TCNCYH Plui truong SO (3D) - 2012
Summary
CHARACTERISTICS OF COAGULATION DISORDERS IN PATIENTS WITH MAJOR HEPATECTOMY AT VIETDUC HOSPITAL
The study was to evaluate the coagulation disorders and the risk factors to DIC in patients major hepateclomy The results shovied that the average age was 47 12 i 13 9 (20 - 70), male 67 4%. female 32 6% Hepateclomy > 3 lobe of liver in liver disease and Irauma The results showed that 7 8% of slight bleeding, bleeding 5 3% Decreased pliileli't count, and fibrinogen, prolonged APTT and PT. D-dimer increased The syndrome encountered after major hr^p.nloctdmy DIC 34 7%, decreased coagulatidn 13.8%, fibrinolytic 3 2% and increased cdagulation 1.1% Twd risk factcrs associated with syndrome DIC was remaining liver volume ^ 40% and hypotension 2 15 minutes
Keywords: major hepatectomy, coagulation disorders, dissominatod intravascular coagulation
HJNH ANH NOI SOI CUA N^P VAN DA DAY - T H U C QUAN 0 BENH NHAN CO HOI CHUNG TRAO NGUgC DA DAY - THUC QUAN
Ddo Vi^t H J n g . N g u y d n Thj Van H i n g . Ddo v a n Long TrMng Dai hgc Y Hi Nft Trao ngu^ d9 ddy - th{K qudn iTNDD • TO) Id mOt b^nh ly ph6 bi4n. tuy nhi6n. ti6u chuSn ving Oi ctiin (Join lain chua c6 Bai thudng giai ptiSu ciia n^p van da d6y - (hue quin 65 duvc chung minh cd It6n quan tin tj^h ly ThlDD • TQ Muc lieu nghien cuu nhSm phin loai nSp van da diy • thuc quin ttieo Hill d nhung binh nhSn C6 binh ly TNDD - TQ va tim jiieu moi lien quan giua phin dO nSp van da diy • thuc quin vi l6n thuong thuc quin trin nd* so* f/ieopMn loai Los Angeles Ket qui nghiin cuu cho thiy gin 37% binh nhin C6 bit thutmg vi nip van da diy - thuc quin 45% binh nhin c6 tdn thuong thuc quin trin nil soi cd bit IhuOng vi nip van Nip van da day - tlvfc quin c6 mit lien quan v&i tdn thuong thuc quin trin ndi soi (Chi-square 7.778. p < 0.05. r = 0.576) Di phu hop giiia phin di nip van da diy - thuc quin vi t6n thuong thuc quin trin nil soi thip Phin toil nip van da diy - thyc quin trin nil so cung dp nhung thing tin hinj Ich vi linh trang Irio nguoc da diy • thuc quin vi cd quan hi (flit chi vin binh If TNDD - TQ. die biit Ii tinh trang tin thuong mim mac thuc quin trin nil sol
Tu khoa: Trao ngu'p'c d? d i y - th^rc quan, n4p van d f day - thi/c q u i n
I. DAT V A N 0 £ '^dt d tdm vi ddng vai trd trdng vide tad gdc His
nhqn Sy kec ddn o tjdn trong gdc His tao ndn nip
Trao nguoc da ddy - thuc quin (GERDQ) Id van da ddy - thuc quin cd thi quan sdl duoc kin
mdt bdnh ly phi bien trdn thi gidi cOng nhu d Vidt quat ngudc ddn soi Nip van cd tac dung Idm cdc '
Nam Cd nhiiu phuong phap duoc ap dung d i chit trong da ddy dl chuyin theo mdt chiiu vS
chan doan tuy nhien tidu chuin vang hidn van ngan trdo ngu(?c nhd vi tri dii diin vdi bd cong
chua cd, Ndi soi la mdt phuong phap cd gid tri d i nhd. 0 Vidt Nam, tin thudng thi/c quin trong hft
phat hidn ton thuong cua nidm mac thuc quan, tuy chung trao ngudc da ddy - thuc qudn chu yju
nhien chi 40 - 50% benh nhdn cd hdi chung trdo audc ddnh gid theo phdn loai Los - Angeles vd cho
ngudc da day - thuc quan phdt hidn duoc tin tdi nay vin chua cd nghidn cuu ndc md t i bSl
thuong mem mac thuc quan qua ndi soi. Hinh thudng giai phiu cOa nip van da day - thyc quSn
dang chd nil gi&a thuc quan - da day da duoc coi cung nhu tim hiiu mdi lidn quan gitta nip van nSy
la hang rao co hoc chong trao ngudC trong dd co vd hdi chdng trdo nguq'C da ddy - th^c q^,j^ Vi
TCNCYH Phu truong 80 (3D) - 2012 vay, chCing tdi t i l n hanh nghien c&u nay n h l m
muc t i e u :
