Chun on v iu tr u tuyn gip qua chc ht bng kim nh

Theo nghin cu ca Gio s, Tin s Nguyn Vng:Cc tuyn gip to chim 1 v tr quan trng trong bnh hc ni tit. Hng trm triu ngi trn th gii c tuyn gip to v VitNams ngi mc bnh cng ln ti hng triu. Trng hp in hnh, tuyn gip phnh to to thnh 1 khi sng ngay gia c, rt d nhn nn nhn dn quen gi l bu c (cch gi ny khng chun v phn ln cc tuyn gip to khng phi l bu m l thng tn gi bu).Cc tuyn gip to thng dng lan ta : th cc (hn, thy thuc chuyn khoa quen gi l bu gip nhn) ch chim t l khong 5 10% nhng li c quen tm c bit v hu ht cc loi u thc s tuyn gip trong c ung th u thuc nhm bnh ny..Trn lm sng pht hin 1 ngi c tuyn gip to thng khng kh, tuy nhin xc nh ng loi bnh ca tuyn gip c thi x l thch hp tht khng n gin, k c trng hp chp lp lnh cho thy c cc gip lnh (nodule froid thyroidien). Trc 1 bu gip th cc n c, khng pht hin c cc triu chng biu th 1 ri lon ni tit, t ra nh lm sng hc cng phi phn bit 1 trong 5 kh nng : bu gip cc n thun, tnh trng hot ng tt (bnh nng), u nang gip (loi tht hoc gi), vim tuyn gip (cp, bn cp, De Quervain, mn tnh nhiu lympho bo Hashimoto), u tuyn lnh tnh (loi b, nang nh, nang trung bnh, nang ln, t bo a axit); ung th hoc loi biu m (tip biu m nh, ti, dng biu b, t bo khng l, hnh thoi, t bo a axit, ty) hoc cc loi khc (sacom, u lympho c tnh).Cch iu tr v tin lng ca nhng nhm bnh ny rt khc nhau. Do cn chn on xc nh r tng loi bnh, iu ny i hi s kt hp ca nhiu xt nghim cn lm sng (phng php khm lm sng n thun ngy nay khng th no chnh xc, c bit i vi bu gip cc n c). Mt s xt nghim hin i nh chp nhit, chp lp lnh, o mc c nh it phng x, ghi vang siu m, chp scane nhiu khi khng cho ph chn on xc nh. Loi xt nghim hnh thi hc nh sinh thit, t thit thng vn c gi tr ni bt trong chn on chnh xc, trc y ch c th lm c tuyn gip sau 1 phu thut ct b u hoc sau khi bnh nhn cht, do ch mang tnh cht hi cu (hay nghin cu). Trong khi y c bit bao nhiu ngi mc bnh tuyn gip khng c ch nh phu thut. V vy chn on xc nh trc iu tr ni chung v trc gii phu ni ring mt thng tn tuyn gip (nht l cc cc gip lnh) lun lun t ra cho nh lm sng nhim v gii quyt d kin st phc iu tr. Chc ht kim nh l 1 k thut xut hin trn lm sng t th 19 song b b ri v mi n 1947, Marcel Zara (Php) l ngi u tin chc vo cc gip v xc nh c kh nng c nc trong u. ng cng dng k thut chc tho cha khi nhiu trng hp u nang gi ca tuyn gip. Cng vi pht trin ca chuyn ngnh su chn on t bo hc qua chc ht kim nh, trong vng 3 thp k gn y chn on t bo hc tuyn gip cng c 1 bc pht trin mi c Chu u, Chu M ln Chu . Nhng phng php n gin v c hiu qu ca Marcel Zara cha c nhn ln rng ri v b lng qun ngay nc Php. VitNamt 1972 mt s thy thuc (Nguyn Vng v cng s) chc ht bng kim nh v cha khi cho nhiu bnh nhn c u nang gi tuyn gip. Da vo bng phn loi m hc quc t v cc u tuyn gip ca T chc y t th gii nm 1974 v nhng cuc iu tra rng ln Vit Nam c th nhn xt tnh trng u nang gip Vit Nam nh sau :+ t nht cng c trn di 100.000 trng hp u nang gip cc loi thng trc c chn on hay khng c chn on.+ Khi p dng k thut chc ht kim nh, ch nh vi bt c loi u nang no cng l iu tr phu thut, s bnh nhn c m b hn ch v iu kin kinh t v tai bin phu thut khng cho php p dng trn lan phng php ny.+Tai bin phu thut khng t, theo thng k ca bnh vin Vit - c trong nhiu nm, t l khong 10% trn hng ngn trng hp (chy mu, sc trong khi m, ging khn hay mt ting do ct phi dy thn kinh qut ngc mt hoc c 2 bn, bnh ttani (ttanie) do ly mt tuyn cn gip i km bnh phm phu thut). Chn on t bo hc qua chc ht kim nh tuyn gip c th em li nhng kt qu tt ng thi hn ch ti a nhiu cuc phu thut kh nguy him.M hc - t bo hc tuyn gip :M hc l tuyn ni tit c mi, tuyn gip cu to bi cc nang (cn gi l ti tuyn) nm trong 1 m lin kt mch rt giu mao mch. Nang thng hnh cu, kch thc thay i, ng knh khong 0,02 1mm, trung bnh 0,1 0,2mm. Biu m lt nang thuc loi n, lng nang cha cht keo. Bao quanh mi nang c 1 mng y lin tc