1

CHNG I

TIM MCH
THP TIM
Mc tiu
1. Nm c cc du chng lm sng v cn lm sng ca thp tim.
2. Vn dng chn on v iu tr thp tim.
3. Nm c tm quan trng ca phng thp s cp v th cp.
Ni dung

I. I CNG
1. Thp tim: l mt bnh vim nhim ton th, biu hin nhiu c quan m ch
yu l khp v tim, bnh c nhng c im sau:
- L hu qu chm ca vim ng h hp trn do liu cu tan huyt nhm A.
- Xut hin thnh tng t cch nhau hng thng, hng nm c khi c chc
nm.
- C ch sinh bnh nghing v t min.
- Thng tn van tim c th mn tnh, tin trin a n suy tim.
- Phng bnh hu hiu.
2. Dch t hc
- Tui tr: 5 -15 tui.
- Ma lnh m lm d vim hng.
- Sinh hot vt cht: bnh ca th gii chm pht trinth 3, ca nhng tp
th sng chen chc cht chi.
- Bnh xy ra sau vim hng lin cu nng, c khi sau vim hng lin cu
khng r, d ti pht bnh nhn thp tim c khi b ti nhim lin cu.

II. BNH NGUYN, C CH SINH BNH

1. Bnh nguyn
Lin cu tan huyt nhm A l vi trng gy bnh do hin tng qu mn sau
nhim lin cu. Nu cn c vo Protein M th c khong 60 type khac nhau, lin cu
gy vim hng thuc type 1, 2, 4, 12. T l mc bnh khong 30%.
2. C ch sinh bnh
- Cha r, nghing v t min. C s tng t gia khng nguyn ca lin
cu v khng nguyn tim (mang khng th chng liu cu v tim, protein M, khng
nguyn glycoprotein c bit ging protein ca van tim).
- Khng th (KT) c hiu: Khng th chng tim, chng t bo no, KT chng
Glycoprotein, Antistreptolysin O. Cc khng th ny tng t tun th 1 n tun th
4 ca bnh.
- C a di truyn: D mc bnh, c nguy c ti pht ko di sut i.

III. GII PHU BNH

Thng tn tin trin

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1. Giai on u: c ph m lin kt, thm nhim t bo thoi ha dng fibrin, c th
hoi t (c tim).
2. Giai on sau
- C ht Aschoff nm gn mch mu, ht ny c cu to:
+ Trung tm l mt vng hoi t dng fibrin, sau n mt vng t bo dng biu
m vi nhng t bo khng l nhiu nhn ngoi cng l t bo a dng nht l
lympho v tng bo.
+ Nhng nt ny tn ti nht l mng trong tim gy ra cc nt so van tim v ct
c ca van tim.
-Thng tn tim: c th c 3 lp cu to tim v m lin kt.
- Mng trong tim: Thng tn vnh vin van hai l 40%.Van 2 l + van ng
mch ch 40%. Van ng mch ch n thun 10-15%. Van dy x cng cun li
gy h, van dnh cc mp li gy hp.
- C tim: Gin cc si c tim, vim x, thm nhim t bo a nhn dng
Aschoff.
- Mng ngoi tim: Tn thng c hnh thi si khng c hiu hay phn ng
vim dng fibrin v thng c dch mu vng khong 200ml c khi mu , c.
- Tn thng m lin kt: Vim thoi ha dng fibrin.
+ Tn thng khp: tit dch fibrin, v trng, khng n mn mt khp.
+ Thng tn no: Gp th vn gy ma git.
+ Thng tn da: l cc ht Meynet cn gi l ht Aschoff ngoi da.

IV. TRIU CHNG HC

1. Lm sng: Thay i nhiu ty c quan b tn thng v trm trng.
1.1. Khi pht
- St cao t ngt du nhim c nu biu hin vim khp l chnh.
- St t t, st nh khng r nu vim tim l chnh.
1.2. Khp: in hnh l vim cc khp ln l chnh vi sng - nng - - au hn
ch c ng di chuyn hi phc nhanh chng trong vng 2 - 3 tun nht l khi c
iu tr, lnh hon ton khng li di chng khp, cc khp thng gp l: khp
vai, khp gi, khuu, c tay, c chn, c khi khng vim in hnh, c vi trng hp
khng biu hin khp.
1.3. Tim: Vim tim l biu hin nng nht ca thp tim, l biu hin duy nht c li
thng tn quan trng vnh vin v gy cht ngi. C th gy vim tim c 3 lp cu
to ca tim:
- Vim mng ngoi tim
+ Tim tng gy au vng trc tim.
+ C khi nghe c ting c mng ngoi tim.
- Vim c tim
+ Ting tim m
+ Suy tim nhp nhanh, c ting nga phi, c ngoi tm thu, cng c khi nhp tim rt
chm, lon nhp. Bloc nh tht cc cp.
- Vim mng trong tim:
+ Hay gp l cc ting thi tm thu mm, ting RTC mm, ting thi tm trng
y tim do h van MC.

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1.4. Nhng biu hin khc
- Thn kinh:
+ Ma git: l nhng c ng khng t , nhanh bin ln chi, c, mt. Trng
lc c gim, xut hin mun v thng gp n.
+ Vim no v vim dy thn kinh cng c th gp.
- Ngoi da
+ Nt di da (ht Meynet) ng knh vi milimt n 1cm thng thy mt dui
ca cc khp ln, mt chc khng au, khng c du hiu vim thng xut hin
mun.
+ Ban vng: vng cung khng thm nhim, thay i nhanh, gp thn v gc chi.
- Thn: Vim thn tng : c protein niu nh, huyt niu vi th. Cng c khi gp
vim cu thn cp lan ta.
- Phi v mng phi: Trn dch mng phi, ph phi xung huyt mt hay hai
bn.
- Bng: au bng c khi nhm vi rut tha vim.
2. Cn lm sng
2.1. Biu hin phn ng vim cp trong mu
- VS tng cao thng >100 mm trong gi u.
- Bch cu tng 10.000 - 15.000/mm3 ch yu a nhn trung tnh.
- Fibrinogen tng: 6 - 8 g/l; Tng (2 v gamma Globulin.
- Creactive Protein (CRP) dng tnh.
2.2. Biu hin nhim lin cu
- Cy dch hng tm lin cu: Ngoi t vim ch 10 % dng tnh.
- Khng th khng lin cu tng trong mu > 500 n v Todd/ml.
- Antistreptokinase tng gp 6 ln bnh thng.
2.3. in tim: Ri lon dn truyn nh tht, PR ko di. C cc ri lon nhp: NTT,
bloc nh tht cc cp.
2.4. X quang: Bng tim c th ln hn bnh thng.

V. TIN TRIN V BIN CHNG

1.Th thng thng: Lm sng ci thin rt nhanh.
- Triu chng khp gim sau 24h, PR di ra sau vi ngy, VS tng sau 2 - 3
tun.
- Tt c cc triu chng mt sau 2 thng.
2. Th nng
- Thp tim c tnh
+ Gp tr nh < 7 tui.
+ Vim tim ton b c bit l c tim cp hoc no, thn, phi.
+ St kn o au khp t.
+ iu tr t kt qu.
- Th tin trin
+ Tin trin chm hn.
+ C s ni tip cc t cp v t lui bnh.
+ Lun b di chng trm trng tim.

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3. Th di chng: Thng mng trong tim:
- Van hai l: Tn thng nhiu nht gy h hp van 2 l sau 2 nm.
-Van ng mch ch: Hp h van ng mch ch, h MC n thun cn
hp th him.
- Van 3 l: him, thng kt hp vi cc van khc.
4. Vim mng trong tim nhim khun: bin chng ng s nht, Osler hay gp h
cc van hn l hp.
5. Ti pht: Hay gp bnh nhn khng d phng tt.

VI. CHN ON
1. Chn on xc nh: Kh khn trong t thp u tin, da vo cc tiu chun
ca Jones.
1.1. Tiu chun chnh
- Vim tim.
- Ban vng.
- Vim khp.
- Nt di da.
- Ma git.
1.2. Tiu chun ph
- St
- au khp
- PR ko di
- VS tng, bch cu tng, C Reative Protein (+)
- Tin s thp hay b bnh tim sau nhim lin cu.
1.3.Tiu chun mi b nhim liu cu
- Tng dn nng khng th khng lin cu.
- Va b bnh tinh hng nhit (Scarlatine).
Khi chn on thp tim phi c 2 tiu chun chnh, hoc 1 tiu chun chnh + 2 tiu
chun ph v mi b nhim lin cu.
1.4. Nhng k thut mi
- Siu m 2 bnh din c th thy trn dch mng tim, cc bin i cc van tim, mc
ri lon chc nng tim.
- Siu m Doppler: Pht hin h van 2 l, van MC, nh gi mc h.
2. Chn on phn bit
2.1. Vim a khp dng thp: Vim nhiu khp nh, bin dng khp, teo c, cng
khp, tin trin ko di.
2.2. Vim khp do lu cu: Vim 1 khp thng khp gi, dch khp c vi khun.
2.3. Lao khp: C th suy kit, st dai dng, thng sau lao phi, khp thng gp:
khp hng, ct sng lng.
2.4. Lupus ban : Ban hnh cnh bm ngoi da, bin i mu da, au nhiu khp,
thng tn thn nng, tn thng mng phi, bng.
2.5. Vim mng ngoi tim, c tim do virus: Bnh rm r, cp tnh, st cao, c mng
ngoi tim, khi hon ton khng li di chng.
VII. TIN LNG: Ph thuc vo tn thng tim.

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- Nu khng tn thng tim t u hoc vim tim nhng tim khng to, chn on
v iu tr sm, d phng y , khng ti pht th tin lng tt 90% phng c
bin chng tim.
- Nu tn thng tim t u khng d phng y theo phc th tin lng
xu i nhiu.
- Theo Fridberg v Jones: 10 - 20% bnh sau t thp tim u s tr thnh tr tn
ph. T vong sau 2 - 6 nm.
- S cn li sng n tui trng thnh: - 65% bnh nhn sinh hat bnh thng.
- 25 % sng sc khe gim st nhiu v l gnh nng cho gia nh v XH.

VIII. KT LUN
- L bnh gp ngi tr, nguyn nhn do lin cu.
- Bnh cnh a dng.
- Chn on ban u kh, khi chn on c k c k thut mi th tim b vim.
- Din bin kh lng, d phng sut i ni ln tm quan trng tc ng ln tim
c bit l bung tim tri.

BNH HP VAN HAI L

Mc tiu
1. Nm vng cc triu chng lm sng v cn lm sng ca bnh van hai l.
2. Nm c cc th lm sng ca bnh van hai l.
3.Nm vng cc phng tin iu tr ni khoa bnh van hai l.
4. Nm vng ch nh iu tr ni khoa, iu tr ngoi khoa v phng nga cc bin
chng
Ni dung

I. I CNG
Hp van hai l l mt bnh kh ph bin nc ta chim khong 40,3% cc
bnh tim mc phi. Bnh c pht sinh loi ngi t khi bt u sng thnh tng
qun th do iu kin sinh sng thp km, cht chi thiu v sinh d gy ly nhim
bnh. T 1887 Bouillaud ri Sokolski m t bnh. n 1920 Duckett Jones (Hoa
k) nghin cu bnh ny v n 1944 ng mi cng b by tiu chun chn on
bnh.. Cng nhng nm ny Cutter v Levine Phillipe (Hoa k) tm cch phu thut
hp van hai l ng thi trong nm Souttar ti Anh cng m c hp van hai
l. Giai on ny bnh hp van hai l l bnh tim mch ph bin nht, gy tn ph
v t vong nhiu. T nm 1944 vic pht minh ra Penixillin dit cc loi lin cu v
c bit to ra loi Penixillin chm (Benzathyl Penixillin) c tc dng phng nga
bnh ny do n nay cc nc pht trin nh Thy in, H lan v c bnh
thp tim gn nh mt hn.
Tuy vy, cc nc chm pht trin bnh ny cn ang ph bin. Bnh hay
gp tui lao ng 20 - 30 tui t l bnh hp hai l rt cao khong 60 - 70 %, t l
t vong n 5%. Bnh c nhiu bin chng phc tp v a n tn ph. Bnh gp
n nhiu hn nam (3/1) v nng thn mc nhiu hn thnh th.

II. BNH NGUYN V C CH SINH BNH

Ch yu do thp tim 99%, s cn li do bm sinh, hoc do Carcinoid c tnh,
lupus ban h thng, vim khp dng thp c nghin cu cn cho l do virus
Coxsackie gy ra. Tc nhn gy bnh ch yu l do lin cu khun tan huyt nhm
A gy vim hng gy tn thng thp tim. S d lin cu hng gy bnh thp tim
m khng vo cc c quan khc l do c cc ng thng bch mch gia hng v
tim. Cu trc bo thai hc cho thy c ng ni mch mu v thn kinh gia tim v
c.
Nm 1976 Taranta (Hoa k) chng minh c c ch bnh sinh trc tip ca
c t lin cu khun ln tim. Cc khng th khng tim xut hin bnh nhn thp
tim c vim tim, c c cc phn ng khng nguyn cho gia cc cu trc tim v
lin cu A. Ni tm li c ch sinh bnh nh sau:
- Lin cu khun nhm A xm nhp vo c th gy vim hng ng thi sinh
ra nhng c t. Ngoi ra, trong m tim ngi ta cng tm thy nhng cht liu c
cu trc min dch ging protein M v vy cc khng th hnh thnh cng chng lun
li cc van tim.
- Hin tng t min cho nhm ln gy vim tim v vim khp. Vim tim c th t
khi nhng sau 2 nm n c th li di chng van tim, c 3 bnh nhn th c 1
bnh nhn b di chng van tim nh dy dnh x gy hp van tim.

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III. TRIU CHNG HC
1. Lm sng
1.1. Ton thn: Nu mc bnh trc tui dy th, bnh nhn km pht trin th cht
gi l ln hai l (nanisme mitral). Nu xy ra sau tui dy th tr pht trin gn nh
bnh thng.
1.2. C nng
- C khi pht hin tnh c bi khm sc khe hng lot m bnh nhn khng
c triu chng c nng no ngay c khi gng sc.
- C khi bnh nhn i khm v kh th, ho v khc ra mu, hi hp nh trng
ngc, nut nghn do tm nh chn p vo thc qun nht l khi gng sc.
1.3. Du chng thc th: Nghe tim l ch yu, c th nghe khi nm nga, nm
nghing tri hoc c khi phi bnh nhn lm ng tc gng sc. Hp van hai l
in hnh thng nghe c cc du chng sau theo tn sut hay gp.
- Ting T1 anh mm (do van x dy p vo nhau).
- Rung tm trng (RTTr) mm do van hp lung mu b tng mnh xung tht
tri va vo cc ct c v cu c tht tri b vim dy x cng, vi ha hoc RTTr
mt khi van hp kht, van v t chc di van dy, vi ha, dnh vi nhau.
- T2 mnh y tim do s tng p lc ng mch phi do hai van MC v MP
ng khng cng lc to nn T2 tch i (van MP ng mun hn van MC).
- Ting thi tin tm thu gia tim hay mm do lung mu i qua ch hp nu cn
li nh tri, nh tri phi bp thm mt ln na y nt s mu xung tht tri;
nhng khi b rung nh hay nh tri gin ri th khng cn nghe ting thi tin tm thu
na.
- Ting clc m van hai l mm hoc trong mm. Ting ny ch c khi van cn
mm.
- Khi p lc ng mch phi tng cao tht phi gin nhiu lm gin vng van MP
gy ra ting thi tm trng van MP gi l ting thi Graham - Steel.
Cng c nhng trng hp hp van hai l khi khm bnh khng nghe c
g m nh bin chng v nh cn lm sng nht l siu m gi l hp van hai l
cm.
2. Cn lm sng
2.1. in quang: C 2 t th thm d trong hp van 2 l:
- T th thng:
+ Bn phi: Tm nh tri to ln sang pha phi thng c 3 giai on.
Giai on 1: Nh tri to to thnh 2 cung song song vi b trong l nh tri, b ngoi
l nh phi.
Giai on 2: Nh tri to ln ra ct cung nh phi, to thnh hai cung ct nhau.
Giai on 3: Nh tri to ln ra ngoi to thnh 2 cung song song m cung ngoi l nh
tri v cung trong l nh phi (ngc vi giai on 1).
+ Bn tri: c 4 cung: cung MC, cung MP, cung tiu nh tri, cung di tri vi
mm tim hch ln (tht phi ln).
Rn phi: m, to nn 2 bn bng tim hai khong m rng v ranh gii khng r.
Hai ph trng m do huyt, c th thy c hnh Kerley B. Nu khi c tnh trng
tng p lc MP ch ng th thy vng rn phi m v vng ra phi rt sng.

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- Trn phim nghing c ung bart: thc qun b chn p 1/3 gia. Mt khong
sng trc tim hoc sau xng c (tht phi ln).
2.2. in tm
- Giai on u cha hp kht hoc cha nh hng nhiu trn cc khoang tim: in
tim cn bnh thng.
- Giai on sau: dy nh tri vi P (0,12s hoc P hai pha, pha m ln hn pha
(+) V1. Trc in tim lch phi v dy tht phi.
Ngoi ra cn c th thy tnh trng ri lon nhp nh ngoi tm thu nh, nhp nhanh
nh, rung nh l hay gp hn c. C th c blc nhnh phi khng hon ton.
2.3. Siu m tim
L phng tin chn on xc nh chnh xc hp van hai l nht l khi hp
van hai l trn lm sng khng pht hin c. Siu m cn cho php ta nh gi
van v t chc di van c dy khng ta c quyt nh thay van hay tch van.
Trong hp n thun
- Kiu mt bnh din: Van l van trc v sau dnh vo nhau nn di ng song
song cng chiu, cc l van dy ln. Van c dng hnh cao nguyn hay giy trt
tuyt. dc tm trng EF b gim. Nu hp kht dc tm trng c th gim
<15 mm/s. ng knh nh tri tng. ng knh tht phi tng, vch tht phi dy.
C th thy c du tng p MP gin tip.
- Siu m 2 chiu: Xc nh c s di ng ca van, do kch thc bung
tim ng thi o c din tch l van.
- Siu m Doppler c th pht hin c hp van hai l c kt hp vi cc tn
thng khc c thi x tr thch ng. ng thi o p lc ng mch phi,
theo di p lc ng mch phi trc v sau iu tr.
2.4. Tm thanh c ng
Kt hp vi in tm nh gi mc hp ca van da vo khong Q T1 v khong T2 - CM. Nu Q - T1 cng di v T2 - CM cng ngn th hp van hai l
kht, hin nay thm d ny t s dng do c siu m tim
2.5. Thng tim
Thy c s chch lch p tm trng gia nh tri v tht tri, du hiu
c trng ca hp hai l. Hin nay, siu m c tnh cht quyt nh nn t s dng
phng tin ny. Ngi ta ch s dng khi c nghi ng c h hai l hoc cc bnh
van ng mch ch phi hp (him).

IV. CHN ON
1. Chn on xc nh
Da vo cc tiu chun lm sng v cn lm sng, nh m t trn. Quyt
nh nht vn l du nghe tim v siu m tim.
2. Chn on phn bit
- Rung tm trng trong hp van 3 l: RTTr trong mm, T1 khng anh.
in tim c dy nh phi. Siu m tim l quyt nh.
- U nhy nh tri (Myxoma): nghe rung tm trng thay i theo t th. Khng
c T1 anh. Bnh nhn thng hay c ngt. Chn on da vo siu m tim.
3. Chn on giai on
C 4 giai on ca hp hai l

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- Giai on 1: Khng c triu chng c nng k c khi gng sc. Khm lm sng
pht hin tnh c.
- Giai on 2: C hi chng gng sc r: Kh th, hi hp, nh trng ngc, ho
hoc ho ra mu, cha c biu hin suy tim.
- Giai on 3: C kh th nhiu, c suy tim phi nhng iu tr c hi phc.
- Giai on 4: Hp van 2 l c suy tim nng, iu tr khng hi phc.
4. Chn on th
4.1. Th n thun: c th dung np tt, bnh nhn cha c du hiu c nng v
thng pht hin bnh tnh c.
- Th in hnh: Nh m t trn v khi khm lm sng, X quang, in tim c th
chn on c.
- Hp van hi l cm: Bnh nhn c th c hoc khng c triu chng c nng.
Nghe tim khng thy cc du hiu c trng cc hp van hai l. Th ny i hi tm
cc bin chng ca hp van hai l v cn lm sng nht l siu m tim gip chn
on.
- Th tin trin: thng l nhng trng hp hp van hai l khp hay rt kht. Bnh
nhn vo vin vi cc bin chng nng n. Ri lon nhp, hen tim, ph phi cp, tc
mch vv...
4.2. Th phi hp
- Hp hai l phi hp h van hai l: phi phn bit h hai l l chnh, hp l ph hay
ngc li.Nu h van hai l l ch yu: nghe TTT mnh mm tim ting thi to, lan
xa, s c rung miu tm thu. Rung tm trng nh, X quang, siu m, in tim c
dy gin tm tht tri v nh tri. Ch yu siu m tim nh gi c mc h hai
l c bit l vi siu m Doppler.
- Phi hp vi bnh van ng mch ch.
+ Hp van hai l phi hp h ng mch ch: ngoi hp van hai l cn nghe ting
thi tm trng lin sn III bn tri v lin sn II bn phi lan xung dc b c
tri, in tim c dy tht tri, siu m doppler tim cho php chn an.
+ Hp hai l kt hp hp ng mch ch: ngoi triu chng hp van hai l cn nghe
thm ting thi tm thu lin sn III bn phi v lin sn II bn phi lan ln 2 bn
ng mch cnh km s rung mu.
Chn on in tim c dy tht tri tm thu, X quang v siu m tim cho php chn
on.
- Hp van hai l kt hp bnh van 3 l:
+ Hp hai l kt hp h 3 l: nghe TTT trong mm tim hoc ngay mi c. ting
TTT mnh ln khi ht vo su v nn th, c th s gan to v p theo nhp p ca
tim. Tnh mch c p. Phi thng sng hn.
+ Hp van hai l kt thng lin nh: Hp hai l kt hp thng lin nh gi l hi chng
Lutembacher. Chn on xc nh nh siu m tim v thng tim.
Hp van hai l c th cn phi hp vi cc bnh l tim mch khc nh tng huyt p
nhng him gp
5. Chn on bin chng
Hp van hai l thng c cc bin chng sau.
5.1. Ri lon nhp tim
- Ri lon nhp xoang thng l nhp nhanh. Ngoi tm thu nh, cn nhanh trn tht.

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- Cung nh v rung nh l nhng bin chng nng n ca HHL. T nhng ri lon
nhp tim nay c th gy ra bin chng tc mch ngoi vi v cng lu s dn n suy
tim phi.
5.2. Tc mch: C 2 c ch tc mch:
- Tc mch vng i tun hon: Do mu nh tri chm lu chuyn
xung tht tri nn mu d ng. Nu cc ri lon nhp nhanh nh rung nh, nhp
nhanh trn tht to iu kin thun li hnh thnh cc mu ng. Sau khi nhp tim
chm li cc mu c a xung tht tri v vo i tun hon gy tc mch no,
chi, thn, mc treo vv...
- Tc ng mch phi: Do cc mu ng c hnh thnh t cc tnh mch
ngoi bin, vo tht phi gy tc ng mch phi. Hoc c th do p lc phi tng
trong hp hai l nn c th hnh thnh cc mu ng ti ch gy tc ng mch
phi.
5.3. Nhim trng
- Nhim trng ti phi do mu ng mch phi l mi trng pht trin cho
vi trng: C th vim phi lan ta, vim phi khu tr.
- Nhim trng ti tim c th gy ra vim ni tm mc bn cp Osler. Bin
chng ny him gp nhng khi xy ra th tin lng xu v iu tr kh v c th tht
bi.
5.4. Suy tim
- C th c cn hen tim ph phi cp hay gp khi gng sc hoc ban m. Do mu
ng trong phi nhiu ban m thn kinh ph giao cm hot ng mnh nn lm
dn mch, thot huyt tng vo ph nang gy ph phi.
- Suy tim phi. y cng l bin chng ng thi cng l giai on cui cng
ca bnh. Nu khng c iu tr trit . Cc bin chng trn c th xy ra khi
bnh nhn gng sc v tinh thn, th cht v nhn mt nhim trng da, phi.
c bit ph n c thai, lc chuyn d hay thi k kinh nguyt.

VI. IU TR
1. iu tr ni khoa
Ch c tc dng tt khi hp van hai l mc nh v trung bnh. Nu hp kht, vi
din tch l van <1.5 cm2 th iu tr ngoi khoa mi c tc dng.
1.1. iu tr suy tim
1.1.1. Ch sinh hot n ung
Hn ch lao ng nng, n lt, iu tr phng thp ti pht, phng nga Osler.
1.1.2. Li tiu
Khi c th tng khong 2 kg so vi trc.
Furosemid 40 mg x 1-2 vin/ngy.
Trong cn suy tim cp c th dng Lasix 20 mg tim tnh mch chm. Ch khi
dng li tiu cn dng thm kali (nn cho loi mui K+ hu c tt hn v c, nh
K+, Mg++ aspartate bit dc Panangin) phng h kali mu, d ng c Digital.
1.1.3. Digital
t c tc dng trong suy tim do hp hai l, ngay c khi c suy tim phi. Digital c tc
dng tt trong suy tim do hp hai l c bin chng rung nh ngn nga cc cn
rung nh c nhp tht nhanh, lm nng thm tnh trng suy tim, c th dng liu ngm
chm. Digital 0,25 mg x 1 vin/ ngy trong 5 ngy, ngh 2 ngy ri dng li. Hoc
Digital 0,25 mg x 1 vin / ngy trong 3 ngy, ngh 3 ngy ri dng li.

11
Khi iu tr Digital cn lu du chng ng c Digital nh:
- Bnh nhn nn ma, au bng, m mt, nhn i, i cu phn lng.
- Ngoi tm thu tht nhp i hay c tnh.
- Hoc nhp tim tng vt ln (trong khi ang dng Digital) hoc chm li vi Blc nh
tht cc cp, hoc nhp b ni.
- Nu xut hin cc triu chng trn nn ngng Digital v cho tng cng thm Kali
bng ng tnh mch hoc ng ung, ch b sung thm Mg++.
1.1.4. Cc thuc gin mch
- c s dng nhiu trong nhng nm gn y. Thuc gin mch c th iu tr
lin tc, ko di. Thuc gin mch c tc dng gim tin gnh, hu gnh gip cho
suy tim hi phc tt.
- i vi suy tim trong hp hai l tt nht l nhm Nitrat v dn xut nht l khi hp
hai l c tng p lc ng mch phi, ph phi mn tnh v cp tnh. Risordan LP 20
mg x 1-2 vin / ngy, hoc Imdur (mononitrate Isosorbid) 60 mg x 1/2 - 1 vin / ngy.
1.2. iu tr phng tc ng mch h thng
- Tc mch c th: ng mch no, ng mch mc treo, ng mch ngoi v, ng
mch lch, ng mch thn, ng mch vnh.....
- Bin chng tc mch gia tng bnh nhn hp van hai l c bin chng rung nh
v suy tim, c bit khi mi xut hin rung nh.
- hp van hai l c bin chng tc mch nhiu hn h van hai l. 20-60% tc li ln
th hai sau tc ln th nht trong 6-12 thng nu khng c d phng hu hiu
bng cc thuc chng ng.
- iu tr tc mch cng sm cng tt:
+ Heparin 10.000 - 20.000 UI / ngy x 5 - 10 ngy. C th dng Heparin c trng
lng phn t thp c bit i vi tc mch no. Sau dng cc thuc khng
ng loi khng Vitamin K nh Sintrom, Previscan, Dicoumarin gi u 48-72 gi
trc khi ngng Heparin duy tr t Prothrombin cn khong 30-35% hoc IRN 2,5-3
l tt nht.
+ Sau khi chuyn rung nh v nhp xoang bng thuc hoc sc in, nong van hai l
l phng php d phng tc mch ti pht tt nht. Hoc nhng bnh nhn
khng c iu kin nong van, phu thut s van, thay van c th ung thuc d
phng tc mch ko di nhiu nm liu thp 100 - 500 mg / ngy bng Aspirin
(aspegic 100mg), dipiridamole vv...
1.3. iu tr d phng
- Phng thp ti pht bng Benzathylpenixilin 1,2 triu n v mi 15-20 ngy, tim
bp su sau khi th test.
- Ngoi ra phng bi nhim phi hoc Osler bng khng sinh Penixilin nhanh
hoc Erythromycin 0,5g trc cc can thip nh nh rng, x nht ngoi da vv... Khi
c du hiu vim tnh mch chi di c th phng tc ng mch phi bng cch t
li lc tnh mch ch di.
2. iu tr ngoi khoa
iu tr phu thut van hai l c nhiu tin b. Nong van hai l bng tay hoc
bng dng c hoc bng bng (catheter baloon).
2.1. Nong van hai l bng bng
a ng thng qua ng tnh mch i i vo nh phi, xuyn qua vch lin nh
vo nh tri nong van 2 l bng bng. K thut ny c thc hin ti Vit

12
Nam. Phng php ny c ch nh cho bnh nhn tr tui <40, hp van hai l
n thun, van cn mm mi, t chc di van cha h bin nhiu, khng c cc
mu ng nh tri hoc tiu nh. Bin chng ca phng php ny l chc thng
thnh tm nh tri gy ra trn mu mng ngoi tim cp, gy chn p tim cp.
2.2. Nong van hai l kn (close mitral commissurotomy)
- Bng tay hoc dng c: thc hin nhng bnh nhn: c din tch l van hai l
hp <1.5 cm2, van cn mm hoc x ho, cha c vi ho nhp xoang hay rung nh,
nhng khng c tin s tc mch, khng c bnh van ng mch ch, hoc h van
hai l (nu h van hai l nh <2/4 th khng chng ch nh), tui < 40, khng b bi
nhim phi hoc thp tim ang tin trin, khng b Osler.
- Kt qu sau nong c 5-10% trng hp ht triu chng hp van hai l, triu chng
tng p lc ng mch phi gim dn v tr v bnh thng. Mt s bnh nhn
nong van hai l khng kt qu hoc thp tim ti pht gy dnh li cc mp van phi
nong li ln 2 nhng kt qu thnh cng thp hn v t l t vong cao hn 10 ln lc
ban u.
- Bin chng khi nong van v sau khi nong
+ Suy tim v ri lon nhp sau phu thut
+ St
+ Hi chng sau nong van
+ Trn dch mng ngoi tim
+ Tc ng mch no thong qua.
+ H van hai l sau khi nong thng gp nhng bnh nhn b vi ho van h bin
nhiu t chc di van.
+ Ngng tim khi ang nong
+ Hen tim, ph phi cp
+ Lon nhp tim (ngoi tm thu tht, nh, rung cung nh, nhp nhanh kch pht trn
tht v tht, rung nht)
+ Osler gy t dy chng, sa van hai l
2.3. M tim h
Cn c tim phi nhn to
- Sa van hai l: phu thut vin c th m rng hoc thu hp vng van hai l, ct
b phn b si lot, vi ho hoc ly cc mu ng nh, tht, v cc l thng trn
mt l van khu ni cc tr c v dy chng b t. Bnh nhn khng phi thay van
nn gim c nguy c min dch thi ghp, gim nguy c vi ho, tc mch nn
vic chng ng n gin hn thay van, gim nguy c vi ho, tc mch nn liu
php chng ng n gin hn.
- Phu thut thay van: c ch nh trong cc trng hp
+ hp van hai l t chc van x dy vi ho nng
+ Hp kt hp h van hai l nng hay h van hai l n thun.
+ Si lot van do Osder
- Cc loi van thng dng thay van hai l
+ Van Starr-Edwards: c lng gi qu bng bi, khi tht bng bi chuyn ng ln pha
nh ng van nh tht.
+ Van SCDT-Custer l dng van Starr ci tin.
+ Van Magovevu-cromt l van Starr ci tin

13
+ Van Kuy-Suzuki thay bng bi bng a phng, c nhiu u im v huyt ng
hn dng van bi, khi phu thut thay van t l t vong thp hn, gim qu trnh to
cc mu ng van v quanh van, l van nhn to mi nht c ci tin t van
Starr. Vi hnh dng v cht liu khc nhau nh Titanium, Teflon, Pyrolytic-carbon,
Silastic, Polyproline.... to c nhiu loi van khc nhau:
+ Cuged-ball
+ Starr-Edwards: 7 loi. Smeloff-custer: 2 loi: Braald-custer, Cuged-disc
+ Beall c 5 loi: Kay-Shiley, Kay Suzuki, Starr-Edwards, Cooley-Cutter, Tilting disc.
+ Bjork-Shiley c 3 loi
+ Lalehei-kaster: 4 loi
Tng cng c 27 loi van nhn to
- Van hai l sinh hc: Phc hi mt cch c bn huyt ng, khng b nhim khun,
khng to cc mu ng, khng b thng t vng van sau thi gian di phu thut,
v vy n m ra trin vng pht trin sau ny.
2.4. Bin chng sau khi thay van
Ngoi cc bin chng nh nong van cn c thm cc bin chng.
- t t trong khi phu thut
- t t do hot ng ca van b ri lon.
- Dnh kt Fibrin, sau vi ho ti van v quanh van mn.
- Osler do vi khun v nm.
- Abces quanh vng van.
- H quanh vng van hai l.
- Block nh tht cp cao hoc bloc b His (do ct cc tr c)
- Hp hoc h MC th pht sau thay van hai l
- Gim kh nng b p tun hon khi gng sc.
- Kh iu tr bng phng php sc in, to nhp khi cn thit.
iu tr nong van hai l hay phu thut tim kn hay h cn tip tc iu tr phng
thp, phng Osler, iu tr chng ng, suy tim th mi ko di cuc sng ca bnh
nhn.

14

TNG HUYT P
Mc tiu
1. Nm vng kin thc c bn v tng huyt p, mt bnh tim mch ph bin hin
nay.
2. Nm vng phn loi, cc bin chng ca tng huyt p cng nh cc c ch
sinh bnh tng huyt p
3. Nm vng cc nhm thuc v tc dng dc l, ch nh v tc dng ph trong
iu tr tng huyt p.
4. Vn dng c phc iu tr tng huyt p trong thc tin lm sng
Ni dung

I. I CNG
1. Dch t hc
Tng huyt p (THA) l triu chng ca nhiu bnh, nhiu nguyn nhn
nhng c th l mt bnh, bnh tng huyt p, nu khng tm thy nguyn nhn.
cc nc Chu u - Bc M t l tng huyt p trong nhn dn chim 15 - 20%
ngi ln. C th nh sau: Benin 14%- Thi lan: 6.8%- Zaire:14%- Chile: 19-21%,
Portugaise: 30%, Hoa k: 6-8%. Nhn chung t l rt thay i. Vit Nam, t l tng
huyt p chung l 11,8% (B Y T Vit Nam, 1989). T l ny gia tng ng quan
tm v trc 1975 t l ny min Bc Vit nam ch c 1-3%(ng Vn Chung). Ti
BVTW Hu nm 1980 t l THA trong s cc bnh ni khoa ch c 1% nhng 10 nm
sau, nm 1990, tng n 10%. Thng k gn y nht ca Vin Tim Mch ti
Min Bc Vit Nam cho thy t l THA l 16,3% (2002).
2. nh ngha
T chc Tng huyt p Th gii (TCYTTG) v U ban Quc gia Cng lc Hoa
k (1997) u thng nht mt ngi ln b tng huyt p khi huyt p tm thu trn
hoc bng 140mmHg v hoc huyt p tm trng trn hoc bng 90mmHg.
nh ngha ny n gin nhng c nhc im l tr s huyt p khng hon ton
n nh v huyt p thay i theo tui, gii...

II. BNH NGUYN V C CH SINH BNH

1. Bnh nguyn
1.1.Tng huyt p nguyn pht: chim gn 90% trng hp b tng huyt p (theo
Gifford - Weiss).
1.2. Tng huyt p th pht
- Bnh thn: Vim cu thn cp, vim cu thn mn hai bn do mc phi thn
a nng, nc b thn, u thn lm tit rnin, hp ng mch thn...
- Ni tit
+ Bnh v tuyn thng thn, hi chng Cushing, hi chng Conn, u sn
xut qu tha cc Corticosteroid khc (Corticosterone, desoxycortisone), sai lc
trong sinh tng hp Corticosteroid.
+Bnh ty thng thn, u ty thng thn (Pheochromocytome).
- Bnh tim mch: Bnh hp eo ng mch ch, vim hp ng mch ch
bng cho xut pht ng mch thn, h van ng mch ch.
-Thuc: Cc Hormone nga thai, cam tho, carbenoxolone, A.C.T.H.
Corticoides, Cyclosporine, cc cht gy chn n, cc IMAO, cht chng trm cm
vng...

15
- Nhim c thai nghn.
- Cc nguyn nhn khc: Bnh cng gip, bnh Beri-beri. Bnh Paget
xng, bnh a hng cu, hi chng carcinoid, toan h hp, tng p s no...
2. Mt s yu t lm d (thun li): c xem nh c lin quan n tng huyt p
nguyn pht tuy vn cn bn ci l
- Yu t di truyn, bnh tng huyt p c tnh gia nh.
- Yu t n ung, n nhiu mui, n t protit, ung nhiu ru, ung nc
mm t Ca++, Mg++, K+. Trong ni bt v c tha nhn l s lin quan gia ion
Na+ v tn sut bnh tng huyt p. Ion Na+ lm tng huyt p qua trung gian gia
tng th tch mu v nht l qua s co tht mch mu.
- Yu t tm l x hi, c tnh trng cng thng (stress) thng xuyn.
3. C ch sinh bnh ca tng huyt p nguyn pht
Tng huyt p ng mch thng km theo nhng bin i v sinh l bnh
lin quan n h thn kinh giao cm, thn, renin-angiotensin v cc c ch huyt
ng, dch th khc (Phm Khu -1982).
3. 1.Bin i v huyt ng
- Tn s tim tng, lu lng tim tng dn, thi k u c hin tng co mch
phn b li mu lu thng t ngoi vi v tim phi do sc cn mch mu cng
tng dn. Tim c nhng biu hin tng hot ng b tr v dn n dy tht tri.
Huyt p v sc cn ngoi bin ton b tng dn. Lu lng tim v lu lng tm
thu cng gim, cui cng a n suy tim.
- Trong cc bin i v huyt ng, h thng ng mch thng b tn
thng sm c ton b. Trc kia ngi ta ngh ch c cc tiu ng mch b bin
i co mch lm gia tng sc cn ngoi bin. Hin nay, ngi ta thy cc mch mu
ln cng c vai tr v huyt ng hc trong tng huyt p. Chc nng t c bit
n ca cc ng mch ln l lm gim i cc xung ng v lu lng mu do tim
bp ra. Do thng s v dn ng mch (compliance artrielle) biu th tt kh
nng ca cc ng mch. S gim thng s ny cho thy cng ca cc ng
mch ln, l din bin ca tng huyt p ln cc ng mch v v lu di s lm
tng cng tim dn n ph i tht tri. ng thi vic gia tng nhp p
(hyperpulsatilit) ng mch a n s h hng cc cu trc n hi sinh hc
(bioelastomeres) ca vch ng mch.
- Ti thn, tng sc cn mch thn, gim lu lng mu ti thn chc nng
thn suy gim tuy trong thi gian u tc lc cu thn v hot ng chung ca
thn vn cn duy tr.
- Ti no, lu lng vn gi c thng bng trong mt gii hn nht nh
thi k c tng huyt p r.
- Khi huyt p tng, sc cn ngoi bin tng th tch huyt tng c xu
hng gim cho n khi thn suy th tch dch trong mu tng c th tng a n
ph.
3.2. Bin i v thn kinh:
thi k u nh hng ca h giao cm biu hin s tng tn s tim v
s tng lu lng tim. S hot ng ca h thn kinh giao cm cn biu hin
lng Catecholamine trong huyt tng v dch no ty nh adrenaline, noadrenaline, tuy vy nng cc cht ny cng rt thay i trong bnh tng huyt p.
- H thn kinh t ng giao cm c iu khin bi h thn kinh trung ng
hnh no-ty sng v c hai h ny lin h nhau qua trung gian cc th cm p lc.

16
Trong tng huyt p cc th cm p lc c iu chnh n mc cao nht v vi
ngng nhy cm cao nht.
3.3. Bin i v dch th
- H Renin-Angiotensine Aldosterone (RAA): Hin nay c chng minh
c vai tr quan trng do ngoi tc dng ngoi vi cn c tc dng trung ung no
gy tng huyt p qua cc th th angiotensine II (UNGER-1981, M. PINT, 1982).
C tc gi chia tng huyt p nguyn pht da vo nng renine cao, thp trong
huyt tng, c s t l nghch gia nng renine-angiotensine II trong huyt
tng v tui.
- Angiotensine II c tng hp t angiotesinegne gan v di tc dng
renine s to thnh angiotesine I ri chuyn thnh angiotesine II l mt cht co mch
rt mnh v lm tng tit aldosterone. S phng thch renine c iu khin qua
ba yu t: -p lc ti mu thn - lng Na+ n t ng ln xa v h thn kinh
giao cm. S thm d h R.A.A, da vo s nh lng renine trc tip huyt tng
hay gin tip phn ng min dch v angiotensine II, nhng tt nht l qua tc dng
ca cc c ch men chuyn.
- Vasopressin (ADH): c vai tr kh r rng trong c ch sinh bnh tng huyt
p c tc dng trung ng gim huyt p (qua trung gian s tng tnh nhy cm
thn kinh trung ng i vi phn x p t xoang ng mch cnh v quai ng
mch ch) tc dng ngoi vi co mch (trc tip v qua hot ha cc si Adrenergic)
(J.F. Liard, 1982. B.Bohns,1982).
- Cht Prostaglandin: tc dng trung ng lm tng huyt p, tc dng ngoi
vi lm gim huyt p (F.H. UNGER, 1981; MA Petty, 1982).
- Ngoi ra cn c vai tr ca h Kalli-Krein Kinin (K.K.K) trong bnh tng huyt
p v mt s h c vai tr cha r nh: h Angiotensine trong no v cc
encephaline, h cng dopamine bin i hot ng th cm p lc. Mt c ch
iu ha lin quan n cc th th Imidazolique trung ng v ngoi bin c
ghi nhn t nhng nm 80 vi s xut hin thuc huyt p tc dng ln th cm
Imidazole gy dn mch.
3.4.C ch sinh bnh ca tng huyt p th pht:
Ty vo nguyn nhn gy bnh.

III. TRIU CHNG HC

1. C nng
a s bnh nhn tng huyt p khng c triu chng g cho n khi pht hin
bnh. au u vng chm l triu chng thng gp. Cc triu chng khc c th
gp l xong, hi hp, mt, kh th, m mt... Khng c hiu. Mt s triu chng
khc ca tng huyt p ty vo nguyn nhn tng huyt p hoc bin chng tng
huyt p.
2.Triu chng thc th
2.1. o huyt p: l ng tc quan trng, cn bo m mt s quy nh.
- Bng cun tay phi ph c 2/3 chiu di cnh tay, b di bng qun
trn khuu tay 2cm. Nu dng my o thy ngn nu dng loi l xo phi iu chnh
6 thng 1 ln.
- Khi o cn bt mch trc. Nn bm n khong 30mmHg trn mc p lc
lm mt mch (thng trn 200mmHg) x xp nhanh ghi p lc khi mch ti xut
hin, x xp ht. t ng nghe ln ng mch cnh tay, bm nhanh bao hi n
mc 30mmHg trn p lc ghi, x chm t t vi tc 2mmHg trong 1 giy (hay

17
mi nhp p). Huyt p tm trng nn chn lc mt mch (pha V Korottkoff). tr
em v v ph n c thai nn chn pha IV Korottkoff.
- Nu o li ln 2 cn ch 30 giy. Nu lon nhp tim phi o li ln 3 v ly
trung bnh cng ca cc tr s.
- Phi o huyt p nhiu ln, trong 5 ngy lin. o huyt p c chi trn v chi
di, c t th nm v ng. Thng thng chn huyt p tay tri lm chun.
2.2. Du hiu lm sng
- Bnh nhn c th bo ph, mt trn trong hi chng Cushing, c chi trn
pht trin hn c chi di trong bnh hp eo ng mch ch. Tm cc biu hin x
va ng mch trn da (u vng, u m, cung gic mc..).
- Khm tim mch c th pht hin sm dy tht tri hay du suy tim tri, cc
ng mch gian sn p trong hp eo ng mch ch. S v nghe ng mch
pht hin cc trng hp nghn hay tc ng mch cnh trong ng mch ch
bng...
- Cn lu hin tng (huyt p gi) gp nhng ngi gi i ng, suy
thn do s x cng vch ng mch lm cho tr s huyt p o c cao hn tr s
huyt p ni mch. C th loi tr bng cch dng th thut Osler hay chnh xc
nht l o huyt p trc tip. Mt hin tng khc cng ang c c gng loi tr
l hiu qu o chong trng bng cch s dng phng php o lin tc huyt p
(Holter tensionnel).
- Khm bng c th pht hin ting thi tm thu hai bn rn trong hp ng
mch thn, phng ng mch ch hoc khm pht hin thn to, thn a nang.
- Khm thn kinh c th pht hin cc tai bin mch no c hoc nh.
3. Cn lm sng: Cn n gin, mc ch nh gi nguy c tim mch, tn
thng thn v tm nguyn nhn.
3.1. Billan ti thiu (theo T chc Y t th gii)
Mu: Kali mu, Cratinine mu, Cholestrol mu, ng mu, Hmatocrite,
Acide Uric mu. Nc tiu: Hng cu, Protein.
Nu c iu kin nn lm thm, soi y mt, in tim, X quang tim, siu m...
3.2. Cc xt nghim hay trc nghim c bit
i vi tng huyt p th pht hay tng huyt p kh xc nh.V d: Bnh
mch thn:cn chp U,I,V nhanh, thn , trc nghim Saralasin. U ty thng thn
(Pheochromocytome): nh lng Catecholamine nc tiu trong 24 gi, trc
nghim Rgitine.

IV. CHN ON
1.Chn on xc nh: Cn phi chn on sm v ng n bnh THA. Ch yu
bng cch o huyt p theo ng cc quy nh nu trn. Tuy nhin iu quan
trng l nn t chc nhng t khm sc khe khm xt ton din nhm pht
hin sm nhng trng hp tim tng hoc cha c triu chng.
2.Chn on giai on tng huyt p: c hai cch phn giai on, trong phn giai
on ca TCYTTG chi tit v thch hp hn.
2.1.Theo T.C.Y.T.T.G (1996) chia lm 3 giai on.
- Giai on I: Tng HA tht s nhng khng c tn thng thc th cc c quan.
- Giai on II: C t nht mt trong cc bin i cc c quan sau:
+ Dy tht tri: Pht hin bng lm sng, X quang, in tim, siu m.

18
+ Hp lan ta hay tng vng cc ng mch vng mc (giai on I v II y mt ca
Keith-Wagener-Baker).
+ Thn:Anbumine niu vi th, Protein niu, ur hoc cratinine mu tng nh.(1.2-2 mg%)
+ C hnh nh mng va x ng mch trn siu m hoc X quang ( ng mch
ch, ng mch cnh, ng mch chu hoc ng mch i)
- Giai on III: C du hiu chc nng v thc th do tn thng cc c quan
ch:
+ Tim: suy tim tri, cn au tht ngc, nhi mu c tim.
+ No: tai bin mch no thong qua, xut huyt no, tiu no hoc thn no. Bnh
no THA. Lon thn do mch no (vascular dementia)
+ y mt: xut huyt vng mc xut tit c hay khng c ph gai th (giai on III
v IV) cc du hiu ny l c bit ca giai on c tnh (giai on tin trin nhanh).
Cc biu hin khc thng gp giai on III nhng khng c hiu lm ca
tng huyt p.
+ Thn: creatinine huyt tng tng r (> 2mg%), suy thn.
+ Mch mu: phng tch, bt tc ng mch, tc ng mch ngoi bin c triu
chng r.
Tng HA c tnh hay tin trin nhanh l mt hi chng gm c:
- Huyt p ti thiu rt cao trn 130mmHg.
- y mt giai on III v IV theo Keith-Weigener.
- C bin chng thn, tim, no.
- Bnh nhn tr tui di 40.
- Tin trin nhanh, t vong trong vng 2-3 nm.
2.2. Xp loi THA theo T chc Y t th gii v Hi THA th gii (2003)
Xp loi

HA tm thu
(mmHg)

HA tm trng
(mmHg)

Ti u
Bnh thng
Bnh thng cao

< 120
< 130
130-139

< 80
< 85
85-89

THA nh (giai on 1)

140-159

90-99

THA va (giai on 1)

160-179

100-109

THA nng (giai on 2)

180

110

3. Phn loi tng huyt p

3.1- Theo tnh cht:
- Tng huyt p thng xuyn:nh tng huyt p lnh tnh v tng huyt p
c tnh.
- Tng huyt p giao ng, huyt p c lc cao, c lc bnh thng.
3.2- Theo nguyn nhn: Gm
- Tng huyt p nguyn pht (v cn).
- Tng huyt p th pht.

19
V- TIN TRIN V BIN CHNG
1. Tim: Suy tim v bnh mch vnh l hai bin chng chnh v nguyn nhn gy t
vong cao nht i vi tng huyt p. Dy tht tri l bin chng sm do dy c tim
tri. i ph sc cn ngoi bin nn gia tng sc co bp lm cng tim tng ln v
vch c tim dy ra. Dn dn suy tim tri v vi kh th khi gng sc, hen tim hoc
ph phi cp sau chuyn sang suy tim ton b vi ph, gan to, tnh mch c ni.
Xquang v in tim c du dy tht phi.
Suy mch vnh biu hin bng cc cn au tht ngc in hnh hay ch c
lon nhp. in tim c ST chnh xung di ng thng in cc chuyn o tim
tri, r hn chuyn o Pescador khi bin chng nhi mu s xut hin sng Q
hoi t.
2. No: tai bin mch no, thng gp nh nhn no, xut huyt no, tai bin mch
no thong qua vi cc triu chng thn kinh khu tr ch ko di, khng qu 24gi
hoc bnh no do tng huyt p vi l ln, hn m km theo co git, nn ma, nhc
u d di.
3. Thn
- Va x ng mch thn sm v nhanh.
- X thn gy tnh trng suy thn dn dn.
- Hoi t dng t huyt tiu ng mch thn gy THA c tnh.
- giai on cui thiu mu cc b nng thn s dn n nng Renin
v angiotensine II trong mu gy cng aldosterone th pht.
4. Mch mu
- Tng huyt p l yu t sinh va x ng mch, to iu kin cho s hnh
thnh va x ng mch.
- Phng ng mch ch, bc tch. Him gp nhng bnh cnh rt nng n d
a n t vong.
5. Mt: khm y mt rt quan trng v l du hiu tt tin lng.
Theo Keith- Wagener-Barker c 4 giai on tn thng y mt.
- Giai on 1: tiu ng mch cng v bng.
- Giai on 2: tiu ng mch hp c du bt cho (du Gunn).
- Giai on 3: xut huyt v xut tit vng mc.
- Giai on 4: ph lan ta gai th.

VI. IU TR
1. Nguyn tc
1.1. Mc tiu
- a huyt p tr v tr s sinh l n nh.
- Ngn nga cc bin chng.
- Ci thin cc bin i bt thng cc ng mch ln.
Do phi gii quyt 3 vn :
+ iu tr nguyn nhn tng huyt p; Ct b u ty thng thn, ct b thn teo,
thng ng mch b tc...
+ iu tr triu chng tng huyt p: Bng phng php ni khoa khng dng hoc
dng thuc hoc phu thut (v d ct b mt s dy thn kinh giao cm).

20
+ iu tr bin chng ca tng huyt p: Mc tiu chung ca iu tr l nhm a
huyt p v tr s bnh thng hay di tr s 140/90mmHg. Tn trng huyt p sinh
l ngi gi.
1.2. Nguyn tc chung: Cn lin tc, n gin, kinh t v c theo di cht ch.
2. Phng php iu tr
2.1. Tit thc v sinh hot
Hn ch mui di 5gNaCl mi ngy, hn ch m, cc cht bo ng vt,
king ru, thuc l, ch c. Trnh lao ng tr c cng thng, lo lng qu , nn
tp th dc nh, i b th gin, bi li.
2.2.Thuc
Cn nm vng c ch tc dng, tc dng phi hp cc loi thuc iu tr tng
huyt p v cc tc dng ph khi s dng trc mt v lu di. C 3 nhm thuc
chnh:
- Li tiu
+ Thiazide v dn xut
c ch ti hp th Na+ v Cl- trong ng ln xa nh Hydrochlorothiazide
(Hypothiazide)... vin 25mg ngy ung 2 vin. Chlorthiazide vin 500mg ung 2 vin/
ngy l nhng loi c dng rng ri trong tng huyt p. Ngoi ra cn c
Chlorthalidone (Hygroton) vin 50mg-100mg x 1ln/ngy v Metolazone (Diulo)
2,5mg-5mg x 4ln/ngy hay mi 2 ngy/ln v tc dng ko di.
Tc dng ph thiazide: Tng acid uric, tng cng mu, gim Kali mu, li tiu
Thiazides t tc dng khi tc lc cu thn di 25ml/pht, lm tng LDL
cholesterol v gim HLD cholesterol.
+ Li tiu quai Henl
Cng lm h Kali mu, nhng khc nhm thiazide l tc dng nhanh v ngn, ph
thuc liu.Thng dng l Furosemide (Lasix) vin 40mg x 1-2vin/ngy c ch nh
khi suy thn nng, cn tng huyt p cp tnh nhng v lu di tc dng khng hn
nhm Hypothiazide. Cc loi khc trong nhm cn c Edecrine (Acide ethacrynique),
Burinex (Butnamide). Tc dng ph tng t Thiazide nhng liu cao c c tnh
ln tai.
+ Li tiu xa gc Gi Kali, gm c 2 nhm nh:
- Nhm khng Aldosterone nh Spironolactone (Aldactone)vin 25-50mg x
4ln/ngy. Canrnone (Phanurane) c hiu lc i vi nhng trng hp cng
Aldostrone, thng dng phi hp thiazide.
- Nhm th 2 l nhm c tc dng trc tip nh Amiloride (Modamide), Triamterene
(Teriam) loi ny thng phi phi hp vi cc nhm khc v tc dng thi Na yu.
Tc dng ph: v nam, bt lc ri lon kinh nguyt.
+ Li tiu phi hp
C th trnh c tnh trng gim Kali trong mu, loi ny phi hp mt loi
Aldosterone v mt loi thiazides nh Aldactazine, Moduretic, Ditriam..
- Loi chn giao cm
Tc dng c ch Renin, gim ng c tim, gim hot ng thn kinh giao cm trung
ng, c nhiu nhm. Chn lc tim, khng chn lc tim v loi c tc dng ging
giao cm ni ti hay khng c. Thng dng c propranolol (Avlocardyl, Inderal) l
loi khng chn lc, khng c tc dng giao cm ni ti (ASI) vin 40mg dng 16vin/ngy. Tc dng ph: Lm chm nhp tim, ri lon dn truyn nh tht, lm nng

21
suy tim, co tht ph qun, hen, hi chng Raynaud, h ng mu, ri lon tiu
ha, mt ng, d ng hoc tc dng di khi ngng iu tr (gy ra cn au tht ngc,
nhi mu c tim cp).
- Cc thuc c ch men chuyn
c ch s to thnh angiotensine II, ngoi ra cn c tc dng:
- Tng cng hot ng h Kali-Krine-Kinine ngn cn s phn hy bradykinine.
- Kch thch s tng hp Prostaglandine. Do sau cng a n dn mch.
Ch nh: Tng huyt p cc giai on, k c loi tng huyt p rnine cao v thp.
Tc dng ph: t c tc dng ph ngoi ri lon v thm n, nga, ho khan, lu khi
phi hp li tiu gi Kali, thuc chng vim, chng Steroid.
Chng ch nh: Khi tng huyt p c hp ng mch thn hai bn hoc ch c mt,
ph n c thai.
C 3 nhm chnh
- Captopril (Lopril, Captolane) vin 25-50mg liu 50mg/ngy.
- Enalapril (Renitec) vin 5-20mg, liu 20mg/ngy.
- Lisinopril (Prinivil, Zestril) vin 5-20mg, liu 20mg/ngy.
Hai nhm sau cng c tc dng ko di v khng c nhm Thiol t tc dng ph nn
c a thch hn.
- Thuc c ch Canxi
Ngn cn s i vo t bo ca ion Ca++. c ch lung Ca++ chm ca knh Ca++
ph thuc in th. Tc dng ny t l vi nng v hi quy khi c ion Calcium. C
hai ni tc dng.
- Trn mch mu: s gim lung Ca++ a n s dn c v lm dn mch. iu
ny lm gim sc cn ngoi bin v ci thin dn n cc mch mu ln.
- Trn tim: lm chm nhp tim cn bng t nhiu phn x nhp nhanh th pht v
gim s co bp c tim.
Cc tc dng ny ty vo loi c ch Ca++ c s dng. Loi 1-4 dihidropyridine c
tc dng chn lc mnh i vi mch mu, cn Verapamil v Diltiazem tc dng ln
c hai ni. Cc loi c ch Ca++ tc dng tt i vi tng huyt p renine thp
(ngi ln tui) c th:
+ Nhm 1-4 Dihydropyridine: Nifedipine (Adalate) vin nhng 10mg-20mg LP, liu 2
vin/ngy.
+ Diltiazem (Tildiem) 300mg LP, liu 1 vin/ngy.
+ Verapamil (Isoptine) 120-240 LP, liu 1-2 vin/ngy.
Tc dng ph chim 10-20% trng hp. Thng thng l nhc u, ph ngoi
bin, phng mt. Him hn l h huyt p th ng, mt, xong, ri lon tiu ha,
hi hp, pht ban, bun ng v bt lc. Cc loi Verapamil, Diltiazem c th gy ri
lan dn truyn nh tht, nhp chm. Khng c dng c ch Canxi khi c thai, i
vi Verapamil v Diltiazem khng dng khi c suy tim, blc nh tht nng nhng
cha t my to nhp.
- Thuc tc dng ln thn kinh trung ng
C nhiu loi nhng hin nay t dng do c nhiu tc dng ph d c hiu qu.
- Anphamethyldopa (Aldomel, Dopegyt): H huyt p do to ra anphamethylnoadrenaline lm hot ha cc c quan th cm giao cm no, do c
ch trng lc giao cm. Vin 250mg hoc 500mg, liu t 500mg n 1,5g trong 24

22
gi. c s dng khi c suy thn. Tc dng ph: h huyt p th ng, thiu mu
huyt tn, bt lc, suy gan.
- Reserpine vin 0,25mg liu 2-6 vin/ngy. Tc dng ph h huyt p th ng,
thiu mu huyt tn, bt lc, suy gan, hin nay t dng.
- Clonidine (Catapressan): Tc dng ln vng hnh ty cng trng lc giao cm
h huyt p. Vin 0,150mg liu 3-6 vin/ngy. Cn lu phi ngng thuc t t nu
khng s lm huyt p tng vt ln. Tc dng ph: Trm cm kh ming, to bn, ri
lon tnh dc.
- Cc thuc tc dng trung ng khc: Guanabenz, Guafacine, Tolonidine,
Hyperium.
- Thuc dn mch
- Prazosin (Minipres): Tc dng c ch cm th anpha sau tip hp nn c hiu lc
tt. Vin 1mg dng liu tng dn t 1-2 vin - 10 vin/ngy nu cn. Tc dng ph:
chng mt, ri lon tiu ha d kch ng, tiu kh, h huyt p th ng, nht l vi
liu u tin.
- Dihydralazine (Nepressol) vin 25mg, liu t 1-4 vin/ngy. c dng khi c suy
thn, c nhiu tc dng ph. Nhp tim nhanh, gi mui nc, hi chng gi luput ban
, vim a dy thn kinh ngoi bin khng dng khi c suy vnh, phng ng mch
ch bc tch, thng c ch nh trong tng huyt p c suy thn.
- Minoxidil (Loniten) tc dng rt mnh, ch dng khi tng huyt p khng cc loi
khc, suy thn mn; t dng hin nay.
3. iu tr c th
3.1. nh gi THA theo mc nguy c ca T chc y t Th Gii v Hi tng
huyt p Th Gii (ISH) nm 2003.
Theo cc bc sau:
* nh gi cc yu t nh hng n tin lng, bao gm:
+ Yu t nguy c ca bnh tim mch:
- Mc Huyt p tm thu v tm trng (1-3).
- Nam > 55tui.
- N > 65 tui.
- Ht thuc l.
- Cholesterol ton phn > 250mg%.
- Tiu ng.
- Tin s gia nh b bnh tim.
+ Yu t khc nh hng xu tin lng:
- HDL-C gim.
-LDL-C tng.
-Albumine niu vi th bnh nhn tiu ng.
-Ri lon dung np Glucose.
-Bo ph.
-Li sng tnh ti.
-Fibrinogene mu tng.
-Nhm kinh t x hi cao.
-Nhm dn tc nguy c cao.

23
- Vng a l nguy c cao.
+ Tn thng c quan ch: nh giai on II ca tng huyt p theo phn ca
t chc y t th gii trc y bao gm: c dy tht tri, tn thng y mt, c
prtin niu,...
+ Tnh trng lm sng i km: nh giai on III theo theo phn ca t chc y t
th gii trc y bao gm: suy tim tri, suy vnh, suy thn, suy tun hon no.
3.2. Phn loi nguy c gip tin lng bnh
Bng 1:
THA I

THA II

THA III

Khng c yu t nguy
c (YTNC)

Nguy c thp

Nguy c trung bnh

Nguy c cao

1-2 YTNC

Nguy c trung bnh.

Nguy c trung bnh

Nguy c rt cao

(3 YTNC hoc tn
thng c quan ch
hoc tiu ng.

Nguy c cao.

Nguy c cao

Nguy c rt cao

Bnh tim mch i km

Nguy c rt cao

Nguy c rt cao

Nguy c rt cao

i vi tng huyt p nguy c thp v trung bnh cn theo di thi gian ri nh gi

li huyt p v yu t nguy c, p dng cc bin php khng dng thuc. i vi
nhm nguy c cao v rt cao cn iu tr thuc ngay phi hp vi khng dng thuc.
* p dng phc iu tr theo c nhn. C th tm lc theo s di (trang
sau):
- Trong iu tr 2 loi thuc, loi th 2 c chn vn trong 4 nhm thuc bc 1.
Nu tht bi, sau khi cn nhc cc kh nng khng iu tr, liu lng cha
thch hp... th c th xt n vic phi hp thm loi th 3 nh loi dn mch hay
cc loi khng adrenergic trung ng
- Ch nh chn lc thuc theo phng php iu tr tng c nhn bnh nhn (ca
Hi ng quc gia v tng huyt p ca Hi Tim mch Hoa k JNC VI nm 1999).
+ Li tiu: Ngi gi, da en, ph n tin mn kinh, c ri lon nhu m thn.
+ Chn bta: Ngi tr, da trng, nam gii bnh nhn cng giao cm, hot tnh
renine cao, bnh mch vnh, bnh nhn b glaucom v au na u.
+ c ch men chuyn: Tng huyt p nng, khng iu tr, hot tnh renine cao,
suy tim hay suy thn, ri lon tnh dc, tng lipt mu, i ng, tng acide urc
mu.
+ c ch canxi: ngi gi, da en, bnh mch vnh, i ng. Bo ph tng huyt
p khng kim sot c bng chn bta th pht sau cng aldosterol nguyn
pht, bt lc, tng lipt mu v tng acide urc mu.
+ Khng adrenergique ngoi bin: Bnh nhn tr b trm ut, hen suyn, bnh phi
tt nghn, i ng tng lipit mu.

24
IU TR KHNG DNG THUC
- Gim cn nng.
- Hot ng th lc.
- iu chnh cc yu t nguy c.
IU TR DNG THUC
S dng mt trong cc loi thuc:
- Chn giao cm anpha hoc bta.
- L tiu.
- c ch canxi.
- c ch men chuyn, c ch angiotensine II

Tht bi

Hai loi thuc

Tht bi
-iu chnh liu lng
Ba loi thuc
hoc
Tht bi
- Th thay 1 loi thuc
trong 4 loi trn.
nh gi nguyn nhn, s chp hnh iu tr
* iu tr cn tng huyt p cp tnh
Cn phi dng loi h huyt p bng ng tnh mch nh:
- Nitroprussiate de Na (Nipride) chuyn tnh mch liu 0,5-2mg/pht (10mg/gi)
c chn dng trong hu ht cn tng huyt p. Tc dng ph: ng c
Thiocyanate.
- Nitroglycerine chuyn tnh mch dng bnh nhn c suy vnh cp khi khng
chng ch nh, liu 5 - 10mg/pht.
- Labetalol (Trandate) loi c ch c anpha v bta giao cm, dng tt nhng
bnh nhn nhi mu c tim cp, chuyn tnh mch 1-2mg/pht.
- Anpha Methyldopa hay clonidine chuyn tnh mch.
- Cc loi c ch men chuyn: Captopril 25mg ngm di li.
- Thng phi hp thm Lasix chch tnh mch.

VII. D PHNG
1. D phng cp I
i vi nhng ngi cha b tng huyt p cn lu vn sinh hot hng ngy
nht l cc thi quen c hi sc khe phi khm nh k pht hin tng huyt p

25
hay cc bnh lin quan. Trong i tng ny ch n nhng ngi c yu t nguy
c mc bnh cao cho d nhng ln u cha pht hin THA nhng cn trao i
tuyn truyn phi hp d phng cng nhn vin y t tuyn trc.
2.D phng cp II
i vi ngi tng huyt p, cn phi cht ch hn na trong ch n ung,
ngh ngi theo di huyt p u n v c k hoch iu tr ngoi tr theo di tin
trin, tc dng ph ca thuc. Cn ch yu t kinh t trong iu tr v y l mt
liu trnh lu di, tn km.

VIII. TIN LNG

Tin lng bnh nhn thng ph thuc vo:
- Tr s huyt p: Tr s huyt p cng cao th t l t vong cng ln.
- Cc bin chng: L yu t tin lng gn rt quan trng nht l khi c bin chng.
- V tin lng xa: Cholesterol mu c v tr quan trng v d a n x va ng
mch vnh, nhi mu c tim sau ny.
- Vn iu tr cng gi vai tr ng k, tin lng kh quan nu iu tr sm,
ng cch, c theo di lu di.

IX. KT LUN
Tng huyt p l mt bnh chn on xc nh d nhng vn cn phc tp v bnh
nguyn, c ch, vic iu tr c nhiu tin b nhng khng trnh khi nhng tc
dng ph ng k. Bnh nh hng ln n sc khe con ngi. V vy tng huyt
p l vn ln ang c nc ta v th gii quan tm. Trong iu tr tng huyt
p cn ch phi hp iu tr bnh nguyn v c bit l cc yu t nguy c.

26

SUY TIM
Mc tiu
1. Nu c cc nguyn nhn suy tim.
2. Trnh by c cc triu chng lm sng v cn lm sng.
3. Vn dng c trong chn on suy tim.
4. Hc thuc cc thuc s dng iu tr suy tim
5. Nm vng cc phc iu tr suy tim
Ni dung

I. I CNG
1. nh ngha: Suy tim l trng thi bnh l, trong c tim mt kh nng cung cp
mu theo nhu cu c th, lc u khi gng sc ri sau c khi ngh ngi.
Quan nim ny ng cho a s trng hp, nhng cha gii thch c nhng
trng hp suy tim c cung lng tim cao v c trong giai on u ca suy tim m
cung lng tim cn bnh thng.
2. Dch t hc: Ti chu u trn 500 triu dn, tn sut suy tim c lng t 0,4 2% ngha l c t 2 triu n 10 triu ngi suy tim. Ti Hoa K, con s c lng
l 2 triu ngi suy tim trong 400.000 ca mi mi nm. Tn sut chung l khong
1-3% dn s trn th gii v trn 5% nu tui trn 75. Ti nc ta cha c thng k
chnh xc, nhng nu da vo s dn 70 triu ngi th c n 280.000 - 4.000.000
ngi suy tim cn iu tr.

II. NGUYN NHN

1. Suy tim tri: Tng huyt p ng mch, h hay hp van ng mch ch n
thun hay phi hp, nhi mu c tim, vim c tim do nhim c, nhim trng, cc
bnh c tim, cn nhp nhanh kch pht trn tht, cn cung ng nh, rung nh
nhanh, cn nhp nhanh kch pht tht, blc nh tht hon ton, hp eo ng mch
ch, tim bm sinh, cn ng ng mch, thng lin tht.
2. Suy tim phi: Hp van 2 l l nguyn nhn thng gp nht, tip n l bnh phi
mn nh: Hen ph qun, vim ph qun mn, lao x phi, gin ph qun, nhi mu
phi gy tm ph cp. G vo ct sng, d dng lng ngc, bnh tim bm sinh nh
hp ng mch phi, t chng Fallot, thng lin nh, thng lin tht giai on mun,
vim ni tm mc nhim trng, tn thng van 3 l, ngoi ra mt s nguyn nhn t
gp nh u nhy nh tri. Trong trng hp trn dch mng ngoi tim v co tht mng
ngoi tim, triu chng lm sng ging suy tim phi nhng thc cht l suy tm
trng.
3. Suy tim ton b: ngoi 2 nguyn nhn trn dn n suy tim ton b, cn gp cc
nguyn nhn sau: bnh c tim gin, suy tim ton b do cng gip trng, thiu
Vitamine B1, thiu mu nng.

III. C CH BNH SINH

Chc nng huyt ng ca tim ph thuc vo 4 yu t: Tin gnh, hu gnh, sc co
bp c tim v nhp tim.
Sc co bp

Tin gnh

Cung lng tim

Hu gnh
Tn s tim

27

1. Tin gnh: l ko di ca cc si c tim sau tm trng, tin gnh ph thuc

vo lng mu dn v tht v c th hin bng th tch v p lc mu trong tm
tht th tm trng.
2. Hu gnh: hu gnh l sc cn m tim gp phi trong qu trnh co bp tng mu,
ng hng u l sc cn ngoi vi, hu gnh tng th tc cc si c tim gim; do
th tch tng mu trong th tm thu gim.
3. Sc co bp c tim: Sc co bp c tim lm tng th tch tng mu trong th tm
thu, sc co bp c tim chu nh hng ca thn kinh giao cm trong c tim v lng
catcholamine lu hnh trong mu.
4. Tn s tim: Tn s tim tng s tng cung lng tim, tn s tim chu nh hng
ca thn kinh giao cm trong tim v lng Catcholamine lu hnh trong mu. Suy
tun hon xy ra khi ri lon cc yu 1,2 v 4, suy tim xy ra khi thiu yu t 3.
Trong suy tim, cung lng tim gim, giai on u s c tc dng b tr
- Mu li tm tht lm cc si c tim b ko di ra, tm tht gin, sc tng mu
mnh hn nhng ng thi cng tng th tch cui tm trng.
- Dy tht do tng ng knh cc t bo, tng s lng ti lp th, tng s n
v co c mi nh du bt u s gim st chc nng co bp c tim. Khi cc c
ch b tr b vt qu, suy tim tr nn mt b v cc triu chng lm sng s
xut hin.

IV. CHN ON
1. Suy tim tri
1.1. Triu chng lm sng
- Triu chng c nng:
C 2 triu chng chnh: Kh th v ho. Kh th l triu chng thng gp nht. Lc
u kh th khi gng sc, v sau tng cn, c khi kh th t ngt, c khi kh th
tng dn; ho hay xy ra vo ban m khi bnh nhn gng sc, ho khan, c khi c
dm ln mu.
- Triu chng thc th:
- Khm tim: Nhn thy mm tim lch v pha bn tri, nghe c ting thi tm thu
nh mm do h van 2 l c nng.
- Khm phi: Nghe c ran m 2 y phi. Trong trng hp cn hen tim c th
nghe c nhiu ran rt, ran ngy.
- Huyt p: HATT bnh thng hay gim, HATTr bnh thng.
1.2. Cn lm sng
- X quang: Phim thng tim to, nht l cc bung tim tri, nh tri ln hn trong h 2
l, tht tri gin vi cung di tri phng v dy ra, phi m nht l vng rn phi.
- in tm : Tng gnh tm trng hay tm thu tht tri. Trc tri, dy tht tri.
- Siu m tim: Kch thc bung tht tri gin to, siu m cn cho bit c chc
nng tht tri v nguyn nhn ca suy tim tri nh h van ng mch ch...vv.
1.3. Thm d huyt ng: Nu c iu kin thng tim, chp mch nh gi chnh xc
mc nng nh ca mt s bnh van tim.
2. Suy tim phi
2.1. Lm sng
2.1.1. Triu chng c nng: kh th nhiu hay t ty theo mc suy tim, kh th

28
thng xuyn, nhng khng c cn kh th kch pht nh suy tim nh suy tim tri.
Xanh tm nhiu hay t ty nguyn nhn v mc ca suy tim phi.
2.1.2.. Du chng thc th: Ch yu l mu ngoi bin vi gan to, b t, mt
nhn, n au tc, iu tr tch cc bng tr tim v li tiu gan nh li, ht iu tr gan
to ra gi l gan n xp, nu gan b mu lu ngy gan khng nh li c gi l
x gan tim vi gan b sc, mt chc. Tnh mch c ni, phn hi gan tnh mch
c (+) t th 450. p lc tnh mch trung ng v tnh mch ngoi bin tng cao.
Ph: Ph mm lc u 2 chi di v sau ph ton thn, c th km theo c
trng, trn dch mng phi. Tiu t 200-300ml/ 24gi.
Khm tim: Ngoi cc du hiu ca nguyn nhn suy tim, ta cn nghe nhp tim
nhanh, c khi c ting nga phi phi, thi tm thu van 3 l do h van 3 l c
nng hu qu ca dn bung tht phi. Huyt p tm thu bnh thng, huyt p tm
trng tng.
2.2. Cn lm sng
- X quang: Tr trng hp suy tim phi do hp van ng mch phi c c im l
phi sng, cn li cc nguyn nhn suy tim phi khc trn phim thng phi m, cung
ng mch phi gin, mm tim hch ln do tht phi gin. Trn phim nghing tri
mt khong sng sau xng c.
- in tm : Trc phi, dy tht phi.
- Siu m tim: Tht phi gin to, tng p ng mch phi.
- Thm d huyt ng: Tng p lc cui tm trng tht phi, p lc ng mch ch
thng tng.
3. Suy tim ton b: Bnh cnh suy tim phi thng tri hn. Bnh nhn kh th
thng xuyn, ph ton thn, tnh mch c ni t nhin, p lc tnh mch tng cao,
gan to nhiu, thng c c trng, trn dch mng phi, huyt p tm thu gim,
huyt p tm trng tng, Xquang tim to ton b, in tm c th dy c 2 tht.

V. PHN SUY TIM

1. Theo Hi Tim Mch New York: Chia lm 4 : 1: Bnh nhn c bnh tim
nhng khng c triu chng c nng, hot ng th lc vn bnh thng. 2: Cc
triu chng c nng ch xut hin khi gng sc nhiu, hn ch hot ng th lc.
3: Cc triu chng c nng xut hin ngay c khi gng sc nh, lm hn ch hot
ng th lc. 4: Cc triu chng c nng xut hin thng xuyn k c khi bnh
nhn ngh ngi.
2. Phn suy tim mn theo Trn Trinh & V nh Hi
- Suy tim 1: Kh th khi gng sc, ho ra mu, khng ph, gan khng to.
- Suy tim 2: Kh th khi i li vi vn tc trung bnh, khi i phi ngng li
th, ph nh, gan cha to hoc to t, 2cm di b sn. Phn hi gan tnh mch
c (+) t th 450.
- Suy tim 3: Kh th nng hn hoc gim i, ph ton, gan > 3cm di sn,
mm, phn hi gan tnh mch c (+) t th 450, iu tr gan nh li hon ton.
- Suy tim 4: Kh th thng xuyn, bnh nhn phi ngi dy th, gan >
3cm di b sn, mt chc, b sc, iu tr khng p ng hoc nh li t.

VI. IU TR SUY TIM

1. Cc thuc iu tr suy tim.
1.1. Digitalis

29
c a vo s dng iu tr suy tim t lu, hin gi vn cn c s dng
rng ri. N c c tnh sau:
- Tng sc co bp c tim.
- Lm chm nhp tim.
- Lm gim dn truyn trong tim.
- Tng tnh kch thch c tht.
* Ch nh
Digital c ch nh r rng trong suy tim tr c rung nh. Tuy nhin nu l nhp
xoang th vai tr ca n vn cn b tranh ci. Ngoi ra ch nh khc ca n l trong
cc lon nhp trn tht nh rung nh, cung nh, nhp nhanh trn tht kch pht kiu
Bouveret.
* Chng ch nh
Tuyt i khi c nhim c digital.
Cc chng ch nh khc:
- Bloc nh tht 2 v 3 khng c my to nhp.
- Trng thi tht cng kch thch nng.
- Bnh c tim nghn.
- Thiu oxy.
- H kali mu.
Digital t c li v thm ch c th cn nguy him khi: nhi mu c tim cp (ngoi tr
nu c cn rung nh nhanh), suy tim nhp chm khng c my to nhp, suy tim giai
on cui, tm ph mn, vim mng ngoi tim co tht, suy tim c cung lng tim
cao, cc bnh tim do qu ti chuyn ha nh nhim thit huyt t, nhim bt.
* Giao thoa thuc
Cc thuc sau c th lm tng nng digoxin: erythromycin, tetracycline, quinidine,
amiodarone, verapamine.
Trong iu tr suy tim mn c hai loi hay c dng l digoxin v digitoxin nhng v
digoxin tc dng nhanh, thi nhanh do t hiu qu iu tr nhanh trong khi kh
gy ng c nn c a dng hn. Lu l digoxin thi qua thn v digitoxin thi
qua gan v th nu suy thn nn dng digitoxin trong khi suy gan th nn dng
digoxin. ph n c thai digitoxin qua c hng ro nhau thai trong khi digoxin th
khng. Trn thc t khng c mt phc no hon ton ng cho mi bnh nhn.
Liu iu tr ty theo nhy cm ca ngi bnh vi thuc theo nguyn tc l ngi
gi hoc l suy tim vi tim dn rt ln, ngi bnh gy th phi gim liu thuc. Ni
chung liu thng thng iu tr tn cng l digoxin 0,25mg (2 ln / ngy trong
vng mt tun sau tr v liu duy tr l1/2 - 1 vin / ngy, ung cch nht hoc l
thm ch c th ung hng ngy khng ngh ty theo i tng. i vi digitoxin bt
buc phi ngh chng hn ung 3 ngy ngh 3 ngy do thi gian na i di. Vng
iu tr ca thuc: digoxin mu 1- 2,5ng/ml, digitoxin mu 15- 35 ng/ml. Tuy nhin i
vi tr em vng hiu qu xung quanh 3 (1ng/ml khi iu tr phi theo di cc triu
chng ng c c thi x tr kp thi.
1.2. Ch ngh ngi v tit thc
Ch hot ng ca ngi bnh ty thuc vo mc suy tim. Khi c suy tim
nng phi ngh ngi tuyt i ti ging bnh. n nht l cn thit di 2gam mui
/ngy nu suy tim I v II, di 0,5gam/ngy nu suy tim II,IV.
1.3. Thuc li tiu

30
Vn c coi l ch o trong iu tr suy tim tr. Vi suy tim nh th li tiu
thiazide liu va phi cng p ng tt phi hp vi ch n nht. Khng nht
thit phi cho sm thuc li tiu quai tr phi khng c p ng vi Thiazide. Liu
thuc Thiazide 25mg (1-4 vin / ngy, Trofurit 40 mg (2-3 vin/ ngy. Hai loi ny l
li tiu thi mui cho nn phi cho tng t mui kali km theo (1-2g/ngy). Khi tnh
trng tr nng c th phi hp tng t vi li tiu gi kali tc dng ng ln xa
(Spironolactone) v lc hay c cng aldosterone th pht.
1.4. Thuc dn mch
* Cc dn cht nitrate
c s dng rng ri nhm gim triu chng h hp (kh th) ca suy tim. Liu
khi u nh sau tng t t nhm trnh tc dng ph nh au u. Liu iu tr
i vi Isosorbide dinitrate khong 120mg/ngy. Tng t c th dng mononitrate,
trinitrine dn, molsidomine.
* Cc cht dn ng mch C tc dng ci thin tnh trng cung lng thp.
Hydralazine hiu qu nhng nhc im phi dng liu cao kh thc hin (12 - 16
vin chia 4). Prazosine c tc dng cng tt nhng b yu i kh nhanh chng sau
. Ni chung ngy nay cc thuc ny t c s dng.
* Cc thuc c ch men chuyn
lm ci thin r rt tin lng ca bnh nhn b suy tim. N khng nhng ci
thin triu chng m cn ci thin c c tin lng sng. Nguyn tc s dng
phi tun theo nhm trnh tai bin do thuc c th xy ra nht l nhng bnh nhn
ang c dng li tiu. Liu khi u nh (6,25mg/ngy vi Catopril) sau tng
ln ti liu 50 - 150mg/ngy ty theo trng hp.
1.5. Cc thuc c ch beta
Trc kia c xem nh chng ch nh. Tuy nhin gn y chnh thc a vo
iu tr suy tim. Cc loi thuc sau c chp nhn rng ri: metoprolol,
bisoprolol v nht l Carvedilol. S dng thuc ny theo nguyn tc l cho khi suy
tim n nh (khng dng trong suy tim cp), liu nh tng dn. Vi Carvedilol vin
12,5mg liu khi u 1/4-1/2 vin/ngy.
1.6.Cc cht c ch phosphodiesterase (Amrinone, Milrinone, Enoximone)
C ch tc dng l tng lng AMPc t c hai tc dng:dn ng mch v tng
co bp c tim khng l thuc vo cc th th (. Thuc c dng trong suy tim vi
biu hin suy huyt ng nng sau khi dng dopamin v dobutamin khng c hiu
qu.
2. iu tr theo th loi suy tim
2.1.Suy tim cp
Bng 1. Cc bin php x tr trong suy tim cp
1. Bin php chung

An thn bng morphin

2. iu chnh cc yu t lm d

Lon nhp, thiu mu, tng huyt p

3. iu chnh thiu oxy

Th oxy, h hp h tr nu cn.

4. iu tr c hiu

Thuc: li tiu, gin mch,tng co bp c tim,

bng ni ng mch ch, phu thut: thay van,
ng l thng bm sinh.

Bng2. Cc thuc dng trong iu tr suy tim tri cp.

31
Thuc

C ch

Tc dng sinh l

Hiu qu iu tr

Li tiu
*Furosemide 40-80mg tim
TM

Li tiu

Gim tin gnh

Chng ph phi

Dn tnh mch
Dn tnh mch

Gim tin gnh

Gim tin gnh

Chng ph phi
Chng ph phi

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

Tng co bp c tim
*Dobutamine: 250-750(g/pht
*Dopamine: 100-600(g/pht

*Digital(lanatoside
digoxine)1 ng tnh mch

Dn tiu ng Gim tin gnh v Chng ph phi v

tng lu lng tim
mch v tnh hu gnh
mch
Ging giao cm

Tng co bp tim

Tng lu lng tim

Ging giao cm

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

Tng lu lng
tim, tng huyt p
(liu cao).
Chng ph phi
lm gim p lc
phi.

C,
c ch bm
Na-K ATPase

2.2.Suy tim mn tnh

* Cc mc tiu iu tr suy tim mn

IU TR SUY
TIM

IU TR
NGUYN NHN

GIM TIN
GNH
(li tiu)

IU TR TNH
TRNG SUY
TIM

GIM HU
GNH
(dn mch)

IU TR CC
YU T LM D

TNG CO BP
C TIM (tr tim)

GIM TN S
TIM
(c ch beta)

S 1: Thi x tr suy tim mn

Bng3. Phc iu Tr Suy Tim (Theo M. KOMAJDA v Y. GROSGOGEAT)

Giai
on Phng php kinh in
suy
tim
(NYHA)

Phng php thay th

32
I

Khng iu tr

Khng iu tr

II

- Hn ch th lc
- Ch n king mui
- Digital
-Digital + Li tiu Thiazid

- Hn ch th lc
- Ch n king mui
- Li tiu? c ch men chuyn?
- Li tiu + CMC hoc
Li tiu + Dn mch

III

- Digital + Li tiu quai.

- Digital + Li tiu + Dn mch

IV

- Li tiu + CMC hoc Dn mch

+ Digital ? hoc
- Li tiu + CMC hoc Dn mch
- Digital + Li tiu + Dn mch
+ thuc tr tim?
+ Thuc tr tim mi
- Chn bta?
- Ghp tim
- Ghp tim.

33

SUY MCH VNH

Mc tiu
1. Nm c nguyn nhn chnh gy bnh mch vnh.
2. Nm c triu chng, cch chn on.
3. Nm c cc th lm sng ca au tht ngc
4. Nm vng nguyn tc iu tr, cc phng tin ni ngoi khoa iu tr suy vnh.
Ni dung

I. I CNG
1. Bnh mch vnh (BMV) l mt bnh rt thng gp trong s cc bnh tim cc
nc pht trin. Thng thng bnh sinh ca SMV l do lng ng m lp di
ni mc cc ng mch vnh. Tnh trng x va tin trin dn dn lm hnh thnh
cc mu ng gy thuyn tc trong lng mch. Bin chng ch yu ca bnh mch
vnh l gy cn au tht ngc, nhi mu c tim v cht t t.
2. Dch t hc ca BMV: bao gm au tht ngc v nhi mu c tim chim khong
chng 6% n ng > 50 tui. chu u hng nm c thm khong chng 0,3-0,6
% ngi mc bnh. V t l t vong th mi nm chim khong 120-250 ngi cht /
100.000 ngi dn cc nc cng nghip pht trin. T l ny tng ln vi tui:
800 - 1000 ngi cht /100.000 la tui 65 - 74 i vi nam gii, 300/100.000 i
vi ph n cng la tui (Vademecum clinique 1988).
Vit nam cha c thng k ton dn nhng cc thng k ti cc bnh vin ln
cho thy bnh nhn b bnh mch vnh hu ht tui 50 tr ln. Nm 1996 thnh
ph H ni c khong 200 bnh nhn BMV nhp vin cn thnh ph H ch Minh
c khong 400 bnh nhn.

II. BNH NGUYN

1. Bnh mch vnh: l nguyn nhn ch yu.
- a s l do x va mch vnh.
- Khng phi do x va: co tht mch vnh, vim mch (vim nhiu ng mch
dng nt, lupus ban , bt thng bm sinh).
2. Bnh van tim: Bnh van ng mch ch: hp, h van ng mch ch, giang mai.
3. Bnh c tim ph i: Hai nhm nguyn nhn sau ny c th gy suy vnh c nng
trong mch vnh khng c hp.

III. C CH BNH SINH

1. C tim v oxy
S tiu th oxy c tim: ph thuc vo:
+ Tn s nhp tim
+ S co bp c tim (inotropisme)
+ Sc cng trong thnh tim.
+ Sc cng ny ph thuc vo p lc trong bung tht v th tch tm tht.
S gia tng mt trong cc yu t trn s lm gia tng s tiu th oxy c tim. Ni
cch khc s tiu th ny t l theo:
+ Tn s tim x p lc ng mch tm thu
+ Hoc tn s tim x p lc ng mch tm thu x thi gian tng mu.
2. D tr vnh: gm 2 thnh phn

34
- D tr vnh (Reserve coronaire): D tr vnh c thc hin bng cch ly oxy
ca c tim, hu nh ti a trng thi c bn. D tr lu lng vnh c kh nng
gia tng n 300 - 400% tr s c bn. S thch nghi v gia tng nhu cu oxy thng
km theo s gia tng song song ca lu lng vnh. Lu lng vnh ph thuc
vo: p lc ti mu v sc cn vnh do kh nng dn mch di ngoi tm mc.
- Dng vnh (flux coronaire) thng ti a k tm trng. Do kh nng dn cc
mch mu ni tm mc rt yu, v vy khi c gim lu lng vnh s ti mu s
xy ra ch yu di ni mc.
3. Kh nng vn mch ca ng mch vnh: ph thuc vo
- Yu t co tht mch
+ Sc bp k tm thu: quan trng i vi tht tri hn tht phi.
+ Cu c bt qua mt ng mch vnh thng tm mc.
+ Kch thch th th alpha, c ch th th bta vi Dopamine liu trn 15mg/kg/ph
qua trung gian noadrenaline, trc nghim lnh, dn xut ca lo mch thromboxane A2 - prostaglandine F - Neuropeptide Y.
- Yu t dn mch
+ Cc cht bin dng do TMCT: adenoside, lactate, ion H+, CO2, bradykinine.
+ c ch th th alpha - kch thch th th bta vi dopamine liu di 5mg/kg/ph cc th th i giao cm kch thch i giao cm qua trung gian acetylcholine, c ch
calci, dn xut nitr - prostacycline - prostaglandine E, EDRF (yu t dn ni mc) VIP (peptid rut dn mch: vasodilatator intestinal peptid) cht P.
4. Tnh trng thiu mu c tim (TMCT)
Xut hin khi c s mt thng bng gia cung cp oxy v nhu cu oxy c tim.
- C ch: c th do hu qu
+ Gia tng nhu cu oxy (thiu mu th pht) khi gng sc s gia tng tiu th oxy
c tim c thc hin qua s gia tng tn s tim, HA tm thu v s co bp c tim.
Trong trng hp hp MV c ngha ngha l trn 70% ng knh ng mch
vnh, lu lng vnh khng th gia tng thch ng v song song vi s gia tng nhu
cu oxy nn a n TMCT.
+ S gim t ngt lu lng vnh (thiu mu nguyn pht) tng ng vi s co
tht mch vnh m khng c tn thng mch mu, tuy vy cng c th xy ra trn
mt ng mch vnh b hp t trc.
Cn au tht ngc xy ra khi nhu cu oxy ca c tim vt qu kh nng chu cp
ca h thng mch vnh. au l biu hin trc tip ca thiu mu cc b c tim v
s tch ly cc cht chuyn ha do thiu oxy. Mt khi c tim thiu mu cc b pH
gim trong xoang vnh, mt kali t bo, tng sn xut lactat, xut hin cc bt
thng ECG, chc nng tht xu i. Cc yu t xc nh tiu th oxy c tim l nhp
tim, s co bp c tim, p lc tm thu. Khi c tng mt hoc l nhiu yu t ni trn
cng vi tnh trng dng mu vnh gim th s to ra cn au tht ngc.
5. Hu qu TMCT: theo cc bc sau:
- V bin dng: tit lactate.
- V huyt ng: ri lon s th gin, gim co dn tht v sau l gim s co
bp.
- V ECG: xut hin ri lon s ti cc.
- V lm sng: xut hin cn au tht ngc.

35
III. GII PHU BNH
Mt hoc nhiu ng mch vnh b hp do mng x va. C nhng vng hoi t v
x trong c tim, thng thng khu tr trong lp di ni tm mc. Tht tri c th
ph i.

IV. TRIU CHNG

1. Triu chng c nng: l cn au tht ngc vi c im sau
V tr: sau xng c.
Hng lan: xung mt trong cnh tay ngn tay tri, tuy nhin n c th lan ln vai ra
sau lng, ln xng hm, rng, ln c.
Tnh cht au: c th m h kiu nh c g chn ngc, co tht hoc l nh l c vt
g nng p ln ngc. Ngi bnh hay khng c cm gic nh l au. Lu l
nhng ngi bnh m t im au chnh xc vng mm tim, au nhi nng thong
qua th thng khng phi l au tht ngc do suy vnh.
Thi gian: au ngn v ko di khng qu vi pht.
au thng khi pht sau gng sc, gim v mt khi ngh ngi hoc l dng thuc
gin vnh. Lnh cng l yu t d gy khi pht cn au.
2.Triu chng thc th
Trong cn c th chng c g tuy nhin c th c tng tn s tim v tr s
huyt p, nghe c th c thi tm thu gia v cui tm thu do lon chc nng c nh
v thiu mu cc b.
3. Triu chng ECG: ghi c trong cn au ngc l c ch nht qua cho php
thy cc bin i xy ra trong cn suy vnh: ST chnh xung l in hnh, ngoi ra
i khi thy ST chnh ln, ri lon nhp nht l ngoi tm thu tht. Ngoi cn khi
ngi bnh ngh ngi ECG thy bnh thng 30% ngi bnh c au tht ngc
in hnh.

V. CHN ON
1. Chn on xc nh
1.1. Chn on lm sng:: da trn bnh cnh au ngc c trng nh m t
trn xy ra khi gng sc v gim bt sau khi ngh ngi. C th khng nh chn on
bng theo di ECG thy hi phc tr v bnh thng cc bin i do thiu mu cc
b hoc bng dng test iu tr th vi nitroglycerin di li thy bin mt cn au
trong vng 1,5-3 pht. Khng thy p ng gim au nhanh c th loi tr nghi ng
c cn au tht ngc (tc l khng phi au tht ngc do suy vnh hoc l ngc
li l dng nng nht ca suy vnh l nhi mu c tim).
1.2. Chn on cn lm sng
1.2. 1. in tim gng sc: gip chn on sm, d hu v theo di iu tr.
- K thut: dng xe p lc k hay thm ln, tng dn cng mi 30W i vi xe p
hoc dng biu Bruce i vi thm ln. Cn c chuyn vin theo di ECG v HA
lin tc khi tin hnh. nhy ca phng php: 60% v c hiu 80% trong
pht hin mch vnh. T l t vong di 0,01%.
- Ch nh:
+ Chn on cn au tht ngc n nh hay cn au ngc khng in hnh.
+ Bilan ngi tr c nhiu nguy c bilan b bnh mch vnh n nh c hay khng
iu tr.
+ nh gi hiu qu ca iu tr TMCT

36
+ nh gi kt qu phu thut mch vnh hay sau nng mch vnh, bilan sau nhi
mu c tim vo ngy th 10 - 15.
+ nh gi chc nng ca mt s bnh van tim (tr hp van ng mch ch).
+ nh gi chc nng ca suy tim cn b.
- Tiu chun nh gi: c da vo nhiu yu t nh: ST chnh xung v nm
ngang trn 1mm hoc i xung trn 0,08 mm sau phc b QRS; ST chnh ln (him
gp); thi gian gng sc; cng ti a t c; xut hin cn T in hnh; in
tm bin i trong hay sau trc nghim gng sc; huyt p v tn s tim; mc t
tn s tim theo l thuyt; xut hin lon nhp khi lm test v/ hoc c du suy tim tri.
Kt qu test gng sc gn lin vi tui v gii ngi bnh (kh kt lun ph n
<55 tui, dng gi >20% ngi < 40 tui trong khi gim cn < 10% ngi > 60
tui).
1.2.2. o in tim Holter trong 24 gi: Gip chn on bnh mch vnh im lng,
chn on v theo di cn TN Prinzmetal, hoc s gia tng kch thch tm tht.
1.2.3. ng v phng x
- Nguyn tc: Kho st s ti mu c tim vng bng cch so snh s phn b cht
ng v phng x Thalium 201 vo c tim khi ang gng sc v sau mt thi gian ti
ti mu khi ngh ngi.
- ch li v hn ch: Nhy hn trc nghim gng sc (80%), c hiu hn (90%) cho
php xc nh vng b thiu mu, nh gi chc nng c tim. Gii hn ca phng
php: dng tnh gi nu c block nhnh tri, gi thnh cao.
- Chp bung tht bng phng x: bm tnh mch cht Technium. C th nh gi
s co bp tng vng v ton b tht tri cng nh chc nng tim tri.
1.2.4. Siu m tim v Doppler
- Siu m 2 chiu: nhm:
+ Phn tch s hot ng tng phn nh gim co bp, khng co bp thm ch ri
lon co bp khu tr, tim bt thng thn chung ca ng mch vnh nh calci
ha.
+ Tnh ch s co hi tht tri nhm nh gi chc nng tht tri ton b.
Vi Doppler gip chn on h van 2 l do thiu mu c tim, p lc mch
phi. Cc bin i v s lm y tht, nh gi lu lng ng mch khi gng sc
v ngh ngi.
- Siu m tim gng sc chn on thng qua vic thy bt thng vn ng thnh
tim cho nhy cm chn on > 90% nu hnh nh tt.
1.2.5. Chp mch: Bm cht cn quang chp ton b h mch vnh v bung tht.
i vi h mch vnh c gi tr nh gi mc , v tr tn thng mch vnh cng
nh tnh trng ti mu, phn b mch mu v s calci ha, cc bt thng bm
sinh, i vi bung tht nhm phn tch s co bp tng phn, chc nng tht tri,
ch s tng mu v h 2 l do thiu mu c tim. Chp ng mch vnh l phng
tin quyt nh dng nh gi nng ca bnh mch vnh cng nh dng
chn on khi cc phng tin thm d khc khng cho php xc nh suy vnh. C
th ni chp mch vnh l xt nghim khng th thiu c i vi bnh l mch
vnh c bit khi cn thit phi can thip ngoi khoa, tuy vy y l k thut tn km
v i hi chuyn vin.
1.2.6. Chp nhp nhy c tim bng Thallium 201 hoc Technitium 99m: c nhy
cm 70-90% v c hiu 60-90% nhng t tin.

37
2. Chn on phn bit
2.1. au vng trc tim do ri lon thn kinh thc vt: l thng gp trn thc t
nht l tui tr. au thng mm tim, khng c khi pht khi gng sc m l khi
ngh ngi. Cn au c th ko di hng gi hng ngy. Ngoi ra c th km thm
cc triu chng ri lon thn kinh thc vt khc.
2.2. au do bnh ct sng - xng sn: vim khp, vim thn kinh lin sn.
Khm n au khu tr, au khng c lan.
2.3. au do bnh ng tiu ha
- au do co tht thc qun cng sau xng c, c km kh nut, . i khi lan ra
hai cnh tay v cng gim bt sau khi dng nitroglycerin. Chp cine thc qun cho
php chn on chnh xc.
2.4. Hi chng tro ngc d dy - thc qun: gy cm gic nng sau xng c,
nng ln khi nm nga, du bt sau khi dng cc thuc khng acide.

VI. CC TH LM SNG CN AU THT NGC:

1. au tht ngc n nh: cn au xy ra lin h vi gng sc.
2. au tht ngc khng n nh
- Mi khi pht cn au tht ngc nng (< 2 thng) v/hoc xy ra cn = 3
cn/ngy.
- au khi ngh ngi hoc l ch khi hot ng rt nh nhng.
- Cn au tht ngc tng tin: thuc loi n nh nhng gn y nng hn, au ko
di hn, hay xy ra hn v xy ra vi gng sc nh hn trc.
Bnh nhn c mt trong 3 tiu chun trn c gi l c cn au tht ngc khng
n nh (Harrson 2005).
3. Co tht vnh: cn c gi cn au tht ngc Prinzmetal. Xy ra trn mch vnh
hon ton bnh thng hoc l c mng x va gy hp gn v tr ca co tht. au
tht ngc c tnh tng t nhng m trm trng hn v xy ra in hnh khi ngh
ngi cng vi hnh nh on ST chnh ln rt cao trn ECG. Lu l co tht vnh
c th gy nn nhi mu c tim cng nh cc ri lon nhp c tnh. Chn on xc
nh da trn chp ng mch vnh c tim TM Methergin (ergonovine).
4. Thiu mu cc b c tim yn lng: c pht hin bi ghi Holter hoc l trc
nghim ECG gng sc ch yu xy ra nhng ngi c thiu mu cc b c tim c
triu chng. Ghi nhn c bin i ST-T nhng v triu chng mc d c bnh mch
vnh.
5. Nhi mu c tim: Xy ra khi tc mt hoc nhiu nhnh ca mch vnh. Nhi mu
c tim (NMCT) l s hoi t thiu mu nng v h thng c tim vi in tch tn
thng bng hay trn 2cm2.
5. 1. Triu chng lm sng: au ngc tng t nh l cn au tht ngc tuy nhin
cng mnh hn nhiu v ko di hn (> 30 pht), t thuyn gim khi ngh ngi
v sau khi dng nitroglycerine. Tuy nhin 25% ca nhi mu c tim l im lng v mt
lm sng.
5.2. Triu chng cn lm sng
5.2.1. in tm thng thng
Nhi mu c sng Q: ST chnh ln, T o ngc, sng Q hoi t.
Nhi mu khng c sng Q: ST chnh xung, bin i dai dng ST-T m khng
c xut hin sng Q.
5.2.2. Men: tng CPK, CPK-MB, GOT, LDH, Troponin T.

38
5.3.Chn on
Theo T chc Y t th gii NMCT c chn on xc nh khi c hai trong 3
du hiu sau: cn au tht ngc bin i, thay i ECG theo tin trin ca bnh v
s gia tng men tim.
Mt s trng hp khng c th chn on xc nh NMCT m ch c th ni
c th c NMCT. Thng th c triu chng lm sng in hnh rt gi nhng m
thiu bng chng khch quan trn ECG v men. Nu lm sng nghi ng nhiu th c
th l NMCT nh. Trc mt bnh nhn nam gii >35 tui, n gii >50 tui c au
ngc th phi xem xt iu tra c NMCT hay khng. Phi chn on phn bit vi
au do vim phi, tc ng mch phi, vim mng ngoi tim, gy xng sn,co
tht thc qun, phnh tch ng mch ch v nhng tnh hung gy bnh cnh au
bng cp tnh do bnh trong bng.
5.4. Bin chng
5.4.1. Ri lon nhp: ngoi tm thu, rung tht, nhp nhanh tht, bloc nh tht...
5.4.2. Suy tim: c chong hoc khng.
5.4.3. Phnh thnh tim.

VII. IU TR
1. Nguyn tc iu tr
1.1 Ci thin cc yu t nguy c
y l bin php hng u c gi tr v t tn km, p dng c cho cc i tng
giu/ngho nhng i hi s quyt tm v cng tc ca bnh nhn. C th nh v
sinh i sng v ch n ung gim m, tp luyn th dc i b, bi li, i xe p,
trnh stress, theo di, khm bnh, xt nghim lipid u n, lm trc nghim gng
sc hng nm.
1.2. iu tr cn nguyn
Nu bit c. Tuy c kh nng ci thin r nhng ch p dng trong nhng c
nhn, n v c iu kin kinh t cao. V d: iu tr x va ng mch bng cc
thuc gim m, iu tr phu thut vi cc tn thng van tim bm sinh hay mc
phi.
2. Phng tin
2.1. iu tr ni khoa
Bng cc thuc nh: dn xut nitrs, molsidomine, chn bta, c ch calci, cc phn
t khc, maleate de perexilline (Pexid), chng ngng tp.
2.2. Nong ng mch vnh qua da (Angioplastie coronaire transluminale percutane)
(PTCA)
X dng mt catheter a vo M vnh qua da xc nh mc hp mch vnh,
sau s x dng mt bong bng nh, ng knh 2-4mm bm ln v tr b hp,
c xem kt qu khi nng c trn 50% so vi khu knh trc, t l thnh cng
thng t n 90-95% trong giai on u tin.
2.3. Phng php phu thut cu ni ch - vnh (Pontage aorto-coronaire)
Phng php c thc hin bng cch ghp tnh mch hin trong v nht l ng
mch v trong vo v tr mch vnh b tn thng. T vong phu thut khong 1-4%,
phng php ny ci thin d hu v triu chng ca bnh nhi mu c tim.
3. iu tr c th cn au tht ngc gng sc
3.1. iu tr ct cn au tht ngc gng sc

39
Nn ap dng ngay trc khi vo vin v p dng cng sm s cng c tc dng
ngn nga bin chng xu hn xy ra.
- Ngh ngi, trnh gng sc.
- Dng cc dn xut Nitrs ngm di li (Natirose vin 0,75mg) c th lp li sau
5pht hay bm Natispray liu 0,4mg lp li sau 5 pht nu cn, nu khng gim sau
15 pht cn phi t vn c phi cn au tht ngc khng n nh hoc nhi mu
c tim.
3.2. iu tr lu di cn au tht ngc gng sc
* Cc loi chn bta
Tr phi c chng ch nh, y l thuc iu tr chn lc cn au tht ngc gng sc,
iu tr hu hiu khi nhp tim ngh ngi t 50-60/ph v khi gng sc di 100/pht.
Khi u bng liu thp, tng dn liu ln khi khng c bin chng. C th:
- Propranolol (Avlocardyl vin 40mg) loi khng chn lc, khng c hot tnh giao
cm ni ti, liu 2-4 vin chia 2 ln mi ngy.
- Atenolol (Tenormine) vin 50-100mg, loi chn lc ln tim nhng c hot tnh giao
cm ni ti, liu 50-100mg, ngy 1 ln.
- Metoprolol (Lopressor) vin 100mg hay Seloken vin 100-200mg, chn lc tim,
khng c hot tnh giao cm ni ti, liu 50-100mg/ngy 1 ln.
- Acebutolol (Sectral) vin 200-400mg, chn loc ln tim, c hot tnh giao cm ni
ti, liu 400mg/ngy ch dng 1 hay 2 ln (khi u 200mg/ngy chia 2 ln).
Nu khng c p ng cn xem c c ch co tht ng mch vnh trong cn, ch
quan trng l khng bao gi ngng t ngt iu tr chn bta v d c nguy c dn
n lon nhp, nhi mu c tim v t t.
* Cc dn xut Nitrat
Thng c s dng u tin v phi hp vi 1 loai thuc khc (nh chn bta
v hay chn calci) gm:
- Nitroglycerine (vin hay bm xt) rt t chng ch nh (ngoi tr bnh c tim tc
nghn) v t tc dng ph (thng gp l h huyt p, nhc u).
- Cc dn xut Nitrat n, i hoc Nitrat dng vin hay bng dn.
Hin tng dung np (tolerance) vi cc dn xut Nitrs hay gp vi liu cao, ko
di. Hin tng gim i, nu tn trng khong trng Nitrat, ngha l khng ung
Nitrs sau 18h v khng dn t 20 gi v 8 gi sng, iu ny gii thch s quan
trng phi hp vi chn bta hoc c ch calci c bit bnh nhn c cn au
ban m.
C th:
- ng ung:
+ Trinitrine (Lnitral) nang 2,5 mg v 7,5mg liu: 2 nang/ngy chia 2 ln.
+ Isosorbide dinitrate nh: Langoran nang 20-40mg hay 80mg L.P. Liu 4080mg/ngy. Risordan vin 10-20mg liu 40mg/ngy chia 2,3 ln mi ngy. Risordan
LP vin 20-40mg liu 40mg/ngy.
+ hay 5- isosorbide mononitrate nh: Monicor LP 20mg ngy ung 2 nang.
+ Molsidomine (Corvasal) khng phi l dn xut Nitrs nhng c tc dng tng t
ngoi ra cn c tc dng chng ngng tp tiu cu. Bit dc: Corvasal vin 2-4mg,
liu 1/2 - 1vin. ch li ca nhm ny l khng c hin tng dung np.

40
- ng dn: Trinitrine nh Cordipath liu 5mg, dn vo bui sng v bn ngc, nn
dn ngt qung, ch dn vo ban ngy.
* Thuc c ch canxi
Nu chng ch nh chn bta (nh suy tim mt b, ri lon dn truyn nh- tht, hen
ph qun hi chng Raynaud) th ngai cc dn xut Nitrat v Molsidomine, vic s
dng cc loi c ch calci l thuc chn lc nht l trong cn au tht ngc hn hp
hay co tht ch yu.
C th:
- Diltiazem (Tildiem) vin 60mg hay Bi-Tildiem vin 90-120mg liu 2 vin 60mg/ngy
trc khi n hay vin 90mg 2 ln/ngy.
th nng: 180mg/ngy chia 3-4 ln, chng ch nh: suy nt xoang, bloc nh tht
2, 3 khng t my to nhp, suy tim tri, c thai. Tc dng ph: nhp chm
xoang, bloc nh tht, ph chi di, suy nhc, bun ng, ri lon tiu ho.
- Nifedipine (Adalate) vin 10mg. Liu 2 nang mi ngy khi n, th nng c th dng
3-4 nang ngy. Chng ch nh: c thai, tc dng ph, phng mt, nhc u, ph
chn, au bng, h huyt p, nhp nhanh.
- C th phi hp c 2 loi trong th nng hoc khng nong mch vnh c nh:
+ Tenormine 80-100mg/ngy + Adalate 3 nang/ngy hay Monicor LP 1 nang/ngy.
Khi phi hp chn beta v Diltazem cn theo di tn s tim v ri lon nhp xoang.
+ Hoc Seloken 100-200mg/ngy + Corvasal 4mg 3 ln/ngy + Adalate 1 nang 4
ln/ngy. Nitriderm TTS. 5mg dn t 20 gi n 8gi.
+ Hoc ngoi l th khng: Pexid vin 100mg 1 vin/ngy trong 3ngy + sau
2 vin/ngy cn theo di chc v tc dng ph nhiu nh: xong, tn thng gan,
thn kinh.
* Cc thuc khc
- Thuc hot ho knh kali (Nicorandil) tc dng dn ng v tnh mch vnh v c
ngoi bin. Khng gim co bp tim v khng c hin tng khng tr.
- Amiodarone tc dng chng lon nhp v chng thiu mu cc b. Lu tc dng
ph.
- Trimetazidine.
- Gim au v an thn.
* Phng php can thip
- Nong v t stent (gi ): da vo kt qu chp mch v c chng minh c
s thiu mu bng nghim php gng sc thallium. Chng ch nh khng nhiu
ngoi tr hp thn chung ng mch vnh tri hoc ng mch vnh vi ho.
- Bc cu ni ng mch ch - vnh:khi bnh nhn c triu chng lm sng, nong
vnh tht bi km hp ti pht, tn thng nhiu nhnh nht l thn chung vnh tri
km suy chc nng c tim nng.
4. iu tr cn TN Prinzmetal
- Trong cn: Nitroglycerine hay 1 nang Adalate ngm t t khi nm.
- Tip theo cn phi iu tr bng c ch calci, heparine, dn xut nitrate liu cao,
khng dng cc cht c ch bta.
Ch : Chng ch nh phi hp Tildiem vi Cordium hay Tildiem vi Isoptine.
5. iu tr cn au tht ngc khng n nh

41
Cn nm ti trung tm hi sc tim mch. Nu
- Do co tht (ban m, ngh ngi) cn cho Nitrat v c ch calci.
- Do cn TN gng sc tng dn hay nng ln: Cho chn beta, Nitrat v/hay c ch
canxi.
C th:
- Ngh ngi, monitoring, Oxy.
- Theo di lm sng, in tm v sinh ha (CPK).
- An thn: Tranxene 15-30mg/ngy.
- Chng au: Morphine 1/2 -1ctg di da hoc tnh mch, nu khng p ng dn
xut Nitrs.
- Dn xut Nitrat: chuyn lin tc bng bm in nh Risordan liu 2-5mg/gi hay
Lenitral liu 1mg/gi hay Corvasal, khng nn chuyn qa 48 gi.
- c ch calci: Tildiem 3-4 vin/ngy.
- Chn beta: nu khng do c ch co tht. Acebutolol 200-400mg/ ngy
- Tenormine 80-100ng/ngy.
- Heparine chuyn lin tc 400-800 v/kg hoc heparin trng lng phn t thp
(Enoxaparin 1mg/kg tim di da 2 ln/ngy).
- Aspirine 250-300mg/ngy.
Nu khng p ng d iu tr phi hp nitres + c ch bta + c ch canxi:can
thip mch vnh cp.
6. iu tr thiu mu c tim im lng
- Cn tng cng iu tr chng au tht ngc.
- Lp bilan mch vnh.
7. iu tr nhi mu c tim
Nhi mu c tim c xem l mt bin chng trm trng ca suy mch vnh
hocthiu mu c tim. Vic iu tr phi thc hin ti trung tm hi sc tim mch.
Mc ch iu tr l gim au, hn ch ti a s lan rng m nhi mu, phng nga/
iu tr ri lon nhp v cc bin chng c hc.
C th:
- Nhp vin ti trung tm sn sc tng cng tim mch theo di tim lin tc.
- Gi mt ng tnh mch cp cu nhng trng hp lon nhp.
- iu tr tiu si huyt sm vi streptokinase, APSAC, hay cht hot ha
plasminogene m (tPA) c th gim thiu din tch nhi mu v t vong v gii hn
ri lon chc nng tht tri. nhng i tng thch hp, tiu si huyt cn cho
cng sm cng tt ti cc n v tng cng hoc trung tm chm sc mch vnh.
Bnh nhn c cho trong vng 3 gi sau khi xut hin triu chng kt qu tt hn
c, tuy nhin cho php s dng thuc < 12 gi sau nhi mu. Bin chng bao gm
xut huyt, ri lon nhp do ti ti mu, v trong trng hp x dng vi
streptokinase c th c d ng. Thuc chng ng (aspirine v heparine) bt u
cng lc vi thuc tiu si huyt. Chp mch vnh tip theo thng dnh cho
nhng bnh nhn b au ngc ti din hoc trc nghim gng sc dng tnh trc
khi ra vin. bnh nhn chng ch nh tiu si huyt, cn thc hin nng mch
vnh ban u m bo lu lng vnh. cc trung tm c can thip mch vnh
thng c a chung hn tiu si huyt

42
- Kim sat cn au: Morphine sulfate 2-4 mg TM mi 5-10 pht cho n khi ht au
hoc cc triu chng ph xut hin (x tr bng naloxone 0.4-1.2mg TM) ; h huyt
p (nu nhp tim chm x tr bng atropine 0.5mg TM, nu khng c th chuyn dch
vi s thn trng).
- Nitroglycerine 0.3 mg ngm di li nu HA tm thu trn 100mmHg; nu vn cn
au ngc cn cho TM nitroglycerine (bt u vi 10microgam/pht, tng dn n
mc ti a 200 microgam/pht, theo di cht ch bng monitor).
- Oxygen 2-4 lt/pht bng xng mi, nhm duy tr nng bo ha O2 >90%.
- An thn nh (V d: Diazepam 5 mg ung X 4ln / ngy).
- n nh chng to bn: Dng cc cht nho phn Vd. docusate sodium 100200mg/day)
- Chn bta: c tc dng gim tiu th O2 c tim, hn ch din tch nhi mu, gim t
l t vong. Thuc c tc dng tt trong trng hp tng huyt p, nhp tim nhanh,
au tht ngc tn ti; chng ch nh khi suy tim, HA tm thu di 95 mmHg, nhp tim
< 50l/pht, bloc nh tht hoc tin s b bnh co tht ph qun. Cho TM v d
metoprolol 5mg / 5-10 pht cho n liu tng cng 15mg sau cho ng ung
metoprolol 25-100mgX 2 ln/ ngy.
- Thuc chng ng/ thuc chng ngng tp tiu cu:
Bnh nhtsau khi c dng tiu s huyt thng c tip ni chng ng bng
aspirine v heparine, thi gian bt u ty thuc loi tiu si huyt. Trong trng
hp khng th dng tiu si huyt c th cho aspirin 80-325mg/ngy v liu thp
Heparin 5000 v tim di da hoc tim tnh mch / 12 gi. Liu heparin hu hiu
(thi gian PTT gp i thi gian chng) sau duy tr bng thuc chng ng ung
c khuyn co x dng nhng bnh nhn suy tim nng, c cc mu ng tm
tht chn on bng siu m, hoc c vng ri lon vn ng ln trong NMCT trc.
- Cc thuc c ch men chuyn: gim t vong nhng bnh nhn ri lon chc
nng tht tri khng c triu chng sau NMCT (ch s tng mu di 40%) v c th
cho nhng bnh nhn huyt ng n nh. Vd: captopril 6.25mg liu tt u tin
sau tng ln 50mg ung 3ln / ngy.

VIII. D PHNG
Gm nhiu bc tin hnh mt cch c h thng:
1. Xc nh nguy c
Thu thp ng thi cc thng tin v cc yu t nguy c phi hp cho php nh gi
ton b mc rng nguy c mang tnh c th ca ng mch vnh c li
khuyn c hiu.
2. Li khuyn c hiu
Dnh cho c ngi cha b v c ngi b ri
- Ht thuc: b hon ton thuc l. Nguy c ht thuc li ln hn khi c nhiu yu t
phi hp. Vic d phng cn ch c bit nu l nam gii.
- Huyt p: cn c ch iu tr theo di cht ch nhng trng hp mc bnh d
ch mi giai on u tin hoc ch tng huyt p gii hn.
- Tng cholesterol mu: cn ch khi cholesterol mu tng trn 220 mg% vi s
khuyn dng ch n c bit cng nh cn phi c khm xt v iu tr dc
bit khi tng trn 260mg%.
-Tng cng luyn tp v hot ng th lc nhiu hn. Vic gim th trng bao hm
vic gim r cc yu t nguy c.

43
- i tho ng: s iu tr lin tc c theo di cht ch vi mt trung tm chuyn
khoa l s chn la thch hp cho bnh nhn.
-Thuc nga thai ph n bng ng ung: gim thiu ti a vic x dng.

44

BNH C TIM
Mc tiu
1. Nm c nguyn nhn, c c ch bnh sinh 3 nhm bnh c tim khc
nhau, ch yu vo bnh c tim dn l nhm bnh thng gp nc ta.
2. Nm ca triu chng lm sng v cn sng cc bnh c tim dn gip vn
dng trong thc hnh lm sng.
3. Chn on phn bit c ba loi bnh c tim.
4. Bit vn dng iu tr cc loi thuc theo cc tnh hung cng nh bin
chng ca tng bnh c tim.
5. Bit r cc bin php phng nga cc bnh c tim.
Ni dung

I. NH NGHA
Theo bo co ca Lc lng c nhim T chc Y t th gii (TCYTTG):
Bnh c tim l bnh gy tn thng c tim m nguyn nhn thng khng bit r.
Bnh thng khng lin quan n cc bnh nh tng huyt p, bnh tim bm sinh,
bnh van tim, bnh ng mch vnh hay bnh mng ngoi tim.

II. PHN LOI

C 3 loi da vo c ch sinh bnh
- Bnh c tim dn n hay sung huyt (Dilated cardiomyopathy)
- Bnh c tim hn ch (Restrictive cardiomyopathy)
- Bnh c tim ph i (Hypertrophy cardiomyopathy)
y l cch phn loi thng dng nht hin nay da vo khi nim ban u ca
Goodwin v c TCYTTG cng nhn.
Ngoi ra cn c cch phn loi theo nguyn nhn l bnh c tim tin pht v bnh
c tim th pht nhng hin nay t dng. Bnh c tim tin pht cn c tn gi l bnh
c tim, cn bnh c tim th pht gi l bnh c tim c hiu ngha l cc bnh c
nguyn nhn r rng hoc l hu qu ca bnh ca cc c quan khc.

III. DCH T HC
Bnh c tim c m t u tin t nm 1957 v pht hin khp th gii.
Tuy vy ty theo c im chng tc, vn ha, a l ca tng quc gia m tn xut
ca cc bnh rt khc nhau. Bnh c tim dn l nhm bnh gp hu ht cc ni
trn th gii, cn bnh c tim hn ch l bnh him gp nht. Bnh c tim ph i
chim t l trung bnh. Bnh c tim dn v ph i gp cc nc vng chu v
Thi bnh dng. Trong khi bnh c tim hn ch li gp cc vng chu Phi, Nam
M, Trung M v mt s vng ti n .
T l mc bnh c tim dn ti Thy in c c tnh l 10/10.000 dn/ nm.
Ti Trung quc trong mt nghin cu ti mt nh my trn 60.000 cng nhn ghi
nhn 65 ngi b, trong c 52 ngi b BCT dn v 4 trng hp b BCT ph i.
Ti Chandigarh Chu Phi 3,7% trng hp m t thi c bnh c tim. Trong 38
trng hp pht hin th 28 ca b BCT dn, 9 ca b x ha c tim ni tm mc, 1 ca
b bnh c tim, ph i.
i vi bnh c tim ph i th t l chnh xc cha bit r v d nhm ln cc bnh
khc.

45
Trong khi bnh c tim hn ch hu nh gp cc nc nhit i. Uganda
14% trng hp t vong suy tim l do x ha c tim- ni tm mc. Nigeria l
10%.
nc ta, hin nay cha c t l ton dn; tuy nhin nhiu tc gi ghi
nhn t l BCT dn chim a s v gy nguy c t vong rt cao.
BNH C TIM DN

I. NH NGHA
Bnh c tim dn l hi chng dn tht tri vi s gia tng khi lng tht ch
yu l tht tri vi ri lon chc nng tm thu hay tm trng m khng c tn
thung nguyn pht mng ngoi tim, van tim hay thiu mu c tim.
Trn lm sng bnh c tim dn c biu th qua s dn hai tht, tht tri
nhiu hn tht phi, do s tr trong bung tht, l ngun gc cc cc mu ng
gy tc mch.
V gii phu bnh, l s x ha k c tim, cc t bo c ph i v thoi
ha khng c hiu.
II. NGUYN NHN: Thng iu tr bng cch loi tr.
1. Mt s yu t c ra nh: Nhim trng (entrovirus), dinh dng, ng c
(ru), tng HA, tn thng vi tun hon vnh, min dch, sau sinh.
2. Chn on bnh c tim dn v cn: Ch xc nh khi loi tr cc nguyn nhn
bit c.

III. SINH L BNH

1. S dn tht v gim co bp: a n s gim ch s tng mu v s gia tng th
tch cui tm trng. iu ny s lm gim s lm rng tm nh, lm tng p lc nh
tri v p lc cui tm trng ca tht tri. giai on u, nhp tim nhanh b tr
vi s gim th tch tng mu tm thu nhm duy tr lu lng tim (Q = FxV). V sau
s xut hin gim lu lng tim, s gia tng p lc mao mch phi (OAP) v sau
cng l s gia tng p lc mao mch phi v suy tht phi.
2. S gim p lc ti mu thn: a n s kch thch h renine - angiotensine aldostrone. iu ny lm gia tng th tch mu nhng gy s co mch ngoi bin.
S thiu mu di ni tm mc thng gp do s gim d tr vnh.

VI. LM SNG
1. Hi bnh
1.1. Tin s
- Tin s c nhn v iu tr hin ti hay trc y.
- Gia nh.
1.2. Triu chng c nng:
- Mt mi, kh th cc mc .
- Ph ngoi bin, au ngc, hi hp, tin s thuyn tc ngoi bin hay no.
2. Khm lm sng
- Tim: Nhp tim nhanh, huyt p ng mch bnh thng hay thp, mm tim lch tri,
ting T3, T4, thi tm thu h hai l v/hay h ba l, cc du hiu ca suy tht phi.
- Phi: Ran m phi, trn dch mng phi.

46
V. CN LM SNG
1. X quang phi: Tim to vi s gia tng t l tim/lng ngc, du xung huyt phi, trn
dch mng phi.
2. in tim: Nhp nhanh xoang, bt thng khng c hiu on ST-T, ph i tht
tri, bloc nhnh tri khng hon ton hay hon ton, bt thng nh , sng R gim
bin . i khi c sng Q d nhm hoi t c tim, ri lon nhp nh v nhp tht.
3. Sinh ha: Ion : gim Natri mu, suy thn chc nng, CPK bnh thng.
4. Siu m tim vi Doppler tim
4.1. Siu m 2 bnh in v TM: Dn cc bung tim nht l tht tri, gim ch s co
hi, gim co bp ton th vch tim, c khi khng co bp d nhm suy mch vnh, c
th thy cc mu ng v trn dch mng tim.
4.2. Doppler tim: Tm du h 2 l (c nng), du h 3 l hay h ng mch phi, s
ri lon chc nng tm trng, nh gi cung lng tim.
5. Cc phng php thm d c bit:
5.1. Chp nhp nhy c tim: ch s tng mu gim.
5.2. Thng tim: cho php nh gi p lc bung tim, s hot ng cc bung tim,
cc van tim. Sinh thit c tim ch cn khi mun tm nguyn nhn.
5.3. Holter nhp, trc nghim gng sc, kch thch tim.

VI. TIN TRIN

1. Bin chng: Suy tim ton b, rung nh, nhp nhanh tht v t t, tc mch ngoi
bin v no b, phi.
2. T l sng trung bnh: 6 thng n 3 nm sau khi xut hin cc triu chng, 20%
bnh nhn c din tin thun li hn.

VII. CHN ON PHN BIT

- Bnh c tim thiu mu tin trin.
- Bnh c tim do tng huyt p tin trin.
- Bnh van tim, c bit l h van hai l nng.
- Bnh c tim tc nghn.
Ni chung, bnh c tim dn nguyn pht c chn on khi loi tr sau khi loi
tr tt c cc nguyn nhn dn tht tri, c bit l bnh mch vnh nng hay h
van tim nng.

VIII. HNG IU TR
1. Bin php chung
2. iu tr thuc: kt hp thuc dn mch v li tiu c nh gi cao.
3. iu tr bin chng: nh ph phi cp, chong tim, rung nh, ri lon nhp tht.
4. Ghp tim.

BNH C TIM TC NGHN (BCT PH I)

I- NH NGHA: Bnh c tim tc nghn c tim (BCTTN) l s ph i tt c hay
mt phn lm tc nghn ng tng mu k tm thu. Th ph i vch tim thng
gp nht v l nguyn nhn do tc nghn bung y tht tri.
II- NGUYN NHN: Cha r.

47
1. Di truyn: Theo nhim sc th tri chim 55% trng hp, c th do:
- Ri lon hot ng cc catecholamines.
- S gia tng lu di calcium t bo gy ra s ri lon chc nng c tim v mch
mu.
2. Trong 45% trng hp: bnh xy ra n c v khng r nguyn nhn do (2/3
nam gii).
3. i khi bm sinh khng c ngun gc gia nh.

III- SINH L BNH

1. Chc nng tm thu tht tri: ri lon v gim hot ng tng mu tht tri, qua
c 2 gii thch:
- Gradient trong tht tri l hu qu ca s lm rng sm tht tri tng ng. 75%
lung mu tm thu c tng ra 1/3 u k tm thu. S di chuyn van 2 l ra
trc (SAM) ch l hu qu s xon vn ca bung tht tri.
- S di chuyn ra trc van 2 l (hiu qu Venturi) do s gia tng tc qua mt
bung y c th tch thu nh.
2. Ri lon chc nng tm trng tht tri: a n
- Nhng bt thng v s dn n v s lm y tht tri.
- Cc ri lon trn c th ci thin vi cc thuc c ch canxi (Verapamil).

Khi u tm thu
Thi k tm thu sm
Gia tm thu
S di chuyn l van ra pha trc trong k tm thu bnh c tim ph i

IV- CHN ON XC NH TH THNG THNG BCTTN

1. Hon cnh pht hin: Xy ra ngi tr, tui trung bnh: 25 - 30 tui, khng THA,
ph i vch khng i xng
1.1. Khm h thng: (nghe tim) v bnh nhn thng chu ng tt trong mt s na
trng hp.
1.2. Du hiu chc nng: (khng c hiu) pht hin bng hi bnh.
- Kh th, gng sc, hi hp, nhp nhanh, au ngc khng in hnh xy ra khi gng
sc.
- Hi bnh gip xc nh v tin s c nhn gia nh (t t, tui cht b m). C th
pht hin nhng du hiu gi nh: au tht ngc (30%), ngt, xu (25%) nhng
ph phi, ri lon nhp t gp hn.
2. Khm thc th
- Huyt p bnh thng.
- S vng trc tim c du chm mm, lch tri.

48
- Nghe tim: thi tm thu (90% ca) kiu tng mu gia k tm thu, vng gia tim lan
ra mm, cng thay i theo thi gian, gia tng khi gng sc, ngoi tm thu tht,
khi lm nghim php Valsalva, gim khi ht vo, cc ting tim bnh thng, c T4
thng. C thi ton k tm thu do h 2 l vi cng gim khi ht Nitrite d Amyle
hay khi lm th thut Valsalva.
3. in tim: Khng c du c hiu.
- Nhp tim: thng l nhp xoang, ngoi ra cn gp rung nh (5-10%), ri lon nhp
tht.
- Ph i tht tri (60%), c khi 2 tht.
- Ph i vch tim: sng Q thanh mnh (< 0,04), su (50%) V5, V6, D1, aVL.

Tnh mch c

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

49
- Tnh trng van tim: s di chuyn van 2 l ra trc.
- Mng ngoi tim bnh thng.
- Chuyn ng ra trc van 2 l k tm thu (S.A.M).
- S ng li sm gia k tm thu ca van MC kiu cnh bm. Tuy vy, 3 du
ny khng thung xuyn v khng c hiu.
6.2. Doppler tim.
- Doppler mu: cho thy s gia tng tc trong bung tng mu tht tri gia k,
du h 2 l phi hp.
- Doppler mch: cho thy nhng bin i c bit ca s lm y tht tri.
- Doppler lin tc: c gi tr cao v cho php xc nh gradient ti a trong bung tht
tri, l d 2 l v p lc ng mch phi.
6.3. Cc xt nghim c hiu khc
- h tr cho iu tr trc m hay khi c nghi ng tn thng vnh phi hp nh
k thut thng tin, chp mch vnh.
- o in tim lin tc 24-48 gi Holter.
- in tim khuch i cao tm in th chm.
- in tim gng sc khi hp qu kht.
- ng v phng x bng Thallium, IRM... t dng.

V- TIN TRIN
- Suy tim tri.
- Ri lon nhp: rung nh, ngoi tm thu nh, ngoi tm thu tht, nhp nhanh tht.
- Bin chng khc xen k vo: vim ni tm mc, tai bin thuyn tc.
- t t do cn nhp nhanh, nghn bung tht, chim 2-3%.

VI- TH LM SNG C BIT

1. Bnh c tim ph i khng c gradient trong tht tri v cn phi s dng cc trc
nghim dc l, da vo tin s gia nh iu tr.
2. Bnh c tim ph i mm: c tin lng nh hn, gp nam gii tui trung bnh
35, c sng T m, su khng l trc vng tim.
3. Bnh c tim ph i ngi THA ln tui.
- THA trc y khng c tin s gia nh b bnh c tim tc nghn, tin lng kh
hn nu iu tr sm.

VII- CHN ON PHN BIT

1. Lm sng
- Hp van ng mch ch: da vo c im ting tim v siu m.
- H 2 l: hay kt hp bnh c tim tc nghn, da vo Doppler iu tr.
-Xa hn: vi thng tht, hp phi.
2. ECG. Cn phn bit sng Q suy vnh, nu cn chp ng mch.
3. Siu m
- Khi c ph i tht tri, siu m cn tm nguyn nhn (THA, hp ch).
- C th c s phi hp bnh c tim tc nghn v bnh tim THA.

VII- HNG IU TR
- Thuc: chn bta, c ch canxi,disopyramide, amiodarone.

50
- iu tr phu thut.
- iu tr bin chng nh ph phi cp, rung nh, lon nhp tht.
-Khng sinh d phng.

BNH C TIM HN CH
I- NH NGHA: Bnh c tim hn ch l mt triu chng lin quan n tr ngi lm
y tht vi bt thng chc nng tm trng (s dn c tim) do bnh ni tm mc,
di ni mc v c tim.

II- NGUYN NHN

1. X ha ni mc c tim l nguyn nhn thng gp ca bnh c tim hn ch
vng nhit i. Bnh Loeffler: hay gp Chu u. Cn phi phn bit 3 giai on
qua sinh thit c tim: giai on hoi t sm, giai on thuyn tc v giai on x
ha mun.
2. Cc nguyn nhn khc: bnh nhim kt, nhim huyt t, bnh sarcoidose, x
cng b, bnh glycogen, K, chiu x, thi ghp.

III- BIU HIN LM SNG

1. Hi bnh
- Tin s (d ng, i xa...)
- Triu chng: suy nhc, kh th gng sc, suy tht phi, ph c chng.
2. Lm sng: o HA, nhp nhanh xoang thng xuyn, pht hin cc du hiu suy
tim (P) (d nhm vim mng ngoi tim co tht) v du suy tim (T).

IV- CN LM SNG
1. X quang lng ngc: bng tim ln, va phi, trn dch mng phi, cc du hiu dn
nh, xung huyt phi.
2. ECG: Du dy tht (P), tht (T), bin i on ST-T, c th c gim in th.
3. Sinh hc: CTM: c bch cu i toan tng trong x ha ni mc-c tim. nh lng
st huyt thanh, ferritin. Bilan min dch (x cng b).
4. Siu m tim vi Doppler tim.
4.1. Siu m tim hai bnh din v TM.
- X ha ni mc-c tim: hnh nh cht mm tim tri v / hay tht phi, dn nh, dn
TM, cc mu ng trong bung tim.
-nh gi tnh trng tht, chc nng tim, van v mng tim.
4.2. Doppler tim: pht hin h 2 l v cc van khc, ri lon chc nng tm trng
nh bt thng nh dn, dn n tim ca tht.
5. Cc xt nghim c bit khc nh: Thng tim, chp mch, sinh thit c tim,
Holter...

V- CC TH BNH C TIM TC NGHN C BIT KHC

1. X ha ni mc c tim: bnh Chu Phi v bn nhit i, tn thng x ha u
mm tim, sau lan ra, bnh cnh lm sng ty theo v tr tht b tn thng.
2. Vim ni tm mc Loeffer: vng n i, bnh nhn tr, tng bch cu i toan, biu
hin suy tim 2 tht v thuyn tc, siu m cho thy dy vch tim khu tr, van 2 l
lch ra sau, dn nh, h van nh tht.

51
VI- TIN TRIN
1. Chung: V tm thu nng, ri lon nhp nh v tht, thuyn tc.
2. Cho tng bnh: Ammylose: t vong trong 6 thng khi iu tr. Sarcoidose: suy tim,
t t. X cng b: bnh c tim tri, tng p phi. Loeffler: nng.

VII- CHN ON PHN BIT

1. Vim mng ngoi tim co tht.
2. Bnh c tim dn.
3. Bnh c tim ph i.

52
Bng 1: CHN ON PHN BIT BNH C TIM
Bnh c tim dn

Bnh c tim hn ch

Bnh c tim ph i

Triu
chng

- Suy tim sung huyt, T - Kh th, mt

>P
- Suy tim sung huyt, bn P
- Mt
- Cc du hiu ca bnh h
- Thuyn tc phi v thng: thoi ha bt, st
ton th

Triu
chng
thc
th

- Tim to nh(va
- Tim to nh
- Tim to va (rt to
- T3 hay T4
- Rung tm thu mm,
- C T3 v T4
- H van nh tht, nht - H van nh tht, du hiu mch ng mch cnh 2
l 2 l
(p lc TM khi ht vo (du th.- T4 hay gp
- Ting TTT/ vi th thut
Kussmaul)
Valsalva

X
quang
lng
ngc

- Tim to va (rt to,

nht l tht tri
- Tng p phi

in
tim

- in th thp
- Nhp nhanh xoang
- Ri lon nhp nh v - Ri lon dn truyn tht
tht
- Ri lon dn truyn nh &
- on ST-T bt tht
thng
- Ri lon dn truyn
tht

Siu
m tim

- Tht tri dn & r/lon - Gia tng dy thnh tht - Ph i khng i xng
c/nng
tri v khi lng tht
vch
- Vn ng bt thng - Khoang tht tri bnh - Hp bung y tht (T)
van 2l tm trng th thng hay thu nh
- Vn ng bt thng ra
pht sau s lm dn - Chc nng tm thu pha trc (SAM) van 2 l
bt thng v p lc b/thng
- Tht tri bnh thng
lm y bt thng
- Trn dch mng tim
hay nh

- Tim to nh
- Tng p TM phi.

- Kh th, au ngc
- Mt, ngt, hi hp

- Tim to nh (va
- Nh tri ln

- Nh tri ln
- Ph i tht tri.
- Bt thng on ST-T
- Bt thng sng Q
- Ri lon nhp nh & tht

- Dn tht tri v ri - Tm nhun c tim vi Fe201 - Tht tri bnh thng

Thm
d
y lon chc nng
- Tht tri c k/thc bnh hay nh
hc ht
- Gia tng sc co bp tim
thng hay nh
nhn
- Chc nng tm thu bnh - Ph i khng i xng
thng
vch
Bng 2: DU HIU SIU M TRONG BNH C TIM

-(Bung TT
- dy vch TT
- S co bp TT

++ ( )

- ()

- () hay
+ ()
+ () hay

Ghi ch: ++: gia tng, -: gim, (: bnh thng

VIII. IU TR
1. iu tr bnh c tim dn
1.1. Bin php chung

+ ()
hay - ()

53
- Ngh ngi khi c nhng cn suy tim (T).
- Ch n king mui.
- B ru, cc thuc ng c tim v gim co bp tim.
1.2. iu tr thuc (ngoi cn ph phi) kt hp vi loi dn mch v li tiu.
* Thuc c ch men chuyn
L nhm c xem c hiu qu nht v gim t vong do suy tim tri (giai on III v
IV NYHA).
* Phi hp Dihydrazine-dn xut Nitrs
C th dng nhng kh chu ng v phi dng liu cao.
* Chng ng bng khng vitamin K
Khi khng c chng ch nh, c dng trong trng hp dn bung tht nng vi
s bin i chc nng co bp tim, cc mu ng trong bung tht, tin s tc mch.
* Nhiu phc iu tr ang nh gi nh
- Thuc dn mch kt hp vi thuc tng co bp tim.
- Chn beta: cn s dng ti bnh vin vi iu kin khng c chng ch nh, tim
cng kch thch v nn dng liu thp sau tng dn.
1.3. iu tr bin chng
- Ph phi cp.
- Chong tim: dng thuc tng co bp tim (nhm kch thch (: Dobutamin, Dopamin)
- Rung nh: Digital v/ hay amiodarone. Thuc chng lon nhp nhm IA v IC khng
c dng.
- Ri lon nhp tht: amiodarone.
1.4. Ghp tim
1.5. iu tr nhng bnh c tim dn thng gp
- Bnh c tim do nghin ru: cai ru, iu tr suy tim ton b kinh in, n giu
vitamine nhm B. Ch c t bnh nhn sng c trong vng 3 nm nu khng cai
ru v iu tr kp lc.
- Bnh c tim chu sinh: iu tr nh bnh c tim dn chung..Lu khuyn ngng
sinh trnh ti pht.
2. iu tr bnh c tim tc nghn (Bnh c tim phi i)
2.1. Chng ch nh cc bin php sau:
- Gng sc, th thao nng (t t).
- Digital.
- Dn xut Nitrat (tr khi c suy mch vnh phi hp) v cc loi dn ng mch
n thun.
- Isoproterenol v cc loi cng giao cm (Dopamine, dobutami).
2.2. Phng tin
* Thuc
Khng thay i t l t t.
+ Chn bta
Propranolol (Avlocardyl 160-320 mg/ngy) c th gim triu chng 30-35% cas.
+ c ch canxi

54
Verapamil (Isoptine 360 mg/ngy): ci thin triu chng khi khng p ng chn
bta, nhng c nhiu bin chng (h HA, ri lon nt xoang, bloc NT...), v vy ch
dng bnh vin.
+ Disopyramide (Rythmodan)
C li v lm gim lon nhp, gim co bp nn gim tc nghn.
+ Amiodarone (Cordarone)
Gim du hiu c nng dng khi cc loi thuc trn tht bi hay khi lon nhp tht
nng.
* iu tr phu thut
- Phu thut ct c tim vch lin tht phn y.
- Thay van 2 l: khi phu tht trn khng tt, t l t vong do m 5-8%, kt qu gn
90% t 6 thng n 1 nm, lu di ch 70% trong 5 nm.
2.3. Ch nh
* Bnh c tim tc nghn khng triu chng ngi tr
iu tr bng chn (hay verapamil c ch nh khi:
- Tin s gia nh t t.
- Ph i tht tri, r.
- Nghn co bp trong bung tht tri.
Cn theo di lm sng mi 3 thng v siu m mi 6-12 thng.
* Bnh c tim nghn mch nng c triu chng ngi tr
- iu tr ni khoa l ch yu (chn (va /hay verapamil).
- Phu thut cn bn n khi p lc trong bung tht tri trn 50mm tnh trng c
bn.
* Bnh c tim ph i bnh nhn THA ln tui
- Mc ch iu tr l phi kim sot THA, gim khi lng tht tri.
- iu tr ni khoa l chnh, dng thuc liu tng dn, theo di p ng bng siu
m.
2.4. iu tr bin chng
* Ph phi cp
Dng li tiu, chn ((celiprolol, propranolol) v /hay Verapamil.
* Rung nh
Sc in, digital, chng lon nhp loi I.C, Amiodarone, khng vitamin K (ch dng khi
rung nh mn tnh v nh tri gin).
* Lon nhp tht
iu tr thng t hiu qu, c th dng amiodarone n thun hay phi hp chn
(v Verapamil.
* Khng sinh d phng
Khi p dng cc th thut ngn nga vim ni tm mc nhim khun.
3. iu tr bnh c tim hn ch
3.1. iu tr khng c hiu
Khng dng li tiu v dn mch. Digital ch cho khi rng nh. To nhp: khi ri lon
nhp chm trm trng. Chng ng khi c cc mu ng, tc mch.
3.2. iu tr c hiu

55
* Sarcoidose
Corticotd.
* X cng b
Corticoid v hay c ch min dch.
* Nhim thit huyt t
Trch mu. C li nu thc hin sm. Thuc desferoxamine gip lm gim nhim st
c tim.
* iu tr ngoi khoa
Khi iu tr ni khoa tht bi. Ct lc lp ni mc b x v thay van tim b nh hng
ca bnh. C ch trn mt s ngi bnh
* Ghp tim

IX. PHNG NGA BNH C TIM

1. Bnh c tim dn
Vic phng bnh hn ch do nguyn nhn cha r. Tuy vy nguyn nhn nhim
trng, nhim virut chng ta c th quan tm iu tr. i vi bnh c tim c hiu
nh bnh c tim chu sinh hay nghin ru th c th ngn nga bng cch gio dc
v li sng, nng cao sc khe.
2. Bnh c tim ph i
Do bnh c tnh di truyn nn cn qun l cc trng hp mc bnh.
3. Bnh c tim hn ch
Cn pht hin sm tr di 15 tui qua bch cu acid khng ht.

56

VA X NG MCH
Mc tiu
- Nm vng mt s gi thuyt v c ch bnh sinh v cc yu t nguy c va
x ng mch.
- Vn dng c cc triu chng lm sng v cn lm sng trong chn on
va x ng mch.
- Nm vng nguyn tc iu tr, cc phng tin iu tr chnh.
- Bit vn dng cc bin php c th c bit l cc thuc iu tr lipid mu
trong x tr v d phng x va ng mch
Ni dung

I. I CNG
T chc Y t th gii nh ngha: Va x ng mch l s phi hp cc hin
tng thay i cu trc ni mc ca cc ng mch ln v va, bao gm s tch t
cc b cc cht lipid, cc phc b glucid, mu v cc sn phm ca mu, m x v
cn lng acid, cc hin tng ny km theo s thay i lp trung mc.
Ni chung va x ng mch l hin tng x ha thnh ng mch bao
gm cc ng mch trung bnh v ng mch ln. Biu hin ch yu l s lng ng
m v cc mng t bo ti lp bao trong thnh ng mch gi l mng va.
Va x ng mch c pht hin cc xc c Ai cp t 50 nm trc
Cng nguyn. VXM gy ra 2 bin chng nguy him l nhi mu c tim v tai bin
mch no. cc nc cng nghip 50% t vong do tim mch trong nguyn nhn
VXM chim 50%. Ti M ngi trn 60 tui c 88% VXM, ngi gi hn th
khng ngi no khng b VXM. Bnh tuy vy vn gp ngi tr. Trn 300 lnh
M tui trung bnh 22 cht trong chin tranh Triu tin, khi m t thi thy 77% b
VXM vi mc nhiu hay t. nc ta cha c s liu ton dn.

II. NGUYN NHN- C CH BNH SINH

1. C ch bnh sinh
1.1. Nhc li cu to thnh ng mch
Thnh ng mch cu to bi 3 lp ng tm t trong ra ngoi nh sau:
- lp o trong hay lp ni mc: ch c mt lp duy nht cu to bi cc t bo ni
mc nm trong khong di khng c t bo v ngn vi trung mc bi lp n hi
trong.
- lp o gia hay lp trung mc to thnh bi nhng t bo c trn, si collagen v
elastin, gii hn ngoi mc bi lp n hi ngoi.
- lp o ngoi hay ngoi mc l lp m lin kt c cc mch mu nui.
1.2. Qu trnh pht trin VXM
Mng va x ng mch c to thnh do s dy ln ca cc thnh ng mch
bao gm mng li m si bao bc chung quanh bi lp m pht xut t khong
di ni mc ca bao trong. Mng VXM gp ch yu cc thn ng mch ln
(MC bng, m vnh, chu i, cnh v ch xung) c bit hay nhng vng
xoy mu nh nhng ch un cong hay ch i.
Mng VXM xut hin sau nhiu nm vi nhng c ch m ngy nay dn dn
c bit r hn:
- Giai on u do ri lon huyt ng ti ch (hin tng xoy mu) lm bin i
cu trc bnh thng ca lp trong. Tn thng xut hin sm nht l tnh trng ph

57
n khng c m, v sau mi xut hin cc t bo n m di dng cc t bo c
ht, t li thnh m di t bo ni m. Giai on ny thnh mch b ri lon to
iu kin cho lng ng lipid. Tip theo l s hnh thnh nhng vt m trn b mt
ni mc.
- Giai on hai, mng va n thun xut hin. Mng va dy gia c vng hoi t
nm trong mt v x. Vng hoi t cha rt nhiu acid bo v cholesterol. Mng va
x tin trin rt nhanh lm cho ng mch hp dn.
- Giai on sau cng l s bin i thnh mng va gy bin chng lm tc nghn
khu knh ng mch v tai bin thiu mu cc b. Hin tng ch yu ca qu trnh
pht trin ny l s lot ca lp o trong, ngha l lp t bo ni mc b x rch, mu
s chy vo qua ch lot to nn cc mu t. S rch ca ni mc gy nn s dnh
ca tiu cu, xut pht ca nghn mch, v to thnh cc tc, cc tc s bao ph
ch lot. y l khi u ca cc bin chng v sau. Cc mng va x pht trin
ngy cng nhiu, cc mng canxi gn lin nhau, t chc x pht trin nhiu hn gy
bt tc ng mch.
1.3. Nhng gi thuyt bnh sinh VXM
C nhiu gi thuyt cp nhng cha hon ton sng t.
1.3.1.Gi thuyt p ng tn thng thnh ng mch: Lp ni mc chu nhiu tn
thng khc nhau nh s gia tng cholesterol cao mn tnh hay do chn thng,
thuc, vi khun, min dch d ng, t min. Ni mc khi b tn thng s lm cho
n bo gn vo ni mc, di chuyn xuyn qua ni mc v chuyn thnh i thc
bo. i thc bo c kh nng bt gi cc ht lipid, nht l LDL bin i. S hin
din ca i thc bo lm gia tng tn thng lp ni mc.
1.3.2.Gi thuyt t bo: s xm nhp vo thnh ng mch ca bch cu n nhn
mt kh nng thc bo lm tn thng hoc kch thch pht trin cc t bo c trn,
i thc bo, t chc lin kt, pht trin nhng vng tn thng t gy VXM
nh thuyt tn thng nu.
1.3.3. Gi thuyt v ti lp th: Cc men ti th t bo thnh mch c th gy thoi
ho v tch t m t bo c trn nht l men cholesterol ester hydrolase.
1.3.4. Gii thuyt n dng: ti ni tn thng ni mc ng mch sn sinh nhng
dng isozyme kch thch pht trin t bo c trn ca thnh mch ging c ch to u
lnh tnh, sau l qu trnh to va x.
1.3.5. Gi thuyt v tng lipid: y l gi thuyt c nhiu ngi cng nhn nht
v:
- C th gy XVM trn thc nghim ng mch vi ch n nhiu m v
cholesterol.
- Nhng ngi c nng lipid mu cao hay b VXM hn nhng ngi bnh
thng
thnh phn cu trc ca mng VXM ch yu l lipid.
Ngoi ra hin nay nhiu tc gi cn a ra gi thuyt mi v c ch bnh sinh x
va lin quan n vai tr nhim trng nh Helicobacter pylori, Clamydia pneumonia,
Cytomegalovirus.
2. Cc yu t nguy c XVM
2.1.Tng lipid mu: hu ht cc kho st dch t hc u xc nhn tng cholesterol
mu l nguy c chnh VXM v l nguyn nhn bnh tim mch thiu mu. Tuy nhin
nguy c ph thuc vo loi lipoprotein chuyn ch cholesterol. LDL Cholesterol c
vai tr quan trng i vi bnh sinh VXM. C th ni rng bt k s gia tng LDL

58
cholesterol mc no trong mu u c nguy c gy VXM. Lipoprotein (a) hay
Lp(a) cng l yu t nguy c cao khi vt qu 0,3 g/l.
Chylomicron hnh nh t c ngha trong vic gy XVM mt phn v n hin din
c trong iu kin sinh l, mt phn ngi ta him thy s gia tng VXM song song
vi s gia tng chylomicron.
HDL Cholesterol ngc li l yu t chng x va cao v chng vn chuyn
cholesterol v gan trong iu kin thnh ng mch qu tha cholesterol, do cn
gi chng l nhng cholesterol tt.
2.2. Cc yu t nguy c khc:
- THA: L YTNC rt cao, nht l i vi cc mch mu no. HA cao lm tng sinh t
bo c trn lm dy trung mc ng mch v lm gia tng cht elastin, cht keo v
glycosaminoglycans. p lc do HA cao to ra cng lm d v mng x va cng
nh lm gia tng tnh thm ni mc i vi cholesterol.
- Ht thuc: cng l YTNC chnh, nguy c mch vnh tng gp i ngi ht
thuc, nht l nhng ngi ht 40 iu/ ngy.
- i ng: l nguyn nhn gy ri lon lipid, nn d gy XVM.
-Bo ph, t hot ng.
-Stress.
-Cc thuc nga thai.

