Bnh vim khp dng thp

Gi bi Admin, lc 08:41 21/08/2011, | Bnh lin quan h min dch | Bnh Gt - Khp
Vim khp dng thp (VKDT) l mt bnh hay gp nht trong cc bnh
khp. L mt bnh mang tnh cht x hi v s thng c, v s din bin
ko di v v hu qu dn n s tn ph.
Bnh VKDT c bit t lu, nhng cho n gn
y mi c c s thng nht v tn gi, v tiu
chun chn on v v c ch sinh bnh. Bnh c
nhiu tn gi:
Thp khp teo t (sydenham 1683)
Bnh khp Sacc (charcot 1853)
Vim khp dng thp (Garrod 1890)
Vim a khp mn tnh tin trin (PCE, PCP)
Vim a khp nhim khun khng c hiu
(Nesterov)
Thp khp mn tnh dnh v bin dng
Hin nay bnh c mang tn vim khp dng thp
phn bit vi cc bnh khp khc (thp khp cp, vim khp mn tnh thiu nin,
thp khp phn ng).
Bnh VKDT gp mi ni trn th gii, bnh chim t 0,5 - 3% dn s ( ngi ln).
Vit Nam c t l 0,5% trong nhn dn v 20% s bnh nhn mc bnh khp iu
tr bnh vin. C th ni VKDT l bnh ca ph n tui trung nin v 70 - 80% bnh
nhn l n tui trung nin v 60 - 70% c tui trn 30. Bnh c tnh cht gia nh
trong mt s trng hp.
I. Nguyn nhn v c ch sinh bnh
1. Nguyn nhn
Trc y c nhiu gi thuyt c a ra v nguyn nhn ca bnh, gn y
ngi ta coi VKDT l mt bnh t min dch vi s tham gia ca nhiu yu t.
- Yu t tc nhn gy bnh: c th l mt loi virus, nhng hin nay cha c xc
minh chc chn.
- Yu t c a: bnh c lin quan r rt n gii tnh v la tui.
- Yu t di truyn: t lu ngi ta nhn thy bnh VKDT c tnh cht gia nh.
Trong nhng nm gn y c nhiu cng trnh nghin cu nu ln mi lin quan
gia bnh VKDT v yu t khng nguyn ph hp vi t chc HLA DR4 ( bnh nhn
VKDT thy 60 - 70% mang yu t ny, trong khi ngi bnh thng c 15%)
- Cc yu t thun li, l nhng yu t pht ng bnh nh suy yu, mt mi,
chn thng, bnh truyn nhim, lnh v m ko di, phu thut.
2. C ch bnh sinh
Lc u tc nhn gy bnh (virus?) tc ng vo mt c th c sn c a thun li
v c nhng yu t di truyn d tip nhn bnh, c th sinh ra khng th chng li
tc nhn gy bnh, ri khng th ny tr thnh tc nhn kch thch c th sinh ra mt
khng th chng li tc nhn gy bnh, ri khng th ny li tr thnh tc nhn kch
thch c th sinh ra mt khng th chng li n (ta gi l t khng th). Khng th
(lc u) v t khng th vi s c mt ca b th, kt hp vi nhau trong dch
khp tr thnh nhng phc hp khng nguyn - khng th. Nhng phc hp khng
nguyn - khng th c mt s t bo i n thc bo, l bch cu a nhn
trung tnh v i thc bo, sau nhng t bo ny s b ph hu bi chnh cc men

tiu th m chng gii phng ra tiu cc phc hp khng nguyn - khng th trn.
S ph hu ca cc t bo thc bo gii phng nhiu men tiu th, nhng men ny s
kch thch v hu hoi mng hot dch khp gy nn mt qu trnh vim khng c
hiu, qu trnh ny ko di khng chm dt i t khp ny qua khp khc, mc d tc
nhn gy bnh ban u chm dt t lu.
Tnh trng vim khng c hiu ca mng hot dch khp lc u l ph n, sung
huyt, thm nhp nhiu t bo vim m phn ln l a nhn trung tnh, sau mt thi
gian hin tng ph n c thay bng qu trnh tng sinh v ph i ca cc hnh
lng v lp lin bo ph, cc t bo vim c thnh phn ch yu l lympho v tng
bo. Cc phn lng ca mng hot dch tng sinh v ph i s pht trin v n su
vo u xng phn di sn khp gy nn cc thng tn phn ny. Cui cng,
sau mt thi gian tin trin ko di, t chc x pht trin s thay th cho t chc
vim v dn n tnh trng bin dng v dnh khp. Do , c th ni tn thng xut
hin sm nht, c bn nht l nguyn nhn dn n mi tn thng khc trong bnh
VKDT l tnh trng vim khng c hiu mn tnh ca mng hot dch khp.

2.1 Cc quan nim hin nay v nguyn nhn v c ch sinh bnh

Cho n nay, nguyn nhn ca bnh VKDT cn cha c bit r. Theo quan im
hin i, th y l bnh ca m lin kt. Tn thng m lin kt trong VKDT l hu
qu ca s ri lon min dch (t min dch). C nhiu yu t chng t ngun gc t
min dch ca bnh nh s c mt ca cc yu t dng thp (Rheumatoid factor - RF),
mt s t khng th, s c mt ca cc phc hp min dch, cc t bo lympho nhy
cm vi cc thnh phn ca m lin kt. iu tr chng nhim khun khng em li
kt qu, ngc li, iu tr bng cc thuc c ch min dch c hiu qu tt.

Mt s gi thit c nu ln nh mi lin h ca yu t c a (nh HLA DR4) i

vi mt s yu t gy khi pht bnh, trong yu t nhim virus (virus Epstein Ban, khu tr cc t bo lympho, c kh nng lm ri lon qu trnh tng hp cc
globulin min dch, hoc parvovirus, thm ch c virus rubeole).
Vai tr ca yu t di truyn cng c lu v t l mc bnh cao nhng ngi
thn trong gia nh bnh nhn, nhng cp sinh i cng trng, v HLA - DR4.
Mt s yu t thun li c lin quan n s khi pht bnh: chn thng, kh hu,
ch dinh dng, chn thng tm l, cc ri lon v chuyn ho v ni tit, song
cha c chng minh.
Cc nghin cu hin i nu ln mi lin quan gia cc yu t nhim trng - gen
- qu trnh t min ca c th l trung tm ca c ch bnh cn bnh nguyn ca
VKDT ch khng phi l mt vi hin tng n l.
T thp k by mi tr li y nhiu cng trnh nghin cu v min dch hc v
sinh hc phn t lm sng t thm v c ch bnh sinh ca VKDT, gm:
- Min dch dch th vi yu t dng thp mu v dch khp.
- Cc cht trung gian ho hc trong dch khp.
- Cc t bo ni mc mao mch v s iu khin cc t bo vim, khi pht phn
ng vim.
- Vai tr ca i thc bo v cc cytokin
- C ch gy tn thng sn v xng
- Vai tr ca h thn kinh ngoi vi v p ng vi phn ng vim

S trn c gii thch nh sau:

Khi u l s c mt ca i thc bo M, thc bo mt khng nguyn m hin nay
c gi thit l mt lympho bo T4 b tr. T bo ny, c hot ho, tit IL
(Interleukine) - 2 v nhn ln kiu n dng. Cc T4 hot ho kch thch cc t bo
thc hin, trc tip hoc gin tip qua trung gian ca mt i thc bo khc, bng
cch tit cc cytokin khc nh: ILI, OAF (yu t hot ho hu xng - osteoclast
activating factor), FAF (yu t hot ho cc nguyn bo x - facteur activant les
fibroblastes). Cc t bo thc hin bao gm:
- Ostoclaste - hu ct bo;
- Chondrocyt - hu sn bo: hu sn bng cch tit ra cc men tiu protein v cc
prostaglandin;
- Nguyn bo x mng hot dch: cng hu hoi m khp bng cch tit hai cht
trn.
Cng mt phn ng kch thch min dch ban u kch thch clone ca lymphocyt B,
n cng nhn ln n dng, v c thun li bi IL do T4 tit ra. Lymphocyt B sn
xut yu t dng thp (YTDT). YTDT cng vi khng nguyn l IgG, to nn phc hp
min dch (PHMD) lu hnh. PHMD hot ho b th, v b thc bo bi cc bch cu
a nhn ca mng hot dch c mt ti ch hoc b li ko n dch khp. Cc bch

cu gii phng ra cc men tiu protein, prostaglandin, v cc con superoxyd rt c,

gy vim v hu hoi m.
iu c trng cho phn ng vim ca VKDT l tnh mn tnh. Ngi ta cho rng s
tn ti ca phn ng ny l do khng hn ch c s nhn ln n dng ca
lymphocyt T4, s nhn ln ny bnh thng phi c ngng li bi nh hng ca
lymphocyt T8 c ch, vy m yu t ny li b thiu trong VKDT. Cn nguyn nhn
gy thiu ht lymphocyt T8 cn cha r.
2.2. C ch hu khp v gii phu bnh trong VKDT
Yu t gy hu khp l mng mu mng hot dch (pannus synovial), c cu to
bi mng hot dch tng sinh, cha mt u ht vim rt giu t bo.
c im tng sinh v gi u ca mng mu - gii thch s xm ln v hu hoi
sn. Cc t bo cu to nn mng ny tit cc cht c bit, lm cho t bo mng
hot dch d dnh vo sn v gy tn thng bo mn th pht.
Chng sn sinh ra osteopontin, mt thnh phn ca khoang ngoi t bo, lm
thun li s xm ln ca sn bi cc t bo sinh mng hot dch (synovioblastes).
Pannus mng hot dch cha cc t bo mng hot dch loi n clon. S lan to gi u
c gii thch bi s mt c ch, tip xc v s th hin ca protein p53.
Phn mng hot dch bm ch ranh gii sn - u xng chnh l pannus nu
trn v gy hu khp, l nguyn nhn cc tn thng thy c trn X quang.
II. Triu chng lm sng
a s trng hp bnh bt u t t tng dn, nhng c khong 15% bt u t
ngt vi cc du hiu cp tnh. Trc khi cc du hiu khp xut hin, bnh nhn c
th c cc biu hin nh st nh, mt mi, gy st, t cc u chi, ra nhiu m hi,
ri lon vn mch.
A. Vim khp
1. Giai on bt u (khi pht):
V tr ban u: 2/3 trng hp bt u bng vim mt khp, trong 1/3 bt u
bng vim mt trong cc khp nh bn tay (c tay, bn ngn, ngn gn), 1/3 bng
khp gi v 1/3 l cc khp cn li.
Tnh cht: sng au r, ngn tay thng c hnh thoi, du hiu cng khp bui sng
thy t 10 - 20%. Bnh din bin ko di t vi tun n vi thng ri chuyn sang
giai on r rt.
2. Giai on r rt (ton pht)
a. V tr vim khp:

- Bn chn 70%
- C chn 70%
- Ngn chn 60%
- Khp khuu 60%
Cc khp khc: hng, ct sng, hm, c n him gp v thng xut hin mun.
b. Tnh cht vim:
i xng 95%
- Sng phn mu tay hn phn lng bn tay
- Sng au v hn ch vn ng, t nng , c th c nc khp gi.
- C du hiu cng khp bui sng 90%
- au tng nhiu v m (gn sng)
- Cc ngn tay c hnh thoi nht l cc ngn 2, 3 ,4.
c. Din bin: cc khp vim tin trin tng dn v nng dn, pht trin thm cc
khp khc, cc khp vim dn dn dn n tnh trng dnh v bin dng, bn ngn
tay dnh v bin dng t th na co v lch trc v pha xng tr (bn tay gi thi,
ngn tay hnh c c), khp gi dnh t th na co.
B. Triu chng ton thn v ngoi khp
1. Ton thn
Bnh nhn gy st, mt mi, n ng km, da nim mc xanh nht do thiu mu, c
nhng biu hin ri lon thn kinh thc vt...
2. Biu hin ngoi da
Ht di da: 10 - 20% ( Vit Nam ch thy trong 5% trng hp) c coi nh l
mt du hiu c hiu. l nhng ht hay cc ni ln khi mt da, chc, khng au,
khng c l r, khng di ng v dnh vo nn xng di, c kch thc t 5 mm
n 20 mm ng knh. V tr hay gp nht l trn xng tr gn khp khuu, hoc
trn xng chy gn khp gi, hoc quanh cc khp khc, s lng c t mt n vi
ht.
- Da kh, teo v x, nht l cc chi.
- Gan bn tay v chn thy gin mch, hng.

- Ri lon dinh dng v vn mch c th gy lot v khun chn ph mt on

chi nht l chi di.
3. C, gn, dy chng, bao khp
- Teo c r rt vng quanh khp tn thng nh c lin ct v c giun bn tay, c
i, cng chn. Teo c l hu qu do khng vn ng.
- Vim gn: hay gp vim gn Achille.
- Dy chng: phn ln l vim co ko nhng c nhng trng hp gin dy chng
gy lng lo khp.
- Bao khp: c th phnh ra thnh cc kn (kyste) hot dch, vng khoeo chn tn
l kn Baker.
4. Ni tng
Rt him gp trn lm sng
- Tim: tn thng c tim kn o, c th c vim mng ngoi tim, ri lon dn
truyn, t thy tn thng mng trong v van tim.
- H hp: vim mng phi nh, x ph nang.
- Hch: hch ni to v au mt trong cnh tay.
- Lch: lch to v gim bch cu trong hi chng Felty.
- Xng: mt vi, gy xng t nhin.
5. Mt, thn kinh, chuyn ho
- Mt, vim gic mc, vim mng mt th mi...
- Thn kinh: vim v x dnh phn mm quanh khp c th chn p vo cc dy
thn kinh ngoi bin.
- Thiu mu nhc sc m nguyn nhn hin nay cha c bit r.
- Ri lon thn kinh thc vt.
- Nhim amyloid c biu hin ch yu thn, thng xut hin rt mun.
III. Xt nghim v X quang
A. Xt nghim
1. Xt nghim chung
- Cng thc mu: hng cu gim, nhc sc; bch cu c th tng hoc gim.
- Tc lng mu tng.
- Si huyt tng, phn ng ln bng (+).
- in di protin: albumin gim v globulin tng.
- Mt s xt nghim nh lng haptoglobin, seromucoid, orosomucoid v phn ng
C protin... c th dng tnh.
2. Cc xt nghim min dch
Waaler - Ro se v latex: nhm pht hin yu t dng thp trong huyt thanh (t
khng th), l mt globulin min dch IgM c kh nng ngng kt vi globulin
(IgM). Nu dng hng cu ngi hoc hng cu cu tin hnh phn ng th l phn
ng Waaler - Rose, nu dng ht nha latex th gi l ta latex.
Waaler - Rose (+) khi ngng kt vi pha long huyt thanh bnh nhn nh hn
1/16, tet latex (+) khi ngng kt vi pha long huyt thanh nh hn 1/32.
Cc phn ng ny thng (+) mun sau khi mc bnh trn mt nm. T l (+)
khong 70 - 80% trng hp, mc (+) ca phn ng khng song song vi mc
nng nh ca bnh.
Cc xt nghim min dch khc t c s dng trn lm sng v khng c gi tr
c hiu nh min dch in di, chuyn dng lympho bo, di tn bch cu, nh lng
cc thnh phn b th.

Trong mt s trng hp (5 - 10%) c th tm thy t bo Hargrave, khng th

khng nhn, khng th khng acid nhn, khng th khng quanh nhn trong mu
bnh nhn, tuy nhin cc xt nghim ny t gip ch trong chn on bnh VKDT.
3. Dch khp
Lng mu xin gim r rt (tet mu xin + + +), dch khp lng, gim nht, c mu
vng nht.
Lng t bo tng nhiu, nht l a nhn trung tnh m trong bo tng c nhiu
ht nh, l nhng t bo nut nhng phc hp khng nguyn khng th, ngi
ta gi chng l nhng t bo hnh nho (Ragocytes), khi s t bo hnh nho chim trn
10% s t bo dch khp th c gi tr chn on bnh VKDT.
Lng b th trong dch khp gim (so vi trong mu)
Phn ng Waaler - Rose v tet latex c (+) sm hn v cao hn so vi mu
(dng dch khp tin hnh xt nghim).
B. Sinh thit
Ngi ta thng sinh thit mng hot dch hoc ht di da chn on nhng
trng hp kh.
1. Sinh thit mng hot dch (Hnh 10)
Tin hnh st gi bng kali sinh thit hoc bng phu thut. Trong VKDT thy 5
tn thng sau:
- S tng sinh cc hnh lng ca mng hot dch.
- Tng sinh ca lp t bo ph hnh lng, t mt lp pht trin thnh nhiu lp.
- Xut hin nhng m hoi t ging nh t huyt (dng t huyt - necrose
fibrinoide).
- Tng sinh nhiu mch mu tn to phn t chc m.
- Thm nhp nhiu t bo vim quanh cc mch mu, m ch yu l lympho bo
v tng bo.
Khi thy c t 3 tn thng tr ln c th hng n chn on xc nh.

2. Sinh thit ht di da
- gia l mt m ln hoi t dng t huyt.
Xung quanh bao bc bi rt nhiu t bo lympho bo v tng bo.
C. X quang
1. Nhng du hiu chung
- Giai on u: thy tnh trng mt vi u xng v cn quang phn mm
quanh khp.
- Sau mt thi gian thy xut hin nhng hnh khuyt nh hay bo mn xng phn
tip gip gia sn khp v u xng, khe khp hp do sn khp b tn thng.
- Sau cng l tnh trng hu hoi phn sn khp v u xng gy nn dnh v bin
dng khp.
2. Hnh nh c bit
Cn chp hai bn tay vi khi xng c c tay, cc khp bn ngn v ngn tay.
Nhng du hiu X quang bn ngn tay thng xut hin sm v c hiu:
- Khe khp v ranh gii gia cc xng c hp v m, sau dn s dnh li thnh mt
khi.
- u xng bn tay v ngn tay xut hin cc hnh bo mn, khe khp hp ri
dnh khp:
- Khng thy tn thng khp ngn xa.

IV. Tin trin bin chng tin lng

A. Tin trin
Bnh c din bin ko di nhiu nm, phn ln c tin trin t t tng dn, nhng
c ti 1/4 trng hp c tin trin tng t, c nhng giai on lui bnh r rt. Rt
him thy trng hp lui dn ri khi hn.
Bnh c th tin trin nng ln khi b nhim khun, lnh, chn thng, phu thut.
Trong qu trnh din bin ca bnh ngi ta chia ra 4 giai on da theo chc nng
vn ng tn thng X quang (theo Steinbroker).
1. Giai on I
Tn thng mi khu tr mng hot dch, sng au ch phn mm, X quang cha
c thay i, bnh nhn cn vn ng c gn nh l bnh thng.
2. Giai on II
Tn thng nh hng mt phn n u xng, sn khp. Trn hnh nh X
quang c hnh bao mn, khe khp hp. Kh nng vn ng b hn ch, tay cn nm
c, i li bng gy nng.

3. Giai on III
Tn thng nhiu u xng, sn khp, dnh khp mt phn. Kh nng vn ng
cn t, bnh nhn ch cn t phc v mnh trong sinh hot, khng i li c.
4. Giai on IV
Dnh khp v bin dng trm trng, mt ht chc nng vn ng tn ph hon
ton.
Giai on ny thng gp sau 10 - 20 nm.
Theo mt thng k Bnh vin Bch Mai sau 10 nm ta thy khong 50% vn
giai on I, II khong 40% giai on III, ch c 10% giai on IV.
B. Bin chng v tin lng
Trong qu trnh tin trin, bnh nhn c th b cc bin chng:
- Nhim khun ph, nht l lao.
- Cc tai bin do dng thuc iu tr VKDT: thuc steroid, thuc chng vim, chng
gim au, thuc chloroquin, mui vng, c ch min dch.
- Chn p thn kinh, do cc tn thng phn mm quanh ng i ca cc dy
thn kinh ngoi bin, hoc tn thng ct sng c chn p tu c.
- Bin chng tim, thn v mt: him.
- Tin lng ca bnh da vo nhiu yu t. bnh thng nng nu c biu hin ni
tng, s khp vim nhiu, phn ng Waaler - Rose (-), chn on v iu tr mun
V. Th lm sng
A. Th bnh theo triu chng

1. Th mt khp: hay gp khp gi, chn on kh, cn tin hnh sinh thit
mng hot dch.
2. Th c kch to: hi chng Felty, bnh nhn c kch to, bch cu gim, i khi
c gan to, ni hch v sm da.
3. Th c km hi chng Sjogren Gougerot: VKDT c vim teo tuyn nc bt
v tuyn nc mt, cn gi l hi chng kh mt v ming.
4. Th xut hin sau bnh bi phi (hi chng Caplan), thng l nhim bi
than v bi silic.
B. Th bnh theo tin trin
1 Th lnh tnh: tin trin chm, s lng khp b t.
2. Th nng: nhiu khp, c st, c biu hin ni tng, tin trin nhanh v lin
tc.
3. Th c tnh: st cao, trn dch khp, tin trin rt nhanh dn n dnh v bin
dng khp.
C. Th theo c a
1. Th nam gii: nh v khng in hnh.
2. Th ngi gi: mc bnh sau 60 tui, bnh nh, d nhm vi thoi ho khp.
3. Th c phn ng Waaler - Rose (-), gi l th huyt thanh m tnh. Bnh nng,
iu tr kh.
VI. Chn on
A. Chn on xc nh
Chn on xc nh d dng khi c y triu chng ngha l phi giai on
mun (III, IV), vn t ra l cn chn on sm iu tr c nhiu hiu qu. Hi
Thp khp ca M (ARA - American Rheumatism Association) a ra mt tiu
chun chn on, cho n nay hu ht cc nc u cng nhn v s dng tiu
chun chn on ny. c gi l tiu chun ARA.
1. Tiu chun chn on ARA 1958: gm 11 im sau y:
- C du hiu cng khp vo bui sng.
- au khi thm khm hay khi vn ng t mt khp tr ln.
- Sng ti thiu t mt khp tr ln.
- Sng nhiu khp th khp trc cch khp sau di ba thng.
- Sng khp c tnh cht i xng hai bn.
- C ht di da.
- Du hiu X quang: bo mn u xng, hp khe.
- Phn ng Waaler - Rose, tt Latex (+) (t nht lm hai ln).
- Lng muxin gim r rt trong dch khp.
- Sinh thit mng hot dch tm thy t 3 tn thng tr ln.
- Sinh thit ht di da thy tn thng in hnh
- Chn on chc chn c khi c t 7 tiu chun tr ln v thi gian trn 6 tun.
- Chn on nghi ng c khi c 4 tiu chun v thi gian 4 tun.
2. Cc tiu chun chn on khc
- Tiu chun chn on Nu c 1968 n gin hn, ch gm 4 im thng dng
iu tra c bn.
- Tiu chun chn on ca vin Thp khp Lin X 1978 cng ging nh tiu
chun Nu c nhng chi tit hn.
- Nm 1987, Hi thp Khp M ra mt tiu chun chn on mi gm 7 im,
hin ang c nghin cu p dng v c gi l tiu chun ARA, ni dung nh sau:

2.1. Cng khp bui sng ko di trn mt gi.

2.2. Sng au ti thiu ba v tr trong s 14 v tr khp (khp ngn tay gn, bn
ngn, c tay, khuu, gi, c chn, bn ngn chn, bao gm c hai bn); thi gian ko
di trn 6 tun l.
2.3. Sng au ti thiu mt trong ba v tr: khp ngn tay gn, khp bn ngn tay,
khp c tay, thi gian trn 6 tun.
2.4. Sng au i xng
2.5. Ht di da
2.6. Phn ng tm yu t dng thp dng tnh
2.7. Hnh nh X quang in hnh
Chn on xc nh khi c t 4 tiu chun tr ln.
3. Trong iu kin v c im Vit Nam, do thiu cc phng tin (Xquang,
chc dch, sinh thit...). Chn on xc nh nn da vo cc yu t sau
- N, tui trung nin.
- Vim cc khp nh hai bn tay (c tay, bn ngn v ngn gn), phi hp vi cc
khp gi, c chn, khuu.
- i xng.
- C du hiu cng khp vo bui sng
- Din bin ko di trong hai thng
B. Chn on phn bit
1. Trong giai on u (khi cha c dnh khp v bin dng) cn phn bit
vi:
- Thp khp cp: da vo tui, tnh cht di chuyn...
- Thp khp phn ng: xut hin sau cc bnh nhim khun, vim khp khng i
xng, khng li di chng.
- Hi chng Reiter: vim khp, niu o v kt mc mt.
2. Trong giai on sau
Hi chng Pierre Marie: vim nhiu khp, c ngn tay v chn di trng, nguyn
nhn thng do u ph qun.
- Biu hin khp trong cc bnh to keo nht l bnh lupus ban h thng v x
cng b. Phn bit da vo cc du hiu ton thn, ni tng v xt nghim c hiu.
- Bnh gt: vim nhiu khp, ni u cc quanh khp, lng acid uric trong mu tng,
bnh ch yu gp nam gii tui trn 30.
- Bnh vim ct sng dnh khp: bnh nam gii, vim ct sng v cc khp ln
chn.
- Thp khp vy nn: vim khp km theo c vy nn ngoi da.
- Biu hin khp ca cc bnh tiu ho (vim i trc trng chy mu), bnh thn
kinh (bnh Tabes), bnh mu, ung th... mun phn bit cn hi bnh v thm khm
k.
- Thoi ho khp: au mi l du hiu ch yu, t khi thy sng nng .
VII. iu tr
A. Nguyn tc chung
- VKDT l mt bnh mn tnh ko di hng chc nm, i hi qu trnh iu tr phi
kin tr, lin tc c khi sut c cuc i ngi bnh.
- Phi s dng kt hp nhiu bin php iu tr nh ni khoa, ngoi khoa, vt l,
chnh hnh, ti gio dc lao ng ngh nghip.
- Thi gian iu tr chia lm nhiu giai on: ni tr, ngoi tr, iu dng.

- Phi c ngi chuyn trch, theo di v qun l bnh nhn lu di. Tm li vn

mang tnh cht x hi, lin quan n nhiu chuyn khoa v nhiu ngnh khoa hc.
iu tr bng thuc: a tr liu, ng thi ch nh c ba nhm thuc sau:
1. Thuc chng vim (chng vim khng steroid v glucocorticoid).
2. Cc thuc gim au (theo s bc thang ca T chc Y t th gii)
3. Cc thuc iu tr c bn (traitement de font) - cn gi l DMADRS (Disease
modifying Antirheumatis Druds): thuc chng thp khp c th thay i c a hoc j
gi l- SAARDs: Slow Acting AntiRheumatis Druds- Thuc chng thp khp tc dng
chm.
- Cc chin lc iu tr: s dng ngay t u cc thuc c th ngn chn c s
hu hoi xng v sn nhm thay i c din bin ca bnh: kt hp corticoid v
thuc iu tr c bn. iu tr triu chng ng thi vi iu tr c bn v gim dn
thuc iu tr triu chng khi iu tr c bn t hiu qu. Cc thuc iu tr c bn
c php duy tr lu di nu khng c tc dng ph.
B. p dng thc t
1. iu tr ton thn
a. Cc thuc chng vim
Glucocorticoid: hin nay c ch nh sm trnh hu khp. Dng thi gian
ngn. Sau dng k tip bng cc chng vim khng steroid.
Thuc chng vim khng steroid: ch nh mt trong cc thuc thuc nhm ny.
Cc nhm thuc ny c phn chia nh sau:
* Theo thnh phn ho hc c cc nhm chnh: carboxyl acid, Enol v nhm khng
c cu phn acid, t li tch ra 7 nhm thuc CVKS: nhm salycyle, nhm pyrazol,
nhm indol, nhm propyonic, nhm anthranilic, nhm oxycam v nhm khc, trong
c dn xut ca aryl - acetic acid.
* Theo thi gian bn hu cc thuc CVKS chia thnh hai nhm: nhm I c thi gian
bn hu ngn (< 6 gi) v nhm II c thi gian bn hu di (> 12 gi). Cc thuc
thuc nhm I l Profenid, Ibuprofen, Voltaren, Indometacin. Cc thuc nhm II l
Phenylbutazon, Felden, Tilcotil, Mobic. Cc bnh nhn ln tui nn cho cc thuc c
thi gian bn hu ngn.
* Theo kh nng c ch chn lc men COX (cyclooxygenase)
C hai nhm CVKS: thuc c ch COX khng chn lc (cc thuc CVKS c) v thuc
c ch COX - 2 c chn lc: Mobic (c), Lodin SR (c) Lodin SR (Anh), Celebrex
(M).
Trong c th c hai loi Cycloxygenase (COX) khc nhau c gi l COX 1 v COX-2
m vic tm ra chng dn n s pht trin ca mt th h thuc CVKS mi. Men
COX -1 xc tc qu trnh sn xut prostaglandin c tc dng bo v v mt sinh l
(PGI2 Prostacyclin),cn men COX-2 c to ra do phn ng vim (cm ng bnh l)
sn xut cc dng prostaglandin gy vim (PGE2).
Cc thuc CVKS khng chn lc (thuc CVKS c) c ch ng thi cc men COX-1
v COX-2, th ch c ch COX-2 c tc dng kim sot c cc trng hp vim v
au, cn c ch COX -1 li gy ra nhng tc dng ph trn thn v ng tiu ho.
Cc thuc CVKS c ch COX -2 chn lc c tc dng c ch s hnh thnh cc
prostaglandin v TXA2 c to ra do cc phn ng vim, ng thi cng c ch cc
cht trung gian gy vim khc nh superoxid, cc yu t hot ho tiu cu,
metalloprotease, histamin... trong khi , tc dng c ch ln COX-1 l ti thiu, do
lm gim thiu tc dng ph trn thn v ng tiu ho. Cc thuc CVKS c ch

