Nghien cmi dac diSm lam sang, can lam sang & benh nhar viem loet dai trang tai Benh vien Trung irong Quan doi 108
Study on clinical, paraclinical characteristics of patients ulcerative colitis at 108 Military Central Hospital
Nguyin Dire Ninh, Vu Van Khien, Vu Thanh Trung, Benh vi0n Trung ucmg Quan dpi 101 Du-cmg Minh Th4ng, Doan Thanh Cong
Tomtit
Muc tieu: Md t l mot sd d i e diem lam sang, can lam sang va ket q u i npi soi cua bdnh n h l n vidm loet dai trUc trang tai Khoa Cap eUu (C1-3) va Khoa Ndi Tieu h d a - Benh vienTl/QD \Q&. Doi tugng vd phuang phdp: Nghien cUu md t l eat ngang tren 43 benh nhan (BN) ehan doan xae djnh bj vidm loet dai trUe trang,
^ e u trj ndi trii. T^t c l cac BN dugc kham lam sang, xet nghiem mau, cay phan va npi sol dai trang, sinh thidt lam xet nghiem md bdnh hoe. Kit qud: Nhdm tudi thudng gap > 60 (51,2%); 97,6% bdnh nhan dl ngoai phan lan mau. 44,2% bdnh n h l n xdt nghidm thay kali mau giam, t i Id bdnh nhan thieu mau la 39,4%. Vidm gap nhieu nhat la doan true trang (48,8%), tdn thuong dang xung huydt chiem t i Id eao nhat vdi 81,3%. Xet nghidm mo benh hoe thay mUc do xam lan chCi ydu van d Idp bi^u md vdi t i Id 81,4%, ton thuong xudng
\gp ddm la 18,6%. Ton thuong viem nidm mac tuyen chldm t i Id cao n h i t la 69,8%. Kit ludn: Bdnh vidm loet d a l t r u c t r i n g thudng gap d B N tren 60 tudi, ton thuong gap nhieu nhat d t r U c t r l n g v l d a i t r i n g sigma vdi dae diem vidm nidm mac tuydn chCi yeu is Idp bieu md, cay phan t i le gap vi khuan t h i p .
TUkhda: Viem loet dai trUc t r i n g , benh nhan, dai trUc trang.
Summary
Objective: Describe some clinical and paraclinical characteristics, endoscopic and hlstopefthologlcal results of patients with ulcerative colitis. Subject and method: A descriptive study involved 43 patients diagnosed with ulcerative colitis treated at the Deparment of Emergency (Cl-3) and Department of Hepatogastroenterology, 108 Military Central Hospital. All the patients underwent elinieal examination, blood tests, stool culture, and colonoscopy with biopsies. Result: The most common ages were over 60 (51.2%). 97.6% of patients had blood stool. 44.12% of patients had low serum potassium and 39.4% of patients had anaemia. Imflamatlon changes were seen most common at the rectum (48.8%) in which erythema of the mucosa accounted for the highest percentage (81.3%). Histopathologieally, we found most of the case (81.4%) had lesions involved epithelial layer only and 18.6% of cases had submucosa damages. Mucosa imflammatory changes accounted for the highest proportion (69.8%). Conclusion:
Ulcerative colitis usually affects patients over 60, presents endoseopically with erythema and ulcerative lesions locating mainly at the rectum and the sigmoid colon. Mucosa imflamatory changes involving
PhSn bifn khoa h^c: TS. NGUYEN TIEN THINH
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mainly epithelial layer were the most common histopathologieal characteristic. Bacteria Infection is not popularin stool culture.
Keywords: Ulcerative colitis, patient, colorectal.
I.Oatvande
Viem loet dai t r i i c trang (VLOTT) la bdnh d a n g cd xu h u d n g t a n g d cae nUde dang phat trien [1], [4].
Nguyen n h l n g l y benh chUa rd r i n g nhUng benh c d lien quan t d i qua t r i n h dap Ung midn djeh, vdi bieu hien ehu yeu I I dau b u n g , t i e u c h l y phan mau kem t h e o sdt va g l y sut can, mat m a u [5 - 6]. Benh luc dau cd t h i ehi khu t r u tai true t r a n g , vd sau lan d i n v i o t r o n g , t o n t h u o n g cd t h e t o a n b d dai trang. Nam v l nU deu cd t h e mac bdnh nhU nhau va t h u d n g gap or lUa t u d i 15 - 30 va 60 - 70 t u o i . Benh thUdng khdng dupe ehan d o l n v l dieu t n kjp t h d i . Chfnh vi the, vide chan d o l n chfnh xac de dieu t n I I vide l l m het sUc khd khan n h I m tranh de lai nhUng bien chUng nguy hiem. C l e bien chUng t h u d n g thay I I ngudl bdnh bj suy kidt, thieu mau, s6c d o nhiem ddc, cd t h e thCing dai trang t r o n g t r u d n g h p p nang [6].
