UT HUYT TIU HO TRN SV.Bo Quyn - y2003 SV.Thnh Tm - y2003 I. i cng: - L mt bnh cnh rt nghim trng, l cp cu ni-ngoi khoa.

- Cn hi sc cp cu tnh trng mt mu cng sm cng tt. - S phn bit XHTH do v tnh mch thc qun(TMTQ) gin vi XHTH khng do v TMTQ gin c ngha rt quan trng trong x tr.V d hu ca XHTH do v TMTQ gin xu hn.

II. Tip cn bnh nhn XHTH trn : *Bc 1 : C XHTH khng? Cc tnh hung pht hin : 1. Nn ra mu : mu ti, sm, caf mu sc tu thuc vo nng HCl, thi gian mu ng, s lng mu mt. - Cn phn bit : Ho ra mu. Chy mu t vng hm mt. Do thc n : tit canh. 2. i cu phn en : phn lng mu nu en nh b cf, mi khm (C th i cu ra mu ti trong trng hp XHTH trn t, thng km chong) - Cn phn bit : To bn : phn cng, en nu Phn en xanh do sc t mt.

 Do s dng thuc c cht Fe, cht than, bismuth, cam tho. 3. Triu chng mt mu cp tnh : tu thuc vo lng mu mt. Mt <500 ml : t c biu hin lm sng. Mt < 10% - 20% VTH : Mch tng >15ln/ph hoc HA h >10mmHg khi thay i t th. Mt >20% VTH : sc. -Phn bit vi xut huyt ni.

*Bc 2: XHTH trn hay di? XHTH trn XHTH di TCLS -i ra mu/i cu phn en -i cu ra mu (10% i cu ra mu) Tube Levin -Ra mu -Khng ra mu T s BUN/CR -Tng -Khng tng Ni soi DD-TT Ni soi HM-TT

*Bc 3: Mc xut huyt : Cn lu tc mt mu v lng mu mt. Chn on lng mu mt da vo sonde DD. Bng phn XHTH:

Nh Trung bnh Nng Lng mu mt <10% VTH 10 20 % VTH > 20% VTH DHST C th thay i nh,sau bi hon dch v bt M:100-120ln/p HAthu> 90mmHg Hoc Tilt test (+) M: > 120 ln/ph HAthu<90 mmHg Hoc HA kp Lm sng Hi hp, mt khi gng sc. Da nim cn hng Da xanh, nim nht. Chong vng chng mt khi gng sc. Nc tiu/24h Da xanh, nim trng bch. u chi lnh Tot m hi

Thiu niu hoc v niu. Hct 30% 20 30% <20% S lng HC >3triu/mm3 2 3 triu/mm3 < 2triu/mm3 i vi ngi gi, ngi c bnh l tim mch, bnh phi mn tnh th Hct < 25% l nng.

*Bc 4: Chn on nguyn nhn : - Chy mu do lot d dy-t trng, v tnh mch thc qun gin v nhng tn thng cp tnh d dy-t trng chim 90% nguyn nhn.

Nguyn nhn T l Lot t trng 24 Vim d dy cp 20 Lot d dy 15 V TMTQ gin 14 Vim thc qun 6

Hi chng Mallory-Weiss 5 Khc (**) 10 Khng xc nh 6

-Khc (**) :

Hi chng Mallory Weiss D M t trng (lun ngh khi bn xut huyt c mnh ghp MC) Ti tha t trng K d dy : thng mu n trong phn, t khi XHTH r, tui >40, st cn nhanh, hch c (+). Chy mu ng mt : do nhim trng ng mt, K ng mt, pxe ng mt hoc giun chui ln ng mt Vim tu hoi t xut huyt, K u tu. Ng c NH3, acid, baz. Do thuc : NSAIDs, steroide, khng ng. Bnh l v mu : gim tiu cu, leucimie, suy tu, hemophilie, DIC. *Bc 5: XHTH cn ti din hay khng?

- Nu ang ti din : Sonde DD cn ra mu ti Tip tc i mu mu cng ln, tiu phn lng mu nhiu hn.

