Y HOC V I E t NAM THANG 3 • SO 1/2014 ^ _ ^
SIEU AM CHAN D O A N VIEM RUOT THITA CAP TAI BENH VIEN VIET DUC
T O M TAT
Dat van de va Muc tieu: Viem rupt thya cap thudng g3p tren lam sang la dau bung cap. TrUcfng hdp dien hinh de dang de chan doan, nhUng doi khi no CO the rat khd khan de thye hien mot chan doan trong cac trUcJng hdp khong dien hinh. Vr vay, chung toi nghien ciru hoi ciru nay nham danb gia mu'c dp chan doan chinh xac ciia sieu am tren nhiitig benh nhan dau bung ho chau phai nghi ngd co viem rugt thiTa cap. Ooi tu'dng va Phu'dng phap: Gom 127 benh nhan (58 nam va 69 niT) tuoi tir 6-89 tuoi (trung binh:
34,8 nam). TLT cac ket qua sieu am, viem rugt thira dydc phan Ioai nhU sau: 1) xuat tiet: cac Idp thanh rugt thya con ro, chi co phii ne mem mac; 2) viem tay:
thanh rugt thya day, Idng rong, tang dUdng kinh ngang kich thudc s lOmm, va 3) hoai ty; thanh rugt thira khong xac djnh dUOc cac Idp va mat lien va tang dudng kinh dang ke tao thanh mpt khoi. Ket qua:
Sieu am thay dUdc 127 ruot thya trong tong sd 158 b|nh nhan lam sang co dau hieu viem rupt thira (80,4%). Trong nhij'ng trUdng hdp thay dUdc rugt thira nay, sieu am co dp nhay la 95,7%, do dac hieu 89,1%, va dp chinh xac 93,7%.Trong 31 benh nhan sieu am khong thay ruot thira, cd 6 trudng hdp (19,3%) dUdc chan doan lam sang va phau thuat la VRT. Danh gia mirc dp nghiem trgng ciia tinh trang viem, sieu am va giai phau benh co si/ phu hdp trong 59,8% cac trUdng hdp. So con lai, sieu am thUdng danh gia thap mirc do viem cua rupt thift, do vay nen khi sieu am can xem xet khi phan biet giu'a VRT 6 mirc do xuat tiet hoSc viem tay, dieu nay rat quan trgng de dUa ra quyet djnh dieu trj phau thuat.
r(/'AAdia;viem motthio cap, seu am, dau bung dip.
S U M M A R Y
ULTRASONOGRAPHY FOR THE DIAGNOSIS OF ACUTE A P P E N D I C I T I S
AT VIET DUC HOSPITAL Background and Purpose:Acute appendicitis is common in clinical acute abdominal pain. Typical cases are easy to diagnose, but somebmes it can be very difficult to make a diagnosis of atypical cases.
Therefore, our retrospective study aims to evaluate the diagnostic accuracy of ultrasound in pabents right- sided lower abdominal pain suspected to have acute
* Trudng D^l hgc Y Ha Ndi
** B4nh vien HN Viet Dui:
Phin bipn khoa hpc: PGS.TS Trjnh V i n Tuan
Pham Hong Dire*, Nguyen Dinh Minh**
appendicitis. Subjects and Methods: Subjects included 127 patients (58 male and 69 female) aged bet?A(een 6-89 years of age (mean: 34.8 years). From the results of the ultrasound, appendicitis is classified as follows: 1) catarrhal: a clear layer structure of the appendiceal wall and mucosal edema; 2) phlegmonous: an ill- defined layer structure of the appendiceal wall, moderate enlargement of the apendix, and maximum transverse dimension of SIO mm; and 3) gangrenous: unidentifiable layer struc- ture of the appendiceal wall and marked enlargement to form a mass. Results: Ultrasound see appendix 127 of 158 patients with clinical signs of appendicitis (80,4%), In the case that this is appendicitis, ultrasound sensitivity was 96.7%, specificity 89.1%, and 93,7% accuracy. In 31 patients ultrasound did not show appendicitis, with 6 cases (19.3%) were clinically diagnosed as appendicitis and surgery. Assess the severity of inflammation, ultrasound and pathology consistent with the 59.8% of cases. The rest, ultrasound often underestimate the degree of inflammation of the appendix, the ultrasound should therefore be considered when distinguishing between levels of catarrhal or or phlegmonous appendicitis, it is important to make a decision to surgical treatment,
Keywords: Acute appendicitis, Ultrasonography, Acute abdomen
l . O A T V A N O E
Viem rudt thira (VRT) la cap ciru hay gap nhat trong benh ly ngoai khoa bung, chiem tdi 53% mo cap ciru bung tai benh vien Viet Dire.
