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CHNG 6

NI TIT

I THONGMc tiu1. Trnh by c nh ngha, c im dch thc, bnh nguyn v cchbnhsinh

2. Trnh by c tiu chun chn on i tho ng

3. Phn loi i tho ng.4. Trnh by c cc triu chng cn lm sng vbnh.5.Bin chng cp v mn ca i tho ng

6. Trnh by c cch tit thc trong i tho ng

7. Trnh by c mt sloi thuc thng dng trong iu tri tho ngNi dung

I.NH NGHAI THONG- Theo TCYTTG 1999: "i tho ng (T) l mt tnh trng ri lon chuyn haa nguyn nhn c trng bi tnh trng tng glucose mu mn tnh vi cc ri lonchuyn ha carbohydrate, m, protein do hu qu ca khim khuyt tit insulin,khim khuyt hot ng insulin hoc chai".- Theo TCYTTG 2002: T l mt bnh mn tnh gy ra do thiu sn xut insulinca ty hoc tc dng insulin khng hiu qudo nguyn nhn mc phi v/hoc dodi truyn vi hu qutng glucose mu. Tng glucose mu gy tn thng nhiu h

thng trong cth, c bit mch mu v thn kinh.- Theo Hi THoa K2004: Tl mt nhm cc bnh l chuyn ha c trngbi tng glucose mu do khim khuyt tit insuline, khim khuyt hot ng insuline,hoc chai. Tng glucose mu mn tnh trong Tsgy tn thng, ri lon chcnng hay suy nhiu cquan, c bit l mt, thn, thn kinh, tim v mch mu .

II. DCH THC30-50% bnh nhn mcTtype 2 khng c chn on.

- Tn sut bnh T trn th gii: trn th gii, T chim khong 60-70% ccbnh ni tit. Trong nm 1995 cc quc gia c sngi mc Tnhiu nht v sngi don mc Tvo nm 2025 l n (19 ln 57 triu), Trung Quc (16

ln 38 triu), Hoa K (14 ln 22 triu); trong n l nc c t l tng nhanhnht.1985: 30 triu ngi mc T; 2000: 171 triu; 2030: dbo 366 triu; trong asbnh nhn = 65 tui cc nc pht trin v t45-64 tui cc nc ang phttrin.3,2 triu ngi Ttvong do bin chng Thng nm, tng ng 6 trnghp/pht


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- Tn sut bnhTtrong nc:2002: thnh ph: 4,4%, ng bng: 2,7%, trung du: 2,2%, min ni: 2,1%.H Ni: 1991: 1,2%, 1999-2001: 2,42%, thnh phHu1992: 0,96%, thnh phHch Minh: 1993: 2,52 (0,4%.

Theo TCYTTG, nm 2000 Vit nam c 791.653 ngi mc T v tng ln2.342.879 ngi vo nm 2030.

III. BNH NGUYN V CCHBNH SINH

1. Ttype 1:C cc yu t: di truyn, mi trung, min dch.

1.1. Di truyn

Ttype 1 phi hp cao vi sgia tng thng xuyn ca khng nguyn HLA, KN

HLA u thphi hp vi Ttype 1 thay i ty theo chng tc, HLA B8, B14,15,B18, Cw3, DR3 v DR4 gp bnh nhn Tchng tc da trng, trong khi HLA

Yu tkhi pht:- Nhim khun- Thc n

Yu tthc y- Nhim khun- Thc n

Nhy cm di truyn Phn ng tmin Tlm sng

Khng c phn ng t Thuyn gim

Hai giai on pht trinTtype 1:- G1: To p ng tmin hng nh vi TB o ty, biu hin bi sxuthin cc tkhng thGAD65, IAA, ICA, IA-2 (n c hay phi hp)- G2: Tin trin tp ng tmin vi TB o ty sangTtype 1.

Ngun: TCYTTG - 4.2002


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DR3, DR4 c lin quan viTth1 chu , chu Phi v chu MLatinh. HLA DR3hoc DR4 gp 95%Ttype 1 so vi 45-50% nhm chng chng tc da trng.Nghin cu nhng cp sinh i ng hp tgi rng nh hng di truyn Ttype 1 t gp hn l type 2. Chc 30% nhng cp sinh i ging ht nhau bTtype 1 s pht trin thnh bnh. iu ny cng gi rng yu tmi trng lin

quan n bnh sinh T. Ngc li, cp sinh i ging nhau caTtype 2 dxyra trong vng nm u tin bbnh nhiu hn l anh chem rut.1.2. Yu tmi trngTtype 1 l hu quca snhim trng, nhim c lm tn thng ty, hthngmin dch tn cng v ph hy tbo bta ty. Yu tmi trng kt hp vi tnthng chc nng t bo o ty bao gm virus (quai b, rubella, virus coxsackieB4), tc nhn c ha hc (nitrophnyl-urea c cho chut), v cc cht c hyhoi tbo khc nhhydrogen cyanide tbt sn hhng hay tcsn.1.3. Yu tmin dch

1.3.1. Min dch thdch

Khng thlu hnh chng li nhng tbo o ty c tm thy phn ln bnhnhnTtype 1 ngay lc c chn on (60 - 90%) ri gim. Cng c nghin cucho rng tKT khng tbo tiu o (ICA: islet cell autoantibody) c pht hintrong 5 tun u sau khi khi bnh 85-90% Tth1. Ngoi ra > 60% KT khnginsuline c tm thy trc khi iu tr insuline (autoantibody to insuline: IAA).Ngoi ra cn c KT khng Tyrosine phosphatase IA-2 v IA2.

Ngoi ra, phn ln KT khng t bo o trc tip chng li Glutamic AcidDecarboxylase (GAD hay GADA), mt loi men nh vtrong tbo bta ca ty. Csging ht gia thnh phn protein ca virus coxsackie cha chui 24 amino acidtng ng vi GAD65.

1.3.2. Min dch tboCng ng vai tr trong bnh sinh T type 1: ngi ta nghin cu trn chutBB v nhvo KT n dng cho thy ri lon TB lympho lin quan n Ttype 1(gim lympho T c ch, v tng t lympho T gip /lympho T c ch). Nhngnghin cu rt gn y gi rng bnh l min dch ca o ty bt u nhiu nmtrc khi chn on lm sng; tin trnh min dch xy ra chm v tip tc.

Cc yu tkhc ngoi liu php min dch c thnh hng n din tin tnhinca suy tbo trong Ttype 1Bng 1: Cc yu tnh hng nT

Yu t Tc dng

Tui Tui cng trth lng insulin ni sinh cn li cng thp

Cc t khngth

Bnh nhn c ICA + th tc ph hy TB cng nhanh. Cc tkhngthkhc t c gi trtin on hn.

khnginsulin

Bnh nhn T type 1 thng c bng chng ca khng insulin;y c thl mt yu tthc y smt b chuyn ha.

Gii Mt snghin cu cho thy nam gii bnh din tin nhanh hn

iu trT iu trmnhTlm chm tc gim sn xut insulin.

2. Ttype 2

2.1. Yu tdi truyn


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Yu tdi truyn l tri c gi sau khi nghin cu cc cp song sinh gingnhau, nu mt ngi mcTth 100% ngi cn li cng mcT.2.2. Yu tmi trng

Tui, bo ph, tnh ti l yu tnguy cda n bnh T. Ttype 2 boph nht l bo bng, tnh ti thng c sthiu lin kt insuline vi ththv sauththtrong ni bo, kt qul mt p ng vi insuline.Ngoi ra Ttype 2 thng xy ra qun thc nguy ccao khc nhau, bao gmkhng insuline, gia tng bt thng m m, tng VLDL, nhtng insuline khi iv sau n, tng HA (trong hi chng chuyn ha).Skhng insuline trong Ttype 2 l hu quca nhiu cchbnh sinh khcnhau. Phn ln c ch ny c l do hu qu ca ri lon chuyn ho nh tngglucose mu, tng acide bo khng - ester ho. Mt khc nhng nghin cu gn ytrn qun thtin i tho ng, thy rng skhng insuline m cxy ra rtsm trong qu trnh pht trin ca bnh. Insuline receptor kinase, phosphatase linquan ti hot ng insuline, cht chuyn vn glucose v tng hp glycogene.

Ri lon chc nng tbo trongTtype 2: c 5 ri lon:1. Ri lon tit Insulin:

- Gim p ng ca insulin i vi glucose: mt pha sm.- Ri lon tit insulin theo nhp: ri lon pha dao ng chm. S tit insulin

sinh l gm 2 loi dao ng: dao ng nhanh (mi 8-15, khng lin quan glucose),dao ng chm (mi 80-120, lin quan cht chvi nng glucose).2. Bt thng chuyn ha prinsulin: trong Ttype 2 tproinsulin v cc sn phmchuyn ha trung gian / insulin: tng.

3. Gim khi lng tbo .

4. Lng ng amyloid (amylin) ti o ty. Gp trong 90% trng hp Ttype 2.Xy ra sm gy mt dn khi lng tbo o ty, nht l tbo .

5. Vai tr ca ccht ththinsulin 2 (IRS 2: Insulin Receptor Substrate 2), NF-kB,ri lon chc nng ti th, stress oxy ha.

IV. TIU CHUN CHNONI THONGchn on T, hin nay ngi ta dng tiu chun chn on mi ca TchcY tTh gii (TCYTTG) nm 1998 v c xc nh li 2002. Chn on xcnh T nu c mt trong ba tiu chun di y v phi c t nht hai ln xtnghim hai thi im khc nhau:

1. Glucose huyt tng bt ktrong ngy 200 mg/dl (11,1 mmol/l), km batriu chng lm sng gm tiu nhiu, ung nhiu, st cn khng gii thch c.

2. Glucose huyt tng lc i 126 mg/dL (7mmol/l) (i c ngha l trongvng 8 gikhng c cung cp ng).

Endopeptidase

Proinsulin

Des 64,65 Proinsulin

Des 31, 32 Proinsulin

InsulinC peptide


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3. Glucose huyt tng hai gi sau ung 75g glucose 200 mg/dl(11,1mmol/l) khi lm nghim php dung np glucose bng ng ung (OGTT).Giai on trung gian:

+ Ri lon glucose mu i (IFG: Impaired Fasitng Glucose): khiglucose mu i Go (FPG) 110 mg/dl (6,1 mmol/l) nhng < 126 mg/dl (7,0 mmol/l).

+ Ri lon dung np glucose (IGT: Impaired Glucose Tolerance): khiglucose mu 2 gisau OGTT (G2) 140 mg/dl (7,8 mmol/l), nhng < 200 mg/dl (11,1mmol/l).

- Go < 110 mg/dl (6,1 mmol/l): glucose i bnh thng.- Go 126 mg/dl (7,0 mmol/l): chn on tm thi l theo di T(chn on

chc chn l phi iu kin nu trn).nh gi kt qukhi lm nghim php dung np glucose bng ng ung:

- G2 < 140 mg/dl (7,8 mmol/l): dung np glucose bnh thng.- G2 140 mg/dl v < 200 mg/dl (11,1 mmol/l): ri lon dung np glucose

(IGT).- G2 200 mg/dl (11,1 mmol/l): chn on tm thi l T.

Lu : TCYTTG cn sdng glucose mao mch chn on T(cn lu ntnh chnh xc ca my o dng huyt mao mch); trong khi Hi T Hoa K(ADA) chsdng glucose huyt tng tnh mch trong chn on T.Bng 2: Tiu chun chn on Tv cc ri lon glucose mu khc (theo TCYTTG -1999)

Nng glucose mmol/L (mg/dL)

Mu ton phn Huyt tng

Tnh mch Mao mch Tnh mch Mao mchT:

+ Go 6,1 (110) 6,1 (110) 7,0 (126) 7,0 (126)

+ G2 10,0 (180) 11,1 (200) 11,1 (200) 12,2 (220)

IGT:

+ Go (nu c)v

< 6,1 (< 110)v

< 6,1 (< 110)v

< 7,0 (< 126)v

< 7,0 (< 126) v

+ G2 6,7 (120) 7,8 (140) 7,8 (140) 8,9 (160)

v < 12,2 (< 220)

IFG:

+ Go v 5,6 ( 100)v

< 6,1 (< 110)

5,6 ( 100)v

< 6,1 (< 110)

6,1 ( 110)v

< 7,0 (< 126)

= 6,1 (= 110) v

< 7,0 (< 126)

+ G2 (nu o) < 6,7 (< 120) < 7,8 (< 140) < 7,8 (< 140) < 8,9 (< 160)


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CHIN LC CHNONI THONG THEO WHO 2002

Bng 3: CC GIAION LM SNG CATGlucose mubnh thng

Tng glucose mu

T

Giai

on

Typeiu ha Gmu bnhthng

RL G mui hocRLDNG

Khng cninsulin

Cn insulinkim sot

Cn insulinsng

Tp 1:

+ Tmin

+ V cn

Tp 2:

+ khnginsulin u th

+ Khimkhuyt titinsulin u th

Cc type cbit khc

T thainghn

Go(mmol/l) Glucose mu bt k(mmol/l)

Khng triu chng7,8 7,8-11,1 Khng triu

chng 11,1

< 6,1 6,1 Go < 7 XN li Go XN li

Bnhthng

RL Glucosei

XN li KhngXN na

6,1 Go 10% ngi > 35 tui, 25% ngi 40 tui, nhng i khi cng xy ra trnh, c tnh gia nh.


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a strng hp c km bo ph v bn thn bo ph li lm trm trng thm tnhtrng khng insulin. Nhiu bnh nhn khng c xem l bo ph da trn nhngtiu chun kinh in nhng li c stch tmnhiu vng bng.Him khi nhim toan ceton ngoi trkhi c stress hoc nhim trng.Nng insulin mu bnh thng hoc cao trong trng hp khng insulin chimu th; hoc nng insulin gim trong trng hp c khim khuyt khnng titinsulin.

C yu tgia nh r (c ldo di truyn). Cc yu tnguy cca Ttype 2 baogm: tui ln, bo ph, t hot ng thlc, tng huyt p, ri lon lipid mu, tin sgia nhT, tin sbTthai nghn v thuc mt snhm chng tc c nguy ccao mcT.3. Cc tp c bit khc:bao gm- Gim chc nng tbo bta do khim khuyt gene: MODY1 n MODY 6. TthMODY (Maturity-onset diabetes of the young): do khim khuyt 1 gene lm gimchc nng tbo bta gy gim tit insulin. Thng xy ra sm (trc 25 tui), c

trng bi ri lon tit insulin, trong khi hot ng insulin khng bnh hng hocnh hng khng ng k. vi tng glucose mu mc nh. Loi thng gp nhtl MODY 3 do t bin NST 12 yu tnhn tbo gan (HNF1 alpha).

