B GIÁO D C VA ÀO T O VI N NGHIÊN C U KHOA H C Y D B QU C PHÒNG C LÂM SÀNG 108  V THÀNH TRUNG M TS C I M LÂM SÀNG, C N LÂM SÀNG VÀ K T QU I U TR VIÊM MÀNG B NG NHI M KHU N T B NH NHÂN X GAN LU N ÁN TI N S Y H C Hà Nôi - 2019 PHÁT B GIÁO D C VA ÀO T O VI N NGHIÊN C U KHOA H C Y D B QU C PHÒNG C LÂM SÀNG 108  V THÀNH TRUNG M TS C I M LÂM SÀNG, C N LÂM SÀNG VÀ K T QU I U TR VIÊM MÀNG B NG NHI M KHU N T B NH NHÂN X GAN Chuyên ngành: N i Tiêu hoá Mã s : 62.72.01.43 LU N ÁN TI N S Y H C Ng ih ng d n khoa h c: GS.TS MAI H NG BÀNG PGS.TS PHAN QU C HỒN Hà Nơi - 2019 PHÁT L I CAM OAN Tôi xin cam oan s li u k t qu nghiên c u lu n án trung th c ch a h c s d ng b o v m t h c v M i s giúp cho vi c th c hi n lu n án ã lu n v n ã c c m n thơng tin trích d n c ch rõ ngu n g c rõ ràng c phép công b Tác gi lu n án V THÀNH TRUNG L IC M N Trong su t trình h c t p nghiên c u, ã nh n s giúp c r t nhi u c a cá nhân t p th V i lòng bi t n sâu s c, xin g i l i c m n chân thành t i GS.TS Mai H ng Bàng, PGS.TS Phan Qu c Hồn, nh ng ng tình h i th y ã t n ng d n Tôi xin chân thành c m n Khoa Tiêu hóa, Ph òng L u tr h s , Phòng K ho ch t ng h p thu c B nh vi n B ch Mai,B mơn khoa N i tiêu hóa, Phòng sau i h c thu c B nh vi n TWQ tr c ti p tham gia gi ng d y giúp 108, quý Th y, Cô giáo ã tơi q trình h c t p th c hi n lu n án Tôi xin chân thành c m n lãnh tơi có c h i h c t p nâng cao trình o c quan c p ã t o i u ki n cho Cu i cùng, xin g i l i tri ân sâu s c bè ã ln n gia ình, ng i thân b n ng viên, h tr t o i u ki n t t nh t cho su t trình h c t p, làm vi c hoàn thành lu n án Hà N i, ngày 10 tháng 03 n m 2019 Tác gi Lu n án V Thành Trung DANH M C VI T T T Ti ng Vi t: BANC : B nh án nghiên c u BC NTT : B ch c u a nhân trung tính BN : B nh nhân CMTH : Ch y máu tiêu hóa CS : C ng s DCT : D ch c tr ng TKS : i u tr kháng sinh TTKN : i u tr theo kinh nghi m HCGT : H i ch ng Gan Th n HCNG : H i ch ng não gan NKH : Nhi m khu n huy t TANTMC : T ng áp l c t nh m ch c a THBH : Tu n hoàn bàng h TMDD : T nh m ch d dày TMTQ : T nh m ch th c qu n VMBNKTP : Viêm màng b ng nhi m khu n t phát XHTH : Xu t huy t tiêu hóa Ti ng Anh BT : S di chuy n c a vi khu n (Bacterial translocation) CAIDS : H i ch ng r i lo n mi n d ch liên quan n x gan (Cirrhosis- associated immune dysfunction syndrome) GALT : Mô b ch huy t liên quan Tissue) n ru t (Gut Associated Lymphoid GOV : Giãn t nh m ch th c qu n d dày (Gastroesophaeal varices) HE : B nh não gan (Hepatic encephalopathy) HRS : H i ch ng gan th n (Hepatorenal Syndrome) IGV : Giãn t nh m ch t i d dày không liên t c v i th c qu n (Isolated gastricvarices) MIC :N ng c ch t i thi u (Minimal