1 Phan loai n i p van da day - thuc quan theo Hill d benh nhan cd hpi ch&ng trap nguoc da day - thyc quan.
2 Tim hieu mdi lidn quan gi&a n i p van da day - thuc quan va ton thuong th&c quan tren ndi soi theo phan loai Los Angeles,
II. e 6 l TU'gNG VA PHU'aNG PHAP
i . D d i tipong
Nghien c u u trdn 103 benh nhan tdi kham tai banh vien Dai hoe Y Ha Ndi t& thang 10/2010 d i n thang 3/2011
Ti^u chuin chon b$nh nhSn: Benh nhan dupe chan doan GERD b l n g lam sang va ndi soi
Lam sang: cd 1 trong cac trieu ch&ng bao gdm ndng rat, o chua, dau vung thuong vi vdi tinh c h i t sau an, khi cui, lan nguc, c6
Bdnh nhan d u o c c h i n doan viem thyc quan
N i p gap rd, doc theo bd cong nhd, doi dien vdi den soi Nep g i p cdn, thi m d ra va ddng vao nhanh
N i p g i p khdng cdn rd va den ndi soi khdng duoc to ch&c 6m chat
trao nguoc b l n g ndi soi cd cac v l t do, trpt, loet, l i n g dong fibrin d thyc quan (1/3 dudi),
Tidu chuSn lo$i tru Bdnh nhan cd mdt trong cac benh 1)^ ung t h u da day, gian tinh mach t h y c q u i n . x u l t h u y l t tidu hda, HIV hoac n l m (+).
2. P h u o n g phap
Nghien c&u dup'c t i l n hanh theo phuong phap md ta c l t ngang
Phdng v i n theo m i u bdnh an thong nhat, hdi ly do den kham d l xac dinh bdnh nhan phu hpp tieu c h u i n lya chpn
Phdng v i n bang d i l m GERDQ gdm 6 cau hdi trong dd cd 4 cau v l trieu ch&ng, 2 cau ve anh hudng cua benh ly tdi benh nhan
Bdnh nhdn duoc tiln hanh ndi soi, ton thuong thuc quan duoc danh gia theo phan loai Los Angeles
Bdnh nhan d u o c danh gia phan dd n i p van da day thuc quan khi quat nguoc den soi theo phan loai Hill
D d i O d l l D d l l l
O d I V Khdng cdn nep gap, khoang trong cua thuc quan bi m d cho phep nhin thay bieu md vay t&
phia dudi, thoat vi thuc quan.
H i n h 1. P h a n d d ndp v a n da day - t h y c q u a n t h e o Hill
TCNCYH Phti truang BO (3D) - 2012
Theo Hill, dd 1 vd II la binh thudng, dd 111 vd IV Id bat thudng.
Test urease phdt h i i n n h i i m H.pylori.
3. Phu'ong phap x y ly s i l i ^ u S u dgng p h i n m i m SPSS 16.0.
III. K^T QUA
Ty I i x u i t hi^n cac t r i i u chung: dau t h u o n g vi (77%), d chua (62%), ndng rdt (57,3%.) , cac t r i i u chiing ndy x u i t hidn n h i i u n h i t Id 2-3 ngdy/tuin.