- Gim hot tnh insulin do khim khuyt gene: khng insulin tp A, Tthteom, hi chng Rabson Mendenhall...- Bnh l ty ngoi tit: bnh ty xsi, vim ty, chn thng/ct bty, ung th,xkn ty, bnh nhim sc tst...- Bnh ni tit: hi chng Cushing, to u chi, pheochromocytoma, u tit glucagon,cng gip, u tit somatostatin, u tit aldosterone...- Tdo thuc, ha cht: Vacor, pentamidin, acid nicotinic, corticoid, hormon tuyngip, thuc ng vn giao cm bta, thuc ng vn giao cm alpha, li tiuthiazide, Dilantin, interferon alpha...

- Nhim khun: Rubella bm sinh, Cytomegalovirus...- Cc thkhng thng gp ca Tqua trung gian min dch: tkhng thkhngththinsulin, hi chng ngi cng...

- Mt shi chng di truyn i khi kt hp vi T: hi chng Down, tht iu vnng Friedrich, hi chng Klinefelter, hi chng Turner, ma vn Huntington, hichng Lawrence-Moon-Biedel, lon dng trng lc c, porphyria, hi chngPrader-Willi, hi chng Turner, hi chng Wolfram...

4. Tthai nghn

Tthai nghn (TTN) l tnh trng ri lon dung np glucose mu vi cc mckhc nhau, khi pht hay c pht hin u tin khi c thai; d dng insulin haychtit thc iu trv ngay ckhi Tvn cn tn ti sau khi sinh. nh nghany khng loi trtnh trng ri lon chuyn ha glucose xy ra trc hay xy racng lc khi c thai m khng c nhn bit trc .

VI. CN LM SNG1. Glucose huyt tng tnh mch

Lc i, hoc bt khoc 2 gisau lm nghim php dung np glucose mu bngng ung; c gi trnh nu trn phn chn on.

2. Insuline mu


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Thp, i khi chcn vt T typ 1; ngc li tng hoc bnh thng hoc hithp Ttyp 2.

3. Nng C-peptide

C-peptide l thnh phn cu ni hai chui A v B ca phn tproinsuline do tusnxut. Proinsulin Insulin + C peptide. C peptide gip nh gi nng dinsulin nisinh.4. HbA1c

Khi glucose mu tng th tp trung glucose trong hng cu tng, dn n tHbA1c cng tng. HbA1c cho php nh gi nng glucose mu trung bnh trong 2thng trc .

5. Fructosamine

nh lng tng thprotein gn glucose (c bit l albumine). Trsbnh thng l1 - 2.5 mmol/l, thay i tutheo phng php nh lng. TrsFructosamine phnnh nng glucose mu trung bnh trong hai tun trc.

6. Cc xt nghim min dch - di truyn- Di truyn: c thpht hin c cc khng nguyn HLA-DR3 v/hay HLA-DR4, HLA-DQ, HLA-DRB (14,15), HLA-DR/DQ.

- Yu tmin dch thdch: KT khng tbo tiu o (ICA): du chim rtquan trng trong hot ng min dch ca Ttype 1. KT khng insuline (IAA). KTkhng Tyrosine phosphatase IA-2 v IA2(. KT khng Glutamic Acid Decarboxylase(GAD65 hay GADA65).

7. Bilan vbin chng hay bnh phi hp- Ctone niu: c chnh trong trng hp Tmt b nng, nht l khi

nghi ng c b nhim toan cetone, thng (+) trong hn m nhim toan ctone

type 1 hay type 2 mt b nng do mc mt sbnh phi hp.- o in tim, chp phim phi, soi y mt, chp ng mch vng mc, sium doppler hoc chp ng mch chi di nu nghi ngc xva gy hp, bilanv lipide, XN chc nng thn (ur, cratinine mu, albumine niu vi th, protinniu).

- o in cEMG, trc nghim thm d bnh thn kinh tng htimmch, Holter o HA v mch 24 gi.

VII. CHNONBng 5: Cc c im chnh caTtype 1 v type 2 (theo TCYTTG 2002)

c im Type 1 Type 2

Tui khi pht in hnh < 35 > 35

Yu ttbm di truyn t Nhiu

Cc tkhng thchng li TB

C (90-95%) Khng

Vc dng Bnhthng/gy

Bo ph

Insulin/C-peptide huyt tng Thp/khng c Cao

c im chuyn ha chnh Thiu insulin Hi chng chuyn ha vi

km nhy cm insuliniu trinsulin p ng Cn liu cao


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Cc thuc kch thch tit insulin Khng p ng p ng

1. Chn on Ttype 1Khng c bn ci l:

- Khi u tui tr< 40 tui.

- Glucose mu tng theo tiu chun chn on ca TCYTTG nh ni trn.- Du lm sng rm r: tiu nhiu (tng sinh niu thm thu), ung nhiu, n

nhiu, gy nhiu, v suy kit (asthnie).- Tnh trng gim insuline tuyt i da n nhim ctone v nhim toan-

ctone nu khng iu tr(C-peptide


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30-50% xy ra trsinh i ging nhau

Tin snhim siu vi, nhim c

100% xy ra trsinh i ging nhau

Khng c.

VI. BIN CHNG1. Bin chng cp

Bin chng cp c hiu bnh nhnTtype 2 l tng thm thu do tng glucosemu, hglucose mu, nhim toan lactique;Ttype 1 l nhim toan cetone.1.1. Tng thm thu do tng glucose mu (HHS: Hyperglycemic HyperosmolarState)

Thng xy ra ngi gi. Gim chc nng thn v ri lon kht thng gp ngi gi, cng lm tng cng v tnh trm trng bin chng ny. Hn m vithm thu HT > 340 mOsm/Kg nc, khng c nhim toan ceton. Lm sng tintrin nhanh, mt nc, st v ri lon thc (sng s, hn m, co git ng kinh).Mt nc ni v ngoi bo, chyu ni bo. Thnhanh, nng, nhng khng c micetone.

CLS: - Glucose mu tng >8g/l (44 mmol/l), c tht n 20g/l, nhng lun lun >7g/l, Natri mu tng rt cao (>150mmol/l); Kali c th bnh thng hoc gim doiu chnh glucose bng insuline, cetone niu (-). Thng c suy thn chc nng,ur lun trn 1,5 g/l.

- pH mu bnh thng, dtrkim khng thay i- C nhiu cch tnh tng thm thu:

hoc1.2. Hglucose muL triu chng ng ngi, nht l bnh nhn gi T type 2 iu tr bngsulfonylureas. Nu bnh nhn T c bin chng thn kinh tng lm mt png tit catcholamine, lm che du triu chng h glucose mu nn bnh nhncng nhthy thuc khng cnh gic c. Hglucose mu bnh nhn Tgil ngun gc ca tai bin mch mu no hoc mch vnh, cng tng tsut T,ngay cdu hglucose mu mc va nhng nu lp li nhiu ln cng rt nguyhi v khng hi phc.1.3. Nhim toan acid lacticXy ra bnh nhn Ttype 2 ln tui, thng c tn thng suy tbo gan, hocsuy thn, v thng do iu trbng Biguanide. Him gp1.4. Nhim toan cetone i tho ng (DKA: Diabetic Ketoacidosis)

Gp bnh nhn T type 1, type 2 him. Tin triu c thrt kn o: mt mi,chn n, nn ma. au vng thng v, c hiu theo tht lng. Tiu nhiu v khtnc nhiu, nc tiu c cetone > ++ l triu chng bo ng, ngay ckhi khng ctriu chng lm sng. C vi trng hp nhim toan cetone nng xy ra trong vigi, hoc vi ngy, v tc xut hin l yu tchnh gip tin lng.Du lm sng r vi kh thdo nhim toan: thnhanh 25 l/ph, kh th4 th caKussmaul. Ri lon thc, thng thng khng c du thn kinh khu tr v Babinski(-). C du mt nc ni v ngoi bo. Ri lon tiu ho (nn ma, au bng nhiu,i chy cng lm mt in gii). Hi thc mi acetone, hnhit thng gp. Dnng t.

Cn lm sng: glucose niu (++++) v cetone niu (+++).

Na 2 + G mmol/L >320 mOsm/K nc (Na +K+ ) 2 + G + Ur > 340 mOsm/Kg nc


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- ECG: phi thc hin mt cch h thng ngay khi bnh nhn mi vo vin,nh gi bin sng T v xem c bt thng vdn truyn tim tng ng vi kalimu

- Glucose mu: 3 - 5g/l.- Thceton trong HT rt cao- HCO3

-gim < 10 mEq/l, pH gn 7,0 hoc thp hn (BT: 7,30)- Ri lon kali mu: giu bnh thng hoc tng, nhng gim nhanh trong

3 gisau. V ththeo di in tim u n l cn thit.


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Bng 7: Tiu chun chn on nhim toan ceton T (DKA) v tng thm thu dotng glucose mu (HHS) - (theo ADA 2004)

DKA

Nh Va Nng

HHS

G huyt tng (mg/dl) > 250 > 250 > 250 > 600pH ng mch 7,25-7,30 7,00-7,24 < 7,00 > 7,30

HCO-3 huyt tng(mEq/L)

15-18 10 - < 15 < 10 > 15

Ceton niu + + + t

Ceton huyt thanh + + + t

Posm huyt thanh * Thay i Thay i Thay i > 320

Khong trng anion ** > 10 > 12 > 12 Thay i

Tnh trng tri gic Tnh Tnh/ngg Sng s/hnm Sng s/hnm

*: Posm (mOsm/kg) = 2 Na (mEq/L) + G (mmol/L)

**: Khong trng anion = Na+ - (Cl-+ HCO3-) (mEq/L)

2. Bin chng mn tnh

2.1. Bin chng vi mch2.1.1. Bnh l vng mcTNguyn nhn chnh gy m. Gm 2 giai on: bnh l vng mc Tkhng tngsinh (NPDR: nonproliferative diabetic retinopathy) v bnh l vng mc T tngsinh (PDR: proliferative diabetic retinopathy).Bng 8: Cc giai on bnh l vng mcT

Giai on Thay i bnh hc thng gp

Thay i lu lng mu qua vng mc

Mt TB quanh mao mch vng mcGiai on tin lm sng

Dy mng y

Vi phnh mch vng mc v xut huyt dng chm

Tng tnh thm mch mu vng mc

Giai on sm:

NPDR mc nh

Xut huyt dng chm nhbng gn

Giai on trung gian: Thay i khu knh tnh mch

+ NPDR mc va Bt thng vi mch trong vng mc

+ NPDR mc nng Mt mao mch vng mc

Thiu mu cc bvng mc+ NPDR mc rt nng

Xut huyt lan ta trong vng mc v vi phnh mch lan ta

Tng sinh mch da th

Tng sinh mch nhiu ni

Tng sinh mch mng mt

Giai on mun:

PDR

Tng nhn p do tng sinh mch


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Xut huyt dch knh v quanh vng mc

Tng sinh xmch mu

Co ko vng mc, x vng mc, bong vng mc

+ Ngoi bin chng vi mch vng mc, ti mt cn c cc bin chng sau: ri lonchit quang nn nhn khi tkhi m, ri lon mu sc (xanh, vng), c thutinh th,vim thn kinh th, lit cvn nhn, glaucome (do tng sinh mch mu ti mng mtlm ngn cn lu thng dch knh ttin phng ra hu phng)2.1.2. Bnh l vi mch thn (bnh l thnT)Thng xy ra ng thi vi bnh l vng mc, l nguyn nhn hng u suy thnmn tin trin. Triu chng u thgiai on sm l proteine niu xut hin sau 10-15 nm khi bnhT, m biu hiu giai on u l albumine niu vi th.Bng 8: Cc phng php tm sot albumin niu (theo ADA - Diabetes Care 1.2004;NEJM 4.2002)

Giai on Mu khng theo thi gian Mu theo thi gian

Khng hiuchnh

Hiu chnh theo C creaNT

Qua m 24 h

g/ml mg/g g/min mg/24h

BT < 20 < 30 < 20 < 30

Alb niu vi th 20-200 30-300 20-200 30-300

Alb niu i th > 200 > 300 > 200 > 300

giai on c albumine-niu vi th, sinh thit thn sthy dy mng y mao mch

vi cc lng ng lan to trong lp gian mch cu thn. Khi cc lng ng ny cdng nt, c gi l xho knh-cu thn dng nt Kimmelstiel v Wilson; dngtn thng ny t gp. Sau mt thi gian di, albumine niu tng dn v xut hinproteine niu r, nu vt qu 5 g/24 gi. C thc gim protide mu, ph c hiuca mt hi chng thn h, v thng phi hp hng nh vi tng HA trm trng,vi bnh l vng mc v thn kinhT.2.1.3. Bin chng thn kinhTBng 9: Phn loi bnh l thn kinhT(theo ADA 2005):

Cm gic cp tnh

Vn dng-cm gic mn tnhBnh l a dy thn kinh

i xng Tng

TK s

TK thn

TK chi

Vn ng gn gc chi (teo c)

Bnh l mt dy thn kinhmt hay nhiu

Bnh l a dy TK hy myelin do vim mn tnh cng tn ti

nh ngha bnh l thn kinhTtheo ADA 2005: Shin din ca cc triu chngv/hoc du hiu ca ri lon chc nng thn kinh ngoi bin ngi Tsau khi loi trcc nguyn nhn khc (Chn on bnh l thn kinh T l mt chn


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on li tr. Thng phi hp vi bnh l vng mc, bnh l thn to thnh tambnh (triopathie) c hiu caT.- Bnh l TK cm gic cp tnh: him, xy ra sau 1 thi gian kim sot chuyn hakm (nhnhim toan ceton) hay do thay i t ngt kim sot glucose (vim TKdo insulin). Triu chng cm gic xy ra cp tnh v ni bt, tng ln vm, khng

c du hiu TK khi khm LS.- Bnh l a dy TK vn ng - cm gic mn tnh: cn gi l bnh l TK xa gc ixng. Thng gp nht, > 50% trng hp. ng vai tr chyu trong bnh sinhlot bn chn T.Biu hiu lm sng ch yu cm gic bng, cm gic chm chch, cm gic ingit, dcm, tng cm gic au v cm gic au su. Triu chng nng vm. Xyra ch yu bn chn v chi di. 50% khng c triu chng v chc chnon khi thm khm; c khi c biu hin lot bn chn khng au.Khm thy mt cm gic rung (dng m thoa 128 Hz), cm gic p lc (dng dngcsi n 10g - 10g monofilament), cm gic au v cm gic nhit, mt phn x

gn gt.. Thng km cc du hiu ri lon thn kinh tng ngoi bin: bnchn lnh hay nng, i lc tnh mch mu chn dn, da kh, nt chai vng t .- Bnh l mt dy thn kinh: t gp, khi pht t ngt. Tn thng TK gia (5,8%),TK tr(2,1%), TK quay (0,6%), TK mc chung. Tn thng TK s(III, V, VI, VII) rthim gp (0,05%). Khong 1/3 bnh nhn c biu hin chn p TK (TK tr, TK gia,TK mc v TK gia bn tay). Bnh l teo c do T thng gp bnh nhnTtype 2 ln tui vi triu chng au nhiu, yu v teo cgn gc mt hay haibn.

