Y HOC VIET NAM THANG 10 - SO 1/2014
KHAO SAT DAC DIEM NOI SOI DA DAY - THITC QUAN TREN BENH NHAN XO GAN
T O M TAT
Myc tieu: Mo ta va so sanh nhiing dac diem cua cac sang thUOng tren thirc quan, da day qua noi soi d cac benh nhan xd gan. Phu'dng phap: Ngiiien ciJli c3t ngang tiln ciili. Ket qua: Co 46 benh nhan trong nghien ciTu vdi 47,8% Child B va 42,6% Child C. Bleu hien cua tinh trang t3ng ap lu'c tinh mach cii'a tren thifc quan va da day hien dien 6 100% so benh nhan:
Gian tTnh mach thy'c quan chiem ty le cao 20/26 (43,5%) chii yeu la dd I (65%), benh gian tam phinh vj chiem 13/33 (28,3%) cac tru'dng hdp vdi 26/46 (56,5)% trong so dd hoan toan khong kem theo gian b'nh mach thifc quan, Chi cd sir tu'dng quan giij^ do gian ti'nh m?ch thi/c quan vdi do nang ciia xd gan theo Oiiid-Pugh. Ket lu$n; Gian tinh mach thiTc quan xuat hien trin phan ldn cac tru'dng hdp xd gan nhu'ng benh da day t§ng ap cifa va gian tinh mach da day cung xuat ilien vdi ty l§ khdng thap, dong thdi cac sang thu'dng khac tren da day, thu'c quan cijng can du'dc quan tam.
T^khoa: Xd gan, da day-thirc quan, thang diem Child-Pugh, gian tinh mach thu'c quan, gian tinh mach da day.
SUMMARY
SURVEYING CHARACTERISTICS OF ENDOSCOPY ON THE OESOPHAGUS AND THE STOMACH I N C I R R H O T I C PATIENTS
Objective: To describe and compare the characteristics of the lesions in the esophagus, stomach via endoscopy in patients with cirrhosis.
Method: Prospective cross-sectional study. Result:
46 patients in the study with 47.8% and 42.6% Child B Child C. Expression of the state portal venous pressure on the esophagus and stomach Is present in 100% of patients : varicose veins of the esophagus accounts for a high proportion of 20/26 (43.5%) is mainly grade I (65%), heart disease bulge stretch occupy 13/33 (28.3%) cases with 26 / 46 (56.5)% of them totally without esophageal varices. Only the correlation between tiie degree of esophageal varices with the seventy of cirrhosis according to Child-Pugh.
Conclusion: Esophageal varices appear in the majority of cases but disease cirrhosis portal hypertension and gastric varices appeared stomach at
* Bfnh vien H^nh Phuc An Glang
** Bgnh vien 103
Chju trach nhiem chinh: Lu" Quoc Hung Eniall: [email protected] Ot:^0913.706.427 Phan bien khoa hpc: PGS.TS Nguyen Thj Bach Tuyet Ngay nh?n bai: 30.8.2014
Lu- Quoc Hung*, Tran Viet Tu**
a rate not less, and other lesions in the stomach, esophagus should also be considered.
Keywords: cirrhosis, esophagus-stomach, Chid- Pugh's score, oesophageal varices, gastric varices.
I. D ^ T VAN DE
Xd gan la benh thu'dng gap trong chuyen khoa tieu hda d Viet Nam va the gidi vdi nhieu bien chuhg. Xuat huyet tieu hoa do v5 gian tTnh mach thi/c quan la mdt trong nhihig hau qua ciia tinh trang tang ap ILTC tTnh mach cii^a, mpt tinh trang thu'dng gap trong xd gan giai noan mat bii.