T i n g d i i m GERD: 53,4% d u d i 8 vd 46,6% lir 8 trd Idn,
2. Phdn loai n i p v a n da ddy - t h y c quan theo Hill
- Ty 1$ bdnh nhan m i c bOi chdng trao nguoc da ddy - thyc quan cd n i p van da ddy - thuc qudn b i t thudng Id g i n 37% trdng dd nhdm bdnh nhdn dd IV gap n h i i u hon (22,3%).
1. Dac d i i m n b d m b^nh nhan nghien c y u DSc di4m tu6i vi gtOt
TUOI 18 • 85 t u i i . Trung binh la 40,85 ± 12,81 Nhdm t u i i hay gdp n h i t Id t u 30 - 49 t u i i (56%) Ty 10: nam 42,7%,, nu' 57.3%i.
Ddc illim vi lim sing
Ly do d i n khdm chu y i u id do d chua (40,8%) vd ndng rdt (38,8%)
B a n g 1. Ty le t i n t h y o n g t h y c q u a n d" cdc n h d m n i p v a n k h a c n h a u
- Ty Id n h i i m H pylon d nhdm b i n h nhdn m i c GERD la 42,7% O nhdm bdnh nhan cd n i p van b i t thudng ty IC n h i i m H pylon t h i p hon (36 8%) tuy nhidn s y khac bidt khdng cd y nghTa
T i n t h y o n g t h y c tren noi soi
Khdng Cd Tong
q u a n
n (%) n (%) n (%)
Phan O d I 14(93,3)
1(6,7) 15(100)
Idai nep van D o l l 25 (50) 25 (50) 50(100)
da day - t h y c q u a n D 9 I I I 8(53,3) 7 (46,7) 15(100)
Do IV 9(39,1) 14(60,9) 23(100)
T d n g
56 (54.4) 47 (45.6) 103(100) Ty te ton thuong thuc quan tren ndi soi d nhdm cd n i p van b i t t h u d n g cao hon nhdm n i p van binh thudng va s u khac biet cd y nghla (p < 0,05)
J . Mdi lien qiran giO'a n i p v a n da day thu'c quan va t d n thiFong thu-c q u a n tren ndi soi theo phSn loai LA
- Ty ie benh nhan cd ton thuong thuc quan trdn ndi soi la 45,6% trong dd 91,7% la dd A, 8,5% Id dp B, khdng cd dd C vd D (theo phan loai Lofe Angeles)
B a n g 2. Ty Pe cac n h d m n i p v a n khac n h a u d n h d m c d va k h d n g c d t d n t h u ' o n g t h u c q u a n t r e n n d i s o i
Tong
Phan loai
D p i B o l l B d l l l Dp IV
nep van DD - T Q
n (%) n (%) n (%) n (%) n (%)
T i n t h y o n g t h y c K h d n g c d
14 (25) 25 (44,6)
8(14,3) 9(16,1) 56(106)
q u a n tren noi s o i C d 1 (2,1) 26 (53,2)
7(14,9) 14 (29,8) 4 7 ( 1 0 0 )
T i n g
15(14,6) 50 (48,5) 15(14,6) 23 (22,3) 103(100)
TCNCYH Phu truong 80 (3D) - 2012 Ty le bdnh nhan cd n i p van b i t thudng d nhdm cd ton thuong thyc quan tren ndi soi nhieu hon nhdm khdng cd ton thuong thuc quan tren ndi soi va s u khac bidt nay cd y nghTa (p < 0,05)
Bang 3. Danh gia cac y l u td lien quan t d i tdn thuOng thuc quan tren ndi soi
Trude khi loai t r u yeu td nhieu Sau khi loai trii' y l u td nhilu
Chi-square P Chi-square P
Cac b i i n cd lien quan Can ndng
Phan dp n i p van da ddy - thyc quan S6 b u d c loai tru. 2 budc
19,167 6,724
r = 0,576 p •
<0,05
<0,05
= 0,01
17,115 7,778
<0,05
<0,06
Sau khi loai tru y l u to n h i l u , can nang va phan dd nep van da day - thyc quan cd lien quan chat che tdi tdn thuong thuc quan trdn ndi soi.