Tai Khoa Cap cufu v l Khoa Ndi Tidu hda - Bdnh vien T U O D 108 t r o n g nhUng nam gan d l y cd nhieu bdnh nhan VLBTT. De tai nghidn cUu t i m hieu: Bae diem lam s i n g , c l n l l m sang d bdnh nhan VLDTT d l dieu trj tai Bdnh vidn TLTQD 108.
2 . D d i tuong va phifong phap 2.1. Doi twang
Doi tugng nghien cUu la cae benh n h l n VLDTT dupc chi d j n h ndi sol dai t r a n g o n g m e m tai Khoa Cap cUu ban d l u , Khoa Ndi tieu hda - Benh vidn Tl/QD l O S t C r t h l n g 1/2013 den 12/2015 (3 nam).
Tieu chudn chgn benh nhdn
Bdnh nhan dupc chan doan I I VLDTT dua vao eac trieu chung sau: Dau b u n g I m i hoac t h i n h cdn kem t h e o ed b u d n di ngoai.
Roi loan dai tien: Chu yeu I I ia Idng nhieu lan m d t ngay, phan cd nhay, mau; tao b d n , sau bai phan cd nhay, mau.
Tiiu chudn logi khdi nhom nghien cUu Benh nhan mac c l e benh nhU: Bdnh t i m mach, d l i t h a o d u d n g , tang huyet I p , benh than man t i n h , suy t i m sung huyet, rdi loan d d n g mau, suy l i d hap, benh Crohn.
Cac b d n h n h i e m khuan t i e u hda: Do a m i p , do true khuan, d o lao.
Khdng ndi soi dupe hdt t o l n b d dai t r i n g vl b i t kj' l>? do nao.
2.2. P/iuWig phdp; Tidn cthj m d t l , cat ngang.
C l e budc t i e n hanh n g h i e n eiJu
L l m sang: Hoi b e n h : Hdi kT t i d n sO" eae yeu t d n g u y eO gay bdnh dai trUc t r a n g nhU: Nguyen n h l n d j Ung; nguydn n h l n b d n h t U m i e n ; sau cac t r u d n g h p p nhiem ddc: T h y r o x i n , asen, p h o t p h o , nhiem t o a n m l u , ure m l u cao...
K h i m lam sang: Di n g o l i ra mau, dau bung vCing ha vj h o l e dpc theo khung dai trang, bung trudng hoi, rdi loan tidu hda, sdt, gay sut can, rdi loan nUdc didn giai, thieu mau, t h a m trUc trang cd mau.
Can lam sang: Xet nghiem mau cd t h e ttiay thidu mau nhuoe sle, t i n g bach cau, m l u ISng tang.
Rdi loan dien g i l i : Giam kali.
Soi dai trUc trang: Ton thUPng v i e m . Tren dai t h ^ ngUdl ta t h u d n g t h a y ed eac hinh anh: Niem mac x u n g huyet, cae mach m a u cuong t u t h a n h tUng d i m , h o l e n i d m mac dai t r i n g bae mau, mat d p l i n g b d n g . Tang t i e t nhay 6 vDng nidm mac bj t d n thUdng v i g m ed t h e t h a y h l n h anh nhUng eham c h l y mau rai rae d niem mac dai t r a n g .
Tdn t h u o n g loet: Trdn dai t h e cDa benh viem dai t r i n g ngUdi ta t h a y h i n h anh v i d m t h u d n g kem theo vdi cac 6 loet cd t h e chl I I vet xUde hoac t r o t niem mac, cd d loet thUc su sau, b d deu m e m mai, d day ed nhay, mO, mau...
Khi soi dai t r u e t r a n g b a n g d n g ndi soi m e m se t i e n h l n h lay m a u b e n h p h a m de l l m xet nghiem m d benh hpc va nudi cay t i m vl khuan. Khi soi tien hanh sinh t h i d t 2 - 6 m i n h d eac vCing t o n t h u o n g : Mieng 6 loet canh 6 lodt, e l e vi:ing l i n h de xet n g h i d m m d b d n h hpc.
XCr ly sd lieu: Theo phUPng p h i p t h d n g ke y sinh hpcstjfdung phan m e m SPSS 13.0.
