JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
Nghien cmi su* thay doi mot so thong so danh gia huySt dong mach mau gan 6^ benh nhan xo* gan
Changes of hepatic vessel morphology and hemodynamics in cirrhotic patients
Dyong Quang Huy*, *Benh vien Qudny 103 Le Quang Nhut** **TnrdngDgi hgc TdyBo Tom t a t
Muc tiiu: Nghien cdu nham khIo s i t mot so thdng so danh g i l huyet dpng mach mau gan d benh nhan xa gan. Doi tupng vd phuang phdp: Tien cdu, md ta eat ngang 117 benh nhan xO gan Child-Pugh B/C va 45 ngddi nhom chdng tai KhoaNoitieuhda-Benh vien QuIn y 103./(et qud; 86,3% benh nhan xo gan cd chieu ddng c h l y tTnh mach cda hudng gan vdi dudng kinh gian, van toe va luu lupng ddng chay g i l m so vdi cac thong s6 tuong dng d nhdm chdng {p<0,01). Dpng mach gan gian cd van tdc dong chay tang, dudng kinh va van toe tTnh mach gan giam so vdi nhdm chdng (p<0,01). Cd moi tuong quan thuan kha chat che gida lUulUpngtTnhmaehedavdi van tde t i m thu tTnh mach gan (r = 0,40, p<0,01). Ket/uon;
d benh nhan xd gan eo bien doi cac thong so huyet dpng mach mau gan theo xu hudng tang dudng kfnh, van tdc dong chly dpng mach gan, g i l m van tdc ddng chly tTnh mach cda va tTnh mach gan.
Tdkhda: Xo gan, huyet dpng mach mau gan, tTnh mach cda.
Summary
Objective: To evaluate the change of hepatic vessel hemodynamics (including portal vein, hepatic artery and hepatic vein) in patients with cirrhosis. Subject and method: Prospeaive, cross-sectional descriptive study carried out on 117 cirrhotic patients (54 patients with Child-Pugh B and 63 patients with Child-Pugh C) and 45 control subjects in Digestive Department of 103 Military Hospital. Result 86.3% cirrhotic patients had hepatopetal flow with obviously higher diameter, lower velocity and flow capacity than respective parameters in control group (p<0.01). Hepatic artery enlarges with increased flow velocity while decreased diameter and velocity of systolic hepatic vein in comparison to that in control group (p<0.01). There was closely positive correlation between portal venous capacity and systolic velocity of hepatic artery (r = 0.40, p<0.01). Conclusion: There are changes of hepatic vessel hemodynamics in cirrhotic patients.
Keywords: Liver cirrhosis, hepatic vessel hemodynamic, portal vein.
Xo gan la benh ly kha pho bien, can nguyen chu
rdpu q u i mdc vdi ty le t d vong tdong ddi cao d hau het cae quoc gia tr^n the gidi.
yeu la do nhiem virus viem gan B, C va lam dung 6 b e n h nhan gan x o c o s u b . e n a o . c a u t m c n
• mo gan cung n h u hlnh thai va huyet dong cac macn mau gan. Nhieu nghien ciJu da xac dinh sU bien dS Ngay nhan bai: 2mv2Q17. ngay chap nh^n ^ng: 5/4/2017 huyet ddng mach mau gan lien quan v61 tang ap l^c Ngudi phan hoi. Dumg Quang Huy. tTnh mach ciJa (TALTIMC). Do vSy nghien ciJu bien Email: [email protected] vien Quany 103 doi huyet dgng mach mau gan se gop ph^n chan 42
TAP CHf Y DUOC LAM SANG 108 T$p 12-565/2017
d o l n xo gan va giup danh gia hieu q u i cCia mdt sd bien p h I p g i l m ap luc tTnh mach cda.
Hien nay d Viet Nam ehung tdi chda cd nhieu nghien cdu ve huyet ddng mach m l u gan d benh n h i n x d gan, vi vay chdng tdi ti^n hanh de t l i nghien cdu nay n h I m muc tieu Tim hieu su thay doi mot so thdng so ddnh gid huyet ddng mgch mdu gan d binh nhdn xa gan.
