1 B GIO DC V O TO B Y T TRNG I HC Y H NI -****** - Lấ VIT DNG ĐặC ĐIểM HìNH ảNH SIÊU ÂM Và CắT LớP VI TíNH TRONG HộI CHứNG FITZ HUGH CURTIS Chuyờn ngnh : Chn oỏn hỡnh nh Mó s : 60720311 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS Bựi Vn Lnh H NI 2014 LI CM N Sau hai nm gn bú hc ti mỏi trng i hc Y H Ni thõn yờu, tụi ó nhn c s quan tõm, giỳp rt nhiu ca cỏc thy cụ, cỏc anh ch, cỏc bn ng nghip v gia ỡnh, gi õy lun ó hon thnh, tụi xin by t lũng kớnh trng v bit n sõu sc ti: PGS TS Bựi Vn Lnh - Phú Giỏm c, Trng khoa chn oỏn hỡnh nh bnh vin i hc Y H Ni Thy ó ch bo cho tụi kin thc v kinh nghim chuyờn mụn, ng thi cng to mụi trng hc tớch cc y hng cho tt c hc viờn; thy ó tn tỡnh hng dn, giỳp v ng viờn tụi quỏ trỡnh hon thnh lun ny PGS TS Nguyn Duy Hu - Ch nhim B mụn Chn oỏn hỡnh nh Trng i hc Y H Ni, Trng khoa Chn oỏn hỡnh nh Bnh vin Hu Ngh Vit c Thy ó truyn t cho tụi kin thc quý bỏu v chuyờn mụn, Thy luụn l tm gng sỏng v hc v lm vic khụng ch cho riờng tụi m cũn cho tt c cỏc hc viờn khỏc Ths Lờ Tun Linh - Ging viờn B mụn Chn oỏn hỡnh nh Trng i hc Y H Ni, Phú Trng khoa Chn oỏn hỡnh nh Bnh vin i hc Y H Ni Thy ó dn dt v ch bo cho tụi nhng kin thc c bn v phng phỏp t quan trng tip cn v chn oỏn, thy rt nhit tỡnh ging dy v ó hỡnh thnh cho tụi mt tỏc phong lm vic nghiờm tỳc, cú trỏch nhim Thy luụn quan tõm ng viờn, to iu kin cho tụi sut quỏ trỡnh hc ti khoa Tụi xin chõn thnh cm n cỏc nh khoa hc hi ng chm lun ó gúp ý, ch bo cho tụi nhng kin thc v kinh nghim quý bỏu tụi cú th vng bc hn trờn ng hc v nghiờn cu sau ny Tụi xin gi li cm n chõn thnh ti cỏc bỏc s, k thut viờn v hc viờn sau i hc ó v ang cụng tỏc, hc ti khoa Chn oỏn hỡnh nh, khoa Khỏm - Cp cu Bnh vin i hc Y H Ni, nhng ngi ó giỳp tụi rt nhiu cng nh chia s vi tụi nhng khú khn quỏ trỡnh hc Tụi xin gi li cm n ti Ban giỏm hiu, Phũng o to sau i hc v B mụn Chn oỏn hỡnh nh trng i hc Y H Ni ó giỳp tụi thi gian hc ti trng Tụi xin chõn thnh cm n ng y, Ban Giỏm Hiu, B mụn Chn oỏn hỡnh nh trng Cao ng Y t Thanh Húa ó to mi iu kin thun li cho tụi sut quỏ trỡnh hc tp, nghiờn cu hon thnh khúa hc ny Cui cựng, tụi xin dnh tỡnh cm v lũng bit n sõu sc ti cha m, anh ch v v tụi, nhng ngi ó luụn bờn tụi, quan tõm, ng viờn v chia s nhng nim vui cng nh ni bun cuc sng XIN TRN TRNG CM