BNH VIN BCH MAI

KHOA C XNG KHP

C h b i n : PGS. TS. V Th T h a n h T h y

CO XNG KHP

NH XUT BN Y HC

g p

BNH VIN BCH MAI

K H O A C

X N G

K H P

C h b i n : PGS. TS. V Th T h a n h T h y

C H N
N H N G

O N

B N H

c o

T H N G

I U

X N G

K H P

G P

(Ti bn ln th nht c sa cha v b

NH XUT BN Y
H

T R

NI-2012

HC

sung)

Ch bin:

PGS. TS. V Th Thanh Thy

Tham gia bin son:

PGS. TS. V Th Thanh Thy

PGS. TS. Nguyn Th Ngc Lan
TS. Trn Th Minh Hoa
TS. Nguyn Mai Hng
PGS. TS. Nguyn Vnh Ngc
TS. Nguyn nh Khoa
TS. Nguyn Vn Hng
ThS. Trn Th T Chu
ThS. Nguyn Phng Thy
ThS. Bi Hi Bnh
ThS. Hong Vn Dng

LI GII

THIU

Bnh v i n B c h M a i l m t trong nhng b n h v i n u n g n h

v N i khoa ca n g n h y t V i t N a m , bnh v i n l n i lm vic
ca nhiu gio s, b c s giu k i n h n g h i m , l c s o to thc
h n h cho c c sinh vin i hc, sau i hc ca T r n g i hc
Y H N i v cng l n i thc h i n c n g tc chi o t u y n i
vi c c c s y t t u y n d i . Trong n h i u n m qua, bnh v i n
thc h i n tt c n g tc ch o t u y n , b i n son n h i u ti
liu, o to, b i d n g n n g cao nghip v k h m cha bnh
cho cc thy thuc c c tuyn d i .
Trong dp n y , ti x i n g i i t h i u c u n s c h m i xut bn
c h u y n v bnh l C X n g K h p - l m t trong n h n g
bnh n i khoa t h n g gp trn t h g i i c n g n h V i t N a m ,
bnh c t h x y ra m i la t u i , nh h n g rt n h i u n k h
n n g lao n g , sinh hot v cht lng sng ca n g i b n h v
l m t trong nhng n g u y n n h n gy tn p h , l g n h nng k i n h
t cho gia i n h v x h i . Tuy n h i n , s h i u b i t v bnh l c
x n g k h p , v p h n g p h p chn o n , iu tr v p h n g bnh
ti nhiu c s y t c n hn c h i k h i gy ra tai b i n i u tr,
l i h u q u tn p h cho n g i bnh.
Cun sch " C h n o n v i u tr c c b n h C X n g K h p
t h n g g p " l m t ti l i u c h u y n n g n h c b i n son c n g
phu v i s n g g p ca tp t h c c g i o s, b c s ca khoa C
X n g K h p B n h v i n B c h M a i v m t s g i n g v i n c a b
m n N i tng hp T r u n g i hc Y H N i . y l c u n s c h
t n g i h o n chnh v c c bnh l n i khoa v c x n g

khp, gip cho cc bc s, sinh vin y khoa trong thc hnh lm

sng chn on, iu tr bnh c xng khp thng gp c
hiu qu hn.
Cun sch l tm huyt v c gng trong nhiu nm ca tp
th cc gio s, bc s lm vic lu nm trong lnh vc c
xng khp ti Bnh vin Bch Mai, nn ti hy vng s p ng
c nhu cu ca cc bc s mun tm hiu v lnh vc ny.
Ti xin trn ng gii thiu vi bn c v xin cm om s
cng tc nhit tnh v y trch nhim ca cc tc gi.
PGS. TS. Trn Thy Hnh
Nguyn Q. Gim c Bnh vin Bch Mai

LI NI U
(Ti bn ln th nht)

Bnh l C X n g K h p l bnh t h n g gp, l m t trong

n g u y n n h n h n g u g y tn ph. C n g v i s p h t t r i n ca
nn y hc, c c bnh l n i khoa v c b i t l c c bnh C
X n g K h p n g y c n g c quan t m trong n g h i n c u v
thc h n h l m s n g , v i mc c h chn o n sm, i u tr k p
thi v p h n g bnh h i u qu n n g cao cht lng sng, t r n h
nguy c tn p h cho n g i bnh.
Trong nhng n m qua, s h i u bit v bnh l x n g k h p , v
p h n g p h p c h n o n , i u tr v p h n g bnh t i nhiu c s y
t nc ta c n c nhng hn ch, do c n nhng tai b i n
iu tr, x y ra hu qu tn ph cho n g i bnh. N h n dp k
nim 40 n m n g y t h n h lp khoa C X n g K h p B n h v i n
Bch M a i (1969 - 2009) v sau nhiu n m p , c h n g ti x i n ra
mt c u n sch " C h n o n v i u tr nhng bnh C X n g
Khp t h n g gp", n h m mc ch cp nht c c tin b n g
chn on, i u tr cng n h p h n g bnh, hy v n g s p n g
c nhu c u cho b c s trong thc h n h c h n o n v i u tr
cc bnh x n g khp thng gp c h i u qu h n .
Cun sch c v i t trong i u k i n n g n h n i khoa v
c h u y n khoa c x n g k h p a n g p h t t r i n rt m n h m , n g y
c n g h i n i v i nhng t i n b v t bc v sinh hc p h n t.
Tuy n h i n c u n s c h n y m i ch p n g n h n g v n thc
h n h c bn, c h a cp y c c m t bnh trong gn 200 c c
bnh l C X n g K h p v k h n g t h k h n g c nhng t h i u st
nht nh.

iu mong mun ca chng ti l bnh nhn xng khp

c khm, chn on v iu tr bnh mt cch tt hn. phng
bnh v trnh cc bin chng bnh, tn ph khng ng xy ra.
Chng ti cng mong mun cun ti liu ny s c th l ngi
bn ng hnh gip cc bn ng nghip trong thc hnh lm
sng v rt mong s gp ca cc bn ng nghip.
Vi kinh nghim v tm huyt ca c tp th cc tc gi,
chng ti hy vng cun sch ny s l mt vin gch gp phn
xy dng v pht trin chuyn ngnh C Xng Khp Vit
Nam.
Chng ti xin by t lng bit n n Nh xut bn Y hc,
Bnh vin Bch Mai v gio s tin s Trn Ngc n - Ch tch
Hi Thp khp hc Vit Nam, gio s u ngnh khp Vit
Nam ht sc ng vin v to mi iu kin thun li cho
cun sch sm c ra mt bn c.

H Ni ngy 29 thng 2 nm 2012

TM cc tc gi
CH BIN
PGS. TS. V Th Thanh Thy

MC

LC

Trang
L i gii thiu

L i ni u

P h n loi mt s bnh khp t h n g gp

PGS. TS. V Th Thanh

9
Thy
16

Bnh long x n g
PGS. TS. V Th Thanh

Thy
35

Thoi ha khp
TS. BSCKI1. Nguyn Mai

Hng
56

Thoi ha ct sng
TS. BSCKII. Nguyn Mai Hng
Hoi t v k h u n chm x n g i
TS. Nguyn

65
Vn Hng

au ct sng tht lng v a u thn kinh ta (hng)

PGS. TS. V Th Thanh Thy

75

Vim khp d n g t h p

88
PGS. TS. Nguyn

Th Ngc Lan
HO

Chn o n v iu tr bnh g t
ThS. Hong Vn Dng

124

Lupus ban h thng

PGS. TS. Nguyn

Vnh Ngc

X cng b t o n t h

138
PGS. TS. Nguyn

Vnh Ngc

H i chng Gougerot - Sjogren

PGS. TS. Nguyn

Vnh Ngc

149

Vim a c v vim da c

163
TS. Nguyn nh

Khoa

Bnh l ct sng huyt thanh m tnh

TS. Trn Th Minh Hoa

169

Bnh l vim im bm gn v phn mm

ThS. Trn Th T Chu

190

Vim khp thiu nin t pht

203
ThS. Trn Th T Chu

Vim khp nhim khun

222
ThSrBi Hi Bnh

Vim xng ty nhim khun

232
ThS. Bi Hi Bnh

Bnh lao ct sng

244
ThS. Nguyn Phng Thy

Ung th di cn xng

252
ThS. Hong Vn Dng

a u ty xng

267
TS. Nguyn nh Khoa

Xt nghim cn lm sng trong chn on, iu tr v

theo di bnh l c xng khp
TS. Nguyn nh Khoa

275

T chc phng tim khp ti bnh vin

TS. Trn Th Minh Hoa

288

Tim corticosteroid vo khp v t chc phn mm

cnh khp

290

TS. Trn Th Minh Hoa

Ni soi khp gi

303
TS. BSCKII. Nguyn Mai Hng

Ti liu tham kho

312

PHN LOI M T s BNH

THNG
GP

KHP

PGS. TS. V T h T h a n h T h y
I. B N H C A T CHC LIN K T
1. L u p u s b a n h t h n g
2. V i m a c
3. V i m a c v da ( v i m da c )
4. X c n g b t o n t h v c c h i c h n g lin q u a n
- X cng b t o n t h .
- H i c h n g Sharp.
- H i chng CREST.
5. V i m k h p d n g t h p
6. B n h s t i l l n g i l n (AdulCs s t i t l d i s e a s e )
7. H i c h n g S j o g r e n ( S j o g r e n ' s s y n d r o m e )
8. C h n g a u n h i u c d o t h p ( P o l y m y a l g i a R h e u m a t i c a )
9. B n h l v i m
thc mch

mch

(Vasculitis),

phn

loi theo

kch

9.1. Cc mch
nhnh)

ln b tn thng

(ng

mch

ch v

cc

- Vim ng mch (thi dng) t bo khng l (Giant-cell

(temporal) arteritis).
- Vim ng mch Takayasu (Takayasus arteritis).
9.2. Cc mch mu trung

bnh

Vim nt quanh ng mch (Polyarteritis nodosa).

- Bnh Kawasaki (Kawasaki's disease).
9.3. Cc mch mu nh (tiu tnh mch,
mao mch v cc ng mch nh)

tiu ng

mch,

- u ht Wegener (Wegener's granulomatosis).

- Hi chng Churg-Strauss (Churg-Strauss syndrome).
- Vim nhiu mch nh (Microscopic polyangiitis).
Bnh Henoch-Schonlein (Henoch-Schonlein purpura).
- Bnh cryoglobulin mu v cn (Essential cryoglobulinemic).
li. BNH L CT SNG H UYT THANH M TNH
1. Vim ct sng dnh khp
2. Bnh l n g rut c vim k h p (Enteropathic Arthritis)
Vim lot i trng (Ulcerative colitis) v bnh Crohn.
- Vim khp phn ng ng rut (Enteropathic reactive
arthritis).
Bnh Whipple.

10

3. V i m k h p v y n n
4. H i c h n g Reiter v v i m k h p p h n n g
IM. BNH KHP TINH TH
1. B n h g t
2. B n h k h p d o t i n h t h k h c ( P s e u d o g o u t )
IV. B N H L N H I M KHUN LIN Q U A N T I H X N G
KHP
1. V i m k h p n h i m k h u n
- Vim khp n h i m k h u n sinh m .
- V i m khp n h i m k h u n sinh m do lin cu.
Vim khp n h i m k h u n sinh m do p h cu.
- Vim khp n h i m k h u n sinh m do t cu.
- Vim k h p n h i m k h u n sinh m do v i k h u n k h c .
2. V i m k h p d o lao
3. V i m k h p s a u

bnh

Lyme

(do x o n

khun

Borrelia

burgdoreri)
4. V i m k h p d o v i r u s
5. V i m k h p d o k s i n h t r n g , n m
6. V i m k h p b n h n h n A I D

li

7. Ct tuy vim
8. St thp (Rheumatic Fever) hay t h p k h p cp, t h p tim
V. BNH THOI HOA KHP V CC R i LON XNG
KHP LIN QUAN TI CHUYN HOA V CC BNH L
KHC...
1. Thoi hoa khp (nguyn p h t v t h p h t )
- Thoi hoa a khp.
- Thoi hoa ct sng.
- Thoi hoa khp gi.
- Thoi hoa khp hng.
Thoi hoa khp khc.
2. Hoi t v khun x n g
- Hoi t v khun chm xng i.
Hoi t xng t i cc v tr khc (t gp hn).
3. L o n g x n g
- Long xng khng c gy xng bnh l.
- Long xng km theo c gy xng
- Long xng trong bnh ni tit.
- Long xng trong cc bnh khc.
4. Nhuyn x n g
5. Bnh Paget

12

6. B n h k h p d o n g u y n n h n n i t i t ( t u y n g i p , t u y n
yn, tuyn thng thn...)
7. B n h k h p d o n g u y n
nhim sc t st...)

nhn

bnh

mu

(Hemophilia,

8. B n h k h p d o n g u y n n h n t h n k i n h ( g i a n g m a i t h n
kinh- Tabes, l o n d n g t h n kinh giao c m - h i c h n g
Sudeck, x c t b n teo c, r n g n g tuy...)
9. B n h k h p d o c c n g u y n n h n k h c
- Do t m t h n .
- Do thuc, vaccin, h u y t t h a n h . . .
- Do hoa cht, c h t c.
- Loi khc.
VI. C C B N H K H C K H P
1. B n h k h p s a u c h n t h n g
- T r n dch, t r n m u khp.
- Vim m n g h o t dch sau c h n t h n g .
- V i c h n t h n g do n g h nghip.
2. C c d d n g (do b m s i n h , m c p h i )
3. C c k h i u v l o n s n
- u l n h , n a n g nc.
- u c t n h ( n g u y n p h t , t h p h t ) .
- L o n sn x n g , sn.

13

4. Bnh khp sau bnh c tnh

- Hi chng Pierre- Marie.
- Bnh Leucemia, Hodgkin.
- Carcinoid.
5. C c bnh k h c
- Bnh khp Amyloid (Amyloid arthropathy).
- Sickle cell disease, beta thalassemia.
- Bnh vim mng hot dch th lng nt sc t (Pigmented
villonoduar synovitis).
- Sarcoidosis.
VII. CC BNH L PHN MM CNH KHP
1. Chng a u c (myalgia), a u si c (ibromyalgia)
2. Vim g n (Tendinitis)
3. Vim ti thanh mc (Bursitis)
4. Vim g n ni b m t n , vim li cu
5. Hi chng ng hm
6. Vim quanh khp (periarthritis)
7. Vim m t b o (cellulitis), vim m si (ibrositis)

14

VUI. NHM B N H T H P T R EM
1. V i m k h p t r e m t p h t ( I d i o p a t h i c c h i l d h o o d
ICA)

arthritis-

- T h khi u vi khp (Oligoarticular-onset I C A ) .

- T h khi u n h i u khp (Polyarticular-onset I C A ) .
- T h khi u h t h n g (Systemic-onset I C A , cn gi l b n h
Still t r em).
2. V i m k h p lin q u a n n b n h l n g r u t - c t s n g
huyt thanh m tnh
- Vim ct sng d n h khp.
Bnh
l
khpspondyloarthropathy).

ct

sng

thiu

nin

(Juvenile

- Vim khp v y n n t h i u n i n .
- B n h l khp lin quan n b n h ng r u t .
3. V i m k h p t h p h t s a u c c b n h h t h n g
- Lupus ban h thng.
- Vim da c, vim a c.
- Ban x u t h u y t Scholein- H enoch.
4. C c b n h k h p k h c
- H i chng M a r a n .
- H i chng Ehlers- Danlos.
- Cystic brosis.
- Vim khp lin quan ti cc t h i u h t m i n dch...

15

BNH LONG XNG

PGS. TS. V Th Thanh Thy

i. I CNG V BNH LONG XNG

1. Tm quan trng
- Trn th gii c khong 200 triu ngi b long xng (LX).
- 30% ph n 50 b xp ln t t sng tr ln do
long xng.
- Chu u: c 30 giy li c mt ngi b gy xng do
long xng.
- Ring M hng nm c khong 25 triu ph n c nguy c
long xng. 1,4 triu ngi b gy c xng i do long xng.
- Mi nm c 1/5 s trng hp b gy c xng i v xp t
sng do long xng b t vong.
- 1/3 s ph n v 1/5 s nam gii c nguy c long xng.
- T l gy xng do long xng hng nm cao hn t l
nhi mu c tim cng t qu v ung th v. Nguy c gy c
xng i nam cao hn nguy c ung th tin lit tuyn.
D on: t l gy c xng i s tng t 1,7 triu ngi
(nm 1990) ln n 6,3 triu ngi (nm 2050), trong 50% s
l ngi chu .
Chi ph rt tn km: hng nm chi ph cho long xng M
l 14 t la (USD), chu u: 350 triu EUR, Anh: t bng

16

- C h u : t l g y xng do l o n g x n g cng a n g t n g ln
n g k, c b i t l cc nc cng nghip p h t t r i n n h
Singapore, H n g Kong.
- Theo Cooper, 1992: c t n h c k h o n g 3,2 t r i u n g i b
gy c xng i do L X . L a u , 1996: xp l n t s n g H n g
Rong: 30%.
Bng 1. Chi ph trc tip hng nm k c nhp vin i vi long xng (ti
M)
Bnh
Tim mch

T l %

(t USD)

4,6

20,3

Long xng

10

13,8

Hen

15

7,5

2. n h n g h a l o n g x n g
c
ca
gy

L o n g x n g l t n h t r n g b n h l ca h t h n g x n g c
t r n g bi s g i m k h i xng, g y t n h i n v i cu t r c
t chc x n g l m g i m chc ca x n g g y nguy c
xng.
Bnh thng

Long xng

Hnh 1. So snh long xng t sng

17

- Tiu chun chn on bnh LX theo T chc Y t t h gii WHO (Kanis, 1994) da vo T- Score (phng php o bng
my DEXA t i ct sng v c xng i):
+ Bnh thng: T- Score > - 1,0.
+ Gim mt xng: -2,5 <T- Score - 1.
+ Long xng: T < - 2,5.
Tuy nhin cn lu khi chn on LX khng da hon ton
vo mt xng (MX) m cn kt hp vi nh gi nguy c
long xng. V d nu T- Sc ore < 2,5 nhng khng c yu t
nguy c th ta khng chn on l long xng m chn on l
gim MX.
li. CHC NNG V CU TRC CA XNG
. Chc nng ca xng
C nm chc nng:
- Nng c th.
Vn ng: l ni bm ca cc c
vn ng.
Bo v: to khung bo v cho cc tng
v ty sng.
L nhng khoang to mu.
- Chc nng chuyn ha cc cht
khong: l kho cha cc cht khong: 99%
lng calci ca c th l trong xng,
nu calci trong mu gim do bt c mt
nguyn nhn no th calci trong xng s
huy ng ra ngoi duy tr s thng
bng ni mi ca c th.

18

Hnh 2. Chc nng

ca khung xng

2. C u t r c m x n g
Xng l m t m lin k t c bit bao gm cc t b o v cht
k h u n xng (bone matrix). C h t k h u n xng bao gm cc si
collagen v cc m lin k t k h c giu cht glucoaminoglycin,
k h u n xng c t h tr t h n h calci hoa. M x n g c xng c
(xng v) v xng xp; 80%-90% k h i lng xng c c
calci hoa; 15 - 25% k h i lng xng xp c calci hoa. Xng
c c chc n n g bo v cn xng xp c chc n n g chuyn hoa.
Cc t bo xng bao gm: huy ct bo l cc t bo khng l
a n h n , c n h i m v t i u xng. To ct b o l t b o c n h n
h n h thoi, c n h i m v sn sinh ra cc t h n h p h n ca n n
xng (cc si collagen v cc cht nn), c v a i t r quan t r n g
trong q u t r n h calci hoa.
Vic t o x n g (bone b r m a t i o n ) v huy x n g (bone
resorption) d i n ra theo c c h thay x n g c b n g x n g mi.
Bnh t h n g hai q u t r n h n y c duy t r mt cch c n b n g
cho n k h o n g 30 - 35 t u i , t t u i n y tr ln to ct b o h o t
ng q u mc, h u y x n g cao h n to x n g d n t i g i m k h i
xng theo t h i gian, c b i t giai o n m n k i n h , g y n n
t n h t r n g l o n g xng.
3. Khi lng xng nh (peak bone mass - PBM)
L mt xng t c ti a vo tui t 20 - 35 (Tuy
n h i n t u i t c P B M t y theo t n g t c gi). P B M c n g cao
t h nguy c l o n g x n g sau n y c n g t h p .
Nhng

yu t nh hng n

PBM:

Di truyn: 60- 80% do yu t di truyn. Mt s gen lin

quan n g i m M X l n h n g gen i u hoa
collagen, cc t h t h estrogen, v i t a m i n D.

s t n g

hp

19

- Dinh dng: rt quan trng trong qu trnh pht m n cua

xng khi cn nh va tui thanh nin, c bit l vn e s
dng calci gip xng khoe v PBM t c nh cao.
- Tnh trng sc khe tui ang pht trin cng tt th
xng cng khe.
- Vn tp luyn: trong qu trnh pht trin ca xng, tp
luyn tng sc chu t i s lm tng MX, nu t hot ng s
hn ch t c nh cao ca khi xng.
- Hormon gii tnh: nu gim s lm chm tui dy th, gim
s pht trin ca xng, gim khi lng xng nh.
IU. NHNG YU T c TH GY NGUY c LONG XNG
1. Tui, gii, chng tc, di truyn, tin s gia nh
- T 50 tui: n: (3 ph n/1 b long xng); nam: (5 nam
gii/1 b long xng): tui cng cao, hot ng ca to ct cng
gim v hot ng ca hy ct bo cng tng, trong khi s hp
thu calci rut gim i v s ti hp thu calci ng thn cng
gim. Ngoi ra ngi gi, cc ni tit t cng gim, s hp thu
tin vitamin D qua da cng gim ...
- Chng tc: ngi da trng v chu c nguy c long
xng cao hn ngi da en.
- Di truyn: c mt s gen lin quan n lm gim mt
xng v long xng.
- Tin s gia nh: ngi c m v ch gi b long xng th
c nguy c cao b long xng.
2. Th cht: thp b nh cn (BMI<19), gy st nhanh
3. Li sng: tnh ti, ht thuc l nhiu, ung ru nhiu
4. Dinh dng: ch n khng dinh dng, thiu calci,
vitamin D, c...

20

5. B n h l
- Cc t n h t r n g g y g i m hormon sinh dc: m n k i n h , ct
bung t r n g , m t k i n h ko d i , k h n g sinh ...
- Cng c n g i p , cng t u y n g i p , i t h o ng
thuc insulin.

ph

- Vim khp d n g t h p , v i m ct sng d n h khp, b i n d n g

ct sng.
- H i cng Cushing, a u tuy xng ( M u l t i p l e Myeloma).
- B n h d d y r u t gy r i l o n h p t h u , c h n n , b n h l
gan m t , suy t h n , t n g calci m u , suy t y , sau g h p p h t n g ,
b t ng ko d i , ung t h , t h i u m u h u y t t n , bnh
hemoglobin, b n h t o x n g b t ton...
6. s dng mt s thuc: cc thuc corticoid, heparin,
phenyltoin, i u t r t h y r o i d q u l i u , thuc h a t r l i u , tia x ,
thuc chng ng k i n h , tetracyclin, cyclosporin, r i f a m p i c i n . . .
IV. PHN LOI LONG XNG
1. Tin pht: do tui v tnh trng mn kinh
2. Long xng th pht: xut hin do cc bnh l v s dng
mt s thuc gy L X .
3. Long xng bm sinh: do thiu gen tng hp vitamin D v
cc l o i gen k h c .
V. CHN ON LONG XNG
1. Triu chng lm sng
1.1. Triu chng
Biu hin kn o, tin trin thm lng khng c triu chng
sm cho n k h i c b i u h i n gy xng. C c t r i u chng c
n n g u t i n ca LX c t h lin quan n q u t r n h xp t

21

sng, gy c xng i hoc gy xng ngoi vi (xng cng tay,

xng di n).
- au ct sng do xp cc t sng:
Xut hin t nhin, hoc lin quan ti gng sc hoc chn
thng nho. Thng biu hin au ct sng cp tnh, khi pht
t ngt, khng lan, khng c triu chng chn p t h n kinh
km theo. au c tnh cht c hc: gim r khi nm v gim dn
ri bit mt trong vi tun. au xut hin khi c mt t sng
mi b xp, hoc t sng ban u b xp nng thm. Khong
60% trng hp c xp t sng do long xng nhng khng c
biu hin lm sng.
- au ct sng mn tnh do ri lon t th ct sng:
Sau cc t au ct sng cp tnh tng t, dn dn, cc t
au mi ny s xut hin trn nn au ct sng mn tnh, do
cc ri lon t t h ct sng gy nn. Bnh n h n dn xut hin
s gim chiu cao, g on lng, c th ti mc cc xng sn
cui cng c st vo cnh chu. Cc bin dng ny lm cho bnh
nhn au ct sng v au do c st sn-chu.
- Gy xng: cc v tr thng gp l u trn xng i,
xng cnh tay, u di xng cng tay.
- Ngoi ra, bnh nhn c th c biu hin kh th do hi
chng d dy rut (do cc xng sn b yu, khng m nhim
c chc nng lm im bm cho cc c lin sn v c bng).
- V hu qu l: bnh nhn tr t h n h ngi tn ph, c th
c biu hin v tm thn nh trm cm ...
1.2. Cc thm d chn on long

xng

1.2.1. X-quang quy c

Giai on sm: c th thy hnh nh tng thu quang, hnh
nh t sng rng lc, tng ng vi s tn t i ca cc b
xng thng ng. X-quang cho php khng nh s mt xng

22

ch k h i c b i n chng g y hoc l n t sng. V k h i k h i

lng x n g m t t 30% tr ln t h n g m i p h t h i n c,
do k h n g d n g X-quang chn o n sm.
- Giai on mun: thy cc bin dng t sng, xp ln t
sng (XLS) (vertebral a c t u r e ) l b i u h i n r t hay gp trong
l o n g xng, l n g u y n n h n a u t h t l n g v c t h gy t n
ph. V n xc nh c X L S hay k h n g l r t quan t r n g
c b i n p h p i u t r kp t h i v n u b n h n h n c m t t sng
b ln xp t h 20% s c nguy c b xp l n t t i p theo trong
vng 12 t h n g ( H a r r y K Genant - 2001) v nguy c g y c x n g
i l 2 l n .
P
Bnh thng:
0

IPi
s a
Ln hnh nm

Ln nh:
20-25%

h '-J_a
i

Ln trung A
bnh: 2
25-40%

^"

Ln p

. ^ U -m= 4 .

g,,

Sau

Trc
Ln nng:
3, trn 40%

Hnh 3. Xp ln t sng xp loi theo phng php bn nh lng

Khi chiu cao ca cc b (trc, gia, sau) ca thn t sng gim i t 20% tr ln
so vi nhau th gi l ln t sng v c chia theo mc nh sau:
1: chiu cao (ca bt c mt b no ca thn t sng), gim i t 20-25%
2: chiu cao (ca bt c mt b no ca thn t sng) gim i t 25-40%.
3: chiu cao (ca bt c mt b no ca thn t sng) gim i t > 40%

23

Ch triu chng m tnh quan trng l khng c cc vng

huy xng trn hnh nh X-quang ca thn t sng. Cc t
sng c mt ng nht, c kt c vng mm t sng (hnh
nh vin tang). Khe a m khng b hp. Cc cung sau hu
nh bnh thng.
Ch n h X-quang c t sng: gim chiu cao, g vo ct
sng, lm sng nghi ng c xp t sng.
Lu :
- Cn nh: khng phi tt c cc trng hp gy xng u do long xng
- Cn nhc Son xng nu gy khng r hoc gy do tc ng gin tip
- Cn nhc chp MRI hoc sinh thit xng nu nghi ng gy lin quan n
carcinoma di cn
- Cn nhc chp MRI nu nghi ng c di lch sau hoc bn
1.2.2. Phng php o mt xng
1) Phng php hp ph nng lng tia X kp (Dual Energy
Xray-Absorptionmetry - DEXA):

o hp t h tia X k p (DXA)
Nhng v tr o chnh

Ct sng trc sau (PA)

on gn (trn) xng i

Hnh 4. o hp th tia X kp (DXA)

24

+ N g u y n l: hai c h m tia p h t ra vi bc s n g k h c nhau

i qua v n g x n g n h o MX, k h i l o n g xng, s hp t h u
tia g i m .
+ V tr o:

o M X c xng i , ct sng: l t i u c h u n v n g
c h n o n l o n g xng.

o ngoi bin nh: xng cng tay, xng gt.

* Phng php nh gi xp ln t sng (XLS) bng kt
hp vi p h n g p h p D E X A .
o

u i m : p h t h i n c n h n g t r n g hp X L S
m k h n g p h t h i n c b n g X-quang t h n g quy.

Hnh 5. nh gi xp ln t sng bng phng php DEXA

2) Phng php siu m: ch c ngha sng lc l chnh.

25

3) Chp ct lp vi tnh nh lng (QCT) cho php nh gi khi

lng xng vng ct sng, tuy nhin gi thnh t v bnh
nhn chu tia x nhiu.
1.2.3. Cc xt nghim mu
Nhng

xt nghim

thng

quy:

Tc lng mu.
Cng thc mu.
Calci, phospho, protein ton phn, albumin ton phn,
phosphatase kim, men gan, creatinin, in gii .
Calci niu.
K h i c c c d u h i u n g h i n g n h : nam gii b long
xng, gy xng khng gii thch c; ch s z (Z-score)
thp (<-2); p ng iu tr km; nhiu yu t nghi ng long
xng th pht trn lm sng th c t h lm thm mt s xt
nghim sau:
- TSH.
Vi nam gii: testosteron mu.
Vi mt s ph n: FSH mu, estradiol mu.
PTH mu.
- Cht chuyn ha vitamin D.
- in di protein mu v tng phn tch nc tiu.
Sinh thit xng.

26

Cc du n ha

sinh:

To xng

Hy xng

Huyt thanh: alkalin phosphatase

c hiu cho xng (BAP); amno
terminal oi type 1 collagen (PINP);
osteocalcin. Propeptid c v N ca
collagen typ 1

Nhng lin kt cho pyrinium v

nhng on collagen lin quan
(telopeptid c v N: CTx, NTx).
Acid phosphatase khng tartrat
hydroxyprolin
Hydroxylysin glycosid

Gi tr ca du n sinh

ha:

- nh gi hot ng lun chuyn xng v hin tng m t xng.

- n h gi nguy c g y xng, c b i t l c t h s d n g k t
hp p h n g p h p o M X n h gi nguy c g y x n g .
- n h gi h i u q u i u t r n g n h n .
- C i t h i n s t u n t h i u t r .
V. C C T H U C I U TR L O N G X N G
- M c ch:
+ T n g k h i lng xng.
+ C i t h i n c u t r c v chc ca xng.
+ G i m nguy c g y xng.
- Ch nh:
+ C t i n s b g y x n g do l o n g xng.
+ c c h n o n b l o n g x n g b n g p h n g p h p o m t
xng k t hp c y u t nguy c.

27

1. Nhm bisphosphonat
c ch hot ng hy xng thng qua: i lc ha hc mnh
cho cc tinh th calci v lin kt ngu nhin trn b mt ca
xng. Lm gin on cc hot ng ca cc t bo hy xng
thng qua mt s cht trung gian, ngoi ra cn kch thch hot
ng ca to ct bo v i thc bo.
Hin t i mt s thuc nhm thuc ny ang c s dng
rng ri trn th gii nh:
(1) S dng qua ng ung:
- Alendronat: 70 mg/mi tun.
- Risedronat: 35 mg/mi tun.
Ibandronat: 2,5 mg/mi ngy.
Lu : cn ung vo bui sng, trc n t nht 30 pht, ung vi mt cc
nc lc y (200 mi), khng c nm t nht 30 pht sau khi ung.
Chng ch nh: h calci mu, lot thc qun.
(2) S dng qua ng tnh mch:
Pamidronat: liu 30-60 mg, kt hp vi huyt thanh ngt
5%, truyn tnh mch trong vng 2-4 gi. Ba thng iu tr nhc
l i mt ln. Nu do ung th di cn xng c th iu tr
thng/1 ln.
- Acid zoledronic (ACLACTA): 5 mg, truyn tnh mch chm
trong vng 15 pht/mi nm mt ln.
- Zometa: 4 mg, truyn cng huyt thanh ngt 5%, truyn
trong vng 15 pht. Ch nh tt cho nhng trng hp long

28

x n g n n g , c b i t l trong n h n g t r n g hp b Kahler, u n g
t h x n g di c n (4 t u n l n ) .
* M t s t c d n g p h k h c : h calci m u , lot thc q u n :
h o i t x n g h m ( r t h i m ) , do k h i bnh n h n c b n h
r n g m i n g c n t h n t r n g k h i ch n h .
2. C a l c i t o n i n
- Do cc t b o nang t u y n g i p sn x u t , l m t polypeptid
gm 32 acid a m i n . Calcitonin c h i tng hp ( M I A C A L C I C ) c
n h n g u i m n h : m n h gp 50 l n calcitonin n g u i , t h i
gian t c d n g l u h n , k h n g n h h n g n s b i n i ca cc
yu t n i sinh.
C c h t c dng: c c h h o t ng ca h y ct b o , k h c h
t h c h hot ng ca t o ct b o . N g o i t c d n g l m g i m h y
xng, miacalcic c t c d n g g i m a u m n h do: g i m t n g hp
cht t r u n g gian g y a u n h prostaglandin; t n g nng p
endorphin gp 15-30 l n ; t c n g trc t i p l n t r u n g t m a u
ca h t h n k i n h t r u n g ng; t c ng l n c h t d n t r u y n t h n
k i n h ca h t h n k i n h t r u n g n g n h cathecholamin,
serotonin.
* T c d n g p h : d n g ( r t h i m ) ; b n g m t ; b u n n n v
nn, n h n g s h t sau m t h a i n g y i u t r . D n g x t h u n h
k h n g c t c d n g p h , i k h i g y v i m m i .
- L i u : 50 U I - 200 U I calcitonin t i m bp hoc d i da. H i n
t i dng x t m i c s d n g r n g r i h n d n g t i m .
3. C c t c n h n i u h a t h t h e s t r o g e n c h n l c
(Selective Estrogen Receptor Modulators- S E R M )

29

- Raloxifen (Evista) 60 mg ung/mi ngy: l mt cht tng

hp, c tc dng ging estrogen nhng ch tc ng trc tip ln
th th estrogen t i m xng m khng tc ng ln th th
ny t i m v, ni mc t cung do khng gy tc dng ph
ging estrogen t nhin nh: nguy c ung th v, ni mc t
cung v cn c tc dng ln chuyn ha lipid lm gim
cholesterol, LDL. Tuy nhin, thuc ny khng ci thin c
tnh trng sau mn kinh mt s bnh nhn c biu hin ri
lon sau mn kinh. Mt s tc dng ph cn lu l: chut rt,
bc ha, nguy c huyt khi su ...
4. Hormon thay th
Thng c th xem xt s dng trong nhng trng hp mn
kinh sm (trc 45 tui) hoc c nhng biu hin ri lon sau mn
kinh. Tc dng: phng mt xng, gim nguy c gy xng.
- Estrogen: 0,625 mg ung hng ngy kt hp
progesteron. Tc dng ph: xut huyt m o, nguy c ung
v, ni mc t cung, huyt khi. Vic ch nh thuc ny
c t vn bi cc bc s ph khoa. Khng nn dng keo
nhiu nm.

vi
th
cn
di

- Tibolon (Livial): 0,25 ng/ngy. L mt steroid tng hp,

thng qua cc sn phm chuyn ha ca mnh, Livial tc ng
ln th th ostrogen, progesteron, androgen trc tip hoc gin
tip t i cc m. Tc dng ph: cng ngc, ln cn; huyt khi
su. Cn kim tra estrogen mu, TSH, siu m mch.
5. Nhng thuc khc
Vitamin K: c bit l vitamin K2 (Glakay), c nhiu
nghin cu chng minh lm tng mt xng, gim nguy c
gy xng do thc y qu trnh to xng. Liu: vin X 3
ln/ngy.

30

Parathyroid

hormon

(1-34

agment

of

parathyroid

hormon): teriparatide (Forteo) 20 ig t i m d i da n g / n g y c

t c d n g kch thch cc hot ng ca to ct b o , l m g i m h y
x n g , t n g m t x n g do l m t n g d y ca v xng,
t n g s lng b x n g v s k t n i gia cc b xng. T c
d n g p h : bun nn, a u u . Ch nh: k h i c nguy c g y
x n g v i u tr b n g cc p h n g p h p k h c k h n g c k t q u
v k h n g i u tr q u hai n m . Chng ch n h : b n h
osteosarcoma, ung t h xng, t r em, t n g calci m u .
- Strontiumranelate (Protelos) c tc dng tng to xng v
g i m huy xng.
- RANKL (Receptor Activator of Nuclear factor- Kappa B
ligand): c t c d n g g i m chu t r n h huy xng.
- Hormon tng trng (GH): c tc dng lm tng ng ha
xng v c.
- Isolavon: cng c chng minh lm gim s mt xng ...
6. Nhng thuc iu tr phi hp
- Calci: 0,5 gram/mi ngy; v: 1-1,2 gram/mi ngy i vi
ph n c t h a i v t r n 60 t u i .
Vitamin D v dn xut ca vitamin D (25-OHD, 1,25
(OH D)): r t cn t h i t cho s h p t h u calci, cn c t c d n g l m
t n g t r n g lc c, p h n g nguy c n g . L i u : 400 U I n 800
U l / m i n g y . T c d n g p h : t n g calci m u v calci n i u o
cn k i m t r a t h n g x u y n hai y u t ni t r n .
2

7. iu tr ngoi khoa trong trng hp gy xng

- iu tr ngoi khoa i vi gy c xng i v cc xng
ngoi v i : ging n h cc t r n g hp g y x n g k h c m k h n g
p h i do l o n g x n g .

31

- iu tr ngoi khoa nhng trng hp xp ln t sng do

long xng:
gim au c th dng phng php to hnh t sng nh
tim cht cement polymetalmetacrylat vo thn t sng. Tuy
nhin, vn theo di lu di v nh hng n t sng bn
cnh nh t h no th vn cn ang c nghin cu.
Tm l i : vn ch nh v la chn thuc iu tr long
xng ph thuc vo: tui, tnh trng c gy xng hay khng,
tnh trng MX t i v tr ct cng v c xng i. S can thip
khng dng thuc bao gm ch cung cp calci, tp luyn,
gim thiu nhng nguy c long xng v nguy c ng l rt
quan trng.
VII. PHNG BNH LONG XNG
Vic phng long xng cn c t ra ngay t khi cn nh,
t t c cc la tui.
1. Vn dinh dng
m bo cht dinh dng, protein, calci, vitamin D, c,
vi lng.
2. Rn luyn th lc
Thng xuyn u n, tng sc chu ti ca c th mi la
tui s gip xng chc khoe, lm tng mt xng v lm
gim s mt cht xng.
3. Trnh ht thuc l
B thuc l c th lm gim nguy c gy c xng i 40%.
4. Trnh ung nhiu ru
S dng nhiu ru lm tng nguy c gy c xng i.

32

5. P h n g t r n h n g
T p l u y n t n g chc c bp, k h m k i m t r a t h lc
t h n g x u y n , t r n h t c d n g p h ca n h n g thuc c t h d
gy ng.
6. i u tr d p h n g l o n g x n g b n g calci v v i t a m i n D n u
c h n k h n g y v n h n g b n h n h n b n h n g bnh
hoc s d n g cc thuc lin quan n l o n g xng, c b i t l
k h i s d n g glucocorticoids t 3 t h n g tr ln.
7. Kim tra mt xng
i vi n g i c nguy c v n u ch s TScore g i m i SD
t h nguy c gy x n g do l o n g x n g t n g l n gp i.

33

HNG DN IU TR LONG XNG

Hi long xng M

IOF
(International
Osteoporosis
Foundation)

Tui > 65

I
Yu t
nguy c

C yu t
nguy c

o MX

TScore <-2,5

Khng

o MX

Tscore<-1,5

iu tri

34

iu tr

o MX
I
Tscore < - 2,5

iu tri

THOI HOA

KHP

TS. B S C K I I . N g u y n Mai H n g
I. I CNG
1. nh ngha
Thoi hoa khp (THE) l hu qu ca qu trnh c hc v
sinh hc l m m t c n b n g gia tng hp v huy h o i ca sn
v x n g d i sn. S m t c n b n g n y c t h c b t u bi
n h i u y u t: d i t r u y n , p h t t r i n , c h u y n hoa v c h n t h n g !
T h o i khp lin quan n t t c cc m ca khp ng cuo
c n g b i u h i n bi cc thay i h n h t h i , sinh hoa, p h n t v
c sinh hc ca t b o v c h t c b n ca sn d n n n h u y n
hoa, n t lot v m t sn k h p , x hoa x n g d i sn, t o gai
x n g ra khp v hc x n g d i sn.
2. Dch t hc
Thoi ha khp gp mi chng tc, dn tc, mi iu kin
k h h u , a l, k i n h te. T n s mc b n h t n g ln theo t u i .
- Nam v n mc bnh ngang nhau, tuy nhin t l thoi hoa
khp gi n cao h n nam, n h n g t l T H K h n g n a m
hn n .

cao

li. NGUYN NHN V c CH BNH SINH

1. Nguyn nhn
Tn thng c bn trong THK xy ra sn khp. C 2 gi
t h u y t c a ra:

35

- Thuyt c hc: di nh hng ca cc t n cng c hc, cc

vi chn thng gy suy yu cc m collagen tn hi cc cht
proteoglycan (PG) trong t chc ca sn khp.
- Thuyt t bo: cc t bo sn b cng l i do tng p lc, gii
phng cc enzym tiu protein, nhng enzym ny lm huy hoi
dn dn cc cht c bn trong t chc sn, l nguyn nhn dn
ti thoi khp.
2. C ch bnh sinh
- Vai tr ca cc cytokines tin vim: interleukin-ip (IL-l)
v yu t hoi t u (TNFa) l nhng cytokin tin vim ch yu
gy nn qu trnh d hoa trong thoi hoa khp. I L - i p l yu t
chnh trong vic ph huy sn khp kch hot cc enzym trong
khi TNFa gy qu trnh vim.
- Vai tr ca nitric ocid (NO): cc gc t do tham gia qu
trnh d hoa sn. NO c tng hp t L-arginin di tc ng
ca men nitric oxid synthase cm ng (NOS) cc men ny c
tng hp nhanh sau khi cc t bo b kch thch do mt cytokin
nht nh. Trong thoi hoa khp, sn khp tit nhiu NO so vi
sn bnh thng. NO thc y I L - l p gy THK ch yu bng
cch c ch tng hp cc cht cn bn si colagen v tng hot
tnh ca metalloprotease.
- Thay i sinh hoa hc v c hc lp xng di sn: cc
proteoglycan cht cn bn b mt dn v cc li si collagen b
thoi hoa lm tn thng cu trc v s ton vn chc nng ca
t chc, lm tng bt thng cc enzym proteolytic c bit l
metalloprofease (MMPs). B mt sn b bo mn dn v x hoa,
cc mnh v ri vo dch khp v b cc t bo i thc bo mng
hot dch thc bo do vy thc y qu trnh vim.
HI. PHN LOI
Theo nguyn nhn chia 2 loi THE nguyn pht v th pht.

36

1. T h o i hoa k h p n g u y n p h t
- S lo hoa: l n g u y n n h n c h n h , x u t h i n m u n , t h n g
n g i sau 60 t u i , t n t h n g n h i u v t r , t i n t r i n c h m ,
mc k h n g n n g .
- Yu t di truyn: nhng yu t nh hm lng collagen v
k h n n g tng hp PG ca sn c mang t n h d i t r u y n . M i
y p h t h i n s a d n g v h n h t h ca gen collagen typ 2
trong m t gia n h mc b n h t h o i hoa khp giai o n sm.
- Yu t ni tit v chuyn
l o n g x n g do n i t i t .

hoa: m n k i n h , i t h o ng,

2. Thoi hoa khp th pht

P h n l n l do cc n g u y n n h n c gii, b n h p h t sinh do
n h n g r i lon l m thay i c t n h ca sn v l m h h i b
m t khp. B n h gp m i la t u i (thng t r d i 40), k h u t r
mt v i v t r , n n g v t i n t r i n n h a n h .
- Tin s chn thng: g y x n g khp, cai lch, t d y
chng (khp vai...), t n t h n g sn c h m hoc sau ct sn
c h m , v i c h n t h n g lin t i p do n g h n g h i p (khp b n tay,
khp vai ca cc v s q u y n anh; khp k h u u ca cng n h n
v n h n h b a m y ; khp gi ca v n ng v i n b n g r hoc c
t ; khp c c h n ca d i n v i n b a l ; ct sng ca t h m than)...
- Cc d dng bm sinh v ri lon pht
t r t khp h n g b m sinh, l i ci.
- Tin s phu

thut:

trin:

l o n sn v

ct sn chm....

- Tin s bnh xng: b n h Paget hoc h o i t x n g

- Ri lon chy mu: 90% b n h n h n Hemophilie c t r n
m u khp, gp khp gi, c c h n , k h u u tay. T r n m u t i
p h t g y t n g sinh m n g h o t dch, t h c y s t i n t r i n t h o i
hoa khp t h p h t .

37

- Bnh ni tit v ri lon chuyn hoa:

+ Bnh to u chi: tng hormon qu mc lm sn khp dy
ln, mt tnh n hi chu lc.
+ Bnh Cushing v s dng corticosteroid ko di:
corticosteroid c ch chc nng to ct bo gy cng cn gip
th pht, kch thch hot ng ca huy ct bo v lm tng qu
trnh huy xng ui sn.
+ Cc tinh th lng ng trong dch khp: tinh th urat (bnh
Gout), Calciumpyrophosphate dihydrate (CPPD).
+ Bnh da xm nu hay alcapton niu: do mt enzym b
khim khuyt dn t i tch t sc t trong sn gy thoi hoa t
bo sn.
+ Bnh nhim sc t: c s lng ng st trong sn khp v
mng hot dch.
IV . C IM LM SNG V CN LM SNG
1. Triu chng lm sng
- au khp: thng lin quan n vn ng: au m , tng
khi vn ng, khi thay i t th, gim au v m v khi ngh
ngi.
+ au din bin thnh tng t, di ngn tuy trng hp,
ht t c th ht au, sau ti pht t khc hoc c th au
lin tc tng dn.
- Hn c h vn ng: cc ng tc ca khp bc ln hoc
xung cu thang, ang ngi gh ng dy, ngi xm, i b lu
xut hin cn au ...
- Bin dng khp: thng do mc cc gai xng, do lch trc
khp hoc thot v mng hot dch.

38

- Cc du hiu

khc:

+ T i n g lc k h c k h i v n ng khp.
+ D u h i u " p h r khp": l d u h i u cng khp b u i s n g
ko d i k h n g q u 30 p h t .
+ C t h s t h y cc "chi x n g " quanh khp.
+ Teo c: do t v n ng
+ T r n dch khp: i k h i gp, do p h n n g v i m t h p h t
ca m n g h o t dch.
+ T h n g k h n g c b i u h i n t o n t h n .
2. C c p h n g p h p t h m d h n h n h c h n o n
2.1. X-quang

qui

C 3 d u h i u c b n :
- H p khe khp: khe k h n g ng u , b k h n g u .
- c x n g d i sn: gp p h n u xng, t r o n g p h n
x n g c t h y m t s hc n h s n g h n .
- Mc gai xng: p h n t i p g i p gia x n g , sn v m n g
hot dch. Gai x n g c h n h t h v m c, m t s m n h ri
ra n m trong khp hay p h n m m q u a n h khp.
+ Tiu
ca Kellgren

chun
v

chn

on

thoi

hoa

khp

trn

X-quang

Lawrence

Giai o n 1: gai x n g n h hoc nghi ng c gai x n g

G i a i o n 2: mc gai x n g r
G i a i o n 3: hp khe khp va
Giai o n 4: hp khe k h p n h i u k m x x n g di sn.

39

2.2. Chp cng hng t-

CHT(MRI)

Phng php ny c th quan st c hnh nh khp mt

cch y trong khng gian 3 chiu, pht hin c cc tn
thng sn khp, dy chng, mng hot dch.
+ Cng hng t nh gi mng hot dch (MHD)
Trong cc trng hp THK in hnh, quan st trn cc lp
chui T I , c th nhn bit c tnh trng bnh l ca MHD,
MHD vim s c nh gi theo nhng sau:
- 0: mng hot dch khng dy
- 1: mng hot dch dy di 2mm
- 2: dy t 2 - 4mm
+ nh gi thng tn sn
Thng thng nht, cc thng tn sn lun l cc thng
tn v cu trc ( 1) v v hnh thi ( 2 - 4).
- 1: c bt thng v cu trc trong ca sn, nhng bt
thng xut hin ui dng x si hoc ph trong khi phn
khoang trn b mt khng c s bin dng no.
- 2: c nt khng u ca b mt khoang trn hoc qua s
st gim di 50% cao sn.
- 3: c s bt thng v cao ca ton b sn, dy
trn 4mm v/hoc mt trn 50%.
4: tng ng vi tnh trng sn b ph hy hon ton, l
phn xng di sn, i khi km theo vt ph xng tua vch.
+ nh gi thng tn xng di sn
Nhng vt ph xng c th hin trn T2, l nguyn nhn
gy nn nhng vt nt, lot ca xng di sn.

40

V m t l t h u y t , cc k t q u i chiu gia cng h n g t

( M R I ) vi n i soi khp (NSK) cho t h y c mt s t n g ng
gia 2 p h n g p h p n y t r o n g vic n h gi t n h t r n g t h n g
t n sn. T u y n h i n , N S K v n c la chn l tiu c h u n v n g
chn on T H K .
2.3. Ni soi khp (Athroscopy)
N i soi k h p (NSK) l m t t h t h u t cho p h p quan s t trc
t i p khp n h h t h n g t h u k n h v i ngun n h s n g l n h
qua m t ng d n nh, b n g c c h quan s t trc t i p b n g m t
t r n mt m n h n h v t u y n m u , cho p h p n h gi r t c h n h
xc v mc , t n h t r n g , p h m v i v nh k h u c cc t n
t h n g ca sn, m n g h o t dch, d y chng... cc t n t h n g
k h n g t h p h t h i n c t r n X-quang t h n g thng.
N i soi cn cho b i t mc calci hoa ca sn khp, i u m
k h n h n t h y k h i chp X-quang cng n h l y b n h p h m x t
n g h i m . N S K cn cho p h p p h n tch tng t h p h n x n g d i
sn, n h t l k h i t h n g t n c chiu h n g b lot. i k h i
t h n g t n n y cng n h n g voi m ta c t h cm n h n c
t h n g qua que t h m d. Hoc n h n t h y trc t i p b n g m t
n h n g m n h sn t h o i hoa bong ra, t r i n i t r o n g dch khp.
- Sinh thit mng hot dch kt hp khi ni soi lm cc xt
n g h i m t b o , sinh hoa, m i n dch cho p h p c h n o n c h n h
xc hn cc t n t h n g b n h l t r o n g khp.
2.4. Siu m khp
C th pht

hin

c:

Hp khe khp.
- Gai xng: h n h t n g m c b n g c n lin tc v i v x n g
ngoi v i ca khp.

41

- Trn dch khp: thng thy ti cng trn trong, trn

ngoi v ti cng trn xng bnh ch.
- Mnh xng sn t do trong khp: thng gp ti cng
trn xng bnh ch, biu hin hnh tng m km bng cn,
di ng.
- Dy bao hot dch.
2.5. Chp ct lp vi tnh (CTscanner)
Pht hin cc tn thng ca sn khp, tuy nhin khng
thy r tn thng ca mng hot dch.
2.6. Chp x hnh xng (Scintigraphie)
Hnh nh tng hp thu phng x t i xng di sn khp
b thoi hoa.
2.7. Chp bm thuc cn quang vo khp
Hin t c ng dng.
3. Cc xt nghim khc
+ Xt nghim mu v sinh hoa: tc lng mu bnh thng,
s lng bch cu bnh thng, CRP c th tng khi c vim th
pht MHD.
+ Dch khp: bnh thng hoc c tnh cht vim mc t
trong cc i tin trin. Dch thng c mu vng, nht bnh
thng hoc gim nh, c <1000 t b o / l m m
3

V. CHN ON XC NH
Da theo tiu chun chn on THK theo Hi thp khp hc
M(ACR)1991.

42

Bng 2. Tiu chun chn on thoi hoa khp theo Hi thp khp hc MACR (American College of Rheumatology) 1991
Thoi hoa khp gi

Thoi hoa khp hng

1. Mc gai xng ra 1. au khp hng (hu

khp (X-quang)
nh c ngy)
2. Dch khp l dch 2. Tc mu lng
thoi hoa
< 20mm gi th nht.
3. Tui trn 38
3. X-quang chm xng
4. Cng khp di 30 i v/hoc ci c gai
pht
xng
5. Lc khc khi c 4. Hp khe khp hng
ng

Thoi hoa khp bn

ngn tay
1. au v/hoc cng
bn tay trong cc thng
trc
2. Kt c xng ti
thiu 2 trong 10 khp
c la chn *
3. Sng ti thiu 2 khp
bn ngn
a - Kt c xng ti
thiu mt khp ngn xa
hoc
b - Bin dng ti thiu 1
trong 10 khp*

Chn on xc nh khi Chn on xc nh khi Chn on xc nh khi

c yu t 1,2,3,4
c yu t 1,2,3 hoc 1, c yu t 1,2,3a hoc b
2,4 hoc 1,3,4
hoc 1,2,5 hoc 1,4,5
VI. CHN ON PHN BIT
1. V i m k h p d n g t h p
1.1. Vim khp dng thp th mt khp
Khi vim khp dng thp (VKDT) ch khp ln, chn
o n p h n b i t vi t h o i khp i k h i k h k h n , c n da v o cc
y u t sau:
Dch khp: dch cha nhiu bch cu >5000/lmm , t l bch
cu a n h n t r u n g t n h cao, v nht g i m so vi khp t h o i
hoa, mucintest (+).
3

43

Xt nghim mu: tc mu lng tng, CRP tng, yu t

dng thp dng tnh, anti CCP (+),.
X-quang: c hin tng bo mn v mt khong u xng
thnh di, khe khp hp, nham nh.
1.2. Vim khp dng thp th nhiu

khp

VKDT: hay gp khp ngn gn v khp c tay

THK: khp ngn xa, khp ngn bn tay
Nhng du
phn bit:

hiu

lm

sng

ca VKDT

chn

on

Biu hin vim khp v gim chc nng vn ng nhiu.

- Nhiu khp cng b tn thng, thng khp bn tay, i xng.
- Tin trin nhanh hn.
- Du hiu cng khp bui sng >1 gi.
- C biu hin ton thn: st, thiu mu do vim
2. Bnh ct sng huyt thanh m tnh
- Vim khp vy nn: bnh l kt hp thng tn vy nn
da hoc mng v tnh trng vim khp chi v/hoc ct sng.
Bnh Reiter: biu hin mt tam chng gm vim khp,
vim niu o, vim kt mc mt. i khi km tn thng ngoi
da (ban dng nt).
Vim ct sng dnh khp: vim khp cng chu v ct sng,
khp hng, gi.
3. Bnh khp lin quan n bnh l rut
- Vim lot i trng, hay gp khp gi c chn, c im
vim khp khng bo mn kt hp vim i trng.

44

- B n h Crohn: v i m k h p c n g c h u , v i m ct sng hoc cc

khp chi d i p h i hp v i v i m lot i t r n g .
4. V i m k h p v i t i n h t h
B n h g t (Gout): t h n g b i u h i n v i m khp cp t n h khp
chi d i (khp n g n ci, c c h n , khp gi). X t n g h i m t n g
acid uric m u , c t i n h t h h n h k i m t r o n g dch khp.
B n h g i g t (Pseudogout): c t h c n g t n t i v i t h o i
khp.
Nguyn nhn
do s l n g ng cc t i n h
th
Calciumpyrophosphate d i h y d r a t khp. X-quang c n h n g v t
vi hoa sn khp. Dch k h p c cc t i n h t h h n h thoi.
VII. C C T H LM S N G
1. T h o i hoa k h p g i : n c h i m 80% t r n g hp.
1.1. Nguyn

nhn

- Cc d t t ca t r c k h p gi:
- K h p gi quay ra n g o i (genu valgum).
- Khp gi quay v o t r o n g (genu v a r u m )
- K h p gi q u d u i (genu recurvatum...)
- C c d i chng ca b n h k h p gi: d i chng c h n t h n g , v i
c h n t h n g do n g h n g h i p . D i chng v i m (vim khp d n g
thp,
lao khp, v i m
m...). C h y m u
t r o n g khp
(hemophilie)
1.2. Triu chng

lm

sng

- a u khp gi ( k h i ngh v ban m ) .

- C n g khp k h i k h n g v n ng (bui s n g d i 30 p h t ) .
- G i m k h n n g v n ng (kh k h n vi m t vi ng tc).
- C t i n g lc k h c k h i c ng.

45

Tng cm gic
au xng.
S
xng.

thy

Nhit da
vng khp bnh
thng hoc m
ln khng ng k.

Hnh 7. Thoi ha khp gi

2. Thoi hoa khp hng
Nam thng mc bnh nhiu hn n. Chu t gp thoi
hoa khp hng hn chu Au.
2.1. Nguyn

nhn

Thoi hoa khp hng th pht chim 50% trng hp,

thng do nhng nguyn nhn sau:
Lon sn v trt khp hng bm sinh
- Chm khp dt: l hu qu ca lon sn sn chm xng
i (bnh Legg - Perths - Calv).
- Hoi t v khun chm xng i do vim tc ng mch
nui dng u xng i...
Li ci bm sinh
Di chng chn thng, vi chn thng.
Di chng vim Gao, vim ct sng dnh khp, vim khp
dng thp, vim m...)

