{"id":3374,"date":"2025-10-02T11:14:07","date_gmt":"2025-10-02T04:14:07","guid":{"rendered":"https:\/\/hienbacsi.com\/?p=3374"},"modified":"2025-10-02T13:04:55","modified_gmt":"2025-10-02T06:04:55","slug":"kinh-nghiem-chan-doan-va-dieu-tri-benh-nao-gan","status":"publish","type":"post","link":"https:\/\/hienbacsi.com\/index.php\/2025\/10\/02\/kinh-nghiem-chan-doan-va-dieu-tri-benh-nao-gan\/","title":{"rendered":"Kinh nghi\u1ec7m ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111i\u1ec1u tr\u1ecb b\u1ec7nh n\u00e3o gan"},"content":{"rendered":"\n

ThS BS Tr\u1ea7n H\u1eefu Hi\u1ec1n<\/mark><\/strong><\/p>\n\n\n\n

Th\u00e0nh vi\u00ean H\u1ed9i Gan Ch\u00e2u \u00c2u EASL t\u1eeb 2018<\/mark><\/strong><\/p>\n\n\n\n

\u0110\u1eb7t l\u1ecbch kh\u00e1m b\u1ec7nh gan qua zalo bs Hi\u1ec1n: 0987842200<\/strong><\/mark><\/p>\n\n\n\n

Trong q\u00faa tr\u00ecnh \u0111i\u1ec1u tr\u1ecb l\u00e2m s\u00e0ng t\u1ea1i Vi\u1ec7t Nam v\u00e0 tu nghi\u1ec7p t\u1ea1i BV King\u2019s College Hospital ch\u00fang t\u00f4i \u0111\u00e3 g\u1eb7p v\u00e0 x\u1eed tr\u00ed \u0111a d\u1ea1ng c\u00e1c tr\u01b0\u1eddng h\u1ee3p b\u1ec7nh n\u00e3o gan v\u1edbi nhi\u1ec1u t\u00ecnh hu\u1ed1ng theo nguy\u00ean nh\u00e2n v\u00e0 m\u1ee9c \u0111\u1ed9. Xin chia s\u1ebb \u0111\u1ebfn qu\u00fd \u0111\u1ed3ng nghi\u1ec7p n\u1ed9i khoa v\u00e0 c\u00e1c sv y khoa n\u0103m 2 tr\u1edf l\u00ean.<\/p>\n\n\n\n

\"\"
BS Hi\u1ec1n trong chuy\u1ebfn c\u00f4ng t\u00e1c Paris – Ph\u00e1p<\/strong><\/figcaption><\/figure>\n\n\n\n

1. \u0110\u1ecbnh ngh\u0129a v\u00e0 ph\u00e2n lo\u1ea1i b\u1ec7nh n\u00e3o gan<\/strong><\/p>\n\n\n\n

B\u1ec6NH N\u00c3O GAN \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng n\u00e3o do suy gan v\u00e0\/ho\u1eb7c shunt th\u00f4ng c\u1eeda – h\u1ec7 th\u1ed1ng, bi\u1ec3u hi\u1ec7n t\u1eeb thay \u0111\u1ed5i tinh vi \u0111\u1ebfn h\u00f4n m\u00ea (theo AASLD\/EASL 2014 v\u00e0 EASL 2022). Kh\u00f4ng ph\u1ea3i do nguy\u00ean nh\u00e2n n\u00e3o kh\u00e1c g\u00e2y ra, m\u00e0 ch\u1ee7 y\u1ebfu t\u1eeb t\u00edch t\u1ee5 amoniac v\u00e0 \u0111\u1ed9c t\u1ed1 kh\u00e1c t\u1eeb gan.<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

Ph\u00e2n lo\u1ea1i b\u1ec7nh n\u00e3o gan theo AASLD\/EASL 2014 (v\u1eabn \u0111\u01b0\u1ee3c EASL 2022 tham chi\u1ebfu):<\/p>\n\n\n\n

