Y Hpc TP. Hb Chi Minh * Phu Ban Tap 19 * So 5 '^ 2015 N g h i e n cuu Y hoc
THANG DIEM GLASGOW BLATCHFORD CAI TIEN TRONG D l / E>OAN KET c u e LAM SANG 6 BENH NHAN XUAT HUYET TIEU HOA TREN
Qudch Tien Phong*, Quach Trong DUc*, Le Thdnh Ly**
T O M T A T
Ma dam Xuai huyei tieu hoa (XHTH) trin Id mgi cap cieu ngi, ngemi khoa (huang ^ , ph&n Bng nguy ca ngay khi tiip nhdn benh nhdn (BN) XHTH tren Id rat quan trgng dot vai cdc bdc si lam sdng, xdc dinh gid tri thang diBn Glasgow Bhitchfard cdi tieh (Bhttchprd CT) so vai tiiang dian Glasgow Blaichford ddy dii (Bhichford DD) va thang diem Rockall ldm sdng (RoeMll LS) trong die dodn kit cue ldm sdng d BN XHTH trin c^ vdo vien.
Muc tieu: So sdnh gid tri dia thang diem Blaichford CT zxri ihang diem Blaichford DD, Rockall LS trong du dodn yiu cau can ihiep y khoa (CTYK). nguy ca tu vong vd xuai huyH tdi phdt (TV vd XHTP) trong thai gian namvKn.
Phuang phdp: Mot nghien cieu dodn hi tiin dm khdo sdt cdc BN hi XHTH tren ca'p zmo khoa ngi tiiu hoa, Benh vien Chg Ray tie 10/2014 deh 04/2015. Tinh dian so cdc thang diem Blaichford CT, Blaichford DD, Rockall LSvdso sdnh dien tich duai duang cong ROC (AUC) dexdc dinh gid tri du dodn dta cdc ihang dian.
Kei (jud: Co 196 BN XHTH tren du tieu diuah dugc Idido sdi. tuoi irung bink 54,58 ± 16,46, ty le namlnu:2,32!l, ty le xuat huyei idi phat ti-ong hinh viin (BV):2,6%, ty li tie vong trong BV: 7,7%, yeu cau can CTYK 59,7% (truyen mdu 42,3%, can thiep ngi soi 31,6%. phdu thuat 0,5%). Ve du dodn yeu rau i^n CTYK:
Thang dian Blaichjixrd CT (AUC=0,806) co gid tii tieang duang vai ihang dian Blatdifbrd DD (AUC=0,817, p=0,365 )vat6l han thang diim Rockall LS (AUC=0,651, pO.OOOl). Ve du dodn nguy ca tie zxmg vd xudi huyii tdi phdl trong thai gian nam vien: Thang dian Blaichford CT (AUC=0,74) (^ gid tri tiecmg ducmg nhu cdc thang dian Blate^fbrd DD (AUC=0,765, p=0.084) vd ihang diem Rockall LS (AUC=0,769, p=0.538).
KH luan: Thang dian Blatchfbrd cdi tiin cdng toi nhu cdc thang dian dang sie dung trong du dodn kB cue lam sang a BN XHTH tren vd co the dp dung rgng rdi trong thiec hdnh ldm sdng dqc biet trong du dodn yeu cau can CTYK
Tit khoa: Xuoi huyii tieu hoa trin, thang dian Glasgow Blatchfjrd cai tieh, thang dian Glasgow Blate^ifixrd day dil, thang dian Rockall lam sang can thiep y Idwa, tie vong vd xuai huyei tdi phdt trong binh viin.
ABSTRACT
A MODIFIED GLASGOW BLATCHFORD SCORE IN PREDICTING CLINICAL OUTCOMES OF PATIENTS WTTH UPPER GASTROINTESTINAL BLEEDING
Quadi Tien Phong, Quach Trong Due, Le TharJi Ly
* Y Hoc TP. Ho Chi Minh * Supplement of Vol. 19 - No 5 - 2015:9 -17 Back grcmnd: Uppa gastrointestinal bleeding (UGIB) zoas an common intanal and external emergency, risk stratification when receiving patients with UGIB is very essential for clinidans, identified valuation a modified Glasgow Blaichford score (mGBS) by compared vnth full Glasgow Blaichford score (GBS) and clinical Rcxicall score (cRS) in predicting dinical outcomes cf patients presenting wiih UGIB.
* Bo mon Npi - D^i Hpc Y Dugc Tp Ho Chi Minh, •* Trudng khoa tieu hoa Benh vien Chg Riy Tdc gtd lien lac. BS Quach Tien Phong DT: 01668903525 Enmil: [email protected]
Chuyen D e Npi Soi Tieu Hoa
N g h i e n cuu Y hpc Y H p c TP. H o Chi Minh * Phu Ban Tap 19 * So 5 * 2015
Objective: To compare tlie perfonnance of tlie niGBS with full GBS, cRS in prcdiding required medical intervention, ris/c cf mortality and re-bleeding during hospitalization.
