Y HOC VIET NAM T H A N G 8 - SO 1/2011
SO SANH HIEU QUA DIEU TRI THAT
TTNHMACH THl/C QUAN
• • • •
(TMTQ) DON THUAN V6l THAT TMTQ KET HOP Vdl TERLIPRESSIN TRONG DIEU TR| CHAY MAU TIEU HOA 6 BENH NHAN XO GAN
Vu Van Khien*, Du'dng Minh Thang*, Ma Phu'dc Nguyen**
TOM TAT:
Nghien cu'u 37 benh nhan xd gan co bien chu'ng chay mau tieu hoa, dUdc chia thanh 2 nhom va ket qua cho biet: Nhom dieu trj ket hdp (that tTnh mach thiTc quan +Terlipressin) cho hieu qua tdt hdn so vdi nhom that tinh mach thi/c quan ddn thuan ve: Hieu qua cam mau (100%), khong co benh nhan co CI^TH tai phat, lu'dng mau truyen ft (1 ± 0,2); thdi gian nam vien trung binh thap (7,8 ± 1,2). Khong co benh nhan nao xuat hien hpi chu'ng gan than sau dieu trj.
SUMMARY
COMPARISON EFFECTS OF ORDINARY ESOPHAGEAL VARICES LIGATION AND ESOPHAGEAL VARICES LIGATION WITH TERLIPRESSIN IN THE TREATMENT OF DIGESTIVE BLEEDING FOR PATIENTS WITH LIVER
CIRRHOSIS
A study on 37 patients with liver cirrhosis having complication of digestive bleeding, arranged in 2 groups demonstrates that: those under combination therapy (esophageal varices ligation and Terlipressin) show better therapeutic effects than those with ordinary treatment including: Haemostatic efficiency (100%), no rebleeding, low bloodtransfusion (1 ± 0,2); low average time of hospitalization (7,8 ± 1,2) and no hepatorenal syndrome after treatment.
I . DAT VAN OE
Chay mau tieu hda (GMTH) do gian vd tmh mach thu'c quan (TI^TQ) la mot trong nhii'ng bien chiing cap tfnh, nguy hiem va de dpa triTc tiep den tfnh mang cua benh nhan. Thdng ke nghien ciili tren the gidi da cho thay: CI^TH do gian vd TMTQ chiem ty le 14-17% trong chay mau du'dng tieu hda tren (11,12) va nguy cd chay mau tai phat chiem khoang 12-30%. Thdng ke cung cho thay ty le tiT vong GMTH do gian v6 TI^TQ chiem khoang 30-70%. Do vay, GMTH do gian vd TMTQ la mot cap cu'u tdi khan cap, phai du'dc dieu trj kjp thdi de giam nguy cd tuf vong cho benh nhan. Hpi nghj Quoc te ve dieu trj tang ap tinh mach cifa tai Bravo -2005 va Atlanta -
2006 da chi ra rang: That TMTQ qua ndi soi la bien phap u'u tien hang dau cho benh nhan xd gan cd bien chu'ng GMTH do v3 TMTQ hoac/va gian vd tmh mach da day. Dong thuan cung khuyen cao can sir dung cac thudc van mach (tru'dc, trong va sau dieu trj) la can thiet de tang hieu qua sau can thiep bang npi soi. Ghinh vi vay, trong 2 nam qua, chiing tdi da sCr dung Terlipressin ket hdp vdi that TMTQ qua npi soi cho benh nhan xd gan cd bien chu'ng GMTH do vd TMTQ va mot sd benh nhan chi sii" dung that TMTQ ddn thuan (khdng dung ket hdp vdi Teriipressin). De tai nghien cu'u nham muc dfch:
So sanh hieu qua dieu tri that TMTQ ddn thuan vdi that TMTQ kit hdp vdi Terlipressin trong dieu tri GMTH do gian vd TMTQ d benh nhan xdgan.
I I . DOI Tl/QNG VA PHUONG PHAP NGHIEN CUfU
* Doi tu'dng: Gom 37 benh nhan xd gan, cd bien chu'ng GMTH do gian vd TMTQ nam dieu trj npi trii tai khoa Ndi tieu hda - Benh vien TL/QD 108 trong thdi gian ti^ 03/2009 den 06/2010 du'dc du'a vao trong nghien cufu nay.