N! H Ni, ngy 18 thỏng nm 2014 Lờ Vit Dng LI CAM OAN Tụi l Lờ Vit Dng, Cao hc khúa 21, Trng i hc Y H Ni, chuyờn ngnh Chn oỏn hỡnh nh, xin cam oan õy l Lun bn thõn tụi trc tip thc hin di s hng dn ca thy PGS.TS Bựi Vn Lnh Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp nhn ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 18 thỏng 09 nm 2014 Ngi vit cam oan Lờ Vit Dng DANH MC T VIT TT CHT Cng hng t CLVT Ct lp vi tớnh CRP C-reactive protein EIA Enzyme Immunoassay ELISA Enzyme Linked Immuno Sorbent Assay FHCS Fitz Hugh Curtis Syndrome IUD Dng c t t cung PCR: Polymerase Chain Reation PID Viờm vựng chu S Siờu õm WHO T chc Y t th gii MC LC T VN Chng 1: TNG QUAN TI LIU 13 1.1 Gii phu 13 1.1.1 Gii phu bao gan, khoang quanh gan v hỡnh nh siờu õm cựng ct lp vi tớnh 13 1.1.2 Gii phu v t cung v phn ph 16 1.2 Hi chng Fitz-Hugh-Curtis 18 1.2.1 Nguyờn nhõn v c ch bnh sinh 18 1.2.2 c im lõm sng ca hi chng Fitz Hugh Curtis 24 1.2.3 c im cn lõm sng ca hi chng Fitz Hugh Curtis 24 1.3 Chp ct lp vi tớnh bng 27 1.3.1 Vai trũ ca ct lp vi tớnh chn oỏn FHCS 27 1.3.2 Hỡnh nh chp CLVT hi chng FHC 27 1.4 Chn oỏn v iu tr FHCS 30 1.4.1 Chn oỏn xỏc nh hi chng FHC 30 1.4.2 Chn oỏn phõn bit: 30 1.4.3 iu tr FHCS 31 1.5 Mt s nghiờn cu trờn th gii v nc 33 1.5.1 Trờn th gii 33 1.5.2 Vit Nam 38 Chng 2: I TNG V PHNG PHP NGHIấN CU 40 2.1 a im v thi gian nghiờn cu 40 2.2 i tng nghiờn cu 40 2.2.1 Tiờu chun chn bnh nhõn 40 2.2.2 Tiờu chun chn oỏn 40 2.2.3 Tiờu chun loi tr 40 2.3 Phng phỏp nghiờn cu 41 2.3.1 Thit k nghiờn cu 41 2.3.2 C mu nghiờn cu 42 2.3.3 Phng tin nghiờn cu 42 2.3.4 K thut siờu õm bng 43 2.3.5 Quy trỡnh chp ct lp vi tớnh 43 2.3.6 Phng phỏp thu thp thụng tin 44 2.3.7 Cỏc ch s v bin s cn quan tõm nghiờn cu 44 2.4 X lý s liu 47 2.4.1 Sai s 47 2.4.2 Cỏch khc phc sai s 47 2.4.3 X lý s liu 48 2.5 o c nghiờn cu 48 Chng 3: KT QU NGHIấN CU 49 3.1 Thụng tin chung 49 3.1.1 Phõn b theo tui 49 3.1.2 Phõn b theo ngh nghip 50 3.1.3 Phõn b theo quờ quỏn 50 3.2 c im lõm sng v xột nghim ca bnh nhõn FHCS 51 3.2.1 c im lõm sng 51 3.2.2 Xột nghim 54 3.3 c im hỡnh nh siờu õm v CLVT hi chng FHCS 57 3.3.1 c im hỡnh nh siờu õm hi chng FHC 57 3.3.2 c im hỡnh nh CLVT hi chng FHC 61 3.4 Vai trũ ca siờu õm v CLVT hng dn iu tr hi chng FHC 69 3.4.1 Phỏt