Bang 4. D p phu hp'p giO'a phan dp n i p van da day - thicc quan va tdn thirong thuc quan tren ndi soi
Phan do n i p van da day - thyc quan
Binh thudng B i t thudng T i n g
T i n thyong Khdng cd
39 17 56
thyc quan tren ndi soi Cd 26 21 47
Tdng
65 38 103 Kappa = 0,145
Dd phu hop giua hai phuong phap nay trong chan doan hdi chdng trao nguoc da day - thuc quan la r I t thap-
IV. BAN LUAN
Dac d ' l m nhdm benh nhan nghidn cdu Tuoi trung binh cac benh nhan trong nghien cuu cLia chung tdi t h i p hon cac nghidn cuu cua cac tac gia khdc trdn T h i gidi nhung tuong t u k i t qua cua cac tac gia Viet Nam, Trong nghien c&u cua Bor Ru Lin, cac benh nhan cd nhdm nep van b i t thudng tre tuoi hon so vdi nhdm bdnh nhan cd n i p van binh thudng [8]. Nghien c&u cua chung tdi cung cd k i t qua tuong t u Ve gidi, trong nghidn cuu cua chung tdi. n& chiem ty le n h i l u hon nam D t l u ndy gp'i y mdt sd dac diem khac bidt v l md hinh bdnn ly trao nguoc da ddy - thuc quan d Vidt Nam Tuy nhien do so luong benh nhan trong nghien c&u cua chung tdi cdn It nen v i n c l n thdm nhilu nghidn cuu vdi quy md Idn hon.
Dac d i l m lam sang trong nhdm benh nhan nghidn c&u cua chung tdi cOng tuong t y nhu k i t qua cua cac tac gia Viet Nam Dau thuong vj khdng phai la ly do d i n kham cua h l u h i t cac benh nhan nhung la trieu ch&ng xuat hien nhilu (77%) D i l u ndy phu hop vdi quan diem mdi cua Hdi nghi Montreal cho r i n g dau thuong vi cd t h i d u o c coi la trieu ch&ng chinh cua bdnh ly trao nguoc da day - thuc quan
Phan dd nep van da ddy - thuc quan theo Hill Trong nghidn c&u cua chung tdi, ty le nhdm n i p van b i t thudng la g i n 37%. Nghien c&u cua tdc gia Oberg d Thuy D i l n chi ra 63% benh nhan cd hpi Chung trdo nguoc da day - thyc quan cd n i p van b i t thudng [9], D i l u nay goi y b i t thudng v l giai p h i u cua n i p van nay cd the la mdt y l u t6 tao
TCNCYH Phij truong 80 (3D) -2012
nen s y khac biet v l ty H m l c b^nh d nude ta va cac nude chau Au. Mdt s6 nghien c&u chl ra ring tu6i cd lidn quan tdi ly id n i p van da day - thyc quan b i t thudng, Fujivi^ara trong nghien cdu cua minh nhan t h i y tu6i cua cac bdnh nhan d nhdm n i p van dd IV cao hon cac nhdm khac [5] Nghidn c&u cua Bor Ru Lm lai cho k i t qua ngupe la' [8], Nghidn c&u cua Chung tdi cho k i t qua tuong t y nhu cua tac gia Bor Ru Lm, Tac gia nay cung da chi ra BMI cd tuong quan thuan vdi phan dd n i p van da day - thyc quan tuy nhidn trong nghien cu'u ciia chung tdi chua Chung minh d u p e
Ty le n h i l m H pylon d cac benh nhan m l c hdi Chung trao ngu'p'c da day - thyc quan trong nghien c&u cua Chung tdi la 42,7%, t h i p hon n h i l u khi so sanh vdi ty Id n h i l m H pylori d ngudi khde manh trong nghidn cuu cua tdc gia V u o n g T u y l t Mai (75,2%) [3], D i l u nay phu hop vdi cdng b l cua mdt so tac gia trdn t h i gidi, trong dd tdc gia Koike da giai thich vide n h i l m H pylon ngan can tinh trang viem thuc quan trao nguoc thdng qua viec gdy viem tec da day vd lam giam bai t i l t acid [7]
Nghien c&u cua chung tdi cdn ghi nhan ty ie n h i l m H pylon a nhdm n i p van b i t thudng t h i p hon nhdm n i p van binh thudng Trong nghien cuu cua Chung tdi, ty Id bdnh nhan d nhdm n i p van bat thudng cd tdn thuong thuc quan trdn ndi sot cao hon d nhdm nep van binh thudng va s y khdc bidt la cd y nghia K i t qua nay tuong t u nhu cua tac gia BorRu Lm, Oberg
v l mo) lidn quan giua phan dd n i p van da ddy - thuc quan va ton thuong thyc quan tren ndi soi theo phdn loai Los Angeles, 45,4% bdnh nhdn cd ton thuong thuc quan trdn ndi soi, Trong s6 dd, 91,7% la dd A, 8,5% la dd B, khdng cd dd C va D (theo phan loai Los Angeles) K i t qua nay khac vdi mdt sd nghien c&u khac d Viet Nam [ 1 , 2], cd t h i la do benh nhdn trong nghidn c&u cua chung tdi thudng tdi khdm sdm ndn khdng x u l t hidn cac dd VTQTN nang.