- Bnh l thn kinh tng (BLTKT):

Stm tt bin chng thn kinh tng cc cquan:

Bt thng

tit mhi

Bt thng

tim mch

Ri lon

ddy-rut

Ri lon

vn mch

Bnh thn kinh

tng

Bnh thn kinh

c

Bt thngvng t

Bt thngiu ho nhit

Bt lc

2.2. Bin chng mch mu lnBiu hin x va nhiu mch mu ln: thiu mu c tim im lng, NMCT (50% tvong), vim tc ng mch chi di gy hoi t kh, vim xng; tc mch bnchn; cng chn, phi ct ct chi. Tai bin mch mu no. Tc mch thn: c thpht hin c ting thi ng mch thn; hu quTHA, suy thn.

3. Bin chng nhim trng

Dbnhim trng: lao, nhim siu vi v vi trng, nht l nhim trng ng tiu daidng v ti pht nhiu ln nht l ng tiu thp, lm dcho vim thn b thn


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ngc dng v suy thn. Nhim trng da v nim mc: nht tcu vng, vim mh, vim bao qui u.., i khi chnh bi cnh nhim trng ny lm khi pht Tcsn.

4. Cc bin chng khc4.1. Tng HAThng phi hp vi T, i khi c trc khi Txut hin, hoc thng thngdo bnh l cu thn, xva; tn sut gp nhiu Ttype 2 nht l bo ph v cstng quan gia bo ph v THA.4.2. Bin chng daNgoi tn thng nht nhim trng, da cn c nhng biu hiu sau: vim teo dngmbiu hiu bng nhng nt m phn trung tm teo li, vng vin xung quanh tmdn, nh vngn tay hay chi di, dng da do insuline, ph i m mhoc teom m.

4.3. Bn chn T

- Sinh bnh hc nhim trng bn chnT: 3 yu tphi hp+ Bnh l mch mu ngoi bin (vi mch v mch mu ln).

+ Bnh l thn kinh ngoi bin.+ Suy gim min dch: do gim chc nng TB lympho, do tng glucose mu,

do dy mng y.

- Phn loi nhim trng+ Mc nh:

Lot bmt.

Chy mhay huyt thanh.

Hoi tkhng c hay rt t. Khng c biu hin nhim c ton thn.

+ Mc va:

Lot bmt su hn.

Thng c chy m.

Hoi tm mc trung bnh.

Vim xng tuxng c thc.

Biu hin ton thn nh: st, BC tng.+ Mc nng:

Lot bmt hay su hn (vo m di da, xng, khp). Chy m.

Hoi tm nng v lan rng.

Biu hin nhim c ton thn nng n: nhim toan, nhim khunhuyt.

VII.IU TR1. iu tri tho ng tp 11.1. Mc tiu iu tr:- Lm bin mt triu chng, trnh bin chng lu di, bng cch kim sot glucosemu tt, vi tHbA1c < 7%, kt hp iu chnh ri lon lipide, protide tt, trng lng


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n nh bnh thng, v trnh nhim cetone. Trnh pht trin bin chng thoi ha(hn chbin chng cp v mn tnh).- Trnh tai bin do iu tr(teo m m, hglucose mu) v gio dc bnh nhn bitbnh ca h.


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Bng 9: Mc tiu iu trT

Mc tiu iu trc khuyn co ca Chu Thi Bnh Dng

Xt nghim Tt Kh Xu

Go (mmol/l)

G bt k(mmol/l)

4,4 - 6,1

4,4 - 8

< 7

< 10

> 7

> 10HbA1c < 6,2% 6,2 - 8% > 8%

Mc tiu iu trca ADA (Hip HiTHoa K)

XN B/Thng Mc tiu phi t nkhi iu tr

Cn thay i khochiu tr

G trc n (mg/dl)

G lc i ng(mg/dl)

< 110

< 120

80 - 120

100 - 140

< 80, > 140

< 100, > 160

HbA1c < 6% < 7% > 8%

1.2.iu trtng qut v chin lc iu tr1.2.1. Gio dc bnh nhn vbnh T: gio dc cho bnh nhn bit cch dngthuc, tit thc v cc tai bin ca thuc nht l du hglucose mu kp thi str nh dng ng nhanh hoc bo cho BS. Chuyn khoa bit hoc nhp vinngay.

1.2.2. Tit thc v vn ng* Tit thc: bnh nhn Ttp 1 thng l gy, nn phi tng nhu cu calo

hng ngy.

* Vn ng v tp th dc va phi, ng nhin phi hp insulin. Theo dikglucose mu v cn thn liu insulin v dnguy chglucose mu.

1.2.3.iu trbng insulin* Cc loi insulin c sdng

- Insulin thng: tc dng nhanh; nu TDD c tc dng sau 15-30 pht, tc dng tia sau 1 gi, ko di 4-6 gi., nn c tim trc n 20- 30 pht..

Tim bng nhiu ng (TM, TB, TDD, trong phc mc), mi cch tim cthi gian tc dng khc nhau, dng ng tim, bt tim- Insulin trung gian (NPH) (tc dng ko di >8 giv


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* Cch tim v ng tim: thng thng bng ng TDD, trng hp bin chngcp nhhn m toan ceton hoc tng thm thu th truyn TM, tim TM.Ch : Chc insuline nhanh l c thtim bng ng TM, cn cc loai trung gian,chm, km th khng dng ng TM* Cch bo qun insulin: insulin n nh nhit t7 oC-27oC, tuy nhin tt nht

nn bo qun 4 -8 oC, khng nn tim ngay sau khi ly ttlnh ra.* Tc dng phinsulin.- Hglucose mu

- Phn ng min dch do iu trinsulin: Dng insulin: di dng may. Hin nayhim gp v c loi insulin bn sinh hc hay insulin ngi.-khng insulin.- Lon dng m m ti chtim: c 2 biu hin: teo m mdi da; ph i mmdi da vn cn l vn kh trnh.- Tng glucose mu mu thun: hiu ng Somogyi: qu liu insulin lm hglucose,

gy kch thch cc hormon lm tng glucose mu (catecholamin, cortisol, glucagon),cng lm nng thm cc bin chng.

- Ph: do gimui ginc.* Chnh iu trinsulin-Ttp 1: iu trthay thsut i- T tp 2: iu tr tng cng hay vnh vin tu thuc vo bin chng hay bnhphi hp-Tthai nghn

* Phc iu trinsulin

- i vi insulin nhanh: chnh trong trng hp cp cu nhhn m toan ceton,hn m tng thm thu (truyn TM, bng seringue chuyn hoc bm). Ngoi rainsulin nhanh thng c chnh khi glucose mu dao ng, kh kim sot. Timdi da trc n 30 pht. Tim nhiu ln, hoc tim 2 mi hoc 3 mi nhanh trcba n, hoc phi hp thm vi insulin chm hoc hn hp vo bui ti- i vi insulin NPH: hoc chnh trong Tm glucose mu n nh, cn tim2mi/ngy: 1 bui sng v 1 vo bui chiu. Hoc phi hp vi insulin nhanh trongkthut 3 hoc 4 mi tim: trung gian tim vo ti, insulin nhanh th tim sng, trav ti.

Nhanh Nhanh Trn (Nhanh+NPH)

8 gi 12 gi 20 gi 8 giTrc n Trc n Trc n

sng 30pht tra 30pht ti 30pht


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S1: Siu trinsulin vi 3 mi tim/ngy (2 nhanh+1 loi hn hp)


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Nhanh Nhanh Nhanh NPH

8 gi 12 gi 20 gi 22 gi 8 giTrc n Trc n Trc nsng 30ph tra 30pht ti 30phtS2: Siu trinsulin vi 4 mi tim/ngy (3 nhanh + NPH)

Hn hp (nhanh+NPH) Hn hp (nhanh+NPH)

8 gi 20 gi 8 giTrc n Trc n

sng 30ph ti 30phS3: Siu trinsulin vi 2 mi tim/ngy (2 loi hn hp)

-i vi insulin NPH trn ln: Loi ny c sdng theo 2 cch sau:+ Kthut 2 mi tim/ngy: tim 2 mi trn ln, chn loi trn ln ny vi mc chl loi nhanh lm gim nhanh glucose mu sau n, cn loi chm tc dng cngy

(mi ban ngy) v sut trong m n sng (mi ban m).+ K thut 3 mi: insulin nhanh tim bui sng v bui tra, mi trn ln tim votrc n bui ti, kthut ny hiu quhn 2 mi.

- i vi insulin chm. Kthut tim 1 mi; chnh i vi bnh nhn Tc nhucu insulin tng i khng nhiu lm1.2.4. Thuc c chmin dch

iu trc chmin dch trong Ttp 1 giai on mi khi pht l mt tin b.Mc d c vi trng hp lui bnh hoc gim nhu cu insulin, phn ln bnh nhnbiu hin khng dung np ng. Loi c chmin dch c hiu nht l KT ndng, chng c hiu trn ssn xut tbo T. Mt vi thuc khng nhm c ch

min dch nhProbucol c xu hng lm mt gc tdo, v Nicotinamide c chs


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tng hp Poly (ADP ribose) (mt loi men phc hi s thng tn NAD) nhm lmsuy yu tbo cung cp NAD.1.2.5. Ghp tu

2. iu trTtp 2.

2.1. Mc tiu iu tr:- Kim sot glucose mu tt nh ni trn-iu trcc yu tnguy cphi hp (thuc l, HA. Ri lon lipid mu)

2.2. Cc phng tin iu tr:- Gio dc bnh nhn- Tit thc v vn ng th lc, gim cn nng.- Thuc hglucose mu: Gm cc nhm thuc ung chng i tho ng sau:

+ Thuc tng tit insulinSulfamides (Sulfonyl Urase)

Metiglinide (Repaglinide) v D. phenylalanine (Nateglinide)+ Biguanide: Tng sdng glucose m (c, tbo m).

+ c ch-glucosidase+ Cc nhm thuc khc: cng to iu ho glucose mu tt qua cchti rut, vgim tng glucose mu sau n. Hoc nhm Thiazolidinedione gip ci thin khng insulin

2.3. p dng thc t

i vi Ttp 2, nht l i vi ngi trtui hn, tit thc v vn ng th lcl c chn la u tin. bnh nhn c glucose mu tng nh< 200 mg/dl vHbA1c < 8.5% nn p dng 4-6 vn ng v tit thc, nu khng ci thin c

glucose mu tt th mi sdng thuc ung hglucose mu2.3.1. Tit thc:* Khu phn thc n hng ngy:- Tit thc gim calo bnh nhn bo ph (20 kcalo/kg/ngy)

- Duy tr calo bnh nhn c trng lng bnh thng (30 kcalo/kg/ngy).- Tng calo bnh nhn gy (40 kcalo/kg/ngy)* Tn trng cn bng tit thc gia 3 loi thc n sau

- Glucide: 50-55% (50%) khu phn calo hng ngy ( l khu phn cnbn). Dng tri cy trong mi ba n, nhng cng hn ch. ng chm hay ng

a (loi c bt) v nhng loi c si (lgume kh) lm chm tng ng sau n vhp thu chm. Hn chdng ng n (hp thu nhanh). C thsdng cc chtngt nhn to nhng saccharine, Aspartam

- Lipide: 30-35% (trung bnh 35%) khu phn calo hng ngy. u tin l duthc vt

- Protide: 15% khu phn calo hng ngy.- Ru: ung bia ru vi lng va bnh nhn T c th chp nhn

c, vi iu kin phi tnh calo/ngy (1g ru cho 7 Calo) v khng nn dng khibng i, dhglucose mu.

2.3.2. Vn ng, tp thdc:

Gim cn; ci thin c ng mu trong v sau khi vn ng th lc (gim khng insulin, tng tnh nhy cm insulin ngoi bin). Gim LDL-C, tng HDL-C. Tc


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dng c li trn tim mch. Tng khnng ti a sdng oxy, lm chm li nhp timlc nghngi v lc gng sc, gim va phi HA2.3.3. Cc thuc ung hglucose mu:

* Thuc c tc dng kch thch tit insulin:

- Nhm Sulfonyl Urase: Chuyn ho gan, 1/2 i khc nhau, thi theo ng mthay thn, lin kt proteine mu cao, nguy chglucose mu v kch thch tu titinsulin.

+ Tc dng ca Sulfonyl urase (S.U). S.U. c tc dng chyu l kch thch tutitinsulin

Hot ng ngoi tu-trn tng hp glucose ti gan, vn chuyn glucose, gii phngglucagon

S.U gim khng insulin v gim glucose mu sau n do gim c tnh glucose,v tng tim lc trc tip trn gan, khi glucose mu gim th tbo gan nhy cmhn i vi insulin

S.U cn c tc dng lm tng tnh nhy cm sau thth.+ Cc nhm thuc S.U.

* ThhI: c 1/2 i ko di: hin nay t dng- Chlorpropamide: Diabnse 500mg/vin (thi gian 1/2 i l 36 gi)- Carbutamide: Glucidoral, vin 500mg, Tc dng 1/2 i l 45 gi. Tc dng

ko di 24 - 60 gi. Liu dng 1/2 - 1 vin/ng, dng 1 liu duy nht.* ThhII: gm:

- Gliclazide: Diamicron 80 mg, Prdian, Glucodex, Clazic, vin 80mg. Tcdng 1/2 i l 12 gi. Tc dng ko di 12 - 24 gi. Liu dng 1-3 vin/ng. Dng 2ln/ng (trc hoc trong ba n sng v trong ba n ti). i vi ngi ln tui,

gim 1/2 liu.Diamicron MR 30 mg, Clazic SR 30mg, tc dng chm, ung 1 ln bui sng,

liu 1-2 vin/ln- Glibenclamide: Daonil 5mg, Hmi-Daonil 2,5mg, Daonil faible 1,25mg (5

gi). Tc dng 1/2 i 6 - 16 gi. Tc dng ko di 12 - 24 gi. Liu dng thngthng 1-2vin/ng, c th tng 3v/ng. Ung ngay trc ba n chnh. 1 - 3 ln/ng

- Glipizide: Glibnse, Minidiab: tc dng 1/2 i l 3-7 gi; tc dng ko di6-12 gi; 5mg/vin; liu 5 - 20mg/ngy, 2 ln/ng.* ThhIII: Glimepiride (Amaryl*, Amarel*) vin 1mg, 2mg, 3mg. Tc dng 1/2 i l5 - 8 gi. Tc dng ko di 12-24 gi, Liu dng l 1mg/ng, c th tng dn theo

bc cp 1mg, 2mg, 3mg, 4mg, 6mg, thi gian tng theo khong cch 1-2 tun; thngthng liu 1-4 mg/ng. Ung trc ba n im tm hoc ba n chnh, ung mtliu duy nht trong ngy.- Glinide: c tc dng kch thch tit insulin khi glucose mu cao, nn iu ho cglucose trong ba n, kim sot c ng mu sau n. Gm:

+ Rpaglinide (Novonorm*, Prandin*): vin 0,5mg, 1mg, 2mg; liu 4mg/ngychia hai, ung trc n 15 pht. Ko di 3 gi

+ D-phenylalanine (Natglinide). Starlix*, vin 60-120mg, liu 60-120mg/lnx3 ln/ngy, cho trc n; ko di 1 gi30 pht

* Biguanides:

a. Metformin (Dimethylbiguanide):


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- Metformine tc dng nhanh: Glucophage, Siofor, Fordia, vin 500mg,

-Metformine tc dng chm: Glucophage retard (Metformine HCL) 850mg;Siofor 850mg; Fordia 850mg

Glucophage cho liu u tin 500mg, 2-3 ln/ng; ung trong lc n hoc saukhi n; sau 10-15 ngy c th thay Glucophage retard 850mg, 2 ln/ng.