 DHST tip tc thay i theo chiu hng xu sau iu tr ban u. Hct tip tc gim sau truyn mu. - Ni soi li: Forrest ci bin :

ang chy mu Ia Chy mu phun thnh vi Ib Chy r r Chy mu gn y IIa L mch mu IIb Cn cc mu ng IIc C chm khc mu Khng chy mu III Khng thy du hiy chy mu

*Bc 6: c yu t thc y XHTH khng? S dng thuc: Aspirin, Clopidogrel, NSAIDs, Corticoide. Stress nng: nhim trng nng, sau phu thut, sau chn thng nng, hoc bng Ru Thuc l

 Nhim H.pylori.

CC XT NGHIM C BN CHO 1 BNH NHN XHTH: 1.Xt nghim thng quy: -CTM -TQ, TCK -GS -Chc nng thn. -Hct mi 12h.

2.Xt nghim chn on nguyn nhn v gi v tr chy mu: -Ni soi thc qun- d dy- t trng: (++) cn thc hin sm v l cch gip xc nh v tr tn thng tt nht, v nn thc hin sau khi BN c iu tr sc. y va l phng tin chn on va c th iu tr cm mu. -Xt nghim v gan: (+) nhm pht hin tnh trng suy t bo gan hoc cc ri lon ng mu SGOT, SGPT Bilirubin TP, TT in di m NH3 HbsAg, antiHCV Siu m bng.

-Chp ng mch chn lc vng tng: t khi c ch nh, ch hu hiu khi ni soi khng tm ra nguyn nhn v v tr chy mu.V qua c th thc hin k thut thuyn tc mch cm mu.

X TR CP CU XHTH *Mc tiu: A. Cm mu sm trc khi tn thng lan rng. B. Phng nga chy mu ti pht.

1.Khi BN nhp vin cp cu cn thc hin tc th: Lp 2 ng truyn tnh mch ngoi bin ln. Gi thng ng h hp, cho bnh nhn th Oxy m 4lt/ph, nm u thp. Ly mu TM ngay th nhm mu, phn ng cho, CTM, TS, TC.

2.Chng sc: Truyn dch ng trng. Truyn mu khi Hct <20% (mc tiu a Hct>25%), i vi nhng bnh nhn gi, c bnh l tim mch i km th truyn mu khi Hct<25% (Hct>30%). - Khi mt mu t c th truyn ngay nhm mu O. - HCL v Huyt tng ti ng lnh c th thay th mu ton phn khi cn truyn 1 lng ln. - nhng bnh nhn ang chy mu: vic truyn mu phi tip tc tng ng vi s mt mu ang din ra cho n khi cm mu. - Bnh l v ng mu nn c iu chnh bng huyt tng ti ng lnh hoc iu tr bng yu t khc.

 Gim tiu cu <50K/mcl nn c iu chnh bng TC. Theo di huyt ng trong khi hi sc nhng bnh nhn XHTH c bit khi c km bnh tim mch (CVP). * Theo di bnh nhn da vo: DHST Hct mi 6 12 h CVP nu c thc hin ng sonde mi - d dy Lng nc tiu (c th qua sonde tiu)

3. Cm mu: A/XHTH do lot d dy t trng: 80% t cm mu. Mc tiu iu tr ch yu khng phi l cm mu m l phng nga chy mu ti pht, thng dng thuc c ch tit dch v: PPIs liu cao, antiH2.Khi cp cu nn dng thuc qua ng tnh mch sau chuyn sang ung cng sm cng tt. Cc phng php cm mu qua ni soi: + Dng nhit : laser, t in, que nhit, sng ngn. + Chch Adrenalin, hoc cn tuyt i. + Dng keo sinh hc, kp cm mu. Can thip phu thut khi: + Cm mu qua ni soi tht bi sc mt mu.

+ Mu chy t ng mch hoc gn ng mch ln (lot mt sau hnh t trng n vo ng mch v t, lot b cong nh thng vo ng mch vnh v tri, him hn l lot mt sau thn d dy thng vo ng mch lch)

B/V TMTQ gin: C 5 pp cm mu: 1. Cm mu qua ni soi bng chch cht x ho TM hoc tht bng dy thun hoc phi hp c 2.