MeGwd: A prospediue cohort study investigating all patients presenting zmth UGIB at internal gastroenterology deparmcnt in Cho Ray Hospiialfrom 09/2014 io 04/2015. We calculated mGBS. full GBS, cRS and compared the area under ihe ROC curve io determine the predict value ofthe scores.
Results: One hunderd and ninety-six patients wae included. Median age of 54^8+16,46, male/female ratio of 23211. The re-bleeding and mortdity rale during hospitalization was 2,6% and 7,7%, the inadence of medical interventions was as follow: transfusion 42,3%, endoscopic therapy 31,6% and surgery 0,5%, respectively. About predicting requued medical intervention: the mGBS (AUC=0.806) performed as vxll as ihe full GBS (AUC=0.817, p=0365) and outperformed the cRS (AUC=0.651, p<0.0001). About predicting the risk of mortality and re-bleeding during hospitalization: the mGBS (AUC=0.74) performed as well as the full GBS (AUC=0.765, p=0.084) and cRS (AUC=0.769, p=0.538).
Ccmclusicm: The mGBS performed as xodl as current scoring systems for prediction of dinical outcomes in patients presenting zoith UGIB and zvcmld widely applicable in dinical practice, espedally prediding required medical interventions.
Key words: Uppa gastrointestinal bleeding, modified Glasgcrw Blaichford score, full Glasgow Blatchfjrd scare, clinical Rockall score, medical interventions, moriality and re-bleeding during hospitalization.
D A T V A N D E
Xuat huyet tieu hoa (XHTH) la tinh trang cap cuu noi, ngogi khoa gap pho bien 6 cac phong cap cuu, ian suat moi mic khoang 36 -160AO0O00 ngucri nhap vien moi nam \'a thuong de dpa tinh mang ngucri benh voi ty le tii vong cao 3,5- 14%< •". Trong do XHTH tren chiern 80%, gap 4 Ian so voi xuat huyet tieu hoa duoi va ty le nay CO xu huong tang a cac nuoc dang phat trien.
Phan fang benh nhan(BN) XHTH tren vao vien la viec rat quan trpng trong chien lupc dieu tri cua cac bac si lam sang, giup dua ra phuong phap dieu tri toi uu de ciru song BN ldp thtri vol chi phi cham soc y te thich hgp nhat, dac biet la doi voi cac nuoc dang phat trien"°>.Cac huong dan dong thuan quoc te da khuyen cao nen sii dung cac thang diem tien lupng co gia tri giiip dua ra quyet dinh dieu tri ban dau thich hpp va cap dp cham soc hpp lyO "i*). Trong so cac tiiang diem thi ihang diem BlatdifordP' va Rockallt^^ la CO nhieu nghien cuu chiing minh nen dupc chap nhan va sir dimg rong rai T\hat<^°>. Tuy nhien, ca hsd thang diem deu bao gom nhieu thong so, kho nho \'a CO mpt so yeu to chii quan co dinh nghia khong ro rang nen van khong dupc cac bac si Iam sang ap dung thuong quy^-a^i. Gan day
thang diem Blatdiford cai tien (BlatchfordCI) chi bao gom cac yeii to dinh lupng khach quan cua thang diem Blatchford day dii (BlatchfordEJD) (mach, huyet ap, BUN, hemoglobin) nguoi ta nhan thay cung tot nhu cac thang diem dang dirpc sir dungf , boi viec loai bo cac yeii to chii quan nen Ihang diem BlatchfordCT ngan gpn hon va hy vpng se de dang dupc ap dung tren lam sang hon. Do do chung toi tien hanh nghien cuu nay nham xac dinh gia tri thang diem BlatchfordCT so voi thang diem BlatchfordDD va thang diein Rockall lam sang (Rockall LS) trong d u doan ket cue Iam sang 6 BN XHTH tren cap vao vien.
Muc tieu nghien ctru
So sanh gia tri cua thang diem BlatchfordCT voi cac thang diem BlatchfordDD, Rockall LS ve du doan yeu cau din can thiep y khoa (CTYIQ, tif vong (TV) va xuat huyet tai phat (XHTP) trong ihoi gjan nam vien 6 BN XHTH tren cap.
Phuong phap nghien cuu Thiei ke'nghien c«w
Chung toi fliiic hien nghien cihi doan h? tien cuu doi voi tat ca cac BN hi XHTH tren vao b?nh vien (BV) Chp Ray tir 10/2014 - 04/2015.
