PHC IU TR X GAN TIN TRIN

BNH VIN BCH MAI

PHC IU TR

Khoa: Tiu ha

PHC IU TR X GAN TIN TRINCp nht ngy 30 /12 /2009I. nh ngha:

X gan l tn thng gan mn tnh khng hi phc, gy ra do nhiu nguyn nhn, c trng trn m bnh hc bi s x ha lan ta, o ln cu trc t bo gan, hnh thnh cc nt (nodule) c cu trc bt thng.X gan chia lm 2 giai on:

Giai on tim tng (cn b).

Giai on tin trin (mt b).

II. Chn on:

1. Lm sng:

X gan cn b: Triu chng lm sng ngho nn. Khai thc tin s vim gan, nghin ru

X gan mt b: Triu chng lm sng biu hin

Hi chng suy t bo gan.

Hi chng tng p lc tnh mch ca.2. Xt nghim:

Cng thc mu ngoi bin.

ng mu c bn (PT%).

Sinh ha mu: Albumin, billirubin TP/TT, AST, ALT, GGT, (FP, glucose, ure, creatinin, in gii , canxi, NH3 ( khi tin hn m, hn m gan).

Xt nghim virus: HbsAg, Anti HCV. Nc tiu: tng phn tch nc tiu, in gii niu (khi c c trng)

Siu m bng.

Soi thc qun d dy pht hin gin tnh mch thc qun, d dy.

Nu c c trng: xt nghim sinh ha, t bo.

3. Chn on xc nh: Da trn lm sng v xt nghim c Hi chng suy t bo gan.

Hi chng tng p lc tnh mch ca.

4. Chn on nguyn nhn: Do ru, do virus, t min, cc nguyn nhn him gp.

5. Chn on phn bit: Vim gan, tc mt, x gan tim, tng p lc tnh mch ca do cc nguyn nhn khc.

III. iu tr:

1. Nguyn tc iu tr:

Hi phc chc nng gan.

D phng bin chng: Xut huyt tiu ha, nhim trng dch c trng, tin hn m gan.

D phng tin trin: Nng x gan (theo Chid-Pugh), ung th ha.

2. Thuc iu tr c th:

Ri lon ng mu: vitamin K dng 3 ngy nu t l prombin khng tng dng s dng vitamin K . Truyn huyt tng ti nu c nguy c chy mu.

Tng o thi mt: ursolvan, Cholestyramin (Questran)

Truyn albumin human nu albumin mu gim (Albumin < 25g/l) v c ph hoc km trn dch cc mng

Truyn dung dch acid amin phn nhnh: morihepamin, aminosteril N-hepa 500 ml/ ngy

Vitamin nhm B ung hoc tim

Li tiu: nu c ph hay c trng: bt u bng spironolacton 100mg/ ngy tng dn c th phi hp vi furosemide liu ban u 40mg/ ngy. Trong qu trnh dng thuc li tiu giai on gim cn nn duy tr gim u 500g/ ngy khng vt qu 1kg/ ngy

iu tr c trng:

+ Hn ch lng mui hng ngy 250 BCNTT/(l (0,025G/l) hoc cy dch mng bng pht hin VK.

4. Chn on phn bit:Vim phc mc th pht do thng tng rng, vt thng thnh bng, p xe thnh bng.

III. iu tr:

1. Nguyn tc iu tr:

iu tr khng sinh sm khi nghi ng c nhim trng dch c trng.

D phng cc bin chng: Hi chng gan thn, tin hn m gan.

2. Thuc v iu tr c th:

Khng sinh ton thn: i vi trng hp khng c nn, khng c sc, khng c bnh no gan v creatinine < 265 (mol/l ( 51 (mol/l dng ciprofloxacine 500mg hng ngy hoc trimethoprim/ sulfamethoxazole 800mg/160mg/ ngy tun dng 5 ngy t th 2 n th 6, dng ko di.

IV. Theo di v ti khm:

1. Cc ch s cn theo di:

Nhit , tnh trng nhim trng. C trng, s lng nc tiu.

CTM.

2. Ti khm:

Sau 1 4 tun.

V. Ti liu tham kho:1. Bacterial infections in portal hypertension. Textbook of Hepatology 3rd (2007), 761 770.

2. Bruce A. Runyon. AASLD pratice guideline: Management of Adult Patients with Ascites Due to Cirrhosis: An Update. HEPATOLOGY, Vol. 49, No. 6, 2009, 2087 2107.

