Slide 1

Khuyn co da trn y hc bng chng t ESPGHAN & NASPGHAN trong chn on v iu tr nhim H. pylori tr em

TS.BS. Nguyn Th Vit HB mn Nhi HY H Ni

t vn Phng thc xy dng khuyn co ca ESPGHAN & NAPSGHAN da trn y hc bng chng Khuyn co t ESPGHAN & NASPGHAN:i tng no nn c lm testTest no nn c s dngi tng no nn c iu trPhc iu tr no l ph hp nht

Ni dung trnh byt vn Australians Barry J. Marshall and Robin Warren were awarded the 2005 Nobel Prize in medicine for showing that bacterial infection, not stress, was to blame for painful ulcers in the stomach and intestine.Press comment in Australia 2005

Ti sao phi c khuyn co iu tr dit HP cho tr emC s khc bit gia tr em v ngi ln v bnh l lin quan n nhim H. pylori:T l nhimT l bin chngKhng c/ him gp cc biu hin c tnhc trng la tui v phng php chn on v thuc iu trT l khng khng sinh cao=> Cc khuyn co ngi ln c th khng ph hp vi tr emTnh hnh nhim H. pylori trn th gii

Source: Steven J 2005 S khc bit v nhim H. pylori gia cc nc pht trin v ang pht trin

Nhim Helicobacter pylori Phng thc xy dng khuyn co ca ESPGHAN & NAPSGHANPht trin hng dn2000: Hi tiu ha - gan mt - dinh dng chu u (ESPGHAN): a ra thng bo ng thun (consensus statements) v nhim H.pylori tr em2000: Hi tiu ha - gan mt- dinh dng bc M (NASPGHAN), cng a ra ng thun v vn ny bao gm c khuyn co cho iu tr2004: nhm nghin cu Helicobacter ca Canada bt u t chc hi ngh ng thun v tip cn nhim H. pylori tr em2005: ESPGHAN v NASPGHAN bt u xy dng hng dn da trn y hc bng chng (Evidence Based Medicine)Pht trin hng dn2006: ESPGHAN & NAPSGHAN cng thng nht 4 vn chnh v nhim H. pylori tr emi tng no nn c lm test: khc nhau gia:Sng lciu trap dng trn lm sngTest no nn c s dngi tng no nn c iu trPhc iu tr no l ph hp nhtThnh vin hi ng pht trin hng dnBenjamin Gold - NASPGHAN Sibylle Koletzko - ESPGHAN Cc nh tiu ha nhiCc nh dch t hcCc nh vi sinh hcCc nh m bnh hcPhng php thu thp ti liu v bng chng y hcThit k h thng thu thp ti liu do Karen Goodman - mt nh dch t hc chu trch nhim Ngun ti liu t: PubMed, MEDLINE, EMBASE, Cochrane Library, Biosis Previews, EBM Reviews, ISI Web of Science, ScopusThi gian cc ti liu c ng ti: 2000 - 2009Dng ti liu c ng ti: cc loi bi bo, tng quan, v H. pylori trn i tng bnh nhn tr hn 20 tui.

Bng chng xy dng khuyn co410 bi bo & 80 bi tng quan p ng ng tiu chun la chn a vo phn tch (2000 2007)248 bi bo (2007 2009)nh gi cht lng ca bng chng (quality of evidence) c cc nh dch t hc v cc nhm thnh vin ring r tin hnh theo h thng phn loi ca Oxford Centre for Evidence-Based Medicine ((http://www. cebm.net/index.asp)Cht lng ca bng chng(Quality of evidence)

B phiu cho hi ngh ng thun v nh gi cht lng ca bng chngNAPSGHAN & ESPGHAN b phiu 2 ln cho mi thng tin cn thng nhtCc thng tin c thng nht s c xem xt li da trn phn hi ca bnh nhn v cc tng quan c cu trc cht ch khi ngay khi c cc nghin cu miCc thng tin tho lun c coi l ng thun khi c 75% thnh vin b phiu A (+), A, hoc A()Mc ng cho mi thng tin tho lun c biu th bng %

NAPSGHAN & ESPGHAN b phiu 2 ln cho mi thng tin cn thng nhtCc thng tin c thng nht s c xem xt li da trn phn hi ca bnh nhn v cc tng quan c cu trc cht ch khi c cc kt qu nghin cu trn th giiCc thng tin tho lun c coi l ng thun khi c 75% thnh vin b phiu A+, A, hoc AMc ng cho mi thng tin tho lun c biu th bng %