2. Dng thuc co mch: - Vasopressine Triglycyllysine (Glypressin): ch hu hiu trong 50% cas, v 25% b tai bin trm trng. - Somatostatin (Stilamin): lm gim p lc TM gan v h ca nhng half-time ngn ch vi pht. - Octreotide Acetat (Sandostatin): hot tnh tng t Somatostatin nhng mnh hn gp 45 ln (theo tc gi Bauer).

3. t sonde Blakemore - C: XHTH trn t khin iu tr ni tht bi - CC: BN c tin cn m DD-TQ - Theo di: + Mi 30p bm ra DD coi cn chy mu khng? Nu cn, bm bong d dy sao cho Vbng = 250ml kh. Nu vn chy th bm thm bng TQ cho 70ml kh.

+ Ngy u: x ht hi trong bng TQ mi 6h trong 30p (vn gi ng ti ch). Nu chy li: bm bng TQ nh lc u Nu ht chy: sonde thm 24h vn khng chy th x bong DD ri rt sonde + Nu phi sonde qua ngy 2 th mi 4h x bong TQ 30p. - Tai bin: Lot, v TQ, nng nht l ngt th.

4.Lm cu ni trong gan qua TM c ngoi.

5.Phu thut: ch p dng khi chch x tht bi 2 ln hoc iu tr ni v t sonde Blakemore khng hiu qu. - Khu cc bi TMTQ chy mu. - To cu ni ca-ch. - Cu ni Warren. - Ct ngang TQ, trit mch theo pp Sugiura

Ti liu tham kho:

1.iu tr ngoi khoa tiu ho HYD 2007. 2.iu tri ngoi khoa H Y Phm Ngc Thch . 3.Bnh hc ngoi khoa tiu ho HYD 2007. 4.S tay lm sng ngoi BV.Bnh Dn - Y2000. 5.The Washington Manual of Medical Therapeutics 32nd.
0
#2

X-man


Group:Cu Thnh Vin Posts:655 Joined:29-September 03 Gender:Male Location:H Y Dc Interests:Thch mu xanh da tri Thch i do thnh ph mt mnh Thch m hi Thch k lut v ng gi!
Posted 17 October 2008 - 07:56 PM

Junior Member

kin

Quote - S phn bit XHTH do v tnh mch thc qun(TMTQ) gin vi XHTH khng do v TMTQ gin c ngha rt quan trng trong x tr. V d hu ca XHTH do v TMTQ gin xu hn.

ni s phn bit ny quan trng cho x tr th sao li "v d hu ..." ?! V c c bi cng khng thy ch no c ni n cc yu gip phn bit hai tnh trng bnh ny.(?) Thc s, vic phn bit ny l rt quan trng cho vic x tr cp cu m khng c iu kin ni soi tiu ha trn, m c th ra l ch nh t sonde Blakemoore m thi. Vic phn bit xut huyt do v dn TMTQ v lot d dy t trng c th da vo lm sng vi tinh cy nht nh thi (tt nhin ri). Cc yu t gip phn bit: hi chng tng p lc tnh mch ca, tin cn lot DDTT, tin cn v biu hin bnh l gan mn. - V phn iu tr, cu t cn phi nh l "ni soi sm trong 24h u khi huyt ng n nh". Cu ny th hin ht tinh thn chn on v iu tr ca XHTH trn ri . Th nht, y l mt cp cu ni - ngoi khoa. Yu cu n nh ngay huyt ng. Th hai, phi nhanh chng chn on xc nh nguyn nhn xut huyt v

ni soi cho kh nng chn on chnh xc km theo kh nng can thip rt cao cho c hai nhm bnh l chnh gy XHTH trn ny. - Bi vit thiu nh ngha ca XHTH trn. (l chy mu trong lng ng tiu ha do tn thng t ming, thc qun, d dy, t trng n pha trn gc Treitz). - Mt lu nh na l vi BN XHTH do v dn TMTQ th nn c iu tr d phng hn m gan do XHTH l mt yu t thc y hn m gan rt ln. PS: ti liu nn tham kho - HI SC CP CU NI KHOA - B mn Ni HYD TpHCM. Mt ma xun nho nh Lng l dng cho i!
0
#3

lynn_ly

Group:Cu Thnh Vin Posts:3,363 Joined:20-June 07 Gender:Not Telling
Posted 18 October 2008 - 03:38 AM

