LY LUAN & THUG TIEN
TIM HIEU VE BENH LY:
CAC GlA THIET LIEN QUAN VA CACH CHAN DOAN DOI VOI DIEM KICH HOAT CON DAU MANG CO
•> NGUYiN TH! QUYNH MAI Hoc vi$n ThS thao Thuxmg Hai - Trung Qudc
Da phan cac ctfn dau c6, vai, liTng, dui deu lien quan den iioi chuTng cdn dau mang cd, mot loai trieu chuTng phuTc t^p cua dau cd. Trieu diuTng nay phan Idn gap d ngu'di gia va nhu'ng ngu'di u'a van dong (trong do co cac VOV). Qua lam sang, chung toi quan sat thay cdn dau mang tinh nguySn phat de hoi phuc, cdn dau mang tinh thuT phat tCr cac benh khac cung CO the dat du'dc tac diing tri hoan cao, dieu quan trong hdn het do la tam hieu biet cua ngu'di dieu trj doi vdi diem Icich hoat cdn dau mang cd va ho CO the tim thay mot each chuan xac hay khong diem kich hoat do. Nghien cuTu nay co the giup ich cho bac sy lam sang, dieu trj vien co nhan thuTc ro hdn khi muon suT dung nguyen ly diem kich hoat cdn dau mang cd de chu'a trj cho cac benh nhan dau co, vai, lu'ng, dui, nham nang cao hieu qua dieu trj.
1. Benh ly cua diem kich hoat ctfn dau mang cd
1.1 NhS^n thitc ve nto hpc vd gidi phau benh ly
Mang CO ve mat lam sang la mpt diem ben ngoai khac tiep xuc voi nhiing not dau hinh bo soi, an len hogc dam kim vao cac not nay se xuat hien hien tuong co co va cam nhan dugc nhiic, truong, dau circ ki m?nh me. Gan day, cac nha khoa hoc Trung Quoc da phuc che dugfc diem kich ho^t con dau mang CO man tinh, quan sat tiieo mat cat dpc duoi quang kinh thay duoc cac not dau cua diem kich hoat hoan toan giong voi gia thuyet ve
hinh thai diem kich hoat. Xet theo phuong dien hinh thai mo thi loai diem kich ho^t sgi co to nay la mpt dam cac not co quap soi to co hinh thoi CO dauva duoi noi tiep tap hpp voi nhau. Duoi dien kinh, ben trong cac not CO quap nay xuat hien bien dang hinh lap the va hien tupng giam nhan ho^c di chuyen nhan, dong thoi CO di?n vi tu phat (SEA) tan so cao khac thuong va co dien vi dang soi nho voi dien ap thap khi kich thich co, chiing to hoat hoa diem kich ho?it la mpt loai cua hien tupng benh li.
Diem kich hoat con dau la mpt the phuc hpp, tiic la not kich hoat
nam tren bung co, goi la diem kich hoat trung uong, tir do lien ket vai CO bap va phan noi co voi gan, hay nhung cho bam cua xuong ciing CO the xuat hien thay doi mang tinh benh ly, dupe gpi la kich boat diem ciia cac diem bam, Tu do, kich hoat diem ciia mpt co se dupe chia thanh 2 loai la kich hoat ^ e m trung uong va kich ho^t diem ciia cac diem bam. Kich boat diem cua cac diem bam thong thuong tiiuoc viem mang bao gan. Trong cong tac lam sang, kich hoat diem cua cac 4 e m bam dien hinh nhu sung mang bao gan va viem mang bao gan hep, khi tien hanh tri lieu, trir nhimg cho nay ra, con phai xem xet den dieu tri kich hoat di^m trung uong nam tren bung co. Ngupc lai, khi tien hanh dieu tri diem kich boat trung uong, doi luc phai xem xet den dieu tri kich hoat diem cua cac diem bam.
