CHUYEN p i : CO Xl/ONG KHOP - NHUfNG TIEN BO TRONG CHAN POAN VA OlEU TKl .
NGHIEN CUtJ HINH ANH SIEU AM KHOfP BAN NGON CHAN I TRONG BENH GUT
Pham Ngoc Tmng*, Nguyin Thi Ngoc Lan**
TOM T A T
Muc tieu nghien cu'u 1. Md ta dac diem hinh anh sieu am khdp ban ngdn chan I trong benh gut. 2. Ddi chieu hinh anh sieu am khdp ban ngdn chan I vdi lam sang va hinh anh Xquang. 067 ti/Vng nghien ciht: Gdm la 66 benh nhan du'dc chan doan la gut theo tieu chuan ciia Bennett va Wood nam 1968 nhap vien dieu trj tai khoa Cd Xu'dng Khdp benh vien Bach Mai, tir thang 2/2009 den 7/2009. Phifdng phap nghien citu: Tien cu'u md ta cat ngang. Kit qua. Dau hieu du'dng ddi gap ty le 100% tren benh nhan gut man (ddt cap gut man va gut man) va khdng gap tren benh nhan gut cap (0<0,01). Khuyet xu'dng gap ty le 16,7% benh nhan gut cap, 69% trong ddt cap gut man va 80% trong gut man tinh (p<0,05). Viem mang hoat djch gap ty le 100% trong gut cap (gut cap va ddt cap gut man) va khdng gap trong gut man (p<0,01); dp day mang hoat djch viem la 3,89 ± 0,97 mm. Ke't luan: Sieu am cd kha nang phat hien tdn thu'dng khdp ban ngdn chan I d giai doan sdm ciia benh vdi dp nhay cao (100%).
Cac hinh anh tdn thu'dng tren sieu am trong giai doan cap la viem mang boat djch va djch khdp;
cdn trong giai doan gut man tinh la dau hieu du'dng ddi va khuyet xu'dng.
SUMMARY
Objectives: 1. to identify the characteristic sonographic features of gout. 2. To compare high-resolution ultrasound (US) with clinical and conventional X-ray in the first metatarsophalangeal joints (1st MTPJs) of patients with gout. Subjects: 66 gout patients, diagnosed following- Bennet and wood 1968
criteria, hospitalized in Rheumatology Department, Bach Mai hospital from February 2009 to July 2009. Methods: prospective cross- sectional study. Results: Double contour sign 100% in chronic gout and none in acute gout (p<0,01). Erosions of MTP joints were seen in 16,7% in acute gout; 69% in acute phase of chronic gout and 80% in chronic gout. US detected synovitis in 100% acute gout and none in chronic gout (p<0,01). Mean synovial thickness on US was 3,89 ± 0,97mm.
Conclusions: US detected early 1st MTPJs damage with high sensitivity (100%). The sonographic features of gout in acute phase is synovitis and joint effusion; in chronic gout is double contour and erosions.
I. DAT VAN DE
Giit la mdt trong so benh khdp do rdi loan chuyln hda thudng gap nhat. Nguyen nhan ciia benh la do su ldng dpng tinh thi urat d cac md cua ca thi, bdt ngudn tir tinh trang tang acid uric trong mau. Vdi su gia tang sd ngudi cao tudi, hpi chung chuyln hod gia tang lam ty le benh giit ngay cang tang cao d nhieu qude gia tren the gidi. Mdt khao sat d Anh va Dire (2000-2005) cho thdy ty 1?
mdc benh gut vao khoang 1,4% dan sd [2]. 6 Viet Nam, theo mdt nghien ciiu dich te tiln hanh d mdt sd tinh miln Bdc vao nam 2000, tyle benh la 0,14% [1].
Nhung thap nien gdn day, tham dd sieu am trong cac benh ly ca xuomg khdp dang phat triin nhanh chdng va dugc xem nhu la mdt phuang phap quan trgng trong chdn doan
NOI KHOA - SO 4/2009
va theo ddi dap iing diiu tri trong nhilu benh khdp [3]. Sieu am cd thi phat hien dugc nhihig hinh anh dac trung cho giit ma khdng g^p d nhimg benh khdp khac, dd la hmh anh dudng ddi, bao mdn xuang khdp sdm, dac biet la hien tugng ldng dgng tinh thi urat [6].
Myc tieu nghien cuu cua de tai:
1. Md ta dac diim hinh anh sieu am khdp ban ngdn chan I trong benh giit.
2. Ddi chilu hinh anh sieu am khdp ban ngdn chan I vdi lam sang va hinh anh Xquang.
II. DOI TU'gNG VA PHUaNG PHAP NGHIEN CUtJ
1. Doi tuong nghien cuu
Gdm la 66 benh nhan dugc chdn doan la giit dieu tri ndi tni tai khoa Ca Xuang Khdp b?nh vien Bach Mai tir thang 2/2009 din 7/2009 dap ling cac tieu ehudn dudi day.
