Siu m ng tiu ho

Hnh nh bnh thng v bnh l

BS. Nguyn Khi Vit
Khoa CHA bnh vin Bch Mai
ng tiu ho = khng kh + nc

Thm khm siu m l k thut kh do
Kh OTHkh quan st, dch lng rut nhm
khi dng nang, phn to nhiu nh gi, gi u
Nhng siu m l k thut quan trng bc u
trong chn on bnh l OTH.
Cc k thut s dng.
- K thut p u d
- S dng u d tn s cao 7.5-10 MHz
- Hnh nh hi ho m harmonic



Ba hi chng c bn

Hi chng bt tc ( ng):
cc quai rut gin, thnh mng

Hi chng u:
dy thnh rut khng i xng, dy trn on di
hnh nh gi thn

Hi chng vim:
dy thnh rut i xng, dy chu vi,
+/- tn thng rng
1. Thm khm tng th: u d 3 4 MHz
Thm khm ton b khung i trng v ton b rut non



K thut thm khm
1. Thm khm tng th:
Xc nh cc on tn thng bnh l



K thut thm khm


1. Thm khm tng th
Xc nh cc on tn thng bnh l

2. Thm khm khu tr:
s dng u d nng


K thut p u d
rt quan trng
K thut thm khm


1. Thm khm tng th

Xc nh cc on tn thng bnh l

2. Thm khm khu tr


u d phn gii cao (> 7 mHz)

tia ti phi thng gc
K thut thm khm
3,5 mHz 7,5 mHz
K thut thm khm
Hnh nh hi ho m harmonique
K thut thm khm
1. Pht hin cc lp thnh rut bnh thng trn gii phu siu m
5 lp



Trong lng
C nim
Di nim mc
Lp c
Thanh mc
Gim m
Gim m
Tng m

Tng m
Tng m
Triu chng hc
C di nim
Di nim mc
Lp c
Thanh mc
Lng ng tiu ho
2. Xc nh on tn thng bng cch nh gi:
Dy thnh rut
- v tr: i trng hay rut non, d dy, t trng
- kch thc
- tn thng theo chiu ngang
- tn thng theo chiu dc

Bt thng phi hp:
- m quanh ng tiu ho
- lot, d
- vim phc mc
- apxe, hch bng
Triu chng hc
v tr i trng hay rut non ?
Triu chng hc
v tr i trng hay rut non ?

Bnh Crohn : hi trng, i trng
Bnh i trc trng chy mu i trng tri, trc trng
Bnh ti tha : i trng xichma
Vim i trng thiu mu : i trng tri

U hch rut non
U trung m rut non, i trng
Ung th tuyn i trng
U dng biu m (carcinoid) rut non, rut tha
Triu chng hc
v tr d dy hay t trng ?
Triu chng hc
v tr d dy hay t trng ?

Bnh Crohn : t trng
lymphome : d dy
u trung m: d dy
bnh l lot: d dy, t trng





Tn thng pht trin theo chiu ngang: bnh l vim v nhim trng
tn thng cc lp ca thnh rut
Tn thng nng lp nim Tn thng tt c cc lp
nc v di nim mc c th n ra c ngoi OTH





Vim i trc trng chy mu
Vim i trng nhim khun Bnh Crohn

Triu chng hc
Tn thng pht trin theo ngang: mt phn bit cc lp
thnh rut
Bnh Crohn mn tnh
U lymphom th thm nhim
Bnh l mch mu
Triu chng hc

Tn thng pht trin theo ngang: cc khi u
V tr nim mc, di nim mc
V tr di nim mc v lp c
Xm ln xuyn thnh
polype
U dng biu m (carcinoid)
Ung th tuyn xm ln
Triu chng hc
Tn thng pht trin theo chiu dc
Khu tr Khi u
theo on tn thng vim, vim t
xichma, thiu mu, mu t
nhiu on tn thng vim
ton b, b rng vim i trc trng chy mu,
vim i trng do vi khun

Triu chng hc
Tn thng pht trin theo chiu dc
khu tr khi u
theo on tn thng vim, vim t
xichma, thiu mu, mu t
nhiu on tn thng vim
ton b, b rng vim i trc trng chy mu,
vim i trng do vi khun