dy khong 500A, gia cc nang c 1 s t bo cn nang, rt nhiu mao mch c l nh, nhiu nhnh tn ca dy thn kinh giao cm, mch bch huyt t bo si, si to keo, t bo i Hnh thi v kch thc ca cc nang c th thay i nhiu ty chc nng v hot ng sinh l tuyn gip.Biu m nang c 2 loi t bo : t bo nang v t bo C. Chng thng c hnh thi ng nht mi loi v cch sp xp cng u nhau. T bo nang thay i t dt, hnh khi ti hnh tr cao, hnh thi trung gian thng gp l hnh khi thp. Nhn trn nm gia hay gn y t bo, ngho cht nhim sc, cha 1 hay nhiu ht nhn nh.Knh hin vi in t cho thy b mt t do (cc nh) ca t bo nang dng khi thp khng c rim bn chi m ch c cc hnh vi nhung mao ngn sinh ra t bo tng v c hng tht thng nhng bao gi cng i vo cht keo. Mt bn ca cc t bo ny ni vi nhau bng nhng phc hp ni in hnh : cc th chng v nhng que tn. Ti lp th hnh que nh, tng i t, phn b khng u. Ribosom v li ni bo tng c ht kh pht trin. My Golgi c nhiu ti nh dt hay dn khi b cng ra tr thnh khng bo. C nhiu th c c mng gii hn nm ri rc trong bo tng tp trung vng nh, cc th tiu bo, th thc bo, th tiu thc bo, nom nh nhng git nh hoc tiu cu keo, cn thy 1 s git m nh. T bo cn nang hay t bo C, c s lng t hn, nm gip mng y v khng bao gi tip xc trc tip vi cht keo. Chng thng to hn t bo nang song bt mu km hn. Nt c trng ch yu ca cc t bo ny di knh hin vi in t l s hin din trong bo tng rt nhiu ht c c mng bao bc, ch tit canxitonin (mt hocmon polypeptidic) c gii phng ra t bo vo cc mao mch k cn.Cht keo trng thi tng, nhn thy sng, ng nht. Khi nang hot ng tnh cht bt mu v qunh ca cht keo khng thun nht na, sau khi c nh cht keo c tnh cht bt c 2 mu : va nhum c phm axit ln bazo. Keo c nhum sm vi phm cozim, azocacmin, PAS v cc phm axit khc. Keo long nhum xanh nht vi xanh anilin hay xanh metylen. Ngi ta coi cht keo l 1 cht tit d tr trong c nhiu nucleoprotein (do a bazo), cc enzym v mt glycoprotein thyroglobulin do t bo nang tng hp bi ribosom li ni nguyn sinh ht t cc axit amin (tyrosin) ca mu c chuyn vo y Golgi v thm phn gluxit ri c chuyn vo lng nang ho nhp vi it trong cht keo di dng monoiodotyrosin (MIT) v iitotyrosin (DIT) v sau c c li thnh triiothyronin (T3) v tetraioothyronin (T4). Cht keo c thyroglobulin it ha va PAS ln xanh Alcian dng tnh ny s b cc t bo nang thc bo to thnh nhng git nh cht keo trong bo tng (th thc bo). Cc th tiu bo di chuyn n ch cc git keo nh ny to thnh cc th tiu thc bo, thyroglobulin iot ha, do thy phn axit, b thoi bin, li gii phng T3, T4 cng nh cc iootyrosin st li. Khi y T3, T4 s c vo mao mch quanh nang, mt mt to ra tyrosin li vo mao mch nhp vo ngun d tr axit amin lu thng, mt khc it v c t y li tham gi vo chu trnh it hoc c ti s dng trc tip ti ch hoc li tr v dng mu.Chc nng sinh l biu m nang :Biu m nang c 2 chc nng sinh l : tng hp, d tr, gii phng c hocmon lin quan n chuyn ha c s (T3 T4); sn sinh canxitonin duy tr nng canxi trong mu nhng gii hn nht nh. Hot ng ca tuyn gip phn nh s thay i hnh thi cc nang, biu m ph v cht keo trong lng nang.Chuk hot ng c th chia lm 3 giai on : giai on ngh hay tin keo (m t bo c), giai on hot ng tit hay to keo (nang nh); giai on d tr, bi xut hay thnh thc (nang ln).S vn chuyn cc sn phm ch tit ca t bo nang thng xuyn din ra thng qua cc git keo i vo lng nang v c ti hp thu cng vi cc hocmon i qua mng y vo li mao mch khong k. giai on u t bo dt, sm mu, t bo tng, nhiu glycogen, t li ni bo tng, t ribosom v khng dnh nhau. Dn dn giai on to keo c tin hnh vi ti lp th phong ph, ht ribosiom tng nhiu, li ni bo tng pht trin, my Golgi nm trn nhn vi nhiu ti, hc : t bo cao dn, hnh khi. Lng nang t ch o hoc khoang hnh sao vi t vi nhung mao lt, dn ra tr thnh h keo. Giai on ny din ra khong 1 gi ri cht keo ni bo bin mt. Khong k trn ngp li mao mch phong ph. T bo no hot ng th n to, mc cao, hnh tr c th c hnh phn chia; nhn trn, to dn, cc git keo cng to v c bit ni r sau khi kch thch bng thyrotropin. Cht