hin tn thng bao gan v khoang quanh gan 69 3.4.2 Chn oỏn xỏc nh FHCS 72 3.4.3 Tng quan gia chn oỏn FHCS i chiu vi kt qu iu tr ni khoa phỏc FHCS 73 3.4.4 Tng quan gia chn oỏn FHCS t hỡnh nh ca siờu õm v CLVT 73 Chng 4: BN LUN 74 4.1 c im ca i tng nghiờn cu 74 4.2 c im lõm sng v xột nghim ca bnh nhõn FHCS 75 4.2.1 c im lõm sng 75 4.2.2 c im xột nghim 77 4.3 c im ca hỡnh nh siờu õm hi chng FHC 81 4.3.1 c im hỡnh nh siờu õm bao gan v khoang quanh gan 81 4.4 c im ca hỡnh nh CLVT hi chng FHC 83 4.4.1 c im hỡnh nh CLVT bao gan v khoang quanh gan 83 4.5 Vai trũ ca siờu õm v CLVT hng dn iu tr hi chng FHC 88 KT LUN 92 TI LIU THAM KHO PH LC DANH MC BNG Bng 3.1 Bng 3.2 Bng 3.3 Bng 3.4 Bng 3.5 Bng 3.6 Bng 3.7 Bng 3.8 Bng 3.9 Bng 3.10 Bng 3.11 Bng 3.12 Bng 3.13 Bng 3.14 Bng 3.15 Bng 3.16 Bng 3.17 Bng 3.18 Bng 3.19 Bng 3.20 Bng 3.21 Phõn b bnh nhõn FHCS theo cỏc nhúm tui 49 Phõn b bnh nhõn FHCS theo quờ quỏn 50 Phõn b bnh nhõn FHCS theo lớ vo vin 51 Phõn b bnh nhõn FHCS theo thi gian mc bnh 52 Cỏc triu chng c nng ca bnh nhõn FHCS 53 Du hiu lõm sng ca bnh nhõn FHCS 53 S lng bch cu, nng CRP, nng men gan, mỏu lng ca bnh nhõn FHCS 55 Giỏ tr trung bỡnh s lng bch cu, nng CRP, nng men gan, mỏu lng ca bnh nhõn FHCS 56 dy bao gan, mc dy bao gan v v trớ dy bao gan ca bnh nhõn FHCS 57 dy bao gan ca bnh nhõn FHCS 61 Trung bỡnh chiu dy bao gan ca nhng bnh nhõn nghiờn cu 62 c im hỡnh nh ranh gii bao gan v nhu mụ gan; phõn b mch mỏu nhu mụ gan ca bnh nhõn FHCS 64 c im hỡnh nh b gan v t trng nhu mụ gan ca bnh nhõn FHCS 65 c im hỡnh nh CLVT vựng chu ca bnh nhõn FHCS 67 Phỏt hin hỡnh nh tn thng viờm bao gan v khoang quanh qua siờu õm v chp CLVT 69 So sỏnh s phỏt hin viờm nhim phn ph thụng qua hỡnh nh siờu õm v CLVT 70 Phỏt hin hỡnh nh viờm vựng chu qua siờu õm v chp CLVT 71 Thi gian iu tr FHCS 72 Chn oỏn xỏc nh FHCS i chiu kt qu iu tr 72 Tng quan gia ca lõm sng v xột nghim vi kt qu chn oỏn CLVT 73 Tng quan gia chn oỏn FHCS t hỡnh nh ca siờu õm v CLVT 73 DANH MC BIU Biu 3.1 Phõn b bnh nhõn FHCS theo ngh nghip 50 Biu 3.2 Phõn b bnh nhõn FHCS theo tin s bnh 51 Biu 3.3 T l vi khun xột nghim ca bnh nhõn FHCS 54 Biu 3.4 T l hỡnh nh siờu õm t dch bng ca bnh nhõn FHCS 59 Biu 3.5 T l hỡnh nh siờu õm vựng chu ca bnh nhõn FHCS 60 Biu 3.6 T l c im