BNH X GAN (CIRRHOSIS)

ThS.BS.CKII Trn Ngc Lu Phng

MC TIU: Sau khi hc xong bi ny cc hc vin cn phi nm c cc
mc tiu c bn nh sau
1. Nu c nh ngha v k c nguyn nhn x gan.
2. K c cc c ch sinh l bnh ca x gan
3. K c triu chng lm sng v cn lm sng ca x gan.
4. Nu c tiu chun chn on phn x gan v cch chn on sm.
5. M t c 3 bin chng: hn m gan nhim trng dch bng v hi chng gan thn.

NI DUNG BI GING
1. I CNG
Bnh thng gp
T l: thay i ty nc.
M: t vong ng hng th 8 (26.000 35.000 ca/nm)
Phng ty M: 65% do ru.
ng Nam Chu Phi: ch yu do vim gan siu vi mn (B, C)

2. NH NGHA
X gan l nh ngha v m hc
Phi tha 2 tiu chun:
- To m x lan ta gan (fibrosis)
- Bin i thnh cu trc dng nt

Hnh 24.1: Hnh nh m hc gan bnh thng (Ngun: L Minh Huy, BM gii phu bnh,
i hc y Dc TPHCM)
 Hnh 24.2: Hnh nh m hc in hnh ca x gan (Ngun: L Minh Huy, BM gii phu
bnh, i hc y Dc TPHCM)

3. PHN LOI
3.1. Theo hnh thi
X gan to x gan teo
X gan nt to x gan nt nh hn hp.

3.2. Theo lm sng

3.2.1. Gan cn b
Khng triu chng hay triu chng khng c hiu
Pht hin qua tng sot tin phu hay ni soi bng hay m bng.
C th chuyn qua mt b khi c yu t thc y:
- Vim gan cp chng ln.
- Nhim trng nng.
- Sau phu thut.
Sinh thit > 30% tiu thy bnh thng.
3.2.2. X gan mt b
Khi c t nht 1 trong 4 du hiu sau: Vng da, Bng bng, Bnh no gan, xut huyt tiu
ha do v dn TMTQ.

4. NGUYN NHN
4.1. Nhim virus v KST
Vim gan siu vi mn (B, C, D) (+++)
Nhim KST:
- Nhim sn l nh gan (C.sinensis)
 - Nhim sn mng (Schistosoma)

4.2. Do c cht
Ru (+++)
Thuc
- Tim mch: Methyldopa, Amiodarone
- Chng ung th: MTX.
- Gy m: Halothane

4.3. Tc nghn
Tc mt: bm sinh mc phi
Tc nghn ng ra TM gan:
- Suy tim (x gan tim).
- Hi chng Budd-Chiari

4.3. T min dch

Vim gan t min: C khng th khng nhn ANA (+)
X gan mt nguyn pht: C khng th khng ty th AMA (+)

4.4. Ri lan chuyn ha

ng (Wilsons Disease): vng Kayser Fleichser.
st (Hemochromatose): Tng Ferritine.
Thiu alpha-1 antitrypsin
Bnh glycogen type 4
Tng galactose mu.
Tng tyrosine mu

4.5. Gan nhim m khng do ru (Non Alcoholic Fatty Liver disease NAFLD)
ang l vn nng bng hin nay.
C 1 s trng hp chuyn sang NASH (Non Alcoholic Steato-Hepatitis): Vim gan mn
do thai ha m v dn n x gan

Hnh 24.3: Vng Keyser Fleischer trong bnh ng (Ngun: Harrison's Principle of
Internal Medicine, Vol 2, 18th edition, 2012)
5. SINH L BNH HC
5.1. Bnh sinh hc (pathogenesis)
T bo (TB) gan tn thng thc y qu trnh hyalin ha v thoi ha m gy cht, hoi
t TB dn n sp khung reticulin lm kch thch to nguyn bo si v nguyn bo si
c, tin collagen chuyn thnh colagen bao quanh vng tn thng.
Khong ca tng to m lin kt.
Tiu qun mt tng to m lin kt, collagen
==> Kt qu l chia ct m gan gy bp nght tiu thy, to thnh TB gan tn to.

