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CHNG IV

Nguyn tc chung v k thut chp ct lp vi tnh lng ngc

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Chp ct lp vi tnh u tin c p dng cho s no vi thit b ct lp qui c , thi gian qut 360o quanh trc c th ca bng X quang t 2-4sec v thi gian gia hai lp ct t 11 n 16sec hn ch kt qu chn on ca chp ct lp lng ngc . T khi cng ngh chp ct lp xon c ra i , phm vi ng dng ca chp ct lp vi tnh cho ton thn ngy cng m rng v hiu qu hn . Vi nhng th h my mi cho php qut lin tc 30sec hoc di hn, loi tr c nhng thay i gii phu gia hai ln nhn th ca bnh nhn v cho php t c nng thuc cn quang mch mu mc cao mt cch n nh , li ch ca chp ct lp vi tnh (CLVT) i vi bnh l ngc tr nn khng thua km so vi s no v c th tm tt vo ba im sau :

1. Loi b c vn chng lp ca cc cu trc gii phu bng k thut to nh thng dng nh chp X quang chun vi nhng lp ct ngang t mng cn thit cho chn on .

2. Cho php to nh c i quang t chc rt cao so vi phim X quang qui c nhng vn m bo phn gii khng gian cn thit cho chn on .

3. Kh nng ti to nh 3D v nhng hng cn thit khc i vi ton b lng ngc c bit quan trng trong chn on bnh l mch mu trung tht .

Nh nhng u th ni trn , chn on hnh nh bng chp CLVT ni chung thun li v t ph thuc vo ngi c hn so vi k thut to nh khc . Ch nh chp CLVT lng ngc : Chp X quang chun vn l khm xt thng qui hiu qu nht cho chn on v i quang ca cc cu trc trong ngc cao , d thc hin , liu x v gi thnh thp . Chp CLVT c p dng tip theo khi tn ti nhng cu hi chn on m phim Xquang chun khng gii p c . Di y l mt s ch dn thc hnh :

ng b bt thng trung tht hay rn phi cha r do bm sinh , bt thng gii phu , phnh hay phnh tch ng mch hoc chn y ca khi u gy ra .

Hnh khi , hnh thm nhim hay hnh nt m nhu m phi cn c nh gi y hn v cu trc v hnh thi ; nu nghi ng ung th , cn phn bc khi u c ch nh iu tr hp l .

Nghi ng mt hnh bt thng vng c-ngc hay ngc-bng v X quang chun khng c kh nng hin nh chn on cc vng ny .

Nhng trng hp kh phn bit hnh m gi nhu m phi vi mng phi trn phim chun .

Bnh l thnh ngc hay ct sng c lin quan ti mng phi v phi . Hnh bt thng lan to trn phim ngc chun cn c lm sng t tn thng

thuc nhu m hay ng th nh , c im v lan rng ca tn thng . Trng hp ny nn chp ct lp phn gii cao .

Chp CLVT cn c ch nh khi phim X quang ngc chun bnh thng hoc gn nh bnh thng nhng trn lm sng vn rt nghi ng mt bnh l kn o trong ngc nh :

Khi u c tnh ngoi phi cn tm nt di cn ti phi . Cc bt thng ni tit hoc ho sinh lin quan ti lng ngc nh nhc c nghi c bt thng tuyn c ; ri lon chuyn ho calci nghi bt thng tuyn bng gip trng ; tng catecholamin tng huyt p nghi u bt mu chrom ngoi thng thn hoc hi chng ni tit cn u nghi ung th ph qun ...

Ho ra mu khng tm c nguyn nhn , c t bo c tnh trong m , c ting rt thng xuyn khi th , thm nhim phi iu tr khng hiu qu .

Nhim khun phi ti pht bnh nhn khng c suy gim min dch . Lm sng nghi nghn mch phi hoc d dng ng-tnh mch phi . Bt thng chc nng h hp nhng khng thy bt thng trn phim ngc chun . au ngc cp tnh hoc au ngc ko di m khng tm thy bt thng trn in tm

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Ch nh chp CLVT ngc hin m rt rng nn khng th c mt chng trnh khm xt chung cho mi yu cu chn on . Da trn tnh nng k thut ca my chp c di tay cng vi phn tch k cu hi chn on , ngi bc s chuyn khoa phi quyt nh cc thng s k thut v chng trnh khm xt cho tng bnh nhn da trn nguyn tc gi tr chn on cao nht vi nguy c v gi thnh thp nht . Cn c gng t c kt lun ca khm xt trc khi cho bnh nhn ri khi my chp .

K thut khm xt

Ba k thut khm CLVT lng ngc thng dng c th la chn tu theo tnh nng k thut ca

thit b c di tay v yu cu chn on ca tng bnh nhn :

1. Chp ct lp qui c vi dy lp ct t 3-10mm v bn bnh nhn chuyn dch tng bc sau mi vng qut ca bng X quang , qut lin tip

2. Chp ct lp phn gii cao vi dy lp ct nh hn 2mm v thi gian qut mt vng 360o ca bng nh hn 2sec ; khng cn lin tip .

3. Chp ct lp xon c lng ngc vi rng ca chm tia X ( dy lp ct ) t 3-10mm v bn bnh nhn chuyn dch lin tc theo tc nh trc .

Chp ct lp qui c b hn ch v to nh 3D v MPR nn hin t s dng . Trng hp thit b khng c tnh nng qut xon c , bc s khm xt cn bit nhng hn ch ca k thut , nht l kh nng b st tn thng nh do phi di chuyn khi th . Chp ct lp phn gii cao thng thc hin nghin cu chi tit cu trc phi nh trong bnh l lan to hoc khu tr ca nhu m phi nh bnh t chc k , gin ph qun , gin ph nang , x phi . Hnh nh thu c khng thun li cho phn tch cc cu trc ca trung tht , khng p dng cht cn quang tnh mch trong k thut ny . Cn t cc thng s ca chng trnh ti to c phn gii khng gian cao . Nn t trng quan st t 15-20cm , dy lp ct 1-2mm bc chuyn bn 10-20mm t c nh phn gii cao nhng mc chiu x trn bnh nhn khng qu cao . Chp ct lp xon c nn lu mt s chi tit di y:

Pitch : l t l gia tc di chuyn bnh nhn (s) vi rng ca b chun trc (w) , cng chnh l dy lp ct , trong mi tng quan vi thi gian qut 360o ca bng Xquang (t)

s (mm/s) P = ------------- t (sec)

w (mm) Theo Wang v Vannier , nn chn pitch nh hn cn bc 2 ca 2 tc l di 1,4 . Pitch cng ln th thi gian khm xt cng ngn nhng nhiu nh tng theo . Pitch > 2 s to ra nhng khoang hp khng c d kin gia cc lp ct . Cc my chp CLVT hin c thi gian qut t 0.8 n 2sec/360o . Nu t thi gian qut 1sec/360o , tnh pitch rt n gin : khi chuyn bn vi tc 12mm/s v dy lp ct 8mm , pitch=1,5 .

Trng quan st (FOV) : l rng ca ma trn ti to nh . t FOV cng rng th phn gii khng gian ca nh cng gim do nn t FOV va bng chiu ngang lng ngc ca bnh nhn c c phn gii tt nht .

t ca s nh L v W : Lng ngc l c khc bit ln nht v t trng cc cu trc gii phu , thng phi c 2 ca s cho mt lp ct l ca s m mm cho trung tht - thnh ngc v ca s cho nhu m phi ; nu cn thit c th phi t thm ca s xng . Nn lu ba im khi t ca s c nh tt nht cho chn on : 1- phn bit mt cu trc cn quan tm vi cc cu trc ln cn , cn t L mc gia ca t trng chnh lch th d mt nhn phi c t trng +50 gia nhu m phi c m 800 th L tt nht 375 . 2- Mc ca s cng phi tng khi dy lp ct cng gim . 3- rng W phi bao trm c t trng mi cu trc cn phn tch trn nh : ca s m mm phi c rng W t 500-600

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mi c th xem c t m n xng ; ca s nhu m phi phi t W t 1300-2000 mi c th xem c t nhu m phi n xng .