Khi so sanh hai nhdm cd vd khdng cd tdn thuong thuc quan tren ndi soi, ty le n i p van bat thudng d nhdm cd ton thuong thyc thuc quan tren ndi SOI la cao hon va s u khac bidt cd y nghTa, O i l u nay tuong t y nhu k i t qua nghidn cuu cua tac gia Bor Ru Lin va tac gia Conti^actor [4, 8],
Khi t i l n hanh danh gia mdi lidn quan gida cac y l u t l tdi t i n t h u o n g t h y c quan trdn ndi soi, chung tdi dS Chung minh dup'c can nang va phan dd n i p van da day - t h y c quan cd lien quan chat chS tdi t i n thuong thyc q u i n trdn ndi soi Tac gia Kang va cdng s y da chi ra r i n g b6o byng la y l u t l nguy co ddc lap cua t i n t h u o n g t h y c quan trdn ndi soi [6], nghien c&u cOa chung tdi chua c h u n g minh d u p e BMI la y l u t l cd l i l n quan t d i t i n t h u o n g thyc quan trdn nfii soi Tuy nhidn, trong s6 nghidn cuu cua chOng tdi, trong 13 bdnh nhan thua can. 61 5%
cd t i n thuong thyc q u i n trdn ndi soi va ca 4 bdnh nhann beo phi d i u cd t i n thuong thyc q u i n tr6n n i l soi, D i l u nay gp'i y tdi b6o phi la y l u td nguy CO cua bdnh ly trao ngup-c da day - thyc q u i n va c l n them n h i l u nghien c u u khac d l k h i n g dinh.
Khi danh gia dd phu hp'p giua phan dd n I p van da day - t h y c quan va tdn t h u o n g t h y c quan tren n i l soi, nghien c&u cua chung tdi cho t h i y dd phu hpp gi&a hai p h u o n g phap nay rat t h i p K i t qua nay gdp p h i n cung c6 y k i l n cho r i n g bdn canh each danh gia c6 d i l n v l tdn t h u o n g nidm mac thuc quan theo Los Angeles, phan dd n i p van da day - thyc quan cd t h i d u o c s u dung d l tidn dodn tinh trang trao n g u o c
V. K^T LUAN
1 Phan loai n i p van da day - thyc quan theo phan loai Hill d bdnh nhan GERD
Ty 1$ cac loai n i p van da day - thyc quan 14,6%-dd I, 48,5%-dd II. 14,6%-dd III. 22,3%-dd IV.
37% n i p van b i t t h u d n g
D i l m GERDQ d nhdm n i p van b i t thudng t h i p hon nhdm n i p van binh thudng. Tridu chung 2 nhdm khdng cd s y khac bidt
2 Mdi lidn quan giua n i p van da day - thuc quan va t i n t h u o n g t h y c quan tren ndi soi theo phdn loai Los Angeles.
