Ti^PCHI KHOA HOC Tlfeu H 6 A V I & T NAM 2012 - TAP Vll - s 6 29
Nghien cvCu / Original Research Articles
Vi§m, Loet d^ day i& trang va nhiSm Helicobacter pylori S b^nh nh§n dSn tOc E Dd t^i B^nh vifn tinh Dak LSk
Peptic ulcer disease and Helicobacter pylori infection in the Ede patients in the provincial Hospital of Dak Lak
L6 QUANG TAM', BUI HOU HOANG^
'B^nh vi§n Da khoa tinh Dak Lak; ^B$ m6n NOi. Dai Hgc Y Dift?c TP. HCM
Abstract
Background: Peptic ulcer disease (PUD) and Helicobacter pylori (HP) infection are the common diseases.
The prevalence of HP infection vary significantly between countries to countries and ethnic groups in the same country. Aim: To determine the prevalence of HP infection, the rate of pathologic lesions ofPUDf and the related factors in the Ede ethnic patients in the Provincial hospital of Dak Lak. Materials and Methods: cross-sectional study has been carried out on 240 Ede ethnic patients in the Provincial hospital of Dak Lak from April to October 2010. All patients were carried out upper gastrointestinal endoscopy and biopsy to identify the pathologic lesions evaluated according to the Sydney classification system. We determined the relationship between HP infection and pathologic lesions, arui environmental, social factors.
Results: The prevalence of HP infection was 60,4%. The rate of pathologic lesions of PUD according to mild, moderate and severe degree respectively as followed: the rate of chronic gastritis was 100% (75.0%;
23.8%; 1,2%), active gastritis: 65.8% (62.0%; 28,5%; 9,5%), atrophic gastritis: 36,25% (66.7%; 25.3%;
8,0%). intestinal metaplasia: 25% (all lesions were mild). Gastritis alone occured 97,5%; gastritis associated with ulcer occupied 2,5%. The common lesions of gastritis found by endoscopy were erythematous/exudative gastritis (53,8%) and flat erosive gastritis (24,6%). Independently related factors to predict the HP infection:
pathologic lesions of gastritis on endoscopy: erythematous/exudative gastritis (PR 1,8; CI 95% 1.1-3.0).
atrophic gastritis (PR 1,9, CI 95% 1.1-3,6) and flat erosive gastritis (PR 2,1, CI 95% 1,3-3,2); polulation and social factors: uncommom hand washing (PR 1.6, CI 95% 1.1-2,5) and the number of people living together (PR 1,3, CI 95% 1,1-1,6). Conclusions: although the HP infection rate in Ede patients was higher than that in Kinh patients but the ulcer rate was lower in the Ede patients. It is nessesaiy to educate Ede communities about health care and to improve their living condition.
Keywords: Helicobacter pylori (HP), peptic ulcer disease (PUD); the Sydney classification system.
Tom t^t
Dgt vSh d e : Viem lo^t da day td trang (VLDDTT) vji nhilm Helicobacter pylori (HP) Ih b6nh IJ khS phd high. 111$ nhiem HP c6 khdc biet ldn giffa cdc quoc gia v^ giffa cdc nhdm dSn toe trong cOng mOt nirdc. Muc tidu: Xdc dinh ti 1$ cdc dang t6n thUdng VLDDTT, ti le nhilm HP vd mgt so yeu td li6n quan tr6n b6nh nhdn (BN) ddn tgc E DS bi VLDDTT tai Benh vien tinh Ddk Ldk. Dd'i trf<?ng v^
phrftfng pliap: NghiSn ciJu c^t ngang, thifc hi0n tr6n 240 BN ddn tOc E De tai Benh vi6n Da khoa dnh
TAPCHl KHOA HOC T i e u H O A VlfeT NAM 2012 • T^P v n - s d 29
D5k Lak tir 04-10/2010. Ta't ci BN du<?c nOi soi da dky ti dSnh giS tdn thirdng vk sinh thi^t. K^t qu5 md b$nh hpc (MBH) dir<;lc dinh gid theo h$ tblSng ph9n lo^i Sydney. Xic dinh m^i li€n quan giffa nhilm HP vdi cic tdn thudng VLDDTT vil c4c y^u ttf mdi trirdng, xa hOi. Kfi't qui: TI 1^ nhilm HP la 60,4%.
TJ 1$ cac d?ng tdn thtfdng MBH dtfdc phdn bd' theo cic mifc dd nh?, trung Mnh vS nSng iSn lUdt nhtf sau: viSm d? day (VDD) m?n tinh la 100% (75.0%; 23,8%; 1,2%), VDD hoat dOng la 65,8% (62,0%;
28,5%; 9.5%), vi«m teo nifim mac da day lk 36,25% (66,7%; 25,3%; 8,0%), dj skn ruOt la 25% (tSft c5 dfiu d mlTc dO nh?). Vifim ddn thuSn chifim 97,5%; vifim kfim lofit chifim 2,5%. Dang vifim thudng gap nha't qua nOi soi la vifim xung huy^t xu8ft tifit (53,8%) va vifim trflt phJng (24,6%). CSc yfiu id lifin quan d0c l^p dd tifin doan nhilm HP: cdc dang tdn thtfdng trfin nOi soi: vifim xung huyfit xuift tifit (PR 1,8;
KTC 95% 1.1-3.0). vifim teo nifim mac (PR 1,9. KTC 95% 1,1-3.6) va vifim trdi phing (PR 2.1. KTC 95% 1.3-3.2); cac yfi'u td'dansd.xa hdi: rto tay khdng thtfdng xuyfin (PR 1,6, KTC 95% 1,1-2,5) vasd ngtfdi sdng chung (PR 1,3. KTC 95% 1,1-1.6). Kfi't lu^n: TI lfi nhilm HP d BN fe Dfi cao hdn so vdi dan lOc kinh. TI lfi lofit d ngtfdi 6 Dfi rSft tha'p. Cia giSo dgc cdng ddng vi c5i thifin difiu kifin sdng cho ddng bao dan tdc fe Dfi.