COX-2 chn lc c ch nh vi cc i tng c nguy c cao, c bit cc bnh

nhn c tn thng d dy t trng.
b. Cc thuc gim au: iu tr theo s bc thang ca T chc Y t th gii.
Bc 1: gim au n thun
Bc 2: gim au kt hp
Bc 3: morphin
Thng dng bc 1 v 2. V d:
Paracetamol: 0,5g x 2-6 vin/ngy
Hoc Efferalgan Codein~ (paracetamol + Codein): 2-6 vin /ngy
c. Cc thuc chng thp khp tc dng chm - DMADRs.
Nhm thuc ny c cc tn gi nh sau:
- Thuc iu tr c bn (traitement de font): iu tr theo c ch bnh sinh.
- DMARDs - Thuc chng thp khp c th thay i c a (Disease modifying
AntiRheumatis Druds)
- SAARDs - Thuc chng thp khp tc dng chm (Slow Acting AntiRheumatis
Druds)
Gi l cc thuc chng thp khp c tc dng chm do kt qu ca chng t c
sau vi thng s dng, bnh c th thuyn gim hon ton: khp ht sng au, tc
lng mu tr v bnh thng, phn ng tm yu t dng thp m tnh tr li, qu
trnh hu sn xng ngng li, thm ch cc ht di da bin mt. Tuy nhin, chng
khng iu tr khi bnh, v nu ngng thuc th bnh li ti pht. Nhm ny gm cc
thuc sau:
* Thuc chng st rt tng hp:
Gm sulphat chloroquin (Nivaquin) v sulphat hydroxychloroquin (Plaqunil), c
ch nh rng ri, l thuc u tay Vit Nam.
Tc dng sau 1 - 4 thng iu tr, c ch nh vi th mi mc v nh. Liu dng:
200 - 600 mg/ngy. Vi ngi Vit Nam , liu thng thng 200mg/ngy.
Tc dng ph: chn n, nn, au thng v song khng gy lot d dy t trng. Tai
bin ng s nht l vim m li vng mc, him gp song gy mt th lc khng
hi phc, thng gp bnh nhn c iu tr thuc chng st rt tng hp trn hai
nm. Phi soi y mt thng xuyn (6 thng/ln, v ngng thuc ngay khi c du
hiu tn thng u tin. Mt s tc gi ch trng khng iu tr thuc chng st rt
tng hp qu 2 - 3 nm. Song vi liu 200 mg/24h th hu nh khng gp tai bin ny.
Hydroxychloroquin t tc dng ph hn chloroquin.
* Methotrexat (MTX) liu nh
Hin nay y l thuc DMADRs hng u c ch nh i vi VKDT. Liu 7,5 n
15 mg mi tun, ng tim bp hoc ung. Thng bt u bng liu 7,5 mg/tun (3
vin). Nu ung, chia ba ln, cch nhau 12 gi. Nu tim bp: mi tun mt mi duy
nht. Dng ko di nu c hiu qu v dng np tt. Hiu qu sau mt thng. Khi
t hiu qu, c th gim liu cc thuc kt hp: ln lt gim corticoid, CVKS, thuc
gim au cui cng. Liu MTX c th tng hoc gim tu hiu qu.
Trc khi iu tr, kim tra CTM, men gan, chc nng gan (t l prothrombin v nh
lng albumim huyt thanh) v creatinin. Lm li hng thng. Nu ph n tui sinh
, phi c bin php trnh thai hu hiu. Ngng thuc trc hai thng nu mun
sinh .
Mui vng: l thuc rt ph bin iu tr bnh vim khp dng thp trc kia,
nay t dng v methotrexat liu nh: c hiu qu hn.
* Penicillamin (Trolovol)

C ch tc dng cha bit r. Thng dng liu tng dn: 1 vin 300 mg mi ngy
trong mt thng ri 2 vin hng ngy trong 2 -3 thng. C th dng liu cao hn. Lui
bnh xut hin sau 2 -4 thng 60% s bnh nhn. Kh nhiu tc dng ph. Hin t
c ch nh.
* Sulfasalazin (Salazopyrine)
Liu 2 -3 g/ngy. t c s lui bnh khong 30% trng hp, sau hai thng iu
tr, hiu qu r nht sau 4 -6 thng.
Tc dng ph: ri lon tiu ho (nn, bun nn, au thng v, thuyn gim khi
dng thuc bo v d dy), lot ming, st, mt s tai bin rt him gp nh vim
gan, vim phi d ng, vim mao mch. Hin t c ch nh vi VKDT.
* Mt s thuc c t bo: bao gm cc thuc nhm mc ch c ch min dch
nh azathioprin, chlorambucil, cyclophosphamid: vim mng hot dch dng thp
dng nh c nguyn nhn min dch, do dng cc thuc ny nhm mc ch gim
min dch. Thc t, c ch ca thuc cha r, c th gy gim min dch chm, hoc
c th do hu cc t bo l thnh phn ca thm nhim vim.
* Chlorambucil: liu 12 mg/ngy trong t nht 3 thng. Lui bnh c th ko di 2-3
nm, thm ch hn.
* Cyclophosphamid: liu 100 - 150mg/ngy
* Azathioprin: liu 2,5 mg/kg/ngy. Hiu qu tng t nh chlorambucil. Tuy nhin,
cc thuc ny kh c: gy suy tu xng, mc c hi tng ng vi liu thuc,
i hi theo di cht ch. Thuc l yu t thun li cho nhim khun. Rt hay gp
Zona. Cc ri lon tiu ho thng lnh tnh, khng gy lot d dy t trng.
Chlorambucil v cyclophosphamid c th dn n v kinh v v tinh trng, nn phi
trnh dng ngi tr, tr trng hp c bit. C th gy qui thai, nu dng ph
n ang tui sinh sn phi km bin php trnh thai. Cyclophosphamid cn gy dng
tc v i mu. Cc thuc nhm ny cn lm tng nguy c mc bnh bch cu v u
lympho, nn l tr ngi chnh khi ch nh trong VKDT.
* Cyclosporin A: c ch nh trong VKDT khng p ng vi Methotrexat.
2. Cc phng php iu tr khc
- Bolus cortison: truyn chm 0,6-1,0 gam methylprednisolon mi ngy trong 3-5
ngy lin tc. c ch nh trong VKDT rt tin trin. Kt qu tt c duy tr sau 23 thng. C mt s nguy c: khi pht nhim trng nng, cao huyt p, thm ch t
t. Do , phi theo di k v ch nh thn trng.
- Thay huyt tng (plasmaphrses): mc ch lc b bt cc yu t gy vim
mch trong huyt thanh (cc phc hp min dch lu hnh trong mu ngoi vi ca
bnh nhn), c ch nh trong cc th c bit nh VKDT c vim mao mch nng
(vim a dy thn kinh, hoi th). Kt qu rt tt i vi vim mch, song t ko di
v phi c k tip cc cortison liu php v cc thuc hu t bo. Khng hiu qu
i vi VKDT khng c vim mch.
- Lc lympho bo (Lymphaphrse): loi b cc lympho bo tn thng bng cch
dn lu t ng ngc hoc lc t mch mu: ci thin c tnh trng vim a khp,
song c th ti pht dn dn tr li. Trn thc t, t gi tr iu tr.
- Chiu x h thng lympho ton thn: nhm tiu dit cc lympho bo, c bit l
CD4 m chc nng b ri lon. Liu thng dng l 2.000 rads. Thng t c s
ci thin r rt bnh song khng hon ton 75% trng hp trong 2-3 thng chiu
x. C th t c s ci thin bnh trong 2-4 nm sau chiu x, song phi trnh
chiu vo tuyn nc bt s gy kh ming.
3. iu tr ti ch

* Tim cortison ti khp

Ch nh: khp gi, vai, c chn. t ch nh i vi khp hng.
Kt qu tt, song trnh lm dng v phi lm vi iu kin tht v trng.
Ct b mng hot dch bng phng php ngoi khoa (m hoc di ni soi):
Ch nh: khp gi, c tay, khuu, ngn tay, song t khi ch nh cc khp khc.
Phi c tin hnh trc khi c hu hoi sn v xng mi t c kt qu tt.
Sau m, mng hot dch dn c to li, song khng vim d di nh lc u. Nu
m m c nhiu bt li th nay c th lm qua ni soi khp, kt qu rt tt, theo di
sau m nh nhng, nhanh chng phc hi chc nng vn ng. Ct b mng hot
dch cng c th thc hin vi cc nt dy chng vim do VKDT.
Hu mng hot dch bng cch tim ni khp cc cht phng x:
Dng cc cht pht ra tia b ta (yttrium 90 i vi khp gi v rhenium 87 i vi
cc khp ln khc, erbium 169 i vi cc khp nh tay) hoc ho cht nh acid
osmic.
Ch nh nh i vi ct b mng hot dch.
Kt qu nh gi sau 1-2 nm rt tt 60% cc trng hp. Khng nn lp li do
nhiu tch lu cc hot cht phng x.
4. Cc iu tr trong tng lai gn
- SKB 03-856 (c ch MAP- kinase): c ch thc chuyn vn cc tn hiu qua mng
nhn v iu ho tng hp TNF v IL1.
- Cc cht c ch ICE (interleuhine- 1B Converting Enzyme): rt c hiu qu v c
kh nng lm ngng tng hp IL- 1B, lm gim c c ch gy tin vim ban u ca
VKDT.
- Cc c ch tng hp TNF: thuc ang trong giai on th nghim lm sng. Hin
c mt bit dc ca M l Etanercept, liu 25mg tim di da 2 tun 1 ln. Kt qu
kh quan, song gi tin cn t.
5. Vn iu tr bng ngoi khoa, vt l
- iu tr ngoi khoa c ch nh trong hai trng hp: ct b mng hot dch khi
bnh ch cn khu tr gi v phu thut chnh hnh phc hi chc nng, (ghp cc
khp nhn to bng cht do, kim loi).
- iu tr vt l i vi bnh VKDT l mt yu cu bt buc nhm hn ch n mc
thp nht cc di chng, nhm ti gio dc li kh nng lao ng ngh nghip do bnh
nhn. iu tr vt l bao gm iu tr bng in, bng tay, bng mui khong, vn
ng
th
ng
v
ch
ng

GS TS. Trn Ngc n

Nhim khun tit niu s dng khng sinh
Nhim khun tit niu ni chung gm hai loi khc bit nhau:
- Nhim khun tit niu c hiu (specific infection) do cc loi vi khun c bit gy nn
nh vi khun lao, lu, hoc nm (actinomicosis).
- Nhim khun tit niu khng c hiu (non specific infection) l loi nhim khun thng
gp trong ng tit niu do cc loi trc khun gram (-) hoc cc loi cu khun gram (+)
gy nn. Trong chng nhim khun tit niu ch yu ni n loi nhim khun tit niu
khng c hiu.
I. i cng

Nhim khun tit niu ni chung gm hai loi khc

bit
nhau:
- Nhim khun tit niu c hiu (specific infection) do
cc loi vi khun c bit gy nn nh vi khun lao,
lu,
hoc
nm
(actinomicosis).
- Nhim khun tit niu khng c hiu (non specific
infection) l loi nhim khun thng gp trong ng
tit niu do cc loi trc khun gram (-) hoc cc loi
cu khun gram (+) gy nn. Trong chng nhim
khun tit niu ch yu ni n loi nhim khun tit
niu
khng
c
hiu.
Cc loi trc khun hay gp l Escherichia Coli
(E.Coli), Enterobacter aerogens, Proteus vulgaris,
Proteus mirabilless, Pseudomonas aerruginossa, v.v
Loi cu khun hay gp l Staphylococcus aureus.
Nhim khun c th xy ra bt k ni no trn ng
tit niu (hoc trn c quan sinh dc ca nam gii).
Nhim khun c th l th pht t mt nhim khun no ca c th theo ng mu lan ti.
Trong cc loi nhim khun tit niu, loi nhim khun thn l quan trng nht v n c th ph
hy nhu m thn, nh hng ti chc nng thn, gy suy thn, nguy him ti tnh mng ngi
bnh.
II. Nguyn nhn sinh bnh
1. Cc ng dn vi khun ti c quan tit niu
Rt kh xc nh con ng dn vi khun t nhim khun ca c th ti mt c quan ng
tit
niu
Nhn chung c 4 ng chnh dn vi khun tit niu i theo con ng ngc ln trn sau khi vi
khun xm nhp qua l so niu o. vi khun cn c th xm nhp do a cc dng c qua niu
o vo bng quang nh cc trng hp thm d hay soi ng tit niu.
Ngy nay ngi ta cn nu ln nhim khun l do nhng chuyn ng Brown n gin a vi
khun
ln
thn
do
c
ri
lon
dng
chy
ca
nc
tiu.
T
l
nhim
khun
c
th
thay
i
theo
tui
v
gii:
- Nhim khun niu thng hay xy ra tr s sinh n 10 tui v 80% xy ra tr n gii.
tr nam gii trong su thng u thng do c van niu o (Cohen, Bahona, Torp).
- Nhim khun tit niu t gp hn tui 10 20. T hn 20 tui nhim khun li nhiu hn.
- Ph n b nhim khun tit niu t l thun vi hot ng tnh dc v iu kin v sinh km v vi
khun c th t tng sinh mn lan ti, tin nh, m o ri vo niu o, ln bng quang
nam gii, on niu o cch ming so chng 3 4 cm c nhim vi khun (Helmholz). l
nguyn
nhn
a
vi
khun
vo
bng
quang
qua
niu
o.
- i vi nam gii ngoi 60 tui, t l nhim khun tit niu cao ln v nc tiu ng trong
bng quang do bnh u x tuyn tin lit, x cng c bng qaung, ung th tuyn tin lit, v.v
1.2. Nhim khun theo ng mu
T l nhim khun theo ng mu thp hn ng nhim khun ngc dng nhng li rt
quan
trng.
S lng mu cung cp qua cc mch mu vo thn chim khong s lng mu lu thng t
tim, bt c thi im no. Do khi trong mu c vi khun xut pht bt c nhim khun no
ca c th cng d gy nhim khun thn, nht l khi trn ng niu o li c tc hoc khi
thn
b
tn
thng.
Loi cu khun ti thn gy nhim khun to thnh nhng p xe v thn v c th lan rng ra
t
chc
quanh
thn
gy
p
xe
quanh
thn.

i khi nhim khun theo ng mu li pht sinh ngay t thn. trong trng hp ny cc vi
khun gram (-) c sn thn, vo mu ri li tr li gy ti nhim khun thn bng nhng p
xe nh trong thn.
1.3. Nhim khun theo ng bch huyt
Nhim khun tit niu c th do t ng bch huyt tuy t gp hn.
Mt s tc gi cho rng nhim khun i trng c th ti ng tit niu qua h thng bch
mch. Nm 1910 Franke c chng minh ng bch huyt t rut tha v manh trng thng vi
thn
phi.
Mt s tc gi khc cho rng vim c t cung c th gy nhim khun thn qua ng bch
mch
qua
niu
qun.
Tuy nhin cc gi thuyt nhim khun tit niu qua ng bch mch hin cn c nghin cu
v bn ci.
1.4. Nhim khun lan truyn trc tip t cc c quan ph cn
p xe trong bng nh p xe rut tha, vim ti tha i trng sigma v.v c th gy
nhim khun bng quang.
2. Cc yu t thun li gy nhim khun tit niu
Nhim khun tit niu xy ra do mt s yu t thun li tc ng thm.
2.1. Tc nghn v ng nc tiu
Khi trn ng tit niu c s tc nghn (do si, khi u) hoc c hin tng tro ngc
nc tiu, lm cho nc tiu ng pha trn niu o, bng quang, niu qun, i b thn
v.v vi khun s ng, tp trung v t c th gy vim, nhim khun ti ch ngc dng
ln
pha
trn.
tr em b to bn (Neumann, Norgrady) cng d b nhim khun ng niu v kh i tiu,
li nc tiu ng. Khi iu tr ht to bn th cng ht hin tng nhim khun niu.
2.2. D vt ng niu
Si thn d gy nhim khun niu, ngay c khi si khng gy tc ng niu.
D vt bng quang nh khi t ng thng, hoc bnh nhn a d vt vo bng quang hoc ch
khu v.v u tng kh nng nhim khun bng quang v ng tit niu ni chung.
2.3. S khng ca c th
Khi c th sc khng km do b m yu hay mc bnh mn tnh, nhim khun tit niu d
xy ra. Bnh nhn b bnh i ng d b nhim khun niu.
3. ng nhim khun mt s c quan tit niu sinh dc
3.1. Thn
Thn b nhim khun ch yu do ng ngc dng nht l khi c hin tng tro ngc
nc
tiu,
dn
dn
lm
teo
thn
do
vim
thn
cp
v
mn.
Thn cng c th b nhim khun theo ng mu.
3.2. Bng quang
Bng quang b nhim khun c th t thn xung, nhng thng thng ngc dng t niu
o
n
tuyn
tin
lit.
Nhim khun bng quang c th theo ng bch mch t c t cung, hay t cung b vim
nhim, v cng c th b lan thng t p xe rut tha, vim ti tha i trng sigma v.v
3.3. Tuyn tin lit
Thng thng t niu o do vim niu o
3.4. Niu o
c hai gii, nhim khun niu o thng thng i ngc dng t ngoi vo niu o. T
c th gy vim bng quang v tuyn tin lit hay xa hn. Niu o cng c th b nhim
khun t tuyn tin lit v bng quang i xung.
3.5. Mo tinh hon

Thng thng mo tinh hon b nhim khun xui dng qua ng dn tinh nhng cng c th
do ng bch mch t tuyn tin lit b vim.
3.6. Tinh hon
Tinh hon thng b nhim khun theo ng mu (ph cu khun, brucellae) v nhiu khi
b nhim khun do lan truyn trc tip t vim mo tinh hon.
III.
Triu
chng
lm
sng
Bnh c th gp bt c c quan no ca ng tit niu nn triu chng lm sng rt a
dng, ty thuc vo v tr tn thng, vo tui mc bnh v vo din bin cp hoc mn tnh ca
bnh.
Theo gii phu ca ng tit niu ta c th chia thnh hai nhm:
Nhim
khun
ng
tit
niu
trn.
- Nhim khun ng tit niu di.
1. Nhim khun ng tit niu trn (hoc cao)
Nhim khun ng tit niu trn l tnh trng nhim khun thn v 1/3 ng niu qun
trn, ch yu nhu m thn v i b thn cn gi l bnh vim thn b thn.
Trong th cp tnh, ngi bnh st cao 39 40 , rt run, mch nhanh, au vng tht lng mt
bn hoc hai bn, ton trng b nh hng: bun nn, nn, km n, mt ng.
Km theo bnh nhn c th i nc tiu, i but, i lc i ra mu.
Khi nhim khun km theo tc ng tit niu do si hoc nguyn nhn no khc, bnh nhn
c
th
c
cn
au
qun
thn.
Khm vng tht lng bnh nhn au nhiu, thnh bng cng v c th s thy thn cng to v
au.
2. Nhim khun ng tit niu di (hoc thp)
Nhim khun ng tit niu di l tnh trng nhim khun 1/3 ng niu qun, bng
quang, niu o v mt s b phn sinh dc lien quan vi ng tit niu nh tuyn tin lit, tinh
hon
Ngoi cc trng hp nhim khun nng, cp tnh, hoc phi hp vi vim thn cp, thng
thng nhim khun ng tit niu di t st hoc st khng cao, khng nh hng nhiu n
ton trng nh vim thn b thn m ch yu l nhng du hiu kch thch ca bng quang:
bnh nhn i but, i rt, i nhiu ln, i ra m (nc tiu c) v c khi i ra mu.
Thm khm thc th, bnh nhn cm thy au vng h v, c khi c cu bng quang do nc
tiu ng. Thm trc trng tuyn tin lit c th to v dau (vim tuyn tin lit).
Ngoi hai th bnh trn, c nhng trng hp nhim khun tit niu khng c biu hin lm sng
mu ch pht hin c khi nui cy vi khun trong nc tiu.
IV.
Chn
on
Ngoi mt s triu chng lm sng k trn, chn on nhim khun tit niu da vo cc du
hiu cn lm sng m ch yu l tm vi khun trong nc tiu.
1. Xt nghim nc tiu (xt nghim ch o)
Xt nghim nc tiu mang tnh cht quyt nh khi thy c vi khun trong nc tiu vi s
lng > hoc bng 10 m 5 /ml hoc c nhiu bch cu vi s lng ln hn hoc bng 10 m
4/ml.
Ngoi ra, ta c th thy trong nc tiu c t bo m v hng cu.
Khi nui cy vi khun, nht thit nn lm nhim khng sinh thch hp v hiu qu cho ngi
bnh.
Xt nghim nc tiu rt quan trng cho chn on do khi ly nc tiu lm xt nghim
phi lm ng quy trnh k thut trnh tp khun ln vo khi ly xt nghim.
Nhiu khi phi lm hm cc th tc ly nc tiu xt nghim nh chc kim trn xng mu vo

bng quang ly nc tiu tr em hay thng niu qun qua soi bng quang ly nc tiu
tng bn thn lm xt nghim v.v
2. Xt nghim mu
Hng
cu
thp
nu
bnh
nhn
i
mu
nhiu,
thiu
mu.
Bch
cu
tng,
nht
l
bch
cu
a
nhn
trung
tnh.
Tc

lng
mu
cao.
U r mu cao, creatinin mu cao khi chc nng thn b nh hng (kt hp vi tnh h s thanh
thi).
3. X quang
Du hiu X quang cng rt cn thit pht hin nguyn nhn gy tc ng niu, nh gi l
tnh trng tc v chc nng thn, pht hin hin tng tro ngc nc tiu (cng nh cc d
vt
hoc
d
dang,
ng
niu).
- Chp h tit niu khng chun b c th thy si bng quang, hnh bng thn.
- Chp niu tim tnh mch (UIV) nh gi chc nng thn, tnh trng tc ng niu, mt
s d dng tit niu, v gip chn on thng tn i b thn khi b vim nhim.
- Chp niu ngc dng (UPR) pht hin hin tng tro ngc nc tiu v gip chn on
mt s nguyn nhn gy tc ng niu.
4. Siu m
C th gip ta thy c hnh dng kch thc t chc nhu m thn, i thn, b thn, ng
niu v mt s nguyn nhn gy tc ng niu.
V.
Tin
trin
ca
bnh
Bnh
thng
tin
trin
trn
ba
hng:
1. Bnh pht trin nng ln: vi khun vo mu sinh sn pht trin gy nhim khun huyt hoc
sc nhim khun rt nng. Bnh nhn st rt cao 39 - 40 , mch p nhanh, huyt p h,
vt
v
kh
th,
tm
ti
v
rt
d
t
vong.
2. Bnh lui dn khi c pht hin, iu tr kp thi v c hiu qu
Cc triu chng lm sng mt dn, tuy nhin vn phi theo di nc tiu tip. Cn tin hnh nui
cy nc tiu tm vi khun sau khi khi bnh v vi tun sau khi khi bnh.
Nn tip tc chp x quang v lm xt nghim cn thit tm nguyn nhn gy bnh, iu tr trit

trnh
ti
pht
bnh.
3.Bnh iu tr cha ng nguyn tc, cha pht hin c nguyn nhn gy bnh (hin tng
tro ngc nc tiu nguyn nhn tc ng niu v.v) hoc mi iu tr lui bnh tm thi
ngng iu tr, vi khun cn tn ti bnh s ti pht v chuyn dn sang mn tnh.
Thn b hy hoi, x ha dn dn, chc nng thn suy gim dn n bnh nhan b cao huyt p
hoc suy thn dn dn dn n suy thn nng rt kh cho iu tr sau ny.
VI.
iu
tr
Cn phi iu tr tch cc lu di (c theo di ngay c sau khi khi bnh) v phi hp iu tr
ni, ngoi khoa.
1. iu tr ni khoa
1.1. iu tr khng sinh (xem phn s dng khng sinh)
1.2. B tr th dch
Cn theo di s lng nc tiu bi tit hang ngy cn bng th dch.
Nu bnh nhn khng trong tnh trng nng, khng b suy tim, suy thn nng, cho bnh nhn
ung
nc
nhiu
(trn
2
lt
/ngy).
Nu bnh nhn i t, n ung km cn truyn b dch tng cng lu lng tun hon.
Khi truyn dch cn ch theo di lng vo v ra ca c th, huyt p ng mch, huyt p tnh
mch trung tm v cc cht in gii (cl, Ka+, Na+, Ca++,), chng toan mu cho bnh nhn.

1.3. Tng cng sc khng ca c th bng cc thuc tr tim, tr sc.

1.4. Li tiu
Nu lng nc tiu t (sau khi b dch) cho thuc li tieur nh Lasix (ung hoc tim tnh
mch) liu lng s dng ty theo mc cn thit thng thng dung 20 40 mg/24h.
2. iu tr ngoi khoa
Gii quyt cc nguyn nhn tc ng niu qun nh m ly si tit niu to hnh ng
niu,
gii
phng
cht
hp
ng
niu,
bc
u
x
tuyn
tin
lit.
Gii quyt hin tng tro ngc nc tiu bng m cm niu qun bng quang theo phng
php
Politano

Leadbetter.
iu tr bng quang thn kinh
3. S dng khng sinh trong nhim khun tit niu
thuc khng sinh c th pht huy y tc dng cha bnh, ng thi hn ch mc
ti a cc bin chng hoc s mt hiu qu ca thuc do hin tng khng khng sinh ta cn s
dng
khng
sinh
an
ton,
hp
l
v
c
hiu
qu.
Mun t c yu cu trn ta cn thn trng khi iu tr khng sinh cho ngi bnh, v phi ch
n cc nguyn tc sau.
3.1.Chn khng sinh no?
Nhng yu t sau y nh hng ti s la chn khng sinh.
3.1.1 Loi vi khun gy bnh
Xc nh loi vi khun gy bnh qua soi knh l iu cn thit u tin ta iu tr khng sinh.
Nhiu khi qua soi nc tiu tm vi khun ta c th thy c chng loi v s lng vi khun
bc
u

c
quan
im
iu
tr
khng
sinh
ng
n.
Tuy nhin trong nhng trng hp nghi ng hoc bnh nhn c st cao rt run, cn nui cy vi
khun trong nc tiu, khi cn thit nn tin hnh c vic cy mu pht hin nhim khun
huyt.
Kt
qu
nui
cy
vi
khun
v
khng
sinh

cho
ta
bit.
- Vi khun gy bnh thuc mt chng loi hay phi hp nhiu chng loi.
- Cc loi khng sinh thch hp, nhy cm cho iu tr dit khun hay km khun.
3.1.2 C quan b bnh
i vi nhim khun ng tit niu di, ngoi cc khng sinh thng thng, ta c th dung
loi
khng
sinh
nhm
aminosid
hoc
cc
loi
sulfonamide,
nitrofuratoin.
Ngc li khi c bnh ng tit niu trn, c bit thn v cc trng hp suy thn, cn rt
thn trng khi s dng khng sinh c o thi qua thn nh nhm aminosid (aminoglycosid),
cc loi sulfamid, nitrofuration, cephaloridin
3.1.3. Tnh trng bnh
Bnh
din
bin
mn
tnh,
cp
tnh
hay
ti
cp.
Trng hp mn tnh phi s dng khng sinh c hiu qu theo khng sinh .
Trng hp ti hoc ti cp cn iu tr khng sinh mnh c hiu qu, nhiu khi phi phi hp
nhiu loi khng sinh vi nhau.
3.1.4. C a ngi bnh
Ty theo tui v c a ngi bnh m s dng khng sinh thch hp.

tr
em
nn
trnh
dung
cc
loi
thuc.
+
Nhm
phenicol:
chloramphenicol
+
Nhm
tetracylin,
oxytetracylin,
metacylin,
doxycyclin
+
Nhm
quinolon
kinh
in:
acid
nalidixic
+
Nhm
sulfamid
v
furadatin
(nitrofurantoin)
v.v
- ph n c thai: trong giai on c thai v cho tr b, cn thn trng khi dung thuc khng
sinh.

+
Khng
nn
dung
cc
loi
thuc.
+
Nhm
phenicol:
chloramphenicol
+
Nhm
tetracycline:
c
bit
t
4
thng
tr
i.
+
Nhm
sulfonamide
v
nitrofurantoin.
+
Nhm
quinolon:
acid
nalidixic,
norfloxacin,
ofloxacin.
+
Nhm
macrolid:
erythromycin,
josamycin.
Thn trng khi dung nhm aminosid nh gentamycin amikacin, tobramycin c bit loi
streptomycin.

ngi
cao
tui:
cn
thn
trng
khi
s
dng
cc
loi
thuc.
+
Carboxypencillin
lm
gim
kali
mu
d
gy
lon
nhp.
+
Pencillin
dung
liu
cao
c
th
gy
ng
kinh
lan
a.
+
Nhm
cloramphenicol.
+
Nhm
sulfamid
Gim liu lng hoc dung cch xa khong cch gia hai ln dung thuc i vi cc thuc nh
streptomycin, gentamycin, kanamycin, cephaloridin, tetracylin.
3.1.5. Cc phn ng ph ca thuc
Cn xem xt k cc phn ng ph ca thuc, trc khi chn thuc s dng, c bit i vi
cc c a d ng, tr em, ngi c tui, v.v
3.2. Chn ng a khng sinh vo c th
Ty
theo
tnh
trng
bnh:
- i vi nhng ngi nhim khun cn a thuc nhanh nht vo c th th tim ng tnh
mch.
- i vi nhng trng hp khng i hi cp bch lm th c th dung khng sinh tim bp tht,
tim
di
da
hoc
tim
tnh
mch
chm,
hoc
ng
ung.
Dung ng no cng cn ty thuc vo loi thuc. C thuc ch dung ng ny m khng
c
dung
vo
ng
khc.
Nu tnh trng bnh cho php (khng qu cp) th dung ng ung l phin phc hn c, v
cch cho ung thuc ny cng m bo nng cn thit ca thuc ti nhim khun.
3.3. Liu lng thuc
Phn nhiu cc thuc khng sinh bi tit qua ng thn, v nng thuc nc tiu cao
hn t chc, tuy nhin khi nng ny cha iu tr cc trng hp nhim khun cp
ng
tit
niu.
Do khi iu tr ta phi s dng, bo m chc chn thuc c tc dng dit khun hay km
khun vi nng cao hn nng trong nc tiu, nhng ni c iu kin, cn theo di bng
khng sinh , tm nng c ch ti thiu (MIC: minimal inhibitory concentration), nng dit
khun ti thiu (MBC: minimal bactericidal concentration), dit khun ca huyt thanh
3.4. Theo di vic s dng khng sinh
Khi quyt nh iu tr bng khng sinh th nht thit phi theo di cht ch, t nht cng
phi theo di xem ngi bnh c chu c thuc khng? Kt qu thng thng phi ch ly
mch
nhit
,
th
mu,
lm
cng
thc
bch
cu
iu tr nhim khun tit niu cp hoc mn thng thng thi gian iu tr ko di ti thiu 14
ngy. Nn ch vi khun li c th xut hin trn xt nghim hay nui cy 1, 4, 8 tun sau khi
iu
tr.
Nu thy vi khun nn iu tr tip trnh cho bnh khng tr thnh mn tnh.
C th cho thuc iu tr tieps sulfonamide 0,50 g x 2 ln /ngy hoc nitrofuantoin 50mg x 2
ln/ngy
trong
1
thng
hoc
hang
thng.
Nu iu tr ng quy cch m thy bnh khng , cn r sot li chn on, xem c bin
chng g mi xut hin, xem li cht lng thuc, hn dung, cch bo qun, v thc hin, y lnh.
Cng c khi phi thay i khng sinh hoc iu chnh liu lng, phi hp vi khng sinh khc

3.5. Phi hp khng sinh

Nhn chung ch nn iu tr mt loi khng sinh ph hp vi khng sinh .
Vic phi hp khng sinh ch thc hin c trong cc trng hp sau:
- Phi hp khng sinh nhm lm gim kh nng xut hin chng khng, nht l khi ngi
bnh
gim
sc

khng.
- Phi hp khng sinh nhm iu tr nhim khun do nhiu loi vi khun gy nn. Mi loi khng
sinh nhm dit mt loi vi khun, hoc kt hp dit cc loi vi khun.
- Ph hp khng sinh tng kh nng dit khun: phi hp carbenicillin vi gentamycin iu
tr
trc
khun
m
xanh
(Pseudomonas
aeruginosa).
Khi phi hp khng sinh phi ht sc lu n tc dng i khng ca thuc trnh dung cc
thuc i khng sinh.
Mt s thuc khng sinh thng dung trong nhim khun tit niu

PGS. TS. Nguyn K

Vim ph qun cp tnh v mn tnh - Cch iu tr

Gi bi Admin, lc 10:47 31/08/2011, | Bnh ng h hp
Ph qun l nhng ng nh dn kh vo trong bung phi. Vim ph qun
cp tnh l tnh trng nhim khun nhanh & ngn hn cc ph qun. Vim
ph qun cp tnh gy ra sng & tng tit dch (m) gy ra kh th. C th
c ho v th kh kh do lng dch xut tit nhiu trong ph qun.