1.2 Nhan thwc ve sinh ly benh ly
Nghien ciru ve diem kich hoat con dau tai nhung nam 70 cua the ky truoc da phat hien trong soi co to cua diem kich hoat xuat hien dien vi tu phat voi tan suat cao, hon niia, thi nghiem tren cac not CO ciia xac nguoi va not diem kich boat CO cua loai cho quan sat thay CO cac not co quap cua soi co to.
Can cir tren trieu chiing lam sang, Simon va cpng sir suy doan ^ ^ m noi than kmh co trong not cua diem ^
kich hoat khi a trang thai imh co the xuat bi^n Acetylcholine tang cao that thudng. Sau do, thong qua tiem Enzim ho^t hoa khang Acetylcholine vao cue bp co b%) da phyc che l^i dupe hien tupng diem kich ho^t CO bSp tuong tu, do do co gia thuyet Acetylcholine doan cuoi ciia bM van dpng tang trao ra ngoai.
Gan day, thong qua phuong phap do di?n CO tren diem kich boat mo hinh dpng vat phat hi?n: trong sgi CO to diem kich hoat xuat hi?n rat ro dien vi tir phat tan suat cao voi hinh thai buoc song khac thuong, khi tac dyng kich thich ben ngoai khien CO the xuat hien phan xa nguoc lai, nhe hon, soi co to khoe manh thong thuong xuat hien dien vi dien co cao, thoi gian n g ^ nhung day dac, trong khi do spi to co cua diem kich boat lai xuat hien song spi mong dien vi thap, thai gian keo dai va day d&c, tang them khang dinh cho gi^ thuyet duoi t r ^ g thai tinh simg truoc cua cho noi than kinh co co lupng Acetylcholine lien tuc trao ra ngoai. He khi co xung dpng than kinh truyen den, thi doan cuoi cua tiian kinh da kh6ng con dO giiip spi CO CO bop, lupng Acetylcholine can thiet duoc dieu ti^t vao khe giua cac diem noi than kinh co.
2. Cac gid thi^t lien quan ve benh ly diem kich hoat ctfn dau mang ctf
2.1 Gia thih tong thi Gia thiet nay cho rang ton thuong hay m?t moi qua do cua co bap se dan den mat hieu lye chirc nang ban van dpng, giai phong lupng Ion Acetylcholin, kich hogt thu the Acetylcholin mang sau spi itiianh, san sinh so lupng Ion ban van dpng c6 dien vi yeu va duy tri su phan cue cua mang te 20 IT^chlThlthaosAa^U
bao CO, thuc day mang co tuong giai phong phan Ion ion Canxi, anh huong den eo bop lien tuc spi CO to, dSn den dot co co ngan va truang ly:c co tang, hinh thanh cac not truong cang ma chiing ta c6 the so thSy. Su CO bop Hen tyc cua co bap khien xuat hi?n thieu mau cue bp va trang thai trao doi chat cue bp cao, cuoi cung dan den thieu hut san sinh nang lupng trao doi va ton thuong mo; ton thuong mo 1^ lam giai phong 5-Hydroxytryptamine, Amine mo vaBradykinin, cac loai vat chat nay tang nhanh thieu mau cue bp, truyen den than kinh gay ra con dau diem kich hoat, anh huong than kinh giao cam xuat hien trieu chiing giao cam eye bp, boat boa than kinh giao cam eye bp kich thich giai phong lupng Ion Acetylcholine, hinh thanh nen mpt vong tuan hoan ac tinh luan hoi.
2.2 Gia thiet thoi ccr phdng di^n
Do phat hi$n trong diem kich hoat CO 2 thanh phan di$n vi boat dpng tu chii- phan thii nhat la dien vi thap keo dai lien tuc, bien dp song vao khoang 10-80mV; phan thii hai bat dau la nhiing di^n vi tieu cue kep mang gia tri am, bien dp song vao khodng 100-600mV:
Co ket qua cho rang dien vi boat dong voi bien dp song cao la dac trung cua diem kich boat, nhung cung CO y kien lai cho rang di^n vi cao lai la mpt dang phong di^n cua thoi CO, dgng phong di?n cua tiioi CO nay la do kich thich hung phan khong binh thuong cua giao c ^ than kinh k h i ^ spi co to co bop ma thanh. Gia thiet nay giai tiiich dupe benh nhan eo diem kich boat con dau mang co ngoai dau cae vung
lan can, con kem theo tri$u chiing phan img thib kinh tu chit.
