mch mu, kch thch s tng hp prostaglandine v
phn hy glycogne gan. Tc ng ln th th ny lm gia tng phn hy
phosphatidylinositol gy nn s huy ng calci.
+ Th th V2 chu trch nhim ca tc dng vasopressin trn thn. ADH lm tng
tnh thm nc ca lp thng b ng gp. Thiu ADH s ti hp thu nc b gim
dn n tiu nhiu. C ADH th ngc li, tnh thm ca lp thng b tng r, nc
c ti hp thu. Tc dng ny xy ra do ADH gn vi th th V2.
Trn tim mch ADH tc dng ln th th V1 trn cc tiu ng mch ngoi bin
lm tng huyt p. Tuy nhin bn thn ADH li lm chm nhp tim, c ch thn kinh

477
giao cm li lm gim bt tc dng tng huyt p. D sao tc dng lm tng huyt
p c th ni bt khi th tch mu gim lc ADH huyt tng tng rt cao.
V vai tr tc dng ca th th V1, V2 cn c nhiu kin cha thng nht. Ring
i vi th th V2 mi kin u ng khi kch thch lm tng ti hp thu nc.
Vi cc th th V1 c kin cho rng V1 c tc dng lm gim p ng chng bi
niu ca AVP trn thn.
3. iu ha s tit ADH
p lc thm thu v th tch huyt tng l 2 yu t quan trng nht.
- Cc yu t kch thch s tit ADH:
+ Yu t thn kinh thc vt: xc cm, au, vn ng.
+ Cc dc cht: acetylcholine, morphine, nicotine.
+ Sc nng.
+ Cc yu t thm thu: Truyn dung dch u trng, tng p lc thm thu huyt
tng, gim th tch huyt tng.
- Cc yu t c ch s tit ADH:
+ Dc cht: Adrenaline, Alcool.
+ Lnh.
+ Yu t thm thu: Truyn dung dch nhc trng, gim p lc thm thu huyt
tng.
+ Tng th tch huyt tng.
III BNH NGUYN I THO NHT
1.TN trung ng (TN thn kinh)
Cc thng tn vng di i tuyn yn gy suy tuyn yn c th l nguyn nhn
gy TN,. cc thng tn vng di i nh u s hu (craniopharygiomas) hoc
cc thng tn khc ca thn kinh trung ng do thm nhim, thng d dn n
TN.
TN cng c th do chn thng, hoc do cc phu thut u di i, u tuyn yn.
TN do gia nh, l mt bnh him, do di truyn, xy ra tui nh.
TN v cn thng xut hin cui tui u th, thanh nin v tui trng thnh,
bnh cnh cng thng c s gim s lng si thn kinh cha ADH. C khong
30 -40% cc bnh nhn c khng th trc tip neuron vng di i tit ADH.
TN do di truyn thng i km vi i tho ng, teo mt, ic, TN vi ri lon
men ca ADH lu thng do gia tng enzyme Vasopressinase xut hin lc mang
thai.
2. TN thn
Bnh xut hin do thn khng p ng vi tc dng sinh l ca ADH, trong trng
hp ny ADH trong mu bnh thng hoc gia tng.
Cc bnh thn mn tnh, nht l cc bnh gy tn thng vng ty, v cc ng gp
c th dn n TN do thn.
Cc ri lon in gii: H kali mu, tng Calci mu lm gim kh nng c c nc
tiu.
C nhiu loi thuc gp phn lm xut hin bnh TN do thn nh lithium,
Demeclocycline, Methoxyflurane, Amphotericin B, Aminoglycosides, Cysplatin,
Rifampiciny.

478
Trong thai k, mt aminopeptidase t nhau thai lm tng chuyn ho AVP gy thiu
AVP dn n tiu nhiu..
3.Ung nhiu tin pht (thi ung nhiu-potomanie)
Thc cht khng phi bnh TN, bnh nhn ung nhiu do tm l. Lng nc
ung c th nhiu hn c trng hp TN tht s. Bnh thng gp trn mt c
a lon thn, bnh xut hin t t sau mt sang chn tm l. Phn bit vi TN
da trn nghim php nhn kht.
IV. TRIU CHNG LM SNG
Cc triu chng lm sng ca TN c th xut hin t ngt, tin trin nhanh chng
vi 2 triu chng tiu nhiu v ung nhiu.
1. Tiu nhiu
L triu chng chnh ca TN, lng nc tiu t 5 -10l/ ngy, c khi ln n 15 -
20l/ ngy, c khi t hn nhng c bit nc tiu long nh nc l.
2. Kht v ung nhiu
Lun lun i km vi tiu nhiu vi 3 c im kht nhiu, khng ngng, khng ht
kht.
S kht nc nh thc bnh nhn dy trong m.
Ton trng bnh nhn vn tt, tr trng hp TN km s thng tn lm ph hy
vng di i - tuyn yn.
Nu bnh nhn khng th ung c (v d hn m v chn thng s no, thuc
m...) c th dn n t vong.
Cc trng hp chn thng s no hoc phu thut u c th lm xut hin
bnh cnh ny, cn theo di lng nc tiu, nng huyt tng v nc tiu
bnh nhn c hn m gip ngn nga thiu nc trm trng, do TN khng c
chn on.
Rt him khi TN km ph hy trung tm kht, lm trm trng nhanh chng bnh
cnh dn n t vong.
Cc trng hp hp niu o km gy thn nc cng rt him.
V. DU SINH HC
1. Cc xt nghim thng quy
- T trng nc tiu sng sm lc i < 1,005.
- p lc thm thu nc tiu 200 mOsm/kg nc.
Nu bnh vn ung y , thng cc xt nghim sinh hc t ra vn bnh thng
nh:
- Cng thc mu bnh thng, c th c mt thiu mu nh do long mu.
- in gii hon ton bnh thng (mu)
- in gii niu /24h bnh thng
Chn on xc nh phi da trn cc test ng, cc test ny va chn on
ngun gc ri lon va phn bit mt TN vi mt ung nhiu do tm l
(potomanie)
2. Cc test ng hc:
bnh nhn TN, cc test ng hc nhm mt mt nh gi s hn ch nc c
kch thch tit ADH khng, mt khc nh gi s lng hormone c tit ra lm
gim TN.