16B phiu cho hi ngh ng thun v nh gi cht lng ca bng chngCc phiu bu khng ghi tn, c 6 thang im c s dng:1. Nht tr cao (agree strongly): (A+)2. Nht tr trung bnh (agree moderately): (A)3. Ch nht tr (just agree): (A-) 4. Khng ng (just disagree): (D-)5. Khng ng mc va (disagree moderately): (D)6. Khng ng mc cao (disagree strongly): (D+)Kt qu ng thunVng b phiu u tin: 22 kin c chn la t 43 kin tho lunVng b phiu cui cng ng thun 21 kin v a ra khuyn co21 KHUYN CO CA ESPGHAN & NAPSGHANi tng no nn c lm test? KHUYN CO 1-2Khuyn co 1: Mc ch trc tin ca ch nh xt nghim trn cc bnh nhn c cc triu chng d dy rut l xc nh nguyn nhn ca triu chng ch khng ch xc nh nhim H pyloriMc thng nht: 100% (A+ 92%, A 8%)Mc bng chng: Khng thch hpKhuyn co 2: Test chn on nhim H pylori khng c khuyn co tr c au bng chc nng (functional abdominal pain) Mc thng nht: 92%(A+ 54%, A 23%, A-15%, D-8%) Mc bng chng: caoBN LUN KHUYN CO 1-2Cc triu chng nh nn, au bng hoc cc ri lon tiu ha khc l triu chng khng c hiu, c th do nhiu nguyn nhn thc th khc nhau ca h tiu tiu ha hoc ni khcMi lin quan gia au bng do vim d dy t trng c H. pylori (+) m khng c lot vn cn cha thng nhtCc bng chng hin ti cha chng minh c mi lin quan gia nhim H. pylori v au bng ti dinKhng nn tin hnh cc test chn on nhim H. pylori cho cc bnh nhn au bng c cc tiu chun ph hp vi au bng chc nngKHUYN CO 3Khuyn cao 3: Tr em l con ca nhng cha m b ung th d dy nn c cn nhc lm test chn on nhim H. pyloriMc thng nht: 93% (A+ 29%, A 50%, A-14%, D 7%)Mc bng chng: thpBN LUN KHUYN CO 3C mi lin quan gia nhim H. pylori & ung th d dy, MALT lymphomaWHO (1994): H. pylori l nguyn nhn gy ung th 1Meta-analysis: nguy c ung th d dy tng 1-2 ln BN nhim HP, dit HP lm gim nguy c ung th d dyNhng ngi c tin s gia nh b ung th d dy c xem xt l nhm nguy c cao (lin quan ti gen, cc yu t mi trng, v nhim HP cng chng)70% of lymphoma MALT d dy c iu thnh cng bng dit HPQun th c t l ung th d dy cao => cn thit phi, sng lc ung th d dy v tr em nn c sng lc nhim HP (gim st tr c thiu sn hoc d sn rut)C mi lin quan gia nhim H. pylori & ung th d dy, MALT lymphomaWHO (1994) cng b HP l nguyn nhn gy ung th 1Meta-analysis: nguy c ung th d dy tng 1-2 ln BN nhim HP, dit PH lm gim nguy c ung th d dyNhng ngi c tin s gia nh b ung th d dy c xem xt l nhm nguy c cao . Nguy c c bit cao tr b nhim HP c b hoc m b ung th d dy (khng nhng lin quan ti gen, cc yu t mi trng, m cn nhim HP cng chng)70% of gastric MALT lymphomas c iu thnh cng bng dit HP. Chuyn vng c trng ca MALT lymphomas c ghi nhn l mt marker HP c lp (HP independence)Sng lc nhim HP trong qun th bnh thng khng c khuyn co qun th c t l ung th d dy cao, sng lc ung th d dy l cn thit, v tr em nn c a vo chng trnh sng lc HP c bit gim st tr c thiu sn hoc d sn rut

24KHUYN CO 4Khuyn co 4: Tr em b thiu mu thiu st khng p ng vi iu tr bng b sung st, loi tr cc nguyn nhn khc c th cn nhc lm cc test chn on nhim H. pyloriMc thng nht: 100% (A+ 36%, A 36%, A-28%Mc bng chng: thpBN LUN KHUYN CO 4Nhim HP c th l nguyn nhn thiu mu thiu st & cc test khng xm nhp khng xc nh c nguyn nhn hoc/v iu tr thiu mu thiu st khng hiu qu => c th ch nh ni soi d dy, sinh thit nim mc loi tr bnh rut celiac disease, test v nui cy HPCc bng chng hin ti (cc nghin cu can thip): iu tr dit HP c hiu qu cho cc BN thiu mu thiu stCn c thm cc nghin cu xc nh nhim HP c phi l nguyn nhn gy thiu st khng (khng c tn thng nim mc)

