Chuyên đề bụng bệnh lý

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi
I. Lng rut cp tnh tr cn b i cng:
1. Lng rut l hin tng on rut pha trn chui vo lng ca on rut pha di theo chiu nhu ng hoc ngc li. Tu theo din bin chia lm 3 loi: lng rut cp tnh tr cn b (di 24 thng tui), lng rut bn cp tr ln v lng rut mn tnh ngi ln. 2. Lng rut cp tnh tr cn b l mt cp cu ngoi khoa hay gp nht la tui ny, cn c pht hin v x tr sm, trnh hoi t rut gy t vong. 3. Nhng nm gn y, nh c Chn on v iu tr sm hn, nh nhng tin b v gy m hi sc tr em, c bit nc ta nh p dng rng ri phng php tho lng bng bm hi vo i trng, t l t vong ca lng rut cp gim i r rt. Ti khoa phu thut tr em bnh vin Vit c, t l t vong do lng rut cp t 25,4% (1957 1967) gim xung cn 1,71% (1980 1984) v 5 nm gn y (1999 2003) khng c t vong. II. Nguyn nhn sinh bnh: Lng rut cp c nhiu nguyn nhn gy ra: 1. Nguyn nhn thc th: Ch c 2 8% lng rut cp tm c nguyn nhn khi m: Manh trng v i trng ln di ng, khng dnh hoc Mt s trng hp lng rut cp c khi im l ti tha ch dnh lng lo vo thnh bng sau. Meckel, polyp, u, rut i hay bi giun. 2. Nguyn nhn khng r rng: Phn ln lng rut cp c nguyn nhn khng r rng. C nhiu cch gii thch khc nhau gii thch c ch lng rut. 1) Thuyt virus: Cc tc gi theo thuyt ny cho rng do mt nhm virus gy vim hch mc treo, gy kch thch v gy ri lon cc phn x thn kinh thc vt, lm thay i nhu ng rut gy nn lng rut. Trn thc t: 1

Lng rut cp thng vo ma virus pht trin. a s cc trng hp lng rut cp khi m ra thy vim tm thy bng chng cho thy vim hch mc treo
hch mc treo r. lin quan n virut. 2) Thuyt gii phu: Mt s tc gi nhn thy tr em t 4 12 thng tui manh trng pht trin to nhanh hn nhiu so vi hi trng, do c s khc nhau v nhu ng gia hi trng v manh trng gy nn lng rut. Gi thit ny gii thch c v sao lng rut hay gp la tui ny v thng xy ra vng hi manh trng. 3. yu t thun li: Lng rut cp thng t thy nguyn nhn c th nhng ngi ta thy c mt s yu t thun li gy bnh: III. Tui: Gp nhiu nht 4 8 thng. Gii: Nam b bnh nhiu hn n. T l nam/n = 3/2 Th trng v ch n: hay tr kho mnh, b bm v Thi tit: Vit nam gp nhiu nht vo ma ng Yu t bnh l: Mt s trng hp lng rut cp xy ra Gii phu bnh: Ba lp: lp ngoi, gia, trong. Mt u ca khi lng: l ni tip gip gia 2 lp gia Mt c khi lng: l ni tip gip 2 lp gia v ngoi. Mc treo nui dng: kt gia 2 lp gia v trong. C
2/1. b sa m. Rt him gp tr gy cm, suy dinh dng. xun (t thng 11 n thng 4 dng lch). sau vim rut, a chy, vim nhim ng h hp. 1. Khi lng: Ct dc mt khi lng n gin ta thy:
v trong v l khi im ca khi lng.
khi lng cng hp, mch mu nui dng on rut lng cng b cn tr, rut cng nhanh b hoi t. 2

Him gp: mt khi lng c 2 u, 2 c v 5 lp. a s on rut trn chui vo on rut di theo chiu Him gp lng rut git li do giun a: on rut trn 2. Chiu lng: nhu ng. do nhu ng qu mnh m ph on rut di. 3. Thng tn gii phu bnh: Cc thng tn gii phu bnh ca lng rut cp do 2 yu t gy ra: cn tr lu thng rut do khi lng lm tc lng rut vf cn tr tun hon mch mu nui dng on rut lng. Mc thng tn tu thuc vo thi gian iu tr bnh sm hay mun v c khi lng rng hay hp. Khi m c th thy: bng: c dch trong hay c. Rut trn ch lng: gin cha hi, dch ng. Mc treo rut: nhiu hch vim, ph dy hay lm chm Khi lng: Khi tho ra on rut lng c th ch ph n
xut huyt. hi tm, hng li nhanh. C trng hp khi lng cht khng tho ra ht c, hoc khi tho ra on rut thng, hoi t. 4. Phn loi: 1) Da vo v tr lng: Lng rut non: ch c rut non lng vo rut non (lng hi hi trng, hng hi trng). Him gp v kh Chn on. Lng i trng: ch c i trng lng vo i trng Lng rut non vo i trng: hay gp nht, chim 90 (lng manh i trng, i - i trng). Cng t gp. 95% (lng hi manh trng, hi i trng) 2) Trn thc t hay gp 3 loi: Lng rut hi manh trng: u khi lng l van Bauhin, c khi lng l manh trng rng nn d tho. 3

Lng rut hi i trng: u khi lng l hi trng, c khi lng l van Bauhin l ni hp nht nn nhanh dn n hoi t rut v rt kh tho. IV. Lng rut manh - i trng: u khi lng l y manh Lm sng: 1) C nng: Thng tr b bm, ang n chi bnh thng, t nhin: Khc tht tng cn: l biu hin sm v ni bt nht. Cn khc xut hin t ngt, d di, n ngi, b b, mi cn 10 15 pht sau tr mt thip i, tnh dy c th b li, nhng ch mt lt sau cn khc li tip din n. a mu: Trung bnh 6 8h sau cn khc u tin (cng sm th khi lng cng cht, cng kh tho). Mu hng ln nhy, ti hay nu, c khi c c cc mu ng. y l du hiu xut hin tng i mun nhng nhiu khi mi lm b m cho tr i khm 2) Ton thn: t thay i: khng st, cha c du hiu mt nc. 3) Thc th: Do bng khng chng nn s nn ngoi cn au thy khi lng hnh quai rut, chc, mt nhn nm theo khung ai trng (thng h chu phi ), n au, c phn ng thnh bng. y l mt du hiu c hiu nht chn on lng rut. H chu phi rng (do manh trng b y ln cao) nhng ch thy khi n rt sm (v rut non v ng hi v Nn: Thng xut hin ngay sau cn khc u tin, i khi nn l triu chng khi u. Nn ra sa, thc n va trng, c khi lng l i trng nn cng rng v d tho. 1. Triu chng sm:

nc s nhanh chng ti lp y nn h chu phi khng cn rng na). Du hiu ny t c gi tr. Thm trc trng: c mu (s dng sonde Nlaton hoc ngn tay t). 2. Triu chng mun: Tc rut r hoc vim phc mc + a mu. 1) C nng: Cn khc ko di nhng t d di hn. Nn ra nc mt, nc phn. a mu nu en nhiu ln.
2) Ton thn: Mt nc, nhim trng, nhim c: l , hc hc, st 39 - 40C. 3) Thc th: V. Bng chng nn kh s thy khi lng. Thm trc trng: Mu nu en. C th s thy khi Cn lm sng:
lng. 1. Xquang bng khng chun b: t c gi tr chn on, c gi tr tin lng (nh gi bnh nhn n sm hay mun). Hnh khi m h chu phi hay trn rn tng ng vi v Hnh khng c hi h chu phi: do manh trng di Mc nc hi rut non do tc rut. Lim hi: do rut b hoi t v thng. Chng ch nh tr khi lng. chuyn ln trn.
bm hi hay tht baryt vo i trng. 2. Xquang c bm hi hoc tht baryt ai trng: Nhm 2 mc ch l Chn on va iu tr (tho Xquang bm baryt: cho thy r tn thng c hiu lng). ca lng rut. Nhng ngi chp v c chp b n tia, hn

na nu baryt vo bng do thng rut th rt nguy him. Bm hi: Tin hnh d hn, t b n tia hn, t nguy him hn nu hi vo bng cho d tn thoing nhn khng r bng). Thng c ch nh khi va chn on va tho lng. Cc hnh nh thng gp: + Hnh y chn. + Hnh cng cua. + Hnh vng bia. Chng ch nh: khi c du hiu vim phc mc. Khng c v c th thay cho Xquang. Tuy nhin c 3. Siu m: kh khn l tr quy khc, giy gia v ph thuc nhiu vo kinh nghim ca ngi lm siu m. Hnh nh khi lng: + Ct ngang: Hnh vng bia l mt vng trn ng knh > 3cm, vng trung tm m m, vng ngoi gim m. Ct dc: Hnh bnh Sandwich l mt khi m m V tr khi lng: c hiu khi lng nm ngoi khung gia, c vin quanh bi mt vnh t m. i trng (lng rut non), khng thy c trn phim chp i trng. VI. Siu m ngoi mc ch chn on, cn c s Chn on: Lm sng: dng theo di trong v sau tho lng. 1. Chn on xc nh: + Khc cn. + Nn. + a mu. + S thy khi lng. 6

Nu khng s c khi lng: + Da vo Xquang hoc siu m. + Chn on xc nh khi thy hnh nh khi lng. - Trng hp n mun: triu chng vim phc mc + a mu = lng rut. + Thuc Fusamax iu tr long xng 2. Chn on phn bit: a mu: L, polyp rut (trc trng), vim ti tha Meckel: tr khng quy khc thnh cn d di v t nn Song ch c ngh ti 3 bnh ny khi loi tr lng rut. Nn: vim mng no, vim nhim ng h hp. Cn khm k v ni khoa, Xquang phi chn on xc nh. Khi lng: bi giun: thng nm ri rc quanh rn, b mt khi khng nhn, s thy cc rnh ca bi giun. Nu cn yu cu chp i trng hay siu m chn on. VII. Din bin v bin chng: Sau khi hnh thnh khi lng, di nh hng ca cc sng nhu ng rut, on rut lng ngy cng chui su vo on rut pha di. Cng vi on rut lngm mc treo nui dng cng b ko theo vo v ngy cng b ko cng, gp gc v b c khi lng b tht nght. Do vy lng rut cp tnh khng t tho ra c. Nu khng c Chn on sm v iu tr kp thi s dn n hoi t rut gy vim phc mc, bnh nhn c th t vong. VIII. iu tr: Khi chn on xc nh lng rut cp th iu tr cng sm cng tt (lng rut cp khng th t tho c. Lng rut mn c th t tho c). C 2 phng php: 1. Tho lng hoc bm hi hoc tht baryt vo i trng: n gin, d thc hin, cho kt qu tt v t tn km. a. Ch nh: 7

n sm trc 48h. Cha c vim phc mc. Tin m bng atropin + aminazin hoc gy m tnh Bm hi vi p lc P < 10cmHg (hoc tht baryt) vo Theo di trn lm sng, di mn hunh quang hay siu
b. K thut: mch. i trng. m. c. Tiu chun tho lng: Da vo lm sng: + p lc bm hi t ngt tt xung (do hi sang rut non). + Bng chng u. + Khng cn s thy khi lng. Cha chc chn: chp Xquang bng thy hnh nh hi sang rut non l ch nh t ong gia bng, hoc siu m bng kim tra thy mt hnh nh khi lng nu lng rut c tho. Theo di di mn hunh quang tng sng hay siu m: + Manh trng ngm y hi hay baryt. + Mt hnh nh khi lng. + Hi hoc baryt t ngt trn sang rut non. d. Theo di sau tho lng: Bnh thng: sau tho lng tr ng yn, tnh dy chi Pht hin cc bin chng: ngoan, b tt, khng nn, sau 6 8h a phn mu vng. + St cao sau tho lng: ch cn iu tr thuc h st, chm lnh. + Tho cha ht: c bit trong trng hp lng kp hi hi - i trng mc d hi hoc baryt sang rut non nhng vn c th cn st lng hi hi trng. 8

+ V rut: do bm p lc cao qu (hng van an ton, phn lm tc cc ng dn ), bm hi hoc tht baryt khi bnh nhn n qu mun 3. Phu thut: a s cc nc m tt c cc trng hp lng rut vi u im: thy r tn mt thng tn x tr, nu c nguyn nhn thc th gy lng rut th gii quyt c ngay. Vit nam ch m trong mt s trng hp c ch nh: a. Ch nh: tho lng bng phng php bm hi hay tht baryt bnh nhn n mun > 48h. C du hiu vim phc mc. M ni kh qun, t ng thng d dy. M bng ng trng gia trn rn hoc ng b Kim tra thng tn. Tho lng bng tay: Dng tay nn nh nhng t di ln khng kt qu.
b. K thut:
ngoi c thng to bn phi.
trn ngc vi chiu lng y khi lng ra. tuyt i khng c ko on rut chui vo khi lng. Nu rut tm, p huyt thanh m v phong b mc treo bng novocain v ch i, nu rut hng tr li th bo tn. Vic ct rut tha, c nh manh trng vi lng rut tm cch gii quyt nguyn nhn nu c: manh trng Ct on rut khi khi lng hoi t: tu theo tnh cp l khng cn thit. di ng, ti tha Meckel trng bnh nhn, kinh nghim phu thut vin, v kh nng gy m hi sc. Sau khi ct on rut c th:

+ Ni ngay 2 u rut tn tn bng ch lin kim 4.0 5.0. + a 2 u rut ra ngoi kiu Mikulicz. c. Chm sc sau m: ng thng d dy, khng sinh, b nc in gii. Pht hin cc bin chng sau m: st cao co git, vim
phi, hoi t rut, bc ming ni, bin chng ca hu mn nhn to Bin chng cp tnh ca si ng mt ch: Thm mt phc mc (tc mt cp do si kt Oddi) (y l bin chng hon ton c hc): 1. i cng: 1) Thm mt phc mc l danh t dng ch tnh trng tc mt cp v hon ton do di chuyn ca si ( nht l si nh nm vo vng tng ng vi c tht Oddi) hay nhiu si thp cht phn thp ca ng mt ch cp tnh lm mt ng trn ch tc ca ng mt ch dn n ton b ng mt trong v ngoi gan k c ti mt gin to cp tnh. p lc ng mt tng cao lm nc mt ngm qua thnh ng mt, ti mt v mt gan vo trong bng (thm ra nh m hi v khng c l thng trc tip gia ng mt vi bn ngoi) em theo cc vi khun gy nn tnh trng nhim khun phc mc v nhim c (ban u nc mt cn tng i sch, v sau s tng i bn) 2) thm mt phc mc l mt Chn on trong m. 2. Triu chng lm sng: 1) C nng: Tam chng Charcot: au bng gan in hnh + st + Nn, b trung i tin. 10 vng da. 2) Thc th:
I.

Bng chng n au khp bng (lc u au vng h sn phi,
sau lan ra khp bng) nhng bng au v phn ng mnh nht vng h sn phi hay na bng phi. Cm ng phc mc r. Gan to, ti mt to v au. Da, nim mc vng (tc mt). St. Tru mch do au (mt s trng hp). biu hin nhim khun trong nhng gi u cha r
3) Ton thn:
rng. Giai on sau tnh trng nhim khun nhim c r: st cao, rt run, mi kh, li bn, hi th hi. 3. Cn lm sng: 1) Xquang: Chp bng khng chun b hoc chp gan xa c th thy: Gan to, bng ti mt to. Dch gc sn honh phi. Gan to, c th c dch di gan, khoang Morrison. ng mt trong v ngoi gan c th c si phn thp
2) Siu m:
ng mt ch. 3) xt nghim mu: Bilirubin, photphatase kim tng.(tc mt) Bch cu tng cao, bch cu a nhn tng, mu lng Amylase mu tng. Ure c th bnh thng trong nhng gi u.
tng.(nhim khun)
4) xt nghim nc tiu: c sc t mt, mui mt. 4. X tr: 1) Nh gi bi lan trc m. 2) Hi sc: bi ph nc, in gii , khng sinh. 11

3) Lp bng theo di: mch, huyt p, nhit , CVP, nc tiu 4) Ch nh ph thuc vo tnh trng bnh nhn v kh nng ca phu thut vin: M cp cu: + M ng mt ch, ly si. + t dn lu Kehr hoc dn lu ng mt n thun. + kim tra ng mt pha di thng dn lu Kehr. + Lau ra v ng bng. II. M c tht Oddi qua ni soi. Chc mt qua da lm gim p lc ng mt ri m iu tr thc th si ng mt ch nh trn. Vim phc mc mt: 1) nh ngha: vim phc mc mt l tnh trng vim phc mc ton th do nc mt trn vo bng qua l thng. Thng hay gp trong cc trng hp vim ti mt hoi t , p xe ng mt v hay thng tn ng mt (hoi t ng mt ch ) sau tc mt cp v vim ng mt gy tnh trng nhim khun nhim c nng. 2) Khc vi thm mt phc mc ch l tnh trng nc mt thm qua thnh thnh ti mt, ng mt th trong vim phc mc mt nc mt thc s chy qua l thng trc tip gia ng mt vi bn ngoi v gy nhim khun nhim c nng hn nhiu. 3) biu hin ca vim phc mc bao gm 2 hi chng chnh: hi chng vim phc mc. Hi chng tc mt.
sau.
1. i cng:
12

4) bin chng vim phc mc mt xy ra mun hn, tnh trng ton thn nng hn v biu hin nhim khun d di hn thm mt phc mc. 2. Lm sng: 1) C nng: au bng h sn phi: + Tng cn (lc u). + Sau lan khp bng v au lin tc. nn, bun nn B trung i tin. Tnh trng nhim khun:
2) Ton thn: + St cao 39 - 40 C. + Mi kh, li bn, hi th hi. i t hay v niu (+/-) Shock do nhim khun nhim c. Da, nim mc vng Bng chng:
3) Thc th:
+ Cm ng phc mc (+). + Co cng thnh bng hay phn ng thnh bng khp bng nht l na bng bn phi. + du hiu tc mt: ti mt to, gan to: thng kh pht hin do b che lp bi tnh trng vim phc mc. G bng c vng thp. Thm trc trng, m o: ti cng Douglas phng v
au. 3. Cn lm sng: 1) Xt nghim mu: du hiu nhim khun: + Bch cu cao (> 15000 20000/mm3), bch cu a nhn tng. 13