2. Doi tucfng va phUorng phap 2.J. Doll tupng
Nhdm nghien cdu: Gom 117 benh n h i n xo gan d phan mde Child-Pugh B (54 benh nhan) va Child- Pugh C (63 benh nhan) dieu t n ndi tru tai Khoa Npi tieu hda - Benh vien Q u I n y 103 t d thang 03 nam 2014 den t h i n g 03 n I m 2016. C h i n d o l n xo gan khi l l m s i n g va xet nghiem cd day du 2 hpi chdng kinh dien la suy chdc nang gan va TALTMC cung vdi nhdng thay doi hinh thai gan tren sieu am gan.
Chiing toi loai khdi nhdm nghien cdu c l e trUdng hop xo gan kem theo ung t h u bieu m d te bao gan; dang ed bien chdng nang n h u xuat huyet tieu hda h o l e cd cae benh ly tim mach, hd hap, ndi tiet kem theo; dang sd dung mpt sd thudc I n h hddng den huyet d p n g dpng mach gan n h d thudc chen [3, thudc ldi t i e u . . .
Nhdm chdng: 45 ngddi khde manh khdng cd benh ly gan mat, t i m mach, hd hap, ndi tiet cd phan bd tuoi, gidi t d o n g dddng vdi nhdm benh.
2.2. Phi/dngphap
T\\\ix ke nghien edu: Mo t l , cat ngang, so s i n h gida nhdm benh va nhdm chdng.
Tat c l eae benh nhan chpn vao nghien edu dddc kham l l m sang va ehi djnh c l e xet nghiem can lam sing can thiet de x l c djnh hoi chdng suy chdc nang gan v l TALTMC. Phln loai mdc dp xd gan theo thang diem Child - Pugh (1973).
Sieu am d i n h gia huyet ddng mach mau gan:
Thuc hien tren may sieu am Envisor cua hang Phillips, dau do convex 3,5MHz cd du che dd Doppler m l u va Doppler xung. Cae ddi tdpng nghien cdu (nhdm benh va nhdm chdng) nhm I n ft n h l t 6 gid, nghi ngoi trong vdng 15 phut trudc lam sieu am, t u the nam ngda 2 chan du6l thang h o l e nam nghleng t r l i , t h d nhe blnh thudng. €)au tien ehung tdi thde hien sieu am 2 chieu
danh gia kfch thUde, nhu md, b d gan sau do chuyen sang sieu am Doppler cae mach mau gan. Sau d d d dien eat ehech dddi sddn p h l i de dat cda sd sieu am Doppler tTnh mach cda (TMC), dpng mach gan (£)MG) va tTnh mach gan (TMG). Cd the bd sung them dien cat qua ke sddn de nhin rd t h i n OMG va TMC. Khi dat cda so sieu am, de cd cle thdng so dinh luong chinh xac c l n dieu chinh gdc 6 < 20° (gdc tao bdi chieu ddng c h l y va true cda chum tia sieu am) nham ban che sai so [2], [5].
KhIo sat TMC:
Dudng kfnh TMC do tai than TMC (D - mm).
X l c djnh huyet khoi TMC: Hinh I n h khdi hoi am trong Idng TMC ( t h i n h o l e 2 n h l n h chfnh), khdng ed ddng chay dang d i p va khdng cd luong shunt dpng-tTnh mach.
X l c djnh chieu dong chay TMC: Binh t h u d n g ddng m l u TMC la ddng hudng gan (ddng mau do) va pho Doppler n I m tren dddng gdc. Chieu xa gan (ddng d i o ngdpc) khi ddng cd mau xanh va pho Doppler nam dddi dddng gdc. Ddng 2 chieu khi ddng TMC ed mau hon hpp xanh do tren sieu am Doppler mau.
£)o van toe TMC t d pho Doppler TMC (Vm - cm/s) (cho nhdng benh n h i n ed ddng TMC hddng gan va khdng cd huyet khdi than TMC).
Ldu lupng ddng chay TMC (FV - Ift/phdt) tfnh theo cong thde:
FV = 15;rD^ X Vm/1000 (D: L I dUdng kfnh (mm), Vm: Van toe (cm/s)).
Khao satfiMG (DMG rieng):
Bddng kinh DMG do tai rdn gan (mm).
Do van toe dinh tam thu (Vs - cm/s), van toe cudi tam trdong (Vd - cm/s) t d pho Doppler DMG.
Khao sat TMG; Cd 3 TMG nhdng chung tdi chpn TMG phai de k h I o sat huyet dpng vi d l y I I TMG Idn nhat, do true tiep vao tTnh mach chu dudi, trong khi TMG gida va TMG t r l i thudng hdp vdi nhau t h I n h mdt t h i n chung trUde khi dd vao tTnh mach chu dudi.
