NGHIEN CUtJ NGUYEN NHAN, DAC DIEIVI LAIVI SANG VA HINH ANH NOI SOI BENH NHAN XUAT HUYET DA DAY TA TRANG TAI BENH VIEN TRUNG ITONG HUE VA
BENH VIEN TRirONG DAI HOC Y DlTOC HUE
Le Thi Duong*
TOM TAT
Oat van de: Viec co mot each nhin tong quat ve nguyen nhan, lam sang va dac diem npi soi la rat can thiet cho viec chan doan nhanh va CO thai dp xir tri hdp ly cac tru'dng hdp XHDD-TT.
Xuat phat tir yeu cau do chiing toi tien hanh nghien ciiu tinh hinh XHDD-TT tai Benh vien Trung u'dng Hue va Benh vien Tru'dng Oai hpc Y Dddc Hue t i i thang 3/2009 den thang 4/2010 nham cac muc tieu sau: Khao sat mot sd dac diem lam sang, nguyen nhan thu'dng gap va hinh anh npi soi ciia xuat huyet tir da day ta trang- Oanh gia mdi lien quan giu'a nguyen nhan, hinh anh tdn thu'dng tren npi soi vdi mire dp xuat huyet.
Odi tu'dng va phu'dng phap: Chon nhu'ng ngu'di dddc chan doan XHDD-TT tai khoa Npi tieu hoa BV Trung L/dng hue va khoa Noi BV Tru'dng Dal hpc Y Dddc Hue tir thang 3/2009 den thang 4/2010. Npi soi dng tieu hoa bang dng sol mem, Olympus GIF-XQ 140-phan dp xuat huyet bang tieu chuan Rockall. Xii ly sd lieu: Sir dung chUdng trinh Medcal-Excel 2003.
Ket qua: Nguyen nhan XHDD-TT la loet da day 27,9%, loet ta trang 26,7%, viem da day 15.1%. Lim sang: ve mire dp XH-48,8% mire dp nhe, 43,1% mu'c dp trung binh, 8 , 1 % mu'c dp nang. Npi soi: vj tri mat tru'dc hanh ta trang 16.27%,.hang vi 13,95%, tamvi- thdc quan, mat sau HTT 10,47%. Nguyen nhan loet da day co mu'c dp XH nang + trung binh 43,2%, loet ta trang co mire dp XH nang + trung binh 38,6%.
Ket luan: Nguyen nhan chay mau do loet da day va loet ta trang chiem ty le cao. Xuat huyet da day thu'dng non ra mau bam lan thu'c
an, xuat huyet d ta trang thu'dng ndn ra mau den bang. Vj trf bd cong nhd va mat sau hanh ta trang thu'dng gap xuat huyet mire dp nang va trung binh.
ABSTRACT
RESEARCH ON THE CAUSES, CLINICAL CHARACTERISTICS AND ENDOSCOPY
IMAGE OF PATIENTS BLED FROM GASTRODUODENAL I N HUE CENTRAL
HOSPITAL AND HUE UNIVERSITY OF MEDICINE AND PHARMACY HOSPITAL
Background: It is necessary to have an overview of the causes, clinical and endoscopy characteristics. This helps doctors to have the rapid diagnosis and suitable treatment attitudes for cases of gastroduodenal hemorrhage. From these requirements, we studied the situation of gastroduodenal hemorrhage in Hue Central hospital and Hue university of Medicine and Pharmacy from March, 2009 to April, 2010.
Objectives:
Survey some clinical characteristics, common causes and endoscopy image of Gastroduodenal hemorrhage
Assess the relationship between causes injury Image on endoscopy to the level of bleeding.
Subjects and methods: Choose patients who were diagnosed gastroduodenal hemorrhage in department of Digestion Internal, Hue Central hospital and department of Internal Medicine, Hue university of Medicine and Pharmacy from March, 2009 to April, 2010. Gastrointestinal endoscopy with soft probe, Olympus GIF-XQ 140
Y HOC VIET NAM THANG 9 - SO OAC BIET/2011 - grading bleeding by Rockall standard. Processing
data: Using the program Medcal-Excel 2003.