PHC IU TR X GAN C

TIN HN M GAN HN M GANCp nht ngy 30 /12 /2009I. nh ngha:

Hn m gan l ri lon chc nng thn kinh tm thn do suy gan, l bin chng quan trng v nng n ca tnh trng suy gan nng, hoc sau nhng phu thut ca-ch bnh nhn x gan. Hn m gan thng l giai on cui cng ca suy gan d dn n t vong.II. Chn on:

1. Lm sng: Xut huyt tiu ha, nhim trng dch c trng thng l cc nguyn nhn khi pht tnh trng hn m gan.

Biu hin ri lon tm thn v thn kinh.

nh gi mc hn m theo thang im Glassgow.

Ri lon nhp th, hi th c mi to thi.

5 giai on hn m ca Morgan (1987) GTr/chng01234

Tnh trng tinh thnBnh thngQu vui, lo lng, gim ch Mt phng hng, ri lon c x, qu bunL m, ln ln, chm chpHn m

Flapping tremor(-)Himt, khng uThng cLun lun c

Ni s120

NH3 mu ng mch (mg/l) 200

2. Xt nghim:

Cc xt nghim nh gi chc nng gan. Cc xt nghim loi tr nguyn nhn hn m khc: in no , MRI s no.

3. Chn on xc nh:

Da trn lm sng v xt nghim.

4. Chn on phn bit:

Tai bin mch no.

Alzheimer, Parkjinson, ng kinh.

III. iu tr:

1. Nguyn tc iu tr:

iu tr sm kt hp iu tr nguyn nhn gy khi pht hn m gan.2. Thuc:

Ornicetil: dng loi ng 5g truyn tnh mch 10 20 g/ 24 gi

Dung dch acid amin phn nhnh: Morihepamin, AminoNhepa 500 / 24 gi

Lactulose: ung hoc cho qua sonde 5 10 g / 24 gi hoc tht tho

Khng sinh ng rut: Ciprobay 500mg ( 2 ln /ngy hoc Neomycin hoc Flagyl

Vitamin nhm B ng tim

Ch n gim protid tng cht x. Lng protein a vo < 1g/kg/ngy

Tm nguyn nhn khi pht hn m gan x tr nguyn nhn.

3. iu tr duy tr:

Lactulose

Ch n gim protid tng cht x.

Phng trnh xut huyt tiu ha, nhim trng dch c trng.

IV. Theo di v ti khm:

1. Ch s theo di:

Tinh thn, s lng nc tiu, c trng. Cc xt nghim nh gi chc nng gan.

2. Ti khm: 1 - 4 tun.

V. Ti liu tham kho:1. Hepatic encephalopathy. Textbook of Hepatology 3rd (2007), 728 750

2. Julie Polson and William M. Lee. AASLD Position Paper: The Management of

Acute Liver Failure.HEPATOLOGY, May 2005, P 1179-1197.PHC IU TR XUT HUYT TIU HACp nht ngy 30 / 12 /2009A. XUT HUYT TIU HA DO LOT DD-TT:I. nh ngha:

Xut huyt tiu ha do lot d dy t trng l tnh trng chy mu do lot n thng cc mch mu d dy t trng, l mt cp cu ni ngoi khoa.II. Chn on:

1. Lm sng:

Nn ra mu ti hoc mu cc.

i ngoi phn en.

Thiu mu: Mch nhanh, huyt p tt, nim mc nht, v m hi, tnh trng shock do gim th tch.

2. Xt nghim:

CTM, MCB, ure, creatinin, G, HBsAg, Anti HIV

Bnh nhn > 50 tui: Lm in tm , CK, CKMB.3. Chn on xc nh:

Da vo ni soi thc qun d dy t trng.

Bng phn loi xut huyt tiu ha qua ni soi ca Forrest (1991)Tnh trng chy muTiu chun ni soi

IA. ang chy muChy mu mch thnh tia

IB. ang chy muChy mu r rat khng phun thnh tia

IIA. Chy mu cmy lot c cc mu ng

IIB. Cn du hiu bt thngThy r mch mu y lot

IIC.m bm tm nim mc

III. Mu ngng chy khng c du hiu bt thngTn thng khng c du hiu chy mu

4. Chn on phn bit:

XHTH do v gin TMTQ.