479
2.1 Nghim php nhn kht:
Cn thc hin bnh vin v tai bin nguy him c th xy ra.
Mc ch xem ADH c kh nng bi tit hay khng.
- Cho bnh nhn i tiu ht nc tiu, cn bnh nhn ri nm ngh.
- Ly mch, HA mi 15 pht, nc tiu mi 30 pht. Tip tc theo di chng no m
bnh nhn cn chu ng c, khng kh chu.
- Cc triu chng bo ng l: lo lng, cc du khi u ca mt nc nh kh
nim mc, kht nhiu, mch nhanh, nht l HA h. Phi ngng nghim php khi cn
nng gim n 3% trng lng c th.
Kt qu
ngi bnh thng:
Lng nc tiu gim < 5ml/ pht
T trng nc tiu (1,020 tng dn.
bnh nhn TN:
Lng nc tiu ln hn 5ml/ pht
Nng thm thu nc tiu < 200 mosm/kg H
2
O
T trng 1,001 - 1,005
2.2. Cc nghim php kch thch tit ADH
C in c test ca Carter v Robbins hoc test ci tin ca J. Deccourt hoc test
nicotine, mc ch nhm kch thch tit ADH di tc ng ca chuyn dch mui.
Cc test hin nay t dng. Hoc test chuyn dch mui u trng ng thi nh
lng ADH. TN ADH s khng tng (Robertson 1980).
Ni chung cc test ny hin nay t dng.
3. Cc test c bit va chn on va thm d iu tr
3.1 Test Chlorothiazide
Bnh thng Chlorothiazide l mt thuc li tiu lm mt NaCl. bnh nhn TN,
ung Chlorothiazide li lm gim tiu mt cch mu thun m khng lm m tnh
thanh thi nc t do. C ch cha c hiu r. C gi thuyt cho rng TN ci
thin do s mt mui ca thuc. Test ny ngy cng t dng.
3.2 Cc test iu tr c hiu
Chlorpropamide lm tng cng hot ng ca ADH ng thn.
Clofibrate v Carbamazepine c tc dng kch thch vng di i tng tit ADH.
Ngi ta o thi nc t do trong 24 gi hoc trong cc mu nc tiu ly t 3
thi k (8-14 gi, 14 gi - 19 gi, 19 gi - 8 gi) thuc s lm gim lng nc tiu,
v nht l tng c c nc tiu.
Nu thanh thi nc t do tr v m tnh mi c php kt lun thuc c tc
dng tt.
Cc test ny c v tr quan trng trong vic la chn iu tr lu di sau ny cho bnh
nhn.
3.3 Dng tinh cht thy sau tuyn yn:
Nhm phn bit TN do thiu ADH v TN do thn. Pitressin 5/1000/v (5 milliunits)
truyn tnh mch chm trong mt gi hoc 5 n v vasopressin tannate du tim
bp s lm gim TN do thiu ADH, nhng khng gim nu TN do thn khng
tc dng ca ADH.

480
4. nh lng ADH bng min dch hunh quang
Nng c th bnh thng nhng khng gia tng trong nghim php nhn nc,
test tng mui.
TN do thn, nng ADH cn bn tng cao.
VI. IU TR
1. Thuc iu tr c cu trc ging AVP
1.1.Desmopressine (DDAVP)
1.1.1.Bit dc
Minirin
1.1.2.Trnh by
Thuc c trnh by di 2 dng: Dng xt mi, l cha 2,5ml. Dng chch, 4g/ml.
Bo qun +2
o
n +8
o
C.
1.1.3. Ch inh
y l thuc c chn la u tin trong iu tr bnh i tho nht trung ng.
Ring dng chch ch nh cho bnh nhn i tho nht trung ng nhng bnh
nhn khng th dng dng xt do kh chu hoc i tho nht sau phu thut thn
kinh hoc sau chn thng.
1.1.4.Dc ng hc
Desmopressine c cu trc ging ADH t nhin. Tuy nhin so vi ADH t nhin
desmopressine c tc dng chng li s tiu tin (tc dng ln th th V2) mnh hn
v ko di lu hn, nhng cc tc dng khc ln th th V1 li t hn AVP. Sau khi
chch liu 1-4g TM ch 15-30 pht sau l c tc dng gim tiu, tc dng ko di 5-
20 gi tu theo liu lng. Vi liu cao hn (0,3-0,4g/kg cn nng) thuc c tc
dng lm tng yu t VIII v yu t von Willebrand gp 3-4 ln nng cn bn. Vi
liu 0,4g/kg cn nng, thuc c tc dng gin mch, mt ng , huyt p tm
trng st v nhp tim gia tng thong qua. Bng ng xt mi thuc ch cn cho 2
ln/ngy l .
1.1.5.Liu lng
Vi dng xt mi: Ngi ln 0,1-0,2ml (10-20g). Tr em 0,05-0,1ml (5-10g) ngy
1-2 ln. Thng thng mi l Minirin cha 25 ln xt, mi ln xt cha 0,1ml tc l
10g desmopressine.
Vi dng chch: c th chch TM, bp hoc di da 1-2ln/ngy. Ngi ln:
1-4g (0,25-1ml). Tr em trn 1 tui: 0,4-1g (0,10-0,25ml). Tr em t 1 tui tr
xung: 0,2-0,4g (0,05-0,10ml).
1.1.6. Chng ch nh
Nhy cm vi cc thnh phn ca thuc s dng.
Mang thai, cho con b.
1.1.7. Tng tc thuc
D thuc t tc dng ln th th V1, khng nh hng nhiu ln tim mch, tuy nhin
khi dng ng thi vi cc thuc vn mch khc cng cn thn trng.
Tc dng chng tiu tin c th thay i khi dng chung cc thuc khc:
- Clofibrate, indometacine, carbamazepine, chlorpropamid: tng tc dng
chng tiu tin.
- Glibenclamide: gim tc dng chng tiu tin.
1.2. Lypressine

