Y HOC VI^T NAM THANG 8 - S61/2011 IV. KET LUAN
Ty le HS sau rang chung la 63,7o/o, Chi sd dmfl:= 0,99 chi sd DMFT= 1,32. T] le HS rao rang la 55,90/0, viem Idi chiem 46,6o/o.
HS nu" cd kien thu'c tdt va thai dp diing ve cham sdc RM hdn HS nam, Gidi tfnh khdng anh hudng tdi thiTc hanh cham sdc RMciia HS.
NgUdi cham sdc tre cd trinh dp hoc van cao ed anh hUdng den kien thu'c tdt, thai dp dung va thiTc hanh diing ve cham sdc siTc khde RM cua HS.
HS cOa gia dinh ed thu nhap rao cd kien thiTc tot hdn HS cfia gia dinh thu nhap thap.
Bd me tac dpng tot thi eon ed thiTc hanh dung va ngUde lai (p=0,00).
TAI LIEU THAM KHAO
1. Vu Thj Kieu Diim, VO Hai Phong, Ngd Dong Khanh (1993): Ket qua dieu tra ca ban tinh trang SK RM d miSn Nam Viet Nam.
6.
Vien RHM thanh phd Hd Chi Minh. K? ydu cong trinh Khoa hpc, tr 17. 20.
Dao Thj Dung (2006): Danh gia hiSu qua can thiep chuong trinh Nha hpc dudng tai mdt sd tnJdng lieu hoc quan Ddng Da Ha Npi.
Dao Thj Dung (2009): Xac djnh t^ Id bSnh rang mieng ciia HS tieu hoc tai Ha Ndi, Tap chi Y hpc Viet Nam thang/ sd 1/2009. tr 30,32.
Cao Van Tam, Nguyen Thj Mai Phuong (1999): Nang cao nhan thCrc va thuc hiinh v$
sinh rang mieng d hgc sinh khdi 5 trudng tiiu hgc Le Lai -An Hal - Hai Phong. TrUdng quan 1^ can bd Y te, tr 9.
Vien R i n g Ham Mat Ha No! (2008): Bao cao tong ket hdi nghj Nha hoc dudng to^n qudc, tr 1,2,3,6.
World Health Organization (1997): Oral health surveys basic methods. Geneva.
NGHIEN CQU DAC DIEM LAM SANG, CAN LAM SANG VA MlTC DO CHAY MAU DO GIAN VCf TINH MACH PHINH Vj d BENH NHAN XO GAN
Nguyen Manh H u n g * , Vu Van Khien*
SUMMARY
STUDY ON CLINICAL AND SUBCLINICAL'S CHARACTERISnCS AND BLEEDING FROM GASTRIC VARICES IN PATIENTS WITH LIVER
CIRRHOSIS
A study on 43 patients with liver cirrhosis who have complication of digestive bleeding due to gastric varices in 24 months (June 2008 - 2010) shows that:
rate of men with liver cirrhosis is higher than women (men/women = 2.58). Hepatitis virus B infection (72o/o) Is the main risk often found in patients with liver cirrhosis. Rate of severe and moderate digestive bleeding are respectively 48.8% and 39.6%. Rate of rebleeding (65.2%) is higher than that of primary bleeding (34,8%). Number of patients with liver cirrhosis in Child C amount up to 53%. Rate of F2 and F3 gastric varices are respectively 67.4% and 27.9%
I . DAT VAN DE
Chay mau tieu hda (CMTH) d benh nhan xd gan phan Idn do gian vd tinh mach thUc quan (TMTQ) va/hoac tTnh mach da day {JMDD) va ty
* Khoa Ngi diu hoa (A3) - Benh vien TI/QD 108
le nay chiem khoang 14-17o/o trong tdng sd benh nhan cd chay mau dUdng tieu hda tren (2-4).