XHTH do rch tm v

XHTH do di dng mch, khi u.

XHTH do polyp thc - qun d dy t trng chy mu.

Chy mu ng mt.

III. iu tr:

1. Nguyn tc iu tr:

B khi lng tun hon, truyn mu.

Ni soi d dy xc nh chn on v can thip cm mu.

S dng thuc c ch bi tit acid sm.

2. iu tr c th:

u tin hng u trong Hi sc l b li lng dch mt v ti hi li tnh trng n nh huyt ng.

Tt c bnh nhn phi c t ng truyn tnh mch. bnh nhn c ri lon huyt ng, t 2 ng truyn tnh mch ln (kch thc 16-18G) mt trc khuu tay hay t catheter tnh mch trung tm nu khng th t c ng truyn tnh mch ngoi bin.

Cho th oxy qua xng mi 3-6 L/pht

Cc bnh i km phi c nhn bit v iu tr thch hp.

Bi ph th tch:

Bi ph th tch c bt u truyn tnh mch dch mui ng trng 20 ml/kg. a s bnh nhn truyn 1-2 L dch mui ng trng (NaCl 0,9%) s iu chnh c th tch dch b mt.

Cc dch keo t tin hn v khng c chng minh l c li hn so vi dch mui trong sc mt mu. Tuy vy nu sau khi truyn dch mui ng trng ti tng liu 50 mL/kg song bnh nhn vn cn du hiu sc cn truyn dch keo (500-1000 mL) bo m th tch trong lng lng mch

Plasma ti ng lnh l thch hp i vi BN b XHTH cp c tnh trng ri lon ng mu. Truyn tiu cu cho BN ang b XHTH v c con s tiu cu < 50.000/mm3.

Truyn khi hng cu: i vi ngi > 60 tui duy tr Hb>100g/l

c ch bm Proton ng tim TM: thuc c ch bm proton (PPI) 80mg tim tnh mch sau duy tr 8 mg/gi trong 72 gi ( vi omeprazole, pantoprazole, esomeprazole), ring omeprazole khng truyn c m tim TM. Nu dng rabeprazole liu 40mg tim tnh mch sau duy tr 4 mg/gi trong 72 gi Ni soi d dy t trng cp: tim cm mu, clip...

Theo di st huyt ng

Hi chn bc s chn on hnh nh phi hp can thip hoc hi chn ngoi khoa khi ni soi cm mu tht bi hoc nu sau ni soi cm mu 2 ln vn chy mu ti pht

3. iu tr duy tr:

Thuc c ch bm proton dng vin: Esomeprazole 40mg/ngy, Pantoprazole 40mg/ngy, Rabeprazole 40mg/ngy. Ch phi hp iu tr dit H.P nu c sau khi XHTH n nh.

IV. Theo di v ti khm:

1. Ch s theo di:

Mch, huyt p, nim mc, phn.

CTM.

2. Ti khm:

Sau 1 thng.V. Ti liu tham kho:

1. Chn on v iu tr xut huyt tiu ha cao. Bnh hc Ni khoa (dnh cho i tng sau i hc) tp 1, 28 - 35.

2. Peptic ulcers. Textbook of Gastroenterology 5th (2009), 936 981.

3. Ian M. Gralnek, M.S.H.S., Alan N. Barkun, and Marc Bardou, Management of Acute Bleeding from a Peptic Ulcer.Th e new england journal o f medicine. august 28, 2008, p928-937B. XUT HUYT TIU HA DO NGUYN NHN KHC: d dng mch

Ni soi cp cm mu nu c th (ni soi d dy, soi i trng)

Siu m gan mt nu nghi ng chy mu ng mt.

Khng tm thy nguyn nhn chy mu: ch nh chp mch, chp MSCT rut ty v tr chy mu nghi ng la chn ng mch chp

Mt s trng hp chy mu nng m chp mch khng thy tn thng cn hi chn vi bc s ngoi m thm d.PHC IU TR UNG TH BIU M T BO GANCp nht ngy 30 / 12 /2009I. nh ngha:

Ung th biu m t bo gan nguyn pht l khi u c tnh xut pht t t bo biu m gan, chim 70 90 % cc loi u gan, t l mc nam cao hn n, tui thng gp 40 60 tui.II. Chn on:

1. Lm sng:

Tin s nhim virus vim gan B, C, x gan.

Cc triu chng lm sng ca x gan.