2.3 Gia thiet rSi lo^n chitc nang ban van dong than kinh ca
Gia tiiiet nay cho rang chiic nang bdn van dpng trong di^m kich boat tren mang co bi roi loan, do do xuathi ?n them rat nhi eudiemobenh vol hang lo^t diem kich boat. Moi mot (£em 6 b?nh bao gom 2 phan la cam giac va van dpng: tiianh phan cam giac dupe xem la "diem man cam nho", trong khi do tiianh phan van dpng lai duoc xem la "fiem boat dpng nh6" Diim 6 b$nh man cam se gay nen dau nhiic, dau cac vimg lan can, phan img co nit cue bp cua CO hoac kich thich nh^y cam den spi day than kinh, Cdc diem nho nay so it phan bo tai hau het co bap tren toan co the, nhung nhieu nhat van la tap trung 6 khu v\rc cua ban van dpng. 6 diem hog,t dfing nho chiing ta co the sii dung ifien CO do ghi chep lai thay doi dien vi tu phat, nhung loai dien vi nay khac voi don vi v | n dpng binh thuong is cho no xuat hien di?n the duong truoc. Hon niia, dien vi nay khong xuat hien o khu thupc giai tmong Cling. Khi cham kim vao khu viic dien vi nay, se san sinh hi?n tuong dac tnmg la phan img co riit cue bO diem kich hpat,
2.4 Gia thik sff hoa vit seo mo Cff
Vao khoang the ky 20, khi cac nha khoa hpc Dire tien hanh kiem tra tren mo co cua cac benh nhan eo trieu chimg dau co miic do nang phat hien trong co bap co cac mo seo, sau nay cho rang cac bo spi dai hoac not ciing la do so hoa vet s?o mo co ma thanh, do do co the ton tai mpt vai mo seo trong co bSp cua hpi chiing con dau mang
CO. Da tung c6 tac gia cua Tnmg Quoc dua ra nhan finh: sau khi cac mo mem ciia co the gap phai ton thuong cap tinh hay man tinh, no se sdn sinh cac loai Peptit hoan xung tren mo mem va cac vimg lan cgn, sy thay doi ham lupng cac hpp chat hiiu co nhu Setoronin (5-Hydroxytryptaraine) can co the thong qua phan xa than kinh va he thong dieu tiet dich the san sinh ra qua trinh chuyen bien b | n h ly va sinh ly de thich nghi voi h6i phyc chuc nang sinh ly da hi dao loan va siia chua cac mo bi pha vo, do do tao nen vet seo, dinh ket, co nit, t i c nghen. Dieu tri b5ng dao kim dupe ra doi tren nen tdng nay va gat hai duprc nhung thanh cong nhat dinh.
Song, do con han che trong ITnh vi^c nghien ciiu ve hinh thai hpc mo va sinh ly dien co, nen gia thiet nay sau do bi cac nghien ciiu ve diem kich boat con dau thay the, nhat la doi voi nuoc ngoai. Nhung chiing ta khong the phu nhan, sy tri hoan keo dai cua dau eo man tinh CO the gay nen eo riit mang va dinh ket co, trong truong hpp nay thi tieu dao kim lai mang ve hieu qud dieu tri tuong doi khd quan.
Mpt dieu trung hpp niia, do la diim dieu tri eiia tieu dao kim vd cac phuong phap tri lieu khac deu gan voi diim kich boat.
