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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 10 - N°2 /201|j
Gia tri cua sieu am noi soi trong clian doan nguyen nhSn gian 6ng mat chu khi khong phat Men dugc tren cong huong tu duotig mat-tuy
Value of endoscopic ultrasound in diagnosis of unexplained common bile duct dilatation on magnetic resonance cholangiopancreatography
Nguyen Van Sang *, Nguyen Ngoc Dai Lam*, Benh vien E Trung uang, Vu Hong Anh , Pham Hong Dire Dgi hoc YHdNoL
Muc tieu: Nham danh gia chan doan cua sieu am ndi soi tren nhdng benh n h l n co gian ong mat chd (OMC) ma khdng t h l y dUpc nguyen n h l n tren cdng hUdng tU. Ddi tdgng vd phdang phdp: D i n h gia hdi cUu 28 benh nhan gian OMC dUpe tham k h i m sieu am (5A) npi sol, phan tich ket qua vdi phosphatase kiem huyet thanh trudc khi lam SA ndi soi trong k h o i n g thdi gian 1 nam. Kef qud: 28 benh nhan (11 nam, tuoi trung binh 54,4} cd gian OMC. 10 benh nhan cd phosphatase kiem trong huy^t thanh tang. Cac chan doan sau tham kham SA ndi soi la: Sdi OMC cd 10 trudng hop (37,5%) vdi kfch thUdc Idn n h i t la 10 mm, u OMC ed 1 (3,5%) benh nhan. SA ndi soi thay binh thudng cd 13 (46,4%) benh nhan va 2 trong so nhUng benh nhan nay ed tui thUa quanh nhu ta trang. NhUng benh nhan cd benh ly OMC deu cd xet nghiem chUc nang gan bat thudng, trong khi 14/21 (66,6%) benh nhan sinh hda gan binh thudng cd SA ndi soi binh thudng. Khdng cd su" khac biet dang k^ ve dUdng kfnh trung binh cua OMC giUa nhom co va khdng cd benh ly (p>0,05). Ket luan: SA ndi soi la mdt tham kham cd hieu q u i eho benh n h l n gian OMC khdng tim dUOc nguyen n h l n tren cdng hUdng tU dUdng m i t . Dudng kinh trung binh cua OMC va cac xet nghiem chUc n I n g gan binh thudng khdng loai trUcd benh tiem an.
TdkhOa: Sieu I m ndi soi, sdi ong mat chu, cong hUdng tU mat tuy, chup ndl soi m i t tuy ngUpc ddng, bdng ta trang.
Summary
Objective: To evaluate the diagnostic performance of endoscopic ultrasound (EUS) in patients with unexplained dilated CBD on MRCP. Subject and method: 28 patients referred for EUS evaluation of a dilated CBD were retrospectively analyzed with respect to serum alkaline phosphatase prior to EUS and subsequent outcome after EUS over a 1-year period. Result 28 patients (11 males; mean age 54.4 years) with dilated CBD were retrospectively identified. Ten patients had elevated serum alkaline phosphatase.
The diagnosis obtained after EUS examination was: CBD stones in 10 patients (37.5%) with largest size of CBD stone being 10 m m , mass in CBD in 1 patient (3.5%), benign biliary stricture in 2 patients (7.1%), biliary stricture with underlying chronic pancreatitis in 1 patient (3.5%) patient, respectively. EUS
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examination revealed normal CB in 13 (46.4%) patients and t w o ofthese patients had periampullary diverticulum. AN patients with abnormal liver function tests had a detectable CBD disease whereas 14/21 (66.6%) patients w i t h normal liver biochemistry had normal EUS findings. There was no significant difference in the mean CBD diameter between the groups with and w i t h o u t disease finding (p>0.05). Conclusion: EUS is a useful investigation modality for patients with unexplained dilated CBD on MRCP. Underlying disease can not be ruled out in patients with normal mean CBD diameter and liver function tests.
Keywords: Endoscopic ultrasound, c o m m o n bile duct stones, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, ampulla.