+ Tc mu lng tng. Hi chng tc mt: + Bilirubin mu tng. + Photphatase kim tng. du hiu suy thn: + Ure mu tng. + Ri lon nc, in gii Cc du hiu suy chc nng gan: + ri lon ng mu 2) Xquang bng khng chun b: Lit rut c nng: quai rut gin. Dch trong bng: bng m. Bng gan to v ti mt to.
3) Siu m: c Ch nh khi nhng bnh nhn c du hiu tc mt khng r trn lm sng (trng hp r vim phc mc v tnh trng bnh nhn nng: khng cn). 4. X tr: 1) Lm bilan v hi sc tt: Truyn dch, dng khng sinh trc m, t sode d dy) 2) M bng ng trng gia trn rn: Gii quyt tnh trng tc mt: + M ng mt ch ly si + t dn lu Kehr. + Ct ti mt nu ti mt c thng tn khng hi phc. Gii quyt tnh trng vim phc mc: + Lau ra bng bng huyt thanh m. + t dn lu bng. 3) Theo di cc bin chng sau m: nhim khun. Bc ming ni, ch khu. Vim ng thn cp. Phi 14

III. Vim ng mt cp: 1) Vim ng mt cp thng gp trong cc trng hp ti mt khng hon ton. ng mt gin v tr mt sau mt vi ngy, vi khun pht trin tong ng mt gy nn. 2) C ch: vi khun xm nhp ng mt theo cc con ng sau: Vi khun di chuyn t ng rut ln: + Theo giun a. + Theo c ch nh mt ci bm ht vi khun: si mt di chuyn phn thp ng mt ch + s co rt ca ng mt (bm). - vi khun theo ng bch huyt t rut lnv khu tr ti ng mt. 3) Vi khun ng mt thng gp l: E. Coli. Klebsiella. Enterobacter. Entero coccus. Vi khun k kh (Clostridium v Bacterocide fragillis). 1. i cng:
4) Vim ng mt cp cp nu iu tr khng trit s gy nn vim m v p xe ng mt. t ng mt vi khun s trn vo mu gy nhim khun huyt. 2. Lm sng: 1) C nng: Cn au bng gan. Ri lon tiu ho: nn, bun nn. Tnh trng nhim khun: St: st nng, st rt 39 -
2) Ton thn: 40C, thng gp hn v bui chiu. Mt mi.
15

Vng da ngy cng m (tin trin cng vi cc cn i t hay v niu. Nc tiu sm mu (nh nc vi). Tnh trng tc mt va phi: au bng gan), da sm.
3) Thc th: + Gan to, mt mm. + Ti mt to va, khng cng lm. + Vng h sn phi c phn ng. + Da, nim mc vng m. Tnh trng ri lon chc nng gan: + thng tn chc nng ng mu ca gan: Cc m chy mu di da hay cng mc mt. 3. Cn lm sng: 1) Mu: nhim khun: Bch cu tng > 15.000/mm3, bch cu Tc mt: a nhn tng. + Bilirubin mu tng bilirubin trc tip tng) + Photphatase kim tng. Amylase tng. Chc nng thn: Ure, creatinin mu tng Chc nng gan:
+ t l prothrombin gim. + Ri lon ng mu (giai on nng). 2) Vi khun: Cy mu v dch mt: 3) Xquang: Chp gan xa: Bng gan to. Bng hi trong ng mt. Si ng mt khng cn quang. Bng ti mt to.
4) Siu m gan mt: 16

Gan to. ng mt trong v ngoi gan gin:
+ Hi trong ng mt. + C th thy nguyn nhn gy tc (si, giun) 5) Chp ng mt: Qua da hay ni soi. xc nh nguyn nhn gy tc mt.
4. iu tr: 1) Nguyn tc: S dng khng sinh: + Hot ph rng: tc dng c vi vi khun k kh ln i kh. + c kh nng ngm tt vo ng mt + Phi hp nhiu loi khng sinh. + Tt nht l theo khng sinh . + Hay dng: Cephalosporin III + Metronidazole + Amyloside. iu chnh cc ri lon in gii, ri lon chc nng cc Gii phng tm thi ng mt: c quan (gan, thn). + Chc mt qua da. + M c tht Oddi qua ni soi. 2) iu tr thc th: m ng mt ch ly si v d vt. Bm ra ng mt. t dn lu Kehr Vim m v p xe ng mt:
IV.
1. i cng: 1) Khi vim ng mt cp khng c iu tr s tin trin sang th nng hn (th ure mu cao, hi chng gan thn, vim m v p xe ng mt). Nh vy vim m v p
17

xe ng mt l mt trong nhng hu qu ca vim ng mt khng c iu tr ng. 2) Bt ngun t vim lot ng mt, vim m v p xe ng mt l tnh trng xut hin m trong ng mt v c bit gm nhiu p xe nh ( m nh) tp trung quanh cc ng mt trong gan (n tn cc ng mt nh). Chng to thnh hnh nh chm nho trong cc ng mt, t khi thnh cc ln. Nhng ny c d ~ 1 2cm. 3) Hu qu ca vim m v p xe ng mt l: Chc nng gan b hu hoi trm trng. Nhiu p xe gan tp trung li nht l gan tri to Nhiu p xe tp trung li thnh 1 nu st mt
thnh p xe gan tri nhiu bin chng. gan c th v gy vim phc mc mt. 5) Bnh cnh lm sng: Vim ng mt cp th nng c suy gan, suy thn. Nhng p xe gan.
2. Lm sng: 1) Ton thn: Suy kit nng: Hi chng vng da tc mt r. Cc du hiu suy thn: i t, ure mu cao. Ph 2 chi di. Tnh trng nhim khun nhim c nng: st cao lin Hi th c mi ceton (ure huyt cao). L m. bng co cng, n au khp bng. Gan to 2 thu, c th s thy cc p xe nh ln
tc, hc hc, mi kh, li bn, hi th hi.
2) Thc th:
nhn trn mt gan (d nhm vi ung th gan, nht l gan tri). 18

Rung gan (+). n k lin sn 9 ng nch gia bn phi rt au. Ti mt to hay bnh thng (nhiu khi do bng co cng Dch trong bng. Trng hp p xe khu tr bn tri: n vo mi c thy co
nn kh s thy.
cng. 3. Cn lm sng: 1) xt nghim: Tnh trng nhim khun nng: + Bch cu tng rt cao: 15.000 20.000/mm3, ch yu l bch cu a nhn trung tnh. + tc mu lng tng cao. Tnh trng tc mt: + Bilirubin tng + Photphatase kim tng. Tnh trng ri lon chc nng ng mu: + T l Prothrombin gim + Thi gian ng mu ko di. Tnh trng suy thn cp: Ure, creatinin mu tng cao. Cy mu: c th c vi khun. bng gan rt to, bng ti mt to. Vm honh phi cao hn vm honh tri. Tng cc ng knh honh nh, honh ct sng. Hnh nh mng phi: phn ng mng phi. Trn dch Hnh nh bin chng: p xe gan v: p xe di c honh
2) Xquang: chp gan xa:
mng phi thc s. (mc nc hi ln) 3) Chp mt qua da hay chp mt ngc dng: hnh nh microapxe dc theo cc ng mt trong gan: hnh nh chm nho, cnh hoa 19

4) Siu m gan mt: Gan to, c nhng long m nh khp gan hoc mt ng mt trong v ngoi gan gin. C th thy nguyn nhn gy tc mt: si, giun khi long m khng ng nht 1 phn thu no .
(hnh nh m m c bng cn) 4. bin chng: Nu khng c x tr kp thi, vim m v p xe ng mt c th gy ra cc bin chng sau: v vo bng gy: + Vim phc mc ton th. + p xe di c honh (do c khu tr). + V vo mng phi: trn m mng phi. + V vo ph qun: r mt ph qun. + V vo mng tim: chn p tim cp: nng, thng ch gp do p xe bn tri. 5. iu tr: Cn Chn on phn bit vi p xe gan amip do iu tr hon ton khc nhau.iu tr cn kh khn cho d s dng khng sinh mnh v hi sc tt: t l t vong vn cao (nht l tr em) 1) Hi sc tt. 2) Khng sinh ton thn: 3) M sm: 4) iu tr nguyn nhn tc mt: m ng mt ly si: bm ra ng mt, dn lu Kehr (trng hp bnh nhn qu nng: lm ti thiu: dn lu ti mt). 5) X tr cc p xe: p xe nm trn mt gan: + Cha v su: dn lu bng cch ph cc qua ng mt ra v dn lu cc p xe qua ng Kehr. + Nu cc p xe khu tr: Chn on ct gan (nht l bn gan tri) + v: ht sach (d c nguy c r mt sau ny). 20

P xe v vo bng t do gy vim phc mc ton th: m cp cu: + X tr vi ng mt nh trn. + Lau ra bng, dn lu. p xe v ln mng phi: + Giai on u: chc ht dch, t ng dn lu. + p xe ng mt v ln kh ph qun: dn lu t nhin mt thi gian, khi n nh: iu tr si mt. + p xe gan (thng l gan tri) v ln mng tim: gy chn p tim cp: Nhanh chng gii phng chn p tim bng cch m mng tim ti thiu hoc chc ht, sau iu tr si mt. - Tin lng nng. V. Chy mu ng mt: 1) Chy mu ng mt l tnh trng thng thng bt thng gia mt mch mu trong gan (hay ngoi gan) vi ng mt (thng trong gan) hu qu l mu xut pht t ng mt qua c tht Oddi xung t trng v c tng ra ngoi di hnh thc nn mu, a mu. 2) Nguyn nhn chy mu ng mt: Sau chn thng (t mu di bao, trong nhu m gan) U gan. Phng ng mch gan. Si hay giun (chy mu ng mt nhit i): 1. i cng:
+ P xe ng mt do giun. + Vim ng mt do si. + p xe ng mt do si (khong ca). vim ti mt chy mu. Sau 1 s th thut Chn on iu tr: Lot ng mt
ch do dn lu Kehr. 3) Gii phu bnh: thng thng ng mt trong gan vi: 21

ng mch gan ng mch ca ng mch trn gan
+ thng thng gia ng mch v ng mt gan tri. + Vim tc tnh mch ca + Vim ng mt nhim khun chy mu. 4) Sinh l bnh: Mt ng gy nhim khun, vim lot v p xe thnh ng mt ch dn n chy mu. 5) triu chng kinh in: Tam chng Hemobilia: au bng, vng da, nn mu. 2. triu chng lm sng: 1) Chy mu ng mt thng gp trn nhng bnh nhn c tin s bnh l v gan mt (giun chui ng mt, p xe ng mt) tuy vy vn c thi gp trn bnh nhn khng c tin s g v gan mt. 2) C nng: Chy mu ng tiu ho trn: nn mu, i ngoi phn en: + Mu nn: nhng cc mu hay cc thi mu di hnh bt ch (do mu chy trong ng mt ng li theo hnh khun ng mt). + Phn en khm, nt khng thnh khun, c khi ln mu . + Chy mu khng theo quy lut no c nhng dai dng tng t, ko di gy tnh mch nng. + Chy mu thng xut hin sau cc cn au bng qun d di vng gan, nn xong: ht au hay hn (do mu ng li gy dn cng ng mt c tng ra ngoi) 3) Ton thn: hi chng vng da tc mt: Nhiu mc , i khi kn Tnh trng nhim khun: 22 o d nhm vi du hiu mt mu.

+ St cao 39 - 40C trong cc t vim ng mt tin trin. + Mi kh li bn, hi th hi. Tnh trng mt mu cp: Nhiu mc : + Nng: Shock, tru mch, huyt p tt. + Nh: ton trng gn nh bnh thng. 4) Thc th: Gan to. Ti mt to. Rung gan (+)
3. Cn lm sng: 1) Xt nghim: 3 biu hin: Mc mch mu: Hng cu gim, Hb gim, Hct gim Mc tc mt: Bilirubin mu tng, photphatase kim du hiu nhim khun: Bch cu tng, bch cu a xt nghim gip Chn on phn bit vi x gan: (nhiu mc ). tng. nhn tng. + Amonic mu: + in di protein mu. + Phn ng keo loi 2) Ni soi tiu ho: Ch nh: khi ton trng bnh nhn tng i n Hnh nh: mu chy t bng Valter ra (loi tr mu nh (huyt p > 90mmHg). chy t thc qun hay d dy t trng. 3) Chp mt tu ngc dng: Hnh nh: Nguyn nhn tc mt. Hnh nh p xe:nho thuc phn tn ng mt L phng tin Chn on c tnh cht c hiu nht. 23
4) Chp ng mch gan chn lc:

Hnh nh: + ng thuc + thuc sang ng mt th mun. 5) Chp gan xa: v tr chy mu. 6) Siu m gan mt: Hnh nh: tc mt do si. p xe gan nh (c th l ni thng thng gia mch
mu v ng mt) 4. Chn on phn bit: 1) Chy mu do lot d dy t trng: ton thn: tu mc chy mu. nhim khun: khng st. Tnh cht nn: mu ln thc n. Khm: du hiu mt mu. Xquang: chp d dy. xt nghim: mt mu. ni soi. Ton thn: nng, c biu hin ca suy gan. nhim khun: khng st. Tnh cht nn: Mu ti. Khm: mch mu + x gan Xquang: chp thc qun. xt nghim: mt mu + suy gan. Ni soi: ni soi thc qun.
2) Chy mu do tng p lc tnh mch ca:
5. iu tr: 1) Hi sc tch cc: Truyn mu ngay nhm a bnh nhn ra khi tnh trng nguy him. S lng mu v Ch nh ph thuc vo: mch, huyt p, s lng hng cu, Hb, Hematocrit. Bi ph nc, in gii.
24

t sonde d dy t trng: ra v theo di tnh trng Theo di tnh trng ton thn nh gi mu vn chy mu cn hay khng. tip tc chy hay cm. + Cc biu hin: nn mu, phn en. + Cc du hiu sinh tn. S dng khng sinh ng mt: mc ch: + Dit vi khun ng mt. + hn ch ln men thi ng rut do vi khun phn hu mu. + tht tho: trnh tr rut v lm bnh nhn d chu. 2) phu thut: Ch nh khi tnh trng chy mu khng cm hoc khi xc nh nguyn nhn. M ng mt ch ly nguyn nhn gy tc mt (si, Ra ng mt bng huyt thanh m: nc mt trong: kim tra ng mt ngay nu c iu kin. Nu mu cm (t dn lu Kehr) Nu mu cn chy: giun, mu cc ) kim tra tnh trng chy mu.
+ Tht ng mch gan ring. + Ct vng gan c ngun chy mu (trng hp tt nht l xc nh c v tr trc m) thng Ch nh cho ct gan tri. Ct ti mt khi: + Vim dy. + bp khg xp (do mu ng t chc ho gy tc c ti mt). + Si kt hp. + Khi c chy mu ti mt. VI. VII. Vim tu cp do si ng mt: Vim ti mt hoi t hay vim hoi t ng mt ch: 25

1. C ch: Si gy tc ng mt ch lm ti mt cng qu mc + vim nhim gy hoi t lc c. 2. Lm sng: Tng t vim phc mc mt. 3. Siu m: Si ng mt ch + ti mt to, thnh dy. 4. iu tr: M cp cu: VIII. Ly si ng mt ch. Ct ti mt + dn lu Kehr. Cc bin chng khc: nhim khun nhim c. Thng tn tim do tc mt.
1. Tru tim mch t ngt do:
2. Vim thn cp: Cc cht ng trong ng mt tro ngc vo mu v bi tit qua thn gy nn. Lm sng: i t. cn lm sng: ure mu tng, ure nc tiu gim.
3. Vim tc tnh mch ca v nhim khun huyt. Si ng mt ch I. i cng: 1. Si ng mt ch l si nm trong ng mt chnh, on t ch ng ti mt gp ng gan chung ti ch ng mt vo t trng (hay t di hp lu 2 ng gan chung ti bng Valter khng k ti mt). 2. Bnh thng gp la tui trng thnh, tng theo tui, khng c s khc nhau nhiu theo gii. 3. Chn on tc mt do si ng mt ch thng d vi cc triu chng au, st vng da xut hin tng t km cc phng php Chn on b tr rt c hiu qu. 4. Din bin ca bnh rt phc tp. Nu khng c iu tr kp thi s gy cc bin chng cp hay mn tnh nguy him ti tnh mng bnh nhn. 5. iu tr: tng i n gin l phu thut ly si v dn lu ng mt (dn lu theo phng php Kehr) nhng kt qu 26

lu di khng c tt lm, hay ti pht do si trong gan, nhim khun ti pht, hp ng mt v thiu cc phu thut pht hin si trong m. II. Sinh l bnh: Hnh thnh ti ch. T trn gan ri xung. T ti mt xung. 1. Ngun gc si:
Vit nam t khi gp si ng mt ch n thun, a s l si ng mt ch phi hp vi si trong gan. 2. C ch: sgk. III. IV. Gii phu bnh(?) Lm sng: Sgk.
1. Th in hnh: 1) Tin s: au bng kiu giun chui ng mt. 2) C nng: a. Tam chng Charcot: au, st, vng da din ra theo th t thi gian v ti i ti li nhiu ln, y l mt c im ni bt ca si ng mt ch: au: in hnh l cn au bng gan: + Xut hin v kt thc thng t ngt. + V tr: au vng h sn phi km theo xuyn ra sau lng hay ln vai phi. c th au vng thng v. + Din bin: c lc au m nhng cng c lc au d di (do si gy tc hon ton hay bn phn ng mt lm cho p lc ng mt tng cao). Lc u au ti ch tng cn nhng sau lan rng ra bng, au lin tc km theo nhng bin i ton thn th hin tnh trng vim phc mc. + Cng : ph thuc vo v tr v kch thc vin si cng nh tnh trng vim nhim ng mt. 27

+ Trong khi au nu n ung s lm cho au nng hn do ng mt b kch thch co bp mnh hn. St: + Xut hin sau au vi gi (6 12h) do ng mt b tr v nhim khun. + Thng cn st xut hin vo bui chiu: st cao km rt run, sau v m hi (nhim khun cng nng th st cng cao v d dn n nhim khun huyt). + Sau nhit tr li bnh thng hoc hi tng. Vng da: + Xut hin sau au bng v st. + C nhiu mc : rt r hay kn o. si mt gy tc mt vi mc cng cao th vng da cng m (lc u vng nh, sau tng dn c th vng m). *Ba triu chng trn xut hin theo trnh t nn v ko di khong 5 7 ngy, nu c iu tr chng nhim khun v gim au tt th cc triu chng lui dn theo th t nh vy. Ri sau mt thi gian, cc triu chng li xut hin tr li theo th t . b. Ri lon tiu ho: Nn: + Thng xut hin km theo au. + S lng nhiu. + cht nn: thc n v dch d dy n nn khan. Chn n, mt mi. y bng. Phn: thng mu sc bnh thng do tc mt cp
tnh, khng hon ton v trong thi gian ngn. c. Tiu t: nc tiu sm mu (nh nc vi: do c nhiu sc t mt). d. Nga: thng i km vi vng da: l biu hin ca nhim c ca mui mt. 28