Triu chng hc
Tn thng pht trin theo chiu dc
khu tr khi u
theo on tn thng vim, vim t
xichma, thiu mu, mu t
nhiu on tn thng vim
ton b, b rng vim i trc trng chy mu,
vim i trng do vi khun
Triu chng hc
Tn thng pht trin theo chiu dc
khu tr khi u
theo on tn thng vim, vim t
xichma, thiu mu, mu t
nhiu on tn thng vim
ton b, b rng vim i trc trng chy mu,
vim i trng do vi khun

Triu chng hc
Tn thng phi hp: m quanh ng tiu ho

thm nhim, tng m, ng nht:
vim rut tha, vim i trng xichma


Triu chng hc
Tn thng phi hp: tn thng phc mc

vim phc mc (dch hoc kh t do phc mc)

di cn phc mc
Triu chng hc
Siu m Vim rut tha

-Vim rut tha r ch cn chn on bng
lm sng
-Siu m ph thuc vo ch quan ngi lm,
ngi c kinh nghim, k nng nhy
80-90%, c hiu 90-100%
Cn nh: Khng tm thy RT khng c
ngha l khng c RT
-Vai tr siu m: chn on loi tr (si niu
qun, vim TM..), trng hp VRT kh
Siu m Vim rut tha
-Lm sng: au HCP,
st
-V tr in hnh:
HCP
-V tr khc:
+Sau manh trng
+Tiu khung
+Di gan
Siu m Vim rut tha
K thut thm khm siu m:
-Thm khm c hai th bng quang y
v vi
-Dng u d tn s 3.5 MHz thm
khm ton b bng
-Sau thm khm khu tr h chu
phi hoc v tr nghi ng bng u
d tn s cao di tn t 5-10 MHz.
Siu m Vim rut tha
Mc tm rut tha:
-Tm manh trng: ln, thnh mng,
khng nhu ng, cha kh v phn
tng m khng u.
-Hi trng: nh, thnh dy, nhu ng
nhanh, n xp hon ton
-V tr rut tha in hnh thng sau
hi trng.
Siu m Vim rut tha
Nhn din rut tha:
-Cu trc ng tiu ho (gut signature), mt u tt
-Mc t y manh trng
-K ngang > 6mm, thnh dy>3 mm
-ng khng nhu ng, n khng xp.
-Trn SA doppler: tng sinh mch trn thnh (c bit
r trn doppler nng lng)
-au khi n u d (Mac-Burney siu m +)
c im h tr:
-Si trong RT (stercolithe).
-Thm nhim m xung quanh RT: tng m mc ni
-T dch xung quanh manh trng, c hch phn ng
+/-

Siu m Vim rut tha
RT bnh thng
Vim RT
Bnh nhn n 25 tui, au HCP
C st, phn ng khu tr HCP
Cu trc mt u tt, thnh dy
n khng xp, thm nhim m xung quanh
Vim RT
Siu m Vim rut tha
Nam 19 tui, au h chu phi,
Khng c st, phn ng kn o,
Bch cu tng nh

Dy khu tr ngn rut tha, n khng xp:

Siu m Vim rut tha

Vim rut tha giai on sm
Si RT
(stercolithe)
M tng m
VRT c tng sinh mch trn doppler
Siu m Vim rut tha
VRT c si
Ct dc
Ct ngang
Siu m Vim rut tha
RT tiu khung
Bung trng bnh thng
ng m o
Siu m Vim rut tha
VRT lc ch
Tiu khung Mc treo rut
Si phn
Siu m Vim rut tha
VRT sau manh trng
Siu m Vim rut tha
Siu m thng rut tha:
1.T dch ng kn quanh manh trng.
2. vim ty (m qunh rut tha)
3.p xe
4.Dy m quanh manh trng
5.Mt lp di nim mc vng quanh theo
chu vi
Siu m Vim rut tha
Siu m khi vim RT
(m qunh):
-L vim c khu tr bi
mc treo RT, hi trng, mc
ni v cc quai rut non
xung quanh vy bc.
-Khi HCP gii hn khng
r, thng gim m, cc
quai rut xung quanh hi
t.
-Cu trc RT mn c th
thy
Siu m Vim rut tha
Siu m p xe RT:
-Khi dch m khng u (dch m), c th
c hi ng phn cao.
-Thnh dy khng u v t m
-C th thy phn cn li ca RT trong p
xe
-SA Doppler: tng tn hiu trn thnh
-SA gip nh v p xechc kim ht m
hoc t ng thng dn lu m
BN n, 38 tui, au HCP
C st, phn ng thnh bng r
Tng bch cu

