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PHC IU TR NGOI KHOA 7

M CL C PH N I. CHUYN KHOA NGO I T NG H P ............................. 1

1. Vim rut th a ............................................................................................. 2 2. S i ti mt v bi n ch ng vim ti mt ..................................................... 11 3. S i ng mt ch v bi n ch ng c p tnh .................................................... 17 4. p - xe rut th a ........................................................................................ 26 5. Vim phc m c .......................................................................................... 32

6. B nhtr ....................................................................................................... 39 7. Tc rutc gi i .......................................................................................... 43 8. Vim phc m c do th ng t ng rng ........................................................... 51 9. Abcess c nh hu mn ................................................................................. 57 10. R hu mn .............................................................................................. 67 11. Chnon,i u tr tcng m ch m c treo ........................................... 76

PH N II. CHUYN KHOA NGO I TI T NI U .............................. 84

12. Viembangquang ..................................................................................... 85 13. Soith ntitni u ...................................................................................... 93 14. S i ni u qu n .......................................................................................... 102

15. Viemtuyntinli t ................................................................................ 111 16. Nang th n mc ph i ............................................................................... 115 17. S i bng quang ....................................................................................... 120

18. Ti th a bng quang .............................................................................. 125

19. Tinh hon khng xu ng ......................................................................... 128

20. Gin tnh m ch th ng tinh ..................................................................... 133 21. U c bng quang ..................................................................................... 138

22. H p ni u o .......................................................................................... 148 23. Tngs n ti n li t tuy n .......................................................................... 154 24. Baoquy u rng, h p ngh tquy u ................................................... 164 25. Trn dch mng tinh hon ...................................................................... 169 26. Thn n c do cht h p khc n i b thn ni u qu n ............................ 172 27. Rbngquangm o ........................................................................... 175


28. U tuy nth ng thn ............................................................................... 177 29. Ucd ngvt ....................................................................................... 184 30. Xon tinh hon ....................................................................................... 187 31. U mo tinh hon ..................................................................................... 189

32. Ch nth ngdp nt v v tth ng c quansinhd c ngoi .............. 191 33. Ch nth ngd ngvt -v vt hang .................................................... 202 34. Ni u qu n g p khc v cht h p gy n c thn .................................. 205 35. Ch nth ngv bng quang .................................................................. 212 36. S i ni u o ............................................................................................ 216 37. Ch nth ngd ngvt-v vt hang ..................................................... 220 38. Ch nth ngvv tth ngkhngxcnh c a thn ........................... 223 39. U c t bo thn ...................................................................................... 230 40. i u tr s i thn ...................................................................................... 234 41. Ch nth ngc quansinhd c nam ....................................................... 238 42. Nhi m khun ng ti t ni ukhngxcnh v tr .............................. 244 43. H ng dn s d ng khng sinh trong b nh l ti t ni u ......................... 252

PH NIII.CHUYNKHOAUNGB U .................................... 261 44. B nh u lympho hodgkin ......................................................................... 262

45. B u nhn tuy n gip ............................................................................ 271 46. Ung th gannguynpht ....................................................................... 277 47. Ungth bngquang ............................................................................... 287 48. Ungth bu ng tr ng .............................................................................. 296 49. Ungth tuy n gip ................................................................................. 305 50. Ungth ph i khng ph i t bo nh ...................................................... 314 51. Ungth ph i t bo nh ......................................................................... 337 52. Ungth thc qu n .................................................................................. 344 53. Ungth trc trng .................................................................................. 352 54. Ungth d dy ....................................................................................... 365 55. Ungth i trng ................................................................................... 376 56. Ungth v .............................................................................................. 387


PH NIV.PHC I U TR CHUYN KHOA CH NTH NG CH NH HNH B NG .......................................................................... 407

Chi trn ....................................................................................................... 408

57. Gyx ngn ....................................................................................... 408 58. V o c .................................................................................................... 409

59. Trt kh p cng vai n ....................................................................... 410 60. Kh p gi x ngn ............................................................................. 411 61. Vimx ng cnh tay ............................................................................. 412 62. Kh p gi x ngcnhtay ....................................................................... 413 63. Gy trn l i c u cnh tay ....................................................................... 414

64. Gy trt c x ngcnhtay .................................................................... 415 65. Gythnx ngcnhtayph c t p ........................................................ 416 66. Gythnx ngcnhtaycli t TK quay ............................................. 418 67. Gy h lin l i c ux ngcnhtay ....................................................... 419 68. Gy h III thnx ngcnhtay ........................................................ 420 69. Gy h II thnx ngcnhtay ......................................................... 421 70. Gy c gi i phuvx ngcnhtay ...................................................... 422 71. Gy l i c ungoix ngcnhtay ......................................................... 423 72. V o khuu .............................................................................................. 424 73. Gythnx ngcnhtay ....................................................................... 425 74. Gy lin l i c u cnh tay ........................................................................ 426

75. V tth ngbntayph c t p .................................................................. 427 76. Vim t y bn tay k c vim bao ho t dch ........................................... 428 77. V tth ngbntayt nth nggng p................................................. 429 78. V tth ngbntayt nth nggndui ............................................... 431 79. T nth nggng p vng c m (vng II) ............................................ 432 80. T nth nggng p di ngn I .............................................................. 434 81. T nth nggng p c a c tay v c ng tay .......................................... 435 82. T n th nggng p bn c tay ........................................................... 436 83. T nth nggndui di ngn I............................................................. 437 84. L ch tr csaugy ud ix ngquay ................................................ 438


85. V tth ngc t ngn v t bn ngn tay .............................................. 440 86. X ng t bn ngn tay ......................................................................... 441 87. Gy trt kh p c tay ............................................................................... 442 88. Gy ph c t pmomkhuu ...................................................................... 444 89. Gy ni kh px ngkh p ngn tay ...................................................... 445 90. V tth ngc t c tay ............................................................................. 446 91. Gy h thnhaix ngc ng tay ........................................................... 447 92. Gy ud iq ngquay ...................................................................... 448 93. Gyiquay .......................................................................................... 450 94. Hi ch ng ng c tay ............................................................................. 451 95. Gy monteggia ....................................................................................... 452

96. V tth ngc t c ng tay, cnh tay .......................................................... 453 97. T nth nggng p vng I, III, IV, V ................................................... 454 98. T nth nggndui c ng v bn ngn tay ........................................... 455 99. V tth ngc t c ng tay ......................................................................... 456 100. B nh de quer vain v ngn tay c sng ............................................... 457

101. D tt dnh ngn b ngvd i 2 ngn tay ............................................ 459 102. Phc i u tr gyx ngchu .......................................................... 460 103. Gy c x ngi .............................................................................. 469 104. Gyx ngvnglinm u chuy nx ngi ...................................... 475 105. Gythnx ngi .............................................................................. 479 106. Gy u d ix ngi ...................................................................... 485 107. Cc t nth ngvngkh p hng .......................................................... 490 108. B ng ..................................................................................................... 496

109. Gyx ngbnhch ............................................................................ 500 110. T nth ngdychngcheosau ........................................................... 504 111. T nth ngdychngcheotr c ....................................................... 506 112. Phc i u tr thoi ha kh p g i ..................................................... 509 113. Gy mm chy ...................................................................................... 514

114. Chn p khoang c p tnh ...................................................................... 518

115. Gyhaix ngc ng chn ..................................................................... 521


116. Gyx ngbnchnvngnchn ...................................................... 525 117. D tt bmsinhc quanvnng ....................................................... 529 118. Kh p gi ............................................................................................... 535

119. Khuy t h ng ph n m m ....................................................................... 538

120. Mng qu p ........................................................................................... 541

121. U nang bao ho t dch ........................................................................... 543 122. Phc chnonvi u tr gyx ngh ....................................... 546 123. Gyx ngvngc chn, gy hai mt c ............................................ 551

PH N V. CHUYN KHOA PH U THU T TH N KINH- C T S NG ..................................................................................................... 556

124. Ch nth ngs no n ng..................................................................... 557 125. Ch nth ngs nonguyc th p ....................................................... 569 126. Mu t d i mng c ng m n tnh ........................................................ 576 127. Mu t ngoi mng c ng ..................................................................... 582

128. Mu t trong no .................................................................................. 588

129. V tth ngs no h ........................................................................... 593 130. p-xe no ............................................................................................. 601

131. Phc i u tr no ng th y .............................................................. 609 132. Phc i u tr tngplc ni s ....................................................... 615 133. Phc i u tr khuy t s .................................................................... 621 134. D dch no t y sau ch nth ng ........................................................ 626 135. Vim mng no do vi trng sau phu thut s no& ch nth ngs no

................................................................................................................. 632

136. D d ngngtnhm ch no ................................................................ 638 137. U tuy n yn .......................................................................................... 646

138. X phu Gamma knifetrongi u tr cc u vng sn s ...................... 651 139. Phc chnonvi u tr d d ngngtnhm ch no : avm ...... 657 140. Phc i u tr cavernoma .................................................................. 663 141. Phc i u tr xu t huy td i nh n t pht do v ti phnh m ch mu

no ........................................................................................................... 668

142. U dy th n kinh VIII ............................................................................ 678


143. U mng no .......................................................................................... 683

144. U sao bo .............................................................................................. 690

145. H p ng s ng tht l ng ........................................................................ 696 146. Tr t t s ng ...................................................................................... 703 147. Phc i u tr aul ng nhng b nh nhn x p t s ng b ng phu

thut t o hnh thn s ng...710 148. Tim phong b th n kinh chnonnguynnhnb nhlauCSTL

m n tnh ................................................................................................... 714

149. i u tr vim thn s nga m .......................................................... 722 150. Ch nth ngct s ng v t y s ng c .................................................. 727 151. Cc t nth ngct s ng c .................................................................. 731 152. D tt gai s ng ch i .......................................................................... 742 153. Lao ct s ng ......................................................................................... 746 154. Thot v a m c .............................................................................. 752 155. Thot v a m thtl ng ................................................................... 758 156. Phc i u tr co git n a m t ........................................................... 765 157. Phc i u tr u ct s ng, tu s ng ................................................... 769 158. Phc i u tr audyV ................................................................... 774 159. X tr t nth ngm ng th n kinh cnh tay ......................................... 779 160. Ch nth ngct s ngl ng- thtl ng ................................................ 789 161. Hi ch ng ng c tay ........................................................................... 798


1

PH NI.PHC I UTR

CHUYN KHOA NGO IT NGH P


2

VIMRU TTH A

I. IC NG 1.1Khini m

Vimrutth almtc pc ungo ikhoavth nglnguynnhngy

aub ngc p c tr emvng itr ngthnhd i50tu i.B nhth ngxu t

hi n tu it 20 n30.

Tuy ngy cng c nhi u xt nghi mm i chn on vim rut th a

nh ngtl khngchnon cvn m c15-15,3%.Tl nycaoh n n

gi i.

C kho ng 14 lo i vi khun gy vim rut th a, a ph n l Escherichia

coli v Bacteroidesyragilis.Vvy,ngoiphu thutct rut th a (m hayni

soi) l i u tr chun, s d ng khng sinh d phng lm gi m tnh tr ng

nhi mtrngv tm vapxetrong b ngv iVRTc pch acbi nch ngv

khngsinhi utrchoVRTc pcbi nch ng(ho it ,pxeRT,vimphc

m cRT)lc nthi t.

ph ncthai,nguyc sythaisaum rutth al4%.

1.2.D cht h cvsinhb nhh c Minmckho ng250.000cavimrutth a Mv itl nam: nl

1,4:1.Nguyc bvimrutth atnh t1l ntrong i nam vnl nl tl

8,6%v6,7%.Tl vimrutth aminml10/10.000.

Chnonvimrutth akhkhndolinquan nnhngc quanxung

quanhrutth ak c nam v nvccvtrkhcnhauc arutth a.