3) Ton thn: Nhiu mc : a. Si mt cha gy tc mt hoc cha c bin chng: ton thn thay i t. b. Khi c biu hin tc mt: Mi u: nhim khun nh, cng mc mt hi vng. Khi c vim ng mt: tnh trng nhim khun r hn,
tnh trng chung bin i nhanh v cng r khi tc mt lu. St cao lin tc 38 - 39C, nng hn v bui chiu, Mt mi, chn n, gy st nhanh chng. Da nim mc vng, mi kh, li bn, vt gi. Khi vim ng mt nng: hi chng gan thn: nhp tim chm.
+ Suy gan: x gan c chng, mt, xut huyt di da. + Suy thn: li b, i t, v niu. 4) Thc th: a. Da nim mc vng nhiu mc , ph thuc mc v thi gian ng mt, tnh trng nhim khun ng mt. b. Khm bng: Bng t di ng theo nhp th (do au). Vng h sn phi n au v phn ng thnh bng r. Gan to do mt di h sn phi khong 1 khot ngn
tay, thng to u c 2 thu, mt mm, rung gan au. Nu tc mt lu: x gan mt: gan to v chc. c. Ti mt: + Trong t cp: cng to, di ng theo nhp th, c th nhn thy hay s thy, i khi to xung gn h chu phi (c im ny khc vi phng Ty l khi tc mt do si th ti mt teo). + Khi ht t au cp, ti mt xp xung khng thy na.
29

+ Tc mt lu ngy + sau cc t vim ng mt: ti mt c th b vim teo nh: khm lm sng c th thy v nghim php Murphy (+).(?). + Mt s im au khc: im sn lng, im cnh mi c, h sn phi, im ti mt. c. Nc tiu: thng sm mu khi c biu hin tc mt. d. Phn: mu sc bnh thng, khng ph thuc vo kch thc vin si. V. Cn lm sng. 1) Huyt hc: nhim khun do mt: Bch cu tng, bch cu a nhn tng. Tc mu lng tng. Cy mu. Bilirubin tng ch yu l bilirubin trc tip (bnh thng: 1. Xt nghim mu:
2) Ho sinh: biu hin mt: 10 15mmol/l). Khi c vng da, vng mt thng > 20 mmol/l. GOT, GPT tng, cholesterol, cc thnh phn ca lipid. Phosphatase kim tng:
+ y l enzym do gan tit ra (khi tc mt enzym ny li trong ng mt gy tro ngc vo mu). + Vit nam, s thay i Bilirubin mu r rt hn s thay i v phosphatase kim. + Amylase tng (bnh thng: 10 U/l) nht l vim tu cp do soi mt. 3) Cc du hiu ca vim ng mt nng: Suy thn: Ure, creatinin mu cao, ri lon nc, in gii. Ri lon chc nng gan v ng mu:
+ T l prothrombin gim. + Thi gian ng mu ko di. + ng mu ri rc (nng). 30

5) Cc xt nghim khc: thi gian quick, ure mu, transaminase .. ch gip nh gi bin i chc nng gan, thn hoc phn bit vi vim gan virut, khng gip cho Chn on xc nh. 2. Siu m: L bin php c gi tr thng c p dng. Hnh nh:
+ Gan to, tnh trng nhu m gan. + ng mt trong v ngoi gan gin, dy mng ca thnh ti mt. + Tnh trng ca ti mt: dy mng ca thnh ti (si ti mt gy vim dy ti mt), kch thc ti mt. + Tnh trng si ng mt ch: kch thc, v tr (hnh nh cn sng siu m v bng cn, cc u khc ch c tng m, khng c bng cn). + Cc thng tn khc phi hp. + Hnh nh si trong gan (nu c). Nhc im: Kh chn on trong cc trng hp: + Bnh nhn bo ph. + Bng chng hi do cng dn ng tiu ho. + Si ng mt ch thp + t trng c hi. 3. Chp ng mt: 1) Chp ng mt ngc dng qua ni soi (ERCP): K thut: + a ng ni soi d dy t trng vo on 2 t trng. + ng soi c l nhn bn, nhn r nm rut ln: a ng catheter qua c Oi vo ng mt ch bm thuc cn quang sau chp. Tc dng: + nh gi ng mt v hnh nh si ng mt. + C th dng sonde Dormia ko si xung t trng.
31

+ M c tht Oddi khi si mt b kt, gii phng ng mt hay iu tr si ng mt ch v bin chng ca si. Nhc im: + i hi phi c siu m. + Khng thc hin c trong cc trng hp: Cht hp c Oddi. si ci vo Oddi hay bt cht u di ng mt ch. Hp ng mt ch hay ng ba ng gan. 2) Chp ng mt trong m: Mc ch: + thm d ton b ng mt trong v ngoi gan + Trnh st si. + Kt hp vi o p lc ng mt. - K thut: t kim trc tip vo ng mt ch, sau bm thuc cn quang hoc t ng catheter qua ng c ti mt (trong nhng trng hp ct ti mt), sau bm thuc cn quang. 3) Chp ng mt qua da: Ch nh: + Gim p lc ng mt trong nhng trng hp cp. + Trng hp ng mt trong gan gin to. + Khi khng thc hin c k thut chp mt ngc dng qua bng Valter. + Ngy nay thng c Chn on trc m cho bit v tr si, d vt ng mt v cc thng tn phi hp v tnh trng ng mt. K thut: + S dng kim chc d ng mt qua da v nhu m gan vo ng mt. + Bm thuc cn quang v chp. Nhc im: c nhiu bin chng: + Chy mu. + R mt vo bng gy vim phc mc. 32

V vy ch nn lm trong nhng c s ngoi khoa c iu kin. 4) Chp ng mt sau m qua dn lu Kehr. 5) Chp ng mt ng ung: nh gi hnh nh ti mt. Nay t dng. Ch : phi th test trc khi tim hay truyn thuc cn nh gi hnh nh ca ng mt trong v ngoi gan:
6) Chp ng mt ng tnh mch: quang vo tnh mch. + Hnh nh ng mt ch. + Hnh nh ti mt (sau vi gi) nu ti mt cn cng: gin tip nh gi chc nng ti mt. *Hai phng php chp mt qua ng ung v ng tnh mch ch c Chn on trong trng hp tc mt khng vng da, hnh nh thu c thng m v mt nhiu thi gian: nay t dng. 4. Ni soi ng mt (ng cng, mm). 1) Ni soi ng mt trong m: + Kim tra trc tip trong ng mt t bng Valter ti ng ba ng gan. + Mc ch: ly nt si, d vt cn st. Quan st tnh trng ng gan. 2) Ni soi ng mt qua da. 3) Ni soi ng mt qua c tht Oddi. 5. Xquang khng chun b: t c gi tr: Chp bung khng chun b: thng khng thy s ng mt ch do si loi ny khng cn quang, tuy nhin c th thy hnh nh cn quang ca si vi ho di sn phi v trc ct sng hoc c th thy hnh nh cn quang si ti mt. Chp gan xa: Hnh nh gan to, bng ti mt to. 33

6. Ctscanner: Hnh nh si mt v kch thc cc ng mt. Thng c s dng khi phi hp nh gi cc tng ln t s dng do c hiu qu ca siu m.
cn (tu tng). 7. Xt nghim nc tiu: 1) Tnh trng mt: do mt tro ngc vo mu v bi tit qua nc tiu: Mui mt, sc t mt tng (bnh thng trong nc tiu khng c) 2) Lm albumin, ng: nh gi bilan. 8. Thng t trng (nghim php Hetzer Lyca): t s dng. VI. Chn on: 2. Mc ch: 3. Chn on xc nh: Lm sng: Tam chng Charcot ti din. Cn lm sng: sinh ho, siu m, ERCP.
4. Chn on phn bit: 1) Vi cc bnh vng da, khng tc mt: a. Vim gan virut: Ton thn: + St thng xut hin trc v khi xut hin vng da th ht st. + Mt mi nhiu. C nng: + au: cm gic tng tc vng gan ch khng au d di. + Vng da. + i t. + Tiu vng. + Phn bc mu. Thc th: Gan hi to nhng ti mt khng to. Cn lm sng:
+ GPT, GOT tng 34

+ Bilirubin tng, ch yu l bilirubin trc tip. + Xt nghim nc tiu: phn li sc t mt, mui mt: sc t mt tng, mui mt khng tng. + Phn bit chnh xc nh siu m v phn ng huyt thanh tm kim tra. b. Thiu mu tan mu: Hay gp trong st rt, nhim khun huyt. Khng au bng gan, khng st, ch c vng da n Gan v ti mt khng to. Cn lm sng: hng cu gim, hct gim, nc tiu c
thun.
huyt sc t trong nc tiu. c. Bnh do xon khun gy vng da, chy mu. Da vng nh cam. Chy mu. au nhiu trong cc c. Cn lm sng: thy vi khun mu v nc tiu. Siu
m c gi tr c bit. 2) Vi cc nguyn nhn vng da tc mt. a. U u tu: Ton thn: + Triu chng nhim c r: nga, tim p chm. + Ton trng km. C nng: + Khng au tc vng gan. + Khng st (thi gian u), sau st tng t do c bi nhim. + Vng da tng dn, lin tc. Thc th: + Ti mt cng to nhng khng au. + Nc tiu vng m. + Phn trng, bc mu. 35

+ C th s thy u u tu khi u to. Cn lm sng: + Siu m: khng si, u tu to, ng mt ch, ti mt gin. + Ni soi, chp mt ngc dng. b. U bng Valter: Lm sng gn ging u u tu. Cn lm sng:
+ Chp t trng: khuyt vng on 2 t trng. + Ni soi t trng Chn on xc nh. c. U nang ng mt: Ngi tr: Triu chng tc mt. U h sn phi lin vi gan, khng di ng nh ti mt. Siu m v chp ng mt chn on xc nh. Tr em. t khi au v st. Vng da tng t. Gan v ti mt cng to, khi mm cng nm di h sn Chp khung t trng, ng mt qua da chn on
d. U nang ng mt ch.
phi. xc nh. e. Ung th ng mt: Triu chng tng t u u tu, lm sng c biu hin tc mt (trng hp u di ch tc mt vo ng mt ch). Kch thc ti mt: tu thuc vo v tr gy tc trn ng mt: + U di ch ti mt vo ng mt ch: ti mt cng to, khng nn thy u v khung t trng khng rng. + U trn ch ti mt vo ng mt ch: 36

Siu m: khi tng m khng km bng cn. Chp ng mt qua da.
6. Vng da do vim ti mt v nhim khun ng mt: Chn on phn bit ch yu da vo siu m: VII. Ti mt vim dy, dch quanh ti mt (c th c si ti ng mt ch khng gin, khng thy si. Din bin: (?) mt).
1. Khi tm thi: Tc mt mt phn (do si mt mt phn, co tht hay ph n nim mc thnh ng mt ch) khi iu tr ni (khng sinh, gim co tht) lm ng mt ch gin ra, vim nhim v ph n mt i, ng mt thng tr li: ht st, au, vng da gim dn. Si vn tn ti v bnh nhn n nh trong thi gian di hay ngn ph thuc vo: v tr, kch thc si v s nhim khun ng mt. 2. Din bin cp v bin chng. VIII. Cc th lm sng: Lm sng kinh in v in hnh ca si ng mt 1. Th tc mt: ch + cc du hiu: + au bng gan. + Mc vng da thay i. + Hi chng nhim khun. Chn on xc nh: nh siu m. Trng hp nghi ng tc mt do u ng mt: chp mt
ngc dng hoc m bng thm d.. 2. Th vng da lin tc: Hay gp nhng bnh nhn c tin s din bin ca si mt nhng khng c theo di v chn on sm ngay t u. Nhng du hiu vng da v nim mc trong thi gian di khng gim do si gy vim ng mt dn n tc 37

mt v nhim khun (d nhm vi tc mt do u hoc vim gan mn). Tin trin: Nng: vim ng mt m dn n suy thn cp. 3. Th khng vng da: Si ng mt ch th tim tng: lm sng khng r: i khi au h sn, khng c cc du hiu km theo, pht hin tnh c. Th vim ng mt: au tc vng gan + hi chng Th cc bin chng ca si mt: bnh nhn n vi nhim khun. bnh cnh lm sng ca cc bin chng cp tnh: + Vim tu cp (ph tu cp). + p xe ng mt. + Si mt + Cc bin chng ca p xe ng mt: *Lng ngc: trn m mng phi, theo di mng ngoi tim. *Bng : vim phc mc ton th. 4. Cc th gii phu c bit: Si ng mt ch vng bng Valter. + Si nh nhng d gy kt v tc mt hon ton. + din bin nhanh, nng, cn x tr sm. Si ng mt ch: + Si trong gan. + Din bin lu di. + Nhim khun thng xuyn. + D st si trong cc nhnh gan. + D ti pht. IX. iu tr: 1) Khi c chn on xc nh l si ng mt ch: iu tr tch cc nhm ly si, to lu thng ng mt, chng nhim khun. 38 1. Nguyn tc:

2) Ht sc trnh m cp cu khi cha cn thit do cha nh gi ht c: tnh trng chung ca ngi bnh, ri lon chc nng ca cc tng lin quan, bnh nhn cha sc chu ng. Ch c m cp cu khi c bin chng, phng php ch yu l ly si v dn lu Kehr, khng lm g phc tp. 3) Phi hp iu tr ni khoa v ngoi khoa nhm chun b cho iu tr ngoi khoa c tt hoc iu tr phi hp chng vim nhim. 4) Phng php iu tr tt nht l m c chun b nhm: Bnh nhn c lm bilan y . Chn thy thuc c kinh nghim. Gim t l st si.
2. Phng php iu tr: 1) Chun b bnh nhn: Khng sinh v hi sc tch cc trong trng hp nhim khun ng mt nng v c bin chng nng: iu chnh li cc ri lon v chc nng gan: Vitamin K vi ngy trc m (nhm hn ch nhng ri lon ng mu o thiu vitamin K). Khng sinh chng nhim khun ng mt, chng vim tc. Tt nht tm vi khun, khng sinh . La chn khng sinh ngm tt vo ng mt v c theo di vi trc khun ng rut (cephlosporin III, Flagyl ) S dng thuc lm gim co tht ng mt, chng tc nh gi chc nng 1 s tng khc (tim, thn) v iu Nng cao th trng bnh nhn: truyn m, mu trc Chn thy thuc c kinh nghim. 39 mt. chnh cc ri lon nu c. m.

2) Phng php iu tr: c nhiu phng php iu tr si ng mt ch, la chn ph thuc vo: Tui v tnh trng ton thn ca bnh nhn. S phi hp ca si ng mt ch vi: si trong gan, si ti Tnh trng nhim khun ng mt. Kch thc v s lng si. Tnh trng bng v tin s v phu thut bng
mt.
(c lin quan ti si mt) trc y. a. Phng php m ng mt ly si v dn lu (m m) Gy m: + Gy m ni kh qun. + S dng thuc gin c. + S dng khng sinh ton thn khi khi m. ng m trng gia trn rn hoc ng di sn phi. K thut:
+ M ng mt ch + dn lu Kehr: M ng mt ch ly si. Bm ra ng mt, kim tra si trn gan. Kim tra lu thng on thp ca ng mt ch (nu c iu kin nn chp ng mt hay ni soi ng mt hay siu m gan mt trong m nhm trnh st si). t ng dn lu Kehr (ch T) hoc cc loi dn lu mt dn lu mt cn nhim khun ra khi bng, bo m gi p lc trong ng mt mc gn nh bnh thng trong cc r mt v an ton ch khu khi c m ng mt. Lau ng bng v dn lu di gan. + Dn lu Volleker: Ch nh: khi c vim cht hp c Oddi. K thut: qua ni m ng mt ch a vo ng mt ch 1 sonde thm d v pha c Oddi. Ly u sonde thm d lm nn, dng dao in m dc ch 12h chng 1cm, a c sonde thm d xung t trng. Qua t trng v ni m 40

c tht a dn lu vo ng mt ch. Khu ng mt ch v t trng. Nhc im: r v hp t trng sau m. + Dn lu ng mt trong gan qua nhnh h phn thu qua nhu m gan. + Ni ng mt v ng tiu ho: *Ch nh: khi thng tn phn thp ca ng mt m khng gii quyt c bng cch m c tht Oddi. Cht hp phn thp ng mt ch. Bnh ng mt phi hp (nang ng mt). Si ti pht phi m nhiu ln. Si trong gan phi hp. *Ni trc tip: ni ng mt (ti mt, ng mt ch, ng mt trong gan) vi t trng: u im: Tin hnh nhanh, thun tin. Nhc im: Vim ng mt ngc dng sau m. Kh thc hin khi t trng vim dnh. *Ni gin tip: ni ng mt vi 1 hng trng trn mt quai rut bit lp (kiu Omega hay kiu Roux en Y). u: hn ch c vim ng mt ngc dng sau m. Ni c mi v tr ca ng mt. C th m thng quai Y ra da sau qua l m thng a dng c vo ly si. Nhc: Kh v k thut. Cc ri lon do mt khng qua t trng. *Ni ng mt vi ton thn trn 1 quai hng trng bit lp: khc phc c cc nhc im ca 2 phng php trn. + Ct ti mt: *Ch nh: Nghi ung th. Thng tn ti mt khng c kh nng hi phc: vim hoi t, si ti mt, chy mu ng mt. + M nhu m gan ly si:
41

