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  • 1. Chuyn SI NG MTT 9 Y07

2. Tng quanI S lc gii phuII S lc sinh lIII Triu chng bnh ng mtIV Cn lm sng bnh ng mt SI TI MT SI NG MT CH SI GAN 3. I S lc gii phu ng TM d = 3cm k = 3mmTi mt:d = 3-5 x 7-10cmV = 30-60 mLng mt ch d = 5-6cm k = 5-6mmhp nht 3mm 4. I S lc gii phu 5. I S lc gii phu 6. I S lc gii phu 7. II S lc sinh l 8. II S lc sinh l 9. III Triu chng bnh l ng mt Bnh l ng mt dn n triu chng lmsng do: nhim trng, tc nghn hay c hai Tc nghn ng mt c th do ngoi thnh (extramural : ung th ty ), trong thnh (intramural : cholangiocarcinoma ) hay trong lng( si ng mt ) Nhim trng do 3 yu t : s nhy cm ca cth, qu trnh vim nhim v s tr mt Triu chng lm sng thng gp: st, aubng, vng da, bun nn nn 10. III Triu chng bnh l ng mt au bng: cn au qun mt ( biliary colic ) _ V tr: h sn (P) hay thng v lan sau lng,gia hai xng b vai hay vai (P) _ Tnh cht: khng qun tng cn m au lintc, cng c th d di lm bnh nhnkhng dm th mnh _ Thi gian: 30 pht n vi gi, vi gi sau nhay au v m lm bnh nhn thc gic _ Triu chng i km: bun nn, nn 11. III Triu chng bnh l ng mt Vng da: _ Bilirubin ton phn > 2.5 mg/dL -> vng kt mc,> 5 mg/dL vng da r _ Nc tiu vng sm thng l triu chng bnhnhn pht hin u tin _ Loi tr cc nguyn nhn gy vng da khc: tngsn xut bilirubin ( thiu mu tn huyt, nhimtrng, bng, phn ng truyn mu, thuc ), hay rilon bi tit bilirubin ( vim gan do virus, ru, xgan, thuc ) 12. III Triu chng bnh l ng mt 13. III Triu chng bnh l ng mt St: _ Biu hin tnh trng nhim trng: vim ti mtcp hay nhim trng ng mt do tc nghn, sauchp ng mt xuyn da hay ni soi ng mt _ Charcots triad: au bng h sn (P) + st +vng da -> vim ng mt cp ( acute cholangitis) _ Pentad of Reynolds: triad + thay i trng thitm thn + tt huyt p -> nhim trng ng mtnng 14. IV Cn lm sng bnh l ng mt X-Quang bng: _ t c gi tr chn on bnh ng mt _ 15% si ti mt c nng calcium thy r trn X-quang bng _ Loi tr cc nguyn nhn khc trong bcu tip cn au bng: thng tng rng, tcrut, vim thy di phi phi ( x-quang ngc ) 15. IV Cn lm sng bnh l ng mt Siu m: _ Rt c gi tr trong chn on si ti mt v ccthay i bnh l trong vim ti mt cp ( dy thnhti mt, t dch quanh thnh, si chn p c timt) _ nhy > 95%, c hiu > 98% nu cthc hin bi cc bc s siu m c kinh nghim _ Tc nghn: ng mt ngoi gan dn d > 10mmv ng mt trong gan d > 4mm _ Siu m trong m: thng tn trong gan, khnng ct b, mch mu lin quan 16. Siu m bng 17. IV Cn lm sng bnh l ng mtBarkun AN, Barkun JS, Fried GM, et al. Useful predictors of bile duct stones inpatients undergoing laparoscopic cholecystectomy. McGill Gallstone TreatmentGroup. Ann Surg 1994;220:329. 18. IV Cn lm sng bnh l ng mt 19. IV Cn lm sng bnh l ng mt Chp nhp nhy ng mt (Scintigraphy ) _ Quan st tan b cy ng mt, nh gi chc nng ganv ti mt, pht hin mt s bt thng ng mt nh si _ Hu ch trong chn on vim ti mt cp _ nhy v c hiu tng ng siu m _ Chp nhp nhy ng mt vi 2.6-dimethyliminodiaceticacid chuyn ha gan ( HIDA ) _ Bnh thng: hnh nh ti mt v cc ng mt thy trongvng 30 pht sau ung _ Bt thng: khng thy ti mt sau 4 gi _ Khng s dng cho bnh nhn nn i, vng da, suy gan 20. HIDA SCAN 21. IV Cn lm sng bnh l ngmt CT-scan: _ Gi tr chn on bnh l si ng mt tngng hay thp hn siu m, v mt si v dchmt gn ging nhau trn CT-scan tr trng hpsi vi ha nhiu _ Pht hin si ng mt v ti mt vi nhy55% - 65% _ Tuy nhin CT u im hn trong