1. Dat va n cTe
Hien nay, de danh gia cac bat t h u d n g cua he thdng d u d n g mat cd nhOng p h u o n g phap n h u sieu I m (SA), chup eat ldp vi t i n h (CLVT), cdng hUdng tU (CHT) d u d n g m a t - t u y , SA ndi soi va chup d u d n g mat tuy ngUpc d d n g qua ndi sol (ERCP) [1]. Mae du SA la phuong phap t h u c hien nhanh, khdng xam lan va re tien de danh gia d u d n g mat, nhUng chat lupng hinh I n h phu thude phan Idn vao t d chUc t h a m kham.
CLVT, mac du khdng xam lan, n h u n g la p h u o n g phap dung tia X, phai d u n g thudc c i n quang va cd dp nhay thap t r o n g phat hien eac benh d u d n g mat.
Mae du ERCP dUpe coi la tieu chuan vang de danh gia d u d n g mat, nhung d o n d la p h u o n g phap x l m lan va cd kha nang gay bien chdng nang n h u viem tuy, nen can cd cac p h u o n g phap ehan d o i n khac khdng xam lan v l an t o i n hon giup d i n h gia benh ly dudng mat. CHT dUdng mat la p h u o n g phap chan doan hinh I n h khdng xam lan dUpc lUa chpn t r o n g danh gia cac benh dUdng mat vi nd cung cap t h d n g tin kha chfnh xac ve t i n h trang cua he t h d n g dUdng mat, Mac d u nhUng tien bp t r o n g cdng nghe CHT da cai thien kha nang phat hien hinh I n h bat t h u d n g ve dudng mat, n h u n g nd van cd han ehe n h u can p h i i sU d u n g thudc ddi quang va khdng ed k h i nang chan doan m d hoc [1]. SA ndi sol da k h I c phuc nhOfng nhUpc diem cua eac p h u o n g p h I p tren va noi len n h u la m d t cong eu quan t r p n g de d i n h gia eac b^nh d u d n g mat. Ngoai viec cung cap t h d n g tin chan doan quan t r p n g lien quan den g i i i phau dudng mat, n d cdn tao eo hdi de lay mau m d / t d n t h u a n g d o do g i u p chan doan m d benh hpc. Nd eung g i u p x i e d i n h mUc do x l m lan va phan dp ton
t h u o n g ac tfnh [2]. Cho den nay, eac nghien cUu t r o n g nUde ehUa xae dinh rd p h u p n g p h I p t d t n h i t de ehan d o i n g i l n d u d n g mat khdng trieu ehUng cung n h u vai trd eiJa SA ndi soi d nhdng benh nhan da lam CHT dUdng mat nhung khdng the x i c d j n h n g u y e n nhan gian dUdng mat [2]. ThUc te lam sang, n h d n g b e n h nhan cd gian d n g mat ehu tren SA ddgc ehi d i n h CHT dUdng mat. Neu CHT dUdng mat khdng ehan d o a n 6dgc n g u y e n nhan h o l e k h d n g khang d j n h ddgc b i n h t h u d n g thi ehi d j n h t i e p ERCP. D e nghien eUu gia t n eua sieu I m ndi soi, c h u n g t d i d i n h g l l hdi cdu t r e n n h d n g b e n h nhan dUOc SA ndi soi do ed gian o n g mat chu t r e n CHT d u d n g mat va t i e p t h e o lam ERCP de xac nhan ket qua eCia SA ndi soi.
2 . D o i tupng va phUCng phap
T U t h a n g 11 nam 2013 den thang 12 nam 2014, ehung tdi nghien cUu hdi eUu tren 28 benh nhan duoc SA ndi sol de danh gia gian dng mat ehu (OMC) khdng rd nguyen nhan tren SA b u n g va chup CHT d u d n g mat. NhOfng benh nhan ed tlen sU phau t h u a t h o l e can thiep chup dUdng mat qua npi soi ngUOc d d n g 6dOc loai khdi nghien cUu nay. TrUdc khi SA npi soi, djnh lupng phosphatase kiem huyet t h a n h , do d u d n g kfnh OMC tren CHT d u d n g mat va ghi n h l n eac dau hieu hinh anh khac.
