CHN ON

X GAN
V Th M Dung
vodung@ump.edu.vn

MC TIU

Trnh by nguyn nhn gy x gan

Trnh by triu chng lm sng x gan
Trnh by thay i v xt nghim mu
& sinh ha trong x gan

DN BI

I CNG
PHN LOI
NGUYN NHN
TIP CN BNH NHN X GAN
BIN CHNG
IU TR
3

I CNG
Gan: thc hin nhiu chc nng sng
Tch tr vitamin, mui khong
Sn xut cc protein cn thit
Sn xut cc yu t ng mu
Chuyn ho cc cht
Sn xut cc cht chng nhim trng,
loi b vi khun khi dng mu
4

I CNG

Vim gan: gan b vim, sng phng

Vim gan mn: vim gan > 6 thng
X ha: m so thay t bo gan cht
X gan: to so nng khp gan
Suy gan: gan b tn thng nhiu,
khng th thc hin cc chc nng
5

X gan
Giai on cui ca cc bnh gan mn
M hc
. t bo gan b thoi ho, hoi t
. t bo gan tn sinh
. hnh thnh di x
Cu trc tiu thy gan thay i thnh
nnt tn sinh b bao quanh bi m x
khng c chc nng gan

PHN LOI

X gan nt nh
X gan nt to
X gan th hn hp

PHN LOI

X gan nt nh
Vch u, dy, nt tng sinh < 3mm
Nghin ru
Suy dinh dng
Thm nhim st
mt
Tc tnh mch gan
8

PHN LOI

X gan nt to
Vch
Cc nt to nh khc nhau > 3 mm
Nhiu so x ho khong ca
Tn sinh cc t bo ln nhn ln
XG do VGSV
Thiu 1-antitrypsin
XG mt nguyn pht
9

PHN LOI

X gan th hn hp
X gan nt nh + X gan nt to
XG nt nh XG nt to

10

BNH HC

i th
B mt khng u
Nhiu nt vng
Gan to do nhiu nt tng sinh
Gan teo nh giai on cui

BNH HC
Tiu chun chn on x gan
Nt tn sinh
X ho
(tch t m x to tiu thu gi)
Cu trc gan bt thng
T bo gan bt thng
(tinh th ho, lon sn, tng sn)

NGUYN NHN

5-10% NL
> 90% TE

~ 20 years

30 years

NGUYN NHN

Ru: ung qu nhiu, 10 nm

Nam > 21 n v cn/tun
N > 14 n v cn/tun

NGUYN NHN
mt
XG mt nguyn pht
XG mt th pht
Vim ng mt x ho nguyn pht

Primary sclerosing cholangitis with typical

stricturing and dilation pattern

NGUYN NHN

Chuyn ho
Thiu 1-antitrypsin
Nhim st (Heamochromatosis)
Thm nhim ng (Wilson)
Glycogenosis IV
Galactose mu
Tyrosinosis bm sinh
20

NGUYN NHN

Mch mu
Bnh tc nghn tnh mch
Hi chng Budd-Chiari
X gan tim
Vim mng ngoi tim co tht
Ri lon min dch
Vim gan t min
21

NGUYN NHN

Suy dinh dng

Nhim trng
Giang mai s sinh x gan
Sn mng: trng gy phn ng
m x khong ca
St rt X gan ?
SR & XG SDD & VGSV ?
22

NGUYN NHN

Sang thng dng ht

Brucellosis
Lao
Sarcoidosis
X gan cn nguyn n

23

TIP CN BN X GAN
Phn hnh chnh
Ch cc c im lin quan bnh
Ngh nghip
Tui: thng ln tui
Gii: nam > n

24

TIN S

Vng da
Vim gan
S dng thuc
Truyn mu
Nghin ru
Bnh di truyn gia nh
25

Din tin t nhin ca Bnh gan mn

Bnh
gan
mn

X
gan
cn
b

X
gan
mt
b

Gin tnh mch thc qun xut huyt

Bng bng
Bnh no gan
Vng da

T
vong

LM SNG

Hi chng suy t bo gan

Hi chng tng p tnh mch ca

27

TRIU CHNG C NNG

Mt mi
St cn
Bing n
Tiu chy
Teo c
Ph chn
St
28

TRIU CHNG C NNG

Da vng
Bng to
Xut huyt
chy mu cam, li
xut huyt di da
xut huyt tiu ho
Gim kh nng tnh dc
bt lc
lnh cm

TRIU CHNG THC TH

Gy
St
Vng da
t bo gan suy chc nng
i sng hng cu

Tng sc t
Xut huyt di da
To tuyn mang tai
30

TRIU CHNG THC TH

Ngn tay di trng

Bn tay co kiu Dupuytren

Mng trng
(Terrys nail)

Hgjdhll
flm,vbb

34

Muehrckes nail

TRIU CHNG THC TH

Lng bn tay son

Ph chn
Lim mng xanh da tri (Azure lunula)
Vng Kayser-Fleicher: bnh Wilson

TRIU CHNG THC TH

Sao mch
c ngc
cnh tay
lng bn tay
N ho tuyn v nam
Thay i phn b lng
Teo tinh hon

TRIU CHNG THC TH

Khm bng
Bng bng

TRIU CHNG THC TH

Khm bng
Bng bng
Tun hon bng h
Lch to
Gan to, gan teo

TRIU CHNG THC TH

Khm bng
Bng bng
Tun hon bng h
Lch to
Gan to, gan teo

CN LM SNG

Huyt hc
Hng cu (thiu folate)
i sng HC
Haemoglobin
Bch cu
Tiu cu
41

CN LM SNG

Cc yu t ng mu
Gan tng hp
I (Fibrinogen), II (Prothrombin),
V, VII, IX, X
T: VII ngn nht, X, IX
V khng ph thuc vit K
Vit K 10 mg
PT (TQ) ci thin t nht 30%
42