- Glucinan, Stagid: liu 2-3 vin/ng, ung trong lc n.

- Tc dng: khng kch thch tit insulin, nn khng c tc dng phhngmu. Tuy vy do nhiu cchtc dng n vn lm gim tc dng ng mu lci, c bit l sau n; thuc c tc dng u th trn gan, gim tn sinh ng gan, ci thin p ng sau th th, tng tiu thglucose t bo ch, iu hoc ri lon lipde mu, gim ngng ngon ming. Chnh u tin cho Ttp 2bo

* Thuc c ch(-Glucosidase: c chhp thu glucose rut

a. Acarbose: Glucobay, Glucor*. Vin 50mg, 100mg. Liu cho tng dn 50 mg(3 ln/ng, ung ngay khi bt u n.

b. Voglibose (Basen*) Th h th 2. Vin 0.2mg, 0.3mg. Liu 0.2mg, 3ln/ng, ngay trc n

* Benfluorex: (Mediator):

- Tc dng: tc dng ging Metformine, vin 150 mg. Liu: 1-3 vin/ngy (tngdn liu), bt u 1-2, 3 vin/ngy.

* ThiazolidineDione

- Chnh tt trongTtp 2 khng bo c khng insulin.- Tc dng: Tng tnh nhy cm insulin, Gim glucose, TG, tng HDL.

* Cc nhm thuc mi:

Glitazones tc dng ln th th, gim c tnh khng insulin mt cchtrc tip m ch, gim glucose mu, nhng d tng cn. Gm Rosiglitazone(Avandia) v Pyoglitazone bt u dng ti Php nm 2000.Avandia (Rosiglitazone maleate): liu 4mg/ngy, sau 12 tun nu cn kim sotng huyt tt hn, c thtng 8 mg/ngy. Dng lc i hoc no. Chnh:- Ttp 2 khng kim sot ng huyt tt sau tit thc v tp thdc.- Phi hp vi SU hoc metformine khi T2 c iu tr bng tit ch vthuc SU hoc metformine m cha n nh glucose mu ttCCtrong suy tim 3-4 (NYHA), suy gan hoc bnh gan c ALT >2,5 ln BT. Tcdng ph: ph do gimui, nc, thiu mu, rng trng trli trong giai on tinmn kinh

2.3.4.iu trinsulin trongTtp 2.* iu trinsulin tm thi (cn gi l i tho ng tp 2 cn insulin hoc vin n

insulin (insulino-ncessitant, insulinorequrant):

iu trinsulin bnh nhn Ttp 2 khi:- Triu chng nng ra, mc d c iu trtit thc v thuc ung hglucose mu.

+ Du 4 nhiu: kht, tiu nhiu, ung nhiu, n nhiu v gy r.

+ C ctone niu (+++)+ Tng glucose mu nhiu v trng din (>3g/l), (HbA1c >7% mc d iu

trthuc ung ti a (gy tng c tnh ng).-au nhiu chi di.


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- Cc tnh hung cn insulin:

- Cc bnh nhim trng- Can thip phu thut.

(Mc ch nhm trnh smt qun bnh glucose mu do phi hp vi mt sbnh

trm trng nhnhim trng hoc can thip phu thut).- Hoc nhng bnh nhn Ttp 2 ang iu trbng cc loi thuc lmtng glucose (nhcorticoides..)

- Hoc i tho ng thai nghn.Trong phn ln cc trng hp ny, s s dng insulin c thc hin ti bnhvin hay ti nh, glucose mu c theo di u n thch nghi liu insulin. Typ ng m bc ssquyt nh ngng insulin v trli iu trthuc ung chngT.

Chnh insulin trong trng hp ny c th n c hoc cng phi hpvi thuc ung chngT.

- Nu insulin < 40UI, Glucophage 2 vin/ngy, bui sng v bui ti, ri 3v/ng,insulin gim t2-4 UI mi 2 ngy.

*iu trinsulin lu di (sau cng): c chnh trong nhng trng hp sau:- Bnh thn, gan, tim hoc bin chng mt, khng th tip tc iu trcc

loi thuc ung chngTc.

- Hoc v bnh Ttin trin nhiu nm, mt cn bng glucose mu trngdin. Ty khng sn xut insulin.

+ Cch sdng insulin trong Ttp 2: insulin c th thay th thuc vin hocphi hp 2 loi insulin v thuc ung gi l iu trhn hp. Liu insulin thch nghitheo glucose mu. Sln tim ging nhtrong tp 1.

3. iu trbin chng i tho ngC rt nhiu bin chng, ccp v mn, mt sbin chng vtim mch nhTHA,bnh mch vnh, thn th trnh by cc phn iu trtheo chuyn khoa. ychng ti ch ni s viu tr cc bin chng cp thng gp nhhn m toanceton, hn m tng thm thu, bin chng mn nhbin chng thn kinh3.1. Bin chng nhim toanceton (acidocetose)iu trny thc hin trung tm c bit, v chuyn khoa, theo di cht ch3.1.1. Chng mt nc v cung cp muiti lp li dch trong lnh vc ngoi bo v tng thtch. Phi bit trng lng cabnh nhn trc khi b nhim toan: nu mt 10% trng lng th b lng dchtng ng trng lng mt. V dbnh nhn 60 kg, mt 10% trng lng thb 6 lt: 3 lt trong 6 giu v 3 lt trong 24 gisau, gm:

- Dung dch mui ng trng: 1 - 2 lt trong 2 giu (Nu HA ti a < 80 mmHg,v khng c hoi tctim, th chuyn dch c phn tln).

- Ri ngng thay bng dd glucose 5%, thm ch 10% nu glucose


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3.1.3. Cn bng in gii: Bicarbonat: chnh cn thn v c nguy chkali mu:

+ Nu tn sth> 26 l/pht.+ pH mu gim < 7,10 mi chnh chuyn Bicarbonate. Nu khng s

gy phn ng di kim chuyn ho mt khi ceton bchuyn ho. Kim chuyn hoslm thay i strao i Kali lm tng nguy cri lon nhp tim

Liu 500-750 ml Bicarbonate ng trng (ch khng chuyn mt mnhBicarbonate, m phi cho cng mui ng trng).3.1.4. Kali: C thcung cp kali sau khi iu tr, tutheo in gii v bin i intim.

3.1.5. Cc iu trkhc- Khng sinh.

-iu trbnh nguyn.

- Ngn nga bin chng xut huyt tiu ho do thuyn tt mch.3.2. Bin chng hn m tng thm thu

3.2.1. B dch: Mt nc do tng thm thu thng n 10 -11 lit/24, mt cngoibo ln ni bo. V th cn cung cp nc khi lng ln, nhng kh v theo lthuyt phi chuyn nc nhc trng, nhanh, phi c sn dng tc th (ncct v glucose ng trng), nn hon ton bnh nhn phi khoa c bit (cnguy cvhng cu). Thc tthng dng mui ng trng: chlorure natri 0,9%,1-2 lt trong 1-2 giu. Sau b nhc trng 0,45%. Lng dch b c thl 6-8 lt/12 giu, phn cn li trong 24 hoc 48 gisau.3.2.2. Insulin: Tim ngay, liu thp hn liu ca nhim toan acidocetose; u tin 10-15 UI, ri 1-2 UI mi 1/2 gibng sringue in. Nu khng c sringue in, thdng sringue thng cho liu 5-10 UI, lp li mi 2 gi/ln, nu glucose mu < 200

mg% th phi chuyn glucose 5% hoc dextrose 5%, nhng phi duy tr glucose mu250-300 mg%, trnh ph no3.2.3. iu chnh Kali mu: theo di kin gii xem c hkali khng, nu ccho kali 10-30mmol/L

3.2.4. Hparine: cho sm trnh thuyn tc, thay i tin lng.

3.2.5. Khng sinh: iu trnhim trng tin hoc thpht.3.2.6.iu trnguyn nhn.3.2.7. Chng sc- Thuc vn mch dobutamine 5-15 g/kg/pht, hoc dopamine 3-5 g/kg/pht.

- Chuyn plasma.Tm li: trong 36 giu phi t n mc ch sau:- Glucose mu gn 250 mg%- Nng thm thu HT gn


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3.3.2. Myo-inositol: c tng thm sdn truyn TK, nhng khng ngn chn csSorbitol.3.3.3. c chSorbitol-dehydrogenase: gim oxyde ha sorbitol thnh Fructose bngcht S.0773 l mt tin dc (prodrug) c cung cp bi Geinsen v cng s, liu100mg/kg/ngy/3ngy.

3.3.4.iu trhHA tthTrong thi gian u, thng thng phi sa i tnh trng gim th tch mu, phihp vi thuc. Thuc iu trhiu qunht l

- Khong-corticoid nh Fludrocortison, liu 100 - 300(g/ngy (vi thc nnhiu mui, 2-6 g mui/ngy).

- Mtoclopramid (primperan): thuc i khng dopaminergic, liu primperan10mg/vin x 3ln/ngy,.

- Thuc i khng ththalpha-adrenergic tin synap+ yohimbin vin 2mg, liu 4mg x 3 ln/ngy

+ Cn thn bnh nhn c tin sTBMMN- Dihydroergotamin: thuc co ng mch, ngoi iu trmigrain cn iu trh

HA tthdo thn kinh, do c tc dng i khng ththserotonin 5 HT2, nhng liucao c tc dng ng vn ththadrenergic v tc dng serotonic.

+ Tamik*, vin 3mg x 2 vin/ngy, trong khi n;

+ Seglor* nang 5mg, ikaran LP* vin 5mg, liu 10mg/ngy, chia 2+ Khng nn phi hp bta-bloquant

- c chbta: mt srt t bnh nhn c tng ththbta, th propanololc chnh (liu thp).

- Thuc ng vn alpha 1: Nu tht bi khi dng cc loi thuc trn, th dngcht ng vn alpha 1 nh midodrine (gutron). Liu 2.5-4 mg mi 6 gi, thngthng phi hp vi dihydroergotamin v cafein.

- Thuc ng vn ca somatostatin c tc dng di: i vi cc thhHA tthkh tr, xy ra trong thi ksau n, th dng Octreotid liu 0,1-0,5 g/kg TDD vobui sng hoc ti

- Thuc c chtng hp prostaglandin: nhindometacin, ibuprofen, cng ckhnng sa i hHA tthsau n bnh nhn T.3.3.5.iu trlit ddy:- Lit ddy gy bun nn, hay nn th iu tr

+ Metoclopramid (primperan), cht i khng dopamin, vin 10mg, ung 4ln/ngy, Nhng nu ddy lit nng th phi dng ng tim v hp thu thuc tiddy km.

Cc thuc khc nh:+ Cisapride (prepulside*): c th lm gia tng phng thch acetylcholine t

tng thn kinh c rut (plexux myenteric), kch thch vn ng hang vv t trng,liu 10-40 mg trc n 30 pht

+ Dopaminobloquant: domperidone (motilium), ci thin ri lon nhp in ddy, 20mg/vin, liu 10-40 mg/ngy, c th 80mg/ngy chia bn ln, cho 30 phttrc n.

+ Thuc ng vn cholinergic (ging ph giao cm): bethanechol chloride10mg, 2 ln/ngy


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+ Cht c ch cholinesterasase: pyridostigmin bromid 1-2 mg/ngy, c thlm gim kh ming

+ Erythromycin: kch thch ththmotilin, kch thch co tht hang vsau n viNu tt cu tht bi, c thphu thut ct jujenum, v nui n qua ng rut3.3.6.iu tri chyT

+ Primperan, hay loperamid (imodium, 2-4mg x 4 ln/ngy). Tc dng ca loperamidlm gim sln i cu v cng lm tng p lc cvng hu mn lc nghngi

+ Hoc phi vin ti codein (30mg x 4 ln/ngy), opinium+ Clonidin: tc dng c li trn ctng nhu ng rut v tng tit rut non, liu 0,6mg/vin x 3 ln/ngy, gim nhu ng thy r.+ Octreotid: 50-75 (g TDD 2-3 ln/ngy, c thlm gim sln i cu t6 xung 1ln. Tuy nhin octreotide c tha n bin chng h glucose mu ti din dogim tit cc hormon chng iu ho.

+ Diphnoxylat + atropin: lomotil 2mg-5mg, 2-4 ln/ngy, ung. Ch diphenoxylatl thuc c s dng sau cng, v tht cn thn v d gy phnh i trng(megacolon)

-i khi kt hp khng sinh chng nhim khun.3.3.7.iu trbin chng ti bng quang:

Thng gim kch thch bng quang, nu c cu bng quang, dng ththut Crede.Nu tht bi th dng thuc ging ph giao cm nh bethanechol HCL 10mg, 2ln/ngy, C th dng alpha-bloquant (xatral) liu cao gim khng ngthot tiu, nhng c thgy hHA tthv ri lon phng tinh.

Nu tht bi, th phu thut ct on cbng quang lm mt sco tht ca c

vng on di nam gii.3.3.8.iu trbt lc

+ Thuc i khng alpha-adrenergic: yohimbin 4mg, 3 ln/ngy, c thgim33% trng hp, v nu cn

+ Regitin v papaverin: c thtim trc tip vo dng vt, mt sc kt qutt, nhng dbnhim trng, hoc cng qu mc, hoc xho..

+ Sidenafil (VIAGRA): thuc lm tng tGMP vng, gy cng dng; vin25mg. 50mg, 100mg. Liu 25-50mg, 1 gitrc khi hot ng sinh dc

+ Caverject: l prostaglandine E1, gy dn ng mch dng vt, v dn ctrn thhang, l10-20(g, tim vo thhang 5-20(g

+ Hoc t prothese dng vt.3.3.9.iu trtriu chng au trong bnh thn kinh ngoi bin- Gabapentin (Neurontin): thuc nhm chng ng kinh, co git, c cu trc gnging cu trc ca GABA/acid gamma aminobutyric, vin 100mg, 300mg v 400mg,liu 300mg x 2 ln/ngy, ti a c thti 1200mg, tc dng ti a sau 2-3 gi, nai 5-7 gi, Thn trng khng nn dng: trem, c thai, cho con b, suy thn, ti xli xe

- Thuc khng trm cm 3 vng (amitriptylin, nortriptylin, desipramin): c sdng chng au trong bnh thn kinhTtlu:

* Liu lng: Chia liu nhgim tc dng ph.nh gi tim mch trc khi chnh.