Ttf khda: Helicobacter pylori (HP), viem lofii da day ta trang (VLDDTT), hfi thdng phSn loai Sydney.
D^t vafn dfi
VLDDTT la bfinh IJ tieu hda kha phd bifi'n trfin thfi gidi [25]. MOt sd nghifin ciJu da trung tSm tai Ha Npi va TP. Hd Chi Minh cho thS'y so' Itfdng BN VDD cd khuynh htfdng gia tang trong khi dd sd Itfdng BN lofit lai giJm di [27]. Vfi nguyfin nhan, HP la mfit trong nhffng tdc nhan chinh gay VLDDTT va cung la yfi'u td' sinh ung thtf thufic nhdm I d ngtfdi [4]. Ti lfi nhilm HP cd stf khac bifit ldn giffa cfic qudc gia phat tridn va dang phat tridn va tin suaft nhilm HP cung khac nhau giffa cfic nhdm dan tfic trong cdng mdt ntfdc [12]. Dan tdc E De la dan tfic bSn dia chlnh tai Dak Lak [7]. Ddng bao E Dfi vin cdn gitt cac t^p qudn sinh hoat raft lac hau, thdi quen an udng. vfi sinh cd nhan, ldi sdng cfing ddng nhilu thfi'hfi d chung mfit nha... la cdc dilu kifin cd the gay lay nhilm cdc loai bfinh, trong dd cd nhilm HP[7],[13].
Myc tifiu
Khio sat d lfi nhiem HP, ti lfi cdc tdn thtfdng qua nfii soi vl MBH d BN dan tfic E Dfi bi VLDDTT
tai Bfinh vifin u'nh Dak L.ak va xac djnh mdi lifin quan giffa ti lfi nhilm HP vdi cSc dang tdn thtfdng VLDDTT va cac yfiu tddan sd, xS hdi.
Dd'i ttfi^ng v^ phtfdng phdp
Dd^i ttfdng: 240 BN dSn tdc 6 Dfi dtfdc nfii soi tai Bfinh vifin Da khoa tinh Dak Lak tir 04-10/2010.
Tifiu chf chpn m§u: Tifiu clii chpn: cd bidu hifin iam sang gpi J VLDDTT, dtfpc nfii soi tieu hda tren dd phat hifin cdc dang tdn thtfdng VDD va/hoac lofit DDTT. sinh thidt dd danh gia tdn thtfdng MBH va thtfc hifin test nhanh urease.
Tifiu chf lo^i trit: BN da dtfdc nfii soi dfiu hda trfin; cd sO'dyng khang sinh, Ihud'c khdng tifi't acid, bismuth trong vdng 1 thdng tinh dfi'n ngay soi; ung thtf da day; dang bj xu9ft huyfi't tifiu hda trfin; tifin sil phiu thu^t cit da day.
Phtfdng phap nghifin cihi: Cit ngang md ti.
C3 mSu: Cd mlu dtfpc tinh theo cdng thtfc sau:
Z2(i.„g)Xp(l-p)
TAP CHI KHOA HOC nfeU H d A V I ^ NAM 2012 - TAP v u - s d 29
Trong dd:
- a: xdc sua't sai iSm loai 1, chpn a = 0,05 thi Z(,...ffl=l,96
- p: tri sd mong mudn c i a d lfi nhilm HP d bfinh VLDDTT. Chpn p = 0,81 [17]
- d; do chinh xdc (sai s d cho phfip), chpn d = 0,05
- N: cd miu, dnh todn dtfpc: 236,488; cd miu la'y trdn la 240 BN.
Cdc bifi'n sd': Nhdm bifi'n sd nfin: ludi, gidi dnh, trinh dfi hpc vd'n, nghfi nghifip, khu vtfc sdng, dnh trang hdn nhan. Nhdm bidn sd v l cdc yfi'u td mdi trtfdng, xa hfii: chfi dfi an ddc trtfng ciia ddn tfic E Dfi, ngudn ntfdc siS" dung, ntfdc udng dun sdi, thdi quen riS'a tay trtfdc khi an, kidu nha d, cd nha vfi sinh hay khdng, sd ngtfdi chung sdng trong mOt nhd. Nhdm bifi'n sd v l nOi soi vd MBH: theo hfi thdng phdn loai Sydney cdp nhat [3].
Xii ly va phSn tfch stf iifiu: SijT dung phin mem STATA 10.0. Tinh cdc chl stf: tan stf, d lfi %, khodng tin cjy 95%, d sd d le hifin m i c (PR), dfi nhay, dp chuyen, gid tri dfin dodn dtfdng, gid tii tifin dodn dm, hfi sd phii hdp Kappa. Phdn dch ddn bidn; so sdnh cdc d lfi diing phfip kiem khi blnh phtfOng (Chi-squared test) hode phfip kidm chinh xdc Fisher (Fishers exact test) khi cd > 20% tin stf mong ddi trong bdng < 5. Phdn tich da bitfn: sd"
dung hdi qui Poisson (Poissons regression) vdi stf do PR.