Tieu ehudn chpn benh: Chdn doan benh giit theo tieu ehudn cua Bennett va Wood nam 1968; chdp nhan tham gia nghien ciiu.
-Tieu ehudn loai benh nhan nghien ciiu:
Cd chdng chi dinh chup Xquang; khdng ddng y tham gia nghien ciiu.
2. Phuong phap nghien cihi
- Nghien ciiu tiln ciiu, md ta cdt ngang 3. Npi dung nghien ciru
a) Khai thac trieu chimg lam sang
b) Cac xet nghiem huyit hpe va sinh hoa dugc thuc hien tai cac phdng xet nghiem benh vien Bach Mai.
c) Chup X quang thudng quy khdp ban ngdn chan I, 2 tu thi thdng va nghien tai khoa chan doan hinh anh benh vien Bach Mai.
d) Sieu am bang may sieu am Philips cua My (HD3 ultrasound system), ddu dd linear tan so cao 5-9 MHz.
Md ta mdt sd hinh anh sieu am trong benh giit [5], [6]
Hinh anh sieu am Dau hieu du'dng ddi Khuyet xu'dng Viem manq hoat dich Djch khdp
Mota
D Hai du'dng song song: du'dng tang am khdng deu mdng (do tinh the urat lang ddng tren sun khdp) va du'dng vien ciia vd xu'dng.
Sir mat lien tue du'dng tang am ciia vd xu'dng ma du'dc nhin thay it nhat tren hai mat cat qua khdp.
Mdt vimg giam am khdnq thay ddi khi an dau dd Mdt vimg giam am thay do! khi an dau dd
- s l lieu dugc xii ly bdng phdn mIm SPSS 16 for Windows.
III. KET QUA NGHIEN CUtJ
1. D$c diem nhdm nghien cihi
Tdng sd benh nhan nghien cim la 66 benh nhan gdm 6 benh nhan giit edp, 47 b?nh nhan dgt edp giit man va 13 b?nh nhan giit man.
CHUYEN DJ: CO XtJONG K H O P - NHOfNG TIEN BQ TRONG CHAN POAN VA Olfcu tjii
Bang 1: Dac diem nhdm benh nhan nghien ciiu
STT 1 2 3 4 5
Oac diem Tudi
Gidi Ru'du
BMI Acid uric
Ket qua nghien cdu
55,8 ± 12,2 (32;83), tudi khdi phat benh: 48,7 ± 12,3 (26;78) Nam chiem da sd(97%); ty le nam/nu' la 32/1
63,6% benh nhan udng ru'du bia thu'dng xuyen 22,02 J:2,64(18;29); >23 la 30,3%
539,3 ± 146,2 (umol/l), tang 78,8%; nhdm tang 594,5 +169,9(nmol/l)
2. Dac diem ton thuong khdp ban ngdn chan I tren sieu am va Xquang 2.1. Ddc diim sieu dm khdp bdn ngdn chdn I trong binh gdt
Bang 2: Dac diem sieu am khdp ban ngdn chan I
Hinh anh sieu am
Du'dng ddi
Khuyet xu'dng
Viem MHD
Dich
Giai doan gut
Cd Khdng
Cd Khdng
Cd Khdng
Cd
Khdng
Phan loai gut Gut cap
(1) 0 (0%)
6 (100,0%)
1 (16,7%)
5 (83,3%)
6 (100,0%)
0 (0,0%)
4 (66,7%)
2 (33,3%)
Gut man Ddt cap gut man
(2) 47 (100,0%)
0 (0,0%)
26 (55,3%)
21 (44,6%)
47 (100,0%)
0 (0,0%)
31 (66,0)
16 (34,0%)
Gut man (3)
13 (100,0%)
0 (0,0%)
10 (76,9%)
3 (23,1%)
0 (0,0%)
13 (100,0%)
8 (61,5%)
5 (38,5%)
P
Pl-3 < 0,01 Pl.2<0,01 ,
P2-3 > 0,05 bi-'3 < 0,05 Pi-2>0,05
p2-3 > 0,05
Pl-3 < 0,01 P2-3 < 0,01 Pl-3 > 0,05 Pi-2>0,05
P2-3 > 0,05
NQI KHOA - SO 4/2009
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2.2. Dgc diim tSn thuang khdp bdn ngdn I tren X quang Bang 3: Dac diim tin thuang tren Xquang
Hinh anh Xquang
Khuyet xu'dng
Giai doan gut
Cd Khdng P
Phan loai cut Gut cap
(1) 1 (16,7%)
5 (83,3%)
Gut man Ddt cap gut man
i2) 26 (55,3%)
21 (55,3%)
Gut man (3)
10 (76,9%)
3 (23,1%)
