Y HOC VlgT NAM THAHG 8 - SO 1/2014 (2) s y thay doi nong do acid uric va LDH mau
s a u j a n b g c h c a u :
- Nong do acid uric giam dang ke sau khi gan (P<0,01), tren ca benh nhan nam va nu* (tri so tu'dng utig tru'dc va sau gan la 412 va 359 pmol/L doi vcfi nam; va 313 va 236 pmol/L doi veil nD").
- Nong dp LDH giam dang ke sau khi gan (P<0,01) ( t n so tu'dng u'ng tru'dc va sau gan la 2958 va 1367 U/L).
TAI LIEU THAIVI KHAO
1. Cobe Laboratories (1999), "Section 8A - WBC operation" Colje- Spectra Apheresis System Operator's manualOotoe BCT, Inc., pp 8A1-8A13.
2. Committee of the American Society for Apheresis (2007), "Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence - based Approach from the Apheresis Applications Committee of the American Society
for Apheresis", Joumal of Clinical Apheresis 11, pp. 131.
3. Curtis JE, et a l . (1972), " Leukapheresis therapy of chronic lymphocytic leukemia", Blood 39, pp.
163-175.
t. Novotny JR, Kribben A (2005), "Grading of symptoms in hyperleukocytic leukaemia: a clinical model for the role of different blast types and promyelocytes in the development of leukostasls syndrome", European Journal of Heamatology 74, pp. 501-510.
5. Porcu P, Faras S, et a l . (2002),
"Leukocytoreduction for acute leukemia".
Therapeutic Apherresis, 6, pp. 15-23.
6. Tan D, Hwang H, Goh YT (2005) "Therapeutic Leukapheresis in Hyperleukocytic leukaemias - The Experience of a Tertiary Institution in Singapore", Annals Academy of Medidne In Singapore 34, pp. 229-234.
7. Zipursky, Bow E, Seshadri RS & Brown E]
(1976), "Leukocyte density and volume in normal subjects and in patients with acute lymphoblastic leukemia", Biood4%, pp. 361-371.
DAC DIEM L A M S A N G , CAN L A M S A N G V A CAC YEU TO TIEN LirCTNG HOAI TO* T R O N G V I E M TUI M A T CAP DO S6l
Phan Khanh Vift*, Le Trung Hai**, Pham Nhu- Hifp*
T6IVI TAT
Nghien cutJ 103 benh nhan viem tui m|t cap do sol du'dc dieu trj bang phau thuat cat tui mat npi sol cho ttiify cac dac diem chfnh cua viem tui mat cap do soi la dau bung vung ha su'dn phai hay thu'dng vi (100%}, an dau vung tiil mat(100%) bleu hi?n bang dau hieu tui mSt to, an dau hay nghiem phap Murphy (+), s6t (44,7%0, bach cau >10 000 (55,3%). Tren sieu 3m tui mat to (86,4%), vach tui mat day > 4mm (87,4%), djch guanh tui m§t (12,6%). T6n thu'dng dSc trung trong mo cua viem tiii mat cap do sol ia tui mat to, c3ng, ijianh phu ne va dfnh vao cac tang lan c$n.
Cac dau hieu tien lu'dng ho?i tu" bao gom Cac benh nhan Idn tuoi (> 65), co sot, kham co tui mat Idn, phan irng dudi su'dn phai, sieu am c6 soi ket c6 tOl m§t, xet nghiem mau cd du'dng mau, bilirubin, men gan tSng.