    \n
  • Theo nguy\u00ean nh\u00e2n<\/strong>: Lo\u1ea1i A (suy gan c\u1ea5p), Lo\u1ea1i B (shunt th\u00f4ng c\u1eeda m\u00e0 kh\u00f4ng suy gan), Lo\u1ea1i C (x\u01a1 gan \u00b1 shunt).<\/li>\n\n\n\n
  • Theo m\u1ee9c \u0111\u1ed9 nghi\u00eam tr\u1ecdng<\/strong>:\n
      \n
    • B\u1ec7nh n\u00e3o gan t\u1ed1i thi\u1ec3u (MHE) ho\u1eb7c b\u1ec7nh n\u00e3o gan th\u1ea7m l\u1eb7ng (CHE): Kh\u00f4ng r\u00f5 r\u00e0ng l\u00e2m s\u00e0ng, ch\u1ec9 ph\u00e1t hi\u1ec7n qua test t\u00e2m th\u1ea7n kinh (nh\u01b0 Psychometric b\u1ec7nh n\u00e3o ganpatic Encephalopathy Score – PHES ho\u1eb7c Stroop test).<\/li>\n\n\n\n
    • B\u1ec7nh n\u00e3o gan bi\u1ec3u hi\u1ec7n (OHE): R\u00f5 r\u00e0ng, ph\u00e2n \u0111\u1ed9 theo West Haven Criteria (WHC):\n
        \n
      • \u0110\u1ed9 I: Thay \u0111\u1ed5i t\u00ednh c\u00e1ch, r\u1ed1i lo\u1ea1n gi\u1ea5c ng\u1ee7, gi\u1ea3m t\u1eadp trung.<\/li>\n\n\n\n
      • \u0110\u1ed9 II: L\u01a1 m\u01a1, run v\u1eaby (asterixis), m\u1ea5t ph\u01b0\u01a1ng h\u01b0\u1edbng.<\/li>\n\n\n\n
      • \u0110\u1ed9 III: Ng\u1ee7 g\u00e0, nh\u1ea7m l\u1eabn n\u1eb7ng, r\u1ed1i lo\u1ea1n h\u00e0nh vi.<\/li>\n\n\n\n
      • \u0110\u1ed9 IV: H\u00f4n m\u00ea.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n\n\n\n
      • Theo th\u1eddi gian<\/strong>: Episodic (c\u01a1n k\u1ecbch ph\u00e1t), Recurrent (t\u00e1i ph\u00e1t <6 th\u00e1ng), Persistent (li\u00ean t\u1ee5c).<\/li>\n\n\n\n
      • Theo y\u1ebfu t\u1ed1 kh\u1edfi ph\u00e1t<\/strong>: C\u00f3 ho\u1eb7c kh\u00f4ng.<\/li>\n<\/ul>\n\n\n\n

        2. Ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111\u00e1nh gi\u00e1<\/strong><\/p>\n\n\n\n

        Ch\u1ea9n \u0111o\u00e1n b\u1ec7nh n\u00e3o gan d\u1ef1a tr\u00ean l\u00e2m s\u00e0ng \u1edf b\u1ec7nh nh\u00e2n c\u00f3 b\u1ec7nh gan, lo\u1ea1i tr\u1eeb nguy\u00ean nh\u00e2n kh\u00e1c (nhi\u1ec5m tr\u00f9ng, xu\u1ea5t huy\u1ebft n\u00e3o, r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i). Theo EASL 2022, \u0111o amoniac huy\u1ebft t\u01b0\u01a1ng \u1edf b\u1ec7nh nh\u00e2n c\u00f3 r\u1ed1i lo\u1ea1n \u00fd th\u1ee9c v\u00e0 b\u1ec7nh gan; n\u1ebfu amoniac b\u00ecnh th\u01b0\u1eddng, c\u1ea7n xem l\u1ea1i ch\u1ea9n \u0111o\u00e1n b\u1ec7nh n\u00e3o gan.<\/p>\n\n\n\n

        \"\"
        Y\u1ebfu t\u1ed1 kh\u1edfi ph\u00e1t b\u1ec7nh n\u00e3o gan th\u01b0\u1eddng g\u1eb7p<\/figcaption><\/figure>\n\n\n\n
          \n
        • Test \u0111\u00e1nh gi\u00e1<\/strong>:\n
            \n
          • L\u00e2m s\u00e0ng: Asterixis, Glasgow Coma Scale (GCS), Animal Naming Test (n\u1ebfu <12 con v\u1eadt trong 1 ph\u00fat, nghi b\u1ec7nh n\u00e3o gan).<\/li>\n\n\n\n
          • Test t\u00e2m th\u1ea7n kinh: PHES, Critical Flicker Frequency, EEG cho MHE\/CHE (AASLD khuy\u1ebfn c\u00e1o test \u1edf b\u1ec7nh nh\u00e2n \u1ea3nh h\u01b0\u1edfng ch\u1ea5t l\u01b0\u1ee3ng s\u1ed1ng, nh\u01b0 l\u00e1i xe ho\u1eb7c l\u00e0m vi\u1ec7c).<\/li>\n\n\n\n
          • H\u00ecnh \u1ea3nh: MRI n\u00e3o th\u01b0\u1eddng b\u00ecnh th\u01b0\u1eddng, CT \u0111\u1ec3 lo\u1ea1i tr\u1eeb nguy\u00ean nh\u00e2n kh\u00e1c.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n

