TAP CHI Y Dl/QfC HQC C^N THg - SO 11-12/2018
4. Pham Thu Linh (2003), "So sanh gia tri chan doan cua sieu dm tim Dobutamine - Atropine vd dien tdm dl gdng siic trong benh ly dpng mach vdnh", Yhgc TP. Hd Chi Minh tap 7 - Phg bdn ciia so 1 - 2003, Tr. 50-56.
5. Pham Nguyin Vinh (2006), "Nghiem phdp gdng siic", Binh tim mach, NXB Y hoc, Tr.
113-125.
6. Kye Hwan Kim (2016), "Prognostic value of computed tomographic coronary angioraphy and exercise electrocardiography for cardiovascular events". The Korean Journal of Internal Medicine Vol. 31, p. 880-890.
7. Montalescot G (2013), "2013 ESC Guidelines on the management of stable coronary artery disease", Eur. H. Journal 2013 (34), p. 2949-3003.
8. Morrow AD (2012), "Stable Ischemic Heart Disease", Braunwald's Heart Disease P""
edition,'?. 1210-1270.
9. Neha Sekhri (2008), "hicremental prognostic value of the exercise elecUocardiogram in the initia] assessment of patients with suspected angina: cohort study", BMJ Research, p. 1-8.
10. Psirropoulos D (2001), "Detection of myocardial ischaemia in the elderly vs tiie young by stress Thallium-201 scintigraphy and its relation to important coronary artery disease", innokpateia2001, p. 76-83.
11. Simon Greulich (2012), "Comparison of exercise electrocardiography and stress perfusion CMR for the detection of coronary artery disease in women". Journal of Cardiovascular Magnetic Resonance 2012, p. 1-9.
(Ngdynhgn bdi: 11/11/2017-Ngdy duyet ddng: 02/01/2018)
N G H I E N ClTU D A C DIEM L A M SANG, CAN L A M SANG, BIEN CHlTNG VA D A N H GIA K E T Q U A DIEU TRI 6 BENH NHAN
x a G A N M A T B U CAP
Vo Tan Cuvng*, Nguyen Phgm Minh Chau, Phgm Van Linh Tru&ng Dgi hoc Y Dugrc Cdn Tha
*Email: [email protected] TOM T A T
Dgt vdn di: Xa gan Id mgt binh mgn tinh, tien trien tir tir, ddn din suphd huy lan tda te bdo nhu md gan gdy nhieu bien chung ndng ni. Trong do, xa gan mdt bu cdp Id nguyen nhdn quan trgng gdy tu vong tren cdc binh nhdn xa gan. Mgc tiiu nghien ciru: khdo sdt ddc diim ldm sdng, can ldm sdng, biin chimg vd ddnh gid kit qud diiu tri & benh nhan xa gan mdt bit cdp. Boi tugng vd phuffng ph^ nghiin cd-u: Phuang phdp nghien cdu md td cdt ngang trin 151 b?nh nhdn dugc chdn dodn xa gan mdt bit cdp diiu tr} tgi khoa ngi Tieu hda - Huyit hge ldm sdng cua Binh viin Da khaa Trung Uang Cdn Tha tir thdng 05/2015 din thdng 05/2017. Kit qua: Nam giai chiim ty li 58,3%, tuoi trung binh Id 59,93±13,57 tudi. Co tru&ng vd vdng da la hai trieu chung chiem ty le cao nhdt ldn lugt Id 76,2% vd 78,8%. Co 86,1% gidm tiiu cdu, 77,4% b^nh nhdn cd PT gidm, bilirubin todn phdn trong mdu cd 53% tdng >51/imol/L, albumin mdu cd 96% gidm. Cd 24,5%
benh nhdn co tdng creatinine mdu Biin chung xudt huyet tiiu hoa do v&gian tinh mgch thgc qudn chiim ty li cao nhdt 45%, dip theo la cdc biin chung cd tnr&ng, binh ndo gan vd viem phiic mgc nguyin phdt ldn lugt Id 25,2%, 18,5%vd 11,3%. Th&i gian ndm viin trung binh Id 7,3±2,93 ngdy.
Cd 20 b4nh nhdn chiem ty li 13,2% truang hgp tie vong hogc ngng lin dugc ngu&i nhd xin ve. Ket
TAP CHl'Y Dirge HQC CAN THg - s 6 11-12/2018
lugn: Dgc diim ldm sdng cua benh nhdn xa gan mdt bit cap rdt da dgng, ket qud dieu tri cd 86.8%
binh nhdn dn xudt vien, 13,2% tu vong-xinye. Th&i gian ndm viin trung binh 7,3±2.93 ngdy.