Inhibitory Concentration) NAFLD : B nh gan nhi m m không r u (nonalcoholic fatty liver disease) NSAIDs : Các thu c kháng viêm không steroid (Nonsteroidal antiinflammatory drugs) P.H : T ng áp l c t nh m ch c a (Portal hypertension) PMNL : B ch c u a nhân (Polymorphonuclear Leukocytes) PSS : Các nhánh bàng h c a-ch (porto-systemic shunts) RES : H th ng l SBP : Viêm màng b ng nhi m khu n t phát (spontaneous bacterial i n i mô (Reticulo Endothelial System) peritonitis) SIBO : Tình tr ng phát tri n m c c a vi khu n ru t non (Small IntestinalBacterial Overgrowth) SeBP : Viêm phúc m c nhi m khu n th phát (Secondary bacterial peritonitis) SIRS : H i ch ng viêm h th ng (systemic inflammatory response syndrome) SFP : Viêm phúc m c t phát n m (Spontaneous fungal peritonitis) TIPS : K thu t t o shunt c a ch gan (transjugular intrahepatic portosystemic shunt) M CL C DANH M C B NG DANH M C BI U DANH M C HÌNH DANH M C S TV N Ch ng 1: T NG QUAN TÀI LI U X GAN: NGUYÊN NHÂN, NH NG BI N I H TH NG,LÂM SÀNG VÀ BI N CH NG 1.1 Khái quát v x gan 1.2 Nh ng nguyên nhân gây x gan 1.3 Các bi n c tr i v gi i ph u, mi n d ch, vi sinh h c s hình thành d ch ng x gan 1.3.1 Các bi n i v gi i ph u x gan 1.3.2 Các r i lo n mi n d ch liên quan 1.3.3 Các bi n n x gan i v vi sinh h c liên quan 1.3.4 S hình thành d ch c tr n x gan 10 ng x gan 12 1.4 Tri u ch ng lâm sàng, c n lâm sàng b nh nhân x gan 13 1.4.1 Tri u ch ng lâm sàng 13 1.4.2 Tri u ch ng c n lâm sàng 14 1.5 Các bi n ch ng c a x gan 15 1.5.1 Xu t huy t tiêu hóa t ng áp l c t nh m ch c a 15 1.5.2 H i ch ng gan th n 16 1.5.3 B nh não gan 17 1.5.4 Nhi m trùng b nh nhân x gan 18 VIÊM MÀNG B NG NHI M KHU N T PHÁT B NH NHÂN X GAN 19 2.1 Khái quát v VMBNKTP 19 2.2 T n su t phân b 20 2.3 C ch b nh sinh gây VMBNKTP 22 2.3.1 Thuy t Bacterial translocation –BT c i n: 22 2.3.2 C ch sinh b nh h c VMBNKTP c a Such.J Bruce A.Runyon (1998) : 23 2.3.3 C ch sinh b nh h c VMBNKTP c a Wiest R, Garcia-Tsao G (2005) 24 2.3.4 C ch sinh b nh h c VMBNKTP c a Anadon MN Arroyo V (2007); Runyon B.A (2010): 25 2.3.5 C ch sinh b nh h c VMBNKTP c a Such J (2013) 25 2.3.6 C ch sinh b nh h c VMBNKTP c a Reiner Weist c ng s (2014): 26 2.3.7.T ng h p v c ch b nh sinh VMBNKTP 27 2.4 Lâm sàng ch n oánVMBNKTP 27 2.5 Các xét nghi m ch n oán VMBNKTP 28 2.5.1 Các ph ng pháp c y d ch c tr ng 28 2.5.2 Ch n oán VMBNKTP d a ch s B ch c u a nhân d ch c tr ng 29 2.5.3 Ch n oán VMBNKTP d a vào DNA vi khu n có d ch c tr ng 30 2.6 Ch n oán phân bi t 31 2.6.1 Viêm phúc m c nhi m khu n th phát 31 2.6.2 Nhi m khu n huy t 32 2.6.3 Viêm phúc m c t phát n m 33 I U TR VIÊM MÀNG B NG NHI M KHU N T PHÁT 33 