III. PHN THEO SINH L BNH TN THNG NG MCH

1.Theo tn thng ng mch
- I: Bin i chc nng ni mc. Tn thng ny lin quan n lng cholesterol
cao v cc yu t nguy c.
- 2: Bong lp ni mc. Lin quan n ri lon lipid, thuc l, tiu ng.
- 3: nh hng n c trung mc, mng si c th din tin nng gy nt v.
Lin quan n ri lon lipid, huyt p cao v di truyn.
2. Theo tin trin VXM ca Stary: gm c 8 giai on
- Stary 1: Ch c i thc bo cha nhiu ht lipid.
- Stary 2: Di m xut hin.
- Stary 3: Lipid xut hin ngoi t bo ni mc.
- Stary 4: lng ng nhiu lipid ngoi t bo.
- Stary 5: thng tn va x. T bo c trn di chuyn v tng sinh trong mng.
- Stary 6: thng tn c huyt khi hoc xut huyt.
- Stary 7: thng tn vi ho. Lng ng canxi thay th lipid vi ho v mnh vn t
bo.
Stary 8: Mt s v tr tn thng thay th bng cht keo to thnh thng tn si
ho.

III. TRIU CHNG HC

Din tin triu chng lm sng thng tri qua 3 giai on:
- Giai on tim tng: cha c biu hin lm sng
- Giai on lm sng: c cc triu chng thiu mu c quan in hnh
- Giai on bin chng cc c quan do s thiu mu cc b gy ra.
Triu chng thng ph thuc vo cc c quan b tn thng.
1.VXM ch

59
Hay gp theo th t l gc ng mch ch, ng mch ngc, ng mch ch bng
nht l ni phn chia ng mch chu.
Triu chng:
- au tht ngc nu c tn thng XVM vnh.
- Nu tn thng ng mch ch: cc triu chng lm sng l triu chng h van
ng mch ch hay hp ng mch ch hoc phi hp.
- Bc tch ng mch ch: nu nng c trng thi au tht ngc d nhm nhi mu
c tim nhng khng p ng thuc dn mch vnh tr Morphine.
2. VXM bng
Giai on u nh ch c ri lon tiu ha v sau au bng v m, sau n.
- Khi nng hay hp nng: c th gy xut huyt hay thng d dy,hoi t mc treo,
rut.
- Khm c th pht hin ng mch ch phnh gin v bin chng nng ln v gy
trn mu bng, t vong.
- Chn on cn phi hp siu m, siu m Doppler v nht l chp ng mch ch
bng.
3. VXM no
Biu hin sm l tnh trng thiu mu vi xong, tai, ri lon tr nh, mau qun; v
sau l ln, khng tp trung c, mt ng. Bin chng nng n l tc mch mu no
gy lit na thn, ri lon ngn ng, ri lon thc hay xu hn l hn m.
4. VXM vnh
Vi cc biu hin ca suy vnh mn, hay cp tnh nh nhi mu c tim
5. VXM thn
Thiu mu thn lu ngy lm x ha, THA do hp ng mch thn. Xc nh chn
on cn da vo xt nghim nc tiu, siu m, chp mch thn hay sinh thit
thn.
6. VXM chi di
Tn thng gp hu ht cc ng mch tr ng mch mu bn chn t gp hn.
Triu chng thiu mu chi thng gp vi: t lnh hai chn, cn au cch hi, HA
hai chn chnh lch hay khng bt mch c bn tc mch. Bin chng v sau c
th gy hoi t. Chn on cn da vo siu m Doppler, chp ng mch.
Phn XVM theo Fontaine c 4 giai on:
+ Giai on 1: Khng c biu hin triu chng lm sng
+ Giai on 2: c cn au cch hi gm hai mc :
- 2a: ng knh i b trn 100m
-2b: ng knh i b di 100m
+ Giai on 3: cn au cch hi xut hin khi ngh ngi.
+ Giai on 4: hoi t cc u chi.
7. VXM ni khc: Him gp hn nh:
- ng mch thi dng: gy nhc u nh bnh Horton hay Migrain.
-ng mch y mt: gy ri lon th gic
-ng mach h khu no tuyn yn: gy i tho nht
-ng mch ty: gy i tho ng

IV. CHN ON

60
Chn on da vo nhiu du chng v kt qu thm d cn lm sng khng c
mt tiu chun r rt. C th:
- Cc ri lon c nng do thiu mu cc b c quan hoc ngoi bin.
- S hin din ca nhng yu t nguy c.
- Tnh trng ng mch ngoi bin.
- Kt qu xt nghim: soi y mt, xt nghim bilan lipid, chp ng mch cn
quang, siu m doppler.

V. IU TR
1. Nguyn tc iu tr
C 3 mc ch chnh
- iu tr cc yu t nguy c chnh: ri lon lipid, i tho ng, tng huyt p,
thuc l trc khi c cc triu chng (phng bnh s cp) hoc sau khi c cc triu
chng (phng bnh th cp).
- iu tr cc bin chng va x ng mch (VXM) s cp v th cp (iu tr
chng ngng kt tiu cu)
- iu tr c hiu tn thng
Mt s nguy c phi hp song song cn iu tr nh: iu tr thay th hocmon trong
tin mn kinh, ch n king trong bo ph, tng hot ng th lc
2. iu tr c th
2.1. Thay i cc yu t nguy c (YTNC)
Mt s YTNC caVXM c th tc ng nhm ngn chn s tin trin hoc lm
gim dn XVM: ngng ht thuc, kim sot HA, n nh ng mu, trnh dng
ru qu nhiu, tp th dc u n nht l kim sot s ri lon lipid mu. Nhiu
nghin cu cho thy s iu tr c kh nng gim c ngha ng k cc bin
chng tim mch, tuy nhin t c tc dng gim thiu cc mng VXM.
2.2. Thuc c ch men chuyn v thuc chn bta
Nhiu nghin cu cho thy hai thuc ny c th gim nguy c nhi mu c tim v
bnh tim do thiu mu cc b ni chung. V d thuc c ch men chuyn gim t 14
n 28% bin c tim mch; thuc chn bta gim t l t vong sau nhi mu c tim
20%, gim ti pht nhi mu 25% v gim t t 30%.
2.3. iu tr tng lipid mu
iu tr va x ng mch l mt iu tr ton din bao gm nhiu bin php ni v
ngoi khoa, tuy vy mt trong nhng mc tiu c bn vn l thoi trin mng va x
c s lng ng lipid, gim i cc thnh phn lipoprotein mu c hi.
* Phn loi tng lipid mu theo Friedrickson
L phn loi thng dng nht, kinh in. C 5 th:
- Loi 1: tng ch yu chylomicron, t TG/CT > 2.5.
- Loi 2: chia lm 2 th: th IIa: tng LDL-C vi t TC/TG >2.5 v th IIb: tng c
LDL-C v HDL-C, t TG/TC hoc TC/TG <2.5.
- Loi 3: t gp, tng IDL-C, t TG/TC< 2.5.
- Loi 4: tng VLDL-C, t TG/TC > 2.5
- Loi 5: him, tng c chylomicron v VLDL-C.
Trong cc th trn th cn iu tr l IIa, IIb v th IV do nguy c gy va x ng
mch cao.

61
* Thuc gim lipid mu
Gm 4 nhm chnh:
- Nhm 1:l cc cht bt gi mui mt. Tc dng chnh l gim LDL-C. y l nhng
resin trao i ion gn vi mui mt trong rut non lm gin on s lu hnh mui
mt trong chu trnh gan rut v kch thch s chuyn cholesterol thnh mui mt
trong gan. iu ny s kch thch s to thnh cc th th LDL do s lm gim
LDL huyt thanh. ng u nhm l cholestyramine (Questran), gim cholesterol
15-30% v triglycerid t 5-15% vi liu dng 4-16 g/ngy. Colestipol liu 5-20 g/
ngy. Tc dng ph: to bn, y bng, bun nn.
- Nhm 2: cc fibrate c tc dng tng hot tnh lipoprotein lipase lm gia tng qu
trnh thoi bin VLDL-C v IDL-C do gim triglycerid. u im l HDL -C gia tng
khi x dng fibrate. Tc dng ph bao gm ri lon tiu ho, gia tng to si mt.
Thuc thng dng nh fenofibrate (Lipanthyl) lm gim CT (15-30%) v TG (1530%), liu t 100-300mg/ ngy. Gemfibrozil 600 mgx 2ln/ngy hoc Clofibrate
500mg x 2-3 ln/ngy.
- Nhm 3: c acid nicotinic v dn cht. Tc dng khi dng liu cao. C tc dng
gim s to thnh VLDL trong gan do gim HDL. Nicotinic acid gim CT (5-15%)
v TG (15-30%) v lm gia tng c HDL-C. Thuc thng dng l probucol (Lurselle)
liu 0.3-0.6g/ ngy. Tc dng ph:phng mt, tng dng mu, tng acid uric mu,
ri lon tiu ho, c cho gan. Cn theo di chc nng gan khi iu tr. Phng mt
c th khng ch bng aspirin.
- Nhm 4: l cc statin, lm gim CT >30-50 % v TG 15-50%. y l nhm thuc c
tc dng mnh h cholesterol mu. C ch tc dng l c ch men HMG CoE
reductase lm ngn cn qu trnh chuyn ho to cholesterol ni bo. c ch qu
trnh ny s lm gia tng tng hp th th LDL do s lm gim cholesterol huyt
thanh. Thuc thng dng l Fluvastatine liu 20-40mg/ngy, Lovastatine 1080mg/ngy, Pravastatin 10-40mg/ngy, Simvastatin 5-40 mg/ngy. Tc dng ph
bao gm kh tiu, bn, au bng, co rt v c th c vi gan nn cn theo di men
gan.
* Vic chn la thuc
Cn cn c vo s gia tng thnh phn lipid l ch yu.
- Nu tng CT: u tin l cc resine, statin ri n cc fibrate hoc nicotinic acid. C
th phi hp resin vi statin hoc resin vi nicotinic acid
- Nu tng TG: u tin l cc fibrate ri n nicotinic acid. C th phi hp fibrate v
resin hoc nicotinic acid v resin
- Nu tng c CT v TG: u tin l fibrate ri n statine, nicotinic acid. C th phi
hp resin vi nicotinic acid hoc fibrate vi resine hoc resine vi statin.
Vic iu tr tng lipid mu thng phi ko di nhiu thng nhiu nm v chi ph
cao nhiu tc dng ph nn cn phi cn nhc. Ngoi vn iu tr cc yu t nguy
c rt quan trng vic x dng thuc phi lm th no t c mc chun nh CT
phi gim di 200mg% v hoc TG di 200mg%.
* Thuc chng oxt ha
Nh cc vitamine A, C, E, du gan c.
2.4. Thuc dn mch
Papaverine 0.04g X 2-4 vin/ ngy, Hydergine 3-6mg/ ngy, Tegretol 100mgX 3-6
vin/ ngy. Ngoi ra cn c nhiu ch phm tng t c th p dng Vastarel,
Fonzylane, Praxilen, Torental, Sermion, Trivastal, Cervoxan.

62
2.5. iu tr ngoi khoa
Phu thut ly b cc nghn hoc nong ng mch bng bng kt hp t stent, bt
cu qua ch tt.
2.6. Phng nga cc mu ng
Cc mu ng to thnh trn mng VXM lm cho tin trin bnh nhanh v gy ra
cc bin chng nh mch vnh. Aspirin c hiu qu trong phng nga ti pht
NMCT cp, liu dng 100mg/ ngy n thun hoc phi hp dipyridamol
(Persantine) liu 75-150 mg/ ngy.

III. D PHNG BNH VXM

Chia ra 2 mc d phng, tin pht v th pht.
1. D phng tin pht
Nhm d phng sm k c khi mi sinh:
- Bo m ch sa m, trnh cc thc n lm tng lipid nh ng v tinh bt.
- Gim mui trong ch n nhm lm gim tng huyt p. m bo ch n
nhiu rau qu, nn n nhiu c ti. Khng ht thuc l.
- C ch luyn tp d phng bo ph. Tp th dc ty theo mc u c tc
dng chng tng lipoprroteine c hi.
- Sinh k hoch trnh tng cn sau sinh.
2. D phng th pht
Cho cc bnh nhn b bin chng VXM.
-iu tr tch cc cc nguyn nhn hoc yu t nguy c gy bnh nh thuc l i
tho ng, tng huyt p. Gim stress, tng cng hot ng th lc.
- Theo di v iu tr cc bin chng ti cc trung tm u n c theo di nhm
trnh ti pht.

63

CC THUC CHNG LON NHP TIM

Mc tiu
- Trnh by uc nh ngha ca ri lon nhp tim
- Nm vng c cch phn loi cc thuc chng lon nhp
- Nm vng c mt s thuc chng lon nhp tiu biu.
- Nm c ch nh iu tr.
Ni dung

I. NH NGHA
Ri lon nhp tim l s ri lon hot ng in sinh hc ca tim v ba mt:
- S to thnh xung ng
- S dn truyn xung ng
- Phi hp c hai mt trn

II. PHN LOI

Thuc chng lon nhp tim c chia lm 4 nhm theo phn loi ca VaughanWilliam.
- Nhm I: c tc dng n nh mng t bo ngha l c ch dng Natri nhanh qua
mng t bo vo lc kh cc. Trong nhm ny chia lm 3 phn nhm:
+ Nhm Ia: ng u l quinidine, c tc dng gy t mng, lm ko di thi
k tr hiu qu v in th ng. Thuc c tc dng c ch co bp tim.
+ Nhm Ib: c tc dng gy t mng nh hn. Ngc li, c tc dng rt
ngn thi k tr hiu qu v in th ng. t c ch s co bp tim. i din l
Xylocaine.
+ Nhm Ic: c c 2 tc dng trn nhng khng thay i thi k tr v in th
ng. i din l flecaine.
- Nhm II: l thuc c ch cc th th giao cm bta, gim nng catecholamine.
C tc dng c ch co bp tim. ng u l propranolol. Nhm ny c 2 tiu nhm:
nhm chn lc ln tim v nhm khng chn lc ln tim, trong c thuc c tc
dng giao cm ni ti v thuc khng c tc dng giao cm ni ti.
- Nhm III: ng u l amiodarone. C tc dng ko di thi k tr v in th
ng thng qua tc dng c ch knh kali ra khi t bo. t lm gim s co bp tim.
- Nhm IV: nhm c ch knh canxi chm vo trong t bo. c ch c s dn
truyn ln t ng. Lm gim s co bp tim. ng u nhm l verapamil.
Ngoi ra cn c mt s thuc c tc dng chng ri lon nhp tim nhng cha phn
loi chnh thc vo nhm ca Vaughan-Williams. l digital v ATP.

III. NHNG THUC CHNG LON NHP CHNH

1. Quinidine: nhm Ia ca Vaughan-Williams, hin nay t dng v tc dng ph nhiu.
Liu lng: quinidine sulfate tr em 30-60mg/kg/ngy chia lm 4 ln; ngi ln:
300-600mg/ngy chia lm 4 ln. Loi tc dng chm c liu tng cng tng t.
Bi tit: qua gan.
Tng tc thuc: amiodarone, cimetidine, verapamil lm tng nng quinidine
trong mu. Phenyltoine, phenobarbital, rifampicine lm gim nng quinidine trong
mu. Quinidine cn lm tng nng digital khong 50%, cng nh tng tc dng
ca warfarine.
c tnh: chn n, nn, bun nn. Gy lon nhp khong 15% ngi ln trong

64
c xon nh v ngt.
2. Disopyramide (Rythmodan): nhm Ia ca Vaughan-Williams
Liu lng: ngi ln 300-1000mg/kg/ngy, chia lm 4 ln.
Bi tit: 50% qua thn v 50% qua gan.
Tng tc thuc: atenolol, erythromycine lm tng nng disopyramide. Tng tc
dng ca warfarine v tng c tnh ca lidocaine.
Tc dng ph: kh ming, b tiu, nhn m, to bn, lm suy tim nng do gim co
bp tim, gy lon nhp.
3.Lidocaine (Xylocaine): nhm Ib ca Vaughan-Williams.
Liu lng: liu tn cng bng ng tnh mch 0.5-1.0 mg/kg/ln. C th lp li
sau 5-10 pht khi c kt qu, liu ti a l 5mg/kg. Liu duy tr: 20-50microg/kg/pht,
gim liu nu dng thuc trn 24 gi.
Bi tit: qua gan.
Tng tc thuc: thuc c ch bta, cimetidine lm tng nng lidocaine.
Phenyltoine, phenobarbital, rfampycine v isoproterenol lm gim nng . Tng
c tnh lidocaine khi dng phi hp disopyramid.
Tc dng ph: ch yu ln h thn kinh nh co git, d cm, mt cm gic v ngng
h hp.
4. Flecaine: thuc nhm Ic
Liu lng: ngi ln ung 200-400mg/ngy.
Bi tit: 50% gan v 50% thn.
Tng tc thuc: amiodarone, cimetidine lm tng nng thuc trong mu.
Propranolol lm tng nng c hai trong mu. Tng nng digital khong 50%.
Tc dung ph: cc biu hin thn kinh nh run, dau u, d cm, gim i khi gim
liu. Lm gim co bp tim nn khng dng khi c suy tim. C tc dng gy lon nhp
tim nu dng bnh nhn c tn thng c tim.
5. Propranolol: nhm II ca Vaughan-Williams
Liu lng: ung 2-5mg/kg/ngy chia lm 4 ln. ng tnh mch 0.1-0.2mg/kg/liu
trong 5 pht. C th lp li sau mi 6 gi.
Bi tit: qua gan.
Tng tc thuc: cimetidine, furosemide, quinidine lm tng nng thuc.
Phenyltoine, phenobarbital, rifampicine lm gim nng trong mu.
Tc dng ph: lm chm nhp tim, tng bloc tim, tng suy tim, co tht ph qun, lm
tng ng mu, c th trm cm, lit dng.
6. Amiodarone: nhm III ca Vaughan-Williams.
Liu: ung tn cng ngi ln 10mg/kg chia 2 ln / ngy trong 10 ngy sau
gim liu duy tr 5 mg/kg/ ngy trong 2 thng ri gim li na liu.
Tng tc thuc: amiodaron lm tng tc dng ca warfarine khong 100%,
digoxine 70%, quinidine 33% v procainamid 50%. Thuc lm tng nng ca
flecaine, phenyltoine. C tc dng hp ng vi thuc c ch bta, chn canxi nn
khng dng phi hp cc loi ny khi c suy tim.
Tc dng ph: rt t. C th gy vim phi, lng ng kt mc mt, ri lon chc
nng ti gan, tuyn gip, xm da nu iu tr lu di.
7. Adenosine: thuc khng nm trong phn nhm Vaughan-Willams nhng c tc
dng chng lon nhp tim tt nn c tc gi xut nhm VI. (Digital c xut

65
nhm V)
Liu lng: chch tnh mch nhanh liu 50-250microg/kg. C th nhc li sau 5-15
pht.
Bi tit: tc dng cc ngn, ch di 10 giy.
Tng tc thuc: dipyridamol, diazepam lm tng nng adenosine. Theophyliine
v quinidine lm gim nng thuc. Adenosine c th c tc dng hp dng vi
verapamil.
Tc dng ph: kh th, au ngc, nn nhng gim nhanh.

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

66

IN TM BNH L
Mc tiu
1. Nm vng c ch bnh sinh v in tm cc hi chng bnh l c tim.
2. Vn dng c cc tiu chun in tm trong chn on lm sng.
Ni dung

I. I CNG CC T TH IN HC CA TIM
1. V tr in hc v gii phu ca tim
Tim bnh thng c tm tht phi chim mt trc tim, cn tm tht tri nm
phn tri - bn v sau ca tim. Trc tim bnh thng i t y tim n mm tim trc
tim hng t sau ra trc xung di v qua tri. Tuy vy do nhng yu t bnh l
v sinh l khc nhau, t th in tim c nhiu thay i, nhng thay i ny pht sinh
do tim quay theo 3 trc chnh.
- Trc trc - sau: i qua tm ca qu tim. Khi xoay theo chiu kim ng h, tim s
t th thng ng. Khi xoay ngc chiu kim ng h t th tim s nm ngang.
- Trc dc: i t gia y tim n mm tim. Khi xoay theo chiu kim ng h, tm
tht phi s chim ton b mt trc tim v tm tht tri s chuyn ra sau, xung
di. Khi xoay ngc chiu kim ng h, tm tht tri s chim phn ln pha trc
ca tim.
Bng 1: Cc biu hin ca in tim theo t th tim
Trc xoay ca tim
1- Tim quay quanh
trc dc

2- Tim quay quanh

trc trc sau
3- Tim quay quanh
trc ngang

Chuyn o tim

Biu hin in tim

Biu hin in tim

- Trc tim
-D
- VR

Tht (P) ra trc

RS V5, V6
SI Q III
rS, QR, Qr

Tht (T) ra trc

RS V2, V1
QI S III

Mm tim sang (P) SI,

- Ch.o thng dng RIII
- VL
QS rS
- Ch.o thng dng
- aVF

Mm tim ra trc
QI, Q II, Q III
qR

Mm tim sang (T)

RI SIII
qR, qRS
Mm tim ra sau
SI, SII, SIII
QS, Rs

- Trc ngang: hng t phi sang tri, i qua trung tm ca khi c tim. Nu
tim quay v pha trc, mm tim s hi xoay ra trc v y tim ra sau. Cn nu tim
quay ra pha sau, s bin i s ngc li. Thc t khi tim quay bao gi cng theo
c 3 trc trn.
2. T th in hc
T th in hc tim gip ta nhn bit c s thay i ca in tm , hiu
thm c ch pht sinh v hnh dng cc sng trn cc chuyn o khc nhau. Thc
t ngi ta hay xc nh t th in tim theo Wilson. Phng thc ny cho php ta
xc nh t th tim quay theo trc hay gp nht l trc trc sau. C 6 t th trong
t th trung gian hay gp nht, tim bnh l v phn ln cc ca dy tht tri
thng c s lin quan gia t th tim v trc in tim.
Bng 2: Cc t th in hc ca tim
T th T

Trc T

Cc phc hp tht ging nhau

67
1- Nm ngang
2- Na ngang
3- Trung gian
4- Na ng
5- Thng ng
6- Khng xc nh

0o - 300
0o 0o

VL V5, V6
VL V5, V6

VF V1, V2
VF thp

0o 30o
0o 60o

VL V5, V6
VL thp

VF V5, V6

0 90
khng xc nh

VL V1, V2

VF V5, V6
VF V5, V6

II. HI CHNG DY C TIM

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

Phi

Tri

Bnh thng
Dy nh phi
Dy nh tri
1.1. Dy nh tri:
1.1.1. Nguyn nhn:
- Hp 2 l, thng gp nht (cn gi l P hai l).
- H 2 l, hp h van MC, tng HA.
1.1.2. Triu chng:
- Sng P rng trn 0,12 , c th lm mt c khong PQ, l triu chng c bn v
sm nht.
- Sng P ch i, hai nh, khong cch 2 nh trn 0,03, nh sau thng cao hn
nh trc cc chuyn o ngoi bin. chuyn o V1, V2 c sng P 2 pha vi
pha (-) > pha (+). chuyn o thc qun bin nh tng cao gp 5 - 10 ln
chuyn o ngoi bin.
- Trc sng P trn mt phng trn lch tri + 300 n + 450.

68

P rng
P hai nh
P hai pha (-) > (+) V1
1.2. Dy nh phi
1.2.1. Nguyn nhn:
- Tm ph mn (cn gi l P ph ).
- Cn gp trong h van 3 l, bnh tim bm sinh nh t chng Fallot, thng nh...
1.2.2. Triu chng:
- P cao nhn > 2,5 mm, nu trn 3mm l chc chn, c khi ch nhn ch khng cao
do trn dch mng ngoi tim hay kh ph thng.
- V1, V2 c P 2 pha vi pha (+) > pha (-) hoc xut hin nhnh ni in nh rng.

P cao nhn
P 2 pha (+) > (-) V1
Nhnh ni in nh
1.3. Dy hai nh: Phi hp hai hi chng trn
1.3.1. Nguyn nhn: Thng gp l do tn thng c van 2 l v van 3 l, thng
nh...
1.3.2. Triu chng: Ch yu l sng P rng.
- ngoi bin: C th sng P rng v cao hoc c du dy nh tri nhng P c nh
trc ln v rng hn.
- trc tim: chuyn o V1, V2: c th gp P di 3 hnh thc:
+ Sng P hai pha kiu pha dng ln hn pha m + bin cao + nhnh ni in
rng
+ hoc sng P cao trn 3mm
+ hoc sng P m rt su.
2. Hi chng dy tht
Cc biu hin chung ca dy tht l.
- Bin sng R cao ln do cc si c tim gia tng v s lng v di (c khi
sng R khng cao do tc ng trung ha v in hc).
- Dn truyn chm tr th pht trong tm tht lm QRS dn rng.
- Thay i trc in tim v t th in hc tim.
- Nhnh ni in xut hin mun do dy c tim lm s dn truyn t ni tm mc ra
thng tm mc chm i.
- Vng chuyn tip (RS) lch tri hay phi.

69
- S thay i ti cc do s mt cn i gia khi lng c tim v kh nng cung
cp mu.
C 2 khi nim cn bit lin quan n s bin i ti cc, tuy rng cng c
g tr tng i. l:
- Tng gnh tm thu: l s tng gnh tht ca ng tng mu k tm thu nh trong
hp MC, hp MP. C tim dy ng tm lm on ST - T bin i ngc chiu
QRS.
- Tng gnh tm trng: l s tng gnh tht do lng mu dn v tht k tm
trng nh trong h van MC, h 2 l. Khi c tim dn ra lm s bin i ti cc
nh nhng hn. Sng T thng dt, dng. on ST c th chnh xung i vi
dy tht tri. Trong tng gnh tht phi s c ri lon dn truyn trong tht.
2.1. Dy tht tri
2.1.1. Nguyn nhn: Tng huyt p, h van MC, thiu nng vnh mn tnh, hp
van MC, h 2 l, cn ng ng mch, hp eo MC.
2.1.2. Triu chng
2.1.2.1. Phc b QRS
+Chuyn o trc tim
* Phc b QRS dn rng t 0,11 - 0,12 - qu gii hn ny phi nghi c bloc
nhnh tri.
* Sng R V5, V6 > 25mm - 30mm (i vi ngi c thnh ngc mng). C
khi R khng cao do t th tim xoay phi hay tri qu mnh, khi cn xc nh mm
tim t in cc thm d.
* Nhnh ni in trn 4,5 trong 2/3 trng hp.
*Sng Q bao gi cng c mt v c xu hng su hn (dy vch lin tht
tri) nhng khng qu 1/4 chiu cao sng R i sau n, chiu rng sng Q trn 0,04.
*Sng S mt hoc rt nh, nu S r phi xem chng c phi hp bloc hay dy
tht phi hoc tim xoay tri qu mnh, hoi t...
* V1, V2 sng S di ra, t s R/S nh, i khi c dng QS.
* Vng chuyn tip dch phi.
+ Cc ch s:
*Sokolov-Lyon: SV1 + RV5 trn 35mm hoc tng s sng R+S ln nht trong cc
chuyn o trc tim trn 45mm.
* Du Shane: sng Q V5, V6 > 4mm km theo cc du hiu khc ca dy
tht tri.
Trong ch s Sokolow- Lyon l ng tin cy nht; nhng lu phi trn 25
tui mi c gi tr cao.
+ chuyn o ngoi bin: trc in tim lch tri do chu nh hng ca t th in
hc ca tim.
* T th nm: chuyn o D1, aVL c dng R hay QR, R ca aVL trn 12mm
Tng R1 + S3 tng c khi trn 26mm. Ch s White-Bock:Tng i s QRS1-QRS3
trn 18mm (bnh thng t 15mm n 18mm).
*T th ng hay na ng: D3 v aVL c dng QR hay R, sng R aVL
trn 20mm. D1 v aVL c dng RS.
*T th trung gian: 3 chuyn o mu v aVL, aVF c dng R hay qR.
- on ST-T:

70
+ Tng gnh tm thu: ST-T c xu hng ngc chiu QRS.
+ Tng gnh tm trng: sng T lun lun (+) v nhn, ST hi lch xung cht t.
2.1.3. Cc du hiu phi hp: c th gp.
- Bloc nhnh tri khng hon ton.
- on ST-T bin i su hn.
V1, V2
R V5, V6
r (1)

(3)
(1a)
(1b

(1)

(2)
Hnh nh sng in tim chuyn o trc tim phi V1,2 v tim tri V5,6 cng c
ch to thnh cc sng in tim trong dy tht tri.
2.2. Dy tht phi
2.1.1. Nguyn nhn: Hp 2 l, tm ph mn, h 3 l, thng lin nh, t chng Fallot,
hp van MP, thng lin tht, o gc ng mch, thn ng mch chung, tng p
phi tin pht, phc hp Eisenmenger...
2.1.2. Triu chng:
-Phc b QRS: khng dn rng qu gii hn bnh thng.
-Chuyn o trc tim:
+ Chuyn o V1, V2: du hiu quan trng l s tng bin sng R, sng R cao
trn 7mm, ch s Sokolov - Lyon: RV1 + SV5 >11mm c gi tr chn on, c khi R
khng cao trong mt s trng hp nh tm ph mn, kh ph thng, khi QRS
thng c dng rS, W, QS... Nhnh ni in mun 3% - 3,5% nu trn 5% l c
bloc nhnh phi phi hp.
+ Chuyn o V5,V6: sng S su hn bnh thng, c th bng R hay dng rS.
+Vng chuyn tip: lch v V5, V6.
+ Chuyn o ngoi bin: Trc phi, gc ((110 o.
- on ST-T: C 2 kh nng:
+ Tng gnh tm thu: ST-T chuyn tri chiu QRS.
+ Tng gnh tm trng: Bloc nhnh phi.
V1 V2

V5 V6

71

Hnh nh dy tht phi vi dng Rs V1,V2 v S V5, V6

2.3. Dy hai tht
2.3.1. Nguyn nhn: Thng gp trong hp h van hai l c tng p phi, bnh hai
l - ng mch ch, hp van hai l c tng p phi, tm ph mn km THA, thng
lin tht hoc cn ng ng mch c tng p phi.
2.3.2. Triu chng: thng phi hp, c th gp:
- Dy tht phi chuyn o tim phi + dy tht tri chuyn o tim tri.
- Dy tht tri chuyn o tim tri + du dy tht phi chuyn o ngoi bin.
- Du hiu Katz-Watchel: tng R + S cc chuyn o trc tim (50mm.
3. Bloc nhnh
3.1.Bloc nhnh tri: 90% trng hp bloc nhnh tri c km theo dy tht tri nng
hay nh. Tin lng xu v tn thng c tim nng, nhnh tri b His b t.
3.1.1. Nguyn nhn: Thiu nng vnh mn tnh, tng gnh tht do cc bnh THA,
hp h MC, hp eo MC, hoc bnh c tim ngi tr (him gp).
3.1.2. Triu chng:
- Chuyn o QRS: thng dn rng; nu bloc nhnh tri hon ton thi gian QRS
> 0,12
+ V5, V6: phc b QRS c mc nh, cao nguyn hay ch i, c khi c dng
rSR, nhnh ni in mun, mt sng Q. Nu c Q phi nghi c hoi t c tim. Sng
S cng mt, nu c phi nghi tim nm ngang hoc tim xoay theo kim ng h rt
mnh hoc c phi hp bloc nhnh phi khng hon ton.
+ chuyn o ngoi bin: ty vo t th tim.
* Tim xoay sang tri hay gp nht (90%), hnh nh trc tip D1, aVL, gin
tip D3.
* Tim khng xoay: D1, D2, c hnh nh trc tip, D3 c hnh nh trung gian.
* Tim xoay phi: t gp; D2, D3, VF c hnh nh trc tip.
- on ST-T: Chnh v m ngc vi QRS.
V1, V2

V5, V6

Hnh nh bloc nhnh tri V5,6 v

gin tip V1,2
3. 2. Bloc nhnh phi
Ngc vi BNT, BNP d hon ton hay khng hon ton thng i n c,
tin lng tt, c th gp trn tim bnh thng.
3.2.1. Nguyn nhn: Nu l tim bnh l s c.

72
- Bloc nhnh phi hon ton: Thiu nng vnh ngi gi, tng gnh tht tri do THA,
hp MC, NMCT trc vch.
- Bloc nhnh phi khng hon ton: Thng gp trong tng gnh tht phi, thng
nh, thng tht, thng nh-tht, suy tim phi, hp hai l, hp 3 l, bnh tm ph cp
c dn tht phi, ngoi ra cn gp trong tm ph mn, bnh Ebstein.
3.2.2. Triu chng:
- Phc b QRS chuyn o trc tim: Ch yu V1, V2, V3R, V4R. C dng rsR
vi R dn rng, trt m hay c mc vi nhnh ni in i khi 6% -10%; khi c
phi hp dy tht phi th R cng cao. V5, V6 c dng QRS vi S dn rng, trt
m (du hiu gin tip).
- Chuyn o ngoi bin: thng gp nht l aVR dng qR hay QR, rsR, rSR vi
R hay R dn rng trt m.
Ngoi ra cc chuyn o ngoi bin c th gp:
* Bloc Wilson: bloc nhnh phi c trc tri.
* Bloc him: bloc nhnh phi c trc phi rt mnh.
- on ST - T: tri chiu QRS.
BNP khng hon ton hay gp ngi tr v tr em bnh thng. Nu bnh
l, bloc nhnh (P) khng hon ton thng km theo thiu nng vnh, dy tht, tm
ph cp v mn, vim mng ngoi tim.

V1,V2

V5,V6

Hnh nh bloc nhnh phi vi hnh nh trc tip V1, 2

v gin tip V5, 6
4. Ri lon in gii
4.1. Kali
4.1.1. Tng Kali mu: Bnh thng nng K+ mu t 3,5 - 5,5 mEq/l. Khi nng
K+ trong mu tng cao s c ch tnh t ng ca cc lc ch v nt. Cc du hiu
in tm thng t l rt cht ch vi m K+ ca mu.
Biu hin chung ca tng Kali mu l:
- QT ngn li, T cao nhn.
- Bloc nh tht cc mc khc nhau, bin i QRS.
- Khi nng hn, sng P dn, dt, PQ di ra, ST chnh ln v sau cng xut
hin nhp nt, t ng tht, rung tht, ngng tim.
4.2. Gim K mu: Khi K < 3,5mEq/l, in th ngh s gim v in th hot ng ko
di. Triu chng ch yu l s bin i ST-T.

73
- Khi K+ mu t 3,5 - 3mEq/l: cha c thay i ng k.
- Khi di 3.5mEq/l: Bin sng P cao ln, ST chnh xung, T dt, sng U
cao hn. Khi nng hn sng T ln vo sng U.
Ch : Sng U c th cao trong dy tht tri, nhim Digital, nhim Quinidin.

74

Ngng tim
mEq/l

12,5
Hai pha

Rung tht

10,5
QRS dn rng
7,5

T cao nhn
Bnh thng

5,0

T dt

2,5
RLDT Nh tht
Sng U(+)
00
Ngng tim
S bin i in tm theo nng kali mu
4.2. Canxi mu
Ca++ mu c tc dng r vo giai on 2e ca in th hot ng tim.
4.2.1. Gim canxi mu: lm ST di ra v QT di theo. Ca++ cng gim th ST cng
di ra nhiu. Khi nng hn QRS s hp li, sng T c th m hay dng.
4.2.2. Tng Canxi mu: lm ST ngn li, QT cng ngn theo.
Tng Canxi mu
Gim Canxi mu

QT ngn
QT di
5. Tc dng thuc
5.1. Digital: Vi liu thp Digital ko di giai on in tm ; liu cao (ngm
Digital) s rt ngn giai on 2e v vi liu c lm in th ngh gim i v gim tc
giai on O, tng tnh chu kch thch, gim tnh dn truyn (cc trung tm lc ch.
5.1.1. Liu ngm Digital: ST chnh xung vi c im: c hnh y chn (cn
gi l ru mp kiu Mexico), hoc vung gc, ST chnh theo hng i lp vi QRS.
- Sng T dt, 2 pha ri m (tc dng Conn)
- QT ngn ti (++).

75
- PQ di ra v sng U cao ln.

ST vung gc

ST

hnh

chn
5.1.2- Du ng c Digital: Ni chung c th ni c nhim c nu ri lan nhp v
ri lon dn truyn nh tht nh sau:
- Ngoi tm thu thng gp nht v nht l ngoi tm thu tht (tht phi
thng gp hn ngoi tm thu tht tri), thng ngoi tm thu tht i nhp i, ba, c
th ngoi tm thu a dng, a hoc lun phin...
- Bloc nh tht cc : t cp 1, cp 2 (kiu Luciani-Wenkebach hoc kiu 2/1)
ri n cp 3.
- Cc loi nhp khc u c th gp him hn.
5.2. Quinidine
C tc dng rt quan trng ln mng t bo lm gim in th ng, K+, Na+,
++
Ca .
5.2.1. Du ngm Quinidine:
- QT di ra l du hiu in hnh nht. Sng U cao ln.
- Sng T thp v rng ra c khi 2 pha hay hi (-).
- ST chnh, sng P dn rng, phc b QRS dn rng.
5.2.2. Du ng c Quinidine: c th gy ra ngoi tm thu tht, nhp nhanh kch pht
tht, rung tht, ri lon dn truyn nh tht hay ri lon dn truyn trong tht.
QRS dn rng

Sng P mc
ST chnh xung

Tdt Sng U cao

76

RI LON NHP TIM

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

I. NH NGHA
Ri lon nhp tim (RLNT) l s ri lon hot ng in sinh hc ca tim v ba mt
- S to thnh xung ng
- S dn truyn xung ng
- Phi hp c hai mt trn

II. NGUYN NHN V C CH SINH BNH

1. Nguyn nhn
- Cc bnh nhim khun: thp tim l nguyn nhn thng gp nht; ri n cc
bnh nhim khun khc nh thng hn, bch hu.
- Do nhim c: thng gp l cc loi chng lon nhp nh: digital, quinidine
procainamid,reserpine, thuc chn beta.
- Do ri lon in gii: nh tng hoc gim kali mu, magn mu, canxi mu.
- Cc bnh ton thn: nht l cng gip, d ng thuc, i tho ng.
- Cc bnh c tim: do nhi mu c tim, thoi ha,lao,unh th, chn thng, cc
bnh tim bm sinh nh thng tht, cn ng ng mch, t chng Fallot.
- Do ri lon thn kinh thc vt: do xc cm hoc gng sc.
- Do phu thut.
- Do di truyn.
2. C ch bnh sinh: RLNT xy ra khi
2.1. Ri lon v s hnh thnh xung ng: c th gp
- Tng tnh t ng ca nt xoang: lm ton b tri tim s p theo vi tn s nhanh
nh nhp nhanh xoang.
- Gim tnh t ng ca nt xoang: tim s p chm gp trong nhp chm xoang,
nhp b ni,
- Tng tnh t ng ca ch nhp di nt xoang: l nhng ngoai tm thu.
- Ngoi ra mt s si c tim c th pht ra xung ng nh trong cn nhp nhanh
tht.
2.2 Ri lon v dn truyn xung ng: khi xung ng b tr ngi lm s dn truyn b
chm i ta gi l bloc. Bloc c th sinh l khng c tn thng thc th ca c tim
xy ra bt k v tr no ca ng dn truyn nh bloc nhnh, bloc nh tht, bloc
xong nh. Bloc cng ch c th theo mt chiu t trn xung, hoc hai chiu. c bit
c th gp c ch vo li trong RLNT l mt c ch c bit gp trong ngoi tm
thu, cn nhp nhanh tht hoc trn tht.
2.3. Phi hp c ri lon dn truyn xung ng v hnh thnh xung ng: c ch ny

77
s to ra nhng RLNT phc tp hn nh phn ly nh tht, song tm thu..

III. TRIU CHNG HC MT S RLNT THNG GP

1. Nhp nhanh xoang
- Nguyn nhn: xc ng, st cao, suy tim, cng gip, thiu mu.
- Triu chng hc: hi hp, nhp tim trn 80ln/ pht c khi ngh ngi v nhp gia tng
khi gng sc.
- Chn on: nh in tim vi nhp xoang tn s trn 80 ln/ pht.
2. Nhp chm xoang
- Nguyn nhn: luyn tp th dc nhiu, cng ph v do nhi mu c tim vng saudi, thai nghn, ung nc c nhiu gaz hoc lnh qu, do dng thuc c bit l
cc thuc RLNT lm nhp chm nh digital, cardizem, verapamil, chn beta qu
liu...
- Triu chng: thng khng c triu chng r, nng hn c th xong, ngt, mch
quay chm di 60l/pht. in tim: nhp xoang vi tn s di 60l/pht.
3. Ngoi tm thu: l nhng nht bp sm, ngun gc t tm nh hay tm tht, c th
xy trn tim lnh hay tim bnh l
- Nguyn nhn: thng gp trn tim bnh thng, c th khng tm thy nguyn
nhn, c khi tm thy nguyn nhn nh sau: lm dng cc cht kch thch nh thuc
l, c ph, c khi xy ra trong k kinh nguyt, c thai, c th do tc dng ph ca mt
s loi thuc nh digital, quinidine, adrenaline, isoprenaline; do tn thng c tim
nh nhi mu c tim, h kali mu.
- Triu chng: cm gic hng ht, au nhi tim, ang ng git mnh hoc nghn
c, hoa mt chng mt, thong ngt. Nghe tim c th pht hin nhp khng u n
l hoc nhp i nhp ba. Nhp mch c ngoi tm thu (NTT) thng yu i hc mt.
- Chn on: nh vo in tim. Cn phn bit NTT tht hay trn tht.
+ NTT trn tht thng khng c s bin dng ca phc b QRS v on ST-T;
khng c ngh b sau nht NTT m ch c s dch nhp.
+ Ngc li NTT tht thng c s bin dng ca phc b QRS vi s bin i ST-T.
4. Rung nh
- Nguyn nhn: bnh tim mch nh bnh van hai l l nguyn nhn hng u, nh
mu c tim, thoi ha c tim, vin mng ngoi tim, tim phi mn, hi chng WPW,
cc bnh ngoi tim nh cng gip (th nh sau hp hai l), ngoi ra c th gp
trong suy gip, u ty thng thn, i tho ng, tng ur mu, vim phi... v mt
s trng hp khng tm thy nguyn nhn.
- Triu chng: nh trng ngc, chong vng kh chu, c khi xong ngt, au ngc,
kh th. Triu chng ch quan cng r rt nu rung nh (RN) xy ra cp tnh v tn
s tim nhanh. Nghe tim c nhp tim khng u v bin , tn s, khng trng mch
quay. Huyt p thng thp, thng thay i qua cc ln o.
- Chn on: ch yu nh vo in tim. Sng P khng cn thay vo l cc sng f
ln tn tn s 350-600 ln/pht. Cc mc b QRS c thay i nht l v bin
nhng ch yu l v khong cch gia cc sng khc nhau c on di, on ngn.
5. Cung nh
- Nguyn nhn: cc bnh van tim nht l van hai l, bnh thiu mu c tim, cc bnh
tim khc nh tm ph mn, thng nh, vim mng ngoi tim... C th gp trong
nhim c digital, thc hin cc th thut hoc phu thut tim v v cn.
- Triu chng: bnh nhn thng c cm gic rt kh chu v triu chng thng

78
rm r hn rung nh nht l cn kch pht. Nghe tim thy tim p nhanh u 130-150
ln/pht. Tnh mch c thng p rt nhanh hn tn s tim.
- Chn on: nh vo in tim thy sng P thay bng sng F nh rng ca tn s
250-350 ln/pht. Phc b QRS bnh thng v u nhau.
6. Nhp nhanh kch pht trn tht: thng xy ra trn tim lnh
- Triu chng: hi hp tng cn km theo kh chu tot m hi, lo lng, tiu nhiu
sau cn.
- Chn on: in tim c nhp tim nhanh tn s khong 180 ln/pht u. QRS bnh
thng, sng P thng ln vo QRS, c th c ST chnh xung. n nhn cu
thng ct c cn.
7. Nhp nhanh tht: l cp cu tim mch:
- Nguyn nhn: xy ra trn tim bnh l nh nhi mu c tim, suy vnh ri n thp
tim, bnh van tim, bnh c tim, ng c digital, cc th thut trn tim v v cn.
- Triu chng: rm r vi au ngc, kh th, ngt, ri lon huyt ng. Nhp tim rt
nhanh trn 160 ln/ pht, mch kh bt.
- Chn on: in tim cho thy cc phc b tht nhanh, phc b tht gin rng tn
s 120-160 ln/ pht. Nhp nh chm hn v phn ly vi tht.
8.Xon nh: l cp cu tim mch.
-Thng do nhng nhm thuc chng lon nhp nhm 1 gy ra; gim kali mu cng
l yu t thun li.Triu chng ch yu l ngt, try tim mch. in tim s thy sng
kh cc bin dng ln tn, c ch nh v ch phnh to ty theo chu k.
9. Rung tht: l cp cu tim mch v thng gy ra t t. Nguyn nhn thng do
thiu mu c tim, suy tim, ng c digital, ng c quinidine. Triu chng l t t.
in tim c ri lon nhp tht a dng.
10. Ri lon dn truyn nh tht (Bloc nh tht)
Da vo in tim c 3 loi:
- Bloc nh tht 1:PQ (hoc PR) ko di trn,20 giy
- Bloc nh tht 2: c 2 th:
+ Bloc Mobit 1 (hay Luciani-Wencbach): Khong PQ ko di ri mt dn hn sau
lp li chu k mi nh vy.
+ Bloc Mobit 2 (hay Bloc nh tht mt phn): Hai, ba.. sng P mi c mt sng QRS
- Bloc nh tht 3: Nh v tht phn li hon ton, thng nh chm hn tht.
Da vo triu chng c nng c th chia lm 2 nhm:
+ Bloc nh tht khng c triu chng:
+ Bloc nh tht c triu chng:
Triu chng gi l ngt (cn Adam-Stokes) hay ch c xong.

IV. IU TR RI LON NHP

1. Mc ch
1.1. Lon nhp tim kch pht: Cn ct cn ngay.
1.2. Lon nhp tim dai dng, bn b: a v nhp xoang hoc l kim sot tn s tht
trong trng hp khng vi iu tr chuyn nhp.
2. Ch nh iu tr cp cu
2.1. Suy nng chc nng ca tht tri.
2.2. Biu hin triu chng lm sng hoc l trn ECG thy thiu mu cc b c tim.

79
2.3. Lon nhp khng n nh bo trc kh nng rung tht.
3. iu tr khng thuc
3.1. Xoa xoang cnh, n nhn cu
3.2. Shock in
3.3. To nhp:Ct cn nhp nhanh bng phng php vt tn s hoc l kch thch
sm.
3.4. Ct b qua ng tnh mch t chc dn truyn
3.5. Phu thut
* Ti to mch mu trong bnh c tim thiu mu cc b.
* Ct lc t chc dn truyn.
* Ct lc sinh lon nhp.
* Ct b phnh tht tri.
4. iu tr lon nhp nh bng thuc
Mc ch

Thuc

C ch

Phng lon nhp

Disopyramide
Flecainide
Propafenone
Amiodarone

c ch t ng nh

Ct vng vo li nt nh
tht

Striadyn
Verapamil
c ch

Lm nghn dn truyn nh tht

Kim sot tn s tht trong

rung nh

Digoxin
Verapamil
c ch
Amiodarone

Nghn dn truyn nh tht

5. iu tr lon nhp tht bng thuc

5.1. Phng nga trong nhi mu c tim cp
- Xylocaine
- Disopyramide
- Amiodarone
- Procainamide
5.2. Phng nga bnh nhn ngoi tr
- Mexiletine
- Disopyramide
- Propafenone
- c ch
- Amiodarone
5.3. Ct lon nhp tht
- Lidocaine
- Flecaine
- Amiodarone

80
Lu
- Cn thn khi dng phi hp v d khng dng amiodarone cng vi disopyramide
(lm ko di QT gy xon nh)
- Nhiu loi lm gim s co bp c tim (c bit l disopyramide, flecaine, thuc c
ch. V th phi rt thn trng khi c suy tim.
6. iu tr c th
6.1. Nhp nhanh xoang
iu tr ph thuc vo nguyn nhn. Chng lo lng, h st. Digital v li tiu khi c
suy tim, th oxy khi c thiu kh cp tnh, b mu khi thiu mu v khng gip khi c
cng gip. Nu nhp nhanh xoang do mt thch nghi th lc v / hay lo lng gy ra
s kh chu cho bnh nhn v sau khi loi tr tt c nguyn nhn thc th, c th
cho chn bta liu thp c th lm bt tn s tim khi gng sc. Thng dng
Propranolol khi u 1/4 vin x 2 ln sng v chiu sau tng liu dn nhng
khng qu 1/2 vinx 3 ln/ ngy. iu tr c th ngng khi bnh nhn c luyn tp
th lc ti thch nghi.
6.2. Nhp chm xoang
iu tr c ch nh i vi nhp chm xoang kch pht, giai on cp NMCT sau
di. Atropine c th lm tng nhp v huyt p. Liu Atropine:1mg tim di da
hoc chch tnh mch. Nu huyt p thp c th b dch. Kh khn duy nht l khi
iu tr nhng hi chng phi hp nhp nhanh - nhp chm, khi i lc cn phi
t my to nhp kim sot.
6.3. Rung nh
Lu chuyn nhp thnh cng cn iu chnh yu t nguyn nhn (bnh tim gy
rung nh, cng gip...). Mc tiu iu tr nhm l chuyn nhp v xoang hoc ch
lm chm tn s tht.
* Sc in
Liu 250- 300j. Hn hu mi ch nh cp cu v d nh cn ti lp nhp xoang ngay
trong tnh trng chong, ph phi cp nng, tn s tht > 200ln / pht. Sc in l
iu tr chn la trong trng hp rung nh trn bnh nhn c hi chng tin kch
thch. T l thnh cng khong 85% trng hp.
Ch nh sc in trong trng hp rung nh mn tnh:
+ Rung nh <1nm
+ ng knh nh tri <50mm
+ Tim khng ln lm
+ Dung np huyt ng km.
* iu tr bng thuc
Vi mc ch chuyn nhp hoc ch n gin l hm bt tn s tht.
- Nu khng c suy tim, tim khng ln c th dng Flecaine IV liu 2mg/kg chuyn
trong 10 pht cho php ti lp nhp xoang trong 3/4 trng hp (rung nh mi khi
pht).
- C th ti lp nhp xoang bng Amiodarone (Cordarone) vin 200mg cho liu tn
cng 4-6 vin/ngy (c th ung 1 ln) trong 2 ngy u sau duy tr 1 vin/ ngy
trong 5 ngy. Sau khi ti lp nhp xoang c th iu tr duy tr bng quinidin hoc
Amiodarone. Tuy nhin ngy nay a s dng Amiodarone duy tr.

81
- Trong kh nhiu tnh hung rung nh, ngi ta chp nhn ch cn lm chm tn s
tht bng digital (ngoi tr hi chng WPW), khi cn c th phi hp vi
Amiodarone.
- Nu nh khng c suy tim, tim khng ln, ngi ta c th dng c ch (hoc l c
ch canxi loi lm nhp tim chm (Verapamil, Diltiazem) mt khi m nhp tim vn cn
nhanh qu mc mc du s dng digital.
- Him khi tn s tht vn khng hm c bng iu tr ni khoa, lc ny c th cn
ti k thut ph hy nt nh - tht bng nng lng tn s radio (radiofrequency)
to bloc nh tht kt hp vi t my to nhp.
Trc khi chuyn nhp rung nh mn tnh nht l bnh nhn c nguy c cao tc
mch do huyt khi bung tim (bnh van tim) cn phi s dng thuc chng ng 3
tun phng nga tc mch sau chuyn nhp.
6.4. Cung ng nh
iu tr hiu qu nht l sc in vi nng lng thp 25-50 W sau khi
dng an thn nh. Tuy nhin ngi ta hay a dng nng lng cao hn bi l hay b
rung nh sau khi sc bng nng lng thp. ngi b cung nh sau khi m tim h
hoc l cung nh ti lp trong nhi mu c tim cp c bit l nu ang dng digital
th nn to nhp nh vi tn s 115-130 % tn s cung nh c th chuyn nhp v
xoang. To nhp nh cng c th a cung nh v rung nh v lm cho kim sot tn
s tht d hn. Nu nh tnh trng ngi bnh v mt lm sng khng cho php
chuyn nhp ngay th c th lm chm tn s tht bng cc thuc c ch nt A-V
nh c ch bta, c ch canxi, hay l digital. Digital t c hiu qu nht v i khi li
chuyn cung nh thnh rung nh. Khi dn truyn qua nt A-V b hm bng cc thuc
trn th c th dng cc thuc nhm I (A hoc C) hay amiodarone chuyn nhp.
Trong trng hp cung nh bin chng trong hi chng W.P.W th chng ch nh
digital. Mt khc nu nh ngi bnh ang c dng digital th nn ch vi ngy
sau (thuc c thi ra) mi sc.
- Phng cung nh: cc thuc nh quinidine, flecaine, propafenone, amiodarone.
6.5. Nhp nhanh trn tht
* Nhp nhanh b ni, nt xoang, nh do c ch vo li
Nu tnh trng bnh nhn tt khng c tt huyt p th c th dng cc th th
cng ph v ct cn c trong 80% trng hp (nn nh khng c xoa
xoang cnh ngi c thi tm thu ng mch cnh). Nu vn khng c c th
cho adenosine 6-12mg IV hoc Verapamil 2.5-10mg IV. Cng c th dng Digital, c
ch bta. Phng php to nhp nh hoc tht ct cn c dng khi thuc
khng c tc dng. Sc in p dng khi c thiu mu cc b c tim nng hoc l tt
huyt p.
Phng nga:
- Cc thuc digital, c ch bta, c ch canxi hoc l nhm IA, IC.
- Phng php t b ng dn truyn bng sng nng lng tn s radio.
* Nhp nhanh nh c c ch tng tnh t ng
C th do ng c digital hoc l gp trong bnh phi hoc tim nng c gim
kali hoc ang dng theophylline v cc thuc cng giao cm khc. Loi a c
bit hay gp ngi bnh ang dng theophyline. Rung nh gp trong 50-70%
ngi c dng lon nhp ny. Tn s tht khng u do c thay i mc bloc.
Trong lon nhp do digital hay c dng bloc 2/1, iu tr l ngng digital. Trong loi
nhp nhanh c ch t ng khng do digital iu tr kh hn v mc ch ca iu tr

82
l hm tn s tht (bng c ch bta, digital, c ch canxi hoc ct lc lon nhp
bng t bng sng nng lng tn s radio hay phu thut).
6.6. Nhp nhanh tht
Nu dung np km th sc in ngay. Nu khng sc c th dng cc thuc
chng lon nhp sau: ty chn gia Amiodarone, Flecaine, Xylocaine, Mexiletine,
Cibenzoline, Disopyramide, mi loi thuc ny c th ct cn t 50 - 70 % trng
hp. V d Xylocaine (hay c dng nht do gi thnh r v kh an ton) liu tn
cng 50-75mg TM duy tr vi 20-50microg/kg/pht. Sau khi ct cn cn iu tr duy
tr bng thuc ng ung nh chn bta, Amiodarone v cc thuc khc. Cn ch
iu tr nguyn nhn, yu t thun li. Cng c th ct cn nhp nhanh tht vo li
bng kch thch in ni mc bung tim.
6.7. Nhim c digital
C th gy cc ri lon nhp v dn truyn. iu tr gm ngng ngay Digital,
cho kali 4 - 8g /ngy ng ung hoc l IV. Cc ri lon dn truyn nh ch cn cho
Atropine 0,25 - 1mg i.v hoc l di da mi 3 - 4 gi, nu nng phi t my to nhp
tm thi. Cc ri lon nhp do Digital ni chung p ng tt vi phenytoine tim
250mg tnh mch, nu tht bi c th dng Xylocaine. Hin nay c thuc khng
th khng Digoxin (Digidot mi ng 80mg c th gn vi 1mg digoxin) cho d l ng
c Digoxin, Digitoxin, hay l Lanatoside C.
6.8. Ngoi tm thu nh
Thng lnh tnh v v triu chng khng cn iu tr. Tuy nhin nu gy
nh trng ngc nhiu hoc l khi ng nhp nhanh kch pht trn tht th c th
dng an thn v thuc c ch (sau khi loi b cc yu t lm d (thuc l, ru, kch
thch giao cm).
6.9. Ngoi tm thu tht
- V triu chng ngi khng c bnh tim: thng khng cn iu tr.
- Nu c triu chng: dng an thn, c ch B ta, thuc chng lon nhp
nhm I, Amiodaron (loi thuc ty thuc vo tnh trng tim cng nh th loi ngoi
tm thu). Chng hn nu l loi ngoi tm thu nguy him (dng R/T, a dng) th
phi s dng thuc tc dng nhanh nh Xylocaine tnh mch xa ngoi tm thu.
6.10. Rung tht
Phi sc in ngay (>300J). Trong lc ch i sc phi p tim ngoi lng
ngc, thng kh h tr.
6.11. Xon nh
p tim ngoi lng ngc. Isoprenalin trong trng hp trn nn bloc nh tht
cp 3. Nu nh gi xon nh (trn nn ngoi tm thu tht) th cho Xylocain.
6.12. iu tr bnh xoang nh
* To nhp
* Cc thuc chng lon nhp
* Thuc chng ng (trong trng hp hi chng nhp nhanh- chm).
Ni chung tin lng nhng bnh nhn c bnh xoang nh l tt v thng
khng cn to nhp, v th to nhp ch c ch nh nhng bnh nhn c triu
chng c nng (xong, thong ngt ti), mt khc cng vi mc ch ci thin s
dung np vi gng sc.Trong hi chng nhp nhanh chm i khi cn ch nh thuc
chng lon nhp i vi vi ri lon nhp nhanh m cc thuc loi ny thng lm
nng thm ri lon chc nng nt xoang, lc my to nhp c l cn phng

83
nhp chm qu mc sau tc dng ca thuc. Vi tc gi khuyn dng chng ng
phng nga tc mch h thng trong hi chng nhp nhanh chm (hnh thnh cc
mu ng trong nh tri).
6.13. iu tr bloc nh tht
C th dng Atropin (liu 0,25-1mg tim tnh mch hoc di da mi 3-4h)
hoc Isoprenaline (0,01-0,2(g/kg/pht) nu tn s tht qu chm trong lc ch i
t my to nhp tm thi hay l vnh vin.
Ch nh t my to nhp:
1. Nhi mu c tim:
+ Khi c bloc nh tht 3 do nhi mu thnh sau c km:
- Tn s tim < 40 ln/ pht khng c p ng vi Atropin.
- Suy tim.
- Lon nhp tht cn iu tr thuc chng lon nhp.
+ Bloc nh tht 3 hoc l Mobitz 2 do nhi mu c tim thnh trc.
+ Bloc hai nhnh.
+ To nhp vt tn s ct lon nhp tr.
2. Bnh xoang nh gy triu chng.
3. Bloc nh tht loi Mobitz 2.
4. Bloc nh tht cp 3 mn tnh c hay khng c triu chng.
5. Ct cn lon nhp vo li.
Phng php to nhp: hin nay dng ch yu l VVI (to nhp ch b c ch bi
tht, n ch to nhp tht) v DDD (to nhp ch kp va nh v tht n cho php thit
lp li s ng vn nh - tht).

84

VIM MNG NGOI TIM

Mc tiu
- Nm c cc du hiu lm sng v cn lm sng ca vim mng ngoi tim
c dch.
- Nm c cc du hiu lm sng v cn lm sng ca chn p tim cp.
- Nm c cc du hiu lm sng v cn lm sng ca vim mng ngoi tim
co tht.
- Trnh by c cc phng php ni ngoi khoa trong iu tr vim mng
ngoi tim.
- Nm c k thut chc d mng ngoi tim
Ni dung

I. I CNG
Vim mng ngoi tim (VMNT) l bnh ca mng ngoi tim (MNT). Cn phi
x tr cp cu. Nu chm s t vong nhanh (trn dch mng ngoi tim p tim cp).
Hoc phi x tr ngoi khoa nu chm s dn n tin lng xu (VMNT co tht).
Ngy nay nh c siu m gip cho chn on chnh xc, v sm. iu tr kp
thi gim t l bin chng xu cho bnh nhn.

II. NGUYN NHN

1. Nhim khun: lao, virus, cc vi khun khc (thng gp trong nhim trng khc)
2. Vim: thp tim,vim a khp dng thp, lupus ban
3. Phn ng d ng min dch: Phn ng d ng sau m tch van tim 2 l, hi chng
sau nhi mu c tim, nhng phu thut lin quan n mng ngoi tim
4. Ung th: Nguyn pht hoc th pht nh ung th gan, ung th phi, ng th
trung tht
5. Cc abcs ln cn: gan, phi, di c honh
6. Bnh tim thiu mu cc b
7. Chn thng lng ngc: gy trn mu mng ngoi tim. V ng ngc: trn dch
dng chp MNT
8. Ri lon chuyn ha: tng ur gy phn ng VMNT. Lng ng cholesterol
MNT
9. Do hu qu ca iu tr: Thuc chng ng, iu tr phng x di ngy lng
ngc
10. Do nm.
11. Suy tim nng: Bnh nhn b bnh van tim, bnh c tim c trn dch mng ngoi
tim.
12. Bnh EBSTEIN.
13. V cn.

III. VMNT C DCH IN HNH

1. Lm sng
1.1. Triu chng ton thn: Ty thuc vo nguyn nhn: c th st, chn n, mt
mi, gy st.
1.2. Triu chng c nng
au ngc: rt thng gp, au lan ta khng thnh cn km cm gic p ngc
tri.

85
Kh th: kiu nhanh nng, vt v bt an.
Kh nut: do tim vo thc qun pha sau, km theo c ho v nc.
1.3. Triu chng thc th
Nhn, s: mm tim p yu hay cm gic khng thy p.
G: din c ca tim ln.
Nghe: nhp tim nhanh, ting tim m xa xm do b cn bi mng nc. Nu dch t s
nghe ting c mng ngoi tim (khi nn th ting ny vn cn) du ny quan trng v
n xc nh c dch mng ngoi tim.
Trn thc t lm sng khi c trn dch mng ngoi tim s lng nhiu, c fibrin to
vch ngn khu tr lc nghe vn thy ting tim r. C th c ting c mng ngoi
tim.
Cc du hiu tr tun hon ngoi vi:
Ph, gan to, tnh mch c ni, phn hi gan tnh mch c (+)
p lc tnh mch ngoi bin tng (bnh thng 8-12 cm H2O)
p lc tnh mch trung tm tng (bnh thng 4-7 cm H2O)
Mch nhanh nh, huyt p ti a gim, huyt p kp. C th c mch nghch thng
Kussmaul (khi ht vo mch nh i). Bnh thng khi ht vo mch cng nh hn lc
th ra do p lc ph nang tng cao (mu v tm tht tri t. Trong VMNT do thiu
nng tm trng(mu v tim tri cng t (do mch nh cng r hn
S nhanh v huyt p ti a cui th ht vo v th th ra trn 10 mmHg (bnh
thng di 10 mmHg)
2. Cn lm sng
2.1. in tm
- Do tn thng (ri lon chuyn ha v vim nhim) lp c tim di thng tm
mc (pht sinh ra mt dng in tn thng, biu hin bng mt vect hng t
tm im tim n trung tm ca vng tn thng; ngha l hng xung di, sang
tri, v ra trc. Chiu ln trc chuyn o ta thy ST chnh ln ng hng cc
chuyn o (ri lon ti cc).
Theo Bots chia 3 giai on bin i ST-T:
+ Giai on 1: ST chnh ln ng hng cc chuyn o ngoi bin v
trc tim. Khng c hnh nh soi gng thnh i din nh trong nhi mu c tim.
+ Giai on 2: Sau 3 tun.ST h dn xung ng ng in. T dt xung v
T (-). Nhng ST vn cn chnh ln.
+ Giai on 3: Trn 1 thng.ST chnh xung v T (-) nhng khng nhn v
khng i xng nh trong bnh c tim thiu mu cc b.
- Du hiu in th giao lu (lun phin in hc): do MNT nhiu dch tim di ng
mnh nh bi trong nc. Sau mi chu chuyn tim, tim khng tr v v tr c.(sau
mi ln kh cc tim v tr khc, do trc QRS thay i.
-Du in th gim: tng s tr tuyt i ca Q,R,S ca 3 chuyn o mu <15
mm chuyn o trc tim: V2 tng bin / R+S / < 9 mm V5,V6 / Q+R+S / <
7 mm
2.2. X. Quang
- Soi: bng tim to, co bp yu.

86
- Chp X.Q: tim to b 2 bn cung di, gc honh tim hnh t. Cung tim
ngn. Do hnh tim ging nh qu bu. C th thy hnh tim 2 b (b trong l bng
tim, b ngoi l mng ngoi tim), phi sng: do thiu nng tun hon tm trng.
2.3. Siu m tim
- Cho bit s lng dch v v tr ca dch cc thnh tim quyt nh chc
d mng tim, trong dch c nhiu fibrin v c vch ha khng?
- Xem b dy ca mng ngoi tim c hng iu tr ni hoc ngoi khoa
kp thi. nh gi nhng ri lon huyt ng thng qua hnh nh p tht phi
thi k tm trng. nh gi chc nng tm trng. Thm d p lc trong tim phi.
Thm d sc cng ca thnh tim.
C th trn siu m:
+1 bnh din TM o kch thc ca khong dch k tm tng t tnh ra
d on lng dch mng tim.
+ thm d theo 2 bnh din 2D: quan st ton b tim mt cch tng qut,
xem lngdch khu trr hay ton th
Vi 3 du hiu chnh cn nh gi:
+Khong trng Echo mt sau ca tim.
+Khong trng Echo gim nhiu hoc mt hn ch ni nh tri v tht tri.
+Mng ngoi tim khng vn ng.
Ch : Lng dch: dch mng tim t 30 ml c th pht hin c. Ngi bnh
thng khe mnh c th c 50 ml DMT. Khi lng dch bao ph ton b tim nhn
thy c trn siu m 2D lng dch khong 300 ml.
Xc nh cht cha trong mng tim (phn b sung)
Vn ng bt thng ca tim trong TDMT: vn ng nghch thng vi vch lin
tht.
2.4. Chc dch mng tim
Ly dch chn on xc nh, chn on nguyn nhn c hng iu tr
ng. Dch mng tim thng c 3 mu hay gp.
+Dch vng chanh: Lao, vi rt, d ng, t pht, bnh h thng
+M c trng- nu: Nhim trng huyt, abcs v
+Dch mu : K, lao, chn thng chy mu, do thuc chng ng.
3. Chn an phn bit
- Tim to: Do bnh c tim, suy tim nng
- Cn au tht ngc: Nhi mu c tim, vim phi, v.v....
Vai tr ca siu m rt hu ch trong chn on loi tr d dng.
4. Chn on nguyn nhn
+ Da vo lm sng v xt nghim dch mng tim.
+ Cc nguyn nhn nh ni phn trn.

IV. CHN P TIM CP

1. nh ngha
L tnh trng p lc trong khoang MNT t ngt tng cao, p vo tim v ngn
cn s y mu v tm tht trong k tm trng gy thiu nng tm trng cp,
thiu nng tm thu cp ngn cn tim bp.

87
p lc trong khoang mng tim tng cng cn tr tim dn ra y trong th
tm trng. Do t mu v tim, huyt p v lu lng tim gim. Nhp tim tng
b tr nhng bin i ny, khi p lc trong khoang mng tim t gn 15cm nc,
cung lng tim v huyt p s gim t ngt hn na v lm sng xut hin chong.
Nu p lc trong mng ngoi tim khng c h thp (bng cch ly mu hoc dch
ra), bnh nhn s t vong. Ch 200ml dch hoc mu l c th gy t vong.
2. Sinh l bnh
Bnh thng p lc trong khoang mng tim bng 0 hay m nh, do h tr
tng sc ht mu v tim vo k tm trng. Khi dch trong mng tim nhiu s lm
thay i p lc ca n (lng dch ln qu hoc lng dch khng nhiu nhng hnh
thnh qu nhanh) p lc khoang mng tim s gn bng hay bng p lc trong tim,
khi c du hiu chn tim (tim ht mu v rt kh): tng p lc tnh mch c, huyt
p kt, mch nghch thng, gim cung lng tim.
3. Chn on
3.1. Triu chng c nng
Khi u t ngt vi kh th d di, au ngc, vt v, da xanh ti, tat m
hi.
3.2.Triu chng thc th
Tim nhanh, ting tim m (kh nghe) mch nghch thng (KUSSMAUL). Du
tr tun hon ngoi bin r. (gan ln, tnh mch c ni.).
Ba du hiu cn bn ca chn p tim cp l:
-Tt huyt p, huyt p gim dn cho n khi khng o c. Khi c du
hiu ca chong; lo lng, bt rt, ti nht, da lnh v m v cui cng l mt tri gic.
-p lc tnh mch tng. p lc tnh mch c th tng n 15-20cm nc.
Km vi tnh mch c ni r (tuy nhin, gan c th khng to trong trng hp chn
p tim cp).
-Ting tim nh, yn lng, ting tim nghe xa xm v m, khng thy c cc
ny vng trc tim.
Hn na c th c mch nghch thng. Mch nghch thng l do s gim
qu mc p lc ca mch khi ht vo (bnh thng gim di 10mmHg). C th c
du Kussmaul (tnh mch c ni khi ht vo).
3.3. Cn lm sng
- X Quang: Khi chn p tim cp xy ra trong trng hp khng c trn dch mng
ngoi tim trc , th trn phim X quang thng khng pht hin c du bt
thng v trn dch mng ngoi tim t hn 250ml (nhng c th gy t vong) khng
pht hin c trn phim X quang thng thng.
Khi chn p tim cp xy ra bnh nhn c trn dch mng ngoi tim, trn
phim X quang c th thy bng tim hnh bu, ging nh ci bao hoc bng tim hnh
cu vi gc rt nhn hp bi b di phi ca mng ngoi tim vi c honh. Mc
d khng c hnh nh no t n xc nh chn on trn dch mng ngoi tim nhng
c th nghi ng nu bng tim to nhanh v km vi trng phi sng.
- in Tm : in th giao lu ton b (sng P, QRS v T) c chn on trn
dch mng tim hoc chn p tim. Tuy nhin du hiu ny khng phi lun lun c.
Du hiu in tm in hnh ca chy mu trong mng tim l sng T cao nhn
t ngt cc o trnh trc ngc. iu ny xy ra d c sng T i xung trc
. Hn na, chn p tim cp do v tim c th gy ra nhp chm t ngt v phn ly

88
in c. in th phc b QRS thp t ngt trn in tm khin lun lun nghi
ng rng c trn dch mng tim.
- Siu m: Siu m l mt phng php khng xm nhp, gip chn on
sm nht v chnh xc nht trn dch mng tim. Mt khc cng gip nhn bit tnh
trng p tim.
+ mt bnh din (TM): thy s thay i bt thng bung tht phi v tri
theo chu k th: khi ht vo: tht phi dn rng, khi th ra: tht phi hp li. Ngc
li khi ht vo tht tri b p lm hp li.
+ 2 bnh din (2D): - nhn thy c ton din dch trong khoang mng tim,
du sp tht (P), nh (P), nh (T), lng ln khu tr pha sau.
Ch : - Du sp tht (P) c nhy cm cao v chuyn bit cao
- Du sp tht (T): Sau khi m tim vch tht (P) v nh (P) thng
dnh st vo thnh ngc. nn khng c biu hin ECHO khi chn tim. Hn na
sau m tim trn dch mng tim thng pha sau, do to ra chn p tim khu tr
s thy du sp tht (T).
- Du chn tim c th khng c du sp tht (P) khi vch tht (P) dy
cng hoc c tng p ng mch phi.
- Thng tim: Du kinh in trong thng tim l p lc trong mng ngoi tim tng, p
lc nh (P) v tht (P) tng v bng nhau, ng dc x ni bt v mt ng dc y
v p lc tht (P) cui tm trng tng bng nh (P).
4. Chn on phn bit
Suy tim phi cp c th nhm vi chn p tim, v suy tim phi cp c th cho
hnh nh X quang vi bng tim to v phi sng. Hn na c th c p lc tnh mch
trung tm tng v huyt p gim. Tuy nhin, suy tim huyt him khi gy ra mch
nghch thng.
Trn dch mng tim khng gy chn p c th i km vi suy tim huyt.
Trng hp ny cng him khi c mch nghch v khi nghe tim ghi nhn c m thi
do bnh tim hu thp hoc do bnh tim khc hn l nghe ting tim xa xm.

IV. VIM MNG NGOI TIM CO THT

1. nh ngha: VMNT co tht l tnh trng MNT vim dy, c khi nhim vi, bp cht
ly tim, lm tim khng dn ra c, dn n gim th tch tm trng,ko theo gim
th tch tm thu hu qu cui cng lm cung lng tim gim.
2. Chn on
2.1. Lm sng
Ni bt hi chng tr tun hon ngoi bin vi:
+ Ph, gan to chc b sc, tnh mch c ni to
+ C th c c chng
+ Xm da nh, nht l cc chi do lu ngy ging nh x gan, nhng khc l
khng c tun hon bng h vng trn rn (ca - ch)
+ Nghe tim: - Ting tim thng m t
- Ting c mng ngoi tim.
- C th c ting ba p do trong k tm trng van 3 l v m ra,
khi lng mu ln tr li trong nh phi nho xung va vo thnh tm tht
b dy cng khng c kh nng dn ra ( k tm trng cch ting th 2 khong
0,10s - 0,13s).

89
2.2. Cn lm sng
- X.Quang: tim to t, hoc khng to, b r, c th c vi ha.
- in tm : ST gim, sng T dt hoc m tnh,c th c rung nh.
- Siu m tim: Mng tim dy, co bp khng ng u. Thnh sau tht tri c th
c dng cao nguyn. Nh tri to hn bnh thng.
TM (tnh mch) ch di v TM gan gin. Chc nng tm trng gim. Chc nng
tm thu gim.ng cong vn tc .M.P.(ng mch phi) c dng 2 pha,do vn tc
gim i gia k tng mu. Doppler xung kinh in v Doppler m gip nhn bit
VMNTCT cng nh phn bit bnh c tim hn ch.
- Thng tim: ng cong p lc tht (P) c b nho - cao nguyn (dip-plateau).
p lc tht (P) tng c bit p lc cui tm trng, do mng tim x cng cn tr
c tht dn ra (chn on phn bit vi bnh c tim hn ch loi x chun ni mc).

V. IU TR
1. iu tr ngoi khoa
1.1. Ch nh
- Dch mu, m lu ngy.
- Mng tim dy.
- i vi VMNT co tht ty thuc vo mc dy dnh, vi ha MNT m c
th phu thut ct b ton b MNT hay m ca s.
1.2. Theo di sau m
- Nhim trng.
- Ri lon nhp.
- Cc c quan ln cn nh hng nht l trung tht, mng phi.
2. iu tr ni khoa
2.1. iu tr chung
au do vim mng ngoi tim c th gim bt bng cch cho cc thuc chng
vim khng corticoid nh Aspirine 500 mg/ 4 gi. Nu au ko di qu 48 gi c th
x dng c corticoid liu 1 mg/kg. Sau 5-7 ngy nu gim au c th gim liu v
ngng thuc.
2.2.iu tr nguyn nhn gy bnh
* Vim mang ngoi tim do lao
Dng thuc khng lao sm, mnh, phi hp t nht 3 loi khng lao. Phc iu tr
thay i ty theo tin trin v khng sinh . Thi gian iu tr ko di 12-18 thng.
Trong trng hp din tin thnh co tht mng ngoi tim cn phi tng cng thuc
chng lao v cn nhc xem c nn dng corticoid. Corticoid c th lm bt dch
nhanh tuy vy ch c th dng corticoid khi thuc khng lao c hiu qu. Nhiu
nghin cu cho thy s phi hp hai loi khng lao v corticoid trng hp trn
dch mng ngoi tim ci thin lm sng nhng trng hp khng th phu thut. Tuy
nhin bin php tt nht khi c hin tng dy dnh vn l bc tch mng ngoi tim.
* Vim mng ngoi tim do vi khun sinh m
Dng khng sinh ton thn da vo khng sinh ca cy m mng tim kt hp
khng sinh bm ti ch mng tim. Nu mng tim dy, m c qunh cn phi dn
lu phu thut.
* Vim mng ngoi tim do thp
Corticoid v penicilline.

90
* Vim mng ngoi tim cp lnh tnh
C khi khng cn iu tr. C th dng aspirine 1-3 g/ngy.
* Xut huyt mng ngoi tim
Sau chn thng cn phi phu thut.
* Vim mng ngoi tim do ung th
Dng ha tr liu, x tr liu, nu cn dn lu phu thut hoc to ca s mng phimng tim nu ti din tit dch.
* Vim mng ngoi tim sau nhi mu
Ni chung t nguy him, c th dng aspirin hoc corticoid.
* Vim mng ngoi tim do ure mu cao
Lc thn hoc chy thn nhn to.
* Chn p tim cp
Chc dch mng tim.
* Vim mng ngoi tim mn tnh co tht
C th dng li tiu gim dch. Digital ch dng khi c rung nh tn s tht nhanh.
Nu do lao cn iu tr phi hp.
Ct b mng ngoi tim l bin php trit nhng cn thc hin sm.
2.3. Chc dch mng tim
* Mc ch
- L th thut quan trng nht chn on xc nh v nguyn nhn (ngay
c khi dch t)
- Tho bt dch trnh p tim trong chn p tim cp trnh ri lon huyt
ng nh hng n chc nng tim, hoc nng n hn l t vong.
* Cc v tr chc d mng tim
Bnh nhn phi c thm khm xc nh din c ca tim, xc nh bng tim trn
X quang. Tu trng hp c th m chn v tr.
-Lin sn V tri pha trc, ngoi b di tri ca vng c tim khi g 2 cm,
cn c gi l ng Dieulafoy, l ng hay dng v t nguy him.
-ng Marfan:
Gc gia mi c v mn sn tri, trn ng trng gia, cch mi c 3-5cm v
sang tri 1cm.
Vng ny khng c phi ph ln tim, c ng dng tt khi trn m mng
phi tri phi hp, khi c trn dch mng phi tri kt hp th dch mng tim chc
c y khng chc chn l dch mng phi hay dch mng tim.
-Vng tam gic an ton lin sn V hay VI bn tri l vng tip gip gia
phi, mng phi v b vai tri ca li xng c, khi chc, kim hng ra sau nh
nhng, trnh ng mch v trong bn tri (nm cch b tri xng c 1,25 - 2,5cm
lin sn IV v V).
-Vng lin sn IV phi, cnh b phi thuc vng c ca tim 1 cm. c p
dng khi dch mng ngoi tim tp trung bn phi, d nhiu dch hay t, thm ch vi
mililit do vim mng ngoi tim do thp cng c th thy c dch.
-Vng lin sn V hoc VI bn phi cnh b c phi, kim i hng ra sau
vo trung tht, trnh b trn gan.

91
-Vng lin sn VII hoc VIII pha sau tri trn ng gia xng b vai tri,
khi chc tay tri gi cao, v tr ny c dng khi trn dch mng ngoi tim mc
ln chn p vo phi (du Ewart) m kh c th ly c dch theo cc v tr khc.
Nu chc d qua siu m th ng gia mn hinh l ng gia u d v
v tr u d l v tr kim chc, hng u d l hng kim i ti.
* Cch chc d mng ngoi tim
Trc tin phi xem hnh nh cc mt ct trn siu m, nh v tr lng dch
nhiu nht v tuy theo quyt nh ng chc d
+Chun b bnh nhn trc chc d: - Gii thch trn an tinh thn ca bnh
nhn. Bnh nhn nm thng hoc t th 45 .- Cho bnh nhn th oxy. o HA,
nhp tim, mch, khm gan ( so snh vi sau khi ht dch)
+ Chun b thuc men v dng c my mc theo di v cp cu khi cn thit:
my shock in, my theo di in tm , thuc Morphin, Seduxen, Novocain v
cc thuc chng ri lon nhp khc.v.v....
+nh du v tr chc d.
+ Trong khi tin hnh th thut: St trng ti v tr chc d,v xung quanh vng
chc d. Ph tm khn c l sau khi st trng xong.
Cho an thn bng thuc: Mocphin (nu khng c suy h hp) hoc seduxen
tim TM. Dng kim nh gy t ti ch v tr chc (bng xylocain hoc novocain) va
gy t va thm d ht dch ra (chc b trn ca X. sn di)
Ch : Lng dch ly ra t t trnh thay i p lc t ngt lm thay i t th
ca tim. Nu p tim cp cho ly dch nhanh. Sau khi ht dch xong cn bm t kh vo
khoang mng tim, s lng bng 2/3 hoc 1/2 lng dch ly ra.
+ Sau chc d:
- Ly mu dch xt nghim: sinh ha, t bo, vi trng v cy ng thi lm khng
sinh iu tr.
- o li HA, mch, nhp tim, khm li gan: lng dch ly ra ci thin ngay triu
chng c nng. HA khng cn kt. gan nh li, nhp tim chm hn.
- o li .T.: Bin in th cc sng in tim cao hn ht hnh nh in th giao
lu (nu trc khi chc d c).
- Cho bnh nhn nm theo di phng cc tai bin nh: d dch vo trung tht, trn
kh mng phi, ri lon nhp tim.v.v....
- Nn cho bnh nhn i chp li X.Q. tim: xem bng tim nh li, xem mng ngoi tim
c dy mc no c hng iu tr ni hay ngoi khoa kp thi cho bnh nhn
- C iu kin siu m tim li cho bnh nhn nh gi chnh xc hn v lng dch
v dy ca mng ngoi tim sau khi chc d mng tim. S. khng phn bit
c dch MNT do vim,do chn p trn mu hay dng chp nhng phn bit
c: C si fbin, cc mu, hay K mng tim di cn thy cc khi di cn trong mng
tim c dch.

92

BNH TIM BM SINH

Mc tiu
- Lit k c nhng bnh tim bm sinh gp ngi ln
- Trnh by c nguyn nhn ca bnh tim bm sinh
- Trnh by c triu chng v cch chn on cc bnh tim bm sinh
- Nm vng v vn dng c cc ch nh ni khoa v cc phng tin iu
tr ni khoa trong iu tr bnh tim bm sinh ngi ln.
- Nm vng v vn dng c cc ch nh ngoi khoa v cc phng tin
iu tr ngoi khoa trong iu tr bnh tim bm sinh ngi ln
Ni dung

I. I CNG
Bnh tim bm sinh l nhng d tt tim v mch mu ln to nn do nhng bt
thng trong bo thai thng th 2-3 ca thai k, vo giai on hnh thnh cc
mch mu ln t ng tim nguyn thy. T l chng 5% tr s sinh theo ti liu
Php, M, Vit nam hin cha c mt thng k no.

II. BNH NGUYN

2.1. Cc bnh ngi m mc phi trong thi k thai nghn: Nhim siu vi ch yu l
bnh o ban (Rubella), hi chng Rubella thng c ic, c thy tinh th, u b
v c th phi hp vi cn ng ng mch, hp van ng mch phi, thng lin tht.
2.2. Cc yu t di truyn c hoc khng ri lon nhim sc th nh mc tim bm
sinh trong hi chng Marfan, lch khp hng, hi chng Down, bin d n gene
cng c cp n trong di truyn mang tnh gia nh ca bnh thng lin tht,
thng lin nh, o ph tng...
2.3. Gn y ngi ta pht hin nhng b m nghin ru m mang thai c th
sinh ra tr c d tt bm sinh gi l hi chng ru i vi bo thai, gm u b, mt
ti h, trn g, hm nh, chm pht trin thai nhi, thng lin tht, thng lin nh...

III. S B PHN LOI

Shunt tri-phi, phi-tri hoc khng c Shunt
1. Loi Shunt tri - phi: l loi tim bm sinh khng c tm. Mu chy t bn tri c
p lc cao sang bn phi c p lc thp hn. Tuy nhin lu ngy do tng p lc
ng mch phi nng n c th o shunt lc ngi ta gi l hi chng
Eisenmenger. Trong nhm ny hay gp thng lin nh, thng lin tht, cn ng ng
mch.
2. Loi c Shunt phi - tri: Thng l nhng d tt gy tng p lc khoang tim phi
lm mu t phi sang tri gy trn ln mu ng mch v mu tnh mch pht sinh
tm, tm xut hin khi Hb > 5g/100ml v bo ha O2 < 70%, y l bnh tim bm
sinh gy tm. Cc bnh thuc nhm ny nh t chng Fallot, tam chng Fallot,
Ebstaine.
3. Loi khng c Shunt: l d tt bm sinh trong tim hay trn cc mch mu ln
nhng khng c shunt nh hp eo ng mch ch, hp di van ch hay phi...

IV. BNH TIM BM SINH C LUNG THNG TRI-PHI

1. Thng lin nh
L bnh tim bm sinh thng gp nht (15-20% trng hp). Dng n thun ch
chim khong 20% trong tng s cc trng hp thng lin nh. T l n /nam vo

93

1.1. Th lm sng
- L th pht: nm trung tm cn gi l cn l Botal. L hnh trn hoc bu dc,
i khi ko di hoc l dng ca s. ng knh trung bnh vo khong 20-30mm.
- L xoang tnh mch nm trn hoc di:
+L trn ch vo ca tnh mch ch trn, loi ny hu nh lun km bt thng
tr v tnh mch phi khng hon ton (trc tip vo nh phi hoc l phn thp
ca tnh mch ch trn).
+ L phn vch thp: ko di ti tn tnh mch ch di (l xoang vnh).
- L tin pht: him gp hn nhng loi trn. L thng nm phn y ca mng
trc l xoang vnh. N c th n thun hoc l phi hp vi li phu l vch van
hai l.
1.2. Sinh l bnh:
y l loi c lung thng chiu tri phi do p lc nh tri cao hn. ln ca
shunt tu thuc vo kch thc ca l v sc cn tiu ng mch phi. Mc du lu
lng shunt ln nhng p lc ng mch phi khng tng hoc l tng t. Qu ti
th tch lm gin bung tim phi v mch mu phi. Ngc li bung tim tri cng
nh ng mch ch kch thc li nh. V sau tiu ng mch phi b tn thng
(vim tng sinh ni mc, thuyn tc) s lm tng sc cn a ti tng p phi v th
tch shunt gim. Cui cng khi p lc bung tim phi tng qu s lm o shunt v
ngi bnh s c tm.
1.3. Triu chng chn on:
1.3.1. L th pht: trong 90% trng hp s nghe c ting thi tm thu kiu tng
mu van ng mch phi. Ting thi lan dc b tri xng c nhng cc i
lin sn 2 hoc 3 cnh c tri. Ting thi c c tnh cng va phi, m sc
m nhng cng c th c m sc th mnh ging ting thi gp trong hp van ng
mch phi. Ting T2 tch i c nh theo chu chuyn h hp. Trong trng hp
tng p phi nng c th nghe c ting thi tm trng do h van ng mch
phi.
Hnh nh Xquang ni bt cc du chng gin tim phi v ng mch phi. in tm
hay c trc QRS lch phi v nht l hnh nh bloc nhnh phi hay gp th khng
hon ton.
Siu m l phng tin chn on rt hu hiu, trn hnh nh siu m hai
bnh din cho thy tht phi tng kch thc do qu ti th tch tm trng. N cho
thy trc tip hnh nh khuyt vch lin nh v vi siu m mu thy lung shunt qua
vch, siu m cn quang thy vng ra trong nh phi nu shunt tri phi v trong
trng hp o shunt c th thy cht cn quang qua tim tri.
Thng tim: c hai triu chng sau cho php khng nh chn on
- ng thng chy t nh phi sang nh tri d (7-8 ln/10).
- Nng Oxy nh phi giu hn trong tnh mch ch.
Ngoi ra thng tim cng cho php nh gi p lc ng mch phi, o lu lng
ca shunt, o sc cn ng mch phi.
Tin trin
Tu thuc vo ng knh l thng tc l lu lng shunt. Tui th trung bnh 35-40
tui. Bnh nhn lu ngy s tin trin suy tim phi, lon nhp (hay c rung nh), khi

94

1.3.2. L tin pht: chim 20 % cc trng hp thng lin nh. Tui th trung bnh
thp hn (30 tui), phu thut kh hn.
Lm sng ngoi triu chng ca thng lin nh cn c thi tm thu mm do
bt thng van hai l. in tm trc tri trong khi li c bloc cnh phi. Thng tim
c thng lin nh thp cng nh thy dng mu chy ngc ln nh do h hai l.
Siu m Doppler cng cho php chn on tng t.
1.3.3. Thng lin nh phi hp tr v bt thng tnh mch phi: hay gp tr v bt
thng tnh mch thu trn phi hoc gia phi vo phn tn ca tnh mch ch trn
(dng sinus venosus).
Thng tim chp mch cho php chn on rt tt.
1.3.4. Hi chng Lutembacher: phi hp hp hai l v thng lin nh.
2. Thng lin tht: l loi tim bm sinh hay gp nht chim 20-30% cc bnh tim
bm sinh. Nu tnh chung c cc bnh tim bm sinh c thng lin tht phi hp n
chim 50%. y l loi tim bm sinh c shunt tri phi (dng n thun).
2.1. Gii phu bnh hc: c nhiu v tr thng lin tht.
- Hay gp nht l thng phn mng.
- cao v pha trc di van ng mch phi.
- cao pha sau di l vch ca van ba l.
- Thp nm phn c ca vch lin tht.
Tht tri c th thng vi nh phi (khng thc s l thng lin tht), thng phi
hp vi bt thng van 3 l.
2.2. Sinh l bnh: do p lc tht tri cao hn p lc tht phi cho nn s c shunt
tri phi qua vch lin tht. ln ca shunt tu thuc vo kch thc l thng v
sc cn tiu ng mch phi. tr em ng knh l thng >1,2cm2 /m2 c th
(hoc >1/2 l van ng mch ch) th khng cn chnh p gia hai bung tht v
cho th tch shunt ln nu sc cn phi thp to tng p phi cung lng . L
thng c th t ng theo thi gian hoc l shunt s gim (hay ci thin lc 2 tui)
do tng ng knh l van ng mch ch.
Trong loi thng lin tht phn c l thng s nh i k tm thu.
Sc cn tiu ng mch phi tng ln c th do cc yu t sau:
- Tng p phi hu mao mch: to nn do mu v nh tri qu nhiu trong khi van
hai l ng v khi m thot mu khng kp to hp c nng van hai l.
- Tnglu lng phi sau ny c hu qu dy cc si c lp o gia cc mch mu
nh (giai on I), tng sinh ni mc (giai on II), thoi ho hyalin v x ho (giai
on III), hoi t gin khu tr (giai on IV). Lu lng shunt s gim theo nhng p
lc ng mch phi vn tng.
Sinh l bnh s khc nu c hp ng mch phi (bm sinh hoc mc phi do
thch nghi th pht) cho bnh cnh gn ging t chng Fallot.
Ngi ta chia cc nhm thng lin tht chnh nh sau:
- Thng lin tht l nh, c shunt tri phi p lc ng mch phi bnh thng, y
l bnh Roger.
- Shunt ln l to, sc cn tiu ng mch phi bnh thng hoc tng t.
+ Nhm II a: p lc ng mch ph tm thu < 70% p lc h thng.

95
+ Nhm II b: p lc ng mch phi tm thu > 70% p lc h thng.
- Nhm III: tng p phi v tng sc cn phi nng, shunt tri phi nh, c th c
shunt hai chiu nh. Khi o shunt gi l hi chng Eisenmenger.
- Nhm IV: phi bo v (hp ng mch phi van hoc phu), ranh gii vi t chng
Fallot (ngoi tr shunt tri phi).
2.3. Triu chng chn on
- Lm sng: triu chng c nng thay i tu theo nhm thng lin tht cng nh
tui ngi bnh m c th v triu chng hoc l kh th. Tr em c th chm ln,
bin dng lng ngc. Khm c thi ton tm thu to c rung miu (khng phi lun
vy), m sc th rp cc i lin sn 4 cnh c tri lan mi hng. Ting T2 phi
bnh thng hoc l mnh tch i. Ngoi ra cn c th nghe ting thi tm thu kiu
tng mu do tng lu lng phi nghe thy khong lin sn 2-3 cnh c tri,
rung u tm trng do hp van hai l c nng nghe c mm tim. Khi tng
nng sc cn tiu ng mch phi ting thi s gim cng hoc l mt, khng
cn nghe thy ting rung tm trng mm.
- X quang: c th c hay khng thy bng tim ln tri ln bn tri cng nh tnh
trng gin ng mch phi.
- in tm : dy tht tri, nh tri, khi c tng p phi c th thy du dy tht
phi.
- Siu m doppler: cho php thy c l thng lin tht cng nh lung shunt qua
l thng, nh gi c ln ca shunt cng nh tnh trng tng p lc ng
mch phi.
- Thng tim chp mch: chp bung tht tri cho php thy chnh xc thng lin tht.
Ngoi ra thng tim cn cho bit c p lc ng mch phi cng nh sc cn tiu
ng mch phi, lu lng shunt.
3. Cn ng ng mch
3.1. Gii phu: v tr ca ng bt ngun t ng mch ch trc eo vo ng mch
phi tri i khi ch phn nhnh ng mch phi. Him khi vo ng mch phi
phi. ng knh tr em di 7-10 mm rng 5-7mm, ng cng c th c hoc khng
to ln theo tui.
3.2. Sinh l bnh: ng ng mch to shunt tri phi. Nu shunt ln p lc ngang
bng hai bn h tun hon. Tng p nh tri v tnh mch phi gy co tht tiu ng
mch phi phn x trong thi gian di c th hi phc lm gim bt lu lng shunt.
Lu ngy sc cn tiu ng mch tng thc th khng hi phc v tin ti o shunt
hoc l mt shunt.
Trong mt s him trng hp c tng p phi cng nh tng sc cn phi
ngay do bt thng cu trc bo thai ca tiu ng mch phi.
3.3. Triu chng chn on:
- Lm sng: thng pht hin tnh c khi khm sc kho bi bnh thng dung np
tt. Nghe tim l c bn chn on vi ting thi lin tc vng h n tri. tr b
m i khi ch nghe ting thi tm thu.
Nu shunt ln c th nghe ting rung tm trng do hp c nng van hai l,
hiu p ng mch tng.
- X quang: bng tim thng bnh thng, trong trng hp shunt ln tht tri c th
gin.
- in tm : bnh thng nu shunt nh hoc hnh nh dy tht tri nu shunt ln.

96
- Thng tim: cho php khng nh chn on khi ng thng t ng mch phi vo
ng mch ch thnh hnh ch (tuy nhin thng khng cn thit.
- Siu m doppler mu: cho php nhn thy ng thng cng nh shunt, nh gi lu
lng shunt cng nh p lc ng mch phi.
3.4. Tin trin:
- Suy tim: tu thuc vo lu lng shunt v p lc ng mch phi. Bnh cnh suy
tim tri sau suy tim ton b tr nhanh vi iu tr tr tim.
- Vim ni tm mc nhim trng trn thnh ng: nng n kh iu tr. C th lm
phnh ng lm phu thut kh khn.
- Phnh ng: c nguy c v.
3.5. Th lm sng:
- Cn ng ng mch tr b: thi tm thu vi ting T2 mnh van ng mch
phi. Chn on c th kh phn bit vi thng lin tht. Nu nh c tng hiu p,
ng mch ch gin cng nh tng m mch phi loi ny thng lm suy tim sm
v cn phi c can thip phu thut sm.
- Cn ng ng mch c tng p phi mnh: kh th, c th tm (nht l chi di),
hay nhim trng phi, du suy tim nng, bin dng lng ngc, chm pht trin th
lc.
Nghe tim khng cn ting thi lin tc, T2 rt mnh i khi c thi tm trng
do h van ng mch phi c nng.
X quang tim ln, cung ng mch phi phng trong khi ngoi vi phi sng lc
tng sc cn tiu ng mch phi v shunt nh.
in tm tng gnh tm trng tht tri phi hp tng gnh tm thu tht
phi (do lu lng shunt ln hoc sc cn phi ln).
Thng tim ngoi vic chn on o p lc ng mch phi cn cho php
phn nh c c ch ca tng p lc (do tng lu lng hay sc cn phi).
- Dng phi hp: hp eo ng mch ch, thng lin tht, hp ng mch ch.
4. Phnh xoang Valsalva
Ti phnh Valsalva thng tim tng v c pht hin tnh c. Tuy nhin c nguy
c v ti phnh v vim ni tm mc nhim trng.
4.1. V: thng nhn mt ng tc gng sc v gy au ngc d di, tnh trng
chong v kh th d di. Thng thng ti phnh v vo tht phi v him khi v
vo nh phi. Khm tim c ting thi lin tc cng mnh nm vng thp b tri
xng c v du hiu ngoi vi ca h van ch. X quang v in tm cho thy
du hiu qu ti c hai tht. Thng tim phi thy shunt tri phi ln tng nh hoc
tht cng nh cho bit mc tng p phi. Siu m doppler cng cho php chn
on v phnh Valsalva. Tin trin t vong nhanh chng trong vng vi tun hoc vi
thng v suy tim.
Nu v ti phnh vo mng tim c th lm trn mu mng ngoi tim, v vo
nh tri to ting thi lin tc nhng khng c shunt, v vo tht tri gy h van ng
mch ch.
Chn on phn bit vi d ng mch vnh, d ch ph.
4.2. Cc bin chng khc: nhim trng ti phnh c th cng lm v. Khi ti phnh
ln v pha vch lin tht c th lm cho ri lon dn truyn.

V. BNH TIM BM SINH C LUNG THNG PHI - TRI

1. T chng Fallot

97
L d tt bm sinh phi hp bao gm 4 chng sau:
- Hp ng mch phi.
- Thng lin tht.
- ng mch ch lch sang phi.
- Dy tht phi ng tm.
Lm sng tm ngn tay chn di trng, tr em khi mt hay ngi xm, kh th
ngt co git. Nghe c thi tm thu cng mnh th rp khong lin sn 3
cnh c do hp ng mch phi. Ting T2 gim cng hoc l mt.
X quang bng tim bnh thng nhng c hnh i hia, cung gia tri lm, cc
ng mch phi nh v trng phi sng.
in tm c dy tht phi v nh phi.
Siu m cho thy ng mch ch ci nga, thng lin tht phn mng, dy
tht phi cng nh kho st van ng mch phi v thn nhnh ca n.
Thng tim chp mch cho php chn on cc bt thng trong d tt bm
sinh ny.
2. Bnh Ebstaine
L bt thng bm sinh him gp ca van ba l. L vch v l sau dnh nhau
v ch tch nhau 1/3 di. Chng lm thnh l van di thp bt thng. nh
vy to bnh cnh tht b nh ho.
- Phn tht b nh ho co bp cng lc vi li nh v th cn tr qu trnh lm y nh.
L van ba l hp hoc l h. Kt qu l tr tun hon thng ngun ca van ba
l, nu c phi hp thng lin nh th s c shunt phi tri, nu vch lin nh bnh
thng th c tr tnh mch ngoi vi (gan ln, tnh mch c ni, c chng).
- Nghe tim c cc ting tim tch i do bloc cnh phi hon ton, thnh phn T1 ca
van ba l m sc kim loi. Hay gp ting thi tm thu do h van ba l c im l
dch sang tri so vi bnh thng lm nhm h hai l.
- X quang c bng tim ln lm cho c th nhm trn dch mng ngoi tim. in tm
c lch trc phi dy nh phi v hnh nh bloc cnh phi.
- Siu m M-mode thy van ba l ng chm 0,04-0,12s so vi van hai l, siu m
hai bnh din thy bm thp van ba l.
- Thng tim chp mch cho thy tnh trng nh ho tht cng nh o p lc bung
tim phi.
- Tin trin thay i, i sng trung bnh 13 nm. Nu qua khi thi k nin thiu c
th sng 30-40 nm. Nguyn nhn t vong do tai bin mch no, suy tim phi, ri
lon nhp.
5.3. Phc hp Eisenmenger: c m t ln u tin vo nm 1897 khc vi t
chng Fallot. Tm mun, bao gm cc d tt sau:
- Thng lin tht cao.
- ng mch ch xut pht t ch thng lin tht c th c ci nga.
- Dy tht phi.
- Gin ng mch phi.
in tm : Thng dy 2 tht. Xquang: Tr nh tim to v rn phi m.
Hin nay ngi ta xp tt c cc bnh tim bm sinh c Shunt tri-phi nhng o
Shunt phi-tri gi l hi chng Eisenmenger.

98
VI. BNH TIM BM SINH KHNG SHUNT
1. Hp eo ng mch ch
- Lm sng: thi tm thu cnh c tri cng va phi, khng c rung miu nhng
lan ra sau lng r, huyt p tng v mch ny mnh chi trn, huyt p thp v
mch yu chi di.
- in tm , Xquang: Dy tht tri mnh hay va ty hp eo ng mch ch gn
hay xa l van ng mch ch, tht tri ln va phi vi gin ng mch ch phn
trn xng n tri km theo du gm mn xng sn (ng mch lin sn
gin).
- Siu m-Doppler: Thy c v tr, kch thc ca hp, dng chy tng tc qua
ni hp v du nh hng ca hp eo ng mch ch (gin tht tri....).
- Thng tim, chp mch: p lc tht tri tng, p lc ng mch ch tm thu tng
cao phn trn hp nhng bnh thng ng mch bn. Chp mch cho bit v tr
hp, mc gim ca tun hon bn ca ng mch lin sn, ng mch v
trong.
Ngoi hp eo ng mch ch cn gp hp di van ng mch ch bm sinh do tn
ti mt mng di ch cn ng tng mu tht tri.
2. Hp van ng mch phi: Chim 7% bnh tim bm sinh gm hp van, hp di
van, hp phu, v phi hp:
- Lm sng: thi tm thu mnh van ng mch phi km rung miu, T2 nh hoc
mt, tm mun.
- in tm , Xquang: dy tht phi chn lc, thn ng mch phi gin v phng,
ln tht phi, gim mch mu c 2 trng phi (phi sng).
- Siu m-Doppler: Cho bit th hp van, di van, phu hay phi hp, tht phi
dy, tc mu qua van ng mch phi tng cao, chnh p qua ch hp tng.
- Thng tim, chp mch: thy chnh p lc gia tht phi v ng mch phi
tng (p lc bung tht phi tng cao trong khi thp ng mch phi). Chp mch
cho thy hp, cht cn quang i qua ch hp van.

VII. IU TR
1. Thng nh
Phn ln thng nh khng dn n suy tim. chnh p lc gia 2 bung nh khng
cao do thng nh cng khng b bin chng vim ni tm mc nhim trng. Do
thng khng cn phi dng khng sinh d phng khi nh rng, cha rng hoc lm
th thut ngoi khoa.
1.1. Ni khoa
Ch c vai tr tng i nht l khi cha c ch nh phu thut nh:
- iu tr bi nhim phi.
- iu tr ri lon nhp khi c rung nh, nhp nhanh kch pht trn tht.
- iu tr suy tim.
- iu tr phng chng tc mch.
ng l thng lin nh bng ng thng a mt dng c gi l d i a vo
l thng bt l mt th thut c cc nh ni tim mch thc hin.
1.2. Ngoi khoa
Bng phu thut tun hon ngoi c th, ng l thng lin nh bng cch khu
trc tip hay bng ming v tng hp. Thng nh c th t ng vi tn sut t 14-

99

Ch nh phu thut: tui phu thut thay i c tc gi cho nn m tui i hc t

3- 5, hoc c th m tui t 15 -20 tuy vy nhn chung ch nh phu thut thng
nh thng khng khn cp nh thng tht v bin chng tng p phi thng xy ra
mun hn. C nghin cu cho ngi ln tui mi pht hin cng nn m. Ch nh
thng thng nht khi:
- Ch s dng mu phi/ ch s dng mu ng mch ton th (1.5/l
- Cha i shunt (nng O2 bo ha ng mch (92% hoc sc cn MP <
15 n v Woods/m2 c th).
Khng phu thut khi: p lc ng mch phi o bng Doppler gn bng p
lc mch h thng, lung thng rt t v 2 chiu, bo ho O2 lc ngh di 92%
v gim hn khi gng sc. (Vin tim TP H ch Minh)
2. Thng lin tht (TLT)
V ni khoa ni chung cn iu tr cc bin chng ca TLT nh suy tim, bi
nhim phi, vim ni tm mc nhim trng. Phu thut tr s sinh thng c t vong
cao 10-20% so vi tr ln 2%. Thng lin tht cng c th t ng, cc trng hp
nng lu d chuyn sang hi chng Eisenmenger kh khn khi phu thut.
2.1. Thng tht c l thng nh, shunt nh
Khng c ch nh ngoi khoa v bnh nhn thch nghi tt. Ch cn d phng
nhim trng ni tm mc. Tuy vy TLT l nh c km h van ng mch ch (hi
chng Laubry - Pezzi) d nh cng nn m sm.
2.2. Thng tht ln, shunt tri - phi ln (thng lin tht nhm II)
Chim 50%. Ni khoa gip iu tr cc bin chng hai khi bnh nhn khng c
ch nh phu thut. iu tr ch yu ngoi khoa vi tun hon ngoi c th, bng
cch dng ming v nhn to. Nguy c t vong t 1-2% trong th nh v < 10%
trong th nng. Tai bin phu thut thng gp do tn thng b His gy bloc nh
tht hay bloc nhnh.
Ch nh: nn t vn sm tui t 2 -10, ch s p lc ng mch phi/ p lc
ng mch ton th (0.75 km theo suy tim cn phu thut ngay. Nu suy tim n
nh khi iu tr ni khoa
Ngoi hai nhm mu lm sng trn cn hai nhm c bit khc t gp hn:
- Nhm III vi s tng p phi nng, gn vi hi chng Eisenmenger nhng shunt
tri-phi vn cn d rt yu. Khng c ch nh phu thut.
- Nhm IV vi hp van hay phu MP (Thng lin tht c bo v phi) gn vi t
chng Fallot, nhng shunt tri - phi vn cn d rt yu. Cn phu thut nu dy
tht phi r.
3. Cn ng ng mch (COM)
Tt c bnh nhn COM nu khng t ng c cn ch nh phu thut do
c nhiu nguy c nu khng gii quyt nh: vim ni tm nhim trng, suy tim tri,
tng p phi, vi ho ng ng mch.
3.1. Ni khoa
tr s sinh v cn b c th dng indometacine (Indocid) 25mgx 1-2
vin/ngy 1 thng lm ng li ng ng mch do thuc c ch tc dng co tht ca
Prostacycline. C tc gi s dng Aspirine cng c kt qu. Nu khng c kt qu

100

3.2. Ngoi khoa

Bng th thut ct buc hay nt l thng nu l thng ng knh di 5mm v
tr (8kg. p dng phu thut vi tui t 1-2 tui nhng c th ln hn nhng cha
i shunt. T l nguy c t vong khi phu thut t 1-2% do suy tim, Osler.
Theo Kirklin tt c CM c triu chng hoc tr khng ln d iu tr ni khoa
tch cc c th phu thut bt k tui no.
- Cn ng ng mch vi shunt ln v tng p phi nh:
iu tr ngoi khoa: Ct buc. Nguy c t vong cao hn so vi nhm trn.
- Cn ng ng mch vi shunt nh v tng p lc phi nng.
iu tr: Ch nh phu thut cn bn ci.
Nu sc cn p lc phi trn 10 v /m2, khng cn ch nh phu thut. Nu sc
cn mch phi thp hn nhng ng ng mch ngn, vi ho nhiu nn phu thut
tim h trnh v ng mch khi kp trong phu thut kn.
4. T chng Fallot
- Ni khoa: iu tr ch c tnh tm thi, lm bt cc triu chng chun b cho phu
thut. Gim s tng mu tht phi bng cc thuc c ch bta nh propanolol 40mg
x 1 v ung. Cho thuc chng ng hay chng ngng tp tiu cu nh Aspirine 0.25g/
ngy. Tr s sinh c tun hon phi khng c th chuyn prostaglandine E1
gi ng ng mch m. Tt c tr c dung tch hng cu cao cn cho thm vin st
ung. Chng cn thiu Oxy kch pht: cho nm u thp gi - ngc, O2, Morphine
1ctg 0.01-0.1 mg/kg TB, truyn natri bicarbonate.
- Ngoi khoa: c th phu thut tm thi hoc phu thut sa cha. Tui l tng
phu thut sa cha hay tn gc (v l thng tht bng mnh ghp v sa cha
hp MP rng ra) l 2 tui. chm tui ln s c nhiu bin chng sau m.
Tnh trng tht tri v kch thc ng mch phi l nhng yu t quan trng gip
quyt nh k thut ny.
V phu thut tm thi c hay k thut thng dng l Blalock - Taussig (ni h n
tri v nhnh tri MP) v Blalock - Taussig c bin ci (ni bng ng Gore- Tex).
Khng thc hin phu thut Blalock - Taussig tr nh di 6 thng tui hoc MP
c ng knh (3mm v d b thuyn tc.
Cn gii phu sm khi triu chng c nng ngy cng tng hoc th tch hng cu
khong 65%.
T l t vong khong < 5% i vi Blalock v 10% i vi iu tr tn gc. K thut
Blalock ch cho kt qu tt trong khong 50% trng hp trong vng 10 nm.
5. Hp ng mch phi
- Ni khoa: t c tc dng. c coi nh khi chnh p lc tht phi/ MP (25
mmHg, nng khi chnh t 25-50 mmHg. Can thip cng chm cng hp nng
hn do ph i vng phu. C th p dng phng php nng van thay cho phu
thut m. Hin nay ch nh nong bng qua da nhng c gi tr cao nu tui nh. y
l phng php chn lc, t vong hu nh khng c.
- Ngoi khoa: ch p dng khi khng nong van qua da c. Khi p lc tht phi cao
hn p lc ng mch phi trn 50 mmHg. Phu thut to van ng mch phi hai
l c km theo hay khng sa cha phu phi. Khi c suy tim phi t l t vong cao
trn 14%.

101
6. Hp eo ng mch ch
Ngoi khoa: Cn t vn phu thut ngay khi bnh nhn cn chu ng c.
Tui l tng l t 10 -15 tui, v sau nguy c cao do b x va phi hp. Nguy c
t vong di 5%. Phu thut bng cch ni tn hoc bt cu ni bng ng nhn to.
7. Phc hp v hi chng EISENMENGER
-Ni khoa: iu tr bin chng suy tim: O2, tr tim, li tiu...
-Ngoi khoa: khng c ch nh phu thut ngoi tr thay tim.

102

VIM NI TM MC NHIM KHUN

Mc tiu
1. Trnh by nguyn nhn, c ch bnh sinh ca vim ni tm mc nhim khun.
2. Trnh by cc triu chng lm sng, cn lm sng v tiu chun Duke trong chn
on VNTMNK.
3. Nu cc th lm sng, nguyn tc iu tr vim ni tm mc nhim khun.
Ni dung

I. I CNG
1. nh ngha
Vim ni tm mc nhim khun (VNYMNK) l bnh nhim trng mng trong
tim, tn thng ch yu l cc van tim, nhng lp ni mc ca cc mch mu ln
cng b tn thng trong bi cnh lm sng chung. Bnh do nhiu tc nhn gy
bnh v nhiu ng vo khc nhau cui cng khu tr ni tm mc, tn thng
vi c trng l lot v si nht l cc van tim, ng hng u l van 2 l ri n van
ng mch ch. Van 3 l t gp hn v thng trn c a c bit (chch Hroine
bng ng tnh mch).
2. Dch t hc
2.1. Vim ni tm mc nhim khun a s xy ra bnh nhn b nhim khun,
tui thng gp < 50, nam nhiu hn n, 60 - 80% bnh nhn c tin s b bnh
tim trc ch yu l bnh van tim, 30% do thp; VNTMNK hay gp van hai l
dn ti van ng mch ch, 10 - 20% do bnh tim bm sinh. V d: bnh cn ng
ng mch, thng lin tht, t chng Fallot, hp MC; 10 - 30% sa van hai l.
Cc bnh tim thoi ha cng l c s a n vim ni tm mc c bit l hp
van MC vi ha ngi gi, him hn ph i vch khng i xng, hi chng
Marfan, hp van ng mch ch do giang mai v 20 - 40% khng c bnh tim t
trc.
2.2. Vim ni tm mc nhim khun bnh nhn chch ma ty: thng gp
nam tr tui khng c bnh tim, da thng l ngun ly nhim, van 3 l thng
hay b tn thng hn c.
2.3. Vim ni tm mc bnh nhn mang van nhn to chim 10-20%, a s l
nam gii, van MC thng b hn van 2 l, tn thng thng cnh van trn
ng khu van nhn to vi vng van. Bnh thng xy ra trong tun u hay
trong nm u sau phu thut (chim 1-2% trng hp), t l mc bnh gim cn
1% trong nhng nm tip theo.

II. NGUYN NHN V C CH SINH BNH

1. Vi khun gy bnh
1.1. a s trng hp vi khun gy bnh l lin cu, thng l lin cu nhm D, t
nhy cm vi Pnicilline thng thng. Lin cu tan huyt (gy tan huyt b phn)
v lin cu tan huyt (li rt nhy cm vi Pnicilline, ngoi ra cn gp vim ni tm
mc do lin cu (hin nay, t cu l vi khun cng hay gp nht l do nhim trng
huyt sau no ph thai (loi ny thng nng, t l t vong cao do khng khng
sinh). Ngoi ra cng c th gp vim ni tm mc do trc trng Salmonella, Brucella.
1.2. ng vo
Bng 1: Nguyn nhn v ng vo ca vi khun trong vim ni tm mc nhim trng
ng xm nhp

Tn thng

Vi khun

103
Rng, ming

Nh rng, U ht dnh lin cu

Lin cu

Tai mi hng

Vim hng, vim tai, ct

Amygdale, vim xoang

Lin cu D, lin cu

Tit niu

Thng tiu, soi bng quang, Lin cu D, t cu vng,

m tit niu
trc khun Gr (-)

Ph khoa

Ph thai, sinh , vim ni

mc t cung

T cu, lin cu D

Da

Bng, bnh v da

T cu

Tiu ha

Vim ti mt, U tiu ha

Lin cu D, lin cu, t cu

ng thng

T cu

Shunt chy thn nhn to

Trc khun Gr (-), t cu

Dng ma ty

Trc khun Gr (-)

M tim

Nm

2. C ch sinh bnh
2.1. Tn thng ni mc
nh v ca vi khun trong tn thng ni tm mc theo l thuyt thng nm v tr
i din tn thng ni mc theo nh lut Venturi.

Mu v vi khun

Ch hp
V tr thng gp ca
vi khun

Hiu qu lut Venturi v inh v ca vi khun

2.2. Vi khun
S c nh v s tng sinh ni vi khun ty thuc vo:
- sc khng vi khun t nhin ca huyt thanh: tnh bo v ca b th - s him
c ca vi khun Gram (-) do s nhy cm t nhin i vi b th.
- s hin din nhng khng th ngng kt lm to nn nhng m vi khun
- c tnh kt dnh c th do s tham gia ca nhng cht slime do mt s vi khun
tit ra nh t cu vng.
T cu vng -> lin cu khun tan huyt -> Pseudomonas aeruginosa
2.3. Cc biu hin min dch
Ph thuc vo:
- thi gian nhim trng
- s tn ti ca ngun kch thch khng th.

104
III. GII PHU BNH
Ngi ta phn bit 2 th ch yu sau y:
1. Vim ni tm mc cp c tnh
Tin trin nhanh, xut hin trn mt ni tm mc lnh, th ny nng n,
thng gy t vong nhanh v trong bi cnh nhim trng huyt. Tn thng gii
phu bnh l lot, n mn, sau cng l thng cc van, c th t cc dy chng, lot
si c th gy nn p xe mt s ph tng nh gan, lch, thn. Th ny c gi l
c tnh v trc khi c khng sinh t vong l 100%.
2. Vim ni tm mc bn cp nhim khun Jaccoud-Osler
L tn thng lot si xy ra trn cc bnh van tim, tim bm sinh c trc. Vi
khun gy bnh c pht hin nh cy mu hoc gii phu t thi vi cy m ni
tn thng. Trc khi c khng sinh, y l mt bnh nng, t vong 100%, nhng
t khi c khng sinh t l t vong c gim nhng vn cn l bnh nng.

IV.TRIU CHNG HC
1. Triu chng lm sng
1.1. Giai on khi u
Thng bt u vi st khng r nguyn nhn trn bnh nhn b bnh tim, v
vy nu bnh nhn c mc bnh tim m st khng r nguyn nhn trn 10 ngy,
km suy nhc c th, km n, xanh xao phi ngh n vim ni tm mc bn cp
nhim khun (Osler). Thm d chn on bng cch:
- Tm ng vo ca vi khun.
- Xt nghim nc tiu tm protein v bch cu niu.
- Cy mu nhiu ln, khng nn cho khng sinh lm cy mu tr nn m tnh.
- i khi bnh c th bt u bng tai bin mch mu no vi lit na ngi hay
nhi mu ph tng.
1.2. Giai on ton pht
Thng sau vi tun cc triu chng r dn:
- St v suy nhc: St dao ng km rt run hoc st kiu ln sng, nhit 39400 xen k nhng t khng st do phi cp nhit mi 3 gi mt ln, st thng
km da xanh, thiu mu, gy.
- Nghe tim: Bnh tim t trc thng khng thay i. Theo th t thng gp l
bnh h van ng mch ch, h van hai l, hp van hai l, bnh van 3 l v van
ng mch phi him gp hn. Bnh tim bm sinh c th gp nh cn ng ng
mch, thng lin tht, hp ng mch phi, hp di van ng mch ch, hp eo
ng mch ch, t chng Fallot.
- Ngn tay di trng rt c gi tr chn on trn bnh tim c st nhng du hiu ny
thng mun, ngoi ra xut huyt di da, nim mc cng c th gp.
- Lch to: 2- 4cm di b sn, rt c gi tr chn on nht l khi phi hp vi
bnh tim c st.
- Thn: kinh in l i mu i th hay vi th, Protein niu gp trong 70% trng
hp.
- Cc du chng khc: Tc cc ng mch nh:
+ Tc mch no gy lit na ngi.
+ Tc mch chi gy au chi, da xanh ti, lnh.
+ Tc mch lch gy au h sn tri, lch to nhanh.

105
+ Tc mch mc treo: au bng.
+ Tc mch thn: au tht lng d di, i ra mu, thng v niu phn x trong 3
gi u.
+ Nhi mu phi: au ngc, ho ra mu, kh th.
+ Vim mng no m, xut huyt mng no.
+ Tc mch kt mc mt.
2. Cn lm sng
Cng thc mu: Thiu mu, bch cu tng.
Mu lng tng.
Lm in tm , chp X quang phi.
Soi y mt: Tc ng mch vng mc.
Lm cn Addis.
Protein niu.
Ur mu thng tng > 0,5g/lt.
in di Protein: globulin tng.
Cy mu: Lm 9 ln trong 3 ngy lin tip, lc nhit tng cao v trn nhiu
mi trng khc nhau.
Siu m tim: Hin nay c coi l xt nghim c nhy chn on cao,
ngoi ra cn cho php theo di tin trin ca bnh. Vi k thut siu m 2 bnh
din ngi ta c th xc nh c s hin din ca tn thng si trn cc van
tim, siu m c th pht hin c t dy chng hay thng van tim. Nu thy
tn thng si th chn on chc chn mc d cy mu (-), nhng khng thy
tn thng si khng loi tr chn on.

V. CHN ON XC NH
p dng tiu chun chn on lm sng ca Duke nm 1994.
1. Hai tiu chun chnh
1.1 Cy mu dng tnh
- Vi khun c hiu phn lp c trong hai ln cy mu ring bit
- Cy mu dng tnh tn ti
1.2. Bng chng tn thng ni tm mc
- Siu m dng tnh
- H van mi xut hin
2. Su tiu chun ph
- Yu t thun li: c bnh tim, dng thuc ng tnh mch
- St > 38o
- Biu hin van tim: tc mch, phng mch, xut huyt, du hiu Janeway.
-Biu hin min dch: vim cu thn, nt Osler, du Roth, yu t thp.
-Bng chng vi sinh hc: cy mu dng tnh nhng khng c cc tiu chun
chnh, du huyt thanh hc nhim khun cp.
-Siu m tim: c du VNTMNK nhng khng c cc du hiu chnh.
Vn dng chn on
1. Tiu chun bnh l
+ vi khun: cy mu hoc c nt si gy tc mch hay p xe trong tim

106
+ tn thng gii phu bnh: si, p xe trong tim c m hc xc nh
2. Tiu chun lm sng
c chn on xc nh VNTMNK khi c:
- 2 tiu chun chnh, hoc
- 1 tiu chun chnh v 3 tiu chun ph, hoc
- 5 tiu chun ph

VI. TH LM SNG
1. Vim ni tm mc nhim trng bn cp cy mu m tnh
Vim ni tm mc nhim trng bn cp cy mu m tnh khi cy mu lin tc 9 ln
trong 3 ngy trn nhiu mi trng khc nhau u m tnh, nhng c th tm thy vi
khun trn cc tn thng khi gii phu t thi.
c im ca vim ni tm mc bn cp nhim trng cy mu m tnh l:
- Hay gp trn nhng bnh nhn b tn thng van ng mch ch.
- Thng km theo cc bin i ni tng.
- Thng km thiu mu, gim bch cu, tng globulin.
- Bnh thng nng, t l t vong cao mc d iu tr tch cc. Ti sao cy mu m
tnh ? cha r nguyn nhn, nhng c my nhn xt sau:
+ Trong lch c s nang ha ca vi khun.
+ Mt s bnh nhn km theo st pht ban, Lupus ban ri rc.
+ (globulin thng tng.
2. Th lin cu nhm D
Thng gp trong 10-15% trng hp, bnh hay xut hin sau nhim trng
sinh dc-tit niu, bnh p ng vi Peniciline liu cao kt hp vi Gentamycine,
bnh c xu hng hay ti pht.
3. Th do t cu
- Nhim trng da, tit niu v sinh dc.
- Thng gp tn thng trn van 3 l.
- Lm sng biu hin suy tim khng hi phc.
- T l t vong cao mc d iu tr tch cc.
4. Th thn
Chim 8-12% trng hp.
Biu hin lm sng vi i mu, Ur mu cao, ph v tng huyt p, tin lng xu.
5. Vim ni tm mc bn cp trn bnh tim bm sinh
Thng hay gp l t cu.
6. Vim ni tm mc trn phu thut tim kn hoc h
Biu hin sm 3-5 ngy sau phu thut, thng gp l t cu v cc vi khun khc.

VII. NGUYN TC IU TR
1. iu tr ni khoa
Ch yu x dng khng sinh v thng thng ty theo khng sinh m iu tr.
2. iu tr ngoi khoa
Ty theo tnh trng huyt ng hc m ch nh can thip.
3. iu tr d phng

107
V trng tuyt i cc dng c phu thut, cc dng c thm khm hoc bng khng
sinh cho cc bnh nhn c bnh tim mc phi hoc bnh tim bm sinh khi c can
thip th thut hay phu thut.

VIII. TIN TRIN V TIN LNG

Khi cha c khng sinh t l t vong 100%, t khi c khng sinh tin lng c kh
hn nhng t l t vong cn cao 20-40%. Tin lng bnh ph thuc vo cc yu t
sau:
1. Tui ln > 70.
2. Khng tm thy ng vo ca vi khun.
3. Suy thn.
4. Biu hin thn nng, tc mch hay suy tim sm.
5. Th cy mu m tnh.
6. Ti pht sau 2 thng tuy iu tr tn gc.
Tin trin: Thng khi trong cc trng hp iu tr sm. Tuy nhin di chng ca
bnh nh vim thn mn vi tng Ur mu, tai bin mch no vi lit na ngi,
tin lng cn ph thuc vo bnh tim c trc v mt s trng hp t vong do
suy thn hay tc mch.

IX. IU TR VIM NI TM MC NHIM KHUN

1. iu tr ni khoa
1.1. iu tr tit cn: ch yu bng khng sinh. Cn x dng khng sinh dit khun,
sm liu cao, lin tc, ko di, s dng nhng khng sinh cng lc trong c vai
tr ca cn lm sng gip chn la thuc ph hp. Cn xc nh s nhy cm vi
khun da vo khng sinh qua vic xc nh nng c ch ti thiu ( Minimum
Inhibitory Concentration = MIC) , nng ti thiu dit khun ( Minimum bactericidal
concentration = MBC) ca khng sinh v kh nng dit khun dn c hoc phi
hp.
- Lin cu (Streptococci) nhy cm vi Penicilline G c MIC 0.1ug/ml: dng mt
trong nhng phc sau:
+ Phc A:PNC G 12-18 triu v/ ngy, tim TM cch 4 gi mt ln trong 4 tun.
+ Phc B: PNC G nh phc A kt hp Gentamycine liu 1 mg/kg tim TM
mi 8 gi, c hai loi dng trong 2 tun.
+ Phc C: Ceftriazone 2g tim TM hoc TB 1 ln/ ngy , trong 4 tun.
+ Phc D: Vancomycin liu 15 mg/kg tim TM mi 12 gi trong 4 tun.
- Lin cu nhy cm PNC c 0.1 ug/ml< MIC< 0.5ug/ml:
+ Phc E: PNC G 18 triu v/ ngy, tim TM cch 4 gi mt ln trong 4tun. Phi
hp Gentamycine 1 mg/kg tim TM mi 8 gi trong 2 tun u.
+ Hoc dng phc D nu bnh nhn d ng PNC.
- Trng cu khun (Enterococci) hoc lin cu khun nhy cm Penicilline c MIC
0.5ug/ml hoc Streptococci viridans bin th dinh dng:
+ Phc F: Penicilline G 18-30 triu v/ ngy hoc Ampicilline 12 g/ ngy tim TN
cch 4 gi mt ln. Phi hp vi Gentamycine 1 mg/kg tim TM mi 8 gi. Dng c
hai loi trong 4-6 tun.
+ Phc G: Vancomycine 15 mg/kg tim TM mi 12 gi . Phi hp Gentamycine
nh phc F. C hai loi dng trong 4-6 tun.
- T cu cn nhy vi Methicilline bnh nhn c van tim t nhin:

108
+ Phc H: Nafcilline hoc Oxacilline 2 g tim TM mi 4 gi trong 4-6 tun. C th
kt hp hoc khng vi Gentamycine 1 mg/kg tiem TM mi 8 gi trong 3-5 ngy u.
+ Phc I: Cefazolin 2 g, tim TM mi 8 gi, trong 4-6 tun, c kt hp hoc khng
vi Gentamycine nh trong phc H.
+ Phc J: Vancomycine 15 mg/kg tim TM mi 12 gi trong 4-6 tun c hoc
khng kt hp vi Gentamycine nh phc H.
- T cu khng vi Methicilline hoc Corynebacterrium van t nhin.
Phc K: Vancomycine nh phc J, c hoc khng c phi hp vi
Gentamycine nh phc H i vi t cu nhng dng tip tc Gentamycine t 4-6
tun vi Corynebacterium.
- Vi bnh nhn c van tim nhn to:
+ Streptococci hoc Enterococci: phc F hoc G.
Do Streptococci: PNC hoc Vancomycine trong 6 tun kt hp Gentamycine
trong 2 tun u hoc lu hn.
Do Enterrococci: PNC hoc Vancomycine, phi hp vi 1 loi aminoglucoside
trong 6-8 tun.
+T cu cn nhy cm Methicilline: phc H.I hoc J trong 6-8 tun, kt hp
Gentamycine trong 2 tun u v Rifampicine 300mg ung mi 8 gi trong 4-6 tun.
+ T cu khng Methicilline: phc J trong 6-8 tun, phi hp gentamycine
trong 2 tun u v Rfampicine 300mg ung mi 8 gi trong sut liu trnh.
- Vi vi khun nhm HACEK:
Phc L: dng phc C.
- Mt s trng hp c bit:
+ C th dng Cephalosporine th h khc thay th Cefazoline.
+ Streptomycine c th thay th Gentamycine vi liu 7.5 mg/kg TB mi 12 gi.
+ Khi cha c kt qu cy mu: Nu khng c van tim nhn to: dng khng sinh
theo phc F hoc G. Nu c van tim nhn to: phc K. Nu c tim chch ma
tu: phc J.
+ Kt qu cy mu m tnh: nu p ng lm sng tt: tip tc iu tr nh trn .
Nu khng p ng lm sng sau khi iu tr c 7-10 ngy: dng phng php
nui cy c bit hoc di ngy hn, tm thm cc mm bnh khc nh Brucella,
Leigiolla, Chlamidia, Rickettesia, nm... ng thi p dng phc iu tr phi hp
c 3 loi khng sinh: Vancomycine+Gentamycine+Rifampicine. Nu sau 3 tun vn
khng phi ngng khng sinh v lm li bilan chn on.
1.2. iu tr ng vo vi khun v iu tr cc bin chng.
2. iu tr ngoi khoa
Ch nh:
- Suy tim nht l do tn thng van ch hoc van tim nhn to.
- T chc si c kch thc ln > 10 cm.
- H van tim nng d khog c suy tim.
- Tn ti nhim trng ko di d dng khng sinh thch hp 8-10 ngy.
- Tai bin mch no ti din nhiu ni.
- p xe vch tim hoc p xe vng van ng mch ch.
- VNTM ti pht sau 6 thng.

109
- Tn thng vng xoang Valsalva hoc vng nh tht.
- Vim ni tm mc do nm.
- Trn van tim nhn to th sm sau thay van < 2 thng.
3. D phng
y chnh l iu tr hu hiu hn c. Cn phi thm khm h thng rng ming
hoc tai mi hng. Ch cc i tng c nguy c cao nh thay van tim nhn to.
Trit tit khun cc dng c phu thut.

110
Khng sinh d phng trong VNTMNK
Ngun nguy c

Ni ch yu

Khng sinh chn la u tin

Rng
amygdal

Lin cu khun

Amoxcillline 500mg/6 gi TM ; nu c nguy

c rt cao: PNC G 10-20 triu v/ ngy
hoc Amoxcilline 0.5g/ 6 gi + Gentamycine
1mg/kg/12 gi.

Tit niu sinh dc

Cu khun rut

Amoxcilline 1g/ 4 gi hoc Amoxcilline

0.5g/ 6 gi + Gentamycine 1 mg/kg/ 12 gi.

Da

T cu khun

Dicloxacilline 1.5 g/ ngy; Pristinamycine 2

g/ ngy

Ph khoa

LCK, Cu khun Amoxcilline 1g/4 gi + Gentamycine +

rut, loi k kh
Metronidazole 500 mg/ 12 gi

Tiu ho

Cu khun rut, vi Nguy

c
qu
cao:
Amoxcilline+
khun rut loi k Gentamycine +Metronidazole
kh

M tim

T cu

ming,

Cefazoline 2 g + Gentamycine 1.5 mg/kg

TM trc m, 8 gi sau v 16 gi sau m.

104

CHNG 2

TIU HA
LOT D DY T TRNG
Mc tiu
1. Trnh by c c im dch t hc, c ch bnh sinh v cc yu t nguy c gy
bnh.
2. Trnh by c cc triu chng v bin chng lot.
3. Chn on v nu c cc phc iu tr lot.
Ni dung

I. DCH T HC
Tn sut bnh tin trin theo thi gian v thay i ty theo nc, hoc l theo
khu vc. Cui th K 19 Chu u, lot d dy thng gp hn, v ph n. Gia
th k 20, tn sut lot d dy khng thay i, nhng lot t trng c xu hng tng,
v hin nay t l lot t trng /lot d dy l 2/1, v a s gp nam gii. C khong
10-15% dn chng trn th gii b bnh LDDTT. Anh v c l 5, 2-9, 9%, M
l 5-10%. Hin nay c khong 10% dn chng trn th gii b LDDTT.

II. BNH SINH

1. Pepsine: c tit ra di dng tin cht pepsinnogene di tc ng ca acid
HCL bin thnh pepsine hot ng khi pH <3, 5 lm tiu hy cht nhy v collagen.
2. S phn tn ngc ca ion H+: tin trnh lot c khi pht do tng tit HCL do
lng t bo thnh qu nhiu hoc qu hot ng, do lng dch v c bn hoc
sau kch thch rt gia tng, s phn tn ngc v s i vo ca ion H+ lm thng
tn thnh d dy v gy ra lot; do lm trung ha ion H+ lm gim t l lot rt
nhiu. Nguy c lot cng cao khi s tit acid cng nhiu.
3. Yu t bo v ca nim mc d dy
3.1. Hng ro nim dch: chng li s tn cng ca ion H+, yu t chnh l lp
nim dch giu bicarbonate to bi glycoprotine c cha cc phospholipides khng
phn cc, nm trn b mt ca lp gel ny c tnh nhy n hi. Khi pepsine ct
chui peptide phng thch cc tiu n v glycoproteines; chng lm mt tnh cht
nhy n hi ny. Cc ion H+ xm nhp vo lp nhy, nhng chng b trung ha bi
bicarbonate. Nhng khi pH<1, 7 th vt qu kh nng trung ho ca n v ion H+
n c lp nim mc d dy v gy ra lot.
3.2. Lp nim mc d dy: tit ra glycoproteines, lipides v bicarbonate, chng c
kh nng loi b s i vo bo tng ca ion H+ bng 2 cch: trung ha do
bicarbonate, v y ion H+ vo khong k nh bm proton H+- K+ - ATPase.
3.3. Lp lamina propria: ph trch chc nng iu ha. Oxy v bicarbonate c
cung cp trc tip cho h nim mc bi cc mao mch c rt nhiu l h, m cc t
bo ny rt nhy cm vi toan chuyn ha hn l s thiu kh. Mt lng
bicarbonate y phi c cung cp cho t bo nim mc ngn chn s acid
ha trong thnh d dy gy ra bi ion H+ xuyn qua hng ro nim mc ny.

105
4. Vi Khun H.P: gy tn thng nim mc d dy t trng ng thi sn xut ra
amoniac lm mi trng ti ch b acid gy ra lot. HP sn xut men urease
lm tn thng nim mc d dy; n cng sn xut ra proteine b mt, c ho ng
ng (+) vi bch cu a nhn trung tnh v monocyte. N cn tit ra yu t hot ho
tiu cu, cc cht tin vim, cc cht superoxyde, interleukin 1 v TNF l nhng cht
gy vim v hoi t t bo. HP cn sn xut ra cc men protease, phospholipase
lm ph hu cht nhy nim mc d dy.

III. BNH NGUYN

1. Di truyn: cho rng lot t trng c t tnh di truyn, tn sut cao mt s gia nh
v lot ng thi xy ra 2 anh em sinh i ng non, hn l d non.
2. Yu t tm l: hai yu t cn c l nhn cch v s tham gia ca stress
trong lot. Th tm thn nh hng ln kt qu iu tr, lot cng thng xy ra
ng c nhiu san chn tnh cm, hoc trong giai on cng thng tinh thn nghim
trng nh trong chin tranh.
3. Ri lon vn ng: l s lm vi d dy v s tro ngc ca t trng d dy.
Trong lot t trng c s lm vi d dy qu nhanh lm tng lng acid ti t trng.
Ngc li trong lot d dy s lm vi d dy qu chm, gy tr acide d dy.
4. Yu t mi trng
4.1. Yu t tit thc: khng loi tr lot phn b theo a d l c s ng gp ca
thi quen v n ung. Nh Bc n n nhiu la m lot t hn min Nam n ton
go. Tht vy nc bt cha nhiu yu t tng trng thng b lm gim lot.
Cafine v calcium l nhng cht gy tit acide; ru gy tn thng nim mc d
dy.
4.2. Thuc l: lot d dy t trng thng gp ngi ht thuc l, thuc l cng
lm xut hin cc lot mi v lm chm s lnh so hoc gy khng vi iu
tr. C ch gy lot ca thuc l vn hon ton cha bit r c th do kch thch dy
X, hy nim dch do tro ngc t trng d dy hoc do gim tit bicarbonate.
4.3. Thuc
- Aspirin: gy lot v chy mu, gp d dy nhiu hn t trng, do tc dng ti ch
v ton thn. Trong d dy pH acide, lm cho n khng phn ly v ha tan c vi
m, nn xuyn qua lp nhy v n mn nim mc gy lot. Ton thn do Aspirin c
ch Prostaglandin, lm cn tr s i mi t bo nim mc v c ch s sn xut
nhy d dy v t trng.
- Nhm khng vim nonsteroide: gy lot v chy mu tng t nh Aspirin nhng
khng gy n mn ti ch.
- Corticoide: khng gy lot trc tip, v ch lm ngn chn s tng hp
Prostaglandin, nn ch lm bc pht li cc lot c, hoc ngi c sn t tnh
lot.
4.4. Hlicobacter Pylori (HP): c Marshall v Warren pht hin nm 1983, HP
gy vim d dy mn tnh nht l vng hang v (type B), v vim t trng do d sn
nim mc d dy vo rut non, ri t gy lot. 90% trng hp lot d dy, v
95% trng hp lot t trng c s hin din HP ni lot.

IV. TRIU CHNG HC

1. Lot d dy

106
1.1. Triu chng: au l triu chng chnh c nhiu tnh cht.
- au tng t mi t ko di 2 - 8 tun cch nhau vi thng n vi nm. au gia
tng theo ma nht l vo ma ng to nn tnh chu k ca bnh lot. Tuy nhin
cc biu hin lm sng ca vim vng hang v xy ra trc lot c th lm mt tnh
chu k ny.
- au lin h n ba n, sau n 30 pht - 2 gi; thng au nhiu sau ba n tra
v ti hn l ba n sng.
- au kiu qun tc, au i him hn l au kiu rt bng. au c lm du bi
thuc khng toan hoc thc n, nhng khi c vim km theo th khng hoc c
th lm au thm.
- V tr au thng l vng thng v. Nu lot nm mt sau th c th au lan ra
sau lng. Ngoi ra c th au bt k ch no trn bng.
Mt s trng hp lot khng c triu chng v c pht hin khi c bin
chng.
1.2. Lm sng: ngho nn, c th ch c im au khi ang c t tin trin, trong
lot mt trc c th c du cm ng nh vng thng v. Trong t lot c th st
cn nh nhng ra khi t au s tr li bnh thng.
1.3. Xt nghim: Cc xt nghim sinh ha t c gi tr trong chn on:
- Lu lng dch v c bn thp (BAO)
- Lu lng sau kch thch (MAO) bnh thng hoc gim trong lot loi 1. Trong
lot loi 2 v 3 s tit dch v bnh thng hoc tng. Trong lot d dy km v toan
cn ngh n ung th.
- Chp phim d dy baryte v nht l ni soi cho thy c hnh nh lot thng nm
hang v, gc b cong nh, i khi thy thn d dy hay tin mn v.
2. Lot t trng: xy ra ngi ln vi mi la tui. Tuy nhin, nhn chung n xy ra
trc 60 tui. Nam = 2 n v thng c yu t gia nh.
2.1. Triu chng: au l c trng ca lot t trng thng r hn lot d dy, v
y khng c vim phi hp. Cc t bc pht rt r rng. Gia cc k au, thng
khng c triu chng no c. au xut hin 2 - 4 gi sau khi n to thnh nhp ba k,
hoc au vo m khuya 1 - 2 gi sng. au i v au kiu qun tht nhiu hn l
au kiu nng ran. au thng v lan ra sau lng v pha bn phi (1/3 trng
hp). Cnng c 10% trng hp khng au, c pht hin qua ni soi hoc do
bin chng v 10% trng hp lot lnh so nhng vn cn au.
2.2. Xt nghim: Trn 90% lot nm mt trc hoc mt sau ca hnh t trng
cch mn v 2 cm. i khi 2 lot din gi l Kissing ulcers. Ni soi cho hnh
nh lot trn, l hay gp nht, lot khng u, lot dc v lot hnh mt ct khc di
salami t gp hn.
S tit acid d dy thng cao bt thng. Ni soi v phim baryte, cho thy
ng thuc thng nm theo trc ca mn v trn hai mt hoc hnh nh hnh t
trng b bin dng.Trong trng hp lot mn tnh x ha, hnh t trng b bin
dng nhiu, cc np nim mc b hi t v lot lm mn v b co ko, hoc hnh t
trng b chia ct thnh 3 phn to thnh hnh cnh chun. Mt hnh nh bin dng
khng i xng lm dn np gp y ngoi v teo np gp y trong to thnh ti
tha Cole lm cho l mn v b lch tm. Ni soi c th nhn ra d dng lot do

107
y mu xm sm c ph mt lp fibrin, i khi c che y bi cc np nim
mc b sng ph, cc lot dc kh phn bit vi mt lot ang lnh so, trong
trng hp ny bm bleu de mthylene n s nhum fibrin c mu xanh.
nh lng acid v gastrin c ch nh nu nghi ng 1 s tit bt thng do
u gastrin, mt s ph i vng hang v, cng ph gip hoc suy thn.

V. CHN ON
1. Chn on lot d dy: t ra khi lm sng c cn au lot in hnh xc nh
bng chp phim d dy baryte v bng ni soi. in hnh l ng thuc khi lot
b ca d dy. V ni soi d nhn ra ming lot y ca n ph mt lp fibrin mu
trng xm, b u hi nh ln do ph n hoc c bao quanh bi cc np nim
mc hi t. iu quan trng l phi xc nh bn cht ca lot bng sinh thit
phn bit vi ung th th lot v lot ung th ha.
2. Chn on lot t trng: Gi bng cn au lot in hnh t trng, thng xy
ra ngi tr tui, c nhm mu O. Xc nh bng ni soi v phim baryte, cho thy
ng thuc thng nm theo trc ca mn v trn hai mt hoc hnh nh hnh t
trng b bin dng.Trong trng hp lot mn tnh x ha, hnh t trng b bin
dng nhiu, cc np nim mc b hi t v lot lm mn v b co ko, hoc hnh t
trng b chia ct thnh 3 phn to thnh hnh cnh chun. Mt hnh nh bin dng
khng i xng lm dn np gp y ngoi v teo np gp y trong to thnh ti
tha Cole. Ni soi c th nhn ra d dng lot do y mu xm sm c ph mt
lp fibrin.
3. Chn on phn bit
3.1. Vim d dy mn: au vng thng v m h, lin tc, khng c tnh chu k,
thng au sau n, km chm tiu y bng. Chn on da vo ni soi sinh tit c
hnh nh vim d dy mn vi tm nhun t bo vim n nhn, x teo tuyn tit.
3.2. Ung th d dy: Thng xy ra ngi ln tui, au khng c tnh chu k,
ngy cng gia tng, khng p ng iu tr lot. Cn ni soi sinh thit nhiu mnh
cho hnh nh ung th d dy.
3.3. Vim tu mn: C tin s vim tu cp nht l ung ru mn, c th km i
chy mn v km hp thu. au thng lan ra sau lng vng tu. Xt nghim men
amylase mu thng tng 2-3 ln. Siu m v chp phim X quang thy tu x teo c
si, ng tu dn.
3.4. Vim ng mt ti mt mn do si: Tin s si mt, lm sng c cn au
qun gan, nhim trng v tc mt. Chn on da vo siu m v chp ng mt
ngc dng cho hnh nh si, ti mt x teo.

VI. BIN CHNG

Thng gp l chy mu, thng, x teo gy hp, thng bt hay t do, lot su
km vim quanh tng, t bit lot d dy lu ngy c th ung th ha.
1. Chy mu: thng gp nht nhng kh nh gi tn s chnh xc. Khong 1520% bnh nhn lot c mt hoc nhiu ln chy mu; lot t trng thng chy mu
(17%) so vi d dy (12%), ngi gi chy mu nhiu hn ngi tr. Bin chng
chy mu thng xy ra trong t lot tin trin nhng cng c th l du hiu u
tin.

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Chn on da vo ni soi cn thc hin sm khi ra khi chong. Tn sut ti pht
l 20%, tin lng tt nu chy mu t ngng trong vng 6 gi u. Nguy c ti
pht cao >50% nu:
+ Chy mu t tiu ng mch to thnh tia.
+ Mch mu thy c nn lot
+ Chy mu ko di >72 gi.
2. Thng: lot n su vo thnh d dy hay t trng c th gy thng. y l bin
chng th nh sau chy mu (6%), n ng nhiu hn ph n. Lot mt trc hoc
b cong nh th thng vo khoang phc mc ln, lot mt sau th thng vo c quan
k cn hoc hu cung mc ni.
- Triu chng: thng khi u bng cn au d di kiu dao m l du vim
phc mc v nhim trng nhim c. Chp phim bng khng sa son hoc siu m
c lim hi di c honh nht l bn phi.
3. Lot xuyn thu dnh vo c quan k cn: thng l ty, mc ni nh, ng
mt, gan, mc ni ln, mc treo i trng, i trng ngang thng gp l lot mt
sau hoc lot b cong ln. Cc lot ny thng au d di t p ng vi iu tr,
lot xuyn vo ty thng au ra sau lng hoc biu hin vim ty cp, lot thng
vo ng mt chp ng mt hoc siu m c hi trong ng mt hoc baryte
vo ng mt. Nu r d dy - i trng gy i chy phn sng v km hp thu,
cn iu tr phu thut.
4. Hp mn v: thng gp nht khi lot nm gn mn v. Gy ra do lot d dy
hoc t trng hoc phn ng co tht mn v trong lot d dy nm gn mn v, hp
c th do vim ph n mn v.
- Triu chng: Nng bng sau n. Ma ra thc n c > 24 gi. Du c ch d dy
lc i v du Bouveret. Gy v du mt nc.
- Chn on hp mn v: bng
+ Thng d dy c dch >100ml.
+ Phim baryte d dy cn tn ng baryte >6gi.
+ Phim nhp nhy, chm lm vi d dy >6 gi khi thc n c nh du ng v
phng x Technium 99.
+ Xc nh c nng hay thc th bng nghim php no mui ko di, sau 1/2 gi v
4 gi: nu sau 1/2 gi >400ml, v sau 4gi >300ml l thc th, nu <200ml l c c
nng, hoc lm li no mui sau 3 ngy chuyn dch >100ml l thc th.
5. Lot ung th ha: t l lot ung th ha thp 5-10%, v thi gian lot ko di >10
nm. Hin nay ngi ta thy rng vim mn hang v nht l th teo, thng a n
ung th ha nhiu hn (30 %), cn lot t trng rt him khi b ung th ha.

VII. IU TR
1. iu tr ni khoa
1.1. Ch n ung v ngh ngi: Ngh ngi c th xc v nht l tinh thn trong giai
on c t au lot. Trong giai lot tin trin cn n ch n lng v thc n kim
tnh nh cho sa, trnh cc thc n kch thch cay nng nh tiu t. C bia ru
v nht l thuc l v lm chm lnh so v d gy lot ti pht. Thc t hin nay
chng minh thc n t quan trng ch cn n u trnh nhn i gy tng tit acide.

109
n ph ban m hoc trc lc i ng gy tit acide ban m, nn cn chng ch
nh. Thuc l c chng minh c hi gy tng tit acide, chm lnh so v lm
tng ti pht.
- Tm l liu php: cn gii thch bnh nhn yn tm v hp tc trong iu tr.
Nu bnh nhn qu lo lng c th cho thm an thn: Diazepam, Ttrazpam,
Chlodiazepate
1.2. Thuc iu tr lot c chia lm cc nhm sau
* Thuc khng toan: Bicarbonate natri v calci khng c dng na do tc dng
di v lm tng calci mu gy si thn. Ngi ta thng dng kt hp hydroxyde
nhm v magn gim tc dng gy bn ca nhm v gy i chy ca magn; tuy
nhin chng cng to cc mui phosphate khng ha tan lu ngy gy mt phospho
(tnh cht ny c khai thc iu tr tng phospho mu trong suy thn). Cc bit
dc thng l Maalox, Gelox, Alusi, Mylanta c thm Simticon l cht chng si
bt lm gim hi trong d dy, Trigel c phi hp thm cht lm gim au,
Phosphalugel c trnh by di dng gel nn c tnh cht bng nim mc v gi
li trong d dy lu hn; liu dng 3-4g/ngy.
* Thuc khng tit: l cc thuc lm gim tit acid dch v qua nhiu c ch khc
nhau do khng th th H2, khng choline, khng gastrine v khng bm proton ca
t bo vin thnh d dy.
- Thuc khng choline: t lu l nn tng ca iu tr lot n c tc dng c ch dy
X, gim tit trc tip do tc ng trc tip ln t bo vin v gin tip bng hm sn
xut gastrin, s tit pepsine cng b gim. c ch dy X cn lm gim nhu ng d
dy: gim co tht thn v hang v lm gim au, lm chm lm vi thc n c. Hiu
qu tt ca khng choline trn cn au c xc nh, nhng tc dng trn s
lnh so th cn bn ci, thuc c in trong nhm ny l atropin ngy nay t c
dng v c nhiu tc dng ph vi liu iu tr 1mg/ng, thng gy kh ming, snh
bng, tiu kh. Chng ch nh trong tng nhn p, u x tin lit tuyn. Hin nay
thuc khng choline c vng 3, v pirenzpine chn th th muscarine chn lc M1
trn t bo vin, nn khng c tc dng trn co tht c trn v s tit nc bt nn
c ch nh rng ri. Pirenzpine lm nhanh s lin so trong lot d dy v t
trng. Trong hi chng Zollinger Ellison phi hp pirenzpine v Khng H2 rt c
hiu qa ln s tit acid hn l dng mt mnh khng H2. Thuc bit dc l
Gastrozpine, Leblon.
- Thuc khng H2: c ch s tit acid khng ch sau kch thch histamine m c sau
kch thch dy X, kch thch bng gastrine v c th nghim ba n.
+ Th h 2: Ranitidine (Raniplex, Azantac, Zantac, Histac, Lydin, Aciloc...) Vin
150mg, 300mg, ng 50mg.
Cu trc hi khc vi cimtidine do c 2 nhnh bn nhn imidazole nn liu
tc dng thp hn v t tc dng ph hn, tc dng li ko di hn nn ch dng
ngy 2 ln. Hiu qu cao hn cimtidine trong iu tr lot d dy t trng v nht l
trong hi chng Zollinger Ellison. Tc dng ph rt t trn androgen nn khng gy
lit dng.
Liu dng 300mg/ng ung 2 ln sng ti hoc mt ln vo bui ti nh
cimtidine.

