Bai08-Loet Da Day

8/4/2019 Bai08-Loet Da Day

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LOT D DY

Mc tiu hc tp1.Nu c nh ngha v c im dch t hc ca lot d dy t trng

2 Phn tch c nguyn l chung v c ch bnh sinh ca lot d dy3.M t c cc tn thng chnh v i th, vi th trong lot d dy mn tnh

I. NH NGHALot d dy L tn thng mt cht cp hay mn tnh, to nn mt l khuyt nim mc

n qua c nim ti h nim mc hoc su hn.

Lot d dy v lot t trng c th pht trin ring l hoc kt hp vi nhau. Nhng trnnhiu phng din, c ch bnh sinh cng nh v c im hnh thi hc chng c nhng cim c bn ging nhau.

lot d dy ph bin l lot mn, lot cp ch xy ra trong nhng iu kin c bit.Nhng t tin trin cp trn mt lot mn l hin tng thng gp.

II. DCH T HCTheo cc ti liu nc ngoi, t l lot d dy cc nc u M vo khong t 5-10%

dn s.

Vit Nam, nhiu nghin cu khc nhau cho thy, t l lot d dy t 4-8% dn s.

Lot d dy l bnh kh ph bin, thng c coi nh mt bnh ca nam gii (bnh qunchim 4/5 tng s bnh nhn).

Lot d dy phn ln hay c chn on vo tui trung nin, song c th h b mcln u vo lc tr. Ring ph n bnh hay gp tui mn kinh v tin mn kinh.

lot d dy c th thuyn gim ri li ti pht, do vy "bnh nhn mt ln b lot th lun lunl mt bnh nhn lot d dy".

III. BNH CN- BNH SINH1. Bnh sinh

Qua nghin cu ngi ta tm thy c nhiu yy t lin quan n s pht trin ca bnh.Qu trnh hnh thnh lot l hu qu ca s mt cn bng gia yu t tn cng ( acid, pepsin ...)v yu t bo v ( s nguyn vn ca biu m ph, s ch nhy v lp cht nhy, vai tr ca tunhon, thn kinh...). Mi qu trnh lm cho yu t tn cng tng ln m khng c s cng c cayu t bo v, hoc yu t bo v gim st, c hai u c th lm cho tn thng mt cht khng

th sa cha c dn n lot d dy, t trng. Ngi ta nhn thy rng yu t tn cng ng vaitr ch yu trong lot t trng, cn trong lot d dy l s suy gim ca yu t bo v.

2. Bnh cn

2.1.Vai tr ca acid, pepsin

Acid v pepsin dch v l yu t tt yu cn thit cho qu trnh hnh thnh lot d dy ttrng, c bit vai tr quan trng ca acid c xc nh trong hi chng Zollinger- Ellison vinhiu lot d dy v t trng do ch tit qu nhiu gastrin v sn xut qu nhiu a cidechlohydric . Tuy nhin khng phi mi trng hp lot d dy t trng u c tng acid. Caphein


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lm tng dch v thng qua vic lm gim glucose mu do bng i ko di cng lm tngnguy c b lot. Histamine trong mu tng lm tng tit dch v, v vy c th gp trng lot ddy cp sau bng nng.

2.2.Vai tr ca H. pylori

Ti hi tho quc t ti Dublin, Irland (7/1992) kt lun: " H. Pylori ng vai tr ch

yu trong nguyn nhn sinh bnh ca lot d dy t trng ". T l H. Pylori dng tnh gp 85-100% s bnh nhn lot t trng v 70% trong lot d dy. Trong iu tr kt hp dit H. Pylori tl lin so cao hn, thi gian ngn hn v t l ti pht gim hn rt nhiu so vi nhng trnghp H. Pylori khng c dit.

H. Pylori khi vo d dy chng khu tr trong lp cht nhy v bm vo b mt t bobiu m. Di knh hin vi in t, ngi ta thy vi khun bm vo mng pha nh ca t bohoc gia cc khe lin t bo. Ti nim mc d dy H. Pylori to ra vim lot d dy qua ccc ch sau:

-Tit ra men ur-ase thy phn u r thnh CO2

v amoniac.

+CO2 nhiu gy y bng, m ch, kh tiu.+NH3 nhiu to mi trng kim thun li

cho HP tn ti, pht trin. NH3 gy hin tng

khuych tn ngc H+ , ng thi ngn cn qu

trnh tng hp cht nhy ca t bo v lm thay

i cht lng ca cht nhy cng nh s phn b Hnh1: Vi khun HP nim mc d dy

ca cht nhy.

- HP tit ra cc men catalase, protease, lipase, glycoproteinase... tham gia vo qu trnh phn hycht nhy, ph hy mng t bo biu m, ph t cc cu ni gian bo. Ngoi ra n cn sinh raadhesin gip HP gn cht vo t bo nim mc tip tc dng men ca n ph hy lp t bo

su bn di.- HP tit ra c t t bo ( cytotoxin ), hy hoi t bo tuyn nim mc v gim tng hpcht nhy.

Nh vy s ton vn ca cc lp o nim mc khng cn na, kt hp vi tn thngca t bo biu m , cc yu t tn cng HCL, pepsin s tc ng trc tip vo t bo biu mlm chng b hy hoi , do c th dn ti lot.