Triu chng lm sng ca cc hi chng cn ung th: St ko di, h ng huyt, gy st cn bt thng

2. Xt nghim:

CTM MCB, AFP, Protid, Albumin, Canxi, men gan (ALT, AST), (FP

Doppler mch gan, CT gan 3 pha.

HbsAg, anti HCV, Anti HIV.

Bilan di cn: x quang tim phi,..3. Chn on xc nh:

Pht hin khi u trn chn on hnh nh + (FP >400ng/ml.

Chc ht TB v/hoc sinh thit khi u gan lm m bnh hc xc nh ung th biu m t bo gan.

4. Chn on phn bit:

Apxe gan, apxe gan ng mt.

Nang gan, khi u lnh tnh trong gan, di cn ung th ti gan.

III. iu tr:

1. Nguyn tc iu tr:

Phu thut l phng php iu tr trit nht, c u tin hng u.

Ty vo kch thc, v tr, tnh cht mch ca khi u v tnh trng nhu m gan cn li la chn phng php ph hy khi u.

2. iu tr c th:

- Nui dng ng tnh mch nu suy kit

X gan tin trin x tr theo phc

Truyn albmin ch khi c thiu nhiu (Albumin mu < 25g/l)

Ch nh phu thut ct gan:

+ U gan mt khi 38.5.

Siu m bng, C.T gan bng khi p xe ln hoc nhiu hoc cn nh gi i p xe c nhiu vch.

3. Chn on xc nh:

LS: tam chng fontan

Siu m: gim m trong gan

Chc d gim m ra m mu chocola, khng thi, nui cy khng c VK

Phn ng huyt thanh amip (+) hoc tm thy amip trong m.

4. Chn on phn bit:

Apxe ng mt.

Ung th gan.

Nang gan bi nhimIII. iu tr:

1. Nguyn tc iu tr:

Chc ht apxe kt hp iu tr dit amip.

Phng trnh cc bin chng apxe gan amip.

2. iu tr c th:

Thuc dit amip: metronidazol 25 30mg/kg cn nng hoc 1,5 2 g / 24 gi thi gian t 7 14 ngy ty p ng

Chc ht m p xe khi > 3 cm

Nu cn st c th phi hp khng sinh hoc khi chc p xe c km m vng.

Cy mu c vi khun dng thm theo khng sinh

Dit amip ng rut:

+Tinidazole 2g/ngy 3 ngy hoc

+ Direxiod 0,21g 4-6 vin/ngy ko di 21 ngy

3. iu tr h tr:

IV. Theo di v ti khm:

1. Cc ch s theo di:

Nhit , tnh trng bng. CTM, mu lng.

Siu m bng.

2. Ti khm:

Sau 2 4 tun.

V. Ti liu tham kho:

1. iu tr apxe gan do amip. iu tr hc ni khoa (2007), 202 204.B. APXE GAN NG MT:

I. nh ngha:

Apxe gan ng mt l m trong nhu m gan v ng mt trong gan, vim nhim hoi t cp tnh do vi khun i kh hoc ym kh gy nn.

II. Chn on:

1. Lm sng:

au HSP st vng da - gan to. Tin s c giun chui ng mt, si mt.

2. Xt nghim:

CTM, mu lng, MCB, ure, glucose, G, ALT, AST, bilirubin ton phn, trc tip, CRP. HBsAg, HIV

Cy mu khi st cao trn 38,5, cy m p xe

Siu m bng.

3. Chn on xc nh: Da vo Lm sng.

Siu m: mt hoc nhiu gim m trong gan.

Chc ht apxe c m mu vng hoc xanh c mi thi, nui cy m c vi khun mc.4. Chn on phn bit: Apxe gan amip.

Ung th gan.

III. iu tr:

1. Nguyn tc iu tr:

Khng sinh dng liu cao, phi hp khng snh hoc dng khng sinh ph rng, khuch tn tt trong mu c thi tr qua gan mt.

Tham kho khng sinh chn khng sinh thch hp.

Chng sc nu c, chng au.

Chc ht m di hng dn ca siu m nu apxe >5cm.

iu tr bin chng.

2. iu tr c th:

iu tr chng sc nu c, t catheter TMTT theo di ALTMTT. B dch ng trng: NaCl 9%o, glucose 5%..