ngm thuc ca bao gan trờn CLVT 63 Biu 3.7 c im hỡnh nh CLVT t dch bng ca bnh nhõn FHCS 66 Biu 3.8 T l hỡnh nh chp CLVT phn ph 68 10 DANH MC HèNH Hỡnh 1.1: Gii phu bao gan v cỏc dõy chng ca gan 13 Hỡnh 1.2: Hỡnh: A bao gan bỡnh thng B bao gan dy v ngm thuc cn quang 15 Hỡnh 1.3: Hỡnh CT tỏi to coronal (a trc; b sau) ch cỏc khoang phỳc mc v dõy chng 16 Hỡnh 1.4: Thit ct ngang v ct dc cnh gia ca t cung 17 Hỡnh 1.5: nh hng ca C Trachomatis lờn ng sinh dc n 20 Hỡnh 1.6: Hỡnh nh viờm dớnh bao gan vo thnh bng trc qua ni soi bng 25 Hỡnh 1.7: Dy bao gan v ngm thuc i quang t 26 Hỡnh 1.8: Hỡnh nh m vũi trng trờn siờu õm 27 Hỡnh 1.9: Hỡnh nh dy bao gan dng di v ngm thuc sau tiờm trờn CLVT 28 Hỡnh 1.10: Hỡnh minh o chiu dy bao gan 29 Hỡnh 1.11: Hỡnh nh ỏp-xe bung trng trỏi trờn CLVT 29 Hỡnh 2.1: Mỏy CLVT dóy u dũ Somatom Emotion ca hóng Siemens ca Khoa Chn oỏn hỡnh nh Bnh vin i hc Y H Ni 42 Hỡnh 4.1: Hỡnh nh siờu õm dy bao gan v tng sinh mch ngoi vi gan 81 Hỡnh 4.2: Hỡnh nh siờu õm m vũi trng hai bờn 82 Hỡnh 4.3: Hỡnh nh siờu õm t dch rónh thnh i trng phi v tỳi cựng Douglas 83 Hỡnh 4.4: Hỡnh nh CLVT dy hn hp v ngm thuc bao gan mt trc 84 Hỡnh 4.5: Hỡnh nh CLVT dy bao gan v ri lon ti mỏu nh ngoi vi gan 86 Hỡnh 4.6: Hỡnh nh CLVT Viờm phn ph hai bờn v thõm nhim t chc m tiu khung 88 Hỡnh 4.7: Hỡnh nh siờu õm bao gan trc v sau iu tr 90 Hỡnh 4.8: Hỡnh nh 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Thi gian iu tr: II c im lõm sng v xột nghim: 2.1 Tin s - Viờm nhim ng sinh dc - S dng bin phỏp trỏnh thai (t vũng) - No hỳt thai - Chm cú con(vụ sinh) - Thi gian: 2.2 Lõm sng: - au h sn phi - au h chu phi hoc h v - au tng lờn i li, ho, hớt sõu - Nụn, bun nụn - au thng v - Ra kh h, mỏu õm o - au thnh tng cn - Triu chng khỏc: Ton thõn: - Nhit : 37.5; 37-380C; 38-390C; - M: 4.>390C HA: 2.3 Cn lõm sng: 2.3.1.Xột nghim mỏu: Xột nghim mỏu lng: Ch s Tc Gi u mỏu lng Gi hai Kt qu Bỡnh thng Tng Nng CRP: Ch s Kt qu CRP (mg/dl) Bỡnh thng Tng (0,5mg/dl) Tng: >0,5 (mg/dl) S lng bch cu: Ch s Kt qu WBC Bỡnh thng (4-10G/l) Tng >10G/l Men gan: Bỡnh thng Tng SGOT(U/L) (37 U/L) (>37 U/L) SGPT(U/L) (40 U/L) (>40 U/L) Men gan Kt qu 2.3.2 Xột nghim vi sinh hc: Bnh phm: Dch õm o Vi khun Cú Khụng Chlamydia Trachomatis N Gonorrhoeae Mycobacterium