481
1.2.1. Bit dc, trnh by, dc ng hc
Diapid, trnh by di dng dung dch xt mi. L 12ml. Bo qun +2
o
n +15
o
.
Thuc tng hp c cu trc ging AVP c tc dng kch thch s ti hp thu nc
phn xa ca ng thn.
1.2.2. Ch nh
iu tr i tho nht do thiu ADH do bt k nguyn nhn no.
1.2.3. Liu lng,chng ch nh
Mt xt cho mi l mi, 3-6 ln/ngy, phi cch nhau t nht 4 gi gia cc ln xt
(Mi xt phng thch 0,12ml dung dch tc l 6/v lypressine. Mi l xt c 100 ln).
Khng dng cho ngi suy mch vnh, mn cm vi thuc, gy m vi hallogen,
ph n mang thai, cho con b.
2. Cc loi thuc ung
2.1. Chlorpropamide
2.1.1.Bit dc, trnh by, dc ng hc
Dabinese (Pfizer), Diabetoral (Boehring Mannheim), Chloronase (Hoechst) trnh by
di dng vin nn, hm lng 250mg/vin. Thuc thuc nhm sulfonylurease th
h I lm h glucose huyt, ring i vi i tho nht, liu lng 250-500mg/ngy
thuc lm tng thm thu ca nc tiu v lm gim s tiu tin 25-75% trn cc
bnh nhn TN nng. tuy nhin thi gian cn thuc c tc dng gim tiu rt thay
i. Thuc c tc dng tng cng hot ng ca ADH trn ng thn. Tc dng ph
quan trng l h glucose mu.
2.1.2. Ch nh
i tho ng Typ 2, TN trung ng, c th dng phi hp vi DDAVP, TN
thn.
2.1.3.Liu lng, chng ch nh
250-500mg/ngy. Chng ch nh trong trng hp suy gan, suy thn hoc
suy gip nng, tin s d ng vi sulfamide, ph n c thai, cho con b.
2.2. Clofibrate
2.2.1. Bit dc, trnh by, dc ng hc
Lipavlon (ICI; Avlon), Atromid (ICI), Clofibral (Negma), Normolipol
(Delagrange)...Trnh by di dng vin, hm lng 500mg. Thuc c bit ch
yu dng trong iu tr tng VLDL, LDL cholesterol, triglyceride, ngoi ra thuc cng
c tc dng lm gim tiu nh chlorpropamide nhng yu hn, c ch tc dng
cha hon ton r, thuc khng c tc dng trn bnh TN do thn. chng minh
c thuc lm tng tit AVP. Tc dng ph gy au c, yu, tng men ca c.
2.2.2. Ch nh
Tng cholesterol, tng triglyceride mu, TN trung ng
2.2.3. Liu lng, chng ch nh
500mg 3-4 vin/ngy. Chng ch nh: suy gan, suy thn
2.3. Carbamazepine
2.3.1. Bit dc, trnh by, dc ng hc
Tgrtol hoc Tegretal (Ciba-Geigy), Biston (Spofa, Tchcoslovaquie), Sirtal
(Labaz). Trnh by di dng vin, hm lng 200mg. Ch nh ch yu ca thuc
l: ng kinh, au dy thn kinh tam thoa, ngoi ra thuc cng c tc dng gp phn