            Y\u1ebfu t\u1ed1 kh\u1edfi ph\u00e1t th\u01b0\u1eddng g\u1eb7p: Nhi\u1ec5m tr\u00f9ng (50%), ch\u1ea3y m\u00e1u ti\u00eau h\u00f3a, r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i (h\u1ea1 kali), t\u00e1o b\u00f3n, l\u1ea1m d\u1ee5ng l\u1ee3i ti\u1ec3u.<\/p>\n\n\n\n

            Kinh nghi\u1ec7m: Lu\u00f4n ki\u1ec3m tra y\u1ebfu t\u1ed1 kh\u1edfi ph\u00e1t tr\u01b0\u1edbc khi \u0111i\u1ec1u tr\u1ecb c\u1ee5 th\u1ec3 b\u1ec7nh n\u00e3o gan, v\u00ec x\u1eed l\u00fd ch\u00fang c\u00f3 th\u1ec3 gi\u1ea3i quy\u1ebft 90% tr\u01b0\u1eddng h\u1ee3p OHE.<\/p>\n\n\n\n

            \"\"
            BS Hi\u1ec1n tu nghi\u1ec7p t\u1ea1i BV King\u2019s<\/figcaption><\/figure>\n\n\n\n

            3. \u0110i\u1ec1u tr\u1ecb b\u1ec7nh n\u00e3o gan: C\u00e1ch ti\u1ebfp c\u1eadn t\u1eebng b\u01b0\u1edbc<\/strong><\/p>\n\n\n\n

            \"\"
            C\u00e1c li\u1ec7u ph\u00e1p \u0111i\u1ec1u tr\u1ecb b\u1ec7nh n\u00e3o gan \u0111\u01b0\u1ee3c nghi\u00ean c\u1ee9u<\/figcaption><\/figure>\n\n\n\n

            \u0110i\u1ec1u tr\u1ecb b\u1ec7nh n\u00e3o gan t\u1eadp trung v\u00e0o gi\u1ea3m amoniac, c\u1ea3i thi\u1ec7n microbiome \u0111\u01b0\u1eddng ru\u1ed9t, dinh d\u01b0\u1ee1ng v\u00e0 can thi\u1ec7p n\u1ebfu c\u1ea7n. \u01afu ti\u00ean \u0111i\u1ec1u tr\u1ecb OHE; MHE\/CHE ch\u1ec9 \u0111i\u1ec1u tr\u1ecb ch\u1ecdn l\u1ecdc.<\/p>\n\n\n\n

            B\u01b0\u1edbc 1: X\u1eed l\u00fd c\u1ea5p c\u1ee9u v\u00e0 y\u1ebfu t\u1ed1 kh\u1edfi ph\u00e1t<\/strong><\/p>\n\n\n\n

              \n
            • N\u1ebfu GCS \u22648 ho\u1eb7c b\u1ec7nh n\u00e3o gan \u0111\u1ed9 III\/IV: B\u1ea3o v\u1ec7 \u0111\u01b0\u1eddng th\u1edf, th\u1edf m\u00e1y n\u1ebfu c\u1ea7n (tr\u00e1nh benzodiazepine, \u01b0u ti\u00ean propofol). T\u00ecm v\u00e0 \u0111i\u1ec1u tr\u1ecb y\u1ebfu t\u1ed1 kh\u1edfi ph\u00e1t \u0111\u1ed3ng th\u1eddi.<\/li>\n\n\n\n
            • Trong ICU: Truy\u1ec1n t\u0129nh m\u1ea1ch kh\u00e1ng sinh n\u1ebfu nghi sepsis, b\u1ed5 sung thiamine (\u0111\u1eb7c bi\u1ec7t nghi\u1ec7n r\u01b0\u1ee3u), tr\u00e1nh h\u1ea1n ch\u1ebf protein.<\/li>\n<\/ul>\n\n\n\n