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HGLUCOSE MUMc tiu1.Trnh by c cchbnh sinh v bnh nguyn ca hglucose mu.

2. Trnh by c nhng triu chng lm sng v cn lm sng lin quan n h

glucose mu.3. Bit cch xtr v theo di bnh nhn bhglucose mu theo tng mc .

4. Bit phng thc tm kim nguyn nhn v bin php dphng hglucose mu.Ni dung

I.NH NGHAHglucose mu cn c gi l hng huyt, din t nhng biu hin lmsng v cn lm sng xy ra i vi cthngi khi nng glucose huyt tngtnh mch (50 mg/ dl (2,7 mmol / l).

Hglucose mu l mt trong nhng cp cu ni khoa thng gp trn lm sng, lmt trong nhng nguyn nhn gy tvong bnh nhn i tho ng sdnginsulin hoc sulfamide hng huyt trong tltvong 3 - 7% bnh nhn itho ng tp1. Tuy nhin thc tlm sng gii hn nng ng mu ni trnc ththay i do tnh hung lm sng cp hay mn ty thuc vo tui cng nhbnh l i km nht l bnh nhn i tho ng c thi gian mc bnh ko di.

II. BNH NGUYN1. Hng huyt lc i km cng insulin1.1. Phn ng insulin- Chn khng y vsv cht lng hoc l do qun ba n bnh nhni tho ng iu tr.

- Hot ng th lc qu mc: ngi khng bi tho ng lng thu nhnglucose ca cvn (tng 20-30 ln trn mc cn bn) c b tn sinh ng gan. iu ny l do gim insulin lu hnh do tng catecholamine do vn ng lmc chtbo beta. iu ha ny bgim bnh nhn ang iu trinsulin. Khi ccni lng ng thuc di da tip tc phng thch insulin trong qu trnh hot ng vtng hp thu insulin nhng vng cgn gc.- Hthng iu ha glucose btn thng bnh nhn i tho ng bbnh lungy. Phn ln bnh nhn i tho ng tp 1 c skm p ng glucagon khi hng huyt

- Qu liu insulin. Do khng nhn r hoc do thay i nng Insulin trong lthuc(40 UI/ ml thay th100 UI/ ml)

- Qu liu sulfamide hng mu, thuc c tc dng ko di (Chlopropamide cthi gian bn hy trn 35 gi...) c bit bnh nhn c thng tn gan, thn, ngiln tui dc nguy chng huyt.- Cc nguyn khc

+ Stress: Khi bstress (bnh tt, nhim trng, phu thut...) thng tng liu Insulincn bng ng mu. Khi stress chm dt cn phi gim liu.+ Suy v thng thn (bnh Addison) gy h ng huyt v th cn gim liuInsulin.

+ Bnh l ddy i tho ng: Bnh l thn kinh thc vt cc tng lm ddy

gim trng lc lm chm a thc n tddy vo rut, nguy chng saun bnh nhn sdng Insulin.


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+ Thai nghn. Nhu cu tiu thng tng trong thai nghn v th cn gim liuInsulin trong 3 thng u.+ Suy thn: Lm ging ha Insulin v thuc hng huyt bko di.

+ Thuc dng phi hp: Bnh nhn i tho ng c phi hp thuc iu trnh:Allopurinol, c ch beta, clofibrate, cimetidine, thuc chng ng, hydralazine,indomethacine, Maleate de perhexilline, miconazole, phenolbarbitale phenylbutazole,probenecide, salycile, sulfamide chng nhim khun, IMAO.quinine, quinidine, cchmen chuyn, disopyramide, tricycliques, propoxyphene, octreotide, tetracycline,mebendazole, cibenzoline, stanozolol, fluoxetine, ethanol, sertaline, tromethamirne,gancilovir, lithium, temafloxacilline.

+ Hng huyt gi(dng ln lt Insulin v cc thuc hng huyt): lin quann bnh nhn c bnh l tm thn phi hp.

+ Hng huyt tmin. C khng thkhng Insulin. Hng huyt xy ra 3 - 4gisau n v c quy cho sphn ly gia phc hp min dch khng th& Insulinlm phng thch Insulin tdo... Hng huyt tmin do tch ly slng khng

th ln c khnng phn ng vi Insulin ni sinh, c ghi nhn bnh nhniu trmethimazole trong bnh Basedow ti Nht Bn, cng nhmt sbnh nhnlymphoma, a u ty, hi chng lupus, trong paraprotein v khng thphn ngcho vi Insulin.Hng huyt do khng thkhng ththInsulin tng i him, bnh nhn nyc thi kkhng Insulin v chng gai en (acanthosis nigricans).H glucose mu cng c ghi nhn s p ng vi iu tr glucocorticoid mkhng thy trong lc huyt tng v c chmin dch.- H ng huyt do dng Pentamydine: Loi thuc dng iu tr nhim khunPneumocystic carinii bnh nhn AIDS, thuc lm tng Insulin cp do tc dng trn

tbo beta (10 - 20% bnh nhn).- U tbo beta tuyn tu.

1.2. Hng huyt lc i khng cng insulin.1.2.1. Cc ri lon phi hp vi gim lu lng glucose gan.- Do mt mt slng tbo gan nhteo gan vng cp, nhim c gan cp.

- Do ri lon cung cp acid amin n gan (chn n thn kinh, nhn i lu ngy, hichng uree mu cao, suy vthng thn).

-Do bt thng chuyn ha glucose trssinh (thiu men thoi bin glycogen,men tn sinh glucose).

1.2.2. Hng huyt do ruRu (ethanol) chuyn ha ti gan nhNAD v xc tc bi ethanol dehydrogenase.V thdng ru lu ngy lm gim lng NAD gan. y l cht cn thit trongphn ng tn sinh ng. Hng huyt do ru do gim tn sinh ng kmgim ngun d trglycogen ti gan. Ngoi ra insulin mu gim thun li cho tngcetone mu v trong nc tiu.Bnh nhn hng huyt do ru thng km thiu vitamine B1 (Beriberi) cp vthngoi sdng glucose cn phi hp vi vitamine B1. Ngoi ra do hai yu tnitrn vic sdng Glucagon trong hng huyt do ru khng c tc dng.

Triu chng thng xy ra sau n t8 - 12 gi. Bnh nhn trc ung nhiuru vslng cng nhthi gian lm gim ngun dtrglycogen mt phn don ung khng y .


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1.2.3. U ngoi tuyn tu.

Fibrosarcome sau phc mc, ung thgan, ung ththng thn, ung ththn, ungthddy rut, lymphoma v bch cu cp. nh lng Insulin khong 8 (U/ml volc hng huyt lc i. C lc stit Insulin lc ch.Khong 50 % khi u c tit peptid c trng lng phn t thp vi tc dng gingInsulin gi l peptide hot ng ging Insulin khng bkim hm (NSILA peptide =nonsupressible Insulinsulin like activity) bao gm human Insulin like growth factor vmt vi cht ca somatomedine.

2. Hng huyt phn ng (hng huyt khng xy ra lc i)Hng huyt phn ng xay ra sau n 2 - 3 gihoc mun hn 3 - 5 gi.2.1. Hng huyt do thc n sau ct ddy.y l hu quca cng Insulin sau ct ddy. Thc n xung nhanh sau n, hpthu glucose nhanh lm tng ng huyt, kch thch tit Insulin lm bnh nhn chngmt, xm xong, vmhi. (ddy trng nhanh sau n, kch thch thn kinh phvv sn xut hormone d dy rut kch thch t bo beta (beta cytotropicgastrointestinal hormone). C thdng khng cholinergic nhpropantheline (15 mg /ngy 4 ln), nn n tng ba nh, hn chng hp thu nhanh, c thdng thucc chmen alpha glucosidase.2.2. Hng huyt chc nng do thc n.

Thng gp bnh nhn mt mi mn tnh, loi u, kch thch, yu, km tp trung,gim tnh dc, nhc u, i sau n...2.3. Hng huyt mun.

Hng huyt sau n 4 - 5gisau khi ung ng gi tin triu i tho ngth2.

III. BNH SINH HGLUCOSE MUKhi nng Glucose mu bt u gim di mc sinh l skch thch vng di ikch thch tuyn yn tit ACTH (tng Cortisol) v STH (tng glucose).Khi hglucose mu nhiu cn pht sinh cm gic thm n ng v kch thch hli - hnh ty gy kch thch ty thng thn tit adrenaline, hph giao cm (nhnX), ty tng (tbo alpha) tit glucagon, ddy rut tit gastrin, secretine, kch thchtit ADH.Adrenaline cng glucagon lm tng thoi bin glycogene v tng tn sinh glucose tigan, adrenaline (cng giao cm & thn kinh thc vt: mhi, lo lng, nhp timnhanh)

Gastrin v secretine lm tng hp thu glucose ng tiu ha. Kch thch hi giaocm (i bng, bun nn v nn).

Nhng triu chng trn thng xut hin sm nhng chyu v trm trng ca hglucose mu tc ng chyu trn tbo no (v khng c ngun dtrglycogene)xy ra trong vng vi pht. Thiu glucose mu ko theo gim tiu thoxy. Nhu cuglucose tbo no khong 60 mg / pht v xy ra hn m khi cn 30 mg / pht.Thng tn tbo no khng hi phc khi nu s thiu nng lng trm trng vko di. Do nhy cm vthiu nng lng ca cc vng thuc no bc khc nhau,v th th txut hin triu chng ca cc giai on gii phu lm sng xut hinln lt nhsau.

+ Giai on vno: Lm, bun ng, kch thch tm thn, nhn i.+ Giai on di vno v no trung gian: hot ng tng, vt v, co git.


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+ Giai on no gia: co cng c, un vn, gin ng t v khng p ng nhsng, git nhn cu.+ Giai on trc ty no: du mt no.

+ Giai on ty no: hn m su, mt trng lc c, mt phn xgic mc.

Chm no bph nnht l bnh nhn i tho ng, hoi t, xut huyt, dgy dng. Ngoi ra mch vnh, htiu ha v h hp xy ra mun hn v khngthng xuyn.

IV. TRIU CHNG1. Triu chng lm sng

Cn lu triu chng lm sng thng t tng ng vi nng glucose mu.Triu chng hglucose mu thng xy ra khi i hoc xa cc ba n, tng ngthi gian tc dng ti a ca thuc (insulin hoc sulfamide hng huyt) i vibnh nhn i tho ng. Triu chng trn ci thin nhanh khi cung cp glucosetc thi.

1.1. Hng huyt mc nh:- Du ton thn: Bnh nhn c cm gic mt mi th lc ln tinh thn, bun ng,chng mt- V mhi (du chng rt quan trong trong giai on ny).- Du tiu ha: i bng v co tht vng thng v, c thnn hoc a chy.- Du tim mch: Hi hp, nhp tim nhanh hoc ngoi tm thu. Huyt p tng. auvng trc tim km ri lon nhp hoc dng au tht ngc.- Du thn kinh: Chut rt, dcm u chi v quanh mi, nhc u thng xuynhoc kch pht. Ri lon iu tit, nhn i, run lnh (dnhm do nhim trng.- Du tm thn kinh: Ri lon nhn cch v tnh kh: kch thch, vui v, ling thong,

hoc i khi bun bhoc nng tnh.- Du h hp: cn kh thdng hen.Nu giai on ny pht hin kp thi v x tr n gin vi cc thc ung c chang, du hiu lm sng ci thin nhanh.1. 2. Hng huyt nng:C tht ngt hoc xy ra trn nn cc biu hin lm sng ktrn. Trong giai onny biu hin lm sng chyu l du tm thn kinh.- Tm thn kinh: Sng s, n, cn trm cm vi xu hng tst, kch nghoc cng kch, hoang tng, o gic, mt thc thang qua.

- Cng hm (du quan trng dnhm un vn) v du hglucose mu nng.- ng kinh ton thhoc khu tr dng Bravais Jackson, lit na ngi, khu tr, rilon tiu no - tin nh: chng mt, ri lon vn ng (nhm tai bin mch muno).

Giai on ny s dng glucose u trng ng tnh mch trc tip hn l chong ung bnh nhn shi phc nhanh.

1.3. Hn m hglucose muKhi u thng khng t ngt, km co c, co git, tng phn xgn xng, cong t, cng hm, nhiu m hi, km nt mt bng v hi phc sau khichuyn glucose sm trc khi qua giai on khng phc hi vi hn m su thng

tn no khng hi phc v tvong nu hglucose mu nng v ko di.2. Cn lm sng:Glucose huyt tng: (50 mg/dl (2,7 mmol / l)


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+ Triu chng lm sng v cn lm sng thng khng tng ng vi nhau.

+ ng huyt tnh mch chnh xc nhng thi gian trkt quthng chm v thtrong bi cnh ti cp ng huyt mao mch cng l du chng tin cy v kt quc tc thi. Khng nn ci kt qung mu tnh mch m nn lm song hnh.

V. CHNON HNG HUYT1. Chn on xc nh:Tam chng Whipple+ Triu chng lm sng hglucose mu.

+ Nng glucose mu di 2,7 mmol/l (50 mg%).+ Ci thin triu chng khi dng cc cht cha ng

2. Chn on nguyn nhn

2.1. Bnh nhn mc bnh i tho ngiu trvi cc thuc Insulin hoc thuc sulfamide hng huyt tin sghi nhnvi ln qua li khai bnh nhn nu cn tnh, thng qua ngi nh nu bnh nhnhn m.

Xc nh iu kin xut hin cng nhyu tthun li (qun ba n, qu liu thucnsulin, hot ng thlc qu mc nhng qun b nng lng, hoc sdng thmcc thuc lm tng tim nng ca thuc hng huyt (xem phn nguyn nhn).Rt ra thu qutrn cn hng dn cho bnh nhn v ngi nh ngoi gio dchng huyt cn phi.Gim liu Insulin hoc thuc vin hng huyt.

Xem li chdinh dng vs lng v cht lng nht l thnh phn glucidetrong cc ba n nht l nhng lc au m.iu chnh li gin cho hp l.Tng ba n gia gi(ba n ph) ngoi ba n chnh.Cn ch + Bnh nhn i tho ng c iu chnh ng huyt tt khng thtrnh nguychng huyt.+ Hng huyt trn bnh nhn i tho ng trkhng phi l du hiu xu,nhng trn bnh nhn ln tui hoc c bnh l tim mch (suy vnh, tng huyt p) lyu tnng vi nguy ckhi pht tai bin tim mch (nhi mu ctim, tai bin mchno).