Results: The causes of gastroduodenal hemorrhage were stomach ulcer 27,9%, duodenal unlcer 26,7%, gastritis 15.1%. Clinical:
level of bleeding 48, mild level: 8%, average level: 43,1%, severe level: 8,1%. Endoscopy: the front position of duodenum was 16.27%, antrum was 13,95%, cardiac stomach- esophagus, the back position of duodenum was 10,47%. The cause of stomach ulcer having level of bleeding: severe + average: 43,2%, duodenal unlcer having level of bleeding: severe + average: 38,6%.
Conclusions: The cause of bleeding due to duodenal unlcer and stomach ulcer accounts for high rate. Gastrointestinal bleeding often vomited blood and food bruising, duodenum bleeding often vomited black, diluted blood. Position of the small curvature and the back position of duodenum often bled in severe and average level
I. OAT VAN OE
Xuat huyet tieu hda cao noi chung va xuat huyet da day-ta trang ndi rieng la bien chung do ton thucmg cau true va he thdng mach mau nuoi dudng bdi nhieu nguyen nhan khac nhau. Trudc mdt benh nhan xuat huyet da day-ta trang, dac biet la nhirng trudng hgp cap tinh, vdi bieu hien non ra mau, di cau ra mau hoac ca non va di cau ra mau. ChSn doan nguyen nhan, vi tri, muc dp chay mau dl cd thai dp dieu trj trong nhieu trudng hop cdn khd khan, phuc tap. Sue khoe ngudi benh phu thudc vao nhiing quyet dinh vl chan doan va dilu tn kip thdi, chinh xac cua thay thudc.
Trudc day, khi hdi sue cap cuu va cac phucmg tien tham dd chuc nang dac biet nhu ndi soi chua phat triln, thai dp xir tri chu ylu la can thiep ngoai khoa. Trong nhirng nam gin day, ciing vdi sir phat trien manh me cua
khoa hpc ky thuat, cac phuang tien can lam sang, phuang lien hdi siic cap ciru, cac bien phap cam mau ciing phat trien manh, giup cho cdng tiic chan doim va dieu trj chinh xac, hieu qua ban nhung ty le tai phat va tii' vong
\an ci)n cao, trong liic day la benh ly thudng gap. Trudc tinh hinh do, chiing toi tien hanh do tai nham muc ticu:
Khao sat mot so dac diem lam sang, nguyen nhan thudng gap ciia xuat huyet tir da day ta trang.
Diinh gia moi lien quan giira nguyen nhan, hinh anh ton thuang tren ndi soi vdi miic dp xuat huyet.
II. o 6 l TUpNG VA PHaONG PHAP NGHIEN CCfU
1. Doi tuong nghien cuu
Cac benh nhan xuat huyet tir da day - ta trang nhap vien dieu trj tai khoa Npi Tieu boa Benh vien Trung uang Hue va Benh vien trudng Dai hpc Y Dugc Hue tir thang 4/2009 din 3/2010. Tieu chudn chpn mdu:
Ndn ra mau va hoac di cau phan den - Xac nhan bang ndi soi cd chay mau tai da day ta trang, ke ca chay mau dang tiep dien hay chay mau da cam.
2. Phuong phap nghien cuu
- Phuang phap md ta cat ngang. Cac budc dugc tien hanh nhu sau:
+ Khai thac benh sir + Tham kham lam sang
+ Tham dd can lam sang: ndi soi, sinh boa Sir dung may ndi soi dng mem hieu OLYMPUS GIF-XQ 140.
Phuang phap xir ly so lieu: Cac sd lieu dugc dua vao xir ly tren may vi tinh theo chuang trinh Medcal va ho trg phan mem Excel 2003. Khoang tin cay dugc chpn la 95%.
III. KET QUA NGHIEN ClfU
1. Phan bo t u o i vii gidi xuat huyet da t[i»yj-Ja t r a n g Gidi
Tudi ^
j< 40 40- <60
60- <80
> 8 0 Tdng Xhdn .\ci:
N a m SL 18 24 17 4 63
%
20,9 27,9 19,8
73,3
SL 3 7 8 5 23
^Q'
%
3,5 8,1 9,3 5,8 26,7
Tdng sd SL
21 31 25 9 86
o/o 24,4 36,0 29,1 10,5 100
Tudi TB chung
55,3 ± 19,1 (tii 17 91tu60
, )d tuoi t u 40 den dudi 60 cbicMii tv lc cao nhiit (36,0%).