46

2.2. Triu
* C

chng

lm

sng

nng:

- a u v n g b n hoc p h n t r n m n g , l a n xung i , c k h i
ch a u t r c i v k h p gi. a u x u t h i n t t t n g d n ,
a u t n g k h i i l i , n g l u , thay i t h i t i t , g i m k h i ngh
ngi. C t h c d u h i u " p h g khp" k h i k h i ng.
- H n c h v n ng: lc u k h l m m t s ng t c (ngi
xm, l n xe p , bc ln bc cao...), v sau h n c h n h i u , i
k h p k h i n g , p h i chng gy.
* Thc

th

- C cc i m a u m t t r c k h p v p h n t r n m n g . o
t h y c h n b n h n g n h n c h n l n h t r o n g m t s t r n g hp.
- H n c h v n ng m t s ng t c : lc u l d u i c v
quay, v sau h n c h cc ng t c k h c n h t l gp.
*

X-quang:

- H p khe
t h n g hp
ngoi.

khp:
phn

- c x n g u i
sn: t h y chm x n g
i, ci, x n g c h u ,
l d y c h n g t r n . . .
trong p h n x n g c
thng
c
cc
hc
xng, c k h i hc x n g
to m t h n g v o k h p .

H n h

T h o j

h a

k h p

h n g

- Mc gai xng: mc
n h i u v t r t r n ci,
chm x n g i , l d y c h n g t r n . . .
C h n o n theo t i u c h u n c h n o n ca H i t h p khp hc
M - A C R (American College of Rheumatology) 1991. ( B n g 2).

47

3. Thoi hoa khp b n tay

Thoi hoa khp bn tay thng gp khp bn ngn xa (ht
Heberden), hoc khp ngn gn (ht Bouchard), hoc khp
bn ngn tay ci.
+ Triu chng lm sng: thng au t, hn ch vn ng khp.

Hnh 9. Thoi ha khp bn ngn tay

+ Chn on: theo tiu
chun chn on thoi hoa
khp bn tay theo ACR
1991 (Bng 2).
4. Thoi hoa khp bn
ngn chn I
- Lm sng: au, vim
khp bn ngn do vim
bao khp.
- X-quang: c gai xng
Hnh 10. Thoi ha khp bn ngn
chn I

48

6. Gai x n g g t
- Lm sng: au vng
gt c h n c b i t k h i n g
dy, k h i t gt c h n xung
i.
- X-quang: c h n h n h
mc gai x n g gt c h n .
Hnh 11. Thoi ha xng
gt chn

VUI. CC PHNG PHP IU TR

Mc tiu iu

tr:

- Gim au
- D u y t r v t n g k h n n g v n ng.
- H n c h v n g n nga b i n d n g k h p
- T r n h cc t c d n g p h ca thuc
- N n g cao c h t lng cuc sng cho n g i bnh.
1. i u tr n i k h o a
- Gio dc bnh nhn: t r n h cho khp b q u t i h i v n ng
v t r n g lng, g i m t r n g lng vi cc b n h n h n bo p h .
Sa cha cc t t h x u g y lch t r c khp.
- Vt l tr liu: c t c d n g g i m a u , duy t r d i n h dng c
c n h khp, i u t r cc a u g n v c k t hp.
- N h i t i u tr: siu m , h n g ngoi, c h m n n g , l i u p h p
sui k h o n g , b n c h i u q u cao.

49

1.1. Thuc iu tr triu

chng

Thuc gim au
+ Paracetamol (acetaminophen): c khuyn co s dng
u tay trong THK do nhm ny t c vi d dy v thn so vi
thuc chng vim khng steroid (CVKS).
- Thuc chng vim khng steroid-CVKS (NSAIDs)
+ Cc thuc CVKS (chng vim khng steroids) mi, da trn
c ch c ch chn lc men ng dng COX- 2 gim thiu tc
dng ph trn thn v ng tiu hoa, dung np tt cho ngi
c tui: Mobic (meloxicam) 7,5-15mg/ngy, Celebrex (celecocib)
200mg/ngy.
+ Thuc chng vim khng steroid khc: Felden. Brexin
(Piroxicam), Votaren ...
+ Thuc bi ngoi da: cc loi gel: Voltaren Emugel, Profenid
gel, Gelden... c tc dng gim au ng k v khng gy ra cc
tc dng ph nh dng ng ton thn. Bi t i khp au 2-3
ln/ngy
- Corticosteroid
+ ng ton thn: khng c ch nh.
+ ng ni khp: c hiu qu ngn i vi cc triu chng
c nng ca THK.

Hydrocortison acetat: mi t 2-3 mi tim cch nhau 57 ngy, khng vt qu 3 mi tim mi t.

Cc ch phm chm: DepoMedrol (Methyl prednisolon

acetate), Diprospan (betamethasone dipropionate) tim mi
mi cch nhau 6-8 tun. Tuy nhin thuc c th lm tn
thng sn khp nn khng tim qu 3 i nm.
1.2. Thuc iu tr theo c ch bnh sinh
(DMOADs - Disease Modiying Osteoarthritis Drugs)

50

 y l m t n h m thuc i u tr m i , k h n g t h i u q u tc
t h m sau m t thi gian d i ( t r u n g b n h t h n g ) v h i u q u
n y c duy t r c sau k h i ngng i u tr (sau vi t u n n 2-3
t h n g ) . D u n g n p thuc t t , k h n g c t c d n g p h . N h m n y
gm m t s l o i c t c d n g kch t h c h t b o sn, t n g tng hp
proteoglycan, c c h cc men... hoc thay i cht n h y (dch
k h p n h n to).
- Glucosamin sulfat
+ Ch phm: s dng ng ung hoc tim, Viartril-S: 250
mg, 6 vin/lngy
X 6-8 t u n , Virtril-S
400mg(ng) t i m bp 3
ng/1 t u n X 4-6 t u n , Bosamin 500mg, 3 l n / 1 ngy..
- Chondroitin suat: bao gm cc thnh phn ca
Glucosaminoglycan c g n t h m cc p h n t ng, c ngun gc
t sn b, t h n g d n g n g ung, thuc n h m thuc p n g
chm.
- Nhng ch phm kt hp glucosamin sulphat v
chondroitin.
1.3. Thuc c ch cytokin
S sng thucc ch cytokin (Interleukin , TNF-a) l xu
h u n g m i trong i u t r T H K .
+ Ch phm Diacerhein, mt dn xut ca anthraquinon lm
k m h m N F - k B , c t h n g n c h n sn x u t I L - i p , k m h m s
sn x u t ca n i t r i c oxid (NO). Diacerhein
(Artrodar-Omg)
1-3
vin/ngy.
1.4. Thuc t ch ph huy sn
Doc ch cc men ph huy cht c bn ca sn, hin ang
c n g h i n cu p dng:
- Tetracyclin: tetracyclin c bit l Minocyclin v Doxycylin
c t h c t c d n g l m g i m h o t ng ca men Collagenase, c

51

ch hot ng ca men ph huy sn, gim qu trnh tiu

xng, cc thuc ny cn c tc dng khng vim.
Yu t tng trng: IGF-1
- iu tr gen: hin ang c nghin cu p dng.
1.5. B sung cht nhy dch khp
+ Acid hyaluronic (HA) di dng hyaluronate de sodium.
(Adant, Arthrum H, Artz, BioHy, Durolane, Fermathron, Gon, Hyalgen, Hyalan G-F 20 (Synvisc Hylan G-F 20), NRD-101,
Orthovisc, Ostenil, Replasyn, SLM-10, Suplasyn, Synject and
Zeel)
Trong bnh THK nng ca HA gim xung lm cho
nht ca dch khp cng b gim do nh hng n tnh n
hi lm sn khp khng c bo v v b huy hoi. V vy tim
hyaluronic acid ni khp c tc dng:
- Ngn chn tc dng ca cytokin v ngn sinh tng hp
PGE2.
- Gim sinh tng hp Bradykinin vc ch cm th au.
- Bao ph v bi trn b mt sn khp.
Hyaluronic acid c p dng trong tim ni khp u c
chit xut t mo g, t cung rn ca ng vt c v, t s ln
men ca vi khun (steptococcucs zoepidicus, steptococcucs
equisimilis...) hoc do tng hp.
+ Hin nay ti Vit Nam p dng ba dng bo ch ca HA:
- Dng t nhin Hylaluronan (Hyalgan, Hyruan, Hyasyn...) c
trng lng phn t t 5-7,5xl0 dalton. Tim khp: 20mg/ng/l
tun X tun.
6

52

- D n g l n men t v i k h u n (Go-on) c t r n g lng p h n t

t r u n g b n h l , 4 x l 0 dalton. T i m khp: 20mg/ng/l t u n 3 n 5
tun.
6

- Dng tng hp G-F 20 (Synvisc - Hylane-F20...) c trng

lng p h n t cao t 2 3 x l 0 dalton v t h i gian b n huy ko d i
n h t l 36 gi. T i m khp: n g / t u n X 3 t u n .
6

1.6. Nhmbisphosphonat (Alendrona Risedronat, Pamidronat...)

Nhm bisphosphonates hin ang c dng iu tr bnh
l o n g xng. Theo c ch b n h sinh, m x n g d i sn khp
c t h b h y t r o n g T H K , do cc thuc c t c d n g k h n g huy
xng v g i m tiu xng.
C ch:
- Kch t h c h t n g t r n g cc t b o sn, thay i trc t i p
chuyn hoa sn.
- T n g tng hp collagen v proteoglycan.
- Ngn cn t bo cht theo chng trnh, bo v sn.
2. iu tr ngoi khoa
iu tr ngoi khoa thng c ch nh khi hn ch chc
n n g n h i u , hoc a u khp k h n g p n g vi cc p h n g thc
i u tr n i khoa.
* iu tr bng ni soi khp (NSK)
- Trc y t h t h u t m khp c coi l b i n p h p h u
h i u t r o n g i u tr cc t n t h n g m n g h o t dch, sn khp,
tuy n h i n c nguy c cng k h p hoc n h i m t r n g v chi p h
cao. G n y n h vo s p h t t r i n ca khoa hc k t h u t , N S K
c p d n g i u t r t h o i h a khp gi ( T H K G ) tin t r i n , c
b i t t r o n g n h n g t r n g hp b n h n h n l n t u i hoc k h n g c
i u k i n thay khp v n h i u l do k h c n h a u .

53

* Phng php c xng chnh trc (osteotomy)

Phu thut nhm sa cha s bin dng trc khp v ci
bin im t ca khp, di chuyn trc chu t i khp t b ph
huy nht, c p dng trn nhng bnh nhn b lch trc khp
nh: khp gi vo vo trong hoc cong ra ngoi. au c th c
ci thin khi t t h tt lm cho sn khp tt hn. Phng php
ny va l d phng, va iu tr THK gi.
* Cy t bo sn t thn - ghp sn (autologous chondrocyte
implantation - ACI) qua ni soi khp l hng i mi trong iu
tr THK. C th s dng 2 phng php:
- Cy ghp sn t thn (Autograft): ly chnh sn bnh nhn
ghp cho chnh h.
- Cy ghp sn ng loi (Allograt): ly sn ca ngi khc
cy ghp cho bnh nhn.
* Phng php vi gy

(Micro-fracture)

y l k thut lm sch nhng vng sn b tn thng ti

tn lp xng di sn trong khi vn duy tr mp sn bnh
thng theo phng thng ng. Qua dng c ni soi to nhiu
l nh t i vng sn tn thng trong khi vn gi lp xng ui
sn cn nguyn vn. Sau khi gy vi gy, vng tn thng c
lp y bi khi t mu to ra mi trng cho nhng t bo tuy
xng bin hoa thnh t chc x sn.
* Phu thut thay khp nhn to
Thay khp nhn to tng phn hoc ton phn: ch nh
cc t h nng tin trin, gim nhiu chc nng vn ng, v khi
cc phng php iu tr trn khng ci thin phc hi chc
nng khp.
c ch nh tui trn 50, trong trng hp cn thit vn
c the thay khp ngi tr, tuy nhin do li sng v hot ng

54

ca n g i t r , khp n h n to p h i chu n h n g sang c h n n n

n h i u k h i p h i i h i thay l i t r o n g v n g 15 n m sau.
IX. PHNG BNH
- Chng t t h x u trong lao ng v sinh hot.
- T r n h cc ng t c q u m n h , t ngt.
- K i m t r a n h k n h n g n g i lao ng nng.
- Chng bo p h .
- C h v n ng t h dc t h thao hp l: t p cc b i t p
chy b k h i khp c h a c t n t h n g X-quang (khe khp cn
b n h thng). i b hoc p xe t i ch l cc b i n p h p t p
luyn tt.
- P h n g p h p t h y t r l i u (tp l u y n d i nc v bi) l
p h n g p h p t t i v i b n h n h n T H K , c b i t l k h i c
t n t h n g t r n h n h n h X-quang.
- V i n g h nghip ca b n h n h n : t m cc b i n p h p b n h
n h n t h c h n g h i v i i u k i n l m vic v t n h t r n g b n h , da
t r n n g u y n tc t r n h cho khp t n t h n g k h n g b q u t i .
- P h t h i n sm cc d t t ca xng, k h p , i u t r
kp t h i .

55

THOI H O A C T

SNG

TS. BSCKII. Nguyn Mai Hng

I. I CNG
Thoi hoa ct sng (THCS)
sng phi chu ng nhiu cc
cc bin i hnh thi gm cc
thn t sng v cc mm gai

l bnh kh thng gp. Do ct

t i trng xy ra lin tc, dn ti
bin i thoi hoa cc a m,
sau.

Bnh THCS thng tin trin chm, biu hin bi s tng dn

dn cc triu chng: au, cng ct sng v hn ch vn ng.
li. DCH T HC
Bnh THCS c lin quan cht ch vi qu trnh lo hoa,
thoi hoa t sng c c pht hin thy > 80% cc i tng
trn 55 tui. Theo bo co ca Kellgren v Lawrence THCS tht
lng gp 30% nam gii v 28% ph n t 55 n 64 tui.
Anh mi nm c 2,2 triu ngi n khm v l do au vng
tht lng, 10% -20% trong s ny phi nm vin iu tr.
Bnh THCS cng c khc bit v chng tc: t l b bnh
THCS ngi chu thp hn so vi ngi chu Au.
HI. SINH BNH HC
1. Thoi hoa a m (osteochondrosis intervertebral disc)
ngi cao tui lng nc trong nhn a m ngy cng
gim, thnh phn khc nh proteoglycan cng gim, lm gim
tc dng lm m gia cc t sng v to nn cc khong trng

56

v v t n t r n b n trong a m , b n trong n h n n h y , v
l a n toa ra ti v n g si x u n g quanh n h n n h y . T h m vo b
d y t h n t sng cn b p h huy bi cc b i n i t h o i hoa,
p h t sinh n h i u t n g sinh m sn v ct hoa k h n g ng u .
T t c cc b i n i n y l m a m g i m t n h n h i v g i m
c h i u cao, tr n n k m p n g vi t i t r n g q u mc l mt
y u t quan t r n g d n t i t h o i h a a m .
2. Thot v a m
- T h o t v a m l n h n n h y b dch chuyn ra n g o i v
t r b n h t h n g v p h a sau, hoc sang hai b n . P h n ln t r n g
hp t h o t v a m x y ra a m n m gia t sng L 4 v
L, hoc gia t sng L v S i . o n ct sng c, t h o t v a
m x y ra ch y u gia t sng C5 - C6, v C6 - C7.
- T h o t v a m p h a trc: t gp, n h n n h y t r i ra c
t h l c h v o t r o n g khe gia m t trc ca t h n cc t sng v
d y c h n g dc trc, l n p h a t r n hoc xung p h a d i . Tuy
n h i n , t r n g hp hay gp h n l p h n n h n n h y ca a m
t i n ra n g o i theo h n g chch, i qua x n g v cui c n g t c h
ri p h n ra p h a trc ca t h n t sng.
- Cc nt sn Schmorl (Schmors cartilage nodules- h t
Schmorl): l h i n t n g m t p h n ca n h n n h y c h u y n dch
vo b n t r o n g t h n ca t sng. T i p sau m sn sinh sn
v p h n n g ct hoa x y ra v n g t i p g i p v i p h n l i ra ca
a m . Cc h t Schmorl gp nam gii n h i u h n p h n ,
s k h c n h a u n y do ct sng ca nam gii t h n g p h i chu t i
trng l n hn ca n .
3. Thoi hoa thn t sng
T h o i h a t h n t sng: b i u h i n ca cc b i n i t h o i hoa
m n t n h , t i v n g t h n cc t sng c cc gai xng, hay gp
ct sng c, o n ct s n g l n g t h p v ct sng t h t l n g .

57

IV. V TR
- Thoi hoa t sng c: lc vn ng ca on ct sng c ln
nht vng t sng C5 v C6 v cng ln cao hn th cng
gim dn do vy thoi hoa xy ra ch yu cc t sng C5,
C6 v C7, v him khi xy ra on cao hn.
- Thoi hoa t sng lng: c hiu bi hnh thnh cc gai
xng nh.
- Thoi hoa ct tht lng: cng tng t nh thoi hoa ct
sng lng, ch khc bi kch thc cc gai xng on tht
lng th ln hn. mt s bnh nhn ln tui, cc chi xng c
th pht trin dc theo sut ton b chiu di ca ct sng
(Forestier) hoc "ankylosing hyperostosis" ch cc trng hp
nng ny.
- Thoi hoa ca sn khp lin mm gai sau: gp BN >40
tui, t l b cc bin i thoi hoa cc khp lin mm gai sau
hay gp on ct sng c v tht lng. Tui cng cao th chiu
cao ca cc a m cng gim, v t i trng dn vo khp nh
ca ct sng. Gim chiu cao ca cc a m ct sng cng lm
cho cc mm khp ui ca cc t sng b dch chuyn xung
pha ui, to lc nn trn bao khp ca cc khp lin mm gai.
- i khi, mt t sng b trt ra pha trc t sng bnh
thng, hin tng ny c gi l "gi-trt t sng'
(pseudospondylolisthesis).
V. TRIU CHNG LM SNG
- au v cng khu tr, au r dy thn kinh. au khu tr
xut pht t cc dy chng cnh ct sng, cc bao khp.
- Co tht cc c cnh ct sng.

58

- a u r d y t h n k i n h c t h do c h n p r ca d y t h n
k i n h ng sng, hoc c t h ch l a u l a n t r u y n dc theo t h n
k i n h i b c lin quan vi t n t h n g n g u y n p h t t i ch.
- Cc xt nghim: thng khng c g c bit.
C c t h l m s n g ca t h o i hoa ct sng: 3 t h l m s n g
1. au tht lng cp
- Gp la t u i 30 - 40. Cn a u x u t h i n sau mt ng t c
m n h q u mc, t ngt v t r i t t h (bng, b, vc, y, ng...).
- a u t h n g v n g ct sng t h t lng. C t h a u c h a i
b n , n h n g k h n g l a n t i i , hoc khp gi. V n ng b h n
ch, v k h thc h i n cc ng t c , t h n g k h n g c d u h i u
thn kinh.
- C t h k m co cng c c n h ct sng vo b u i s n g v g i m
sau k h i v n ng.
- K h m thc t h : a u k h i s n n v n g t h t l n g . P h n x ,
cm gic, v n ng, v cc d u h i u t h n k i n h k h c u b n h
thng.
- M t SBN c t h t i n t r i n t h n h a u l n g m n t n h .
2. au tht lng mn tnh
K h i a u t h t l n g (TL) k o d i > 4 t h n g - 6 t h n g .
- a u t h t l n g m n t n h l do a m b t h o i hoa n h i u ,
n h i k m , c h i u cao g i m , g i m k h n n g chu lc, p h n l i
ra sau ca a m kch t h c h cc n h n h t h n k i n h gy a u .
- C c y u t nguy c gm: m a n g vc n n g , xoay n g i , c t h
b r u n g (i xe m y , ngi t l u ) , bo p h , t p l u y n t h lc
q u mc.

59

- Lm sng:
+ Thng gp la tui 30 n 50 tui.
+ au m vng tht lng, khng lan xa, au tng khi vn
ng, thay i thi tit, au gim khi ngh ngi.
+ Ct sng c th bin dng mt phn v hn ch mt s
ng tc ci nghing...
3. Thot v a m
- Xy ra khi vng si b rch t v nhn nhy li vo trong
ng sng, chn p ln r ca dy thn kinh sng hoc ln
tuy sng.
- T l au vng tht lng do thot v a m khong 1%
n 2%.
- Thng xy ra nhng ngi t 35 n 45 tui, nam gii
nhiu hn n.
* Triu chng:
- au t ngt, nh dao m, au lan xung mng, v pha
sau ngoi i, tng ln khi ho, ht hi, rn.
- Khm thy ct sng vo, du hiu Lasegue, Valleix, git
dy chung dng tnh bn b au, phn x gn xng gim
nh, teo c, c th ri lon c trn.
* Du hiu X-quang:
Chp X-quang thng: ch thy cc du hiu chung ca thoi
ha ct sng: hp khe a m, gai xng, hp l lin hp.
Chp MRI: thy r trng thi thoi hoa v thot v ca
a m.
Ngoi ra c th chpng sng c cn quang, a m cn
quang, ct lp vi tnh (CT scanner).

60

- C c k t h u t
n y c n g c t h p h t
h i n c t h o t v
a m v hp n g
sng, m chp Xquang b n h t h n g
khng
pht
hin
c.

Hnh 12. MRI thot v ct sng tht lng

4. Thoi hoa ct sng c
C t h gp t h o i h a t t c cc t sng c n h n g t h n g
gp t h o i h a C5-C6 hoc C6-C7.
* T r i u chng:
- a u v n g gy: i k h i l a n x u n g vai v c n h tay. T mt
v n g c n h tay, cng tay v n g n tay.
- H n c h v n ng cc ng t c ca c.
- Nhc u : t v n g c h m , l a n ra t h i d n g , t r n hay
h m t , k h n g c d u h i u t h n k i n h .

sau

- H i chng giao c m c B a r r - Liou: nhc u , c h n g m t ,

tai, hoa m t , m m t . L o n c m t h n h sau hng, n u t vng.
- H i chng c h n p t u y c: m t s t r n g hp h i m gai
xng mc p h a sau t h n t c h n p v o p h n trc tuy,
bnh n h n c du h i u l i t cng na n g i hoc t chi t n g d n .
- Nhiu triu chng xut hin do cc gai xng chn p vo
n g m c h t sng, c b i t l v n g t r n ca c gm: c h n g
m t c h o n g nhc u , v cc cn t h i u m u cc b t h o n g qua.

61

Thoi hoa t sng c c th gy ra 3 hi chng i khi chng

cho nhau: chn p r dy thn kinh sng, chn p tuy sng v
chn p ng mch ng sng.
* Chn on: ch yu da vo hnh nh X-quang, ct lp vi
tnh hoc MRI.

VI. IU TR
1. Vt l tr liu
C tc dng gim au, sa cha t th xu v duy tr dinh
dng c cnh khp, iu tr cc au gn v c kt hp.

62

- N h i t i u tr: siu m , hng ngoi, chm nng, l i u p h p

sui k h o n g , b n c h i u q u cao.
- Ko, phong b k h p gian m m , c h m cu, xoa bp, m t - x a .
- T p luyn: i vi trng hp a u t h t lng m n tnh (bi...)
2. Thuc gim au, chng vim khng steroid - CVKS
(NSAIDs)
- Thuc g i m a u : Paracetamol (acetaminophen).
- C c thuc chng v i m k h n g steroids: da t r n c c h c
c h chn lc men ng d n g COX- 2 g i m t h i u t c d n g p h
t r n t h n v ng t i u hoa, dung n p t t cho n g i c t u i :
Mobic
(meloxicam)
7,5-15mg/ngy,
Celebrex
(celecocib)
200mg/ngy.
- Thuc chng v i m k h n g steroid k h c : dicloenac, Felden.
Brexin (Piroxicam) 2 0 m g / n g y . . .
- Thuc bi n g o i da: cc l o i gel n h : Voltaren Emugel,
Profenid gel, Gelden... c t c d n g g i m a u n g k v k h n g
g y ra cc t c d n g p h n h d n g ng t o n t h n .
- Thuc g i n c: Mydocalm
50mg X 3 v i n / n g y .

150mg X 2 v i n / n g y ,

Myonal

- Thuc chng t r m cm: i k h i c ch nh k h i b n h

n h n a u v n g t h t l n g k m theo lo u ko d i , t r m cm.
+ A m i t r y p t i l i n 25mg, 1-2 v i n / n g y , Dogmatil.
+ T i m n g o i m n g cng: k h i c b i u h i n a u t h n k i n h ta.
(Hydrocortison acetat: m i t 3 m i t i m cch nhau 5-7 n g y ,
k h n g vt q u 4 m i t i m m i t).
3. iu tr ngoi khoa
Ch n h k h i l m s n g c cc b i u h i n :

63

- Hi chng ui nga.
- C biu hin hp ng sng vi cc du hiu thn kinh tin
trin nng, nh hng nhiu n chc nng vn ng.
- Trt t sng 3, 4.
- au lng ko di nh hng ti cht lng cuc sng m
cc bin php iu tr ni khoa khng kt qu.
VU. PHNG BNH
- Pht hin sm cc d t t ca ct sng iu tr kp thi.
- Gio dc bnh nhn: trnh cho ct sng b qu t i bi vn
ng v trng lng, t r n h cc ng tc mnh t ngt (b vc
qu nng, vn ngi...), gim trng lng vi cc bnh nhn
bo ph.

64

HOI T V KHUN C H M XNG

TS. N g u y n V n H n g
I. NH NGHA
H o i t chm x n g i l m t b n h thuc n h m b n h h o i
t xng v i t n h t r n g cht ca cc t b o c h a i p h n ca
xng l t y m t o m u v cc t b o xng. B n h cn c gi
vi cc t n k h c n h h o i t v k h u n chm x n g i , h o i t
do t h i u m u cc b, h o i t v mch, v i m t c h x n g sn.
li. DCH T HC, NGUYN NHN, c CH BNH SINH
B n h c t h gp m i la t u i t u y n h i n p h n l n cc t r n g
hp x u t h i n n a m gii, d i 50 t u i . T l n a m n v o
khong 8:1, v i t u i b b n h t r u n g b n h ca n cao h n nam gii
khong 10 t u i . T n t h n g c t h gp m t khp h n g hoc c
hai b n . B n h c h i m k h o n g 10% tng s ca thay k h p h n g
hng nm.
P h n chm v c x n g i c n u i dng bi ng mch
bt v h ng mch m ( H n h 15), l cc n h n h ca ng mch
chu trong va ng m c h i s u . H i n tng h o i t x n g x y
ra k h i c t n h t r n g k h n g cung cp lng xy c n t h i t
v n g t chc x n g b bnh. H i n tng n y t h n g x y ra
p h n t y m ca xng, ni c t mch m u n u i dng. V n g
xng de b i t n t h n g l p h n trc t r n ca chm x n g i ,
s t ngay u i p h n b m t chu lc
x n g ton t h n g c h i n t n g cht
x n g i k h i lan t i t n p h n xng
ton t h n g k h n g c k h n n g phc

ca x n g i . p h n
ca cc b x n g v t y
u i sn. P h n x n g b
h i h o n t o n h thng

65

mch mu. Khi c tn thng trn X-quang th thng s c

xp chm xut hin sau t vi tun cho n vi nm.

Hnh 15. H mch mch mu nui dng chm v c xng i

Hoi t chm xng i c th t pht hoc l hu qu ca
mt s tnh trng sinh l hoc bnh l nh thai nghn, ung
ru, tc mch, chn thng, do dng thuc.
Sinh bnh hc ca hoi t chm xng i c lin quan n
mt s c ch sau. Tc mch hoc huyt khi cc ng mch
nh phn chm xng i do cc git m, kt dnh hng cu,
cc bng hi. Ph hy cu trc ca thnh mch mu do cc tn
thng vim mch, hoi t do tia x, hoc do gii phng cc yu
t gy co mch. Cc tn thng ny dn n gim hoc mt
cung cp mu cho t chc xng. Tip theo c hin tng sung
huyt cc t chc xng ln cn dn n mt cht khoang va
gim khi lng cc b xng. Xng d b xp khi b t . Qu

66

t r n h n y d i n ra lin tc d n n h y hoi k h p sau 3 n 5

n m n u k h n g c p h t h i n v i u tr.
III. TRIU CHNG LM SNG
Hoi t chm xng i c th tin trin m khng c cc
.
">
o
biu h i n t r n l m s n g . T n t h n g ca xng p h t h i n c
t r n p h i m chp cng h n g t c t h x u t h i n trc cc b i u
h i n l m s n g t vi t u n cho n v i t h n g . Cc t r i u chng
bnh t h n g x u t h i n t r o n g giai oi t i n t r i n ca b n h vi
biu h i n a u hoc nhc v n g b n hoc quanh khp h n g b
bnh. N u giai o n m u n c t h c h n c h v n ng khp
h n g , d n g i t p t n h .
Cc triu chng thc th khng c tnh cht c hiu. giai
o n sm c t h c h n c h cc ng t c v n ng ca khp
h n g b t n t h n g . a u k h i t h m k h m n h t l cc ng t c
xoay hoc d n g khp h n g . B n h n h n c t h duy t r k h n n g
v n ng ca khp h n g b t n t h n g t r o n g n h i u n m vi s
gii h n ca cc ng t c v n ng. K h i b n h t i n t r i n n n g ,
bnh n h n t h n g c a u n h i u , cng hoc h n c h v n ng
khp h n g n h i u . T h i gian t i n t r i n ca b n h t k h i x u t h i n
n giai o n cui thay i t v i t h n g n h n g n m .
IV. XT NGHIM CN LM SNG
1. Cc xt nghim hnh nh
X-quang thng khp hng: c gi tr chn on giai
on t i n t r i n ca b n h . T u y n h i n , p h n g p h p n y t c gi
tr c h n o n giai o n sm ca b n h . P h i m X-quang t h n g
c t h b n h t h n g n h i u t h n g sau s x u t h i n ca cc d u
h i u l m s n g u t i n . C h a i t t h chp c t h g i p p h t
h i n t n t h n g l chp khp h n g t t h t h n g trc sau v
chp p h n b n ca khp vi t t h c h n ch. N h n g b i u h i n

67

sm nht ca hoi t chm xng i bao gm cc thay i nh

v mt ca xng, cc hoi t v cc nang xng. C th c
hnh nh trng li lim c trng ca bnh (gii tng thu
quang di sn) khi c xp xng di sn (Hnh 14). Giai on
mun hn c th thy mt hnh cu ca chm xng v xp
chm. Giai on cui c th thy khe khp hp v cc hnh nh
ca thoi ha th pht ci.

Hnh 16. Hnh nh X-quang thng hoi t chm xng

i giai on 2 (A, B) vi cc nang xng xen ln vi cc
vng x ha phn chm; giai on 3 (C, D) vi hnh nh
trng li lim (mi tn).

X h n h x n g : c gi tr chn o n i vi cc b n h n h n
nghi ng c t n t h n g h o i t chm xng i n h n g h n h n h
X-quang b n h thng. H n h n h t n g t n h i u do h n h t h n h t
chc x n g mi hoc t n g c h u y n ha quanh t chc xng b
h o i t. H n h n h " b n h r n " hay h n h n h im l n h trong
v n g n n g t u y t gp n h n g r t c t r n g cho h o i t chm
xng i . l h n h n h g i m t n h i u v n g t r u n g t m ca
mt v n g t n g t n h i u ( H n h 17). Ngoi t r d u h i u n y , cc
h n h n h k h c ca x h n h x n g k h n g c h i u cho h o i t
chm xng i .

Hnh 17. Hnh nh "bnh rn" ca hoi t chm xng i trn x hnh
xng (mi tn).

69

CT scan: c th gip pht hin sm hoi t chm xng i

vi biu hin x ha vng trung tm ca chm (du hiu hoa
th), nh gi kch thuc cua vng hoi t, pht hin xp chm
nh phn trc.
Chp cng h n g t (MRI): l phng php gi tr nht
pht hin hoi t chm xng i giai on sm khi cha
c xp chm v cc xt nghim hnh nh khc bnh thng, vi
nhy ti trn 90%. Cc biu hin bao gm hnh nh mt vng
gim tn hiu xut hin phn chm xng, c bit l vng
xng di sn. Hnh nh thng gp nht l cc tn thng
xut hin vng trc trn ca chm, i khi lan rng xung
phn hnh xng. C th gp hnh nh gim tn hiu vng ra
xng trn chui xung T i v T2. Hnh nh tng tn hiu pha
trong c ranh gii r vi vng gim tn hiu pha ngoi. Du
hiu ng vin kp c trng gp trong 50-80% cc trng hp
(Hnh 16). Vng tng tn hiu trn T2 l do tng lng nc
trong lng mch hoc khong gian bo vng tn thng.

Hnh 18. Hnh nh hoai t chm xng i trn MRI vi vng gim tin
hiu pha ngoi v tng tn hiu pha trong

TO

2. C c x t n g h i m s i n h h a
C c x t n g h i m m u v sinh h a bnh n h n h o i t chm
x n g i h o n t o n b n h thng.
V. GIAI ON BNH
Xc nh giai o n b n h ca h o i t chm
c da v o cc cc xt n g h i m h n h n h
B n g p h n l o i c n h i u n g i chp n h n
H i p h i quc t v l u n chuyn v h o i t
giai o n :

xng i thng
v m b n h hc.
c x y d n g bi
x n g bao gm 7

- Giai o n 0: cc xt n g h i m c h n o n u b n h t h n g .
C h n o n da v o m b n h hc, x u t h i n h o i t t r n sinh
t h i t xng.
- Giai o n 1: X-quang t h n g v CT scan b n h t h n g , c
bt t h n g t r n x h n h x n g hoc M R I , sinh t h i t xng c
hoi t. C t h c hoc k h n g c cc b i u h i n l m s n g .
- Giai o n 2: c cc h n h n h b t t h n g t r n X-quang l
h n h n h ca x n g cht r chm x n g i . N h n g h n h n h
n y c t h bao gm n h n g g i i h o i t , cc l n g ng calci, cc
nang v n g chm hoc c x n g i . C h m x n g i v n cn
c h n h cu t r n c p h i m trc sau v b n cng n h CT scan.
- Giai o n 3: chm x n g i c cc b i n i c hc. C h n h
n h t r n g li l i m x u t h i n ngay p h n x n g d i sn.
Chm x n g v n cn g i h n h d n g cu.
- Giai o n 4: c b t k b n g chng n o ca xp chm x n g
i v i d u h i u hp khe khp.
- G i a i o n 5: c t h c b t k hoc t t c cc d u h i u v
h n h n h m t t r n c n g vi d u h i u hp khe khp. C
cc b i u h i n ca t h o i h a khp t h p h t sau cc b i n i c

71

hc ca chm xng i, vi cc biu hin x ha, nang xng

phn ci v c th c gai xng.
Giai on 6: ph hy nng chm xng i vi cc biu
hin thoi ha nng.
VI. CHN ON
1. Chn on xc nh
Da vo cc yu t dch t, tui v gii kt hp vi cc triu
chng lm sng v cc xt nghim hnh nh.
2. Chn on phn bit
giai on v 2 chn on xc nh thng kh khn. Vi
giai on cn phn bit vi tt c cc bnh c tn thng
xng, sn v mng hot dch khp. Giai on 2, cc tn thng
bo mn xng khng c hiu trn X-quang cn c xc nh
bng x hnh xng v MRI vi cc bnh nhn thuc nhm
nguy c b hoai t chm xng i. ph n c thai cn phn
bit hoi t chm xng i vi tnh trng long xng thong
qua do mang thai. Vi giai on 3 v 4, cc du hiu trn Xquang c hiu cho hoi t chm xng i. Tuy nhin giai
on 5 v 6 rt kh phn bit hoi t chm xng i vi cc
bnh khp hng khc v giai on cui cc bnh ny u c
biu hin ging nhau.
VII. IU TR
iu tr hoi t chm xng i l mt trong nhng vn
gy nhiu tranh ci nht. Mc tiu ca iu tr nhm bo tn
cu trc t nhin ca khp cng lu cng tt. Vic la chon
phng php iu tr c da vo mc tn thng ca chm
xng i. Tn thng di 15 % th tch ca chm c p
dng cc bin php iu tr bo tn. Tn thng t 15 n 30 %

72

t h tch chm c i u tr b n g khoan g i m p lc hoc to

h n h x n g . V i t n t h n g t r n 30 % t h tch chm, p h n g
p h p i u tr p d n g l p h u t h u t thay t o n b khp hang. Co
bn p h n g p h p c p d n g bao gm.
i u t r b o t n : vi giai o n 0, v 2 c t h i u t r b n g
cc b i n p h p bo t n hoc khoan g i m p lc. i u t r bo t n
bao gm vic ngh ngi, g i m t i t r n g cho khp h n g b n g vic
d n g gy n n g . G i m a u b n g thuc chng v i m k h n g steroid
hoc g i m a u n t h u n . K t hp vi cc p h n g p h p v t l
tr l i u n h m duy tr sc m n h ca c, t r n h co r t , cc d n g c
h tr i l i . Tuy n h i n cc b i n p h p n y k h n g g i p n g n cn
tin t r i n ca bnh.
Cc thuc h m m u c t h c s d n g cc b n h n h n
hoi t chm x n g i c lin quan v i r i l o n chuyn h a m.
Thuc chng c t h g i p g i m k h n n g n g n g t p t i u cu,
t n g cng t u i m u v t i t o mch v n g x n g t n t h n g .
Bisphosphonat c t h c ch n h t r o n g i u t r hoi t
chm vi mc ch l m g i m q u t r n h h y h o i x n g p h n
xng b h o i t v ko d i t h i gian trc k h i c xp
chm xng.
Phu thut thay khp hng: p dng cho nhng trng
hp a u ko di, p n g vi i u tr k m v m t chc n n g v n
ng t i n t r i n nhanh. N n c t i n h n h trc k h i chm
xng i b xp h o n t o n , t h n g giai o n 3, 4.
K h o a n g i m p c h m : k h i cc b i n p h p i u tr bo t n
k h n g mang l i h i u q u . T h n g p d n g cho cc t r n g hp
giai o n , 2 v 3. M c ch ca b i n p h p n y l n h m l m
gim p lc trong xng, g i p t i t o l i h t h n g ti m u
xng, to i u k i n p h n xng l n h l n cn t h a m gia q u
t r n h t i to xng. K t qu t t t t 30 n t r n 90 %
t r n g hp.

73

To h n h x n g : l mt k thut
Phng php ny loi b phn xng b
chnh ca chm xn i nhm phn b
sn khp c chng bi t chc xng

nhm bo tn khp.
bnh vng chu ti
l i lc t vo phn
lnh pha ui.

G h p x n g , t b o gc: l nhng hng iu tr mi s

dng k thut ghp xng khng c ti to mch hoc t bo
gc nhm phc hi l i t chc xng b hoi t ca chm, t
gip phc hi chc nng ca khp hng b tn thng. Tuy
nhin cc phng php ny mi trong giai on th nghim v
ha hn m ra nhng hng iu tr mi, hiu qu i vi hoi
t chm xng i trong tng lai.

Hnh 19. K thut khoan gim p trong iu tr hoi t chm xng i

giai on sm

74

AU CT SNG THT LNG

AU THN KINH TOA

(HNG)

PGS. TS. V T h T h a n h T h y
I. NH HNG CHAN ON AU CT SNG THT LNG
a u ct sng t h t l n g l b i u h i n r t hay gp, c t i 80%
ngi b b i u h i n n y t r o n g m t i ngi. T u i b t u b
thng t 30 - 50 v t l gia nam v n l t n g n g . L
n g u y n n h n l m g i m k h n n g lao ng t u i d i 45 v chi
ph ca b n t h n cng chi p h i u t r r t t n k m .
T h n h p h n ct sng bao gm:
t sng (Vertebra), a m (Intervertebral), m m ngang
(Transverse process), m m gai (Spinous process), cc khp b
m t t sng (Facet j o i n t ) , t h n k i n h t sng, ng m c h t
sng, d y t h n k i n h , r t h n k i n h , k h i cc d y chng, k h i c
cnh ct sng. K h i c t n t h n g b t c mt t r o n g n h n g t h n h
p h n t r n u gy a u CSTL.
N g u y n n h n hay gp l c h n t h n g c, d y chng ct sng,
thoi hoa khp v a m , t u y n h i n s t n g quan gia b i u
h i n l m s n g v c h n o n h n h n h l r t t.
Vic chn o n n g u y n n h n n h i u k h i k h k h n , i u quan
trng c h n g ta p h i t r li c 3 c u h i sau: c p h i a u do
bnh t o n t h k h n g ? C y u t stress v t m l v x h i l m
t n h t r n g a u t n g ln v k o d i k h n g ? C t n t h n g t h n
k i n h i hi p h i xem xt v n p h u t h u t k h n g ? t r li
c n h n g c u hi n y , c h n g ta cn h i b n h t m v k h m
l m s n g cn t h n v l m cc t h m d cn t h i t .

75

Hnh 20. Cc thnh phn ca ct sng

1. Mng mm

5. Thn t sng

9. Din khp

2. Mng nhn

6. a m

10. Dy thn kinh

sng

3. Mng cng

7. Gai sng ngang

11. Ty sng

4. Khoang mng
cng

8. Mm sau gai

CHN ON NG CHNG TA CAN

1. Hi bnh
Khai thc nhng yu t nguy c: mang vc, xon vn, lm
vic t t h rung Oi xe), bo ph, cng vic bun t. tuy nhin
c nhng bnh nhn khng c yu nguy c.
Tui: nu xut hin tui < 45, nguyn nhn c th sau chn
thng, bnh l (vim t sng a m, bnh l ct sng huyt
thanh m tnh...), bnh vo ct sng bm sinh.

76

Gii: nam gii t r t u i ; cn k h a i t h c cc b i u h i n ca cc

bnh b n h l ct sng h u y t t h a n h m t n h , n h vim ct sng
d n h khp...
2. Tin s au
2.1. Hon

cnh

khi pht

au

- t ngt: t h n g lin quan n chn t h n g , cn xem xt

tn t h n g xng, hay p h n m m .
- N u k h n g c k h i p h t a u : cn xem xt do n g u y n n h n
k h n g do c hc.
- N u a u t n g lc hoc c a u b n g c t h xem x t n g u y n
n h n t cc t n g t r o n g b n g h o c v n g t i u k h u n g .
2.2. Xc nh v tr au
C lan hay k h n g ? C l i n quan n d u h i u kch t h c h r
thn kinh khng?
2.3. Nhng

yu

t tc ng

n tnh trng

au

a u t n g k h i v n ng: n u a u t n g ln, c b i t l k h i i:
cn xem xt do n g u y n n h n do t h o i hoa hoc c hp ng sng.
N u c k m cng khp bui s n g v a u h n k h i v n ng c
t h ngh n m t b n h t r o n g n h m b n h l ct sng h u y t
thanh m t n h .
a u t n g k h i ho hoc h t hi, t h n g do kch t h c h r .
N h n g y u t k h c : h o n cnh gia n h ; k h n g thoa m n
trong cng vic, stress; t r n h v n hoa t h p ; n g i l n t u i ;
h t thuc l; k i n h t k h k h n u l y u t nguy c gy a u ct
sng t h t l n g .
3. C c t r i u c h n g v t h n k i n h
K h a i t h c cc t r i u chng v t h n k i n h b n h n h n a u ct
sng t h t l n g l i u cc k quan t r n g v n h t t h i t p h i l m .
N u c cc b i u h i n t h n k i n h s g i p ta xc n h v t r t n
t h n g v xem xt vic can t h i p sm n u cn t h i t .

77

3.1. Nhng biu hin kch thch r

Yu chi, d cm, t b:
- Nu xut hin tui t 20 - 50: thng do thot v a m
(him gp tui ui 20).
Nu triu chng au c tnh cht d xut hin ngi > 60
tui: thng do th pht sau hp ng sng do thoi hoa.
- Cng c th do ung th di cn hoc nhim khun gy tn
thng dy thn kinh v r thn kinh.
3.2. Nu c ri lon c trn (rut, bng

quang)

Thng l biu hin ca hi chng ui nga, cn khn cp

chn on nguyn nhn v x l kp thi.
Nhng vn cn quan tm nht: ngi ln tui; tin s
chn thng, gim chiu cao c st, au vo ban m, khi ngh
ngi; c tin s b ung th; s dng glucocorticoids.
Bng 3. Nhng du hiu thn kinh hay gp trong tn thng a m
au

Cm gic

Vn
yu

L3 -4

Trc bn i,
gia gi

Trc bn i

C dui gi

Bnh
gim

L4-5

Mt sau i, pha
bn bng chn,
pha sau bn
chn, ngn ci

Pha sau bn
bng chn, sau
bn chn, k
chn ngn ci

C gp sau
c chn; c
dui ngn
ci

Khng c g
c bit

Mng, sau i,
bng chn, gt,
trn bn chn,
mt bn ngn ci.

Mng,sau
bp chn,
bn ca
chn, mt
2 ngn ci

C gp gan
bn chn
bnh thng
hoc gim

Gim phn
x gn gt

L5
SI

78

i,
mt
bn
bn

ng

Phn x

V tr

ch

4. C h n o n p h n b i t a u t h t l n g
4.1. au do nguyn nhn c hc (97%)
C n g c, bong g n (70%); t h o i hoa a m , d i n khp; t h o t
v a m ; h png sng; x p l n t do l o n g xng; b n h l
ct sng; g y x n g do chn t h n g ; b n h b m sinh (g, vo
n n g ct sng, t sng n i t i p ) , t r t t sng, t i u t sng;
v b n trong a m ; t r c h a m t sng.
4.2. au khng do nguyn nhn c hc (1%)
- U n g t h : Kahler; carcinoma do d i c n (metastatic
carcinoma), k h i u sau m n g bng, lymphoma, leukemia; u
t h n k i n h ct sng, k h i u t sng t i n p h t .
- N h i m k h u n : ct t u y v i m , v i m a m do n h i m k h u n ,
abscess cnh ct sng, abscess ui nga.
- V i m khp, v i m ct sng d n h khp, v i m khp v y n n ,
hi chng Reiter's, b n h v i m k h p - ng r u t .
- Scheuermann's (Osteochondrosis)
- Bnh Paget's.
4.3. Bnh v ni tng (2%)
- B n h l v n g t i u k h u n g : t i n l i t t u y n , b n h n i mc t
cung, bnh v i m m n t n h v n g t i u k h u n g .
- B n h t h n : si t h n , v i m t h n b t h n , abscess quanh
thn.
- P h n h ng mch c h .
- Bnh
t t r n g .

tiu

h a : v i m t u , v i m t i m t , lot d d y

79

5. C c t h m d
5.1. Chp Tm X-quang:

chp t t h trc sau, nghing v

chch.
5.2. Sc intigraphy xng: pht hin ung th di cn hoc nghi
ng nhim trng.
5.3. Computed tomography (CT)
Khng bm thuc cn quang: cho thy cu trc xng t
sng, pht hin hp ng sng.
- C bm cn quang c th pht hin tn thng thn kinh.
5.4. Chp cng hng t trng (MRl): c th nh gi c
cu trc m mm v xng, pht hin khi u. C th pht hin
c 30% nhng tn thng khng c triu trng lm sng.
5.5. in c: pht hin tn thng ngun gc thn kinh.
Tm l i : au CSTL c rt nhiu nguyn nhn, trong c
nhiu trng hp khng c nguyn nhn thc th, tuy nhin cn
tin hnh chn on loi tr nhng bnh l nh nu trn.
li. CHN ON V IU TR AU THN KINH TOA (HNG)
Thn kinh toa l thn kinh ln nht ca c th to nn bi
cc r thn kinh. N bt u i t t 9ng L3, bao gm cc r
t L3 - L4 - L - S i . au thn kinh (TK) hng l hi chng
rt ph bin, nh hng nhiu n kh nng lao ng, nht l
nhng ngi lao ng chn tay. Bnh thng gp tui 30-60,
nam nhiu hn n (t l 3/1). Ngy nay do nhng tin b ca
khoa hc k thut, vic chn on v iu tr au TK hng c
nhiu hiu qu hn.
1. Nguyn nhn
au TK ta (hng) c nhiu nguyn nhn nhng ch vu vn
do nhng tn thng ca ct sng tht lng (CSTL). C th sp

80

xp c c n g u y n n h n a u T K h n g theo n h m t i n cho vic

thc h n h :

Hnh 21. V tr thn kinh ta

1.1. Thot

v a

L n g u y n n h n p h b i n n h t (khong 60-90% theo n h i u

t c gi). a m n m khe lin t sng (S), g m 2 t h n h
phn: p h n t r u n g t m l n h n n h y c t n h n h i cao; p h n
ngoi v i gm n h i u si sn a n ng t m theo c h i u ngang v
chch theo c h i u ng. N h t n h n h i , a m l m n h i m v
n h g i m sc, bo v ct sng (CS) k h i b c h n t h n g ( n g
dn c s , k h i n g v c nng...), n h n g n g i t r n 30 t u i , a

81

m () thng khng cn mm mi, nhn nhy c th b kh,

vong sn bn ngoi x ha, rn nt v c th rch. Trn c s
nu c lc tc ng mnh vo c s (chn thng, gng sc...),
nht l sau ng tc ci xung nng vt nng, n h n nhy c th
qua ch rch ca a m thot V ra ngoi chui vo ng sng
gy chn p r TK hoc ty sng. Ty theo v tr ca ch rch,
c th c thot v bn hoc trung tm.
Chn on thot v a m (TV) trn lm sng da vo
cc yu t: xy ra sau chn thng v gng sc, au tng khi
ho, ht hi; c cc triu chng ca CS: t t h vo chng au, co
cng c cnh cs, du hiu nghn, gp khc ng gai sng.
1.2. Cc bt thng vng ct sng tht

lung

a. Loi mc phi:
Trt t sng TL5, thoi ha cc khp lin cung S, bnh
Paget, gy ph i cung S, hp ng sng dn n chn p mt
hoc nhiu r TK, cc loi u lnh tnh ca xng v cc thnh
phn khc ca cs, ung th nguyn pht hoc th pht cc S,
vim S do t cu, lin cu, do lao, gy S do chn thng.
b. Bm

sinh:

Gai i Si c th l iu kin thun li cho TV. Hpng

sng bm sinh gy au TK hng kiu nhiu r v 2 bn, du
hiu au cch hi, ng knh ng sng hp trn phim chp bao
r hoc chp ct lp vi tnh.
c. Cc nguyn nhn trong ng sng:
u ty v mng ty chn p vo r TK hng, vim mng nhn
ty kh tr, p xe ngoi mng cng vng TL. Chn on da
vo c im lm sng ca tng loi kt hp vi triu chng
dch no ty (DNT) nh phn ly m - t bo trong p ty do u,
phn ng vim mng v cn mng ty trong vim mng nhn
v p xe. Chn on quyt nh da vo chp ty c cn quang
hoc chp CT, M i n .

82

d. Cc nguyn nhn kh chn on: t h n g ch xc n h c

sau p h u t h u t : d n T / M quanh r, d n T / M m n g cng, p h i
d y c h n g v n g , r T K 5 hoc S i to hn b n h thng.
e. Cc nguyn

nhn nm trn ng i ca dy

TKhng:

V i m khp c n g c h u (lin quan g n v g i i p h u g y kch

thch T K h n g ) , cc k h i u v n g y c h u g y c h n p
dy T K h n g . .
2. Triu chng
2.1. Lm

sng

* T r i u chng chc n n g : a u l t r i u chng n i b t , k h i

u l a u t h t l n g , v i gi hoc v i n g y sau a u t i p tc
t n g ln v l a n xung m n g , kheo v cng b n c h n theo dng
i ca d y T K h n g . C k h i a u m n h n g t h n g a u d d i ,
a u t n g k h i ho, h t hi, ci. a u t n g v m , g i m k h i n m
y n t r n g i n g cng, gi co l i . c m gic k i n b, t cng hoc
n h k i m c h m b n g o i b n c h n cho qua m u c h n n n g n
ci (r TL5), gt c h n hoc n g n t (r S i ) . M t s B N b a u
h b v a u k h i t i u , i t i n do t n t h n g r n g x m p h m
cc r thuc m r i T K u i nga.
* Thc th:
- Ct sng (CS): phn ng co cng c cnh c s , c s m t ng cong
sinh l, vo c s , cc t t h chng au, gy k h c ng gai sng...
- T r i u chng r: d u h i u Lasegue d n g t n h . K h m p h n
x, c m gic, v n ng, t n h t r n g teo c x c n h r b t n
thng:
+ R L: p h n x g n gt b n h t h n g , g i m hoc m t c m
gic p h a n g n ci (c t h t n g giai o n kch t h c h ) , k h n g i
c b n g gt, teo n h m c cng c h n trc n g o i , cc c
mu chn.

83

+ R SI: phn x gt gim hoc mt, cm gic gim hoc mt

pha ngn t, khng i c bng mi chn, teo c bp cng
chn, c gan bn chn.

Re L4
(a em L34)

2.2. Triu chng cn lm

R 15
(a em L4-5)

Ri SI
(a em L5-S1)

sng

* Xt nghim:
- C bn: CTM, LM khng c hiu nhng c gi tr chn
on phn bit ban u gia vim, ung th v s nguyn
nhn khc.
- Dch no ty (DNT): protein thng tng nh nu c p r.
Nu c vim hoc chn p ty, DNT s c bin i protein va TB
theo cng thc c hiu.

84

- C c X N sinh ha: calci, phospho, phosphatase k i m . . . n u

c n g h i ng cc b n h c h u y n h a hoc ung t h .
*

X-quang:

- C h p t h n g quy: quan t r n g n h gi h n h t h i ca
S , a m .
- C h p a m () c cn quang, chp cn quang ct
lp v i t n h .
- Chp bao r .
- CT (chp ct lp v i t n h ) .
- M R I (chp cng h n g t h t n h n ) .
Dy thn kinh ct sng (tht lng) b chn p

Thot v a m

Hnh 23. Hnh nh MRI thot v a m gy chn p thn kinh

Cc k thut chp X-quang, c bit l chp CT, MRI cung

cp n h n g t h n g t i n r t quan t r n g cho vic c h n o n n g u y n
n h n a u T K h n g , t u y n h i n cn p h i k t hp cht ch vi t i n

85

s v bnh cnh lm sng. V khng c s tng xng gia lm

sng VI hnh nh X-quang, ph thuc qu nhiu vo hnh nh
x-quang c th dn en sai lm nghim trng trong chn on.
Cc phng php thm d khc: in c v o thi tr dy
TK cho php chn on v tr ca thot v a m.
3. iu tr au thn kinh hng
Ty theo nguyn nhn.
3.1. iu tr ni khoa
3.1.1. Ch vn ng
- Nm ngh t i ch trong giai on u: khong mt thng.
- Vn ng hp l trong nhng giai on sau, tp vn ng
t h n th nh nhng tng cng chc ca c cnh ct sng.
3.1.2. Vt l tr liu: dng nhit, xoa nn chnh hnh, in xung,
sng ngn, chm cu, ko gin ct sng, tm sui khong, p
bn...
3.1.3. Tm l liu php: ng vin gip bnh nhn kt hp
ngh ngi, th gin.
3.1.4. iu tr bng thuc
- Gim au: Paracetamol; opioid, Dialtavic, Idarac, tramadol.
- Thuc gin c: Myonal, Mydocalm.
- Chng vim khng steroid: diclofenac (Voltarene),
meloxicam (Mobic), naproxen (Felden), celecoxib (Celebrex)... c
th dng dng tim t .2 n 3 ngy giai on cp, sau thay
bng ng ung.

86

Anticholinergics
(Clonazepam).

(trihexyphedyl);

benzodiazepin

- N e u r o t i n , Lyrica.
- V i t a m i n B12, Methylcoban.
- T i m c n h ct sng (L- S i ) ; t i m n g o i m n g cng
hydrocortison acetat, triamcinolon (Depomedrol).
3.2. iu tr phu thut
- Cc trng hp tm thy nguyn nhn: vim S do vi
t r n g , t h o t v a m i u t r n i khoa tch cc k h n g k t q u ,
cc k h i u l n h t n h v c t n h c h n p r hoc d y T K h n g gy
a u n n h i u v cc r i l o n k h c .
- C c t r n g hp k h n g r n g u y n n h n : i u t r p h u t h u t
n u c l i t v teo c, r i l o n c t r n , a u t i p h t n h i u l n n h
hng n g h i m t r n g n lao ng v sinh hot, a u ko d i
k h n g p n g v i i u t r n i khoa t 3-6 t h n g . Trong cc
trng hp t r n , p h u t h u t c k h i t m t h y T V , d y d n h
d y chng, d y chng to, sung h u y t t n h mch...

87

VIM K H P D N G T H P

PGS. TS. Nguyn Th Ngc Lan

I. I CNG
Vim khp dng thp (Rheumatoid Arthritis- Arthrite
Rhumatoide) l bnh c c trng bi vim nhiu khp i
xng, thng km theo du hiu cng khp bui sng v s c mt
ca yu t dng thp trong huyt thanh. Thut ng vim khp
dng thp do Garrod ngh nm 1858. Waaler (1940) v Rose
(1947) pht hin ra yu t dng thp bng phn ng ngng kt
hng cu cu. y l mt trong cc bnh khp mn tnh thng
gp nht. Bnh gp khong 0,5 - 1 % dn s mt s nc chu u v
khong 0,17 -0,3% cc nc chu . T l ny t i min Bc Vit
Nam, theo thng k nm 2000 l 0,28%. v lm sng, bnh ch
yu gp n gii, tui trung nin, bnh thng din bin mn tnh
xen k cc i vim cp tnh. Mc ch iu tr nhm khng ch
qu trnh vim khp bnh nhn c th c cuc sng bnh
thng. Bnh duy tr c tnh trng n nh, trnh c cc t
tin trin nh cc thuc chng thp khp tc dng chm (Slow
Acting AntiRheumatis Druds) hay cn gi l nhm thuc
DMARS (Disease Modiying Anti Rheumatis Druds).
li. TRIU CHNG HC BNH VIM KHP DNG THP
1. Triu chng lm sng
Bnh din bin mn tnh vi cc t cp tnh. Trong t cp
tnh thng sng au nhiu khp, st, c th c cc biu hin
ni tng.