Advanced Member

Th su / ngy cui tun ... Ch Lynn lm bing lm, nhng sing c thng tin Y hc, va c c bi vit ny bn Din n iu Dng Vit Nam thy hay hay i vi ngi khng trong ngh nh ch Lynn ... em v post vo y gp "vui vn ngh" !!! hihi ... Cho gin cht !!! Hy vng Quyn + Tm v Dr xman khng phin --------------------------------------------------

Xut huyt tiu ho

(refer: http://www.hoidieudu...opic.php?p=2645 )

I.I CNG:
Xut huyt tiu ho l hi chng do nhiu bnh l gy ra gm:

Bnh l ng tiu ho: vim, lot, k Bnh l ton thn

Xut huyt tiu ho trn: Tn thng t gc Treitz tr ln, thc qun d dy, t trng gy i mu, i cu ra mu. Xut huyt tiu ho di:Tn thng t gc Treitz tr xung hng trng, manh trng, i trng, gy i cu ra mu.

II.NGUYN NHN:
6 nhm: XHTH Trn chim 80-85%. XHTH Di chim 15% 1. Ti ng tiu ho: Vim lot d dy t trng: chim 80-85%

K ng tiu ho U mch mu, polype Ti tha, lng rut Nhi mu do tc mch mc treo Hi chng Mallory-Weiss

2. Gan-Mt-Ty: Hi chng tng p lc tnh mch ca do x gan

ng mt: vim, k ng mt Vim tu th hoi t xut huyt K vng c vng Oddi

3. Bnh v mu:

Suy tu Leucemia cp, mn Hemophilie

Ri lon s lng, cht lng tiu cu

4. Do thuc: Corticoid, khng vim Nonsteroid, khng ng

5. Do ng c: Ni sinh: Suy thn, NH3 tng, nhim trng huyt, stress.

Ngoi sinh: Do cht c Acid, Baze, cht c khc gy tn thng ng tiu ho.

6. Nhim khun v d ng:

Siu vi: SXH, cm Vi trng: thng hn

KST: st rt c tnh th XHTH, Amibe

D ng ng tiu ho

III.PHN LOI:
1. XHTH nh Mu chy < 20% khi lng tun hon c th hay < 500ml

Triu chng ton thn khng thay i

Du hiu sinh tn bnh thng: M < 100l/p, HA n nh

Cn lm sng: khng thay i HC > 3triu, Hb > 11g/dl, Hct > 30%

2. XHTH trung bnh

Lng mu mt 20-40% khi lng tun hon c th hay mt 1000-1500ml

Triu chng ton thn xut hin: da xanh, nim nht, hoa mt, chng mt, nc tiu gim trong 24 gi.

M > 100 l/p, HA gim nh

3. XHTH nng: Mu mt > 40% khi lng tun hon c th hay >1500ml

Chi lnh v m hi, thiu niu hoc v niu

M > 120l/p, HA gim hoc kp

Cn lm sng : CVP thp, HC < 2 triu, Hct < 20%

IV.X TR:
Nhm 3 mc ch:

Hi phc khi lng tun hon c th Cm mu

Gii quyt nguyn nhn v phng nga ti pht A.Hi phc khi lng tun hon c th: rt quan trng Cho bnh nhn nn u thp bt ng Lp ng truyn tnh mch c nh bng dung dch ng trng Tin hnh ly mu xt nghim: CTM, Gs, Hct, Ur, Creatinin, SGOT, SGPT, ng mu ton b. Khm v nh gi mc chy mu

1. Chy mu mc nh:

Thnh lp ng truyn v c

nh

Thm d mc v v tr chy

mu

Cm mu Chun on nguyn nhn

2. Chy mu mc trung bnh Bi phc ch yu bng dung dch ng trng NaCL 0.9%, Lactat Ringer

Th Oxy Theo di tnh trng chy mu

3. Chy mu mc nng

Th Oxy 2-4 l/p

C ch nh truyn mu: truyn 1/3 khi lng tun han l mu, 2/3 khi lng tun hon l dung dch ng trng, truyn n khi ht du hiu thiu oxy no, M, HA n nh, Hct > 20%, HC >2 triu Trng hp khi cha c nhm mu kp thi, ta truyn dung dch thay th mu Gelafundin