Ngu ng cc arutth alt manhtrng,cchphad ivalveh imanhtrng

kho ng3cm.Rutth aditrungbnhkho ng8-10cm,ikhidit i25cm.


3

Cc v tr c a rut th a: qu t ng c saumanh trng, d imanh trng,

trongti ukhung,tr ch itrng,sauh itrng...

Stctronglngrutth alnguynnhnch y ugyvimrutth a.

Qutrnhdi nti nb nhchialm5giaio n:(1)tclngrutth agycng

lngrut,(2)gyti tT8-T10th nkinht ngdn naub ng vngth ngv

kodit 4-6gi ,(3)plctronglngruttngdn ntngplctronglng

m ch thnhrutth a a ntcngh nm chmuvthi umunuim,(4)

sthi umunuidn nph n ngvimvxm nhpvikhunvothnhrut

th a,(5)ph n ngvimvxmnhpvi trngxuynqua thnh rutgyvim

phcm cthnhvaukhutr %d iph i.

Th igiandi nraqutrnhnycth thay i.Mts nghinc uchol

th igian trungbnhdn nho i t l46-71gi .Tuynhina s ng l

80%rutth av sau48gi au.

Mts th khclvimrutth atipht,vimrutth abnc p,vim

rutth am ntnh.

1.3.Nguynnhngyb nh Tcngh n lngrutth a(60%)do:

- S iphnmnhnc acchns iny l ccs ix c a n, lgiuna,

giun kim, sn dy, l carcinoma, carcinoid.

- Cngcth lcch chb chhuy ttngs ntoln(nguynphthayth pht

t mtngu nnhi m, cbi t tr em).

- Tcngh ncndochnpt ngoi,xonv n,bgp.

Th ngt nvimcth bt ut mtchlotnimm c.

II.CH NON 2.1.Ch nonxc nh 2.1.1. Tri uch ngc nng - Tri uch ngg i:audi chuy n t th ngvhayquanh r n sng h chu

ph i,xu thi naukhu tr h chuph i,au tr c, saunn,b nhnhn

th yng im tm i,s t.


4

- Tri uch ngkhngg i:khngau h chuph i,cti ns autr c(k c vimrutth atiphtcngkhngnghchnonc pc uchob nhnhn.

2.1.2. Tri uch ngtonthn - S t t 37,5 - 38C.Trongtr ngh ps tcaoh n,c nph inghv tmcc

nguyn nhn khc

- Hich ngnhi mkhun:v m th chc,mikh,l ibn.

2.1.3. Tri uch ngth cth - Ph n ngthnhb ng:khmnh nhngvngh chuph ith yc thnhb ng

vngnycngh nnhngvngkhcc a b ng.Cng nsuxu ng,c mgic

coc cngtng,b nhnhnauph inhnm thay ytayth ythu cra.

+ Tri uch ng nau i mMc-Bumey,ngoiramts i mkhcnh i m Lanz,Cladolnhngd uch ngban u,saudi nti nquacph n ngdi, khngthnhb ng,coc ngthnhb ngnh vcoc ngthnhb ngddi.

+ D uhi ucothtl ngchu,d uc bt,Rovsing,tngc mgicdavngb ng. - Thmtrctrnghaythmm o ph nth ythnhph itrctrnghayb ph iticngm oau. 2.1.2. C nlmsng - Cnlmsngdngtrongchnonxcnh:

+ Cngth cmu

+ Sium:hnh nhvimrut th atrnsiuml rut th a nkhngx p

v i ngknh> 6mm.Ngoi ra lhnh nh tngm, tham nhi mm xung

quanh(d uc aph n ngvim)v apxe.

Siumllachn utintrongchnonvimrutth a.

+ CTscan:hnh nhvim rut th a l (1) tng ngknhngangc a rut

th a>6mm,(2)thnhrut th ady>2mm,(3)s iphn(30%),(4)d uph n

ngvi mxungquanh(tham nhi mm ,cokeom ctreo,dchquanhrutth a).

CT cchnhkhilmsngvsiumg pkhkhntrongchnon.


5

+ MRI:th ng cs d ngchocctr ngh pVRTkhchnon thai

ph hayng ich ngchnhch pCTb ng(nh yl100%v chi ul

98%).

- Xtnghi mdng trong ch non ccb nhkm theovph cv ph uthu t

+ Xt nghi m sinh ha: glucose, ure, creatinine, i n gi i , GOT, GPT,

protein, albumin

+ ngmuc b n:PT,APTT,much y,Fibrinogen

+ Xquangngcth ng

+ i ntim(trongtr ngh pcnghing b nhltimm ch)

+ Tytr ngh pc th cth cccchnhcnlmsngc th khc.

2.2.Th lmsng 2.2.3Th theol atu i 2.2.3.1Vimru tth atr em - Vimrutth a l atu inhnhi:r thi mg p,chnonth ngkhkhn,

th ng munkhivimphcm c

- Vimrutth a tr 2-5tu i:nhngtri uch ngnh s t,ach ynn,tr ntrc

qu ykhc,cochnbnph ig pvob ng,b ngch nglanhngd uhi ur t

hayg ptrongvimrutth a.Thmtrctrngmtcchnh nhngth ythnh

ph itrctrngaur tcgitrchnon.

2.2.3.2Vimru tth a ph n cthai Trong 6 thng u c a th i k thai nghn, tri u ch ng vim rut th a

kh ngcnhi ukhcbi tsov iph nbnhth ng.Trong3thngcu it cung

toymanhtrnglncaovxoayngoinni mauc arutth ab yln

caovl chrasaul ng.

2.2.3.3Vimru tth a ng igi Cctri uch ngauchnn,bu n nn,r tth ngg p ng iginh ng

t r m rh n.Ph n ng thnhb ng ng igi r tkno,hayg pch ng

b ng,nhi utr ngh pkhngcs t.


6

2.2.4Theoti ntri n 2.2.4.1Vimru tth ath nhi m c B nhnhns tcao39-40,m chnhanh nh ,th nng,t thuy tp, u

chitml nh.B ngch ngnh ,nnb ngaukhngr,khngrph n ng.Th

nyc n cm s m,k th pi utrkhngsinhli ucao,h is ctchcc.

2.2.4.2Vimru tth ath t cru t Hay g p ng i gi, b nh di n bi n chm, b nh nhn c d u hi u au

b ngc nkmtheos t,x-quangb ngth ycquairutgin,m cn cvh i

h chuph ihayti ukhung.

2.2.4.3Vimru tth adolao 2.2.4.4Vimru tth adoksinhtrng 2.3Ch nonphnbi t 2.3.1V iccnguynnhnkhctrong b ng - Th ng lotd dyttrng

- Vimtimtc p

- Vimt yc p

- Vimtith ameckel,vimh chm ctreovimrut tr em

- Vimph nph ,ch angoit cungv ,v nanghongth ,xonunangbu ng

tr ng ph n

- U manh trngvtcrut ng igi

2.3.2Ccb nhldoti tni u - C nauqu nthnhayvim ngti tni u

- Vimc ichubnph i

2.3.3M ts b nhln ikhoa Vimthyd iph iph i,mts tr ngh ps tviruscth gyauh

chuph i

III.I U TR 3.1i utr n ikhoa tr cm - B iph n cvi ngi is d ngccdungdch ngtr ng(Natriclorid0,9


7

%,Glucose5%,Ringerlactat)

- Dng khng sinh :

+ Chnkhngsinhcph khngkhuntrnvikhunGram mvkkh.

+ Cephlosporin th h 2, 3 (Cefotetan, Cefoxitin, Cefuroxim, Ceftriaxone,

Ceftazidim )

+ Cc Penicillin (ampicillin, piperacillin, ticarcillin)k th pv iccch t c

ch beta-lactamase (Clavulanat, Sulbactam, Tazobactam)cngth ng cs

d ng ntr.

+ nhngng id ngv iPenicillinthCarbapenemllachnt t.

+ Aminoglycoside s d ngtrongi u trvikhunGram (-)nh ngkhiph i

h pv iPenicillins lmtngctnhnnth ngt clachn.

+ Ph ih pkhngsinhdi tvikhuny mkhlc nthi t,nh tlkhiVRTc

bi nch ngpxehayvimphcm crutth a.

+ Trongtr ngh pn ng,phnt ngb nhnhntheoy ut nguyc chn

khngsinhthchh p.

Nhm

b nhnhn ntrli u atrli u

Ng i

tr ngthnh

Cefoxitin, Ertapenem,

Moxifloxacin, Tigecyclin

ho cTicarcillin - Clavulanic

acid

Metronidazolk th pv i

Cephazolin, Ceturoxim,

Ceftriaxon, Ceotaxim,

Ciprofloxacinho cLevoloxacin

Bnh nhn

cnhi uy u

t nguyc

knipenem-cilastatin,

Meropenem,Doripenemho c

Piperacillin-tazobactam

Metronidazolk th pv iCefepim,

Ceftazidim, Ciprofloxacinho c

Levofloxacin

- Gi mau:r th nch chnhkhicnangtheodivchnhm ch ar

rng.Khib nhnhnaunhi uvcchnhm ,dngthu cgi maucho

b nhnhntym cau(diclofenac,paracetamol,dolargan)

3.2.Ph uthu t


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- H uh tcctr ngh pk c rutth acbi nch ng ucth chnhm

nisoictrutth a,laur a b ng.Chnh tdnl utytnhtr ngb ngv

tinl ngc aphuthutvin.

* Chnhm m trongcctr ngh p

- Phuthutnisoig pkhkhnphtsinhtrongm

- S om ct ngd i b ngtinl ngdnhnhi u

- Ch ngchnhb mh i b ng:

+ B nhnhncb nhltimph in ng

+ B nhnhngiy u,suyki t

3.3.i utr saum *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan

- Cc lo idungdch ng tr ngv,dungdchkeo(c th tncc lo idung

dch).

- Ccch ti ngi i

- S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,p

lcTMTTvs l ngn cti u/gi ...

*Dinhd ngsaum

- Cc dung dch nui d ng ng tnhm ch saum : ( ng, m,m ...)

trongnhngngy usaum davotontr ngb nhnhn,xtnghi mprotein,

LDH,HDH...saum

- Nhng tr ng h p vim rut th a c p, ho c vim rut th am c th cho

b nhnhn n s m saum .Nhng tr ngh pvimphcm cho ckhiphu

thutvintinl ngsaum cnguyc bi nch ng,cth cho b nhnhnn

khictrungti nho ctheoyl nhc aphuthutvin.

*S d ngkhngsinh:theokhngsinh (n uc).Ph thuctnhtr ngng i

b nh. Cc nhm hay dng: cefalosporin, nhm carbapenem, quinolon,

imidazon...K th pkhngsinhtrongcc tr ngh pvimphcm cho ctin

l ngb nhnhncnguyc bbi nch ngsaum .


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*Ccthu cgi mau:tytnhtr ngng ib nhvm cau(cclo ithu c

th ngdng:diclofenac,paracetamol, morphin, dolacgan, nospa...)

*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h

p...

- Lmccxtnghi msaum i utr,theodicctaibi n,bi nch ng:

Ccxtnghi mhuy thc:cngth cmu,ngmutrongtr ngh pm tmu

ho cnghing ch ymu

Ccxtnghi msinhhamu,nhgich cnngganthnvtnhtr ngdinh

d ng: Glucose, Ure, Creatinin, GOT, GPT, Protein ton ph n, Albumin,

G...khinghing cd uhi ubi nlo n.

Chnonhnh nh:sium,Xquang,ctl pvitnhtythuctnhtr ngdi n

bi nhu phu.

- Ch chmscsaum :

+ T ich:thaybngv tm ,dnl u,

+ Tonthn:v sinhcnhn,ngvinan ing ib nh...