C mi lin quan gia nhim H. pylori & ung th d dy, MALT lymphomaWHO (1994) cng b HP l nguyn nhn gy ung th 1Meta-analysis: nguy c ung th d dy tng 1-2 ln BN nhim HP, dit PH lm gim nguy c ung th d dyNhng ngi c tin s gia nh b ung th d dy c xem xt l nhm nguy c cao . Nguy c c bit cao tr b nhim HP c b hoc m b ung th d dy (khng nhng lin quan ti gen, cc yu t mi trng, m cn nhim HP cng chng)70% of gastric MALT lymphomas c iu thnh cng bng dit HP. Chuyn vng c trng ca MALT lymphomas c ghi nhn l mt marker HP c lp (HP independence)Sng lc nhim HP trong qun th bnh thng khng c khuyn co qun th c t l ung th d dy cao, sng lc ung th d dy l cn thit, v tr em nn c a vo chng trnh sng lc HP c bit gim st tr c thiu sn hoc d sn rut

26KHUYN CO 5Khuyn co 5: Khng c bng chng cho thy nhim HP l nguyn nhn ca vim tai gia, vim ng h hp trn, bnh quanh rng, d ng thc n, SIDS, xut huyn gim tiu cu v cn v chm pht trin th cht Mc thng nht: 100% (A+ 36%, A 28%, A-36%Mc bng chng: thpBN LUN KHUYN CO 5C nhiu biu hin ngoi ng tiu ha c cho l c lin quan ti nhm HPTuy nhin cc bng chng gn y khng khng nh iu nyC mi lin quan gia nhim H. pylori & ung th d dy, MALT lymphomaWHO (1994) cng b HP l nguyn nhn gy ung th 1Meta-analysis: nguy c ung th d dy tng 1-2 ln BN nhim HP, dit PH lm gim nguy c ung th d dyNhng ngi c tin s gia nh b ung th d dy c xem xt l nhm nguy c cao . Nguy c c bit cao tr b nhim HP c b hoc m b ung th d dy (khng nhng lin quan ti gen, cc yu t mi trng, m cn nhim HP cng chng)70% of gastric MALT lymphomas c iu thnh cng bng dit HP. Chuyn vng c trng ca MALT lymphomas c ghi nhn l mt marker HP c lp (HP independence)Sng lc nhim HP trong qun th bnh thng khng c khuyn co qun th c t l ung th d dy cao, sng lc ung th d dy l cn thit, v tr em nn c a vo chng trnh sng lc HP c bit gim st tr c thiu sn hoc d sn rut

28Phng php chn on no nn c s dng? KHUYN CO 6 - 7Khuyn co s 6: V tr sinh thit d dy xc nh s c mt ca HP trn tiu bn m bnh hc khi ni soi thc qun, d dy t trng l thn v v hang vMc thng nht: 93%(A+ 33%, A 40%, A-20%, D-7%)Mc bng chng: Trung bnhKhuyn co 7: Chn on ban u nhim HP nn da trn 2 kt qu dng tnh: kt qu gii phu bnh (+) + Test nhanh urease (+) hoc nui cy (+). Mc thng nht: 100% (A+ 36%, A 50%, A- 14%) Mc bng chng: trung bnhBN LUN KHUYN CO 6-7Bnh thng HP c nhiu nht hang v, nhng khi pH d dy cao (nng acid thp) th HP thng khu tr thn vSinh thit 2 mu (hang v & thn v) v:Hp thng nm ri rc v phn loi theo tiu chun SydneyMt mu sinh thit lm gii phu bnh v 1 mu lm test nhanh urease testv mt mu cho nui cy nu cn thitNhn i th, nhim HP c nghi ng khi c ht sn nim mc (nodular mucosa) vng hang v hoc trt (erosion) hoc lot hnh t trng v d dy

