DANH GIA VE CHAN DOAN VA DIEU TR! TAC R U O T
DO BA THL/C AN TAI KHOA NGOAI BENH VIEN BACH MAI
Tran Hig'u Hoc
Bg mdn Ngoai - Tnfdng Dal hgc Y Ha Ngi Tic rudt do ba thifc iin khdng phai hidm gap vi chan doin chinh xic trtfdc md thudng khdng dS dang.
Muc tieu: Phin tich dac diem lim sang, can lam sang va xac dinh cic yeu td nguy ca ciia tSc rugt do ba thifc an. Bo'i tugng va pbuang pbap ngbien cdu: hoi cdu md ta cic benh nhin bj tac rudt da bii thitc iin dugc dieu tri phau thual tai khoa ngoai benh vien Bach Mai. Ket qua: 86 benh nhin (26 nam vi 60 nif), 62,7% tren 50 tudi; didn bien cap hay bin cap vdi thdi gian den vien ke tif khi cd trieu chdng trung binh li 6,34 ngiy. Dau bung 100% cic trtfdng hgp nhUng bi trung tien chi tha'y d 72,1%, quai rugt ndi 37,2% va da'u hieu rin bd 19,8%o. Mgt sd yeu td nguy ca nhU: cit da diy 34,2%; phau thuit khic ctia d bung 21,1 %; ngoii ra cd iin nhieu chai xa, dimg thudc giam tidt, glim co hay rang mieng khdng toin ven. Chan doin trudc md chinh xic 36,1 %; phan nhieu tic d hoi tring (67,4%o), da sd cd 1 khdi bi (69,8%). Xd tn chii yeu la md rugt lay ba thdc an (80,2%o). Kdt luan: de chan doin tic rudt do ba thifc an cin chti y tinh chat dien bien vi cic ydu td nguy ca va xd ly sdm md rugt lay ba thifc an cho kdt qua tdt
Tff khoa: tac ruot, ba thffe an
I. DAT VAN DE
T i e rudt la mdt c i p cflu ngoai khoa thfldng gap, chie'm gan 2 0 % c i c c i p cflu bung. Day I I tlnh trang benh ly cua n h i i u nguyen nhan trong dd ba thflc an la nguyen nhan khdng p h i i h i i m gap nhflng ft khi cd the c h i n doan chfnh xac trfldc md bdi trieu chflng benh khdng cd tinh dac hieu. Mpt sd' cdng trinh nghien cflu trong nfldc cho t h i y xu hfldng gia tang benh ly nay d nfldc ta trong nhflng nam gan day. Nghien cflu nay nham muc tieu:
Phan tich dac diem lam sang, can lam sang va giai phau benb ly cua tie rugt do ba thdc an, va xac dinh cac yeu td nguy ca d cac benb nhan nay.
II. DOI TUONG vA PHUONG
P H A PNGHIEN cCu
1. Do'i tfldng nghign cffu: gdm t i t ca c i c benh nhan cd c h i n d o l n sau md la tac rudt do ba thflc an hoac bie'n chflng do tac rupt do ba thflc an dflpc d i i u trj tai khoa Ngoai benh vien Bach Mai
trong 7 nam (1999 - 2005). Loai trfl khdi nghien cflu nay nhflng benh nhan cd khdi ba thflc an dflpc phat hien tinh ed trong cac phau thuat bung va dfldc xfl ly ludn trong luc md chfl khdng gay t i e rudt.
2. Phffdng phap nghidn cffu: hdi cflu md t l va phan tfch lai hd sd benh an dfla vao cac chl so' sau:
- Dac d i i m chung ve tudi, gidi vdi phan chia nhdm tudi, chu y tudi tren 50.
- N g o l i c i c trieu chflng lam sang va can lam sang chung cua t i e rupt, chu y xem xet va phan tfch c l e yeu td'thuan lpi, y i u t d nguy co lam hinh thanh ba thflc an nhfl van d l an udng, nhflng b i t thfldng g i i i phau va sinh ly cua da day, tlnh trang rang mieng, benh man tfnh...
- Trong md danh gia tlnh trang tac rudt do ba thflc an v l vj trf, so' Iflpng cac khd'i ba cung nhfl tdn thflong tai runt va c l e h thflc xfl ly.