Tu khda. xa gan. xa gan mdt bit cdp.
A B S T R A C T
T H E C L I N I C A L , P A R A C L I N I C A L C H A R A C T E R I S T I C S , C O M P L I C A T I O N S AND A S S E S S T H E T R E A T M E N T R E S U L T S O F
A C U T E D E C O M P E N S A T I O N C I R R H O S I S
Vo Tan Cuong, Nguyen Pham Minh Chau, Pham Van Linh Can Tho University of Medicine and Pharmacy Background: Cirrhosis is a chronic disease, progressing slowly, leading to the destruction of liver parenchyma causing severe complications. In particular, acute decompensated cirrhosis is the leading cause of death in cirrhotic patients. Objectives: clinical, paraclinical characteristics, complications and assess the treatment results of acute decompensation cirrhosis.
Materials and Method: A cross - sectional study was conducted on 151 patients with acute decompensation cirrhosis in Deparment of Gastroenterology — Hematology at Can Tho Central General Hospital from 5/2015 to 5/2017 Results: Men are 58,3%, average age is 59,93 ± 13,57 years old. Ascites and jaundice were the two highest rates, 76,2% and 78,8% There were 86,1%
of thrombocytopenia, 77,4% of patients with PT decreased, total bilirubin in blood had 53%
increased >51fimol/L, albumin decreased 96%. There were 24,5% of patients with elevated creatinine levels. Complications of gastrointestinal bleeding due to esophageal variceal occupy the highest rate of 45%, followed by ascites, hepatic encephalopathy and primary peritonitis as 25,2%, 18,5% % and 11,3%. Average hospitalization was 7,3 ± 2.93 days. Twenty cases of death or serious death occurred in 20 patients. Conclusion: clinical characteristics of acute decompensation cirrhosis are diversity, 86,8%patients sitrvival, 13,2% patients serious or death, average hospitalization was 7,3 ± 2.93 days.
Keywords: cirrhosis, acute decompensation cirrhosis.
I. D A T VAN D E
BSnh xa gan dugc cdng bd lan ddu tien nam 1819 do nha lam sang hgc ngudi Phap R.T.Laermec md td khi md tii thi ngudi linh nghien rugu. DSn nay xa gan da trd thanh mgt bSnh pho bien thudng gap tren the gidi ciing nhu d ViSt Nam [3]. Xa gan Id mdt benh man tinh, tiin trien tir tir, ddn din su phd huy lan tda t l bdo nhu md gan. CJ giai dogn sdm (xo gan cdn bu) trieu chiing nghSo ndn, benh nhan de bd qua va khdng din kham benh, den khi trieu chiing ro rdng thi benh da chuySn sang giai dogn mudn (xa gan mdt bii) gay ra nhilu biSn chiing ngng ne cd thS din dSn tii vong nhu: xudt huyit tieu hda do vo gidn fihh mgch thuc quan, hgi chung gan than, benh nao gan, ung thu gan...[6]. Ngdy nay, du <E co nhieu tiSn bd ddng ke trong dieu tri benh nhdn xa gan mdt bu cdp, nhimg day vdn Id nguySn nhan quan trgng gdy tii vong d benh nhdn xa gan, tai Bd Dao Nha khi nghiSn ciiu benh nhan xa gan nhgp vien trong 10 ndm ghi nhan ty IS tii vong Id 15,2% [9]. Tgi Cdn Tlha, diiu tri xo gan mdt bii cap da dugc thuc hien trong nhiSu ndm nay, nhung viec nghien ciiu danh gid kit qua diSu tri hxmg dgt cap chua dugc quan tam nhilu. Do dd, chung tdi thuc hiSn nghiSn cuu vdi muc tiSu khdo sat ddc diim lam sang, can ldm sdng, biin chiing vd ddnh gid kit qua dieu tri d benh nhan xa gan mdt bu cdp.
IL D O I TlTgfNG VA PHlTCfNG P H A P N G H I E N C U t J 2.1. D i i tiTtfng nghiSn cihi:
TAP CHf Y Dirge HQC CXN THg - S6 11-12/2018 Benh nhan > 16 tudi chdn dodn dgt cdp xa gan mdt bii dieu tri tai khoa ndi Tieu hda - Huyit hgc ldm sang cua Benh vien Da khoa Trung U"ang Cdn Tha tir thdng 05/2015 din thdng 05/2017.