P
Pl-3 < 0,05 Pi-2>0,05
P2-3 > 0,05
< 0,05
3. Doi chieu giira sieu am, lam s^ng va hinh anh Xquang trong ton thuang khdp b^n ngdn I do giit.
Bang 4: Lien quan giura hat td phi khdp ban ngdn chan I tren lam sang vdi ton thuang khuyit xuang tren Xquang va sieu am (n = 60)
Hat td phi ban ngdn I :, Khdng
Cd Tdng
P
Khuyet xu'dng/ Xquang Khdng
20 51,3%
3 14,3%
23 38,3%
Cd 19 48,7%
18 85,7%
37 61.7%
<0.01
Khuyet xu'dng Khdng
13 33.3%
1 4,8%
14 23,3%
/ sieu am Cd 26 66,7%
20 95,2%
46 76,7%
<0,05
P
>0,05
>0,05 60 100%
Lien quan gifta khuyit xuomg khdp ban ngdn chan I Uen Xquang va sieu am (n=60).
CHUYgN BE: CO XJONG K H O P - NHUfNG TIEN B 0 lllkONG CHAN OUAW V A U I C U iKi
Bang 5: Lien quan gifta khuyit xuong tren Xquang va sieu am (n = 60)
Khuyet xu'dng tren Aquang Khdng
Cd Tong
P
n
% n
% n
%
Khuyet xu'dng tren sieu am Khdng
13 56,5%
1 2.7%
14 30,3%
Cd 10 43,5%
36 97,3%
46 67,9%
<0,001
Tdng 23 100%
37 100%
60 100%
I I I . BAN LUAN
3.1. Dac diem sieu am cua ton thuang xuong khdp
- Trong nghien ciiu nay Ddu hiiu dudng doi khdp ban ngdn chan I phat hien vdi ty le 100% trong giit man tinh va khdng gap trong giit edp tinh (p<0,01) trong dd ddu hieu dudng ddi ca hai ben la 88,3%, mat cat gan chan nhieu nhdt vdi ty le 63,3%. Tac gia Thiele R.G 2007 [5] nghien cim tren 23 benh nhan giit, dau hieu dudng ddi gap vdi ty le 92% va khdng gap d nhdm chiing (p<0,001). Wright va cpng su 2007 [6]
nghien ciiu 33 nam dugc chan doan gut, dau hieu dudng ddi gap ty le 22% va khdng d nhdm chiing (p<0,001). Ddu hiiu khuyit xuang chiing tdi gap 16,7% trong giit edp tinh; 69% trong dgt edp giit man va 80%
trong giit man tinh (p<0,05).- Nghien ciiu Thiele R.G [5] va Wright gap khuyit xuong theo thir tu la 65% va 67% va khdng thdy trong nhdm chiing (p<0,01). Viem mdng hogt dich gap 100% d benh nhan giit cap va khdng gap trong giit man (p<0,01); viem mang hoat dich hai ben la 66,7%; bl day trung binh mang hoat dich viem la 3,89 ± 0,97 mm. Kit qua nghien ciiu ciia chiing tdi tuong tvr nhu kit qua nghien cuu cua cac tac gia khac [6]. Dich khdp: Dich khdp gap
66,7% d giai doan cap; 65,95% trong dgt cap giit man va 61,5% giai doan man (p>0,05). Nghien ciiu Thiele R.G va Schlesinger 2007 [5], Wright 2007 [6] cho thay ty le dich khdp ban ngdn chan I trong benh giit theo thii tu la 74% va 71%. Tuy nhien trong hai nghien ciiu nay, cac tac gia thay cd ty le cao dich khdp trong nhdm chiihg 73% [5].
3.2. D|ic diem ton thuong khdp ban ngon chan I tren lam sang va X quang
- Ldm sdng: Giit edp tinh 100% benh nhan chi dau cac Ididp chi dudi va khdp ban ngdn chan cai thudng gap nhdt (65,2%); Cd den 88% benh nhan dau khdp d miic dp nang. Trong giit man tinh ^on thuang nhilu nhdt d Ididp ban ngdn chan cai (63,6%); v| tri hat td phi thudng gap nhat d khdp ban ngdn chan cai (33,3%).
Xquang: Khuyit xuang tren Xquang trong giit edp la 16,7%; dgt edp giit man la 53,3% va giit man la 76,9% (p<0,05).