Khng sinh phi hp, liu cao: thng l gram m, i khi gram dng

+ Cephalosporin th h 3: 2-6 g/24h cefotaxim (claforan), cefoperazone ceftriaxone.

+ Aminoglycoside

+ Quinolon

Nn dng hai khng sinh v metronidazole

khi c kt qu KS ca cy mu hoc cy m: kt hp KS theo KS.

Chc ht m p xe di hng dn SA, cy m.

H st nu st cao: paracetamol.

B nc, in gii theo G v ALTMTT.

Nng cao th trng.

Ly si ng mt ch bng ERCP hoc dn lu ng mt tm thi trong trng hp bnh nhn nng.

Ch nh ngoi khoa khi c bin chng p xe gan v hoc khng ly si c qua ERCP

3. iu tr h tr:IV. Theo di v ti khm:1. Ch s cn theo di:

Nhit , tnh trng ton thn.

CTM, mu lng.

Siu m bng

2. Ti khm:

Sau 2 4 tun.V. Ti liu tham kho:1. iu tr apxe gan do vi khun. iu tr hc ni khoa (2007), 206 207.

PHC IU TR VIM TY CPCp nht ngy 30 / 12 /2009I. nh ngha:

Vim ty cp l hin tng ty b vim do hot ha cc proenzym ngay ti tuyj, gy nn ty t tiu hy v gii phng cc enzym tiu protid v ezym tiu lipid vo mu v vo trong bng.

II. Chn on:

1. Lm sng:

Khi pht t ngt.

au thng v d di, tng cn lan ra sau lng v mn sn tri km bun nn nn, bng chng hi.

Trng hp nng c biu hin shock.

2. Xt nghim:

CTM, CRP, glucose mu, ALT, AST, calci mu, Lipase, Amylase, cc thnh phn lipid mu (Cholesterol, Triglycerid, LDL, HDL), CN gan thn,.

Tin lng tnh theo bng im Imrie S hoc CT bng,

Mt s trng hp nng cn lm kh mu

Ni soi quan st vng bng vater khi khng tm thy nguyn nhn

SNS khi khng tm thy nguyn nhn

Tin hnh ERCP trong trng hp si mt, tc mt hoc nghi divisum ty3. Chn on xc nh:

Da trn lm sng, xt nghim v chn on hnh nh (siu m, CT bng).

Bng im IMRIE nh gi tin lng nng

Tui > 55 Bch cu > 15.G / L ng huyt > 10 mmol/L bnh nhn khng c TS tiu ng LDH huyt tng > 600 U/L AST hoc ALT huyt tng > 100 UI/L Calcium huyt tng < 2 mmol/l PaO2 < 60 mm Hg Albumin huyt tng < 32 g/L Urea huyt tng > 16.0 mmol/L

Tnh im: mt im cho mi tiu chun xut hin sau 48 gi nhp vin

Vim ty cp c nh gi l nng khi im Imrie >=3CT Severity Index

Phn Balthazar hoi t ty

Grade A: Ty bnh thng0Khng hoi t0

Grade B: Ty to ton b hay cc b1Hoi t < 30%2

Grade C: Ty khng ng nht, c thm nhim m quanh ty2Hoi t 30 50%4

Grade D: C dng chy quanh ty3Hoi t >50%6

Grade E: C hai hoc nhiu dng chy quanh ty4

CT index = Phn Balthazar + hoi t ty

4. Chn on phn bit: Vim lot d dy t trng. Giun chui ng mt.

Nhi mu c tim sau di.

III. iu tr:

1. Nguyn tc iu tr:

Chng shock nu c.

c ch bi tit dch ty, lm mt hot tnh ca dch ty bi tit.

Bi ph nc v in gii, m bo nhu cu nng lng ca ngi bnh.

Chng vim nhim.

iu tr triu chng.

2. iu tr c th:

Nhn i n khi ht au bng bnh nhn c cm gic i, amylase v lipase bnh thng

t sonde d dy dn lu khi c tc rut hoc bnh nhn nn nhiu

iu chnh nc v in gii

Nui dng TM: Glucose 20%(insulin) + protide (1500- 2000 kcal/ngy)

iu tr gim au: Perfalgan, Dolargan

TD men ty, CN thn v in gii c bit h Kali mu

Th nng nn truyn dch theo p lc TMTT, HA v nc tiu

Khi c tn thng d dy t trng dng thuc c ch H2hoc c ch bm proton

Nu c sc hoc c suy tng phi iu tr ti khoa TTC (th d: tt HA hoc tng creatinin mu hoc SP02 10.000 hoc st hoc vim ty hoi t hoc nguyn nhn vim ty do si mt. Trong trng hp do si ng mt ch cn tin hnh dn lu mt mi hoc t stent hoc ct c oddi ly si qua chp mt ty ngc dng (ERCP)

Ngoi khoa: Khi p xe ty m chc ht khng gii quyt c, vim ty hoi t gy chy mu trong bng, tc nghn (si v giun) m ERCP tht bi.