88

Biu hin ti khp

- V tr khp tn thng thng gp nht l cc khp ngn
gn, b n n g n , c tay, k h u u , gi, c c h n , b n n g n c h n , hai
bn. M t s n g h i n cu cho t h y t i V i t N a m , cc khp x u t
h i n t n t h n g sm n h t l khp c tay (50- 60%), khp b n
ngn tay, khp gi gp v i t l t n g n g l 10- 15%. N h n g
khp n h k h p vai, khp k h u u h i m k h i gp giai o n k h i
p h t u t i n (2,4%).
T i t h i i m t o n p h t , cc v t r khp v i m t h n g gp l
khp c tay (80-100%), khp b n n g n (70-85%), khp t n g n
gn (70-75%), k h p gi (55-75%), khp c c h n (40-75%), khp
khuu (20-50%), khp vai (2,4-60%). i k h i c t n t h n g khp
h n g . Khp v i m t h n g i xn.SLhai b n .

tn thng

H j n h

25. Vim khp ngn gn

89

Bnh ch b tn thng t i ct sng c, c th gy hy xng,

dn n cc di chng thn kinh (biu hin giai on mun v
him gp).
- Tnh cht: trong cc t tin trn, cc khp sng au, nng, t
khi . au kiu vim. Cc khp ngn gn thng c dng hnh
thoi. Cc khp thng b cng vo bui sng. Trong cc t tin
trin, du hiu cng khp bui sng ny thng ko di trn mt
gi. Thi gian ny ngn hoc di tuy theo mc vim.
- Bin dng khp: nu bnh nhn c iu tr ng cch khi
chc nng khp cha b tn thng, chc nng khp c th bo
tn. Nu khng iu tr, bnh nhn s c nhiu t tin trin
lin tip, hoc sau mt thi gian din bin mn tnh, cc khp
nhanh chng b bin dng vi cc dng rt gi nh bn tay gi
thi, c tay hnh lng lc , ngn tay hnh c c, ngn tay ca
ngi th tha khuyt, ngn gn hnh thoi, cc khp bn ngn
bin dng, t gn dui ngn tay (thng gp gn ngn tay 4 ,
5), gan bn chn trn, ngn chn hnh vut th... Cc khp b
huy hoi nh vy s khin bnh n h p nhanh chng tr thnh
tn ph. Giai on mun, thng tn thng cc khp vai, hng.
C th tn thng ct sng c, gy nhng bin chng v thn
kinh (c th lit t chi).

yt <!

Hnh 26. C tay bin dng hnh

lng lc v t gn dui ngn
tay 4 v 5

*< ri IsM t*

Hnh 27. Bn tay gi thi

90

Hnh 28. Ngn tay bin dng hnh c ngng

Hnh 29. Bin dng hnh ngn tay ca

ngi th tha khuyt (th lm khuy)

Hnh 31. Bn chn bin dng

hnh vut th

Hnh 30. Bin dng

hnh gan chn trn
91

 Biu hin ton thn v ngoi

khp

Hnh 32. Ht di da
- Ht di da: s lng: c th c mt hoc nhiu ht. V tr:
ht xut hin trn xng t r gn khuu, trn xng chy gn
khp gi hoc quanh cc khp nh hn tay.
Tnh cht: chc, khng di ng, khng au, khng bao gi v.
Cc bnh nhn Vit Nam t gp cc ht ny (ch khong 4%
s bnh n h n c ht di da).
- Vim mao mch: biu hin di dng hng ban gan chn
tay, hot t v khun hoc tc mch ln thc s gy hot th.
Triu chng ny bo hiu tin lng nng.
- Gn, c, dy chng v bao khp: cc c cnh khp teo do
gim vn ng. C th gp triu chng vim gn (thng gp
gn Achille), i khi c t gn (thng gp ngn tay gn ca
ngn tay th 4,5). Cc dy chng c th co ko hoc lng lo.
Thng gp kn khoo chn (kn Baker), kn ny c t h thot
xung cc c cng chn.

92

- Biu hin ni tng: cc b i u h i n n i t n g ( t r n dch m n g

phi, m n g tim...) h i m gp, t h u n g x u t h i n trong cc t
tin trin.
- Triu chng khc: c t h gp mt s t r i u chng k h c
t h i u m u (c c i m ca t h i u m u do vim); r i l o n
k i n h thc v t (cn bc ha...), hng ban gan b n tay, gan
chn; h i chng ng h m c tay, c c h n ; v i m mong
n h i m bt (thn)...

nh
thn
bn
mt;

2. Cc triu chng cn lm sng v X-quang

- H i chng v i m sinh hc:
Tc m u l n g : t n g t r o n g cc t t i n t r i n , mc p h
thuc t n h t r n g v i m khp.
T n g cc protein v i m : protein c p h n n g (CRP); y-globulin,
si huyt...
T h i u m u (thuc h i chng v i m ) , c cc t n h c h t t h i u
m u b n h sc hoc n u t h i u m u k o d i , t r m t r n g s c t n h
cht nhc sc hng c u nh; f e r r i t i n t n g ; k h n g p n g v i
iu t r st m s h i phc k h i t n h t r n g v i m c c i t h i n .
- Cc xt nghim min dch:
+ Waaler (1940) v Rose (1947) p h t h i n ra y u t d n g
t h p b n g p h n n g n g n g k t hng c u cu, do p h n n g
t m y u t d n g t h p R F (Rheumatoid Factor) mang t n h a i t c
gi n y : p h n n g Waaler- Rose v/hoc latex. P h n n g c
coi l d n g t n h k h i t gi t 1/32 t r l n .
+ Nhiu k h n g t h t m i n trong huyt thanh bnh n h n
vim k h p d n g t h p c p h t h i n n h k h n g t h k h n g
y u t canh n h n (APF - a n t i perinuclear factor), k h n g t h
k h n g c h t sng ( A K A - a n t i k e r a t i n antibodies) song c h a t h
p d n g p h b i n v v n k t h u t . N m 1998, Schellekens

93

pht hin protein ilaggrin l khng nguyn ch ca c khng

th APF v AKA, trong phn t acid amin citrullin l thnh
phn cu to ch yu trong cc quyt nh khng nguyn ca
protein ny. Do vy, xt nghim tm khng t h c hiu c tn
l khng th anti cyclic citrullinated peptid (anti-CCP
antibodies) c trong huyt thanh bnh n h n vim khp dng
thp c th thc hin d dng v ph bin hn. Gi tr ca
chng l xut hin sm, thm ch trc khi c vim khp, v c
gi tr tin lng vim khp dng thp c huy hoi khp. Khi c
mt ng thi c RF v anti-CCP th c hiu trong vim
khp dng thp rt cao. Kt qu t nhiu nghin cu cho thy
so vi RF th anti-CCP c nhy ca cao hn trong giai oan
sm ca bnh vim khp dng thp; c c hiu cao hn
(gip chn on phn bit vi cc bnh khc co biu hin vim
khp); c gi tr tin lng v s biu hin thnh mt vim khp
dng thp thc s trn c s mt vim khp khng xc nh
c nguyn nhn tt hn; c s thay i nong khng the
lin quan vi mc p ng vi iu tr cht ch hn. Mt
trng hp vim khp dng thp c anti-CCP dng tnh s c
kh nng tn thng ph huy khp nng hn (nh gi gin
tip bng hnh nh Xquang) ca, nhanh hn mt trng hp co
anti-CCP m tnh.
Hnh 33.
A. Khp bn ngn
tay bnh thng
B. Hp khe khp
c. Hnh bo mn,
v hp khe khp

94

* Chn on hnh

nh

H n h n h X- quang quy c:
+ G i a i o n sm: h n h n h m t cht k h o n g u x n g c n h
khp, c t h t h y h n h hc t r o n g xng; h n h b o m n x n g
(hnh k h u y t nh) r a xng; khe khp hp. N g o i ra c t h
thy h n h nh sng phn mm.
+ Giai o n mun: huy u x n g d i sn, d n h khp, b n
t r t khp, lch trc k h p .
- Cng h n g t k h p c tay:
T n m 1996, Ostergaard v McQueen t i n h n h chp
cng hng t khp c tay b n h n h n v i m khp d n g t h p
a n h gi t n h t r n g v i m m n g h o t dch. T i p n h i u cc t c
gi k h n g nh v a i t r ca cng h n g t khp b n c tay
trong c h n o n sm bnh. N g o i h n h n h b o m n (erosion),
cng h n g t cn p h t h i n tng h i n t n g p h x n g do
h i n tng v i m m n g h o t dch gy sung h u y t t n g v n g ca
xng v s x m n h p ca dch r v i m .

1**1

s
*

7 *
- '** ti
ti

..

tri

Hnh 34. Cng hng t:

hnh bo mn khi xng
c tay

Hnh 35. Cng hng t:

ph xng thuyn

95

III. CHN ON
1. Chn on xc nh bnh vim khp dng thp
Nm 1958 Hi Thp khp hc M (American College of
Rheumatology- ACR) ra tiu chun chn on bnh vim
khp dng thp (ACR 1958) gm l i yu t da vo lm sng,
hnh nh X-quang, m bnh hc mng hot dch v huyt
thanh. n nm 1987, hi ny thng nht ci tin tiu chun
chn on gm 7 yu t (ACR 1987) m hin nay vn c ng
dng rng ri trn phm vi ton t h gii. Tiu chun ACR 1987 nh sau:
1. Cng khp bui sng ko di trn mt gi.
2. Vim t nht 3 trong s 14 khp sau: ngn gn, bn ngn tay,
c tay, khuu, gi, c chn, bn ngn chn (2 bn).
3. Trong c t nht mt khp thuc cc v tr sau: ngn gn,
bn ngn tay, c tay.
4. C tnh cht i xng.
5. Ht di da.
6. Yu t dng thp huyt thanh (K thut t c hiu 95%)
dng tnh.
7. X-quang in hnh khi xng c tay (hnh bo mn, mt
cht khong u xng).
Thi gian din bin ca bnh t nht phi 6 tun
Chn on xc nh khi c t nht 4 trong s 7 yu t
D dng nhn thy rng theo tiu chun ny, d c s
khng c phng xt nghim cn lm sng cng vn c th chn
on xc nh c bnh vim khp dng thp.

96

2. T i u c h u n n h g i i t i n t r i n
- n h gi t t i n t r i n theo l m s n g (theo h i t h p khp
hc c h u u E U L A R ) .
- C t n h t 3 khp s n g v t n h t mt trong s 3 tiu ch sau:
+ Ch s Ritchie t 9 i m t r ln.
+ C n g khp b u i s n g t n h t 45 p h t .
+ Tc m u l n g gi u 28 m m .
(Ch s R i t c h i e c t n h n h sau: s i m t i m t khp c
xc nh k h i t h y thuc n n g n tay ci v o m t khp, n u b n h
n h n k h n g a u : 0 i m ; a u n h : i m ; a u va ( n h n m t ) :
2 i m ; a u n h i u (gt tay t h y thuc ra): 3 i m . Ch s R i t c h i e
l tng ca i m ca cc k h p t r o n g c t h ) .
- n h gi t t i n t r i n theo cng thc D A S 28- Disease
activity score.
Thang i m n h gi mc h o t ng b n h c V a n
Riel s dng n m 1983 vi 44 khp. N m 1995, Prevoo v cng
s c i t i n , ch s d n g 28 khp. N h i u n g h i n cu t i p
cng cho t h y DAS 28 c gi t r d b o mc t n t t v t n
t h n g X-quang h y khp t r n p h i m t t h n so v i DAS c i n .
Cng thc DAS 28:
DAS 28 = [ 0,56 7 (Skhpau)+ 0,28 . (S khp sng)
+ 0,701n (mu lng lh)] 1,08 + 0,16
Trong : s khp sng, s khp au c nh gi trn 28
khp bao gm: khp m m c n g vai, k h p k h u u tay, c tay, b n
ngn tay n 5, k h p n g n g n b n tay t n 5, k h p gi
(tnh c hai b n ) .
- n h gi: mc h o t ng b n h

97

+ DAS < 2,9 im: bnh khng hot ng

+ 2,9 DAS 3,2 im: mc hot ng nh
+ 3,2 < DAS 5,1 im: mc hot ng trung bnh
+ DAS > 5,1 im: mc hot ng mnh
3. Chn on phn bit
* Thp khp cp
- Gp ngi tr tui.
- Sng au cc khp nh, vim cp tnh, kiu di chuyn.
- C tin s nhim lin cu khun: st, au hng trc
khong mt tun, ASLO dng tnh. Thng km theo vim
tim: nhp t i m nhanh, c th c ting thi (th thng van tim),
c t h c tn thng c t i m hoc mng ngoi tim. Cc triu
chng p ng tt vi thuc (corticoid hoc thuc chng vim
khng steroid).
* Chn on xc nh theo tiu chun Jones- ci tin nm
1992.
- Lupus ban h thng
+ Thng gp n, tr tui.
+ au khp hoc au c l chnh, v tr tng t nh trong
bnh vim khp dng thp. Vim khp trong bnh lupus thng
khng c hnh bo mn trn X-quang.
+ Thng km theo ban cnh bm, nhy cm vi nh nng;
tn thng thn; st ko di, rng tc, mt kinh.
* Chn on theo tiu chun ACR 1982 p dng cho bnh
Lupus ban h thng.
- X cng b

98

+ N , trung nin.
+ a u k h p : cc k h p n h nh b n tay t n g t n h b n h
vim khp d n g t h p .
+ T h n g k m theo h i chng Raynaud v c t n t h n g da
c b i t : d y , cng, r i l o n sc t...
* C h n o n theo t i u c h u n ACR v i b n h x cng b.
- Thoi hoa khp
+ T h n g gp n , t r u n g n i n .
+ a u khp n h b n tay, c b i t khp n g n xa; c t h
t n t h n g c khp n g n gn. C t h c cc h t Heberden (
ngn xa) hoc Bouchat ( n g n gn). N g o i ra, t h u n g a u cc
khp chi u i , c b i t khp gi. a u k i u c hc, c d u h i u
p h ri khp d i 30 p h t . Khp t h n g k h n g c d u h i u v i m .
+ Xt n g h i m : m u v dch khp: k h n g c h i chng v i m
sinh hc, RF t h n g m t n h .
- Gt mn tnh
+ T h n g l n a m gii, t r u n g n i n .
+ Khp sng au cc khp nh nh bn tay, chn, i xng
hai b n .
+ T i n s c t s n g a u cp t n h n g n c h n ci hoc cc
khp chi u i vi t n h c b i t ca cn g t cp. C t h c
h t tophi.
+ C th tm thy tinh th urat ht tophi hoc trong dch
khp; acid uric m u t h n g t n g ( t r n 420 imol/1), c t h k m
cc r i l o n c h u y n hoa ng v/hoc l i p i d m u .
* Chn on theo tiu chun chn on gt ca Bennett v
Wood 1968.
- H i chng P i r r e r M a r i e

99

+ Thng gp nam gii, trung nin.

+ Thung c tin s nghin thuc l, thuc lo; ho khc ko
di hoc ho ra mu.
+ Khp sng au cc khp nh nh bn tay, chn, i xng
hai bn.
+ Ngn tay di trng hoc mt knh ng h l triu chng
rt gi .
* Chp phim X-quang thng pht hin c u ph qun phi,
u trung tht.
* Ct b u khp s ht sng au v mng tay, ngn tay tr
l i bnh thng.
IV. IU TR BNH VIM KHP DNG THP
S ra i ca cc thuc chng thp khp tc dng chmDMARD's Disease Modifying Anti Rheumatis Druds (thuc
chng thp khp c t h lm chuyn bin bnh) lm thay i
tin lng c bn ca bnh vim khp dng thp ni ring v
cc bnh khp khc ni chung (xem thm bi ny). y l mt
nhm thuc c vai tr ht sc quan trng, c t h iu tr "tn
gc" bnh vim khp dng thp, do nhm thuc ny gn y
cn c gi l cc thuc "thay th corticoid" (steroid
sparing drugs).
1. Mc ch iu tr
- Kim sot qu trnh min dch v qu trnh vim khp.
- Phng nga huy khp, bo v chc nng khp, gim thiu
ti a cc triu chng bnh nhn c t h c cuc sng
bnh thng.
- Trnh cc bin chng ca bnh v ca cc thuc iu tr.

100

- G i o dc, t v n b n h n h n , v t l t r l i u v phc h i chc

n n g cho bnh n h n .
2. Nguyn tc iu tr thuc
- Kt hp nhiu nhm thuc: thuc iu tr triu chng
(thuc chng vim, thuc g i m a u ) v thuc chng t h p khp
t c d n g c h m -DMARD's ngay t giai o n u ca bnh). C c
thuc i u t r c t h p h i duy t r n h i u n m , t h m ch p h i
d n g thuc sut i t r n n g u y n tc s n h m thuc v l i u
thuc t i t h i u c h i u qu. R i n g corticoid t h n g ch s d n g
trong n h n g i t i n t r i n .
- Cc thuc iu tr triu chng c th gim liu hoc ngng
h n theo t h t: corticoid, thuc chng v i m k h n g steroid,
gim au.
- Phc thng dng, c hiu qu, t tc dng ph, n
gin, r t i n n h t nc ta l methotrexat phoi hp v i
chloroquin trong n h n g n m u v sau l methotrexat
n c.
3. Lp k hoch iu tr

N h m l p k hoch i u t r , cn t h i t xc n h cc t h n g
s sau:
Xc nh giai on bnh l tin trin hocn nh.
- Xc nh tnh trng tinh thn ca bnh nhn, nht l trong
t t i n t r i n bnh.
- nh gi chc nng vn ng ca bnh nhn v vn ng
ch ng, t h ng.
- Lng ha cc c quan b tn thng.
- L n g hoa cc thuc a n g c d n g .

loi

- nh gi cc tai bin do thuc, c bit khi s dng khng

ng cch.
- Cc tai bin do dng corticoid ko di: tn thng d dy t
trng vi cc tai bin, tng ng mu, long xng, tng huyt
p, hi chng Cushing do corticoid, lao v cc bi nhim khc...
- Cc tai bin do thuc chng vim khng steroid: tn thng
d dy- t trng, thn...
- Cc tai bin do cc thuc iu tr c bn: suy tuy, suy gan,
suy thn, lao v cc bi nhim khc...
4. iu tr ni khoa
4.1. Glucocorticoid
Ch nh dng corticoid: ch thuc thuc chng thp khp
tc dng chm -DMARD's c hiu qu; t tin trin hoc
ph thuc corticoid.
- Nguyn tc iu tr: dng liu tn cng, ngn ngy trnh
huy khp v trnh ph thuc thuc. n khi t hiu qu, gim
liu dn, thay th bng thuc chng vim khng steroid.
Liu glucocorticoid
+ t tin trin nng (c tn thng ni tng nh trn dch
mng tim, mng phi, st, vim nhiu khp...): thng dng
mini bolus: truyn tnh mch 80- 125mg methyl-prednisolon
pha trong 250 mi dung dch sinh l trong 3-5 ngy lin tip. Sau
liu ny, duy tr tip tc bng ng ung vi liu 1,5-2
mg/kg/24 h tnh theo prenisolon.
+ i tin trin thng thng: thng bt u bng liu 11,5 mg/kg/ngy. Gim dn 10% liu ang dng mi tun tuy
theo triu chng lm sng v xt nghim. Khi liu cao, thng
chia ung 2/3 liu vo bui sng v 1/3 liu ung vo bui chiu
Khi liu t 40 mg/ngy tr xung, ung mt lan duy nht vo
102

lc 08g, sau n . T h n g sau 1-2 t h n g , c t h t h a y t h corticoid

b n g thuc chng k h n g steroid.
+ T r n g hp p h thuc corticoid: duy t r 5-7,5mg/24h, ung
l n duy n h t vo lc 08g, sau n .
4.2. Thuc chng vim khng steroid
+ Ch nh ca thuc chng v i m k h n g steroid: giai o n
khp v i m mc va p h i . Ch nh ngay t u hoc sau k h i
d n g corticoid. C t h d n g ko d i n h i u n m k h i cn t r i u
chng vim. L u cc chng ch nh ca thuc.
+ C t h ch nh

m t t r o n g cc thuc sau:

diclofenac

(Voltaren): 100 m g / n g y ; p o x i c a m ( F e l d e n , B r e x i n ) : 20
mg/ngy;

meloxicam

(Mobic):

7,5

mg/ngy;

celecoxib

(Cebebrex ): 200-400 m g / n g y . L i u da t r n n g u y n tc l i u
t i t h i u c h i u qu.
4.3. Cc thuc gim au
+ S dng kt hp cc thuc gim au theo s bc thang
ca T chc Y t t h gii (WHO). i v i b n h v i m khp d n g
thp, t h n g d n g thuc g i m a u bc hoc 2. y l n h m
thuc r t t h n g c ch n h k t hp, v thuc c h i u q u t t ,
t t c d n g p h . C t h ch n h t r o n g cc thuc sau:
+ Paracetamol: 2-3 gam/ngy
+ Paracetamol kt hp vi codein (Efferalgan Codein): 4-6
vin/ngy.
+ Paracetamol kt hp vi dextropropoxyphene (Di- antalvic):
4-6 vin/ ngy.
+ Floctafenin (Idarac) 2-6 vin/ngy (vin nn 200 mg/vin),
ch nh trong trng hp t n t h n g t b o gan, suy gan.

103

4.4. Nhm thuc chng

thp khp tc dng chm MARD's

Thuc chng st rt tng hp.

+ Bit dc: Hydroxychloroquin (Plaquenil vin nn 200
mg) hoc Quinacrin Hydrochlorid (Atabrine vin nn 100 mg).
Liu dng: 200-600 mg/ngy, Vit Nam thng dng 200
mg/ngy.
+ Chng ch nh: bnh nhn c thai- do thuc gy nhng
thiu ht bm sinh nh h hm ch, tn thng thn kinh
thnh gic v thiu ht ct sau... Tuy nhin, mt nghin cu
trn 133 bnh nhn lupus c tn thng da c thai c iu tr
hydroxychloroquin nm 2005 cho thy thuc ny khng gy u
qui v khng gy c i vi ngi m, v vn c th cho con
b. Ngoi ra, chng ch nh vi ngi c suy gim G6PD
(glucose-6 phosphate dehydrogenase) hoc c tn thng gan.
Tc dng khng mong mun: chn n, nn, au thng v;
xm da kh da; vim t chc li vng mc khng hi phc,
gy m. Tuy nhin vi liu thp th t l tai bin cui cng ny
khng ng k, song cn kim tra th lc, th trng, soi y
mt mi 6 t h n g v khng dng qu 6 nm.
- Methotrexat (Rheumatrex)
+ C ch: do methotrexat c cu trc tng t acid lic, c
ch chnh ca thuc l tranh chp vi v tr hot ng ca acid
folic trong qu trnh tng hp pyrimidin,' dn en giam tng hp
ADN. Ngoi ra, methotrexat cn c tnh cht chng vim v c
ch min dch.
+ Ch nh: hin nay y l thuc thuc chng thp khp tc
dng chm - DMARD's hng u c ch nh i vi vim
khp dng thp v thp khp vy nn.
+ Chng ch nh: h bch cu, suy gan, thn, tn thng
phi mn tnh.

104

+ T c d n g k h n g mong m u n : t h n g gp lot m i n g , n n ,
bun n n . C t h gp c t b o gan v tuy.
+ L i u : t r u n g b n h 10 - 20 mg m i t u n (5-20 mg/tun) t i m
bp hoc ung.
+ C h p h m : 2,5 mg/vin, ng t i m bp 10 m g hoc 15 mg.
+ C c h d n g : t h u n g k h i u b n g l i u 10 m g / t u n . T h n g
ung m t l n c l i u v o m t n g y c n h t r o n g t u n . T r n g
hp k m h i u q u hoc k m d u n g n p , c t h d n g ng t i m
bp hoc t i m d i da, m i t u n t i m m t m i duy n h t v o
mt n g y c n h t r o n g t u n . L i u methotrexat c t h t n g hoc
gim t u y h i u q u t c. D n g ko d i n u c h i u q u v
dng np t t . H i u q u t h n g t c sau 1-2 t h n g , do
t h n g duy t r l i u chn t r o n g m i - 2 t h n g m i chnh l i u .
K h i cc t r i u chng t h u y n g i m , c t h g i m l i u cc thuc
k t hp: l n lt g i m l i u corticoid, t h a y b n g chng v i m
k h n g steroid, thuc g i m a u g i m cui c n g . Thuc t h n g
duy t r n h i u n m , t h m c h sut i. Tuy n h i n , sau m t giai
on n nh ko d i , t h n g x u t h i n t n h t r n g " k h n g "
methotrexat. N u k h n g c h i u q u n n k t hp hoc i cc
thuc k h c trong n h m . Thuc k t hp: t h n g k t hp v i
thuc chng st r t t n g hp.
- Cc xt nghim cn tin hnh trc khi cho thuc v kim
tra trong t h i gian d n g thuc:
- T bo mu ngoi vi: ngng thuc khi s lng bch cu
u i 2000/mm3.
- Enzym gan, chc nng gan (t l prothrombin v albumin
huyt thanh).
- Chc n n g t h n (t n h t l creatinin h u y t t h a n h ) .
- Chc n n g h h p : n u b n h n h n c b n h p h i m n t n h
t h k h n g c ch n h thuc n y . N n ch o chc n n g h h p

105

trc khi ch nh methotrexat khng nh l phi bnh

thng. Cn chp l i phi mi khi c cc triu chng h hp.
- Nu bnh nhn l ph n tui sinh , hoc l nam gii c
v mun sinh phi c bin php trnh thai hu hiu. Ngng
thuc t nht trc 2 thng mi c php t h thai.
- Cn b sung acid folic (Liu tng ng vi liu
methotrexat) nhm gim thiu tc dng ph v mu.
- Thng kt hp thuc chng st rt tng hp v
methotrexat. S kt hp ny gim tc dng ph v gan.
- Sulfasalazine (Salazopyrine)
+ Thnh phn: kt hp gia 5-aminosalysilic v sulapyridin
+ Ch nh: do methotrexat l thuc c la chn hng u,
nn ch dng thuc ny khi c chng ch nh i vi
methotrexat hoc c dng kt hp vi methotrexat.
+ Ch phm: vin nn, 0,5 gm.
+ Liu v cch dng: liu 2-3 gam/ngy. Ba ngy u mi
ngy vin, ba ngy tip mi ngy 2 vin, chia 2 ln. Nu
khng thy tc dng ph, duy tr ngy 4 vin, chia 2 ln.
+ Tc dng khng mong mun: ri lon tiu hoa, chn n,
au thng v, ban ngoi da, bng nc, lot ming, protein
niu, hi chng thn h, vim gip trng, gim tiu cu, bch
cu, huyt tn, hi chng dng lupus.
- CyclosporinA(NeoralSandimmume)
+ C ch: c ch vn chuyn ADN v phng nga s tch t
mARN c vai tr to ra mt s cytokin. Thuc cng c ch cc
pha ban u ca s hot hoa t bo T i vi cc i thc bo
lm gim tng hp cc interleukin- 2. Thuc c tc dng c ch
min dch song khng c c tnh i vi tuy xng.

106

+ Ch nh: vim khp d n g t h p t h nng, k h n g p n g

vi methotrexat.
+ C c h d n g : d n g n c hoc k t hp v i methotrexat.
+ L i u : b t u b n g l i u 2,5 m g / k g / n g y , chia 2 l n , cch
nhau 12 gi. Sau 4-8 t u n , n u k h n g c h i u q u , t n g 0,5-1
mg/kg/ngy t r o n g 1-2 t h n g ; cho n k h i t 5 m g / k g / n g y . C n
t h n t r n g v i l i u t r n 4 m g / k g / n g y . L i u an t o n l 2-3
mg/kg/ngy. G i m l i u k h i chc n n g t h n suy g i m . Chng ch
nh k h i b n h n h n c t i n s b n h t h n trc ( t h a n h
t h i creatin u i 80 m l / p h t ) .
+ Bit dc: Neoral vin 25 v 100 mg; Sandimmumeng
100 mg.
Cc tc nhn sinh hc (cc thuc c chcytokines)
L cc t c n h n g y chn hoc t n g t c vi cc chc n n g
ca cc cytokines h o t ng t r o n g c c h b n h sinh ca v i m
khp d n g t h p . c s d n g t i M , P h p v m t s nc
khc, c h a c nc ta. T r o n g s n y , i n h n h n h t l cc
thuc k h n g T N F .
+ Entanercept-Enbreil):ng 25 mg. Liu 25 mg 2 ln mi
t u n hoc 50 m g m i t u n . T i m di da.
+ Inliximab- Remicade:ng 100 mg. Liu 3 mg/kg/ln.
T r u y n t n h m c h c h m (t n h t 2 gi) v o t u n 0, 2 v 6; s
nhc l i m i 8 t u n .
+ Ch nh trong cc trng hp vim khp dng thp nng,
k h n g vi cc i u t r t h n g t h n g k h c ; t h n g v n k t hp
vi methotrexat.
+ Tc dng khng mong mun ng ngi nht ca cc thuc
n y l lao v cc n h i m k h u n c h i .

107

4.5. iu tr ti ch
+ Do hin nay c cc thuc iu tr ton thn tt, cc iu tr
t i ch ny ngy cng t c s dng.
+ Tim cortison t i khp vi cc khp cn vim mc d
c iu tr ton thn.
+ Ct b mng hot dch bng cch dng hoa cht (tim acid
osmic ni khp) hoc bng phng php ngoi khoa (ct ui
ni soi hoc m m): hin t c s dng, c bit t khi c cc
thuc chng thp khp tc dng chm - DMARD's.
4.6. Cc phng php khc
+ Phc hi chc nng: c nhiu bi tp gim cng v au
khp, chng dnh khp. Ngoi ra cn trnh vn ng qu mc
cc khp tn thng, trnh cc ng tc c t h gy ra hoc lm
au khp tng ln. Ngi bnh cn s dng cc loi qun o
mm d mc, qun o ci bng khoa; s dng cc loi nc ung
ng trong hp d m, cc nh, dng c m hp d s dng;
dng tha c cn di v to; giy dp i quai dn... nhm to iu
kin v khuyn khch ngi bnh vn ng v t phc v. cn
cho ngi bnh c thi gian c th thc hin cc thao tc
mt cch bnh tnh. Chm sc cc khp cnh tay, bn tay,
hng dn bnh n h n khi nng vt cn nng bng c hai tay.
Nu bnh nhn au nhiu, c th bng np c bn tay. Vi khp
hng v/hoc gi, nn khuyn bnh nhn nm t t h xp trn
ging cng; nm thng, ng hoc i do, t r n h ng hoc
ngi qu lu; nn dng can chng h tr i vi bn khp au.
+ Y hc c truyn v nc sui khong: trong cc t tin
trin, cc thuc chng vim mnh l cn thit. Song giai on
bnh thuyn gim, c th nc sui khong nng c t h gia tng
tc dng ca phc hi chc nng khp. Chm cu hoc mt s
bi thuc nam (trinh n hong cung, c hot Lai Chu hoc

108

cc thuc c i u c h t h n h vin n n n h H y d a n ,
Vibtin...) c t c d n g chng v i m khp c t h l m t h u y n g i m
t r i u chng vim, g i m l i u cc thuc chng vim, do l m
gim t c d n g p h ca cc thuc n h m n y .
5. iu tr ngoi khoa
Chnh h n h , thay khp n h n to, c b i t l cc k h p b n
tay r t c c h cc nc t i n t i n . Tuy n h i n nc ta ch
thy c cc k h p l n n h k h p gi, khp h n g .
6. Cc thuc trong tng lai gn
Cc n g h i n cu v cc thuc c c h t b o B hoc T n h
Mycophenolat mofetil ( C e l l C e p t ) hoc thuc c c h t b o B
(B-cell depletion: n h R i t u x i m a b (Rituxan ) hoc p h n g p h p
ghp t bao ngun a n g c n g h i n cu cc nc t i n t i n , c
nhiu ha h n trong i u t r b n h lupus v c v i b n h v i m
khp dng t h p . Tuy n h i n , cc thuc n y a n g t r o n g giai
on n g h i n cu.

109

C H N O N V I U TR B N H G T

(GOUT)

ThS. H o n g Vn Dng
I. I CNG BNH GT
1. nh ngha v phn loi
L tnh trng vim khp do s lng ng cc tinh th mui
urat (Monosodium urat - MSU) trong dch khp hoc m.
Nguyn nhn do tng acid uric (AU) mu.
Gt c chia lm hai loi l gt nguyn pht v gt th pht:
- Gt nguyn pht do ri lon chuyn hoa bm sinh hoc
gim kh nng o t h i A U ca thn m khng c tn thng
thc th t i thn.
- Gt th pht c lin quan n cc bnh l khc hoc do thuc.
Trong c hai loi, tnh trng tng AU mu mn tnh c th l
hu qu ca tng sn xut A U hoc gim o thi urat qua
thn hoc phi hp c hai c ch.
2. Dch t hc
Bnh gt thng gp nam gii tui trung nin, nh khi
pht bnh l 50 tui, nhng t l mc bnh tng dn c hai
gii nam v n cc nhm tui cao hn.
T l hin mc gt l 0,7%- 1,4% nam gii v 0,5%- 0,6%
n gii. T l ny tng ln 4,4%- 5,2% nam v 1,8%- 2,0% n
trong tui trn 65. nhng bnh nhn khi pht gt sau 60
tui, t l "mc bnh ca nam v n l gn bng nhau v nu
gt khi pht sau 80 tui th t l n l i cao hn nam. Theo mt
nghin cu nh gi m hnh bnh tt t i khoa c xng khp

no

bnh v i n Bch M a i trong 10 n m (1991-2000) t h g t chim t l

8% (so v i trc y l 1,5%).
3. Bnh nguyn v bnh sinh
3.1. Tnh trng tng acid uric mu
Acid uric m u cao c t h l h u q u ca t n g sn x u t A U
hoc g i m o t h i A qua t h n . 80%- 90% b n h n h n g t
n g u y n p h t c t n h t r n g g i m o t h i A U n i u mc d chc
n n g t h n b n h t h n g , c t h do g i m q u t r n h lc, t n g t i
hp t h u hoc g i m b i t i t , n h n g c c h n o l quan t r n g n h t
th v n c h a c r r n g .
A U m u cao c t h t h p h t sau m t s b n h l: suy t h n ,
bnh l t u y t n g sinh, bo p h .
S d n g m t s thuc n h : v i t a m i n B12, aspirin, cyclosporin,
li t i u thiazid, n g h i n r u .
Khong 10%- 20% b n h n h n g t n g u y n p h t l do t n g
tng hp p u r i n d n n t n g sn sinh A U . C 4 l o i r i l o n d i
t r u y n trong t n g hp p u r i n l: (1) T n g h o t ng men PRPP
synthetase, (2) T h i u men glucose-6- phosphatase, (3) T h i u
men fructose-l- phosphate aldolase, v (4) T h i u men H G P R T .
3.2. Nguyn nhn tng acid uric mu
3.2.1. Tng sn sinh AU hoc urat
- Do ri lon v mt s men do tin pht hoc mc phi: thiu
men (hon t o n hoc m t p h n ) H G P R T ; t n g h o t ng men
PRPP.
- N h n g b n h g y t n g sn x u t n h n p u r i n : b n h t n g sinh
t y v lympho, b n h g y t a n m u , b n h c t n h , b o p h , s
dng thc n hoc thuc (ru, thuc c t b o , w a r f a r i n , thc
n nhiu n h n purin).

IU

3.2.2. Gim o thi uratthn

(c th do tin pht hoc th pht)

Suy thn, tng huyt p, mt mc, bo ph, cng cn gip,

suy gip, s dng mt s thuc (ethanol, li tiu, salicylat liu
thp, cyclosporin, ethambutol, pyrarinamid, levodopa.)
3.3. Qu trnh lng ng tinh thurat v hnh thnh vim do
tinh th
nng di 7,0mg/dl (416 imoV) v pH bng 7,4 AU gn
nh hoa tan hon ui dng ion (+) urat. Khi nng A U trong
mu ln hn 7,0 mg/dl, vt qu nng hoa tan t i a, urat
kt ta thnh cc vi tinh th MSU. Cc iu kin thun li cho
s lng ng v kt ta tinh th bao gm nhit thp ( cc
khp ngoi vi), gim pH dch ngoi t bo v gim kh nng
gn urat ca protein mu. Ngoi ra cn c cc yu t khc nh
chn thng v nng urat t i ch tng nhanh do s huy ng
ca nc t m ngoi vi.
Kh nng gy vim ca tinh th lin quan n kh nng gn
vo cc immunoglobulin v protein, c bit l b th v
lipoprotein. Phc hp ny gn vo c quan th cm b mt i
thc bo v tng bo, dn n hot hoa v gii phng cc
cytokin, yu t hoa hc v cc hot cht trung gian khc. Cc i
thc bo s thc bo tinh th urat v ph huy lysosom gi phng
arachidonat, collagenase, cc gc oxy hoa gy nn tnh trng
vim khp.
3.3. Nhng yu t nguy c
Nhng yu t kch thch lm tng nguy c vim khp cp do
gt: chn thng, phu thut, bt ng, ung ru, nhn i
lu, n nhiu thc n nhiu nhn purin v nhng thuc lm
tng nng urat, ung nhiu ru. Gt tin pht thng lin
quan n bo bu tng m mu, i tho ng, t n g huyt p,
va x ng mch. Gt th pht lin quan n ru, tng sinh
ty xng, bnh do tng sinh m bch huyt.

112

l i . T R I U C H N G LM S N G
1. Vim khp
li Cn in hnh
1.1.1. V tr khp tn thng
Thng gp cc khp chi di nh: ngn chn ci, gi, bn
ngn v cc khp k h c . C t i 75-90% c t n t h n g khp t
b n n g n c h n , c b i t l t r o n g cn g t u t i n (50%).
1.1.2. Hon cnh xut hin
- Cn thng xut hin t pht, khi pht t ngt vo ban
m, sau mt ba n hoc ung ru q u mc; mt chn thng;
mt can thip p h u t h u t ; mt t d n g thuc: aspirin, li t i u
(thiazid, urosemmid), ethambutol, thuc gy huy t bo...
- Nhng t vim khp thng c th t ht sau 3-10 ngy v
ti p h t n h i u t. Do ngi t h y thuc cn khai t h c k t i n s
nhng t vim khp.
- C th c mt s triu chng xy ra trc khi c cn gt cp
n h a u u , a u t h n g v, t i u n h i u , t b n g n c h n . y l
thi i m t t i u t r p h n g nga, k h n g cho cn g t cp
khi p h t .
1.1.3. Tnh cht khp vim
Khp au d di, bng rt, au n cc , au lm mt
ng. a u ch y u v m , ban n g y c g i m a u . T h n g k m
theo c m gic m t m i , i k h i st 38-38,5 c, c t h k m r t
run. a u t n g v m t r o n g 5-6 m t i p .
- Khm: khp b tn thng sng, nng, , au. Nu l khp
ln t h n g k m t r n dch, k h p nho t h n g l s n g n .

113

1.2. Cn khng in

hnh

Vim khp bn cp tnh, tnh cht sng au khng d di,

c th trn dch khp gi n thun.
- Vim nhiu khp cp: du hiu gi l khi pht t ngt,
vim 3-4 khp, thng l chi di. Th ny thng gp trong
giai on tin trin ca bnh.
Biu hin t i cc v tr cnh khp: vim gn, nht l vim
gn Achille, vim ti thanh mc khuu tay.
1.3. Cc biu hin khc
1.3.1. Ht Tphi
Ht Tphi l nhng tinh th MS lng ng sn khp, u
xng, phn mm quanh khp, c bit l Quanh khp gi v
khp khuu, dc theo gn bn tay v bn chn, quanh cc
khp t ngn gn v xa bn tay. Cc ht Tphi thng chc
v di ng, da ph pha trn c th bnh thng hoc mng v
. Khi v ra b mt, cht lng ng trng nh phn v c mu
kem hoc vng nht. Ht Tphi c th xut hin ni khng
lin quan n khp nh vnh tai. Tinh th ny cn c th lng
ng t i mt s v tr khc nhng him.

l ., " '
Hnh 36. Ht Tphi bn tay v
vnh tai

114

1.3.2. Tn thng

khp mn tnh do tinh

thurat

Do t c h l y m u i M S U (Monosodium urat) t r o n g m c n h
khp, t r o n g sn v u x n g l n g u y n n h n g y t h o i h a
sn k h p , h y u x n g v t n g sinh m n g h o t dch.
- V i m n h i u khp, khp s n g k m theo b i n d n g do h y
hoi khp v do h t T p h i . V i m k h n g i x n g k m theo
cng khp.
- X-quang c t n t h n g l cc k h u y t v hc r t gi : d n g
mc c u . H p khe k h p , gai xng, i k h i r t n h i u gai.
1.4. Cc triu chng khc km theo
1.4.1. Biu hin thn
* Si t h n
10-20% b n h n h n g t c si t h n .
T h n g b i u h i n b n g cn a u q u n
i m u .

t h n , hoc ch

- Si k h n g cn quang, ch t h y c t r n u r v v s i u m ,
t h n g hai b n .
* B n h t h n do g t
t gp. Bnh c th c lp, khng kt hp vi si thn.
- Triu chng: protein niu khng thng xuyn v va phi;
i m u , bch cu n i u v i t h . Toan m u c t n g d o m u b i u
h i n k h sm; t h n g k t hp t n g h u y t p .
- Suy t h n : trc k i a , suy t h n t i n t r i n r t hay gp g t ;
c 25% b n h n h n g t t v o n g d o b n h t h n n h n g n g y
nay t l n y g i m d i n h i u .

115

1.5 Xt

nghim

1.5.1. Xt nghim acid uric mu

A U mu tng cao: nam bnh thng t 180 mo - 420
imoM (4,0-8,6 mg/dL). N bnh thng t 150 imol/1 - 360
imoV, (3,0-5,9 mg/dL).
Nu AU mu bnh thng cng khng loi tr chn on v
ngc l i nu AU cao khng c triu chng vim khp cng
khng chn on gt, v c t i 40% bnh n h n ang c cn gt
cp nhng A U bnh thng.
1.5.2. nh lng acid uric niu 24 gi
Vi mc ch hng dn iu tr: nhm xc nh tng tnh
trng bi tit urat (trn 600 mg/24h) hay gim thi tng i
(ui 600 mg/24h). A U niu tng l nguy c dn n si thn v,
khng c dng nhm thuc h A U theo c ch tng o thi.
1.5.3. Xt nghim ch khp
- Dch khp vim, rt giu t bo (trn 2.000 TB li mm ), i
khi > 50.000 T B / l m m ch yu l bch cu a nhn (khng
thoi hoa)
3

- Thy c tinh th MSU, cho php xc nh chn on gt.

y lu .lu chun vng.
1.5.4. Cc xt nghim thng thng
- Tc lng mu, CRP bnh thng, c th tng trong giai
on cp.
Bch cu, tiu cu bnh thng, i khi tng trong cn gt cp.
- Nc tiu:
+ nh gi A U niu, nu tng th nguy c si thn.
+ Protein niu, t bo niu, cn: c th (+).

116

1.5.5. X- quang

khp

- Giai o n u : h n h n h XQ khp ni chung b n h thng.

- Giai o n mun: t n t h n g khuyt, hc t i u xng, hp
khe khp, gai xng do h t Tphi v t h o i ha khp t h p h t .
III. CHN ON BNH GT
1. Chn on xc nh
C h n o n xc n h g t k h i t m t h y t i n h t h M S U t r o n g
dch khp hoc h t t phi. T i n h t h u r a t h n h k i m , lng c h i t
quang, n m trong t b o trong giai o n cp n h n g c t h n h
hn v t h n v n m n g o i t b o t r o n g giai o n gia cc t
cp (xem d i k n h h i n v i p h n cc).

/
1

Hnh 37. Tinh th monodium urat lng chit quang trong dch khp, quan
st di knh hin vi phn cc, (a) t do, (b) trong bch cu a nhn
Tiu chun Bennett v Wood (1968):
a. Hoc tm thy tinh th MSU trong dch khp hay trong cc
htTplii.
b. Hoc t i t h i u c t r n 2 t r o n g cc t i u c h u n sau y :
- Tin s hoc hin ti c ti thiu 2 t sng au ca mt
khp v i t n h cht k h i p h t t ngt, a u d di, v k h i h o n
ton trong vng hai tun.

117

- Tin s hoc hin t i c sng au khp bn ngn chn ci vi

cc tnh cht nh trn.
- C ht Tphi.
- p ng tt vi colchicin (gim vim, gim au trong 48h)
trong tin s hoc hin t i .
Chn on xc nh kh c tiu chun
ca tiu chun

a hoc 2 yu t

b.

2. Chn on phn bit

2.1. Vim khp dng thp
Trong trng hp gt cp tn thng vim khp cp tnh
ch mt s khp c bit chi di th t cn phn bit vi
vim khp dng thp. Tuy nhin trong trng, hp gt mn tnh
c tn thng nhiu khp vi bnh cnh vim a khp th rt
cn chn on phn bit vi bnh l vim khp dng thp.
- Chn on phn bit da vo:
+ Gii tnh (thng nam gii), tui.
+ Tnh cht cc t vim khp cp tnh giai on u (khai
thc k tin s cn gt cp).
+ Tm cc ht t phi vnh tai, bn tay hoc cc v tr khc.
+ Tng acid uric.
+ Hnh nh X quang l hnh khuyt ln xa khp, hnh mc cu.
+ Cng khp bui sng di gi, xt nghim yu t dng
thp thng m tnh.
2.2. Vim khp nhim khun
Do vim khp trong gt c tnh cht cp tnh (sng, nng,
au) nn i khi cn phn bit vi vim khp nhim khun.

118

- C h n o n p h n b i t da vo:
+ H o n c n h x u t h i n : t r o n g v i m khp do n h i m k h u n
thng c ng vo (do t i m , chc, c h m cu, c h n t h n g c
rch da...), t r o n g g t l t p h t .
+ T n h cht cn gt, s t i p h t n h i u l n , m i l n ko d i v i
ngy n t u n l gim.
+ Chc h t dch xt n g h i m t bo, n u i cy v i k h u n v PCR
lao dch khp cng n h t m t i n h t h u r a t t r o n g dch khp.
2.3. Vim khp do tinh th khc
Vim khp ngoi do tinh th MSU, cn c th gp vim
khp do t i n h t h k h c n h calci oxalat, phosphat, do thuc...
2.4. Vim khp phn ng
- Hnh nh vim khp cp tnh, ngn chn hnh khc di cn
p h n b i t v i g t cp. K h i c n k h a i t h c t i n s n h i m t r n g
sinh dc, t i t n i u hay t i u hoa trc t r o n g v i m khp
phn ng.
2.5. Phn bit vi mt s bnh khc nhu: vim m t bo,
vim tc t n h mch chi di....
VI. IU TR BNH GT
Mc tiu iu tr i vi bnh nhn gt bao gm iu tr cn
gt cp; n g n nga cc cn g t t i p theo; i u t r b i n chng do
k h n g iu tr; i u tr h A U m u d i h n n u cn.
1. Chng vim gim au
1.1. Gim au
Acetaminophen/Tylenon hoc cc thuc g i m a u k h c .

119

1.2. Thuc chng vim khng steroids

(CVKS)

Diclophenac, indomethacin, naproxen, meloxicam, celecocib.

C tc dng chng vim trong cn gt cp, sau gim liu t
t khi triu chng vim thuyn gim. Tc dng ph: au d
dy, xut huyt tin ha ... khng dng khi c suy thn.
1.3.

Colchicin

- Liu: 0,5 - mg/ngy. Nu khng png c th ung 0,5

mg mi 2 gi cho ti khi ht vim khp v khi c tc dng ph
(nn, a chy). Tuy nhin khng nn qu 4 mg mi ngy. Cn c
th s dng test chn on. Tc dng ph: a chy, nn, au
bng. X l : cho thm imodium: 2 mg X 2 n 4 vin/ngy.
Ngoi ra c t h gy gim bch cu (him).
1.3.

Cortic oid

- ng ton thn: c th c ch nh iu tr ngn ngy,

ch nh khi iu tr nhng thuc trn khng hoc trong
nhng trng hp bnh nhn c km mt s bnh nh: gan
thn, bnh ng d dy rut v khi c chng ch nh dung
nhng thuc trn. Tuy nhin, tuyt i khng c dng ko
di gy nhiu tc dng ph v lm tng A U v tng nguy c to
ht Tphi.
- Corticoid t i ch: (Depo Medrol, Diprospan, hydrocotison
acetat ... c th tim trc tip vo khp vim). Tuy nhin, cn
c thc hin bi thy thuc chuyn khoa v khng tim qu 3
ln trong mt nm i vi mt v tr.
2. Thuc gim acid uric
2.1. Cc thuc c ch tng hp AU
- Cc thuc nhm ny c ch nh tuy theo lng AU mu
tnh trng ca bnh nhn (tn s cn gt cp, ht Tphi...).

120

- D u y t r thuc n h m n y cho n k h i A U m u t d i 360

mmol/1, t h m c h 320 mmo]/l t r o n g t r n g hp g t m n t n h c
ht Tphi.
- T h n g d n g lin tc t r o n g 1-2 t h n g . Sau , t u y theo
lng A U m u ma chnh l i u . C n h n g t r n g hp p h i duy t r
sut i n u b n h n h n k h n g t u n t h c h n n g h i m n g t ,
AU m u khng v bnh thng.
* A l l o p u r i n o l : b i t dc Z y l o r i c
- C ch:c ch xanthin oxydase
- Ch nh: i u t r d p h n g gt, n h t l t r n g hp c t n g
A U n i u , si t h n . Song k h n g c d n g allopurinol ngay
trong k h i a n g c v i m khp cp v s l m cho t n h t r n g v i m
nng ln. N n i k h o n g m t t u n sau, k h i t n h t r n g v i m
gim, m i b t u cho allopurinol. N u a n g d n g allopurinol
m c t cp, v n t i p tc d n g v i l i u t h p .
- L i u : 100- 200 m g / n g y c t h cao h n t y p ng. K h i
u 100 m g / n g y , sau t n g l n sau 1-2 t u n n u k h n g p
ng i u t r . i vi n g i gi, l i u k h i u : 50 m g / n g y . i
vi n g i suy t h n : cn g i m l i u .
- Tc dng ph:
+ Cn g t cp do g i m acid uric m u t ngt.
+ T n g n h y cm da: ban, sn nga, m day, shock p h n v .
+ Vim mch mu, vim gan (him).
+ N n t h n t r n g k h i b n h n h n g i m chc n n g t h n v s
l m t n g nguy c t c d n g p h t r n . K h n g d n g k h i a n g s
dng amoxicilin, l m t n g nguy c d ng.
* F e b u x o s t a t : l thuc c ch x a n t h i n oxidase mi, c n h i u
u i m h n allopurinol. Thuc chuyn hoa t i gan n n c t h
d n g cho b n h n h n suy t h n n h n va. Thuc h i n nay

121

LUPUS BAN H THNG

PGS. TS. Nguyn Vnh Ngc

I. I CNG
Lupus ban h thng (LBH) l bnh l c tn thng a h
thng v c c trng bi s c mt ca khng th khng
nhn v nhiu t khng th khc. LBH l mt bnh kh ph
bin. khoa Khp Bnh vin Bch Mai, L B H ng hng th 5
trong s 15 bnh xng khp ni t r thng gp nht. Tui mc
bnh trung bnh 30, thng t 16-50 tui, song c th mi la
tui (tr em, ngi c tui). Bnh xy ra ph n nhiu hn (t l
n/nam l 9/1). Nguyn n h n ca bnh c th l hu qu ca s
tc ng qua l i gia yu t di truyn, ni tit, mi trng sng
(thuc, tia cc tm, nhim trng, vus ni sinh...). C ch trung
gian l cc t khng th v c th l phn ng tng nhy cm
chm vi trung gian t bo.
li. TRIU CHNG
1. Lm sng
LBH khng phi l mt cn bnh n c, biu hin rt a
dng, t biu hin nh trn da, tn thng khp cho n suy
thn tin trin nhanh, co git, nhng tn thng thn kinh v c
th gy m loa. Nhng triu chng m thy thuc iu tr
thng gp na l triu chng mt mi ko di, tng huyt p,
tng m mu, long xng, i tho ng, bnh mch mu no.
1.1. Ton thn
St l triu trng thng gp nht (50-80% cc trng hp).
St bao gi cng km theo mt mi v gy st.

124

1.2. C xng

khp

B i u h i n 90 -100% t r n g hp. C t h ' n h i u d n g t n

t h n g c x n g khp.
- C : v i m c gy a u c, g i m c lc, t n g enzym c, sinh
thit c c t h m n h i m t chc k. L o n dng c. a u c gp
trong 50% cc t r n g hp, t h n g i k m theo cc t r i u chng
ton t h n v cc b i u h i n k h p .
- X n g : hoi t u xng: 10% t r n g hp theo t i l i u
nc ngoi.
- K h p : c h i m 90% cc t r n g hp. a u khp n t h u n : gp
trong 1/9 bnh n h n , t h n g gp cc khp nh, nh, i x n g
2 bn. Vim n h i u khp cp, b n cp, hoc m n t n h . T h n g
vim khp hai b n , c t n h c h t i xng. V t r c n g t n g t
n h vim khp d n g t h p song k h n g c huy h o i khp. T u y
nhin cn c b i t c h b i n chng v i m khp n h i m k h u n ,
thng gp khp gi, do cc v i k h u n sinh m , g r a m d n g
v m .
1.3. Da v nim mc
Chim 70%. 1/4 bnh nhn bt u bnh bng cc triu
chng ngoi da, n h n g c n g c 1/4 b n h n h n l i k h n g c b i u
hin da trong sut q u t r n h b b n h . Ban c n h b m : l t h
lupus da cp, t h n g x u t h i n k h i ra n n g . Ban phang, m u
hng, d n g c h m sn, t p t r u n g t h n h m , n h y c m v i
corticoid, c t h b i n m t h o n t o n hoc l i cc d t t h m
sau i u tr. Ban m n y t h n g c t n h c h t ly t m , t i n l n
t r n , d i tai, vai. Ban c t h x u t h i n l i t r o n g t t i n t r i n .
Nhy cm v i n h n n g . B a n d n g a (gp ch y u t r o n g lupus
m n t n h ) . l cc m n g ban k h u t r , n c hay n h i u
vng, sn, bong v y , t h n g c m t , t a i , da u , t h n . Lot
ming, m i : cc v t lot, h o i t v k h u n v n g m i hng. H i
chng Raynaud (20-30%). T r o n g mt s r t t cc t r n g hp c

125

th gy bin chng lot cc u ngn. Cc tn thng vim

mch: ban , ph quanh mng, u cc ngn tay, m ci, m
t, mng xanh tm hnh li, lot bp chn, hoi t u ngn.
1.4. Thn
Chim 70-80% trng hp. Ch yu l tn thng cu thn.
Nhng biu hin thn l nguyn n h n gy t vong th hai
trong LBH. Cc biu hin thn a dng, bao gm: hi chng
thn h, suy thn, i protein, i mu vi th.
1.5. Thn kinh-tm thn
Chim 30-40% cc trng hp, biu hin phong ph, l
nguyn nhn th ba ca t vong sau bin chng nhim trng v
tn thng thn. Cn ng kinh ton th: 15% cc trung hp,
p ng tt vi cc thuc chng co git v corticoid. au u v
cn Migrain, ngt, t qu. Tn thng thn kinh s no, thn
kinh ngoi bin, lit do vim tuy ct ngang, ma vn: him gp.
Cc biu hin tm thn: chim 40-50% cc trng hp. Bao gm
tnh trng lon thn hay cc biu hin tm thn cp hay mn.
1.6. Tim mch
C ba lp tim u c th b, thm ch c mch vnh.
Vim mng ngoi tim: trn dch mng tim ton th, i khi
ch biu hin bng ting c mng tim, khng bao gi li di
chng vim mng ngoi tim co tht. Ch biu hin trn lm
sng trong 20-30% cc trng hp nhng ln ti 60% trn siu
m tim; vim ni tm mc Libman-Sack. Trn lm sng thy
ting thi van hai l hay van ng mch ch. C th gy bin
chng suy tim sung huyt hay b Osler; vim c tim (5%):
thng khng c biu hin lm sng m c pht hin bng
siu m. Thng gy lon nhp tim, block dn truyn, t khi c
lon nhp hon ton; huyt khi ng-tnh mch (8-20% cc

126

t r n g hp). Hay gp v n g t n h m c h cc chi, cng c t h

t n h m c h cc t n g , t n h mch ch. T n t h n g mch v n h b i u
h i n b n g cn a u t h t ngc hay n h i m u c t i m . c t n h hay
t i p h t ca n h n g h u y t k h i n y gi s c m t ca cht
chng n g l u h n h lupus hay k h n g t h k h n g phospholipid;
t n g h u y t p : gp t r o n g 15-70% b n h n h n , do suy t h n hay
d n g corticoid.
1.7. Phi - mng phi
T r n dch m n g p h i m t b n hay hai b n gp t r o n g 25-50%
bnh n h n , t h n g t i p h t t r o n g 10% cc t r n g hp. V i m
phi lupus k h n g i n h n h , t r i u chng r m r (2-10%).
1.8. Mu
G i m bch cu: t h n g gp trong m t giai o n t i n t r i n
ca bnh (20-80%), c h y u l g i m lympho b o , l d u h i u
quan t r n g trong c h n o n ; t h i u m u : gp t r o n g 25-30% b n h
n h n , t h n g l t h i u m u k i u v i m , t h i u m u h u y t t n v i
test Coombs d n g t n h ; g i m t i u cu: gp t r o n g 10-15% cc
trng hp. y l g i m t i u cu ngoi b i n , do n g u y n n h n
min dch. G i m t i u c u mc va p h i , t 50100.000/mm ; hch to: gp t r o n g 20-60% b n h n h n , gan to
(40%), lch to h i m gp h n (10-20%).
3

1.9. Tiu ho

t
Ri lon chc n n g gan, c chng. V i m t u y cp. Ri l o n
tiu hoa.