482
lm gim tiu, c ch cha hon ton r, thuc kch thch tit ADH. Tc dng ph
quan trng l c ch tu xng.
2.3.2. Ch nh
i tho nht trung ng, ng kinh, au dy thn kinh tam thoa. Do thuc c nhiu
tc dng ph v vy thuc ch nn ch nh khi cc thuc khc khng dng c.
2.3.3. Liu lng, chng ch nh
100-200mg hai ln mi ngy. Chng ch nh: D ng vi thuc, mang thai (nht l 3
thng u), suy gan, ri lon to mu, bnh tng nhn p, ong nc tiu, cc ri
lon v tim mch.
2.4. Hydrochlorothiazide
2.4.1. Bit dc, trnh by, dc ng hc, ch nh
Dichlotride (Merck, Sharp, Dohm), Esidrex (Ciba-Geigy)...Trnh by vin 25mg.
Thuc thng c dng gip tng thi mui v nc nhng trng hp ch nh
thng thng nh ph, tng huyt p, suy tim... tuy nhin thuc c tc dng gim
tiu mt cch nghch l tt c nhng trng hp TN, tc dng ny xt hin th
pht sau khi nc tiu b long nhnh ln ca quai Henle, cng nh th pht sau
khi th tch gim nh ng ln xa. Vi liu lng tiu chun, thuc lm gim 30-
50% lng nctiu tt c cc th TN, do thuc rt hu ch khi dng h tr
vi cc thuc ung khc trong iu tr TN trung ng cng nh TN do thn
2.4.2. Liu lng, chng ch nh
1-5mg/kg/ngy. Khng dng thuc khi suy thn nng, ph n mang thai, cho con b,
d ng vi sulffamide, bnh gout mn, h Natri, k Kali mu.
3. Mt s nguyn tc trong iu tr
3.1. Gio dc, theo di
Gio dc bnh nhn ch ung nc khi tht s kht. Theo di thy Natri huyt tng
< 130mEq/l xut hin 2 ln xt nghim chng t ung qu nhu cu tht.
3.2. Thi gian ca liu trnh
i vi TN trung ng trong phn ln cc trng hp phi iu tr sut i, ngay
c nhng trng hp nguyn nhn gy bnh c loi b, mt s rt t cc
trng hp bnh c ci thin n mc ngng iu tr, thng khng phi do AVP
hi phc s tng tit m c th do cc yu t khc nng hn nh suy thng thn,
tit AVP lc ch t u c tnh, tnh trng mt nc trm trng do ri lon c ch kht
nc. Tuy nhin c nhng bo co bnh hi phc do mi nm nn th ngng
iu tr vi ngy nh gi s hi phc.
3.3. Tch cc tm nguyn nhn
Cn tch cc tm hiu nguyn nhn gy bnh bng nhiu phng tin v chn on
hnh nh hc, cc xt nghim dch no tu cng nh nhng thm d v ni tit vng
di i, thu trc tuyn yn ngay c khi hnh nh h yn bnh thng.
3.4. i tho nht ngi mang thai
Thuc duy nht c dng l DDAVP, liu dng thng cao hn mt t so vi bnh
nhn TN khng mang thai do nhau thai sn xut vasopressinase, Trong thai k
chp nhn natri mu thp hn 5mEq/l so vi ngi TN khng mang thai. DDAVP
khng c tc dng ln co c t cung. Thai k khng c dng cc thuc ung iu
tr TN do kh nng gy qui thai.
3.5. Ung nhiu tin pht

483
iu tr ch yu gio dc bnh nhn. Thuc an thn kinh khng hiu qu i vi
ung nhiu do tm l. Hn ch ung cng lm bnh ci thin nhng kh thc hin,
thc t vi nhng bnh nhn ny cng hn ch ung, cng lm kht nhiu hn.
Dng DDAVP lm tiu t li nhng khng tc ng g trn tnh trng ung nhiu do
tm l, bnh nhn vn tip tc ung, do lun lun dn n ng c nc, hi hn
l li, biu hin trong 24-48 gi vi h Natri mu, nhc u, chng mt, lo lng,
bun nn, nn, ln ln, co git, hn m, ngay c t vong. Cn chn on chnh xc
trc khi quyt nh iu tr. Nu cn, thuc cng c th cho vo lc i ng, cn cn
nhc k liu lng sao cho thuc khng ko di tc dng n ngy hm sau, l
lc bnh nhn li ung nhiu c th gy ng c nc.


484
SUY THU TRC TUYN YN
Mc tiu
1. Trnh by s lc chc nng ca tuyn yn
2. Nm c cc nguyn nhn suy thy trc tuyn yn
3. Triu chng lm sng ca suy thy trc tuyn yn
4. Trnh by cc triu chng cn lm sng ca suy thy trc tuyn yn
Ni dung
I. I CNG
Tuyn yn l tuyn quan trng iu chnh s hot ng ca cc tuyn ni tit khc
gi l tuyn tip nhn gm tuyn thng thn, tuyn gip, tuyn sinh dc, tuyn v...
Mc khc tuyn yn c iu ha hot ng bi vng di i.
Mt s tha hoc thiu hormon tuyn yn s biu hin lm sng hc bng s tng
hay gim hot ng ca cc tuyn , y l hin tng Feed- Back. Tuyn yn c
hai thy chnh, thy trc v thy sau:
1. Thy trc: C 3 nhim v
1.1. iu chnh s pht trin c th: do STH (Somathormone, Somatotropine,
Somatotrope, hoc GH: Growth hormone) tit ra t t bo a acide. S tit STH
cng c iu ha bi cht trung gian Somatomdine hoc IGF-1 l cht c tit
ra t gan, rut, ty.
1.2. iu chnh s hot ng ca cc tuyn ch: nh
- TSH: iu chnh hot ng tuyn ca tuyn gip (thyreotrope).
- ACTH: do t bo a base tit ra, iu chnh hot ng tuyn thng thn
(corticotrope).
- Hormon sinh dc: LH, FSH (gonadotrope)
FSH: Follicule stimulating hormone, nam, ph trch s pht trin tinh hon, ng
sinh tinh v sn xut tinh trng. n, FSH kch thch nang trng (De Graaf) pht
trin.
LH: Lutotrophin Hormone, nam, c tc dng dinh dng t bo Leydig, kch thch
bi tit testostrone. n, LH phi hp vi FSH lm nang De Graaf chn v ch tit
estrogene, LH c tc dng lm rng trng v to hong th, ch tit progestrone v
estrogne.
- Hormon tit sa: PRL (lactotrope): PRL c tit gia tng khi khi c thai, cho con
b, c stress, T PRL n tng cao hn nam gn 50%. S iu ha tit PRL ch
yu l do nh hng km hm ca Dopamin. Mt s thuc i khng
dopaminergique thng c dng nh thuc tm thn, thuc bng d dy rut
cng gy tng tit PRL quan trng.
Bnh thng: PRL < 25 ng/ml n., < 18ng/ml nam.
1.3. Tc dng n chuyn ha c bn nht l chuyn ha ng.
2. Thy sau
Cha ng hormon ADH (Vasopressin, Oxytocin), ADH c tit ra t vng di
i (hypothalamus).
II. NGUYN NHN: Suy tuyn yn: c th do nhiu nguyn nhn.
1. Pht trin /Cu trc
- Tn thng yu t chuyn vn