3. Xff ly so lieu: sd lieu thu thap dfldc xfl ly b l n g thd'ng ke y hpc chflpng trinh Epi Infd 6.04.
III. KETQUA
1 . Dac diem chung
- Tudi v l gidi: Trong 7 nam tfl 01 - 1999 d i n 12 - 2005 cd 86 benh nhan tac rudt do ba thflc an dflpc phau thuat bad gdm 26 nam va 60 nfl, tudi thap nhat la 17, tudi cao n h i t la 82. Phan chia nhdm tudi dflpc ghi nhan trong bang 1.
Bang 1. Pban chia nhom tudi Nhdm tudi
1 0 - 19 2 0 - 2 9 3 0 - 3 9 4 0 - 4 9 5 0 - 5 9 6 0 - 6 9 7 0 - 7 9
> 8 0 Tdng so
N 3 20 4 5 10 13 29 2 86
(%) (3,5) . (23,4) (4,7) (5,8) (11,6) (15,1) (33,7) (2,3) (100,0)
Kit qua cho t h i y benh gap n h i i u hdn rd ret d Ifla tudi tren 50 vdi Xy le 62,7%.
- Sd benh nhan phan chia theo tflng nam nhfl sau ( b i i u dd 1):
2 0
15
10
5
0
Phan bo b e n h nhan theo nam
r
;_. - . „
fSa
f%
Ai
1999 2000 2001
-
i A^
m
•
A£
^
2002 2003 2004 2005
Bieu dd 1. Phan bd benh nhan theo nam
Qua bleu do tren, ty le benh nhin bi tie rugt do ba thifc an cd xu htfdng ngiy cang ting len khi rd ret.
- Thdi gian trung binh ke tfl khi benh nhan cd
trieu chflng d i u tien den khi v i o vien trung binh la 6,34 ngay vdi so lieu cu the nhfl sau:
+ Trfldc 24 gid: 1 8 benh nhan (20,9%);
+ Tfl 24 - 72 gid: 23 benh n h i n (26,8%);
+ Sau 72 gid: 45 benh nhan (52,3%);
Qua k i t q u i tren ta thay cac benh nhan bi tac rudt do ba thflc an thfldng den viSn k h i mudn, trfldng hpp d i n cham n h i t la n g l y thfl 1 5 cua benh.
2. Trieu chffng lam sang
Cac d i u hieu l l m sang dflpc ghi nhan trong bang 2.
Bang 2. Trieu chdng lam sang
Tri^u chffng Dau bung Ndn
Bi trung dai tien Trfldng bung Quai rudt ndi D i u hieu ran bd Sd t h i y khd'i
Tan suat 86 84 62 77^
32 17 17
(%) (100,0)
(97,7) (72,1) (89,5) (37,2) (19,8) (19,8) Mach:
< 9 0
> 9 0
67 19
(77,9) (22,1) H u y i t I p tam thu:
< 9 0
> 9 0
2 84
(2,3) (97,7) Nhiet dp:
< 37,5
> 3 7 , 5
77 9
(89,5) (10,5) Dau bung la trigu chflng ludn cd d mpi trfldng hpp nhflng d i u hieu b i trung dai tien chi gap d 7 2 , 1 % ; d i u hieu ran bd t h i y d 19,8%. Cd 19,8%
trfldng hdp sd t h i y khd'i tren lam sang va dd'i chieu khi md la khd'i ba thflc an, dd la nhflng benh nhan gay, thanh bung mdng.
Mach, huye't I p cua benh nhan thfldng thay ddi ft: mach tren 90 la 2 2 , 1 % va huyet I p tdi da dfldi 90mmHg la 2,3%. Da s d c i c benh nhan cd nhiet dp dfldi 37,5.
3. Cac dau hieu can lam sang
- Xquang bung khdng chuan bi: trong so 84/86 benh nhan dflpc chup phim bung khdng c h u i n bi cd 79 tnfdng hdp cho t h i y hinh anh dan rudt va mflc nfldc - hdi vdi c i c mflc dp khac nhau (94,1%).