Dudng kinh TMG (mm) phai do tai vj tri c l e h cho do vao tTnh mach chu dddi k h o i n g 2em.
Do v I n tde dau t i m thu TMG p h l i t d pho Doppler TMG (cm/s).
So lieu thu dUdc dupe x d ly theo phddng phap thong key sinh hoe.
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N°5/2017
3. K4t qua va ban luan
Bang 1 . Dac diem tuoi, gidi ciia nhom nghien ctiTu (NC) Vci nhom chiJng
Gidi Nam
NO Tuoi trung binh (nam)
Nhom chlhig (n = 45) SL(n)
38 7
T y l e % 84,4 15,6 Sl,07± 10,6*
Nhom NC(n = 117) SL(n)
100 17
T ^ l e % 85,5 14,5 52,40± 12,23
P
>0,05
>0,05
>0,05 Khdng khac biet ve tudi, gidi d nhdm xo gan va nhdm chdng. Da so ele benh nhan xd gan trong nghien cdu la nam gidi (85,65), X^ le nam/nd I I 6 / 1 .
Bang 2. Chilu dong chdy TMC 6 nhdm xtf gan (n = 117) chieu dong ch&y
HU6ng gan Xagan Dong 2 chieu Khong xac djnh Huyet l<hdi TMC
So luang (n) 101
4 9 3 4
T y l e % 86,3
3,4 7,7 2,6 3,4
11,1% benh nhan xO gan ed thay doi chieu ddng chay TMC (xa gan h o l e ddng 2 chieu) t d o n g t u nhd ket q u i eua nhieu nghien cdu khac nhU cua Mittal P v l CS (2011) gap 12% [3]. Day I I dau hieu the hien ap lye TMC tang cao, dong mau ve gan bj can t r d chuyen hddng sang cac vong ndi, dan ldu m l u v^ tim khdng qua gan. Cd 4 benh nhan xO gan (chiem 3,4%) cd huyet khoi TMC nam trong ty le cho phep (td 1 - 8%). Hinh t h l n h huyet khoi TMC I I do ddng chay TMC cham do TALTMC va rdi loan ddng mau [4].
Bdng 3. So sanh gia trj trung binh mot so thong so danh gia huyet dong mach mau gan giuia 2 nhom Chi so
TMC
BMG
TMG
BKTMC(mm) Van toe TMC (cm/s) LUU luong (lit/phut) BKBMG (mm) Vs (cm/s) Vd (cm/s) BKTMG(mm) Van toe TMG (cm/s)
Nhom ChUng (n = 45) 10,75 + 0,96 36,78 ± 5,93 2,03 ± 0,52 4,16 ±0,49 56,18 ±10,08
21,30 ±4,28 7,53 ± 0,94 39,72 ± 8,26
Nhom XU gan (n = 117) 13,65 ±1,81 19,72 ±7,62 1,77 ±0,88 5,33 ±1,45 70,72 ± 25,74 21,22±10,12 6,72 ±1,26 29,33 ±12,41
P
<0,01
<0,01
<0,01
<0,01
<0,01
>0,05
<0,01
<0,01 6 benh nhan xo gan do t o chufc xo va cue tan tao chen ep lam c^n tr6 dong mau ve gan dan den TALTMC, the hien dUcing kinh TMC tang trong khi van toe va luu luong d6ng chay giam ro l(hi so sanh »*
cac chi sd tuong ufng d nhom chufng, p<0,01. £)^ bu dap lai tinh trang gi^m luu luong mau tif TMC v^ gan, BMG thuOng gian va tang tde da ddng chay (hien tuong dap ijng dem BMG) [1]. Vdi TMG do luang mau ttiu hdi ve It (mau khdng qua gan ma ehCi yeu theo eac vong noi eCta ehii ve tim) nen dudng kinh cung vdi v?n
TAP CHf Y DUOC LAM SANG 108 Tap 12-S6 5/2017
toe ddng chay giam. Kix q u i nghien cdu cCia chung tdi d l the hien rd d i e diem sinh ly bgnh nay d benh nhan xo gan [2], [5].