Kfi't qua: Bing 1 id ti lfi nhilm HP dtfdc phdt hifin ttleo dmg phtfdng phdp. TI lfi nhilm HP qua MBH la 60,4%, khdng cd stf khdc bifit gitta vific chin dodn bing MBH vd test nhanh urease (p = 0,852) cung nhtf khi kfi't hpp kfi't qui ci3a hai phtfdng phdp (p = 0.396).
TI lfi nhilm HP
Bdng 1: Ti lfi nhilm HP u-fin BN VLDDTT dtfdc phdi hifin bing MBH, test nhanh urease hode
kdt hpp cd hai P P A
MBH
Urease test
C i h a i HP
(-)
(+)
(-)
(+)
(-)
(+) Tdng
n 95 145 97 143 86 154 240
%
39,6 60,4 40,4 59,6 35,8 64,2 100
KTC 9 5 % 33,4 - 45,8 54,2 - 66,6 34.1-46,7 53,3 - 65,8 29,7-41,9 58.0 - 70,3
Cdc d?ng tdn thtfdng VLDDTT: Vifim ddn thuin chifi'm 97,5%, vifim phtfi hdp vdi lofii chifi'm 2,5%. Ktft qud cho thay d lfi lofit rat tha'p trong nghifin ctfu ndy.
Cdc ddc didm tdn thtfdng qua nfii soi Bdng 2: Binh khu vd dang VDD Djnhldiu
Hang vi Thdn vi Todn bO DD
n 200
2 38
%
83.4 0,8 15,8 D?ng VDD
Vifim XH/XT Vifim trdi phing
Vifim tt-dt ndi Vifim teo Vifim xua't huydt
Vifim TNR-DD Vifim PDNNM
Tdng
129 59 18 23 2 7 2 240
53,8 24,6 7.5 9,6 0,8 2,9 0,8 100,0
Vifim XH/XT: vifim xung huydt/xuit dfi't;
Vifim TNR-DD: vifim ttdo ngtfdc ruOt-da day;
Vifim PDNNM: vifim phi dai nfi'p nifim mac.
Cdc d^ng tdn thtfdng theo MBH:
T « P C H [ KHOA HgcTifeU H 6 A V I ^ T NAM 2(H2 - T * P VII-Stf 29
B5ng 3; Tl !§ cdc d^ng tdn thiTdng VDD theo MBH Bifi'n stf MBH
Dinh khu
Hinh thdi
Gid tri bifi'n stf Hang vi Than vi Todn bfi DD
Vifim man Vifim hoat dfing
Teo nifim mac Di sdn rufit Hifin difin HP
n 112
1 127 240 158 87 60 145
%
46,7 0,4 52,9
100 65,8 36,25 25,0 60.4
Nh«
75,0 62,0 66,7 60,0 59,3
TB
23,8 28,5 25,3 0,0 30,3
N«ng
1,2 9,5 8,0 0,0 10,4 Bdng 4: Gid trj ciia nfii soi tiong chin dodn djnh khu VDD vd vifim teo
Vifim TV Vifim HV Vifim teo
Sens 24,2%
99,5%
13,8%
Spec 91,9%
100%
92,8%
PV*
77,5%
100%
52,2%
PV 51,5%
50%
65,4%
Kappa 15,4%
66,4%
7,9%
Bdng 5: Phdn bd nhilm HP tiieo tdn tiitfdng vifim lofit trfin nfii soi Bitfn stf
Vifim vd lofit Vifim ddn tiiuSn Dinh khu TV, TBDD'
Dinh khu HV»
Vifim XH-TN-PD' Vifim xu^t huyfi't Vifim TNR-DD=
Vifim PDNNM>
Vifim xung huyfi't Vifim tidt phing Vifim tidt ndi '. Yifim teo nifim mac
N 6 234
40 200 11 2 7 2 129 59 18 23
HP(+) n 6 139
29 116
2 1 0 1 78 37 10 18
%
100,0 59,4 72,5 58,0 18,2 50,0 0,0 50,0 60,5 62,7 55,6 78,3
PR 1,7 1,3 1
3,3 3,4 3,0 4,3
KTC 95%
1,5 - 1,9 1,0-1,6 Tham cliitfu
1,4 - 7,9 1,4 - 8,4 1,0-9,4 1,8 -10,3
P 0,045'
0,087
0,007 0,006 0,053' 0,001' 'Xua't huydt - trdo ngtfpc - phi dai; ^Trdo ngtfpc rufit-da ddy; 'Phi dai ntfp nifim mac; "Thdn vi;
Todn bO da day; 'Hang vi; 'Fishers exact test
TAP CHf KHOA HOC T l £ u H 6 A VlfeT NAM 2012 - TAP v n - S 6 29
B^ng 6: Phdn b6' nhilm HP theo MBH Bifi'n stf
Dinh khu TV va TBDD Dinh khu HV Viem man hoat dfing Mtfc dfi vifim man TB vd nSng
Teo nifim mac Di sdn rufit
N 128 112 158 60 87 60
HP(-l-) n 87 58 143 49 63 40
%
68,0 51,8 90.5 81,7 72,4 66,7
PR 1,3 37,1 1,5 1,4 1,1
KTC 95%
1,1-1,6 9,4 - 146,0
1,3-1,8 1,1 - 1,6 0,9 - 1.4
P o,ou
< 0,001
< 0,001 0,004 0,253 Bdng 7: Phdn h6 nhilm HP theo cdc bi^n so' nen
Bitfn s6' Gidi dnh
Nhdm tudi
Khu vtfc stfng
Nghfi nghifip
Hoc vifn
