32 Tap chi GAN MAT VIET NAM so 12-2010
N h a n m o t t r u o n g h o p c h a y m a u t i e u h o a c a p t i n h m i i c d o n a n g d a d u o c d i e u t r i b i i n g k y t h u a t T I P S ( T r a n s j u g u l a r I n t r a h e p - atic p r o t o s y s t e m i c s h u n t )
On the occasion o f a serve acute bleeding case treated by TIPS
LE VAN TRUONG*, VU VAN KHIEN**, NGUYEN TIEN THINH**,
MAI HONG BANG**, DUONG MINH THANG**
Tom tat
Bai bao gioi thieu mot benh nhan, nam gioi, bi chay mau tieu hoa tai phat muc dp rat nang do gian vo tTnh mach phinh vi va tTnh mach thuc quan tai benh vien TUQD 108. Benh nhan nay da duoc cap cuu kip thoi, duoc sir phoi hop cua nhieu chuyen khoa vit da dieu tri cam mau bang ky thuat TIPS.
Ky thuat TIPS da ma ra mot chuang mai trong dieu tri chay man tieu hoa d benh nhan xa gan.
Abstract
The article introduces a male patient who used to have liver cirrhosis and serious rebleeding due to gastric varices and esophageal varices and was hospitalized in the Central Military Hospital 108. He underwent timely therapy thanks to the combination of specialties and treatment of hemotasis by Transjugular Intrahepatic Portosystemic Shunt (TIPS). TIPS has brought out a new chapter in the treatment for bleeding in patients with liver cirrhosis.
1. Loi gioi thieu:
Chay mau tieu hoa (CMTH) do gian vd tTnh mach phinh vj P benh nhan xo gan chiem ty le khdng cao so vPi ty le CMTH do gian vd tTnh mach thuc quan (TMTQ) va chi chiem khoang 5-10% trong tdng sd benh nhan xa gan cd CMTH do hpi chirng tang ap lire tTnh mach cira. Tuy nhien. tan suat va ty le CMTH tai phat do va tTnh mach phinh vi (TMPV) nhieu han so vdi CMTH do vd TMTQ. Mire dp cap tinh 2. Benh an:
Hp va ten berth nhan: Nguyen Chi Th.
Sinh nam 1966; Nam.
Dia chi thudng trii: Trung liet - Ddng Da - Hit Ndi
Ngay vao vien: 28 04/2010;
Ngiiy ra vien: 12 05 2010;
Sd luu tru benh an: 65 1
Dieu tri tat: Khoa Ndi tieu hda, khoa Can thiep mach - Benh vien TUQD 108.
ciia CMTH do va TMPV thi tuong duong nhu CMTH do vd TMTQ. Sau day, chiing tdi xin trinh bay mdt trudng hop CMTH cap tinh, mire dp nang da duoc dieu tri thanh cdng bang ky thuat can thiep mach: Ky thuat phan luu cira chii trong gan qua dudng tTnh mach canh (Transjugular Intrahepatic Portosystemic Shunt: TIPS).
Chdn doan khi ra vien: Chay mdu tieu hda muc do ndng do gian vo tinh mach phinh vi, tren benh nhdn xo gan- da dieu tri thanh cdng bang ky thuat TIPS.
I. Lam sdng.
* Benh nhan cd tien sir udng nhieu rucat va den nam 2000 phat hien xa gan. Tir nam 2007 cho den nay da cd 06 lan bi chay mini tieu hda do Khoa Noi tieu hoa**- Khoa Can thiep mach* - Benh vien TU'QD 108
Tap chi GAN MAT VI ET NAM s6 12-2010 33
gian va tTnh mach phinh vi. Benh nhan chi dieu tri bang cac thuoc npi khoa. Benh nhan ciing da duac npi soi da day -ta trang nhieu lan co phat hien gian TMPV, nhung khong dieu tri qua can thiep npi soi.
* Ngiiy 28/04/2010, benh nhan xin viio dieu trj tai khoa Can thiep mach (A2-3) - Benh vien TUQD 108, voi chan doim: Xa gan con bii.