1.

Vim

ph

qun

cp:

Vim ph qun cp thng xy ra do nguyn nhn siu vi (virus) tn cng vo lp

nim mc ca ph qun. Nhng triu chng nh sng, tit dch l hu qu ca nhng
phn ng ca c th chng li s nhim khun. Cn phi c thi gian c th git
cht
siu
vi
&
lm
lnh
cc
tn
thng

ph
qun.
Trong hu ht cc trng hp, cc virus thng gy ra cm cm cng l nguyn nhn
gy ra vim ph qun. Nhng nh nghin cu cho bit cc vim ph qun gy ra bi
vi khun t hn nhiu so vi nhng g chng ta ngh trc y. Rt him khi vim ph
qun
cp
gy
ra
do
nm.
Bn

vim

ph

qun

nh

th

no?

Virus gy ra vim ph qun cp bay l lng trong khng kh hay dnh vo tay ca
ngi b nhim, ..., khi h ho. Bn c th b vim ph qun cp khi tip xc vi cc
virus
(ht,
tip
xc
da
trc
tip
vi
virus,
...).
Nu Bn c ht thuc hay mi trng xung quanh nhiu bi bm th Bn d b vim
ph qun cp hn v b ko di hn. iu ny c th do cc ph qun b tn
thng trc v nhim siu vi ln ny ch l nguyn nhn bng pht cn vim
ph
qun
cp.
Vn

iu

tr:

Hu ht cc trng hp vim ph qun cp u t khi sau vi ngy hoc mt tun.

Do hu ht cc vim ph qun u c nguyn nhn virus nn cc khng sinh khng
c vai tr iu tr y. Ngay c khi ho c m c & c mu i chng na, khng
sinh hu nh cng khng c tc dng ci thin bnh nu nh nguyn nhn l virus.
Nu Bn ht thuc, hy ngng thuc l hoc ch t l gim thiu lng thuc ht trong
thi
gian
hi
phc
vim
ph
qun
cp.

 mt s trng hp, BS c th k toa cc thuc thng thy trong iu tr hen suyn

nhm
mc
ch
lm
sch
m
nht
trong
ph
qun.
Triu

chng

ho

trong

vim

ph

qun

cp

ko

di

bao

lu?

Ho trong vim ph qun cp c th ko di nhiu tun, thm ch nhiu thng. Ho ko

di l do cc ph qun cha lnh ln. Tuy nhin ho c th l triu chng ca bnh l
khc
nh
suyn
hoc
vim
phi.
Nn

Bc

trong

cc

trng

hp

sau:

Ho, kh kh ko di hn mt thng, c bit nhiu hn khi ng hay khi vn ng

nhiu
Ho

hn

mt

Ho,

thng

mt,

st

Ho

khc

ra

cao

dch

lin

mu

th

khi

Sng

nm

ph
g

trnh

ti

hi.
tc

ra

Kh

Lm

ho

chn

nhim

vim

ph

qun

cp?

Nu Bn ht thuc th y l mt l do b thuc. Ht thuc gy ra tn thng cc

cu trc ph qun v virus d dng tn cng gy bnh v lm cho vt thng ph
qun lu lnh. Ngoi ra thng xuyn ra tay loi b virus dnh trn tay trong sinh
hot
hng
ngy.
2.

Vim

ph

qun

mn

tnh

-Theo Hi tho quc t ti Anh 1965, vim ph qun mn l ho khc lu ngy, t nht
l 90 ngy trong mt nm v ko di 2 nm lin tc, sau khi loi tr cc nguyn
nhn
khc
(lao,
apxe,
gin
ph
qun...)
- C 3 loi chnh: th n thun ho khc m nhy; th m m (hay mc i mc li);
v
th
kh
th.
Nguyn nhn ch yu l s xm nhp ca vi khun v s suy gim kh nng
khng
ca
c
th
Yu t thun li lm suy gim sc chng ca nim mc l khi thuc l v khng
kh

nhim
Triu

chng

thay

khc

nhau

ty

tng

giai

on:

- Mi bt u l ho v khc m: Ho xy ra nhiu trong mt nm, tng t, d xut

hin khi tri lnh hoc thay i thi tit, c th ho khan nhng thng ho c m mu

trng v c bt. Khi ho lu ngy, m c hn, mu vng v c m, khi lng m

hng ngy t nht 5-10ml (y mt y bao dim) v sau tng nhiu hn. Khi tin
trin lu ngy, thm bin chng gin ph qun hoc apxe ho, khi lng m c th
hng chn. Cc t ho m thng xy ra lp i lp li, ban u 4-5 ln mt nm, mi
ln
10-15
ngy,
v
sau
thng
xuyn
v
ko
di
hn.
- Kh th l mt triu chng quan trng, xy ra giai on mun hn. Lc u ch l
cm gic "trng hi" nng n nh b nn trong ngc, dn dn bnh nhn cm thy
thiu
khng
kh
thc
s.
- Ngoi ra cn c mt s triu chng khc, tuy khng thng xuyn nh gy st, xanh
xao,
bun
ng
l
m
sut
ngy,
tim
p
nhanh...
iu

tr

- Ty tng trng hp c th, v nguyn tc, iu tr vim ph qun mn gm 3 ni

dung chnh: chng nhim khun mi (bi nhim); phc hi lu thng khng kh; chng
nguy
c
suy
h
hp
Phng bnh: d phng 3 cp: 1. d phng cn nguyn, loi tr cc yu t gy bnh
(d phng c bn); 2. d phng "chm tr": pht hin kp thi, iu tr ng lc; 3. d
phng "tn ph": tch cc iu tr d mun, hn ch tn ph, y li t vong
- Chng ht thuc v cc nguyn nhn gy nhim khng kh (khi, bi, khng kh
bn)
trong
gia
nh
cng
nh
ni
lm
vic
-

Cha

cc

vim

nhim

mn

Gim
Phng

cc

bnh

nhim

tnh

vng

mi

hng

ung
khun

hp

cp

ru
tnh

cho

tr

em

- iu tr sm v trit cc vim nhim ng h hp.

Bnh ng h hp thng gp
Gi bi Admin, lc 21:52 16/08/2011, | Bnh ng h hp
Hin nay tnh hnh vim nhim gy tn thng ng h hp (t mi,
hng, thanh qun, n kh ph qun, phi) din bin rt phc tp. C nhng
loi bnh tm c nguyn nhn gy bnh v c thuc cha tr, nhng
cng c mt s loi bnh tm ra c nguyn nhn gy bnh nhng cha
tm ra c thuc c tr. Do , bin php d phng, khng bnh xy ra
l iu ht sc quan trng.
Vim nhim ng h hp do vi khun
Loi vi khun gy bnh thng l: Ph cu v hemophilus influenzae... Loi vim
nhim ny thng biu hin qua cc du hiu sau:
- Bnh nhn st, lc u st t sau st ngy mt nhiu, st cao t 38o - 39o - 40oC,
hoc ngay t u st cao, ra nhiu m hi, mt bng, chn tay mnh my nng,
mch p mnh, ny, nhanh, cm gic rn rt vng thi dng, n khng thy

ngon, mt cm gic thm n.

- au tc ngc, c im au khu tr mt vng no ca thnh ngc tng ng
vi vng phi b vim nhim bn trong, au c th lan ln vai, xung pha bng,
nhng bao gi cng c im au xc nh.
- Ho lc u t, sau ho tng dn theo thi gian v mc st, lc u ho c khc t
m sau nhiu m hn, m mu xanh, vng, qunh, dnh c hoc mu g st hoc
c ln t mu.
- C th c kh th v kh th nhiu hay t l ty theo mc st.
V iu tr: Loi vim nhim ng h hp do vi khun dt khot phi dng khng
sinh cng sm cng tt. Dng khng sinh liu cao ph hp vi loi vi khun gy bnh.
Loi khng sinh c th dng l: pnicillin, amoxycillin, ampicillin, cphalexin,
erythromycin, cotrimazol, chloramphenicol hoc ciprofloxacin u c c. C th
dng mt loi khng sinh ko di 3-4 hoc 5-7 ngy ty tng trng hp, nhng
thng th phi hp hai loi khng sinh, v d: Phi hp pnicillin hoc cphalexin vi
chloramphenicol hoc vi cotrimazol. Cn thuc ho nn dng loi gim ho long m
cho d ho khc nh: Bisolvon, bromhathiol, exomuc, rhinathiol, hoc thuc nam tr
ho c th dng loi b ph, cam tho, bc h... Vic s dng khng sinh cng nh cc
loi thuc gim ho long m, phi do bc s khm k n v hng dn iu tr, ngi
bnh khng nn t mua thuc v cha tr ly.
Vim nhim ng h hp do virut:
Loi virut thng gy bnh l: rhinovirus, coronavirus, adenovirus,
influenzeavirus...
Loi vim nhim ny thng biu hin cc du hiu sau:
- Bnh nhn c th st nhng st khng cao ch 38oC, hoc c trng hp khng st
nht l ngi cao tui, nhng trong ngi cm thy n lnh, gai gai rt, thng c du
hiu nh cm cm: Nhc u, chy nc mt, nc mi, ht hi s mi, au mnh
my, au cc bp c, c khi c cm gic au nh dn, mt mi, khng mun lm bt
c vic g, nm ngh vn thy mt, au rt hng, vng c ni cc hch mm, nh,
khng au.
- Bnh nhn ho khng thnh cn nhng ho nhiu c th khi ho khc ra t mu, ho ko
di v c th ho bt c lc no trong ngy, thng ho nhiu v m lm mt ng,
ngi rt mt. Ho t khi c m, nu c th m thng trng, trong nh nc di. Khi
ho c m xanh, m vng hay m nhy m l trng hp c bi nhim vi khun.
Trng hp ny bc s c th cho dng khng sinh chng bi nhim.
- Bnh nhn c th c kh th, nghe phi c th thy mt s ran m, ch yu vng
hai y phi. Vim nhim ng h hp do virut thng c tnh cht dch, nn t khi
xy ra vi mt ngi m bao gi cng c nhiu ngi hoc mt s ngi cng b. Ho
ko di thng l ngi gi yu, suy nhc gy mn hoc sn c mt s bnh mn
tnh, kh nng chng ca c th km.
- iu tr loi vim nhim ng h hp do virut thng gp nhiu kh khn, v hin
nay cha c thuc c tr dit virut gy bnh, dng khng sinh khng c tc dng.
Trng hp ho ko di, nh hng n sc khe ngi bnh, bc s c th cho dng
thuc gim ho nh nu trn.
Vim nhim ng h hp mt s bnh l c bit khc:
Bnh lao phi, thng biu hin qua cc du hiu lm sng sau: Ho khc ko di,
hay st v chiu, m nm hay m hi trm. St cn, xt nghim m c th
pht hin c vi khun lao dng tnh (+), hnh nh trn phim Xquang c du hiu

tn thng lao. Hin nay c cc loi thuc chng lao iu tr c hiu qu tt.
Bnh ung th ph qun, phi cng ho ko di, c khi ho khc ra mu, bnh nhn
khng st, gy st nhanh, lm sinh thit ly bnh phm xt nghim c th pht
hin c t bo ung th. Nu c pht hin sm iu tr kp thi c th ko di cuc
sng cho bnh nhn.
Bnh SARS, y l loi bnh vim ng h hp cp nng, bnh mi pht hin nhng
nm gn y. Nguyn nhn gy bnh l do loi virut Corona, y l loi Coronavirus
hon ton mi l so vi cc Coronavirus c ngun gc t ngi v ng vt c bit
t trc ti nay. Triu chng ca bnh l st cao trn 38oC, kh th, ho khan, au u,
au mnh my. y thuc loi bnh dch ly truyn rt nguy him, t l t vong cao
do vim phi nng. Hin nay cha c thuc c tr.
Bnh cm g do virut cm A H5N1:
V triu chng lm sng bnh cm A H5N1 thc cht l hi chng vim phi cp
tnh rt nng, au ngc, kh th, tm ti, sc, trn phim Xquang thy hnh nh vim
phi k, tin trin nhanh, tn thng lan ta c hai phi. Bnh nhn t vong v suy h
hp nng, hin nay cha c thuc cha tr c hiu.
Tm li:
Nhng loi bnh l tn thng m nguyn nhn gy bnh l do vi khun nu c
iu tr khng sinh ph hp th bnh c th din bin tt n khi bnh, cn mt s
tn thng bnh l do virut nht l nhng bnh mi pht hin c trong nhng nm
gn y th cn gp nhiu kh khn v cha c thuc c tr, nn thc hin cc bin
php d phng mt cch nghim ngt, cht ch khng bnh xy ra l iu quan
trng hng u.
BS CK2 Nguyn c L
Gan Nhim m
Gi bi Admin, lc 18:29 18/08/2011, | Bnh gan
Gan nhim m c th l mt hu qu ca rt nhiu bnh, k c do ung
nhiu ru, cc bnh v chuyn ho, do s dng thuc v cc ri lon v
dinh dng.

I. I CNG
C rt nhiu c ch gy ra tnh trng gan nhim m. Mt trong nhng c ch
thng gp l do s oxy ho acid bo gan b gim, thng do s ri lon chc nng
ca ty lp th.
Hu ht cc trng hp gan nhim m khng c triu chng. Chng thng c
pht hin qua triu chng gan to thy c khi kim tra sc kho nh k, hoc qua
nhng bt thng nh cc ch s aminotransferase mu hoc alkaline phophatase
c th hin trong cc xt nghim thng qui.

 Gan nhim m l mt nguyn nhn him gp ca tnh trng suy gan bo pht.
Siu m v chp ct lp in ton c nhy khong 60% trong vic pht hin
tnh trng gan nhim m. Sinh thit gan c ch nh khi xut hin triu chng, khi
cc ch s men gan tng ko di trn su thng, hoc khi thy cn thit cho vic chn
on.
Vic kim sot tnh trng gan nhim m ph thuc vo nguyn nhn gy bnh.
Ch iu tr c th bao gm cai nghin ru; ngng dng cc thuc c nhiu kh
nng gy nn gan nhim m; kim sot cc bnh v chuyn ha, v d bnh tiu
ng; v gim cn vi mt ch n king t cht bo cho nhng ngi bo ph.
Khng c thuc iu tr c hiu no c khuynco
Gan ng mt vai tr trung tm trong s tch tr v chuyn ho ca cc cht bo.
Gan nhim m c nh ngha nh l mt s tch lu ca cht bo trong gan vt
qu 5% trng lng ca gan hoc quan st di knh hin vi thy nhiu hn 5% s t
bo gan cha cc ht m. Gan nhim m c pht hin trong khong mt phn ba
cc trng hp khm nghim t thi ca nhng ngi khe mnh t vong do tai nn .
Trong hu ht cc trng hp, cht bo ng ch yu l triglycerides, nhng trong
mt vi trng hp th phospholipids chim a s. Gan bnh thng cha khong 5 g
lipid cho mi 100 g trng lng ca gan, trong khong 14% l triglyceride, 64% l
phospholipids, 8% cholesterol, v 14% l cc acid bo t do . Trong gan nhim m,
lng cht bo chim c th chim n 50% trng lng ca gan, trong hn mt
na l cc triglyceride. Gan nhim m c th l mt kt qu ca rt nhiu bnh, bao
gm nghin ru, cc bnh v chuyn ha, cc ri lon v dinh dng, v ca vic s
dng thuc. S tch lu cht bo s phn b trong cc tiu thu gan, s phn b ny
ph thucvo nguyn nhn v s ko di ca tnh trng gan nhim m. Cht bo
ng trong t bo gan c th dng macrovesicular (nhng ht m ln y lch
nhn) hoc microvesicular (rt nhiu ht m nh nm xung quanh nhn t bo) tu
thuc vo din tin ca bnh. Cc chn on phn bit ca nhng bnh c lin h vi
gan nhim m c lit k Bng 46.1. Trong vic ghp gan vi nhng l gan b thm
nhim m t mc trung bnh n nghim trng, c nh ngha nh l c s hin
din ca cht bo nhiu hn 30% (i vi mc trung bnh)v 60% (i vi mc
nghim trng), th c mi lin h cho thy t l thiu ht chc nng tin pht cao hn
v t l sng st ca m gan ghp thp hn so vi vic cy ghp ca nhng l gan c
mc nhim m thp.
NHNG NGUYN NHN GY RA GAN NHIM M
Mn tnh
Cp tnh
Nghin ru
Gan nhim m trong thai k
Bnh bo ph (vim gan
Hi chng Reye
nhim m)
Bnh i ma
Bnh tiu ng
Jamaican
Tng lipid mu
Cc cht c dng
hp cht (carbon
Phu thut ni hi-hng
tetrachloride,
trng
trichloroethylene,
Thiu ht dinh dng
phosphorus, fialuridine)
protein-nng lng
Nui n qua ng tnh mch Thuc (tetracycline,
Nhng ri lon di truyn v valproic acid,
amiodarone,
oxi ha acid bo ty lp th
Cc bnh gan khc(vim gan glucocorticoids v
tamoxifen)
C mn tnh, bnh Wilson )

Bnh h thng (vim rut,

hi chng suy gim min dch
mc phi-AIDS)
II. BIU HIN LM SNG
Phn ln cc trng hp gan nhim m khng c triu chng. Cc bnh nhn
thng c pht hin mt tnh trng gan to, hoc nhng s bt thng nh v ch s
aminotransferase hoc alkaline phosphatase khi i khm bnh nh k. Trong cc
trng hp khc, tnh trng gan nhim m c ngh n khi bnh nhn c ch nh
lm siu m hoc chp ct lp in ton tm sot mt bnh khc, v d nh bnh
si mt. Tuy nhin, gan nhim m c th ch biu hin vi triu chng mt mi v
cm gic kh chu vng thng v phi. Vi tnh trng gan nhim m nng c th c
triu chng vng da, au bng, bun nn, i ma v gan to nh. nhng bnh nhn
gan nhim m do nhng nguyn nhn khc nhau th cng c km theo nhng triu
chng ton thn v nhng du hiu c trng ca nhng nguyn nhn .
Nhng bt thng v kt qu xt nghim ca tnh trng gan nhim m thng rt
t. Hu ht cc trng hp c s tng nh v cc ch s aminotransferases huyt
thanh, alkaline phosphatasse hoc g -glutamyl transpeptidase. Thng thng ch pht
hin mt bt thng v xt nghim gan, v d nh tng ch s alkaline phosphatase.
Cc bt thng khc t gp hn l tng bilirubin huyt thanh trc tip v gim
albumin huyt thanh. Gan nhim m nng c th biu hin vi triu chng vng da v
nhng bt thng r rt trong cc kt qu xt nghim gan.
S thm nhim m ca gan c th pht hin bng siu m hoc chp ct lp in
ton (CT). Vi phng pht siu m chun on, tnh trng thm nhim m gan
biu hin bng echo dy trong nhu m gan ("gan sng-bright liver"): du hiu ny c
lin quan vi s suy gim ca chm sng m v tng s r nt ca hnh nh tnh
mch ca v cc tnh mch gan. Vi CT , biu hin ca s thm nhim m gan l
mt vng c m thp hn , tnh mch ca vcc tnh mch gan l nhng cu trc
c m cao hn. nhy ca cc k thut chn on hnh nh ny i vi gan
nhim m ch t c 60%. nhy trn c tng quan vi mc thm nhim m
gan v tng n 80%-90% khi c hn mt na cc t bo gan trong vng nh chp
c b thm nhim m dng macrovesicular. S thm nhim m gan thng lan
ta nhng thnh thong rt khu tr v c th nhn bit r ch trong mt vng gan.
Nhng thm nhim m khu tr nh vy cn c phn bit vi mt thng tn
chong ch. Ngc li, trong vi trng hp nhng thm nhim m lan ta gan xut
hin nhng vng khu tr ri rc c th b nhn lm vi nhng thng tn chong
ch. Mt v d ca dng ny l gan thm m ca cnh sau ca thu IV ca gan gy ra
bi dn lu tnh mch rut bt thng k c cc tnh mch ca trong gan ca phn
thu. Hnh nh cn hng t vi nhng chui rung xoy tng i khng nhy pht
hin gan nhim m, ch c s khc bit t 5% ti 15% v cng cc tn hiu gia
gan bnh thng v gan cha c trng lng cht bo chim10%. S thm nhim m
khu tr in hnh th hin s tng cng cc tn hiu ca cc hnh nh T 1
-weighted spin-echo , v cc hnh nh T 2 - weighted th khng nhy mt cch r rng
i vi thm nhim m . Cc k thut hnh nh chuyn pha ho hc l cc k thut
ci tin pht hin cc vng gan nhim m. Cc k thut nh vy cho php phn
bit khi u gan vi mt thm nhim m cc b gan. Mt k thut spin-echo b
sung (hnh nh quang ph proton n gin- simple proton spectroscopic imaging) th
hin nhy cn trong pht hin thm nhim m gan trn th vt th nghim v
ngi. K thut b sung da trn s khc bit v mc di chuyn ca cc proton
trong phn t nc v trong cc phn t acid bo. Nhng hnh nh thu c trong cc

k thut ng b v tng phn c thm hoc bt thu c hnh nh ca m

nguyn cht v nc tinh khuyt. Thnh thong khi nhng k thut hnh nh khng
th phn bit c mt thm nhim m cc b vi mt thng tn chong ch, v d
nh mt ung th nguyn pht hay di cn, th chp X quang mch mu mc treo rut
hoc sinh thit gan trc tip cn thit cho chn on m hc.
III. SINH THIT GAN
Sinh thi gan khng c ch nh trong vic iu tr nhng bnh nhn gan nhim
m c pht hin mt cch tnh c. Sinh thit gan thng khng cn thit i vi
nhng bnh nhn c s ch s alkaline phosphatase hoc aminotransferase huyt
thanh tng nh (aminotransferase huyt thanh tng khng qu 2 ln ch s bnh
thng), bilirubin bnh thng d tm thy hnh nh ca gan nhim m tr khi c triu
chng lm sng hoc kt qu xt nghim cho thy c nhng bnh v gan khc. Sinh
thit gan c ch nh nu c cc triu chng: bnh nhn mt mi nhiu, men gan
tng trn 6 thng, v c nhng bt thng v cc xt nghim chc nng gan, c bit
khi cc triu chng v chc nng gan ngy cng xu i.
IV. BNH HC
Tnh trng m trn lan trong gan lm cho gan to. Bnh thng gan c mu vng
nht, b mt trn lng. S thay i thm nhim m cc b l mt nt thm nhim
m, m gan xung quanh thm nhim m t hoc khng thay i . Nhng nt m ny
khng phi l nhng u m bi v m thm nhim xut hin bn trong t bo gan. Di
knh hin vi, lipid c th xut hin bn trong t bo gan di dng nhng ht nh
(microvesicular) hoc ln (macrovesicular) hoc thnh thong kt hp c hai. Thoi
ho m dng microvesicular thng kt hp vi cc bnh nghim trng hn (Bng
46.1). Vic c nh cc mu sinh thit gan vi bng formalin trong qui trnh x l
thng qui lm cho m b ho tan, do nhng ht m tr thnh nhng hc trng
bn trong bo tng ca t bo gan. S hin din ca lipid c th c khng nh
trong cc lt ct ng lnh vi s tr gip ca cht du red O hoc Sudan black;
nhng bc ny him khi cn thit. S tch lu lipid d hnh thnh hn xung quanh
tnh mch trung tm cc bnh gan do ru. Tnh trang vim nhim nh vi cc t
bo lympho v bch cu trung tnh c th tm thy cng vi tnh trng thm nhim
m. Trong nhiu trng hp, thm nhim m kt hp vi cc bnh gan tin trin,
bng chng l c s hin din cas hoi t t bo gan, vim nhim t trung bnh ti
nng vi cc t bo lypho v bch cu trung tnh, v th trong sut Mallory (bng
chng ca vim gan do ru), x ho, hoc thm ch l x gan. Thm nhim m c
c im m hc ca nhiu bnh gan khc nh vim gan C mn tnh v bnh Wilson .
Kim tra vi knh hin vi in t , lipid tn ng l nhng bng c bao quanh bi
cc lp mn trn lng v li ni cht th. Triglycerides v apoprotein c tng hp
li ni cht th, v do s tng tng hp hay gim tit m chng b ng thnh
nhng git ln.
V. QU TRNH CHUYN HO LIPID GAN
Gan c mt chc nng quan trng trong qu trnh chuyn ha cc cht bo. Lipid
lu thng trong mu di dng lipoprotein. Thnh phn lipoprotein bao gm mt nhn
lipid k nc, ch yu l triglycerides v cholestrol ester, bao quanh l mt lp v gm
phospholipid phn cc v apoprotein. Su lp chnh ca lipoprotein c phn loi
da trn mt v cu thnh ca chng . Nhng lipoprotein giu triglyceride l nh
trp cha nhng triglyceride t khu phn v c tit t cc t bo rut vo trong
bch mch, v nhng lipoprotein t trng rt thp (very low density lipoproteins
-VLDLs) c tng hp v tit ra nh t bo gan. Cc lipoprotein t trng thp (low
density lipoproteins -LDLs) v cc lipoprotein t trng cao (high-density proteins -