2.3.Yu t tinh thn

Mi tnh trng gy cng thng thn kinh ko di, nhng chn thng tm l s gy comch v tng tit acid lm cho nim mc b tn thng dn ti lot. Vt lot li kch v no v vno li kch thch d dy theo c ch phn hi. V vy v lm sng nhiu tc gi ngy nay khng

xem lot d dy nh mt tn thng khu tr n thun m coi nh mt bnh ton thn vi tn gi" bnh lot".

2.4.Yu t n ung

Vic n ung cc cht kch thch nh ru, n thc n qu nng hoc qu lnh, thc nkhng cht dinh dng v vitamin hoc n no nhng khng c ngh ngi u c th gy tcng khng tt ti nim mc d dy, t gp phn vo qu trnh pht sinh bnh.


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Ht thuc l lm hn ch qu trnh lin so lm thun li cho bnh ti pht, c l n lmcn tr qu trnh tng hp prostaglandin.

2.5 Cc thuc

Ung cc thuc nh aspirin, khng vim khng steroid s c ch tng hp prostaglandin(c vai tr phc hi t bo v sinh sn cht nhy) do lm gim sc chng ca nim mc d

d dy d dy t trng. Ung corticoid liu cao v dng nhiu ln lm thc y vic lot phttrin.

2.6.Yu t di truyn

Ngi ta nhn thy rng ngi b lot d dy t trng c tin s gia nh chim 60% nhng ngi lin quan rut tht. Trong nim mc d dy ca nhng bnh nhn ny c s lngt bo thnh nhiu gp 1,5 -2 ln so vi ngi bnh thng v nhm mu ca h thng l nhmmu O (cao hn nhm mu khc 1,4 ln).

IV. HNH THI HC1. Lot cp

1.1.i th

Cc lot d dy thng nh, kch thc thng di 1cm, hnh trn v t khi n su quanim mc. y lot c mu nu xm do s ging ha ca mu chy ra. khc vi lot d dy ttrng mn tnh, lot cp do stress c th gp bt c v tr no ca d dy. lot c th ch mt n c, nhng thng l nhiu khp d dy t trng.Vng ra v y lot a s l bnhthng.

1.2.Vi th

Lot cp tnh nht l do stress l nhng tn thng din ra rt nhanh. y lot thng phmt cht hoi t c mu hay cht nhy ha ln, t chc bn di thng ph n v xung huyt.Ty theo thi gian, lot c th hnh thnh t chc ht mng (ngho t bo,t huyt qun tnto).Nim mc b lot ch yu ph v xung huyt, xm nhp vim khi c, khi khng. T bo

biu m ph c th tng ch tit nhng khng c hin tng qu sn hay ch tit. Khng thyhnh nh ca t chc so v nhng mch mu thnh dy nh trong cc lot mn tnh.

2. Lot mn

2.1 i th

2.1.1.V tr

Nhng lot mn tnh thng gp t trng hn d dy, t l khong 3/1 ln hn Huht cc lot hnh t trng xy ra on u ca t trng , thnh trc ca t trng hay b hnthnh sau.

Lot d dy hay gp hn b cong nh. mt trc, mt sau v b cong ln gp t hn.

2.1.2.S lng

Thng thng a s bnh nhn ch gp mt lot, rt him khi c 2-3 hoc hn. C t10-20% s bnh nhn lot d dy ng thi vi lot t trng .

2.1.3.Kch thc

Nhng tn thng nh hn 0,3 cm hu ht l nhng vt trt nng, cc tn thng ln hn0,6 cm th hu nh chc chn l lot. Khong 90% cc lot d dy t trng c ng knh trndi 2cm v cng c khong 10% cc lot lnh tnh ln hn 4 cm.

2.1.4.Hnh thi


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Kinh in, lot d dy t trng c hnh trn, bu dc, nim mc ra lot c th nh vpha lng lot, cc np nhn ca nim mc thng c xu hng qui t v pha lot. Vi lotc tin trin nhiu nm , nim mc ra c th hi g cao mt cht. Nhng lot c b g cao r ththng l c tnh.

Nhng lot c tin trin nhiu nm vi nhng

giai on hoi t v x ha k tip nhau sdn n lot trai: ming lot nhn hoc mo

m khng u, nhiu gc cnh, nhn nhm.

Qua din ct c th thy nhng th x trng.

su ca cc lot khc nhau,c

nhng lot ch tn thng nim mc

v c nim, nhng cng c nhng lot Hnh2: lot d dy mn tnh

y nm trong lp c hoc st ti thanh mc hoc xuyn thng thnh d dy.

y cc lot thng mm v sch, vi lot c nht l lot x trai, y lot g gh, c

khi cc mch mu b nghn l ra rt r (l ngun gy chy mu e da n tnh mng).2.2.Vi th

Tn thng hnh thnh r rt nn v b lot vi nhng mc khc nhau ty thigian tin trin ca bnh.

-Nn lot gm bn lp nh sau:

+ Lp hoi t : gm cc mnh vn t bo, bch cu b thoi ha v t huyt.

= Lp ph dng t huyt: c coi l tn thng c trng. Do tc dng ca acid HCL, khinhum Van Gieson cc si to keo s bt mu da cam r. lp ny c xm nhim vim khngc hiu vi bch cu a nhn chim u th.