5.2. Vng xon bnh l

M si cng vi si collagen co rt lm nght mch mu dn n tng p ca v ph i,
x ha ni m mao mch gy thiu mu gan, cui cng l hoi t TB gan.
Ngoi ra tng p ca lm gia tng s ni tt trong gan dn n thiu mu nui

5.3. C ch to x (fibrogenesis)
Phc tp, lin quan nhiu yu t.
Ch yu l TB hnh sao (stellate cell).
Do bt thng cc Cytokines, Proteinase v cc cht c ch.
==> Kt qu lm thay i cht nn ngoi bo (extra cellular matrix)

Hnh 24.4: C ch to x lin quan hot ha t bo sao (Ngun:Kumar & Clark- Clinical
Medicine, 7th edition, 2009)
5.4. C ch cc biu hin ca x gan
5.4.1. Tng p lc tm ca gy ra
Gin TM TQ / d dy.
Tr
Tun hon bng h bng
Ti lp tun hon rn.
5.4.2. TB gan tn to mt chc nng lm suy t bo gan
Gim yu t ng mu gy ra ri lon ng mu.
Gim tng hp albumine.
Gim thi tr c cht.
5.4.3. C ch ph v bng bng/ x gan
Gim albumin lm gim p keo.
Tng p lc tnh mch ca.
Gim dn lu bch huyt
==> Kt qu lm gim th tch tun han, v cng Aldosterone th pht.

6. LM SNG
6.1. Hi chng suy t bo gan
Triu chng khng c hiu
- Mt mi, st cn, n km.
- Kh tiu, y bng.
- Gim kh nng tp trung, lao ng.
- Ri lon kinh nguyt, lit dng.
- Gim Libido
- Thiu mu.
Triu chng c hiu
- Vng mt, vng da, Mng trng, Sm da.
- Sao mch, Bn tay son, Mi son.
- Chy mu da nim. (do gim tiu cu, RL ng mu)
- Co c Dupuytren.
- Ph chi, bng bng.
- V to nam gii.
- Ph i tuyn mang tai 2 bn (x gan ru)
Hnh 24.5: Du hiu co c Dupuytren (Ngun: Kuntz, Hepatology Textbook and Atlas, 3rd
edition, 2008)

Hnh 24.6: Du hiu bn tay son (Ngun: Kuntz, Hepatology Textbook and Atlas, 3rd
edition, 2008)

Hnh 24.7: Du hiu sao mch mi son (Ngun: Kuntz, Hepatology Textbook and Atlas,
3rd edition, 2008)
Hnh 24.8: Du xut huyt di da (Ngun: C. Forbes, Color Atlas and Text of Clinical
Medicine, 2nd edition, 2005)

Hnh 24.9: Du hiu sao mch da (Ngun: Kuntz, Hepatology Textbook and Atlas, 3rd
edition, 2008)
Hnh 24.10: du hiu v to nam gii (Ngun: C. Forbes, Color Atlas and Text of Clinical
Medicine, 2nd edition, 2005)

Hnh 24.11: Du hiu mng trng

(Ngun: Kuntz, Hepatology Textbook and Atlas, 3rd edition, 2008)
Hnh 24.12: Du hiu ph i tuyn mang tai (x gan ru) (Ngun: C. Forbes, Color
Atlas and Text of Clinical Medicine, 2nd edition, 2005)

Hnh 24.13: Bng bng vng da (Ngun: C. Forbes, Color Atlas and Text of Clinical
Medicine, 2nd edition, 2005)
Hnh 24.14: Bng bng km thot v rn (Ngun: C. Forbes, Color Atlas and Text of
Clinical Medicine, 2nd edition, 2005)
 Hnh 24.15: Ph trng mm h chi
(Ngun: C. Forbes, Color Atlas and Text of Clinical Medicine, 2nd edition, 2005)

Hnh 24.16: Ph h chi do gim p lc keo (Ngun: C. Forbes, Color Atlas and Text of
Clinical Medicine, 2nd edition, 2005)

6.2. Hi chng tng p ca

Tun hon bng h kiu ca ch.
Hnh nh u sa (caput medusae) trn bng
Lch to Cng lch (XH gim tiu cu, thiu mu).
Dn TMTQ gy i mu ti
Tun hon rn, c th nghe c venous hums
Bng bng.
Tr (khng c hiu)
 Hnh 24.17: Tun hon bng h kiu ca - ch (Ngun: Kuntz, Hepatology Textbook and
Atlas, 3rd edition, 2008)