Phan Idn benh nhan xd gan se xuat hien gian tTnh mach thy'c quan, da day trong sudt giai doan tien trien ciia benh [ 1 ] . Dp gian tTnh mach, vj tri cijng nhu' dp nang ciia tinh trang xd gan theo Child-Pugh ludn dl kem vdi nguy cd cao xuat huyet tieu hda tren [ 3 ] . Ciing vdi hau qua gay gian cac tTnh mach, tinh trang tang ap li/c tinh mach c i f t cdn gay ra nhieu tac ddng khac tren ong tieu hda, ma dac biet la sang thu'dng tren da day va thiTc quan. Benh ly da day do tang ap liTc tTnh mach cira thu'dng khdng dddc quan tam va lu'u y nhieu. Cac nha lam sang ludn ban khoan khi nao thi can tam soat tinh trang gian tTnh mach [ 3 ] , dac biet tren ddi tu'dng benh nhan xd gan. Do dd, npi soi da day du'dc khuyen cao nham tam soat, chan doan va dieu tri gian tTnh mach thi/c quan, da day tren ddi tu'dng benh nhan xd gan la can thiet. Vi vay, chung tdi tien hanh thu'c hien nghien ciTu nay.
Vdi muc tieu: Mo ta va so sanh nhWng dac diem cua cac sang thu'dng tren thu'c quan, da day qua ngi soi dbenh nhan xdgan.
II. DOI TU'ONG VA P H U a N G PHAP NGHIEN CUU 2 . 1 . Dol tu'dng nghien cu'u
- Tieu chuan clion b e n h :
Tat ca benh nhan nhap vao khoa Tieu Hda Benh vien Thdng Nhat thanh pho Ho Chf Minh trong thdi_ gian tCr 01/2012 den 03/2014 vdi tieu chuan chan doan xd gan nhu'sau:
+ Hdi chu'ng suy te bao gan (tren lam sang va can lam sang).
+ Dau hieu dai the cua gan (lam sang va can lam sang).
+ Tien su" benh xd gan rd rang, -I- NhuTig benh nhan nay dong y npi soi da day, - Tieu chuan loai truT:
+ Benh nhan khdng dong y ndi soi da day ta trang
Y HOC VIET H A H T H A N G 10 - SO I f i l Q I 4
-I- Cac benh nhan du'dc chan doan ung thu'gan -I- Du'dc chan doan benh nao do gan, 2.2. Phu'dng phap nghien cu'u Nghien ciru cat ngang tien ciru.
2.3. Phu'dng phap chon mau Chpn mau thuan tien (tlida tieu chuan chon).
2.4. Noi dung nghien cu'u
Danh gia nhOtig dac diem ciia benh nhan xd
gan nhu sau:
-I- Dac diem dan so hoc.
+ Dac diem lam sang va can lam sang.
+ Ket qua ndi soi thu'c quan-da day-ta trang ghi nhan neu cd: viem da day do tang ap li/c tTnh mach cira, viem loet kem theo, gian tTnh mach thi/c quan, mu'c dp, gian tTnh mach phinh vj,
2.5. Xii ly so lieu: theo phan men SPSS 20.0.
III. KET QUA NGHIEN CUU Gi6i tinh
Nam Nff Tong
Tan s6'{n=46) 25 21 46
Tv le (»/o) 54,3 45,7 100 BSnh nhan nam chiem ty IS 54,3%, benh nhan nu'45,7%.
Bang 3.2. Dac diem ve tud'i ciia ddi tu'dng nghien ciru Nhom tuoi
<40 4 1 - 5 0 5 1 - 6 0
> 6 1
Tan s d ( n = 46) 4 10 11 21
Ty le (»/o) 8,7 21,7 23,9 45,7 Tuoi trung binh (BLC): 57,30 (12,40)
Nho nhat: 32; Ldn nhat: 78
Nhom tuoi trSn 61 tuoi co ty le cao nhat trong so benh nhan tham gia nghien cu'u. Vdi do tuoi tmng binh 57,30, do tud'i Idn nhat 78 va tuoi thap nhat 32 tuoi.
Bang 3.3. Ly do nhap vien ciia ddi tu'dng xd gan Li do nhap vien
Met moi, chan an Dau thifdnq vi Oau ha sUdn piiai Oau dau, ciionq mat Sot cao Vang da Tang men gan Co cliu'6nq
Tonq
Tan so (n=46) 34
3 3 2
46
Ty le (»/o) 73,9
6,5 6,5 4,4 2,2 2,2 2,2 2,2 100 Co 73,9% benh nhin nhap vien vi met moi va chan an.