+ Lp m ht: c hnh thnh vi nhng t bo x non, si to keo, nhiu huyt qun tn to

v xm nhim cc t bo vim, trong ch yu l bch cu n nhn.+ Lp x ha: l lp so x chc c cha si to keo, Cc mch mu thnh b dy ln r rt vis xm nhp vim bao quanh.

3.Lot Zollinger-Ellison

L mt loi lot c bit, khng ging vi loi lot thng thng. Lot thng nhiu (ckhi c ti hng trm lot nh), gp nhiu v tr khc nhau, nguyn nhn do tng tit gastrin(hay gp trong u o langerhans).

V. LIN H LM SNG1.Triu chng

Hu ht cc lot d dy gy au tc, nng rt vng thng v. au c chu k: au-khi-

au. Ma lnh au nhiu hn ma nng, thng au lc i, gim au khi nh cc cht kimhoc thc n. i vi nhng lot su, au thng m ra sau lng, lan ln trn bn tri hoc lanln ngc. bun nn, nn, chua, st cn l nhng triu chng ph thm thng gp.

2.Chn on

Cc phng php chn on hnh nh nh X quang, Siu m, ni soi d dy c th phthin bnh chnh xc ti 98% cc lot d dy t trng .

3.iu tr


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Lot d dy t trng ch yu l iu tr ni khoa bng cc thuc khng tit acid, trung haacid dch v, cc thuc bng v bo v nim mc, an thn, kt hp dng khng sinh khi HP dngtnh.

iu tr phu thut ch t ra cho lot trai, lot ln,su vi bin chng chy mu m iutr ni khoa khng p ng.

4.Bin chng- Chy mu: kh ph bin, thng l chy mu nh, lu ngy bnh nhn d b thiu mu

- Thng: thng thng xy ra sau tin trin lu nm ca bnh, nhng cng c khi thng d dyxy ra trn bnh nhn tr, lot cp.

- Cht hp: Do s x ha quanh lot. Nu lot ln cc mt ca d dy, nim mc xungquanh lot s b co ko gy cht hp to hnh nh d dy hai ti hay ng h ct. Nhng lot xtrai mn v rt d a n hp mn v, lm d dy gin rng hn bnh thng v sa xung thp.

-Ung th ha: lot t trng khng c ung th ha. Lot d dy bt k v tr, kch thc, thi gianno phi cnh gic ln hn tuy nhin cc lot ln, lot trai v tr b cong nh nht l onngang l ng ngi hn c. Nhng trng hp ny cn ni soi d dy v ly sinh thit nhiu

mnh vng lot v ln cn vng lot lm xt nghim vi th pht hin tn thng c tnh ha.


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UNG TH D DY

Mc tiu hc tp1.Nu ln 4 yu t chnh trong bnh cn ca ung th d dy

2.Nu c 3 c im i th ca ung th d dy giai on sm v giai on mun3.M t c 5 tp vi th ca ung th d dy.

I. DCH T HCTrong cc loi u c tnh d dy th ung th biu m d dy l quan trng nht v cng l

ph bin nht, chim t l 90-96%, sau n lymhpo:4%, carcinoid:3%, cc loi u khc rt tgp.

Theo nhiu thng k, ung th d dy chim khong 10% cc loi ung th ni chung v50-70% ung th ng tiu ha. Trong my chc nm tr li y, ung th d dy c xu hnggim u n c v t l mc bnh v t l t vong.

T l gia cc nc c s khc nhau rt nhiu. c bit cao Nht bn,Trung Quc,Chil, Costarica, Scotland. Mt s nc khc nh M, Canada, Hy lp c t l bnh thp. v dt l bnh trn 100.000 dn nht bn l 46,6 trong khi Canada 12,1, M l 7,2 ( thp hngn 7 ln so vi Nht).

Vit Nam cha c iu tra dch t hc trn phm vi c nc. Nhng qua mt s thngk cho thy ung th d dy cng l mt loi ung th c t l bnh cao. Ti trung tm Y t BchMai trong 18 nm (1958-1975 ), ung th d dy chim t l 12,2%, Bnh vin K H Ni (17%),cc tnh min trung 14%, thnh ph HCM:2,2 %.

V tui: Ung th d dy thng c pht hin tui trn 50, t gp tui thanh nin vc bit him gp tui thiu nin. Vit Nam , ti bnh vin Vit c mi nm vn m cho 4-

5 trng hp bnh nhn di 25 tui, trong c c bnh nhn 14 tui.V gii: Ung th d dy gp nam nhiu hn n t 1,5-2 ln.

II. BNH CN, BNH SINHC nhiu yu t nh hng ti qu trnh hnh thnh ung th d dy, di y l mt s

yu t chnh:

1. Yu t mi trng, ch n

Cc yu t nh hng v mi trng c coi l quan trng hng u. Khi cc chng tcdi c t nhng vng c nguy c cao ti nhng vng nguy c thp ( hoc ngc li) t l phtsinh bnh c xu hng ph hp vi cc a phng mi. Vng Vn in ngoi H ni ngunnc ung c hm lng nitrate cao gp hng chc ln cho php.

- Ch n l th phm ch yu v thi quen nu nng no lm tng nguy c b ung th ddy v d n nng, hun khi, mt s n ln men, dm tm ( da ci non )

- S c mt ca cc cht gy ung th nh cc ha cht nitrite bo qun thc phm nh dimtiu, hn the bi cc cht nitrate s c chuyn ha thnh nitrite ( nitros a min l nhng cht ckh nng gy ung th d dy.