Tuy nhien, ty le gian tinh mach da day (gastric varices) chu yeu do gian tTnh mach phinh vj ehi chiem khoang 200/0 trong tdng so benh nhan xd gan cd tang ap liTc tTnh mach ciTa va trong so benh nhan cd gian TMDD thi nguy cd chay mau chiem khoang 250/0 trong tdng sd benh nhan nay (2,4). Chay mau tieu hda do gian vd TMDD thudng hay tai phat va cd mufc dp nang hdn so vdi gian TMTQ (3). Cho den nay, dieu trj chay mau tieu hda do gian vd tTnh mach mach plilnh vj chii yeu bangnpi khoa, ket hdp vdi ran thiep qua npi soi (tiem xd tTnh mach phinh vj bang keo sinh hpc Hystoacryl) (5-8). Tai Viet Nam, trong cac nam gan day, nhd cd nhieu phUdng tien npi soi nen da phat hien nhieu benh nhan xd gan co gian tTnh mach thUc quan va tTnh mach phinh vj da day. Viec tim hieu ve dac diem bui gian tTnh mach da day, tTnh mach phinh vj da day d benh
44
Y HQC VigT NAM THANG 8 - SO 1/2011 nhan xd gan cdn chUa dUdc nhieu. Chfnh vi vay,
trong nhieu nam qua khoa Cap culi ban dau (Cl- 3) va khoa Npi tieu hda - Benh vien TI/QD 108 (^ nghien ciili de tai nay nham tim hieu ve: Dac di&n lam sang, can lam sang va hinh anh ngl soi gian phinh vidbenh nhan xdgan
VL. DOI T U O N G VA PHUOI^G PHAP
* Ddi tu'dng: 43 benh nhan xd gan, cd bien chiiYig chay mau tieu hda da dxidz xac chan la do gian vd tTnh mach phinh vj dUdc dUa vao trong nghien cufu nay. Tat ca cac benh nhan deu 6\idc kham xet tai khoa Gap cii'u ban dau (Gl-3) va sau do dsidc dieu trj npi trii tai khoa Ndi tieu hda (A3) - Benh vien TLTQD 108 tiT 06/2008 den 06/2010 (24 thang).
* Phu'dng phap: Tat ca benh nhan deu dUde kham lam sang (cd nang, thiTc the) va xet I I I . KET QUA
nghiem can lam sang (hda nghiem, sinh hda, miln djch va sieu am gan mat...) va d\idz npi soi da day-thUe quan de danh gia miTc dp gian TMTQ va tinh mach da day. Danh gia miTc dp xd gan theo bang phan loai ciia Child-Pugh (9).
Danh gia miTc dp mat mau dUa theo bang phan loai nam 1982 va dUde chia thanh 3 mufc: Nhe, viTa va nang (1)
* Phan loai gian tTnh mach phinh vj dUa theo phan loai ciia Sarin va cs (nam 1992): dUa tren vj trf ciia cac bui gian tTnh mach phat hien qua ndi soi, dUde chia thanh bon miTc: F l : Gian TMTQ cd gian tTnh mach da day lan xudng bd cong nhd;
F2: gian TMTQ lan xudng viing phinh vj; F3:
khdng cd gian TMTQ, chi cd gian tTnh mach vung phinh vj; F4: khdng ed gian TMTQ, chi cd gian tTnh mach viing than vj, hoac ta trang (2)
Bang 1: Dae diem chung va cac yeu td nguy cd.
Dac diem lam sang Tdng sd benh nhan nghien cufu
Ty le: Nam/nQ' Tudi trung binh
Cac veu td'nauv cd aav xd aan Cd nhiem virus viem gan B
Cd nhiem virus viem gan C Do udng nhieu rUdu
Nghien rUdu - Viem gan B/hoac C
n (O/o) 43 31/12 (2,58) 45 ± 12,5 (29-78)
31/43 (72o/o) 3/43 (70/0) 7/43 (16,20/0)
2/43 (4,6o/o)
Nh$nxet: Nam gidi bj xd gan nhieu hdn so vdi nu' (2,58). Nhiem virus viem gan B (72o/o) la yeu td nguy cd hay gap nhat trong nhdm nghien ciTu.
Bang 2; MiTc dp mat mau va sd lan CMTH
Mufc dp mat mau tren lam sang n (%)
Nhe 5/43 (ll,6o/o)
Vii^ 17/43b(39,6o/o)
Nang 21/43 (48,8o/o)
Sdl5n chav mau tieu hda
Chay mau lan dau 15/43 (34,8o/o)
Chay mau tieu hda tai phat 28/43 (65,2o/o)
MII'C dd xd aan:
Child A/B/C (O/o) 21/27/53 (O/o)
Nh$n xdt: Phan Idn benh nhan CMTH miTc dp viTa va nang. Ty le CMTH tai phat (65,2o/o) gap nhieu hdn so vdi CMTH lan d i u (34,8o/o). Sd benh nhan xd gan giai doan Child C chiem 530/0.
Bang 3; Dac diem bui gian tTnh mach tren ndi sol
Mii'c dp gian tinh mgch tren ndi soi n (%)
LoaiFl 2/43 (4,6o/o)
Loai F2 29/43 (67,40/o)
Loai F3 12/43 (27,90/0)
Loai F4
Nh$nxdt: Sd benh nhan cd gian tTnh mach gap nhieu nhdm F2 va F3
45
Y HOC VIET NAM T H A N G 8 - SO 1/2011 IV. BAN LUAN
1. Dac diem chung ve x d gan va cac yeu t d nguy cd gay benh. Trong qua trinh thu thap sd lUdng nghien ciili, chiing tdi da thiet lap mot bang theo ddi rieng ve nhuYig ddi tUdng nay.