Lam sang dien hinh thi ehan doan de dang, nhyng vi cd nhu'ng trydng hdp khdng dien hinh nen chan doan diing chi tren 8 0 % cac trydng hdp [5]. Neu ehan doan mudn thi hau qua eiia bien chirng VRT rat nghiem trong, eho nen phau thuat dydc chi djnh rdng rai nhUng trydng hdp nghi ngd ehir khdng chd ddi cho den khi chan doan chac chan. Do dd dan den b/ le md eat bd rudt thira khdng bi viem ehiem tdi 20 den 30%
va dyde eoi la chap nhan dydc [5]. Khai niem nay hien nay dang bi thach thire vi viec loai bd rugt thira binh thydng lam lang phf ve thdi gian va tien bac, hdn nii'a cd the ed nhUng bien chirng do phau thuat gay nen anh hudng chat lydng cuoc sdng. Nhy vay, van de la can chan doan
Y HOC VtET NAM THANG 3 -
sdm va chinh xae, vl ea dydng tinh gia va am tinh gia deu gay ra bien chu'ng.
Mirc dp nghiem trpng ciia tinh trang viem la mot yeu td quan trpng de quyet dinh dieu tri viem rudt thira. Mirc do nay dyoc danh gia dya tren ed sd cac ket qua kham lam sang, xet nghiem mau, va sieu sieu am. Trong sd nay, ket qua sieu am la dae biet quan trgng. Chiing tdi so mirc do nghiem trpng eiia tinh trang viem bang sieu am vdi giai phau benh de xac djnh tfnh chfnh xac cua chan doan sieu am eua viem rugt thira. Chfnh vi vay ehiing tdi nghien cu'u de tai: "Sieu am ehan doan viem rugt thira cap tai Benh vien Viet Dire"
nham thay dyde gia trj chan doan eua sieu am trong chan doan VRT cap nhat la trong nhu'ng trydng hdp khdng dien hinh.
n. DOI TU'ONG VA PHU'ONG PHAP NGHIEN CUU - 127 BN khdng phan biet tuoi, gidi, nghe nghiep va ndi cy trii cd ho sd benh an day dii dydc lyu trCr tai kho lyu trti' hd sd cua benh vien Viet Ou'c trong hai thang 11 va 12 nam 2Q12, vdi cac tieu
chuan sau: lam sang ed bieu hien VRT, dyde sieu am thav d\idc rugt thii^ trydc md va cd ket qua giai phau benh.
- Cae ddi tUdng bao gdm 58 nam va 69 nu' tuoi tir 6 den 89 nam (trung binh: 34,8 nam). Nghien ciru tien ciru md ta eat ngang. Phydng tien nghien ciru: May sieu am (My) ed dau dd dal quat 3.5MHZ va dau dd phang 5-7,5 MHZ tai phdng tryc cap ciru va phdng sieu am eua khoa Chan doan hinh anh, Benh vien Viet Oirc.
- Kham lam sang va sieu am chan doan deu dydc thye hien bdi eac bae sT phau thuat va bac sT chan doan hinh anh cd nhieu kinh nghiem. Dya va hinh anh sieu am, viem rugt thira dydc phan loai nhy sau: 1) xuat tiet: eac Idp thanh rugt thira cdn rd, chi cd phii ne niem mac, dydng kinh ngang ldn nhat > 6mm; 2) viem tay: thanh ruot thira day khdng ro ldp, long rgng, tang dydng kinh ngang kich thyde ^lOmm, va 3) hoai tiT:
thanh rupt thiTa khong xac dinh dydc cac Idp va mat lien va tang dydng kfnh dang ke tao thanh mdtkhoi(H.l)[2].
Mau rudt thda cat bd dddc nhudm miu vdi hematoxylin-eosin va hinh inh md benh hgc cho cic hinh anh tu'dng uhg: 1) xuat tiit: nhe xim nhap te bao viem khu tru vio niem mac; 2) viem tiy: thim nhiem bach cau trung tinh lan toi trong thinh rugt thda vdl nhdng dip xe boac loet; 3) hoal thd:
hoal tdmu toin bo thinh rudt thu^.
T H U ^ V l t I NAM THANG 3 - SO 1/2014 ___^_
IM. KFT QUA
Trong 158 benh nhan eo nghi ngd lam sang cd VRT, sieu am khdng tim thayrudt thiTa ed 31 trydng hdp (19,6%), trong dd eo 6 benh nhan (19,3%) dydc chan doan lam sang va phau thuat la VRT.
Sieu am thay dydc rugt thiTa ed 127 trydng hdp (80,4%), trong dd rudt thya binh thu'dng la 34 trydng hdp va rudt thiTa viem cd 93 trydng hdp (gdm; 25 viem rudt thifa xuat tiet, 51 viem rudt thiia viem tay, va 17 viem rugt thira hoai tiO (Bang 1).