Hnh 24.18: Hnh nh u sa (caput medusae) (Ngun: C. Forbes, Color Atlas and Text of
Clinical Medicine, 2nd edition, 2005)
 Hnh 24.19: Lch to + bng bng (Ngun: C. Forbes, Color Atlas and Text of Clinical
Medicine, 2nd edition, 2005)

7. KHM THC TH
Khm gan
- a s x gan teo.
- Giai on u: x gan to khm c gan to, chc, b t, khng au.
- Ch pht hin khi u gan.
Khm ton din: Tng hp triu chng ca 2 hi chng

8. CN LM SNG
8.1. Xt nghim thng qui
8.1.1. XN mu
Cng thc mu: Gim 1 hay c 3 dng TB mu do cng lch (thng: gim tiu cu,
gim hng cu)
Sinh ha mu
- Ur thng gim.
- Ion : Na thng gim do ng dch.
8.1.2. TPTNT: Bnh thng
8.1.3. Chn on hnh nh: XQ phi c th trn dch mng phi phi.

8.2. Xt nghim chuyn su

Pht hin 2 hi chng: suy TB gan v tng p ca
Tm nguyn nhn ca x gan
8.2.1. XN mu
Du suy TB gan
- TQ di > 14s.
 - in di: Albumine gim Globulin tng (-globulin).T l: A/G < 1
- Tng bilirubine kiu hn hp / trc tip (GGT v Phosphatase kim bnh thng)
Men gan SGOT SGPT tng < 200 hoc bnh thng.
Tm nguyn nhn
- Siu vi: HBsAg, AntiHBs, AntiHCV.
- Ceruloplasmine gim: ng
- Tng Ferritine: st
- Vim gan t min: ANA (+), AntiLKM (+)
- X gan mt nguyn pht: AMA (+)
8.2.2. XN dch bng
Phn bit dch thm dch tit
X gan: dch thm
- m < 25g/l.
- LDH < 2/3 bnh thng LDH mu ca phng XN.
- m (dch bng)/m mu < 0,5.
- T bo < 250 (ch yu n nhn).
Ch s SAAG > 11g/l. Kt lun: Tng p lc ca
8.2.3. Chn on hnh nh
8.2.3.1. Pht hin tng p ca
Ni soi DD
- Dn TMTQ / phnh v.
- Bnh d dy tng p ca. (G sm)
Siu m bng
- Lch to.
- Ti lp tun hon rn.
- Dch bng (d lng t)
8.2.3.2. Pht hin hnh nh i th x gan
Siu m bng
- Gan th dy.
- B gan g gh.
Soi bng (t lm hin nay)
8.2.4. Cc xt nghim khc
o p lc TM ca > 12mmHg.
Sinh thit gan: (+++)
- Tiu chun vng
 - t thc hin.
- Phn bit: vim gan mn x gan.
- nh c mc x ha trn m hc: Dng thang im METAVIR: F1 F2
F3 F4

Hnh 24.20: Hnh nh ni soi ca dn TMTQ (Ngun: Current diagnosis and treatment:
gastroenterology, hepatology and endoscopy, second edition; 2012)

Hnh 24.21: Hnh nh ni soi ca dn TM phnh v (Ngun: Current diagnosis and

treatment: gastroenterology, hepatology and endoscopy, second edition; 2012)

Hnh 24.22: Hnh nh siu m ti lp tun hon rn (mi tn en) (Ngun: Kuntz,
Hepatology Textbook and Atlas, 3rd edition, 2008)
Hnh 24.23: Hnh nh siu m ca x gan (Ngun: Kuntz, Hepatology Textbook and Atlas,
3rd edition, 2008)

9. VN CHN ON
9.1. Chn on xc nh
Thc t: Cn 2 trong 3 tiu chun sau
- Du hiu suy TB gan trn LS (c hiu) v / hoc trn CLS.
- Du hiu tng p ca trn LS v / hoc trn CLS.
- Khm gan to chc v / hoc hnh nh x gan trn siu m bng.
Lm sng nghi ng + ch s Bonacini > 7 im
- Tiu cu > 340 0
280-339 1
220-279 2
160-219 3
100-159 4
40-99 5
< 40 6
- T s ALT/AST > 1,7 0
1,2-1,7 1
0,6-1,19 2
< 0,6 3.
- INR < 1,1 0
1,1-1,4 1
> 1,4 2
9.2. Chn on nng (Child - Pugh)
Bng 24.1: Phn x gan theo Child-Pugh (Ngun: T. Yamada, Textbook of
Gastroenterology, 5th edition, 2011)