+ Hng huyt thng xy ra vm gn sng cn kim tra ng mu lc 4gisng nu bnh nhn c cc biu hin nghi ng.

+ Hin tng Somogyi (tng ng huyt phn ng) l biu hin ca hnghuytrc .2.2. Bnh nhn khng mc bnh i tho ng2.2.1. Cc xt nghim cn lm.

Chn on thng kh i hi nhiu phng tin nh lng Insuline mu, CPeptide v cc kch thoc cc cht khc v cc test nhsau- Nghim php nhn n. Bnh nhn bt buc phi nm vin nhn n hon ton hocchn hn chglucide (50 g glucide, 50 g protide v 70 g lipide)Thi gian nhn: Nhn n cho n lc xut hin triu chng hng huyt hoc 3ngy vi lao ng.

Xt nghim cn lm ng thi+ng mu mao mch v tnh mach (gi phng xt nghim) mi 4 gicho n khi


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xut hin du hng..

+nh lng insulin+nh lng peptide C huyt tng.on nhn

Da vo tlinsulin / glucose (I/G) theo 2 cng thc sau:Insulin (pmol/l) / glucose (mmol/l) (20 (bnh thng).Hoc (100 X insulin (U/ ml) / (ng mu - 30 mg%) (50 (bnh thng)

Lu : 1(U / ml = 7,17 pmol/l.2. Test hglucose mu bng insulin nhsauBnh nhn cn c theo di st.Kthut: ly mu nh lng ng v peptide C vo cc thi im Gn.Liu insulin 0,1 UI/ kg (loi insulin tc dng nhanh).nh gi kt qu:

- Hng huyt khi ng mu di 50 mg/dl.- Hm tit insulin ni sinh c xc nh nu peptide C huyt tng gim di 65%g trbnh thng.- Khng hm hoc hm yu: u tuyn tit insulin, hng do dng sulfamide. Khnghm peptide C chng c c tit nulin ni sinh tng cn phi thm d nguynnhn bng chn on hnh nh. Nhnh vu tit insulin bng chp CT scanner.Chp mch chn lc ng mch mc treo trng trn. Phn tch u tuyn tit insulinn c trong bnh cnh a ni tit th I, chyu trem, c th tng sn o lanta, khng nhn thy (nesidioblastose)2.2.2. Chn on nguyn nhn hng n do: Cn phn bit 2 tnh hung

Hng huyt thc thv hng huyt chc nng.1. Hng huyt thc th

Thng xy ra khi bng i, bui sng, n mun hoc bba, sau vn ngqu mc. Biu hin lm sng thng nng. Cn ch n iu kin, tnh hung xyra cng nhyu tphi hp. nh lng ng thi glucose mu, insulin v peptideC. C thto li tnh hung bng nghim php nhn n. C 3 tnh hung xy ra nhsau:

1. Insulin mu, peptide C v tinsulin/ glucose u tng.U tit insulin, Kch thch tit insulin ni sinh do thuc hay khng., Sulfamide hng huyt, Quinine

2. Insulin v tinsulin/ glucose u tng nhng peptid C thp.Dng insulin ngoi sinh, Chng gi bnh., Nghim php phm php (manoeuvrecriminelle). Tm khng thkhng insulin nu dng insulin b, heo khng c nu dnginsulin ngi.3. Insulin thp, tinsulin/ glucose bnh thng hoc thp.

C thlin quan n bnh tt, nhim c hoc do thuc,hng huyt do u ngoity (u mc treo nh vphc mc, sau phc mc, lng ngc), u gan, u v thngthn, u biu m. Thng hng huyt ti din, nng. Chn on ddo u ln,chp CT scanner, nh lng tng IGF2 (insulin like growth factor 2).

2. Hng huyt chc nng:Thng xy ra 2- 4 gisau n, Thng khng c du thn kinh cm gic. Rt him


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khi hn m. Biu hin i cn co v mhi. Bnh nhn thng c tin sct ddy, ni v trng, ct thn kinh X chn lc. l hng huyt do cng insulin(do thc n xung qu nhanh trong rut non) cn phn bit hi chng Dumping. Cnphi nh lng ng mu khi xy ra sctrn. Cn thc hin li test. Bnh nhnkhng c can thip bnh l ddy (thng l phn) hng huyt do cng

insuline hoc nhy cm qu mc i vi insuline. Phn ng thn kinh thc vt mkhng phi hng huyt phnlo u v trm cm.2.3. Mt stnh hung c bit- Ngc ru cp: hdng huyt lun tm kim ngi hn m do ru, suydng.- Nhim c gan: Glycol, tetrachlorure de carbone, annannite phalloide.- Dng Hypoglycine (tri cy xanh vng Jamaique)- Bnh nng: suy thn, suy gan, suy tin yn, suy thng thn cp, suy dng, suytim, chong nhim trng.- S dng mt s thuc nh (acetaminophene, c ch bta, chlorpromazine +orphenadrine, ethionamide, disopyramide, haloperidol, maleate de perhexilline,quinine, pentamidine, propoxyphene, salicyles)...

VI. BIN CHNG V HU QU1. Ph no sau hng huyt:Hn m ko di mc d ng mu tr vbnhthng km ph gai th. Ph phi cp: Do co mao mch phi.

2. Hu quthn kinh:Bnh l thn kinh ngoi vi: teo ctun tin, phn xa ca tchixy ra vi tun sau khi bmt hoc nhiu cn hng huyt nng, thng phihp vi dcm tchi. Thng tn sng trc ty sng c thb.3. Ri lon tm thn kinh ko di:in, ng kinh sau hng huyt, hi chng

parkinson, ma vn.4. Gy hoc xp t sng:Xy ra khi c cn ng kinh nng.Lu : Bnh nhn c tui (trn 60 tui) nht l c bnh l tim mch dc nguy ctaibin tim mch (cn kim tra in tim nu nghi ngthiu mu ctim im lng).Bnh nhn i tho ng, hglucose mu c th xy ra vm thng khngnhn bit c. V vy kim tra ng mu mao mch vo lc 4 gisng.

5. Di chng thng xuyn: l di chng ca nhng cn cp tnh, lp li v khngnhn bit. Lit bn thn, mt ngn ng, ma vn, hi chng Parkinson. Mt tr tudn dn, tnh trng sa st tr tu, hi chng teo ctchi xa gc v mt phn xgnxng.

VII.IU TR1. iu trtriu chng

1.1. Bnh nhn cn tnhUng cc thc ung cha ng cho n khi ci thin triu chng.

Khng c ung cc loi ng ha hc (sacharinate de sodium, saccharineatedammonium) dnh cho ngi i tho ng.1.2. Bnh nhn hn m: iu trcp cu

1.2.1.Dung dch Glucose 30% hoc 50%.Bm trc tip tnh mch mt lng glucose nhsau

Lng Glucose = [ Trng lng (kg) X 0,2 ] X [ Gbt - Gh ]Trong Gbt l nng glucose huyt tng cn t v dG =1 g/l, Gh l nng


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glucose mu lc bhng mu v dGh = 0,2 g/l. Nhvy mt bnh nhn nng50 kg, Lng glucose cn bm lc u l: 50 x 0,2 x (1 X 0,2) g = 8 g glucose.Khng nn truyn nhgit m phi bm trc tip tnh mch t nng glucosemu tng nhanh v cao.1.2.2. Glucagon (ng 1 mg)Tim tnh mch, tim bp hoc tim di da vi liu 1 - 2 mg, c thlp li sau 10 -20 pht (thi gian bn hungn). Khng sdng glucagon i tng nghin runng do d trglycogen gan km, hoc bnh nhn nhn i lu khng cnglycogen dtrgan. Bnh nhnTtp 1 lu ngy cng t p ng vi glucagon.1.2.3. Hydrocortisone: 100 mg.chch tnh mch

2. iu trduy tr

+ Nu bnh nhn tnh c thn c th tip tc n nhbnh thng.+ Nu khng n c (nn ma, khng dung np..) Truyn tnh mch Glucose 10%theo liu 1500-200 ml/ 24 gi(150-200 gam Glucose) cho n khi nng glucose

huyt tng trli bnh thng sau nhiu gi. Khng cho liu cao v c thchckhnng dung np ti a 1.5g glucose/gi+ Cn theo di ng mu thng da vo thi gian bn hy ca thuc gy hng huyt (Insuline, Sulfamide hng huyt..), phi iu trvt qu thi giantc dng ca thuc gy hng huyt+ Kim tra in tim c bit bnh nhn ln tui, bnh mch vnh, tng huyt p.

NHNGIU NN LM NHNGIU NN TRNH

Xtr ngay Hi bnh squ lu

Khng chi kt qung mu Chi kt qung mu

Bm trc tip tnh mch Chuyn tnh mch nhgitGlucose 20% Glucose 10%

Glucagon An thn nu vng vy

Theo di sau khi li Khng theo di

in tm bnh nhn ln tui Khng kim tra in tm

4. iu trnguyn nhn

4.1. Lin quan n bnh nhni tho ng+ Xc nh cc iu kin xut hin: qun ba n, thc n cha t ng, dng qu

liu Insuline, hot ng thlc qu mc nhng qun b nng lng. Dng phi hpmt thuc c tim nng lm tng tc dng thuc sulamide hng huyt+ Cn thay i chthiu tr:Thay i hoc gim liu Insuline, liu sulfamide hng huytiu chnh li thnh phn nng lng lng Glucide mi ba n cho hp l.iu chnh gin, nn thm ba n phgia cc ba n chnh.+ Khng nn chnh cc thuc Sulfamide hng huyt cho bnh nhn trn 70tui, nht l cc thuc c thi gian bn hy qu di (Chlopropamide).+ Suy thn v suy gan (tng nhy cm thuc hng huyt)+ Phi hp mt sthuc lm tng tc dng thuc hng huyt hoc bng cchgim liu thuc thng ngy.


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+ Khng p dng tiu chun cn bng ng huyt l tng nhng bnh nhnTtrn 60 tui.+ Cn ch hin tng Somogyi gy tng ng huyt thpht vo bui sng dohng huyt trong m4.2.iu trcc bnh l gy hglucose mu- U ty tit insuline: Phu thut,Diazoxide (ung hoc tnh mach) liu 300-1200 mg /ngy + thuc li tiu. Octreotide tim di da liiu 100-600 (g / ngy. Ha tr liubng Streptozotocine- 5 fluoro uracile.Chng hng huyt bng chuyn glucosev iu trthm Sandostatine.- U ngoi ty tit insuline:Phu thut, Chng hng huyt (kh) bng chuynGlucose, chuyn di da lin tc Glucagon bng bm theo nhp khng lin tc.- Bnh nhn bphu thut ct ddy: Gio dc bnh nhn v thn nhn du hiu vcc xtr hng huyt.Glucagon v Glucose u trng lkun c sn nh.Chiau nhiu ba n. Gim loi ng hp thu nhanh. Thc n phi hp protide vglucide.

VIII. DPHNG+ Cn gio dc hglucose mu cng nhcch str hng mu cho bnh nhni tho ng v thn nhn ca h.

+ Xtr hglucose mu cn phi cp thi, ti chbng mi bin php c ththchin trc khi chuyn bnh nhn vo vin, khng nn chi kt qung mu.+ Lu tc dng hng huyt ca mt sthuc khi phi hp.

+ Trnh ttng ng l kth i bnh nhn i tho ng+ Phng chm KHNG N KHNG DNG THUC HNG HUYT, NUDNG THUC HNG HUYT BT BUC PHI N cn p dng cho tt c

bnh nhn i tho ng..


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BO PHMc tiu1. Trnh by c nh ngha, bnh nguyn v sinh l bnh ca bo ph

2. Trnh by c tiu chun chn on v phn loi bo ph

3. Triu chng, cc phng php nh gi bo ph4. Bit r cc bin chng ca bo ph5. Trnh by c tit thc, hot ng thlc v tp thdc gim bo ph

6. Trnh by c thuc iu trbo phNi dung

I.NH NGHA:c nhiu cch nh ngha1. Bo ph c nh ngha bng squ ti lng mcth, c bit lin quan nchuyn ha nng lng, ko theo hu quxu cho sc khe.2. Hoc gi l bo ph khi tng trn 25% trng lng cthv c nh gi da

vo kch thc v gii.3. i a sdng cng thc BMI nh gi mc bo ph. BMI t20-25kg/m2c xem l tt, qu ti trng lng khi BMI >27kg/m2 v theo phn loi hin nay,c quc tchp nhn, bo ph c nh ngha bng BMI (30 kg/ (m2). Tgi trny, ngi ta xem nhl stch mqu nhiu, bi v n ko theo mt sgia tngc ngha vbnh sut v tsut.

II. TN SUT:Bo ph cng ngy cng gia tng nht l cc nc pht trin kinhttrn thgii; c bit trong 10 nm li y, la tui gp cao nht l >30 tui. Tnsut bo ph phthuc vo tiu chun chn on. Tn sut bo ph thay i tutheotui, gii tnh v a d, chng tc, tnh trng kinh tx hi:

- Tui: 2% lc 6-7 tui, 7% tui dy th, v cao nht tui (50 (u M).- Gii: ngp nhiu hn nam (25% so 18%).

- a d, chng tc: min ng nc Php l 33%, min Ty 17%. Ti Nam Phi boph gp cc tnh pha Nam nhiu hn cc tnh pha Bc. Trong thp kqua, t lbo ph ca ton nc Mt25 - 33%, tng 1/3. Phnda en tui t45-55 tui ctlbo ph gp 2 ln so nda trng cng tui.

chu u, gn y khong chng 15 nghin cu dch tvsqu ti trong lng 17 nc ca chu u. S s dng tiu chun chn on khc nhau tu theonghin cu (BMI, hoc cng thc Lorentz, hoc cng thc Broca).-iu kin kinh, x hi c lin quan n chdinh dng, phong cch sng:

+ Trung Quc, s trem bo ph tng cao trong nhng nm gn y, do cnung chiu, n ung qu mc, tkhi c chtrng mi gia nh chc mt con;+ Singapore, trem bo ph ti cc trng tiu hc gia tng mt cch ng k.

+ Ti thnh phHCh Minh, do mc sng ngy cng cao, nn sbo ph tremcng nhngi ln gia tng.Nhng ngc li ti Mmc kinh tx hi thp th tn sut bo ph cao hn so vimc sng kinh tx hi cao.Nhng ngi ln bo ph c khong 50-100% nguy ccht sm so ngi c BMIkhong 20-25 kg/m2.


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Bng 1: Tn sut qu trng theo nhiu nghin cu khc nhau chu u.

Tn sut bo phNc v tui ngh/cu nh ngha qu trng

Nam N C2 gii

Bulgarie: 35-71 tui

an mch: 18-20 tui7 nc: 40-59 tui

- Bc u

- Nam u

-ngc

- Tyc

- H lan: 19-31 tui

- Rumani:15-65 tui

+ Thnh ph.