Khi km si trong gan v si ny gm cht vo ng mt v nhng v tr khng th ly qua ng mt. Nhc: d gy chy mu v r mt sau m, Phi t dn lu ng mt ch qua nhu m gan sau m nhu m ly si ra ng mt sau m. + Ct gan: Khi si hoc p xe khu tr mt thu no hoc chy mu ng mt m khu tr c v tr chy mu, nht l gan tri. + M to hnh c Oddi b cht: b. M c Oddi bng ni soi ly si: Phng php: qua ni soi t trng v chp ng mt tu ngc dng (ERCP) xc nh chn on v v tr, kch thc, s lng si ng mt ch. Trng hp si < 1cm, bnh nhn c bnh phi hp khng tin hnh m m c th: + M c tht Oddi a vo ng mt sonde ly si Dormia hay Forgaty ko si xung t trng. + t dn lu ng mt qua ng dn lu t qua ng mi d dy. c. ly si ng mt ch qua m ni soi ct ti mt: Thc hin vi si nh, c trang thit b. Phng php:
+ Ct ti mt thng qua ni soi (ng ch nh) bng. + Nong ng ti mt hoc m dc ng mt ch theo ng ti mt. + a vo ng mt ch sonde Dormia ly si. + t dn lu Kehr. d. Tn si trong hoc ngoi c th: dng: Xung in thu lc. Siu m, Laser phi hp vi phu thut hay ni soi ng
mt. 42

3) Sn sc sau m: Khng sinh ton thn 7 10 ngy. Bm thng ng Kehr nu tc. Chp kim tra ng mt say 7 10 ngy. Rt Kehr khi chc chn:
+ Khng st si. + ng mt khng hp. + Khng c nhim khun ng mt. Ung th i trng tri I. i cng: 1. Trong s cc loi ung th ng tiu ho , ung th i trc trng ng th 2 sau sau ung th d dy. Trong ung th i trng bao gm cc thng tn c tnh xut hin i trng t manh trng n ranh gii gia i trng xch ma v trc trng. 2. Ty theo v tr ca u, ung th i trng c nhiu tn gi khc nhau: ung th manh trng, ung th i trng gc gan, ung th i trng ngang, ung th i trng xch maTrong ung th i trng tri nhiu hn ung th i trng phi. 3. Ung th i trng tri l cc ung th nm on i trng t 1/2 tri i trng ngang, qua gc lch, i trng xung ti ranh gii gia i trng xch ma v trc trng (ung th v tr bn l ny c xp vo loi ung th phn trn bng trc trng). 4. V mt dch t hc: 1) Tui: t l mc tng theo tui: t 20 tui thy xut hin ung th v tng ln r rt t sau 45 tui. 2) Gii. 3) Yu t gia nh, di truyn: C yu t gen bm sinh i vi ung th i trng. Hay gp nhng gia nh c: + Nhiu ngi mc bnh a polypes. 43

+ Hi chng ung th gia nh (hi chng Lynch): ung th hay gp on u i trng phi + adenocarcinome khc ngoi i trng (ung th ni mc t cung). + Ung th mang tnh di truyn c bit: Ch gp i trng. Nhng ngi c huyt thng trc tip (b, m, con ci) vi ngi b ung th i trng c nguy c cao gp 2 3 ln ngi bnh thng. 4) Yu t thun li: Cc bnh mn tnh: + Vim lot i trng. + Bnh Crohn i trng. + Vim i trng do Schistosoma. + Polype i trc trng. Cc bnh ngoi khoa: + Sau m cm niu qun vo i trng. + Sau m ct ti mt. + Sau m ct d dy do lot lnh tnh. + Thc qun ngn. Ngh nghip: Tip xc vi phng x, aming.. Ch dinh dng: n nhiu m, nhiu calo, t canxi,
thc n c t cht si c th ln men. 5. i vi ung th i trng thi gian tin trin rt lu di, k t khi xut hin khi u cho n khi n t ti khi lng cn thit xut hin triu chng hoc s thy mt khong 5 15 nm. giai on pht trin m thm ny khng c triu chng lm sng nhng hy vng sng ca bnh nhn s tt hn nu c Chn on giai on cha c triu chng. 6. Ngy nay vi tin b ca khoa hc, vic s dng ng soi mm c th Chn on ung th i trng v phu thut a
44

li kt qu kh quan hn l so vi cc ung th ng tiu ho khc. II. Tnh cht u: Thm nhim hnh vng l ch yu, rt nhanh chng Th u si: rt t. 95% l ung th biu m tuyn in hnh. Ung th biu m tuyn khng in hnh: t hn Ung th biu m t bo nhy: him gp. 1. i th: dn n tai bin cht hp lng i trng. 2. Vi th:
3. ng lan truyn: 1) Ti ch: ung th pht trin ngay thnh rut, nht l lp di nim mc, nhng thng khng i xa qu 2cm cch u chnh. 2) ng trc tip: u lm thng i trng v xm ln ti cc c quan khc. 3) ng mu: ch yu l ng tnh mch i trng ri theo ng tnh mch ca v gan, ln phi v cc ni khc (bung trng). V th m thng thy ung th hay di cn ti gan rt sm. 4) ng bch huyt: theo cc chui hch nm dc theo cc cung ng mch ln, ln n tn gc ng mch mc treo trng trn. 5) Di cn theo lng i trng: cc t chc ung th t khi u ban du, rng vo lng i trng v lan i xa khi v tr ban u. Nhiu cng trnh cho thy trn cng mt ngi bnh c th gp ung th nhiu v tr khc nhau trn khung i trng. Chnh nhng mnh t chc ung th lang thang ny s l nguyn nhn gy nn ung th ti pht ti ming ni sau ny, nu trong khi m khng c nhng bin php hu hiu che bo v thnh bng. 45

III. Chn on: 1. Giai on sm (khi cha c triu chng): chn on sm ung th i trng ngay t khi n cha c biu hin lm sng v x tr sm, hp l ng vai tr quan trng trong kt qu iu tr v thi gian sng sau phu thut ca bnh nhn. Mt s ngh c a ra: 1) i vi bnh nhn n vin vi bt k l do no: Bnh nhn tui 40: thm hu mn trc trng Bnh nhn tui > 50: xt nghim tm mu bng ngn tay. trong phn v soi i trng xch ma. C 5 nm mt ln li n kim tra. Nu c iu kin th xt nghim mu trong phn cho mi i tng n khm bnh mt cch c h thng. Nu xt nghim (+) th tin hnh tip cc thm d khc: thm trc trng, soi i trng, soi trc trng. 2) Tin hnh xt nghim hng lot mang tnh sng lc Chn on i vi qun th dn c khng c yu t nguy c cao v khng c triu chng lm sng. 3) i vi nhng i tng thuc nhm nguy c cao, nht l nhng ngi c tin s bnh thuc nhm di truyn v c tnh cht gia nh: khm v xt nghim sng lc trc khi bc vo tui dy th. 2. Giai on c triu chng: 1) Lm sng: a. C nng: au bng: + au kiu bn tc rut (hi chng Koenig) hoc au bng qun nh co tht i trng. + i khi c cm gic au bng kh chu, m h pha bng h sn phi, d nhm vi vim tnh mch/lot lot d dy t trng. 46

Ri lon tiu ho: + To bn rt thng gp, xen k c cc t a lng + a mu: Phn c mu bao quanh hoc trn ln vi mu ti hay en thm hoc phn c nhy mi nh l hoc phn c mu cc nh + mi nhy l l mu c. + Bt k khi no thy a mu ngi trung nin hoc ngi gi do khm thy th phi t cu hi c ung th i trng khng. b. Ton thn: Tnh trng thiu mu khng r nguyn nhn: mt mi, nht nht, suy nhc -- Chn n, st cn, mt mi. c. Thc th: Khm thc th k cng c th nh gi s b mc lan rng ti ch ca ung th, pht hin cc di cn xa, tm cc bnh phi hp ca cc c quan khc c th nh hng n vic iu tr. U bng: t khi thy Tc rut cp: C th khm thy hch bn, hch thng n to. Gan to, bng c chng, tun hon bng h nu c di Thm trc trng:
cn tc tnh mch ca. + Bng trc trng rng hay c phn. + C mu dnh theo ngn tay hay khng. + C xm ln vo m o, ti cng trc trng bng quang, ti cng trc trng m o hay khng: cm gic cng rp, ln nhn khi ngn tay khm qua thnh trc trng, thnh m o. + C th thy khi ung th trc trng. 2) Cn lm sng: a. Chp Xquang khung i trng c baryt: Tht tho sau bm baryt t trc trng ln. 47

Nu l ung th i trng s thy: + Hnh tht hp tn ti thng xuyn trn phim chp hng lot cng mt v tr: tng ng vi ung th th vng nhn: on hp ko di khng u, vn vo, hp trn mt on di khong vicm, mt cc np nim mc. ch tip gip vi i trng lnh pha trn v di thy hnh nh ging nh du ng m ngoc,d nhm vi co tht i trng. + Hnh ct ct: thuc hon ton khng qua c mc d tng p lc khi thuc cn quang tht vo. C khi thy nh ln mt mu hp, ngn, nhn, trng nh ngn la nn. Gp trong th tc rut cp. + Hnh khuyt: hnh khuyt nhiu vng trn, vin khng u. Hnh khuyt trung tm hay b ca i trng. Hnh nh Xquang ch c gi tr chn on khi tn ti Hnh nh Xquang khng c gi tr khng nh chn thng xuyn trn nhiu phim chp hng lot. on ung th i trng v c nhiu thng tn bnh l khc c th nhm (lao, bnh Crohn, phn, co tht). Cng khng nn chp khung i trng c thuc cn quang khi c du hiu r l ung th i trng v c th gy ra tc rut cp. Soi i trng ng mm dn dn c xu hng thay th cho phim chp khung i trng. Nhng nn phi hp 2 phng php ny v khi soi i trng khng t c ht ton b khung i trng v nhiu khi kt qu soi khng ct ngha c ht cc triu chng. b. Ni soi i trng ng mm: cho nhng bnh nhn nghi ng hay chc chn ung th i trng. Chun b sch i trng, soi trc m, tr trng hp gy Tt nht gy m ng tnh mch soi. 48 tc hoc nhng nguyn nhn khc khng cho php.

Soi ng mm ton b i trng: Pht hin nhng khi u c d > 5cm, c th b st nhng thng tn khi u nm lp di nim mc hay nhng ch gp gc. Sinh thit bt buc nhng v tr nghi ng, nu kt qu gii phu bnh l ung th: m khng cn Xquang. c. xt nghim nh lng CEA huyt thanh: Thng nh lng 2 loi cng lc (CEA v CEA 19-9). Trong ung th i trng c 2 loi u tng cao gp 2 ln bnh thng. CEA tng khng c hiu cho ung th i trng. N c th tng cc ung th thuc ng tiu ho v khng thuc ng tiu ho khc. CEA c gi tr: + nh hng Chn on. + Tin lng sau m: nu CEA khng gim xung mc bnh thng: tin lng xu. + Pht hin ti pht sau m ct u trit cn: CEA tr li bnh thng sau m ri t t tng dn trong thi gian theo di: ung th ti pht. d. Cc xt nghim khc: Sinh thit hch: bn, thng n. Chp nhp nhy min dch phng x: Dng khng
th n dng c nh du phng x tim vo mch mu. Cc khng th ny gn vo cc khng nguyn cng tn do ung th gy ra. Dng my qut tia phng x pht hin Xquang tim phi tm di cn. CTscanner: nh gi mc lan trn ngoi thnh rut MRI Siu m: tm nhn di cn gan, phc mc (lm chm
i vi ung th i trng.
ht k).
49

Siu m ni soi: nh gi mc xm ln khi u trn thnh i trng v vng st k khi u. Pht hin cc hch bch huyt to quanh thng tn. Xt nghim c bn: Phn tch nc tiu, s lng bch cu, Hb, Hct, protein,Ca, bilirubin, Photphatase kim, creatinin. Soi hu mn trc trng: + Hnh nh u si lot g cao, mu thm, gia c lot v d chy mu khi chm vo. + Di ng hay khng. + Sinh thit u. + nh gi kch thc lng rut b hp v lng rut trn u. 3. Trng hp c bit: M cp cu v tc rut: khi m ra thy nguyn nhn gy tc rut l ung th i trng. 4. Chn on phn bit vi ng th i trng phi: Gii hn: i trng ln + na phi i trng ngang. Gii phu bnh:
+ Thng manh trng v i trng gc gan + U th si gy nn hp mt phn i trng. + U di cn ng tnh mch, bch huyt. Lm sng: + Hi chng Koenig. + Thng s thy u. Cn lm sng: hnh ct ct, hnh cng cua, hnh Bin chng: nhim khun, vim phc mc do thng. khuyt. 5. Nhng nguyn nhn dn n chn on mun ung th i trng tri: a s bnh nhn khng i khm ngay t khi xut hin cc triu chng u tin.
50

Bnh nhn tr < 40 tui khin thy thuc khng ngh ti kh nng ung th. thc t tir l ung th i trng tri tui ny l 3,5%. bnh nhn c th trng tt nn thy thuc khng ngh n ung th: 60% ung th i trng tri khng c du hiu lm sng. Chp nhn d dng s gii thch v cn c i vi 1 s hin tng bnh l: a lng cho l ng c thc n, vim i trng *Tm li: Chn on ung th i trng phi ch n nhng triu chng v du hiu gi . Tip chp khung i trng cn quang v ni soi ng mm khng nh. IV. X tr: Phu thut l ch yu. Ho tr liu, vt l (tia x) tr liu trong v sau m c 1. Nguyn tc:
nhiu trin vng. 2. Phu thut iu tr ung th i trng ngoi bin chng: 1) Chun b sch i trng. 2) Chun b sch i trng. 3) M ct b thng tn v hch bch huyt thuc vng tng ng, ct b u ngay c khi di cn xa. C th ngn nga tc rut v chy mu trong mt thi gian di. 4) Phu thut trit cn: Ct i trng tri i vi ung th phn cn li. Ct i trng ngang khi u nm gia i trng ngang
hoc ct ton b i trng ngang khi u nm nhiu v tr trn i trng ngang. 5) Phu thut tm thi (khi khng cn kh nng ct b u): Lm hu mn nhn to vnh vin trc khi u.
51

6) Khi di cn: Ct ly c khi u di cn + ct 1 phn hay ton b tng b xm ln cng vi ung th i trng. Vi ung th i trng phi: Ct i trng phi, a 2 u rut ra ngoi, ni th hai . Ni hi i trng ngang nu l u gy tc rut. Vi ung th i trng tri: Ct i trng kiu Hartmann: u trn a ra ngoi lm hu mn nhn to, u di ng kn, m th 2 sau 2 3 thng ni li sau. (ch on i trng di nu > 10 chy mu s c nguy c hnh thnh ti cng gy nhim khun). Lm hu mn nhn to trn khi u. M ct i trng th 2 sau 15 ngy. 7) Ch v k thut: Thm d kh nng ct b u, tm di cn xa v cc bnh Khng nn s nn nhiu vo khi u khi khng cn thit Dng 2 di bng mm (mche) buc tht kn lng i khc phi hp trc trong khi m bng. trnh nguy c lm lan xa t bo ung th. trng pha trc v sau khi u, khng cho cc t bo t khi u rng ra lan xa trong lng rut. V. Bm ra 2 u i trng trc khi ni bng nc mui sinh No vt hch k. Bin chng: 26,3% cc trng hp ung th i trng tri c bin chng i hi phi x l m cp cu. Khi bnh i trng khng c chun b nn bn. Mt s trng hp cn c nhim khun, p xe quanh u, d i trng d dy, d i trng ti mt 1. Tc rut: Hnh thi lm sng l mt tc rut thp. Nu tnh trng cho php trng hp tc rut m ct l, providin.
i trng cp cu ni ngay hoc ni th 2 sau mt thi
52

gian khi tnh trng chung n nh v i trng c chun b sch. 2) Thng gy vim phc mc: Thng ngay ti ch khi ung th (do nhim khun) hoc thng on i trng trn khi u (do b gin cng qu mc). Thng hay gp ngi gi. Ct i trng nhng khng ni ngay a 2 u rut ra ngoi, ni sau 1 thi gian khi tnh trng nhim khun ht. p xe, r: p xe quanh i trng ch c khi u, thng gp nht l gc lch. Lm sng: rt run, st, i khi s thy u. R t gp hn, r vo bng quang (i ra m hoc i ra hi), vo rut non (a chy, chp khung i trng c baryt thy thuc cn quang thng vi rut non), rt t khi r vo i trng (a chy, hi th rt thi). VI. Chy mu: rt t khi gp, nht l loi chy mu d di. Tin lng sau m: ph thuc: 1) Dukes A: ung th cha xm ln ti thanh mc, cha c di cn hch. 2) Dukes B: thanh mc b xm ln cha di cn hch. 3) Dukes C: ton b thnh i trng b xm ln, c di cn hch. 4) Dukes D: ung th i trng c di cn xa. Dukes A, B: ? 2. bit ho ca cng tt. 3. C bin chng hay cha. 4. U th lch bi l tin lng xu hn th lng bi. 5. Tr c tin lng xu hn gi. 6. Tin lng sng 5 nm ca ung th i trng l 45%. t bo u: bit ho cng cao, tin lng
1. Giai on ca u: Theo phn loi Dukes:
53

VII. Theo di sau m: 100% bnh nhn ung th i trng sau m c nh trit cn phi c theo di: 1. Mc ch: Pht hin sm cc ti pht, di cn, thng tn ung th mi Phng php: xut hin trn phn i trng cn li. + Khm lm sng. + CEA huyt thanh 2 thng/ln (i vi Dukes B, C) + xt nghim phn tm mu 6 12 thng/ln. + Ni soi i trng bt buc sau 1 nm. Nu khng c g ni soi li sau 2 3 nm. + Khng s dng chp khung i trng c baryt trong theo di. Khi c bin chng: m li hoc s dng tia x trong m. 2. iu tr ho cht v tia x. Ung th i trng phi VIII. i cng: 1. Trong s cc loi ung th ng tiu ho , ung th i trc trng ng th 2 sau sau ung th d dy. Trong ung th i trng bao gm cc thng tn c tnh xut hin i trng t manh trng n ranh gii gia i trng xch ma v trc trng. 2. Ty theo v tr ca u, ung th i trng c nhiu tn gi khc nhau: ung th manh trng, ung th i trng gc gan, ung th i trng ngang, ung th i trng xch maTrong ung th i trng tri nhiu hn ung th i trng phi. 3. Ung th i trng phi l nhng ung th t manh trng n 1/2 i trng ngang. 4. Ung th tin trin lu di, k t khi xut hin khi u cho n khi n t ti khi lng cn thit xut hin triu chng hoc s thy mt khong 5 15 nm. giai on 54

pht trin m thm ny khng c triu chng lm sng nhng hy vng sng ca bnh nhn s tt hn nu c chn on giai on cha c triu chng. 5. Ngy nay vi tin b ca khoa hc, vic s dng ng soi mm c th chn on ung sm th i trng v phu thut a li kt qu kh quan hn l so vi cc ung th ng tiu ho khc. 6. V mt dch t hc: 1) Tui: t l mc tng theo tui: t 20 tui thy xut hin ung th v tng ln r rt t sau 45 tui. 2) Gii. 3) Yu t gia nh, di truyn: C yu t gen bm sinh i vi ung th i trng. Hay gp nhng gia nh c: + Nhiu ngi mc bnh a polypes. + Hi chng ung th gia nh (hi chng Lynch): ung th hay gp on u i trng phi + adenocarcinome khc ngoi i trng (ung th ni mc t cung). + Ung th mang tnh di truyn c bit: Ch gp i trng. Nhng ngi c huyt thng trc tip (b, m, con ci) vi ngi b ung th i trng c nguy c cao gp 2 3 ln ngi bnh thng. 4) yu t thun li: Cc bnh mn tnh: + Vim lot i trng. + Bnh Crohn i trng. + Vim i trng do Schistosoma. + Polype i trc trng. Cc bnh ngoi khoa: + Sau m cm niu qun vo i trng. + Sau m ct ti mt. 55