- Nhng ngi nghin thuc l nng, tn s d mc ung th d dy cao hn t 2-6 lnngi khng ht.


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- Rau xanh v cc loi hoa qu ti nh cam qut... c cha cc cht chng oxy ha c vai trngc li vi ung th d dy.

2. Cc yu t nguy c

- Vim d dy mn tnh: nhng bnh nhn vim teo vng hang v mn tnh c nguy ctng gp 18 ln. Vim d dy mn teo vng thn v v thiu mu c tnh r rt cng lm cho nguy

c mc ung th d dy gp 3 ln.-Lot d dy : nhng lot mn tnh ko di lu nm nht l b cong nh v lot x trai

c kh nng c tnh ha cao, trung bnh khong t 7-10%.

-Sau ct on d dy : phn cn li c nguy c cao, t l ung th mm ct dao ng t1% n 16%. Ngi ta cho rng tro ngc dch rut l yu t quan trng nht v s tc nglin tc ca dch tro ngc s gy nn nhng bin i nim mc d dy nh vim teo, d snrut, lon sn. Sau ct on d dy cn gy nn gim toan, vi khun ti ch pht trin to iukin thun li nitrit c trong thc n chuyn thnh nitrosamin.

-Polip u tuyn: kh nng tr thnh ung th ca polip u tuyn rt cao, trung bnh c ti30%.

3. Vai tr ca H. PyloriT chc y t th gii ( WHO) nm 1994 xp H. Pylori vo nhm I nhng tc nhn gy

ung th d dy ngi. T l nhim H. Pylori tng ng mt cch cht ch vi ung th d dyv vic gii quyt vn nhim H. Pylori s dn ti vic gim t l ung th d dy.

4. Yu t di truyn

Ngi ta nhn thy c mt s chng tc c t l ung th d dy cao. Ngi c nhm mu A cnguy c b bnh cao hn nhm mu khc. c bit ngi c h hng gn vi ngi b ung th ddy,kh nng b bnh ca h cao hn nhng ngi khc. Tuy nhin ch c 4% s bnh nhn bung th d dy c tin s gia nh b mc bnh ny.

III. HNH THI HC

1.V trMi v tr ca d dy u c th pht trin ung th, nhng hay gp nht vn l vng hang

v- mn v (50-60%), th hai l vng b cong nh 20-30%), sau l tm v (10-20%) v t gphn b cong ln( 0,5%), y d dy , mt trc, mt sau.

2. S lng

V s lng ung th thng thng ch c mt , tuy nhin cng c trng hp nhiu .Trng hp ny, cc ung th ng tch bit khng ph thuc vo nhau, c kch thc to nhkhc nhau. Loi nhiu chim 1-8% v v i th u c dng polyp, v vy ngi ta cho rngbnh a polyp d dy l c s sinh ra th ung th nhiu .

3. Gii phu bnh

3.1. i th3.1.1. Ung th d dy sm

Nhng u c kch thc di 3cm, s xm ln c gii hn ch yu nim mc hocdi nim mc nhng cha xm nhp vo lp c c gi l ung th d giai on sm.

Ni chung ung th sm cha c di cn nhng c t trng hp di cn.


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Nm 1962, hip hi ni soi tiu ha Nht Bn da trn c s soi d dy ng mm vnghin cu mnh d dy ct b qua phu thut phn loi ung th d dy sm thnh 3 tip.Ngy nay phn loi ny c quc t cng nhn v nhiu nc p dng.

- Tip I. tip li:

U pht trin li trn mt nim mc d dy c dng polyp, dng cc hay dng nh nhung mao

( Villous). Tip I gp khong 20%- Tip II.-tip phng c chia thnh 3 nhm nh

+ IIa: Phng g: T chc u pht trin nim mc to thnh mt mng nh hi g ln,ranh gii r v ch cao hn mt cht so vi nim mc xung quanh.

+ IIb-Phng dt: t chc u pht trin nim mc to thnh mng nh hi chc v tngi phng so vi nim mc bnh thng xung quanh.

+ IIc- Phng lm: Vng u hi lm xung thp hn so vi nim mc xung quanh. Tip nythng gp nht chim t l t 30-50%.

-Tip III. tip lot: tn thng lot c su tng i r, loi ny gp khong 20-40%. Tip IIIthng c kt hp vi phn nhm ca tip II.

3.1.2. Ung th d dy giai on munKhi u thng c kch thc ln, pht trin xm nhp vo lp c thnh d dy, c th ti

thanh mc, xm nhp vo cc tng ln cn v cho di cn. giai on mun, vic phn loi i thi khi kh khn v c ba qu

trnh tn thng si, lot, xm nhp thng xen

k nhau.Ty theo tn thng no chim

u th m ngi ta chia thnh cc loi di y:

- Ung th th si:

Tn thng u thng c gii hn r, pht trin

ch yu li vo trong lng d dy. U pht trin nhmt dng polyp c cung hoc t mt polyp sn c

thoi ha thnh ung th. B mt u c nhng nh nh, Hnh 2: Ung th d dy th si

giu huyt qun v c th c nhng chm lot nh

nn rt d chy mu. Trng hp khi u tng i ln

c chn rng thng to thnh khi trn hnh nm.

c bit khi u to c th chim phn kh ln b mt

d dy vi nhng khi si nhiu thy hnh spl,

b khng u c cc khe rnh v ch li lm do

qu trnh hoi t v chy mu to ra mi hi thi.- Ung th th lot:

Th lot hay gp nht chim trn 50% cc trng hp, Hnh 3: Ung th d dy th lot

gm cc dng sau:

-Ung th lot ha: u thng ln, hnh a, ng knh c th ti 8-10 cm. Lot trungtm do t chc u km c nui dng b hoi t to nn.