Dot cdp xa gan mdt bu (acute decompensation Cirrhosis) dugc dinh nghia la sir phat trien cdp tinh cua mdt hodc nhiSu bien chiing ciia xa gan (cd trudng, bSnh nao gan, xuat huyet tieu hda do vd gidn tTnh mgch thy:c qudn, nhiem triing) lam nguyen nhan d^i den b^nh nhdn phdi nhap viSn diSu tri .Cac benh nhan nay thudng cd hodc khdng kem theo cac ddu hieu suy cdc ca quan khac (than, huyet hgc,...). Dgc diem cac trieu chiing trong giai dogn cap xa gan mdt bii:
- Su phdt trien cap tinh ciia cd trudng dugc dinh nghia la su xudt hiSn cd trudng giai doan 2 hoac 3 theo phan loai ciia cdu Igc bd cd trudng thi gidi (International Ascites Club Classification) trong thdi gian tdi da 2 tudn. Bao gdm cd trudng ldn ddu xudt hien hogc cd trudng xuat hien trd lai sau dieu tri.
- Benh nao gan cdp dugc dinh nghia la sir phdt triln cdp tinh ciia thay dSi tri gidc trSn cac benh nhdn xa gan ma trudc ddy tri gidc binh thudng va khdng cd bdng chung do cdc nguySn nhdn tdn thuang than kinh khdc. Bao gdm cac benh nhan cd benh ndo gan ldn ddu hoac mOt dot benh nao gan mdi.
- Xuat huyet tieu hda cdp do vd gian tinh mgch thuc quan Id cdc benh nhdn nhdp vien vi ndn ra mau vd/ho^c di cdu phdn den.
- Cac nhiem trimg cap cd lien quan den xa gan mdt bu nhu viSm phiic mac nguySn phdt do vi khuan, nhiem trung tieu, viSm phdi.
TiSu chuan chgn mau - Benh nhdn > 16 tuli.
- Chdn dodn xa gan mdt bu bieu hien qua hgi chiing tdng dp luc tinh mgch ciia vd hdi chiing suy t l bao gan.
- Nh^p vien do cdc biSn chiing ciia xo gan nhu cd trudng, xuat huyet tiSu hda do vd gian tiiih mgch thuc quan, viem phiic mac nguySn phdt do vi khudn, benh nao gan.
Tieu chuan lo^i trir
- Benh nhan img thu gan hogc nghi ngd ung thu gan.
- Cdc bSnh nhan cd cac benh ly kem theo: bSnh huyet hgc (bach cau cap, suy tuy), suy than mgn giai dogn culi, suy tim, benh phdi mgn tinh.
- Benh nhan khdng ddng y, khdng hgp tdc vdi n ^ e n ciiu.
Dia diem va thoi gian nghien ctiu: Thu thdp sd lieu tgi khoa Ndi tieu hda - Huyet hgc lam sang Benh vien Da khoa Trung uang Cdn Tha tii 05/2015 dSn 05/2017.
2.2. Phirtrag phdp nghiSn cihi
Thiet k l nghiSn cihi: Phuang phdp nghiSn cuu md ta cat ngang.
Co* mau va phirong phap ch^n mau: NghiSn ctiu chiing tdi thu thdp dugc 151 benh nhdn.
N$i dung nghien cuu: Dgc diem ldm sdng: vdng da niem, phu chan, sao mgch, xuat huyet da niem t\i nhiSn, nii hda tuylt vii d nam, cd trudng, Idch to, tuan hodn bang he.
Dgc diim can lam sang: Cdng thuc mdu liic nhap vien ciia benh nhdn: sd lugng hdng cdu, hemoglobin, sd lugng tiSu cdu, sd lugng bach cdu. Hda sinh mau: ure, creatinine, protein, albumin, men gan ( SGOT vd SGPT), bilirabin, Natri, Kali mdu. Ddng cam mau: Ty le prothrombin, aPTT, fibrinogen mau. SiSu dm bung: Dudng kinh tTnh mach ciia < 13 nun,
> 13 mm, Lach: to hay khdng, chilu cao lach. Cdc biin chung ciia xa gan mdt bit (Cd trudng, viem phiic mac nguySn phat do vi khudn: X6t nghiem dich mdng bung, benh nao lOI
TiBtP CHI Y DtrgC HQC C&N THg - SO 11-12/2018
gan: Chdn doan va phdn do benh ndo gan thudng dua vao tieu chudn West Haven, xuat huyit tieu hda do vd gian tinh mach thuc qudn: Ddnh gia miic do xudt huyit, d^c diim n^i soi. Ddnh gid kit qua diiu tri: S l ngdy nam vien cua bSnh nhdn, kit qud diiu tri: Do, giam: sau dgt diiu tri benh nhdn dugc xudt vien hodc chuyin vl tuyIn dudi. Tir vong-xm vl: benh nhan tir vong tgi benh vien hogc nang len dugc than nhan xin ve nha tir vong.