Tvf I(ti6a: Vien tiil mat cap, Lam sang, Sieu am, Viem tui mat hoai tuf
* B?nh vien tinh Quang Trj
*« Cue Quan y - Bo Quoc phong
* * * Benh vien Trung u'dng Hue Chju trach nhiem chinh: Phan K h a n h V i ? t Email: ^h?nhviet7QigiQmail.com Ot: 0914.059.623 Phan bien khoa hoc: PGS.TS Nguyen VSn Xuyen Ngiy nh$n bai: 9.6.2014
S U M M A R Y
CLINICAL, PARACLINICAL FEATURES AND P R O G N O S n C FACTORS
FOR THE DEVELOPMENT OF GANGRENOUS CHOLECYSTITIS I N ACUTE CALCULOUS CHOLECYSTIHS Study on 103 patients with acute calculous cholecystitis treated by laparoscopic cholecystectomy indicated that the main features of acute calculous cholecystitis were right hypochrondium or epigastrum pain (100%), gallbladder point(+) (100%) presented by thick-watled gallbladder or possitive l^urphy sign, fever (44,7%), increased white blood cell over 10 000 (55,3%), Sonography showed large GB size (86,4%), thlck- walled gallbladder > 4mm(87,4%) and Perlcholecystic fluid (12,6%). Per-operative pathological features of acute calculous cholecystitis were lage GB, hydrops, oedematous GB wall and adhesions with around tissue
Prognostic factors for patients at increased risk for having gangrenous cholecystitis included age greater than 65 years, fever,large GB, tenderness on palpation in the right upper abdominal quadrant, stone impacted in the cystic duct on ultrasonography, elevation of SGOT,SGPT,Bitirubin and glucose In blood test
Keywords: acute cholecystitis, clinical, ultrasound, gangrenous cholecystitis
Y HOC VIET NAM T H A N O 8 • SO irai»;i
I. BAT VAN OE
Viem tui mat cap do soi la benh ly viem ntiiem cap tinh cua tui mat gay ra bcJi stf tac nghen tui Hartman hay dng till mat do soi tui mat hay sit lang dong cua bun tui mat. Viem nhiem ciia thanh tui mat la viem vo l<huan it nhat trong giai doan dau cua benh. Tang ap lUc trong tui mat va su* hien dien cua mat qua bao hoa cung v6i chan thu'dng cua niem mac gay ra bdi vien sol da khdi phat 1 dap CTng viem cap. Sau giai doan nay 20-50 % cac benh nhan co su* phat trien cua cac vi ithuan ruot ai l<hi' hoac thinh thoang la kj khi lam cho viem tui mat trcf nen hu'u khuan [4]
Viem tui mat hoai tit, mpt tinh trang tien trien n3ng ne han cua viem tui mat cap, la mot thach thu'c ve ky thuat cung nhu' tang ty le bien chiJng va tiJ vong trong phau thuat cat tui mat npl soi [6]. Nhu* vay viec chan doan sclm, chinh xac, tien WBng dung mii'c dp thu'dng ton se giup chung ta dieu trj k|p thcfl nhat la cat tui mat npi soi dieu tri viem tui mat cap do soi trong thdi gian vang se mang Iai ket qua tot cho benh nhan. Bii vlit niy niu lin 1 so dac diem lim sing, c$n lim sing vi cic yiu to tlin lifpng hoal tif trang viim tui mat dip da sdl
II. OOI TirpNG VA PHirONG PHAP NGHIEN ClJU 2.1. Soi tu'dng nghien cu'u
Gom 103 benh nhan (BIM) viem tui mat cap (VTMC) do sol du'dc dieu trj bang cat tui mat npi soi tal benh vien trung u'dng Hue til thang 12/2007 den thang 3/2012
- Tieu chuan loai trirr VTMC do soi co kem sdi du'dng mat chinh, u duiSng mat, VTMC do sol kem u tuy, u da day, VTMC do sdi cd benh ly hd hap va tim mach nang, VTMC du'dc mo cat tui mat npi soi nhmig giai phau benh khong cd tinh trang viem cap hoac khong cd sdi till mat.
2.2. Phu'dng phap nghlSn ciJu; Nghien dtu tien ciiu, md ta cat ngang
2.2.1. Nghiin cuti dc die diim chung, lim sing vi xit nghiim
• Bac diem chung; tuoi, gidi, dja du'.
- Trieu chimg sot va cac dau hieu nhilm triing.
• Cac dSu hieu cd nang va thirc the : Oau bung, vj tri dau, tfnh chat dau, tui mat sd thay, dau
hieu Murphy khi khdng sd thay till mat, phan ung ha su'dn phai
- Xet nghiem mau: so lu'dng bach cau, bilirubin, men gan.
2.2.2. Sieu im: kich thu'dc tui mat, dp day thanh tui mat, sdi tui mat, dich quanh till mat
2.2.3. Giil phau benh
- Dai the; tui mat Idn, chu'dng nu'dc ,vach tui mat day, djch quanh tui mat, sdi ket co tui mat.
- Vi the; viem tui mat cap khong hoai tii" va viem till mat cap hoai til.