- Npi soi da day - ta t r l n g : thu thuat n l y dflpc tie'n hanh d 18 benh nhan, trong dd d 11 benh nhan cd ba thflc an. Ke^t qua sau md thi cd 18 trfldng hdp ngoli ba thflc an gay tac rudt cdn cd c i c cue ba thflc an d da day.
4. Chan doan
- Chan d o l n dung trfldc md la t i e rudt do ba thflc an: 3 1 .
- C h i n d o l n trfldc md la tac rudt chfla rd nguyen nhan: 27.
- Chan d d I n trfldc md I I benh ly k h l c ; 28 trfldng hdp, cu t h i nhfl sau:
T i e rudt sau md: 15 ; Tac rudt do u dai trang:
2; T i c rudt do u trflc trang: 2; Flpp mdn vj: 3; Hep ta trang: 1; Viem rudt thfla: 2; Viem phuc mac: 3.
Nhfl vay trfldc md chl c h i n doan dflpc nguyen nhan la do ba thflc an trong 3 6 , 1 % c i c trfldng hop, nhflng trfldng hpp cd md cu thi c h i n d o l n la t i e rupt sau md, ccn n h i i u trfldng hdp khdng x l c dinh rd nguyen nhan.
5. Ton thfldng khi md - Vj trf t i e :
-I- T i e d hdng trang: 28 trfldng hop (32,6%) -f- T i e d hdi trang: 54 trfldng hop (62,8%) -1- T i e d gde hdi manh trang: 4 trfldng hdp (4,6%).
Da so c i c trfldng hpp ba thflc an thfldng gay tac d hdi trang, thfldng trai qua mdt thdi gian dien b i i n benh kha l l u (thdi gian trung binh 6,34 ngay).
- Sd lfldng khd'i ba thflc an: dfldc ghi nhan trong bang 3.
Bang 3. Sd lUgng ba thdc an So' khd'i ba thflc an
- 1 khd'i - 2 khdi trd lgn
-1- 2 khdi + 3 khd'i -1- 4 khd'i + 5 khd'i
n 60 26 11 8 4 3
(%) (69,8) (30,2) (12,8) (9,3) (4,7) (3,4)
Trong so 26 BN cd tfl 2 khd'i ba thflc an trd len thi cd 18 trfldng hop (20,9%) phat hien cd c l ba thflc an trong da day, t i t ca c i c trfldng hpp nay d i u dfldc xfl ly bang each md da day de l i y .
- Ton thfldng rudt tren chd t i e : Gian ddn thuan: 59 (68,6%); Gian va xung huyet: 4 (4,7%);
Cd c i c c h i m x u i t huyet: 4 (4,7%) ; Tfm, ran thanh mac: 4 (4,7%); Cd x o l n rudt nhflng khdng hoai tfl rudt 3: (3,4%); Thung rudt: 1 (1,2%);
Khdng md t l chi t i l t : 11 (12,7%).
- Cach thflc xfl ly: M d rudt l i y ba thflc an: 69 (80,2%); D i y ba thflc an xudng dai trang: 17 (19,8%). , ., . 6. Cac yeu to' nguy cd
Cd 38/86 trfldng hpp t h i y c i c yeu td nguy cd nhfl trong b l n g 4:
Dd'i vdi tien sif in udng chi cd mgt benh nhan dttac ghi ro la di an qui hdng, sd cdn lal khong ghi cu the. Cd 5 benb nhan tac rudt do ba thifc in dang dieu tri benh da day ti trang bing cac thude giim tiet, giim co nbU: Ranitidin, Omeprazol, Buscopan nhttng khdng ghi rd lieu lugng vi thdi gian dung thudc.
Tinh trang rang mieng lam anh htfdng trdc tiep den sifc nhai eh! cd 3 trtfdng hap dttac ghi nhan.
Bang 4. Cac yeu td nguy ca
•yg'u to nguy Cd Cat da d l y
Phiu thuat khac d d bung An udng n b i l u c h i t xd Benh phd'i hpp
Dung thud'c giam tie^t, giam co Rang mieng khdng toan ven Benh tam than
Tdng cdng
n 13 8 2 7 5 3 0 38
(%) (34,2) (21,1) (5,2) (18,4) (13,2) (7,9) (0) (100,0)
I V . B A N L U A N
- Tudi mSc benh: tudi cao la mdt yeu td' lien quan tdi ty le mac benh, gap n h i i u rd ret d lfla tudi tren 50 (62,7%) tfldng tfl nhfl nhan xet cua nhieu t i c gia khac [ 1 , 6] v l dac biet so' benh n h i n n h i i u hdn ban d 2 dp tudi 20 - 29 va 70 - 79. Sfl g i l m sut sflc nhai, giam tiet cac men tieu hda cd the la nhflng ye'u td' I n h hfldng tdi benh ly nay.