110
+ Th h 3: Famotidine (Pepcidine, Servipep, Pepcid, Quamatel, Pepdine). Vin
20mg, 40mg; ng 20mg. Tc dng mnh v ko di hn ranitidine nn ch dng mt
vin 40mg 1 ln vo bui ti.
Cc tc dng ph cng tng t nh i vi Ranitidine.
+ Th h th 4: Nizacid (Nizatidine), vin dng nang 150mg, 300mg, liu 300mg
ung 1 ln vo bui ti. Tc dng v hiu qu tng t nh Famotidine.
- Thuc khng bm proton: l th th cui cng ca t bo vin ph trch s tit
acide chlorhydride, do thuc c ch bm proton c tc dng chung v mnh nht.
+ Omeprazol (Mopral, Lomac, Omez, Losec). Vin nang 20mg, 40mg; ng 40mg.
Liu thng dng 20mg ung 1 ln vo bui ti. Thuc tc dng rt tt, hiu qu
ngay c nhng trng hp khng H2. Hiu qu lnh so i lot t trng sau 2 tun
l l 65%, i vi lot d dy l 80 - 85%. Thuc tc dng rt nhanh sau 24 gi c
ch 80% lng acide dch v.
Liu trnh i vi lot t trng l 4 tun, lot d dy l 6 tun.
Liu gp i dnh cho nhng ngi p ng km hoc hi chng Zollinger Ellison.
Tc dng ph vi trng hp nh bn, nn ma, nhc u, chng mt, i
khi c ni m ay v nga da. ngi gi c th c l ln, hoc o gic, cc triu
chng ny gim khi ngng thuc. V mu, c th c gim bch cu, tiu cu, v
him hn l thiu mu huyt tn.
Chng ch nh: ph n c thai v cho con b.
+ Esomeprazole (Nexium): ng phn ca Omeprazole c thi gian bn hu lu hn
v c tc dng c ch tit Acide v dch v tt hn. Vin 20mg, ngy x 2 vin.
+ Lanzorprazol (Lanzor, Ogast) vin 30mg, liu 1 vin ung vo bui ti.
Tc dng v ch nh tng t nh Omeprazol.
+ Pentoprazole (Inipomp) vin 20mg, 40mg. Liu 40mg/ng.
+ Rabeprazole (Velox, Ramprazole) vin 20mg. Liu 40mg/ng.
- Thuc khng Gastrin
Proglumide (Milide) l thuc i khng gastrin. N lm gim tit acide khi tim
gastrin, nhng khng lm gim khi tim histamin, c ch nh trong iu tr lot c
tng gastrin mu v nht l trong u gastrinome.
* Thuc bo v nim mc
- Carbnoxolone (Caved s, Biogastrone): l dn xut tng hp ca cam tho, kinh
nghim dn gian xa dng iu tr lot d dy. N lm tng sn xut nhy v
ko di tui th ca t bo nim mc, tc dng kp ny ging nh PGE2, c th do
lm chm thoi ha prostaglandine. Ngoi ra carbnoxolone lm c ch hat ng
ca pepsine, n cng c tnh cht khng vim.
Carbnoxolone lm nhanh s lnh so lot d dy v nht l n cha trong
nang tan chm cng hiu qu trong lot t trng. Tuy nhin x dng ca n cn hn
ch do tc dng ph ging nh aldosterone: gi mui v ph, h Kali mu, cao
huyt p. Do khi dng cn theo di trng lng, huyt p v in gii .
- Bismuth (Peptobismol, Trymo, Dnol): trc y cc mui bismuth natri hp thu
nhiu gy ra bnh no do bismuth nn khng cn c dng trong iu tr. Hin nay

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bismuth sous citrate (C.B.S) do khng hp thu v trong mi trng acide kt hp vi
protine ca m hoi t t lot, to thnh mt phc hp lm acide v pepsine
khng thm qua c. sc vt th nghim, n cng bo v nim mc chng li s
n mn ca ru v ca aspirine.
Trnh by: vin 120mg, ngy 4 vin chia 2 ln sng ti trc n.
Khng nn dng thuc nc hoc nhai v thuc lm en rng v li.
- Sucralfate (Ulcar, Kal, venter, sulcrafar): l thuc phi hp gia sulfate de sucrose
v mt mui nhm. Cng nh sous nitrate de bismuth trong dung dch acide n gn
vo b mt lot mang in tch (-) kt hp vi in tch (+) ca thuc, lm thnh
mt lp m, gip chng li s phn tn ngc ca ion H+. Hn na n cn hp
ph pepsine v mui mt, lm bt hot chng, cho nn c dng iu tr vim
d dy do tro ngc dich mt. Trong iu tr lot d dy t trng, n lm gim au
nhanh v lm lnh so tng ng nh Cimtidine. Mc d hp th t nhng cng
khng nn dng trong trng hp suy thn nng, v n cha nhiu aluminium. Ngoi
ra n cn gy bn v do tnh hp ph ca n lm ngn chn hp thu cc thuc nh
tetracycline, phnytoine.
- Prostaglandine E2 (Cytotec, Minocytol) c nhiu c ch tc dng: c ch tit acide,
kch thch tit nhy, tng tit bicarbonate v lm tng ti mu cho lp h nim mc
d dy. Vin 200(; liu 400-600(. Tc dng phu gy i chy
* Thuc dit H.P: ch yu l cc khng sinh:
- Nhm (lactamine nh Pnicilline, Ampicilline, Amoxicilline, cc Cphalosporines.
- Nhm cycline: Ttracycline, Doxycycline.
- Nhm macrolides: Erythromycine, Roxithromycine, Azithromycine, Clarithromycine.
- Nhm Quinolone v nhm imidazoles: Mtronidazole, Tinidazole, Secnidazole...
- Nhm Bisthmus: Nh trymo, denol, Peptobismol.
2.3. p dng iu tr
* Lot d dy
Trong trng hp khng tng toan tng tit: thng ch yu ch dng thuc
bo v nim mc. V d: Ulcar gi 1g, ngy 3 gi, ung 30 pht -1 gi trc n v 1
gam trc khi i ng, c th dng thm an thn nh Tranxne 5mg ti ung mt
vin.
Nu c nhim H.P th p dng pht iu tr hin nay l phi hp 3 thuc
dit H.P nh sau: Bismuth + Ttracycline + Mtronidazole hoc Bismuth +
Amoxicillin + Metronidazol. Tuy nhin c mt s trng hp khng vi
Ttracycline v Metronidazole (40-50%), nn ngi ta thch phi hp Bismuth +
Clarithromycin + Tinidazole. Trong thi gian 6 - 8 tun, t l lnh so 80-85%.
Trong trng hp c tng toan tng tit p dng pht iu tr tng t nh
lot t trng nhng thi gian 6 - 8 tun.
Theo di iu tr: rt quan trng trong iu tr lot d dy sau 3 - 4 tun iu tr
cn kim tra ni soi v sinh thit, sau 3 thng, ri 6 thng v hng nm trong 5
nm u. Cn sinh thit nhiu mnh trn nhiu vng v nhiu vng khc nhau (8 -12
mu). Nu c d sn cn tch cc kim tra li sau khi iu tr tch cc 3 tun. Nu c
lon sn hoc c hnh nh ung th cn phu thut.

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* Lot t trng: a s u c tng toan v tng tit nn thng p dng pht phi
hp: 1 khng tit mnh + 1 bo v nim mc. V d: 1 khng H2 mnh nh Ranitidin,
Famotidine hoc Omprazole + Sucralfate, c th l Ranitidine 300mg hoc
Famotidine 40mg ung chia 2 ln sau n hoc mt ln khi i ng + Sucralfate 3g
ung 3 ln trc n 30 ph v 1gr trc lc i ng.
Trong trng hp c H.P, cho thm thuc dit H.P nh trong lot d dy, thi
gian cho khng sinh thng l 2 tun. Kt qu mt s pht iu tr 3 thuc nh
sau:
- Bismuth (480mg/ng)+Tetracycline 1, 5g/ng (hay Amoxicillin)+Mtronidazol (1,
5g/ng) x 2 tun lnh bnh l 85%.
- Ranitidin (300mg/ng)+Amoxicillin (1, 5g/ng)+Metronidazol (1, 5g/ng) x 2 tun,
sau tip tc dng Ranitidine thm 2 tun, t l lnh bnh l 89%.
- Omprazol (40mg/ng) + Clarithromycine (0, 5g/ng) + Tinidazol (1, 5g/ng) x 1
tun, lnh bnh l 93, 2% hoc Omeprazol (40mg/ng)+Clarithromycine (0,
5g/ng)+Amoxicilline (1, 5g/ng) x 1tun, lnh bnh l 90%.
Trong mt s vng t l khng cao ngi ta p dng pht 4 thuc
nh sau: Bismuth+Tetracycline (hoc Amoxicilline)+Metronidazol+ Omeprazole v c
th rt ngn thi gian iu tr xung 2 tun.
3. iu tr ngoi khoa
3.1. Phu thut ct 2/3 d dy: vi lot d dy sau khi iu tr tch cc 6 tun m
lot khng thay i hoc trong trng hp c lon sn th cn phu thut ct b 2/3
theo kiu Bilroth hoc Pan loi tr lot cng nh loi b vng tit gastrine v
acide.
Trong lot t trng, phu thut rt hn ch, ch dng cho lot bt tr. Cc ch
nh phu thut chung: l lot bin chng chy mu cp nng khng cm c bng
phng tin ni khoa, lot gy bin chng hp mn v kht v thc th, lot thng
hoc lot xuyn thu vo ty gy vim ty cp ti pht nhiu ln.
Cc bin chng phu thut bao gm
Hi chng Dumping: thng xut hin na gi sau khi n vi au thng v,
bun nn, chong vng, hi hp, v m hi, mt l do lm y t trng qu nhanh,
do thc n u trng, c ch bnh sinh phc tp do nhiu nguyn nhn:
- Gim th tch do cn bng li p lc thm thu u trng.
- Phn x thc vt, gii phng hormon vn mch nh serotonin, bradykinine,
V.I.P., gy ra do cng dn rut. Cn phn bit vi h ng mu xy ra chm 1-2
gi sau n do tit qu nhiu insulin v hp thu mt lng ln ng. iu tr ch yu
l n c nhiu ba nh, t ng v sa, dng pectine lm chm vi d dy.
Hi chng quai ti: sau phu thut do ng thc n v nht l mt trong
quai ti lm vim thng biu hin bng au v ma ra mt.
Suy dng: do nhiu nguyn nhn:
+ Do ct b d dy qu nhiu gy thiu dch v v n qu t v d dy
qu nh.
+ Km hp thu th pht do thiu mt, ty.

113
+ Ln men vi trng trong quai ti v hng trng. Ngoi ra cn thiu st,
B12, Folate, long xng nhuyn xng, d nhim trng nht l lao.
Bin chng xa l do tro ngc t trng d dy gy vim ming ni, ri d sn
v lon sn nim mc gy ra ung th ha thng 10-15 nm sau.
3.2. Phu thut ct b dy X
Gip loi b pha u ca s tit, lm gim tit ban m v lm gim lng tit
acid do gastrine.
* Ct thn d dy: ct on vo bng quanh thc qun, cng c th ct bng
ng ngc. Phu thut ny thng gy ra ri lon vn ng cn b sung bng ni
v trng hoc chnh hnh mn v gip lm vi d dy. Cc hu qu c th c sau
phu thut ny l:
- Hi chnh Dumping v tro ngc mt ty.
- i chy v ri lon mt ty do mt iu chnh thn kinh.
- Bezoard do ri lon lm vi d dy v gim tit dch v.
* Ct dy X chn lc: ch ct cc si i vo d dy thng km chnh hnh mn v.
* Ct dy X siu chn lc: ch ct nhnh dy X i vo y v v gi li nhnh Latrjet
iu hnh hang v, nn bo ton c chc nng hang mn v nn t gy ra bin
chng.
3.3. Mt s ch nh c bit
- Trong lot mn v + tng toan: ct dy X + lot + xt nghim m hc.
- Trong lot kp: ct dy X + ct hang v.
- Lot ti pht sau phu thut: ty theo cch phu thut trc.
+ Sau ct d dy lot ti pht t trng hoc hng trng.
+ Sau ct dy X, thng lot ti pht ch c.

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VIM D DY
Mc tiu
1.K cc nguyn nhn gy vim d dy cp v mn.
2.Chn on c cc th vim d dy cp va mn thng gp.
3.iu tr tt mt s th bnh vim d dy thng gp.
Ni dung

I. I CNG
Vim d dy l bnh m triu chng lm sng c khi rm r nhng c khi rt nh
nhng, m thm. Chn on cn c ni soi v sinh thit. iu tr c khi n gin
nhng c khi cn nhiu kh khn.
Ngi ta chia vim d dy lm 2 th: Vim d dy cp v vim d dy mn. Chn
on phn bit ty thuc vo nguyn nhn, c im t chc hc v s phn b v
gii phu ca vim d dy.

II. VIM D DY CP
1. Nguyn nhn
- Ru: Gy vim d dy cp i khi gy chy mu, c gi l vim d dy do n
mn. Thng xy ra khi ung ru mt lng ln trong mt thi gian ngn.
- Thuc khng vim khng steroides (NSAIDs), Aspirin.
- Stress
- Ung phi cht n mn (thng l cht kim)
- Virus: CMV, Herpes.
- Vi khun: Lin cu alpha tan mu, Clostridium septicum
- Tng ure mu
- Phng x.
2. Cc th vim d dy
2.1. Vim d dy chy mu hay vim d dy n mn
L nguyn nhn hay gp ca chy mu tiu ha cao nhng t khi nng. S n
mn i khi hon ton m thm. Ni soi cho thy n mn nhiu , c th lan n
ton b nim mc d dy hoc ch khu tr thn, hang v hay phnh v d dy. Nim
mc tr nn rc nh b chy rn nhng c khi gn nh bnh thng.
V m hc, s n mn ch ph hy n lp nim mc, khng lan n lp c
nim do khng nh hng n cc lp mch mu di nim mc. Cc thng
tn thng hi phc hon ton. y l c trng ca loi vim ny. Bt k lc no,
ngi ta c th tm thy nhng b n mn c nhng biu hin nhng giai on
tin trin hay hi phc khc nhau. C th gp thng tn nn phng hay np
gp nim mc. Gia cc n mn l vng mt biu m v thot qun tng hay lan
rng va lp h nim mc (Lamina propria). S n mn c th pht trin trn nim
mc trng c v bnh thng v mt m hc hoc trn nhngnim mc c bin hin
cc giai on vim ca d dy. Nu tin trin ko di, s n mn c th lan n lp
h nim mc to nn lot cp khi chy mu tr nn trm trng hn.

115
- Nguyn nhn hay gp l do dng thuc khng vim khng Steroide. c bit l
Aspirin: mi trng acide dch v Aspirin khng ion ha d c hp th bng s
khuch tn th ng. Vo mi trng trung tnh ca biu m nim mc d dy
Aspirin bin thnh dng acide ion ha, ph hy t bo v to ca m cho hin tng
lot do acide. Khi c dng km vi Bicarbonate Natri, Aspirin khng gy tn
thng nim mc d dy v khng b ion ha, v do khng c hp th d
dy. Khi Aspirin c bc bi mt nang, n s i qua khi d dy v c hp th
rut non. Ngoi ra Aspirin v cc AINS khc cn ngn cn tng hp Prostaglandine
(l yu t bo v nim mc d dy cng nh kch thch tit acide v pepsin d dy)
v vy lm thng tn nim mc d dy. Phenylbutazol v Indomethacine l 2 thuc
d gy vim d dy nht.
- Ru cng l nguyn nhn gy vim d dy cp chy mu nht l khi ung mt
ln nhiu trong thi gian ngn, m trc y khng ung.
- Tng p tnh mch ca cng l mt yu t lm d cho chy mu d dy.
- Cc stress th pht nghim trng nh bng, nhim trng, chn thng, phu thut,
sc, suy h hp, suy thn, suy gan cng thng gy vim hay lot cp. Bnh nguyn
trong cc trng hp ny cha c hiu r ht c l do thay i lng mu n
nim mc d dy dn n hoi t nh nim mc.
Lm sng
Bnh nhn c th kh chu nh vng thng v, chm tiu, snh bng ngay sau n,
hi, bun nn, nn mu km i cu phn en.i khi khng c triu chng. Chn
on tt nht nh soi d dy ngay lc c chy mu v nu khng cc thng tn c
th lnh v bin mt. X quang vi k thut i quang kp c th pht hin c cc
vt n mn cn ny.
2.2. Vim d dy cp phi hp vi H. PYLORI: Khi u ca nhim H.P c th l
hu qu ca d dy d c tng tit acide sn v ko di hn 1 nm. Bnh nhn thy
kh chu nh vng thng v. C nhiu c im dch t hc ca vim d dy cp c
th quy cho H.P nhng c im ni soi v m hc th khng thy r. Nhim H.P cp
l tin cho vim d dy mn hot ng.

III. VIM D DY MN
1. Xp loi
- Vim d dy mn do ho cht: Tro ngc dch mt, dch kim t rut, Cc thuc
khng vim non-steroides.
- Vim d dy c hiu: vim d dy tng Eosine(u hat tng bch cu a acide,
vim d dy rut tng bch cu a acide)
- Vim d dy u ht: Crohn, lao, Histoplasma, giang mai, sarcoidose, d vt, nhi m
k sinh trng, v cn.
- Bnh d dy ph i: bnh Mntrier, gi lymphoma d dy, hi chng ZollingerEllison.
- Bnh d dy sung huyt (tng p ca): khng phi vim d dy tht s
- Vim d dy khng c hiu:
+ Nhm khng n mn: (vim d dy t min type A, vim d dy do mi trng
type B, vim d dy mn c lin quan n HP).

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+ Nhm n mn:vim d dy lympho, vim d dy dng thu u.
Cc t bo vim xm nhp ch yu l limpho v tng bo, mt t bch cu a nhn
v bch cu a acide. Thng tn lp nng ca vng tuyn tit ca nim mc d
dy c th lan xung su, gy d sn, gim sn v teo t bo.
2. Cc th vim d dy mn
Ngi ta chia lm hai loi vim d dy mn chnh, ngoi ra cn c cc biu hin bt
thng khc d dy hoc do tn thng th pht hoc khng do vim. mn tnh.
2.1.Vim d dy mn type A
Vim vng thn v y d dy, c yu t t min. Bao gm vim d dy nng, vim
d dy dng teo v teo d dy. Vim d dy ny thng km thiu mu c tnh. S
xut hin khng th khng t bo thnh v khng yu t ni gi cho yu t bnh
sinh ca c ch t min. Loai ny gp khong 20% ngi trn 60 tui. Triu
chng ngo nn, vim dng teo km v toan, thiu mu v nguy c ung th d dy.
Chn on bng ni soi v sinh thit.
2.2. Vim d dy mn type B: (Vim d dy vng hang v, Vim d dy do H.P chim
80%).
Vim hay xy ra vng hang v, gp a s ngi tr. H.P c nh trn cc phc
hp ni kt lm v cc cu ni lin bo v tit dy c cc cht nhy trung tnh. Cc
t bo b bong ra l lp di nim mc. ng thi protese ca vi khun H.P lm
gia tng s khuch tn cc ion H+ gy ph v glycoprotein lm gim tnh nhy trn
lp nim mc. Trong th ny, nng Gastrin huyt tng lc i cao khng thng
xuyn, c khi bnh thng. Loi vim d dy ny c th dn n vim teo d dy
hoc teo hn d dy, nang bch huyt d dy, u limpho t bo B d dy (MALT).
Dch v c cung lng acide thp s dn n nhim trng v nguy c ung th nht l
khi c iu tr vi cc thuc khng H2 hoc thuc c ch bm proton H+.
Chn on bng ni soi v sinh thit, test nhanh urease thc hin trn cc mnh
sinh thit nim mc d dy hoc test th ur v xt nghim tm khng th khng H.P
trong mu (ELISA) hay cy tm HP.
Lm sng ch c triu chng kh chu vng thng v, n kh tiu.
S phn loi trn c khi khng phi hon ton r rng, ngi ta cn phn type AB
ch thng tn lin quan c thn v hang v d dy.
2.3.Vim d dy do tro ngc: thng do tro ngc dch mt t t trng vo d
dy gy vim ng tuyn mn v, vim vng tin mn v. Lm sng triu chng t rm
r, Bnh c th kt hp vi lot d dy.
2.4. Bnh d day tng p ca: (bnh d dy xung huyt)
Tht s khng phi l mt phn ng vim, v khng tm thy s thm nhim cc t
bao vim lp nim mc cng nh lp h nim ca d dy. y ch l mt bin
chng, hu qu ca bnh l tng p ca hay do x gan. Nhng trng hp lm trit
tnh mch trng thc qun qua ni soi, thng dn n xung huyt d dy phn
ng sau .
Qua ni soi, chng ta c th thy nim mc d dy dy ln, , xut huyt thnh
tng m nh trong nim mc, to thnh mng li hay dng khm.

IV. IU TR

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1. i cng iu tr
Vim d dy l tn gi chung cho cc bnh l d dy do tn thng nim mc d
dy c hiu hoc khng c hiu. Mt cch phn loi c cc nh lm sng v
gii phu bnh thng dng d l da vo cc tn thng c gi tn theo cc
c im v m bnh hc, vi khun v v tr tn thng ca d dy.V vy, cch iu
tr c th hn v kh chnh xc hn.
Mc ch iu tr l bo v t bo, hi phc s tit acide tr li bnh thng, loi b
nguyn nhn, hn ch bin i lm teo nim mc d dy gp phn ngn nga ung
th.
2. iu tr vim d dy cp.
2.1.

Vim d dy do n mn

2.1.1. Vim d dy do ru v thuc khng vim

y l nguyn nhn hay gp do ung ru cp mt lng ln, do dng thuc khng
vim khng corticoides v c corticoides. Tn thng nhiu ch di dng cc vt
nim mc b n mn, chy mu.
iu tr bao gm
- Chm dt nguyn nhn cng sm cng tt.
- m bo th tch tun hon c hiu qu bng dch truyn, nhn n v nui dng
bng ng ngoi ming.
- Ra d dy cm mu bng cch dng nc mui ng trng lnh ha
Adrenalin.
- Thuc khng tit: Cimetidine hoc Ranitidine, hoc Omeprazole tim tnh mch.
- Thuc trung ha Acide.
- Thuc bng nim mc: c th dng Sucralfate dng gel, hoc Misoprostol (cytotec
600g - 800g /ng.
- Truyn cc cht gy co mch nh Vasopressine hoc Sandostatin khi chy mu
nng.
- Cm mu bng laser, nhit hoc quang ng.
- iu tr d phng cho cc trng hp phi dng thuc khng vim: Dng khng
H2 hoc c ch bm proton H+.
2.1.2. Vim d dy do ha cht
Tc nhn gy vim c th l cc kim mnh nh KCl, hoc st, hoc Cocaine. iu
tr trong cc trng hp ny l ;
- Gim au, nhn n, nui dng bng ng tnh mch.
- Hi sc tim mch, h hp.
- Nu c vim x gy hp th c ch nh phu thut ni d dy rut.
2.1.3.Vim d dy do chn thng thc th
Sau t ng thng d dy, sau iu tr cm mu d dy bng ni soi, bng laser,
nhit ng.
iu tr bng nhn n, truyn dch, bng nim mc d dy v khng tit.

118
2.1.4.Vim d dy do x tr
Vim hang v, tin mn v. Tn thng c th su lm thng, chy mu hoc hp.
iu tr bng cc thuc bng nim mc, khng tit v ngng x tr.
2.1.5. Vim d dy do thiu mu
L biu hin ca bnh ton thn nh trong bnh Scholein- Henoch, nhim
Cytomegalovirus.
iu tr bng thuc bng nim mc v khng tit, thuc dit virus.
2.1.6. Bnh d dy xung huyt
Gp trong tng p tnh mch ca ca bnh x gan.
iu tr ch yu bng thuc chn giao cm nh Propanolol, hoc Nadrolol 60mg80 mg/ng sao cho mch cn 3/4 so vi trc khi dng phi hp vi khng tit acide.
2.1.7. Vim d dy do nhim trng
Nguyn nhn thng gp l lao, CMV, Candida Albican, Histoplasmosis, bnh
Crohn. iu tr c hiu bng khng sinh, khng nm, thuc dit virus. Trong trng
hp nng th c th phu thut.
2.2.Vim d dy cp khng do n mn phi hp nhim Helicobacter pylorii (HP) cp
hoc mn. iu tr thuc dit HP gm Omeprazo(40mg/ng) phi hp Amoxicillin (1, 5
g/ng), Clarytromycine(500mg/ng) trong 7- 10 ngy.C th km thuc bng nim mc
nh Bismuth.
3. iu tr vim d dy mn
3.1.Vim d dy mn khng do n mn
3.1.1.Vim d dy mn type A
y l vim d dy vng thn, thng l vim teo nim mc, lin quan n thiu
mu c tnh, do hin din trong mu cc khng th khng t bo thnh, khng th
khng yu t ni, thng phi hp vi cc bnh t min khc nh vim tuyn gip
t min, suy thng thn, x ng mt tin pht.
iu tr: cha c iu tr c hiu: thng dng cc thuc trung ha acide, vitamin
C, st, vitamin B12, corticoides. Cn theo di din tin dn n ung th d dy.
3.1.2.Vim d dy mn type B
Tn thng vng hang v d dy gp trong 80% trng hp v rt quan trng, n
cn c gi l vim d dy do HP.
iu tr khng tit phi hp khng sinh dit HP.
3.1.3.Vim d dy type AB
Vim d dy phi hp Tn thng c hang v v thn d dy.
iu tr bao gm thuc khng tit, khng sinh, bng nim mc, Vitamin B12, st
ci thin tnh trng thiu mu.
3.1.4..Vim d dy do tro ngc
Vim d dy vng mn v gp sau ct 2/3 d dy.iu tr bao gm thuc thay i
thnh phn dch mt nh Cholestyramin phi hp sucralfate v Cizapride hoc
Metoclopropramide lm y nhanh thc n ra khi d dy.

119
3.1.5.Vim d dy ph i: (bnh Mntrier)
Cn gi l vim d dy lympho, tn thng lan rng c d dy ch yu b cong
ln.
iu tr bng khng Cholin, khng tit, Tranexamic acide (Frenolyse), corticoides v
Ortreotide km khng sinh nu c thm nhim HP, hoc km thuc dit virus nu c
nhim CMV.
Trng hp nng, c th phi ct d dy ton phn.
3.2.Vim d dy mn do n mn: t gp, Tn thng nim mc d dy dng thu
u vi cc nt nh c n mn trung tm gp vng hang v thn d dy, cn
gi l vim d dy dng lympho. Bnh ny c tng IgE trong mu gi cho nguyn
nhn min dch. Bnh p ng vi Cromoglycate 80- 160mg/ng.
3.3.Vim d dy th gi u lympho: Thng phi hp tn thng lot. Bnh thng
lnh tnh, c l l mt phn ng vim c ng hoc c th l MALT (mucous
Associated limphome Tissuse) trong trng hp nhim HP.
iu tr: Nu c bng nhng c HP th phi dit tn gc bng khng tit, khng sinh
3.4.Vim d dy i toan: Him gp.Do cc ht bch cu i toan to thnh cc polype
nh vng hang v cn c gi l u t bo quanh mao mch.
iu tr bng Prednisolone l thuc chn lc liu 10-15mg/ng, cc tn thng s
thoi trin sau v ba ngy.

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

I. I CNG
Vim ng mt ti mt cp (VMTMC) l mt cp cu ni - ngoi khoa thng
gp, c th c bin chng nng thm ch t vong nu khng c chn on v
iu tr kp thi. VMTMC nc ta c cc c im dch t hc v c ch bnh
sinh khc vi cc nc u M. Vic iu tr v theo di i hi s phi hp ni ngoi khoa.

II. DCH T HC
VMTMC nc ta ch yu l do giun hoc si mt, trong 95% l si ng
mt ln. Si mt l bnh ng hng th hai trong cc bnh gan mt nc ta sau
cc bnh vim gan.
Si mt cc nc u M th ch yu l si ti mt (90%) m thnh phn ch yu
l si Cholesterol. Php, t si mt ngi ln khong 10-15%. Ty u v
Nam M t l ny l 10-30%. Nht Bn si mt chim t l 5%, ch yu l si sc
t mt.

III. BNH NGUYN

1. Vim ng mt ti mt cp khng do si
1.1. Giun chui ng mt.
1.2. Nhim khun huyt: thng do E. Coli, thng hn.
1.3. Chn p ng mt: do cc khi U ng mt, u u ty, hch chn p.
1.4. Th thut thm d ng mt: Ni soi ng mt, ct c vng Oddi.
2. Vim ng mt ti mt cp do si: si cholesterol, si sc t mt.

IV. C CH SINH BNH

1. C ch to si Cholesterol
Bnh thng, t bo gan tng hp cc axit mt v bi tit cholesterol vi t l 1 gam
cho mt lt mt. Cholesterol ha tan trong mi trng mui mt to thnh mt dung
dch. Lecithin cng l mt thnh phn ca mui mt gip cho s ha tan ca
Cholesterol.
Thng thng, t l mui mt/ cholesterol (SB/C)> 10, t l Phospholipid/
Cholesterol (L/C)> 3; khi cc t l ny thay i: SB/C gim, L/C gim th c hin
tng bo ha cholesterol to si.
S bo ha cholesterol l tin cho s kt ta cholesterol to si v thng gp
trong cc trng hp sau:

121
Gim bi tit mui mt:
-

Gim hp thu rut: bnh Crohn, ct on rut.

Bo ph: bi tit mui mt c tng nhng khng tng bng bi tit cholesterol.

Tui cao, dng nhiu Oestrogen.

Tng bi tit cholesterol.

-

Ch n giu calo

Oestregen, Clofibrate lm tng tng hp cholesterol.

Vai tr ca ti mt:
- Ti hp thu nc do lm cho Cholesterol d kt ta hn.
- Tit ra mucus lm cho Cholesterol vmui mt d kt ta hn.
2. C ch to si sc t mt: c hai tc nhn ng lu
2.1. Nhim trng: Cc vi khun, ch yu do giun mang theo khi chui vo ng mt,
gy vim nhim lm ng mt gin, nhu ng km v ng mt. Thnh ng mt
ph n v nim mc c th b bong ra. c bit cc men vi khun (Glucuronidase) s
bin Bilirubin thnh Bilirubinat d kt ta. Nhng yu t trn lc u to trong ng
mt mt cht gi l bn mt, v sau kt dn thnh si mt.
2.2. K sinh trng: Nhiu nghin cu thc nghim cng nh cc quan st khi m si
mt cho thy giun a v trng giun a lm nhn cho vic to si. Thng phi
hp vi c ch nhim trng.

V. LM SNG
1. Si ti mt
1.1. Si ti mt khng c triu chng: chim phn ln trng hp, t l gy cn au
qun gan v bin chng hng nm ch c 2%.
1.2. Cn au qun gan
1.2.1. C nng: au h sn phi lan ra sau lng hoc b vai. au t ngt ddi
ngay t u hoc tng dn, thng au lin tc vi cc cn kch pht. au tng khi
th su.Nn ra thc n, dch mt, co khi nn ra giun. au thng ko di t 15' n
3 gi.
1.2.2. Thc th
- Giai on sm triu chng thng ngho nn: bng mm, im au vng ti
mt, gan v ti mt khng c hi chng nhim trng hoc tcmt.
- Giai on mun sau 6 gi: hi chng nhim trng r, ngi gi hoc c a
xu c th c hi chng nhim c. Ti mt ln v au, h sn phi au v
khng, phn ng thnh bng nu c thm mt phc mc. C th c hi chng
vng da, xut huyt,
2. Si ng mt
Khi c vim ng mt thng c 3 nhm hi chng chnh:
2.1. Triu chng do tn thng gan mt: vi cn au qun gan nh trn.
2.2. Hi chng nhim trng: St xy ra ng thi hoc vi gi sau au: St cao, rt
run, c th c biu hin nhim c nng.

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2.3. Hi chng tc mt: ty thuc v tr, kch thc v thm ca vin si. C th
nh thong qua, c khi r vi nc tiu vng m, kt mc mt v da vng; t gp
hn l phn bc mu, nga. Vng da thng xut hin 1-2 ngy sau triu chng
au v st.
au, st, vng da lm thnh tam chng Charcot c trng cho si ng mt.

VI. XT NGHIM CN LM SNG

1. Xt nghim sinh hc
1.1. Cng thc mu: bch cu tng ch yu a nhn trung tnh.
1.2. Cy mu: khi cha dng khng sinh, thng gp l E. Coli.
1.3. Xt nghim dch mt: ht dch mt bng thng t trng hoc bng ni soi: cy vi
khun, tm trng giun, sn l gan.
1.4. Bilirubin mu: tng trong tc mt, ch yu loi trc tip.
1.5. Nc tiu: sc t mt, mui mt tng, urobilinogen (-) khi tc mt hon ton.
1.6. Transaminase, Phosphatase kim, gamma GT trong mu tng khi tc mt ko
di.
1.7. Phc hp Prothrombin gim, nghim php Kohler dng tnh.
2. Chn on hnh nh.
2.1. Chp bng khng sa son: thng t thy si.
2.2. Siu m bng: rt c gi tr d s dng. C th thy hnh nh trc tio ca si
(tng m mnh, c bng lng) hoc hnh nh gin tip qua hin tng gin cc
ng mt.
2.3. Chp ct lp t trng: chnh xc hn i vi si ng mt nhng t tin.
2.4. Chp ng mt: Thng c ch nh l chp ng mt ngc dng c
bm thuc cn quang, c th kt hp vi ct c vng Oddi ly si, c gi tr chn
on v iu tr cao.
Chp ng mt qua da: ch tin hnh khi c ch nh phu thut.

VII. CHN ON
1. Chn on xc nh
-

au h sn phi km st, vng da vng mt.

Siu m bng hoc chp ng mt cn quang.

2. Chn on phn bit

2.1. au h sn phi cn phn bit vi
2.1.1.Vim ty cp: au lin tc, c cc im au ty, Amylase mu tng, siu m
bng: Ty ln, ph n, cc ng dch, c th phi hp vi vim ng mt - ti
mt do giun, si
2.1.2. p xe gan amip
St trckhi au, gan to v au, im au khi tr vng gan, thng khng c vng
da vng mt. Chn on da vo siu m v ELISA tm khng th amip
2.1.3. Lot d dy t trng

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Khng st, khng vng da, au c tnh chu k, gim au sau n nh hoc ung
khng toan. Chn on bng ni soi d dy t trng.
2.1.4. Ri lon vn ng ti mt
D nhm vi si mt th khng vng da, thng gp ph n, khng st, khng
vng da, gim au t nhin. Siu m khng c giun hoc si
2.2. Vng da cn phn bit vi
2.2.1.Vim gan
C trng hp au nhiu d nhm vi si mt. Vng da th ht st. Bilirubin gin
tip tng cao, ALAT v ASAT tng rt cao. Siu m gip phn bit.
2.2.2.U u ty: Tc mt t t ngy cng tng, thng khng au, khng st. Chn
on bng siu m bng v nht l CT Scan

VIII. BIN CHNG

1. Bin chng cp tnh
1.1. Bin chng gan v ng mt
1.1.1. Thm mt phc mc: Tc mt lm ti mt cng to v gin mng, cc ng
mt cng cng to lm mt thm ra ngoi, vo bng. Bnh nhn au nhiu hn v
lan ra ton bng. Khm bng c phn ng thnh bng, nht l h sn phi.
1.1.2. Vim hoi t ti mt hoc ng mt ch: Thnh ti mt v ng mt ch c th
b vim dy, trn c nhng ch b hoi t. Nhng ch c th c mc ni hoc
cc tng xung quanh ti dnh bt li hoc bc vo bng gy vim phc mc, gp
ti mt nhiu hn ng mt ch, lm sng c hi chng nhim trng nhim c
nng, bng ngoi khoa. Chn on bng siu m v chp ct lp t trng.
1.1.3. p xe ng mt: nhim trng v tc mt nng, gan ln v au. Siu m pht
hin cc p xe trong gan.
1.1.4. Chy mu ng mt: Do p xe hoi t nhu m gan lm mt nhnh ca ng
hay tnh mch trong gan thng vi ng mt hoc do vim ti mt chy my.
Thng hi chng tc mt nh hoc khng r. bnh nhn thy mt mi, chong
vng, hoa mt, sau i cu phn en hoc nn ra mu, trng hp in hnh trong
cht nn c cc cc mu ng hnh thi bt ch. Chy mu ng mt thng dai
dng v d ti pht.
1.2. Bin chng ton thn v cc c quan khc
1.2.1. Nhim trng huyt v chong nhim trng: Thng do vi khun Gram m. St
cao km rt run, mch nhanh huyt p ty v kp, tay chn lnh, ni vn tm, nc
tiu gim. Cy mu thng dng tnh. Tin lng nng.
1.2.2. Hi chng gan thn vi tiu t, v niu. Ur mu tng nhanh.
1.2.3. Vim ty cp: au lin tc, nn nhiu, cc im ty au, Amylase mu tng.
Siu m hoc chp ct lp t trng thy tn thng ty.
2. Cc bin chng mn tnh
2.1. X gan: do mt v vim nhim ko di v ti pht nhiu ln. Chc nng gan
gim dn v cui cng i ti x gan do mt.

124
2.2. Vim ti mt mn: do vim ti mt ti pht nhiu ln. nhim trng t rm r, ti
mt khng ln, c th c m qunh vng ti mt. Siu m thy ti mt teo nh,
thnh dy v thng c si.
2.3. nc ti mt: Gp trong si c ti mt hoc vim ti mt mn gy tit dch
lng.
2.4. Vim x c Oddi: do si bng Vater lm vin c Oddi lu ngy lm x v lm
nng thm s cht hp ng mt.

IX. IU TR
1. iu tr
1.1. iu tr triu chng
* Tit thc: hn ch m, trng. Cung cp nng lng, nc v in gii.
* Chng au
+ Chng co tht
Atropin 0, 25mg, 2-4 ng/ngy; chng ch nh trong trng hp u x tin lit
tuyn hoc tng nhn p.
-

Buscopan 20mg, 2-3 ng /ngy

Phloroglucinol (Spasfon)

+ Gim au mnh phi hp

-

Dolargan 100mg tim bp hoc chuyn tnh mch 1-2 ng.

Khng dng Morphin v gy tng co tht c vng Oddi.

* Chng nhim khun

+ Nguyn tc chung
-

Khng sinh phi hp ng tim. liu cao.

Khng sinh chn ban u c tc dng tt ln cc vi khun Gram m, k kh,

sau iu chnh theo kt qu cy mu hoc dch mt.
-

iu chnh theo tnh trng chc nng thn.

Dng ko di, t 15 -21 ngy.

+ Phng tin iu tr
-

Ceftriaxone (Rocephine): 1 g/12 gi tim TM chm.

Amoxicilline+ acid clavulanic (Augmentin): 1 g/12 gi tim TM chm

Metronidazole (FLAGYL): 1-1, 5 g/ngy, chia 2-3 ln, ho trong glucose 5%,
chuyn TM trong 30 pht.
-

Ciprofloxacin (Ciflox): 400mg/12 gi tim TM chm.

+ Mt s phc c th:
-

Augmentin 1 g/12 g tim TM chm

Ceftriaxone + Flagyl

Ciprofloxacin + Flagyl

125
-

Ceftriaxon + Gentamycin + Flagyl

* Vitamin K
Trong trng hp tc mt ko di, t Prothrombin gim nhiu: 5mg, 2 ng/ ngy
trong 3 ngy.
2.2. iu tr nguyn nhn
* Giun a
Dng thuc lit giun sm bng
-

Pyrantel palmoat (Combantrin, Helmintox): 125mg/10kg ung mt ln

Albendazole (Zentel): 400 mg, 2 vin ung 1 liu duy nht.

* Do si
+ Thuc lm tan si ng ung
Ch nh i vi si cholesterol.
-

ng ung

C ch: cc dn xut ca mui my c th lm tan si Cholesterol nh c ch

ha tan ht micelle ca vin si, ring i vi acid Ursodesoxycholic th c thm c
ch tng cng l s to ra giai on tinh th lng.
-

Tiu chun chn bnh

Bnh nhn c cc cn au qun gan nh hoc trung bnh nhng khng c

cc bin chng nh vim ti mt cp, vim ng mt, vim ty, tc nghn ng
mt.
Si cholesterol: cn c vo tnh cht si khng cn quang trn phim x quang,
tt hn l trn chp ct lp vi tnh, si c mt nh hn hoc bng dch mt, khng
c hnh nh vi ha. Mt du chng gi si Cholesterol khc l hnh nh tri ni
ca si khi chp cn quang ti mt do trng lng ring ca si gn bng thuc cn
quang.
ng ti mt phi thng thong m bo chc nng lm y v lm rng ti
mt.
-

Kch thc ca si t 5-10mm, tt nht l si 5 mm.

+ Cc thuc lm tan si
Ursodesoxycholic (URSOLVANT, URSODIOL): dng liu 10-15mg/kg/ ngy.
Thn dng ban m l thi im l s tit mui mt thp nht v s tit cholesterol
cao nht.
Chenodesoxycholic (CHENODEX, CHENODIOL): 14-16 mg/kg/ ngy. Hin
nay khng dng do liu tan si th thn gy nhiu tc dng ph nh i chy, tng
men gan v tng cholesterol mu.
C th phi hp URSOLVANT 5mg/kg + CHENODEX 5 mg/kg c tc dng
lm tan si tt hn URSOLVANT n c v t tc dng ph.
Thi gian iu tr trung bnh: 6 thng i vi 5 mm v 2 nm i vi si 1015mm.

126
Hiu qu: URSOLVANT lm tan si trong khong 49% i vi si di 10 mm
v ch 29% i vi si trn 10 mm.
Tc dng ph: thng gp vi CHENODEX: i chy 920-40%), tng men gan, tng
cholesterol LDL (10%).
+ Lm tan si trc tip
Bm trc tip thuc lm tan si vo ti mt: Methyl Ter Butyl Eter (MTBE). t c
s dng v t hiu qu.
+ Phu thut
-

Ct ti mt bng phu thut m bng hoc tt nht l ni soi.

M ng mt ch ly si, sc ra, dn lu Kehr.

+ Ni soi
Chp ng mt ngc dng qua ni soi khng ch l phng php chn
on chnh xc si mt m cn gip phi hp iu tr ly si, gip bnh nhn trnh
c phu thut m bng c in.
- K thut:
+ Ni soi t trng, chp ng mt bng thuc cn quang.
+ Xc nh v tr si, nh gi kh nng c th ly qua ni soi
+ Ct c vng Oddi bng dao ct, phi hp ct v ng cm mu, kch
thc on ct ty thuc kch thc vin si, kch thc ng mt, di ca
phu ng mt, thng t 10-15mm.
+ a r Dormia hoc bng ln ng mt ch qua ming ct ko si xung
t trng. Trong trng hp kch thc si ln th c th tn si c hc trc tip ti
ch trc khi ly si.
- Bin chng
+ Bin chng sm:
Xut huyt
Thng t trng hoc him hn l thng ng mt ch.
Vim ty cp
Vim ng mt cp l bin chng nng, c th gy t vong.
Kt r Dormia bng vater.
+ Bin chng mun (sau 30 ngy)
St si
Hp th pht ming ct
Vim ti mt cp
- Ch nh
+ Si ti pht ng mt bnh nhn ct ti mt
+ Bnh nhn ln tui, nguy c bin chng do phu thut cao.
+ Si ng mt khng km theo si ti mt

127
+ Trong trng hp cp cu, c km theo chng nhim trng, suy thn cp,
xat huyt tiu ha, vim ty cp...
+ Tn si ngoi c th
- Tn si ngoi c th: c Sauerbruch thc hin ln u tin trn ngi vo nm
1985.
+ C ch: tn si ngoi c th c thc hin nh 2 c ch sau:
Lm tng t l b mt/th tch ca vin si, lm d cho s ho tan si
To ra cc mnh si nh di 3 mm, c th di chuyn d dng xung rut non m
khng gy ra triu chng g.
+ Nguyn l k thut: my tn si ngoi c th s pht ra mt sng va p mnh c
tc dng to ta mt p lc rt cao v tr vin si nhng p lc xung quanh li bnh
thng, do va c tc dng tn nh vin si, va khng gy thng tn cho cc
m ln cn.
Si cholesterol khng cn quang, ng knh di 20 mm.
Ti mt v ng mt khng b tc nghn
+ Chng ch nh:
Khng c cc bin chng nh vim ti mt cp, vim ty cp.
Khng c si ng mt
Khng c ri lon ng mu hay ang dng thuc chng ng.
Ph n c thai.
+Tc dng ph, tai bin: thng ch c vi chm xut huyt nh di da ni tn,
him khi gp tiu mu hoc khi mu t gan.

X. D PHNG
- D phng si cholesterol bng tit thc gim cholesterol, gim m bo ha,
thn trng khi dng thuc nga thai, iu tr bnh huyt tn nu c.
- Tuyn truyn, gio dc v v sinh n ung, v sinh mi trng, x l phn
thi nng thn. Khuyn khch phong tro trng v s dng rau sch. Ra tay
trc khi n.
-

X giun nh k mi 2-3 thng

iu tr tt cc t nhim trng ng mt

128

VIM GAN MN
Mc tiu
1. Nm c bnh nguyn v c ch bnh sinh trong vim gan mn.
2. Khm v pht hin c cc triu chng ca vim gan mn.
3. Chn on c v bit cch d phng
4. Trnh by c cc pht iu tr vim gan mn theo tng nguyn nhn gy
bnh.
Ni dung

I. I CNG
Vim gan mn (VGM) l biu hin ca nhiu loi tn thng gan do nhiu loi
nguyn nhn khc nhau trong vim v hoi t t bo gan ko di > 6 thng. Th
nh l th khng tin trin hoc tin trin rt chm v khng a n x hoc ung
th gan cn th nng l th vim hoi t dn dp hoc nhiu t tin trin tn cng
vo t bo gan ri cui cng a n x v ung th ha. Vim gan mn gy ra
do nhiu loi nguyn nhn thng gp l sau vim gan siu vi nht l B, C, v B
phi hp vi D v gn y l vim gan mn G; vim gan mn t min, vim gan mn
do thuc.

II. GII PHU BNH

Cc tn thng thng phi hp gia tm nhun t bo vim, hoi t v x ha.
Tm nhun t bo vim ch yu l khong ca, lm cho khong ca b dn rng
ra, vim cn xy ra quanh cc tiu thy gan, vi cc t bo gan b hoi t. Cc t
bo vim tm nhun ch yu l cc t bo vim n nhn nht l lymphocyte v
plasmocyte v monocyte
Hoi t t bo gan thng l nng v lan rng, c bit l hoi t tng m nh vi
ba t bo ch tip cn vi khong ca, hoi t ny gi l hoi t kiu mi gm, rt
c trng cho vim gan mn hot ng. Mt loi hoi t khc cng thng gp l
hoi t kiu cu ni, ni lin khong ca v tnh mch trung tm tiu thy.
X v nt tn to thay i t nhiu ty theo giai on din tin ca bnh, trong giai
on sau x chim u th v lm cho cu trc gan hon ton b o ln ng thi c
s xut hin ca nt tn to, cn biu hin vim th li gim dn cho hnh nh giai
phu bnh nh trong x gan v cui cng c th b ung th ha.

III. PHN LOI VIM GAN MN

Hin nay ngi ta phn loi da vo s phi hp ca lm sng, huyt thanh hc v
thay i v m hc cho nn cho nhiu gi tr thng tin hn. Phn loi vim gan mn
l da trn cc yu t sau
- Nguyn nhn.
- Hot tnh m hc cn gi l .
- tin trin gi l giai on.
1. Phn loi theo nguyn nhn
Lm sng v huyt thanh cho php chn on c vim gan mn do siu vi, ch
yu l siu vi B, C, phi hp D, cc loi siu vi khc; vim gn mn t min gm cc

129
tiu nhm: type 1, type 2 v type 3; vim gan mn do thuc; vim gan mn khng r
nguyn nhn gi l Cryptogenic chronic hepatitis.
2. Phn loi theo
S phn chia l da vo s lng gi m hc ca hot tnh vim hoi t khi sinh
thit gan. S lng gi v nng m hc bao gm hoi t quanh khong ca
v s ph v lp t bo gan quanh khong ca bi t bo vim hoi t gi l hoi t
kiu mi gm. S ni kt ca cc hoi t ny to thnh hoi t cu ni, ni lin
khong ca v mch mu trung tm, hoc cc khong ca vi nhau. Nhiu h thng
cho im mc hoi t ny, nhng ph bin nht hin nay l bng ch s nh gi
hot tnh m hc (HAI: hepatitis activity index) da trn cng trnh nghin cu ca
Schnell v Ishak. HAI l mt bng o v , n cng lng gi x ha m hin
nay c dng chia giai on bnh. N cng c dng o hot tnh ca
bnh trc v sau iu tr. Lm sng VGM chia ra 3 nh, va v nng.
3. Phn loi theo giai on
Phn loi ny phn nh giai on tin trin ca bnh, da trn mc x gan.
- Khng c x.
- X nh.
- X va.
- X nng c c x cu ni.
- X gan tht s.
4. Phn loi phi hp vi m hc: chia ra 3 loi
4.1. Vim gan mn tn ti: tm nhun t bo vim n nhn lan ta nhng cn gii
hn trong khong ca, ranh gii quanh khong ca cn nguyn vn v khng c s
xm ln ca tin trnh vim hoi t vo tiu thy gan, hoc ch c mt t x quanh
khong ca m khng c x gan. Thng l bnh nhn Khng c triu chng hoc
rt nh nh mi mt, chn n, bun nn. Thc th rt ngho ch c th gan hi ln
hoc bnh thng. Men transaminases ch tng nh v khng c hoc rt t a n
x gan.
4.2. Vim gan mn tiu thy: ngoi vim khong ca, xt nghim m hc c hoi t
v vim trong tiu thy. V hnh thi hc, vim gan mn tiu thy tng t nh tin
trin chm ca vim gan cp. Ranh gii quanh khong ca vn cn nguyn vn,
khng c x quanh khong ca hoc ch hn ch, cu trc thy cn gi c v t
khi chuyn qua vim gan mn hot ng v x gan. V vy vim gan mn tiu thy
c xem nh l mt th ca vim gan mn tn ti. i khi hot tnh trn lm sng
ca vim gan mn tiu thy gia tng mt cch t nhin, hot tnh ca men
transaminase tng t nh trong vim gan cp v c tn thng m hc gan thong
qua. Thut ng hin nay ca vim gan mn tiu thy l tng ng vi th nh hoc
va v giai on l khng c x hoc x ti thiu.
4.3. Vim gan mn hot ng: v lm sng c c trng ca hoi t lin tc
khong ca, quanh khong ca, vim tiu thy gan v x, mc t nh cho n
nng. Vim gan mn hot ng c bit nh l mt tin trnh tn thng gan a
n x, suy v cht. c im v hnh thi hc ca vin gan mn hot ng bao
gm:

130
- Thm nhim dy c t bo vim n nhn trong khong ca lan rng vo tiu
thy gan (trong vim gan mn t min l plasmocyte).
- Hy hoi t bo gan quanh tiu thy lm ph v hng ro t bo gan quanh
khong ca (hoi t kiu mi gm).
- Vch x bao quanh khong ca v lan rng t khong ca vo trung tm lm c
lp t bo nhu m vo trong mt m v bao ly cc ng mt.
- C s ti to nhu m gan thnh lp th hoa hng, b gan b dy ra v ti to (nt
tn to)
Bng 1: Ch s hot tnh m hc ca Schnell- Ishak trong vim gan mn
Hnh thi m hc

nng

Ch s

1. Hoi t quanh khong ca,

bao gm hoi t mi gm v
hay cu ni

Khng

PN nh

PN va

PN ng k

PN va+ BN

PN ng k+ BN

Hoi t nhiu thy

10

Khng

Nh

Va

ng k

Khng

Nh

Va

ng k

Khng

Lan rng khong ca

X cu ni

X gan

2. Hoi t ni tiu thy

3. Vim khong ca

4. Si x

Tng s

22

IV. TRIU CHNG

1. Lm sng
Triu chng khi u c th biu hin nhng t rm r nh trong vim gan cp
(1/3 trng hp), phn cn li thng m thm lm phn ln bnh nhn khng nhn
bit c, thng ch biu hin bi triu chng c nng chung l mi mt, cm gic
nng tc vng h sn phi, nhiu lc c au c, au khp hoc nhiu lc ch c
cm gic nhc mi chung chung. Trong nhng t tin trin, cc triu chng thng
phong ph v rm r hn vi st, vng da vng mt, nc tiu vng hoc sm mu,
au c v au khp v nht l au tc vng gan v nga. Khm thy gan ln va,

131
cng chc n au tc, vng da vng mt, hng ban v dn mch hnh sao. C th
c lch ln 30% nht l khi c tng p ca, km thm c bng; hch ln 15-20%
thng l hch nch v hch c.
Cc biu hin ngoi gan c th gp: ban da, vim tuyn gip t min Hashimoto,
vim mch, vim cu thn, hi chng Sjogren, vim i trc trng lot chy mu,
thiu mu, chy mu do gim tiu cu.
Giai on sau khi c bin chng x gan cc biu hin vim thng gim dn
thay vo l cc triu chng ca x gan vi bng v suy gan l ni bt; hoc cc
triu chng ca ung th gan vi gan rt ln, cng c nhiu khi u ln nhn.
2. Xt nghim
2.1. CTM: BC v HC thng gim c th gim lun c TC, VS thng tng cao.
2.2. Chc nng gan: thay i nhiu.
- Bilirubin tng c trc tip v gin tip.
- Men transaminase thng tng gp >5 ln bnh thng.
- Gammaglobulin tng nhng albumin gim, t A/G rt thp.
- T prothrombin gim, yu t V gim.
- Phosphatase kim tng.
2.3. Min dch
- HBsAg(+), ADN virus, ADN polymerase v HBeAg(+) trong vim gan mn hot
ng B.
- Anti HVC v HVC-RNA (+) trong vim gan mn virus C.
- KT- khng nhn, KT-khng c trn, KT- khng ti lp th (+) trong vim gan t
min.
2.4. Sinh thit gan: l mt xt nghim cn thit gip chn on nguyn nhn v giai
on, trm trng ca vim gan mn cho hnh nh vim hoi t xm nhp tiu thy
gan vi hoi t mi gm, hoi t cu ni, hoi t mng xen ln vi t chc x pht
trin nhiu khong ca xm nhp tiu thy v cc nt tn to trong giai on sau.

V. CHN ON NGUYN NHN

1. Vim gan siu vi
1.1. Vim gan mn B: trong thi k lui bnh c khong t 1-10% bnh nhn vn
mang virus, nguy c mang mm bnh mn c lm d bi tnh trng suy gim
min dch trc . Nhim bnh t s sinh thng im lng nhng c n 90% c
nguy c chuyn thnh mn, trong khi nhim bnh tui thiu nin khi c
min dch, th biu hin lm sng vim gan cp r hn nhng ch c 1% tr thnh
mn tnh. Mc tn thng gan rt thay i t nh, va v nng; mc tn
thng m hc lin quan n trm trng ca bnh. Mt nghin cu c theo di
ko di 5 nm cho thy thi gian sng cn 97% trong VGM tn ti, 55% trong vim
gan mn hot ng.
Ngoi tn thng m hc, s nhn ln ca virus cng rt quan trng trong
vn tin lng, ngi ta chia vim gan mn ra lm 2 pha da trn s ch im
nhn ln ca virus (HBeAg, HBV- DNA), c s hin din ca khng nguyn
nuclocapside ni bo (HBcAg). Trong pha t nhn i virus, khng c mt ca

132
HBeAg v HBV- ADN nhng c anti HBe, khng c mt ca HBcAg ni bo, pha ny
rt t ly nhim, v tn thng gan t. Bnh nhn c pha nhn ln virusk c khuynh
hng nng, trong khi bnh nhn khng c pha nhn ln virus, thng l vim
gan nh hoc va hoc ngi lnh mang bnh. S chuyn t nhin t vim gan
mn c nhn ln sang vim gan mn khng nhn ln hng nm l t 10-15%.
Tn thng gan do nhim virus B mn khng phi trc tip gy ra do virus, m lin
h n phn ng min dch chng li t bo gan do cc khng nguyn ca chng,
nht l HBcAg.
Lm sng ca vim gan mn siu vi B rt thay i t nhim khng triu chng cho
n rt nng n thm ch t vong do suy gan. Khi bnh a s thng m thm, ch
mt s t biu hin nh mt vim gan cp. cc triu chng thng gp l mt mi,
vng da tng t, km chn n, v sau xut hin cc triu chng ca x gan v tng
p ca nh ph, bng, chy mu nht l t tnh mch trng thc qun, ri lon
chy mu ng mu, bnh no gan, lch ln. cc triu chng ngoi gan gn ging
nh vim gan siu vi cp do s lng ng cc phc hp min dch Ag-Ab nh au
khp, vim khp, ban da, vim cu thn, vim mch.
Xt nghim
- Men transaminase tng t 100- 1000 v trong SGPT tng nhiu hn, nhng khi
c x gan th SGOT chim u th hn.
- Phosphatase kim tng va. Bilirubin tng gp 3-5 ln bnh thng.
- Albumin mu gim.
- T prothrombin gim nht l trong giai on nng y cng l yu t tin lng.
- Cc cht ch im l HBeAg v anti HBe, HBV- DNA, HBsAg, anti HBc thng (+).
1.2. Vim gan mn D (Delta): c pht hin nm 1977, y l loi virus c bit n
ch c th pht trin khi c s hin din ca virus B.
Bnh cnh lm sng vim gan mn D tng t nh vim gan mn virus B, nu ng
nhim th bnh cnh lm sng s rt nng nhng dng nh khng lm gia tng
tin trnh a n mn tnh, cn bi nhim ngi vim gan B mn s lm cho tn
thng gan nng ra rt nhiu.
Chn on da vo s hin din ca HDV Ag v anti HDV c 2 type IgG v IgM. S
hin din ca HDV Ag trong gan v HDV- RNA trong huyt thanh chng t c s
nhn ln ca virus. S hin din ca khng th lu hnh khng li microsome ganthn (anti LKM: khng liver kidney microsome) l yu t quan trng gip chn on
vim gan D mn, y l la LKM3 khc vi LKM1 trong vim gan t min.
1.3. Vim gan mn C: Trc y gi l 0A0B (khng A khng B). Din tin mn tnh
sau vim gan C l 50-70%. Ngoi ra vim gan mn sau chuyn mu 10 nm 20%
a n x gan. Ngay c cho nhng th nh v va v khng c triu chng v ch
tng nh men transaminase, sinh thit gan ch c thng tn nh v va. T l vim
gan mn C cn b a n x gan l 50%. nhng bnh nhn c anti HVC mc d
khng c triu chng v men transaminase bnh thng. Khi sinh thit gan cng c
tn thng vim gan mn v c th pht hin HCV- RNA lu hnh trong mu. Din
tin ca VGM C thng chm v m thm. Mc tin trin ph thuc vo nng
HCV- RNA v thi gian nhim bnh.
Biu hin lm sng ca VGM. C cng tng t nh B: thng nht l mt mi, vng
da t gp. Cc biu hin ngoi gan do phc hp min dch t gp hn B ngoi tr

133
phc hp globulin ngng kt lnh. Tuy nhin n thng phi hp vi hi chng
Sjogren, Lichen phng, porphyrin da.
Cc xt nghim tng t VGM B, nhng men transaminase thng tht thng v
t cao hn. i Khi c cc t khng th.
- Anti - LKM1 thng(+) nh VGM t min type 2.
- Anti - C100, Anti C22/33 (+).
2. Vim gan mn t min: cng l mt bnh mn tnh trong gan b vim, hoi t,
x ho mt cch lin tc cui cng a n x gan, chim 10-20% VGM. Bnh gy
ra do mt phn ng t min chhng li cc Khng nguyn hin nay vn cha xc
nh ht, 3/4 trng hp gp ph n tr. cc biu hin t min ngoi gan cng
nh cc bt thng min dch huyt thanh cng c cho loi bnh ny.
Tin trnh tn thng gan l qua trung gian min dch t bo chng li t bo gan,
trn c s c t tnh di truyn c khi pht bi ha cht v siu vi. Cc bng
chng h tr cho VGM t min l:
- Tn thng m hc gan ch yu l t bo T c v tng bo.
- Cc t khng th lu hnh: khng nhn, khng c trn, khng tuyn gip..., yu t
thp, tng Globulin mu. - Km cc bnh t min khc: vim tuyn gip, vim a
khp dng thp, huyt tn t min, vim lot i trng, vim cu thn tng sinh, i
ng, Hi chng Sjogren.
- Yu t ha hp t chc: HLA-B1 (Human leucocyte antigen), - B8, - Drw3 v Drw4.
- Bnh p ng tt vi iu tr corticoide v thuc ch min dch.
Bnh cnh lm sng cng tng t nh vim gan mn siu vi. Khi bnh c th t
t hoc t ngt vi mt mi, chn n, mt kinh, mn trng c, au khp, ban da,
vim i trng, trng dch mng phi, mng tim, thiu mu, vim kt mc, kh mt,
ph, lch ln.
Xt nghim: ngoi nhng ri lon sinh hc nh trong vim gan mn siu vi, y
Gamma globulin cao >2, 5g%, Yu t thp(+). Khng th khng nhn, khng ty lp
th (+).
Chn on: da vo cc yu t sau:
- Khng c bnh nguyn r.
- Thng phi hp vi cc ri lon min dch khc: Lupus, PCE, Hashimoto, thiu
mu huyt tn, hi chng Sjogren...
- Hin din trong huyt thanh cc t khng th.
Ty theo cc type khng th ngi ta chia lm 3 th:
+ Type 1: thng xy ra ph n tr, Gamma globulin tng, khng th khng nhn
v c trn.
+ Type 2: thng xy ra tr em a trung hi, khng th LKM1.
+ Type 3: c khng th khng khng nguyn ha tan gan.
3. Vim gan mn do thuc: mt s thuc nht l khi dng ko di >6 thng, c th
gy ra VGM, thng gp nht l: Clormtacine, acide Tinilique, (-mthyldopa,

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Nitrofurantoine, Papaverine, Oxyphnactine, Isoniaside, Amiodarone, Aspirine,
Actaminophen, Vitamin A, Methotrexate, PTU...
Cc tn thng do thuc thng l rt nng v x gan thng hin din trc khi
pht hin ra bnh.
Chn on cn da vo cc yu t sau:
- Tin s dng cc thuc c cho gan ko di.
- Din tin tt khi ngng thuc.
- Khng tm c cc nguyn nhn khc.
- Mt s xt nghim kh c hiu cho tng loi thuc: Sinh thit gan c s nhim
lipide-phospo t bo gan trong vim gan mn do Amiodacrone, KT antimitochondrie
anti-M6 trong vim gan mn do Isoniaside, Anti LKM3 trong VGM do tinilique, anti
LM trong vim gan mn do dihydralazine...

VI. CHN ON TH
1. Vim gan mn tn ti
1.1. Lm sng
- C nng: thng rt m thm v nh nhng, khng c triu chng hoc ch hi
mt, chn n, kh chu vng thng v hoc h sn phi; i khi tc nh vng gan.
-Thc th
+ Vng mt, vng da: khng c hoc rt kn o.
+ Hng ban v nt nhn khng c.
+ Gan: khng ln hoc ln nh 1 vi cm, mm ch tc nh m khng au.
+ Hch khng c. Lch khng ln. Khng c tng p ca.
1.2. Xt nghim
- Sinh ha
+ Men transaminase khng tng hoc ch tng nh 2-3 ln.
+ Phosphatase kim, Bilirubin, Gamma globulin khng tng hoc ch tng rt t.
+ Khng c hot tnh nhn ln ca virus.
- M hc: vim nh khong ca vi cc t bo vim n nhn, nhng khng bao gi
vt qu khong ca. B gan cn bnh thng hoc rt t b bin i. Cu trc gan
cn nguyn vn.
1.3. Tin lng
Tt, khng c hoc rt t a n x gan v ung th gan.
2. Vim gan mn hot ng
2.1. Lm sng
- C nng: biu hin r nht l cc t bc pht vi st va, mt mi, chn n, au
khp au c, v nht l au tc vng h sn phi. Nc tiu m mu, nga v
vng da vng mt.
- Thc th:

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+ Mt thng vng nht l trong t tin trin.
+ Hng ban v nt nhn ngy cng nhiu nht l giai on khi c x gan.
+ Gan ln 3-4cm di sn, cng tc n au v sau tr thnh chc cng, b sc.
+ Hch ln t l 20%.
+ Lch ln 30%.
+ Tng p ca: thng xut hin v sau khi c x gan.
2.2. Xt nghim
- Sinh ha
+ Men transaminase thng tng > 5 ln bnh thng.
+ Phosphatase Kim v Bilirubin mu thng tng gp 3-5 ln bnh thng.
- Globulin tng > 25%.
+ T prothrombin v yu t 5 gim.
+ Hot tnh nhn ln ca virus r: ADN virus, ADN polymerase (+).
- M hc
+ Vim vt qu khong ca xm nhp tiu thy gan.
+ Hoi t dng mi gm, hoi t cu ni.
+ Hoi t m hoc mng.
+ X tng sinh, xm nhp tiu thy gan.
+ Cu trc gan b o ln.
2.3. Tin lng: xu, cui cng a n x gan v ung th gan.

VII. IU TR
1. iu tr vim gan mn virus B
* Mc ch ca iu tr vim gan mn virus: lm ngng s nhn ln ca virus v lm
ngng hot tnh sinh hc v m hc. C 3 mc p ng:
- p ng loi 1: ngng s nhn ln ca virus nh du bi s bin mt ca ADN
virus trong huyt thanh.
- p ng loi 2: khi s ngng nhn ln virus c ko di bi s chuyn huyt
thanh HBe (khng th khng HBe).
- p ng loi 3: ngng hon ton s nhn ln virus v s chuyn huyt thanh HBs
(anti HBs).
* Thuc
- Lamivudine: (Didoxythiacytidine, Zefflix* ca hng Glaxowellcome) thuc khng
virus Herpes v Retrovirus hiu qu trong vic c ch s nhn ln ca virus qua c
ch sao chp tng hp ca DNA virus v DNA polymerase. Vin 100mg ung ngy 1
vin, ung trong 3 thng, hiu qu lm (-) AND virus trong HT l 100%, nhng sau
khi ngng thuc th 64% dng tnh tr li. N cng lm gim HBeAg v HBsAg
nhng chm hn.

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Liu trnh 1 nm cng ch lm m tnh HBeAg 39% bnh nhn. Lamivudine cng
c dng trong d phng ti nhim virus B trong ghp gan bng phi hp vi
Globuline min dch khng HBsAg. Trong vim gan B phi hp vi nhim HIV dng
liu 300mg/ng cho thy rt hiu qu.
- Famciclovir: liu 1500mg/ng chia 3 ln trong 16 tun lm gim t l ng k AND
virus v hot tnh ca men transaminase sau 1 tun. S dng liu th 2: 750mg/ng
trong 16 tun na cng lm tng ng k s i huyt thanh khng HBe. N cng
dng trong iu tr d phng trong ghp gan, hoc trong trng hp khng iu
tr vi Interferon.
- Adefovir: (Hepsera) vin 10mg/ ngy 1 vin dng 6 thng n 1 nm, cn theo di
chc nng thn.
- Interferon: Loi interferon alpha tc dng qua 2 c ch: mt l c ch RNA virus v
tng hot tnh ca men khng virus. Hai l lm gia tng p ng min dch t bo
bng cch gia tng s trnh by khng nguyn ha hp t bo loi 1 v kch thch
hot ng ca lympho bo T gip v T git. Liu 5 triu n v tim di da hng
ngy hoc 10 triu n v tim di da hoc tim bp tun 3 ln, dng trong 4-6
thng. p ng loi 2 khong 40%. p ng tt hn bnh nhn c nng HBV
DNA < 200pg/mL v bnh nhn c men transaminase > 100-200 .v.
Tc dng ph: - Nh cm cm vi st, nhc u, mi mt.
- Thiu mu, gim bch cu a nhn, gim tiu cu.
- Tc dng ph nng hn nhng t gp v ph thuc c a l: ri lon
tm thn, ng kinh, suy hoc cng gip.
Interferon tc dng ko di: Peginterferon 2a (Pegasys), mi tun ch tim 1 ln, liu
90-180mcg.
- Corticoide: cho trc iu tr Interferon trong 4 tun, v khi dng t ngt s c
phn ng di min dch vi s gia tng hy t bo b nhim virus, s gip cho
Interferon tc dng tt hn, nhng bnh nhn x gan c nguy c suy gan nng.
- Ghp gan: ch nh cho suy gan nng, nhng cng khng trnh c tnh
trng vim gan ti pht trn gan ghp (80%). iu tr interferon trc khi ghp gip
lm chm tin trnh vim ny.
2. iu tr vim gan mn D
Ch c Interferon mi c hiu qu trong iu tr VGM D, nhng thng kh nh gi
hn v bnh nhn ny thng phi hp vi nhim HIV v VGM.C. Vi interferon
alpha p ng c ch s nhn kln ca virus l 50%, ng thi thng km theo s
gim men transaminase, v gim hot ng m hc, nhng him khi t c mt
s ngng hon ton nhn ln ca virus, v khi ngng iu tr s c s ti xut hin
ca khng nguyn v ca RNA virus, cng nh s gia tng tr li ca men
transaminase. Liu interferon cao hn 10triu .v (3 ln/ tun v ko di 6 - 12
thng.
Ghp gan cng c thc hin khi suy gan nng v cng c nguy c vim gan trn
gan ghp.
3. iu tr vim gan mn C: Corticoides khng c kt qu.
* Interferon alpha l thuc iu tr hiu qa nht hin nay. N lm bin mt s tng
men transaminase sau 1-2 thng iu tr. Nhiu nghin cu cho thy interferon lm

137
men transaminase tr li bnh thng trong 50% trng hp, cng nh lm gim
hot tnh m hc. Liu 3 triu n v tun 3 ln tim di da trong vng 6 thng. Cn
thn trng x dng interferon khi c suy gan nng, v khi ngng iu tr s c phn
ng di, v mt hot tnh vim gan mn s lm cho gan b suy thm.
Hiu qu lu di ca vic iu tr interferon vn cha c bit ht. V sau khi
ngng iu tr 3 - 6 thng th gn 1 na c hin tng ti pht. Hin nay c
interferon tc dng ko di: Peginterferon 2a (Pegasys), mi tun ch tim 1 ln, liu
90-180mcg, tc dng tt hn v t tc dng ph hn nhng gi cn cao.
* Ribavirin: l mt cht ng vn nuclotide c ph virus rng, c th dng lm n
tr liu chng virus C, n gip ci thin v m hc v men gan t 30 n 50% bnh
nhn. Tuy nhin n lm gim lng virus khng ng k v p ng sinh hc khng
duy tr c sau khi ngng thuc. Liu dng l 1000-1200mg/ng, dng trong 6
thng.
iu tr ghp gan cng tng t nh VGM B.
2.4. iu tr vim gan t min
Ch yu l dng corticoides v thuc c ch min dch.
* Corticoides: Dng n c th cho liu 30-60mg/ng cho ngi ln trong vng 2-3
tun sau gim liu dn, duy tr men transaminase mc bnh thng, vi liu
thng thng l 10-20mg/ng.
Nu corticoide khng hiu qu th phi hp vi Azathioprine liu 50mg/ng. Liu trnh
ny hiu qu trong 80% trng hp. d n c hay phi hp vi Azathioprine cng
cn ko di t nht l 2 nm. Nu sau thi gian ny thy men bnh thng v khng
cn hoi t t bo gan th ngng iu tr v theo di. Nu ti pht th phi iu tr li
nh t u. Thng t l ti pht l khong 60-90% trng hp, do nhiu khi phi
iu tr sut i.
* Ciclosporine: l thuc c nhiu trin vng hin nay ang dng iu tr trong
trng hp khng vi iu tr corticoides. Liu 5-6mg/kg, dng ko di 1-2 nm.

138

X GAN
Mc tiu
1.K cc triu chng v bin chng ca x gan.
2.Lit k cc tiu chun chn on bnh.
3. iu tr cc bin chng ca x gan nht l nhim trng v xut huyt.
Ni dung

I. I CNG
X gan: tn Hy lp l kirrhose, c ngha l gan b x, do Laennec t ra t
nm1819 khi m t tn thng gan do nghin ru lu ngy.T bnh c mang
tn ng gi l x gan Laennec.

II. NH NGHA
Ngi ta nh ngha bnh x gan da trn cc tn thng gii phu bnh ca gan, .
Do ty theo nguyn nhn m bnh cnh x gan, ngoi cc triu chng chung ca
n, c th km theo cc biu hin lm sng khc c trng cho nguyn nhn gy
bnh.
Tn thng c trng cho x gan l mt qu trnh tn thng mn tnh, khng hi
phc ca x gan km theo s x ha lan ta kt hp vi s thnh lp cc nt nhu
m gan ti sinh. Cc tn thng ny a n hoi t t bo gan, lm xp khung li
nng ca gan t dn n s lng ng ca cc t chc lin kt, cc sn mch
mu trong gan tr nn ngon ngoo khc khyu, cc nhu m gan cn st li pht
sinh thnh tng nt. Tn thng ny l hu qu ca tn thng gan mn tnh do
nhiu nguyn nhn khc nhau.

III. DCH T HC
Php, tn sut x gan c triu chng l 3000/1 triu dn, trong do ru vang
chim a s.(nam: 90%-95%; n: 70%-80%); do bia: 10%, do vim gan mn virus l
10%. S ngi ung nhiu ru:30.000/1 triu dn c nguy c x gan l 10%. Nu
trung bnh ung khong 80gr ru/ngy i vi nam v 60 gr/ngy vi n trong 10
nm th nguy c x gan l 50%. T l t vong do x gan: 300 ngi/1 triu dn/nm.
ng nam , vng Sahara chu Phi, khong 15% dn chng nhim virus vim
gan B, C ngay c khi cn nh tui, trong 25% dn n x gan.
Hoa K, t l nhim virus B t hn, thng gp ngi c nguy c cao nh ng
tnh luyn i nam, nghin ht ma ty, vim gan C sau chuyn mu th c khong
50% dn n x gan, t l sng sau 20 nm l 20%. Vit Nam, cha c s liu
thng k c th.

IV. BNH NGUYN

C nhiu nguyn nhn gy x gan, vn cn 1 s nguyn nhn cha bit r.
1. X gan ru
L nguyn nhn thng gp chu u, gp ngi ung ru nhiu, tuyn mang
tai ln, nt dn mch. SGOT/SGPT >2, GGT tng, xc nh bng sinh thit gan, vi
hnh nh nt dn mch. SGOT/SGPT >2, GGT tng, xc nh bng sinh thit gan,
vi hnh nh

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2. X gan do nhim trng
ng hng u l vim gan B, C v hay phi hp D gy x gan nt ln(x gan sau
hoi t). y l hu qu ca vim gan mn hot ng m khng tm thy s nhn
ln ca virus. Xt nghim huyt thanh cho thy mang mm bnh B, C mn: HBsAg+,
AntiHBc+, HCV(+). Cc nhim khun khc t gp l: Brucellose, Echinococcus,
Schistosomiasis, Toxoplasmosis.
3. X gan do bin dng
3.1 Bnh thit huyt t di truyn
Xt nghim c st huyt thanh tng, bo ha ferritine v transferritine mu tng.
3.2. Bnh Wilson: (x gan ng): ng huyt thanh tng.
3.3 Cc bnh t gp: Thiu (antitrypsin, bnh porphyrin niu, bnh tng galactose
mu, bnh Gaucher, fructose niu, .
4. X gan do ri lon min dch
4.1. X gan mt nguyn pht
y l bnh vim mn tnh ng mt nh trong gan khng nung m, gp ph
n, 30t-50t, biu hin mt mn tnh, tng Gama- globulin IgM v khng th khng
ty lp th.
4.2 Vim gan t min
Gy hy t bo gan mn tnh, thng c t cp, xt nghim mu c khng th
khng c trn, khng th khng nhn, khng th khng ty lp th.
5. X gan c hc
5.1. X gan mt th pht
Do nghn ng mt chnh mn tnh, do hp c oddi, do si.
5.2. Tt mch
Tt tnh mch trn gan trong hi chng Budd-chiari, suy tim phi lu ngy, vim
mng ngoi tim co tht.
6.X gan do thuc: mthotrexate, maleate de perhexilene, methyl dopa, thuc nga
thai, oxyphenisatin, izoniazide,
7. Cc nguyn nhn khc cha c chng minh: Bnh vim rut mn tnh, i
ng, sarcoidosis.

V. C CH BNH SINH
Din tin x gan l din tin chm qua nhiu nm, nhiu khi nguyn nhn mt
nhng bnh vn tip tc tin trin do 1 vng lun qun:
1. Cc yu t min dch
Duy tr tnh trng tn thng t bo gan, c th gp cc khng nguyn(KN) chng
t bo gan, chng hng cu, chng gama- globulin c thnh lp trong din tin x
gan, t gy hy hoi t bo gan, hy hng cu, gy thiu mu v tng nguy c
nhim trng.
2. Tng p ca

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Lm gim thm s lu thng mu trong h thng ca, lm thiu mu tng i
trong t bo gan, t bo gan s nhn thiu oxy v cht dinh dng d b hoi t
thm, n n x ha, so, o ln cu trc gan lm tng p ca.
3. Xut huyt: V bt c nguyn nhn g s lm tng thiu mu t bo gan, gy hoi
t v suy gan.
4. Cc thng ng tnh mch trong gan, phi: Cng lm gim lng mu n gan
gy thiu mu, hoi t v suy gan.
5 Cc nt tn to t mch mu: L nguyn nhn chn p ln cc mch mu lm thiu
mu

VI. LM SNG
Bnh cnh lm sng ca x gan rt bin thin, thay i ty giai on.
1. Giai on cn b
C rt t du chng c nng v thc th, pht hin nh khm iu tra sc khe,
theo di nhng ngi c nguy c cao.
1.1.

Triu chng c nng

n km ngon, kh tiu, nng tc vng thng v, gim tnh dc, ri lon kinh
nguyt.
1.2.Triu chng thc th
Gan ln b sc mt nhn chc khng au, lch ln, khng c c trng, c gin
mch g m, nt gin mch hnh sao, hng ban lng bn tay. Chn on xc nh
bng sinh thit gan.
2. Giai on mt b
y l giai on c nhiu bin chng. Bnh c biu hin qua 2 hi chng:
2.1.Hi chng suy gan
Vi chn n, n chm tiu, y bng, ri lon kinh nguyt, lit dng, v ln, chy
mu chn rng, chy mu cam, chy mu di da, lng tc d rng, mng tay khum
mt knh ng h, ngn tay di trng gp trong x gan mt, mt ngc v chi trn
gy, 2 chn ph mm, da vng nh, thiu mu, nt gin mch hnh sao ngc v
lng, hng ban lng bn tay, mi , li bng , v ln, teo tinh han, vim thn
kinh ngoi bin, gan nh li.
2.2.Hi chng tng p tnh mch ca
Khi u l du trng hi hoc i cu phn st hoc i cu ra mu, nn mu.
Khm c:
-Tun hon bng h kiu ca ch vng thng v v 2 bn mn sn, vng h v
v 2 bn h chu, hoc quanh rn(hnh u sa) hoc c khi l nhng ni tt gia
h ca v ch bn trong. Trong trng hp bng ln chn p tnh mch ch di s
c thm tun hon bng h kiu ch ch phi hp.
- Lch ln: lc u mm, v sau x ha tr nn chc hoc cng, pht hin bng du
chm .

141
- C trng: th t do. Nguyn nhn chnh l do tng p tnh mch ca, ngoi ra
cn do cc yu t khc nh gim p lc keo, gim sc bn thnh mch, yu t gi
mui v nc.
- Tr: thng l tr ni do tng p lc tnh mch mc treo trng di, biu hin bng
i cu ra mu ti.

VII. CN LM SNG
1.Hi chng tng p tnh mch ca
1.1.o p lc tnh mch ca
Bnh thng: 10-15cm nc, tng khi>25cm nc; p lc tnh mch lch tng, thi
gian lch ca ko di.
1.2. ng knh tnh mch ca, tnh mch lch.
Bnh thng 8-11mm, khi c tng p ca th ng knh ln hn 13mm, ng knh
tnh mch lch > 11mm (o bng siu m)
1.3. Ni soi bng Gin tnh mch phc mc, mc treo, tnh mch rn, hoc soi thc
qun d dy thy c trng tnh mch thc qun, d dy.
2. Hi chng suy gan
2.1. Protid mu Gim, nht l albumin, gama- globulin tng, A/G o ngc
2.2 T prothrombin Gim, y l 1 yu t tin lng nng.
2.3. Cholesterol mu: Gim, nht l loi ester ha.
2.4. Cc xt nghim chc nng gan c hiu: Nghim php Galactose niu+, thanh
thi caffein (+).
2.5. Ri lon in gii:Natri mu tng hoc gim, kaki mu gim, natri niu gim
(natri niu < 25 mEq/ 24 gi.
2.6. NH3 mu tng
3. Hi chng vim
3.1. Fibrinogen mu: tng >4g/l.
3.2. LDH>250v, CRP>20mg/l, VS: tng.(khi c x tin trin)
4. Hi chng hy t bo gan
Biu hin khi c vim trong x gan tin trin vi tng ALAT, ASAT.
5. Hi chng thiu mu: ng sc, hoc gim 3 dng t bo mu khi c cng lch.
6. Cc xt ngim ghi hnh
-Siu m gan: gan nh, b khng u, hnh rng ca, dng nt, tnh mch ca tnh
mch lch gin, ti lp tnh mch rn, thuyn tc tnh ca.
-Chp ct lp t trng: cho hnh nh tng t
7. Sinh thit gan
L xt nghim quyt nh trong chn on x gan, gp phn chn on nguyn
nhn v phn loi x gan.

VIII. CHN ON XC NH

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Da vo cc yu t sau
-Tin s c bnh gan mn tnh
-Lm sng Da vo 2 hi chng tng p ca v hi chng suy gan.
-Cn lm sng: Cc xt nghim mu, siu m, sinh thit gan.

IX. CHN ON PHN BIT

1. Suy dng
C tin s, bnh s b mt protein nh ct on rut, suy kit ko di, thiu n trm
trng. Xt ngim c gim protein mu nhng chc nng gan bnh thng, siu m,
sinh thit gan bnh thng.
2. Thn h: Ph tin trin nhanh, c protein niu> 70mg/kg hay > 3, 5gr/24 gi, in
di protein mu c tng globulin l ch yu, siu m v sinh thit gan bnh thng
3. Lao mng bng: Da vo tin s, bnh s c du nhim lao, bng t do hoc khu
tr, au, bng dch tit ch yu limpho, tm BK trong dch bng.
4. U c tnh bng: Bng dch tit, c t bo l, chn on bng chp ct lp t
trng, sinh thit khi u hay chc ht kim nh.
5. Ung th gan: C th trn 1 gan lnh hoc trn 1 gan x. Gan ln nhanh, cng,
bng c th l dch mu, Alpha - FP (+), DCP(+), siu m, CT, sinh thit.

X.TIN TRIN, BIN CHNG

1 Tin trin: m , ko di qua nhiu nm, t giai on cn b vi rt t triu chng,
chn on bng sinh thit gan, n giai on mt b vi triu chng lm sng r,
cn lm sng in hnh. Giai on ny c nhiu bin chng.
2 Bin chng: Nhiu v phc tp vo giai on cui
2.1. Nhim trng Rut, bng, tnh mch ca, phi, thn.
2.1.1. Nhim trng bng
Khi pht c th gp sau vim rut, vi biu hin bng tng nhanh hn, au bng t
nhin, st. Khm bng au khi n, chc d mng bng dch bng c tng t bo >
500/mm3 v trn 50% l bch cu trung tnh, phn ng rivalta c th (+), cy c th
c vi trng gy bnh.
2.1.2. Huyt khi tnh mch ca do nhim trng: Lm sng c bng tng nhanh, au
bng t nhin, st, i tin ra mu. Chn on bng siu m cho hnh nh huyt
khi trong tnh mch ca.
2.2.Bnh l d dy t trng Lot d dy t trng, bnh d dy tng p ca.
2.2.1.Lot d dy t trng: Hay gp lot hnh t trng hn lot d dy. c im
lot thng rt t triu chng, kh lin so, d ti pht nn c nhiu bin chng nh
thng, chy mu.
2.2.2. Bnh d dy tng p ca: Nim mc d dy rc, nhng thc s khng
phi vim. Dn dn, nim mc c hnh khm v c th km theo trng tnh mch
d dy. Tn thng ny hay xy ra bnh nhn c iu tr tht tnh mch trng
thc qun.
2.3. Chy mu Da, nim mc, ni tng, chy mu t tnh mch trng thc qun, t
tr trong tng p ca.

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2.3.1. Chy mu t tnh mch trng thc qun: Do p lc tnh mch ca qu cao.
Bnh khi pht t ngt vi nn mu nhng khng c triu chng bo trc. Tnh
trng chy mu c khi rt nng vi biu hin chong do mt mu, e do tnh mng.
Ni soi thc qun c trng tnh mch 3 c chy mu. Ngoi ra c th chy mu
cc v tr trng tnh mch khc nh tr, trng tnh mch d dy vng phnh v,
trng tnh mch rut non (him).
2.3.2.Chy mu do gim yu t ng mu: Chy mu no, chy mu di da.
2.4. Hn m gan L tin trnh ca giai on cui x gan. Thng c cc yu t lm
d nh nhim trng, xut huyt, ri lon nc in gii, sau phu thut ni tt tnh
mch ch cn gi l bnh no gan.
2.5 Hi chng gan thn: L bin chng nng, t vong cao. y l suy thn cp rt
nng, pht khi trn 1 gan suy, bng qu nng, dng li tiu ba bi hoc thuc c
cho thn. Lm sng biu hin tnh trng thiu niu hoc v niu, c du hiu suy
thn, c protein niu, hng cu niu, natri mu gim < 130 mEq/L, thm thu
nc tiu cao hn huyt tng.
2.6. Ung th gan: Thng gp sau x gan ngoi tr x gan do tim v x gan do
mt.
2.7. Ri lon ng mu: C ri lon dung np glucose nhng t khi gy nn bnh
cnh i tho ng tht s, hoc ng mu gim trong suy gan nng.
2.8.Ri lon yu t ng mu

XI. IU TR
1.iu tr nguyn nhn
Mt khi x gan xy ra ri th vn iu tr nguyn nhn tht qa kh. Loi b
nguyn nhn tc hi nh ru, c cht th vi ch n thch hp, ngh ngi, cung
cp dinh dng c th hi phc nu qu trnh x ang giai on sm..
1.1. iu tr triu chng
1.1.1.Ch n ung ngh ngi
Ch hn ch mui rt quan trng. n nht 0, 5g mui/ng, t m < 50g/ng, protide
khong < 2g/kg/ng. Nng lng khong 1500 - 2000 calo/ng, nc ung < 1l/ng da
vo bilan nc.(c th 100g tht/ng hoc thay bng 2 qu trng, khng qu 0, 25l
sa/ng, bnh m khng mui vi b v mayonaise, tri cy, salad, nc st c chua,
khng dng sa chocolate, ko bc h) nn dng m thc vt, hn ch hot ng
th lc.
1.1.2. iu tr c trng
Kh khn hn so vi c trng do cc nguyn nhn khc.n nht v ngh ngi nu
khng gim bng v Na+niu< 25mmol/ngth cn x dng li tiu.
- Li tiu:Thng bt u vi khng Aldosterone nh spironolactone 100-200mg/ng
hoc Amiloride 10mg- 15mg/ng hoc Triamterene. Sau 4 ngy nu p ng km th
thm Furosemide 80mg/ng hoc thiazide 50mg- 100mg/ng, nu khng p ng cn
xem li ch n, huyt p, p lc keo.
Theo di: cn nng, lng nc tiu hng ngy, xt nghim in gii mu 2 ln
/1tun khi cn ang nm vin gip theo di qu trnh iu tr.Ti a gim khng qu

144
2kg/ng v tiu ti a 3 lt/ng khi c ph ngoi bin v khi ht ph th gim liu li tiu
iu tr duy tr tu p ng bnh, km tit thc hn ch mui
- Chc tho bng:Ch nh khi c trng cng; ph to; Child B; Protrombin>40%;
Bilirubin mu < 10mg/dl; Tiu cu> 40.000/mm3; creatinin mu<3mg/dl;Natri
niu>10mmol/24h. Chc tho tun 1 ln, mi ln ly 1 n 5 lt v phi truyn tr li
mi 6g albumin lt/1ldch (c th dng Dextran hoc polygeline).
- Dn lu kn: Dn lu mng bng vo tnh mch c qua 1 ng teflon.
Nu cc phng php trn khng lm gim bng th t shunt phc mc tnh
mch(peritoneovenous shunts) hoc t TIPS v cui cng l ghp gan
1.2.iu tr tng p tnh mch ca
- Ni thng ca ch: lm gim bng nhanh nhng c nguy c gy bnh no gan, v
hiu qu khng ci thin my.
- Thuc chn giao cm: (Propanolol, Nadolol) c tc dng lm gim p lc ca
thng qua nh hng gin mch trn sng mch tng, lm gim kch thc tnh
mch trng v h thng tnh mch ca, kt hp vi gim cung lng tim. Thuc
c dng vi liu sao cho mch cn so vi mch ban u khi ngh ngi vi iu
kin khng c chng ch nh.C th phi hp vi Isosorbide mononitrate(Imdur)
Tuy nhin, tng p ca trong x gan l khng hi phc cho nn phng php iu
tr c chn la l ghp gan.
1.2. iu tr suy gan
Khng c iu tr c hiu.
- Cc thuc chuyn ha m: Cholin, Methionin, Inositol khng lm hi phc c
chc nng gan
- Cc vitamin B, C, A, D, K, acide folic, folate, km
- Testosteron: khng dng v lm v ln hn, t l t vong tng hn.
1.3. Thuc chng x
- Corticoides: Ch dng trong vim gan mn t min.
- Cc cht c ch prolyl hydroxylase nh HOE 077 cn trong th nghim
- Colchicin: lm ngn qu trnh x gan ru, dng 1mg/ng, 5 ngy 1 tun trong
nhiu thng cng cha thuyt phc mnh m
2. iu tr binchng
2.1. iu tr chy mu tnh mch trng thc qun
y l mt iu tr cp cu nhm duy tr th tch tun hon, tuy nhin khi b dch qu
nhiu c th lm tng p lc ca hn, hu qu l chy mu nhiu hn v v vy nn
cn thn.
- Truyn mu ti hoc huyt tng ti v theo di bng p lc tnh mch trung
ng, lng nc tiu, tnh trng tinh thn kinh. Khong 50% trng hp c th t
ngng nhng nguy c chy mu li cn cao.
- Thuc co mch: (dng giai on cp): Vasopressine hoc Somatostatin. Truyn
Vasopressin(Pitressin) 20 v/100ml dextrose 5% IV trong 10ph p lc ca s gim
sau 45- 60 pht, hoc 0, 4v/ml trong 2 gi gy co mch tng lm gim mu trong h

145
ca, hiu qu 80% v c hn khng chy mu tip. Tc dng ph: thiu mu c
tim, thiu mu ng tiu ha, suy thn cp, h natri mu. lm gim bt bin chng
ny c th dng phi hp nitroglycerin iv 40mg/ph. Glycerin(Terlipressin) c tc dng
di hn Vasopressin, truyn 1mg/mi 4 gi trong 24 gi
Somatostatin hoc Octreotide lm co mch tng trc tip, kim sot chy mu tt v
t tc dng ph hn Vasopressin, liu u tin 250 (g sau truyn 25-50 mg/h..
- Cm mu bng sonde Blakemore hoc sonde Minnesota. Nguy c sc vo phi v
v thc qun do lot, thng.
- Chch x: iu tr chy mu cp v chch lp li duy tr cho n khi xp tnh mch.
Thuc thng dng l polidocanol. Bin chng: lot nim mc c th gy chy mu
hoc hp thc qun, thng.
- Tht tnh mch trng qua ni soi th kim sot chy mu tt hn v gim c
bin chng cng nh chy mu ti pht.
- Phu thut cp cu: t TIPS.
- Thit on thc qun cp cu bng sng kp qua ng m thng d dy mt
trc. Thi gian lm th thut ngn t bin chng, t vong thp
- Cimetidine hoc Ranitidine: d phng lot ddy cp do stress.
- Khng sinh d phng nguy c cao nhim khun d dy rut: dng Norfloxacin.
- Tho phn:loi b mu khi rut, dng lactulose.
- iu tr d phng chy mu ta pht: Phi hp Nadolol v Isosorbide mononitrate
vi chch x nh k hoc vi tht tnh mch trng (band ligation)
2.2.iu tr bnh d dy do tng p ca
Xc nh bng ni soi. C ch nh dng thuc chn giao cm, trong khi khng H2
t ra t hiu qu.
2.3.iu tr vim phc mc nhim khun tin pht (SBP)
Khng sinh c chon la l Cefotaxime 6g/24h x 5-7ngy. Ch cn dng bng
ng tnh mch sau 48 gi thy gim bch cu trong dch bng. Sau iu tr
d phng vi Norfloxacin 400mg/ng, hoc Ciprofloxacin 750mg/tun, hoc Bactrim
cho 5 ngy/tun, ti thiu l 6 thng, c hiu qu phng ti pht.
2.4. iu tr hi chng gan thn
Hn ch dch, mui, protein, kali, khng dng thuc c cho gan, iu tr nhim
khun nu c, khng dng Manitol.Li tiu liu cao v thn nhn to cng khng ci
thin. Cc thuc co mch nh metaraminol, angiotensin II, ornipressin t c hiu qu
trn thn. Cht c ch nitric oxide cn trong th nghim. TIPS thc hin cho Child C
t hiu qu m nn t vn ghp gan.

XII. PHNG BNH

Trnh nghin ru, phng vim gan siu vi bng tim chng bt buc cho nhng
ngi c nguy c cao v vn ng ton dn tim phng vacxin vim gan B 3 mi
cch nhau 1 thng sau 1 nm nhc li, vn ng truyn mu t thn v an ton
truyn mu, thn trng khi dng cc thuc c cho gan; phng v iu tr suy dinh
dng, vim ng mt mn tnh.

XIII. TIN LNG

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Tin lng lu di l xu, 5% sng sau 5 nm, ph thuc bin chng. Tin lng
xu khi c vng da ko di, xut huyt, hn m gan, teo gan vng cp, nhim khun,
Child C ca phn loi Child- Pugh.
Bng 1: Thang im nh gi giai on x gan theo ch s Child - Pugh

1 im

2 im

3im

Bnh no gan

khng

l ln

hn m

Bng

khng

kn o

va phi

Bilirubin

< 35 mol/l

35-50 mol/l

> 50 mol/l

Albumin

> 35 g/l

28-35 g/l

< 28 g/l

T Prothrombin

> 50 %

40-50 %

< 40 %

Thang im nh gi giai on x gan theo ch s Child - Pugh l:

Child A: im 5 hay 6. Child B: im t 7-9. Child C im t 10-15.

147

HN M GAN
Mc tiu
1. K cc nguyn nhn gy hn m gan.
2. Nu c cc triu chng ca cc giai on hn m gan.
3. iu tr tt hn m gan ngoi sinh
Ni dung

I. I CNG
Hn m gan cn gi l bnh no gan, hoc no- ca ch, c nh ngha l nhng
ri lon no th pht gy ra do mt tnh trng suy gan qu nng do nhiu nguyn
nhn hoc khi pht sau phu thut ni thng ca ch.

II. BNH NGUYN

Trong trng hp suy gan qu nng hoc do ni tc ca ch, mu t tnh mch ca
n gan khng cn c t bo gan chuyn ha, tr thnh cc cht c lm ri lon
chuyn ha m nht l no. Cc cht c do bin dng ny bao gm amoniac,
mercaptan, acide gama amino butyri v cc acide amin nhn thm
1.Cc nguyn nhn gy hn m gan ngoi sinh
- Khi pht hn m gan xy ra trn 1 gan x hoc c ni tc ca ch:
- n qu nhiu protid hoc chuyn m
- Xut huyt tiu ha nng
- Dng li tiu mnh lm mt nc v h kali mu
- Dng cc thuc c cho gan:Tetracycline, thuc khng lao, thuc an thn, thuc
ng, thuc h huyt p.
- Sau phu thut trn 1 gan x
- Nhim trng gan, mt, thn, phi, rut.
- Chc tho bng: Thng chc nhiu ln hoc 1 ln qa nhiu lm gim lng tun
hon qua gan
2. Cc nguyn nhn gy hn m gan ni sinh
Do tn thng gan nng n v lan rng nh trong vim gan ti cp, vim gan nhim
c do phospho v c, do Tetraclorure de carbone, do nm Amanite phaloide, do
thuc hay do ung th gan hoc x gan giai on cui.

III. BNH SINH

Yu t quan trng nht trong bnh sinh ca hn m gan l t bo gan b suy nng v
hay ldo s ni tc trong hay ngoi gan, ni mu h ca vi tun hon chung. Hu
qu l nhiu cht c c hp thu t rut khng c gan kh c v a n
nhng bt thng v bin dng trong h thn kinh trung ng.
Cc thuyt hin nay gii thch c ch hn m gan l:
1. Thuyt Amoniac
Cho rng Amoniac t ng tiu ha khng c chuyn ha qua hng ro gan n
no gy c cho no. Ngi ta nhn thy ngi hn m gan c amoniac mu tng

148
cao nht l amoniac trong mu ng mch.Cht chuyn ha sau cng ca amoniac
l Glutamin cng thy tng cao trong dch no ty v trong no ca bnh nhn hn
m gan. Tuy nhin, cng c 1 s nghin cu i ngc li gi thuyt ny.
2.Thuyt ng vn
Do Zive ra, do tnh ng vn ca amoniac lm 1 s acide bo chui ngn v
Mercaptan l cht c c gc lu hunh tng trong mu khi gan suy.
3.Thuyt v cht dn truyn thn kinh gi
Fisher v cng s cho rngbiu hin thn kinh trong x gan l do s tch ly cc
cht dn truyn thn kinh gi. Dopamin, noradrenalin, tyrosin v phenylalanin c
phng thch t s phn hy protein i trng. Nng cc cht ny gia tng trong
huyt tng bnh nhn hn m gan.
4.Thuyt v serotonin
Serotonin c tng hp t L- Tryptophan c nng cao trong no bnh nhn
hn m gan
5.Thuyt v GABA l cht c ch dn truyn thn kinh
Trong thc nghim gy hn m gan sc vt John chng minh s gia tng
nng GABA trong mu, s gia tng tnh thm ca mng no ca GABA, lm c
ch dn truyn thn kinh gy l m
6. Thuyt v Benzodiazepines
no c nhng th th benzodiazepines lm d hot ng ca GABA.. Hai cht
c tm thy tng cao trong mu bnh nhn x gan l Diazepam v N- dmethyldiazepam

IV. TRIU CHNG

1. Lm sng
Hn m gan chia lm 4 giai on
1.1Giai an 1
Biu hin thn kinh cn nh v kn o nh mt nh hng khng gian thi gian,
l m, ng g, ci ni v c cu gt, ni nht gng, ch vit nguch ngac, c th
c du rung v cnh.
1.2. Giai an 2
Triu chng cng r thm. c bit c du rung v cnh, triu chng thp, tng
phn x, c du Babinski hoc tng ng, tng trng lc ngai thp, hi th c
mi gan.
1.3. Giai an 3
Hn m tht s vi mt nhn thc, cm gic v vn ng
1.4. Giai an 4
Giai on 4 A: Hn m nhng cu vo cn p ng.
Giai on 4B: Hn m su c th km ri lan sinh thc
2. Cn lm sng
Ngoi cc xt nghim v bnh gan cn c

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2.1. Ammoniac mu
Thng cao nhng khng t l han tan vi nng. Bnh thng t 60-80 mg.
Trong hn m gan, tng trn 160g/ L. Cn lm ammoniac trong mu ng mch.
2..2. Ri lan v in gii v kim toan
Natri mu thng gim, Kali gim, calci t b nh hng, d tr kim tng, pCO2
gim.
2..3. Dch no ty. Glutamin, acide glutamic tng.
2..4. Cc xt nghim v suy chc nng gan.
2-5. in no : in th cao, i xng, sng chm delta.
2.6. CT scan v MRI: C th c teo no vng v hay ph no.

V. CHN ON
Ch yu da vo 4 yu t chnh sau y
- Bnh nhn c tin s mt bnh gan cp hoc mn, hoc sau phu thut ni ca
ch.
- C ri lan nhn thc: l ln ri hn m.
- C cc triu chng thn kinh nh tng trng lc c, tng phn x, rung v cnh,
Babinski, i khi c du ng kinh.
-in no : in th cao, i xng, sng chm..
- Cc triu chng khc: Hi th c mi gan, glutamin dch no ty tng cao.

VI. TIN LNG, D PHNG

y l bin chng nng ca x gan, tin lng rt nng, t vong 90- 95% nht l
hn m gan ni sinh. Ring i vi hn m ngoi sinh nu iu chnh c cc yu
t thun li sau 48- 72 gi bnh nhn c th ra khi hn m.
Tin lng ph thuc cc yu t thun li gy hn m v tin trin ca bnh x gan.

VII. IU TR
- Xc nh v iu tr nguyn nhn khi pht.
- Can thip gim s sn xut v hp th Nit v cc cht c khc trong rut
- Thuc lm thay i cn bng cc cht dn truyn thn kinh mt cch trc tip hoc
gin tip
1. iu tr hn m cp hay bnh no gan cp
+ Ch n: Gim protein cn 20gram/ngy, 2000 calo/ngy. Tng dn khi
hi phc ln tng 10g /ngy trong tng vi ngy mt nhng vi loi hn m gan mn
tnh th hn ch protein thng xuyn.Gii hn dung np l 40-60g/ng, nn dng
protein thc vt.
+ Tht tho loi b cc Nit v Phosphat.
+ Dng lactulose:10-30ml x 3ln /ngy hoc lactilol 0, 3-0, 5g/kg/ng.
+ Neomycin 1g x 4ln /ngy x 1 tun.hoc Metronidazol 200mg x4 ln/ng x 5-7ngy.
+ Duy tr nng lng v dch da vo cn bng nc v in gii.

150
+ Ngng li tiu.
+ Cc thuc an thn: c th dng Oxazepam.
+ Levodopa: tin cht ca Dopamin qua c hng ro mch no, ch s t bnh
nhn chu c.
+ Bromocriptine: mt ng vn receptor dopamin c hiu, tc dng di.
+ Flumazenil: mt i khng receptor benzodiazepine c th lm gim dn truyn
trong 70% trng hp.
+ Thuc tng thi amoniac qua thn: Benzoate de Sodium
+ Cc acide amin nhnh: cha c ng v thuc t.
+ Bt cc nhnh ni ca- ch.
+ Ghp gan.
2. i vi bnh no gan mn: trnh dng cc thuc c cha Nit; protein t thc vt
50gr/ng; i tin 2ln/ng; dng lactulose hay lactilol; nu triu chng xu hn th
chuyn sang iu tr nh ch ngi hn m cp

151

UNG TH GAN NGUYN PHT

Mc tiu
1. K c cc yu t bnh nguyn v yu t nguy c ca ung th gan nguyn
pht.
2. Trnh by c cc triu chng lm sng v cn lm sng ca ung th gan
nguyn pht.
3. K c cc phng php iu tr ngoi khoa v khng phi ngoi khoa ca
ung th gan nguyn pht
4. Trnh by c ch nh, c ch v nguyn tc iu tr ung th gan nguyn
pht bng cch tim cn tuyt i v gy tc mch bng ha cht
Ni dung

I. I CNG
ng hng th 4 trong cc loi ung th trn th gii.
Trung quc, ng nam : ng hng u nam gii.
Min Bc VN: ng th 3 trong cc loi ung th.
TP H Ch Minh: ng th 1 nam v th 5 n.
ng nam : c tn sut cao, lin quan nhim virus vim gan B.
Tin lng xu, t l sng st sau 5 nm di 3%.
Cc th t chc hc thng gp l:
Ung th biu m t bo gan (Hepato-cellular Carcinoma)
Ung th biu m ng mt (Cholangio-cellular Carcinoma).
Cc loi khc: Ung th nguyn bo gan, Angiosarcome

II. BNH NGUYN V YU T NGUY C

1. Virus vim gan B
Tn sut UTG ngi HBsAg (+) > 200 ln so vi ngi HBsAg(-).
Tn sut HBsAg UTG > 6-20 ln dn s ni chung (Chu : 60-80%).
Protein X trn genome virus B c l c vai tr trong t bin gy ung th.
Vng dch t nhim virus vim gan B cao th cng c tn sut ung th gan
cao.
Gy ung th gan qua 2 c ch: trc tip v gin tip qua trung gian x gan
2. Virus vim gan C
Cc nghin cu v sinh hc phn t, s dng RT-PCR, cho php pht
hin ARN ca virus C trong 50-70% huyt thanh v trong 55-100% t chc gan
nhng bnh nhn UTBMTBG v khng c HBsAg.
90% ung th gan lin quan vi virus C xut hin trn mt nn gan x
Nhng bnh nhn ung th gan c Anti-HCV dng tnh (c hoc khng c HBsAg)
thng c cc thng tn gan nng hn (70% x gan, trong 60-70% thuc Child

152
B hoc C) so vi nhng bnh nhn ch c HBsAg dng tnh (50% x gan, trong
65% thuc Child A) v gan thng c nhiu khi u hn
3. X gan: do bt k nguyn nhn no.
4. Aflatoxin B1: c t nm mc (Aspergillus), thng gp trong u phng mc;
c chng minh l cht gy ung th gan chut, gia cm
Vai tr sinh ung th c l qua trung gian cht chuyn ha l Epoxide gn vo cc
acid nucleic v thay i s sao m ADN.
Tng tc vi protein 53 t bin.
5. Cc yu t khc
5.1. Ru: c l thc y qu trnh sinh ung th
5.2. Ni tit t nam Androgen, thuc nga thai ung.
5.3. Ha cht (Thorotrast),
5.4. K sinh trng (Schistosoma japonicum, Sch. mansoni, clonorchis sinensis)
5.5. Thiu alpha 1-antitrypsin, thng gp cc kiu hnh ZZ v MZ.
5.6. Nhim huyt thit t (Hmechromatose), H/c Budd-Chiari.

III.TRIU CHNG
1. Triu chng c nng v ton thn
1.1. au bng: thng gp, cm gic nng tc h sn phi, lan sau lng, him khi
au d di.
1.2. Ri lon tiu ha: chn n, bun nn, nn, i chy.
1.3. St: lin tc, dao ng.
1.4. Gy st r giai on mun.
2. Triu chng thc th
2.1. Gan ln: nhn thy hoc s thy di b sn phi, cng, b mt khng u,
au nhiu hoc t, c khi c nh khng di ng theo nhp th. C khi gan ln vt
qu ng gia.
2.2. Vng da: ch yu do chn p ng mt trong gan.
2.3. Bng: t hoc nhiu, c th gp bng mu, ti to nhanh sau chc tho.
2.4. Nghe: ting thi trn vng gan
3. Sinh hc
3.1. Cng thc mu: thiu mu, c bit c khi c a hng cu.
3.2. Tc lng mu tng tng
3.3. Chc nng gan: ch ri lon trong ung th gan trn nn x gan hoc khi khi U
chim trn 75% th tch gan.
Enzyme gan: Phosphatase kim, gamma GT, 5 Nuclotidase, Alpha-2 Globulin,
SGOT thng cao hn SGPT.
3.4. Cc cht ch im ung th
3.4.1. Alpha Foeto Protein (AFP)

153
L mt Glycoprotein do gan phi sn xut, gim 3 tun sau sinh, nng
ngi trng thnh khong 4-10 ng/ml.
khi AFP > 1000ng/ml: hu nh chc chn ung th gan nguyn pht.
Tng nh trong u qui bung trng, tinh hon, mt s ung th tiu ha, vim gan
hoi t
AFP c i lc Lectin (AFP - L3) mi c tm ra, c hiu hn AFP nhng k thut
xt nghim phc tp.
Nu khng c iu kin nh lng, c th nh tnh AFP bng phng php min
dch khuch tn (Ouchterlony).
3.4.2. DCP (Descarboxy Prothrombin hay PIVKA-II) dng tnh 70% bnh nhn
ung th gan nguyn pht v khong 50% nhng bnh nhn ung th gan c AFP
bnh thng.
3.4.3. Alpha L-Fucosidase: enzyme ny tng cao trong ung th gan nguyn pht, vi
c hiu 90% v nhy khong 75%, cng tng trong u gan lnh tnh.
4. Thm d hnh nh
4.1.Siu m
Mt hoc nhiu khi (nodule) trong gan.
Echo giu, ngho, hn hp, dng khm
X y mch mu, ng mt (bending sign), vin gim m chung quanh
Tng sinh mch mu trong u, thng c huyt khi trong tnh mch ca.
4.2. Chp ct lp t trng: mt /nhiu khi gim mt (hypodense), bt thuc
khng u, gip hng dn chc ht, sinh thit.
4.3. Chp ng mch
Xt nghim c bn tin phu, gip xc nh v tr, ti mu, kh nng ct b u
qua trung gian mt Catheter lun vo vo ng mch thn tng
Hnh nh bi tng sinh mch mu (th ng mch)
Ti mu t chc ln xn, h mch mu (th nhu m)
lung mu tnh mch v sm (th tnh mch)
5. Gii phu bnh
5.1. Sinh thit: sinh thit di s hng dn ca siu m, CT scan hoc soi bng
Sinh thit: chnh xc nhng d chy mu.
5.2. Chc ht kim nh: t bin chng, nhng chnh xc v nhy thp hn sinh
thit.

IV. CC HI CHNG CN UNG TH

1. H ng mu: do t bo u tit yu t c hot tnh tng t Insulin.
2. Tng Calci mu: do u tit yu t ging hormon cn gip.
3. a hng cu: do u tit yu t tng t Erythropoietine
4. Yu t V bnh thng nghch l

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V. TIN TRIN & BIN CHNG
1. Tin trin: thng l nng, tin lng xu, t vong 6-12 thng
2. Cc bin chng:
2.1.Bng ung th:
2.2.Vng da: chn p ng mt trong gan
2.3.Xut huyt
- Xut huyt tiu ha cao: huyt khi ca
- Phc mc: v nhn ung th
2.4.Chn p tnh mch trn gan hoc tnh mch ch di
2.5.Di cn: trong gan, phi, mng phi, xng, hch, no.

VI. CHN ON PHN BIT

1. Gan au km st
1.1. p xe gan
1.2. Sn l gan: yu t dch t + tng bch cu i toan + huyt thanh chn on
2. Vng da
2.1. Do u chn p: Gan v ti mt ln, phn bit nh siu m.
2.2. Vim gan: giai on tin vng da, SGPT tng rt cao, cc ch im huyt thanh
ca virus vim gan v thm d hnh nh.
3. U h sn phi
3.1. Vim gan mn
3.2. Kn gan, Adenome, lymphosarcome,
3.3. K gan th pht: Tm ung th nguyn pht, Alpha FP bnh thng, t chc hc

VII. IU TR
1. iu tr ngoi khoa
1.1. Phu thut ct b khi u
Phu thut ct gan vn l phng php iu tr trit nht i vi ung th gan
nguyn pht. * Ch nh
Thng ch nh phu thut c p dng cho cc bnh nhn ung th gan giai on
I, II v IIIA.
- Mt s tiu chun thng c xt trong ch nh ct gan
+ Kch thc di 5 cm
+ Mt thu
+ Khi u c v
* Chng ch nh phu thut
-Chc nng gan km do x gan
-Khi u xm ln c hai thy gan

155
-Khi u xm ln hoc lm tc ng gan chung
-Khi u xm ln tnh mch ch di
-Huyt khi tnh mch ca
-Xm ln hch lympho
-Di cn xa (thng gp l phi v xng)
Ngay sau phu thut, s ti pht khi u l c th xy ra, c khi cn ct b ln 2 hoc
thm ch ln 3. Khong cch an ton cn c ti thiu l 1 cm cch t chc u.
Vit Nam, GS Tn tht Tng thc hin t nhng nm 70, phu thut nhng u
nh n c, sau nng min dch bng LH1 cho kt qu tt. K thut ny
thng p dng cho u n c c kch thc di 5cm, tui di 70. Chc nng
gan cn li l yu t chnh quyt nh tin lng, thng ct theo thy hoc phn
thy.
Nht, t vong sau m l 3 - 11%, sng trn 3 nm l 46%. Kt qu tt nht
khi u di 2cm, t l sng trn 5 nm l 60, 5%.
Php, Bismuth thc hin 35 trng hp t 1970-1984 t l sng trn 2 nm
l 32%. Thi gian sng cn ty thuc vo ch s Child-Pudg trn 3 nm l 51% cho
Child A, 12% cho B v C.
Bin chng: Cc bin chng thng gp sau m ct gan l chy mu, nhim khun,
bng v suy gan. Him hn l d ng mt.
1.2. Ghp gan
Li ch chnh ca phng php ny l loi b tt c phn ung th v cc tn thng
trc n, loi b nguy c do tng p lc ca, vn cn nguy c ti pht vim gan trn
gan ghp. Kt qu Hannover cho thy thi gian sng trn 3 nm l 15%,
Pittsburgh vi u nh n c th sng trn 5 nm l 45%.
Cc trng hp ch c mt u di 5 cm hoc c di 3 u nh hn 3 cm th tin
lng sau ghp rt tt, gn ging nh cc bnh nhn ghp tng khc do cc l do
khng phi ung th.
2. iu tr khng ngoi khoa
2.1.Tim cn tuyt i qua da trc tip vo khi u di s hng dn ca siu m
Nm 1982, ln u tin Nht bn, cc tc gi Ebara M v Okuda K... nghin
cu phng php iu tr UTBMTBG bng phng php tim Ethanol vo khi u
gan v thu c kt qu kh quan. Sau c nhiu nghin cu Php, , Trung
Quc...vi cc kt qu tt.
* C ch: Ethanol gy ra huyt khi ng mch trong u, t gy ra mt s hoi t
ng khi u v tnh trng thiu mu cc b khi u.
* Ch nh
- Cc bnh nhn c chn on xc nh l UTBMTBG
- S lng khi u khng qu 3 khi, tt c u l u c v bc
- Kch thc u thng nh di 5 cm, thc t kch thc tu thuc s lng khi u
(1 u 12 cm, 2 u 6 cm, 3 u 4 cm).
- Phn Child-Pugh A v B; T Prothrombin trn 60%.

156
* Phng php
Phng tin, dng c:
- K thut tim ethanol c thc hin di s hng dn ca siu m hoc CT
Scan.
- Kim tim Chiba hoc Terumo: 0, 7-0, 9 X 7-15 cm.
- Ethanol tuyt i: 99, 8 %, ng ng 5 cc.
- Lidocain 1%, thuc gim au, dng c st trng.
* K thut
- Xc nh khi u gan cn chc di siu m hoc CT Scan
- Xc nh v tr chc kim, gy t
- Chc kim qua da vo trung tm khi u di s hng dn ca siu m hoc CT
scan
- Tim chm Ethanol vo khi u, va tim va quan st s khuch tn Ethanol ti
ch
- Rt kim ra st v gan, thay ng tim c lidocain gy t v gan
- Rt kim, bng ti ch.
- Liu lng: 1-2 v tr tim/mt ln x 2 ln mi tun; Mi ln tim 2-12 cc.
Tng liu Ethanol phi tim c tnh theo cng thc Sugiura N (Nht Bn) 1983
V = 4/3 (r + 0.5)3.
Trong : V l tng liu Ethanol
R: bn knh khi u
Kt qu s b ca mt s nghin cu: theo nhiu nghin cu ca nhiu tc gi
ngoi nc (Livraghi, Ebara...) v trong nc (Mai Hng Bng) th kt qu rt kh
quan, t l sng thm sau 3 nm l 71% (Child A), v 41% (Child B), mt s bnh
nhn sng trn 7 nm. Phn ln bnh nhn ci thin tt v lm sng, AFP gim r,
t l khi u hoi t hon ton trn siu m l hn 60%. K thut ny cn c th gip
iu tr cm mu trong trng hp v khi ung th gan.
2.2. Phng php gy tc mch
Phng php gy tc mch c s dng ln u tin vo nm 1975 ti M.
Nakamura iu tr gy tc mch cho 200 bnh nhn ung th gan nguyn pht v
cho t l sng thm 2 thng, 12 thng v 24 thng tng ng l 71%, 48, 1% v 20,
8%. Nhm gy tc mch c phi hp vi lipiodol c thi gian sng thm di hn c
ngha
* C ch
Bnh thng, gan nhn 2 ngun mu cung cp l ng mch gan v tnh mch ca,
trong cc khi u nhn mu ch yu t ng mch gan, do vic gy tc mch
bng cch tim vo nhnh ng mch chn lc nui dng khi u s gp phn gy
hoi t khi u nhng khng gin on s ti mu i vi gan lnh. Vic phi hp
tc dng gy thiu mu hoi t vi tc dng ca cc ha cht chng ung th s lm
tng tc dng iu tr.

157
* Cc k thut gy tc mch
+ Bt tt ng mch gan chn lc bng mnh bt b gelatin, a vo nhnh ng
mch nui dng u thng qua ng mch i v ng mch thn tng.
+ Bt tc ng mch gan siu chn lc
+ Bt tc ng mch gan kt hp tim ha cht chng u (TACE), cc ho cht
thng dng l doxorubicine, cisplatin...
+ Bt tc ng mch gan bng ha du (TOCE)
Tc dng ph sau bt tt l: st, au bng, nn, bng, hn m gan, tng
transaminase.
Ngoi ra c th gy bin chng tt mch ngoi gan hoc gy p xe ha.
Cc k thut ny c th lp li sau mt khong thi gian t 3-6 thng.
* Ch nh
+ Cc khi u gan khng phu thut ct b c
+ iu tr cp cu xut huyt phc mc do v khi u gan
+ Gy tc mch trc m lm gim bt kch thc khi u v tng thi gian
sng thm sau m.
+ Trong mi trng hp, tnh mch ca khng c c huyt khi
2.3. Cc iu tr tm thi khc
* Phng x tr liu
Trc y iu tr phng x ngoi cho bnh nhn ung th gan nguyn pht c
s dng. Nhng do kt qu hn ch nn hin nay t c ch nh. Nhng cht
phng x c s dng l I131-antiferritin, khng th n cln gn I 131-anti HCC.
Hin nay chu u cng c nghin cu iu tr tia x chn lc vo khi u vi kt
qu ban du c ko di hi gian sng thm ca bnh nhn.
* Ha tr liu
Cc ha cht thng c s dng l 5 FU, cisplatin, doxorubicin, Mitomycine C...
ng s dng phong ph: ung, tim tnh mch, tim vo dy chng trn, tnh
mch ca...
* Min dch tr liu
Cc phng tin min dch thng c s dng l phng tin c ngun gc vi
sinh vt (BCG, corynebacterrium, ..), ha cht (levamizole, Isoprinosin...) hoc nhm
Cytokin (IL2, IFN-beta, IFN-gamma...). Tuy nhin khng c phng php no hon
ton c hiu.
Mt s tc gi ngh tim BCG di v gan sau khi ct b khi u vi hy vng tng
min dch khng c hiu. Lai v cng s s dng phi hp Doxorubicine + IFNalpha 2 cho thy c gim kch hc u, gim cc bin chng so vi nhm chng.
K thut chuyn gen: a cc gen tr liu c hiu n tiu dit cc t bo c tnh
nhng khng lm thng tn t chc gan lnh. Cc vect virus nh adenovirus
thng c s dng. Cc khng th n dng phn ng vi khi u cng dc
s dng phn b cc gen n cc t bo ung th.

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* Tamoxifene
S ph thuc kch dc t v s hin din ca th th ni tit trong ung th gan, gi
cho s pht trin ca u l do kch thch t, tuy nhin nghin cu s b vi Tamoxifen
cho kt qu cn tranh ci.
* Nhit tr liu
Thng dng sng cao tn (radio frequence ablation:RFA) pht ra nhit nng thng
qua mt cy kim cm sn trong lng khi u, nhit cao s gip tiu hu t bo ung
th. Kt qu bc u kh tt.

VIII. KT LUN
Ung th gan nguyn pht kh ph bin nc ta, triu chng a dng v
thng khi pht m thm, chn on phn ln giai on mun nn iu tr kh
khn, tin lng thng rt xu.
D phng ung th gan ch yu da vo tim chng phng virus vim gan B
v iu tr cc bnh vim gan mn do virus.

159

UNG TH D DY
Mc tiu
1. M t c im dch t hc bnh ung th d dy.
2. K cc yu t nguy c v c ch gy bnh ung th d dy.
3. Lit k cc triu chng lm sng v cn lm sng.
4. nh gi y chn on ung th d dy theo phn TNM tin lng.
5.Ch nh c th iu tr ung th d dy theo tng giai on
Ni dung

I.I CNG
Ung th d dy ng hng u ca cc ung th ng tiu ha. Mc d t l
t vong c chiu hng gim trong sut 60 nm qua nhng t l bnh so vi cc
ung th khc vn cn cao.

II. DCH T
T l bnh ung th d dy thay i gia cc quc gia khc nhau. Nht Bn, Trung
Quc, Chil v Ireland t l mc v t l t vong c xu hng gim ng k.
M, trong nhng nm gn y, t l bnh ny gim ( nam t 28/100.000 dn
xung cn 5/100.000 v n t 27/100.000 xung cn 2, 3/100.000) t l nam/ n
l 1, 7, tui trung bnh l 63. T l t vong gim t 33/100.000 vo nm 1930 xung
cn 3, 7/100.000 vo nm 1990. Nm 1996 c khong 22.800 trng hp ung th
d dy mi mc c chn on v c 14000 ngi cht.
Nht, t l ung th d dy l 69/100.000, tui trung bnh l 55, v tn sut mc
bnh c lin quan n chng tc (ngi M gc da en, da v gc Ty Ban Nha
t l ung th gp 2 ln so vi ngi M da trng). Ngoi ra mi trng, cc cht
c xem l cc carcinogene t thc n cng c lin quan n bnh.V dch t hc,
nguy c ung th d dy cao tng lp c i sng kinh t x hi thp
Ring Vit nam th cha c thng k c th

III. UNG TH BIU M TUYN D DY

Khong 85% ung th d dy thuc loi adenocarcinomas (ung th biu m tuyn d
dy), 15% l loi lymphomas-non-Hodgkin v leio-myosarcomas v cc loi u th
pht t gp.
Ung th biu m tuyn d dy c chia lm hai loi: loi lan ta v loi rut non.
1. Gii phu bnh
1.1. Loi rut non
L loi ung th d dy hay gp. Cc t bo tng sinh c cu trc ng dng tuyn.
Lon sn tuyn (dysplasia) l c trng th bnh ny, lon sn mc cao gp
trong giai on tin trin cng nh giai on im lng ko di t 5 n 15 nm.
Lon sn c th xy ra trn nn vim d dy mn teo tuyn cng nh vng c d
sn rut v c hai phi hp s lm tng nguy c ca Adenocarcinoma d dy. Tn
thng dng lot, thng gp hang v v b cong nh d dy v thng c giai
on tin trin tin ung th ko di. Khi u c ranh gii r, di cn theo ng mu
n gan v theo ng bch huyt n hch, t l gp ngi gi nhiu hn.

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1.2. Loi lan ta: y l loi ung th t bit ha hn loi rut. T bo tng sinh thm
nhim thnh tng mng, lm dy vch d dy. N pht trin khp ni d dy k c
tm v lm mt kh nng gin d dy (gi l th linitis plastica hoc th t) kh nng
di cn xa. N thm nhim phc mc v sau phc mc, lan ta vo cc ng bch
mch, xng. Loi ny thng gp ni m ung th d dy c xem c nguy c
thp nh Hoa K v gp ngi tr nhiu hn. Loi ny c tin lng xu hn
loi rut. Ngoi ra cn mt dng khc l Adenosquamous tin lng rt xu v tin
trin rt nhanh v di cn sm.
Ty su v rng ca u, chia lm ung th b mt v ung th xm nhp.
1.3.Ung th b mt:
Ch gii hn nim mc v h nim mc, cha n lp c, biu hin 3 dng:
+ Typ I: Li ln hoc dng polype
+ Typ IIa: Np nim mc ch g ln, Typ IIb: Nim mc bng phng, Typ IIc: Nim
nc hi ln xung.
+Typ III. L s o su xung nh hnh hang, c bao quanh bi nhng nt nim
mc. C trng hp phi hp gia cc loi lm cho n c tnh cht ca lot.
1.4.Ung th th xm nhp:
Vt qua lp nim mc n lp c, thanh mc. C 3 loi.
+ Ung th th si: Mt khi trn nn cng v si vo bn trong lng d dy, khng
c lot hay hoi t.
+ Ung th th lot: Cc np nim mc hi t dng li ngoi vng ph n.
+ Ung th th xm nhim: Tn thng lan ta tm nhun ton b d dy (th t)
- Ung th d dy thng lan rng v pha thc qun ch ni d dy thc qun khi
ung th nm thn, phnh v. hang v, ung th thng lan xung v gy hp mn
v, nhng xm ln qua t trng th him. Ung th c th lan n mc ni nh, mc
ni ln, lch, i trng, ty, hch vng k cn.
- Ung th d dy thng di cn n phi, gan, no, xng, hch thng n (hch
Virchow), hch nch tri (hch Irish), hch quanh rn (hch Sister Mary Joseph),
bung trng (u Krukenberg), phc mc, trc trng
2. Cc yu t nguy c v c ch sinh bnh ca ung th d dy
2.1. Cc yu t c khng nh
-Lon sn d dy mc nng: Thng gp cc th vim, lot d dy mn vi
lon sn tuyn. Khong 10% c th tin n ung th d dy sau 5 n 15 nm.
-Vim teo d dy mn, d sn rut.
- Polyp dng tuyn c tnh gia nh (FAP): C lin quan n ung th.
- Adenomas d dy.
- Barrette thc qun: Gy ung th vng tm v.
- Vi khun Helicobacter pylori: Gy vim d dy mn vng hang v, vim teo tuyn d
dy, lot d dy, u limpho d dy (MALT) v ung th d dy.
2.2. Cc yu t c th gy ung th d dy

161
- Sau phu thut ct d dy vng hang v 15 25 nm theo di t l ung th l 50 70% v c lon sn gn ming ni.
- Thiu mu c tnh ngi gi: C lin quan n vim d dy mn tp A vng
thn d dy vi s xut hin khng th khng t bo thnh v khng th khng yu
t ni.
- Bnh Menetrier (Vim d dy ph i): C nhiu yu t gi c lin quan n ung
th. Nhng khng c bng chng lin quan n polype dng tuyn d rng biu
hin ph i i khi c dng nh polype.
- Hamartomas d dy.
- Thc n: Ngi ta nhn thy rng nhng ngi n nhiu v ko di cc thc n
c bo qun bng p mui, hun khi hay sy kh c nng nitrat cao thng
kt hp vi ung th d dy. Di tc dng ca vi khun Nitrat s b bin thnh
nitrosamin, mt cht gy ung th.
Nitrate

Nitrite

Nitrosamin.

(+)
Vi khun
- n t tri cy, rau ti: Gi bi vitamin C c ch s bin i nitrite thnh
nitrosamin. Hoa k, s gim t l mi mc ca ung th d dy kt hp vi s
gim ca nhng thng tn let dng rut vng thp ca d dy; gi rng, s
bo qun thc phm tt hn, kh nng lm ng lnh thc phm tt (hn ch s
pht trin vi khun) c th cung cp rng ri cho mi tng lp x hi, lm gim t
l mc ung th d dy.
- Tnh trng kinh t x hi cng c vai tr quan trng: T l ung th d dy cao cc
nc c i sng thp, kh nng nhim khun cng cao.
- Thuc l v ru cng c xem nh l yu t nguy c.
2.3. Yu t nghi ng:
-Polyp tng sn
-Polyp tuyn vng y v.
-Lot d dy lnh tnh.
-Nhm mu A thng d b ung th d dy hn cc nhm khc. C l nhm mu
ny, kh nng bo v ca nim mc d dy chng cc yu t gy u yu hn cc
nhm mu khc.
3. c im lm sng
- giai on sm: 80% thng khng c triu chng, s cn li thng c triu
chng ca lot, nn bun nn, chn n, gim khu v, au bng, xut huyt d dy,
gim cn, nut kh.
- giai on tin trin: Du chng st cn l ni bt (60%), bun nn, nn, chn n,
cm gic nng tc sau n, au vng thng v, i khi c cn au lot, chn ru
v thuc l, c th c st. Chy mu nh v r r thng gp nht, vi biu hin
thiu mu nhc sc. Hp tm v thc qun gy kh nut i vi th ung th cao.
Hp mn v, tin mn v gy au bng, nn, mt nc.

162
-Khm Bng: C khi bnh thng hoc c khi s c khi u hoc mng ranh gii
khng r vng thng v. Ung th d dy c th lan n thanh mc dnh vo cc
c quan ln cn nh tu, i trng, hch, mc ni, di cn n phc mc, bung
trng (u Krukenberg), hch quanh rn (nt Sister Mary Joseph), di cn n hch
bch huyt vng v hch Virchow.(hch thng n), xng, phi, gan, tu, no.
- Khm tng qut: C th thy thiu mu, ph hoc vng da, c trng.
- Cc biu hin lm sng t gp: (Du chng cn u): Gim sn ty, nhng mng sc
t en da vng nch (Acanthosis nigricans), hi chng Trousseau, vim da c,
thiu mu huyt tn vi th, sng ha tuyn b, bnh thn mng.
4. Cn lm sng
4.1. V mu
- Tng Fibrinogen v cc protein khc ca phn ng vim.
-VS tng va.
-Thiu mu: gim hng cu.
-nh lng CEA (carcinogenic embryonary antigen): Tng, ch thy giai an
mun trong 1/2 trng hp, c ch trong vic theo di din tin sau phu thut ct b
d dy.
4.2. Dch v: Phn tch cho thy v toan do teo d dy trc hoc phi hp vi
ung th.
4.3. Ni soi v sinh thit: L mt tin b trong chn an ung th b mt, cho xc
nh v tr, tnh trng lan rng ca u, tnh trng chy mu.
4.4. Xt nghim t bo hc: bng chi t bo.
4.5. Siu m bng, siu m ni soi, Scanner bng: nh gi rng, su v pht
hin di cn ca ung th.
4.6. Xt nghim ty, chc d no ty, scanner s, sinh thit da: khi c gi di cn.
4.7. X quang: Vi k thut chp nhum Baryte thng thng cho ta hnh nh:
- Hnh nh khuyt vi gc nhn cm vo thnh d dy trong ung th si hoc lot
si
- Co rt v cng trong ung th tm nhun lan rng.
- Let hnh nm (hnh nh tam ti hay hnh li to) trong ung th th lot si.
- K thut i quang kp gip chn an tt cc thng tn nh nm st b, tng
ng vi 3 type ca gii phu bnh. (type 1: polypoide, type 2: lot nng, type 3: let
o hang).
5. Chn on
- Chn an cng sm th c may iu tr khi (giai on Tis), v thi gian sng
cng di. Pht hin da vo X quang v ni soi sinh thit hng lat. Nht, hin
nay pht hin sm ung th d dy n 90% trng hp so vi Hoa K l 40%. y
l giai on T1, T2 v thng t triu chng.
- Vo giai an mun, triu chng cng r v nng, c th di cn xa, iu tr rt hn
ch.

163
- Khi ni soi, cn phi sinh thit t nht 10 mnh. Trong th t, cn phi sinh thit
su. Trong thi k lm so khi iu tr, cn phi sinh thit 2 t.
6. Tin lng
- Ty thuc th m hc ca ung th, v tr ca u, s xm ln ti ch v di cn.
- Tin lng tt: Ung th d dy giai on sm (tn thng nim mc, di nim
mc)
- Ung th lai rut non c gii hn r hn nn tin lng tt hn lai ung th lan
ta, ung th vng tm v v phnh v ln do chn an chm nn tin lng xu hn
ung th phn thp ca d dy, di cn phc mc tin lng xu hn.
- Phn loi theo TNM cho php nh gi v tin lng sng, nhng cn da vo
ln ca u (T), tn thng hch (N) v s xut hin ca di cn (M).
T1: U cha vt qu nim mc, tng ng vi ung th b mt.
T2: U n lp c.
T3: U n thanh mc.
T4: U dnh vo c quan ln cn.
N0: Khng c hch.
N1: ch c hch gn d dy, phm vi quanh 3 cm.
N2: Hach vng b xm nhp nhng c th ct b c.
N3: di cn hch lan rng: Khng th ct b c.
M0: Cha c di cn tng
M1: c di cn
Bng 1: Bng tin lng theo hip hi nghin cu ung th d dayd Nht Bn
G/

TNM

Sng n 5 nm (%)

Tis N0M0(g/h lp mng nhy nim mc)

100

IA

T1N0M0 (xm nhp n/m, h n/m)

95

IB

T2N0M0 (xm nhp n lp c)

82

II

-T1N2M0 (xm nhp n/m, cn trong vch)

-T2N1M0(xm nhp n/m, cn trong vch

55

-T3N0M0 (lan khi vch)

IIIA

-T2N2M0 (xm nhp n c hoc lan vch)

-T3, N1-N2, M0 xm nhp n c hoc lan vch

30

IIIB

T4, N0-N1, M0(dnh chung quanh)

15

IV

-T4N2M0 (dnh chung quanh hoc)

-T1-T4, N0-N2, M1 di cn xa

TIN LNG CC GIAI ON LYMPHOMA D DY THEO ANN ARBOR.

-G/1:Ch d dy:T l tng i gp 26-28%
-G/2:C hch bng: 43-49%.

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-G/3:C hch trn c honh.
-G/4: tn thng lan to (giai on 3v 4 l 13-31%).

IV. CC LOI UNG TH D DY KHC

1. Lymphoma d dy tin pht
1.1. Dch t
Him gp hn lai adenocarcinoma, chim di 15% tan b ung th d dy v
khong 40% cc u lympho ng tiu ho. C khong 1/3 trng hp khng c
hch. Loi ny gia tng trong sut 20 nm qua.
U lympho d dy c th nguyn pht hoc th pht, gp mi la tui, nht l sau
50 tui. Nhim H. pylori dng nh lm gia tng nguy c pht trin lymphoma d
dy c bit l loi MALT (mucosa-associated lymphoide tissue). Hnh thi u lympho
d dy a dng, u sinh ra t cc t chc di nim mc lan vo bn trong thnh,
trn mt din rng hoc to thnh mt khi nguyn vn. nim mc c hnh nt,
nim mc dy ra, i khi b n mn, khi ln to ra u dng polype, hoc c khi lan
n t trng.
1.2. Triu chng
Gy st, au thng v, bun nn v nn, thiu mu, st, chy mu, t khi thng.
Lm sng s c khi u (1/3 trng hp)
1.3. Chn on
Phn bit vi Adenocarcinoma d dy i khi rt kh da vo ni soi v sinh thit
(i khi phi sinh thit su). X quang khng c hnh nh no l c hiu, nhng nu
phi hp thng tn dng polype v let trt trn cng mt bnh nhn th gi cho
chn an.
1.4. Di cn
Hch, gan, ty xng, lch, phc mc, tng trn c hanh.
1.5.Tin lng
Tt hn adenocarcinome, 40%- 60% bnh nhn sng c 5 nm.
Tin lng cc gioai on ca lymphoma d dy theo Ann Arbor.
-G/1:Ch d dy:T l tng i gp 26-28%
-G/2:C hch bng: 43-49%.
-G/3:C hch trn c honh.
-G/4: tn thng lan to (giai on 3v 4 l 13-31%).
2. Sarcome c trn
Chim 1%- 3% c tnh bt ngun t c. Tn thng thn d dy, gy lot v chy
mu. N him khi xm nhp vo cc tng ln cn v khng di cn hch nhng c
th lan n gan v phi.
3. U carcinoid d dy
Chim 0, 3% ung th d dy. y l loi u ni tit to ra cc cht c nhiu hot tnh
sinh hc nh serotonin, histamin, somatostatin v cc kinin nhng khng gy cc
triu chng phng mt, tiu chy v cc triu chng tim phi nh trong hi chng

165
carcinoid. Tn thng thng lp di nim mc nhng c th lot n lp c.
Tn thng nhiu ni km tng gastrin mu.
4. U trung m khc: c tnh bt ngun t m thn kinh
5. Sarcome mch mu Kaposi: Ch yu da, ni tng c bit d dy. Biu hin
di dng nt di nim mc, i khi let c mu sm, ng knh 1-2 cm.
Thng gp bnh nhn AIDS hoc bnh nhn ang iu tr bng liu php c ch
min dch.
6. U d dy th pht: Thng him, nguyn pht t mt melanome c tnh, ung th
v, phi, ty, tinh hon, tuyn mang tai. Hnh nh X quang ging vi lymphome hoc
u d dy th lan to. Chn an bng ni soi, sinh thit

V. IU TR
1. iu tr Carcinoma d dy
1.1. Phu thut
- Phu thut vn l ch nh hng u, pht hin sm, kt qu sau phu thut cng
cao (t l sng sau 5 nm l 37% Nht v 10-15%: Hoa k).
- Ct cch b khi u t nht 5 cm.
- Ct bn phn: Ung th b mt 1/3 di cha di cn hch th ct d dy bn
phn l .
- Ct ton phn: Ung th 1/3 gia v trn ct d dy ton phn tt hn ct bn phn
hoc ct cc trn, no b hch tan b.
- Ct lch phi hp khi ung th d dy b cong ln.
- U tm v: Ct phn cui thc qun v phn u d dy.
- t stent, ct bng tia laser km cm mu vi Nd:YAG (Argon v Neodymium:
Yttrium aluminum garner) qua ni soi trong trng hp u chy mu v qu giai on
phu thut.
1.2. iu tr ngai khoa tm thi: Khi phu thut bng thy c di cn xa.
1.3. iu tr khng phu thut
* Ho tr:
Ci thin c triu chng au, triu chng ton thn, lm chm ti pht t hch
hoc cc di cn, iu tr giai on ung th khng phu thut c v b sung cho
can thip phu thut.Thng dng a ho tr liu nhng cha thy tng thi gian
sng, c cho gan, tim v thn nn dng thn trng cho ngi gi.
PLF
*5-FU: 2600mg/m2 truyn tnh mch trong 24 gi, mi tun 1 ln trong thi gian 6
tun Chng ch nh: ph n c thai, bch cu < 2.500/mm
*Cisplatin: 50mg/m2/ truyn tnh mch trong 15 pht tun 1, 3, 5 v 8.
*Calcium folinate 500mg/m2 truyn tnh mch trong 30 pht mi tun 1 ln trong 6
tun.
FAMtx
*Methotrexate 1500mg/m2 truyn 30 pht ngh 60 pht trong ngy th nht.

166
*5-FU: 1500mg/m2 truyn trong 30pht, ngy th nht.
*Calcium folinate 15mg/m2 truyn trong 24gi sau khi truyn methotrexate trong
ngy u, t ngy th 2 tr i, truyn trong 6 gi.
* Doxorubicin: 30mg/m2 truyn trong 30pht, lp li ngy th 15 v 29.
Thuc c nhiu tc dng ph nh bun nn, st, i chy, vim thc qun, suy ty,
gim bch cu ht, nhim c c tim, rng tc, ni my ay.
* X tr
* Dng1 liu 28- 35Gy trc tip ti y khi u trong khi phu thut, hoc trn mt ct
trong khi phu thut.
* Dng liu 45-50Gy, 20-30 ln kt hp vi ho tr cho cc trng hp khng phu
thut c v c tin lng xu(di cn mng bng, xng, hch su), hoc cng
vi phu thut s lm gim au v chm s ti pht u v hn ch di cn.
Kt qu iu tr phu thut: Theo JRSGC
-Tut i: T1, T2, hch no vt xa vng tn thng, cha c di cn gan, phc mc.
T l sng sau 5 nm l 50%.
-Tng i: T1, T2, cha di cn, hch gn vng tn thng. T l sng sau 5 nm
l 25%.
-Khng iu tr tng i: T3, ln, rng, di cn gan, phc mc.T l sng sau nm
nm l 15%.
-Khng iu tr tut i: Khi u qu ln, u giai on T4N1, T4N2, c hn 4 hch
pht hin khi phu thut (2%).
1.4. Cc bin php h tr khc: Bi ph st, dng thuc gim au thng thng,
morphin v cc dn xut ca n.
2. iu tr Lymphoma d dy v cc loi ung th khc ca d dy
2.1. Lymphoma d dy.
-G/1: Ct bn phn hay ton phn km ho v x tr sau phu thut: 4 liu CHOP,
phi hp mt hay hai ln x tr 39, 6Gy. Thnh cng 80%. Nu l loi MALT
lymphoma th phi hp dit tn gc HP.
-G/ 2, 3, 4: Phu thut km ho tr liu, loi lan to sng khng qu 2 nm.
- Nu khng phu thut c: Ho v x tr: 4 liu CHOP phi hp x tr 25, 5Gy
na bng trn.
Theo di ti pht sau phu thut: Ni soi d dy trong vng 3 nm u, ch vng
bch huyt Waldeyer v y l v tr hay ti pht.
Kt qu iu tr: Sng > 5 nm l 50%
2.2. Sarcome c trn
- c tnh bt ngun t c. Tn thng thn d dy, gy lot v chy mu. N him
khi xm nhp vo cc tng ln cn v khng di cn hch nhng c th lan n gan
v phi.
- iu tr phu thut kt hp ho tr liu cho trng hp c di cn
2.3. U carcinoid d dy

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- y l loi u ni tit to ra cc cht c nhiu hot tnh sinh hc. Tn thng
thng lp di nim mc nhng c th lot n lp c. Tn thng nhiu ni
km tng gastrin mu.
- iu tr bng phu thut, ho tr km Octreotide c th ci thin triu chng nhiu
bnh nhn.
2.4. U trung m khc
- c tnh bt ngun t m thn kinh.
- iu tr ch yu bng phu thut.
2.5. Sarcome mch mu Kaposi
- Ch yu da, ni tng c bit d dy.
- Thng gp bnh nhn AIDS hoc bnh nhn iu tr bng liu php c ch
min dch.
- iu tr bng phu thut, tin lng rt xu.
2.6. U d dy th pht
iu tr bng ha tr, tin lng xu.

BNH AMIP GAN

Mc tiu
1. Gip sinh vin chn on c bnh abcs gan
2. Nm c cc pht iu tr p xe gan theotng loi nguyn nhn.
3. Nm c hm lng, liu lng, c ch tc dng v tc dng ph ca cc
thuc x dng trong iu tr p xe gan.
Ni dung

I CNG
L tnh trng vim, nhim trng v nung m xy ra gan. Nguyn nhn ch yu l
do Amip v vi trng sinh m. V c ch bnh sinh v ng xm nhp cng nh v
tr ca abcs ngi ta chia lm hai loi: Abcs nhu m v abcs mt qun.ng
xm nhp ca tc nhn gy bnh thng qua 1 trong 5 c ch sau:
- Qua ng tnh mch ca.
- Qua ng nhim trng huyt.
- Nhim trng ng mt ngc dng.
- ng tip cn
- Do chn thng

ABCS GAN AMIP

I.I CNG
L loi nguyn sinh vt (protozeaire) thuc h Entamoeba. ngi c 4 loi:
Entamoeba, Endolima, Pseudolima v Dientamoeba. Ch c loi E.histolytica cn gi

168
l E. hot ng l gy bnh. Th E.minuta sng cng sinh khng gy bnh trong i
trng v dng kn gy ly lan bnh.
Tn sut nhim amip

II. NG XM NHP V BNH SINH

Kn Amip theo phn ra ngoi, c th tn ti 10-15 ngy. Kn khng b tiu hy bi
thuc tm v clor, trong formol 0, 5% sau 30 pht kn mi cht.
S xm nhp lin quan n kh nng thc bo ca chng, sn sinh ra men
collagnase v mt protein gy c t bo.
Thng tn mch mu gip amip theo tnh mch vo tun hon ca hoc bch
mch n gan. Him khi vo tun hon chung to thnh abcs phi, no, lch do
amip.

III. TRIU CHNG LM SNG

Bnh cnh lm sng gi khi tin s c amip rut nht l ang hoc mi xy ra mt
vi tun.
Giai on u (mt vi ngy u) l vim gan amip (Amebia hepatitis)
Giai on abcs gan: Thng xy ra kh t ngt vi st cao, c th km rt run 39400 C, v mt nhim trng, c th km bun nn hoc nn, au nhiu h sn phi.
au gia tng khi th su, ho, nhng thng khng c hi chng tc mt, khm thy
gan ln nht l gan phi. Gan thng mm hoc cng,
Cc th khng in hnh
Th vi cn au bng cp
Th thiu mu suy kit
Th gi u
Th bin chng

IV.XT NGHIM
1.Cc xt nghim khng c hiu
- CTM.
- VS.
- Men Transaminase.
- Bilirubine mu.
2.Xt nghim phn tm amibe
3.Xt nghim huyt thanh tm ch im amibe
4.Cc phng php ghi hnh
- Siu m gan
- Chp ct lp t trng.
- Chp cng hng.
- Chp phim
- Chiu

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- Chc ht m
- Chp nhp nhy gan vi technitium 99
- Xt nghim amibe trc tip

V.CHN ON
Da vo tin s v bnh s l amibe. Chn on gi khi c tam chng Fontan:
St, gan ln v au.
Chn on t ra khi trn siu m hoc CT cho hnh nh Abcs.
Da vo ch im amibe bng huyt thanh hc:

VI.CHN ON PHN BIT

1.Phn bit abcs gan amibe v abcs mt qun
2.Ung th gan
3.Vim ti mt cp

VII. IU TR
iu tr abces gan amip l mt iu tr ni ngoi khoa hoc kt hp vi th thut
thut chc ht c hng dn siu m hoc CT scanner. Kt qu iu tr ph thuc
vo nhiu yu t nh: tnh trng chung ca bnh nhn, giai on pht trin v chn
on bnh, tnh trng tn thng gan giai on vim, abces giai on sm, kch
thc cn nh (<6 cm), cha ha m ht, s lng, kch thc v v tr ca cc
abces.
1. iu tr ni khoa
1.1 Bin php chung: ngh ngi, n ung cung cp nng lng v cht dinh
dng, gim au v h st nu cn. nh paracetamol 500mg x 3 vin/ngy hoc
Efferalgan (paracetamol+codein) 530mg x 3vin/ngy, Diantalvic (paracetamol+
dextroprofan 530mg x 3 vin/ngy.
1.2 Thuc
+ mtin: l thuc dit amip t chc (amip hot ng) c s dng rt lu c
c tnh khuych tn m rt tt, chit xut t cy Ipca. Thuc c c tnh tp trung
cao gan, phi, lch, thn, thi tr chm qua thn vn cn trong nc tiu 1-2
thng sau iu tr. C ch tc dng l chn s tng hp protein mt cch khng hi
phc do s c ch di chuyn ca Ribosome trn ARN thng tin.
Tc dng ph: bun nn, i chy, au c nhng tc dng ph quan trng nht l tim
mch gy vim c tim nhim c do gy ph v hoi t si c tim, gy suy tim, lon
nhp tim nguy him. Cc triu chng nhim c trn tim l nhp tim nhamh, lon nhp,
au vng trc tim, v suy tim cp; do trnh dng cho bnh nhn c bnh tim
mch, cn kim tra in tim trc, trong v sau khi iu tr. Bt thng in tim trong
trng c emetin l: nhp tim nhanh, P-R ko di, QT di, QRS dn rng, T o
ngc. C hai loi:
- metin Chlohyarate: ng 30, 60, 40 mg. Liu 1 mg/kg dng 7- 10 ngy. Liu trnh
th hai phi sau phi cch liu trnh u 4 tun. p ng tt gim st sau 2- 3 ngy
- Dhydrometine l loi tng hp c c tnh thp hn mtine. Liu 1, 5 mg/kg
dng 10- 15 ngy. Liu trnh th hai phi sau liu trnh u 3 tun.