1.10. Mt
V i m v n g mc, x u t t i t v n g mc (10%); v i m k t mc; h i
chng Sjogren: x teo t u y n l , t u y n nc bt.

127

2. Cc xt nghim cn lm s n g
Nhng xt nghim sinh hc va c gi tr chn on ln gi
tr tin lng v c th ni ln c tnh tin trin ca bnh.
2.1. Hi chng vim
Tc lng mu tng cao trong cc i cp ca bnh (80100% cc trng hp). Protein c phn ng tng t trong cc t
tin trin, nu thy cao nhiu phi ngh n bin chng
nhim khun.
2.2. Hi chng min dch
- LBH l bnh h thng hay gp nht, c tn thng ni tng
nhiu nht, bt thng v min dch phong ph nht trong
nhm. C mt cc khng th khng nhn, c hiu vi mi the
bnh (98% cc trng hp), c pht hin bng phng php
min dch hunh quang gin tip. Hunh quang trong LBH
thng l kiu ng nht hay lm m. Cc khng th khng
ADN t nhin (chui kp ca ADN): gp trong 70-90% cc bnh
nhn LBH. y l mt test rt c hiu cho lupus. Ngi ta s
dng phng php min dch hunh quang gin tip trn
Crithidia luciliae, hay t bo biu m ngi (Hep), hoc phng
php min dch phng x hay ELISA.
Cc khng th khng phospholipid: 10% bnh nhn lupus
c huyt thanh giang mai (BW) dng tnh gi. 20% c cc cht
chng ng lu hnh lupus v 30% c cc khng th khng
cardiolipin v khng beta2 GPI. S c mt ca cc t khng
th ny gi hi chng khng phospholipid. S c mt
antiprothrombinase (cht chng ng lupus) biu hin bng
thi gian cephalin hot hoa ko di song khng biu hin bng
chy mu m gy tc nghn mch.

128

- C c test Latex, Waaler-Rose d n g t n h trong 30% t r n g

hp. C c lupus c y u t d n g t h p t h n g t b t n t h n g t h n
hn cc lupus k h n g c y u t n y .
IM. C H N O N
1. C h n o n x c n h
p dng tiu chun ACR (American College of Rheumatology)
1997 (t 96% nhy v 96% c hiu) n h sau:
1. Ban h n h c n h b m m t
2. Ban d n g a m t v t h n
3. N h y cm vi n h n n g
4. Lot m i n g hoc m i hng
5. Vim a khp k h n g c h n h b o m n
6. Vim m n g t i m hoc m n g p h i
7. T n t h n g t h n : protein n i u > 500mg/24h hoc t b o n i u
(c t h l hng cu, hemoglobin, t r h t , t b o ng t h n h o c
hn hp).
8. Tn thng t h n kinh - t m t h n khng do cc nguyn n h n khc.
9. Ri l o n v m u :
- T h i u m u h u y t t n c t n g hng cu l i
- Hoc g i m bch cu < 4.000/mm

- Hoc g i m lympho b o < 1.500/lmm

- Hoc g i m t i u cu < 100 0 0 0 / m m

10. R i l o n m i n dch:
Khng th khng ADN

129

- Hoc khng Sm
- Hoc tm thy khng th antiphospholipid da trn:
a. khng th anticardiolipin loi IgG hoc IgM
b. Yu t chng ng lupus
c. Test huyt thanh giang mai dng tnh gi ko di
trn 6 thng, c xc nhn bng test c nh xun khun hoc
hp th khng th xon khun bng phng php min dch
hung quang.
l i . Khng th khng nhn: t gi bt thng ca khng th
khng nhn bng phng php min dch hunh quang hoc cc
th nghim tng ng, khng c cc thuc kt hp c th gy
"lupus do thuc". C h n o n x c n h k h i c > 4 t i u chun.
2. Chn on phn bit
Cn chn on phn bit vi cc bnh c tn thng cc khp
nh nh v tuy theo triu chng no ni bt th phi chn on
phn bit vi cc bnh thng c tn thng nh: thp khp
cp, vim khp dng thp, cc bnh to keo khc (x cng v ton
th, vim da v c), xut huyt gim tiu cu, cc bnh c tn
thng thn, mng tim, mng phi do cc nguyn nhn khc.
3. Cc th lm sng
3.1. Cc th lm sng
Tin lng ph thuc vo cc th lm sng
Th cp tnh: biu hin tn thng nhiu ph tng. Tin
trin nhanh, t vong sau vi thng do cc tn thng thn,
thn kinh, tim, phi, nhim khun.
Th mn tnh: t tn thng ni tng, din bin chm. Biu
hin ngoi da nh, tin lng tt.

130

Th bn cp: t i n t r i n t n g t, n n g d n . Sng s t sau 510 n m . B n h n n g t h m trong t h i k t h a i n g h n , n h i m

k h u n p h , c h n t h n g , p h u t h u t . T h n g t vong do b i n
chng t h n , t h n k i n h , n h i m k h u n .
4. Nhng hi chng lupus khng in hnh
- H i chng k h n g phospholipid (antiphospholipid syndrom):
l s k t hp cc h i chng: h u y t k h i n g - t n h m c h ,
xy t h a i lin t i p , g i m t i u c u m i n dch, t h a y i v cc
k h n g t h trc t i p chng l i cc t h n h p h n phospholipid t
bo. H i chng n y c t h l p h n trong n h n g b i u h i n ca
L B H , n h n g cng c t h l d n g c h n h ( k h n g c cc b i u h i n
l m s n g k h c ) ca lupus B H T . T n sut mc h i chng
k h n g phospholipid v o k h o n g 30% n h n g b n h n h n lupus.
- Lupus do thuc:
Thng

do

cc

thuc:

hydralazin,

procainamid,

D-

penicillamin,
Quinidin,
Rimion,
P-bloquants
(Sectral),
Methyldopa, Largactil, Sulfasalazin, Tegretol, interferon, k h n g
gip t r n g tng hp... T l n mc bnh t h n . B i u h i n l m
sng t h n g l lupus da hay khp phi hp vi cc d u h i u t o n
t h n . Hay gp n h n g b i u h i n n h u m p h i v c t r n dch
m n g phi hay t r n dch m n g n g o i t i m . H i m k h i c t n
thng t h n hay cc t n t h n g t h n k i n h t r u n g ng. K h i
ngng iu t r cc thuc g y bnh, cc d u h i u l m s n g h t i
trong v i n g y hoc v i t h n g . i k h i p h i d n g t h m corticoid.
IV. IU TR
1. Nguyn tc iu tr
- P h i n h gi cc t n t h n g , mc n n g n h ca b n h ,
cc bnh k m theo, q u y t n h b i n p h p i u t r . i u t r
cp cu p h i t ra cho cc t r n g hp b n h n n g .

131

- Qu trnh iu tr bao gm: iu tr cc t tin t n n v

iu tr phng cc t ti pht bnh. p dng iu tr tuy theo
tng c th.
- Thng hay s dng cc thuc c ch vim hay thuc can
thip vo chc nng min dch. c n phi cn nhc nh gi
c tc dng ph ca thuc (tng huyt p, nhim khun,
long xng...).
- Hin nay vic iu tr bao gm cc thuc sau:
1. Thuc chng vim khng steroid (CVKS): mi thuc trong
nhm ny.
2. Corticoid: liu tuy mc nng nh ca bnh, cho php ci
thin tin lng ca bnh ng k.
c
3. Cc thuc chng st rt tng hp (CSRTH): c coi l thuc
iu tr c bn ca bnh.
4. Thucc ch min dch: ch nh trong cc th nng
5. Cc thuc khc (Danazol, globulin min dch, Dapson...)
2. iu tr c th lupus ban h thng
2.1. iu tr theo th
i vi th lnh tnh: l th khng c tn thng cc ni
tng e doa n tnh mng. Cc thuc ch nh bao gm: CVKS
v chng st rt tng hp. giai on tin trin, ch nh thm
corticoid liu nh (10-20 mg/24h), ngn ngy.
- i vi th nng: l th c tn thng cc tng quan trng,
thng l cc thn. S dng corticoid liu cao: 1-2 mg/kg/24 h.
Khi bnh c kim sot, gim liu 10% mi tun. en khi t
20 mg/24h th gim chm hn. C th dng liu gp i cch
ngy. Kt hp vi thuc chng st rt tng hp. Trong trng
hp bnh nng va c th ung hng ngy azathiopnn 5-

132

2,5mg/kg/24h. K h i b n h n n g , e doa t n h m n g hoc c x u

hng t n g t n t h n g c quan cn d n g l i u cao corticoi p h i
hp vi thuc c c h m i n dch k h c .
- T r n g hp t n t h n g n i t n g e doa t vong, d n g bolus
(pulse therapy) vi methylprednisolon. Sau duy t r t i p b n g
liu 30-40 mg prednison. L i u p h p t r n t h n g t t v i t n
thng t h n , song t k t qu i v i t n t h n g t m t h n k i n h .
Khi khng c h c bnh, g i m d n l i u corticoid. T h n g k t
hp d n g thuc chng st r t tng hp. Cng c t h d n g bolus
cyclophosphamid 10-20 mg/kg/24h t r u y n t n h mch 3-4 t u n
mt l n hoc d n g ng ung 1,5 - 2,5 mg/kg/24 h. N n k t hp
mesna (Uromitexan) d p h n g b i n chng b n g quang.
tr kt hp: tuy theo tng trng hp c th m s dng
cc thuc k h n g sinh, chng ng, h p , an t h n k i n h . . . C t h
phi hp lc h u y t t n g , cyclosporin A, Mycophenolat mofetil
cng t h y h i u q u t r o n g t h c t n t h n g t h n .
- Ghp thn khi tn thng thn gy suy thn khng hi phc.
2.2. iu tr theo triu chng
- St: c th dng cc mt trong cc loi thuc: aspirin,
CVKS, corticoid.
- au khp: tuy theo mc au c th dng mt trong cc
thuc sau: aspirin, chng v i m k h n g steroid (CVKS), thuc
chng st r t tng hp. N u c b i u h i n v i m k h p r t h c t h
d n g t h m corticoid.
- Ban da: dng corticoid ngoi da, kt hp vi CSRTH.
- Vim mng phi, mang ngoi tim: png tt vi thuc
CVKS hay corticid.
- Tn thng phi: dng corticoid.

133

- Tng huyt p: dng cc thuc li tiu, chn beta giao cm,

c ch men chuyn hay cc thuc khc
- Gim tiu cu, thiu mu huyt tn: dng corticoid rt c
hiu qu. Trng hp b khng corticoid hay ph thuc corticoid
c the dng cc thuc khc nh danazol, dapson hay tim
truyn vinblastin. Nhng thng p dng ct lch, sau tim
vaccin khng ph cu. Truyn gamma-globulin min dch,
thng rt c hiu lc ngn hn, ch c dng khi gim tiu
cu nng v chun b cho phu thut, c bit ct lch.
- Tn thng thn: dng corticoid, thm ch bolus corticoid.
Nu khng hiu qu c th s dng thuc c ch min dch
(bolus tnh mch). Nu bnh nhn c vim thn giai on cui,
cn c k hoch chy thn nhn to hay ghp thn.
- Tn thng thn kinh trung ng: c th dng corticoid
hoc thuc c ch min dch.
- Cn Migrain: propranolol.
2.3. iu tr kt hp v mt s tnh hung c bit
Long xng do dng corticoid: cc bnh nhn lupus hay
dng corticoid liu cao ko di nn hay c bin chng long
xng, c bit l trn bnh nhn n c tui. C th lm gim
tc dng ny bng cch cho calci hng ngy (lg/ngy) v
vitamin D. c n theo di calci mu v niu trnh bin chng
si thn.
- Hoi t v khun u trn xng i: cng gp trong lupus
c bit trn bnh nhn c vim mao mch v/hoc hi chng
Raynaud v dng corticoid ko di. P h t hin sm s lmg gim
nguy c phi phu thut chnh hnh.
- Cc bnh c do corticoid: cng hay gp. C th phng nga
bng cc bi luyn tp c chi. Trnh cc ch phm corticoid
cha Fluo cng nga c bin chng ny.

134

- L B H p h i p h u t h u t : n u b n h n h n a n g d n g corticoid
trc , t h l i u thuc corticoid v n p h i c duy t r t r o n g lc
p h u t h u t . L c t h n g d n g ng t n h mch t r o n g lc g y
m v t i p tc duy t r t r o n g k h i m vi l i u 200-300 m g
hydrocortison hoc 50-60 m g methylprednisolon. Sau v i n g y ,
k h i d n g c ng ung, c t h quay l i l i u trc k h i m
m k h n g c n p h i g i l i u cao.
- Lupus v t h a i n g h n :
T h a i n g h n l m n n g t h m b n h lupus (c b i t l n n g
t h m t n t h n g t h n ) v d g y sy t h a i , non, t h a i cht l u .
V vy ch k h u y n m t p h n mc b n h lupus c t h a i t r o n g cc
iu k i n sau: p h i k h n g c cc d u h i u t i n t r i n b n h v
lm s n g v c n l m s n g t r o n g 6 t h n g n n m l i n trc
. Chng ch nh t r n n g u y n tc p h n c t h a i k h i b
lupus ban h thng: t h a n h lc ( t h i ) c r e a t i n i n <50
ml/pht. T n g h u y t p n n g . T n g p lc n g m c h p h i .
Bnh van t i m k h n g b . C t i n s h u y t k h i r. P h thuc
corticoid >0,5 m g / k g / n g y . Trong k h i c t h a i p h i theo di n h
l t h a i n g h n c n h i u nguy c. Trong cc t h n h , corticoid
c d n g vi l i u 0,2-0,3 m g / k g / n g y . N u b n h n h n a n g
d n g corticoid p h i theo di i u t r v t n g l i u do t h a i n g h n .
Nu bnh n h n k h n g d n g corticoid t h t r o n g 3 t h n g cui
phi cho corticoid l i u 0,5 mg/kg/24h, hoc t r o n g t r n g hp x y
thai
hay
no
thai.
Hin
nay
vn
cho
tip
tc
hydrroxychloroquin, c b i t t r o n g t i n s c b n h t h n . Trong
cc lupus t i n t r i n v n u t h a i n g h n c theo di, c t h
d n g azathioprin hay cyclosporin A . Sau k h n g n n g i m
liu corticoid t r o n g v i t h n g . N h n g b m b l u p u t c i u
tr bng corticoid hay cc thuc chng st r t t n g hp v n c
t h cho con b . V n t r n h thai: k h n g n n d n g d n g c t
cung v c nguy c n h i m t r n g . N n d n g thuc t r n h t h a i l i u
cc t h p ( L u t e r a n 5, Androcur, Androan). Chng ch n h d n g

135

thuc trnh thai trong trng hp tin s c huyt khi, khng

th chng ng lu hnh hoc phn ng BW dng tnh gi.
V. THEO DI V TIN LNG
Lupus l mt bnh t min dch h thng mn tnh c cc t
tin trin bnh v lui bnh. Bnh c rt nhiu c im lm
sng c khi biu hin rt nh nhng cng c khi bnh tin trin
r t nhanh dn n t vong. Thng gp cc i tin trin trn
nn mn tnh. Tuy nhin, xp x 20% s bnh nhn c thi gian
lui bnh trung bnh 5 nm, mt s c thi gian lui bnh ko di
hng chc nm. Ngy nay hu ht nhng bnh nhn LBH t
vong thng do bin chng nhim t r n g c hi (33%), suy thn
mn tnh (18%), bin chng no-mch mu (10%) ch t khi do
chnh bn thn n. Nhim khun, suy thn thng l nguyn
nhn t vong trong thp nin u ca bnh. Tc mch thng
l nguyn nhn cht trong thp nin th hai. D phng cc t
tin trin c p dng trong cc giai on lui bnh. Cc bin
php phng v: t r n h nh nng trc tip v c ch dinh
dng thch hp; cn thn khi dng cc loi thuc d gy mn
cm, nht l khng sinh; phng nhim khun (bnh nhn
lupus c nguy c nhim khun cao, c bit trong trng hp c
suy thn, bt thng van tim, phi dng liu cao corticoid hay
cc thuc c ch min dch k h c . ) trong mt s trng hp c
th tim vaccin phng bnh; phi khuyn ngi bnh dng
phng php trnh thai ngay t ln khm bnh u tin. Khi
bnh khng hot ng cn m bo ti a chc nng cc c
quan, trnh dng thuc c ch min dch.

136

Hnh 39. Ban dng a mt

Hnh 38. Ban hnh cnh bm

mt

Hnh 40. Lot nim

mc hng

Hnh 41. Tn thng cu thn

trong lupus
Hnh 42. Pht hin khng th
khng nhn bng phng
php min dch hunh quang

137

BNH X CNG B TON T H

PGS. TS. Nguyn Vnh Ngc

I. I CNG
X cng b ton th (XCBTT) l bnh h thng thng gp
ng th hai sau lupus ban h thng. y l mt bnh t
min dch, c trng bi tnh trng x hoa da v m di da do
tn thng cht c bn ca thnh phn to keo da l ch yu.
Cc yu t bnh sinh chnh l cc yu t ni tit, di truyn, mi
trng. N g i t a pht hin nhng gia nh c nhiu thnh
vin b XCBTT hoc cc bnh t min khc. Bnh xut hin
nhiu hn nhng ngi th m vng v m than so vi ngi
khng lm ngh m gi rng bi silic c th l mt yu t
khi pht. Trong XCB s dy v mt n hi ca da l do tng
sinh v tch ng qu mc collagen da v t chc ui da.
li. LM SNG V XT NGHIM
1. Triu chng lm sng
l mt bnh ton th ca m lin kt, c ri lon a h
thng, c trng bi nhng tn thng da, mch mu v ni
tng, ch yu l thc qun, phi, tim, v thn. Bnh thng gp
n (80%), la tui 40-50. Cho ti nay, cha c phng php iu
tr tht hiu qu, nn vic chn on sm l v cng quan trng,
nhm ngn chn kp thi tc tin trin ca bnh, phc hi chc
nng cho bnh nhn. Bnh t tn thng ni tng hn cc bnh
khc trong nhm. Din bin mn tnh, ko di, trn c s cc t
cp tnh. Tin lng kh d on, c th t vong t ngt do tn
thng c tim.

138

1.1. Hi chng

Raynaud

R t t h n g gp, c m t 85-100% trng hp. X u t h i n sm

v n n g . C t i t r n 90% b n h n h n X C B T T c b o trc
bng h i chng Raynaud (thng l k h n g i n h n h ) , c k h i t
t r n 10 n m trc. H i chng n y t h n g b t u cp, n h i u
t, vi n h n g lon dng u n g n , n h i u k h i c t a i , m i ,
c t h l i so. v m t l m s n g bnh n h n t h y t , m t cm
gic cc u chi, chut r t , r i lon v n mch, hoc c cc giai
on in h n h : co mch (bn tay t r n g bnh); g i n m c h gy
huyt: tm, a u nhc; tr l i b n h thng. T r i u chng nng: tc
mch, hoi t, lot u chi.
1.2. Tn thng da (100%)
T h u t ng x cng b c d n g ch t n h t r n g b n h l
da, k h u t r hay lan toa, t r o n g da cng l i , g i m hoc m t
tnh co d n . T n t h n g ca da v m d i da t r o n g X C B T T l
t r i u chng quan t r n g n h t c h n o n b n h k h i k h m l m
sng, t h n g qua 3 giai o n : p h n (35% cc t r n g hp), t i p
l cng hoc x, v cui c n g l teo. T n t h n g da t h n g
thy m t , tay, t h n . T r i u chng m t r t i n h n h : b m t
v cm, vi cc chi k h n g k h i u n h xc p. t h n g l t h
tin t r i n nhanh, mau d n n t vong. N g o i ra, c r i l o n sc
t v bch b i n , c h n h n h " k h m x c" da. X cng n g n
tay, m n g n t v gin n n b n tay co qup. Lot da u
ngn v m u tay do t h i u d i n h dng. Vi hoa t chc da, g n v
u ngn. X hoa lan ln cng tay, c n h tay, m t v t o n t h n .
P h cng m t , c, gc chi k h n g u (li lm).
1.3. B my vn ng5%)
a u m i c, teo c, g i m c lc gc chi, v i m c. X n g khp:
a u , v i m , d n h cng khp; t i u x n g cc khp n g n tay, u
xng t r .

139

1.4. Tiu ho
Thc qun tn thng sm, kh nut, nc bt (35% cc
trng hp). Nim mc 1/3 trn thc qun x cng, gim co bp,
hp, lot. D dy, rut: au bng, chung bng, a chy, hi
chng km hp thu, sa d dy, hp mn v, rut km nhu ng.
Gan, lch, hch t b tn thng.
1.5. Phi (25%)
X phi k lan toa, hu qu l ri lon thng kh phi xut
hin sm v thng gp. Tng p lc ng mch phi nguyn
pht hoc th pht sau x phi. Tm ph mn.
1.6. Tim (15%)
Bnh x c tim (suy tim, ri lon nhp), c th gy t t. Suy
tht phi do bin chng tm ph mn tnh. Vim mng ngoi
tim (mn tnh, khng bin chng).
1.7. Thn
Suy thn cp. (t ngt, km tng huyt p c tnh) do x cc
ng mch thn. Nh: protein niu (10%).
1.8. Mt
Tn thng y mt (x ng mch)
2. Xt nghim
Hi chng vim sinh hc: biu hin bng tc lng mu
cao, tng nng brinogen... Cc ri lon v mu: thiu mu
huyt tn, gim tiu cu, bch cu... Sinh thit da: thng lm
vng mt trc ngoi cng tay, dnh cho nhng trng hp lm
sng nghi ng. Hnh nh vi th di knh hin vi quang hc
thng c m t l thng b c th bnh thng hoc teo i
nhng trung b bao gi cng dy ln nhiu do s tng sinh ca
140

cc si collagen, k h i n mao mch b cht hp, ng t h i l m cho

khong cch t t h n g b t i h b rng ra; lp t r u n g b c s
xm n h i m r i r c cc t b o vim. Cc t h n h p h n lng, t u y n
b, t u y n m hi t h a tht.
HI. C H N O N
1. C h n o n x c n h
H i n nay t i u c h u n chn o n X C B T T ca H i t h p khp
hc M (ACR) 1980 c d n g p h b i n t r n t h gii, bao gm
cc tiu c h u n sau:
Tiu chun c h n h : x da v n g gn
Tiu chun ph:
X da u chi
- So n g n tay hoc v t lot u n g n tay
- X p h i v n g y
Chn on dng tnh k h i c tiu chun chnh, h o c
c 2 t i u c h u n p h .
2. T h l m s n g
2.1. Th lan toa (ton
2.2. Th khu

thn)

tr

H i chng CREST:
- Calcinose: calci hoa t chc d i da u chi
- Raynaud: h i chng Raynaud
- Oesophagienn (atteinte): t n t h n g thc q u n

141

- Sclrodactilie: XCB u ngn tay

- Tlangiecsies: cc chm ban mt.
2.3. Th kt hp
- Hi chng Gougerot - Sjogren (hi chng kh):
- Vim khp + teo x tuyn l v tuyn nc bt.
IV. IU TR
1. Cc thuc iu tr x cng b ton th
Trong rt nhiu thuc c ngh, ch c D-penicillamin,
thuc chn calci v c ch men chuyn l t ra c hiu qu nht.
Cc thuc c s dng iu tr gm:
- D- penicillamin ung liu tng dn ko di nhiu thng.
- Corticosteroid: ung liu trung bnh, sau duy tr liu thp
khi c triu trng khp, c, phi.
iu tr hi chng Raynaud: dng thuc chn calci,
reserpin...
iu tr triu chng khi c tn thng cc ni tng (thn,
tim, phi, tiu hoa, nhim khun...).
Gi v sinh, chm sc da, u ngn, iu tr sui khong.
iu tr ton thn:
- D- penicillamin (bit dc l Trolovol): l thuc duy nht
dc khuyn dng hin nay. Thuc c th lm gim dy ca
da v phng nga cc tn thng ni tng. Thuc cng c tc
dng c ch min dch. Liu dng: bt u bng liu ung 250
mg/ngy trong 2-3 thng (vin 125 mg, 250 mg), tng n liu
ti a, t n 750-1250 mg/ngy trong 12-24 thng. Nu t
hiu qu, khng c cc biu hin da, s gim chm liu cho n

142

k h i t l i u duy t r 250 m g / n g y . T c d n g p h : x y ra t r o n g
khong 30 - 40% cc t r n g hp, bao gm: st, c h n n , n n ,
p h t ban, h bch cu, t i u cu, t h u m u do suy tuy, h i chng
t h n h , nhc c nng. Do v y 1/4 b n h n h n p h i ngng
thuc. C c t c d n g k h c , c b i t n h k h chu v d d y , r u t ,
st, p h t ban s t gp hn n u d n g thuc theo k i u "i n h , i
chm". P h i theo di lng bch cu, t i u cu t r o n g m u v
protein n i u .
- Corticoid:
c d n g v i mc ch g i m m i n dch, song k t q u k h n g
r r n g . Thuc c h i u q u v i p h n n g v i m k h p , c v
phi, v i m m n g n g o i t i m cp song k h n g c h i u q u vi cc
tn t h n g n i t n g v t i n lng chung ca bnh. K h i x u t
hin t n t h n g p h i c y u t v i m r r t c p h t h i n qua
ni soi p h q u n v p h n t c h dch ra p h q u n p h n a n g n g i
ta c t h d n g corticoid l i u cao (60 - 80 m g p r e d n i s o l o n / n g y
chia n h i u l n ) trong t h i gian n g n . Thuc cng gp p h n c i
thin t n h t r n g t n g p lc ng m c h p h i n u d n g sm v
kt hp vi thuc chn k n h calci. V i l i u 30 - 40 prednisolon
mg/ngy chia n h i u l n , thuc c t c d n g l m g i m r r t cc
biu h i n v i m , p h n h n g k h n g c t c d n g t r n q u t r n h x
hoa. N h n chung n n t r n h d n g corticoid i v i d n g x hoa
da v c k h n n g g y t n t h n g t h n m h i u q u ca thuc
thc ra cng k h n g r r t .
- Interferon gamma l i n hp:
L cht c c h sn x u t collagen bi cc n g u y n b o x ca
da b n h t h n g v da x cng. C h i u q u i vi cc t r i u
chng da, k h p , thc q u n ( k h nut) v t h n .
- Colchicin: d n g l i u - 2 m g / n g y , c t c d n g c c h tch
ly collagen do c c h chuyn t i n collagen t h n h collagen i n
vitro. Ni chung h i u q u k h n g r r n g , ch c h i u q u i vi

143

triu chng da khi dng trong thi gian di. Thuc c dung
np tt hn so vi D- penicillamin.
Cc thuc c ch min dch: cyclophosphamid c th ci thin
triu chng vim phi k nng mc d gy nhiu tc dng ph.
- Thuc chng ngng tp tiu cu: cc sn phm sinh hc ca
tiu cu tc dng ln thnh mch. Aspirin liu thp c ch
thromboxan A2 (cht gy co mch v ngng tp tiu cu mnh).
C th dng dipyridamol liu 200 - 400 mg/24 gi, chia nhiu
ln trong ngy.
- Ngi ta cng th dng mt s cc thuc khc nh vitamin
E, du thc vt (Piascledine), EDTA hoc salazopirin, iod, tinh
cht gip trng, song hiu qu cha r rng. Ngoi ra ngi ta
cn s dng cc phng php iu tr vt l lm mm da,
phc hi chc nng vn ng, c bit l iu tr sui khong
(nc nng).
2. iu tr triu chng
2.1. iu tr hi chng Raynaud
Cc bin php chung: cn khuyn bnh nhn mcm, i
gng tay, t t chn trong ma lnh, trnh stress, khng dng
cc thuc nh amphetamin, ergotamin, chn beta giao cm.
Bnh nhn XCBTT vn c th dng thuc trnh thai cha
estrogen v progesteron. Bnh nhn cn c h tr tm l (th
gin, t luyn tp, dy bnh nhn t lm tng nhit da bng
c ch iu hoa ngc. Vi cc t kch pht tha, mc nh
th ch cn cc bin php trn y l . Cn khi cc triu
chng tr nn thng xuyn, nng, c bit khi c ri lon dinh
dng t chc hay lot th phi dng thm thuc vi mc tiu
gin c trn mch mu, lm tng cng tun hon.
Cc thuc iu tr hi chng Raynaud: ty theo tng bnh
nhn, dng mt trong cc loi thuc sau y:

144

- Thuc c c h alpha giao cm: prazosin, reserpin, alphamethyldopa,

guanetidin,
phentolamin,
phenoxybenzamin,
nicergolin, tolazolin.
- Thuc chn calci: diltiazem, n i e d i p i n , verapamin.
- Thuc i k h n g vi serotonin: ketanserin.
- Prostaglandin: PG E,, P G E , PG I (prostacyclin).
2

- C c thuc k h c : t r i n i t r i n bi da, stanozolol, dazoxiben,

thyrocalcitonin, liothyronin, indapamid, g r i s e o u l v i n , ioxsuprin.
- Thuc chn giao c m alpha n h prazosin c t c d n g t t
n h n g k h d n g np. Do v y thuc cn d n g l i u t h p r i t n g
dn l i u t r n h cc t c d n g p h (mch n h a n h , h h u y t p
t t h ng).
- Reserpin ng ung vi l i u 0,1 - 0,5 m g / n g y . Trong
trng hp lot da n g n tay, thuc c t h d n g n g t i m
chm n i ng mch v o ng mch c n h tay hay ng m c h
quay v i l i u 0,5 - m g hoa t a n trong dung dch m u i n g
t r n g trong n h i u p h t .
- Vic s d n g thuc chn calci l m t bc t p h m i t r o n g
iu t r h i chng Raynaud. Trong t h i t i t l n h c t h d n g
nifedipin (Adalat) 10 hoc 20 mg, 3-4 l n / n g y ( t r u n g b n h 30 60 mg/ngy). N u n i f e d i p i n k h n g dung n p c t h c h u y n
sang d n g diltiazem (Tildiem) 3 - 4 v i n / n g y .
- T r n g hp h i chng Raynaud n n g c h o i t cc n g n
tay c t h t r u y n d u n g dch dextran t r n g lng p h n t t h p
(Rheomacrodex). M nitroglycerin ( T r i n i t r i n , kem l e n i t r a l 2%)
hay m prostaglandin E (PGE ) c bi n g o i da, t r n cc
ngn tay t ra c h i u q u t i ch.
2

M t p h n g p h p m i gy g i n m c h n g n tay l g y cng
gip b n g cch d n g sodium l i o t h y r o n i n (triiodothyronin) 75 [Ig

145

hng ngy. Kt hp triiodothyronin v reserpin t ra c hiu

qu nht.
Bng 4. Phc tham kho iu tr hi chng Raynaud
Tn xut v mc
trm trng ca t co
mch

Gi iu tr

1. Bt him hay mc
trung bnh

Cc bin php bo v, ngng ht thuc

khng cn dng thuc

2. t thng xuyn
nhng khng c lon
dng.

Cc bin php bo v v chn calci.

3. i thng xuyn c Bin php bo v, chn cal hoc reserpin

lon dng nhng cha ng ung, liothyronin
c lot m
4. i thng xuyn c PGE, truyn tinh mch, reserpin truyn ni
lot au
ng mch sau dng chn calci; hoc
reserpin kt hp vi liothyronin
2.2. i vi tn thng

da

Kh da c th gim nu trnh tip xc vi x phng v bi

thuc m. Bnh nhn cn tp th dc thng xuyn duy tri
mm do ca chi, ngn v nhy cm cua da. Xoa bp da
vi ln trong ngy cng c tc dng tt. Trnh lm da b chan
thng v d gy lot. Cc vt lot da phi c chm sc cn
thn bng thuc ra st trng hay ct lc ngoi khoa. Cc vt
lot b nhim khun phi c iu tr bng cc thc* khng
sinh, cng c th kt hp vi thuc dit khun t i ch.
* Calci hoa di da: dng colchicin mg/ngy c tc dung
gim vim t i ch, gim au v lot da.
* Vim x da c: iu tr nh vim da c, gm corticoid liu

u
v
,
cyclophosphamid, methotrexat.
c

146

d c h

asathioprin,

2.3. i vi triu chng

tiu

ho

* Chng tro ngc thc qun: n n h i u ba nh, thuc

chng acid ung vo gia cc ba n , k u cao k h i n m .
T r n h n m u n ban m . K h n g n m trong v i gi sau k h i n ,
t r n h c a p h , ch, s c la v cc cht n y gy g i m c lc c t r n
v n g t h p ca thc q u n . Thuc:
- Chng acid: cimetidin, r a n i t i d i n , famotidin, omeprasol (2040 mg/ngy) c h i u q u r t t t .
- K h n g sinh ph rng n h n h m cyclin c t c d n g chng l i
s t n g sinh v i k h u n : tetracyclin 0,5 g X 4 l n / n g y .
* Nut kh: p h i n h a i k thc n v y thc n x u n g b n g
cch nut vi nc. C t h d n g thuc chng acid ( r a n i t i d i n ,
omeprasol), ketanserin.
* Hi chng km hp thu: t h n g do g i m v n ng t t r n g
v do v i k h u n . C t h d n g k h n g sinh n h m cyclin theo t .
Nu k h n g c t c d n g t h c t h c h u y n sang cc k h n g sinh
khc n h erythromycin, metronidazol. Octreotid, ng n g ca
somatostatin cng c t c d n g t r o n g mt s t r n g hp t n g
sinh v i k h u n v g i tc. K h u y n b n h n h n n thc n m m v
ung cc thuc n h u n t r n g i v i t o b n do t n t h n g r u t .
2.4. i vi triu chng c xng khp
* Vim c cp: t h n g p n g v i glucocorticoid; thuc
k h n g ch nh t r o n g cc t r n g hp X C B T T k h n g c t n
thng c.
* au khp: a s p i r i n v cc thuc chng v i m k h n g steroid,
vt l t r l i u , t i m t i khp, g h p khp g i i vi cc khp b
huy h o i n h i u n h khp gi, h n g . D n g prednisolon 5
mg/ngy ung cch n g y gp p h n c i t h i n t o n t r n g v
a u khp.

147

2.5.

Xphi

X phi trong XCBTT l khng hi phc. iu tr ch yu l

iu tr triu chng v iu tr bin chng. Nhim trng phi
iu tr bng khng sinh. Thiu oxy th cn phi cho th oxy
nng thp. Vai tr ca glucocorticoid trong phng nga tin
trin ca tn thng t chc k phi khng r rng.
2.6. Tn thng thn do mch mu
Pht hin sm cc tn thng thn ng vai tr quan trng
trong vic bo tn chc nng thn. Cn tin trin nhanh chng,
c th gy t vong, thng c km theo tng huyt p. Do a s
bnh n h n c tng renin nn cc thuc c ch men chuyn c
tc dng bnh n v bo tn chc nng thn nh mt thuc h
p tt. Cc thuc thng dng l: captopril (37,5-75 mg/ngy),
enalaprin, lisinopril, peridopril. Chng c tc dng tt trong
tng huyt p, t tn thng thn cp, tng p lc ng mch
phi, suy tim. Thn nhn to c th ch nh trong trng hp
tn thng thn tin trin.
2.7. Tn thng tim
i hi phi theo di cn thn vic dng digitalis v thuc li
tiu. Trn dch mng ngoi t i m c th p ng vi thuc li tiu.
Trn!; v i tiu qu mc v c t h lm gim hiu qu ca th tch
huyt tng, gim th tch tng mu ca tim v lm tn thng
thn. Cc thuc c ch calci lm ci thin cung lng tim.
V. THEO DI V TIN LNG
Mc tn thng v mc nng ca bnh rt khc nhau
tuy tng c th. mt s bnh nhn, trong nhiu nm ch c
nhng thay i hn ch da cc u chi trc khi xut hin
nhng tn thng r rt ni tng. Trong khi , nhiu bnh
nhn khc, tn thng da lan rng v bnh l ni tng pht trin

148

ch trong vng mt vi n m . N h n g trng hp chi t n t h n g

ni t n g m k h n g c b i u h i n da h i m gp. N h i u t r n g hp
bnh t m ngng, t h m ch t n t h n g da c t h tr v gn n h
bnh t h n g sau n h i u n m . Tin lng v n t ra x u h n i vi
chng tc da en, nam gii, b n h n h n c t u i . T u i t h p h
thuc vo t n h t r n g n n g n h ca cc t n t h n g n i t n g , c
bit l t n t h n g ca t i m , p h i v t h n . Trong h u h t cc
trng hp t vong x y ra do suy t h n , suy t i m hay suy h h p .
Cc ung t h v, phi c t h x y ra t h p h t b n h n h n
XCBTT. T h k h u t r (di, mng, vng, nt) t i n lng t t .

l i
\

*CR

:
% #

1
1

"L t! >
BL
gi

Hnh 43. Biu hin ca bnh x cng b ton th

149

HI CHNG

GOUGEROT-SJGREN

PGS. TS. Nguyn Vnh Ngc

I. I CNG
Hi chng Gougerot-Sjogren (HCGS) l mt chng bnh t
min c cc t khng th chng l i t bo ca h thng ng
tuyn ngoi tit, -c bit l tuyn nc mt, tuyn nc bt v
nhiu tuyn khc ( da, nim mc h hp v tiu hoa...)- v mt
dch t, HCGS l mt chng bnh khp rt ph bin, chim t l
0,5% dn s M v ng hng th hai sau vim khp dng thp,
nhng a s t c chn on ng v kp thi. v nguyn
nhn, HCGS l kt qu ca s tng tc gia nhiu yu t khc
nhau. l cc yu t di truyn, lin quan n s c mt ca
cc yu t HLA-DR, cc tc nhn virus nh vus Epstein-Barr,
HIV-1,
human
herpesvirus
6,
hepatitis
c
virus,
cytomegalovirus, mt iu hoa t min (mt dung np min
dch v sn xut cc t khng th nh ANA, anti-Ro, anti-La;
mt iu hoa qu trnh cht theo chng trnh v suy gim cc
hormon tuyn sinh dc v thng thn.
li. TRIU CHNG
1. Lm sng
Do l mt ri lon t min c hiu c quan vi hai triu
chng ni bt l kh mt v kh ming, hi chng ny cn c
gi l "Hi chng kh". Ngoi ra c th gp nhng tn thng
h thng khc (c xng khp, thn, gan, phi, huyt hc, da
liu, thn kinh...). Bnh thng gp nhng ngi trong tui
30-50. Hn 90% cc bnh nhn c HCGS l n, c bit vo tui
mn kinh, khng c s phn bit v chng tc. Bnh bt u rt
150

kn o , m t h m , t h n g ch c t r i u chng k h m t hay k h
m i n g n c, do v y t h i gian t r u n g b n h chn o n m u n t i
8 nm.
1.1. Tn thng mt - hi chng kh mt
Cc t r i u chng c n n g m t bao gm: c m gic c v t l , c
sn hay ct t r o n g m t , nga m t , m t . M u n h n , b n h n h n
thy s n h s n g , bng r t m t , i k h i g i m t h lc v i c m
gic c m n che trc m t . K h m l m s n g p h t h i n m t ,
vim k t mc, t n g chp m t , r m t .
1.2. Biu hin ca hi chng

kh

ming

Cc t r i u chng ch quan ca h i chng k h m i n g bao gm

triu chng k h m i n g v mi, c m gic k h k h n k h i n h a i , c m
gic bng r t li, t n t h n g v gic b, s u r n g . K h m l m
s n g p h t h i n s n g t u y n nc bt, n i m mc m i n g d n h v
, li k h , m t gai, s u r n g .
1.3. Cc biu hin h thng ca HCGS
HCGS c th gy tn thng bt k b phn no ca c th, t
ng h hp, tai, m i , hng, t h n , gan, n g t i u hoa, h t h n
kinh, c khp, t i m , h sinh dc v h m i n dch. T n t h n g
n i m m c v d a bao gm b i u h i n k h da do t h i u t i t m hi,
ban xut huyt v bch bin, v i m mch da, HC (l g).
Raynaud (54%). T n t h n g h t h n g v n n g bao gm
au khp, a u c, y u c gc chi, v i m a khp. T n t h n g b
m y h h p l vim kh ph qun kh, vim p h qun mn
tnh (57%), x p h i (15%), v i m p h i lympho b o k , r i l o n h
hp (30%- 60%), hay v i m p h nang. T n t h n g t i m m c h
k h n g c h i u , c h y u l v i m m n g n g o i t i m , v i m mch,
t i m to. iu h i n t i u h o a t v k h n g c h i u , bao gm t n
t h n g thc q u n (76%), d d y (vim d d y teo), r u t , t y
t n g (vim t u cp hay m n , suy t u y n t u y ngoi t i t ) , gan.
T o n t h n g t h n ch y u ng t h n (20-40%). T n t h n g

151

t h n k i n h t m t h n bao g m bt thng thn kinh trung

ng (20% bnh nhn c HCGS tin pht), bnh l^thn kinh
ngoi vi (10-20% bnh nhn). T n t h n g n i t i t bao gm
vim tuyn gip Hshimoto, suy gip hay cng gip. Biu
h i n t a i m i hng bao gm kh mi, vy mi, chy mu mi
(60%), khn ting, vim thanh qun, vim tai gia gy gim
thnh lc, hay vim xoang thng hay ti pht.
2. Xt nghim cn lm sng
2.1. Xt nghim

nhn

khoa

Khm mt c th pht hin hai du hiu chnh ca kh

mt: cn kit bi tit v vim kt gic mc kh, qua cc test
Schirmer v rose bengal.
- Test Schmer: dng mt bng giy thm Whatman No 41
c chiu di 35 mm v chiu rng 5 mm, c nh du tng
5mm. Test ny thc hin khng cn gy t t i ch. 5 Bm giy
gp sau t gii hn 2/3 ngoi ca ti cng kt mc di.
o chiu di (mm) ca giy thm b m bt u t ch gp sau
5 pht. Tit nc mt bnh thng vt 15 mm trong 5 pht.
- Test Rose bengale: ngi ta nh mt git rose bengal 2%
sau khi gy t t i ch, sau yu cu bnh nhn nhm mt
trong khong mt pht, c kt qu thc hin trong nh sng
xanh ca n khe ca knh sinh hin v i sau khi ra b mt mt
bng dung dch nc mui sinh l. Kt qu dng tnh khi tn
t i mt m nhum mu r rt v ngi ta nh gi nhng
chm xut hin do biu m huy hoi. Mc nhum mu
c nh gi t 0 n 3 trn kt mc hnh mi, trn, v gic
mc trong khu vc gia khe mi. Cc chm c m v tnh
im: (phn b r i rc), 2 (phn b tp trung), 3 (kt hp l i
vi nhau). Ch s 9 c xc nh i vi tng mt theo Van
Bijsterveld. Nu nh tng ch s ln hn 4 trong ba vng ca t
nht mt mt, test c coi l dng tnh.

152

- o t h i gian v p h i m nc m t v i luorescein-Test "break

p time".
Test n y n g h i n cu cht lng nc m t , n h gi s n
nh ca p h i m nc m t , n g y c n g c s d n g t r o n g s cc
tiu c h u n c h n o n . N h mt git luorescein 1% t r o n g t i
cng d i n h u m p h i m nc m t t h n h m u xanh v quan s t
di n khe v i n h s n g xanh. N g i ta o t h i gian gia p
thuc v x u t h i n v t r c h u t i n ca t m p h i m n h u m m u
ng n h t . T h i gian p h i m nc m t v d i d n g h t k h gia
hai l n chp m t xc n h t h i gian v p h i m nc m t hay gi l
"break-up time". T i n h n h o 3 l n lin tc v i t n g m t . T h i
gian n y l n hn 10 giy n g i b n h t h n g v c t h vt q u
mt p h t . Gi t r d i 10 giy c coi l b n h l. y l test
kh nhy n h n g t c h i u . S d n g t n h ca n ch cho p h p
kt l u n v s m t n n h ca p h i m nc m t .
K h m m t u i n khe ca k n h sinh h i n v i t h n g p h t
hin c thay i p h i m nc m t trc gic mc. N t r n n
nht d n h hn, cht y cc h t l lng, v n g n h y hay m t
bo b i u m nh. Cui c n g n h l u o r e s c e i n cho p h p n h gi
s t o n v n b i u m k t mc v gic mc. C t h p h t h i n v i m
gic mc chm n n g , l a n toa v m ca n, c n g n h t m
kim si b i u m (vim gic mc si), chng t g i m n g h i m
trng bi t i t nc m t .
2.2. Khm ming
j ) o dng chy nc bt: o l u lng d n g chy nc bt b n g
test t h u t h p nc b t t o n p h n k h n g kch t h c h . Test c
thc h i n b n g cch t h u t h p nc bt t r o n g 15 p h t , test c
coi n h d n g t n h k h i t h n 1,5 m i nc bt t o n p h n t h u
thp c. Test d n g t n h c k h n n g t i thc h i n cao
(84,2%) k h i l p l i sau n m trong i u k i n c h u n . T h m na
test chc n n g n y c c h i u cao (80,7%) i v i b n h n h n
co HCGS t i n p h t .

153

- Xt nghim m bnh hc tuyn nc bt ph.

Sinh thit tuyn nc bt ph mi l mt phng php
chn on c bn HCGS, cho php pht hin cc tn thng c
trng ca bnh: thm nhim tuyn bi lympho bo v tng bo
thnh c gii hn r, i khi to t h n h hch ympho vi trung
tm mm thc s. Phn loi mc t h m nhim theo Chilsom
c s dng rng ri nht. Ngoi ra v c r t nhiu nguyn
nhn gim tit nc bt, sinh thit tuyn nc bt ph l cn
thit khng nh s c mt ca t h m nhim lympho bo. Tn
thng m bnh hc bao gm 3 t h n h phn: thm nhim
lympho tng bo, tn thng ng dn v nang tuyn, x hoa.
Phng din c trng ca t h m nhim l xp xp thnh c
gii hn r, i khi t chc thnh hch lympho. Phn loi mc
t h m nhim theo Chilsom c s dng rng ri nht.
Chilsom lng ha hin tng t h m nhim bng cch xc
nh mt nh l mt khi t bo gm 50 t bo n nhn. Ong
cng phn ra 5 giai on:
0: tuyn bnh thng;
: t h m nhim nh khng to t h n h ;
2: t hn trn mt n v b mt 4 Dim ;
2

3: mt trn mt n v b mt;
4: nhiu hn trn mt n v b mt.
Cn phi c giai on 3 ca Chilsom chn on chc chn
HCGS.
2.3. Du hiu sinh hc
Xt nghim mu pht hin hi chng vim vi tng tc
mu lng, thiu mu kiu vim (35% trng hp), gim bch
cu (30% trng hp), tng bch cu i toan (30% trng hp).
Gim tiu cu pht hin c vi t l 20% trng hp.

154

2.4. Ri lon min

dch

trong

HCGS

H C G S l mt trong ba bnh t m i n p h b i n n h t . Y u t
dng t h p (60-70%) va k h n g t h k h n g n h n (70%) t n g t r o n g
hu h t bnh n h n . K h n g t h chng k h n g n g u y n n h n hoa
tan Ro (SSA) v La (SSB) l c i m r i lon m i n dch c h n h
ca HCGS t i n p h t . K h n g t h k h n g S S (anti-Ro) c m t
trong k h o n g 70% bnh n h n mc HCGS, cn k h n g t h k h n g
SSB (anti-La) d n g t n h trong 40% t r n g hp. N g o i ra cn
gp k h n g t h k h n g alpha b d r i n isotyp I g A (59%), k h n g t h
k h n g cm t h quan acetylcholin. G i m b t h m u lin quan
cht ch v i cc b i u h i n h t h n g v k t q u x u ( p h t t r i n
ca u lympho v t vong) b n h n h n mc HCGS t i n p h t .
III. CHN ON HI CHNG GOUGEROT- SJOGREN
. Tiu c h u n c h n o n
Trong n h n g n m g n y , t i u c h u n c h n o n M - u H i
chng GS n m 2002 c p d n g rng r i t r n t h gii.
Tiu chun chn on M-u hi chng Gougerot- Sjogren (2002).
1.1. Triu chng

mt

()

Tr li d n g t n h vi t i t h i u mt t r o n g ba c u h i sau:
M t ng/b c b k h g y k h chu h n g n g y t 3 t h n g
nay k h n g ?
- ng/b c cm gic thng hay c ct hay sn trong m t khng?
- Ong/b c nh nc mt n h n to hn 3 l n trong mt ngy khng?
1.2. Triu chng

ming

(li)

T r li d n g t n h v i t i t h i u mt t r o n g ba c u h i sau:
- n g / b c t h y k h m i n g h n g n g y t 3 t h n g
khng?

nay

T k h i ln ln n g / b c t h y s n g t u y n nc bt dai d n g
hoc t i p h t k h n g ?

155

 ng/b c thng ung nc cho d nut thc n cng

khng?
1.3. Du hiu mt (UI)
Tn thng mt khch quan v hin nhin xc nh bi kt
qu dng tnh vi t i thiu mt trong hai test sau:
- Test Schimer (< 5 mm trong 5 pht)
- Ch s im rose bengal hay ch s mt khc >4.
1.4. Du hiu gii phu bnh (IV)
Ch s > khi sinh thit tuyn nc bt ph. Mt xc
nh bng tp hp t i thiu 50 t bo n nhn. Ch s xc
nh bng s trn 4mm m tuyn.
2

1.5. Tn thng tuyn nc bt (V)

Tn thng tuyn nc bt khch quan v hin nhin xc
nh bi kt qu dng tnh vi ti thiu mt trong ba test sau:
Chp x hnh tuyn nc bt.
- Chp tuyn nc bt cn quang tuyn mang tai.
- Lu lng nc bt khng kch thch < 1,5 mi trong 15 pht.
1.6. T khng th (VI)
C mt t i thiu mt kiu khng th sau:
- Khng SSA hay SSB.
- Khng t h khng nhn
- Yu t dng thp
Bnh nhn c chn on mc HCGS khi 3 trong s 4 tiu
chun khch quan dng tnh (HI, IV, V hoc VI)
Hi chng Gougerot- Sjogren tin pht c chn on xc
nh khi c 4 trong 6 tiu chun ni trn v c sinh thit tuyn
nc bt bt thng v t khng th huyt thanh dng tnh

156

HCGS t h p h t c chn o n dng t n h (xc nh) k h i c

mt bnh h thng k t hp, c m t mt trong cc tiu c h u n hoc
l i , v bt k tiu chun n o trong s cc tiu chun I U , I V , V.
Cc t i u c h u n l o i t r : i u t r b n g tia x v n g u c
trc , v i m gan siu v i c, u lympho c t trc, A I D S ,
sarcoidosis, p h n n g t h i l o i m n h g h p , hay b n h n h n a n g
c i u t r b n g thuc k h n g cholin.
2. Chn on phn bit
Chn on p h n b i t bao gm cc b n h c gy k h m t ,
ming v s n g t u y n m a n g t a i . v m t l m s n g h i chng
"giong kh" c t h gy ra bi m t s cc b n h k h c , bao gm
AIDS, t n g l i p i d v p r o t i d m u typ I V hay V , sarcoidosis, v
nhim t i n h bt, s d n g m t s thuc. Cui c n g c n g c h i
chng k h sau b m sinh v d i t r u y n .
3. Cc th bnh ca hi chng Gougerot- Sjogren
N m 1965 Bloch p h n b i t HCGS t i n p h t v t h p h t .
C khong 50% cc t r n g hp b n h k h n g r n g u y n n h n :
l HCGS t i n p h t . Khoang t 2-5% n h n g n g i t r n 60 t u i
c mc h i chng n y . M t na cc t r n g hp cn l i b n h k t
hp vi cc b n h l k h c (vim khp d n g t h p , lupus ban h
thng, x cng b t o n t h , v i m da c....): l HCGS t h p h t .
Khong 30% b n h n h n mc cc b n h h t h n g c H C G S k m
theo. Chn o n da t r n s c m t ca 2 t r o n g s 3 b i u h i n
sau: vim k t gic mc k h , k h m i n g v b n h l h t h n g k t
hp hay bnh l t n g sinh lympho.
3.1. Hi chng

Gougerot-

Sjogren

tin

pht

HCGS t i n p h t c t i n t r i n l n h t n h v c h m . v l m
s n g h i chng k h n n g h n so vi t h t h p h t ; k h m t v
kh m i n g r r t h n . v p h n g d i n sinh hc v m i n dch,
hi chng k h t i n p h t c m t s n t c t r n g , vi t l cao
cc t k h a n g t h , c b i t l cc t k h n g t h k h n g c h i u c

157

quan (t khng th anti-SSA, anti-SSB), t n xut cao ca gen

HLA-DW3.
3.2. Hi chng Gougerot- Sjogren kt hp vi vim khp
dng thp
Gordon nh gi tn xut HCGS th pht trn bnh nhn
vim khp dng thp (VKDT) dao ng t 31% n 62%. Theo
Sauvezie (2001) HCGS cng r rt khi VKDT cng nng v tin
trin lu hn. a s bnh nhn VKDT c tn thng m bnh
hc khng phn nn v triu chng kh. Nu c cc phn nn
th kh mt thng xuyn gp hn l kh ming hay sng tuyn
mang tai. Bnh nhn VKDT c hi chng kh c biu hin bnh
nng v hot ng vi ch s tn ph cao, mt mi v khp sng
nhiu hn.
3.3. Hi chng Gougerot- Sjogren kt hp vi lupus ban
h thong
Theo cc tc gi KeUey, Talal, Kaplan th t l HCGS th
pht trn bnh nhn lupus dao ng t 20-50%. Bnh cnh lm
sng ca lupus ny c trng bi t l cao bt thng cc vim
khp bo mn, c t h gi th chm ln gia lupus v VKDT.
Nhng bnh nhn ny thng d pht trin vim mch, x phi
k, toan hoa ng thn xa v t khng th anti-SSA.
IV. IU TR HI CHNG GOUGEROT- SJOGREN
Nguyn tc iu tr l lm gim cc triu chng v phng
tin trin bnh. iu tr bo tn l tt nht, bao gm kch thch
tuyn ngoi tit v thay t h bi tit b thiu ht.
1. iu tr ti ch hi chng kh
1.1. iu tr ti ch kh mt v vim gic kt mc kh
C th nh nc mui sinh l hay nc mt nhn tao
(methylcellulose, dung dch 1% hyaluronic acid, nh 4-6 ln mi

158

ngy) mang l i c i t h i n chc n n g trong 45% cc t r n g hp.

D n g cc y u t t i u n h y n h thuc n h m t cha
hyaluronidase, bromhexin (Bisolvon). D n g thuc n h m t cha
cyclosporin A 0,05-0,1% (Restasis). C t c dng l m g i m t h m
nhim lympho b o t u y n l , bo t o n chc n n g b i t i t nc
mt. Thuc n h m t cha corticoid c ch nh r t h n c h v c
th c nguy c n h i m t r n g , t h i n u thng, t h n g gic mc.
C t h d n g tetracyclin i u t r v i m m m t , m t . C t h
dng thuc m n h n khoa l m l n h so gic mc, k n h p t r n g
cha thuc, t t r bt l ng d n l (Lacriset), p h u t h u t bt l
ng l hay sa cha k t mc, gic mc, m m t . B t tc khe l
vi n t b n g silicon n h Lacriset c i t h i n k h m t t r o n g 57%
bnh n h n . C t h i u t r v t lot gic mc b n g n h h u y t
thanh t t h n , a l b u m i n n g i hay p h u t h u t t i t o phc t p
nh ghp m n g i .
1.2. iu tr kh ming
K h u y n b n h n h n n g m ko n dt chua hay n h a i ko cao
su, thng x u y n ung nc, x c m i n g hay d n g glycerin, nc
bt n h n to. N n d n g thuc n h r n g k h n g c c h t t y , v
s dng t h m t i ch fluo, gel ming. N g i ta c n g s d n g
dng c i n kch t h c h t i t nc bt. C c c h t t h a y t h
nc bt d n g qua ng p h u n (Artisial), hay c g i i p h n g
ra t b n h cha gn t r o n g ming, c n t r n h d n g thuc
atropin, l i t p h giao cm, thuc h n g t m t h n . N u t u y n
mang t a i q u to t h c t h p h u t h u t . Chng ch nh chiu x
t i ch v n t o t h u n l i cho x u t h i n h i chng t n g sinh
lympho c t n h . s d n g k e m dng da k h n g m i c t h g i m
kh da.
2. iu tr ton th
C hai cch l iu tr triu chng vi mc ch kch thch
t i t cc t u y n ngoi t i t v i u tr n g u y n n h n chng l i q u
t r n h v i m v r i l o n m i n dch.

159

2.1. iu tr triu

chng

C th dng cn thuc Jaborandi, Suarlem, bromhexin

(Bisolvon),
Potassium
iodin,
bromhexin,
trithioparamethoxyphenylpropen. Cc thuc cng ph giao
cm (pilocarpin, neostigmin, cevimelin). C th dng bromhexin
ng ung vi liu 16 mg X 3 l n mi ngy. Pilocarpin
(Salagen) c th gim kh mt v ming. N kch thch hot
ng ca acetylcholin trn t h th muscarinic trong tuyn nc
bt, dng liu ung t 5 n 10 mg, t 3 n 4 ln mt ngy.
Cn cevimelin (Evoxac): i hi t ln dng hn pilocarpin,
nhng c th gy bun nn. Dng interferon-alfa ngi ci
thin tit nc bt v gim t l kh ming. iu tr sng
tuyn mang tai c th dng thuc chng vim khng steroid hay
liu thp corticoid nh prednison.
2.2. iu tr nguyn nhn
iu tr vim khp c th dng thuc chng vim khng
steroid, liu thp corticoid nh prednison, thuc chng st rt
tng hp chloroquin hay Plaquenil (hydroxychloroquin). Luyn
tp nh nhng c th gim cng khp. i vi vim khp trong
vim khp dng thp. Cc thuc c ch min dch gy c t bo
nh cyclophosphamid (Cytoxan), methotrexat (Rheumatrex),
mycophenolat
(CellCept),
hay
azathioprin
(Imuran).
Methotrexat c s dng nh thuc tit kim steroid. i
vi cc tn thng thn kinh ngoi vi th cha c iu tr c
hiu, tuy nhin c th dng lc huyt tng i vi tn thng
thn kinh th pht. i vi tn thng thn kinh trung ng c
th dng cortiocid ng tnh mch, kt hp vi thuc c ch
min dch nh methylprednisolon v cyclophosphamid. i vi
vim mch th c th dng thuc c ch min dch khi cn thit.
Trong hi chng Raynaud th dng pentoxifyllin v nifedipin.

