chay mau tieu hoa tren

                                                                                                BS Do HuNG

                                                                                                 Bai giang Y 6

I- Dai cuong

I- 1. Dinh nghia

- Chay mau tieu hoa (CMTH) la hien tuong chay mau vao long ong tieu hoa do ton thuong mach mau tu mieng toi hau mon.

- Chay mau tieu hoa tren duoc bieu hien bang dau hieu non mau,ia phan den do ton thuong mach mau tu lo thuc quan toi goc ta hong trang ( goc Treitz ).

  Chan doan CMTH khong kho , nhung chan doan nguyen nhan, vi tri, muc do thuong kho khan hon. Nguyen nhan CMTH tren thuong gap o benh ly da day, ta trang, duong mat va tang ap luc tinh mach cua. Thai do dieu tri phu thuoc nhieu yeu to nhu : nguyen nhan chay mau,muc do chay mau, tinh trang benh nhan ...

  Dau hieu lam sang thuong gap CMTH tren la non mau, ia phan den co the tiem an hoac o at dan toi soc mat mau va tu vong neu khong duoc chan doan va dieu tri kip thoi.

I- 2. Thai do xu tri chung

 Dung truoc benh nhan CMTH tren mot so viec can lam nhu

I- 2- 1. Xac dinh tinh trang chay mau

Dua vao so luong mau non, mau chay qua sonde da day, so luong phan den, tinh trang benh nhan de danh gia muc do chay mau nhe, trung binh, nang.

-Danh gia muc do chay mau:

           Muc do

dau hieu

nhe

Trung binh

nang

mach

<90

90-100

>100

Huyet ap tam thu

>100

80-100

<80

Hong cau

>3,5

2,5-3,5

<2,5

Hematocrite

>35 %

25-35 %

<25 %

Huyet sac to

>12 g/l

>60 %

10-12 g/l

40-60 %

<10 g/l

<40 %

Mat mau

% V tuan hoan

< 20

20 - 30

> 30

Danh gia muc do chay mau co noi soi theo Rockall

              Diem

Thong so

0

1

2

3

Tuoi

<60

60-79

≥ 80

Huyet dong

Khong soc

Mach <100

HATT > 100

Mach  ≥ 100

HATT ≥ 100

Tut huyet ap

Benh ly di kem

Khong

Thieu mau co tim,suy tim, cac benh nang khac

Suy than, suy gan, di can ung thu

Chan doan

Rach tam vi, khong thay ton thuong

Loet, viem trot thuc quan

K duong tieu hoa tren

Dau hieu chay mau tren noi soi

o loet day sach hoac co can den o day

Mau trong duong tieu hoa tren, mau dang chay,diem mach, cuc mau dong

   Tong diem < 3 diem tien luong tot, neu >8 diem nguy co tu vong va xuat huyet cao.

    Sau khi xac dinh muc do chay mau mot so cong viec can lam nhu:

- Xet nghiem nhom mau

- Dat duong truyen dich, mau. theo doi huyet ap tinh mach trung tam

- Dat sonde bang quang, sonde da day.

II. Mot so benh thuong gap trong CMTH tren

II- 1 Chay mau do loet da day ta trang, ung thu da day

 Chay mau do loet da day ta trang la bien chung thuong gap cua loet da day ta trang. Thuong ton cua o loet an thung mach mau lam chay mau tu day o loet, bo o loet. Vi tri thuong gap o hanh ta trang va bo cong nho, cac thuong ton chay mau thuong gap o loet hanh ta trang gap nhieu hon va co kha nang tu cam.Cac thuong ton o da day hay gap do loet bo cong nho, ung thu bo cong nho,ung thu hang vi thuong kho tu cam mau.

II-1-1 Chan doan xac dinh

Dau hieu co nang : Benh nhan co cam giac non mau, u tai, chong mat, tham chi co cam giac tanh tanh mau vung hong thuong thay o benh nhan chay mau tai dien

- Non mau lan thuc an,mau lon con nau den hoac do.

- ia phan den, phan khong thanh khuon,mui thoi kham.

Khi gap dau hieu nay can hoi tien su dau vung thuong vi,dung cac loai thuoc gay chay mau da day ta trang nhu Aspegic, Prednisolon, Non-Steroid... de xac dinh nguyen nhan chay mau.

Dau hieu thuc the : Chat non dac diem chay mau do loet da day ta trang mau do lan thuc an, dich tieu hoa

Phan den la phan nhay den nhu ba ca phe khong thanh khuon, mui thoi kham dac trung.