keo vo lng nang ngy cng nhiu, dn dn c li, nang phnh to, t bo nang li thp dn. Sau giai on ny (khong 80 pht), tuyn gip tuy vn c nhng vng bit ha nhng ging tuyn thnh thc, hocmon trong cht keo li c s dng, cht keo vng ngoi long ra to iu kin cho s hp thu hay tiu keo. Biu m nang li dn dn tr v hnh khi, ri tr; bo tng li l r sng v 1 chu k mi bt u.Nh vy hot ng ca tuyn gip thay i theo hnh thi t bo ph; sn phm ca t bo c bi xut ra (cht keo) cng nhiu, nang cng to th t bo cng gim hot ng v ngc li. Trong thc t, bnh hc ca tuyn gip thng l bnh hc v s thay i hnh thi biu m nang m s m u thng l s ph i v qu sn c biu m ph ln ton b nang.Cho n nay, nhiu vn v chc nng tuyn gip cng c lm sng t hon ton v v th vic tm hiu nguyn nhn v c ch sinh bnh nhiu khi c kh khn. Ngi ta tm mi lin quan mt thit ca hocmon tuyn gip vi tng trng, chuyn ha c tim v nhp tim, hot ng c ch chc nng to mu, sinh sn v hot ng ca thn.Mt lot cng trnh nghin cu cng nh thc lm sng cho thy tc dng chuyn ha ca cc hocmon tuyn gip iu mt nh sinh nhit, chuyn ha lipit, gluxit, protit, canxi v nhiu loi vitamin. Cng thy c nhng lin quan nht nh gia cc hocmon tuyn gip vi 1 s hocmon nh insulin, prolactin, hocmon hng sinh dc, strogen vi c u gip n pht, c nhiu iu b n trong nhn sinh bnh nht l nhng cc lnh. Ngi ta c 4 loi khng th chng gip trong mt s bnh n gip k c t l thp 1 s ngi bnh thng nhng nguyn nhn su xa ca vic hnh thnh khng th vn cha r.Trong bi cnh y, l ng nhin i vi cc u nang gip, hiu nguyn nhn v c ch sinh bnh cn c nhng hn ch hoc ch mi a ra c cc gi thuyt.Bo hc : Bo m nang l phn t bo chnh, biu hin di 3 hnh thi ph hp vi cc loi tng ng trong m hc nhng khng ging thc s. Cng nh trong m hc, hnh thi t bo nang thay i theo cc vng khc nhau ca tuyn gip, giai on hot ng ca nang v 1 phn no theo tui, gii tnh. Nhng khc vi m hc, khng phi bao gi cng phn bit c r rng trn t bo, cc t bo bnh thng ca tuyn gip. Vic phn bit t bo bnh thng v t bo bnh trong tuyn gip nhng trng hp nht nh i hi nhiu kinh nghim, li phi c cung cp nhng thng tin lm sng cn thit nh tui, gii qu trnh bnh, th gii phu ca thng tn.T bo cao, hnh tr : kch thc t bo tng i ln, c th t ti 16 - 18m. Nhn v tr trung gian hay thp, hnh trn hay bu dc, bt mu va phi do cu trc hi c, li nhim sc mng, t thy ht nhn, nu thy chng thng c t, nh. Bo tng a baz t xanh xm nht ti hi tm, ranh gii gia cc t bo thng khng r. c bit nhng t bo ring l, d nt bo tng khi lm phin , thng ch thy l m hoc khng thy mng t bo. trng thi hot ng bo tng l r sng nh c bt v cha cc hc to nh khc nhau. Nh nhiu loi t bo tuyn khc, y cng thy cc loi ht cn hc nh, s lng va phi, mu xanh nht hay hi en, nm st nhn, gn cc hc nhng khng bm cht vo chng nh cc t bo ng thn. Cc ht ny hnh nh thy r hn khi c hot ng ch tit nng ca t bo tr. i khi thy t bo tr trng thi ngh ngi tit chm; bo tng hi c t hoc khng thy hc, tnh bt u mnh hn, cu trc bo tng vi cc ht khng nhn r, nhn sm, khng thy ht nhn, nhng t bo ny thng xp thnh nhng m c nh.T bo hnh khi : biu hin trn thc t bng hnh trn t bo , kch thc va phi, ng knh khng qu 12 - 13m. Nhn trn nm gia, t khi ngoi ra t bo, li nhim sc mng, mt khc nhau, t khi nhn thy c cc ht nhn nh. Bo tng c b r hn, bt u mu a baz nhng mc khc nhau.T bo dt : pht hin khng kh tuy t. Chng hnh trn a din hay dt hn, ng knh ln nht khng qu 10 cng lm l 15m. Nhn nh, nm gia, khi trn, khi dt, bo tng a baz bt mu ti, nhiu khi dp nhn khng r. nhiu ln chng ti ch thy chng l nhng t bo nhn tr, khng thy bo tng rt ging lympho bo thnh thc song bt mu nht hn. T bo loi ny thng i i vi nhng vng nhiu keo c mu xanh hay tm sm.T bo cn nang (t bo C, t bo sng) : c tng ng t bo nang hnh khi tr ln song bo tng sng, mu hng nht a axit, c 1 s ht mn v c th c cc hc ni bo tng.T bo ln a axit (cn gi l t bo K hoc t bo Hurthe Askanazy) : t bo trn, to ng knh thng trn 15m, c trng bng bo tng nhiu, vnh rng, mu xm xanh nht hay tm nht, c nhiu ht a axit. Ranh