JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.5-N°1/2010
Nghien cihi gia tri cua noi soi mat tuy ngugc dong trong chan doan soi, giun ong mat chu
The value of Endoscopic Retrograde Cholangiopancreatography (ERCP) in the diagnosis of common bile duct stone and ascarid
Mai Hong Bang, Dirong JVIinh Thang, Tran Van Riep, Bui Van Lac, Nguyen Tien Thinh, Thai Doan Ky, Trjnli Xuan Hiing, Le Van Truomg, Nguyen Tlianh Tu
Benh vien Trung uong Qudn dgi 108
Tom tat
Nghien cUu ve d§c diem hinh anh va gia trj chan doan soi, giun dng mat chii qua noi soi mat tuy ngUcic dong. Ket qua cho thiiy da sd benh nhan c6 soi va/hoac giun dng mat chii don thuan (70,2%); sdi nam d toan bo dng mat chCi chiem ty le cao (57,7%); kich thU6c sdi phan idn tU 1-2cm va da sd sdi c6 hinh bau due; hinh anh gian dUdng mat ngoai gan la 86,8% va khuyet sdi 73,7%. Npi soi mat tuy ngUdc dong la mpt phUdng phap c6 gia tri cao trong chan doan benh 1^ sdi, giun dng mat chu: do nhay (97,9%), do dac hieu (100%) cung nhu gia tri chan doan diing (98%) deu cao hdn so vdi sieu am.
Summary
We studied on imaging characters of common bile duct stone by using ERCP and the diagnostic value of this technique. The results showed that most of patients had stone and/or Ascarid in common bile duct alone (70.2%) in which stone size ranged predominally from 1 to 2cm diameter and ovan stone was the most common. Extrahepatic biliary dilatation was found in 86.8% of patients and stone-induced shadow was 73.7%. ERCP is a high valuable diagnostic method for CBD stone and ascarid of which the sensitivily (97.9%) and the speciality (100%) as well as the correct diagnostic value (98%) are all higher than that of ultrasonography.
1. Dat va'n de
Sdi, giun dudng mat la benh rat phd bie'n d Viet Nam [1,2]. Viec chan doan sdi, giun dng mat chii (OMC) trudc day thudng dUa vao lam sang, xet nghiem, sieu am, chup X quang, chup cat Idp vi tinh, chup cpng hudng tU... cac phuong phap nay co gia trj khac nhau nhung mdi chi dUng lai d muc dich chan dean, treng dd sieu am la phUdng phap dUdc SLT dung rpng rai nha't. Npi soi mat tuy ngUpc dong (NSMTND) la mpt ky thuat cao da dUdc ap dung rpng rai tren the gidi tu nhieu nam nay. NSMTND vUa giiip cho chan doan cac benb ly mat - tuy ddng thdi cd the can thiep dieu tri nhU: lay sdi, giun trong dUdng mat tuy, cat cd Oddi, bdm rCfa dudng mat, dat stent dudng mat [1,2,4,5]. Chiing tdi tie'n hanh de tai nghien cufu nham muc tieu: 77m hiiu d$c diem hinh anh va gia tn chan
doan soi, giun ong mat chu qua noi soi mat tuy ngMc dong.
2. Doi ti/dng va phUdng phap nghien curu 2.1. Doi twang ngfiien ciiu
Gdm 104 benh nhan dupe tie'n hanh NSMTND tai Benh vien TWQD 108 trcng thdi gian tU 2006-2008.
2.2. Phwang ptiap nghien cdu Tie'n cUu mc ta cat ngang.
- Tieu chuan chpn benh nhan nghien ciJfu: Benh nhan dUdc chan dean ve lam sang, can lam sang va sieu am nghi ngd cd sdi hoSc/va giun trong dng mat chii:
+ Lam sang: dau ha sudn phai, sdt, vang da...
+ Sieu am: gian dudng mat ngoai gan va/hoSc trong gan, cd hinh anh nghi sdi, giun OMC.
Tap 5-s6 1/2010 TAP CHi Y DLTOC LAM SANG 108
+ Prothrombin >=70%, mau chay va mau dong binh thudng.
+ Kich thude cua sdi do tren sieu am <=25mm.
- Tieu chuan loai trU:
+ Kich thude sdi (do tren sieu am) >=25mm.
+ Rdi lean dong mau.
+ Suy gan, suy than nang.
+ Cd benh ly ac tinh dUdng mat tuy.
+ Suy tim, suy hd hap, qua gia ye'u.
+ Benh nhan tUchdi lam NSMTND.