Kham bung khong co gi dac biet trong CMTH do loet da day ta trang.Co the thay u vung thuong vi do ung thu da day.

Can dat sonde da day hay tham truc trang trong cac truong hop khong co chat thai.

Dau hieu toan than co dau hieu mat mau tuy muc do. Co the choang,vat va hay nam yen nhung tinh. Da xanh,niem mac nhot , chi lanh. Kham mach,huyet ap thay mach nhanh nho deu, huyet ap toi da, toi thieu deu giam.

Xet nghiem mau hong cau, Hematocrite, huyet sac to deu giam.

Noi soi da day khi benh nhan on dinh vua de xac dinh nguyen nhan chay mau, vua xac dinh tinh trang chay mau va dieu tri tiem cam mau

Forrest    F1: mach mau dang phun

               F2 : cuc mau dong bam day o loet

               F3 : co loet nhung khong con chay mau

X-quang de chan doan CMTH hien nay it dung, nhung films X-quang cu co ton thuong da day ta trang rat co gia tri trong chan doan CMTH

Chan doan phan biet voi chay mau duong mat, chay mau do TALTMC 

II -1 -2 . Dieu tri  

Nguyen tac chung

Tho oxy ho tro 3-6 l/ phut

Hoi suc truyen dich, mau can cu tinh trang mat mau

Dieu tri noi khoa - truyen dich, mau. Dat hai duong truyen khi co roi loan huyet dong.

Truyen plasma tuoi khi co roi loan dong mau.

Truyen tieu cau khi tieu cau < 50 G/l

Truyen mau khi Hb < 70-80 g/l hoac < 100 g/l co tut huyet ap.

Dat sonde da day de rua da day cam mau bang lam lanh da day, qua day theo doi tinh trang chay mau va cho an khi benh nhan on dinh. 

Dung mot trong cac loai thuoc sau:

+ Esomeprazol, Omeprazol, Pantoprazole: truyen ngay tinh mach 80 mg, sau do truyen 8 mg/ h trong 72 h,tiep do cho uong 40 mg/ ngay trong 27 ngay.

+ Lanzoprazol: truyen ngay tinh mach 90 mg, sau do truyen 9 mg/ h trong 72 h,tiep do cho uong 30 mg/ ngay trong 27 ngay.

 Thuoc khang histamin H2 tinh mach : Ranitidin : truyen ngay tinh mach 50 mg, sau do truyen 6,5 mg/ h trong 72 h,tiep do cho uong 150 mg x 2 lan/ ngay trong 27 ngay.

, Cimitidin 800mg/24 gio.

The gioi khong con khuyen cao dung khang Histamin trong XHTH

Thuoc chong co that, giam tiet dich vi Atropin, Baralgin....

Khang sinh toan than,khang sinh duong ruot, thut thao.

Noi soi can thiep : Tiem xo cam mau bang Adrenalin 1/10 000 hoac tiem xo cam mau bang Ethanol,Polidocanol 1-3 % sau dieu tri noi tiep.

Dieu tri ngoai khoa khi hoi suc,dieu tri noi that bai, chay mau du doi, keo dai tai phat nhieu lan, chay mau kem bien chung thung da day ta trang,hep mon vi,chay mau tieu hoa tren o nguoi co tuoi.

Cac phuong phap phau thuat

-Mo da day khau cam mau day o loet chay mau, that mach mau gan o loet o nhung benh nhan nang, gia yeu.

-Khau day o loet cam mau va cat day than kinh X ( cat than than kinh X, cat day than kinh X chon loc va sieu chon loc ) hien nay it su dung .

- Cat da day kinh dien kem theo o loet hoac khong tuy thuoc tinh trang benh nhan, trang thiet bi, gay me hoi suc, trinh do chuyen mon.

- Triet cac mach mau toi vung loet chay mau

II - 2 . Chay mau duong mat

Chay mau duong mat la su thong thuong bat thuong cac mach mau trong hay ngoai gan voi duong mat gay chay mau xuong ta trang bieu hien bang non mau va ia phan den.

Benh thuong xay ra tung dot,keo dai tren benh nhan co tien su soi mat hoac da mo mat nhieu lan.