* Ngay 28/04/2010 da soi da day: gian TM phinh vi dp 111, xung huyet, de chiiy mau (xem anli 1 va 2). Den 19 gia, ngiiy 29/04/2010 benh nhiin non ra mini dii tuoi, so luong • 1000 ml.
Anh 1: Khong co gian TMTQ (Npi soi
Anh 3 vii 4: Chay mau thanh tia do (Npi soi ngay
* Khoa Noi tieu hoa (A3): Dii lien hanh iiem xa bin gian TM phinh vj va buoc dim ciim man tam thai: Bin gian TM phinh vi khong con phun mau. Khoa A3 dii cho dat tTnh mach duoi don, tntyen dich, bo sung mau, dien bien benh co xu billing tam tin dinh.
kem theo di ngoai nhieu lan ra phan den. lim mau do. Benh nhan trong trang thai vat va. kieli thich, vii hoang hot. Benh nhan da duoc hoi sire tich cue: truyen mini, truyen djch va duac chuyen sang khoa Npi tieu hoa (A3) dieu tri cap ciiu. Luc 20 gia, ngiiy 29/04/2010, dii duoc npi soi da day ta triing, vai ket qua cu the nhu sau:
Biii gian tTnh mach phinh vj dang chay mini thanh tia vit trong long da diiy clay mint (xem anh 3 vii 4). Khong co gian TMTQ, khong co loet da day...
\d TM phinh vj/mau trong da day 29/04/2010).
' Tii) nhien, den 5 gia ngay 30/04/2010, benh nhan dot ngpt len can clan nguc, non ra mau do tuoi so lugng tren 1000 ml mau. Benh nhan hot hoang, vat va, sau do ljm dan. Khiim: da vii niem mac nhcrt nhat, va mo hoi, chan tay lanh, dong tir bat diiu gian, nhjp tha nhanh nong.
34 Tap chi GAN MAT VIET NAM s6 12-2010
mach quay khong bat duoc va huyet ap rat thap (30/10 mmHg).
* Hdi chdn chuyen khoa: Khoa Ndi tieu hda.
khoa Can thiep mgch, khoa Hdi sue tich cuv.
khca Gay me, vdi kit ludn: Chay mdu tieu hda tdi phat mice dd ngng, do vd tinh mach phinh vi.
Quyet dinh: Cd chi dinh dieu tri bang ky thuat can thiep mach: Ky thuat phdn luu cua chu trong gan qua dudng tinh mach canh.
Benh nhan da dugc hoi sue tich cue va chuyen len phong can thiep mach de thuc hien ky thuat TIPS lite 6 gio -ngay 30 04/2010 va den 6 gio 45 thu thuat da thirc hien thanh cong tot dep.
Ngay 01/05/2010: benh nhan duoc dieu tri tai khoa Hoi sue tich cue (A 12) - dien bien on 3. Ban luan
3.1. Dgc diem CMTH do gian vd tinh mgch phinh vi dbenh nhan xo gan
Cung giong nhu CMTH do gian vo TMTQ d benh nhan xo gan, CMTH do gian vo TMPV deu mang tinh chat cap tinh, dot ngot va hau nhu khong co cac dau hieu bao trude. Dieu dac biet nira la tan suat CMTH do gian vd TMPV thudng nhieu han so vdi CMTH do gian vd TMTQ va cac lan tai dien tiep theo thudng nang han, nguy kich han so vdi lan trudc. Tren lam sang, bieu hien ciia CMTH di gian vd TMPV thudng dugc the hien bang hdi chirng:
Ndn ra mau va hoac di ngoai ra phan den, kem theo cac dau hieu eita mat mau cap tinh: Mach nhanh, huyet ap tut, va md hdi.... Ddi vdi benh nhan nay, chiing tdi da xac dinh day la tnrong hgp CMTH mire dd nang, cac dau hieu CMTH deu the hien day dii va mang tinh chat cap tinh ciia benh. Chinh vi vay, cluing tdi da xac dinh ngay tir dau can phai thuc hien phac dd dieu tri tich cue va tdi uu nhat: Hdi sire tich cue nham phuc hdi the tich mau, bit nude -dien giai va dieu tri theo nguyen nhan.