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-Lot ung th ha: ung th pht trin trn c s mt lot d dy mn tnh nht l nhnglot ln, lot x trai, do ngoi tn thng u cn c nhng c im ca lot mn tnh.

- Ung th th xm nhp:

Khi u pht trin c c tnh xm nhp v lan rng vo thnh d dy sm ngay t giai on u.U gm c 2 th sau:

-Ung th lot xm nhp: Khi u ng thi va c lot va c xm nhp.-Ung th x t ( linite plastique):

Khi mi pht trin v th n thun c th chn on nhm. ngi ta c cm tng lmi lp ca vch d dy vn cn nguyn vn, ch dy ln nh xm nhp dng vim km x ha.

Khi ung th pht trin, vch d dy dy ln nh ba, c khi ti 2-3 cm, chc nh mo cau,lm cho mt phn ln hay ton b d dy co li c th nh hnh chic chai hay hnh bt tt ngn.Qua mt ct cn phn bit c cc lp nhng dy, x ha, mu trng c bit. Khi xm nhpvo thanh mc biu hin bng cc ht nh v c th gy dnh nhiu vo cc c quan k cn.

3.2. Vi th

Xc nh ung th d dy v vi th khng kh khn, nhng phn loi m hc ung th rt

phc tp v chng rt khc nhau v a dng. Theo phn loi ca t chc y t th gii (WHO)1977 gm 5 tip:

-Ung th biu m tuyn

-Ung th biu m khng bit ha

-Ung th biu m tuyn vy

-Ung th biu m t bo vy

-Ung th biu m khng xp loi

3.2.1.Ung th biu m tuyn

Bao gm cc loi sau:

-Ung th biu m tuyn nhCc t bo u sp thnh hnh tuyn Hnh 4: UTBM tuyn d dy

c cc nh chia nhnh c trc lin kt

pht trin vo trong lng tuyn. t bo u hnh tr hay vung tng i u nhau. Ngoi cu trcnh chim u th cn c th gp cc hnh tuyn ng.

- Ung th biu m tuyn ng: t bo u sp xp to hnh tuyn ng l chnh. Khi ct ngang tuync kch thc khc nhau, lng tuyn c th gin rng thnh nang. T bo u hnh tr hoc hnhvung, khi tuyn gin rng cha nhiu cht nhy, t bo tr nn thp dt. Quanh cc tuyn ungth thng c nhiu m lin kt bao bc.

-Ung th biu m tuyn nhy: m ung th c mt lng ln cht nhy, cht ny cha y

trong lng tuyn lm cho lng tuyn gin rng v trn c vo m m. C trng hp khng chnh tuyn r rt, t bo u tp trung thnh tng m, tt c nh bi trong b cht nhy. Trongtrng hp ny thng c mt s lng t bo hnh nhn nht nh, t bo u cng trn, cht nhyy nhn lch v mt pha, trng nh chic nhn.

3.2.2.Ung th biu m khng bit ha:

T bo u khng khng sp xp to hnh tuyn, chng tp trung thnh m ln hoc thnh ,thnh b hay phn tn ri rc trong m m c t chc lin kt x rt pht trin. Cc t bo u cth gi li t bo biu m d dy hoc khc bit hon ton. Mt s trng hp, t bo trn


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nh tng i ng u tng t t bo lypho. Mt s khc t bo u rt a hnh thi, nhn tonh a dng , nhiu nhn qui v nhn chia khng in hnh.

Hnh 5: UTBM tuyn nhy Hnh 6: UTBM t bo nhn

Ung th biu m tuyn v ung th biu m khng bit ha l loi hay gp nht, trong ung th biu m tuyn thng c t l cao hn

3.2.3.Ung th biu m tuyn vyL th u him, cu trc gm m tuyn v m t bo vy.

3.2.4. Ung th biu m t bo vy

L loi ung th t gp d dy, t bo u tp trung thnh m, ging biu m lt ca biub. U hay gp tm v khu vc gn thc qun nhng cng c th thy hang v, mn v.Ngi tacho rng u thng pht trin trn c s biu m vy lc ch hay t nhng d sn vy d dyhoc t thc qun lan vo d dy.

3.2.5.Ung th khng xp loi

T bo u v cu trc u khng ging vi cc dng m t, do khng th xp chngvo mt trong nhng th trn c.

IV.TIN TRIN1. cc cch phn loi ch yu

- Phn loi ca Gutman v Ivan Bertrand:

Giai on O : ung th ti ch

Giai on I : ung th xm ln nng, ch nim mc

Giai on II: ung th xm ln h nim mc

Giai on III: ung th xm ln lp c v thanh mc

Giai on IV: ung th di cn hch

- Phn loi ca Duke, ngh cho ung th i trng cng c p dng cho ung th d dy.