Ket qua nghien cufu trinh bay trong bang 1 da cho thay sd benh nhan nam gidi mac nhieu hdn (gap 2,58 lan) so vdi benh nhan ni?. Tudi trung binh trong nhdm nghien ciili la: 45 ± 12,5 (29- 78). Cac ket qua nghien ciTu cua chiing tdi cung phii hdp vdi nghien ciTu ciia cac tac gia tai Benh vien Chualong Korn (Thai Lan) va cac tac gia deu thay rang benh nhan nam gidi mac xd gan nhieu hdn so vdi niT gidi, vdi ty le nam/nu' = 1,66. Tuy nhien tac gia chi mdi nghien culi d 24 benh nhan cd dieu trj bang hystoacryl.
Song hanh vdi dac diem nay, chiing tdi cung thay rang cac yeu td nguy ed gay xd gan cung cd chieu hudng tang len d benh nhan nam gidi. Sd lieu bang 1 eho thay: Sd benh nhan xd gan nhiem virus viem gan B va nghien rUdu chiem ty le rao, tUdng iTng la: 72o/o va 'l6,2o/o. Ket qua nghien ciTu nay cung phii hdp nghien ciTu ciia cac tac gia trong va ngoai nUde. Nghien cii'u tai Thai Land cho thay sd benh nhan xd gan cd CMTH do gian v5 tinh mach phinh vj bj nhiem virus viem B va cd tien siT nghien rUdu chiem ty le tUdng iitig la: 83,3o/o va 37,5o/o. Ket qua nay cung minh ehiitig ve mii'c dp nguy hiem cua virus viem gan B, nghien rUdu....ia nhu'ng tac nhan de dUa den hinh thanh xd gan.
2. Mii'c dp mat mau va sd lan chay mau tieu hda. Tat ca sd benh nhan trong nghien cii'u ciia chiing tdi khi den vien deu d diidc coi la nhu'ng benh nhan cap ciTu do chay mau tieu hda.
Ket qua nghien ciili bang 2 eho thay: Sd benh nhan CMTH tai phat chiem ty le (65,2o/o) cao hdn so vdi benh nhan CMTH lan dau. Dieu i^ay da cho thay CMTH do gian v5 tTnh mach da day (chu yeu tTnh mach phinh vj) thi gap nhieu hdn, de tai phat nhieu hdn so vdi CMTH do gian v6 tTnh mach thUc quan. Chiing tdi da gap 02 benh nhan cd CMTH do gian vd TM phinh vj lan thii' 8. NhU vay, ket qua nay rat phii hdp vdi vdi cac edng bd trong y van va cac cong lid trong-ngoai nUde.
Nghien cii'u ciia Noophun P va cs (8) cho biet ty le chay mau tai phat trUdc khi dUdc dieu trj dac hieu dii&ntyle 620/0.
Phan loai mii'c dp CMTH diTa theo 5 thdng sd (Mach, huyet ap, hong cau, huyet sac td va hematocrite) (1). Ket qua nghien cufu bang 2 cho thay sd benh nhan CMTH do gian v5 tTnh mach
da day-thUc quan mufc dp viia va mufc dp nSng, chiem ty le tUdng uYig: 39,6o/o va 48,8o^. So benh nhan cd GMTH mufc dp nhe chi§m ty le rat thap. Dieu nay da cho thay phan Idn CMTH do gian v3 tTnh mach da day-thiTc quan deu d mufc nang. Do vay, ddi vdi nhuHg benh nhan nay ran cd chien lUdc dieu trj phii hdp.
Chiing tdi cung phan loai mii'c dp xd gan theo phan loai ciia Ghild-Pugh theo 3 mii'c (A, 8, G) va ket qua nghien culi bang 2 eho thay sd benh nhan xd gan giai doan Child C chiem ty le rao nhat 53o/o. Ket qua nghien ciili nay cung phii hdp nghien ciili ciia cac tac gia khac. Nghien ciili ciia Noophun P va cs (8) eho biet mii'c dp xd gan: Child (A/B/C) tUdng u'ng la:
250/0/480/0/290/0. Tac gia cQng thiTa nhan rang:
Mii'c dp xd gan cang nang (Child G) thi tien lUdng benh cung phii'c tap va ed lien quan chat che den den hieu qua dieu trj ram mau d nhii'ng benh nhan nay.
3. Dac diem bui gian tTnh mach da day tren npi soi Tat ca benh nhan trong nghien ciili ciia chiing tdi, deu dildc npi soi da day-thUe quan ft nhat 01 lan. Cho den nay, cd nhieu each phan loai ve gian tTnh mach da day va moi each phan loai cho nhiTng Uu nhUdc diem khac nhau.