HDLs, gm HDL-2 v HDL-3) c thnh phn ch yu l cholesterol esters v c sn

xut t cc qu trnh chuyn ho trong mu. Cc lipoprotein t trng trung bnh
(intermediate-density lipoproteins - IDLs) v cc LDLs l nhng sn phm chuyn ho
ca VLDLs. Cc acid bo l nhng yu t chnh quyt nh s tng hp v bi tit cht
bo ca gan .Cc ngun acid bo t do chnh cho s tng hp triglyceride trong gan
l thc phm, t s phn hu ca m m, v t s tng hp ca chnh cc t bo
gan. Sau ba n, cc triglyceride thc phm c chuyn t trong rut vo trong
bch huyt di dng nh trp v c thu phn thnh acid bo v nh men
lipoprotein lipase c trong mt trong mch bch huyt. Cc acid bo ny c s
dng lm nng lng cho c, c d tr di dng cc triglyceride ti ester ho
trong cc m m, hoc c s dng gan. Mt vi acid bo c ngun gc t phn
tha ca nh trp sau khi c a ti gan v thu phn bi men triglyceride
lipase ca gan. Trong giai on nhn n, s thu phn cc triglyceride d tr trong m
m l ngun acit bo chnh c a vo gan. S tng hp ni sinh ca aicd bo
trong gan din ra trong bo tng ca t bo gan, bt u vi s kh carbon acetyl
coenzyme A (CoA), l cht c chuyn ho t glucose, thnh malonyl CoA. Phn ng
ny c theo sau bi s xc tc ca mt chui phc hp a enzyme, trong s xc
tc ny i hi phi c dng kh ca nicotine adenine dinucleotide phosphate
(NADPH).
Cc acid bo t do trong gan c oxy ho bi cc ty lp th, v c s dng cho
qu trnh tng hp triglyceride hoc c dng trong qu trnh to ra phospholipid
hoc cholesterol ester . Bc khi u thng gp ca qu trnh oxy ho hoc tng
hp cht bo l s hot ho ca cc acid bo bi glycerol 3-phosphate. Glycerol 3phosphate c hnh thnh t s ging ho ca dihydroacetone phosphate, l mt
sn phm ca s chuyn ho glucose trong chu trnh Krebs (chu trnh tricarboxylic
acid - TCA).
S tng hp v tit ra VLDL m ng cho s tit xut triglyceride d tha ra khi
gan. Triglyceride, cholesterol, cholesterol esters v phospholipid u c tng hp
trong li ni cht th ca t bo gan. Apoprotein B100, cng c tng hp trong
li ni cht th, bao gm 30% n 40% ca lng protein trong VLDL huyt thanh v
95% protein trong LDL huyt thanh. Gan cng tng hp Apo-Al - mt thnh phn ch
yu ca HDL - v Apo E, mt thnh phn ca c VLDL v HDL. Nhng apoprotein mi
sinh ra c tng hp trong li ni bo th v c chuyn ti ti cha ca li ni
cht trn, l ni vic gn kt vi cc lipid bt u v tip tc sau khi vn chuyn ti
b my Golgi. B my Golgi l ni nhng protein v lipoprotein mi sinh c c c
v tit ra ngoi ti b mt y ngoi ca t bo gan vo khong Disse nh c ch thi
ca t bo . Cc bc trong qu trnh oxy ha ca acid bo sau s hot ho cc acylCoA ester ca chng bao gm transesterification thnh cc acylcarnitine i vo ty
lp th, s ti to ca cc Acyl-CoA ester bn trong ty lp th, v intramitochondrial b
oxidation spiral vi s to thnh acetyl CoA. Phn cn li th c chuyn ho qua chu
trnh TCA thnh carbon dioxide hoc qua con ng 3-hydroxy-3-methylglutaryl CoA
(HMG-CoA) thnh cc ketone (acetoacetate v 3-hydroxybutyrate) . Cc triglyceride
chui va c th vo trong ty lp th m khng cn s vn chuyn trung gian
carnitine .
Phn 2: Cc dng gan nhim m
I. GAN NHIM M DO RU
1.Sinh bnh hc
Nhiu nm qua c nhiu bn ci v vai tr ca ru v s suy dinh dng trong
sinh bnh hc ca gan nhim m. Vai tr chnh yu ca ru trong vic gy ra gan

nhim m c cng c qua nhng m t s hnh thnh gan nhim m trn th

vt th nghim vngi c cho ung km ru theo trong mt ch n cn bng
v y . Yu t chnh trong sinh bnh hc ca gan nhim m do ru l s gia tng
kh nng san c ca acid bo trong gan Ngun gc ca cc acid bo ph thuc vo
vic ung ru mi y hay lu. Cc acid bo c th c to ra t s thu phn
ca triglycerides trong m cha m sau khi ung mt lng ln ethanol . S phng
thch cc acid bo trong nhng iu kin nh vy tng t nh trong trng hp cng
thng. S phng thch acid bo ny c iu ha phn ln qua s phng thch
epinephrine, bi v ngi ta thy nhng bnh nhn phu thut tuyn thng thn v
dng cht c ch adrenergic (dibenamine) v nhng cht c ch hch th hin tng
ny khng xy ra. Sau qu trnh n ung lu nm vi ethanol th thc phm l ngun
to ra acid bo v lng cht bo ng tng ln bi s tiu ho nhng thc n nhiu
m. S gia tng ca triglyceride trong gan c m t nhng ngi ung ru vi
mt ch dinh dng in hnh ca M l 36% ngun nng lng t m, tri ngc
vi nhng ngi c ch dinh dng t m (5% ngun nng lng t m). Thnh
phn ca acid bo trong triglyceride ng phn nh thnh phn ca acid bo trong
khu phn n, v d c nhiu laureate (12:2) v myristate (14:0) t du da v
linolenate (18:3n-3) t du lanh trong khu phn, ngc vi palmitate (16:0) v oleate
(18:1n-9) c tng hp ni sinh khi khu phn n t m. Cc ester acid bo
triglyceride chnh hin din trong gan bnh thng l palmitate (16:0) v oleate
(18:1n-9). nhng mu sinh thit t nhng bnh nhn gan thoi ho m do ru, t
l ca linoleate (18:2n-6) v linolenate (18:3n-3) thp hn v t l ca oleate (18:1n-9)
cao hn bnh nhn tiu ng c gan thoi ha m v nhng ngi kho mnh. S
gii thch thch hp cho nhng pht hin ny l ch dinh dng km, s c ch
hot tnh kh bo ha ca D6 v D5 do ung ru mn tnh v s thoi ha ca cc
acid bo khng c kh nng sinh cholesterol do s peroxidation ca cht bo.
Tng tng hp v gim phn gii ca acid bo trong gan l kt qu ca vic nghin
ru mn tnh.Nhng tc ng ny ca ca ru c lin h ch yu n t l gia
dng kh v dng oxi ho ca nicotine adenine dinucleotide (NADH/NAD + ), v t l
ny tng ln trong sut qu trnh chuyn ho ca ru . S tng tng hp ca acid
bo c kch thch bi s tng NADPH xut hin khi gim cn bng t NADH c
chuyn thnh dng b oxy ho ca nicotine adenine dinucleotide phosphate NADP + .
Tuy nhin, s tng tng hp acid bo khng phi lc no cng c chng minh, vai
tr ca n trong s ng acid bo gy ra do ru khng quan trng bng trong s
gim oxy ho. S oxi ho acid bo, l qu trnh oxi ho lm chuyn ha acetyl CoA
thnh CO 2 , b gim do tc ng c ch ca s tng t l NADH/NAD + trong c
-oxidation spiral ca acid bo ln chu trnh TCA . Acetyl CoA sinh ra t s chuyn ha
ru cnh tranh vi acetyl CoA sinh ra t acid bo vo trong chu trnh TCA .
Nhng bin i ng ch vi cu trc ca ti lp th xut hin sau khi ung ru .
Cho chut ung ru trong mt thi gian di lm gim mitochodrial cytochromes aa3
v b, s h hp ti lp th ti a vi nhng c cht khc nhau, v s hnh thnh
adenosine triphosphate. Carnitine palmitoyltransferase I (CPT-I) xut hin chut sau
khi cho chut ung ru lm suy yu s oxi ho acid bo . CPT-I xc tc cho bc
nh gii hn tc chuyn ch ca acid bo vo trong khun ti lp th. S xa b
DNA ti lp th ca gan c tm thy mt vi bnh nhn nghin ru c thoi ha
m dng bng nh.. iu ny cho thy nhng s xa b nh vy l kt qu ca s
peroxide lipid tng cng v n gp phn lm tng s oxi ha acid bo. nhng
ngi tnh nguyn khe mnh c cho ung lng ru trung bnh 96g mi ba n,
ngi ta o bng php o nhit lng gin tip v thy rng c s tng mc tiu
hao nng lng trong 24 gi v gim oxi ho lipid .

S hnh thnh triglyceride do nng acid bo tng nh s gia tng nng

-glycerophosphate, s gia tng ny nh lng NADH tng do ru v s tng hot tnh
ca men L- -glycerophosphate acyltransferase ti lp th , men ny xc tc bc
u ca con ng hnh thnh triglyceride. Hot tnh ca men phosphatidate
phosphohydrolase, diacylglycerol, l men xc tc cho qu trnh dephosphorylate ca
phosphatidate thnh diacylglycerol, mt bc gii hn tc trong qu trnh tng hp
triglyceride, tng ln ngi v ng vt b gan nhim m .
Vic gim thnh lp t bo gan v s phng thch cc lipoprotein khng phi l
nguyn nhn chnh ca gan nhim m do ru, bng chng l c s tng km theo
ca nng lipid mu . Tuy nhin, c v nh l s gii phng lipoprotein t gan khng
th kim hm c s lng lipid c to ra gan v do gp phn vo s ng
ca lipid. Cui cng s ri lon chc nng gan kt hp vi ng cht bo c kh
nng gp phn lm tng phng thch lipoprotein, bng chng l cui cng nng
lipid huyt thanh tng, v xa hn na l gia tng m ng trong gan sau khi ung
ru ko di. Acetaldehyde c bit to thnh cht dn tubulin ; kt qu l c ch s
hnh thnh cc vi ng v tit xut protein . Vic iu tr bng ru chut lm suy
yu s bi tit gan v cc glycoprotein mng t phc hp Golgi n mng huyt
tng v ci thin receptor mediated endocytosis.
Cc t bo Kupffer ng mt vai tr trong bnh sinh ca gan nhim m. Ph hu t
bo Kupffer bng cch dng gadolinium chloride cho nhng con chut c cho ung
ru trong 6 tun thy c s gia tng r rt lng m trong gan c th nhn bit v
mt m hc . Gadolinium chloride hoc nhng khng sinh dng kh khun trong
rut ngn chn s ng triglyceride gy ra bi vic ung mt lng ru trong
mt thi gian ngn chut . Khng sinh ci thin c nng ni c t tng ln
trong mu khong ca v s tng sn xut prostaglandin E 2 (PGE 2 ) bng cch tch
bit cc t bo Kupffer sau khi ung ru. Bi v PGE 2 tc ng ln cc t bo gan
lm tng s tng hp triglyceride, c th l gan nhim m sau khi ung mt lng
ru trong mt thi gian ngn c th c trung ho bng cch tng tnh thm ca
rut i vi ni c t; kt qu l tng s hnh thnh PGE 2 bi t bo Kupffer.
Peroxisomes trong t bo Kupffer cng tham gia vo s oxy ho acid bo .p ng
km ca h thng peroxisome ca qu trnh oxy ha acid bo trong vic cho vo
ethanol ko di c th gp phn sinh ra gan thm m do ethanol.
2.Biu hin lm sng
Gan nhim m thng xy ra sau khi ung mt lng ru t trung bnh n nhiu
u n trong mt khong thi gian ngn . Trong mt cuc kho st trn 55 bnh
nhn nghin ru mn tnh ang cai nghin khng c triu chng lm sng hay cn
lm sng ca bnh gan, kt qu sinh thit gan cho thy 56% b thm nhim m . Tnh
trng thm nhim m nng kt hp vi triu chng kh chu, tnh trng yu km,
chn n, bun nn, cm gic au nh bng v gan to nh. Khong 15% bnh nhn
nhp vin b vng da. Cc triu chng dch, portal hypertension vi lch to, xut
huyt do dn tnh mch thc qun t khi xy ra phn ln cc trng hp nng . Du
hiu thng gp l aminotransferase v alkaline phosphatase huyt thanh tng nh.
Trong cc trng hp ch s enzym huyt thanh tng th ch s aspartate
aminotransferase (AST) huyt thanh tng cao r rt so vi ch s alanine
aminotransferase (ALT), thng th ALT mc bnh thng. Du hiu mt vi ch s
alkaline phosphatase tng cao r rt c th xut hin khi km theo au vng thng
v phi, st, bch cu tng v n c th gy nhm ln vi tc ng mt ngoi gan . Ch
s g -glutamyl transpeptidase cng tng nhng khng c gi tr nh gi mc
tn thng t bo gan bi v n thng tng cao nhng bnh nhn nghin ru
khng c tn thng gan r rt do sn sinh microsomal bi ru. Khong 25% bnh

nhn c s albumin huyt thanh gim v globulin huyt thanh tng . Cc du hiu
lm sng v kt qu xt nghim thng khng phn bit c gan nhim m, vim
gan do ru, x gan, v kt qu sinh thit c th c s kt hp du hiu ca c ba
bnh gan do ru trn. Tuy nhin, nhng bnh nhn ch c gan nhim m m khng
triu chng th thng khng nghim trng bng nhng bnh nhn c km theo
nhng ri lon bt thng khc. Tnh trng lm sng ca h c th ci thin cng vi
cc ch s aminotransferase huyt thanh gim thp trong vng 10 ngy sau khi king
ru v bt u mt ch dinh dng y . Ngc li, nhng bnh nhn vim
gan do ru th cc ch s aminotransferase vn tip tc tng. nhng bnh nhn x
gan khng hot ng thng c cc du hiu ca tng p tnh mch ca v c th c
cc ch s aminotransferase bnh thng. T l mc bnh cao ca cc bnh nhn vim
gan siu vi C pht hin c qua huyt thanh chn on, vic s dng kt hp cc
loi thuc khng hp php v s cc bnh nhn b hi chng suy gim min dch mc
phi ngy cng tng trong nhm cc bnh nhn nghin ru mn cng gy kh khn
cho vic chn on gan nhim m . Chn on vim gan siu vi phi c ngh ti khi
m ch s ALT huyt thanh cao hn ch s AST huyt thanh. Chn on vim gan siu
vi C i hi phi c nh lng RNA ca siu vi vim gan C. Kt qu tr nn m tnh
sau 2 tun nhim bnh. Cc kt qu xt nghim tm khng th siu vi vim gan C
dng tnh sau khi nhim bnh 4 n 10 tun, v kt qu dng tnh gi tng ln
mt vi bnh nhn vim gan do ru v tng gammaglobulin mu.
Nhng bnh nhn nghin ru c ch s amiotransferas huyt thanh tng cao cng
c th tng b vim gan do ng c acetaminophen. Chn on ny cn c kim
chng bng tin s dng acenomiphen v c nng acetaminophen trong mu tng
cao trc . Nhng bnh nhn vim gan do ng c acetaminophen thng c thi
gian prothrombin xu i mt cch nhanh chng, trong khi tnh trng ny khng xy ra
bnh nhn gan nhim m n thun v l mt din tin bt bnh thng bnh
vim gan do ru. Nghin ru mn tnh c kh nng lm tin trin ca bnh vim
gan do ng c acetaminophen nng thm bi v n lm lm tng men oxi ho a
chc nng ca ti th (microsomal mixed-function oxidase), l mt loi men lm
chuyn i acetaminophen thnh mt cht chuyn ho c hi v lm gim
glutathione gan, l mt cht kt hp vi cc cht c thi ra t cc quchuyn ha.
Nhng bnh nhn nghin ru cng c th b vim gan do ng c acetaminophen
sau khi ung qu liu mt lng acetaminophen di 2,6 g .
3.iu tr:
iu tr bnh gan nhim m bao gm king ru v c mt ch dinh dng y
. Theo ch iu tr trn, tnh trng ng m bt thng trong gan s mt hn
trong vng 1 n 4 tun. Ngh ngi tuyt i khng gip ch cho kt qu iu tr. Cc
kch t nam, trong mt vi nghin cu cho thy l nhng cht lm tng tc chuyn
ha lipid (nhng trong vi nghin cu khc khng thu c kt qu nh vy ), c th
gy bt li bi v chng c th gy ra mt v do khng c ch nh trong iu
tr. iu tr ban u cho mt bnh nhn gan nhim m do ru i hi chp hnh tt
liu php cai ru. Nhng triu chng sm ca hi chng cai nghin l bn chn, lo
lng, run git, m hi, mt ng, v trong vi trng hp c o th. S cai nghin c
lin quan n s tng nhp mch v huyt p km vi dn ng t. Theo sau c
th l nhng cn ng kinh hay m sng ru cp. Cc triu chng ca hi chng cai
nghin ru thnh thong cng c th gy kh khn cho vic chn on phn bit vi
cc triu chng ca bnh vim gan th no (hepatic encephalopathy), cng c trng
hp chng xut hin cng mt lc. Tuy nhin, hi chng cai nghin c c trng bi
cc triu chng tip lin ca tng hot ng thn kinh t ch v mt ng hon ton;
cn trong bnh no gan th cc du hiu ca tng vn ng v mt ng thng ch

din ra tm thi, thng xut hin ban m v thay th bng tnh trng ng g vo
sut ngy.
Cn m sng ru cp, bin chng quan trng nht ca hi chng cai ru, thng
xut hin vo khong 2 n 3 ngy sau khi ngng ung ru nhng cng c th xut
hin tr hn, khong 7 ti 10 ngy sau . Bnh nhn c triu chng mt nh hng,
l ln, o gic, kch ng, hot ng khng t ch v thnh thong ln cn ng kinh.
Cc bnh nhn thng b st, mch nhanh, tot m hi, mt bng v dn ng t.
Cc triu chng trn thng gim bt sau 3 ti 5 ngy. Du hiu cui cng ca hi
chng ny l bnh nhn chm vo gic ng su v c nhng khong tnh ko di dn.
T l t vong ca sng ru cp c bo co khong 30%.
Cc triu chng sm ca hi chng cai nghin ru v din tin ca ti ng kinh
hay cn sng ru cp c th phng nga bng thuc an thn. Thuc thng c
dng lm du thn kinh cho nhng bnh nhn bnh gan l benzodiazepines liu
thp, v d nh oxazepam (Serax) hoc lorazepam (Ativan), nhng thuc ny b
chuyn ho v bt hot bi glucuronidation m khng qua gan . Oxazepam, dng liu
15 - 30 mg hoc lorazepam liu 0.5 - 1.0 mg, thng dng 3 ln mt ngy l
kim sot cc triu chng ca hi chng cai nghin m khng gy nn tc ng an
thn r rt. Nhng bnh nhn b sng ru cp c th cn phi c ch ng ban u
khi dng thuc an thn bng lorazepam tim mch, 0.5 -1.0 mg mi 5 pht cho n
khi bnh nhn bnh tnh tr li. Sau chuyn sang liu ch nh tip tc duy tr
tnh trng n nh ca bnh nhn. Cc Benzodiazepine, v d diazepam (Valium), l
nhng cht c chuyn ho ban u thnh dng c hot tnh bng h thng men
mixed-function oxidase, nn trnh s dng bi v hot ng ca h thng ti lp th
ny c th tng ln bnh nhn nghin ru mn hay bnh nhn bnh gan tin trin.
Kim sot hi chng cai nghin ru i hi s ch n bi hon in gii v dch
truyn. Cn phi da trn nh gi nhu cu hng ngy, tnh n nhng tht thot
tng do kch ng, st, m hi. Trong trng hp bnh nhn n ung km, lng
dch truyn c t nht 1.000 mL dextrose 10% phng h ng huyt v 1.000
mL nc mui sinh l. Vitamine B c tim bp 100 mg kim sot tnh trng thiu
ht vitamine B. Tim tnh mch hoc ung a sinh t c acid folic, 1 mg/ ngy do
nhng thiu ht cc vitamine ho tan nhng bnh nhn ny.
4.Tin lng
Gan nhim m mt bnh nhn nghin ru thng l mt bnh c th hi phc;
tuy nhin, nu tip tc ung ru thng dn n vim gan do ru v x gan. Nguy
c x gan lin quan n lng ru v khong thi gian ung ru. S hot ho t
bo hnh sao c tm thy cc mu sinh thit ca nhng bnh nhn gan nhim m
m khng c du hiu ca vim gan do ru hay x gan; s lng ca cc t bo hnh
sao c kch hot c tng quan vi mc ca chng thoi ho m . Mc ca s
thm nhim m, s hin hin ca cc th Mallory, v bng chng ca vi x ho
quanh tnh mch hoc quanh t bo ti sinh thit gan ban u u c lin quan vi s
tng nguy c x gan .
II. BO PH
Gan nhim m thng ph bin bnh bo ph v lin quan n mc bo ph.
S phn phi m bt thng bng (trong bnh bo ph ni tng), l s tng t l
gia vng bng v vng mng, lin quan nhiu nht n mc thoi ho m . Gan
nhim m hin din 80% n 90% nhng bnh nhn mc bnh bo ph . Trong
mt nghin cu Italy cho thy rng bo ph l yu t nguy c thoi ho m cao hn
so vi nghin ru, bi v t l lu hnh ca bnh thoi ho m nhng ngi bo ph
khng ung ru cao hn 1,6 ln so vi nhng ngi ung ru nhng khng bo ph .

T l lu hnh ca bnh thoi ho m tng ln mt cch r nt trong nhm nhng

ngi ung ru bo ph. Bnh vim gan thoi ho m do ru cng l bnh thng
thy c lin quan n bnh bo ph. Tin cn khng ung ru nhiu hoc khng
nghin ru cn thit phn bit hai loi bnh ny. Bnh tiu ng v tng
triglyceride mu thng gp nhng bnh nhn ny. Hu ht cc bnh nhn khng
c triu chng, bnh gan c pht hin khi thy ch s aminotransferase huyt
thanh tng. Cc triu chng chnh l mt mi v cm thy kh chu vng thng v
phi. Gan to c pht hin 90% cc trng hp, nhng him khi thy lch to. AST
huyt thanh c khuynh hng tng cao hn ALT, t l ca chng khng gip phn bit
c bnh ny vi gan nhim m do ru hoc vim gan do ru. Ngc li, bnh
vim gan thoi ha m khng do ru, ch s ALT huyt thanh thng cao hn ch s
AST huyt thanh . Gim trng lng bng khu phn n hn ch, ch n t m
thng lm gim tnh trng thm nhim m, ci thin cc triu chng, gim
triglyceride huyt thanh, v thnh thong cng gip lm gim aminotransferase huyt
thanh . Trong mt nghin cu cho thy bnh bo ph nhng bnh nhn khng ung
ru c ch s aminotransferas tng cao c 30% kt hp vi x ha vch ngn v 11%
vi bnh x gan . Trong nghin cu theo di ko di trung bnh 9,8 nm sau ln sinh
thit gan u tin khng thy c s tin trin thnh x gan nhng bnh nhn gan
nhim m khng c hin tng vim nhim hoc x ha . Ngc li, bnh vim gan
thoi ho m khng do ru gy ra thng tin trin chm cui cng tr thnh x
gan .
C ch sinh bnh hc chnh xc ca gan nhim m bnh bo ph vn cn ang
c tm hiu. S tng tng hp acid bo v altered partition l nhng nguyn nhn
chnh gy nn s tng tit lipoprotein giu triglyceride c lin quan n di truyn
chut bo ph . Khi lng m m tng ln cng vi tng to ra acid bo v khng
insulin l c ch khc ca bnh . S ri lon chc nng ca t bo Kupffer, c tm
thy chut Zucker tng lipid mu tiu ng bo ph nhng khng thy trn nhng
chut Zucker bnh thng, c th ng mt vai tr trong vic thoi ho m bng cch
cho php chui cytokines ko di, v d nh yu t hu khi u a (TNF- ), p ng vi
ni c t .
III. BNH TIU NG
Gan to bnh nhn tiu ng c th do s ng glycogen hay m. tr em b
bnh tiu ng type I khng kim sot c, s ng glycogen nhiu hn l
ng m l nguyn nhn chnh lm cho gan to v ch s aminotransferas tng. Trong
nhng trng hp ny, gii quyt gan to cng vi vic kim sot vic tng ng
huyt . Bnh gan nhim m t ph bin nhng bnh nhn tiu ng type I nhng
rt thng gp bnh nhn tiu ng type II, gp trong khong mt na cc trng
hp. Nguyn nhn gy ra thm nhim m gan nhng bnh nhn tiu ng type I
l tng s gii phng acid bo t cc m m th cp thnh ng huyt v s thiu
ht nng insulin. nhng bnh nhn tiu ng type II, nguyn nhn gy ra tnh
trng thm nhim m ldo tng cht bo v ng trong khu phn n v s tng
chuyn ho i vi cc acid bo. S bin mt ca DNA ca ti lp th t bo gan c
tm thy trong c v mu sinh thit gan nhng bnh nhn tiu ng type II . Pht
hin ny gi rng chc nng ca ti lp th b h hng c th l suy km s oxi ho
acid bo v gp phn gy ra thoi ho m gan. Gan nhim m c ci thin
nhng bnh nhn tiu ng type II sau khi loi b lng m v carbonhydrate d
tha trong khu phn n v gim trng lng c th. Bnh bo ph v tiu ng c
v l nhng yu t nguy c cho bnh x gan khng ngun gc. Trong mt nghin cu
bnh chng , t l lu hnh ca bnh bo ph vtiu ng type II l 55% v 47% s
nhng bnh nhn x gan khng nguyn nhn. Cn nhng bnh nhn b x gan

xc nh c nguyn nhn th t l trn l 24% v 22%. S bnh nhn bo ph ln

tiu ng type II chim 23% s bnh nhn x gan khng r nguyn nhn. Cn t rong
nhm bnh nhn x gan c nguyn nhn r rng th t l ny chim 5%.
IV. TNG LIPID MU
Gan nhim m c tm thy qua siu m chim khong 50% tng s bnh nhn
c chuyn n t mt bnh vin iu tr ri lon lipid t nhn. Tng glyceride mu
l bt thng chnh v lipid c lin quan n s hin din v mc trm trng ca
gan nhim m . Tng lipid mu (gm c tng triglyceride mu, tng cholesterol mu
hoc c hai) tng c bo co l pht hin 20% n 81% nhng bnh nhn x
gan khng do ru .
V. NI TT HNG- HI TRNG
Ni tt hng-hi trng l mt phng php iu tr gim cn hiu qu nhng
bnh nhn bo ph nng. Phng php ny khng cn c s dng na v n lin
quan ti nhiu bin chng hu phu, bao gm s hnh thnh bnh gan tin trin. Tnh
trng thm nhim m gan tng ln l do s ng triglyceride xut hin tt c
cc bnh nhn. Trong nhiu trng hp, n c lin quan ti s thoi ha m gan,
tng s x ha, v x gan, dn ti nhiu trng hp b x gan v cht. S thm nhim
m tng nhiu nht trong sut 6 thng u sau phu thut, l giai on gim cn
nhanh; tnh trng ca bnh nhn dn dn tr li nh trc khi m trong vng 2 nm
sau. im yu ca phu thut ni tt hi-hng trng l tuy c iu tr ht triu chng,
kt qu xt nghim tr v bnh thng, gim thm nhim m, khng cn tnh trng
hoi t v vim nhim nhng khng lm thay i c s x ho .
Khng tm ra nguyn nhn ca bin chng tn thng gan do phu thut ni tt
hng-hi trng. S gim cn nhanh chng sau phu thut l do s thiu ht proteinnng lng v s gim cc amino acid thit yu c th l mt yu t bnh sinh ca
thoi ha m gan . Mt yu t quan trng hn c th ls pht trin qu mc ca vi
khun trong on rut ni i km vi s sn sinh ra cc ni c t v cc cht c.
Khng sinh liu php ngn nga c s thm nhim gan v cht sau phu thut ni
tt rut ch. Metronidazole ci thin tnh trng lm sng v nhng pht hin v
m hc ca gan ngi sau phu thut khng ph thuc s hin din ca s thiu
ht protein nui dng . Cc cht c hi gan, khng tnh n c nng ca acid
litocholic (do vi khun to ra t chenodeoxycholic) ln ethanol (do vi khun to ra t
carbohydrate) , c nhn thy tng cao ng k sau phu thut.
VI. SUY DINH DNG
Gan nhim m v x ho nh xung quanh tnh mch ca xy ra tr em b hi
chng Kwashiorkor (hi chng thiu ht dinh dng nghim trng tr em) . Gan
nhim m c th hi phc tr v bnh thng vi mt ch dinh dng giu protein .
C gan nhim m do hi chng Kwashiorkor ln do ch n thiu ht protein kh
rhesus u khng tin trin thnh x gan . X gan thng gp vi qun th ngi
trng thnh thiu n, nhng nguyn nhn ca x gan c nhiu kh nng do mt loi
virus hay cht c no . Sau chin tranh th gii th II, khng tm thy bng chng
v m hc ca gan nhim m, hoi t hay x gan nhng thng dn thiu n . S
thm nhim m do kwashiorkor v nhng th vt c nui vi ch dinh dng t
protein c khu tr ch yu vng quanh tnh mch ca. c im ny c dng
phn bit Kwashiorkor vi gan nhim m do ru, trong s thm nhim ch yu
tiu thu trung tm. Nhng ng vt b thiu ht protein-nng lng c s gim
tng hp protein gan . Cc kt qu thc nghim vi kh rhesus cho thy c s gim
tit xut triglycerides gan . C ch thch hp nht ca tnh trng thm nhim m
gan l s gim tng hp lipoprotein, v kt qu l gim bi xut lipid ra khi gan. Vi

khun pht trin qu mc sn sinh ra cc ni c t, ko theo l s thng tn ti lp

th dn n s peroxide lipid, cng c xem nh l c ch ca gan nhim m bnh
nhn thiu ht protein-nng lng .
VII. NUI N KHNG QUA NG RUT
S tng cc ch s aminotransferas, alkaline phosphatase v bilirubin huyt thanh
thng gp nhng bnh nhn trng thnh c iu tr vi ch nui n khng
qua ng rut. Sinh thit gan thnh thong thy c thm nhim m gan, thng c
kt hp vi tnh trng mt v vim khong ca. tr s sinh c nui dng qua
ng tnh mch m c nhng kt qu xt nghim gan bt thng th nhng pht
hin chnh tm thy mu sinh thit gan l tc mt, vim khong ca v x ha
quanh gan . c tr s sinh v ngi trng thnh, nhng kt qu xt nghim bt
thng v gan v nhng bin i v m hc c gii quyt sau khi ngng nui n
khng qua ng rut. tr s sinh, vic ko di ch nui n khng qua ng
rut s gy ra s x ho v x gan khng hi phc . Thm nhim m nhng bnh
nhn trn c nhiu kh nng c gy ra do vic cung cp d tha carbohydrate so
vi t l carbohydrate bnh thng trong khu phn. Gan nhim m thng gp nht
sau khi tim truyn mt lng ln calorie trong mt thi gian ko di . chut c
nui n khng qua ng rut vi ch nhiu carbohydrate nhng khng cht bo
to ra tnh trng gan nhim m kt hp vi tng tng hp acid bo gan v gim
tit triglyceride. B sung thm lipid vo dung dch ng truyn lm gim s tng
hp acid bo, tng s oxi ha acid bo, ci thin s tit xut triglyceride v lm gim
mc triglyceride gan. S pht trin qu mc ca vi khun sn cng vi vic to ra
ni c t cng c th l mt c ch gy ra gan nhim m, bi v vic dng polymyxin
B chut ang c nui n qua ng tnh mch lm gim ng k s sn sinh ra
TNF bi cc i thc bo phc mc v lm gim cha dng lipid v triglyceride gan .
VIII. GAN NHIM M CP THAI K
Gan nhim m cp thai k l bnh nghim trng, him gp v c kh nng gy
cht ngi, th hin in hnh trong qu th ba ca thai k, thng gia tun 32 v 38
ca thai k. T l mc phi vo khong 1 trong 10.000 thai ph . Thng gp ln
mang thai u tin, vi song thai con trai . Triu chng thng l mt mi, bun nn,
nn i, nhc u v au bng vng thng v, c th tin trin n vng da v suy
gan vi bnh no, ri lon chc nng thn, v bnh ng mu. Trong vi trng hp,
c triu chng ca cao huyt p, ph ngoi bin v protein niu-l nhng c trng
ca tin sn git. Khi khm lm sng, gan kh khm c do tnh trng mang thai.
Cc xt nghim cho thy s tng aminotransferase v alkaline phosphatase mc
trung bnh (cc gi tr trn thng thy trong sut thai k). Bilirubin thng bnh
thng lc ban u nhng c th tng r rt. Thng c tng bch cu, h ng
huyt, tng ur niu v thi gian prothrombin ko di. Siu m chn on v CT c
th gip cho vic chn on, nhng ch yu l sinh thit gan. mu sinh thit gan
tm thy tnh trng thm nhim m microvesicular, d thy vng tiu thu trung
tm. Hoi t dng m t bo gan v s vim nhim v mt cng thng gp.
Sanh con t nhin c t l sng cn ca c m v con cao hn r rt so vi sinh ch
huy c s tr gip y khoa. Ghp gan thnh cng trong mt trng hp .
Nguyn nhn gy ra gan nhim m cp thai k khng r. Kh nng nhiu nht
ldo gim s oxi ho acid bo ca ti lp th. Nhng bt thng trong cu to vi th
ca ti lp th v trong s hot ng ca cc men chu trnh ur ti lp th c tm
thy trong gan ca nhng bnh nhn ny. nhng tr s sinh ca nhng ngi m
c mt hay nhiu ln b bnh ny c s thiu ht ca chui di 3-hydroxyacyl-CoA
dehydrogenase, l mt men xc tc trong bc th ba ca qu trnh oxi ho ti lp