gii gia cc t bo thng r, mt cc tnh. Khi t bo ln a axit khng c nhiu ht a eozin th phn bit vi t bo C rt kh. Trn t bo bnh thng him gp v kh phn bit t bo K v C.i thc bo tuyn gip : khng nhiu, c th gp 2 loi : i thc bo thng thng trng thi t do, c kh ln ging nh cc m khc, i thc bo c trng : hnh trn hay bu dc, ng knh khong 25 - 40m, thm ch hn na c th c gi tc. Bo tng (nhiu khi c nhn) c nhiu hc l r sng, hnh bn c (hc sng xen k u n vi nhng vng bo tng cn li mu xanh) cn gi l thc bo bt. Nhiu khi tnh bt mu ca i thc bi b ph hoi nghim trng : t bo tr nn l m, kh nhn, ng nt khng r nh t bo cht. Nhiu i thc bo cha cc th vi ni bo tng di dng cc ht ln mu en hay xanh nht en v c xem nh vt tch ca s thc bo ch yu i vi hemosiderin v cht keo. Nhn ca loi i thc bo c trng ny thng nh, nm lch 1 bn v hay c hnh teo c.Hnh vi nang : thng gp nhng s lng khng nhiu. l nhng cu trc nhiu nhn ng nht vi nhn trn, bo tng thng khng c ranh gii r, chng xp hnh trn hay hnh nhn, d nhn khi c cht keo trong lng. Nhiu khi chng ch gi hnh ng tuyn v hnh gi hoa hng nh vi lng o, thm ch ch c mnh tuyn hnh mng nga, cnh cung.Nhum PAS quanh cc hnh vi nang c mng y lin tc bc, bt u ti cn nhum M.G.G (May Grunwarld Giemsa) mng y mu sng nht.Cht nn keo : t khi thiu. N biu th di dng 1 cht thun nht v bo, mu xanh hay hng tm vi sm nht thay i tu keo nhiu, t, c hay long. C khi keo c ti mc vn cc li thnh hnh que hay hnh ct mng tay, mu hng tm sm. Ngoi cc thnh phn trn lun lun thy hng cu, i khi t lympho bo, si to keo, t bo si, t bo ni m. i chiu vi m hc, vic nhn dng cc t bo tuyn trn phin c kh hn v trn thc t nhiu khi c 3 hnh thi tr, khi, dt u ch phn nh bng 1 hnh thi duy nht : t bo trn, thm ch khng nhn c bo tng ch c nhn tr. Trong m hc hnh thi biu m nang lun tng phn vi mu cht keo trong lng : t bo cao, keo t v long; t bo cng thp, dt keo cng nhiu v c. Nhng trn t bo mi lin quan ny nhiu khi khng biu hin r hay c trng. Tuy nhin vn c th xc nh c 5 yu t ring cho t bo tuyn gip : cc t bo biu m tuyn, hnh vi nang vi vng nhn tng i r, cht nn keo thng ng nht, cc ht cn hc trong bo tng, cc i thc bo t do nht l loi c trng cho tuyn gip.Nguyn nhn gy bnh : ngoi nhng trng hp t gp nh u nang pht trin trong u tuyn hoc rt c bit nh u nang sinh ra trong qu trnh hy hoi v pht trin ca 1 ung th tuyn gip, thng gp 3 loi u nang gip sau : u nang gi chy mu n thun, u nang tht, u nang gi chy mu trn c s 1 u gip n thun c trc.U nang gi chy mu n thun : v mng li mao mch ca tuyn gip rt phong ph, mng manh li tip gip ngay cc tuyn nhiu khi dn rng nn nhng ri lon vn mch d gy nn chy mu khong k. Mt khi s thoi ha, hy hoi tuyn li xy ra th kh nng sinh u nang cng c iu kin thc hin. Mu t khong k trn vo lng tuyn lm tuyn cng dn ra, t bo b hy hoi v dn dn ti tuyn mu khng cn biu m ph, bin thnh 1 bc mu, chn p cc ti tuyn xung quanh. U nang gi chy mu n thun v th khng c vch v t bo ph lt. C ch ca chy mu cn bn ci : ri lon vn mch do cm xc mnh, t ngt, nhim c, nhim khun, tng hot ng tuyn yn - tuyn gip, tit qu nhiu kch gip t (TSH). Chng ti gp 1 s trng hp c bit nhng rt in hnh : bnh nhn thy xut hin rt nhanh khi sng gia c sau khi nghe ting st, nghe tn la n gn hoc khi c bo ngi thn t ngt qua i.U nang tht : gi l u nang tht v y l 1 u thc s c vch v biu m lt vch nang. Nguyn nhn cha xc nh r mi ch l gi thuyt; ngun gc u t cc di tch phi st li, v d pht trin t ng gip li, cc mn bn (tuyn mang cui) sinh ra cc u nang mang (kystes branchiaux).U nang gi chy mu trn 1 u gip n thun c trc : trn thc t y l loi u nang gi ph bin nht c hnh hnh trong giai on mun ca qu trnh to u gip c bit cc u gip n thun nhiu cc. Mt bnh nhn c th c ng thi nhiu u nang gi chy mu. V vy s hnh thnh u nang gi gn lin qu trnh to u gip. D bt k nguyn nhn no (thng gp nht l do thiu it), nhn chung qu trnh to u gip din ra qua 2 thi k. giai on u tuyn gip phn ng vi s kch thch ca TSH va bng qu sn (tng s lng cc