Thuc cn quang : i vi lng ngc , tim thuc cn quang tnh mch ch cn thit khi cn phn bc mt ung th ph qun-phi , nghi ng bt thng mch mu hoc c mt tn thng phc tp phi-mng phi . Nn dng thuc cn quang c nng Iode t 240 n 300 mg/ml trnh nhiu nh tnh mch di n v tnh mch ch trn ; loi khng in tch ( non-ionic ) c a dng v him gy phn ng ph lm gin on khm xt .

tim v trung tht a- Nhc li v gii phu

Trung tht c chia lm ba khoang d nhn bit cc cu trc bn trong v ccbnh

hay gp ca tng khoang; l trung tht trc, gia v sau. Trung tht trc l khoang ngc

t sau xng c cho ti mng tim trc; trung tht sau l mng tim sau cho ti thnh ngc sau.

Cc thnh phn khc gia trung tht v trung tht sau ( tr khoang mng tim v mng phi)

hnh thnh khoang trung tht gia. T trn xung di, trung tht chon t h thng c cho

ti vm honh.

Rn phi kh xc nh gii hn c th hc, l vng b mt trung tht ln vo

phi v cc mch mu, ph qun v dy thn kinh i vo phi .

Hai rn phi khng i xng nhau nn khi xc nh mt cu trc bt thng vng ny l hch hay mch mu cn phn tch nh mt cch h thng `v tim thuc cn quang gip phn bit r rng hn v cng d nhn bit khi chon ch bnh l hn.

Hch bch huyt rn phi c ng knh ngang bnh thng t 0,3 n 0,6 cm v c th thy c trn cc lp ct. Ch khi ng knh ngang ca hch ln hn 1cm mi c th coi l bnh l v hch bch huyt thng nm dc theo ph qun v mch mu.

Tuyn c tr nh v thiu nin c m ca m mm v sau 20 tui dn dn

c thay th bng t chc m. Hnh dng tuyn c thay i tng ngi; hai thu tri v

phi ca tuyn c khi tch ri c khi ho nhp lm mt. dy ca t chc tuyn tr

em khng qu 1,8cm v ngi ln khng qu 1,3cm.

Tuyn c c th to ln ngi cng gip hoc sau iu tr bng Corticoid, ho cht. Khm xt tim thng dng siu m nhng chp CLVT c th s dng : -nh gi hnh dng v kch thc tim. -nh gi s lin quan v tr gia cc bung tim v mch gc. -Pht hin khi chon ch trong bung tim. -nh gi chc nng cu ni ng mch ch vnh. Cn mun nh gi c nng cc van tim, cc bung tim ch c my CT siu m nhanh

mi thc hin c. Cc vi ho trong lng ngc (ngoi mch mu) thng l di chng ca mt qu

trnh bt thng i trc, chng c th gp nhu m phi, trung tht, rn phi v cc

hch bch huyt, mng phi, thnh ngc. Nguyn nhn cc vi ho c th d on nh

v tr, hnh dng ca vi km theo nhng kin thc v nhng bnh l lm sng phi

hp. Tr cc thm vi thnh ng mch ch v ng mch vnh, nguyn nhn hay

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gp nht l do mt qu trnh nhim trng c; t gp hn l do u ri n cc ri lon

chuyn ho, bnh ngh nghip hoc do mt qu trnh iu tr.

B- bnh l trung tht v rn phi: 1- ng mch ch ngc: a.Hp eo ng mch ch do qu sn lp gia ca thnh mch gy hp lng ng

mch gy tng huyt p chi trn v gim huyt p chi di; v tr hp hay sau quai

ng mch ch, di ch pht xut ng mch di n tri. Chp CLVT c tim

nhanh thuc cn quang mi pht hin c hnh hp lng ng mch.

b.Phnh ng mch ch: c hai dng phnh ng mch ch l hnh ti v hnh thoi. Bnh thng ng mch ch ngc c khu kch t 3 3,5cm. nu ng knh ng

mch ch ln hn 4cm c th coi l phng ng mch ch hnh thoi. C khi khu knh ng mch ch khng qu 4cm nhng vn l phng ng mch v b khng i xng, l trng hp phng hnh ti. Khu knh ca vng ng mch ch b phnh nu khng qu 5cm, kh nng v rt him; nu t 5 10 cm rt d v. V tr ca phnh ng mch ch hay gp on MC xung v y thc qun sang bn phi. D hay v ti phnh ng mch ch cho thy mu t t trng c hiu trong trung tht.

c.Phnh tch ng mch ch l bnh cp cu tng i hay gp do hu qu vt nt thnh ng mch ch gy bc tch lp ni mc to ra mt lng mch gi trong lp o gia ca thnh mch. Phnh tch ng mch ch ngc c chia thnh hai th khc nhau: Tip A l loi phnh tch ng mch ch ln v chim 60 70% cc trng hp.

Tip B t gp hn, c v tr phnh tch ng mch ch xung, t eo ng mch ch lan xung di. Tip A hay lan ti van ng mch ch v l pht xut ng mch vnh tim v thng khng m c.

Chn on phnh tch ng mch ch c hai tiu chun l: -ng mch c 2 lng, lng gi v lng tht; lng tht ngm thuc cn quang

mnh hn. Lng gi c khi rng hn lng tht.

-Thy l ni mc gia hai lng gi v tht, nhiu khi nh vi ho ni mc cho php nhn bit l ni mc ngay c trn phim khng tim thuc.

2- Kn: a) Kn ph qun hay gp nht trung tht gia nhng cng c khi trung tht sau v

trc, kn c m dch nhng cng c khi l cht nhy vi m cao hn. Kn c hnh trn hoc bu dc, b r v mng, khng ngm thuc cn quang. Thng thy kn di chc ba khi ph qun v pht trin lch sang phi.

b) Kn mng tim thng khng c triu chng lm sng. Kn c b mng, khng

ngm thuc cn quang, hay gp nht gc tm honh phi v cha ng t trng dch

trong kn. y chnh l c s phn bit kn vi khi m cng hay thy cng v tr.

3- Vim trung tht - p xe trung tht thng xy ra do thng hoc v thc qun.

Hnh CLVT l trung tht rng ra vi cht cha bn trong c m dch, km theo

nhng bt khng kh.

4- Chn thng:

-Trn kh trung tht, pht hin trn nh nh m m ca khng kh.

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Vng trn kh hay lan ti vng di da c hoc ch trn kh mng phi. Cng

c khi gp trn kh trung tht t pht khng do chn thng.

-Chy mu hoc mu t trong trung tht do chn thng, phu thut hoc v

phnh tch ng mch ch ngc. Nhn bit do trung tht rng ra v cha m mu

t bn trong.

5- Cc khi u: c th gp nhiu loi u trong trung tht, sau y l mt s u tng

i hay gp:

a) U tuyn c l loi u hay gp nhiu nht trong trung tht ngi ln. Khong

50% cc u tuyn c khng c triu chng lm sng, 30% c nhc c. Rt kh phn

bit u c vi u lnh tuyn c trn nh CLVT v cng kh phn bit u Hodgkin tuyn c

vi cc u tuyn c khc.

Trn nh CLVT, cn bit hnh thi tuyn c theo tui : bnh thng tuyn c c

hai thy vi dng ch V nm ngang, nh quay v pha cn xng c . dy ca thy

thay i theo tui : di 5 tui, khong 1,4cm v khong 1,0cm trong khong tui t 10-

19 . m ca tuyn tng ng c vn, khong 36HU . Trn 25 tui, tuyn c bt

u gim m do cu trc m thay th dn . dy tuyn ngi trng thnh c

gii hn bnh thng l 1,3cm . Theo Nicolaou, khi dy tuyn ln hn 1,3cm hoc

phn tuyn c m m mm rng hn 7mm c th coi nh qu sn tuyn hoc u

tuyn c vi nhy 100% .