2.3. Phwang tien nghien cuu
- May sieu am Senos 7500 va 5500 (My) - May chup mach hieu Philips (My)
- May npi soi ta trang eCra ben Olympus-EVIS 240 (Nhat Ban)
- Catheter telfen ciia hang Wilson- Cook, day d i n (Guidewires), rp lay sdi, dung cu tan sdi.
- Ngudn cat dot.
- Cac thude nhU: thude can quang, thude tien me (Seduxen), thude me, tbudc giam nhu dpng rupt va cac thude cap cUu khae.
2.4. Quy trinti nghien cuV - Lua chpn benh nhan.
- Chuan bj benh nhan.
- Thue hien ky thuat NSMTND.
- Theo doi sau NSMTND.
- Thu thap va phan tich sd lieu.
2.5. Cac bwdc cua ky tfiuat NSMTND - DUa may xudng ta trang.
- Tim Papilla va ludn catheter vao Papilla.
- Bdm thude can quang chup dudng mat tuy.
- Cat ed Oddi, ludn rp vao lay sdi/giun.
- Chup dudng mat kiem tra lai.
- Bdm riia dudng mat.
2.6. Xwtysolleu: bang phan mem SPSS 11.5
3. Ke't qua nghien ciiru
104 benh nhan dUde tie'n hanh NSMTND tai Benh vien TWQD 108 tU 2006-2008. T^ le nam/nOr 38,5%/61,5% (-1/1,6); tren 40 tudi gap 84,6%.
Bang 1. So sanh kha nSng phat hien sdi va giun OMC giUa NSMTND va sieu am
Kha nang phat hien Sdi ddn thuan
Giun Sdi + giun
Tdng
Sieu am n
55 25 9 89
% 52,9
24 8,7 85,6
NSMTND n
61 24 10 95
% 61,6 24,2 10,1 96
P
<0,05
>0,05
<0,05
<0,05 Bang 2. So sanh gia tri chan doan sdi, giun OMC ciia NSMTND va sieu am
Gia tri Dp nhay Dp dac hieu Chan doan diing
Sieu am (87/87+11)
88,7%
(4/4+2) 75%
(87+4)/(87+2+4+0) 98%
NSMTND (95/95+2) 97,9%
(2/2+0) 100%
(95+2)/(95+2+2+0) 98%
Bang 3. Vj tri sdi qua qua sieu am va qua NSMTND
Vi tri sdi mat Sdi OMC ddn thuan Sdi OMC va dudng mat trong gan
Sieu am n
62 16
% 59,6 15,4
NSMTND n
73
% 70,2
JQURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.5-N°1/2010
Sdi OMC+ trong gan+ tiii mat Tdng
1 89
0,96 85,6
1 97
0,96 93,3
78.1
1 vien 2-3 vien >3 vien
•NSMTND BSieu am
Bieu do 1. Sd lupng sdi vien OMC tren sieu am va NSMTND
' ^ 63.4 ' "" " " '
ID NSMTND sSleu am
<1cm 1-2cm >2cm
Bleu do 2. Kich thude sdi OMC
Bang 4. Hinh dang sdi OMC qua sieu am va qua NSMTND
i-linh dang sdiHinh tron Hinh bau due
Hinh da dien Sdi bun
Tdng
Sieu am n
6 54
1 3 64
% 9,4 84,8
1,6 4,7 100
NSMTND n
8 58
2 3 71
% 12,3 81,7 2,8 4,2 100 Sdi hinh bau due chie'm t-^ le cao nha't ca tren sieu am (84,8%) va tren NSMTND (81,7%).
Tap 5-s6 1/2010 TAP CHi Y DL/OC LAM S A N G 108
90 80 70 60 50 40 30 20 10 0
86.8. 83.7
^dj^
&4
-n:T-
10.6 14.4
68.3
• NSMTND HSieu am
Gian Gian Tui mat Hinh soi Hep
trong gan ngoai to duong
gan mat
Bieu do 3. Hinh anh dudng mat, tiii mat tren sieu am va NSMTND
4. Ban luan
Hien nay sieu am la phUdng phap dUdc sCf dung rpng rai trong chan doan sdi mat, sieu am de dang tham do va danh gia dupe cac chi tieu nhu: dudng kinh OMC, sd lUdng sdi, kich thude sdi, vj tri cua sdi, dac diem ciia giun va xac giun trong dudng mat.
Trong nghien ciili cua chiing tdi, sieu am cd ty le chan doan dUdng tinh sdi va xac giun trcng dudng mat la 85,6% (trdng dd chan dean dUdng tinh sdi mat la 52,9%, chan ddan sci ke't hdp v6i xae giun la 8,7%).