2. Phan bo nguyen nhan xuat huyet da ( Nguyen nhan
Viem da day Loet da day
Tinh mach trUdng da day Ung thd da day
H/c Mallory- Weiss Loet ta trang
Viem da day -i- Loet ta trang Loet da day + Loet ta trang
Cong
liiy - (il t r a n g Sd benh nhan
13 24 3 5 9 23
6 3 86
Ty le (O/o) 15,1 27,9 3,5 5,8 10,5 26,7 7,0 3,5 100
.\77(?/7 xet: Nguyen nhan xuat huyet do loet da day chiem ty le cao nhat 27,9% (24 trudng hgp).
3. Lam sang
3.1. Chisd huyet ddng theo mire do XH (Phan theo mire dp XH ciia Rockall)
Chi sd huyet ddng theo
mu'c do xuat huyet So benh nhan Ty le (O/o)
Nhe 42 48,8
Trung binh 37 43,1
Nang 8,1
Tong sd 86 100
Nhdn xet: Da so benh nhan cd chi so hujet dpng a mire dp nhe \ a trung binh.
3.2. Tinh chat non
- - . y U r i chay m^u Chat ndn ^~~~~~~-—-^__
Mau tddi Mau bam
Mau bam lan mau tddl Khong co mau
Da <
SL 12 17 13 12
Jay o/o 22,2 31,5 24,1 22,2
Ta trang SL
0 10
0 13
o/o 0 43,5
0 56,5
P
>0,05
<0,05
Y HOC VIET NAM THANG 9 - SO OAC BIET/2011
Nhdn xet: Ndn ra mau tuai, mau bam lan mau tuai chi co trong XHDD khong gap trong ta trang.
3.3. Tinh chat phan
Tinh chat phan Oen
Den lan mau tddi Khong co mau
Tong so
So benh nhan 39
9 38 86
Ty le (O/o) 45,4 10,5 44,1 100
Nhdn xet: Da sd benh nhan di cau phan den l> lc la 45,4%.
4. Noi soi
4.1. Hinh dnh dgi the qua ndi soi
Hinh anh noi soi Loet sill
Loet non Loet xd chai Phil ne Sung huyet Su'dt Loet nong Rach xddc Gian tTnh mach
Tong cong
So benh nhan 5
28 23 7 5 2 4 9 3 86
Ty le (O/o) 5,8 32,6 26,7 8,1 5,8 2,3 4,7 10,5
3,5 100
Nhdn xet: Ty le loet non chiem 32,6% cao nhat
4.2. Vj tri chdy mdu qua ndi soi
V i t r i Sd benh nhan Ty le (O/o)
Tam vj thiic quan 10,47
Phinh vi 3,49
Than da day 11 12,79
Bd cong nho 10 11,63
Hang vj 12
Tien mon vi
13,95 6,98
Mieng ndi 3,49
Hanh ta trang Mat trUdc 14
Mat sau D D - T T phdi hdp
Tong so 86
16,27 10,47 10,47 100
5. C ac moi lien (|uan
5.1. Lien quan giira nguyen nhdn vd miic do xudt huyet
Trung Nguyen nhan
Viem da d^y^
Loet da day
TTnh mach trudng da day Ung thu' da day H/c Mallory - Weiss
Loet tci trang
Viem da day+ Loet ta trang Loet da day + Loet ta trang
Tdng cdng
SL 12
J_
4 8
42
o/o
. 2 M 11,9_
4 ^
A5_
i 9 A 14,3
IA.
43_
100
j j n h -f- Nang SL
1 19
1
17
44
o/o . 2 ^ 43,2
IA IA.
IA.
38,6 6,8
lA^
100
<0,01
<0,01
>0,05
>0,05
<0,05
<0,05
>0,05
>0,05
.\7;(//; .xet: Rcnh ngu\ cn \iC"m da diiy, loci da day, h/c Mallor>'-Weiss, loet ta trang cd sir khac biet CO y nghTa thong kc gifra mire do xuiil huycl nhe v(Vi mire dp nSng va tmng binh.