S dy v chiu rng tuyn c

Nhng ch tiu sau c th gip xc nh mt u tuyn c : (1) trn 30 tui; (2) khi

hnh cu hoc a thy; (3)m tuyn bng hay vt qu c vn ca thnh ngc;

(4)Tn thng c t chc m bao bc; (5) C vi ha trong khi v (6) Khi pht trin

mt pha hoc ngay ti ng gia .

u lnh tuyn c (u khng xm ln) c ranh gii r, hnh trn, bu dc hoc nhiu

thu trong trung tht trc, khng thy bao ngoi ca u v khong 25% c nhng vi

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ho. Cc u c tuyn c (u xm ln) chim khong 30% thng c m cao hn, ngm

thuc cn quang mc thp, cu trc bn trong khng ng nht, c khi c vi ho

kiu v trng, hay dnh vo mng phi hoc mng tim. U c th lan theo mng phi ra

trung tht sau v lan xung di ti tr honh .

Hnh u lnh tuyn c

U tuyn c xm ln thnh ngc v di cn mng phi

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b) Kn tuyn c c th l bm sinh, do vim hoc do u. Cc kn tuyn c c hnh

dch thnh mng trung tht trc, c th gp chy mu hoc vi ho trong kn.

c) U qui (Teratoma) l u hay gp trung tht do t bo mm gy ra. Phn ln l

u c, mt s nh l u kn. Cc u qui c th lnh hoc c tnh: cc u lnh l khi c b

r trung tht gia, bao ca u c th ngm thuc cn quang. 50% Teratoma c thnh

phn m trong u v c c nhng ct ho, vi ho trong u. Cc u c c b khng u,

thm nhim vo m ca trung tht vo mch mu v ng th. V u dy hn v ngm

thuc mnh.

d) Bu gip trng chm, hu ht trung tht trc v lin tip vi phn bu

gip c; cc bu gip hay c vi ho. m bu gip c khi t ti 100HU khi

cha tim thuc v li ngm thuc cn quang mnh. Cng c th gp ung th gip trng

trong trung tht trc m khng c u c, hay gp ngi gi, cc u c ny hay c

hoi t trong u v km theo hch to trung tht.

e).Lymphoma: Cc u hch trong trung tht c th l u Hodgkin, u khng

Hodgkin v cc hch di cn t ung th ph qun, v, u c, thn v cc u hc t.

Cc u hch Hodgkin v khng Hodgkin hay gp hai bn i xng; cn cc hch

di cn giai on u hay gp mt pha ca trung tht.

g).U thc qun:

C th gp ung th thc qun, mt s trng hp l u c trn lnh tnh

(leiomyoma); cc u thc qun cn phn bit vi dy thnh thc qun do vim, do so

bng, cc ti tha thc qun v kn. Thnh thc qun trn nh CLVT bnh thng

khng vt qu 3mm. Hnh dy thnh thc qun trn 5mm, v tr lch tm km vi hp

lng thc qun v gin trn v tr hp gi mt khi u thc qun. T chc bt thng

lp m cnh thc qun l du hiu nghi ng u pht trin ti cu trc xung quanh. Tim

thuc cn quang tnh mch gip hin r t chc v gii hn ca u thc qun.

Ung th thc qun chim khong 10% cc ung th ng tiu ha . Ngoi mt s

ung th tuyn c ngun gc d dy hay gp hn on cui thc qun, hu ht ung th

thc qun l ung th t bo vy . Cc du hiu thng gp ca ung th thc qun trn

chp ct lp l (1) hp lng thc qun v/hoc gin trn ch hp ; (2) dy thnh thc

qun lch tm hay ng tm ; (3) mt lp m bao quanh thc qun c hoc khng km

theo xm ln vo tng ln cn v (4) hch cnh thc qun (hnh )

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Ung th thc qun c thnh dy lch tm v c lot thnh

. nh gi lan rng ca mt ung th thc qun trc m thng kh khn,

hin nay nu kt hp vi siu m ni soi c th ci thin nhiu . Phn bc TNM cc ung

th thc qun thng da vo bng phn loi ca y ban hn hp ung th M (AJCC)

sau y :

Tis = Carcinoma in situ

T1 = U xm ln ti lp di mng nim hoc di nim

T2 = U xm ln lp c

T3 = U xm ln thanh mc

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T4 = U lan ti cc cu trc trung tht

N0 = Cha xm ln hch vng

N1 = Xm ln hch vng

M0 = Cha di cn xa

M1 = c di cn xa (k c hch ngoi trung tht)

Phn giai on ung th thc qun

G 0 = Tis, N0, M0

G 1 = T1, N0, M0

G 2A = T2/3, N0, M0

G 2B = T1/2, N1, M0

G 3 = T3, N1, M0 hoc T4, N0/1, M0

G 4 = T1-4, N0/1, M1

Vai tr ca chp ct lp trong nh gi kh nng phu thut cn nhiu tranh ci

v trong nhiu trng hp cn gp kh khn khi xc nh tnh trng xm ln ca u ti

ng th, mng tim v ng mch ch . Tuy nhin vai tr ca chp ct lp c nh

gi cao trong pht hin cc di cn xa nh gan, phi, mng phi v xng sng lin k

cng nh bin chng thng thc qun do u . Kim tra sau m v pht hin tn thng

ti pht, chp ct lp vi tnh cng a li nhiu li ch .

Cc khi u nguyn pht hay gp cc tng ca trung tht

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U c : 1- U gip trng sau c 2- U tuyn c

3- U qui, u x 4- Lymphoma nguyn pht

5- U tuyn gip sau kh qun 6- U ngun gc thn kinh

7- U thc qun, sc cm x

U dng kn : 8- Kn tuyn gip 9- U kn tuyn c

10- U qui 11- U trung m

12- Kn c ngun gc ph qun

13- Thot v mng no tu

14- Kn thn kinh-rut

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15- U bch mch

Khi u giu m : 16- U m tuyn c

17- U dermoid 18- Lipoma

19- U m c tnh ( liposarcoma)

5. Cc bt thng rn phi.

lm r cc cu trc bt thng rn phi cn c kin thc vng chc v gii

phu hc vng rn phi v ti y c nhiu mch mu phi, d nhm vi hch to. Ct

lp sau tim thuc cn quang l cch tt nht nhn bit cc hch to.

a) Lao phi: km theo tn thng lao nhu m phi, giai on cp c th thy

cc hch cnh kh qun v ph qun to ra. Cc hch ny ngm thuc cn quang ngoi

bin ( do vim) v khng ngm thuc trung tm do hoa t, b u ho. Phn ln cc

hch lao pht trin khng i xng qua ng gia v v sau s thm vi.

b) Bi phi: C th gp hch to rn phi nhng him khi qu ln, c th c vi

ho hnh vng trong hch nhng cc du hiu hch khng c bit m ch da chnh

chun on bi phi l hnh nh nhu m phi.

c) Bnh Sarcoit (BBS): hch to trong bnh Sarcoit (bnh ny hin nay t gp

Vit Nam) thng thy hch hai bn kh qun, hai bn rn phi v trc quai ng

mch ch. Cc hch c khi t li thnh m nhng khng thm vi; nu c ch giai

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on mun ca bnh. Hnh nh hch m t trn nu vng mt cc tn thng Sarcoit

nhu m phi, cn cnh gic u hch ca Lymphoma.

Phi

A- Nhc li mt s im quan trng v gii phu v k thut.

C hai k thut chp CLVT quy c v chp CLVT vi phn gii cao u b

xung nhng thng tin chn on qu cho cc phim lng ngc chun v CLVT c

phn gii i quang cao hn v cho cc nh lp ct ngang. Hai u th ni trn cho php

nhn bit v nh gi y hn cc qu trnh bnh l ca phi.