2.2.4. Cic yiu to liin quan din viim til mat hoal tW.
2.2.5. xif If so lieu bang phan mem SPSS 10.0 for Windows
III. KET QUA N G H I E N Ciru
3.1. Sac diem chung
- Tudi; nhd nhat la 23, tudi Idn nhat la 84, tuoi trung binh 54,4 ± 14,7, Tudi >40 chiem 84,5%
- Gidi; nu' (67%) cd xu hu'dng nhieu hdn nam (33%), Ty le nD'/ nam = 2/1
- Oja du'; thanh thj (47,6%) va ndng thon (52,4%) - Trieu chung sdt va cac dau hieu nhiem triing; ve mat nhiem triing (100%), sot (T">37°8) 44,7%
3.2. Cac dau hieu cd nang vd th^c the va xet nghiem mau
- Cac triSu chimg lam sang; Oau bung viing ha su'dn phai hay thu'dng vj (100%), mu'c dp dau am i (95,1%), dir dpi (4,9%), an dau viing tui mat (100%), tui mat Idn khi kham (17,5%), Murphy(+) (82,5%), phan ung ha su'dn phai (5,8%) - Xet nghiem mau: Bach cau tren 10 ngan chi€m 55,3%, bilirubin tang {>19Mmol/l) 13,6 %, Men gan tang(> 80ui/l) 13,6 %.
3.3. Sieu am: hii mat Idn (86,4%), vach till mat day >4mm (87,4%), sdi nhieu vien (61,2%), kich thu'dc sdi >10mm (50,5%), sdi ket co hay ong (33,0%), dich quanh tiii mat (12,6%).
3.4. Glal phiu b^nh.
• Oai the: kich thu'dc tiii mat Idn (100%), till mat cang (34%), vach day(84,5%), sdi ket cd hay dng (33,0%), hoai tir tiii mSt (9,7%), dich 6 bung (40,8%), dfnh nhieu ciia tiii mat (48,5%).
- Vi the: VTMC khdng hoai tiT ( 88,35%), VTM hoai tir (11,65%)
3.5. Cac ySu tff lien quan den tinh tr?ng
ho^itu'tuimSt
y HOC VI£T HAM THANG a - s61/2014
Die diem Tuoi > 65 Gidi nam Sot ( r > 37"81 Dau bunq du'doi Tui mat Idn Phin irtiq HSP Sdi ket cd tui mat Bach cau >10 000/mm' G>7mmol/l Bi>19wmol/l SGOT>80ul/l SGPT>80ui/l
VTMC 16,5%
33,0%
39,6 % 3,3%
8,8%
2,2%
28,6%
53,9%
3,3%
11,1%
8,9%
10,0%
VTM hoai ta 50%
33,3%
83,3%
16,7%
83,3%
36,4%
66,7%
66,7%
36,4%
36,4%
54,5%
45,5%
P 0,015
1 0,005 0,102 0,000 0,001 0,018 0,4 0,02 0,044 0,001 0,007
IV. BAN LUAN
Viem tiii mat cap la mot bien chirnp ciia sdi tiil mat la mpt benh hay q3p tren lam sang.
Theo nhieu nghien ciTu, day la 1 benh hay gap d ngu'di trung nien vd Idn tudi, trang nghien ciru cua chiing tdi tudi trung binh la 54,4 ± 14,7, Tuoi >40 chiem 84,5 %. Theo Breitenstein S [5], VTMC hay gSp d tuoi trung nl€n va ngu'di gia. T^
II benh d ngu'di du'di 40 tudi va ngu'di tren 40 tudi la 1/3,5. Gidi nii' hay gap hdn nam ma cac hdc mon sinh due nH chju trach nhiem cho sir khac biet nay. Ty le HU/ nam trong nghien ciiXi ciia chiihg tdi la 2/1 phii hdp vdi nhieu nghien dtu khac. Trudc day sdi tOi mit hay gap d thanh thj, hien nay do miit sdng va dllu kien ve sinh d nong thon da du'dc cai thien nen ty l | sdi hii mat d 2 ndi khdng con cd su' khac biet niTa. Kit qua cua chung toi: thanh thj (47,6%)^ va' ndng thdn (52,4%).
Trong nghien cuti ciia chung tdi, ve mSt nhiem triing 100%, sdt ( f >37''8) 44,7%. Tat ca cac BN ciia Chung tdl deu cd ve mat nhiem triing tir mdi mat bdng, luSi trang nhe cho den rnpi khd, iuSi bSn, hdl thd hdi dac truHg ciia nhiem triing. Tuy nhien tridu chirng sdt chi gSp 44,7%
cao hdn Nguyen Thdnh Cdng 32,08% , thap hdn Hoang Manh An 100%, Nguyin Van Hal 57,6%
[11, [2], [31. Sot la m^t trieu chu'ng todn than.
No phu thuoc vao su' dap img cua cd the, ddc lire cua vl' khuan, cd dung kh^an^ sinh hay khdng ? Cac dieu ki|n nay thay ddi tuy timg ndi nen cd xuat dd khac nhau.