5.2. Lien quan giiia vi tri tdn thuong tren ndi soi v&i muc do xuat huyet
Mu'c do xuat huyet Vi t r i tren ndi soi ' Tam vi thi/c quan
Phinh vi Than da day
Bd cong nhd Hang vj Tien mon vi
Mieng ndi
Hanh ta trang Mat tru'dc Mat sau D D - T T phdi hdp
Tdng
h SL
4 2 6 1 7 4 1 10
1 6 42
he
o/o
9,5 4,8 14,3
2,4 16,7
9,5 2,4 23,8
2,4 14,3 100
TB-HNang SL
5 1 5 9 5 2 2 4 8 3 4 4
o/o
11,4 2,3 11,4 20,5 I M
4,6 4,6 9,1 18,2
6,8 100
P
>0,05
>0,05
>0,05
<0,05
>0,05
>0,05
>0,05
>0,05
<0,05
>0,05
Nhdn xeV.Vi tri bd cong nho \ ii mat sau HIT xuiit huyet mire dp nang \ ii trung binh chiem ty le cao so vdi mire dp nhe. Si,r khac biin cd y nghTa th6ng ke \di p<0,05.
IV. BAN LUAN
*
1. Tuoi, gidi
Da so cac tac gia cho rang nam co ty 1?
xuat huyet DD - TT cao hon nir 2-4 lan. Kit qua nghien cim cua chung tdi nam cd ty le 73,3 %; nu- 26,7%. XHDD TT gap cao nhat
chung cho lira tuoi dudi 60 chiem 60,4%, day la nhom tudi cd tien lupng tdt, dugc tinh 0 diem trong thang diem xuat huyet tieu hoa ciia Rockall. Nhdm tuoi tir 60 dhn dudi 80 chilm 29,1%, nhdm tudi tir 80 trd len chiem
10,5%, day la hai nhdm tudi cd tien lugmg xau hon va dugc tfnh lan lugt 1 va 2 diem
Y HOC VIET NAM THANG 9 - SO DAC BliT/2011
binh cua 86 benh nhan xuk huylt DD TT la 55,3 ±19,1.
Theo Phan Trung Nam ca cdng svr, xuat huyet tieu hda cao cd 36,6% d nlidm tudi tii- 40
<60 tu6i, trong dd nam 68,4%, nu 31,6%.
Manish KV. tir mdt nghien cim dugc thuc hien trong nam 1995 d My cho thin co den 44,5% sd benh nhan bi xuat hu\ci ticu hoa cao cd dp tudi tir 60 trd len. Dieu na\
phii hgp vdi nghien ciru ciia chiing toi.
2. Nguyen nhan
Ket qua ciia chimg tdi xuat huyet do loet da day la 27,9%, tiep den la loet ta trang 26,7%, viem da day 15,1%, hpi chirng Mallory Weiss 10,5%, \iem da da> phoi hgp loet ta trang 7,0%, ung thu da day 5,8%, loet da day phdi hgp loet ta trang \ a tTnh mach trudng 3,5%. Nghien cim ciia Chib va cdng sir xc cac nguyen nhan ciia xuat huyet ducmg tieu hda tren khdng phai do tinh mach trudng cd 42,5% loet da day, 16,2% loet ta trang, 8,8% hdi chung Mallory Weiss. So sanh vdi ket qua nghien cuu cua chung toi su khac biet khong co y nghia thdng ke (p>0,05).
Nghien curu cua Tran Van Huy nam 2000 ciing ghi nhan loet da day chiem ty le cao nhdt trong cac nguyen nhan xuat huyet tieu hoa cao (27,9%), loet ta trang 26,7%, viem da day 19,1%, ung thu da day 6,6%, Mallory Weiss 5,7%. Su khac biet khdng co y nghia thing ke so vdi kit qua nghien cuu cua chung tdi (p>0,05).
3. Lam sang
3.1. Chi sd huyet dpng
Theo Rockall va Hoang Trpng Thang thi chi s6 mach, huylt ap gop phhn quan trpng trong viec danh gia muc dp mat mau cua xuat huylt DD - TT. Trong nghien cuu cua chimg toi, chi sd mach, huylt ap da s6 tuong ung va phu hgp vdi muc dp mat mau.