Bang 3.4. Dac diem tien can ciia ddi tu'dng xd gan Tien can
Uong ru'du Viem gan B Viem gan C
Co Khonq
Co Klionq
Co Kiiong
Tan so (n = 46) 8 38 22 24 17 29
Ty le (%) 17,4 82,6 47,8 52,2 37 63
Binh nhan co uong rWdu cd ty li 17,4%. Binh nhan cd tien can mac benh viem gan C va viem gan 6 cd ty ie tWOng uhg 37% vi 47,8%.
Y HOC VIET NAM THANG 1 0 - S O 1/2014
Bang 3.5. Dac diem lam sang cua ddi tu'dng xd gan Tien can
Tri giac tinii tao Vang mat Sao macti Long ban tay son Tuan hoan bang he
Gan to Lachto
Co Klnong
Co Khong
Co Khong
Co Khong
Co Khonq
Co Khonq
Co Khonq
Tan so (n = 46) 46
0 1 45 1 45 1 45 0 46 9 37 2 44
Ty le (%) 100
0 2,2 97,8
2,2 97,8 2,2 97,8 0 100 19,6 80,4 4,3 95,7
Tri giac cua benh nhan luc nhap viSn tat ca (100%) la tinh tao. Cac trieu chuhg nhu" vang r mach, long ban tay son co ty li 2,2%. Co 19,6% benh nhan cogan to.
Ten xet nghiem Tieu cau PT INR Albumine Protid
Ten xet nghiem GOT
Bilirubin toan phan Bilirubin trut tiep
n 46 46 46 46 46 n 46 46 46
Hdn vi K/uL Giay g/L g/L Ddn vi
U/L pmol/L pmol/L
Trung binh 152,24
89,59 1,07 36,70 70,11 Trung vj
80 12,4
2,9
€)d lech chuan 75,74 13,04 0,13 5,36 5,75 Min - Max
13 - 835 3,0 - 72,2 0,8 - 37,7
Tieu cau cd gli tri trung binh la 152,24, do lech chuan la 75,74. Albumin co gli tri trung binh la 36,7 do lech chuan ii 5,36. GGT, bilirubin toan phan va tri/c tiep khong cd phan phoi chuan vdi trung vi ISn IWdtIa 80,12,4, 2,9.
Bing 3.7. £>ac diem ve tv le l<et qua xet nqhiem mau ciia doi tuonq xd Ten xet nghiem
Tieu cau (n= 46) TP(n=46) INR (n= 46) Bilirubin toan phan (n=
46) Bilirubin true tiep
(n= 46) Albumine (n= 46)
Protid (n=46)
Glam (<140K/ul) Binh thu'dng Glam (<70%)
Binh thu'dnq Tang(>l,28) Binh thifdnq Tanq(>17 pmol/l)
Binh thu'dnq Tanq(>4,3 mol/l)
Binh thu'dng Giam (<35q/l)
Binh thudnq
Tan so Cn=46) 24 22 4 42
4 42
9 37 10 36 15 31 Giam (<50g/l) , 0
qan Ty le (»/o)
52,2 47,8 8,7 91,3 8,7 91,3 19,6 80,4 21,7 78,3 32,6 67,4 0
Y HOC Vl|T NAM THANG 10 . S 6 1/2014
Ti le A/G GOT
Binh thu'dnq
<1
>1 Tang (>45U/I)
Binh thu'dng
46 17 29 33 13
100 37 63 71,7 28,3 G5 52,2% benh nhan co giam tieu cau d benh nhan xd gan man, co 32,6% benh nhan co giam albumin mau, khong co benh nhan nao giam protid mau va co 71,7% benh nhan co tang GGT mau.
Bang 3.8. Chi so ALT, AST d benh nhan xd qan Chi so men gan
ALT
AST
Tanq Binh tiiudng
Tanq Binh thu'dng
Tan so Cn = 46) 22 24 31 15
Ty le (%) 47,8 52,2 67,4 32,6
Nonq «6 (U/L) Trung vj: 37,00 Nho nhat: 12 Ldn nhat; 714 Trung vj: 55,00 Nhd nhat; 13 Ldn nhat; 382 Ty li benh nhan CO chi so men gan ALT &ng la 47,8%. Trung vi chi so ALT 37 U/L, gli tri thap nhat 12 U/L vi gli tri cao nhat 714 U/L.