nang) va bng ph i (tng th tch cc nang). S qu sn v ph i ny lm tuyn gip to ra c tnh lan ta song tuyn vn bo ton c hnh thi thun nht ca thng tn. Ban u nang qu sn c t bo biu m hnh tr hoc hnh khi, lng cha t hoc khng c keo. Xen k nhiu nang loi trn c 1 s nang ln, biu m thp, dt, c khi dng ni m, lng cha nhiu keo. Dn dn cc nang rng cha nhiu keo c, thun nht, a eozin pht trin thm. Ty mc thiu it v phn ng ca tng c th hoc thi gian mc bnh m cc ti tuyn nh (u gip tip nhu m) hay ti tuyn ln (tip keo) chim u th. Giai on qu sn lan ta c ca tuyn gip, theo kinh nghim tip nhu m d phc hi hn nu c iu tr ng, kp thi.Sau 1 vi nm hoc nhiu nm tu tng cc th u gip s chuyn sang giai on cc khng thun nht, c th ko di hng chc nm cho ti sut i ngi v kh nng hi phc rt hn ch.Thng tn qu sn b ca thi k u s dn dn i i vi thng tn trin lm o ln cu trc lan ta, ng thi dn ti cc thng tn a dng. Bn cnh nhng cc ti to (hay cc thay th) gm nhiu nang nh c biu m qu sn, ph i, thm ch sinh nh, xut hin nhiu nang ln dn rng, cha y keo c nhiu khi thoi ha, ho nhp vo nhau hnh thnh cc u nang keo c khc nhau. Cht m (m lin kt mch) cng c nhng bin i phc tp : mng li mao mch khng u na, tr nn khc khuu nn di ra nhiu, song lng hp li i khi dn rng na. Mng li mao mch mi ny l nguyn nhn ca hin tng thiu mu cc b, hoi t k c chy mu. Hin tng ph, ngm keo, x ha v thoi ha trong lm khuych tn cc ti tuyn. Xut hin nhng tiu cc ti tuyn thoi ha vi nhiu m bo, i thc bo cng c nhng vng canxi ha to thnh nhng ht m thm ch ct ha. Do s yu t ca mng li mao mch mi cc ri lon tun hon xy ra hu nh hng nh, i t chy my nh n thun n nhi mu ln, tuy kh pht hin trn lm sng song d thy trong m hc biu hin nhng m mu c canxi hoc nhng bc mu thc s, c hemosiderin v colesterol c trng cho nhng u nang gi chy mu.Nhng hoi t chy mu khng c biu m ph song thng c vch mng si to keo.Bnh cng ko di cng c nhiu t qu sn v thoi trin, nhng ti to so ha, lm cho m x tng sinh chia ct cc vng thng tn; tuyn gip khng ch to ra m c nhiu mi, nhiu cc, ch cng, ch mm to thnh hnh nh u gip nhiu cc trong qu trnh to u gip mun trn lm sng.R rng l vi nhng thng tn su sc n mc y, kh nng cha khi bnh phng php ni khoa trc nay vn c coi l khng hin thc.U gip cc khng ng nht l giai on bnh thng gp nht lc phu thut trong nhiu thp k va qua trn th gii cng nh Vit Nam.Chn on : k thut chc ht tuyn gip bng kim nh hu nh c th p dng cho mi trng hp tuyn gip to th cc (1 cc n c hay nhiu cc) c tnh trng bnh nng, trc iu tr ni chung v trc phu thut ni ring cng nh c th tin hnh ngay t ln khm lm sng u tin trc mi xt nghim khc. i vi tr nh, ph n c thai, ngi gi yu cn cn trng khi xt nghim. Bnh nhn cn c ngh ngi thoi mi khi tin hnh th thut : nu cn cho ung thuc trn tnh.i vi u nang gip khng c chng ch nh tuyt i ngay c vi bnh Basedow hoc u gip c ang tin trin (bnh Plummer), nhiu tc gi vn chc vo thng tn xc nh.Tuy nhin c 1 s nguy c cn c lu : nu ang chy mu nng, chn p kh qun, dng kim nh ( s 24 26 ) chc ht nhanh s hn ch tai bin. Nhng ngi mc bnh tim nht l bnh mch vnh hoc nhng ngi c trng thi thn kinh d b kch thch, nu khng c chn on k (gii thch, ng vin, ngh ngi, ung thuc trn tnh trc 1 gi) c th b ngt xu khi lm xt nghim. Nhng trng hp u gip c ang tin trin, bnh Basedow vi cc triu chng lm sng in hnh, cn chun b bnh nhn chu o, xt nghim nhanh, theo di nghim ngt. Kinh nghim Vit Nam v cc nc khc cho thy c nhng trng hp tai bin nguy kch sau khi chc : bnh nhn b cn kch pht tuyn gip dn n t vong t ngt. C trng hp gy lan trn ung th theo ng kim chc : thc ra tai bin ny c tnh l thuyt nhiu hn, trn thc t ch gp rt c bit, mt trong hng vn trng hp ung thu tuyn gip (theo Wildmeister W. v cng s 1973). Soderstrom N. cho nguy c lan trn ung th do kim chc khng ln hn nguy c s nn u khi thm khm.K thut ly bnh phm, lm phin qua chc ht kim nh : mi bnh nhn u phi c kim tra k tuyn gip bng nhn, s nn khi sng, c bit khng b qua ng tc nut ca h : cc cc gip lun lun