Nguyen nhan chu yeu gay nhiem trung duong mat do soi mat, giun chui duong mat lam chay mau duong mat, co ba vi tri thuong gap la

-Ton thuong vung cuong gan : Su thong thuong mach mau voi duong mat, thuong nam sau ong mat mach mau bi ton thuong la dong mach gan hoac tinh mach cua. Chay mau duong mat sau dan luu Kehr.

- Ton thuong o trong gan chay mau co the khu tru o mot o ap xe cua phan thuy gan hoac o mot so ong mat u dong trong gan.

- Ton thuong tui mat thuong do soi tui mat, viem tui mat gay chay mau vao duong mat.

 Ngoai ra con co mot so nguyen nhan khac nhu chan thuong gan do tai nan giao thong, lao dong, vet thuong hoa khi,bach khi, sau tham do duong mat nhu chup mat qua da, sinh thiet gan. Gan day co the gap sau mot so thu thuat nhu lay soi qua nhu mo gan, tan soi mat bang song, sau mo co that Oddi.

II- 2 -1. Chan doan

 Trieu chung

Theo Whitmann chay mau duong mat co dau hieu lam sang nhu :

-Dau bung vung gan, dau con, thuong sau dau co non mau benh nhan cam thay do dau hon, day la net dac biet cua benh nay.Nguoi ta cho rang mau chay vao duong mat lam cang dan duong mat gay dau do tang ap luc duong mat va co bop, sau khi mau bi tong ra khoi duong mat thi benh nhan cam giac do dau hon.

-CMTH tren : benh nhan thuong non mau hay di ngoai phan den,mau non thuong la nhung cuc mau hay cac thoi mau dai hinh but chi do mau chay vao duong mat duoc dong lai theo hinh khuon duong mat. Di ngoai phan den co truong hop chay mau nhieu phan co mau do tuoi do chua kip phan huy. Chay mau thuong dai dang khong theo mot quy luat nao.

- Vang da. Dau hieu vang mat, vang da cung co khi ro rang hay kin dao, doi khi de nham voi dau hieu mat mau.

  Mot so tac gia thay CMTH + hoi chung tac mat hoac CMTH + sot + dau vung gan phai nghi toi chay mau duong mat.

Tham kham

Toan than co dau hieu mat mau cap tinh the hien tuy muc do da xanh,niem mac nhot,vat va, dau chi lanh nang hon benh nhan roi vao tinh trang soc nhu truy mach, huyet ap tut. Mat mau it benh nhan o trong trang thai gan nhu binh thuong.

Cac dau hieu nhiem khuan : sot cao ret run tung dot, hoi tho hoi, luoi ban.

Kham bung doi khi thay gan to,tui mat to, rung gan duong tinh.

Xet nghiem.

Dau hieu mat mau : so luong hong cau, Hematocrite,huyet sac to deu giam tuy muc do.

Dau hieu nhiem khuan so luong bach cau tang, bach cau da nhan trung tinh tang.

Dau hieu tac mat bilirubin mau tang, men phot phat kiem tang.

Cac phuong tien giup chan doan nguyen nhan

- Sieu am gan mat thay hinh anh tac mat do soi, co the thay hinh anh ap xe gan nho co the la noi thong thuong giua mach mau va duong mat.

- Noi soi da day tien hanh khi benh nhan tuong doi on dinh, huyet ap toi da tu 90 mm Hg tro len thay mau chay tu  nhu bong Vater ra,qua day loai tru duoc cac nguyen nhan chay mau khac, va co the chup duong mat nguoc dong thay nguyen nhan tac mat ,hinh anh ap xe gan o thuoc nhoe o duong mat.

- Chup dong mach gan chon loc la phuong phap chan doan dac hieu cho phep xac dinh vi tri chay mau, hinh anh thay duoc co o dong thuoc va co su thong thuong thuoc sang duong mat.

Chan doan xac dinh dua vao cac dau hieu tren, dieu quan trong la danh gia muc do chay mau dua vao bang phan loai tren.

Chan doan phan biet voi CMTH do loet da day ta trang,ung thu da day,tang ap luc tinh mach cua.

II -2 -2. Dieu tri

Nguyen tac dieu tri

Hoi phuc khoi luong tuan hoan bang truyen mau,dich dua vao su danh gia muc do chay mau noi tren.

Theo doi tinh trang chay mau,cac dau hieu sinh ton

Dat sonde da day theo doi chay mau

Cho khang sinh duong mat,duong ruot

Thut thao tranh u tre duong ruot lam benh nhan de chiu

Phau thuat khi chay mau khong cam.