K thut chp CLVT vi phn gii cao (HRCT) i hi cc lp ct phi c

dy 2mm v thi gian lp ct cng 2mm giy.Do k thut my ngy cng tin b,

hin nay c my qut 1 giy mt lp ct v dy lp ct1mm; my qut xon c,

nh HRCT phi cng c cht lng cao hn i vi cc chi tit gii phu hc tiu thu

v di tiu thu.

V gii phu c th pht hin cc thu, rnh lin thu. Cc rnh lin thu hin

trn nh l cc vng khng c cc mch ln, cn trn nh HRCT chng l vt trng m

nu chp vi ca s nhu m phi. Trn cc lp ct phi bnh thng t th nm nga,

do nh hng ca p lc thu tnh v trng lc, c th thy hnh m qu mc, c khi

thnh m phn sau ca y phi .

Trn nh CLVT cc qu trnh bnh l ph nang v bnh l t chc k cng cn

phn bit nh trn phim phi chun .Du hiu ph qun cha khng kh trn nh

CLVT cng c gi tr nh trn nh lng ngc chun .

B Cc bnh l phi c tn thng khu tr thnh .

1 . Kn c ngun gc ph qun l cc khi trn hay bu dc n c , c m

ca nc ng nht , hay gp vng thu di ti khu vc trung tm ( gn rn phi ).

Chng c th t 1 n 5 cm ng knh . khong 30% cc kn c thng vi ph qun v

do vy c th thy mc nc- kh trong kn. Mt s kn ( nht l kn thng vi ph qun

) li c th nhim khun lm cho dch ttrong kn thnh m v c t trng tng ln ;

phn bit cc kn nhim trng vi p xe phi rt kh khn.

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2 . U tuyn ph qun (Bronchial adenoma) Loi u ny hay gp tui 30 50

vi du hiu lm sng ho ra mu.

Cc u tuyn nyhu ht l u carcinoid ri n cylindroma, epidermoid

carcinoma v pleomorphic adenoma . 80% cc u tuyn xut pht t ph qun

thu, phn thy v di phn thu , v vy rt hay gy ra xp phi v vim phi, hnh

nh by kh (air trapping) gp t hn. 20% cc u tuyn ph qun gp vng ngoi bin

v hin trn nh ct lp l nhng trn, b r, kch thc t 2 5 cm .

3.Ung th ph qun (Bronchial Carcinoma) V m hc, xp theo mc hay

gp l ung th biu m dng biu b (Squamous cell) ri n ung th biu m dng

tuyn (adenocarcinoma), n ung th t bo nh v cui cng l ung th t bo ln hay

thnh khi u ln ngoi bin. Nhiu tc gi cng b kt qu nghin cu so snh gia

chp ct lp qui c v chp ct lp vng xon (th tch) cho thy chp xon c c kh

nng pht hin cc nhn phi vt tri .

c im ca nhn phi c tnh :

nh ngha : Tt c cc trng hp trn X quang chun thy mt nt trn hay

bu dc vi kch thc di 3cm v khng km theo hnh xp phi hay vim phi u

c coi l mt nhn phi n c (solitary pulmonary nodule) . Khi nhn phi vt

qu 3cm s gi l khi v kh nng c tnh rt cao, cch x tr ch cn l sinh thit v

phu thut . Khong t 40 n 72% cc ung th phi c pht hin giai on cha c

du hiu lm sng l nhn phi n c ngoi bin .

Nhn phi n c ngoi bin c tua gai b

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U ph qun ngoi bin c hang thy trn phi phi

v c hch cnh phi kh qun . Tn thng x nh phi tri

Trn nh CLVT, cc ung th ph qun thng l khi c trung tm hoc

ngoi bin c : ln trn 2cm (75 n 85% l ung th) . V tr cc nhn phi cng c

ngha nh hng : 60% di mng phi hoc 1/3 ngoi, 30% 1/3 gia v ch c 10%

l 1/3 trong . Mt s tc gi cn nu v tr hay gp ca nhn ung th phi l thy trn

v phi phi nhiu hn . B khng u, khng r hoc c gai. Khong 15% c hang , b

dy v thnh trong khng u ( hay gp ung th Epidermoid). vi ho lch tm

trong u c th thy 5% cc trng hp. Khong 30% i km vi xp phi phn thu,

thu hoc vim phi do tc nghn ph qun , khng thy hnh ph qun cha kh. Hch

rn phi to mt bn c th km theo hch trung tht l hnh nh hay gp km theo

nhng cng c khi khng thy hch to , nht l loi ung th t bo nh. Khong 10%

c trn dch mng phi i km do u i ti mng phi. Cc u ngoi bin hay c dy mng

phi ni tip cn u. cc trng hp pht hin mun c th thy u lan ti xng sn

thnh ngc v xng sng. Cc nhn di cn, tri li hay thy thy di, hnh trn hoc

bu dc, b u v m thp hn .

Theo P. Grenier (2002), cc du hiu di y gi mt nhn phi c tnh :

Kch thc trn 20mm B c tua gai Trong nhn c hnh ph qun sng hoc hnh gi hang Vi ha dng c tnh trong nhn (lch tm, lm tm ri rc) Hnh knh m khu tr c kch thc trn 10mm Nhn hn hp (c phn c, phn knh m)

Cc du hiu trn ch cn c 1 du hiu l hng ti c tnh .

134

S xp thu trn phi phi trn phim thng, nghing v

chp ct lp vi tnh ; mc gim thng kh cng tng, rnh

lin thu cng di chuyn ra trc v vo trong, cui cng

rnh lin thu bm st b phi trung tht trc . m

m phi b xp cng tng ln theo mc phi b xp

S xp thu gia phi phi trn phim thng v nghing .

Trn phim ct lp, thu gia b xp c hnh tam gic tng

m bm st b phi ca bng tim .

135

S xp thu di phi phi trn phim thng v nghing .

Trn phim ct lp, rnh lin thu ln di chuyn dn ra sau

v vo trong v hnh thnh khi tng m cnh phi ct sng,

cc di rn phi cng xoay dn ra sau .

S xp thu trn phi tri trn phim thng, nghing v

chp ct lp vi tnh

S xp thu di phi tri trn phim thng. nghing .

Trn chp ct lp vi tnh , thu phi xp hnh thnh khi

tng m cnh ct sng v bao bc ng mch ch xung

Du hiu vin (Halo Sign) l hnh knh m bao quanh nhn phi c mt s tc

gi coi l hay gp trong giai on sm ca vim, nht l vim do nm Aspergillus v

vim lao ngi suy gim min dch .

136

Du hiu ph qun sng gp trong chp ct lp lp mng ti cc nhn phi c

bo co gp trong ung th ph qun nhiu hn trong nhn phi lnh tnh .

4. Cc u di cn: Cc u di cn c ngun gc rt khc nhau v hnh dng, kiu mu

u di cn cng c nhng im khc bit. Di cn dng k thng phi hp vi cc tn

thng mch mu phi hay gp t u nguyn pht v , gip trng, thn, tin lit tuyn,

saccm xng v choriocarcinoma.

Di cn dng nt trn hay gp t ung th thn, i trng, cc u sc t v cc

sarcoma. U di cn ph qun km xp phi do tc nghn ph qun li hay gp ngun

gc t ung th ph qun, thn, v, i trng v u sc t.

Cc di cn theo ng mu thng c dng ht k cho n nt nh v nt ln

hnh trn, kch thc t 1-4cm. Trong cc di cn ng mu thng khng thy cc

hch to rn phi v trung tht.

U di cn n c him gp hn, c th xut pht t i trng, Sarcome xng,

ung th thn, tinh hon, v.

U di cn c hang him thy v gp trong cc u nguyn pht ca t bo sng

(Squamous) ca u, c v c t cung . Rt him gp u di cn c vi ho v nu gp nn

hng ti cc u tuyn tit nhy , gip trng v u t bo mm .