160

2.3. Thuc
HCGS tin

sinh
pht

hc

- Cch

tip

cn

mi

trong

iu

tr

- i u t r mc t i u t b o B: r i t u x i m a b
(anti-CD20),
ocrelizumab (humanized anti-CD20), epratuzumab (anti-CD22),
belimumab (anti-BAFF). Ch n h l m s n g ca r i t u x i m a b
trong HCGS t i n p h t : h i chng k h , ri l o n chc n n g t u y n
nc bt, v i m khp, v i m bao hot dch khp n n g , b n h l
thn k i n h ngoi v i , v i m cu t h n , v i m m c h c globulin t a
lnh, v i m cng mc k h n g thuc t h n g t h n g , g i m n n g cc
t bo m u , u lympho B.
- i u tr mc t i u t b o T: efalizumab ( a n t i - C D l l a ) ,
alefacept (anti-CD2), abatacept (anti-CD80/86), i n f l i x i m a b
(anti-TNF). M t n g h i n cu ca M a r i e t t e n h gi k t q u ca
Remicade (inliximab) t r n 103 b n h n h n HCGS, cho t h y
thuc chng TNF-alpha k h n g n n d n g u tay t r o n g i u t r
HCGS t i n p h t .
- iu t r hng cytokin: etanercept (anti-TNF), tocilizumab
(anti-IL6r), a n t i - I L l O , a n t i - I L l 7 , a n t i - I F N . V a i t r ca y u t
hoi t u T N F - a l p h a v n cn c h a r trong c c h b n h sinh
ca HCGS t i n p h t , n h n g c t h n n g v a i t r q u y t n h .
Hai n g h i n cu gn y n h gi t c d n g ca E n b r e l
(etanercept) t r n 33 b n h n h n cho t h y h i u q u h n c h ca
etanercept trong HCGS t i n p h t .
- iu tr hng b t h : eculizumab (anti-C5a/C5b-9).
V. THEO DI V TIN LNG
HCGS l m t b n h m n t n h c t i n t r i n l n h t n h , n h n g
c t h c b i n chng u lumpho non-hodgkin (1-3%) hay b i u
hin h thng n n g n . Theo H a r r i s (1999), b n h n h n mc
HCGS c nguy c b i n chng t h n h u lympho t n g gp 44 l n so
vi n g i t h n g . Lot gic mc l m t b i n chng h i m gp,
thng xy ra t r o n g GS t h p h t , sau v i m khp d n g t h p . T

161

vong xy ra c bit trong HCGS th pht v khi c bnh l

tuy sng.

Hnh 46. Kh ming

Hnh 47. Sinh thit tuyn nc

bt ph mi di

VIM A C V VIM D A

TS. N g u y n n h K h o a
I. I C N G
Vim a c v v i m da c l b n h h t h n g c h a r n g u y n
n h n , c c c h t m i n . B n h c t r n g bi t n h t r n g v i m ,
thoi ha ca cc si c v n , g y y u c, teo c, c b i t l cc c
gc chi, dn n g i m hoc m t chc n n g v n ng. T r o n g
vim da c, n g o i t n t h n g c cn c n h n g t n t h n g c
hiu t r n da. Bnh gp n n h i u hn nam gii (t l n / n a m
khong 2/1); c t h gp m i la t u i song hay gp n h t
tui t 40 n 60 ( n g i ln) v 5 - 1 5 t u i ( t r em).
li. TRIU CHNG LM SNG
1. Hi bnh
- Cn khai t h c cc t r i u chng t o n t h n h st, s t c n ,
mt mi, c h n n , a u c, a u khp.
- Hi tin s xut hin ca ban ngoi da, mu sc, v tr.
- Khai thc k cc du hiu gi tnh trng yu c gy kh
k h n k h i l m n h n g ng t c n h c h i tc, l n xung cu
thang, gi tay ln k h i u , k h n g dy k h i n g i g h t h p ,
hoc p h i chng tay m i k h i n g dy ...
- Khai thc mt s triu chng khc c th nh ho, kh th,
kh nut.
- H i t i n s s d n g thuc (c b i t l cc thuc corticoid,
thuc h cholesterol m u n h m statin), ung r u , n h i m
k h u n , b n h l ung t h .

163

2. Thm k h m lm s n g
- nh gi tnh trng ton thn v cc du hiu ton th.
- nh gi tn thng ngoi da: trong vim da c, ban
thng xut hin nhng vng da tip xc vi nh sng mt
tri nh vng mt, c gy; c the thy nhng dng ban du hiu
c hiu nh sau.
+ Ban mu tm mi mt trn km theo ph quanh m mt.
+ Du hiu Gottron: ban mu hoc tm sm, thng i
xng, mt dui ca cc khp, c bit l cc khp bn ngn,
cc khp ngn tay, khuy, gi, mt c trong.
+ Ban hnh ch V hay du hiu "khn qung" vng vai c gy.
+ Du hiu bn tay "th my": da cc gn tay (pha gan
tay) c tnh trng dy, kh, c vt rn nt, bong da.
- Yu cu bnh nhn thc hin mt s ng tc nh ng
ln, ngi xung (trn gh thp), khm vn ng ch ng ca
chi trn v chi di, quan st dng i ...
- Khm c lc v trng lc c: c th thy cc biu hin nh
au c khi nn bp, gim trng lc c, teo c v nh gi c lc
bng cch dng tay thy thuc khng l i mt s ng tc nh
dng khp, gp dui t chi, ci nga quay u; ch so snh
hai bi;. Trong vim c v vim da c, giai on sm thng l
yu c c tnh cht i xng gc chi (cc nhm c vng i chu hng, vai - cnh tay, c gy), mun hn c th c thm yu
cc c ngn chi.
- Khm phn x gn xng: c th c gim phn x gn
xng co gc chi.
- Khm khp: c th c sng au nhiu khp hoc tnh trng
co cng khp.

164

- T h m k h m h hp, t i m mch v cc c quan k h c p h t

hin cc b i n chng hoc b n h l phi hp n h v i m phi, suy
h hp, lon nhp t i m , v i m c t i m , t r n dch m n g n g o i t i m ,
suy t i m .
3. Cn lm sng
- C c x t n g h i m c b n c n l m : cng thc m u , tc
mu lng, CRP, sinh h a m u c b n ; tng p h n tch nc t i u .
- Xt n g h i m men c t r o n g h u y t t h a n h : n h gi
Creatinin phosphokinase (CK) l quan t r n g n h t .

men

+ Creatinin phosphokinase (CK) t h n g t n g , c t h t n g cao

t vi l n n vi chc l n t r s b n h t h n g .
+ Cc men khc: L D H , aldolase, SGOT, SGPT cng c t h t n g .
- Xt n g h i m m i n dch: khng th khng n h n thng
dng t n h ( t r n 70% t r n g hp); k h n g t h k h n g J o - l v
khng t h k h n g Mi-2 t u y t l dng t n h t h p (15-20%) song
rt c h i u cho vim a c (Jo-l) v v i m da c (Mi-2).
i n c : c t h t h y t n g hot ng t p h t (lc ngh),
gim bin , r u n g si c, i n t h a pha (lc co c).
- S i n h t h i t c (c t u i hoc c Delta) l t h m do c
hiu nht:
+ Trong vim a c: t h m n h i m t b o v i m c h y u trong
cc si c, a s l t b o l y m p h o T.
+ Vim da c: t b o v i m t h m n h i m c h y u quanh cc
mch m u , a s l t b o l y m p h o B.
- C h n o n h n h n h : ngoi chp X-quang t i m phi, cc
thm d h n h n h k h c n h ct lp v i t n h (CT scan), cng hng
t (MRI), siu m c t h c ch nh trong mt s trng hp.
MRI v siu m c k h n g ch h tr chn on m cn gip la
chn v t r sinh t h i t c thch hp.

165

+ Chp x-quang tim phi, CT scan phi phn gii cao

pht hin cc du hiu ca bnh phi k, x phi.
+ MRI (thung lm c i) c th pht hin du hiu vim
v ph n ca cc c b tn thng.
+ Siu m c th pht hin tnh trng teo cc b c b tn thng.
- Mt s thm d khc c t h c ch nh nu cn:
+ o chc nng h hp theo di tin trin ca bnh phi
k nu c.
+ in tm pht hin lon nhp tim hoc ri lon dn
truyn nh tht.
+ Siu m tim nh gi trn dch mng ngoi tim, chc nng
c tim.
HI. CHN ON XC NH
1. Chn o n x c nh
Da vo tiu chun chn on nm 1975 ca Bohan v Peter
- Yu c gc chi c tnh cht i xng.
Tng men c (CK) trong huyt thanh.
- in c : c cc c c hiu du hiu bnh l.
Sinh thit c: c cc tn thng vim c c hiu.
Chn on xc nh vim a c khi c 3 hoc 4 tiu chun
trn, vim da c nu c 3 tiu chun cng vi ban c hiu da
2. Chn o n p h n bit
- Cc bnh h thng khc nh vim mch, lupus ban h
thng, x cng b ton th, hi chng chng (vi) lp (overlap
syndrom).

166

- L o n dng c, teo c do bnh l t y sng, nhc c, v i m

ty do b i l i t , h i chng Guilain-Barre.
- Suy g i p , cng g i p , h i chng Cushing.
- Vim c do cc n g u y n n h n k h c nh: vus, v i k h u n , k
sinh t r n g ) .
- B n h c do thuc: colchicin, A Z T , penicillamin, ethanol,
corticosteroid, cc thuc h colesterol m u ( n h m statin).
- Bnh c do r i l o n i n g i i : h k a l i m u , t n g calci m u ,
h magne m u .
IV. IU TR
* Corticosteroid l i u cao l b i n p h p i u t c h y u n h t
- iu tr t n cng
+ Prednisolon 1-2 m g / k g / n g y (khong 40-80 m g / n g y ) hoc
liu t n g n g ca methyl prednisolon, t 2-4 t u n , c t h
ko di hn.
+ Hoc t r u y n methyl prednisolon t n h m c h l i u bolus 7501000 m g / n g y trong 3-5 n g y l i n ; i u t r t h n h t n g t.
- iu tr duy tr: k h i t n h t r n g l m s n g v men c c d u
hiu ci t h i n r r t , b t u g i m l i u d n cho n k h i men c
tr v b n h t h n g chuyn sang l i u duy t r 5-10 mg
prednisolon m i n g y .
+ N u c t n t h n g da va hoc n n g , c t h
choloroquin 250 m g / n g y hoc steroid bi n g o i da.

thm

+ Xem xt p h i hp corticosteroid v i cc thuc c ch m i n

dch k h i bnh n h n k h n g p n g v i l i u cao corticoid hoc c
tnh t r n g p h thuc corticoid (bnh n n g l n k h i g i m l i u
prednisolon xung d i 20 m g / n g y ) .
Methotrexat 15-25 mg/tun, ung m i t u n m t l n (bt
u t l i u t h p 7,5-10 mg/tun); hoc azathioprin 1-2
mg/kg/ngy t r o n g 4-6 t h n g .

167

 Hoc cyclophosphamid nu bnh nhn

c chng ch nh vi methotrexat (v d
phi): truyn tnh mch 500-700 mg/m ,
trong su thng, sau c th duy tr 3
nm; hoc duy tr bng cc thuc khc.
2

khng p ng hoc
c vim phi k, x
mi t h n g mt ln,
thng/ln trong 1-2

- Cng c th dng cc thuc c ch min dch khc nh

mycophenolat mofetil, cyclosporin.
+ Truyn globulin min dch tnh mch (IV-Ig) i vi nhng
bnh nhn nng khng steroid, hoc c tn thng cc c h
hp e da tnh mng. Tng liu l 2g/kg, truyn tnh mch,
chia u trong vng 2-5 ngy.
+ iu tr l liu php duy tr chc nng vn ng ca
khp trnh bin chng co cng khp.
+ iu tr cc bin chng v triu chng phi hp khc nu c.
V. THEO DI V TIN LNG
- Thm khm lm sng (nh gi c lc) v xt nghim men
c nh k: giai on iu t t n cng 1-2 tun mt ln, sau 13 t h n g mt ln.
Theo di pht hin v iu tr bin chng ca corticoid nh
h kali mu, tng huyt p, i tho ng.
o mt xng v xem xt s dng calci, vitamin D v
bisphosphonat.
- Nu s dng cc thuc c ch min dch cn theo di tc
dng ph ca thuc qua vic xt nghim nh k cng thc
mu, men gan, creatinin.
- Theo di pht hin bnh l c tnh, c bit l bung
trng (bnh nhn vim a c/vim da c nguy c b cc bnh
ung th tng cao hn ngi bnh thng).

168

B N H L C T S N G H U Y T T H A N H
M

TNH

TS. T r n T h M i n h Hoa
Bnh l ct sng th huyt thanh m tnh (Seronegative
spondyloarthropaties) l mt n h m b n h v i m t sng, v i m
khp c lin quan n n h i u c quan. K h i n i m v b n h l ct
sng t h h u y t t h a n h m t n h ( B L C S T H T A T ) c W r i g h t v
Moll n u ra v o n m 1964, da t r n h i chng Reiter do Hans
Reiter m t u t i n v o n m 1916. H i n nay, b n h l ct sng
t h huyt t h a n h m t n h gm c m t s b n h sau: v i m ct sng
dnh khp, h i chng R e i t e r / v i m khp p h n ng; b n h v i m
khp vy nn, b n h khp trong cc bnh l t i u h a : v i m i
trc t r n g chy m u , b n h Crohn.... b n h l ct sng k h n g xc
nh, bnh vim khp t h i u n i n t h v i m ct sng d n h khp.
N h m bnh n y c mt s c i m l m s n g v x t n g h i m
c t r n g n h : v i m t sng, v i m khp c n g chu, t n t h n g
khp ngoi b i n , v i m p h n m n cnh khp, t n t h n g n g o i
khp (da, n i m mc, m n g , mt....).
N h m Bnh l ct sng t h h u y t t h a n h m t n h
(BLCSTHTAT), l m t n h m b i n h b n h x n g khp t h n g gp
chim t l 15,4% t r o n g cc b n h n h n i u t r n i t r t i khoa
C Xng K h p B n h v i n Bch M a i . y l n h m b n h ch
yu gp t u i t r gp n g i t r t u i (80% b n h n h n mc
bnh d i 40 t u i ) t l mc b n h gp n a m gii l 60%. B n h
tin t r i n ko d i , c cc t cp t n h n u n g i b n h k h n g
c c h n o n v i u tr sm s d n n cc h u q u n n g n
v chc n n g v n ng khp, ct sng k h n n g lao ng v l

169

mt trong nhng nguyn nhn gy tn ph hay gp n h t trong

cc bnh l xng khp.
Nhm bnh ny c mi lin quan cht ch (30-85%) vi
khng nguyn bch cu HLA-B27 ca h thng ha hp t chc
(MHC: major histocompatibility complex), tuy nhin yu t gen
khng phi l nhn t quyt nh bnh. C ch bnh sinh ca
nhm BLCSTHTAT cha c bit r, hin nay c ba gi thuyt
v c ch bnh sinh c nhiu tc gi cng nhn nht l:
- Bnh l ct sng (BLCS) l mt bnh trung gian min dch
do s c mt ca cc khng nguyn, khng th trong dch khp
v mng hot dch bnh nhn, v s tn t i ca cc khng
nguyn ny c coi l mt trong nhng nguyn nhn gy bnh.
- Vai tr ca HA-B27 trong qu trnh pht sinh v pht trin
ca bnh.
- Vai tr ca mt s vi khun: Sallmonella, Chlamydia
trachomatis, Yersinia...
Trong nhm BLCS, bnh vim ct sng dnh khp v vim
khp phn ng l hai bnh hay gp nht chim t l 80-90%.
Hin nay tiu chun chn on nhm bnh l ct sng
(BLCS) ca Amor (1970) c thay t h bng tiu chun chn
on ca nhm nghin cu BLCS chu u (1990), ph hp vi
lm sng v c nhy v c hiu cao. Tiu chun chn
on ca nhm BLCSTHTAT gm" c:
1. au, vim t sng. Hoc 2. Vim mng hot dch khp
(ch yu l khp chi di v khng i xng).
C km theo mt trong cc hi chng sau y: c tin s gia
nh cc bnh: vim ct sng dnh khp, bnh vim khp vy
nn, bnh l rut, au vng chu hng, bnh l phn mm
quanh khp, vim khp cng chu, vim niu o sinh dc.

170

T u y n h i n i vi b n h vim ct sng d n h khp, h i chng

Reiter c t i u c h u n r i n g b i t theo tiu c h u n ca h i T h p
khp hc M (ACR).
N g u y n tc iu tr chung cho n h m bnh l ct sng t h
huyt t h a n h m t n h :
* i u tr bo t o n , duy t r chc n n g v n ng khp: v n
ng khp, t h dc l i u p h p . . .
* i u tr chng vim, g i m a u : s d n g cc thuc chng
vim k h n g steroid (NSAIDs) hp l, an t o n v h i u q u .
* i u t r phc h i chc n n g v p h u t h u t chnh h n h
khp: s dng cc p h n g p h p i u t r l l i u p h p phc h i
chc n n g t h c h hp vi t n g giai o n b n h , i u k i n sc khoe
ca ngi bnh. T i n h n h p h u t h u t chnh h n h khp hoc
thay khp n h n to k h i cn t h i t .
* Hng dn, gio dc b n h n h n h i u b i t v b n h c n g n h
trong iu t r bnh. C s hp t c lin h t h n g x u y n gia b c
s, bnh n h n v n g i n h ca bnh n h n t r o n g sut q u t r n h
iu t r bnh... T v n h u n g nghip p h hp v i k h n n g v n
ng v t n h t r n g sc khoe ca n g i b n h .
I. VIM CT SNG DNH KHP
1. i cng
Vim ct sng dnh khp (VCSDK) l mt bnh vim khp
m n t n h cn c t n gi l b n h Bechterevv, S t r u m p e l l ...v l
bnh hay gp n h t t r o n g n h m b n h l ct sng t h h u y t
thanh m t i n h ( B L C S T H T A T ) . B n h V C S D K c moi lin quan
cht ch n h t vi H L A - B 2 7 (80-90%). B n h t h n g gp nam
gii (80-90%), t u i mc b n h t r , u i 30 t u i c h i m t l 80%.
Bnh c t n h cht gia n h (3-10%).

171

1.1. Dch t hc
Bnh VCSDK c mi quan h vi yu t HLA-B27. Cc
nghin cu cng ng cho thy c khong 0,1-2% dn s c yu
t HLA- B27 dng tnh mc bnh VCSDK. Tuy nhin t l ny
c s khc nhau tuy theo v tr a l v chng tc: Bc M t
l HLA-B27 dng tnh trong cng ng l 7%, trong c ti
90% bnh nhn VCSDK c HLA-B27 dng tnh, ngc li, t l
HLA-B27 Nht Bn ch 0,4% v t l bnh VCSDK rt thp.
Bnh l ct sng th huyt thanh m tnh (BLCSTHTAT) ni
chung v c bit l bnh VCSDK c mi lin h cht ch vi
khng nguyn bch cu HLA-B27 ca h thng khng nguyn
hoa hp t chc MHC (major histocompatibility complex). HLAB27 l allen ca locus HLA-B, l mt trong 3 locus lin quan
n phn t MHC lp . Nghin cu gen HLA-B, ngi ta thy
rng HLA-B27 l alloantisera gm c 7 phn nhm c xc
nh l HLA-B*2701, HLA-B*2702, HLA-B*2703, HLA-B*2704,
HLA-B*2705, HLA-B*2706, v HLA-B*2707, trong HLAB*2705 l phn nhm hay gp nht trong cng ng. S phi
hp BLCSTHTAT v HLA-B27 c xc nh, kt qu
nghin cu ca Dougados M cho thy t l HLA-B27 bnh
VCSDK l 90%, bnh vim khp phn ng (VKP) l 55%,
bnh Reirter l 70%, v bnh vim khp vy nn l 42%. Theo
nghin cu ca Nguyn Th Vn Anh th t l ny gp bnh
VCSDK Vit Nam l 87%."
Khng nguyn HLA-B27 tuy c mi lin quan cht ch vi
cc bnh trong nhm bnh l ct sng (BLCS), nhng khng c
mi tng quan gia HLA-B27 vi mc nng ca bnh cng
nh tin trin ca bnh. Do xt nghim xc nh HLA-B27
khng phi l xt nghim thng quy chn on bnh m
ch c gi tr tham kho khi c nghi ng trn chn on lm
sng hoc trong nghin cu ph h ca bnh.

172

1.2. C c h bnh

sinh

C c h b n h sinh ca bnh V C S D K h i n nay c h a c b i t

r. Tuy bnh VCSDK c m i lin quan vi y u t H L A - B 2 7 ,
n h n g H L A - B 2 7 k h n g p h i l n g u y n n h n sinh b n h . Theo
nhiu n g h i n cu cho t h y H L A - B 2 7 l y u t gen c s, d i
tc ng ca cc y u t mi t r n g n h v i k h u n , thay i m i n
dch... d n n bnh l V C S D K .
1.3. Gii phu bnh
Tn t h n g c b n ca b n h l q u t r n h v i m m n t n h v i
s x m n h i m ca cc t b o lympho, t n g bo, i thc b o
vo cc t chc xng di sn, cc i m b n t n ca g n , d y
chng, bao khp d n n x hoa v calci hoa m b i u h i n sm
nht v i n h n h n h t l t n t h n g khp c n g chu. Q u
trnh vim t i n t r i n m n t n h d n n bao k h p , m n g hot
dch, sn khp x teo, vi hoa, ct hoa v d n h khp.
Tn t h n g v n g ct sng c h y u l p h n t chc m n m
gia dy chng d i trc ct sng v t h n t sng b v i m ko
di dn n vi hoa, ct hoa v to n n h n h n h cu xng.
Qu t r n h x hoa v vi hoa d y chng b n n g o i l a n r n g t o n
b ct sng d n n d n h ct sng t o n n h n h n h "ct sng
t h n cy tre".
2. Triu chng lm sng
2.1. Lm sng
* Khi bnh:
80% b n h n h n mc bnh t u i d i 30, nam c h i m u
t h 90%.
- Bnh t h n g x u t h i n t t (80%) vi cc t r i u chng a u
mi v n g ct sng l n g , t h t lng, c t h c d u h i u cng v

173

hn ch vn ng ct sng bui sng, tnh trng ny c ci

thin sau khi bnh nhn vn ng, tp th dc
Bnh c th xut hin t ngt (20%) vi du hiu au dy
thn kinh hng, vim khp ngoi bin (khp gi, khp bn c
chn...), hoc vim cc im bm gn nh vim gn Achille,
vim gai chu, vim mu chuyn ln.
Thi gian khi pht ko di vi thng n vi nm a s
bnh nhn vn sinh hot v lm vic bnh thng nn thng b
b qua v khng c chn on.
* Ton pht:
- Biu hin lm sng chnh ca VCSDK l tn thng ct
sng v tn thng khp ngoi bin c th xut hin ring r
(th ct sng) hoc phi hp vi nhau (th phi hp). Khc vi
cc nc Ty u, Vit Nam bnh VCSDK ch yu l th phi
hp vi tn thng ct sng v cc khp ngoi bin trm trng,
bnh nhn chn on mun iu tr khng ng nn t l tn
ph kh cao.
- Vim khp ngoi bin:
+ Khp tn thng: vim mt hoc vi khp ch yu chi
di (khp gi, khp bn c chn, khp hng...), vi biu hin
lm sng nh au khp, vim khp, hn ch vn ng, c th c
trn dch khp (khp gi).
+ Vim cc im bm gn: hay gp nht l vim gn Achille,
vim cn gan bn chn vi biu hin lm sng l au vng gt
chn, vim mo chu, vim mu chuyn ln, vim li c trc
xng chy...
- Ct sng:
+ au ct sng l mt trong nhng triu chng xut hin
cc giai on khi pht, ton pht v tin trin ca bnh. Bnh
nhn c triu chng au ct sng tht lng, ct sng lng hoc

174

ct sng c m t h m n g y c n g t n g n h t l v m v s n g d n
n b n h n h n r t k h xoay tr m n h , r t k h dy v o b u i
s n g . T n h t r n g n y g i m dn vo ban n g y sau k h i b n h n h n
t p t h dc hoc v n ng sinh hot.
+ a u ct sng k m theo h n c h v n ng ct sng t h t l n g
cc ng t c ci, n g h i n g , nga, xoay, b i u h i n t r n k h m
lm s n g n h ct sng m t ng cong sinh l, teo c c n h ct
sng, v xc nh b n g cc n g h i m p h p :
K h m ct sng c: h n ch v n ng ct s n g c m i t
t h (ci, nga, n g h i n g , quay), ct sng c n q u mc ra
trc, g i m k h o n g c c h cm-c, t n g k h o n g c c h c h m - t n g .
K h m ct sng lng: ct sng ngic g, gin lng ngc gim.
K h m ct sng t h t lng: g i n ct sng g i m ( n g h i m
p h p Schober (+): b n h n h n n g t h n g , h a i gt c h n c h m
l i . T h y thuc n h d u mt i m t r n ct sng ngang v i t
t h t l n g n m L, sau o ln p h a t r n ct sng m t o n 10
em. Hng d n b n h n h n ci xung t i mc t i a , o l i
khong cch n h du: n g i b n h t h n g k h o n g c c h d n
ct sng t n g ln t r n 5 em, cn b n h n h n V C S D K k h o n g
cch n y t n g r t t hoc k h n g thay i). K h o n g cch tay t
gim ( N g h i m p h p tay t : b n h n h n n g t h n g , h a i gt
chn c h m l i , ci xung h t sc. T h y thuc o k h o n g c c h
t u ngn tay n n g n c h n ci, b n h t h n g k h o n g c c h
ny u i 20 em, n g i b n h k h o n g c c h tay t t r n 20 em
t h m t r 30-50 em.
a u v n g khp c n g chu: l d u h i u sm, b n h n h n
t n g cm gic a u k h i n v o v n g k h p c n g c h u v c t h
a u l a n dc x u n g hai m n g v i theo ng i ca d y t h n
k i n h toa.
- Cc t r i u chng n g o i khp:
+ T o n t h n : c t h c m t mi, st nh, n ung km, g i m cn.

175

+ Tn thng mt: vim mng mt th mi, vim mng mch

nho, vim mng b o... Vit Nam tn thng ny t gp (24%), trong khi cc nc Ty u t l ny l 20-35%.
+ Tn thng ni tng: h ng mch ch, x phi, nhim bt
thn... ni chung t gp nhng tin lng thng nng.
2.2. Xt nghim
* Xt nghim X-quang: l xt nghim quan trng nht trong
chn on xc nh bnh v giai on bnh.
- Chp X-quang qui c: c gi tr chn on cao, gi thnh
thp v c th p dng mi c s y t.
Khp cng chu: l du hiu sm chn on, thng tn
thng c 2 bn, c 4 mc tn thng:
+ Giai on : khe khp rng ra do mt calci di sn.
+ Giai on li: khe khp m, c hnh rng ca ra khe khp
(tem th).
+ Giai on ni: x hoa khp, c th dnh mt phn khp.
+ Giai on IV: dnh khp cng chu hon ton (mt khe khp).
Ct sng: bao gm cc mc tn thng t nh n nng,
mt ng cong sinh l, x hoa v calci hoa dy chng cnh ct
sng (du hiu ng ray), nu calci ha dy chng trc ct
sng (Romanus). Hnh nh cu xng v "t sng cy tre"
giai on mun.
- Khp ngoi vi: hnh nh hp khe khp, bo mn chm khp
mt calci...
- Chp ct lp vi tnh (Citi-scanner), chp cng hng t ht
nhn (MRI): c th xc nh c tn thng khp cng chu
giai on sm khi cha pht hin c bng phng php chp

176

X-quang quy c. N h n g y l k t h u t k h n g t h p d n g
rng r i t r n l m s n g v gi t h n h cao, t r a n g t h i t b t t i n .
* Xt nghim mu: cc ch s v bng chng vim nh: mu
lng t n g , protein c p h n n g (CRP) t n g a s b n h n h n
VCSDK.
* HLA-B27: t l dng tnh l 80-90%, nhng khng phi l
xt n g h i m t h n g quy c h n o n b n h v t i n lng b n h v
gi t h n h xt n g h i m q u cao. Tuy n h i n y l x t n g h i m c n
thit gp p h n v o c h n o n xc n h b n h V C S D K n h n g
bnh n h n ch c b i u h i n l m s n g m k h n g c t n t h n g
khp c n g chu t r n p h i m X-quang.
* Chc nng h hp: gip cho tin lng bnh.
3. Chn on
3.1. Chn on xc nh
Da vo tiu chun chn on Nu c (New York) nm 1984:
* Tiu chun lm sng:
- Tin s hay hin ti c au vng tht lng, hay vng lngtht lng.
- Hn ch vn ng tht lng c 3 t th ci, nga-nghing,
v quay.
- gin lng ngc gim.
* Tiu chun X-quang: vim khp cng chu (giai on III, IV).
Chn on xc nh khi c mt tiu chun lm sng v mt
tiu c h u n X-quang.

177

3.2. Chn on phn

bit

* Cc bnh ct sng: vim t sng do vi khun (bnh nhn

st, rt au vng t sng b tn thng, chp X-quang c hnh
nh tn thng thn t sng...), thoi hoa ct sng (thng gp
ngi ln tui, khng c biu hin vim ct sng trn lm sng
v xt nghim), au, g t sng trong bnh Scheuermann,
bnh Forestier.
* Cc bnh khp: lao khp hng, gout, thoi hoa khp hng,
khp gi...
4. Tin trin v phn loi
Bnh VCSDK tin trin mn tnh vi cc t ti pht dn
n teo c, dnh khp, cng ct sng v bnh nhn c th b
tn ph.
Bnh VCSDK gm c cc th lm sng chnh: th ct sng,
th gc chi, t h hn hp, th ph n.
5. iu tr
Mc ch iu tr: nhm kim sot au, v vim, duy tr kh
nng vn ng khp ct sng, v phng bin dng khp, ct sng.
5.1 Vn ng liu php
Vn ng gi mt vai tr rt quan trng trong qu trnh iu
tr nhm hn ch teo c, dnh khp, bo ton v duy tr chc
nng vn ng ct sng, khp cho bnh nhn. T vn, cung cp
cc thng tin v hng dn cho ngi bnh tp cc bi vn ng
liu php: vn ng ct sng v khp cc t th c nng ng:
nm ng trn nn cng vi gi mng hoc khng c gi, khng
ngi xm, khng mang vc nng.... Tham gia cc mn th thao
thch hp nh bi, i b, i xe p... Nu c iu kin c th

178

phi hp vi cc p h n g p h p i u t r v t l t r l i u k h c n h
chiu tia hng ngoi, siu m , b f a r a f i n , t m nc k h o n g , t m
b n , xoa bp... Trong giai o n b n h t i n t r i l cp t n h : a u ,
h n c h v n ng ct sng n h i u , v i m cc khp ngoi b i n ,
bnh n h n p h i c ngh ngi, v n ng n h n h n g , t r n h cc
bi t p khp q u n n g .
5.2. iu tr thuc
Thuc chng v i m k h n g steroid:
* Indomethacin: 2 5 - 7 5 m g / n g y l thuc c h i u q u t t t r o n g
k i m sot bnh v chi p h t h p , t u y n h i n c n t h n t r n g ch
nh i vi b n h n h n c b n h v i m lot d d y .
* Cc thuc g i m a u chng v i m k h n g steroid k h c ; t u y
tng i u k i n k i n h t v p n g ca b n h n h n c t h la
chn mt t r o n g cc thuc sau: naproxen (lOOOmg/ngy),
proxicam ( 2 0 m g / n g y ) , V o l t a r e n (50-100mg/ngy), Mobic (7.515mg/ngy).... cn l u t c d n g kch n g d d y ca n h m
thuc n y k h i i u t r b n h n h n .
Sulfasalazin: 5 0 0 - 1 0 0 0 m g / n g y , c h i u q u t t t h b n h
phi hp, v i m khp ngoi b i n v c b i t giai o n s m
ca bnh.
* Cc thuc k h c :
cyclophosphomid...

m u i v n g , chloroquin,

methotrexat,

- H i n nay cc n h m thuc sinh hc mi n h cc k h n g t h

chng y u t hoi t u T N F a : i n l i x i m a b (Remicade),
Entanecept... a n g c p d n g i u t r c h i u q u t t cho
bnh V C S D K , t u y n h i n v gi t h n h i u t r r t t n n c h a
t h i u t r ph b i n cho n g i b n h .
- Corticoid: k h n g n n i u t r corticoid t o n t h n cho b n h
n h n V C S D K v h i u q u k h n g t t v c r t n h i u t c d n g

179

ph. Ch nn ch nh iu tr t i ch: tim khp, tim cc im

bm gn...
5.3. Phu thut chnh hnh
Thay khp hng hon ton, thay chm khp hng, thay khp
gi c ch nh trong cc trng hp bnh n h n b dnh khp,
bin dng khp iu tr khng phc hi bng cc phng php
iu tr ni khoa.
VCSDK l mt bnh vim khp mn tnh, cn phi c
chn on v iu tr sm, iu tr ng ngay t i cc c s y t
a phng nhm hn ch tnh trng dnh khp, bin dng khp
gip nng cao cht lng sng ca ngi bnh.
li. BNH VIM KHP PHNNG
1. i cng
Vim khp phnng (VKP) l mt bnh vim khp v
khun xut hin sau mt nhim trng mt c quan no
trong c th (ch yu l nhim khun h tit niu sinh dc v
h tiu hoa). VKP l mt bnh mang tnh cht h thng khng
ch gii hn tn thng khp m cn mt s c quan khc
nh mt, h tit niu sinh dc, h tiu hoa...
Vim khp phnng (VKPU), do Hans Reiter m t ln u
tin vo nm 1916 v c tn gi l bnh Reiter vi ba triu
chng in hnh l vim kt mc mt, vim niu o v vim
khp. Bnh VKP thng gp ngi tr tui, 90% bnh nhn
t 20-40 tui, t l mc bnh nam v n gn ngang nhau.
Mc v tin trin ca bnh rt khc nhau, c khoang 1020% bnh vim khp phn ng l biu hin giai on sm ca
bnh vim ct sng dnh khp. V vy vic chn on v iu tr
sm bnh vim khp phn ng s gip cho ngi bnh trnh

180

c n h n g h u q u n n g n v chc n n g v n ng khp v
k h n n g lao ng.
1.1. Dch t hc
Do mc n n g n h ca b n h V K P r t k h c n h a u n n
nhng t r n g hp n h u r t d b qua v v y t l mc b n h
ca V K P r t k h c xc n h c h n h xc. Tuy n h i n theo
nghin cu ca n h i u t c g i t h t mc bnh s n g y c n g gia
tang c n g tc t n g ca cc b n h ly t r u y n qua ng t n h
dc cng n h s h i u b i t v b n h v k h n n g c h n o n b n h
cua c n b y t c n n g cao, M t l mc b n h V K P l
40/100.000 d n v t l m i mc b n h V K P h n g n m M l
3,5 trng hp t r n 100 000 d n .
1.2. C ch bnh sinh
C c h b n h sinh ca b n h V K P h i n nay c h a c b i t r
VKP l mt t n h t r n g v i m khp v k h u n x y ra sau m t
nhim k h u n n o t r o n g c t h m k h n g t m t h y v i k h u n
t i khp. V K P l h u q u ca q u t r n h t n t i dai d n g ca
k h n g n g u y n v i k h u n v s khuych t n ca k h n g n g u y n v i
khun hoc phc hp m i n dch l n g ng t i k h p v y
chnh l m t t r o n g n h n g n h n t k h i p h t v duy t r p h n
ng vim t i m n g h o t dch khp.
Yu t gen cng g i m t vai t r quan t r n g t r o n g b n h sinh
ca bnh V K P , c b i t l y u t H L A - B 2 7 d n g t n h 3070% b n h n h n V K P .
2. Triu chng
2.1. Lm

sng

* T i n s: cn p h i k h a i t h c k t i n s n h i m k h u n ng
t i t n i u sinh dc, n g r u t t r o n g t h i gian 6-24 t h n g (c
b i t l t r o n g t h i gian 4-8 t u n t r c k h i x u t h i n v i m khp).

181

* Vim khp: thng vim mt hoc vim vi khp ln ch

yu chi di v khng i xng. Cc khp hay b tn thng
nht l: khp gi, khp bn c chn, khp bn ngn chn, khp
cng chu... Biu hin lm sng: au, vim khp, hn ch vn
ng, c th c trn dch khp gi, khp bn c chn. Nhiu
trng hp bnh VKP c tn thng khp nh nh khp bn
ngn tay, bn ngn chn n c to nn hnh nh ngn tay,
ngn chn hnh khc di (hnh xc xch).
* Vim im bm gn: l c im lm sng in hnh ca
bnh VKP vim gn Achille, vim cn gan bn chn, vim
im bm gn mo chu... l cc im bm gn hay b tn
thng nht.
* Hi chng tit niu sinh dc: vim niu o (i kh, i
but) hay gp nam gii. n gii hay do vim c t cung
nhng thng din bin m thm khng biu hin triu chng
trn lm sng.
* Hi chng mt: vim kt mc, vim vng mc thng kt
hp vi au mt, s nh sng i khi c th gim th lc cp tnh.
* Hi chng d dy, rut: au bng,a chy ko di khng r
nguyn nhn, khng nh hng n sc khoe.
* Tn thng da v nim mc: xut hin da v mng, vim
lot bao qui u, vim lot li, nim mc ming....
* Tn thng ni tng: rt him gp, c th gp vim mng
ngoi tim, h ng mch ch v thng l tin lng rt nng.
2.2. Xt

nghim

Khng c xt nghim c hiu chn on VKP nhng

cn tin hnh lm mt s xt nghim chn on phn bit
vi mt s bnh khc:
* Mu: cng thc mu, mu lng. Cc xt nghim sinh hoa mu.

182

* Nc t i u : protein, t bo
* Dch khp: m u sc, s lng bch cu...
* N u i cy: nc t i u , dch khp
* Xt nghim min dch xc nh s c mt ca cc k h n g nguyn,
khng th ca mt sloi vi khun: Chlamydia, Salmonella...
* X-quang: chp X-quang cc khp t n t h n g .
3. C h n o n
3.1. Chn on xc

nh

C t h p d n g m t t r o n g hai t i u c h u n c h n o n b n h
VKP: t i u c h u n c h n o n ca A m o r v t i u c h u n c h n
on ca n h m n g h i n cu b n h l ct sng c h u u:
Chn o n xc nh:
* Tiu c h u n c h n o n ca Amor (1983) gm cc t i u c h u n
sau:
- Vim v k h u n m t hoc v i khp k h n g i xng.
- l a chy, hay h i chng l .
- Vim m n g t i p hp m t .
- Vim n i u o, c t cung.
- Vim lot t r t da, n i m mc.
- C a: H L A - B 2 7 (+), hoc c t i n s gia n h b n h V C S D K .
- Cc xt n g h i m t m t h y t c n h n gy b n h trc t i p hoc
gin t i p .
B n h V K P c c h n o n k h i c 4/7 t r i u chng t r n . Tuy
n h i n t i u c h u n ca A m o r h i n nay t p d n g v n h y t h p .

183

* Tiu chun chn on ca nhm BLCSTHTAT gm c:

1. au, vim t sng. Hoc
2. Vim mng hot dch khp (ch yu l khp chi di v
khng i xng).
C km theo mt trong cc hi chng sau y:
- C tin s gia nh bnh vim ct sng dnh khp.
- Bnh vim khp vy nn.
- Bnh l rut.
au vng chu hng.
Bnh l phn mm quanh khp.
- Vim khp cng chu.
- Vim niu o sinh dc.
3.2. Chn on phn

bit

Bnh VKP cn chn on phn bit vi cc bnh sau:

* Vim khp nhim khun: bnh nhn st, cc biu hin ca
nhim khun t i ch hoc ton thn, khp vim cp tnh, tn
thng vim thng lan toa c t chc mm canh khp, c th
xc nh c vi khun gy bnh bng cc xt nghim dch
khp, mu...
* Bnh gt: thng gp nam, tui trung nin, vim khp
cp tnh hay gp nht l khp bn ngn chn ci, khp bn c
chn, khp gi, xt nghim acid uric mu tng cao, c th tm
thy tinh th urat trong dch khp...v p ng tt vi iu t r i
bng colchicin.
* Vim khp dng thp: c bit vi th bnh vim khp
dng thp t h mt khp.

184

* V i m khp trong b n h suy g i m m i n dch mc p h i b n h

n h n n h i m H I V : bnh n h n c t i n s nghin h t ma tuy, m i
dm, t h t r n g suy k i t , st ko di, n h i m lao, n h i m n m ,
hch to, v i m lot da v n i m mc, xt n g h i m c H I V
dng tnh....
4. iu tr
Thuc chng v i m k h n g steroid: mc ch k i m s o t v i m
mng hot dch: Voltaren (50-100mg/ngy, indomethacin (50lOOmg/ngy), Mobic (7,5-15mg/ngy)
- Sulfasalazin: 1 0 0 0 - 2 0 0 0 m g / n g y , c h i u q u t t t r o n g i u
tr k i m s o t bnh, c b i t n h n g b n h n h n c n h i m
Chlamydia trachomatis t h i gian i u t r p h i k o d i 3-6 t h n g
mi t c h i u q u .
- L i u p h p c c h m i n dch: Methotrexat, azathioprin...
- Corticoid: ch c h i u q u t t k h i i u t r t i ch: t i m n i
khp, t i m cc i m b m g n .
- K h n g sinh: ch i u t r k h i xc n h c n g u y n g y
bnh: quinolon, tetracyclin, lymecyclin...
5. Tin lng
Tin lng V K P n h n chung l t t , b n h V K P c t h k h i
hon t o n , mc d t h i gian mc b n h c t h ko d i t v i
tun, vi t h n g n v i n m . Tuy n h i n b n h V K P hay t i
p h t k h n g p h i ch do t n h t r n g t i n h i m k h u n m cn do
cc stress, cc c h n t h n g k h n g c h i u k h c . M t i u l u
l c k h o n g 10-20% b n h v i m khp p h n n g l b i u h i n ca
giai o n sm ca b n h v i m ct sng d n h k h p , v v y vic
chn o n sm, i u t r n g v kp t h i b n h V K P s c h i u

185

qu tt trong iu tr v kim sot bnh n h n t r n h c cc

tn thng xng khp, bin dng khp v nguy c b t n ph.
III. VIM KHP VY NN
1. i cng
Vim khp vy nn (VKVN) chim t l t 5-7% bnh nhn
mc bnh vy nn (loi tr nhng bnh n h n vy nn c yu t
dng thp dng tnh v nhng bnh nhn nghi ng phi hp
vy nn v bnh vim khp dng thp), v y nn l mt bnh
thng gp chim t l 1-2% trong cng ng, bnh thng xut
hin tui 20-30. C ch bnh sinh ca bnh vim khp vy
nn hin nay cha c bit r, mc d yu t gen c coi l
mt trong nhng nguyn n h n gy bnh, v t mc bnh ny
ngi song sinh l 70%. Tuy nhin mt s yu t mi trng,
nhim khun khc cng c cp n, bi v rt nhiu tn
thng vy nn phi hp vi nhim lin cu, t cu nn vim
khp vy nn cn l mt th ca bnh vim khp phn ng.
Vim khp vy nn c tnh gia nh (50%), t l mc bnh nam
v n l 1:1.
2. Triu chng
2.1. Lm sng
- Vim vi khp:
+ Vim vi khp chim t l 70% bnh nhn VKVN.
+ Vim vi khp khng i xng khp ln nh khp gi, v
ch yu l mt s khp khc nh khp bn ngn gn, khp bn
ngn xa, khi xng bn chn.
+ Sng n mt hoc nhiu ngn tay, ngn chn (hnh xc xch,
di ln).

186

- V i m n h i u khp i xng: bnh cnh gn ging n h v i m

khp d n g t h p , y u t d n g t h p m t n h v c h i m t l 15%
bnh n h n V K V N .
- Vim cc khp lin t k h n g i xng: v i m cc khp lin
t k h n g i x n g tay, c h n c h i m t l 10%.
- Vim k h p b i n dng: c h i m t l 5% b n h n h n V K V N ,
biu h i n l m s n g b i n d n g co r t cc n g n tay, c h n do t i u
xng v calci hoa t chc m n c n h khp.
- V y n n p h i hp v i b n h ct sng:
Chim t l 5% bnh n h n V K V N , c cc t r i u cVing l m s n g
v hnh n h t n t h n g khp c n g chu t r n p h i m X-quang ging
nh bnh vim ct sng d n h khp v 40% bnh n h n thuc
nhm n y c HLA-B27 d n g t n h .
- T n t h n g vy n n da, m n g .
- Tn t h n g n g o i khp:
Bnh l vim m t c h i m t l 30% bnh n h n V K V N , ngoi ra
c t h c cc t r i u chng st, gy s t , cng khp b u i s n g , a u
ct sng t h t lng...
2.2. Xt nghim
- Y u t d n g t h p R F d n g t n h 10% b n h n h n v i m
khp vy n n .
- M u l n g t n g giai o n t i n t r i n ca bnh.
- Acid uric m u t n g 10-20% b n h n h n V K V N .
- B th huyt thanh tng.

187

 X-quang: hnh nh mt calci, bo mn u xng, lot

xng ngn tay, chn... hoc hnh nh tn thng khp cng
chu, ct sng ging nh tn thng trong bnh vim ct sng
dnh khp.
3. Chn on
Chn on phn bit:
- Hi chng Reiter: thng tn thng khp ln chi di v
c t l HLA-B27 dng tnh cao hn bnh VKVN v khng c
tn thng vy nn da.
- Gt: bnh nhn vim khp vy nn khng tm thy tinh
th u r t trong dch khp.
- Vim khp dng thp: da vo tn thng da, mng v
khng c ht thp di da bnh nhn VKVN.
4. iu tr
4.1. Vt l tr liu
iu tr phi hp vi iu tr thuc phc hi chc nng
vn ng khp, chng teo c, dnh khp. Hn ch tn thng da,
tm bn, t m nc khong, chiu tia cc tm...
4.2. Thuc
* Thuc chng vim khng steroid: mc ch kim sot
tnh trng vim khp. Tuy tng trng hp bnh nhn c th
iu tr mt trong cc loi thuc sau y:
Ibuproen: 600mg, 4 ln mt ngy.
Indomethacin: 200mg/ngy, c hiu qu tt c hai th ct
sng v th ngoi bin.

188

- Piroxicam: 2 0 m g / n g y
* Thuc thay i h n h t h i bnh:
- M u i v n g : c h i u qu t t trong i u t r V K V N t h ngoi
bin. L i u d n g : t i m bp l i u lOmg/tun v t n g d n trong cc
tun t i p theo 20-30-40mg/tun. N u t h i u q u t t d n g l i u
duy t r 5 0 m g / t h n g t tng l i u l lOOOmg.
- Thuc chng st rt: c
hydroxychloroquin 2 0 0 m g / n g y .

hiu

qu

kim

ch

bnh

- Sulfasalazin: lOOOmg/ngy.
- Cc thuc c c h m i n dch: methotrexat 7,5-25mg/tun.
- Corticoid: r t t h n t r n g k h i i u tr t o n t h n v c nguy
c lm t n g bnh k h i g i m l i u hoc k h i ngng thuc.
- T i n v i t a m i n E: c h i u q u t r n t h n g h i m l m s n g sau
6 tun n 3 t h n g , v i l i u i u t r 3 0 m g / n g y .
- Cyclosporin A: c h i u q u t h V K V N n n g n h n g t h n
trng theo di lng creatinin m u v h u y t p t r o n g q u t r n h
iu tr.
- L i u p h p tia: i u t r p h i hp methoxypsoralen v i tia t
ngoi sng d i A c h i u q u vi V K V N ngoi v i c t n t h n g
da nhiu.
* Phu t h u t chnh h n h k h p i vi n h n g b n h n h n b i n
dng khp n h i u .
5. Tin lng
Tin lng b n h p h thuc vo mc t n t h n g da v s
lng khp v i m , c k h o n g 5% b n h t i n t r i n n n g d n n
tn ph.

189

B N H L VIM I M B M G N V
PHN M M

ThS. Trn Th T Chu

I. I CNG
1. nh ngha
- Vim gn (Tenoditis): l tnh trng vim t i mt gn.
- Vim bao gn (Tenosynovitis): l tnh trng vim bao hot
dch bao quanh gn, lm sng au v cn tr s vn ng ca gn.
- Vim im bm t n ca gn: vim quanh vng bm tn ca
gn vo xng.
- T i mt s v tr gii phu c di mc (vng x) to vi nn
xng thnh ng hm, trong ng hm c lt bi bao hot
dch v trong cng l gn, c th c c dy thn kinh v mch
mu. Khi bao hot dch pha trong b tn thng s sng phng
ln v chn p cc thnh phn bn trong gy ra cc triu chng
gi l hi chng ng hm.
2. Nguyn nhn gy bnh
- Cc vi chn thng do cc hot ng qu mc ko di, lp
i lp l i do ngh nghip, luyn tp th thao, thi quen sinh
hot. y l nguyn nhn thng gp nht.
- Mt s bnh l: vim khp dng thp, vim khp vy nn,
vim ct sng dnh khp, gt, thoi hoa khp, i tho ng.
- Cc d t t gy lch trc ca chi l mt yu t nguy c gy
tn thng cc phn mm quanh khp.
- Vim phn mm quanh khp do nguyn n h n nhim
khun.

190

- V i m g n do s d n g thuc: hay gp do s d n g thuc

k h n g sinh thuc n h m quinolon.
li. TRIU CHNG LM SNG
1. Biu hin lm sng
- a u v t r g n b t n t h n g , c t h a u lin tc hoc a u
t n g k h i v n ng, a u t i ch hoc lan dc theo c c g n b t n
thng, c t h gy h n c h v n ng khp lin quan.
- K h m t i ch: c t h s n g hoc k h n g s n g , c t h c n n g
, n vo a u chi, c t h s t h y u cc n h n i dc t r n g n .
- K h m v n ng: l m m t s ng t c co d u i c c g n b
tn t h n g t h y a u t n g , c t h c h n c h v n ng khp lin
quan, c lc g i m h n so vi b n l n h .
- T o n t h n : h u h t t r n g hp k h n g
t h n t r n h n g t r n g hp v i m g n do
trong mt s b n h l n h v i m khp d n g
dnh khp t h c t h c cc b i u h i n k m
nhim t r n g , cc b i u h i n ca b n h c h n h .

nh hng n t o n
n h i m k h u n hoc
t h p , v i m ct sng
theo n h h i chng

2. Triu chng cn lm sng

Xt nghim mu: nhn chung khng c thay i tr nhng
trng hp vim g n hoc bao g n t r o n g cc b n h l k h c .
Chp X-quang: h u n h k h n g c h n h n h b t t h n g
nh ch v i m g n hoc bao g n t h n g t h n g . N u v i m
hoc bao g n t r o n g n h n g b n h l k h c t h c t h c h n h
tn t h n g k h p c h i u v i b n h c h n h . C t h t h y h n h
calci hoa u g n .

nu
gn
nh
nh

S i u m g n b n g u d t n s cao (7,5 - 20 M H z , v i khp

vai v khp h n g d n g u d 3,5 - 5 M H z ) g i p n h gi p h n
m m q u a n h khp. C t h t h y h n h n h kch thc g n b t n
t h n g to h n , g i m m v c t h c h n h n h t dch quanh

191

gn b tn thng. Nhng trng hp c t gn c th thy

hnh nh mt lin tc ca gn. C th thy hnh nh calci hoa
u gn, c th thy hnh nh bao gn dy ln nu c vim bao
gn. Tuy nhin nhy v c hiu ca phng php siu
m khng cao c bit nhng v tr kh t u d hoc
nhng v tr qu nng.
Chp cng hng t cho thy hnh nh ca ton b khp v
phn mm quanh khp b tn thng do gip nh gi chnh xc
c v tr, kch thuc, tnh trng tn thng ca gn v bao gn.
3. Phn loi
* Vim gn vng bm tn
- Vim gn khu vc khuu tay: hay gp nht l li cu ngoi
xng cnh tay.
Vim gn khu vc hng: vng cc mu chuyn, ngi.
- Vim gn khu vc gi: li cu trong v ngoi xng i.
- Vim gn khu vc c chn: gn Achille.
* Vim bao gn:
- Vim bao gn n thun: hay gp hi chng ng hm c
tay, hi chng ng hm ng gt.
- Vim bao gn co tht: hay gp bnh De Quervain l biu
hin vim bao gn c dng di v dui ngn ngn tay ci.
* Vim gn dng nt ca gn gp cc ngn tay gy du hiu
ngn tay l xo.
HI. CHN ON
1. Chn on xc nh
Ch yu da vo triu chng lm sng ti ch b tn thng
siu m. Trong nhng trng hp chn on khng r rng co
th phi s dng cng hng t.

192

2. C h n o n p h n b i t
Cn chn on phn bit vi mt s tn thng ca nhng
t h n h p h n k h c quanh k h p n g o i g n v bao g n n h : t chc
di da, d y , r t h n k i n h , xng, m n g xng...
IV. MT S VIM GN THNG GP
4.1. Vim li cu ngoi xng cnh tay

Vng
au

Li cu ngoi
xng cnh tay

Hnh 48. Vim li cu ngoi xng cnh tay

193

L im bm tn ca gn cc c dui chung cc ngn, ui

ngn t, tr sau, nga ngn...
Khm: nhn bn ngoi t thay i, nu bnh nhn xoa bp
nhiu c th thy sng n nh, n nh vo li cu ngoi thy
au chi, gim c lc bn tn thng.
Cozens test:
- Bc s t ngn tay ci ln li cu ngoi xng cnh tay
bnh nhn, gi c nh khuu tay ca bnh n h n t t h
90, tay cn l i nm bn tay bnh nhn. Bnh nhn s thy
t i li cu ngoi khi bc s vn ng p sp cng tay v
bnh n h n dui c tay c i lc ca bc s.

ca
gp
au
khi

Bc s dui thng khuu tay bnh nhn, p sp cng tay v

gp c tay bnh nhn ra ngoi s gy au t i li cu ngoi.

vng au
Hnh 49. Vim mm trm quay
Cn lm sng:
Xt nghim mu: nhn chung khng c thay i.

194

Chp X-quang: h u n h k h n g c h n h n h bt thng. C

t h t h y h n h n h calci hoa u g n .
P h n ln k o d i m t t h i gian r i t k h i n h n g hay t i
p h t c b i t l n h n g t r u n g hp c calci hoa.
4.2. Vim bao gn mm trm xng quay (bnh De
Quervain)
L bnh l vim bao gn c dng di v dui ngn ngn tay
ci do n h p h u t h u t n g i T h y S t n l De Q u e r v a i n p h t
hin n m 1895.
Bnh thng c dng di v dui ngn ngn ci trt d dng
trong bao gn. K h i bao n y b v i m s c h n p cc t h n h p h n
bn trong gy a u v h n c h v n ng n g n ci.
- Nguyn nhn: hay gp ph n, do vn ng ngn ci qu
mc ko d i n h git, b con, dt... Cc n g u y n n h n k h c c
t h gp n h c h n t h n g d n g n g n ci q u mc, v i m k h p
dng thp, lao, so sau p h u t h u t hoc k h n g r n g u y n n h n .
T r i u chng l m s n g :
- Sng au vng mm trm xng quay, au tng khi vn
ng ngn ci, a u lin tc, a u n h i u v m . a u c t h lan
ra ngn ci v l a n ln c n g tay.
S thy bao gn pha ngoi mm trm quay dy ln, c th
c n n g , n t h y a u chi.
- Khi vn ng ngn ci c th nghe thy ting ku ct kt.
- Test Finkelstein: gp ngn ci vo trong lng bn tay, nm
cc ngn tay t r m l n n g n ci, u n c tay n g h i n g v p h a t r .
K h i b n h n h n t h y a u chi v n g g n d n g d i v g n d u i
ngn ci hay gc n g n ci l t r i u chng ca v i m bao g n De
Quervain.
Siu m c th thy bao gn dy ln v c dch bao quanh ...

195

4.3. Ngn tay l xo

L tnh trng vim bao gn ca cc gn gp cc ngn tay gy
cht hp bao gn. Mt s trng hp gn gp b vim xut hin
cc x, lm di ng ca gn gp qua vng ngn tay b cn tr.
Moi ln gp hay dui ngn tay rt kh khn, bnh n h n phi c
gng mi bt c ngn tay ra hoc phi dng tay bn lnh ko
ngn tay ra nh kiu ngn tay co l xo. V vy bnh c tn l
ngn tay l xo.
Triu chng lm sng:

Hnh 50. Ngn tay l xo

- au ngn tay t i v tr bao gn b vim v t i cc x, kh c
ng ngn tay. Triu chng ny nng hn vo bui sng, mi
ng dy.

196

- N g n tay c t h b k t t t h gp vo lng b n tay hoc

dui t h n g
- C t h c t n t h n g mt hoc n h i u n g n tay c n g mt lc.
- K h m n g n tay c t h c s n g , s dc g n gp c t h t h y
cc x dc t r n g n gp n g n tay.
- Thng s t h y cc x v t r khp t b n n g n tay, cc x
di ng k h i gp d u i n g n tay.
4.4. Hi chng ng hm c tay
Trong ng hm c tay c gn c gp ngn ci di nm
trong bao hot dch quay, g n cc c d u i n n g v s u cc n g n
nm trong bao hot dch t r , gia hai bao hot dch n y l t h n
kinh gia. K h i cc bao h o t dch n y b v i m s g y s n g n
chn p t h n k i n h gia g y ra cc t r i u chng n g h m
c tay.
* Nguyn nhn:
- Vim khp dng thp
- Cc chn thng vng c tay: gy xng ca nhm xng
c, sai khp x n g b n nguyt, g y c tay k i u Pouteau Colles.
- Mt s ngh nghip s dng c tay nhiu: p, vn xoay...
- N h i u t r n g hp k h n g r n g u y n n h n .
* Triu chng lm sng:
- Ri lon cm gic vng thn kinh gia chi phi, bnh nhn
thy t v a u b u t cc u n g n tay ci v n g n hai, ba v
vng gan tay c b i t k h i b n h n h n l m ng t c d u i c tay,
thng a u lin tc, t n g v m , n n g ln k h i t h i t i t l n h .
- V n g c tay c t h s n g n h so v i b n l n h .
- Khm: lm mt s nghim php lm tng sc p ln ng hm.