+ Sau m ct d dy do lot lnh tnh. + Thc qun ngn. IX. Ngh nghip: Tip xc vi phng x, aming.. Ch dinh dng: n nhiu m, nhiu calo, t canxi, Tnh cht u: Th u si: hay gp nht, u si vo trong lng i trng, Th thm nhim cng gy hp. 95% l ung th biu m tuyn in hnh. Ung th biu m tuyn khng in hnh: t hn Ung th biu m t bo nhy: him gp.
thc n c t cht si c th ln men. 1. i th: mt hay nhiu u, vi cc hnh thi: thnh mi, mm, thng km theo lot gia. 2. Vi th:
3. ng lan truyn: 1) Ti ch: ung th pht trin ngay thnh rut, nht l lp di nim mc, nhng thng khng i xa qu 2cm cch u chnh. 2) ng trc tip: u lm thng i trng v xm ln ti cc c quan khc. 3) ng mu: ch yu l ng tnh mch i trng ri theo ng tnh mch ca v gan, ln phi v cc ni khc (bung trng). V th m thng thy ung th hay di cn ti gan rt sm. 4) ng bch huyt: theo cc chui hch nm dc theo cc cung ng mch ln, ln n tn gc ng mch mc treo trng trn. 5) Di cn theo lng i trng: cc t chc ung th t khi u ban du, rng vo lng i trng v lan i xa khi v tr ban u. Nhiu cng trnh cho thy trn cng mt ngi bnh c th gp ung th nhiu v tr khc nhau trn khung i trng. Chnh nhng mnh t chc ung th lang 56

thang ny s l nguyn nhn gy nn ung th ti pht ti ming ni sau ny, nu trong khi m khng c nhng bin php hu hiu che bo v thnh bng. X. Chn on: 1. Giai on sm (khi cha c triu chng): chn on sm ung th i trng ngay t khi n cha c biu hin lm sng v x tr sm, hp l ng vai tr quan trng trong kt qu iu tr v thi gian sng sau phu thut ca bnh nhn. Mt s ngh c a ra: 1) i vi bnh nhn n vin vi bt k l do no: Bnh nhn tui 40: thm hu mn trc trng Bnh nhn tui > 50: xt nghim tm mu bng ngn tay. trong phn v soi i trng xch ma. C 5 nm mt ln li n kim tra. Nu c iu kin th xt nghim mu trong phn cho mi i tng n khm bnh mt cch c h thng. Nu xt nghim (+) th tin hnh tip cc thm d khc: thm trc trng, soi i trng, soi trc trng. 2) Tin hnh xt nghim hng lot mang tnh sng lc Chn on i vi qun th dn c khng c yu t nguy c cao v khng c triu chng lm sng. 3) i vi nhng i tng thuc nhm nguy c cao, nht l nhng ngi c tin s bnh thuc nhm di truyn v c tnh cht gia nh: khm v xt nghim sng lc trc khi bc vo tui dy th. 2. Giai on c triu chng: 1) Lm sng: a. C nng: au bng: + Mi u ch c cm gic y, chng bng, kh chu, sau pht trin tng dn tr thnh cm gic au nh co 57

tht. Cn au thng kt thc hoc gim i bng hin tng trung tin hoc si bng lc cc kiu bn tc rut (hi chng Koenig). + i khi c cm gic au bng kh chu, m h pha bng h sn phi, d nhm vi vim lot d dy t trng. Ri lon tiu ho: + au bng km a lng. + a mu: dng vi th, ch khi soi tm hng cu trong phn mi bit l c chy mu. b. Ton thn: Tnh trng thiu mu khng r nguyn nhn: mt mi, Chn n, st cn, mt mi. nht nht, suy nhc. c. Thc th: khm thc th k cng c th nh gi s b mc lan rng ti ch ca ung th, pht hin cc di cn xa, tm cc bnh phi hp ca cc c quan khc c th nh hng n vic iu tr. U bng: u nm h chu phi, vng bn phi cnh rn Chng bng v gin nh manh trng: tc rut khng C th khm thy hch bn, hch thng n to. Gan to, bng c chng, tun hon bng h nu c di Thm trc trng: hay h sn phi. U c th di ng nhiu hay t. hon ton.
cn tc tnh mch ca. + Bng trc trng rng hay c phn. + C mu dnh theo ngn tay hay khng. + C xm ln vo m o, ti cng trc trng bng quang, ti cng trc trng m o hay khng: cm gic cng rp, ln nhn khi ngn tay khm qua thnh trc trng, thnh m o. + C th thy khi ung th trc trng. 58

2) Cn lm sng: a. Chp Xquang khung i trng c baryt: Tht tho sau bm baryt t trc trng ln. Nu l ung th i trng s thy: hnh khuyt nham nh
ng vi ung th th si. Hnh lot: th hin bng ng thuc thng xuyn trn phim chp lin tip. C khi i km vi hnh khuyt. Thnh i trng thng tn cng mt v mm mi vn c v mt cc np nim mc. Hnh nh Xquang khng c gi tr khng nh chn on ung th i trng v c nhiu thng tn bnh l khc c th nhm (lao, bnh Crohn, phn, co tht). Cng khng nn chp khung i trng c thuc cn quang khi c du hiu r l ung th i trng v c th gy ra tc rut cp. Soi i trng ng mm dn dn c xu hng thay th cho phim chp khung i trng. Nhng nn phi hp 2 phng php ny v khi soi i trng khng t c ht ton b khung i trng v nhiu khi kt qu soi khng ct ngha c ht cc triu chng. e. Ni soi i trng ng mm: cho nhng bnh nhn nghi ng hay chc chn ung th i trng. Chun b sch i trng, soi trc m, tr trng hp gy Tt nht gy m ng tnh mch soi. Soi ng mm ton b i trng: Pht hin nhng khi u tc hoc nhng nguyn nhn khc khng cho php.
c d > 5cm, c th b st nhng thng tn khi u nm lp di nim mc hay nhng ch gp gc. Sinh thit bt buc nhng v tr nghi ng, nu kt qu gii phu bnh l ung th: m khng cn Xquang. f. xt nghim nh lng CEA huyt thanh: Thng nh lng 2 loi cng lc (CEA v CEA 19-9). Trong ung th i trng c 2 loi u tng cao gp 2 ln bnh thng. 59

CEA tng khng c hiu cho ung th i trng. N c th tng cc ung th thuc ng tiu ho v khng thuc ng tiu ho khc. CEA c gi tr: + nh hng Chn on. + Tin lng sau m: nu CEA khng gim xung mc bnh thng: tin lng xu. + Pht hin ti pht sau m ct u trit cn: CEA tr li bnh thng sau m ri t t tng dn trong thi gian theo di: ung th ti pht. g. Cc xt nghim khc: Sinh thit hch: bn, thng n. Chp nhp nhy min dch phng x: Dng khng
th n dng c nh du phng x tim vo mch mu. Cc khng th ny gn vo cc khng nguyn cng tn do ung th gy ra. Dng my qut tia phng x pht hin Xquang tim phi tm di cn. CTscanner: nh gi mc lan trn ngoi thnh rut MRI Siu m: tm nhn di cn gan, phc mc (lm chm Siu m ni soi: nh gi mc xm ln khi u trn
i vi ung th i trng.
ht k). thnh i trng v vng st k khi u. Pht hin cc hch bch huyt to quanh thng tn. Xt nghim c bn: Phn tch nc tiu, s lng bch cu, Hb, Hct, protein,Ca, bilirubin, Photphatase kim, creatinin. Soi hu mn trc trng: + Hnh nh u si lot g cao, mu thm, gia c lot v d chy mu khi chm vo. + Di ng hay khng. 60

+ Sinh thit u. + nh gi kch thc lng rut b hp v lng rut trn u. 3. Trng hp c bit: Nhiu khi ung th i trng c pht hin trong cp cu v vim phc mc: m ra l ung th i trng thng, c th xy ra ngay ch khi u, c khi thng trn khi u (ch b cng dn qu mc do u cht hp). 4. Chn on phn bit: a. Vi ung th i trng tri: Gii hn: i trng xung + i trng xch ma + na tri Gii phu bnh: i trng ngang. + Khu tr i trng xch ma (75%). + U th cht hp, vng nhn nn gy hp kht lng i trng. + Hay di cn ng bch huyt, tin lng xu. Lm sng: + To bn, au qun bng kiu vim i trng, s khng thy u tr khi u i trng xch ma thm nhim c vo trc trng th thm trc trng c th thy. Bin chng: tc rut cp do bt. b. Vi lng rut mn tnh, lao hi manh trng, co tht rut. U manh trng thng l nguyn nhn dn n lng rut mn tnh. Chnh v th khi Chn on lng rut mn tnh ngi ln bao gi cng phi kim tra xem c u manh trng hay khng. Trn lm sng, trc khi m, nhiu khi rt kh phn bit gia lao hi manh trng v ung th manh trng, ngay khi m ra nhiu khi cng khng xc nh c. XI. X tr: Phu thut l ch yu. Ho tr liu, vt l (tia x) tr liu trong v sau m c 1. Nguyn tc:
nhiu trin vng. 61

2. Phu thut iu tr ung th i trng ngoi bin chng: 1) Chun b sch i trng. 2) M ct b thng tn v hch bch huyt thuc vng tng ng, ct b u ngay c khi di cn xa. C th ngn nga tc rut v chy mu trong mt thi gian di. 3) Phu thut trit cn: Ct i trng phi: i vi ung th t manh trng n Ct i trng ngang khi u nm gia i trng ngang na phi i trng. hoc ct ton b i trng ngang khi u nm nhiu v tr trn i trng ngang. 4) Phu thut tm thi (khi khng cn kh nng ct b u): Ni hi i trng ngang: i vi u nm on t manh trng n i trng gc gan. 5) Khi di cn: Ct ly c khi u di cn + ct 1 phn hay ton b tng b xm ln cng vi ung th i trng. Vi ung th i trng phi: Ct i trng phi, a 2 u rut ra ngoi, ni th hai . Ni hi i trng ngang nu l u gy tc rut. 6) Ch v k thut: Thm d kh nng ct b u, tm di cn xa v cc bnh Khng nn s nn nhiu vo khi u khi khng cn thit Dng 2 di bng mm (mche) buc tht kn lng i khc phi hp trc trong khi m bng. trnh nguy c lm lan xa t bo ung th. trng pha trc v sau khi u, khng cho cc t bo t khi u rng ra lan xa trong lng rut. XII. Bm ra 2 u i trng trc khi ni bng nc mui sinh No vt hch k. Bin chng: l, providin.
1. Tc rut: 62

1) Tc rut: Trong trng hp ny i trng khng c chun b nn bn. Mt s trng hp cn c nhim khun, p xe quanh u, d i trng d dy, d i trng ti mt Nu tnh trng cho php trng hp tc rut m ct i trng cp cu ni ngay hoc ni th 2 sau mt thi gian khi tnh trng chung n nh v i trng c chun b sch. 2) Thng rut gy phc mc: Ct i trng nhng khng ni ngay a 2 u rut ra ngoi, ni sau 1 thi gian khi tnh trng nhim khun ht. 3) Lng rut (u manh trng). 4) Nhim khun: bnh cnh lm sng ging nh p xe rut tha, rt d nhm. p xe quanh khi u. XIII. Tin lng sau m: ph thuc: 1. Giai on ca u: Theo phn loi Dukes: 1) Dukes A: ung th cha xm ln ti thanh mc, cha c di cn hch. 2) Dukes B: thanh mc b xm ln cha di cn hch. 3) Dukes C: ton b thnh i trng b xm ln, c di cn hch. 4) Dukes D: ung th i trng c di cn xa. Dukes A, B: ? 2. bit ho ca cng tt. 3. C bin chng hay cha. 4. U th lch bi l tin lng xu hn th lng bi. 5. Tr c tin lng xu hn gi. 6. Tin lng sng 5 nm ca ung th i trng l 45%. XIV. Theo di sau m: 100% bnh nhn ung th i trng sau m c nh trit cn phi c theo di: 1. Mc ch: 63 t bo u: bit ho cng cao, tin lng

Pht hin sm cc ti pht, di cn, thng tn ung th mi Phng php: xut hin trn phn i trng cn li. + Khm lm sng. + CEA huyt thanh 2 thng/ln (i vi Dukes B, C) + xt nghim phn tm mu 6 12 thng/ln. + Ni soi i trng bt buc sau 1 nm. Nu khng c g ni soi li sau 2 3 nm. + Khng s dng chp khung i trng c baryt trong theo di. Khi c bin chng: m li hoc s dng tia x trong m. 2. iu tr ho cht v tia x. Ung th d dy giai on sm i cng. iu tr. 1) phu thut l ch nh bt buc v nu m trit tin lng sng > 5nm rt cao. 2) phu thut trit cn: ct rng ri + no vt hch k. Ct ton b d dy theo nguyn tc.
I. II.
Phn trc. 1. Nguyn tc:
2. phu thut: 1) Ct bn phn rng ri. Trn u > 10cm. Ly mc ni ln. No vt hch R3.
2) Ct ton b d dy. 3. Khng dng ha cht phi hp sau m. IV. Tin lng sng > 5nm trn 90%. 64

Ung th d dy I. i cng: 1. Ung th d dy bao gm cc thng tn c tnh nm d dy trong phm vi t tm v n mn v. Ung th d dy l mt bnh l thng gp v chim t l cao nht trong cc loi ung th ng tiu ho cho d trong nhng nm gn y c xu hng gim i. 2. V mt dch t: Ung th d dy hay gp cc nc ngho tp trung ng Gii: nam gp nhiu hn n (2/1). Tui: thng gp ngi nhiu tui ( Vit nam: 45 Tnh cht gia nh: Trong cng mt iu kin sng, nam , ng u l ch yu.
55 tui). ung th d dy mang tnh cht gia nh r rt. Nguy c mc bnh cao trong cc th h ca 1 gia nh c ngi b ung th d dy. Nhm mu: nhm mu O c t l ung th d dy cao Cc yu t thun li: hn. + n thc n nhiu nitrosamin trong thc phm lu (da mui). + thc n giu nitrat: c kho, tht hun khi. + Cc thng tn tin ung th: polyp d dy, vim d dy teo. + H.P. + thnh phn Vitamin C trong thc phm gim. 3. Ung th d dy l mt bnh l c tnh, tin trin nhanh, nu mun th kh nng iu tr t kt qu. Tuy nhin vi cc tin b trong chn on nh ni soi, siu m ni soi, gii phu bnh c th pht hin sm giai on ung th mi ch nim mc, di nim mc hoc thi k u ca 65

giai on tin trin. Do vy kh nng phu thut c kt qu ngy cng cao. 4. iu tr ch yu l phu thut. Nh c dhn on sm, k thut no vt hch trit nn t l sng lu sau phu thut ngy cng tng. Vit nam > 90% sng sau 5 nm nu c chn on v iu tr giai on sm. Cn giai on tin trin, t l ny khng qu 10%. II. Gii phu bnh: 1. V tr: Hang mn v (50 60%) > B cong nh (25 30%) > Tm v (10%) > B cong ln. 2. i th: Th u. Th lot. Th thm nhim cng. Ung th tuyn (Carinome) (90%): dng in hnh v Ung th t chc lin kt (sarcome) :10%.
3. Vi th: dng khng in hnh + U c trn. + U lympho. + U thn kinh. 4. Thm nhim: Theo chiu su: l c s cho vic phn loi ung th sm Theo b rng: l c s cho phu thut ct d dy. Theo h thng hch bch huyt. hay tin trin.
5. Phn loi: 2) Theo thng tn: Giai on u: + I: u li dng polyp. + II: U b mt: 3 loi: hi g ln, phng v lm. + III: Th lot. 66

Giai on tin trin: + Lot. + Si. + Thm nhim cng. 2) Theo tin trin (TNM): T: + T1: U lp nim mc. + T2: Xm ln nim mc, di nim mc v c. + T3: Xm ln thanh mc v ngoi thanh mc. + T4: Ton b thnh d dy v ngoi d dy. N: + No: cha c di cn hch. + N1: Di cn hch cnh u. + N2: Di cn hch dc theo 2 b cong. M: + Mo: Khng c di cn xa. + M1: c di cn xa: c cc du hiu lm sng, cn lm sng. III. Chn on: cc du hiu lm sng 2 giai on l giai on sm v giai on tin trin l khc nhau. Khi bnh nhn n sm cc triu chng khng in hnh cn khi bnh nhn n mun th cc triu chng rt r. 1. Khi bnh nhn n sm: ung th d dy sm l nhng trng hp ch khu tr lp nim mc v lp di nim mc, cha vt qua lp c nin (nn c tn gi l ung th nng). Cc triu chng lm sng c tnh cht gi hng ti vic Ch nh cc thm d cn lm sng (ch yu l ni soi v sinh thit). 1) Hon cnh: cc triu chng c th xut hin trn bnh nhn hon ton kho mnh, thng > 40 tui, cha c tin s g v d dy, t trng hoc trn bnh nhn c yu t nguy c cao: 67

tin s vim lot d dy t trng nht l nhng trng tin s vim nim mc d dy mn tnh, C lot d dy C tin s chy mu ng tiu ho. b ct 2/3 d dy do lot lnh tnh qu 5 nm au tc trn rn: au nh, i khi ch thy m ch, hp lot d dy t trng c theo di v iu tr, t trng c Chn on l lnh tnh.
2) C nng: y tc, mt s trng hp au nng rt. au khng c tnh cht chu k, thng khng lin quan n ba n, i khi au nhiu hn sau n. y bng, kh tiu, m ch: lun xut hin sau khi n. Chn n: Cm gic khng mun n, khng thm n. n Nn, bun nn, hi, chua. Gy st: bnh nhn c cm gic gy hn trc. Theo di Mt mi, thiu mu.
khng tiu cng gy chn n. 3) Ton thn: thy c st cn. 4) Thc th: Khng c g c bit. i khi cc chy mu ca ng tiu ho l du hiu u tin ca bnh. 5) cn lm sng: Xquang d dy c thuc cn quang: + C th thy hnh nh ung th giai on u: * ng thuc trn b mt nim mc d dy. *Hnh nim mc hi t. *Mt on cng. + Cc hnh nh ny thy thng xuyn v c nh trn cc phim chp hng lot. Ni soi d dy ng mm: + L phng php Chn on ung th d dy quyt nh nht. 68