Cac ket qua nghien ciiu tren the gidi da cho biet: Ty le gian tinh mach da day (chit yeu la tinh mach phinh vi) chiem khoang: 20% trong cac benh nhan cd tang ap luc tTnh mach cira (portal hypertension) va cd khoang 25% sd
dinh. Ngay 02/05/2010 chuyen ve khoa A3.
Tuy nhien, den 10 gid 02/05/2010: Sdt 39°C, dau dau, kem theo la ma... huyet ap: 180/100 (mmHg), xet nghiem: BC = 18.000/mm3, SGOT = 2300 U/l SGPT = 2456 U/l Pro- thrombin = 36%
• Khoa A3 dii dieu tri: Ha ap, nudi dudng (tntyen dich), khang sinh, loi tieu, nhuan mat, thut thao va sir dung cac thudc chdng hdn me gan.... Sau 01 man dieu tri tich cue, benh dn dinh din va den 12/05/2010 benh nhan da ra vien.
• Ket qua ndi soi da day (trudc khi ra vien):
Khdng cdn gian tTnh mach phinh vi.
benh nhan cd gian tTnh mach da day ed nguy nguy co CMTH do gian vd cac tTnh mach nay (1-3). Trong nghien ciru ciia Sarin SK vacs (1) cho biet nguy co chay mau tien phat do gian vd TMDD chiem ty le la: 10-36% va dac biet gian vd TM phinh vi de tai phat nhieu hon so vdi gian TMTQ. Cac nghien ctiu ciia eae tac gia khac cho biet: Ty le tir vong do gian vd tTnh mach phinh vi sau 1 nam chiem tdi 52%. Hau qua gian tTnh mach phinh vi dua den: CMTH va hdi chiing nao gan - hdn me gan, trong dd nguy ca CMTH chiem vi tri hang dau.
3.2. Quan diem dieu tri CMTH do gian votinh mach phinh vi.
Tai 2 Hdi nghi chuyen de ve dieu tri Hdi cluing tang ap tTnh mach cira (Bravo 2005 va Atlanta 2006) da khuyen cao: CMTH do gian vd TMPV can phai uu tien dieu tri qua ndi soi la bien phap hang dau. Ddi vdi benh nhan trong nghien ciiu ctia chimg tdi, do dieu kien trang thiet bi chua day dit, nen chiing tdi da sir dung tiem xa bang cdn tuyet ddi (Ethanol 99,9%) de dieu tri CMTH do vd TMPV. Tuy nhien, hieu qua tiem xa bang cdn tuyet ddi khdng cd hieu quit cao, va do vay da cd CMTH tai phat d benh nhan nay. Ngay nay, cac khuyen cao tren the gidi da dua ra: Nen sir dung N-butyl-2- cyanoacrylate (biet duoc Histoacryl) la mot
Tap chi GAN MAT VIET NAM so 12-2010 35
dang keo sinh hoc de dieu tri CMTH do gian vo TMPV a benh nhan xo gan. Cac nghien cuu cung cho biet hieu qua cam mau co the dat toi
100% (3). Tuy nhien, do Histoacryl rat de dong von vi vay de gay tac may trong qua trinh noi soi, vi vay no khong duoc ung dung nhieu khi ma co sd chua co nhieu may npi soi
Ngay nay, tren the gidi eo 2 phuong phap khac duoc bo tro them trong dieu tri gian vo TMPV, bao gom: ky thuat phan luu cua chii trong gan qua tTnh mach canh (Transjugular Intrahepatic Portosystemic Shunt: TIPS) va ky thuat nut tTnh mach da day qua dudng tTnh mach nguoc dong co bong chen (Balloon-occluded Retro- grade Transvenous Obliteration: BRTO). Tuy nhien, ung dung nhieu nhat ctia 2 ky thuat nay duoc uu tien hang diiu khi ma cac bien phap dieu tri npi soi that bai. Chinh vi vay, chiing toi da su dung ky thuat TIPS dc dieu tri cap ciru cho benh nhan niiy lii diing chi dinh. Ky thuat thuc hien bang each luon catheter viio tTnh mach canh trong ben phai, hudng viio tTnh mach tren gan, tir do dung kim Colainto cd 16G choc xuyen qua gan vao tTnh mach cua, tao thanh mpt dudng ham trong gan. Sau dd tien hanh dat mpt Stent trong gan dc tao thanh dudng ham (shunt) trong gan ndi giua tTnh mach cira vdi tTnh mach tren gan va mau se di qua dudng nay de vc TM chit.