Tuy nhien, tren the gidi hay ap dung each phan loai ciia Sarin va cs dUa tren vj tri ciia bui gian tTnh mach, gian ddn dpc hay gian tTnh mach da day ket hdp gian tTnh mach thUc quan. Ket qua nghien cii'u da cho thay sd benh nhan cd gian tTnh mach phinh vj, cd ket hdp vdi gian TMTQ (F2) chiem ty le rao nhat: 67,4o/o va tiep dd gian tTnh mach phinh vj ddn dpc (F3) chiem 27,9o/o.
Khdng ed benh nhan nao cd gian tTnh mach d hang vj va hanh ta trang (F4).
Ket qua nghien cii'u nay cung phii hdp vdi nghien ciili ciia cac tac gia Thai Lan va cac tac gia thay rang trong 24 benh nhan nghien cufU, so benh nhan cd gian tinh mach loai F2 va F3 tUdng uing: 70,8o/o va 250/0
Viec phan loai cua Sarin viTa danh gA mufc dp gian tTnh mach, viTa chi ro vj trf giiip djnh hudng dieu trj (2). Cac nghien ciiii cho thay vdi benh nhan xd gan gian tTnh mach da day to^\ F2, F3 thi cd the ran thiep tdt bSng npi sol (5-8).
Trong thiTc hanh lam sang, ngUdi ta hay sir dyng keo sinh hpc (Hystoacryl) de tiem xd bui gian tTnh mach phinh va cho hieu qua ram mau dat 1000/0. Tuy nhien, han che cua ky thuat nay dJ gay bit tac dUdng thong noi soi, nen khdng dU0c ufhg dung d nhulig cd sd ma may npi soi tIeu hda 46
Y HQC VIET NAM THANG 8 - SO 1/2011 khdng nhieu. Ngay nay, de bd trd cho ky thuat
nay thi ran thiep ndi mach 6\idc iTng dung nhieu thdng qua 2 l<y thuat: Phan lull ciTa chu trong gan qua dUdng tTnh mac canh {Transjugular Intrahepatic Portosystemic Shunt: TIPS) va ky thuat nut tinh mach da day qua dudng tTnh mach ngUde ddng cd bong chen {Balloon-occluded Retrograde Transvenous Obliteration: BRTO)
(10). Tai benh vien TI/QD 108, tiT nam 2009 den nay da trien khai ky thuat TIPS de thiTc hien dieu trj diT phdng chay mau tieu hda tai phat cho b4nh nlian xd gan da cd bien chirng CMTH nhieu lan do gian vd tTnh mach phinh vj cd hieu qua tdt trong dieu trj, cu the: khdng de chay mau tai phat, va cd the cam mau cap cirtj tdt neu nhU bien phap dieu tn ndi soi that bai.
Minh hoa gian tinh mach da day tren npi soi
Gian tTnh mach phinh vj ddn ddc (F3) V. KET LUAN
Nghien ciTu 43 benh nhan xd gan cd CMTH do gian vd tTnh mach da day eho biet: Nam gidi bj xd gan nhieu hdh so vdi nC? (2,58). Nhiem virus viem gan B (72o/o) la yeu td nguy ed hay gSp d benh nhan xd gan. Ty le CMTH miTc dp ning va viTa tUdng iTng: 48,8o/o va 39,6o/o. Ty le CMTH tai phat (65,2o/o) gap nhieu hdn so vdi CMTH lan dau (34,8o/o). Sd benh nhan xd gan giai doan Child C chiem 53o/o. Ty le gian tinh mach da day dang F2 va F3 tUdng iihg: 67,4o/o va 27,90/0
TAI LIEU THAM KHAO
1. Ho4ng Gia Ldi. Xuat huyet tieu hda. Bai giang tieu hoa NXB Quan doi, nam 1995;
trang 143-147
2. Sarin SK, Lahoti D, Saxena SP, et al.
Prevalance, elassifiration and natural history
Gian tTnh mach phinh vj ddn dpc (F3)
of gastric varices; A long-term follow-up study in 568 portal hypertension patients.
Hepatology 1992; 16; 1243-1349.
Merican I , Burroughs AK. Gastric varices.
Euro. H. Gastroenbd Hepatol. 1992; 4; 511-520 Sarin SK. Long-term follow-up of gastric variceal sclerotherapy: An eleven year experience. Gastrolntest. Endosco 1997; 46;
08-14
Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices.
Gastrolntest Endosco 1986; 32; 264-268.
Gimson APS, Ramage JK, Panes MZ, et al. Randomised trial of variceal banding ligation versus injection sclerotherapy for bleeding oesophageal varices. Lancet 1993;
342; 391-394.
47