vic pht hin vtr v nguyn nhn tc mt ngoi gan v l mt cngc rt c gi tr trong chn on cc bnh l ngmt c lin quan n u: u gan, u ty, abscess ganhay bnh nhu m gan ( x ha ng mt ) 22. CT-Scan 23. IV Cn lm sng bnh l ngmt Chp hnh ng mt (Cholangiography ): MRC, CTc, ERCP, PTC _ L phng php chnh xc nht v nhy nht nh gi gii phu ng mt trong v ngoi gan,nh gi chnh xc v tr v nguyn nhn bnh lng mt _ MRC: khng xm ln v cung cp thng tin chnhxc gii phu ng mt. Khng cn cn quang vmt mt/nc l phase-contrasted _ CT cholangiography: khng xm ln, thuc cnquang truyn TM bi tit vo ng mt 24. IV Cn lm sng bnh l ng mt Chp hnh ng mt (Cholangiography ): _ERCP(endoscopicretrogradecholangiopancreatography): c gi tr nht trongchn on cc bnh l c tnh ng mt ng mtv si ng mt, quan st c on xa ng mtch v tc nghn vng nh, sinh thit m, iu trtm b bng stent trn bnh nhn tc mt hon tonkhng th phu thut. Tuy nhin, ERCP khng cungcp thng tin v kch thc u, mc xm ln, di cn _ PTC (percutaneous transhepatic cholangiography):tc mt on gn hay trn nhng bnh nhn khngth thc hin ERCP, thng qua PTC c th tcatheter ng mt gii p hay lm cc mc giiphu trong m, nong ng mt khng phu thut 25. ERCP 26. ERCP 27. ERCP 28. EUS 29. PTC 30. IV Cn lm sng bnh l ng mt Cc xt nghim sinh ha mu:Bilirubin ton phn trc tip gin tipALT, ASTALPMarker K : CA 19.9, CEACTM: WBC, Neu, ng mu: APTT, PT, INR 31. IV Cn lm sng bnh l ng mt Vi khun hc: 32. Khng sinh d phng nn thc hin trn cc bnhnhn m phin ng mt, cc th thut trn ngmt ( ERCP, PTC ) Trn bnh nhn nguy c thp nh m ni soi ct timt v cn au qun mt hay vim ti mt mn ->khng cn dng khng sinh d phng Trn bnh nhn nguy c cao: ln tui, vim ti mtcp gn, c kh nng chuyn m m -> Cephalosporinth h 1 ( Cephazolin ) liu duy nht Bnh nhn nhim trng ng mt hay vim ti mtcp -> khng sinh iu tr 33. 1. Yu t nguy c Bo ph Gim cn nhanh C thai Sanh nhiu N Tin cn gia nh 1 th h Thuc: ceftriaxone, nui n ng tnh mch ton phn,estrogen sau mn kinh Chng tc: Native American (Pima Indian), Scandinavian Bnh hi trng, m ct hay bypass Ln tui ( > 40t )Adapted from Bellows CF, Berger DH, Crass RA: Management of gallstones. AmFam Physician 72:637-642, 2005 34. 2. C ch bnh sinh: si cholesterol 3 giai on: 1. S bo haqu mccholesterol/mt 2. Thnh lptinh thnhn 3. Hnh thnhsi Theo Nguyn Tn Cng 1997: 40% 35. 2. C ch bnh sinh: si sc t Si sc t en: sm mu, cng, cu to bicalcium bilirubinate, calcium phosphate,calcium carbonate, gp trong ri lon tnhuyt, x gan, ct hi trng, t lin quannhim trng Si sc t nu: mm hn, lin quan n tnhtrng mt v nhim trng ( c bit lKlebsiella ), cu to bi thn t bo vi khun,calcium bilirubinate v calcium palmitate 36. 2. C ch bnh sinh: Vim ti mt cp th sung huyt hay xut tit Vim ti mt mng m Vim ti mt cp th hoi th _ Thm mt phc mc _ Vim phc mc mt _ m qunh ti mt 37. 3. Lm sng Si ti mt khng triu chng Si ti mt c triu chng Si ti mt c bin chng 38. Si ti mt khng triu chng Pht hin tnh c khi lm cc xt nghim chn onhnh nh thng quy hay trong phu thut vng bngv cc nguyn nhn khc Khng c cn au qun mt Khng c ch nh ct ti mt phng nga trong huht cc trng hp v 10,000 bn si ti mt khngtriu chng theo di trong 10 nm ch c 200 bn xuthin cc bin chng cp tnh v 5 bn t vong, 100 bnxut hin vim ty cp v 10 bn t vong -> t vongchung 15 bn. Trong phu thut 10,000 trng hp,10-50 trng hp t vong do cc bin chng phuthut ( WGO practice guidelines 2010 ) 39. Si ti