197

+ Dui c tay ht c, dng ba phn x g vo vng c tay gy nn

t v au cc ngn , 2,3 v dc 1/2 ngn 4 (du hiu Tinel).
+ Dng dy gar tht cht phn trn cng tay, sau mt thi
gian ngn thy au nh trn.
+ Nghim php gng
km ca ngn ci v ngn
tr thy c lc gim r so
vi bn lnh

H H ^ ^ H
^^^^^^^^B

Dy chng c
y

+ Mt s trng hp
nng hoc vim ko di s
thy teo c m ci v gim
cm gic nng ca cc
ngn , 2, 3 v 1/2 ngn 4.
Cn lm sng

ta

Cc gn
gp

- in c: c s dn
Hnh 51. ng hm c tay
truyn bt thng ca
thn kinh gia thuc on cng tay. in c gip phn bit vi
hi chng r - dy thn kinh ct sng c, hi chng m ri
thn kinh cnh tay.
- Siu m bng u d tn s cao thy dy bao gn v dch t
quanh bao gn trong ng hm c tay.
4.5. Vim gn gt
Nguyn nhn: vim gn gt phn ln do hot ng qu mc
bn chn nh nhy, i giy cao gt... Ngoi ra mt s bnh ton
thn nh vim khp dng thp, i tho ng hoc do d tt
lch trc xng gt.
* Triu chng lm sng
- Triu chng au l ni bt, au vng gn gt, au nhiu
khi i l i v khi king chn, au nhc nhi hoc au chi.

198

- K h m g n gt t h y s n g r, t n n g , s c t h t h y n i
cc, n a u ; gp dui m n h b n c h n t h a u t n g .
- T r n g hp n n g c t g n t n g p h n hoc t o n b l m
bnh n h n r t a u v m t k h n n g i b, k h n g n g c
t r n cc n g n c h n . T h test Thompson t h y b t t h n g : cho
bnh n h n n m sp, hai c h n t do ( k h n g t vo v t g).
Bc s d n g tay ln bp c h n b n h n h n . N u k h n g c t
gn gt t h b n c h n s d u i n h , n u c t g n gt t h b n
chn k h n g c ng v c t h t h y c ch lm x u n g dc g n gt
(so v i b n l n h ) .
* Cn lm sng
- Chp X-quang ch c vai tr chn on phn bit vi cc tn
thng xng gt. i k h i t r n p h i m n g h i n g c t h t h y h n h
nh g n gt phng to n h s t n g p h n v i t chc m bao
quanh g n .
- Siu m gn gt thy tng kch thc, gim m siu m
do p h n trong g n , bao g n dy ln, c t h c t dch n g o i
bao g n .
- Chp cng hng t (MRI): tng kch thuc gn gt, bao
gn dy, c t h t g n t n g p h n hoc t o n b (biu h i n bi
cc b t t h n g t n h i u t r o n g g n ) . M R I c n g g i p cho c h n
on p h n b i t vi cc t n t h n g k h c v n g c c h n .
4.6. Vim im bm gn u trn xng mc
- L biu hin ca vim u di gn c nh u i. Nguyn
n h n t h n g do v n ng q u mc n h i b n h i u , leo n i , t p
t h dc...
- Vim u di gn c nh u i biu hin au vng u
t r n x n g m c , a u t n g k h i gp gi hoc k h i n vo. H u n h
k h n g c s n g , t r n h n g t r n g hp b n h n h n xoa bp n h i u
vng au

199

4.7. Vim im bm gn li cu trong xng

chy

Gn chn ngng to bi gn c may, c thon, c bn gn;

bm tn l i cu trong xng chy. Quanh cc gn ny c cc
ti hot dch nh.
- Vim gn chn ngng biu hin sng, au vng li cu
trong xng chy, c th km theo nng, . C khi trn lm
sng kh phn bit vi vim bao hot dch v hi chng dy
chng bn chy ca khp gi. Chn on chnh xc cn s h
tr ca siu m v cng hng t khp gi.
4.8. Vim im bm gn li cu ngoi xng i
Di chu chy tip ni c cng mc i chy lp nng mt
ngoi ca i n bm vo li cu ngoi xng i. Vim di
chu chy thng xy ra ngi chy nhiu.
- Triu chng chnh l au vng li cu ngoi xng i, au
tng khi chy. t khi c sng nng , n vo vng li cu ngoi
xng i c im au chi.
V. IU TR
1. iu tr ti ch
1.1. iu tr khng

dng

thuc

Hn ch vn ng gn b tn thng.
Nhng trng hp au nhiu c th phi c nh tm thi
gn b tn thng bng np, mng bt...
- Chm lnh nu c sng nng .
- Chiu tia hng ngoi, iu tr kick shock.
1.2 Thuc
Thuc gim au thng thng: acetaminophen...

200

Thuc chng v i m k h n g steroid ng ung hoc bi t i ch:

dng t i k h i h t s n g a u .
T i m corticoid t i ch.
- M c ch t i m corticoid t i ch l a corticoid nng cao
ti v t r g n , bao g n b vim. K h i t i n h n h t i m corticoid t i
ch p h i m bo v t r n g t u y t i . Cc c h p h m t h n g
dng l:
+ Hydrocortison acetat (Nng l m l = 25mg): l l o i t c
dng nhanh, t h i gian b n huy n g n .
L i u cho l n t i m quanh k h p t 5-2,5mg (0,2 - 0,5ml) t u y
v tr tim. T i m k h n g q u 3 l n cho m i t i u t r , m i m i
cch nhau 3-4 ngy, m i n m k h n g q u 3 t.
+ Depo-Medrol ( M e t h y l prednisolon acetat, nng m i =
40mg): t c d n g ko d i .
L i u cho mt l n t i m c n h khp t 8 - 2 0 m g / l l n (0,2 0,5ml/lln) t u y thuc v t r , m i m i c c h n h a u 7-10 n g y ,
khng qu 2 l n t r o n g m t t, m i t cch n h a u 3-6 t h n g ,
mi n m k h n g q u 3 t.
+ Diprospan (Betamethason dipropioat, nng l m l = 4mg):
L loi t c dng ko d i .
L i u cho mt l n t i m c n h khp t 0,8 - 2 m g / l l n (0,2 0,5ml/l ln) tuy thuc v t r , m i m i c c h n h a u 7-10 n g y ,
khng q u 2 l n t r o n g m t t, m i t cch n h a u 3-6 t h n g ,
mi n m k h n g q u 3 t.
- Chng ch nh t u y t i t i m corticoid t i ch
+ Cc tn thng do nhim khun, nm hoc cha loi tr
c n h i m k h u n (chng ch n h t u y t i)
+ T n t h n g n h i m t r n g t r n hoc gn v t r t i m .
- Chng ch n h t n g i t i m corticoid t i ch.

201

+ Cc chng ch nh ca corticoid: cao huyt p, i tho

ng, vim lot d dy t trng: phi iu tr v theo di trc
v sau tim.
+ ang dng thuc chng ng hoc c ri lon ng mu.
Cc bin chng do tim corticoid t i ch l rt t nhng c
th xy ra gm:
+ au sau tim vi gi, c th ko di mt vi ngy, thng
hay gp sau tim mi u tin
+ Nhim trng.
+ t gn do tim vo trong gn
+ Teo da t i ch
+ Teo dy thn kinh do tim vo trong dy thn kinh.
+ Mng sc t da: thng gp sau tim vim bao gn De
Quervains do tim qu nng, biu hin mng da mo m, sng
mu. Tnh trng ny s ht trong vi thng n hai nm.
+ Ti pht sau iu tr
a s bnh nhn png tt vi iu tr ni khoa (90-95%)
song t l ti pht cn cao, nht l i vi cc bnh nhn khng
c gio dc cc bin php phng bnh.
2. iu tr bnh chnh nu c
Cc trng hp vim gn, bao gn km theo vim khp dng
thp, vim ct sng dnh khp, i tho ng... cn phi iu
tr ng thi v ko di cc thuc c bn cng vi ch sinh
hot ph hp.
3. Phu thut gii phng chn p, ct b phn vim nu
iu tr n i khoa tht bi

202

VIM K H P TH IU NIN T

PHT

ThS. T r n T h T C h u
I. I CNG
"Vim khp t h i u n i n t p h t " c d n g m t n h n g
trng hp v i m khp t r em m k h n g p h i do n h i m k h u n
hay chn thng. T u i b t u b b n h d i 16, v i cc t r i u
chng v i m khp t n t i t n h t 6 t u n . B n h bao gm 7 t h
bnh, cc tiu c h u n c h n o n cho m i t h b n h da theo p h n
loi ca h i ngh T h p khp hc quc t ( I L A K ) t i C h i L n m
1995 v c c i b i n n m 1997.
Cng n h cc b n h t m i n dch k h c , n g u y n n h n g y
bnh cng c h a c r r n g t u y n h i n n g i ta ni n h i u t i
tnh t r n g n h i m t r n g l m k h i p h t b n h c n g vi s t h a m
gia ca h thng m i n dch.
Bnh

thng

khi

pht

sau

nhim

virus,

Chlamydia

Mycoplasma, Streptococus, Salmonella, Shigella.

Vai t r ca h thng m i n dch: s lng ca cc t b o T b
thay i c b i t l t l CD4/CD8 t r o n g m u ngoi v i . N h n g
bin i ca t b o B cng c ghi n h n . T h n g b i n i v
cht lng n h i u h n v s lng v i s x u t h i n ca cc t
k h n g t h t r o n g m u . C c k h n g t h t h n g gp gm: k h n g
t h k h n g n h n t r o n g t h v i m v i khp, IgG R F t r o n g giai
on sau ca t h v i m n h i u khp. 35% I g M RF, 75% IgG R F v
75% k h n g t h k h n g histon d n g t n h t r o n g b n h v i m k h p
thiu nin t pht.

203

li. TRIU CHNG LM SNG

Mi th bnh c triu chng lm sng, din bin bnh v tin
lng bnh khc nhau.
1. Th khi pht h thng (systemic arthritis)
T l mc bnh l nh nhau gia nam v n, c th xy ra
mi la tui.
- Ton trng: mt mi, st ko di mi ngy t n 2 cn.
- Ni ban: c cc dng dt sn, ban , ban hng mm v
nhanh chng bin mt, thng xut hin khi st cao. Ban l
mt trong nhng triu chng kh quan trng. Nu trong sut c
qu trnh b bnh khng xut hin ban th vic chn on bnh
cn phi cn nhc.
Ni cc hch bch huyt l triu chng kh ph bin. Gan
lch him khi to.
Vim khp: triu chng ny khng nht thit phi xut hin
ngay t khi mi b bnh. Vim khp thng xut hin sau vi
tun b bnh nhng cng c trng hp sau gn chc nm b
bnh mi xut hin vim khp. Thng l vim 2 - 3 khp ln.
Khp thng gp nht l khp gi (60%), sau n khp c tay
v khp bn ngn tay (55%), khp c chn (45%). Vim khp c
tnh cht i xng hoc khng i xng.
Vim tim: l triu chng hay gp. Ch yu l vim mng
ngoi tim vi cc biu hin nh au ngc, kh th, xut hin
trong giai on tin trin ca bnh. C n 80% trng hp
khng c triu chng ca vim mng ngoi tim nhng khi siu
m tim pht hin ra c trn dch mng ngoi tim. Vim ni tm
mc v vim c tim him gp hn.
Tin trin ca bnh rt a dng, c th ch b bnh trong thi
gian ngn khng l i di chng nhng cng c th b bnh c

204

i vi n h n g d i chng b i n d n g khp nng. R t k h t i n lng

c b n h ngay trong giai o n u b bnh tuy n h i n sau 6
t h n g b bnh n u a t r c n h n g t r i u chng sau y t h t i n
lng k m : t n t i cc t r i u chng t o n t h n , v i m n h i u khp,
hemoglobin m u t h p , s lng bch cu v t i u cu t n g , c
th c cc t r i u chng ngoi khp k h c k m theo n h n g m u
ni mch r i r c p h i hp v i suy t b o gan v t n t h n g n o ,
suy chc n n g gan do i u t r b n g salicylat...
2. Vim nhiu khp RF m tnh (polyarthritis: seronegative)
- T l mc bnh gia n v nam l 3 : 1.
- T u i mc bnh: m i la t u i , t u y n h i n p h b i n t r n
10 t u i .
Vim t 5 khp tr ln trong vng 6 t u n , vi cc k h p
a dng, c t h v i m c t n h cht i xng cc k h p n h
vim c t n h cht i xng c cc khp n h v n h hoc
khng c t n h cht i x n g cc khp n h v nh. C c
thng gp: gi, c tay, b n n g n tay, c c h n .

vim
hoc
vim
khp

- Tin lng t h n g t t , i k h i c n h n g t r n g hp b i n
dng khp nng.
3. Vim nhiu khp RF dng tnh (polyarthritis:
seropositive f o r rheumatoid a c t o r )
Bnh gp ph bin tr n > 10 tui
Cc triu chng vim khp ging nh vim khp dng thp
ngi ln: v i m cc k h p nh v n h c t n h c h t i xng,
thng gp v i m khp b n n g n tay t h 2 v t h 3. V i m k h p
t h i d n g h m ko d i k h i n cho h m u i k m p h t t r i n
l i di chng cm l m , h m d i t h t ra sau t o n n v m t n h
m t chim.
i k h i c cc biu h i n ngoi khp n h h t d i da, vim mch.

205

Nu khng c iu tr ng cch bnh d l i di chng

bin dng v ph hy khp nng.
4. Vim mt khp hay vi khp
C ti 50% tr mc bnh vim khp thiu nin t pht c biu
hin vim vi khp. Nu vim mt khp th thng vim khp
go! Mt s trng hp s pht trin thnh vim nhiu Khp sau
mt nm b bnh v c xp vo th "vim trn vi khp".
- Tui b bnh thng khong 2 -3 tui
- T l mc bnh gia nam v n 5 :
- S khp vim < 5 khp.
- Cc khp thng gp: gi, c chn, khuu, c tay, cc khp
nh bn tay v ban chn, vim khp khng i xng. Vim
khp gi n c chim khong 70% trng hp, mt khp c
chn n c chim khong 15% trng hp.
- 25 - 50% c biu hin mt nh vim mng mch nho,
l i nhng di chng nng n mt nh vim dnh mng mt, x
ha c gic mc, c n h n mt, glaucom. Nhng biu hin
mt thng kn o, d b qua.
- Tin lng bnh thng tt nu ch c tn thng khp, tuy
nhin c th gy tnh trng ph i khp c bit l khp gi.
. Chi bn bnh thng di hn bn lnh do tn thng vim kch
thch sn ni tng pht trin. Khi c tn thng mt th tin
lng km.
5. Vim nhiu hn vi khp (extanded oligoarthritis)
- Khi mi khi bnh tr ch vim < 5 khp v vy kh phn
bit vi th vim vi khp nhng ch sau nm b bnh s khp
vim tng ln.

206

- T i n lng t h n g k m . B n h c xu hung t i n t r i n , n h a n h
chng d n n h y x n g v b i n d n g khp.
6. Vim khp thiu nin t pht th vim ct sng dnh
khp ( e n t h e s i t i s related a r t h r i t i s h o c u v e n i l e a n k y l o s i n g
s p o n d y l i t i s h o c pre - a n k y l o s i n g s p o n d y l i t i s )
- Bnh t h n g gp t r l n t 12 - 16 t u i , nam n h i u h n
n tuy n h i n i k h i v n gp t r nh.
- H i chng v i m cc i m b m t n : v i m t i cc i m b m
gn ni b m t n ca cc d y chng v o xng, i m b m t n
cua cc cn cd v bao hot dch v o xng. Cc v t r t h n g gp
nht la i m b m t n cua g n Achille vo x n g gt, gai c h u
trc t r n , i m b m t n ca cc c n c gan b n c h n .
- P h n ln t r c b i u h i n v i m cc khp ngoi v i (82%), ch
c khong 24% t r c b i u h i n t r i u chng ct sng t h t l n g .
Cc khp t h n g gp: h n g , gi, c c h n k h n g i xng, cc
khp nho b n chan. N h n g b i u h i n ct sng t h n g gp
tre ln v t h n g b t u b n g v i m cc k h p chi d i , sau
mt thi gian mi x u t h i n cc t r i u chng ct sng. H i
chng vim i m b m t n l m t c i m r t i n h n h g i p
phn b i t t h bnh n y v i cc t h b n h k h c ca b n h v i m
khp t h i u n i n t p h t .
- T n t h n g m t t h n g gp l v i m m n g m t cp t n h :
mt o v a u (7 - 27%).
- Bnh t h n g t i n t r i n n h a n h , d d n n d n h khp gy
tn ph.
7. Vim khp vy nn
T u i b b n h : 7 - 1 1 t u i
Cc b i u h i n k h p t h n g x u t h i n trc k h i c cc t n
thng da.
207

S khdp vim thng t, c khp ln v khp nh, khng i

xng. Triu chng vim ngn tay (ngn tay hnh khc di) v
nhng tn thng lm mng tay l nhng triu chng rt gi
cho chn on bnh (75%). Khp gi l khp thng gp nht
sau n ngn tay v ngn chn.
Nhng tn thng da ca bnh vy nn cn c tm v pht
hin bt k tr vim khp no c bit l da u, quanh rn,
k mng l nhng vng d b b st.
Tin trin ca bnh rt a dng, c trng hp nhng tn
thng khp rt nh, nhng cng c nhng trng hp tn
thng khp nng thm ch c ch nh thay khp.
8. Tn thng mt trong bnh vim khp thiu nin t
pht
Vim mng mch nho gp 20 - 50% tr em gi b vim vi
khp c bit l nhng trng hp c khng th khng nhn
dng tnh. Thng bnh khng c triu chng v t h i hi tr
c vim khp cn phi c i khm bc s nhn khoa thng
xuyn pht hin v iu tr kp thi.
Vim mong mt cng l tn thng mt thng i km vi
vim khp. Bi vy vi nhng tr vim khp mn tnh th ngay
t ln u tin pht hin bnh nn cho tr i khm bc s
chuyn khoa mt. Vi th vim vi khp trong nm u nn i
khm mt 3 thng mt ln v 6 thng mt ln t nm th 2 tr
i. Vi th vim nhiu khp nn khm mt 6 t h n g mt ln. Vi
th vim khp c tn thng ni tng nn khm mt hng nm.
Vi th vim ct sng dnh khp nn khm mt 6 thng mt
ln. i vi nhng tn thng vim mng mch nho ch cn
iu tr bng nh corticoid cng p ng rt tt. Tuy nhin c
nhng trng hp tn thng nng phi thay thy tinh th do
c thy tinh th.

208

HI. C N LM SNG
- Xt n g h i m cng thc m u : c t h c t h i u m u nhc sc
c b i t co t h g i m hng cu v bch cu trong t h v i m khp
c t n t h n g n i t n g .
- M u l n g : t h n g t n g cao trong t h v i m khp k h i p h t
h thng (50 -100 m m / g i u ) . N h n g t h v i m khp k h c m u
lng c t h k h n g t n g hoc t n g mc k h c n h a u t y v o
tnh t r n g bnh.
- X-quang:
+ T h vim khp c t n t h n g n i t n g chp X-quang x n g
khp t h n g k h n g c thay i .

Th vim khp dng thp v

vim khp vy nn X-quang
ging vim khp dng thp v
vim khp vy nn ngi ln
Th vim mt hoc vi khp Xquang thy u xng mt cht
vi, khe khp hp, u xng
pht trin to hn bn lnh, im
ct ha hnh thnh sm

Hnh 52. Cc th vim khp

Th vim ct sng dnh khp:
hnh nh vim khp cng chu
c hai bn
209

- Cc xt nghim min dch di truyn:

+ Khng th khng nhn dng tnh trn 24 - 48% tr vim
khp mn tnh, c bit hay gp th vim mt hay vi khp c
tn thng vim mng mch nho.
+ Yu t dng thp (R) dng tnh ch 5% tr vim khp
mn tnh tuy nhin rt c gi tr tin lng v phn loi bnh.
Thng vim khp mn tnh thiu nin th nhiu khp c RF
dng tnh bnh nng hn th RF m tnh. RF dng tnh
thng gp tr em gi ln tui, t gp tr trai v tr nh tui.
+ Khng nguyn HLA B27 thng gp th vim ct sng
dnh khp. Nhng trng hp vim ct sng dnh khp va c
HLA B27 va c HLA - DR Bl*08 thng c biu hin vim
mng mt cp tnh.
c
+ Allen DR*1104 thng gp t h vim mt hay vi khp.
+ HLA DR4 thng dng tnh trong th vim nhiu khp.
IV. CHN ON XC NH
1. Th khi pht h thng
Gp mi la tui
Nam = n
St: st ko di 2 tun, vim t khp tr ln, km theo t
nht mt trong nhng triu chng di y:
+ Ni ban: c cc dng dt sn, ban , ban hng mm v
nhanh chng bin mt, thng xut hin khi st cao.
+ Ni cc hch bch huyt.
+ Vim tim: ch yu l vim mng ngoi tim.
+ C gan to hoc lch to.

210

+ R F v K T K N m t n h .
2. T h v i m n h i u k h p RF m t n h
T u i mc bnh t - 3
T l mc bnh gia n v nam l 3 :
Vim t 5 khp tr ln, cc khp nh v nh. T h n g gp:
gi, c tay, b n n g n tay, c c h n .
RF m t n h .
3. T h v i m n h i u k h p RF d n g t n h
Ch y u gp n.
Vim khp: v i m cc khp n h v nh c t n h cht i xng.
RF dng t n h t 2 l n tr ln, gia 2 l n l m x t n g h i m
cch nhau t n h t 3 t h n g .
4. T h v i m m t k h p h a y v i k h p
T u i mc bnh: k h o n g 2 - 3

tui

T l mc b n h gia nam v n 5 :
S khp v i m < 5. Cc khp t h n g gp: gi, c c h n , k h u u ,
c tay, cc khp n h b n tay v b n c h n , v i m khp k h n g
i xng.
C t h c t n t h n g m t .
C t h K T K N d n g t n h .
5. T h v i m n h i u h n v i k h p
Vim < 5 khp k h i m i b b n h . Sau 6 t h n g n n m s
khp v i m t n g ln.

211

6. T h vim khp v c c im b m t n
- Tui mc bnh: 12 - 16. Nam > n.
- Vim cc im bm t n v vim khp: cc khp thng gp
hng, gi, c chn khng i xng, cc khp nh bn chn.
Nhng biu hin ct sng thng gp tr ln.
- Hoc ch c vim khp hoc vim cc im bm tn km
theo 2 trong s cc biu hin ui y:
+ au vng khp cng chu hoc au vng ct sng tht
lng.
+ HLA B27 dng tnh.
+ Vim khp tr trai t 6 tui tr ln.
+ Vim mng mt cp.
+ C tin s b bnh vim ct sng dnh khp, bnh vim khp
v im bm tn, hi chng Reiter, vim khp cng chu c km
theo cc bnh l vim ng rut, vim mong mt cp tnh.
7. T h vim khp v y nn
- T u i b bnh: 7 - l i tui
- Vim khp: khp gi l khp thng gp nht sau n
ngn tay v ngn chn c nhng tn thng da ca bnh
vy nn.
Hoc vim khp km theo hai trong s nhng biu hin
di y:
+ Vim ngn tay (ngn tay hnh khc di).
+ Tn thng lm mng tay.
+ Vy nn.

212

V. I U TR
1. N g u y n t c c h u n g
Mc ch ca i u tr l k i m sot t i n t r i n ca b n h c n g
cht ch c n g t t n h m h n c h n mc t i a n h n g t h n g
tn m n t n h m c t h l c ch v i m m n g h o t dch m n
tnh, h n c h p h h y v b i n d n g k h p , k i m . s o t cc y u t
gy vim, gim a u v h n c h n h n g n h h n g v t i n h t h n
ca t r .
a tr cn c khuyn khch tham gia mi hot ng x
hi, c gng duy t r cuc sng sinh hot b n h t h n g . T r c n
c i hc t r n g lp b n h t h n g n h n h n g a t r k h c
tuy n h i n cng cn cho t r c ngh ngi v c b i t c gic
ng y .
iu tr l liu php l mt phn rt quan trng lun phi i
i vi i u tr thuc
Khi s dng thuc cho tr phi cn nhc k lng, hn ch
s dng n h n g thuc n h h n g n p h t t r i n v t h c h t v
tinh t h n ca t r .
2. L liu php
Khi cc khp vim th t th gp l t th gim au, nu
khng c phc h i chc n n g kp t h i t h khp s b d n h l i
t t h gp gy t n p h n n g n . Bi v y mc t i u ca l liu
p h p l:
- Duy tr n mc ti a tm vn ng ca khp
- Nu cn tm thi bt ng khp th nn la chn t th sao
cho gi c gc v n ng ln n h t .
- Gim au nhm gim s co cng cc c xung quanh khp.

213

3. Thuc
iu tr bnh vim khp thiu nin t pht bao gm 3 nhm
thuc chnh: "thuc gim au thng thng, thuc chng vim
gim au v cc thuc iu tr c bn bao gm nhm thuc
chng thp khp tc dng chm (SAARDs) v cc thuc c t
bao. Cc thuc iu tr c bn tc ng vo h thng min dch
cua c th m khng tc ng trc tip vo khp. Khi liu thuc
gim au cn cao th chng t nhm thuc iu tr c bn cha
c tc dng v cn thit phi xem l i liu dng cng nh liu
php iu tr.
3.1. Thuc gim au thng thng
Acetaminophen (Paracetamol).
3.2. Chng vim gim au khng steroid (NSAIDs)
Hu ht tr p ng tt vi nhm thuc ny. Di y l mt
s thuc vn c s dng an ton tr nh:
- Aspirin: liu dng: 75 - 90 mg/kg cn nng/ngy. Thuc c
mt s tc dng ph: ng c salicylat, tai, nhim toan chuyn
ha, kch ng nim mc d dy, nh hng n chc nng gan
v gy hi chng Reye's. Thuc c khuyn co khng nn s
dng phi hp vi methotrexat do lm tng tc dng c
cho gan.
Ibuproen: cn thn trng khi s dng thuc trn bnh nhn
lupus ban h thng do thuc c th gy tnh trng vim
mng no v khun. Mt tc dng ph na ca ibuprofen l gy
thiu mu tan mu v gy rn lon sinh bch cu. Liu dng:
35 mg/kg/ngy (dng vin), 45 mg/kg/ngy (dng siro) chia
ba ln.
Naproxen: c c dng vin v dng siro. Thuc cng c tc
dng ph gy vim d dy, ngoi ra thuc cn gy tnh trng

214

gi p o r p h i r i n t r n da (12 - 15%) v c t h l i so l i n h t r n
mt v tay. L i u d n g : 15 m g / k g / n g y chia 2 l n .
Meloxicam:

c t h

dng

cho

tr

2 tui,

liu

0,25

mg/kg/ngy. L i u t i a 15 m g / n g y .
Celecoxib: c t h d n g cho t r t 2 t u i , l i u 6-12 m g / k g / n g y
chia hai l n .
3.3. Corticoid
n g t o n t h n : ch n h trong giai o n t i n t r i n ca
vim khp t h i u n i n t p h t t h c t n t h n g n i t n g .
- L i u d n g : prednisolon 0,1 - 0,2 mg/kg c n n n g / n g y ung
mt l n vo b u i s n g , d n g t r o n g t h i gian n g n k h i cc khp
sng a u n h i u .
- N h n chung n n h n c h s d n g ko d i do n h i u t c d n g
ph, c bit l m n h h n g n s p h t t r i n t h c h t ca t r .
T i m t i k h p : c ch n h rng r i c b i t t r o n g t h
vim mt hoc vi khp. V i t r n h k h i t i m n n s d n g p h i
hp vi gy t t i ch. K h i t i m p h i m bo v t r n g t u y t i
L i u d n g : Triamcinolon hexacetonid t i m cho khp gi 0,5
mg/kg c n n n g mt l n t i m . M i t i u t r t i m t i a 3
ln, m i l n cch nhau 3 n g y . Cc khp k h c l i u d n g c
tnh theo t l so vi khp gi (bng ui):
Bng 5. V tr tim trc tip vo khp
Khp

T l so vi khp gi

Hng

Tng ng

Vai

3/4

215

c chn

5/8

Khuu

5/8

C tay

3/8 - 1/2

Mi t iu tr ch c tim ti a 3 khp
N h m t : iu tr nhng tn thng mt, phi c ch
nh v theo di ca chuyn khoa mt.
3.4. Thuc iu tr c bn
Nhng thuc ny i hi phi c theo di st tnh trng
mu v nc tiu trong qu trnh iu tr v ch nn s dng
khi khng p ng iu tr vi nhng thuc t c hn. Thuc
khng c tc dng ngay khi iu tr m ch c tc dng sau vi
tun n vi thng. Ngy nay thuc c khuyn co s dng
ngay t giai on sm ca bnh.
Methotrexat:
- L thuc c dng ph bin nht trong iu tr vim khp mn
tnh tr em. Thuc c tc dng ci thin c lm sng v X- quang.
Liu dng: vin 2,5 mg X 5 - 10 mg/m da/tun
vin/tun). Liu ti a c th ln ti 20mg/m da/tun.
2

(2-3

Tc dng ph: bun nn l tc dng ph hay gp nht,

thng ko di 36 ting sau mi liu iu tr mi tun, c th
lm gim triu chng ny bng cc thuc chng nn. Cc tc
dng ph khc: nhng ri lon chuyn ha ca gan, x phi, tn
thng thn.
- Trong qu trnh iu tr bng methotrexat cn phi thng
xuyn kim tra cc ch s sau: cng thc mu, tng phn tch
nc tiu, ure, creatinin, bilirubin ton phn, AST, ALT,
phosphatase kim, albumin mu mi 2 tun trong 3 t h n g u
iu tr sau kim tra nh k hng thng. Chp X-quang

216

phi h n g n m . N m n m m t l n t i n h n h sinh t h i t gan

p h t h i n t n h t r n g x gan.
- K h n g n n i u t r p h i hp cc thuc salicylat
trimethoprim - sulphamethoxazol v i methotrexat.

- N n p h i hp i u t r methtrexat vi acid olic n h m g i m

cc tc d n g ngoi m k h n g l m g i m t c d n g i u t r .
- Thuc t h i u q u i u tr t i a sau 6 t h n g hoc c t h
sm hn.
T h u c c h n g st r t t n g hp

(Hydroxychloroquin):

L thuc c tc dng iu tr tt vi th vim mt hoc vi

khp. Thuc i k h i cng c d n g i u t r t h v i m khp
c t n t h n g n i t n g n h n g v i t h n y methotrexat c t c
dng t t hn. Thuc cn c t c d n g t t t r o n g i u t r b n h
lupus ban h t h n g t r em.
L i u d n g : 6mg/kg c n n n g / n g y .
Tc dng ph: n i ban, bc m u tc, t n t h n g gic mc.
Nhng t c d n g p h n y c t h h i phc sau k h i n g n g thuc.
Mt s t t r n g hp thuc gy suy t y xng, t n t h n g v n g
mc k h n g h i phc, c t h gy m . C n h n g k h u y n co thuc
khng n n s d n g q u 2 n m .
Theo di trong q u t r n h i u tr: cn k i m t r a m t m i 4 - 6
t h n g mt l n v i cc test k i m tra m u sc, t m n h n . Cng thc
mu, t n g p h n tch nc t i u v chc n n g gan cn c k i m
tra m i 3 t h n g . t r nh vic k i m t r a n h n b i t m u sc l r t
kh v vy thuc k h n g n n ch nh cho t r di by t u i .
Sulphasalazin:
- Thuc c ch nh iu tr nhiu nht vi nhng trng
hp v i m khp c H L A B27 d n g t n h (vim khp t h i u n i n t

217

pht th vim ct sng dnh khp). Vi nhng th vim khp

khc cng c ch nh nhng t hn.
- Liu dng: 50 mg/kg cn nng/ngy, liu ti a 2g/ngy. Ban
u dng liu thp sau tng dn liu cho n liu duy tr.
Tc dng ph: ni ban, nn, bun nn, lot hng, gy hi
chng Stevens - Johnson, gim bch cu trung tnh. Cc tc
dng ph him gp khc: gim tiu cu, gim c ba dng, thiu
mu hng cu to, gy bnh SLE do thuc, hi chng Raynauds,
tn thng phi v gan.
Theo di trong qu trnh iu tr: cn kim tra cng thc
mu, men gan, tng phn tch nc tiu hng tun cho n khi
t c liu duy tr, sau kim tra hng thng.
Thuc c th c tc dng sau 6 - 8 tun iu tr liu duy tr.
D - penicillamin:
Trc kia thuc c s dng nhiu nhng t khi c
methotrexat th t s dng. Tuy nhin thuc vn c tc dng tt
trn mt s tr vim khp mn tnh.
- Liu dng: lOmg/kg/ngy, ung liu duy nht, ung khi i.
- Tc dng ph: gim bch cu trung tnh, ni ban, gy bnh
lupus ban h thng. Cc tc dng ph him gp: gy nhc
c, hi chng Goodpasture, vim a c.
- Theo di trong qu trnh iu tr: kim tra cng thc mu
v tng phn tch nc tiu mi 2 tun trong thi gian u iu
tr, sau kim tra hng thng.
- Thuc thng c tc dng sau 6 thng iu tr.
M u i vng: ngy nay t s dng do hiu qu iu tr khng cao.
Liu dng: lmg/kg cn nng/tun, tng dn liu, liu ti a
50 mg. Tim bp hoc ung. Dng tim bp hiu qu iu t r i
cao hn nhng tc dng ph nhiu hn v kh s dng trn tr

218

nh. D n g ung d s d n g vi t r n h n h n g h i u q u i u t r
thp v hay gy g i m n h u ng rut.
Tc d n g ph: g i m bch cu t r u n g t n h , g i m t i u cu, n i
ban, lot ming, b t t h n g cc t h n h p h n nc t i u .
Theo di k i m tra m u v nc t i u h n g t h n g .
C d n g t i m v d n g ung thuc u c t c d n g t i a sau
6 t h n g i u tr.
E t a n e r c e p t ( E m b r e l ) l mt t c n h n sinh hc c t c d n g
chn cc c quan t h c m ca T N F a k h n g cho c h n g t n g t c
vi cc T N F t r n t b o b m t . y l l o i thuc m i a n g
nghin cu s d n g i u t r cho t r em vi n h n g t r n g hp
vim khp n n g v k h n g p ng i u t r v i methotrexat.
Thuc c b i t c h i u q u cao i v i n h n g t r n g hp v i m
khp c t n t h n g n i t n g .
- L i u d n g : 0,4 mg/kg t i m di da 2 l n m t t u n .
- Thuc v n a n g t i p tc c n g h i n cu v h i u q u i u
tr v t c dng p h .
Cc p h n g p h p i u t r k h c n h t r u y n t n h m c h
globulin m i n dch, d n g k h n g t h n dng, k h n g cytokin...
ang c n g h i n cu n g d n g i u t r cho v i m khp m n
tnh t r nh.
3.5. Th vim khp c tn thng ni tng
Khc vi th vim khp n thun, th bnh ny ngoi iu
tr cc t r i u chng ca khp cn p h i i u t r c n h n g t n
thng t o n t h n k h c . Corticoid l thuc c ch n h i u
tr n h n g t r i u chng t o n t h n n h st... L i u t n g n g v i
prednisolon 0,25 - mg/kg c n n n g / n g y t h n g ung m t l n
vo b u i s n g . N h n g t r n g hp c t n t h n g n i t n g n n g

219

nh vim mng ngoi tim nng th nn chia liu 2/3 ung bui
sng v 1/3 ung bui chiu.
Khi cc khp vim r th nn iu tr NSAIDs vi liu thch
hp v phi hp vi vt l tr liu. Vt l tr liu l mt liu
php iu tr rt quan trng cn c p dng cng sm cng
tt vi tr, ngay c khi cc triu chng ton t h n vn tn t i .
Dng cc thuc iu tr c bn nh methotrexat, etanercept...
3.6. Th vim nhiu khp RF m tnh
Ch yu iu tr bng NSAIDs v nhng trng hp tn
thng khp nhiu xt phi hp vi thuc iu tr c bn
(methotrexat).
3.7. Th vim nhiu khp RF dng tnh
th ny a tr d b dnh khp v bin dng khp v vy
nhng thuc iu tr c bn cn c s dng ngay t u.
3.8. Th vim mt hoc vi khp
Tim corticosteroid ni khp phi hp vi NSAIDs rt c hiu
qu vi nhng trng hp s khp vim t. Vic tim ni khp s
gip hn ch tnh trng sn ni tng pht trin. C th xt ch
nh dng cc thuc iu tr c bn. Nhn chung bnh thng
c kim sot tt bng NSAIDs v tim ni khp. Thuc iu
tr c bn u tin c la chn l hydroxychloroquin. Trong
trng hp c tn thng mt th phi dng cc thuc nh mt
theo ch dn ca chuyn khoa mt.
3.8.1. Th vim trn vi khp
th ny cc khp thng vim nng v tin trin, bi vy
cc thuc iu t r i c bn cn c ch nh sm.

220

3.8.2. Th vim ct sng dnh

khp

N u cc khp ch b i u h i n v i m k h n g lin tc t h N S A I D s
cng k i m sot bnh. Salicylat t c t c d n g t r o n g t h
ny. K h i cc khp vim Kn tc ko d i t h ch n h d n g thuc
iu t r c b n , thuc u t i n c la chn l sulphasalazin.
Trong t r n g hp k h n g p ng v i sulphasalazin t h d n g
methotrexat hoc etanercept. V t l tr l i u v t p l u y n h t sc
quan trng vi t h n y . K h i c t n t h n g m t cn c n h
mt theo ch d n ca c h u y n khoa m t .
3.8.3. Th vim khp vy nn
iu tr ging nh th vim ct sng dnh khp. Nhng
trng hp n n g t h cng p h i p h i hp N S A I D s v cc thuc
iu tr c b n n h sulphasalazin v methotrexat. M u i v n g
i k h i cng c t c d n g trong t h n y . C n g ging n h cc t h
bnh k h c t p l u y n v v t l t r l i u l r t quan t r n g . T r o n g
nhng trng hp t n t h n g m t n n g t h vic i u t r l r t
kh k h n .

221

VIM K H P N H I M K H U N

ThS. Bi Hi Binh
I. I CNG
1. nh ngha
Vim khp nhim khun (VKNK- septic arthritis) hay vim
khp sinh m (pyogenic arthritis) l vim khp do vi khun
sinh m khng c hiu (khng phi do lao, phong, nm, k
sinh trng hay virus) gy nn.
2. Nguyn nhn
Hay gp nht l do t cu (Staphyxocus) c bit l t cu
vng (S. aureus) (50-70%); lin cu (Streptococcus) nh s.
pneumoniae, lin cu tan huyt beta (S. pyogenes); ph cu
(Pneumococcus); lu cu (Neisseri gonorrhoeae). V i khun
gram m (15%): E. coli, thng hn (Salmonella), trc khun
m xanh (P.aeruginosa), Haemophilus
influenza. Mt s vi
khun t gp nh Borrelia burgdorferi gy bnh Lyme. C
khong 10% trng hp nhim ng thi nhiu loi vi khun,
thng gp sau chn thng.
3. ng ly nhim
Phn ln mc VK do vi khun lan truyn theo ng mu
xm nhp vo khp. C th theo ng k cn t nhim khun
xng hoc phn mm cnh khp. Hoc nhim khun trc tip
sau chn thng, sau tim khp hoc sau phu thut.

222

li. T R I U C H N G LM S N G - CN LM S N G V CHN
ON
Bnh n h n (BN) c t h c t i n s khoe m n h , t u y n h i n c t
l cao cc t r n g hp v i m khp n h i m k h u n x y ra t r n n n
bnh n h n mc cc b n h n h v i m khp d n g t h p , b n h l
mch m u , suy g i m m i n dch, i t h o ng, d n g corticoid
ko di, lot da do v i m mch, do t ...
V t r t n t h n g : 90% b n h n h n c t n t h n g m t khp,
trong khp gi hay gp n h t , t gp h n l cc k h p h n g ,
vai, C tay, c c h n , k h u u tay... Cc khp n h ca b n tay hay
ban c h n t h n g g p t r o n g n h n g t r n g hp t i m t i ch trc
tip hoc do b ng v t cn. T r o n g t r n g hp b n h n h n c
tin s d n g thuc t r u y n ng t n h mch, t l v i m khp ct
sng khp c n g chu, khp c n cao h n v i m cc khp ngoi
bin. Vim n h i m k h u n n h i u khp hay gp n h t n h n g
bnh n h n v i m khp d n g t h p .
Trong thc t hay gp hai b n h c n h l m s n g : v i m k h p
nhim k h u n k h n g p h i do l u cu v do l u cu.
1. Nhim khun khp khng do lu cu
1.1. Triu chng ti khp
- V i m khp b i u h i n bi cc t r i u chng s n g , n n g , ,
au. C t h t r a n dch k h p , co c, h n c h v n ng. T u y n h i n
trong t r n g hp khp n m v t r s u n h k h p h n g hoc
khp c n g c h u t h k h p h t h i n s n g k h p . C t h gp v i m
m t bo, v i m bao t h a n h dch, ct t u y v i m cp v i cc t r i u
chng l m s n g t n g t . T u y n h i n cc b n h c n h t r n c t h
p h n b i t v i V K N K c i m t h n g b n h n h n k h n g hoc
t h n c h v n ng k h p .

223

1.2. Triu chng ngoi

khp

- Hi chng nhim trng: st cao trn 38c, c khi n 40c

hoc hn, c khi rt run. Tuy nhin st cao khng thng gp
nhng bnh nhn gi yu, suy gim min dch hoc ang mc
bnh vim khp dng thp.
1.3. Triu chng

cn lm

sng

Xt nghim cng thc mu ngoi bin: thng tng s lng

bch cu, t l bch cu trung tnh tng.
- X-quang quy c: trong giai on sm thy hnh nh sng
n phn mm, khe khp c th rng do t r n dch. Trung hp
mun hn th khe khp hp, huy hai u xng i din (hnh
nh soi gng), c th c dnh, bin dng khp (thng giai
on rt mun).
- Siu m, chp ct lp vi tnh (CT Scan), cng hng t
(MRI) c tc dng pht hin nhng t r n dch khp v tr su
nh khp hng, hoc vim khp cng chu.
Di y l hnh nh xquang ca 3 bnh nhn khc nhau b
vim khp nhim khun ti cc v tr: khp hng, khp c chn
v khp bn ngn chn.
Hng

c chn

Bn ngn chn

Hnh 53. Hnh nh vim khp trn X-quang

224

Hnh 54. Hnh nh VKNK khp gi kh pht hin trn X-quang

thng v r trn cng hng t
- Cy mu nhm pht hin vi khun gy bnh v lm khng
sinh phc v cho i u t r . K h o n g 50% t r u n g hp n h i m
k h u n do t c u v n g cy m u d n g t n h , t u y n h i n t l n y
thp h n v i cc v i k h u n k h c .
- Xt n g h i m dch k h p r t quan t r n g . H t dch k h p m
hoc d i hung d n ca s i u m , CT scan.
+ Xt n g h i m m t b o dch k h p : b n h t h n g d i 180 t
bo/ml dch vi a s l bch c u n n h n . T r o n g V K N K , t
bo dch khp c t h t n g ti 100.000 (25.000- 250.000)/ml v i
a s l bch c u a n h n t r u n g t n h (>80-90%). L u c t h
p h t h i n t i n h t h u r a t t r o n g dch k h p . T r o n g t r n g hp n y
k h n g n n ch quan t m n b n h g t m c n xem c n h i m
k h u n k h p k h n g v V K N K cng t h n g x y ra B N g t .
+ Soi ti, n h u m gram t b o dch k h p c t h t m t h y v i
k h u n g y b n h . Cy dch khp cho k t q u d n g t n h t r n

225

90% trng hp. Lu cho dch khp vo chai dch cy mu c

th cho kt qu dng tnh cao hn.
2. Nhim khun khp do lu cu
C hai bnh cnh lm sng trong nhim trng do lu cu l
hi chng nhim khun do lu cu (disseminated gonococcal
inection syndrome- chim 2/3 trng hp) v vim khp thc s
do lu cu (true gonococcal septic arthritis- chim t l 1/3).
2.1. Hi chng nhim khun do lu cu
Cc triu chng thng bao gm: st, rt run, ban v mn
m ngoi da cng cc triu chng khp, triu chng t i b phn
sinh dc. Mt s t bnh nhn c ban thn mnh hoc mt
dui ca chn pht trin thnh mn m xut huyt. Vim khp
thng khp nh c tnh cht di chuyn km vim bao hot
dch - gn gi, c tay, bn tay, c chn v mt c chn. Tn
thng da v khp c xem l do phn ng min dch ca c
th vi s xut hin ca lu cu trong mu v lng ng phc
hp min dch t i m hn l do bn t h n vi khun. Chnh v vy
cy dch khp thng m tnh. Cy mu cho t l dng tnh vi
lu cu 45% trng hp. Thng t r n dch khp vi s lng
dch t, lng t bo dch khp cng t hn trong cc VKNK
khc, khong t 10.000-20.000 bch cau/ml.
2.2. Vim khp thc sdo lu cu
Trong trng hp VKNK thc s do lu cu, thng tn
thng mt khp ln n c nh hng, gi, c tay, c chn.
Dch khp c khong 50.000 BC/ml, lng dch nhiu. Cy dch
khp (+) trn 40% trng hp, nhum c th dng tnh (song
cu hnh ht caf bt mu gram m). Cy mu thng m tnh.
Cy dch tn thng da, t ng sinh dc trong mi trng
Thayer-Martin cho kt qu dng tnh cao (50-80% trng hp).

226

3. C h n o n p h n b i t v i m k h p n h i m k h u n
- V i m khp do g t cp: t r i u chng v i m r m r, s n g n n g
a u t ngt, t h n g v t r cc khp chi di, c b i t b n
ngn c h n . Tuy n h i n k h i h i t i n s t h n g c n h n g t v i m
tng t t h i gian ko d i k h n g q u 2 t u n , t h n g k h i p h t
sau ba n t h n h son. i u t r b n g colchicin hoc chng v i m
gim a u k h n g steroid p n g nhanh.
- Vim khp do lao: t r i u chng v i m k m r m r, s n g n n g
u t. T r i u chng t o n t h n k n o (st n h v c h i u , gy
st hch ngoi bin..7), c t h gp cc lao v t r k h c (phi).
- V i m khp do virus, n m , k sinh t r n g : da v o cc t r i u
chng l m s n g , c b i t n u i cy p h n l p n g u y n n h n
gy bnh.
- Vim khp p h n ng: soi, cy dch k h p l u n m t n h .
- Ct tuy vim: c h n h n h t n t h n g v i m x n g t r n Xquang, chp ct lp v i t n h . . .
III. IU TR
1. N g u y n t c
C h n o n b n h s m , d n g ngay k h n g sinh ng t n h
mch, d n lu m khp k h i cn t h i t , b t ng khp t n g i
co t h n g n c h n c t n h t r n g huy h o i khp.
- Thc h i n ngay vic cy m u , l y dch khp, l m x t
nghim dch k h p n h a n h b n g p h n g p h p soi t i n h u m
gram t m v i k h u n .
C n c k t qu soi ti n h u m g r m k t hp v i cc y u t
nguy c d o n c h n g v i k h u n t la chn ngay k h n g
sinh t h c h hp- trc k h i c k t q u cy m u hoc dch khp
(thung c sau 3-5 n g y hoc l u hn t u y l o i v i k h u n ) .

227

- Lu vic s dng khng sinh tim trc tip vo khp l

khng cn thit v tc dng khng tt hn, thm ch c th gy
nn tnh trng vim khp do tinh th thuc.
2. iu tr c th
2.1. iu tr vim khp nhim khun khng do lu cu
Khi cha c kt qu cy mu, cy dch khp v khng sinh
soi ti nhum gram dch khp m tnh: dng ngay khng
sinh cephalosporin t h h 3 ng tnh mch (TM) nh
cephotaxim 3g/ngy chia 3 l n (cch 8 gi mt^ ln), hoc
cetriaxon 1-2 g, mt ln/ngy c th bao ph y cc nhim
vi khun thng thng (cng ng) ngi ln.
- Trng hp soi ti nhum gram dc\ khp pht hin vi
khun gram dng: oxacillin hoc nafcillin 2g mi 6 gi mt ln
(8 g/ngay). Hoc clindamycin 2,4g TM/ngy chia 4 l n (mi 6 gi
mt ln).
- Nu nghi ng nhim t cu vng khng khng sinh (v d
VKNK mc phi bnh vin): vancomycin 2g/ngy chia hai ln
(pha vi dung dch ng trng truyn tnh mch).
Nhng bnh nhn nghi nhim t r n g trc khun m xanh
(P. aeruginosa) hoc nhim trng khp khi ang dng thuc
khc ng truyn tnh mch cn phi hp thm khng sinh
nhm aminoglycosid (v d gentamycin 3 mg/kg/ ngy- dng
mt ln tim bp vo bui sng) hoc cephalosporin t h h 3 (v
d cetriaxon 1-2 g, tnh mch mt l n trong ngy, hoc
ceftazidim 3g/ngy chia 3 ln).
- Trng hp cy dch khp hoc cy mu dng tnh th vic
iu tr theo khng sinh .
+ Vi nhim khun do t cu vng nhy cm vi khng sinh
th dng oxacillin, hoc nacillin, hoc clindamycin nh trn.

228

Trng hp t c u v n g k h n g m e t h i c i l l i n t h d n g vancomycin
2g/ngy chia 2 l n vi t h i gian k h o n g 4 t u n .
+ N h i m k h u n do p h cu hoc l i n c u do v i k h u n n h y
vi p e m c i l l i n t h d n g penicillin G, 2 t r i u n v t n h m c h m i
4 gi trong 2 t u n . Do H. influenzae v s. pneumoniae
khng
pencillin t h i u t r b n g c e t r i a x o n 1-2 g, m t l n / n g y hoc
cefotaxim g, 3 l n / n g y t r o n g 2 t u n .
+ P h n l n n h i m k h u n gram m c t h cha b n g m t
k h n g sinh t h h 2 hoc 3 t n h m c h t r o n g 3-4 t u n hoc thuc
nhom u o r o q u i n o l o n n h levoloxacin 500mg T M hoc u n g m i
24 gi.
+ N h i m k h u n t r c k h u n m x a n h n n i u t r t n h t 2
tun phoi hp aminogiycosid v i mt_ k h n g sinh peniciUin p h
rng n h mezlocillin 3g t n h m c h m i 4 gi, hoc ceftazidim l g
moi 8 gi. T h i gian d n g t r o n g k h o n g 2 t u n , sau d n g
khang sinh l u o r o q u i n o l o n n h c i p r o l o x a c i n 750 mg ung 2
ln/ngy n c hoc p h i hp v i m t thuc n h m p e n i c i l l i n
pho r n g n h t r n , hoc p e n i c i l l i n p h r n g p h i hp m t thuc
nhm aminoglycosid.
Thi gian i u t r v i m k h p n h i m k h u n t u y l o i v i k h u n ,
nhy cm- t n h t r n g k h n g thuc... T h n g t h n g k h o n g
t 1-2 t u n t r u y n t n h m c h sau c h u y n sang n g ung
bang k h n g sinh t h c h hp. L i u t r n h i u t r t 2- 4 t u n .
D n lu m v cc c h t b n b n t r o n g dch k h p r t c n
t h i t trong i u t r . L i u p h p n y c t c d n g g i m a u , g i m
n^uy c t o v c h n g n , giam nguy c h o i t do l m g i m p lc
trong khp, l o i bo n h n g c h t g y v i m , l o i b m t p h n v i
k h u n t r o n g k h p . T h m ch ch b n g h t dch k h p t r o n g
t r n g hp khp k h n g t o v c h n g n cng cho k t q u t t . N i
SOI ra khp c t h t i n h n h ngay hoc sau k h i h t dch khp
k h n g c k t q u . T r o n g m t s t r n g hp c n p h u t h u t m
khp l o i b v c h n g n cng n h m n g h o t dch, sn k h p
hay p h a n x n g b n h i m k h u n . P h u t h u t m k h p l i u

229

tr tt nht cho nhim khun khp hng, c bit tr em- i

tng chm xng i d b e doa bi nhim khun. Khng cn
thit bt ng khp trong VKNK ngoi tr ch nh trong
trng hp bnh nhn rt au m iu tr thuc ton thn cha
khng ch c. Lu tp t h ng tng bc cho bnh nhn c
tc dng chng dnh khp, tuy nhin cn t r n h n lc nn
khp tn thng trong trng hp triu chng vim cha kim
sot tt. Vic kt hp glucocorticoid vi khng sinh chng t
ci thin tin lng ng vt thc nghim c nhim khun t
cu vng. Tuy nhin cha c nghin cu no tin hnh trn
ngi c nh gi y .
2.2. iu tr vim khp nhim khun do lu cu
Trng hp lu cu nhy cm penicillin c th dng
amoxicillin ung 1500 mg/ngy chia 3 ln, hoc dng
ciproloxacin ung 1000 mg chia hai ln/ngy (ngoi tr).
- Trng hp nghi ng lu cu khng penicillin: khi u
cetriaxon l g tnh mch mi 24 gi trong 7 ngy. Mt khi triu
chng t i ch v ton thn kim sot tt c th chuyn dng
ciprooxacin ung 500 mg hai ln/ngy. Hoc spectinomycin 2g
tim bp mi 12 gi/ngy trong 7 ngy.
Thng vim m khp gi do lu cu thng ch cn phi hp
khng sinh 7-14 ngy kt hp vi ht dch khp l , him khi
cn ni soi ra khp hoc phu thut m khp. Trng hp hi
chng nhim khun do lu cu nn cho khng sinh phi hp
iu tr c Chlamydia trachomatis tr khi c bng chng chc
chn l khng bi nhim thm vi khun ny.
IV. THEO DI- TIN LNG- D PHNG
1. Theo di
Da vo triu chng lm sng: tnh trng vim t i khp v
ton thn.

230

Da vo xt n g h i m : s lng bch cu, t l bch cu t r u n g

tnh, tc m u lng, protein c p h n ng. N u cc ch s t r n
gim l c p ng vi i u tr.
2. Tin lng
Hu ht VKNK do lin cu khi khng li di chng. Tuy
nhin v i k h u n do trc k h u n gram m hoc do t cu ni
chung tin lng k m , t h n g bnh n h n v n a u v h n c h
vn ng d n h i m k h u n c k h n g ch. N h n g t r n g
hp nhim k h u n i u t r m u n (thng sau 7 n g y ) cng t i n
lng x u hn. T r n g hp t n t h n g khp h n g t i n lng
xu hn cc khp k h c .
3. D phng
Thc hin v trng tuyt i khi lm cc th thut, phu
t h u t tin h n h t i khp.
iu tr tt cc nhim khun ti cc c quan khc, c bit
t i da, phn m m v xng.
i vi bnh lu phng bng cch thc hin hnh vi tnh dc
an t o n .

231

VIM X N G T U N H I M

KHUN

ThS. Bi Hi Bnh
I. I CNG
1. nh ngha
Vim xng tuy nhim khun (VXTNK- Osteomyelitis) cn
gi l ct tuy vim l tnh trng nhim trng ca xng, thng
l ca v hoc tuy xng do vi khun sinh m khng c hiu
(khng phi do lao, phong, nm, k sinh trng) gy nn.
2. Nguyn nhn
Hay gp nht l do t cu (Staphylococus) c bit l t cu
vng (S. aureus); lin cu (Streptococcus) nh s.
pneumoniae,
lin cu tan huyt beta (S.pyogenes); ph cu (Pneumococcus);
lu cu teisseri gonorrhoeae). V i khun gram m: E. coli,
thng hn (Salmonella), trc khun m xanh (P.aeruginosa),
Haemophilus
influenza.
li. TRIU CHNG LM SNG- CN LM SNG V CHAN
ON
V mt bnh cnh lm sng chia vim xng ty nhim
khun (VXTNK) thnh 3 th: VXTNK ng mu, VXTNK
ng k cn v VXTNK mn tnh.
1. Vim xng ty nhim khun ng mu
Chim 20% cc trng hp VXTNK v ch yu gp tr em
(thng tn thng xng di), sau l nhng ngi ln

232

 a n g t r u y n thuc ng t n h mch (thng t n t h n g

ct sng).
1.1. Nguyn nhn
Trn 95% trng hp gy ra do duy nht mt loi vi khun
(VK). V i k h u n hay gp n h t l t cu v n g (khong 50%
trng hp). C c V K t h n g gp k h c bao gm lin cu t a n
huyt n h m B, Esc heric hia
col hay gp n h m t r s sinh; lin
cu n h m A hay gp n h m t r ln t u i h n . T r o n g v i m a
m t sng E. coli v cc t r c k h u n ng r u t k h c c h i m
khong 25% t r n g hp. T c u v n g , trc k h u n m xanh hay
gp trong V X T N K b n h n h n a n g t r u y n m u t r o n g b n h
vin v t h n g k h u t r cc x n g c n g , x n g c n hoc ct
sng; trong k h i Sallmonella
v t cu v n g l n g u y n n h n
chnh trong V X T N K cp t n h v t r x n g d i t r o n g n h m b n h
n h n b cc b n h l m u .
1.2. Vim xng ty nhim khun ng mu cp tnh
Hay gp mt xng duy nht, ph bin l hnh xng ca
xng d i t r em (xng c h y , x n g i , x n g c n h tay), sau
l x n g t sng n g i ln v n h n g n g i d n g thuc
ng t i m t r u y n , s d V X T N K t r em t h n g k h u t r cc
h n h x n g g n sn t i p hp, l ni c t i thc b o , ng
thi l ni cc m c h m u t n t p hp t h n h xoang ln l m c h m
tc d n g m u . Ngc l i do p h n b g i i p h u mch m u
n g i l n k h c t r em ( k h n g cn a sn t i p hp) n n V X K N K
x n g d i n g i l n l i hay gp t h n xng.
Triu chng lm sng:
- tr em thng din bin cp tnh, st cao rt run, sng
n n g v n g t n t h n g . K h i c ban v n g da t i ch k m
s n g phng p h n m m t h n g do m vt qua v x n g ,
m n g x n g l a n v o p h n m m l n cn.