Benh nhan du'dc chia thanh 2 nhdm: Nhdm that TI4TQ ddn thuan (n =19) va nhdm that TMTQ + Glypressin (n =18).
* Phu'dng phap: Tift ca benh nhan deu du'dc kham lam sang (cd nang, thi/c the) va xet nghiem can lam sang (hda nghiem, sinh hda, mien djch va sieu am gan mat ). Tru'dc khi tien hanh thii thuat, benh nhan du'dc dieu trj tfch ciTc: Truyen mau, truyen djch, khang sinh.
* Danh gia mii'c dp gian TMTQ di/a theo phan loai ciia Hiep hpi Npi soi Nhat Ban. Mii'c dp xd gan diTa theo bang phan loai ciia Ghild-Pugh va chia thanh 3 rnuTc (Child A, Child B va Child C).
* Thu'c hien ky thuat that Ti^TQ qua npi soi: ThiTc hien tai khoa Ndi tieu hda, tren may ndi soi EVIS 180 (hieu Olympus- Nhat Ban).
* Cach dung Teriipressin ddi vdi nhom dieu tn ket hdp: Teriipressin (Biet du'dc
*Khoa Ngl tieu hoa - Benh vien TI/QD108 ** Binh vien Old Ray
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Y H9C VigT NAM THANG 8 - SO 1/2011 Glypressin, san xuat bdi Gong ty du'dc pham
Frring, Kiel Du-c). Thuoc du'dc dung tru'dc khi tha TMTQ 15 phiit, vdi lieu Glypressin x 2 ong/tiem cham tn/c tiep tinh mach. Sau dd cii' 6 gid tiem cham triTc tiep vao tTnh mach, tong 6 ong/ngay. Ngay thuT 2 dung: Glypressin/tri/c tiep tinh mach/6 gid x 4 dng/ngay. Thudc du'dc diing trong 2 ngay.
* Cac thong so de theo doi so sanh 2 nhdm: Sau 5 ngay dieu tri
III. KET QUA
- Dac diem lam sang va can lam sang ciia 2 nhdm.
Hieu qua cam mau (Khdng chay mau tieu hda tai phat sau 5 ngay that TMTQ).
- Lu'dng mau can truyen ciia moi nhdm.
Thdi gian nam vien
- Gac bien chiiYig sau dieu trj ciia moi nhdm:
Dau, sot, hpi chu'ng gan-than
Bang 1 . Dac diem lam sang va can lam sang chung ciia 2 nhdm Dac diem chung moi nhom
Tuoi trung blnh Gidi (Nam/nOO Ty le Child A/B/G Gian TMTQ dp I I / I I I
Mii'c dp mat mau: Nhe/viTa/nang Tien suT da cd GMTH do vd TMTQ
That ddn thuan (n = 19)
46 ± 4 16/3 2/10/5
2/17 1/11/7
5/19
That -1- Glypressin (n = 18)
45 ± 3 16/2 1/11/6
1/17 1/10/7
4/18
Nhan xet: Khdng cd sy" khac nhau ve dac diem lam sang va can lam sang giffa 2 nhdm dieu trj, Bang 2. Hieu qua dieu trj ciia 2 nhdm nghien cu'u
Hieu qua dieu trj That ddn thuan (n = 19)
That + Glypressin (n = 18)
Hieu qua cam mau 17/19 (89,4%) 18/18 (100%)
Chay mau tai phat sau 5 ngay 1/19 (5,2%) Lu'dng mau can truyen sau 48 gid thiTc
hien thii thuat (ddn vj mau) 3,1 ± 0,5 1,1 ± 0,2
Thdi gian nam vien trung binh (ngay) 10,5 ± 2,3 7,8 ± 1,2
Nhan xet Khdng cd sir khac nhau ve dac d em lam sang va can lam sang giu^a 2 nhdm dieu trj Bang 3. Bien chu'ng chung ciia 2 nhdm
Cac bien chu'ng sau diieu trj Thit ddn thuan (n = 19)
ThSt + Glypressin (n = 18)
Dau bung 2/19 (10,5%) 1/18 (5,5%)
Dau ngiTc 3/19 (15,7%) 2/18 (11,1%)
Sdt 2/19 (10,5%) 1/18 (5,5%)
Hdi chu'ng gan than xuat hien sau dieu tri 2/19 (10,5%) Nhan xet Cac bien chiiYig sau dieu trj nhdm dieu trj ket hdp cd xu th§t ddn thuan. Dac biet cd 2 benh nhan nhdm that ddn thuan xuat hien
hu'dng giam hdn so vdi nhdm hdi chu'ng gan than.