+ Vnngs msaum

+ Vrung

- Ch dinhd ng

Tiuchu nravi n - Tonthn:tnhto,khngs t,huy tng n,nu ng c,

- T ich:v tm li nt t

- Ti khm sau 1 thng.

IV.BI NCH NGSAUM - Ch ymusaum

- Abcessthnhb nglbi nch ngth ngg pnh t.Tl tngd nlntheogiai

o nb nh,vi cs d ngkhngsinhdphnglmgi mtl abcessthnhb ng

- Vimphcm csaum :nguynnhnlm mrutth a,b cm mrutth at

khidotutchbucmch y ulqutrnhho it donhi mkhunt rutth a

lan sng ymanhtrng.C nph im l is mvh is ctchccsaum .


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- Vimphcm ckhutr(abcesst nd trong b ng):nguynnhnldob c

g crutth aho cdolaum b ngch as ch

- R manh trng

- Tcrutsaum :cth xu thi ns msaum ho cxanhi unmsaum .Tc

ruts mth nglinquan n nhimkhuntrong b ng,tcrutxasaum

ladodych ngho cdnhruthnhthnhsaum .

- AbcessticngDouglas:Th ng g psaum vimphcm c,dolaub ngv

dnl ukhngt t.Phthi n cqungngyth 5saum :S t,auh vkm

c cc tri u ch ng kch thch trc trng ho c bng quang nh mt r n v a

nhi u l n rami nhy, i rt,...thm trc trng th y c kh i ph ng thnh

tr ctrctrngcngau,siumgipxcnhkh iabcs.X tr:Khngsinh

ton thn, th tn c mhumn,..sauvingys trchthom abces qua

ngtrctrng(trchdnl ungoiphcm c).

TILI UTHAM KH O: 1. B nhhcngo ikhoa,tr ng ihcyHNi

2. B nhhcngo ikhoasau ihc,tr ng ihcyHNi

3. C pc ungo ikhoa,tr ng ihcyHNi


11

S ITIM TVBI NCH NGVIMTIM T

I. IC NG: 1. Khini m

Ti mt c nhi m v l u gi mt - ch t l ng c s n xu t b i gan g m c

nhi u thnh ph n nh : cholesterol, bilirubin (sc t mt) v mu i mt Trong

ba n, ti mt co bp a dch mt vo rut non, h tr tiu ha ch t bo.

S i ti mt c hnh thnh khi c s lng ng, k t t c a cc thnh ph n

trong dch mt, c kch th c dao ng t vi mm n vi cm.

2. Nguyn nhn

S i ti mt c hnh thnh ch y u t s k t t c a cholesterol, do m t

cn b ng c a cc thnh ph n c trong dch mt. V d nh khil ng cholesterol

trong dch mtgiatngqum c,v t qu kh nnghatanc a mu i mt hay

khil ng mu i mt gi mi s dn t i hnh thnh s i cholesterol.

Ngoi ra, cn c th g p s i sc t mt hnh thnh do s k t t c a bilirubin

trong mt s b nhnh thi u mu h ng c u li m,x gan

3. D ch t

S i ti mt l b nhth ng g p n c ta, chi m t i kho ng 8 10% dn

s .Ban u, nhng tri u ch ng c a s i c th r tm h vth ng ch pht hi n

tnh c quathmkhms c kh enh k, ho c khi s igyrabi n ch ng

II. CH NON 1. Lm sng

a)C nng:

- auvngHSP, ckhikhngau chphthi nb nh tnhc khi siu m

b ng


12

- Cbi uhi nnhi mtrngtrongtr ngh pcvimtimtnh s t,mikh,

l ibn

- Khngcbi uhi nvngda,vngmttr tr ngh pcb nhlkmtheonh

s iOMC,vimgan,x gan,ho cs ik tc timt.

- Mts tr ngh pcth gyvimtuc pdos itimt.

b)Ton thn:

- Cth khng nhh ngt itonthnho c nhh ngrr ttrongTr ngh p

timtvim,ho it .

c)Thcth :

- Thmkhmb ngcth bnhth ng iv is itimt

- Khicvimtimts th ytimtto,auvcph n ngthnhb ngvngh

s nph i.Nghi mphpMurphy(+).Khitimtho it cth gyvimphc

m c.

2. C nlmsng:

Cc xt nghi m dng trong ch nonxc nh - Sium b ng:Th ngsium2l nc a2bcssiumkhcnhau trong

tr ngh ps i ngmtch nthu n.

- Ch pCT-Scanner:dng trong tr ngh pnghics i ngmt ch , s i trn

ganho ct nth ngkhckmtheo

Cc xt nghi mdng cho tin l ng, theo di, i u tr v ph c v ph u thu t

- XN mu: T ng phn tch t bo mu, ng mu ( prothrombin, APTT,

Fibrinogen),much y,Coc cmu,HbsAg,antiHCV,antiHIV

- Sinh ha mu: Glucose, Ure, Creatinin,GOT, GPT, Bilirubin ton ph n,

Billirubintrcti p,Proteintonph n,Albumin,G,Amylase, Lipase

- SHn cti u

- Xqtimph ith ng

- i ntm



13

3.Ch nonphnbi t *C nauqu ngan

*C naub ngdolotd dy ttrng:Nisoid dyxcnhchnon

*Vimrutth a:Khicvimtimt ng igid chnonnh m

*Ugan:ch pCT b ngxcnhchnon

III. I UTR : 1. i utr n ikhoa Ch nh - S itimt nthu n:N ub nhnhncc nau,nkm,nnc nchothu c

gi mau,ginc vtruy ndch

- Khi c vim timt,i utrnikhoatr cm

i utr c th *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan

- Cc lo idungdch ngtr ngv,dungdchkeo(Glucose5%,10%,20%;

Natriclorid 0,9 %).

- Ccch ti ngi i(Kali,Calci,Magie)



- i uchnhsthi uh tn cvi ngi idavoi ngi i

*S d ngkhngsinh:ph thuctnhtr ngng ib nh,dngcckhng sinh tc

d ngt t trn ngmtnh Sulperazolho ccckhngsinhCefalosporin th

h II,III,IV;nhmQuinolon,CarpapenemTr ngh pcnhi mtrngn ng,

cth ph ih p2 3lo ikhngsinh i utrchob nhnhn.

*Chothu cgi mau,ginc :tytnhtr ngng ib nhvm cau(cc

lo ithu cth ngdng:diclofenac,dolacgan,nospa...)

*i utrh mengan:dngccthu ch menganchob nhnhnxu ngd i

100U/llt tnh tkhichunbm .

*Trongtr ngh pb nhnhncbi nch ngvimt y:Dngccthu cgi m

ti tnh (ccthu c cch H1,ch nknhH+,), tsonded dy.


14


p...

2. i utr ngo ikhoa - Ph nl ncctr ngh p cm nisoicttimt

- Chnhm m khi:

+ Cs om ct ngtrn b ng,tinl ngdnhnhi u

+ Phuthutnisoig pkhkhn

3. i utr sauph uthu t: *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan


dch).

- Ccch ti ngi i



*Dinhd ngsaum



LDH,HDH...saum .Nhngtr ngh pm nisoicttimtcth chob nh

nhnns msaum .



imidazon...




p...



ho cnghing ch ymu


15




Chnonhnh nh:sium,Xquang, ctl pvitnhtythuctnhtr ngdi n

bi nhuphu.

- Ch chmscsaum :



+ Vnngs msaum

+ Vrung

- Ch dinhd ng

Tiuchu nravi n - Ton thn:tnhto,khngs t,huy tng n,nu ng c,



IV.TAIBI NVBI NCH NG 1. Cc tai bi n trong m v x tr :

- T n th ngcc thnhph n cu ng gan ( ng mt ch , ng gan ph i,ng

m ch gan...). X tr:khu ng mt; khu m ch mu; n i ng mt v i rut

- T nth ng itrngngang,ttrng,d dy:khuph ch i ngtiuhav

dnl ud igan.

2.Ccbi nch ngsaum vx tr : - Ch ymusaum :phuthutl i c mmu

- Vim phc m cdotut ngc timt:phuthutl i c mmt,laur a

b ngvdnl u b ng

- Rmt:n urt, ngmtthngthi utrnikhoas h t.N ut nth ng

ngmtl n,dchmtrnhi uph im khuho cn icht nth ngv i

ngtiu ha.


16

- Suyki tsaum ,nhi mkhunv tm :i utrb ngkhngsinhm nh,li ucao,

t tnh ttheokhngsinh vtruy nalbumin, m,dch,i ngi i


17

S I NGM TCH VBI NCH NGC PTNH

I. IC NG:

1. nhngha - S i ng mt ch l tnh tr ng c s itrong ng mt tnh t d i h pl u2

ng gan t i bng Vater khng k n ti mt.

2. Nguyn nhn:

- Nguyn nhn t o s i do tr v nhi m khun ng mt, c bi t l vai tr

c agiuna.Nghinc u c u trc s ing i ta th y li s i c xc v tr ng giun

a.

- Thnh ph n c a s i mt n c ta ch y u l mu i mt ( calcium- bilirunate),

trongkhithnhph n s i mt ccn cph ngtyhayBc M ch y u l

cholesterol.

- St s i sau m v s i mt ti pht n c ta cn r t cao do nhi u y u t nh

nhi m trng ng mt ti di n, h p ng mt, s i trong gan... v thi u p

d ngccph ngti n pht hi n s i trong lc m .

3. D ch t

- B nhth ng g p l a tu itr ngthnhvtngtheotu i, khng c s khc

nhau nhi u gia nam v n

- Vi t Nam nguyn nhn t o s i ph i k n nhi mtrng ng mt v nhi m

ksinhtrng(giuna)(linquan n v n phng b nh).

III. CH NON 1. Lm sng:

a)C nng: - Tm ch ng Charot:

+ aub ng h s n ph i


18

+ S t: xu t hi nsauccc nauvigi (6-12 gi ) do nhi m khun ng

mt, v ic ns t rt run v v m hi .

+ Vng da

- Trongcc t tc mt c th th yng i b nhit,n c ti u smmunh

n c v i v ng a.

b) Th c th :

- Gantoth ng u v c 2 thy, mt m m,rungganau.

- Ti mt to c th r tr,ding theo nhp th ikhixu ng g n h chu ph i,

trong tr ng h p ti mt vim teo do vim nhi u l n lc nghi m php

Murphy (+).

- H s n ph i nau,ph n ng thnh b ng r

c) Ton thn:

- Tnh tr ng nhi m khun:h ith hi, s t 38-39 0 C

- c bi t c r i lo n ch cnngngmuc agannh ch ymud i da, c ng

m c do tc mt

2. C n lm sng

Cc xt nghi m dng trong ch nonxc nh - Sium b ng:Th ngsium2l nc a2bcssiumkhcnhautrong

tr ngh ps i ng mtch nthu n.

- Ch pCT-Scanner:dngtrongs i ngmttronggan,s imttiphtho c

trongnhngtr ngh pbi nch ngc as imtnh VFMmt,vimt yc pdo

s iOMC....


- XN mu: T ng phn tch t bo mu, ng mu (prothrombin, APTT,

Fibrinogen),much y, Coc cmu,HbsAg,antiHCV,antiHIV

- Sinh ha mu: Glucose, Ure, Creatinin, GOT, GPT, Bilirubin ton ph n,


- SHn cti u


19

- XQ timph ith ng

- i ntm

+Tytr ngh pc th cth cccchnhcnlmsngc th khc.

3. Ch nonphnbi t 3.1. V i cc b nh vng da khng t c m t:

- Thi u mu do tan mu t ng t

- Vim gan do virus

- Xon khun

3.2. V i cc b nh t c m t khc:

- U u t y

- U bng vater

- Unang ng mt

- Ungth ng mt

III. I U TR 1. i u tr n i khoa Ch nh - S i r t nh ng mt ch , khng tc mt, tinl ng c th t tri xu ng t

trng c

- S i trn gan, nh , khng c ch nh m

- i u tr tr c m i v i nhng b nh nhn c ch nh m

i u tr c th *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan

- Cc lo idungdch ngtr ngvdung dchkeo(Glucose5%,10%,20%;

Natriclorid 0,9 %).