+ Thn qu-Thus: 31-40 tui

41-50 tui

>20% Broca

>20% Broca

>27 BMI

>27 BMI

>20% Broca

>20% Broca

>25% BMI

>20% TLLT

>25% Broca

10%

13%

23%

14%

16%

24%

25%

22%18%

28%

41%

14%

32%

41%

19%

III. BNH NGUYN1. Qu ti calo:Vphng din chuyn ho, bo ph do qu ti calo vt qu nhucu c th. Tuy nhin c skhc nhau tuc nhn trong sdng nng lng vnhu cu cvn. C bnh nhn n nhiu nhng khng bo, l do cn cha bit, vtrong mt gia nh, cng chdinh dng, nhng li c ngi gy kbo. iuny gi thng c ttnh di truyn vbo ph.

2.n nhiu:tc qu nhu cu cththng l nguyn nhn bo ph (95%). n nhiudo nhiu nguyn nhn:- Thi quen c tnh gia nh: gii thch thng gp nhiu ngi bo ph trong mt gianh, khng phthuc di truyn.- Bnh tm thn kinh.

- Gim hot ng thlc m khng gim n: gp ngi gi hoc t hot ng.3. Nguyn nhn di truyn:69% ngi bo ph c bhoc mbo ph; 18% cblnmu bo ph, chc 7% l c tin sgia nh khng ai bo ph.

Theo Mayer J. (1959) nu cb ln mu bnh thng th 7% con hsbbo

ph. Nu mt trong hai ngi bo ph th c 40% con hbbo ph. Nhng nu cbln mbbo ph th tlbo ph con l 80%.Phn nh gia vai tr ca di truyn thc sv vai tr ca dinh dng cn cha r.Di truyn c tnh tri v yu tdi truyn lm cho khnng phn chia tbo mddng hn.

4. Nguyn nhn ni tit:him- Hi chng Cushing: phn bmmt, c, bng, trong khi cc chi gy nh.- Cng insulin: do u ty tit insuline, tng n ngon, n nhiu v tn sinh m m,tng tiu glucid.- Gim hot tuyn gip: him, phi ch rng chuyn ho c bn c biu th

bng calori/m2 bmt da thng gim ngi bo ph. Tht vy, bmt da gia


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tng l do tng m m, l m t tiu thoxy. Tri li, trong phn ln cc trng hpbo ph khc, sgim chuyn ho cbn ny khng c ngun gc tuyn gip.- Hi chng bo ph-sinh dc (hi chng Froehlich hay Babinski-Froehlich): bo ph thn v gc chi v suy sinh dc, biu hiu thiu nin vi ngng pht dc cquan sinh dc, c thkm ri lon khc nhi tho nht, ri lon th lc v tm

thn. Theo A. Froehlich nguyn nhn do u vng di i.- Ngi b thin: m m tng quanh hng, phn cao ca i, ging nhhi chngbo ph-sinh dc- Ru l ngun quan trng ca nng lng.

5. Nguyn nhn do thucGn y, thuc c thm vo danh mc nguyn nhn ca cc yu tbo ph, biv gia tng dc liu php. Tng cn c thl sn phm ca cc hormone steroidesv 4 nhm chnh ca cc thuc kch thch tm thn:

- Khng trm cm cin (3 vng, 4 vng, c chIMAO).

- Benzodiazepine.- Lithium.

- Thuc chng lon thn.Vy gii hn sdng thuc kch thch tm thn kinh phng nga tng cn, c thlm gim liu php iu tr

IV. SINH L BNH1. Sphn bv tin trin ca khi m2 gii

tr


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Bo ph sc vt, di truyn hay gy nn bi thc nghim; cng nhbo ph ngi,thng ko theo tnh trng khng insulin phi hp tng insulin mu v viglucose mu bnh thng hoc tng. Skhng insulin ny tm thy trong thcnghim mc tbo ch chnh ca hormon, m c, m m. Trc ht m mcpha p ng bnh thng vi insulin trc khi insulin bkhng. Kiu din tin ny

ging nhau cbo ph di truyn v bo ph do n qu nhiu.- khng insulin bnh nhn bo ph: xem ssinh l bnh tbo ph

n khng insulin sau:

Bo ph

khng insulin

Gim bt giglucose mc tbo

gai on sau n

Gim sinh nhit do tit thc

Lm trm trng thm qu ti trng lng

Hnh 1: Ssinh l bnh tbo ph n khng insuline:

5. Tng chuyn ha cbn

ngi bo ph, khi lng gy (tc khi tht, ni hu nhc nht ca chuynha cbn) l cao r so vi khi lng gy ngi c trng lng bnh thng, vthngi bo ph c stiu thqu mc nng lng lin quan n chuyn hacn bn.

6. Gim sinh nhit do chtit thc:Sinh nhit do chtit thc ngi bo phthp hn ngi c trng lng bnh thng.

Hu quca hai sthay i nghch l ca chuyn ho nng lng cho thy rng ngi bo ph, stiu thnng lng ton thchmc trn rt t so vi stiuthnng lng ton thngi bnh thng.7. n nhiu:Tht vy, trong chng mc no , giai on cn bng trng lng,

nng lng a vo bng nng lng tiu th.8. Yu tdi truyn t tnh ca bo ph:1/3 bo ph do di truyn. Khng di truyn;truyn theo gia nh c stham gia ca yu tmi trng khong hn 1/3 trnghp. Th3 phn cn li l yu tmi trung khng lan truyn

9. Gne ca bo ph:Gene Leptin l mt loi protein, c m ho bng gene ob,chc trong m mtrng. Thiu protein ny sgy bt thng chuyn ho chut(bo ph, tng insulin, tng ng mu, gim thn nhit). Githuyt cho rng c lLeptin ngn cn thi n ung qua trm hypothalamus. Nhiu nghin cu cho thyleptin c m msn xut nhiu nht lc i v trong qu trnh Tthc nghim,v cng trli bnh thng trong vi gisau khi n hoc tim insulin. iu ny chothy rng Leptin tc ng nhmt tn hiu chn ngy.


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Mt khc, chut ob/ob, cho Leptin vo s lm gim trng lng ng k. Leptincng iu nh shp th thc n, ng mu, insulin mu. N lm tng chuynho ton th, nhit c thv mc hot ng th lc. Hn na, Leptin cng tcng trn con vt bnh thng v c thlm mt i 12% trng lng cthv tt cmca n trong vng 4 ngy.

bnh nhn bo ph, gne ob rt gia tng. Sgia tng ny tlvi trng lng cth. ng ch l gii ngii, Leptin c tit ra vi mc bsung iu hohormon. Nhvy r rng rng bo ph khng phi do Leptin bgim tng hp, cngkhng phi do Leptin bt thng. Theo Catherine Le Stunff v cs, ngi bo ph,Leptin tng 10 ln cao hn lng Leptin ngi bnh thng, v tlvi khi lngm. Sgia tng Leptin khng lm gim sngon ming ngi bo ph, nhng tiptc lm tng sn nhiu v cng lm tng trng, iu ny cng ccho l ll c skhng Leptin ngi bo ph.

V. TRIU CHNG:chyu da vo cc chsnh gi c bo ph hay khng1. Cng thc Lorentz tnh trng lng l tng (TLLT) ch yu da vo chiu

cao.TLLT (nam) = chiu cao - 100 -hoc TLLT (n) = chiu cao - 100 -Nu TLLT tng >25% l bo ph.Hoc IC = (TLHT/TLLT) (100%. (trng lng hin thc/trng lng l tng)

Nu IC = >120% - 130%:Tng cn qu mc

Nu IC = >130% bo ph.2. BMI:(Body Masse Index=Chskhi lng c th): Trng lng (kg)/chiu cao(m2).

- Theo Tchc quc tvbo ph (International Obesity Task Force) 1998

Tng trng khi BMI = 25 - 29,9; Bo ph khi BMI (30,0- Theo tiu chun chn on bo ph p dng cho ngi chu : bo ph khi BMI (25

3. o dy ca np da tam u: gia khong cch tci tay v vai, trung bnh16,5mm nam, 12,5mm n.

4. Bo ph c th khng c triu chng: hay c kh th gng sc, mt, kh chunng, ri lon tiu ho, thoi ho khp do qu ti cth(khp hng, i, ct sngtht lng).5. Ri lon chuyn ho lipide: tng lipoprotein (type VLDL, LDL).

6. Hu qutm thn kinh bo ph c thtrm trng:lo lng vi tng HA.

7. Gim dung np glucose mu, Tth2 (Hi chng chuyn ho).

8. Bo ph trm trng:gim thng kh phi (hi chng Pickwick), suy tim-phi.

VI. CC PHNG PHPNH GI BO PHC nhiu phng php nh gi m m (bo ph): phng php o nhn trc(anthropomtrique) lm sng, phng php mi bng hnh nh siu m, ngay cctlp c ttrng (tomodensitomtrique). Schn la gia cc phng php khc nhauny tuthuc vo ngcnh v mc tiu nghin cu hng n.

1. Phng php o nhn trc1.1. Chskhi lng c th (BMI). Kt qua nh nu trn phn triu chng.

1.2. Cng thc Lorentz: tnh trng lng l tng (TLLT), cng thc ny da votrng lng bnh nhn tnh bng kg v chiu cao tnh bng cm nh nu trn:


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1.3. dy ca np gp da: dy ca np gp da phn nh dy ca lp mdi da, c tho c bng mt compas Harpender hoc Holtane, c tay cmrng, c khc shng nh.Cch o: tay tri cm compas, ri kp np gp da thng ng gia ngn trv ngnci, thc scho bit dy ca np da.

o dy np gp da nhiu vtr khc nhau l cn thit: cc im quanh gc cnhtay v i, cnhu, tam u, trn bvai, trn xng chu, thng v, trung vvhv. Ngc li, ngii, np gp da vng i v hvl dy hn np gp da pha trn rn v cnh tay.V d: o dy ca np da tam u gia khong cch tci tay v vai, trungbnh 16,5mm nam, 12,5mm n1.4. Chsphn bmcc np gp da (Phng php nh gi phn bm m):nhiu ch s hoc phng php c a ra:o dy np gp da phn nhquan trng lp mdi da, cha ra 2 chsdo hn

- Chsm-cca Jean Vague

Chsm- ccnh tay - i (CSMCCT) gm dy np gp da quanh gc cnhtay v i, mc khc chu vi ca i cng c o cng ngang mc . CSMCCTcho php nh gi s lng sphn bm v cgia vng cDelta v ci,nhng khng lin quan trc tip n lp mbng.Gi trbnh thng ca CSMCCTnc trng lng bnh thng, l 0.76 - 0.8,v nam gii 1.01 - 1,10. Jean Vague c thnh ngha nhiu thkhc nhau vsphn bhypergynoide, gynoide, mixte, androide, hyperandroide.- Chsgia dy m m-cDelta v cmu chuyn (trochantrien): chsgiady m mvng Delta v pha sau mu chuyn l t nhy cm vi lp cbndi. 0,7 nam, v 0,3 n.

1.5.o chu viChsphn bkhi mphn chu vi

- Chscnh tay-i: o chu vi cnh tay v i phn gc l ddng thc hin.y l chsng tin cy o lng sphn bm. Tca chu vi cnh tay vichu vi ca i gc: 0,58 nam v 0,52 n.

- Vng bng/vng mng: ch s gia chu vi vng bng/vng mng c M.Ashwell a ra nh l mt chso lng ng tin cy vsphn bm. Trsbnh thng l 0,92 - 0,95 nam; 0,75 - 0,80 n. Bo ph nam khi VB/VM >0,95v n>0,80. Hoc theo ATP III, vng bng nam 88 cm

2. Siu m

dy ca m mnng c thc o trc tip chnh xc bng cch t u dthng gc vi mt da, khng p, ti im mun xc nh. Kthut c thphn bitr rng gii hn phn m, cv xng.

3. Chp ct lp ttrng

Phng php ny mi c p dng gn y nh gi sphn bm. N cth nh lng m phn b di da v quanh tng. T phn ct ngang cascanner, c thtnh c bmt chon chca m m. Li im ca phng phpny c thxc nh bmt m msu quanh tng. Phn ct ngang qua L4-L5 scho php phn bit chnh xc skhc nhau vphn bmgia 2 gii. Snh gibng phng php ny cho kt qung tin cy, chnh xc, tuy nhin gi k thut

t, dng cnng nkh thc hin cc tuyn thng thng.


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4. Impdance mtrie:o phn trm lng m ca c thhin c v lng m ltng da vo trng lng, chiu cao, gii, t tnh ra lng mqu ti l baonhiu phn trm.

VII. PHN LOI BO PH1. Phn loi theo tui:ngi ta c thphn bit 2 thbo ph:- Bo ph xy ra tui trng thnh: (thph i) stbo mcnh v tng trngl do tch tqu nhiu lipide trong mi tbo, iu trgim glucide l c hiu qu.- Bo ph tui tr: (thtng sn ph i) khng chcc tbo ph i m cn tng slng, kh iu tr.

2. Bo ph nam gii v ngii da theo sphn bmBo ph nam gii (androide): thng gp nht n ng, u thphn cao cth,trn rn, gy c, vai ngc, bng, bng trn rn.Bo ph ngii (gynoide): thng gp phn, u thbng di rn, hng, i,mng v cng chn.

Bo ph thng gp l bo ph androide phn.3. Phn loi da theo tvng bng/vng mng (VB/VM)o chu vi vng bng/vng mng v tr tr nh ni trong phn VI (cc phngphp nh gi bo ph). Bo ph nam khi VB/VM >0,90; bo ph nkhi VB/VM>0,85.

4. Da vo cng thc Lorentz

IC = (TLHT/TLLT) (100%. (trng lng hin thc/trng lng l tng)Nu >120% - 130%: tng cn qu mcNu >130%: bo ph.

5. Da theo chsBMIBng 2: Bng phn loi theo Tchc quc tvbo ph (International Obesity TaskForce)1998

Phn loi BMI (kg/ (m2). Nguy c

Gy

Bnh thng

Tng trng

Bo ph:

II

II

III

18,5

18,5 - 24,9

25 - 29,9

30.0

30,0 - 34,9

35,0 - 39,9

40

Tng va

Tng r

- Bo ph va hay chung

- Bo ph nng

- Bo ph qu mc hay bobnh

Hin nay p dng ph hp vi c im tng vng qua nghin cu thc tccquc gia chu , TCYTTG chnh thc ng cc quc gia chu ly tiu chunban hnh thng 2/2000 lm tiu chun chn on bnh bo ph.Bng 3: Tiu chun chn on bnh bo ph da vo BMI v so vng eo - p dngcho ngi trng thnh chu .