10 Chuyen D e N o i Soi Ti^u H o a
Y H p c T P . H b C h i M i n h * P h u Ban T a p 19 * So 5 * 2015 N g h i e n ciru Y hpc
Phumig phdp chon inau
Chpn mau lien tiep khong xac suat TUu chuan chon benh
- Tuoi > IStuoi
- Tat ca BN XHTH tren vao khoa tieu hoa BV Chp Ray trong thai gian nghien cuu voi cac trieu chung cua XHTH tren (non ra mau do, mau den, tieu phan den, tieu mau do voi thong miii da day CO mau).
- Dong y tham gja nghien cuu Tieu chuan loai trii
- Benh nhan bi XETTH tren da dupc hoi sire hoac can fhiep roi 6 tuyen truoc chuyen vao BV Chp Riy (sai ket qua sinh hieu liic nhap vien).
- Benh nhan co tien su bi XHTH tren tai phat trong thoi gian lay mau nghien cuu.
- Benh nhan khong dong y npi soi.
- Benh nhan khong dupc npi soi trong 24 gio dau.
EHnh nghia cdc bien so Kei cue ldm sdng
Can ttiiep y khoa, ttr vong va XHTP trong thoi gian nam vien.
Can thiip y Idwa
Truyen mau, chi dinh npi soi can tiiiep, can thiep mach hay can thiep phau thuat.
Truyin mdu
Quyet dinh truyen mau dupc xac dinh boi cac bac si dieu tri thuong chung toi truyen mau khi BN XHTH tren co Hb < 10 g/dL hoac co dau hi#u roi loan huyet dpng mac du da hoi sue bu d}ch. Doi vdi cac truong hpp XHTH do tang ap luc finh mach cira (TALTMQ duy tri Hemoglobin (Hb) tir 7-8 g/dL, con nhung tniong hpp XHTH khong do TALTMC duy tri Hb > 7-8 g/dL, neu eo benh mach vanh kem theo thi muc tieu Hb duy tri khoang 10 g/dL.
Oil dinh noi soi can ihiep
Tuy quyet dinh oia bac a npi soi va timg truong hpp oi tiie^ doi voi XHTH do loet da day
ta trang (DD-TT) thi can thiep theo phan dp Forrest (IA, IB, HA, HB). Con XHTH do vo dan finh mach tiiuc quan (VDTMTQ) tiiuong can thiep that TMTQ khi thay TMTQ gian lon (dp ILHI) CO dau hieu chay mau.
Xuai huyei tdi phdt
Dupc dinh nghia khi BN XHTH da dupc dieu tri on dinh vai gio hay vai ngay sau dot nhien non ra mau, tieu mau Iai sau khi tieu phan vang va/hoac co dau hieu toan than ciia XHTH nhu: mach > 110 lan/phiit, huyet ap tam thu < 90 mmHg (sau khi on dinh huyet dpng), giam nong dp Hb > 20 g/L (hoac giam dung tich hong cau >
6%) hoac tang Hb < 10 g/L (hoac tang dung tich hong cau < 3%) mac dii da truyen hon 2 don vi mau trong 24 gio sau khi npi soi dieu tri va phai dupe chaii doan qua npi soi lai thay xuat huyet tir vi tri xuat huyet ban dau.
Benh ngi khoa di kem
Suy tim, benh gan hay suy gan, benh mach vanh, suy than, ung thu di can.
Suy iim
Dau hieu lam sang oia suy tim sung huyet mat bii, roi loan chuc nang tam truong tren sieu am tim hoac phan suat tong mau ciia < 45%.
Both gan hay suy gan
Hinh anh dac trung oia xo gan hoac b^nh gan da dupc biet den voi cac dau hieu lam sang oia hpi chiing suy is bao gan va hpi chiing tang ap iuc tmh mach cua.
Both mqdi vdnh
Dau tii3t nguc dien hinh voi dien tam do co dau hieu thieu mau cue bp, bat thuong test gang sue hoae chup mach vanh bat thuong.
Suy than
Khi dp Ipc cau than < 60 ml/phiit Tieu phan den
Dupc danh gia tiiy vao quyet dinh eua bac si lam sang.
Chuyen D e N p i Soi T i e u Hoa
N g h i e n ciiu Y hpc Y Hpc T P . Ho Chi Minh * Phu Ban Tap 19 * So 5 * 2015
Phan tich thong ke
So lieu sau khi da thu tiiap se duoc ma hoa va nhap vao chuong trinh quan li va phan tich dii Ueu SPSS20.0, SigmaPlotlS.O. Danh gia dp ehinh xac oia tiiang diem Blatchford CT, Blatchford DD va Rockall LS trong du doan yeu cau can CTYK, tii vong va XHTP trong BV bang dien tich duoi duong cong ROC (AUC). Sii dung phep kiem chi binh phuong de so sanh su khac nhau giiia eac thang diem.