              B\u01b0\u1edbc 2: \u0110i\u1ec1u tr\u1ecb d\u01b0\u1ee3c l\u00fd<\/strong><\/p>\n\n\n\n

                \n
              • Lactulose (non-absorbable disaccharide)<\/strong>: Thu\u1ed1c \u0111\u1ea7u tay (AASLD\/EASL c\u1ea5p \u0111\u1ed9 I, A). C\u01a1 ch\u1ebf: Axit h\u00f3a ru\u1ed9t, chuy\u1ec3n amoniac th\u00e0nh ammonium kh\u00f4ng h\u1ea5p thu, l\u00e0m prebiotic. Li\u1ec1u kh\u1edfi \u0111\u1ea7u 15-30 mL x 3 l\u1ea7n\/ng\u00e0y, \u0111i\u1ec1u ch\u1ec9nh \u0111\u1ec3 \u0111\u1ea1i ti\u1ec7n 2-3 l\u1ea7n\/ng\u00e0y m\u1ec1m. L\u01b0u \u00fd: Gi\u1ea3m li\u1ec1u n\u1ebfu ti\u00eau ch\u1ea3y, tr\u00e1nh m\u1ea5t n\u01b0\u1edbc.<\/li>\n\n\n\n
              • Rifaximin<\/strong>: Kh\u00e1ng sinh kh\u00f4ng h\u1ea5p thu, th\u00eam v\u00e0o lactulose cho d\u1ef1 ph\u00f2ng th\u1ee9 ph\u00e1t OHE t\u00e1i ph\u00e1t (sau 2 c\u01a1n trong 6 th\u00e1ng, EASL 2022 c\u1ea5p \u0111\u1ed9 I, A). Li\u1ec1u 550 mg x 2 l\u1ea7n\/ng\u00e0y. Gi\u1ea3m vi\u00eam h\u1ec7 th\u1ed1ng, c\u1ea3i thi\u1ec7n microbiome.<\/li>\n\n\n\n
              • L-ornithine L-aspartate (LOLA)<\/strong>: T\u0103ng t\u1ed5ng h\u1ee3p urea v\u00e0 glutamine, gi\u1ea3m amoniac. AASLD 2014 khuy\u1ebfn c\u00e1o d\u00f9ng th\u00eam n\u1ebfu kh\u00f4ng \u0111\u00e1p \u1ee9ng lactulose\/rifaximin (c\u1ea5p \u0111\u1ed9 I, B). EASL 2022 kh\u00f4ng khuy\u1ebfn c\u00e1o routine, nh\u01b0ng meta-analysis cho th\u1ea5y c\u1ea3i thi\u1ec7n b\u1ec7nh n\u00e3o gan covert\/overt. Li\u1ec1u: th\u00eam LOLA 3g\/ng\u00e0y t\u0103ng d\u1ea7n \u0111\u1ebfn 6g x 3 l\u1ea7n\/ng\u00e0y.<\/li>\n\n\n\n
              • C\u00e1c thu\u1ed1c kh\u00e1c<\/strong>: Branched-chain amino acids (BCAAs) n\u1ebfu kh\u00f4ng dung n\u1ea1p protein (AASLD c\u1ea5p \u0111\u1ed9 I, B). Neomycin\/metronidazole thay th\u1ebf nh\u01b0ng tr\u00e1nh d\u00e0i h\u1ea1n do \u0111\u1ed9c t\u00ednh. Kh\u00f4ng b\u1ed5 sung zinc th\u01b0\u1eddng quy (EASL 2022).<\/li>\n<\/ul>\n\n\n\n

                B\u01b0\u1edbc 3: Dinh d\u01b0\u1ee1ng v\u00e0 modulate microbiome<\/strong><\/p>\n\n\n\n