Hdn nhdn
Nam Ntt 10-19 20-29 30-39 40-49 59-59 a 60 TT NT Nong dan
CNV*
H S S V Khdc MDchtt
ca'pi ca'p 11 ca'p III
> ca'p III chtfa kfi't hon
Da kfi't hdn Ly di, ly tildn; gda
N 123 117 20 38 75 52 36 19 29 211 175 31 22 12 59 81 48 29 23 37 172
31
HP(-f) n 70 75 16 20 42 35 23 9 19 126 103 19 15 8 34 51 32 15 13 23 104
18
%
56.9 64.1 80,0 52,6 56,0 67,3 63,9 47,4 65,5 59,7 58,9 61.3 68,2 66.7 57,6 63,0 66,7 51,7 56,5 62,2 60,5 58,1
PR 0,9 1 0,7 0,7 0,8 0,8 0.6 1,1 1 1,1 1,2 1,2 1 1,1 1,2 0,9 1,0 1 1 1
KTC 95%
0 , 7 - 1 , 1 Tham chifi'u
0,3 - 1,3 0,4 - 1,2 0,5 - 1,5 0,4 - 1,5 0,3 - 1,3 0,8-1,5 Tham chifi'u
0,6-1,7 0,7 - 2,0 0,6 - 2,3 Tham chifi'u
0,7 - 1,7 0,7 - 1,9 0,5 -1,6 0,5 - 1,9 Tham chitfu
0,6-1,5 0,5 -1,7
P 0,255
0,212 0,225 0,567 0,490 0,208 0,549
0,871 0,595 0,734 0,689 0,554 0,727 0,953 0,904 0,828
T ^ P CHl KHOA H g c TifeU H 6 A V I & T NAM 2012 - TAP VII- S(5 29
'Cdng nhdn vi6n, *'Hgc sinh, sinh vi6n
Bdng 8: Phdn bd nhiSm HP theo cdc bifin sd m6i trifdng, xd h0i Bifi'n stf
ChtfdOanfeDfi Utfng ntfdc khfing s6i
Khdng rUa tay TX' Khfing cd nhd vfi sinh
d nha dai fe Dfi Stf ngtfdi chung sdng
< 10 ngtfdi 10-20 ngtfdi
> 20 ngtfdi
N 147
73 137 184 141
105 88 47
HP(-f) n 99 59 105 113 91
43 59 43
%
57,4 80,8 76.6 61,4 64,5
41,0 67,1 91,5
PR 1,4 1,6 2,0 1,1 1,2
1 1,6 2,2
KTC 95%
1,1 - 1,7 1,3 - 1,9 1,5-2,6 0,8 - 1,4
1,0-1,5
Tham chitfu 1,1-2,4 1,5 - 3,4
P 0,006
< 0,001
< 0,001 0.567 0.119
0.014 0,000 'Kh6ng n^a tay thtfdng xuySn
Bdng 9: Mdi lidn quan giffa nhilm HP vdi mgt sd ydu td theo phdn u'ch da bidn TT
1 2 3 4 5 6 7 8 9 10
Yfi'u ttf ChtfdpanEDfi Utfng ntfdc khdng sfii Khdng nj"a tay thtfdng xuyfin
Sfi' ngtfdi chung stfng Vifim loan bfi da day Vifim kfim lofit
Vifim XH/XT Vifim ttpt phing
Vifim tipt ndi Vifim teo nifim mac
PR 0,9 1,2 1,6 1,3 1,2 1,8 1,8 2,1 1,5 1,9
KTC 95%
0,6 -1,4 0,8 -1,7 1.1 - 2,5 1,1 - 1,6 0,8 -1,8 0,7 - 4,1 1,1-3,0 1,3-3,2 0,7-3,1 1,1-3,6
P 0,665 0,378 0,027 0,032 0,445 0,198 0,014 0,001 0,296 ' 0,040 : Sau khi phdn dch ddn bitfn, cd 4 ytfu ttf ddn stf, lifin quan vdi nhilm HP (p < 0,1). Khi phdn tich xd hpi vd 6 ydu ttf vfi tdn tiitfdng U-fin nfii soi cd hdi quy da bifi'n Poisson, chi cd cdc ytfu td nlii'
TAP CHl KHOA HOC TlSU H 6 A Vl^T NAM 2012 - TAP VII - s 6 29
rfia tay khdng thtfdng xuyfin; sd ngtfdi sfi'ng chung ttong mfit gia dinh vd cdc dang VDD tifin npi soi (vifim xung huyfi't. vifim trdi phing vd vifim teo nifim mac) cd lifin quan dflc idp vdi nhilm HP vd cd J nghla difi'ng kfi (KTC95% ciSa PR khdng chlJa gii til 1; td't cd PR d i u > 1), cd gid tri tifin dodn nhifim HP. Trong dd. sd ngtfdi chung sdng id yfi'u td lifin quan thudn dfic ldp cd gid tii tifin dodn nhilm HP, khi so ngtfdi chung stfng tdng lfin mfit bdc (< 10 ngtfdi, 10-20 ngtfdi vd > 20 ngtfdi) thi d lfi nhifim HP cao gd'p 1,3 lin (PR = 1.3; KTC95%:
1,1-1,6).
Ban lu^n
PhSn btf theo gidi tfnh: TI lfi nam. nff lin Itfdl id: 51,3% vd 48,7%. Ttfdng ttf nhtf cdc nghien ctfu tiong ntfdc [10],[19].
Phfin btf theo tud'i: Tudi nhd nhd't Id 10; tudi cao nhd't Id 80; nifi'i ttung Mnh: 38.8 ± 14. Nhdm ludi mdc bfinh nhieu nha't Id 30-49 (chifi'm 53%).