Giai on I : ung th nng trn nim mc

Giai on II: ung th xm nhp vo cc lp vch

Giai on III: ung th di cn hch

- Phn loi theo h thng T.N.M.

T: khi u

Tis :ung th ti ch


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T1 : ung th pht trin nim mc v xm nhp vo h nim mc

T2: ung th xm nhp vo lp c v lan rng chim mt phn d dy ( di 1/2).

T3: ung th xm nhp vo lp c v lan rng trn 1/2 d dy nhng cha xm ln vo cctng ln cn.

T4: Ung th chim 1/2 d dy v xm ln vo cc tng ln cn.

N: Hch bch huytNo: cha c di cn vo hch bch huyt quanh d dy

N1: cha c di cn v hch bch huyt quanh d dy

N2: di cn vo hch bch huyt dc ng mch pha tri d dy, ng mch gan chung,ng mch lch v vo hch dc dy chng gan t trng v vo cc hch bch huyt m khiphu thut cn kh nng ly c.

N3: di cn vo hch dc ng mch ch, ng mch mc treo, ng mch chu v cchch m khi phu thut khng cn kh nng ly c.

M: di cn xa

Mo: cha c di cn xaM1: c di cn xa

2. Cc giai on tin trin

Cng nh nhiu loi ung th khc, ung th d dy cng tin trin theo ba giai on:

+ Lan ti ch: giai on sm m ung th ch khu tr nim mc v h nim mc . giai on mun,ung th xm nhp vo lp c v c th ti thanh mc ca vch d dy.

+ Lan ti khu: Lan theo ng k cn. y l mt kiu tin trin c bit, ung th xmln vo mc ni, c th lan n cung gan, vch i trng v mt s t trng hp lan vo cunglch hoc lan ra mt sau vo vng ty lm cho phu thut ung th khng th thc hin c.

+ Lan ton thn: L di cn theo ng mu v ng bch huyt . Hch khu vc rt d b

xm ln. Nhng trng hp c can thip phu thut, 50-80% c di cn vo hch quanh ddy cn trn t thi, trn nhng bnh nhn giai on mun khng phu thut c, gn nh.100%. Ung th d dy cng thng cho di cn vo cc hch xa, hay gp hn l cc hchthng n,hch c, hch dc ng mch ch, hch trung tht.

Ngoi hch, ung th d dy cn c th di cn vo tt c cc c quan, trong hay gpnht l gan v gim dn theo th t: phi, mng phi, thng thn, xng, tuyn gip v da,bung trng( u Krukenberge) vi c im: u c v bc, mt trn nhn, mt hi chc, din ctc nhiu mu sc, c nhng chy mu, hoi t ,thoi ha nhy. M u gm nhng cu trc tuynbit ha hoc ging ung th biu m dng rut ca bung trng.

V. LIN H LM SNG

1. Triu chngUng th biu m d dy l mt bnh thm lng, ni chung thng din bin khng ctriu chng cho ti khi mun.

Cc triu chng gm c: st cn, au bng, chn n, nn, thay i cc thi quen v nung. t gp hn l cc triu chng v ri lon nut, thiu mu v xut huyt. Khi khi u ln, nhtl mn v, tin mn v s gy cht hp, cui cng bnh nhn t vong thng do suy mn gynn.

2. Chn on


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C nhiu phng php chn on v vic pht hin sm ung th d dy l rt quantrng

- Phng php ni soi: ngy nay nh s ra i v ci tin khng ngng, cc my ni soid dy ng mm gip cho chn on ung th d dy ngy cng chnh xc hn v pht hinc ung th giai on sm.

Nht Bn, ni ni soi cho ton b nhn dn qua cc chng trnh chiu ln mn hnhti ch chn on c ung th d dy sm chim khong 35% cc trng hp ung th d dymi c pht hin. (t l ny chu u mi l 10-15%). nc ta, hin nay nhiu bnh vin c trang b my ni soi, vic chn on ung th d dy c nhiu tin b , nhng ung th d dycn t c pht hin sm.

- Phng php t bo hc : t bo hc chi qua my ni soi v t bo hc p mng sinhthit c p dng ph bin hn c. Cc phng php ny n gin, r tin, cho kt qu nhanh v chnh xc ti 80-85%.

-Phng php m bnh hc sinh thit: khi soi d dy kt hp vi sinh thit lm xtnghim m bnh hc l phng php khng th thiu c trong chn on ung th d dy , cbit l trong vic pht hin ung th giai on sm.

nng cao hiu qu chn on ung th d dy ngi ta thng kt hp 3 phng phpvi nhau, kt qu t t 90-97%.

3. iu tr

iu tr ch yu bng phu thut

4. Tin lng

Vic tin lng ung th d dy ph thuc vo su ca s xm ln, phm vi, khongcch ca cc di cn hch v di cn xa, cc tip m hc. t l sng thm 5 nm sau iu tr phuthut i vi ung th d dy sm l 90-95%. Ngc li vi ung th d dy mun, t l sngthm 5 nm vn di 10%.