Tuberculosis Candida Trc khun Gr(-) Trc khun Gr(+) Cu khun Vi khun khỏc III Siờu õm 3.1 c im hỡnh nh siờu õm bao gan, khoang quanh gan: dy bao gan: 1: 3mm) T dch bng: 1: Khụng cú dch; 2: Cú dch khoang quanh gan; 3: Dch rónh i trng phi 4: Dch Douglas; 5: Dch rónh i trng trỏi; 6: Dch quanh lỏch 3.2 c im hỡnh nh siờu õm vựng chu T cung: 1: Bỡnh thng; Viờm niờm mc t cung; Phn ph: 1: Bỡnh thng; Viờm phn ph bờn; 3: Viờm phn ph bờn 4: p-xe phn ph IV Ct lp vi tớnh: 4.1 c im hỡnh nh CLVT bao gan, khoang quanh gan: dy bao gan: 1: Khụng phỏt hin bt thng; 2: Dy dng di mng 1-2mm; 3: Dy dng bng rng 3mm; Dy hn hp (gm dng di v bng rng) Tớnh cht dy bao gan: 2: Dy bao gan lan ta: 5cm 1: Dy bao gan khu trỳ: 3mm) T dch bng: 1: Khụng cú dch; 2: Cú dch khoang quanh gan 3: Dch rónh i trng phi 4: Dch Douglas; 5: Dch rónh i trng trỏi; 6: Dch quanh lỏch 4.2 c im CLVT vựng chu Thõm nhim m tiu khung: 1: Bỡnh thng; Cú thõm nhim viờm t chc m tiu khung Mc thõm nhim m tiu khung Thõm nhim viờm khu trỳ Thõm nhim viờm lan ta T cung: 1: Bỡnh thng; dch bung t cung Phn ph: 1: Bỡnh thng; 2: Viờm phn ph bờn; 3: Viờm phn ph hai bờn; 4: p-xe phn ph V iu tr: 5.1 iu tr ni khoa: Theo phỏc FHCS: - Thi gian iu tr: Thi gian iu tr Ni trỳ Ngoi trỳ Ni trỳ Ngoi trỳ Tng thi gian iu tr Ngy 5.2 iu tr ngoi khoa: Thi gian iu tr Tng thi gian iu tr Ngy 5.3 Theo dừi ỏp ng sau iu tr vi chn oỏn S, CLVT l FHCS: c im hỡnh nh siờu õm sau 14 ngy iu tr ca bnh nhõn FHCS Hỡnh nh siờu õm Cú dy bao gan T dch bng Viờm vựng chu Tng Trc iu tr Sau iu tr c im hỡnh nh CLVT sau 14 ngy iu tr ca bnh nhõn FHCS Hỡnh nh siờu õm cú khụng Dy bao gan T dch bng Viờm vựng chu Tng 1.Khi bnh; 2.Thuyờn gim () Khụng phi chuyn phỏc iu tr ... tài: Đặc điểm hình ảnh siêu âm cắt lớp vi tính hội chứng Fitz- HughCurtis” với hai mục tiêu: Mô tả đặc điểm hình ảnh siêu âm cắt lớp vi tính hội chứng Fitz- Hugh- Curtis Đánh giá vai trò siêu âm cắt. .. điểm lâm sàng hội chứng Fitz – Hugh – Curtis 24 1.2.3 Đặc điểm cận lâm sàng hội chứng Fitz Hugh Curtis 24 1.3 Chụp cắt lớp vi tính ổ bụng 27 1.3.1 Vai trò cắt lớp vi tính chẩn đoán... 75 4.2.2 Đặc điểm xét nghiệm 77 4.3 Đặc điểm hình ảnh siêu âm hội chứng FHC 81 4.3.1 Đặc điểm hình ảnh siêu âm bao gan khoang quanh gan 81 4.4 Đặc điểm hình ảnh CLVT hội chứng FHC