+ Quan st ton b d dy t trng, c bit ch vng t tm v n mn v. + Hnh nh: *Th u li (dng polypoid): thng tn ch hi li ln b mt, vi nt nh, mu sn si, ranh gii tng i r. Nhn trc tip hoc bi xanh methylen. *Th b mt: Thng tn nm b mt d dy, c khi ch l 1 cht nng trn mp nim mc to, ph i, ranh gii khng r (sinh thit nhiu mnh xung quanh v tr ny). *Th lot: Ton thn l nhng lot nng, b khng u, hi li cao, nim mc . + Qua ni soi tin hnh sinh thit mt cch c h thng xc nh thng tn ung th: *Sinh thit nhiu mnh (6 8 mnh). *Sinh thit nhiu vng: vng thng tn, vng ranh gii gia vng thng tn v vng bnh thng. *Sinh thit nhm xc nh chc chn ung th. Trng hp cn nghi ng th phi sinh thit mt mng. *Ngi c vi th phi c kinh nghim. Trong tt c cc trng hp ni soi phi xc nh c ranh gii ca thng tn, mc thm nhim + Nhng trng hp nghi ng: soi + sinh thit li sau 3 6 thng. Siu m ni soi: xc nh r mc thm nhim mt cch chnh xc, nht l nhng trng hp ung th giai on u. Cc phng php khc: phn sau. *Tm li: Chn on ung th d dy giai on sm thc cht l ni soi kt hp vi kinh nghim c thng tn m hc. Cc triu chng cng vi c im ca bnh nhn ch c gi tr gi (?). t l Chn on sm so vi ung th d dy ni chung thay i theo tng ni (15 40%). 69

2. Giai on tin trin: y l nhng trng hp ung th d dy vt qua lp c nim hoc xa hn na. a s ung th d dy Vit nam hin nay c Chn on giai on ny. Khi thng tn pht trin thnh khi u (cc th) th cc biu hin lm sng hon ton c th xc nh mt cch d dng. Tuy nhin tu tng mc tin trin m cc du hiu s th hin nh sau: 1) C nng: au bng thng v: au tc ko di v ngy cng tng. au khng c cn d di lin tc. au khng c tnh cht chu k. au tng ln sau khi n. Nn, bun nn: Do cm gic y bng, n khng tiu. C khi nn ra thc n ngy hm trc (trng hp c hp mn v). Chn n: y bng, kh tiu. bnh nhn hon ton khng thm n, i khi s n, k c nhng mn n mi khi vn a thch. 2) Ton thn: Gy st r trong mt thi gian ngn, ngy cng nhanh. Thiu mu: da xanh, hoa mt chng mt, nim mc Da vng mai mi kiu vng rm. Mt mi + km n lm bnh nhn suy kit. Mt s trng hp c st nh 37,5 - 38C. Trng hp bnh nhn n mun, ton thn suy kit
nht.
nng. thiu mu nng, ph. 2) Thc th: U bng: + v tr: trn rn. + L mt khi u ranh gii r rng hoc nh mt mng cng khng c ranh gii r.
70

+ Di ng hay c nh tu theo mc v v tr u: u v tr mn v, hang v khi cha c thm nhim ra xung quanh s di ng d dng Mng cng: + Do u dng thm nhim cng hoc u thm nhim sang cc tng xung quanh. + Khng di ng. + n au tc hay khng au. du hiu ca cc bin chng do ung th d dy: + hp mn v: bng lm lng thuyn, lc c ch khi i, nn ra thc n ng, u to cng v di ng. + Chy mu tiu ho trn: i ngoi phn en, nn mu d di nu chy mu cp (trng hp lot n thng mch mu d dy) + Thng d dy: bnh nhn thng n vi triu chng ca thng d dy, ung th ch Chn on c trong m cp cu. + Tc rut.(?) + Hch thng n tri. + Nhn di cn gan: gan to, bng c chng: nhng trng hp n qu mun. + U bung trng (u Krukenberg). 4) Cn lm sng: Chp Xquang d dy hng lot c baryt, nu cn thit chp trn phim p. + Th si: *Hnh khuyt, thnh d dy li vo lng m nt, nham nh. *Nu gia c lot hoi t s thy ng thuc in hnh. *Hnh nh ct ct gy cht hp hon ton. + Th lot: 71

* ng thuc ln, b nham nh, b cng mt ht cc np nim mc hi t. * lot ln gia khi u li vo lng c hnh thu knh. *Lot hang v, b cong ln, ng thuc b cong nh + Th thm nhim *Mt on b cong cng thng xuyn mt on d dy. *D dy co rt, teo nh v thun di thnh hnh ng cng (trng hp thm nhim ton b d dy). *Hnh khuyt, hnh cao nguyn, hnh ct ct, hnh bnh ng (thng tn ng mn v). + Nhng hnh nh kh kt lun hn: ng thuc hoc hnh cng thng xuyn b cong nh :cn soi d dy v sinh thit xc nh. + Mt s thng tn khc nh hp mn v (d dy dn to), ung th tm v (chp nm u dc: thnh tm v dy, bng m ca u, ng thuc tm v). + Th t v tr hay gp ca khi u: Hang mn v > b cong nh > b cong ln v phnh v ln. Ni soi: Dng ng mm. + Th u si: *Khi u li vo lng d dy, to nh khng u. * gia v trn b mt :n vo t chc khi u c nhiu t chc hoi t mu trng sm, li lm, nhiu hc hoc nhng lot y trng cng hay nhng m hoi t chy mu. + Th lot: *Thng tn thng nm b cong nh, mt trc, mt sau d dy. * lot y nng, rng, nham nh, c m sn si, b li lm, khng u, g cao. *Nim mc xung quanh mt np, i khi c m cht nng ri rc. 72

*D chy mu. + Th thm nhim: *Thng nm vng hang v, mn v hay lan ton b d dy. *Lng d dy b cht hp, trn b mt l m lot cht nng ri rc, c tng m t chc hoi t vi gi mc trng bm thnh tng mng. + Trng hp kh xc nh: *Lot thng. *Khng c lot, ch thy nim mc c v dy, mt np nhn, mt bng (thm nhim). + Tin hnh sinh thit ng phng php nh ung th giai on sm trn hoc kt hp siu m ni soi. Cc phng php khc: + Siu m: *Siu m cc tng: gan, tu, thn, bung trng pht hin di cn. *C gi tr trong Chn on, iu tr v tin lng. + Ctscanner: *Thng tn thm nhim vo cc tng bng. *xc nh chnh xc v tr, kch thc, mc thm nhim c Ch nh iu tr. + xt nghim t bo hc: *Tm t bo ung th trong dch d dy qua li tm. *Ni soi sinh thit qut bng chi (Brown) trn b mt d dy tm t bo ung th. + xt nghim sinh ho: *Nng CEA tng cao: gp trong ung th ng tiu ho ni chung. *C gi tr theo di tin trin, kt qu iu tr, theo di ti pht. + Sinh thit: 73

*Thy r hnh nh bin i t chc c t bo c tnh xm ln xung cc lp ca thnh d dy km theo s lon sn ca rut. *90% ung th tuyn (carcinome), 10% ung th lin kt (sarcome). IV. Chn on phn bit ung th d dy: 1. Trng hp khng s thy u: 1) Lot d dy t trng: au bng c chu k ko di nhiu nm. Khng chn n. Khng gy st. iu tr thuc d dy c . Xquang: hnh nh lot d dy t trng in hnh. Ni soi + sinh thit. Cp hoc mn tnh. xut hin sau khi n cc thc n chua cay, sau ung cc
2) Vim d dy:
loi thuc gim au khng vim khng steroid hoc cc thuc iu tr vim khp. Ni soi + sinh thit: lot cht nng, np nim mc sng n, rc nht l vng hang mn v, km thm vim t trng. 3) Polyp d dy: n c, c cung, cung ngn u to, nhiu mi, Sinh thit: t gp hn. Cn au ko di, c tng cn au d di. n t, hi nhiu. Xquang: bnh thng, ni soi: bnh thng, siu m tu: sn si. 4) Vim tu mn:
hnh m m, hnh si tu, hnh nang gi tu. 74

5) Bnh l khc: Thot v honh tro ngc. Ni soi.
2. Khi s thy u bng: 1) U lnh d dy: V. yu: C chng. Hch thng n tri. Di cn gan: nhiu nhn, ri rc c 2 thu . Xquang, ni soi khng thy thng tn thc th nim Sinh thit. Ctscanner. Xquang, ni soi, siu m. Chn on kh nng phu thut: mc.
2) U gan, u i trng ngang, u tu. 2) U bung trng: Xquang, ni soi, siu m, Ctscanner. 1. Khng m nhng trng hp c di cn xa v ton thn
Nu tnh trng ton thn tt th vn c th m. 2. Khi m ra khng ct d dy nu: Di cn phc mc. U thm nhim cht vo cung gan. U thm nhim vo nhiu tng: gan, i trng, mc
treo i trng ngang. Nu hp, c th lm ni v trng hoc m thng hng trng cho n. VI. iu tr: phu thut l ch yu, min dch, v ho tr liu l h tr, tia x khng tc dng. 1. Phu thut: L iu tr ch yu. 1) Ch nh: Ung th giai on u.
75

Ung th giai on tin trin trn bnh nhn c kh Ung th giai on tin trin in hnh trn lm sng, nng phu thut. cn lm sng cn c th phu thut c hoc iu tr tm thi hoc trit . Ung th d dy c bin chng cp tnh: phu thut tm Trng hp ung th di cn xa nhng ton thn kh, phu thi hay trit l ph thuc vo thng tn. thut trit hay tm thi. 2) Phng php phu thut trit : Nguyn tc: Ct d dy bn phn hoc ton b khng li t chc ung th. + Ct rng ri khi u: ly ht t chc u, vt qu t chc lnh pha trn thng tn > 5cm, pha di thng tn ly ht mn v. + C th ct thm ln hoc ct rng ri khi u sang cc t chc khc nh ui tu, i trng ngang, ti mt. + Ly ton b t chc hch ca d dy kiu cun chiu. + Ct ton b mc ni ln. 3) Mt s trng hp: ung th d dy cc di (hang mn v): + Ct d dy bn phn: *Pha di ct mn v. *Pha trn ct khi u t nht 8cm. *Ly ht mc ni ln. *No vt hch: ti thiu phi vt hch n ht chng 2 (R2) tc l hch cung gan, vnh v, tm phnh v, cung lch. R3 i vi ung th giai on sm. + Ct ton b d dy: Khi thng tn cao, cn cch tm v < 8cm. Gi l ct ton b theo yu cu (Ct ton b theo nguyn tc: u to nh th no cng ct ton b). ung th d dy cc trn (tm v): 76

+ Phng php Sweet: *Ct thc qun + cc trn d dy. *Ni thc qun + d dy cn li sau khi to hnh mn v. + Ct d dy hon ton. 2. iu tr ho cht: VII. H tr. a tr liu: 5FU + Adriamycin + Mytomycin. Ch nh: Ung th di cn mi giai on. Tin lng: ph thuc:
1. Mc pht trin ti ch (tng quan vi cc tng ln cn). 2. Hch di cn c hay khng. 3. bit ho: bit ho cng cao, tin lng cng tt. Hp mn v I. i cng: Sgk. 1. S lc v lot d dy t trng v bin chng: 2. Hp mn v l thut ng dng ch tnh trng tr lu thng (lu thng kh khn hoc ngng tr hn) cc cht dch v thc n t d dy xung t trng. 3. Nguyn nhn ca t trng ny c th do: Sgk c. 1) trong d dy t trng: lot d dy t trng. ung th d dy t trng. Lot mn v, tin mn v. Cc loi u lnh tnh. So bng vng hang v. Teo c hang v, hp ph i mn v. Lot do lao, giang mai. Hch trong bnh lympho hch.
*Trong lot d dy t trng, v ung th d dy t trng l hai nguyn nhn hay gp nht. 77

2) Nguyn nhn bn ngoi d dy t trng: U u tu vo vng mn v. Si ti mt, vim ti mt co ko vng hnh t trng, mn Ung th ti mt, ung th ng mt di cn. Vim tu mn gy dnh co ko..
v.
4. Hu qu dn n tnh trng d dy dn cha y dch v thc n ng ng thi gy cc ri lon in gii, ri lon th dch (mt nc, mu c) cng nh ri lon dinh dng. 5. Tnh trng hp thng din bin t t: Lc u hp khng hon ton v trng lc thnh d dy cn tt, d dy co bp mnh thng vt sc cn do cc triu chng lm sng thng rm r (au nhiu, nn nhiu v sm). V sau hp tr nn hon ton, d dy gin to, trng lc c thnh d dy gim cc triu chng lm sng bt rm r hn. Tuy nhin cng c lc hp xy ra t ngt v nhanh. l trng hp hp mn v do b thc n: cc b thc n lav cht hp ng mn v nh t nt chai. 6. Trong bi ny trnh by hp mn v do lot d dy t trng. II. Gii phu bnh: Sgk. C ch gy hp mn v do lot d dy t trng. 1. V tr: Mi lot d dy t trng gn hay xa mn v u c th gy hp mn v nhng ch yu l nhng lot mn v, hnh t trng hay b cong nh. 2. C ch: 1) C hc: lot x chai gy cht hp mn v/hnh t trng. lot b cong nh co ko trc ng mn v gy hp.
2) Ph n do vim nhim xy ra trong qu trnh lot v ng. 78

3) Tht c mn v.(?) III. Lm sng: C th chia hi chng hp mn v thnh 2 giai on. 1. Giai on u (hp va): 1) C nng: au vng thng v:cm gic nng bng trong bng, au tng cn, tng ln sau ba n, au du i nu bnh nhn nn c (thc n, dch). Nn: + Ban u bnh nhn thng ch c cm gic y bng hay bun nn. +Sau tng xut hin nn sm sau ba n hoch khi c cn au. + Cht nn l thc n mi n xong, i khi ln dch ng. + sau khi nn, bnh nhn thy d chu, au. 2) Ton thn: Cha c biu hin g r rt (cha c tnh trng mt nc, in gii). 3) Thc th: Khng c biu hin g r rt. * Cc triu chng trn gim i khi c iu tr nhng s sm xut hin li nu iu tr ni khng trit . 2. Giai on sau (hp nhiu): 1) C nng: au thng v: + au gim i so vi giai on u, khng cn d di nh trc. + au lin tc, lun c cm gic y, m ch, chng bng. Nn: + mun sau n, khng ch xy ra sau ba n v cn au na m xut hin thng xuyn.
79

+ S ln nn c th khng nhiu nhng s lng dch v thc n mi ln nn th rt nhiu, nn ra c thc n ca ngy hm trc. + Nn c cm thy d chu, bt y v chng bng: bnh nhn t mc hng gy nn. + C khi cht nn c mu en d tng nhm nn mu. 2) Ton thn: nhim c mn tnh. Suy sp r do thiu dinh dng, mt nc v in gii. Gy cm, mt hc hc, mt lm su, da kh v nhn
nheo, st cn. 3) Thc th: Bng lm lng thuyn: Trn rn phng, di rn lp xp, 2 xng cnh chu nh cao: cm gic bnh nhn ch cn da bc xng. D dy gin to: Nu bnh nhn thnh bng mng c th nhn thy tng lc trn rn d dy ni nh nh di da.. Du hiu Bouveret: s p bn tay trn thnh bng vng trn rn: cm gic d dy co bp tng t chm vo lng bn tay. G vng bng di: c v khng c hi ca rut non. Lc bng khi i: ngi khm dng 2 tay nn 2 bn mo
chu bnh nhn, gh st tai vo thnh bng bnh nhn ri lc nh thy ting c ch chng t s ng dch v thc n trong lng d dy. C khi d dy co bp c th nghe thy ting ng c. IV. Cn lm sng: Ht dch v (lc sng sm, lc i): 1. Giai on u: + C hin tng a tit, a toan: Lng dch v lc i > 60ml (bnh thng: 20 60 ml), toan > 84 mEq (bnh thng: 41 84 mEq) 80

+ C th ht ra c t thc n cn li ca ba trc. Xquang c thuc cn quang: Nn s dng thuc cn quang tan c trong nc, trng hp bt kh khng phi s dng baryt khi chp th nn ra d dy sau khi chp nhm 2 mc ch:Gip bnh nhn au. phng nu thng th baryt khng vo bng (rt c). + Chp hng lot: c hin tng ng dch d dy to nn hnh nh: *D dy co bp nhiu v mnh, sng nhu ng tng ln tng t v r nht vng hang mn v, trn phim thy c pha trc b cong nh v b cong ln, c nhiu ch li lm biu hin s co bp mnh ca d dy. *Hnh hp t trng hay mn v. *Hang v dn dn ra. *Thuc vn qua c mn v nhng tc chm hn bnh thng (dch ng trong d dy nhiu hn bnh thng). Trn phim c th thy hnh t trng ngm thuc hoc ngm khng u, khng bit chc l hnh t trng c lot hay khng. + Chp 6h sau khi ung thuc cn quang: *T th ng, chp bng khng chun b. *Hnh nh: D dy gin hnh y chu. thuc cn quang cn li nhiu hoc cn nguyn trong d dy. Ni soi: + Thy dch ng trong d dy. + Nn ra d dy trc khi soi. + ng soi khng qua c mn v xung t trng. + C th thy nguyn nhn gy hp: lot, ung th. + Nu n soi xung c t trng c th thy cc thng tn t trng. xt nghim: cc xt nghim huyt hc v sinh ho cha c biu hin g r rt 81