Ty le binh nhan cd chi so men gan AST tang li 67,4%. Trung vi chi so AST 55 U/L, gli tri thap nhat 13 U/L vi gli tri cao nhat 382 U/L.
Bang 3.9. Kile do xd qan theo Child-Pugi' Md'c do xd gan theo Child-Pugh
Child-Pugh A Child-Puqh B Child-Puqh C
Tfing
Tan so (n = 46)
.
4 22 20 46
Ty le % 8,7 47,8 43,5 100 Child-Pugh Booty le cao nhat (%) trong mut do xd gan.
Bang 3.10. Ket qua npi soi thifc quan da day Xet nghiem viSm gan Gian tTnh mach thu'c
quan(n= 46) Bo gian TI«1TQ
(n= 20) Gian TM tam phinh vi
(n= 46)
Cd Khonq
D o l 06 2 06 3 Cd Khonq
Tan sd[n=46) 20 26 13 6 1 13 33
Ty lg (%) 43,5 56,5 65,0 30,0 5,0 28,3 71,7
Nil sol thifc quan phit hien gian tinh mach thifc quin cd 20 benh nhan chiem 43,5%. Vi giin do 1 co ty li cao nhat 65%, 28,3% benh nhan cd gian tinh mach tam phinh vi.
IV. BAN LUAN
4.1. Sac diem dan so hoc
Trong nghien cilU nay, ty le benh nhan nam 25/46, nff du'dc ghi nhan la 22:46. Dieu nay cd the giai thich dua vao nguyen nhan gay xd gan.
0 nam, nguyen nhan chu yeu la do uong ru'du, trong l<hi dd tai Viet Nam hien nay chung tdi ghi nhan, nguyen nhan tiu the d nff la do nhiem HBV hoac HCV. Ngoai ra, chung tdi nhan thay so benh nhan phan bo nhieu d nhdm tuoi tff >60.
4.2. Oac diem lam sang va can lam sang cua tang ap \\ic dia
Tat ca benh nhan xd gan trong nghien ciiu nay deu cd ty le nhat djnh (nhff da neu) cac trieu chu'ng tren lam sang cung nhu' can lam sang nhd tuan hoan bang he, lach to va bang bung. Tuy nhien d day chiing tdi lu^i y nhieu den dau hieu lach to va giam tieu cau. Lach to hien di?n d 4,3% cac benh nhan xd gan. Lach to tren lam sang dffdc xem la yeu to nguy cd cua gian ldn
Y HOC VigT NAM THANG 10 - SO 1/2014 fihh mach thi/c quan [ 4]. Ben canh dd, giam tieu
cau la mpt bieu hien ciia hdi ciiiyng tang ap lu'c tTnh mach cira tren lam sang va chfnh no bao hiju tinh trang nay ca khi benh nhan chu'a cd dau hieu xq gan rd rang. Khuyen cao the gidi cung cho rang nen tien hanh ndi soi tieu hda tren cho nhu'ng benh nhan xd gan bat dau cd sd lu'dng tieu cau < 140.000/mm^ hay kich thu'dc lach > 135mm^ [3], [4]. Vi the ma, chung ta cd the phdng ngira xuat huyet tieu hda tren do vd gian tTnh mach thu'c quan bang cac xet nghiem de phat hien lach to va giam tieu cau vi dieu do cd the dy* doan du'dc nguy cd hien dien ciia gian tTnh mach thu'c quan.
4.3. Phan loai theo thang diem Child-Pugh Chiing tdi ghi nhan ty le benh nhan Child B va C (giai doan mat bit ciia xd gan) chiem ty le rat cao. Ket qua nay cao hdn han bao cao ttr cac nu'dc Au My. Nghien ciTu cua chiing tdi thifc hien tai benh vien da khoa Idn ciia thanh pho, tuyen cuoi ciia cac benh vien, cac benh nhan chi du'dc chuyen den hay den kham khi benh da thu'c si/
nang. Dd la khi da xuat hien cac bien chirng, hay ndi each khac la xd gan da mat bii. Hp den vdi chiing tdi la vi nhuTig bien chu'ng nay. Day chinh la thach thu'c chung ciia chung tdi khj ma cac benh nhan chi den kham khi da qua mupn. Chinh nhUng dieu nay giai thich vi sao ty le benh nhan Child B va C trong mau ciia chung tdi cao den nhu' vay. Day that sir la mpt thach thirc cho cac bac sT dieu tri.