20

*S d ngkhngsinh:ph thuctnhtr ngng ib nh,dngcckhngsinhtc


h II,III,IV;nhmQuinolon,CarpapenemTr ngh pcnhi mtrngn ng,

cth ph ih p2 3lo ikhngsinh i utrchob nhnhn.



*i utrh mengan:dngccthu ch menganchob nhnhnxu ngd i

100U/llt tnh tkhichunbm .

*Trongtr ngh pb nhnhncbi nch ngvimt y:Dngccthu cgi m

ti tnh (ccthu c cch H1,ch nknhH+,), tsonded dy.


p...

2. i u tr ph u thu t: a) Ph u thu t nh m m cch:

+ L y h t s i pht hi n ctrong ng mt.

+ Gi i t ahontonl uthng ng mt

b) Vi c l accph ngphpph u thu t ph thu c : + Tnh tr ng chung c a bnh nhn.

+ Tnh tr ng b nh l c a s ivth ngt n c a h th ng gan mt

+ Trnh k thut v kinh nghm c a phu thut vin v gy m h i s c

* M m OMC l y s iv t ng d nl ukehr. Trong mt s tr ng h pkhi ng mtt ng i s ch, m b o l y h t s i c

th khukn ng mt khng c n t dnl ukehr(m ng mtlt ng).

- Dn l uVolker (dn l u ng mt ch qua t trng) n unh c cht h pc

oddi:

- M c tht Oddi qua t trng.

- N i ng mt v i ng tiu ha clmkhi:th ngt n ph n th p c a


21

ng mt m khng gi i quy t c b ng m c thtOddinh :chth p ph n

th p OMC, b nh ng mt ph i h p(nang ng mt), s i ti pht nhi u l n

hay s i trong gan ph i h p...

- C hai lo i n i ng mt v i ng tiu ha: trc ti p v gin ti p:

+ Ki u trc ti p l n i ng mt (ti mt,OMC,hay ng mt trong gan)

v i t trng

+ Ki u n i gin ti p l n i ng mt (ti mt,OMC,hay ng mt trong

gan) v i t trng v i hng trng trn mt quai rut bi t lp ki u Omega hay

Roux en Y.

- Ct ti mt khi: vim ho i t , vim m hay vim teo, c s i, nghi ng ungth

ho c trong nhngtr ng h p ch ymu ng mt.

* M nhu m gan l y s i khi c s i trong gan k t h p v s igmch t vo ng m t v nh ng v tr khng th l yqua ng m t * C t gan:

- Nhi u s i ho c nhi u m khu tr v trnonh t l gan tri

- Ch ymu ng mtmkhutr c v tr ch y mu phnthyno

* L y s i ng m t ch qua m n i soi:

- L y s i ng mt ch qua nisoi:th ng sau ct ti mt nisoiquanong

ng c ti mt ho c m ng mt ch , s i c l y b ng k p gp s ihayb mr a

ng mt cho tri xu ng t trng.

- Ch nh khi s ickchth c nh v c n trang b cngnh thnhth o c a

kp m .Nongc vngOddilth thut c th c thc hi nkmtheo lm

tngkh nngs i tri xu ng t trng khi ti nhnhb mr a.

c) Bi n ch ng sau m v x tr:

* Ch y mu b ng. X tr: m l i c m mu

* R mt:

- N u r qua dnl uv i s l ng t c th i u tr ni khoa.

- N u r mt gy vim phc m c,pxed i honh: M l i c m mt

3. i u tr sau m :


22

- Theoditontr ng:M ch,nhi t,HA,nhpth ,tnhtr ng b ngvdn

l u

-Truy n m,dch,i ngi i nuid ngkhib nhnhnch a cn

+ S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,

p lcTMTTvs l ngn cti u/gi ...

+ i uchnhsthi uh tn cvi ngi idavoi ngi i

- S d ngkhngsinh:theokhngsinh (n uc).Ph thuctnhtr ngng i


imidazon...

- Chothu cgi mau,ginc :tytnhtr ngng ib nhvm cau(cc

lo ithu cth ngdng:diclofenac,paracetamol, dolacgan, nospa...)

- Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,h

p...


+ Ccxtnghi mhuy thc:cngth cmu,ngmutrongtr ngh pm t

muho cnghing ch ymu

+ Ccxtnghi msinhhamu,nhgich cnnggan,thnvtnhtr ng

dinhd ng:Glucose,Ure,Creatinin,GOT,GPT,Proteintonph n,Albumin,


+ Chnonhnh nh:sium,ctl pvitnhtythuctnhtr ngdi nbi n

huphu.

- Ch chmscsau m :

+ T ich:thaybngv tm ,dnl u,chnkehr,theodil ngdchmt,tnh

ch tdchmtraquadnl uKehr


+ Vnngs msaum

+ Vrung

- Theo di dch mt qua kehr :

+ Mu vng l bnh th ng,mu l b tth ng


23

+ S ml dch mtbnhth ngngy u tin kho ng 300-500ml/24h, khi c

trung ti n mt ph n dch mt xu ng t trng th dch mt qua kehr gi m xu ng

cn kho ng 200- 300ml/24h; t ngy th 5, 6 tr icn150- 200ml/24h.

+ C mu khng, c m khng, c bn mt ko, c s ibnkhng,xemn i

dnl ucb r dch ra hay khng.

+ Ch nh rt dnl ukehrt ngy th 15 -30 ho ch n.Cth rt khi dch

mt trong, khng c mu, m , bn mt, ch p th yl uthnghonton.Cth

k p th dnl uxemcs t,aukhng.Tr c khi rt c n ch p ng mt qua

ng dnl ukehr kh ngnh l n cu i khng cn st s i ng mt

- Dnl ud igan c rt sau 24 - 48 gi .

- Theo di cc bi n ch ngtrn x l kp th i

IV. CC BI N CH NG C P TNH C A S I NG M T CH

1. Vim ng m t c p - ng mt tr gin do s i gy tc khng hon ton, vi khun pht tri n trong

ng mtgyvim ng mt

- i u tr:

+ Dng khng sinh c ph tc d ng rng v i cc ch ng vi khun ng rut

c i kh ln y m kh, khng sinh c kh nngng m t tvo ng mt v c s

k t h p gia cc nhm

+ i u chnh r i lo nn cvi n gi i, c bi t l cc r i lo n ch cnnggan

v thn

+ Gi iphng ng mt t m th inh chc mt qua da hay m c tht oddi

qua ni soi

+ i u tr thc th m ng mt, l y s i, r a ng mtv t dnl ukehr

2. Vim m vabcees ng m t - Xu t hi n m trong ng mtv c bi t cc abcess nh tncc ng

mt nh tronggan.Th ngabcess ng mt l hu qu c avim ng mt

khng c i u tr

- i u tr:


24

+ Khng sinh ton thn

+ H i s c t t

+ M c p c u gi i quy t tc mt: m ng mt l y s i giun, r a ng mt

3. T c m t c p (s i k t oddi)

- Ton b ng mt trong v ngoi gan k c ti mt b dn c p tnh, p lc

ng mttngcaov n c mt ng mquathnh ng mt, ti mt v m t gan

vo trong b ng

- i u tr:

+ Ph i m c p c u gi iphng ng mt n u th tr ngng i b nh cho

php, m ng mt ch l y s iv tdnl uKehrho c dnl u ng mt n

thu n

+ Trong mt s tr ng h p c th chc mtquada gi m p lc ng mt

r i m sau

4. Ch ymu ng m t - Mu ch yvo trong ng mt do s thng th ngb t th ng gia cc h

th ng m ch mu trong hay ngoi gan v i ng mtth ng l trong gan.

-Trong qu trnh tc mt c vim ng mt c bi t l c cc abcess ng

mt s thngth ngmtnhnhng m ch nh v i ng mt, mu ch y vo

trong ng mt to thnh c cmungxu ngttrngng c ln d dy khi n

ng i nn ra mu hay xu ng rutingoiphnen.

- i u tr:

+ Truy n mu h i ph c kh il ng tu nhonm t.

+ Khngsinh ng mt

+ Th t tho

+ Ph i m n u tnh tr ng ch y mu khng c m

+ M ng mt ch gi i quy t tnh tr ng tc mt

+ Ct cung gan c ngu n g c ch y mu ho c thtng m ch gan

+ t ng dnl ukehr

+ Ct ti mt trong ch ymu ng mt: n u nguyn nhn t ti mt


25

5. Vim phc m c m t

- Bi u hi n bao g m hai hi ch ng : Hi ch ng vim phc m c v hi ch ng tc

mt

- i u tr: ph i m c u, x lnh mt vim phc m c, m ng mt ch l y s i

t dnl ukehr, ct ti mt n u ti mtcth ngt n v gi i quy t tnh tr ng

vimnh laur av t dnl u b ng.

6. Vim t y c p do s i ng m t - T i ph n th p c a ng mt ch c ph n chung v i ng Wirsung khi s i k t

voys t oi u ki n cho dch mt trong c vo ng t y v dch mt ho t

ha men trypsinogen thnh tripsin ngay trong lng ng t y, men ny t tiu h y

t y c p th ph n nh ngcngg p th ho i t

- i u tr: nn m s m gi i quy t tnh tr ng tc mtnh m ng mt l y s i

k t, t ng dn l ukehrhayct ti mt.

i v ith ngt n c a t y n u l vim t y c p ph n th dnl uhu cung m c

n i sau khi m bao t y, cn n u vim t y c p ch y mu th ph i l y h t ph n t y

ny t dnl u.Ph i m thng hngtrng cho b nhnhnnnhng ngy sau

m .

V. TIU CHU N RA VI N

- B nh nhn n u ng c, v t m li n t t, ch p Kehr thng t t, k p Kehr

khngau.

- Cc ch s xt nghi m trong gi i h nt ng ibnhth ng ho cbnhth ng.

- H n khm l i sau 01 thng xt rt Kehr.


26

P - XERU TTH A

I. NHNGHA Kh irut th a lhuqu saucngc ath ng thnhrut th a cphn

lo it vimtay(mqunh) np-xerutth a.Kh inybaog m:rutth a,

m cn i,rutnon, itrng...

II.CH NON 2.1.CH NONXC NH 2.1.1 Tri uch ngc nng - Tri uch ngg i:audi chuy n t th ngvhayquanh r n sng h chu

ph i,xu thi naukhu tr h chuph i,au tr c, saunn,b nhnhn

th yng im tm i,s t.Tri uch ngauth ngxu thi ntr cnhi ungy

+ Tri uch ngkhngg i:khngau h chuph i,cti ns autr c

(k c vim rut th a ti pht cng khng ngh chnon c p c u chob nh

nhn.

+ B nhnhncth i utrthu ckhngsinhho c/vch ngvimtr c

2.1.2Tri uch ngtonthn - Hich ng nhi mkhun:S t t 37,5 - 38C,v m th chc,mikh, l i

bn.

2.1.3Tri uch ngth cth - Khmb ngcth th yb ngtr ng ccm ckhcnhau

- Ph nl ns th ykh ivngh chuph ichc, nau,dingh nch

- Ph n ngthnhb ngvc m ngphcm ctyt ngtr ngh p

2.1.2C nlmsng - Cnlmsngdngtrongchnonxcnh

+ Cngth cmu


27

+ Sium:hnh nhvimrut th atrnsiuml rut th a nkhngx p

v i ngknh>6mm.Ngoi ra lhnh nh tngm, tham nhi mm xung

quanh(d uc aph n ngvim)v apxe.