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X GAN

Mc tiu hc tp1.Nu c cc nguyn nhn chnh trong bnh cn ca x gan

2.Nu c hnh thi tn thng i th v vi th ca x gan

I. I CNGX gan l mt bnh tin trin mn tnh, nng, khng hi phc. X gan c cc c im:

-Cu trc bnh thng ca gan o ln, tn thng ton gan.

- Tng sinh x lan ta to thnh cc vch x.

- Cc t bo gan b tn thng, thoi ha, hoi t v ti to thnh cc nt gan tn to.

Hnh thi bnh l ca x gan khng do nguyn nhn quyt nh. Cc yu t gy bnhkhc nhau c th to nn hnh thi tn thng nh nhau. Tri li cng mt yu t gy bnh c th

pht trin nhng hnh thi tn thng theo chiu hng khc nhau.Cn c vo kch thc cc nt gan tn to ngi ta chia x gan ra lm 2 loi:

- X gan cc nh: hu ht cc nt gan tn to c ng knh di 3cm. V d nh trong x gando ru.

- X gan cc ln: a s cc nt gan tn to c ng knh trn 3 mm

V d x gan sau hoi t.

Hnh1: Gan thoi ha m v x ha do ru Hnh2 : Bnh Willson

Cc nguyn nhn gy x gan bao gm:

-Ru 60-70%

-Vim gan do virus 10%

-Bnh ng mt 5-10 %

-Bnh nhim sc t st tin pht

-Bnh Willson: him

-Bnh thiu Alpha1- antrypsin: him


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-Khng r cn nguyn: 10-15%

II. SINH BNH HCRu v cc cht bin dng ca ru c tc dng c vi t bo gan cng nh vi cc t

bo khc ca c th.

Mi ngy ung trn 160 gam Ethanon trong 10-20 nm s gy ra tn thng nng gan.

Trong giai on u ru gy ra thoi ha m. Sau nu tip tc ung ruu, khong 10-15% ngi nghin ru b x gan.Ngoi ra ru cn c th gy ra vim gan do ru.

1. Sinh bnh hc ca gan thoi ha m

Trong t bo gan ru c tc dng:

-Tng tng hp acid bo

-Gim oxy ha cc acid bo trong ty lp th

-Gim vn chuyn cc lipoprotein ra ngoi t

bo gan. Do gy ng m trong cc t bo gan.

2. Sinh bnh hc ca x gan

Do tc dng ca ru,cc t bo gan thoi ha,hoi t.Cc t bo gan cn li ti to, hnh thnh cc nt gan

tn to. ng thi qu trnh x ha tin trin trong Hnh 3 : Gan thoi ha m do ru

ton gan, to thnh cc vch x mnh, vy quanh cc nt gan tn to, hnh nh c trng ca xgan. Hin nay ngi ta vn cha bit r c ch ca x ha. Cc t bo gan thoi ha, hoi t ,ru v cc cht bin dng c th l nhng kch thch gy x ha.

III. GII PHU BNH1. i th

Trong giai on u gan ln, thng trn 2 kg, mu nu vng, dnh m.

Sau nhiu nm gan tr nn teo nh, mu nu, rn chc, b sc cnh.Trn b mt ca gan v khptrong gan c nhiu nt gan ti to, a s c ng knh di 3 mm, vy quanh bi cc vch xmnh.

2.Vi th

Hnh 4: Tiu thy gi trong x gan Hnh 5: gii x b cht tiu thy ganTn thng lan rng ton gan, cu trc bnh thng ca gan b o ln.

T chc x pht trin mnh v lan ta, to thnh cc vch x chia ct cc tiu thy gan, nilin tnh mch trung tm vi khong ca, cng nh gia khong ca vi khong ca.

Cc t bo gan thoi ha, hoi t v ti to hnh thnh cc nt gan tn to b vy quanhbi nhng vch x. Trong nhng vch x ny xm nhim nhiu t bo lymphocyte tng sinhnhiu ng mt tn to.


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IV. LM SNGx gan do ru tin trin chm, m thm, khng c triu chng lm sng trong nhiu

nm.

Trong giai on gan thoi ha m, bilirubin v phosphates alkaline trong huyt thanh cth tng nh.

X gan c th biu hin bng 2 hi chng lm sng:-Hi chng tng p lc tnh mch ca: C trng, tun hon bng h di da bng, lch

to, gin tnh mch thc qun, gin tnh mch trc trng ( tr).

-Hi chng suy t bo gan: suy nhc, chn n, st cn, cc nt nhn 1/2 trn thnmnh, ban lng bn tay, gin mch, vng da, ph chi di, ri lon ni tit.

Bnh nhn c th cht do: Suy gan - hn m gan, hoc xut huyt tiu ha do v tnhmch thc qun, hoc nhim trng.

UNG TH BIU M GAN NGUYN PHTMc tiu hc tp1.Nm vng c im dch t hc ca ung th gan

2.Nu c 3 nguyn nhn chnh trong bnh cn ca ung th gan

3.Nu c 3 hnh thi tn thng i th v 2 tip vi th ca ung th gan

I. I CNGUng th gan nguyn pht l mt u cc tnh pht sinh t cc thnh phn t bo biu m

hoc lin kt to nn gan. i a s ung th gan nguyn pht l ung th biu m ( trn 90%), ungth ca t chc lin kt gan rt him gp.

Bnh rt him ngho, t vong cao v sm (c t l t vong cao nht trong cc bnh nhnung th t vong ti cc bnh vinVit c, Bch Mai, Vit X) .

