VIEM GAN TS.BSCKIL Tran Thi Khénh Ting MYC TIEU ' Sau khi hoc xong bai nay, hoc vién cé thé: 1. Néu diege dinh nghia viém gan cdp va man 7 oa 2. Ligt ke dteoe ede nguyén nha thucing gdp gay viém gan cdp vit man 3. M6 té duge cdc biéu hign lam sang va cGn lam sang ctia viém gan cdp va man, NOI DUNG BAI GIANG 1. DAICUONG Viém gan 1a bénh & chit mé gan do nhiéu nguyén nhan khée nhau giy ra mite d6 viém va hoai tir khée nhau, Viem gan cép duge dic trmg béi sit pha hiy té bao gan va sy hign dién té bao viém trong m6 gan kéo dai dudi 6 thing. Da s6 viém gan cip phuc hdi hoan toan, mét sé chuyén sang viém gan man. Viém gan man Khi nhting tn thuong nay kéo dai tit 6 thang tré lén, Dang viém gan man nhe c6 thé khéng tién trién hay tién trién rét cham, trong khi 46 dang nang cé thé tién trién dén xo gan va ung thir gan. 2. NGUYEN NHAN Nhiém tring: + Vinus huéng gan (HAV, HBV, HCV, HDV, HEV); khong huéng gan (CMV, EBV, herpes simplex virus) - Kysinh tring, vi khudn, Rugu: + Thude: tén thurong gan do thude (rug induced liver injury — DIL) ~ _Réi loan chuyén héa: bénh gan nhiém é : md khong do lin Fatty Liver Disease: NAFLD), Hemochromatosis, bénh Wilson rion ayes + Tw mién: viém gan ty mién + Khéc: di truyén, dp... 2.1. Cée nguyén nhan giy viém gan cp ~ Virus: HAV, HBV, HCV, Hpy 6 : virus); ohiét Kinin ning. MEY Ong hucéng gan (CMV, EBV, herpes simple Thuédc va d6e t6 - Rugu Réi loan chuyén héa; bénh Wilson ‘én thuong gon do thiéu méu cue b (ischemic liver injury), tie mét 782 Scanned with CamScannera2 3 . Tén thong gan do thiéu mau cyc b6 = Vidm gan ty mign, Ce nguyén nhén gay viém gan man + Virus: HBV, HCV, HDV + Rugu + Réi logn chuyén héa: NAFLD, Hemochromatosis, bénh Wilson + Thudc va d6c t6 ~ Viém gan ty mién. BIEU HIEN LAM SANG Biéu hign lim sang cia viém gan rét bién thién, cé thé hoan toan khéng cé triéu chimg ké cé vitm gan cdp hay man hay ¢6 eéc trigu ching dién hinh cia bénh gan. a Vitm gan efip Bénh cdnh lam sing cia viém gan cp thudng trdi qua 3 giai doan: Giai doan tin vang da: thurdng céc trigu chimg khéng dién hinh bénh gan, cé céc triéu ching ohu ahiém virus thng thuéng 32, + Métméi, suy nhuge, sét nh Buén nén, chén &n, thay @di vi giée + Dau ha sudm phai do gan lon + Dauco, khép, nhite diu, ndi ban 6 da... Giai dogn ving da + Vang mit, ving niém va vang da + Nude tiéu sim mau Phan cé thé nhat mau Céc trigu chimg giai doan dau cé thé gidm di nhu s6t, mét mdi... Gial dogn phye hdi ~ Vang da gidm din, tiéu nhidu, cdm gide khée hon, an ngon hon DOi khi cam gisc mét, ving da cé thé kéo dai vai tun, Vitm gan man Vinh asd bénh nhin khéng c6 trigu ching co ning va cd thye thé, Trong det bing pht cp, ©6.bénh cénh lm sang tuong tyr viém gan cp te titu chimg cia viém gan man cé thé gp li Mét mai Scanned with CamScanner+ Chinn = Gan to, dic biét trong béah gan do rugu. / i Negoai ra 6 thé gap cdc trigu chimg ngoai gan nhur trigu chiing cila cdc bénh ly Khép, thin, dai trang, thin kinh... tiy theo nguyén nbin gay viém gan man. 4. BIEU HIEN CAN LAM SANG 4. Xét nghigm sinh héa gan mit 4.1.1. Viém gan cdp sash AST, ALT ting cao thudng trén 10 lan gidi han trén binh thudng (upper limit of normal: ULN), thudng > 300 U/L + Trong viém gan cdp do virus, ALT ting cao hon AST, do nrgu AST thuéng cao hon gp 2 lin ALT va thuimg duéi 300 U/L. ~ Déi véi tin thyong gan do thiéu mau cyc b6: ALT va