100% cac BN vao vien vi dau bgng, trong dd dau HSP chiim 87,4%, TV va HSP 7,8%, TV 4,9%.%. Nguyin Thanh Cong khao sat 53 benh nhan VTMC, 1;^ do vdo vien 100% Id dau biing 94 34 dau HSP, 5,66% dau TV. Nguyin Vin Hai khdo sat tren 66 bdnh nhan VTMC thi 100% deu dau bung HSP. Nhin chung dau bung la mpt trieu chiing rat hay gSp vd Id trieu chu'ng khien BN phdi nhap vien [2], [3].
An dau viing tiii mat gdp 100% cac tru'dng hdp. Bleu hien bdi sd thay tiii mat Idn 17,5%.
Cac tac gia khac; Nguyen thdnh cdng 52,83%, Nguyen Van Hai 21,2% [2], [3]. Nhin chung ty l | sd thay TM ciia chiing tdi it lidn cac tac gia khac.
Ty le nay tiiy thupc vap tinh trang BN gay hay beo, thdnh bung day hay mdng. Cac BN gid hole gay thi rat d l phat liien, cac BN map thdnh bung day, hay cac BN dau bung vdi tang cdm giac da, CO ciing, phan ting viing HSP thi rat khd phat hien tneu chiing nay. Khi khdng sd thay TM chiing tdi Idm nghiem phap Murphy, ty l | (+) ciia chiing tdi Id 82,5 %, Cao hdn cac tdc gia Nguyin Van Hdi 19,7%, Nguyen Thanh Cdng 47,17% [2], [3].
Phan ling phuc m^c chiem 5,8% thu'dng gap khi cd hien tuUng tham mat phiic mac, viSm phiic mac mat hay khi till mat bj viem nhiem ndng.
T'i''le bach cau >i0 ngdn la 55,3%. Ket qud ciia chiing tdi cung tu'dng tir ket qud cua Nguyen thanh Cdng bach cau tang >10 ngdn la 50,9%
[2]. Nhu' vay ty le khdng tang bach cau kha Idn, ly do la phan Idn cac BN nhap vien mudn va cd sir dung cdc chat giam dau khang viem hay dimg khang sinh nen qua trinh viem cd phan ndo bj ngan chan vd do dd trong 1 sd tru'dng hdp bach cau khdng con cao niJa. Cdc xet nghiem mau khac nhu'bilirubin tang (>19^mol/l) 13,6%, Men gan tang(> 80ul/l) 13,6% cd the du'dc giai thfch Id do hien tu'dng viem nhllm ciia tiii mat lan sang cac vung lan can nhu' du'dng mat chfnh, hay giu'dng gan vdi cac o hoai tCi va gay nen si/ tang nhe cua men gan vd bilirubin trong mau. Khi cac chi so ndy tang cao can canh giac cd sdi du'dng mat chfnh kem theo.
Sieu am la 1 phu'dng tien lira chpn dau tien de chifn doan benh ly till matTheo Birbas K.N [4] 90% cac h'U'dng hdp VTMC do sdl cd the chan doan xac djnh du'a vao cac dau hieu lam sang vd sieu am.Trdng nghien ciiti cua chiing tdl da sd ghi nhan tren sieu am la hinh dnh tiii mat to.
Y HOC VIET NAM THANG 8 - 5 b 1/2014 vach day, dich quanh tui mat trong mot so
tru'cJng hdp., phu hdp vdi cac tac gia khac Hinh anh dai the trong mo thu'dng thay la tui mat to, thanh tui mat phu ne, dinh vdi mac noi hay cac tang xung quanh la cac trieu chihig hay gap vdi t i n suat 100%. Cac dau hieu khac bao g5m soi ket co hay ong (33,0%), djch 6 bung (40,8%), hoai tCrtui mat (9,7%).
Viem tlii mat hoai tii la mot dang tien trien cua VTMC, ty Ie' thay' doi tir 2-29,6% cac tru'dng hdp VTMC, \\%n quan (Jen ty le bien chu'ng va tii vong cao, tuy nhien chi co khoang 9 % cac^ benh nhan VTM hoai tti' du'dc chan doan tru'dc mo [ 6 ] .