3.2. Tinh chdt ndn ra mdu vd di cdu ra mdu Tinh chat hon ra mau: Irong nghien cuu ciia chimg tdi, dau hieu ndn ra mau tuai vii non ra mau tuai lan miui bam doi vdi vi tri cha> mau tii' ta trang lii 0%, con doi vdi vj tri chay mau tii' da day la 22,2% va 24,1%. Dau hieu khong non ra mau lii 22,2% doi vdi xuat hu>et a da day nhung chiem 56,5% doi vdi xuat huyet a ta trang. Sir khiic biet ve tinh chat non ra mau giua hai vi tri da diiy va ta trimg la co y nghTa thong ke (p<0,05). Dua
\ ao tinh chat non ra mau cung co the ggi y vi tri xuat huyet. Xuat huyet d da day, thucmg non ra mau bam lan thirc an nhung co trudng hgp non ra mau tuai du' dpi. Nhung xuat hu>et d ta trang hay d sau mon vi thuong it khi non ra mau hoac chi non ra mau den sam hay nude mau den loang.
Tinh chat di cau; 39 benh nhan di cau phan den chiem 45,4%, cd 9 benh nhan di cau phan den lan mau tuai chiem 10,5%.
Xuk huylt d da day va ta trang thudng di chu phan den, nhung trudng hgp xuat huyet nhieu, d at co the di cau ra mau tuai lan mau bam. Dieu nay hoan toan phii hgp vdi ket qua nghien cuu cua chung toi.
4. Noi soi
4.1. Hinh dnh dgi the qua npi soi
Co 28 trudng hgp loet non chiem ty le cao nhat 32,6%, 23 (26,7%) truong hgp loet xa chai, 3 trudng hgp gian ttnh mach da day viing phinh vi, 9 trudng hgp tdn thuang rach xudc dang Mallory-Weiss, 5 truong hgp (5,8%) cd hinh anh loet siii trong do 3 trudng hgp nhilm cung viing bd cong nhd, 2 truong hgp vimg hang vi khi lam giai phau benh ket qua K bieu md da day.
4.2. Vi tri chdy mdu qua npi soi
Npi soi cd thi chan doan nguyen nhan, vi tri va muc dp xuat huyet 85- 90%.
Da so ciic lac gia tinh chung cho till cii cao. 0 mire dc) xuat huyet vira va nang thi benh cac nguNcn nhim giiN xuiU huNcI da day lii ngiiycMi loet da diiy lii hay gap nhat
trang thi cr \ i tri da dii> thuirng co ly lc laii 5.2. Lien quan giiia vi tri tdn thuang
r r
hern til trimg. Ket qua nghiC'ii ciru cii;i chiing tren npi soi vdi mire dp xuat huyet
toi \ i tri chin mau o hiinh ta triing dirng himg Vi (ri ciia o loot cung la mdt trong nhimg thir yen sau \i tri da day. Hiinh tii iriing ticu chuiin quan trpng dimh gia mire dp xuat 26,74"o (10.27'!(. + l(),47"o), da d;i\ 62,79% huyet. Theo ket qua nghien cim cua chung trong do: hang \i l.\')>"(i; bir cong nho tc)i. vi tri ber cong nhd vii mat sau hanh ta 1 l.(i3"o. tam \i thuc quan 10,47"/(i; than da triing hi hai vi tri cd ty le xuat huyet nSngcao diiN 12.79%; tien mon \i 6,98"»; mieng noi nhat (hir cong nhd cd vdng noi ddng mach
\a phinh \i mdi \i tri 3,49']i). vimh vi). Nhan xet nay cung phii hgp vai rhco Tran Van Hu> \a cpng sir ty lc cua Shinji N. Tuy nhien trong nghien cim cua cac \ i tri xuiit huyet ticu hda cao nhir sau: da Woong >' lai lha\ rang \ i tri cua d loet khong da> 50" 0, ta trang 25%. Sy khac biet ve t> lc phiii la yeu td nguy cadoi viri chay mau tai phat.