IV. BAN LUAN
1. D$cdi&n chungngMencuUcua2niidm.
Chiing tdi da so sanh dac diem lam sang, can lam sang va mot so cac yeu td khac trong 2 nhdm la khdng cd sy" khac nhau cd y nghia (p >
0,05). Nhu* vay, hai nhdm nay tu'dng dong nhau ve dSc diem lam sang, can lam sang, cung nhu' ve tien sii' da cd GMTH do gian v3 TMTQ d 2 nhdm b?nh nhan xd gan. Ket qua nghien cii\j chung cho thay sd benh nhan nam mac benh xd
gan nhieu hdn so vdi nu', va tuoi trung nien thu'dng gap trong ca 2 nhdm. Phan Idn benh nhan deu bj xd d giai doan Child B va Child C. Sd benh nhan xd gan cd bien chiing GMTH thu'dng cd TMTQ gian d dd I I I va trong tien sir da cd khoang 22-25% cd GMTH do vd TMTQ. Nhu'ng dac diem nay da cho thay phan Idn benh nhan xd gan trong nghien ciili ciia chiing tdi da d giai doan benh kha nang. Nhu'ng ket qua nay cung
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Y HOC VI^T NAM T H A N G 8 - SO l i z o r i F>hii hdp nhan dinh vdi cac tac gia khac trong va
ngoai nu'dc (1-3)
2. Hieu qua sau 5 ngay dieu tri.
Tiiy theo tiTng trung tam nghien cu'u va tiiy theo cac tac gia nghien culi khac nhau de lay mdc thdi gian danh gia hieu qua dieu tri. Gac nghien cu'u ciia Hiep hpi nghien ciru ap li/c tinh mach ciTa tai Anh lay cac mdc sau: 48 gid, sau 72 gid, sau 120 gid (5 ngay) de danh gia hieu qua dieu trj cap cuTu cho benh nhan xd gan cd bien chu'ng GMTH do gian TMTQ. Tuy nhien, gan day cac tac gia thu'dng lay mdc sau 5 ngay la mdc chung sau dieu trj CMTH do vd TMTQ (6)
Trong nhu'ng nam gan day, vdi siT tien bd khdng ngiTng ciia khoa hpc ky thuat, nhieu thudc van mach da du'dc ra ddi, vdi cac thudc the he sau tdt hdn so vdi thudc the he tru'dc. Muc tieu sir dung cac thudc van mach la lam giam ap liTc tinh mach ciTa (Portal pressure) va khi da lam giam du'dc aps liTc tinh mach ciTa se lam giam ap liTc trong bui gian TMTQ. Cac nghien cu'u ciia Moitinho, Vinel va cs da cho thay cac thudc van mach se lam giam ap liTc TMC du'di 20 mmHg, nd lam giam nguy cd GMTH tiT bui gian va lam giam nguy cd tiT vong nhieu hdn so vdi nhdm khdng diing cac thudc van mach.
Teriipressin (biOt d-Tc: Glypressin) met loM thuec CO m^ch ®- ®-Tc dng ddng nhiOu trong
®i6u trt3 GMTH do vi TMTQ. G,c kOt qulj nghian C0u cho thEy hieu qua cam mau cua Teriipressin giao dpng tiT 75-80% (5), dong thdi nd cung lam giam nguy cd tiT vong so vdi nhdm Placebo (RR 0,66; 95%)
Trong nghien ciTu cua chiing tdi cung da ap dung each tfnh nay de danh gia hieu qua cua 2 nhdm dieu trj. Chung tdi thay rang hieu qua cam mau nhdm dieu trj ket hdp (100%) cao hdn so vdi nhdm that ddn thuan (89,4%). Cung tu'dng tiT nhu' vay, nhdm that ddn thuan cd 1/19 benh nhan (5,2%) cd chay mau tai phat sau 5 ngay dieu trj. Trong khi dd, khdng cd benh nhan nao d nhdm dieu trj ket hdp xuat hien CMTH tai phat sau 5 ngay dieu trj.