5 .U hch : Lymphoma phi thng gp tn thng a di dng nt b khng r nt hoc nhng phn thu ng c c hnh ph qun cha kh bn trong d nhm vi vim phi. Tn thng thnh hang cng c th thy trong lymphoma dng Hodgkin lm d nhm hn vi lao phi. Cc thng tn phi ca lymphoma hu nh lun lun gn vi cc hch to ca lymphoma rn phi v trung tht.Trn dch mng phi c th gp trong 1/3 cc lymphoma c khi km hnh dy mng phi khu tr, kh phn bit vi cc u trung m mng phi.

137

Phn loi cc nhm hch trung tht ( theo Hi lng ngc M )

2R Hch cnh kh qun trn bn phi

2L Hch cnh kh qun trn bn tri

4R Hch cnh kh qun di bn phi

4L Hch cnh kh qun di bn tri

5 Hch khoang ch-phi 6 Hch trung tht trc (cnh quai ng mch ch) 7 Hch di chc ba kh ph qun 8 Hch cnh thc qun 9 Hch dy chng phi phi v tri 10R Hch kh-ph qun phi

10L Hch cnh ph qun tri

11 Hch trong phi 14 Hch trn honh

Hch c du * pht hin c qua soi trung tht, nhm 5,6 v 2L qua m ngc

t pha trc

138

6. U carcinoid : U carcinoid c xp vo nhm u thn kinh ni tit ca phi in

hnh hoc khng in hnh . Cc u ny phn ln pht trin nh mt khi trong lng

ph qun v nhanh chng gy tc ph qun, c th pht trin ra ngoi ph qun .

Cc u khng in hnh thng pht trin nhanh v di cn sm hn . Ba du hiu in

hnh ca u carcinoid l (1) khi trn b r hoc a thy; (2) ct ct hoc hp lng

mt ph qun v (3) hay gp gp nt vi ha lch tm trong u . Cc u ny thng rt

giu mch nn ngm thuc rt mnh sau tim cn quang .

7. Ung th t bo ph qun ph nang (bronchoalveolar cell carcinoma) : loi ung th

ny c 3 du hiu gi trn chp ct lp vi tnh l (1) sng dng bt khng kh

trong u cn gi l hnh gi hang (2) hnh ph qun sng trong u trn chp ct lp

mng; (3) co ko mng phi v c th c (4) du hiu vin .

8 . .Lao phi: lao phi l bnh ang c chiu hng tng cc nc trc y c

coi l thanh ton bnh lao. Vit Nam, lao phi cn l mt bnh x hi tng i

ph bin v hay thy kt hp vi suy gim min dch . Chn on hnh nh lao phi

da cn bn trn xt nghim m v phim X quang chun lng ngc.

Cc tn thng lao phi hay gp nh v cc phn thu sau (2) ca thu trn

hai phi.

Trn nh CLVT c th thy cc loi tn thng sau:

-U lao c hnh trn hay bu dc, b r hoc khng r, kch thc t 1 4cm v

rt hay km theo hnh tng m ( thm nhim) nhu m xung quanh, cn gi l cc tn

thng v tinh.

-Hang lao, cc hnh hang c b mng hoc hi dy vi b trong ca hang nhn

u, him thy hnh hi mc dch trong hang. Quanh hang thng c cc tn thng

ng c nhu m, nhng thay i dng x phi v hnh gin ph qun cc b. Dy mng

phi, nht l mng phi nh rt hay gp. T cc hang lao, tn thng c th lan theo

ng ph qun m bin thnh ph qun ph vim lao.

-lao k l th lao lan theo ng mu, trn nh CLVT l nhng nt rt nh di

dng hi chng k.

-Hch lao cng l hnh nh thng km theo cc thng tn nhu m: khi tim

thuc cm quang, cc hch lao hay c hoi t khng ngm thuc trung tm v theo

thi gian rt hay thy cc thm vi hch.

9. Gin ph qun. C nhiu nguyn nhn gy ra:

139

- Bm sinh trong hi chng Kartagener, x ho dng kn, a u ht mn

tnh tr em v suy gim men alpha l- antitrypsin.

-Sau nhim khun nh bnh vim mn tnh kiu t chc ht (th d lao phi), si,

hi chng Swyer- James.

- Sau tc nghn ph qun do sc vo ng th hoc sau ng c khi ng

th.

-Sau cc so x nhu m phi

Theo truyn thng, chp ph qun cn quang c coi l tiu chun vng i vi gin

ph qun nhng gn y nhiu tc gi qua nghin cu cho thy c th coi chp ct lp

phn gii cao hon ton c th thay th chp ph qun .

Tiu chun chn on gin ph qun trn chp ct lp vi tnh bao gm 3 nhm

du hiu l : (1) ph qun gin; (2) thnh ph qun dy v (3) ph qun y nim dch :

Ph qun gin : lng trong ca ph qun rng hn ng mch i km, chia thnh

3 bc : bc I : lng ph qun < 2 ln khu knh mch mu i km; bc II : lng ph qun

bng 3 khu knh mch v bc III : lng ph qun > 3 khu knh mch . Lng ph qun

khng gim ng knh sau ch chia i 2cm . Gin ph qun ngoi vi tnh theo 1/3

ngoi ca trng phi .

Thnh ph qun dy : Bc I thnh ph qun > 0,5 khu knh ng mch i km;

bc II thnh ph qun > 0,5-1 khu knh mch v bc III thnh ph qun > 1 khu knh

mch i km .

Ph qun y nim dch : l nhng cu trc tng m hnh ng hay hnh ch Y

di dng c phn nhnh hoc trn do ct ngang qua m khng phi l hnh mch mu

.

Hnh gin ph qun c th gp 3 dng trn chp ct lp vi tnh phn gii cao :

* Dng ti hoc kn l nhng hnh kn kh hoc kn dch-kh, dch thnh mng

c th ti 3cm ng knh v c mc dch- kh bn trong; cc kn ny c th t thnh

m nh t ong hoc lin tip nhau trn mt vt di.

* Dng ng hoc tr c thnh ph qun dy, lng ph qun gin t thnh nhng

m cu trc ng. C khi gp hnh ngn gng tay nu cha y nim dch nhy. Du

hiu con du trn (Signet Ring Sign) nu lp ct vung gc vi trc dc ca ph qun

gin km theo hnh mch mu ct ngang c khu knh nh hn lng ph qun.

*Dng bi: Cc ph qun gin, thnh dy t thnh m vi b xung quanh

khng u.

140

10. Cc ti khng kh di dng kn vi ln trn mt 1cm vi b rt mng , c

th i km vi mt vng x phi hoc n c. Cc kn kh ny d gy ra trn kh mng

phi v thng kh phn bit vi gin ph nang dng ti.

C. Cc bnh phi c tn thng lan to nhu m

1. Triu chng hc : V gii phu hc phi, n v nh nht l chm ph nang

(acinus) ri n tiu thu s cp ( primary lobule), sau n tiu thu th cp

(secondary lobule).

Cc tiu thu th cp c th phn bit trn nh HRCT. l n v phi hp bao

bc bng vch t chc lin kt. Mt tiu thu th cp gm 3- 5 ph qun tn cng v

cha ng 30 50 tiu thu s cp, ng knh mt tiu thu th cp t 1 2,5 cm; cc

tiu thu ny khng c s phn b ng dng m thng thy r vng ngoi vi ca

phi tip gip vi mng phi.

a) Xp phi l tnh trng tng m phi do dch hoc t chc c thay th

khng kh v do b vng xp phi th hin tnh trng gim mnh th tch phi. C

th chia xp phi thnh 2 nhm chnh : Xp phi tc nghn v khng tc nghn. Xp

phi tc nghn do s thng thng gia ph qun v vng ngoi vi b nghn hoc do tn

thng trong lng ph qun hoc do p t ngoi vo.