BN LUN KHUYN CO 6-7 nhy ca phng php xm nhp: M bnh hc 66-100%Test nhanh urease 75 - 100%Nhn nh kt qu:Khi 2 test cng (+) => tng gi tr chn onKt qu 2 test khng ging nhau => cn ch nh test khng xm nhp (test th v test phn)Nu ch c 1 kt qu dng tnh (nui cy/m bnh hc (+)) v c lot chy mu => c th bt u liu php KS dit HPMeta-analysis cho thy, nhy ca cc test chn on xm nhp gim v c hiu cao trong trng hp lot ang chy mu KHUYN CO 8 - 9Khuyn co s 8: Test th 13C-UBT l test khng xm nhp ng tin cy xc nh tnh trng dit H. pylori Mc thng nht: 94% (A+ 67%, A 20%, A- 7%, D- 6%)Mc bng chng: CaoKhuyn co 9: Test ELISA pht hin khng nguyn trong phn c lng gi l test khng xm nhp ng tin cy xc nh tnh trng dit H. pylori Mc thng nht: 86%(A+ 21%, A 29%, A- 36%, D 7%, D- 7%) Mc bng chng: trung bnhBN LUN KHUYN CO 8 - 9Test th c lng gi nhiu trn tr em cho gi tr cao trong c chn on v iu trQuy trnh lm test th tr nh: Nhn n => Ung cc dung dch c tnh acid (hot tnh ca men urease gim trong mi trng acid cao) => Ung nc trnh s phn hy ca dung dch thuc th bi cc vi khun rut => chnh xc ca test th gim hn tr di 6 tuiTest phn c 2 loi s dng khng th n dng v a dng trong test phn s dng khng th n dng c chnh xc tng ng test th chnh xc ca test phn khng bj nh hng bi tui v khng c s khc bit so vi ngi lnKHUYN CO 10 - 11Khuyn co s 10: Test tm khng th (IgG, IgA) khng HP trong mu, huyt thanh, nc tiu khng ng tin cy p dng trn lm sng (chn on v iu tr)Mc thng nht: 87% (A+ 53%, A 20%, A- 13%, D- 7%, D 7%)Mc bng chng: CaoKhuyn co 11: Sinh thit d dy hoc cc test khng xm nhp (test th, test phn) nn c tin hnh sau khi ngng PPI 2 tun v ngng khng sinh 4 tun Mc thng nht: 100% (A+ 47%, A 40%, A- 13%) Mc bng chng: Cao

BN LUN KHUYN CO 10 - 11 nhy v c hiu ca cc test da vo nng khng th dao ng lnIgG c hiu vn dng tnh sau vi thng - vi nm sau khi nhim trng c gii quyt => khng khuyn co s dng trong lm sngNng khng th thay i theo tui => nhy thp tr nh:IgA ch dng tnh 20 50% tr nhim HPIgG c nhy tt hn IgA nhng vn thp tr em so vi ngi lnKhng sinh v thuc gim tit acid c th lm cho test m tnh gi do lm gim ti lng vi khun i tng no nn c iu tr?KHUYN CO 12Khuyn co s 12: Ch nh iu tr dit H. pylori cho tt c cc trng hp lot d dy t trng c H. pylori (+)Mc thng nht: 100% (A+ 79%, A 13%, A- 7%)Mc bng chng: CaoCc nghin cu a phn tch trn ngi ln cho thy hiu qu lm lnh n lot v phng lot ti pht ca cc phc dit HPT l ti pht lot d dy t trng cao nhng tr khng c iu tr dit HPNn c ch nh iu tr dit HP cho nhng bnh nhn HP (+) v c lot lin so hoc c tin s lot