Bang 1: Hinh thai ruot thi/a tren sieu am Sieu am ruot thiTa
Binh thu'cJng
Viem
Xuat tiet Viem tay Hoai tCr Tonq
So lu'dng (n) 34 25 51 17 127
Ty le (%) 26,7 19,7
•10,2 13,4 100,0
Chiing toi danh gia dp ehinh xac chan doan ciia sieu am cho 127 benh nhan thay dyde rudt thira bSng phydng phap nay. Doi chieu vdi giai phau benh cho thay cd 88 trydng hdp dydng tfnh that, 31 trydng hdp am tinh that, 5 trydng hdp dydng tinh gia, va 3 trydng hdp am tfnh gia. Nhy vay, do nhay la 96,7%, dp dac hieu 8 9 , 1 % , do chfnh xae 93,7%, gia t n tien doan dydng 94,6%, gia tn tien doan am tinh la 91,2%.
Mirc dp VRT tren hinh anh sieu am phii hdp vdi hinh anh md benh hpc la 76 trydng hdp (59,8%), Trong 51 trydng hdp khdng phii hdp, cd 42 trydng hdp sieu am danh gia d mirc do viem thap hdn so vdi md benh hgc, trong dd cd 28 trydng hdp la VRT d miTc dp xuat tiet va 14 trydng hdp viem d mirc dp viem tay; edn 9 trydng hdp thi ngype lai, sieu am danh gia d mirc d d eao hdn so vdl md benh hpe, trong do co 6 trydng hdp la hoai tiT (Bang 2),
Bing 2: Chan doan mirc do viem rugt thira tren sieu am va giai phau benh s i e u a m m o t thiTa
Phij hdp
Khong phu hop
Xuat tiet Viem tay Hoai tiJ
Sieu a m 76 28 17 6
Mo b e n h hoc 76
3 28 14
IV. BAN LUAN
Trong nhiJng nam gan day, sieu am da dat dydc mpt vj t r i quan trgng trong chan doan viem njgt thira cap tinh. Mgt so nghien ciTu cho thay sir dung sieu am de phat hien viem rugt thiTa cap dat dydc do nhay 75-95%, do dac hieu la 95, va d ^ chfnh xac 85-95% [ 2 ] , [ 3 ] .
Mii'c dp nghiem trpng ciia tinh trang viem la rat quan trpng de d u ^ ra quyet dinh phau thuat VTR cap. Vi VRT xuat tiet cd the t y khdi, nen dieu tri bao ton theo doi dydc ehi djnh cho nhihig tru'dng hdp nay. Ngydc lai, VRT viem tay ho§c hoal tir t a n dieu t n phau thuat.
Ve cac dSc diem sieu am ciia rupt thiTa binh thydng, Wada cho rSng rugt t h i i ^ ed the dydc xae dinh binh thydng hoac loai trir VRT cap chi khi rupt thus co dydng kinh ngang ^ 6mm. Mat
khae, Puylaert [ 7 ] cho rang rudt thira la mdt cau triic dng cd dau tit va thanh ed ba Idp ro rang.
Cau triie nay cung dype thay trong rudt thu^
viem d mire dp xuat tiet, cdn neu thanh giam am kem cd am vang thi gap trong VRT viem tay. Khi benh tien trien den viem rudt thira hoai tu", v d ed niem va thanh rudt bj pha hiiy.
Kfch thyde tdi da cua rudt thiTa eung la mpt yeu to quan trgng de danh gia VRT tren sieu am.
Motoyama va es [ 6 ] cho rang dydng ktnh ngang
^ 10 mm gap trong VRT thanh ii mii hoac hoai tir la mdt dau hieu cho dieu tri phau thuat.
Jeffrey va cs [ 4 ] xac dinh dydng kinh ngang ciia rudt thiTa ^ 7 mm gap d 84 trong tdng so 86 benh nhan bi VRT cap tfnh. Mat khae, Ido va cs.
[3] eho rang hoac la mdt dydng kfnh £ 5 mm, hoac mat eau triie ldp, ngay ca vdi mdt dydng
Y HOC VIET NAM THANG 3 - « « kfnh 4 m m , ^ mdt ehi dinh phau thuat, va vdi lu'u y dp nhay la 87,3%, dp dae hieu la 98,5%, va do ehinh xae la 96,7% cho eae dac diem nay. Tuy nhien, dieu nay dan den md' cat rudt thira khdng can thiet d 14% benh nhan bi VRT xuat tiet hoac rugt thiTa khdng viem (17 trong td"ng so 119 benh nhan phau thuat).