38
TfiPCHfYDUOC L A M SANG 108
3.K£tqui
Bdng 1 . Tuoir gidi va dac diem 13m sang VLOTT Thong so
TJ le nam/nQ Nhom tuoi
< 3 0 3 1 - 4 0 4 1 - 5 0 5 1 - 6 0
> 6 0
n ( % ) 23/20(1,15)
5/43(11,6%) 7/43(16,3%) 8/43 (18,6%) 11/43(25,6%) 22/43(51,2%)
Thong tin Lam sang VLBTT Phan CO nhay - mau 0 a u bung Mot ran Sot Gay sOt can Bau m6i kh6p
n ( % )
42/43 (97,6%) 37/43 (86,0%) 15/43(34,9%) 8/43(18,6%) 11/43(25,6%) 2/43 (4,6%) Nhdn xet ly Id nam/nOf ngang nhau. So benh nhan > 60 t u d i m&c VLDTT eao n h a t Cae tridu ehUng lam sang hay gap t r o n g VLDTT la: P h i n cd mau, dau b u n g , m d t ran.
Biing 2 . Xet nghiem can lam sang: Huyet hoc, dac diem ndi soi V j t r i t o n t h U f m g
True trang Dai t r i n g Sigma Dai t r i n g xudng Dai trang ngang Dai trang len Xet nghidm huydt hpc Huydt sac to Kali m l u
n (%) 1 Pham vi ton tht/tmg 21/43 (48,8%) 1 Vidm 1 doan dai trang 15/43(34,9%)
04/43 (9,4%) 02/43 (4,6%) 01/43 (2,3%)
17/43(39,5%) 19/43(44,2%)
Vidm'2-4 doan dai trang Viem toan bd Hinh I n h t d n t h u o n g Xung huydt PhCl ne l l n s i n C h i m , ndt xuat huydt
n { % ) 33/43 (76,7%)
9/43 (20,9%) 1/43 (2,3%)
35/43(81,3%) 6/43(13,9%) 2/43 (4,8%)
Nhdn xet Dac diem tren ndi soi: Vj t r i hay gap trdn ndi soi: TrUe trang (48,8 (76,6%), vidm xung h u y ^ t chiem t J Id cao nhat (81,3%). Ha kali m l u ehlem 44,2%
)), vidm 1 doan dai t r a n g
Bdng 3. M d bdnh hoc (MBH) va vi sinh vat Miic dd xam ian tren MBH
Xam \in bieu mo Xam ian icfp deny
n ( % ) 35/43 (81,4%)
8/43(18,6%)
f>ac diem ton thitfcmg 1 Lo^t nham nhd, hoai td
\ Qua san bieu mo tuyen Viem niem mac tuyen 1 Xuat huyet ni§m mac
n ( % ) 3/43 (6,9%) 6/43(13,9%) 30/43 (69,8%)
4/43 (9,3%) 1 Nhdn xet Trdn m d bdnh hoc: X l m lan Idp bieu m d ehidm 81,4%, vidm nidm mac tuyen ehlem 69,8%.
4. Ban luan
4.1. Bac diim ldm sang
Kdt q u i nghien cUu tren 40 t r u d n g hpp viem loet dai triic trang chay mau, ehung tdi thay lUa t u d i
hay gap nhat la > 60, chiem t i Id 51,2%. Nghien cUu cCia t i c g i l Nguyen Duy Thang tren 1065 t r u d n g h p p tai Benh vidn Ndng Nghiep ciing thay d p t u d i t U 6 1 den 80 ehidm t i Id 44,5% [2]. Tac gia Nguyen ThUy Vinh nghidn cufu tren 6157 t r u d n g h p p den soi dai
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t r a n g tai Vidn HOu Nghi t h a y d o t u d i t u o n g t U chiem 68,7%. TI Id ve gidi t h i nghien cijfu cua ehung t d i lai t h a y t y le nam cd nhidu h d n so vdi bdnh n h l n nOf, nhUng t^ le n l y chenh Idch k h d n g d a n g k l . Cae nghidn eUu nay cQng cho kdt q u i phu h o p cae nghien culi t r o n g va ngoai nUde.