233

- tr di 2 tui (ni mch mu i qua a sn tip hp) v

ngi ln (khng cn a sn tip hp), nhim khun xng
khp c th lan t hnh xng vo khp ln cn gy vim khp.
tr em ln hn 2 tui, khi a sn tip hp v mch, nu vng
hnh xng tn thng nm trong bao khp th vi khun vn c
th gy vim khp bng cch vt qua v xng xm nhp vo
khp. Do vim khp khuu, khp vai v khp hng c th do
VXTNK ca xng quay, xng cnh tay v xng i.
- Ngun gc nhim khun thng khng r rng tr em, c
th sau mt chn thng gy t mu ngoi hoc tc mch; trong
khi ngi ln nhim khun khp c th sau mt vim phi,
xoang, vim ng tit niu, hoc khng r ngun gc.
Triu chng cn lm sng:
- Xt nghim cng thc mu ngoi bin: bch cu mu
thng tng, t l bch cu a nhn trung tnh thng cao trn
75%.
- Phn ng vim: mu lng v CRP (protein c phn ng)
thng tng.
- Cy mu tm vi khun v lm khng sinh phc v iu
tr.
- X-quang chun giai on sm ch thy sng n phn mm.
Du hiu phn ng mng xng thng ch thy sau 10 ngy c
biu hin nhim khun. Du hiu tiu xng thng thy t
tun th 2-6, khi c t 50-75% t trng xng t i ch b mt.
Him gp hn l hnh nh tiu xng c b vin phn ng r,
hoc apxe Brodi (Brodis abscess) tr au (vim) nhiu thng
m khng st.
- Siu m cho php pht hin sng n phn mm, c bit
cc apxe c km theo.

234

- c h n o n s m V X T N K t r o n g 24-48 gi u c t h d n g
p h n g p h p chp x h n h x n g 3 pha ( d n g 99 Technetiummonodiphosphonat) cho n h y cao (90-95%) n h n g c
h i u t h p , c b i t k h i c cc t n t h n g x n g k h c k m theo.

Hnh 55. Hnh nh vim xng nhim khun u di xng chy T

trn X-quang thng v trn chp ct lp vi tnh (cng mt bnh nhn)
235

- Chp ct lp vi tnh (CT Scan) v chp cng hng t (MRI)

cng c gi tr cao chn on nhng tn thng xng, phn
mm do vim xng.
- Chc ht bng kim m hoc di hng dn ca siu m,
chp ct lp ly bnh phm soi ti, nui cy tm vi khun, lm
khng sinh phc v iu tr.
1.3. Vim t sng a m (khng do lao)
L dng ph bin nht ca VXTNK theo ng mu
ngi ln.
Vi khun t mch mu tuy sng xm nhp vo cc t sng
giu mch mu v nhanh chng lan t b mt t sng vo a
m. Trong VXTNK do vi khun sinh m v tr tn thng ct
sng tht lng hay gp hn (trn 50%) so vi ct sng ngc
(35%) v ct sng c. Ngc l i trong lao ct sng ngc hay b
tn thng hn.
Triu chng lm sng:
Triu chng ton thn ban u c th st cao, gai rt, v
sau st nh m .
- au m t i vng tn thng, co c cnh ct sng, hn ch
vn ng ct sng,n t i v tr tn thng c t h au chi.
- Bnh nhn c t h c triu chng chn p thn kinh nh
lit, ri lon i tiu tin... do cc bin chng chn p ca
apxe hoc xp, trt t sng.
Triu chng cn lm sng:
- Xt nghim cng thc mu ngoi bin: bch cu mu
thng tng, t l bch cu a nhn trung tnh thng cao trn
75%.

236

- P h n ng vim: m u l n g v CRP (protein c p h n ng)

thng t n g .
- Cy m u d n g t n h trong k h o n g 20-50% t r n g hp.
- X-quang i n h n h l h n h n h hp khe lin t sng, b
m t t h n t sng t r n v d i ch t i p gip vi a m t n
t h n g b b o m n n h a m nh ( h n h n h soi gng).
- Chp ct lp v i t n h (CT Scan) hoc chp cng h n g t
(MU) cho t h y r t n t h n g t sng, a m cng n h p h t
h i n t h y cc apxe c c n h ct sng, apxe t u y sng, apxe t r u n g
tht...
- Chc h t d i h n g d n ca chp ct lp v i t n h l y b n h
phm soi ti, n u i cy t m v i k h u n , l m k h n g sinh phc
v i u tr.

Hnh 56. Hnh nh vim a m t sng v tri t sng L4-L5 trn

X-quang thng v trn cng hng t (cng mt bnh nhn)

237

 Chn on sm vim xng ty nhim khun trong 24-48

gi u bng phng php chp x hnh xng ba pha (dng 99
Technetium-monodiphosphonat) cho
nhng c hiu thp.

nhy cao

(90-95%)

2. Vim xng ty nhim khun th pht sau mt nhim

khun k cn
Chim khong 80% cc trng hp VXTNK v ch yu xy
ra ngi ln. Bao gm VXTNK sau chn thng trc tip, sau
chm cu, b cn hoc sau phu thut, thay khp gi; hoc t
nhim khun phn mm k cn gy ra. S suy gim tun hon
t i ch hoc d vt t i nhim khun l cc yu t lm cho vic
iu tr tr ln kh khn.
2.1. Nguyn nhn
Khong trn 50% l do t cu vng, ng thi n cng l
nguyn nhn cn bn ca VXTNK sau phu thut. Tuy nhin
khc vi VXTNK ng mu, VXTNK ng k cn thng
phn lp c nhiu vi khun t i nhim khun. Cng vi t
cu vng, chng ta c t h phn lp c t cu da (.
epidermidis), vi khun gram m cng nh cc vi khun i kh
khc. VXTNK sau phu thut hoc sau nhim khun phn
mm vng hu hng, xoang, tiu hoa hoc tit niu c th do
nhiu vi khun ym kh v i kh. Nhim khun do trc khun
m xanh thng sau gim phi inh.
2.2. Triu chng lm sng
Thng thng chn on dng ny thng chm, khi nhim
khun tr thnh mn tnh. Cc triu chng au, st sng
nng biu hin cp tnh c th do vim ban u. C the
au, tit dch t i ch dai dng. Khi pht trin thnh vim man
tnh thng triu chng ton thn v t i ch khng rm r. Mt

238

dng c b i t ca V X T N K ng k cn l v i m x n g nh
bn c h n hay gp trong bnh l mch m u ngoi b i n , c b i t
l trong i t h o ng. Bnh l t h n k i n h ngoi b i n do i
t h o ng gy ra nhng t n t h n g p h n m m , lot t r t do t
vim m t bo, lot da d i n h dng... cng vi t i m u
khng y t i ch dn n g i m p n g v i m ca c t h v i
vim. T t c cc y u t t r n to t h u n li cho m t V X T N K .
2.3. Cn lm sng
Xt n g h i m m u : bch cu m u t h n g t n g , t l bch cu
a n h n t r u n g t n h t h n g cao t r n 75%.
- Phn ng vim: m u l n g v CRP (protein c p h n ng)
thng t n g .
- Cy m u t m v i k h u n g y b n h v l m k h n g sinh , c
t h p h n lp c n h i u v i k h u n t i n h i m k h u n .
- Cc t r i u chng v c h n o n h n h n h t n g t n h
V X K N K theo ng m u cp t n h , t u y n h i n d c x u hung
chuyn t h n h m n t n h .
3. Vim xng ty nhim khun mn tnh
Vi V X T N K cp t n h , n u c i u t r kp t h i v t t v n c
khong d i 5% c t h c h u y n t h n h m n t n h . V X T N K m n
tnh thng xy ra sau n h i m t r n g ng k cn h n . c
t r n g ca V X T N K m n t n h l d i n t i n ko di, c n h n g giai
on b n h k h n g hot ng xen k v i n h n g giai o n b n g
p h t tr l i . H n h t h n h l r t x n g ra n g o i da, chy m , c
khi l r t h o t ra c m n h xng cht. K h i l r b tc c t h l i
c mt t b n g p h t n h i m k h u n . H n h n h X-quang, CT scan
thng b i u h i n mt v i m x n g t i n t r i n chm, c t h t h y
h n h n h m n h xng cht. Cc b i n chng m u n ca V X T N K
mn t n h bao gm gy xng b n h l, carcinoma t b o v y ca
ng d, b n h n h i m amyloid.

239

IU TR
1. Nguyn tc
Chn on bnh sm, dng ngay khng sinh ng tnh
mch, dn lu mu v t chc hoi t (nu c).
Thc hin ngay vic cy mu, ly dch khp, lm xt nghim
dch khp nhanh bng phng php soi ti nhum gram tm vi
khun. Cn c kt qu soi ti nhum gram kt hp vi cc yu
t nguy c d on chng vi khun t la chn ngay khng
sinh thch hp- trc khi c kt qu cy mu hoc ch m
Khng sinh (KS) thuc nhm dit khun, liu cao khi u
dng ng tnh mch (TM). Trong a s b u n g hp nen dung
KS chng t cu vng liu cao (oxacillin, nacillin, cefazon
hoc vancomycin), nu nghi ng nhim khun thm vi khun
gram m cn kt hp vi mt thuc thuc nhm cephalosporin
th h 3, hoc aminoglycosid, hoc Auoroquinolon.
Khi c kt qu khng sinh , iu tr da vo kt qu p
ng v khng sinh .
2. iu tr c th
2.1. Vim xng ty nhim khun ngi ln
- Do nhim t cu vng:
+ Oxacillin (hoc cloxacillin) 2g/ln tnh mch, ngy dng 4
. t
v.
, ?
.
e
mch t n h i 2 tun
nu p ng tt c t h chuyn ung lg/ln, 4 n/ngy, tng thi
gian 4-6 tun.
c

T h i

a n

l g

t n h

Q Hoc cephazolin l-2g/ln tnh mch ngy 3 ln cch nhau

+

9 ni
f
>
.
y n ng ung cephaiexin 2g/ln, ngy dng 4 ln, tng thi gian 4-6 tun
n

240

u n

s a u

c h u

+ Hoc clindamycin 600mg/ln t n h mch, n g y d n g 3-4

l n , sau chuyn ung clindamycin 300-450mg/ln, n g y ung
4 l n , tng t h i gian k h o n g 4- 6 t u n .
+ Trng hp t cu v n g k h n g methicillin: vancomycin
l g / l n pha dung dch n g t r n g t r u y n t n h mch, n g y 2 l n
cch 12 gi, sau chuyn ung r i f a m p i c i n 300mg/ln, ung
ngy 2 l n (nu c b n g chng v i k h u n n h y cm), tng t h i
gian 4- 6 t u n .
- Do n h i m lin cu beta t a n m u : benzylpenicillin (penicillin
G) 2 t r i u U l / l n T M , n g y 4 l n trong 2-4 t u n . N u l m s n g
ci t h i n t h chuyn ung amoxicillin l g / l n , n g y ung 3 l n ,
tng thi gian 4-6 t u n .
- Do n h i m Salmonella
spp: ciproloxacin 750 mgAn ung,
ngy 2 l n cch 12 gi, trong 6 t u n (chng ch nh p h n
c thai).
- Do n h i m trc k h u n n g r u t

Enterobactericeae:

+ Pelacin 1 3 m g / k g / n g y , t n h mch hoc ung, chia 2-3 l n ,

kt hp gentamycin 3 m g / k g / n g y (tim bp m t l n ) .
+ Hoc c e f t r i a x o n l - 2 g/ngy t n h mch, n g y mt l n .
+ Hoc ticarcilin 200 m g / k g / n g y t n h mch chia 3 l n .
+ Hoc fosfomycin 200 m g / k g / n g y t n h mch chia 3 l n .
Thi gian

iu

tr:

VXTNK ng mu cp tnh: 4-6 tun, nu thi gian iu tr < 3

tun t l t h t b i cao gp 10 l n . iu tr phu t h u t trong trng
hp apxe ngoi xng, di m n g xng, k t hp c vim khp
nhim khun, hoc k h n g ci t h i n t r i u chng sau 24-48 gi.
Vim a m t sng: 4-6 t u n . N u tc m u l n g k h n g
gim t r n 2/3 so vi trc k h i i u tr hoc CRP k h n g v c
bnh t h n g t h p h i n h gi l i iu tr hoc ko d i t h i gian

241

iu tr. iu tr phu thut phn ln khng cn thit, tr khi

ct sng mt vng hoc c triu chng chn p thn kinh, hoc
apxe phn mm lan rng khng th gii quyt bng dn lu
di da.
Ct tuy vim ng k cn: thm ch ngay c khi chn on
sm th phu thut vn c yu cu kt hp vi khng sinh
thch hp ko di 4- 6 tun.
2.2. Vim xng ty nhim
trong cc sch Nhi khoa).

khun

tr em (Xin tham kho

2.3. Vim xng ty nhim khun mn tnh

Cn cn nhc gia nguy c v li ch ca vic iu tr tch cc
loi tr han VXTNK mn tnh. Mt s bnh nhn khng chu
c nhng cuc phu thut lin tip, hoc p h i s dng khng
sinh ko di, hoc ct ct chi. Nhng bnh nhn ny thm ch
cm thy thoi mi hn khi sng chung cng vi bnh. Vi nhng
bnh nhn ny, liu php khng sinh ng ung tng t iu
tr t cp l thch hp. Mt khi quyt nh iu tr tch cc bng
phu thut, iu quan trng l cn m bo nng cao th trng
bng ch dinh dng hp l, bo m cn bng chuyn hoa.
Nn dng khng sinh thch hp trc khi phu thut nhiu ngy
khng ch tnh trng nhim khun. Sau tip tc dng
thuc 4- 6 tun ng tnh mch sau m. Vic s dng khng
sinh ung sau khi dng ng tnh mch 4-6 tun vn cn gy
tranh ci. Gn y cc bin php ghp xng, ghp phn mm,
chuyn mch nhm ci thin tnh trng nui dng t i ch to
ra nhng tin b ln trong iu tr VXTNK mn tnh.
IV. THEO DI- TIN LNG- D PHNG
1. Theo di
Da vo triu chng lm sng: tnh trng vim ti khp v
ton thn.

242

Da vo xt n g h i m : s lng bch cu, t l bch cu t r u n g

t n h , tc m u l n g , protein c p h n ng. N u cc ch s t r n
gim l c p n g vi i u tr.
2. Tin lng
V X K N K cp t n h n u i u t r tch cc v t t v n c khong
di 5% c t h chuyn t h n h m n t n h . T r n g hp V X K N K
mn t n h i u t r t h n g dai dng, n h i u k h i k h n g t r i t i
hi p h i k t hp v i i u t r p h u t h u t l y b vim v m n h
xng cht.
3. D phng
Thc h i n v t r n g t u y t i k h i l m cc t h t h u t , p h u
t h u t t i n h n h t i xng, khp.
iu tr t t cc n h i m k h u n t i cc c quan k h c , c b i t
t i da, p h n m m v khp.

243

BNH LAO CT

SNG

ThS. Nguyn P h n g Thy

I. I CNG
Theo y vn, lao ct sng l mt trong nhng bnh lu i
nht. Cc tn thng lao ct sng c pht hin nhng xc
p A i Cp vo khoang 3400 nm trc cng nguyn. n nm
1779 bc s Percivall Pott l ngi u tin m t bnh lao
ct song vi biu hin lit hai chi di v g lng, do vy bnh
lao ct sng cn gi l bnh Pott.
Vo u t h k 20, bnh lao l nguyn nhn hng u dn
n t vong. Ngy nay, s ra i ca cc thuc iu tr lao cng
vi iu kin kinh t - x hi c ci nhin lm gim t l
mc bnh v t vong do lao. Tuy nhin, cc nc ang pht
trin nh Vit Nam, do iu kin v sinh thp v tnh trng dinh
dng km nn bnh lao vn cn chim mt t l tng i cao.
Trong cc bnh lao xng khp, lao ct sng hay gp nht v
chim khong 50% cc bnh lao xng khp. Lao ct sng lun
th pht sau lao cc c quan khc nh: phi, hch, thn. Vi
khun lao s theo ng mu i n ct sng, trung bnh
khong 2- 3 nm k t khi c lao nguyn pht n khi xut hin
cc triu chng ca lao ct sng. Lao ct sng nu khng c
pht hin v iu tr sm s dn n lit hai chi di do chn p
tuy, ph huy xng v gy bin dng nng (g) ca ct sng.
Lao ct sng thng hay gp nht ct sng ngc v ct sng
tht lng, trong on di ca ct sng ngc chim t l cao
nht (40- 50%), tip theo l ct sng tht lng (35- 45%). Lao
ct sng c ch gp khong 10%. Bnh lao ct sng gp c hai

244

gii nam- n vi t l mc b n h n h n h a u v l a t u i t 20- 40

chim 60% s bnh n h n b lao ct sng.
T n t h n g c b n trong b n h lao ct sng l s k t hp ca
vim xng t u y v vim a m t sng, t h n g b t n t h n g
2 t sng lin nhau. Khi u , t n t h n g p h a trc ca
t h n t sng ch t i p gip vi s n khp, t v i k h u n lao s
i n a m l i n k v g y v i m a m t sng.
ngi ln, vim a m t sng xy ra th pht sau vim
t h n t sng. t r em, do a m t sng c n h i u mch
m u n n vim a m do lao c t h l v t r n g u y n p h t . K h i
tn t h n g lao t i n t r i n s d n n p h huy ct sng v g y g.
ng t u y c t h b h p v b c h n p bi abcess, t chc h t hay
do v i k h u n lao x m n h p trc t i p v o m n g n h n t u y . T n
thng lao ct sng ngc t h n g g y g n h i u h n ct sng
t h t lng. K h i t n t h n g lao l a n n cc d y chng k c n v
t chc p h n m m xung quanh s t o n n abcess l n h . ct
sng t h t l n g , abcess l n h c t h l a n xung v n g b n theo bao
c t h t l n g c h u v d ra n g o i da.
li. TRIU CHNG LM SNG
1. Lm sng
1.1. Cc biu
thuc vo:

hin

lm sng

ca bnh

lao ct sng

ph

+ Giai on tin trin ca bnh.

+ V tr tn thng.
+ C c b i n chng: t n t h n g t h n k i n h do c h n p , abcess.
1.2. Cc biu hin lm sng thng gp gm
- au lng: xut hin sm nht v hay gp nht. au lng c
t h l a u t i ch hoc a u k i u r .

245

+ au t i ch: au vng ct sng b tn thng. Giai on

u, au tng khi vn ng, gim khi ngh ngi. Sau , au
lin tc c ngy, au kiu vim, au ngy cng tng, au tng
v m, dng cc thuc gim au thng thng nh
paracetamol t kt qu.
+ au kiu r: do tn thng lao chn p vo mt vi nhnh
ca r thn kinh, au lan theo ng i ca cc r v dy thn
kinh. ct sng c, au lan xung vai v tay theo m r i thn
kinh cnh tay; lng, au lan theo dy thn kinh lin sn.
tht lng, au lan xung mt trc bng hoc xung 2 chn
theo dy thn kinh toa. au t n g ln khi ho, ht hi, rn mnh.
- Cc triu chng ton thn: st, gy st cn.
- Cc triu chng thn kinh do chn p tuy sng: gp
khong 50% bnh nhn lao ct sng, biu hin yu- lit 2 chi
di, gim- mt cm gic, hi chng ui nga, ri lon c trn.
Lao ct sng c t gp hn lao ct sng lng- tht lng nhng
tin lng nng hn v bnh nhn thng b cc bin chng thn
kinh nhiu hn. Bnh nhn c th b lit t chi do chn p tuy c.
Khi tn thng phn di ca ct sng c bnh nhn c th kh
nut, th rt v c th c cc triu chng khc nh: vo c,
ging khn.
1.3. Khm lm sng
- Ct sng: mt on ct sng cng , gin ct sng gim,
cc ng tc ca ct sng b hn ch. C cnh ct sng co cng,
khi g vo vng gai sau ca ct sng c th b au chi t i vng
tn thng. Giai on mun, li t sng ra sau.
- Abcess lnh: ph thuc vo v tr tn thng
+ Ct sng c: khi abcess i ra pha trc ngay thnh sau
hng (c th nhn thy khi khm hng), hoc c th i xung ti
hm thng n theo cc c cnh c.

246

+ Ct sng lng: k h i abcess c t h i ra p h a sau n i ngay

di da.
+ Ct sng t h t lng: k h i abcess n i ngay d i da v n g t h t
lng, v n g m n g hoc i ra p h a trc xung bn, c t h d ra
v n g m n g hoc v n g y c h u .
+ K h i abcess m m , k h n g a u , c t h b v, chy nc v n g
v b u , l i v t lot v l d d a i d n g k h n g l i n .
Lao p h n t r n ca ct sng c: t h n g t i n t r i n nhanh,
hu h t bnh n h n b abcess t h n h sau hng, cc t r i u chng
t h n k i n h t h n g x u t h i n sm v i b i u h i n l i t na n g i
hoc l i t t chi.
C t h tm t h y t n t h n g lao phi hp: lao phi, hch, t h n , . . .
Tuy nhin, c r t n h i u bnh n h n b lao ct sng (theo mt s
nghin cu 62- 90%) k h n g c biu h i n lao ngoi ct sng.
2. C n l m s n g
2.1. Xt nghim

mu

Tc m u l n g t n g
Protein - c p h n n g (CRP) t n g .
2.2. Phn ng Mantoux:
n h n lao ct sng.
2.3. X-quang
Rt

quan

thng
trong

d n g t n h khong 84- 95% bnh

quy
trong

chn

on

Giai o n sm: a m t s n g hp. Giai o n m u n : a

m b p h huy g n n h h o n t o n .
- H n h n h huy x n g p h n trc ca t h n t sng. K h i b
p h h u y n h i u t h n t sng c h n h c h m .

247

 Phn mm quanh t sng hi m m h!.. Giai on mun,

c hnh abcess lnh (hnh m quanh tn thng- hnh thoi hoc
hnh c hnh, m khng ng u, c ch vi hoa m hn).
2.4. CTScanner
- Gip xc nh chnh xc cc tn thng: huy xng khng
ng u, kt c xng, hp khe t sng.
- Pht hin cc tn thng phn mm, c bit xung quanh
t sng v ngoi mng cng.
- Gip pht hin cc tn thng giai on sm v xc nh
hnh dng- tnh cht ca abcess (hnh nh calci hoa trong
abcess, hay gp trong tn thng lao).
2.5. Chp cng hng t
L phng php r t c gi tr trong chn on cc bnh
vim a m-t sng do vi khun v lao, gip nh gi s tin
trin ca bnh, mc tn thng phn mm quanh t sng.
- Phng php c gi tr nht trong pht hin cc chn p
thn kinh do tn thng lao.
- Gip chn on phn bit lao ct sng vi vim a m t
sng do vi khun.
2.6. M bnh hc
Sinh thit qua da vo vng t sng b tn thng di hi
dn ca CT Scanner ly ra bnh phm lm xt nghim: m
bnh hc, nui cy, PCR- BK.
- M bnh hc: thy t chc, t bo c hiu do lao: lympho
bo, t bo bn lin, t bo khng l, cht b u.

248

2.7. Tm tn thng

lao phi

hp

Xquang phi, CT Scanner phi, soi p h q u n t m B K .

- B K m.
- Sinh t h i t hch.
III. CHN ON
Chn on xc nh da vo: lm sng, cn lm sng
2. Chn on phn bit vi cc bnh gy tn thng ct
sng
- Vim a m t sng do v i k h u n (t cu,..): b n h n h n c
hi chng n h i m t r n g n n g , t m t h y ng vo ca v i k h u n
(abcess c, v i m khp n h i m k h u n , n h i m k h u n ng t i u
hoa- t i t niu), X-quang- C.T.Scanner- M R I : k h n g c h n h n h
abcess l n h , m b n h hc.
- Cc t n t h n g c t n h ( n g t h d i c n xng, Kahler):
Xquang- CT Scanner- M i n k h n g c h n h n h abcess l n h , tuy
, nh lng Ig, Scintigraphy xng, m bnh hc.
VI. IU TR
1. Ni khoa
D n g cc thuc chng lao t 9- 12 t h n g tuy theo t n g b n h
n h n c t h .
2 t h n g u t i n d n g 4 thuc, t r o n g 2 thuc n n chn la
u t i n l: isoniazid v r i f a m p i c i n , k t hp v i 2/3 l o i thuc
sau: pyrazinamid, ethambutol, streptomycin.

249

Sau duy
pyrazinamid.

tr

vi

thuc:

isoniazid,

riampicin,

Trong qu trnh iu tr, cc bnh n h n b lao ct sng cn

c theo di thng xuyn gm: p ng vi iu tr, tc dng
ph ca thuc iu tr lao.
Khi bnh nhn p ng vi iu tr km: au ct sng ngy
cng tng- khng thuyn gim, cc triu chng thn kinh do
chn p tin trin nng hn, bin dng ct sng (g) nhiu hn,
mu lng khng gim c th do v i khun lao khng thuc, cn
xem xt kh nng phu thut cho bnh nhn.
2. Ngoi khoa
2.1. Ch nh iu tr ngoi khoa trong cc trng hp sau:
+ Tn thng thn kinh do chn p tuy: lit 2 chi di, yu 2
chi di, lit t chi, hi chng ui nga.
+ Bin dng ct sng nhiu gy hn ch vn ng ca ct sng.
+ Bn trt khp hoc trt khp do tn thng lao ph huy
t sng nhiu.
+ Abcess cnh t sng.
+ Khng png vi iu tr ni khoa.
+ Khi sinh thit vo vng t sng b tn thng, hnh nh m
bnh hc khng c hiu, khng gip cho chn on xc nh.
2.2. Phng php m
+ Ph thuc vo: v tr v mc tn thng ct sng, bin
dng ct sng, mc chn p tuy sng.
+ Phng php m: ly abcess, ly xng cht, gii phng
chn p, lm cng khp.

250

2.3. Vn c

nh

+ K h i t n t h n g ct sng n h : b n h n h n n n n m n h i u ,
t r n h v n ng v mang vc nng, k h n g cn c n h b n g bt.
+ Trong t h i gian b n h t i n t r i n , b n h n h n cn n m n h i u ,
nn d n g ging bt b n h n h n c t h thay i t t h n h i u
l n trong n g y , t r n h cng khp v teo c, t h i gian c nh
3- 6 t h n g .
+ B bt k h i t n t h n g n n g ct sng c hoc ct sng b di
lch n h i u c t h gy c h n p .
V. TIN LNG
Cc bnh n h n lao ct sng n u k h n g b cc b i n chng
nng thng c t i n lng t t .
Cc b i n chng trong q u t r n h i u tr v t n h t r n g k h n g
thuc l n h n g y u t quan t r n g quyt nh t i n lng ca
bnh n h n .

251

U N G TH DI CN X N G

ThS. H o n g Vn Dng
I. I CNG
Ung th di cn xng l mt hu qu nghim trng ca ung
th ni chung. Tt c cc loi ung th u c t h di cn vo
xng, song gp ch yu t cc ung th biu m nh ung th v
(n), ung th tin lit tuyn, ung th phi, ung th d dy.
Xng l kho cha lng ln cc yu t t n g trng t i ch
nh: TGF- beta (transorming growth factor), FGF (firoblast
grovvth factor), - LGF (insulin- like grovvth actor), PTH rP
(PTH related protein)...
Khi t bo ung th di cn vo xng, chng to ra phn t
kt dnh trn b mt t bo gn vi t bo m (stroma) ca
mng li xng. Vic gn kt ny s kch thch cc t bo m,
tin to ct bo, t bo min dch tit ra cc yu t tng trng
(enzym) bao gm: cc cytokin ( I L l , IL6), TNF (tumor necrosis
actor), TGF
EGF
(epidermal grovvth
factor),
PTHrP(parathyroid hormon- related protein), - LGF (insulin- like
growth factor), yu t hot hoa i thc bo, RANK (receptor
activator of nuclear actor Kb).
Nhng enzym ny c th tc ng trc tip, song phn ln
phi thng qua s hin din ca to ct bo mi kch thch c
huy ct bo hot ng gy huy xng, ng thi thc y to ct
bo to xng mi.
Qu trnh tiu xng ca huy ct bo l i kch thch cc t bo
min dch to ra cc yu t pht trin u, t kch thch t bo

252

ung t h p h t t r i n to ra vng xon b n h l l m cho qua r i lon

chuyn hoa xng c n g n n g hn.
N h vy hai q u t r n h tiu xng v huy xng ng thi xy
ra V t r di cn xng, song t u y theo c t n h ca t b o ung t h
m qua t r n h huy xng l n h n to xng hoc ngc l i .
li. TRIU CHNG LM SNG UNG TH DI CN XNG
1. Biu hin ton thn
- Tui: ung t h d i c n xng t h n g gp t u i t r n 50, bnh
r t h i m gp t h a n h n i n v t r em. Theo Tosiaki, A. Nina
(2000) nghin cu t r n 74 b n h n h n ung t h cc l o i c di cn
xng th t u i t r u n g b n h l 59 t u i . M t n g h i n cu k h c ca
PN. Scuttellari (2000) t r n 100 b n h n h n ung t h d i c n xng
c t u i t r u n g b n h l 63 t u i . T i V i t N a m , theo L C h D n g
nghin cu t r n 524 b n h n h n ung t h d i c n xng t 19552002 tui trn 50 tui chim n 343/524 (65,5%). D i cn xng tr
em thng t u nguyn bo t h n kinh, sarcom xng.
- Thi gian t k h i p h t h i n ung t h n g u y n p h t n k h i c
di cn xng c t h v i t h n g , vi n m , hoc ng t h i x u t
hin ung t h di c n x n g v ung t h n g u y n p h t , c n h n g
trng hp p h t h i n c d i c n ung t h v o x n g n h n g
khng t m c n g u y n p h t . T u y thuc b n cht ung t h
nguyn p h t , giai o n b n h lc m i c h n o n m t h i gian
xut h i n ung t h d i c n x n g l k h c nhau. Theo A. B u r r u t i
v cng s (2000) cho t h y 20% b n h n h n c b i u h i n ung t h
di cn xng vo t h i i m c c h n o n ung t h t i n l i t
tuyn.
- Trong ung t h di c n xng, v t r d i cn vo ct sng chim t
l cao n h t (80%, trong hay gp l ct sng t h t lng), tip n
l khung chu, u t r n xng i (40%), xng sn (30%), v
xng s (20%). Ch c 2-5% c d i cn xng ngoi bin (cng b n

253

tay, cng bn chn), trn 90% bnh nhn c di cn xng vo

xng trc. Tuy theo loi ung th nguyn pht m c t l cc v tr
di cn khc nhau: di cn ct sng tht lng, khung chu hay gp
nhng ung th trong tiu khung (ung th tin lit tuyn, t cung,
bung trng), di cn xng sn hay gp trong ung th v, ung
th phi v c n 50% di cn vo cc xng ngoi vi (cng bn
tay, cng bn chn) gp trong ung th phi.
- Biu hin ton t h n c t h c nh: mt mi, chn n, gy
st cn nhiu v nhanh, thiu mu (c bit k h i ung th di
cn vo tuy xng). Yu c, bun nn, to bn, k h t , c th l
ln, hn m l cc biu hin ca t n g calci mu.
2. au xng khp
- Khi ung th pht trin, xm ln v di cn thng gy ra
au n d di cho ngi bnh n tn lc t vong. au xng
khp l triu chng ph bin nht ca ung th di cn xng.
y l du hiu gi di cn vo xng nhng bnh nhn
bit ung th nguyn pht. Khong trn 80% bnh n h n ung th
di cn xng c biu hin au xng. Tuy nhin, au xng
khp c th gp trong nhiu nguyn nhn khc nhau nh: lao
xng khp, a u tuy xng, hoi t chm xng i v khun,
thoi hoa khp, long xng... M t khc, c nhng trng hp
di cn xng m khng c biu hin au hoc au rt nh. Theo
Schaberg v Gainor (1985), 36% bnh nhn c di cn ct sng
m khng c biu hin au xng.
C ch au trong ung th di cn xng: c hai c ch chnh.
+ au lin quan n khi u di cn: kiu au ny thng au
v na m, gn sng khin bnh nhn phi thc gic trong
m v au v c th gim dn sau nhng hot ng trong ngy.
Kiu au ny do cc yu t gy vim nh seretonin v do kch
thch mng xng, v vy au gim khi dng corticoid.

254

+ a u theo k i u c hc: n h n g t n t h n g x n g khp do d i

cn ung t h gy n n b t t h n g v cu t r c g i i p h u n h l n ,
xp t h n t sng, c h n p t h n k i n h gy n n k i u a u c hc.
au t n g k h i v n ng, i l i b h n ch, c b i t n h n g ng
tc l m t n g sc p ca ct sng.
+ Vi bnh nhn ung th di cn xng, a s cc trng hp
a u l s phi hp hai k i u a u t r n .
- Cng au: au trong ung th di cn xng thng au
nng, n g h i m trng, g y tr n g i ln cho c b n h n h n v t h y
thuc v p ng k m vi thuc g i m a u t h n g thng.
n h gi mc a u t r n l m s n g c n h i u t h a n g i m n h
gi a u , mi l o i c n h n g c t n h ring. Ph b i n n h t , l
thang im VAS (Visual Analog Scales), d p d n g cho t t c
cc l o i ung t h . Tuy n h i n nhc i m ca VAS l ch da vo
yu t ch quan ca b n h n h n . Thang i m n y c chia
t h n h 10 vch (T 0 n 10, t n g ng 10 em), m i vch l i chia
nh t h n h 10 m m (Tng 100 mm), m i vch t n g ng ng
au ca bnh n h n t n g d n (vch 0 l k h n g a u , vch 10 l
au t i a). Trong ung t h di c n x n g t h n g bnh n h n a u
trn 7 i m .
- V tr au: thng au nhiu v tr khc nhau, v tr hay gp
l ct sng, k h u n g c h u , khp h n g .
3. Cc biu hin thn kinh
- Nhng biu hin thn kinh c th do khi ung th di cn
chp p trc t i p , c t h do t n t h n g t h n t sng (ln, xp)
gy c h n p t h p h t . S x m l n , c h n p t h n k i n h , k h n g
nhng gy a u n m cn g y cc b i n chng t h n k i n h k h c
n h : l i t v n ng, r i l o n c m gic, r i lon c t r n .
- Tuy on tuy hay r thn kinh b chn p m c nhng biu
h i n l m s n g o n t u y chi phi.

255

+ au thn kinh toa mt hoc hai bn: au vng tht lng

lan dc xung i, cng bn chn theo ng i thn kinh toa,
nghim php Valleix (+), Lasegue (+).
+ Gim hoc tng phn x gn xng (tuy theo p r hay p
tuy) c th c ri lon cm gic hoc r i lon c trn.
4. Gy xng bnh l
Gy xng bnh l l tnh trng gy xng t i nhng v tr
c tn thng xng t trc m khng do sang chn hoc sang
chn rt nh. C th gy cc xng di, t sng biu hin dng
ln, xp. Xng b di cn tr nn r t yu, d gy, i khi gy
xng l triu chng u tin ca ung th di cn xng. V tr
thng gp l cc xng di tay, chn v ct sng.
5. Di cn c quan khc ngoi xng
Ung th di cn xng c coi l di cn xa ca mt ung th,
l giai on cui ca mt ung th. Mt bnh nhn c th pht
hin ung th di cn nhiu c quan, tuy nhin c th ch pht
hin ung th di cn xng m cha di cn c quan khc.
HI. TRIU CHNG CN LM SNG
1. Mt s biu hin xt nghim c th gp nh
- Cc xt nghim v bilan vim: trong ung th di cn xng
cc xt nghim mu lng, protein c phn ng (CRP) u tng,
thm ch tng kh cao.
- Tng phosphatase kim mu th hin s huy xng mnh
ca huy ct bo, i khi c biu hin t n g phosphatase acid th
hin tng qu trnh to xng ca to ct bo (thng gp trong
ung th tin lit tuyn di cn xng).

256

- T n g calci m u k h i c s huy xng n h i u . y l t r i u

chng gp k h p h b i n t r o n g ung t h d i c n xng. i k h i c
biu h i n l m s n g nguy h i m t n h m n g n h : y u c, b u n
nn, t o b n , k h t , c t h l l n , h n m , r i l o n n h p t i m .
- Thiu m u c t h do di cn tuy xng gy suy tuy, do suy dinh
dng.
- H i n nay, vic xc nh cc du n ung t h r t c gi tr
khng nhng cho chn on, tin lng cc ung t h (T) n g u y n
pht m cn c tr trong vic chn on v t r ung t h di cn
xng, tuy theo l o i ung t h n g u y n p h t m c du n k h c nhau
nh:
+ D n g k h n g t h n d n g (c h i u t n g l o i k h n g
nguyn ung t h ) c g n c h t p h n g x n h d u t m v t r d i
can xng. M t s d u n T n h : PSA (T t u y n t i n l i t ),
alpha FP (T gan), CEA (d dy), CA125 (T bung trng)...
+ D n g p h n g p h p m i n dch p h n g x nh lng cc cht
trong chuyn hoa x n g k h i c ung t h d i c n xng. Cc cht
gm: P I N P (propeptid of type procollagen, t h h i n s h o t
ng ca to ct bo) v I C T P (Carboxyterminal p y r i d i n o l i n
cross-linked telopeptide of type collagen). P h n g p h p n y c
nhy 7 1 % , c h i u 42% trong vic p h t h i n u n g t h d i
cn xng.
2. Chn on hnh nh
So vi cc p h n g p h p c h n o n h n h n h k h c t h X-quang
quy c xng c n h y v c h i u t h p hn n h i u trong
vic chn o n u n g t h d i c n xng. Theo DJ. Perez (1983)
nhy ca X-quang l 15%.
H n h n h t n t h n g t r n X-quang quy c x u t h i n c h m
nhiu t u n hoc n h i u t h n g so vi l m s n g v x h n h xng.
Nhng t n t h n g t r n em v m t t r n 50% cht k h o n g

257

trong xng (dng huy xng), hoc t n g trn 30% cht khong
trong xng (dng kt c xng) th mi pht hin c trn
Xquang. Do vy khi hnh nh X-quang in hnh th ung th di
cn xng giai on mun.
- Biu hin trn X-quang: tiu xng, kt c xng v th
hn hp (kt hp gia tiu v c xng).
- Th tiu xng: y l th hay gp nht, c th c cc hnh thi
khc nhau:

+ Hnh hc khng cn quang, ng u, thng c gii hn

r, trn hoc bu dc kch thc 1-2 em, i khi rt nh. Thung
c nhiu, tn thng lm cho xng c hnh nh "mi gm" (hnh
58). Hnh thi ny thy t h n xng di, vm s. i khi tn
thng l nhng vng khng cn quang, ranh gii khng r,
thng khung chu. Vi nhng tn thng tiu xng th hnh
thi tn thng, b vin tn thng c gi tr gi lnh
258

tnh, c t n h ca t n t h n g . N m 1980, Lodwick a ra

bng p h n t n t h n g x n g t r n X-quang ( c n g cao t h
c t n h c n g cao).
+ Hnh nh xoa mt on xng, gp cung hoc cung sau
t sng (t sng cht m t ) , xoa m t m t p h n t h n t sng
hoc m t o n n g n h n g i h n g ( h n h 57).
- Th to xng (hay cn gi kt c xng).
Thng gp trong ung th tin lit tuyn v mt s c quan
khc n h u n g t h v , p h i . T n t h n g hay k h u t r xng
chu v t sng vi c c b i u h i n n h :
+ Nhng im m, m m c b vin khng r rt, khi tn
thng n h v n h i u l m cho xng c h n h t h i n h b n g
(hnh 59).
+ H n h n h t sng m c ( h n h 60).

1 IM L.
p * --mi

E?

9 \ \,
.
1

/
t '*

. *'

Hnh 59. Kt c xng ton b

Hnh 60. Kt c t sng

259

tnh, c t n h ca t n t h n g . N m 1980, Lodvvick a ra

bng p h n t n t h n g x n g t r n X-quang ( c n g cao t h
c t n h c n g cao).
+ Hnh nh xoa mt on xng, gp cung hoc cung sau
t sng (t sng cht m t ) , xoa m t m t p h n t h n t sng,
hoc mt o n n g n h n g i h n g ( h n h 57).
- Th to xng (hay cn gi kt c xng).
Thng gp trong ung th tin lit tuyn v mt s c quan
khc n h ung t h v , p h i . T n t h n g hay k h u t r xng
chu v t sng v i c c b i u h i n n h :
+ Nhng im m, m m c b vin khng r rt, khi tn
thng n h v n h i u l m cho xng c h n h t h i n h bng
(hnh 59).
+ H n h n h t sng m c ( h n h 60).

wHt" *

m
_ ;:

'

#''

w
s
vt

Mf)
_
1

Hnh 59. Kt c xng ton b

Hnh 60. Kt c t sng

259

- Th hn hp l t h phi hp c tiu "xng v c xng

Tn thng xng trong ung th di cn xng thng gp
nht l dng huy xng. Dng tn thng huy xng hoc kt
c xng chim u t h tuy theo ung th nguyn pht: dang
huy xng thng gp trong ung th thn, tuyn gip, vu phi
Dng kt c xng thng gp trong ung t h tin lit tuyn
Dng hn hp thng gp trong ung th v.
Chp x hnh xng
y c coi l phng php la chn u tin nh gi
ung th di cn xng. Phng php ny cho php kho st ton
b h thng xng, c kh n n g pht hin ton thng sm hn
X-quang nhiu t h n g (trn 6 thng). X hnh xng c nhy
cao, tuy nhin c hn ch l c hiu khng cao, nhng tn
thng xng lnh tnh cng c t h biu hin tng hot tinh
phng x trn x hnh xng (Vim xng, chn thng, thoi
khp...). phn bit nhng hnh nh tn thng trn x hnh
xng cn phn tch tn thng v s lng tn thng, cch
phn b, mc t n g hot tnh phng x, oi khi cn tin hnh
chp SPECT nh gi s ti mu qua 3 pha chp. Nhng tn
thng lnh tnh thng n c, nhng 0 vim xng thng
tng hot tnh phng x trn c 3 pha chp (dynamic, bood pool
v static), nhng hoi t v khun chi t n g hot tnh phong
x pha cui (static). Theo M M . Steinborn v cng s (1999)
a ra nhy l 84,4% v dc hiu l 72%.
Hnh nh in hnh ung th di cn xng l hnh nh tng
hot tnh phng x a vi hnh dng kch c v t trng khc
nhau, phn b khng i xng, khng u, r i rc trn ton b h
thng xng c bit trn ct sng (hnh 61).

260

Hnh 61. Hnh nh x hnh xng

Hnh n h k h n g i n h n h ung t h d i c n x n g n h : n h n g
tn thng n c t n g h o t t n h p h n g x (ht spot). Khong
6-8% bnh n h n d i c n x n g ni chung l d n g n c. Tuy
nhin, theo D I . Boxer v cng s (1989) t h 20% b n h n h n ung
th v c d i c n x n g d n g n c. Xc sut t n t h n g
n c l t n t h n g u n g t h d i c n r t k h c n h a u gia cc v
tr t r n c t h . Theo Corcoran v cng s (1986) t h n h n g t n
thng n c s 50% l ung t h , t n t h n g ct sng t h
80% l ung t h , t r o n g k h i t n t h n g n c x n g sn
ch c 12% l u n g t h . T r o n g m t s t r n g hp t n g h o t t n h
phng x lan toa t r n t o n b h xng, h n h n h t h n b m,
hay cn gi l "superscan".
- Cc p h n g p h p chn o n k h c
Chp ct lp v i t n h (CT), c h p cng h n g t (MRI)

261

Cc phng php ny c nhy v c hiu cao hn so vi

x hnh xng trong vic pht hin ung t h di cn xng ti cc
V tr nghi ng. Tuy nhin phng php c ny c hn ch l
khng kho st c ton thn v gi t h n h t. Theo MM.
Steinborn v cng s (1999) nhy ca M R I l 91,4%, x hnh
xng 84,8%. Nghin cu ca Eustace v cng s (1997) cng cho
kt qu tng t: 96% vi M R I v 72% vi x hnh xng.
CT v M R I rt c gi tr trong vic nh gi nhng tn
thng chi tit t i tuy xng m x hnh xng khng pht hin
c. Toshiaki Taoda v cng s (2000) nghin cu tn thng
di cn ct sng ca 74 bnh n h n ung t h cc loi bng hai
phng php x hnh xng v M R I cho thy: kch thuc khi u
trung bnh m x hnh xng p h t hin c l 11,2 mm v 6,6
mm vi M R I . Ung t h di cn xng biu hin trn MRI l
nhng tn thng khng r ranh gii, gim tn hiu trn T i ,
tng tn hiu trn T2 v ngm thuc i quang t mnh sau
tim thuc (hnh 62, 63).

Hnh 62. TI signal

262

Hnh 63. T2 signal

. S P E C T v P E T (Single photon emission

tomography v Positron Emission Tomography).

computing

Nhng phng php ny gip pht hin ung th di cn

xng sm h n so vi x h n h x n g p h a n g ( k h i u n g t h
mi ch k h u t r t r o n g t u y x n g ) . S P E C T v P E T c u n g cp
nhng h n h n h t r o n g k h n g g i a n ba c h i u v cho b i t c
ri l o n chc n n g t i v n g t n t h n g , c b i t l F D G PET
(luorodeoxyglucose,
positron
emission
tomography). T u y n h i n g i t h n h r t cao. H i n c h a t h c
hin c V i t N a m .
- Sinh t h i t x n g v g i i p h u bnh.

Hnh 64. Sinh thit t sng

di CT

Hnh 65. T bo ung th di

cn xng

Nhng t n t h n g n c m cc p h n g p h p c h n o n
hnh n h c h a k t l u n , c n t i n h n h sinh t h i t xt n g h i m
m bnh hc n h m c h n o n xc n h . Sinh t h i t g i i phau

263

bnh l tiu chun vng trong chn on tuy nhin nhy ca

phng php khng cao do thng khng ly c chnh xc tn
thng. Ngy nay nh c hng dn ca chp ct lp vi tnh
nh hng kim sinh thit nn kh n n g sinh thit ng khi u
r t cao.
C mt s dng ung th di cn c th xc nh c khi u
nguyn pht do cc t bo ny bit hoa km, vn gi c hnh
thi t bo t chc nh ung th t bo sng ca thn, ung th
tuyn gip dng nang, ung t h tuyn nhy ca rut. Tuy vy
a s kt qu sinh thit ung t h di cn xng thng cho bit to
chc ung th biu m hay ung th m lin kt, rt kh xc nh
ung th nguyn pht.
VI. IU TR V TIN LNG
- Mc ch iu tr:
+ iu tr triu chng: gim au, iu tr gy xng, tng
calci mu... t nng cao cht lng cuc sng.
+ Ngn chn hoc lm gim qu trnh huy xng, lm chm
qu trnh tin trin ca bnh.
- Cc phng php iu tr:
+ Liu php hormon: c bit c gi tr vi cc loi ung th
cc tuyn ni tit nh ung th v, ung t h tin lit tuyn. Liu
php'hormon lm ci thin c thi gian sng thm cho bnh
nhn. Theo M . Bolla v cng s (2002) cho thy 78% bnh nhn
ung th tin lit tuyn giai on tin t r i n sng trn 5 nm khi
c iu tr liu php hormon kt hp x tr so vi 62% bnh
nhn ch c iu tr x tr.
+ Bisphosphonates: c rt nhiu nghin cu chng minh
biphosphonat c tc dng c ch hot ng huy xng ca huy
ct bo ng thi kch thch to ct bo to xng, iu hoa li
qu trnh chuyn hoa xng, lm cho xng tr nn chc khoe

264

hn. Ngoi ra c h n g cn c t c d n g g i m a u , i u tr t n g
calci m u r t t t . N h n g n g h i n cu gn y cn cho t h y
bisphosphonates c t c d n g n g n c h n s p h t t r i n ca t b o
ung t h di c n . Theo H . Flavio v cng s (2003) i u t r
clodronat trong 6 t h n g cho 32 b n h n h n ung t h t i n l i t
tuyn c di c n xng t h y r n g : 29/32 (90,6%) bnh n h n c cai
thin t r i u chng a u (VAS t r u n g b n h trc i u tr 7,7, sau
iu tr 2,1), n n g cao c bc t h a n g t h t r n g . C n h i u t h
h thuc, c n g v sau thuc c n g u v i t v t c dng. N h n g
t h h u ch c ng ung n n k m h i u q u hn n h
clodronat, Etidronat, Alendronat, t h h sau c d n g t r u y n
tnh mch c h i u q u r t t t trong i u tr ung t h d i c n
xng nh: pamidronat (Aredia), Zoledronat (Zometa).
+ X tr ngoi, y l p h n g p h p c p dng t lu.
Chiu x vo n h n g v n g di cn vi mc ch g i m au, h n c h
s p h t t r i n ca k h i u .
+ Dng dc cht phng x (x tr trong): vi mc ch
gim a u t r o n g u n g t h d i c n x n g , n g y nay n g i ta
s d n g dc c h t p h n g x i u t r r t c h i u q u . P h
bin
l
Strontium-89
v
P32
(phosphorous-32),
S a m a r i u m . Theo RG. R o b i n s o n v cng s (1995) cho
thy 60-80% b n h n h n c i u t r S r c g i m a u sau
1-3 t u n i u t r v k o d i 3-6 t h n g . Theo H o n g V n
T u y t (2004) i u t r P-32 cho 60 b n h n h n u n g t h c d i
cn x n g t h y : 52/60 (86,67%) c p n g g i m a u , g i m
au t t n h t t r o n g 2 t u n u (66,7%).
153

8 9

+ D n g t c n h n sinh hc t c ng theo c c h b n h sinh

ang c n g h i n cu p dng. Osteoprotogerin (OPG) l m t
tc n h n sinh hc c vai t r i u hoa r i l o n chuyn hoa x n g
trong ung t h d i c n x n g a n g c n g h i n cu t r n
thc nghim.

265

V. TIN LNG
Ung th di cn xng c coi l di cn xa ca mt ung th
Thi gian sng thm ph thuc vo nhiu yu t: ung th
nguyn pht, bit hoa ca ung t h nguyn pht, mc di
cn, ton trng bnh nhn, tnh hnh iu tr. Thi gian song
thm rt hn ch. Theo RT. Greenle v cng s (2000) thi gian
sng thm trung bnh ca ung th tin lit tuyn di cn xng
l 2 nm. Theo H. Katagiri thi gian sng t h m ca bnh nhn
ung th. v c di cn xng trung bnh l 24 thng. Trong khi
thi gian sng thm ca ung th phi c di cn xng khng
qu 6 thng.

266

A u TY
(BNH

XNG

KAHLER)

TS. N g u y n n h K h o a
I. I C N G
a u t y x n g l b n h t n g sinh c t n h ca d n g plasmocyt
(tng bo) t r o n g t y xng, gy n n n h n g t n t h n g hy
xng khu t r hoc l a n ta v n h n g r i lon do h u q u ca
tnh t r n g t n g t n g hp cc globulin m i n dch n d n g b t
thng (monoclonal protein, cn gi l protein M , paraprotein).
Bnh thng gp n h t t u i 40-80, t l nam n xp x nhau
(t l mc b n h n a m c t h cao hn n mt c h t ) .
li. TRIU CHNG LM SNG
1. Lm sng
Ty mc v giai o n ca bnh, c t h c t n h i u n h n g
du h i u sau y :
- a u x n g l t r i u chng t h n g gp n h t , c t n h cht lan
ta, hay g p cc x n g sn v ct sng. a u c lc ngh ngi,
tng k h i v n ng, i l i k h k h n . C t h k m theo g y xng
bnh l v h i c h n g c h n p t y .
- Y u c, m t m i , s t c n .
- X u t h u y t g i m t i u cu: chy m u cam, c h n r n g , ban
xut huyt da.
- Nhim khun ti pht.
- Cc t r i u c h n g ca suy g i m chc n n g t h n .
- C t h thy nhng khi u xng nh cc xng sun, xng s.

267

- Hi chng tng calci mu: kht nc, i tiu nhiu, nn

bun nn, to bn.
- Hi chng tng nht ca mu: chy mu nim mc, ri
lon th gic v cc triu chng thn kinh nh au u, co git
hn m.
2. Cn lm sng
2.1. Xt nghim

mu

Cng thc mu: thiu mu bnh sc hng cu bnh thng

(70%); tiu cu bnh thng hoc gim, bch cu bnh thng
hoc tng.
- Tc mu lng thng t n g rt cao.
- Tiu bn t bo mu ngoi vi: hnh nh hng cu kt t
thnh chng.
Sinh ha mu: c th c t n g calci mu, tng protein ton
phn, tng ure, creatinin, phosphatase kim bnh thung hoc
tng nh, c th c t n g acid uric mu, h natri mu.
in di protein huyt thanh v in di min dch: tng
gamma globulin, xut hin nh cao nhn n dng M t i vng
gamma globulin trong khong 50-60% bnh nhan la IgG, 2025% IgA, 15-20% l cc chui nh (light chm) n thun!
2.2. Xt nghim

nc

tiu

- Protein niu c th dng tnh.

C th thy protein Bence Jones (bn cht l cc chui nh
t do), xc nh bng phng php nhit hoc in di protein
nc tiu. Ch , phng php xt nghim" nc tiu thng
thng c th khng pht hin c protein Bence Jones.
2.3. Chn on hnh

nh

x-quang xng (xng sn ct sng, xng s, xng chu,

cc xng di): mt xng lan ta hoc tiu xng t h n h (hnh

268

nh xng s b n b n , xp l n cc t h n t sng h y xng

cc xng sn, x n g d i , g y xng bnh l).
X hnh xng: tp trung phng x vng xng tn
thng thng b n h t h n g hoc t n g r t n h .
Chp cng hng t (MRI): nh gi mc tn thng ca
ty xng, p h t h i n cc t n t h n g x m l n t y xng.

Hnh 66. Hnh nh tn thng tiu xng thnh xng s, gy xng bnh
l xng cnh tay v hnh nh t bo plasmocyt BN a u ty xng

269

2.4. Huyt ty v sinh thit ty

xng

Tng sinh n dng t bo plasmocyt trong ty cc mc

trng t h n h khc nhau, vi t l plasmocyt trn 10%.
CHN ON
1. Chn o n x c nh
Chn on xc nh theo tiu
chun nm 2003 ca nhm lm
vic quc t v a u ty xng
(International Myeloma Working
Group).
1.1. a u ty xng c triu
chng
T l plasmocyt trong ty t
nht l 10%, hoc thy u t bo
plasmocyt trn sinh thit cc t
chc khc
C protein n dng trong
mu (tng gamma globulin vi
nh cao nhn M trn in di
protein huyt thanh) hoc protein
Bence Jones nc tiu.
C bng chng ca tn thng
v suy gim chc nng cc t
chc:
- Tng calci mu.
- Suy thn.
- Thiu mu (H GB < 100 g/L).
- Tn thng xng.

270

Hnh 67. X hnh bnh nhn

a u ty xng

. N h i m k h u n n n g hay t i p h t ( t r n 2 l n m t n m ) .
- N h i m amyloid cc t chc.
- H i chng t n g nht m u .
1.2. a u ty xng

khng

triu

chng

- Nng protein n d n g t r o n g m u >30 g/L v/hoc;

- T l t n g b o t r n 10% qua sinh t h i t t y xng v;
- K h n g c n h n g t r i u chng ca t n t h n g cc t chc,
ni tng.
1.3. Bnh

gamma

globulin

n dng

v can

(MGUS)

Nng protein n d n g trong m u <30 g/L v;

- T l t n g b o d i 10% qua sinh t h i t t y xng v;
- Khng c n h n g t r i u chng ca t n t h n g cc t chc,
ni tng.
2. C h n o n p h n b i t
- Carcinoma d i c n xng.
- U n g t h n g u y n p h t ca
lexemi.

xng (sarcom), u

lympho,

- Bnh x n g do c h u y n h a .
- Bnh macroglobulin Waldenstrom.
IV. IU TR
1. N g u y n t c i u tr
a u t y x n g k h n g t r i u chng ( t n h c p h t hin): k h n g
cn t h i t p h i i u t r , c h y u theo di.