Nghien cu'u nay sir dung tieu chuan dydng kfnh eiia Motoyama va es [ 6 ] , nhyng nhu'ng tieu chuan nay cd the danh gia thap mirc dp nghiem trgng eiia VRT. Nhy vay, ty le VRT viem tay khi dydng kfnh ngang tdi da la ^ 10 mm cd the dyde tang len bang each sir dung dydng kfnh ngang la
> 7 mm nhy Jeffrey va cs [ 4 ] ,
Sieu am cung cd the phat hien cac dau hieu khac nhy: khdng cd nhu dpng, an khdng xep, ed sdi phan, day thanh rugt hoi manh trang, dich trong ldng rupt thiTa, dich quanh rudt thiTa, phan irng day to chiTc md quanh rugt thira va cae bien chirng ap xe hoac dam quanh rupt thiTa.
Ddi vdi ky thuat sieu am, loai bd khi rudt bang each an dau dd tir tir viing ho chau phai [ 7 ] . Mdt chii y la benh nhan dau chdi khi an d i u dd d diem MacBurney cung la dau hieu lam sang quan trgng trong tham kham sieu am ciia VRT. Tuy nhien, viec chan doan sieu am VRT ddi hdi bac sy ehuyen mdn cd kinh nghiem va ky nang tham kham.
Trong nghien cuU nay, sieu am khdng the thay rudt thira 31 trydng hdp (19,6%). Trong sd nay cd 6 benh nhan (19,3%) dydc chan doan lam sang la VRT. Nguyen nhan cd the khdng thay rupt thira bao gom vydng khf dydng rudt, benh nhan cd the trang beo phi, ( m d dydi da qua nhieu va chieu day thanh bung qua mirc), va vi t r i rudt thiTa nam sau trong 6 bung hoac phfa tren manh trang. Gan day, mpt so tac gia da nhan manh tfnh hiTu dung ciia ehup cat Idp vi tinh cho Chan doan VRT, nhat la bang ky thuat chup da day dau dd [1] va nd cd the cd gia tri trong trydng hdp rudt thiTa khdng the phat hien dydc bang sieu am. Tuy nhien, sieu am la phydng phap ddn gian va cd kha nang md ta cau true ldp ciia thanh rupt thus nen nd van dydc la phydng phap
rat hihj ich va nen dydc lya ehpn dau tien, dac biet tham kham sieu am VRT d tre em.
V. KET LUAN
Trong nhu'ng t r y d n g hdp thay dydc rupt thiTa, sieu am cd dp nhay la 9 6 , 7 % , do dac hieu 8 9 , 1 % , va dp chinh xae 9 3 , 7 % . Trong 6/31 benh nhan sieu am khdng thay rudt_ thiTa (19,3%), dyde chan doan lam sang va phau thuat la VRT.
MiTc dp VRT tren hinh anh sieu am phu hdp vdi hinh anh md benh hgc la 76 trydng hdp (59,8%).
Sieu am cd the danh gia thap mirc dp nghiem trgng cua tinh trang VRT, do vay nen khi sieu am can xem xet khi phan biet giii'a VRT d mu'c do xuat tiet hoac viem tay, dieu nay rat quan trgng de dya ra quyet dinh dieu tri phau thuat.
TAI LIEU T H A M KHAO
1. Daily R, Danton G, Munera F: "ER radiology evaluation of appendicitis and alternative diagnoses of the right lower quadrant: Emphasis on multidetector CT", Applied radiology, 20U, Volume 40, Number 07.
2. Himeno S, Yasuda S, Oida Y et all:
"Ultrasonography for the Diagnosis of Acute Appendicitis", Tokai 3 Exp Clin Med, 2003, Vol 28, No 1, pp 39-44.
3. Ido K, Adachi M, Tsuruta R et all: "A prospective study on the diagnostic of acute apperndicitis with ultrasonography in the initial examination (in Japanese)", 3 Jpn Surg Assoc 1996, 57: 1851-1858.
4. Jeffrey RB, Jain KA^ Nghiem HV: "Sonographic diagnosis of acute appendicitis: interpretive pifalls", A W , 1998, 162:55-99.
5. Mohammad AAM, Tariq SM, Irfan UK, et all:
"Role of ultrasound in acute appendicitis", J Ayub Med Coll Abbottabad, 2007,19 (3).
6. Motoyama S, Matsuoka T, Terashima H: "Key points of ultrasonographic diagnostis and conservative therapy in acute appendicitis", 3 Abdon Emerg Med, 1995,15: 445-451, 7. Puylaert JBCM: "Acute appendicitis: US
evaluation using graded compression", Radiology, 1986,158; 355-360.