th ca acid bo . S thiu ht ny l do mt gen ln gy ra. C s phn t ca s

thiu ht ny l do s hon chuyn mt guanosine bng cytosine tiu n v a ca
trifunctional protein c 2 gen . Tr c khim khuyt ny b h ng huyt, hn m
v c nng cc men gan bt thng hoc t t khng tm ra nguyn nhn. iu
cho thy nhng cht chuyn ho c hi c sinh ra t qu trnh chuyn ho acid
bo xen k bo thai cng vi s thiu ht enzym c th nh hng xu n gan ca
nhng thai ph mang gen di hp t qui nh khim khuyt ny.
IX. HI CHNG REYE
Hi chng Reye c trng bi s thm nhim m v bnh no tr em v thng
c bnh cnh nhim virus trc i km vi st v cc triu chng h hp. N c t
l t vong cao . Trong mt vi trng hp bnh khi u vi bnh cnh ca bnh thu
u, v tr c iu tr bng aspirin trong sut giai on nhim virus. i mahu
nh lun lun xut hin trc tin vo lc khi bnh ca bnh no. Nhng mc
thay i ca bnh no v chng gan to pht hin c khi thm khm lm sng. Xt
nghim thy c nng aminotransferase huyt thanh tng, nng bilirubin tng
nh hay va, nng ammonia mu tng, thi gian prothrombin gim v thnh
thong ng huyt gim. Sinh thit gan thy thm nhim m dng microvesicular
lan ta.
S ri lon chc nng ti lp th c th l mt yu t ch yu trong sinh bnh hc
ca hi chng Reye, bng chng l nhng bt thng trong vi cu trc ca ti lp th
vs thiu ht hot tnh enzyme chu trnh ur nhng bnh nhn ny. S tng nng
cc ni c t trong huyt thanh v tng nng ca TNF- nhng bnh nhn
cp tnh c th gp phn lm ri lon chc nng ca ti lp th . Nhng yu t u tin
c th c vai tr quan trng trong sinh bnh hc ca hi chng Reye l do tiu ho
cc salicylate, l nhng cht c th gy ra s bin i vi cu trc ca ti lp th v
phosphorylation oxy ha n c, v nhng bnh nhim tin triu nh virus cm hay
nhim varicella virus. Peptide c u tn cng bi nhm amino caPB2 protein ca
virus cm A tng tc vi protein ca ti lp th . Hi chng Reye c th l mt biu
hin ca s thiu ht men dehydrogenase ca acyl-CoA chui trung bnh , do mt gen
ln sinh ra do sai st v di truyn ca chuyn ho acid bo.
X. JAMAICAN VOMITING SICKNESS
Jamaican vomitting sickness xut hin sau khi n qu akee cn sng. Ph bin
nhiu nht tr em, gy ra i ma nhiu, h ng huyt, co git v hn m trong
vng vi gi sau khi n. Gan b cn kit glycogen d tr v v c s thm nhim m
dng bng nh. Cht c ca tri cy l hypoglycin A, c dng ti hin li cc
din tin lm sng trn ng vt th nghim. Cc chuyn ho qua nc tiu ca
hypoglycin A c nhn bit nhng bnh nhn ny . C ch chnh ca s ng c
ny l s c ch qu trnh oxi ha acid bo v c ch s hnh thnh glucose trong c
th.
XI. DO NHIM HP CHT C
1. Carbon tetrachloride
Ng c carbon tetrachloride qua ng tiu ho hay h hp gy ra bun nn, i
ma, au bng, tiu chy, amintransferase huyt thanh tng cao v vng da trong
vng 2 ngy sau khi n. Nhng thay i v m hc gan nh hoi t tiu thu trung
tm v thm nhim m lan to. Trong nhng trng hp nng xut hin suy gan v
hoi t ng thn cp. Vic ung ru c th to ra nhng tc ng c hi ca carbon
tetrachloride. Nu bnh nhn hi phc th khng li du hiu tn thng gan vnh
vin. Sinh bnh hc ca hoi t t bo gan l s hot ha ca carbon tetrachloride

thnh cht chuyn ho t do c bn v cht ny gy ra s peroxide ho. C ch ca

s thm nhim m l do gim s tng hp protein v gim tit VLDL ca t bo gan .
2.Trichloroethylene
Vic ht Trichloroethylene c th gy hoi t t bo gan v thm nhim m. Nhng
tn thng ny c th xy ra sau triu chng kht kht s mi do ht keo hay cht ho
tan cng nghip. Hu ht cc trng hp u hi phc .
3.Phosphorus
n nhm phosphorus gy bun nn, i ma v au bng v vng da din ra sau
4 n 5 ngy. Hoi t v thm nhim m d thy nht vng quanh khong ca ca
thu gan. Thung bnh nhn b suy gan bng pht dn n ci cht .
4.Fialuridine
Fialuridine l mt cht ng ng ca thymidine c s dng nh mt loi thuc
nghin cu iu tr bnh nhn vim gan B mn . By trong s 15 bnh nhn trong
cuc nghin cu tn thng gan nghim trng km vi vng da v nhim acid
lactic. Ba trng hp khc b tn thng gan nh. Mt vi bnh nhn b ivm tu, bnh
thn kinh hoc bnh v c. Xt nghim bnh hc ca gan cho thy s ng m
dng bng nh v nhng bt thng vi cu trc r nt gan. Nhng nghin cu xa
hn cho thy fialuridine gn kt ch yu vo DNA ti lp th. Kt qu l lm gim
lng DNA ti lp th bnh thng v nhng bt thng v nng ca cc enzyme
c m ho bi cc gen ti lp th.
XII. DO THUC
1.Tetracycline
Tetracycline dng qua dng ung c th gy ra thm nhim m dng bng nh,
thnh khng li hu qu v lm sng. S xut hin v mc ca thoi ha m
c lin h vi liu dng. Trong vi trng hp thm nhim m nng, suy gan v t
vong c th xut hin khi dng tetracycline qua ng tnh mch thai ph iu
tr nhim trng tiu (107). C ch chnh ca gan nhim m do tetracycline l gim
tng hp protein v gim bi tit VLDL gan.
2.Valproic acid
Thuc chng co git acid valproic him khi gy ra thm nhim m dng bng nh
gan, thng l kt hp vi hoi t gan, c bit tr em, c th dn ti suy gan v t
vong. Nhng bt thng gan thng xut hin t 2 n 4 thng sau khi bt u s
dng thuc . Cc sn phm chuyn ho ca valproic acid tng t vi hypoglycin A,
acid pentanoic, thng c lin quan n c t to ra bnh i ma Jamaican v c
ghi nhn l lm suy yu s oxi ha aic bo chut.
3.Amiodarone
Amiodarone l mt benzofuran c cha iodine to ra hiu qu cao trong iu tr cc
chng lon nhp tim. Vic s dng cht ny thng lin quan n s tng nng
aminotransferase trong huyt thanh. Tr liu lu di c th gy ra thm nhim m
dng bng ln gan v nhng bin i bnh hc tng t trong vim gan do ru.
Qua st di knh hin vi in t thy nhng lysosome c cha nhng th myelin
dng l mng do s ng ca phospholipid . L tng nht l nn ngng s dng
amiodarone mt khi c du hiu tn thng gan; tuy nhin, vic ny thng khng
thchin c nu nh amiodarone l thuc duy nht kim sot c lon nhp kh tr
e da mng sng bnh nhn.
4.Glucocorticoids

Glucocorticoid dng liu cao c th gy ra gan nhim m . Tc ng ny phn ln

xut hin tr em. Nguyn nhn chnh gy ra gan nhim m l do tng gii phng
acid bo t cc m m . Gan nhim m c th hi phc khi ngng glucocorticoid.
5.Tamoxifen
Tamoxifen l mt hp cht khng estrogen nonsteroid c s dng ch yu trong
iu tr h tr trong bnh ung th v. N cnh tranh vi estrogen cc v tr gn kt
m v v cc m khc. Thnh thong gy nn s gia tng men aminotransferase v i
km vi thm nhim m gan c ghi nhn trn siu m v sinh thit gan. Kt qu
sinh thit gan thc hin t thng th 7 n thng th 12 sau khi bt u iu tr bng
tamoxifen nhn thy c nhng c im ging vi cc c im gii phu bnh ca
bnh l gan nhim m khng do ru, l thoi ha m dng bng ln, vim nhim
thu v khong ca, cc th Mallory v x ho .
XIII. NHNG RI LON DI TRUYN CA QU TRNH OXI HA TI LP TH
Mt vi khim khuyt him gp ca cc enzym trong qu trnh oxy ha
mitochondrial b trong acid bo c bo co .Nhng khim khuyt ny c qui
nh bi gen ln, n gy ra s gim oxi ho acid bo v hu qu l dn n thm
nhim m gan v nhng ri lon chuyn ha nghim trng khc nh h ng
huyt. Cc triu chng lm sng nghim trng th hin nh nhi v thiu nin. Cc
du hiu v triu chng thng gp l hypoketotic hypoglycemia, ngt lm, hn m,
gim trng lc hay yu c, toan lactic, myoglobin niu, gan to v tng ammonia mu
. Gim ng huyt xut hin khi i ch yu do hu qu ca vic gim tn to
ng do s sn sinh acetyl CoA ti lp th khng hp l. Chn on s thiu ht cc
enzyme c th c thc hin qua pht hin s tch t cc cht chuyn ho trung
gian ca ca acid bo sinh ra do s thiu ht cc enzym, hoc bng xt nghim trc
tip hot tnh ca enzym trong nguyn bo si. Chng ti ch m t ch yu ba trong
cc loi thiu ht enzym ny. nhng thng tin xa hn v cc loi thiu ht enzym Roe
v Coates cung cp y hn ). S thiu ht ca men kh hydro ca chui va acylCoA (MCAD) l khim khuyt hay gp nht c ghi nhn vi t l c on l
1:15.000 dn s . Cc bnh nhn b MCAD c th c cc triu chng gi n hi
chng Reye, nhng MCAD c th phn bit vi hi chng Reye bng s hin din cc
cht chuyn ho sinh ra t qu trnh chuyn ho lipid b thiu ht, s thiu ht nhng
bin i vi cu trc c trng ca ti lp th trong hi chng Reye v cc xt nghim
enzym trc tip. S thm nhim m gm c 2 dng microvedicular v macrovesicular.
C s phn t ca s khim khuyt ny s hon i bin im mt lysine thnh mt
glutamate hoc lysine thnh aspartate do to nn mt protein khng bn vng .
Khim khuyt acyl-CoA chui di (LCAD) t gp hn MCAD. Nhng bnh nhn LCAD c
cc triu chng tng t vi cc triu chng ca MCAD. Tuy nhin, bnh c tim v
myoglobin niu ti pht thng gp hn. Khim khuyt men 3-hydroxyacyl-CoA
dehydrogenase chui di (LCHAD) thng kt hp vi thm nhim m nng km theo
s hoi t v x ho. Trong mt s t trng hp c th pht hin bnh thn kinh
ngoi bin v bnh l sc t vng mc. S khim khuyt LCHAD c pht hin mt
vi tr sinh ra t nhng b m b gan nhim m cp trong thai kv n cho thy rng
nhng b m ny mang gen d hp t qui nh khim khuyt enzym.
iu tr ngn ngy nhng bnh nhn khim khuyt enzym h thng bao gm cung
cp ng kim sot tnh trng h ng huyt. Phc iu tr di ngy bao gm
trnh n king ko di bng cch n thng xuyn, hn ch n nhiu m v nhng
bnh nhn MCAD nn dng medium-chain triglyceride thay v ch n ton m.
XIV. BNH H THNG VI GAN NHIM M

Sinh thit gan thng cho thy s thm nhim m nhng bnh nhn vim gan C
hay bnh Wilson . nhng bnh nhn vim gan C mn, mc thoi ha m c lin
quan n trm trng ca s x ha v vi din tin ca s x ha . Nng bnh
nhn vim gan C genotype 3a c mc thoi ha m v din tin x ha nng hn
v cng c nng mRNA ca virus C (HCV) trong huyt thanh cao hn cc bnh
nhn vim gan C genotype khc . Bo ph ni tng c xc nh bng cch o vng
bng c mi tng quan mnh m vi s thoi ha m tt c cc bnh nhn vim
gan C mn. S th hin ca protein li ca HCV gy ra thoi ha m chut bin i
gen c tm thy bnh nhn vim gan C mn .
Trong cc bnh h thng, thm nhim m l c im thng thy nhng bnh
nhn c xt nghim v gan bt thng, l nhng ngi b vim rut hay b hi
chng suy gim min dch mc phi. Nguyn nhn ca gan nhim m trong nhng
trng hp ny bao gm suy dinh dng hoc nui n khng qua ng rut. tr
em, cc bnh Weber-Christian, galacto mu, khng dung np fructose, thiu
-lipoprotein huyt v bnh ng ester cholesterol thng kthp vi thm nhim m
gan. Bnh Wolman, th hin vi gan lch to trong giai on s sinh, l mt bnh
him gp c c trng v m hc bi s ng lipid trong m bo.
Lot d dy - t trng
Gi bi Admin, lc 19:28 18/08/2011, | Bnh lin quan d dy- t trng
Lot d dy- t trng cn gi l bnh Cruveilhier. C tc gi gi chung l
bnh lot (maladie uleereuse- ulcer disease). Tu v tr ca tng lot c
cc tn gi: lot b cong nh, lot hang v, lot tin mn v, lot hnh t
trng.

y l bnh kh ph bin trn th gii v Vit Nam: cc nc pht trin c

chng 10% hin mc v hng nm tng ln khong 0,2%; Vit Nam theo iu tra
ca B y t mt s tnh Min Bc trong nm 1974- 76, lot d dy- t trng chim
26% cc bnh ni khoa (Tp san Ni khoa 3.1979) thng ng hng u cc bnh
tiu ho, c khi l hng u trong cc bnh ni khoa nhiu bnh vin. Bnh c chiu
hng
tng
trong
nhng
nm
gn
y
nht
l
lot
d
dy.
T lu chng ta bit r cc triu chng, bin chng v cch chn on v bnh
c bit gn 1 th k nay nhng lun lun c nhng nhn nh mi v c ch sinh
bnh, sinh l bnh hc v t c nhng ch trng v iu tr bng ni khoa v
ngoi
khoa.
C nhiu gi thuyt v sinh l bnh hc nhng gi thuyt c nhiu ngi chp nhn
nht v cng t ra cc phng php thm d v iu tr hp l l s mt thng
bng gia yu t gy lot (HCl, peprin...) v cc yu t chng lot (cht nhy nim
mc, ti sinh ca t bo biu m...) Ngy nay ngi ta cho rng lot HTT l do mt
dch v c axit cao vt qu kh nng chng ca mt nim mc HTT bnh

thng; cn lot d dy l do tnh trng gim dinh dng, chm ti sinh ca nim
mc d dy khng kh nng chng li mt dch v c axit bnh thng, thm ch
t axit. V tr lot thng gp l t trng ri n b cong nh, sau n mn v; cc
v
tr
khc
t
gp.
S hiu bit v cc thng tn gii phu bnh hc s gp phn lm hiu r cc hnh
nh
X
quang
v
ni
soi:
lot mi thng nm gia mt nim mc ph n sung huyt: trn X quang biu hin
1 ng thuc gia mt qung sng khi ni soi l mt lot trn c b ph n.
lot lu thng c x cng xung quanh c khi ch thy so x m khng cn lot:
iu ny th hin s bin dng ca hnh t trng cng nh s quy t ca np nim
mc
trn
X
quang
hoc
khi
ni
soi.
Triu chng lm sng chnh l au bng vi c im: au vng thng v; au mn
tnh t vi ba nm n hng chc nm; au chu k thng v ma rt; mi chu k ko
di t nht cng 7 ngy hoc 10 ngy tr ln. Cc chu k au thng c lin quan n
cc chn thng tm thn hoc lm vic cng thng; c th au lc i, n vo th
bt au, hoc au vi gi sau ba n. Khng c mt triu chng thc th no khi
bnh cha c bin chng. Th trng chung ca bnh nhn bnh thng, c khi ch hi
gy
trong
chu
k
au
v
km
n,
mt
ng.
Tm li, triu chng lm sng rt ngho nn, quan trng nht l hin tng au mn
tnh, khng km theo st v c chu k. Nu khng c c tnh ny, bnh nhn v
thm ch c thy thuc cng d nhm vi vim i trng mn tnh. Bi vy phi chp
X
quang
hoc
ni
soi.
X quang c gi tr chn on nhng cc hnh nh phi c hng nh trn nhiu
phim chp hng lot. C th chia lm hai koi: Cc hnh nh trc tip l ng thuc;
vt l lng. Xung quanh cc hnh nh trc tip ny c mt vng sng do ph n xung
quanh lot. Nhiu khi thy r cc hnh nh trc tip ny, phi p nn vng nghi
ng khi chiu v chp. Cc hnh nh gin tip l np nhn nim mc quy t vo mt
im; vng li b cong ln i xng vi lot bn b cong nh; s bin dng ca
hnh t trng theo cc hnh nh thng gi l ui n,ba cnh con bi nhp; on
b cong nh cng , hnh vn rt kh phn bit vi mt tn thng c tnh.
Chp vi baryt n thun l mt phng php c in, t phin phc, c gi tr ln
trong chn on lot d dy- t trng. Tuy vy phng php ny vn c th b qua
cc lot nh, cc lot thnh trc hay sau d dy, nht l kh phn bit mt s
trng hp lnh hay c tnh. b khuyt cc nhc im ny, ngi ta p dng
phng
php
chp
cn
quang
kp
v
ni
soi.
Ni soi nhm mc ch pht hin v nhn nh k lot. i vi cc vng nghi c
lot, ngi ta bm vo xanh metylen. Nu c lot, lot s gi cht xanh metylen
li; nu khng, cht xanh metylen s tri tut i; lot b cht nhy che ph, ngi ta
s bm nc ct vo ra sch tng cht nhy, lm bc l r lot. Mun nhn nh
tnh cht lnh tnh hay c tnh ca mt lot d dy, cn phi cn c vo hnh dng
lot, hnh thi ca y v b, xut pht im ca chy mu trn lot, tnh cht cc
np nhn nim mc v tnh trng nhu ng xung quanh lot.
Mt lot c nhng c tnh nh gi kh nng lnh tnh hay c tnh, nhng khi
ni soi xc nh c lot, phi dng tm bng pht ln lot xt ngim t bo
hc, nht l phi sinh thit v sinh thit nhiu ln (7-8 mu, Liguory c khi ly 15-16
mu
mi
pht
hin
c
t
bo
ung
th
trn
mt
mu).
Gn y, Kawai m t bn hnh thi ni soi ca lot hnh t trng c lin quan n
kt qu iu tr v tin lng bnh: lot trn thng gp nht, kt qu iu tr ni
chung tt; lot mo m, hnh tam gic hoc hnh sao, th hin tnh cht mn tnh,
iu tr c kt qu chm hn; lot thng th hin tnh cht mn tnh lu, iu tr

ni khoa thng rt dai dng; lot Salami (vt lot nh, nng) hoc vt xc th
hin s ti pht sau khi lnh, iu tr c kt qu nhanh.
Xt nhim dich v: Lot d dy: xt nghim axit baz t c gi tr: dich v c th t axit,
nhiu axit hc bnh thng. Xt nghim t bo vi cn li tm hoc bng nghim
php ttracycline c ch li hn, nhng trn thc t t khi thy c t bo ung th.
Lot hnh t trng: Xt nghim axit baz ng mt vai tr quan trng do tnh cht
tng axit ca dch v c hiu ca lot hnh t trng; ngoi ra xt nghim cn l c s
cho ch nh phu thut khi cn thit cng nh cho nh gi kt qu phu thut. Nn
lm c hai loi xt nghim dch v c bn v dch v sau khch thch. dch v c
bn, lu lng axit bao gi cng tng; dch v sau kch thch, lu lng axit ti a
vit tt l MAO hay PAO (maximam acid output hay pick acid output) cng tng.
Thng lm hai nghim php: vi pentagastrin v vi insulin, tu c ch gy tng axit
m lu lng axit ti a tng trong mt hoc c hai nghim php .
Din bin theo chu k l mt c im ca bnh lot d dy t trng. Khong cch
gia cc chu k di ngn khc nhau tu theo mi bnh nhn v thi k bnh. Do
rt kh nh gi kt qu iu tr ca mt loi thuc nu ch cn c n thun trn
biu hin m phi da vo kt qu ni soi xt nghim axit- baz dch v i vi lot
hnh t trng. Ni chung cc chu k au dn dp xy n thng c mt ngha xu,
bo
hiu
mt
bin
chng.
Lot hnh t trng thng gy chy mu nhiu hn l lot d dy. Lot d dy d b
thng hn lot hnh t trng. Vt thng vo phc mc hoc c bt bi cc tng
gn y (gan, tuy, mc treo, vv.) gy bnh cnh thng nhng vn cn vng c trc
gan v khng c lim hi trn phim X quang; cc trng hp ny cn c theo di
k. Nu biu hin lm sng c nghi ng mt thng bt, chng ti thng ht ht dch
v ri qua ng bm vo d dy 100-200ml khng kh, nh vy, c th lm xut hin
lim
hi
trong
cc
thng
bt.
Cc bin chng chy mu v thng c th l biu hin u tin ca mt bnh lot d
dy t trng tim tng mt ngi t trc n gi khng c du hiu no lin quan
n
vng
thng
v
Bin chng mn tnh: Hp mn v d gi trn lm sng do tnh cht au bng sau
khi n, ni r nhu ng d dy thng v,nn c s lm du cn au v lm mt
ln sng nhu ng d dy, nht l ting c ch khi lc bng lc i; cng d khng
nh bng X quang; sau 4-6 gi baryt vn lu cu trong d dy v d dy gin to, hnh
lng
cho,
sa
xung
ngang
hoc
di
mo
chu.
Ung th ho: ch c lot d dy mi b ung th ho vi t l trung bnh 5%; lot on
ngang b cong nh d ung th ho hn on cng, cng gn tm v cng t kh nng
ung th ho. pht hin sm mt lot d dy b ung th ho cn theo di nh k
bnh nhn bng ni soi kt hp vi sinh thit (chc chn nht); nu khng c cc
phng tin trn, phi theo di bng X quang kt hp vi lm sng sau mi thi gian
iu
tr
tch
cc
vi
cc
thuc
c
hiu
hin
nay.
Cc th bnh: Ngoi cc th m thm ri biu hin t ngt bng cc bin chng
thng hoc chy mu, cn lu n hai th lot d dy- t trng kt hp vi cc bnh
khc.
Th kt hp vi x gan c t 10-17% i vi bnh nhn x gan trn th gii v 10%
Vit Nam. V sinh l hc, cng l s mt thng bng gia hai yu t gy lot v
chng lot ca ton thn ni chung v ca nim mc d dy t trng ni ring. c
bit, yu t gy lot tng nhiu do nhng cht ging gastrin rut non hp th a
v h thng ca khng c gan kh hot tnh v gan x khng lm c chc
nng na; ngoi ra, cht li vo trong th dch qu nhiu bi cc tun hon
bng
h
ca
ch.

Th kt hp hai bnh ny rt phc tp. V chn on, hi chng lot rt m thm kn

o, c khi ch th hin bng cc ri lon tiu ho thng thng, d cho l x gan nu
khng chp X quang hoc ni soi pht hin lot. V cch x tr, khi bnh nhn x
gan b chy mu tiu ho, thng d phng on l do v tnh mch thc qun trong
tng p lc ca do x gan. Tt nhin, thi x tr bng ni hay ngoi khoa s khc
hn nu chy mu tiu ho bnh nhn x gan li do lot d dy t trng km theo
ch khng phi do v tnh mch thc qun. Chn on phn bit ny ngy nay khng
cn l mt vn kh na nh ni soi cp cu vi ng soi tiu ho loi mm. Vic s
dng corticoide cho bnh nhn x gan hoc vim gan mn tn cng chi nn p dng
khi bit chc chn khng c lot d dy- t trng km theo.
Th kt hp vi u ty: cn gi l hi chng Zollinger Ellnon (thng hay ni n trong
y hc th gii nhng Vit Nam cha thy cng b trng hp no). Sinh l bnh hc
cng l c ch tng yu t gy lot do s bi tit qu nhiu gastrin ca u tu thng
lnh tnh v xut pht t t bo , thng ui hoc thn tu (2/3), c khi ngoi tu
(10%). Cng c khi khng c u thc s m ch l mt tnh trng qu sn t bo . Do
tnh cht tng axit qu mc m bnh lot trong hi chng ny c nhng c im
c gi tr gi nh sau: Km theo a lng (30-50%) d gy tnh trng kit nc v in
gii, c khi phn ln m (chng phn m) cng lm cho bnh nhn gy st nhanh. C
nhiu lot ri rc nhiu ni, c khi nhng v tr rt bt thng.: on 2 t trng,
hng trng, c khi c thc qun nu bnh nhn hay . iu tr ni khoa nh mt lot
d dy t trng thng thng u khng kt qu v bnh tin trin nhanh chng
sang cc bin chng thng hoc chy mu. iu tr ngoi khoa nh mt lot d dy
t trng thng thng cng khng kt qu, lot ti pht rt nhanh ngay ming ni,
hng trng (c khi c thc qun), bt buc phi m li nhiu ln.
Xt nghim axit- baz dch v thy m HCl v tr c bn rt cao (trn 100mEq/l)
v lu lng azzit c bn (BAO) cng rt cao (trn 15 mEq/gi).
Tc nhn gy tnh trng tng axit dch v qu mc hin nay c xc minh chc
chn bng nh lng gastrin mu: trn 1000pg/ml (bnh thng: 15-100pg/ml).
Bnh lot trong hi chng Zollinger Ellon c th gii quyt c mt cch c bn
bng phu thut loi b u tit gastrin nu xc nh c v tr ca u hoc ct b d
dy.
Hin nay, cc thuc c ch ni tip nhn H2 histamin (cimetidne, ranitidine,
famotidine, nizatidine) v nht l cc thuc c ch bm proton (omeprazon,
lansoprazol, pantoprazol) c nhiu thnh tu trong iu tr ni khoa bnh ny.
Nguyn sinh bnh
Trn c s SLBH mt thng bng gia 2 yu t gy lot v chng lot, hin nay y
hc bit nhiu yu t gp phn vo nguyn sinh bnh lot d dy- t trng.
U tit gastrine (gastrinome) tr thnh mt bnh danh kinh in: hi chng
Zollinger
Ellon

ni

trn.
Cc stress: cc chn thng h thn khinh trung ng (do tai nn, do phu thut..
c gi l lot Cushing) v nht l cc bnh nhn b bng nng (lot Curling) hoc
cc trng hp b chong nng do cc vim ni khoa: thuc l, ru, cafe; cc thuc
chng vim: acide acetylsalicytiqu (aspirine), cc thuc chng vim khng c nhn
steroid anti inflammatory drug: NSAID) v cc thuc corticoide (cortisone,
prednisone,,
predlisolone..)
Helicobacterpylori (HBP) c Warren v Marshall xc nhn nm 1983 l mt mc ln
trong nguyn sinh bnh lot d dy t trng, b xung thm mt phng hng iu
tr c bn bnh ny: tit tr HBP c kh nng iu tr dt im bnh lot hoc t nht
cng lm gim r rt tn s ti pht. chn on nguyn nhn HBP, c nhng bin
php cn c bnh phm sinh thit nim mc d dy khi soi (nghim php urease, m

bnh hc nui cy) v nhng bin php khng cn bnh phm ni trn (nghim php
th
vi
ur
phng
x,
huyt
thanh
chn
on).
iu tr lot d dy t trng cn t 4 yu cu: gim au nhanh, tin so lot, ngn
nga
ti
pht,
ngn
nga
bin
chng.
iu tr theo sinh l bnh hc nhm 2 mc tiu: gim yu t gy lot, tng cng yu
t
bo
v.
gim yu t gy lot, ngoi vic loi b cc yu t ngoi lai (ru, nht l thuc l,
aspirine, NSAID), tc nhn chnh cn lm gim l HCl; pepsine tuy l cht c kh nng
phn hu protein ca nim mc d dy nhng ch l tc nhn ph v phi c HCl,
pepsine mi c hot ho t pepsinogne.C th lm gim HCl bng 2 cch:trung
ho
HCl
v
c
ch
bi
tit
HCl.
1. trung ho HCl c cc thuc khng toan (antacids); 4 loi mui c dng
thng thng: Natri bicarbonat, canxi carbonat, Alumin hyroxy, Manhdi hydroxyd.
Cn lu l lm tng Natri bicacbonat c tc dng nhanh v mnh nn gy 1
feedback lm tng tit gastrin lm cho HCl li c tit nhiu hn trc
2. c ch bi tit HCl c cc thuc khng tit toan (antisecretories). Vic sn xut
v bi tit HCl chu tc ng ca nhiu khu t v no qua h phn no, giy thn
kinh ph giao cm v cc th th H2 histamine cng vi bm proton t bo ba.
Ngoi vic trnh cc chn thng tnh cm cc cm xc ng lo u, bc dc, cch
lm vic cng thng c th dng cc thuc an thn loi diazepoxide hoc sulpiride.
C th c ch cht trung gian dn truyn acetyl choline vi cc thuc khng choline
kinh in nh belladone, atropine, buscopan. Cc thuc ny c tc ng ln c 2
nhm im cm th Muscarine choline nn thng gy kh mm, kh mt, nhp tim
nhanh.. nu dng vi liu cao c hiu lc c ch tit toan. khc phc nhc
im ny hin nay c Pirenzepine, 1 cht gn rt cht vo cc im cm th
Muscarine
M1
trn
t
bo
ba
v
rt
t
trn
cc
im
M2.
Cc hp cht khng htamine tng hp tc ng bng c ch chong ch histamine
im cm th trn t bo ba c gi l cc thuc chn H2 histamine (H2 blocker)
hin c nhiu th h: cimetidime ri ranitidine, famotidine, nizatidine.
Mnh hn c trong cc thuc khng tit toan l cc thuc c ch bm proton tc ng
ln khu cui cng ca vic sn xut v bi tit HCl gi l bm proton H+/K+ ph
thuc men ATP (H+ /K+ proton pump ATP dependent) qua c ch lm mt hot tnh
ca men H+ /K+ ATPase. Hin c 3 th h thuc c ch bm proton c s dng
trn
lm
sng:
omeprazol,
lansoprazol,
pantoprazol.
3. tng cn bo v nim mc d dy 1 s thuc trc y c dng nh bt
relisse, carbenoxolone hin khng c cp n, ch yu hin nay l sucralfate v
prostaglandin.
Tc dng ca sucralfate da trn c ch bao ph nim mc d dy- t trng v lot:
tip xc vi dch v a toan, sucralfate (aluminium sacchoe sulfate) tr thnh 1 mng
qunh
dnh
bao
ph
nim
mc
v

lot.
Prostaglandine E v I c nim mc d dy tng hp v tc dng nh mt cht ni
ti c ch bi tit HCl v bo v nim mc. Mt s cht ng ng vi prostaglandine
c tng hp v s dng trong lm sng: misoprostol, enprostol.
iu tr theo nguyn sinh bnh: dit HBP.
C 3 nhm thuc chnh: khng sinh, Imidazol v Bismuth.
Cc khng sinh thng dng nht l amoxillin (hoc ampicillin), tetracycline v gn
y l clarithromycine. Kh nng dit HBP chu nh hng ca pH dch v:Mc Nully
(1989) cho thy khi pH dch v c nng cao th MIC90 (m ti thiu c ch) ca
khng sinh c gim r rt; iu ny ni ln vai tr ca cc thuc khng tit toan,
c bit thuc c ch bm proton, trong vic phi hp vi khng sinh dit tr HBP.