Phircmg phap xu- li s l liSu: Nhdp, phdn tich va xir ly sd HSu bang phdn mem thdng ke SPSS 18.0.
H I . K E T Q U A N G H I E N CU*U
Qua nghien ciiu trSn 151 benh nhdn, chiing tdi thu dugc mgt sd ket qua sau:
Ve dgc diim chung ciia mau nghien ciiu: nam gidi chiSm ty le 58,3% cao hon so vdi nii (41,7%), 94% benh nhdn Id til 40 tuli ti-d len, tuli trung binh la 59,93±I3,57 tuli, phan loai benh nhan theo Child-Pugh cd 70,9% benh nhdn xa gan Child C vd khdng cd bSnh nhdn ndo Child A.
3.1. D^c diem lam sang, cdn Idm s^ng vd biin chirng 6^ bSnh nhdn xo* gan m^t bii cap
Bang 3.1. Ddc diim hdi chung suy t l bao gan va hgi chiing tdng dp luc tinh mgch cira Trieu chung lam sang Ty le % Tnlu chu-ng lam sang Ty l | %
Vangd Phil 36,4
Sao mach Co trudng
Xuat huyet da niem 38,4 Tuan hoan bang he 47,7
Nii hda tuyen vii d nam 28,] Lach to
Nhdn xet: Cd truong vd vang da Id hai trieu chiing chiSm ty IS cao nhat lan lugt la 78,8% vd 76,2% benh nhdn xa gan mdt bii.
Bdng 3.2. Ddc diSm cdng thuc mau Cong thuc mau H6ng c4u
Hemoglobin
Tieu cau B^cli c^u
< 2 tri?u/mm'' 2-3 trieu/mm^
> 3 trieu/mm^
>12 g/dL 7-12 g/dL
<7g/dL
>150.000/mm'
<150.000/mm'
>10.000/mm-'
<10.000/tntn'
Tan so n=151 11 66 74 25 104 22 21 130 48 103
Tyl?(%) 7,3 43,7
49 16,6 68,9 14,5 13,9 86,1 31,8 62,8
Gia tri trung binli 3,02±0,75
9,38±2,49
93,69±49,18 8,34±4,54 Nhdn xet. Cd 83,4% benh nhan miic hemoglobin <12g/dL, sd lugi^ hong cau trung buih Id 3,02±0,75 trieu/mm^, 86,1 % giam tiiu cdu va 31,8% cd tang sd lugng bach cdu.
Bdng 3.3. D^c diem ddng cdm mau va hoa sinh mau chiic nang gan Can ISm sang
PT (%) >70 40-70
T y l f ( % ) 22,5 53,6
Can lam sdng | Ty le (%) SGOT
(U/L)
S37 1 14,6
>37 1 85,4
TAP CHI Y Dl/QC HOC CXN THOT - S6 11-12/2018 Cdn lam sang
aPTT(gidy) Fibrinogen (g/dL) Bilimbm TP
(}imol/L) Protein
(g/L) Albumin
(grt-)
<40
>40
<40
>2
<2
<34 34-51
>51
>65
<65
>35 28-35
<28
Tylf(%) 23,8 49,7 50,3 42,4 57,6 31,8 15,2 53 32,5 67,5 4 32,4 63,6
C^n lam sang SGPT (U/L) Ure (mmol/L) Creatinin (^mol/L) Natri (mmol/L)
Kali (mmol/L)
<40
>40
>7,5
<7,5
>120
<120
<135 135-145
>145
<3,5 3,5-4,5
>4,5
Ty le (%) 51 49 43,7 56,3 24,5 75,5 65,6 33,7 0,7 31,2 48,3 20,5 Nhdn xet: Cd 77,4% benh nhdn cd PT gidm, aPTT keo dai chiSm ty IS 49,7% vd 57,6% cd fibrinogen mau gidm. Bilimbm toan phan trong mau cd 53% benh nhdn cd bilirubin toan phan mdu tang cao >51|amol/L. Protein mdu cd 67,5% gidm, albumin mdu cd 96% giam, 63,6% Id giam ngng dudi 28g/L. Cd 24,5% benh nhan cd tang creatimne mau. Natri va kali mdu gidm ldn lugt trong 65,6% va 31,2% benh nhdn.