KHUYN CO 13Khuyn co s 13: Khi tr c nhim HP pht hin qua m bnh hc nhng khng c lot d dy t trng, c th cn nhc iu tr dit HPMc thng nht: 79% (A+ 29%, A 50%, D- 21%)Mc bng chng: ThpBN LUN KHUYN CO 13Cha c bng chng chng minh mi quan h nhn qu gia vim d dy do HP khng c lot v au bng => iu tr dit HP c th khng ci thin tnh trng au bngHP lm gia tng nguy c gy ung th d dy t trng nhng yu t gy ung th b nh hng bi cc yu t c lc ca vi khun, p ng ca c th v mi tng tc gia c th v vi khunQuyt nh iu tr dit HP cho trng hp vim d dy t trng khng c lot ph thuc vo s nh gi ca bc s, s cn nhc gia bc s v gia nh v cc nguy c tim tng & hiu qu khi p dng iu tr trn tng c thKHUYN CO 14Khuyn co 14: Chin lc test v iu tr khng c khuyn co trn tr emMc thng nht: 80% (A+ 47%, A 20%, A- 13%, D- 13% v D7%)Mc bng chng: Trung bnhChin lc test & iu tr l ch nh iu tr cho tt c cc trng hp xc nh c nhim HP bng test chn on khng xm nhpMc tiu lm test chn on l xc nh nguyn nhn iu tr => khng khuyn co iu tr dit HPPhc no nn c s dng v s dng trong tnh hung no?KHUYN CO 15Khuyn co 15: Tr em l con ca cha m b ung th d dy c nhim HP nn c ch nh iu tr dit HPMc thng nht: 93% (A+ 20%, A 47%, A- 27%, D+ 6%)Mc bng chng: ThpBn lun trnh by trong khuyn co 3KHUYN CO 16Khuyn co 16: nh gi t l khng khng sinh tr nh v tr v thnh nin nn c tin hnh ty theo tng quc gia v vng a l khc nhauMc thng nht: 100% (A+ 60%, A 20%, A- 27%, D+ 6%)Mc bng chng: Khng thch hpTnh hnh khng KS gia tng trn nhiu quc giaHiu qu iu tr ph thuc vo mc nhy cm KSKhng c thng tin v tnh trng khng KS ca HP trn ton th giiKHUYN CO 17Khuyn co 17: La chn s 1 cho cc phc dit HP nn l:PPI + amoxicillin + imidazolePPI + amoxicillin + clarithromycinBismuth + amoxicillin + imidazolePhc trnh t: PPI + amoxicillin trong 5 ngy sau PPI + clarithromycin + metronidazole trong 5 ngyMc thng nht: 100% (A+ 36%, A 40%, A- 14%)Mc bng chng: Trung bnhLiu lng thuc trong phc la chn 1 dit HPAmoxicillin: 50mg/kg/ngyClarithromycin: 20mg/kg/ngyMetronidazole: 20mg/kg/ngyBismuth (bismuth subsalicylate, bismuth subcitrate): 8mg/kg/ngyPPI (thuc c ch bm proton): 1-2mg/kg/ngyHot tnh sinh hc ca PPIS dng PPI 2 ln/ngy mang li hiu qu iu tr tt hn s dng PPI 1 ln/ngy (OR = 1,51 (ITT) & 1,97 (PP)PPI c tc dng gim tit acid => tng pH v gim lng dch tit trong d dy do Ko di thi gian lm rng d dy => tng nng KS (clarithromycin) MIC (minimal inhibitory concentration) ca amoxicillin & clarithromycin gim khi pH tngPPI cng c kh nng c ch H. pylori v PPI c ch s pht trin ca VK pH trung tnh v hot tnh ca men ureaseAliment Pharmacol Ther 2002(16), 11491156So snh hot tnh sinh hc ca PPIPPI (mg)Tmax (h)Hot tnh sinh hcGn proteint/2 (h)Esomeprazole (20mg)1264 - 89971,3Lansoprazole (20mg)1,7 80971,5Omeprazole (20mg)235 - 60950,5Pantoprazole (20mg)277971Rabeprazole (20mg)252971t1/2 = Thi gian bn hy tmax = thi gian t nng ti a huyt tngPPIs: Differences in PK and Clinical Outcomes , Clin Pharmacokinet 2008Hot tnh sinh hc ca esomeprazole Tt c PPI c chuyn ha gan qua h thng CYP450 v cc ng phn qua CYP2C19 & CYP3A4Esomeprazole l dng ng phn S ca omeprazole v l hn hp chm ca c 2 dng ng phn R v S. ngi chuyn ha ca esomeprazole qua CYPC19 v CYP3A4 trong esomeprasole c chuyn ha nhiu hn bi CYP3A4 so vi omeprazole v ng phn R, chuyn ha t hn bi CYPC19 => din tch di ng cong ca esomeprazole ln hn omeprazole vi cng liu s dng => hiu qu lm gim acid tt hn => mang li hiu qu iu tr tt hn trn lm sngPPIs: Differences in PK and Clinical Outcomes , Clin Pharmacokinet 2008Hiu qu ca esomeprazole so vi cc PPI khcA Meta-Analysis: Comparison of Esomeprazole and Other Proton Pump Inhibitors in EradicatingHelicobacter pylori Digestion 2006;73:178186