3. iu tr h tr:IV. Theo di v ti khm:

1. Cc ch s theo di:

Ton trng, mch, huyt p, nhit , thnh bng, lng nc tiu.

Amylase mu, lipase mu, CTM, CRP, in gii , ure, creatinin, ng mu.

2. Ti khm:

Sau 2 4 tun

V. Ti liu tham kho:

1. iu tr vim ty cp. iu tr hc ni khoa (2007), 226 229.

2. Acute pancreatitis. Textbook of Gastroenterology 5th (2009). 1780 1829.

PHC IU TR VIM GAN B MN TNHCp nht ngy 30 / 12 /2009I. nh ngha:

Vim gan mn tnh l bnh gan c tn thng hoi t v vim, c hoc khng c km theo x ha, din ra trong thi gian trn 6 thng.

II. Chn on:

1. Lm sng:

Khai thc tin s c HbsAg (+), vng da, vim gan. Cc triu chng lm sng thng khng c hiu, c th biu hin ca t trin trin hoc bin chng x gan: Vng da, c trng

2. Xt nghim:

HBsAg, HBeAg, Anti HBe, Anti -HBc IgM v IgG, Anti-HCV

CTM, MCB

SHM: ure, creatinin, glucose, GOT, GPT, Bilirubin, protid, Albumin, G, aFP, TPT nc tiu

Sinh thit gan theo hng dn phn sau

Siu m gan 3 thng mt ln

3. Chn on xc nh:

HbsAg (+) v men gan cao lin tc trn 6 thng.

Sinh thit gan lm gii phu bnh c hnh nh hoi t khong ca (hnh cu ni, mi gm).

4. Chn on phn bit: Vi cc nguyn nhn gy vim gan mn tnh khc nh: virus vim gan C, t min, do thuc, ru.

III. iu tr.

1. Ch nh iu tr:

i vi bnh nhn vim gan virus B mn tnh c HBeAg dng tnh v HBV DNA cao (> 105 copies/ ml):

+ ALT bnh thng: 3-6 thng XN ALT mt ln, 6-12 thng XN HBeAg mt ln. Cn sinh thit gan i vi BN > 40 tui c ALT bnh thng , tin hnh iu tr khi c vim hoi t mc va v nng hoc x nhiu

+ ALT t 1-2 ln so vi bnh thng: 3 thng XN ALT mt ln, 6 thng XN HBeAg mt ln. Cn sinh thit gan i vi BN > 40 tui hoc ALT tng thng xuyn. Tin hnh iu tr khi c vim hoi t mc va v nng hoc x nhiu

+ ALT >2 ln so vi bnh thng: Nu c vng da hoc x gan mt b iu tr ngay, nu khng c th tr hon iu tr sau 6 thng

i vi bnh nhn vim gan virus B mn tnh c HBeAg m tnh

+ ALT bnh thng c HBV DNA < 104 copies/ ml: 3 thng XN ALT mt ln trong nm u, nu khng tng sau 6-12 thng XN ALT mt ln.

+ ALT t 1-2 ln so vi bnh thng :

3 thng XN ALT v HBV DNA mt ln, nu nng virus khng thay i cn tin hnh sinh thit gan i vi ngi trn 40 tui. Tin hnh iu tr khi c vim hoi t mc va v nng hoc x nhiu

+ ALT >2 ln so vi bnh thng v HBV DNA 104 copies/ ml : Tin hnh iu tr.

2. Thuc: Cc thuc dn cht nucleotid:

Lamivudine: liu dng 100mg/ ngy y l thuc c t l khng thuc cao nht .T l khng thuc 14- 32 % sau 1 nmv t l ny l 60-70% sau 5 nm.

Adefovir Dipivoxil: liu dng 10mg/ngy. T l khng thuc sau 1 nm l 11%, 5 nm l 20-29%.