Phau thuat

Mo OMC lay cac nguyen nhan tac mat nhu soi,giun,mau cuc,rua duong mat bang dung dich natriclorua dang truong am, dat dan luu Kehr

That dong mach gan khi thu thuat lay soi,giun,mau cuc, rua duong mat khong ket qua

Cat gan cat vung gan co nguon goc chay mau la tot nhat khi da dinh dung vi tri chay mau truoc va trong mo.

Cat tui mat khi nguyen nhan chay mau tu day.Cat tui mat khi tui mat viem day,cang to do mau dong,co soi tui mat. Cung co y kien cat tui mat vi nhu chay mau tai day.

II - 3 . Chay mau do tang ap luc tinh mach cua

Chay mau do tang ap luc tinh mach cua thuong gap trong bien chung do xo gan

II -3 -1. Chan doan

Dau hieu co nang

CMTH tren bieu hien bang non mau,di ngoai phan den voi dac diem :

Chay mau nang

Non mau do tuoi, du doi, o at.

Di ngoai phan den keo dai.

Tinh trang nguoi benh co suy te bao gan

Dau hieu toan than

Bieu hien tinh trang mat mau cap , thieu mau ngoai vi da xanh,niem mac nhot, dau chi lanh. Roi loan huyet dong mach nhanh nho,huyet ap tut

Bieu hien tinh trang suy te bao gan o cac muc do khac nhau nhu : Tho o voi ngoai canh, ngu ga, hon me.

Dau hieu thuc the

Cac dau hieu xo gan,lach to,tuan hoan bang he,bung co dich o bung.

Dau hieu xet nghiem

Dau hieu mat mau cap so luong hong cau,hematocrite,huyet sac to deu giam.

Xo gan : Ti le A/G dao nguoc

Suy gan : Men gan SGOT,SGPT cao,Amoniac mau cao, roi loan chuc nang dong mau

Noi soi tien hanh khi tinh trang benh nhan on dinh,ngung non mau. Ton thuong gom nhung bui tinh mach dan to,cang manh, mau dang phun tia do, mau cuc dong o thuc quan,tam vi.

Sieu am gan va tinh mach cua co hinh anh gan xo, tinh mach cua dan to.

Chan doan xac dinh dua vao cac dau hieu tren, dieu quan trong la danh gia muc do chay mau dua vao bang phan loai tren.

Chan doan phan biet voi CMTH do loet da day ta trang,ung thu da day, chay mau duong mat.

II -3 -2. Dieu tri

Noi khoa

Hoi phuc khoi luong tuan hoan bang truyen mau,dich thay the mau dua vao su danh gia muc do chay mau noi tren.

Bao ve chuc nang gan : tho oxy ho tro lien tuc, duy tri huyet ap toi da tu 100 mm Hg tro len

Dat sonde da day co bong chen nhu sonde Sengstaken-BlacMore, sonde Linton

Thuoc giam ap luc tinh mach cua nhu Poste-hypophyse, Vasopresine lieu dung 0,4 dv/ph/24 gio dau

         0,2 dv/ph/ngay thu hai

         0,1 dv/ph/ngay thu ba

Somatostatin ( Stilamin ) 250 micrg 2-3 lan/24 gio.

Tiem xo cam mau ( Ethanol,Polidocanol, Sodium Tetradecal Sulfat ) hay that cac tinh mach dang chay mau.

Ngoai khoa khi dieu tri noi that bai ngoai ra cung co chi dinh khi de phong chay mau.

Cac phuong phap nhu :

Han che mau toi vung thuc quan nhu that tinh mach vanh vi,cat lach.

Phan luu mach mau cua chu voi cac kieu trung tam va ngoai vi nhu noi tinh mach cua - chu, noi tinh mach lach-than, phau thuat Warren ( that tinh mach vanh vi,mon vi,cat tinh mach lach that dau trong, noi dau trung tam tinh mach lach voi tinh mach than )....

Tac dong truc tiep vao vung thuc quan chay mau nhu phau thuat Sweet..., khau tinh mach.

III- Ket luan

CMTH tren la bien chung cua nhieu benh. Dien bien lam sang co the nhe sang nang.

Benh nhan can duoc theo doi tai benh vien

Lua chon phuong phap dieu tri can co su thong nhat chan doan giua cac bac sy de chon phuong phap tich cuc.

Noi soi da day la phuong phap tot de chan doan va dieu tri.