KET QUA
Trong thoi gian til 09/2014 den 04/2015, tai khoa Npi tieu hoa benh vien Chp Riy, chung toi ghi nhan c6 1232 BN vao vien vi XHTH ti'en, trong do CO 196 truong hpp thoa tieu chuan chpn mau dupc dua vao nghien ciiu. Ket qua nghien Cliu ghi nhan: Ve dac diem chung oia dan so nghien ciiu dupe trinh bay trong bang 1. Ve ket qua npi soi thue quan da day ta trang fhi ta nhan thay nguyen nhan cua XHTH tren ehu yeu van la do VDTMTQ 40,8% va viem loet DD-TT 37,8%
(Bang 2). Ve thang diem Blatchford CT thi diem so trung binh la 7,76 ± 3,85 diem, tiiap nhat la 0 diem va cao nhat ia 15 diem va doi voi gia tri du doan ve yeu cku can CTYK (truyen mau, chi dinh npi soi can thiep, phau thuat): thang diem Blatchford CT eo dien tich duoi duong cong ROC AUC=0,806 (KTC 95%: 0,745-0,866, p<0,001) va voi die'm dt >8 (dp nhay la 75,32% va dp ehuyen la 70,1%) tiii BN eo nguy eo can CIYK cao hon gap 9 Ian so voi diem so Blatchford CT<8 (OR=9,42, p<0,0001). Doi voi dy doan nguy CO TV va XHTP trong thoi gitm nam vien: thang diem Blatchford CT co dien tich duoi duong cong ROC AUC=0,740 (KTC95%: 0,616-0,863, pO,0001) voi diem cat 12 (dp nhay la 50% va dp chuyen la 89,8%) thi benh nhan co nguy co cao TV va XHTP ti^Dng BV. Khi so sanh ttiang diem Blatchford CT voi thang diem Blatchford DD va Rockall LS ta nhan thay: Ve dix doan yeu cau can CTYK: Thang diem Blatchford CT (AUC=0,806) CO gia tri tuong duong nhu thang diem Blatchford DD (AUC=0,81, p=0,365) va tot hon tiiang diem Rockall LS (AUC=0,65, p<0,001)
(Bang 3). Nhung khi xet gia trj dia cac tiiang diem tien lupng doi voi du doan nguy co npi soi can thiep tinh rieng fhi cac ttiang diem cho thay CO gia tri khong cao bang so voi du doan yeu cau can CTYK noi ehung (Bang 4).Ve du doan nguy eo TV va XHTP trong thcd gian n^m vien: Thang diem Blatchford CT (AUC=0,74) co gia tri hiong duong voi cac thang diem Blatchford DD (AUC=0,765, p=0,084) va RockaU LS (AUC=0,769, p=0,538) (bang 5).
Bdng 1: Dac diem ciia dan so nghien deu T6ng 56 BN
Tu6i Gifti
BNKdik^m
"nnh trgng liic nh|p vi§n
CTYK
XHTP trong BV TV trong BV
196 54,58 ± 16,46 Nam
NU C6 Klidng
Ngit Tieu phSn den
Tnjyen mSu Noi SOI can thl#p
Phiu thu$t
137(69,9%) 59(X,1%) 138(70,4%) 58(29,6%) 7(3,6%) 165(84,2%)
83(42,3%) 62(31,6%) 1(0,5%) 5(2,6%) 15(7,7%) Bang 2: Ddc diem zx ngi soi thuc qudn dq ti-dng a BN XHTH ti-in
ddytd
D$c dilm vd noi soi VDT«/ITQ LoStD[3-TT Vi§m DD-TT Ungthu' RSch ISm vi DTMTQ+LoSt DD-TT
Khdng xac dinh Lo^t Vmfc quan Nguyfin nhSn kh^c
T6ng Cong
Sdiipg^g 80 52 22 12 8 7 7 4 4 196
Til|(%) 40,8 26,6 11,2 6.1 4,1 3,6 3,6 2,0 2,0 100,0 Bang 3: Dien tidi dudi duang cong ROC c thang diehi ve yeu mu can CTYK
Tiiang dilm mGBS
GBS cRS
AUC 0,806 0,817 0,651
KTC95%
0,760,87 0,760,88 0,57-0,73
P
<0,001
<0,001
<0,001 So siinh mQBS(p) 0,37
-
<0,001
12 Chuyen De Noi Soi Tieu Hoa
Y H p c TP. Ho Chi Minh * Phu Ban Tap 19 * So 5 * 2015 N g h i e n c u u Y hpc
Bieum I: Duang cong ROC \'eyeucdiicdn CTYK Bdng4: Dien iich dudi duong cong ROC dia cdc thang diem ve yeu
Tttang mGBS GBS cRS
AUC 0,593 0,643 0,688