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+ Nhm Nitro- imidazole thng: l Mtronidazole (Flagyl, Klion) cng dit amip m,
cn dit amip lng rut, c ch tc dng l do kh ferrodoxin, cht kh ny phn
ng vi cc phn t ln ca vi khun dit chng. Thuc hp thu qua rut nhanh
80% sau 1 gi, thi gian bn hy sau 8 gi. Nng cao trong mu sau 5-7 gi.
Tc dng phu: l nhc u, nn ma, chn n kh ming, c v kim kh, mt, chng
mt. cc sc vt th nghim c th gy d bin gen nn khng dng cho ph n
mang thai. Liu 25 -30 mg/kg trong 10 - 15 ngy. Thuc c trnh by di dng
vin 0, 25mg x 4-6v/ngy hoc l 0, 5g trong 100ml, liu 1g/ ngy; chuyn tnh mch
chia 2 ln trong vng 1 gi.
+ Cc imidazole khc: Tinidazole, Nimorazole, Secnidazole (Flagentyl) v
Ornidazole. Cc thuc ny c thi gian bn hy ko di nn ch cn dng ngy 2 ln,
5-7 ngy. Trong cc loi ny, ch c Tinidazloe (Fasigyne) dit amip tt, cn cc loi
khc km hn mtronidazole trong iu tr amip. Vin 0, 5 g liu 3 vin/ngy, ung
trong 5 ngy.
- Chloroquin c nng cao trong phi gp 200 ln/huyt thanh v trong gan 400
ln/huyt thanh. c ch tng hp DNA v ARN, lm chm s nhn i v sao chp
ca ARN. C th dng ngn nga abces gan amip khi amip rut hot ng, hoc
phi hp vi metine v Mtronidazole trong iu tr abces v c th dng lu di.
Liu lng dng l 1 g trong 2 ngy u v 0, 5 g trong 3- 4 tun.
- Cc khng sinh:
+ Paromomycine (Humatin) thuc nhm Amino glycoside. Liu 25-30 mg/kg trng
lng, dng 5-10 ngy.
+ Nhm Cyclines: Tetracycline vin 0, 25g x 4-6 vin/ngy ; Doxycyclines, vin
100mg x 2in/ngy x 2 tun.
+ Erythromycine, vin 0, 25g hoc 0, 5g ; liu dng 1, 5g/ngy x 2 tun.
Cc khng sinh ny tc dng yu trn amip nn ch dng phi hp.
- Cc thuc dit amip lng rut:
Diloxanide furoat l dn xut ca dichloroacetanide, c ch tc dng cha c bit
r rng. Liu 500 mg x 2 ln/ngy x 10 ngy.
Lodoquinol (Direxiode, Enterovioform). Liu 650 mg x 2 ln/ngy x 3 tun.
2. Th thut: Chc m di s hng dn ca siu m, nh siu m v CT scanner
c th pht hin cc abces cn nh hoc sau khi iu tr bng thuc abces lng
ha hon tan v khng dn sch. Xc nh v tr abces sau chc ht di s
hng dn ca siu m hoc CT scanner, ra sch m sau c th bm trc tip
thuc dit amip vo abces nh dhydroemetin, Flagentyl. V ht lp li nu kim
tra cn m, kt qa rt tt gim au v st rt nhanh rt ngn thi gian iu tr.
3. Phu thut: nay gim dn ch c p dng cho nhng abces qu ln, p xe st
bao gan do v, p xe gan v hoc nm v tr khng chc ht c.

VIM NHU M GAN DO VI TRNG

I.GII PHU BNH
L s nhim trng nhu m gan v s tm nhun cc t bo a nhn trung tnh v
cc i thc bo cui cng do hoi t v t m.Abcs gan nhu m do vi trng c th

171
n c hoc nhiu . y l bnh t gp ch yu nhng ngi gi trn 60 - 70
tui.

II.NGUYN NHN VNG XM NHP VI TRNG

- Qua ng tnh mch ca v bch.
- Qua th nhim trng huyt.
- Vi trng n trc tip do cc vt thng h.
- Cc chn thng bm dp, bi nhim v abcs ha.

III.TRIU CHNG LM SNG

Thng c triu chng lm sng ca nhim trng hoc bnh l nhim trng tin
pht.

IV.XT NGHIM
1.Cc xt nghim khng c hiu
BC tng a nhn trung tnh tng, thiu mu, VS tng cao, Phosphatase kim tng,
cy mu c th xc nh c nguyn nhn.
2.Ghi hnh: Siu m v CT rt c gi tr chn on abcs.
3.Cy m

V.IU TR
Ch yu bng khng sinh thch hp nht l khi xc nh c vi trng, kt hp
chc ht m hoc phu thut. Khi cha c kt qu vi trng, cn phi hp vi
Cephalosporin th h III vi Aminoglycosides v Mtronidazole. Cc khng sinh, liu
lng v cch x dng nh trong iu tr p xe gan mt qun.

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VIM GAN MT QUN

I.I CNG
y l bnh cnh kh ph bin ng hng th hai sau abcs gan amibe. Si
v giun chui ng mt l hai nguyn nhn v yu t lm d thng gp nht.

II.NG XM NHP VI TRNG V C CH BNH SINH

Trong iu kin bnh thng, c vng Oddi hot ng tt, trong ng mt khng c
vi trng hoc s lng rt t khng gy bnh. Trong trng hp c si ng mt
gy tc nghn, tr v tng p lc dch mt to iu kin thun li cho vi trng i
ngc dng. Trong giun chui ng mt, ngoi c ch c hc nh si giun cn trc
tip mang vi khun t ng rut v c th c k sinh trng vo ng. Ngoi ra
cn c cc bnh l khc nh ung th ng mt, u u ty, bnh l c vng Oddi.
Vim x cht hp c vng Oddi hoc cc bnh l him gp hn nh lot d dy t
trng thng vo ng mt, ung th i trng, ung th d dy hoc cc th thut
soi, chp ng mt ngc dng c th gy vim nhim ng mt. Do phn
ln cc nhim trng l do E. Colie, v cc loi Gram m ng mt v k kh
Bacteroide v Clostridium

III.GII PHU BNH

1.i th
Gan thng to c hai thy hoc u th gan tri, c th gy hin thng mt.
Ngoi ra c th c x ng mt hoc x gan mt, vim ti mt mn
2.Vi th
Cc vim hoi t vi s hin din ca t bo a nhn trung tnh, thc bo thoi
ha, mt, nghn mt nhim trng. ng mt b gin, c th c hnh nh xc v
trng giun trong abcs v trong ng mt hoc x gan mt.

IV.TRIU CHNG
1.Lm sng
- Khi pht
- Ton pht
2.Cn lm sng
CTM Bch cu tng c th ln n 20000 a nhn trung tnh tng.
Bilirubine mu tng nht l bilirubine trc tip, Phosphatase kim tng.
(GT v men ALAT, ASAT c th tng.
Xt nghim ghi hnh
Siu m ni soi cho kt qu tt on cui ng mt ch, bng Vater, c vng Oddi.

V.CHN ON
Cn t ra nhng bnh nhn c tin s si, giun ng mt. Lm sng c du
hiu tt mt nng, gan ln au nhiu ch rung gan rt au. p ng km hoc
khng p ng vi iu tr. Chn on xc nh cn da vo siu m, chp ct lp
t trng.

VI.BIN CHNG V TIN LNG

173
1.Ni khoa
Nhim trng huyt v chong nhim trng Gram m.
Hi chng gan thn.
Trn dch mng phi v mng tim.
Vim ty cp, c th l mt bnh cnh i km.
X gan mt.
2.Ngoi khoa
abcs v vo bng gy vim phc mc.
Thm mt vo mng bng gy vim phc mc mt.
Chy mu ng mt

VII. IU TR
y l bnh cnh nng ngoi nhim trng cn km nhim c v bin chng ngoi
khoa, do cn t trong bi cnh iu tr ni ngoi khoa v hi sc cp cu.
1. iu tr ni khoa
- Bin php chung: cung cp y dinh dng, nng lng v cn bng
nc in gii.
- Khng sinh: cn hng n cc vi trng Gr (-) ng rut k kh, v y l
bnh cnh abces thng km theo tc nghn ng mt nn dng khng sinh ph
rng nng cao trong ng mt, thng dng bng ng tim v di ngy
thng >2 tun l. Tt nht l da vo vi trng, khng sinh v kt hp khng
sinh. Cc khng sinh thng dng l:
- Pnicilline 4 - 6 triu n v/ngy
- Ampiciline 2 - 3 g/ngy
- Cc Cephalosporin th h III: Cfotaxime (Claforan) 3 g/ngy, Ceftriaxone
(Rocphin) 2 g/ng.
- Cc dn cht: Carbenicilline thng nhy cm vi trc khun m xanh v
protus (liu 200 mg/kg/ng), Ureidopenicilline nh: Azlocilline, Piperacilline liu
3g/ng. Tc dng tt vi trc khun m xanh, Proteus hemophilus, Enterocoque.
- Cc Moxalactam, Carbapenem, Monobactam.
- Nhm Aminoglycoside: thng dng Gentamycine liu 3-5 mg/kg trng
lng/ngy, hoc cc khng sinh khc: Amikacin liu 15 mg/kg/ngy; Netilmicine liu
5-7 mg/kg/ngy.
Ch : nhm Aminoglycosides c th gy c tai trong v thn.
- Nhm Quinolone: Ofloxacine (Oflocet) liu 400 mg/ngy; Ciprofloxacine liu
15 - 20 mg/kg/ngy.
- Nhm Mtronidazole: nht l ng tim truyn, thng dng trong trng
hp nhim trng k kh Bacteroide liu 1, 5 g/ngy.
- Gim au v chng co tht ng mt dc dng trong trng hp c si
co tht ng mt vi Spasmaverine 40 mg x 3 vin/ngy. Buscopan ng 10 mg x 2-

174
3 ng/ngy; Spasfon (Phloroglucinol) ng 80 mg x 2 -3 ng/ngy; hoc gim au
thuc nhm Noramidopyrine: Visceralgin ng 500 mg x 1-2 ng/ngy. C th gy
gim bch cu ht. Visceralgine forte: phi hp Noramdopyrine (500 mg) +
Tinmonium (25 mg) l mt thuc chng co tht c trn, tim bp su hoc tim tnh
mch chm trnh tt huyt p.
- Chng chong do nhim trng Gram m nu c. Ngoi dng khng sinh tch
cc cn chuyn dch y v dng cc thuc vn mch nng huyt p nh
Dopamine, Dobutamine (Dobutrex). Chuyn bng bm in vi liu 5-10 g/kg/pht.
2. iu tr ngoi khoa
Kh thc hin v bnh nhn au trong tnh trng nhim trng nng c th c chong,
hn na y c nhiu abces kch thc nh c th nm su kh c th pht
hin hoc loi b. Phu thut cn nhm loi b cc tc nghn c hc nh giun
hoc si.
Th thut qua ni soi: bng ni soi v chp ng mt ngc dng gip xc nh
chn on. Ngoi ra cn c s dng ly giun, si, x c vng i gip gii ta
tc nghn c hc.

175

VIM TY CP
Mc tiu
1. Nm c cc triu chng lm sng v cn lm sng ca Vim ty cp
2. Chn on c cc th v bin chng vim ty cp
3. Trnh by c cc phc iu tr vim tu cp theo th bnh v nguyn nhn.
Ni dung

I. M U
Vim ty cp (VTC) l mt bnh l cp tnh ca tuyn ty, c th thay i t
vim ty ph n cho n hoi t ty trong mc hoi t lin quan n trm
trng ca bnh. Thut ng VTC xut huyt t c ngha trn lm sng bi v mt
lng xut huyt k t nhiu c th thy trong VTC cng nh trong cc ri lon khc
nh chn thng ty hay u ty v cng nh trong suy tim sung huyt nng.

II. BNH NGUYN

-

Si

Do ru gy VTC v vim ty mn

Sau phu thut bng sau ni soi v chp ng mt ty ngc dng.

Chn thng vng bng.

Bin dng

Nhim trng: quai b, vim gan siu vi, giun a

Do thuc

lot d dy t trng thng dnh vo ty

Ti tha t trng

ng ty chia i

III. C CH BNH SINH

1 Thuyt tc nghn v tro ngc
Do si giun u lm khi pht VTC. S tc nghn ny thng km theo s tro
ngc dch ty c hot ha c th km theo dch mt l nhng yu t gy hot
ha men ty.
2 Thay i tnh thm ca ng ty
Bnh thng nim mc ng ty khng thm qua cc phn t > 3000Da s gia tng
tnh thm xy ra khi c acide acetyl salicilic, histamin, Calcium v Prostaglandin E2.
Khi hng ro biu m c th thm qua cc phn t t 20.000 - 25.000 Da. iu
ny cho php thot cc phospholipase A, Trypsin v elastase vo m k ty gy
ra VTC.
3 Thuyt t tiu
Thuyt ny cho rng cc men nh trypsinogen, Chymotrypsinogen, prolastase v
phospholipase A2 c hot ha ngay trong ty gy ra VTC.
4 Thuyt oxy ha qu mc

176
Theo thuyt ny vim ty cp c khi pht l do s sn xut qu mc cc gc
oxy ha t do v cc peroxyde c hot ha do s cm ng men ca h thng
microsom P450.

IV. LM SNG
1 au
au thng khi pht t ngt vi cn au bng cp au c th thy i t nh n
rt nng, au thng xuyn v c cn tri hn ln trong VTC do giun khi u l
au cn kiu giun chui ng mt
2 Nn
Nn cng l triu chng thng gp (70-80%)
3 Bng chng
Do lit d dy v rut cng thng gp
4 Hi chng nhim trng
Trong trng hp do giun v si, c th xy ra ngy u hay ngy th hai cn trong
VTC do ru nhim trng thng n mun sau 5-7 ngy do bi nhim. Trong th
nng xut huyt hoi t cc triu chng ton thn nng n vi hi chng nhim
trng nhim c bng chng v au lan rng au lan rng c th c du bng
ngoi khoa. Ngoi ra cn c du xut huyt ni hay cc mng bm tm quanh rn
hay vng hng (du Cullen v Turner)
5 Vng da: c th l do nguyn nhn ca giun hay si hay trong trng hp u ty
b vim hay ph n chn p ln ng dn mt.

V.XT NGHIM
1 Amylase mu
Thng tng 4 n 12h sau khi au trong VTC th ph Amylase thng gim
sau 3-4 ngay, trong VTC phi tng trn 3 ln bnh thng.
2. Amylase niu
Amylase c hp thu v thi tr qua ng tiu, do thng tng chm
hn sau 2-3ngy thng cao nht vo ngy th 4-5 v ko di 5-7 ngy.
T s Amylase niu/Amylase mu l 1, 7 n 2.
3. Lipase mu
Thng tng song song vi Amylase mu c hiu hn. Ko di hn nhng nh
lng phc tp v mt nhiu thi gian nn thc t t p dng. Bnh thng lipase
mu 250v/L.
4. ng mu
Lc u do s phng thch Glucagon nn c th lm tng ng mu hay do hoi t
o langerhans ng mu c th ln hn 11 mmol/l.
5. Calci mu
C gim trong VTC nng thng xut hin ngy th 2-3 v ko di mt vi tun
calcimu< 2mmol/l l tin lng nng.
6. LDH

177
Tng trong VTC hoi t khi LDH >350Ul/l th c nghi l tin lng nng.
7. PO2
Thng 60mmHg xy ra 25% trng hp vim ty hoi t nht l trong trng hp
c hi chng suy sp h hp ngi ln.
8. Cng thc mu
Bch cu trung tnh cao, nht l VTC do giun v si, khi bch cu >16000/mm3 l
yu t nng.
9 Siu m ty
Ty ln cu trc ngho hn bnh thng siu m cn gip pht hin dch trong
bng, giun si hay cc bin chng ca n nh p-xe v nang gi ty.
10 Chp ct lp t trng (CT Scanner): c 5 giai on A, B, C, D, E. C ngha tin
lng.
11 X quang
Thng t gi tr trong chn on VTC trong trng hp lit rut nhiu c th c
hnh nh quai rut gc.

VI.CHN ON
1 Chn on xc nh
Cn ngh n vim ty khi bnh nhn c cn au bng cp vng thng v v h
sn tri km nn ma nhiu ton thn c hi chng nhim trng, bng chng
nhiu khm cc im au ty r phi hp vi amylase mu hay niu > 3ln bnh
thng hay h s thanh lc >5. Siu m hay chp ct lp t trng c hnh nh VTC.
2 Chn on gin bit
2.1 Thng tng rng
c bit l thng lot d dy t trng cn da vo tin s lot vi cn au kiu
dao m khm c du bng ngoi khoa v mt vng c trc gan, chp phim bng
khng chun b c lim hi di c honh. y amylase mu khng cao ch tng
2-3 ln bnh thng.
2.2 Vim ng mt ti mt cp
Cn da vo tin s si ng mt, cn au qun gan khm thy cc triu chng
v gan mt vi gan ln, ti mt ln v au vng da vng mt siu m gip pht hin
ti mt ln thnh dy.
2.3 Tc rut, lng rut cp.
2.4 Nhi mu c tim
Thng gp ngi gi c tin s cn au tht ngc khm cc im ty khng au.
Gin bit da vo amylase mu v in tm v cc men CPK, CPK-MB v
Troponin mu gia tng.

VII.BIN CHNG
1.Ti ch
-p xe ty: nhim trng nng, st cao 39-40 0 C ko di trn 1 tun vng ty rt au
khm c mng g ln rt au xc nh bng siu m hay chp ct lp t trng.

178
-Nang gi ty: vo tun th 2-3, khm vng ty c khi n cng v tc, amylase cn
cao 2-3 ln siu n c khi echo trng, chp ct lp t trng c du hiu tng t.
-Bng do thng hay v ng ty hay nang gi ty vo bng trong trng hp VTC
xut huyt do hoi t mch mu lm xut huyt trong bng.
2 Ton thn
-Phi: c trn dch nht l y phi tri, xp phi hay vim y phi tri bin chng
nng n nht l hi chng suy h hp ngi ln.
-Tim mch: gim HA hay sc m nguyn nhn do phi hp nhiu yu t nhim trng
nhim c, xut huyt v thot dch.
-Mu: c th gy ra hi chng ng mu ni mach (CIVD) nh trong trng hp
vim rut xut huyt hoi t.
-Tiu ha: vim lot d dy t trng cp, nh l mt bin chng Stress do au hay
nhim trng, nhim c v thng biu hin di dng xut huyt. Thuyn tc tnh
mch ca.
-Thn: thiu hay v niu do suy thn chc nng do gim th tch tun hon, hoi t
thn v thng thn v mt bin chng t gp, do vim lan t ty. Vim tt tnh mch
v ng mch thn l bin chng nm trong bnh cnh chung ca vim tt mch.
-Bin chng chuyn ha: tng ng mu hay h calci mu

VIII. IU TR
iu tr vim tu cp mang tnh cht ca mt iu tr cp cu ni ngoi khoa kt hp
vi hi sc cp cu; ngoi bin php iu tr chung trong vim ty cp cn ch n
iu tr theo nguyn nhn v iu tr bin chng nh trong vim tu cp do giun cn
x dng ngay thuc lit giun v khng sinh, trong vim tu cp do si cn kt hp
iu tr loi tr si.
1. iu tr vim tu cp th thng
1.1. Nguyn tc iu tr: phn ln vim ty cp l th ph (85-90%) iu tr ch yu
bng phng php ni khoa v bnh s thoi trin sau 5-7 ngy. Cc bin php
thng thng l:
- Gip ty ngh ngi lm gim au v gim tit bng nhn, ht dch v.
- B nc v in gii: trong vim ty cp do bnh nhn khng n ung c, st,
nn ma, v hin tng thot dch, nn bnh nhn thng thiu nc.Trong trng
hp nng do hin tng tit dch vim v tng tnh thm thnh mch nn cn chuyn
dch keo hoc c trng lng phn t cao.
- Nui dng bng ng ngoi ming cho n khi cc triu chng au gim nhiu
mi bt u cho n dn, bt u l nc ng, ri h ng ri cho gim s
tit dch ty.
- Cc thuc c ch choline t hiu qu trong vic c ch tit dch ty m cn gy
chng bng v che lp du bng ngoi khoa.
- Cc thuc gim au tht s ch dng khi bin php nhn v ht dch khng lm
gim au, nhng khng dng morphin v c nguy c lm co tht c oddi, c th dng
dolargan hoc Viscralgin.

179
- Khng sinh: trong vim ty cp do ru ch c dng chng bi nhim nn
thng c dng chm. Tri li trong vim ty cp do giun, nhim trng rt sm,
nn cn x dng khng sinh ngay t u thng l khng sinh gram (-) bng ng
tim nh: Ampicillin, Gentamycin. Trong trng hp nhim trng nng cn phi hp
cphalosporin th h 3 v quinolon th h 2; nu nhim trng nng v ko di, cn
x dng khng sinh chng k kh nh nhm Imidazole, Beta Lactamin hoc nhm
Macrolide chng k kh (Clindamycine, Dalacine).
- Trong vim ty cp do giun a chui vo ng mt ty nht l giai on sm khi
giun cn sng v mi chui mt phn vo ng mt ty, th vic x dng thuc lit
giun c tc dng nhanh t ra rt c hiu qu; y c xem l iu tr nguyn nhn
gip lm gim au v lm lui bnh rt nhanh.
- Trong vim ty cp do si: hin nay c th x dng phng php ni soi v chp
ng mt ngc dng gip chn on, ng thi x c vng oddi v ko hoc tn
si.
- Trong vim ty cp xut huyt hoi t: thng km chong do cn iu tr tch
cc bng b dch v in gii. Nu albumin mu gim nhiu <60g/l cn chuyn dung
dch c p lc keo nh albumin, plasmagen hoc dung dch c trng lng phn t
cao nh Rhodex; nu c xut huyt (HCgim >1 triu hoc Hct gim >10%) th cn
chuyn mu. Ngoi ra cn dng cc thuc vn mch nh dopamin hoc Dobutamin
(Dobutrex).
1.2. p dng thc t
- Nhn i: thng l 2-3 ngy cho n khi gim au nhiu th bt u cho n dn
tng t mt bng nc ng sau chuyn dn sang n cho, lc u l cho
ng lng sau c dn, cn theo di du au bng.
- Ht dch v: Bng t sonde d dy ht dch v lin tc c th lu sonde.
- Chuyn dch: thng thng 2-3 lt/ngy bng ringer lactate hoc bng Clorua natri
v glucose ng trng.
Trong trng hp vim ty cp do giun th cn cho thuc lit giun sm bng
lvamisole, vin 50mg hoc 150mg, liu 150mg ung hoc nghin nh bm qua
sonde; palmoat de pyrantel, vin 125mg liu 10mg/kg, Mbendazole vin 200mg,
liu 600mg hoc albendazole vin 200ng hoc 400mg liu 400mg. ng thi x
dng khng sinh sm nh ampicilline tim bp liu 2g/ng v hay l gentamycine, liu
3-5mg/kg/ngy.
2. iu tr vim tu cp th xut tit
Cn tch cc ht d dy v b nc v in gii y , thng thi gian ht dch
d dy ko di 5-7 ngy khi rt sonde phi theo di k tnh trng au thng v,
lng dch b cao hn v y tnh trng mt nc, in gii v prrotein thng
cao hn do st, nn ma nhiu lit rut nng hn v nht l dch xut tit nhiu
trong bng, thng dch b hng ngy c th ln n 3-4 lt ch cho thm dch c
trong lng phn t cao hoc albumin; ng thi tng cng khng sinh ch yu l
phi hp gentamycine liu nh trn kt hp vi cphalosporine th h 3 nh
Cefotaxime, ceftriazole hoc cefuroxime liu 3g/ng hoc quinolone th h 2 nh
ofloxacine 400mg/ngy, ciprofloxacine liu 1000mg/ ngy chuyn tnh mch hoc
khng sinh chng k kh nh Metronidazole liu 1.000mg/ngy chuyn tnh mch
trong vng 1 gi.

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3. iu tr vim tu cp nng
Vim tu cp nng l thut ng m t th vim ty cp xut huyt hoi t. Tuy
nhin ngoi yu t xut huyt hoi t, cn c vn xut tit qu nhiu dch trong
bng qua c ch dng dch vim hin nay (coule inflamatoire), cng nh hin
tng nhim trng nhim c gy p x ha ty cng l yu t gy vim ty cp
nng. y l mt bnh cnh cp cu ni ngoi khoa rt nng, t l t vong c th
n 80%.
3.1. iu tri ni khoa
Trc tin l phi t bnh nhn trong 1 n v hi sc cp cu ni-ngoi khoa. t
1 cathter Swan ganz ln c th gip tip dch sau ny.
* Nui dng bnh nhn: iu quan trng l phi cung cp y cht dinh dng
v giu nng lng. Bt lun din tin ca vim ty cp nng nh th no cng cn
cung cp nng lng ti u vi 60 calo/Kg trng lng, trung bnh 3.000- 3.500
calo/ng ch yu l glucide v lipide. Ban u l cho n bng ng t catther di
n. Ngay khi gim au nhiu v Khng c triu chng tt rut th chuyn qua n
bng ng tiu ha bng cch t sonde d dy mi c 2 nng: nng ngn t
trc mn v, nng di t 30 - 40 cm trong on u ca hng trng.
* iu chnh nc in gii v thng bng Kim toan: bng cch chuyn cc dung
dch ng, mui (in gii) v albumin. iu quan trng l phi duy tr huyt ng
mc bnh thng, ha long ca mu thch hp gip trao i qua mao mch
d dng trnh tt mch do nhn mu tng.
Lng dch chuyn cn da vo mch huyt p, Hct, in gii v nht l p lc
tnh mch trung tm. Thng thng l 3 - 4 lt/ng, trong mt s trng hp nng c
th chuyn n 10 L trong 48 gi u.
Tt nht l chuyn Ringer lactate. Nu Khng c th chuyn 1/2 ng v 1/2 mui
ng trng. C 1 lt dch cho 1 n v albumin huyt thanh ngi (12, 5 g).
Nu hng cu gim >1 triu hoc Hct gim >10% cn chuyn mu ti hoc hng
cu Khi.
* iu tr suy thn: trong giai on u thng l suy thn chc nng, v sau l thc
th do tn thng ng thn. Ngn nga ngay t u bng cch iu chnh tt huyt
ng. Trong trng hp suy thn cp cn s dng Manitol 20% chuyn nhanh hoc
lasix lm test bi niu, c lc cn dng Lasix liu cao 0, 5 - 1g/ 24 gi. Nu tht
bi cn chy thn nhn to, nhng trong nhng trng hp ny tin lng thng
rt nng.
* Ht d dy lin tc: y l mt bin php rt hu hiu gp gim tit dch v, dch
ty, gim chng hi d dy; gip ty c ngh ngi cho nn c tc dng lm gim
au rt tt. y cng l mt phng tin gip theo di chy mu d dy.
* iu tr trn dch mng phi v suy h hp cp: Nu trn dch mng phi nhiu cn
choc dn lu. Suy h hp cp cn h tr bng th my, iu chnh di s theo di
kh mu.
* Chng chong: nu cc bin php tch cc trn thc hin y nhng tnh
trng chong vn xy ra th cn s dng n cc thuc vn mch v nng huyt p
nh: Dopamin ng 200mg c th cho liu trung bnh 10g/Kg/ ph. Dobutamin c
nhiu u im hn dopamin liu 5g/kg/ph. Adrnalin v thm ch c Noradrnalin.

181
* Thuc gim au: Ch s dng khi ht d dy khng lm gim au, c lc au qu
lm bnh nhn khng chu ni c th gy chong do au; v vy cn chng au cho
bnh nhn bng Dolargan 100mg, 2-3 ng/ng hoc Meperidin 100mg tim bp
iu ch l khng dng Morphin v c th gy co tht c vng Oddi. C th dng
xylocaine 2%, liu 0, 5- 1 g ha trong 500ml dung dch glucose chuyn tnh mch
hoc phong b quanh ty.
* Cc thuc c ch men tu: thc t cho thy cc thuc c ch men ty nh
Traxylol, Zymogen hoc cht c ch yu t Kunitz (Inhibiteur de Kunitz) u khng
c hiu qu. Thuc c ch protease nh apotinin, Gabexate ch c hiu qu khi
dng rt sm nht l d phng. Hin nay ngi ta s dng Somatostatine nh
Sandostatine, Octriotide liu 200-400g/ng tim di da hoc bm mch v sau
chuyn mch bng bm in, t ra c hiu qu trong vic c ch tit men ty
nhng cn cho sm.
* Thuc khng ng: v mt l thuyt c v hp l trong bi cnh vim nhim qu
nng n c nguy c gy ra hi chng C.I.V.D. Nhng trong thc t trong nhng
trng hp ny xut huyt ty nn khng x dng c thuc khng ng.
* Thuc c ch gc oxyde t do: Theo c ch hin nay trong vim ty cp v vai tr
ca cc gc Oxy ha t do v cc Peroxydes. H. Sanfey s dng Superoxide
dimutase c ch cc cht gc ny nhng cho n nay cho thy cha c hiu qu
my trn lm sng.
* Khng sinh
Vim ty cp do giun v si thng xy ra v rt sm, ch yu l Gr (-) ng rut
nht l E. Coli nn cn cho ngay khng sinh t u. Trong vim ty cp nng cn
phi hp Aminoglucozide nh Gentamycine 160mg/ng vi cphalosporine th h 3
nh cefotaxime 3g/ng, hoc ceftriazone 2g/ng. Hoc phi hp gia cephalosporine
th h 3 vi quinolone nh ciprofloxacine 1g/ng, hoc ofloxacine 400mg/ng bng
ng tim tnh mch.
Nu nhim trng ko di hoc nghi ng c bi nhim k kh th phi hp thm
mtronidazole chuyn tnh mch 1g/ng. Liu trnh thng l 10- 15ngy ty theo loi
vi trng, mc tn thng v din tin ca bnh.
Trong vim ty cp do ru nhim trng thng chm nn khi nhim trng thng
l rt nng nn cng cn phi hp mnh v ph khun rng nh nu trn.
* Khng tit acid HCL mnh: c th dng ngn nga do stress ng thi cng
c ch tit dch v v dch ty. Ranitidine 150-300mg hoc Famotidine 20-40mg T.B.
hoc chuyn tnh mch, omeprazol 40mg/ng hoc patoprazol 40mg/ng duy tr pH
dch v > 4.
3.2. Ra phc mc: kt hp vi cc bin php iu tr ni khoa ni trn, ra phc
mc gip loi b cc cht c v vi trng. p dng vo giai on u ca vim ty
cp hoi t, n gip lm gim au v gim chong, ci thin tnh trng suy h hp
gip gim Amylase v lipase trong mu v trong nc tiu, lm tng calci mu. Ci
thin ri lon nc v in gii v cn bng kim toan. Trong mt s trng hp c
li cho nhng ri lon ngoi ty. Trong mt nghin cu ca Fagniez cho thy n gip
gim c t l bnh sut v t sut trong vim ty cp nng. Nhng cc bin chng
th pht nh nhim trng huyt, p xe ty th khng thay i my.

182
3.3. Chc ht di s hng dn ca siu m hoc CT: c dng iu tr p
x hoc cc nang gi ty. Di s hng dn ca siu m v CT xc nh c
hoi t, a kim vo chc ht loi b m, vi trng v cc cht c gy ra do vim
nhim trng v hoi t.
3.4. iu tr ngoi khoa
* Trong trng hp khng c si: ch nh phu thut ty thuc vo kt qu ca iu
tr hi sc v ni khoa. Trong trng hp hi sc khng ci thin hoc ch thong
qua ri li nng ra. Mc ch l ly b m ty b hoi t, cm mu v dn lu. C th
i bng ng bn, ng sau, hay ng trc xuyn qua phc mc.
* Trong trng hp c si hoc giun
Nu vim ty cp do giun trong giai on sm mt vi ngy u th c th cho thuc
lit giun tc dng nhanh nh lvamsole hoc Pyrantel, Albendazole. Nu tht bi c
th ko giun qua ng ni soi hoc phu thut.
Nu do si nht l khi si c kch thc > 0, 5mm v kt vo c vng Oddi th ly si
qua ng ni soi kt hp vi vic x c vng Oddi (Sphinterotomie), ri ko si
bng Dormia hoc bng Ballon hoc tn si bng my c hc ri ko si bng cc
phng tin trn. Kt hp vi phu thut cm mu loi b m hoi t hoc m. C
th thc hin m sm 24-48 gi u. Trong trng hp c chong cn nng huyt
p trc khi m.

183

UNG TH I TRC TRNG

Mc tiu
1. K c cc yu t nguy c gy ung th i trc trng.
2. Xp loi v tin lng cc giai on ung th i trng.
3. Nm vng triu chng ca ung th i trc trng.
4. Ch nh v phi hp ng cc bin php iu tr ung th i trc trng.
Ni dung

I.I CNG
Ung th i trc trng l nguyn nhn ln gy t vong cc nc Bc M, Chu
u, sau ung th tin lit tuyn, ung th v v ung th phi. Nm 1996, c khong
134 ngn trng hp mi mc Hoa K v 55 ngn ngi t vong ng hng th
hai sau ung th phi. n nm 2004, c 146.940 trng hp mi mc v 56, 730
trng hp t vong. C s gia tng ng k v t l ung th i trc trng cc
nc c t l thp trc nhng nm 1950. Vi s tin b nhanh chng ca sinh hc
phn t cho nhng nhn nhn v c ch bnh sinh ca ung th i trc trng, t
t ra vn phng nga cp 1 v bnh xy ra sau mt thi gian di c s tng
tc v bin i gen v yu t mi trng, cho nn c th pht hin bnh giai on
tin ung th v ung th giai on sm iu tr lm tng tui th cho bnh nhn.

II. DCH T HC
T l bnh cao cc nc pht trin nh Bc M, c, New Zeland, v cc nc
Chu u, thp cc nc Chu , Nam M, Sahara, Chu Phi. S khc bit v a
d cng cho thy c s khc bit v v tr ca ung th i trc trng v d nh ung
th i trng ngi da en tng t nh ngi da trng nhng ung th trc
trng th ngi da trng cao hn da en v nam nhiu hn n. Nhng ngi nhp
c t ni c t l ung th i trng thp n ni c t l cao cng cho thy t l mc
bnh tng nhanh hn so vi ni c. Cc nc c t l tng nhanh l , B o Nha,
tng va Anh v an Mch, t l nh Php v Thy S. V v tr, t l ung th
i trng phi v i trng sigma c xu hng tng hn nhng t l ung th trc
trng th gim, iu ny phn nh s nhy cm khc nhau ca s chuyn hnh thi
ca u on gn v xa ca i trng. V v tr th ung th i trng sigma l
25%, trc trng l 20%, ch ni gia sigma v trc trng l 10%, i trng ln v
manh trng chim 25%, i trng ngang 15% v i trng xung thp nht 5%.
Yu t mi trng ng vai tr quan trng trong s pht trin ca bnh. Trn cng
mt vng, li sng khc nhau c t l mc khc nhau, trong thc n c lin quan
n bnh nh thc phm giu m, protein, ng, t rau v si x, t yu t vi
lng.
Bnh ny thng gp ngi trn 50 tui l nhiu hn.

II. BNH NGUYN V C CH BNH SINH

a s ung th i trc trng thng pht sinh t cc polyp dng tuyn bm cht vo
b mt nim mc bao gm dng polyp non khng tng sn, polyp tng sn hay polyp
tuyn. Ch c polyp tuyn l c tnh r v c mt t l nh bin thnh ung th. Polyp
i trng gp trn 30% tui trung nin v ngi gi nhng ch c 1% l c tnh.
a s polyp khng c triu chng v mu n trong phn ch c trong 55 trng hp.

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V mt lm sng, polyp tuyn tr thnh ung th ty thuc vo ln, c im m
hc, v kch thc ca chng. Ung th thng pht sinh t polyp tuyn dt, nht l
loi polyp c ng knh > 2, 5 cm. V vy khi pht hin c c polyp th ngay khi
cha c bng chng l c tnh, phi theo di ni soi nh k mi 5 nm v nhng
bnh nhn ny c n 30- 50% c th pht sinh thm nhng polyp tuyn khc v c
nguy c cao hn na cho ung th i trng.

III. CC YU T NGUY C
1. Ch n
Bnh xy ra cc nc pht trin, ni c i sng kinh t - x hi cao, dn thnh
ph. v c lin quan n ch n giu nng lng, nhiu du tht v m cng nh
ngi c tng cholesterol mu v bnh mch vnh.
1.1. M ng vt
Ch n giu m lm tng tng hp cholesterol v acide mt gan, lm tng
lng sterol trong i trng. Vi khun trong rut s chuyn ngc cc sn phm ny
thnh acide mt th pht v cc cht c tc dng c khc trong phn. Cc cht
chuyn ha sau cng ny c l lm tn thng nim mc i trng v gia tng hot
ng tng sinh ca biu m i trng qua trung gian ca arachidonic lm tng
prostaglandin gy ung th.
n nhiu tht hn s lm gia tng t l vi khun k kh trong lng rut lm chuyn
i acide mt thnh cht sinh ung th nht l ung th i trng xung v i trng
sigma. C l do s khc nhau v t l m bo ha v cha bo ha trong thnh
phn tht. X dng du c c nhiu cht Omega 3, mt loi m khng bo ha a v
du olive l loi bo ha n th tt hn dng m ng vt. Yu t nguy c ny
cng cn thy ngi c tng cholesterol v beta- lipo-protein mu.
1.2.Cht x
Nghin cu dch t hc v trn sc vt th nghim cho thy cht x trong ch n
c tc dng bo v chng li s pht sinh ung th i trng.
Vai tr ca n cha c bit r. Vi khun trong i trng cng lm ln men cc
cht x to thnh cc acide bo chui ngn, lm gim pH ca i trng, lm thay i
tnh cht ca phn v c kh nng c ch cc cht gy ung th.
1.3. Yu t gy ung th, vitamin v cc yu t vi lng
- Fecapentaenes: L cht chuyn ha ca cc acide bo khng bo ha di tc
dng ca vi khun i trng cng c vai tr quan trng trong ung th i trng.
- Tht, c nng chy: Sn phm to ra l loi acide amin c cu trc dng vng
cng l yu t gy nn ung th.
- Bia, ru cng vy, c nguy c cao gy ung th khi x dng nhiu. Ngi ta cn
thy nhng ngi lm vic trong cc xng sa cha xe hi cng c t l ung th
i trng cao gp 2-3 ln ngi bnh thng, ngi ta cng cha bit r ti sao.
- Vitamin A, C: C tc dng nh l cht chng oxy ha, c tc dng ngn nga ung
th i trng. Rau ti xanh v cc loi rau dng hoa, vitamin E, acide folic, calci,
yu t vi lng nh Selenium cng c tc dng ngn nga c ung th i trng.
Tuy nhin c ch chnh xc th cng cha hon ton bit r.
2. S khng insulin

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Hot ng th lc c lin quan ngc li. Ngi mp ph, c khng insulin vi
gia tng insulin mu s lm tng nng yu t tng trng ging insulin typ 1 (IGF1), yu t ny s kch thch tng sinh nim mc rut.
3.Yu t di truyn v cc hi chng
Khong 25 % bnh nhn b ung th i trc trng c tin s gia nh b bnh, gi
cho yu t di truyn c sn. C 2 nhm chnh l bnh polyp gia nh v bnh ung th
khng do polyp c tnh di truyn.
- Polyp i trng c tnh cht gia nh: C hng ngn polyp dng tuyn sut chiu
di ca i trng. Bnh do thiu ht mt nhnh ca nhim sc th s 5, thng gp
sau tui dy th vo khong 25 tui v c kh nng pht trin thnh ung th trc 40
tui. Nn ct b i trng khi pht hin bnh polyp ny, trong khi vi cc thuc
NSAIDs cng c tc dng gim s lng v kch thc polyp nhng ch c tnh tm
thi. Con chu ca cc bnh nhn ny cn phi c ni soi theo di ngay c khi
trc tui dy th v c khong 50% c nguy c pht trin cc ri lon tin ung th.
V vy phi theo di bng soi trc trng v sigma m khng cn phi soi ton b
khung i trng hay chp nhum baryte cho n 35 tui.
- Ung th i trng khng phi polyp c tnh di truyn: Gp t nht 2 th h, l loi
ung th biu m tuyn, xy ra trc 50 tui, gp i trng ln, c th phi hp vi
ung th bung trng, ung th ni mc t cung. Tin lng tt hn loi polyp.
4. Vim rut
Ung th i trng gia tng bnh nhn b vim rut mn ko di. Ung th thng
pht trin bnh vim lot i trng hn l bnh Crohn v nguy c ny tng ln t
8- 30% nhng ngi b vim rut mn ko di trn 25 nm, nht l ngi tr vim
ton b i trng. Pht hin bin chng ny khng phi bng nhng t ti pht ca
bnh, bng i th qua ni soi, bng chi t bo m chnh l s lon sn tuyn ca
i trng.
5. Cc yu t nguy c khc
- Nhim khun Streptococcus bovis: Vi khun t trong phn gy vim ni tm mc
hay nhim khun huyt c th gy ung th i trng tim n v ung th ng tiu
hoa cao m nguyn nhn cha bit r. Ni soi tiu ha v chp X quang l cc tt
sng lc.
- M thng niu o- sigma: Ung th pht trin sau phu thut t 25- 30 nm, ti ni
m nim mc sigma lun tip xc vi nc tiu v phn.
- Thuc l: Nht l nhng ngi ht lin tc trn 35 nm. Nguyn nhn cha r.

IV. GII PHU BNH

Ung th i trc trng a s l ung th dng tuyn, t gp hn l loi
lymphoma i trng v u carcinoide. Ung th c th ch n c 1 v tr tn thng
hay phi hp vi polyp hay c th c nhiu v tr tn thng trn c i trng.
1. i th
Cng nh ung th d dy, ung th i trng cng c 3 th.
- Ung th th si hay dng polyp. Tn thng c th rng, li ra ngoi v thng c
hnh nh nhiu nhung mao.
- Ung th th lot si: Hay gp, c hnh nh lot trn khi si.

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- Ung th th thm nhim: Nhim cng v dy vch i trng m khng c lot trn
nim mc. Loi ny t gp hn nhng tin lng xu.
2. Vi th
Phn ln ung th i trng thuc loi biu m tuyn, kh nng bit ha cao, trung
bnh hay thp. C khong 20% thuc loi biu m ch tit nhiu cht nhy, c th
gp loi biu m dng biu b vi t bo lt tng(loi ny him gp).
Tin lng ph thuc bit ha v s lan rng hay di cn xa.

V. TRIU CHNG
1. Lm sng
Ung th i trc trng thng c biu hin m thm vi din tin qua nhiu nm
khng c triu chng hay ch c thay i nh v thi quen i cu. Triu chng
thng c khc nhau ty thuc v tr ca khi u.
- V phn tng i lng khi i qua van hi manh trng i vo i trng phi, cho
nn vi ung th i trng ln, t khi c triu chng nghn rut hoc thay i thi
quen i cu. Tn thng i trng phi thng c dng lot lm mt mu m
mn tnh m khng c thay i phn r rng. Bnh nhn thng c triu chng mt
mi, hi hp biu hin ca thiu mu mn, nhc sc do thiu st, c th s c
khi u vng h chu phi hay di h sn phi. V ung th chy mu tng t
nn xt nghim mu n trong phn c khi m tnh.
- Ung th i trng ngang v i trng xung: Phn c hn, khi ung th pht
trin n ln, n gy hp lng i trng tng i hay hp hon ton, i khi gy
thng. Lm sng biu hin au bng tng cn kiu bn tc v tc rut.
- Ung th i trng sigma v trc trng: Thng c biu hin ca hi chng l vi i
cu phn mu, mt rn, phn b dt km biu hin thiu mu m i khi nhm vi tr
c chy mu. Khm trc trng pht hin c khi u cng, si au v d chy mu
khi ng vo.
V bnh thng din tin m thm nn c khi ch pht hin bnh khi c bin
chng tc rut hay pht hin v tr di cn ca ung th m gan l v tr di cn trc
tin.
2. Cn lm sng
2.1. Soi i trng sigma
y l th thut n gin, nhanh chng gip pht hin 2/3 n 3/4 cc trng hp
ung th trc trng v sigma khi c biu hin hi chng l. N cn gip sinh thit
hoc ct b u khi c th hoc iu tr cm mu ti ch.
2.2. Soi i trng ton b
L phng tin chn on rt tt gip pht hin v tr tn thng cng nh sinh thit
chn on m hc.
2.3. Siu m ni soi, CT scanner
L phng tin chn on tt cc tn thng khu tr di nim mc cng nh
pht hin di cn vo cc c quan k cn, gip chn on giai on TNM.
2.4. Chp phim nhum i trng c baryte

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Pht hin cc khi u c ng knh > 2 cm, vi hnh nh lot si, hnh nh hp lng
i trng khng u nh hnh li to. Trng hp khi u nh < 1cm th cn dng k
thut chp i quang kp.
2.5. Cng thc mu
Hng cu, Hb gim khi c thiu mu.
2.6. St huyt thanh
Gim khi thiu mu do thiu st.

VI. BIN CHNG

1.Tc rut
L du chng cng nh bin chng thng gp ca ung th i trc trng, c th
tc mt phn hay hon ton. Tc do khi u gy nn hay do chn p ca hch.
2. Thng
Thng c th xy ra ngay ti khi u hoc trn khi u c bit manh trng.
3. Chn p cc c quan ln cn
U v cc hch di cn c th gy chn p vo d dy, chn p bng quang, chn p
h thng tnh mch tng gy c trng, chn p thn kinh chi di gy au.

VII. CHN ON: Da vo

- C hi chng l, thay i hnh dng phn, hay ch c ri lon thi quen bi phn.
- C thiu mu nhc sc.
- au bng, st, st cn.
- Khm trc trng c mu dnh gng, c u.
- Soi trc trng- sigma khi c biu hin hi chng l.
- Soi ton b i trng, sinh thit xt nghim m hc, chp nhum i trng c
baryte.
Bng xp loi v tin lng ca Dukes.
Cc yu t tin lng v nh gi giai on ca ung th i trc trng ty thuc
vo su ca u, s xm ln vo vch rut, hin din ca hch vng cng nh s
di cn xa ca u (TNM). Theo phn loi ca Dukes, ung th i trng c 4 giai on:
- Giai on A (T1N0M0): Tn thng nng, khng xm ln vo lp c hoc hch
vng.
- Giai on B: Tn thng xm ln xung su hn nhng cha n hch vng.
B1: T2N0M0. Tn thng ch gii hn lp c.
B2: T3N0M0. Tn thng xm ln n thanh mc
- Giai on C: TxN1M0. C hch vng
- Giai on D: TxNxM1. C di cn gan, phi, xng.
Di cn ca ung th i trng thng theo ng tnh mch ca n gan l hay gp
nht v l ni di cn u tin, him khi thy di cn n phi no, hch thng n
m thiu di cn n gan. Ngoi l l khi ung th v tr xa trc trng, cc t bo ung

188
th c th theo m ri tnh mch cnh ct sng n phi v hch thng n m
khng n gan qua h tnh mch ca. 50% ngi c th sng n 6- 9 thng khi
pht hin c di cn gan (gan ln, chc nng gan bt thng) hay 20- 30 thng khi c
cc nt nh trong gan vi tng CEA v bt thng trn CT scan.
Xp loi theo TNM
* T (tumour) biu th xm nhp ca ung th vo thnh i trng, nh s t T1
n T3, trong T1 cn nim mc trong khi T3 xuyn n thanh mc.
* N (nodule) biu th c nh hng n hch vng hay khng.
* M (metastase) c di cn hay cha.

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Bng 1: Xp loi theo TNM
GIAI ON

T
%
sng
khong 5 nm

Dukes

TNM

Gii phu bnh

T1N0M0

U gii hn nim mc v h nim mc

> 90

B1

T2N0M0

II

U lan n lp c

85

B2

T3N0M0

II

U lan n hay xuyn qua thanh mc

70-80

TxN1M0

III

U nh hng n hch vng ln cn

35-65

TxNxM1

IV

Di cn xa (gan, phi)

VIII. D PHNG CP 1
1. Ha d phng
- Aspirin v cc NSAIDs: C tc dng c ch s tng sinh t bo do c ch tng
hp prostaglandin. N lm gim nguy c ung th i trc trng v gim c t l
t vong do ung th.
- Acide folic v calci: Lm gim nguy c ung th i trc trng dng polyp tuyn.
- Ch n giu cc cht chng oxy ha nh vitamin C, A c trong tri cy, rau
xanh lm gim thp t l ung th i trc trng nht l vi ngi c tht cc polyp
tuyn lnh tnh..
- Liu php thay th Estrogen dng cho ph n sau tui mn kinh cng lm gim
nguy c ung th i trc trng nh vo vic gim tng hp IGF-1.
2. Cc tt sng lc
Chng trnh sng lc ung th i trc trng vi mc ch pht hin sm
trng hp ung th b mt v khu tr nhng ngi khng c triu chng.
Chng trnh sng lc ny quan trng i vi nhng ngi trn 40 tui, c tin s
gia nh b bnh th h th 1 v ngi c a polyp dng tuyn.
- Xt nghim thng quy l khm trc trng, khm ph khoa ph n trn 40 tui
v tin lit tuyn nam gii v bng siu m. Vic lm ny thc hin mi 3- 6 thng
v l phng tin r tin.
- Mu n trong phn: Xt nghim c mt s gii hn, ch dng tnh khong 50%
trng hp ung th i trc trng v chy mu thng xy ra tng t v c khi
dng tnh gi, Vvy khi c mu n (+) th cn phi lm thm xt nghim nh ni
soi trc trng hay ton b i trng hay chp nhum i trng c baryte.
- Soi sigma- trc trng: Khi c biu hin mu n trong phn (+).
- Soi i trng ton b: Khi c ri lon thi quen tng phn.
- CEA mi 3 thng cho ngi c nguy c cao.
Hip hi ung th Hoa K khuyn co nn lm xt nghim mu n trong phn hng
nm v ni soi sigma trc trng mi 5 nm bt u t 50 tui ngi khng c triu
chng m khng c nguy c ung th i trc trng. Ni soi i trng ton b hay
chp nhum i trng i quang kp thc hin mi 10 nm c th thay cho soi i
trng sigma v xt nghim mu n trong phn.
- Tm t bin gen c ch u APC (adenomatous polyposis coli) trong phn l xt
nghim ang c thc hin.

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IX. CHN ON PHN BIT
1.U Amp i trng
Manh trng v i trng sigma l 2 ni thng gp u amp: Tnh cht lnh tnh
ca u trn phim chp nhum baryte vi biu hin u c hnh trn hay bu dc, hp
ng tm, thnh u n. Chn on bng ni soi v sinh thit, iu tr th.
2. Lao hi manh trng
Thng th pht sau lao phi. lm sng c du nhim lao, ri lon phn dng tiu
chy hay c to bn xen k, au bng tng cn c du bn tc rut, s c mng
au h chu phi, IDR (+), phim i trng c baryte cho thy c hnh nh hp u
v mt chc nng van Bauhin, ni soi i trng cho thy c hnh nh tn thng lot
c hoi t dng b u vng manh trng.
3. Bnh crohn hi trng, i trng
Bnh c nhiu t tin trin, ko di nhiu nm, c ri lon phn km biu hin du
chng ngoi rut nh ng mt, khp, lot ming. c im trn phim nhum i
trng c baryte cho hnh nh hp nh si ch. Chn on xc nh bng ni soi sinh
thit vi s hin din t bo biu m khng l.
4. Vim lot i trc trng chy mu
Bnh t mim, thng xy ra nam gii, t 20 n 40 tui. Lm sng c st tng
t trong giai on tin trin km au khp v i cu mu ti. Ni soi cho hnh nh
lot nng lan rng ton b i trng v trc trng, sinh thit ch thy c t bo vim
m khng c lon sn.

X. CC LOI UNG TH I TRNG KHC

1. Lymphoma i trng
Lymphoma i trng tin pht ch chim khong < 0, 5% ca cc th c tnh ca i
trng, gia tng hi chng Sjogren, bnh m ht Wegener, vim khp thp, lupus
ban h thng, v hi chng suy gin min dch mc phi.
Lm sng biu hin triu chng au khng c hiu, st cn, to bn v chy mu
tiu ha. Ni soi i trng cho thy tn thng khi u bit lp hay tn thng thm
nhim lan ta. Khong 50% tn thng nm hi trng, 50% c km hch c tnh.
Chn on bng ni soi sinh thit. Tin lng bnh cng xu, sng 2 nm ch c
40%.
2. U carcinoid
Thng gp nht rut tha, i khi n c pht hin dng polyp trc trng
khng triu chng v c n 25% carcinoid trc trng c biu hin chy mu. U
carcinoid ca trc trng v rut tha t khi di cn. Cc vng khc th t gp hn v
thng gy hp v chy mu v thng di cn. Kh nng c tnh ca u carcinoid l
cao.

XI. IU TR
iu tr ung th i trng, trc trng ch yu l ngoi khoa. X tr v ho tr liu
thng c tnh cht h tr, c th x dng ng thi hay sau khi phu thut.
Hiu qu iu tr ty thuc vo giai on pht hin bnh khi c ch nh phu thut
cng nh qu trnh theo di v iu tr b sung sau m. Ngoi ra, n cn ty thuc

191
vo mt s yu t c nh hng n qu trnh hnh thnh ung th, thng c gi
l cc yu t nguy c.
1.Phu thut
Phu thut ct b khi ung th i trc trng khi pht hin l ch nh gn nh tuyt
i. Ha liu php v x tr ch mang tnh cht h tr.
Tuy nhin trc khi phu thut cn thc hin
- Ni soi ton b i trc trng khi c th thc hin c: mc ch pht hin cc
ung th hay cc polype c nguy c ung th ha cc vng khc ca i trng.
- nh lng khng nguyn gy ung th c ngun gc t phi (CEA:
carcinoembryonic antigen), mt marker ca ung th i trc trng, phn giai on
v c chng trnh sn sc v theo di hu phu.
- Chp CT scanner: Khng gip ch trc tip cho nh v v phu thut i trng,
nhng c th gip pht hin nhng trng hp di cn gan nh m siu m c th b
st.
- Siu m ni trc trng: l mt k thut siu m mi, gip kho st vng chu v
nh gi giai on ung th trc trng.
Mc ch ca phu thut l ct b rng ri vng rut b nh hng v c vng dn
lu bch huyt v c h mch mu cung cp cho vng . Vng rut b ct bao gm
5cm trn v di vng b nh hng bi khi u, trong mt s trng hp c th rng
hn, bao gm ton b vng c cung cp bi mt mch mu b tht trong qu trnh
phu thut. Tuy nhin d c ct rng hn, tin lng sng vn khng tt hn nhng
trng hp ct va . Trong trng hp ca trc trng, khi cn bo tn c vng
hu mn, c th ct phn di cch vng b nh hng ch 2 cm.
Phu thut cn c ch nh ngay c khi c di cn xa, v c th lm gim cc
triu chng xut huyt, tc rut, au bng, lm cht lng cuc sng ca bnh nhn
nhng ngy cn li tt hn.
Theo di sau m:T l ti pht ung th sau m ty thuc vo giai on ca bnh.
Nhng ung th xuyn thnh thng c t l ti pht cao hn. Nhng bnh nhn
c yu t nguy c di truyn thng d ti pht hn. Ung th ngay ti ming ni cng
l mt nguy c khc khi vng ct khng loi b ht cc t bo c tnh khng
nhn c bng mt thng. V vy theo di sau m l bt buc.
Khm nh k l phng php theo di hu hiu nht. Nu trc m cha lm ni
soi i trng c th sau m mt vi thng cn thc hin th thut ny. Bnh nhn
cn c theo di t nht hai ln trong mt nm vi ni soi (tt nht), X quang hay
siu m bng. Nhng trng hp c nguy c cao c th 3 ln mt nm v nguy c
ung th hay polype tuyn (c nguy c ung th ha) ti pht c th 3-5 % (cho ung
th) v 15% (cho polype).
2.X tr
Chy tia vng chu c ch nh b sung sau phu thut ct b ung th trc trng,
nht l khi khi u xuyn thnh n thanh mc v d ct b rng, thng thng,
khi u c th di cn sm n vng ny do c h bch mch rt phong ph. X tr
d trc hay sau m phng c di cn vng chu, nhng khng ko di c
i sng cho bnh nhn. X tr trc khi m khi ung th lan rng, ln, c th khng
ct b ht c. tuy nhin bn thn mt mnh x tr khng th cha c ung th
i trc trng.

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3.Ha liu php
iu tr ha cht mt mnh c hiu qu gii hn, v vy thng dng nh l mt iu
tr b sung cho phu thut. Hiu qu nht cho n nay vn l 5-FU. C th dng mt
mnh hay phi hp thm vi mt s thuc khc. Hiu qu ch gim 15-20% kch
thc khi u trong 50% trng hp (hiu qu mt phn).
Trong trng hp di cn gan, a 5-FU trc tip vo khi u qua ng mch gan
hiu qu hn truyn qua tnh mch ngoi bin, nhng t tin v cng c hn trong
khi i sng bnh nhn cng khng di hn.
Phi hp 5-FU vi acide folinic (cn gi l yu t leucovorin hay citrovorum) ci thin
hiu qu ca 5-FU n gp 3 ln, tuy nhin c tnh cng tng ln.
* Liu lng c th
- 5-FU 425mg/m2 TM (5') + Ca-folinate 200mg/m2 TM. Dng t ngy 1-5. Ngy th
29, lp li liu trnh. C th 6 chu k
Nhng trng hp di cn gan n thun, khng km theo cc vng khc c th c
ch inh ct mt phn gan v t l sng n 5 nm chim 20-30%.
Phi hp phu thut vi x tr, ha liu php c nh gi tt nhng bnh nhn
giai on B hay C, xem nh l bin php tit cn trong trong hp cha c di cn.
C tc gi cn dng thm levamisol, mt thuc x giun v c tc dng iu ha min
dch c th lm gim kh nng ti pht 40%, nhng khng ko di cuc sng trn 5
nm bao nhiu so vi khng dng levamisol.
4. Min dch liu php
Khng th n dng 17-1A edrecolomab (Panorex) ang c th nghim. Kt qu
ca nhiu th nghim cho thy c hiu qu tt hn so vi ha tr liu 5 FU n c
hay phi hp. u im ln nht ca min dch tr liu l n c th tip tc tiu dit
nhng t bo ung th cn st li. Hin nay ngi ta ang th nghim cho K i trc
trng giai on II (DukesB2/B3). Tc dng ph ca min dch liu php bao gm d
ng vi protein ca chut, nn, bun nn, tiu chy.

XII. PHNG BNH

- Ch n: t m ng vt, nhiu cht x (ang cn bn ci)
- Thuc: x dng Aspirin v cc thuc khng vim khng steroide khc (NSAID) t
ra c hiu qu, lm gim nguy c ung th i trc trng.
- Cc thuc khng oxyd ha nh vitamin C, E mt thi c cp n nhng
khng c bng chng c th.
- Estrogen cho ph n mn kinh c th lm gim nguy c ung th i trc trng
nhng ngi ny.
- Ch sng lc cho nhng i tng c nguy c cao (c thn nhn, c bit thn
thch loi 1) mc ung th i trc trng. Hiu qu nht l ni soi i trng 2 hay 3
nm mt ln. C th nh lng CEA mi 3 thng. n gin hn l khm nh k 3-6
thng mt ln vi thm trc trng, m o, siu m bng. Theo di mu n trong
phn c nhy v c hiu thp nn t khi x dng d phng php ny d
thc hin v t tn km.

193

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

I. I CNG
Cc bnh vim rut mn tnh thng gm hai bnh chnh:
Vim i trc trng chy mu (Recto-colite hmorragique) hoc vim lot i trng
(ulcerative colitis) theo cch gi ca cc tc gi Anh M.
Bnh Crohn hay vim rut tng vng.
C 2 u c cc c trng sau
- Mt tnh trng vim mn tnh rut.
- Thng gp thiu nin v ngi tr.
- Tin trin ko di, khi tng khi gim nhng khng bao gi lnh t pht.
- Bnh nguyn cha c bit r.
- Cha c phng php iu tr ni khoa tn gc.
- iu tr bng thuc khng vim, Corticoide, v c ch min dch c hiu qu khng
hng nh.

II. BNH CROHN

1. Bnh nguyn v c ch bnh sinh
Thng tn rut l hu qu ca mt s hot ha khng c kim sot ca
h thng min dch ca nim mc.
Cc yu t nhim khun v di truyn cng tham gia vo c ch bnh sinh.
2. Cc triu chng lm sng
2.1 Cc triu chng thng gp
au bng: thng gp, c v tr thay i, thng au qun dc khung i trng, c
khi c hi chng Koenig
i chy, c khi i chy ra m hoc mu, tn s thay i.
Trong cc t cp thng c suy nhc, chn n, st cn v st nh
C th phn lp mt s biu hin lm sng thng gp nht:
i chy ko di km st.
Hi chng gi rut tha (thng tn hi trng hoc hi trng-i trng phi): au h
chu phi khng r rng, mng gii hn khng r h chu phi.
Hi chng l

194
Hi chng ging bnh i trng chc nng.
Vim i trng cp nng: i chy t, thng c mu, au bng d di ton bng,
bng chng. Ton thn c st, tim nhanh, mt l. Xt nghim: thiu mu, gim
albumin mu.
2.2. Cc thng tn vng hu mn - tng sinh mn: c gi tr gi chn on.
Cc vt xc (fissure) v lot cp hu mn - trc trng.
Hp x ha ng hu mn, c khi hp rt nng.
p xe v cc l d, c th c bin chng d bng quang hoc d sinh dc
2.3. Cc triu chng ngoi tiu ha
Xng khp: vim khp:vim ct sng dnh khp, vim khp cng chu.
Da, nim mc: hng ban nt, hoi th da m, hng ban a dng.
Mt: vim mng b o, lot gic mc.
Gan mt: gan nhim m, vim gan mn, vim gan u ht, si ti mt
3. Tin trin v bin chng
3.1. Tin trin: bnh tin trin thnh tng t; 90% cc t tin trin c th khng
ch c bi liu php corticoide. Trong trng hp xu, cc t cp ngy cng
dy hn.
3.2. Bin chng
- Tc rut: Lng rut hp do vim v do qu trnh x ha tin trin.
- D v p xe trong bng
- Xut huyt tiu ha
4. Chn on bnh Crohn: Do khng c tiu chun c hiu nn chn on bnh
cn da vo tng th cc triu chng lm sng v cc thm d sau.
4.1. Sinh hc
- Cy phn v xt nghim k sinh trng loi tr i chy nhim khun.
- Trong t cp c tng bch cu, tc lng mu tng.
- Feritine gim, albumin gim, thiu mu hn hp (thiu cht v do vim), tng tiu
cu.
- Cc xt nghim c th cho hi chng km hp thu.
4.2. Ni soi: l xt nghim c bn cho chn on, ng thi gip nh gi mc
lan rng ca thng tn: 70-80% c thng tn i trng, 20-30% ch thng tn
ring bit rut non.
Thng tn nng nh sung huyt, ph n nim mc, lot apt hoc lot dc.
Thng tn tin trin su nh lot su, so x (so lot, gi polyp, hp..).
Gia cc nim mc bnh l c cc khong lnh.
4.3. T chc hc: ph n lp m, thm nhim lympho bo, lot v u ht dng biu
b t bo ln khng c hoi t b u.
4.4. Thm d hnh nh

195
- Chp i trng cn quang: c ch trong trng hp ni soi khng hon ton hoc
c cc l d khng pht hin c bng ni soi. Cc du hiu X quang bao gm cc
thng tn lot, gi polyp to thnh hnh nh lt , l d, hnh nh hp cc quai
rut, trng hp in hnh c hp nhiu ch cch nhau bi nhng on rut lnh b
dn to.
- Chp ct lp vi tnh bng: trong trng hp c khi bng hoc nghi c nung
m.
5. iu tr bnh Crohn
5.1. Cc phng tin iu tr
5.1.1. Cc dn xut salicylic
- Sulfasalazine: thuc c in nht trong nhm ny, cu to bi sulfapyridine gn vi
acid 5 amino salicylic (5 ASA), t hp thu rut non, khi vo i trng s b cc vi
khun rut phn hy gii phng 5 ASA.
Sulfasalazine ch tc dng trong trng hp c thng tn i trng hoc hi - i
trng, c th dng trong cc t tin trin, khng hiu qu trong duy tr giai on lui
bnh.
- Mesalazine l dn xut Salicylic khng c cha Sulfapyridine v dung np tt hn.
- Cc thuc khc: Asacol, olsalazine, balsalazide.
- C ch tc dng: c ch s tng trng ca t bo T, s trnh din khng nguyn
ln cc t bo T v s sn xut khng th ca t bo B. ngoi ra tc dng khng
vim thng qua s c ch cyclo-oxygenase lm gim s sn xut prostaglandin.
5.1.2. Corticoid
L mt phng tin iu tr quan trng trong cc t cp:
+ Prednisolon liu 1 mg/kg/ng trong 3-7 tun, sau gim liu theo kiu bc thang
mi 10 mg cho n 1/2 liu, sau gim mi 5 mg mi tun ko di cho liu trnh
12 tun.
+Cc loi Corticoid mi: fluticasone propionate, tixocortol pivalate, beclomethasone
dipropionate, v budesonide, cc thuc ny c u im l c i lc ln cc th th
corticoid ln hn loi corticoid c in, ng thi tng s chuyn ha qua gan ln
u nn t tc dng ph ton thn hn.
Trong , Budesonide thng c s dng nhiu trong bnh crohn, thuc gi
phng hi trng v tc dng chnh ln on cui hi trng v i trng phi, vi
liu dng t 6-9mg/ng.
5.1.3. Cc thuc c ch min dch
+ Azathioprine: c hiu qu r nht, c bit cc bnh nhn ph thuc Corticoid
hoc duy tr t lui bnh, cng hiu qu trong iu tr cc l d rut - da hoc d
hu mn- tng sinh mn.
Tc dng chm, triu chng bt u ci thin sau 3 thng
Tc dng ph:c ch ty, vim ty cp, vim gan cp, khng dung np tiu ha v
phn ng d ng.
+ Methotrexate cng hiu qu trong cc th l thuc Corticoid hoc khng p ng
iu tr Azathioprine, tc dng xut hin sm t thng u tin.

196
5.1.4. Nui dng nhn to
L iu tr tt trong cc t cp, nui dng qua ng ngoi rut hoc ng rut
em li t l lui bnh cao v tng ng Corticoid
5.1.5. Cc phng php iu tr khc
- Khng sinh:
+ Metronidazole tc dng tt trong cc thng tn hu mn tng sinh mn.
+ Ciprofloxacine (Ciflox) cng c hiu qu tng t.
+ Gn y clarythromycin cng c chng minh l mt phng tin hu ch trong
bnh Crohn.
- Min dch
+ Cc khng th n dng chng yu t hoi t u loi ((Anti-TNF () v Interleukine
10 (IL 10) t ra c kt qu ng khch l trong nhiu nghin cu: INFLIXIMAB
5.2. Ch nh v chin lc iu tr bnh Crohn
t tin trin nh hoc trung bnh
- Mesalazine 4g/ng
- Sulfasalazine 3 - 4 g/ng, duy nht trong th i trng
- Metronidazole 10 - 20 mg/kg/ng hoc Ciprofloxacine 1g/ng.
- Budesonide 9 mg/ng trong th hi trng (i trng phi
t tin trin nng hn hoc tht bi iu tr ni trn
- Prednisolon 1 mg/kg/ng
- Nu tht bi, Corticoid ng ton thn 1 mg/kg/ng
t tin trin trm trng
- Corticoid ng ton thn 1 mg/kg/ng
- nui dng ton b dng ngoi rut khi suy dng nng khng sinh
- nu tht bi, Cyclosporine TM hoc phu thut
iu tr duy tr t lui bnh
- Mesalazine 2 - 4 g/ng
- nu tht bi, Azathioprine
Th l thuc Corticoid hoc th tin trin mn tnh
- Azathioprine.
- nu tht bi, Methotrexate.
- nu vn tht bi, phu thut hoc Corticoid liu thp (<10mg/ng).
Th khng Corticoid
- nui dng ng ngoi rut hoc ng rut
- nu tht bi, Methotrexate, Cyclosporine
- IL 10 hoc Anti-TNF.

197
Phng ti pht sau m
- Mesalazine 2-3 g/ng

III. VIM I -TRC TRNG CHY MU

1. Bnh nguyn: nhiu kh nng c vai tr ca cc yu t di truyn. S hot ha h
thng min dch c vai tr quan trng. Vai tr ca cc yu t nhim khun cha r
rng.
2. Gii phu bnh: nh khu: ch yu trc trng v t nhiu i trng, him hn
l thng tn ton b i trng (pancolite).
3. Lm sng
3.1. Th thng thng: vim trc trng - i trng xich ma nh - va:
i cu nhy mu nhiu, c khi khng c phn, km mt rn, c khi c to bn.
Ton trng t thay i v khm thc th khng pht hin c g.
Thm trc trng c th thy nim mc dng lt v c mu dnh gng.
Th ny khng c bin i v sinh hc.
Chn on da vo
Loi tr vim i trng nhim khun v k sinh trng da vo cy phn v xt
nghim k sinh trng, cn lm trong t tin trin u tin.
Soi i trng -hi trng: thng tn trc trng v i trng sich ma ng nht, gii
hn trn r, phn i trng cn li v on cui hi trng bnh thng. Nim mc ,
dng lt , chy mu t nhin hoc khi tip xc, thng khng c lot.
Sinh thit ton b khung i trng, c nim mc bnh ln nim mc lnh.
3.2. Cc biu hin ngoi tiu ha
Khp: au hoc vim khp, nh hng ch yu cc khp ln ca chi,
Da: thng gp nht l hng ban nt, c th c vim da m hoc lot ap t ming.
Mt: vim thng cng mc, vim mng mt v vim mng b o.
Cc thng tn khp, mt v da thng tin trin song song vi cc thng tn
rut.
4. Tin trin v bin chng
4.1. Tin trin: bnh tin trin thnh tng t, gia cc t c cc t lui bnh
khng c triu chng.
4.2. Bin chng
- Dn i trng, hay i trng ln nhim c: gp trong cc t tin trin cp nng.
- Thng: thng b che lp bi Corticoide.
- Xut huyt lan ta.
- Nguy c ung th biu m i trng tng ln trong trng hp vim ton b i
trng.
5. iu tr vim i trc trng chy mu
5.1. iu tr ni khoa

198
Ch yu da vo cc thuc khng vim dng ko di.
+ Salazosulfapyridine (Salazopyrine) v cc dn xut nh Pentasa, Rowasa v
Dipentum, dng trong cc th nh hoc dng iu tr duy tr cc i lui bnh, c ch
phm dng di dng tht vo trc trng.
+ Corticoide: trong cc t tin trin va hoc nng, lu tc dng ph khi dng ko
di.
+ Tit thc hn ch ti a si c dng trong cc t tin trin
5.2. iu tr ngoi khoa
5.2.1. Ch nh
Cc t tin trin nng sau tht bi ca mt t iu tr ni khoa mnh v ngn.
Bin chng thng hoc xut huyt lan ta
Trong trng hp ung th hoc lon sn nng
Trong cc th mn tnh lin tc khng p ng iu tr ni khoa gy suy kit
5.2.2. cc phng php iu tr ngoi khoa
- ct i trng-trc trng km m thng hi trng
- ct i trng-trc trng km ni hi trng-hu mn
- ct i trng km ni hi trng-trc trng

199

HI CHNG KM HP THU
Mc tiu
1. Trnh by c cc triu chng lm sng v cn lm sng ca hi chng km
hp thu
2. K c mt s nguyn nhn thng gp ca hi chng km hp thu
Ni dung

I. I CNG
Hi chng km hp thu biu hin tnh trng suy gim mt phn hoc hon
ton chc nng hp thu ca ng tiu ha. Chn on hi chng km hp thu thng
khng kh khn nhng vic chn on nguyn nhn thng phc tp.

II. TRIU CHNG LM SNG

- Gy st mc d vn cn cm gic ngon ming
- i chy
- Chng bng
- Huyt p thp: do thiu nc v suy dng.
- Cc triu chng lm sng v sinh hc ca thiu vitamin: do hu qu ca km hp
thu ko di
- Thiu mu: do km hp thu st, B 12 v acide folic.
- Chy mu
- Cn tetanie: do thiu calci
- Yu c: do suy dng, h Kali mu.
- Qung g: do thiu vitamine A
- Vim a dy thn kinh ngoi bin: do thiu vitamine B12 v B1.

III. XT NGHIM
Cc du hiu sinh hc gin tip
- Thiu mu, Fe huyt thanh gim, folate v vitamin B12 gim.
- Calci mu gim
- T prothrombin gim
- Albumin mu gim
- Cholesterol mu gim
Cc thm d chc nng hp thu
- nh lng m trong phn: > 6 g/24 gi.
- Trc nghim D-Xylose: < 250 mg/l vo lc 2gi.
- Trc nghim Schilling km yu t ni < 10%.

200
IV. CC NGUYN NHN CHNH CA HI CHNG KM HP THU
Bng 1: Cc nguyn nhn thng gp ca hi chng km hp thu:
Nguyn nhn

Chn on

Trc t bo rut (lng rut)

Vim ty mn, ung th ty
Tc mt, d mt
Tng sinh vi khun rut

Phim bng khng chun b, siu m hoc

chp ct lp
Xt nghim gan, siu m
Tt th, chp lu chuyn rut

T bo rut
Bnh coeliac

Sinh thit t trng

Thiu immunoglobulin

nh lng Ig

Nhim giardia

Xt nghim k sinh trng

Bnh Whipple

Tin s, bnh s

Thng tn rut: bnh Crohn, ct rut, d

rut, u lympho...

Chp lu chuyn rut, ni soi..

Sau t bo rut
Dn bch mch tin pht hoc th pht

Xt nghim hnh thi, sinh thit, thanh lc

alpha-1-antitrypsin.

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

201
i chy thng gim i khi iu tr khng sinh
4. Suy ty ngoi tit
Thng do vim ty mn, him hn l ung th ty, ct b ty...

195

CHNG 3

H HP
PH VIM THY-PH QUN PH VIM
Mc tiu
1.Nu c cc nguyn nhn gy vim phi.
2.Nm vng triu chng lm sng, chn on vim phi thu v ph qun ph vim
3. Bit c iu tr b tr v iu tr triu chng.
4. Bit iu tr nguyn nhn gy vim phi.
5. Bit c bin php d phng vim phi
Ni dung

I. NH NGHA: Vim phi l mt bnh cnh lm sng do thng tn t chc phi

(ph nang, t chc lin kt k v tiu ph qun tn cng), gy nn do nhiu tc nhn
nh vi khun, virus, nm, k sinh trng, ha cht...
Ngi ta phn ra vim phi thy v ph qun ph vim.

II. DCH T HC: Bnh thng xy ra nhng ngi c c a xu nh ngi

gi, tr em suy dinh dng, c a c cc bnh mn tnh, gim min dch, nghin
ru, suy dng hay cc bnh phi c trc nh (vim ph qun mn, gin ph
qun, hen ph qun...). Bnh thng xut hin lc thay i thi tit, yu t mi
trng thun li v c th to thnh dch nht l virus, ph cu, Hemophillus.
- cc nc: Ba Lan vim phi cp chim 1/3 cc trng hp nhim trng h
hp cp (Szenuka 1982), Hungari th t l l 12 % cc bnh h hp iu tr (1985),
t l t vong cc nc pht trin l 10-15 % tr nh ngi gi, Chu u t l t
vong ca vim phi l khong 4,4 %, Chu 4,1-13,4 %, Chu Phi 12,9 %
(Hitze.K.L 1980)
- Vit Nam: Bch Mai v Vin Qun Y 103 th vim phi cp chim t l 16-25
% cc bnh phi khng do lao, ng th 2 sau hen ph qun (inh Ngc Sng
1990) Vim phi cp (t 1981-1987) Vin Lao v phi l 6,7 % (Hong Long Pht
v cng s). Vin Qun Y 103 (t 1970-1983) khong 20- 25,7 % cc bnh phi, th
3 sau vim ph qun v hen ph qun, theo Chu Vn th khong 16,5 %.
T l t vong cc bnh vin H Ni # 36,6 % so vi cc bnh phi (Nguyn
Vit C 1988). V t l t vong ca vim phi Vit Nam khong 12 % cc bnh
phi (Chu Vn )

III. BNH NGUYN: Do nhiu nguyn nhn gy bnh khc nhau

1. Do vi khun
Cc loi vi khun gy nn vim phi thng gp nht hin nay l: Ph cu khun,
Hemophillus influenzae, Legionella pneumophila, Mycoplasma pneumoniae.Ngoi ra
cn c cc loi vi khun khc nh Lin cu, t cu vng, Friedlander (Klebsiella

196
pneumoniae), Pseudomonas aeruginosa, cc vi chun k kh nh Fusobacterium,
hoc l cc vi khun gram m, thng hn, dch hch...
2. Do virus
Nh virus cm (Influenza virus), virus si, Adenovirus, u ma, bnh tng bch cu
n nhn nhim khun. M vim phi do virus 73 % nhim khun h hp- 40% do
virus cm.
3. Nm: Actinomyces, Blastomyces, Aspergillus...
4. Do k sinh trng: Amip, giun a, sn l phi.
5. Do ha cht: Xng, du, acid, dch d dy.
6. Do cc nguyn nhn khc: Nh bc x, tc ph qun do u ph qun phi, do
ng...

IV. C CH BNH SINH

Tc nhn gy bnh vo phi thng l qua ng th (khng kh, vi khun ng
h hp trn) b ht xung, gp iu kin mi trng thun li, sc khng ca c
th km hoc do c lc vi khun mnh... Hoc tc nhn gy bnh cc c quan
ln cn nh mng phi, mng tim, gan... hay n qua ng mu, bch mch v
ngc li t phi c th n c quan ln cn v vo mu gy nhim trng huyt.
Vai tr c a rt quan trng nht l ngi nghin ru, thuc l, suy dng, gim
kh nng min dch v cc bnh mn tnh phi ng gp vai tr quan trng trong
bnh sinh v p ng iu tr.

V. GII PHU BNH

1.Vim phi thy: Thng tn c th l mt phn thy, mt thy hay nhiu thy,
hoc c khi c hai bn phi, thng gp nht l thy di phi phi.
Theo s m t ca Laennec th c cc giai on
1.1.Giai on sung huyt: Vng phi thng tn b sung huyt nng, cc mao mch
gin ra, hng cu, bch cu v fibrin thot vo trong lng ph nang, trong dch ny
c cha nhiu vi khun.
1.2.Giai on gan ha : Trong mt n 3 ngy t chc phi b thng tn c mu
xm v chc nh gan, trong t chc ny c th c xut huyt.
1.3.Giai on gan ha xm: Thung tn phi c mu nu xm cha hng cu, bch
cu, vi khun v t chc hoi t.
1.4.Giai on lui bnh: Trong lng ph nang cn t dch long, c t bch cu.
2. Ph qun, ph vim: Cc thng tn ri rc c hai phi, vng thng tn xen ln
vi vng phi lnh, cc tiu ph qun thng tn nng n hn, cc thng tn
khng u nhau v khi khi thng li x.

VI. TRIU CHNG HC

1. Ph vim thy: in hnh l do ph cu.
y l nguyn nhn hng u gy vim phi thy, chim t l 60-70%, xy ra mi
la tui nhng thng gp l tr con, ngi gi, suy dinh dng, gim min dch th
t l cao hn, bnh thung xy ra vo ma ng-xun v c khi gy thnh dch, hoc

197
xy ra sau cc trng hp nhim virus ng h hp trn nh cm, si, herpes...
hay ngi bnh hn m, nm lu, suy kit...
1.1. Giai on khi pht: Bnh thng khi u t ngt vi st cao,rt run, st giao
ng trong ngy, c au tc ngc, kh th nh, mch nhanh, ho khan ton trng
mt mi, gy st, chn n, mi ming c Herpes, nhng cc triu chng thc th
cn ngho nn.
1.2.Giai on ton pht: Thung t ngy th 3 tr i, cc triu chng lm sng y
hn, tnh trng nhim trng nng ln vi st cao lin tc, mt mi, gy st, bing
n, kht nc, au ngc tng ln, kh th nng hn, ho nhiu, m c c mu g
st hay c mu, nc tiu t v sm mu.
Khm phi c hi chng ng c phi in hnh (hoc khng in hnh) vi rung
thanh tng, n cc khong gian sn au, g c, nghe m ph bo gim, m thi
ng v ran n kh chung quanh vng ng c. Nu thng tn nhiu th c du suy
h hp cp, c gan ln v au, c khi c vng da v xut huyt di da, tr em c
ri lon tiu ha nh bun nn, nn, bng chng.
Cn lm sng: Xt nghim mu c lng bch cu tng, bch cu trung tnh tng,
tc mu lng cao, soi ti v cy m c th tm thy ph cu, c khi cy mu c
ph cu. Chp film phi thy c mt m m b r hay khng r chim mt thy hay
phn thy v thung gp l thy di phi phi.
1.3. Giai on lui bnh: - Nu sc khng tt, iu tr sm v ng th bnh s
thoi lui sau 7 - 10 ngy, nhit gim dn, ton trng khe hn, n cm thy ngon,
nc tiu tng dn, ho nhiu v m long, trong, au ngc v kh th gim dn.
Khm phi thy m thi ng bin mt, ran n gim i thay vo l ran m. Thng
triu chng c nng gim sm hn triu chng thc th. Xt nghim mu s lng
bch cu tr v bnh thung, lng mu bnh thng, thng tn phi trn X quang
m dn. Bnh khi hn sau 10-15 ngy.
Nu khng iu tr hay iu tr khng ng, sc khng qu km th bnh s nng
dn, tnh trng nhim trng, nhim c tng ln, suy h hp, nhim trng huyt hay
c nhiu bin chng khc nh p xe phi, trn dch, trn m mng phi,mng tim...
2. Ph qun ph vim: Bnh thng xy ra tr em v ngi gi, ngi suy kit,
hn m, sau cc nhim vi rt lm suy yu min dch hay c mt bnh mn tnh...
Bnh khi pht t t st, tng dn, kh th cng lc cng tng dn n suy h hp
cp, tong trng biu hin mt nhim trng nhim c cp, nng, c th l m, m
sng... khm phi nghe c ran n, ran m, ran ph qun, ri rc c hai phi, lan
ta rt nhanh, y l mt bnh cnh lm sng va thng tn phi v ph qun lan
ta.
Xt nghim mu thy bch cu tng cao, bch cu trung tnh tng, lng mu tng
c bit l phim phi thy nhiu m m ri rc c hai phi tin tin theo tng ngy.
Nu khng iu tr hay iu tr chm bnh s dn n suy h hp nng, nhim trng
huyt, ton trng suy sp v c th t vong.

VII. CHN ON
1.Vim phi thy
1.1. Chn on xc nh
- Hi chng nhim trng.

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- Hi chng c phi in hnh (hoc khng in hnh)
- Hi chng suy h hp cp (c th c)
1.2. Chn on nguyn nhn: Da vo
- Din tin lm sng.
- Yu t dch t.
- Kt qu xt nghim m.
- p ng iu tr
1.3. Chn on phn bit
- Ph vim lao: Bnh cnh ko di, hi chng nhim trng khng rm r, lm cc xt
nghim v lao phn bit.
- Nhi mu phi: C a c bnh tim mch, nm lu, c cn au ngc t ngt, d
di, khi huyt nhiu, chong.
- Ung th ph qun - phi bi nhim: Thng tn phi hay lp i lp li mt vng
v cng v sau cng nng dn.
- p xe phi giai on u.
- Vim mng phi da vo X quang v lm sng.
- Xp phi: khng c hi chng nhim trng, m ph bo mt, khng c ran n. X
quang c hnh nh xp phi.
2.. Ph qun ph vim
2.1.Chn on xc nh
- C a suy kit, sau nhim Virus, c bnh mn tnh.
- Hi chng nhim trng cp v nng
- Hi chng thng tn ph nang lan ta
- Hi chng thng tn ph qun.
- Hi chng suy h hp cp
2.2. Chn on phn bit
- Ph qun ph vin lao: Phi lm cc xt nghim v lao.
- Hen ph qun bi nhim: Tin s hen ph qun, cn kh th xy ra trc sau
c hi chng nhim trng, p ng vi cc thuc gin ph qun.
- Gin ph qun: Bnh ko di, tin s ho v khc m nhiu vo bui sng, suy h
hp mn, ngn tay hnh di trng.

VIII. BIN CHNG

Do c lc ca tc nhn gy bnh mnh, sc khng km, c bnh mn tnh,
iu tr khng ng, bnh s dn n
- p xe phi
- Trn dch, m mng phi, mng tim.
- Ph phi cp (do thng tn lan ta).

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- Nhim trng huyt.

IX. CC TH LM SNG
1. Do t cu vng
C th tin pht qua ng th hay th pht qua ng mu (nhim trng mu),
lm sng c th ging nh do ph cu,nhng thng l di dng nhiu p xe nh
phi, ph qun ph vim, tr em thng l p xe phi v trn m mng phi gi
l t cu phi - mng phi, bnh nhiu bin chng rt nng v t l t vong cao.
2. Do Friedlander
L loi trc khun Gr (-), gy thng tn hoi t phi rt nng v nhanh gy ho ra
mu nhiu, ly nhim mnh v t l t vong rt cao.
3. Do virus
Thung xy ra trong cc v dch nh cm, si, hay nhim virus ng h hp
trn, bnh khi t ngt. Hi chng c phi khng in hnh, triu chng thc th
ngho nn v khi sau 7 n 10 ngy.
4. Do nm
Thng thng tn phi c hai bn, ch yu vng gn rn phi ri lan dn ra, c
khi ri rc khp hai phi, triu chng lm sng ging ph qun ph vim, c khi
huyt chn on nh tm nm trong m.
5. Do k sinh trng
- Do giun a: L mt thng tn nh phi c th c ho, c t m, nhng thng
tn ny mau bin mt t nhin gi l thm nhim mau bay hay hi chng Loeffler.
- Do amip: Thung th pht sau amip gan nhng cng c khi nguyn pht ti phi,
thng tn ch yu l y phi phi st vi c honh (c khi phi tri), hi chng
nhim trng va phi, au ngc v ho ra mu hay m c mu chocolat. Cn xt
nghim soi ti m tm amip, p ng vi thuc khng amip tt.
6. Do ha cht
Thung gp nht l xng du do ht vo, triu chng lm sng xy ra sau 6-12 gi
khi ha cht vo phi, thng tn ch yu l y phi phi, c au ngc d di v
ho ra mu, c st cao. Phi iu tr sm bng khng sinh (chng nhim trng) v
corticoid.

X. IU TR
Nguyn tc iu tr l sm, mnh, u liu trnh v theo di din tin bnh.
1. iu tr h tr
- Ngh ngi ti ging trong giai on bnh tin trin.
-Tit thc d tiu, m bo calo, thm m v cc loi vitamin nhm B,C
- B nc v in gii v st cao, n ung km, nn, i chy...
2. iu tr triu chng
2.1.Thuc h st
Thuc h st thng c tc dng gim au. C th dng paracetamol 0,5g x 3-4
ln/ngy. hoc l Acetaminophene, Diantalvic...

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2.2. m bo thng kh
Nu c suy h hp th dng xy qua sonde mi 5-10 lit/pht ty mc (lu nu
c suy h hp mn th gim liu cn 1-2 lt /pht v ngt qung).
2.3. Cc thuc gin ph qun
Nu c du co tht ph qun c th cho thm Theophylline 100-200 mg x 3
ln/ngy.
2.4. Cc loi thuc ho v long m
-

Nu ho nhiu c th dng Codein (Acodin, Neocodeon...) 100 mg x 3 ln/ngy.

- Nu m c v kh khc c th dng cc loi nh Terpin, Benzoat Natri,

Eucaylyptin... hoc Acemuc, Exocemuc, Mucosolvon, Rhinathiol... 2-3 gi/ngy.
Hoc 3-4 vin/ngy.
3. iu tr nguyn nhn
y l iu tr chnh gii quyt nguyn nhn gy bnh. C th l khng sinh,
thuc phi dng sm, ng loi, liu, da vo khng sinh , khi cha c khng
sinh th da vo yu t dch t, din tin lm sng ca bnh,kinh nghim ca thy
thuc, th trng bnh nhn v phi theo di p ng iu tr c hng x tr kp
thi.
3.1. Do ph cu, lin cu
Khng sinh chnh hin nay vn l: Penicilline G. 500.000-1000.000 v x 4 ln/ngy
TB. Nu nng c th tng liu v chuyn tnh mch. C th dng Cefapirine
(Cefaloject) 0,5g-1g mi 8-12 gi.
Nu b d ng vi Penicilline th dng loi Macrolide nh Erythromycine tim hay
ung 2g/ngy chia 4 ln hay Roxythromycine 150mg x 2 ln/ngy.
3.2. Do t cu vng
* T cu vng nhy cm vi Methicilline, c th dng Cefapirine hay nhm
Aminoside nh Amikacine 15mg/kg/ngy tim bp hoc nhm Fluoroquinolone nh
ofloxacine chuyn tnh mch hay ung 400mg/ngy chia 2 ln.
* T cu vng khng Methicilline
C th dng Cefalosporine th h III: nh Cefotaxime (Claforan, Cefomic) 3g/ngy
chia 3 ln hay Vancomycin 30-50 mg/kg/ngy tim tnh mch chia 3 ln.
Nu nng c th phi hp vi Amikacine.
3.3. Do Hemophillus Influenza
C th dng:
- Ampicillne 2-3g/ngy ung chia 3 ln hay TB.hoc Ofloxacine hoc Cefapirine
- Gentamycin 3-4 mg/kg/ngy TB chia 2-3 ln
3.4. Do Mycoplasma, Legionella
C th dng nh iu tr Hemophilus influenzae.
3.5. Do Klebsiella pneumoniae
Thng iu tri phi hp Cefalosporine th h III vi Amikacine.

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3.6. Do vi khun k kh
- Penicilin G hay Metronidazol 1-2 g/24 gi. Hoc Cefalosporine II, III
3.7. Do ha cht
Khng sinh thng dng l
- Pnicilin G phi hp vi Prednisone 5 mg x 6 - 8v/ngy.
Cc trng hp vim phi c bin chng phi iu tr ko di cho n khi triu
chng lm sng v cn lm sng tr v bnh thng (xt nghim nhiu ln) trnh
bin chng v ti pht.

XI. PHNG BNH

Vim phi l mt trong nhng bnh nhim trng ng h hp di ph bin
nht, ngy nay nh vo nhiu loi khng sinh mi, mnh nn t l bin chng v t
vong gim nhiu. Tuy nhin vn c trng hp xy ra thnh nhng v dch nht l
do virus. phng bnh, gim bin chng phi nng cao th trng, gi m trong
ma lnh, loi b nhng yu lm d nh mi trng khng trong sch, khng ht
thuc l, phng nga v iu tr sm, tn gc cc nhim trng ng h hp trn,
cc t cp ca bnh phi mn tnh, iu tr sm v theo di st giai on sm ca
nhim trng ng h hp, trnh ly lan.
Ngy nay c mt s vaccin ca nhiu loi virus c x dng v c mt s
thuc chng virus.

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HEN PH QUN
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, c ch sinh bnh v bnh
nguyn hen ph qun.
2. Nu c triu chng lm sng v cn lm sng cn hen ph qun in hnh.
3. Pht hin sm bin chng cn hen ph qun cp nng
4. Nu c cc phc iu tr hen ph qun theo bc v bin php phng nga.
5.Trnh by c phc iu tr cn hen ph qun cp nng
Ni dung

I. NH NGHA
Theo GINA 2002 (Global Initiative for Asthma) th hen ph qun l mt bnh l vim
mn tnh ca ph qun trong c s tham gia ca nhiu t bo v nhiu thnh
phn t bo; vim mn tnh gy nn mt s gia tng phi hp s tng p ng ph
qun dn n nhng t ti din ca ran rt, kh th, b st lng ngc v ho c bit
xy ra ban m hay vo sng sm; nhng t ny thng phi hp vi s tc
nghn ph qun lan rng nhng thay i, s tc nghn ny thng c tnh cch hi
phc t nhin hay do iu tr. Nhng quan im c bn trn y gp phn tch cc
vo vic nng cao cht lng chn on v iu tr hen ph qun.

II. DCH T HC
Hen ph qun l mt bnh thng gp, xut hin mi la tui, tr em chim a s
so vi ngi ln, t l 2/1. Nhng nghin cu dch t hc trong nhng nm gn y
cho thy tn sut trung bnh khong 5 %, tr em di 5 tui 10 %. Rt nhiu nghin
cu gn y cho thy tn sut ny gia tng gp 3 - 4 ln trong nhng thp nin qua.
lu hnh hen ph qun ti Php trong la tui 18 - 65 tui l 3,9 % (Charpin v
c.s 1987, Maladies respiratoires 1993, tr 335), ti trong la tui 5 - 64 tui l 5 %
(Paolette v c.s 1989, Maladies respiratoires 1993, tr 335). Ti Vit Nam, H Ni,
trong nm 1991 l 3,3 %, nm 1995 tng ln 4,3 % (Vng Th Tm v c.s trong bo
co ca hi ngh tng kt 5 nm 1991 - 1995 ca Vin chng lao v bnh phi);
thnh ph H Ch Minh, lu hnh hen ph qun l 3,2 (1,39 % (Phm Duy Linh
v c.s bo co trong Hi tho Y dc hc ln th 5 ti thnh ph H Ch Minh t
ngy 25 - 27/11/1996), thnh ph Hu, lu hnh hen ph qun nm 2000 l
4,58 (1,12% (L Vn Bng).

III. BNH NGUYN

1.Hen ph qun d ng
1.1 Hen ph qun d ng khng nhim khun
- D ng nguyn h hp: thng l bi nh, cc loi b nh nh
Dermatophagoides ptronyssimus, bi chn m, cc lng mng cc loi gia sc
nh ch, mo, chut, th v.v...; phn hoa, cy c, hay ngh nghip trong cc xng
dt.
- D ng nguyn thc phm: thng gp l tm, cua, s, hn, c chua,
trng...

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- D ng nguyn l thuc aspirine, khng vim khng steroide, pennicilline;
mt s phm nhum mu v cht gi thc phm.
1.2. Hen ph qun d ng nhim khun
-Vi khun thng gp l streptococcus
pneumoniae,
staphylococcus aureus...

pyogenes,

streptococcus

- Virus: thng gp l virus hp bo h hp, parainfluenza, cm.

- Nm: nh nm Cladosporium hay Alternaria, cc nm mc.
2. Hen ph qun khng do d ng
2.1. Di truyn: tin s gia nh, lin quan n khng nguyn ha hp t chc HLA.
2.2. Gng sc: khi gng sc v nht l khi ngng gng sc.
2.3. Lnh: khng kh lnh.
2.4. Ri lon ni tit: trong thi k trng thnh, thi k trc kinh nguyt, lc mang
thai, thi k mn kinh.
2.5. Yu t tm l: tm trng lo u, mu thun cm xc, chn thng tnh cm.
4. C ch sinh bnh
Hen ph qun xy ra qua 3 qu trnh
4.1. Vim ph qun: l qu trnh c bn trong c ch hen ph qun bt u t khi
di ng nguyn lt v c th to ra phn ng d ng thng qua vi tr ca khng th
lgE. Nhng t bo gy vin ph qun bao gm t bo mast, bch cu a nhn (i
toan, i kim, trung tnh), i thc bo ph nang, bch cu n nhn, lympho bo v
tiu cu phng thch cc cht trung gian ha hc gy vim nh histamine,
srotonine, bradykinine, thromboxane, prostaglandine, leucotrine, PAF v mt s
interleukine.
4.2. Co tht ph qun: do tc ng ca cc cht trung gian ha hc gy vim v vai
tr ca h thn kinh t ng gm h cholinergic, h adrenergic v h khng
cholinergic khng adrenergic.
4.3. Tng phn ng ph qun: xy ra sau khi d ng nguyn vo c th, qua tc
ng ca cc t bo gy vim. y l mt trng thi bnh l khng c hiu cho hen
ph qun.
5. Triu chng lm sng cn hen ph qun in hnh
5.1. Giai on khi pht
Cn hen ph qun thng xut hin t ngt vo ban m, nht l na m v
sng; thi gian xut hin ty thuc vo nhiu yu t nh tip xc d ng nguyn h
hp, thc n, gng sc, khng kh lnh, nhim virus ng h hp trn, v.v... Cc
tin triu nh nga mi, ht hi, chy nc mi, nc mt, ho tng cn, bn chn
v.v... nhng khng phi lc no cng c.
5.2. Giai on ln cn
Sau , cn kh th xy ra, kh th chm, kh th k th ra xut hin nhanh, trong
cn hen lng ngc bnh nhn cng ra, cc c h hp ph ni r, c th c tm u
tay chn sau lan ra mt v ton thn. Nhp th chm, ting th rt ko di. ng
xa c th nghe ting rt hay s s ca bnh nhn. Nghe phi c nhiu ran rt v ran
ngy. Cn kh th di hay ngn ty theo tng bnh nhn.

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5.3. Giai on lui cn
Sau vi pht hay vi gi, cn hen gin dn, bnh nhn ho khc m rt kh khn,
m c qunh, c nhiu ht nh nh ht trai. Lc ny nghe phi pht hin c
nhiu ran m, mt t ran ngy. Khc m nhiu bo hiu cn hen ht.
5.4. Giai on gia cc cn
Gia cc cn, cc triu chng trn khng cn. Lc ny khm lm sng bnh thng.
Tuy nhin nu lm mt s trc nghim nh gng sc, dng actycholine, th vn
pht hin tnh trng tng phn ng ph qun.
6. Triu chng cn lm sng
6.1. Thm d chc nng h hp
6.1.1. Ri lon thng kh
- o FEV1 (th tch th ra ti a trong giy u) v FEV1/FVC (t s Tiffeneau):
trong cn gim di 80% so vi l thuyt.
- o PEF (lu lng th ra nh): trong cn gim di 80% so vi l thuyt.
6.1.2. Kh mu: o PaO2, PaCO2, SaO2, v pH mu, y l xt nghim b sung
nh gi mc suy h hp.
6.2. Cc xt nghim v d ng
6.2.1. Test da: dng phng php ly da, da l dng tnh.
6.2.2. Test tm khng th: nh khng th ngng kt, khng th kt ta thng l
lgG, lgM.
6.2.3. nh lng lgE ton phn v lgE c hiu.
6.3. Phim lng ngc: trong cn hen, lng ngc cng phng, cc khong gian sn
gin rng, c honh h thp, phi tng sng, rn phi m.
7. Chn on
7.1. Chn on xc nh: cn c ch yu vo
7.1.1. Tin s c nhn v d ng: nh chm, my ay, c tip xc vi d ng nguyn
trc , tin s gia nh v hen, d ng hoc cc yu t khc nh gng sc, lnh
v.v...
7.1.2. Hi chng hp tiu ph qun do co tht: kh th chm, ch yu k th ra,
phi nghe nhiu ran rt, ran ngy, phim phi cho thy hnh nh kh ph thng.
7.1.3. Cn kh th c tnh cht hi qui, p ng tt vi thuc gin ph qun, tt
phc hi ph qun vi ng vn bta 2 dng tnh tc sau khi dng ng vn bta 2
th FEV1 > 200ml v FEV1/FVC > 15%.
7.2. Chn on phn bit
7.2.1. Hen tim: bnh nhn c tin s cc bnh van tim nh hp van hai l, h van
ng mch ch, cao huyt p, kh th nhanh, c 2 k, phi nghe nhiu ran dch,
rt t ran ngy, phim phi cho thy hnh nh dch, tm in xc minh thm
nguyn nhn.
7.2.2. t cp bnh phi tc nghn mn tinh: c tin s bnh phi tc nghn mn
tinh thng do thuc l, c hi chng nhim trng, kh th nhanh, khng c tin s

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c nhn v gia nh v d ng hay hen, phi nghe ran m to ht km ran rt v ran
ngy, tt phc hi ph qun vi ng vn bta 2 m tnh.

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8. PHN LOI TRM TRNG HEN PH QUN QUA TRIU CHNG LM SNG
TRC IU TR
BC 1 (TNG CN)
- Nhng triu chng xy ra < 1 ln / tun.
- Nhng t bc pht ngn.
- Nhng triu chng ban m < 2 ln / thng.
+ FEV1 hay PEF 80% so vi l thuyt
+ PEF hay FEV1 bin thin < 20%
BC 2 (DAI DNG NH)
- Nhng triu chng xy ra > 1 ln / tun nhng < 1 ln / ngy.
- Nhng t bc pht c th nh hng n hot ng v gic ng.
- Nhng triu chng ban m > 2 ln / thng.
+ FEV1 hay PEF 80% so vi l thuyt.
+ PEF hay FEV1 bin thin 20 30%.
BC 3 (DAI DNG VA)
- Nhng triu chng xy ra hng ngy.
- Nhng t bc pht nh hng n hot ng v gic ng.
- Nhng triu chng ban m > 1 ln / tun.
- Hng ngy phi s dng thuc kh dung ng vn (2 tc dng ngn
+ FEV1 hay PEF 60 - 80% so vi l thuyt
+ PEF hay FEV1 bin thin > 30%
BC 4 (DAI DNG NNG)
- Nhng triu chng xy ra hng ngy.
- Thng xuyn c nhng t bc pht.
- Nhng triu chng thng xy ra ban m.
- Gii hn nhng hot ng th lc.
+ FEV1 hay PEF 60% so vi l thuyt.
+ PEF hay FEV1 bin thin > 30%

9. Bin chng
9.1. Bin chng cp
9.1.1. Hen ph qun cp nng: c th xut pht t hi chng e da hen ph qun
cp nng, hi chng ny c th tng ng vi tnh trng cn hen cp khng p
ng vi iu tr thng thng v nng dn; hoc xy ra rt cp i khi trong vng vi
pht. l tnh trng nguy cp c tin lng sinh t trong thi gian ngn.
S chn on phi c thc hin sm v c tnh cp cu.
- Nhng du chng h hp
+ Tnh trng nguy cp h hp vi tm, v m hi, kh th nhanh nng, tn s
trn 30 ln/pht km du c ko cc c h hp.

207
+ Ri lon tri gic: lo u km vt v hay ngc li l m c th i dn vo
hn m.
+ C th th chm chng t c s suy kit c h hp v bo trc s ngng h
hp.
+ Nghe phi: im lng c hai bn phi.
+ Lu lng th ra nh di 150 lt/pht.
+ PaO2 < 60 mmHg, PaCO2 > 45 mmHg.
+ pH mu < 7,38.
- Nhng du chng tim mch
+ Mch nhanh thng trn 120 ln/pht, mch chm l du chng rt nng bo
hiu ngng tun hon.
+ Mch nghch l lm mch gim bin trong k th vo, c th xc nh bng
cch o hiu p tm thu gia k th ra v k th vo thng trn 20 mmHg.
+ Tm ph cp vi du chng suy tim phi.
+ Huyt p c th tng lin quan n s tng PaCO2, huyt p h trong nhng
trng hp qu nng.
9.1.2. Trn kh mng phi: do v bng kh ph thng.
9.1.3. Nhim khun ph qun - phi: thng do Streptococcus pneumoniae,
Haemophilus influenza, staphylococcus aureus, mycoplasma pneumonniae,
legionella pneumophila.
9.2. Bin chng mn
9.2.1. Khi ph thng a tiu thy
- Thng c kh th khi gng sc, khi lm vic nng, tm mi v u chi, lng
ngc bin dng hnh c g hay hnh thng, g vang, m bo gim.
- Th tch cn v dung tch cn chc nng tng, c ri lon thng kh phi
hp, PaO2 ch gim giai on sau v PaCO2 ch tng giai on sau.
9.2.2. Suy h hp mn
- Tm v kh th: th nhanh nng, th ra mi khp cht, du hiu HOOVER.
- Suy h hp mn nghn c gim r cc th tch cn, cc lu lng trung bnh
v lu lng nh, tng gin phi, suy h hp mn hn ch c gim th tch phi,
gim gin phi, ty theo mc suy h hp m PaO2 di 65 - 70 mmHg v
PaCO2 trn 43mmHg.
- Kh th cng ngy cng tng dn t kh th khi gng sc, n kh th khi
leo ln dc hay ln cu thang, n kh th khi i nhanh trn ng phng, n kh
th th i chm trn ng phng, cui cng kh th khi lm vic nh nh v sinh,
ci o qun, v sau kh th khi ngh ngi. Tm mi, u chi, mt nu nng tm ton
thn.
- Triu chng suy tim phi: Trn lm sng v trn cn lm sng.
- PaO2 gim n 70 mmHg, PaO2 tng 50-80mmHg, SaO2 < 75 %, pH mu c
th gim < 7,2.

208
10. iu tr
10.1. X tr hen ph qun theo cc bc
+.Bc 1 (Hen ph qun cch khong)
Trong hen ph qun cch khong, trm trng ca t bc pht cp thay i theo
tng bnh nhn v theo thi gian. Nhng t bc pht cp nng rt t gp.
Thuc s dng trong hu ht cc bnh nhn hen ph qun cch khong nh l
thuc ng vn 2 kh dung tc dng nhanh, ngoi ra c th s dng cromone hay
thuc khng leukotriene. Thuc khng cholinergic, ng vn 2 ung, hay
theophylline tc dng ngn c th dng xen k vi thuc ng vn 2 kh dung, mc
d nhng loi thuc ny c thi gian bt u tc dng chm v hay l c nguy c c
nhiu tc dng ph hn. Thng thng nhng t bc pht cp nng hn hay ko
di hn c th i hi s s dng mt t iu tr ngn bng glucocorticoide ung.
+ Bc 2 (Hen ph qun dai dng nh)
Nhng bnh nhn b hen ph qun dai dng nh cn phi c s dng thuc
hng ngy hon thnh v duy tr s kim sot hen ph qun. Tr liu u tin l
thuc khng vim dng hng ngy. iu tr chn la mt loi glucocorticoide kh
dung (200 - 500g Beclometasone dipropionate, hay Budenoside, 1000 - 250g
fluticasone chia 2 ln/ngy). Thuc dng xen k l theophylline thi chm, cromones,
v khng leukotriene, nhng nhng loi thuc ny km hiu qu hn glucocorticoide
kh dung hay ch c hiu qu mt s bnh nhn. iu tr lu di theophylline thi
chm cn phi theo di nng theophylline trong huyt thanh vi nng iu tr l
5 - 15g/ml.
Thm vo iu tr u n trn, bnh nhn hen ph qun bc 2 c th s dng mt
loi thuc ng vn 2 kh dung tc dng nhanh, nhng khng c qu 3 - 4
ln/ngy.
Nhng thuc gin ph qun khc c th c s dung nh thuc khng cholinergic,
ng vn 2 ung tc dng nhanh, hay theophylline tc dng ngn, mc d nhng
loi thuc ny c thi gian bt u tc dng chm v hay l c nguy c c nhiu tc
dng ph hn.
Nu tr liu lu di c bt u vi theophylline thi chm, cromone hay khng
leukotriene, m nhng triu chng tn ti sau 4 tun iu tr, th glucocorticoide kh
dung phi c s dng. Glucocorticoide kh dung c th c s dung ban u
thay v nhng loi thuc khc, hay s dng km vi nhau.
+ Bc 3 (Hen ph qun dai dng va)
Nhng bnh nhn b hen ph qun dai dng va cn phi dng thuc hng ngy
t c v duy tr s kim sot hen ph qun. iu tr chn la l phi hp mt
glucocorticoide kh dung (200 - 1000 g beclometasone dipropionate, 400 - 1000 g
budenoside, 250 - 500 g fluticasone chia 2 - 3 ln/ngy) vi mt ng vn 2 kh
dung tc dng di 2 ln/ngy.
Mt phi hp glucocorticoide kh dung vi mt ng vn 2 kh dung tc dng di l
mt phi hp tt v tin li.
Mc du phi hp glucocorticoide kh dung vi mt ng vn 2 kh dung tc dng
di l c hiu qu nht, nhng nhng bnh nhn hen ph qun dai dng va c th

209
s dng xen k nhng loi thuc nh theophylline thi chm, thuc ng vn 2
ung tc dng di, thuc khng leukotriene.
Thm vo tr liu u n hng ngy, thuc ng vn 2 kh dung tc dng nhanh c
th c s dung ct cn, nhng khng c qu 3 - 4 ln/ngy. Thuc khng
cholinergic kh dung, thuc ng vn 2 ung tc dng nhanh, hay theophylline tc
dng ngn c th thay th cho thuc ng vn 2 kh dung tc dng ngn, mc d
nhng loi thuc ny c thi gian bt u tc dng chm v hay l c nguy c c
nhiu tc dng ph hn.
+ Bc 4 (Hen ph qun dai dng nng)
Trong hen ph qun dai dng nng, mc tiu iu tr l t c kt qu tt nht nhng triu chng ti thiu, cn s dng thuc ng vn 2 kh dung tc dng
nhanh ti thiu, PEF tt nht, ti thiu cn hen xut hin khong 1 ln / ngy, v tc
dng ph ti thiu. Tr liu trc tin l glucocorticoide kh dung liu cao hn (> 1000
g beclometasone dipropionate / ngy phi hp vi ng vn 2 kh dung tc dng
di 2 ln / ngy.
Thuc ng vn 2 kh dung tc dng di l thuc c chn la, nhng c th s
dng nhng loai thuc xen k nh theophylline thi chm, thuc ng vn 2 ung
tc dng di, thuc khng leukotriene. Nhng loi thuc ny c th thm vo tr liu
phi hp gia glucocorticoide kh dung liu cao vi ng vn 2 kh dung tc dng
di. Thuc ng vn 2 kh dung tc dng nhanh cng c s dng khi cn. Nu
cn, glucocorticoide ung c th c s dng vi liu thp nht, tt nht ch cho
mt lu duy nht vo bui sng gim thiu nhng tc dng ph h thng.
Glucocorticoide kh dung liu cao c th c s dng, nhng s s dng ny
khng c chng ming r rng l gy nhng tc dng ph h thng t hn so
vi s s dng mt liu tng ng glucocorticoide ung. Nhng iu tr ny rt
tn kem v c th gy nn nhng tc dng ph ti ch nh au ming. Khng c
mt chng c no t nhng nghin cu khuyn co nn s dng glucocorticoide kh
dung trong hen ph qun n nh ngi ln.
10.2. iu tr h tr
- Liu php oxy: khi cn th oxy khong 2l/pht.
- Khng sinh: ch dng khi c bi nhim ph qun - phi.
10.3. iu tr cn hen ph qun cp nng
10.3.1. Liu php oxy: phi thc hin lin khng cn ch kt qu kh mu, cung
lng cao 6l/pht nu khng c suy h hp mn, nu c suy h hp mnh cung
lng thp 2l/pht.
10.3.2. Thuc gin ph qun
+ Thuc kch thch bta 2: tim di da Terbutaline (Bricanyl) 1 ng 0,5 mg l
bin php cp cu
ban u ngay ti nh bnh nhn.
+ Khi nhp vin th dng kh dung Salbutamol, 1 ml cha 5 mg ha 4ml dung
dch sinh l qua my kh dung cho ht trong 10 - 15 pht, c th lp li ty din tin
lm sng, 30 pht mt ln. C th dng Salbutamol tim tnh mch lin tc bng ng

210
tim t ng, liu lng ban u thng l 0,1 - 0,2 g/kg/pht, tng liu tng 1
mg/gi theo din tin lm sng.
+ Adrnaline: ch nh chi cc thuc kch thch bta 2 b tht bi; liu lng khi
u thng l 0,5 - 1 mg/gi tim tnh mch bng ng tim t ng.
+ Aminophylline: c th kt hp, dng bng ng chuyn tnh mch vi dung
dch Glucoza 5 % lin tc vi liu lng 0,5 - 0,6 mg/kg/gi.
10.3.3. Khng sinh: c s dng khi c nhim trng ph qun - phi km theo, c
th dng Cephalosporines, Macrolides hay Fluoroquinolones h hp.
10.3.4. Corticosteroide: Methylprednisolone (Solumedrol) 60 - 80mg mi 6 gi.
10.3.5. Th my: c ch nh trong th ngt cp hay trong th m iu tr bng
thuc b tht bi gy suy kit c h hp.
10.4. Theo di bnh nhn
Mc ch iu tr cn hen cp l lm th no cc triu chng gim nhanh v ci
thin chc nng h hp cng nhanh cng tt, ng thi gim thiu ti a tc dng
ph ca thuc.
Nu iu tr ban u khng c kt qu, nu PaCO2 cn thp, th c th tip tc iu
tr ti bnh phng; nhng nu PaCO2 tng v pH b toan ha th bnh nhn phi
c chuyn n phng hi sc thc hin thng kh h tr.
i vi hen ph qun cp nng l mt cp cu ni khoa, bt buc phi nhp vin
gp vo khoa hi sc h hp. Nu chn on l hi chng e da hen ph qun cp
nng hay hen ph qun cp nng hay hen ph qun cp nng nh th phi a
ngay bnh nhn n khoa hi sc bng xe cp cu c trang b.
10.5. Phng nga cn hen ph qun ti pht
Hin nay theo GINA ngi ta khuyn co nn dng Seretide trong iu tr duy tr
kim sot cn hen ph qun v ngi ta nhn thy nhng bnh nhn hen ph qun
c iu tr bng Seretide rt t b xy ra cn hen ph qun nng.
10.6. Phng trnh cc yu t bt li ca mi trng
- Trnh cc hot ng th lc khng cn thit.
- Trnh tip xc bi, khi nht l khi thuc l v cc cht kch thch khc.
- Trnh tip xc vi nhng ngi b nhim trng h hp.
- Gi mi trng trong nh trong lnh.

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SUY H HP CP
Mc tiu
1. Trnh by c nh ngha, bnh nguyn, c ch sinh bnh suy h hp cp
2. Nu c triu chng lm sng v cn lm sng v phn giai on suy h hp
cp
3. Trnh by c phc iu tr theo tng giai on suy h hp cp
4. X tr ban u ng cch theo tng mc v chuyn tuyn ng lc
Ni dung

I. NH NGHA
Suy h hp cp l s ri lon nng n ca s trao i oxy mu; mt cch tng
qut, suy h hp cp l mt s gim thc s p lc ring phn kh oxy trong ng
mch (PaO2) < 60 mmHg, p lc ring phn kh carbonic trong ng mch (PaCO2)
c th bnh thng, gim hay tng.
C 2 loi suy h hp cp
- Suy h hp cp vi thiu oxy mu km kh ccbonic.
- Suy h hp cp vi thiu oxy mu km gim kh ccbonic.

II. BNH NGUYN

1. Nguyn nhn ti phi
1.1.S mt b cp ca nhng suy h hp mn
Yu t lm d l nhim trng ph qun - phi, thuyn tc ng mch phi, trn kh
mng phi.
1.2. Nhng bnh phi nhim trng:
Chng xy ra trn phi lnh th ch gy suy h hp cp khi nhng nhim trng phi
lan rng ra nhiu thy: ph qun ph vim do vi trng m, lao k, nhim virus c
tnh.
1.3. Ph phi cp
1.3.1.Ph phi cp do tim
- Tt c nhng nguyn nhn gy suy tim tri: tng huyt p lin tc hay cn tng
huyt p, suy mch vnh trong nhi mu c tim l nguyn nhn thng gp nht,
hp h van ng mch ch, h van hai l, bnh c tim.
- Hp van hai l.
- Thuyn tc ng mch phi.
1.1.2. Ph phi cp trn tim lnh: do yu t tng p lc mao qun.
- Chuyn dch qu nhiu.
- Nguyn nhn thn kinh: chn thng s no, u hay phu thut chm n thn no,
vim no.
1.1.3. Ph phi cp do tn thng thc th

212
Trc ht phi k n cm c tnh do nhiu yu t: yu t virus, yu t c a, v
nhng th nng gp ch yu ngi b bnh tim tri, hp hai l, nht l ngi
gi, n b c thai; tr em b nhim virus nng di dng vim tiu ph qun - ph
nang. t gp hn l do cht c (hroin, oxyd ccbon, nc rn c), sc nhim trng,
thuyn tc do m, cht ui, hi chng Mendelson (ht phi dch v do ).
1.4. Hen ph qun e da nng, hen ph qun cp nng
y l bnh thng gp, thng l do iu tr khng ng cch hay khng kp thi
c th do c a bnh nhn d b hen ph qun nng.
1.5. Tc nghn ph qun cp
Bnh ny t gp, tr em c th do vt l, ngi ln c th do u, xp phi cp c
th do t ni kh qun.
2. Nguyn nhn ngoi phi
2.1. Tc nghn thanh - kh qun
Bnh ny do u nh u thanh qun, bu gip chm, u thc qun vng c, u kh qun;
do nhim trng nh vim thanh qun, un vn; do vt l ln.
2.2. Trn dch mng phi
t gy suy h hp cp nu trn dch t t, ch gy suy h hp cp khi trn dch cp,
lng dch tng nhanh.
2.3. Trn kh mng phi th t do
Thng do lao phi, v bng kh ph thng, v kn kh bm sinh, t pht (khng r
nguyn nhn), c th do v p xe phi lun lun km trn m mng phi.
2.4. Chn thng lng ngc
Bnh ny gy gy xng sn t gy tn thng mng phi v phi.
2.5. Tn thng c h hp
Nguyn nhn thng gp l vim sng trc ty sng, hi chng Guillain Barr
km lit ln cp Landry, un vn, rn cn, ng c thuc tr su gc phtpho hu
c, bnh nhc c nng, vim a c.
2.6. Tn thng thn kinh trung ng
Nguyn nhn thng l chn thng s no, ng c thuc, tai bin mch mu no;
nhng nguyn nhn gy nn tn thng trung tm h hp.

III. C CH SINH BNH

1. C ch gy nn thiu oxy mu
1.1. Gim thng kh ph nang
p lc kh oxy trong ph nang c xc nh bi s qun bnh gia tc mt i
ca kh oxy, chc nng chuyn ha m v tc i mi ca kh oxy bi thng kh
ph nang. Nu thng kh ph nang gim mt cch bt thng th p lc oxy trong
ph nang gim ri p lc ring phn kh oxy trong ng lch gim theo. S gim
thng kh ph nang c th th pht sau mt tn thng trung tm h hp (hn m,
ng c thuc) hay mt s v hiu ha hot ng lng ngc - phi (tn thng sng
trc ty sng, tn thng c h hp hay dy thn kinh chi phi).
1.2. S mt cn bng gia thng kh / ti mu

213
S km hi ha gia thng kh v lu lng mu l nguyn nhn gy nn s ri
lon trao i kh trong mt n v phi; t thng kh / ti mu gn bng 1; p lc kh
oxy v kh ccbonic trong ph nang l 100 mmHg v 40 mmHg gn bng p lc
ring phn kh oxy v kh ccbonic trong ng mch. Nu khng kh gim, t thng
kh / ti mu: VA / Q bng 0 th p lc kh oxy v kh ccbonic trong ph nang v
p lc ring phn kh oxy v kh ccbonic gn bng nhau, p lc ring phn kh oxy
v kh ccbonic trong tnh mch l 40 mmHg v 45 mmHg.
Nu s ti mu gim, th t thng kh / ti mu c khuynh hng v hn, p lc
kh trong ph nang v trong ng mch gn bng p lc kh ht vo (PO2 =
150mmHg, PCO2 = 0). phi, t thng kh / ti mu thay i theo vng v theo
bnh l. C 3 loi bt thng ca t ny:
- Shunt phi
Bt thng ny l s lu thng mu trong h thng ng mch khng i qua nhng
vng c h hp. Ngi ta gp shunt phi trong ph phi, xp phi.
- Hiu qu shunt
Bt thng ny tng ng vi s khuch tn ca nhng n v phi m thng kh
gim, t thng kh / ti mu gim, nhng nhng ph nang vn cn hot ng t nht
giai on u ca s thng thng vi ng h hp; thiu oxy mu l do s
gim s cung cp kh oxy ca mu tnh mch. Ngi ta gp hiu qu shunt trong
ph phi, bnh phi cp, vim ph qun cp, vim ph qun mn, trn dch mng
phi.
- Hiu qu khong cht
Bt thng ny do s gim thng kh ca mt n v phi vn cn h hp c, t
thng kh / ti mu c khuynh hng v hn. S nghn hay ph hy mch mu
phi (thuyn tc ng mch phi, kh ph thng) gy nn mt khong cht thm vo
khong cht gii phu.
S thiu oxy mu cng nng khi s lng ph nang khng tham gia vo s trao i
kh vng nhiu; s tng thng kh (th b) a n mt s gim kh ccbonic mu
nu kh trong ph nang khng b li trong k th ra (vim ph qun mn, hen ph
qun cp nng).
1.3. Ri lon khuch tn
Mt vi bnh phi nh bnh phi k x ha gy nn tn thng mng ph nang mao mch, b dy mng ny > 0,5(, nh vy s lm gim s trao i kh oxy t ph
nang sang mao mch. Vai tr bloc ph nang - mao lch gy nn thiu oxy mu cn
bn ci.
2. C ch gy nn s thay i kh ccbonic trong mu
p lc kh ccbonic trong ph nang v trong ng mch thay i ngc chiu vi
thng kh ph nang. Nhng s thay i ca s to kh ccbonic thng nh v ng
mt vai tr khng quan trng trong nhng s thay i kh ccbonic trong mu.
2.1. Gim kh ccbonic mu
Hin tng ny l hu qu ca s tng thng kh gy nn do thiu oxy mu.
2.2. Tng kh ccbonic mu

214
Hin tng ny l mt s khng thch ng ca h s thanh lc phi i vi kh
ccbonic, n tng ng vi mt s gim thng kh ph nang.

IV. TRIU CHNG HC

1. Lm sng
1.1. Nhp th v bin h hp
Thiu oxy mu v hay l tng kh ccbonic mu gy nn th nhanh, tn s th
khong 40 ln / pht phi hp vi s co ko cc c h hp, thy r hm trn
xng c v cc khong gian sn; tr em c th km theo cnh mi php
phng. Trong nhng trng hp c tn thng do lit (vim a r thn kinh, lit 4
chi do tn thng ty sng, bnh nhc c nng...), tn s th thng gim, bin
h hp yu, bnh nhn khng ho c, do gy nn ng m gii trong ph
qun.
Theo di nhp th rt quan trng v nhp th chm c th l s ci thin ca trao i
kh oxy mu nhng cng c th l s suy kit c h hp nht l trong trng hp
hen ph qun cp nng.
Trong cc bnh thanh - kh qun, ngi ta thy c s phi hp kh th vo.
1.2. Tm
Tm l du chng ch yu, xut hin mi, u tay chn, mt hay ton thn khi
hemoblogine kh > 50g / l. T ny tng ng vi bo ho kh oxy trong mu ng
mch l 85 %. Tm cng r khi hemoglobine mu cng cao (suy h hp mn); khng
thy r tm khi thiu mu nng. Tm thng phi hp vi tng kh ccbonic mu, tm
i km gin mch u chi, i khi c v m hi.
1.3. Du chng tun hon
Thiu oxy mu v tng kh ccbonic mu lm tng t catcholamine v nh vy lm
mch nhanh, gy nn nhng cn tng huyt p v tng cung lng tim, c th c
lon nhp trn tht, giai on sau huyt p c th h.
1.4. Du chng suy tht phi cp
c bit thng gp trong t cp ca suy h hp mn. Du chng chnh l: gan
ln, du hiu phn hi gan tnh mch c, nng hn l tnh mch c ni t nhin (
t th 450), nhng du chng ny gim khi suy h hp cp gim.
1.5. Du chng thn kinh tm thn
Du chng ny ch gp trong suy h hp cp nng; l trng thi kch thch, vt v,
ri lon tri gic nh l m hay hn m.
2. Cn lm sng
2.1. Kh mu
2.1.1. Bnh thng
- PaO2 l 80 - 95 mmHg.
- PaCO2 l 38 - 43 mmHg.
- pH mu l 7,38 - 7,43
- D tr kim l 24 - 26 mmol / l.
2.1.2. Bnh l

215
-Thiu oxy mu: PaO2 c th gim ch cn 25 mmHg.
-Ri lon kh ccbonic: s a n ri lon cn bng toan kim.
-Tng PaCO2: a n toan h hp m s b tr l nh nhng cht m ca mu
v ca m v nh s thi ion H+ qua thn.
Khi c tng PaCO2 cp, c ch m lc u l huyt tng v huyt cu, sau l
m v thn can thip trong giai on 2 vo gi th 24 bng cch tng thi tr ion H+
v ti hp thu ion Na+ v bicarbonate.
Toan h hp gi l cn b khi nhng cht m t bo c s dng gi cho pH
khng gim. S b tr ny c gii hn bi s gia tng bicarbonate khng qu 50
mmol/l.
-Gim PaCO2: a n kim h hp vi gim bicarbonate huyt tng.
2.2. Kho st tim mch
Tm in v thng tim phi, siu m Dopler tim kho st cc tn thng tim.
2.3. Phim lng ngc
Xt nghim ny cn thc hin c th pht hin nhng tn thng ch m phi,
mng phi, trung tht.

V. PHN GIAI ON SUY H HP CP

Bng 1: Cc giai on ca suy h hp cp
Triu chng

Giai on 1

Kh th

Khi gng sc, Lin tc, lng Lin tc, lng

khi nm lng ngc di ng ngc khng di
ngc di ng kh khn
ng, c h
c
hp cn hot
ng mnh

Lin tc, cc c
h hp hot
ng yu, th
nng, ri lon
h hp

25-30 khi gng

sc

25 - 30

> 40

Tm

Khi gng sc

Mi, u chi

Mt, m, u
chi

Ton thn

M hi

++

+++

Mch ln/pht

90 - 100

100 - 110

110 - 120

> 120

Huyt p

Bnh thng

Bnh thng

Cao

Cao hay h

Ri lon thc

Khng

Khng

Vt v

L m, hn m

SaO2 (%)

80 - 90

70 - 80

60 - 70

< 60

PaCO2 (mmHg)

40

45 - 55

55 - 70

> 70

pH mu

7,35 - 7,40

7,30 - 7,35

7,25 - 7,30

< 7,25

D tr kim

Bnh thng

Bnh thng

Gim

Gim

Tn
s
ln/pht

th

Giai on 2

Giai on 3

30 - 40

Giai on 4

< 10

VI. TIN TRIN V BIN CHNG

Suy h hp nu c iu tr ng mc th c th lui bnh hon ton. Trong qu
trnh tin trin c th bi nhim phi hay ng tiu nht l i vi nhng bnh nhn
c t ni kh qun hay t xng tiu.

216
Suy h hp cp nu iu tr khng kp thi th c th tin trin nng dn, bnh nhn
c th hn m v t vong.

VII. IU TR
1. Nguyn tc iu tr
- Lm thng thong ng h hp.
- Liu php oxy.
- t ng ni kh qun, m kh qun, h tr h hp.
- Chng nhim khun, bi nhim.
- Kim ha huyt tng.
2. iu tr c th
2.1. iu tr h tr v gii phng ng h hp
* Lau ht sch mm, hng, mi
* t canuyn Mayo khi tt li
* Ht m gii, cht xut tit bng my ht
Ra ph qun, lm long m bng kh dung, bng bm dung dch bicarbonate de
natri 14 hay dung dch chlorure de natrri 9, 2 - 5 ml mi ln ri ht ra.
* Bi ph nc v in gii v thng bng toan-kim
m bo c s cn bng gia lng dch ra v vo hng ngy, trnh kh qunh
m, cht xut tit ph qun. Nu c toan h hp th phi truyn dch kim nh
bicarbonate natri 14.
2.2. Liu php oxy
* Th oxy
Kh oxy phi lm m v lm m oxy trc khi s dng cho bnh nhn. Kh oxy
phi qua mt bnh cha nc v c lm m bng my siu m hay bng nhng
tm c lm nng ln.
* Nhng phng tin th oxy
+ Xng mi thng oc p dng
Thng dng nht u ca ng xng c nhiu l, t khng vt qu l mi sau
(chiu di l khong cch gia mi v di tai).
Xng mi c th dng cho nhng cung lng t 1 - 6 lt / pht, thng dng trong
nhng trng hp suy h hp nh hay va.
* Ch nh
+ Th oxy nguyn cht
p dng trong rt t trng hp nh ngng tim, chy mu nng.
+ Kh th c tng cng oxy
- Nhng bnh nhn c nng kh carbonic mu bnh thng hay gim: Tt c
nhng tnh trng thiu oxy mu th PaO2 u gim di 65 mmHg, cho th oxy vi

217
cung lng 4 - 6 lt / pht bng xng mi hay trong nhng trng hp thiu oxy
nng hn th s dng mt n oxy.
- Nhng bnh nhn c nng kh carbonic trong mu cao mn tnh: l nhng
trng hp suy h hp mn, cung lng oxy dng bnh nhn b suy h hp mn
l thp khong 1 - 3 lt / pht, th ngt qung v c kim sot nng cc kh
trong mu.
2.3. t ni kh qun
* Ch nh
- Khi c tr ngi ng h hp trn nh ph n, vt thng thanh qun, hn m gy
tt li.
- Khi cn gim khong cht tng thng kh ph nang, h tr h hp, cn th oxy,
th my.
- Khi c tng kh ccbonic mu.
- Khi cn bo v ng h hp, phng ht sai lc.
* Phng php
C hai phng php:
+ t ni kh qun ng mi
Cn gi l t ni kh qun m, l phng php c dng ph bin, nht l i vi
tr s sinh, tr cn b v tr em, c bit trong bnh un vn v trong hi sc ni
khoa. Bnh nhn t t th Jackson ci tin: nm nga, k vai cao 5-7 cm
nga c va phi hoc t th na ngi, nht l khi s mu, m, dch...t phi bnh
tro sang phi bn kia.
t ni kh qun ng ming
Bnh nhn c t trong t th nh trn: t th Jackson hay na ngi. Cho th
oxy vi pht trc khi t ng.
Thng thng, ng khng t qu 3 ngy.
2.4. M kh qun
* Ch nh
Nh ch nh t ni kh qun hay khng t c ng hay khi cn t ng qu 3
ngy.
* Phng php
- M kh qun cao: d thy kh qun hn
- M kh qun thp.
2.5. Tai bin c th gp khi t ni kh qun v m kh qun
* Tai bin khi t
Chy mu, ph n thanh qun, thng kh qun, co tht thanh mn, ngng tim.
* Tai bin sau khi t
Nhim khun ni t, vim phi, lot, hoi t kh qun, r kh thc qun, tn thng
dy thanh m, xp phi, trn kh mng phi, trn kh trung tht, trn kh di da.

218
2.6. H tr h hp
* Dng c h tr h hp bng tay
Kh th c cung cp cho bnh nhn l kh tri.
- Loi c bng: Ambu, Canister.
- Loi c ti xp: Ranima, Drager.
* Th my
+ Ch nh
Th my c dng khi cc phng php h tr h hp thng thng khng c
hiu qu.
Ba loi bnh nhn ln tng ng vi ba mc khc nhau v kh carbonic trong
mu. Mi loi bnh nhn cn mt cch thc iu chnh h hp nhn to khc nhau:
- Loi bnh nhn th nht: l loi c mt s gia tng nhiu kh carbonic km mt s
gim kh oxy mu, nh s mt b cp ca nhng suy h hp mn, th oxy phi bt
u vi cung lng thp, sau tng dn ln nhng rt chm, kh nng cung cp
oxy (FiO2) cao nht l lc khi u.
- Loi bnh nhn th hai: l loi ang hnh thnh s tng kh carbonic mu, bnh
nhn ny c th h hp hon ton bnh thng vi FiO2 khong 50%.
- Loi bnh nhn th ba: l loi c mt s gim kh carbonic mu. Hin tng tng
h hp th pht sau thiu kh oxy mu. Tuy nhin do c bnh l phi bn di, nn
s tng h hp khng ko theo mt s tng PaO2 c. Bi vy bnh nhn nng
dn dn, cng ngy n oxy cng tr nn trm trng.
- C 5 loi my th:
+ My th to ra chu k da trn tn s.
+ My th to ra chu k da trn th tch.
+ My th to ra chu k da trn p lc.
+ My th to ra chu k da trn dng kh.
+ My th to ra chu k hn hp.
2.7. Chng nhim khun
Cc vi khun gy bi nhim thng l Streptococcus pneumoniae, Haemophilus
influenza, Stapylococcus aureus, Klebsiella pneumoniae, v.v..., nn phi cho cc
khng sinh thch hp.

219

SUY H HP MN
Mc tiu
1. Bit c cc nguyn nhn ca suy h hp mn
2. Hiu uc c ch bnh sinh suy h hp mn.
3. Trnh by c cc triu chng lm sng v cn lm sng ca suy h hp mn.
4. Nu c cc bin php iu tr suy h hp mn va v nng.
5. Trnh by mt s bin php cn d dt trong iu tr suy h hp mn
Ni dung

I. I CNG
Suy h hp mn l mt tnh trng trong lng oxy cn thit cho c th khng th
cung cp hay s dng c khi ngh ngi hay khi gng sc.
Trong thc t, suy h hp mn c chn on khi c ri lon mn tnh cc kh
mu, gim PaO2 v tng PaCO2

II. BNH NGUYN

Nguyn nhn gy suy h hp mn c rt nhiu, a dng, c th b my h hp v
ngoi b my h hp.
Ngi ta phn bit 3 loi suy h hp mn: nghn, hn ch v phi hp.
1 Suy h hp mn nghn: thng gp nht
1.1. Bnh phi tc nghn mn tnh(COPD): l mt tnh trng bnh l ca vim ph
qun mn hoc kh ph thng c hn ch lu lng kh. S tc nghn ny xy ra t
t c khi tng phn ng ph qun v c th khng hi phc hay phc hi mt phn
nh m thi.
Nguyn nhn chnh gy bnh phi tc nghn mn tnh l ht thuc l, sau l ht
thuc l th ng, nhim mi trng, nhim trung ng h hp, v nhim ngh
nghip.
C 4 c im sinh l bnh ca bnh phi tc nghn mn tnh:
+ Nghn tc ng dn kh:
- Do hu hoi nhu m phi l hu qu ca s gim antiprotease trong c
s gim (1 - antitrypsin v/ hay gia tng protease l neutrophil elastase l mt
enzyme c tc dng lm v cc vch ph nang, gy vim ph qun, gim biu m
c lng v tng tit cht nhy.
- Do s bin i ca ng dn kh: do hin tng vim mn l ph, gia
tng t bo ly v t bo tit cht nhy, gia tng s lng v ng knh cc vi mch
ca ng dn kh, ph i v qu sn lp c trn ng dn kh.
+ S gia tng hot ng ca trung tm h hp: gi c mt mc thng
kh ph nang cn thit.
+ S bt thng c h hp: do s gia tng kch thch t trung tm h hp,
thay i v mt hnh hc ca cc c h hp, cc yu t chuyn ho bt li v tnh
trng mt c.

220
+ Bt thng gia thng kh v ti mu: c shunt mao mch do tc nghn
ng dn kh (VA/Q gim) v khong cht ph nang do kh ph thng (VA/Q tng).
1.2. Hen ph qun: nht l th tin trin ko di, nng, khng phc hi.
1.3. Nghn ng h hp trn: do u, hp do so.
2. Suy h hp mn hn ch trong v ngoi phi
2.1. Trong phi
- Di chng nng lan to 2 bn (x phi).
- Cc bnh phi k lan to gy x: do d ng thuc, cht c, sau x tr, bnh
Sarcoidose.
- Ct b phi.
- Ph phi k mn (suy tim).
2.2. Trong lng ngc
- Dy dnh mng phi, trn dch mng phi mn.
- Tim qu ln.
2.3. T bng v thnh lng ngc
- Thot v honh.
- Bng ln.
2.4. Do c v thn kinh
- Cc bnh c nh hng n c h hp.
- Cc thng tn thn kinh trung ng lm nh hng n c h hp: vim
sng trc tu sng, x cng ct bn teo c, vim no, tai bin mch no, bnh
Parkinson...
2.5. Thng tn trung tm h hp, cc th th ng dn truyn n trung tm.
- Trung tm: suy gip, ph nim, nhim kim chuyn ho.
- Th th: bnh thn kinh i tho ng.
- ng dn n trung tm: vim ty ct ngang, x cng ri rc...
3. Suy h hp mn phi hp
- Gin ph qun.
- Vim phi mn lan to do vi trng thng hay lao.

III. C CH BNH SINH

1. Gim PaO2: l ri lon khch quan quan trng nht, c gi l thiu oxy mu
mn khi PaO2 di 70 mmHg xy ra trng din trong sut thi k bnh n nh.
Thiu oxy mu mn tr nn ng ngi t mc PaO2 = 55 mmHg
1.1 Gim vn chuyn oxy:
S vn chuyn oxy n m ty thuc vo cung lng tim (Q) v vo sc cha oxy
ca mu ng mch (CaO2).
TO2 = Q x CaO2

221
Trong CaO2 li tu thuc vo dung lng oxy tc l vo lng hemoglobin s
dng c v vo bo ho oxy.
Trong trng hp thiu oxy mu nng (PaO2 < 50 mmHg, SaO2 < 85%), CaO2
gim lm gim TO2. Tuy nhin s gim PaO2 thng c cn bng bi s gia
tng nng hemoglobin (a hng cu th pht). Nh vy s vn chuyn oxy
thng khng b nh hng nhiu tr nhng t suy h hp cp hoc nhng lc
thiu oxy mu nng nh trong gic ng.
1.2. Phn ng tng to hng cu (a hng cu th pht)
Phn ng tng to hng cu c li do cho php bo m s vn chuyn oxy y ,
nhng c hi do lm tng nht mu v nh th gp phn lm tng khng lc
mch mu phi dn n s xut hin tng p ng mch phi.
1.3. Tc ng mn tnh trn no
Thiu oxy mn gy bt thng v thn kinh - tm thn nh ri lon ch v tr nh,
kh khn v t duy tru tng, v hnh vi kho lo, v cc ri lon vn ng gin
n
1.4. Tc ng trn huyt ng
Thiu oxy mn lm tng sc cn mch mu phi do co tht mnh, ph i tng dn
c trn thnh ng mch gy tng p ng mch phi v tng gnh tim phi. Tim b
tr s tng gnh ny cng tng tn s v cung lng tm thu m bo s cung
cp oxy. Cn lu s tng p phi l mt c ch thch nghi, gip chn la mt s
mao mch phc v ti mu tt, ci thin lin h thng kh/ti mu.
2. Ri lon c hc thng kh
2.1. Trong suy h hp mn nghn
Trong suy h hp mn nghn, th tch th ra ti a trong giy u (VEMS) gim, t
s Tiffeneau (VEMS/CV%) gim.
2.2. Trong suy h hp hn ch
Cc th tch phi gim, dung tch phi ton phn (CPT) gim, gin phi gim lm
th vo kh hn.
3. Lin h thng kh-ti muV/Q
- Tng hiu qu ni tt.
- Tng khong cht ln nhiu.
- Gim PaO2 v tng PaCO2.
4. Hot ng cc trung tm h hp
Trung tm h hp bnh nhn b suy h hp mn khng cn b kch thch bi
PaCO2 cao mn tnh, ch cn duy tr hot ng do kch thch thiu oxy mu nn khi
cho th oxy liu cao s gy c ch trung tm h hp. lm CO2 gia tng.

IV. TRIU CHNG HC LM SNG

Phi hi bnh t m mi xc nh c thi gian v trm trng kh th gng sc,
ho khc, nghin thuc l, cng nh nhim mi trng bnh nhn ang sng hay
lm vic nh ht cht c, bi.

222
Ngoi ra cc du chng ring ca tng bnh nguyn, cc du chng suy h hp
mn c th r.
1. Tm v kh th
Tm xut hin kh SaO2 di 85% (bnh thng trn 95%).Kh th khi thiu oxy
nng (nng t t do tin trin t nhin hay t ngt do bi nhim).
2. Ri lon hnh vi
Ri lon hnh vi xut hin khi PaCO2 trn 50-55 mmHg c th tin trin t nhin
tng dn hay t ngt do nguyn nhn lm d nh thuc c ch h hp. Bnh nhn
d kch thch, nhc u, ri lon thc c th sng khoi hay r, c th run p
cnh bo ng hn m do tng CO2.
3. Du tm ph mn
Do thiu oxy v do tng kh CO2: tm (Ch ch r khi c km theo tng hng cu
phn ng), du hiu suy tht phi.
4. Quan trng hn l cc du chng nh, sm hn
Thng phi lu mi pht hin c, thng gp trong suy h hp mn nghn.
4.1. Th nhanh nng km lng ngc gin rng c mc ch b tr thiu oxy v gii
hn s xp cc ph qun nh do th ra su
4.2. Du co ko chng t c gia tng p lc m mng phi do nghn ng h hp.
4.3. Tng s co cc c thang, ph i cc c ny khi th vo.
4.4. Th ra mi khp cht: mc ch lm gim hiu s p lc gia ph nang v
ming lm gim bt s xp cc ph qun.
4.5. Gin lng ngc v du HOOVER (gim ng knh ngang phn di lng ngc
khi ht vo).
4.6. Tt thi dim chy
+ H ming thi dim chy cch trn 50 cm.
+ Chm ming thi dim chy cch 100 cm.
Nu khng tt th c nguy c suy h hp mn.

V. TRIU CHNG CN LM SNG

1. Thm d chc nng h hp
- Trong suy h hp mn nghn: c gim FEV1, FEV1/FCV
- Trong suy h hp mn hn ch: cc th tch phi gim, dung tch phi ton
phn (CPT) gim, gin phi gim.
2. Kh mu: c gi l suy h hp mn khi PaO2 di 65-70 mmHg v PaCO2 >45
mmHg.
- Trong suy h hp mn va
+ PaO2 cn ln hn 60 mmHg.
+ V hay PaCO2 cn nh hn 50 mmHg.
+ SaO2 90%.

223
+ Km pH mu v Hct bnh thng.
- Trong suy h hp mn nng
+ PaO2 nh hn 60 mmHg.
+ V hay PaCO2 cn nh hn 50 mmHg.
+ SaO2 nh hn 90%.
+ Km pH thp v Hct tng.
3. Mt s thng s khc c gi tr chn on trong tm ph mn
- in tm .
- o p lc ng mch phi trc mao mch: nhy hn tm in , bnh
thng t 13-18mmHg, c o trc tip v ngoi mi t cp hay bi nhim.

VI. IU TR
1. i cng
- Chnh trm trng ca suy h hp mn quyt nh s iu tr ny. Bnh nguyn
d l ri lon thng kh do nghn hay do hn ch hoc do ri lon khuch tn ph
nang - mao mch ch c vai tr ph trong iu tr.
- trm trng ca suy h hp mn c biu th ch yu bi PaO2, SaO2 v
PaCO2, ngoi ra cn c pH mu, d tr kim, Hct.
2. iu tr suy h hp mn va
Trong suy h hp mn va, c:
- 60 mmHg < PaO2 < 70 mmHg v hay 43 mmHg < PaCO2 < 50 mmHg.
- pH mu, Hct bnh thng.
- SaO2 = 90%
2.1. Bin php chung
- Ngng thuc l hon ton v vnh vin
- a bnh nhn ra khi mi trng b nhim khng kh t nhin hay ngh nghip.
- Loi b mi nhim trng ng h hp, tiu ho trn nht l xoang v rng l
ngun gc thng gy cc nhim khun i xung.
- Thay i mt kh hu tt hn.
- Gim mp ph lm gii hn kh nng thng kh.
2.2. iu tr triu chng
* Phng chng cc bi nhim ph qun - phi
- Vaccin chng cm v chng mt s vi khun d gy nhim khun
- iu tr thch hp mnh mi t bi nhim ph qun - phi, iu tr bng khng
sinh thch hp, mnh, dung np tt ti phi nh khng sinh h Macrolide:
Roxithromycine [Roxid], Rulid, 150 mg, 2 vin/ngy chia 2 ln], hay khng sinh h
Cephalosporine (Cephadroxil [Opedroxyl, Oracefal], 500 mg, 3 vin/ngy, chia 3 ln,
trong thi gian trn 8 ngy.
* Tho m

224
- Ch yu bng vn ng liu php: v rung lng ngc tip theo l tp khc m vi
c gng ti a, tp h hp ng cch, tn dng s hp tc lc c honh v c thnh
bng.
- Thuc tan nhy nh Acetylcysteine (Acemuc) 200 mg, 3 gi/ngy chia 3 ln.
- Thuc iu ho nhy nh Ambroxol (Mucosolvan), 30 mg, 3 vin/ngy, chia 3 ln.
* Thuc gin ph qun
L mt phng tin iu tr chnh, lu di, d thm d chc nng h hp c hay
khng c pht hin co tht ph qun.
-Theophylline nhanh (vin Theophylline 100mg) hay chm (vin Theodur, 200 mg
hay 300 mg), 10-15 mg/kg/ngy, nu dng loi nhanh th chia 3-4 ln, nu dng loi
chm th 2-3 ln.
- Salbutamol nhanh (vin Ventolin, 2 mg hay 4 mg) hay chm (vin Volmax, 4 mg
hay 8 mg), 0,2 - 0,3 mg/kg/ngy, nu dng loi nhanh th chia 3 ln, nu dng loi
chm th chia 2 ln.
2.3. Chng ch nh
- Thuc an thn, thuc ng v c th gy c ch trung tm h hp.
- Mt s thuc khng c tc dng, thm ch nguy him nh Corticoid, thuc kch
thch h hp (v ch lm mt c h hp, tng kch thch), chng ng ko di.
3. iu tr suy h hp mn nng
Trong suy h hp mn nng c:
- PaO2 < 60 mmHg v hay PaCO2 > 50 mmHg.
- pH mu thp, Hct tng.
- SaO2 < 90%.
3.1. Cc bin php iu tr trn c p dng trit .
3.2. Thuc ci thin trao i kh oxy
Almitrine bimesilate (Vectarion) 15 mg, 3 vin/ngy, chia 3 ln.
3.3. Liu php oxy
- Rt cn thit, phi duy tr PaO2 trong khong 60-80 mmHg, cho oxy vi lu lng
thp 0,5 - 1,5 lt/pht trnh c ch trung tm h hp, thng dng khong 1l/pht
-S th oxy ny phi c thc hin ng k thut: phi t xng mi hng kh
su, oxy phi qua mt bnh nc sch, c o lu lng chnh xc, theo di k, tt
nht l bng kh mu, lc u o kh mu 2ln/tun, sau 1ln/thng.
- Thi gian th mi ngy 12-15 gi/ngy mi bo m c s bnh thng ho
cc yu t chnh nh p lc ng mch phi, Hct v gim kh th gng sc.
3.4. Th my
Khi cc bin php trn khng c hiu qu
4. Mt s bin php iu tr d dt
- Corticoide: s dng trong hen ph qun nng, bnh phi tc nghn mn tnh

225
- Thuc tr tim: Digoxine khi c suy tim, tuy nhin d gy lon nhp nh vy c hi
hn l c li.
- Li tiu: nh Furosemide c th gy nhim kim, gy c ch trung tm h hp
(nhim kim l do tng thi ion hydro v ti hp thu bicarbonat).

226

TRN DCH MNG PHI KHNG DO LAO

Mc tiu
1. Trnh by c nh ngha v dch t hc ca trn dch mng phi.
2. Phn tch c bnh nguyn ca trn dch mng phi.
3. Trnh by c triu chng lm sng v cn lm sng cc th trn dch mng
phi.
4. Chn on c trn dch mng phi, chn on phn bit.
5. Trnh by c bin chng v d chng ca trn dch mng phi
6. Trnh by c cc phng thc iu tr: iu tr nguyn nhn, iu tr triu
chng, iu tr h tr v ch nh iu tr ngoi khoa trn dch mng phi.
Ni dung

I. I CNG
Trn dch mng phi (TDMP) l bnh thng gp trong cc bnh l ca b my h
hp, chn on xc nh TDMP thng khng kh lm, nhng chn on nguyn
nhn mi l iu quan trng v quyt nh hng iu tr.
Ty thuc vo nguyn nhn v din tin bnh m dch mng phi c nhiu tnh cht
khc nhau v mu sc (trong, vng chanh, c, m, mu, trng c..) v sinh ha
(dch thm, dch tit, mu...), v t bo (bch cu a nhn, lymphocyte, hng cu, t
bo ni m), v vi trng v cc tnh cht khc.