4.4. Oac diem noi soi tren thu'c quan da day Ket qua ciia chiing tdi la 43,5% cao hdn so vdi nghien ciru trong nu'dc tru'dc day la 37,1%.
Mpt lan nuS cd the giai thich la do phan ldn benh nhan ciia chiing tdi da d giai doan nang, chi den kham hay nhap vien khi da cd bien chirng. Ket qua chung tdi ghi nhan nguy cc xuat huyet tieu hda tren tang theo dp gian tTnh mach thi/c quan, ngay ca vdi cac sang thu'dng khac tren thi/c quan va da day. Y van the gidi rang: nguy c0 xuat huyet lien quan den kfch thu'dc gian tTnh mach thirc quan [5], nguy cd xuat huyet tieu hda tang song hanh vdi dp gian tinh mach thu'c quan [6]
va nguy cd vd gian tTnh mach thi/c quan tang theo dd gian ro ret: 13/20 (65%) d do I va 6/20(30%) d dp II ya 1/20 (5,0%) III [1], [2].
Ket qua ciia chiing toi ghi nhan tang nguy cd cao bi xuat huyet tieu hda tren cho benh nhan xd gan n§u gian tTnh mach thiTc^quan tir dd II trd len.
Do dd, hi vong vdi cd mau Idn hdn, khoang tin
cay thu nhd lai, chung ta cd the ket luan du'dc mdi tu'dng quan nay. Gian tTnh mach thi/c quan gay tang nguy cd xuat huyet len cao han khi gia tang kich thu'dc, nhat la tai gidi han d dp IL Y van tir tru'dc den nay deu khang djnh dieu do, va chi ra do la thdi diem can phai can thiep cho benh nhan de de phdng bien chirng xuat huyet tieu hoa, nguyen nhan gay tir vong thu" hai tren benh nhan x d g a n [ 7 ] .
V. KET LUAN
Bleu hien ciia tinh trang tang ap ly'c tTnh mach cira tren thy'c quan va da day da dang, cd the phoi hdp vdi nhau, hien dien d tat ca benh nhan xd gan vdi gian tTnh mach thu'c quan xuat hien tren phan Idn cac tru'dng hdp va cd tu'dng quan vdi dp nang theo Child-Pugh. Tuy nhien benh da day tang ap cira va gian tTnh mach da day cung xuat hien vdi ty le khdng thap, dong thdi cac sang thu'dng khac tren da day, thiTc quan cung can du'dc quan tam.
TAI LIEU THAIVI KHAO
1. L^i To HUtfng (2008), So sanh gia tn tien liTflng giua thang diem MELD va Child - Pugh tren benh nhan Xd gan mat bu. Luan an chuyen khoa cap I I . Oai hoc Y Du'dc TP. Hd Chi l^inh.
2. Ma Phu-dc Nguyen (2005), Gia tri ciia ty (e so lu'dng tieu cau tren du'dng kfnh lach trong dir doan gian tinh mach thi/c quan tren benh nhan xd gan, Luan van thac sy y hoc, Oai hoc Y Du'dc TP.HCM.
3. Ho Tan Phat (2003), Khao sat moi tUdng quan giu'a mire dp xd gan theo piian loai Child - Pugh va mire dp gian tinh mach thi/c quan qua npi soi da day ta trang, Luan van thac sT y hpc. Dai iioc Y Di/dc thanh pho Ho Chi Minh.
4. Ferguson 3W (2011), Endoscopic Diagnosis, Grading and Predictors of Bleeding in Esopiiageal and Gastnc Varices, Tech Gastrointest Endosc, 7:
pp.2-7.
5. Kumar & Clark (2012), Clinical medicine, 5th edition, Uf.B. Saunders, 363-372.
6. Merke), Schipiliti, Bighin, Bellini (2012), Portal hypertension and portal hypertensive gastropathy in patients with liver cirrhosis: a haemodynamic study. Dig Liver Dis., (4): pp.69-74.
/ . Merii, Nicolini, Angeloni (2013), The natural history of portal hypertensive gastropathy in patients with liver cirrhosis and mild portal hypertension. Am J Gastroenterol.(10): pp.59-65.