raw can ngi soi can thiep Thip nhit
0,510 0,563 0,614
Cao nhdt 0,676 0,722 0,763
P
<0,036
<0,01
<0,001
Biai do 2: Dudng cong ROC zx nguy ca can ngi soi can thiep
Bdng 5: Dien tich dudi dudng cong ROC ciia cdc thang dian ve nguy caTVvd XHTP tiong BV
Ttiang dilfn mGBS
GBS cRS
AUC 0,740 0,766 0.769
KTC95%
0,62-0,86 0,65-0,88 0,67-0,87
P
<0,001
<0,001
<0,001 So sdnh mGBS(p) 0,084 0,538 BAN LUAN
D^c diem chung cua dan so nghien cuu Tuoi
XHTH tren eo the gap it mpi lua tuoi. Trong
nghien cuu ciia chiing toi, BN XHTH tren co tuoi trung binh la 54,58 + 16,46 hioi, ttiap nhat la 18 tuoi va eao nhat la 91 tuoi, nhom tuoi < 60 tuoi chiem da so voi ti le 63,8%. Tuoi trung binh tiong nghien cuu cua chiing toi khong co su khac biet so voi nghien cuu trong nuoc nhung fhap hon mpt so nghien cuu ngoai nuoe. Su khae nhau nay co the do su chenh lech ve tuoi thp tnmg binh 6 cac nuoe dang phat trien va cac nuoe da phat trien.
Gidi
XHTH tren xay ra 6 ea nam va nu, tiong do nam chiem uu the hon. Theo kef qua nghien ciru ciia chiing toi, BN nam bi XHTH tien cao hon 2,32 lan. Dieu nay phii hpp voi y van va cae nghien cihi trong va ngoai nuoctii'Sii^. Khi xel moi lien quan giua tuoi, gioi voi cac bien so ket cue lam sang, chiing toi ghi nhan khong eo su lien quan.
Benh noi khoa (BNK) di kem
Trong nghien cuu ciia chiing toi, BN co BNK di kem chiem ti le 70,4%; ti le nay gan bang voi nghien ciiu etia tac gia Nguyen Thanh Thiiy thue hien tai benh vien Chp ray va cao hon so voi cac tac gia lam tai eae benh vien khac trong nudd^-^^. Dieu nay co the do benh vien Chp Riy la benh vien tuyen cuoi nen BN XHTH tren co BNK di kem chiem ti le cao. Mae khae, ket qua nghien euu ciia chiing toi nhan thay co su lien quan co y nghia thong ke giiia BNK di kem voi yeu eau can CTYK (OR=2,93; p=0,001). Dieu nay phii hpp voi y van va cac nghien ciiu trong va ngoai nuoc la BN XHTH ti-en bi cung luc nhieu BNK la mot trong nhiing yeu to du doan nguy co tir vong cao.
Tieu phdn den
La trieu ehiing thucmg gap nhat 6 BN XHTH tren. Theo ket qua nghien euu cua chiing toi, BN XHTH tren co trieu chiing tieu phan den la 84,2%. Ti le nay thay doi khac nhau tiiy nghien ciiu'^^-^"'^. Nhin chung, trieu chung tieu phan den chiem ti Ie cao > 50%.
Chuyen D e Ng i Soi Tieu Hoa
Nghien cuu Y hpc Y Hpc TP. H'6 Chi Minh * Phu Ban Tap 19 * So 5 * 2015
Ngat
BN XHTH tien co trieu chung ngat dupc bao cao tiong cac nghien oiu hay tiong y van chiem ti le tiiap. Trieu chiing ngat trong nghien ciiu oia chiing toi chiem ti le 3,6%.
Dac diem npi soi thuc quan da day ta trang Npi soi la tieu chuan vang giiip xac dinh nguyen nhan XHTH tren, vi tri chay mau va can thiep cam mau neu co chi dinh. Theo ghi nhan ket qua npi soi tiong nghien cuu ciia chiing toi:
CO 44,4% BN bi dan tirih mach tiiuc quan; 26,6%
BN bi loet DD-TT, 11,2 % BN bi viem DD-TT xuat huyet va con lai la do cac nguyen nhan khac. Ti I? nay thay doi khac nhau tuy nghien Cliu tai cac trung tam khac nhau, rttiung nhin chung nguyen nhan hang dau a i a XHTH tien van la viem loet DD-TT va VDTMTQ.