II. DCH T HC
Ngoi cc TDMP c nguyn nhn ngoi phi - mng phi, nguyn nhn do nhim
trng c mt vai tr quan trng, bnh thng xy ra ngi c c a xu, c bnh
mn tnh. TDMP chim t l kh cao so vi cc bnh ng h hp di, iu tr ni
khoa nhiu lc khng hiu qu, li nhiu bin chng v d chng lu di nh
hng n chc nng h hp. Ngy nay nh c nhiu loi khng sinh tt v mnh
nn hn ch phn no t l t vong v gim nh bin chng.

III. BNH NGUYN

Ngi ta phn bit
1.Ti Phi - mng phi
1.1. Nhim trng
Thng th pht sau cc thng tn phi (vim phi, vim mng phi, abcs phi
v vo xoang mng phi, ung th phi hoi t hoc bi nhim...) hoc t cc c
quan ln cn (gan, mng tim, trung tht).
1.2. Siu vi
Nguyn pht hay th pht

227
1.3. Ung th
Ph qun, phi, mng phi tin pht hay do di cn, Bnh BBS (Besnier - Boeck Schaumann)
1.4. K sinh trng
Thng gp do amp (do pxe gan, pxe di c honh v vo xoang mng phi),
sn l.
1.5. Thng tn ng ngc v vo mng phi gy TDMP dng trp.
1.6. D ng, Hodgkin giai on nng, bnh to keo.
1.7. Chn thng ngc, phu thut lng ngc, tai bin chc d mng phi...
1.8. Khng r nguyn nhn.
2. Ngoi phi-mng phi
Thng gp l dch thm do cc bnh l tim (suy tim), gan (x gan), thn (HCTH,
suy thn), suy dinh dng.Hoc u nang bung trng (H/C Demons Meigs), bnh t
min, bnh to keo, vim ty cp.
y ch nhn mnh n nguyn nhn do vi khun sinh m, thng gp l ph
cu, lin cu, t cu vng. E.Coli, Klebsilla pneumoniae, Actinomyces,trc khun m
xanh, nu c mi thi l do hoc phi hp vi cc loi ym kh.
Cc thng tn c th nguyn pht ti mng phi nhng thng l th pht sau cc
thng tn phi, mng tim, hoc t cc c quan khc nh gan, trung tht, abcs
di c honh... hoc t ng mu n (nhim trng huyt) hoc trn mt c a
thng tn phi c sn (lao, ung th...) ri bi nhim hoc trn dch sau trn kh
mng phi.

IV.C CH BNH SINH

Bnh thng gia hai l mng phi c mt lp dch rt mng cho 2 l mng phi
trt ln nhau. Trn dch mng phi xy ra khi c tng tnh thm mao mch, gim p
lc keo trong mu, thay i p lc thy tnh, gim tun hon bch mch, xut
huyt... trong c vai tr ca vim l quan trng nht, gy dy mng phi v chn
p nhu m phi,nhng lng dch ny c th c thm tr li vo gian bo, mu,
sau khi c iu tr gim vim.
Ngi ta chia ra dch thm v dch tit da vo lng Protein, men, t bo, bch
cu... S phn chia ny c gi tr trong chn on nguyn nhn v hng iu tr.

V.TRIU CHNG
1.Th t do (th ton th): Gm c 2 hi chng
1.1.Hi chng nhim trng cp
Vi st cao dao ng, th trng gy st, bing n, v mt hc hc, li bn, nc
tiu t v sm mu, s lng bch cu tng, bch cu trung tnh tng, VS tng.
1.2. Hi chng trn dch mng phi

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1.2.1. C nng
- au xc ngc d di, tng ln khi ho hay th su hoc thay i t th. Nu trn
dch t t th t au hn
- Ho: thng l ho khan, nu km thng tn phi th i khi c m trong hoc
m c m, ho khi thay i t th.
- Kh th: Ty theo s lng dch, tc trn dch, c kh th nhanh, kh th mt
phn do st cao v au.
1.2.2. Thc th
Nhn thy lng ngc bn thng tn g cao, gian sn gin, da vng thng tn c
sng , ph n v c th c tun hon bng h. S thy rung thanh gim, n ke
lin sn rt au, g c, v m ph bo gim hay mt, nu dch t c th nghe
c ting c mng phi.
Nu trn dch qu nhiu, nht l trn dch bn tri y tim qua phi c th gy suy h
hp cp (kh th nhiu, v m hi, tm mi v u chi, nhp tim nhanh, huyt p
gim)
1.2.3. Cn lm sng
- X.quang v siu m cho bit c trn dch. Xquang thng cho thy ng cong
Damoiseau, nu c km trn kh th mc dch nm ngang, nu dch t th ch c t
gc sn honh.
- Chc d mng phi thy c dch m c, nhiu bch cu a nhn, t bo ni m
nhiu, protein cao, Rivalta (+), soi ti, cy v lm khng sinh tm thy vi khun
sinh bnh.
Lu khi khm xt phi hi bnh s tht k, khm ton thn v cc c quan ln cn
tm tiu im nhim trng tin pht hay th pht.
2.Th khu tr
Thng gp trn dch mng phi cnh vng phi b thng tn, bnh nhn c hi
chng nhim trng cp, nhng trn dch th kh xc nh bng lm sng, m ch da
vo x.quang, siu m v chc d. Ngi ta chia ra: trn dch th trung tht, th
honh, th nch, th rnh lin thy, th c vch ngn...

VI. CHN ON
1. Chn on xc nh
Chn on trn dch mng phi thng khng kh i vi th t do, da vo lm
sng, X.quang v quyt nh chn on l chc d c dch, vi th khu tr Xquang,
v siu m l quan trng v lm sng kh xc nh.
2. Chn on nguyn nhn
Da vo mu sc,sinh ha, t bo hc v mi hi ca dch mng phi v quan trng
nht l cy dch mng phi v lm khng sinh .
3. Chn on phn bit

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3.1 Vim phi khng in hnh
Da vo lm sng, Xquang v chc d khng c dch.
3.2. Dy dnh mng phi
Khong gian sn hp, Xquang c du dy dnh.
3.3. Xp phi
Khong gian sn hp film phi c m hnh tam gic, y quay ra ngoi, chc d
khng c dch.
3.4. p xe di c honh
y c honh ln cao, phi da vo Xquang v siu m.

VII. BIN CHNG V D CHNG

Ty theo nguyn nhn
1. Bin chng
V vo phi, ph qun gy p xe phi - khi m
D ra thnh ngc
Trn kh th pht hay phi hp.
Trn dch mng ngoi tim.
Nhim trng huyt.
2. D chng
2.1. Nu iu tr sm, ng th bnh s khi nhng li dy dnh mng phi, c khi
c vch ha mng phi.
2.2. Nu iu tr khng ng hay iu tr tr th s tn ti m cn trong mng phi
lm nhim trng ko di, gy xp phi, suy h hp.
2.3. Ty theo nguyn nhn gy bnh v p ng iu tr v phng php iu tr.

VIII. IU TR
Nguyn tc l sm, mnh, liu trnh, phi hp, v theo di din tin iu tr.
1. iu tr ni khoa
1.1. iu tr nguyn nhn
Phi cn c vo vi chun ca dch mng phi v khng sinh , nu cha c khng
sinh th da vo bnh cnh lm sng, tnh cht dch mng phi, kinh nghim lm
sng yu t dch t v din tin ca bnh.
Ch yu l khng sinh bng ng ton thn v ti ch vo mng phi.

230
* Khng sinh ng ton thn: Nn phi hp t nht 2 khng sinh dit khun bng
ng tim bp hay tnh mch trong cc trng hp nng, c nguy c khng thuc
cao.
- Do ph cu, lin cu: Khng sinh vn c tc dng tt hin nay l
+ Pnicilline G 1-3 triu n v/6 gi tim bp, c th phi hp vi
+ Gentamycine 3-4 mg/kg/24 gi chia 3 ln nu phn ng vi Pnicillin th dng
+ Erythromycin 1500-2000 mg/ngy chia 3 ln hay Roxycillin 150 mgx 3v/ngy.
- Do t cu vng: Hu ht t cu vng khng vi Pnicillin; nn dng
+ Cefalosporine II: (Ceclor, Keflor...) liu 3-6 g/ngy chia 3 ln TB hay TM hoc
+ Cefalosporine III (Cefomic, cefobis, claforan, Rocphin...) liu nh trn, phi hp
vi mt thuc nhm aminoside nh
+ Amiklin 1 - 2 g/ngy tim bp (TB) hay Gentamycine. Hoc l dng
+ Vancomycine 30-60 mg/kg/ngy TB hay TM phi hp cc loi k trn.
- Do Klebsiella pneu. (Friedlander). Dng nhm aminoside nh
+ Amiklin1 - 2 g/ngy tim bp hay Gentamycine v/hay l
+ Cefalosporine III liu 3-6 g/24 gi chia 3 ln TB hay tnh mch (TM).
+ Tobramycine 3-5 mg/kg/24 gi TB hay TM.
- Do vi khun k kh:
+ Pnicillin G: liu 4- 12 triu n v/ngy TB, TM chia 4 ln phi hp vi
+ Metronidazole 250 mg x 4-8 vin/ngy v thm Gentamycine nu cn, hoc
+ Clindamycin (Dalacin C) 300-450 mg x 4 ln/ngy hoc
+ Cefalosporine III liu nh trn.
- Do Pseudomonas: Dng
+ Cefalosporine III phi hp Gentamycine hay Kanamycine hoc dng
+ Carbenicilline 70 mg/kg/8 gi TB hay TM phi hp 1 aminoside.
Nu khng tm thy vi khun th da vo bnh cnh lm sng, yu t dch t, kinh
nghim thy thuc...
* Khng sinh vo mng phi: Thc hin sau khi chc d tho dch mng phi, sc
ra mng phi bng dung dch mui sinh l, a khng sinh vo mng phi, c ch
nh nht l trong trng hp mng phi dy khng sinh khng th ngm vo c.
Khng sinh ch nh a vo mng phi thng l nhm Lactamin, Gentamycin...
1.2. iu tr triu chng
* Gim au v h st: Paracetamol 500 mg x 3 - 4 ln/ngy, hoc Acetaminophene,
Diantalvic. Nu au nhiu c th dng loi Efferalgan - Codein 2 -3 vin/ngy.
* Nu kh th nhiu tho bt dch, khng qu 500 ml/ln. Hoc th oxy qua sonde
mi.
* Chng dy dnh mng phi

231
Prednisone 5 mg x 6 -10 vin/ ngy chia 2 ln hoc Hydrocortisone,
Depersolone... bm vo mng phi 1-2 ngy 1 ln.
1.3. iu tr h tr
1.3.1. Ngh ngi ti ging giai on bnh tin trin.
1.3.2. n nh, d tiu, nhiu m, calo v vitamin nhm B,C.
1.3.3. B nc v in gii , nht l c st cao, ly dch mng phi nhiu...
2. iu tr ngoi khoa
2.1. Dn lu mng phi ti thiu, sc ra mng phi v a khng sinh vo mng
phi nht l trng hp m qu c.
2.2. Bc tch mng phi khi c dy dnh, to vch, kn...
Bnh c xem l khi khi ton trng khe, n ngon, khng st,ht triu chng thc
th, X quang v chc d khng c dch, xt nghim v mu tr v bnh thng.

IX. D PHNG
Chn on TDMP thng khng kh nhng tm nguyn nhn v din tin iu tr
phc tp, c nhiu bin chng v di chng. Cc tc nhn gy bnh thng t
ng h hp do phi pht hin v iu tr sm cc nhim trng ng h hp
trn, ph qun phi, nht l cc bnh nhn c c a xu, mc bnh mn tnh...
Phi iu tr sm, mnh, y v theo di st cc bnh nhn vim mng phi
c hng gii quyt tt, phng bin chng.

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TRN KH MNG PHI

Mc tiu hc tp
1. Trnh by nguyn nhn trn kh mng phi
2. Bit cch chn on xc nh.
3. Bit cch chn on cc th lm sng ca trn kh mng phi
4. Trnh by c v iu tr chung v iu tr triu chng trn kh mng phi
5. Bit c phng php iu tr trn kh mng phi.
Ni dung

I.I CNG V NH NGHA

1.i cng
Trn kh mng phi trn kh mng phi c Laennec m t t nm 1819 v n
1888 th Galliard m t r rng hn. 1937 Sattler soi lng ngc thy bng kh ph b
v gy trn kh mng phi v sau ngi ta thy cc bng kh, kn kh phi v vo
mng phi.
2. nh ngha
Trn kh mng phi l tnh trng kh lt vo gia 2 l mng phi lm xp phi, c trn
kh mng phi hon ton v khng hon ton.
Gm c:

Trn kh mng phi nguyn pht

Trn kh mng phi th pht

II. DCH T HC
Trn kh mng phi t pht thng gp ngi tr t 20-30 tui, t l nam 4/1 so
vi n. Theo Salmeron.(1995) th t l hng nm ca trn kh mng phi l
9/100.000 dn, ti pht >28%.
- Khong 20% trn kh mng phi l bin chng ca cc bnh nhim trng phi.
- Khong 40% trn kh mng phi do lao v (40% khng r nguyn nhn.
- 25% trn kh mng phi ti pht sau 2 nm, 50% ti pht sau 6 nm
- Thng trn kh mng phi gp trong cn hen nng

III. NGUYN NHN

C nhiu nguyn nhn gy trn kh mng phi nguyn pht hay th pht.
1. Trn kh mng phi nguyn pht
Thng gp ngi tr v nam > n = 4 ln thng do:
- V bng kh ph
- Vim ph nang do virus
- Khng r nguyn nhn
Thng xy ra ngi c tin s ht thuc l, gng sc, ho mnh, stress...
2. Trn kh mng phi th pht

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- Lao phi
- Nhim khun ph qun - phi (20%)
- Bnh phi tc nghn mn tnh nht l kh ph thng.
- Trong cn hen ph qun
- Ung th ph qun thm nhp hay di cn mng phi.
- Bnh phi k, x phi, bi phi Silic, Sarcoidosis
- Cc bnh phi khc
3. Trn kh mng phi do chn thng, th thut thm d
- Chn thng thng lng ngc, gy xng sn lm thng phi
- Th thut chc d mng phi, sinh thit mng phi, t ni kh qun, chm cu.
- Chc tnh mch di n
- Dn lu mng phi
4. V cn

IV. C CH BNH SINH

Bnh thng p lc trong khoang mng phi l m (-3 n - 5 cm H20) khi khng kh
lt vo mng phi th s lm nhu m phi co li, lng ngc dn ra nn dung tch
sng, dung tch ton phn v dung tch cn gim...
- Mc ri lon chc nng h hp do trn kh mng phi ph thuc vo mc
trn kh (xp phi) v chc nng ca phi trc khi b trn kh - C th c trn mu
mng phi sau trn kh do thng tn dy chng gia 2 mng phi.
- Thng thng th khng kh lt vo mng phi khi th vo v thot ra khi th ra,
nu th ra m kh khng thot ra c l trn kh c van do gy nn kh th tng
dn v a n suy h hp trm trng, y lch trung tht.
- Trn kh mng phi c th gy nn do vt thng xuyn thnh ngc hay qua l
tng do thng, v ph nang, v bng kh, v p xe phi...
- Nu l d ca mng phi c bt li th trn kh s tiu dn.
- Nu trn kh mng phi xy ra trn 1 dy dnh mng phi th s gy trn kh mng
phi khng hon ton.

V. LM SNG
1. Th trn kh mng phi t pht hon ton
Thng gp ngi tr (20-30tui) vi triu chng u tin l cn au ngc t
ngt d di nh dao m, lm bnh nhn khng dm th su, ho d di v ho lm
au tng ln. C th c chong nu trn kh mng phi nhanh v nhiu, mch
nhanh, nh, huyt p h, tay chn lnh, v m hi nhp th nhanh- nng, tinh thn
ht hong lo u... sau triu chng gim dn sau vi gi, vi ngy.
Khm phi nhn thy lng ngc bn tn thng dn ln, cc khong lin sn
rng, g vang nh trng, rung thanh gim v nghe m ph vo mt ton b, c th
nghe c m thi v hay ting vang kim kh. G vang, rung thanh gim v m ph

234
bo mt gi l tam chng Galliard. Giai on sau c th c g c y phi do trn
mu hay trn dch sau trn kh.
Nu trn kh mng phi nh c th triu chng c nng khng r, g vang
nh phi v biu hin suy h hp khng r rng.
2. Xt nghim cn lm sng
2.1.X quang phi chun thng, nghing
Cho thy bn trn kh mng phi lng ngc gin to, thy tng sng hn bnh
thng, ton b nhu m phi b y v pha rn phi to thnh mm ct, trung tht b
y v pha i din, c honh b y thp xung. C th thy gc sn honh tu do
trn mu hay trn dch phi hp hay mc dch nm ngang (nhiu), c khi nhn thy
cc thng tn ca ch m phi gi nguyn nhn gy trn kh mng phi.
Nu trn kh mng phi khng hon ton th ch thy 1 vng sng khu tr v thy
c l tng b dy v dnh.
2.2. Chp ct lp vi tnh
C th gip xc nh c thng tn phi di vng trn kh v gip xc nh
nguyn nhn trn kh, nhng khng phi lc no cng xc nh c.
2.3. Cc thm d khc
- Bng p lc k: Gip xc nh p lc trong mng phi nh gi l trn kh mng
phi c van hay khng, bt l d li cha.
- Soi lng ngc: Th thut ny gip nh gi kh tt thng tn ch m phi gy
trn kh mng phi nht l c ch nh khi phi dn lu mng phi v gip d phng
trn kh mng phi ti pht hay pht hin cc bng kh khc v klebs
3. Cc th lm sng
- Trn kh mng phi ton b (hon ton)
- Trn kh mng phi khu tr (khng hon ton): do c dy dnh mng phi c
- Trn kh mng phi c van: Khng kh vo mng phi nhng khng thot ra c,
y l mt th nng c th a n t vong nu khng can thip kp thi.
- Trn kh mng phi c 2 bn: Him gp, thng t vong nhanh
- Trn kh mng phi bnh nhn c suy h hp mn (COPD, Lao x...) gy suy h
hp cp/ suy h hp mn dn n suy h hp mt b.
- Trn kh mng phi th im lng: thng l trn kh mng phi khu tr, nh, i km
vi hen ph qun, kh ph thng... nn ch pht hin khi chp phim phi.

VI. CHN ON
1. Chn on xc nh
Thng khng kh vi trng hp trn kh mng phi hon ton vi triu chng c
nng rm r nh cn au xc ngc t ngt nh dao m, km biu hin suy h
hp cp (kh th nhanh, nng, tm, v m hi...) hay km chong (mch nhanh nh,
huyt p tt, biu hin ca suy tim phi cp, tay chn lnh...) v tam chng Galliard.
Chn on chnh l X quang. Vi cc th khu tr, im lng th phi kt hp vi tin
s., bnh l h hp, yu t lm d v quan trng l X quang.

235
2. Chn on nguyn nhn
Thng rt kh v khong 50% trng hp trn kh mng phi l khng r nguyn
nhn. Phi da vo tin s, bnh s v triu chng lm sng cng vi cc xt
nghim khc xc nh bnh chnh gy trn kh mng phi.
a s cc trn kh mng phi l t pht v c yu t lm d nh gng sc, ho mnh,
cn hen ph qun nng, tress...
- Phi lu cc th thut thm d lng ngc nh t ni kh qun, soi ph qun, o
tnh mch di n, sinh thit phi, mng phi xuyn thnh, chc dch mng phi,
dn lu mng phi... mt s trng hp chc d, sinh thit gan, chm cu v mt s
cc th thut khc.
- Chn thng lng ngc: thng gp l gy xng sn.
3. Chn on phn bit
- Khi thng phi: thng c 2 phi, khng c triu chng c nng cp tnh, m ph
bo gim ton b 2 bn, c th c biu hin suy h hp mn, xc nh chn on
bng X quang..
- Kn phi: Hnh nh X quang v cn thit th ct lp vi tnh.
- Hang phi: Cn c vo tin s,bnh s v hnh nh X quang.

VII. BIN CHNG V D CHNG

1. Bin chng
- Trn mu, dch mng phi sau trn kh.
- Nhim trng m mng phi qua khng kh vo mng phi
- Suy tim phi cp, suy h hp cp
- Trn kh mng phi c van.
2. D chng
- Dy dnh mng phi
- Trn kh mng phi mn (khng hi phc)
- Trn kh mng phi ti pht sau nhiu nm

VIII. IU TR
1. iu tr h tr
- Ngh ngi ti ging trong giai on cp, cho nm t th fowler nu c suy h hp
cp.
- Trnh lo u, xc ng: Phi c yn tnh, c th dng thm thuc an thn nh
Seduxen hay Diazpam, valium 5 mg x 1 - 2 vin/ngy nhng phi lu bnh nhn
c suy h hp mn.
- Khng lm vic gng sc sau cn cp
- n nh d tiu, ngng ht thuc
2. iu tr chung

236
- Gim au: nu au nhiu c th dng Paracetamol hay Acetamynophen 500 mg x
3 - 4 vin/ ngy.
- Gim ho: v ho c th lm au ngc tng ln hay lm kh th: dng loi c ch ho
nh: Paxeladin 3 v/ngy (khng c ch trung tm h hp).
Th oxy qua sond mi liu trung bnh 2-3l/1' nu c suy h hp nhng phi lu
loi trn kh c van hay khng c van.
- Khng sinh: thng trn kh mng phi s b bi nhim do vi khun t khng kh
hay t ph qun phi vo mng phi. Nn dng khng sinh ng ton thn v loi
c ph khun rng nh Cefalosporin III: 3 - 4g/24 TB hay TM.
3. iu tr trn kh
Mc ch l lm cho ch m phi dn ra, trnh suy h hp cp v xp phi. Phng
php ch yu l ht kh mng phi bng bm tim, v tr thng chn l gian sn II
trn ng trung n.
Ty theo loi trn kh m c ch nh khc nhau.
* TKMP ng: thng thng th kh t hp th tr li sau mt thi gian, nu 3 - 4
ngy sau m lng khng gim kh th c th dng bm tim ln v kim ht,
khng nn ht sm, v ch ht t t, lng t trnh gy shock do thay i v tr
cc tng hoc gim p t ngt.
* TKMP m: phi dn lu mng phi bng catheter vi p lc m, a vo lin
sn II ng trung n hay lin sn 4 - 5 ng nch trc, a ng thng v
pha nh phi, hoc dng my ht (- 20 n 40 cm H20). Sau 3 - 5 ngy th kp ng
thng li: 24 - 48 gi xem trn kh c tr li hay khng, theo di mch, nhit,
huyt p v kim tra bng X quang nh gi.
* TKMP c van: y l mt cp cu ni khoa nn phi tin hnh nhanh.
- Nu khng c iu kin th dng kim ln chc vo mng phi v tr nu ni vi
dy chuyn Serum a vo mt hnh cha Nacl 9, nhng cu dy chuyn xung
10 -15 cm.
- Nu c dng kim loi 14 - 16 Gi chc ht c qua my lin tc, p lc ht 15 cmH2O.
4. iu tr d phng trn kh ti pht
- C th tm thng tn gy TKMP bng phng php ni soi xc nh nh m
kn kh, bt l thng l tng...
- Lm dy dnh mng phi bng keo sinh hc.
5. iu tr nguyn nhn gy trn kh mng phi
Vit Nam nguyn nhn thng gp nht l do lao, ngoi ra do nhim trng, siu vi
v mt s yu t khc do phi xc nh nguyn nhn iu tr nhm trnh
TKMP ti pht hay nng ln.
Lu trnh cc yu t lm d nh gng sc, stress, ho mch, ht thuc l.
6. iu tr ngoi khoa
Ch nh iu tr ngoi khoa khi c cc trng hp sau.
- Trn kh - trn mu mng phi do chn thng

237
- Trn kh - m do v p xe phi hay do lao
- Trn kh mng phi do chn thng ngc. (chn thng h, gy xng sn, d
vt...)

238

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

I. I CNG V NH NGHA
p xe phi l mt tnh trng nung m, hoi t ch m phi sau mt qu trnh vim
cp, m nguyn nhn ch yu l vi khunn m, k sinh trng...
Ngi ta chia ra lm hai loi
1. Nung m phi tin pht: L s nung m cp tnh vng phi cha c tn thng
c.
2. Nung m phi th pht: L nung m xy ra trn mt thng tn phi c sn
nh hang lao, nang phi, ung th phi hoi t, gin ph qun.
Bnh c bit t lu, nhng s chn on c r rng hn t khi c quang
tuyn X.

II. DCH T HC
C rt nhiu hi ngh v ti liu ni v p xe phi v bnh ny trc y chim t l
kh cao. Nhng k t khi c cc phng tin gip chn on nguyn nhn v nht
l c nhiu loi khng sinh mi, c hiu nn t l ny gim i nhiu. Ap xe phi
chim t l 4,8 % cc bnh phi (Chu Vn 1991), hay chim 3% cc bnh phi
iu tr ni tr vin lao v bnh phi (Nguyn Vit C 1987)
Bnh thng gp mi la tui, nhng tui trung nin c t l cao hn, bnh xy ra
nhiu hn nhng ngi c a suy kit, gim min dch, nghin ru, thuc l, i
tho ng, cc bnh phi mn tnh. Din tin bnh ty thuc vo chn on
sm, iu tr ng v liu trnh.

III. BNH NGUYN

1. Cc tc nhn gy bnh
1.1. Vi khun k kh: y l nhng vi khun thng gp nht, chim t l khong
60% (Cameron 1980), hay 89% (Barlett 1982), d pht hin chng v hi th v m
rt hi thi, chng c th gy nn nhng p xe lan ta, bn cp v thng kt hp
vi cc loi vi khun khc nh lin cu, ph cu... Cc loi vi khun k kh thng
gp l Bacteroide melaniogenicus, Fusobaterium nucleotum, Bacteroide fragilis
Peptococus, Peptostreptococcus...
1.2. T cu vng: Thng gp tr em nh nht l tr cn b, cc triu chng lm
sng nh st cao, ri lon tiu ha (nn, chng bng...) st cn. Bnh cnh lm

239
sng va phi va mng phi (trn kh, dch mng phi) gy suy h hp, nhim
trng nhim c nng.
1.3.Klebsiella Pneumoniae (Friedlander): Tin trin lan rng rt nhanh, khi huyt,
bnh cnh rt nng v nguy c t vong cao.
1.4.Nhng vi khun khc: Nh ph cu, lin cu,nhm A hay tan mu, cc vi khun
Gram (-) nh Pseudomonas aeruginosa, Hemophillus influenzae, Legionella
pneumophila.
1.5.K sinh trng: Thng gp nht l amip, c th l nguyn pht nhng hu ht l
th pht sau Aaip gan, rut, thng tn thng gp l y phi, phi st vi c
honh v thng km thng tn mng phi (phn ng), m c mu chocolat
nhng thng gp l mu ti. C th t gp hn l nm.
2. Cc nguyn nhn thun li: Gy p xe phi th pht
2.1.Cc u phi, ph qun gy nghn, bi nhim hay hoi t (ung th)
2.2.Gin ph qun: Va l nguyn nhn va l hu qu ca p xe phi
2.3.Trn nhng thng tn phi c sn: hang lao, kn phi bm sinh...
3. Yu t lm d
3.1.Cc chn thng lng ngc h, t ni kh qun.
3.2.Nhng c a xu: i tho ng, suy gim min dch, suy dng nng,
nghin ru...

IV. C CH BNH SINH

a s p xe phi l nguyn pht, vi khun gy ra p xe phi theo cc ng vo sau
y:
1. ng kh- ph qun
Do ht vo t khng kh, cc sn phm nhim trng mi hng, rng - li, amygdal,
cc phu thut tai mi hng, rng hm mt, cc d vt ng th, trong lc hn
m, t ni kh qun, tro dch d dy... Do bnh nhn b ri lon phn x nut,
khng ho v khc m c, lit cc c h hp, c honh, tt nghn ng th
gy ng...
2. ng mu
Do vim tnh mch, vim ni tm mc, gy thuyn tc,nhi mu v p xe ha, hoc
t mt tiu im xa n (nhim trng huyt) thng gy p xe nh c hai phi.
(thng gp do t cu vng)
3. ng k cn
p xe di c honh, p xe gan do amip, p xe mt qun, p xe trung tht, p xe
thc qun, vim mng phi m, vim mng ngoi tim... hay do ng bch mch.
Mt s trng hp p xe phi th pht trn mt hang phi c trc nh hang lao,
kn phi hay mt s bnh c trc nh gin ph qun, ung th phi hoi t hay u
gy tc nghn ph qun...

V. GII PHU BNH

S hnh thnh apxe phi qua giai on

240
- Lc u trong nhu m phi b vim xut hin mt hay nhiu vim ha m, nhu m
phi b ng c, nu iu tr giai on ny th thng tn c th phc hi hon
ton. Nu khng th cc vim ny s hoi t lan rng v kt hp li thnh mt
ln hoi t v c m. y l giai on nung m cp v p xe phi hnh thnh, c
v mng bao bc. Sau thng tn cc ph qun ln cn v bnh nhn s khc ra
m, v cc t chc hoi t.
- Sau mt thi gian (khong 6-8 tun) th vim x bt u bao quanh p xe to nn
nhiu vch ngn, hoc l m s lan qua vng ln cn gy nn cc thng tn mi.
- Sau khong 12 tun l th v x dy v tr thnh p xe phi mn tnh, bn trong
c m ht v biu b ha t cc nhnh ph qun ln cn, nhu m ngm nhiu fibrin
v nhiu t bo lympho, c khi thng tn mch mu gy ra ho ra mu, nu thnh
ph qun b ph hy nhiu s dn n gin ph qun.

VI. TRIU CHNG HC

Do nguyn nhn no, p xe cng u din tin qua 3 giai on.
1. Giai on nung m kn
1.1. C nng: Giai on ny ch c ho khan hoc c khi khc t m. Triu chng
au ngc m , au su v tng ln khi ho hay th su, t kh th tr khi thng tn
phi lan rng hay do tnh trng nhim c nhim trng nng.
1.2. Tng qut: st cao, rt run, mt mi, chn n, gy st, v mt hc hc, nc
tiu t, sm mu.
1.3.Thc th: Thng rt ngho nn,c khi ging mt hi chng ng c phi
khng in hnh.
1.4. Cn lm sng
- Xt nghim mu thy bch cu tng, bch cu a nhn tng, mu lng cao.
- Chp phim phi c th thy mt hnh m trn hay bu dc, thng gp y phi
phi hn.
2. Giai on khi m
Sau thi gian nung m khong 5-7 ngy ty loi vi khun, bnh nhn au ngc tng
ln, ho nhiu, tnh trng suy sp, hi th hi, c th c khi huyt trc ri sau
au ngc v ho nhiu ri c ra nhiu m, thng rt hi thi, s lng c khi 300400 ml,c trng hp ch ho ra m t, tng bi c nh hnh ng xu v ke di. Sau
khi c m th ngi cm thy d chu hn, st gim, au ngc gim dn.
3. Giai on nung m h
Sau thi gian t 3-5 ngy,tnh trng nhim trng gim dn, du c nng gim nu c
iu tr tt. Nhng thng l hi chng nhim trng ko di, th trng suy sp nhiu
do m cha c tng ra ht gy vim nhim ko di v c khi lan rng thm, do
iu tr khng ng hay sc khng xu. Biu hin suy h hp mn, ngn tay hnh
di trng.
Khm phi giai on ny c hi chng hang vi ran m to ht, m phi hang v
c th nghe c ting ngc thm.Chp phim phi thy c mt hnh hang trn, b
dy, c mc hi- nc. Quan trng nht l xt nghim m tm nguyn nhn gy
bnh khi cha x dng khng sinh.

VII. CHN ON

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1. Chn on xc nh
Giai on nung m kn thng kh khn v triu chng ngho nn, khng in hnh,
nu c th th ch da vo X quang v siu m.
Trong giai on c m th chn on tng i d dng hn. Ni chung chn on
da vo:
- Hi chng nhim trng cp.
- Khi m nhiu (hoc m hnh ng xu), hi thi.
- Hi chng hang, quan trng l X quang phi c hnh nh mc hi - nc.
- Ngn tay hnh di trng.
2. Chn on nguyn nhn
Ch yu l cy m, lm khng sinh (khi cha s dng khng sinh) nu tm amip
th phi ly m c mu v em xt nghim ngay.
Lu hi k bnh s, tm yu t thun li gy bnh.
3. Chn on phn bit
3.1. Giai on nung m kn: phn bit vi
- Vim phi: c th din tin lnh hn hay c th s pxe ha.
- Cc khi u phi: c th lnh tnh hay c tnh,hi chng nhim trng khng c, c
khi huyt, lm sng, X quang v soi ph qun... gip chn on phn bit.
3.2. Giai on nung m h: phn bit
- Ung th ph qun - phi hoi t, hay cng c th l nguyn nhn ca p xe phi.
Trng hp ny th trong lng khi u hoi t khng u, khng c mc hi-nc,
ni soi, sinh thit v tm t bo l trong m xc nh.
- Gin ph qun bi nhim: Trong tin s c ho khc m ko di, chp ph qun c
cn quang gip chn on. Lu p xe phi thng l bin chng ca gin ph
qun.
- Hang lao bi nhim: thng hang nm vng nh phi, b mng, ho ra mu, BK
m thng dng tnh, phim phi khng thy mc hi nc.
- p xe gan v vo phi: qu trnh bnh l l triu chng gan trc sau n
phi. Siu m, x.quang gip chn on.

VIII. TIN TRIN V BIN CHNG

Phi theo di bnh lin tc v nhit , triu chng lm sng, s lng v tnh cht
ca m khc ra, cng thc mu, tc mu lng. Phim phi phi c chp hng
tun, sau 1 thng, 3 thng, 6 thng... cho n khi khi hon ton.
1. Din tin
Trc khi c khng sinh th p xe phi l bnh rt nng, t l t vong cao, nht l tr
em v ngi gi.
1.1. Ngy nay nh c khng sinh tt, c hiu nn iu tr ni khoa y c th
khi bnh hon ton. Thng thng nhit gim dn sau khi khi m, s lng m
gim dn v c th ht sau 7-10 ngy iu tr, nhng xt nghim v mu lng v c

242
bit l x.quang th chm hn nhiu c khi 3-6 tun sau, li x hoc khng cn di
chng g trn phim phi c.
1.2. li hang tha: tn ti rt lu v c th xem nh lnh bnh nu trong qu trnh
theo di trn X quang khng c g thay i (v mng, khng c dch...)
1.3. p xe phi mn: Sau 3 thng iu tr tch cc bnh thoi trin, ht hi chng
nhim trng cp, ngng khi m, nhng bnh khng lnh hn v c tng t khi
m tr li thng tn trn phim tn ti mi hay c xu hng lan ta hay thm mt
p xe khc, c du ngn tay di trng r.
2. Bin chng
2.1. Ho ra mu nng: C th do p xe n vo cc mch mu ln.
2.2. Trn dch tng dch si hay trn m mng phi li di chng dy dnh mng
phi, gy suy h hp mn.
2.3. Gin ph qun, x phi
2.4. Nhim trng huyt
2.5. p xe phi mn tnh.
2.6.T vong: do bnh nng, hoc do bin chng, c trng hp t vong ngay sau
khi c m do tt ph qun v phn x co tht ph qun (sc phi)

IX. IU TR
1. Nguyn tc iu tr
iu tr p xe phi phi tun theo nhng nguyn tc sau y
+ iu tr ni khoa kp thi, tch cc, kin tr.
+ Nu c th la chn khng sinh theo kt qu ca khng sinh th p xe
phi s chng khi.
+ Ch nh m sm trc khi c cc bin chng nng nh ho ra mu nng,
vim m mng phi.
2. iu tr c th
2.1. iu tr ni khoa
2.1.1. iu tr h tr
(1) Tit thc: nhiu protide, cung cp y nng lng, c th chuyn huyt
tng ti hay kh hay lipofundin hay cc loi dung dc acide amine nh Alvesine,
Cavaplasmal...phi hp vi vitamine nhm B nh Becozyme tim.
(2) Dn lu t th: cho bnh nhn khc m v m d dng.
(3) Ht ph qun: bng ng ht mm t tn p xe ht m v cc cht
m ra, y l mt phng php dn lu tt hn.
(4) iu chnh ri lon nc v in gii: nu c thng mt nc do st cao,
hay ri lon in gii v toan kim do suy h hp cp, gp trong nhng trng hp
nng.
(5) Th oxy: khi c tnh trng suy h hp cp, bng ng xng mi, cung lng
cao khong 6 lit/pht, nu c suy h hp mn th th oxy vi cung lng thp
khong 2 lt/pht.

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2.1.2. iu tr bng khng sinh
(1) Vi khun k kh
+ Penicilline G liu cao khong 20 triu n v/ngy, tim bp hay tim tnh
mch chia 3-4 ln hay chuyn tnh mch ho trong Glucoza 5% ri u; c th phi
hp vi Metronidazole 250 mg, 4-6 vin/ngy, chia 4 ln hay Tinidazole 500mg,
3vin/ngy, chia 3 ln, hay Metronidazole, chai, hm lng 500 mg, liu lng 20-30
mg/kg/ngy, chuyn tnh mch cch nhau 12 gi, c hiu qu cao trn Bacteroide
fragillis v Fusobacterium. Ngi ta thng phi hp vi mt aminoside nh
Gentamicine, ng, hm lng 40 mg v 80 mg, liu lng 1-1,5 mg/kg/8 gi, tim
bp hay chuyn tnh mch chm hay Amikacine (Amiklin), chai, hm lng 250 mg,
liu lng 15 mg/kg/ngy c th dng 1, 2 hay 3 ln tim bp hay chuyn tnh mch
chm.
+ Clindamycine (Dalacine), vin nang, hm lng 75 mg v 150 mg, liu
lng 15 mg/kg/ngy, hoc 1 vin 150 mg cho 10 kg cn nng/ngy hoc 1 vin 75
mg cho 5 kg cn nng/ngy, c hiu qu cao trn Bacteroide fragillis v
Fusobacterium.
+ Cefoxitine (Mefoxin), chai, hm lng 1 g v 2 g, liu lng 1-2 g/8 gi,
tim bp hay tim tnh mch chm, c th chuyn tnh mch, c hiu qu cao trn
Bacteroide fragillis v cc vi khun k kh khc.
(2) Klebsiella pneumoniae
y l mt loi vi khun c c tnh cao, gy tnh trng nhim trng nhim c rt
nng do phi c iu tr nhanh v tch cc.
Ngi ta thng phi hp Cefalosporine th h 3 nh Cefotaxime (Claforan), chai
nc, hm lng 1 g; chai bt, hm lng 500 mg; hay Ceftriaxone (Rocephine)
chai nc, hm lng 2 g; chai bt, hm lng 1 g; liu lng trung bnh 50-60
mg/kg/ngy, trong trng hp bnh nng c th tng ln 200 mg/kg/ngy, chia 3 ln,
tim bp hay tim tnh mch, c th chuyn tnh mch. Phi hp vi aminoside nh
Gentamicine hay Amikacine, liu lng nh trnh by trn.
(3) Staphylococcus aureus
+ Staphylococcus aureus ngoi bnh vin: l loi vi khun nhy cm vi
Methicilline (MS), th ngi ta dng Cefazoline, chai, hm lng 500 mg v 1 g, liu
lng 25-50 mg/kg/ngy, chia 2 hay 4 ln, tim bp, tim tnh mch trc tip hay
chuyn tnh mch. Ngoi ra c th dng Cefadroxil (Oracefal), vin nang, hm lng
500 mg, liu lng 50 mg/kg/ngy, chia 3 ln. C th phi hp vi Clindamycine
(Dalacine), ng, hm lng 600 mg, liu lng 15-40 mg/kg/ngy, tim bp hay ho
vi chlorure natri sinh l hay glucoza 5% tim tnh mch chm.
+ Staphylococcus aureus trong bnh vin: l loi vi khun khng
Methicilline (MS), th ngi ta dng Vancomycine (Vacocime), chai bt, hm lng
125 mg, 250 mg, 500 mg, liu lng 30 mg/kg/ngy, tim tnh mch hay chuyn tnh
mch trong 60 pht, chia 2-4 ln; hay Cephalosporine th h 3 (Cefotaxime:
Claforan; Ceftriaxone: Rocephine) hm lng v liu lng nh trnh by trn;
phi hp vi Gentamicine hay Amikacine. Ngoi ra c th dng phi hp vi
Ofloxacine, vin, hm lng 200 mg, liu lng 2 vin/ngy, chia 2 ln.
(4) Pseudomonas aeruginosa

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Thng dng phi hp mt loi Betalactamine nh Carboxypenicilline
(Carbenicilline), liu lng 70 mg/kg/4 gi tim bp hay tim tnh mch chm; hay
Ureidopenicilline (Mezlocilline), liu lng 35 mg/kg/4 gi tim bp hay tim tnh
mch chm hay mt loi Cephalosporine th h 3 phi hp vi mt Aminoside.
Trong trng hp khng phn lp c vi trng th nn phi hp
+ Mt Cephalosporine th h 3 phi hp vi mt Aminoside v Metronidazole.
+ Penicilline G phi hp vi mt Aminoside v Metronidazole.
+ Cephalosporine th h 3 phi hp vi mt Aminoside hay vi Vancomycine.
Thi gian iu tr tu thuc vo tnh trng bnh, trung bnh phi 4-6 tun.
(5) Amp
Phi hp Metronidazole 250 mg, 4-6 vin, chia 4 ln, hay Tinidazole 500 mg, 3
vin/ngy, chia 3 ln hay Metronidazole, chai 500 mg, liu lng 20-30 mg/kg/ngy,
chuyn tnh mch cch nhau 12 gi, phi hp vi Dehydroemetine, ng, hm lng
20 mg, liu lng 1 mg/kg/ngy trong 10 ngy.
2.2. iu tr ngoi khoa
iu tr ct b phn phi b p xe c ch nh trong trng hp p xe phi chuyn
sang th mn tnh, ngha l sau 3 thng iu tr ni khoa khng c kt qu.
Ngoi ra c th m cp cu trong trng hp bnh nhn ho ra mu lin tip nhiu
ln, mi ln khong 200 ml.

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GIN PH QUN
Mc tiu
1. Trnh by c bnh nguyn v gii phu gin ph qun.
2. Lit k c cc triu chng lm sng v cn lm sng gin ph qun.
3. Trnh by c tin trin v bin chng gin ph qun
4. Trnh by c cch iu tr gin ph qun..
5. Nu c cc bin php d phng gin ph qun.
Ni dung

I. NH NGHA
Gin ph qun l s gin khng hi phc cc ph qun nh v trung bnh km theo
s lon dng cc lp ph qun v a tit ph qun, c th do bm sinh hay mc
phi, thng b bi nhim nh k. Gin ph qun gp nam 4 ln nhiu hn n.

II. BNH NGUYN

1. Mc phi
Hin nay c xem nh l thng gp nht; nhng th ny c th khu tr hay
lan ta.
1.1. Th khu tr
- Nhng nguyn nhn gy hp ph qun mt phn: gy nn s dch tit dn
n nhim trng v ph qun b gin ra, i khi trong 2 - 3 tun l. Nhng nguyn
nhn ny thng ch c pht hin nh ni soi ph qun, trc tin l khi u c
th lnh tnh hay c tnh, c th l vt l nht l i vi tr em, c th l lao bi
nhng l d hay u ht t mt lao s nhim tin trin hay trn di chng calci ha.
- p xe phi: di chng so x hay trn mt p xe phi mn tnh.
- Aspergillose ph qun: t gp hn nhng rt c bit l c s phi hp vi
nhng biu hin tng nhy cm type I v type II (tm nhng cht kt ta khng
aspergillus), c th c tng bch cu i toan v khu tr ph qun rt gn gc, nh
vy ch tn thng cc ph qun ln cn cc ph qun trc tn cng cn tt (bnh
Hinton).
1.2. Th lan ta
- Di chng ca cc bnh ph qun - phi cp nng trong thi k thiu nin:
c th b qun lc khi u hi chng a tit ph qun - phi. Si v ho g l 2 bnh
thng gp nht, nhng bnh nhim siu vi nng nht l do Arbovirus l nhng
nguyn nhn gy nn di chng gin ph qun.
- Bnh nhy nht (bnh x ty tng nhy - kn): l nhng bnh bm sinh di
truyn; trong nhng bnh ny c ri lon v tit dch do s thanh lc b chm li, gy
nn nhng nhim trng ph qun - phi ti pht dn n nhng th gin ph qun
rt nng vi suy h hp mn v cht trc thi k trng thnh.
2. Bm sinh
Gin ph qun thng l lan ta, rt t gp.
2.1. Bnh a kn phi: thng phi hp vi a kn thn, ty v gan.

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2.2. Suy gim min dch
- Suy gim min dch th dch: Suy gim ton th hay khng c (globuline
mu, suy gim chn lc IgA huyt thanh hay ngay c ch suy gim IgA tit.
- Suy gim min dch t bo: do tn thng s thanh lc l bnh lng bt
ng; bt thng ny thng nm trong hi chng Kartagener (gin ph qun phi
hp vi o ph tng v vim xoang sng - xoang hang).

III. GII PHU BNH

1. i th
Nhng ph qun ln khng b tn thng, do ni soi khng th pht hin c;
nhng tn thng bt u phn phn nhnh th 4 v lan ra t phn phn nhnh
th 8. Ph qun tn cng b tn thng hoc b cht thng gp nht, ch m phi
khng c h hp s gy nn hi chng hn ch, gin ph qun c gi l tn
cng; hoc ph qun tn cng cn thng vi nhng ph qun xa hn, ch m phi
cn c h hp, gin ph qun c gi l trc tn cng.
Trong gin ph qun, c nhiu dng tn thng v gii phu khc nhau:
- Hnh ti, hnh bng hay hnh gi kn gp trong gin ph qun trc tn cng.
- Hnh chui ht v hnh tr gp trong gin ph qun trc tn cng.
Thng c nhng bt thng phi hp:
- Vim ph qun trong nhng vng ln cn gy nn hi chng tc nghn phi
hp vi hi chng hn ch do gin ph qun.
- Gia tng mng li mch mu h thng, nhng tiu ng mch tr nn
ngon ngho, dn mu theo chiu ngc dng do nhng ni tt ng mch - ng
mch gi l ng mch ha tc l tnh mch phi c ly mu trong ng mch
phi pha bn b bt thng ng mch ph qun.
2. Vi th
2.1. Tn thng nim mc
Di mt lp biu b gn nh bnh thng lc u, sau b d sn v cui cng b
hy hoi, c mt mng m dy ln v thm nhim trng t bo vim v nhiu mch
mu c tn to t mch mu ph qun. Trong mt vi th bnh, nhng tn
thng vim vi s ph i lp nim mc v tng tit tri ln, gy a tit ph qun
trn lm sng. trong mt s trng hp khc, lp nim mc b teo li vi s gim
nhng tuyn thanh dch - nhy v x ha lin tuyn nang, nh vy khng c s tng
tit. Hai loi ny thng phi hp trn cng mt bnh nhn.
2.2. Tn thng di nim mc
M lin kt b tn thng phi hp vi s gim v s sp xp ln xn nhng si
n hi v si c; b ct on bi si collagen tn to v c hnh gi u c.
2.3. Tn thng sn
l tn thng thoi ha sn c thay th bi nhng m calci ha hy ct ha
hay bi s x ha collagen; nhng ph qun mt i ci ct nng v tnh n hi.
2.4. Tn thng ph nang

247
Gp phn quan trng trong ri lon chc nng h hp v trong s trao i kh oxy
phi, nhng tn thng ny rt thay i ty ngi bnh, ty v tr cng mt bnh
nhn, l vim phi li teo hay ph i, vim ph nang xut huyt, xp phi.

IV. TRIU CHNG LM SNG

1. Triu chng chc nng
1.1. Khc m
Gp 80 % trng hp gin ph qun.
- Thi im: nhiu nht vo bui sng, i khi ri u trong ngy.
- Lng: thay i ty theo tng bnh nhn, thng l nhiu, khong t 20 100 ml / ngy,
hay c th nhiu hn trong t cp; tuy nhin c nhng th kh, khng khc m.
- Mi v: lt, mi thch cao, i khi c mi hi; nu lng s c 4 lp t trn
xung di
l: m bt, m thnh dch nhy trong, m mi nhy, m m c.
- Phn tch: t c v nhim trng thng km theo.
1.2. Ho
L triu chng thng km theo khc m.
1.3. Ho ra mu
Quan trng, gp trong 8 % trng hp, c th km theo m hay i khi n c.
Ho ra mu c th di hnh thc tia mu mu hn l en chng t c t vim
hay ho ra mu c s lng nhiu hn mu chi tng ng vi s chy mu h
thng c xem nh bin chng.
1.4. Kh th
t gp, mc d mt s gin ph qun ch c chn on giai on suy h hp
mn.
2. Nhng biu hin khc
2.1. Nhng nhim trng phi - ph qun cp ti pht nhiu ln
Vi st va 38o - 38o5, c 2 c im l v tr nhim trng c nh gi c bt
thng bn di, tng trng thng khng thay i.
2.2. Trn dch mng phi thanh dch - si hn l m
3. Khm lm sng
3.1. Hi bnh
Chnh xc nhng tnh hung pht hin bnh, thi gian b bnh; trn thc t, thng
khng chnh xc, c th trong thi k thiu nin bnh nhn b bnh ho g hay si
nng. Hi bnh bit tnh chu k a tit ph qun, tn sut nhng t bi nhim
nht l vo ma ng v lin quan n nhng nhim trng mi - hng (vim mi,
vim xoang, vim amian); hi bnh bit n tin s c nhn v gia nh, ht
thuc l v ngh nghip hin ti v qu kh.
3.2. Khm thc th

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- Khm phi: c th bnh thng ngoi t cp, c th pht hin ran ngy, ran
rt, ran m to ht. Khi b bi nhim c th nghe c ran n kh hay ran n t nh
ht hay hi chng trn dch mng phi.
- Ngn tay hnh di trng.
- Trong nhng th tin trin, c hai bin chng nng l suy h hp mn v
tm ph mn.

V. CN LM SNG
1. m
1.1. T bo
C nhiu t bo biu m ph qun, c nhiu bch cu a nhn trung tnh thoi ha
v cht nhy, khng c si n hi.
1.2. Vi trng: hay gp nht l Haemophilus influenza v ph cu, ngoi ra c th gp
vi trng gram m nh Pseudomonas aeruginosa; vi trng k kh; ngoi ra phi tm
BK.
2. Phim phi
2.1. Phim chun
Thng c hnh m dng li i t rn n co honh; i khi c hnh nh m mt
cch c h thng nhiu nht thy gia v thy di phi; i khi c hnh nh hoa
hng nh ging nh nhng kn kh chng ln nhau, c th c hnh nh mc nc
kh trong giai on m.
2.2. Chp ct lp t trng
Cho php pht hin d dng phn ln cc gin ph qun th hnh tr. Hin nay trong
thc t t chp nhum ph qun; chp ct lp t trng gip chn on chnh xc nht
l nhng bnh nhn b suy h hp mn.
3. Thm d chc nng h hp
3.1. o chc nng h hp: cho thy c s kt hp c hai hi chng hn ch v tc
nghn.
3.2. Kh mu
Ch ri lon trong th nng tc l trong gin ph qun c suy h hp mn v tm
ph mn, c th c PaO2 gim, PaCo2 tng, SaO2 gim.
4. Thm d ph qun
4.1. Ni soi ph qun
xc nh nhng ph qun b vim, ng thi c th ly m kho st vi
trng.
4.2. Chp nhum ph qun
t s dng t khi c chp ct lp t trng, tuy nhin vn cn thit trc khi quyt
nh phu thut; chp nhum ph qun cho thy cc loi gin ph qun sau y:
- Hnh tr hay gp nht.
- Hnh tnh mch trng hay hnh trng ht.
- Hnh bng hay ti.

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- Thng c s phi hp nhiu loi gin ph qun.
- Cng gp nhiu loi in hnh nh cy cht khng c phn nhnh tiu ph
qun - ph nang, nhng ph qun b xp li trong mt on b xp phi.
- V tr: nhng ph qun thng b thng tn nm gia ph qun
phn nhnh th 4 v th 8. Trong nhng th lan ta, bnh tri nhng thy di
(on cnh tim, on tn y), thy gia v thy li. Ngoi ra c nhng th khu tr
mt bn hay hai bn.

VI. TIN TRIN

1. Th nh
Nhng t bi nhim xy ra khng thng xuyn; bnh ch gii hn mt vng,
khng lan ra ch m phi, khng b suy h hp.
2. Th nng
Nhim trng xy ra thng xuyn, phi s dng khng sinh, sau nhiu nm tin trin
s xut hin suy h hp mn v tm ph mn; bnh nhn c th t vong sau vi
nm.
3. Bin chng
3.1. Vim phi thy, ph qun ph vim, p xe phi, trn dch mng phi.
3.2. Lao phi, p xe no bnh xng khp ph i do phi, t gp.
3.3. Ho ra mu thng gp; c th m dnh mu hay ho ra mu ton s lng
nhiu.

VII. IU TR
1. iu tr ni khoa
iu tr trong nhng t nhim trng ph qun - phi nh ph vim hay p xe phi.
1.1. Dn lu t th
L mt phng php iu tr rt cn thit, quan trng v bt buc phi thc hin cho
bnh nhn m c th thot ra ngoi, thc hin 3 ln /ngy, mi ln khong 10
pht.
1.2. Vn ng liu php
Rt cn thit bnh nhn c th khc m ra cng nhiu cng tt.
1.3. Khng sinh
- Ti tuyn trung ng th phi cy m v lm khng sinh chn la
khng sinh thch hp.
- Tuy nhin trong khi ch i kt qu cy m hay ti tuyn c s, theo y vn
th nhng vi trng thng gp l Streptococcus pneumoniae, Hemophilus influenza,
Mycoplasma pneumoniae, Legionella pneumophila; do phi dng ngay khng
sinh, thng dng l:
+ Cfalexine, 500 mg, 3 vin / ngy chia u 3 ln c th phi hp hay khng
vi mt thuc thuc nhm Fluoroquinolones nh Ciprofloxacine (Quintor), 500 mg, 3
vin / ngy chia u 3 ln hay Ofloxacine (Zanocin), 200 mg, 2 vin / ngy chia u 2
ln.

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+ Cfadroxil (Oracfal), 500 mg, 3 vin / ngy chia u 3 ln.
+ Roxithromycine (Rulid), 150 mg, 2 vin / ngy chia u 2 ln.
- Nu nng th phi chuyn bnh nhn ln tuyn trung ng iu tr,
khng sinh phi c dng bng ng ngoi tiu ha tc l ng tim tht hay
tim tnh mch hay chuyn tnh mch. Ngi ta c th dng mt loi Cphalosporine
th h 3 nh Cfotaxime (Claforan), l 1 g, tim tht 2 g / ngy chia u 2 ln hay
Ceftriaxone (Rocephine) l 1 g, tim tnh mch 1 ln 2 g / ngy phi hp vi mt
Aminoside nh Amikacine (Amiklin) l 500 mg, tim tht 15 mg / kg / ngy 1 ln hay
chia u 2 ln, nu c m hi tc l c bi nhim vi khun k kh th phi dng
thm Mtronidazol, l 500 mg / 100 ml, 3 l / ngy chuyn tnh mch chia u 3 ln.
1.4. iu tr trit cn
Cc nhim khun tai mi hng: bng cc khng sinh thch hp.
1.5. iu tr ho ra mu
Thng kh iu tr v khng c thuc iu tr c hiu.
- Nu nh c th iu tr ti tuyn c s thng dng Adrenoxyl, ng 1.500
g,
3 - 4 ng tim tht chia u 3 - 4 ln.
- Nu nng th phi chuyn ngay ln tuyn trung ng, c th dng Octrotide
(Sandostatine), ng 50 g, 100 g, tim di da 3 ng loi 50 g / ngy chia u 3
ln v phi theo di st tnh trng ho ra mu v loi ho ra mu ny rt kh cm, nu
vt kh nng iu tr ni khoa th phi hi chn vi ngoi khoa can thip phu
thut cm mu.
2. iu tr ngoi khoa
2.1. Th khu tr mt bn
Ch nh phu thut l tt nht.
2.2. Th c tn thng hai bn
- Nu tn thng cn khu tr, n nh v i xng th c th ct hai bn.
- Nu tn thng khng i xng th ct mt bn chnh.
2.3. Th lan ta
Thng khng phu thut, c th ch ct nhng tn thng chnh.
Phu thut c th p dng l ct mt vng, ct don, ct mt thy hay mt l phi.
3. iu tr d phng
3.1. Tim vacxin phng nga cm cm nu c.
3.2. Nu khng c vacxin th khi b cm cm thng xy ra vo ma thu ng th
phi dng ngay khng sinh bng ng ung nh nu trong phn iu tr d
phng nhim trng ph qun - phi.
3.3. V sinh rng ming v tai mi hng.
3.4. Chuyn ngay ln tuyn trung ng khi bnh nhn c bin chng ho ra mu
nng bng xe cp cu c trang b.

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BNH PHI TC NGHN MN TNH

Mc tiu
1. Trnh by c nh ngha, c im dch t hc, bnh nguyn, c ch sinh bnh
v sinh l bnh bnh phi tc nghn mn tnh
2. Nu c triu chng lm sng v cn lm sng v phn giai on bnh phi tc
nghn mn tnh.
3. Chn on xc nh v phn bit c bnh phi tc nghn mn tnh
4. Pht hin sm t bc pht cp bnh phi tc nghn mn tnh
5. Trnh by c phc iu tr theo tng giai on, mc trm trng bnh phi
tc nghn mn tnh v bin php d phng
Ni dung

I. NH NGHA
Bnh phi tc nghn mn tnh (BPTNMT) l mt bnh biu hin bi s gii hn lu
lng kh, s gii hn ny khng hi phc hon ton. S gii hn lu lng kh
thng xy ra t t v phi hp vi mt s p ng vim bt thng ca phi i
vi cc ht c hay kh. BPTNMT bao gm vim ph qun mn v kh ph thng.
Bao gm vim ph qun mn, kh ph thng v hen ph qun khng hi phc.
S chn on BPTNMT cn c vo triu chng ho, khc m, kh th v hay l c
tin s tip xc vi cc yu t nguy c. S chn on c xc nh bng ph dung
k. sau khi dng thuc gin ph qun m FEV1 < 80% so vi tr s d on phi
hp vi FEV1/FVC < 70%

II. DCH T HC
BPTNMT l nguyn nhn hng u ca bnh sut v t sut trn th gii. Nm
1990 theo TCYTTG thi BPTNMT ng hng th 12 trong s nhng bnh nng.
BPTNMT l nguyn nhn t vong ng hng th 4 sau bnh tim, ung th, bnh
mch mu no. Theo bo co kt qu hp nhm t vn ca Chu Thi Bnh
Dng v BPTNMT ln th VI 1 - 2/6/2002 ti Hng Kng th ti cc nc Chu
Thi Bnh Dng, t l mc BPTNMT khong 3,8%, nhng gn y qua mt s mu
nghin cu cho thy t l ln n 6,3% ngi trn 30 tui.
Theo TCYTTG v Ngn hng Th gii th t l mc bnh trn ton th gii nm
1990 l 9,34/1000 dn nam, v 7,33/1000 dn n. T l mc bnh cao nht cc
nc ang ht thuc l nhiu v ngc li.

III. NHNG YU T NGUY C

1. Nhng yu t k ch
1.1. Gnes: Yu t di truyn ng lu nht l thiu ht bm sinh 1 antitrypsine.
S pht trin sm v nhanh kh ph thng ton tiu thu
1.2. S tng p ng ph qun: nh hng n BPTNMT l khng r.
1.2. S tng trng phi: lin h vi qu trnh xy ra trong giai on mang thai, cn
nng lc sinh v s tip xc vi mi trng trong thi k thiu nin.
2. Nhng yu t tip xc

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2.1. Ht thuc l: lin h rt cht ch vi BPTNMT, iu ny xy ra c l l do nhng
yu t di truyn. Khng phi tt c ngi ht thuc l u bi BPTNMT, khong 15 20% ngi ht thuc l b BPTNMT, 85 - 90% bnh nhn b BPTNMT l do thuc l.
Ht thuc l > 20 gi / nm c nguy c cao dn n BPTNMT. Tip xc th ng vi
thuc l cng c th gp phn gy nn BPTNMT. Ht thuc l trong thi k mang
thai cng l mt yu t nguy c cho bo thai, do nh hng n s tng trng v
pht trin phi trong t cung
2.2. Bi v cht ho hc ngh nghip: nhng bi v cht ho hc ngh nghip (hi
nc, cht kch thch, khi) c th gy nn BPTNMT c lp vi ht thuc l
2.3. nhim mi trng trong v ngoi nh: Vai tr ca nhim khng kh ngoi
nh gy BPTNMT khng r. nhim mi trng trong nh nh cht t, cht t
chy t nu n v hi nng l nhng yu t gy nn BPTNMT.
2.4. Nhim khun: nhim trng h hp thi k thiu nin c th gy BPTNMT
thi k trng thnh.

IV. C CH SINH BNH

1. Vim v cc yu t nguy c ca BPTNMT
S lin quan gia ht thuc l v vim c nghin cu rt nhiu. Thuc l kch
hot i thc bo v t bo thng b sn xut ra TNF v mt s cht trung gian
gy vim nh IL8 v ILB4.
2. Mt qun bnh gia proteinase v antiproteinase
Thiu 1 antitrypsine l mt cht c ch mt s proteine thuyt thanh nh
neutrophile elastase lm gia tng nguy c gy kh ph thng; elastin l mt thnh
phn chnh ca thnh ph bo b hu bi neutrophile elastase. S mt qun bnh
gia proteinase v antiproteinase ni sinh c th gy nn s ph hu phi v c th
xy ra do s suy gim hot tnh ca antiproteinase do stress oxy ho, do thuc l v
c th do nhng yu t nguy c khc ca BPTNMT.
3. Nhng stress oxy ho
Trong BPTNMT c mt s mt qun bnh r rng cht oxy ha v cht chng oxy
ha, trong ch yu l cc cht oxy ha, l hydrogen peroxide (H2O2) v nitric
oxide (NO). Nhng stress oxy ha ngoi vic gy tn thng trc tip phi cn gp
phn vo s mt qun bnh proteinase - antiproteinase Nhng cht oxy ha cng
xc tin vim. Cui cng nhng stress oxy ha c th gp phn lm hp ng h
hp.

V. SINH L BNH
1. S tng tit cht nhy v ri lon chc nng h hp
S tng tit cht nhy l do s kch thch cc tuyn tit cht bi nhng cht trung
gian gy vim nh leucotrien, proteinase v neuropeptides. Nhng t bo lng b d
sn dng vy dn n s suy gim h s thanh thi nhy - lng.
2. S gii hn lu lng kh th v s cng phng phi
S gii hn lu lng kh th khng hi phc, mt s t c th hi phc, do hin
tng ti cu trc, x ha v hp ng th nh. Nhng v tr gii hn ng th l
tiu ph qun c khu knh < 2mm, trong BPTNMT khng lc ng th tng gp
i bnh thng. S ph hy ph bo gy kh ph thng. S gii hn lu lng kh

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c biu hin bi s gim FEV1 v t FEV1/FVC trong t FEV1/FVC gim
thng l du hiu u tin ca s gii hn lu lng kh.
3. Bt thng v s trao i kh
S mt qun bnh gia thng kh / ti mu l c ch ch yu do tn thng thnh
ng th ngoi vi v kh ph thng. Trong kh ph thng c s gim DLCO / L, t
gy nn thiu oxy mu. Tnh trng thiu oxy mu v tng kh ccbonic t xy ra
khi FEV1 < 1.00L. Lc u tnh trng thiu oxy mu ch xy ra lc gng sc, nhng
khi bnh tin trin nng th tnh trng thiu oxy mu xy ra lc ngh ngi.
nhng bnh nhn b BPTNMT nng, tnh trng thiu oxy gy co cc ng mch
khu knh nh v cc tiu ng mch.
4. Tng p phi v tm ph mn
Tng p phi xy ra chm trong din tin ca BPTNMT (Giai on III), sau l tm
ph mn. Nhng yu t gy nn tng p phi l s co mch, s ti cu trc nhng
ng mch phi. S co tht mch ngoi nguyn nhn do thiu oxy mu cn do s
tng hp hay phng thch NO b gim v s tit bt thng ca nhng peptides co
mch nh endothelin 1. S tng p phi v s gim h thng mch mu phi do kh
ph thng c th dn n ph i tht phi v suy tim phi.

VI. TRIU CHNG HC

1. Triu chng chc nng
1.1. Ho: ho mn tnh, thng l triu chng u tin ca BPTNMT, Lc u ho cch
khong, nhng sau ho xy ra hng ngy, thng sut c ngy, t khi ho ban m.
Mt s trng hp, s gii hn lu lng kh c th xy ra m khng ho.
1.2 Khc m: vi s lng nh m dnh sau nhiu t ho.
1.3. Kh th: l triu chng quan trng ca BPTNMT v l l do m hu ht bnh
nhn phi i khm bnh, kh th trong BPTNMT l mt loi kh th dai dng v xy
ra t t, lc u ch xy ra khi gng sc nh i b hay chy ln thang lu, khi chc
nng phi b gim, kh th tr nn nng hn v bnh nhn khng th i b c
hay khng th mang mt xch n, cui cng l kh th xy ra trong nhng hot
ng hng ngy (mc o qun, ra tay chn hay c lc ngh ngi)
2. Triu chng thc th
Khm thc th t c gi tr trong chn on BPTNMT. Nhng triu chng thng
gp l
+ Tm trung tm.
+ Cc khong gian sn nm ngang, lng ngc hnh thng.
+ Du hiu Hoover (dt 1/2 c honh phi hp vi s thu li vo trong nghch
l ca y lng ngc trong k ht vo).
+ Tn s th lc ngh > 20 ln / pht, nhp th nng.
+ Bnh nhn th ra vi mi mm li vi mc ch lm chm li lung kh th
ra c th lm vi phi c hiu qu hn.
+ Nghe phi m ph bo gim, c ran wheezing.
3. Nhng tt v nhng xt nghim b sung cho chn on BPTNMT

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i vi nhng bnh nhn c chn on BPTNMT giai on II v III, nhng tt v
nhng xt nghim sau y c th c s dng:
3.1. nh gi gim chc nng h hp bng ph dung k
Kt qu o ph dung l tiu chun vng chn on BPTNMT v theo di tin
trin ca bnh.
+ o FEV1 v FEV1/FVC.
+ Sau khi dng thuc gin ph qun m FEV1 < 80% so vi tr s l thuyt
phi hp vi FEV1/FVC < 70% chng t c gii hn lu lng kh khng hon ton
phc hi.
+ FEV1/FVC l t s c nhy cm cao ca s gii hn lu lng kh v
FEV1/FVC < 70% c xem nh l du hiu sm ca gii hn lu lng kh bnh
nhn b BPTNMT trong lc FEV1 vn cn bnh thng (80% so tr s l thuyt).
3.2. Tt hi phc ph qun sau khi kh dung thuc gin ph qun
+ Nhng bnh nhn khng s dng thuc gin ph qun kh dung tc dng
ngn trc 6 gi, thuc ng vn 2 tc dng di trc 12 gi hay theophylline
thi chm trc 24 gi.
+ o FEV1 trc khi s dng thuc gin ph qun.
+ Thuc gin th qun phi c s dng di dng kh dung qua mt bu
ht hay kh dung my. Liu lng thch hp l 40g ng vn 2, 80g khng
cholinergic hay phi hp c 2 loi.
+ o FEV1 li 3 - 45 pht sau khi dng thuc gin ph qun.
+ Kt qu: Mt s tng FEV1 > 200ml v trn 12% so vi FEV1 trc khi s dng
thuc gin ph qun c xem nh l c gi tri.
5.3.Kh mu: nhng bnh nhn b BPTNMT lu nh gi tm ph mn.
5.4. Chp phim lng ngc: cho thy kh ph thng.

VII. PHN GIAI ON BPTNMT THEO TRIU CHNG LM SNG

+ Giai on 0: c nguy c.
+ Giai on I (BPTNMT nh): Ho mn tnh v khc m, thng bnh nhn
khng ch n.
+ Giai on II v III(BPTNMT va v nng): Bnh nhn thng kh th khi
gng sc, y l giai on m bnh nhn i khm bnh c chn on l
BPTNMT, c th do nhim trng h hp.
+ Giai on IV (BPTNMT rt nng): Nhng triu chng ho, khc m tip tc
xy ra mt cch in hnh, kh th nng ln v nhng bin chng c th xut hin.

VIII. PHN LOI MC TRM TRNG CA BPTNMT

Bng 1: Cc mc trm trng ca BPTNMT
Giai on

c im

0: c nguy c

+ Ph dung bnh thng

+ Triu chng mn tnh (Ho, khc m)

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I: BPTNMT nh

+ FEV1/FVC < 70%

+ FEV1 80% tr s l thuyt.
+ C hay khng c cc triu chng mn tnh (Ho, khc m)

II. BPTNMT trung bnh

+ FEV1/FVC < 70%

+ 30% FEV1 < 80% tr s l thuyt
50% FEV1 < 80% tr s l thuyt
30% FEV1 < 50% tr s l thuyt
+ C hay khng c cc triu chng mn tnh (Ho, khc m,
kh th)

III. BPTNMT nng

+ FEV1/FVC < 70%

+ 30% FEV1 < 50% tr s l thuyt
+ C hay khng c cc triu chng mn tnh (Ho, khc m,
kh th)

IV BPTNMT rt nng

+ FEV1/FVC < 70%

+ FEV1 < 30% tr s l thuyt hay FEV1 < 50% tr s l thuyt
phi hp vi suy h hp mn

IX. CHN ON PHN BIT

Bng 2: Cc chn on phn bit thng gp ca BPTNMT
Chn on

Triu chng

BPTNMT

+ Khi pht trong khong tui 1/2 i ngi

+ Nhng triu chng tin trin chm
+ C tin s ht thuc l ko di
+ Kh th khi gng sc
+ Gii hn lu lng kh khng hi phc nhiu

Hen ph qun

+ Khi pht sm thng trong thi k thiu nin

+ Nhng triu chng thay i tng ngy
+ Nhng triu chng xy ra ban m
+ D ng, vim mi v hay l chm
+ Tin s gia nh hen ph qun
+ Gii han lu lng kh hi phc nhiu

Suy tim sung huyt

+ Ran m nh ht y
+ X quang lng ngc cho thy bng tim ln, ph phi
+ Tt chc nng h hp cho thy ri lon thng kh hn ch
+ Khng c gii hn lu lng kh

Gin ph qun

+ Khc m m s lng nhiu

+ Thng phi hp vi nhim trung m
+ Ran m to ht
+ Phim lng ngc hay CT scan phi cho thy c gin ph qun v

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vch ph qun dy ln

X. T BC PHT CP BPTNMT
3 triu chng chnh ca t bc pht cp ca Bnh phi tc nghn mn tnh l: gia
tng kh th, gia tng m m, gia tng lng m.

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Bng 3: Chn on mc nng ca BPTNMT
Nh

Va

Nng

1 trong 3 triu chng chnh, cng nh 1 trong nhng 2 trong 3 triu Tt c 3 triu
chng chnh
du chng sau y: nhim trng ng h hp trn chng chnh
trong 5 ngy qua, st m khng c nguyn nhn r
rng, gia tng ran rt, gia tng ho, gia tng nhp th v
tn s tim 20% so vi bnh thng.

+ Chc nng h hp: thng thng khi PEF < 100lt/pht, hay FEV1 < 1.00L
chng t mt t bc pht cp nng, tr trng hp bnh nhn b gii hn ng
th nng mn tnh.
+ Kh mu: Khi PaO2 < 60mmHg v hay l SaO2 < 90% chng t suy h hp.
Khi PaO2 < 50mmHg, PaCO2 > 70mmHg v pH < 7,30 th cn phi x tr cp cu.
+ Phim lng ngc chn on phn bit.
+Tm in gip chn on ph i tim phi, lon nhp v thiu nng vnh.
+ Cng thc mu: ch yu cng thc bch cu v a hng cu c th c Hct
> 55%)
+ Xt nghim m c th tm thy Streptococcus pneumoniae, Hemophilus
influnzae v Moraxella catarrahalis.

XI. IU TR
1. X tr BPTNMT n nh
1.1. Gim cc yu t nguy c
1.1.1. Ngng thuc l
L phng php iu tr c nht c hiu qu lm gim yu t nguy c.
Ngng thuc l sm bnh nhn b BPTNMT c th ci thin FEV1, tuy nhin cc
ng kh mt khi b tc nghn trm trng th s ngng thuc l t c li.
1.1.2. Thuc
* Nhng thuc thay th nicotine: dng vin, dn.
* Thuc chng trm cm: nh bupropion v nortriptyline, thng dng loi bupropion
thi chm n c hay kt hp vi cao dn nicotine.
1.2.. iu tr bng thuc
1.2.1. iu tr kt hp:
C th lm gia tng tc dng gin ph qun, s kt hp gia mt ng vn 2 tc
dng ngn vi mt khng cholinergic nhng bnh nhn BPTNMT n nh lm ci
thin nhiu hn v ko di hn FEV1 so vi s dng mt loi thuc.
S s dng mt ng vn 2 tc dng ngn, mt khng cholinergic v hay l
theophylline c th ci thin chc nng h hp.
1.2.2 Glucocorticosteroid
Trong BPTNMT glucocorticosteroid ung v kh dung t c hiu qu hn trong hen
v vai tr trong iu tr BPTNMT n nh gii hn trong nhng ch nh c bit.
1.2.3 Nhng iu tr khc

258
* Vaccin: chng cm v chng ph cu cha 23 type huyt thanh.
* Khng sinh: S dng khng sinh d phng, dng lin tc khng c hiu qu trn
tn sut xut hin nhng t bc pht cp ca BPTNMT.
* Nhng cht chng oxy ha: c bit l N-acetylcystein lm gim tn sut xut hin
nhng t bc pht cp hay c th c vai tr trong iu tr nhng bnh nhn c
nhg t bc pht cp ti pht.
* Thuc gim ho: khng dng.
1.2.4.S tp luyn
Mc tiu chnh ca s tp luyn h hp l gim nhng triu chng, ci thin cht
lng sng v lm tng s tham gia hng ngy cc hot ng v th cht v tinh
thn.
1.2.5 Oxy liu php
Thng c ch nh bnh nhn BPTNMT giai on III nng, c th bng 3
phng cch bao gm iu tr lu di lin tc, trong cc hot ng th lc v lm du
cn kh th cp. Mc tiu u tin ca oxy liu php l lm gia tng PaO2 ti thiu l
60mmHg lc ngh v hay l cung cp SaO2 ti thiu l 90% duy tr chc nng
sng ca cc c quan.
Oxy liu php lu di lin tc thng c ch nh trong giai on III nng nhng
bnh nhn c:
+ PaO2 < 55mmHg hay SaO2 < 88% c hay khng c tng kh ccbonic hay
+ PaO2 t 55 - 60mmHg hay SaO2 = 89%, nu c tng p phi, ph ngoi
bin gi suy tim hay a hng cu (Hct > 55%).
iu tr lu di oxy (>15gi/ngy) nhng bnh nhn b suy h hp mn c th lm
gia tng s sng st. Oxy liu php lin tc lm gim p lc ng mch phi v c
th ngn nga c s din tin ca tng p phi.
BNG TM TT IU TR MI GIAI ON BPTNMT
Giai on

iu tr c khuyn co s dng

Tt c

+ Trnh nhng yu t nguy c

+ Tim phng cm

+ Nh trn

+ Thuc gin ph qun tc dng ngn

II

+ iu tr u n vi mt hay hn thuc gin ph qun

+ Tp luyn
+ Glucocorticosteroid kh dung nu triu chng lm sng v chc nng h
hp c p ng

III

+ iu tr u n vi mt hay hn thuc gin ph qun

+ Tp luyn
+ Glucocorticosteroid kh dung nu triu chng lm sng v chc nng h
hp c p ng hay nu c nhng t bc pht cp

IV

+ iu tr u n vi mt hay hn thuc gin ph qun

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+ Tp luyn
+ Glucocorticosteroid kh dung nu triu chng lm sng v chc nng h
hp c p ng hay nu c nhng t bc pht cp
+ iu tr cc bin chng
+ Oxy liu php lu di nu c suy h hp mn

2. X tr t bc pht cp BPTNMT
2.1. Chp X quang lng ngc
C th cn thit v qua kt qu X quang cho thy trn 23% bnh nhn nhp vin c
nhng biu hin bnh l.
3.2.Thuc gin ph qun
Kh dung thuc ng vn 2 tc dng ngn nh salbutamol v khng cholinergic
nh ipratropium c hiu qu bng nhau trn bnh nhn BPTNMT. Nhng loi thuc
ny cng c tc dng cao trn tt c tc dng ca tt c nhng thuc gin ph qun
s dng bng ng tim bao gm methylxanthines v nhng loi thuc cng giao
cm. Mt s nghin cu cho thy phi hp thuc ng vn 2 tc dng ngn vi
khng cholinergic c hiu qu cao do tc dng hip lc m khng lm gia tng tc
dng ph. Ch sau liu ti a khi u thuc gin ph qun, c th thm mt liu kh
dung gin ph qun t ra c li.
2.3. S dng corticoide
Trong t bc pht cp ca BPTNMT s s dng corticoide h thng trong 2 tun l
c li. Trong 2 tun liu lng c chia nh sau: 3 ngy s dng
methylprednisolone 125 mg/6 gi, sau cho prednisone trong 2 tun (60mg/ngy
t ngy th 4 n ngy th 7, 40mg/ngy t ngy th 8 n ngy th 11, v
20mg/ngy t ngy th 12 n ngy th 15).
2.4. Khng sinh
Khng sinh t ra c hiu qu trong t bc pht cp bnh phi tc nghn mn tnh.
Tu theo loi vi trng thng gy nhim trng ph qun phi m s dng khng sinh
thch hp.C th s dng Cephalosporine th h 3, Macrolides, Fluoroquinolones h
hp.
2.5. Oxy liu php
Trong t bc pht cp bnh phi tc nghn mn tnh v thiu kh, s s dng oxy
l cn thit v c li cho bnh nhn. Tuy nhin vn cn lu chnh l khi s dng
oxy liu php s c nguy c gy tng kh carbonic mu v suy h hp.
2.6. Thng kh p lc dng khng xm nhp
Thng c s dng cho bnh nhn ni tr b t bc pht cp bnh phi tc
nghn mn tnh. Phng php ny khng nhng lm ci thin chc nng h hp v
lm gim PaCO2 m trong mt s trng hp c th trnh s dng t ni kh qun.
2.7. Chng ch nh
Trong iu tr nhng bnh nhn b t bc pht cp bnh phi tc nghn mn tnh,
nhng iu tr sau y khng c li: thuc tan nhy, vt l tr liu lng ngc,
methylxanthines.
p dng thc t

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+ Mc nh: p dng X quang lng ngc, kh dung gin ph qun.
+ Mc va: X quang lng ngc, kh dung gin ph qun, corticoid h thng, oxy
liu php, thng kh p lc dng khng xm nhp.
+ Mc nng: X quang lng ngc, kh dung gin ph qun, corticoid h thng, oxy
liu php, thng kh p lc dng khng xm nhp, khng sinh.

TM PH MN
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, bnh nguyn, c ch sinh bnh
tm ph mn.
2. Nu c triu chng lm sng v cn lm sng ca cc giai on tm ph mn
v tin trin.
3. Bit cch chn on bnh v giai on bnh
4. Pht hin sm t bc pht cp tm ph mn
5. Trnh by c phc iu tr v d phng tm ph mn
Ni dung

I. NH NGHA
Tm ph mn l mt s ln rng tht phi bi mt s ph i v hay l gin
th pht ca tht phi sau nhng ri lon hay bnh ca h h hp. Bnh do mt
bnh bn trong ch m phi; mt vi trng hp c th do mt bt thng ca s
ch huy thng kh, mt tn thng lng ngc v hay l h thng c h hp, hay c
th do nhng bnh ca tun hon phi. Tng p phi lun lun i trc tm ph
mn trong c suy tim phi.

II. DCH T HC
Ngi ta kh xc nh tn sut ca tm ph mn; t sau 50 tui, tm ph mn l
bnh tim mch ng hng th ba thng gp nht sau bnh tim thiu mu v tng
huyt p. Bnh thng th pht sau bnh ph qun mn tc nghn. Tht vy
nhng nc ht nhiu thuc l v b nhim mi trng th vim ph qun mn v
kh ph thng c tn sut cao v tm ph mn chim 1/3 nhng trng hp suy tim.
Hin nay n ng b nhiu hn n b, c l l do thuc l.

III. BNH NGUYN

1. Bnh phi tc nghn mn tnh
Bnh phi tc nghn mn tnh l nguyn nhn chnh gy nn tng p phi v tm
ph mn. S tng p phi ch yu th pht sau tnh trng thiu oxy mu do bt
thng t s thng kh - ti mu.
2. Nhng bnh phi k
Bnh l phi k c th th pht sau bnh sarcoidose, bnh bi amian, bnh cht to
keo, nhng cng c th khng r nguyn nhn. Trong tt c nhng bnh ny c hi
chng hn ch thng kh nhng khng c hi chng tc nghn. Thm nhim vim
k chn p v ph hu nhng tiu ng mch vch, lm gia tng sc khng ca
cc mch mu phi. i khi, nhng tn thng ny phi hp vi s ng li ca
nhng tiu ph qun bi mt qu trnh vim quanh tiu ph qun.

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3. Gim thng kh ph bo vi phi bnh thng
Bnh nhc c, lon dng c; g vo ct sng v qu mp ph.
4. Nhng bnh cht to keo
Trong nhng bnh cht to keo nh lupt ban h thng thng c tn thng
mch mu phi. X cng b v nhng bnh tng t v d nh hi chng CREST
cng c tn sut cao tn thng mch mu phi v din tin sang tm ph mn.
5. Bnh huyt khi - thuyn tc ng mch phi
5.1. Huyt khi gy nghn nhng ng mch phi c nh v tiu ng mch
Nhng huyt khi gy nghn v ti knh ho ca nhng ng mch c c nh v
tiu ng mch phi c tm thy nh sinh thit v t thit nhng bnh nhn b
tng p phi c nguyn nhn khc nhau. gii thch nhng huyt khi ti ch ny,
ngi ta chng minh c nhng tn thng ni mc ca vi tun hon phi, mt s
mt qun bnh kch pht gia hin tng ng mu v ly gii fibrine ti ch, v s
hot ho ngng tp tiu cu vi tun hon ny.
5.2. Thuyn tc ng mch phi mn gn gc
S hin din mt hay nhiu cc mu t chc ho, bt nhng nhnh ln ca ng
mch phi vi s hnh thnh t t tm ph mn. S ly gii fibrine ti ch khng
lm cho huyt khi tan ra hoc l pha trc hoc l pha sau gy bt li nhng ng
mch phi gn gc, phi hp vi mt s gim gin n ca nhng mch mu
trung tm phi.
6. Bnh tnh mch phi
Nhng tnh mch phi ln c th b bt li bi nhng di cn ca ung th nh ung th
v hay phi, bi nhim trng nh lao hay histoplasmose, bi qu trnh vim c hch
nh sarcoidose hay nhng nguyn nhn khc t gp hn nh vim trung tht x
ho.
7. Tng p phi tin pht
Tng p phi tin pht din tin sang tm ph mn khng do bnh tim hay bnh phi
bn di; cn gi l tng p phi khng r nguyn nhn. Tng p phi tin pht l
mt bnh him. Bnh c th gp mi la tui, nhng nhng triu chng u tin
thng xut hin ngi tr. Gn y, ngi ta xc minh c s gia tng khng th
khng nhn nhng bnh nhn ny

IV. C CH SINH BNH

. Gim PaO2 l ri lon khch quan quan trng nht, c gi l thiu oxy mu mn
khi PaO2 di 70 mmHg xy ra trng din trong sut thi k bnh n nh. Thc ra
thiu oxy mu mn ch tr nn ng ngi t mc PaO2 = 55 mmHg v lc c th
c nhng tc hi v cn phi iu tr.
+ Phn ng tng to hng cu c li do cho php bo m s vn chuyn oxy y
, Nh vy s vn chuyn oxy thng khng b nh hng nhiu tr nhng t
suy h hp cp hoc nhng lc thiu oxy mu nng nh trong gic ng, nhng a
hng cu c hi l lm tng nht mu v nh th gp phn lm tng khng lc
mch mu phi dn n s xut hin tng p ng mch phi.

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+ Thiu oxy mn gy bt thng v thn kinh - tm thn nh ri lon ch v tr
nh, kh khn v t duy tru tng, v hnh vi kho lo, v cc ri lon vn ng
gin n.
+ Thiu oxy mn lm tng sc cn mch mu phi do co tht mnh, ph i tng dn
c trn thnh ng mch gy tng p ng mch phi v tng gnh tim phi. Tim b
tr s tng gnh ny cng tng tn s v cung lng tm thu m bo s cung
cp oxy. Cn lu s tng p phi l mt c ch thch nghi, gip chn la mt s
mao mch phc v ti mu tt, ci thin lin h thng kh / ti mu.
Tm ph mn xut hin sau tng p phi, nguyn nhn thng gp nht gy tng
gnh tht phi l s gia tng sc khng mch mu phi, xy ra ch yu nhng
ng mch khu knh nh v nhng tiu ng mch.
H thng mch mu phi bnh thng l mt vng rt d gin n, vi sc khng
thp, khi gng sc va phi, lu lng mu tng gp ba ln v ch gy nn mt s
gia tng nh p lc ng mach phi. Tuy nhin, khi d tr mch mu phi b cn i
do mt s gim dn dn din tch v tnh gin n ca h thng mch mu phi, mt
s gia tng nh ca lu lng tim c th gy nn mt s tng p phi r rng.
Tnh trng thiu oxy gy co cc ng mch khu knh nh v tiu ng mch. Ngi
ta nhn thy rng toan mu (pH < 7,2) lm gia tng s co mch phi. Trong tnh
trng thiu oxy mn, nhng hu qu ca kch thch gy tng p phi ny thng
c lm nng bi s tng nhy mu lin h vi a hng cu th pht. i
ngc vi nhng hu qu ca s thiu oxy, kh carbonic tc ng trn tun hon
phi qua trung gian ca toan mu gy nn mt s co mch trc tip. S gia tng kh
carrbonic lm gim s p ng ca nhng trung tm h hp vi kch thch carbonic
v gy nn s ti hp thu bicarbonate thn.

V. TRIU CHNG HC
1. Giai on u
1.1. Triu chng lm sng ca bnh phi tc nghn mn tnh: vim ph qun mn,
kh ph thng do thuc l, hen ph qun ko di trong s phc hi ph qun km,
gin ph qun, thng xy ra nhng t bc pht cp. Sau mi t bc pht, bnh
li nng thm.
Tn thng chc nng ca phi trong nhm bnh ny biu hin th tch th ra gng
sc trong giy u (FEV1) gim, FEV1/FVC gim, sc cn ng th v th tch
cn (VR) tng.
1.2. Triu chng ca nhng bnh phi hn ch: nh lao x phi, gin ph nang,
mp ph, g vo ct sng, d dng lng ngc, bnh x phi lan to, dy dnh mng
phi, bnh mch phi.
Tn thng chc nng ca nhm bnh ny l dung tch sng (FVC) gim.
1.3. C th phi hp nhng triu chng ca hai nhm bnh trn.
Giai on bnh phi mn tnh ny tin trin c th nhiu nm, thay i t 3 nm n
20 nm.
2. Giai on tng p lc ng mch phi
2.1. Triu chng lm sng
- Triu chng chc nng gip pht hin
+ Kh th gng sc: lun lun c

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+ Hi chng vim ph qun: ho v khc m.
+ au gan do gng sc: thng m h.
- Triu chng thc th
Ngoi triu chng bnh gc, nhng triu chng v tim sm nht l ting tim th hai
mnh van ng mch phi, du Harzer t gp hn, nhp tim nhanh khng c gi
tr lm, mng tay khum mt knh ng h, c th c au gan khi mnh vo vng
h sn phi.
2.2. Triu chng cn lm sng
- Phim ph
Ngoi nhng du chng ca bnh ph qun - phi gc, thng gp nht l cung
ng mch phi phng.
- Siu m
Siu m 2 bnh din cho thy gin tht phi. Siu m Doppler mu c th nh gi
p lc ng mch phi trn 35mmHg.
- Bilan huyt ng
o p lc tnh mch trung ng, nu tng l du chng sm ca tm ph mn.
3. Giai on suy tim phi
3.1. Triu chng lm sng
- Triu chng chc nng
Kh th cng ngy cng tng dn t kh th khi gng sc, n kh th khi leo ln
dc hay khi ln cu thang, n kh th khi i nhanh trn ng phng, n kh th
khi i chm trn ng phng, cui cng kh th khi lm vic nh nh v sinh, ci
qun o, v sau kh th c khi ngh ngi.
- Triu chng thc th
+ Triu chng ngoi bin
Gan ln v au,tnh mch c ni ln v p, ph, tm, mt li v xung huyt, o p
lc tnh mch trung ng trn 25 cm nc, ngn tay hnh di trng.
+ Triu chng tim mch
Nhp tim nhanh, c khi lon nhp hon ton, du hiu Harzer, T2 mnh v tch i
van ng mch phi.Ting nga phi phi thi k tin tm thu, ting thi tm thu
van 3 l.
3.2. Triu chng cn lm sng
- Phim phi
Thn ng mch phi phng to, ph i tht phi r rng lm tim c hnh hia v
trong phim chp nghing trc tri thy mt khong sng sau xng c. Trn dch
mng phi c th xut hin.
- Tm in : c dy nh phi (P ph) v dy tht phi
- Siu m Doppler mu: o p lc ng mch phi trn 45mmHg

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- Bilan huyt ng:Trong giai on suy tht phi r rt th p lc ng mch phi
tng ln trn 45 mmHg
- o cc kh trong mu: PaO2 gim, PaCO2 tng. SaO2 gim v pH mu gim c
khuynh hng nhim toa h hp
- Huyt hc: a hng cu, tng hematocrite.

VI. TIN TRIN

Tm ph mn tin trin t t, gy tn thng chc nng v cu trc ca phi dn
n suy h hp tng phn ri suy h hp ton b ri suy tim phi v cui cng l suy
tim ton b. Ngy nay d c nhiu phng php iu tr hin i, nhng suy tim phi
vn chim mt t l t vong rt cao: 60 - 70% t suy tim phi ln u hay ln th
hai.
S tin trin ca bnh ph thuc vo nguyn nhn gy bnh, v nht l ph thuc
vo vic ngi bnh c pht hin bnh ca mnh sm hay khng, khi c pht hin
bnh ri c c iu tr v theo di thng xuyn hay khng.
Nhng suy h hp mn nghn m nguyn nhn thng gp l bnh phi tc nghn
mn tnh do thuc l s dn n tm ph mn rt d dng. Cc t bc pht cp ca
bnh phi tc nghn mn tnh s lm nng thm tm ph mn, c trng hp ch
sau 3 nm c du hiu suy tim phi. i vi hen ph qun th hen ph qun d
ng nhim khun c khi sau 5 - 10 nm c du hiu suy tim phi, ngc li hen
ph qun d ng khng nhim khun th rt t a n tm ph mn.
i vi suy h hp mn hn ch nh x phi do lao, nhng phi l lao x lan ta th
s a n tm ph mn, ngc li nu lao x mt phn nh th khng a n tm
ph mn, nhng nu c mc thm gin ph qun th chng b tm ph mn v lc
l suy h hp mn phi hp. Trng hp ny nu c nhim trng ph qun phi
km theo th cng lm nng thm tm ph mn.
Nu bnh nhn c theo di v iu tr tt th bnh c th n nh, c th t 10 - 20
nm hoc lu hn na mi c bin chng suy tim, c trng hp c th chung sng
vi bnh nhn sut i.

VII. IU TR
1. Ch n ung v ngh ngi
+ Ngh ngi rt cn thit, nn lm vic nh, khi c du hiu suy tim cn
gim hoc b cc cng vic phi gng sc.
Ch n nht, t mui, c th n 1 - 2 g mui / ngy. Trong trng hp suy
tim nng, ph nhiu, ch n nht kht khe hn; mi ngy ch dng 0,5 g mui,
nhng khng ko di.
2. Liu php oxy
Ngi ta c th cho th oxy bng xng mi, oxy nn c dn qua mt bnh
nc lm m, khng nn cho th oxy 100% vi liu lng thp 1,5 - 2 lt / pht,
mun c hiu qu phi dng t nht 12 gi / 24 gi, nhng tt nht l 15 - 20 gi / 24
gi. Ngi ta cung cp oxy th no duy tr mt PaO2 trn 60 mmHg v SaO2 trn
90%, nu c nh th th s gim t l t vong v mang li cho bnh nhn mt i
sng tng i thoi mi.
3. Thuc ci thin t thng kh - ti mu phi

265
Bismesialate dalmitrine (VECTARION).Cch dng: iu tr tn cng vi 50 mg, 1 - 2
vin / ngy trong 3 thng, sau phi iu tr duy tr, sau iu tr tn cng, ngh 1
thng, tip tc iu tr 2 thng. Hin nay rt t s dng.
4. iu tr suy tim
Trong tm ph mn c th c suy tim ton b, nhng ch yu vn l suy tim phi, do
thuc iu tr chnh l li tiu, sau l digitale, c th phi hp vi cc thuc
dn xut nitr.
4.1. Li tiu
+ Furosemide (LASIX): 2 - 4 vin loi 40 mg / ngy, chia u; hoc loi tim 2
- 3 ng loi 20 mg / ngy, chia u.
Khi dng li tiu furosemide phi thn trng v s gy kim chuyn ho, nh vy c
th c nguy c lm nng thm suy h hp do hiu qu kch thch h hp ca kh
carbonic b gim i.
+ Spironolactone (ALDACTONE): 50 mg - 100 mg (1 - 2 vin) / ngy, trong
nhng th nng c th tng ln 6 vin / ngy, chia u. thng dng Aldactazine
(Aldactone 50mg+Alizide 15mg) x 2 vin/ngy
4.2. Digitale: thng hay dng digoxine, ch s dng trong suy tim cn b, cho liu
nh 0,25 mg - 0,50 mg (1 - 2 vin) / ngy, khng dng khi suy tim mt b.
4.3. Dn xut nitr: nh Isosorbide mononitrate (Imdur) 60mg x 1/2 vin/ngy
4.4. c ch men chuyn: nh captopril 6,25mg/ngy hay Lisinopril 2,5mg/ngy
Thuc li tiu v digitale, dn xut nitr hay c ch men chuyn trong trng hp
ny khng quan trng bng cc phng php ci thin thng kh ph nang nh liu
php oxy.
5. Thuc gin mch
Cc thuc gin mch n nh hay ci thin ch xy ra ti a 1/3 s bnh nhn. Hiu
qu ca cc loi thuc thay i tu theo tng bnh nhn.
+ Nhng thuc c ch calci nh Nifedipine, Dittiazem c th s dng..
+ Ngoi ra ngi ta cn dng Hydralazine vi hy vng lm gim p lc tun hon,
nhng thuc ny c tc dng lm gim oxy mu, do ri lon t s thng kh - ti
mu.
+ Thuc c ch th th endothelin (Bosentan): Cht endothelin 1 l mt cht gy co
mch ni sinh gy tng p phi,
Bosentan gip ci thin kh nng gng sc v huyt ng bnh nhn tng p
phi, thuc c s dng trong 12 tun, liu khi u l 62,5 mg x 2 ln/ngy trong
4 tun l u, v sau tng liu ln 125 mg x 2 ln/ngy
+ Chuyn tnh mch lin tc prostacycline.
+ Thuc Sildenafil (Viagra) trong iu tri tng p phi th pht sau x phi:
Sildenafil lm gia tng chn lc gin mch v lm ci thin s trao i kh bnh
nhn b x phi v tng p phi.
Epoprostenol c s dng bng ng tnh mch hay Sildenafil c s
dng bng ng ung, sau khi huyt ng thay i ca bnh nhn tr li tr s bnh
thng c s dng tip theo kh dung Nitric oxide 10 - 20 ppm, h ung 50mg

266
Sildenafil hay chuyn ti a Epoprostenol (trung bnh 8ng/kg/ pht). Thi gian tc
dng ca Sildenafil t 120 150 pht.
Cho n nay, Sildenafil l thuc chn la tt nht trong iu tr gin mch phi.
6. Corticoides
Rt c hiu nghim trong iu tr t cp, Prednisone ung 5 mg, 4 vin / ngy hay
kh dung dipropionate de beclomethasone, hay Depersolone 30 mg tim tnh mch
va c tc dng chng vim va c tc dng chng d ng va lm gim tit dch.
7. Khng sinh
Khng sinh ch dng khi c bi nhim ph qun - phi, vi khun thng gp l
Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis,
Mycoplasma pneumoniae, Legionella pneumophila, Staphylococcus aureus.
- Nu nh th thuc thng dng hin nay l
+ Azithromycine: 250 mg x 2 vin / ngy, chia 2 ln trong ngy u sau
250mg x 1 vin trong 4 ngy.
+ Cefadroxil (Droxyl, Oracefal): 500 mg, 3 vin / ngy, chia 3 ln.
+ Ciprofloxacine 500mg x 3 vin / ngy, chia 3 ln.
- Nu nng thuc thng dng bng ng tim tht hay tnh mch
Mt trong cc loi Cephalosporine th h I (Cefapirine: Cefeloject = 2g/ngy chia 2
ln) II (Cefuroxime: Zinnat = 750mgx2 hay 3 chai/ngy chia 2 hay 3 ln) III
(Cefotaxime: Claforan = 2g/ngy chia 2 ln) IV (Axepim = 2g/ngy chia 2 ln) c th
kt hp vi Aminosides (Amikacine: Amiklin = 15mg/kg/ngy, 1 hay 2 hay 3 ln) hay
Fluoroquinolones (Ciprofloxacin: 200mg x 2 l - 4 l chuyn tnh mach).
8. Liu php vn ng
Tp th rt quan trng, lm tng gin n ca phi v lng ngc, tng thng kh
ph nang, nht l th bng c honh.
9. Loi b nhng yu t gy kch thch
Phi cai thuc l, trnh tip xc vi bi bm, cc kh c...

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UNG TH PH QUN - PHI NGUYN PHT

Mc tiu hc tp
1. Trnh by c nh ngha, c im dch t hc v bnh nguyn ca ung th ph
qun phi nguyn pht.
2. Nu c triu chng lm sng v cn lm sng tu theo v tr khi u.
3. Nu c cc xt nghim cn thit chn on xc nh.
4. Nm c cch phn giai on ca ung th ph qun phi nguyn pht theo
TNM.
5. Bit cch iu tr theo hai nhm chnh v theo TNM
Ni dung

I. I CNG
Ung th ph qun phi nguyn pht (UTPQPNP) hin nay c tn sut ang tng ln
mt cch ng s.
L nguyn nhn gy t vong do ung th hng u nam v hng th 4 n.
Bnh nguyn ch yu l thuc l.
Pht hin thng mun nn iu tr kh v vy tin lng lun lun nng.

II. BNH NGUYN

1. Gii: ung th ph qun phi gp nam nhiu hn n vi t l 6/1.
2. Tui
Bnh gp ti a nam khong 65 tui v n khong 75 tui.
3. Mi trng
Bnh thng gp cc thnh ph ln gp 3 ln so vi nng thn.
4. Nguyn nhn
4.1. Thuc l
Khi thuc l c xc nh 1 cch chc chn l nguyn nhn gy ung th ph
qun phi. 90% ung th ph qun phi l do thuc l. T l ung th ph qun phi
tng theo s iu thuc ht trong ngy v s nm nghin ht. Nu ht trn 20
gi/nm th t l ny tng r rt.
Khi thuc l lm chm s thanh lc nhy lng lm tn thng nhng chc nng
thc bo ca b my h hp.
Nhng enzyme ca nim mc ph qun khng thch ng vi s tn cng ny: bin
cc cht trong khi thuc l thnh cht gy ung th.
Cai thuc l lm gim nguy c nhng khng lm mt nguy c.
4.2. nhim mi trng khng kh chung.
Khi k ngh, khi xe hi cha benzopyrene v mt s cht c nh hydrocabure
a vng, cht khc nh kim loi, cht phng x.
4.3. nhim mi trng ngh nghip.

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Bi thch min, bi m hay cc cht trong k ngh nh chrome, niken, arsenic, mc
in sn phm k ngh du m, cc cht phng x.
Khi thuc l c tc dng hp lc gy ung th.
4.4. Mt s yu t khc.
So phi c th lm d ung th dng tuyn hn cc th khc.

III. PHN LOI

1. Phn loi theo gii phu bnh
Theo OMS ung th ph qun phi c phn thnh nhng loi sau:
1.1. Ung th dng biu b.
1.2. Ung th t bo nh khng bit ho.
1.3. Ung th dng tuyn.
+ Ung th tuyn nang bit ho cao.
+ Ung th tiu ph qun ph nang.
+ Ung th tuyn t bit ho.
1.4. Ung th t bo ln khng bit ho.
1.5. Ung th phi hp dng biu b v tuyn.
1.6. Ung th carcinoide.
1.7. Ung th tuyn ph qun.
1.8. Ung th nh ca biu b b mt.
1.9. Ung th hn hp carcinosarcome.
1.10. Sarcomes.
1.11. Khng xp loi.
1.12. Ung th trung biu m (ung th mng phi).
1.13. U mlanine.
Trong 4 loi u l thng gp.
2. Phn giai on ung th phi theo TNM (theo hip hi M trn h thng ung th)
2.1.U tin pht
To: Khng thy u
Tx: U ch pht hin sm bng t bo ung th trong cht tit ph qun.
TIS: ung th biu m ti ch
T1: U c d 3cm, soi ph qun khng thy lan n ph qun thu.
T2: Uc d>3 cm hay u khng k kch thc hoc lan n mng phi tng hoc c
xp phi hoc c vim phi nghn, c lan n ph qun thy hay cch ca ph qun
2cm. Xp phi/vim phi nghn ch 1 phi
T3: U khng k kch thc xm ln thnh ngc hay c honh hay mng phi trung
tht hay mng ngoi tim (m khng tn thng tim, mch mu ln, kh qun, thc
qun, ct sng)

269
Hoc u trong ph qun gc cch ca ph qun < 2cm.
T4: * U khng k kch thc xm ln trung tht hay tim hay mch mu ln, kh qun,
thc qun, ct sng, ca ph qun
*Hoc trn dch mng phi
2.2. Tn thng hch
No: Khng c di cn n hch
N1: di cn n hch quanh ph qun hay rn phi
N2: Di cn hch trung tht cng bn v cnh ca ph qun
N3: di cn hch trung tht khc bn, hch rn phi khc bn, hch c thang hay
thng n cng hay khc bn
2.3.Di cn xa
Mo:khng di cn xa
M1: di cn xa nh thng thn, gan, xng, no
Bng 1: Phn theo TNM
Giai on

Ung th biu m n

Tx

No

Mo

Giai on 0

TIS

No

Mo

Giai on I

T1

No

Mo

T2

No

Mo

T1

N1

Mo

T2

N1

Mo

T3

N1

Mo

T1-3

N2

Mo

Bt k T

N3

Mo

T4

Bt k N

Mo

Bt k T

Bt k N

M1

Giai on II
Giai don IIIa
Giai on IIIb
Giai on IV

IV. TRIU CHNG HC LM SNG

1. Biu hin trong lng ngc
1.1.Ho
Ho thng tng ln v tn s v trm trng.
1.2. Ho ra mu
Lng nhiu hay t, chim t l 50% trng hp.
1.3. Vim ph qun phi do nghn.
U pht trin trong lng ph qun gy nghn ph qun khng hon ton lm ri lon
thanh thi nhy lng, gy tr, t d dng b vim ph qun phi thu phi
tng ng.

270
- Vim ph qun phi do nghn c c im: vim phi khu tr, p ng chm hay
khng hon ton vi khng sinh thch hp, vim phi lp i lp li cng mt v tr.
1.4. Ting-rt khu tr
Ran wheezing gi nghn khu tr khng hon ton.
1.5. Xp phi
Khi c hi chng xp phi l khi ph qun b hp hon ton.
1.6. Trn dch mng phi
C th l trn dch thanh t huyt hay trn mu, c th do u lan trc tip hay do di
cn, c khi do phn ng ca xp phi.
1.7. au ngc
au c nh v dai dng chng t ung th di cn n thnh ngc, mng phi hay
trung tht.
1.8. Hch ln
Hch c th rn phi, trung tht, c thang, c th din tin m thm hay gy chn
p, n mn cc ph qun, cc mch mu hay cc m ri thn kinh ln cn.
1.9. Biu hin chn p, tc nghn do u, do di cn, do hch vng
+ Tnh mch ch trn trong trung tht b chn p lm c ln ra, sau ph o
khoc, tm mt, gin tnh mch di da vai, ngc.
+ Thn kinh qut ngc tri b chn p, gy khn ging, lit dy thanh m tri
(dy thanh m phi c vng cao quanh ng mch di n nn t b chn p).
+ Thn kinh honh: cc dy thn kinh ny i dc theo trung tht trc mi
bn, mt trong hai c th b chn p, gy lit na c honh tng ng, ch pht hin
nh ri phi, thy c honh di ng ngc chiu.
1.10. Hi chng Pancoast Tobias
Ung th nh phi xm ln mng phi nh chn p cc r di ca m ri thn
kinh cnh tay, thn kinh giao cm c. Hi chng gm au vai, au cnh tay km hi
chng CLAUDE BERNARD HORNER cng bn (ng t co, sp m, hp khe mt)
c khi n mn xng n.
2. Biu hin ngoi lng ngc (di cn)
3 c quan hay b di cn nht l
+ H xng gy au xng, au tri lc nm ngh, ti pht vi cc thuc gim
au thng dng.
+ H thn kinh trung ng: t l u phi di cn ln no rt cao, gy lit cc dy
thn kinh s no, lit na ngi.
+ Gan.
+ Cc di cn khc nh mng bng, thng thn, thn, ng tiu ho.
3. Hi chng h thng
Cc hi chng ny bin mt khi ung th c ct b v ti pht khi di cn pht trin.
3.1. Tng calci mu

271
Tng calci mu do parathormone bt thng v mt cht gy tan xng khc
parathormone.
Tng calci mu gy bun nn, nn, tiu nhiu, l ln ng lm, sng s.
3.2. Hi chng tit ADH bt thng
Gy h natri mu, gim p lc keo, tng t trng nc tiu, nc tiu cha nhiu
natri.
3.3. Hi chng CUSHING
Ung th ph qun phi tit ra cht lng t nh ACTH, thng t hot ng hn
ACTH tht.
3.4. Hi chng carcinoide
Cn xung huyt da, ph mt, tng tit nc mt, tng tit nc bt, tiu chy nn,
h huyt p do 5 hydroxytryptamine (serotonine) v 5 hydroxytryptophane c tit
ra trong u carcinoide hoc ung th t bo nh khng bit ho.
3.5. V ln
Ung th t bo ln tit ra khch thch t sinh dc gy v ln.
3.6. Ri lon thn kinh c: C ch cha r, hi chng ny khng bin mt khi ung
th c ct b.
Thng gp l: hi chng nhc c, thoi ho tiu no, c khi c no v tu, hi
chng thn kinh ngoi bin.
3.7. Ngn tay di trng
3.8. Hi chng PIERRE MARIE (hi chng xng khp ph i do phi).
Xng khp ca cc chi i xng au, sng ko di. X quang thy vim v tng
sinh mng xng, thng gp u xng chy v xng mc, km ngn tay
chn di trng. Bin mt khi ung th c ct b.
3.9. Gim min dch t bo khng c hiu
Phn ng b lao (+) l mt yu t tin lng tt sng st sau m gp i phn ng
b lao (-).

V. TRIU CHNG CN LM SNG

1. X quang
+ Ung th dng biu b v ung th t bo nh khng bit ho thng rn
hay gn rn, ung th dng tuyn v ung th t bo ln thng xa rn trong ch
m.
+ Ung th dng biu b thng di dng khi m trn b khng u, khng
ng cht, mt bn, c th hng ha, d gy vim phi do nghn hay xp phi.
+ Ung th t bo nh khng bit ho thng di dng khi m, t ng cht,
b khng u, c xu hng lan ra xung quanh.
+ Ung th dang tuyn thng di dng khi trn, u, m, b r.
+ Ung th tiu ph qun ph nang thng di dng khi trn n c hoc
nt thm nhim lan rng mt hay hai phi.
+ Ung th t bo ln thng di dng khi trn, m, b kh r.

272
Cc tn thng ung th thng khng bao gi b calci ho.
2. Chp ct ln t trng
Gip xc nh chnh xc cc tnh cht ca khi m bt thng trong nhu m phi, v
trung tht, gip sinh thit di s hng dn ca CT SCANNER chn on m
hc.
3. Soi ph qun
Soi ph qun bng ng soi mm gip chn on trc tip v thm d s lan rng
ca ung th bng cch chi ra ph qun v sinh thit tn thng hay sinh thit c
h thng cc ph qun.
4. T bo hc
Kho st t bo trong m cho kt qu dng tnh trn 70%, dng tnh gi t, pht
hin c t bo ung th ngay khi hnh nh x.quang bnh thng. Do t bo hc
trong m l mt xt nghim sng lc nhm c nguy c.
5. Sinh thit hch
Hch ngoi vi d dng c sinh thit, sinh thit hch trung tht c tin hnh
phng m do bc s chuyn khoa lm.
6. Chc ht xuyn thnh bng kim nh
p dng cho nhng ung th ngoi bin, kh soi ph qun. C th chc di s
theo di trn mng hunh quang. D gy trn khi mng phi.
7. Sinh thit mng phi
Sinh thit mng phi phi tin hnh mi trng ngoi khoa. C th kho st t bo
hc dch mng phi.
8. M thm d
bnh nhn c ch nh m. Sinh thit v xt nghim gii phu bnh tc th v
quyt nh m tip tc hay khng.
9. Thm d di cn
Phi lm siu m v chp ct lp t trng mi kt lun c mt cch cht chn.
10. Thm d chc nng h hp
Ch yu l xt ch nh m v thm d kh nng phi lnh.
Nu VEMS 1/2 bnh thng v paCO2 bnh thng 40 3 mmHg th khng cn
thm d thm.
11. Cht ch im ung th
Ch xc nh c l c khi u, gip theo di din tin sau iu tr.

VI. CHN ON PHN BIT

1. Lao phi
Chn on kh khn trong nhng trng hp sau: BK m m tnh v khng tm
thy t bo ung th trong m trong 3 ngy lin, trn phim X.quang c khi m hnh
trn, ng knh 2-3 cm b r hoc mt m m. Gp cc trng hp ny nn iu
tr th lao mt cch tch cc, ng thi tm mi cch pht hin t bo ung th. Sau
mt thng chm nht l hai thng nu hnh nh trn phim r nt hn l ung th.

273
2. Vim phi
Sau mt thi gian iu tr vim phi, nu sc kho khng tr li bnh thng, cc
tn thng trn phim X.quang khng xo ht, lng mu vn cao... cn ngh n ung
th ph qun phi.

VII. IU TR
V mt iu tr ngi ta chia ung th ph qun phi ra lm 2 nhm chnh.
1. Ung th khng phi ung th t bo nh khng bit ho.
C thi gian nhn i 100-200 ngy, gm 3 loi: ung th dng biu b, ung th dng
tuyn, ung th t bo ln.
1.1. Phu thut l phng php hu hiu nht, p dng cho cc giai on ung th
n, giai on 1 v giai on 2 v mt s trng hp chn lc nh T3, No, Mo hay
T1, N2, Mo.
Kt qu:
- Ung th n: sng st sau 5 nm khong 60%. Theo di k v d b ti pht
khong 5%/nm/ngi.
- Ung th nt n c: m ct b thu phi. Tin lng tu theo kch thc
khi u, theo hch vng v theo s bit ho ca t bo k.
Sng st sau 5 nm khong 40-60% nu kch thc < 3cm v khng c hch vng.
Sng st sau 5 nm khong 20% n < 40% nu kch thc > 3cm v c hch vng.
1.2. Khng phu thut c dng a ho tr liu v x tr liu nu khng c chng
ch nh.
+ X tr liu kt qu khng tt lm, i khi khng hn bnh nhn khng c x tr
liu.
- a ho tr liu
Bng 3: Kt qu mt s a ho tr liu
c im

Paclitaxel
/carboplatin

Gemcitabine
/carboplatin

Paclitaxel
/Gemcitabine

S bnh nhn

308

309

312

Thi gian sng st trung bnh

7,9 thng

7,6 thng

8,4 thng

Sng st 1 nm

33%

31%

33%

Bng 4: T l sng st sau 5 nm

Tc gi v nm cng b

S
nhn

Arriagada et al-2004

1867

bnh

Nhm thuc iu tr
Cisplatin
Etoposide
Vinorelbine
Vindesine
Vinblastine

sng st 5 nm
%
hoc

44,5

274
Winton et al-2004

482

Cisplatin- Vinorelbine

69

Strauss et al-2004

344

Carboplatin- Paclitaxel

71(4 nm)

Rosell et al- 2005

840

Cisplatin -Vinorelbine

51

2. Ung th t bo nh khng bit ho

y l loi ung th pht trin nhanh, di cn sm v nhiu ngay khi bnh c v khu
tr, do mi c gng ct b u v hiu, nn a ho tr liu v x tr liu l chnh.
2.1.Ho tr liu
Thuc c ch topoisomerase I bao gm irinotecan v topotecan. Phi hp
irinotecan hay topotecan vi ciplastin cho kt qu tt, tuy nhin c mt s tc gi
phi hp etoposide vi cisplatin hay vi carboplatin
2.2. X tr:
X tr c dng trc hoc sau ho tr liu bi bc s chuyn khoa.
3. iu tr triu chng v iu tr h tr cho c hai loi
- Chng au, chng nhim khun, gim ho.
- Chng chn p thn kinh: dexamethasone 20-80 mg /ngy
- Ht dch mng phi.
- Chng suy tu, chng thiu mu.
4. Phng bnh
-Tuyn truyn tc hi ca thuc l trn cc phng tin truyn thng i chng
vn ng mi ngi b thuc l
-Chng nhim mi trng trong nh, mi trng ngh nghip.

271

CHNG 4

THN TIT NIU

HI CHNG THN H
Mc tiu
1. Trnh by c nh ngha, c im dch t hc, bnh nguyn, c ch sinh bnh,
sinh l bnh hi chng thn h.
2. Nu c cc triu chng lm sng, cn lm sng ca hi chng thn h.
3. Nm c chn on xc nh v chn on phn bit hi chng thn h
4. Bit ch nh iu tr triu chng v c ch sinh bnh ca Hi chng thn h.
5. Bit cc kh nng xy ra v hng gii quyt sau khi iu tr corticoide.
Ni dung

I. I CNG
Thut ng Thn h c Friedrich Mller dng ln u nm 1906 ch nhng
bnh thn m cc tn thng gii phu bnh ch c tnh cht thoi ha, khng c
c tnh vim. Nm 1908 Munk dng thut ng Thn h nhim m ch mt loi
bnh thn m v lm sng c ph v Protein niu, gii phu bnh c xm nhp th
m lng chit ng thn v cu thn bnh thng.
Ngy nay, nh tin b ca k thut sinh thit thn v knh hin vi in t, ngi ta
thy rng cc bin lon sinh ha ca thn h nhim m xut hin nhiu bnh khc
nhau, tn thng cu thn cng a dng mc d cc biu hin lm sng v sinh ha
tng i ging nhau. Nh vy, thn h nhim m khng phi l mt bnh n
thun nh quan nim trc kia.
Hi chng thn h (HCTH) thng biu hin tn thng ti thiu cu thn hoc
nhng tn thng dy v thoi ha mng y ca mao mch cu thn.
HCTH n thun nguyn pht nhy cm vi Corticoides thng khng c tng
huyt p, suy thn v tiu mu. Mt s ln trng hp khng li di chng tui
trng thnh.

II. DCH T HC
Bnh gp ch yu tr em, 90% trng hp xy ra tui di 16.
Tn sut gp 2/ 30.000 tr em, ngi ln gp t hn 2/300.000.
tr em, HCTH tin pht xy ra tr trai nhiu hn tr gi (t l nam / n l 2/1).
Tui thng gp nht tr em l 2 - 8 tui, v thng l HCTH n thun.
Ngi ln t gp hn, thng l HCTH khng n thun v xy ra c hai gii.
Theo William G. Couser khong 1/3 bnh nhn ngi ln v 10% bnh nhn tr em
c HCTH l triu chng ca mt bnh ton th, thng l i tho ng, Lupus
ban ri rc hoc Amylose thn. S cn li l HCTH nguyn pht.

272
III. NGUYN NHN
1. Nguyn pht (v cn)
1.1.Thn h nhim m: Tn thng ti thiu mt chn li biu m mng y cu
thn.
1.2. HCTH do Vim cu thn (VCT)
- Vim cu thn mng.
- VCT tng sinh mng.
- VCT thoi ha tng , on.
- VCT tng sinh lan ta.
- VCT tng sinh ngoi thnh mch (VCT tng sinh hnh lim).
2. Th pht sau cc bnh
2.1.Bnh ton th
- Lupus ban h thng.
- Vim quanh ng mch dng nt.
- Ban xut huyt dng thp
- Vim a c.
- Takayashu.
2.2. Bnh c tnh
- Hodgkin.
- Bnh bch cu mn th Lympho.
- a u ty xng.
- Ung th biu m.
2.3.Nhim c thai nghn.
2.4. Cc bnh chuyn ha
-Amylose nguyn pht- th pht.
- i tho ng.
- Suy gip.
2.5. Cc bnh nhim c
- Cc mui ca kim loi nng Hg, Au..
- Thuc:Trimthadione, Paramthadione, Pnicillamine, Probncid.
- Cc d nguyn.
2.6. Nguyn nhn v mch mu
- Tc tnh mch ch.
- Tc tnh mch thn.
2.7. Nhim trng

273
- Vi trng: lin cu, giang mai, vim ni tm mc bn cp.
- K sinh trng: st rt, Bilharziose.
2.8. Bnh v mu
- Hng cu hnh lim.
2.9. HCTH bm sinh v gia nh.

IV. SINH L BNH

1. Protein niu
Protein niu trong HCTH rt nhiu, thng trn 3,5g/24 gi / 1,73 m2 din tch c
th, c th t n 40g / 24 gi. tr em, gn y ngi ta xut prtin niu
cn chn on l 1,66 g/ngy/m2 din tch c th, nu albumin mu gim di 25
g/l. Protein niu thay i ph thuc vo mc lc cu thn v albumin mu, v vy
prtin niu c th gim trong trng hp gim nhiu mc lc cu thn hoc gim
rt r v nhanh ca albumin mu.
Protein niu c th gm ch yu l albumin hoc nhng protein c trng lng phn
t nh hn: gi l protein niu chn lc. Trong trng hp khc, protein niu cha
phn ln l cc protein huyt tng, c bit l IgG: gi l khng chn lc.
Protein niu l do cc bt thng ca hng ro cu thn m tnh thm chn lc vi
cc i phn t tr nn bt thng.
Trong mt s trng hp, chnh hng ro chn lc theo in tch ca cc i phn
t b ri lon: C nhng bin i v mt sinh ha lan ta khp cu trc cu thn, bt
thng ny khng th xc nh bng knh hin vi quang hc c. Protein niu chn
lc l thng gp trong tnh hung ny.
Trong cc trng hp khc, chnh hng ro chn lc theo kch thc ca cc i
phn t b thng tn. C cc bt thng ca cu trc cu thn, d thy bng knh
hin vi quang hc. Protein niu trong trng hp ny thng l khng chn lc.
2. Gim albumin mu.
Gim albumin mu < 30 g/l, thng gp hn l < 20 g/l.
Gim albumin mu ch yu l do mt albumin qua nc tiu, c s tng quan gia
mc protein niu v albumin mu.
Ngoi ra cn c yu t gia tng d ha ca thn i vi albumin: Albumin sau khi
lc, c ti hp thu tr li ng ln gn bi s hp thu ni bo v sau b thoi
bin ti tiu th.
C 2 c ch chnh b tr li s mt albumin qua nc tiu
+ Tng hp albumin gan gia tng.
Bnh thng gan tng hp 12 - 14 g albumin /ngy ngi ln, bnh HCTH c
th gia tng tng hp thm khong 20%. Nh vy c th thy rng s tng hp ny
l khng b s mt protein qua nc tiu.
Mt s yu t nh tui, tnh trng dinh dng km, cc bnh gan c sn t
trc cng c th hn ch s tng tng hp ny. iu ny c th gip gii thch
trong mt s trng hp gim albumin mu rt r, vi protein niu < 10 g/24 gi,
trong khi mt s trng hp khc, c protein niu ln hn nhiu, m albumin mu
cn bnh thng hoc gim va phi.

274
+ C s chuyn vn albumin t khu vc khong k vo huyt tng.
Nhng s b tr ny cng khng y hi phc li albumin mu.
3. Ph
Ph l triu chng thng gp vi tnh cht ph mm, d n lm (du godet). Ph
xut hin nhng vng p lc m k thp nh xung quanh hc mt, mt c chn.
Him hn, c th lin quan n mng phi, mng bng, i khi gy kh th.
Ph l do tnh trng gi mui v nc m c ch do cc yu t sau:
+ C ch gim p lc keo huyt tng.
C ch ny lm vn chuyn nc v in gii vo khu vc k v c th dn n
gim th tch mu v t gim th mu ny tc ng, mang tnh cht sinh l, ln h
thng thn kinh - ni tit (giao cm, RAA, Arginine vasopressine) lm kch thch s
ti hp thu ng thn i vi nc v mui b tr s gim th tch mu.
+ Nhng c ch ti thn c hiu.
c to ra bi s gim albumin mu hoc albumin niu. C th gii thch s gi
mui v nc trong HCTH nh sau: S ti hp thu mui (natri) gia tng rt sm
trong nhng t bo chnh ca ng gp v c s gia tng hot ng ca bm Natri
(Na+/K+/ATPase) v ca knh Natri biu m.
4. Tng lipid mu
Bt thng ny thng c thy trong HCTH. Lc khi u, chnh tng
Cholesterol mu l chnh, tng Triglycride mu xut hin th pht sau .
Cc bt thng Lipide ny thng gp hn khi albumin mu gim < 20 g/l.
Cc Lipoprotein t trng thp (LDL), rt thp (VLDL) v loi trung gian (IDL) u
tng, cc lipoprotein t trng cao (HDL) l bnh thng hoc gim.
Theo phn loi ca Fredrickson v Lees ri lon thng gp nht l type IIa v IIb
(60%), sau l type V (30%), him hn l type III hay IV (10%). Cc bt thng
lipide hi phc khi HCTH bin mt.
C ch ca tng Lipid trong HCTH c gii thch do cc yu t sau y:
- Tng tng hp gan Lipoprotein t trng thp rt thp (VLDL):
y l c ch chnh, thng lin quan vi nng ca gim albumine mu. Khi
gim p lc keo ca huyt tng s kch thch tng hp apoLipoprotein B. Gia tng
men HGM CoA rductase, acide mvalonique, tin cht ca cholesterol v cc acide
bo t do, cng c th b nh hng.
- Gim men Lipoprotein Lipase (LPL)
ng vai tr quan trng bng cch lm gim thoi bin VLDL. Nhng acide bo t
do c ch hot ng ca LPL. S thiu ht apo C II v nhng hparan sulfate, do
bi tit trong nc tiu, cng c ch hot ng ca enzyme ny.
- Gim men Lecithin cholesterol acyl transferase(LCAT):
iu ny ng gp vo nhng bt thng v Lipide trong HCTH bng cch gim
tng hp HDL bt u t nhng VLDL.
- Mt qua nc tiu HDL v apo A1

275
Mt qua nc tiu HDL v apo A1 cng c ghi nhn, nhng nng ca HDL
huyt tng phn ln l bnh thng.
Tc ng sinh x va ca nhng bt thng Lipide ny cha c chng minh mt
cch r rng, c l v thi gian ngn trong tin trin ca HCTH.
Tng Lipde mu cng c th to thun li ngng tp tiu cu v nhng bin chng
huyt khi tc mch, lm gim p ng ca Lymph bo i vi nhng kch thch
khng nguyn. Tng Lipde mu cng c th l mt yu t ca x ho cu thn.
5. Tng ng mu.
Nhiu bt thng cm mu c quan st thy trong HCTH, l nguyn nhn gy ra
tng ng mu v nhng bin chng huyt khi tc mch. Tng ng mu trong
HCTH do cc c ch sau:
- Gia tng fibrinogen mu do tng tng hp gan.
- Gia tng cc yu t II,V,VII,VIII v X, gim cc yu t IX,XI,XII do bi tit trong
trong nc tiu v trng lng phn t thp.
- Gim hot ng tiu fibrin do gim plasminogene v tng antiplasmine (alpha
2 macroglobuline, alpha 2 antiplasmine).
- Thiu ht nhng cht c ch qu trnh ng (Prtin C, antithrombin III).
- Tng ngng tp tiu cu.
Nhng bt thng ny, kt hp vi tng Lipide mu v gim th tch mu, to
thun li xut hin huyt khi tnh mch v tc mch phi.
6. Tng kh nng b nhim trng
Dng nh l do gim gammaglobulin mu, ngoi ra cn do mt b th qua nc
tiu. Chnh nhng iu ny lm sai st ca p ng Lymph bo i vi khng
nguyn.
7 Suy dinh dng v chm pht trin
Ngoi nhng tc dng ca stroide, suy dinh dng v chm pht trin do mt
prtin v mt nhng hocmn gn lin vi cht mang prtin (TBG,T3,T4, Vitamin
D)

V. TRIU CHNG
1. Ph
Thng xut hin nhanh, t ngt, cng c th ph xut hin sau nhim trng nh
ng mi hng.
Tnh cht ca ph: Ph trng mm, n lm, gi du n lu, ph ton thn, khng c
hin tng vim au vng b ph. C th c dch cc mng bng, mng phi,
mng tim, b phn sinh dc.
Cc bin chng nng: ph phi, ph thanh qun thng gp tr em.
2. Triu chng nc tiu
Lng nc tiu thng t 300-400ml/24 gi.
Mt nhiu protein niu: trn 3,5gam/24 gi. C th t 3-10g/24 gi, trng hp nng
c th 30-40g/24 gi.

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Lng Protein tng ln lc ng, lc gng sc, c m lng chit, tr m trong
nc tiu.
Lipid niu: thc cht l nhng kt ta ca Ester Cholesterol.
Ure v Creatinine niu tng.
3. Triu chng th dch
- Gim Protein mu rt quan trng.Protid mu di 60 g/l, trung bnh l 50 g/l.
- Albumin mu gim di 30 g/l, trung bnh 20 g/l. Albumin mu l ch s chnh xc
nh gi nng ca HCTH.
- Ri lon cc Globulin huyt thanh:

2 Globulin tng.
Globulin tng.

Globulin thng gim trong HCTH n

thun, trong HCTH khng n thun c th bnh thng hoc tng.
- Cc thay i v lipid: Cholesterol mu tng, Phospholipid v Triglycerides tng. Ri
lon Lipid trong HCTH lc khi u tng Cholesterol l chnh. Tng Triglycerides
mu xut hin th pht sau . Ri lon Lipid thng gp hn khi Albumin mu
gim di 20 g/l.
- Cc triu chng khc:
+ Na+ mu v Ca++ mu gim.
+ Tng Hematocrit, tng hng cu chng t mu d ng.
+ Gim Antithrombin III do mt qua nc tiu, tng tiu cu v Fibrinogen.
+ Ri lon ni tt: gim Hormone tuyn gip nu hi chng thn h ko di.

VI. CHN ON
1. Chn on xc nh
1.1. Da vo lm sng v cc xt nghim thng thng.
+ Cc tiu chun chn on: da vo cc tiu chun sau y:
1. Ph.
2. Protein niu 3,5g/24 gi.
3. Protein mu <60g/l, Albumin mu < 30g/l.
4. Lipid mu tng trn 900 mg%. Cholesterol mu tng trn 250 mg% hoc
trn 6,5 mmol/l.
5. in di Protein mu: Albumin gim, t l A/G < 1, Globulin: 2 tng, tng.
6. Nc tiu c tr m, tinh th lng chit.
Trong tiu chun 2 v 3 l bt buc.
1.2. Da vo cc thm d chc nng v thn:
- Hi chng thn h n thun: Cc chc nng thn bmh thng.
- Hi chng thn h khng n thun: Ri lon cc chc nng lc ca cu thn,
chc nng bi tit v ti hp thu ca ng thn.
1.3. Sinh thit thn

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- C gi tr rt ln trong chn on xc nh tn thng ca HCTH.
- Gip phn loi tn thng trong HCTH mt cch chnh xc.
- HCTH n thun tr em 80% l tn thng ti thiu.
2. Chn on phn bit
2.1. HCTH n thun v khng n thun:
HCTH n thun: huyt p bnh thng, khng c suy thn, khng c i mu.
HCTH khng n thun: huyt p tng v/hoc suy thn v/hoc i mu. Ngoi ra,
cn da vo in di Protein niu: trong HCTH n thun Protein niu ch yu l
Albumin (Protein niu chn lc).
2.2. Ph do cc nguyn nhn khc: X gan, suy tim, ph suy dinh dng.

VII. BIN CHNG

1. Nhim trng
- Ngoi da: Vim m di da
- Phi: vim phi.
- Phc mc: vim phc mc tin pht do ph cu, nhng c th do cc vi khun
khc.
- Mng no:vim mng no t gp.
- ng tit niu: nhim trng ng tit niu.
2. Cn au bng do hi chng thn h.
au bng trong HCTH do cc nguyn nhn khc nhau
- Vim phc mc do ph cu.
- Vim rut do nhim trng, c th do t cu.
- Do ph ty, ph dy chng Treitz hoc tc tnh mch ch, tnh mch thn.
3. Try mch
Gim th tch mu nng nht l khi s dng thuc li tiu mnh lm gim th tch
mu t dn n suy thn cp chc nng. Trong trng hp ny, truyn Plasma
hoc cc cht c trng lng phn t cao th c kh nng hi phc.
4. Tc mch
Mu trong tnh trng tng ng: do gim Albumin, gim Antithrombin III, do tng cc
yu t ng mu (tiu cu, fibrinogen). y l loi bin chng c in chim 5-20%
ca HCTH. Thng tc tnh mch thn, tnh mch ca, tnh mch phi.
5. Thiu dinh dng
Nu b bnh lc cn nh: tr s gim ln so vi cng la tui.
Gim min dch, d mc cc bnh nhim trng.
Suy kit.
Ngoi ra, gim Ca mu (ti hp thu Ca rut gim), ri lon chuyn ha Vitamin D do
mt Protein.

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VIII. TIN TRIN, TIN LNG
1. Tin trin
C nhiu kh nng xy ra: nu p ng tt vi iu tr, HCTH c th lui bnh v khi
hn hon ton. Trong mt s trng hp, bnh ti pht nhiu t, nhiu nm lin ri
lui bnh hoc chuyn sang suy thn mn.
2. Tin lng: ph thuc vo
- Tui.
- Th bnh: n thun, khng n thun
- Thng tn gii phu bnh ca HCTH.
- p ng iu tr.

IX. IU TR
1. Nguyn tc
iu tr Hi chng thn h bao gm:
- Ch tit thc sinh hot.
- iu tr triu chng.
- iu tr c ch bnh sinh.
Hi chng thn h n thun nguyn pht khng c tng huyt p, suy thn v tiu
mu thng nhy cm vi Corticoides. Mt s ln trng hp khng li di chng
tui trng thnh.
i vi cc Hi chng thn h th pht sau mt bnh khc, th iu tr c bn vn l
iu tr bnh chnh, t l p ng vi Corticoides thp hn so vi Hi chng thn h
n thun nguyn pht.
2. Ch ngh ngi n ung
2.1. Hn ch mui
Hn ch mui tu thuc vo triu chng ph ca bnh.
Trong th Hi chng thn h c ph nh: hn ch mui tng i (di 2g/ngy).
Hn ch mui tuyt i (di 0,5 g/ngy) trong nhng th ph to.
2.2. Tng lng Protid
Trong hi chng thn h, nhu cu Protid tng ln do mt mt lng ln qua ng
tiu, v vy nu bnh nhn khng c tng Ure mu th cn tng lng Protid trong
ch n trn 2g/ kg/ngy. Nu bnh nhn c suy thn th ch n s gim Protid
theo mc suy thn.
2.3. Nc
Tu thuc vo mc ph v lng nc tiu, thng thng phi hn ch lng
nc ung vo khong 500 - 700 ml /ngy.
3. Thuc
3.1. iu tr triu chng.

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- iu tr ph: Cn lu rng trong hi chng thn h, th tch huyt tng
thng l bnh thng hoc gim. V vy s dng thuc li tiu mnh c th gy
gim th tch nng, iu ny cng d xy ra khi ang gim albumin mu cng trm
trng (<15g/l). iu tr li tiu cng cn thn trng lc khi u. Cc li tiu thiazide
thng c chn la u tin. Li tiu khng lm mt Kali (Spironolacton,
triamtrene, amiloride) c th dng trong trng hp gim kali mu. Khi triu chng
ph nng n v khng p ng vi iu tr li tiu mui, cc li tiu quai c ch
nh.
- iu tr tng lipid mu: trong nhng nm gn y iu tr tng lipid mu c
ngh trong hi chng thn h khi ri lon ny nghim trng. Nhm thuc c
chn la y l nhm Statine.
- iu tr cc bin chng:
Tu cc bin chng gp bnh nhn Hi chng thn h c tm thy, chng hn
trong cc trng hp c huyt khi cn phi c ch nh chng ng.
- Cho thm Ca, st, cc loi vitamine, khng sinh nu cn.
3.2. iu tr c ch bnh sinh.
3.2.1. Corticoides (Prednisolone) ngi ln 1mg / kg / ngy. Tr em 1,5 mg - 2 mg /
ngy.
Liu tn cng 4 - 8 tun.
Liu cng c bng 1/2 liu tn cng (0.5mg/kg/ngy ngi ln) ko di t 2 - 4
tun.
Liu duy tr 5 - 10 mg/ ngy.
Thi gian ca liu trnh Corticoides thng t 4,5 n 6 thng.
3.2.2 Cc loi thuc c ch t bo.
+ Chlorambucil vin 2mg, liu 0,1-0,2 mg/kg thi gian 3 thng n 1 nm. C th
phi hp vi Corticoides.
+ Cyclophosphamide (Endoxan) vin 50mg, ng 100mg liu bt u 5mg/kg/24h
iu tr trong 12 tun.Phi hp vi Prednisolone cho kt qa tt. Lc phi hp, liu
Cyclophosphamide 2,5mg/kg/ngy trong 90 ngy.
+ Azathioprine vin 50mg ung 2-3mg/kg/ngy t 1-6 thng.
Thuc gim min dch iu tr c kt qu trong cc trng hp HCTH khng n
thun, cc trng hp khng Corticoides, ph thuc Corticoides v loi chng ch
nh Corticoides.
3.3. iu tr nguyn nhn
i vi nhng trng hp hi chng thn h th pht iu tr loi b nguyn nhn
l cn thit.

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VIM CU THN CP
Mc tiu
1. Trnh by c nh ngha, dch t hc v nguyn nhn ca vim cu thn cp.
2. M t c c ch sinh bnh vim cu thn cp
3. Pht hin c cc triu chng lm sng, cn lm sng vim cu thn cp.
4. Chn on xc nh, chn on phn bit ca vim cu thn cp.
5. iu tr c vim cu thn cp.
Ni dung

I. I CNG V DCH T HC
1. i cng
Hi chng vim cu thn cp l biu hin lm sng ca mt thng tn vim cp
ca nhng cu thn, c trng vi s xut hin t ngt hng cu niu, protein niu,
ph v tng huyt p.
Hin nay, nh nhng tin b khoa hc, nht l k thut sinh thit thn. Ngi ta u
thng nht rng: Vim cu thn cp (VCTC) khng ch l mt bnh n thun m l
mt hi chng gi l hi chng cu thn cp. L do l v bnh cnh lm sng thng
ging nhau nhng tn thng m bnh hc li a dng, bnh pht sinh khng ch do
lin cu m c th sau nhim t cu, ph cu, virus.Hi chng vim cu thn cp
cn biu hin th pht sau cc bnh nh lupus ban h thng, ban dng thp,
vim quanh ng mch dng nt.
Vim cu thn cp c tnh hay vim cu thn bn cp hin nay c gi l vim cu
thn th tin trin nhanh. Tn gi ny c trng cho bnh l tin trin nhanh, t vong
sm do suy thn v t khi ngi bnh qua khi 6 thng nu khng c iu tr .
2. Dch t hc
2.1. T l mc bnh: t l mc bnh VCTC sau nhim lin cu khng c bit mt
cch chnh xc v nhiu trng hp bnh c gi iu tr ngay tuyn trc. Tn
sut bnh gim dn cc nc cng nghip hin i, nhng vn cn thng gp
cc nc nhit i, cc nc ang pht trin. (Chu Phi, vng Carib, Chu , Nam
M...).
Bnh xut hin di dng tn pht, hoc c th thnh tng v dch, c bit
nhng ni i sng v sinh km (nhng v dch Trinidad, Maracaibo, Minnesota)
2.2. Lin quan gii v tui: Bnh rt him trc hai tui, thng gp tr con t 3
n 8 tui, tr nam thng gp hn n (t l nam/n = 2/1). ngi ln t gp hn
so vi tr em.

II. CN NGUYN
Vim cu thn cp c th do nguyn nhn nhim khun hoc khng do nhim
khun.
1. Vim cu thn cp do nhim khun gm
1.1. Vi khun thng gy bnh nht l lin cu tan huyt bta nhm A (group A)
c coi l mu hnh ca vim cu thn cp. Chng thng gy bnh nht l chng
12, cc chng khc (1, 2, 4, 18, 24, 25, 49, 55, 57, 60) cng c th gy bnh nhng

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him gp hn, Thng chng 4, 12, 24 nu l nhim khun c hng, chng 14,
19, 50, 55, 57 nu l nhim khun ngoi da (khc vi thp khp cp v trong thp
khp cp chng lin cu no cng c th gy bnh).
1.2. Mt s vi khun khc him gp hn cng c th gy vim cu thn cp nh t
cu, ph cu, thng hn, no m cu, Klebsiella Pneumoniae,...
1.3. Mt s siu vi gy vim hng cp dch t, quai b, si, thy u, Epstein Barr,
vim gan siu vi B, Cyto megalo Virus (CMV)...
1.4. Nguyn nhn do nhim nm: Histoplasmose
1.5. Nguyn nhn do nhim k sinh trng: Plasmodium falciparum v Malariae,
Toxoplasma Gondii, sn mng,...
2. Vim cu thn cp khng do nhim khun
2.1. Cc bnh to keo: c bit l luput ban h thng, vim quanh ng mch
dng nt, btut huyt dng thp.
2.2. Cc bnh biu hin qu mn cm vi mt s thuc nh Penicilline, Sulfamide,
Vaccine hay mt s thc n nh tm, cua...

III. S TM TT C CH VIM CU THN CP DO LIN CU

KHUN
Khng nguyn (KN)

Khng th (KT)

Lin cu tan huyt bta

- AHL (antihyaluronidaza)
- ASLO (antistreptolysin O)
- ANDAZA (antidesoxyribo nucleaza)
- ASK (antistreptokinaza) lu hnh

Phc hp KN - KT

tr lng cu thn

Lng ng cc phc hp min

Hot tc cc b th

Phn ng vim v tng sinh nhng mao

dch ln mng y ca mao

qun cu thn

qun cu thn

IV. DU CHNG LM SNG V CN LM SNG

1. Trong vim cu thn cp do nhim khun
Di y l bnh cnh in hnh ca vim cu thn cp sau nhim lin cu khun.
1.1. Lm sng
Bnh thng gp tr em v xut hin sau mt t nhim khun c hng hoc ngoi
da t 7-15 ngy. Nhim khun ngoi da thng bnh di ngy hn.

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1.1.1. Giai on khi pht
Thng l t ngt nhng c th c du hiu bo trc vi:
- Ton thn mt mi, st 38-390C hoc nh hn.
- au vng tht lng hai bn, ri lon tiu ha, chn n, au bng, bun nn.
- Cng c th bnh nhn n vin v cn vim hng, vim da.
1.1.2. Giai on ton pht
- Ph:
Lc u thng xut hin mt, nh nng m mt, ph c th khi
nhanh, nhng cng c th lan xung chi ri ph ton thn. Ph trong vim cu thn
cp c c im:
+ Ph mm, trng, n lm li du ngn tay.
+ Ph quanh mt c, mt trc xng chy, mu bn chn.
C th ph nng vi ph ton thn nh trn dch mng phi, mng bng, ph phi
cp, ph no. Ph trong vim cu thn cp ph thuc vo ch n ung.
- i t hoc v niu: Xut hin sm, nc tiu ch c 500-600ml/24gi. Khi c
thiu niu (nc tiu di 500ml/24gi) hoc v niu (nc tiu di 100ml/24gi)
l biu hin suy thn cp.
- Tng huyt p: Tng huyt p c ti a ln ti thiu, thng r hai tun u.
Trn 60% VCTC c tng huyp p. Ph phi cp trong VCTC l tai bin thng gp
do tng huyt p, ph v suy tim tri.
- i mu: t khi i mu i th, nu c thng xut hin sm cng vi ph, nc
tiu hay sm mu ( khi hng cu niu trn 300.000/pht). Thng gp hn l
i mu vi th. Hng cu mo m d v. Tr hng cu l du hiu c gi tr nht,
chng t hng cu t cu thn xung. i mu i th thng khi sm nhng i
mu vi th th ko di, hng cu niu c khi 3-6 thng mi ht.
1.2. Xt nghim cn lm sng
1.2.1. Mu: Cng thc mu c thiu mu nh, lng mu tng nhiu tun v tr li
bnh thng khi n nh.
1.2.2. Nc tiu
- Protein: 0,2 - 3g/24gi. in di protein niu c tnh khng chn lc(t alb/globulin <
1, clearance IgG / transferin > 10%). Protein niu trong VCTC lun c v l yu t
theo di din tin ca bnh.
- Cn addis: Hng cu 100.000 - 500.000/1 pht, Bch cu 20.000/1 pht.
- Tr Hng cu l xt nghim c gi tr chn on, tuy nhin cng c t l khng gp.
1.2.3. Ur, creatinine mu
Ur mu c th bnh thng hoc tng nh v t c ngha tin lng khi khng
vt qu 1g/l. Nu ur mu cng ngy cng tng dn l mt ch dn xu, creatinine
mu bnh thng, nu tng cao dn song song vi ur l mt ch dn xu.
Tt nht theo di VCTC l tnh thanh lc cu thn vi creatinine. Nu Ccr di
50ml/pht l mt tin lng d dt.
1.2.4. B th mu gim

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90% bnh nhn c b th mu gim, gim thnh phn C3 l ch yu. Sang tun th
su ca bnh mi tr v bnh thng.
1.2.5. Cc xt nghim khc
Ch yu pht hin lin cu v cc khng th nh ngoy hng tm lin cu khun,
ALSO tng hn 400v Todd, in tim c PR ko di.
1.2.6. Sinh thit thn
Ch cn thit ngi ln tui, gip chn on th gii phu bnh v gip tin lng
bnh.
Trong thc t 2 xt nghim hng cu niu v protein niu cng xc nh
VCTC.
1.3. Tin trin: Vi nhiu kh nng
- Tt: l din tin thng gp ca bnh VCTC, sau 8-15 ngy bnh nhn i nhiu,
ht ph, huyt p v nc tiu tr li bnh thng. C trng hp sau 3 thng, c
khi 6 thng cc triu chng trn mi tr li bnh thng. Nhng trng hp ny gi
l khi chm, t l ny t. tr em, t l khi bnh cao (85-95%) so vi ngi ln
(50-75%).
- Xu
+ Vim cu thn cp th tin trin nhanh hay c tnh ch din tin vi tun hoc vi
thng, c khi dai dng hn, nhng thng t vong trong vng 6 thng,chim t l
di 10%. Lm sng khi pht nhVCTC kinh in nhng dn n suy thn cp
nhanh.
+ Tin trin xu cng dn n t vong ngoi 6 thng: ph v protein niu dai dng,
thng xut hin hi chng thn h, trc y gi l vim cu thn cp bn cp,
bnh dn dn suy thn, khng phc hi.
+ Bnh din tin ko di nhiu nm vi tng t lui bnh, nhng cui cng cng dn
n t vong, hn m do tng ur mu hoc do tai bin mch no do tng huyt p
gi l suy thn mn.
TM TT S TIN TRIN CA VIM CU THN CP NGI LN
- Khi hon ton (60%)
- Cht trong t cp (1-2%)
(Trong vng 2-6 tun)
Vim cu thn cp

- Tin trin nhanh (5-10%)

(T vong trong vng 6 thng)
- VCT mn (10-20%)
(Tim tng mn tnh nhiu nm)

1.4. Cc th lm sng khc ca vim cu thn cp do nhim khun

1.4.1. Th i mu n thun:
Thng gp tr em, i mu c th n c, khng ph, khng thiu, v
niu. Tin trin ni chung tt, nhng c th ti pht.

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1.4.2. Th tim mch
Thng gp ngi ln, tr, khi pht d di vi tng huyt p, ph phi,
ph no.Chn on c bn da vo xt nghim nc tiu vi hng cu niu v
protein niu. Tin trin nu khng t vong giai on u, v sau ph ko di nhiu
nm.
1.4.3. Th v niu: Biu hin ca mt suy thn cp, trc y c khi khi t pht,
ngy nay vi thn nhn to t l khi bnh nhiu hn, khi nc tiu phc hi th bnh c
th khi hon ton nh cc th khc.
1.4.4. Th nh hay thong qua: c pht hin tnh c nh xt nghim mt cch c h
thng, nht l nhng bnh nhn c vim mi, vim hng, rt him chuyn sang mn
tnh.
1.4.5. Th s sinh v tr em nh tui: Khi pht c khi d di bng cc cn co git
v suy tim cp, tuy nhin khi qua khi, tin lng thng tt hn ngi ln.
2. Vim cu thn cp khng do nhim khun
2.1. Luput ban h thng
70% luput c vim cu thn cp c th biu hin di hai dng:
- Nh: nhng thng nng ln v iu tr bng hormon v thng thn.
- Nng: km vi vim a khp, vim a mng.
2.2. Ban dng thp
30% c vim cu thn cp biu hin vi i mu v protein niu.
2.3. Vim cu thn cp do hin tng qu mn
Nh do thuc, vacxin, din bin thng tt sau khi ngng thuc.

V. CHN ON
1. Chn on xc nh
Da trn 3 du chng lm sng, ph, tng huyt p, thiu hoc v niu v hai
du chng cn lm sng: protein niu v hng cu niu.
2. Chn on gin bit
- t cp ca vim cu thn mn da vo tin s, bnh s, ngoi ra c th siu m
o kch thc thn, nu thn nh hn bnh thng l vim cu thn mn.
-Vim cu thn cp sau nhim lin cu vi Vim cu thn cp khng do lin cu:
da vo bnh s, cy vi khun, dch mi hng, m ngoi da, khng th ALSO v cc
khng th khng lin cu khc.

VI. THEO DI V TIN LNG

Vim cu thn cp sau nhim lin cu thng gp tr em v tin lng tt hn,
ngi ln t gp nhng tin lng nng hn.
Nhn chung, tin lng thng tt nu bnh hi phc hon ton. Trong Vim cu
thn cp ngay trong t cp, c th cht do ph phi cp, suy tim, suy thn cp,
nhim khun.

VII. IU TR
1.Tit thc, ngh ngi

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1.1. Tit thc
- Bnh nhn thiu v v niu c tng ur, creatinine mu: lng nc vo
500-600ml/ngy, mui 2g/ngy, Prtide 20g/ngy.
- Bnh thiu v v niu c ph tng huyt p, ur, creatinine mu khng tng:
mui 0,5 - 1g/ngy, Prtide 40g/ngy.
1.2. Ngh ngi
Ngh ngi tuyt i t 3 tun n 1 thng cho n khi ht triu chng. Sau tr li
hot ng t t ngay khi cn protein niu v i mu vi th thng t 6 tun n 2
thng.
2. Khng sinh
Ch cho khng sinh khi cn tn ti du hiu nhim lin cu.
Cha c t liu no khng nh rng khng sinh c th ngn nga s nng ca
bnh vim cu thn cp do lin cu, khng sinh khng c tc dng ln cu thn,
thng s dng l Pnicilline 1 triu n v /ngi ln, 500.000 n v / tr em. Nu
d ng Pnicilline th dng Erythromycine 0,2 x 5 vin/ngy ngi ln hoc
Tetracyline. Khng sinh dng trong 10-12 ngy.
3. Cc thuc Corticoides
Bao gm prednisolone, mthylprednisolone. Khng c tc dng trong cc th thng
thng, thm ch c hi. Nhm thuc ny c th c s dng trong cc th tin
trin nhanh.
4. iu tr bin chng
4.1. Tng huyt p.
King mn, ngh ngi tuyt i.
Thuc h huyt p: Cc nhm thuc h huyt p thng c s dng hin nay l:
+Thuc c ch canxi:C nhiu thuc nh nifdipine, amlodipine, felodipine,
manidipine. y l nhm thuc thng c s dng chng tng huyt p do bnh
thn hin nay.
+Thuc c ch men chuyn: nh catopril, enalapril, perindopril. L nhm thuc c
xem l c tc dng bo v thn. Cn lu tc dng ph tng kali mu.
+ Thuc c ch thn kinh trung ng: Trong nhm ny thuc thng c s dng
l mthyldopa (Aldomet)
4.2. Ph phi
iu tr nh cc ph phi khc,cho Lasix liu cao c th n 200mg tim tnh mch,
Uabain, th oxy, Morphin khi cn thit.
4.3. Ph no
Truyn glucose u trng, Manitol.
4.4. Th v niu
Nhng ni khng c iu kin lc thn nhn to c th iu tr th Furosemid
(Lasix) liu cao hoc c th thm phn phc mc.