Khi t dch h chu phi c mc ni
xung quanh bao bc


p xe RT
Siu m Vim rut tha
Siu m Vim rut tha
Chn on phn bit:
1.Vim hch mc treo
2.Bnh Crohn
3.Vim thn, b thn
4.Si niu qun phi
5.Vim phn ph.
6.Vim ti tha Meckel
7.Vim on cui hi trng
Vim hch mc treo
Si niu qun phi
Vim ti tha
-t gp, ch yu nc phng ty
-V tr: ch yu HCT (T xichma, T
tri), c th HCP.
-LS: tam chng au HCT+st+BC tng.
-SA:
+Ti tha vim: tng m bn trong
hay bn kia thnh rut, c bng cn.
+vim m m xung quanh T: tng m
+c th p xe, r, vim PM, tc rut
Vim ti tha
Hnh nh siu m
dy khu tr thnh rut c cha tng m km bng cn =ti tha
phn ng tng m ca m xung quanh
au khu tr HCT



N, 56 tui, au HCT
C st, phn ng khu tr
Hnh nh ngoi vi thnh T xichma
Cha nt m m, thm nhim m xung quanh
Vim ti tha T xichma
BN n, 31 tui, au HCT
C st, a chy
Tng bch cu






Hnh nh m m ngoi vi i trng tri, thm nhim m xung quanh:
Vim ti tha T tri (mt ti tha).
BN nam 55 tui, au bng
a chy
BN n 23 tui, au bng
a chy t 3 nm nay






Dy thnh on rut cui rng, mt phn
bit cc lp thnh rut
Bnh Crohn
Dy thnh i trng tri lan rng
Mt phn bit cc lp thnh rut

Vim i trc trng chy mu
Bnh l vim khc
BN nam 50 T, au bng, a chy
mi iu tr khng sinh gn y
Dy lp di c nim, lan rng

Vim i trng gi mc
Bnh l vim khc
Bn nam 79, bnh l ng mch lan
to, au bng mng sn tri.

Dy thnh i trng lan rng,
mt phn bit cc lp
Vim i trng thiu mu
Bnh l vim khc
Lng rut
-Ngy nay vic chn on khi lng rut
bng siu m c gi tr cao ( nhy 98-
100%, c hiu 88-100%) v d thc
hin.
-Lng rut l mt trong cc nguyn nhn
gy au bng cp tr nh, thng t 6
thng-2 tui.
-V tr: ch yu l hi-manh trng
Lng rut
Tiu chun chn on khi lng:
-Ct dc: hnh nh bnh sandwich
-Ct ngang: hnh nh bia bn, hnh bnh
rn doughnut sign
-Gin cc quai rut thng lu khi lng

Lng rut
Biu biu din mt ct
dc v 3 mt ct ngang
ca khi lng; 3 quai rut v
mc treo c th thy r.
on rut nhn lng (A)
cha hai lp ca on rut
b lng: lp qut ra (B) b
ph, v lp vo (C) trung
tm ca khi lng km theo
mc treo (M). Mc treo c
mt vi hch bch huyt (L).
MS = ch tip xc ca cc
b mt nim mc on rut
nhn lng v lp qut ra, S
= ch tip xc ca b mt
thanh mc lp qut ra v lp
vo trung tm.
Lng rut
A: Khc rut nhn lng
B: Khc rut b lng
C:Lp trung tm ca
lp rut b lng (lp ra)
Lng rut
A: Khc rut nhn lng
B: Khc rut b lng
C:Lp trung tm ca
lp rut b lng (lp vo)
Lng rut
L: Hch mc treo trong khi lng
C: Lp trung tm ca on
rut b lng
M: Mc treo
Ct ngang trc khi lng
Lng rut
Ct dc trc khi lng
Ct ngang
Ct dc
Rut non i trng

U lnh tnh U c tnh
U tuyn, u m ung th tuyn, u hch

U c tnh U lnh tnh
Ung th tuyn polyp adenomat
U carcinoid bnh polyp
U di cn U m
U trung m
LNH
U ng tiu ho