3.1 Nguyên t c i u tr 33 3.2 i u tr VMBNKTP 34 3.2.1 S d ng kháng sinh theo kháng sinh 34 3.2.2 S d ng kháng sinh theo kinh nghi m 34 3.2.3 S d ng kháng sinh k t h p li u pháp bù Albumin 36 3.2.4 ánh giá hi u qu i u tr kháng sinh 36 3.3 i u tr d phòng VMBNKTP 37 3.4 Tình hình kháng kháng sinh 37 ngồi n Tình hình nghiên c u VMBNKTP Ch ng 2: 2.1 IT it NG VÀ PH c 38 NG PHÁP 40 ng nghiên c u 40 2.1.1 Tiêu chu n ch n b nh nhân 40 2.1.2 Tiêu chu n lo i tr b nh nhân 40 2.2 Ph ng pháp nghiên c u 41 2.2.1 Thi t k nghiên c u 41 2.2.2 C m u nghiên c u 41 2.3 Ph ng ti n nghiên c u 41 2.4 Các b c ti n hành nghiên c u 44 2.4.1 M u b nh án nghiên c u 44 2.4.2 Th m khám lâm sàng c n lâm sàng 44 2.4.3 Các thang i m ánh giá m c 2.4.4 Tri u ch ng c n ng, th c th 2.4.5 Xét nghi m d ch c tr 2.4.6 ng x gan bi n ch ng khác 45 b nh nhân x gan có VMBNKTP 49 b nh nhân x gan có VMBNKTP 50 nh danh vi khu n kháng sinh 53 2.4.7 Th c hi n trình i u tr 56 2.4.8 i u tr x gan có bi n ch ng VMBNKTP 59 2.5 Phân tích x lý s li u 63 2.6 Sai s kh c ph c 63 2.7 H n ch c a 2.8 o tài: 63 c nghiên c u 64 Ch ng 3:K T QU NGHIÊN C U 65 3.1 3.1.1 C I M LÂM SÀNG VÀ C N LÂM SÀNG X GAN 65 c i m tu i gi i nhóm nghiên c u 65 3.1.2 T l m c b nh theo nhóm tu i 3.1.3 c i m y u t ti n s 3.1.4 c i m lâm sàng b nh nhân x gan 65 nhóm BN x gan có VPMNKTP 66 b nh nhân x gan có bi n ch ng VMBNKTP 66 3.1.5 Phân lo i m c x gan theo Child-Pugh 67 3.1.6 K t qu huy t h c sinh hóa 3.1.7 M c giãn TMTQ 3.2 Xét nghi m d ch c tr BN x gan có VMBNKTP 68 b nh nhân VMBNKTP 70 ng b nh nhân VMBNKTP 71 b ng b nh nhân x gan có VMBNKTP 71 3.2.1 c i m d ch 3.2.2 c i m d ch c tr 3.2.3 c i m v sinh hóa-hóa nghi m d ch c tr 3.2.5 S l ng k t qu xét nghi m Rivalta 71 ng BC NTT d ch c tr 3.2.6 K t qu c y 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(2011) Carbapenems: Past, Present, and Future Antimicrobial Agents and Chemotherapy, 55(11), pp 49434960 189 Felisart, J., et al (1985) Cefotaxime is more effective than is ampicillintobramycin in cirrhotics with severe infections Hepatology, 5(3), pp 457-462 ... c hi n sàng, c n lâm sàng k t qu phát tài: “M t s c hi u bi t c i m lâm i u tr viêm màng b ng nhi m khu n t b nh nhân x gan nh m m c tiêu: + Mô t c i m lâm sàng, c n lâm sàng b nh Viêm màng b... Tri u ch ng lâm sàng, c n lâm sàng ng x gan [46] b nh nhân x gan 1.4.1 Tri u ch ng lâm sàng Các tri u ch ng lâm sàng bi u hi n ph thu c vào giai o n x gan n n b nh lý gan m n tính X gan có giai... 10 ng x gan 12 1.4 Tri u ch ng lâm sàng, c n lâm sàng b nh nhân x gan 13 1.4.1 Tri u ch ng lâm sàng 13 1.4.2 Tri u ch ng c n lâm sàng 14 1.5 Các bi n ch ng c a x gan