SA ndi soi dagc thUe hien bang may Exera 11 180 cua hang Olympus, tan sd 7,5 MHz, benh nhan n i m nghieng trai, giam dau t i e m t m h mach. Nhdng phat hien SA ndi soi duoc ghi lai va dupc khang d j n h b i n g chup d u d n g mat ngupc d d n g tiep dd, hoac phau t h u a t va sinh thiet khang djnh khdi u ac tfnh.
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Benh nhan cd sol OMC dUpc phat hien tren SA ndi soi, se tiep tuc chup c I n quang d u d n g mat trUde khi cat CO that d u d n g mat. Chan doan xac dinh cd sdi OMC khi sdi thay duoc qua bdng Vater trong qua trinh ndi soi. Tuong t u n h u vay, chan d o i n bun hay m i n h v d sdi cd the dUOc nhin thay qua ndi soi. Tat ca cac benh nhan trong nghien cUu nay dupe theo ddi lam sang moi thang 1 lan.
3. Ket quS
Chung tdi cd 28 benh n h l n d i p Ung c i c tieu chuan nghien cUu, vdi 11 nam va 17 nU (nd gap 1,5 nam), t u o i t r u n g binh 54,4 + 12,0 (nhdm tuoi gap nhieu nhat la tU 50 tuoi t r d len). Khdng ai t r o n g sd nhdng benh nhan nay cd benh vang da, 4 benh nhan (15,0%) cd tlen sU dau bung mat. Trong 21 benh nhan (75,0%) dupc tham kham sieu I m trude d d do dau m p hd vung bung tren, thay 4 benh nhan cd ket q u i la gian OMC. 5 benh nhan (42,5%) cd tlen s U c a t b d t u i mat.
D u d n g kinh OMC g i l n t r u n g binh tren CHT dudng mat la 8,9 + 1,1 m m , d n h d m nhUng benh nhan da cat bd tui mat la 8,8 ± 1,0 m m va su khae biet khdng cd y nghia t h d n g ke vdi n h d m benh cd tui m i t c d n nguyen ven (9,1 ± 1 , 1 mm;p>0,05).
Ket q u i SA ndl soi: Binh t h u d n g ed 13 (46,4%) benh nhan. Sdi OMC cd 10 trudng hpp (37,5%) vdi kich thude idn nhat la 10mm, khoi cd 1 t r u d n g hpp (3,5%), hep dudng mat lanh tfnh cd 2 trudng h p p
(7,1%), hep d u d n g mat do viem t u y m a n t m h co 1 (3,5%) benh nhan.
NhOng t r u d n g h o p cd sdi OMC 6dgc khang din|
b i n g ERCP va lay sdi sau e i t eo t h I t O d d i . Mdt b§nK n h l n ed khdl dupc sinh t h i e t ndi soi sau c i t cotfrSt Oddi va dupc ehan d o a n m d b e n h hpc la ung thl|
d u d n g mat. T r o n g 2 b§nh nhan bj hep dUdng mSt lanh tfnh, cd m p t dUpc n o n g qua npi soi. Cac b§nh nhan cd ket q u i SA ndl sol binh t h u d n g dupc theo ddi t r o n g t h d i gian 1-12 t h a n g va t r o n g thdi gian n i y d l cd khdng cd trieu c h d n g h o l e bien chUnggi ve d u d n g mat tuy.
Xet nghiem phosphatase kiem t r o n g huy^
thanh eho thay 21 t r u d n g h p p cd chi sd binh t h u d n g , edn 7 benh nhan t i n g cao. Trong sd 7 bfnh nhan n i y deu phat hien cd benh ly OMC (5 cd s6i, 1 ung t h u d u d n g mat v l 1 hep lanh tfnh) (HI va H2).