0 nghien cUu eiia cbiing toi, dp nhay cua phUdng phap sieu am la 87%, dp dac hieu la 86,7% va gia tri chan doan diing la 85,6%. Theo Nguyen Duy Hue dp nhay cCia sieu am la 95,6%; dp dac hieu 72%, chan doan dung 92,9% [2]. Cdn theo Pham Quang CCf dp nhay cua sieu am la 90,2%; dp dac hieu la 76,1%;
chan doan diing la 91,2% [1].
Trong 99 ca chup dUdng mat thanh cong chiing toi tha'y t^ le chan doan sdi va giun dUdng tinh la 96%
(sdi ddn thuan chie'm 61,2%; sdi va giun ke't hdp 10,1%); ed 2 trUdng hdp am tinh that; cd 2 trUdng hdp am tinh gia tren phim chup khong quan sat dUdc sdi nhung khi dung catheter cd bdng thi lay ra dUde nhieu sdi biin. Sd dT nhU vay la do sdi bun khong tao thanh khdi, de mun nat, thude can quang ngam xen ke vao trong sdi lam eho bong can quang eiia sdi khong ro.
Dp nhay cua phuong phap chup mat tuy ngUdc dong cija chiing toi la 97,9%; dp dSc hieu la 100% va gia trj chan doan diing la 98%. Ke't qua nay cung tUdng tu nbu ke't qua nghien cUu Pham Quang CCf vdi
chan doan diing 98,7%. Nhu vay ro rang NSMTND cd uu the hdn, cd gia trj cac hdn trdng chan doan sdi, giun OMC so vdi sieu am. Theo Tadataka Yamada, NSMTND cd gia trj dac biet trong cha'n doan sdi OMC, la tieu chuan vang de chan doan sdi OMC va rat It cd trudng hdp chdng chi djnh vdi NSMTND [4]. Ke't qua nghien eUu cua Khan, NSMTND chan doan vj tri tac mat dat 100%, chan doan nguyen nhan tac mat dat 98% [3].
Chiing toi tha'y tren sieu am sd benh nhan cd t9 le sdi hoac/va giun OMC ddn thuan chie'm 59,6% ccn lai la sdi hoac/va giun OMC ke't hpp sdi dudng mat trdng gan 15,4%; sdi OMC ke't hdp sdi ttii mat chie'm 9,6% va chi cd 0,96% cd sdi ca OMC, sdi dudng mat trdng gan va tiii mat. Khi chup mat tuy ngUdc ddng ty le sdi OMC ddn thuan cd t9 le cao hdn chie'm 70,2%, cdn sdi d cac vi tri khac tUdng dUdng vdi sieu am, 6 mpt sd tae gia khac ty le sdi OMC ddn thuan lai thap hdn cCia chiing tci, nhU trdng nghien cijru ciia Pham Quang CCf ty le sdi OMC ddn thuan chi chiem 30%
trcng khi sdi ke't hdp OMC, dudng mat trong gan, tui mat chie'm tdi 21,6%[1]. Ke't qua giOra sieu am va NSMTND trong nghien cUu eua ehung toi khae nhau ed y nghla thdng ke vdi p < 0,05. SU khac nhau nay la do sieu am khd khao sat dUde vung dng gan va ddan thap OMC, con NSMTND quan sat dUde toan bp dudng mat trong gan va OMC, it khi bd sdt sdi.
Ve sd lUdng vien sdi d OMC, chiing tdi th^y trcng sd 64 benh nhan cd sdi dang vien tren sieu am thi cd 78,1% la sdi 1 vien; 6,3% sdi tU 2-3 vien ccn lai sdi
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.5-N°1/2010
dUde 71 benh nhan cd sdi vien trong dd 43,7% la 1 vien sdi; 15,5% sdi 2-3 vien, 40,8% cd hdn 3 vien sdi.