KHUYN CO 18Khuyn co 18: Ch nh nh gi tnh trng nhy cm KS nn c tin hnh trc khi bt u phc iu tr c clarithromycin cho cc vng/qun th c t l khng clarithromycin > 20%Mc thng nht: 93% (A+ 33%, A 40%, A- 20%, D-7%)Mc bng chng: Trung bnhKHUYN CO 19Khuyn co 19: Thi gian ca liu trnh iu tr dit HP ca phc 3 thuc nn t 7-14 ngy. Cn cn nhc v chi ph, kh nng dung np tuc v cc tc dng ph khi quyt nh iu trMc thng nht: 93% (A+ 27%, A 40%, A- 27%, D-6%)Mc bng chng: Trung bnhBN LUN KHUYN CO 17 - 19Mc tiu iu tr l m bo kh nng dit HP 90%Hiu qu iu tr cao s:Ngn chn kh nng khng thuc v lan truyn khng thuc trong cng ngGim thiu cc bin php chn on (ni soi) v iu tr khcCc phng php tin hnh th nghim lm sng trn tr em cn cha nhiu v khng t chun => phn ln cc khuyn co xut pht t cc th nghim trn ngi lnBN LUN KHUYN CO 17 - 19Hiu qu iu tr dit HP tr em trn cc nghin cu gn y khng cao (65,6%) => c th do tnh trng khng KS cao c bit l clarithromycinnh gi tnh trng khng KS tr em cha c tin hnh nhiuiu tr dit HP sau khi c kt qu KS cho hiu qu cao hn => nh gi mc khng KS trc iu tr Cc th nghim lm sng s dng phc iu tr theo trnh t cho hiu qu iu tr dit HP cao hn phc chun (97,3% v 75,7%)BN LUN KHUYN CO 17 - 19Hiu qu iu tr dit HP ca phc c bismuth cao v t tn km trong mt s th nghim lm sng => c th khuyn co l la chn u tinThi gian iu tr nn ko di 7-14 ngy:Nghin cu a phn tch tr em cho thy thi gian iu tr di mang li hiu qu dit HP tt hnNghin cu a phn tch v hiu qu iu tr ca phc trnh t trong thi gian di 14 ngy mang li hiu qu iu tr tt hn phc chunKHUYN CO 20Khuyn co 20: nh gi hiu qu dit HP bng cc phng php chn on khng xm nhp nn tin hnh sau khi kt thc qu trnh iu tr t nht l 4-8 tunMc thng nht: 93% (A+ 53%, A 27%, A- 13%, D-7%)Mc bng chng: ThpBN LUN KHUYN CO 20Khi bnh nhn ht triu chng tr vn cn nh gi tnh trng nhim HP c gii quyt cha v khng cn triu chng khng c ngha l dit ht vi khunTest s dng nh gi hiu qu iu tr: test th 13C-UBT v test phn s dng KT n dngKhng c ch nh ni soi thng quy sau iu tr tr khi bnh nhn c lot hoc ly mnh sinh thit nui cy vi khun v lm khng sinh

KHUYN CO 21Khuyn co 21: Nu iu tr tht bi, 1 trong 3 la chn:Ni soi d dy t trng, nui cy vi khun v lm KS hoc s sng KS khc nu KS ny cha c s dng iu tr trc FISH trn mnh sinh thit nh gi nhy cm clarithromycin nu cha lm trc Thay i phc iu tr bng cch thm thuc khng sinh, bismuth, tng liu hoc thi gian iu tr Mc thng nht: 100% (A+ 29%, A 43%, A- 28%)Mc bng chng: ThpBN LUN KHUYN CO 21Khng thuc th pht sau s dng iu tr dit HP rt hay gp tr em => sau phc la chn 1 tht bi tr nn c nui cy vi khun la chn thuc cho phc la chn 2Nu khng th nui cy c vi khun tr nn c s dng KS khc vi KS la chn ban u hoc lm FISH xc nh tnh nhy cm clarithromycin => quyt nh vic s dng clarithromycin trong phc la chn 2Phc la chn 2Ch nh: phc la chn 1 tht bi Phc 4 thuc: PPI + metronidazole + amoxicillin + Bismuth Phc 3 thuc: PPI + levofloxacin (moxifloxacin) + amoxicillin TUY NHIN cc phc nh gi hiu qu v tnh an ton ca levoffloxacin trn tr em RT HN CH KHNG CH NH phc ny nu tr s dng fluoroquinolon trc Thi gian iu tr: 14 ngy

Nhim theo nhm tui%Nhim H. pylori Vit NamHoang Thi Thu Ha 2006`

Xin chn thnh cm n