Trn nh CLVT xp phi c nh c hiu do gim khi lng phi v chuyn v

cc rnh bin thu.

b) Vim ph qun mn tnh l mt chn on lm sng da trn tnh trng tng

xut tit cht nhy ph qun. Trn nh HRCT ch thy thnh ph qun dy m ph

qun khng gin, tng ng vi hnh tng m di phi hoc phi bn

( dirty chest ) trn phim lng ngc chun.

c) Gin ph nang l tnh trng gin khng hi phc cc khoang cha khng kh

sau ph qun tn cng kt hp vi s ph hu cc vch ph nang. Gin ph nang c

chia thnh 4 tp l :

+ Gin ph nang trung tm tiu thu, cc tiu ph qun h hp b ph hu

thng thy lc u thu trn, v hay gp ngi nghin thuc l ; Phi qu sng i

km nhng ti khng kh nh v tha tht cc mch mu so vi phi bnh thng

+ Gin ph nang a tiu thu, cc chm ph nang v cc tiu thu th cp b

ph hu ng dng. Th gin ph nang ny hay gp thu di v c hiu trong cc

trng hp suy gim men alpha 1 antitripsin nhng cng c th gp ngi nghin

141

thuc l. Trn nh CLVT cng c hnh qu sng phi ( gim m CT ) tng vng

rng , nhiu khi kh phn bit vi gin ph nang trung tm tiu thu mc nng.

+ Gin ph nang cnh vch c tn thng chn lc ph nang v ti ph nang

ngoi vi ca tiu thu. Hnh gin ny khu tr c hiu st mng phi hoc st vch

tu thu. l cc ti nh cha kh c th pht trin thnh ti ln gin ph nang. Trn

nh CLVT hay gp cc ti gin ph nang cnh mng phi trung tht.

+ Gin ph nang khng ng u cn gi l cnh cc so phi thng phi hp

vi x phi khu tr ( nh trong lao phi ) hoc x phi ton th ( nh bi phi hay

sarcoit ).Hnh nh lm sng ca loi gin ph nang ny gn lin vi bnh phi gc.

d) Tn thng t chc k phi c hnh dy vch lin tiu thu trn hnh nh

HRCT l hnh nh hay gp. Cc vch lin tiu thu bnh thng him thy hin trn nh

HRCT, nu thy l nhng vt rt mng di t 1-2 cm vng st mng phi. Trong

vim t chc k, cc vch ny dy ln trn 1mm v hin ra nhiu trn cc lp ct; c khi

km theo hnh tng mt cc mch mu v ph qun tiu thu hin ra di dng hnh

vt m hoc nt trn nh ( nu ct ngang ).Cng c khi thy nhng vt cong m gn

mng phi vi chiu di 2 10cm, song song vi thnh ngc.

Cc nt k b r, kch thc t 1 3mm hoc hn na cho n 1cm xut hin vng

ngoi vi ca phi,loi nt ny l mt dng ca tn thng t chc k hay gp trong cc

bnh vim c t chc ht , sarcoit, cc di cn v bnh bi phi.

Hnh tng ong gm nhng kn kh ng dng c ng knh t 5 10mm vi

thnh dy v hnh nh c hiu ca x ho t chc k phi giai on mun. Loi tn

thng ny hay gp thu di v tr bnh Sarcoit v Silicosis li hay thy thu trn.

Khi tn thng x pht trin hn na s c hnh m thnh m km vi gin

ph qun do co ko.

Dng th hai ca tn thng k li khu tr vng t chc k trung tm quanh

ph qun mch mu c th di dng ph, thm nhim hay x ho to ra hnh dy

thnh ph qun trn cc lp ct.

Dng ny hay gp trong cc bnh vim v c khi kt hp vi vim bch mch

trong ung th, lymphoma v bnh Sarcoit.

2. Cc bnh vim: Vim phi c th do nm, do virut thng biu hin di dng

tn thng t chc k. Bnh vim tiu ph qun (Bronchiolitis) cho hnh nh li nt

hoc nt t 1 10 mm km theo qu sng do tng thng kh hoc ngc li, nu cc ph

qun nh b tc nghn s to thnh nhng m tng m do cc ph nang y t chc

vim v x c hai bn phi.

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3. Bnh Silicosis v bi phi ca th m than:

Thng thng hnh nh ca bnh xut hin sau tc ng ca ngh nghip lin tc

t 10 20 nm. Ring Silicosis cp tnh ca ngi lm trong m than c th xy ra bnh

ph nang lan to do bi Silic trong thi gian lm ngh ch mt nm. Hi chng Caplan

c th phi hp vi bi phi nht l nhng ngi th m than b bi phi.

Hnh nh HRCT l nhiu nt m t 1 10mm thy vng trn v vng gia

phi. Khong 10% cc nt ny c vi ho trung tm. Cc hnh nh i km l tn

thng dng t chc k nh dy vch lin tiu thu, cc vt m v nt mng phi, cc

di x, hnh tng ongv hnh gin ph qun do co ko.

Hch rn phi hay gp, mt s nh hch c th thm vi mng hnh v trng c

bit trong bnh bi Silic. Bnh c th tin sang giai on nhng m x pht trin

thu trn, i khi thnh hang.

4. Asbestosis : Cc tn thng t chc k hay gp nht vng y phi v cng

c nhng hnh nh tn thng k m t trong Silicosis. Hay phi hp vi bnh l

mng phi trong Asbestose nh mng dy mng phi. Tn thng Asbestosis c th gp

na l xp phi trn, l nhng tng m di mng phi hnh trn hay hnh thu

knh km hnh ui sao chi l hnh b mch ph qun i vo m. Mt s t

trng hp c th chuyn thnh u ph qun hoc mesothelioma mng phi.

5. Bnh Sarcoit : Bnh hay gp Chu u, Vit Nam hin c coi l him gp.

Ph n da en tui 20 40 c tn xut mc cao. 50% khng c triu chng lm sng.

Tn thng hay gp nht l hch to rn phi v trung tht, mt s t c th c trn

dch mng phi.

Du hiu trn nh CLVT hay gp l tn thng t chc k di dng hnh knh

m gn mng phi, tn thng dng ph nang t gp hn

Mng phi, thnh ngc v c honh

Cc bnh l mng phi nh trn kh, trn dch thng c th nh gi bng X

quang phi chun. Tuy vy bnh l thnh ngc v c honh nhiu khi b b st trn

phim chun. Cc tn thng sm xng sn nhiu khi rt qu cho chn on bnh l

phi thng ch pht hin bng chp CLVT. Bnh thng chp CLVT khng thy

c l tng v l thnh ca mng phi, ch khi c kh, dch hoc t chc mm chen vo

gia hai l mng phi mi c th nhn bit c chng.

A.mng phi.

143

1. dch mng phi pht hin trn chp CLVT sm hn nhiu so vi phim chun.

Hnh dy mng phi km vi t dch i khi kh phn bit; thay i t th bnh nhn lc

chp ct lp c th gip chn on phn bit. Cc trn dch mng phi dng tit, dng

thm, dng dng chp cho m ng nht gn vi nc v khng phn bit c

trn nh.

Trn mu mng phi c m cao v thng khng ng nht.

Chn on phn bit trn dch mng phi vi dch mng bng c th da vo v

tr ca dch: lp dch ngoi bin vm honh l ca mng phi, cn dch vng trung tm

l ca mng bng.

Trn dch mng phi mt bn hoc hai bn m khng phi hp vi tn thng

nhu m phi ngi tr thng l lao, ngi gi thng l u.

Trn dch mng phi do u hay gp nht trong di cn mng phi ri n

lymphoma v lxmi. Cc trn dch mng phi do chn thng hoc sau m c tin s

thun li cho chn on.

Mt s trn dch mng phi do bnh l bng nh vim tu cp, apxe di

honh, dch mng bng, suy thn .v.v.. c th xc lp c chn on nu ch n lm

sng v bnh l ton cnh ca bnh nhn.

Trn m mng phi thng gp th pht sau vim phi nhim trng hoc nhim

trng m huyt.

2.Dy mng phi c hai nguyn nhn hay gp l x v u. X mng phi l di

chng chung ca trn m, trn mu, lao, k c asbestosis v nhim bt talc phi.