2.5 M6i quan he giita diim kich hoat vd kinh lac
Nhung nam gan ddy, nhiim lam ro ban chat ciia kinh lac, mpt tu tuong moi dupe ra doi, do la "gid thiet mang co". Co nguoi tong ket dupe moi tuong quan trong dieu tri lam sang voi vi tri giai phau cua 255 diem kich boat ciing cdc huyet dao truyen thong ma Simon va Travell da dua ra tai cac nghien
ciiu lien quan, phat hien co den 92% so diem kich boat c6 cimg vi tri gidl phlu tuong xiing voi huyet dao, 76% vimg lien doi ciia diem kich boat co huong di chuyen tning khop voi huyet dao, nhung nhan thue eua Travell va Simon doi voi diem kich boat khong he giong vai each xae dinh chuan xac ve huyet dao nhu cua Trung Y. Hai tac gia nay chi xac dinh vi tri phat benh tren moi ca va dai khai vi tri ciia diim kich boat tren co bdp do, cimg voi pham vi phan bo cua cac vimg Hen doi ra sao, kieu phan bo nay se chiu chi phoi boi yeu to ca the va miic dp benh nang hay nhe. Cho du mpt so diem kich hoat con dau vd huyet dao Tnmg Y c6 moi tuong quan nhat dinh, song khong the hodn toan giong nhau, Tir do, chiing toi manh dan dua ra gia thiet nhirng diem kich hoat dupe tim thay tren nguoi benh chinh la cac huyet dao da dupe xuat hien trong so do huyet dao cham ciru cua Trung Quoc co dai Vi vay, dua tren kinh nghiem chuan doan "3 tieu chuan vang" de tim diem kich boat se mang lai hieu qud dieu tri cao hon so voi can cir vao so do huyet dao Tnmg Y 3. Tim diem kich hoatva each dieu trj
Danh tan diem kich hoat Id chia khoa then chot giup dieu tri CO hieu qud. Do do, 1dm sao de xac dinh chuan xae vi tri ciia diem kich boat moi Id trpng diem chinh Dua tren tieu chuan chan doan chii quan cua Simon ciing tong kSt mang tinh kinh nghiem ciia chimg toi, cac co so duoi day duoc xem Id thuang su dyng trong dieu tri lam sang cho diem kich hoat con dau mang co:
(1) Kiem tra benh sir va the trang: con dau bat chprt phdt ra tir ca
hoac mpt thoi gian ngan ngay sau khi CO bdp dimg siic qua dp; ca bap met moi do chiu tac dung luc lien tyc hay co tinh tich liiy dan den eon dau timg viing, hay con dau timg vimg ma khong ro nguyen nhan.
Can cii vao vi tri con dau tien hdnh dp dyng kiem tra the trang chuyen biet danh cho khoa xuong khdp, buoc dau xac dinh vimg co bi met moi. Do con dau se dnh huong den cong nang boat dong cua khap, nen diem ndy khong kho thao tac.
(2) Dinh vi dac trung qui luat can dau vimg lien doi: can cir qui luat dau viing lien doi ciia cac co bi met moi, tir do xac dinh diem kidi boat. Tai vi tri cua diem kich boat an vdo se thay dau, dong thai so dupe cac ddi truong cimg hay not co quap, hoac not co qudp xuat hien ngay tren dai cuong cung, Nhung can mot lye manh khoang 2-4kg de an len diem dau ndy, khi do phan mong tay se chuyen sang mau trang, Khi an sau hon se xuat hien dau vimg lien ddi. Nhiing co bdp khac nhau thong tiiuong se co mot so diem dau CO dinh khong giong nhau, m6i mpt diem dau do 1^ co nhung vimg dau lien doi eo dinh rieng biet.
(3) An nhanh va cham cim diem kich hoat co the dan den phan ung ehuQt rut cue bp.
(4) Van dpng eua cac co met moi va pham vi keo dan bi gioi han, cimg voi luc co tra nen kem.
(5) Thieu ngu, hoac dl met moi va ngu that thuong (mat ngu, de tinh),
(6) Chi tieu khach quan: duoi trang thai tiiih, qua dien eo do c6 thi quan sat dupe dien vi tu phat cua ^ I m kich boat co ^nh. Chup cpng huong tir h o ^ sieu am tai noi co d e m kich hoat se thay anh day hon. •
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