271

La chn phng php iu tr ph thuc tui v mc

bnh: vi nhng ngi trn 65 tui, bnh nng, phng php
iu tr chun l dng phc MP.
2. Ha tr liu n thun
Vi nhng bnh nhn khng c iu kin ghp ty t thn
hoc khng c ch nh (tui cao, th trng yu, c nhng bnh
l phi hp).
- La chn u tin: phc MP (melphalan + prednisolon),
t l p ng 40-60%;
- Melphalan: 0,25 mg/kg/ngy X ngy 1-4 + prednisolon
lOOmg/ngy, chia 2 l n X ngy 1-4, lp l i sau mi 4 tun, hoc;
- Melphalan 0,15 mg/kg/ngy _x ngy 1-7 + prednisolon 60
mg/ngy X ngy 1-7, lp l i sau mi 6 tun.
Mt s phc khc: nu phc MP tht bi hoc bnh tin
trin tr l i
- MPT: melphalan + prednisolon + thalidomid (100-200 mg
ung t ngy 128);
VAD:
vincristin
+
doxorubicin
dexamethason, nhc l i mi 5 tun;

(adriamycin)

- Vincristin 0,2 mg/m /ngy tryn tnh mch, ngy 1-4;

2

Adriamycin 9 mg/m /ngy, truyn tnh mch, t ngy 1-4;

2

- Dexamethason, 40 mg/ngy, ngy 14, 912, 1720;

C th thay t h dexamethason trong phc VAD bng
methyl prednisolon (VAMP) g/m /ngy, ngy 14;
2

BVAP: carmustin (BCNU) +

prednisolon;

272

vincristin + adriamycin +

VMCP: v i n c r i s t i n
prednisolon.

melphalan

cyclophosphamid

3. Ha tr liu liu cao phi hp vi ghp ty

Ha tr liu cao bng phc VMCP xen k vi phc
BVAP v phi hp v i g h p t y hoc g h p t b o m m (stem
cell) t t h n .
4. a u ty xng khng thuc
Xem xt s dng phc VAD, hoc c th phi hp cc phc
ha tr l i u t h n g t h n g ( n h M P ) vi n h n g thuc sau:
- Thalidomid.
- Lenalidomid (dn cht ca thalidomid) c th dng thay
t h cho thalidomid n u c c t n h v i thalidomid.
- Bortezomib (Velcade) l mt chtc ch protease c tc
dng c t b o t r o n g a u t y xng, c t h ch nh cho n h n g
bnh n h n k h n g thuc.
5. iu tr h tr
- Gim au xng: paracetamol, cc dn cht ca thuc
phin, calcitonin, x t r .
- Hn ch hy xng v gy xng: calcitonin,
bisphosphonat.
- Zoledronat acid (Zometa), 4 mg truyn tnh mch, mi
t h n g mt l n .
- Pamidronat (Aredia), 90 mg, truyn trong vng 4 gi, nhc
li hng t h n g .
- Hi chng p ty: liu cao corticoid, x tr, hoc ngoi khoa.
- Thiu mu:

273

+ Erythrompoietin (epoetin alfa).

Thiu mu do tn thng thn: dng liu trung bnh 50100 Ul/kg, tun 2-3 l n .
Thiu mu do ha tr liu: dng liu cao 150 -300 Ul/kgx 3
ln/tun, hoc 40.000 U I , mt l n mi tun; hoc 120.000 UI
mi 3 tun.
+ Cc thuc khc: st, vitamin B12, folic acid.
- Truyn mu.
- iu tr t n g calci mu: truyn dch, li tiu, calcitonin,
bisphosphonat, corticoid.
- Tng nht mu: lc huyt tng.
- D phng v chng nhim khun bng khng sinh.

274

XT NGHIM C N LM S N G TRONG
O N , I U TR V T H E O
C XNG

DI B N H

CHAN
L

KHP

TS. N g u y n n h K h o a
T h m d cn l m s n g c vai t r quan t r n g trong c h n o n
v iu tr m t s b n h l c xng k h p . T u y n h i n cc xt
nghim n y n n c ch n h k h i cn t h i t v vic n h gi k t
qu p h i c k t hp vi vic h i bnh v t h m k h m l m s n g
mt cch k lng. Ch n h m t lot x t n g h i m m h o n t o n
khng c n h n g t r i u chng l m s n g c h i u d d n n
nhng k t qu d n g t n h g i v sai st trong c h n o n . M t
khc, mt s b n h k h p t h n g gp n h v i m khp d n g t h p
(VKDT), t h o i khp, v i m khp vy n n , t h p p h n m m (vim
gn, im b m g n ) c t h c chn o n da vo l m s n g m
khng cn n cc x t n g h i m c h i u . C ba mc ch c h n h
khi ch nh xt n g h i m :
Mc ch chn on xc nh v phn bit: v d lm
sng nghi ng lupus ban h thng (SLE) n h n g xt n g h i m
khng t h k h n g n h n l i m t n h t h k h n n g lupus l r t
thp; hay b n h g t hoc g i g t c t h c h n o n xc nh k h i
tm thy t i n h t h c h i u trong dch khp.
- Mc ch tin lng, nh gi mc bnh v tn thng
ni tng: v d t r o n g b n h lupus, cn t h i t p h i n h gi t n
thng t h n qua x t n g h i m nc t i u , creatinin m u v n u
c bt thng v nc t i u t h cn p h i xt n g h i m protein n i u
24 gi. Hoc l n h n g b n h n h n lupus c k h n g t h k h n g
dsDNA d n g t n h t i n lng v l u d i t h n g x u v t h n g
s c tn t h n g n i t n g ( n h v i m t h n v v i m mch). Hay

275

r
nh gi c h n h x c h n , T M L b n h t h n g n n i u chnh theo
tui, theo cng thc t h n g d n g l:
TML (nam) = Tui/2 (mm/h)
TML (n) = (Tui + 10)/2 (mm/h)
- Trong cc bnh l vim, hng cu c xu hng d kt t vi
nhau l m tc l n g ca hng cu t n g ln, n g u y n do c t h l
do t n g lng brinogen t r o n g h u y t t h a n h . T M L cn c t h b
nh hng bi s l n g v h n h t h i hng cu cng n h nng
v c t n h ca m t s p r o t e i n t r o n g h u y t t h a n h .
TML c th thp gi to trong mt s bnh l ca hng
cu n h bnh hng cu h n h l i m , hng cu h n h cu.
- T M L t h n g t n g trong cc bnh l vim, n h i m k h u n
cng n h mt s b n h l c t n h . T M L t h n g t n g r t cao
trong nhng b n h l gamma globulin n d n g n h b n h a u
ty xng (Kahler). T M L cung c t h t n g trong t h i u m u ,
hay k h i s d n g m t s thuc, c h n g h n n h cc thuc h
cholesterol m u .
li. PROTEIN c PHNNG (C-REACTIVE PROTEIN, CRP)
CRP l m t protein trong h u y t t h a n h , c tng hp gan,
bnh thng c nng r t t h p v t h n g t n g trong cc p h n
ng vim cp t n h , c b i t l v i m do n h i m k h u n . Nng
CRP t n g n h a n h k h i c t h p h n n g l i cc t c n h n gy v i m
sau g i m n h a n h k h i q u t r n h v i m t h o i l u i hoc sau k h i
c i u t r m t c c h t h c h hp (thay i n h a n h h n so v i
TML).
1. Phng php
CRP thng c o bng phng php min dch hoc
quang k laser.

277

2. nh gi kt qu
- ngi bnh thng khe mnh, CRP thung di 02
mg/dl, nhng cng c th ti mg/dl.
- Tng CRP mc nh n va (1-10 mg/dl) thng gp
trong cc bnh l vim nh VKDT, vim ng mch te bao
khng l, bnh gt v.v. o CRP c t h c ch trong vic theo di
tin trin ca VKDT.
- CRP tng rt cao (>10 mg/dl, c t h t i 20-30 mg/dl)
thung gp trong cc bnh l nhim khun (kh nng bi nhim
khun ti 85% nu CRP > l mg/dl).
- Trong cc bnh t min: CRP khng tng hoc ch tng rt
nh. V vy, nu bnh n h n lupus c CRP t n g r t cao, cn phai
xem c bi nhim hay khng.
- Bnh nhn suy thn c t h t n g CRP.
Bng 6. Thay i bilan vim trong mt s bnh l cd xng khp
Bch
cu
mu ngoi vi

Tc mu
lng

CRP

Vim khp v khun

ang tin trin (VKDT,
VCSDK,...)

Thng bnh
thng

Tng

Tng va (110 mg/dl)

Thoi khp

Bnh thng

Bnh thng

Bnh thng

Cc bnh t min (lupus,

vim a c/vim da c
x cng b ton th)

Bnh thng
hoc gim

Bnh thng
hoc tng

Bnh thng
hoc tng rai
nh

Gt (cn gt cp hoc
t cp ca gt mn)

Bnh thng
hoc tng

Tng

Tng va (110 mg/dl)

Cc bnh CXK do nhim

khulB tnh hoc c

Tng

Tng

Thng tng
rt cao (>10
mg/dl)

Thng bnh
thng

Thng
cao

c tnh (ung
Kahler.vv)

rt

Bnh thng

HI. Y U T D N G T H P ( R H E U M A T O I D FACTOR, RF)

Yu t d n g t h p l cc globulin m i n dch k h n g l i o a n Fc
ca p h n t globulin G (IgG). H u h t t t c cc typ I g u co
c t n h ca R F xong cc p h n g p h p xt n g h i m c h u n h i n
nay ch y u xc n h k h n g t h I g M . R F t h n g c ch nh
khi l m s n g n g h i ng c V K D T , mc d RF c t h d n g t i n h
trong mt s b n h k h c .
1. Phng php
C rt nhiu phng php nh tnh v nh lng RF, xong
ch yu d n g p h n g p h p h p t h m i n dch, n g n g k t h t
latex, hoc quang k m i n dch.
2. n h g i k t q u
50-75% bnh nhn VKDT c RF (+). RF cng c th dng
tnh 3-5% n g i b n h t h n g . RF t h u n g d n g t n h n h n g
bnh n h n c H L A - D R 4 v n h n g bnh n h n V K D T n n g , t i n
trin nhanh. R F c n g r t t h n g gp trong h i chng sJogren
tin p h t , cc b n h t n g cryoglobulin m u h n hp cung n h
nhng bnh n h n c n h i m k h u n m n t n h n h v i m n i t m
mc b n cp v v i m gan m n t n h . N g o i ra R F cng c t h
dng t n h m t s b n h n h n b cc b n h t m i n k h c n h
bnh h t h n g (bng l i ) .
Bng 7. Mt s bnh c th c yu t dng thp dng tnh
Vim khp dng thp
Hi chng Sjogren
Lupus ban h thng
Cc hi chng vi (chng) lp (vi
vim a c v vim da c, x cng
b)
Bnh sarcoidosis
Bnh tng cryoglobulin mu

Nhim virus: rubella, EBV, CMV,

vim gan B v c
Nhim khun mn tnh: lao, giang
mai
Vim ni tm mc
X gan
Cc bnh l c tnh: u limpho
Bnh phi mn tnh

279

IV.

KHNG

TH

KHNG

CCP

(ANTI-CYCUC

CITRULINATED PEPTIDE ANTIBODIES, ANTI-CCP)

Citrulin c to thnh t acid amin arginin, sau khi loi
b nhm amin. Ngi ta tm thy nhiu bnh nhn VKDT c
k h n g t h khng l i cc peptid cha citrulin. Anti-CCP c ch
nh khi trn lm sng nghi ng c VKDT v nhng bnh
n h n c chn on VKDT, anti-CCP c dng nh mt yu
t tin lng bnh.
1. Phng php
ELISA l phng php c s dng ph bin nht.
2. nh gi kt qu
nhy ca ca anti -CCP trong VKDT khong t 40-70%,
nhng dc hiu c t h cao ti 98%, nht l khi s dng
nhng b test t h h mi (nh CCP-2). nhng bnh nhn c
vim khp cha r rng, k h n g t h khng CCP dng tnh l
mt yu t tin on quan trng i vi bnh VKDT: 90% nhng
bnh n h n ny s tin t r i n t h n h VKDT trong vng 3 nm.
Nhng bnh nhn c anti -CCP dng tnh a s cng s c RF
dng tnh. Nhng bnh n h n VKDT c mt ng thi c RF v
anti -CCP thng c tin lng xu hn v chc nng vn ng
v tn thng trn X-quang.
V. KHNG TH KHNG NHN (ANT1-NUCLEAR ANT1BODY, ANA)
1. Phng php
Phng php nhum min ch hunh quang gin tip l
phng php c s dng ph bin nht hin nay. Phng
php ny s dng t bo biu m ngi HEp-2 lm cht nhn
bit (substrate). Nhng t bo ny c t trn lam knh, ri
nh huyt thanh bnh n h n ln trn, cui cng vi khng th

280

khng o n Fc ca I g G c g n cht h u n h quang v c k t qu

di k n h h i n v i h u n h quang. N g o i ra cng c the s dung
phng p h p E L I S A vi mc ch nh lng, xong k h n g cho
bit c h n h t h i .
2. nh gi kt qu
Kt qu xt nghim ANA thng bao gm vic nh gi hiu
gi k h n g t h v h n h t h i quan s t c di k n h h i n v i
hunh quang.
- Hiu gi khng th ln hn hoc bng 1/40 c coi l
dng t n h , n h n g t r o n g lupus hay n h n g b n h h t h n g k h c
hiu gi t h n g t r n 1/160. K h o n g 20% n h n g n g i gi b n h
thng, c b i t l p h n , c t h c A N A d n g t n h , xong h i u
gi thng d i 1/160.
- Hnh thi nhum t bo trong xt nghim ANA phn nh
s p h n b cc t k h n g n g u y n trong n h n t bo. H n h d n g
ng n h t r t t h n g gp trong lupus, n h n g l i k m c h i u
cho bnh lupus n h t . D n g ngoi v i t h n g gp k h i c mtcac
khng t h k h n g l i c h r o m a t i n (nhim sc the, gm D N A va cc
protein histone), k h c h i u cho lupus ban h t h n g v
bnh lupus do thuc. H n h d n g l m m chng t bnh n h n
c cc t k h n g t h k h n g l i cc protein lin quan n RNA, c
th gp trong b n h lupus, bnh ca t chc lin k t h n hp v
hi chng Sjogren. T h h t n h n (nucleolar) l mt c t r n g
ca x cng b t o n t h .
- Hu ht bnh nhn lupus ban h h thng (95-100%) c
ANA (+), song A N A c n g c t h d n g t n h trong mt s b n h l
t min k h c n h v i m t u y n gip, v i m khp t h i u n i n v
bnh vy n n X t n g h i m A N A r t c ch trong s n g lc bnh, c
nhy r t cao t r o n g b n h lupus (v v v y n u b n h n h n c
ANA m t n h , s r t t c k h n n g l lupus), song c c
hiu thp, n h t l k h i d n g t n h vi h i u gi t h p . K h i b n h

281

n h n c ANA dng tnh cn xt nghim t h m cc t khng th

khng cc t h n h phn ca n h n khc nu c iu kin.
Bng 8. Tn sut xut hin khng th khng nhn trong mt s bnh
Bnh

Tn xut gp (Vo)

Lupus ban h thng

95-100

X cng b ton th

>90

Bnh t chc lin kt hn hp

100

Vim da c /Vim a c

>70

Vim khp dng thp

20-30

Hi chng Sjogren

40-70

Lupus do thuc

>90

Vim khp t pht thiu nin (th vi

khp)

70

Vim gan t min

90-100

Vim tuyn gip Hashimoto

40-50

VI

CC

K
H NG

TH

KHNG

ADN

(ANTI-DNA

ANTIBODIES)
Khng th khng dsDNA (ADN chui kp) rt c hiu trong
bnh lupus, trong khi khng t h k h n g ssDNA (ADN chui n)
c th gp trong nhiu bnh l vim khc nh lupus do thuc v
vim gan mn tnh.
1. Phng php
Min dch hunh quang gin tip hoc ELISA. Phng php
min dch hunh quang rt nhy v c hiu xc nh khng

282

t h k h n g dsDNA. P h n g p h p E L I S A r t i n h n v d l m
tuy n h i n bi v D N A p h n l p r t d b b i n t n h trong cc
khay nha d n g l m E L I S A cho n n c the g y n n d n g t i n h
gi vi cc k h n g t h k h n g ssDNA. N h vy n u d n g ELISA
xc nh k h n g t h dsDNA, n u k t q u d n g t n h trong
khi xt n g h i m A N A l i m t n h t h r t n h i u k h n n g bnh
nhn ch c k h n g t h k h n g ssDNA (dng t n h gi).
2. Phn tch kt qu
Khng th khng dsDNA dng tnh khong 75% bnh
nhn lupus v r t h i m gp n g i b n h t h n g hay cc bnh l
vim v t m i n dch k h c , v vy c c h i u r t cao i vi
bnh SLE. Ngoi ra, trong bnh SLE, k h n g t h k h n g dsDNA
cng thng c t n g quan m t t h i t v i t n t h n g vim t h n
v hiu gi k h n g t h t h n g t n g g i m t y theo mc hot
ng ca bnh. V v y x t n h i m n y r t c ch trong chn o n
v theo di d i n b i n ca bnh v k t q u i u tr.
VII. MT S T KHNG TH KHC
Khng th khng histon: dng tnh 50% bnh nhn
SLE, n h n g gp 100% b n h n h n lupus do thuc. Do vy n u
xt nghim n y m t n h t h c t h loi t r lupus do thuc.
- Cc khng th khng phospholipid: bao gm anti cardiolipin, y u t chng n g lupus v k h n g (J2-glycoprotein.
Nhng k h n g t h n y gp k h o n g 40% b n h n h n lupus v c
th lin quan n t n h t r n g h u y t k h i , tc mch, x y t h a i lin
tip hoc t h a i l u n h n g b n h n h n n y .
- Cc khng th khng cc khng nguyn nhn ha
tan: ch y u x c n h b n g E L I S A .
+ Anti-Smith (Sm): khng nhy trong lupus (20-30% dng
tnh), n h n g r t c h i u cho b n h lupus ( c h i u ti 99%).

283

+ Anti-ribonucear
protein
(RNP) dng tnh 30-40%
bnh nhn lupus v trong bnh t chc lin kt hn hp, c th
co hiu gi rt cao (ti trn 1/10000).
+ Ant-Ro (SS-A): khong 40% bnh nhn lupus (+), thng
c lin quan vi tnh trng da nhy cm vi nh sng, lupus
ngoi da bn cp, lupus tr s sinh v hi chng Sjogren.
+ Anti-La
(SS-B): dng tnh 10-15% bnh nhn lupus.
Rt hay gp bnh n h n c hi chng Sjogren v lupus s sinh.
- K h n g t h k h n g c e n t r o m e r : xc nh bng min dch
hunh quang gin tip hoc ELISA, dng tnh 30% bnh
n h n x cng b v thng l t h bnh cc b (hi chng
CREST).
- K h n g t h k h n g Scl-70: dng tnh 30% bnh nhn x
cng b v thng l th lan ta.
- K h n g t h k h n g J o - l : l khng t h khng l i histidin
tRNA synthetase, xut hin 25% bnh n h n b vim a c, c
bit l nhng bnh n h n vim a c c bnh phi k.
- K h n g t h k h n g Mi-2: (+) 15-20% bnh nhn vim da
c v rt c hiu cho vim da c.
- K h n g t h k h n g t n g b o ca b c h c u a nhn
t r u n g t n h (ANCA): rt c ch trong chn on mt s bnh
vim mch (vasculitis). v mt phng php, trc y thng
dng phng php min ch hunh quang gin tip trn bch
cu a n h n trung tnh; da vo hnh thi p h t quang ngi ta
chia 2 loi: dng lm m tng bo (c-ANCA) v dng quanh
nhn (p-ANCA). Ngy nay ch yu s dng phng php
ELISA. C-ANCA rt c hiu cho bnh tng sinh ht (u ht)
Wegener (khong 80% dng tnh) trong khi p-ANCA ch yu
gp trong vim nt a ng mch v i th, bnh vim mch
Churg-Strauss v mt s bnh vim mch khc.

284

VUI. X T N G H I M B T H
H thng b t h l m t p h n quan t r n g trong p ng m i n
dch dch t h . C c b t h b h o t h a bi cc sn p h m t v i
khun hoc bi cc phc hp m i n dch. Trong mt s bnh t
min, h t h n g b t h b h o t h a q u mc, d n n t n g s
tiu t h ca m t s b t h v g i m nng trong m u .
. Phng php
CH50 c xc n h b n g cc p h n g p h p t h m d chc
n n g n h k h n n g t i u m u ca b t h . Cc y u t b t h ring
bit n h C3, C4 t h n g c n h lng bng cc p h n g p h p
min dch n h quang k m i n dch hoc ELISA.
2. nh gi kt qu
o C3, C4 v CH50 r t c ch trong theo di bnh n h n lupus.
Nhng bnh n h n a n g c lupus t i n t r i n hoc c t n t h n g
thn thung c n n g C3 v C4 t h p , c b i t l C4. K h i bnh
n nh, n h n g b t h n y t h n g t r v mc b n h t h n g . CH50
cng t h n g t h p t r o n g m t s bnh c t n g cryoglobulin m u
v bnh v i m mao m c h d n g m a y (vim mch g i m b t h
mu). Trong n h n g b n h l t m i n k h c , nng b t h
thng b n h t h n g .
IX. ACID URIC MU
Xt n g h i m acid uric m u co ngha n h gi v theo di
mc t n g acid uric m u b n h n h n g t i h i p h i i u
tr. N h n g b n h n h n u n g t h , c b i t l cc bnh m u c
tnh, k h i c d n g h a t r l i u l i u cao cng cn t h i t p h i theo
di nng a x i t uric m u . K h o n g 5-10% nam gii ni chung c
t n g acid uric m u k h n g t r i u chng, c n nh l t n g acid uric
mu k h n g c ngha l b b n h g t , ngc l i mt s b n h n h n
gt, n h t l g t cp, t i t h i i m cn v i m cp c t h k h n g c

285

t n g acid uric mu. Tng acid mu n thun khng triu

chng (cha b bnh gt) thng cng khng cn thit phi iu
tr, t r khi acid uric mu qu cao (trn 760 moi /Li nam v 700
moi / L n) c nguy c gy tn thng thn.
X. KHNG NGUYN HLA-B27
T l HLA-B27 trong dn s ni chung vo khong 5-8% v
trn 90% bnh n h n vim ct sng dnh khp c HLA-B27
dng tnh. Trong cc bnh l ct sng huyt thanh m tnh
khc nh vim khp phn ng (hi chng Reiter), vim khp
vy nn (th c vim ct sng), vim ct sng lin quan ti cc
bnh ng rut, t l HLA-B27 dng tnh vo khoang 50-80%.
Bi v HLA-B27 c t h dng tnh mt t l nh ngi bnh
thng, cho nn xt nghim HLA-B27 t c gi tr trong chn
on xc nh vim ct sng dnh khp. Tuy nhin HLA-B27 c
th c ngha chn on trong trng hp lm sng nghi ng c
vim ct sng dnh khp, hoc i vi nhng trng hp c vim
mng b o mt bn cp km au lng kiu vim song trn Xquang thng quy hnh nh vim khp cng chu khng r.
XI. XT NGHIM DCH KHP
Chc ht dch khp nhm nh gi mu sc, nht, m s
lng v cng thc t bo, nhum gram, nui cy, xt nghim
PCR tm vi khun v tm cc vi tinh th. Chc h t xt nghim
dch khp gn nh l bt buc trong chn on xc nh vim
khp nhim khun. Nhum gram v nui cy c t h khng cn
thit nu dch khp c biu hin ca bnh l khng vim nh
vn trong v c nht cao, hoc khi lm sng hon ton khng
ngh n kh nng nhim khun. m s lng bch cu a
n h n trong dch khp rt quan trng trong chn on nguyn
nhn ca vim mt khp nh vim khp nhim khun hay vim
khp do vi tinh th. S lng bch cu di 2.000 Xl0 /L thng
l t r n dch khng do vim. Trn dch khp do vim thng c
9

286

s bch cu t 2.000-50.000 X107L. Vim khp n h i m k h u n

thng c s bch cu t r n 50.000 X l 0 / L . K h i t m v i t i n h t h
nn s dng dch khp m i chc v d n g k n h h i n v i p h n cc.
9

Bng 9. c im ca cc loi dch khp

Binh
thng
Mu
sc

Khng
mu

Nhml
(Khng
vim)

Nhm li
(Vim)

Nhm HI
(Nhim
khun)

Khng
mu hoc
vng nht

Vng hoc
vng trng

Vng hoc
mu
m
trng
xanh

Nhm
IV
(Dch
mu)

Trong

Trong
Hi c
c
c
sut
trong
Cao
Gim
Gim
nht Rt cao
Gim
S bch
<200
<2000
2000-50,000 >50,000
cu
BCa
<25%
>50%
>90%
<25%
nhn
Ty
Nui
m tnh
m tnh
Dng tnh
m tnh
thuc
cy
Ch : s lng bch cu trong mt s t trng hp vim khng nhim
khun c th ti 75.000-100.000/1. Trong vim khp nhim khun, s lng
bch cu thng trn 100.000/1.

287

T C H C P H N G T I M K H P T I B N H VIN

TS. Trn Th Minh Hoa

Mc ch s d n g p h n g t h t h u t tim khp
- Tin h n h t h thut tim khp.
- Tin h n h th thut chc d dch khp, chc tho dch
khp, ra khp.
Phng c gi t t l phng tim khp.
Yu c u thit k p h n g t h thut tim khp
- Din tch: 12- 16 m

- c thit k t iu kin kh khun v trng nh phng m.

- C n pht tia cc tm kh trng.
- Nn c h thng iu ha, thng kh m bo v trng.
- C h thng nc sch ra tay, hp k h n sch lau tay hoc
my sy kh tay, c h thng nc t h i vo ng nc thi
y t x l.
- OI ging t h m khm l i bnh n h n trc tim v tim
bnh nhn.
- 02 gh xoay dnh cho bnh n h n v thy thuc.
- n soi X-quang kim tra ilm X-quang ca bnh nhn
trc tim.
- OI bn ghi chp h n h chnh.
- Hp thuc chng sc theo quy nh.

288

- T thuc, hp n g d n g c v t r n g (xng c l , kp c
mu, bng b n g gc...).
Yu c u d n g c , p h n g t i n
- Bm t i m , k i m t i m v k h u n , t t n h t d n g bm t i m
nha mt l n , l o i 20 mi, lOml, k i m s 17 G, 20G, 2 5 G . . . . d i 35cm.
-Bng cn 70, dung dch Betadin hoc cn iod, b n g dnh y t.
- Hp ng d n g c k h t r n g (xng c l , kp c m u ,
bng b n g g c . )
- Ong n g h i m v t r n g , ng n g h i m c chng n g b n g
heparin, lam k n h .
- Dung dch acid acetic 7N ( l m test mucin).
- Thuc: gy t , m , thuc chng shock.
- Dch t r u y n N a C l 9%0 bm ra vo khp (500-1000 mi).
- Hydrocortisol hoc cc c h p h m t n g ng..., cht nhn
(Go-on, Hyruan...) t i m vo khp n u c ch nh.
Yu c u c n b y t
M t bc s - M t y t ph.

289

TIM

CORTICOSTEROID VO

KHP

V T CHC P H N M M CNH KHP

TS. Trn Th Minh Hoa

I. I CNG
- Tim khp v t chc phn mm cnh khp (intra-articular,
and periarticular soft tissue iiection) l mt liu php dng
kim nh a thuc vo khp hoc phn mm cnh khp
iu tr t i ch mt s bnh khp.
- C ch tc dng ca cc thuc steroid dng dung dch treo:
+c ch qu trnh tng hp cc cht gy vim prostaglandin.
+c ch gii phng enzym tiu m.
+c ch s hot hoa ca bch cu v i thc bo.
Nn tim khp bng cc ch phm coticosteroid c tc dng
chng vim, gim au, gim p h n t i ch r t nhanh do vy
c hiu qu lm gim cc t r i u chng sng, au v ci thin vn
ng cho ngi bnh trong mt thi gian ngn.
- Tim khp c p dng iu tr trong lnh vc khp hc
trn 40 nm nay, v cng ngy cng chng minh y l mt
phng php iu tr n gin, an ton c hiu qu, v chi ph
thp trong iu tr t i ch mt s bnh l xng khp.
- Do tnh u vit ca phng php iu tr ny, nn hin nay
c nhiu c s y t v cn b y t l m dng iu tr trong khi
khng nm vng c ch inh, chng ch nh cng nh k
thut tim v gy ra nhiu hu qu ng tic cho ngi bnh

290

n h n h i m k h u n v t r t i m , v i m k h p m , t g n , teo c,
huy xng.... y l m t thc t r n g cn p h i k h u y n co cho
cn b y t v n g i b n h p h i cn t r n g k h i p dng l i u p h p
iu t r n y .
li. CH NH TIM KHP V TIM PHN MM QUANH
KHP
1. Tim khp v tim phn mm quanh khp ch c ch
nh i u tr t i c h c h o c c b n h l p h n m m c n h k h p
- Vim g n v cc i m b m g n : h i chng De Quervain,
(vim mm c h m quay), v i m m m c h m t r , v i m l i cu c n h
tay, vim m o chu, v i m g n Achilles...
- Vim bao g n : n g n tay l xo (vim bao g n gp n g n tay),
a u quanh khp vai, h i chng ng h m c tay....
- Vim sn sn (hi chng Trietze), v i m sn sn...
2. Mt s bnh vim mng hot dch khp khng c hiu
nh
- T h o i hoa khp giai o n n h : khp gi, khp t h i dng
h m , khp b n c c h n , khp vai....
- Vim khp d n g t h p : khp gi, khp b n c tay, khp
khuu tay, khp vai, khp b n n g n tay, khp b n c chn....
- B n h l ct sng t h h u y t t h a n h m t n h : v i m ct sng
dnh khp, v i m khp p h n ng, v i m khp vy nn, v i m khp
mn t n h t h i u n i n ...
- Vim khp sau c h n t h n g ( k h n g c t r n m u khp do
chn thng).
- Bnh gt v bnh gi gt khc.
- M t s b n h h t h n g (t c ch nh t i m khp).

291

3. Tim cnh ct sng, tim ngoi m n g cng, tim v o a

m
Cn lu rng ch nn p dng tim khp sau khi cc bin
php iu tr ni khoa cc trung hp ny khng c kt qu (vt l
tr liu, thuc gim au, thuc chng vim khng steroid) nhm
trnh vic lm dng tim khp v tim phn mm quanh khp.
III. CHNG CH NH
Khng c p dng tim khp cho cc trng hp:
1. Vim khp nhim khun: vim khp m, lao khp
2. u xng khp (lnh tnh v c tnh)
3. Tn thng khp do bnh l thn kinh, bnh mu
4. Nhim khun ngoi da vng tim khp.
Thn trng ch nh tim khp i vi bnh nhn c tin s
i tho ng, tng huyt p, bnh mu, nhim nm, suy gim
min dch (HIV).
Thc t cho thy rng nu tim khp trong cc trng hp
ny khng nhng khng ci thin tnh trng bnh m lm cho
bnh tin t r i n nhanh v t r m trng hn, nhiu khi nguy him
n tnh mng ngi bnh.
IV. CC LOI THUC s DNG TRONG TIM KHP
Khng phi loi thuc no cng x dng tim khp: mt
thc trng cn phi chm dt l do thiu hiu bit nn nhiu
ngi s dng c thuc khng sinh, vitamin B12, thm tr c
cc thuc chng vim khng steroid (Voltaren, diclofenac.)
tim vo khp. iu ny rt nguy him v cc thuc ny s gy
phn ng vim mnh mng hot dch khp tn h i nghim
trng n cc t chc hot dch, sn khp... lm khp sng to,

292

r t a u c t h d n n h u q u vim d n h k h p , l m k h p m t
k h n n g v n ng. V v y c n p h i n h n m n h r n g , h i n nay
ch n n s d n g cc thuc sau y t i m khp n h :
1. Cc ch phm steroid dng dch treo, chm tan
* Hydrocortison acetat ( l m l = 2 5 m g )
* Triamcinolon (Kenacort, K-cort): hin nay khng s dng
t i m khp.
* Diprospan, Depo-Medrol.
2. Mt s thuc tim khp c bit khc
* Cc cht n g v p h n g x A u

1 9 8

, Er ...
169

* Dch nhn nhn to: acid hyaluronic sodium.

V. K THUT TIM KHP V PHN MM QUANH KHP
1. Nguyn tc
Cn phi m bo ng quy trnh tim khp:
- Tim ng v tr gii phu ca cc im bm gn, cc li
cu, d y chng, bao khp v khp, t u y t i t r n h t i m v o c,
xng, m c h m u v d y t h n k i n h quanh khp v s d n n
h u q u r t x u n h teo c, xp xng, m t v n ng ca
khp...
- Tim khp phi m bo ng cc nguyn tc v trng (st
k h u n , bm k i m t i m v t r n g . . . ) .
- Tim ng liu lng thuc: liu lng thuc tim (t 0,31.5 mi) t u y thuc v o kch thc khp t i m , t r n h a m t
lng thuc q u ln v o k h p hay t chc m m c n h khp v
c t h lng thuc t h a s l m t n g nguy c t n h i t b o
m n g hot dch, c t h g y p xe v k h u n t i ch.

293

- Cn phi tun t h theo cc nguyn tc ca liu trnh tim

nh:
+ i vi thuc hydrocortison acetat th khng tim qu 3
khp trong mt ln tim, mi t tim khng qu 3 l n tim, v
mi l n tim cch nhau 3-5 ngy, ch nn lp l i t iu tr th
2 sau 3 n 6 thng.

294

+ i v i cc thuc n h diprospan, Depo-Medrol... n u t c

h i u q u iu tr ngay l n t i m u tin t h ch cn t i m mt l n ,
hoc ch n n t i m nhc l i m i t h 2 sau 10-20 n g y t c
hiu q u iu tr mong mun. Khng n n t i m n h i u l n vo mt
v t r t r n h nguy c b n h i m t r n g v teo da t i ch.
2. K thut tim khp
- T i n h n h t r o n g p h n g v t r n g ( p h n g t h t h u t ) , m
bo cc yu c u v cc n g u y n t c v t r n g quy n h .
- D n g b m t i m v k i m t i m v t r n g (Loi d n g l n ) ,
g n g tay v t r n g .
- Ch s d n g cc thuc c p h p d n g t r o n g t i m khp.
- Xc nh v t r g i i p h u chn v t r t i m (chn t t h
khp ca bnh n h n , v t r ca b c s...).
- S t t r n g v n g t i m b n g b n g cn iod 3-4 l n .
y
T i m n g v t r xc n h vi l i u thuc t n g n g v i
khp cn t i m .
- D n b n g d n h v t r n g v o ch t i m .
L u : nhc b n h n h n k h n g ra nc v o v n g t i m , v
ch bc b b n g d n h v n g t i m sau 8-12 gi.
3. Tai bin
Tuy t i m khp v cc t chc p h n m m c n h khp l m t
trong cc t h t h u t i u t r n g i n , t t n k m , an t o n v
h i u q u i u t r cao, n h n g n u l m d n g l i u p h p i u t r
n y t r o n g k h i k h n g m bo cc n g u y n tc v t r n g , k h n g
n m vng ch n h , chng ch nh, v t r g i i p h u , k t h u t
t i m v l i u t r n h i u tr t h s g y r t n h i u t a i b i n v b i n
chng cho n g i b n h . Cc t a i b i n hay gp n h t l:

295

- Nhim khun khp tim dn n vim m: do khng thc

hin tt quy tc v khun khi tim, tim thuc qu liu lng,
thuc tim khng m bo... y l mt tai bin nng cn phi
x l kp thi v iu tr khng sinh liu cao cng sm cng tt.
au tng sau khi tim 12-24 gi: do phn ng vim mng
hot dch vi tinh th thuc (vim khp vi tinh th), thng khi
sau mt ngy, khng phi can thip
- Teo da, mt sc t da t i ch tim do tim nhiu ln vo
mt v tr, hoc tim qu nng
- Rt him gp tai bin do biu hin kch thch h ph giao
cm do bnh nhn qu s hi, tim thuc vo mch mu hoc
tim qu nhanh: bnh nhn thy chong vng, v m hi, ho
khn, c cm gic tc ngc kh th, ri lon c trn....x l: t
bnh nhn nm u thp, gi cao chn, theo di mch, huyt p
c cc bin php x l cp cu khi cn thit.
Tim khp v tim phn mm quanh khp l mt liu php
iu tr bnh khp an ton, hiu qu v chi ph thp. Chnh v
vy t c hiu qu tt ca phng php iu tr ti ch,
bnh nhn nn n t vn t i cc c s chuyn khoa khp
c cc bc s khm, chn on v tin hnh tim khp nhm
trnh cc hu qu ng tic c t h xy ra.
VI. TIM CHT NHN HYALURONIC SODIUM VO KHP
1. i cng
Bnh thng hyaluronic acid c trong dch khp l mt cht
cao phn t glycosaminoglycan ch phm kt ni ca glucoronic
acid v N-acetyl glucosamin. Hyaluronic acid (HA) c tng
hp bi cc t bo sn, nguyn bo si, t bo mng hot dch.
HA c trong cc t chc lin kt vi nng t 0,05%-5% v
trong lng phn t t 6 x l 0 n 12xl0 daton (DA). Trong
dch khp HA c nng cao hn do cc t bo B ca mng hot
6

296

dch sn x u t ra vi h m lng t 2mg/ml-4mg/l v c t r n g

lng p h n t l 6- 7x o D A .
6

HA l i phn t chnh trong dch khp ng vai tr truy tr

nhy v t n h n h i , bi t r n khp, g i m sc (l m n
hi cho khp k h i v n ng), n n c t c d n g bo v sn khp.
Trong t h o i hoa k h p nng ca H A g i m xung l m cho
nht ca dch khp c n g b g i m xung gp p h n l m sn khp
b huy hoi t r o n g b n h n y . Do l i u p h p t i m n i khp b
sung cht nhn (Hyaluronic sodium) trc t i p v o khp l mt
trong nhng p h n g p h p i u t r c h i u q u t r n l m s n g i
vi bnh t h o i hoa khp. y l m t l i u p h p i u t r an t o n
v c h i u q u k o d i .
C ch tc dng ca tim HA: bi trn khp, bao ph b
mt sn khp t o t h n h m n h i g i m sc, h n c h chn
thng k h i v n n g do c cc t c d n g sau:
-c ch cht gy vim prostaglandin E2 sn phn ca
Interlekin (IL-1).
Gim sinh tng hp Bradykinin vc ch th th gim au.
- G i m q u t r n h g i n g hoa ca c h t proteoglycan v t n g
sinh q u t r n h t n g hp t b o sn t r o n g khp.
- Gim qu trnh ph huy sn do lm gia tng cc chtc
ch men metaloproteinase.
2. p dng lm sng
- Ch nh t i m c h t nhn v o khp trong bnh t h o i hoa
khp gi, khp v a i
- Cc c h p h m c h t nhn (HA) c p d n g trong t i m n i
khp u c c h i t s u t t m o g, t s ln men ca v i sinh
v tng hp. H i n nay c cc d n g b o c h n h :

297

+ Hyruant c trng lng phn t 2-3 X l o DA

6

+ Hyalgan, Go-On c trng lng phn t 5-7,5 X lo DA vi

thi gian bn huy 17 gi.
6

+ Hyasin (2,5ml cha 25mg Hyaluronate sodium): l hp

cht cao phn t v khun vi thnh phn chnh l Hyaluronat
sodium c tinh khit cao c chit xut t mo g trng.'
+ Synvisc (Hylan G-F 20): c trng lng phn t cao nht
23x106 DA v thi gian bn huy l 36 gi.
- Liu trnh iu tr: tim ni khp (khp gi v khp vai)
mi tun ln ( ng) trong 5 tun lin tc. C th tim nhc
l i liu trnh tip theo sau mi 6 t h n g hoc 12 thng tuy vo
hiu qu v mc bnh.
- K thut tim: m bo ng cc nguyn tc v trng v
cc k thut tim ni khp ( trnh by phn tim khp).
- Tc dng ph: au t i ch tim, da vng tim, vim khp
cp tnh thong qua.
- Tai bin: c cc tai bin nh trong tim ni khp bng
coticosteroid nu khng tun th ng yu cu v trng v
ng ch nh, ng k thut.
VII. QUY TRNH CHC HT DCH KHP
1. Mc ch
Chc ht dch khp l mt th thut dng kim nh a vo
khp chc ht dch vi mc ch chn on v iu tr mt s bnh
khp, c bit c hiu qu trong bnh vim khp m, vim mng hot
dch khp khng c hiu, trn mu khp sau chn thng...
y l mt t h thut thng c tin hnh trong thc t
lm sng bnh khp. Chc ht dch khp l mt t h thut n

298

gin, an t o n c t h t i n h n h t i cc p h n g t i u t h t h u t ca
cc c s y t , t u y n h i n n u k h n g t u n t h u cc n g u y n tc v
t r n g v cc y u c u k t h u t t h t h t h u t n y c t h gy ra
nhng t a i b i n v h u q u n g h i m t r n g cho n g i bnh.
2. C h n h c h c h t d c h k h p
Ch nh x t n g h i m dch k h p k h i c vim k h p v t r n dch
khp do bt k m t n g u y n n h n n o :
- Vim m n g h o t dch k h p c h a r n g u y n n h n .
- T r n dch k h p gi chu k .
- Vim m n g h o t dch khp nghi do n h i m k h u n , lao.
- T r n dch khp sau c h n t h n g .
- Vim m n g h o t dch khp trong cc bnh khp; t h o i ha
khp, vim k h p d n g t h p , v i m ct sng d n h khp, v i m khp
mn t n h t h i u n i n , v i m khp v y nn...
3. C h n g c h n h c h c h t d c h k h p
- Chng ch n h t u y t i t r o n g cc t r n g hp:
+ Bnh n h n b b n h a chy m u .
+ Bnh n h n a n g i u t r thuc chng ng.
+ Tn t h n g da t i v t r chc dch khp.
- T h n t r n g chc h t dch k h p t r o n g cc t r n g hp:
+ Bnh n h n cao h u y t p , suy t i m nng.
+ Bnh n h n i t h o ng c h a k i m sot c ng m u .
+ B n h n h n suy g i m m i n dch nng: H I V
K t h u t chc h t dch khp p h i thc h i n theo n g k
thut v m bo v t r n g . Dch khp c n p h i c xt n g h i m

299

trong vng 8 gi nhit phng v trong 24 gi nu bo qun

dch nhit 4-8C.
4. Nguyn tc chc ht dch khp gi
Chc h t dch khp phi c tin hnh trong phng tiu th
thut.
- m bo cc iu kin v nguyn tc v trng.
- Bnh nhn t nguyn v hp tc tin hnh th thut.
5. Chun b
Cn b y t: bc s v y t: ra tay v st trng bn tay,
eo gng v trng.
Bnh nhn: t t h nm nga, bc l khp gi cn chc dch.
V tr chc khp phi c st trng bng bng cn iod.
- Dng c:
+ Bng cn iod st t r n g 1%.
+ Bm tim nha v khun 20ml-50ml.
+ Kim v khun c 18, 20.
+ Panh v trng.
+ Ong nghim v khun, lam knh xt nghim ( chun b
bnh phm dch khp lm xt nghim nu cn thit).
+ Bng dnh y t, bng chun c nh khp khi cn thit
+ Hp chng chong.
6. K thut chc ht dch k h p g i
St trng vng khp chc 3 ln bng bng cn iod 1%.

300

+ Xc nh mc chc h t dch khp: ng trc t r n hoc

ng cnh b n khp gi.
+ T i n h n h chc v h t dch khp vi bm t i m v k i m v
trng.
+ Bng d n h v t r n g v t r chc k i m sau k h i chc dch khp.
+ Bng chun k h p gi c nh t m thi k h i cn t h i t .
+ D n d n g i b n h : k h n g xoa bp khp sau k h i chc h t
dch. Gi k h v t r chc dch t n h t trong 12-24 gi. H n c h
vn ng khp gi t i t h i u 24-48 gi.
7. Cc xt nghim dch khp
a. Phn tch dch khp:
khp.

xc nh m u sc, nht ca dch

b. Xc nh cc vi tinh thphosphat
calci bng knh hin vi
phn cc: c h n o n p h n b i t bnh g t v bnh v i m khp
do vi t i n h t h .
c. Xt nghim vi khun: n h u m gram, n h u m Gemsa, nui
cy trn cc mi t r m g t m v i k h u n gy bnh, xt nghim
ELISA, PCR c h n o n b n h lao khp, n h i m
Chlamydia
trachomatis, Yesinia, E coli....
. Cc xt nghim khc: t m t b o h n h nho (Ragocyte) trong
bnh vim khp d n g t h p , h t vi trong t b o dch khp trong
bnh Reiter.
8. Tai bin ca chc ht dch khp
Th t h u t chc h t dch khp s k h n g xy ra tai b i n g n u
tin h n h t h t h u t theo n g ch nh l m s n g vi n g u y n tc
v khun v cc y u c u k t h u t .
Cc tai b i n c t h x y ra do chc h t dch khp:

301

- Nhim trng khp do khng thc hin cc nguyn tc v

trng.
- Xc nh sai mc gii phu khi chc dch (s khng ht
c dch, chc vo mch mu, dy thn kinh...)
Phn ng cng ph giao cm (v m hi, bun nn, nn, h
huyt p...) do bnh nhn qu s hi, v khng c bc s t
vn, gii thch trc khi tin hnh chc dch khp.

Hnh 69. Hnh nh chc ht dch khp gi

302

NI SOI

KHP

TS. B S C K I I . N g u y n Mai H n g
I. I CNG
N h n g n g h i n cu u t i n v n i soi c t i n h n h vo
n m 1918 bi K e n j i Takagi, N h t B n b n g chic m y u tin
khng c h t h n g t h u k n h . C n g t h i gian n y , Bircher
Eugen, bc s n g i T h y S t i n h n h n h n g n g h i n cu c
lp v v i t cng t r n h u t i n v n i soi khp (NSK) v o n m
1921. N m 1925, P h i l i p Kreusher, trong t p ch y hc bang
Illinois, m t vic s vic s d n g p h n g p h p N S K
t m h i u n h n g t h n g t n p h n sn c h m . Sau B u r m a n
New York t 1931-1935, thc h i n n h n g cng t r n h quan
trng v l n h vc n y . T n m 1935 n 1960, n h i u t c g i n h
Sommer (1937), Vaubel (1938), Wickerr (1939), H u r t e r P h p
(1955) cng n g h i n cu v NSK.
K t k t h u t N S K p h t t r i n n h a n h chng, t quan s t
khp mt c c h t h ng t i c t h n h gi m t ca sn
khp n h v o mc b m k t hp v i n h n g can t h i p ln sn
khp, m n g h o t dch....
T n nay, N S K l u n c c i t i n , h o n t h i n v t
ra c h i u q u t r o n g vic c h n o n v i u t r cc b n h khp
do k h n n g thc h i n d d n g v r t t b i n chng.
li. K THUT NI SOI KHP Gi
N i soi khp gi c thc h i n trong i u k i n v t r n g , g y
m t o n t h n hay g y t n g o i m n g cng hoc gy t t i ch.
S d n g m y n i soi khp ng cng, m y b o m n g h o t dch.

303

 n g ni soi: ng knh 5 mm v di 20 em, s dngng soi

gc nghing 0, 30, 70, ng ni soi gm h thng cc ong knh
nh v h thng dn nh sng, h thng ny ni vi my
camera video nh mt thit b nh lp vo ng ni soi, sau o
hin th hnh nh ln mn hnh.
Ong soi khp c t vo trong khp gi qua mt vt rch
nh, ngoi ra cng cn thm ng vo khc a cho dung
c v thc hin cc thao tc phu thut. Trong qu trnh SOI
hoc lm th thut, khp gi s c bm cng ln bi dung
dch NaCl 0,9%.
HI. CCNG DNG NI SOI KHP Gi
1. Ni soi khp chn on
Ni soi khp chn on c ch nh khi cc bin php thm
khm lm sng v cc xt nghim (chp X-quang, chp ct lp,
chp cng hng t, xt nghim t bo hc ...) khng khng
nh c chn on.
Nh quan st trc tip bng mt trn mt mn hnh v
tuyn mu, k thut NSK cho php kim sot c ton b
khp gi ch qua ng vo, c t h quan st t khoang ny
sang khoang khc, t nh gi chnh xc v mc , tnh
trng, phm vi v nh khu c cc tn thng ca sn, mng
hot dch, dy chng...
Sinh thit mng hot dch kt hp khi ni soi lm cc xt
nghim m bnh hc, sinh hoa, min dch, cho php chn on
chnh xc hn cc tn thng bnh l trong khp.
1.1. Chn on bnh khp
Vim mt khp cha r nguyn nhn.
Vim mng hot dch th lng nt sc t.

304

Thoi hoa

khp.

Vim khp dng

Lao

thp.

khp.

1.2. Cc bnh

Bnh l sn
- u sn c
- Np gp
1.3. Bnh

sn
chm.

cung.
sn.

l dy

chng

2. N i s o i k h p c a n t h i p i u tr
2.1. Ra

khp

Bng NaCl 0,9% 4-5 lt, r a khp l o i b cc t chc vim,

mnh sn bong l m c i t h i n n g k v t r i u chng, c ch
nh i vi:
- T h o i hoa k h p
- Vim khp d n g t h p .
- Vim k h p m
- Bnh g t
2.2. Ct b mng

hot

dch

(synovectomie)

Tng p h n hoc h o n t o n .
- i vi t h t h u t ct m n g h o t dch ( M H D ) t n g p h n
pha trc k h p , n i soi c t h thc h i n ch ct M H D t n
thng, ngoi t r cc t h n g t n d n g u M H D l p h i ct b
hon t o n . C n vi p h n sau khp, n u l t r n g hp ct hot
dch t n g p h n , c t h n i soi theo cc ng b sau n h b n h

305

 n g ni soi: ng knh 5 mm v di 20 em, s dngng soi

gc nghing 0, 30, 70, ng ni soi gm h thng cc ng knh
nh v h thng dn nh sng, h thng ny ni vi my
camera video nh mt thit b nh lp vo ng ni soi, sau
hin th hnh nh ln mn hnh.
ng soi khp c t vo trong khp gi qua mt vt rch
nh, ngoi ra cng cn thm ng vo khc a cho dng
c v thc hin cc thao tc phu thut. Trong qu trnh soi
hoc lm th thut, khp gi s c bm cng ln bi dung
dch NaCl 0,9%.
HI. CCNG DNG NI SOI KHP Gi
1. Ni soi khp chn on
Ni soi khp chn on c ch nh khi cc bin php thm
khm lm sng v cc xt nghim (chp X-quang, chp ct lp,
chp cng hng t, xt nghim t bo hc ...) khng khng
nh c chn on.
Nh quan st trc tip bng mt trn mt mn hnh v
tuyn mu, k thut NSK cho php kim sot c ton b
khp gi ch qua ng vo, c th quan st t khoang ny
sang khoang khc, t nh gi chnh xc v mc , tnh
trng, phm vi v nh khu c cc tn thng ca sn, mng
hot dch, dy chng...
Sinh thit mng hot dch kt hp khi ni soi lm cc xt
nghim m bnh hc, sinh hoa, min dch, cho php chn on
chnh xc hn cc tn thng bnh l trong khp.
1.1. Chn on bnh khp
Vim mt khp cha r nguyn nhn.
Vim mng hot dch th lng nt sc t.

304

Thoi hoa

khp.

Vim khp dng

Lao

thp.

khp.

1.2. Cc bnh

Bnh l sn
u sn c
- Np gp
1.3. Bnh

sn
chm.

cung.
sn.

l dy

Chng

2. Ni soi k h p c a n t h i p i u tr
2.1. R*

khp

Bng NaCl 0,9% 4-5 lt, r a khp l o i b cc t chc vim,

mnh sn bong l m c i t h i n n g k v t r i u chng, c ch
nh i v i :
- Thoi hoa k h p
- Vim khp d n g t h p .
- Vim khp m
- Bnh g t
2.2. C i b mng

hot

dch

(synovectomie)

Tng p h n hoc h o n t o n .
- i v i t h t h u t ct m n g h o t dch ( M H D ) t n g p h n
pha trc khp, n i soi c t h thc h i n ch ct M H D t n
thng, ngoi t r cc t h n g t n d n g u M H D l p h i ct b
hon t o n . C n vi p h n sau khp, n u l t r n g hp ct hot
dch t n g p h n , c t h n i soi theo cc ng b sau n h b n h

305
r

thng. Phng php ny i hi ngi thc hin phi c kinh

nghim, c th ct c ton b hot dch pha sau khp m
vn t r n h c nhng r i ro v khc phc c nhng im bt
tin trong phu thut.
- Phu thut ct MHD qua ni soi cho php ct b c ht
v chnh xc nhng vng hot dch b bnh, thm ch l trn
din rng.
2.2.1. Ch nh ni soi ct mng hot dch
Tt c mi bnh vim MHD mn tnh sau thi gian iu tr
ni khoa khng kt qu.
a.

Vim khp dng thp

Ct mng hot dch c ch

nh khi gia iu tr ni khoa
khng kim sot c s pht
trin ca bnh. Trong trng
hp ny, hot dch c ct b
hon ton.
6. Thoi ha khp
y l phu thut ha hn
mang nhiu ci thin trong cuc '
chin chng l i s thoi ha sn
, _
\r\^A 4 ^.TA';
u V T J
Hnh 70. Hnh n so V m
khp do ti gi hoc v l do
lui ",
3 - 1 1 ' ,
khp dng thp
no nh chn thng ... trc
khi i n ch nh thay khp gi
nhn to.
Cc trng hp au khp gi do thoi ha giai on sm,
vic ct cc mnh sn, sa cha cc phn sn khi b bong khng
u n, qu sn bao khp b rch do thoi ha, bm ra khp
gi, bo phn sn tn thng c tc dng lm gim au khp.
S!

: s

phu thut qua ni soi s gip lm gim c nhng nguy c

gy chy mu ti din.
2:1.2. Sa cha sn chm
- Triu chng in hnh ca rch sn chm trong khp gi l
au khi ng hoc b "kt" khp gi, bnh nhn c th gp khp
gi nhng khng th dui gi ra c v phi la t h dui,
i khi khng th dui khp gi ra v phi ni soi cp cu ct
sn chm.
- Phu thut tin hnh ct sn chm hoc khu sn chm b
rch qua ni soi khp cho n nay ngi ta chng minh rng
c kt qu tt hn m m.
2.1.3. Ly d vt trong khp
Ni soi c t h ly cc d vt trong khp gi nh cc mnh sn
trong bnh l vim sn tch ri, hoc cc mnh sn hoi t b
bong ra.
3. Ct cc u c cung
Vi trng hp c khi u (pseudotumorale), ct hot dch
tng phn xa b chn u l bin php hu hiu nht.
4. Phc hi ti to dy chng
- Triu chng ca t dy chng cho trc t i khp gi l
au hoc mt vng khi i. Khi u l mt chn thng vng
gi i khi khng nng nhng t t h xoay, gi sng ln, khng
th gp hoc rt au khi gp gi. Thi gian sau, khp gi c th
c gp dui tt nhng bt u xut hin t r i u chng au hoc
mt vng, bnh nhn hay b "sn" gi khi i, ln xung bc
thang kh khn. Khm lm sng thng pht hin c vi test
Lachman hoc jerk test. Phim X-quang thng khng pht hin
c g hay c chn on nhm bong gn. Chup M R I thng
cho php khng nh chn on.

308

- P h u t h u t d y c h n g cho trc trong t n t h n g t d y

chng cho trc ca k h p gi. y l mt k t h u t dng si
gn b n h ch t h a y t h d y c h n g cho trc b t .
- t d y c h n g cho trc n u k h n g i u t r s dn n
thoi h a khp gi v g y a u .
5. C t gai x n g
6. Bao k h p
Ct cc ch d n h , ct np bao h o t dch d y nhn, l y b mt
phn ca bao h o t dch t n t h n g .
7. N i s o i n h g i t i n t r i n v k t q u i u tr
- n h gi k t qu ca cc can thip ngoi khoa c tin h n h
ti khp gi n h t h t h u t ct b bao hot dch, ct gai xng....
- n h gi h i u q u ca thuc trong i u t r bnh khp hoc
sau p h u t h u t n i soi.
IV C C BIN C H N G C A N I SOI K H P G I
N h n g b i n chng ca N S K r t h i m gp.
1. C c b i n c h n g t r o n g k h i n i s o i k h p
1.1. Bin chng

do gy

Khng c mt loi bin chng no c t r n g cho phu t h u t N S K

1.2. Bin chng

ti

ch

+ B i n c h n g m c h m u : t n t h n g ng mch hoc t n h
mch khoo r t h i m gp.
+ B i n c h n g t h n k i n h : x u t h i n v n g m t c m gic
t r n da hoc v n g c c m gic k i n b k h u t r , c t h t h y do
t h n g t n m t v i n h n h t h n k i n h c m gic n h n m u i

309

da ngay v tr so. Nhn chung, cm gic kh chu gim dn i

theo thi gian. H im khi gp thng tn nng.
+ Bong d y c h n g b n : bong dy chng bn trong thng
gp do nguyn nhn trong qu trnh ni soi nghing xng chy
ra ngoi qu mnh bc l sn chm trong.
+ G y d n g c: nhng dng c s dng c th v v gy
trong khi phu thut vin ang ni soi khp.
2. Nhng bin chng sau m
2.1. Bin chng tc mch
Tc tnh mch rt him gp (0,12%) cho d c c iu tr
chng ng d phng, c th tc mch phi l nguyn nhn gy
t vong (0,003%), tuy nhin rt him khi xy ra.
2.2. Vim khp
- T l t hn 0,5%, iu tr cn phi can thip l i , ra khp
bng ni soi v iu tr khng sinh ph hp.
2.3. Mu t trong khp
- Biu hin l trn mu khp gi, au khp, (t l 0,5%).
iu tr cn chc ht v ra khp.
2.4. Trn ch khp gi
Mt s trng hp khp gi-tng tit dch. Nu tnh trng ko
di cn phi tim corticoid vo trong khp.
2.5. Hi chng lon dng thn kinh giao cm
(algodystrophique)
Rt him gp, biu hin bng au v cng khp. Tin trin
ko di t 12-18 thng. Sau iu tr thng khi hn.

310

V. K T L U N
T nhiu nm nay, ni soi khp vi s pht trin ca cc
t h i t b n i soi, b n g c c h n h n trc t i p qua ng soi a ra
nhng t h n h cng t r o n g l n h vc chn o n v i u tr cc bnh
khp, c b i t t r o n g b n h l khp gi, vai.
Tuy nhin kt qu ni soi khp ph thuc vo nhiu yu t
c bit l t n h t r n g b n h l, t n t h n g c, n h n g bnh p h i
hp, t u i gi, t r n g lng c n nng, k h n n g hot ng ca
bnh n h n .
Th thut ni soi khp c nhiu u im ln, cho php can
thip c h n h x c cc t n t h n g t i khp, c b i t l t a u , thi
gian n m v i n n g n , c h m sc t i p theo sau n i soi khp n
gin, t b i n chng.

311

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