1 IM 2 IM 3 IM

Bilirubin (mg/dl, mol/ l) <2.0 (< 35 ) 2 3 (35-51) > 3 (>51)

Albumin (g/l) > 35 28 35 <28

TQ (Prothrobine Time) 14s 15 17s 18s

Bng bng Khng C R

Hn m gan Khng Nh-TB Nng

CHILD A: 5-6 im, B: 7-9 im, C: 10 -15 im

9.3. Chn on phn bit

9.3.1. Bnh cnh vng da
Vim gan cp.
Tc mt.
Tn huyt.
==> Da vo bnh cnh lm sng + cc XN.
9.3.2. Bnh cnh bng bng ph chi
Lao mng bng.
Ung th mng bng.
Cc bnh l c th gy ph: suy tim, bnh l thn, suy dinh dng.
==> Da vo dch bng + bnh cnh lm sng.
9.3.3. Bnh cnh hn m
Hn m chuyn ha: Tiu ng
Hn m do h TKTW: vim mng no, TBMMN
9.3.4. Bnh cnh xut huyt tiu ha
XHTH lot d dy.
Lu : XHTH v gin TMTQ c th l biu hin u tin ca x gan

9.4. Chn on sm x gan

L do
Giai on vim mn hoc x ho giai on F1 F2 F3: Can thip nguyn nhn
==> ngng tin trin / lui bnh.
i tng no
Ngi c nhng yu t l nguyn nhn ca x gan d cc XN chc nng gan hon ton
bnh thng v cha c biu hin lm sng.
Sinh thit gan: L tiu chun vng
Phng php khc
Fibroscan: o cng ca gan bng sng.
Fibrotest: Xt nghim cc ch du sinh ha trong mu ri dng cng thc ton hc tnh ra.

10. BIN CHNG

10.1. Bnh no gan (hn m gan)
10.1.1. C ch
Tng p ca lm tng phng thch c cht vo thng tun hon
Suy TB gan lm tng NH3 acid bo, acid amin thm v cht dn truyn TK gi.
10.1.2. Yu t thc y
n nhiu m.
XHTH.
Bn, tiu chy, nn i
Dng li tiu qu mc, dng an thn.
NT dch bng, HC gan-thn
10.1.3. Lm sng
Ri lon tri gic khng du TK khu tr.
Du rung vy (asterixis, Flapping tremor)
Hi th mi gan: Mi tri cy chn thi
10.1.4. Cn lm sng: NH3 mu > 1.5mg/l
Bng 24.2: Phn bnh no gan (Ngun: Trn Ngc Lu Phng tng hp)

TR TU
TRI GIC DU TK
NHN CCH

1 RL chu k thc ng. Qun, l ln nh. Run chi.

Kch ng Mt phi hp ng tc.
Ging ni run.

2 Nm yn, chm p L ln va, mt nh Rung vy (+).

ng hng TG. Gim phn x.
Nhn cch kg ph hp Ni kh
3 Ng g, c th nh L ln r Rung vy (+).
thc Mt nh hng khng Gim phn x.
gian Babinski (+) 2 bn

4 Hn m C th cn p ng kch Rung vy (-)

thch au

(Ngun: The Washington Manual of medical therapeutics. 33 rd Edition 2010.)

10.2. Vim phc mc nhim khun nguyn pht (nhim trng dch bng)
10.2.1. C ch
VK gram (-) ng rut (E.coli, Klebsiella) xuyn thnh i ra ngoi dch bng
Gim protid mu v protid dch bng ==> gim opsonin ha vi trng trong dch bng ==>
vim phc mc nguyn pht.
10.2.2. Lm sng
Rt a dng.
a s c biu hin khng in hnh
- St n thun.
- Bng bng nhanh
- Bng bng khng p ng iu tr
- Xut hin H/C gan thn.
- Xut hin bnh no-gan
t khi c triu chng in hnh: st + au bng lan to + khng bng.
10.2.3. Cn lm sng
Chc dch bng xt nghim gip chn on xc nh
- C th l dch thm/ dch tit.
- Bch cu a nhn > 250mm3
- Bch cu a nhn chim > 50% tng s bc.
- Khng cn ch kt qu cy vi trng.