Bang 3.4. Ddc diim siSu dm bung Sieu am bung Duong kinh tinh mach cua
Chilu cao lach
Tan so
<13mm
>13mm
<120 mm
>120mm
Tyle(%) 84,8 15,2 47,7 52,3
Trung binh
12,17 ± 1,47 mm 117,05±18,2mm Nhdn xet: Cd 15,2% trudng hgp tang dudng kinh tiiih mgch cira va 52,3% benh nhan cd chieu cao Idch >120mm trSn siSu am.
Bdng 3.5. Ty Ig cdc biSn chiing ciia dgt cap xa gan mat bu Bi^n chirng
Xuat huyet tieu hoa Co truong Benh nao gan
Viem phuc mac nguyen phat Tong cong
Tan so 68 38 28 17 151
Tylf(%) 45 25,2 18,5 11,3 100 Nhdn xet: BiSn chiing xuat huyet tieu hda do vd gidn tinh mgch thirc qudn chiSm ty le cao nhdt 45%, tiep theo la cac bien chiing co trudng, benh nao gan va viem phiic mgc nguyen phat ldn lugt la 25,2%, 18,5% vd 11,3%.
Tren cdc benh nhan viSm phiic mac nguySn phdt do vi khuan khi xet nghiem dich mdng bung, chiing tdi ghi nhdn sd lugng t l bdo trung binh cua chgc dd dich mdng bung la 1230,94±603,97 t l bao vd ty IS trung bmh cua bach cau da nhan trung tinh trong dich mang bung la 80,29±6,72%.
TAP CHi Y Dl/QC HQC CAN THO - s 6 11-12/2018 Bang 3.6. Phdn do benh ndo gan theo lam sdng
Benh nao gan D p i DO 2 Dp 3 Dp 4
Tan s6 (n=28) 0 1 10 17
Tyl?(%) 0 3,6 35,7 60,7 Nhdn xet: Cd 96,4% benh nhdn benh nao gan vdo vien vdi dd 3 vd 4.
Bang 3.7. Miic do xudt huySt tieu hda Mirc dd xukt huyet
Nhe Trung bmh
Nang
Tan so (n=68) 6 28 34
T y l | ( % ) 8,8 41,2 50 Nhdn xet: Co 91,2% benh nhan nhap vien vdi tinh trgng xudt huySt tiSu hda mu:c dg trung binh-ngng.
Bdng 3.8. Ddc diim ndi soi thuc qudn - dg ddy a benh nhan xudt huySt tiSu hda Sac diem noi soi
So biii giSn VI tri Miic dp Dau do
<4biii
>4biii 1/3 duoi 2/3 du4i D p n D p n i
RC- RC-I-
Tan so (n=68) 45 23 43 25 26 42 0 68
Tylf(%) 66,2 33,8 63,2 36,8 38,2 61,8 0 100 Nhdn xet: 33,8% benh nhdn cd >4 biii gian tinh mgch thuc
d 1/3 dudi thuc qudn, khdng cd biii gian nao d 1/3 tren thuc quan, 100% bSnh nhdn cd ddu dd trSn ngi soi.
3.2. Ket qua diiu tri dot c4p xtf gan m^t bii Bang 3.9. Thdi gian ndm vien diSu tri
qudn, 63,2% sd biii nam cd 61,8% la gian ddlll.
Thoi gian
<5 ngay 5-10 ngay
>10ngay
Tan so (n=151) 22 110
19
Tyle(%) 14,6 72,8 12,6 Nhan xet: Co 72,8% benh nhan nam vien tu 5-10 ngay, ng^y da so 1^ cac benh nhan nang-xin ve.
B ^ g 3.10. Ket qua dieu tri dot cdp xa gan mdt bCi Ket qua
Do, giam Tu vong- xin ve
Tan so (n=151) | 131
20 1 Trung binh 7,3±2,93 ngay
14,6% benh nhan duoi 5
Tyle(%) 86,8 13,2 Nhdn xet: Cd 20 benh nhan chiem ty le 13,2% trudng hgp tu vong hodc nang ISn dugc ngudi nha xin vS.
Ti^P CHf Y PyglC HPC CAN THOr - so 11-12/2018 Bang 3.11. Ket qua di6u tri theo biSn chiing
^ • ^ • ^ ^ K e t qua dieu tri Bien chirng ^ ^
XHTH
Co truoug Co Khong
Co Khong
B&, giam 56 82,4%
75 90,4%
38 100%
93 82,3%
Ta vong- xin ve
12 17,6%
8 9,6%
0 0%
20 17,7%
"~ ^ ^ K ^ t qua dieu tri Bien chiims ^ ^ ^ ^ VPMNP
Benh nao gan
06 Khong
Co Khong
B&, giam
12 70,6%
119 88,8%
25 89,3%
106 86,2%
Tir vong- xin ve
5 29,4%
15 11,2%
3 10,7%
17 13,8%
Nhdn xet: Ty IS tii vong-xin vS d biSn chiing XHTH, VPMNP, BSnh nao gan lan lugt la 17,6%, 29,4%, 10,7%, biin chiing cd trudng khdng c6 benh nhdn ttt vong-xin vS.