U ng tiu ho

1. U lnh tnh
- Gm: u thuc lp thng b (u nh, tuyn, polyp),
u thuc m lin kt (u c trn, u m, u si thn
kinh)
- Siu m:
+Khi gii hn r, b u
+V tr trong lng rut lm tng kch thc
ng rut
+m thay i: tng m (u m, harmatome),
gim m (u c trn, u x, u nh)
Bn n 35 tui, tnh trng
bnh thng, khm v c si
ti
Khi tng m thnh t trng
Gii hn r, ng nht

U m trong t trng
U ng tiu ho

U ng tiu ho


U m trong rut non
U ng tiu ho

Khi gim m nm trong
khi lng rut v tr hng
trng
Gii hn r, ng nht

U c trn trong hng trng
Khi ngm thuc mnh
ng nht
U ng tiu ho

2. U c tnh
- Gm: u hch (lymphom), u dng biu m
(carcinoid), ung th c trn, di cn v ung th
tuyn

U hch(Lympho)
1.Dy thnh rut:th-
ng>1cm, gim m, dy
chu vi, khng i xng
2.C th di dng nt, khi
(thng c lot)
3.Thng c hch bao quanh
cc mch mu ln
U dng biu m (carcinoid)
-Chim khong 15% u c tnh, di cn hch khi
kch thc ln > 2 cm, 90% v tr hi trng.
-Siu m:
+Nt gim m, gii hn r, v tr lp c nim lin
tc vi lp c dy thnh.
+Tng sinh mch trn thnh.
+Vi ho: him
+Tn thng mc treo: khi mc treo m thay
i, c phn ng mc treo xung quanh.
+C th di cn gan (dng gi kn hoc gi u
mch), di cn hch.

U dng biu m (carcinoid)
Ung th tuyn (Adenocarcinoma)
Siu m
-Khi gim m
-Dy khu tr thnh OTH, dy ton b chu vi, c
th i xng +/-
-Thm nhim ton b cc lp ca OTH
-C th gy tc rut






Dy khu tr thnh T-hnh nh gi thn

BN nam 75 tui, tnh trng sc kho
km, st cn

Ung th tuyn i trng
Hi chng tc rut
Siu m xc nh tnh trng tc rut:
-Kch thc lng rut non gin> 3 cm, rut gi> 5cm, trong
lng cha dch, hi, cc cht khc.
-Tng nhu ng rut trn v tr tc, xy ra tng
hi.
-Chuyn ng ti v lu, chuyn ng cun
xoyh.a ng.
-Cc du hiu khc: dch bng, ph n thnh
rut.
V tr tc: tc mc t trng, hng trng, hi
trng hay i trng.
Nguyn nhn tc: t c gi tr (do tc rut ch
yu do dy chng), mt s t c th thy (do
lng rut, thot v bn, do u, d vt..)
Hi chng tc rut
Tc rut non vi cc van rut
gin ph n, c t dch bng
gia cc quai rut
Tc rut quai kn
(quai rut hnh ch C hoc U)
Hp ph i mn v
I. i cng:
-Bnh c tnh cht gia nh, gp tr t
tun 1 cho n 5 thng tui, t l tr
nam/n=5/1.
-LS: nn vt, nn ra sa, cht nn khng c
mt (tc trn t trng), khm s thy khi
hnh liu HSP.
-SA: chn on tt, thng dng u d TS
cao> 5 MHz.
-Xc nh mn v: mn v trc TMCD, l
hnh trn gim m gia tng m, thnh
dy khong 2 mm.


Hp ph i mn v
II. Tiu chun chn on:
+Hnh trc tip OMV trn lp ct
ngang hnh bia hoc mt b,
ct dc c hnh tr, b dy lp c >
3 mm, chiu di OMV>15 mm.
+Du hiu ph: d dy gin, tng nhu
ng, dy lp c hang v v tin
mn v, lu thng qua OMV hn ch.
Hp ph i mn v
Bnh thng Hp ph i mn v
Hp ph i mn v
Ct dc Ct ngang
> 17 mm
> 3 mm


Thm khm ton b ng TH trn SA
Pht hin on bt thng (khng i, t di ng)
Pht hin dy thnh ng v cc du hiu phi hp
Phi hp cc triu chng lm sng

K thut ph hp

Kt lun