+ CTscan:chnonchnhxctnhtr ngvimrut th av pxe, ng

th iphnbi t cv iccnguynnhnkhc

+ MRI:th ng cs d ngchocctr ngh pVRTkhchnon thai

ph hayng ich ngchnhch pCTb ng(nh yl100%v chi ul

98%).

Xt nghi m dng trong ch n on cc b nh km theo v ph c v ph uthu t

+ Xt nghi m sinh ha: glucose, ure, creatinine, i n gi i , GOT, GPT,

protein, albumin

+ ngmuc b n:PT,APTT,much y,Fibrinogen

+ Xquangngcth ng

+ i ntim(trongtr ngh pcnghing b nhltimm ch)


2.2.Ch nonphnbi t 2.2.1V iccnguynnhnkhctrong b ng - Th ng lotd dyttrng

- Vimtimtc p

- Vimt yc p

- Vimtith ameckel,vimh chm ctreovimrut tr em

- Vimph nph ,ch angoit cungv ,v nanghongth ,xonunangbu ng

tr ng ph n

- Umanhtrngvtcrut ng igi

2.2.2Ccb nhldoti tni u - C nauqu nthnhayvim ngti tni u

- Vimc ichubnph i

2.2.3M ts b nhln ikhoa


28

Vimthyd iph iph i,mts tr ngh ps tviruscth gyauh chu

ph i

III.I UTR 3.1.Nguynt ci utr - Ch y uli utrnikhoab ot n,vm phinctrutth asau3thng

- Chm c pc u trongcc tr ngh p pxekhngvng,nguyc v gy

vimphcm c

3.2.i utr n ikhoac th *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan


Natriclorid 0,9 %).





*S d ngkhngsinh:ph thuc tnh tr ngng ib nh,dngcckhngsinh

Cefalosporinth h II,III,IV;nhmQuinolon,Carpapenemnnph ih p2

3lo ikhngsinh i utrchob nhnhn.



*Dngccthu cch ngvim:alphachymotripsin,lydosinat


p...

3.3.i utr ngo ikhoac th 3.3.1.M c pc u - Phuthutnisoictrutth a,laur as ch b ng,dnl u

- Chuy nm m n uphuthutnisoig pkhkhnho cphtsinhb tth ng

3.3.2.M phin - Phuthutnisoictrutth a,lms ch pxen ucn,dnl u b ng


29

- Chuy nm m n uphuthutnisoig pkhkhnho cphtsinhb tth ng

3.4.i utr saum *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan


dch).

- Ccch ti ngi i



*Dinhd ngsaum



LDH,HDH...saum

- Th ii mchontytheotnhtr ngb ng,theoki nc aphuthutvin



imidazon...i utrk th pkhngsinh.



*Dngccthu cch ngvim:alphachymotripsin,lydosinat


p...



ho cnghing ch ymu





bi nhuphu.


30

- Ch chmscsaum :



+ Vnng s msaum

+ Vrung

- Ch dinhd ng

Tiuchu nravi n - Tonthn:tnhto,khngs t,huy tng n,nu ng c,



IV.BI NCH NGSAUM - Ch ymusaum

- Abcessthnhb nglbi nch ngth ngg pnh t.Tl tngd nlntheogiai

o nb nh,vi cs d ngkhngsinhdphnglmgi mtl abcessthnhb ng

- Vimphcm csaum :nguynnhnlm mrutth a,b cm mrutth at

khidotutchbucmch y ulqutrnhho it donhi mkhunt rutth a

lan sng ymanhtrng.C nph im l is mvh is ctchccsaum .

- Vimphcm ckhutr(abcesstrong b ng):nguynnhnldob cg crut

th aho cdolaum b ngch as ch

- R manh trng


ruts mth nglinquan n nhimkhuntrong b ng,tcrutxasaum


- Abcess ti cng Douglas: Th ng g psaum vimphcm c,dolaub ngv

dnl ukhng t t.Phthi n cqungngyth 5saum :S t,auh vkm

c cc tri u ch ng kch thch trc trng ho c bng quang nh mt r n v a

nhi u l n rami nhy, i rt,...thm trc trng th y c kh i ph ng thnh

tr ctrctrngcngau,siumgip xcnhkh iabces.


31

X tr:Khngsinhtonthn,th tn c mhumn,..sauvingys trchtho

m abcsqua ngtrctrng(trchdnl ungoiphcm c).


32

VIMPHCM C

I. IC NG - Vim phc m c l mt hi ch ng chung do nhi u nguyn nhn gy ra.

- Nhi m khun phc m cth ng ti n tri n n ng do:

+ D ti pcnv im mb nhcs n.

+ D lanto ratonbkhoangphcm c.

- Phc m c c hai l, di n tch kho ng 1,6 - 2m2 (b ng di n tch da). L thnh c

cc s i th nkinhi t i nn d p ng v nh y c m v i kch thch, vim....l

t ng th c mth n.

- V sinh l b nh phc m c l mng thm th u, c kh nngh p thu l i nhanh

mt l ng dch avokhoangphcm c(c s choi u tr thm phn phc

m c) tuy nhin s h p thu l i khng chn lc, lm cho vim phc m c cng

n ng.

- Phc m c c kh nngch ng l i qu trnh nhi m khundo ho tng thc bo

v ph n ng vim b ng s bao vy c a cc quay rut, m c n i, m c treo...

- Khi phc m c vim l lm di chuy n1 l ng l nn c,i n gi i v Protein

vo

+ Khoangphcm c

+ T ch clink td iphcm c

+ Volngrutbdnto,nh ngkhngckh nngh pthu.

Lmchoc th m tn cvi n gi i, t o cho mt v m t chung - v m t phc

m c (Facies Feritoneal).

- S c phc m c cng do hi n t ng trn gy nn ngoi ra cn do c t vi

khunlm t nth ngc timk t h p (s cth ng PVC gi m, s c phc m c PVC

l itngcao).


33

II.CH NON 2.1. Ch nonxc nh vim phc m c ni chung * Lm sng

- C nng:aub nglint ckhpb ng,cth cnn,btrung iti ndoli t

rutho c iti nphnl ng

- Tonthn:bi uhi nhich ngnhi mtrngnhi mc

- Thcth :b ngtr ng ccm ckhcnhau

C c m ng phc m c ho c nghi m php Bumbergd ngtnh

* C n lm sng

Ch y u chn onnguyn nhn, theo di, tin l ng i u tr v ph c v

phu thut

- Sium b ng:Cdch b ng,cth th yccnguynnhngyvimphc

m cnh vimrutth a,vimho it timt

- Ch pCT-Scanner:Cgitrcaotrongvi ctmnguynnhngyvimphc

m c

- T ng phn tch t bomu,ngmu ( prothrombin,APTT, Fibrinogen ),

much y,Coc cmu,HbsAg,antiHCV,antiHIV

- Sinh ha mu: Glucose, Ure, Creatinin, GOT, GPT, Bilirubin ton ph n,


- SHn cti u

- Xqtimph ith ng

- i ntm


2.2. Phn lo i

C nhi u cch phn lo i.

2.2.1. Theo ti ntri nchiara: + Vimphcm cc ptnhtonth

+ Vimphcm ckhutr(cc pxe)

2.2.2.Theocnnguynb nhsinhchiara: + Vimphcm cnguynpht


34

+ Vimphcm cth pht

2.3. Ch nonphnbi t - Tc rutc gi i c ho i t rut

- Vim t y c p

- Lao phc m c

- Vim lot d dy t trng.

- C nauqu n thn.

- C nauqu n gan.

III.I UTR 3.1. Vim phc m c tin pht

3.1.1. ci m chung * T n t nth ngt u

- Vi khunth ng ch mt lo i (2/3 l t c u khun tan mu, 1/3 l t c u trng).

- Th ng g p tr emd i 10 tu i ho c trn b nhnhnx gan

3.1.2. Nguyn t ci u tr - i u tr ni khoa l chnh

- Nh ngnghing cngph i m trnh b st vim phc m c th pht

3.1.3.i u tr c th *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan


Natriclorid 0,9 %).





*S d ngkhngsinh:ph thuctnhtr ngng ib nh,dngcckhngsinhtc


h II, III, IV; nhmQuinolon,Carpapenemnn ph i h p2 3 lo i khng

sinh i utrchob nhnhn.


35




p...

3.2. Vim phc m c th pht

3.2.1. ci m chung - yl lo i th ng g p lm sng, nhi m khunth ng bt u mt t ng

trong b ng r i nhi m khun khuy ch tn ra, c khi do v .

- Vi khun th ng ph i h p, hay g p l Ecoli, lin c u trng sinh m , t c u,

ph c u.....

- Gi i phu b nh l: thanh m c, ch y u phc m c t ngthnhdyln,tngsinh

m ch mu, ph n , m c treo m c n i u dy ln.

Dch phc m cth ng c, c th khng mi ho c khng th i ( c khi qua

dch phc m c m ta c th chnon c nguyn nhn).

3.2.2.Cnnguynth ng g p - Vim rut th a v

- Th ng lot d dy t trng

- Th ng ti th a

- Xon rut ho i t

- Vim ti mt

- Th m mt

- p xe gan v

- X d sau phu thut.....

3.2.3.i u tr Nguyn tc l ph ii u tr ngo i khoa k t h p v i h i s c ngo i khoa tch cc.

* H i s c ngo i khoa

- Truy ndch,i ngi i bn c,i ngi i

- i uchnhthngb ngki mtoan(Natribicacbonat).

- Khngsinhph rng,m nh,t tnh tltheokhngsinh vph ih pkhng


36

sinh

- mb ohh p,h nhi t...

* i u tr ngo i khoa - Nguyntc:M cngs mcngt ttrnc s h is ctchcc.Ckhiv ah i

s cv am .

- Nidungphuthut:

Gi i quy t nguyn nhn: Ct rut th a, khu l th ng ....

+ Laur a b ngs ch,chccvngth p,cch .

+ Dnl uchi uqu (vtr,kchth c,...c a ngdnl u,rts m,khng

gydnh,nhi mkhun).

- Mts ch:

+ Vc m:Gymnikhqu n.

+ ngm :vo ngtrcti pho c ngtrnggiatrnd ir n.

+ h da,ho cngda th a,ho cngb ngmt l p ton th khing

thnhb ng.

IV.CHMSCVI UTR H UPH U 1. i utr saum *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan


dch).

- Ccch ti ngi i



*Dinhd ngsaum

- Cc dung dch nui d ng ng tnh m ch saum : ( ng, m,m ...)


LDH,HDH...saum

- Chob nhnhnnkhictrungti nho ctheoyl nhc aphuthutvin.


37



imidazon...K th pkhngsinh




p...



ho cnghing ch ymu





bi nhuphu.