IV. B A N L U 4 ^
4.1. D^c diem chung cua mau nghien cihi
Qua nghiSn c ^ trSn 151 benh nhdn, chiing tdi ghi nhan nam gidi chiSm ty IS 58,3%, nii gidi chiem 41,7%, ty IS nam/nu' Id 1,4/1. KSt qua nghien ciiu ciia chiing tdi tuang duong so vdi cac nghien ciiu khdc ciing cd ty IS nam nhilu ban n&. Ket qua nay ciing phii hgp do nam lam dung rugu nhilu ban nii rat nhilu ldn trong khi dd nguySn nhdn gay xo gan chii ySu Id rugu. Tudi tnmg binh ciia mlu nghiSn ciiu Id 59,93±I3,57 tudi vd tii 40 tudi trd len chiim 94%. Kit qud ciia chiing tdi ciing tuan^ duong vdi ket qud nghiSn ciiu cua Huynh Thi Hdng Nggc nhdm tudi tir >60 tudi chiim 52,25% va tren 40 tudi Id 94,59% [4], Qua do cho thdy benh nhdn chii yiu tap tiimg d liia tudi trung nien vd cao nien, la liia tudi lao ddng chinh trong cdng ddng. Dieu nay theo chting tdi la hgp ly vi xo gan Id benh man tinh tiin triln chdm, tit khi mdc phdi mdt nguyen nhau gdy benh thi 10-20 nam sau mdi xa gan.
Khi ddnh gid miic dO ndng cua xa gan theo Child-Pugh, chiing tdi nhdn thdy 70,9%
benh nhdn xa gan Child C theo phan do Child-Pugh va khdng co b?nh nhan nao Child A.
Kit qua nghien ciiu ciia chung tdi phu hgp vdi cdc nghiSn ciiu khdc deu cd ty le Child C cao nhdt nhu Nguyen Thi Hdng Diem [1], hay Huynh Thi Hdng Nggc [4].
4.2. Dac diem ldm sdng, can Itim sang va biin chung cua xu gan mat bu Trong nghien ciiu ciia chiing tdi, cd trudng va vang da niSm Id trieu chiing chiim ty IS cao nhdt (78,8% va 76,2%). Cac trieu chiing lam sdng khdc ciia xa gan rdt da dang vd thay ddi tiiy nghien ciiu, thi hien su da dang trong ddc diSm lam sdng va tiiy theo miic do xa gan.
Thilu mdu cung la mdt bilu hien thudng g^p tren benh nhdn xa gan mat bu Qua nghiSn ciiu chiing tdi ghi nhan cd 83,4% benh nhan dgt cdp xa gan mdt bu cd bieu hiSn thilu mau trSn can ldm sdng vci miic hemoglobin <12g/dL, ket qud nay gan tuang duang vdi cua NguySn Th; Hing Diem [I] ha:y' Mai Huu Thgch [5]. Trong nghien ciiu cua chiing tdi cd 86,1% cdc frudng hgp la giam s l lugng tiiu c^u (<150xl0Vmm^). Day la mOt tinh trang dang bdo dgng, tieu cau giam ket hgp vdi rdi logn ddng cam mau se lam tdng nguy ca xudt huyit trSn benh nhdn xa gan.
v l t>' I? Prothrombin, nghiSn ciiu cua chiing tdi cho thdy gidm <70% chiem 77,4%
trudng hgp. Qua nghien ciiu ciia chiing tdi ghi nhan bilirubin toan phdn trong mau cd 53%
105
TAP CHf Y DUgC HQC CAN THg - s6 11-12/2018
benh nhdn cd bilirubm toan phan mdu tdng cao >51pmol/L. Gan Id co quan true tiep tdng hgp albumin trong ca the, khi gan bj suy se lam gidm tdng hgp albumin mau. Sau nghiSn ciiu chiing tdi ^ i nhgn gid tri trung binh ciia albumin mdu Id 25,83±5,29g/L vd cd 96%
benh nhan gidm albumin mau. NghiSn ciiu cua chiing tdi cd 65,6% trudng hgp cd giam natri mdu vd 31,2% trudng hgp cd giam kali mdu.