Stanley AJ va cdng su (5) da tdng hop 8 thir nghiem nghien ciru ngau nhien vc TIPS, ket qua cho thay: Hieu qua TIPS cao hon so vdi hieu qua cua tiem xo trong phdng chdng chay mau tai phat d benh nhan xo gan cd gian Tai lieu tham khao
1. Sarin SK, Lahoti D, Saxena SP et al (1992) Prevalence, classification and natural history of gastric varices: A long-term follow-up study in 568 portal hypcrtention patients. Hepatology; 16;
1343-1349.
2. Hashizume M, Kitano S, Yamaga H et al (1990).
Endoscopic classsification of gastric varices. Gas- trointest. Endosc; 36; 276-280.
3. Lo GH, Lai KH, Chen .IS et al (2001) A prospective, randomized trial of butyl cyanoacry- late injection versus band ligation in the manage-
TMTQ. Ty le chay mau tai phat ciia TIPS lit 18%o thap hon so vdi ty le chay mau tiii phat d nhdm tiem xo (42%). Tuy nhien, ciing gidng nhu phiiu thuat ndi cira chu, sau dieu tri TIPS hpi chirng nao gan chiem ty le (34%) cao hon so vdi nhdm tiem xo (13%). Ben canh do, ty le tac (hoac hep Stent) ciing hay gap.
Nam 1997, tai Hpi nghi: Benh ly tang ap lire tTnh mach cira, Stanley AJ va cpng sir (5) di) tap hop tren 10 trung tam tren the gidi ve ket qua sir dung TIPS cho 1750 benh nhan xo gan.
Ket qua chung cho biet: Hieu qua cam man dat 91%. Ty le chay mau ttii phat sau 3 thang, sau 1 nam va sau 5 nam dieu tri TIPS tuong irng la: 5,6%; 16,6% va 20,7%. Ty le hep tai phiit TMC sau : 6 thang, 12 thang va 24 thang tuong ung lii: 28%; 40% va 51%.
Trong nghien ciru cua chiing tdi d benh nhan chung tdi da dat diroc muc dich ban diiu. Tuy nhien, do thdi gian lam TIPS cd keo dai, trong tinh trang benh nhan rat nguy kich. Vi viiy quti trinh thuc hien TIPS cung khd khan, keo dai thdi gian, thuc hien ky thuat dudi giiy me.
Chinh nhirng tac nhan nay eta lam cho tinh trang chirc nang gan bi suy vii cd nhiem triing.
Tuy nhien, chimg tdi da dieu tri tot vdi benh nhan nay vit benh nhiin ra vien trong tinh trang sire khde tot, ket qua npi soi lai: khong con gian TMPV. Tuy nhien, TIPS la mdt ky thuat khd, ddi hdi nhieu kinh nghiem va cd day du trang thiet bj, va gia thanh cdn dat. Nghien ciru nay se he md cho chung ta nghien ciru tiep theo dc phuc vu cho benh nhan ngay cang tot hem.
ment of bleeding gastric varices. Hepatology; 33;
1060-1064.
4, Kim T, Shijo H, Kokawa H et al (1997). Risk factors for hemorrhage from gastric fundal varices.
Hepatology; 25; 307-312.
5. Stanley AJ, Jalan R, Ireland HM, Redhead DN, Bouchier IAD, Hayes PC (1997). A comparison between gastric and oesophageal variceal haemor- rhage treated with Transjugular Intrahepatic Por- tosystemic Stent shunt (TIPSS). Aliment Pharmacol Ther, 11: 171-6.