S ng cm mu
PT / aPTT
- thiu VII
- thiu vit K
- iu tr Warfarin
- bnh gan

S ng cm mu
PT / aPTT
- thiu VIII, IX, XI, XII
- Lupus anticoagulant
- iu tr Heparin
- gim prekallikrein
- gim kininogen trng
lng phn t cao

S ng cm mu
PT & aPTT
- thiu V, X
- fibrinogen, II
- thiu vit K
- iu tr Warfarin
- bnh gan

CN LM SNG

Sinh ho mu
Bilirubin TP, TT > GT , 50%
Phosphatase kim
Glutamyl Transpeptidase
5-nucleotidase
ng huyt
46

CN LM SNG

Sinh ho mu
Transaminase
AST
ALT

47

CN LM SNG

Albumin ( 65% Pr, t: 3 tun)

T l Alb/Glo < 1
in di Globulin: -Glo
XGM: 2-Glo, -Glo
Glo min dch
IgA : X gan ru (Laennec)
IgM : X gan mt tin pht
IgG : Vim gan t min
48

CN LM SNG

XN dch bng
Rivalta ()
Protein DMB < 2,5 g/dL
SAAG > 1,1g%: tng p ca
Alb HT Alb DMB
49

CN LM SNG

Khng th khng c trn

Khng th khng nhn
Khng th khng ti lp th
HBsAg, anti-HCV
St, Ferritin, Ceruloplasmin, Cu
-Fetoprotein
50

CN LM SNG

Siu m & CT scan

Gan teo
Cu trc nt
Ni soi
Gin tnh mch trc trng
Gin tnh mch thc qun

CN LM SNG

Sinh thit gan

Tiu chun vng

Phn loi theo Child

A

Bilirubin mu

< 2 mg%

2-3

>3

Albumin mu

> 3,5 g%

3-3,5

<3

Bng bng

khng

Ri lon
thn kinh
Dinh dng

khng

d
kim sot
nh

kh
kim sot
hn m

rt tt

tt

km
53

Phn loi Child-Turcotte-Pugh

1

Bnh no gan

khng

1-2

3-4

Bng bng

khng

nh

TB, nhiu

Bilirubin mu

< 2 mg%

2-3

>3

Albumin mu

> 3,5 g%

2,8 - 3,5

< 2,8

TQ ko di

< 4

4-6

>6

Hoc INR

< 1,7

1,7 - 2,2

> 2,2

XG mt

Bili < 4

4-10

> 10

A: <7

B: 7-9

C: 10-15

Child-Pugh

BIN CHNG
XHTH do v TM thc qun gin
Vim phc mc nhim khun nguyn pht
Hi chng gan thn
Hn m gan
Ung th ho
Bng bng

55

Vim phc mc nhim khun

nguyn pht

au bng
St
Bnh no gan
Tiu chy
Chong nhim trng
Xut huyt tiu ho
Nn
56

VPMNKNP

VPMNKNP cy (+)
VPMNKNP cy (-)
Du khun bng

BCNTT
dch bng
> 250/mm3
> 250/mm3
< 250/mm3

Cy
dch bng
(+)
(-)
(+)

57

VPMNKNP

Nguy c VPMNKNP: Protein DMB < 1 g%

VPMNK th pht
BCNTT 250/mm3
Cy nhiu loi vi khun
Protein > 1 g/dL
Glucose < 50 mg/dL
LDH dch bng > LDH huyt thanh
58

TIN LNG

Yu t tin lng

Bt thng chc nng thn

Ri lon huyt ng
Mc p ng iu tr
59

Tin lng

Tin lng x gan c bng bng km

< 50% sng 2 nm sau t bng u

Sng > 10 nm: rt him
Thi gian sng trung v
- 2-5 nm: x gan c bng bng
- 6 thng: bng bng kh cha
- 2 tun: hi chng gan thn type 1
60

Kh nng sng cn
Child-Turcotte-Pugh
im

Nhm

5-6

Kh nng
sng 1 nm
100%

Kh nng
sng 2 nm
85%

61

Kh nng sng cn
Child-Turcotte-Pugh
im

Nhm

5-6
7-9

A
B

Kh nng
sng 1 nm
100%
81%

Kh nng
sng 2 nm
85%
57%

62

Kh nng sng cn
Child-Turcotte-Pugh
im

Nhm
A
B

Kh nng
sng 1 nm
100%
81%

Kh nng
sng 2 nm
85%
57%

5-6
7-9
10-15

45%

35%

63

Tin lng sng Nguy c phu thut

Child-Turcotte-Pugh
CTP A
5-6 im
Tui th (nm)
15-20
T vong chu phu (%)
10

CTP B
7-9 im
4-14
30

CTP C
10-15 im
1-3
80

Schuppan D, Afdhal NH. Liver cirrhosis 2008

64

IU TR

X gan: bnh e da i sng

Khng c tr liu no
cha lnh x gan hoc
phc hi m so gan
iu tr nhm
ngn nga hoc
lm chm tn thng gan
65

IU TR

iu tr nguyn nhn
Trnh lm tn thng gan
iu tr nng
Nhu cu dinh dng
iu tr bng bng
iu tr bin chng
Ghp gan
66

Take home message

Nguyn nhn x gan

Triu chng lm sng ca x gan
Triu chng cn lm sng ca x gan
V Th M Dung
vodung@ump.edu.vn

68