Dy mng phi do u thng phi hp trong u trung m lnh v c, di cn,

lymphoma v nhng xm ln ti ch do ung th ph qun, nht l u ph qun ngoi

bin v u pancoast, ung th tuyn c.

Dy mng phi lan rng do x mng phi dn n bp nght phi, lm gim th

tch phi, dy mng phi c th thm vi thnh mng rng.

3.Cc u trung m (mesotheliomas) c th lnh c th c. U lnh thng xut pht

t l tng hnh thnh khi t chc mm ranh gii r nt c khi nhiu thu, kch thc t

2 14cm. Cc u nh thng c m ng nht, cn cc u ln m khng u, nht

l sau tim thuc cn quang do hoi t, chy mu, to kn v vi ho trong u. Cc u c

c c tnh cao v tin lng xu. Phn ng u ny xut pht t bnh nhn c tin s

tip xc vi Amian. U trung m c th gy ra dy mng phi lan rng, d nhm vi cc

144

nguyn nhn khc. Tim thuc cn quang c th gip phn bit v u mng phi ngm

thuc mnh cn x mng phi ngm thuc t.

4.Di cn mng phi rt hay gp v rt kh phn bit vi u trung m trn chp

CLVT. Ngun gc ca di cn mng phi thng l ung th ph qun, u nh phi, ung

th tuyn c; cc u ny ti mng phi do tip cn, di cn mng phi theo ng mu hay

gp nguyn pht t v, thn, bung trng v ng tiu ho.

B.thnh ngc.

Cc tn thng thnh ngc thng xut pht t xng sn hoc t chc mm

khoang lin sn bao gm c mch mu v thn kinh. Cc tn thng ny pht trin

thnh khi v y mng phi v pha trong ca khoang ngc to thnh gc t gii hn

tn thng vi thnh ngc. Cc tn thng xng sn do chn thng, do u v do

nhim trng thng gy ra tn thng thnh ngc bao gm cc tn thng nh can

xng, a u tu, ct tu vim do nhim khun, lao hoc nm. Cng c tn thng xng

sn lnh tnh gy tn thng thnh ngc nh lon sn x xng, kn xng, u sn

xng

C. C honh

Cn ch v gii phu hc nhng tr c ln su xung khoang bng cnh ct

sng, tr phi rng hn v di hn tr tri.

1. Thot v honh: C th bm sinh hoc mc phi.

-Thot v qua l thc qun (hiatus) hay gp nht v thng c th pht hin trn

X quang chun.

-Thot v Bochdalek hay gp bn tri v c th thy dc theo b sn honh

sau ; loi thot v ny thng kh ln v c th cha mc ni, m sau phc mc, rut,

lch, gan, thn, d dy v tu.

-Thot v Morgagni (qua khuyt c honh) khoang cnh c (trc gia) c th

cha gan, mc ni hay rut.

-Thot v do chn thng c th xy ra sau chn thng kn hoc vt thng

xuyn loi ny c th khng c triu chng lm sng nhiu thng nhiu nm. Khong

90% loi thot v ny gp bn tri, vng gia hoc sau ca vm honh. Mc ni d

dy, rut, lch v thn u c th chui qua l v c honh vo khoang ngc, loi thot

v ny d c bin chng tht nght.

2. Nho vm honh thng l bm sinh lm cho cc tng bng cng bn di

chuyn ln cao. Hay gp nho vm honh bn phi phn trc gia. Trng hp ny

gan chuyn v ln trn v cn trnh nhm vi khi u ngoi bin ca phi hay u mng

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phi. Nu nho vm honh bn tri thng nho ton b c honh tri ging nh mt

trng hp lit c honh.

Hnh gii phu c honh v v tr ca ba loi thot v

- Thot v Morgagni phn trc gia vm honh

- Thot v cnh thc qun cn gi l thot v khe honh (hiatus hernia)

- Thot v Bochdalek phn sau bn vm honh

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ng mch ch

1- i cng Nhiu bt thng gii phu vng quai ng mch ch (MC) nh quai MC phi, quai MC i, hp eo MC thng gy bin dng trung tht trn ti phim X quang chun; cc bt thng ny c th thy r trn chp CLVT xon c c tim thuc cn quang . Trong phn ny, chng ti ch khu tr vo chp CLVT cc dng phnh ng mch ch bao gm phnh tch

thnh MC , huyt khi trong thnh MC v lot su thnh MC .

Gi l phnh ng mch ch khi ng knh MC theo tng on (on ln, quai. on xung v on MC bng) vt qu 2SD ca gii hn bnh thng . Khu knh bnh thng ca MC ln theo cc tc gi nc ngoi l 35mm, on xung l 30mm v MC bng l 28mm ; ti Vit nam hin cha c cng b chnh thc, theo N T Vu (2005) qua kho st 131 ngi trng thnh bnh thng khng phn bit gii tnh, khu knh MC trn chp CLVT xon c l : MCL : 32mm ; Quai MC : 25mm; MCX v MCB : 24mm .

Theo O. H. Wegener, MC ln, MC xung v MC bng c khu knh >4cm u coi l

phnh ng mch ch . Phnh ng mch ch thng kt hp huyt khi thnh mch, cc huyt khi ny cng thng c v tr gia lp ni mc v lp o gia ca thnh mch, ch khc vi phnh tch MC ch khng c lng gi c dng chy bn trong .

Bng 1 di y gii thiu mt s im chnh ca 3 trng hp bnh l MC nu trn Mt s ch tiu lm sng chnh ca phnh MC (theo S D Qanadli, P Ugolini, A Denys, P Lacombe) Phnh tch Huyt khi

thnh Lot su thnh mch

Typ A Typ B Tui trung bnh 56 69 65 73 T l Nam/N 60/40 70/30 61/39 47/53 Tng huyt p 80% 80% 90% 95% Hi chng MC cp 100% 100% 100% 80% Phi hp phnh MC bng 10% 30% 53% 42%

2- Phn loi : C th chia phnh MC thnh 3 loi tu theo tn thng gii phu : Phnh tch thnh mch, huyt khi thnh mch v lot su thnh mch .

a. Phnh tch MC nh ngha : Phnh tch MC l tnh trng trn mu t ngt trong thnh MC, c bit n t bnh n u tin do Nicholls trnh by nm 1728 . T phnh tch (anevrysme dissequant) do Laennec a ra nm 1826 v c chp nhn cho n hin nay . Tnh trng trn mu thnh mch dn n s hnh thnh lng gi trong thnh MC theo mt s thng bo cho thy c th gp t 1 ti 3, thm ch 4 lng gi trong thnh mch . T l mc bnh ny kh xc nh chnh xc v khng c chn on trc khi cht . Theo mt s bo co gii phu thi th vi s lng ln, t l mc t 0,2 n 0,4% . Theo phn loi ca De Barkey, typ I phnh tch lan rng c MC ln v MC xung, typ II ch khu tr on MC ln v typ III ch khu tr on MC xung . Typ I v II chim