286
Tt nht cho c ph phi, no, v niu l lc ngoi thn m thn nhn to ng vai
tr hng u.
4.5. Cc triu chng khc
- Tng ur mu, creatinine mu, hn ch lng protid a vo nhng phi
m bo nng lng 1200-1600 calo/ngy chng d ha, c th cho Durabulin
hoc Testosterone 25-50mg/ngy.
- iu tr tng K mu bng glucose 20-30%, 300-500ml + 10-20v insulin truyn tnh
mch trong 1 gi n 1g30 pht hay truyn dung dch kim, hoc c th s dng
Resonium (Kayexalate) ung 30g/ngy.
Hon cc tim phng trong thi gian mc bnh vim cu thn cp v ngay c hai
nm u sau khi ht vim cu thn cp, nht l vaccin chng ho g, un vn.
Trong vim cu thn cp th thng thng iu tr i khi ch cn ngh ngi, n nht
l . Trong khi nhng th nng, ty thuc vo bin chng v c cch iu tr khc
nhau. Cng cn lu rng khi pht hin c nguyn nhn ca vim cu thn cp
th vn iu tr nguyn nhn l quan trng

VII. D PHNG
1. i vi vim cu thn cp sau nhim khun lin cu
- Pht hin sm cc nhim khun do lin cu: vim hng, vim Amygdals,
vim da...
- iu tr trit cc nhim khun do lin cu: khng sinh, ct amydals.
- Nng cao v sinh c nhn: b thuc l, gi m c trong ma lnh i vi
vim hng, v sinh c nhn i vi gh bi nhim.
2. i vi vim cu thn cp khng do nhim khun
- Pht hin sm cc biu hin thn trong cc bnh ton th: lupus ban h
thng, ban xut huyt dng thp.
- iu tr tt cc bnh ton th d phng tn thng vim cu thn.

287

SI H TIT NIU
Mc tiu
1. Nm c dch t, nguyn nhn v c ch sinh bnh ca si h tit niu.
2. Bit c din tin ca si v nh hng ca si i vi ng tit niu.
3. Nu c triu chng lm sng v cn lm sng ca si h tit niu.
4. Chn on c v bit ch nh cc phng php iu tr si h tit niu.
5. Bit c cc phng php iu tr ni khoa v bit cch ch nh iu tr ngoi
khoa si tit niu
Ni dung

I. I CNG
Si thn v h tit niu l bnh thng gp nht ca ng tit niu v thng gp
nam gii nhiu hn n gii. Tui mc bnh thng l t 30 - 55, nhng cng c
th gp tr em (si bng quang). Ti cc nc cng nghip pht trin, si Acide
Urique c chiu hng gp nhiu hn cc nc ang pht trin. Vit Nam, si
Amoni-Magi-Phosphat (Struvit) chim mt t l cao hn. Ch n ung khng
hp l (qu nhiu m, Hydrat Carbon, Natri, Oxalat), nhim khun tit niu hoc
sng vng nng, vng nhit i,... l nhng yu t thun li bnh si thn tit
niu d pht sinh. Cc loi si Calci thng l si cn quang, cn si Urat v Cystin
thng khng cn quang.
Theo tc gi Glenn. H. Pneminger t l mc bnh si thn tit niu trn th gii vo
khong 3% dn s.

II. NGUYN NHN V C CH SINH BNH

1. Cu trc ca si
Bowman v Meckel nghin cu si niu v nhn thy vin si c mt tnh cht
c th gm hai yu t:
- Cht Mucoproteine, c tc dng nh cht keo kt dnh cc tinh th vi nhau to
si.
- Cc tinh th ca cc cht bnh thng c ha tan trong nc tiu, ch yu l
Calci v Oxalat. Bn cnh cc cht thng gp ny cn c cht Phosphat, Magi,
Urat, Cystine.
Vai tr ca Mucoprotein trong c ch to si hin nay vn cn c bit rt t.
C th ni rng khi nc tiu b c c hoc khi pH ca nc tiu thay i, th cc
cht ha tan trong nc tiu s kt tinh li thnh cc tinh th, cc tinh th s b loi
tr theo dng nc tiu. Cn phi c cht Mucoproteine th cc tinh th mi lin kt
li vi nhau to ra vin si. Do nhiu trng hp khi th nc tiu, thy c
nhiu tinh th Oxalate hay Phosphate nhng bnh nhn khng c si thn tit niu.
2. iu kin thun li pht sinh ra si
iu kin thng xy ra nht l s c c qu mc ca nc tiu.
Trong iu kin bnh thng, nu c hai iu kin sau y th cc tinh th ha tan c
th lng ng c:
- Dung dch c yn tnh, khng b khuy ng trong mt thi gian di.

288
- Dung dch c cha ng cc vt l nh si ch, xc t bo, vi khun,... th vt ny
c th tr thnh nhn cc tinh th ng xung quanh to si.
Ngoi ra, khi dung dch c c c qu bin ha tan trn ngng bo ha th s
c s kt tinh ca cc cht ha tan.
S thay i ca pH nc tiu s lm cho mt s cht ha tan d kt tinh li c th,
di tc dng ca mt s chng loi vi trng (nh Proteus Mirabilis) c tit ra men
urase lm phn hy ure thnh amoniaque, nc tiu s b kim ha (pH> 6,5) v
nh vy, cht Photsphate - Magi s kt tinh li. Ngc li nu pH nc tiu tr nn
acid (pH< 6) th s l iu kin thun li cho urat kt tinh li.
3. Cc loi si niu thng gp
3.1. Si calcium
Chim t l t 80 - 90 % cc trng hp. Nhng nguyn nhn lm tng nng
calci trong nc tiu l
- Cng tuyn gip cn gip.
- Gy xng ln v bt ng lu ngy.
- Dng nhiu Vitamin D v Corticoid.
- Di cn ca ung th qua xng, gy ph hy xng.
Ngoi ra cn c rt nhiu trng hp c tng nng calci trong nc tiu m
khng tm thy nguyn nhn, gp trong 40-60% trng hp. Ngoi ra cng c th c
nng calci trong nc tiu cao nhng nng Calci trong mu vn bnh thng.
Nng calci cao trong nc tiu khng phi l yu t quyt nh kt thnh si
niu, m n ch l yu t thun li.
3.2. Si oxalat
Chim t l cao cc nc nhit i nh nc ta, oxalat thng kt hp vi calci
to thnh si oxalat calci.
3.3. Si phosphat
Loi si phosphat thng gp l loi amoni-magn-phosphat, chim khong 5-15%
trng hp, c kch thc to, hnh san h, cn quang, hnh thnh do nhim khun,
c bit l do lai vi khun proteus.
Vi khun protus c men urase lm phn hy ure thnh amoniaque, do nc
tiu s b kim ha, nu pH nc tiu trn 7,0 th phosphat s kt ta.
3.4. Si acid uric
Acid uric d tan trong mi trng kim v d kt tinh trong mi trng acid, khi pH
nc tiu di 6. Nguyn nhn ca n thng l:
- Lng Acid uric c bi tit qu nhiu trong nc tiu.
- Nc tiu b c c qu nhiu trong trng hp mt nc do m hi khi lm
vic mi trng nng bc.
Si acid uric d xut hin khi chuyn ha cht purine tng trong c th. Cc nguyn
nhn c th lm tng chuyn ho purine:
+ Dng nhiu thc n c cha nhiu cht purine nh lng heo, lng b, tht c
kh, nm.

289
+ Bnh Gt (Goutte).
+ Phn hy cc khi ung th khi dng thuc ha tr liu.
3.5. Si Cystin:
c hnh thnh do mt khuyt tt ca vic ti hp thu ng thn ca cht
Xystin tng i t gp nc ta. Si Cystin khng cn quang.
4. L thuyt hnh thnh si

Kt th Carr

m Randall

Hoi t thp i

thn
Cho n by gi, vn cha c mt c ch hon ton y gii thch cho vic
hnh thnh v pht trin ca cc vin si trong h thn tit niu. Nhiu gi thuyt
c a ra, nhng cc gi thuyt cng khng gii thch c ht tt c cc
trng hp hnh thnh si. V vy, vic hnh thnh si cho n by gi vn c
xem l mt qu trnh do a yu t tc ng.
4.1. Kt th Carr
nhng ngi hay b si ti pht, tc gi Carr nhn thy u ca nhng ng gp,
quanh cc gai thn c nhng ht si nh, trn, cng. Cc kt th ny c cu
to bi calcium phosphate v mucopotine.
4.2. m Randall
Randall cho rng nu thp i thn bnh thng, nhn nhi th si kh kt hp.
Ngc li, nu v mt l do no , nh trong trng hp vim i b thn, thp i
thn b bin th, thng b i thn v vim, thp i thn b mn l th tinh th s
b kt ta li thp i thn, to thnh nhng m vi ha, v sau bong ra v rt
xung i thn, to thnh si nh.
4.3. Hoi t ca thp i thn
Trong mt s trng hp nh i ng, nhim trng ng tit niu mn tnh hay
trong trng hp dng thuc gim au ko di, ngi ta thy c hoi t thp i
thn, v ni y chnh l nhn cho cc tinh th lng ng to thnh si.

III. DIN TIN CA SI NIU

Sau khi vin si c hnh thnh, nu si cn nh, thng vin si i theo ng
nc tiu v c tng ra ngoi. Nhng nu vin si b vng li mt v tr no
trn ng tit niu, th n s to ra, gy cn tr lu thng ca nc tiu, a n
ng v dn phnh pha trn ch tc. Lu ngy s a n cc bin chng:
- nc tiu.
- Nhim trng.

290
- Pht sinh thm cc vin si khc.
Cui cng s ph hy dn phn thn sn sinh ra n.
1. Nhng nguyn nhn lm cho vin si b vng li:
1.1. Hnh dng v kch thc ca vin si.
Mt vin si ln, sn si th d bm vo nim mc v b vng li.
1.2. Trn ng tit niu c nhng ch hp t nhin do cu trc gii phu
Vin si khng qua c cc ch hp , nhng ch hp l
- C i thn
- C b thn
- Nhng ch hp niu qun
+ Vng tht lng, c cc mch mu sinh dc (mch mu bung trng hoc
tinh hon) bt cho qua v ni niu qun thng b gp khc, nn vin si c
th b vng li.
+ Vng chu hng, niu qun bt cho qua mt s ng mch nh ng
mch chu, ng mch bng quang t cung.
+ Vng st bng quang, niu qun bt cho qua ng dn tinh.
+ Phn niu qun trong ni thnh bng quang,
V vy, vin si niu qun hay b vng li cc on nh sau
- on tht lng 1/3 trn ca niu qun.
- on trong chu hng b.
- on ni thnh ca bng quang.
1.3. bng quang
C bng quang l ch hp ch yu. nam gii, c bng quang c tin lit tuyn bao
bc nn s kh qua hn ph n.
1.4. niu o
n gii niu o khng c ch hp v ngn hn nn si t b vng li hn. nam
gii, niu o c ba ch m rng ra v vin si hay lt vo . Nhng ni l
- Xoang tin lit tuyn.
- Hnh niu o.
- H thuyn gn l so.
2. nh hng ca vin si i vi ng tit niu
Nc tiu t i b thn xung bng quang nh cc nhu ng. Mun c nhu ng
phi c tun t nh sau
- S gin n ca c vng pha trc.
- S co bp ca c vng pha sau.
- S co bp ca cc c dc.

291
Hin tng ny phi xy ra tun t t trn xung di th nc tiu mi i c.
Nhu ng khi pht t i thn, lan xung b thn v n niu qun. Chp i thn
v c b thn l cc ni ch nhp ca cc sng nhu ng.
Khi vin si b vng li bn trong ng tit niu, n s nh hng n ng
tit niu qua 3 giai on
2.1. Giai on chng i
ng tit niu pha trn vin si s tng cng sc co bp tng si ra ngoi.
Niu qun v b thn pha trn vin si cha b gin n. C s tng p lc t ngt
i b thn gy cn au qun thn. Trn lm sng giai on ny bnh nhn
thng biu hin bi nhng cn au qun thn in hnh.
2.2. Giai on gin n
Thng thng sau khong 3 thng nu si khng di chuyn c th niu qun, b
thn v i thn pha trn vin si s b gin n, nhu ng ca niu qun b gim.
2.3. Giai on bin chng
Vin si nm lu s khng di chuyn c v b bm dnh vo nim mc, niu qun
b x dy, c th b hp li. Chc nng thn s b gim dn, thn nc, m nu
c nhim trng, si cn tn ti trong ng tit niu l mt yu t thun li cho vic
nhim trng ti din, lu ngy s gy vim thn b thn mn tnh v a n suy
thn mn. Si niu qun hai bn c th gy v niu do tc nghn.

IV. LM SNG
1. Si ng tit niu trn
Gm si thn, b thn, niu qun. Cc triu chng thng gp l:
- Cn au qun thn: xut hin t ngt, sau khi gng sc, khi pht vng h tht
lng mt bn, lan ra pha trc, xung di, cng au thng mnh, khng c
t th gim au. C th phn bit hai trng hp
+ Cn au ca thn do s tt nghn b thn v i thn: au h tht lng pha
di xng sn 12, lan v pha trc hng v rn v h chu.
+ Cn au ca niu qun: xut pht t h ca tht lng lan dc theo ng i ca
niu qun, xung di n h chu b phn sinh dc v mt trong i.
- Triu chng km theo hay gp l bun nn, nn ma, chng bng do lit rut. C
th c st, rt run nu c nhim trng kt hp.
- Khm thy im sn lng au, rung thn rt au. Cc im niu qun n au, c
th thy thn ln.
Ch rng khng c mi lin quan gia kch thc hay s lng si vi vic xut
hin cng nh cng au ca cn au qun thn. Mt s trng hp bnh nhn
khng c triu chng (si th yn lng), hoc ch c du khng r rng nh au
m vng tht lng mt hoc hai bn.
2. Si ng tit niu di
Gm si bng quang v si niu o.
- Si bng quang s kch thch nim mc bng quang gy tiu but, rt, tiu lu.
- Tiu tc gia dng.

292
- Khm n im bng quang au.
- Si niu o s gy b tiu, khm lm sng thng pht hin c cu bng
quang, s nn dc theo niu o c th thy si.

V. CN LM SNG
1. Xt nghim nc tiu
1.1. Tm t bo v vi trng: nc tiu c nhiu hng cu, bch cu. C th thy vi
trng khi ly tm soi v nhum Gram khi c bin chng nhim trng. Cn cy nc
tiu trong trng hp nghi ng c nhim trng.
1.2. Soi cn lng: c th thy tinh th Oxalat, Phosphat, Calci.
1.3. pH nc tiu: c nhim trng niu pH s tng trn 6,5 v vi trng s phn hy
Urea thnh Amoniac. Khi pH di 5,5 c nhiu kh nng c si Urat.
1.4. Albumin niu: nhim trng niu ch c t Albumin niu, nu c nhiu phi thm
d bnh l cu thn.
2. Siu m: pht hin si, nc ca thn v niu qun, dy mng ca ch
m thn. y l xt nghim thng c ch nh trc tin khi nghi ng c si h
tit niu v n gin, r tin, khng xm nhp v c th lp li nhiu ln khng c hi
cho bnh nhn. Nhiu trng hp si khng triu chng c pht hin tnh c khi
khm siu m kim tra thng quy hoc siu m bng v mt l do khc.
3. X quang bng khng chun b (ASP): xc nh v tr si cn quang, cho bit kch
thc s lng v hnh dng ca si. Rt c gi tr v hu ht si h tit niu Vit
nam l si cn quang.
4. Chp h tit niu qua ng tnh mch (UIV): cho bit
- Hnh dng thn, i b thn, niu qun.
- V tr ca si trong ng tit niu.
- Mc gin n ca i b thn, niu qun.
- Chc nng bi tit cht cn quang ca thn tng bn.
5. Chp X quang niu qun thn ngc dng
- Pht hin si khng cn quang.
- C gi tr trong trng hp thn cm trn phim UIV.
6. Chp X quang niu qun thn xui dng
7. Soi bng quang: thng t dng chn on si, nhng c th ni soi can thip
ly si.

VII. IU TR
1. iu tr ni khoa
1.1. iu tr cn au qun thn do si
- Gim au: thng cc thuc khng vim khng Steroid c tc dng tt trong
trng hp ny, c th dng Voltarene ng 75mg tim tnh mch.
- Trong trng hp khng c hiu qu, cc tc gi phng Ty thng khuyn nn
s dng Morphin.

293
- Gin c trn: tim tnh mch cc thuc Buscopan, Drotaverin,...
- Gim lng nc ung vo.
- Khng sinh, nu c du hiu nhim trng, ch chn nhng loi khng sinh c tc
dng trn vi khun gram m. Cephalosporin th h 3, Quinolone v cc Aminozide
thng c s dng nhiu, cn thay i liu lng theo mc suy thn (nu c)
v trnh dng Aminozide khi suy thn (khng sinh c thn).
- Gii quyt nguyn nhn gy tc nghn niu qun (si, d dng ng niu gy
nc). Mt s trng hp si niu qun gy cn au qun thn khng p ng vi
iu tr ni khoa th cn ch nh can thip phu thut sm gii quyt tc nghn.
Tu theo c a bnh nhn, s lng, kch thc si v tnh trng chc nng thn
tng bn quyt nh dn lu ti thiu b thn qua da hay c th can thip ly si
bng m cp cu.
Dng thuc ung lm tan si c c khng ? y l cu hi t lu c cc
nh nghin cu xem xt. Hin nay, ngi ta kt lun nh sau:
1.2. i vi hn si nh v trn lng
Nh s nhu ng ca niu qun hn si s di chuyn dn c tng ra ngoi.
iu ny din tin mt cch t nhin ch khng phi do thuc lm bo mn hn
si nh mt s ngi thng ngh. Tuy nhin thuc li tiu lm tng dng nc tiu,
thuc chng vim khng stoide lm cho nim mc niu qun khng b ph n lm
cn tr s di chuyn ca si nn c tc dng tt cho hn si chuyn ng d dng.
1.3. Ch c si acid uric l tan c di tc dng ca thuc
y l si khng cn quang thng gp cc nc phng ty. pH nc tiu
thng rt acid < 6 si s tan khi ta cho kim ha nc tiu, cch iu tr nh sau:
- Ch n: gim m, king ru, bia, thuc l.
- Cho bnh nhn ung nhiu nc trn 2 lt nc mi ngy
- Lm kim ha nc tiu bng cc loi thuc
+ Bicarbonate de Sodium 5 -10g/ ngy
+ Foncitril 4000: 1-4 vin /ngy.Loi ny c cha cc ha cht citratesodium,
citratepotassium, acid citrique, v trimthyl phloroglucinol.
Hungarie sn xut vi cc thuc nh Malurit v Magurlit tng t nh Foncitril.
Cch dng liu tn cng 3-4 vin/ngy cho n khi pH > 7 sau duy tr t 1-2 vin/
ngy v duy tr pH nc tiu v n khi siu m thy hn si tan ht.
+ Allopurinol (zyloric)
L thuc c ch purine liu 100- 300mg mi ngy ty theo pH nc tiu dng cng
vi Foncitril cho n khi si tan ht trong trng hp si ln c khi phi dng thuc
lin tc trong nhiu tun c th gy tc dng ph nh bun nn, tiu chy, nga, ni
mn da, suy chc nng gan. Nn ung thuc sau khi n.
+ iu tr thuc phi hp
- Thuc li tiu loi thiazide s gip s ti hp thu calxi qua ng thn thng phi
dng ko di trong nhiu thng mi c kt qu nh Hypochlorothiazide (Esidrex) 1-2
vin/ngy.
- Vitamin B6 c tc dng tt trong vic chng to si oxalat (theo nghin cu Prien).

294
2. iu tr ni khoa sau phu thut m ly si
Vn ti pht si sau m l ht sc gay go, nhng yu t cho s ti pht si l
2.1. St si sau phu thut
L yu t duy tr nhim trng niu lm si pht trin
2.2. Tn ti ch hp trn ng tit niu.
2.3. Nhim trng niu khng iu tr dt im
iu cn thit l phi iu tr dt im nhim trng niu tt nht theo khng sinh
thi gian t 4-6 tun.
3. iu tr ngoi khoa
3.1. M ly si
3.2. Cc phng php khc
- Phu thut ni soi ly si.
- Tn si ngoi c th
- Ly si niu qun qua da.
4. iu tr d phng
Cho bnh nhn ung nhiu nc, trn 2,5lt / ngy ung ri u ra trong ngy.
V ch n: tu thuc vo bn cht ca si m c ch nh thch hp cho tng
bnh nhn.
4.1. i vi si Canxi
- Loi tr u tuyn cn gip.
- iu tr tt u tu xng.
- Cc bnh nhn c Canxi niu tng th c th cho dng li tiu Thiazide lm
gim nng Canxi niu di 2 mmol/l.
4.2. i vi si Oxalate
- Loi tr cc thc n giu Oxalate nh rau mung, Chocolate,...
- i vi si Oxalate c Canxi niu tng v Phospho mu gim th c th b sung
Phospho: 0,5 -1 g ung.
4.3. Si Cystine
Ch n ngho cc acide amine c lu hunh.

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BNH CU THN
Mc tiu
1. Nm c nh ngha, cc cch phn loi ca bnh cu thn
2. Chn on xc nh vim cu thn cp, vim cu thn th tin trin nhanh hay c
tnh.
3. Chn on xc nh c vim cu thn mn nguyn pht, th pht.
4. Bit iu tr cc vim cu thn mn nguyn pht, th pht.
Ni dung

I. I CNG
1.nh ngha
Bnh cu thn l s thng tn chc nng hay thc th biu hin cu thn vi
c im lm sng l ph, Protine niu, tng huyt p, din tin mn tnh v
thng a n suy thn mn. Chn on bnh cu thn ch yu da vo sinh thit
thn. Tin lng ca bnh tu thuc vo nguyn nhn v tn thng m hc trn
sinh thit.
2. Phn loi
C nhiu cch phn loi bnh cu thn, c th k n cc phn loi ca Hambuger
1980, Brenner 1985 v ca Cohn 1991. Di y chng ti cp n cch phn
loi n gin nht c gii thiu bi hip hi cc gio s thn hc Php 2003,
phn loi ny chia bnh cu thn lm hai nhm chnh, tu thuc vo din tin cp
hoc mn tnh ca bnh:
2.1. Cc bnh cu thn cp tnh
- Vim cu thn cp sau nhim lin cu.
- Vim cu thn th tin trin nhanh.
- Bnh cu thn do nhim c thai nghn.
- Bnh cu thn do Lupus.
2.2. Cc bnh cu thn mn tnh
- Bnh cu thn c tn thng ti thiu (thn h nhim m)
- Bnh cu thn x ho v on.
- Vim cu thn mng (trn mng hoc ngoi mng).
- Vim cu thn tng sinh mng.
- Bnh cu thn IgA (bnh Berger)
- Bnh cu thn i tho ng.
- Amylose thn.
- Hi chng Alport.

II.CC TH BNH CHNH THNG GP

1. Vim cu thn cp

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Nguyn nhn do lin cu khun Beta tan mu nhm A, type 12 in hnh cho mt
vim hng, type 49 in hnh sau vim da m. Lm sng cu th thng thng xut
hin sau 10-21 ngy vim hng t ngt xut hin au vng tht lng hai bn, thiu
niu, ph ch yu hai m mt, mt c chn v thng c st km theo. Nc tiu t,
di 500 ml/24 gi, mu nht do nc tiu c nhiu hng cu, c mu sm
khi tiu mu i th.
Tng huyt p c ti a ln ti thiu l thng gp mc va phi
Xt nghim c ASLO tng trn 400 n v Todd, Proteine niu t 0,2-3 g/24 gi, cn
Addis c hng cu t 100.000-500.000/1 pht, nhng bch cu di 20.000/ 1 pht
(cn gi l tnh trng phn ly hng - bch cu trong nc tiu). Thng thy tr hng
cu, tr ht.
Tin trin thng tt: lnh bnh 75-95 % tr em v 50-70 % ngi ln.
2. Vim cu thn cp th tin trin nhanh hay c tnh
c im lm sng thng nng tin trin nhanh n suy thn thng khng hi
phc. V gii phu bnh l c s tng sinh rng ra ngai mao qun xm ln khang
Bowman, bp cht cc vi huyt qun. Bnh chim khong 1% bnh cu thn vim,
c th gp bt c la tui no, c th khi u sau mt vim hng hay vim da.
2.1. Phn lai theo cc type sau
-Type I: Lng ng IgG trn mng y + Khng th khng mng 20%
-Type II: c hiu vi s lng ng phc h min dch vi IgG v b th 40%
-Type III: Khng c lng ng min dch trn cu thn.
Du hiu lm sng ch yu l thiu niu ri nhanh chng a n v niu vi suy
thn nng. Ph kn o huyt p bnh thng hoc tng nh, trong mu i khi tng
(globulin. Bnh t vong trong vi tun n vi thng. Trong mt s trng hp him
c th tr v bnh thng, thng gp sau nhim lin cu,gii phu bnh l thy
thng tn c trong v ngoi mao qun, cc cu thn b ph hy hon ton trong vi
ba ngy, trn min dch hunh quang lng ng lan ta cht fibrin trn cc thng
tn hnh lim, IgG lng ng trn mng y tng ng vi khng th khng mng
y.
3. Vim cu thn mn
Theo quan nim hin nay, vim cu thn mn sau nhim lin cu khun ch chim
10 %, cn li l th pht sau mt bnh l khc v v cn.
3.1. Vim cu thn mn nguyn pht
l vim cu thn khng r nguyn nhn. Do thiu d kin v cn nguyn, phn
loi da trn gii phu bnh v lm sng.
3.1.1.Hi chng thn h do tn thng ti thiu
Hu qu ca mt Protein niu nhiu ch yu l Albumin, c th bt gp sau nhng
thng tn thn hon ton khc bit nhau. Thng gp l mt hi chng thn h
n thun xut hin t ngt, Protein niu nhiu, ph, gim Protit mu, tng Lipit,
Cholesterol mu. Bnh xut hin khng c mt nguyn nhn r rt, thng gp tr
em, nam nhiu hn n, ngi ln th t l hai gii nh nhau.
Thng tn ti thiu khi sinh thit thn, thy bnh thng trn knh hin vi quang
hc, trn knh hin vi in t thnh mao mch bin i xm nhp lan ta vo chn

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mng y ca cc t bo hnh lim, c hin tng ho mng ca cc t bo c
chn. Min dch hunh quang khng pht hin bt k mt s lng ng no, khng
c globuline min dch hay b th lng ng trn mng y.
Tin trin ca bnh thng kh xc nh, tuy nhin ngi ta thy c 10% t thoi lui,
80% lui bnh hon ton (Proteine niu di 0,10 g/24 gi, cc du hiu khc tr v
bnh thng) nh iu tr vi Corticoide sau vi tun hoc vi thng nhng c 40%
trong s ti pht mt ln trong 6 thng, 60% ti pht nhiu ln trong 1 nm, v c
th ph thuc vo Corticoide, ngha l dng thuc bnh ti pht tr li. Nu bnh
khng vi Corticoide th tin lng xa s rt d dn n suy thn.
3.1.2. Vim cu thn th mng (ngoi mng v trn mng)
Biu hin lm sng l hi chng thn h vi i mu vi th.
Thng tn gii phu bnh l bao gm cc chui ht gin on vi dng cht mng
thng gc vi thnh mao qun to nn hnh bn chi trn knh hin vi. Min dch
hunh quang thy c s lng ng ca cc IgG v b th C3. Bnh thng gp
ngi ln hn tr em, tn thng ny chim hn 50% hi chng thn h nguyn
pht ngi ln ca M. Tin trin tng i tt, bnh c th thoi lui sau vi thng,
cc du hiu lm sng mt hon ton, trn sinh thit mt cc cht lng ng, mt s
khc tin trin n suy thn. Ngi ln tin lng xu hn tr em, khong 66%
bnh nhn sng st sau 10 nm khi bnh.
3.1.3. Vim cu thn tng sinh mng
L th t gp ca vim cu thn mn, lm sng bao gm protein niu, tiu mu vi
th, i khi c hi chng thn h in hnh km theo suy thn, tng huyt p, d
a n suy thn mn giai an cui.
Tn thng gii phu bnh l l tng sinh t bo m, t bo thng b ca nang
Bowman (c th c t bo ni b) to nn hnh lim, tng sinh km theo vi lng
ng trong mng y to nn hnh 2 b cn gi l tng sinh thnh. Trn min dch
hynh quang pht hin c lng ng cc b th C1 q, C4, C3, IgG i khi l IgM, c
th thy khng huyt thanh C3 trong cu thn, nng b th trong mu lun lun
thp so vi cc th khc.
Tin lng xu, thng tin trin n suy thn mn, sng st sau 10 nm ch c
khong 20-50%.
3.1.4. Vim cu thn th lng ng IgA t chc m
Biu hin lm sng l cc t i mu i th ti din nhiu ln, proteine niu va
phi, khng km vi hi chng thn h, t khi dn n suy thn. Trn min dch
hunh quang thy lng ng IgA i khi c IgG ln vng m c th pht hin qua
knh hin vi thng, mt s cu thn thy thng tn on, chng cc quai mao
mch dnh vo nang Bowman. Bnh sinh cha c r, thng gp ngi tr. C
th thy IgA trong huyt thanh tng nhng khng hng nh. Khi bnh nhn c
ghp thn th thn ghp cng c nhng biu hin ging nh bnh thn c v vy
ngi ta ngh c kh nng l nguyn nhn ngoi thn.
3.1.5. Vim cu thn th x cng v an
Chim 5-10% hi chng thn h tr em, v 15-20% trong hi chng thn h
ngi ln, nam hay gp hn n. Bnh nhn thng c biu hin tiu mu vi th,
tng huyt p, suy thn mn. Protein niu th ny lun lun cao v l Protein niu
khng chn lc. Tn thng gii phu bnh: trn knh hin vi quang hc thy c lng

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ng cht Hyalin v tn thng x ho tng , tng on, trn knh hin vi min
dch hunh quang thy c lng ng ca IgM v ca C3 tng on.
Tin lng thng xu, a n suy thn tin trin trong 25% trng hp tr em
v trong 70% trng hp ngi ln. Thng a n suy thn mn giai on cui
trong vng 5 n 20 nm
3.2. Vim cu thn th pht mt bnh ton th
3.2.1. Vim cu thn cp bnh nhn Lupus ban
Vim cu thn chim khong 70% trong lupus ban , thng gp ph n tr vi
c im hng ban da, d cm, vi ban hnh cnh bm mt, gy st, st, au
khp..., xt nghim thy c t bo Hargraves, nht l khng th khng nhn trong
mu. Lm sng gm c hi chng thn h khng c tng huyt p, thng tn
khng c hiu vi s lng ng lm dy mng y to nn vng st, th
hematoxylie trong vng m. Tin lng c th suy thn v thng khng c tng
huyt p.
3.2.2. Hi chng Good Pasture hay vim cu thn th on hoi t vi vim ph
nang xut huyt
Thng gp nam nhiu hn n, khi u bng ho ra mu, hnh nh phi m hai
bn khng r rt, sau gy thng tn thn, sau vi thng gy suy thn, tng
huyt p dn n t vong. Cc ph nang vim xut huyt cha y cc i thc bo
sc t st, thn hai t dng fibrin ri dng trong ha. Ngi ta chng minh
nhng thng tn ny phi hp vi t khng th hat ng ng thi chng c ph
nang v mng y cu thn.
3.2.3. Vim cu thn do ban dng thp hay ban Schonlein-Henoch
Thng tn thn chim 35% trong bnh ny. Lm sng thng c i mu, cu
thn thng tn on, Min dch hunh quang thy lng ng IgA vng m v
thnh. Bnh gy thng tn hu ht cc cu thn, tin lng xu, tin trin dn
sang suy thn.
3.2.4. Bnh Amylose thn
Thng gp trong bnh Amylose ph tng, th pht sau cc bnh nhim trng hoc
vim nhim ko di nh vim xng, lao, vim khp dng thp, phong, lit hai chi
di. Bnh c th nguyn pht. Ti Vit nam cha ghi nhn trng hp no, nhng
vng a trung hi c th gp cc la tui nhiu nht t 50-60 tui.
Lm sng biu hin l hi chng thn h, c th ch c proteine niu n thun km
gan lch to, c th i mu vi th, tng huyt p t gp, dn n suy thn. V tiu
ha biu hin bng i chy, to bn, xut huyt, li to, gan to nhng chc nng
gan bnh thng.
Gii phu bnh thy lng ng cc cht dng bt (amyloide) bt mu sang mu
tm ng nh vi cu trc si c hiu trn knh hin vi in t, cht ny bn cht l
Protein, c tm thy ngoi t bo, trong gian cht v thnh.
3.2.5. Bnh cu thn do i tho ng
L tn thng cu thn do i tho ng gy ra, c hin tng x cng cu thn
lan ta, biu hin ban u l dy khng u mng y mao qun cu thn vi lng
ng ni b. Lm sng giai an u l c proteine niu, c hay khng km theo hi
chng thn h, i mu vi th c xu hng chuyn sang suy thn c tng huyt p.

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Giai on hi chng Kimmelstien-Wilson thng tn thnh nt gia mao qun thnh
khi trn km cc thng tn cc ng mch thn.
Theo Mogensen chia bnh l cu thn do i tho ng ra lm 5 giai on
- Giai on 1: Giai on tng chc nng v ph i, xy ra ngay khi i tho ng
c chn on, trc khi iu tr Insulin. Kch thc thn gia tng, cc cu thn ph
i nhng cu trc ca chng th bnh thng. Mc lc cu thn tng, lu lng
mu qua thn tng.
- Giai on 2: C th tn ti dai dng trong nhiu nm v ko di sut i. Mc lc
cu thn c th tng. Albumine niu m tnh nhng c th dng tnh khi b stress.
B dy ca mng y cu thn tng, cht nn gian mch tng nhiu hn v nhng
tn thng ny khng hi phc.
- Giai on 3: l giai on bnh thn i tho ng khi u, ch xy ra 40%
bnh nhn i tho ng, ko di t 10 n 20 nm, biu hin quan trng nht
trong giai on ny l s xut hin ca Microalbumine niu (vi m niu, Protein
niu vi th).
- Giai on 4: giai on bnh thn i tho ng xc lp vi protein niu
thng xuyn trn 0,5g/24gi, thng c tng huyt p, hi chng thn h. Mc lc
cu thn gim trung bnh 1ml/thng. Tn thng cu thn: x ho cu thn lan to,
gm dy mng y v tng cht nn gian mch. Trong 10-20% trng hp tn ti
nhng nt bt mu bi cht PAS tch t gian mch xung quanh cc cu thn (gi
l x ho cu thn dng nt ca Kimmelstiel v Wilson).
- Giai on 5: L giai on bnh nhn b suy thn mn giai on cui.

III. IU TR BNH CU THN

1. iu tr vim cu thn cp sau nhim lin cu
1.1. Tit thc, ngh ngi
- Bnh nhn thiu v v niu c tng ur, creatinine mu: nc vo 500-600ml, mui
2g/24h, protein 20g/ngy.
- Bnh thiu v v niu c ph tng huyt p, ur, creatinine mu khng tng: mui
0,5 - 1g/24h, protein 40g/ngy.
- Ngh ngi tuyt i t 3 tun n 1 thng. Sau tr li hot ng t t ngay khi
cn protein niu v i mu vi th t 6 tun n 2 thng.
1.2. Khng sinh: Ch cho khi cn du hiu nhim lin cu
Pnicilline 1 triu v/ngi ln, 1/2 triu n v / tr em. Nu d ng Penicilline th
dng Erythromycine 0,2 x 5 vin/ngy ngi ln hoc Tetracyline. Khng sinh
dng trong 10-12 ngy.
1.3. iu tr bin chng
- Tng huyt p: King mn, ngh ngi, thuc nh Aldomet (0,25g x 2-4 vin/ngy)
- Ph phi: Lasix liu cao, Uabain tnh mch, th oxy, Morphin khi cn thit.
- Ph no: Truyn glucose u trng, Manitol.
- Th v niu: Furosemid (Lasix) liu cao.
Tt nht cho c ph phi, no, v niu l lc ngoi thn.

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1.4. Cc triu chng khc
- Tng ur mu, creatinine mu, hn ch lng protid a vo nhng phi
m bo nng lng 1200-1600 calo chng d ha, c th cho Durabulin hoc
Testosterone 25-50mg/ngy.
- iu tr tng K mu bng glucose 20-30%, 300-500ml + 10-20v insulin
truyn tnh mch trong 1 gi n 1g30 pht hay truyn dung dch kim.
Tin trin thng tt: lnh bnh 75-95 % tr em v 50-70 % ngi ln.
2. iu tr vim cu thn cp th tin trin nhanh hay c tnh
Lm sng thng nng, tin trin nhanh n suy thn khng hi phc.
-Type I: Prednisolone, vin 5 mg, 2-3 mg/Kg/ 24 gi,
phi hp vi Cyclophosphamid (Endoxan) vin 50 mg, 1-3 mg/kg/24 gi hoc
Chlorambucil (Chloraminophene) vin nhng 2 mg, liu 0,15- 0,2 mg/Kg/24 gi. Thi
gian iu tr thuc chng min dch t 2-4 thng.
Phi hp vi lc plasma 2-4 lit.
-Type II: Methyprednisolone 30 mg/Kg/ 24 gi tim tnh mch x 3 ln trong 2 ngy
Sau duy tr Prednisolone 1-3 mg/Kg/ ngy trong nhiu thng.
-Type III: iu tr nh type II + phi hp thm vi Heparin, cyclophosphamide
(Endoxan).
Ngoi ra cn phi hp vi Heparin 5000-10.000 v trong 4-8 tun.
3. iu tr vim cu thn mn nguyn pht
3.1. Hi chng thn h
iu tr bao gm: Presnisolone

1 mg/Kg/24 gi ngi ln
1,5-2 mg/Kg/24 gi tr em

Nu p ng tt th gim liu theo bc thang c 5 ngy gim 10 mg ri duy tr gin

an mi 20 - 30 mg/ 2 ngy, ung mt ln ngi ln 10 mg/ 2 ngy.
Khi c hin tng khng hay ph thuc corticoide th dng thm cyclophosphamide
2-3 mg/Kg/ 24 gi, hoc chlorambucil 0,2-0,3 mg/Kg/ 24 gi t nht trong 2 thng,
phi theo di cc bin chng v mu v cc tai bin khc.
3.2. Vim cu thn th mng (ngoi mng v trn mng)
Theo trng phi Anh, M ch nh Presnisolone liu cao 1,5-2 mg/Kg/48 gi ung
mt ln vo cc bui sng trong 8 tun thy c hiu qa tt, ngi ta c th cho
thm 4 tun na hoc phi hp vi methylpresnisolone 1g trong 3 ngy lin tc, sau
0,5mg presnisolone/kg/ngy/thng ri 0,2 mg/Kg/ ngy chlorambucil tng cng
trong 6 thng. iu tr ny tt hn l iu tr n thun vi steroide. Khi ti pht th
dng nh c, thuc gim min dch c tc dng sau vi ngy.
3.3. iu tr vim cu thn tng sinh mng
Tin lng xu, tin trin n suy thn, sng sau 10 nm ch c 20-50%.
iu tr phi hp corticoide v thuc gim min dch vi thuc chng ng hay
chng ngng tp tiu cu.
3.4. iu tr vim cu thn th lng ng IgA t chc m

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nhng bnh nhn c tn thng m hc va phi, c Protein niu trn 3g/24 gi
th iu tr Corticoides trong vng 4 dn 6 thng. Khi Protein niu khng ci thin th
c th iu tr c ch min dch nh trong hi chng thn h.
cc nc phng Ty, ngi ta dng Acide bo Omga 3 (du c) trong trng
hp bnh tin trin, hn ch s sn xut v hot tnh ca Cytokines do s lng
ng ca IgA cu thn gy ra.
Trong trng hp c tng huyt p th c ch men chuyn c u tin s dng
gim Protin niu v lm chm s tin trin ca suy thn.
Mt s thuc khc c mt s tc gi s dng trong bnh cu thn do lng ng
IgA l cc thuc chng kt tp tiu cu, Urokinase, hoc cc Globuline min dch
dng liu cao qua ng tnh mch vn cha c kt lun c hiu qu chc chn
trong bnh ny.
3.5. Vim cu thn th x cng v an
Tin lng sng trn 15 nm chim 50%.
iu tr corticoide nh presnisolone liu thp 1/3 - 1/2 mg/kg/24 gi trong 1-2 thng,
hoc dng nh trong th mng.
Khi c ti pht c th iu tr vi cc thuc gim min dch.
4. Vim cu thn th pht mt bnh ton th
4.1. Vim cu thn cp bnh nhn Lupus ban
iu tr: Presnisolone liu cao 2-3 mg/kg/24 gi,
Thuc gim min dch Chlorambucil 0,2-0,3 mg/Kg/24 gi trong 4-8 tun c hiu qa
r rt.
4.2. Hi chng Good Pasture hay vim cu thn th on hoi t vi vim ph nang
xut huyt:
iu tr cng bng corticoide 2-3 mg/Kg/24 gi trong 4-6 tun nhng p ng lm
sng km.
4.3. Vim cu thn do ban dng thp hay ban Schonlein-Henoch
Bnh gy thng tn hu ht cc cu thn, tin lng xu, tin trin dn sang
suy thn. iu tr bng corticoide v gim min dch.
4.4. Hi chng Kimmelstiel-wilson
iu tr i tho ng: rt kh khn, v tnh nhy cm vi Insulin khng n nh.
iu tr bnh thn ch l iu tr triu chng, khng dng Corticoide. Khi c suy
thn mn giai on cui do i tho ng th iu tr thay th thn suy c mt s
kh khn, nht l rt hay gp cc bin chng tc mch v nhim trng trong qu
trnh lc mu.
Ghp i thn - ty c ch nh trong trng hp ny, tuy kt qu rt kh quan v
c hai phng din i tho ng v suy thn nhng thc t t c thc hin v
kh khn v k thut v ngi cho.

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BNH THN V THAI NGHN

Mc tiu
1. Bit c nhng thay i ca h thng thn - tit niu trong thai k bnh thng.
2. Nm c c bn mt s bnh l thn-tit niu thng hay xy ra trong qu trnh
mang thai.
3. Bit c cch iu tr thng thng ca cc bnh l thn tit niu xy ra trong
thai k: tin sn git, nhim trng ng tiu, suy thn cp.
4. Nm c thi x tr v tin lng trc mt thai nghn xy ra trn mt bnh
nhn ang b bnh thn mn tnh.
Ni dung

I. NHNG THAY I CA H THNG THN-TIT NIU TRONG THAI K

BNH THNG
1. Thay i v gii phu h thn-tit niu trong thai k
- Kch thc thn tng ln trong thai k: trn siu m v X quang pht hin chiu di
ca thn tng ln khong 1 cm so vi trc lc c thai. Kch thc ca thn v bnh
thng sau khi sinh.
- Gin i b thn v niu qun: thng c pht hin bng siu m v chp b
thn, iu ny chng t mt tnh trng nc do tc nghn ng bi niu. S
nc ny thng nh, c gi l gin i b thn - niu qun sinh l trong thai k.
Ngi ta thy rng trong thai k c mt s gim trng lc c trn ca h thng
ng dn nc tiu (c th do vai tr ca cc Hormone gin mch nh cc
Prostaglandines, Estrognes v Prolactine) cng thm vi s chn p c hc 2 niu
qun do t cung ln l nguyn nhn ca tnh trng nc ny. S ng nc
tiu ny l mt iu kin thun li cho nhim trng ngc dng, m mc ca n
c th t mt nhim khun niu khng triu chng cho n mt vim i b thn
nng n. Mt s t trng hp kh him, s ng nc tiu ny c th gy cn
au qun thn.
Nhng thay i v hnh thi ca thn c th tn ti cho n 12 tun sau khi sinh. Do
vy cc thm d v hnh thi ca h tit niu thng thng (khng phi trng hp
cp cu) th c khuyn nn lm sau sinh t nht 12 tun.
2. Chc nng thn
Nhng thay i v chc nng thn cng c th xy ra trong thai k. So vi khi khng
c thai, lu lng lc cu thn v lu lng mu qua thn trong khi c thai tng ln
kh sm, ngay t nhng thng u tin ca thai k, v c th t n mc t 30 n
50% trn gi tr bnh thng vo cui thng th 3.
Chnh tnh trng tng lu lng lc cu thn ny s lm tng thi cc cht cn b v
dn n lm gim nng Creatinine mu khong t 35 n 44% so vi gi tr bnh
thng.
Nh vy, nhng ch s v sinh ho thng c xem l bnh thng ngi ph
n khng c thai th vn c th phn nh mt s suy gim chc nng thn trong thai
k.

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ph n c thai, mt nng Creatinine mu trn 80 mol/l (0,8 mg/dl) v nng
Ur mu trn 5 mmol/l (13mg/dl) l c th biu hin mt suy gim chc nng thn
trong thai k (theo Marshall D. Lindheimer v Adrian I. Katz).
+ Proteine niu
Do tng lu lng mu n thn trong qu trnh mang thai, cho nn s lm tng
lng Proteine niu thi ra. Cng mt mc tn thng thn nh nhau th trong
thai k, lng Proteine niu thi ra s tng ln gp i.
+ Chc nng ng thn
thanh thi ton phn v thanh thi tng phn i vi Urat tng ln, lm cho
gi tr bnh thng ca Urat mu gim xung. Do vy, mt nng Urat mu tng
trn 5mg/dl hoc trn 298 mol/l s c nghi ng bnh l.
Mu c xu hng kim ho nh, pH = 7,42 - 7,44.
3. Thay i v th dch
Ph l triu chng rt thng gp trong thai k.
Lng nc ton b trong c th tng ln, trong mt thai k bnh thng ngi m
thng tng cn ton b khong 12,5 kg. Lng nc ton b tng khong t 6 n
9 lt, trong t 4 n 7 lt l do tng th tch khong k v huyt tng.
S iu ho thm thu ca thn thay i kh sm trong thai k, ngng thm thu
ca thn i vi s kht v i vi s tit Vasopressin u gim khong 10
mOsmol/l mi loi. Kt qu l nng Natri mu b gim, tr s bnh thng ca
Natri mu trong thai k khong 130 mmol/l. Nng trn 140 mmol/l c xem l
tng Natri mu.
Tc ging ho ca Vasopressin tng gp 4 ln bnh thng do bnh nhau tit ra
men Vasopressinase, nht l trong giai on sau ca thai k.
C 2 hnh thi kt hp bnh thn v thai nghn
- Bnh thn-tit niu xy ra trn mt thai ph m trc khi mang thai cha c.
- Thai nghn bnh nhn b mt bnh l thn mn tnh.

II. CC BNH THN - TIT NIU THNG XY RA TRONG THAI K

1. Nhim c thai nghn - Tin sn git
Thng xy ra sn ph trn 35 tui v mang thai con so v vo 3 thng cui ca
thai k. Triu chng lm sng bao gm: tng huyt p, Proteine niu v ph.
Bnh sinh ca nhim c thai nghn vn cha c bit r rng, nhng hu ht cc
tc gi u nht tr rng c nhiu yu t phi hp
- Yu t di truyn: t l tin sn git xy ra nhiu hn nhng ngi cng huyt
thng khi so snh vi nhng ngi khng cng huyt thng.
- Yu t min dch: thai nghn c xem nh l 1 qu trnh dung np min dch,
trong thai nhi c cu thnh bi 50% cc t bo l t ngi b.
- Yu t th dch: nng Aldosterone v Renine huyt tng ca thai ph bnh l
thp hn thai ph bnh thng, tng nhy cm khi truyn Angiotensine tnh mch.
- Yu t mch mu: gim ti mu bnh nhau, gim trn 50% ng knh ca cc
ng mch xon nhng sn ph b tin sn git.

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Tn thng m hc ca thn: ch yu xy ra cu thn, biu hin mt tnh trng
Vim ni mc mao mch cu thn. Cc cu thn ln ra v ph n, vi s xm ln
ca cc t bo mng mao mch v cc t bo ni m. Lng ng cht Hyalin dng
si di ni mc. Tuy nhin, nhum min dch hunh quang khng thy lng ng
phc hp min dch. Tn thng m hc thn ny bin mt sau khi sinh vi tun n
1 thng.
2. Nhim trng ng tiu trong thai k
Ph n mang thai thng b nhim trng niu khng triu chng, mt s trng hp
c th biu hin bi mt tnh trng vim bng quang hoc nng hn na l vim i
b thn. Vim bng quang nh thng b b st v nhng triu chng kch thch
bng quang cng c thy khi t cung ln gy kch thch bng quang. Vim i b
thn thng c chn on nh cc triu chng st cao, hi chng nhim trng
r, au tht lng, tiu c,... triu chng thn ln thng kh pht hin trn lm
sng v s hin din ca t cung ln.
Cc sn ph nn c xt nghim nc tiu trong qu trnh mang thai trnh b
st mt nhim trng niu khng triu chng, tt nht l cy nc tiu.
3. Suy thn cp trong thai k
Trong giai on u ca thai k, suy thn cp thng lin quan n tnh trng nghn
gy nn ma nhiu.
giai on sau c rt nhiu nguyn nhn a n suy thn cp nh:
- Bnh l tan huyt vi mch + gim tiu cu.
- Suy thn cp phi hp vi gan nhim m cp trong thai k: Hi chng HELLP
(Hemolysis Elevated Liver enzymes Low Platelets) biu hin bi gim tiu cu, tan
huyt vi mch mu, tng men LDH v Transaminase.
- Hoi t ng thn cp hoc nng hn l hoi t v thn.
- Suy thn cp sau sinh: thng xy ra ngay sau sinh cho n 3 n 6 tun sau .
in hnh v hay gp nht ca suy thn cp trong thai k l hoi t ng thn cp do
thiu mu thn hoc do nhim c, thng l bin chng cu mt bong bnh nhau,
t mu ln sau bnh nhau, thai cht lu hoc tc mch do nc i. Khi s tn
thng ca cc t bo ng thn khng hi phc c th s a n hoi t v
thn, c c trng bi 1 tnh trng x ho v thn lan to khng phc hi, y l
mt bnh cnh rt nng n trong thai k.

III. THAI NGHN XY RA TRN BNH THN MN TNH

Mc d cc bnh nhn b bnh thn mn tnh (bnh cu thn, suy thn mn, ghp
thn,...) thng c khuyn khng nn c thai do nhng hu qu khng tt ca
tnh trng mang thai i vi sc kho ngi m v do nh hng ca cc loi thuc
ang dng ln thai nhi, nhng trong thc t, thai nghn vn c th xy ra trn nhng
bnh nhn ny.
Theo di 3425 thai k xy ra trn 2310 bnh nhn b bnh thn mn tnh t nm
1973 n nm 1995, cc tc gi Davison JM v Lindheimer MD nhn thy cc tai
bin sn khoa s tng ln theo mc suy thn theo bng sau
Bng 1: T l tai bin sn khoa, di chng ca thai k theo nng Creatinin mu
Mc suy thn

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Creatinine mu

Creatinine mu

Creatinine mu

< 1,5 mg/dl

1,5 - 3 mg/dl

>3 mg/dl

Tai bin sn khoa

26%

47%

86%

Sinh thnh cng

96%

89%

46%

Di chng

< 3%

25%

53%

Mc suy thn vo thi im mang thai v tng huyt p l 2 yu t tin lng

chnh cho thai k. V vy, vic theo di v iu tr tch cc tng huyt p nu c l
mt vic rt quan trng trong sut qu trnh thai nghn.
i vi tng bnh l thn c th, thai nghn c nh hng nh sau
1. Bnh thn do i tho ng
Thai nghn khng lm tng tnh trng suy thn, nhng c kh nng nhim trng niu
kh cao, tng Proteine niu v tng huyt p nht l vo nhng thng cui.
2. Bnh l cu thn mn tnh
Thai nghn lm tng huyt p, nhng dung np tt nu trc khi mang thai ngi
bnh khng c tng huyt p v khng c ri lon chc nng thn.
Nhiu tc gi cho rng cc loi bnh cu thn x ho on, bnh cu thn IgA v
bnh cu thn tng sinh mng s trm trng hn khi mang thai.
3. Bnh l thn do tro ngc v vim thn thn b thn mn tnh
Nhng bnh nhn ny thch nghi tt vi vic mang thai nu khng c suy thn, tuy
nhin cn cy nc tiu nh k (mi 2 dn 3 tun), iu tr khng sinh nu cn.
4. Bnh thn a nang
Dung np rt tt nu khng c suy thn. Trong thai k cc nang gan c th tng
kch thc, tng t l b tng huyt p v tin sn git.
5. Si thn
Dung np tt, ngoi tr vic lm tng t l nhim trng ng tiu. Si c th di
chuyn do gin ng niu.
6. Thai nghn bnh nhn chy thn nhn to chu k
Vi nhm bnh nhn ny, mc d c theo di st th tai bin sn khoa vn rt cao,
vi nguy c t vong cho m v thai, phn ln l sy thai v sinh non, nu tr sinh ra
c th cng c nguy c cao v pht trin tinh thn (Susan H Hou). Do vy, vn tip
tc gi thai hay khng trn nhm bnh nhn ny thng xuyn c t ra.
7. Thai nghn nhng bnh nhn ghp thn
i vi nhng ph n b suy thn mn giai on cui th vic ghp thn l phng
php tt nht em li cho h hy vng sinh con. Tuy vy, do nhng bnh nhn ny
thng xuyn phi dng cc thuc c ch min dch v Corticoides nn vic mang
thai phi c theo di k cng bi cc nh Thn hc.

IV. IU TR
1. iu tr cc bnh thn - tit niu thng xy ra trong thai k

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1.1. iu tr nhim c thai nghn - Tin sn git
- Nhp vin, theo di theo chuyn khoa sn ph.
- H huyt p: L vn quan trng nht ca iu tr tin sn git. Thng dng loi
gin mch hoc Alpha methyldopa, trnh dng thuc li tiu v cc thuc c ch
men chuyn.
- Magne Sulphate: l loi thuc c in trong sn git, c tc dng lm gim tn sut
cc cn co git v d phng c cc cn co git trong sn git.
Cch dng: Liu ti ban u l 4g n 6g truyn tnh mch trong vng khong 15
pht, sau truyn tnh mch 2g mi gi duy tr nng Magne mu trong
khong 4 n 6 mmol/l. Nhng trng hp nh hn, cha c biu hin sn git, c
th dng ng tim bp.
- Chm dt thai k: l bin php cui cng.
D phng: Khm thai nh k, theo di k huyt p, Protein niu. i vi nhng
bnh nhn c nguy c cao th phi thm khm t nht 2 tun 1 ln, sau nu tnh
trng nhim c thai nghn vn cn th phi nhp vin theo di trong nhng thng
sau ca thai k.
1.2. iu tr nhim trng ng tiu trong thai k
- iu tr bnh nhn c vi khun niu nhng lm sng khng c triu chng: dng
mt t khng sinh trong vng 7 n 10 ngy.
Bng 2. Cc khng sinh thng c s dng iu tr nhim khun niu
khng triu chng v vim bng quang trong thai k.
Khng sinh

Liu lng

Ampicilline

500 mg x 4 ln / ngy

Amoxicilline

250 mg x 3 ln / ngy

Nitrofurantoin

50 mg x 4 ln / ngy

Cephalexine

250 mg x 2 ln / ngy

Amoxicilline/A. Clavulanic

250/62,5 mg x 3 ln / ngy

iu tr vim thn b thn cp

- Nhp vin.
- Dng ngay khng sinh ng tim tnh mch.
- Thng khi u bng Ampicilline hoc Cephalosporine th h 3 (Ceftriaxone,
Cefotaxime,...).
- Khi tnh trng lm sng ci thin, sau 1 n 2 tun c th chuyn sang ng ung
v phi iu tr tip tc khng sinh t nht 2 dn 3 tun na.
- Theo di v sau bng cch cy nc tiu mi 2 n 3 tun d phng ti pht.
1.3. iu tr suy thn cp trong thai k
- iu tr suy thn cp trong thai k v nguyn tc khng khc g vi iu tr suy thn
cp ngoi thai k, bao gm:
- Duy tr tt huyt ng m bo ti mu thn y .

307
- Thuc li tiu: ch thn trng trong nhng trng hp huyt p h.
- iu chnh ri lon in gii v cn bng toan kim.
- Lc mu ngoi thn khi cn thit: thng dng thn nhn to v thm phn phc
mc khng dng c khi c thai.
- Kt hp Ni - Sn khoa gii quyt nguyn nhn (thai cht lu, bong bnh
nhau,...).
2. Thi x tr trc mt thai nghn xy ra trn bnh thn mn tnh
D phng: khuyn bnh nhn khng nn mang thai i vi nhng bnh nhn b
bnh thn mn tnh, c bit l nhng bnh nhn c suy thn mn.
Dng cc phng php nga thai thng thng.
Thi iu tr trc 1 thai nghn xy ra trn 1 bnh nhn b bnh thn mn tnh
- Theo di v iu tr tch cc tng huyt p, v tng huyt p v mc suy thn ti
thi im mang thai l hai yu t tin lng chnh cho thai k:
- i vi bnh nhn cha c suy thn mn: thai k c th xy ra hon ton bnh
thng, tuy nhin bnh nhn cn c theo di k trong mi trng Sn - Ni khoa,
cn ch rng cc thuc ang c dng di ngy iu tr bnh thn nh
Corticoides, c ch min dch, thuc iu tr i tho ng, mt s thuc iu tr
tng huyt p c th nh hng n thai.
- nhng bnh nhn c suy thn mn th tu thuc vo mc suy thn, nhng
nhng bnh nhn ny thng khng th gi c thai, nht l khi suy thn mn
nng. nhng bnh nhn ang c iu tr thn nhn to chu k th nguy c rt
cao, cho nn khng nn gi thai.
- i vi nhng bnh nhn ghp thn
i vi nhng ph n b suy thn mn giai on cui th vic ghp thn l phng
php tt nht em li cho h hy vng sinh con. Tuy vy, do nhng bnh nhn ny
thng xuyn phi dng cc thuc c ch min dch v Corticoides nn vic mang
thai phi c theo di k cng bi cc nh Thn hc.
Cc tiu chun trc khi mang thai nhng bnh nhn ghp thn:
- Thi gian sau ghp: 1,5 nm i vi ghp thn ngi sng, 2 nm i vi ghp
thn ngi cht.
- Khng c t thi ghp no trong vng t nht 6 thng.
- Liu Prednisone < 15 mg/ ngy.
- Liu Azathioprine < 2 mg/kg.
- Liu Cyclosporine 2 - 4 mg/kg.
- Nng Creatinine mu < 2 mg/dl.
- Huyt p < 140 / 90 mmHg (c th ang dng thuc h huyt p).
- Nng HbA1C bnh thng.
- Cy nc tiu m tnh.
Tm li, cc bnh nhn b bnh thn c th mang thai v sinh con bnh thng nu
cha c suy thn v phi c kim sot huyt p k. i vi nhng ngi b suy

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thn th nguy c ca thai k cng ln nu suy thn cng nng. i vi cc bnh
nhn suy thn mn giai on cui, ch nn mang thai sau khi ghp thn v phi
c t di s theo di st ca cc nh thn hc v sn khoa.

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VIM THN B THN

Mc tiu
1. Trnh by c nh ngha, c im ca vim thn b thn.
2. Xc nh c nguyn nhn, cc yu t thun li ca vim thn b thn.
3. Nu c cc triu chng lm sng, cn lm sng ca vim thn b thn cp v
mn.
4. Chn on c vim thn b thn cp,vim thn b thn mn.
5. La chn c cc bin php iu tr, d phng vim thn b thn ngi ln.
Ni dung

I. I CNG
1. nh ngha
Vim thn b thn l bnh vim t chc k ca thn, nguyn nhn do vi trng. Bnh
c th nh hng n c hai thn cng mt lc nhng cng c th ch ti mt
thn, v ngay mt thn c th khu tr mt phn thn hoc lan ta ton b thn.
Bnh c th cp tnh hoc mn tnh.
2. c im ca vim thn b thn
2.1. V nguyn nhn
Vi trng gy tn thng trc tip, ngoi ra cn c yu t thun li l nc tiu.
2.2. V gii phu bnh
Kt hp tn thng b thn, i thn v nhu m thn m tn thng nhu m l
chnh.
2.3. V din bin
Vim thn b thn hay ti pht, m , nu iu tr khng dt im th vim thn b
thn cp d tr thnh mn tnh.

II. DCH T HC
Vim thn b thn l bnh l thng gp cu h thng thn tit niu. Vim thn b
thn chim 15-40% cc bnh thn v 80% l n gii, tr em ngi gi u c th b
bnh. Ring vim thn b thn cp chim khong 0,2-0,4% cc bnh trong khoa Ni
chung Bnh vin Trung ng Hu. Vim thn b thn cp thng thy xy ra
la tui 20-50 tui, n nhiu hn nam v c n 92% bnh nhn c mt hoc nhiu
yu t thun li. Vim thn b thn mn xy ra nhiu la tui 40-70 tui. Theo tc
gi Nguyn Vn Xang, Vim thn b thn mn chim 30% cc bnh thn mn tnh.

III. BNH NGUYN

1.Vi trng
Cc tc nhn gy bnh vim thn b thn ngy nay c xc nh khng ch gii
hn nhm vi khun m cn c c nm, k sinh trng, virus.
Cc tc nhn gy bnh sau c th c pht hin khi phn lp

310
- Escherichia Coli, Proteus Mirabilis, Enterobacter, Klebsiella, T cu vng,
Pseudomonas, Serratia, trc khun lao, Chlamidia Trachomatis, Ureaplasma
Urealyticum, lu cu.
- Candida Albicans, Candida Tropicalis, Adenovirus, Cytomegalo virus (CMV).
ng vo ca nhim trng
+ ng ngc dng chim i a s trng hp (97%), vi khun s xm
nhp t di ln qua ng niu o. S xm nhp ca cc tc nhn gy bnh
c lm d bi tro ngc bng quang-niu qun.
+ ng mu: cha n 3% trng hp, vi khun n nh v ti thn th
pht sau nhim trng huyt.
2. Yu t thun li
2.1. Tr em: D dng bm sinh niu qun, gin b thn.
2.2. Ngi gi: U x hoc ung th tin lit tuyn.
2.3. Ph n c thai: T cung ln vo niu qun nhng thng cui gy nc
b thn - niu qun, gim nhu ng niu qun do progesterone tng.
2.4. Ngi ln: Si thn tit niu, hp niu o, tro ngc bng quang-niu qun,
i tho ng.
2.5. Cc th thut: thng tiu, soi bng quang, cc nguyn nhn trn s lm nc
tiu, lm d nhim trng v duy tr nhim trng.

VIM THN B THN CP

I. GII PHU BNH
- Thn hi ln v xung huyt, ph n t chc k ca thn.
- Xm nhp bch cu a nhn, t bo lympho t chc k.
- Cu thn, ng thn, mch thn khng hoc rt t tn thng.
- Tn thng thng khi hn hoc cng c th li so x v cc cu thn
vng ny b mt chc nng.
- Th nng c th p-xe ha gy m thn.

II. TRIU CHNG HC

1.Lm sng
1.1. Hi chng nhim trng
- Xut hin rm r, st cao rt run, st dao ng.
- Tng trng suy sp nhanh, mi kh li bn.
- Mch nhanh, huyt p bnh thng.
1.2. au
- au vng h sn lng, mt hoc c hai bn.
- Thng au m vi nhng cn au tri ln d di, c khi lan xung bng quang,
i (cn au qun thn).

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- Khm c th thy thn ln, n au tc, c du chm thn.
1.3. Hi chng kch thch bng quang
- Thng gp tiu but, tiu dt, tiu kh.
- au vng h v, n im bng quang au.
1.4. Hi chng nc tiu: nc tiu c, tiu ra m hoc i khi c th tiu ra mu.
2. Cn lm sng:
2.1. Xt nghim mu
- Bch cu tng, a nhn trung tnh tng, lng mu tng.
- C th c nhim trng mu, cy mu dng tnh.
- Ur, creatinin mu bnh thng, nu tng cao l c suy thn cp hoc t cp ca
suy thn mn.
2.2. Nc tiu
- Nhiu bch cu, c th c tr bch cu, t bo m, hng cu.
- Vi trng thng mt loi, a s l trc khun Gram m, 80% l E. Coli.
- Protein niu khong 1g/24 gi.
2.3. X quang (khng chun b, UIV) v siu m thn tit niu
Gip pht hin cc yu t thun li: si, cc d tt bm sinh h tit niu, hnh dng
kch thc thn.
2.4. Chp ct lp t trng (TDM, CT-Scanner):
Cho thy nhng vng gim t trng, xut hin so v thn, gip chn on nhng
th khng in hnh, nh gi trm trng v tin lng.

III. TIN TRIN, BIN CHNG

1. Tin trin
- Vim thn b thn cp khng c yu t thun li: tin trin thng tt nu iu tr
khng sinh ng v liu. Cc triu chng lm sng s gim nhanh, nc tiu tr
v bnh thng sau 1-2 tun.
- Vim thn b thn cp c yu t thun li lm nghn ng tiu gy nc tiu
nh si, u x tin lit tuyn...
iu quan trng l phi loi b c cc yu t ny, v nu iu tr khng liu,
khng lu th bnh c th ti pht nhiu ln, tr thnh mn tnh a n tng
huyt p, cui cng l suy thn.
2. Bin chng
Thng do iu tr mun, c tnh vi trng cao gy tn thng thn nng, c a
xu, sc khng c th km.
2.1. Nhim trng mu, sc nhim trng
C th t vong, cy mu dng tnh cng mt loi vi trng vi cy nc tiu.
2.2. p xe thn hoc quanh thn
Chn on da vo siu m thn, CT-Scanner gip nh v chnh xc p xe.

312
2.3. Tnh trng khng khng sinh
Mt phn do bn cht loi vi trng a khng, mt phn do dng khng sinh khng
ph hp, khng liu v khng lu.
2.4. Vim thn b thn kh thng
Him, gp nhng bnh nhn i tho ng (70%), chn on da vo siu m
thn thy cc ti hi trong nhu m thn.

IV. CHN ON
1. Chn on xc nh: da vo
- Lm sng: st rt run, au h sn lng, tiu c, thn ln.
- Nc tiu: cy nc tiu trn 100.000 khun lc /ml, nc tiu nhiu bch cu.
2. Tm cc yu t thun li
- Sau t sonde tiu, c si h tit niu, ph n c thai, u x tin lit tuyn,... cc
yu t ny thng c pht hin nh X quang v siu m thn tit niu.
3. Chn on phn bit
- Vim thn b thn bn phi: cn phn bit vi rut tha vim hoc vim ti mt
cp.
- ph n: vi triu chng au cn phn bit vi vim phn ph, thai ngoi t
cung.
Trong cc trng hp trn phn bit ch yu da vo xt nghim nc tiu.
- Phn bit vim thn b thn cp vi t cp ca Vim thn b thn mn: da vo
tin s, thm d bng Xquang, siu m thy thn teo nh khng u hai bn, b g
gh.

V. IU TR
1. Khng sinh
1.1. Chn khng sinh: Tt nht l theo khng sinh . Khi cha c khng sinh th
chn khng sinh:
- C tc dng vi vi trng Gr(-), ch t l hin nay khng vi Ampicilline (2530%).
- C tc dng dit khun, t nh huyt thanh nhanh, nng cao trong nhu m
thn, o thi ch yu qua nc tiu.
Khng sinh p ng cc yu cu trn l
+ Aminopnicillines: dng n c hay phi hp vi Acide clavulanique.
+ Aminoglycosides: n c hay phi hp vi aminopnicillines.
+ Aztronam, Cephalosporines th h 2 hoc th h 3.
+ Cotrimoxazole, Fluoroquinolones.
1.2. Thi gian iu tr
T 2-6 tun, ph thuc vo
- C hoc khng c yu t thun li, bin chng.

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- C a, trm trng lm sng.
- Triu chng sinh hc v nht l thm d hnh thi.
1.3. Liu lng v cch dng
Ty trm trng c th
Dng mt loi khng sinh hoc kt hp hai loi trong nhng ngy u hoc sut liu
trnh; ng ung hoc ng ngoi tiu ha.
- Amoxicilline - acide clavulanique: 1,5g/ngy.
- Gentamycine 1mg/kg/8 gi.
- Aztronam: 1g/mi 12 gi.
- Ceftriaxone 2g/ngy.
- Cotrimoxazole: 960mg x 2v/ngy.
- Ofloxacine: 200mg x 2v/ngy.
2. iu tr trit cc yu t thun li
Si, u x tin lit tuyn... loi b nguyn nhn lm nc tiu.
3. Tit thc
- n nh, ung nhiu nc.
- Trng hp nhim trng nng, mt nhiu nc: phi b nc in gii bng
ng tnh mch.
4. Phng bnh
- Gio dc bnh nhn b si thn tit niu c hng phng
+ Ch n ung
+ Khm nh k, pht hin nhim trng tim tng iu tr dt im. V sinh b
phn tit niu sinh dc.
- Trnh cc th thut: thng tiu, soi bng quang khi khng cn thit.

VIM THN B THN MN

L hu qu ca nhim trng niu ko di, ti pht nhiu ln, iu tr khng dt
im.

I. GII PHU BNH

1.i th
- Thn teo nh, c hai bn nhng khng cn xng hoc ch teo mt bn.
- B thn g gh, li lm khng u.
- i b thn b bin dng, co ko, mo m.
- C khi thn l nhng m hoc mt bc m.
2.Vi th
- X ha t chc k, xm nhp nhiu t bo lympho, tng bo, bch cu a nhn.

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- Nhiu ng thn b ph hy, phn cn li gin rng.
- Cu thn b hyalin ha, mt hnh th bnh thng hoc b t chc x bao quanh
ngoi mng Bowman, hoc trong mng Bowman.
- Mch thn b x cng, chn p bi t chc x.

II. TRIU CHNG HC

1. Tin s: Bnh nhn thng c nhim trng h tit niu ti pht nhiu ln, c yu
t thun li lm nghn, nc tiu: si, u x tin lit tuyn, d dng ng tit
niu...
2. Triu chng lm sng
- C th c hi chng bng quang: tiu but, tiu dt, tiu c, tiu mu.
- Khng ph, tri li c du hiu da kh, n hi gim, kiu mt nc.
- Ch ph khi c suy thn nng, dinh dng km.
- au m vng hng lng, 1 hoc 2 bn.
- Tiu nhiu, tiu m.
- Thiu mu, tng huyt p thng xut hin mun.
3. Triu chng cn lm sng
3.1. Nc tiu
- Protein < 1g/24h.
- Bch cu > 6000/pht hoc > 5/vi trng vt knh 40.
- Vi trng > 105/ml.
- Kh nng c c nc tiu gim sm: lm nghim php c c thng t trng ti
a < 1,018.
- Phn ly chc nng cu v ng thn: kh nng c c gim, t trng thp, nhng
mc lc cu thn bnh thng. y l du hiu sm ca vim thn b thn mn.
- Khi c suy thn
+ Hng cu, hmoglobin mu gim.
+ Ur, cratinin mu tng.
3.3. Xquang v siu m thn
Thn teo nh khng cn xng, b g gh, li lm khng u.

III. TIN TRIN

- Tin trin ni chung l chm. C khi ht vi trng trong nc tiu bnh vn tin trin.
- Thng c cc t kch pht.
- Cui cng dn n suy thn mn.Suy thn cng nhanh khi:
+ Nhiu t kch pht.
+ Huyt p tng.
+ Dng khng sinh c cho thn.
+ Khng loi b c cc yu t thun li: si, u x tuyn tin lit.

315
IV. CHN ON
1. Chn on xc nh: Ch yu da vo: tin s, triu chng lm sng v cn lm
sng.
2. Chn on phn bit: Cn phn bit vi vim cu thn thn mn, da vo:
- Ph hay gp hn, tng huyt p xut hin sm hn
- Nc tiu: hng cu nhiu hn bch cu, khng c m trong nc tiu, lng
Protein niu nhiu hn, ch yu l Albumin.
- Thn nh nhng cn xng, b u.

V. IU TR
1. iu tr nhim trng
Ch yu l cc t cp hoc giai on c vi trng niu mc d khng c triu chng
lm sng nhng pht hin qua theo di t bo vi trng niu.
Dng khng sinh theo khng sinh , trnh cc loi khng sinh c thn.
2. Loi b cc yu t thun li: u, si...
3. iu tr tng huyt p, ri lon toan kim, in gii, thiu mu...

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SUY THN CP
Mc tiu
1. Lit k c cc nguyn nhn ca suy thn cp.
2. Tp hp c cc triu chng lm sng, cn lm sng ca suy thn cp.
3. Bit r cc bin chng ca suy thn cp.
4. nh gi cc triu chng chn on xc nh, gin bit v th bnh ca suy
thn cp.
5. iu tr c suy thn cp.
Ni dung

I. I CNG V DCH T HC
1.i cng
Suy thn cp l mt hi chng xut hin khi chc nng thn (ch yu l chc nng
lc cu thn) b suy sp nhanh chng, xy ra t ngt bnh nhn khng c suy
thn trc hoc bnh nhn mc suy thn mn. Mc lc cu thn c th b
suy gim nng nhng c th c hi phc hon ton mt cch t nhin hoc di
nh hng ca iu tr nguyn nhn. Suy thn cp th hin trn lm sng c trng
vi v niu, nhng c nhng th bnh vn c lng nc tiu bo tn. Gn y
chn on suy thn cp da vo s gia tng cratinine mu so vi cratinine cn
bn bit: nhiu hn 50mmol/l i vi cratinine cn bn di 250 mmol/l hoc
nhiu hn 100 mmol/l i vi cratinine mu cn bn trn 250 mmol/l.
2. Dch t hc
Suy thn cp l mt hi chng tng i t gp. Trong thc t, tn sut mc bnh
ny ch c th c nh gi bng s lng nhp vin hng nm: 1 - 3% bnh nhn
nhp vin hng nm.
Tin lng ca suy thn cp thng l tt nu kh nng phc hi chc nng thn
tt dn. Tuy vy, cn phi tnh n nhng yu t nguy c lm nng ca suy thn
cp: bnh nguyn, ln tui, c a suy yu, kt hp vi suy cc tng khc, iu kin
iu tr (thm phn, dinh dng) v cui cng l kinh nghim ca i ng iu tr.
II SINH L BNH
Chc nng lc cu thn trong suy thn cp gim hoc mt hn, xy ra do cc c
ch sau:
- Gim dng mu qua thn (gim th tch, sc).
- Tnh khng ca tiu ng mch i gim (dn mch sau cu thn).
- Tnh khng ca tiu ng mch n tng (co mch trc cu thn).
- p lc cu thn (nang Baoman) gia tng (tc nghn trong lng ng thn hoc trn
ng bi tit).
- Ngoi ra suy thn cp cn c th do gim tnh thm ca mch mu thn m c ch
hin nay cn cha c bit r.

III. NGUYN NHN

1. Nguyn nhn trc thn (suy thn cp chc nng)

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318
Nhng nguyn nhn chnh ca suy thn cp chc nng bao gm
Mt nc ngoi bo
- Mt qua da (m hi, bng)
- Mt qua ng tiu ho (nn ma, a chy, l d)
- Mt qua thn:
+ iu tr li tiu qa mnh.
+ a niu thm thu trong i tho ng mt b v trong hi chng ly vt tc
nghn.
+ Vim thn k mn
+ Suy thng thn
Gim th tch mu tht s
- Hi chng thn h nng
-X gan mt b
-Suy tim xung huyt
-H huyt p trong cc tnh trng sc: tim, nhim trng, phn v, xut huyt.
Suy thn cp huyt ng (do thuc c ch men chuyn, c ch th th angiotensinII,
Khng vim khng stroid, c ch calcineurines)

2. Nguyn nhn ti thn (suy thn cp thc th)

2.1. Vim ng thn cp
- L nguyn nhn thng gp nht ca suy thn cp thc th (80%).
- Chim hng u l suy thn cp chc nng chuyn sang.
- Vit Nam thng l do st rt i huyt sc t, ng c mt c trm.
- Ng c bi mui kim loi nng: As, Pb, Hg.
- Huyt tn trong lng mch do truyn nhm nhm mu, nhim c quinine, nm.
- Do thuc: khng sinh (Aminosides, Amphotericine B), thuc cn quang.
2.2. Vim cu thn cp
Do vim cu thn th tin trin nhanh. Thng gp th vim cu thn hoi t v
ngoi mng trong bnh cnh vim mch hoi t, hoc vim cu thn tng sinh trong
v ngoi mng trong bnh cnh ca lupus, ban xut huyt dng thp. Ngoi ra suy
thn cp do vim cu thn th tin trin nhanh cn gp trong hi chng
Goodpasture.
2.3. Vim thn k cp
- Do Vi trng: Vim thn b thn cp
- Do Nhim c thuc: Thng qua c ch min dch-d ng. Ngoi suy thn cp
cn c tng bch cu a acid trong mu v trong nc tiu, ban da, hu t bo
gan.
3. Nguyn nhn sau thn (Suy thn cp tc nghn)
- Si niu qun l hng u Vit Nam

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- U x, ung th tuyn tin lit
- U vng khung chu lnh hay c tnh (u bng quang, ung th t cung, c t cung,
trc trng)
- X cng sau phc mc
- Di cn sau phc mc (him)
- Lao lm teo hai niu qun

III. DU CHNG LM SNG V CN LM SNG

V mt lm sng, suy thn cp thng din tin qua cc giai on sau
1. Giai on khi u
L giai on xm nhp, tn cng ca cc tc nhn gy bnh, din tin ty
theo tng loi, bnh nhn ng c th din bin nhanh c th dn n v niu
ngay, bnh nhn sc th din bin nhanh hay chm ty theo nguyn nhn sc v
k thut hi sc lc u.
2. Giai on thiu v niu
Thiu niu khi lng nc tiu < 500ml/24 gi (hoc di 20ml / gi), c th bt
u t t hoc ngay vi ngy u khi bnh, trung bnh ko di 1 - 2 tun, khi thiu
niu ko di trn 4 tun th cn xem thn b hoi t v, vim cu thn cp th tin
trin nhanh, vim quanh tiu ng mch thn, si gy tc niu qun.
V niu khi lng nc tiu < 100ml/24 gi, theo Brenner v Rector th him gp,
nhng Vit Nam th rt thng gp, thm ch nhiu ngy, chnh v nguyn nhn
thiu v v niu nn lm cho ur, creatinine tng cao nhanh trong mu.
Biu hin trong giai on ny ch yu l hi chng tng ur mu cp gm c cc
triu chng:
- V tiu ha: chn n, bun nn, nn ma , to bn hoc a chy.
- V tim mch: Tng huyt p thng gp cc bnh vim cu thn, cn li l do
lm dng dch truyn gy nc, mui, tng huyt p nng, gy ph phi, ph no.
- Du thn kinh: c th kch thch vt v, hn m, co git, c khi ri lon tm thn.
- V h hp: nhp th toan kiu Kussmaul hoc Cheyne - Stokes, ph phi, nhim
khun phi.
- Thiu mu: Thng xut hin sm nhng khng nng lm, khi c thiu mu nng
th cn ngh n nguyn nhn suy thn cp l do xut huyt nng ko di hoc bnh
c suy thn mn trc .
- Ph thng do ung nhiu nc hoc truyn dch qu nhiu, mt khc l ph ni
sinh do gii phng nc t hin tng phn hy t chc, t bo. Trong phn ln cc
trng hp hoi t ng thn cp th khng ph.
- Nu c du hiu vng mt, vng da l biu hin ca tn thng gan mt thng
gp do nguyn nhn Leptospirose, st rt i huyt sc t.
- Ri lon in gii: thng gp trong suy thn cp l tng Kali mu, l hin
tng hy t bo v huyt tn tng t 0,5 - 1mmol/24 gi. Cng c khi tng nhanh 1
- 2mmol/l trong t gi cc bnh chn thng nng, nhim khun, huyt tn. Tng
Kali mu rt nguy him, v mt lm sng thng thm lng ri t ngt bc pht

320
rung tht, ngng tim. Khi c Kali mu trn 5mmol/l cn theo di k in tim v x tr
h Kali mu kp thi. Trn in tim tng Kali mu biu hin sm l sng T cao nhn,
i xng ri QRS di, PR di, Bloc xoang nh, mt sng P ri ngng tim c hoc
khng qua giai on rung tht. Trong suy thn cp tng Kali mu ny cng nng
thm do hin tng toan mu.
Toan mu l hu qu t tng chuyn ha, d tr kim gim 1 - 2 mmol/ ngy, bnh
cng nng th gim cng nhanh, d tr kim c khi gim di 10mmol/l, hin tng
ny lm cho Kali mu tng cng nhanh.
Mt khc, ri lon in gii trong suy thn cp cn c gim Calci, Natri, tng Mg v
Phosphate.
- Nhim trng: trong giai on v niu nhim trng l nguyn nhn hng u gy t
vong thng l nhim trng ng h hp, tit niu v ngoi da.
3 Giai on tiu nhiu
Thng bt u t 300ml/24gi sau bnh nhn tiu nhiu, thng vo ngy th
3 ca giai on ny lng nc tiu t 1lt/ngy. Giai on ny gi l khng hong
v nc tiu c khi ti 3 - 4 lt/24 gi v d gy ri lon nc in gii nng, try tim
mch, nhim trng, vim tc tnh mch, nht l d ho c gy gy nhiu. Trong giai
on ny nu iu chnh nc in gii khng hp l th d gy t vong. Cc ch s
v sinh ho trong mu ch bt u gim dn sau vi ngy i nhiu, ngha l trong
nhng ngy u i nhiu th ur mu, creatinine vn cn tng cao v ur, creatinine
niu vn cn thp. Lng ur, creatinine tng cng nhanh trong nc tiu th s
phc hi cng sm v tin lng cng tt, ng nhin l phi gim song song cc
cht ny trong mu v c nh gi chnh xc bng thanh thi creatinine ni
sinh. Gim Kali v Natri c nh gi bng in gii hng ngy b kp thi.
Trong giai on ny, t trng nc tiu thp di 1,005.
4. Giai on phc hi
Ur, creatinine mu gim dn, mc c c nc tiu tng dn, lm sng tt ln,
tuy nhin chc nng thn phc hi rt chm: kh nng c c c khi phi hng nm
mi hi phc. Mc lc cu thn phc hi nhanh hn.

IV. BIN CHNG V TIN LNG CHUNG

- Trc kia, t l t vong rt cao, c khi n 90%. Hin nay nh nhng tin b khoa
hc k thut, nht l trong lnh vc lc ngoi thn v k thut hi sc, t l t vong
cn khong 50%, T l t vong c lin quan vi:
+Bnh l nguyn nhn: sc nhim trng hoc xut huyt, suy h hp, chn thng
nng,vim tu cp, co git.
+ C a: ln tui, bnh mch vnh, suy h hp, i ng, ung th.
+ Nhng bin chng th pht ca hi sc v c bit nhim trng bnh vin (nhim
trng cathether,bnh phi), suy dinh dng
- Nhng bin chng chnh:
+ Nhng bin chng chuyn ho ring ca suy thn cp: Toan chuyn ho v tng
kali mu. Tng th mu v ph phi. Nguy c suy dinh dng.
+ Nhim trng bnh vin (do t Sonde bng quang hoc v niu ko di lm ng
bi niu mt kh nng khng)

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+ Xut huyt tiu ha do lot cp
+ Nhng bin chng tim mch: Vim tnh mch, tc mch phi, nhi mu c tim, tai
bin mch mu no.
- Cc yu t tin lng ph thuc vo
+ Tui cng cao th bnh cng nng
+ Cn nguyn: nng trong vim ty cp, sau m km theo nhim trng, vim
phc mc, cc a chn thng.
+ Tin lng xa trong a s trng hp khng li di chng v khng
chuyn sang mn tnh, nht l ngi tr. Hn hu 2% trng hp khng lnh hn
c gii thch bng s hoi t v thn c hai bn (cn chy thn nhn to sut i,
ghp thn).

V. CHN ON
1. Chn on xc nh
- Da vo du suy thn: i t, v niu, ur, creatinine mu tng cao dn, tng K
mu v toan mu.
- Da vo tnh cht cp tnh
+ Chc nng thn bnh thng trc
+ Kch thc thn bnh thng hoc ln
+ Khng c thiu mu, khng h canxi mu
2. Chn on gin bit
Cn chn on gin bit gia suy thn cp v t cp ca suy thn mn, da vo:
- Tin s bnh nhn khng c bnh thn tit niu.
- Bnh s din tin cp tnh v c nhng nguyn nhn cp tnh dn n.
- C khi rt kh phn bit v bnh nhn khng nh r tin s, thm ch khi hn m
ri mi vo vin. Cn da thm cc triu chng khc nh:
+ Thiu mu nng trong suy thn mn; thiu mu nh, va phi trong suy thn cp.
+ Tng huyt p: Trong suy thn cp thng cao va phi v t nng. Trong suy
thn mn tng huyt p c lu ngy v cc bin chng ca n trn tim, mt,
mch mu kh r rng.
+ Siu m o kch thc thn thy hai bn thn teo nh trong suy thn mn. y l
du hiu chn on quan trng gin bit.
5.3. Chn on suy thn cp chc nng suy thn cp thc th
Bng 1: Phn bit suy thn cp chc nng v thc th
Ch s

STC chc nng

STC thc th

1. Ur mu

Tng

Tng

2. Cratinin mu

Bnh thung hc tng t

Tng

3. Ur /Creatinine mu( mol/l)

>100

<50

4. F E.Na

< 1%

> 1- 2%

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5. Na/K niu

<1

>1

6. Ur niu/ur mu

>10

< 10

7. Cratinin niu/ Cratinin mu

> 30

<30

8. Thm thu niu/Thm thu mu

>2

<2

(FE Na:Fraction de l excretion du sodium = UNa x Pcre / P Na x U cre)

5.4 Chn on nguyn nhn ca suy thn
Cn thit phi tm nguyn nhn gy suy thn cp trn ngi bnh.
- Suy thn cp trc thn: Da vo cc triu chng mt nc ngoi bo (h huyt
p, nhp nhanh, np nhn da, st cn, c c mu). Da vo cc nguyn nhn lm
gim th tch mu tht s: suy tim. X gan mt b, hi chng thn h.
- Suy thn cp sau thn: Trn nhng bnh nhn ang c cc bnh l gy tc nghn:
si niu qun, cc khi u khung chu, bnh l bng quang, tin lit tuyn.
- Suy thn cp ti thn: Da vo cc triu chng chn on bnh l cu thn,
ng thn,t chc k thn hoc mch mu thn.
Bng 2: Chn on nguyn nhn suy thn cp

Triu chng

Vim ng thn Vim thn Vim

cu Bnh l mch
cp
k cp
thn cp
thn cp

Tng huyt p

Ph

Prtin niu

< 2g/l

< 2g/l

> 2-3g/l

Thay i

Tiu mu vi th

Tiu mu i th

Bch cu niu

Nhim trng niu

VI. IU TR
Nguyn tc chung l iu tr theo nguyn nhn suy thn cp, rt khc bit ty tng
nguyn nhn trc, ti v sau thn.
1. iu tr suy thn cp chc nng.
1.1 Suy thn cp vi mt nc ngoi bo v gim th tch mu.
- iu tr cn bn suy thn cp chc nng bng hi phc li nc, th tch
mu lu thng bng in gii, mu, huyt tng cho phn ln cc nguyn nhn
trc thn
- iu tr chnh bng dung dch mui ng trng 0,9%, hoc nhc trng
0,45% bng ng tnh mch. Trong trng hp khng nng cung cp bng ng
ung.
1.2 Suy thn cp chc nng vi ph.

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- Suy thn cp ca hi chng gan thn cp thng him hi phc v thng
t vong v nhng hu qu ca x gan. Tuy nhin, c th th iu tr bng Albumin
nu Albumin mu < 20g/l, kt hp vi li tiu quai.
- Trong trng hp hi chng thn h, nht l khi gim th tch mu ko di,
vic truyn Albumin v s dng thuc li tiu i khi l iu chnh c hiu qu v lm
bin mt ph.
- Trong trng hp suy thn cp sau suy tim c th iu chnh bng iu tr
suy tim.
1.3.Trng hp c bit do thuc c ch men chuyn v thuc khng vim khng
phi steroide: Ngng thuc.
Chung cho cc suy thn cp chc nng, nng huyt p, cng nh tc dng li
tiu c th s dng cc thuc sau:
Isuprel 0,2 - 0,6mg - 1mg trong 1000ml glucose ng trng truyn tnh
mch.
Dopamin 3 - 5(g/kg/pht cho ngi nng 50 kg truyn vi glucose 5%.
Ngoi ra c th dng cc dung dch vi phn t lng ln nh Dextran, Manitol 20%
300 - 500ml/ngy, thm ch mu v cc ch phm ca mu gi th tch mu
ti cho cu thn.
2. iu tr suy thn cp thc th
2.1. Gim mui v nc
giai on v niu, n lt hon ton, lng nc k c dch truyn v ung mi
ngy khng qu 700ml ngi 50kg.
2.2. giai on thiu niu. hoc ngay ngy u v niu, c nc ngoi bo th
dng
Furosemid (Laxis, Lasilix) mi ln 120 - 160mg, tim tnh mch mi 3 - 4 gi, liu ti
a c th n 1000mg - 1500 mg/24h nhm chuyn th v niu sang th i nhiu.
Furosemid thng thay i lng nc tiu m khng nh hng n chc nng
thn. Nu dng liu lng trong ngy m vn khng c lng nc tiu th
ngng dng.
2.3. Khi c tng K mu
+ Dung dch glucose 20% 500ml + 20v Insulin truyn tnh mch nhanh t 60-90
pht.
+ Resine trao i Cation nh Resonium, Kayxelat (trao i 1-2mmol K+ /g resine):
10-15g x 2 - 3 ln/ngy.
+ Clorua calci 10% 5-10ml tim tnh mch chm 3-5 pht, khi cp cu vi in tim c
bloc xoang nh, QRS gin rng hoc K+ > 7mEq/l.
+ Dung dch kim 14 c 5 pht th truyn 44 mmol, nu bnh ph v tng huyt p
th dng loi kim u trng 4,2 % tim tnh mch chm.
+ Nhng thuc kch thch 2 adrnergique: Nh salbutamol, lm vn chuyn kali
vo ni bo.
2.4 iu tr toan chuyn ho.

324
- Truyn tnh mch Bicarbonat ng trng 1,4 g% hoc trong trng hp cn thit
s dng loi m c 4,2%, 8,4%.
2.5. iu tr lc ngoi thn.
Nht l thn nhn to theo cc tiu chun ca chy thn nhn to trong quan
trng l khi c 1 trong 2 tiu chun sau: Ur >30 mmol/l, Kali mu >6 mmol/l.
3. iu tr suy thn cp sau thn
Suy thn cp sau thn cn gi l suy thn cp tc nghn. Cho nn iu tr quan
trng nht l iu tr loi b yu t tc nghn ny.
4. iu tr nguyn nhn.
Ty tng nguyn nhn iu tr nh iu tr st rt trong nguyn nhn suy thn cp
sau st rt i huyt cu t; m ly si trong suy thn cp sau si tc nghn...

325

SUY THN MN
Mc tiu
1. Trnh by c nh ngha, c ch sinh bnh ca suy thn mn.
2. Xp loi cc nguyn nhn ca suy thn mn.
3. Tp hp c cc triu chng lm sng, cn lm sng ca suy thn mn
4. Chn on xc nh, chn on giai on ca suy thn mn.
5. iu tr suy thn mn trc giai on cui.
6. Ch nh cc phng php iu tr thay th thn suy
Ni dung

I. I CNG V DCH T HC
1. i cng
Suy thn mn l hu qu ca cc bnh thn mn tnh ca thn gy gim st t t s
lng nephron chc nng lm gim dn mc lc cu thn.
Khi mc lc cu thn gim xung di 50% (60ml/pht) so vi mc bnh thng
(120ml/pht) th c xem l c suy thn mn.
Suy thn mn l mt hi chng din bin theo tng giai on: trong giai on sm,
lm sng ch c mt s triu chng rt kn o, ngc li vo giai on cui biu
hin rm r vi hi chng tng ur mu. Qu trnh din bin ca suy thn mn c
th ko di t nhiu thng n nhiu nm.
2. Dch t hc
Xc nh t l mi mc, mc bnh suy thn mn l mt vn kh khn bi trong
suy thn mn giai on u ngi bnh thng t i khm bnh v t hoc khng c
triu chng lm sng. Suy thn mn trc giai on cui t c bit r v khng c
ng k v khng c theo di, nhng t l mi mc suy thn mn giai on cui
cn c iu tr thay th thn suy th ngi ta c th bit c mt cch chnh xc.
Theo thng k Php t l mi mc suy thn mn giai on cui l 120 trng hp
/ 1 triu dn / nm. M v Nht l 300 trng hp / 1 triu dn / nm (s liu nm
2003).
- T l mc bnh suy thn mn c khuynh hng gia tng theo thi gian v khc
nhau gia nc ny v nc khc.
- Suy thn mn l mt bnh l xy ra ch yu ngi ln. Thng k ca Php trong
s 70 bnh nhn mi mc suy thn mn giai on cui th ch c 5 bnh nhn l tr
em v thanh nin, v 65 bnh nhn l ngi ln. Suy thn mn cng c lin quan
vi gii tnh, nam mc bnh hn n hai ln (2/1). tui trung bnh ca s bnh
nhn mi bt u iu tr suy thn mn giai on cui tng dn: nm 1987 l 55 tui,
nm 1998 l 61 tui.

II. NGUYN NHN

Hu ht cc bnh l thn mn tnh d khi pht l bnh cu thn, bnh ng k thn
hay bnh mch thn u c th dn n suy thn mn.
1. Bnh vim cu thn mn
Thng hay gp nht, chim t l 40%

326
Vim cu thn mn y c th l nguyn pht hay th pht sau cc bnh ton
thn nh lupus ban h thng, i ng, ban xut huyt dng thp...
2. Bnh vim thn b thn mn
Chim t l khong 30%.
Cn lu : vim thn b thn mn trn bnh nhn c si thn tit niu l nguyn
nhn thng gp Vit Nam.
3. Bnh vim thn k
Thng do s dng cc thuc gim au lu di nh Phnylbutazone, do tng acid
uric mu, tng calci mu.
4. Bnh mch thn
- X mch thn lnh tnh hoc c tnh.
- Huyt khi vi mch thn
- Vim quanh ng mch dng nt
- Tc tnh mch thn
5. Bnh thn bm sinh do di truyn hoc khng di truyn
- Thn a nang
- Lon sn thn
- Hi chng Alport
- Bnh thn chuyn ha (Cystinose, Oxalose).
6. Bnh h thng, chuyn ho
- i tho ng
- Cc bnh l to keo: Lupus
Hin nay nguyn nhn chnh gy suy thn mn cc nc pht trin ch yu l cc
bnh chuyn ho v mch mu thn (i tho ng, bnh l mch mu thn) trong
khi cc nc ang pht trin nhm nguyn nhn do vi trng, si thn tit niu vn
cn chim vi t l cao

III. VI NT V C CH SINH BNH

C ch sinh bnh ca suy thn mn c gii thch trn c s l lun ca thuyt
nephron nguyn vn: Mc d tn thng khi pht cu thn, mch mu thn, t
chc ng k thn th cc nephron b thng tn nng cng thng b loi tr khi vai
tr chc nng sinh l. Chc nng ca thn ch cn c m nhim bi cc nephron
nguyn vn cn li, khi s nephron nguyn vn cn li ny khng m bo
chc nng ca thn l duy tr s hng nh ca ni mi th s xut hin cc ri lon
v nc in gii, v tun hon, h hp, tiu ha, thn kinh to nn hi chng suy
thn mn.

IV. BIU HIN LM SNG, CN LM SNG CA SUY THN MN

1. Lm sng
1.1. Ph

327
Ty thuc vo nguyn nhn gy suy thn mn m bnh nhn c th c ph nhiu,
ph t hoc khng ph. Suy thn mn do vim thn b mn thng khng ph trong
giai on u, ch c ph trong giai on cui. Trong khi suy thn mn do vim cu
thn mn ph l triu chng thng gp. Bt k nguyn nhn no, khi suy thn mn
giai on cui, ph l triu chng hng nh.
1.2. Thiu mu
Thng gp nng hay nh ty giai on, suy thn cng nng thiu mu cng nhiu.
y l triu chng quan trng phn bit vi suy thn cp.
1.3. Tng huyt p
Khong 80% bnh nhn suy thn mn c tng huyt p, cn lu c tng t tng
huyt p c tnh lm chc nng thn suy sp nhanh chng gy t vong nhanh.
1.4. Suy tim
Khi c suy tim xut hin th c ngha l suy thn mn mun, suy tim l do tnh
trng gi mui, gi nc, tng huyt p lu ngy v do thiu mu.
1.5. Ri lon tiu ha
Trong giai on sm thng l chn n, giai on III tr i th c bun nn, a
chy, c khi xut huyt tiu ha.
1.6. Xut huyt
Chy mu mi, chn rng, di da l thng gp. Xut huyt tiu ha nu c th rt
nng lm ur mu, Kali mu tng ln nhanh.
1.7. Vim mng ngoi tim
L mt biu hin trong giai on cui ca suy thn mn vi triu chng kinh in l
ting c mng ngoi tim, y l triu chng bo hiu t vong nu khng c iu
tr lc mu kp thi.
1.8. Nga
L biu hin ngoi da gp trong suy thn mn giai on c cng tuyn cn gip
th pht vi s lng ng Canxi t chc di da.
1.9. Chut rt
Thng xut hin ban m, c th l do gim Natri, gim Calci mu.
1.10. Hn m
Hn m do tng ur mu cao l biu hin lm sng giai on cui ca suy thn
mn. Bnh nhn c th c co git, ri lon tm thn giai on tin hn m. c
im ca hn m do tng Ur mu mn l khng c triu chng thn kinh khu tr.
Trn y l cc biu hin lm sng chung ca suy thn mn. Ngoi ra tu theo
nguyn nhn dn n suy thn mn mi bnh nhn m c nhng triu chng
tng ng nh thn ln trong bnh thn a nang, thn nc,...
2. Cn lm sng
- Tng ur mu, cratinine mu
- Gim h s thanh thi cratinine

328
- Kali mu: kali mu c th bnh thng hoc gim. Khi Kali mu cao l c biu hin
t cp c km thiu niu hoc v niu.
- Calci mu, phospho mu: trong giai on u calci mu gim, phospho mu tng.
Trong giai on c cng tuyn cn gip th pht th c calci mu v phospho
mu u tng.
- Nc tiu:
+ Protein niu: ty thuc vo nguyn nhn, khi suy thn giai on III, IV th lun c
protein niu nhng khng cao.
+ Hng cu, bch cu: ty thuc nguyn nhn gy suy thn mn.

V. CHN ON
1. Chn on xc nh
Da vo:
- Du chng ca Suy thn:
+ Tng ur, cratinine mu.
+ Mc lc cu thn gim.
- Tnh cht mn ca suy thn: c 3 tiu chun:
+ Tiu chun tin s: c tin s bnh thn, trc y c tng cratinine mu.
+ Tiu chun v hnh thi: Kch thc thn gim (chiu cao < 10cm trn siu m, < 3
t sng trn phim chp thn khng chun b).
+ Tiu chun v sinh hc: C 2 bt thng nh hng n suy thn mn:
* Thiu mu vi hng cu bnh thng khng bin dng.
* H canxi mu.
2. Chn on giai on
Da vo h s thanh thi cratinine, cratinine mu: suy thn mn c chia
thnh cc giai on sau
Giai on
suy thn mn

HSTT cratinine (ml/pht)

Cratinine mu
micromol / l

mg / dl

Bnh thng

120

70-106

0,8 - 1,2

60-41

< 130

< 1,5

II

40-21

130 - 299

1,5 - 3,4

IIIa

20-11

300-499

3,5 - 5,9

IIIb

10-5

500-900

6,0 - 10

IV

<5

> 900

> 10

3. Chn on nguyn nhn

Tm cc nguyn nhn gy ra suy thn mn c ngha quan trng trong chn on.
Khi loi tr c nguyn nhn th suy thn mn mc d khng hi phc nhng c
th lm chm tin trin ca suy thn mn.

329
Cc nguyn nhn suy thn mn bao gm: bnh cu thn mn, bnh vim thn b
thn mn, bnh mch mu thn, bnh thn bm sinh v di truyn.
4. Chn on phn bit
Cn chn on phn bit vi
- Suy thn cp: da vo Bnh s - Nguyn nhn - Tin trin ca suy thn.
- t cp ca suy thn mn:a vo tin s, t l ur mu / cratinine mu
(mol/l) > 100
5. Chn on bin chng
Ch n cc bin chng trn tim mch, mu, tiu ho, thn kinh, nhim trng, ri
lon nc in gii, kim toan...
6. Chn on cc yu t gy nng nhanh ca suy thn
- Tng huyt p
- Nhim khun, xut huyt tiu ho, mt nc
- Tc nghn ng bi niu
- Dng thuc c cho thn
- n qu nhiu prtin

VI. IU TR
Ty thuc vo giai on ca suy thn mn m bin php iu tr p dng c khc
nhau. Hn na cn ph thuc vo yu t kinh t, x hi nht l cc bin php iu tr
thay th thn suy.
1 iu tr suy thn mn trc giai on cui.
Tng ng vi iu tr suy thn mn cc giai on I, II v IIIa, khi thanh lc cu
thn cn trn 10 ml/pht. Cc bin php ny bo tn chc nng thn cn li
1.1. Nguyn tc chung.
- Khi bnh nhn b mt bnh l thn mn tnh, d cha c suy thn hoc suy thn
nh th cng phi c theo di bi thy thuc chuyn khoa thn, nhm pht hin
v iu tr cc yu t gy nng, theo di c h thng ngi bnh tu thuc vo mc
nng nh ca suy thn mn.
- Mc ch ca theo di bnh
+ Theo di liu trnh iu tr bnh thn.
+ Ngn chn s tin trin ca suy thn mn.
+ Trnh cc thuc c cho thn v iu chnh liu thuc cho ph hp vi mc
suy thn.
+ iu tr cc bin chng ca suy thn mn, cc yu t nguy c tim mch, c bit
l tng huyt p v cc yu t i km.
+ Thng tin cho bnh nhn v chin lc iu tr tu theo tng bnh nhn v tng
giai on ca suy thn.
+ Chun b cho vic iu tr thay th thn suy giai on cui: Chng nga vim
gan Virus B, giai on IIIa c th lm ni thng ng - tnh mch.

330
1.2. Lm chm s tin trin ca suy thn mn
1.2.1. iu tr tt nguyn nhn gy suy thn mn.
1.2.2. Duy tr tt huyt p v lm gim Protein niu.
y l mt im rt quan trng trong iu tr suy thn mn cc giai on nh.
nhng bnh nhn ny, ch s huyt p ti u cn t c s ph thuc vo
lng Protein niu:
- Nu suy thn mn c Protein niu < 1g/24 gi th huyt p ti u s l 130/80
mmHg.
- Nu suy thn mn c Protein niu 1g/24 gi v / hoc i tho ng th huyt
p ti u s l 125/75 mmHg.
1.2.3. Cung cp Protein trong ch n thch hp.
Trng hp suy thn nh, trung bnh (ClCr t 30 n 60 ml/pht) Protid c th c
cung cp vi liu lng 1g/kg/ngy. Trng hp suy thn nng hn th Protein cung
cp t 0,6 n 0,8 g/kg/ngy.
1.3. Trnh cc thuc c cho thn v thay i liu dng ph hp theo mc suy
thn.
1.4. iu tr cc bin chng ca suy thn mn.
1.4.1. Cc yu t nguy c tim mch.
- Tng huyt p: duy tr tt huyt p s lm gim t l mc v t l t vong do bnh
l tim mch bnh nhn suy thn mn.
- iu tr ri lon Lipid mu:
+ Dng nhm Statine khi tng Cholesterol mu l ch yu.
+ Nhm Fibrate trong trng hp tng Triglycerid.
- Loi b cc yu t nguy c khc:
+ B thuc l.
+ iu tr tt i tho ng.
+ Gim cn bnh nhn bo ph.
1.4.2. iu tr ri lon cn bng Canxi - Phospho.
- Duy tr nng Canxi mu bnh thng.
- Phospho mu di 1,5 mmol/l.
- PTH mu di 3 ln bnh thng.
1.4.3. iu chnh cn bng kim toan.
- Thng dng mui Natri Bicarbonate, bng ng ung hoc tim truyn tu
theo ri lon nh hay nng.
1.4.4. iu tr tng Acide Uric mu
- Tn cng bng Colchicin
- D phng ti pht bng Allopurinol.

331
1.4.5. iu tr thiu mu
- Mc ch ca iu tr l duy tr Hb mu 11 n 12 g/l.
1.4.6. iu tr ri lon nc in gii
- Ch n nht: c p dng trong hu ht cc bnh thn.
- Gim lng nc ung vo trong trng hp c ph.
- iu tr Tng Kali mu
2. iu tr suy thn mn giai on cui.
Khi mc lc cu thn gim di 10 ml/pht, ngoi cc phng php ca iu tr
bo tn nh trn, m bo s sng ca ngi bnh cn thit phi c cc phng
php iu tr thay th thn suy, bao gm:
+ Ghp thn.
+ Thn nhn to.
+ Lc mng bng.

III.D PHNG
- D phng cp 1: Loi tr nhng yu t nguy c dn n bnh l thn, tit niu
nh ch sinh hot c nhn, v sinh, n ung, s dng thuc c vi thn.
- D phng cp 2: Pht hin sm bnh l thn, tit niu bng thm khm lm
sng, protein niu, iu tr trit bnh l thn tit niu.
- D phng cp 3: Khi c suy thn mn. D phng ny bao gm cc bin php
c hiu: xc nh nguyn nhn, iu tr c hiu qu loi tr bnh l nguyn nhn
dn n suy thn mn, hoc nhng bin php khng c hiu: loi tr cc yu t
lm tin trin nng nhanh ca suy thn.

332

BNH THN I THO NG

Mc tiu
1. Trnh by c khi nim, dch t hc ca bnh thn i tho ng.
2. M t c ch sinh bnh ca bnh thn i tho ng.
3. Chn on xc nh, chn on phn bit bnh thn i tho ng.
4. Chn on cc giai on ca bnh thn i tho ng.
5. Trnh by cc bin php iu tr bnh thn do i tho ng.
Ni dung

I. I CNG
Bnh cu thn i tho ng l t dng ch nhng tn thng cu thn th
pht do i tho ng. Nhng tn thng cu thn ny c nhng c trng v mt
hnh thi c m t bi Kimmelstiel v Wilson t nm 1936. Tuy nhin bnh thn
i tho ng ngoi tn thng cu thn cn c nhng tn thng khc do bn
thn i tho ng gy nn thn nh tn thng ng thn hoc nhng biu hin
ca hoi t i thn hoc bnh l thn kinh bng quang do i tho ng.
Bnh cu thn i tho ng l mt bin chng in hnh ca i tho ng typ I
ph thuc vo Insulin xut hin nhng ngi c bnh l i tho ng t cn rt
tr. Tuy nhin n cng c th xut hin nhng bnh nhn i tho ng typ II,
khng ph thuc Insulin.
Hn nay cc nc u M suy thn mn giai on cui do i tho ng chim
t l cao v ngy cng gia tng.

II. DCH T HC
Bnh cu thn i tho ng (c xc nh bi protein niu thng xuyn
nhng ngi c bnh l vng mc do i tho ng hoc nhng ngi c sinh
thit thn v c kt qu trong ho x - x ho cu thn) thng xut hin bt u t
nm th 10 nhng bnh nhn i tho ng ph thuc Iusulin. T l mc hng
nm t nh cao nht gia nm th 15 n nm th 20 ca i tho ng. Thi
gian mc bnh i tho ng ph thuc Insuline l yu t nguy c chnh ca pht
trin bnh l thn do i tho ng cng nh bnh l vng mc i tho ng,
bn cnh tng ng huyt, tng huyt p cng l cc yu t nguy c khc gy
nn nhng bin chng thn trn bnh nhn i tho ng.
Thi gian sng bnh nhn bnh thn i tho ng l gim nhiu. Nu khng
c iu tr c hiu qu, mt na s bnh nhn l t vong sau 7 nm xut hin
protein niu. T l t vong nhm bnh nhn ny l cao gp 37 ln so vi qun th
chung. Ngc li bnh nhn i tho ng khng c protein niu th c thi gian
sng gn nh bnh thng. Cng cn lu rng phn ln nhng nguyn nhn t
vong bnh i tho ng phu thuc Insulin l t gn lin vi suy thn m thng
lin quan n bnh l tim mch, c bit bnh l mch vnh.
Bnh thn i tho ng l nguyn nhn chim v tr th nht ca suy thn mn
cc nc phng ty: 25 n 50% v hn 90% l i tho ng typ 2

III. C CH SINH BNH

333
C ch ca bnh cu thn th pht sau i tho ng ph thuc insulin cn nhiu
bn ci, nhng nhng gi thuyt gn y th tht l th v v chng c th c nhng
kt qu c li ngn nga v hoc iu tr bnh thn i tho ng.
Vai tr ca nhng bt thng v mt huyt ng hc c nhn thy giai on
khi u ca bnh nhn i tho ng mi c bit gn y. S tng lc v tng
p lc gii thch cho microalbumin niu v cng c l s gin n ca gian mch c
th gy ra x ho cu thn. Nhng yu t gy ra s gia tng lc th nhiu: trc tin
l tng ng mu mn tnh nhng cng cn do tng tit nhng hormone i khng
insulin (glucagon, hormone tng trng) v nhng cht hot mch lm bin i
nhng tiu ng mch n v tiu ng mch i ca thn (c bit l PGE2 v
PGI2).
S tng dng mu qua mao mch ng vai tr ch yu trong bnh l mch (vng
mc v nhng mao mch khc).
Nhng ri lon chuyn ho th pht sau tng ng mu cng tham gia vo s
hnh thnh bnh thn bng cch lm bin i cu trc phn t ca nhng thnh
phn cu thn, c bit l mng y bng cch tng qu trnh ng phn v gim
qu trnh sulfate. Nhng bin i ng chuyn ho polyol (tng sn xut sorbitol v
fructose) m vai tr ca n trong s pht trin c thu tinh th do i tho ng l
chc chn, cng c th tham gia vo s hnh thnh protein niu. N dn n kt qu
tng lc cu thn i vi nhng i phn t v tch lu trong cu thn nhng protein
tun hon gy ra nhng tn thng cu thn

IV. CHN ON
1. Chn on xc nh
Chn on xc nh bnh thn i tho ng l da vo t bo hc. Tuy nhin
trong phn ln trng hp chn on dng tnh thng da vo kt hp protein
niu (m thnh phn ch yu l albumin), tng huyt p, gim mc lc cu thn.
- Albumin niu: C th c nh lng bng nhng k thut min dch c bit
(min dch phng x, ELISA...) Cho php xc nh albumin niu vi lng cn rt t
trong nc tiu. ngi bnh thng albumin c bi tit trong nc tiu khng
vt qu 20-30 mg/ngy hoc 15-20 g/pht. Khi trong nc tiu c albumin t
30mg n 300mg/ngy (t 20 n 200 g/pht) gi l microalbumin niu: y l mt
ch im bt thng sm thn, c gi tr trong chn on giai on cn sm ca
i tho ng trn thn. Khi albumin niu t 300mg/24gi tr ln gi l tiu
albumin niu i th (tng ng vi 0,5g/24gi protein). Cn lu rng vic bi tit
albumin trong nc tiu l rt khc bit gia cc thi im trn cng mt c th, v
th cn lm xt nghim albumin niu nhiu ln nh gi.
- Huyt p: Tng huyt p l triu chng ca bnh thn do i tho ng. Tuy
nhin huyt p ng mch ph thuc vo giai on ca bin chng thn, giai on
microalbumin niu th huyt p tm thu vo ban m gim mt t v hin tng ny
khng cn na khi c albumin niu i th.
- Mc lc cu thn: Mc lc cu thn gim l mt triu chng chn on suy
thn, bin chng ca i tho ng giai on cui. Mc lc cu thn c nh
gi qua h s thanh thi creatinin. Nhng cn lu khi nh lng creatinin c th
sai s do tng ng huyt. Mt s cht khc cng c s dng nh gi h s
thanh thi trong bnh thn do i tho ng nh Inulin, cc cht ng v phng x
125
Iodothalamate, 51Cr - EDTA.

334
Ngoi ba du chng k trn, nh gi c tn thng cu thn trong bnh
thn i tho ng khi chn on cn da vo:
- Thi gian mc bnh i tho ng: mc bnh nhiu nm, ph thuc Insulin.
- Nhng biu hin ca bnh mch mu vi th (nht l bnh l vng mc do i
tho ng).
- bnh nhn i tho ng khi c tam chng ca bnh l cu thn km thi gian
mc bnh nhiu nm v c bnh l vng mc, kh nng c bnh thn i tho
ng l ln hn 95%.
2. Chn on giai on
Nhng nghin cu thc nghim v lm sng (c bit nhng bnh nhn i tho
ng typ I ph thuc insulin, c theo di trong thi gian di) cho thy bnh
thn i tho ng c trng c nhng bt thng v hnh thi v chc nng rt
sm, Mogensen chia thnh 5 giai on:
- Giai on 1: Giai on tng chc nng v ph i, xy ra ngay khi b i tho
ng. Kch thch thn gia tng, cu thn ph i nhng cu trc ca chng th bnh
thng. Mc lc cu thn tng, lu lng mu qua thn tng theo song song, c th
tng tit albumin niu. Tng lc cu thn gim sau vi tun hoc vi thng iu tr
bng insulin, nhng kch thc thn vn khng thay i.
- Giai on 2: C th tn ti dai dng trong nhiu nm v 60% i tho ng typ I
ko di sut i. Mc lc cu thn c th gia tng. S gia tng ny tng quan vi
kch thc thn v s kim sot i tho ng. C l s tng lc v kim sot i
tho ng km l cn thit pht trin bnh thn i tho ng. S tit albumin
qua nc tiu l bnh thng nhng c th gia tng trong nhng tnh hung stress.
B dy ca mng y cu thn tng, cht nn gian mch tng nhiu hn v nhng
tn thng ny l khng hi phc.
- Giai on 3: L giai on bnh thn i tho ng khi u. Ch xy ra 40%
bnh nhn i tho ng. N ko di t 11-20 nm, s bi tit albumin niu tng
thng xuyn trong vi nm t 10-200 g/pht. S tng lc vn tn ti nhng n bt
u gim khi microalbumin niu tng. Ch s huyt p thng tng cao hn so vi
ngi bnh thng. Ngi ta vn cha bit (theo nh gi hin nay) s can thip
iu tr giai on ny (kim sot tt tng ng mu, iu tr tng huyt p) c cho
php lm chm tin trin hay khng ; nhng d sao i na th microalbumin niu
cng gim mt cch ng k.
- Giai on 4: L giai on bnh thn i tho ng xc lp vi protein niu
thng xuyn trn 0,5g/24gi, tng huyt p ng mch l hng nh. Hi chng
thn h thng xut hin. Nhng bin chng khc ngoi bnh thn i tho ng
cng thng gp, c bit l bnh vng mc (thng gy m) bnh thn kinh ngoi
vi v hoc thn kinh t ng. Mc lc cu thn gim trung bnh 1ml/thng ; iu tr
tng huyt p hiu qu c th lm chm s tin trin ny.
Ngc li, ngi ta vn cha chc chn rng s kim sot ng mu nghim ngt
c tc ng n tin trin ca suy thn hay khng.
Tn thng cu thn l c trng: tn ti x ho cu thn lan to, gm dy mng
y tin trin v tng cht nn gian mch, trong 10-20% trng hp tn ti nhng
nt bt mu bi cht PAS (+) tch t gian mch ln cn cc cu thn gi l x ho
cu thn dng nt ca Kimmelstiel v Wilson.

335
- Giai on 5: L giai on suy thn giai on cui. Nhng bnh nhn ny chim mt
phn quan trng trong s bnh nhn c iu tr nhng trung tm lc mu ngoi
thn v ghp thn.
Khi mc bnh i tho ng khng ph thuc insulin (thng gp cao hn 10 ln
so vi nhm khc), bnh thn cng l mt bin chng thng gp, xut hin trong
20 - 40% ca nhng bnh i tho ng typ ny ; 3-8% tin trin n suy thn mn
giai on cui. Trong bnh thn i tho ng ny, khng c s tng lc cu thn.
3. Chn on gin bit
- nhng bnh nhn i tho ng ph thuc Insulin trong thc hnh khng cn
sinh thit thn khng nh chn on nu thi gian i tho ng hn trn 10
nm v c bnh l vng mc do i tho ng. Ngc li, sinh thit thn l cn
thit nu 2 yu t ny l khng hi v hoc bnh cnh lm sng lm nh hng
n mt bnh nguyn khc.
i chiu 2 yu t albumin niu v huyt p thng cho php phn bit gia bnh
nhn i tho ng v bnh i tho ng km tng huyt p c bin chng
thn, khi i chiu 2 yu t ny bnh i tho ng c 6 tnh hung xy ra sau:
Bng 1: Cc tnh hung tng quan gia tng huyt p, albumin niu i tho
ng
Albumin

Bnh thng

niu

microalbumin

macroalbumin niu

niu

Tng huyt p
C

Khng

II

III

i tho ng +
tng huyt p nguyn
pht

i tho ng +
tng huyt p nng
(1)

i tho ng v
tng huyt p nng
(1,2)

IV

VI

Tt

Bnh thn i tho

ng giai on
u

Bnh thn i tho

ng

(1: C ph i tht tri ; 2: C tn thng nhiu c quan khc ca tng huyt p)

V. D PHNG V IU TR BNH THN I THO NG

1. D phng bnh thn i tho ng
- D phng nguyn pht bnh i tho ng typ 1 c th s bng mt iu tr c ch min
dch bi v y l mt bnh t min.
- Lin quan n i tho ng typ 2: cn chng lai cc yu t nguy c (tng cn qu nhiu
v li sng tnh ti).
- D phng nguyn pht v th pht bnh thn i tho ng bao gm
+ Kim sot ng mu l tng: Bnh thng ho c ng mu l u tin hng
u trong cc bin php iu tr. Bin php iu tr Insulin theo qui c (3,4 ln tim
trong ngy) l thng c p dng. iu ny lm gim nguy c bnh thn bnh i
tho ng typ 1. Li ch ca kim sot ng huyt nghim ngt trong i tho ng
typ 2 c l cng c gi tr tng t. Mc ch chuyn ho c yu cu l HbA1c < 7%.

336
Thng thng trn bnh i tho ng c bin chng thn iu tr gi ng huyt
n nh kh khn hn so vi khng c bin chng thn.
+ iu tr chng tng huyt p c th d phng bnh thn do i tho ng hoc lm
chm tin trin ca n. bnh i tho ng typ 2 nhng thucc ch th th
angiotensine II lm gim nguy c prtin niu i th v suy thn mn. bnh nhn i
tho ng typ 1, iu tr thuc c ch men chuyn thng thng lm bnh thng
huyt p cng c th c tc dng tng t.
+ Ngng ht thuc l lm gim 30% nguy c xut hin v nng ca microalbumin
niu trong c 2 th ca i tho ng.
2. iu tr bnh thn i tho ng khi khng nh.
- i vi tt c cc giai on ca ca bnh thn i tho ng, mc tiu ca iu
tr l kim sot c chuyn ho bng tit thc v liu php Insuline.Nhm thuc
Biguanide l chng ch nh trong trng hp suy thn v nhng Sulfamide h
ng huyt khng c k n na ngay khi H s thanh lc cratinin di 30
ml/pht (nguy c h ng huyt vi Sulfamide v nhim toan vi Biguanide)
- nhng bnh i tho ng typ 1 cc thuc c ch men chuyn c ch nh
(k c khong 25% ngi c huyt p bnh thng) v c bng chng v hiu qu
cc thuc ny trong vic lm chm tin trin ca bnh thn i tho ng typ1.
-Trong bnh thn i tho ng typ 2, nhng cht c ch trn th th angioten
sine II (Losartan, Irbesartan) lm gim tc tin trin ca bnh thn.
- Nhng lu khi cho thuc c ch men chuyn v nhng cht c ch trn th th
angiotensine II
+ Nghin cu hp ng mch thn nhng bnh nhn i tho ng typ 2
+ Kim tra u n cc xt nghim sinh hc, trong lu n kali mu v cratinin
mu.
- Mc tiu v huyt p l tng l 130/80 mm Hg hoc ngay c 125/75 mmHg nu
prtin niu trn 1g/24 gi, vi thuc c ch men chuyn hoc c ch th th
angiotensine II.
- t c huyt p trong gii hn bnh thng nhng bnh thn i tho
ng cn thit phi kt hp 2, 3 thm ch 4 loi thuc h huyt p.Thuc li tiu
thng kt hp vi thuc c ch men chuyn hoc c ch th th angiotensine II v
n lm tng tc dng h huyt p v chng prtin niu. Mt ch hn ch mui
va phi (6g/ ngy) c yu cu km theo khi iu tri thuc h huyt p.
- Khi s dng khu phn n nhiu prtin c tc dng lm tng prtin niu v nh
hng n chc nng thn.Khu phn khong 0,8g prtin/kg/ngy l cn thit
c p dng. Trong thc t nguy c suy dinh dng xut hin nu khng c
theo di tit thc cn thn.
- Nhng yu t nguy c trn mch mu cn phi ch v nhng bin chng tim
mch gia tng trn i tng bnh nhn ny.
3. iu tr khi suy thn mn giai on cui.
- p dng bin php iu tr lc mu thng sm hn so vi nhng suy thn mn
khng phi do i tho ng (khi h s thanh lc cratinin tnh bng cockcroft
khong 15 ml/ pht).

337
- V l do tin trin nhanh ca bnh thn v nhng bin chng trn mch mu ngoai
bin (calci ho ng mch), vic to ng mch mu lc mu (to l d ng
tnh mch) phi c lm sm hn (khi h s thanh lc cratinin tnh bng cockcroft
khong 20 -25 ml/ pht).
- Nhn chung, nhng bnh thn i tho ng iu tr bng lc mu ngoi thn
hoc ghp thn c tin lng xu hn so vi nhng bmh nhn khng phi i tho
ng, ch yu v l do bin chng tim mch.
- Tin lng sng l xu nhng bnh nhn c suy thn mn giai on cui do
bnh thn i tho ng v nhng bin chng khc km theo nh tim mch, nhim
trng... Mun d phng nhng bin chng ny cn phi can thip giai on cn
sm vo cc yu t nguy c nh tng huyt p, nc mui, thiu mu, calci ho
mch mu v tng lipid mu...
- Ghp thn: Cn lu n ngi tr v c th ghp i (thn, tu) cng lc.
- Lc mu chu k: C nhng kh khn trong to l d ng-tnh mch, v bn thn
bnh l trn mch mu ca bnh i tho ng lm cc l d ng tnh mch d
hng, khng hot ng c.
- Lc mng bng: c p dng trong cc trng hp lc mu gp tr ngi.

338

BNH THN BM SINH V DI TRUYN

Mc tiu
1. Trnh by c nguyn nhn, c ch sinh bnh thn a nang ngi ln.
2. Tp hp c cc triu chng lm sng, cn lm sng bnh thn a nang
ngi ln.
3. Trnh by c cc bnh ng thn v cu thn di truyn.
4. iu tr c triu chng, bin chng ca thn a nang.
Ni dung

I.I CNG
Bnh thn bm sinh v di truyn thng biu hin nhng ngi tr tui, trong s
c mt s loi bnh rt him gp. Trong nhm bnh ny thng c chia ra:
- Nhng bnh nang thn v nhng bnh gim sn thn.
- Nhng bnh ng thn di truyn.
- Nhng bnh thn ngun gc chuyn ho.
- Nhng bnh cu thn di truyn.

II. NHNG BNH NANG THN

y l mt nhm bnh thn m c im chung l tn ti nhng nang thn. Bao
gm:
- Thn a nang di truyn theo kiu gen tri (Thn a nang ngi ln)
- Thn a nang di truyn theo kiu gen ln (Thn a nang tr em): t gp, thng
c pht hin ngay sau sinh hoc trc 10 tui. Tin lng rt xu, t khi sng
c n tui thanh nin.
- Nhng nang tu thn: bao gm dn phnh ng trc i thn v phc hp
nhng bnh l nang tu thn.
1. Thn a nang ngi ln
y l loi bnh nang thn gp nhiu nht so vi cc loi khc.
1.1. Dch t hc
Theo P. Barjon t l mc thn a nang ngi ln l khong 1/1250 dn.
cc trung tm lc mu v ghp thn ca cc nc Chu u, Hoa K thn a nang
chim t l 10% trong cc nguyn nhn gy suy thn mn giai on cui.
Vit Nam cha c thng k y nhng nhn chung th tn sut khng ln so
vi cc dng bnh khc.
1.2. Nguyn nhn v c ch sinh bnh
Nguyn nhn v c ch sinh bnh ca thn a nang cho n nay c nhiu im
cha c hiu r. Cn nhc li rng trong thi k phi thai thn c pht trin
qua ba hnh thi ni tip nhau: u tin l Pronephros n Mesonephron v cui
cng l Metanephros. S hnh thnh v hon chnh b my thn tit niu ny c mt
m di truyn nht nh.

339
Furgusson nhn xt rng bnh thn a nang di truyn ngang nhau cho c hai gii
nam v n theo kiu gen thn tri mang n. Dalgard nghin cu ph h 284 bnh
nhn v gia nh khng nh tnh di truyn ca thn a nang.
Cc tc gi Frances A Flinter, Frederic L.Loe v Satish Kathpalial chng minh
rng bnh thn a nang ngi ln tnh di truyn c lin kt trong hu ht cc
gia nh qua phc h gen alpha globulin v gen phosphoglyxeral kinase trn nhnh
ngn ca nhiu sc th 16. Tn sut biu hin ca gen l 100% tui 80 tr ln, c
ngha ngi c bn cht di truyn thn a nang nu sng c t 80 tui tr ln
th kh nng b thn a nang l 100%. Nguyn nhn g dn n ri lon di truyn
th cha bit r.
V c ch hnh thnh nang vn cn bn ci. Nhng ngi ta cng bit chc rng
cc nang ny hnh thnh t nhng thnh phn ca nphron nht l ng gp v quai
Henle. Hai bt thng c th gii thch s hnh thnh nang l:
- C nhng tn thng mng y ng thn, iu ny lm dn ng thn.
- Tng sn cc t bo ng dn n tc nghn tng phn trong lng ng thn.
1.3. Gii phu bnh
Tn thng thn thng c hai bn. Thn gia tng kch thc dn, trng lng ca
1 thn c a nang c th nng t 2000 n 4000g. Trong thn c nhiu nang, ln
nh khng u nhau, ng knh t 0,3 - 0,5 cm.
Cc nang thn cha dch khng mu hoc c mu vng rm, mu nu en c khi c
mu khi c xut huyt trong nang hoc di dng dch keo c.
Nhng thng tn ngoi thn c th gp km trong thn a nang gm: gan a nang
(30%), t gp hn l nang lch, bung trng, tu... Nhng tn thng v mch
mu cng c ghi nhn trong 10 n 20% cu thn a nang bao gm: phnh ng
mch ni s, phnh ng mch ch. Nhng bt thng tim c th gp km theo l
sa van 2 l trong 1/4 trng hp, h van 2 l, van 3 l hoc van ng mch ch.
1.4. Lm sng v cn lm sng
Tuy l mt bnh bm sinh v di truyn nhng thn a nang ngi ln thng
c pht hin tui trn di 40. i lc c pht hin mt cch tnh c qua xt
nghim siu m.
1.4.1.Lm sng
Bnh khng c triu chng lm sng trong mt thi gian di. L do khin bnh nhn
i khm bnh ca bnh thn a nang c th l: cn au qun thn, au tc bng
kh chu, bnh nhn t s thy khi u bng, tiu mu, tng huyt p, i khi bnh
nhn n khm ln u tin nhng l cc triu chng ca suy thn cp hoc suy
thn mn. Triu chng lm sng khi bnh r bao gm:
- Bng to ln, tc bng kh chu.
- au vng hng, tht lng.
- i ra mu: khi bnh thn a nang c si hay khi chn thng, bi nhim nang.
- Tng huyt p: gp 75% trng hp.
- Thn ln khi khm, c tnh cht l b mt g gh, nhiu mi, thn ln thng c
hai bn nhng khng cn xng.

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Ngoi ra cn c nhng biu hin lm sng khc thng kt hp l
- Nang gan: 30%
- Nang lch, tu, bung trng, phi...
- H van 2 l, 3 l, van ng mch ch
- Tai bin mch mu no...
1.4.2. Xt nghim cn lm sng
- Nhm xt nghim khng nh chn on:
+ Siu m thn: l bin php hu hiu nht pht hin thn a nang. C th pht
hin c c nhng nang ng knh nh hn 0,5cm. y l k thut gip chn
on sm bnh thn a nang.
+ Chp ct lp vi tnh (CT Scanne): tn km hn siu m nhiu
+ Chp nhum thn cn quang bng ng tnh mch (UIV): C th pht hin thn
to. i thn b ko di thnh hnh kiu chn nhn c khi ch 1,2 i thn b ko di.
Gc i thn vn sc ch t vt khi c vim mn tnh. Cc i ln cng b chn
ln, cht hp, ko di.
+ Chp bm hi sau phc mc: pht hin c thn ln, mt thn khng u, c
nhiu y g gh thnh mi. Hin nay t s dng.
- Nhng xt nghim khc:
+ Cng thc mu: C hin tng tng tit Erythropoietin nn t gp thiu mu ngay
c khi suy thn mn.
+Prtin niu thng c nhng khng cao.
+Nc tiu c hng cu, bch cu khi c bin chng tiu mu, nhim trng niu.
+X quang thn khng chun b: 10% c si thn tit niu.
+ Chc nng thn: Gim khi c suy thn.
1.5. Chn on bnh thn a nang ngi ln
1.5.1. Nhng tnh hung dn n chn on
- C a: trung nin (him khi ngi cao tui)
- Nhng bin chng ca bnh
+ Nng tc vng tht lng.
+ au tht lng
+ i mu i th.
+ Cn au qun thn
+ Nhim trng nang
- Hoc pht hin mt cch tnh c
+ Khi khm mt cch h thng
+ Khi hi tin s v gia nh.
- i khi qua nhng biu hin ngoi thn (v d: nang gan).

341
1.5.2. Nhng tiu chun chn on
Chn on da trn siu m thn. Siu m thn thy thn ln c hai bn vi nhiu
nang ca hai bn thn. Cn lu nhy ca siu m trong pht hin nang tu
thuc vo tui ca ngi b bnh thn a nang n khm.
Theo tc gi Ravine ngh nhng tiu chun chn on thn a nang trong khung
cnh iu tra gia nh ca mt thnh vin trong gia nh c chn on thn
a nang
Bng 1: Chn on thn a nang theo Ravine
Tui

Tiu chun siu m

Di 30 tui

t nht 2 nang ti thn (1 hoc 2 bn)

T 30 n di 60 tui

t nht 2 nang trong mi thn

Trn 60 tui

t nht 4 nang trong mi thn

1.5.3. Chn on gin bit

Thn a nang ngi ln l nhng bnh nang thn di truyn thng gp nht
ngi ln. Bnh ny chim khong 10% nguyn nhn gy suy thn mn giai on
cui cc nc chu u. Khi chn on cn phn bit vi cc bnh nang thn khc
theo bng di y
Bng 2: Cc bnh nang thn thng gp
Nhng nang thn
Loi

Tui trung bnh

lc chn on

Tui b suy thn mn

Tn sut

+ Theo gen tri

30-40

> 50

1/1.000

+ Theo gen ln

0-10

0-10

1/40.000

- Nhng nang vng tu

thn

< 30

< 20

- Nang n

Ngi ln

Khng suy thn mn

50%

- Thn bt bin

Ngi ln

Khng suy thn mn

50 tui

1/5.000

Di truyn:
- Thn a nang:

Khng di truyn:

- Nhng nang thn mc phi Bnh

sau khi b suy thn mn mu
lc mu chu k

nhn

lc

2. Nhng nang tu thn

2.1. Bnh bt bin tu thn
L bnh thng gp trong cc bnh nang tu thn. Theo Gardener t l c th t
1/500 n 1/2000 dn v chim 1/ 200 bnh nhn c bnh ng tit niu. Vit
Nam cha pht hin c.
Thn khng to, ch 30% l to hn bnh thng

342
Nang thn pht trin do phnh gin ng gp v nm vng nm thn hoc vng
thp Malpighi tu thn. Nang c c hai bn nhng cng c trng hp ch b mt
bn. Nang cha dch c nhiu lng ng calci nn bin chng thng gp nhiu
nht l si thn, tit niu.
2.2. Bnh x nang tu thn
L mt loi bnh thn c nhiu nang c hai bn nhng thn khng to ln m li b co
nh, x so. Triu chng lm sng l i m, i nhiu, kht, t trng nc tiu
thp do c vim k thn. Gim kh nng c c ca thn l triu chng xut hin
sm nht. Tng huyt p l t gp. C trng hp c biu hin tc , c trng
hp kt hp vim vng mc sc t. Triu chng cn lm sng nh i mu, protein
niu, tr niu, bch cu niu, vi khun niu l t gp. Khi c lp i lp li nhng ri
lon v xt nghim nc tiu th cn tm nguyn nhn khc hn l x nang tu thn.
Nang thn trong x nang tu thn khng c v thn, c i xng c hai bn v
pht trin t ng gp v quai Henle. Nang ch khu tr thn, khng c kt hp nang
c quan khc. Khong 50% trng hp c biu hin di truyn kiu gen ln. C
trng hp c di truyn kiu gen tri. Do x nang tu thn c rt nhiu bin th
m nhiu tc gi t tiu l phc hp nang tu thn ch nhm bnh ny.
3. Cc bnh nang thn khc
3.1. Thn nang n
Nang nm v thn, mt nang n c hoc nhiu nang n. Nang nh hn ra
pha trc b mt ca thn. Nang thng l b cha dch trong hoc mu vng rm,
thnh phn ging dch lc cu thn.Bnh thng gp ngi c tui nn d nhm
vi thn a nang. Tuy nhin bnh t c biu hin lm sng v c pht hin thng
l ngu nhin qua chp X quang v siu m bng v nhng l do khc. Khi cn chn
on phn bit c th chc ht dch nang thn. Ung th nu c th trong dch c t
bo ung th hoc mu.
3.2. Bnh thn nhiu nang bm sinh
Bnh thn nhiu nang bm sinh thuc nhm lon sn thn, nang tt c cc la
tui, l hu qu ca s ri lon c ch sinh thn lm cho ton b, mt phn hoc
nhiu ca mt hoc c hai thn bin thnh mt cu trc khng thuc bt c giai
on no ca s hnh thnh thn.
Bnh thn nhiu nang bm sinh khc hn vi thn a nang l khng c tnh cht di
truyn v ch thng b mt bn. Tn sut khng ln cho nn khng c t liu. Pht
hin c c tr em trong gia nh cng b. Bn cnh nang c nhng m t chc
thn bnh thng, t chc m bit ho khng y , mt s ng thn c biu m
khng in hnh, c nhng c t chc m, sn v t chc to huyt. Chn on
pht hin. Chn on xc nh nh chp ng mch thn. Vng nang thn l khng
c chc nng.
V iu tr th cn kt hp ct thn khi c chn thng chy mu, nhim khun ti
pht. Tin lng ngi ln l tt, ch b c mt bn.
3.3. Thn a nang mc phi
L mt bnh cnh mi c m t trong nhng nm gn y v xut hin ch yu
l nhng bnh nhn c lc mu thn nhn to chu k trn 3 nm. Bnh nhn
khng c tin s thn a nang v mi xut hin trong qu trnh lc thn nhn to.

343
Nang c th b v gy chy mu t ngt. C th pht hin ung th. T l mc phi
trong qu trnh lc thn nhn to nhiu ngy l 30 - 50%.

III. NHNG BNH NG THN DI TRUYN

y l nhm bnh c tn ti nhng bt thng ng thn lm gim chc nng ti
hp thu hoc bi tit ca ng thn. Thng gp la tui nh: s sinh, tr em. Bao
gm:
1. Nhng bt thng v vn chuyn phosphate ti thn
Di truyn qua nhim sc th. Nhng triu chng chnh l ci xng hoc nhuyn
xng, gim phosphat mu v tng phosphate niu, canxi mu bnh thng, canxi
niu bnh thng hoc gim.
2. Nhng bt thng v vn chuyn nhng acide amin
Bao gm bnh cystin niu v bnh Hartnup.
-Bnh Cystin niu: c trng vi bi tit nhiu nhng acid amin lysin, arginine,
ornithine, cystin nhng ti hp thu ng thn l bnh thng. L bnh di truyn theo
gen ln. Trong cc acid amin k trn ch c cystin l c th b di dng kt tinh
dn n si.
-Bnh Harnup:L bnh l bi tit nhiu acid amin loi mono-amino mono
carboxylique (ch yu l phnylalamin v tryptophane). Di truyn theo gen ln. C
th gy nn nhng thng tn da dng Pellagroid, nhng biu hin thn kinh
(mt iu ho tiu no), gim tr nh.
3. Nhng bt thng ca vn chuyn glucose, i ng thn.
ng niu nhiu (5 n 100g/ngy) nhng khng tng ng mu. Nghim php
dung np glucose bnh thng. Tin trin thng lnh tnh. y l mt bnh di
truyn theo kiu gen tri hoc ln. Thng tn ng thn l phc tp bao gm gim
kh nng vn chuyn glucose ng ln gn hoc gim ngng vn chuyn.
4. i tho nht thn.
L mt ri lon c trng vi mt tnh nhy cm ca nhng t bo ng thn vi tc
ng ca arginine vasopressine (ni sinh hoc ngoi sinh). Ri lon ny c th mc
phi hoc di truyn gn lin vi mhim sc th X.
5. Nhim toan ng thn
L bnh l khng c kh nng thit lp chnh (gradient) bnh thng gia mu v
nc tiu (toan ho do ng ln xa) hoc do mt nhiu bicarbonat (toan ho ng
ln gn).
6. Hi chng Fanconi
y l mt tp hp nhiu bt thng ca ng ln gn, lin quan n acid amin,
Glucose, phtpht, bicarbonat, acid urique, Kali.Triu chng bao gm ln hoc bnh
nhuyn xng, hoc km pht trin tr em, toan chuyn ho, h kali mu.
Hi chng ny c th th pht sau nhng ri lon chuyn ho (Bnh Cystinose,
Galactose, ri lon dung np Fructose, Glycogenose, Bnh Wilson) hoc v cn v
i khi c tnh gia nh.

IV NHNG BNH CU THN DI TRUYN.

1.Hi chng Alport

344
Gm bnh l cu thn di truyn km vi ic. L bnh l di truyn di truyn theo gen
tri, gn lin vi nhim sc th X, i khi lin quan vi gii tnh (gp nhiu nam
gii). Chim 5% nguyn nhn suy thn mn giai on cui chy thn nhn to cc
nc u M. Bnh thng xut hin tui 6 tu (70% trng hp), vi triu
chng i mu i th, ti pht nhiu ln hoc di dng i prtin n c hoc
hi chng thn h (25%). T 30 n 50% c km vi ic.
2.Hi chng Fabry
L bnh l di truyn gn lin vi nhim sc th X, do thiu ht men alpha galactosidase n tch lu nhng glycophingolipide trung tnh. Tn thng thn
c th hin bng prtin niu, i mu vi th, thng dn n suy thn mn giai
on cui tui50.

V. IU TR
Trong khun kh bi ny ch gii thiu iu tr v phng bnh thn a nang ngi
ln.
iu tr bnh thn a nang.
Khng c iu tr c hiu Ch yu l iu tr cc bin chng v tc ng vo nhng
yu t nguy c nu c ca bnh.
V phng din ngoi khoa vic chc ht nang v ct b thn a nang ch l nhng
trng hp c bit.
Trong iu tr thn a nang trc khi suy thn mn cn ch
- Khng ch huyt p tt
a huyt p ngi bnh xung di hoc bng 130/85 mmHg. Phn ln cc thuc
h huyt p l c hiu qu, tuy nhin ba nhm thuc h huyt p c chn la
trong bnh thn a nang l: c ch men chuyn, li tiu, c ch bta. Nh cc bnh
thn khc, kim tra chc nng thn u n cn thc hin khi s dng nhm thuc
c ch men chuyn.
- Chng mt nc, ri lon in gii
Phi thn trng khi ch nh dng li tiu trong thn a nang v c th gy mt nc,
tru mch, mt nhiu natri, kali.
- Nu c i mu i th th cn tm nguyn nhn loi b nguyn nhn.
- X tr si thn tit niu nu c.
- iu tr kp thi cc t nhim khun tit niu, y l yu t quan trng thc y
nhanh qu trnh suy thn.
- iu tr ri lon Lipide mu nu c.
- Bin chng ca thn a nang n n suy thn mn giai on cui ph thuc vo
tui v cc yu t nguy c:
+Suy thn mn do thn a nang ph thuc vo tui
Bng 3: La tui v kh nng suy thn mn trong bnh thn a nang
Tui

Kh nng suy thn mn

40 tui

2%

40 < tui 50

20 -25%

345
50 < tui 65

40%

Tui > 65

50 - 70%

+ Sau y l nhng yu t c gi l yu t nguy c dn n suy thn mn ca

bnh thn a nang:
* Chn on sm.
* Nam gii.
* Gne PKD1.
* Tng huyt p.
* Tng kch thc thn.
Khi thn a nang c bin chng suy thn mn giai on cui. iu tr thay th
thn suy c cc iu lu :
-Lc mng bng cn trnh v thn a nang c thn rt ln lm kh khn cho k thut
ny.
- Khi ghp thn cn phu thut ly b thn a nang trc kho ghp v l do thn a
nang c th chn p vo thn c ghp.
2. Phng bnh thn a nang
V phng bnh trong thn a nang th quan trng nht l pht hin sm, c bin
php ko di i sng cho bnh nhn v a s bnh nhn n tui 50 l c suy thn
nng.
i vi cc gia nh c ngi b bnh thn a nang. Cn khm bnh v lm siu
m hng lot cho cc thnh vin trong gia nh k c tr em v ngi ln. Siu m
c th pht hin a nang trc khi c biu hin lm sng. Cn ch kt hp pht
hin gan a nang v 30% bnh nhn c gan thn a nang.
Khi pht hin c thn a nang th cn theo di v iu tr kp thi cc bin chng
nh tng huyt p, si thn v nht l nhim khun tit niu.
i vi cc thy thuc thc hnh cn ch khi bnh nhn n khm vi cc triu
chng i mu, tng huyt p, a hng cu, thn ln, suy thn... pht hin sm
bnh thn a nang.

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BNH L NG MCH THN

Mc tiu
1. Nm c phn loi cc bnh l ng mch thn.
2. M t nguyn nhn, c ch sinh bnh ca bnh l ng mch thn.
3. Tp hp c cc triu chng lm sng ca bnh l ng mch thn.
4. Phn tch gi tr ca cc xt nghim cn lm sng trong chn on bnh l
ng mch thn.
5. Trnh by c cc bin php iu tr bnh ng mch thn.
Ni dung

I. I CNG
Bnh l ng mch thn bao gm cc tn thng nh hng n ng mch thn,
c th ng mch thn c ln, cng c th mc c va v nh. Bnh c th
l nguyn pht (tn thng bm sinh) hoc th pht sau mt ri lon khc. Din tin
ca bnh ng mch thn c th cp tnh hoc mn tnh. Biu hin ch yu trn lm
sng ca bnh l ng mch thn l tng huyt p. Chn on xc nh vn cn
phi da vo cc xt nghim cn lm sng, nht l chp ng mch thn.
Tng huyt p do bnh l ng mch thn l loi tng huyt p th pht. T l
mc bnh ny vn cn kh xc nh bi v khng phi tt c nhng bnh l c
thng tn ng mch thn u gy nn tng huyt p. Trong qun th tng huyt
p khng chn lc, nguyn nhn do bnh l ng mch thn ch chim di 1%.

II. PHN LOI

Bnh ng mch thn c th c phn loi theo nguyn nhn, theo din tin bnh
hoc theo v tr tn thng ti ng mch thn. Di y chng ti ch xin cp
n hai cch phn loi thng dng l phn theo nguyn nhn v phn theo din
tin ca bnh.
1. Phn loi theo nguyn nhn
Da theo nguyn nhn, bnh l ng mch thn c chia lm 2 loi
1.1 Cc bnh l bm sinh v ng mch thn
Thng gp ngi tr tui, bao gm
- Teo ng mch thn bm sinh
- Phnh ng mch thn
- Thng ng - tnh mch thn
- Sa thn v sa cung thn
- Hp ng mch ch trn ch xut pht ng mch thn
1.2. Cc bnh l tn thng ng mch thn th pht
- X va ng mch thn
- Lon sn x ho lp c ng mch thn
- Tc ng mch thn

347
- Bnh Takayashu
2. Phn loi theo din tin
Da vo din tin, bnh l ng mch thn c chia lm hai loi nhanh (cp tnh)
hoc chm (mn tnh), ch rng mt s nguyn nhn c th c din tin cp hoc
mn tnh tu thuc tng bi cnh (v d: tc mch do tinh th cholestrol).
2.1 Nhng bnh l ng mch thn cp hoc din tin nhanh
- Nhng bnh vi mch huyt khi (mao mch cu thn v tiu ng mch)
- X ho mch mu thn c tnh (mch mu trong thn ca tt c c)
- Thuyn tc do tinh th cholestrol (ng mch trong thn ca c nh)
- Vim quanh ng mch dng nt i th (ng mch c trung bnh)
- Cn x cng b cp (mch mu trong thn ca tt c c)
2.1 Nhng bnh l ng mch thn din tin theo kiu mn tnh
- Hp ng mch thn
- Thuyn tc do tinh th cholestrol
- X ho mch mu thn lnh tnh
- Hi chng khng phospholipid
- Thi ghp mn ca ghp thn

III. NGUYN NHN CA BNH L NG MCH THN

( y ch cp n cc bnh l hp ng mch thn th pht)
1. X va ng mch thn
L nguyn nhn thng gp nht ca tng huyt p do bnh l mch thn (chim
2/3 trng hp). y l bnh l gp ngi ln sau 45 tui. Thng tn x va
gy hp thng xut hin v tr l xut pht ng mch thn t ng mch ch
hoc on 1/3 u ca ng mch thn. Nhng tn thng x va c th c
tm thy nhng ng mch khc nh ng mch cc chi, ng mch vnh, ng
mch cnh...
Tin trin ca tn thng x va dn n hp ng mch thn gp trong khong
50% trng hp, trong gn 20% l tc nghn hon ton ng mch thn.
2. Lon sn x ho lp c ng mch thn
Chim t l 25% trong cc nguyn nhn gy tng huyt p ca bnh l ng mch
thn. Thng gp l lon sn lp o gia ca ng mch. Bnh l ny gp ch
yu l cc ph n tr trc 40 tui. Thng tn trn ng mch thn thng thy
on 2/3 xa gc hoc nhng nhnh phn chia ca ng mch thn, hnh thnh
lin tip nhng on hp v nhng on gin (du hiu chui trng ht trn phim
chp ng mch thn). Thng tn lon sn x ho ny cn c th thy cc ng
mch khc nh ng mch cnh, ng mch chu. Cc loi lon sn khc nh tng
sn ni mc, x ho lon sn xung quanh lp gia l rt him gp.
3. Nhng tn thng mch mu khc

348
C th gp nhng him ng mch thn nh phnh, huyt khi, l d ng - tnh
mch, vim ng mch, chn p t bn ngoi (do khi u bng, u tu thng
thn).