Telbivdine: Liu dng 200mg/ngy t l khng thuc sau 2 nm 21%

Entecavir: Liu dng 0,5mg/ngy, i vi bnh nhn khng lamivudine dng liu 1mg/ngy. T l khng thuc sau 2 nm l 3% .

Tenofovir: 300 mg/ngy . T l khng thuc thpThi gian iu tr i vi nucleoside:

Nu dng thuc 6 thng m HBV DNA gim < 102 copie/ml thm thuc hoc thay i thuc. i vi bnh nhn vim gan virus B mn tnh c HBeAg dng tnh: dng n khi chuyn i huyt thanh HBeAg m tnh v anti HBe dng tnh v tip tc duy tr thuc ti thiu 6 thng.

i vi bnh nhn vim gan virus B mn tnh c HBeAg m tnh: dng n khi no mt HBsAg.

i bnh nhn x gan mt b hoc ti pht sau iu tr liu trnh hoc sau gp gan th dng sut i. Cc Interferon v Peg- interferon: t hiu qu i vi ngi chu

Interferone (: dng iu tr 24 tun vi HBeAg dng tnh, ti thiu 12 thng vi HBeAg m tnh. Tc dng i genotype A tt hn genotype B t hiu qu vi genotype C. Ngi Vit Nam phn ln l genotyp B, C do vy t tc dng khi dng interferon hoc Peg-interferon.

i vi vi HBeAg dng tnh Peginterferone (2a dng 180(g/tun trong 48tun cho thy c 27% o huyt thanh v 29% i vi dng Peginterferone ( 2b.

i vi vi HBeAg m tnh Peginterferone (2a dng 180(g/tun trong 48 tun cho thy c 15% bnh nhn c t l ALT bnh thng ti tun 72 v HBVDNA vn pht hin c tuy nhin nng thp.

3. iu tr h tr:IV. Theo di v ti khm:

1. Cc ch s theo di:

ALT, HBV DNA, HbeAg, AntiHBe, (FP.

Siu m bng.

2. Ti khm:

Sau 1- 3 thng.

V. Ti liu tham kho:

1. Anna S. F. Lok and Brian J. McMahon. AASLD PRACTICE GUIDELINES

Chronic Hepatitis B: Update 2009. HEPATOLOGY, September 2009, P1-36.PHC IU TR VIM GAN C MN TNHCp nht ngy30 / 12 /2009I. nh ngha:

Vim gan mn tnh l bnh gan c tn thng hoi t v vim, c hoc khng c km theo x ha, din ra trong thi gian trn 6 thng.

II. Chn on:

1. Lm sng:

Khai thc tin s vng da, vim gan, truyn mu, nghin chch.

Cc triu chng lm sng thng khng c hiu, c th biu hin ca t trin trin hoc bin chng x gan: Vng da, c trng

2. Xt nghim:

Anti-HCV, nh lng HCV RNA, nh tp HCV

CTM, MCB

SHM: TSH, ure, creatinin, glucose, GOT, GPT, Bilirubin, protid, Albumin, G, aFP, TPT nc tiu

Sinh thit gan l ch nh cn thit nh gi truc khi iu tr

Siu m gan 6 thng mt ln.3. Chn on xc nh:

AntiHCV (+), c HCV RNA, tng ALT4. Chn on phn bit: Vi cc nguyn nhn gy vim gan mn tnh khc nh: virus vim gan B, t min, do thuc, ru.III. iu tr:

1. Ch nh v chng ch nh iu tr:

Ch nh iu tr:

Bnh nhn pht hin c HCV RNA

Tui t 18 tr ln

C tng ALT

Sinh thit gan cho thy c vim gan mn c x ha ng k Metavir ( 2 hoc Ishak ( 3

Bnh gan cn b: bilirubin ton phn 75g/l, khng c c trng khng c bnh no do gan

Cc ch s huyt hc v sinh ha: Hb >13g/l i vi nam v >12g/l i vi n bch cu trung tnh > 1,5G/l, creatinin bnh thng Sn sng tun th iu tr

Ch nh iu tr ty theo tng bnh nhn c th:

ALT thng xuyn bnh thng

X gan mt b

Sinh thit gan khng c x hoc x t vi Metavir < 2 hoc Ishak < 3

Vim gan virus c cp tnh

Nhim HIV

Tui