So vdi cdc tdc gid khdc: Nguyen Sdo Trung (2005), nhdm tudi 31 -50 id 50% [19]; Lfi Trung Thp (2007), nhdm tudi 30-49 Id 51,2% [10]; Nguyin Duy Thing (2009), nhdm ludi 31-50 Id 61,05%. Nhtf vdy, cd stf gitfng nhau c i a nhieu nghifin cd^ v l dfi tudi mic bfinh, nhilu nhd't id nhdm tudi 30-50. Khfing cd khdc bifit vi nhdm tudi m i c bfinh giffa ddn tflc Kinh vd ddn tdc 6 Dfi.
Phan bfi' theo khu vtfc stfng: Chu yfi'u id nfing thfln. chifi'm 87,9 %, cdn thdnh thi Id 12,1%. Difiu ndy phO hpp vl da sd ddng bao E Dfi sdng tdp ttung chd yfi'u tai cdc bufln, ldng.
Phdn bfi' theo trinh dfi hpc vtfn: Da sd la hgc vd'n tiiS'p: 24.6% mil chff; 33,7% hfi't cd'p I; 20%
hfi't cd'p II. TI lfi hpc va'n tha'p vd mil chff cao.
Phdn bfi'theo nghfi nghiep: Ldm nfing id chu yfi'u (72.9%). Da stf ldm ntfdng riy, chi cd mfit so' it tham gia vdo cdc hoai dpng nghi nghifip gifi'ng ngtfdi ddn tfic Kinh.
V l ti lfi nhilm HP:
Bang 10: So sdnh d lfi chin dodn nhiem HP bdng MBH ciia cdc nghifin ctfu khdc Tdc gia (ndm)
Nguyin Sdo Trung (2005) [19]
Lfi Trung Thp (2007) [10]
Suzana (2009) [26]
Chung tdi (2010)
Ti lfi nhifim HP vd mtfc dfi % HP(-l-)
63.0 51,80 23.37 60,4
Nhe 46,0 36,05
22,2 59,3
Trung binh 36.0 38,37
72,3 30,3
Ndng 18,0 25,58 5,5 10,4 Bang 10 cho thd'y kdt qud nghidn ciJu cua
chting toi khd phti hdp vdi cdc nghien cd\i trong nirdc nhutig khdc nhilu vdi nghiSn ciJu cua Suzana (2009). ViSc phdt hien bkng m6t phtfdng phdp so vdi b^ng cd hai phtfdng phdp trong nghien ctfu cfia chiing t6i khdng cd su" khdc bi$t cd y nghla thdng kd. Dieu ndy cung ttfdng ttf nhtf nghien cffu cua Ld Trung Thg [10]. Ti Id nhilm HP se theo ch^n dodn bdng MBH, vi phtfdng phdp ndy da dtfdc xdc dinh Id "tidu chuin vdng" trong ch^n dodn nhilm HP, cho dd nhay vd dd ddc hi^u rd't tdt [15]. Theo cdc nghidn cffu g i n ddy, ti
le nhidm HP dang cd xu htfdng gidm d cdc ntfdc chau A, trong dd cd Viet Nam [28]. Tuy nhien, li le nhilm HP trong nghidn cffu ci5a chung toi vin cdn khd cao.
Phdn bd VLDDTT tr^n nOi soi: Trong nghidn ctfu cua chdng tdi, tdn thtfdng vidm chie'm 100%, ti Id cd lodt kd't hdp chi cd 6 BN, chidm 2,5%.
Trong 6 trtfdng hdp lodt, cd 4 trtfdng hdp Id loet td trdng (1,6%) vd 2 trtfdng hdp lodt DD (0,9%).
Ket qua ndy rd't khdc bidt so vdi nhilu nghidn ctfu trong vd ngodi ntfdc [5],[27]. Mdc du hien nay ti 1$ tdn thtfdng lodt DDTT co khuynh htfdng giam
di vd d lfi BN VDD lai ldng lfin [27] nhtfng cho dfi'n nay chtfa cd mfit nghifin ctfu ndo tifin BN VLDDTT cd kfi't qui tdn thtfdng lofit lai thd'p nhtf nghifin ctfu ndy. Difiu ndy cd thd giii thfch dtfpc bing dac didm ddn sd nghifin ctfu Id ddn tfic fi Dfi
TAP CHl KHOA H O C TlEU H 6 A V I ^ T NAM 2012 • TAP VU- s d 13/
vd chdng vi khuin HP gdy bfinh dnh htfdng ddn khi ndng gdy VLDDTT trfin ngtfdi dan tfic I Dfi.
VI viy, cin cd thfim cdc nghifin cflu sau hdn dd xdc djnh ddc didm ndy.
Cdc d^ng VDD trfin nfii soi:
Bdng 11: So sdnh cdc dang VDD trfin nfii soi vdi mfit stf nghifin ctfu
D^ng vifim DD
Vifim XH/XT Vifim ttpt phing
Vifim trpt ndi Vifimleo Vifim xud't huyfi't
Vifim TNR-DD Vifim PDNNM
Tac gid (ndm) Mihai-a[16]
( 1 9 9 9 ) » 11.0"
13.0 8.2 56.3
2,8 2,0 6,6
QT.Dflc [23]
(2003)%
36.2 35.2 20.0 2,4
1,0 0,4 4,8
NQ.Chung' [18] (2007)%
3,4 89,7
1.7 0 6,1 0,0 0,0
Chiing Ifii (2010)%
58,3 24,6 7.5 9.6 0,8 2,9 0,8 'Viing hang vi; " c d 1.8% vifim DD cd'p; XH/XT: xung huyfi'l xud't dfi't; TNR-DD: u4o ngtfdc rufii- da ddy; PDNNM: phi dai nfi'p nifim mac
Bdng 11 cho thd'y cdc dang VDD rat khdc nhau giffa cdc nghidn ci^u, cd thd do dnh htfdng cua cdc ydu tdnhtf: thdi gian, dia IJ, chung tgc, ddn sdvd xa hgi.