IV. SINH L BNH

Sinh l bnh ca tng huyt p do bnh l ng mch thn c bit qua thc
nghim ch ca Goldblatte vo nm 1934: bng cch tht bt khng hon ton
ng mch thn, gy nn tng huyt p, v tng huyt p ny khng cn na khi m
tht ng mch thn.
ngi c 2 loi hp ng mch thn: hp ng mch thn mt bn vi thn bn
i din bnh thng v hp 2 bn ng mch thn hoc hp ng mch thn mt
bn trn 1 thn c nht.
1. Hp ng mch thn mt bn v thn bn i din bnh thng
Khi mc hp ng mch thn khng nhiu, s gim p lc ti mu thn l va
phi v hot ng thch hp ca h thng rnin - angiotensin s iu chnh nhng ri
lon huyt ng hc ti thn, do vy c th khng c triu chng lm sng.
Khi ng mch thn hp mc nhiu, s b tr trong thn s khng bnh
thng ho c huyt ng ta thn, do vy ti mu thn s gim v kch thch h
thng rnin - angiotensin thng xuyn lm gia tng angiotensin II dn n co tht
cc tiu ng mch chung v gy tng huyt p. Ngoi ra, cn c c ch ca tng
aldosterol th pht v tng gii phng cng nh tng tc dng ca noradrenalin th
pht sau hot ho h thng rnin - angiotensin.
Tng huyt p ch xut hin khi hp mc nhiu, lm gim khu knh ng mch
thn t 70 n 80%.
thn i din khng c hp ng mch, s c s gia tng p lc trong thn a
n tng bi tit natri ca thn ny (gi l natri niu do tng p lc) nhng s tit
rnin ca thn ny th gim nhiu.
thn b hp ng mch, c tng tit rnin, gim bi tit natri, tng lng
Angiotensin II trong thn lm co tht cc tiu ng mch i cu thn (c ch t
iu ho) gp phn vo gi lc cu thn ca thn hp.
Vic s dng cc thuc c ch men chuyn lm ngn cn hnh thnh Angiotensin II
t lm h huyt p ng mch. Nhng i vi thn c hp ng mch th gy ra
mt tnh t iu ho, lc cu thn gim cn i vi thn khng c hp ng mch
th lc cu thn v dng mu qua thn khng thay i hoc gia tng.
Khi hp ng mch thn lu th vic phu thut c th khng cn lm gim huyt
p c na, do c nhng thng tn cc tiu ng mch th pht sau tng
huyt p nhng ni khng hp ng mch.
2. Hp ng mch hai bn hoc hp ng mch thn trn thn c nht
Trong tnh hung ny s gim ti mu ng mch lin quan n tt c thng tn
thn. y khng c thn i din bnh thng gii hn tng huyt p v gia
tng th tch. V tng th tch mu lm gim tit renin, nn tng huyt p ph thuc
mt phn vo s gia tng th tch mu n thn.
Angiotensin II c vai tr rt quan trng trong vic gi chc nng thn. V vy, khi
dng thuc c ch men chuyn gim Angiotensin II c th dn n 1 s gim
trm trng mc lc cu thn v gy suy thn cp.

349
V. BIU HIN LM SNG CA HP NG MCH THN
Biu hin lm sng quan trng nht ca hp ng mch thn l tng huyt p. Vn
c t ra l trc mt bnh nhn c tng huyt p, phi phn bit y l tng
huyt p nguyn pht hay l tng huyt p do hp ng mch thn. Mt s nghin
cu so snh trn s lng ln tng huyt p nguyn pht v tng huyt p do hp
ng mch thn cho thy khng c triu chng quan trng no gip phn bit
rch ri gia hai loi ny.
Tuy nhin, cng c mt vi d kin qua hi bnh, thm khm lm sng v theo di
iu tr bnh nhn tng huyt p m t cho php gi n mt bnh l mch
mu thn gm cc yu t sau:
- Bt u tng huyt p tui di 30 tui hoc trn 55 tui vi tng huyt p
nng.
- Xut hin tng huyt p t ngt hoc tng huyt p nng ln d c iu tr tt.
- Pht hin mt ting thi tm thu vng thng v hoc cnh rn v nht l ting
thi lin tc.
- Pht hin c s suy gim chc nng thn hoc bt thng nc tiu (protein niu,
i mu vi th) trc iu tr tng huyt p.
- Khng c hiu qu khi iu tr bng thuc chn bta, li tiu, dn mch
(hydralazine) v c ch canxi.
- Suy gim chc nng thn khi dng thuc c ch men chuyn.
Trong hp ng mch thn, tr s huyt p thng l rt cao, km vi nhng biu
hin xut tit, ph gai th khi soi dy mt. Nhng tr s huyt p tng t hoc va phi
cng c th thy bnh l hp ng mch thn.

VI. XT NGHIM CN LM SNG

Chn on xc nh bnh l ng mch thn thng da vo chp ng mch thn.
Hin nay vic s dng nhng k thut nh s cho php lm gim lng dn xut
iod cn quang tim vo trong ng mch.
- Siu m Doppler mu ng mch thn: cho php nh gi c v tr hp, mc
hp, s lng ch hp, tnh trng ng mch thn trc v sau ch hp (gin,
phnh, x va,...). y l xt nghim c a chung v khng xm nhp, r tin v
c nhy cng nh c hiu tng i cao.
- Chp thn bng thuc cn quang qua ng tnh mch nh pht vi cc phim
sm thi im pht u tin v pht th nm sau tim thuc thng c s
dng. Gim kch thc thn mt bn, chm bi tit, c s tng nng chm (hnh
nh rt p) l nhng du hiu gi bnh l mch mu thn mt bn nhng t l
phn trm ca dng tnh gi v m tnh gi ca phng php ny kh cao.
- Chp thn bng ng v phng x vi cht DTPA hoc Hippuran nh du cho
php nghin cu s mt cn xng ca lc, phng php ny cng khng c
nhy hn cc phng php khc.
- o hot tnh renin huyt tng trong mu tnh mch ngoi bin: khng phi l mt
xt nghim nh hng v nhy thp (57%) v c hiu cng khng cao (66%).
Rnin huyt tng tng trong 15% trng hp tng huyt p nguyn pht v bnh
thng trong hn 20% trng hp tng huyt p do bnh l ng mch thn.

350
Ni chung hin nay khng c xt nghim khng xm nhp no loi tr chn on
bnh tng huyt p do bnh l mch thn, nu kt qu ca cc xt nghim ny l m
tnh. Nhng du hiu lm sng vn c gi tr gip quyt nh thc hin chp ng
mch thn khng nh tng huyt p do bnh l ng mch thn.
nh lng renin 2 mu mu ca 2 tnh mch thn (t l 1.5) cng l 1 bng
chng c gi tr. Nhng mt kt qu iu tr tt c th t c trong 50 n 75%
trng hp khi t l ny l di 1.5, v vy xt nghim ny cng c nhng hn ch
ca n.
Ngy nay ngi ta cn lm nghin cu chp nhp nhy thn bng DPTA v hoc
Hippuran trc v sau s dng thuc c ch men chuyn. Trong trng hp hp
ng mch thn ghi nhn sau khi s dng thuc c ch men chuyn c ri lon
chc nng bi tit ca thn so vi bn thn lnh.
Trong hp ng mch thn hai bn chn on thng l kh khn. Thng bnh
nhn c 1 tng huyt p rt nng kh kim sot, suy gim chc nng thn l thng
gp. Suy thn cp xy ra khi s dng thuc c ch men chuyn gip gi nhiu n
hp ng mch thn 2 bn, ch c chp ng mch thn mi cho php khng nh
chn on.
Gu D. v cng s nghin cu cc phng php thm d hnh nh ca hp ng
mch thn v c kt lun v nhy cng nh c hiu ca tng phng php
theo bng sau (2002)
Bng 1: NHY V C HIU CA CC PHNG PHP THM D NG
MCH THN:

PHNG PHP

NHY (%)

C HIU (%)

Chp ng mch thn

99

99

Chp cng hng t

97

95

CT-Scanner (c dng Captopril)

93

95

Siu m Doppler ng mch thn

86

93

Chp ng mch nh s (qua tnh

mch)

88

89

UIV phim sm

74

86

Tm li, vic chn on xc nh hp ng mch thn hu nh vn da hon ton

vo cc thm d hnh nh, trong chp ng mch thn vn gi mt vai tr quyt
nh. Lm sng ch mang tnh gi v xt nghim khng xm nhp c a chung
nht cho n nay l siu m Doppler ng mch thn.

VII. IU TR
1. Nhng bin php iu tr p dng trong bnh ng mch thn.
iu tr l tng l cha lnh tng huyt p ng mch bng cch sa cha nhng
thng tn ng mch gy ra t thiu mu thn. S iu chnh, sa cha ny c
th thc hin bi can thip phu thut hoc bi chnh hnh mch mu qua da (nong
ng mch qua da). iu tr thuc hin nay c th bnh thng ho c huyt p
nhng thuc khng tc ng ln c nguyn nhn ca bnh l ng mch thn.
1.1. iu tr thuc

351
Thng s dng thuc c ch men chuyn, kt hp vi thuc li tiu, thuc chn
bta, cc thuc c ch canxi i khi cng c dng.
Tng huyt p thng c kim sot tt bng vic phi hp thuc trong a s cc
trng hp. Ch rng vic dng thuc, c bit l thuc h huyt p nhm c ch
men chuyn c th lm mt tnh t iu ho ca thn, lm gim lc cu thn, cho
nn cn phi kim tra chc nng thn mt cch u n khi dng nhm thuc ny.
Trong trng hp hp ng mch thn 2 bn th nhm thuc c ch men chuyn b
chng ch nh.
1.2. iu tr phu thut
Vi mc ch loi tr tn thng ng mch hoc nhng hu qu thiu mu. C th
can thip bng cch bc tch lp ni mc, bt cu ni ng mch hoc ct trc tip
on tn thng tu theo v tr, mc tn thng cng nh tnh trng suy thn
quyt nh la chn phng php.
1.3. iu tr chnh hnh mch mu qua da
Cho php lm dn ch ng mch b hp. c s dng gn 20 nm nay, ngy
cng c p dng rng ri. u im ca phng php ny l th thut nh nhng,
thi gian hu phu ngn, kt qu rt tt.
Vic la chn bin php iu tr no thch hp cho ngi bnh cn nhc n tui
ca ngi bnh, trm trng v v tr ca ch tc, x va ng mch nhng ni
khc v hu qu nh hng ca tnh trng x va ln cc tng.
Trong trng hp lon sn mch mu thn, thng gp ngi tr, chnh hnh
mch mu hoc phu thut l cc phng php c chn la v thng cho kt
qu tt, cho php cha lnh tng huyt p.
Trong nhng trng hp x va ng mch, phu thut hoc chnh hnh mch mu
cn phi cn nhc k v nhng bin chng, nht l gim chc nng thn c, vic
nh gi chc nng thn cn li l yu t quyt nh cho chn la bin php iu tr.
2. iu tr c th ca tng nguyn nhn
2.1 Nhng bnh vi mch huyt khi.
- iu tr nguyn nhn.
- Dng huyt tng ti trong lc lc huyt tng.
- Liu php corticoid liu cao.
- Tin lng sng ph thuc vo nguyn nhn, t l t vong khong 30 - 40%.
2.2. X ho mch mu thn c tnh.
y l mt iu tr cp cu. Mc ch
- Kim sot huyt p: iu tr thng s dng
+ Nicardipin tnh mch (Loxen) 1 - 10mg/ gi.
+ Labetalol tnh mch (Trandate) 0.5 - 1 mg/ pht.
+ V c ch men chuyn bng ng ung sau khi bnh thng ho th tch.
- Kim sot th tch mu: nh gi th tch mu l cn thit
+ Trong trng hp gim th tch mu; iu chnh nhanh bng dung dch nc mui
sinh l. Chng ch nh dng cc thuc tiu.

352
+ Trong suy tht tri, nn s dng thuc li tiu quai.
Thng thng trong thng u tin chc nng thn b h hng (nng ln do gim
ti mu) v i khi cn lc mu. V sau chc nng thn ci thin dn v c th tr
li bnh thng nu huyt p c ch ng tt (<130/80 mmHg).
2.3. Thuyn tc do tinh th cholestrol
- iu tr triu chng l chnh (ngng chng ng, kim sot huyt p, lc mu).
- Liu php corticoid thngc s dng, n lm gia tng thi gian sng.
- Tin lng ni chung l xu: T vong trn 40% sau 6 thng.
2.4. Vim quanh ng mch dng nt
Vim quanh ng mch dng nt khng gn lin vi vim gan virt: iu tr bng
corticoid i khi cn cyclophoshamid hoc Azathioprine trong nhng th nng.
Trong trng hp c lin quan vi vim gan virt B: iu tr khng virut (Lamivudine)
kt hp vi corticoid.
2.5. X cng b
- Gy thng tn thn cp: Tng huyt p c tnh vi hi chng tn huyt v tng
ur mu
- iu tr cp cu vi h huyt p c bit l c ch men chuyn.
2.6. Hp ng mch thn
- Hp do lon sn si x: chnh hnh mch mu thn qua da l c chn la. Cho
php cha lnh huyt p trong 70 - 90% trng hp. Hp tr li l him.
- Hp do x va: c 2 mc ch iu tr l: kim sot huyt p v bo tn chc nng
thn Sa cha li ng mch thn bng chnh hnh hoc phu thut c ch nh
khi:
+ Thn kch thc > 8 cm pha c hp ng mch.
+ Tng huyt p nng, khng iu tr, vi ph phi, suy thn.
+ Hp trn 75% lng ng mch thn.
+ Hp 2 bn hoc 1 bn trn 1 thn c nht.
2.7. X ho mch mu thn lnh tnh
- Khng c iu tr c hiu, iu tr bao gm
+ iu tr tng huyt p: Cn thit kt hp 2 thuc, trong c mt c ch men
chuyn (bov thn)
+ Sa cha nhng yu t nguy c tim mch.
+ Lm chm tin trin suy thn mn: ch rng iu tr tt tng huyt p v thiu
mu (nu c) l hai yu t chnh gip cho bnh nhn gi c chc nng thn mt
cch ne nh trong thi gian di.
+ iu tr nhng bin chng ca suy thn mn.

353

VIM NG THN CP
Mc tiu
1. Trnh by c nguyn nhn ca vim ng thn cp.
2. M t c c ch sinh bnh ca vim ng thn cp.
3. Tp hp c cc triu chng lm sng, cn lm sng vim ng thn cp.
4. Chn on xc nh, chn on phn bit ca vim ng thn cp
5. Bit cch iu tr vim ng thn cp theo tng giai on.
Ni dung

I. I CNG
Vim ng thn cp l bnh l thng gp gy nn suy thn cp, cn c gi l
hoi t ng thn cp hoc l bnh ng k thn cp. Tn thng ch yu ca bnh l
ny l hoi t lin bo ng thn, l mt bnh l nng v t l t vong cn rt cao nu
khng c x tr mt cch kp thi v c hiu qu.

II. NGUYN NHN

C rt nhiu nguyn nhn gy nn vim ng thn cp nhng tu trung c th chia
lm 3 nhm ln:
1.Hoi t ng thn sau thiu mu.
Tt c nhng nguyn nhn no m lm cho s ti mu thn gim st ko di u
c th lm cho thn thiu mu v gy nn thng tn di dng hoi t ng thn.
Nguyn nhn gim ti mu thn c chia lm 2 nhm:
1.1.Ngun gc trc thn
- Sc gim th tch mu: sau m, sau chn thng, bng, sy no thai, mt nc,
mt mui.
- Sc nhim khun, nhim c.
- Sc tim.
1.2.Ngun gc ti thn
Thng gp nht l do nhng tc dng ngoi ca mt s thuc khi s dng trn
mt vi c a c bit: thuc khng vim khng phi stroids, thuc h huyt p,
thuc c ch men chuyn khi s dng bnh nhn hp ng mch thn hai bn.
2. Hoi t ng thn cp do ng c
C th trc tip ln trn t bo ng thn hoc gin tip ln c ch mch mu v t
gy thiu mu thn.
2.1.Thuc
- Cc thuc khng sinh, nht l nhm Aminosides. Trong nhm ny c nht l
Nomycin, cc loi khc t c hn nh Streptomycine, Kanamycine, Gentamycine.
Cc cphalosporine c vi thn nht l Cfaloridine.
- Cc sn phm iod cn quang.
- Cc thuc chng U: Ciplastine, Cilosporine, Interfron.

354
- Mt s thuc khc nh Phenylbutazone cc thuc gy m (methoxyfluzan).
2.2.Mt vi sc t ni sinh nh huyt sc t (Hb), sc t c (myoglobin)
2.3.Cc ho cht thng dng nh Tetsra Cloruacarbon (CCl4), cn Mtylic.
2.4.c t ca sinh vt:
- Mt c trm, c m, c chp.
- Mt cc.
3. D ng
Cn gi l vim thn k cp d ng (NIA immuuo-allergique) nguyn nhn do thuc
l thng gp: Mthicilline, Pnicilline, khng vim khng phi Stroides, thuc li
tiu, Cimtidine.

III. GII PHU BNH

Tn thng v mt vi th nhiu mc khc nhau v c bit n khng song
song vi mc nng nh ca cc biu hin lm sng. Tn thng bao gm
1. t chc k
Ph n t chc k, xm nhp t bo vim.
2. ng thn
Thng tn ng thn khng ging nhau gia cc on ca ng thn.
- Nh vi lin bo ng thn b dt hoc b dn, nht l ng ln xa.
- Trung bnh vi hoi t cc lin bo ng thn, t bo ng thn mt nguyn sinh cht
v nhn.
- Nng hn hoi t tng on ng thn v c th t tng on ng thn.
Ngoi ra trong lng ng thn cn cha cc tr v xc t bo ng thn, cc sc nh
Hb, sc t mt.
3. cu thn v mch mu
Nhn chung l bnh thng. Trong giai on sm bng k thut min dch hunh
quang c th pht hin fibrin trong lng mao mch cu thn.

IV. C CH SINH BNH

Vim ng thn cp gy nn suy thn cp thng c nhiu c ch tham gia: gim lc
cu thn, tc nghn ng thn, khuch tn ngc tr li dch lc cu thn. Trong 3 c
ch ny th gim lc cu thn l c ch c bn nht.
1. Gim lc cu thn
Mt cch khi qut, gim lc cu thn l hu qu ca 3 c ch chnh sau y:
1.1.Gim dng mu thn
- Hoc do co tiu ng mch n, ngun gc l do tng Angiotensin II (gi thuyt
ca Thurau)
- Hoc do mt tnh t iu ho ti thn do tnh nhy cm ca c vng mao mch gia
tng di tc ng ca cc Catcholamin.
1.2.Gim tnh thm cu thn

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- Do gim din tch lc bi co cc si c gian mch.
- Do gim h s thm ca mng (Kf) th pht sau tc ng ca Angiotension II hoc
ca vasopressine.
1.3.Ti phn b dng mu thn
T vng v sang vng ty do vai tr ca nhng hcmn tc dng mch,
Catcholamin v Angiotensin II, s ti mu c u tin i vi cc nphron c
kh nng ti hp thu mnh.
2. Tc nghn ng thn
Do cc t bo hoi t, cc sc t lm nghn ng thn gy triu chng i t, v niu.
3. Khuch tn ngc tr li dch lc
Hoi t ng thn dn n tng tnh thm ti ch v lm cho mt lng dch lc ca
cu thn c khuch tn tr li theo cc mch mu xung quanh ng thn.

V. LM SNG V CN LM SNG
1. Lm sng
Lm sng ca vim ng thn cp biu hin l mt hi chng suy thn cp i khi
km theo vi bnh cnh ca mt vim gan cp (gp trong bnh nguyn ng c).
Tnh hung pht hin bnh vim ng thn cp rt khc nhau: thng c pht
hin l triu chng thiu, v niu, i khi c pht hin qua mt bin chng nng
nh dch ngoi bo (tng huyt p, ph phi) hoc nhng ri lon nc in gii
khc hoc bnh cnh ca hi chng tng ur mu.
Lm sng tri qua 5 giai on:
1.1.Giai on tn cng thn
Thi gian ca giai on ny ty thuc vo nguyn nhn: cp v t ngt (sc, xut
huyt) hoc chm v ko di (khng sinh c vi thn).
1.2.Giai on thiu, v niu ban u
Xut hin trong 24 n 72 gi sau . Lm sng biu hin:
- dch ngoi bo (tng cn, ph ngoi bin, kh th gng sc)
- ng cc cht azt: du hiu ton thn, ri lon tiu ho, i khi l nhng chm
xut huyt di da.
1.3.Giai on thiu v niu tht s
Thi gian thay i t 7 n 21 ngy. Lm sng ca giai on ny l hi chng tng
ur mu cp in hnh (xem bi Hi chng tng ur mu).
1.4.Giai on i nhiu
Thng xut hin khong tun th ba ca v niu, c khi sm hn, lng nc tiu
tng ln dn. Trong giai on ny i khi cn cn thit phi lc mu, nhng quan
trng hn l b li lng dch, in gii mt.
1.5.Giai on phc hi chc nng thn.
Ur, cratinine mu tr li bnh thng hoc ging vi tr s trc y cha c suy
thn cp.

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Ngoi ra trn lm sng ca vim ng thn cp cng cn lu nhng th vn
c lng nc tiu khng thiu v v niu, c im ca th ny l:
- Chn on thng chm.
- Thng tn thn thng t nng, tin lng thng tt.
- y l th thng gp khi s dng sm li tiu Furosmide v hoc dn mch.
- iu tr lc mu, dinh dng cng ging nh th v niu.
2. Cn lm sng
Ngoi nhng xt nghim tm nguyn nhn cn c nhng xt nghim xc nh suy
thn cp, bao gm:
- Tng ur, cratinin, acide urique mu.
- Ri lon nc in gii: tng Kali mu, h Natri mu, h Calci mu, tng phosphat
mu l nhng ri lon thng gp trong suy thn cp.
- Ri lon toan kim: nhim toan.

VI. CHN ON
1. Chn on xc nh da vo
- Khi pht bnh cp tnh.
- Lm sng vi thiu, v niu lc khi u v c giai on i nhiu sau .
- Xt nghim ur, cratinin, Kali mu tng dn.
2. Chn on phn bit
- Cn phn bit suy thn cp do vim ng thn cp l suy thn cp thc th vi suy
thn cp chc nng do cc nguyn nhn khc (bi suy thn cp).
- Cn phn bit th bnh thiu, v niu v th bo tn nc tiu.
- Cn chn on phn bit gia vim ng thn cp vi cc bnh l khc nh vim
cu thn cp, si tc niu qun.

VII. IU TR
Bao gm iu tr triu chng, bin chng ca vim ng thn cp (tu thuc vo giai
on ca vim ng thn cp p dng c th) v iu tr nguyn nhn
3.1.Trong giai on sm (giai on tn cng thn):
X tr ngay cc nguyn nhn gy vim ng thn cp:Loi b cht c trong nguyn
nhn do ng c.B dch, b mu trong hoi t ng thn cp sau thiu mu,bng
cch:
- iu chnh ngay h huyt p bng cch truyn cc dch keo (albumin, plasma)
hoc mui ng trng.
- Cc thuc tc dng trn mch mu: dopamin liu 3(g/kg/pht ci thin dng
mu thn.
3.2.Giai on i t v niu
Mc ch c bn trong giai on ny l
- Gi cn bng ni mi

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- Hn ch tng Kali mu
- Hn ch tng ur mu
3.2.1 Nc
bnh nhn v niu m bo cn bng m ngha l lng nc vo t hn lng
nc ra. Thng thng cho khong 500ml nc k c n ln ung. Trong nhng
trng hp v niu do mt nc mt mui th phi b dch.
3.2.2 in gii v toan mu
- iu tr tng Kali mu
+ Hn ch a Kali t ngoi vo: rau qu nhiu kali, thuc dch truyn c kali
+ Loi b cc hoi hoi t, chng nhim khun.
+ Li tiu: nhm o thi nc in gii, c bit l kali, c ch nh khi khng c
bng chng c tc nghn sau thn, bt u c th d liu bng Lasix 20mg x 4 ng
tim tnh mch, c th cho liu cao 200mg - 500mg/ 24 gi.Liu rt cao c th c
ch nh nh Furosmide 1000mg/24 gi bng truyn chm qua bm tim in.
Ngoi furosemide c th s dng bumtamide hoc acide etacrynic.
+ Truyn natribicacbonat
C th truyn natribicacbonat 1,4% hoc 4,2% khi ngi bnh c mt lng nc
tiu nht nh (V d 300 - 500ml). C th tim tnh mch natribicacbonat 8,4% nu
mun hn ch lng nc a vo, B Natri bicacbonat gip ci thin toan mu, t
hn ch vic di chuyn kali t ni bo ra ngoi bo.
+ Truyn glucose u trng km insulin tc dng nhanh nhm y kali vo khu vc
ni bo
+ Cho Canxi tim tnh mch chm trong cc trng hp tng kali mu nng, cp
cu (nht l c biu hin tim mch).
+ C th dng cc Rsin trao i ion nh resonium, Kayexalat (30 gam/24 gi)
thi kali qua ng phn
+ Nu kali mu 6,5 mmol/l th cn ch nh lc mu ngoi thn.
3.2.3 iu tr cc ri lon in gii khc
+ Natri v clo: Natri mu h thng l do nc. Tt nht l hn ch nc. Khi
Natri mu h nhiu cn phi b Natri.
+ Canxi: Trong vim ng thn cpt khi c h Canxi mu. Nu c xut hin Ttani do
h Canxi mu c th cho Canxi clorua hoc Canxi gluconate.
3.2.4. iu tr tng ur mu
- Ch n gim m, calo t nht l 35 kcalo/kg / 24 gi, vitamin.
- Cc thuc tng ng ha prtide nh Durabolin 25mg/ngy, Testosteron
25mg/ngy.
- B sung thm vin ketosteril: 1 vin 600mg cho 5 kg cn nng/ ngy.
- Loi b cc nhim khun
- Ch nh lc mu: nn ch nh lc mu sm bng thn nhn to hoc thm phn
mng bng. Ch nh lc mu khi:

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+ Kali mu 6,5 mmol/
+ Ur mu > 35mmol/l
+ Cratinin mu > 600mmol/l.
+ C biu hin toan mu.
3.3.Trong giai on tiu nhiu
giai on ny, tuy i nhiu nhng chc nng thn cha hi phc. Nhng ngy
u ca giai on i nhiu nng ur, cratinin mu cn tng nn iu tr tng ur
mu i khi cn ging nh giai on tiu t v v niu.Trong giai on ny, v tiu
nhiu nn gy mt nc mt in gii. iu tr nhm:
- Tip tc hn ch prtid trong thc n, ch tng prtid khi ur mu gim mc
an ton (10 mmol/l).Cho ch n ung c kali (hoa qu) khi kali mu bnh thng.
-Truyn dch hoc ung chng mt nc, mt in gii. Trong trng hp lng
nc tiu > 3lt/24 gi cn b bng ng truyn tnh mch. Lng dch b tu theo
lng nc tiu. Sau 5 - 7 ngy tiu nhiu c th hn ch dn lng dch truyn v
theo di v lc ny thn bt u chc nng c c.
3.4. Trong giai on hi phc
- Trung bnh sau 4 tun iu tr th chc nng thn bt u hi phc tt v bnh nhn
c th xut vin
- Cn theo di nh k hng thng cho n khi chc nng thn hi phc hon ton.
- Khi ur mu tr v bnh thng th tng dn khu phn prtid, m calo, vitamin
m bo hi phc sc kho tt.
3.5 iu tr nguyn nhn.
Ty thuc vo nguyn nhn gy ra vim ng thn cp.
- iu tr khng sinh trong nguyn nhn nhim khun.
- Loi b cht c trong nguyn nhn ng c.
- Ngng cc thuc khng vim khng phi stroids, thuc c ch men chuyn
Cc thuc khng sinh, Cc sn phm iod cn quang, Cc thuc chng U: Ciplastine,
Cilosporine, Interfron, Phenylbutazone... nu nguyn nhn do thuc.
- iu tri st rt trong st rt i huyt sc t....

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CHNG 5

C XNG KHP
VIM KHP DNG THP
Mc tiu
1. M t c nguyn nhn v c ch sinh bnh ca vim khp dng thp
2. Trnh by c triu chng lm sng v cn lm sng ca vim khp dng thp
3. M t c tiu chun chn on v chn on phn bit.
4. Trnh by c cc phng tin iu tr truyn thng vim khp dng thp
5. M t c cc phng tin iu tr mi.
Ni dung

I. I CNG
1. nh ngha
Vim khp dng thp (VKDT) l mt bnh thp khp mn, t min, ch yu n.
2. Dch t hc
- L bnh thng gp nht trong cc bnh khp. Vit Nam t l mc bnh l
0,5% trong nhn dn v 20% s bnh khp nm iu tr ti bnh vin. Bnh gp
mi ni trn th gii, chim 0,5%-3% dn s ngi ln (theo tc gi Trn Ngc
n, hi thp khp Vit Nam)
- 70 - 80% l n gii v 60 - 70% c tui trn 30.
- Mt s trng hp c tnh cht gia nh.

II. NGUYN NHN V C CH SINH BNH

1. Nguyn nhn: L mt bnh t min vi s tham gia ca nhiu yu t
- Tc nhn gy bnh: c th l vi khun, vi rt, d nguyn ? nhng cha c
xc minh chc chn.
- C a: bnh c lin quan r rt n gii v tui.
- Di truyn: bnh c tnh cht gia nh v 60-70% bnh nhn mang yu t
khng nguyn ph hp t chc HLA-DR4 (trong khi ngi bnh thng l 30%)
- Yu t thun li: sau sang chn, c th suy yu, sinh , lnh m ko di...
2. C ch sinh bnh
Lc u tc nhn gy bnh tc ng nh khng nguyn, n gi vn cha bit l
khng nguyn g, gy bnh trng dng t bo T c khng nguyn kch thch trn
nhng c th cm nhim di truyn trong giai on u ca bnh. Mt tiu nhm t
bo T hot ho trong mng hot dch sn xut nhiu cytokine khc nhau bao
gm: Interferon (IFN-), interleukin 2 (IL2), IL6 v yu t hoi t u (TNF -), c tc
dng gy vim mng hot dch ko di, c trng ca VKDT. Kch thch thm cc t
bo khc trong mng hot dch (bch cu n nhn, t bo B, t bo mng hot dch
ging nguyn bo si), bng cytokine hoc tip xc trc tip vi t bo T hot ho,

356
s dn n giai on bnh th hai ph hu nhiu hn. Cc bch cu n nhn hot
ho v t bo mng hot dch ging nguyn bo si khng ch sn xut cc cytokine
tin vim, khc nhau (c bit l IL.1 v TNF -) v cc yu t tng trng c th
lm phc tp thm tnh trng vim, m cn kch thch s sn xut cc
metalloproteinase ca cht nn v cc protease khc. Chnh nhng tc nhn ny
lm trung gian ph hu cht nn ca m khp c trng ca giai on ph hu trong
VKDT.

III. TRIU CHNG LM SNG

1.Vim khp
1.1. Khi pht: 85% bt u t t, tng dn, 15% t ngt vi cc du vim cp; a
s bng vim mt khp, l mt trong cc khp bn tay (c tay, bn ngn, ngn
gn), gi. Ko di t vi tun n vi thng ri chuyn qua giai on ton pht.
1.2. Ton pht: Vim nhiu khp
- V tr: Sm l cc khp chi, tri xa gc
+ Chi trn: c tay, bn ngn, ngn gn nht l ngn 2 v ngn 3.
+ Chi di: gi, c chn, bn ngn v ngn chn.
Mun l cc khp: khuu, vai, hng, t sng c, thi dng hm, c n.
- Tnh cht: Xu hng lan ra 2 bn v i xng:
+ Sng, au v hn ch vn ng, t nng , c th c nc khp gi.
+ au tng nhiu v m gn sng, cng khp bui sng.
+ Cc ngn tay c hnh thoi, nht l cc ngn 2 v ngn 3.
+ Bin dng khp c trng xut hin chm hn: bn tay gi thi, bn tay lng lc
.
2. Triu chng ngoi khp
2.1. Ton thn: St nh, da xanh, n ng km, gy, ri lon thn kinh thc vt.
2.2. Biu hin cn khp
- Ht di da: ni g ln khi mt da, chc, khng au d: 0,5-2cm thng gp trn
xng tr gn khp khuu, trn xng chy gn khp gi, s lng t mt n vi
ht.
- Da kh teo, ph 1 on chi, hng ban lng bn tay.
- Teo c: r rt vng quanh khp vim, vim gn: hay gp gn Achille.
2.3. Rt him gp trn lm sng:
- Tim: Tn thng c tim kn o, c th c vim mng ngoi tim.
- Phi: Vim mng phi nh, x ph nang.
- Lch: lch to v gim bch cu trong hi chng Felty
- Xng: mt vi, gy t nhin.
Ngoi ra cn c: vim gic mc, vim mng mt, p cc dy thn kinh ngoi bin,
thiu mu nhc sc, ri lon thn kinh thc vt, nhim Amyloid c biu hin ch
yu thn, thng xut hin rt mun.

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IV. CN LM SNG
Gm X quang, du sinh hc v sinh thit
1. X quang: Giai on u thy mt vi vng u xng. Sau l khuyt xng
hay n mn xng phn tip gip vi sn khp, ri hp khe khp. Sau cng l hu
phn sn khp v u xng gy dnh v bin dng khp.
2. Du sinh hc: Gm du vim, ri lon min dch, dch khp.
- Tc lng mu tng, 2 globulin tng, hng cu gim.
- Waaler Rose: Pht hin yu t thp trong huyt thanh. Phn ng dng tnh khi
ngng kt vi pha long huyt thanh bnh nhn t 1/32.
- Dch khp: gim nhy, tng bch cu, t bo hnh nho 10% s t bo dch khp.
t bo hnh nho l nhng bch cu a nhn trung tnh nut nhng phc hp min
dch.
3. Sinh thit: Mng hot dch hay ht di da.
Sinh thit mng hot dch thy nm tn thng: s tng sinh cc hnh lng ca
mng hot dch, tng sinh cc lp ph hnh lng, xut hin nhng m hoi t ging
nh t huyt, tng sinh mch mu tn to, thm nhp nhiu t bo vim quanh cc
mch mu. Khi c t ba tn thng tr ln c th hng n chn on xc nh.
Sinh thit ht di da: gia l mt m hoi t dng t huyt, chung quanh bao
bc bi nhiu t bo Lympho v tng bo.

V. CHN ON
1. Chn on xc nh: Cn phi sm iu tr c kt qu
1.1. Tiu chun ca hi thp hc M 1987: Gm 7 im, trong tiu chun t 1 - 4
phi c thi gian t nht 6 tun, chn on dng tnh cn t nht 4 tiu chun, l
- Cng khp bui sng: ko di t nht 1 gi.
- Sng au t nht 3 nhm khp trong s 14 nhm: ngn tay gn, bn ngn tay, c
tay, khuu, gi, c chn, bn ngn chn (2 bn = 14).
- Sng au 1 trong 3 khp ca bn tay: ngn gn, bn ngn, c tay.
- Sng khp i xng.
- C ht di da.
- Phn ng tm yu t thp huyt thanh dng tnh (Waaler-Rose +).
- Hnh nh X quang in hnh.
1.2. Tuyn c s thiu cn lm sng: chn on c th da vo cc im sau
- Ph n 30-50 tui.
- Vim nhiu khp xa gc chi.
- Khi u t t, tin trin t nht 6 tun.
- au tri v m v cng khp bui sng.
2. Chn on phn bit
- Giai on u (< 6 tun): Cn phn bit vi:

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+ Thp khp cp: da vo tui, tnh cht vim...
+ Thp khp phn ng: sau cc bnh nhim khun, khng i xng.
+ Hi chng Reiter: Vim khp, vim niu o v kt mc mt.
- Giai on sau (> 6 tun): phn bit vi
+ Thoi khp: ln tui, khng c du vim.
+ au khp trong bnh to keo nht l luput ban .
+ Vim ct sng dnh khp: nam gii, au ct sng lng, tht lng cng chu.
+ Bnh Gt: acid uric tng cao trong mu.

VI. IU TR
Kt hp nhiu bin php: Ni, ngoi, vt l, chnh hnh.
1. Th nh
S khp vim t, vn ng gn nh bnh thng (giai on I)
- Aspirine: 1-2g/ngy, chia nhiu ln.
- Chloroquine: 0,2-0,4g/ngy, tc dng c ch men tiu th.
- Thuc dn tc: cy xu h, hy thim, l lt.
- Tp luyn, iu tr vt l, in, siu m, nc sui khong...
2. Th trung bnh
Nhiu khp b vim, vn ng b hn ch (giai on II).
- Ging nh th nh nhng cn thm:
- Dng mt trong cc thuc chng vim nonsteroid: Indomethacine 50100mg/ngy, Diclofenac: 100 - 150mg/ngy; Piroxicam 20mg/ngy.
- C th dng Corticoid liu trung bnh.
3. Th nng
Khng i li c, vn ng cn t hoc mt ht (giai on III).
- Corticoid liu cao: dng ngn hn, bng ung hoc TM.
- Dng mt trong cc liu php: Mui vng: tng liu 1500-2000mg; DPenicilamin: 300mg/ngy; Methotrexate: 7,5-10mg/tun; Cyclophosphamide: 12mg/kg/ngy. Bin php khc nh trn.
4. iu tr mi
Nhng thuc mi c gii thiu sau y iu tr VKDT c th phn thnh 3 loi:
- Thuc c ch Cyclo -oxygnase tp 2 (Cox 2)
- Cc tc nhn sinh hc.
- Thuc chng thp khp lm thay i din tin bnh (DMARD: Disease Modifying
Anti - Rheumatic Drugs).
4.1. Thuc c ch Cox 2
Gn y ngi ta nhn din c t nht l 2 th ng dng ca cyclo
oxygnase (Cox): Cox - 1 l 1 enzyme bn th, c nhiu m v ch yu lin quan

359
n vic sn xut cc prostaglandin cn thit cho qu trnh hng nh ni mi bnh
thng. Tri li, cox -2 l 1 enzyme cm ng c tm thy cc m lnh vi nng
thp, nhng tng ln r rt trong cc m b vim v lin quan n sinh tng hp
PGE2 v tr vim. V cc thuc chng vim khng steroid (AINS) thng thng c
ch vim va c nhiu tc dng ph. Do vy nhng thuc AINS mi c ch u tin
hoc chn lc trn cox-2 th c tc dng chng vim v rt t tc dng ph, l u
im ca cc loi thuc mi.
- MELOXICAM (Mobic): vim 7,5mg v 15mg, ng 15mg.
Liu hng ngy: 15mg/ngy, dng 1 ln trong ngy.
- CELECOXIB (CELEBREX) vim 100mg v 200mg.
Liu hng ngy: 100mg x 2 ln/ngy.
Tc dng ph ca cc thuc trn gm cc tc dng ph chung ca AINS nhng t l
v mc thp hn nhiu so vi cc thuc AINS c in.
Ni chung, cc AINS khng lm chm s tin trin ph hu khp trong VKDT.
4.2. Cc tc nhn sinh hc
S quan tm c tp trung nhiu vo cc tc nhn chng TNF - , 1cytokine vim ch
yu c phng thch bi cc i thc bo mng hot dch, tc ng nh 1 phn t rt
quan trng, ch huy cc loi t bo khc mng hot dch phng thch cc phn t tin
vim v ph hu khp. Hai cht nh th, c cng nhn iu tr VKDT.
- ETANERCEPT: L 1 cht nh trng hp (dimer) gm phn ngoi bo ca 2 th th
TNF ho tan (75kDa) hp nht vi phn Fc trn immuno -globulin G1 (IgG1) ca
ngi. Etanercept gn 1 cch c hiu vi 2 phn t TNF - hoc TNF - tun
hon, nn chn s tng tc ca chng vi th th TNF trn b mt t bo.
+ Ch nh: VKDT t va n nng trn bnh nhn p ng khng y vi 1 hay
nhiu DMARD.
+ Liu lng, cch dng: 25mg tim di da x 2 ln/tun dng trong nhiu thng.
+ Tc dng ph: Phn ng nh ti ch tim.
- INFLIXIMAB: 1 khng th n dng c cu to bi (vng hng nh ca khng
th ngi v cc vng thay i ca chut nhc, c dng bng ng chuyn tnh
mch v kt gn c hiu cc dng TNF - ho tan v xuyn mng.
+ Ch nh: VKDT hot ng
+ Liu lng v cch dng: 10mg/kg chuyn TM liu duy nht, hoc chia ra chuyn
TM 2 ln trong tun.
+ Tc dng ph: b vim phi khi dng liu thp. S bt tin khi dng 2 loi thuc
trn l tim di da v chuyn TM c th hn ch s tun th iu tr.
4.3. Thuc DMARD mi
LEFLUNOMIDE: l 1 dn cht ca isoxazole, l thuc DMARD mi nht c cng
nhn iu tr VKDT. Trong giai on khi pht bnh, t bo T CD4 hot ho, tng
sinh rt nhanh leflunomide c ch s tng sinh bng cch ngn chn t bo T
sn sinh cc pyrimidine cn thit cho s tng hp DNA mi trc khi phn bo.
- Trnh by: vim 100mg v vin 20 mg.

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- Liu lng v cch dng: 3 ngy u: 100mg/ngy.
T ngy th 4 tr i: 10 - 20mg/ngy.
- Tc dng ph: Cc triu chng tiu ho, ni mn ngoi da v rng tc, hi phc
c khi ngng thuc.
ch li lm sng y ca leflunomide khi dng n c iu tr VKDT ch r
rng sau khi dng hng nm.
Phng php s dng DMARD hu hiu
Trong phng php kim t thp truyn thng, DMARD c bt u dng tng i
mun trong qu trnh bnh v sau khng c s dng 1 cch nht qun. M
hnh iu tr hin nay p dng phng php rng ca: Theo , DMARD c s
dng sm sau khi khi pht VKDT v c tip tc sut qu trnh bnh vi mc ch
gi cho tnh trng mt sc ca bnh nhn gn vi mc bnh thng. Khi tc dng
ca thuc DMARD gim i, phc s c thay i bng cch thm 1 thuc mi
vo phc ang dng hoc bng cch thay thuc. Mc ch ca phng php
rng ca l t c s ci thin c bn v kt cc lu di cho bnh nhn VKDT.

361

THOI KHP
Mc tiu
1. Trnh by c nh ngha v dch t hc ca thoi khp.
2. M t c nguyn nhn c ch sinh bnh, v gii phu bnh.
3. Trnh by c triu chng chnh v lm sng, cn lm sng v chn on thoi
khp.
4. Trnh by c cc phng tin iu tr ni khoa v vt l tr liu thoi khp.
Ni dung

I. I CNG
1. nh ngha: L mt bnh mn ca cc khp k c ct sng gy au v bin dng.
2. Dch t hc
- Bnh gp mi dn tc, nam v n mc bnh ngang nhau. Tui cng tng t
l cng cao.
- Bnh vin Bch Mai H Ni: thoi khp chim 10,41% khoa c xng khp
- Php thoi khp chim 28,6% cc bnh xng khp
- M: 80% ngi > 55 tui c du X quang l thoi khp.
Thoi khp theo th t thng gp l: ct sng tht lng, ct sng c, gi,
hng...

II. NGUYN NHN V C CH SINH BNH

1. S lo ho
L nguyn nhn chnh ca thoi khp nguyn pht, xut hin mun thng ngi
ln tui (>60), nhiu v tr, tin trin chm, khng nng. T bo sn gi dn, kh
nng tng hp cc cht to nn si collagen v mucopolysacharide s gim v ri
lon, cht lng sn km dn, tnh chu lc v n hi gim, hn na t bo sn
ngi trng thnh khng c kh nng sinh sn v ti to.
2. Yu t c hc
Ch yu gy thoi khp th pht, thng gp ngi tr (di 40 tui), khu tr mt
vi v tr, nng v tin trin nhanh. Yu t ny th hin bng s tng bt thng lc
nn trn mt khp, gi l hin tng qu ti. Gm:
- Tng cn qu mc do bo ph, tng trng ti do ngh nghip.
- Bin dng khp th pht sau chn thng, vim, u, lon sn lm thay i
hnh thi, tng quan ca khp.
- D tt bm sinh lm thay i din tch nn ca cc mt khp.
3. Yu t khc
- Di truyn: c a gi sm
- Ni tit: mn kinh, i tho ng, long xng do ni tit.
- Chuyn ho: bnh thng phong, bnh da xm nu.
4. Xu hng mi

362
Cc nghin cu mi nht tp trung nghin cu nh hng ca cc yu t tng
trng v ca cytokine i vi hot ng chuyn ho ca t chc sn. Hin nay
ngi ta bit r cc cytokine tin vim c bit l Interleukine 1 (IL-1) v TNF-
c kh nng lm cho cc t bo sn tit ra cht metaloproteinase nh collagenase
v stromeolysine, chng lm tng cng s tiu hu ca sn v kt qu dn n s
hu sn khng hi phc. sn ngi cytokine tc dng ch yu bng cch hn ch
s tng hp hn l kch thch s phn hy cc t bo. Tuy nhin ngi ta vn cha
r yu t no khc c th kch thch t bo sn tng hot ng phn t ca chng
giai on u.

III. GII PHU BNH

Tn thng c bn ca bnh l thoi ho sn khp v a m, thay i phn
xng di sn v mng hot dch.
Sn khp v a m c mu vng nu, m c, kh, mm, mt dn tnh n hi,
mng v nt rn, c th c nhng vt lot, t chc sn b ph hy l c phn
xng di sn, nhn nhy a m mt tnh cng phng m tr nn mm xp.
V vi th thy t bo sn tha tht, cc si Collagen gy, t nhiu ch, cu trc ln
xn, c nhng phn xng di sn x ho dy ln v c cc hc nh, trong cha
cht hot dch. Phn tip gip gia xng v sn mc nhng gai xng.

IV. TRIU CHNG HC

1. Lm sng
1.1. au: au khi vn ng v gim khi ngh ngi, gi l au kiu "c gii".
1.1.1. V tr: khp hoc on ct sng b thoi ho, t lan xa tr khi c chn p r v
dy thn kinh.
1.1.2.Tnh cht: au m , c th c cn cp ct sng xut hin v tng khi vn
ng, thay i t th, gim au v m v khi ngh ngi (khc au do vim). au
khng km sng, nng, , st.
1.1.3. Din bin: Thnh tng t, di ngn tu trng hp, nhng cng c th au
lin tc tng dn (thoi khp th pht), ht t c th ht au, sau ti pht t
khc.
Hn ch vn ng: do au v khi hn ch nhiu thng do cc phn ng co c
km theo. Bnh nhn c th khng lm c mt s ng tc nh quay c, ci st
t, ngi xm..., mt s bnh nhn c du hiu "ph r khp" vo bui sng hoc lc
bt u vn ng.
1.2. Bin dng: do mc gai xng, lch trc hoc thot v mng hot dch.
1.3. Triu chng khc
- Teo c: do t vn ng
- Trn dch khp: do phn ng xung huyt v tit dch mng hot dch, thng
thy khp gi.
- Ting lo xo khi vn ng: t c gi tr v c th thy ngi bnh thng
hoc trong cc bnh khc.
2. X quang
C 3 du hiu c bn

363
2.1. Hp khe khp: hp khng ng u, b khng u, ct sng thy chiu cao
a m gim. Hp nhng khng bao gi dnh khp.
2.2. c xng di sn: phn u xng, hm khp mm t sng c hnh m
m (cn quang nhiu) trong phn xng c thy mt s hc nh sng hn.
2.3. Mc gai xng: phn tip gip gia xng, sn v mng hot dch, mp
ngoi ca thn t sng. Gai xng c hnh th v m (khc cu xng), mt s
mnh gai xng ri ra nm trong khp hay phn mm quanh khp.
Mt s phng php chp c bit c th pht hin sm cc tn thng ca
sn khp v a m nh: chp ct lp, chp ct lp t trng, chp bm thuc cn
quang vo khp, vo a m.
3. Xt nghim khc
- Xt nghim mu v dch khp: khng c g thay i
- Ni soi khp: thy nhng tn thng thoi ho ca sn khp pht hin cc
mnh gai xng ri trong khp.
- Sinh thit mng hot dch: gin bit cc bnh khp khc.

V. CHN ON
1. Chn on xc nh
- Khi bnh: tui, tc nhn c hc, tin s...
- Triu chng lm sng.
- Du hiu X quang.
2. Chn on phn bit
Phn bit vi cc bnh khp do vim: ch yu da vo cc du vim.

VI. IU TR
Cc bin php iu tr hin nay nhm lm gim au v phc hi chc nng khp.
Mc tiu ca iu tr thoi khp vn l ng vin tinh thn bnh nhn, bo tn khp,
luyn tp chng teo c v suy gim chc nng khp. S dng thuc gim au hoc
chng vim nonstroid, tim ti ch corticoid. Phi hp ni khoa, vt l, ngoi khoa.
1. Ni khoa
1.1. Gim au
1.1.1. Aspirine
1-2g/ngy - chia nhiu ln.
Acetaminophene: 1,5 -2 g/ngy.
1.1.2. Chng vim nonstroid
- Diclofenac 100 - 150mg/ngy
- Piroxicam 20mg/ngy
- Meloxicam 15mg/ngy
- Clcoxib 100-200mg/ngy.

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V nhiu bnh nhn mc bnh tui gi nn cn theo di chc nng gan thn trc
v sau khi iu tr bng thuc chng vim nonstroid, c bit i vi nhng bnh
nhn dng thuc ko di.
Khng dng Corticoid ton thn, khi au v sng nhiu c th dng ti ch.
1.2. Tng cng dinh dng sn
Tc dng khng chc chn nh: ni tit t sinh dc (Testosterone),
thuc tng ng ha. Philatop, cao xng...
1.3. Thuc tc dng chm.
1.3.1. Glucosamine sulfate
- L hp cht sulfat ca Glucosamine aminomonosaccharide t nhin.
Glucosamine, mt thnh phn t nhin cu thnh glycosaminoglycan sn khp v
dch khp. C ch tc dng ca Glucosamine sulfat cho n nay cha hon ton
sng t. Cc tc dng nh c ch gc t do superoxide, c ch sinh tng hp nitric
oxide cng l mt cch gii thch tc dng nhanh ca thuc trn cc th nghim lm
sng ngn hn. Tuy nhin trong th nghim lm sng di hn th tc dng ca thuc
c l do bin i chuyn ho ca sn khp bao gm kch thch hot ng ng ha
nh tng tng hp proteoglycan, gim hot ng d ha ca sn khp nh tc dng
trn cc enzyme metalloprotease.
- Trnh by v liu lng: vin 0,25g, gi 1,5g.
Liu hng ngy l 1,5g. Thi gian dng: nhiu nm. Thuc c an ton cao,
cha thy tc dng ph c ghi nhn.
1.3.2. Chondroitine sulfate
Tc dng bng cch c ch cc men tiu sn, nht l men metalloprotase.
- Trnh by di dng vin, liu trung bnh: 3 vin ngy.
- Thi gian dng: t nht 1-2 thng.
1.3.3. Mt s loi thuc ang c th nghim
Bao gm chloroquine, Doxicycline, thuc tng hp glycoaminoglycine hoc
hyaluronate, c th tng cng s phc hi sn hoc gim s hu sn hoc bao
gm c hai.
1.3.4. Liu php thay th cht nhn
Trong thoi khp c gim nng cng nh trng lng phn t ca acide
hyaluronic lm gim nhy ca dich khp. V vy tim vo khp acide hyaluronic
c trng lng phn t cao c tc dng b sung nhn ca dch khp.
- Trnh by di dng sodium hyaluronat (Hyruan) ng 200mg/2,5ml.
- Liu lng v cch dng: ph thuc khp ln, khp nh.
i vi khp gi: Tim vo khp 1 ln 1ng 2,5ml/tun, trong 5 tun lin tip.
Tc dng ph: au nh, cm gic nng khp sau khi tim.
2. Vt l tr liu
- Cc bi tp th dc cho tng v tr thoi khp.
- iu tr bng tay: xoa bp, n huyt, tp vn ng.

365
- Bng nhit: tia hng ngoi, bn nng, parafin.
- Bng nc: nc sui khong, nc nng, bi.
- S dng cc dng c chnh hnh.
Cc phng php iu tr n gin gm iu tr vt l, acetaminophene hay
thuc chng vim nonstroid c tc dng gim au hn 70% bnh nhn thoi khp
giai on sm.
3. Ngoi khoa
Sa li cc d dng khp bng c v khot xng, iu tr thot v a m, lm
cng dnh khp t th c nng, ghp khp nhn to.

VII. PHNG BNH

1. Trong cuc sng hng ngy
- Chng cc t th xu trong sinh hot v lao ng.
- Trnh cc ng tc qu mnh, t ngt, sai t th khi mang, vc...
- Chng bo ph bng ch dinh dng, th dc.
- Kim tra nh k nhng ngi lm ngh lao ng nng pht hin v iu tr
sm.
2. Pht hin cc d tt
Ca xng, khp, ct sng c bin php chnh hnh, nga thoi khp th pht.
3. Kim tra tr em
iu tr sm bnh ci xng, cc tt khp gi: chn cong, i vng kin, bn chn
nga, g vo ct sng.

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BNH GT
Mc tiu
1. Trnh by c chuyn ho ca acid uric v c ch sinh bnh Gt
2. M t c triu chng lm sng v cn lm sng
3. Trnh by c tiu chun chn on.
4. M t c cc bin php iu tr cn gt cp.
5. Trnh by c cc phng tin iu tr hi chng tng acid uric mu
Ni dung

I. I CNG
- Bnh hay gp tng lp ngi c mc sng cao, t l mt s nc chu
u khong 0,5% dn s, nam gp 10 ln so vi n. Vit Nam bnh gp cha
nhiu song trong thp nin gn y thy bnh tng ln r.
- Gt l mt bnh chuyn ho, c trng l c nhng t vim khp cp v c
hin tng lng ng natri urat trong cc t chc, xy ra do tng acid uric trong mu.

II. CHUYN HO CA ACID URIC

Acid uric l sn phm thoi ging ca nucleotid c base l purin. C 3 ngun
cung cp acid uric:
+ Do thoi ging acid nucleic t thc n a vo.
+ Do thoi ging acid nucleic t cc t bo b cht
+ Do tng hp ni sinh v chuyn ho purin trong c th nh cc men c
hiu.
Acid uric c o thi qua nc tiu 450-500 mg/ngy v trong phn
200mg/ngy. Khi qua thn, urat c cu thn lc hon ton, ri ti hp thu gn
hon ton ng ln gn cui cng c ng ln xa bi tit. Trong phn, acid uric
c cc vi khun phn hu.
Nng acid uric trong mu theo hng s ca ngi Vit Nam l 4510mg/l
(208-327 mol/l). Khi nng > 70mg/l (>416,5 mol/l) th c gi l tng acid uric
mu.
Cc nguyn nhn lm tng acid uric mu:
. Tng sn xut acid uric: dng nhiu thc n c cha nhiu purin, tng thoi
ging nucleoprotein t bo, tng tng hp purin ni sinh.
. Gim o thi acid uric niu: gim lc cu thn, gim bi tit ca ng thn.
i khi gim phn hy acid uric do vi khun trong phn.

III. PHN LOI CC HI CHNG TNG ACID URIC MU V BNH GT

1. Hi chng tng acid uric mu v cn v bnh gt nguyn pht
Th ny hay gp nht chim ti 85% cc trng hp, c tnh gia nh v di
truyn do ri lon chuyn ho purin.
2. Hi chng tng acid uric mu v bnh gt ri lon men
Ni chung th ny him gp.

367
3. Hi chng tng acid uric mu th pht
C th xy ra do suy thn, trong mt s bnh mu, bnh ni tit...

IV. C CH SINH BNH

Khi acid uric trong mu tng cao, cc dch u bo ho natri urat v s xy ra
hin tng lng ng urat mt s t chc, c bit l mng hot dch khp, sn
xng, gn, t chc di da, nhu m thn v i b thn...
khp, tng acid uric mu lu ngy dn n hnh thnh cc tphi vi th trong
cc th bo ph mng hot dch, lm lng ng natri urat sn. Cc vi tinh th acid
uric c th xut hin trong dch khp v khi t c mt lng nht nh th s gy
vim khp v l biu hin ca cn gt cp tnh. Trong bnh gt, ti khp s xy ra
mt lot phn ng: cc bch cu tp trung n thc bo lm gii phng cc lysozym,
cc cht ny gy vim; cc vi tinh th cn hot ho yu t Hageman dn n hnh
thnh kallicrein v kinin c vai tr gy vim khp; hot ho cc b th v
plasminogen, dn n hnh thnh cc sn phm cui cng cng c vai tr trong vim
khp.
T khi b tng acid uric mu n cn gt u tin thng phi qua 20 - 30 nm
v ngi ta thy 10 - 40% s bnh nhn gt c cn au qun thn c trc khi vim
khp.

V. LM SNG
Cn gt cp u tin thng xut hin la tui 35-55, t khi trc 25 tui
hoc sau 65 tui. n t xy ra trc tui mn kinh, nam tui cng tr th bnh
cng nng.
iu kin thun li: nhiu khi khng r nhng c th xy ra sau ba n nhiu
tht ru, sau xc cm mnh, sau chn thng k c vi chn thng (i giy cht),
sau nhim khun, dng thuc li tiu nh thiazid, tinh cht gan, Steroid, Vitamine
B12...
1. Cn gt cp tnh
Xut hin t ngt ban m, bnh nhn thc dy v au khp, thng l khp
bn ngn chn ci (60 - 70%): khp sng to, , ph, cng bng, au d di v ngy
cng tng, v chm nh cng rt au; cc khp khc c th b: c chn, gi, bn tay, c
tay, khuu. Him thy khp hng, vai, ct sng. Lc u ch mt khp sau c th b
nhiu khp.
Cn ko di nhiu ngy, thng 5 - 7 ngy ri cc du hiu vim gim dn. Ht
cn khp tr li hon ton bnh thng. Trong cn c th c st va hoc nh, tc
lng mu tng, dch khp thy bch cu khong 5000/mm3 phn ln l a nhn,
di knh hin vi thy nhiu tinh th natri urat. Cn d ti pht khi c iu kin thun
li.
Bn cnh th in hnh, cng c th ti cp: khp vim sng ty d di, au
nhiu v th nh kn o au t d b b qua.
2. Lng ng urat
Hnh thnh cc ht tphi di da v gy bnh khp do urat
2.1. Tphi: Thng xut hin chm, hng chc nm sau cn gt u tin. Khi
xut hin th d tng s lng v khi lng v c th lot. Tphi hay thy sn

368
vnh tai khuu tay, ngn chn ci, gt chn, mu bn chn, gn Achille. Kch thc t
vi milimet n nhiu centimet, hi chc hoc mm, khng di ng do dnh vo nn
xng bn di.
2.2. Bnh khp do urat: Khp b cng, au khi vn ng v lm hn ch vn ng,
khp sng va, khng i xng, cng c th c tphi km theo. Trn X quang thy
hp khe khp, khuyt xng, hnh hc u xng.
3. Biu hin thn
Urat lng ng ri rc t chc k thn, b thn, niu qun.
3.1. Si thn: 10 - 20% cc trng hp gt, iu kin thun li l pH nc tiu qu
toan, nng acid uric cao. Si urat thng nh v khng cn quang.
3.2. Tn thng thn: lc u ch c protein niu, c th c hng cu, bch cu vi
th, sau tin dn n suy thn. Suy thn hay gp th c tphi, tin trin chm v l
nguyn nhn gy t vong.

VI. TIU CHUN CHN ON

1. Tiu chun Rome 1963
- Acid uric mu > 70mg/l (416,5 mol/l)
- C tphi
- C tinh th natri urat trong dch khp hay lng ng urat trong cc t chc khi
soi knh hin vi hay kim tra ho hc.
- Tin s c vim khp r, t nht lc khi u bnh, vim khp xut hin t
ngt, au d di v khi hon ton sau 1 - 2tun.
Ch cn c 2 tiu chun l chn on chc chn.
2. Tiu chun New York 1966
- t nht c 2 t vim cp mt khp chi, c khi bnh t ngt v khi sau 1-2tun.
- C mt t nh trn nhng lin quan n khp bn ngn chn ci
- C tphi
- Dng colchicin bt vim nhiu trong 48 gi.
Ch cn c 2 tiu chun l

VII. IU TR
1. Ch n
- Gim cc cht c nhiu purin nh ph tng ng vt, tht, c, tm, cua... khng n
qu mc. Gim calo nu bo.
- Khng ung ru.
- Ung nhiu nc 2 - 4l/ngy nht l nc c bicarbonat.
2. Thuc
- Mc tiu iu tr
+ iu tr vim khp trong cn gt cp.

369
+ D phng ti pht cn gt, phng lng ng urat trong cc t chc v phng cc
bin chng thng qua iu tr hi chng tng acid uric mu.
2.1. iu tr vim khp trong cn gt cp
Dng thuc chng vim loi nonsteroid:
- Colchicin: tc dng cn tr thc bo ca bch cu i vi cc vi tinh th urat, l
thuc tt nht cho n nay.
Cch dng: 1mg x 3 ln trong ngy u; 1mg x 2 ln trong ngy th 2 v 1mg t
ngy th 3 tr i. Liu duy tr trnh cn ti pht l 0,5 -2mg/ngy (thng 1mg)
ung trong 3 thng.
Tc dng ph: tng nhu ng ng tiu ho d gy i lng; i khi gy c ch ty
xng, rng tc, tn thng ga, c ch h hp...
- Nhiu thuc chng vim nonsteroid c nghin cu s dng, kt qu thy
cng tt tuy cha bng colchicin: Phenylbutazon, Indomethacin, Naproxen,
Ibuprofen, Piroxicam, Diclofenac.
- Corticoid lm gim vim nhanh nhng ht thuc th khp vim tr li, mt khc li
lm tng acid uric mu nn khng c dng.
2.2. iu tr hi chng tng acid uric mu
Ch nh sau khi ct cn gt cp. Thuc dng lu di c th lm cho cc tphi
nh li hoc mt i, cc khp cng hoc tr li bnh thng, hn ch c tin
trin xu ca suy thn, gim cc t vim khp.
2.2.1. Thuc lm tng o thi acid uric niu
Tc dng lm gim ti hp thu ca ng thn thuc d gy si thn nn cn phi
dng liu nh ri tng dn, ng thi cho ung thm nc bicarbonat 2 - 4l/ngy.
Benziodoron (Amplivix 100mg): liu 100 - 300mg/ngy. t tc dng ph i khi c ri
lon tiu ho.
2.2.2. Thuc lm gim sinh tng hp acid uric
Allopurinol (zyloric 100mg): c ch men xanthin-oxydase l men thoi ging
hypoxanthin thnh xanthin v xanthin thnh acid uric v lm gim c sinh tng hp
purin. Thuc dng c khi c suy thn.
Liu: 200 - 300mg/ngy ung 1 ln. t tc dng ph, i khi thy ri lon tiu
ho mn da, au u, chng mt, bun ng...
2.2.3. Thuc lm tiu acid uric trong mu
Uricozym: l men urat-oxydase tc dng lm thoi ging acid uric thnh allantoin,
cht ny c ho tan gp 10 ln so vi acid uric v c d dng o thi ra ngoi
qua thn. Uricozym lm gim acid uric rt mnh.
Tim TM hoc TB 1000-2000 n v/ngy.
Trong qu trnh dng cc thuc lm gim acid uric mu, cn theo di nng acid uric mu
v lng acid uric niu iu chnh liu duy tr, gi nng trong mu < 60 mg/l.

370

VIM CT SNG DNH KHP

Mc tiu
1. M t c nh ngha v cc yu t dch t hc.
2. Trnh by c cc triu chng lm sng v cn lm sng
3. Trnh by c tiu chun chn on v chn on phn bit.
4. Trnh by c cc phng tin iu tr ni khoa, ch nh giai on cp, giai
on sau cp.
5. M t c cc phng php vt l tr liu, iu tr ngoi khoa
Ni dung

I. I CNG
1. nh ngha
Vim ct sng dnh khp (VCSDK) l mt bnh vim khp mn tnh, cha r nguyn
nhn, gp ch yu nam gii tr tui, gy tn thng cc khp gc chi v ct sng,
nhanh chng dn n dnh khp, bin dng v tn ph.
2. Dch t hc
- Gp mi ni trn th gii, nhng t l mc bnh khc nhau do c lin quan n
yu t HLA - B27.
- Vit Nam: VCSDK chim khong 20% s bnh nhn khp iu tr ti BV Bch
Mai, khong 1,5/1000 nhng ngi trn 16 tui.
- Nam gii chim khong 90-95%, tui di 30 chim 80%, 3-10% c tnh cht gia
nh.

II. TRIU CHNG LM SNG

1. Khi pht
- Tui mc bnh: Trn th gii: Gn 70% trc tui 30
Vit Nam: 80% trc tui 30, 60% trc tui 20
- 70% bt t t, 30% bt u t ngt, 75% bt u t khp hng 25% bt u t
ct sng.
- Du hiu ban u: au vng hng, au kiu thn kinh ta, vim gn Achille...
nc ta thng bt u bng vim cc khp chi di (c chn, gi, hng) v au
ct sng tht lng. Cc triu chng ny ko di nhiu thng, nhiu nm.
2. Ton pht
Sng au, hn ch vn ng nhiu khp, teo c, bin dng nhanh. Vim khp
thng c tnh cht i xng, au tng v m.
2.1. Cc khp chi
- Hng: 90% thng bt u mt bn, sau c hai bn.
- Gi: 80% c th c nc.
- Khp c chn: 30%, c th khng li di chng.
- Khp vai: 30%, thng khi khng li di chng.

371
- Cc khp khc: Him gp hn nh khuu, c n, c tay, khng bao gi thy tn
thng cc khp nh bn tay.

372
2.2. Ct sng
Thng xut hin mun hn cc khp chi.
- Ct sng tht lng: 100% au lin tc v m , hn ch vn ng, teo c cnh ct
sng.
- Ct sng lng: thng mun hn vng tht lng, au m , hn ch vn ng, bin
dng (g) hoc cng, teo c.
- Ct sng c: c th mun hn hoc sm hn cc on khc, bin dng hn ch
vn ng.
2.3. Khp cng chu
- L du hiu sm, c hiu (ch yu trn Xquang)
- au vng cng chu, lan xung i
- Teo c mng
- Nghim php gin cnh chu (+)
2.4. Nhng biu hin khc
- St, gy st
- Mt: vim mng mt, vim mng mt th mi
Nc ngoi: chim 20 - 30% trng hp
Vit Nam: khong 3%
- Tim: 5% c ri lon dn truyn, h van ng mch ch
- Cc biu hin him gp khc:
+ X teo da
+ X phi
+ Chn p r thn kinh tu
+ Thot v bn, rn
3. Tin trin
- Xu hng chung: nng dn, dn n dnh khp, bin dng. Nu khng c iu
tr sm, ng, bnh nhn c nhiu t th xu, tn ph.
- Bin chng: suy h hp, tm ph mn, lao phi, lit hai chi do chn p tu v r
thn kinh.
- Tin lng:
+ Xu: Tr tui, vim nhiu khp ngoi vi, st, gy st nhiu.
+ Tt hn: B bnh sau 30 tui, th ct sng l ch yu.
- 50% tin trin lin tc, 10% tin trin nhanh.

III. XT NGHIM V X QUANG

1. Xt nghim
1.1. Xt nghim chung: t c gi tr chn on
- Lng mu tng (90%)

373
- Si huyt tng (80%)
- in di Protein: Albumine gim, Globuline tng
- XN min dch: Waaler Rose, khng th khng nhn, t bo Hargraves phn
ln m tnh v khng c gi tr chn on.
- Cc XN khc t thay i
1.2. Dch khp: thng ly dch khp gi, dch lng v nht, lng Mucin gim, s
lng t bo tng, nht l a nhn trung tnh, Dch khp ch biu hin vim khng
c hiu.
1.3. HLA-B27 (1973): Brewerton (Anh) v Schlosstein (M) nhn thy mi lin h
cht ch gia HLA B27 v bnh VCSDK. Ngi ta thy rng trong VCSDK, 75-95%
bnh nhn mang yu t ny (Vit nam: 87%), trong khi th ngi bnh thng
ch c 4-8% mang HLA B27 (Vit nam 4%).
2. X quang
- Du hiu sm: Vim khp cng chu 2 bn giai on 3 (hp nhiu, c ch
dnh) v giai on 4 (dnh hon ton khng cn ranh gii).
- Giai on mun:
+ Khp hng: hp khe khp, din khp m, khuyt xng, dnh
+ Ct sng: cu xng (thn cy tre), di x (ng ray)

IV. CC TH LM SNG
1. Th theo triu chng
- Th gc chi: 40%, tin lng xu, biu hin vim cc khp hng, gi sm v
nng.
- Th ct sng: Tin trin chm, bt u sau tui 30, di chng nh.
- Th khng au: Ct sng dnh dn, khng au v khng c biu hin vim.
- Th phi hp vi vim khp dng thp: c vim thm cc khp nh bn tay.
2. Th theo c a
- Ph n: nh, kn o
- Tr em di 15 tui: tin trin nhanh, tin lng xu, dnh v bin dng khp
trm trng.
- Ngi gi: nh, d nhm vi thoi ho ct sng.
3. Th bnh theo hnh nh Xquang
- Th khng c du hiu vim khp cng chu
- Th c cu xng pha trc ct sng
- Th c hnh nh ph hu, khuyt xng.

V. NGUYN NHN, C CH BNH SINH V TN THNG GII PHU

BNH
1. Nguyn nhn, c ch bnh sinh

374
Nguyn nhn cha r, khng c bng chng v min dch nhng c bng chng v
vai tr ca nhim khun.

375
C A:
- Nam, tr tui
- HLA_B27 (+)

KHI HN

NHIM KHUN
- Tiu ho
- Sinh dc
- Tit niu

YU T THUN LI:
Chn thng
- V sinh km
- Dinh dng km

VIM KHP PHN NG

VIM CSDK

KHI NHNG HAY TI

PHT

Biu 1: C ch bnh sinh VCSDK

2. Gii phu bnh

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

VI. CHN ON
1. Chn on xc nh
1.1. Tiu chun ca hi thp khp NewYork, 1966
a. Lm sng:
- Tin s hay hin ti au vng tht lng hay lng - tht lng.
- Hn ch vn ng vng tht lng c 3 t th.
- gin lng ngc gim.
b. X quang: Vim khp cng chu 2 bn giai on 3, 4
Chn on xc nh khi c mt tiu chun lm sng v mt tiu chun Xquang.
1.2. p dng thc t Vit Nam:
- Nam gii, tr tui
- au v hn ch vn ng 2 khp hng

376
- au v hn ch vn ng ct sng tht lng.
- Tc lng mu tng cao
- Xquang: Vim khp cng chu 2 bn giai on 2 tr ln
2. Chn on phn bit
2.1. Vi th vim khp gc chi
- Lao khp hng
- Chy mu khp trong Hemophilie
- Vim khp dng thp.
- Goutte
2.2. Th ct sng l ch yu
- Vim ct sng do vi khun (lao, t cu...)
- Tn thng ct sng trong bnh Scheuermann: au, g, khng c biu hin
vim.
- D dng, di chng chn thng gy au v hn ch vn ng.
- Cc bnh c cnh ct sng: vim, chn thng, chy mu
2.3. Mi quan h gia VCSDK vi cc bnh khp c HLA - B27 (+)
- Hi chng Reiter, HLA B27 (+) 80%
- Vim khp vy nn: HLA B27 (+) cao vi th ct sng
- Vim khp mn tnh thiu nin th ct sng: HLA B27 (+) cao

VII. IU TR
1. iu tr ni khoa
1.1. Nhng thuc c tc dng tt
1.1.1. Phenylbutazone
Giai on u tim bp 600mg/ngy, sau chuyn sang ung 150200mg/ngy. Ch tc dng ph ca thuc: mu, tiu ho, da, gi mui nc, tim
mch...
1.1.2. Salazopyrine
Vim 500mg, 2 - 4 vin/ngy, thuc c dng theo c ch chng cc nhim
khun tim tng (tiu ho, sinh dc), tc dng tt 50 - 70% trng hp, ung ko di
nhiu thng.
1.1.3. Cc thuc chng vim khc: Indomethacine, diclofnac, Profnid, Naprosyn.
1.2. Nhng thuc t tc dng
- Aspirine: gim au nhng khng hn ch qu trnh vim
- Stroid: dng ng ton thn v ti ch u t tc dng, khng nn s dng
trong VCSDK.
- Chloroquine: khng c tc dng
- Cc thuc c ch min dch: Khng s dng

377
1.3. Cc phng php khc
Phng php dng tia x mang li nhiu kt qu kh quan.
- Dng quang tuyn X chiu vo ct sng v cc khp vim, mi ln 100r, tng
liu 400-800r.
- Dng ng v phng x: radium 224 tim tnh mch mi ln t 50-200
microgam, tng liu t 1000-1500 microgam.
1.4. Giai on cp
- Ngh ngi
- t chi t th c nng
- Chng vim khng stroid tim, ung: Phenylbutazone, Diclofenac, Profenid
- Gin c: Mydocalin, coltramyl.
1.5. Giai on sau cp
- Tp vn ng tng dn, khng gng sc trnh co cng th pht.
- Chng vim khng Stroid: Phenylbutazone, Diclofnac, Profenid...
- Gin c
- Khng sinh: Salazopyrine 0,5g 2-4 vin/ngy hoc Tetracycline 0,25g 24vin/ngy, khng dng cho bnh nhn di 15 tui.
2. Vt l tr liu
2.1. Cc bin php chng dnh khp, chng t th xu
- Khi bnh ang tin trin, au nhiu, nn khp t th c nng: nm nga
trn nn cng, gi u thp, chn dui thng hi dng. Vi t th ny nu c dnh
khp th bnh nhn vn c th i li c. Tuy nhin ch c c nh trong mt
thi gian ngn, khi qua giai on cp th phi cho vn ng ngay.
- Tp vn ng cng sm cng tt, vn ng mi t th v mi thi gian, y
l bin php tt nht chng dnh khp.
2.2. Cc phng php phc hi chc nng vn ng
- iu tr bng nhit chng hin tng co c
- Dng nc (b bi), nc khong: bnh nhn tp luyn, nht l tp bi mang
li nhiu kt qu.
- Xoa bp, ko lin tc, th dc tr liu.
3. Ngoi khoa
iu tr ngoi khoa c ch nh phc hi chc nng vn ng khi c dnh
khp vi t th xu.
- Ct xng hoc ghp xng chnh li trc ca ct sng, ca chi.
- Thay khp gi bng cht do hoc kim loi: ghp khp hng, khp gi

378

LAO CT SNG
Mc tiu
1. M t c cc yu t dch t, c a
2. Trnh by c triu chng lm sng v cn lm sng ca tng giai on bnh:
khi pht, ton pht v giai on cui.
3. Trnh by c chn on xc nh v chn on phn bit.
4. M t c cc nguyn tc dng thuc chng lao.
5. Trnh by c cc phng php phc hi chc nng, bt ng, ngoi khoa.
Ni dung

I. I CNG
- Bnh c m t ln u tin vo cui th k 19 do mt thy thuc ngoi khoa
ngi Anh tn l Percivall Pott, nn cn gi l bnh Pott.
- Thng th pht nht l sau lao phi, vi khun lao n ct sng bng ng mu.
- Cn gp nhiu cc nc ang pht trin, bnh chim khong 2/3 cc trng hp
lao xng khp. trung tm chn thng chnh hnh TP. HCM nm 1998 c 191
trng hp lao xng khp, trong lao ct sng chim 67,02%.
- Thng gp 20 - 40 tui, nam v n mc bnh ngang nhau.
- Tn thng on lng v tht lng chim hn 90% (t lng 8 n tht lng 2)

II. TRIU CHNG

1. Giai on khi pht
1.1. Du c nng ch yu l au
- au ti ch: au vng ct sng b tn thng, c nh mt v tr khng thay i.
au lin tc c ngy m, tng khi vn ng, i li, gim khi ngh ngi; dng thuc
gim au t hiu qu.
- au kiu r: Do tn thng chn p vo mt vi nhnh ca r thn kinh, au lan
theo ng i ca r v dy thn kinh, c lan xung vai v gy, lng lan theo
dy thn kinh lin sn, tht lng lan theo thn kinh ta. au tng khi ho, ht hi,
rn mnh.
1.2. Thm khm
- Ct sng: Thy mt on ct sng cng , hn ch cc ng tc khng gin ra
khi ci. C 2 bn ct sng c th co cng, g vo vng gai sau ca on tn thng
thy au r.
- Ton thn: C th thy du nhim lao, c tn thng lao phi hp > 50% trng
hp (phi, mng phi, hch...).
1.3. Xquang v xt nghim
- Xquang: Rt quan trng gip chn on.
+ a m hp so vi cc on khc.
+ Thn t sng b nham nh, m phn trc v mt trn.

379
+ Phn mm quanh t sng m m hn.
pht hin sm tn thng cn chp ct lp, ct lp t trng.
- Xt nghim:
+ Cng thc mu: bch cu Lympho tng
+ Tc lng mu tng trong 95% trng hp.
+ Phn ng ni b lao (IDR) dng tnh trong 90% trng hp.
+ Chc kim cnh ct sng ht xt nghim: c th tm thy trc khun lao
(BK).
- Tm tn thng lao phi phi hp: chp phi, tm BK trong m, sinh thit hch.
2. Giai n ton pht
Sau nhiu thng bnh tin trin, tn thng ph hy t sng v a m nhiu gy
bin dng ct sng, p xe v du hiu chn p.
2.1. Lm sng
2.1.1. C nng: au c nh, lin tc, c hi chng r thn kinh thng xuyn v r
rt.
2.1.2. Thm khm
- Li t sng ra sau: nhn nghing thy mt t sng li ra pha sau. Dng ngn tay
mit nh dc theo cc gai sau t di ln trn s thy r du hiu ny.
- p xe lnh: c v tr khc nhau ty v tr tn thng:
+ Ct sng c: Ti p xe i ra pha trc ngay thnh sau hng, c th nhn thy khi
khm hng, hoc i xung theo cc c cnh c n hm thng n.
+ Ct sng lng: Ti p xe c th ra pha sau ni ln ngay di da.
+ Ct sng tht lng: p xe ni ngay di da vng tht lng, vng mng hoc i ra
pha trc xung bn, c khi xung ti kheo chn.
Cc p xe lnh thng mm, khng au, mt s c th v ra chy nc vng v b
u li cc vt lot v l d dai dng khng lin.
- Hi chng chn p: l hu qu xu nht ca bnh, do t sng v a m b ph
hy nhiu, di lch, ln v c xu hng trt ra pha sau chn p vo ty, ui nga.
Ty v tr tn thng, bnh nhn c cc du hiu:
+ Lit t chi: tn thng on c.
+ Lit 2 chn: tn thng on lng, tht lng trn.
+ Hi chng ui nga: tn thng on tht lng di.
Mc t ri lon cm gic, gim c lc n mc nng lit cng, ri lon c
vng.
- Du hiu ton thn: gy, suy mn, st, c th lot mng do nm lu. Tn thng
lao lan rng ra cc b phn khc nh phi, mng phi, hch.
2.2. X quang v xt nghim
- X quang

380
+ a m b ph hy gn nh hon ton.
+ Thn t sng b ph hy nhiu, nht l phn trc to nn hnh chm, di lch
trt ra pha sau.
+ Hnh nh p xe lnh: trn phim chp thng thy hnh m quanh tn thng, c th
khng ng u, c ch vi ha m hn.
- Xt nghim
+ Tc lng mu tng
+ Chc kim cnh ct sng d tm thy tn thng lao in hnh.
+ Chc dch no ty chn on p ty v vim mng no tu.
3. Giai on cui
Khng c iu tr hoc c th qu suy yu: bnh nng dn, lit nng, bi nhim,
lao lan sang b phn khc nh lao mng no, lao mng tim, mng phi v cht v
suy kit.

III. CHN ON
1. Chn on xc nh
Da vo cc triu chng lm sng v Xquang. chn on sm cn chp ct lp
v chc ht cnh t sng. Trong giai on ton pht chn on d v y cc
du hiu, nht l Xquang.
2. Chn on phn bit
- Vim ct sng do vi khun m (V d: t cu): Du nhim trng nng, iu kin
khi pht (nht, hu bi), Xquang khng c p xe lnh.
- Cc tn thng u: ung th, di cn, u mu... da vo cc du hiu ton thn,
Xquang khng c hnh nh p xe lnh. Nu nghi ng, tin hnh chc ht xc nh
chn on.

IV. IU TR
Hin nay ch yu l iu tr ni khoa bng cc thuc chng lao kt hp vi phc hi
chc nng. Vic bt ng v phu thut c ch nh ring cho mt s trng hp.
1. Ni khoa
Dng cc thuc chng lao theo nguyn tc sau
- iu tr cng sm cng tt.
- Phi hp ti thiu 3 thuc chng lao: Rimifon, Streptomycine, Pyrazynamide,
Ethambutol, Rifampicine trong 3 thng, sau gim bt mt loi v tip tc dng
thuc t 6 - 12 thng.
- Lu vn khng thuc ng .
- Nn dng thuc mt ln trong ngy, bui sng, bng i.
- Theo di tnh trng ton thn, tn thng ti ch, tc dng ph ca thuc.
- Thc hin ch n ung, ngh ngi hp l.
2. Phc hi chc nng
- Xoa bp nh nhng cc c km tp luyn ct trnh teo c cng khp.

381
- Sau khi ht au, ht du hiu vim bt u vn ng ct sng t t v tng dn.
3. Vn bt ng
Trc y khi cha c thuc c hiu, iu tr ch yu l bt ng t 6 thng n 1
nm. Hin nay bt ng c chn lc, ty trng hp thi gian t 3 - 6 thng.
- Bt ng trong sut thi gian bnh tin trin nhng khng hon ton, khng lin
tc. Tt nht l dng ging bt bnh nhn c th thay i t th nhiu ln trong
ngy, trnh hin tng cng khp teo c.
- Trng hp tn thng nng ct sng c di lch nhiu e da chn p th cn
b bt.
- Nhng tn thng nh, c chn on v iu tr sm khng cn bt ng bng
b bt.
4. Ngoi khoa
c ch nh trong cc trng hp sau:
- Lao ct sng c nguy c chn p ty hoc p ty.
- Lao c p xe lnh ti ch hoc di chuyn xa.
5. Theo di
Hng thng trong nm u, mi 3 thng trong nm th hai v mi 6 thng trong cc
nm sau:
- Tc dng ph ca thuc: lm sng, sinh hc.
- Hiu qu ca thuc khng lao c nh gi lm sng v X quang mi 2 thng.
- Tiu chun nh gi lnh bnh:
+ Ht au
+ Tng trng tt
+ Ti lp kh nng lm vic, hc tp.
+ Khng cn d m, p xe.
+ Ti sinh xng thy trn X quang.
6. Tht bi iu tr
Sau 4 thng iu tr triu chng lm sng v X quang vn tn ti.
Nguyn nhn tht bi l
- Khng thuc tin pht
- Thiu s hp tc ca bnh nhn
- Dng thuc sai
- T chc iu tr khng ng mc, kim sot iu tr km:
+ Khng thm khm lm sng
+ Thuc khng liu
+ Thi gian iu tr khng
+ Thuc cung cp khng u

382
+ Khng gii thch cn k cho bnh nhn
+ Thiu theo di y khoa u n.
+ Thiu theo di bnh nhn ngng thuc
+ B tc dng ph ca thuc m khng c pht hin

383

VIM QUANH KHP VAI

Mc tiu
1. Trnh by c nguyn nhn ca cc th vim quanh khp vai
2. Trnh by c triu chng lm sng ca cc th vim quanh khp vai
3. Nm vng triu chng X quang ca cc th vim quanh khp vai
4. Trnh by c cc bin php iu tr cc th au khp vai n thun, gi lit
khp vai v cng khp vai
Ni dung

I. I CNG
1. nh ngha
Vim quanh khp vai l mt bnh bao gm nhng trng hp au v hn ch vn
ng khp vai v tn thng phn mm quanh khp ch yu l gn, c, dy
chng v bao khp. Khng c tn thng ca u xng, sun khp v mng hot
dch.
2. Nhc li gii phu
Vai l mt khp c rt nhiu ng tc, ng tc ca cnh tay ra trc, ra sau, ln
trn vo trong, ra ngoi, xoay trn; v ng tc ca ring vai: ln trn, ra sau, ra
trc. V vy c 5 khp tham gia vo vn ng ca vai.
- Khp vai chnh
- Khp c - n
- Khp cng vai - n

- Khp cng vai cnh tay.

m bo s vn ng ca xng b

- Din trc b vai - ngc

Mt c im v gii phu ca khp vai l bao khp rt lng lo, rng, pha trn v
di c tng cng bi mt s gn c to nn bao hot dch - gn - c.
- Pha trc c c di b v gn c nh u tng cng
- Pha trn c gn c trn gai
- Pha sau c c di gai v c trn nh

To thnh m
cc gn c
quay ngn ca
vai

II. AU KHP VAI N THUN: Hay gp nht biu hin ch yu l au.

1. Nguyn nhn
- Chn thng: chn thng mnh vo vng vai, hoc l nhng chn thng do
ngh nghip, thi quen, th thao gp ngi tr.
- Vin gn, thoi ho, vi ho phn mm thng gp ngi trn 50 tui.
- Lin quan thi tit: lnh v m.
- Mt s trng hp khng tm thy nguyn nhn.
2. Triu chng
2.1. C nng

384
- C th xut hin t nhin, nhng thng do khp vai vn ng qu mc hoc v
chn thng lin tip vai.
- au vai, rnh ch V ca c delta, i khi lan xung cnh tay thm ch c cng
tay, mu tay. au kiu c hc, tng khi lm mt s ng tc ca vai, kh nm
nghing, nht l lc t vo vai.
- au tng khi nng vai ln, c th hn ch vn ng kn o do au.
2.2. Thc th
- Khng c hn ch vn ng ch ng v th ng.
- Khng gim c lc
- Khi lm ng tc co cnh tay i khng th au tng.
2.2.1 Du hiu vim cc c trn gai:
- C im au chi di mm cng vai ngoi hoc ngay pha trc mm cng vai,
tng ng vi v tr tn thng ca gn.
- Lm ng tc i khng cnh tay, au tng ln.
- au khi dang tay t 70 -90 .
2.2.2. Du hiu vim gn c di gai
- im au chi khi n vo di mm cng vai pha sau, ngoi.
- au tng khi quay ngi c i khng.
2.2.3. Du hiu vim gn b di c nh u:
- Khi n vo rnh nh u, gy au phn trn - trong ca mt trc cnh tay.
- au khi gp cng tay trn cnh tay c i khng, hoc khi dang hoc hay a ra
trc.
- Tin trin c th dn n t gn.
2.3 X.Quang
Hnh nh X quang cn phi c so snh 2 bn, da trn phim thng t th quay
ngoi, quay trong v trung gian.
- Khp vai ni chung l bnh thng, c th thy mt hoc nhiu im calci ho ti
gn.
- Calci ho thng thy r nht khong di mm cng vai - mu chuyn ln.
3. Tin trin
3.1 Thun li: Ni chung c din tin lnh tnh, a s gim dn ri khi sau vi tun
n vi thng, thi gian ny c th nhanh hn nh iu tr, c th ti pht.
3.2 Khng thun li hay tin trin xu
- Chuyn thnh au vai cp, thm ch cng khp vai.
- c bit khi triu chng au tn ti ko di d iu tr cn phi nghi ng c t
cc gn c quay ngn, thng gp sau 50 tui. Xc nh chn on nh chp cn
quang, v nu c th c chng minh khi lm th thut ngoi khoa ni li.

385
- Gn b thoi ho tng dn khi khng iu tr, s dn n khp vai tui gi, c
trng bi:
+ Lm sng: ngoi au khi vn ng cn hn ch vn ng khi nng cnh tay ch
ng.
+ Xquang cc du hiu in hnh:
1. Gy mm b - cnh tay
2. Mu chuyn b mm v c cc hc nh
3. Hp khe mm cng -cnh tay
4. Gai xng
5. Hp khe cho - Cnh tay
- Khp vai tui gi chy mu: l bin chng him gp ca t cc gn quay do gi,
c chy mu trong khoang khp v ti thanh mc di mm cng -delta. Vai au dt
ngt, hon ton khng vn ng c, km vt bm tm cnh tay rt gi . Chc
ht c mu, xc nh chn on.

III. GI LIT KHP VAI

- Biu hin bng gi lit c delta do t t ngt, r, cp, m cc gn c quay.
+ Ngi ln tui (> 50 tui): Sau mt vn ng sai t th, chn thng khp vai,
hoc sau mt gng sc tc ng ln m cc gn c quay b thoi ho.
+ ngi tr: Him hn, chi th thao, sau mt chn thng mnh.
- t phn di ca c nh u ch xy ra sau 50 tui, sau gng sc trn mt gn
b thoi ho.
1 Triu chng c nng
- au d di c khi km ting lc rc khi t t ngt m cc gn quay.
- m bm tm c th xut hin sau vi ngy, phn trc trn cnh tay.
- au kt hp vi hn ch vn ng r, mt ng tc dng ch ng ca cnh tay
(du hiu ca t gn trn gai) lun lun kt hp vi t gn di gai lm mt ng
tc xoay ngoi ch ng ca cnh tay.
- au bin mt mt cch t pht hoc do iu tr, nhng khng phc hi c kh
nng vn ng. iu ny loi tr kh nng gim vn ng l do au.
2. Thc th
- Cc du hin thn kinh bnh thng c th loi tr lit thc s.
- Mt ng tc nng vai ch ng, trong khi vn ng th ng hon ton bnh
thng. y l du khch quan rt gi .
- Trng hp t gn phn di c nh u, khm thy t gn c phn trc
di cnh tay, khi gp cng tay c i khng.
3. Xquang
- Trn phim chp khp vai c c th c du gin tip ca khp vai ngi gi.

386
- Chp khp vai ct lp vi thuc cn quang chng t c s t m cc gn c
quay, do thy c hnh nh cn quang thng thng gia khoang khp v ti
thanh mc di mm cng - c delta.
- Chp scanner khp c th thy c cc t thng km theo.

IV. CNG KHP VAI

Biu hin ca co tht bao khp (vim bao khp co tht), bao khp dy lm gim vn
ng khp cho - cnh tay.
S co cng ny ca bao khp l do ri lon thn kinh dinh dng lan to, lin quan
n c xng, c, mch mu v da to nn bnh cnh au do lon dng thn kinh
phn x chi trn.
1. Nguyn nhn
Thng gp sau 40 tui, ngi c cng thng thn kinh:
- Tn thng do chn thng khp vai, bt ng b bt ko di.
- Nhi mu c tim, au tht ngc nng, vim mng ngoi tim.
- Lao phi, ung th phi.
- Lit na ngi, bnh Parkinson, u no.
- au thn kinh c - cnh tay, Zona c - cnh tay.
- Cng gip, i tho ng, goutte.
- Thuc: Phenobarbital, INH, Ethionamide, khng gip tng hp, Iode131.
- Cng khp vai i khi kt hp vi au do lon dng bn tay: au, ph, bin i
da vi tng xut huyt, cng khp v c to nn hi chng vai tay.
2. Triu chng
2.1. C nng
- Khi u au vai kiu c hc, c thi tng v m.
- Dn dn trong vi tun, au gim dn trong khi vai cng li ch yu l ng tc
dng cnh tay v quay ngoi.
2.2. Thc th
- Hn ch vn ng ca khp vai, c ch ng v th ng.
- Hn ch mi ng tc nhng r hn c l dng v quay ngoi.
- Nu c gng vn ng, s cm thy mt sc cn c hc v gy au, cc ng tc
cn c th lm c l nh vai tr ca din trc b vai - lng ngc.
- C th thy im au trc hoc di mm cng vai nhng khng c du
vim.
2.3. Xquang
- Phim chp thng: Bnh thng hoc thy long xng, khe khp cho - cnh
tay bnh thng.
- Chp khp vi thuc cn quang: s cho thy hp khoang khp:
+ Ch cn 5-10ml trong khi bnh thng l 30- 35ml.

387
+ Gim cn quang khp, cc ti cng mng hot dch bin mt.

V. IU TR
1. iu tr au khp vai n thun
- Khi t nhin sau vi tun n vi thng, c th ti pht
- C th thc y nhanh qu trnh khi bnh nh iu tr:
+ Ch yu nh tim corticoid ti ch: tim vo di mm cng vai ngoi i vi gn
c trn gai, ti a l 3 ln cch nhau 15 ngy.
+ Cho thuc gim au, c th dng thuc chng vim nonsteroid.
+ Cho gn b tn thng ngh ngi, c th kt hp vt l tr liu n gin nh sng
ngn, siu m.
- Tin trin c th xu chuyn thnh au vai cp, thm ch cng khp vai.
c bit khi triu chng au tn ti ko di, mc d tim ti ch, cn phi nghi
ng c t m cc gn c quay ngn, rt thng gp v mt gii phu, sau 50 tui,
tn thng tng dn dn. iu ny gii thch c im t nhin l ngho triu
chng, khc hn vi bnh cnh ca gi lit khp vai, c cc du hiu t gn r
rng, t ngt v mi xy ra.
S t m ny thng c xc nh nh chp khp cn quang, v nu c th
c chng minh khi lm th thut ngoi khoa khu li.
- Khi khng iu tr, gn b thoi ho tng dn, dn n khp vai tui gi (hoc t
m gn cc c quay ngn do gi) c c trng bi: ngoi au khi vn ng va
phi v khng hng nh, cn c hn ch vn ng khi nng cnh tay ch ng.
2. iu tr gi lit khp vai:
2.1. t m cc gn c quay
2.1.1. ngi tr
t m t thnh vn iu tr ngoi khoa: khu li ch t.
2.1.2. ngi ln tui
Ch nh ngoi khoa rt t nh, do tn thng thoi ho cc gn ln cn. Cho nn
trc ht phi iu tr ni khoa, bao gm:
- Tm thi bt ng tay t th dng.
- Cho thuc gim au v chng vim nonsteroid, c gng trnh tim corticoid ti ch
n mc c th, v s lm hoi t gn tng ln.
- Phc hi chc nng: vn ng liu php tch cc, nhit tr liu. iu tr ngoi khoa
c th c ch nh khi iu tr ni khoa tht bi.
2.2. t gn b di c nh u
Khng c ch nh ngoi khoa tr trng hp c bit.
3. iu tr cng khp vai
3.1. Thng t khi sau 1 - 2 nm
3.2. Qu trnh ny c th c rt ngn nh iu tr.
- iu tr thuc gim au v chng vim nonsteroid

388
- L liu php khi bt u ht au: vn ng th ng nh nhng kt hp vn ch
ng.
- iu tr au do lon dng: Bta bloquant, calcitonine, griseofulvine t hiu qu.
3.3. iu tr ngoi khoa
Ct bao khp

389

BNH A U TY XNG
Mc tiu
1. M t c nh ngha v cc yu t dch t.
2. Trnh by c cc triu chng lm sng v cn lm sng
3. M t c chn on xc nh, chn on phn bit v chn on giai on
bnh.
4. Trnh by c cc phng tin iu tr gc v cc bin php iu tr khc.
5. M t c cc yu t nh gi tin trin v tin lng
Ni dung

I. I CNG
1. nh ngha
a u tu xng l mt bnh tng sinh c tnh cht c tnh ca tng bo
(plasmocyte) ty xng v mt s c quan khc.
Tng sinh tng bo dn n:
- Tng cc globulin min dch trong mu.
- To thnh nhiu tiu xng dn n gy xng bnh l.
- Ri lon chc nng nhiu c quan: suy thn, thiu mu, tng canxi mu, cc triu
chng thn kinh...
2. Dch t
- T l mc bnh khong 3 - 4/100.000 dn; 1 - 2% cc bnh c tnh.
- Tui thng gp: > 40 ; nam > n.
- Ngi da en gp 2 ln ngi da trng v tui khi bnh sm hn.
- Nguyn nhn v bnh sinh vn cn cha r. Tuy nhin, nghin cu v dch t hc
cho thy rng liu thp phng x lm tng t l mc bnh.

II. TRIU CHNG

Do ngun gc v chc nng, tng bo c mt hu ht cc c quan, b phn
trong c th, do khi tng sinh c tnh s biu hin triu chng nhiu ni. Bnh
thng bt u t t tng dn triu chng tn mn nn d nhm vi cc bnh khc:
suy sp ton thn, biu hin xng, thn, mu, thn kinh...
1. Biu hin xng
1.1. Lm sng
- au xng (90%): v tr thng gp l vng ct sng, chu hng, lng ngc, au
tng khi vn ng v gim khi ngh ngi, v sau au lin tc, c khi thy au theo
kiu p r thn kinh.
- Gy xng t nhin (50%): gy xng sn, xng n, xng c, ln v di lch
t sng gy g vo ct sng. Thng c pht hin qua chp Xquang.

390
- U xng: 10% bnh nhn c du hiu ny; u mm khng au ni trn nn xng,
ng knh t 0,5cm n 2cm; thng thy cc v tr nh xng s, xng n,
xng c, xng b vai, ct sng... t thy cc xng chn tay.
1.2. X Quang
- Tiu xng hnh hc, hang: trn xng s, xng sn, xng chu ct
sng... cc hc hnh trn hay bu dc, ranh gii r, kch thc t vi mm n vi cm,
trng nh xng b rng.
- Tiu xng mt on hay mt phn xng di.
- Khi cc hc xng nh v dy c to nn hnh nh long xng lan ta.
- Thn cc t sng bin dng (lm, dt, hnh li), c th di lch gy nn g
vo.
Hin nay c th dng phng php chp phng x nhp nhy, chp ct lp t
trng, chp cng hng t pht hin sm tn thng.
2. Biu hin ngoi xng
2.1. Ton thn: Gy st, mt mi, chn n, da xanh, st dai dng ko di.
2.2. Thn: Tn thng thn gp trong 70% trng hp.
- Protein niu thng l protein nhit tn (chui nh: Bence Jones), ng vn nhit
560C v tan khi si.
- Suy thn mn.
- V niu: xut hin t ngt do globulin tng nhiu v nhanh trong mu gy bt tc
ng thn.
2.3. Mu: thiu mu, xut huyt do gim tiu cu.
2.4. Thn kinh: do cc khi u chn p trc tip hay do cc globulin min dch gy tn
thng.
- p ty v r thn kinh.
- Tn thng cc dy thn kinh s no.
- Vim a dy thn kinh.
- Tng p lc ni s.
- Tn thng y mt.
2.5. Cn tng canxi mu
- L , mt mi, trm cm, d nhm ln.
- Nn, ri lon nc v in gii, ri lon tri gic, hn m.
2.6. Cc biu hin khc
- D nhim khun bi nhim.
- Gan, lch, hch to.
- Ri lon tiu ha.
- Thm nhim m phi (do plasmocyte).
- Nhim Amyloid mt s b phn.

391
III. NHNG THAY I V HUYT HC V SINH HA
1. Tng sinh tng bo (plasmocyte)
- Chc d: cc u xng ni trn da hoc cc vng c tiu xng (trn Xquang)
xt nghim t bo s thy rt nhiu tng bo.
- Ty : tng bo tng cao > 15% (bnh thng < 5%). Trong mu ngoi
bin t khi thy tng bo tng.
V hnh thi, cc tng bo ny c th bnh thng, c th to nh khng u,
nhn c nhiu ht...
2. Tng gama globulin n dng
Do cc tng bo bnh l tit ra, ch yu l IgG, IgA, t thy IgD v IgE, Tng gama
globulin c th hin bng:
- Tc lng mu tng cao (tng kt dnh hng cu).
- Protid mu tng nhiu.
- in di protein huyt thanh thy gama globulin tng nhiu.
- in di min dch: tng 1 trong cc loi gama globulin min dch: IgG, IgA,
IgD, IgE...
- Nc tiu: 50% c protein Bence Jones.
3. Cc xt nghim khc
- Calci mu tng (> 105mg/l) l hu qu ca tiu xng nhiu, lan rng.
- Hng cu v tiu cu gim trong mu.
- Chc nng thn gim.

IV. CHN ON
1. Chn on xc nh: Da vo
- Lm sng: au xng, u xng.
- Xquang: tiu xng hnh hc, long xng lan ta.
- Plasmocyte tng: chc d khi u, ty .
- Xt nghim protid mu, in di, nc tiu.
2. Chn on phn bit
- Cc u xng do di cn ung th.
- Cc bnh gy tiu xng v long xng: cng cn gip, long xng sau
mn kinh, long xng nguyn pht.
- Cc bnh mu c biu hin xng.
3. Cc th bnh
- Th mt vi lan ta ging long xng (Livre v Weissenbach).
- Th khng ch v khng tit gama globulin, ch c hnh nh Xquang, khng c
thay i th dch.
- Th mt u n c.

392
- Th phi hp vi Leucmie.
- Th theo globulin: th chui nh, th IgM, th 2 dng phi hp.
4. Chn on giai on bnh: C 3 giai on
+ Giai on I: gm cc tiu chun: ( 1).
. Hemoglbin > 100g/l.
. Canxi mu < 3mmol/l (< 12 mg%).
. Xquang xng bnh thng hoc mt tn thng n c.
. in di min dch:

IgG < 50g/l

IgA < 30g/l
Chui nh niu < 4g/24 gi.

+ Giai on II: gia giai on I v III

+ Giai on III: 1 trong cc tiu chun sau:
. Hemoglobin < 85g/l
. Canxi mu > 3mmol/l
. XQ: nhiu tn thng
. in di min dch:

IgG > 70g/l

IgA > 50g/l

Chui nh niu > 12g/24gi
- Da vo chc nng thn:
A: Creatinin mu < 177 mol/l (<2mg%)
B: Creatinin mu > 177 mol/l (>2mg%)
- Phi hp tiu chun giai on v chc nng thn ngi ta nh gi tin
lng bnh (theo Dan.L.Longo):
IA sng trung bnh c:

61 thng

IIA, B sng trung bnh c:55 thng

IIIA sng trung bnh c: 30 thng
IIIB sng trung bnh c: 15 thng

V. IU TR
a u ty l mt bnh gy tn thng ty xng v nhiu c quan ngoi xng do
tng sinh c tnh cht c tnh ca tng bo. Do iu tr bao gm cc vn
chnh sau: au xng v ph hy cu trc xng, tng calci mu, suy ty vi thiu
mu dai dng, gim tiu cu v gim bch cu, suy thn v nhim trng bi nhim.
Hu ht bnh nhn cn c iu tr h thng ha cht kim sot khi u v iu
tr triu chng ngn nga bin chng.
1. iu tr gc
1.1. Truyn tnh mch tng t, trong cc loi sau
- L.Phenylalanin Mustard (L-PAM, Melphalan): 8mg/m2/ngy

393
- Cyclophosphamide 200 mg/m2/ngy
Phi hp vi Prednisolon 25-60 mg/m2/ngy. Mi t 4 - 7 ngy, cch nhau 4 6 tun.
Sau c th dng bng ng ung vi liu
Melphalan: 1 - 3 mg/ngy
Cyclophosphamide: 1 - 2mg/kg/ngy
Prednisolone: 1mg/kg/ngy
Dng tng t 1 - 4 tun.
Thi gian iu tr ko di 1 - 2nm. Theo di cht ch v lm sng v xt
nghim iu chnh thuc.
1.2. C th dng liu cao steroid n thun truyn tnh mch
. 200mg Prednisolone cch ngy
. Hoc Methylprednisolone 1g/m2/ngy x 5 ngy
1.3. C th dng ha tr liu phi hp xen k
. Vincristin 0,4 mg/ngy x 4 ngy
. Tip: Doxorubicin 9mg/m2/ngy x 4 ngy
. Tip Dexamethason 40mg/ngy x 4 ngy.
2. iu tr khc
2.1. Chiu x vi th khu tr, tin trin chm, u ngoi ty xng
2.2. Phu thut: th u n c, gii phng chn p
2.3. Cc iu tr triu chng phi hp
- Truyn mu
- Khng sinh
- Lc mu
- Calcitonin
- Li tiu...

VI. TIN TRIN V TIN LNG

15% cht trong 3 thng, 15% cht trong 1 nm, s cn li din bin mn tnh t
2 - 5 nm.
Nguyn nhn cht:

- Suy thn
- Nhim trng huyt
- S lan rng ca khi u
- Nhi mu c tim, bnh phi mn tnh
- i ng, t qu

394

LUPT BAN H THNG

Mc tiu
1. M t c nh ngha, yu t dch t
2. Trnh by c nguyn nhn v c ch sinh bnh.
3. M t c triu chng lm sng v xt nghim
4. Trnh by c tiu chun chn on xc nh v chn on phn bit.
5. Trnh by c bin php iu tr bnh lupt
Ni dung

I. I CNG
1. nh ngha: L bnh c t l cao nht trong nhm bnh to keo (60%) biu hin
vim lan ta hay ri rc t chc lin kt, nguyn nhn do t min.
2. Dch t
- Bnh gp ch yu ph n tr, t l n/nam: 8/1.
- T l mc bnh cao nht la tui 20 - 40.
- Ngi da en c t l bnh v t l t vong cao gp 3 ln da trng, t l bnh cao
theo th t: da en, Chu , da trng.

II. NGUYN NHN V C CH BNH SINH

Ngy nay c xem l bnh t min trn 1 c a c bit.
1. Bng chng v t min
- Trong th dch bnh nhn c nhiu t khng th: khng th khng nhn, khng th
khng acid nhn (AND, ARN), khng cc huyt cu (hng cu, bch cu, tiu cu).
Lng b th gim r rt trong mu (CH50, C3, C4), phn ng BW dng tnh gi,
pht hin cc phc hp min dch trong mu v t chc.
- T l Limpho B v T thay i trong mu.
- C th gy bnh trn sc vt bng phng php min dch.
- iu tr cc thuc c ch min dch c kt qu.
2. Yu t c a
- Ph n, tr tui.
- HLA-DR3 cao hn hn so vi ngi bnh thng.
- Mt s trng hp c tnh cht gia nh.
3. Yu t nguyn nhn
Nguyn nhn trc tip gy bnh cha bit r. Tuy nhin c mt s yu t sau:
- Mt s thuc c th gy bnh Lupt: Hydralazine, dihydralazine, procainamide,
Acbutolol, D pnicillamine, quinidine, Isoniazide, chlorpromazine, sulfasalazine,
minocycline, carbamazpine, interfenon v .
- Cc sn phm k ngh: Formaldhyde, isocyanate v anhydride phtalique.

395
- Cc cht cytokine nh interfon, yu t kch thch sinh bch cu ht, cc khng th
dng trong lm sng nh anti TNF.
- Tc nhn nhim trng: nh parvovirus B19.
4. Nhng xu hng mi v nguyn nhn bnh sinh ca Lupt
4.1. Xc nh nhng gen c th dn ti bnh ny
- Gen C4A lin quan n biu hin bnh Lupt.
- Thiu ht on Fc YRIIa - H131 lin quan n vim thn Lupt.
4.2. Bt thng trong t bo T hoc TCR
- T bo T bnh nhn Lupt thiu men proteinkinase A (PKA).
- S bin i protein t bo theo kiu phosphoryl ha c th lm bin i s hng
nh ni mi v thm ch lm ri lon chc nng min dch.
4.3. Hot ng qu mc ca t bo B v sn sinh t khng th l t trng ca bnh
Lupt
- S tin trin ca Lupt lin quan n tng sn phm interlenkin 10.
- Tng Apoptosis tham gia vo s pht trin ca vic gim t bo v gii phng cc
thnh phn ca nhn t bo, nhng cht c th kch thch h thng min dch sn
sinh ra t khng th.

III. TRIU CHNG

1. Lm sng: Trn lm sng ch yu gp th bn cp.
1.1. Khi pht
- a s bt u t t, tng dn: st dai dng khng r nguyn nhn, au khp hoc
vim khp ging nh VKDT.
- Mt s trng hp khi pht nhanh, cc triu chng y ngay giai on u.
- C khi bnh xut hin sau nhng nguyn nhn thun li: nhim trng, chn
thng, Stress, dng cc thuc c th gy Lupt.
1.2. Ton pht: Tn thng nhiu c quan.
- Ton thn: st dai dng ko di, mt mi, gy st.
- C xng khp: au, vim, bin dng khp, lon dng c, hoi t xng.
- Da nim mc: ban hnh cnh bm mt, ban dng a ngoi da, xm da do
nng, lot nim mc ming, mi, rng tc, vim mao mch di da.
- Mu v c quan to mu: thiu mu ko di, chy mu di da, lch to, hch to.
- Thn kinh tm thn: ri lon tm thn, ng kinh.
- Tun hon, h hp: trn dch mng tim, mng phi, vim c tim, vim ni tm mc,
hi chng Raynaud, vim phi k, vim tc ng mch, tnh mch.
- Thn, gan: protein niu, t bo tr niu, c trng, ri lon chc nng gan.
- Mt: tc tuyn l (hi chng Sjogren) vim kt mc, vim vng mc.
2. Xt nghim
2.1. Cc xt nghim khng c hiu

396
- Cng thc mu: gim cc dng huyt cu mt phn hay ton th, gim ngoi ty:
+ Hng cu gim (thng thng l thiu mu huyt tn)

65%

+ Bch cu gim, ch yu l a nhn trung tnh

32%

+ Tiu cu gim

10%

- Tc lng mu tng cao 92%, si huyt tng

- in di huyt thanh: Globulin tng

45%
86%

- Tm thy phc hp min dch trong mu.

- Phn ng BW (+).
2.2. Cc xt nghim c hiu
2.2.1. T bo Hargraves (LE): l nhng bch cu a nhn thc bo nhng mnh
nhn ca t bo khc b tiu hy do khng th khng nhn xut hin trong bnh
Lupt.
Ngi ta thng tnh t l % ca t bo LE so vi tng s bch cu trong mu. T l
5% th c gi tr chn on. Trong Lupt 60% - 90% c t bo LE.
2.2.2. Tm cc khng th th dch
- KT khng nhn: c xem l dng tnh khi pha long huyt thanh > 1/32.
- KT khng DNA rt c hiu trong bnh Lupt.
- KT chng li cc khng nguyn nhn ha tan: KT khng Sm (+) trong 50%.
- KT khng hng cu, khng Limpho bo, khng tiu cu.
- B th gim trong mu.
- Gim t l Lympho bo so vi t bo B.
2.3. Sinh thit
- Sinh thit da: lng ng globulin min dch: IgM, IgG v b th thnh mt lp gia
thng b v trung b ca da (+ 70%).
- Thn: vim cu thn, dy mng y do lng ng IgG, IgM v b th.
- Mng hot dch khp: tn thng gn ging vim khp dng thp.

IV. TIN TRIN: Ty thuc th bnh

1. Th cp: Tn thng nhiu ni tng v nng, tin trin nhanh v t vong sau vi
thng do cc thng tn thn, thn kinh, phi nhim khun.
2. Th mn: t tn thng ni tng, biu hin ngoi da nh, tin trin chm, tin
lng tt.
3. Th bn cp: Tin trin tng t, ngy cng nng dn. Bnh nng thm nu c
thai, nhim khun, chn thng, phu thut, Stress, lm dng thuc. Thng t
vong v cc bin chng thn, thn kinh, nhim khun. Thi gian sng trung bnh 5
- 10 nm.
4. Hi chng Sharp: l th bnh hn hp gia Lupt v x cng b, c cc du vim
a khp, hi chng Raynaud, ngn tay sng to hnh khc di ln, x hp thc qun,
vim a c. Do t biu hin ni tng nn tin lng tt hn v nhy cm vi Steroid.

397
V. CHN ON
1. Chn on xc nh: Da vo 11 tiu chun ca hi thp hc M, c ci tin nm
1997, chn on xc nh khi c t nht 4 tiu chun:
- Ban hnh cnh bm mt.
- Ban dng a mt, thn.
- Xm da do nng.
- Lot ming hoc mi hu.
- Vim a khp.
- Vim mng tim hoc mng phi.
- Tn thng thn: Protein niu > 0,5g/24 gi hoc tr niu.
- Tn thng thn kinh: co git hoc lon thn.
- Ri lon v mu:
+ Thiu mu tan mu (tng hng cu li); Bch cu < 4000/mm3.
+ Limpho < 1500/mm3 hoc tiu cu < 100.000/mm3.
- Ri lon min dch: trong mu c
+ Khng th khng ADN hoc khng th khng Sm.
+ Nng bt thng ca IgG hoc IgM anti - Cardiolipine, hoc hin din yu t
chng ng lu hnh (anticoagulant circulant).
- Khng th khng nhn (+).
2. Chn on phn bit
- Thp khp cp.
- Vim khp dng thp.
- Bnh trong nhm to keo: x cng b, vim a c, vim nt quanh ng mch.
- Vi cc th c bit ca Lupt cn phn bit vi cc bnh c triu chng tng t:
xut huyt gim tiu cu, vim cu thn, hi chng thn h. Vim mng tim mng
phi do nguyn nhn khc.
3. Thc t Vit Nam: khi c 5 yu t sau y xut hin trn 1 bnh nhn n, tr
tui th c hng chn on Lupt
- St dai dng ko di khng tm thy nguyn nhn.
- Vim nhiu khp.
- Ban hnh cnh bm mt.
- Protein niu.
- Tc lng mu cao.

VI. IU TR
Chung cho mi trng hp Lupt: Gio dc bnh nhn trnh nhng iu c hi nh
thuc l, trnh nh nng mt tri trc tip hoc gin tip, k hoch ha gia nh,
trnh lm dng thuc.

398
Ch nh iu tr ph thuc vo mc nng nh ca bnh:
1. Th nh
Tn thng da - khp.
- Loi thuc dng: Aspirine v khng vim nonstroid, thuc chng st rt tng hp.
+ Aspirine v AINS: ch tc dng ph nht l tiu ha, thn, thn kinh gic quan.
+ Hydroxychloroquine: 400mg/ngy trong nhiu nm.
Tc dng iu tr tn thng da v khp, tc dng d phng xut hin cc t mi,
c kh nng chng huyt khi.
Theo di mt u n: th lc, nhn mu sc, in vng mc .
Cc tc dng ph khc him: mt bch cu ht, bnh thn kinh c hoc bloc nh tht
khi iu tr ko di.
+ Vi iu tr nh trn, cc triu chng khp vn tn ti, c th h tr thm
prednisone < 0,3 mg/kg/ ngy.
2. Th nng
Tn thng cc ni tng.
2.1. Liu php corticoide
- Trong nhng t nng: thng bt u di dng bolus.
+ Methylprednisolone 1g chuyn TM trong 90 pht (sau khi kim tra kali mu v
ECG) trong 3 ngy lin tip. Sau dng ng ung.
+ Prednisone: 1mg/kg/ngy trong th tn thng nhiu tng (bnh thn tng sinh,
tn thng thn kinh lan ta, gim tiu cu hoc tan mu nng) v 0,5mg/kg/ngy
trong nhng th nh hn. Ban u liu corticoide chia thnh 2 - 3 ln trong ngy. V
sau ch dng 1 ln vo bui sng. Khi bnh c khng ch cho dng 1 ln vo
bui sng. Khi bnh c khng ch cho dng mi 2 ngy 1 ln vi liu gp i,
thng c ch nh cho tr em bo v s tng trng.
+ Liu php Corticoide tn cng c ch nh trong 4 tun.
Sau gim liu dn (gim 10% liu /mi 10 - 15 ngy).
2.2. Hydroxychloroquine c dng khi liu prednisone < 0,5mg/kg
+ Liu php corticoide duy tr (0,15 - 0,25mg/kg/ngy) thng c ch nh lu di,
ph thuc vo trm trng ban u hoc cc ti pht trc y.
2.3. Thuc c ch min dch
iu tr loi thuc ny l vn cn tranh lun, d li ch ca chng c tha
nhn trong cc bnh thn tng sinh. N p ng 2 mc ch: ci thin bnh trong
nhng th khng corticoide, cho php gim lng corticoide.
Nguy c tim tng, nht l nhim trng v sinh u lm hn ch ch nh trong mt s
tn thng tng nng. Hai loi thuc thng dng l:
- Cyclophosphamide: hin nay t dng bng ng ung v c nhiu tc dng ph,
m thng dng bng ng tnh mch gin on vi liu 0,5 - 0,8g/m2 ph thuc
chc nng thn v lng bch cu.
- Azathioprine: 2 - 4mg/kg/ngy bng ng ung.

399
Khc vi cyclophospharnide l khng e da chc nng sinh dc v khng chng
ch nh trong lc c thai.
- a s tc gi iu tr thuc c ch min dch phi hp vi liu php corticoide trong
cc bnh thn tng sinh v cc tn thng thn kinh trung ng khng thiu mu,
c bit l trong trng hp ti pht. Phc thng dng l: chuyn TM
cyclophosphamide mi thng trong 6 thng, ri mi 3 thng trong 2 nm. i vi
azathioprine thi gian dng t 12 - 24 thng.
2.4. Cc can thip min dch khc
Ch chim mt v tr hn ch trong iu tr Lupt
- Ciclosporine A: c tc dng thun li trong mt s srie hn ch.
- Methotrexate: Kt qu khng nh trong iu tr vim khp dng thp, c li trong
mt s trng hp tn thng thn v vim c.
- Lc huyt tng: Kt qu t c tri ngc nhau trong vim thn Lupt. Li ch
khng c chng minh trong iu tr tn cng cc bnh thn nng.
- Immunoglobuline tnh mch hin nay ch dng trong mt s trng hp gim tiu
cu nng.
2.5. Cc iu tr mi ang trong thi gian th nghim
- Khng th n dng chng interleukine 10.
- Th nghim Bromocriptine v ghp t bo gc trong trng hp nng v khng
vi cc iu tr khc.

VII.TIN LNG
- Tin lng bnh Lupt ban h thng c ci thin t 20 nm nay, hin nay
t l sng 10 nm vt qu 90%.
- Mt s yu t c ngha tin lng nng l: nam gii, thuc chng tc da en,
khi bnh lc cn tr em, c tn thng thn, thn kinh hoc hi chng khng
phospholipide phi hp.
- Nguyn nhn t vong c phn gia tng do cc nhim trng c hi, x m mch
vnh tng v cc u tn sinh, cn nhn mnh cc nguy c do s dng ko di
corticoide v c ch min dch.

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

Ngun: TCYTTG - 4.2002

- 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.

Yu t khi pht:
- Nhim khun
- Thc n
Nhy cm di truyn

Khng c phn ng t
min

Yu t thc y
- Nhim khun
- Thc n

Phn ng t min

T lm sng

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.

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

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 Bnh nhn c ICA + th tc ph hy TB cng nhanh. Cc t khng

th
th khc t c gi tr tin on hn.

insulin

khng

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.
Endopeptidase
Des 64,65 Proinsulin

Insulin
C peptide

Proinsulin
Des 31, 32 Proinsulin

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).

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

+ 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)

T:

IGT:
+ Go (nu c) < 6,1 (< 110) < 6,1 (< 110) < 7,0 (< 126)
v
v
v
v
+ G2

6,7 ( 120)

7,8 ( 140)

7,8 ( 140)

< 7,0 (< 126) v

8,9 ( 160)
v < 12,2 (< 220)

IFG:
+ Go v

5,6 ( 100) 5,6 ( 100) 6,1 ( 110)

v
v
v
< 6,1 (< 110)
< 6,1 (< 110)
< 7,0 (< 126)

= 6,1 (= 110) v
< 7,0 (< 126)

+ G2 (nu o)

< 6,7 (< 120)

< 8,9 (< 160)

< 7,8 (< 140)

< 7,8 (< 140)

401
CHIN LC CHN ON I THO NG THEO WHO 2002
Go (mmol/l)

Glucose mu bt k (mmol/l)
7,8

Khng triu chng

7,8-11,1

h
< 6,1

Bnh
thng

6,1 Go <
7
RL Glucose
i

Khng triu
chng 11,1

XN li Go

XN li

XN li

11,1

6,1 Go <
7

Khng
XN na

C tr
chng
11 1

I THO NG
11,1
G2

7,8-11,1
7,8

Nghi ng T
G2

RLDNG

nh gi thm

11,1
7,8-11,1

RLDNG

7,8

Bng 3: CC GIAI ON LM SNG CA T

Giai
on

Glucose mu
bnh thng

iu ha G RL G mu
mu
bnh i
hoc
thng
RLDNG

Type
Tp 1:
+ T min
+ V cn
Tp 2:
+ khng
insulin u th
+
Khim
khuyt
tit
insulin u th
Cc type c
bit khc
T
nghn

Tng glucose mu

thai

T
Khng cn Cn insulin Cn insulin
insulin
kim sot sng

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 HLADR4, 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

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 toanctone 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

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

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

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:
(Na 2) + G mmol/L >320 mOsm/Kg nc

hoc

(Na +K+ ) 2 + G + Ur > 340 mOsm/Kg nc

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 (+++).

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
- HCO3- 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

HHS

Nh

Va

Nng

G huyt tng (mg/dl)

> 250

> 250

> 250

> 600

pH ng mch

7,25-7,30

7,00-7,24

< 7,00

> 7,30

15-18

10 - < 15

< 10

> 15

Ceton niu

Ceton huyt thanh

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
m

HCO-3
(mEq/L)

huyt

tng

s/hn

Sng
m

s/hn

*: Posm (mOsm/kg) = 2 Na (mEq/L) + G (mmol/L)

**: Khong trng anion = Na+ - (Cl- + HCO3-) (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

Giai on tin lm sng

Mt TB quanh mao mch vng mc

Dy mng y

Giai on sm:
NPDR mc nh

Vi phnh mch vng mc v xut huyt dng chm

Tng tnh thm mch mu vng mc
Xut huyt dng chm nh bng gn

Giai on trung gian:

Thay i khu knh tnh mch

+ NPDR mc va

Bt thng vi mch trong vng mc

+ NPDR mc nng

Mt mao mch vng mc

+ NPDR mc rt nng
Giai on mun:
PDR

Thiu mu cc b vng mc
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
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 1015 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

Khng
chnh

Mu theo thi gian

hiu Hiu chnh theo C crea Qua m

24 h

NT

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

> 300

> 200

> 300

Alb niu i th > 200

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
Bnh l a dy thn kinh
i xng

Vn dng-cm gic mn tnh

T ng
TK s
TK thn

Bnh l mt dy thn kinh

mt hay nhiu

TK chi
Vn ng gn gc chi (teo c)
Bnh l a dy TK hy myelin do vim mn tnh cng tn ti

nh ngha bnh l thn kinh T theo ADA 2005: S hin din ca cc triu chng
v/hoc du hiu ca ri lon chc nng thn kinh ngoi bin ngi T sau khi
loi tr cc nguyn nhn khc (Chn on bnh l thn kinh T l mt chn

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 Cn thay i k hoch

khi iu tr
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
Trc n
Trc n Trc n
sng 30pht tra 30pht ti 30pht

8 gi

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

416

Nhanh

8 gi

Nhanh

Nhanh

NPH

12 gi
20 gi 22 gi
Trc n Trc n
Trc n
sng 30ph tra 30pht ti 30pht

8 gi

S 2: S iu tr insulin vi 4 mi tim/ngy (3 nhanh + NPH)

Hn hp (nhanh+NPH)

8 gi
Trc n
sng 30ph

Hn hp (nhanh+NPH)

20 gi
Trc n
ti 30ph

8 gi

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 68 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 1015 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 25150mg.
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)

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+ 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

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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/m2.

435
Bng 1: Tn sut qu trng theo nhiu nghin cu khc nhau chu u.
Nc v tui ngh/cu

nh ngha qu trng

Tn sut bo ph
Nam

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

C 2 gii
19%

10%
13%
23%
14%
16%
24%
25%
22%
18%
28%

41%
14%
32%
41%

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/ (m2).

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

Nguy c

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 )

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:
BO PH
Acid bo t
d
Triglyceride
HDL

khng Insulin

Tng huyt p

Glucose mu

i tho ng type 2

Bnh tim mch

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.
Hnh
Vai
trogp,
cua
chng
- Suy
mch2:
vnh:
thng
ngaybeo
c khi ph
khngtrong
c thmhi
cc yu
t nguy c
chuyn
hoa
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 CO2 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 btaendorphine 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

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 Cn bng nng lng a vo v nng

ng th lc ti a 200 Kcal/ngy
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, LDLCholesterol 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

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, 1537.5mg/ng

Tc dng Noadrenergic

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 100150mg/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 - 20cm3).
+ 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
(T3).
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,11,5 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

V(ml)
Gii hn trn

3,5

4,5

9 10

11

1
2

13

14

15

16

17

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 (KIO3).
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 50500g 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 KIO3 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.
T4 < 3g/dl.
FT4I gim
T3 < 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, LT4
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, LT3
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 75125(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 220C. 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
au

+++

Gip

Abces

Bn cp

Im lng

Hashimoto

Riedel

+++

Rt chc

Chc

Rt cht

Cng

nh

474
Du
thn

ton

++

++

FT3, FT4

BT

BT hoc

BT hoc

BT hoc

BT

TSH

BT

BT hoc

BT hoc

BT hoc

BT

Khng th

0 hoc +

0 hoc +

+++

(hoc BT

VS

X hnh

Vng lnh

Khng
iode

bt

Khng
iode

BT
bt

Khng
cht

BT
ng

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 H2O
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 +2o n +8oC.
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 520 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 +2o n +15o.
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 3050% 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

GH

Tt dung np insulin: iu - o Glucose, GH:

ho insulin
-30, 0, 30, 60, 120
pht
(0,05-0,15 U/kg TM)

Din gii kt qu
Glucose <40 mg/dl
GH >3g/L

GHRH tt: 1 g/kg TM

-p ng bnh thng
- o GH: 0, 15, 30, nu GH >3 g/L
-p ng bnh thng
Tt L-Arginin 30 g TM trn 45, 60, 120 pht
- o GH: 0, 30, 60, nu GH >3 g/L
30 pht
120 pht
Tt L-Dopa 500 mg ung

-p ng bnh thng
- o GH: 0, 30, 60, nu GH >3 g/L
120 pht

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

o glucose v cortisol
-30, 0, 30, 60, 90 ph

Glucose <40 mg/dl

Cortisol tng >7-20g/dl

Tt CRH: 1 g/kg TM lc
8g

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

-ACTH c bn tng 2-4

ln v t ti a 20100pg/ml
Cortisol >20-25 g/dl

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.

-Cortisol HT < 4 g/dl n

o 11-deoxycortisol
p ng y
v cortisol lc 8 gi
p ng cortisol BT
o
cortisol
v
>21g/dl, v p ng
aldosterone 0, 30, 60
aldosterone >4 ng/dl trn
c bn
Cortisol >21 g/dl
o cortisol 0, 30, 60
Cortisol >21 g/dl

Tt kch thch ACTH trong

3 ngy: 0,25 mg ACTH 124 (Cosyntropin) TM mi
8 gi/ngy
TSH

LH, FSH

o FT3,F T4, TSH

Tt c bn

Tt TRH: 200-500 g TM

o TSH, PRL: 0, 20, TSH tng >5 mU/l, tr phi

60
hormon gip gia tng

LH,

Tt c bn

FSH,

testosterone,

FT3, F T4, TSH thp

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

GH,
ACTH, p ng phng thch
Nhiu loi Tt kt hp tin tuyn o
cortisol LH, FSH, TSH hormone ring r hay kt
hormon
yn: GHRH (1 g/kg)
CRH (1 g/kg), GnRH -30, 0, 15, 30, 60, 90, hp phi tng
120
(100 g), TRH (200 g)

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 P450C21, P450C18, P450C17, P450C11.
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 9Fluorohydrocortison 25-50g/ngy.

488

CHNG 7

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

Khong k

285 mosmol/l

40%

Ni mch

ung
chuyn

285 mosmol/l

15%

5%
Phi
Da
Tiu ho

Ni bo

Ngoi bo

Thn

489
2. Cc c ch iu ho nc in gii, toan kim
C ch ny rt cn thit v i hi s nhy cm, chnh xc m bo tnh n nh ca
ni mi: l iu kin cn thit cho s sng. C s u tin cho s cn bng thm
thu so vi cn bng th tch ni mi. Hai mt iu ha cn bng nc in gii v cn
bng toan - kim c lin h mt thit vi nhau.
2.1. iu ha cn bng thm thu
Ch yu do c ch tit hc mn chng bi niu ADH (Antidiuretic Hormone) v c ch
kht. Kch thch tit ADH l s tng p lc thm thu v s gim th tch mi trng
ngoi bo. Trung tm kht vng di i, ti y c th th p lc thm thu, s gim
th tch mi trng ngoi bo cng kch thch gin tip trung tm kht.
2.2. iu ha th tch mi trng ngoi bo
Th tch mi trng ngoi bo ch yu do Natri quyt nh, do c ch iu ha th
tch mi trng ngoi bo ch yu do iu ha Natri ngoi bo, s iu ha Natri ngoi
bo ch yu qua trung gian Aldostrone v thn.
2.3. iu ha cn bng ion:
Ion Natri c nu trn.
Ion Kali ngoi bo c lin h mt thit vi ion Natri v pH mi trng ngoi bo. Khi pH
gim, Kali i t ni bo ra ngoi bo lm Kali ngoi bo tng v c thi nhiu ra
ngoi nu thn bnh thng, hoc li nu thn b suy, s kim ha mi trng ngoi
bo c tc dng ngc li.
Ion Calci c iu ha nh Hormone tuyn cn gip (PTH), Vitamin D v lin quan
mt thit vi nng Phospho trong mu.
2.4. iu ha cn bng kim toan
Trong c th c cc h thng m, c kh nng gii hn s thay i ca pH mc
no gi cho pH mu c duy tr trong gii hn bnh thng, trong h m
quan trng nht l h m Bicarbonat:
H+ + HCO3- H2CO3 CO2 + H2O
H m Bicarbonat c vai tr rt ln trong iu ha thng bng kim toan ca c th v
c hai yu t ca h ny c th c iu chnh mt cch d dng: HCO3- bi thn v
CO2 bi phi.

II. MT NC NGOI BO
1. nh ngha: l tnh trng gim th tch ca khoang ngoi bo, gm 2 khoang k v
khoang ni mch. Do mt Ion Natri tng ng vi mt nc, cho nn Bilan Natri lun
m tnh. Nu ch mt nc ngoi bo n thun th nng thm thu ngoi bo bnh
thng (285 mosmol/l) v th tch ni bo khng i (biu hin bi nng Natri mu
bnh thng).
2. Nguyn nhn
2.1. Nguyn nhn mt nc ngoi thn (c trng bi Natri niu < 20 mmol/24 gi)

490
Mt qua ng tiu ho: Nn ma ko di, a chy, l d ng tiu ho, dng
thuc nhun trng,.... hoc mt nc qua da, nim mc: m hi, bng din rng.
2.2. Mt nc qua ng thn (Natri niu > 20 mmol/24 gi), c th do
- Bnh l thn: Bnh l thn k, suy thn mn giai on cui vi tit thc hn ch mui
nhiu, suy thn cp giai on tiu nhiu.
- Bnh l ngoi thn: do tc dng li tiu thm thu: i tho ng, truyn nhiu
Mannitol, tng Calci mu, dng cc thuc li tiu, suy thng thn cp.
2.3. Mt nc vo "khoang th 3"
Do hnh thnh mt khoang dch ngoi bo: vim phc mc, vim tu cp, tc
rut, v hu c vn do chn thng.
3. Sinh l bnh
Mt nc v mt mui theo t l ng trng, cho nn s a n gim th tch dch
ngoi bo m khng c thay i v nng thm thu, khng c thay i th tch dch
ni bo (nng thm thu huyt tng v Natri mu bnh thng).
4. Chn on: Chn on xc nh da vo khm lm sng v cn lm sng:
4.1. Triu chng lm sng
- H huyt p: lc u l h huyt p t th, sau l c khi nm.
- Nhp tim nhanh.
- Sc gim th tch mu khi lng dch mt trn 30%.
- Cc tnh mch nng b xp.
- Thiu niu, v niu.
- Gim cn.
- Du vo da (Casper) dng tnh.
- Da kh, nim mc kh.
- Kht nc: c nhng khng nhiu nh trong mt nc ni bo.
4.2. Triu chng cn lm sng
Khng c xt nghim no phn nh trc tip tnh trng mt nc ca khoang
dch k, thng thy 1 mt nc ng trng khoang ni mch: tng Protid mu
(>75g/l), tng Hematocrite (>50%) m khng c du xut huyt, c th c du suy thn
cp chc nng do gim th tch mu.
4.3. Chn on nguyn nhn
Thng n gin, ph thuc vo tng bi cnh bnh, triu chng lm sng v lng
Natri niu trong 24 gi.
- Mt nc in gii do nguyn nhn ngoi thn:
+ Thiu niu.
+ Natri niu < 20 mmol/24 gi.

491
+ C hin tng c c nc tiu: Ur niu / Ur mu > 10; Creatinine niu /
Creatinine mu > 40; thm thu niu > 500 mosmol / l.
-Mt nc, mui do mt qua ng thn:
+ Lng nc tiu bnh thng hoc tng (>1000 ml/24 gi).
+ Natri niu tng > 20 mmol/ 24 gi.
+ Nc tiu khng b c c: Ur niu / Ur mu < 10; Creatinine niu /
Creatinine mu < 20.

III. NC NGOI BO
1. nh ngha: L mt s tng th tch dch khoang ngoi bo, c bit l khoang
k, dn n ph ton. nc ngoi bo thng do nc v mui (vi lng tng
ng), c Bilan Natri dng tnh.
2. Nguyn nhn
- Ba nguyn nhn thng gp nht l: suy tim, x gan, hi chng thn h.
- Cc nguyn nhn khc ti thn: vim cu thn cp, suy thn cp, mn.
- Nguyn nhn ngoi thn: suy dinh dng, gin mch ngoi bin nhiu nh trong
trng hp c l d ng tnh mch, c thai, ang iu tr cc thuc gin mch.
3. Sinh l bnh
S vn chuyn ca nc v Natri qua 2 bn mng ca mao mch tun theo qui lut
Startling. Thng thng ph l hu qu ca:
- Gim p lc keo ni mch: gp trong gim Protid mu nng. Nc v Natri i t ni
mch ra khong k s gy gim th tch lng mch.
- Tng p lc thu tnh ni mch: trng hp ny 2 khong k v khoang ni mch u
tng th tch, thng do suy tim hoc 1 tnh trng nc v mui do tn thng thn.
- Phi hp nhiu c ch: suy tim xung huyt, gim th tch mu lm thn tng ti hp
thu nc, mui tng th tch tng mu. Trong x gan: ph l hu qu ca tng p
ca, v cng do gin mch tng.
4. Chn on: Chn on xc nh ch yu da vo lm sng.
- Triu chng lm sng nc ngoi bo:
+ Ph: ph ngoi bin, trng, mm, khng au, du n lm dng tnh, c th
trn dch cc mng (tim- phi - bng) hoc khoang k phi.
+ Cc du chng ca nc lng mch: tng huyt p hoc ph phi cp.
+ Tng cn.
- Cn lm sng thng ngho nn: long mu (thiu mu, gim Protid mu), khng
hng nh v khng c triu chng cn lm sng no phn nh c th tch khoang
k.
- Chn on nguyn nhn thng n gin bng phn tch bi cnh xut hin v triu
chng lm sng.

492
IV. MT NC NI BO (TNG NATRI MU)
1. nh ngha: L gim th tch ngoi bo do 1 Bilan nc m tnh vi 1 tng nng
thm thu huyt tng > 300 mosmol/l. S tng thm thu ny s lm cho nc t ni
bo ra ngoi bo.
Biu hin ch yu trn xt nghim l tng Natri mu.
Ch : Nng thm thu huyt tng c th c c lng theo cng thc:
P osmol = [Na+ x 2 ] + Glucose mu = 285 mmol/l.
2. Nguyn nhn
2.1. Mt nc ni bo c tng Natri mu:
- Mt nc mt b: mt nc qua da, qua ng h hp, mt qua thn nh trong i
tho ng, dng Mannitol nhiu, mt qua ng tiu ho nh tiu chy, dng thuc
nhun trng.
- Cung cp nhiu Natri: trong hi sc, trong thn nhn to.
- Gim cung cp nc: ri lon vng di i tr s sinh, ngi gi, bnh nhn hn
m.
2.2. Mt nc ni bo nhng khng tng Natri mu:
- Tng thm thu mu th pht do ri lon cc cht c hot tnh thm thu: Glucose,
Mannitol, Ethylene glycol.
- Cc cht khuych tn t do vo t bo nh Ur, Ethanol,... s khng a n ri lon
nc ni bo.
3. Sinh l bnh
- Bilan nc vn c cn bng.
- S kht nc s iu ho lng nc ung vo v hot ng thn m bo n
nh thm thu gia 2 ngn ni v ngoi bo.
- S bi tit ADH c iu ho ch yu bi s thay i nng thm thu huyt
tng, bi th tch lng mch v bi c ch kht. Khi ADH c tit khng y ,
Bilan nc m tnh to ra cm gic kht nc.
Chng ta c th gp 1 Bilan nc m tnh v tng thm thu mu trong cc trng hp:
- Mt nc qua ng ngoi thn: da nim mc, h hp.
- Mt nc qua thn do thiu ADH hoc do gim nhy cm ca thn i vi ADH.
- Ri lon trung tm kht hoc ri lon cc th th v thm thu vng di i.
4. Chn on
Chn on xc nh
- Triu chng lm sng
+ Thn kinh: Khng c hiu, lin quan vi mc tng Natri mu
L m, ng g.

493
Cm gic mt l.
Ri lon thc dng kch thch.
St.
Co git
Hn m.
Xut huyt no - mng no.
+ Kht: i lc rt d di.
+ Nim mc kh: c bit mt trong ca m.
+ Hi chng ung nhiu, tiu nhiu trong trng hp nguyn nhn do thn.
+ Gim cn.
- Triu chng cn lm sng:
+ Thm thu huyt tng > 300 mmol/l.
+ Natri mu > 145 mmol/l.

V. NC NI BO
1. nh ngha: l tnh trng tng th tch dch ni bo do Bilan nc dng tnh phi
hp vi gim thm thu huyt tng, Natri mu gim <135 mmol/l.
2. Nguyn nhn
- Hp thu nc nhiu hn kh nng bi tit: bnh tm thn ung nhiu.
- Bi tit khng thch hp hoc mn ADH (SIADH).
- Do gim bi tit nc trong x gan, suy tim, hi chng thn h,...
- Trong suy thn mn nng (mc lc cu thn < 20 ml/pht).
3. Chn on
3.1. Triu chng lm sng
+ Ri lon thn kinh: khng c hiu, lin quan n mc Natri mu: bun nn,
nn ma, chn n, nhc u, u m thc, hn m, co git.
+ Tng cn va phi.
+ Khng kht, ngc li khng thch ung nc.
3.2. Triu chng cn lm sng:
+ Thm thu huyt tng < 270 mosmol/l.
+ Natri mu < 135 mmol/l.

VI. TNG KALI MU

1. nh ngha: Tng Kali mu c nh ngha khi nng Kali mu trn 5,0 mmol/l.
Tng Kali mu t ngt c th e do tnh mng ngi bnh.

494
2. Triu chng
2.1. Triu chng tim mch
c biu hin ch yu trn in tm
- Sng T cao, nhn v i xng.
- Bt thng dn truyn trong nh (gim bin sau l mt sng P), ri lon dn
truyn nh tht (Bloc xoang-nh, Bloc nh-tht).
- Sau : ri lon dn truyn trong tht: phc b QRS gin rng.
- Nng hn: nhp nhanh tht, rung tht v ngng tim.
2.2. Triu chng thn kinh c: thng khng c hiu: d cm u chi v quanh
ming. Nng hn c th thy yu c hoc lit khi pht chi di v tin trin dn ln.
3. Nguyn nhn
3.1. Cung cp qu nhiu Kali: him gp ngi bnh thng, thng do iu tr Kali
ng tnh mch hoc ng ung.
3.2. Do Kali t ni bo ra ngoi bo
- Nhim toan chuyn ho.
- Tng phn hu t bo:
+ Hu c vn v dp nt c.
+ Bng nng, tn huyt nng.
+ Hu khi u t pht hoc do ho liu pht.
+ Xut huyt tiu ho nng.
- Hot ng th lc nng.
- Cc nguyn nhn do thuc:
+ c ch Bta khng chn lc
+ Ng c Digital
+ Ng c Fluor v Cyanure.
3.3. Gim tit Kali qua thn
- Suy thn cp.
- Suy thn mn.
- Thiu cc Corticoides khong: Suy thng thn.
- Do thuc: khng vim khng Steroide, cyclosporine A, Heparine, c ch men chuyn,
c ch th th Angiotensin II.
4. Chn on
Tt c cc trng hp nghi ng tng Kali mu phi lm in tm , in gii . Phi
chn on sm cc ri lon dn truyn iu tr cp cu.

495
VII. H KALI MU
1. nh ngha: Gi l h Kali mu khi nng Kali mu di 3,5 mmol/l. N c th e
da n tnh mng ca bnh nhn v gy ri lon tim mch.
2. Triu chng
2.1. Tim mch: Chm ti cc tht do ko di thi k tr.
- Triu chng in tm tu thuc mc gim Kali mu
+ on ST lm xung.
+ Sng T o ngc.
+ Tng bin sng U.
+ Ko di khong QU.
+ Gin QRS sau th ri lon nhp trn tht hoc nhp tht (ngoi tm thu, nhp
nhanh tht, xon nh, rung tht.)
2.2. Triu chng c
- Chut rt
- au c
- Yu c, lit.
- Khi nng dn n c th hu c vn.
2.3.Triu chng tiu ho: bn (do lit rut)
2.4. Triu chng thn: gim Kali mu mn tnh nng c th l
- Biu hin 1 hi chng tiu nhiu ung nhiu
- Nhim kim chuyn ho.
- Bnh thn k mn tnh.
3. Nguyn nhn
3.1.Gim cung cp Kali.
3.2. Chuyn Kali t ngoi bo vo ni bo
- Nhim kim chuyn ho hoc h hp
- iu tr Insulin trong i tho ng.
- Cc tc nhn kch thch Adrenergic
+ Pheochromocytome
+ Salbutamol, Dobutamin, ng c Theophylline
- Bnh lit chu k gia nh.
3.3.Mt qu nhiu Kali
- Qua ng tiu ho: tiu chy, d rut non.

496
- Mt qua ng thn:
+ Li tiu quai v Thiazide
+ Tng tit Hormon Steroid tuyn thng thn, cng Aldosterone nguyn pht,
th pht.
- Bnh thn k
- Bnh ng thn do nhim c: Amphotericine B, Aminoside.
4. Chn on
- Chn on xc nh: da vo nh lng Kali mu v in tm
- Chn on nguyn nhn: thng kh, phi da vo bi cnh lm sng, vo tin s
bn thn, gia nh v Kali niu,...

VIII. NHIM TOAN CHUYN HO

1. nh ngha

- pH mu ng mch di 7,38.
- HCO3- di 22 mmol/l.
- PCO2 gim th pht do tng thng kh b.

2. Triu chng
- H hp:

+ Tng thng kh
+ Sau suy h hp khi nng

- Tim mch: + Gim cung lng tim, thn,gan

+ Lon nhp
+ Gim nhy cm vi Catecholamine
- Thn kinh: + ri lon thc, hn m.
- Xt nghim: Tng Kali mu

IX. NHIM KIM CHUYN HO

1. nh ngha

- pH mu ng mch trn 7,4

- HCO3- mu trn 27 mmol/l.
- Tng PCO2 th pht (b).

2. Nguyn nhn
- Cung cp qu nhiu cht kim trong iu tr.
- Ri lon bi tit cht kim ca thn.
- Do gim th tch mu, kch thch h Renin-Angiotensin: thng phi hp gim Kali
mu v cng Aldosterone th pht.
- Do cng Aldosterone nguyn pht, hi chng Cushing...
3. Triu chng

497
- Thn kinh: nhc u, bun ng, l ln, co git.
- Tim mch: lon nhp tht hoc trn tht, d ng c Digital.
- H hp: gim thng kh.
- Thn kinh c: Chwostek (+), Trousseau (+), yu c.
- Xt nghim: gim K+ mu, gim Ca mu, gim Mg mu, gim Phosphat mu, pH mu
trn 7,42; HCO3- trn 27 mmol/l.
- Thn: tiu nhiu, kht nhiu, ri lon c c nc tiu.

X. NHIM TOAN H HP (PCO2 trn 40 mmHg)

1. Nguyn nhn: kh ph thng, ph phi cp, gim hot ca trung tm h hp.
2. Lm sng: tm, th nhanh nng, nhc u, run chn tay, ri lon tm thn.
3. Chn on: ch yu da vo bi cnh lm sng c bnh nguyn thch hp v xt
nghim ion mu.

XII. NHIM KIM H HP (PCO2 di 40 mmHg)

1. Nguyn nhn: Histeria, tn thng thn kinh trung ng (vim no, trng c
Salisilat...) th gng sc.
2. Lm sng: Th nhanh, su, ri lon thc.
3. Chn on: da vo xt nghim mu. Chn on phn bit gia cc th ca ri lon
thng bng toan kim c tm tt theo bng sau
Bng 1: Chn on cc dng ri lon cn bng toan kim n gin
pH mu

H+

HCO3-

PCO2

Toan chuyn ho

Kim chuyn ho

Toan h hp

Kim h hp

498

SHOCK NHIM TRNG

Mc tiu
1. Pht hin c cc triu chng tin chong.
2. Theo di c bnh nhn shock nhim trng.
3. Bit cch phng shock nhim trng.
4. Trnh by c cc bin php iu tr shock nhim trng Gram m
Ni dung

I. NH NGHA
Shock nhim trng l mt trng thi lm sng pht sinh do s suy tun hon nhng m
do nhim trng huyt thng l Gram m. S gim tun hon cc t chc l nhiu
yu t bnh l:
Sc cn ngoi bin tng.
mu trong huyt qun.
Lu lng tim gim.
Thiu kh m.

II. BNH NGUYN

C khi do vi khun Gr(+) nhng t trm trng Shock nng mc d c h HA nhng c
gin mch ngoi bin, lu lng tim bp v lu lng mu bnh thng. Trong thc t,
Shock nhim trng thng ch do Gr(-) nht l trc khun ng rut, ng u l
Escherichia Coli, Streptococcus Faecili, vi khun khc nh Pseudomonas oeruginosa,
cc Proteus, Klebsiella. Cc vi khun Gr(-) tit ni c t gy cc phn ng bnh l v
ph trch trc tip Shock.
S pht trin ca Shock nhim trng Gr(-) thng c mt s iu kin lm d nh:
C a xu, ngi gi, tr em, ngi c bnh mn tnh
S dng khng sinh ba bi chng Gr(+) dit ht Gr(+) lm tri vi khun Gr(-).

III.SINH BNH HC
1.Nhc li khi nim sinh l cn thit v sinh bnh l
1.1.Khi nim v c quan tip th v ca h trc giao cm
lm co mch ton b, k c tnh mchnhng tnh mch co t hn v c trn thnh
tnh mch mng.
lm gin mch v kch thch tim mch c v tn s ln cng .
S phn phi hai c quan ny rt khc nhau, c nhiu huyt qun, da, c v c
quan ni tng nhng t no v tim.Ngc li h nhiu tim no m t cc c quan
khc.
1.2.Khi nim v cc c vng mao mch

499
Bnh thng cc c vng u mao mch ng li mt s mao mch. Cc mao
mch ny chu tc dng ca nhiu cht khc nhau. c bit c vng sau mao mch
chu co bi catecholamine(Adrenaline v Noradrenaline). C vng u mao mch m ra
bi cc cht chuyn ha toan.
1.3.Cc mch ni tc ca ng mch v tnh mch
Bnh thng cc mch ni tc ng li, nu v l do g c vng m ra nh shock nhim
trng th mu s vo mch ni a n hin tng ni tc lm cho cc m thiu mu.
2.C ch bnh sinh
ngi Shock nhim khun c hai giai on
Giai on tng vn ng (xem bng)
Nc v huyt tng ra ngoi khong k.
Cung lng tim (CO) gim do gim tun hon tr v v gim sc co bp ca c tim
Sn sinh yu t MDF (Myocardial Depressant Factor). MDF do men tiu t bo to ra
vng bng b thiu mu. Tnh cht ca suy tim l suy tim tri (tng p lc cui tm
trng tri).
Bnh nhn thng c toan chuyn ha.
Nu khng iu tr ngay, nhiu tng s b suy: tim, phi, thn, gan, ng tiu ha, ty.
Bng 1: Hai giai on ca Shock nhim khun
Giai on

CI

RPT

HA

CVP

MVO2

DAVO2

PH

Tng vn ng
(Hyperkinetique)

Tng

Gim

Gim
nh

Gim nh

Tng

Gim

Tng

Gim vn ng
(Hypokinetique)

Gim

Tng

Gim

Thay i

Gim

Gim

Gim

CI (Cardiacindex): Ch s tim.
CO (Cardiac output) S lng tim o bng phng php nhit pha long.
CVP: (Central venous pressure): p lc tnh mch trung tm.
DAVO2: chnh lch Oxy mu ng - tnh mch.
RPT: Sc cn ngoi vi ton b.
MVO2: tiu th Oxy.
Trn thc nghim ngi ta thy rng trong Shock ni c t t bo b tn thng qua 4
co ch:
Tn thng t bo do ni c t.
Bch cu phng thch ra men Lysosome (Men tiu t bo).
Hot ha h thng b th.
Ri lon chuyn ha do thiu Oxy t bo. Tn thng ca t bo ni mc, tiu cu
bch cu gy:

500
Tng tnh thm thnh mch.lm cho nc thot ra khong k lm gim th tch mu
hu hiu.
Gim tiu cu: Tiu cu b ph hy s phng thch ra cc cht trung gian nh
Serotonine, Adrnaline, Thromboxan 2 gy co mch.
Bch cu ht gim: Bch cu b ph hy phng thch ra cc men tiu t bo v cc dn
cht ca Arachidonic qua ng b th v ng Properdine
i thc bo sn xut ra TNF v Interleukin gy gin mch nhanh, toan chuyn ha,
hot ha h thng ng mu, xut huyt ty, thng thn.
Thiu Oxy t bo gy ra:
Ri lon chc nng to Glycogen, ri lon chu trnh Krebs, ri lon to mt, tng
Lactate mu.
Ni c t
Gy co tht c trn trc v sau mao mch (tc dng ln th th lm ng mu
phi, bng, thn).
Thng qua yu t Hageman (XII) lm hot ha Bradykinine l cht gin mch gy
ng mu t chc ngoi bin. Bradykinine cn lm tng tnh thm mao mch.
Ngi ta c nu ln tc hi ca Acide Arachidonic v opi ni sinh (Endorphine). Dng
Imidazole ngn cn s hnh thnh Thromboxan A2 hoc dng Prostacycline i khng
vi Thromboxan A2 s khng gy c Shock ni c t. Trn ngi thn v oi l hai
c quan b Shock ni c t nh hng trc tin: gi l thn Shock, phi Shock.
Giai on u: s tit ni c t c tc dng tng t Catcholamine lng va phi
nn gy co mch va phi do tc dng ca Gy co mch da, c, thn, cc tng)
dn mu cho tim, thn, no ng thi kch thch va phi lm tng lu lng tim, giai
on ny c li cho bnh nhn, tuy nhin thn v co mch nn lng nc tiu t
dn.
Giai on sau: S sn xut ni c t qu nhiu lm co qu mc cc huyt qun do tc
dng ca nht l co c vng sau mao mch, mu li trong cc mao mch khng v
tim c lm gim lu lng mu ton c th. S mu ton c th ng thi s to
s thiu Oxy trong cc m, trong t chc. Cc t bo s phn ng bng chuyn ha
theo c ch k kh dn n sn xut ra sn phm chuyn ha toan lm m rng c
vng u mao mch lm mu thm trong cc mao mch bnh htng c mu v c
nhng mao mch bnh thng khng c mu. Hu qu l mu cng ng cc mao
mch dn n cng gim thm lu lng tun hon. ng thi s tr s lm tng p
lc thy tnh, nc in gii thot ra ngoi. iu ny s lm lu lng mu cng gim
thm. Tm li c hai hu qu chnh
Gim lu lng tun hon.
Thiu mu, thiu Oxy m.
M hai hu qu ny chnh l nh ngha ca Shock.
Cc khu trong c ch bnh sinh cng xc tc thc y cho nhau i theo mt vng ln
qun khng hi phc c do Shock nng dn, cui cng s dn n ng mu ri

501
rc ni mch (CIVD: Coagulation intravasculaire dissminee) thng tn lan ta ca
cc mao mch v huyt qun do thiu Oxy lm mu ng ti ch cc thnh mch do
lm tiu th ht cc yu t ng mu dn n chy mu lan ta tt c cc c
quan.

