Khuyến Cáo Xử Trí Xuất Huyết Tiêu Hóa Trên Cấp Tính Không Do Tăng Áp Lực Tĩnh Mạch Cửa

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Khuyến Cáo Xử Trí Xuất Huyết Tiêu Hóa Trên Cấp Tính Không Do Tăng Áp Lực Tĩnh Mạch Cửa

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KHUYN CO X TR XUT HUYT TIấU HểA TRấN CP TNH KHễNG DO TNG P LC TNH MCH CA Nhúm Chuyờn gia v Xut huyt Tiờu húa Hi Khoa Hc Tiờu Húa Vit Nam Ngy 24/6/2009 v ngy 28/7/2009, ti TP H Minh ó t chc cuc hp gm cỏc chuyờn viờn u ngnh, Bỏc s Chuyờn khoa Ni Tiờu hoỏ v Ngoi Tiờu hoỏ , Hi sc cp cu, tho lun v thng nht ý kin v vic mt khuyn cỏo iu tr xut huyt tiờu hoỏ trờn khụng tng ỏp lc tnh mch ca Cỏc cuc hp gm cỏc thnh viờn sau õy : H v tờn Bnh viờn Chuyờn khoa Chc v 1- T Long GSTS BVTQD 108 2- Nguyn Khỏnh Trch GSTS BV Bch mai Tiờu hoỏ Tiờu hoỏ Ch tch Hi KHTHVN Ch tch Hi Ni khoa VN 3- Phm Th Thu H PGSTS BV Bch Mai Tiờu hoỏ Phú Ch tch Hi KHTHVN 4- Trn Ngc Bo BSCKII HYD TPHCM Tiờu hoỏ Phú Ch tch Hi KHTHVN 5- o Vn Long PGSTS BV Bch Mai Tiờu hoỏ Giỏm c BV HY H Ni 6- Trn Bỡnh Giang PGSTS BV Vit c Ngoi Phú Giỏm c 7- Lờ Quang Ngha GSTS BV Bỡnh Dõn Ngoi Phú Giỏm c 8- Nguyn t Anh TS HSCC Trng Khoa, CN B mụn BV Bch Mai 9- Trn Kiu Miờn BSCKII HYD TPHCM 10- V Trng Khanh ThS BV Bch Mai 11- Lờ Thnh Lý TS BV Ch Róy 12- Nguyn Thuý Vinh TS BV H u ngh 13- Nguyn Minh Hi TS BV Ch Róy 14- Tụn Tht Qunh i BS BV Ch Róy 15- Nguyn Tn Cng PGSTS BV Ch Róy Tiờu hoỏ PCT Hi TH TPHCM Tiờu hoỏ Phú Trng khoa Tiờu hoỏ Trng khoa Tiờu hoỏ Phú Giỏm c Ngoi Trng Khoa HCCC Trng Khoa Ngoi Trng Khoa, CNBM 16- H Th Võn Hng Ti ờu ho ỏ SCKII BV 115 17- Lờ Quang BS BV Thng nht 18- Trn Vit Tỳ TS Hc vin Quõn Y 19- Dng Bi Trõm BSCKI BV Nguyn Trỏi 20- Lờ Kim Sang BSCKII BV Trng vng 21- Lý Th Thu Võn BSCKI BV Nguyn Trói 22- Nguyn th Thanh H BS BV K Nng 23- Hunh Vn n BS BVNDG Ngoi Tiờu hoỏ Tiờu hoỏ Tiờu hoỏ HSCC Tiờu hoỏ HSCC Trng Khoa Phú Giỏm c Ch nhim B mụn Trng Khoa Trng Khoa Trng Khoa Trng Khoa Trng Khoa T VN Xut huyt tiờu húa trờn cp tớnh l mt nhng cp cu thng gp nht ca ng tiờu húa v khong hn 50% l loột d dy tỏ trng 1,2 T l xut huyt tiờu húa trờn cỏc nc phng Tõy khong 50 ca trờn 100 000 dõn mi nm, ú c tớnh 20% l XHTH nng ũi hi phi nhp vin v t l t vong cỏc bnh nhõn ny dao ng t 314%2-9 Hu ht nhng trng hp t vong xy bnh nhõn ln tui, thng cú bnh nng kốm theo hoc xut huyt tỏi phỏt12 Nhng bnh nhõn xut huyt tỏi phỏt cú nguy c t vong cao hn mt cỏch rừ rt 2,13 ng thi chi phớ iu tr phi truyn mỏu, ni soi can thip, phu thut tng lờn v thi gian nm vin kộo di14 Tuy nhiờn, mt s nghiờn cu ngi ta thy rng t l t vong c ghi nhn thp hn v iu ny liờn quan ti vic ỏp dng cỏc phỏc iu tr mi hn l nhng tin b hi sc 15,16 Vỡ vy trờn th gii ó cú nhng hng dn chung cho iu tr xut huyt tiờu húa trờn cp tớnh khụng tng ỏp lc tnh mch ca Vic ỏp dng cỏc phỏc iu tr mang li li ớch rt nhiu cho ngi bnh cng nh gim chi phớ iu tr Tuy nhiờn Vit Nam iu kin ti cỏc c s y t cũn rt khỏc nờn vic ỏp dng nhng hng dn chung ca quc t s gp mt s khú khn thc tin lõm sng Chớnh vỡ vy Hi Khoa Hc Tiờu Húa Vit Nam mong mun a khuyn cỏo hng dn iu tr xut huyt tiờu húa trờn cp tớnh khụng tng ỏp lc tnh mch ca da trờn c s khoa hc l nhng hng dn chung ca quc t cú xem xột n