Ket qua nghidn cUu eua ehung t d i da t i m hieu kha ky vd cac trieu chung l l m sang. Ket qua b i n g 1 cung eho biet: Da sd cae benh nhan den vidn kham va dieu tri vdi If d o di ngoai ra m l u , ndn day eung la trieu ehUng t h u d n g gap nhat trdn lam sang chiem 97,6%. Cac tridu chtJng d i ngoai p h i n c d m l u d cac mUc dp khae nhau cd t h d p h i n l l n nhay mau ca h o l e m l u d d tUoi, t h a m trUe t r a n g t h u d n g t h a y mau d d t u o i t h e o tay. Kem t h e o e l e benh n h l n t h u d n g cd e l m glae m d t ran va dau b u n g , dau t u y t h e o vj t r i t o n t h u o n g 6 eae doan dai trang, rat it benh nhan t h i y dau t o a n bp t h e o khung dai trang. Khai t h I c t i e n sd t h i cd 25,6% so b d n h nhan-thay gay sut c l n vl c l e tridu chUng lam sang ndi tren I n h hudng kha nhieu den che dp an u d n g va sinh hoat. Cd 18,6%
ddi t u p n g nghien eUu khi v i o vien thay cd sdt ma chCi yeu la sdt nhe k h o i n g 38°C. Dae bidt, d m d t sd bdnh nhan khi t d n thUdng dai t r a n g r d n g , chiem gan het dai trang, t h i e i c trieu chUng sdt k h i dien hlnh, t u y nhidn ty* Id sdt khdng nhieu chiem 2/43 (4,6%). Ngoai cac tridu chUng cua dUdng tidu hda, eae tai lidu y v i n da de cap nhieu den eae trieu ehUng ngoai d u d n g tieu hda: NhU viem khdp, cac t o n t h u o n g d mat. Trong nghien eUu cua ehung t d i , d o sd lieu con it nen chua gap trUdng h p p nay.
4.2. Dgc diem can ldm sang
Ket q u i xdt n g h i e m m l u cho t h a y t i n h t r a n g rdi loan didn g i l i d cac benh n h l n viem loet dai true trang chay m l u , n o n g d p kali mau giam <
3 , 5 m m o l / l chiem tj^ Id 44,2%, t i Id benh nhan thieu m l u la 39,5% vdi Hemoglobin < 120g/L Chinh t i n h trang dl ngoai ra m l u nhieu keo d l i se lam n d n g d p cac chat dien giai t r o n g m l u g i l m di kem t h e o d d la lam giam dan sd lUdng h d n g cau t r o n g mau, ngoai ra t i n h trang viem loet keo d l i nay eung g d p phan lam giam kha nang hap t h u tai d u d n g t i e u hda dan den t i n h trang thieu mau nhupe s l e d eac benh nhan viem loet dai trUe trang c h l y mau. Kail m a u
giam nhieu cd t h e gay rdi loan nhjp t i m , chUdng bung tao dieu kidn thuan Ipi dan tdi bldn ehufng phlnh dai t r i n g nhiem ddc, dai trang phlnh t o , tidn lUpng xau.
Nghien eUu cOa tae g i l Dao Van Long cd ket q u i 13/20 trudng hpp (65%) n o n g do kali thap hOn binh thudng, 9/20 (45%) t n i d n g h o p cd thieu mau.
Ndi sol dai t r a n g t o a n b d hien nay v i n la p h u o n g p h i p cd g i l t r i q u a n t r p n g t r o n g ehan d o l n b d n h vidm lodt dai true t r a n g c h l y m l u . Qua ndi soi cd t h e xae d j n h dUpc p h a m vi t d n t h u o n g va luu lai dugc h i n h anh t d n t h u o n g t r e n bd m a t n i e m mac, p h l t hidn eac t d n t h U d n g ac t f n h g i u p t i d n lUOng v l didu trj t d t h o n . T r o n g n g h i e n ci3fu nay chUng tdi t h ^ y t d n thUOng v i d m g a p nhieu nhat d d o a n trUc t r a n g chiem t i Id 48,8%, t h u d n g I I v i e m d 1 doan dai t r a n g (76,7%), v i d m nhieu d o a n c u n g c d nhung ehlem t l Id t h a p hOn vdi (20,9%), ehl g a p 1 benh nhan v i d m t o a n b d dai t r a n g ehidm 2,3%. Hinh I n h ndi sol t r o n g cac trUdng h p p vidm t h i da sd thay n i d m mac nd x u n g huydt d p h a m vi v l mUc dp k h i c nhau chiem t y Id 81,3% va ed 13,9% n i d m mac phu nd lan san, Idi vao t r o n g Idng dai t r i n g . Nghidn cUu cda Dho V I n Long thay 20/20 trUdng hdp cd t d n thuong doan true trang, ehidm t l Id cao nhat, c l 20 trUdng hop ddu ed hlnh I n h nidm mac phu ne, x u n g huyet, mun va mat hinh anh mang maeh m l u binh t h u d n g [1], tae g i l Nguyen Duy Thang eung ed ket qua la t i Id vidm loet tai trUe t r i n g chiem t i Id cao nhat.