4.3. Cdc biin chung cua x c gan mat bu
Qua nghiSn ciiu tren benh nhdn dgt cap xa gan mdt bii chtog tdi ghi nhgn biin chiing xudt huyit tiSu hda do vd gian tinh mgch thuc quan chiim ty IS cao nhdt 45%, tilp theo la cac biSn chiing cd trudng, benh nao gan vd viSm phiic mac nguyen phdt lan lugt la 25,2%, 18,5% va 11,3%. Ty IS cdc biin chiing thay doi tiiytheo nghien ciiu.
Qua nghiSn ciiu va theo ddi 151 benh nhan dgt cap xa gan mat bii nhdp vien tai khoa tiSu hda Benh vien Da khoa Trung uang Cdn Tha, chiing tdi ghi nhdn cd 17 trudng hgp cd kit qua xet nghiSm te bao dich mang bung thda tiSu chudn chan dodn nhiem triing dich bdng theo tiSu chudn Albillos. Ty IS nhiem triing dich bdng Id 11,3%, ket qua ndy tuang duong vdi nghiSn ciiu cua Mai Hiiu Thach trSn 182 benh nhdn xa gan cd trudng Id 9,3% [5]. Trong nghiSn ciiu ciia chiing tdi, 100% cac benh nhan viem phiic mac nguySn phdt do vi khudn cd bach cdu da nhdn tnmg ti'nh trSn 250 te bao/mm dich cd trudng.
NghiSn ciiu cua chiing tdi ghi nhdn s l lugng t l bdo bach clu trung bmh ciia dich mang bung Id 1230,94±603,97 t l bdo/mm^. Ty IS trung binh ciia bgch cdu da nhdn trung tinh trong dich mdng bung Id 80,29±6,72%.
De ddnh gid miic do b^nh nao gan, tren lam sang diing cac dau hieu tam than kinh de ddnh gid va phdn do d\ra vao miic do hdn me chia lam 4 d0. Qua nghien cuu chiing tdi ghi nhgn cd 96,4% benh nhan benh nao gan vdo vien vdi benh nSo gan dd 3 vd 4. Qua do, cdn cho thay cdc benh nhdn benh ndo gan thudng nh|ip vien tre trong tinh trang tri gidc rli loan nhiSu va hieu qud cua viec diSu tri du phdng benh nao gan chua cao.
Miic do xudt huySt trong nghien ciiu chiing tdi ghi nhan benh nhdn nhdp vien trong tinh trang xudt huyit tieu hda miic dg ngng chiim ty le cao nhat 50% vd cd 91,2% benh nhdn nhdp vien vdi tinh trgng xudt huyet tieu hda miic do trung binh-ngng. cho thdy xuat huySt tiSu hda do vd gian tinh mach thuc qudn chu ySu Id miic do tnmg binh - ngng vd la mdt cap ciiu toi khdn cdp, phdi dugc diSu tri kip thdi d l giam nguy ca tii vong.
Qua nghiSn ciiu trSn 68 benh nhan xuat huySt do vd gian tinh mgch th^rc quan chiing tdi ghi nhdn cd den 33,8% benh nhdn cd >4 bui gian tmh mach thuc qudn liic noi soi, 63,2% sd biii nam d 1/3 dudi thirc qudn, cd 36,8% sd biii gidn ndm d 2/3 dudi thuc qudn va khdng cd trudng hgp nao biii gian d 1/3 trSn cua thuc quan. Diiu nay cung phii hgp vdi y van gidn tmh mgch thuc qudn trSn b?nh nhan xa gan thudng chi gidn tir 1/3 din 2/3 dudi cua thuc qudn. Ve miic dd gian tinh mach thuc qudn qua ndi soi, qua nghiSn ciiu trSn 68 benh nhan xudt huyet do va gidn tinh mgch thuc qudn chiing tdi thiy gian tinh mach tiiuc qudn do III chiem ty 1$ cao nhdt vdi 61,8%, tilp theo la gian do II 38,2% vd khdng cd bSnh nhan nao gidn dO I.