485
- Lon sn/bt sn tuyn yn
- Khi thn kinh s no bm sinh, encephalocele
- Rng tuyn yn tin pht
- Ri lon hypothalamus bm sinh (lon sn vch ngn-th, hi chng Prader-Willi,
h/c Laurence-Moon-Biedl, h/c Kallmann).
2. Chn thng.
- Phu thut ct lc
- Chiu tia x
- Thng tn u
3. Khi u
- Adenome tuyn yn
- U ngoi tuyn yn (meningioma, germinoma, ependymoma, glioma)
- Nang Rathke
- U sn s hu (craniopharyngiome),
- Hypothalamic hamarthoma, gangliocystoma
- Lymphoma, leukemia
- Meningioma
4. Thm nhim/Vim
- Hemochromatosis
- Vim tuyn yn t bo lympho
- Sarcoidosis
- Histiocytosis X.
- Vim tuyn yn dng ht
5. Tn thng mch mu
- Thiu mu tuyn yn
- Lin quan n thai nghn: nhi mu trong T, hoi t tuyn yn sau sinh
(Sheehan).
- Bnh t bo Sickle
- Vim ng mch
6. Nhim trng
- Nm: histoplasmosis
- K sinh trng: Toxoplasmosis
- Lao.
- Pneumocystis carinii
III. LM SNG
1. Lm sng suy thy trc tuyn yn
Ngc li vi cng chc nng tin pht ca tin yn, thng thng l cng mt
loi hormon, trong suy tin yn thng thng l suy ton th. Biu hin lm sng u
th l ri lon tng trng, dy th, ri lon chc nng sinh dc. Ni chung biu hin
lm sng ca suy tin yn ph thuc vo loi hormone tuyn yn b thiu hoc khng
c.
Thiu GH l nguyn nhn lm gim s pht trin c th.

486
Thiu Gonadotropin nguyn nhn ca ri lon kinh nguyt v v sinh n b v
gim chc nng sinh dc v mt dc tnh th pht nam gii.
Thiu TSH v ACTH thng pht trin sau mt tin trnh suy tuyn yn. Thiu TSH
tr em s lm chm pht trin, v c biu hin suy gip c tr em v ngi ln.
Thiu ACTH s a n suy tuyn thng thn
Thiu PRL gim tit sa.
Sau y l cc biu hin lm sng ca suy thy trc tuyn yn
1.1. Bnh nhi tnh
Tn ti ngi ln tui, cc triu chng tinh thn v tnh dc ca tr em, chiu cao
ca ngi bnh ph thuc vo tui ca h vo lc b suy tuyn yn. Nu pht sinh
lc nh, bnh nhn s ln, nu pht sinh tui thnh nin, chiu cao gn bnh
thng hoc bnh thng.
1.2. Hi chng ph sinh dc
- Bo ph mt trc c, gy khng b.
- Mp ngc, bng v cc gc chi.
- Da mn v mm.
- Sinh dc: tr chm hoc khng pht trin th lc, thiu nin khng dy th,
ngi ln, n b mt kinh, rng lng, v sinh. n ng lit dng, b phn sinh
dc tr con, b phn sinh dc ph n t pht trin.
- Triu chng do u chn.
1.3. Bnh Simonds
-Nguyn nhn: do suy ton b tuyn yn, ch yu l do suy thy trc. Hi chng
suy nhiu tuyn do gim hormon thy trc tuyn yn
-Lm sng
+ Du chc nng: suy nhc, mi mt, thng bui chiu mt nhiu hn bui
sng). Ri lon sinh dc. Thu (lipothymie) do gim HA v gim ng mu
+ Du thc th: xanh; teo da v phn ph thuc; gim tnh cht sinh dc (lit dng,
mt kinh, mn kinh khng c phng mt); gim HA. Du hiu do u tuyn yn chn:
nhc u, nhc sau hc mt, gii hn th trng
- Cn lm sng
+ CTM: thiu mu; Glucose mu gim; Na
+
mu gim, K
+
mu tng
+ Suy thyrotrope: T3, T4 gim, TSH cc nhy gim (hoc bnh thng)
+ Suy gonadotrope: Testostrone, Oestradiol gim, FSH, LH gim
+ Suy corticotrope: Cortisone, ACTH gim, test Synacthene (ACTH) dng tnh
+ Xt nghim phn bit suy vng di i (hypothalamus) hay suy ti tuyn yn:
Test TRH, Test LH-RH, LVP, dng tnh nu nguyn nhn suy ti hypothalamus, m
tnh nu nguyn nhn ti tuyn yn.
+ o PRL huyt tng.
+ Test TRH: tim TM 200 - 400 g TRH, ri o PRL thi im 0, 30, 60, 120.
Kt qu bnh thng: PRL tng < 60 ng/ml n.
< 80 ng/ml nam.
1.4. Sheehan: hoi t tuyn yn sau sinh, triu chng nh hn rt nhiu. Khi u
triu chng ny rt nhanh sau sinh, du bo hiu l khng chy sa, lng mu khng
mc (sau khi co), hoc rng, khng c kinh tr li, khng phng mt, khng ra

487
m hi. Cc triu chng y thng xut hin sau mt thi gian di vi teo da,
mt mu da, suy nhc vi tt c du chng suy tin yn.
1.5. Cn lm sng
Chn on sinh ho ca suy tuyn yn cho thy cc hormone u mc thp. V d
FT4 thp vi TSH thp gi l suy gip th pht. Tng t testosterone thp m
khng c gia tng gonadotropin gi gim nng tuyn sinh dc do suy tuyn yn
gim tit gonadotrophin.