di ng theo nhp nut. Cch kim tra ny cho php loi tr cc u khng phi ca tuyn gip nh ca tuyn nc bt, ca chui hch c. C th bnh nhn ngi thoi mi trn gh (tt nht l gh bnh c m) lng ta thnh gh, u hi nga ra sau hoc bnh nhn nm nga gy n gi mm. Bnh nhn ngi th dch u nang chy ra d hn, nhng nu nm th d thi gian dch u nang ra ko di bnh nhn vn cm thy d chu yn tm.Khi cc gip n c th ng knh thng t 2 3cm nhng u gip nhiu cc, cc cc gip to nh khng u c khi rt ln (ng knh 8 10cm). V tr cc gip rt thay i thng thng gia c nhng cng c th lch hn sang phi hay tri, pha trn c th v tr sn gip mng, pha di c th tip gip xng c.Hu nh tuyt i a s cc u nang gip u c mt cng v i khi c th chn on c trc khi chc nh hi, khm lm sng n thun (u gip 1 cc xut hin v hnh thnh nhanh, to ln nhanh trong my gi hoc vi 3 ngy). Loi u ny hu ht l u nang gi chy mu n thun v d cha khi hon ton ch sau 1 ln chc ht. Khi chc khng cn gy t, bnh nhn khng c nut, d c cm gic bun nut (c th do kim chm vo tuyn gip, kch thch phn x nut 1 s nhy cm). Dng bm tim 20ml dng kim chc s 20 26 ty tui bnh nhn, c uCh dng kim s 16 18 cho nhng u nang ti pht ( bit chn chn bnh nhn c u nang gip) trnh tai bin khi chc. gy n tng nh nhng, d chu cho bnh nhn, nn chc kim khng lp sn vo bm tim. Chc thng vo ni u cng mng v phn thp. Khi kim vo trong u bnh nhn c cm gic st nh v dch u nang s t chy ra ngay (nu lp bm tim, nhiu khi p sut trong u s t y pittng bm tim ln). t th ngi dch u chy ra mnh hn v d ly ht. Gn v cui dch nang chy ra chm c th h tr bng p tay vo phn u cha xp hn. t th nm dch u ra chm hn, ngi chc cn c ngi ph phi hp ng tc chc ht vi nn, p u t t cho n khi u xp hn mi thi.Vic ht dch u nang phi tht nh nhng, t t, trnh kim chc di ng gy chy mu thm, v 1 s ngi c trng thi d kch thch hoc qu yu, hc c th b xu i tm thi nu ht dch ra qu nhanh.Trng hp u nang c mi hay ngch thng, chc 1 ln u cha xp hn cn i ch thay kim chc tip, ht ti khi u hu nh bin mt mi thi. Nu chc tho u nang xp ht song kim tra tuyn gip vn cn khi sng nht nh, cn chc vo thng tn ny ly thm bnh phm xt nghim ring.Lm phin nh thng l, ch nhng trng hp dch long nhiu mi cn cho ly tm, ly cn lm phin . Phin phi tht kh t nhin mi c c nh vo dung dch cn tuyt i ete th tch bng nhau. Nhum Giemsa, HE, Papanicolaou ty phng xt nghim, c th soi ti, nhum hunh quang, lam Alcian, PAS, Soudan III khi cn thit hoc nhum Gram, nui cy tm vi khun gy bnh.Tr trng hp u gip nhiu cc, thng thng sau khi chc tho ht dch, a s cc u gip cc n c s xp hn v bin mt. Dn bnh nhn king ni vi ngy, trnh vn ng mnh vng c, nn bng p vo vng u xp hn ch hin tng r mu li dn ti ti pht u nang.Chn on i th : theo kinh nghim tuyt i a s cc u nang gip c th chn on chc chn bng mt thng nu ht ra dch v u xp hn hoc nh i r rt. S kh xc nh c u nang ghp trn u gip c sn nu dch ht ra l mu ti v u khng xp hoc nh i ti mc nhn bit c.Lng dch ht ra thay i v trong cc u nang n thun, thng tng ng th tch u. V a s u nang (trn 70%) c ng knh khng qu 3cm (qua 605 h s) nn dch ly c thng di 5ml. t khi u nang qu nh hoc qu ln, lng dch di 1ml hay trn 10ml u ch gp di 10% s trng hp bnh nhn, cn trn 50ml ch l c bit.Tnh cht ca dung dch trong u nang (mu sc, qunh) cng thay i theo bnh nhn v ty thuc vo nhiu yu t nh thi gian chy mu, lng keo, phn ng ca c th (c trng bng i thc bo) v kh nng b bi nhim.T hng ngn trng hp u nang gip c xt nghim bnh vin Bch mai, xc nh c 5 nhm dch trong u nh sau : dch long trong nh nc sui (i khi vng chanh) th tch thng trn 5ml. Dch snh, qunh, vng nht, thng c bt. Dch qunh c kh ht, ging keo hay nha chui, dch c nh m, dch mu hay mu thanh dch : nhm ny ph bin nht gp trn 70% s bnh nhn, trong i a s c mu nu in hnh : dch c mu c ph.Qua i chiu lm sng v vi th, nhm dch long trong, dch snh, qunh, c thng gp trong u nang tht; dch c, trong u nang bi nhim v dch nu, c trng cho cc u nang gi chy mu.Chn on vi th : cho php xc nh loi u nang trong tuyt i a s trng hp, nhng thnh phn thng gp :+ Cht nn keo nhiu hay t, khi keo nhiu c, nn tm sm, c hnh kim, hnh vt ct mng tay. Khi keo long, t, nn khng u xanh tm nht.