4.4. Ket qua dieu tri xc gan mat bii cap
Qua nghiSn ciiu chiing tdi nhdn thdy thdi gian nam vien dieu tri tnmg binh cua cac benh nhdn xa gan mdt bii cdp Id 7,3±2,93 ngdy. Trong dd, cd 72,8% bSnh nhan ndm vi^n tii 5-10 ngdy, 14,6% bSnh nhan dudi 5 ngdy ma da sd la cac benh nhan ngng-xin vl. Thdi gian nam vien trong nghien cuu cua chiing tdi thdp han so vdi nghien cuu Mai Hiiu Thgch thdi gian ndm vien trung binh la 9,5±2,1 ngay [5]. Cdc benh nhdn trong nghiSn ciiu chiing 106
TAP CHI Y Dl/QC HQC CAN THg - SO 11-12/2018
tdi cd miic do suy gan nang (Child C) nSn viec diSu tri cac biSn chiing vd diSu chinh cdc rdi loan kem theo nhilu khi phuc tap nSn gdp phdn keo dai thdi gian dieu tri, lam tang chi phi diSu tri.
Ty IS tir vong hogc benh ngng ngudi nhd xin v l trong nghien ciiu chiing tdi chiim 13,2%. Theo tdc gid Sara va cdng su ty IS tii vong trong 28 ngdy d benh nhdn dgt cdp xo gan mdt bii la >15% [8], trong nghiSn cuu CANOIC da cho thdy ty le tii vong trong 28 ngdy ciia dgt cap xa gan mdt bu cd thS ISn dSn 20% vd >30% trong 90 ngay, ty le nay tang theo miic do suy cdc ca quan kem theo [8j. Trong nude, nghiSn cuu ciia Ngo Thdi Himg cd ty IS tir vong Id 25,42% [2].
V. KET LUAN
Dac diSm ldm sdng ciia benh nhdn xa gan mdt bu cdp rdt da dang, ty IS cdc biin chiing trong giai doan cap Id xudt huySt tiSu hda do vd gian tinh mgch thuc qudn chiSm 45%, cd truang la 25,2%, benh nao gan la 18,5% vd viem phiic mgc nguySn phat do vi khuan la 11,3%. Ket qua dieu tri cd 86,8% benh nhan dn xuat vien, 13,2% tfit vong-xin vS.
Thdi gian nam vien trung binh 7,3±2,93 ngay.
TAI LIEU T H A M K H A O
1. Nguyen Thi Hong Diem (2014), Nghien cuu dgc diim ldm sdng, cdn ldm sdng vd gid tri cua thang diim MELD vd Child-Turcotte-Pugh trong tien lugng benh nhdn xa gan giai dogn cuoi tgi Binh vien Da Khoa Trung Uang Cdn Tha, Luan van tot nghiep Bac si npi trii, Trudng Dai hoc Y Dugc Can Tha.
2. Ngd Thai Himg (2013), Nghiin cuu dgc diem ldm sdng, can ldm sdng, bien chimg vd ddnh gid kit qud diiu trf ngi khoa trin benh nhdn xa gan mdt bii tgi Benh viin Ngi^in Dinh Chiiu Bin Tre, Luan an chuyen khoa cdp II, Trudng Dai hpc Y Dugc Cdn Tho.
3. Ha Van Mao, Vu Bdng Dinh (2009), Binh hgc gan mdt tuy, Hgi Gan Mat Viet Nam, Nha xuat ban Y hgc.
4. Huynh Thi Hdng Nggc, Phgm Van Linh, Kha Hihi Nhdn (2015), "Nghien cuu yiu t l du dodn gian tinh mach thuc quan va kit qua dieu tri du phong chay mau tiSn phat do vd gidn tTnh mach thirc quan tren benh nhan xa gan", Tgp chi YDuac hgc Cdn Tha, 2, tr.
41-48.
5. Mai Hftu Thach, Nguyin Trung Kien (2015J, "Nghien cihi ddc diim nhiem trung dich bang d benh nhan xo gan co trudng tai Benh vi?n Da khoa Trung uong Can Tho", Tgp chi YDuge hgc Cdn Tha, 2,U. 7-13.
6. Dooley S. James, et al (2011), Sherlock's Diseases of the liver and biliary system 12th, Wiley Blackwell publishing Ltd.
7. Fayad Leonardo (2015), "The performance of prognostic models as predictors of mortality in patients with acute decompensation of cirrhosis". Annals of Hepatology, 14(1), pp. 83-92.
8. Sara Blasco-Algora, et al (2015), "Acute-on-chronic liver failure: Pathogenesis, prognostic factors and management". World Journal of Gastroenterology, 21(42), pp.
12125-12140.
9. Silva J. Mario, et al (2015), "Ten years of hospital admissions for liver cirrhosis m PoTtagal", European Journal of Gastroenterology and Hepatology, 27, pp. 1320-1326.
(Ngdy nhdn bai: 16/11/2017- Ngdy duyet ddng: 09/01/2018)