Cd 14/21 (66,6%) benh nhan ed xet nghiem chiJc nang gan binh thUdng cho ket qua SA ndi sol binh t h u d n g . DUdng kfnh t r u n g binh OMC d nhdm benh nhan cd phosphatase kiem huyet t h a n h tang cao la 9,1 ± 1,1 m m , khdng c d s u k h a e biet vdi nhdm benh nhan cd xet nghiem e h U c n I n g gan binh thudng (8,9
± 1,1; p>0,48). TUPng tU, khdng ed sU k h I c bietve d u d n g kfnh t r u n g binh OMC gfUa hai n h d m cd benh (8,9 + 0,9) va khdng benh (9,0 ± 1,1 m m ; p>0,05).
Hinh 1. Nguyen Thi N, nU, 87t. A: CHT dudng mat chi thay gian dUdng mat thap, khdng thay sdi
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Hinh 2 . Tran Ngoc V, nam, 56t. SA ndi soi thay gian OMC do chft hep lanh tfnh 4. Ban l u a n
Gian OMC cd t h e d o nhufng nguyen n h a n ' k h l c nhau: Sdi, hep, ung t h u dUdng mat, tui thUa canh bdng Vater (periampullary diverticulum), u dau tuy, roi loan co vdng Oddi va hep nhu t l ldn ... [1], [2].
Gian OMC cd t h e la dau hieu gian tiep eua m d t benh ly dudng mat, n h u n g Cling c d t h e gap d n h d n g benh n h l n Idn tuoi h o l e trang thai g i l n t d n tai sau m d / can thiep eij ( c i t b d t u i mat, lay sdi hoae g i u n O M C . ) ma khdng t i m thay bat ky nguyen n h l n thuc t h e nao khac [3]. Vi vay vdi cac benh n h l n ed gian nhe OMC, t h a m kham bo sung la can thiet de xac djnh cd nguyen nhan gay t i c hay khdng. CHT dudng mat la m d t phUPng t h d c t h a m kham khdng xam lan rat t d t so vdi ERCP de chan doan cac benh gay gian nhe OMC [4]. SA ndi soi la m p t phUPng thUc rat t o t de t h a m k h I m s i t OMC n h d dau d d dddc dat d ngay ta trang. D p nhay eua SA ndi soi phat hien sdi OMC da dupc chUng m i n h I I tUPng duong vdi ERCP va cung d l dupe chdng m i n h la m p t phupng thufc t d t de d a n h g i i cac benh d u d n g mat tuy [5].
Mpt sd nghien edu cho thay SA npi soi va CHT dudng m i t t u y deu la hai p h u o n g p h I p t d t de danh gia cac b e n h d u d n g mat t u y va k h i nang c h i n d o i n cOa c l hai p h u o n g thufc nay deu khdng cd su k h I c b i | t d a n g ke [6]. Tuy nhi'^n, SA'^ldhsoi cd the phat hien dupc n h i ^ u benh ly OMC ma CHT d u d n g mat khdng khang d j n h 6dgc, nhat la sdi nhd OMC [7]. Do
d o , t r o n g nghien cUu nay, ehung tdi d i n h g i i vai t r d eua SA ndi soi d benh nhan gian OMC m l khdng the ket luan nguyen n h l n tren CHT dUdng mat. Trong nghien cdu cua chung tdi SA npi soi d l khang d i n h chan doan eho 50% sd benh nhan khdng t h e ket l u i n tren CHT dudng mat vdi phan ldn cae benh nhan ed sdi OMC. M d t nghien cdu tren 49 benh nhan l i m ERCP de danh gia gian d u d n g mat khdng trieu chUng, cd k h o i n g 60% benh nhan dupc t i m thay ed mdt sd bat thudng tren ERCP vdi 20%) benh n h l n cd hep dudng mat lanh tfnh va 23%) benh nhan cd tui thUa ta trang canh bdng Vater [8]. Trong mdt nghien cUu khie, 90 benh nhan bj g i l n OMC khdng rd nguyen nhan tren SA bung, dUPe danh gia b i n g SA ndi SOI va chan doan chfnh xac chiem 92% [9].