Su khae biet ve kha nang phat hien sdi giua sieu am va NSMTND la ed y nghTa thdng ke (p< 0,0%). NhU vay d nhieu benh nhan khi sieu am chi phat hien 6uac 1 vien sdi trong khi thUc te co nhieu vien. Chinh vi the danh gia sd lUdng vien sdi tren sieu am ehi cd gia trj tUdng ddi. Nghien cUu eua Pham Quang CCf cung cho thay sdi 1 vien ehi cd 27,3%, 2-3 vien chie'm 30,4%;
con tren 3 vien la 36,7%[1]. Nhieu tae gia khac cung nhan xet da sd benh nhan sdi OMC deu eo nhieu vien sdi hoac doi khi giUa sdi ke't hdp vdi xac giun khong xac djnh dupe ro rang hinh anh giUa sdi va xae giun [2,3,5].^
De giam nhieu do sai sd khi danh gia kich thUdc sdi, ehung toi chia sdi ra lam 3 loai theo kich thude:
sdi nhd (dudng kinh <10mm), sdi trung binh (10- 20mm) va sdi Idn (>20mm). Khi do ehung toi so sanh dudng kfnh sdi vdi dng soi. Danh gia ve kich thUde vien sdi ehung toi tha'y trong 64 benh nhan cd sdi vien tren sieu am ty le ve kich thude sdi nhU sau: Ty le sdi OMC kich thude 1-2 em la cao nha't 54,9%; nhom kich thude <1cm cd 39% va tren 2 cm chi co 6,2%. Cdn 71 benh nhan dupc xac djnh sdi vien khi npi soi mat tuy ngUpc ddng thi ty le nay la: sdi 1-2cm chie'm 63,4%;
sdi <1em 3 1 % va sdi >2cm chie'm 5,6%. Ke't qua eCia chiing toi cung phu hdp vdi nghien cUu cua cae tac gia khac khi tha'y rang sdi dudng kinh 1-2cm la phd bie'n nha't. Viec do kich thude sdi tren sieu am cd kho khan do dudng mat nam sau, xae djnh dudng kinh Idn nha't eua sdi khd khan hdn sd vdi chup mat. Trcng trudng hdp nay mpt sd tac gia nude ngoai nghien eUu eho tha'y sieu am npi soi cd dp chinh xae hdn rat nhieu [3,5], tuy nhien sieu am npi soi ehUa dupe ap dung rpng rai d Viet Nam.
Ve hinh dang sdi OMC tren sieu am cung nhu chup mat tuy da sd cd hinh bau due; t9 le phat hien tren sieu am la 84,4% va tren chup mat tuy la 81,7%.
Khi nghien eUu ve hinh anh dUdng mat d benh nhan ed sdi dudng mat da sd cac tae gia deu cho rang cd hinh anh: gian dUdng mat, hinh khuyet sdi, tiii mat to... Trong nghien cUu cua ehung tdi tha'y rang tren sieu am hinh anh gian dudng mat ngoai gan chiem ty le cad nha't 83,7%, hinh khuyet sdi 68,3%, tiii mat td
14,4%. Chup mat tuy cung cho ket qua tUdng tU va khdng c6 su khac biet nhieu so vdi sieu am (p>0,05).
5. Ke't luan
Qua nghien cUu 104 benh nhan dUde npi soi mat tuy ngUdc dong dieu trj sdi va giun dng mat chu tai Benh vien TWQDD 108, ehiing toi rut ra mpt sd ket
luan sau: v ^ - Oa sd benh nhan c6 sdi va hoac giun dng mat
chCi ddn thuan (70,2%), phan Idn la sdi hinh bau due (81,7%) va sdi co dudng kfnh tU 1-2cm (63,4%), 06 86,8% trudng hdp tha'y hinh anh gian dudng mat ngoai gan va 73,7% cd hinh anh khuyet sdi.
- Npi soi mat tuy ngUdc dong la met phUdng phap cd gia trj cac chan doan benh 1^ sdi dng mat chu v6i dp nhay (97,9%), dp dae hieu (100%) va gia trj chan doan diing (98%) deu cao hdn sd vdi sieu am (p
<0,05).
• ' rs^i : Tai lieu tham khao
1. Pham Quang CCf (2000), Nghien cu'u gia trj cCia npi soi mat tuy ngupe dong trong chan doan va dieu trj sdi dng mat chu, De tai nghien cUu khoa hpc cap Bp.
2. Nguyen Duy Hue, Le Tuan Linh (2001), Gia trj cCia sieu am trong chan doan sdi dudng mat chinh- nghien cu'u hdi cufu tai Benh vien Viet Dufc trong 2 nam 1998-1999; Tap chi Y hpc thuc hanh, sd 10, trang 8-10.
3. Khan MA, et al (2006), Comparison of ultrasonography and cholangiography (ERCP/PTC) in the differential diagnosis of obstructive jaundice, JPMA-J-Par-Med - Assoc, United States, Medline 46(9): 188-90.
4. Tadataka Yamada (1999), Endoscopie Retrograde cholangiopancreatography. Textbook of Gastroenterology, Philadenphia Newyork, pp 2718-2722.
5. Zagoni T et al (2007), Diagnostic value of abdominal ultrasonography and Endoscopic Retrograde cholangiopancreatography in obstructive jaundice, ORV-Hetol, Hungaria, medicine 136 (28): 1434-8.