- Thdi gian dg'n vien: k i t qua nghien cflu cho t h i y c i c benh nhan bi t i e rudt do ba thflc an thfldng den vien mudn hon c i c trfldng hpp tac rupt khac gid'ng nhfl ket q u i cua n h i i u t i c g i l khac [ 1 , 2, 7]. Sd dT benh n h i n thfldng den vien cham I I do dien bie'n benh cd dac diem khac biet d chd cue ba thflc an khi nut chat Idng rudt gay tac nhflng khi cd nhu ddng, rudt co that rdi dan ra lam cho cue ba thflc an di chuyen, qua dd djch va hpi p h l n nao di qua chd can trd, do dd cac d i u hieu t i c rudt giam d i . Benh nhan lai e l m t h i y dd dau, d l chju hdn, cd trung tien, bung bdt trfldng nen thfldng khdng den vien ngay. Chfnh v l t h i cd den 45/86 benh nhan (52,3%) den vien sau ngay thfl 3 cua benh va cham n h i t la trfldng hdp den vao ngay thfl 15. Tham chf c l e benh
nhan da den vien nhflng khi c i c trieu chflng tac rudt g i l m di thi thay thud'c cung chl djnh theo ddi tiep.
- Trieu chffng hoc: Nhin chung c i c benh nhan de'n vien deu bieu hien mdt tinh trang tac rudt CO hpc tuy nhien do dac diem d i i n b i i n cua tac rupt do ba thflc an nen n b i l u trfldng hpp d i u hieu khdng hoan toan d i i n hinh. Bf trung dai tien I I trieu chflng rat cd gia trj c h i n doan t i e rudt cd hpc nhflng la dau hieu chu quan cua ngfldi benh, trong nghien cflu nay chi t h i y d 72,1 % c i c trfldng hpp cd t h i do sfl nhan b i l t cua benh nhan nhflng cung cd the do dac d i i m cua tac rudt do ba thflc an cd luc tac hoan toan nhflng cd luc khdng holn toan. Dieu n l y cung dflpc n h i i u nghien cflu khac cho ke't q u i tfldng tfl [ 1 , 2, 4, 8].
Theo mdt so' t i c gia, ba thflc an dflpc hinh t h i n h d da day. Trong q u i trinh di chuyen xudng phfa dfldi, nd cd the gay t i e d vj trf nao dd cua d'ng tieu h o i . Cac t i c gia nay cho rang nhflng d i u hieu sdm gdi y ba thflc an d da day bao gdm khd chju, dau thfldng vj, budn ndn va ndn, d l y bung, c h i n an, sut can, hdi thd hdi [6, 8]-. Y nghTa cua viec xac djnh cac d i u hieu sdm nay r i t quan trpng vi chung gdp p h l n vao viec chan d o l n khdi ba thflc an khi chfla gay ra b i i n chflng t i e rudt de tfl dd dinh hfldng cho viec xfl trf va dfl phdng.
Tuy nhien d nghien cflu cua chung tdi khdng cd sfl ghi nhan nao ve nhflng d i u hieu sdm nhfl da neu tren, cd the do benh nhan khdng chu y d i n nhflng trieu chflng tren cho de'n khi phai nhap vien v l bie'n chflng tac rudt do ba thflc an gay nen.
C I c d i u hieu thflc the thfldng chl giup c h i n doan tac rupt, cdn d i u hieu cd tfnh c h i t gdi y c h i n doan nguyen nhan t i e do ba thflc an nhflsd t h i y khd'i chl gap trong 1 9,8% c i c trfldng hpp.
Tlnh trang toan than d tat ca cac benh nhan cua chung tdi khdng t h i y cd bieu hien sd'c, nhan xet nay tfldng tfl nhfl cua nhieu tac g i l [ 1 , 2, 4,
10] va cd the cung la dac d i i m cua tac rudt do ba thflc an.