488
Bng 1: Tt chn on suy tuyn yn
Hormon Tt Mu mu Din gii kt qu
GH Tt dung np insulin: iu
ho insulin
(0,05-0,15 U/kg TM)

GHRH tt: 1 g/kg TM

Tt L-Arginin 30 g TM trn
30 pht

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


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

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


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

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

Tt CRH: 1 g/kg TM lc
8 g


Tt Metyrapone:
Metyrapone 30 mg/kg lc
na m

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

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

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


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



o 11-deoxycortisol
v cortisol lc 8 gi

o cortisol v
aldosterone 0, 30, 60


o cortisol 0, 30, 60




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


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

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

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


Cortisol >21 g/dl

TSH o FT3,F T4, TSH

Tt TRH: 200-500 g TM
Tt c bn

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

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

489
estrogen


Tt GnRH:
GnRH 100g TM



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

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

490
CN LM SNG B SUNG
- XQ s no xem h yn: Hc xng hm v trn rng ra, s dy, khng u,
nht l phn ngoi. H yn c th rng ra, hoc su hn, cc ng vch khng r,
mm gc yn b mng i, c hnh mm chim.
- Scanner s no.
- o STH (GH) trong 24 gi hoc ngy hoc m mi 20 - 60 pht (v STH c tit
ra theo nhp iu ngy m.
+ o STH niu /24 gi.
+ Somatomdine, hoc IGF huyt tng..
+ o STH trong khi lm Test hm bng cch cho ung ng (HGPO),
Bnh thng STH hoc GH cn bn l < 5ng/ml, sau nghim php dung np
glucose ung, STH < 2ng/ml, nu l bnh to cc vin cc, th test hm suy yu 2
ng/ml.
+ Khm th trng: c gii hn th trng.


491
TNG HOT V THNG THN
Mc tiu
1. Trnh by c cc xt nghim chn on hi chng Cushing.
2. Nu c 5 nguyn nhn chnh ca cng aldosteron nguyn pht.
3. M t c cc xt nghim tm sot v xt nghim chn on cng aldosteron
nguyn pht.
4. M t c cc biu hin lm sng ca cng v thng thn sinh dc theo la
tui.
5. Nu c phng php iu tr cc th tng hot v thng thn: bnh Cushing,
cng aldosteron nguyn pht, cng v thng thn sinh dc
Ni dung
I. HI CHNG CUSHING
S gia tng mn tnh hormon glucocorticoid do nhiu nguyn nhn khc nhau gy ra
hi chng Cushing. Nguyn nhn thng gp nht ca hi chng Cushing l do
thuc. Cc nguyn nhn khc l do ri lon tuyn yn, thng thn hoc do s tit
ACTH lc ch. Danh t bnh Cushing ch hi chng Cushing do tuyn yn tng
tit ACTH.
1. Sinh l bnh
1.1. Bnh Cushing
S tng tit ACTH xy ra tng t ngu nhin gy ra s tng tit cortisol khng cn
tun theo nhp iu trong ngy. 90% trng hp bnh Cushing gy ra do u tuyn ca
tuyn yn.
S tit ACTH khng th b c ch c bi nng glucocorticoid sinh l, v th d
nng glucocorticoid tng cao, ACTH vn tit ra a n s tng tit glucocorticod
mn tnh, nng ACTH cao c ngy ln m, tng t.
Ngoi ACTH, u cn c th tng tit LPH, endorphin. S tit ACTH v cortisol
khng tng thm khi c stress. Nng cortisol tng cao cng nh hng n s
tit TSH, GH v gonadotropin v gy ra nhng triu chng ton thn.
Trong bnh Cushing cng c c s tng tit androgen t tuyn thng thn, DHEA,
DHEA sulfat, androstenedion cng tng v c chuyn thnh dihydrotestosteron
m ngoi vi gy cc biu hin nam ha ph n.
1.2. Hi chng tit ACTH lc ch
Do u khng thuc tuyn yn tng hp v tit ra cc cht ACTH c c tnh sinh hc,
cng c u tit LPH, endorphin v c ACTH khng c hot tnh, c th u tit ACTH
v tit CRH hot tnh khng r. Cc u thng gy tit ACTH lc ch l: ung th biu
m t bo nh phi, u carcinoid phi, u tuyn c, rut, ty, bung trng, u ty
thng thn.
S tit ACTH v cortisol trong trng hp ny thng cao hn trong bnh Cushing
nhiu v cng lin tc hn, tuy nhin cc triu chng in hnh ca hi chng
Cushing li t gp v s tng tit cortisol xy ra nhanh v bnh nhn km n, ngoi ra
cn c cc biu hin khc ca bnh c tnh.
1.3. U tuyn thng thn
U tuyn thng thn tng tit cortisol t pht, tuyn yn s b c ch v s tit
ACTH gim, do phn tuyn thng thn bnh thng bn cn li s teo. Cc
nghim php gy nh hng ln trc h khu no-tuyn yn nh c ch bng