- Ch chmscsaum :



+ Vnngs msaum

+ Vrung

- Khudath2khiv tm s ch,t ch ch tmct tv inhngtr ngh pkhu

dath aho c h da

2. Tiuchu nravi n - Tonthn:tnhto,khngs t,huy tng n,nu ng c,



V.BI NCH NGSAUM - Ch ymusaum

- Vimphcm csaum


38

- Vim phcm ckhu tr (abcess t nd trong b ng):nguynnhn ldo r

tiuhaho cdolaur a b ngch as ch


ruts mth nglinquan n nhimkhuntrong b ng,tcrutxa saum


- Nhi mtrngv tm

TILI UTHAM KH O 1. B nh hc ngo ikhoasau i hc, HVQY 1993, tp 1, 2

2. Ngo i khoa sch b tcsau i hc,HYHN1984

3. Chuyn khoa ngo i NXBYH 1985

4. Tai bi n v bi n ch ng phu thut, HVQY 1988

5. B nh hc ngo i khoa, NXBYH tp 1, 2 ph n b ng 1985, 1986. Ph n t y lch

1991

6.Bchkhoath b nh hc tp1, 2, NXBYH

7. B nh hc ngo i khoa b ng,HVQYNXBQND1997

8. Maingot sAbdominal operations. T1, T2 Appleton & Lange, A. Simon&

Schuter company, Printed in the United State of America 1997

9. David Sabiton; Textbbook of Su rgery, the bilogical basis of mordem

sugical practice, T1, T2 Sauders Companny, Printed in the United State of

America 1997

10. Encclopdie Mdico Chirurgicale, Technipues chirurgicals, Appareil

digestif, T1, T2, T3, Printed in France, 75015 Pari


39

B NHTR

I. IC NG 1.1. nhNgha - Trlmtb nhr tph bi n,tl mctrongcng ngkho ng35%.B nch t

c atrlhi nt ngdnc acctnhm chhumntrctrng

- Trhnhthnhdos dn qu m cmr itnhm chtr + Trnitrn ngl c

Trngo in md i ngl c

1.2. Nguyn Nhn

- Thuy tc hc:ccms ic nh igimr itnhm chchngdnd n,

ml ngl onh tlkhiplcxoangb ngtnggyrasatr.Ccnguynnhn

lmtngplctrong b ng,ccnguynnhntobn,bti u,ng inhi u, ng

nhi u,mangvcn ng

- Thuy thuy tnghc:c ch ngm ccshuntngtnhm chvng ng

humn

II.CH NON 2.1. Lm sng

B nhS - ingoiramut i

- C mgicn ngt c humn,mtr n

- Bitrsarangoi

- N ucbi nch ngthuyntc,n tk humnc mgicauddi.

Khmth cth - Thm trc trng l ng tcquan trng: tr ngh t, thuyn tc, r i lo n ch c

nngc tht


40

- Soihumn

- Khmtonthn:x gangytrtri uch ng

2.2.C nLmSng Cc xt nghi m dng trong ch nonxc nh Soi i trc trng ng m m


- XN mu: T ng phn tch t bo mu, ng mu ( prothrombin, APTT,

Fibrinogen),much y,Coc cmu,HbsAg,antiHCV,antiHIV

- Sinh ha mu: Glucose, Ure, Creatinin,GOT, GPT, Bilirubin ton ph n,


- SHn cti u

- Xqtimph ith ng

- i ntm

- Sium b ng

- Ch pCT-Scanner:dng trong tr ngh pnghics i ngmt ch , s i trn

ganho ct nth ngkhckmtheo

+ Tytr ngh pc th cth cccchnh cnlmsngc th khc.

2.3.Ch nonphnbi t - Dath ahumn

- Polyptrctrng,polyp nghumn

- Sanimm ctrctrng

- iti nau,phnmudovim itrctrng,n tk humn

2.4. Phnlo i - Theo Milligan-Morgan:G mc3lo i

+ Trni

+ Trngo i

+ Trhnh p;trvng

- M c:Chiatrnilm4phn


41

+ I:N mhontontrong nghumn

+ II:Sakhiingoi,tth to

+ III:Sakhiingoi,khngtcoln cph il ytay yvo

+ IV:Th ngxuynn mng i

III.I U TR 3.1.i uTr N i - ChnhchotrI,IIvcctr ngh p iphuthut

- Cchth c:Nghng i, thay ich n,ch ngtobn, th d cli uphp,

thu cDaflon,Ginkorfort,Proctolog.K th pngmhumn.

3.2.i uTr Ph uThu t - Ch nhchotrIIIvIV,trngo ithuyntchuy tkh i

- PhuthutMilligan-Morgan;phuthutFerguson;PTWhitehead

- PhuthutLongo:gi ml ul ngmu nbitr;treo mhumnvo ng

humn.

- K thut khu treo tr b ng tayM.Hussen, Nguy n Trung Tn (c i bin t

ph ngphpLongo):baog m ngkhutri tm chv ngkhutreotr

+ ngkhutri tm chg m12mikhuchX,trn ngl c2cm,l y

l pnimm cvd inim

+ ngkhutreotr:8mikhuchIkhutreo ngkhuth nh t,trn

ng l c 6cm, l y nimm c d i nimm c vmt ph n vo l p c trc

trng

Xuh ngi utrtrhi nnay:b ot nl p mhumn,gi mth tchbi

tr,tauS d ngvngtrn ngl c.

3.3.i utr saum Dng khng sinh ph rng v ph i h p khng sinh ph thuc vo tnh tr ng

b nhlc ang ib nh.Ccnhmhaydngnh Cefalosporinth h II,II,IV;

Penicillin

Thu cnhuntrng

Gi mautym cauc ab nhnhn(diclofenac,paracetamol,dolargan)


42

Thu cctcd ngtngc ngh tnhm ch:thu cctcd ngtngc ngs c

b n m ch mu, lm gi m tnh cng gin v tr c a tnh m ch: Daflon,

Ginkofort.Cchdng:trc p,angch ymu:Daflonvin500mgli u6vin 4

ngyr i4vin 4ngyti pvgi mxu ng2vintrong 6 ngy.

ngt ich:thu cbihayvin t:Titanorein,Proctoloc,efferangan

TiuChu nXu tVi n B nhnhnkhngau,khngch ymu, iti uti nbnhth ng;

IV.BI NCH NGSAUM - Ch ymu:ch ymut di nctchnbitrho ct ngkhu iv iphu

thutLongo.Tym cch ymucth b ot nb ngngmhumnk th p

nhtmchet ichho cph im l ic mmu

- ausaum :ch y ucctr ngh pccttrd i ngl c

- R ilo n iti n

- H phumn:x trb ngcchnonghumn

- Vimtrctrng

- Bi,au udohuqu c agytt ys ng

Ti li u tham kh o:

1. Ngo ikhoac s .NXBYhcHNi

2. Tri uch nghcNgo ikhoa.NXByhcHNi

3. Gi iphuthc hnhngo ikhoa.NXByhcHNi


43

T CRU TC GI I

I. IC NG - Tcrutltnhtr ngb nhlmsl uthngccch ttronglngrutbgi m

ho cm t.ylmtc pc ungo ikhoar tth ngg ptrongc pc u b ng.

- Tcrutcth xyra mil atu iTl nam,nbtcrutlngangnhau.

- Tcrutc hcc3nhm:

+ Donguynnhntronglngrut:giun,bth cn,s iphn

+ Donguynnhn thnhrut:cckh iulnhho cctnh,l ngrut,lao

rut,b nhcrohnrut,vimrutsaux tr,h pmi ngn irut,h prutsauch n

th ng

+ Do nguynnhnt ngoithnhrut:dych ngvdnhr tth ngg p,cc

thotvthnhb ng,thotvni,xonrut...

II.CH NON 2.1.Ch nonxc nh Lm sng

a)C nng - aub ngc n

- Nn

- Btrung iti n

b) Ton thn

- S m:d uhi um tn c,r i lo ni ngi ich ar

- Mun:b nhnhncth tr ngthishock,s cccd uhi uc am tn cv

r ilo nn ci ngi i,d uhi unhi mc,suythn

- Xonrut:shockcth xu thi nngaytrongnhnggi uc ab nh.


44

c)Th cth - B ngch ng

- D uhi urnb

- Quairutn i

- D uhi uti ngrodichuy nc ah ivdchtronglngrut

- S nn c th th y nguyn nhn gy tc rut nh kh i thot v, kh i u i

trng,kh iurutnon,bigiun

- Thmtrctrng:cth s th yutrctrng.

2.2.C nlmsng 2.2.1Ccxtnghi m ch non: - Ch pXquang b ngkhngchunb:th yccquairutgin,hnhm cn c

m ch i,khngch itdotrong b ng

- Sium b ng: th yhnh nhrutginh ivch anhi udchdotcrut,

dch b ng,cth th ynguynnhntcrutnh kh iu,kh il ng,bigiun

- Ch pCT- Scanner:chnonvtrtcrut,tnhtr ngt nth ngc athnh

rutvmts nguynnhngytc:dou,bigiun,bth cn

2.2.2 Cc xt nghi m di utr ,tinl ng,theodib nh: - XN mu: T ng phn tch t bo mu, ng mu (prothrombin, APTT,

Fibrinogen),Coc cmu,HbsAg,antiHCV,antiHIV,nhmmu,

- Sinh ha mu: Glucose, Ure, Creatinin, a Uric, GOT, GPT, Bilirubin ton

ph n,Billirubintrcti p,Proteintonph n,Albumin,Gross,Maclagan,HDL,

LDL,Cholesterol,Triglycerit,G,

- SHn cti u

- Xqtimph ith ng

- i n tim,siumtimn ub nhnhncbi uhi n,ho c ti ns b nh l tim

m ch.

2.2.Ch nonphnbi t 2.2.1.B nhn ikhoa: a)C nauqu nthn:


45

b)Nh imuc tim:

c)C nauqu ngan

d)Ccb nhnikhoa tg pkhcnh :c ngtuy ncngip, r i lo nchuy n

haporphyrin,nhi mcch,gind dyc ptnh,mts thu cgyli trut,

h K+mu

2.2.2.B nhngo ikhoa a)Ccb nhngo ikhoacs tc a b ng: tnh tr ngvimphcm cgy li t

rut

b)Vimt yc p

c)Nh imum ctreorut

d)V phnhngm chch sauphcm c

e)Tcrutdoli trut

f)Hich nggi tc itrngc ptnh:b ngch nglchnh,khngaub ng,

khngnn,vncth trungti nho ctiuch y

III.NGUYNT CI UTR - T tc nhngb nhnhntcrutc gi i ucchnhphuthutc pc u-

B nhnhntcrutnn cm s m,trongvigi u,kodith igianh i

s ctr cm qulucth lmtngtl bi nch ngvt vongsaum .

- B nhnhncchnhb o t nph i c theodist, thmkhmnhi ul n

b nglmsng,ch pX- quang b ngkhngchunb.

IV.I UTR TR CM *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan

- Cclo idungdch ngtr ngv,dungdchkeo(natriclorid 0,9%; glucose

5%,10%,20%;ringerlactac).

- Ccch ti ngi i:Na,K,Ca,





46

*S d ngkhngsinh:ph thuc tnh tr ngng ib nh,khngsinhph rng

tonthn,dng ngtimho ctruy n,ccnhmkhngsinhth ngdungl:

th h 3,suferazon,metronidazone,imipenem,quinolon.


lo ithu cth ngdng:diclofenac,paracetamol, morphin, dolacgan, nospa...)


p,vnm chn ucsock,

* tsonded dy

* tsonde ti u

V.I UTR PH UTHU T 5.1.Nguynt c - ngm : ngm giatrnvd ir n,mts tr ngh p cbi tch

c n ngm nh :lmHMNTphatrnutrongtcrutdou itrng,thotv

b nngh t,thotvingh t

- Tytheotnhtr ngb ngvnguynnhngytccth phuthutnisoi

b ngho cm m .

- Thmd tmnguynnhn tc:v trvnguynnhngy tcn m ch n i

giao nrutph ngvo nx p.

- X lnguynnhntc:tytheonguynnhntcmccchx trkhcnhau.

Rutho it thcto nrutvn ingayn ulrutnon, ahai ura

ngoithnhb ngn utc itrngho cctnhtr ngvimphcm c

- Lmx prut

5.2.Ph ngphpph uthu t * iv iccnguynnhngyt c ru tnon - Do dy ch ng,dodnh:ctdych ng,g dnh

- Doxonrut:n uho it thph icto nrutvkhun ingay(khng

thoxon).N urutch aho it ththoxon,phngb xylocain,pg c m

- Thotvngh t:gi iphngthotv,x lnidungthot v(b ot n,cto n

rut),ph ch ithnhb ng.


47

- V ithotvni:chcth chnontrongm ,gi iphngngh t.

- L ngrutc p:

+ Tr cnb:chnhthol ngb ngh i,th tbarytho cth tn c, ttrn

90%.