V l hinh th^i tdn thi/tfng MBH: Cdc dang VDD c^a chiing t6i so vdi mot tdc gid ntfdc ngodi trong cilng thdi diem nhtf nghidn ctfu cfia Suzana [26]: (1) ll le VDD hoat dgng cua Suzana cao hdn chiing toi vd mffc dg cung khdc hdn, (2) mtfc dg VDD man cung ndng hdn chiing toi, (3) ti 1$ teo niem mac it hdn nhimg mffc d0 lai ndng hdn, (4) ti Id di sdn ruOt it hdn nhutig mtfc dO cung ndng hdn.
Ra't tide chiing tdi khdng lim dtf^c cdc nghidn cffu trong ntfdc mo td chi tid't cdc hinh thdi tdn thtfdng MBH de so sdnh. Nhtf v^y, so sdnh tren cung phin ndo cho thd'y yeu td chung tgc vd dia dtf cung cd dnh htfdng den hinh thdi VDD.
V^ gia trj cua n$i soi t r o n g ch^n do^n d|nh
khu VDD vk vidm teo d? day: Bdng 4 cho thdy nOi soi it cd gid tri trong ch£n dodn vidm thdn vi vd cflng khdng c6 gid tri trong ch^n dodn viem teo. Tuy nhidn. nOi soi lai cd gid tri ctfc kJ tdt trong chin dodn vidm hang vi. Kd't qud ndy phii h0p vdi nghien ctfu ciia Qudch Trgng Dffc [23].
Mdi lifin quan giffa n h i l m HP vdi cac d^ng VDD trdn n0i soi: Ti 1? nhilm HP phdn bdtheo cdc dang VDD di^a trdn phdn loai Sydney c6 stf khdc bi#l cd J nghia thdng ke (p = 0,011) (Fishers exact lest), Cdc dang viem xud't huydt, vidm trdo ngtfdc ruOt - da ddy (TNR-DD) vd vidm phi dai ndp nidm mac (PDNNM) cd tin sdnhd ndfl dtf0c gOp lai thdnh m0t nhdm vd cd ti le nhilm HP thd'p (18,2%); trong dd, khdng cd trtfdng hdp vidm TNR-DD ndo bj nhilm HP; vidm xud't huydt vd vidm PDNNM c6 tl 1$ nhilm HP d i u Id 50%. Cdc dang vidm xung huydt, vidm trdt phlng, vidm tr^
T.4tP CHl KHOA H g c Tifeu H d A Vl&T NAM 2012 - T-iiP VII - s d 29
ndi vd vidm teo cd ti 1$ nhilm HP cao hdn (> 55%).
Ndu Id'y nhdm vidm xudt huyd't, vidm TNR-DD vd vidm PDNNM ldm tham chidu thi nhdm vidm xung huyd't xud't tid't, viem tr^t phJng vd vidm teo cd ti Id nhilm HP cao hdn iln Itf^t 3,3; 3,4 vd 4,3 iln vd stf khdc nhau ndy cd J nghia thdng kd. Nhdm vidm trdt ndi cd ti 10 nhilm HP cao gd'p 3 iln nhtfng khdng cd y nghia thdng kd. Kdt qud ndy khdng phii hdp vdi mOt sd nghien cffu khdc [23],[26].
Mdi lidn quan giiTa n h i l m H P vdi VDD ho^t dOng: Ti 10 n h i l m HP trong VDD man hoat dOng Id 90,5% so vdi nhdm khdng cd vidm hoai dgng id 2,4%. Sir khdc bi0t ndy cd J nghTa thd'ng ke (p < 0,001). Kd't qud ndy hodn todn phi! hdp vdi cdc nghidn cffu trtfdc ddy nhtf ciia Qudch Trgng Dffc [23], Le Trung Thg [ 10] vd cdc tdc gid ntfdc ngodi nhtf Suzana [26], Price [22].
Nhtf vdy, dang VDD hoat dOng Id hinh thdi ddc trtfhg nhat cua VDD do nhilm HP.
Mdi lien quan giCTa n h i l m H P vdi mdc d0 VDD man tinh: Kd't qud nghien cffu cho tha'y li Id nhilm HP d nhdm cd tdn thtfdng VDD man mffc dd tnmg binh vd ndng Id 81,7%, cao gap 1,5 iln so vdi d le d nhdm cd tdn thtfdng VDD man mffc dO nhe Id 53,3% vd stf khdc biet ndy Id cd J nghla (p < 0,001). Kdt qud ndy cung phfl hdp vdi nghien cffu ciia Qudch Trong Dffc (2003) [23], ttfdng ttf nhtf cua Pajares (1996) [21], vd cua Suzana (2009) [26]. D i l u ndy k h i n g dinh rdng HP Id ydu t d c h u dao hoac ke'l hdp gdy VDD man.