Dac diem ve can thiep y khoa
Biai do 3: Duong cong ROC ve nguy ca tie vong vd XHTP ti-ong BV
Truyen mdu
Theo ket qua nghien ciiu ciia chiing toi, so lupng BN dupc truyen mau la 83A96 chiem ti le 42,3%. Theo nghien a i u oia Nguyen Thanh Thuy<''iJ, tiii so BN can huyen mau la 103/193, chiem ti le 53,37%. BN dupe truyen mau trong nghien cuu oia Dao Xuan Lam'^'la 41%, Tran Kinh Thanhi'^Ia 45,14%, Cheng va cs'^) la 32% va Chandra") la 34,2%. Co su khac biet ve ehi dinh truyen mau trong cae nghien eiiu khac nhau co the la do quyet dinh truyen mau 6 BN XHTH
tien tiiy thupc nhieu vao quyet dinh cua bac sT lam sang de duy tri Hb muc tieu va dieu kien ciia timg trung tam cu the", nhung nhin chung ti 1| BN XHTH tren cap can truyen mau chiem ti 1?
cao hon 1/3 cac tnrong hpp.
Nqi soi can thiep
BN XHTH tien dupc npi soi can thiep tiong nghien ciiu cua chiing toi la 62/196 benh nhan chiem ti le 31,6% cao hon voi ket qua nghien ctiu oia eac tac gia Nguyen Thanh Thuy("'(17,3%), Tran Kinh Thanh"^ (29,96%), Cheng va csc^)(24%) va Hyett<^' (25,9%) nhung tiiap hon so voi tac gia Robeil: V. Bryant va cs^^Ha 40,3%, nghien cihi aia Dao Xuan Lam'^' la 42,4%. Nhu vay co sp khac biet ve nhu cau npi soi can thiep a cac nghien Cliu khac nhau co the do dan so chpn mau khac nhau va phuong phap xtj tri khae nhau va tiiy dieu kien npi soi can thiep o cac trung tam cti tiie.
Gia tri oia cac thang diem tien lupng tiong d p doan chi dinh npi soi ean thiep 6 BN XHTH tien: Trong nghien ctiu cita chiing toi ghi nhan thang diem Rockall LS co dien tich dudi du6ng cong eiia noi soi ean thiep (AUC=0,688, KTC 95%:0,614-0,763, P<0,0001) va voi diem cat 3 (dp nhgy 87,1%, dp dac hieu 54,5%) BN co nguy ca cao can can thiep npi soi. Thang diem Blatchford DD CO dien tich duoi duong eong a i a npi soi can ttiiep (AUC=0,643, KTC 95%:0,563-0,722, P<0,01) va voi diem dt 9 (dp nhay 82,3%, dp dac hi|u 44%) BN CO nguy co cao can can thifp npi soi va thang diem Blatchford CT co dien ti'ch duoi duong cong cua npi soi can thifp (AUC=0,593, KIC 95%:0,510-0,676, P<0,036),) va voi diem cat 8 (dp nhay 61,3%, dp dac hifu 52,2%) BN co nguy CO cao. Theo mpt nghien euu a i a tac gia Robert V. Bryant va csf> tren 888 benh nhan XHTH tren vao vien d Uc ve nguy co can can thiep y khoa ding nhan thay co 286 benh nhan can npi soi can thiep cfiiem ti If 40,3% va dien ti'ch dudi dudng eong ROC ciia thanh diem Blatchford DD (AUC=0,76, P<0,Oai) va ldn hon thang diem Rockall LS (AUC=0,66, P<0,001). Con ttieo nghien oiu da trung tam cua tac gia Quadi
14 Chuyen D e Npi Soi Tieu Hoa
Y Hpc TP. Ho Chi Minh * Phu Ban Tap 19 * So 5 * 2015 N g h i e n ciiu Y hpc
Trpng Diic va csf -> tien 395 BN XHTH tien cap khong do TALTMC tiii thang diem Blatchford CT (AUC=0,612) tuong duong vdi Blatchford DD (AUC=0,608, pH3,55) va Rockall LS (AUC=0,539).
Phdu thuat can thiep
Theo ket qua nghien ctiu cua chiing toi BN XHTH tren dupe phau tiiuat can thiep la 0,5%.
Nhin chung, BN XHTH tren dupc phau thuat ean thiep chiem ti If tinap tir 0 - 2 % tiiay doi tiiy timg nghien ciiu khac nhau.
Dac diem ve dien tien benh Tile tii:vcmg
Mgc dil cd nhieu tien bp tiong ehan doan va dieu tri XHTH tien nhung ti le tii vong gan nhu khong thay doi tiong cac Ihap nien qua. Theo ket qua nghien ciiu eiia ehiing toi, trong 196 BN XHTH tren cd 176 BN dupc dieu tri on dinh xuat vien (ehiem ti If 89,7%) va cd 15 BN tu vong (chiem ti If 7,7%). Trong so nhiing BN XTTIH tren tir vong thi do nguyen nhan XTTIH nang la 5A5 trudng hpp chi chiem ti If 33,3%, cdn lai 66,7% BN tli vong la do cae nguyen nhan khae.