492
dexamethason liu cao hoc metyparon u khng gy p ng g trn u tuyn
thng thn.
U tuyn ca tuyn thng thn thng ch tit cortisol.
Ung th biu m tuyn thng thn tit nhiu loi hormon thng thn v c tin
cht ca n.
2. Lm sng
Cc triu chng c m t y phn Triu chng hc Hi chng tng v
gim hot v thng thn: mp ph trung tm, thay i da (da teo, mng, d bm
mu, vt nt da), rm lng, tng huyt p, ri lon sinh dc, ri lon thn kinh tm l,
yu c, long xng, si thn, kht v tiu nhiu.
3. Cn lm sng
Cc xt nghim chn on hi chng Cushing.
3.1. Nghim php c ch bng Dexamethason qua m kt hp o cortisol trong
nc tiu (nghim php tm sot)
Ung 1mg dexamethason lc 23h, 8h sng hm sau o cortisol mu; ng thi tnh
lng nc tiu 24h v o lng cortisol t do trong . Nu cortisol mu gim di
3g/dL vo 8h sng hm sau l bnh thng. Nu cortisol mu sng hm sau gim
hn 5g/dL rt kh chn on l hi chng Cushing, nu kt hp thm cortisol t do
trong nc tiu bnh thng c th loi b hi chng Cushing. Nu 2 kt qu bt
thng c th chn on hi chng Cushing sau khi loi cc nguyn nhn lm sai
kt qu.
3.2. o cortisol t do trong nc tiu
Bnh thng 90-100 g trong nc tiu 24h. Tng trong hi chng Cushing.
3.3. Kho st s thay i nhp iu trong ngy
Trong hi chng Cushing c s tng tit cortisol c sng ln chiu, tuy nhin kh
pht hin tnh trng ny v c ACTH v cortisol u thng tit thnh tng t. Nu
bnh nhn khng c stress, nng cortisol huyt thanh 7 g/dL lc 24h c xem
l c hiu cho hi chng Cushing.
3.4. Nghim php c ch bng dexamethason liu thp
Ngy u hng nc tiu 24h, o cortisol t do v 17 OH corticosteroid v o
cortisol mu lc 8h. Ngy th hai v th ba cho bnh nhn ung dexamethason
0,5mg mi 6h. Ngy th ba lng nc tiu 24h, o nh trn; 8h sng ngy th t
o cortisol mu.
Bnh thng: 17 OH corticosteroid trong NT 24h < 4mg, cortisol trong NT 24h <
25g, cortisol mu < 5g/dL.
II. CNG ALDOSTERON NGUYN PHT
1. Nguyn nhn
C 5 th bnh chnh:
- U tuyn tit aldosteron.
- Cng aldosteron v cn.
- Tng sn thng thn nguyn pht 1 bn.
- Cng aldosteron p ng vi glucocorticoid.
- Ung th biu m thng thn tit aldosteron.
2. Lm sng

493
Triu chng lm sng khng c hiu, bnh nhn nh cm thy yu mt; nng hn
gy nhc u, hi hp, ung nhiu, tiu nhiu, tiu m v d cm. Bnh nhn
thng n khm v cc triu chng ca h kali mu v tng huyt p.
Triu chng thc th: tng huyt p t nh n nng, y mt giai on I, II; gim
kali nng c th c h p t th khng km tim p nhanh v gim cm nhn ca
th th p lc. Khi kim mu nng c th c triu chng nh h calci mu
(Chvostek, Trousseau).
3. Cn lm sng
Kali mu gim trong trng hp in hnh, Natri mu hi tng, ri lon dung np
glucose.
4. Chn on
4.1. Tm sot
Nn tm sot cng aldosteron nguyn pht khi c h kali mu c km tng hyt
p, v a s l tng huyt p khng iu tr.
4.1.1. Kali mu
Trnh n nhiu kali v ngng thuc li tiu t nht 3 tun. 20% bnh nhn c kali
mu bnh thng hoc gii hn thp ca bnh thng.
4.1.2. nh gi h thng renin-angiotensin-aldosteron
o hot tnh renin huyt tng bt k (PRA): gim trong cng aldosteron nguyn
pht.
o nng aldosteron trong huyt tng (PAC) lc 8h sng sau t nht 4h nm ngh
v n y mui vo my hm trc.
Nu PAC/PRA > 30 v PAC > 20 ng/mL: cng aldosteron nguyn pht vi nhy
90%, c hiu 91%.
4.1.3. Nghim php Captopril
Ung 25mg Captopril sng, 2h sau ly mu th, bnh nhn t th ngi.
Bnh thng: PAC gim, PRA tng.
Cng aldosteron nguyn pht: PAC v PRA khng i. PAC/PRA > 50, PAC > 15
ng/dL.
4.2. Xc nh chn on
Dng nghim php c ch aldosteron bng NaCl ung hay truyn tnh mch xc
nh aldosteron trong nc tiu v huyt tng khng b c ch c.
4.2.1. Nghim php c ch bng NaCl ung
n mui liu cao trong 3-4 ngy, b sung KCl 40-200mEq/ngy. Ngy sau cng ly
nc tiu 24h o aldosteron, natri, creatinin. Nu Natri nc tiu > 200mEq/L v
aldosteron nc tiu > 10-14 g th gip chn on xc nh.
4.2.2. Nghim php truyn tnh mch NaCl
Nhn i qua m, nm; truyn tnh mch 2L dung dch NaCl 0,9%. Sau o
aldosteron huyt tng (PAC). Chn on xc nh khi PAC > 10 ng/mL.
III. CNG V THNG THN SINH DC
1. Nguyn nhn
1.1. Cng v thng thn
Tng sn, u tuyn, ung th biu m.
1.2. Tng sn thng thn bm sinh do thiu men