Mdi lien quan givta n h i l m H P vdi d) san ru0t va teo nidm m^c: Trong nghidn cffu cua chflng tdi, li Id nhilm HP d nhdm cd teo nidm mac cao gd'p 1,4 iln so vdi nhdm khdng cd leo nidm mac, stf khdc biet ndy cd y nghTa thd'ng kd (p = 0,004), phfl hdp vdi cdc nghien cdti cua Suzana (2009) [26] vd cua Zaitoun (1994) [29]. Trong nghien cff^n ciia chflng tdi khdng thdy mdi lidn quan giffa di sdn rudt vd nhilm HP, khdng phfl hdp vdi cdc nghidn cffu cfla Suzana vd Zaitoun [26],[29]. Mdi ddy (2010), Takeshi Matsuhira nghidn cflli tren quin thd ngtfdi Ddng A, Ddng Nam A, Nam A vd Nhdt Bdn dd ghi nhdn kdt qud nhtf sau: ti id nhilm HP cao d Thdi Lan vd Bangladest vd thd'p hdn d Vi0t Nam, Hdn Qudc, Nhdt Bdn vd mOt sd ntfdc
khdc. Lodt DD chiem tfu t h d d Hdn Qudc vd Nhdt Bdn, ti 10 vidm teo nidm mac, dj sdn rugt vd loan sdn d ngtfdi Nhdt Bdn cflng cao hdn cdc ntfdc khdc [14]. vdn d l di sdn rugt vd teo nidm mac cd le lidn quan ddn chflng lgc, dia dtf, moi trtfdng sdng vd cdc chflng lodi vi khu^n HP khdc nhau.
Mdt lidn quan giita nhiim HP vdi nhdm tudi:
Chung tdi khong Ihify cd mdi lidn quan gifla nhilm HP vdi nhdm tudi, phfl hdp vdi cdc nghidn cffu trong ntfdc [6],[10],[17]. Ngtfdc lai, cdc nghidn cffu d ntfdc ngodi deu cho thify ti 10 nhilm HP tdng Iheo ludi [1],[11]. Nhtf vdy, md'i lidn quan giffa nhiem HP vdi nhdm tudi Ifly thuOc vdo ttfng qud'c gia. 6 cdc ntfdc dang phdt tridn, nhilm HP thtfdng xdy ra tff lflc cdn nhd vd dat dinh cao d Iffa tudi 20, cdn tai cdc ntfdc phdt tridn, tudi bi nhilm thtfdng > 50 vd tin sud't tdng din theo tudi [12].
Md'i lidn quan giifa nhilm HP va khu v^fc sdng:
Hodng Thi Thu Hd (2005) da bdo cdo ti le nhilm HP tai vflng ndng thdn Hd Tdy thd'p hdn c6 ;J nghia thdng kd so vdi d thdnh phd Hd Ndi (OR = 0,59;
do tin cay 95% = 0,43-0,81). Nghidn cfl^ trdn cung cho thd'y ti Id nhilm HP d Vidt Nam cao vd ddc bidt cao d cdc thdnh phd' ldn, ddng dffc, chat chdi vd 6 nhilm nhtf Hd Noi [6]. Mgt nghien cffu khdc do Hong Chen vd cgng stf thtfc hi0n ndm 2009 tai 2 khu vtfc ndng thdn vd ngi thdnh Bic Kinh (Tnmg Qudc) lai cho ket qud ngtfdc lai: d Id nhiem HP 5 ndng thdn cao hdn cd J' nghTa thdng kd so vdi thdnh thi (p<0,05) [2]. Trong nghidn cfl^i cfla chfing tdi lai khong thd'y stf khdc bi0t giffa ndng thdn vd thdnh thi.
Mdi lidn quan giffa n h i l m H P vdi trinh dd hpc vS'n: Khdng thd'y md'i lidn quan giffa ti 10 nhiem HP vdi trinh dd hgc vdn (p = 0,688). Trong khi cdc nghidn cfl\i trong ntfdc khdng de cap vd'n de ndy thi nhilu nghidn cfiTu tai ntfdc ngodi da nghien cflXi khd ky mdi hen quan giffa nhilm HP vd trlnh do hgc vd'n. Nghidn cfl\i cua Zaterka (2007) cho thdy trinh do hgc vd'n thdp vd nhdm ddn tgc Id cdc ydu td nguy cd dgc ldp cfla nhilm HP [30]. Nghien cfl^u cfla Ruihua Shi (2008) cho thd'y ydu tdthu nhdp gia dinh vd trlnh do hgc vd'n thd'p Id cdc yd'u td nguy cd dgc l^p cfla nhilm HP [24]. Stf khdc nhau giffa nghien cffXi cfla chflng tdi vdi cdc nghien cthi trdn cd Ihd gidi thich nhtf sau: nghidn cffu cua chflng toi
TAP CHf KHOA n g c TlfeU H d A VI^T NAM 2012 - T ^ P VII- s6 29
cd nhdm cd trlnh dg hgc vd'n thd'p cao (ti 10 mtl chff;
cd'p I; cd'p II chidm 78,3%). VI v&y, mudn so sdnh dtfdc chinh xdc, cin cd nhOlig nghidn cffu vdi c3 mlu ttfdng dtfdng giffa nhdm cd trlnh dO hgc vdn thd'p vd nhdm cd.trlnh dO hgc vd'n cao hdn.
Md'i lidn quan giiJa n h i l m HP vdi chddO Sn dac trtfng cua dfin t0c t D § : Kdt qud cho Ihdy tl 10 nhilm HP d nhdm cd thdi quen dn ddc Irtfng cfla ngtfdi ddn tOc fe Dd cao gd'p 1.4 iln so vdi nhdm dn udng theo kidu ngtfdi Kinh, stf khdc bi0l ndy cd S nghTa thdng kd (p = 0,006). Chd dO dn cfla ddn t0c 6 Dd Id mOt bid'n sdquan trgng vl mdi lidn quan gitta nhilm HP vd chd dO dn ddc trtfng ciia ddn t0c fe Dd cd Id khdng lidn quan ddn cdc loai thffc dn md lidn quan dd'n cdch chd bid'n thffc dn, sff dung bdt dTa khdng hdp v0 sinh. Ddy Id cdch Idy truyin HP quan trgng hdn.