+ M c pc ukhi nmun,b ngch ng nhi u,thol ngkhngck tqu .

M thol ngn urutcnt t,cto nrutkhirutho it .

+ ng i l n: tg pvth ngdou i trngvth bnc p:m c pc u

n utcrutvx trnh tcdou itrng.

- Tcdodvt:

+ Do giun m rutl ygiunvkhul irut.

+ Dobth cn:ph iki mtratonbt d d yt igch imanhtrng

trnhb st,cth m rutho cbpntbth cnyxu ng itrng.

- Dourutnon:cto nrutcuvn ingay.

- Tc rut saum :i u trnikhoa tr c,m c pc ukhicd uhi ungh t

ho ci utrnikhoath tb .

* iv iccnguynnhngyt c itrng: - Tc itrngph i:u itrng,xon itrngph i ct itrngph i,n i

ngayn utnhtr ngtonthnvtnhtr ng b ngchophp

- Tcdou itrngtri:ct itrngcu,lmhumnnhnt o,n irut th

sau.

- Tcrut tr ctrng:cto nrutcuvlmHMNT.

- Xon itrngsigma:

S m:t ngsondehumnthoxon.

Thoxonth tb iho ct imun,rutho it thct itrnglmHMNT,

n irut thhai.

VI.I UTR VCHMSCSAUM *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan


48

+ Cc lo i dung dch ng tr ng v, dung dch keo (natriclorid 0,9%;

glucose5%,10%,20%;ringerlactac,albumin).Ph thuctnhtr nglmsng

vxtnghi mc ab nhnhn.

+ Ccch ti ngi i:Na,K,Ca,

+ S l ngdchtruy nph thucvotontr ngng ib nh,m chhuy tp,

plcTMTTvs l ngn cti u/gi ...

*Dinhd ngsaum

- Ccdungdchnuid ng ngtnhm chsaum :( ng, m,m ...)trong

nhng ngy u sau m da vo ton tr ng b nh nhn, xt nghi m protein,

LDH,HDH...saum

* S d ng khng sinh: theo khng sinh (n u c). Cc nhm hay dng:

cefalosporin, nhm carbapenem, quinolon, imidazon...


th ngdng: diclofenac, paracetamol, morphin, dolacgan, nospa...)


p...


+ Ccxtnghi mhuy thc:cngth cmu,ngmutrongtr ngh pm t

muho cnghing ch ymu

+ Ccxtnghi msinhhamu,nhgich cnngganthnv tnhtr ng



+ Chnonhnh nh:sium,Xquang,ctl pvitnhtythuctnhtr ng

di nbi nhuphu.

- Ch chmscsaum :



+ Vnngs msaum

+ Vrung


49

- Ch dinhd ng

VII.CCBI NCH NGSAUM VH NGX TR Ch y mu sau m (ch y mu trong b ng, ch y mu v t m ): phu thut l i

c m mu, khu l i v t m .

VPM sau m do b c, x mi ng n i ng khu: phu thut l i, x l nguyn

nhn.

pxe t nd :i u tr khng sinh m nh, ph i h p, truy n dchvi n gi i

Tc rut s m sau m :th ng ph i phu thut l i gi i quy t nguyn nhn

* R tiu ha:

- N ukhngcvimphcm cthi utrnikhoab ng tsonde b nght

r alint c.

- Chokhngsinhm nhph ih p.

- Nuid nghontonb ng ngtnhm ch:truy nalbumin, m,m ,i n

gi i nkhirtiuhali n.

*Nhi mtrngv tm :tchv tm ,chi un,s d ngkhngsinhtheokhng

sinh .

* B c v t m : khu l i v t m , dinh d ng ng tnh m ch b ng truy n

albumin, m,m .

*Xuy thuy ttiuhasaum cth xyra,hayg p b nhnhntr c,trong

vsaum cshock.

*Vimph i,vim ngni u,lottdon mlu...

VIII.TIUCHU NRAVI N - Tonthn:tnhto,khngs t,huy tng n,nu ng c.



TILI UTHAM KH O 1.PGS.TS.HVnQuy t(2006),Tcrut,B nhhcngo idnhchosau i

hc,trang188- 198,Nhxu tb nYhc2006.


50

2.LHng,i utrtcrut,Bigi ngi utrhcngo ikhoa,trang336 -

365,Nhxu tb nYhcChinhnhThnhph H ChMinh2007.


51

VIMPHCM CDOTH NGT NGR NG

I. IC NG - Th ng t ng rng: th ng rut do th ng hn, vim ti th aMeckel ho i t ,

vimtith a itrngho it (tg pth ngm ram ichnon c).Hay

g pth ng lotd dyttrng,i utrk tqu t tn u cphthi ns mv

x trkpth i.

- Chnond vas cctri uch ngi nhnhvrr t

- Theoth ngknam gi inhi uh nngi i

II.GI IPH UB NHL * Lth ng:

- Th ngchmtlth ng,r ttkhith yhaihaynhi ulth ng.

- Lth ngcth mtlotnonhayb chaic ngdoqutrnhti ntri nlu

di

- Vtrlth ngth ng m ttr cttrnghayd dy.

- Tnhtr ng b ng: b ngs chhaybnkhcnhautytheob nhnhn ns m

haymun,th ngxahayg nban,lth ngtohaynh

III.CH NON: 1. Lm sng:

* Ton thn:

- ns m:

+ Tnhtr ngtonthnch athay inhi u

- nmun:tnhtr ngnhi mtrng,nhi mcn ng

*C nng:

- auth ngvtngtddi


52

- Bu nnnho cnn

- Btrung iti n

*Thcth :

- Nhn:b ngc ngkhngdingtheonhpth ckhib ngh ich ng

- S nnth yb ngc ngnh g

- G:vng ctr cganm t,g cvngth p

- Khmtrctrng:auticngDouglas

2.C nlmsng: 2.1Ccxtnghi m ch non: - XQ b ngkhngchunb:hnh nhli mh id ivmhonh2bn(kho ng

80%).

- Cc tr ngh pkhph i ch pCT b ng: ckh tdo trong b ng,ho c

chnonphnbi tv ib nhlkhcnh :tcrut,vimt yc p,

2.2Ccxtnghi m i utr ,tinl ngvtheodib nh - XN mu: T ngphntcht bomu:b chc utng,ngmu: prothrombin,

APTT,Fibrinogen,coc cmu,HbsAg,antiHCV,antiHIV,nhmmu,


ph n,Billirubintrcti p,Proteintonph n,Albumin,Gross,Maclagan,HDL,

LDL, Cholesterol, Triglycerit,G,ment y,

- SHn cti u

- Xqtimph ith ng

- i n tim,siumtimn ub nhnhncbi uhi n,ho c ti ns b nh l tim

m ch.

- Sium b ng:cdchtdotrong b ng.

3.Ch nonxc nh: - Ti ns :i utrvimlotd dyt trng

- autngtddivngth ngv

- B ngc ngnh g

- Gm tvng ctr cgan


53

- XQ b ng:chnh nhli mh id ic honh.

- Ch pctl p b ngm c as kh:ckhtdotrong b ng.

4.Ch nonphnbi t - Vimt yc p:Amylase mu, ni utngcao

- Vimphcm crutth a

- Vimphcm cmt

- Tcrut

IV.I UTR TR CM *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan:

- Cclo idungdch ngtr ng,dungdchkeo,ccch ti ngi i.



- i uchnhsthi uh tn cvi ngi idavoi ngi i .

*S d ngkhngsinh:khngsinhph rng ton thn,dung ng timho c

truy n, cc nhm khng sinh th ng dung l: th h 3, suferazon,

metronidazone,imipenem,quinolon.


lo ithu cth ngdng:paracetamol, morphin, dolacgan, ...)

*Mts thu ckmtheoi utrb nhlph ih p:L iti un ucsuythn,vn

m chn ucsock,

* tsonded dy.

* tsondeti u.

V.I UTR PH UTHU T *Khulth ngd dy- ttrngb ngphuthutm ho cphuthutnisoi,

laur a b ngvdnl u.

*Khulth ng- n ivtrng.

*Cto nd dytrongtr ngh p:

- lotx chai,khkhu,khud b c

- lotcnhi ul nch ymuho cch pmnv


54

- lotnghingh ungth ha

- Tontr ngb nhnhnchophp,trnhkinhnghi mphuthutvin

*Th ng itrng:lm HMNT

*Th ngrutnon:khulth ng,cto nrutn iho cdnl u.

VI.I UTR VCHMSCSAUM *i uchnhtnhtr ngm tn c,i ngi ivthngb ngki mtoan:

- Cclo idungdch ngtr ngv,dungdchkeo(natriclorid0,9%,glucose

5%, 10%, 20%...).

- Ccch ti ngi i:kali,calci,



*Dinhd ngsaum

- Ccdungdchnuid ng ngtnhm chsaum :( ng, m,m ...) trong

nhngngy usaum davotontr ngb nhnhn,xtnghi mprotein...sau

m .

*S d ngkhngsinh:theokhngsinh (n uc),ph thuctnhtr ngng i

b nh.Ccnhmhaydng:cefalosporin,nhmcarbapenem,quinolon,imidazon,

metronidazone...



*Thu cgi mti t:omeprazone,esomeprazone


p...


+ Ccxtnghi mhuy thc:cngth cmu, ngmutrongtr ngh pm t

muho cnghing ch ymu.

+ Ccxtnghi msinhhamu,nhgich cnngganthnv tnhtr ng




55

+ Chnonhnh nh:sium,Xquang,ctl pvitnhtythuctnhtr ng

di nbi nhuphu.

- Ch chmscsaum :



+ Vnngs msaum

+ Vrung

- Ch dinhd ng:

VII.CCBI NCH NGSAUM VH NGX TR *Ch ymusaum (ch ymutrong b ng, ch ymuv tm ):phuthutl i

c mmu,khul iv tm .

*VPMsaum dob c,xmi ngn i ngkhu:phuthutl i,x lnguyn

nhn.Tr ngh pnyn ngn ,tl t vongcao.

*pxe t nd :da theokhngsinh ho c:i u trkhngsinhph rng v

ph ih pkhngsinh,truy ndchvi ngi i.

*Tcruts msaum :th ngph iphuthutl i gi iquy tnguynnhn

* R tiu ha:

- N ukhngcvimphcm cthi utrnikhoab ng tsonde b ng ht

r alint c.

- Chokhngsinhm nh ph ih p.

- Nuid nghontonb ng ngtnhm ch:truy nalbumin, m,m ,i n

gi i nkhirtiuhali n.

*Nhi mtrngv tm :tchv tm ,chi un,s d ngkhngsinhtheokhng

sinh .

* B c v t m : khu l i v t m , dinh d ng ng tnh m ch b ng truy n

albumin, m,m .

*Xuy thuy ttiuhasaum cth xyra,hayg p b nhnhntr c,trong

vsaum cshock.

*Vimph i,vim ngni u,lottdon mlu...


56

VIII.TIUCHU NRAVI N - Tonthn:tnhto,khngs t,huy tng n,nu ng c.

- T ich:v tm li nt t.


- Dngthu cgi mti ti utrli n lottrongkho ng04- 06tu n.

- Khml isau01thng,mts tr ngh pc nnisoil id dy quy tnh

i utrnikhoati phayphuthutctd dy.

TILI UTHAM KH O 1.PGS.TS.HVnQuy t(2006),"Th ng lotd dy - t trng,B nhhc

ngo idngchosau ihc,Tp1,trang98- 110,Nhxu tb nYhcHNi

2006.

2.LHng,Th ng lot d dy - ttrng,Bigi ngi u tr hc ngo i khoa,

Nh xu t b n Y hc Chi nhnh Thnh ph H Ch Minh 2007.