xuat hu\ et d da da\ \ ii lii triing ciia chiing tdi
\il Iran Vim Huy la khdng cd y nghia thdng V. KET LUAN
ke(p>0.05). Nguyen nhan chay mau do loet da day 5. Cac moi lien quan va loet ta trang chilm ty le cao 27,9% va 5.1. Lien quan gira nguyen nhdn vd 26,7 %. Trong khi viem da day chilm 15,1%, muc dp xudt huyit hpi chimg Mallor>'- Weiss chilm 10,5%, cac
Viem da day co mire dp xuk huyet nhe nguyen nhan kliac chilm t>' le tuong doi thap.
chilm ty le cao 12/13 trudng hgp (92,3%). v l trieu chimg lam sang, xuk huylt da Day la nguyen nhan cd tien lugng tdt nhat, day thudng non ra mau bam lan thirc an, co xuat huyet thucmg nhe \a tu gidi ban, hhu truong hgp ndn ra mau tuoi nhung xu^t nhu khong can den sir can thiep cam mau chi huylt d ta trang it khi ndn ra mau hoac chi chn dieu tri npi khoa va theo ddi. Loet da day non ra mau den loang. Mire dp xu^t huyet cd mire dp xuat huylt trung binh va nang nhe thi benh nguyen \ iem da day va hoi chiem ty le 19/24 trudng hgp (79,2%). Loet chimg Mallory - Weiss chilm t\ le cao ta trang co mire dp xuk hu}lt nang vii trung (28,6% vii 19"'o). Mire dp xudt huylt nang va binh chilm ty le cao 17/ 23 trudng hgp trung binh thi benh nguyen loet da day hay (73,9%). Hpi chimg Mallory - Weiss chii N lu gap nhdt (43,2%).
xudt huylt mire dp nhe (8/9=88.9%) va 1 Vi tri bd cong nhd va mSt sau hanh ta truong hgp trung binh (11,1%) khong cd trang xudt hu\lt mire do nang va trung binh mire dp nang.Day cung lii mpt nguyCMi nhan ehilm ty lc cao (20,5%) va 18,2%).
cd tien lugng tot vi xuat hien d ngirdi Ire tuli
va thudng 90% xuat huylt tir cdm. VI- KIEN NGHI
Nlu so tirng nhom xudt huylt nhe, trung xdt ca nhimg benh nhan loet DD-TT binh, nang thi chung tdi cd cac nhan xet sau: cdn dugc theo doi ty le tai phat tren ndi soi.
6 muc dp xuat huyet nhe thi benh nguyen viem cdn phdi hgp giira trieu chimg lam
Y HOC VI^T NAM THANG 9 - SO OAC BIET/2011
nhan chinh xac va cd tien lupng dung.
TAI UEU THAM KHAO
1. Pham Thj Thu Ho (2004), Chan doan va dieu tri xuat huyet tieu hoa cao, Benh hoc noi khoa sau dai hpc, tap 1, Nha xuat ban Yhoc, HaNgi, tr. 27-34.
2. Isselbacher K.J.,Dienstag J.L., Duong Ba True (ban djch) (1999), Non ra mau, ia phan den va phan co mau, Cac ngu\cn ly y hoc noi khoa Harrison, tap 1. Nha xuat ban Y hoc, Thanh pho Ho Chi Minh, tr. 318-319.
3. Khoa Tieu hoa Benh vien Bach Mai (2005), Noi soi tieu hoa, Nha xuat ban Y hoc, HaNpi,tr. 83-89.
4. Hoang Gia Loi (1992), Xuat huyet tieu hoa, B?nh hoc npi khoa sau dai hpc, t$p 2. Nha xuat ban Y hpc. Ha Npi, tr. 42-52.
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huyet tieu hoa cao d Benh vien Truong Dai hpc Y khoa Hue tir nam 2003-2006, Tap chi Y hpc thiic hanh, I loi nghi khoa hoc Y Dupe 50 nam thanh lap truong Dai hpc Y Dupe Hue, (568), tr. 49-50.
6. Hoang Trong Thang (2006), Chay mau tieu hoa, Benh tieu hoa gan mat, Nha xuat ban Y hoc. Ha Npi, tr. 62-77.
7. Loren Laine, and Walter L. Pertcrson (1994), Bleeding peptic ulcer. The new England Journal of Medicine, 331(11), tr.
717-727
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