                  \n
                • Dinh d\u01b0\u1ee1ng: b\u1ec7nh n\u00e3o gan li\u00ean quan sarcopenia (teo c\u01a1), c\u01a1 ch\u1ebf gi\u1ea3m amoniac. AASLD 2014: 35-40 kcal\/kg\/ng\u00e0y, protein 1.2-1.5 g\/kg\/ng\u00e0y (kh\u00f4ng h\u1ea1n ch\u1ebf protein). \u0102n nh\u1ecf, \u0111\u1ec1u \u0111\u1eb7n, th\u00eam b\u1eefa t\u1ed1i mu\u1ed9n. Khuy\u1ebfn kh\u00edch protein th\u1ef1c v\u1eadt (\u00edt t\u0103ng amoniac h\u01a1n th\u1ecbt).<\/li>\n\n\n\n
                • Microbiome: R\u1ed1i lo\u1ea1n vi khu\u1ea9n ru\u1ed9t g\u00f3p ph\u1ea7n b\u1ec7nh n\u00e3o gan (t\u0103ng Enterobacteriaceae, gi\u1ea3m Bacteroidetes). EASL\/AASLD khuy\u1ebfn kh\u00edch probiotic (nh\u01b0 Lactobacillus), nh\u01b0ng d\u1eef li\u1ec7u h\u1ea1n ch\u1ebf. Fecal microbiota transplantation (FMT) l\u00e0 li\u1ec7u ph\u00e1p m\u1edbi, an to\u00e0n giai \u0111o\u1ea1n 1, c\u1ea3i thi\u1ec7n microbiome.<\/li>\n<\/ul>\n\n\n\n

                  Kinh nghi\u1ec7m: khuy\u1ebfn kh\u00edch th\u1ef1c ph\u1ea9m gi\u00e0u fiber (rau c\u1ee7, yogurt) \u0111\u1ec3 h\u1ed7 tr\u1ee3 microbiome.<\/p>\n\n\n\n

                  B\u01b0\u1edbc 4: Can thi\u1ec7p v\u00e0 c\u1ea5y gh\u00e9p<\/strong><\/p>\n\n\n\n

                    \n
                  • Embolization shunt th\u00f4ng c\u1eeda (SPSS)<\/strong>: N\u1ebfu b\u1ec7nh n\u00e3o gan kh\u00e1ng tr\u1ecb v\u00e0 shunt l\u1edbn (\u22658-10 mm tr\u00ean CT). EASL 2022 d\u1ef1a tr\u00ean nghi\u00ean c\u1ee9u h\u1ed3i c\u1ee9u: Hi\u1ec7u qu\u1ea3 \u1edf MELD \u226411, gi\u1ea3m b\u1ec7nh n\u00e3o gan t\u00e1i ph\u00e1t 49%. R\u1ee7i ro: T\u0103ng \u00e1p l\u1ef1c c\u1eeda, ch\u1ea3y m\u00e1u.<\/li>\n\n\n\n
                  • C\u1ea5y gh\u00e9p gan (LT)<\/strong>: \u0110i\u1ec1u tr\u1ecb cu\u1ed1i c\u00f9ng cho b\u1ec7nh n\u00e3o gan t\u00e1i ph\u00e1t\/persistent (EASL 2022: Khuy\u1ebfn c\u00e1o sau c\u01a1n OHE \u0111\u1ea7u, n\u1ebfu UKELD \u226549 ho\u1eb7c MELD cao). Gi\u1ea3i quy\u1ebft b\u1ec7nh n\u00e3o gan h\u1ea7u h\u1ebft tr\u01b0\u1eddng h\u1ee3p.<\/li>\n<\/ul>\n\n\n\n

                    Kinh nghi\u1ec7m: \u0110a ng\u00e0nh (gan, ICU, X quang can thi\u1ec7p, dinh d\u01b0\u1ee1ng) quy\u1ebft \u0111\u1ecbnh.<\/p>\n","protected":false},"excerpt":{"rendered":"

                    ThS BS Tr\u1ea7n H\u1eefu Hi\u1ec1n Th\u00e0nh vi\u00ean H\u1ed9i Gan Ch\u00e2u \u00c2u EASL t\u1eeb 2018 \u0110\u1eb7t l\u1ecbch kh\u00e1m b\u1ec7nh gan qua zalo bs Hi\u1ec1n: 0987842200 Trong q\u00faa tr\u00ecnh \u0111i\u1ec1u tr\u1ecb l\u00e2m…<\/p>\n","protected":false},"author":1,"featured_media":3369,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[131],"tags":[117,67,84,137,51],"jetpack_featured_media_url":"https:\/\/hienbacsi.com\/wp-content\/uploads\/2025\/10\/img_2104.jpg","_links":{"self":[{"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/posts\/3374"}],"collection":[{"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/comments?post=3374"}],"version-history":[{"count":2,"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/posts\/3374\/revisions"}],"predecessor-version":[{"id":3376,"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/posts\/3374\/revisions\/3376"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/media\/3369"}],"wp:attachment":[{"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/media?parent=3374"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/categories?post=3374"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/hienbacsi.com\/index.php\/wp-json\/wp\/v2\/tags?post=3374"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}