mt khng triu chng Ngoi l: bn c ti mt s nn ct ti mtnga nguy c c tnh, si ti mt c ngknh >= 3cm v nguy c ha c cao gp 10 ln( JAMA 1983; 250:2323 ), polyp c ng knh>= 1.5 cm c 46-70% kh nng ung th. i tho ng, chn thng ty sng,thiu mu hng cu hnh lim khng c chnh ct ti mt nu khng c triu chng 40. Si ti mt c triu chng Triu chng lm sng + hnh nh hc LS: cn au qun mt, thng khng vng da do sichn vo ng ti mt nu khng c vim nhim, nuc vng da nn ngh n nguyn nhn khc Khm lm sng v xt nghim chc nng gan bnhthng Siu m bng: khi echo c bng lng, t khi dy thnhti mt hay cc du hiu khc ca vim ti mt cp,kim tra du hiu dn ng mt ch pht hin si Trong mt s trng hp, bnh nhn c cn auqun mt in hnh nhng siu m khng c hnh nhsi ch c bn mt ( sludge ) -> nu bn mt pht hin> 2 ln -> c ch nh ct ti mt 41. Si ti mt c triu chng iu tr: m ni soi hay m m ct ti mtchng trnh Trnh ch n nhiu cht bo v ba n lntrong lc ch phu thut Bnh nhn i tho ng nn c m smhn Ph n c thai iu tr bng ch n khngp ng c th m ni soi tam c nguyt th 2 M ni soi: 90% sau m khng cn triu chng 42. Si ti mt c triu chng: m NS _ u: gim triu chng v loi b nguyn nhn, t au, t mt mu, thi gian nm vin ngn, thm m _ T l bin chng v t vong tng ng PT ct ti mt kinh in _ Chng ch nh: ri lon ng mu, bnh gan giai on cui, suy tim sung huyt, bnh phi tc nghn mn tnh nng _ T l chuyn m h 5% ( khng c vim cp ) 43. Si ti mt c triu chng: m NS 44. Si ti mt c triu chng: m NS 45. Si ti mt c triu chng: m NS Chp hnh ng mt trong m_ Ch nh:+ Tng men gan trc m ( ALT, AST, ALP, Bilirubin )+ Cu trc gii phu khng r khi ni soi bc tch+ Nghi ng tn thng ng mt lc m+ Dn ng mt ch/hnh nh hc trc m+ Vng da+ ng mt ch dn ln vi si nh+ ERCP cho si ng mt tht bi trc m 46. IOC 47. Si ti mt c triu chng: mm Ch nh: _ Bnh tim phi nng _ Nghi ng/ bit ung th ti mt _ X gan v tng p tnh mch ca _ Tam c nguyt th 3 thai k _ Thc hin cc th thut phi hp 48. Si ti mt c bin chng Vim ti mt cp, emphysematous cholecystitisHoi t ti mt, thm mt phc mc, vim phc mc mt LS: au bng lin tc vng h sn (P), thi gian ko dihn cc cn au qun mt trc , st, bun nn nn. Khm: phn ng phc mc, khng thnh bng vngdi sn (P) -> au + khng lan ta khp bng, cocng thnh bng, c th s thy ti mt, du Murphy (+).Vng da c th xut hin do si ng mt ch hay tc nghnng mt ch do chn p bn ngoi t si ti mt tiHartmanns pouch vim nhim ( hi chng Mirizzi ) Cn lm sng: BC tng, bilirubin c th tng nh, amylase ALT AST ALP c th tng t Siu m bng: phng tin hiu qu nht, nhy 85%v c hiu 95%: dy thnh ti mt ( > 4mm ), t dchquanh ti mt, ti mt cng, si kt, du Murphy siu m 49. Si ti mt c bin chngVIM TI MTCP/SIU M 50. Si ti mt c bin chng : X tr Nhn n v t ng sode mi d dy Truyn dch bng ng truyn tnh mch Khng sinh ng tnh mch:Piperacillin/tazobactam 3.375g mi 6 gi,Meropenem 1g mi 8 gi. Theo di st tnh trng bnh nhn: theo di CTMmi 6 gi, o nhit mi 2 gi, khm bng mi2-3 gi a s bnh nhn s ci thin. Nu khng cithin: i khng sinh, m ct ti mt, dn lu timt iu tr chnh: m ct ti mt 51. Si ti mt c bin chng : X tr M ct ti mt ni soi: nn thc hin sm trong vng 48gi sau xut hin triu chng v hi sc n nh ( ti mtbt vim nhim ), v kh nng chuyn sang m m caohn ( 30% ) nu m trong tnh trng vim cp Nn chuyn sang m m nu tnh trng vim lm cn trs quan st cc cu trc quan trng Yu t tin lng chuyn m m: tui ln, nam, bo ph,ASA III IV, thnh ti mt dy Mt s trng hp vim ti mt cp -> m ti mt, khti mt, thng ti mt -> m c