De danh gia hieu qua dieu trj ciia 2 nhdm, chung tdi cung thong ke ve so lu'dng (ddn vj) mau truyen sau dieu trj nhdm dieu tri that ddn thuan va dieu trj ket hdp. Ket qua cho biet sd lu'dng ddn vj mau truyen va thdi gian nam vien trung binh ciia nhdm dieu trj ddn thuan nhiiu hdn so vdi nhdm dieu trj ket hdp. NhCTng ket qua nay da cho thay Terlipressin cd hieu qua tdt tang cu'dng hieu qua sau that TMTQ qua npi soi. Dong
thuan tai Hdi nghj dieu trj tang ap tinh mach cu^
da khuyen cao can sii dung cac thudc van mach:
Tru'dc-trong va sau khi that tinh mach thiTc quan cho benh nhan xd gan cd bien chiing CMTH do vdTMTQ.
Nhieu nghien cu'u thong ke cho biet: Hieu qua cam mau khi siT dung Teriipressin ddn thuan cho benh nhan xd gan CMTH do vd TMTQ giao ddng tiT 56-96%. Gan day, nghien cii\J Lo GH va cs (6) cho biet: Ty le GMTH tai phat sau 48 gid nhdm dieu trj ddn tliuan chiem 20%, trong khi dd nhdm dieu trj ket hdp chi cd 5%. Tac gia cung thdng ke cho thay: ty le GMTH tai phat sdm, thdi gian nam vien va so lu'dng mau truyen nhdm dieu trj ket hdp thap hdn so vdi nhdm dieu trj ddn thuan. Tac gia da theo ddi tiep sau 42 ngay dieu trj thi thay rang thdi gian song nhdm dieu trj ket hdp tang hdn so vdi thdi gian song nhdm dieu trj ddn thuan. Do vay, tac gia cung khuyen cao nen siT dung phac do dieu trj phdi hdp trong dieu tri GMTH cap tfnh do gian vd TMTQ (6)
3. CactM&ichihigsaudieutiicua2nhdm.
Trong bang 3 chiing tdi da thdng ke cac bien chiTng hay gap sau dieu trj. Nhin chung, cac dau hieu nhu": Dau bung, dau ngiTc, sdt cua nhdm dieu trj ddn thuan cd nhieu hdn so vdi nhdm ket hdp, nhu'ng chu'a cd siT khac nhau cd nghia. Dieu dac biet chu khac, chiing tdi thay rang: Hdi chu'ng gan than ciing la mdt trong nhiTng bien chu'ng d benh nhan xd gan cd CMTH do v3 TMTQ. Gac trieu chiing nay cd the xay ra trong bat ky giai doan nao ciia xd gan va nd cd the tang len sau cac thii thuat can thiep dieu trj.
Trong nghien cu'u ciia chung tdi trinh bay tai bang 3 cho thay cd 2/19 benh nhan (10,5%) nhdm that ddn thuan xuat hien cac hpi chiing gan than sau dieu tri that TMTQ. Ngu'de lai, nhdm dieu trj ket hdp thi khdng cd benh nhan nao xuat hien hdi chiTng gan than sau dieu trj.
Dieu nay da cho thay Teriipressin khdng chi giiip tang hieu qua cam mau sau that TMTQ, ma cdn giup dieu trj va ngan ngiTa hpi chiing gan than- mpt trong nhii'ng bien chiing nguy hiem d benh nhan xd gan.
Nghien CLTU ciia gan day da cho thay sir dung Teriipressin rat thfch hdp cai thien chu'c nang d benh nhan xd gan mat bii va benh nhan cd hdi chiing gan than (Hepato-renal syndrome), dac biet khi cd bien' chu'ng GMTH do vd TMTQ.
G^c nghien culi khuyen cao nen siT dung Teriipressin tru'dc khi thiTc hien can thiep npi soi, 28
Y HQC VIET NAM THANG 8 - SO 1/2011 de han che cac bien chung sau that TMTQ (3).