45% bdnh nhan tdn t h u o n g thyc quan trdn ndi SOI cd n i p van da day - t h y c quan bat thudng
Ty le tdn t h u o n g thuc quan trdn ndi soi' 46,7%
nhdm n i p van binh t h u d n g , 60,9% nhdm n i p van b i t t h u d n g (p = 0,008),
Cd mdi lidn quan gi&a nep van da ddy - thuc quan va t i n thuong thyc quan trdn ndi soi (Chi-square 7,78, p < 0 . 0 5 , r = 0.576).
TCNCYH Phu truong 80 (3D) - 2012
Od phLi hop giua ddnh gia phan dd n i p van thyc quan - da day va t i n thuong thyc quan trdn ndi SOI trong c h i n dodn t h i p (Kappa = 0,145)
TAI LIEU THAM K H A O
1. Doan Thj Hoai (2006). Nghidn c&u dac d i l m lam sang, hinh anh ndi soi, md benh hpc va do pH thuc quan lidn tyc 24h trong hdi ch&ng trdo ngup'c da day - thuc quan Luan van Thae s? Y hpc, Trudng Dai hoe Y khoa Ha Ndi
2. T r i n Viet Hung (2008). Nghien cuu hinh anh ndi SOI thyc quan trude va sau nhudm mau b l n g Lugol d bdnh nhan cd hdi ch&ng trdo nguoc da day thuc quan Luan van Thae sy Y hpc, Trudng Dai hoc Y Ha N i l
3. Vuong T u y l t Mai (2001). D i l u tra ty id n h i l m Helicobacter Pylori trong cdng d i n g b l n g ky thuat ELISA. Luan van tot nghidp bac sT ndi tru benh vien, Trudng Dai hoc Y khoa Ha Ndi,
4. Contractor QQ, Akhtar SS. Contractor TQ (1999). Endoscopic esophagitis and gastroe- sophageal flap valve J. Clin Gastroenterol, 28 233 - 237
5. Fujiwara Y, Higuichi K, Shiba M et al (2003). Association between gastroesophageal flap valve, reflux esophagitis, Barrett's epithelium, and atrophic gastritis assessed by endoscopy in Japanese patients J Gastroenterol; 38 533 - 539
b. Kang JY, Tay HH, Yap I, et al (1993). Low frequency of endoscopic esophagitis in Asian patients J Clin Gastroenterol, 16 8 4 5 - 8 5 0 ,
7. Koike T, Ohara S, Sekine H et al (2001).
Helicobacter Pylon infection prevents erosive reflux oesophagitis by decreasing gastric aid secretin Gut, 49 330 - 334
8. Lin BR, Wong JM, Chang MC et al (2006).
Abnormal gastroesophageal flap valve is highly associated with gastroesophageal reflux disease among subjects undergoing routine endoscopy m Taiwan J Gastroenterol Hepatol, 21(3) 5 5 6 - 5 6 2
9. Oberg S, Peters JH, DeMeester TR et al ( 1 9 9 9 ) . E n d o s c o p i c g r a d i n g of t h e gastroesophageal valve in patients with symptoms of gastroesophageal reflux disease (GERD) Surg Endosc; 13 1184-1148.
Summary
ENDOSCOPIC ASSESSMENT OF GASTROESOPHAGEAL FLAP VALVE IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE
Gastroesophageal reflux disease (GERD) is a common disease, however, the gold diagnostic cnteria has not been established The abnormality of gastroesophageal flap valve (GEFV) was demonstrated to have association with GERD Our study was to classify GEFV according to Hill grade in patients with GERD and to investigate the association between GEFV grades and esophageal erosions assessed by Los Ange- les Classification The results showed nearly 37% of patients had abnormal GEFV, 45% of erosive esophagitis cases had abnormal GEFV. GEFV was shown to have association with erosive esophagitis (Chi-square 7.778, p < 0 05, r = 0.576). There was a slight agreement between GEFV and EE in GERD diagnosis In conclusions, endoscopic grading of the GEFV provides useful information on the status of gastroesophageal reflux and is highly associated with GERD, especially erosion esophagitis
Key words: Gastroesophageal reflux disease (GERD), Gastroesophageal flap valve