D i u hieu mflc nfldc - hdi t h i y d 79/84 trfldng hdp dflpc chup Xquang bung khdng c h u i n bi (94,1%), ty le nay cua Tran van Bao la 8 6 % [1], cua Dinh van Dung la 87,39% [2]. D i u hieu nay chl cho phep c h i n d o l n tinh trang tac rudt chfl khdng cd gia trj gdi y nguyen nhan cua tac rudt.
N h i i u trfldng hpp tren phim cd n b i l u mflc nfldc - hdi nhflng rdi benh nhan lai cd trung tien, bung dd trfldng va benh nhan cung dd dau, tuy nhien c l e d i u hieu lai cd the x u i t hien trd lai.
Ndi soi da day - t l trang dflpc tie'n hanh d 18 benh nhan, phat hien cd ba thflc an d 11 benh nhan. Khi md cho t h i y 18 trfldng hdp n g o l i ba thflc an gay t i c rudt cdn cd cac cue ba thflc an d da day. Do do neu ndi soi da day - ta trang p h l t hien cd ba thflc an thi rat cd gia trj cho chan d o l n nguyen nhan cua tac rudt I I do ba thflc an. Dieu nay la mdt d i i m c l n chu y, bat budc cac phau thuat vien khi md t i c rudt do ba thflc an p h i i kiem tra da day mdt c l e h he thd'ng tranh bd sdt.
- Ton thffdng ruot khi md: ke't qua phau thuat cho t h i y hau h i t c l e trfldng hop chi cd met dan (68,6%), rudt tfm va ran thanh mac 4 benh nhan va xoan quai rudt dan khdng hoai tfl rudt 3 benh nhan. Qua dien bien benh va nhflng tdn thflpng rudt ta t h i y rang mac du benh nhan d i n vien khdng phai d giai doan sdm nhflng mflc dp -ton thflpng rudt cung khdng q u i nang n l , nhan xet nay cung tfldng tfl nhfl mpt sd tac gia khac [1, 2, 7, 8].
Trfldng hpp bi thung rupt sau khi lay ba thflc an thi khau lai, 3 trfldng hpp cd xoan rudt nhflng rudt khdng cd d i u hieu hoai tfl nen chl phai t h i o xoan va md rudt l i y ba thflc an, 4 trfldng hdp rudt cd tfm, ran thanh mac thi sau khi lay ba thflc an va l l m xep rudt, dap huye't thanh ndng rudt hdng va nhu ddng td't. Tdm lai trong ca 86 benh nhan khdng cd trfldng hdp nao p h i i cat rudt.
- Cac ye'u t d nguy cd: Qua nghien cflu cho thay 38 trfldng hdp cd yeu td nguy cd trong dd t i i n sfl cat da day b i n phan hay gap n h i t (34,2%). C I c benh nhan cd t i i n sfl benh da d l y t l trang (bao gdm ca d i i u tri ndi khoa va da cat da d l y ) trong nghien cflu n l y t h i p hdn c i c t i c gia k h l c d treng nfldc [1, 2, 4] nhflng tfldng tfl nhfl mdt sd tac gia nfldc ngoai [5, 9, 10]. C I c t i c gia chau Au cho rang cd md'i lien quan gifla sfl thay ddi g i i i phau va/hoac sinh ly cua da day vdi sfl hinh thanh cac khd'i ba thflc an. C h l dp an cd nhieu chat xP cung la mdt y i u td dflpc ndi d i n nhfl mdt nguy cd thfldng gap [2, 71. ,. ,,.,,„ ..,.;
C I c phau thuat k h l c d bung khdng phai I I nguyen nhan trflc tiep dan d i n sfl hinh thanh va p h l t trien cua ba thflc an trong dfldng tieu hda nhflng cd the lam thay ddi giai p h i u v l sfl lflu thdng cua dfldng tieu hda de gay nen t i c rudt. Ty le nay cua chung tdi la 2 1 , 1 % , cua Dinh van Dung la 18,2%.