494
Enzyme hydroxylase P450
C21
, P450
C18
, P450
C17
, P450
C11
.
Men 3 hydroxysteroid dehydrogenase (3 HSD).
2. Lm sng
Triu chng thay i ty theo bnh l khi u t lc cn bo thai, s sinh, tr em
hay ngi ln. Thng ngh n chn on cng v thng thn sinh dc khi c
tng huyt p, h kali mu kt hp vi rm lng, thiu kinh, mn trng c v nam
ha.
2.1. nh hng t bo thai
Thai nam: t triu chng, ch c ph i b phn sinh dc.
Thai n: nam ha b phn sinh dc.
2.2. nh hng trn tr nh
Sn tng trng ct ha sm nn tr ngng tng trng chiu cao sm.
B trai: da bu c nhiu np nhn, sm mu.
B gi: c triu chng nam ha, rm lng, c bp pht trin; da dy, nhiu m hi,
mn trng c; ging khn; m vt ln.
2.3. nh hng tui dy th
Tr nam: dy th sm, mc lng mu, dng vt ln nhng tinh hon nh, khng c
tinh trng v hot ng phng tinh.
Tr n: v khng pht trin, t cung nh, bung trng nh, khng c kinh.
2.4. nh hng trn ngi ln
Nam gii: khng c triu chng c hiu.
N gii: triu chng thay i t gim n tnh vi kinh tha, t hoc tt kinh. V teo,
v sinh (khng rng trng). Nu nng s c triu chng nam ha: mc ru mp,
cm; lng nhiu hn tay, b phn sinh dc; da nhn, ging khn; m vt ln, mi
ln ph i.
3. Cn lm sng
- 17-cetosteroid trong nc tiu 24h tng. Nam > 20mg/24h (bnh thng < 5mg);
n > 14 mg/24h (bnh thng < 3mg).
- Dehydroepiandrosteron sulfat trong huyt tng v trong nc tiu tng.
- Testosteron trong huyt tng v trong nc tiu tng.
IV. IU TR
1. Cushing
1.1. iu tr bnh Cushing
1.1.1. Phu tht
Phng php iu tr bnh Cushing tt nht l phu thut. i vi phu thut vin
c tay ngh cao, vi phu thut tuyn yn bng ng tip cn xuyn qua xng
bm t thnh cng n 80%, t vong him, tai bin khong 2%.
1.1.2. X tr
Chiu x vi cc ht nng c t l thnh cng 80% nhng i hi k thut rt cao
nn khng c p dng rng ri. X tr theo kiu c ch thnh cng 15-20%. Trc
kia iu tr bnh Cushing ta hay dng phng php ct b tuyn thng thn 2
bn nhng phng php ny ch dng khi phng php trn khng thnh cng v n
km hiu qu v c th a n hi chng Nelson (u tuyn ca tuyn yn tng th
tch sau khi ct tuyn thng thn 2 bn).

495
1.1.3. Cc thuc c ch tit cortisol
- Ketoconazol c s dng nhiu, c tc dng trn hu ht bnh nhn, t tc dng
ph. Liu hiu qu 400-500mg/ngy chia 2 ln ung. Thuc c th gy c cho gan
nhng t khi nng.
- Metyparon 2g/ngy cng vi Aminoglutethimide 1g/ngy (ung chia 4 ln). Hai
thuc ny t, c th lm ri lon tiu ha v lm tng ACTH sau khi dng lu.
- Mitotan 3-6 g/ngy. p ng chm sau hng tun, hng thng; c th gy bun
nn, nn, tiu chy, bun ng, mn da, suy thng thn.
- Reserpin, Bromocriptin, Cyproheptadin, Valproat natri trc y cng c dng
c ch ACTH nhng ch mt s t bnh nhn p ng.
1.2. U tit ACTH lc ch
iu tr tn gc l ct b u, nu u c tnh v di cn xa khng th m c th
dng cc thuc k trn ngn s gia tng cortisol.
1.3. U tuyn thng thn
Ch yu l phu thut. Trng hp K biu m tuyn thng thn, nu cn st li
sau m th dng Mitotan c ch s tng hp cortisol.
2. Cng Aldosteron nguyn pht
2.1. U tuyn tit aldosteron
Ct b thng thn 1 bn ni c u tuyn.
Cn iu tr tnh trng h kali mu trc phu thut bng Spironolacton.
Tt hn l ct b thng thn qua ni soi.
2.2. Tng sn thng thn nguyn pht mt bn
Cng p ng tt vi iu tr phu thut nh trng hp u tuyn.
2.3. Cng aldosteron v cn
Tng huyt p khng gim sau iu tr phu thut tuy h kali mu c th ci thin, do
phng php iu tr thch hp trong trng hp ny l ni khoa:
- n lt < 100 mEq Na
+
mi ngy.
- Gi cn nng l tng, c ru, tp th dc u n.
- Spironolacton: iu tr tng huyt p, liu u 200-300 mg/ngy; gim dn n 100
mg/ngy khi huyt p v kali mu ci thin.
- Amiloride cng c hiu qu nu bnh nhn khng dung np Spironolacton.
Nu huyt p khng gim sau khi dng liu y , c th dng thm thuc c ch
calci, c ch men chuyn hoc li tiu.
2.4. Cng aldosteron p ng vi corticoid
Glucocorticoid vi thay i liu t liu sinh l n liu dc l c th kim sot c
huyt p v tnh trng h kali. Tuy nhin Spironolacton cng c hiu qu tng t v
v lu di an ton hn glucocorticoid.
2.5. K biu m thng thn tit aldosteron
- iu tr phu thut. Nu sau phu thut cn st li t chc K th iu tr bng
Mitotan.
- Nu u tit cortisol c th dng Ketoconazol.
- Nu u tit qa nhiu aldosteron c th dng Spironolacton.
3. Cng v thng thn sinh dc
3.1. K biu m thng thn

496
Phu thut. Nu khng thc hin c th dng Mitotan.
3.2. Tng sn tuyn thng thn
Hydrocortison liu gp 1-1,5 ln lng hydrocortison tit ra mi ngy (10-13mg) cho
mi mt vung c th. Hoc c th c lng10-26 mg Hydrocortison/ngy; hoc
Dexamethason 0,5-1 mg/ngy.
Liu c chnh theo 17-cetosteroid trong nc tiu, DHEA trong huyt tng v
nng cc tin cht ca cortisol.
Nu c triu chng mt mui: Syncortyl 1 mg/kg tim bp hoc liu duy tr 9-
Fluorohydrocortison 25-50g/ngy.