+ Hng cu t nhiu thoi ha : hu nh khng bao gi thiu tu mc thoi ha, xc nh chy mu mi, c.+ Mnh vn t bo thoi ha km cht cn t bo.+ Nhng t bo biu m lt vch u nang, loi tr hay dng biu b, t ch tit (u nang tht) hoc khng ch tit, cc t bo biu m tuyt (t gp trong u nang n thun, hay gp trong u nang ghp trn u gip c sn), chng c th thay hnh bin thnh i thc bo vi cc hnh thi chuyn tip.+ Cc i thc bo c trng.+ T bo vim cc loi, nu c thng l bch cu a nhn trung tnh thoi ha chim u th.+ t t bo dt, dng ni m, i khi t bo si, cc si to keo, t bo ln a axit (oncocyte).Cn c vo s pha trn, s lng, cht lng ca cc thnh phn ny c th phn loi thnh 3 nhm u nang :+ U nang tht t nhiu u c t bo biu m loi khi, tr dng biu b, c 3 bin th :1/ Tip ngho t bo : cht nn nht, khng ch ngho t bo biu m m him mi loi t bo khc. Tip ny tng ng vi loi nc trong v i th. Cng c khi cht nn c, tm hng sm, thun nht trong lc c t t bo biu m cng nh cc thnh phn t bo khc (tng ng dch snh, qunh, c v i th).2/ Tip chy mu : him gp, ch yu l hng cu thoi ha t nhiu ln vi t bo biu m.3/ Tip bi nhim : rt him gp, khng r cht nn song c nhiu bch cu a nhn thoi ha ln vi t t bo biu m.U nang gi chy mu n thun : (khng c vch tht s nn khng c t bo biu m ph nh trong u nang tht, thng rt nhiu hng cu thoi ha t hay nhiu) c 4 bin th :1/ Tip chy mu mi : hng cu dy c, t thoi ha nn hnh thi nhn r, ranh gii r. Phn ng i thc bo mnh hay yu, cht keo nhiu hay t tu tng c th.2/ Tip chy mu c hay tng i c : hng cu dy c hay tha tht nhng bao gi cng thoi ha, i thc bo phn ln cng thoi ha, nhiu mnh vn, cht cn t bo. Lng i thc bo v cht keo nhiu hay t tu tng c th, i khi c cc si to keo, c th xp thnh b m nh.3/ Tip a hnh thi t bo : ngoi hng cu c nhiu t bo tuyn, i thc bo cc loi, c th xp thnh m nh, hnh vi nang hoc cc hnh trung gian gia t bo tuyn v i thc bo. Cht keo thay i ty tng trng hp bnh nhn.4/ Tip bi nhim : him gp nhng ni bt bng bch cu a nhn trung tnh thoi ha chim u th, ln p mi thnh phn khc, c khi nh dch m, nhiu hng cu thoi ha v mnh vn t bo. T bo tuyn v i thc bo kh nhn cng nh nn keo.Hai tip chy mu mi v c m t trn chim a s (trn 2/3 tng s trng hp u nang gi chy mu) v c th chn on xc nh khng kh. Song vi tip a hnh thi t bo ch chn on xc nh nu sau chc ht, u xp ngay hon ton.U nang gi chy mu ghp trn u gip n thun c trc : v sinh ra giai on mun ca qu trnh to u gip thng thng nn s bnh nhn n khm ngy cng nhiu, hn hn s lng cc u nang gip n thun (c loi tht hoc gi).Loi u ny gn ging tip a hnh thi ca u nang gi chy mu n thun : bn cnh hng cu dy c, cht nn keo, i thc bo, d thy cc t bo ca cc ti tuyn gip ng ri rc, xp thnh dy, b, hnh vi nang, hay m nh i khi m kh ln. chn on xc nh khng ch da vo hnh nh vi th m phi phi hp chn on vi th vi 2 c im :U gip cc (1 cc hay nhiu cc) n thun (khng c biu hin ri lon ni tit hay bnh nng).Sau ht dch (d c gng ly ht) u gip cc ch nh i ch khng bin mt.Chn on phn bit vi 1 u nang gi chy mu xy ra trn 1 u tuyn gay 1 ung th t khi t ra v him gp v nm trong ch ca bnh ung th hoc u tuyn tuyn gip.iu tr : v nguyn nhn, c ch sinh bnh, chn on 3 loi u nang tuyn gip khc nhau nn phng thc iu tr cng khc nhau, xc nh kt qu iu tr, ngoi quan st kh nng bin mt u v khng ti pht (khi bnh) cn o vng c qua c u bng thc dy trc v sau khi chc tho dch nh k (nu u khng bin mt).U nang tht : chc tho ch lm , khng cha khi bnh, ch c phu thut ct b mi gii quyt c kh nng ti pht u. Song 1 s bnh nhn c u to nhiu ngch, tui cao, mc bnh qu lu hoc sc yu khng mun m, chc tho l cn thit, trnh cho h nhng kh chu tai bin nh b chn p vng c, cm gic nng, kh nut, kh th, chng mt, nhc uKh nng ti pht u nang tht sau khi chc tho l dt khot song thi gian u to li nh c ty thuc c u ban u v tng c th, thng thng t 2 6 thng phi chc li.U nang gi chy mu n thun : trng hp bi