10.3. Hi chng gan - thn

10.3.1. C ch
Ri lon huyt ng hc ca thn
Thn hon ton bnh thng.
10.3.2. Lm sng
Thiu niu
Bng bng ph chi tng nhanh.
t ngt xut hin bnh no gan
10.3.3. Tiu chun chn on
X gan c bng bng trn lm sng.
Creatinine mu > 1.5mg/dl
Khng ci thin creatinine mu sau 2 ngy ngng li tiu v truyn albumine vi liu
1gr/kg/ ngy.
Khng shock v khng dng thuc c thn.
Khng tn thng thn:
- m niu < 500mg/24 gi
- Hng cu niu < 50 / QT 40
- Siu m thn, niu bnh thng

10.4. Cc bin chng khc

X gan ung th ha
Hi chng gan - phi.
XHTH do v dn TMTQ, v dn TM phnh v.
Ri lon ng mu: chy mu nhiu ni trong c th.
11- TM TT:
- X gan c 2 nguyn nhn chnh l nghin ru v vim gan B hoc vim gan C. Gn y
gan nhim m khng do ru cng l 1 trong nhng nguyn nhn cng gy x gan .
- Lm sng cn ch 2 hi chng suy t bo gan v hi chng tng p lc tnh mch ca
- X gan c 3 bin chng quan trng thng gp v ti i ti li : Vim phc mc nhim
khun nguyn pht (Nhim trng dch bng), Bnh no gan v Xut huyt tiu ha do v
gin tnh mch thc qun
* T KHA: X gan, Tng p lc tnh mch ca, Suy t bo gan
CU HI T LNG GI
1. Ni v nguyn nhn x gan:
A. Vit nam v cc nc Chu Phi: nguyn nhn ch yu l do nghin ru
B. cc nc u M: nguyn nhn ch yu l do nhim siu vi vim gan B mn tnh
(nhim HBV)
C. Tc mt do teo hp ng mt bm sinh KHNG TH din tin thnh x gan
D. Bnh l gan nhim m KHNG TH din tin thnh x gan.
E. C A,B,C,D u sai.
2. Ni v triu chng ca x gan:
A. Bn tay son l triu chng ca hi chng tng p lc tnh mch ca
B. Bng bng KHNG PHI l triu chng ca hi chng suy t bo gan.
C. Lch to l triu chng ca hi chng suy t bo gan.
 D. Du sao mch l triu chng ca hi chng suy t bo gan.
E. Tun han bng h kiu ch - ch l du hiu ca hi chng tng p lc tnh mch
ca.
3. Xt nghim cn lm sng trong x gan
A. Dch bng trong x gan thng l dch tit vi Protid (dch bng) < 25g/l.
B. Albumin mu thng gim v t l A/G < 1
C. Men gan (SGOT, SGPT) tng nhiu ln l du hiu ca suy t bo gan
D. A,B,C ng
E. Ch c A, C ng
4. Tnh im Child phn nng ca x gan :
A. Albumin mu > 35 g/l c tnh 3 im
B. Bilirubin mu = 2,2mg/dl c tnh 1 im
C. TQ = 15 giy c tnh 3 im
D. Tng im l 5 im c tnh l child B
E. Tng im l 11 im c tnh l child C
5. Bin chng no KHNG PHI l bin chng ca x gan :
A. Ri lan ng mu
B. Hn m gan
C. Hi chng Thn - Gan
D. XHTH do v dn tnh mch thc qun
E. Nhim trng dch bng .
p n : 1E, 2D, 3B, 4E, 5C
TI LIU THAM KHO
1. Dan L. Longo, Anthony S. Fauci. (2010). Harrisons Gastroenterology and Hepatology.
McGraw-Hill Education, 1st ed, pp. 420-430
2. Mark Feldman (2011). Sleisenger and Fordtrans Gastrointestinal and Liver Disease.
Elsevier, 9th ed, Vol 2, pp. 1517-1535
3. James S. Dooley, Anna S.F. Lok, Andrew K. Burroghs, E. Jenny Heathcote (2011).
Sherlocks diseases of the liver and biliary system. Wiley Blackwell, 12th ed, 2011, pp.
103-117
4. Norton J. Greenberger, Richard S. Blumberg, Robert Burakoff (2009). Current
Diagnosis & Treatment Gastroenterology, Hepatology, & Endoscopy. Mc Grawhill, pp.
478-486.
5. Tadakata Yamada (2015). Textbook of Gastroenterology. Wiley Blackwell, 6th ed, Vol
2, pp. 2070-2105.