Tl le tu vong trong nghien a i u ciia chung toi cao hon mpt so nhien ciiu ciia cac tac gia khac cd the la do tiong nghien cuu a i a chting toi BN XHTH tien do VDTMTQ chiem ti le cao (44,4%) va cd da so BN cd BNK di kem (70,4%).
Xuat huyei tdi phdt
Ti If XHTP d BN XHTH tien trong nghien ctiu chiing toi (2,6%) gan tuong duong vdi tac gja Nguyen Thanh Thiiy (2,5%) va thap hon so vdi mpt sd ket qua nghien ctiu oia mpt so tac gia khac<5''^i^. Deu nay cd ttie la do tieu ehi XHTP tiong nghien ciiu aia chiing toi va Nguyen Thanh Thuy chi xet tiong tiidi gian nam vifn (thdi gian theo doi ngin) tiong khi mpt so nghien eiiu khac tiii thdi gian theo ddi BN lau hon len den 30 ngay sau XHTH cap.
Thang diem glasgow blatchford CT so voi Ihang diem BlatchfordDD va Rockall LS
Phan tang nguy co BN XHTH tren Itic
nhap vifn la rat quan trong dd'i vdi cac bac si trong thuc hanh lam sang, vifc lam sao de d u doan BN XHTH tren cap vao vifn cd nguy co cao can CTYK hay tir vong va XHTP la can thiet de xir tri BN kip thdi va cd che dp cham sdc thich hpp. Cd rat nhieu thang diem (nhu thang diem Rockall, Glasgow Blatchford, AIMS65, Baylor, Cedar Sinai,...) da dupe cac nha khoa hpe tren the gidi nghien ciiu va dua ra de ap dung trong thtJC hanh Iam sang nham phan tang nguy eo BN XHTH tren cap mpt each nhanh va chinh xac nhat, Khi so sanh giiia cac thang diem trudc khi cd ket qua npi soi thi ngudi ta nhan thay thang diem Blatchford DD td ra uu the nhat trong vifc du doan ket a i c lam sang cua BN''"^' va theo hpi nghi dong thuan ctia Hpi Chau A Thai Binh Duong (2011) eiing khuyen cao nen sir dung nen sir dting thang diem Blatchford DD de danh gia nguy eo BN XHTH tren khdng do TALTMCf'^'. Mpt so nghien euu trong nudc cho thay thang diem thang diem BlatchfordDD va Rockall deu cd gia tri kha cao trong du doan ket cue lam sang cua BN XHTH tren<^-^^'^, nhung tren thirc hanh Iam sang cac thang diem tren van chua dupc cac bac si ap dung thudng quy vi khd ap dpng, cd nhieu thdng sd khd danh gia doi hdi can phai cd cac phuong tien ky thuat cao nhu may difn tim, sieu am, ndi soi,... Trong dieu kien y te ctia Vift Nam khi cac BV tuyen trung uong ludn qua tai, cdn cac BV tuyen dia phuong thi dieu kifn CO sd vat chat trang thiet bi y te cdn thieu thdn, nhat la doi vdi cac trung tam y te khdng ed dieu kien noi soi thi vifc sii dpng cac ttiang diem Hen Iupng ed gia tri de xac dinh BN cd nguy CO cao can CTYK hay tii vong la het stic quan trpng, thang diem BlatchfordCT td ra rat thich hpp trong thuc trang cua Viet Nam, ehi can cae XN thudng quy (mach, huyet ap, BUN va Hb) ciing d p doan ket cue lam sang etia BN XHTH tren rat tot. Qua nghien ciiu cua chiing tdi ghi nhan thang diem Blatchford CT (AUC=0,806) cd gia tri gan tuong duong nhu
Chuyen De Npi Soi Tieu Hoa
N g h i e n ctiu Y hpc Y Hpc TP. H b Chi M i n h * P h u Ban T a p 19 * So 5 * 2015
thang diem Blatchford DD (AUC=0,81, p=0,365) va vupt trpi hon thang diem Rockall LS (AUC=0,65, p<0,001) tirong du doan yeu cau can CTYK, trong du doan nguy co TV va XHTP tiong BV: Thang diem Blatchford CT (AUC=0,74) cd gia tri tuong duong vdi tiiang diem Blatchford DD (AUC=0,765,p=0,084) va thang diem Rockall LS (AUC=0,769,p=0,538).