Tlnh trang rang mieng lam anh hfldng trflc tie^p de^n sflc nhai, cd lien quan tdi viec hinh thanh ba thflc an nhflng qua nghien cflu nay chl t h i y d 3 trfldng hdp. Benh phd'i hpp cua nghien cflu n l y la 18,4% gdm: 5 d i i thao dfldng, 1 ddng kinh, 1 benh xd cflng bl. Dieu dc chd t h i y can phai chu y hdn d i n v i n de nay trong tham k h l m cac benh nhan tac rudt.
V . K E T L U A N
Tac rudt do ba thflc an thfldng gap n h i i u hdn d Ifla tudi tren 50, cd dac diem dien bien c i p tfnh (47,7%) hoac b i n c i p (52,3%) vdi thdi gian trung binh ke tfl khi cd trieu chflng d i u tien d i n khi vao vien la 6,34 ngay. Viec c h i n d o l n nguyen nhan dfla tren trieu chflng cfla t i c rudt k i t hpp vdi nhflng y i u td' nguy cd dfldc ghi nhan nhfl benh ly da day ta trang, c h l dp an udng, va se r i t cd gia trj khi ndi soi t h i y cd ba thflc an trong da day.
Tuy nhien tinh trang rang mieng cua benh nhan.
benh ly tuy tang... can dfldc chfl y nghien cflu ky hdn. Xfl tri t i c rudt do ba thflc an thfldng ddn gian, song viec k i i m tra toan bd rudt non dac biet I I da d l y de p h l t hien cac khd'i ba khac chfla gay t i e rudt I I nguyen t i e quan trpng can dflpc chu y.
T A I LIEU
THAM
K H A O1. Tran van Bao (1994). Gdp phan chan doan va xfl trf tac rudt do ba thflc an tai khoa Ngoaj benh vien Nghe an. Luan van td't nghiep b i c sT chuyen khoa c i p II, Trfldng dai hpc Y H I ndi.
2. Dinh van Dung (1996). Nghien cflu v l c h i n d o l n va d i i u trj t i c rupt do ba thflc an tai mpt sd benh vien Idn d Ha ndi. Luan van thae sy Y khoa. Trfldng Dai hpc Y Ha npi.
3. Dang Hanh De. (1972). T i c mpt do ba thflc an sau cat da dly. Thdng tin Ngoai khoa 1, 130 - 1 3 4 .
4. Ha van Quye't va cdng sff (1994). T i c rudt do ba thfle an. Hdi nghj Ngoai khoa c i p cflu bung va CO quan van ddng. Ha Ndi, tr 34.
5. Benharroch D, Krugliak P, Porath A, Zurgil E, Niv Y (1993). Pathogenetic aspects of persimmdn bezears. a case - ccntrol retrospective study, J Clin Gastroenterol, 1 7 (2), 1 4 9 - 1 52.
6. Emerson AP (1987). Foods high in fiber and phytobezoar formation. J Am Diet Assoc, 87 (12), 1675 - 1677. • •
7. Hayes PG, Rotstein OD (1986).
Gastrointestinal phytobezoars: presentation and management, Can J Sur, 29 (6), 41 9 - 420.
8. Holloway W D , Lee SP, Nicholson Gl (1980). The composition and dissolution of phytobezoars. Arch Patho Lab Med 104 (3),159 - 1 6 1 .
9. Izumi S, Isida K, Iwamoto M (1953). The mechanism of the formation of phytobezoars, with special reference to the persimmon ball. Jpn J Med Biochem, 2, 21 - 35.
10. William RS (1986). The fascinating history of bezears. Med. J. Aust 145, (11 - 12), 613 - 6 1 4 .
. - Summary
EVALUATION OF DIAGNOSIS AND TREATMENT OF INTESTINAL OBSTRUCTION BY B E Z O A R
Intestinal obstruction by bezoar is not very rare disease. The analysis of 86 cases treated in the surgical department of Bach Mai hospital shows that the character of clinical and investment findings can suggest the cause when intestinal obstruction happens in patients have the risk factors such as history of peptic ulcer, habitual regimen, the age, ect... It is possibility of acute (47,7%) or subacute (52,3%) progress with 6,34 days of mean pre - permitted time. The treatment for this disease is not complicated, and gastric and intestinal examination during operation is very important.
Keywords: Intestinal obstruction, bezoar 1 ^