Cn lu l cc khng sinh dng n c c kh nng dit HBP rt thp, do cn

phi
phi
hp
vi
nhau.
Cc imidazol thng dng dit HBP l metronidazol va tinidazol. Mt vn ln
hin nay l cc chng HBP khng metronidazol xut hin vi 1 tn s kh cao nhiu
nc trn th gii nht l khu vc ng Nam v bt u c Vit Nam.
Mui Bismuth. Sau thi k btht sngv cc biu hin ri lon no xy ra trong thp
k 70 trn mt s bnh nhn dng lu di Bismuth diu tr bnh d dy v ng
rut, Bismuth nay li c s dng vi mc nh dit HBP nhng di dng mui hu
c c kch thc phn t ln v MIC90 rt thp tripotassium dictrate,
subctate,subgallate.
Cc
phng
thc
dit
BHP
Nh trn trnh by, cc nhm thuc ni trn dng n c rt t hiu lc dit HBP,
khng nhng th cn gy ra tnh trng khng thuc cho nn ng li hin nay l kt
hp nhiu loi: 2 th, 3 th v gn y 4 th thuc; thng thng kt hp 1 khng
sinh + 1 imidazol vi 1 thuc c ch bm proton hay/v Bismuth.
iu tr vi cc thuc y hc dn tc
Ngnh y hc dn tc Vit Nam cng c nhiu cng trnh nghin cu s dng cc
dc liu trong nc diu tr lot d dy t trng. Khng i vo y l ng y, cn
c trn tc dng dc l ca cc dc liu ny, chng ti thy cng c nhiu im
ph hp vi c ch sinh l bnh hc hin nay nh iu chnh axit bo v nim mc
(mai mc, bt cam tho) gim au (hng ph, d cm, c c dc (tc datura) tc
dng khng cholin nh belladone v atropine), chng vim (b cng anh, th phc
linh); ln da non (ngh); an thn (l vng, l sen).Gn y 1 dc liu cy ch dy
(Ampelopsis cantonensis) c Trng i hc dc H Ni nghin cu xc nh c
kh nng lm gim HCl dch v, c ch cc lot, lm gim au v c ch s pht
trin ca 1 s chng vi khun; 1 lun n (V Nam, 1995) cng cho nhng kt qu rt
khch
l
v
nhng
nhn
nh
trn.
Ch n ung v lm vic: Ngoi chu k au, ngi bnh c th lm vic v n ung
bnh thng, ch cn trnh dng qu nhiu ru, ch, c ph, thuc l. Trong chu k
au, cn phi n nh (sa, m, cho, vv.) v king hn cc thc n kch thch ni trn.
Cn phi ngh ti ging nu au nhiu v ch hn ch lao ng tr c v chn tay nu
au
t.
iu tr ngoi khoa: i ph vi trng thi tng axit, hn ch vnh vin vic bi tit
HCl cn dng bin php phu thut qua ng th dch, tc l ct b ni tit gastrin
v HCl nh ct b hang v, ct on 2/3 hay d dy hoc qua ng thn kinh: ct
dy thn kinh ph v (phu thut bo tn). Trc mt s phin phc do ct thn dy X
gy ra, ngi ta dng cc phu thut ct chn lc v ct chn lc trit . Kt qu
iu tr ngoi khoa ni chung kh tt nhng khng trnh khi mt s hu qu v bin
chng trc mt hoc lu di, do , cn c nhng ch nh cht ch.
Ch nh bt buc: lot d dy ung th ho c gii phu bnh hc xc minh,
thng d dy hoc hnh t trng; hp mn v; chy mu nng hoc ti pht dn dp
c
nguy
c
e
do
tnh
mng
bnh
nhn.
iu tr lot d dy bng ngoi khoa nhm hai muc tiu: iu tr khi bnh lot,
nhng ch yu ng b qua mt lot ung th. Nhiu kh khn ny sinh t mc tiu
th hai do nguy c c tnh ca mt lot kh cao (1 trong 6 lot d dy l c tnh)
song xc nh tnh cht c tnh ca mt lot khng phi d dng: Vi phng php
sinh thit, ni soi, vn c khong 10% lot c tnh b b qua; ngay c trong phu
thut, hnh nh i th cng khng gii quyt c chc chn s nghi ng, du c lm
thm xt nghim m bnh hc tc th nhng kt qu m tnh gi cng khng phi l
him. Bi vy, hu ht cc tc gi u loi b phu thut bo tn v thay bng ct

on d dy. Nu cc lot d dy ni chung sau hai ba t iu tr ni khoa tch cc

vn tn ti, cn iu tr ngoi khoa (d lnh tnh v m bnh hc).
Ch nh trong lot d dy t trng: Khc vi lot d dy, lot hnh t trng khng bao
gi chuyn sang c tnh nn phu thut phi nhm ba mc tiu: t l t vong cng
thp cng tt; li hu qu t v nh; cha khi bnh lot. t c ba mc tiu ,
phng php phu thut bo tn bng ct thn dy X t ra l tt nht. trnh cc
nhc im ca phu thut ct thn dy X, ngi ta tin ti cc phng php chn
lc v chn lc trit . Phng php hin nay c p dng kh ph bin, song
Vit Nam kt qu cha c kh quan nh nc ngoi, nht l v mc tiu khi
bnh. Ct on d dy vn l phng php c cc phu thut vin Vit Nam a
chung.
iu tr bin chng
i vi cc bin chng hp mn v, thng v ung th ho lot d dy, ch nh iu
tr
ngoi
khoa
l
tt
yu.
Cc bin chng chy mu hin nay phn ln c iu tr bo tn bng ni khoa,
bng cm mu ni soi. Phu thut cp cu ch cn thu nh trong 1 s t trng hp
m
cc
bin
php
trn

tht
bi.
Cng vi cc bin php thng thng v hi sc ni khoa trong truyn bi ph
mu gi vai tr ct yu, c th iu tr vi: cc thuc chng tit toan tim tnh mch
chm hoc tim bp; tt nht bng cm mu ni soi. Cc thuc dng trong cm mu
ni soi c th l adrenaline 1/1000, cn tuyt i, polidocanol (aethyl oxysclerol) hoc
cht keo (histoacryl). Vic cm mu ni soi c th tin hnh tt hn bng cc kp
(clip). Ngoi ra c th cm mu ni soi bng nhit: Argon Nd laser, cc u d nhit
thu
in
1
cc
v
nht
l
2
cc.
GS. Nguyn Xun Huyn
iu tr lot d dy t trng
Gi bi Admin, lc 19:28 18/08/2011, | Bnh lin quan d dy- t trng
iu tr lot d dy t trng trong vi thp k gn yc nhiu tin b
ng k v lm o ln chin lc iu tr c in trc y l: ct d dy
loi tr lot. Chin lc iu tr hin nay coi iu tr ni khoa l chnh, nu
khng khi mi phi phu thut ct d dy.
Do m ct d dy iu tr lot gim kh nhiu, ti 80 90% so vi trc y,
s
d
c
nhng
tin
b
ln
nh
vy
l
nh:
- Pht hin vi khun Helicobacter pylori c vai tr quan trng trong nguyn nhn gy
lot.
Hiu
bit
mi
v
c
ch
bi
tit
HCl.
- Tm ra nhiu thuc mi rt c hiu qu lm gim bi tit HCl cng nh lm tng
yu t bo v nim mc d dy.
I. NGUYN TC CHUNG
iu tr ni khoa trc ( d lot to, chy mu) v cch tch cc, y v ng
cch,
kin
tr.
Nu
khng
c
kt
qu
mi
phi
phu
thut.
Nu phi phu thut, nn ct dy thn kinh ph v trc, ct d dy sau.
II. CC THUC IU TR LOT
1.Cc
thuc
c
ch
bi
tit
HCl:
1.1. Thuc c ch H2: c ch c quan th cm vi histamin ca t bo thnh.
Thuc
thuc
nhm
ny
n
nay
c
ti
5
th
h:
Cimetidin, ranitidin, nizatidin, roxatidin v famotidin. Thuc cng mi cng t c hn
m
tc
dng
li
mnh
hn,
ko
di
hn,
t
ti
pht
hn.

- Cimetidin ( Tagamet ): 1g/ ngy, ung trong 30 ngy, ung nhiu ln trong ngy,
trong c 1 ln ung bui ti trc khi i ng. Thuc c tnh vi gan v thn, do
phi theo di transaminase v creatinin trong khi dng. T l ti pht sau 1 nm l 90

100
%.
Famotidin
(
Servipep,
Pepdin)
vin
20
mg.
Liu lng cch dng: 40 mg/ ngy x 4 tun, ung 1 ln vo bui ti trc khi i ng.
T
l
ti
pht
t
hn
nhiu
so
vi
cimetidin.
1.2. Thuc c ch bm Proton: c ch hot ng ca men ATPase, do K+ khng
vo trong t bo c v H+ khng ra ngoi t bo to nn HCl. Do HCl khng
c
hnh
thnh.
Lansoprazol:
Lanzor,
Ogast:
vin
30
mg.
Omeprazol:
Mopral,
Lomac,
Losec,
Prilosec.vin
20mg.
Liu
lng:
cch
dng:
20
mg
/
ngy,
4

8
tun.
40
mg
/
ngy,
2

4
tun.
Ung
1
ln
vo
bui
ti
trc
khi
i
ng.
Pantoprazol:
20
mg
/
ngy,
1
hoc
2
tun.
Raberprazol:
20
mg
/
ngy,
1
hoc
2
tun.
Prostaglandin
E1,
E2:
chng
c
hai
tc
dng:
Chng
bi
tit
HCl.
Tng
tit
nhy
v
bicarbonat.
Liu
lng
,
cch
dng:
Misoprotol
(
Cytotec,
Dimixen
)
800
g
/
ngy
x
4
tun.
Enprostol:
70
g
/
ngy.
Tc dng ph: a chy, chng mt, y bng. Ph n trong tui sinh cn dng
thn trng.
2. Thuc trung ha acid
Trung ha acid H+ ca HCl, a pH dch v ln trn 3 lm cho HCl b loi b, khng
cn hot ng. Cc thuc thuc nhm ny u l mui ca nhm v magie: carbonat,
phosphat, trisilycat, hydroxyt. Cc bit dc c rt nhiu: Maalox, Gelox, Polysilane
gel,
Gastrogel,
Gastropulgit,
Phosphalugel,
Barudon
Liu lng cch dng: liu lng ty theo tng bit dc. Cn ung nhiu ln trong
ngy, ung sau khi n 30 pht 1 gi duy tr pH dch v lun lun trn 3 3,5.
Tc dng ph: a chy, si thn, kim ha mu.
3. Thuc to mng lc
Gn vi protein hoc cht nhy ca nim mc d dy to thnh mng che ch nim
mc d dy, nht l che ch cho lot. C rt nhiu loi thuc:
Koalin,
Smecta,
Gelpolysilan.
Actapulgit,
Gastropulgit.
Bismuth:
Subcitrat
bismuth
(
Trymo
).
Tripotasium
dicitrat
bismuth.
Sucralfat.
Liu lng: 480 mg / ngy, chia nhiu ln, ung trc khi n.
Thuc dit Helicobacter pylori: ngoi cc thuc c ch bm proton, mui bismuth, c
rt nhiu khng sinh c tc dng dit HP, nhng mt s khng sinh sau y c tc
dng nht: tetracyclin, amoxicillin, clarithromycin v metronidazol.
III. P DNG THC T
Cn c chn on lot bng ni soi hoc t nht bng X quang. nh gi kt
qu
cng
bng
ni
soi
hoc
X
quang
d
dy.
iu
tr
khi

lot
ang
tin
trin

- C th dng mt trong cc loi thuc chng bi tit HCl, thuc trung ha acid, thuc
to mng bc trn y vi liu tn cng, khng nht thit phi phi hp 2 3 loi
thuc,
m
c
th
dng
mt
loi
ring
r,
cng
c
kt
qu.
- Khng nht thit phi dng cc thuc mi t tin nht mi c kt qu. Cc thuc
chng bi tit HCl, cng nh cc thuc chng acid, thuc to mng bc c tc dng
lin so gn tng t nhau, nu c dng ng cch y .
- Thuc dit HP: nu c HP, nu khng c HP th khng cn dng.
- Ch n ung: khng ung ru, thuc l, c ph, trnh cc cht kch thch gia v,
ht
tiu,
t
dm.
Khi

lot

lnh
so
C ngi cho rng khng cn iu tr duy tr, khi no lot ti pht s iu tr li.
C ngi ch trng phi tip tc iu tr duy tr. C th dng: thuc c ch th th
H2, c ch bm proton nhng liu lng v cch dng phi gim 1/3 hoc so vi
liu tn cng. Thuc to mng bc nh Gastropulgit, Phosphalugel, Gel de polysilan
cng vi liu lng gim bng 1/3 hoc so vi liu tn cng.
Thi gian iu tr duy tr theo tng ngi, t 6 thng n vi nm.
iu
tr

lot
chy
mu
Nn dng cc thuc c ch th th H2 hoc c ch bm proton loi tim, trong 2 3
ngy u khi mu ang chy, khi mu cm th dng thuc ung: Losec tim,
Zantac tim, hoc Nexium tim.
Theo Nguyn Khnh Trch
Chy mu ti khi i ngoi
Gi bi Admin, lc 10:32 31/08/2011, | Bnh ai trng
C nhiu nguyn nhn ca chy mu ti khi i ngoi:
u tin phi k n bnh tr, sau l Polip trc trng v i trng, vim,
nt k ng hu mn, vim lot i trc trng chy mu...

1. BNH TR
y l bnh rt ph bin, gp mi ni, nhiu nht ngi ln tui. Ngy nay
ngi ta hiu r hn bn cht ca bnh tr nh nhng cng trnh nghin cu v s
phn b mch mu ca vng hu mn trc trng. ng hu mn l ni c nhiu mch
mu, to thnh cc bi tnh mch nm lp di nim mc, chng c tnh cht cng
nn c chc nng ca mt ci nm, gi vai tr khp kn hu mn. Nh vy tr l mt
trng thi bnh thng, nhng khi cc m ri tnh mch tr ny dn qu mc s to
thnh bnh tr.
Nguyn nhn pht sinh bnh tr cha c xc nh chnh xc.
Nhiu yu t c coi nh l ngun gc pht sinh bnh tr:
+ T th ng: Tr gp nhiu ngi phi ng lu, ngi nhiu. Khi nghin cu v
p lc tnh mch bnh nhn tr, ngi ta thy t th nm p lc l 25cm H2O -
t th ng p lc tng vt n 75cm H2O.

+ Ri lon i tin: nh l v to bn, bnh nhn phi rn nhiu mi khi i i tin.

+ Ph n mang thai, sinh .
+ C tnh cht gia nh.
+ Nhng khi u trc trng hu mn, u x t cung... Nhng u ny lm cn tr mu
hu mn trc trng tr v cng l nhng nguyn nhn gy ra bnh tr.
Triu chng thng gp ca bnh tr:
i tin mu ti. y l triu chng sm nht v cng l triu chng thng
gp. Lc u chy mu kn o, bnh nhn tnh c pht hin c mu giy v sinh
hoc nhn vo phn thy mt vi tia mu nh dnh vo phn rn, v sau mu chy
thnh git hoc phun thnh tia nh ct tit g. Mun na, c mi ln i tin, ngi
xm, i li nhiu l mu chy. Km theo, bnh nhn thng xuyn b to bn, sau c
th phn mm vn ra mu.
au vng hu mn, cng c th khng au hoc au nh. au nhiu khi c tc
mch hoc nt hu mn.
Sng n vng hu mn: Khi c t cp hoc khi tr sa ra ngoi, c th bi tr sng
kh to.
R nc v nga vng hu mn do vim ng hu mn.
Trn y l nhng triu chng in hnh ca bnh nhn b bnh tr, nhng c khi
giai on u bnh nhn ch c biu hin i tin mu ti n thun.
chn on xc nh bnh tr cn phi thm khm trc trng hu mn, bng
cch thm trc trng v soi ng hu mn. Qua soi s xc nh tn thng ca bi
tr;
s
lng
bi
tr,
kch
thc
v
v
tr
cc
bi
tr.
Bnh tr l mt bnh t nguy him, nhng gy kh chu cho ngi bnh nh au vng
hu mn, nga hu mn, r nc vng hu mn, i tin mu ti ko di dn n
tnh
trng
thiu
mu.
iu tr bnh tr
+ Ch sinh hot: Cn hn ch cng vic nng, trnh ngi lu, ng nhiu, khng
ung ru, bia, khng dng cc thc n d gy kch thch nh t, ht tiu v nhng
thc n d gy tiu lng, nhng trnh to bn. Nn n nhng thc n lm cho phn
mm, cn v sinh gi sch vng hu mn.
+ Thuc ti ch: Thuc n t hu mn dng cho cc thng tn nm trong vng
hu mn trc trng. Pomat dng cho cc thng tn nm pha ra hu mn, Pomat
c bi vo cnh hoc u ngn tay mang gng, t nh vo trong lng ng hu
mn ni c thng tn.
Cc thuc c s dng: Proctolog, Proctoglyvenol, Titanorein dng Pomat hoc
vin n.
+ Thuc ton thn: C tc dng lm bn vng thnh mch nh Oaflon, Ginkow
procto.
+ Thuc lm x bi tr: c tim vo chn cc bi tr, vo lp di nim mc. Cc
loi thuc thng dng:
Du
phenol
5%
Polydocanol.
+
Tht
bi
tr
bng
vng
cao
su.
+ t in: Dng dao in mt cc, hai cc hay dng in trc tip, di tc dng
ca
nhit,
cc
bi
tr
s
ng
li.
+
Liu
php
lnh,
hiu
php
quang
in:
t
s
dng.
+ Phu thut: Ct b bi tr khi c tc mch, cc m ri tnh mch dn n ln, tr
ngoi.

2. POLIP TRC TRNG V I TRNG

Vi bnh ny, bnh nhn c triu chng duy nht l i
tin mu ti vi s lng nhiu, nhiu khi c tnh trng
thiu mu nng. i tin mu ti tng t, khng to
bn cng chy mu. Nu polip c cung di v thp gn
ng hu mn, c th polip sa ra ngoi. Chn on chnh
xc bng soi trc trng hoc i trng s pht hin c
polip c cung hay khng c cung, v tr polip - iu tr
bng cch ct polip qua ni soi nu polip c cung v
cha nghi ng ung th ha.
3. VIM, NT K NG HU MN
Thng do to bn, bnh nhn c rn lm cho ng hu
mn sng, ph n, mng, i khi c nt ng hu mn.
Vim v nt k ng hu mn thng i km vi bnh tr.
Triu chng in hnh nht l bnh nhn rt au vng hu mn, au thng xuyn khi
khng i tin, mu ti thnh git, au lng khi i tin, au nhiu lm cho bnh
nhn khng dm n, v n nhiu i tin nhiu bnh nhn rt au.
4. VIM LOT I TRC TRNG CHY MU
L bnh t min him gp nc ta. Bnh nhn i tin nhiu ln, ln mu ti, s
lng nhiu, c th ln t nhy, nhng bnh nhn au bng. Chn on xc nh bng
soi
trc
trng
v
i
trng.
Nh vy, i tin mu ti l triu chng ca mt s bnh l vng hu mn trc
trng. Khi c biu hin triu chng ny, bnh nhn cn phi i khm ti cc trung tm
y t c phng tin ni soi chn on chnh xc v iu tr kp thi.
Theo Bs.Thuocbietduoc
iu tr bnh xng khp
Gi bi Admin, lc 08:44 21/08/2011, | Bnh Gt - Khp
Cc bnh xng khp phn ln l cc bnh mn tnh c din bin ko di
do trong cng tc iu tr phi:
Nguyn tc chung
Cc bnh xng khp phn ln l cc bnh mn tnh c din bin ko di do
trong
cng
tc
iu
tr
phi:
- iu tr lu di, c chng trnh k hoch tng t, tng giai on.
Phi
theo
di
bnh
nhn
thng
xuyn
v
cht
ch
- Cn cn nhc khi la chn cc thuc nhm pht huy tc dng ti u v trnh tng
k
thuc
do
iu
tr
bnh
xng
khp
thng
l
a
tr
liu.
- Vic la chn thuc cn phi da trn tnh hnh kinh t v nhn thc ca mi bnh
nhn, do iu tr bnh xng khp thng ko di, c khi sut i.
- Phi ch ti cc mt xy dng gia nh, sinh , phc hi chc nng, chuyn ngh
nghip hoc hng nghip, hc tp, tm t tnh cm, ha nhp cng ng ca bnh
nhn.
Cc phng php iu tr bnh xng khp bao gm:
iu
tr
ni
khoa
Vt
l
tr
liu,
phc
hi
chc
nng.
Phu
thut
chnh
hnh,
thay
khp
nhn
to
Qun
l
theo
di
bnh
nhn,
d
phng
cc
t
tin
trin.
- Gii quyt cc vn kinh t - x hi.

iu tr ni khoa
iu tr ni khoa cc bnh xng khp bao gm cc phng php sau: s dng
thuc; vt l tr liu; phc hi chc nng; theo di, gio dc, qun l bnh nhn.
iu
tr
thuc:
c
3
nhm
chnh:
1.
Thuc
gim
au
2. Thuc chng vim: corticosteroid; thuc chng vim khng steroid (Nonsteroidal
Anti-inflammatory
Drg
NSAID).
3. Thuc iu tr c bn hay cn c gi l cc thuc chng thp khp lm thay i
bnh l (Disease Modifying Antirheumatic Drugs: DMARD), cc thuc chng thp khp
tc dng chm (Slow Acting Antirheumatic Drugs: SAARD). iu tr theo c ch sinh
bnh,
theo
c
ch
min
dch.
4. Cc thuc iu tr bnh xng khp khc: thuc iu tr bnh gt; thuc iu tr
thoi ha khp; thuc iu tr long xng.
Thuc gim au
Nhm thuc gim au ng mt vai tr quan trng trong iu tr cc bnh khp.
Nhm ny t c vi d dy v thn hn thuc chng vim khng steroid.
Nhng
nguyn
tc
khi
s
dng
cc
thuc
gim
au:
- Thuc c lm gim au ch khng c tc dng cha bnh, do cn tm nguyn
nhn

iu
tr.
Dng
ng
ung

n
gin
ha
cch
thc
s
dng
Bt
u
l
liu
thp
nht
sau

tng
dn.
S bc thang ch nh thuc gim au theo khuyn co ca T chc Y t Th gii
(WHO):
Bc 1; thuc khng c morphin (paracetamol, salicyles, thuc chng vim khng
steroid
liu
thp,
noramidopyrine,
idarac).
Bc 2: cc thuc c dn cht morphin yu (codein, dextro -propoxyphene,
buprenorphine,
tramadol).
Bc
3:
morphin
mnh
Thuc
gim
au
bc
1:
khng
c
morphin
- Paractamol (Dafalgan): l dng hot ng ca phenacetine. C tc dng gim au
do c ch dn truyn cm gic au ti thn kinh trung ng, paractamol c xp
vo nhm thuc gim au ngoi vi. Paractamol c tc dng h nhit do c ch cc
prostaglandine ti vng di i. Thuc khng c tc dng chng vim. Hiu qa ca
thuc mnh ngang aspirin, song khng gy tn thng d dy t trng nn c a
chung. L thuc c ch nh u tin trong iu tr au triu chng. C th s dng
cho ph n c thai v ang cho con b. C th c vi gan nu dng liu cao v ko
di. Trng hp qu liu (10 gam/ngy), c nguy c hoi t gan cp. Khng dng
thuc khi c suy t bo, mn cm vi paractamol.Liu dng: 1-3g/24h, trung bnh: 12g/24h.
- Floctafenine (Idarac): c tc dng gim au n thun, khng c tc dng chng
vim. Gim au mnh hn aspirin, khng gy tn thng d dy t trng v gan.
Him gp tc dng ph, tr trng hp mn cm vi thuc, c th gy suy thn, gim
tiu
cu
Khng s dng khi biu hin d ng vi floctafenine, glafenine, suy tim nng, bnh
mch vnh, khng phi hp vi cc thuc c ch b. Liu dng: vin 200mg x 2-6
vin/ngy.
Thuc
gim
au
bc
2;
morphin
yu
- Codine: l thnh phn ester methylic ca morphin, c hiu qu gim au bng 1/10
morphin. Khng dng khi c suy t bo gan, mn cm thuc, suy h hp, cho con b
v cc thng cui khi mang thai. Thuc c th gy nn, bun nn, to bn, au u,

ng
g,
d
n.
Dicodin: ch phm gii phng ko di (dihydrocodine), vin 60 mg x 2 vin/ngy.
Efferalgan
codein
(paractamol
+
codeine):
500mg
x
2-6
vin/ngy.
- Dextroproxyphene l dn xut tng hp ca morphin, c hiu qu gim au bng
1/10-1/15 morphin. Khng dng khi c suy t bo gan, mn cm thuc, suy h hp,
cho
con
b
v
cc
thng
u
v
cui
thai
k.
Antalvic:
vin
65mg
x
3-5
vin/ngy.
Di-antalvici: (paracetamol + dextroproxyphene) 500mg x 2-6 vin/ngy.
Thuc
gim
au
bc
3:
morphin
mnh
- Chlorhydrate morphin: dung dch ung, ng tim di da hoc tnh mch 10, 20, 50,
100, 500mg (theo ch nh ca khoa dc bnh vin). Thuc c cc tc dng ph n:
nn, bun nn, to bn, au u, ng g, d ng Khi dng liu qu cao c th gy
bn, au u, ng g, d ng Khi dng liu qu cao c th gy suy h hp. Ty theo
mc au ca bnh nhn thng bt u bng liu 10mg/ln, nu cn tip tc au
c th cho liu tip theo 10mg cch nhau 4 gi; khng c liu ti a, m ty theo p
ng ca bnh nhn,nhng khng c cho qu 30mg trong 1 ln v 180mg trong 24
gi (c th Php); gim liu trong trng hp suy thn, suy gan tin trin, ngi gi
(ngi
gi
cho
na
liu
10mg
=
5mg).
- Sulfate morphin (moscontin 150m, skenan): vin nn, nang dng ht c tc dng
gii phng ko di (12h) hm lng 10, 20, 30, 50, 100, 200 mg/vin. Thng bt u
bng
liu
10mg
30/ln
x
20
ln/ngy.
S
dng
cc
thuc
gim
au
khc:
- Thuc chng vim khng steroid: dng n c hoc kt hp vi morphin trong cc
trng hp au xng, vim khp, trn dch cc mng, ung th xng.
- Corticoids: nn dng trong nhng trng hp au do chn p hoc phn ng vim
(ph n quanh t chc u, di cn ung th xng, gan, tng p lc ni soi. Dng
ng
tim:
Solumedrol
liu
2-3
mg/kg/ngy.
- Tia x: mc ch gim au. Tia x ti v tr xng tn thng, chn p thn kinh, cc
di
cn
no.
Thuc
chng
co
tht:
trng
hp
c
ri
lon
tiu
ha.
- Cc thuc hng thn: chng trm cm 3 vng (laroxyl, anafranil) c dng khi au
do chn p thn kinh, lun dng liu thp hn liu dng chng trm cm: 10-25150mg (ti).
Thuc chng vim corticosteroid trong thp khp hc.
Cc hocmon v thng thn l cc corticosteroid, gm ba nhm chnh l
glucocorticoid (c tc dng chng vim) v mineralocorticoid (c tc dng chuyn ha
nc v in gii lm gi nc) v corti-coid androgen (ni tit t nam testosteron).
Trong lm sng ngi ta s dng cc glucocorticoid tng hp c tc dng chng vim
mnh v t c tc dng ph trn chuyn ha nc v in gii hn.
Cc tc dng chnh c dng trong iu tr: c 3 loi tc dng chnh ca
glucocorticoid c p dng trong iu tr l chng vim, chng d ng v c ch
min dch. Tuy nhin, cc tc dng ny ch t c khi nng thuc trong mu
cao hn nng sinh l. l nguyn nhn d dn n cc tai bin trong iu tr.
Thc t, c ch ca cc glucocorticoid rt phc tp v chng c nhiu tc dng ln
mt t bo ch, v li c nhiu t bo ch chu tc dng ng thi.
Tc
dng
chng
vim:
Glucocorticoid tc dng trn nhiu giai on khc nhau ca qu trnh vim, khng
ph thuc vo nguyn nhn gy vim. C ch chng vim ca cc corticoid tng hp
thng qua nhiu giai on nh sau: c nh trn cc th th c hiu trong t bo,
tng hp lipocortin, c ch phospholipase A2, hot tnh chng vim t chc.