57

ABCESSC NHH UMN

I. IC NG 1.1Khini m Abcess c nh hu mn l b nh thuc nhm b nh v hu mn v trc trng.

L hi nt ng hnh thnh cc m m m nh b s ngquanhvnghu mn, trc

trng. Cc m m m c th ch a m , sau mt th i gian c th b v ra,gyau

n, kh chu thm ch pht s t, shock nhi m khun cho b nh nhn. B nh c n

c pht hi nvi u tr kp th i.

1.2 Nguyn nhn gy nn b nh p xe c nh h u mn

B nh do nhi unguynnhngyra,nh ngch y u vn l mt trong s nhng

nguyn nhn sau:

- Do vim nhi m: vng humnth ng xuyn g p ph i cc b nhnh b nh

tr,n t k humnkhiccctri u ch ng b nh,ph n da vng hu mn r t

d b vim nhi m, t dn n p xe hu mn.

- Do dng thu c: nhng thu cdng i u tr cc b nh v humnth ng c

tnh kch thch cao nn d dn n ho i t cc m v p xe hu mn

- Sau phu thut: nhngng i lm phu thut cc b nh vng hu mn r t d b

vim nhi m n unh khngv sinh s ch s .

- Ngoi ra, v i nhngng i c s c khng y u,c th suynh c, thi u dinh

d ng, d cnguyc b p xe hu mn.

- Do vim nhi m: nhngng it ng b tr,n t k hu mn, polyp hu mn,

vim lot itrnglnhngng i d b vim nhi m. Khi vi khun t n cng

vo nhng vng b hu mn hu mn t oc hi hnh thnh nn apxe hu mn.

- Nhngng i thi u ch tdinhd ng,c th b suynh c, s c khng km

cngkhi n vi khun xm nhp gy nn apxe hu mn.


58

- Cc thu cdngtrongi u tr trc trng c tnh kch ng cao, c th lm ho i

t dn n p xe hu mn.

- B nh nhn v vim nhi m sau cc ti u phu vng hu mn.

- Do vi khun l, khun lao, lin c u, t c u hnh thnh.

1.3 D ch t

Lo i khun gy b nh c a p xe hu mn l cc vi khun ng rutnh

Escherichia ColiCng c th l cc vi khun th ng g p trong cc nhi m

trngthngth ngkhcnh t c u khun, lin c u khun

Theo Danis v Puy - Montbrun (1991), nhng nhi mtrngm ngm c a hu

mn vng chung quanh, lin quan t i ng humnl76%,linquan n vng

trn ng hu mn l 2%, khng lin quan t i hu mn trc trng l 22%.

1.4. Cc lo i p xe h u mn

Lc u th ng t n l tnh tr ng nhi m trng cc ng tuy n Hermann-

Desfosser. Ti p theo l tnh tr ng nung m . Cc nhi m trng ny m vo cc

h c c a ngl c. M theo cc tuy n pht tri n d n ra pha nng r i cu i cng

m ra da vng chung quanh l hu mn, g n hay xa l hu mn.

Ty theo v tr c a m ,ng i ta chia p xe hu mn lm nhi u lo i.

pxed i da m n m r t nng v r t g n l hu mn.

pxed i nim m c m c a p xe n mngayd i nim m c, d i th pn i ng hu mn hay

trncaon ibngtrc trng. Nguyn nhn c apxed i nim m cth ng l

hu qu c ath ngt n n t hu mn b nhi mtrnghaytrtc m ch b nhi m

trng. V ti n tri n,pxed i nim m c khng pht tri n ra pha ngoi vo l p

c mcxuh ng v vo trong lng ng hu mn.

p xe gi accc th t m c a lo i p xe ny n m giac thttrongvc tht ngoi. m n m

l p th p hay l p cao. Khi th p n st vo b d ic tht ngoi v v ra


59

ngoi g n ng hu mn. Khi cao, n v ra pha ngoi vo h ng i-trc trng

hay vo pha trong, bng trc trng.

p xe h ng i - tr c trng

th ny, m n m trong h ng i-trc trng, nng hay su: Thnh trn c a h

ng i - trctrnglc nnghumn,thnhd i l da v m t bod i da.

p xe v tr ny pht tri n nhanh chngraphatr c, ra sau v sng bn i

di n. Khi pht tri n sng bn i di n, n t o thnh p xe hnh mng nga.

pxetrnc th t m n m m td ic nnghumnhaytrnccc tht.

p xe khoang ch u hng - tr c trng

m c a lo i p xe lo i ny n mtrnc nnghu mn. Nguyn nhn c a th

p xe ny c th l nhng p xe c a h ng i - trc trng ph v c nnghu

mn lan t d i ln.Cngc th pht sinh t nhng nhi m trng c a cc

t ng n m trong b ng, lo i ny t g p.

II.CH NON 2.1 Lm sng:

2.1.1 Tri u ch ng ton thn

Ton thn c cc tri u ch ng c a mt nhi m trng c p tnh. B nh nhn c

th c s t, nhi t c th tngcaotrongmtvingy u r i h d n.Ng i

m t m i, b t r t,mkhngng .Khngdmnvs ph ii i ti n.

2.1.2 Tri u ch ng c nng - auhu mn l tri u ch ng g p u tin c a b nh.Ng i b nhth ng th y

aunh c nh tlkhiil i,i i ti nhay ng ln ng i xu ng. C nhngng i

b aut i m c khng dm ng i xu ng.

- Ban u,ng i b nh th y hu mn b s ng,vcc mgicnng, , ton

thn th y m t m i,au u, c th b s t.

- Sau, hu mn s xu t hi n n ts ngph ng, cch l hu mn vi cm, c ng,

ch m vo r tau, gia hnh thnh ch m trng nh lm . lu, cc n t

s ch y m mu vng, c mi hi.


60

- Hu mn b ng a do s kch thch c a dch nh y trong hu mn v dich m

bn ngoi nn lun lm cho hu mn b m t, kch ng v ng a.

- Pht hi n xung quanh hu mn c m n l cc kh i m m ho ch ic ng, c th

ch a m .

- B nh nhn c m th yaubu t, ng a gy kh chu, ng ng i khng yn.

- C th c tri u ch ng s t.

- i ti n ra mu, c dch nh y m theo phn ra ngoi.

- V tth ngch y m kh li n, d ti pht, d gy r hu mn.

- Haycngth ng, khng tp trung, p lckhiiti u ti nv i ti n

Hu mn b sng ty

Tri u ch ngchnhlau.au vng humn,lanrachungquanh.au

nh c nh i v lin t c.autngkhiil i, khi ng i, khi ho, khi r n i ti n. V i

cc lo i p xe nng, b nh nhn khng dm ng i b ng c hai mng, khng dm

ng i trn yn xe.

2.1.3 Tri u ch ng th c th

- Nhn

+ pxed inimm c

Lc m i bt u, nhn khng th y g, khi p xe v , th y mt vi git m trng

long t trong hu mn ch y ra.

- p xe h ng i - trc trng

Lc u, th y mt ch dabngs ngph ng, khng c gi i h n r r t, cch l

hu mn vi centimet. Vi ngy sau, ch t y ny c gi i h n r r t v i mt

ch m trng gia, m hnhthnh.Trongas cctr ng h p p xe ch c


61

mt bn, bn ph ihaybntri.Cngckhi p xe h ng i - trc trng c c

hai bn lm cho p xe c hnh mng nga.

- p xe giaccc tht

Lc u nhn khng th y g.

- p xe khoang chu hng - trc trng

Cngnh pxegia cc c tht, lc unhn cngkhng th y g. Lo i ny

th ng c chnonlpxeh ng i - trc trng. Khi r ch dnl uth y m

t trn cao ch y xu ng. B ng mtkmdi thm th th y p xe ln kh cao,

th ng s khng ch m cypxe, lcm i bi t l p xe khoang chu

hng-trc trng.

Thmh u mn tr c trng B nh nhn n m ng a,haichnco,haiid ng. Ming tc c a th y thu c

ph i r t nh nhng, t t , v n u khng lm b nh nhn r tau,khngchoti p

t c khm. N uaunhi u, nhnnh cc tri u ch ng s khng chnh xc.

Ngntaythmhu mn trctrnglun cbitr n d avotrong ng

hu mn.

- pxed i nim mac Ngn tay s c mt ch ph ng nh , n m b t c v tr no c a chu vi ng

hu mn. Nim m c ch s ngph ngnytr nlng, n nh vo r tau.

- p xe giaccc tht v p xe h ng i-trc trng

C mgic c kh is ngt ngoi l i vi trong lng ng hu mn, n r t

au.Thmkhmhu mn trc trng lm b nh nhn r tau.Vvy nn h n ch

thmkhmhu mn trc trng b ng tay v b ng d ng c .Th ng th b nh nhn

t ch i,khngchothmkhml n th hai.

2.2 C n lm sng

2.2.1 Cc xt nghi m ch non: Th ng th p xe hu mn trc trng c cc tri u ch ngr chnon.Tuy

nhin cc xt nghi m chnoanl:

+ Siumph nm m:th yc pxec nhhumn.


62

+ Siumnisoi:trongnhngtr ngh pkhphnbi tv icckh iuhay

khixcnhrvtr,l nvtnhch tc ath ngt n,cth dngsium

nisoi.

2.2.2 Cc xt nghi m i u tr ,tinl ng v theo di b nh - XN mu: T ng phn tch t bo mu: b ch c utng,ngmu: prothrombin,

APTT, Fibrinogen, co c cmu,HbsAg,antiHCV,antiHIV,nhmmu,


ph n, Billirubin trc ti p, Protein ton ph n, Albumin, Gross, Maclagan, HDL,

LDL, Cholesterol, Triglycerit,G,

- SHn c ti u

- Xq tim ph i th ng

- i n tim, siu m tim n u b nh nhn c bi u hi n, ho c ti n s b nh l tim

m ch.

III.BI NCH NGABCESSH UMN pxehumnban uth ngchgyau nchong ib nhnh ngn u

khngi utrkp th i,b nhs gyranhi ubi nch ngnguyh inh : - Nhi m trng ch y m : b nh n ukhng ci u tr ngay, m s ch y nhi u,

dn n nhi m trng, v b nhcnglanrng ra nhng vng xung quanh, khi n

choi u tr tr nn ph c t ph n.

- R hu mn: lc u, cc p xe hu mn r t c ng, n unh i u tr nh ngl i

khng tri t s khi n cho kh i p xe pht tri n l nh n,dn n v ra v ch y

m , cng ko di s gy ra r hu mn, gy nguy h ichong i b nh.

- i ti n kh: cc p xe hu mn khi n cho ng i b nh lun c m th y b p lc

khii i ti n v ti u ti n, gy nn tnh tr ng to bn, dn n b b nhtr.

IV.NGUYNT CI UTR i u tr p xe hu mn trc trng l dng khng sinh ton thn v r ch dn

l um .

V.I UTR TR CM Khipxeang hnh thnh


63

- H nch nhi mtrng:

S d ng khng sinh: khng sinh ph rng ton thn, dung ng tim ho c

truy n,ccnhmkhngsinhth ng dung l: Ampicilin + Sulbactal; th h 2, 3;

suferazon; metronidazone; imipenem;Khng sinh ch h n ch nhi m trng

ch th ngkhngngnch n c qu trnh lm m ,khngngnch n c p

xe hnh thnh.

- Gi mau

Ban ngy, dng thu c gi mau.T i,tr ckhiing , nn u ng t thu c ng

c th ng c.

Ngm humntrongn c m: ngy nhi u l n ng i vo chun c m lm b nh

nhn au,c m th y d chuvcng p xe hnh thnh nhanh h n.

- nu ng

i ti n lm b nhnhnau,nh t l khi to bn, bt b nh nhn ph i r n. V vy

nnnnh , d tiu, nhun trng. N u c to bn nn dng t thu c nhun trng.

VI. I UTR PH UTHU T - Khipxehnhthnh

+ i utr

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