3.3. Doi chieu giua sieu am, lam sing va hinh anh Xquang trong ton thuong khdp ban ngdn chan I do gut
- Liin quan giita hat to phi khdp bdn ngdn chdn I tren lam sdng vdi khuyit xuang trin Xquang vd siiu am.
NOI KHOA - SO 4/2009
Bang 4 cho thdy sieu am va Xquang phdt hien tdn thuang xuomg tdt ban kham lam sang, su khac biet nay cd y nghia thing ke (theo thii tvr la p<0,05 v^ p<0,01). Xquang phat hi?n 48,7% khuyet xuomg khi chua cd hat td phi tren lam sang va 85,7% khi cd td phi Uen lam sang (p<0,01). Mzic khac sieu am phat hien 66,7% khuyit xuomg khi chua cd h^t td phi tren lam sang va 95,2% khi cd h?it td phi tren lam sang (p<0,05).
Liin quan giita xuang khdp bdn ngdn chdn I trin Xquang vd siiu ant.
Stew am cd kha nang phat hien khuyit xuong tdt hom Xquang thudng qui [3], [4].
Trong nghien ciiu nay sieu am phat hien 43,5% khuyit xuomg khi chua phat hien khuyit xuomg tren Xquang va 97,3% khi cd khuyit xuomg tren Xquang (p<0,01). Dp nh^iy, dp dac hieu va dp chinh xac ciia sieu am so vdi Xquang theo thii tvr la 78,3%;
92,9% va 81,7%.
IV. KET LUAN
Nghien cuu hinh anh sieu am khdp ban ngdn chan 1 cua 66 b?nh nhan giit, chiing tdi cd nhflmg kit luSn sau:
/. Siiu dm khdp bdn ngdn chdn I trong b$nh gdt
+ Ddu hi?u dudng ddi gap ty le 100%
tren benh nhan giit man (dot edp giit m?in va giit man) va khdng g ^ tren benh nhan giit cap.
+ Khuyit xuomg gap ty le 16^7% benh nhan giit edp, 69% trong dgt edp gut man va 80% trong giit man tinh.
+ Viem mang hoat dich g?ip ty le 100%
trong giit edp (giit cap va dgt edp giit man) va khdng g^p trong giit man. Dp day trung binh m^g ho?it djch viem la 3,89 ± 0,97 mm.
+ Djch khdp gIp 66,7% d giit edp;
65,95% trong dgt edp giit man va 61,5% giit m?n.
2. Doi chidu giita siiu am, ldm sdng vd hinh dnh Xquang trong ton thuang khdp bdn ngdn chdn I do gdt
Sieu am va Xquang phat hien tin thuomg xuomg tot hom kham lam sang.
Xquang phat hien 48,7% khuyit xuomg khi chua cd hat td phi tren lam sang va 85,7% khi cd td phi tren lam sang. Ty le nay tren sieu am theo thii tir la 66,7% va 95,2%.
- Sieu am phat hipn khuyit xuomg khdp ban ngdn chan I tdt hem Xquang, sieu am phat hien 43,5% khuyet xuomg khi chua phat hien khuyet xuomg tren Xquang va 97,3% khi cd khuyet xuomg tren Xquang.
TAI LIEU THAM KHAO
1. Trhn Thj Minh Hoa, Darmawan, Cao Thj Nhi, Ta Di«u YSn, Nguyin VSn Hitng, VQ Dinh Chfnh, Tr^n Ngpc An (2002). Tinh hinh b$nh ca xuang khap a hai qudn the ddn cu Trung Liet (Hd Ngi) vd Tdn Trudng (Hdi Duong}. C6ng trinh nghien curu Idioa hpe 2001 - 2002, t§p 1, Nh^
xu4t b^n y hpe, trang 361 - 367.
2 . Annemans L, Spaepen E, Gaskin M, Bonnemaire M, Malier V, Gilbert T, Nuki G (2008) Gout in the UK and Germany: prevalence, comorbidities and management in general practice 2000 2005. Annals of the Rheumatic Diseases ;67:960-966.
3 . Filippucci E, Clapetti A, Grass! W (2003).
"Sonographic monitoring of gout".
Reumatismo;55:lS4 - 6.
4 . Grassi W, Filippucci E, Farina A, Salaffl F, Cervini C (2001). "Ultrasonography in the evaluation of bone erosions" Ann Rheum Dis 60:98 -103.
5 . Thiele R. G and Schlesinger N (2007)."Diagnosis of gout by ultrasound"
Rheumatology 46(7): 1116-1121.
6 . Wright S, Filippucci E, Claire McVeigh, Grey A, McCarron M, Grassi W, Wright G.D, and Taggart A J (2007). "High-resolution ultrasonography of the first metatarsal phalangeal joint in gout: a controlled study". Ann Rheum Dis; 66: 859-864.