C nh trn cc th th c bit trong t bo: do c c tnh ha tan, cc corticoi

dng qua c mng ca tng bo. Ti bo tng, corticoid c c nh trn thu
th c hiu sau khi tch ra t mt protin c gi l HSP 90 (Heat Shock
Protein). S to thnh phc hp corticoid - th th c hiu din ra saukhi corticoi i
chuyn vo trong nhn. Phc hp ny c nh trn cc v tr chnh xc ca AND nhn
v dn n hoc l tng, hoc l gim hat tnh ca gen ln cn. Trong s cc protein
c tng hp di tc dng ca qu trnh ny, mt s c tc dng chng vim v
chng c m ha cc thc phn ng hc nhm sn xut ra cc trung gian vim.
Tng hp lipocortin: cc lipocortin (macrocortin, lipomodulin, renocortin) l cc
protein tn ti trng thi bnh thng trong a s t bo. Khi c corticoid hot ha
tng hp v gii phng, chng c hiu qu chng vim: do hot tnh khng
phospholipase A2, cc lipocortin c th c ch to axit arachidonic, c tc dng gim
tng hp v gii phng prostaglandin, leucotrien, do lm ngng qu trnh vim.
c ch phospholipase A2: corticoid c ch mnh m t sn xut cc trung gian ca
qu trnh vim bng cch ngn chn, c th l khng c hiu, hot ng ca
phospholipase
A2.
Hot tnh chng vim t chc: cc corticoid phn ng mnh v nhanh ngay t giai
on khi pht ca qu trnh vim t chc. Thuc c ch s gin mch v tng tnh
thm mao mch ti vng tn thng; cc h mnh s di chuyn bch; lm gim
hot ng thc bo ca i thc bo, ca bch cu a nhn v i thc bo, do c
ch gii phng cc men tiu ha protein, cc ion super-oxit (cc gc t do), lm gim
hot tnh ca cc yu t ha hng ng, cc cht hot ha ca plasnminogen,
collagenase,
elastase
Thuc tc dng ln s tng sinh ca nguyn bo s, do , ln s tng hp cc si
collagen v mucopolysacharid. Do vy, chng c ch li c bit trong qu trnh tng
sinh
mn
tnh
v
x
ha.
Tc dng chng d ng: cc phn ng d ng xy ra do s gn ca cc IgE hot ha
trn cc receptor c hiu dng bo (masto-cyte) v bch cu kim tnh di tc
dng c d nguyn. S gn cc IgE ny hot ha phospholipase C, cht ny tch
phosphatidyl- inositol diphosphat mng t bo thnh diacyl-glycerol v inositoltriphosphat. Hai cht ny ng vai tr "ngi truyn tin th hai", lm cc ht bo
tng ca t bo gii phng cc cht trung gian ha hc ca phn ng d ng:
histamine, serotonin Bng cch c ch phospholipase C, cc glucocorticoid
phong ta gii phng trung gian ha hc ca phn ng d ng. Nh vy, IgE gn trn
dng bo nhng khng hot ha c nhng t bo . Do , glucocorticoid l
nhng
cht
chng
d
ng
mnh.
Tc dng c ch min dch: glucocorticoid tc dng ch yu trn min dch t bo, t
nh
hng
n
min
dch
th
dch
thng
qua
c
ch:
c ch tng sinh cc t bo lympho T do lm gim sn xut interleukin 1 (t i thc
bo)
v
interleukin
2
(t
T4).
Gim hot tnh gy c t bo ca cc lymphoT (T8) v cc t bo NK (natural killer:
t bo dit t nhin) do c ch sn xut interleukin 2 v interony.
c ch sn xut TNF v c interferon, glucocorticoidlm suy gim hot tnh dit
khun, gy c t bo v nhn dng khng nguyn ca i thc bo.
Mt s tc dng ny cng ng thi l tc dng chng vim. Tc dng c ch min
dch th hin khi dng liu cao (1-2mg/kg/ngy prednisolon hay tng ng). Do c
ch tng sinh, glucocorticoidc tc dng tt trong iu tr bnh bch cu lympho cp,
bnh
Hodgkin.
- Chuyn dng sinh hc: a s cc glucocorticoidhot ng m khng chuyn dng.
Tuy nhin prednison v cortison cn thm mt H-OH gan chuyn thnh

prednisolon
v
cortisol

c
hat
tnh.
- Thi tr: cc glucocorticoidtng hp ch yu c thi tr bng ng thn.
Ch
nh
trong
cc
bnh
khp:
ng
ton
thn:
- Cc ch nh chnh: cc bnh h thng (collagenose), c bit khi c biu hin ni
tng. Vim khop dng thp giai on tin trin, thp khp cp c tn thng tim.
Bnh Horton v gi vim a khp gc chi, vim mch v bnh h thng. Cc trng
hp bnh khp c gc ch nh thuc chng vim khng steroid: ngi gi, bnh nhn
c
lot
d
dy,
suy
thn,
gan
nng.
- Ccc h nh c bit dng corticoid liu thp trong thi gian ngn: vim quanh khp
vai vi ha th tng au, gt hay ti pht, au thn kinh tai m cc bin php iu
tr
ni
khoakhc
tht
bi.
ng ti ch: vim khp mn tnh khng do nhim khun, trn dch khp gi khng
do nhim khun, kn mng hot dch, vim mng hot dch th lng nt v sc t,
mt s trng hp thoi ha khp, vim quanh khp vai, vim gn, vim cc khp
lin
mm
sau.
Chng
ch
nh:
Lot
d
dy
t
trng
i
tho
ng
Tng
huyt
p
Lao
c
hoc
lao
ang
tin
trin.
Bnh
nhimtrng,
virut,
k
sinh
trng
tin
trin.
c
nhn
mt
C a c bit: ph n c thai (khi tht cn thit), tr em (cho khi tht cn thit: liu
t 1/2mg/kg/24h l nh hng n s pht trin ca tr), ngi c tui (thng
gy
ri
lon
iu
ha
ng
huyt).
Cch
thc
s
dng
Nguyn tc dng thuc: dng thuc khi c chn on chnh xc; dng trong thi gian
cn thit; gim liu ngay khi c th; theo di thng xuyn; phng nga cc bin
chng
do
thuc.
Phc

iu
tr
c
bit:
Bolus hay flash - Pulse therapy: truyn tnh mch 750mg-1g methl-prednisolon pha
trong 250-500ml dung dch mui sinh l hay glucose dng tng trong 2-3 gi, dng
mt liu duy nht hay mt ln/ngy trong 2-3 ngy. Sau liu ny, gi tip bng ng
ung vi liu tng ng vi prenisolon 1,5-2mg/kg/24h. Ch nh trong trng hp
c
bit,
phi
theo
di
bnh
nhn
nghim
ngt.
Cc
ng
dng:
ng ung: s dng cc dng thuc vin nh cortison (25mg), prednison (5mg),
prednisolon (5mg), methylprednisolon (4mg), dexamethason (0,5mg), triamcinolon
(4mg),
betamethason
(0,75mg).
ng tim bp hay tim tnh mch: ch dng trong trng hp tht cn thit. Dng
cc thuc nh hemisuccinat hydrocortison, depersolon, dexamathason, solumedrol
ng timbp hin nay hu nh khng c s dng trong thp khip hc v cc tc
dng ti ch kh nghim trng (teo c, nguy c nhim trng).
ng ti ch (tim trong hay cnh khp, tim ngai mng cng tim vo trong ng
sng): phi c bc s chuyn khoa ch nh v tun th v trng cht ch.
Liu dng (tnh theo prednisolon): liu thp: 5-10mg/24h, trung bnh: 20-30mg/24h,
liu cao: 60-120mg/24h (1-2mg/kg/24h). i vi cc bnh thp khp, thng cho liu
0,5mg/kg/24h, sau gim liu 10% mi tun. T liu 15mg tr di gim 1mg/tun.
Dng
ko
di:
khng
qu
5-10mg/24h.

Cc
tc
dng
ph:
Tiu
ha:
lot
d
dy
t
trng
(chy
mu,
thng)
vim
ty
Mt:
c
nhn
mt
sau
di
bao,
tng
nhn
p.
Da; trng c, teo da, ban v t mu, mt, chm lin so, vt rn da.
Ni tit: hi chng Cuhsing (bo mt v thn), chm pht trin tr em.
Chuyn ha:tng ng mu, i tho ng nhim toan ceton, hn m tng p lc
thm thu, gi nc, mt kali. c bit cc ri lon chuyn ha ng rt d xut
hin

ngi
ln
tui.
Tim
mch:
tng
huyt
p,
suy
tim
mt
b
Thn
kinh
tm
thn:
kch
thch
hoc
trm
cm
Nhim khun v gim min dch: tng nguy c nhim khun, khi pht nhim khun
tim
tng.
C quan vn ng: long xng, hoi t u xng, bnh l v c (yu c, nhc c).
Tai bin do dng thuc: cn suy thng thn cp, t ti pht bnh khp do dng
khng
ng
cch.
Theo
di
mt
bnh
nhn
c
iu
tr
corticoid:
Vic theo di c mc ch nh gi hiu qu iu tr, iu chnh liu theo kt qu t
c
v
pht
hin
cc
bin
chng.
V lm sng: huyt p, ng con biu cn nng, ng cong nhit , khm mt.
V xt nghim: in gii (c bit l kali mu), ng mu khi i.
Ch n: n nht, hn ch ng hp thu nhanh (ng, bnh ngt).
Ch

iu
tr
b
sung:
- Kali: thm 1-2gam kalichlorure hoc 2-4 vin kaleorid 600mg/ngy.
Vitamin
D
(Ddrogyl:
10
git)
+
1g
calci/ngy
- Bo v nim mc d dy: thuc phi ung cch xa lc ung prednisolon.
Benzodiazepines
trong
trng
hp
mt
ng
Ch ny phi c thc hin khi liu prednisolon mi ngy vt qu 10mg, v
cng c thc hin nghim ngt khi liu cng cao.
Thuc chng vim khng steroids (NSAID)
Thuc chng vim khng steroids (Nonsteroidal Antiinfammatory Drugs-NSAID) l
mt nhm thuc bao gm cc thuc c ot tnh chng vim v khng cha nhn
steroid.
Nhm thuc ny c nghin cu s dng vi chc nm gn y, c tc dng chng
vim, tai, mi hng, rng, sn ph, phu thut. Nhm ny bao gm rt nhiu cc dn
cht c thnh phn ha hc khc nhau. Song cch thc tc dng ca chng rt gn
nhau: ch yu l c ch cc cht trung gian ha hc gy vim, nht l prostaglandine
(PG) - iu ny gii thch phn ln cc hiu qu ca thuc, song cng gii thch tc
dng ph ca nhm thuc NSAID. a s cc thuc trong nhm cng c tc dng h
nhit v gim au. Cc thuc NSAID ch lm gim cc triu chng vim m khng loi
tr c cc nguyn nhn gy vim, khng lm thay i tin trin ca qu trnh bnh
l
chnh.
Tc
dng
v
c
ch
ca
cc
thuc
NSAID
Cc tc dng chnh l chng vim, gim au, h st v chng ngng tp tiu cu. Ty
tng thuc m mc ca cc tc dng ny biu hin t hoc nhiu.
Cc thuc trong nhm chng vim khng steroid c tc dng chng vim do cc c
ch
sau:
c
ch
sinh
tng
hp
cc
prostaglandin
(cycloygenose):
C hai loi prostaglandin c 2 chc nng khc nhau: prostagladin sinh l v
prostagladin c sinh ra trong qu trnh vim v c 2 enzym ng dng ca COX l
COX-1 v COX-2. COX-1: tng hp cc prostaglandin c tc dng "bo v" c gi l

cc enzym "gi nh" ("house keeping" enzyme). COX-2: khi c cc kch thch vim
hot ha COX-2: tng hp cc prostagladin c vai tr trong cc triu chng vim (S
d
trn,
phn
corticoid).
Cc thuc NSAID khng chn lc (a s cc thuc NSAID kinh in) c ch ng thi
c enzyme COX-1 v COX-2: khi c ch COX-2 thuc c tc dng kim sot c cc
trng hp vim v au, khi c ch COX-1 s gy ra nhng tc dng ph (c bit
trn
thn
v
ng
tiu
ha).
Cc thuc NSAID c ch chn lc COX-2 c tc dng c ch s hnh thnh cc
prostaglandi v TXA2 c to ra do phn ng vim, ng thi cng c ch cc cht
trung gian gy vim khc nh superoxid, cc yu t hot ha tiu cu,
metallopeotease, histamin Trong khi , tc dng cc h ln COX-1 l ti thiu, do
lm gim thiu tc dng ph. Cc thuc NSAID c ch chn lc COX-2 c ch
nh vi cc i tng c nguy c cao, c bit cc bnh nhn c tn thng d dy
t
trng.
Mt
s
c
ch
khc:
Thuc NSAID cn c ch cc kinin cng l nhng cht trung gian ha hc ca phn
ng vim. Mt s thuc NSAID cn c ch c enzym lypo-oxigenase (LOX) (S trn,
phn corticoid). Thuc cng lm bn vng mng lysosome (th tiu bo) ca i thc
bo, do gim gii phng cc enzym tiu th v cc ion superoxit, l cc ion rt c
i
vi
t
chc,
nh
vy
lm
gim
qu
trnh
vim.
Ngoi ra, cn c mt s c ch khc nh thuc cn c ch di chuyn bch cu, c ch
s kt hp khng nguyn khng th, i khng vi cc cht trung gian ha hc ca
vim
do
tranh
chp
vi
c
cht
ca
enzym.
Tc
dng
gim
au:
Cc thuc NSAID c tc dng gim au trong qu trnh vim do lm gim tnh cm
th ca cc u dy thn kinh cm gic, p ng vi au nh v khu tr, khng gy
ng, khng gy nghin. Thuc ny khng c tc dng vi cc au ni tng.
C ch: cc thuc NSAID, s c ch cc prostagladin PGF2a do , lm gim tnh cm
th ca cc u dy thn kinh cm gic vi cc cht gy vi au nh bradykinin,
histamin,
serotonin
Tc
dng
h
st:
Thuc c tc dng h nhit, liu iu tr, trn nhng ngi tng thn nhit do bt k
nguyn nhn g, m khng gy h nhit ngi c thn nhit tnh thng. Thuc
NSAID lm tng qu trnh thi nhit (gin mch ngoi vi, ra m hi), lp li thng
bng cho trung tm iu nhit vng di i. Do , thuc gy h st, l thuc cha
triu
cng,
m
khng
tc
dng
trn
nguyn
nhn
gy
st.
Tc
dng
chng
ngng
tp
tiu
cu:
Tc dng chng ngng tp tiu cu ca thuc NSAID lin quan n c ch enzym
thromboxan synthetase, lm gim tng hp thromboxan A2 l cht ng vn tiu cu.
Dc
ng
hc
thuc
chng
vim
khng
steroid
Mi thuc NSAID u c tnh axit yu, pH t 2-5. Chng c hp thu d dng qua
ng tiu ha, t nng ti a huyt tng t 30-90 pht v thm nhp vi
nng

cao
vo
trong
t
chc
vim.
Thuc lin kt vi protein huyt tng rt mnh (90%) do d y cc thuc khc ra
dng t do, lm tng c tnh ca cc thuc (sulfami h ng huyt, khng
vitamin K, methotrexate). Do vy, phi gim liu thuc cc nhm ny khi dng cng
vi
thuc
NSAID.
Thuc d ha gan (tr salisylic), thi qua thn di dng cn hot tnh.
Cc thuc NSAID c thi tr khc nhau: thuc no c pH vng thp th thi gian
bn hy cng ngn. Thi gian bn hy dch khp chm hn huyt tng, c thuc

c thi tr rt chm. Mt s thuc nh aspirin, dn cht ca propionic c thi gian

bn hy trong huyt tng t 1-2 gi, do vy cn cho thuc nhiu ln trong ngy. C
thuc thi gian bn hy di ti vi ngy (oxicam, pyrazol) th ch cn cho 1 ln/ngy.
Xt
loi
nhm
thuc.
C
nhiu
cch
xp
loi
nhm
thuc
chng
vim
khng
steroid:
Xp
lai
theo
thnh
phn
ha
hc:
Thuc NSAID gm 3 nhm ln: carboxyl axit, enol v nhm khng c cu phn axit.
Trong cc nhm trn, li bao gm 7 nhm thuc:nhm salicyl, nhm pyrazol, nhm
indol, nhm propyonic, nhm anthranilic, nhm oxicam v nhm khc, trong c
dn
xut
ca
aryl-acetic
axit.
Xp loi theo thi gian bn hy cc thuc NSAID: chia thnh hai nhm:
Thi gian bn hy ngn (< 6 gi): profenid, ibuprofen, voltaren, indometacin,
Thi gian bn hy di (> 12 gi): phenylbutazon, feldene, tilcotil, mobie.
Xp
loi
theo
kh
nng
c
ch
chn
lc
enzym
COX:
Thuc
c
ch
COX
khng
chn
lc
(cc
thuc
NSAID
c).
Thuc
c
ch
chn
lc
COX-2:
meloxicam
(mobic)
Thuc
c
ch
chuyn
bit
COX-2:
celecoxib
(celebrex),
Mt s thuc NSAID chnh (xem bng tm tt mt s thuc NSAID).
Tc
dng
ph
trn
ng
tiu
ha:
Thng gp nht l cc tc dng ph nh nh bun nn, cm gic chn n, au
thng v, a chy, to bn. C th gp cc bin chng nng n nh lot d dy
(thng b cong ln) - t trng, thng ng tiu ha. Mt s c a d c bin
chng tiu ha do CVKS: tin s lot c, ngi nghin ru, ngi c tui, bnh nhn
dng
thuc
chng
ng.
Thuc cng thng lm tng transaminase khi dng lu di. Cn ngng dng thuc
khi transaminase tng gp 3 ln bnh thng. Him xy ra bin chng nng nh: vim
gan gy vng da do c ch min dch d ng, tin trin thun li sau khi ngng thuc.
i vi c quan to mu: c t bo gy gim bch cu, suy ty (pyrazols) v ri
lon ng mu (aspirine) do tc dng c ch ngng tp tiu cu ca thuc.
i
vi
thn:
Thuc gy vim thn k cp c hay khng km theo hi chng thn h dng nh do
nguyn
nhn
min
dch
d
ng.
C th gy suy thn cp chc nng do cc prostaglandine gy gin mch thn duy
tr
th
tch
lc
qua
thn
b
c
ch.
i vi thn kinh: au u, chng mt (indocid), gim liu hoc ngng thuc c th
mt triu chng ny. tai v gim ngng nghe do aspirine qu liu.
Trn da - nim mc: khi dng mi thuc NSAID c th gp ban, nga Hi chng Lyell
(bng nc thng b do nhim c nng) c th gp khi dng oxicam, song him.
Tc dng ph khc: lm nhim trng nng thm, mt tc dng trnh thai ca dng c
t cung (do prostagladin ni sinh c tc dng co c t cung, khi dng thuc NSAID, c
ch loi prostagladin ny): gp mi thuc NSAID. Nhim fluo (nifuril), tng huyt p
do gi nc -mui (pyrazols). V mt s tai bin d ng khc gp ngi nhy cm,
hay gp khi dng aspirine.
Bng tm tt mt s thuc NSAID

Tng
tc
thuc:
Vi thuc chng ng: thuc NSAID lm tng tc dng ca cc thuc chng ng (c
bit l khng vitamin K, dn xut ca coumarin) do c tc dng chng ngng tp tiu
cu v lm tng, thnh phn t do ca thuc chng ng trong huyt tng, dn ti
nguy c xut huyt. V vy nn trnh kt hp hai loi thuc ny. Khi vic kt hp l
bt buc th nn chn thuc NSAID loi propionic v thuc chng ng l dn xut c
phenindion
(pindion).
Thuc chng h ng huyt: cc thuc NSAID (salicyl, pyrrazols) lm tng tc
dng ca thuc h ng huyt (sulfamid h ng huyt l dn xut ca
sulffonylur: daonyl, diamicron). Do vy c nguy c h ng huyt v hn m do h
ng
huyt.
Thuc h p: thuc NSAID l gim tc dng ca cc thuc chn bta giam cm, thuc
gin mch li tiu do c nguy c gy cn tng huyt p khi dng thuc NSAID vi
cc thuc trn v nguy c tt p khi ngng dng thuc NSAI o trc tng liu
thuc
h
p
trong
thi
gian
kt
hp
hai
loi
thuc.
Thuc khng axit: hai thuc ny cn dng cch nhau, thuc NSAI ng sau ba n,
cn
thuc
khng
axit
dng
1-2
gi
sau
ba
n.
Ch
nh
v
chng
ch
nh
Ch
nh
trong
khp
hc:
Bnh khp cp tnh: thp khp cp, gt cp, au tht lng cp, au thn kinh ta.
Bnh khp mn tnh: vim khp dng thp, vim ct sng dnh khp, vim khp mn
tnh
thiu
nin,
vim
khp
phn
ng,
thp
khp,
vy
nn
Cc
bnh
to
keo
(Iuput
ban

h
thng).
H
khp
v
ct
sng.
Vim quanh khp do thp: vim gn c, vim bao khp, vim quanh khp vai.
Cc
ch
nh
khc:
iu tr au sau hu phu, chn thnguyn t h thao, au na u, cn au qun
thn,
au
qun
thn.

Mt s bnh l tai -mi - hng (iu tr kt trong vim hng, hu, nh rng).
Vim
tnh
mch
huyt
khi
Cc ri lon v ph khoa, au sau , au sau khi t vng trnh thai, au bng kinh
nguyn
pht.
i vi tr em: vim, st c lin quan n nhim trng ng h hp, gim au do
cc nguyn nhn khc nhau: au sau phu thut, au do tn thng c xng, au do
chn
thng
m
mm
Chng
ch
nh:
Chng ch nh tuyt i: bnh l chy mu; mn cm vi thuc nu bit trc; lot d
dy t trng c hoc ang tin trin; suy gan va n nng: ph n c thai v cho
con
b.
Chng ch nh tng i: nhim trng ang tin trin: hen ph qun.
Lu

vi
mt
s
c
a
c
bit.
Ph n c thai v cho con b: khi tht cn thit th mi s dng corticoid.
Tr con: nn cho cc thuc sau: aspirine liu di 100mg/kg/ngy, indici;
2,5mg/kg/ngy,
voltaren
2mg/kg/ngy,
naprosyn
10mg/kg/ngy.
Ngi ln tui: trnh dng loi thi chm v loi "chm" c th c nhiu bin chng
thn
hn.
ng
dng:
Thng dng ng ung, tt vi mi trng hp. Cc ng dng khc ch dng
trong
trng
hp
c
bit.
ng tim: trng hp cp tnh v au nhiu (au r thn kinh cp, t vim da
khp
cp),
dng
khng
qu
5
ngy.
ng t hu mn: tt i vi cc trng hp vim khp mn tnh do lm gim au
ban m v gim thi gian cng khp bui sng. Song dng ko di c th gy vim
trc
trng.
Bi ngoi da: t tai bin, tt vi au c v chn thng. C th dng mt trong cc
thuc sau: voltaren emullge, rheumon gel, gelden , profenid gel, nifluril cream
Nguyn
tc
s
dng
thuc
NSAID
Bt
u
bng
loi
thuc
c
t
tc
dng
ph
nht.
Dng liu ti thiu c hiu qu, nu khng c tc dng th tng liu dn khng vt
liu
ti
a.
C th phi th nhiu loi thuc c tc dng nht do mi bnh nhn c p ng thuc
v

dung
np
thuc
ring.
Dng dng ung l chnh, nu tim th ch ko di vi ngy.
Thn trng vi cc bnh nhn c tin s d dy, d ng, suy gan, suy thn, ngi gi,
ph
n
c
thai.
Phi theo cc tai bin: d dy, gan, thn, mu, d ng. Lun dn d bnh nhn t pht
hin cc tc dng ph, khi xut in tai bin th ngng thuc ngay.
Ch cc tc dng tng h ca thuc NSAID vi cc thuc khc.
Khng kt hp cc thuc NSAID vi nhau, v khng lm tng hiu qu m ch tng tc
dng
ph.
Cc bin php lm hn ch cc tc dngph ca thuc NSAID trn ng tiu ha.
Nhm hn ch tc dng ph hay gp nht l lot d dy t trng. C th ung cc
thuc chng toan, bc nim mc km theo, vo gia cc ba n (sau n 1-2 gi). C
th
dng
mt
trong
cc
thuc
sau:
Gastropulgitngy 2 gi, chia 2 ln, pha vo nc,ung sau khi dng thuc NSAID
khong
2
gi.
Maalox ngy 2 vin, nhai hoc nhm, chia 2 ln (sau khi dng thuc NSAID khong 2
gi).

Famotidin 40mg hoc omeprazole: mi ti ung 1 vin trc khi i ng .

Misoprostol (cytotex: cht ng ng ca prostagladine E1: vin 200mg, 4 vin/24h,
chia
4
ln:
sau
3
ba
n
v
trc
khi
i
ng
Thuc c ch chn lc hoc c ch chuyn bit COX2: ch nh vi cc i tng c
nguy
c
cao.
Nhm thuc iu tr c bn c ngha l iu tr lu di theo nguyn nhn, hoc theo
c ch bnh sinh Khng c tc dng iu tr cc triu chng trc mt ca bnh, ch
c th lm thay i bnh (DMARD's = Disease Modifying AntiRheumatic Drug's); hoc
thuc chng thp khp tc dng chm (SAARD's = Slow Acting AntiRheumatic
Drug's). Thuc c ch nh cho cc bnh khp t min (vim khp dng thp, cc
bnh to keo), thuc khng dng n c m phi kt hp vi cc thuc c duy
tr ko di (hng nm). Gn y c xu hng kt hp 2-3 thuc thuc nhm ny. Di
y
l
nhng
thuc
thng
c
s
dng:
Thuc
chng
st
rt
tng
hp
(plaquenil,
atabrine)
Hidroxichloroquine
(plaquenil),
0,4g/24h.
Quinacrine
hidrochloride
(atabrine)
0,2g/ngy.
C ch: cha r, c xu hng tc ng ln cc axit nhn, n nh mng cc lysosome
hn
ch
qu
trnh
gii
phng
cc
men
tiu
protein
gy
vim.
Ch nh: vim khp dng thp, lupus ban h thng, x cng b ton th.
Chng ch nh: ph n c thai (thuc c th gy nhng d dng bm sinh nh: h
hm ch, tn thngthn kinh thnh gic v thiu ht ct sau).
Liu
dng:
200-600mg/ngy,
liu
dng
l
200mg/ngy.
Thn trng: khi bnh nhn c suy gim men G6PD (glucose-6 phospate
dehydrrogenase)
hoc
c
tn
thng
gan.
Tc dng ph: chn n, nn, au thng v: xm da, kh da; vim t chc li vng
mc mt khng hi phc, gy m (vi liu thp th t l tai bin ny rt t gp), cn
kim tra mt nh k 6 thng mt ln. Mt s trng hp c biu hin nhim c thn
kinh trung ng nh au u, ri lon cm xc, tm thn, gim trng lc v mt
pht
x.
Methotrexate
liu
nh:
C ch: methotrexate l mt cht khng chuyn ha, c ch sinh tng hp DNA. Do
c cu trc tng t axit folic, thuc tranh chp vi v tr hot ng ca axit folic trong
qu trnh tng hp pyrimidin, dn n gim tng hp DNA. Ngoi ra, methotrexte c
th
c
tnh
cht
chng
vim
v
c
ch
min
dch.
Ch nh: l thuc hng u c ch nh iu tr vim khp dng thp v thp
khp
vy
nn.
Liu:
7,5
n
15mg
mi
tun
mt
ln,
ung
hoc
tim
bp.
Cch dng: mi tun 1 liu 2,5mg x 3 vin, chia 3 ln cch nhau 8 gi, c th dng
liu cao hn (15mg - 20mg). Nu tim bp: mi tun mt mi duy nht 15mg. Liu
methotrexate c th tng hoc gim ty hiu qu iu tr v cc phnng ph. Hiu
qu thng xut hin sau gim liu corticoid, sau thuc chng vim khng steroid,
cc thuc khc gim cui cng). C th duy tr nhiu nm nu c hiu qu v khng
c tc dng ph. Sau 3 thng nu khng thy thuc c tc dng nn ngng thuc v
i
sang
thuc
khc.
Tc dng ph - theo di khi dng thuc: thuc methotrexate c th gy gim bch
cu, c cho gan v thn, tn thng nhu m phi. Khng s dng khi c tnh trng
gim bch cu (< 4000/mm3), suy chc nng gan, thn. Trong thi gian s dng
thuc cn theo di kinh k cng thc mu, chc nng gan, thn gim, ho kh th
methotrexate c th nh hng n di truyn, ph n ang tui sinh , mun
dng thuc phi c bin php trnh thai: nu mun sinh phi ngng thuc trc 2

thng.
Sulfasalazine
(salazopyine):
Thnh
phn:
kt
hp
gia
5-aminosalysilic
v
sulfapyridin.
C ch: c ch enzym ca lympho, tc ng ln chuyn ha prostaglandin, c ch sn
xut t bo T , c ch hot ha t bo lympho B v c ch hot ha cc t bo tiu
dit t nhin, c ch t bo lympho B sn xut cc immunoglobulin (Ig) v yu t
dng
thp.
Ch nh: vim khp phn ng, vim ct sng dnh khp, vim khp mn tnh thiu
nin
th
da
khp,
vim
khp
dng
thp.
Liu:
0,05
x
2-6
vin/ngy
(lc
u
2
vin
sau
tng
dn).
Tc dng ph: ri lon tiu ha, chn n, au thng v, lot ming, ban ngoi da, hi
chng dng luput, bng nc, protein niu, hi chng thn h, vim tuyn gip trng,
gim
tiu
cu
bch
cu,
huyt
tn.
D-penicillamine
(trolocol,
depen):
C ch: c ch nhm aldehyde trong phn t collagen trng thnh, thuc c th lm
gim dy ca da v phng nga cc tn thng ni tng; lm tng lun chuyn
collagen khng ha tan do ct t cc cu disulfide v c ch sinh tng hp collagen.
Thuc
cng
c
tc
dng
c
ch
min
dch.
Ch
nh:
hin
nay
c
ch
nh
duy
nht
vi
x
cng
b.
Liu dng: bt u bng liu ung 250mg/ngy trong 2-3 thng (vin 125mg,
250mg), tng n 750-1250mg/ngy trpng 12-24 thng. Nu t hiu qu, khng c
cc biu hin da, s gim chm liu cho n khi t liu duy tr 250mg/ngy. Mt s
nghin cu mi nht nm 1999 cho thy dng liu 125mg/ngy t tc dng ph hn
v
khng
km
v
hiu
qu.
Tc dng ph: xy ra trong khong 30-40% cc trng hp , bao gm: st, chn n,
au thng v, nn, pht ban, hn bch cu, tiu cu, huyt tn, thiu mu do suy
ty, protein niu hi chng thn h, nhc c nng, vim gip trng bng nc, lot
ming hi chng dng d dy, rut st, pht ban s t gp hn nu dng thuc theo
kiu "i nh, i chm". Phi theo di lng bch cu, tiu cu trong mu v protein
niu.
Bit
dc:
trolovol:
vin
300;
depen:
vin
125
v
250mg
Leflunomide
(Arava):
Mi c a vo s dng 10 nm gn y.c coi l mt loi thuc iu tr mi.
C ch tc dng: c ch tng hp pyrimidine ca con ng chuyn ha novo.
Liu dng: 100mg/ngy trong 3 ngy u (vin 100mg), sau duy tr 20mg/ngy
(vin 20mg). n khi t c hiu qu iu tr (thng sau 6 thng), c th gim
xung cn liu 10mg/ngy, c th dng n c hoc kt hp vi methotrexate.
Cyclophosphamide
(cytoxane):
C ch: thuc nhm ankylan, c tc dng lin kt vi axit nhn v protein bi cc mi
gn vi phn t ln trong t bo; thuc cn c ch phn ng min dch th pht.
Ch nh: luput c tn thng thn. Thng kt hp vi corticoid.
Liu tn cng: 0,1-3,5mg/kg/ngy (ung 1 ln duy nht vo bui sng) dng lin tc
n khi bnh c kim sot th gim liu ri c th ngng.
Phng php bolus cyclophosphamide: truyn tnh mch cch 4 tun 1ln vi liu 1015mg/kg hoc 0,5 - 1g/m2 c th, c ch nh trong cc trng hp lupus c tn
thng thn, mch mu, thn kinh trung ng: phng php ny c tc dng lm
chm qu trnh x ha thn, ngn nga mt chc nng thn, gim nguy c suy thn
giai
on
cui.
Thn
trng:
trng
hp
c
suy
thn,
do
thuc
thi
qua
thn.
Tc dng ph: thuc c th gy nn cc ri lon huyt hc, suy bung trng, v tinh