Nng huyt p cho bnh nhn:

Trng hp b dch, mu m huyt p vn cha ln c, nu lu c th gy suy thn, nhn no, thiu mu c tim ---> c ch nh dng

thuc vn mch:
o Dopamin: liu < 5mg/kg/p

nng huyt p, duy tr chc nng thn

o CC: Adrenalin, Nor-Adrenalin,

hydrocarbinat nng HA Ch : ch dng Dopamin khi huyt p n ngng thn th ngng B.Cm mu 1. XHTH do lot DD-TT: gp thng nht

t sonde d dy:
o t sonde Tube Levin o Ra sch mu trong d dy

bng dung dch NaCl 0.9%

o Lu sonde 6-8 gi theo di,

dnh gi tnh trng chy mu v bm thuc cho bnh nhn.

o Chun on v tr chy mu,

cm mu, iu tr nguyn nhn chy mu.

o Ni soi cp cu nn lm trc

24 gi, v c nhng tn thng s lnh sau 24 gi nh: hi chng Mallory-Weiss, vim cht d dy.

Cm mu qua ni soi:
o Ch nh: Cc mu ng y

lot
o ang c r mu trn vt lot

o ng mch chi ln v thy r o ng mch ang phun mu o Dng Adrenalin 0.1% 1ml + 9ml

NaCl: chch vo ni chy mu cm mu

o Sau khi chch phi dng thuc

c ch bm proton mnh: Losec 80mg(TMC), sau 12-24 gi nhc li 40mg v tip tc liu 40mg/ngy n khi n th chuyn qua ung. Nu khng c c ch bm proton th dng c ch H2 hoc Antacid ho tan ung 3 gi/ln.
o iu tr duy tr bng phc

iu tr lot d dy t trng.

2. XHTH do tng p lc tnh mch ca:

Dn tnh mch thc qun chia 3 trn ni soi Ch nh cm mu qua ni soi sau khi dn tnh mch thc qun II cng phng n do v. Tin hnh: t sonde Blackmoire, dng trong cp cu khi bnh nhn ang v tnh mch thc qun t, sau 24 gi tho sonde.

X ho TM thc qun bng Polidocanol 0.75-2% (thng 1%) chch trc tip vo cc ti tnh mch phng cng trc, chch x nhc li sau 7-10 ngy.

X tr v nga hn m gan: song song

Khng sinh: Neomycin 1.5g/ngy

Klion 0.25-1.5g/ngy

Thuc s : Duphalac 13gi/ngy

Lactulose 1-3gi/ngy

Thuc nga ti pht: Propranolon, ch nh dng liu thp sau tng dn: 2040mg/ngy. g/gi. Tim tnh mch trong 3-4 ngy. Dng Sandostatin lm gim p lc tnh mch ca: liu 25-50 C th dng: Vasopresin 0.3 n v / 1 pht 30 pht sau 0.6 n v / 1 pht 30 pht sau 0.9 n v / 1 pht C.Gii quyt nguyn nhn chy mu: Tu tng nguyn nhn m gii quyt c th Ch nh phu thut:

K Chy mu ti pht nhiu ln

Hi sc ni khoa khng hiu qu, truyn 8 n v mu m huyt p vn khng n nh. V tnh mch thc qun lin tip ---> phng php thng ni ca ch

Ch dinh dng: Trong thi gian ang chy mu nui bng ng tnh mch

Khi cm mu:

Nu do lot DDTT: cho ung sa lnh trung ho acid

Nu do tng p lc tnh mch ca: ung nc ng lnh

Sau 5 ngy XHTT n nh: cho n li bnh thng t lng n c, coi nh XHTH chm dt.

iu tr nguyn nhn tch cc.

----------------------Khi c bi vit trn v vi bi post trn NCYK. Ch Lynn khng r "K" l g .... Ai rnh gii thch cho ch Lynn bit ... cn khng th ch Lynn i m m tm xem "K" l g ... Love is nature's way of giving, a reason to be living !!!