AST ting rat cao cé thé trén 100 lan ULN va tré vé binh thurdng rt nhanh khi tinh trang tuoi mau duge cai thign, thudng sau 3-10 ngay, kém véi LDH ting cao. ALP thudmg tang dudi 3 lin binh thudng Bilirubin c6 thé tang kiéu hn hop hay ting chi yéu bilirubin tryc tiép Prothrombin time, INR kéo dai khéng 4p tig véi vitamin K néu cé suy gan cdp. 4.1.2. Viém gan man ALT, AST cé thé binh thuong hay ting nhe trung binh, thursng dudi 10 lin (< 300 U/L), ‘tng cao trong dot kich phat cp (flare or exacerbation) ._ Bilirubin da s6 binh thuéng, c6 thé ting trong det bling phat cdp hay dign tién dén xo gan mat bi Phosphatase kiém, GGT cé thé binh thuong hay ting nhe, thuéng duéi 2 lin binh thudng. Trong bénh gan rugu man, GGT c6 thé tang cao, dic biét sau khi dng rugu. 4.2. Xétnghigm chuyén biét theo timg nguyén nhain ~ Virus: xem bai phan tich e&c déu An virus gay viém gan ~ Twmién: ANA, SMA va ngudng globulin huyét thanh ~ Hemochromatosis: Fe, Ferritin huyét than va 49 bao hda transferrin + Bénh Wilson: inhuyé 3 }énh Wilson: ceruloplasmin huyét than, ‘Néu ceruloplasmin thép thi dinh hgng dng 08 tue i 24 gi vi Khim mit tin ving Kayser — Fleischer bing dba ke (iam). 43. Sigu am bung se mae can apts dm bung o6 thé sip chin dodn phan bigt vb eb bah 1 gan kde mh the mat cap, Cac dau higu cé thé gap nhu Gan to, tng sang va cdu tric binh thuong, Viém gan man: siéu am c6 thé cho hinh anh gan bj ie thd BO y 1 gan binh thd trie thd, ‘ém déu, gan nbiém mé...tly theo nguyén nhén gly VOM, mean oa 784 Scanned with CamScanner5, TUEP CAN BENH NHAN VIEM GAN 5.1. Viém gan cip Tip cn bénh nhan viém gan cp va bao gdm chin dodn xéc dinh (46i khi it khé phan biét ‘v6i dot bing phat cp cita viém gan man), xéc dinh nguyén nhin géy viém gan cp va dénh gid tién lngng. Bénh nhén viém gan cp thyémg dén khém khi cé trigu ching vang da hay dau tite nh am i ving ha suén phai hay tinh cd phét hién ALT, AST ting cao khi kham bénh do nhiing trigu ching hay bénh ly khdc ngoai gan. ‘Tnréc tién cin loai tri cfc nguyén nhan khéc gay ALT, AST ting cao, dic biét trong tic mat loai trir cic nguyén nhan gay ving da truéc gan va sau gan trong trrdng hop bénh nhan 6 trigu chimg vang da, D6i véi bénh nhan viém gan cfip cdn tim nguyén nhan va diéu tr] nguyén nhan trong mot sé tinh hudng. Da sé céc tnréng hgp cé thé tim duge nguyén nhén viém gan cdp dya vao héi bénh, thim khém lim sing cn thin va céc xét nghigm. Tuy nhién m6t sé trudng hop kh6ng tim durge nguyén nhan, ‘Tien lugng VGC khéng ty thugc vio ngudng ALT, AST, GGT; tién lugng thy thude vao ‘mic tng Bilirubin va dic bigt la tinh trang suy gan cp. Céc traréng hgp Bilirubin ting cao cé hay Khong cé prothrombin time hay INR kéo dai can nhfp vién theo déi. 52. Viém gan man Tiép cn bgnh nhan viém gan man cn xéc dinh nguyén nhén va dénh gié tinh trang xo hoa gan, Mitc 46 xo héa gan gitip tién lrgng VGM nhu nguy co tién trién xo gan, ung thu biéu mé té bao gan, Nhing bénh nhfin bj xo héa tién trién (F3, F4) cé nguy co ung thu biéu mé té bao gan cao, do dé cn tim soat ung thr gan méi 3 - 6 thing. TU KHOA: Viém gan, viém gan man, viém gan cp, CAU HOI TY LUQNG GIA 1. Virus gay viém gan man: A. HAV, HCV B. HBV, HCV C. HCV, HEV D. HAV, HDV 2. Xétnghigm c6 ¥ nghfa tién long trong viém gan clip: A. ALT, AST B. Bilirubin, Prothrombin time C. GGT, ALP D. Protein, Albumin Scanned with CamScanner