Khuyen cao da chi ra ve lieu lu'dng siT dung Teriipressin khi benh nhan cd hpi chu'ng gan than gom: Lieu dau Teriipressin: 2 mg/4 gid x 48 gid, sau dd duy tri lieu thap hdn: 1 mg/4 gid x 5 ngay
V. KET LUAN
Nghien cu'u 37 benh nhan xd gan cd bien chiing GMTH, du'dc chia thanh 2 nhdm dieu trj cho biet: Nhdm dieu trj ket hdp (that TMTQ +Teriipressin) cho hieu qua tdt hdn so vdi nhdm that ddn thuan ve: Hieu qua cam mau (100%), khong cd benh nhan cd GMTH tai phat, lu'dng mau truyen thap (1 ± 0,2); thdi gian nam vien trung binh thap (7,8 ± 1,2). Khdng cd benh nhan nao xuat hien hpi chiing gan than sau dieu tri d nhdm diing k^ hdp
TAI LIEU THAM KHAO
1. Du'dng Hong Thai. Nghien cu'u ket qua tiem xd va that bui gian tinh mach thiTc quan qua ndi soi d benh nhan xd gan. Luan an
Tien sp Y hgc 2001
2. Chalasani N. Imperlale TF. Ismail A et al Predictions of large esophageal varices in patients with cirrhosis. Am. J. Gastroenterol 1999:94:3285-3291.
3. Javier F, Navasa M, Ramon P, et al.
Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis.
Gastroenterology 2007; 133; 818-8Z4.
4. Fiaccadori F, Pedreti G, Biraghi M, et al.
Teriipressin and endoscopic sclerotherapy control variceal bleeding and prevent early rebleeding in cirrhotic patients. Curr Ther Res 1993; 54; 519-5Z8.
5. Chang TT, Lee PY, Tsai YT et al. A randomiezed controlled study of low-dose and high-dose terlipressin in the control of acute oesophageal variceal haemorrhage. J.
Gastroenterol Hepatol 1991; 6; 481-484.
6. Lo GH, Chen WC, Wang HM, et al. Low- dose terlipressin plus banding ligation versus low-dose teriipressin alone in the prevention of very early rebleeding of oesophageal varices. Gut Z009; 58; 1Z75-1Z80.
DANH GIA NONG 0 0 HOMOCYSTEIN TRl/dC VA SAU DIEU TRj THUOC KHANG VIRUS TREN BENH NHAN NHI^M HIV-1
Pham van Thu'c*, Hoang Th[ Thanh Huyen*
TOM TAT
Homocystein \h mot acid amin chiila lUu huynh, dui^c tao thanh tir qua trinh khiT methyl ciia methionine va ehuyen hoa theo hai con du'dng: hoac methyl hda de tai tong hpp thanh methionine hoSc tao thinh cystathionine. TSng nong dp homocystein trong mSu \h nguy cd ciia hinh thanh huyet khoi va tSc mach din dfn nhSl mdu. M^c tieu: Danh gia si/thay doi ve nBng dp homocystein tru'dc vei sau dieu tri bSng thuoc khang virus tren bfnh nhan nhiem HIV-1, tiT do danh gii svtic ddng aia thudc khdng virus tren ehuyen hoa homocystein. Doi tu'dng va phu'dng ph&p nghien cuti: (1) Nghien ciTu mo ta, tien CLI\J vdj ddi tUpng la 31 gdi mai dam da dUpc chan doan nhiem HIV-1; (2) Lay mdu tru'dc va sau khi uong methionine d ca giai doan tnTdc vd sau dieu tri bSng ARV; (3) Djnh lUpng nong d6 homocystein trong mdu. Ket qua: Nong dp homocystein tSng len dang ke sau 6 thdng dieu tri bSng ARV 6 cd nhom taTdc va sau khi uong methionine. Sau dieu trj, ty le benh nhan tdng
*Tni&ng Dai hpc Y Hal Phdng
homocystein tdng tiT 72,8% (tru'dc khi uong methionine) len 95,5% (sau khi uong methionine) K€t luan: Nong dp homocystein tdng co y nghia thong k§
d cd nhdm tru'dc vd sau khi udng methionine sau 6 thdng dieu trj bdng ARV va sU rdi loan ehuyen hoa ndy CO the Id hdu qua ciia ciia sir giam chu'c ndng enzyme dudi tdc dgng cua thuoc khdng virus.
TCf khoa: Homocystein, HIV-1, Viet nam
SUMMARY
EFECT OF ANTIRETROVIRAL THERAPY ON HOMOCYSTEINEMIMA CONCENTRATION I N
HIV-1 INFECTED PATIENTS
Homocystein, a sulfur-containing amino acid is produced by methionine whose metabolism stands at the intersection of two pathways: remethylation to methionine . or transsulfuration to cystathionine.
Hyperhomocysteinemia is clearly an associated risk factor for atherothrombosis and venous thromboembolic disease. Objective: To detect the
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