trng (nu iu tr ko di), vim bng quang chy mu, xb ng quang, ung th
bng quang. Do cn lm cng thc mu v iu chnh liu da vo s lng bch
cu, tiu cu, hematocrit v kim tra nc tiu, soi bng quang tm nhng thay i
c
tnh.
Cyclosporine
A
(Neoral,
Sandimmun):
C ch: c ch cc pha ban u ca s hot ha t bo T, do ngn chn sm s
vn
chuyn
cc
gen.
Ch nh: cc bnh t min, cc th khng thuc ca vim khp dng thp, vim khp
vy
nn.
Liu: 2-5mg/kg/ngy, chia 2 ln. Dng n c hoc kt hp vi methotrexate.
Bit
dc:
neoral
vin
25
v
100mg;
sandimmun
ng
100mg.
Azathioprine
z-AZA
(imuran)
v
6-mercaptopurrine-6
MP
(urinethol):
C
ch:
c
ch
tng
hp
purine.
Ch
nh:
lupus,
vim
mch,
vim
khp
dng
thp
Liu:
AZA
=
2-3
mg/ngy
6-MP
=
1-2mg/kg/ngy
Bit
dc:
imuran
(AZA)
v
urinethol
(6-MP):
vin
50mg.
Cc
tc
nhn
sinh
hc
(entanercept,
infliximab):
Trong thi gian gn y c nhiu nghin cu a ra cc tc nhn gy chn hoc tng
tc vi cc chc nng ca cc cytokine hot ng trong c ch bnh sinh ca vim
khp dng thp. Trong s ny nhng thuc c a s dng sm nht l cc thuc
khng
TNF.
Entanercept (enbre): thuc c c ch tc dng chn cc c quan th cm ca TNF -a
hoc TNF-b, khng cho chng tng tc vi cc c quan th cm TNF trn t bo b
mt. Tim 10 hoc 25mg 2 ln mi tun, c th dng n c hoc kt hp vi
methotrexate.
Infliximab: thuc tc ng c hiu trn cc dng ha tan v qua mng ca TNF-a
truyn tnh mch mt liu duy nht 10mg/kg mi thng, dng n c hoc kt hp
vi
methotrexate.
Mui
vng
(solganal,
ridaura):
C ch: s dng theo kinh nghim, cha chng minh c c ch tc dng, c th
thuc c tc ng i vi i thc bo v chc nng ca b th.
Ch nh: thng c dng iu tr vim khp dng thp, vim khp vy nn.
Thuc c nhiu tc dng ph nn hin nay t c s dng. Tim bp mi tun 1 ln
vi liu tng dn lc u l 50mg, cho n khi t tng liu l 1,2 n 1,5g th chuyn
liu duy tr c 2 tun 1 ln tim bp 50-100mg; ri 3 tun 1 ln v cui cng 4 tun 1
ln. C th dng ng ung vi ridauran hay auranofine 3mg x 2 vin/ngy. Thuc c
kh nhiu tc dng ph nh ban da, da ton thn, vim da, vim thn cp, gim
tiu cu, lot ming, a chy, vim phi k cp, vim thn kinh, ma vn, vim gan.
Gamma
glubulin
tnh
mch:
Ch phm gamma globilin c cha cc thnh phn tng t nh cc khng th
c lm bin i. Tc dng trong cc trng hp gim tiu cu do chn c quan th
cm Fe ca i thc bo. Mt s c ch khc nh hot ha cc khng th khng tc
ng trn qu trnh sn xut cytokine v c quan th cm ca cytokine, lm tng d
ha
cc
globulin
min
dch
sinh
bnh.
Ch nh: vim c t min, ban xut huyt tiu cu min dch, vim mch, lupus gim
tiu
cu.
Chng
ch
nh:
bnh
nhn
thiu
ht
IgA.
Liu:
2g/kg,
chia
2-3
ngy.
Ch
phm:
1-3
v
6
gam

Cc
phng
php
iu
tr
khc:
iu
tr
ti
ch:
Tim
cc
ch
phm
cortisteroid
chm
ti
khp
(nh
dch).
Ct b mng hot dch bng phng php ngoi khoa: m m hoc ct di ni soi.
Ct b mng hot dch bng phng php ha cht, ng v phng x.
Tim
axit
osmic
ni
khp
Tim
cc
cht
ng
v
phng
x
vo
trong
khp.
Cc
iu
tr
c
s
dng:
Cc phng php iu tr sau y c s dng mt s c s mang tnh cht th
nghim v c ch nh trong cc th c bit nng, khng p ng vi cc phng
php
iu
tr
khc:
Thay
huyt
tng
(plasmaphrse)
Lc
lympho
bo
(lymphaphrse)
Cc bnh nhn b bnh khp thng b suy gim chc nng vn ng, kh khn trong
sinh hot hng ngy, nh hng n cuc sng bnh thng ca h. Hn na, cc
bnh khp thng l mn tnh hay ti pht. V vy, ngoi vic dng thuc, cn p
dng cc bin php iu tr phi hp khc ty theo giai on v mc bnh nhm
em li hiu qu iu tr ti a.
Cc phng php iu tr khng dng thuc.
iu tr bng nhit
iu tr bng lnh: c tc dng gim au, chng ph n tuy nhin lnh c th gy
cng khp. C th dng nhiu dng khc nhau ty theo s thun tin, gi c v kch
thc ni p dng iu tr: ti lnh, khn lnh, que bng nc , tm nc hoc hi
lnh Thi gian dng t 5- 10 pht (khng nn qu 20 pht) v c th lm nhit
da h ti 150C.Khng nn p dng chm lnh khi ngi bnh c hi chng Raynaud
hoc
cc
tn
thng
mch
mu.
iu tr bng nng: c tc dng lm tng n hi ca cc si collagen, gim cng
khp,
gim
au.
iu tr bng nhit c th b mt hoc su. C th s dng ti chm, parafin,
nc nng , nhit i l u. Siu m, sng ngn v vi sng c dng trong cc trng
hp cn iu tr nhit su. iu tr nhit su dng cho cc trng hp vim, sng
n v au khp. Cc trng hp vim bn cp, t au nn p dng iu tr nhit b
mt. Trng hp c cng khp, hn ch vn ng iu tr bng nhit c kt qu tt.
iu tr bng nc:
Thng c kt hp vi nhit tng hiu qu. Nc gip ngi bnh th gin, c
tc dng lm gim trng lng cc khp v phn mm v vy gim bt sc cn,
gip khp vn ng d dng hn. Cn ch cc yu t nh p lc thy tnh, nht,
trng lng ring ca nc cng nh hng n hiu qu iu tr bng nc.
Ty mc ch m c th dng cc bn nc cho cc chi, bn nc tan thn, bn tm
hoc b bi c kt hp to sng hoc khng. iu tr bng nc p dng cho cc
trng hp sau m khp, vim nhiu khp c gim chc nng vn ng. Khng p
dng iu tr bng nc ton thn cho cc trng hp c bnh tim mch, h hp,
ngi gi. Vi cc trng hp ny cn gim thi gian v nhit ca nc. Nhit
c duy tr t 37 - 400C.
iu tr bng in:
L phng php kch thch in qua da. Dng ngun in bng pin kch thch cc
si thn kinh da trn l thuyt v cng ca cm gic au: kch thch in v mt si
thn kinh c ng knh ln di da to ra xung in truyn vo r thn kinh ty
sng, i qua cng vo s c tc dng ngn cc xung in t cc si thn kinh c

ng knh nh m cc si ny thng dn truyn cc cm gic au. V th kch thch

in c tc dng gim au.
iu tr bng nh sng:
c dng iu tr mt s tn thng ca da v khp nhng thng p dng
iu tr cc tn thng da l chnh. Tia cc tm vi bc sng t 250 -- 400mm c
s dng iu tr vim khp vy nn c hiu qu tt. C ch tc dng ca nh sng
cha c xc nh r. nh sng laser cng thp c dng iu tr vim khp,
au vai gy, au tht lng. Laser c tc dng gim au v phc hi nhanh cc tn
thng phn mm.
iu tr ngoi khoa (phu thut):
L mt trong nhng phng php p dng trong iu tr bnh khp. Mc ch ca
iu tr phu thut nhm gim au, duy tr hoc ci thin chc nng khp. Ch nh
phu thut khi p dng cc phng php iu tr bo tn nh iu tr ni khoa
(thuc ung, tim) vt l tr liu nhng khng c kt qu hoc ngi bnh vo
giai on cui bnh. Ty tng loi tn thng, phu thut c th ct mng hot dch,
to hnh khp hoc thay khp. i vi cc trng hp mt kh nng vn ng nng,
phu thut nhm gip ngi bnh thc hin c mt s ng tc sinh hot hng
ngy nh t mc qun o, n ung. Tuy nhin, hiu qu ca iu tr ngoi khoa cn
ty thuc vo tng bnh. nhng bnh nhn nh khp vic phu thut thay khp
hoc chnh hnh khp c th gip ngi bnh ly li c chc nng vn ng gn
nh bnh thng v sau phu thut cc tn thng bnh khng cn tn ti. Ngc li,
vi cc bnh m qu trnh tn thng lin tc v nhiu khp ngay c sau phu thut
nh bnh vim khp dng thp th hiu qu ca phu thut c th s khng cao do
tnh trng gim st sc khe ni chung v c tn thng c km theo ni ring. V vy
ch nh iu tr bng phu thut cn phi c cn nhc k v cn c s trao i ,
tho lun k lng gia cc nh thp khp hc, phc hi chc nng v phu thut
nhm a ra quyt nh phu thut ng thi im v em li hiu qu ti a.
Mt s phng php iu tr khc:
Ni soi khp: l mt phng php iu tr hiu qu. Qua ni soi khp, thy thuc
va c th trc tip quan st, nh gi tn thng, sinh thit chn lc vng tn
thng ng thi c th thc hin cc k thut iu tr nh ct mng hot dch, ly di
vt, ra khp Ni soi khp c xem l phng php thay th cho phu thut do s
nhanh chng v hiu qu ca n. Phm vi ch nh ni soi khp tng i rng, c
bitl trng hp tn thng kh tr hoc ch yu mt khp. Ni soi khip thng
c p dng cho cc trng hp sau: cc bnh l khp, nghi ng cc rch hoc t
dy chng, cc tn thng sn chm, c bng chng ca cc mng xng, sn v
trong khp, au khp do chn thng, au khp khng gii thch c nguyn nhn,
cc tn thng hoc cc bt thng c pht hin trn X quang, nhm tin hnh cc
phu
thut
ti
khp.
iu tr phng x: c p dng cho mt s trng hp nh bnh khp trong
hemophilie vi mc ch hy mng hot dch khp, hn ch chy mu ti pht. Vi
mt s trng hp vim mng hot dch ti pht, vim khp dng thp, ng v phng
x c dng l yttrium 99, erbium 169, rhenium 186. Cc ng v ny c tim trc
tip vo khp v c th nhc li. Tng liu iu tr khng vt qu 15mCi.
iu tr bng tia laser: hin nay, laser cng xut cao c ng dng vo y hc nh
mt phng php phu thut. Mt trong cc k thut c ng dng vo iu tr cc
bnh xng khp l gim p a m ct sng bng laser. Sau 3 nm, phn vin vt l
y sinh hc tin hnh c 316 trng hp, vi cc thot v a m ct sng c v
ct
sng
tht
lng,
t
kt
qu
xut
sc
v
tt
trn
80%.

Bm huyt: c tc dng trong nhiu chng bnh, c bit tt vi triu chng co c

nh
au
vai
gy
cp
(tosticolis),
vim
quanh
khp
vai
Phc hi chc nng: l mt phn quan trng trong iu tr cc bnh khp. Phc hi
chc nng c tin hnh ng thi vi phng php iu tr khc. Ty tng giai
on, tnh trng c th ca mi bnh nhn ta c th p dng cc phng php tp
luyn khc nhau. Trong giai on cp, ch yu p dng cc bi tp th ng. giai
on bn cp hoc mn tnh, p dng cc bi tp ch ng, tch cc, tp c dng c,
tp
c
ti.
Gio dc ngh nghip: phn ln cc bnh c xng khp u nh hng n chc
nng vn ng ca khp gy nh hng n kh nng lao ng ca ngi bnh. V
vy, vic gio dc v hng nghip cho ngi bnh l mt phn quan trng gip
ngi
bnh
ti
ha
nhp
vi
cng
ng.
iu dng: rt quan trng trong qu trnh theo di, iu tr cc bnh khp cng nh
gip
ngi
bnh
ti
ha
nhp
vi
cng
ng.
Ngi iu dng vin ng vai tr ngi theo di, gim st v gip ngi bnh
thc hin cc phng php iu tr. H tr ngi bnh trong sinh hot hng ngy.
Thay mt ngi thy thuc trc tip hng dn, gip ngi bnh tp luyn theo
chng trnh, theo di cc bin chng ca bnh hoc do iu tr.
Cc phc iu tr mt s bnh khp thng gp
iu tr bnh vim khp dng thp.
Vim khp dng thp l mt bnh mn tnh. Vic iu tr cn c s la chn thuc
sao cho ph hp vi tng ngi bnh, hon cnh kinh t, iu kin sn c ti ch. C
th
p
dng
mt
trong
cc
phc

sau:
Phc

1:
- Thuc chng vim khng steroid (CVKS). Nn chn loi c tc dng chm v ko di
(voltaren
SR,
feldene,
mobic).
Chlorquine
hoc
methotrexate
liu
thp.
Kt
hp
vi
salazopirin
hoc
arava.
Phc

2:
Corticoid
liu
cao
v
ngn
ngy
(1
thng)
Chlorquine
hoc
methotrexate
liu
thp
Kt
hp
vi
salazopirin
hoc
arava
i
vi
nhng
trng
hp
tin
trin
nng:
Gim
au
chng
vim
khng
steroid
nhm
COX2
Methotrexate
liu
thp
Arava
hoc
nhm
thuc
c
ch
TNFa
(Etanercept,
Ifliximab)
Trong trng hp ngi bnh au nhiu c th cho thm thuc gim au.
iu tr bnh vim ct sng dnh khp:
Ty theo hon cnh c th vi tng ngi bnh la chn v kt hp ng thi
cc
thuc
thooc
cc
nhm:
Thuc
chng
vim
khng
steroid
(thuc
CVKS):
diclofenac.
- Thuc iu tr c bn: salazopyrin (th khp ngoi bin) hoc tetracycline hoc
doxcycycline.
- Thuc gim au: paracetamol hoc cc ch phm khc (da vo s bc thang
ca
WHO).
- Thuc dn c: coltramy, dcoltractyl, myonal
iu tr bnh luput ban h thng:

Vi
th
nh
v
va
iu
tr
theo
phc
.
Corticoid
liu
cao
ngn
ngy
v
gim
liu
nhanh.
Chloroquin
- Phng cc t tin trin: ch v sinh, sinh hot, qun l thai nghn.
Vi th nng, tin tin c th dng methylprednisolon theo phng php Pulse
therapy. Khi kim sot c t tin trin th tip tc iu tr theo phc trn.
iu tr bnh x cng b ton th:
Vi
giai
on
tin
trin
ca
bnh
p
dng
phc
:
D-penicillamin
- Cc thuc iu tr hi chng Raynaud: thuc c ch Alpha giao cm: prazosin,
reseripin, alpha - methyldopa, guanetidin thuc chn canxi: diltiazem, nifedipin,
verapamin.
Corticoid

giai
on
n
nh
p
dng
phc
:
D-penicillamin
Cc
thuc
iu
tr
hi
chng
Raynaud
(nh
trn)
Ngoi ra, vi mi giai on c th p dng bin php iu tr bng tm nc sui
khong nng c lu hunh (M Lm - Tuyn Quang).
iu tr bnh gt
Vi cn gt cp p dng phc :
- Colchicin vi cng thc 3 vin/ngy trong hai ngy u, 2 vin/ngy trong hai
ngy tip theo, sau duy tr 1 vin/ngy trong 7 n 15 ngy.
- Thuc gim axit uric mu (nn dng sau mt tun): allopurinol hoc probenecid.
Ch

dinh
dng
hp
l
- Kim ha nc tiu: natrobicarbonat hoc nc khong c kim.
Vi gut mn tnh p dng phc :
Ch

dinh
dng
hp
l
Colchicine
1
vin/ngy,
dng
ko
di
Thuc
h
axit
uric
mu
dng
ko
di.
Vi c gt cp v mn, mt s trng hp vim khp c th ch nh thuc CVKS.
iu
tr
thoi
ha
khp
i vi phn ln cc trng hp thoi ha khp c th p dng phc :
- Thuc CVKS: ch nh khi bnh nhn au, dng liu thp, ngn ngy.
- Thuc gim au: paracetamol v cc ch phm kt hp khc.
Corticoid
ni
khp
khi
cn
thit.
- Thuc chng thoi ha khp tc dng chm: glucosamine (virathril-S, piascledin, axit
hyaluronic (hyalgan) ni khp
iu tr au ct sng tht lng do thoi ha:
C
th
dng
cc
thuc
sau:
- Thuc chng vim khng steroid: profnid, voltaren, feldene, ticolil.
Thuc
gim
au:
paractamol,
paractamol
+
codein
Thuc
dn
c:
coltramyl,
decontractyl,
myonal
Thuc
chng
thoi
ha
khp
tc
dng
chm:
nh
trn
iu
tr
bng
phng
php
vt
l.
GS TS Trn Ngc n
ng huyt p
Gi bi Admin, lc 16:28 19/08/2011, | Bnh v huyt p

Tng huyt p l bnh thng gp, ph bin ngi gi, bo ph, ...

I. I CNG
1. nh ngha
Theo T chc Y t th gii v Hip hi tng huyt p quc t.
- Huyt p bnh thng nu huyt p ng mch ti a di 140 mmkg (18,7kpa)
v huyt p ng mch ti thiu di 90 mmHg (12kpa).
- Tng huyt p nu huyt p ng mch ti a > 140mmHg v/hoc huyt p
ng mch ti thiu > 90 mmHg.
Ch thch
+ Huyt p ng mch ti a con gi l huyt p tm thu v huyt p ng mch
ti thiu cn gi l huyt p tm trng.
+ Huyt p ng mch khng c nh m c th thay i trong ngy (thng ban
m thp hn ban ngy), theo tui (thng ngi gi cao hn ngi tr, theo gii
thng n thp hn nam).
+ Con s huyt p khng nh gi c hon ton mc nng nh ca bnh (hai
ngi c cng mt con s huyt p, c th c tin lng bnh khc nhau).
2. Tnh trng mc bnh tng huyt p
cc,nc cng nghip pht trin t l t 15 - 20% ngi ln c tng huyt p.
Vit Nam t l vo khong 6 - 12% v s ngi mc bnh vo khong trn di 5 6 triu.
3. Phn loi tng huyt p
Trong tng huyt p c th chia ra:
- Tng huyt p thng xuyn.
Trong loi ny cn c th phn bit.
+ Tng huyt p lnh tnh.
+ Tng huyt p c tnh.
- Tng huyt p cn.
Trn c s huyt p bnh thng hoc gn bnh thng, c nhng cn cao vt. Vo
nhng lc c cn ny, hay c tai bin.
- Tng huyt p dao ng
Con s huyt p c th lc tng hay gim. T chc Y t th gii khuyn rng khng
nn s dng danh t ny v nn xp vo loi tng huyt p gii hn, v cho rng tt
c cc loi tng huyt p u t nhiu dao ng.
Tng huyt p l mt hin tng o c nhng nguyn nhn khng phi lun lun
tm thy. V vy ngi ta chia ra:

+ Tng huyt p th pht cn gi l tng huyt p triu chng nu tm thy nguyn

nhn.
+ Tng huyt p nguyn pht, cn gi l tng huyt p bnh nu khng tm thy
nguyn nhn.
II. NGUYN NHN, C CH, TRIU CHNG
A. NGUYN NHN
Nhng nguyn nhn chnh ca tng huyt p l:
1. Nguyn nhn thn
- Vim thn cp.
- Vim thn mn, mc phi hoc bm sinh (cu thn, k thn).
- Thn a nang.
- nc b thn.
- U tng tit rnin.
- Bnh mch thn (hp ng mch thn).
2. Nguyn nhn ni tit
- Cng aldosteron tin pht (hi chng Conn).
- Ph i thng thn bm sinh.
- Hi chng Cushing.
- U li thng thn (phchromocytoma).
- Tng calci mu.
- To u chi.
3. Nguyn nhn khc
- Hp eo ng mch ch.
- Nhim c thai nghn.
- Bnh tng hng cu.
- Hi chng caccinoid (caxinoid rut non).
- Nguyn nhn thn kinh (toan h hp).
- Ri lon chuyn ho porphyrin cp.
- Nguyn nhn gy tng huyt p tm thu: R ng mch, tnh mch, bnh Paget,
bribri, cng gip trng, h van ng mch ch
Cc nguyn nhn ni trn chim 11 - 15% tng s trng hp tng huyt p (thn
5 - 6%, mch thn 3 - 4%, hp eo ng mch ch 0,5 - 1%, cng aldosteron tin
pht 0,5 - 1%, hi chng Cushing 0,2 - 0,5%, phechromocytom 0,1 - 0,2%). Khi khng
tm thy nguyn nhn no ngi ta gi l tng huyt p nguyn pht, chim 85 - 89%
trng hp tng huyt p (Griffoud). Phn ln trng hp tng huyt p ca ngi
trung nin v tui gi thuc loi nguyn pht.
B. C CH TNG HUYT P
1. Vai tr ca h Renin - angiotensin
ngi, c ba loi tng huyt p km theo tng tit renin, l tng huyt p do
hp ng mch thn. C loi tng huyt p km theo gim tit renin, in hnh l hi
chng cng aldosteron tin pht (hi chng Conn).
2. Vai tr ca h thn kinh
Trong h thng gii phng catecholamin cn c s tham gia ca
tyrosinhydroxylase) L-dopa - decarboxylase, dopamin beta - hydroxylase phnylthanolamin - N mthyltransfrase xc tc.
Trong h thng gii phng serotonin cn c s tham gia ca tryptophahyroxylase
v decarboxylase xc tc.

3. Vai tr ca natri
Mt s ch n nhiu nghi (thc n c 2% mui v nc ung c 1% l mui) s
gy tng huyt p. Trong iu kin bnh thng cc hormon v thn cng phi hp
iu chnh. Khi c natri, h thng ng mch c th tng nhy cm vi angiotensin
II v noradrenalin.
4. Vai tr ca thnh mch
Khi c tng huyt p, tiu ng mch dy ln, ch hp, ch gin v do c th l
nguyn nhn gy thot huyt tng. Ngc li tnh trng tiu ng mch nhiu
collagen pht trin s gy tng huyt p. Nu cho beta aminopropiomitril s lm h
huyt p.
5. Vai tr cc yu t khc
- Prostaglandin loi E v G ca thn l nhng cht chng tng huyt p t nhin.
Thiu nhng cht ny s c tng huyt p.
- Yu t di truyn: tng huyt p di truyn mt s ng vt theo kiu otsm v
bng nhiu en. ng vt c tng huyt p di truyn, tiu ng mch c hin tng
hp rt sm. ngi, yu t gia nh kh r.
C. TRIU CHNG
Triu chng ca tng huyt p ph thuc vo cc giai on ca bnh. Theo T chc
y t th gii tng huyt p c 3 giai on:
Giai on I: bnh nhn khng c du hiu khch quan v tn thng thc th no
(xem di).
Giai on II. bnh nhn c t nht mt trong cc du hiu thc tn sau y:
- Dy tht tri, pht hin c trn lm sng, X quang, in tm , siu m.
- Hp ng mch vng mc, lan rng hay khu tr.
- Protein niu v/hoc creatinin huyt tng tng nh.
Giai on III: bnh tng huyt p gy ra nhng tn thng cc c quan khc
nhau, th hin bng cc triu chng c nng v du hiu thc th sau y:
- tim: suy tht tri.
- no: xut huyt no, tiu no hay thn no, c bnh no do tng huyt p.
- y mt: xut huyt vng mc v xut tit c th c hay khng ph gai th. Cc
du hiu ny c trng cho giai on nng, tin trin nhanh.
Ngoi ra trong giai on II cn hay c nhng biu hin khc nhng khng r rt l
nhng hu qu trc tip ca tng huyt p bng cc biu hin l:
- tim: cn au tht ngc, nhi mu c tim.
- no: huyt khi ng mch trong s.
- cc mch mu: phnh mch tch, vim tc ng mch.
- thn: suy thn.
Tng huyt p c tnh.
Chim 2 - 5% cc trng hp tng huyt p. Phn ln xy ra trn mt ngi c
tng huyt p t trc. Tt c cc loi tng huyt p do nguyn nhn khc nhau u
c th chuyn bin thnh c tnh.
Triu chng kh phong ph ni bt l hi chng no, nhc u d di, bin i y
mt III, IV. S huyt p thng rt cao, c ti a ln ti thiu. Kht nc nhiu,
st cn, ri lon tiu ho. Mt s t c biu hin ng mu ni qun ri rc. Tin trin
nhanh v nng, hay c bin chng no, tim. Trong tt c cc trng hp tng huyt
p c tnh ngi u c tng tit renin, aldosteron.
III. PHNG, CHA TNG HUYT P

A. PHNG BNH
Cha cc bnh c th l nguyn nhn ca tng huyt p nh lit k trn.
Nguyn tc l trn mt bnh nhn tng huyt p phi c gng tm nguyn nhn. Khi
bng mi cch khng tm thy nguyn nhn mi coi nh l tng huyt p nguyn
pht.
Trong ch n ung cn hn ch mui nhng khng cn qu kht khe v hin nay
c nhiu thuc li tiu thi natri. Hn ch cm trong trng hp bo bu. King
thuc l, trong sinh hot trnh mi cng thng khng cn thit. m bo gic ng.
B. CHA BNH
1. Trng hp tng huyt p dao ng
Nu tng huyt p ch va phi, khng cn cho cc thuc chng tng huyt p, ch
cn dng an thn hoc thc hin ch n hn ch mui, ngh ngi, gim mi cng
thng th lc v tinh thn, thc hnh th gin.
Nu tng huyt p nhiu, tuy vn dao ng, ng thi li c nhp tim nhanh, cc
bin php ni trn khng hiu qu th nn cho thuc chng tng huyt p nht l loi
chn bta.
Tt c cc trng hp tng huyt p dao ng u phi c theo di k, qun l
tt v tin trin kh bit trc.
2. Trng hp tng huyt p thng xuyn
Thc hin phc iu tr theo bc thang ca T chc Y t th gii.
Bc I:
- i vi ngi tng huyt p di 45 tui, thuc u tin cn dng l loi chn
bta, hoc thuc c ch men chuyn i angiotensin (Captopril-Enalapril).
- i vi ngi tng huyt p trn 45 tui, thuc u tin cn dng l thuc li
niu.
- Nu iu tr nh vy m huyt p xung th gi liu tc dng. Nu huyt p
khng xung hoc xung qu t th tng dn liu (ba tun tng ln mt ln). Nu
huyt p vn khng xung th chuyn sang bc II.
Bc II:
Phi hp hai th thuc li niu + chn bta hoc c ch men chuyn i
angiotensin. Nu huyt p xung th gi liu tc dng. Nu khng xung hoc
xung qu t, c th tng dn liu. Nu huyt p vn khng xung phi chuyn sang
bc III.
Bc III:
Phi hp thuc li tiu + chn bta vi mt trong 4 loi sau y. Hydralazin, alpha
methyldopa, clonidin v guanethidin. Nu khng th phi hp li niu - chn bta
vi 2,3 trong cc thuc ni trn, ng thi kim tra li xem bnh nhn c thc hin
ng y lnh khng, ch n v sinh hot c ng khng.
Ch thch:
Khi c chng ch nh dng chn b ta (suy tim, mc nh tht nng, hen ph qun,
bnh ph qun kinh din tc nghn, i tho ng, lot d dy t trng) th thc
hin:
- Bc I: li niu.
- Bc II: li niu + alpha methyldopa (hoc clonidin) hoc c ch men chuyn i
angiotensin.
- Bc III: li niu + alphamethyldopa (hoc clonidin) + thuc gin mch.
3. Trng hp tng huyt p c tnh

- Cn c iu tr ni tr ti cc bnh vin hoc cc trung tm cp cu v hay c

bin chng nguy him.
- Vi nhng cn bng huyt p cao vt phi dng thuc mnh loi gin mch nh
diazoxit, nitroprussiat nam tnh mch.
* Kt lun
Tng huyt p l mt bnh c nhng nh hng xu n sc kho v sn xut. C
loi c nguyn nhn r nhng cng c nhng loi khng r nguyn nhn. Hin nay
phng bnh cn c ch n ung sinh hot hp l. Cha bnh hin nay theo tng
bc thang t thp n cao, t mt thuc n nhiu thuc phi hp.Tng huyt p l
mt bnh x hi do phi c s quan tm ca ton x hi v s tham gia ch
ng
tch
cc
phng
chng
ca
chnh
bn
thn
ngi
bnh.

GS.
GS.TS.
Phm
GS. TS. Nguyn Ln Vit

Phm
Gia

Khu
Khi