2. Giai on sau: Ht dch d dy: + Thy dch nhiu, mu nu en ln vi thc n khng tiu. Chp Xquang d dy c thuc cn quang t th ng (chp hng lot) hay soi trc tip trn mn hunh quang: + Hnh nhtuyt ri: thuc qua phn nc ng lan to ra v t t chm xung y d dy :. + Hnh 3 mc: lp di l thuc cn quang, lp gia l nc ng, lp trn cng l hi. + D dy gin to: hnh y chu, y d dy b sa xung di mo chu. + Sng nhu ng: D dy khng cn nhu ng hoc nhu ng rt yu. + Thuc khng qua c mn v m tp trung ch yu y d dy hoc qua rt t to thnh hnh mt di nh nn ch thy hnh nh ca hp mn v m khng thy thng tn gy hp do t trng khng ngm thuc. Trn phim chp c thuc cn quang sau 6h hoc lu hn na vn thy hnh nh nhiu thuc cn quang ng trong d dy. Ni soi: + Ra d dy trc khi soi nu khng thc n ng s che lp n soi v lm tc ng ht. + C th thy c thng tn d dy gy hp (lot, ung th). + Khng th cho ng soi qua mn v xung t trng c. Xt nghim: biu hin r tnh trng mt nc v in gii: + Hng cu, hct c th tng do mt nc. + Na, K, Cl gim. + Ure thng tng. 82

+ Protid mu gim. V. VI. Ri lon v th dch: Sgk. Chn on:
1. Mc ch: 2. Chn on xc nh: 1) Giai on u: thng ch chn on c da trn Xquang v ni soi. 2) Giai on sau: Da vo cc triu chng lm sng v cn lm sng ch yu l: au bng thng v. Nn ra thc n ngy hm trc. Bng lm lng thuyn. Lc c ch khi i. Xquang: d dy gin to hnh y chu, hnh nh. tuyt
ri, sau 6h vn cn ng nhiu thuc cn quang trong d dy. 3. Chn on nguyn nhn: Da trn ni soi v Xquang c th phn bit c cc nguyn nhn gy hp mn v. 4. Chn on phn bit: 1) Bnh gin to thc qun(?). Nut nghn. Nn ra thc n ng trong thc qun Xquang: thc qun gin, pha di cht hp. Khng thy hnh nh ti hi d dy. Hp t trng trn bng Valter:
2) Hp t trng: + Cc triu chng ging nh hp mn v. + Chn on phn bit nh Xquang v ni soi. Hp t trng di bng Valter: + Nn nhiu, c lc nn ra nc mt. + Ton thn suy sp nhanh chng. 83

+ Xquang khng chun b: c mc nc hi vng di gan + Xquang c thuc cn quang: t trng trn ch hp gin rng. 3) Hp gia d dy: Chn on ch yu da vo Xquang vi hnh nh d dy 2 ti, gia b tht hp. 4) Lit d dy do nguyn nhn thn kinh: d dy khng co bp, ra. Cc triu chng xut hin khng thng xuyn v bnh c th hi phc hon ton. VII. X tr: Khi Chn on xc nh l hp mn v th iu Phi coi l mt cp cu c tr hon, phi c thi gian 1. Nguyn tc: tr phu thut tuyt i. chun b 3 5 ngy, hi sc, iu chnh cc ri lon in gii do hp gy nn. phu thut c khi ch gii quyt c tnh trng, c th gii quyt thm c nguyn nhn gy hp tu vo tin trin bnh, tnh trng bnh nhn, phu thut vin 2. Hi sc: 1) Ra d dy: Mc ch: ly ht dch ln thc n ng bnh Ra cn: lm gim vim nim mc d dy do ng. nhn au, nn, kh chu. Gim mc nng, nguy him cho bnh nhn khi t xut b thng. Phng php: + S dng ng Faucher. + Ra d dy bng nc m, sau l cn. 2) Bi ph nc in gii, cc cht dinh dng ng tnh mch: B nc: dung dch mn, ngt, ng trng Nacl 0,9%, Glucose 5%. 84

Bi ph dinh dng: + Dung dch ngt u trng. + Dung dch m, m mang li nng lng v cht dinh dng. + Truyn mu trong trng hp c thiu mu (v d do ung th d dy). Bi ph cc cht in gii theo in gii . Khng sinh ng ung: Amoxicilin 0,5g x 4vin/ngy. Ni v trng:
3) Phu thut: + ch nh: *Th trng bnh nhn qu ti: gi, yu, c bnh phi hp khng sc chu ng 1 cuc phu thut ln. *Ung th gy hp khng c kh nng ct do thm nhim, di cn. *Lot su, nu ct d dy c nhiu nguy him. *iu kin thiu v trang thit b, gy m hi sc, phu thut vin. + u: D thc hin, nh nhng cho bnh nhn. + Nhc: *L phng php ch gii quyt tnh trng ng d dy, cha iu tr trit cn do cha ly c nguyn nhn gy hp (lot, u) *i hi ni v trng ng k thut *Nguy c lot ming ni. Ct d dy: + L mt phu thut va gii quyt c nguyn nhn gy hp, va gii quyt c tnh trng hp. + L mt phu thut ln i hi trnh phu thut vin, gy m hi sc. + Phng php: *Ct 2/3 d dy:lot d dy t trng mn tnh. *Ct 3/4 d dy:Ung th d dy tu mc . 85

*Ct ton b d dy: ung th d dy. *Ct thn kinh X km phu thut dn lu rut (to hnh mn v, ni v trng )i vi lot hnh t trng: c u im l .hn ch 1 s bin chng do ct d dy. I. Chy mu do lot d dy t trng. i cng:
1. Lot d dy t trng l mt bnh ngoi khoa mn tnh, din bin nhiu nm v c th gy ra nhiu bin chng, trong chy mu l mt bin chng hay gp (20 25 %) v l nguyn nhn hng u gy (85%) trong cc nguyn nhn chy mu ng tiu ho trn. y l 1 cp cu c v ngoi khoa ln ni khoa. 2. bin chng chy mu thng xut hin trn bnh nhn c tin s lot d dy t trng nhiu nm nay, nay gp cc yu t tc ng nh: stress, thay i thi tit, sau dng chng vim phi steroid dn n chy mu. 3. lm sng ch yu ca chy mu do lot d dy t trng l nn mu + a phn en hoc ch a phn en n thun. Nu ch da vo lm sng c th chn on c 50% trng hp. Tuy nhin, gn y vi s tin b ca ni soi cp cu c th chn on chnh xc thng tn v rt tt cho vic x tr. Hin nay ni soi gn nh hon ton thay th cho Xquang cp cu. 4. Vi s xut hin ngy cng nhiu ca cc thuc iu tr ni khoa c theo di tt cho vic cm mu v iu tr trit nguyn nhn lot, ngy nay iu tr chy mu do lot d dy t trng ch yu l iu tr khng m (80%), 20% cn li l phu thut. Vi nhng tin b trong gy m hi sc, k thut nn trong khong 10 nm tr li y t l tai bin, bin chng, t vong gim ng k. Do vy ngoi khoa vn chim 1 v tr quan trng trong lot d dy t trng. II. III. Gii phu bnh: Sgk. Lm sng: 86

1) Tin s: tin s Lot d dy t trng nhiu nm (15 20 nm) tin s chy mu do lot d dy t trng iu tr i khi khng c tin s (trng hp lot cp tnh c chn on., ni n nh. hoc lot din bin m thm). Sau 1 s nguyn nhn tc ng , sau cc t au ko di nhiu ngy n 1 tun, c hay khng c s dng thuc d dy hoc khng c cc du hiu bo trc xut hin cc triu chng ca chy mu ng tiu ho trn: 2) C nng: Nn mu: + Chng bng, bun nn, nn mu. + Tnh cht mu: Mu sm ln mu cc, thc n, dch tiu ho. Hoc mu en ln nc mu (trng hp lot hnh t trng). Hoc mu ti d di: trng hp chy mu cao, do lot n vo mch mu). au bng: + xut hin trc, trong khi nn mu. + au trn rn m hoc nng rt. + Him khi au d di. a phn en: + xut hin ngay t u hay sau nn mu. + Phn nt, khng thnh khun, en, thi khm. + Phn en ln mu sm:trng hp chy mu thp hoc chy mu d di nhiu ln. *Nhng trng hp ny c th thy c ti ch hoc qua hi bnh. 3) ton thn: Tu vo s lng mu mt m c nhng biu hin sau: Chy mu nh: 87

+ Lng mu mt < 500 ml. + Ton thn t c thay i r rt: mch < 100, huyt p> 100. Chy mu va: + Lng mu mt 500 1000 ml. + da xanh, v m hi + Mch > 100 120. + huyt p: 80 100mmHg. Chy mu nng: + Lng mu mt: >1000ml. + biu hin shock mt mu: Da xanh ti, nim mc nht, v m hi, u chi lnh. Mch nhanh nh kh bt > 120 l/ph, huyt p < 80 mmHg. *ch theo di din bin ca chy mu c th lc u t nh chuyn sang nng. 4) Thc th: Cc du hiu m tnh: C chng (-), vng da (-), tun Thm trc trng: hon bng h (-), gan to (-), lch to (-). + Phn en, nt, thi khm. + Phn en ln mu. IV. Cn lm sng: 1) xt nghim mu: gip nh gi mc mt mu, theo di v iu tr. Nh gi mc mt mu: + Chy mu nh: Hng cu > 3 triu/mm3, Hb > 10g/l, Hct > 35% + Chy mu va: Hng cu 2,5 - 3 triu/mm3, Hb: 8 10g/l, Hct 30 - 35%. + Chy mu nng: Hng cu < 2,5 triu/mm3, Hb < 8g/l, Hct < 30%
88

Khi cn lm cc xt nghim: tiu cu, cc yu t ng mu. 2) Ni soi: l phng php c hiu qu cao trong vic chn on, xc nh v tr, nguyn nhn, mc chy mu v c th kt hp iu tr ni soi tim x cm mu. Tin hnh soi thc qun d dy t trng cp cu Ch nh: Soi khi huyt ng n nh: huyt p > C th tin hnh ni soi ngay ti phng m hay ti giK thut: ng soi mm d dy t trng c knh nhn trong vng 24h u. 80mmhg, mch < 120. ng bnh nu bnh nhn nng. thng, kim tim x, pince t in, gy t hu hng, hoc thuc an thn, gim au chng co tht. Nu bnh nhn qu nng th gy m ni kh qun. Xc h thng tn sau khi ht sch nc mu, mu cc, kim tra t thc qun, d dy, t trng xc nh cc dng lot, tnh trng chy mu v cc thng tn chy mu khc. Trn ni soi c th thy cc mc chy mu, theo Forrest v hip hi tiu ho: + FI: Mu chy d di hoc ang phun thnh tia y lot. + F2: lot cm mu: u mch mu nh ln gia nn lot, trong lng c mt on cc mu ng en bm, y lot c nhng chm en ca mu cc bm. + FIII: lot ngng chy mu:Trong d dy khng cn mu cc, lot nhn thy r, y trng, xung quanh vin . c th kt hp pht hin cc thng tn phi hp hoc phn bit nguyn nhn chy mu. 89

Tuy nhin trong trng hp c nhiu mu cc, ni soi c th b st thng tn. T l xc nh c thng tn khong 85 95%. 3) Xquang c thuc baryt: hin nay t khi chp trong giai on cp cu. Nh gi da trn:
+ phim chp d dy t trng c c xc nh r thng tn l lot + Chp d dy t trng cp cu tr hon: chp sau khi bnh nhn n nh Hnh nh. ng thuc mo m, bin dng C khi c ni soi, nu c th cng chp thm phim d
dy, t trng. 4) Siu m: gip chn on phn bit. V. Chn on: 1. Mc ch: 2. Chn on xc nh: Sgk 3. Chn on tnh trng chy mu: da trn nh gi ton thn v xt nghim mu hoc ni soi: chy mu nh, chy mu va, chy mu nng. 4. Chn on tnh trng vt lot. 5. Chn on phn bit: 1) Chy mu do vim d dy: c 3 loi: + Vim cht: l nhng vt lot cht nng, kch thc to nh khc nhau, ng knh thong thng di 5mm. + Vim do cc loi thc khng vim khng steoroid nh aspirin, voltaren.. + Vim d dy chy mu, trong c mt loi thng tn c bit l vim ton b d dy chy mu (Dieulafoi). Khi thm khm c th c 2 hon cnh:
90

+ Chy mu sau khi ung thuc: thng tn c th l vim nhng cng c th l chy mu t lot d dy t trng. + Chy mu sau chn thng tinh thn, sau ung ru, sau loi phu thut, sau khi bng. Chn on ch yu da vo ni soi thc qun d dy t trng. Thng tn l cc vt lot cht nng, to nh khng u ri rc ton b nim mc d dy hay khu tr hang v, t trng. C khi thy ton b nim mc d dy vim, cc np nim mc th, c nhiu m xut huyt ri rc. Tuy nhin nhng trng hp ni soi sau 48 72h khng xc nh c thng tn v lc cc vt lot lin so. 2) V cc bi tnh mch thc qun v d dy: Tnh trng chy mu d di: Nn mu ti, a phn Ton thn: Shock do mt mu nng. Thc th: C chng, gan to, tun hon bng h, lch Ni soi: en ln mu nhiu ln.
to + Mu chy thnh tia hay o t, c trng hp khng xc nh c u l thng tn. + tnh mch thc qun v chy mu thng on 2/3 di thc qun, trng hp v thn v kh xc nh v bi no v c nhiu mu cc ng trong d dy.. + Ngoi ra cn phi soi t d dy n t trng tm nhng thng tn phi hp nh: lot, vt xc (Mallory Weiss). 3) Chy mu do ung th d dy: Chy mu t, dai dng, a phn en dai dng l ch Ton thn: gy st, thiu mu. yu.
91

U to vng trn rn, cng chc, sn si, di ng t, khng Ni soi: au. + u si vo lng d dy, gia c lot lot ln ang chy mu hoc c mu cc. + lot x chai b nham nh, y g gh, ln, nim mc xung quanh x cng. + Sinh thit chn on phn bit. 4) Chy mu ng mt: tin s si mt nhim khun ng mt, p xe ng triu chng ch o l tam chng Charcot km chy mt nay xut hin chy mu. mu: + au nhiu vng h sn phi, au ko di, i lc au d di trc chy mu. + St, rt run, st giao ng. + Vng da thnh tng t. a phn en l ch yu, ko di lp i lp li nhiu Nn mu nu en, i khi nn mu c cc hnh thi ln, phn den nhnh bt ch. Trc khi nn mu bnh nhn c au d di vng gan. Ni soi: khng c gin v tnh mch thc qun. Khng c Siu m: hnh nh si ng mt, si ng mt ch, lot d dy t trng chy mu. ng mt gin. 5) Chy mu do vim thc qun: l nhng trng hp vim xc vng 1/3 di thc qun v Thng c tnh cht cp tnh. Chy mu d di, nn ra mu ti (nhng khng ko tm v. Hay gp nhng ngi tr sau khi ung nhiu ru.
di) 92

Ni soi: nim mc thc qun rc c nhiu ng nt chy mu. 6) Chy mu do hi chng Mallory Weiss: Thng tn chy mu do vt rch nim mc tm Thng l do nn nhiu hoc gp nhng bnh nhn phnh v. c hi chng tro ngc, nim mc trt d dy thc qun, tm v co tht lm nim mc nght v rch. Thng tn l nhng vt xc di 1 3cm, chy dc, c Lc u chy mu c th d di sau cm mu. Ni soi thy r nhng vt rch ngng chy mu, c th nng hoc su.
vt mu ng sm mu hoc ang cn rm mu. 7) Chy mu do thot v honh. 8) Chy mu do u lnh d dy: u thn kinh (Schwannome), u c trn (leiomyome) l nhng khi u thng nm tm phnh v, kch thc to, li vo trong lng d dy, c lot hoi t gia v chy mu. Ni soi sinh thit chn on. 9) Chy mu do ung th t trng, u bng Valter. 10) Cc bnh ni khoa: nhim khun huyt: nhim khun huyt dn n ri
lon ng mu, ri lon vn mch, nn bnh nhn nn mu, i ngoi phn en, ng thi c th km chy mu nhiu c quan khc. VI. VII. Cao huyt p. Cc bnh v mu: hemophilie, hemogenie. Din bin: sgk. X tr:
1. Nguyn tc chung: 1) Da vo lm sng v cn lm sng xc nh chy mu ng tiu ho trn v mc chy mu: 93

Nu chy mu nng: hi sc tch cc, ni soi cp cu Nu chy mu va: hi sc + theo di, ni soi cp cu Nu chy mu nh: theo di, ni soi cp cu, tim x trong vng 24h, c th kt hp tim x cm mu. trong vng 24h, c th tim x cm mu. cm mu. 2) Sau da trn kt qu ni soi, cho bnh nhn lm thm cc xt nghim khc nu cn quyt nh hng iu tr ni hay ngoi khoa tip tc cho bnh nhn. 2. C th: 1) hi sc: Chy mu nh: khng cn hi sc, chy mu va: c th cn hi sc, truyn mu, cc ch phm thay th, chy mu nng: cn hi sc tch cc, truyn mu t 1 1,5l. Truyn dch: + ng trung ng: tnh mch di n. ng ngoi vi: tnh mch chi trn. + Mc ch: Bi ph nc, in gii, d phng shock (da trn CVP, huyt p, nc tiu qua sonde bng quang). + Dch truyn: Nacl 0,9%, Glucose 5%, mu t sonde d dy: + Bm ra nc lnh, ht dch d dy. + Mc ch: gim p lc trong lng d dy. L mt bin php cm mu. Lu sonde theo di tnh trng chy mu. t sonde bng quang: Lp bng theo di mch, nhit , huyt p, ton + Theo di lng nc tiu: nh gi lng dch truyn. thn tt nht trn monitor. 2) Ni soi cm mu: Bng ni soi ngoi xc nh thng tn chy mu cn cm mu cho cc trng hp sau: + lot cn ang chy mu (F1) 94