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khong 80% cn typ III chim khong 20% nhng typ ny li hay phi hp vi phnh tch MC bng . Tuy nhin s phn chia ny khng tuyt i v typ II c th pht trin thnh typ I v typ III cng c th chuyn thnh typ I . Phn loi ca Standford c a chung hn v c ngha cho ch nh iu tr : Typ A : Phnh tch ch khu tr on MC ln, typ ny i hi m ngay Typ B : Ch khu tr on MC xung v khng cn m cp cu . b- Huyt khi thnh MC nh ngha : Krukenberg m t bnh huyt khi thnh MC ln u tin nm 1920 v gi l tch thnh khng rch ni mc (dissection sans rupture intimale) . Nhiu nh ngha khc c trnh by trong nhng thp k tip theo v thng c s ln ln vi phnh tch MC c dng chy trong lng gi . Theo nhng thng k gn y, huyt khi thnh MC gp khong 30% phi hp vi phnh tch MC . Theo P. Grenier, c th nh ngha huyt khi thnh l s c mt ca mu trong thnh mch nhng khng c dng chy. Tin trin ca huyt khi thnh MC kh phc tp v n c th chuyn thnh phnh tch mch, v hoc phnh mch dng ti c- Lot su thnh MC nh ngha : Nm 1934, Shennan m t ln u tin, nm 1986 Stanson v nm 1986 Cook coi y l mt tnh trng bnh l ring bit ca MC . y l mt lot th pht trn c s tn thng x va mch, c bc tch v mu t khu tr ti thnh MC vt qu lp n hi trong ca thnh mch . Trn lm sng, lot su thnh mch c th im lng, thng gp ngi trn 70 tui . Ngoi kh nng tin trin thnh hai th bnh trn (phnh tch v huyt khi thnh), lot su thnh mch c th hnh thnh mt gi phnh hnh ti hoc v MC . 3. Chp ct lp vi tnh Chp CLVT ng mch ch cn c my xon c, bm tim in vi lu lng thuc cn quang t 3 n 5ml/s, dy lp ct khng vt qu 5mm v Pitch t 1-1,5:1, nn khi ng qut 20 giy sau thi im bt u tim thuc vo tnh mch nn . Ti to nh 3mm v dng nh MPR, nh MIP thy r ton b chiu di ng mch . Cc ch xut pht ng mch u c v ng mch tng bng c bit l hai M thn cn lm r phn nguyn u. Nn chp ton b MC t trn quai MC cho ti 3cm di chc ba ch chu nhm nh gi c ton cnh ca ng mch v loi tr c phnh tch MC v trn thc t lm sng gp nhiu trng hp phnh tch thnh mch m khu knh MC vn mc bnh thng . ng mch ch ngc : Trn lm sng, phnh MC ngc gp nam nhiu hn n (nam/n khong 1,5), mt t l nh c phi hp vi hi chng Marfan; ch 60-65% c biu hin lm sng nh au ngc, trong ch yu l cc trng hp phnh tch . Nut kh v khn ting (do chn p thc qun v dy thn kinh hi qui) ch gp t l rt nh (3-5%) . Trn phim x quang chun thy bng MC ngc rng 92% cc trng hp, khong cch b ngoi kh qun n b quai MC 7,4cm (N.T.Vu-2005) . Du hiu do v vv: Lim tng m st thnh mch trn nh trc tim cn quang v du hiu thuc cn quang ngm vo huyt khi thnh mch khi tim thuc th hin tnh trng nt ti phnh rt c gi tr chn on . Trng hp thuc cn quang thot ra ngoi thnh mch hoc trn mu mng tim, mng phi cho php xc nh tnh trng v ti phnh

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Hnh 1 : Phnh quai ng mch ch khng c huyt khi thnh trn ngi c bt thng bm sinh dng quai MC phi

Hnh 2 : Cng bnh nhn, nh dng MPVR

Phn tch nh chp ct lp xon c cn lm r nhng im quan trng cho ch nh iu tr sau :

Nu l phnh tch, cn xc nh l typ A hay typ B V tr phnh on ln, on quai hay on xung, ng knh ngang ln nht, tnh

trng huyt khi v vi ho thnh ti phnh . Mi lin quan ca on phnh vi cc ng mch u c, c bit l M di n tri .

Tnh trng ch xut pht ca cc ng mch u c . Ng vo ca phnh tch thng thy r trn siu m Doppler mu qua thc qun, trn

chp CLVT thng kh xc nh, tuy nhin vi cc thit b a dy u d, mt s trng hp c th hin nh ng vo .

Du hiu do v v v ti phnh : c/khng . Tn thng phi hp nh hp eo MC, trn mu mng tim, mng phi .

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Hin nh ng mch Adamkiewicz i vi phnh ng mch ch ngc bng l rt cn thit cho phu thut vin chun b trc m, kh nng ca chp CLVT cn hn ch; mt s tc gi hin nh c 90% ng mch nui tu ny vi my 16 dy u d, m chm tia X 1mm v s dng phn mm MPR vi hin nh kiu xin .

Hnh 3 : Phnh tch ng mch ch ngc bng lng gi ln hn lng tht

Hnh 4 : Phnh MC on quai c huyt khi thnh

Hnh 5 : Phnh MC xung c huyt khi thnh

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Hnh 6 : Da v phnh MC ngc on xung . Lu hnh thuc cn quang thm vo huyt khi v ngm ra lp o ngoi

Hnh 7 : Phnh tch MC ngc bng on trn thn

b- ng mch ch bng : au bng ch gp trn di 50%, s cn li l pht hin tnh c khi khm siu m bng v cc l do khc nhau . S thy khi u bng p theo nhp mch gp 75% . Kt qu chp CLVT i vi phnh MC bng cn lm r nhng chi tit di y : Tnh trng MC trn ch phnh v khu knh MC . Kch thc ti phnh bao gm ng knh ngoi v khu knh cc dng chy trong ti

phnh trn mt ct ngang lan rng theo chiu dc ca ng mch v typ ti phnh : ngc bng, trn thn, di

thn, c lan ti ng mch chu khng . c im dng chy trong ti phnh (lng tht, lng gi, huyt khi trong lng mch) Tnh trng thnh mch : vi ho thnh lin tc hay ngt qung, dy ca t chc huyt

khi thnh, tnh trng ngm thuc thnh mch sau tim cn quang (tnh trng vim mch)

Tnh trng cc cu trc quanh ti phnh (m, niu qun, tnh mch ch di, tnh mch thn, c tnh mch thn sau MC khng, tiu trng v t trng)

Tnh trng ca cc ng mch tng bng tng quan vi c ti phnh, c bit l hai ng mch thn, s lng ng mch thn .

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Chc nng v hnh thi hai thn . Tn thng phi hp nu c (khi u)

Ngoi cc chi tit nu trn, cn quan tm pht hin nhng trng hp c bit sau : Phnh mch vim : Cc phnh MC bng do vim thng km theo tnh trng x khoang

sau phc mc v ti phnh lan ti ng mch chu . Ti phnh hay thm nhim vo on 3 t trng, tnh mch ch di v niu qun nn c th thy thn nc . Vng xm ln ca ti phnh c th ngm thuc thay i sau tim cn quang . Tnh trng au ca bnh nhn do x khoang sau phc mc c th nhm vi biu hin do v nhng v ti phnh do vim thng him gp .

Nt, nguy c v v v ti phnh : Tnh trng ny i hi x tr nhanh . Cc du hiu nghi ng gm : (1) kch thc ngang ca ti phnh v nht l khu knh tng trn 5mm trong 6 thng . (2)Phnh do nm, thng gp phnh dng ti, t c vi ho thnh v phi hp vi du hiu vim quanh MC bng nh c dch quanh ng mch, hnh hi-mc nc v hnh hch to quanh MC v khu knh ti phnh tng nhanh . Nguy c v ti phnh trong trng hp ny khng ch l kch thc ti phnh m cn do mc nhim khun ca thnh mch do t cu, lin cu, k c vi khun k kh v Gram m . c bit lu i vi ngi b suy gim min dch . (3) ti phnh pht trin mi lch tm, t qung hnh vi ho v tr trc y lin tc, thnh ti phnh mng v tr i din vi mt m xng thoi ho t sng (4) Huyt khi thnh ngm thuc sau tim cn quang v (5) Du hiu tng m hnh lim t pht trong huyt khi hoc thnh mch trn nh trc tim thuc .

Ti phnh v : Khi ti phnh v, chp CLVT khng tim cn quang chn on : Hnh lin tc t thnh ng mch ch vi khi mu t tng m khoang sau phc mc; khi ny thng y thn tri ra trc . Sau tim cn quang, thuc cn quang qua ch v chy vo khi mu t cnh thnh mch l hnh nh trc tip ca v .

Hnh 7 : Phnh tch MC ngc bng, nh axial on trn thn Lng tht b lng gi bao quanh

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Hnh 8 : Cng bnh nhn - nh dng MPR

Hnh 9 : Phnh MC bng di thn, da v