nhim (sau chn on vi th) mi kt hp cho khng sinh, chc tho l ch nh chung cho mi trng hp.Nhng u nh d ly ht dch, bng p, king ni sau vi ngy l khi nhanh, khi hon ton. Nhng u ln hn nu c ti pht cn chc tho li. nu sau vi ln chc tho khng khi ch lm bnh , cn kim tra li kh nng u nang tht hay u nang gi ghp trn u gip sn.Chng ti khng dng cc thuc corticoide, cc cht lm bin i u hay gy x cng nh quinine, ur (dung dch), salicylate sodium 10 30%, stradecol 1% (1ml), ttradecylsulfate sodium nh ca 1 s tc gi v c th d gy bi nhim, c ch phn ng i thc bo hoc gy tai bin khc nh bnh nhn chong, ngt xu i. Nhng trng hp ti pht nhiu ln, nu bnh nhn c yu cu c th can thip gii phu.U nang gi chy mu ghp trn u nang gip n thun c trc : v khng chn on c bnh chnh xc, trc y Vit Nam cng nh nhiu nc khc, trc 1 u gip cc bnh nng sau 1 thi gian iu tr ni khoa th thch (6 thng n vi 3 nm), nu u khng nh i can thip phu thut l ch nh c tnh nguyn tc. Vic m trn lan tr thnh khng th chp nhn c, ngay 1 nc pht trin nh Hoa K. Nm 1984, Ramacciotti C.E v cng s cng b Hoa K mt chin lc v liu php ngn chn bnh ny : kt hp chc tho dch u nang gi vi iu tr ni khoa u gip n thun. Liu php ny c p dng vo Vit Nam t nm 1985 c b sung v t bo hc qua chc ht kim nh. Gi liu php l chn bnh vi ngha : nu khng cha khi th cng ngn chn khi u gip khng pht trin thm hoc lm cho u nh i, to iu kin cho ngi bnh c th sng vi khi u sut i nu h khng mun hoc khng c ch nh phu thut. Ramacciotti v cng s s dng liu php ngn chn bnh ny cho nhiu loi bnh ca u gip cc. Thuc iu tr ny l Levothyroxine sodium vi liu lng 0,1 0,3mg/ngy, theo di ban u 3 thng sau nh k o li cc gip trong qu trnh iu tr. Vit Nam ch p dng liu php chn bnh i vi u nang gi ghp trn u gip c sn : chc ht kt hp dng thuc. Liu php ni tng gip nh bt hay vin bt tuyn gip sc vt (ln, b, d, cu) cng c tc dng kim ch pht trin u. C th dng L.thyroxine nh lvothyrox, thyroxine, dng vin 50 - 100m mt ngy (hoc loi git ung vi liu tng ng 1 git = 5m). V dng ko di nn thng ch dng liu 50m/ngy, phi theo di bnh nhn nu c cc triu chng qu liu, khng chu thuc nh gy i, mch nhanh, a chy hay kht s nng (so vi ngi xung quanh) ra m hi tay cn ngng thuc tm thi, kim tra nng T3, T4 trong huyt thanh c bin php iu chnh.Kt qu iu tr v tin lng bnh.U nang tht : ch cha khi hn bng phu thut, chc tho ch l bin php lm du, p dng khi bnh nhn c yu cu thc s t nguyn.U nang gi chy mu n thun : chc ht kim nh thch hp nht vi nhm bnh ny, va c tc dng chn on bnh chc chn va em li kt qu iu tr tt, p ng c 5 yu cu : n gin, nhy, tin cy c c hiu sut v tit kim.Qua i chiu t bo hc v din bin lm sng xc nh khi qut 6 yu t (3 tt v 3 khng tt) anh hng n tin lng bnh nh sau :Tin lng bnh cng tt khi dch ht c kit v cng t (tng ng cc u nang c ng knh di 2cm), u nang xp hn v bin mt, khi chy mu cng mi v phn ng i thc bo cng mnh.Tin lng bnh ti nu cc c im ca dch ht ngc li vi 3 yu t trn hoc c thm 1, 2 hay c 3 yu t sau : nhiu keo c, c nhiu si keo, t bo si, xut hin phn ng vim.Tin lng c coi l rt tt khi bnh khi hn ngay sau 1 ln chc duy nht, tt khi u xp v bin mt vi ngy n vi thng sau khi ht dch nang, khng c ti pht, chp nhn c, sau nhiu ln chc ht mi khi hoc ti pht mun khng c bin chng; ti khi u ti pht nhanh sau mi ln chc, phi can thip phu thut do bnh nhn yu cu.U nang gi chy mu ghp trn u gip n thun c sn : trng hp tin trin tt, sau mi ln chc u gip mm ra dch ht c nhiu t bo tuyn thoi ha, hoi t, nhiu i thc bo v mnh vn t bo. U nh dn thm ch bin mt, thng sau 6 thng p dng liu php chn bnh. Tin lng kh quan hn vi loi u gip 1 cc, nguyn nhn do thiu it nhng vng u gip a phng. Tin lng d dt vi nhng u nang ghp trn u gip cc (c bit loi nhiu cc) lu ngy hoc cha r nguyn nhn.Kh khn ln i vi chng ta l kh nng theo di lu di v lm cc xt nghim kim tra cho bnh nhn c v huyt thanh ln t bo. Kh khn ny ch c th khc phc dn tng bc trong tng lai cng vi vic nng cao dn tr v kh nng kinh t pht trin mnh.