Trong nghien cuti cua chung, cac yeu to lam sang nhu": tuoi > 65 (p= 0,015), sot ( p = 0,005), TM Idn khi tham kham ( p = 0,000), phan lilng HSP (p= 0,001), soi ket co tui mat (p=0,018) va cac yeu to can lam sang nhu*: Glucoza mau luc doi >7mmol/l(p=0,02), Biiirubin mau > 19Mmoi/i (p=0,044), SGOT>80ui/l ( p = 0,001), SGPT>
80ui/i (p= 0,007) la cac dau hieu tien lu'dng hoai tir. Bach cau >10 ngan(p= 0,4), dau bung dU doi (p=0,102 ), vach tui mat day> 4mm (p=0,35 ) CO xu hu'dng cao trong VTM hoai tuf.
Cac dau hieu sot, bach czu tang cao la cac dau hieu nhiem trung toan than thu'dng nang ne trong VTM hoai tu'. Bau bung du* dpi, phan utig HSP, la nhihig dau hieu TM da cd bien chu'ng thiing. viem nhiem da tien trien cua TM , doi khi thung se du'dc mac noi va cac tang den bam tao khoi d HSP the hien tren lam sang la TM Idn. Cac BN tien sir dai du'dng va nhu'ng ngu'di cao t u o i , m?ch mau nu6i duQng TM it nhieu bj x d vGci, hep long de bj t i c trong cd che benh sinh ciia VTMC do dd TM de bj thieu mau nuoi du@ng va hoai tiT.
Bilirubin va men gan cao the hien viem nhiem da lan toa sang cac vung lan can nhu' nhu mo gan va dudng mat va lam tang cac chi so nay.
Ket qua cua chung toi phiJ hdp vdi da so cac gia khac la VTM hoai t i r thu'dng gap d cac BN gia.
Tuy nhien Yacoub W.N [ 7 ] nhan thay gidi nam hay bi VTM hoai tir, trong nghien CU\J cua chung toi khong co sii" khac biet ve gidi ( p = l ) . Cac yeu to khac nhu" bach cau > 10 ngan va vach TM >
4mm chi co xu hu'dng cao trong VTM hoal tir nhu'ng khong cd y nghTa thong ke.
V. KET LUAN
- Benh viem tui mat cap do soi cd cac dac diem tam sang va can lam sang nhu* sau: dau bung vung ha su'dn phai hay thu'dng vj(100%),an vung tui mat dau(100%) bieu hien vdi tui mat to,an dau hay dau hieu Murphy ( + ) , sot gap d 44,7% va bach cau > 10 ngan gap d 55,3% cac benh nhan - Cac hinh anh sieu am gSp trong viem tiii mat cap do sdi la:
+ Tui mat Idn (86,4%)
+ Vach tiii mat day > 4mm (87,4%) + Djch quanh tui mat (12,6%).
- Ton thu'dng dac trutig trong mo ciia viem tui mat cap do sdi la: Tui mat Idn, thanh phu ne, dinh vdi cac tang xung quanh va thu'dng co dieii quanh tiii mat.
- Cac benh nhan Idn tuoi ( > 65), cd sot, kham co tui mat Idn, phan utig du'di su'dn phai, sieu am cd sdi ket CO tui mat, xet nghiem mau cd du'dng mau, bilirubin, men gan tSng thu'dng la bieu hien ciia viem tiii mat hoai tir.
TAI LIEU THAIVI K H A O
1. Hoang M^nh An (2009)," Danh gia ket qua diaj trj viem tui mat cap do soi bSng phau thuat nai soi'; Tap chi YDutic hQC quSn su: 34(4), tr. 81-85.
2. NguySn Thanh Cong (2006),'" Nghien c i ^ d|c diem tam sang, can iam sang va danh gia k 3 qua diSu trj viem tui mat cap bSng ph§u thu^t cat tui mat n6i soi" Luin vSn thac sp Y hgdjn^nq (tgl hoc Y Hue).
3. Nguyen V i n Hal , Nguyen Tu$n (2005), "Ket qua cua cat tui mat npi sol trong vi€m tOi mat cap do soi'; tap chi y hoc thanh pho Hd Chi f^inii.
9(2), tr. 109-113.
4. Birbas K.N (2006), "Gallstone diease". Liver and biliary tract surgery, SpringerWienNewYork, pp.
149-167.
5. Breitenstein S (2006), "Acute and chronic cholecystitis". Diseases of the Gallbladder and Bile Ducts: Diagnosis and Treatment, Blackwell Publishing Ltd, pp. 229-238.
6. W u B (2014), "Predicting gangrenous cholecysti&s", international Hepata-Pana^to- Biliary Assodation, pp. 1- 6.
7. Yacoub W.N (2010), "Prediction of Patients with Acute Cholecystitis RequiringEmergent Cholecystectomy: A Simple Score"
Gastmenteroiogy Research and Practice, 10, pp.
1155-1160.