iu kin thc tin ca Vit Nam Nhng t vit tt: Xut huyt tiờu húa: XHTH, Tnh mch ca: TMC, p lc tnh mch trung tõm: CVP, Bnh nhõn: BN, Huyt ỏp:HA I nh ngha Nụn mỏu (hematemesis) l tỡnh trng nụn mỏu ti hoc mỏu cc hoc cht nụn cú mu bó c phờ (do mỏu ó bin i thnh mu en) i tin phõn en (melena) l i tin phõn ln mỏu b bin i mu ging nh bó c phờ i tin phõn mỏu (hematochezia) l i tin mỏu mu nõu sm, hoc nõu hoc ti thng chy mỏu tiờu húa thp nhng ụi cú th xut huyt tiờu húa trờn vi s lng ln Chy mỏu tỏi phỏt: c xỏc nh nụn mỏu hoc i tin phõn en xut hin tr li Cỏc triu chng ny kt hp vi cỏc du hiu ca mt mỏu (mch nhanh hn 100 ln/phỳt, huyt ỏp tõm thu thp hn 100 mmHg), gim CVP hn mmHg, hay gim nng hemoglobin hn 20g/l sau 24 gi Chy mỏu tỏi phỏt cn phi c chn oỏn qua ni soi Xut huyt tiờu húa trờn khụng tng ỏp lc tnh mch ca l xut huyt tiờu húa t v trớ phớa trờn ca gúc Treizt nguyờn nhõn khụng tng ỏp lc tnh mch ca II Nguyờn nhõn xut huyt tiờu húa trờn cp tớnh khụng tng ỏp lc TMC Khong 80% trng hp cú th tỡm c nguyờn nhõn ca xut huyt tiờu húa Cỏc nguyờn nhõn xut huyt tiờu húa trờn bao gm cỏc bnh lý sau: Nhng nguyờn nhõn ca xut huyt tiờu húa trờn cp tớnh ti Anh17 Nguyờn nhõn Loột tiờu húa Loột d dy tỏ trng thng Viờm thc qun V gión tnh mch Hi chng Mallory Weiss D dng mch mỏu Cỏc nguyờn nhõn him Bnh lý ỏc tớnh ng tiờu húa trờn T l % 3550 815 515 510 15 5 Trong bng ny, xut huyt tiờu húa trờn cp tớnh khụng tng ỏp lc TMC chim t l rt cao III Xỏc nh chn oỏn xut huyt tiờu húa trờn cp tớnh khụng tng ỏp lc TMC Nụn mỏu (Haematemesis) v i tin phõn en c trng (Melaena) l du hiu lõm sng thng gp nht ca XHTH trờn cp tớnh - Mu sc phõn: + 14% cỏc ca XHTH trờn cú biu hin i tin phõn mỏu nõu hay phõn nõu sm + Bnh nhõn XHTH trờn cú biu hin i ngoi phõn mỏu ti thng cn truyn mỏu, ch nh m v t vong vi t l cao hn mt cỏch cú ý ngha so vi cỏc BN b XHTH vi biu hin i ngoi phõn en hoc nõu sm (t l 14% nhúm i tin phõn mỏu so vi 8% i vi nhúm i ngoi phõn en) - t xụng hỳt dch d dy cú mỏu: phng phỏp ny t nhy 90% nh khu chy mỏu ng tiờu hoỏ cao (giỏ tr d oỏn õm tớnh cao nu hỳt qua xụng d dy c dch mt song khụng cú mỏu) Cú th thy cỏc du hiu ca gim th tớch mỏu hoc sc mt mỏu ( Bng 1-2 ph lc E ): - ỏnh giỏ tỡnh trng huyt ng ca BN mt cỏch t m: + Tn s mch + o HA (bao gm c ỏnh giỏ tỡnh trng tt HA liờn quan vi t th) + ỏnh giỏ ỏp lc mch ( ny ca mch quay, thi gian y mao mch u ngún tay), + ỏnh giỏ niờm mc, tnh mch c v th tớch nc tiu hng gi - Sc c xỏc nh mch > 100 ln/phỳt v HA tõm thu < 100 mmHg - Cú tt HA liờn quan vi t th (postural changes) t th ng tn s mch tng thờm 20 ln/phỳt hoc HA tõm thu gim 20 mmHg) nhng bnh vin cú iu kin ni soi ng tiờu húa, vic loi tr chn oỏn XHTH trờn cp tớnh khụng tng ỏp lc TMC v tng ỏp lc TMC thng khụng khú Ti nhng c s ban u chn oỏn XHTH trờn cp tớnh nguyờn nhõn khụng tng ỏp lc TMC da vo: - Lõm sng: bnh nhõn khụng cú du hiu ca bnh lý gan mt nh: vng da, phự, c trng t do, tun hon bng h v tỡnh trng gan lỏch - Cn lõm sng: Xột nghim cụng thc mỏu, in gii, ure, creatinine, ụng mỏu, nhúm mỏu v in tõm Tuy nhiờn, mt s ớt bnh nhõn mc dự cỏc triu chng v bnh lý gan mt khụng rừ nhng nguyờn nhõn XHTH l tng ỏp lc TMC Chn oỏn xỏc nh v chn 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