IV.TRIU CHNG V CHN ON SHOCK NHIM KHUN

1.Hon cnh xut hin
Khi nim:
- Bt k nhim khun khu tr hay ton thn thng
+ ng tit niu: si, sau m.
+ Tiu ha: vim mt qun, vim phc mc rut tha, sau m.
+ H hp: k c m kh qun, vim phi.
+ Sinh dc: sau sinh, no ph thai.
+ Tnh mach: thm d huyt ng, truyn dch.
+ Da: lot da, lot mng, vim da.
-a s l gram m.
-Thng gp trong th thut cp cu.
-40% l nhim khun mu.
-60% Xy ra trn c a suy km.
2.Mt vi c im lm sng
2.1.Do no m cu: Shock xut hin nhanh, chy mu di da, hi chng mng no,
CIVD,xut huyt nhiu ni: no, thng thn,da nh hi chng Schwarztmann
Sanarelli (do tim no m cu cht vo tnh mch).
2.2.Do ph cu: (Nhim khun mu)
TR NH C A GIM MIN DCH. LM SNG NH NO M CU. C CH:
KHNG NGUYN V PH CU VO MU NHIU.
2.3.Do ngoi c t
T cu: Sau vim da, chn m, vim sinh dc
Lin cu tan mu: vim hng, vim da.
2.4.Do vi khun thng hn: Lin quan ti khng sinh liu cao lm tan vi khun.

V. PHNG BNH
iu tr tch cc cc trng hp nhim trng Gram m.
Trnh s dng ba bi cc loi thuc khng sinh dit vi khun Gram dng.

VI. IU TR
1. Ti lp khi lng tun hon v iu chnh thng bng kim toan

502
C th truyn dch ng trng, c th km mt t dung dch Glucose cung cp
nng lng.
Dung dch kim nh Natri bicarbonate.
Khi lng dch truyn c th rt ln ty nng nh.
Trong truyn dch cn theo di p ng, phng nc, suy tim. Nu c dung dch
Dextran l cht cao phn t c trng lng phn t ln, to thnh trong lng huyt
qun mt lp trng lm tiu cu khng dnh vo c v chnh n li trong lng mch
lu hn.
2. Cc thuc vn mch
Hin nay ngi ta hay dng Dopamine liu 5 - 20 g /kg /pht truyn tnh mch rt
chm.
Ch iu chnh toan khi x dng cc thuc vn mch.
Trong trng hp nhp tim nhanh th c th dng Dobutamine thay th cho Dopamine.
Vn s dng Adrenaline v Noradrenaline cn ty theo trng phi, c th phi hp
Dopamine vi Noradrenaline khi Dopamine liu > 20 g /kg /pht m huyt p tm thu
<90mmHg hoc khi nhp tim qu nhanh >130ln/pht.
3. Khng sinh
Nguyn tc l dng sau khi cy mu v da vo khng sinh , nhng trong khi ch
i khng sinh nn dng khng sinh c ph khun rng. Phi dng liu cao nn tt
nht l dng bng ng tnh mch. (Lu bnh nhn c suy thn chc nng hoc
thc th nn cn d dt vi nhng khng sinh c cho thn nh Streptomycine,
Gentamicine).
Cn nm vng loi khng sinh ang s dng, dc ng hc, ch nh, chng ch nh,
tc dng ph v tai bin do thuc.
Theo di p ng ca khng sinh, d phng khng khng sinh (vi khun khng
thuc).
Thi gian s dng khng sinh phi hp l, kinh t nhng phi cht lng
Cc loi khng sinh thng c s dng trong chong nhim trng Gr (-) l:
-Cephalosporin th h III (Ceftriaxon, Cefomic.)
Hp thu tt qua ng tiu ho, thuc phn b khp c th ngoi tr dch no tu ch
vo c khong 20% thuc qua c nhau thai v sa m, thi tr qua nc tiu.
Thuc tc dng tt trn nhiu vi khun rut nh Escherichia Colie, Klebsiella, Proteus
Mirabilis, Shigella, Salmonella.
Tc dng ph v c tnh: C khong 0,05% d ng ging Penicilline, ngoi ra thuc c
th gy ri lon tiu ho nh tiu chy, bun nn, nn ma, nhim nm.
Gim Bch cu, tiu cu, tng men gan
-Aminoglycosides: (Streptomycin, Gentamicin, Tobramycin, Amykacin)

503
L thuc dit khun, thi gian bn hu tu thuc chc nng thn, khng hp thu bng
ng ung, thuc khuych tn vo phn ln cc t chc v th dch ca c th, trong
ti nhu m thn cao hn huyt tng. Thuc hp thu km mt, tin lit tuyn,
khng qua hng ro nhau thai, sa m v hng ro mu no., h thn kinh trung ng
v mt.
Thuc thi tr qua nc tiu 65% sau 6 gi, 85% sau 24 gi.
Ch nh
-Nhim trng Gram m ti thn v h tit niu, nhim khun huyt
Tc dng ph v c tnh
-Ri lon thnh gic: tin nh b c gy chng mt, mt iu ho, rung git nhn cu,
tai, gim hoc mt thnh lc. Trng hp nng tn thng s khng hi phc.
-c vi thn: thuc thi tr, tch ly v thn v gy bnh ng thn cp. Tc dng ny
thng xy ra ngi ln tui, c bnh thn hoc mt bnh l gy mt nc.
Liu lng:
-Amikacin 15 mg/ kg / ngy chia 2 ln.
-Gentamicin 5 mg/ kg / ngy chia 2 - 3 ln / ngy.
Nhm Nitroimidazole: (Metronidazole)
L thuc khng khun, hp thu nhanh gn 80% sau 1 gi, nng trong huyt tng
khi s dng bng ng ung v ng tim tng ng nhau, thi gian bn hu t
8 - 10 gi. Thuc gn vo Protein khong 20%, thuc khuych tn nhanh, mnh phi,
gan mt dch no tu, thn nc bt, tinh dch, dch m o. Thuc thm qua nhau thai
v sa m.
Thuc chuyn ho qua gan, nng cao gan v mt. Thuc thi tr ch yu qua
nc tiu v c mt lng nh khi thi tr cn nguyn hot tnh nn lm cho nc tiu
c mu nu.
Tc dng ph v c tnh:
-Ni my ay, nga, chn n, bun nn, c v kim loi ming, vim ming, i tin
phn lng, nhc u chng mt, gim bch cu a nhn, vim dy thn kinh v nu
dng ko di c th ri lon tm thn.
Nhm Quinolone: l thuc dit khun bao gm:
Th h 1: cc Nalidixic acide, Oxonilic acide, Pipemidic
Th h 2: (Fluoroquinolone) Norfloxacin, Ofloxacin, Ciprofloxacin, Enoxacin, Pefloxacin,
Lomefloxacin, Levofloxacin.
Th h 3: Sparfloxacin (Zagam)
Hp thu tt nhng c i lc vi kim loi nng, b c ch khi dng chung vi Fe, Calci,
v mt s Cation. t nng cao khi dng trc n 1 gi hoc sau n 2 gi
Hp thu: thuc c hp thu nhanh v rt tt hu nh t 100% nng cao nht t
trong huyt tng sau ung 6 gi, thi gian bn hu 6 - 8 gi. Thuc c phn b

504
khp t chc v dch nh phi, da, c t cung, bung trng, m v dch tin lit tuyn,
m. Thuc thi ch yu qua thn (80%).
Tc dng ph v c tnh
-Ri lon tiu ho, au vng thng v, bun nn, nhc u, chng mt, ng g, o
gic, l ln, co git.
-au c, au khp, ni my ay pht ban
-Tng men SGOT, SGPT v LDH, tng BC acid, gim BC trung tnh gim tiu cu.
-Tng tc dng ca Theophyllin, Warfarin.
-Zagam gy ri lon nhp tim trong trng hp QT ko di nn khng c vi
Cordarone.
Chng ch nh
C thai, dang cho con b, tr s sinh, ngi gi trn 70 tui suy gan suy thn, ngi
ang mc bnh tm thn, thiu men G6 PD.
Khng nn dng khi ang li xe, ngi ang lm vic trn cao, s dng my mc.
4. Bin php khc
- Corticoide tim tnh mch liu cao chng s thm qua mng mao mch.
- H tr h hp bng Oxy liu cao, thng kh c hc, khai thng ng h hp trn cho
bnh nhn.
- Thuc tng sc co bp c tim.
- Huyt tng ti, mu ti c th gip cho bnh nhn khi phc lng mu, chng
chy mu.
- Cui giai on II, u giai on III c dng Heparine chng ng mu nhng
kh nguy him. Hin nay ngi ta c th dng Acide Aminocaproide.
- iu tr loi b nhim trng nh ct ti mt, iu tr p xe...

505

TRNG C CP THUC TR SU GC PHOSPHORE HU C

Mc tiu
1. Trnh by c c im dch t hc
2. Nu c c ch bnh sinh v cc yu t lm nng thm tnh trng ng c
3. Trnh by c cc triu chng lm sng cn lm sng.
4. Chn on xc nh v iu tr c trng c theo cc mc .
Ni dung

I. DCH T HC
Thuc tr su gc phospho hu c c s dng rng ri trong nng nghip, chng
c dng dit cn trng do tip xc trc tip hoc qua h thng ca cy c do cn
trng n phi cc loi cy c ny. Ngoi ra ngi ta cn x dng cc thuc ny dit
mt s k sinh trng ngi v sc vt nh ch, rn. Do vic pht trin v x dng cc
thuc ny ngy cng ph bin, nn vic trng c cp loi thuc ny ngy cng nhiu
nc ngoi cng nh trong nc. Cc cht phospho hu c c th gy ra cc triu
chng trm trng cht ngi. Do trng c phospho hu c l mt loi trng c
nguy him v vy cn c chn on sm v iu tr kp thi, ng v y mi
trnh c t vong.
Ng c phospho hu c thng xy ra nng thn nhiu hn thnh ph v ni y
thuc c s dng mt cch rng ri, nht l nhng ngi lm nng nghip v
thng xy ra v ma h nhiu hn ma ng. Gp thanh nin nhiu hn l ph
n. nhng ngi b nhim c mn thng c nng nhim c thp hn ngi
cha tng b ng c. ngi gi, ph n c thai v c bnh mn c sn thng b
ng c nng hn ngi thng.

II. C CH BNH SINH

1. i cng v s dn truyn qua synape
Khi neurone b kch thch, t bo kh cc, xung ng c dn truyn theo si trc n
mt tn cng, ti y xung ng to nn mt kch thch mi lm cho cc ti cha
Actylcholin chuyn ng Brown va vo nhau v ra gii phng Actylcholin, Actylcholin
i qua khe synape n tip xc vi rcepteur ca mng sau synape (mng t bo c...),
gy kh cc ti y, v gy co c.
khe synape, sau khi gy kh cc mng sau synape, Actylcholin b
Actylcholinestrase phn hy thnh Actate v cholin mt tc dng, kt thc qu trnh
kh cc.

506
Synape gia 2 neurone

Synape TK-c

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

Xung ng

Ti cha Actylcholin (Ach)

Ach
Phospho hu c
(-)
Acetylcholinestrase
Actylcholin

Actate + Cholin

Atropin
Mng sau synape

Rcepteur

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

2. C ch tc dng ca thuc tr su gc phospho hu c

2.1. C ch gin tip
Thuc tr su gc phospho hu c vo c th phi hp vi acetylcholinestrase thnh
mt phc th bn, tc phn li xem nh bng khng. Do acetylcholinestrase mt
hn tc dng thy phn Acetylcholine.
Acetylcholinestrase b bt hot ha, ch c b li do s tn to
Acetylcholinestrase, s ti to ny xy ra rt chm sau nhiu ngy, c th hng tun,
thm ch hng thng.

507
Acetylcholine khng c Acetylcholinestrase bt hot ha, tch t li nhng ni
bnh thng n c tit ra trong trng thi b kch thch cng nh trong trng thi ngh
l:
- Giao thoa thc hnh ca ton h i giao cm.
- Giao thoa hch giao cm (c trc v i giao cm) v tm vn ng
- Giao thoa lin thn kinh trung ng
2.2. C ch tc dng trc tip
Trn cc v tr tip th Acetylcholine. Nu thuc tr su gc phospho hu c nng
cao v tc dng ko di th c th lm cho tm vn ng thoi ha kh hi phc.
3. Kt qu tc dng ca thuc tr su gc phospho hu c
Do c ch tc dng c ch men cholinesterase khng hi phc, phospho hu c to ra
3 loi tc dng sau:
3.1. Tc dng dng Muscarine
L kt qu tc dng kch thch ln cc giao thoa thc hnh i giao cm gy ra nhng
du chng hng phn i giao cm trn cc c trn, cc tuyn, tim...H thn kinh trung
ng chu tc dng ny khng c hiu. (Kch thch hay c ch)
3.2. Tc dng dng Nicotine
L kt qu tc dng trn cc giao thoa hch giao cm v tm vn ng c vn trong
quan trngnht l c h hp. Tc dng Nicotine c tnh kch thch lc ban u, ko di
mt thi gian ngn, nhng sau li lm lit cc c quan chu nh hng khi s nhim
c nng v ko di.
3.3. Tc dng trn thn kinh trung ng
C tnh kch thch ri lm lit khi cng v thi gian nhim c tng. Quan trng
nht l tc dng trn cc trung tm sinh thc.
Tc dng dng Muscarine c trung ha d dng bi Atropine, t chu nh hng ca
cc oximes.
Tc dng Nicotine chu nh hng rt t ca Atropine v Oximes tr tm vn ng, chu
nh hng rt tt ca Oximes.
Tc dng thn kinh trung ng chu nh hng kh tt ca Atropine, khng chu tc
dng ca Oximes.
4. S xm nhp-hp th-bin i v thi tr thuc tr su gc phospho hu c
Phn ln cc thuc tr su gc phospho hu c u tan mnh trong lipit, nn chng
c hp th d dng qua da v nim mc nh nim mc mt, tiu ha, h hp,chng
thng c dng di dng kh dung, sau khi pha long hng trm, hng ngn ln.
Thuc xm nhp bng mi ng
- Da, nim mc, nht l khi c sn tn thng nh dng xc gh, bn vo mt, tip
xc da khi s dng thuc

508
- H hp: nh ht phi hi thuc khi m bnh thuc kn, ht phi kh dung khi bm thuc
- Tiu ha: do t t hay ung nhm.
S hp th rt d dng bng mi ng k trn rt nhanh v hon ton, nhanh nht l
qua ng h hp, chm nht l qua da. Chng c th b trung ha phn no bi cht
kim v Hypochlorite.
Trong c th chng b thoi bin bi cc men thy phn v oxy ha, nht l trong gan,
nhng s thoi bin ny rt chm. i vi cht phospho hu c phi hp vi
Acetylcholinestrase, ch thi di dng thoi bin thnh Paranitrophenol.
5. c tnh
Trong cc phospho hu c th thiophot (parathion) l c c tnh ln nht, trung bnh l
mthyl parathion (wolfatox) v nh hn l malathion. v d liu ng c ca parathion l
<5mg/kg th trng, mthyl parathion l 5-50mg/kg th trng, malathion l 50-500mg/kg
th trng. c tnh ny tng gp ln hng chc ln khi 2 th thuc c phi hp vi
nhau.

III.TRIU CHNG
1. Thi gian tim tng: thay i ty theo nhiu yu t.
1.1. ng xm nhp: t nhanh n chm: h hp, tiu ha, da.
1.2. trm trng ca s nhim c: cng nng th thi gian tim tng cng ngn. V
d ng c trung bnh th cc triu chng lm sng thng xut hin sau 1 gi, nhng
nhng trng hp nng th ngn hn ch sau 15- 30 pht v trong trng hp rt nng
nhiu lc ch 30 pht n 1 gi bnh nhn cht.
1.3. Th trng bnh nhn: cng nh tui thi gian tim tng cng ngn (v nng
AchE km). Ngi gi triu chng ng c cng nng hn.
1.4. Yu t nhim mn: Ngi b ng c nh tim tng trc cng b trng c
nhanh hn. Ngi b ng c mn tnh, du nhim c nhanh v nng hn nu c
nhim cp.
1.5. Bng i, ung ru: cng lm trng c bng ng tiu ha xy ra nhanh hn.
1.6..Phi hp nhiu ng nhim c: lm ngn thi gian tim tng.
2. Th t xut hin cc du chng
Du chng dng Muscarine xut hin trc tin. Du chng dng Nicotine v thn kinh
trung ng thng kh phn tch hn, xut hin chm hn. Nhng nu trng c trm
trng th c 3 loi du chng xut hin ng thi.
3. Cc du chng trn cc c quan
3.1. Mt: c du Muscarine r nht, sung huyt kt mc, teo ng t c th rt mnh
bng u kim gm, nhng vn cn p ng vi nh sng, hn lon iu tit, gim p
lc ni nhn. Du teo ng t l du Muscarine rt nhy nn c th l mt trong nhng
du nh gi trm trng lc ban u, tr trng hp mt b tc dng trc tip ca
tr su do thuc bn trc tip vo mt th du ny sm v nng nhng c th du
nhim c ton thn khng nng.

509
3.2. Da: cng l ni biu hin du dng Muscarine r, sung huyt, chy m hi.
3.3. Tiu ha: du chng dng Muscarine. Tit nc bt rt nhiu, tng tit dch tiu
ha nht l dch d dy, tng nhu ng, co tht trn tiu ha gy au qun bng, kh
nut, bun nn, nn. Nu trng c trm trng c nh hng n thn kinh trung ng
th c du i tin v thc.
3.4. Du h hp: biu hin 3 loi tc dng: Muscarine, Nicotine, thn kinh trung ng.
Tc dng muscarine lm tng tit dch ph qun gy ho, tng tit m gii, bt ph qun
gy kh th, nghe ran n t to nh ht, ng thi lm co tht c trn ph qun gy
kh th thm.
Tc dng Nicotine giai on lm lit s lm lit c h hp gy suy h hp nng. Tc
dng ny cng lm nhn li gy tt li lm bt ng h hp.
Tc dng thn kinh trung ng giai on lit s lm lit trung tm h hp, tng cc tc
dng ni trn.
Suy h hp cp, l biu hin tt nhin ca trng c nng, l nguyn t vong chnh.
3.5. Du tun hon: cng biu hin phi hp 3 loi tc dng.
Tc dng Muscarine lm mch chm, huyt p h.
Tc dng Nicotine v thn kinh trung ng: gy cng trc giao cm v kch thch cc
trung tm iu ha tim mch, t nht l trong giai on kch thch a n mch nhanh,
huyt p cao. Trong giai on lit ca tc dng Nicotine, thn kinh trung ng, cc du
chng c th ngc chiu tr li l try tim mch.
3.6. Du c vn: biu hin tc dng Nicotine v thn kinh trung ng.
- Giai on kch thch
Rung c, tht s l rung cc th c l mt du chmg quan trng cho bit trng c
kh trm trng, cn tm k pht hin nht l c ngc,bng, cnh tay, vai v i. Cn
phn bit vi rung c v lnh.
- Giai on lit c: yu c ri n lit c, quan trng nht l c h hp lm ngng th.
Nu trng c ko di, lm tm vn ng b thoi ha th lit c s ko di rt lu.
3.7. Du thn kinh trung ng: biu hin do c 3 loi tc dng
- Muscarine v Nicotine gy thiu kh no, v tc dng thn kinh trung ng trc tip
ca phospho hu c.
- Trong giai on u l kch thch, bt an, co git.
- Trong giai on cui, gim phn x gn xng, ri mt phn x, hn m, lit cc trung
tm thn kinh sinh thc.
- St c th du chng nhim c thn kinh trung ng ca phospho hu c.

IV.TIN TRIN
1. Khng iu tr

510
C th t lnh nu trng c nh. Nhng nu l trng c kh nng th cc du chng
s tng dn a n hn m, suy h hp v cht.
2. C iu tr ng mc
Cc du Muscarine gim v bin mt trc, sau hai du chng Nicotine v thn kinh
trung ng cng thuyn gim dn. Nhng nu trng c qu trm trng hay iu tr
chm, th ban u cc du chng Muscarine gim, bnh nhn c th tnh li, nhng sau
cc du Nicotine v thn kinh trung ng ngy cng nng v a n suy h hp v
t vong.
Nguyn nhn t vong chnh l suy h hp trong hu ht cc trng hp.

V. CHN ON
1. Chn on xc nh
Cn c vo hi bnh, hi thn nhn bnh nhn nht l da vo mi hi c bit ca
thuc tr su trong hi th, trong cht ma, trn o qun, da bnh nhn, da vo cc
du chng lm sng c hiu, nht l du Muscarine c phi hp hay khng vi du
Nicotine v thn kinh trung ng.
Cn lm sng cn cho nhng trng hp nh, khng r loi ng c bng cch nh
lng butyrocholinestrase trong huyt tng hay Acetylcholinestrase trong hng
huyt cu. Hai t l ny gim. Tht ra, s gim hai t l ny khng phn nh trung thc,
m t Acetylcholinestrase trong cc m l t quyt nh trm trng ca s trng
c: T cholinesterase gim < 30% l ng c nh, 50% l ng c va, gim > 70% l
nng.
2. Chn on trm trng: Cn c vo hi bnh:
- Th trng bnh nhn.
- ng nhim c. Nht l ng ung v bng i.
- Lng thuc xm nhp c th.
- iu kin trng c (t c, hay ng c).
- Thi gian t lc nhim c n lc c loi b thuc ra khi c th (sc d dy) v
c iu tr ng mc.
- iu tr tuyn di tt hay khng.
Ni tm li, tt c nhng iu kin no lm cho lng thuc ngm vo c th cng ln,
iu tr ng mc cng chm, cng lm trm trng tng thm.
Chn on trm trng cn cn c vo du lm sng, cc du Nicotine v thn kinh
trung ng nng th trm trng cng cao.
S gim t butyrocholinesterase v Acetylcholinesterase khng phn nh hon ton
trung thc trm trng.
Trong thc t, hi bnh nhn v khm lm sng k c th c tnh trm trng kh
ng n.
2.1. Nh: du Muscarine nh hay n thun.

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2.2. Va: du Muscarine nng + du Nicotin v du TK trung ng va.
2.3. Nng: du Nicotin v thn kinh trung ng nng, du muscarine c th c hay khng.
Hoc du trng c va + yu t nng do hi bnh.
3. Chn on phn bit
3.1. Ng c DDT (Dichloro-Diphnyl-Trichloetan): L cht dn xut ca clorobenzen,
khng thm qua da ch thm qua nim mc tiu ha. Triu chng ng c l gy ri
lon tiu ha, xut hin 1-6 gi sau nh nn ma, a chy, au bng. Tc dng trn h
thn kinh, gy nhc u, d cm, run, co git, cng co git ty thuc vo nng
DDT trong no. Du t nh n nng l rung c, tng phn x, co cng ton thn, co
git, suy h hp, ngng th, ngng tim v cht.
3.2. Ng c 666: L dn xut ca Cyclo hexan,cng gy cc triu chng nhim c
ging nh DDT, nhng thi gian tim tng ngn hn.
3.3. Ng c Carbamate: Lm sng ging ng c phosphore hu c. C ch cng
ging. iu tr bng Atropin, nhng khng dng PAM v lm nng thm tnh trng ng
c.

VI. IU TR
1. Nguyn tc iu tr
- Xc nh c cht: xc nh c phi l Phospho hu c hay khng cn da vo hi
bnh nhn, ngi nh hoc ngi chung quanh; y l loi thuc dit su b khc vi
cc loi thuc khc thng dng hin nay l thuc dit nm v thuc dit c. Tn thuc
thng da vo bng danh mc cc thuc phospho hu c thng by bn trn th
trng. Mu sc, mi v v cu to ca thuc: Thng trnh by di dng lng, c
mu trng nht l khi ho vi nc c mu trng c nh sa v c mi nng nc rt
c bit, khc vi mi ca cc loi thuc st trng khc.
- Gii hn lng cht c hp thu vo c th v loi b cht c ra khi c th.
- Trung ha tc dng ca thuc c c hp thu.
- Phng thch Acetylcholinesterase khi phc th Acetylcholinesterase-Phosphore hu
c.
- iu tr triu chng nhiu lc rt quan trng v c th cu sng bnh nhn nh ng
kinh, tt huyt p, ngng th bng th my.
2. iu tr c th
2.1. Loi b cht c: ty theo ng ng c
- Ty sch thuc khi da v nim mc: ci b qun o dnh thuc, lau sch thuc da,
ra da tht sch bng x phng, hay tt hn nc c pha bng Bicarbonate hay
Hypochloride.
- Nu thuc dnh vo mt th ra mt tht sch.
- Nu trng c bng ng h hp th lp tc a bnh nhn ra khi vng ng c,
c bnh nhn vo khu vc thong mt, tng thng kh phi loi b thuc qua
ng h hp.

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- Sc ra d dy: p dng cho trng c do ng tiu ha. Mun c hiu qu v
khng nguy him, cn thc hin trong nhng trng hp sau y:
+ Sc ra cng sm cng tt. Thc hin trc 6 gi k t khi b nhim c.
+ Bnh nhn khng m.
+ Trc khi sc phi tim Atropine trc, liu thch hp vi trm trng thng l
2mg v cn thc hin t nht l 4 pht (nu tim tnh mch) v 10 pht (nu tim bp),
v khi sc d dy c th lm tng trng thi cng i giao cm sn c v gy phn x
c ch cht ngi.
+Sc d dy phi c thc hin nh nhng, trnh tng kch thch i giao cm thm.
Dng nc pha Bicarbonate, lng nc sc kh nhiu cho n khi ht mi hi.
Thng c th n vi chc lt nc sc ra d dy.
2.2. Atropine liu cao dng sm
- C ch tc dng: Atropine l thuc c ch i giao cm hiu qu nht trong trng c
cp thuc tr su gc photpho hu c.
Atropine c tc dng
+ i khng mnh trn cc du chng dng Muscarine biu hin cc c quan thc
hnh ngoi bin.
+ Tc dng i khng yu hn trn du chng thn kinh trung ng, trn cc du
chng dng Nicotine hch giao cm, v hon ton v hiu i vi s lit c vn do
tc dng ti tm vn ng.
- Tc tc dng: Liu trung bnh 2mg Atropine Sulfate hay Tartrate tim bng ng
tnh mch: 1 pht sau bt u c tc dng, nu tim bp hay di da th 8 pht sau, v
t tc dng ti a sau 6 pht i vi tim tnh mch v 35 pht nu tim bp hay di
da.
- Thi gian v liu lng dng Atropine: Khi s trng c c xc nh, th tim
Atropine cng sm cng tt.
+ Trng c nh: D cha c du chng trng c vn tim bp 1-2mg Atropine, lp
li nu cn cch nhau 30 pht. cho n khi ht du chng Muscarine v c du no
Atropine. Sau duy tr trng thi no Atropine nh va trong 24 gi hay hn. Ch :
gim liu trc, gim thi gian sau.
+ Khi trng c va: tim tnh mch 3-5mg Atropine, lp li liu 2-4mg cch nhau
khong 10-15 pht cho n khi du chng Muscarine bin mt v c no Atropine nh.
Sau duy tr Atropine nh hoc va trong vng 48 gi hay hn.
+ Trng c nng: Nht l khi c kh th, co git, hoc hn m th tim tnh mch 5 n
8mg Atropine ngay. Lp li liu 5mg cch khong 5-8 pht cho n khi ht co git v
gim tit dch ph qun v tit nc bt. Sau tr li pht iu tr trng c nng
va, cho n khi ht du chng Muscarine v c no Atropine. Duy tr trng thi Atropine
va hoc nhiu trong vng 48 gi hay hn.
- p ng vi Atropine v theo di bnh nhn: Atropine liu cao dng sm ci thin r
bnh cnh lm sng, lm mt du Muscarine, ci thin thng kh phi, lm chm s lit

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trung tm thn kinh nn ci thin c hn m, co git v kh th, nhng trong nhng
trng hp rt nng, th s ci thin ch nht thi. Bnh nhn sau b lit h hp v
Atropine hon ton v hiu i vi s lit tm vn ng.
i vi nhng trng hp trng c va hay nng, khi s dng Atropine liu cao, cn
theo di bnh nhn tht st iu chnh liu lng, pht hin du chng bo hiu
tng trm trng tr li, khi gim liu Atropine. Theo di st s pht hin s ti xut
hin cc du chng trng c.
Trng c Atropine
+ Trng c nh: kh ming, mi, hng, gy kh nut, cm gic nng ch quan, mt
phng , tim nhanh, kh tiu, gin ng t, lm nhn gn kh.
+ Trng c va: cc du chng trn tng nhiu c bit nhit ngoi bin tng cao,
bun ng nhiu, bn, b tiu, chng mt, bt an, ni nhiu.
+ Trng c nng: ngoi nhng du chng trn, du chng thn kinh trung ng nng,
r hn vi st cao, mt nh hng, o gic du chng tm thn, qu kch thch, ni
sng chy by.
- Nguyn tc gim liu Atropine: Cn gim liu t t v theo di st cc du Muscarine
ti pht hoc xut hin du Nicotine nng; do cn gim theo kiu bc thang nh v
cn gim liu trc khi gim ln tim Atropine.
2.3. Pralidoxime (P2AM = Pyridine 2 - Aldoxine Methiodide)
- C ch tc dng: Pralidoxime c c tnh tc dng vi phc th AchE - PHC kt
hp vi phospho hu c gip gii phng AchE t do ti hot ng. Nhng oximes cn
c dng sm th mi hiu qu. Tc dng oximes r nht trn tm vn ng.
- Tc tc dng: Tim tnh mch, P2AM c tc dng rt nhanh, yu c v rung c
gim ch sau 5-30 giy, ti a sau 5-10 pht.
- Thi gian v liu lng dng: P2AM c tim trc 36 gi. Tim tnh mch 10002000mg chm (500mg/pht) c th lp li nhiu ln. Tuy nhin trong trng hp trng
c nng v c ngun phospho tch lu lu trong c th nh trong trng hp trng c
qua ng tiu ho c sc ra chm th c th dng PAM liu cao v ko di n 57 ngy. Trong trng hp trng c va th liu PAM l 2 n 4 gam/ ngy bng ng
tnh mch chia lm 4 ln. Trong trng hp trng c nng v c ngun tch lu th
dng liu cao phi hp tim v chuyn qua ng tnh mch duy tr liu cao ca
PAM trong mu, liu thng dng l 6 n 8 gam/ ngy v ko di hng tun.
- p ng vi P2AM: du chng thuc tm vn ng p ng tt nht.
2.4. H tr h hp
- Khai thng ng h hp: ht m gii kh c du suy h hp d nh, nu t p ng
iu tr th nn t ng ni kh qun.
- Th Oxy: khi c suy h hp cung lng cao 8-10L/pht hay 3-4L/pht ty theo trm
trng (nu c suy h hp mn th th oxy cung lng thp 1-3L/pht.)
- H hp nhn to: l phng tin iu tr cn thit trong nhng trng hp nng, p
ng khng hon ton vi iu tr, suy h hp cp. H hp nhn to cn c ko di

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rt lu c th 2-3 tun. Do cn phi c my th mi m bo h hp nhn to tt v
ko di, cn khai thng kh qun v cho th my ng lc v kp thi.
Cm dng Aminophylline hay thuc tng t v Aminophylline c tc dng ph
l gy nn ma, chng mt, hn lon tinh thn, co git h huyt p.
2.5. Cc bin php iu tr khc
- Chng sc: bng nhng phng tin thng l d dt khi dng cc thuc tng huyt
p. Kinh nghim cho thy nu gii quyt tt cc khu khc th vn chng sc t c
t ra. Nu tt huyt p cn b dch v cho thuc nng huyt p nh Dopamine v
Dobutamine.
- Truyn dch: khng nhm thi cht c m ch nhm chng sc nu c, b lng
nc mt qua m hi, ma, tit dch v nui dng. Loi dch v lng dch truyn s
thay i ty theo nhu cu. Truyn dch cng l mt phng tin a Atropine vo c
th v nui dng bnh nhn.
- Chng co git: bt an, lo lng, c th dng thuc chng ng kinh nh
diphnylhydantoine, cc thuc an thn nh, trnh lm lit cc c quan thn kinh sinh
thc. Cm dng Morphine v lm suy h hp m thng c lm d do hi chng
Muscarine..
- D phng bi nhim: nht l phi nn dng khng sinh c hot ph rng nh nhm
Cphalosporine th h 3 nh Cefotaxime, Ceftriazone liu 2-3 gam/ ngy hoc
Quinolone th h 2 nh Ofloxacine hoc Ciprofloxacine bng ng chuyn tnh mch.
- Chng cc thc n c cha lipide nh sa v lm gi tng s hp thu ca thuc.
2.6. Theo di bnh nhn
- Theo di tht st khng nhng khi bnh nhn hn m, m ngay c khi tnh, c p
ng iu tr.
- Theo di pht hin cc du chng v bin chng nng xut hin, hay cc du chng
nng ti xut hin tr li sau khi gim liu Atropine, c thi x tr kp thi.

VII. PHNG NGA

1. Qun l cht ch s phn phi v x dng thuc tr su gc phosphore hu c.
2. Ph bin rng ri cc khi nim v c tnh ca thuc cho dn chng nht l nng
dn v nhng ngi bo qun thuc.
3. Ph bin cc nt ln v iu tr xung tn tuyn di. Nht l vic sc rut v iu tr
sm bng atropine bng liu cao.

VIII. TIN LNG

Nu c iu tr sm, ng mc, th nhng trng hp nh va c tin lng tt,
nhng tin lng nhng trng hp nng vn xu, nht l c suy h hp ko di.
Nhng trng hp trng c nng v cp bnh nhn hn m v ri lon trung tm sinh
thc rt sm gy t vong nhanh lm khng kp hi sc thng l cht ti ch hay trn
ng di chuyn bnh nhn n bnh vin vi ngng tim, ngng th.

IX. KT LUN

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Trng c cp thuc tr su gc photpho hu c l mt cp cu ni khoa trm trng,
cn c nh gi ng mc v trm trng, x tr, ng mc tht sm vi cc bin
php loi b cht c. Atropine liu cao, ti lp nhiu ln, P2AM liu cao v lin tc
ng thi cn phi hp v h tr h hp nhn to nht l th my ko di chng
ssuy h hp v ngng th. Ngoi ra cc bin php chng chong, ngn nga bi nhim
v nui dng cng l nhng bin php h tr quan trng gip cu sng bnh nhn.

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BNH T MIN
Mc tiu
1.Nm c c ch bnh sinh bnh t min
2. Bit c cc bnh t min thng gp.
Ni dung

I. I CNG
Bnh t min l tnh trng bnh l xy ra do b my min dch mt kh nng phn bit
cc khng nguyn bn ngoi v t khng nguyn. T khng nguyn l thnh phn ca
c th, v l do no tr thnh vt l, t khng th ca c th chng li cc t khng
nguyn ny lm bnh t min xy ra.
Cn phn bit bnh t min vi phn ng t min, phn ng t min lm xut hin cc
t khng th nhng khng gy bnh, nh cc t khng th c to sau s hoi t m
gp phn loi b cc cht phn hu.
Bnh cn c mang nhiu tn khc nhau nh: Bnh do t khng th, bnh do t cng
kch, bnh do t duy tr, bnh t d ng, bnh t mn cm, tn gi thng c dng
nhiu nht l bnh t min.

II. C CH BNH SINH

Cha c c ch no c th gii thch tt c cc trng hp bnh t min, c th c ch
thay i theo bnh.
Bnh thng cc thnh phn ca c th trong thi k bo thai tip xc vi h li
ni m, sau ny tip xc li s c nhn bit l ca c th, khng lm pht sinh khng
th chng li, l tnh dung np min dch. Tnh dung np min dch ny v lm pht
sinh bnh t min trong 4 trng hp sau:
1. Trng hp 1
C s trng hp ngu nhin gia mt khng nguyn l vi mt thnh phn ca c th.
C th sn xut khng th chng li khng nguyn ny (v d vi khun) ng thi chng
lun b phn c cu trc ging khng nguyn. V d bnh thp tim, cht hexosamine c
trong lin cu (tan huyt nhm A cng c trong glucoprotein van tim, do khng th
khng lin cu, khng lun van tim.
2. Trng hp 2
Do tc ng ca nhim c, nhim khun, chn thng, mt s t bo ca c th b tn
thng v thay i cu trc tr thnh vt l, cc t bo min dch coi chng l khng
nguyn l v sn xut khng th chng li. V d vim gan virus.
3. Trng hp 3
Mt s b phn ca c th mu khng tip xc trc tip, t bo min dch khng n
c, khi chng xut hin trong mu (v d chn thng) c th s to khng th
chng li, nh trong bnh nhn mt, khi b tn thng mt bn lm xut hin khng th
chng lun mt kia gy nn bnh vim mt giao cm (ophtalmie sympathique).

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4. Trng hp 4
Do tn thng hoc suy yu kh nng kim sot ca chnh cc t bo min dch. H
thng c ch tng hp t khng th b suy yu, do vy cc t bo min dch pht trin
v sn xut khng th chng li cc thnh phn vn vn quen thuc ca c th. V d
mt s bnh ca h lin vng ni m thng c km thiu mu huyt tn do xut hin
cc khng th hng cu t sinh.

III. CC LOI T KHNG TH, HU QU CC PHN NG T MIN

1. Cc loi t khng th
Cc t khng th trong bnh t min tc ng gy bnh bng nhiu cch nh hu hoi,
lm thng tn, c khi li kch thch c quan ch gy nn nhng biu hin khc nhau.
C hai loi t khng th
- T khng th chnh: gy bnh tht s nh t khng th chng b mt hng
cu, chng bch cu, chng mng nn, chng th th acetylcholine.
- T khng th ph: i km bnh t min ch khng quyt nh s gy bnh. V
d: t khng th chng t bo thnh d dy trong bnh Hashimoto l mt t khng th
khng c hiu cho c quan bnh l gip, t khng th chng cc ht nhn, chng ti lp
th, chng c tim.
2. Hu qu ca cc phn ng t min
- Tiu t bo do thc bo, b th, lympho T c t bo (thiu mu tan mu)
- Lng ng phc hp min dch ti cc m ch (lupus ban h thng)
- Vim mn vi thm nhim t bo n nhn (Hashimoto)
- Hoi t t bo, thoi ha dng t huyt (vim cu thn cp)
- Kch thch t bo (Basedow).

IV. C TNH CHUNG CA CC BNH T MIN

Vi quan nim v bnh t min nh nu trn do c s lm dng trong chn
on, ngoi vn cn c nhiu kin ngc nhau trc nhiu bnh c tht s l bnh t
min hay khng ? Ni chung hiu bit v bnh vn cn phi tip tc tm hiu thng
nht. Sau y l mt s c im ca bnh t min:
- Bnh thng gp ngi tr hoc ng tui (thng t 20 n 40 tui). Tr
em v ngi gi t gp hn. N gp nhiu hn nam. Thng c yu t di truyn, c tnh
cht gia nh.
- Bnh tin trin tng t, nng dn (v vy bnh c tn l bnh t duy tr) din
tin thng phc tp, a dng t cp tnh, ti cp n nh, dai dng.
- C th tn thng ng thi nhiu c quan.
- Khng c nguyn nhn trc tip r rt. Tuy nhin bnh c th xy ra sau cc
tnh hung sau: Nhim c, nhim trng cp, mn, thai nghn, sang chn tinh thn hoc
th cht, tc nhn vt l nh chy nng, K, sau dng mt s thuc, bnh c th p
ng kh tt vi mt s thuc c ch min dch nht l corticoide.

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V phng din chn on, khng c tiu chun chung cho cc bnh t min tuy nhin
bnh cnh lm sng, din tin v mt s xt nghim gi hng n bnh t min nh
gim v c hng cu, bch cu, tiu cu c th km tng lympho, tng tc lng mu,
tng gamma - globulin...
Chn on chnh xc da trn s pht hin cc t khng th, cng c hiu, cng
chnh xc, iu ny ch c th c thc hin cc trung tm chuyn su.

V. XP LOI
Nhng bnh t min l tp hp mt nhm bnh khng ng nht, c ch sinh bnh
cha c hiu r hon ton v s xp loi cn tranh ci. Sau y l s xp loi c
nhiu ngi ng :
1. Cc bnh t min chc chn
pht hin c t khng nguyn v t khng th. Bnh c th thc nghim
c, v d bnh Lupus ban h thng, hi chng Goodpasture, bnh nhc c,
vim tuyn gip Hashimoto.
2. Cc bnh rt c th l t min
pht hin c t khng th, v d thiu mu c tnh vi t khng th chng yu t
ngoi lai v chng t bo thnh ca nim mc d dy.
3. Cc bnh c th l TM
Do cc biu hin lm sng v s ci thin sau iu tr bng c ch min dch, v d
vim lot i trng xut huyt.
4. Phn ng TM
Gm nhiu bnh, pht hin c t khng th nhng ngi ta khng r cc t
khng th ny c ng vai tr gy bnh hay ch n thun nh mt du ch im ca
bnh. V d khng th khng myeline trong bnh x cng ri rc.

VI. MT S BNH T MIN CHNH

1. Cc bnh cht to keo
1.1. Lupus ban h thng Do cc t khng th chng cc khng nguyn nhn, nh
ADN, Ro, Sm.
Thng xy ra n, tr (90%). Tn thng nhiu c quan. Da: ban hnh cnh bm
mt, lot nim mc ming, rng tc. C xng khp: vim, au c, vim nhiu khp.
Thn: gy hi chng thn h. Thn kinh: tn thng nhiu ni ca thn kinh. Tim
mch: vim mng ngoi tim kh, c dch, co tht, vim c tim, vim ni tm mc, nhi
mu c tim do vim mch vnh, huyt khi mao mch. Phi: vim phi km theo xp,
x phi, vim mng phi. Huyt hc: ri lon ng mu, thiu mu, tan mu. Tiu ha:
tiu chy, thng rut, gi tc rut, vim ty cp, tng men gan. Mt: vim mch mu
vng mc gy m, vim lot kt mc, vim thn kinh th, kh mt.
1.2. Vim khp dng thp Do t khng th khng HLA DR4, DR1, nguyn nhn khi
pht c th l virus Epstein Barr.

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1.3. Hi chng Sjorgen Do t khng th chng t bo thng b ng nc bt, t
khng th chng khng nguyn nhn, gy hi chng kh (mt, nc bt, mi).
2. Bnh ni tit
2.1. Vim tuyn gip mn Hashimoto Bnh do t khng th chng Thyroglobulin, chng
Thyroperoxidase, vi tiu th. Thng xy ra n, tuyn gip c th ln hay khng,
thm nhim lympho. Giai on u c th c cng gip thong qua sau suy gip,
din tin chm, c th km cc bnh t min khc.
2.2. Bnh Basedow do t khng th TSI, TBII, TGI.
2.3. i tho ng (typ 1) do t khng th khng o Langerhans, khng glutamic
acid decarboxylase, khng t bo b ta.
2.4. Mt s bnh ni tit t min khc
-Addison tin pht: TKT chng v thng thn.
-Suy cn gip tin pht: TKT chng t bo chnh ca tuyn cn gip.
-V tinh trng tin pht t min: TKT chng tinh trng.
3. Huyt hc
3.1. Thiu mu c tnh Biermer do TKT chng t bo thnh, TKT chng FI v TKT
chng FI + Vitamin B12 gy thiu mu u st, teo nim mc li, d dy km thm
nhim lympho.
3.2. Thiu mu tan mu t min do TKT chng KN b mt hng cu t nhin, biu hn
tan mu cp hay mn, xy ra mi la tui. Cp, thng xy ra tr em sau mt s
bnh cp nh: vim phi do Mycoplasma, Eaton, quai b, zona, thy u, cm, vim gan
siu vi... Mn, thng xy ngi ln sau cc bnh mn nh bch cu lympho mn,
lupus ban h thng, Hodgkin, nhc c, vim i trc trng chy mu, Basedow, x
gan...
3.3. Gim tiu cu t min Do TKT chng tiu cu, bnh t gp hn, gy ban xut huyt
gim tiu cu mn n c hay kt hp mt s bnh mn nh bnh bch cu lympho
mn, hodgkin, lympho khng hodgkin, u tuyn c, thiu mu tan mu TM, lympho ban
h thng...
3.4. Bt sn ty do t khng th chng t bo mm ty xng.
3.5. Gim bch cu do t khng th chng bch cu.
4. Thn kinh
4.1. Bnh nhc c nng
4.2. X cng ri rc do t khng th chng myeline thng xy ra ngi tr (15-40
tui) vi cc thng tn thn kinh a dng, ri lon cm gic vn ng, tiu no, cc
thng tn v mt, thng tn ty xng, vi cc bt thng v tinh thn. Bnh din
tin tng t nng dn.
4.3. Hi chng Guillain Barr vim a r dy thn kinh, cha hin r v TKT, gy lit
ngoi bin 2 chi di, dch no ty: phn ly m t bo.

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5. Tiu ha gan mt
5.1. X gan do mt tin pht do t khng th khng Mitochondrie
5.2. Vim gan mn tn cng do t khng th chng c trn, t khng th chng
lipoprotein ca t bo gan.
5.3. Bnh Coeliakie do t khng th chng Reticuline.
5.4. Vim lot i trng xut huyt: cha tm thy t khng th.
5.5. Bnh Crohn gy hp tng on ng tiu ha nht l i trng, lm sng v cn
lm sng d ln vi lao i trng, cha tm thy t khng th.
6. Thn
6.1. Mt s bnh vim cu thn v vim ng thn k: do t khng th chng khng
nguyn nhn v khng nguyn u, khng IgG.
6.2. Hi chng Goodpasture: do t khng th chng mng nn cu thn.
7. Phi
Hi chng Goodpasture: do t khng th chng mng nn ph nang phi. Vim ph
nang x ha v cn. Bnh u ht ca Wegener, hai bnh sau ny cha r t khng th.
8. Da
Pemphigus tht s: T khng th chng cht lin bo ca thng b. Pemphigus bot:
t khng th chng mng nn ca thng b. Vitiligo t khng th chng melanocyte.
9. Vim mch
Nh cc bnh vim ng mch thi dng, bnh u ht ca Wegener, bnh Churg
Strauss, vim nt quanh ng mch. Cc bnh ny cha r t khng th.

VII. KT LUN
Bnh t min l mt tp hp bnh phc tp m nguyn nhn gy bnh, c ch bnh
sinh cn nhiu iu cha r, do iu tr cn nhiu iu cha nh mun, trong
tng lai iu tr c hiu bng khng th n dng c nhiu ha hn.

521

LIU PHP KHNG SINH

Mc tiu
1. Trnh by c cc loi khng sinh thng s dng trn lm sng.
2. Hiu c c ch tc dng, dc ng hc ca tng loi khng sinh
3. Xc nh c nhng ch nh, chng ch nh, tc dng ph ca cc loi khng sinh
4. Trnh by c cc c ch, nguy c v bin php nhm hn ch khng khng
sinh.
Ni dung

I. NH NGHA KHNG SINH

Khng sinh l nhng tc nhn khng khun c ngun gc t vi sinh vt, hu hiu
nng thp. Hin nay khng sinh c xem nh l nhng hp cht ha hc khng
khun hoc dit khun tc ng mc phn t, hu hiu vi liu lng thp v s
dng iu tr bnh nhim trng.

II. MT S NGUYN TC KHI CH NH KHNG SINH

1. Pht hin v xc nh nhim trng: Da vo khm xt lm sng (tiu im tin pht
v th pht nhim khun), cn lm sng (cng thc bch cu), xt nghim vi khun
(nhum Gram, cy mu,CRP...)
2. Tnh hung lm sng ch nh khng sinh
Cp cu, iu tr nhim trng thng thng hay iu tr d phng.
3. Chn la loi khng sinh
Hiu r c ch tc dng loi khng sinh ang s dng, tm hiu c quan b nhim
khun, loi vi khun.
5. Tnh trng ngi bnh (chc nng thn v gan):
Khi men gan >2.5 ln nng bnh thng cn thn trng cc khng sinh gy c tnh
cho gan.
nh gi h s thanh thi creatinine (ml/pht)
nam = [(140 - tui) x cn (kg)] / [Ccrea (mol/l) x 0,8]
n = 0,85 [(140 - tui) x cn (kg)] / [Crea (mol/l) x 0,8]
Bng 1: Cc giai on suy thn
Giai on suy thn

Creatinine (mol/l)

thanh thi (ml/pht)

Giai on khi u

13 - 300

30 - 50

Giai on tin trin

300 - 600

15 - 30

Giai on sau cng

600 - 1000

< 15

Chy thn nhn to

< 10

Khi chc nng thn gim cn gim liu lng khng sinh thi qua thn.

522
5. Phi hp khng sinh hay dng n c (ch khng thuc).
6. ng vo ca khng sinh (ti ch, ung, tim bp, tnh mch, chuyn tnh mch...)
7. Theo di p ng ca khng sinh: d phng khng khng sinh v tc dng ph
ca khng sinh, bit cch x tr cc tai bin do thuc.
8. Thi gian s dng khng sinh: hp l, kinh t nhng phi cht lng.

III. PHN LOI KHNG SINH

1. Nhm beta lactamin
1.1. Phn nhm penicillin (Penicilin G, V, M, A...)
1.2. Penemes (Thienamici v imipeneme - meropenem)
1.3. Cephemes (cephalosporine th h 1, 2 v 3). Cephamycine, oxacepheme...
2. Nhm khng sinh c ph khun rng
Tetracyline
Phenicole (Chloramphenicol)
Rifamycine
Fosfomycine
3. Nhm Aminoside
Streptomycine,gentamycine, amikacine, tobramycine,
isepamicine, aminocyclitol, spectinomycine.

netylmycine,

dibekacine,

4. Nhm khng sinh c ph khun trung bnh

Macrolide (erythromycine, spiramycine, josamycine, midecamycine) Fusidamine.
Glycopeptide: Vancomycine v Teichoplanine
5. Nhm khng sinh c ph khun hp
Lincosamide (Lincomycine, clindamycine)
Polypeptide cyclique (Polymycine B, E, Bacitracine, Mupirocine)
6. Nhm c ch sinh tng hp vi khun
Thuc chng phong: Sisulone (Dapsone), Clofazimine (Lamprene)
Sulfamide (n thun, phi hp (sulfamide + trimethoprime)
Khng sinh ng tiu. Quinolone (th h 1, 2 v 3),
Nitrofurane
Khng sinh ng rut. 5 nitro imidazole (metronidazole, nimorozole, ornidazole,
tenonitrozole, tinidazole, secnidazole...) 8 hydroxyquinoleine: Broxyquinoline (entercine),
Tibroquinol (intetrix)
Khng lao (rifampicine, Isoniazide, ethambutol, pyrazinamide...)

523
IV. C CH TC DNG CA KHNG SINH
1. c ch tng hp vch t bo
Nhm Beta lactamine (penicilline, cephalosporine): c ch s lin kt ngang cui cng
ca cu trc Mucopeptide ca vch t bo lm vi khun d b tan.
- Vancomycine, Bacitracine: c ch hnh thnh Mucopeptide ca vch
2. c ch mng nguyn tng
- Nhm Polymycine (Polymycine B), Gramicine A: tc ng ln cu trc ha hc c
bit ca mng gy ph v mng.
3. c ch tng hp protein
- Nhm Phenicol: c ch tc ng ca peptidyl transferaza lm cn tr kt hp Aa vo
chui peptide mi sinh n v 50S ca ribosome.
- Nhm Cyline: c ch s gn ca aminoacyl tRNA vo phc hp m RNA ca n v
30S ribosome.
- Nhm Macrolide v Lincosamide: kt hp vi tiu n v 50S ribosome
- Nhm Aminoside: bng cch gn vo protein tip nhn trn n v 30S ca ribosom
lm c sai thng tin ca RNA.
- Nhm Mupirocin (polypeptide): c ch Isolosine tRNA synthetase
4. c ch chuyn ha t bo
Bactrime: cnh tranh c ch enzyme lin quan 2 giai on ca sinh tng hp acid folic.
- Sulfonamide do c cu trc tng t nh PABA (acid para aminobenzoic) l mt cht
chuyn ha cn thit trong qu trnh tng hp acid folic gip tng hp Purine v DNA) i
vo phn ng thay cho PABA nhng khng c hot tnh sinh hc, kt qu ngn cn s
pht trin vi khun.
- Trimethoprime: c ch men Dihydrofolic redutaza, men ny bin i acid dihydrofolic
thnh acid Tetrahydrofolic, mt giai on trong chui phn ng tng hp purin v DNA.
5. c ch tng hp acide nhn hoc hot ng
- Rifampin: c ch tng hp DNA (c ch RNA polymeraza ph thuc DNA)
- Nhm Quinolone: c ch tng hp DNA (c ch tiu n v A ca DNA gyraza)
- Nhm Imidazole: c ch tng hp DNA
- Novobiocin: c ch tng hp DNA

V.CC LOI KHNG SINH THNG DNG TRN LM SNG

1. Nhm Penicilline
1.1 C ch tc dng: Dit khun bng cch lin kt vi protein ca vch vi khun thng
qua c ch lin kt ngang ca vch t bo, lm tan vch do c ch thm thu.
1.2 Dng trnh by: Benzylpenicillin, penicillin G, procaine penicillin, benzathyl
penicillin, Phenoxypenicillin.

524
1.3. Dc ng hc
Penicillin phn b cc t chc. (thp mt, tuyn tin lit, t chc xng v dch
no ty (ngoi tr trong vim mng no).Thuc thi qua nc tiu (60 - 90% trong 6
gi). Penicilline thi qua thn (10% lc cu thn v 90% tit ng thn v b c ch mt
phn bi Probenecid. Thuc qua nhau thai v c trong sa m. Thuc nhy cm vi
lin cu, ph cu, lu cu, no m cu, trc khun gram dng, xon khun
(Leptospira, Giang Mai, Borrelia), vi khun k kh. Thuc b khng t nhin vi trc
khun gram m (Bacteroide, Legionella, Mycoplasma, Mycobacterium...). khng vi
t cu (85 - 95%), lu cu (15%), v ph cu.
Penicilline c ch nh trong nhim trng do lin cu, ph cu, no m cu, xon
khun (treponeme), clostridium perfingens v d phng nhim trng hoi th. Nhim
trng h hp, rng ming, tai mi hng, thn, sinh dc, da, t chc mm, ni tm mc,
nhim trng mu vi cc vi khun ni trn.
1.4. Liu dng
Penicillin G: 2 - 4 triu V / TM 4gi thng ch nh trong giang mai thn kinh.
Penicillin V: 250 - 500 mg/ ln/ ngy 4 ln.vim thanh qun do lin cu nhm A.
Benzathine penicilline 1,2 - 2,4 triu V/ 3 - 4 tun 1 ln hin x dng trong d phng
thp tim, vim cu thn, vim thanh qun do lin cu..
Procaine penicillin ; hin t dng.
Vim mng no hoc vim ni tm mc: 10 - 24 triu V / ngy, dng tnh mch ngt
qung 2-4 gi ln.
2. Nhm Penicillin c ph rng
Trnh by: Aminopenicillin,Caeboxypenicillin, Uredopenicilli.;
Dc ng hc: Penicilline A c khun ph rng i cu khun rut v trc khun gram
m. Thuc phn b khp cc t chc v dch c th (30% dch no ty), thi tr trong
nc tiu (75% trong 6 gi), ng mt (20%) qua nhau thai v sa m.
Ch nh: Penicilline A c ch nh vim mng no, nhim trng tai, mi, hng, phi,
thn, sinh dc, ng mt, tiu ha, ni tm mc, nhim trng huyt, thng hn, bnh
Lyme, bnh pasterella, bnh do listeria.
Ampicilline:250-500 mg/ 6 gi ng ung trong vim xoang, vim thanh qun, vim tai
gia, ng tiu.
Liu ampicilline 2 - g/ TM 4 - 6 gi nhim trng gram (-) nng
3. Dng kt hp
Nhm penicillin + c ch beta lactamase (clavulanic, sulbactam,tazobactam).
Augmentine (Amoxicilline + Acide clavulanique.) vim xoang, vim tai gia v nhim
trng da.
Unasyn (ampicillin + sulbactam): k kh, vim ng h hp trn v di do gram (-),
ng tit niu, nhim trng t chc mm,

525
Timentin (Ticarcillin + clavulanic acid) vi khun k kh, vi khun rut, nhim trng ti t
chc mm
Zosyn (piperacillin + tazobactam) ch nh nh trn
4. Nhm Penicillin khng penicillinase
Trnh by: Methicillin, Oxacillin, Cloxacycillin, Dicloxacillin, Nafcillin..
Dc ng hc: Penicilline M ngoi ch nh nh trn cn c ch nh i t cu
cc c quan c, khp, t chc mm, phi, sinh dc, ni tm mc, nhim trng huyt.
Penicilline M hp thu qua ng ung (ngoi tr meticilline) tc dng i vi t cu.
Tc dng ph c tnh ca penicilline v dn cht
Chong phn v, vim thn k, thiu mu, gim bch cu. Vim gan (oxacillin v
nafcillin)
D ng: biu hin ngoi da (nga, ni m ay, hng ban), bnh huyt thanh (st, vim
khp, hch to, lch to, giam bch cu).Lon khun rut: tiu chy (Amocillin).
au ti ch, vim huyt khi, nhim Na, Kali. Chch Penicilline gn thn kinh ta cng
gy tc dng tng t.Bnh no cp; ri lon thc, co c, tng phn x, co git, hn
m. Dng liu cao penicillin (> 20 triu), liu cao oxacillin, cloxacillin, ticarcillin.Xut
huyt khi dng > 40 triu penicillin/ngy, carbenicillin, ticarcillin, azlocillin, piperacillin
(trn 3 tun).
Liu cao Nafcillin gy gim bch cu, ticarcillin, mezlocillin v pipericillin gy gim kali
kim ha, tng men gan v c ch ngng tp tiu cu
5.Nhm cephalosporine
5.1. Trnh by v phn loi
- Th h I: cefazolin, cephalothin, cephapirin, cephradine, cefadroxyl.
- Th h II:
+ cefuroxime, cefonicid, cefamandole
+ cefoxitin, cefotetan
+ cefmetazole
+ cefuroxime axetil, cefprozyl, cefdinir, cafaclor, lobracarbef
- Th h III: cefotaxim,, ceftriaxone, ceftizoxime, cefoperazone)
- Th h IV: Cefepime
5.2. Dc ng hc
Cephalo I hp thu tt qua ng tiu ha (ch yu l cephalexine, cefadroxil,
cefatrizine, cefradine), thuc phn b khp c th ngoi tr dch no ty, thi tr qua
nc tiu, thuc qua nhau thai v sa m.
Thuc tc ng trn nhiu khun rut (Klebsiella, Escherichia coli, Proteus miabilis,
shiigella, salmonella), Haemophilus Influenzae, t cu, lin cu, bch cu clostridium
perfingens, xon khun, leptospira. khng mt vi chng ca E.coli (10%), Klebsiella

526
(10%), P.Mirabilis (15%), H. Influenza.
Cepha I v II c ch nh bnh nhim trng cc vi khun nhy cm ng h hp,
tai mi hng, tit niu sinh dc, xng khp, da, t chc mm, nhim trng nng ngoi
tr vim mng no.
5.3. Liu lng
Cefazolin: 1-2 g/ TM, TB/ 8 gi.
Cephalothin, cephapirin, cephradine: 1-2 g/ TB. TM / 4 gi
Cefadroxyl, cephalexin, cephadrine: 500 - 1000mg/ 6 gi/ ng ung.
Cephalo II khng hp thu qua ng tiu ha (ngoi tr cefuroxime), tc dng tt hn
th h I, nhng cng khng qua mng no.
Cefuroxime 1,5 g/ TM, TB mi 8 gi. Cefonicid 1-2 g/ ngy, cefamandole 1-2 gamTM.
TB/ 4-6 gi bnh l nhim trng ng h hp, vi khun k kh.
Cefoxitin 1-2 g/ TM mi 4 - 8 gi, cefotelan 1 - 3 g/ TM mi 12 gi, cefmetazole 2 gam
TM / 6 - 12 gi.
Cefuroxime axetyl 250 - 500 mg/ ung mi 12 gi, cefdinir 300 mg/ ung mi 12 gi,
cefaclor 250 - 500 mg/ ung mi 12 gi.
Cephalo III v IV c tc dng tt v c khun rng hn so vi th h I v II. Nng
thuc trong dch no ty bng 20% huyt tng, bn hy 1 gi, thi trong nc tiu v
mt dng khng i (60% trong 24 gi).
Cephalo III ceftriaxone 1-2 g / TB, TM mi 12 - 24 gi., cefotaxime 1-2 g/ TB,TM mi 4 12 gi, ceftizoxime 1 4 gam/ TB,TM 8- 12 gi, cefoperazone 2 - 4 g/TM mi 12 gi
Cephalosporine th h IV. Cefepine (500 mg - 2 gan/ TM hoc TB mi 8 - 12 gi dng
trong nhng trng hp nhim trng nng, khng, thng phi hp metronidazole
nhim trng tiu ho nng.
5.4.Tc dng ph v c tnh
Chong phn v, vim thn k, thiu mu, gim bch cu. Cephalosporine th h III c
th gy si bn v bnh gan mt v th h II gy xut huyt.
D ng (0,05%) ging penicilline Ri loi tiu ha: tiu chy, bun nn, nn ma, nhim
nm,tiu cu, tng men gan.
c cho thn do cephaloridine. Dng ng tnh mch c th gy au, vim huyt khi
ti ch (ch yu cephalothine), vim no km ri lon thc, co git (liu cao bnh
nhn suy thn). Gim prothrobine (d phng vi vitamine K)
6. Nhm Macrolide
6.1.Tn thuc trn th trng
Erythromycin, Dirithromycin, Propiocine, Oleandomycin, Spiramycin
6.2. C ch tc dng
Tc ng trn tng hp protein bng cch lin kt vi tiu n v 50S ribosom

527
6.3. Dc ng hc
Tc dng kim khun Hp thu ng tiu ha khng u. Phn b cc t chc (ngoi
tr no, dch no ty v nc tiu), thi tr ch yu qua dch mt.
Thuc tc dng i cu khun v gram m, mt vi trc khun gram m, k kh.
khng t nhin vi vi khun rut (pseudomonas, Mycoplasma hominis). khng cho
vi haemophilus influenzae (60%), cu khun rut (50 - 70%), t cu (15 - 30%), ph
cu (22%), lu cu, trc khun.
6.4. Ch nh
Cc bnh l thng c ch nh nh vim hng, vim xoang, vim xng, vim ph
qun, vim phi, nhim trng da (mn trng c).
6.5. Tc dng ph v c tnh
Ri lon tiu ha, au thng v, nn, tiu chy, au bng.Tn thng gan min dch d
ng: mt, vng da. tai v kch tnh mch (chuyn tnh mch).
Tng tc dng thuc chng ng, digoxin, theophyllin, khng histamin,cyclosporine (do
c ch cytochrome P450).
Erythromycine 250 - 500 mg/ mi 6 gi hoc 0,5 - 1 g/ TM mi 6 gi.
Trnh liu trn 4 gam/ ngy.
Dirithromycin 250 - 500 mg/ ung mi 12 gi
Clarithromycin 250 - 500 mg/ uonongs mi 12 gi
Azithromycin 500 mg ung/ ngy u ri 250 mg/ ngy trong 4 ngy
7. Lincosamide.
7.1. Tn th trng
Lincomycin (lincocine), clindamycin (dalacine)
7.2. C ch tc dng
Trn s tng hp protein bng cch lin kt vi tiu n v 50S ribosom
7.3. Dc ng hc
Tc dng dit khun, hp thu ng tiu ha hon ton (clindamycine tt nht), thuc
phn b khp c th c bit xng v khp (rt km dch no ty), chuyn ha
gan, thi tr qua mt v phn, lng t hn nc tiu. Clindamycine c tc dng tt
hn.
Tc dng i vi nhm k kh, lin cu, ph cu, t cu. khng t nhin i vi
Haemophilus nluenzae, lu cu, no m cu v vi khun gram m. Nhy cm khng
thng xuyn i vi t cu vng khng erythromycine v methicilline, mt s
clostridiae (10 - 30%) v bacteroides (20%).
7.4. Ch nh
Nhim trng nng c bit do t cu v vi khun k kh (ngoi tr vim mng no,
nhim trng thn v h tit niu).

528
7.5. Liu lng
Liu Clindamycin 20 - 30 mg / kg / ngy (chia 2 ln)
7.6. Tc dng ph v c tnh
Ri lon tiu ha, tiu chy, vim rut kt mng gi (tiu chy, co cng thnh bng,
st, mt nc v in gi, xut huyt rut).Nn, nga hu mn, vim ming, vim li,
ri lon v gic. Vim tnh mch, h huyt p, ri lon nhp tim, ngng tim (khi tim tnh
mch nhanh). Thng tn t bo gan, c quan to mu (gim 1 n 3 dng). D ng:
nga, ni m ay, pht ban, hi chng Lyell v Stevens Johnson.
8. Nhm cycline
8.1. Tn th trng
Tetracycline, oxytetracycline, doxycycline, minocycline.
8.2. C ch tc dng
Tc ng trn s tng hp protein bng cch lin kt vi tiu n v 50S ribosom
8.3. Dc ng hc
Thuc c tc dng kim khun, thuc phn phi t chc ni v ngoi bo (ngoi tr
no, dch no ty v khp), thuc t b chuyn ha (ngoi tr doxycycline), thi tr di
dng hot tnh qua ng mt v trong nc tiu.
Thuc hp thu khng u qua ng tiu ha, hp thu km khi dng chung aluminum
hydroxide, gim tc dng khi dng Ca, Fe.
8.4. Ch nh
Bnh Brucella, st hi quy, st Q, vim phi khng in hnh, bnh mt ht, nhim
trng c quan sinh dc, bnh ht xoi (Nicolas favre) dch hch. St rt khng
chloroquine, mn trng c. Thuc c ph khun rng. khng t nhin vi Seratia, vi
khun rut, mt vi loi proteus, Pseudomenas aeruginosa, mycobacterium. khng
hin nay vi vi khun k kh (80%), trc khun rut (75%), lin cu nhm B (50%), lin
cu nhm C v G (45%), lin cu nhm A (30%), ph cu (16%), t cu (30%),
Escherichia coli (50%), Klebsiella (50%), Salmonella (25%), Shigella (40%).
8.5. Tc dng ph v c tnh
Di ng.Ri lon tiu ha, vim ming - hu hng - thc qun,.Vim gan, suy thn, tng
p ni s.Dng Demeclocyclin gy i tho nht (c ch ADH), tng ure mu nu dng
chung vi li tiu.Gn vo xng, rng tr em gy chm pht trin xng, hng rng,
vng rng.Thuc qua nhau thai gy tc dng tng t cho bo thai. Ri lon nhp tim.
Chong phn v khi dng ng tnh mch (doxycycline), hin tng cm quang. Ri
lon tin nh,Nhim nm candidose tiu ha.
9. Nhm Phenicol
9.1. Tn th trng
Chloramphenicol, Thiamphenicol. (hin khng dng ti M).

529
9.2. C ch tc dng
Tc ng trn s tng hp protein bng cch lin kt vi tiu n v ribosom 50S
9.3. Dc ng hc
Tc dng km khun, thuc khuch tn cc t chc v th dch (dch no ty 50%),
Thuc thi di dng cn hot tnh trong nc tiu (70% i vi thiamphenicol v 15%
i vi chloramphenicol) trong mt (5 - 6%) v trong phn (20%). Thuc qua nhau thai
v c trong sa m. Thuc khng t nhin vi pseudomonas, Acinetobacter,
Mycobacterium...)
9.4. Ch nh
Nhim trng cp tnh ng h hp, gan mt, mng no (Haemophilus), niu o
(gonococcus), tiu ha nh do thng hn hoc salmonella, vi khun k kh.
9.5. Liu lng
12,5 - 25 mg/kg/ TM mi 6 gi, liu ti a 1 gam/ TM mi 6 gi.
9.6. Tc dng ph v c tnh
Thiu mu: Ty thuc vo liu dng v thi gian s dng, c bit ngi c suy gan, s
hi phc sau vi tun.. Bt sn ty: khng ph thuc liu dng cng nh thi gian dng,
tin lng nng. Hi chng xm: gp tr em v tr em non, nn, nhp th nhanh,
tm nhanh, phn xanh, ng lm, try mch v t vong. Dng ko di gy vim thn kinh
th gic, vim thn kinh ngoi vin, ri lon tiu ha, gy ni m ay v pht ban. Trnh
khi c thai, cho con b, tr s sinh, suy gan, thiu mu.
10. Nhm Aminoglycoside
10.1. Tn th trng
Streptomycin, gentamycin, tobramycin, amykacin, neltimycin, framycetin, sisomicin,
paromomycin, kanamycin, dibekacin...
10.2. C ch tc dng
Tc ng trn s tng hp protein bng cch lin kt tiu n v ribosome 30S.
10.3. Dc ng hc
Thi gian bn hy ty thuc chc nng thn., Khng hp thu bng ng ung.
Thuc khuch tn vo phn ln t chc v th dch ca c th, trong ti nhu m thn
cao hn huyt tng. Thuc hp thu km mt, tuyn tin lit, khng qua hng ro
nhau thai, sa m v hng ro mu no, h thn kinh trung ng, mt.Thuc thi qua
nc tiu siu lc ch yu (65% sau 6 gi, 85% trong 24 gi).
- Ch nh: Nhim trng vi khun gram m ti thn v h tit niu, nhim khun huyt v
vim ni tm mc, nhim trng da, nhim trng h hp v khp xng.
10.4. Liu dng
Streptomycine: 15 - 25 mg / kg / ngy. Chia 1 - 2 ln
Amikacin: 15 mg / kg / ngy.. chia 2 ln.

530
Gentamycin 5mg / kg / ngy. chia 1 - 3 ln ngy.
Tobramycin 5 - 7 mg / kg / ngy. Chia 2 - 3 ln ngy.
Spectinomycin 40 mg / kg / ngy (Dng 1 ln)
10.5. Tc dng ph v c tnh
Ri lon thnh gic: tin nh b c gy chng mt, mt iu ha, rung git nhn cu,
tai gim hoc mt thnh lc, nng gy t thng khng hi phc.Yu t thun li nh l
dng mt s thuc c c tnh vi thnh gic (furosemide, vincomycin), ngi cao tui,
suy thn, thai nghn (nh hng thai nhi).
c vi thn: Thuc thi qua thn, tch ly v thn v gy bnh ng thn cp, thng
xy ra ngi ln tui, c bnh thn, b mt nc.
Gin c vn: Gy lit mm, nh hng c quan h hp xy ra ngi b bnh nhc
c, gy m c curate, tim thuc nhm aminoside vo mng bng, mng phi, c s
dng canxi phi hp. D ng: chong phn v.
11. Nhm Quinolone
11.1. C ch tc dng
Tc ng trn s tng hp DNA bng cch c ch DNA gyrase (tiu n v A)
11.2. Trnh by
Th h 1: Flumequin, cc acid nalidixic, oxolinic, pipemidic.
Th h 2 (fluoroquinolone): norfloxacin, ofloxacin, ciprofloxacin.
Th h 3: Sparfloxacine (Zagam)
Th h 4: Trovofloxacine.
11.3 Dc ng hc
Hp thu tt nhng c i lc vi kim loi nng, b c ch khi dng chung vi Fe, Ca v
mt s cation, nn dng 1 gi trc v 2 gi sau n. Tc dng dit khun, Thuc c
hp th nhanh tt hu nh 100%, t nng cao sau khi ung khong 6 gi, thuc
phn b khp cc t chc v dch nh phi, da, mn nc, c t cung, bung trng,
m v dch tuyn tin lit, m. Thuc thi ch yu qua ng thn 80%, thi gian bn
hy t 6 - 8 gi.
11.4. Ch nh
Cc nhim khun gram dng, m v k kh (nhim trng da, tit niu, c quan sinh
dc, h hp v lao
11.5. Tc dng ph v c tnh
Ri lon tiu ha, au vng thng v, bun nn. Nhc u, chng mt, ng g, o gic
l ln, co git. au khp, au c, v to. Ni m ay, pht ban, hin tung cm quang.
Tng men gan SGOT, SGPT, v LDH, tng bch cu acid, gim bch cu trung tnh,
gim tiu cu. Zagam gy ri lon nhp tim trong trng hp QT ko di (khng c
phi hp vi cordarone). Tng tc dng ca theophylline.

531
11.6. Chng ch nh
C thai, ang cho con b, tr s sinh, ngi gi trn 70 tui.Suy gan, suy thn, bnh
nhn b tm thn, thiu men G6PD. Ngi li xe, lm vic trn cao, s dng my mc.
12. Nhm Nitroimidazole
12.1. C ch tc dng
Tc ng trn tng hp DNA bng cch tch lu cc cht chuyn ho c tch nh
hng trn nhiu tin trnh sinh hc
12.2. Trnh by
Metronidazole, Ornidazole, Tinidazole, Secnidazole
12.3. Dc ng hc
Thuc khng khun, hp thu nhanh, t nht 80% sau 1 gi, nng huyt tng khi s
dng bng ng ung v tim truyn gn ging nhau, thi gian bn hy t 8 - 10 gi.
Lin kt vi protein khong 20%. Thuc khuch tn nhanh, mnh vi nng cao
phi, thn, gan, mt, dch no ty, nc bt, tinh dch, dch tit m o. Thuc qua nhau
thai v sa m.
Thuc chuyn ha qua gan, nng cao gan v mt, thp rut, t bi tit qua phn,
m ch yu qua nc tiu v c mu nu.
12.4.Ch nh
Bnh do Amibe, Trichomonas, Giardia intestinalis, vi khun k kh
12.5. Tc dng ph v c tnh
Ni m ay, nga. Chn n, bun nn, v kim loi ming, vim ming, nim li, li
en, i lng.Nhc u chng mt, c th gy vim no v co git, vim ty.Gim bch
cu a nhn, gim bch cu nu dng ko di. Vim a dy thn kinh (cm gic v vn
ng).Thn trng: ph n c thai (3 thng u), ang cho con b.Bnh tm thn v
thiu mu Gy ung th sc vt th nghim.
13. Nhm sulfamide
13.1. C ch tc dng
c ch chuyn ho acid folic bng cch cnh tranh c ch cc enzyme trong 2
giai on sinh tng hp acid folic.
13.2. Trnh by
Sulfamides + Trimethoprime: Bactrim (Cotrimoxazole)
Sulfamide: Adiazine (sulfadiazine), sulfamide chm (fanasyl, fansidar)
13.3. Dc ng hc:
Bactrim c kh nng dit khun, hp thu nhanh v gn nh hon ton (90%), phn b
khp cc t chc nh dch no ty, tuyn tin lit, mt, tai gia, phi. Thoi bin gan,
thi ra trong nc tiu, dch mt v phn. Thuc c khun ph rng i vi vi khun
ng rut (E coli, proteus, citrobacter, salmonella, shigella, vibrio chlera, listeria,

532
pneumocystis carinii, toxplasma gondii). Nhy cm khng thng xuyn vi (Klebsiella,
vi khun rut, lin cu, ph cu, t cu).
khng vi khun k kh, mt vi loi cu khun rut nh pseudomonas aeruginosa,
campylobacter, xon khun, leptospirose, mycoplasma...
Sulfamide: Thuc c tc dng kim khun, dung np tt bng ng ung, phn phi
khp cc t chc k c dch no ty, thi tr qua nc tiu v ng gan mt.
13.4. Ch nh
Bactrim c ch nh trong nhim trng do vi khun nhy cm h tit niu, tuyn tin
lit, h hp, tai gia, tiu ha, thng hn, vim i trng. Nhim trng do
Pneumocystis carinii v do toxoplasma gondii.
Sulfamide (Adiazine) ch nh trong nhim trng ng tiu cp do cc chng nhy
cm. Fansidar dng trong iu tr st rt khng thuc.
13.5. Tc dng ph v c tnh
Pht ban, nga, thng tn nim mc bong biu b dng bng nc (hi chng Lyell,
hi chng Stevens Johnson).St, gim bch cu, thiu mu, tan huyt, vim gan.Ri
lon tiu ha: chn n, bun nn, tiu chy. Thn kinh: mt, mt ng, nhc u, tai.
Tit niu: tiu t, tiu mu
13.6. Chng ch nh
D ng sulfamide, thiu G6PD, suy gan, suy thn, c thai, ang cho con b, tr s sinh.
14. Nhm glycopeptide
14.1. C ch tc dng
Tc ng trn vch t bo bng cch a vo nhng tiu n v vch mi (muramyl
pentapeptide)
14.2. Trnh by
Vancomycin, teicoplanin
14.3. Dc ng hc
Vacomycine c tc dng dit khun do c ch sinh tng hp vch t bo, thay i tnh
thm ca mng t bo.Thay i s tng hp ARN ca vi khun. Thuc khng hp thu
qua ng tiu ha, phn b khp cc t chc ngoi tr dch no ty, thi ra trong
nc tiu (90% trong 24 gi). Thuc nhy cm vi t cu vng, cu khun rut,
clostrdium, lin cu, ph cu, no m cu, lu cu, bch hu.
khng t nhin i vi cc trc khun gram m, mycobacter v cc vi nm.
14.3. Ch nh
Nhim trng do t cu vng khng meticilline (ngoi tr vim mng no), vim ni
tm do lin cu, trc khun rut, t cu. Ch nh khi c st ngi b gim bch cu,
vim phc mc trong qu trnh thm phn.
14.4. Liu lng

533
20-30 mg/kg/ngy chia 2 hoc 3 ln, chch tnh mch 10 mg/kg trn 20 pht. thi gian
bn hu c th ln n 8 ngy.
14.5. Tc dng ph v c tnh
Phn ng lin quan n tim truyn (ging nh chong phn v, ni m ay, nga).
Truyn chm (1 gam/ chuyn trn 60 pht) c tnh trn thn do liu lng cao. c
cho tin nh c tai. Gy ic v chng mt (nng huyt tng qu 80 g/ml). Gim
bch cu (2%), Vim tnh mch, cc phn ng khc (st, bun nn, lnh run, hi chng
Stevens Johnson).
15. Nhm thuc khng lao
15.1. Isoniazid
+ C ch tc dng: c ch tng hp thnh phn lipid ca vch t bo vi khun
+ Dc ng hc: Thuc thu tt qua ng tiu ha, Phn b khp cc t chc k c
TKT.Thi trong nc tiu
+ Liu trung bnh 15 mg/kg/ ngy, ngi ln 300 mg/ ngy, ti a 900 mg/ngy
+ Tc dng ph: mt ng, bt an, au c, tng phn x, co git, ng kinh. Vim gan
(20%) ngng thuc khi men tng gp 3 ln.Vim dy TK ngoi bin (phi hp
Pyridoxin5 25 - 50 mg/ ngy) c bit ngi gi, c thai, i tho ng, suy thn,
nghin ru, tm thn.
15.2. Rifampin
- C ch tc dng: Tc ng trn s tng hp DNA bng cch c ch enzyme
polymerase RNA ph thuc DNA (DNA- dependent RNA polymerase).
- Dc ng hc: Phn b khp tt chc k c thn kinh trung ng(nng 50% so
vi huyt tng), Thi ch yu qua gan v t hn nc tiu
- Liu lng:
Rifampin: 10 - 20 mg/kg (600 mg/ ngy)
Rifabutin: (300 mg/ ngy) dnh cho bnh nhn nhim HIV.
Rifapentine (600 mg/ 2 ln mt tun trong 2 thng)
- Giao thoa thuc: Thuc lm tng chuyn ha thuc chng ng, thuc nga thai,
Thuc lm gim nng mt s thuc methadone, ketoconazone, chloramphenicol,
thuc h ng huyt, thuc chng lon nhp v ciclosporine.
- Tc dng ph nh pht ban da, ri lon tiu ho, viem gan, vim thn k, tng acid
uric (rifapentine).
15.3. Pyrazinamide
- C ch tc dng: dit vi khun trong i thc bo nhng c ch khng r
Tc dng dit khun Phn b khp cc t chc k c mng no (tng ng huyt
tng)
- Liu 15 - 30 mg/kg/ ngy, ti a 2 gam.

534
- Liu duy tr 50 - 75 mg/ 2 ln tun, ti a 4 gam
- Tc dng ph nh nn, bun nn, st, tng acid uric. Liu cao gy c tnh cho gan
15.4. Ethambutol
- C ch tc dng: tc dng kim khun nhng khng r c ch
Hp thu qua ng tiu ha, Thi qua thn 20% v qua phn 50%, thm qua mng no
km.
- Liu lng: 15 - 25 mg/kg/ ngy
- Liu duy tr 50 - 75 mg/ 2 ln tun ti a 2,5 gam.
- Tc dng ph: Tng acid uric, vim thn kinh th, gim th lc, gim th trng.
15.5. Streptomycine.(xem nhm Amonoglycoside)
15.6. Mt s thuc khng lao khc
- Aminosalicylic acid (PAS)
- Clofazimine.
- Capreomycin.
- Cycloserine.
- Ethionamide
- Fluoroquinolones (ofloxacin 750 mg/ ngy 2 ln v ciprofloxacin 400 mg/ ngy 2 ln.).

VI. PHI HP KHNG SINH

1. Mc ch
- Gim kh nng xut hin chng khng ( khng t bin) trong iu tr lao
Nhm iu tr trong trng hp nhim nhiu loi vi khun (vim phc mc, vim ni
tm mc, ph qun ph vim, abces no...)
- Tng kh nng dit khun, nht l trng hp nhim trng nng
- Ngi bnh gim sc khng (suy gim min dch, i tho ng...)
2. Kt qu
- Tng tc dng ph
- Tc dng i khng
PNG tc ng giai on vi khun ang nhn ln, Tetracycline c ch pht trin t bo.
Khi phi hp

Tc dng i khng

Phi hp Erythromycine + Lincomycine hoc Clindamycine + Chloramphenicol

c tc dng i khng do c cng tc ng vo mt ch.
Gim hot tnh do tng k thuc: gentamycine + Penicilline ha cng dch chuyn
(Gentamycine b mt hot tnh bi Penicilline) (gim tc dng.

535
- Tc dng hip ng
c ch cc giai on khc nhau trong cng mt chu trnh chuyn ha ca vi khun.
Bactrime (Sulfamethoxazole + Trimethoprime)
Augmentine (Amoxilline + acide clavulanique) cht sau c tc dng c ch men beta
lactamase (beta lactamine khng b phn hy, pht huy tc dng.
Mi loi khng sinh tc ng vo mt trong nhng qu trnh ca tng hp vch vi khun
Khi phi hp lm tng tc dng (Ampicilline + Oxacilline, Ampicilline + Ticarcilline)
Khng sinh tc ngvo vch to iu kin cho khng sinh khc xm nhp ni bo.
Phi hp Penicilline + Streptomycine.
Oxacilline + Gentamycine (Tobramycine) iu tr t cu.
Carbenicilline hoc Ticarcilline + gentamycine iu tr Pseudomonas aeruginosa.
Cephalothine + Gentamycine iu tr Klebsiella.
3. Cch thc phi hp ( c thc nghim trn lm sng)
Nhm Penicilline + nhm Penicilline hoc cht c ch Beta lactamase
Nhm Penicilline + nhm Nitroimidazole hoc nhm Aminoglycoside
Nhm Penicilline + Aminoglycoside + Nitroimodazole hoc Lcosamide
Nhm Cephalosporine + nhm Penicilline
Nhm Cephalosporine + nhm Penicilline+ Licosamide
Nhm Aminoglycoside + Licosmide hoc Nitroimodazole

VII. KHNG KHNG SINH.

1. C ch khng thuc khng sinh ca vi khun.
1.1 Tng ph hy hoc bin i cu trc ca thuc khng sinh
Do men (qua trung gian ca Plasmid); men betalactamaza khng nhm beta
lactamine; men cephalosporinaza khng cephalosporine; men phosphorylaza,
adeylaza, acetylaza bt hot aminoside; men acetylaza bt hot chloramphenicol.
1.2. Bin i Receptor ca thuc
Lm bin i protein c hiu vi thuc Ribosome lm thay i s gn vo th th
ca thuc, v th VK tr nn khng vi khng sinh (khng aminoside, Erythromycine,
rifampicin, Bactrime...)
1.3. Gim tnh thm mng nguyn tng
Do mt (khng aminoside) hoc lm thay i h thng vn chuyn mng nguyn
tng (khng Beta lactamine, chloramphenicol, quinolone, tetracycline, bactrime...)
khng sinh khng thm vo ni bo
1.4. Tng s to thnh mt men mi
Mt s VK c mang plasmid khng thuc, c kh nng to nn mt men mi c i

536
lc mnh hn (khng sulfonamide).
2. Cc loi khng khng sinh
2.1. khng gi
- H thng min dch ca c th suy gim (dng corticoide, tia x...)
- Vi khun ngoan c trong trng thi ngh (khng nhn ln, khng phn bo do thiu
oxy, pH t chc b thay i).
- Vt cn (do tun hon b tr) khng sinh khng thm ti vim.
2.2. khng tht s
2.2.1. khng t nhin
Do mt s vi khun bn cht khng chu tc dng ca mt s khng sinh (E.Coli
khng Erythromycin, Pseudomonas khng Penicillin...). Vi khun khng c vch nh
Mycoplasma khng chu tc dng ca khng sinh c ch qu trnh tng hp vch
(penicillin, cephalosporin, vancomycin).
2.2.2. khng thu c
Do bin c di truyn, vi khun t ch khng tr thnh c gen khng. Gen khng
c th nm trn nhim sc th trn plasmid hoc Transposon.
+ Plasmid l 1 phn t AND t sao chp nh hin din trong nguyn tng ca vi
khun. Mt Plasmid c th cha mt hoc nhiu gen khng gi l R plasmid.
Cc plasmid ca vi khun thng mang trn n cc gen cho php chng gn vo b
mt nim mc, to ra c t v xm nhp. Cc plasmid khng thuc c th truyn cho
nhau gia cc vi khun lm lan nhanh s khng thuc.
+ Transposon l nhng gen c kh nng di chuyn, cn gi l gen nhy, l nhng on
DNA cha gen khng, c th nhy t plasmid vo nhim sc th v ngc li hoc t
plasmid ny sang plasmid khc.
+ t bin gen: xy ra trc hoc sau khi tip xc khng sinh (ph thuc vo vic c
hay khng tip xc vi khng sinh).
t bin mt bc:
Mc khng khng ph thuc vo nng khng sinh c tip tc, c th ch
sau 1 ln t bin vi khun khng rt cao. Nng c ch ti thiu c th ln n
100(g/ml ( khng SM, Lincomycine, INH).
t bin nhiu bc:
Mc khng lin quan n nng khng sinh sau mi ln t bin nng c
ch ti thiu cao hn ln trc (PNG, Cephalosporine, tetracycline, chloramphenicol,
aminoside, sulfamide...) Gen khng sau khi xut hin s lan truyn t th h ny
sang th h khc, cng vi s phn chia ca t bo vi khun.
3. Nguy c cho vic iu tr do vi khun khng
Gy thnh dch (thng hn);

537
Bnh mn tnh (bnh ng tit niu, h hp);
nhim khun bnh vin (lin quan s dng khng sinh ban u, iu tr d phng, cng
tc v trng, dng c y t nhim khun...)

VIII. D PHNG KHNG KHNG SINH

Khng nn lm dng khng sinh, ch dng khng sinh khi chc chc b nhim khun
Tng cng bin php v trng.
Cn cn nhc iu tr d phng hoc phi hp khng sinh.
Chn khng sinh theo khng sinh , c bit khng sinh c ph hp v c hiu.
Chn khng sinh khuch tn tt vo im nhim khun, ch n dc ng hc ca khng
sinh.
Phi hp khng sinh hp l.
Tn trng thi gian dng thuc, cn c c s ngng thuc (din bin tt trn lm sng, s
tr li bnh thng ca cng thc bch cu, tc mu lng, CRP, X quang...)
Theo di lin tc tnh hnh khng ca vi khun x tr kp thi.

538

TIU SI HUYT, HEPARINE V KHNG VITAMINE K

Mc tiu
1. Trnh by tc dng, liu lng, ch nh, chng ch nh, cc tc dng ph v x tr
ca tiu si huyt trong iu tr bnh tim mch.
2. Trnh by tc dng, liu lng, ch nh, chng ch nh, cc tc dng ph v x tr
ca heparine trong iu tr bnh tim mch.
3. Trnh by tc dng, liu lng, ch nh, chng ch nh, cc tc dng ph v x tr
ca cc thuc khng vitamine K trong iu tr bnh tim mch.
Ni dung

I. TIU SI HUYT
1. i cng
-

Tiu si huyt l s ly gii cc mu ng cha fibrine v tiu cu.

Tiu si huyt (TSH) ch yu c x dng trong nhi mu c tim (NMCT) v

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

539
Bng 1: Mt s tiu si huyt thng dng
Tn cht TSH

Ngun gc

c hiu ln fibrine
ca cc mu ng

Ch nh v liu dng

Alteplase
(Actilyse)

Cng
gen

NMCT: 15mg TM sau

0.75mg/kg/30ph ri duy tr 0.5
mg/kg/60 ph (tng liu < 100
mg).

ngh

Nhi mu phi(NMP):
mg/kg/120 ph
Anistreplase

Vi khun

Trung bnh

NMCT: 30 v/ 5 ph

90

(Eminase)
Reteplase
(Rapilysine)
Streptokinase
(Streptase)
Urokinase
(Urokinase)

Cng
gen

ngh

NMCT: 10 v (2 liu mnh cch

nhau 30 ph)

Cng
gen

ngh

Khng

NMCT: 1.5 triu v/ 45ph

Cng
gen

ngh

NMP:
100.000v/gi
12gi n 24 gi
Khng

trong

NMP: 2.000 n 4.400 v trong

12 n 24 gi

Lu : S dng Heparine TM lin tc kt hp TSH nhm trnh s ti tc cc mch

mu ti thng. Heparine dng ngay khi bt du alteplase, reteplase (1000 v/ gi) v
xa hn vi cc loi khc nh khi fibrinogen > 1g/l i vi streptokinase hoc 4 gi vi
antitreplase.
Hemisuccinate hydrocortisone 100 mg TM ri 50 mg/ 6 gi c cho mt cch h thng
vi anistreplase, streptokinase v urokinase nhm trnh cc tc dng ph d ng
3. Ch nh
3.1. Nhi mu c tim
- NMCT di 12 gi vi cc tiu chun nh sau: au tht ngc > 30 pht, khng
trinitrine, ST chnh ln > 2 mch mu trong 2 chuyn o trc tim, > 1 mch mu i
vi ngoi bin hoc bloc nhnh tri.
- Mt s trng hp c th cho gia gi th 12 v gi th 24, nu cn au tht ngc
v ST cn chnh ln do kh nng NMCT din rng.
TSH m bo ti thng trong khong 70% trng hp, hn ch din nhi mu, gim s
xut hin suy tim v t vong v sau. Tuy vy phung php nong mch vnh vn u th
hn TSH nht l trong NMCT c chong. Cn kt hp h thng TSH vi aspirine v
heparine.
3.2. Thuyn tc phi
- Ch ch nh trong thuyn tc phi mi xy ra < 7 ngy v c ri lon huyt ng.
- Khng ci thin d hu trung hn v di hn do nguy c tm ph mn.

540
TSH ci thin d hu ngn hn nhng NMP c bin chng nh chong do tc nghn
cp mt nhnh ca ng mch phi.
3.3. Tc tnh mch gn
- Ch nh khng qui c: d c ci thin nhanh nhng du chng ti ch vim tnh
mch, TSH khng gim s xut hin nhng bin chng v sau (bnh tnh mch sau
vim) v c nguy c xut huyt khng b qua.
- Ch nh ch yu trong mt s trng hp tc tnh mch gn, vng ch hai, mi
xy ra < 5 ngy, khng tc hoc khng bin chng NMP.
Liu tung t trong NMP v lun phi hp heparine.
3.4.Tc van nhn to
iu tr ch yu l thay van. TSH thng chng ch nh khi c tc mch no thong
qua hoc tai bin mch no. Ch ch nh khi bnh nhn c nguy c cao phu thut hoc
khi ch phu thut.
3.5.Tc tnh mch trung tm
TSH ti ch vi 2 mg Actilyse.
4. Chng ch nh
Khi c chng ch nh phi chn phng n thay th TSH nh: nong van trong NMCT,
ly cc mu ng bng phu thut trong NMP. Sc in ngoi lng ngc khng phi l
mt chng ch nh ca TSH.
Bng 2: Cc chng ch nh ca TSH
Tuyt i

Tng i

- Xut huyt no - mng no.

- Chc ng mch hoc tnh mch trung tm

khng c p (10 ngy), sinh thit gan hoc
- Tai bin mch no(TBMN) kiu thiu
thn, chc mng phi hoc tu sng. Chch
mu, ngay c TBMN thong qua (6 thng).
bp. (48 gi).
- Phu thut no - mng no (3 thng),
- Hi sc tim- phi ko di (xoa bp tim
mt (3 thng), mch mu c t dng c
ngoi lng ngc, t ni kh qun do chn
(2 thng), ni tng hoc chnh hnh nng
thng)
(1thng), tng qut (15 ngy).
- Tui > 75.
- Chn thng no mi xy ra.
- Suy thn, suy gan nng.
- Xut huyt mi xut hin.
- Gim tiu cu, ri lon ng mu.
- Bnh vng mc i tho ng nng.
- Thai nghn.
- Lot d dy- t trng tin trin.
- THA nng khng kim sot

Chng ch nh i vi streptase, eminase, anistreptase: nhim lin cu mi mc, x

dng thuc < 6 thng, hen ph qun, d ng thuc.
5. Tc dng ph
- Xut huyt nng (3-4%) nht l xut huyt mng no (1%, nguy c lin quan tui) v
tiu ho. Phi ngng TSH v heparine, nu xut huyt khng kim sot phi cho

541
aprotinine (antagosan), acid aminocaproique (hemocaprol), acid tranexamique (exacyl).
Nu cn phi chuyn mu, iu tr tn thng xut huyt.
- Xut huyt nh nh chy mu cam, u mu, xut huyt ch chch.
- D ng thuc.

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

542
+ Reviparine (Clivarine) ng 1750 v 4200 v khng Xa.
+ Tinzaprine (Innohep) ng 0.5, 0.7 v 0.9 ml (1ml= 20.000 v khng Xa)

543
3. Ch nh
HKP

Ch nh

Liu lng

D phng bnh l tc mch:

Calciparine TDD 5000 v 2 gi trc

ri chch mi 8 gi.

- Nguy c va.
- Nguy c cao

- Calciparine TDD mi 8 gi vi TCA

gp 1.5 ln chng.

iu tr bnh l tc mch:

- Heparine TM:

- NMCT cp.

500 v/kg/ngy +/- liu tn cng 100

v/kg TM chuyn TM lin tc hoc gin
on (IVD/ 2gi)

- TBMN thiu mu
- Tc ng mch.
- ng mu ri rc ni mch
HPTT

- Calciparine TDD
5000 v/ kg/ngy trong 3 ln chch lin
tip.

D phng bnh l thuyn tc

- Fragmine 2.500 v

- Nguy c va: chch trc mi

th nht di da 4 gi ri chch
mi ngy 1 mi.

- Lovenox 20 mg

- Nguy c cao: chch mi th

nht 12 gi trc ri 1 mi/ ngy.

- Clivarine 1750 v
- Fragmine 5000 v
- Lovenox 40 mg
- Clivarine 4200 v

iu tr:

-Fragmine 100v/kg 2 ln/ngy

au tht ngc khng n nh

- Lovenox 1mg/kg/2 ln/ngy

- Clivarine 175 v/kg 2 ln/ ngy

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

544
5.2. Gim tiu cu do heparine
- lin quan n cc loi heparine, thng gp vi HKP, chim 1%.
- Gim nh.
- Gim nng: triu chng nhm vi xut huyt gim tiu cu: tc mch nhiu cc
mch mu ln, trung bnh(TBMN, NMCT, thiu mu chi di...) hoc TM (TTP), thng
nhiu ln d c chng ng hiu qu, him khi xut huyt. Nng hn a n t vong >
50%.
Thi x tr: xc nh kh nng gim tiu cu bng ng nghim EDTA, ngng ngay
heparine, xc nh kh nng min dch d ng ca s gim tiu cu: tm khng th tiu
cu dnh vi tiu cu khi c heparine (lu tt m tnh khng loi b chn on). iu
tr bt u vi Hirudine (Refludan) hoc Heparinoid tng hp (Orgaran) duy tr sau
bng khng vitamine K.
D phng: Khng dng heparine nu bnh nhn d ng. Thay th bng khng vitamine
K liu hu hiu vo ngy th 7 nhng trc phi khi u 1-2 ngy trc. Trong
thng u cn kim tra tiu cu mi 3 ngy.
Gim tiu cu nh

Gim tiu cu min dch d ng

C ch

Ngng kt tiu cu

Ph hu tiu cu

Ngy

Th 2 v th 5

Th 7 v th 20

c im

- Va (>100.000tiu cu/ml)

- R rt (< 50.000 tiu cu/pht)

- T t

- D di

- Lnh tnh.

- Trm trng (30% t vong)

- Khng triu chng.

- Thuyn tc ng-tnh mch nhiu ni.

- Thng gp (10%)

- Him (1%)

- Tip tc heparine

- Ngng ngay v xc nh v mt sinh

hc ca s d ng.

Thi
x tr

- nh lng tiu cu hng ngy

cho n khi bnh thng

- Dng heparinoid hoc hirudine sau

duy tr bng khng vitamine K.

5.3. Cc tc dng ph khc

- Long xng v tng kali mu.
- Ni ban da.
- Tng men gan.
6. Cch cho thuc
6.1. Trc khi iu tr
Pht hin bt thung cm mu ng mu. Tm xem c suy thn, suy gan khng. D
kin s thay th bng khng vitamine K sm nu cn.
6.2. Trong khi iu tr

545

546
Theo di lm sng: tm du xut huyt. nh lng tiu cu mi 3 ngy.

HKP TM lin
tc,

Trc
nghim

Gii hn hiu iu chnh

qu
lng

TCA

1.5:
1.5 - 3 ln <
chng tng 1000v/gi
ng TCA #
3-4:
45-90 giy
100v/gi

HKP TM/2 gi

liu

S ln lm trc
nghim

- 4 gi sau khi
bt u chuyn
hoc 4 gi sau
gim
khi chch mi th
2.
> 4: ngng 1 gi
sau gim 100
v/ml

HKP di da

tng

< 1.5: tng 0.05 - tng t sau

ml/ln chch.
khi
thay
i
chuyn.
3-4:
gim
- hng ngy
0.05v/ln chch
> 4: b qua 1 ln
chch sau gim
0.05 ml

HPTT iu tr

Khng Xa

HPTT
phng

Khng, tr khi c suy

phi
thn,

0.5 -1 v C th 10-20 v 4 gi sau khi

khng Xa/ml
khng Xa/kg/ngy chch mi th 2
suy gan, xut

huyt

7. Duy tr khng Vitamine K v Heparine

Cn lm sm vo ngy th 1 hoc ngy th 2. Dng liu heparine hu hiu cho n khi
INR (International Normalized Ratio) trong gii hn iu tr. INR vo gi 48- 72 sau khi
bt u khng vit K hoc sau khi chnh liu. Ngng heparine khi liu INR u tin hiu
qu.
Mt s tnh hung x tr khi duy tr khng vitamine K/ heparine.
INR

TCA

Thch hp hoc cao qu

Bnh thng, qu thp hoc Ngng heparine. Gim

qu cao
liu khng vitamine K nu
cn
Qu thp

Thi x tr

Tng liu heparine

Tng khng vitamine K

Qu thp

Bnh thng

Heparine nh c
Tng khng vitamine K

Qu cao

Gim Heparine
Gia tng khng vitamine
K

III. KHNG VITAMINE K

547
C hai nhm, nhm coumarine(coumadine, apegmone, sintrom, tromexane) v cc dn
xut indanedione (previscan, pindione) c tc dng c ch tng tranh vitamine K trong
t bo gan.
1. Dc l hc
Tc dng chng ng gin tip lin quan n s gim tng hp ti gan cc yu t
ph thuc vitamine K: prothrombine (II), proconvertine (VII), yu t Stuart (X) v chng
hemophilie (IX) cng nh protein C v S.
Tc dng chng ng c nh gi qua ch s INR (international normalized
ratio) gip tiu chun ho nhng kt qu chng ng ngha l khng ph thuc vo lab
xt nghim.
Cc khng vitamine K c li l hp thu mnh qua ng tiu ho, di chuyn trong
mu nh s c nh mnh protein ri sau c chuyn ho ti gan. Nhng c im
ny gii thch nhng tng tc thng gp gia cc loi thuc khc ln khng vitamine
K nh hp thu ti d dy, c nh ln gan, thoi bin ti gan, bin i s tng hp
nhng yu t ng mu nht l chu k gan -rut ca vitamine K.
2. Cc loi khng vitamine K
Thng cc loi ny khc nhau ch yu da vo thi gian bn hu, sau n tc
dng ph (d ng vi indanedione).
Thi gian tc dng ngn cho thy c ch khi tc dng chng ng bin mt nhanh trong
khi tc dng ko di li c tc dng chng ng n nh.
Bng 4: Thi gian tc dng ca cc khng Vitamin K
Bit dc

Tn gc

Khi u tc Thi gian tc S ln dng mi

dng
dng
ngy

Coumadine

Warfarine

36-72 gi

3-5 ngy

Apegmone

Ticlomarol

36-72 gi

2-3 ngy

Sintrome

Acenocomarol

24-48 gi

2-3 ngy

Tromexane

Biscoumacetat
e d ethyl

24-48 gi

1-2 ngy

Previscan

Fluindione

36-72 gi

2-3 ngy

Pindione

Phnindione

24-48 gi

1-2 ngy

3. Ch nh
3.1. Bnh l thuyn tc
+ Dng lin 6 thng sau khi tc mch phi hoc tc tnh mch su.
+ Tip tc trong cc trung hp: ti pht, bnh tm ph mn, bt thng ng mu do
thiu protin C.S, ATIII..
+ iu tr d phng trong b bt lu di chi di trong cc trng hp ny ch cn INR
mc va phi: 2-3.

548
3.2. Rung nh: Cho khng vitamine K lu di cn c t ra khi c nguy c tc mch
trong rung nh loi kch pht ri n mn tnh. Ch cc nguy c theo mc nh:
+ nguy c cao: Rung nh bnh van tim mc phi hoc nhn to, hoc van tim b
tc ri, cc ng nh tri, suy tim.
+ nguy c va: rung nh xy ra nhng trng hp khng phi bnh van tim nhng
c nguy c tc mch nh: dy tht, tng huyt p, tui > 75, i tho ng.
+ Nguy c thp: Rung nh khng r nguyn do ngi tr, khng c bnh tim km
theo.
Nguy c thuyn tc

iu tr

Thi gian

Thp

Aspirine

Trung bnh

Khng vitamine K vi INR 2-3

Sut i

Nng

Khng vitamine K vi INR 3-4.5

Sut i

Cc trng hp khc cn cho khng vitamine K trong 1 thng sau gim dn.
3.3.Van tim nhn to
INR

Loi van nhn to

Thi gian dng vitamine

K

3-4.5

C hc (tr nhng trng hp di y)

Sut i

2-3

Van ng mch ch c hc, c cnh, nhp

xoang
Van sinh hc (v sa van) c rung nh
Van sinh hc (v sa van) c rung nh

3 thng sau phu thut

3.4. Cc nguyn nhn tc ng mch khc

- Suy tim bnh tim dn, nhm III v IV ca NYHA nht l khi c ri lon nh hoc
tht.
-

Phnh tht tri sau nhi mu.

- Bnh ng mch chi di (ch nh him v bn ci): vim ng mch ti thng

nhng li mch mu h lu km.
-

Tai bin mch no hoc TBMN thong qua.

4. Chng ch nh
-

Cho b.

- Thai nhng thng u do nguy c gy bnh no do coumarine v thng th ba do

nguy c xut huyt.
-

D ng thuc.

Xut huyt tin trin.

Lot d dy t trng tin trin.

THA c tnh.

549
-

Phu thut thn kinh hoc phu thut mt mi xy ra.

Tai bin mch no mi xy ra.

Suy gan hoc suy thn nng.

550
5. Tc dng tng tc thuc khng vitamine K
Gia tng tc dng khng vitamine K

c ch tc dng khng vitamine K

Gia tng s hp thu ng tiu ho Gim s hp thu ng tiu ho cc khng

cc khng vitamine K
vitamine K
Chm nhu ng rut

Thuc nhun trng.

Thuc chng lot.
Cholestyramine(Questran), than hot ho.

Gim s c nh protin khng vit K

Khng vim khng steroid
Aspirine liu cao.
Sulffamid h ng mu hoc khng
sinh.
Fibrate
Acide tienilique (Diflurex)
Miconazone (Daktakin)
c ch thi qua thn
Probenecide (Benemide)
c ch thoi bin gan thuc khng vit To nn s thoi bin gan ca khng
K
vitamine K
Cimetidine

Barbiturique

Allopurinol

Carbamazepine

Chloramphenicol

Phenytoine (ihyan)

Ketoconazole

Meprobamate
Rifampicine
Griseofulvine
Ru

Gim s tng hp cc yu t ph thuc Tng s tng hp cc yu t ph thuc

vitamine K
vitamine K
Suy gan nng

Ostrogene

Khng vim khng steroid

Corticoid

Amiodarone
Quinidine v dn xut
Gim nng vitamine K

Tng nng khng vitamine K

mt

Thc n vitamine K

Khng sinh ung nht l tetracycline,

sulfamid

Vtamine K ung chuyn

551
Cng gip

6. Tc dng ph
6.1.Xut huyt
- Xut huyt nng (TBMN, xut huyt tiu ho, u mu c y chu hoc sau phc
mc): ngng ngay khng vitamine K, chuyn PPSB ngi (nu qu liu), chch vitamine
K, duy tr Heparine chch TM qua bm in khi INR < 1.5 vi TCA: 1.2-1.5.
- Xut huyt nh khng qu liu: INR> 5: ngng hoc gim khng vitamine K trong
24 gi ri duy tr li vi 1/2 hoc 3/4 liu.
-

Cm mu ti ch.

Vitamine K ung nu qu liu nng INR > 8-10

6.2. Phn ng d ng vi indanedione

Him nhng nng: phn ng da, gim bch cu, gim tiu cu, bnh thn, vim gan.
6.3.Tc dng ph ca coumarine
au d dy, nn, nga, rng lng, lot ming.
6.3.Bnh no do coumarine
Xy ra ngay c vi pindione vo tun th 6 v tun th 9, l nguyn nhn teo mi,
canxi ho u xng, chm pht trin thn kinh vn ng.
7. Cch cho thuc
7.1.Trc khi cho thuc
Loi tr cc chng ch nh hoc tng tc thuc. Loi tr ri lon ng mu (INR,
TCA) hoc suy thn, suy gan, c sn nhm mu.
Bt u liu 1vin/ ngy (3/4 nu bnh nhn ln tui, nh cn, suy gan hoc suy thn
va), INR nh lng sau 48-96 gi.
7.2.Thay i liu mi 1/4 vin
nh lng INR v sau mi 48 n 96 gi cho ton b vic iu chnh liu. INR mi 48
gi khi trong gii hn iu tr. Mi tun cho n khi n nh trong hai ln kim tra mu
lin tip.
7.3. Cp bnh nhn mt phiu theo di thuc chng ng.

552

LIU PHP GLUCOCORTICOIDE

Mc tiu
1. Trnh by i cng v glucocorticoide
2. Trnh by v dc hc lm sng phn loi glucocorticoid tng hp
3. Trnh by tc dng ca glucocorticoide
4. Trnh by ng dng lm sng ca liu php
5. Trnh by v tc dng ph v tai bin khi s dng liu php glucocorticoide
Ni dung

I. I CNG
Glucocorticoide l mt trong nhng hormone c tng hp ti tuyn v thng thn
trong quan trng nht l cortisol. y l hormone chuyn ha cht ng c
tuyn thng thn tit khong 15 - 30 mg /ngy vi 50% s lng c tit cao nht
lc 6 - 8 gi sng. thi gian na i huyt tng ca cortisol khong 70 - 90 pht. nng
cortisol sinh l nh sau:
lc 8 gi sng: 3 - 20 g / dl (80 - 540 nmol / l) trung bnh 10 - 12 g / dl (276 - 331
nmol/l).
Lc 16 gi cn mt na so vi sng.
Lc 22 gi n 2 gi sng: di 3g / dl (80 nmol/l).
Trong Stress: tng ln 40 - 60 g / dl (1100 - 1600 nmol/l).
Liu php glucocorticoid da trn tc dng sinh hc ca cc thnh phn glucocorticoid
tng hp p dng trong lnh vc iu tr nhm mc ch khng vim, chng d ng
v c ch min dch. Corticoide dng tng hp c tc dng mnh hn so vi corticoide
ni sinh. V th nu x dng v lu di khng nhng gy nn mt s tc dng ph m
cn c th gy c ch trc i - Yn - Thng Thn, gy suy v thng thn. Liu
php corticode nhm gp phn hng dn x dng cc glucocorticoide tng hp c
hiu qu.

II. DC HC LM SNG CA LIU PHP GLUCOCORTICOIDE

Cn phn bit liu php glucocorticoide ton thn trc tip hay gin tip v liu php
glucocorticoide ti ch.
1. Liu php glucocorticoide ton thn trc tip
Glucocorticoid tng hp c chia lm 3 nhm da theo thi gian tc dng sinh hc.
thi gian na i tc dng sinh hc da vo khong cch c ch v thng thn sau
mt liu ca hp cht. (1) loi tc dng ngn thi gian sinh hc na i 8-12 gi, (2)
loi trung gian khong 18 - 36 gi v (3) loi ko di 36-54 gi.
+ Thng c x dng l dn xut ca cortisol vi tc dng khng vim v tc dng
corticoide khong. Thuc hp th tt qua ng ung, tc dng sinh hc khong
90%.Cc dng 11 cto c chuyn thnh 11 hydroxy c c tc dng. Cc t

553
chc lin kt, da, cht hot dch u hp thu tt cc cht ny. X dng dng ester tan
trong nc dng ng tnh mch hoc tim bp tht vi tc dng ko di hn.
+ Cc phn t lin kt vi proteine huyt tng: Vi liu thp. Transcortine b bo ha,
khi dng liu cao cc cht albumine dng ph thm (lin kt mnh hn). S lng dng
hot ng ph thuc vo liu v gim albumine huyt tng l nguyn nhn ca tc
dng ph. Ngay c thai nghn v x dng estrogene c th nh hng trn s lin kt
proteine.
+ Chuyn ha ch yu gan v to thnh dng ester hoc glucuronide khng hot ha
v thi trong nc tiu. Chuyn ha chm trong trng hp thai nghn, x gan, tng
hot gip v dng thuc salicyl.
+ Thi gian na i huyt tng ca cc dn cht tng hp thng di hn so vi
cortisol ni sinh nhng tc dng sinh hc th khng lin quan n thi gian na i (c
ch tc dng ni bo).
Bng 1: Phn loi glucocorticoid tng hp
Thi
1/2
sinh
(gi)

gian Tng
i ng (mg)
hc

Tim
nng

Tim
nng

Gluco

corticoid
khong

corticoid

Thi gian
1/2
huyt
tng
(pht)

Nhm Glucocorticoide
Tc dng ngn
Cortisol

20

90

8-12

Cortisone

25

0.8

80-118

8-12

Prednisone

60

18-36

Prednisolone

115-200

18-36

Triamcinolone

30

18-36

Methylprednisolone

180

18-36

Dexamethasone

0.5

25-50

200

36-54

Betamethasone

0.6

25-50

300

36-54

Aldosterone

0.3

300

15-20

8-12

Florocortisone

15

150

200

18-36

Desoxycorticosterone

20

70

Tc dng trung gian

Tc dng ko di

Nhm corticoid khong

acetate

Prednisolone c cu trc cortisol vi cu ni i gia C-1 v C-2, lm tng tc dng

glucocorticoid v gim tc dng corticoid khong. Thm nhm alpha-fluoro C-9 lm

554
tng tc dng c hai, ngc li thm nhm hydroxyl hoc methyl C-16 lm gim tc
dng corticoid khong.
Dexamethasone c ni i C-1 v C-2, nhm fluoro C-9, v nhm alpha methyl
C-16, c tc dng glucocorticoid gp 25-50 ln.
Cu ni i C-2 v C-3, v methyl ha C-2 v C-16 ko di thi gian na i huyt
tng,
2. Liu php glucocorticoide ton thn gin tip
+ Thng dng ACTH tng hp trong thnh phn C tn cng 25-39 hoc 26-39 b
loi b, c tc dng ci thin dung np.
+ Cc cht ACTH tng hp ny lm tng phng thch cc steroide thng thn, cortisol
tng ti a trong vng 30 - 60 pht i vi loi trung gian v tng sau 4 gi v ko di
24 - 36 gi i vi loi chm.
+ Dng polypeptidique ch dng bng ng chch.
3. Cc dng khc
3.1. Tc dng ti ch
Khng gy c nu dng ngn ngy. Nhm steroid cha fluorinated (dexamethasone,
triamcinolone acetonide, betamethasone v beclomethasone) xuyn qua da tt hn
nhm khng cha thnh phn ny nh l hydrocortisone.
3.2. Glucocorticoid dng cho mt
Tn thng t min hoc v cn phn trc ca mt (mng mt, mng mch nho
ca mt), vim nhim sau phu thut hoc do chn thng s dng nhm hn ch ph
n.
3.3. Glucocorticoid dng ht
Trong bnh hen ph qun v bch hu thanh qun.
3.4. Glucocorticoid ng mi
Kh dung trong vim mi d ng.
3.5. Glucocorticoid bnh khp
Dng chch vo khp (cn v trng)

II. TC DNG CA GLUCOCORTICOIDE

1. Mc t bo
+ Glucocorticoide dng t do tc ng ln th th c hiu ni bo.
+ Phc hp steroide - th th c hiu c hot ha v di chuyn vo nhn t bo,
kch thch sao chp ARN v tng tng hp proteine.
2. Mc chuyn ha
Glucocorticoide lm bilan azote m tnh bng cch tng thoi bin v c ch ng ha
proteine (ti gan tng tng hp protein v RNA). Tng thoi bin lipide thng xuyn

555
ng thi bin i chuyn ha protide theo hng chuyn ha cht ng (tng tn
sinh ng, tng ng mu, khng insulin ngoi bin).
Corticoide lm bilan phosphate - calci m tnh bng cch gim hp thu calci rut, tng
thi phosphate thn bng cch c ch hot ng ca to ct bo, c tc dng khng
vitamine D.
Chuyn ha mui - nc b ri lon nng nhng ty thuc vo cc cht. Thng phi
hp vi s kim ha km mt kali v cng lin quan n gim khi lng c (nh
hng ca c ch ng ha v thoi bin proteine).
3. Mc dc ng hc
3.1. Tc dng iu tr
l cc tc dng khng vim, chng d ng v c ch min dch. Cortisol tc ng
3 mc c bn.
- Thay i di chuyn cc thnh phn t bo n v tr vim (gim lymphocyte, gim bch
cu i toan i kim mt s thm nhp bch cu a nhn, gim s di chuyn cc t bo
sn xut yu t ha hng ng..).
- Thay i sn xut v hot ha cc cht vn mch (c ch phng thch histamine, c
ch bradykinine, gim leucotrien C, gim sn xut prostaglandine.)
- Thay i chc nng thc bo (gim kho lu hnh) v lymphocyte (gim lymphocyte T
bi c ch interleukine 2, gim lymphokin, monoki, gim sn xut khng th..). Chng
nh hng trn s tn sinh nguyn bo si, s tng hp collagen, v
mucopolysacaride cng nh lm qu trnh x ha v kt so.
- Tc dng khng vim v chng d ng thng c dng liu thp v ty loi sn
phm.
- Tc dng c ch min dch vi liu cao (1 - 1,5 mg / kg i vi prednisolone)
3.2. Tc dng liu php corticoide ton thn gin tip
+ Do tc dng ca cortisol gy ra.
Tc dng gi mui v nc i khi b che du (tc dng corticoide khong do cortisol
v kch thch tit aldosterone).
Khng c tc dng c ch thng thn i vi ACTH tng hp, nhng v lu di c
ch sn xut ACTH c th xy ra.
+ Cc peptide ny kch thch to hc t (mlanogense) v lu di v c th c tc
dng thoi bin trc tip lipid v thn kinh.

III. NG DNG LM SNG LIU PHP CORTICOIDE

1. Thit lp phng thc iu tr lu di
Ngoi cc ch nh iu tr triu chng ko di (iu tr thay th trong suy thng thn
cp, mn, ph i bm sinh thng thn vi liu sinh l hng ngy ca hydrocortisone
hay cortisone) vic iu tr ko di corticoide rt quan trng cn phi m bo an ton
ti a cho ngi bnh, tun th mt s nguyn tc c bn v chn la phng thc
ph hp cho tng trng hp.

556
1.1. Nguyn tc u tin
- Hn ch ch nh i vi tn thng m s trm trng ca tn thng da trn nguy
c chp nhn do iu tr m khng c mt phng tin iu tri tch cc v tt hn
thay th.
- Cc ch nh trn lm sng:
1.1.1. Chn on v iu tr mt s bnh l v thng thn:
+ Suy v thng thn.
Suy v thng thn mn (Bnh Addison)
Suy v thng thn cp.
+ Tng hot v thng thn:
Chng ph i bm sinh v thng thn (s dng trong th loi bt thng v tng hp
cortisol).
Hi chng Cushing (s dng sau khi ct b cc tuyn yn, thng thn iu tr)
Cng Aldosterone (s dng trong th th pht)
+ Dng trong mc ch thm d chn on: Thng x dng trong cc test dc ng
hc (xem thm d tuyn v thng thn)
1.1.2. Corticoid v s pht trin ca phi:
Pht trin phi ca bo thai i hi cortisol. V vy m x dng liu cao corticoid lm
gim t l suy h hp ngay sau sinh.Tr sinh non thng x dng betamethasone
1.1.3. Cc ri lon khng lin quan thng thn.(iu tr h tr)
1.1.4. Cc ch nh trn lm sng thng gp l:
+ D ng: ph do mch, hen, cn trng cn, vim da tip xc, d ng thuc, vim mi d
ng, ni m ay.
+ Bnh khp: Thp khp cp, vim khp mn,vim mng hot dch, vim gn c.
+ Bnh collagen: Vim nt quanh ng mch, lupus, vim a c, vima khp dng
thp,
+ Vim ng mch thi dng.(Horton)
+ Ghp c quan, (dng liu cao)
+ c ch min dch (dng liu cao)
+ Nhim trng G (-) chong (phi hp vi khng sinh)
+ Tng calci mu: tng calci mu, carcinoma,
+ Mt: Vim kt mc d ng, vim thn kinh th.
+ H hp: hen lin tc, bnh ph qun phi tc nghn, sarcoidosis.
+ Tuyn gip: li mt trong bnh Basedow nng, Vim gip Hashimoto.

557
+ Bnh mu: Hogdkin, ung th mu,thiu mu huyt tn, xut huyt gim tiu cu v
cn, bnh bch cu n nhn,
+ Da: biu hin da ca bnh mu, pempigus c tnh, hng ban a dng, bong biu b
cp, bnh li ni m, hng ban nt
+ Tiu ha: vim gan mn, vim gan hoi t cp, vim i trng let
+ Bnh thn: hi chng thn h, vim cu thn cp,
+ Thn kinh: x cng ri rc.
+ Hi chng West.
+ Hi chng suy h hp cp tnh (SARD) ngi ln.
1.2. Nguyn tc th hai
+ Nguyn tc th hai l tn trng cc chng ch nh kinh in:
-

Lot d dy t trng (liu prednisolone di 15 mg/ ngy t gy tai bin ny)

i tho ng (khng n nh ng huyt)

Tng huyt p (do tc dng gi mui)

Nhim trng tin trin.

Gim th trng r.

Tin s tm thn.

- Cn kim tra trc khi x dng glucocorticoid vi liu dc l.

+ Hin din lao phi hay nhim trng mn tnh khc (X quang phi, IDR).
+ C ri lon dung np glucose hoc tin s i tho ng thai k.
+ C du hin tin long xng (m xng ph n mn kinh).
+ Tin s let t trng, vim d dy hoc vim thc qun.
+ C tng huyt p hoc bnh tim mch.
+ Tin s ri lon tm thn.
2. Cch thc s dng
2.1. Chn loi liu php
Thng u tin l dng trc tip hn l gin tip do nhiu l do: liu chnh xc, thch
ng r, t tc dng corticoide khong, khng tc dng kch thch hc t v lu di v c
th chuyn dng ng chch thay ng ung.
2.2.Chn ng dng
+ ng ung thng c a chung nht.
+ ng tnh mch dng trong trng hp cp cu, v dng liu tn cng ngay t u
m ng ung b hn ch.

558
+ ng tim bp c tc dng phn on liu trong mt thi gian, c tc dng hm
ng k nht l cc ch phm tr tnh m liu hng ngy khng th khng ch.
2.3. Nhp s dng thuc
+ Nhp x dng nhm m bo hiu qu iu tr ng thi ph hp vi nhp sinh hc
ngy m v iu ha cortisol u tin duy tr hot ng tit ca thng thn.
+ X dng mt liu bui sng loi prednisone, triamcinolone v dexmethasone hoc hai
liu khi i lm (2/3 liu) v khong 5 gi chiu (1/3 liu) loi hydrocortisone v cortisone
acetate trong ngy thng c khuyn co.
+ S iu tr khng lin tc c ngh chuyn sang dng liu i cch nht nhm
gim tc dng ph v hn ch s c ch trc i - Yn - Thng thn.
+ Hiu qu iu tr m bo trong cc trng hp thng tn trung bnh, nhng khng
th m bo i vi mt vi th vim nng v nht l ghp c quan m s iu tr i
hi hng ngy.
2.4. Chn la thuc
+ im qua cc dn cht tng hp cortisol chng ta ghi nhn tc dng khng vim tng
dn trong khi tc dng gi mui t n. V th x dng cc dn cht khng vim
cng mnh th thi gian tc dng hm trc i - Yn - Thng Thn cng di, v lu di
y l yu t nguy c tt yu.
+ u tin chn mt trong nhng dn cht c tc dng hm yu (prednisone,
prednisolone, methylprednisolone) m tc dng khng vim m bo vi liu tng
ng v dnh cc loi khng vim mnh trong liu trnh ngn hn.
+ Cc loi cortisone, cortisol, prednisone v prednisolone qua nhau thai t. chnh
nng gia mu m v nhau thai l 10:1 i vi cortisol v prednisolone trong khi
2,5:1 i vi betamethsone v dexamethasone.
2.5. Liu dng
+ Liu dng cn thch ng vi mc trm trng bnh l v v th c s khc bit gia
mt thng tn cp nng vi liu tn cng t 1 - 3 mg / kg/ ngy (prednisolone) hoc
mt thng tn tin trin mc va phi v th cn chn liu hiu qa ti thiu tng
miligram.
3. Theo di iu tr
3.1. Theo di hiu qu iu tr
+ Cn tng liu v nhp iu tr nu cha m bo hiu qu v iu tr.
+ Trng hp t kt qu tt c th chuyn ng tim sang ung, gim liu mt cch
thn trng theo bc thang hng tun t liu ti thiu c hiu qu.
+ Liu php v lu di nn x dng cc dn cht gy hm it liu gn bng liu sinh l
+ Nhp x dng ch yu vo bui sng nhm hn ch suy v thng thn v sau.
3.2. Theo di dung np

559
+ Tm kim cc tc dng ph trong qu trnh iu tr. Cc tc dng ph ny c th l
nguyn nhn ca cc tai bin i khi nguy him v i hi theo di thng xuyn v cn
nng, kch thc, huyt p, nhit , da, c khp, tiu ha v phi.
+ Theo di xt nghim sinh hc ngay khi u liu trnh v nht l khi x dng liu cao
nh: Glucose mu, kali mu, ure mu, creatinine mu, triglycerides, cng thc mu
(bch cu tng khng hn l c nhim trng).
+ Cn tm kim cc tai bin do qu liu, cc tai bin do nghin c th xy ra di liu
php corticoide khi c stress hoc do gim liu qu nhanh, bnh nhn cn c bo
trc v tnh hung ny.
Mt s phng tin cung cp hng ngy cn ch hn ch ri lon chuyn ha ca
Glucocorticoid.
1. Theo di nng lng c x dng d phng tng cn.
2. Hn ch mui a vo d phng ph v tng huyt p v mt kali.
3. Cung cp kali nu cn.
4. Dng khng toan, khng tit, v/ hay dng c ch bm proton.
5. Thit lp thi biu x dng thuc glucocorticoide nu c. Bnh nhn x dng
thuc
trong thi gian di cn c bo v trong thi k c stress cp bng cch tng liu gp
i liu hng ngy.
6. Hn ch ti thiu tnh trng long xng bng cch:
+ Thm hormone sinh dc: 0,625 -1,25 mg oestrogen vo chu k ca progesterone tr
khi vn cn t cung, testosterone thay th cho nam suy sinh dc.
+ Dng calcium liu cao: c th n 1200 mg/ ngy.
+ Dng vitamine D nu calciferol hoc 1,25 (OH)2 vitamne D gim.
+ Dng calcitonin hoc diphosphate nu gy xng xy ra ngay c khi c iu tr
nh trn
4. Ngng iu tr
+ y l mt ch nh ht sc thn trng
+ Ch c a ra nu s p ng v bnh l cho php thc hin iu . Tuy nhin
trong mt vi bin chng nng c th hng n sm hn d nh. S ngng thuc
khng nn t ngt nhm trnh hin tng nghin thuc.
4.1. Cch thc p dng
Nu s ngng thuc khng nn t ngt, gim liu c th nhanh cho n khi t c
liu sinh l, v rng corticoide cn m bo tc dng hormone (ngng nhanh cc loi
corticoid gin tip, nhng nhm c chng c v tc dng).
Tuy nhin khi t liu sinh l, suy thng thn c th b che du nu s iu tr hm,
trong mt vi trng hp hin tng tr thng thn c th cn c xc nh. V th
cn nh gi chc nng thng thn bi thm d chnh xc khng nn da vo nh

560
gi s chuyn ha trong nc tiu (i hi ngng iu tr trong 48 gi) m trc tin
phi nh lng cortisol huyt tng bui sng v test kch thch v i khi nh gi
hon chnh hn chc nng hng v thng thn nu nh p ng thng thn cha
y .
Phc nh sau
+ Nu kho st cho thy chc nng thng thn cn m bo v cn bn cng nh
ng hc, gim liu c th kh nhanh theo bc thang hng tun, bng cch kim sot
li chc nng thng thn khi chm dt iu tr hon ton.
Test ni tit xc nh suy v thng thn t t
Test

Khng c ch

Suy v thng thn

ACTH (liu cao 250 (g)

bnh thng

di bnh thng

H ng mu do insulin

bnh thng

di bnh thng

Metyparone

bnh thng

di bnh thng

Kch thch CRH

bnh thng

di bnh thng

ACTH (liu thp 1g)

bnh thng

di bnh thng

+ Nu chc nng thng thn b ri lon, gim liu cn phi thn trng, bng cch thay
th cortisol bng hydrocortisone m bo nhu cu hormone c bn, v theo di s
phc hi trc i - Yn - Thng Thn v trong nhng tnh hung ny i khi ngi ta
hng n n chn on tr thng thn sau iu tr v nhm n s tr liu thay th.
4.2. Theo di lu di
+ S dng glucocorticoid trn liu sinh l thi gian trn 2 tun u c th c nguy c
suy v thng thn.Tai bin thng t xy ra cc i tng x dng prednisolone
di liu sinh l (12-15 mg/m2 da/ ngy) v thi gian di 2 tun.
+ theo di suy v thng thn ti thiu trn 1 nm sau khi ngng thuc
+ tr em nh theo di mi 3 thng (n 5 nm), tr ln mi 6 thng.
+ ngng iu tri, s theo di khng c li lng v chc nng hng v thng thn
ti lp bnh thng nhiu thng sau khi ngng iu tr hon ton.
+ cn bo trc cho bnh nhn nguy c suy thng thn c th xy ra khi gp stress
v i hi x dng hormone trong vi ngy. v y cng c li trong s kim sot bnh
thng tr li ca trc i - yn - thng thn trong nhng thng sau khi ngng thuc.

IV. TC DNG PH V TAI BIN CA LIU PHP GLUCOCORTICOIDE

1. Do qu liu
1.1. Tai bin sm
- Ri lon tiu ha: mc trung bnh nhng cng c th nng ln bi mt t bc
pht lot d dy hay t trng, c th gy bin chng xut huyt hoc thng. (tng tit
acide d dy, gim tn sinh cht nhy, v i mi t bo v c ch prostaglandine).
- Xut huyt hoc thng rut c th gp. V th cn lu trc cc i tng nghi ng
bnh l d dy t trng.

561
- Ri lon tm thn kinh: Thng xy ra nhng c nhn c a c sn vi biu hin
bng ri lon gic ng, mt ng, sng khoi hoc n nhiu, c th dng m sng, hng
phn, trn cm gn nh l ln, c th gy ng kinh (gim ngng kch thch v no),
chng gi u tiu no (tng p lc ni s).
- Nguy c nhim trng: nht l khi iu tr ko di c t lm bc pht bnh l nhim
trng tim tng hoc do nhim cho vi vi khun m, lao, siu vi (lu bnh u ma,
herpes, zona, si s nng ln nu x dng corticoides) v k sinh trng (nm).
Cc tai bin trn rt kh iu tr do ty theo trm trng v thi gian x dng thuc.
Ty trng hp c th ngng thuc, Nhng i tng b nghin thuc km cn iu tr
thay th cn phi theo di i lc cn phi tng liu. Trn thc t cn theo di ti bnh
vin.
1.2. Tai bin chm
- Lng ng t chc m v ri lon da- c:
Lng ng m (100 mg cortisol/ ngy trong 2 tun) dng Cushing vi qu ti m vng
mt, c v thn thng km ri lon da nh da mng, ban xut huyt, vt rn da, so
gi hnh sao, chm kt so, rm lng, c bit khi dng ACTH tng hp ko di.
Mn trng c thng gp tr v thnh nin, phi hp vi bnh l c do corticoide u
th gc chi, d bo cho suy sinh dc chc nng thng ghi nhn cc dn cht ca
fluor.
-

Ri lon xng:

Biu hin bi s mt khong cht do tr tn sinh xng gy xp ct sng v gy

xng di nht l khi dng liu cao v ko di. C th d phng chng ny bng cch
dng phi hp 25 OH Vitamine D V cch phi hp iu tri fluorure de Na v 25 OH
vitamine D v calcium c hiu qu ngi ln.Hoi t xng v trng do corticoide
thng gp u xng i vi nhiu , cn nghi ng bin chng ny trc mt au
khp khng gii thch c.
- Chng chm pht trin tr em l bin chng ng lo ngi, c th xy ra ngay c liu
thp
Bnh v c.
-

Hin tng gi mui:

Tng cn, ph, tng huyt p v th cn c ch hn ch mui.

- Ri lon v mt: c thy tinh th sau v tng nhn p (khuynh hng u trng,
lng ng MPS trn thy tinh th).
- Ri lon ni tit v chuyn ha: Cng insulin, khng insulin, mt kali, gim kali kim
ha, bc pht i tho ng tim tng hoc lm nng i tho ng c sn. - Suy
nhc sinh dc (nam), ri lon kinh nguyt (n). Gim TSH v T3
- Tng bch cu a nhn (ngay khi khng c nhim trng), gim bch cu i toan.
- Tng ng mu.
- Vim ty cp, gan nhim m.

562
+ Dng corticoid bi ti ch c th gy chng teo biu b da, gim nhim sc t, chng
gin mao mch, mn trng c, vim nang lng.
2. Tai bin do ngng thuc
2.1. Hin tng di
Biu hin bng s ti xut hin triu chng ca bnh chnh gy nn. y l do gim
liu nhanh, cn phn bit vi mt t tin trin ca bnh ngay khi ang iu tr
2.2. Suy v thng thn
Thng thy khi dng liu php corticoide trc tip lin quan n tc dng hm trc i
- Yn- Thng thn do corticoide. Nht l khi x dng liu cao ko di, liu cao hn liu
sinh l.
Suy thng thn d b mn cm khi c stress nhim trng, chn thng, phu thut,
bin chng cp, ngng thuc t ngt. V th d phng cn phi gim liu dn, ch
yu ngang mc sinh l v nht l theo di trc i - Yn - Thng thn v iu tr h
thng khi c stress vi cortisone hoc hydrocortisone liu gp 2 - ln so vi liu hng
ngy.
2.3. Hi chng cai (syndrome de sevrage)
Cn phi theo di trc mt trng hp suy nhc xut hin khi gim liu thuc nhng
khng i km suy v thng thn, Nu iu ny khng tng ng tc dng trn tm
thn kinh ca bnh nhn i vi corticoide. Cn phi n tnh trng thng
thn (inertie surrnalienne)
3. Tai bin do s dng ti ch
+ Khi s dng ti ch (khp, da..) cng c th gy tc dng ton thn nu dng thng
xuyn v liu ng k v cng c th gy cng cortisol v tr thng thn.
+ C th gy nhim trng ti ch (hoc nhim trng trong khp), teo hoc hoi t t
chc di da (nht l khi chch nng), phn ng vim ti ch khi x dng cc dng tinh
th huyn trc (khp, ty).
4. Tng tc gia glucocorticoide vi cc thuc khc
Tng tc gia glucocorticoid vi cc thuc khc
Amphotericin B

gim kali

digitalis

nhim c digitalis, gim kali

GH

khng hiu qu

Li tiu mt kali

gim kali

Vacin t virus

nhim trng nng

nh hng glucocorticoid trn nng cc thuc khc

Aspirin

gim (tng chuyn ha, thanh thi)

Coumarin

gim

Cyclophosphamide

tng (c ch chuyn ha gan)

563
Cyclosporine

tng (c ch chuyn ha ti gan)

Insulin

gim

Isoniazide

gim (tng chuyn ha, thanh thi)

Thuc vin h ng mu

gim

nh hng ca cc thuc trn nng glucocorticoid huyt tng

Khng acid

gim (gim hp thu ti rut)

Carbamazepine

gim (do tng hot ng Cytochrome P-450)

Cholestyramine

gim (do gim hp thu corticoid rut)

Colestipol

gim (do gim hp thu corticoid rut)

Cyclosporine

tng (do c ch chuyn ha gan)

Ephedrin

gim (do tng chuyn ha)

Erythromycine

tng (do gim thi tr)

Mitotane

gim km tng transcortin (nng cortisol khng ng tin cy)

Thuc nga thai

tng (do gim thi tr, gim protein lin kt)

Phenolbarbital

gim(do tng hot ng Cytochrome P-450)

Phenytoin

gim (do tng hot ng Cytochrome P-450)

Rfampin

gim (do tng hot ng Cytochrome P-450)

Troleandomycin

tng (do ri lon thi tr)

Kt lun: Vic tn trng mt s nguyn tc lin quan n ch nh thuc glucocorticoide,

theo di v ngng x dng, bo trc cc s c xy ra, cc bin php d phng v
iu tr tai bin nhm hn ch cc tai bin ng tc xy n cho ngi bnh khi x
dng liu php glucocorticoide.

564

LIU PHP LI TIU

Mc tiu
1.Trnh by c nh ngha cc thuc li tiu v sinh l hnh thnh nc tiu.
2.Phn loi c cc nhm thuc li tiu chnh, cc c ch v ni tc dng ca chng.
3. Nm vng cc ch nh v chng ch nh ca cc thuc li tiu.
4. Bit cc tc dng ph v tai bin khi dng thuc li tiu.
Ni dung

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

565
- Ni tit t: aldostrone, ADH.

II. PHN LOI CC THUC LI TIU

C nhiu cch phn loi cc nhm thuc li tiu theo v tr tc dng, c ch tc dng,
cu trc ho hc,... di y, chng ti gii thiu cch chia cc thuc li tiu ra 4 nhm
da theo v tr tc dng
1. Nhm li tiu gn (diurtiques proximaux): l nhm c tc dng c ch men
Anhydrase Carbonique (Actazolamide) v cc thuc li tiu thm thu (Mannitol).
Nhm li tiu ny khng dng iu tr cc tnh trng ph do nguyn nhn t thn v
khng dng iu tr tng huyt p.
2. Nhm li tiu quai: Furosemide (Lasilix) Bumetamide (Burinex) Pietamide (Eurlix),
acide tacrynic, nhm ny c tc dng c ch ti hp thu Natri nhnh ln ca quai
Henl.
3. Nhm li tiu Thiazides: l nhng dn xut ca Benzothiazide v nhng li tiu
nhm Sulfamide: Hydrochrothiazide (Esidrex), Chlortalidone (Hygroton), Indapamide
(Fludex). Nhm ny c tc dng c ch ti hp thu Natri trn phn u (phn gn) ca
ng ln xa.
4. Li tiu ca ng gp: gm cc thuc: Triamtrne (Teriam), Amiloride (Modamide) v
cc thuc khng Aldosterone (Aldactone) chng c tc dng chung l i khng s trao
i Natri/Kali

III. C CH TC DNG CA CC THUC LI TIU

1. C ch hp th Natri
Tt c cc t bo vn chuyn Na u c bm ph thuc Na/K ATPase trn mng. Cc
bm ny ng vai tr ch o trong vn chuyn Na. Tc dng ca chng c tm tt
trong s sau
Hnh 1 C ch ti hp thu Na trong ng thn

T BO

Nc tiu

3Na+
Na+
2K+

Mu

566

567
Qu trnh ti hp thu Na gm 2 bc
-Na i vo t bo thng qua 1 knh c trn mng t bo pha trn u.
-Vn chuyn Na xuyn qua mng pha y nh bm Na/K ATPase.
2. C ch tc dng ca thuc li tiu quai
- NaCl c lc trong lng ng thn i vo cc t bo nhnh ln quai Henle qua trung
gian 1 cht ti ng vn Na- K - 2 Cl nm mng pha u ca t bo. Nng lng cho
vic vn chuyn ny c cung cp bi Gradient in th thch hp ca Na (ngoi
thp ca ni bo, in tch m ca t bo).
- Cc li tiu quai c ch trc tip s ti hp thu ca Na, K, Cl, nh tranh chp vi v tr
Cl ca cht ti, cc thuc nhm ny cho php thi 20-25% lng Na c lc (trong
ng thn). Cc thuc li tiu ny ng thi c 1 tc dng ln o thi Canxi (c ch ti
hp thu Nacl ua n c ch ti hp thu Calci)
3. C ch tc dng ca li tiu nhm Thiazide
- ng ln xa, Na i vo t bo nh vo cht ti NaCl nm t bo pha u.
- Cc cht Thiazide c ch trc tip ti hp thu ca NaCl bng cch tranh chp v tr Cl
ca cht ti, chng kch thch 1 cch gin tip ln s ti hp thu Ca.
- Tc dng ca ca nhm thuc ny thng yu, ch cho php o thi 5- 10% lng
Na c lc (trong ng thn)
4. C ch tc dng ca li tiu gi Kali
Lin quan n phn v ca ng gp.
- Na i vo t bo qua 1 knh Na biu m trn mng t bo. Nng lng c cung
cp bi Gradient ca Na. Sau Na c bi tit pha mng y ca t bo thng
qua 1 bm ph thuc Na- K- ATPase.
- Aldosterone lm tng s lng knh Na v s lng cc bm ph thuc Na-KATPase.
- Cc thuc li tiu gi Kali (nh Amiloride) c ch trc tip cc knh Na trong khi
Spironolactone i khng vi tc dng ca Aldosterone.
- Tc dng thi Na ca nhm thuc ny thp, cho php bi tit 1-3% lng Na c lc
(trong ng thn)
5. C ch tc dng nhm li tiu gn
- Mannitol li tiu theo c ch thm thu.
- Acetazolamid c ch ng ln gn v c ng ln xa men anhydrase carbonique
theo phn ng:
CO2 + H2O

H2CO3

: cn anhydrase carbonique
: khng cn anhydrase carbonique

H+ + HCO3-

568
IV. CH NH CA CC THUC LI TIU
1. Cc bnh tim mch
1.1. Ph phi cp: ch nh thuc li tiu bnh l ny l cc loi li tiu nhanh, mnh
(nh Furosmid).
1.2. Suy tim ton b, suy tim phi vi ph n v trn dch.
1.3. Tng huyt p: nht l tng huyt p ngi ln tui, thuc li tiu c chn la
l cc li tiu h Thiazid, lu khi phi hp thuc li tiu vi cc nhm thuc khc gy
h huyt p s tng hiu qu ln rt nhiu.
1.4. Vim mng ngoi tim cp v mn.
2. Ni tit, sn khoa v cc bnh dinh dng
2.1. i tho nht: c ch nh s dng cc thuc li tiu mui.
2.2. Hi chng ph chu k v cn (hi chng Mach) vi triu chng tng t ngt trng
lng trong thi k kinh nguyt nh nhc u, thay i tnh tnh, to bn. Trong hi
chng ny thng gp tng aldostrone th pht nn loi Spironolactone v
Triamtrne l c ch nh tt.
2.3. Nhim c thai nghn c phi hp hoc khng c vi tng huyt p: khi s dng
li tiu cn lu c th gy nhim c vi thai nhi v ngay c cho ngi m nht l cc
nhm thiazid.
2.4. Tng calci niu v cn phi hp vi si tit niu. Tng calci niu c gim bi
mt s thiazid nh hydroflumthiazide (Lodrine) v Benzothiazide (Fovane).
3. Bnh l gan
Ph, c trng do x gan v trong mt s bnh vim gan bn cp.
4. Cc bnh l thn
Trong vim cu thn cp, vim cu thn mn tnh, suy thn cp, suy thn mn.
i vi hi chng thn h iu tr thuc li tiu phi cn thn v c th lm gim thm
th tch mu gy suy thn cp chc nng.
Nhn chung, i vi nhm bnh l thn, thuc li tiu nhm Furosmid c ch nh rng
ri v t c v tc dng nhanh, mnh nht l ch trong suy thn cp. Khi suy thn c
tng Kali mu th li tiu tit kim Kali l chng ch nh.
5. Bnh phi: Tm ph cp, tm ph mn c km suy tim phi.
6. Ph vi tng tit dch do ung th

V. LIU LNG CC THUC LI TIU CHNH

1. Li tiu thy ngn
V nhm ny gy nhiu tai bin nn ngy nay t dng. Ch cn nhng dn xut ca thy
ngn hu c l cn dng nh Novurit (Mecuropylline) ng 0,3g, liu dng 1/2 n 2
ng/ngy.
2. Loi c ch men anhydrase carbonique

569
Acetazolamid (Diamox0, dng vin 125mg, 250mg, 500mg: liu lng 250mg500mg/ngy.
Dichlorophenamide (DARANIDE), vin 50mg, liu lng 200mg/ngy.
Cc thuc trong nhm ny thng c s dng iu chnh ri lon toan kim trong
suy h hp mn, lm gim p lc nhn cu ca bnh Tng nhn p (Glaucome), trong
bnh ng kinh.
3. Loi thuc li tiu mui: L nhm thuc tng o thi Natri, Kali. L mt trong nhng
nhm thuc c s dng vi mc ch li tiu nhiu nht hin nay, gm:
3.1. Cc Thiazides: l loi sulfamide li tiu v trong cu trc ca chng c gc
sulfonamide. Trong nhm thuc ny c nhiu bit dc, ch k tn mt s thng dng:
- Chlorothiazide (Diuril) vin 0,5mg, liu lng 1-2vin/ngy
- Hydrochlorothiazide (Hypothiazide) vin 25mg, liu lng 2-3vin/ngy. L loi
thuc thng c dng trong iu tr tng huyt p.
- Clopamid (Brinaldix) vin 20mg, liu lng 1-2vin/ngy
3.2. Cc thuc nhm li tiu quai (quai Henl: bao gm:
- Furosemide (Lasix - Lasilix) vin 40mg, ng 20mg: l thuc c ch nh kh rng
ri v tc dng nhanh (ung sau 45 pht, tim tnh mch sau 10 pht) v mnh.
- Acid tacrynique (Edecrine) vin 50mg, ng 50mg. Vi ng dng tnh mch,
thuc c tc dng nhanh sau 1/2 gi tim v ko di 6-8 gi.
4. Spironolactone
n thun nh Aldactone vin 50mg, liu lng 2-6vin/ngy. Liu duy tr 2 vin/ngy.
Spironolactone phi hp vi Thiazide nh Aldactazine (Spironolactone 25mg + Altizide
15mg) liu lng 3-4 vin/ngy, liu duy tr 1-2 vin.
Cn lu hiu qu c ch aldostrone ko di nhiu ngy sau khi ngng thuc cho nn c
th gy tai bin nng n do mt nc nu liu trnh khng chm dt ng lc.
5. Triamtrne
n thun nh Teriam vin 100mg, liu tn cng 2-3 vin/ngy, liu duy tr 1 vin trong
ngy hoc 2 ngy.
Triamtrne phi hp vi Thiazide nh cyclotriam (triamtrne 150mg + cyclothiazide
3mg)
6. Amiloride
Cng l loi li tiu gi Kali bit dc Modamide vin 5mg, liu lng 1-4vin/ngy.
7. Cc nhm thuc khc c tc dng gy li tiu
7.1. Cc Corticoides: Thng c kh nng gy li tiu sau 3-4 ngy iu tr, ban u l
li tiu n thun tip theo l li tiu thm thu vi bi tit Kali v Natri c th gy gim
Kali ng k.
7.2. Li tiu thm thu

570
- Mannitol 10-20% x 500-1000ml chuyn tnh mch trong 24 gi, c th phi hp
vi mt thuc li tiu mui hoc khng aldostrone. Thng ch nh trong ph no,
thiu v niu sau phu thut, ng c nng o thi c cht nht l thuc
Barbiturate.
Chng ch nh trong suy tim, suy gan, suy thn mn tnh nng.

VI. TC DNG PH, TAI BIN CHUNG V CHNG CH NH

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

571
4.1. Trong suy tim khng dng cc loi li tiu thm thu
4.2. Trong c trng do x gan khng dng loi thy ngn v Acetazolamide.
4.3 Trong i tho ng khng dng loi li tiu mui v Acetazolamide.
4.4. Trong suy thn khng dng li tiu thy ngn v mui
4.5. Nu c tng Kali mu khng dng Spironolactone. Triamtrne.