+ lot cm mu nhng cc mu bm c kh nng bong ra v tip tc chy mu. + Bnh nhn gi yu, c bnh l khc km theo, bnh nhn c thai k thut: + tim x bng Polydocanol 1 3%, Adrenalin 1/10.000, cn tuyt i xung quanh lot hay cnh mch mu. + t in, laser.. 2. 3) iu tr ni khoa: ch nh: + Chy mu ln u, mt mu mc va, nh. + Chy mu cha c bin chng c xc nh qua ni soi: lot mm, non. + bnh nhn cn tr hoc bnh nhn gi yu khng sc chu 1 cuc phu thut. + bnh nhn c bnh l c bit, c thai. phng php: + Trun mu v cc ch phm thay th: mt bao nhiu truyn by nhiu. + Ra d dy nc lnh. + iu tr thuc chng lot d dy: Cimetidin 800 1200mg/ngy, Losec 40mg/ngy. Tim tnh mch chm. + iu tr thuc chng ln mem thi: khng sinh ng rut, tht tho. Phi theo di lin tc mch, nhit , huyt p 80% thch ng vi iu tr ni khoa. kp thi x tr nu iu tr ni khoa khng kt qu. 4) phu thut: a. ch nh: 95 Trng hp chy mu nhiu, nu ti pht c th lm ln

+ iu tr ni khoa khng kt qu. + bnh nhn > 60 tui, iu tr ni khoa nhiu ln nhng hay ti pht. + lot x chai chy mu nhiu + Chy mu nhiu, d di, khng cm, kh nng cn chy mu na. + chy mu trn lot c bin chng: b. Phng php: + Khu lot n thun: trng hp bnh nhn gi yu, khng c kh nng lm g thm. Sau phi theo di st v iu tr ni khoa tch cc, kp thi x tr. + Ct 2/3 d dy: (?) + i vi lot hnh t trng: nguy c bc ming ni: Ct 2 dy X, khot lot, to hnh mn v hoc ct 2 dy X, ct hang v v to hnh mn v. (phi ct ht 2 dy X). Thng lot d dy t trng. i cng:
I.
1. Thng lot d dy t trng l mt bin chng cp tnh ca lot d dy t trng mn tnh (cng c khi nguyn nhn gy thng l do ung th d dy, lot ming ni 2. Hu qu ph bin ca l thng ny l tnh trng vim phc mc cp tnh (ton th hoc khu tr) i hi phi c chn on v x tr sm. i khi ngay sau khi thng, l thng c mc ni ln, ti mt n bt li v c gi l thng d dy bt. 3. Vic chn on thng d dy thng khng kh khn tr thng bt hoc d nhm vi 1 s trng hp khc, Khi thng d dy nu c chn on sm v m sm th t l t vong thp (<1%). Tuy nhin nu mun, tnh trng vim phc mc nng th tin lng xu, t l t vong kh cao (10 15%). 96

4. Trong iu tr thng d dy t trng lun tun theo nguyn tc hi sc v gii quyt tnh trng vim phc mc l chnh, nu c iu kin mi t vn iu tr trit cn (nguyn nhn). 5. V mt dch t II. Gii: Nam > n (5/1) Tui: 20 50. Ma : ng, xun, rt. Sau khi n no, stress, sau dng 1 s thuc (corticoid, 90% xy ra trn ngi c tin s lot d dy hnh t Gii phu bnh: Sgk Thng l mt l xut hin trn 1 lot x chai, i khi Tnh trng bng: trn mt lot non hoc mt lot ung th. + bnh nhn n sm (6 12 h u): c coi l sch, bng ch c dch tiu ho v thc n. Nu c hp mn v th c dch bn v en. + bnh nhn n mun: Dch c c khi l dch m. Nhiu gi mc quanh l thng v khp bng. Quai rut gin mt bng. bng c hi. III. Lm sng: thng rt r rng. 1. Th in hnh. Trn 1 bnh nhn c cc yu t dch t hc thun li thy c cc triu chng sau: Tin s: Sgk C nng: au bng:
aspirin) trng.
+ xut hin t ngt, d di vng trn rn khin bnh nhn phi gp ngi, khng dm c ng.
97

+ au lin tc khng dt cn, lan nhanh ra khp bng, xuyn ra sau lng v lan ln vai. + t khi km theo nn. Nn: l triu chng t gp v thng xut hin mun. B trung i tin: xut hin mun khi c vim phc ton thn: Sm: nhn chung t c thay i trong nhng gi u.
mc.
tuy vy c th c cc biu hin sau: + au nhiu dn n shock: ht hong, mt ti, chi lnh, mch nhanh thng ch thong qua. Mun: c bnh cnh nhim khun nhim c ca vim phc mc: + St cao, b ph, hc hc, da xanh ti. + Mi kh, li bn.. bnh nhn hp mn v: tnh trng ton thn thng nng do cht ng trn vo bng v vo mu gy nhim c. Nhng bnh nhn thng d dy sau chp baryt vo Thc th: L nhng triu chng rt quan trng nht l Nhn: bng: nhim c nng, suy thn nng. trong nhng gi u. + Bng khng di ng theo nhp th. + Hai c thng to ni r. S: + Bng co cng r v lin tc: c cm gic bng cng nh g. co cng nht l vng trn rn, sau lan khp bng. + n au khp bng v tri ln vng trn rn. + C cm ng phc mc. *du hiu co cng v cm ng phc mc l nhng du hiu quan trng nht. Tuy nhin nu bnh nhn n 98

mun, du hiu co cng s mt i v thay vo l bng vim phc mc: Chng, phn ng thnh bng v cm ng phc mc ton b. G: bnh nhn t th na nm, na ngi. + Vng c trc gan mt: c gi tr trong nhng gi u, nu bnh nhn n mun, bng chng: kh thy chnh xc. + c vng thp: trng hp mun, bng c dch. IV. Thm trc trng: ti cng Douglas phng, n au: r khi Cn lm sng: Chiu: c lim hi, c honh di ng km. t lm. Xquang bng khng chun b: t th ng thng hoc bnh nhn n mun. 1. Xquang:
nm nghing. + Thy lim hi di c honh 1 hoc c hai bn : gp trong khong 80% cc trng hp. + Khi c lim hi bnh nhn trong thi gian gn y khng c th thut no trong bng th c th chn on xc nh l thng tng rng. + Khi khng c lim hi khng c php loi tr thng d dy. + Trng hp bnh nhn n mun, c vim phc mc c cc triu chng sau: Cc quai rut gin, bng m do c dch trong bng. Thnh cc quai rut dy: do dch lng ng cc quai rut. 2. Siu m: Sgk. 3. Xt nghim: Khng c gi tr g c bit trong nhng gi u. Sau: bch cu tng >9000, bch cu a nhn > 75%, amylase mu v nc tiu bnh thng. 99
tc mu lng tng..

(cc xt nghim trn ch cho php nh gi tnh trng ton thn ca bnh nhn ch khng cho php chn on xc nh). V. chn on: 1. Mc ch: 2. Chn on xc nh:da trn lm sng l chnh: au bng t ngt d di vng trn rn. Bng cng nh g + cm ng phc mc. tin s lot d dy t trng. Xquang: c lim hi di c honh.
3. Chn on phn bit: 1) Vim phc mc rut tha : do giai on u ca vim rut tha c th au thng v. Khng c tin s lot d dy t trng. t khi au t ngt d di lc khi u m thng m du hiu nhim khun c ngay t u. Xquang: khng c lim hi. Mc co cng nhiu nht h chu phi.
, tng dn v au khp bng.
2) Vim phc mc mt: thng nhm vi thng ti mt do vim: au v co cng r nht vng h sn phi. St + rt run. Vng da vng mt. Bilirubin mu cao. Nc tiu: Mui mt, sc t mt (+). Siu m: Thnh ti mt dy, c si, dch quanh ti mt
3) Vim tu cp: Bnh cnh lm sng ca vim tu cp (nht l vim tu cp th ph) rt ging vi thng d dy (bnh nhn cng c au bng d di trn rn) nhng c mt s im khc bit:
100

t c tin s lot d dy t trng. xut hin sau ba n Bng co cng trn rn nhng thng khng lin tc. Bng im sn lng (nht l bn tri) n rt au. Xquang khng c lim hi. xt nghim: amylase mu v amylase niu tng rt cao siu m: thy hnh nh tu vim ph, mt bng c th tin hnh bm ra bng, ly dch ht em thnh son. vn c th di ng theo nhp th.
(gp 2 3 ln), ng huyt tng, canxi huyt gim.
i th, tm amylase trong nc dch ny. 4) Thng mt tng khc: thng rut non do thng hn, thng ti tha Meckel, thng do ung th d dy. Thng do ung th d dy cng c y triu chng v mc cc triu chng cng ging nh trong thng do lot nhng thng xy ra ngi ng tui khng c tin s d dy. 5) Cc bnh l khc: a. Tc rut: d nhm, khi thng d dy n mun c hin tng vim phc mc gy lit rut, vi mt xon rut, mt huyt khi mch mu mc treo rut, thot v bn trong, mt cn au do lot d dy t trng. b. p xe gan v: thng l p xe gan amip: bnh nhn au bng t ngt, d di. Thng ang c iu tr 1 bnh gan mt hoc c
tin s bnh gan mt (au vng gan, st, vng da ), ton thn c du hiu nhim khun. Lm sng: au i km vi 1 thng tn chong r: ht Trn Xquang: Khng c lim hi m c bng gan to, Siu m: gan to, nhu m gan c khi gim m, v bc hong, nht, mch tng, huyt p h trn dch mng phi phi. r gan phi. 101

xt nghim nu cn: chc d bng thy c dch nu, c th chy mu. c. Vim ti mt cp: du hiu nhim khun c ngay t u. Xquang khng c lim hi, bng ti mt to. Siu m: Thy r hnh nh. vim ti mt. Co cng na bng phi (trng hp thng d dy khi dch
d. Si niu qun phi: d dy qua l thng chy ra theo rnh thnh i trng lan xung ng bn h chu phi). tnh cht au: i mu. Xquang: hnh nh. si. Kh chn on phn bit trc m. Hi chng vim phc mc + hi chng tc rut + a
e. Vim phc mc do thng ti tha Meckel:
phn en. 6) Bnh ni khoa khc: VI. VII. Nhi mu c tim. Vim phi thu y cp. Cn au d dy cp. Din bin: Sgk. Cc th lm sng: bnh nhn thng au bng t ngt d di sau Khm vng trn rn n tc, c phn ng nh. Xquang : nu c lim hi th chn on xc nh. Trong trng hp bnh nhn c tin s lot d dy t
1. Thng d dy bt: dn dn au, ht chong v d chu hn.
Khng c lim hi: phi theo di st. trng : gip ngi thy thuc phi cnh gic trong trng hp ny. 102

Khi chn on l thng bt th phi x tr nh cc trng hp thng in hnh. 2. Thng lot mt sau d dy: 2 triu chng gi l: + au nhiu ra sau lng. + Vng trn rn chng nhiu. Khi m ra nu khng thy l thng mt trc bao gi cng phi kim tra k mt sau d dy trnh b st thng tn ny. 3. Mt s th khc: Sgk Th phi hp: tin lng nng: Thng d dy + chy mu tiu ho: Trn lm sng thy
bnh cnh thng d dy v km theo c nn ra mu hoc a phn en. Thng d dy + hp mn v: + Trc khi thng bnh nhn c biu hin hp mn v. + Bnh cnh nhim c nng. VIII. X tr : Khi chn on xc nh l thng d dy th phi Trong khi ch m phi tin hnh hi sc, ht d dy. Khi m phi nh gi c: tnh trng ton thn ca 1. Nguyn tc x tr: m cng sm cng tt.
bnh nhn, tnh trng l thng v bng, kh nng ca kp m, gy m hi sc chn 1 bin php x tr hp l trn quan im cu sng bnh nhn l chnh, nu c iu kin mi t vn x tr trit cn. Sau m phi lu iu tr tip ni khoa cho bnh nhn. 2. Hi sc trc m: Ht d dy lin tc (phng php Taylor):
103

+ Phng php ny trc kia c th ch nh l phng php iu tr bo tn i vi trng hp thng trn d dy rng, sch (xa ba n) hoc khi tnh trng bnh nhn nng khng m c. Ngy nay ch coi l mt bin php chun b trc m. + Sonde d dy t ng vo v tr hang v, ht lin tc bng tay, my ht p lc nh va . Khng sinh ton thn. N ui dng qua ng tnh mch. Theo di din bin lm sng: au, co cng bng, st,
bch cu, in gii, 3. C th: Thm d v nh gi thng tn: Tnh trng bng: sch hay bn, bnh nhn n sm
hay mun. + 6 12h u: coi l sch, m v gi mc cha c hoc c t. + >12h: bn. Ly dch bng m tm vi khun v lm khng sinh Tm l thng: . + Theo th t nhng v tr thng gp n t gp: mt trc, t trng, + Nu mt trc khng thy th bao gi cng phi kim tra mt sau nh gi tnh cht lot: + lot non. + lot x chai. + lot lnh tnh hay c tnh (cng, nham nh ) c hch di cn nht l b cong nh. + lot c lm hp mn v hay t trng hay khng. Nh gi tnh trng cc b phn ln cn: 104

+ Gan: c di cn hay khng, c x gan khng. + C dch ng khng (nu st d hnh thnh p xe di c honh sau ny) + Lch tu, ti mt cung gan Cch x tr: Khu l thng n thun:
+ Hay c p dng nht. + ch nh: bnh nhn gi yu, tnh trng khng chu ng c phu thut ko di. bnh nhn tr, lot non nhng n mun. Tuyn di khng kh nng lm cc phu thut kh hn. + K thut: vi lot x chai: khot b x chai (lm gii phu bnh) ri mi khu. t mi ch dc theo trc d dy t trng trnh lm hp. Khu xong bao gi cng phi kim tra c hp mn v hay khng. Nu hp mn v: ni v trng. + u: d thc hin, thi gian m ngn, t l t vong thp. + Nhc: Ch gii quyt c bin chng ch khng iu tr c nguyn nhn, nn hay phi m li. + bin chng: *Bc ch khu (3 5 ngy sau m). *hp mn v. *X tr: m li. + Nn: iu tr ni tip, nu khng 80% s au li sau 2 nm, phi m ct d dy. + Nu l lot b cong nh: lm sinh thit trc khu. Nu kt qu gii phu bnh l ung th: m li sm ct d dy. 105

Ct d dy trong cp cu: + ch nh: *Thng lot do ung th. *Thng d dy trn bnh nhn hp mn v. *Thng d dy trn lot x chai, c nhiu ln chy mu. *Nhng l thng kh khu kn c. Ngoi ra cn phi m bo cc iu kin sau: *bnh nhn tr, tnh trng ton thn tt, khng c bnh phi hp, n vin sm (<12h). * bng sch, khng c m v gi mc. *phu thut vin c kh nng. *Gy m hi sc cho php. *Kp m trong tnh trng tnh to, khng qu mt. + u: va gii quyt c bin chng va gii quyt c nguyn nhn. + Nhc: phu thut nng, ko di, kh thc hin c trong m cp cu Khu l thng + ct dy X ton b + to hnh mn v. + u: Va iu tr bin chng va iu tr nguyn nhn. + iu kin: *bnh nhn n sm, ton thn tt. *Gy m hi sc tt. *phu thut vin tt. Khu l thng + Ct dy X chn lc hoc siu chn lc: + u: nh trn. + Nhc: lu. + iu kin: nh trn. phu thut Taylor:
106

+ Cch lm: Khu l thng. Ct ton b Dy X sau. Ct b lp thanh c dc theo b cong nh mt trc d dy t tm v n ch ni thn v hang v. + phu thut ny c tc dng ging nh phng php c ct dy X siu chn lc nhng lm nhanh hn v c th lm trong cp cu. + yu cu: Ton thn tt, khng km bnh tt khc. n sm trc 12h. Lot thng khng km bin chng khc (chy mu, hp mn v). C phu thut vin, gy m hi sc tt. Th thut Newman: + dn lu l thng. + ch nh: *Ton thn bnh nhn xu, khng chu ng c phu thut ko di *bnh nhn n mun, vim phc mc nng, nhiu m, thnh d dy ph n, kh khu, kh ct. *l thng khng c kh nng khu c: x chai ln, t chc mn nt ph n. + th thut Newman ch gii quyt c tm thi lot nhm cu tnh mng cho bnh nhn v thi gian hon cnh khng lm c g khc, sau tin hnh hi sc, m c chun b sau 7 10 ngy. + K thut: qua l thng t 1 Kerh to vo: mt u d dy, mt u t trng, u di dn lu ra ngoi. Khu mp l thng st chn Kehr. Ly mc ni ln qun quanh chn Kehr. C th thay Kehr bng sode Pettzer.. C th m thng hi trng ngay n ui dng. 4. Hon cnh c bit: Trc m chn on l vim rut tha, m ra l thng d dy: Khi m bng l ng Mac Burney thy thng tn rut tha khng ph hp vi chn on trc m v khng ph hp vi tnh trng thc t trong bng: 107

+ rut tha bnh thng hay ch xung huyt, thanh mc mt bng. + bng c nhiu dch nhy, nc c c b thc n, m thc s. Phi ngh n l thng d dy. X tr: + Ct rut tha vi. + kim tra hi trng, tm ti tha Meckel. + ph n: kim tra phn ph 2 bn. Nu khng c g c bit th ng bng, quay ln m bng ng trng gia trn rn. IX. Thng do chp phim c baryt: vim ng thn cp sau Thng + chy mu. thng mun vim phc mc nng: nhim khun m. Tin lng nng khi: thng + hp mn v. Thng ngi gi c bnh phi hp: Tng huyt p, lao,
nhim c, try tim mch, vim ng thn cp.
108

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Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

I. Lng rut cp tnh tr cn b i cng:

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

v trong v l khi im ca khi lng.

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

ngoi c thng to bn phi.

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

2) Ton thn: 40C, thng gp hn v bui chiu. Mt mi.

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

4) Siu m gan mt: 16

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

tc, hc hc, mi kh, li bn, hi th hi.

nhn trn mt gan (d nhm vi ung th gan, nht l gan tri). 18

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

2) Xquang: chp gan xa:

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

ch do dn lu Kehr. 3) Gii phu bnh: thng thng ng mt trong gan vi: 21

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

4) Chp ng mch gan chn lc:

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

2) Chy mu do tng p lc tnh mch ca:

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

1. Tru tim mch t ngt do:

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

+ T l prothrombin gim. + Thi gian ng mu ko di. + ng mu ri rc (nng). 30

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

+ GPT, GOT tng 34

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi

Nguyn c Thng Y6B7 : cng n thi bc s ni tr ngoi