Ton t h u o n g trdn m d bdnh hpc cua v i d m loet dai t r i i c t r a n g c h l y nri^u I I n d n g , chCi yeu a Idp niem mac va dUdi niem mac, khdng ed t o n thUdng Idp cd n h u benh Crohn. D l y la m d t t r o n g nhCfng tidu chuan chinh de phan biet hai b e n h nay. Trdn t h i i c te, khi ndi soi dai t r a n g bSng d n g m e m , eac m i n h sinh thiet dai t r a n g lay bang kim sinh t h i e t t h u d n g la khdng lay 6ugc sau x u o n g Idp ca nen khdng eho ket q u i xet n g h i e m m d b d n h hpc eCia Idp co nay. Nghien cUu cCia chung tdi c u n g t h i y chO yeu t d n t h u o n g a Idp bieu m d nidm mac vdi 81,4%, t d n t h u o n g xudng l d p d d m la 18,6%. Hinh anh m d b e n h hpc phan Idn ddu t h a y cau true khe t u y e n b^t t h u d n g , x o l n van, g i l m sd lupng khe t u y i n v l t h a m nhap l y m p h o b i o va t u o n g bao x u d n g Idp d d m . Trong n g h i e n cufu n l y cac t d n t h u o n g ddu lanh t f n h , t u y nhien cd 13,9% ed hlnh anh qua s i n b l l u m d t u y e n . Do vay, vdi nhUng benh nhan khi bi VLDTT lau n a m , dieu t r i dai d i n g
TAP CHf Y DUOC LAM SANG 108
nhieu l l n , t h i can phai t h e o ddi chat ehe. Cac nghien cUu tren t h e gidi va t r o n g nUde ddu khuyen e l o vdi bdnh nhan VLDTT can t h e o ddi ehat che va can phai dupe ndi soi dai true trang n h a m kiem tra sU h i n h t h i n h polyp va u n g t h U dai trang. Vdi nhUng b e n h n h l n cd polyp dai t r a n g c l n phai dieu t r i triet de nham phdng chdng ung t h U dai trang.
5. K i t luan
5.1. Ve ldm sdng: T^ Id nam nOf m i c VLDTT ngang nhau. Tudi hay gap VLDTT tren 60 t u d i . Tridu ehijfng hay gap t r o n g VLDTT bao g d m : Dl n g o l i p h i n lan mau (92,5%), dau b u n g (96%), m d t ran (67%)...
5.2. Ve can ldm sdng: Tdn t h u o n g hay gap d t n i c trang (56,8%), t d n t h u o n g dang x u n g huydt ehlem t i Id eao nhat vdi 81,1%. - Xet nghiem m d bdnh hoc thay mL?e dp xam lan chCi ydu van d Idp b l l u m d vdi t i Id 82,5%, t d n thUdng xudng ldp d e m la 17,5%.
Tai lidu t h a m khdo
1. Dao Van Long, Nguyen Thj Thu Hien (2010) Dgc diem ldm sdng vd can ldm sdng benh viem loet dgi
true trdng chdy mdu. Tap chi Khoa hoc Tidu hda Viet Nam, tap V, sd 19, tr. 1273-1280.
2. Nguyen Duy Thang (2013) Binh If dgi trUe trdng qua 1065 trUdng hgp ndi soi dgi trdng Sng mem tgi binh viin Nong nghiip. Tap chi Khoa hpc Tieu hda Viet Nam, tap Vlll, sd 3 1 , tr. 2030-2035.
3. Nguyen Thuy Vinh (2012) Tf le binh If dgi trdng eda binh nhdn Benh viin HUu Nghi qua 6157 ea soi dgi trdng. Tap chi Khoa hoc Tidu hda Viet Nam, t i p Vll, sd 26, tr. 1735-1742.
4. Kappelman MD, Rifas-Shlman SL, Kleinman K et al (2007) The prevalence and geographic distribution of Crohn's disease and ulcerative colitis in the United States. Clin Gastroenterol Hepatol 5:1424-1429.
5. Loftus CG, Loftus EV Jr, Harmsen WS et al (2007) Update on the incidence and prevalence of Crohn's disease and ulcerative colitis In Olmsted County, Minnesota, 1940-2000. Inflamm Bowel Dis 13:254-261.
6. Herrinton LI, Liu L, Lewis JD et al (2008) Incidence and prevalence of inflammatory bowel disease in a Northern California managed care organization, 1996-2002. Am J Gastroenterol 103:1998-2006.