T l mc bnh thay i ty theo vng a l: cao nht Trung quc, ng Nam vchu phi nhit i. T l mc bnh thp Chu u , bc M v Uc. Bnh thng gp la tui t20-40 tui nhng vng c t l ung th cao v trn 60 tui vng c t l mc bnh thp.

Hin nay phu thut ct b khi u gan vn c coi l phng thc iu tr c hiu qunht hy vng ko di thm i sng ngi bnh.Tuy vy, do bnh thng c pht hin rtmun nn kt qu iu tr phu thut cng rt hn ch.

Trn th gii ung th gan vn c coi l bnh nan gii v c ch bnh sinh cha r rng, giai on sm bnh khng c triu chng g c bit, nhng n khi lm sng r th mivic cha chy dng nh mun.

Nam gii b carcinoma t bo gan nhiu hn n gii, t l 1/8 i vi nhng vng c t lung th cao, v 2/1 -3/1 i vi nhng vng c t l ung th thp.

85 -90% carcinoma t bo gan xut hin trn mt gan x. Ung th biu m ng mt(cholangiocarcinoma) gp nhiu ng Nam , thng gp ngi gi, nam n mc b?nhngang nhau. Loi ung th ny khng lin h vi x gan.


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II. CN NGUYN V SINH BNH HC1.Ung th biu m t bo gan (Hepato cellular carcinoma)

C 3 yu t quan trng lin quan vi cn nguyn ca ung th biu m t bo gan:

- Vi rus HBV. Cc nghin cu dch t hc cho thy c mt mi lin h r rt gia nhim HBV vcarcinoma t bo gan. T l ung th biu m t bo gan cao nht gp nhng vng c dch aphng HBV nh Vin ng v chu Phi. i loan nhng ngi b nhim HBV c nguy c bcarcinoma t bo gan gp 200 ln nhng ngi bnh thng.

- Alfatoxin B-1 l mt c cht c sn xut bi nm Aspergilus flavus, mt loi nm pht trintrn lc, go ng bo qun km.

Mt s vng ca Chu Phi v ng Nam ngi ta nhn thy c mt mi tng quan mt thitgia nng Alfatoxin B-1 trong thc phm v v t l carcinoma t bo gan.

- X gan: Khong 85-90% carcinoma t bo gan xy ra trn gan x.Mt s loi gan x c t lkt hp vi ung th gan cao hn cc loi khc nh x gan sau hoi t ( 13-24%) v x gan sc t(18-22%). Trong khi ch c 3% x gan do ru c bin chng carcinoma t bo gan.

2. Ung th biu m ng mt (cholangiocarcinoma)

T l ung th biu m ng mt cao ng Nam A c lin quan vi bnh sn l gan do

clonorchis sinensis v opistorchis viverrini. Tuy

nhin c ch gy ung th khng r.

III. GII PHU BNH1. i th

Carcinoma t bo gan v ca ung th biu m ng

mt c th c mt trong 3 dng sau: Hnh 1: Ung th gan th khi

-Mt khi u ln n c chim mt thy gan hoc 1/2 l gan.

-Nhiu khi u ri rc trong gan,mt s khi u c th to n 5 cm ng knh.-M ung th xm nhim lan trn.

Gan to,thng nng t 2-3kg. M ung th c mu trng vng, i khi c nhng vng xuthuyt v hoi t.

2. Vi th

2.1. Ung th biu m t bo gan

Trong cc th ung th bit ha tt v va,

cc t bo ung th gn ging vi t bo gan v

xp thnh b, tuy nhin cc b t bo gan ung th

c b ngang rng hn gm nhiu t bo v cphn cch bi cc xoang mao mch nan hoa.

i khi cc t bo K sp xp thnh dng

nang hoc gi tuyn, dng nh hoc dng o. Hnh 2: ung th gan th b

Cc t bo K c th ch tit mt. M lin kt nng rt t hoc khng c. Trong cc ung thbit ha km , t bo u c th :

- Rt a dng vi nhiu t bo gim sn khng l c nhiu nhn .


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- Cc t bo u t dnh vo nhau, thng l ng tch ri v tr nn trn, t l nhn/nguyn sinhcht ln. Tuy c s bin dng nh vy nhng quan st k c th pht hin thy cc ht sc t mt,nhng hc cha glycogen (khi nhum PAS) chng t chng vn c ngun gc t t bo gan.

-Hoc gm cc t bo nh hon ton khng bit ha.

2.2. Ung th biu m ng mt

y l loi Adenocarcinoma, xut pht t ccng mt trong gan. Cc t bo K c hnh lp

phng hoc hnh tr thp sp xp thnh ng

hoc tuyn. Cc t bo u c th ch nhy.

Khi u c nhiu m m x.

4.Lin h gii phu bnh - lm sng

Triu chng lm sng c trng ca ung

th gan l: gan to, s c u cc v ln nhanh. Hnh 3: Ung th biu m ng mtAlpha-fetoprotein huyt thanh tng cao trong 60-75% cc trng hp ung th t bo gan.

K gan nguyn pht thng di cn n cc hch bch huyt trong vng, phi, xng v tuynthng thn. Tin lng rt xu, bnh nhn thng cht trong vng 6 thng.

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