Bdng 4 . M d i lien q u a n giCiia iUu lUong d o n g chdy TMC v o i h u y e t d o n g DMG va TMG (n = 97*) Cac t h o n g so
BKBMG (mm) Vs (cm/s) Vd (cm/s) BKTMG(mm) van tde TMG (cm/s)
Luu luong dong chdy TMC
^ 1,0 l i t / p h u t (n = 78) 5,28 ±1,26 73,80 ± 25,90 22,76 ±10,30 6,87 ±1,30 31,17 ±12,97
< 1 , 0 l i t / p h u t ( n = 19) 4,62 ± 0,92 57,79 ±17,32
17,55 ±6,89 6,23 ±1,21 21,41 ±7,05
P
<0,05
<0,01
<0,05
<0,05
<0,01 (*: Chi tinh dong TMC hudng gan, khong c6 huy^t kh6i than TMC v^ xic djnh du'oc ph6 Doppler DMG, n = 97) Dddng kfnh cung n h d van tde ddng chay DMG (tam thu va tam truong) d nhdm benh n h i n xo gan cd ldu lupng TMC giam < 1,0lft/phut thap hdn r d s o v d i chi s6 tuong dng d nhdm xo gan cd ldu lUdngTMC binh thudng. Dieu nay cho thay eo che phdc tap trong thay doi huyet ddng DMG khi dap dng vdi tinh trang thay doi huyet dpng TMC (hien tdpng d i p dng dem DMG bj lu m d eung vdi sU tien trien cCia benh gan [1]). Trong khi do huyet dpng TMG dddng n h u bien doi song hanh cCing vdi TMC (van toe TMG g i l m hon d nhdm xO gan cd g i l m ldu luong T M Q [2], [5].
Bang 5. TiTcmg q u a n giiiia v a n t o e TMG v d i cac t h d n g so h u y e t d o n g TMC va DMG
Van tde TMG (cm/s)
Cac bien tuofng quan BKTMC(mm)
Van tdc TMC (cm/s) Luu luong TMC (l/p) BKBMG (mm) Vd (cm/s) Vs (cm/s)
He so t u o n g quan (r) 0,29 0,28 0,40
•0,002 0,09 0,10
P
<0,01
<0,01
<0,01
>0,05
>0,05
>0,05 Van tdc TMG cd tuong quan thuan mdc d d k h i chat che vdi lUu lUpng ddng c h l y TMC (he so tUong quan r = 0,40, p<0,01), tuang quan thuan it chat che vdi van tde trung blnh TMC (he so tUong quan r = 0,28, p<0,01). Khong cd tUOng quan y nghTa gida van toe TMG vdi eac thong sd huyet ddng DMG.
/ = 58531x4-19 218 R'= 01561
Bilu do xuang quan gida van tdc tTnh mach gan vdi luu lupng ddng chly tTnh mach cda
lOURNAL OF 108 - CUNICAL MEDICINE AND PHARMACY Vol.12-N''5/2017
}. Ket luSn
Nghien edu thay ddi huyet dpng mach m l u gan if 117 benh nhan xo gan Child = Pugh B/C so s i n h /dl 45 ngudi nhdm chdng, ehung tdi nhan t h I y :
86,3% benh nhan xo gan cd chieu ddng c h l y TMC hudng gan vdi dddng kfnh gian, van toe va ldu Udng ddng c h l y thap hon rd so vdi eae thdng so :uong dng d nhdm chdng, p<0,01.
DMG gian vdi van toe dong chay tang, dddng (fnh va van tdc TMG giam hfln so vdi nhdm chdng, D<0,01.
Cd mdi tuong quan thuan kha chat che gida luu uong TMC vdi van tdc tam thu TMG (he sd tUdng i u a n r - 0 , 4 0 , p < 0 , 0 1 ) .
rai lieu t h a m Ithao
I. Eipel C, Abshagen K, Vollmar B (2010) Regulation of hepatic blood flow: The hepatic arterial buffer
response revisited. World of Gastroenterology 16(48): 6046-6057.
Mc Naughton DA, Abu-Yousef MM (2011) Dopp/erl/S offheAVermodes/mp/e. Radiographics 31:161-188.
Mittal P, Gupta B, Mittal G, Kalia V (2011) Association between portal vein color Doppler findings and the severity of disease in cirrhotic patients with portal hypertension. Iran J Radiol 8(4):
211-217.
Ponziani FR, Zocco MA, Garcovich M et al (2012) What we should know about portal vein thrombosis in cirrhotic patients: A changing perspective. World J Gastroenterol 18(36): 5014-5020.
Zimmerman P et al (2000) Doppler sonogaphy of the hepatic vasculature. Radiology 29(11): 11 -18.