Theo tae gia Cheng va csf^ cdng bo nam 2012 da nghien ciiu tren 197 benh nhan XHTH tren cap tai My nhan thay thang diem Blatchford CT cd gia tri eao trong vifc du doan ket cue lam sang vdi difn tich dudi dudng cong ROC la 0,85 (KTC 95%: 0,80-0,916, p<0,0001) ddi vdi yeu eau can CTYK va cd difn ti'ch dudi dudng cong ROC la 0,83 (KTC 95%: 0,73-0,94, p<0,0001) ddi vdi tien iupng nguy co TV va XHTP trong thdi gian nam vifn. Nhu vay nghien ciiu aia chting tdi ed ket qua tuong tu vdi tae gia Cheng cho thay thang diem Blatchford CT ed gia tri cao trong du doan ket cue Iam sang d bfnh nhan XHTH tren vao vifn vdi dien tich dudi dudng cong ROC > 0,8.
Cdn theo nghien ciiu da trung tam ctia tac gia Quach Trpng Diic va esC^' tren 395 BN XHTH tren khdng do TALTMC trong d u doan yeu eau can CTYK nhan thay thang diem Blatchford CT (AUC=0,707) cung cd gia tri tuong ducmg vdi thang diem Blatchford DD (AUC=0,708, p=0,87) va tdt hon ttiang diem Rockall LS (AUC=0,594, p<0,001). Nghien eiiu oia chting toi hon nghien ctiu a i a tac gia Quach Trgng Diic la tiiuc hien tren tat ca BN XHTH tren cap vao vifn do nguyen nhan TALTMC va khdng do TALTMC ndi chung, vifc phan biet nay doi vdi BN XHTH cap mdi vao vifn ddi khi rat khd khan va phai chd den ket qua npi soi mdi xac dinh chinh xac, m$t khae nghien ciiu cua chting tdi cung cho thay thang diem Blatchford CT cung td ra kha tot trong dir doan nguy co hi vong va XHTP doi vdi BN XHTH tien cap vao vien.
KET LUAN
Thang di^'m Blatohford CT cung tot nhu cac thang diem dang sir diing tiong du doan ket cue lam sang d BN XHTH tren cap d | c bift trong dp doan yeu cau can CTYK. Cd the ap dung rdng rai thang diem Blatchford CT tiong thuc hanh Iam sang, nhat la dd'i vdi cac BV tuyen co sd.
TAI LIEU THAM KHAO
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1 Blatchford O, Murray OR., Blatchford M (2000), "A nsk soDre to predict need k>r treatinent for uppergastroinlestuial haemorrhage". The Lancet, 356 (9238), pp. 1318-1321.
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4 Chandra S (2013), "AIMS65 score predicts short-temi mortality b u t not the need for m t ^ v e n t i o n m acute upper Gl bleeding".
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6 D a o Xuan Lam Tran Xuan Linh, Biu Nhu$n Quy, Tran Tii H o a n g YSi, (2010), TMhan xet thang d i « n Rockall vi Blatchford trong viec d a n h gia tien l u ^ n g benh nh3n xuat huyei ti§u h6a tren" Tap chi Khoa hpc tiiu h6a Viet Nam, 14 (2), pp. 8-14
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8 Hyett BH, Abougergj M S , Charpenher J. P., Kumar N. L, Brozovic S, et al. (2013)> T h e AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleedmg". Chstrointest Endosc. 77 (4), p p 551-7.
9 Kuipers EJ (2011), "Improved risk as-sessment in upper GI bleedmg" Gastrointest Endosc, 74 (6), pp. 1225-9.
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11. N g u y i n Thanh Thiiy (2014), "So sdnh Ihang dimi AIMS65 vA thmg diem Glasgow - Blatchford trong tien lumg benh nhan xuM km/Sl iiSu hda tren ~, Luan v a n thac sT y hoc Dai hpc Y Dmirc TP H o Chi MinK p p
12. Quach Trpng Diic D a o Hiiu Ngoi, E)inh C a o Minh va cs, (2015), "Gii tri cua thang di&n Blatchford sija doi ircRig xuat huyei tieu hoa tren cap khong d o tang a p Snh mach cua. ket qua nghien a h i doan fi? t a i ciiu da irung tam". TapyhgcTP Ho CfjiMmfi, 19 (1), p p . 263-268.
Chuyen D e Npi Soi Tieu Hoa
V Hpc TP. Ho Chi Minh -^ Phu Ban Tap 19 * Sd 5 * 2015 Nghien ciru Y hpc
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Tian Kim Thanh, Biii Huu Hoang (2011), Thang diem Rockall va Blatchford trong danh gia hen luong a benh nhan xual huyet tieu h6a do loet da day ta trang" Tap chi Khoa hoc tieu hda Viet Nam. II (4), pp. 35 • 38
Ngdy nhdn bdi bdo- 25/8/2025 Ngdy phdn bien nhqn xet bdi bdo: 26/8/2015 Ngdy bdi bdo dugc ddng. 02/10/2015
Chuyen De Npi Soi Tieu Hoa