Malik va cs [10] hoi cdu vai t r d eua SA ndi soi t r o n g d i n h g i i g i l n dUdng mat khdng trieu chUng tren 47 benh nhan t r o n g do 15 t r u d n g hpp ed CHT d u d n g mat. Cac tac g i i chia benh nhan t h a n h hai n h d m : Xet nghiem chufc nang gan binh t h u d n g (n = 32) va bat t h u d n g (n = 15). Ho thay r i n g k h i nang ehan doan cua SA ndl sol la t h a p d benh nhan binh t h u d n g (6%), ngUoc lai cao hon nhieu d n h d n g ngudi bat t h u d n g (53%; p>0,001) [10]. Sdi la nguyen nhan hay gap nhat. Trong nghien cdu cua chung t d i , tat e l c l e benh nhan ed xet nghiem chde nang gan bat t h u d n g deu cd benh phat hien dUpc b i n g SA npi soi (5 cd sdi, 1 ung t h u dudng mat va 1 hep lanh tfnh), t r o n g khi d d cd 14/21 (66,6%) benh nhan cd xet nghiem chdc nang gan binh t h u d n g cho ket qua SA
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ndi sol binh thudng. NgUpc lai vdi nghien cdu cCia Malik va cs [10], chi cd 15/47 (32%) benh nhan tien hanh CHT d u d n g mat trUdc SA npi soi, tat c l c i c benh nhan t r o n g nghien cUu cua chung t d i da thUc hien SA npi sol khi CHT d u d n g mat trudc d d khdng ket luan duoe nguyen n h l n g i y gian OMC.
Van de quan t r p n g la can p h i i danh g i i va theo ddi gian OMC khdng trieu chdng. Cd*the gap b§nh nguy hiem g i y t i c mat khdng the bd qua, nhung cung c d t h e khdng cd benh can khang djnh de tranh dupc nhufng can thiep khdng can thiet. Cac ket q u i tU nghien cUu eda chung tdi chi ra r i n g xet nghiem ehUc nang gan bat t h u d n g cd the giup xac djnh benh n h l n cd nguy co cao de thuc hien t h a m kham SA npi soi. NhUng khdng p h i i tat ea cac benh n h l n cd xet nghiem chdc nang gan binh t h u d n g se ed SA ndi soi binh t h u d n g . Tuong tU n h u vay, dUdng kfnh t r u n g binh OMC khdng ed su khac bfet dang ke gida nhdng ngudi cd nguyen n h l n bit t i e va khdng cd nguyen nhan bit t i c thay dupe tren SA ndi soi. Dleu n i y chi ra r i n g d u d n g kfnh OMC khdng phai la m d t dau hieu eda bit t i e . Tuy nhien, nghien eUu nay bj han che bdi thUc te la nd 11 m p t phan tfch hdi cdu cac t r u d n g hpp. Ngoai ra, c l SA ndi soi va CHT d u d n g mat ed the khdng chan doan dupe hep nhu ta Idn va benh ca vdng Oddi. Tuy nhien, tat ca c i c benh nhan p h i t hien SA ndi soi binh t h u d n g van khdng cd bat ky trieu ehUng h o l e bien chdng mat tuy t r o n g t h d i gian theo ddi hang t h i n g .
5. K e t luan
SA ndi soi la m d t p h u o n g phap chan d o i n quan t r p n g , cd t h e giup chan doan xae d j n h nguyen nhan gay gian OMC khi CHT d u d n g mat binh t h u d n g . Phosphatase kiem huyet thanh tang eao I I yeu t d gpi y den kha nang cd m p t nguyen n h l n g i y bit t i c OMC. Tuy nhien, chi sd phosphatase kiem t r o n g huyet t h a n h binh t h u d n g khdng loai trU k h i nang cd nguyen n h l n gay bft tac OMC.
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