Mdi lidn quan giffa nhilm HP v^ ntfdc udng dun s6i: Kd't qud nghidn cffu cho thd'y d 10 nhilm HP d nhdm udng ntfdc khdng dun sdi cao gd'p 1,6 iln so vdi nhdm udng ntfdc cd dun sdi vd stf khdc bi0t ndy cd J nghia Ihdng ke (p < 0,001). Kdt qud ndy phfl hdp vdi mgt sd nghien cu^ ntfdc ngodi [24],[30]. Vdo ndm 1991, Hultel vd cgng stf da thdnh cdng trong vide phdt hien HP trong ntfdc udng bdng phtfdng phdp PCR [8]. Vi vdy viec dun sdi ntfdc dtfdng nhtf Id cdch hi0u qud dd ngdn ngfla stf idy nhilm HP.
Mdi lidn quan giffa n h i l m HP vdi thdi quen r d a tay trtfdc khi an: Trong nghidn cfl\i cfla chflng ldi, d 10 nhiem HP d nhdm rffa lay khdng thtfdng xuyen trtfdc khi dn Id 76,6%, cao g^p 2 iln so vdi nhdm rffa tay thtfdng xuydn trtfdc khi dn, stf khdc bidtndycd J nghia d i d n g k e ( p < 0,001). Chflng tdi khdng tim thd'y tdi lieu ndo trong ntfdc dd so sdnh.
Mdi lidn quan giffa n h i l m H P vdi kidu nha d:
Tl 10 nhiem HP trong nhdm d nhd ddi theo kid'u ngtfdi E Dd cao gdp 1,2 iln so vdi nhdm d nhd kieu ngtfdi Kinh, nhimg stf khdc bi0l ndy khdng cd J n g h i a (p = 0,119). Chflng tdi cung khdng lim dtfdc tdi li0u ndo dd so sdnh.
Mdi lidn quan giffa n h i l m HP vdi sd ngtfdi sdng chung: 11 le nhilm HP theo tflng nhdm cd sd ngtfdi sdng chung (<10 ngtfdi; 10-20 ngtfdi; >20 ngtfdi) cho thdy stf khdc bi0t cd S nghia thdng ke vdi p < 0,001.
s d ngtfdi sdng chung cdng ddng Ihl d 10 nhilm HP
cdng cao. Ndu idy nhdm <10 ngtfdi ldm tham chidu Ihl so vdi nhdm 10-20 ngtfdi vd > 20 ngtfdi iln Itf^t Id 1,6 vd 2,2 Iln (p = 0,014 vd < 0,001). MOt sd nghidn cffu lai ntfdc ngodi cflng ghi nh^n d 10 nhilm HP tdng d 10 thu?ln vdi sd ngtfdi trong gia dinh [20],[30].
Mdi Hdn quan giffa nhilm H P vdi m0t sdydu td qua phfln tich hfii qui da bidn: BSng 9 cho Ihify trong nghidn cffu cfla chiing tdi cd 4 ydu td ddn sd, xa h0i vd 6 ydu td v l tdn thtfdng trdn n0i soi cd lidn quan vdi nhilm HP vdi mffc ^ nghia p < 0,1. Khi phdn tich h6i qui da bidn Poisson thi chl cdc ydu td sau cd lidn quan dOc ldp dd tidn dodn nhilm HP: vl nOi soi cd cdc dang VDD: vidm xung huydt xudt tidt.
vidm trdt phSng, vidm teo nidm mac dtfdc xdc dinh Id cdc ydu td lidn quan d0c l^p vdi nhilm HP. Ddy Id cdc ydu id khdng thay ddi dtfdc; Cdc ydu td xd hOi:
(1) ydu tdrffa lay khdng thtfdng xuydn vd sdngUEJi chung sdng trong mOt gia dinh Id cdc ydu td lien quan dOc ldp dd tidn dodn nhilm HP. Ddy Id ydu l6 cd thd thay ddi dtfdc bdng cdch gido due Y td cdng c0ng, cdi thi0n dilu kidn sd'ng cua ddng bdo E Dd.
Kd't lufin
- Ti 10 nhilm HP d ddn tgc fe De Id 60,4%.
- Tdn thtfdng VDD chidm da sd(97.5%) so vdi vidm kd't hdp lodt (2,5%).
- v l nOi soi: dang vidm hay gdp nhd't Id viem xung huyd't/xuS't tidt vd vidm trdt phlng.
- v l md hgc: vidm man boat dgng chid'm tfu did (65,8%), Iln Itfdt dd'n teo nidm mac (36.25%), di sdn ru0l (25%).
- Cdc ydu td c6 lidn quan d0c ldp dd tien dodn nhilm HP: cdc dang tdn thtfdng trdn nOi soi (vidm xung huydt xud't tid't, vidm teo nidm mac vd viem trdt phlng); cdc yd'u td ddn sd', xd hOi: (rffa lay khdng ditfdng xuydn vd sd' ngtfdi sdng chung, trong dd sd ngtfdi sdng chung) Id cdc yd'u td lidn quan thudn dOc ldp dd tidn dodn nhilm HP.
Tdi li^u tham khao
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