Yu tphi hp

Phn loi BMI (kg/m2) So vng eo: < 90cm (vi nam) (90cm

< 80cm (vi n) (80cm


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Gy < 18,5Thp (nhng l yu tnguycvi cc bnh khc).

Trung bnh

Bnh thng 18,5-22,9 Trung bnh C tng cn

Bo:

+ C nguy c+ Bo 1

+ Bo 2

23

23-24,925-29,9

>30

Tng cnBo va phi

Bo nhiu

Tng va phiBo nhiu

Qu bo

VIII. BIN CHNG CA BO PHNguy cca qu ti trng lng hay bo ph l gy nhiu bnh thm ch xut hinrt sm v gy tvong nhdo thuc l.Nhiu nghin cu cho thy rng c stng quan rt c ngha gia bo ph dngnam v

cc bin chng chuyn ho nhi tho ng, tng lipide mu, bnh sinh xva,

goute.1. Cc bin chng ca bo ph

Tng cn qu mc (120% - 130% so vi TLLT) Bo ph bnh l (>130% so vi TLLT)

Tnh trng chc nng suy yu Gim tui th

Tng huyt p Vn vchn on

i tho ng Tng nguy cphu thut

Bnh ng mch vnh Bt ng

Bnh ng mt Hi chng Pickwick

Bnh Gout Vim da bmtNgng thkhi ng

Nghn tnh mch su

Tc mch phi

Vim xng khp

Lot do p lc (tth)

N: K tcung, K v, K t sng, K bung trng

Nam: K i trng, K tin lit tuyn

2. Bin chng vchuyn hoChuyn ho glucide: c tnh trng khng insulin, tng tit insulin, pht hin quanghim php dung np glucose bng ng ung bri lon, ddn n bnh itho ng, v vy bo ph l mt yu tnguy cca i tho ng.Chuyn ho lipid: triglyceride huyt tng thng tng trong bo ph, tng VLDL. Stng lipoprotein c lin quan n ri lon chuyn ho glucid ni trn lm cho gan snxut nhiu VLDL hn. Cholesterol mu t khi nh hng trc tip bi bo ph; nhngnu c tng cholesterol trc th d lm tng LDL. HDL thng gim khi ctriglycerid tng.Chuyn ho acid uric: acid uric mu thng tng, c l c lin quan n tng

triglycerid mu. Cn ch n stng acid uric t ngt khi iu trnhm gim cn,c thgy cn Gout cp tnh (do thoi ging protid).


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Vai tr ca bo ph trong hi chng chuyn ho: c m ttrong hnh sau:

3. Bin chng tim mch:Bo ph l mt trong nhng yu tnguy ccho bnh l timmch nh

- Tng guyt p (THA): lin quan cht chgia bo ph v tng HA, tn sutTHA tng trong bo ph bt k nam hay n. Huyt p gim khi gim cn. C chtng HA trong bo ph cha r ht, ngoi x va ng mch hay gp, cn c githuyt do tng insuline mu v khng insuline, lm tng hp thu Natri ng thnv tng tit catecholamine lm co mch.

- Suy mch vnh: thng gp, ngay ckhi khng c thm cc yu tnguy ckhc nhT, tng lipide mu, tng HA.

- Cc bin chng khc nhsuy tim tri, tai bin mch mu no.

4. Bin chng phi

- Gim chc nng h hp do lng ngc di ng km do qu bo.- Hi chng Pickwick: ngng thkhi ng.- Tng hng cu, tng CO2mu.

5. Bin chng vxng khp

Ti cc khp chu lc cao (khp gi, khp hng, ct sng) dbau, thoi

khp.Tn sut hoi tthiu mu u xng i gia tng.Thot va m, trt t sng hay gpCc bin chng ny tng ln phnmn kinh.

6. Bin chng vni tit

- Tng insuline mu v khng insuline v T th 2, do tc dng bta-endorphine hoc gim s lng v cht lng insulin, kch thch tbo bta do nnhiu glucide.

- Chc nng ni tit sinh dc: gim khnng sinh sn. Chu kkinh ko di

khng phng non. Rm lng.7. Cc bin chng khc

BO PH

Acid bo t

khng Insulin

Glucose mu

i tho ng type 2

Bnh tim mch

TriglycerideHDL

Tng huyt p

Hnh 2: Vai t r o cu a be o ph t r ong hi ch ngchuyn hoa


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- Nguy cung thgia tng: ung thtcung, v, i trng, tin lit tuyn.

- Bin chng tng nng ln do bo ph:+ Gan mt: Si mt, gan nhim m.+ Thn: tc tnh mch thn, protein niu.

+ Sn khoa: nhim c thai nghn, sinh kh, mly thai tng.+ Da: rn da, nm k, tng sng ho gan bn chn, bn tay.

IX.IU TRM hnh iu trbo ph: da vo 3 phng cch chnh sau y:- Tit thc gim trng lng

- Tng nng lng tiu dng (Tp thdc).- Thay i chuyn ha thc n.Phng cch 1 v 2 bao hm tit thc v tp thdc.

1. Tit thc gim trng lng v tp thdc

Gim trng lng l mc tiu chnh iu tr, vi gim trng lng mc nht5%n 10% trng lng ban u, bng tit thc v tp thdc cng ci thin lm sngc ngha, ci thin c bnh tng HA, bt thng lipide cng nhglucose mu.Khong 80% bnh nhn T tp 2 c tng trng hoc bo ph, nu gim trnglng t5% n 10% th ci thin c ngha HbA1c.Theo Chng trinh TPhn Lan v Chng trnh Ngn nga bnh T chothy rng nhng bnh nhn c ri lon dung np glucose mu, nu gim trnglng chng 7% sgim c nguy cTtp 2 chng 58%.1.1. Tit thc gim trng lng

- Tit thc gim trng lng: l phng cch u tin v c p dng mt cch

rng ri. Cch thc chnh l tit thc gim calo, gim mv vi thc n khc c khnng gim sinh nng lng cho cth. Nu nng lng a vo thp hn nhu cusinh l, th nng lng thm vo l tm mdtr. Skhc bit ln gia nhu cua vo v nng lng l do si. Khi khng c thc n a vo, nng lngc rt ra tm mdtrl 1500-3000 kcal. Mcthcha 7500 kcal/kg. Vicn bng calo m tnh 1500 kcalo/ngy, th slm gim trng lng cth1 kg mi5 ngy. Lm gim trng lng khong t0,5-1 kg/tun l thch hp cho mt tit thcgim trng lng.i vi ngi ln tui va, 1200 kcalo/ngy duy tr mt > 0,5 kg/tun.Ni chung lng calo cho mi bnh nhn tt nht phi da vo cn nng hin ti.

Tit thc gim calo khi lng calo dng 20-25 Kcalo/kg/ngyNhvy nu lng calo cung cp gim di 500 Kcalo/mi ngy, th s lm gimmt trng lng khong 0,5kg/tun. Thnh cng iu trtuvo tui bnh nhn (boph thiu nin phi c iu trrt sm) v ng lc bnh nhn rt cn cho iu tr.i vi nhng bnh nhn c thi quen n nhiu, chp nhn hn chthc n trongsut cuc sng l rt kh khn.Tit thc t m, gim thc n giu-carbohydrat v tit thc mn khng bo hoci thin c bnh mch vnh. Nn dng nhiu tri cy, cc loi rau, v nhng loiton ht, giu cht x. Nn thay ththc n c cht dinh dng thp, giu calo bngnhng thc n c cht dinh dng cao, t nng lngtrnh cc bnh l tim mch, nn dng cc loi rau, tri cy, cc loi ton ht, cv cc thc n c chbin t mkm luyn tp thdc.


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Sau y l phng cch iu trnn ca Phng php iu tr thay i li sngvit tt l TLC (Therapeutic lifestyle Change) l mt chng trnh gm 12 tun thmkhm, sau l mi 2 tun trong vng 3 thng na c thay thmi 6 tun nhmt mc ch l Triglyceride, HDL-C v tt NPDNGU bnh thng. Mi ln thmkhm nh gi nng LDL-C, vng bng, trng lng, nh gi vic tun th tit

thc v tp luyn thdc ca bnh nhn.Bng 4: Thnh phn cht dinh dng trong tit thc iu trTLC

Cht dinh dng Nhu cu cn thit

Mbo ho < 7% calories ton th

Ma khng bo ho > 10% calories ton th

Mn khng bo ho >20% calories ton th

Mton th 25%-35% calories ton th

Carbohyddrate (ht, tri cy, rau) 50%-60% calories ton th

Cht x 20-30 gr/ngyProtin Ti a 15% calories ton th

Cholesterol < 200 mg/ngy

Tng cng calories ton th(kchotng thlc ti a 200 Kcal/ngy

Cn bng nng lng a vo v nnglng tiu dng duy tr mt trng lngthch hp/ngn chn tng cn

- Tit thc Cambridge (Cambridge diet)Cung cp y yu tvi lng, gim glucide hiu qu, gim cn kh tt, khng taibin

-iu trnhn iNguy him v phi cho nhp vin (bo ph kh iu tr). Nhn i gy dho

m mv protein. Gim natri v c thlm tn thng gan trm trng.1.2. Hot ng thlc v tp thdc

Hot ng thlc v tp thdc lm tng stiu dng nng lng, l iu trutin cho nhng bnh nhn qu ti v bo ph, c xem nh l yu tcha khotrong chng trnh gim trng lng.Mc ch tp luyn thlc nhm cc li im sau

1) Ci thin c ng mu.

2) Gim khng insulin, tng nhy cm insulin ngoi bin.3) Gim trng lng.4) Ci thin lipoprotein (gim triglycerid, cholesterol ton phn, LDL-

Cholesterol v VLDL, Tng HDL- Cholestrol), nn gim c xva ng mch.5) Tc dng c li trn tim mch (tng khnng ti a sdng oxy, lm chm

li nhp tim lc ngh ngi v lc gng sc, gim va phi HA, gim nguy c tcmch, v gim tsut do bnh mch vnh).

Trong hot ng thlc, tn stim khong 50% tn stim ti a. Tn stimti a c tnh theo cng thc sau: (220-tui)/2. V dbnh nhn 50 tui: 220 - 50= 170/pht, th tn stim cho php l 85 ln/pht.

6) Tng sc lc7) Lm gia tng tnh do dai


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Nh l mt chin lc gip ngi bo ph gim trng lng, d sao tpthdc l mt phng cch tuyt ho, Tp thdc tng tiu thnng lng cth,nhng cng ng thi tng ngon ming. i do 5 km lm tng tiu thnng lng200 calo. Thc cht, nu nng lng tiu dng khng tng, th lm gim trng rtkh khn bi v kh m duy tr sgim thc n a vo.

Nn gia tng hot ng th lc t t nh tp th dc 10-30 pht/ngy chon khi t 300 pht/tun.

Theo Surgeon Generals Report on Physical Activity and Health khuyn vimi la tui nn tp luyn th dc trung bnh l 30 pht/ngy nh chy nhanh 30pht, 3 ln/tun, tuy nhin gn y ngi ta khuyn tt hn l 60 pht/ngy.

Theo Bethesda nn tp thdc khong 2 gi ri/tun, n cm, v gimtrng lng l gim c tsutTti M.

Sau khi tp thdc xong, tc dng insulin tng v ko di nhiu gi. Dinh hng ca insulin, gan v cthu nhn glucose v ti dtrli glycogen.

Vn ng thlc thng l i b, p xe hay bi li..

t chy 100 calories (khong 10g cht bo) phi i b20 pht, bi hocnh tennis 12 pht, 8 pht p xe hoc chy b.

Tuy nhin, tp thdc khng lm tt c i vi ngi qu bo, di chuyncthnng nv v vy ra mhi ddng v thng au khp, ngoi ra bnh timmch nng cng hn chtp luynNhng cng c khng t trng hp, vi tit thc v tp thdc vn khng lm gimtrng lng v gi l bo khng cha tr c. V vy bo tr li c thng rtchung.y l l do ngi ta dng thuc v phu thut.

2. Thuc iu trbo ph

Sau 12 tun tit thc gim trng lng v tp luyn th dc m khng ci thinc trng lng th dng thuc.

2.1. Thuc iu ha th thadrnergique (Diethylpropion, Mazindol, Phentermine)hoc ththserotonine (Fenfluramine).

Tt ccc thuc u c tc dng ph, lm mt sn ngon ming, gim trng lng,nn chc dng sau khi cn nhc gia li v hi ca cch thc iu trny.Cc thuc ny dng phi hp c kt qu tt hn l dng n c, nh phi hpFenfluramine vi Phentermine (noradrenergique). Tuy nhin nm 1997 v c mttrng hp c biu hiu bnh van tim mt ph n, nn 1998 Fenfluramine vDexfenfluramine rt khi thtrng, chcn li Phentermine.

2.2. Thuc lm gia tng tiu thnng lngHormonee gip (nhm L-Thyroxin), nhng khng c tc ng thng xuyn, thngt dng v ko di gy c chchc nng tuyn gip hay nhim c gip.2.3. Thuc c tc dng bin i chuyn ha cht dinh dng:Thuc lm gim tiu ha thc n (c ch lipase) hoc bin i chuyn ha(androgen, estrogen, GH)

Hin nay c 2 loi thuc c UBan Thc phm v Dc phm Hoa K/FDA vTCYTTG ch chp thun dng gim cn ko di l Siburtramine (Meridia*,Reductil*) v Orlistat (Xenical*).

iu trbng Reductil (10mg/vin) c thgip gim (2 kg trong vng mt thng v

4,4-6,3 kg sau 6 thng, Reductil khng gy chn n, khng gy l thuc thuc mlm bnh nhn c cm gic mau no khin hn t hn, v vy thch hp cho nhng


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ngi lun c cm gic mau i v thm n nhiu, Reductil cng lm gim tVB/VM,gim lipide mu v glucose mu. Tc dng ngoi ca thuc l kh ming, to bn,au u nh, cm gic hi hp, tng nhp tim THA mt s ngi (him). Thntrng: khng dng cho ngi THA v c bnh mch vnh. CC: trem, mn cmvi thuc, c thai cho con b.

Siburtramine l loi c ch chn lc s ti thu gi c 2 loai serotonin vnorepinephrin, n lm gim ngng ngon ming (do tc dng trung ng lm chobnh nhn c cm gic no sm) v tng sinh nhit, gim vn tc bin dng, nngim trng lng.Orlistat, c ch lipase tu, gim hp thu rut. Tc dng ph l km hp thu m,gim cc viatmin du nhvitamin D v E, nn phi tng cng thm vitamin.


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2.4. Thuc lm mt sngon ming

Thi giantc dng

Liu lng v cch dng

Tc dng Noadrenergic

Benzphetamine 6-12 25-50mg trc n, 25-50mg/ngPhendimetrazine 5-12 35mg trc ba n hoc 105mg/ngy,

17.5-105mg/ng

Diethylpropion 4-6 25mg trc ba n, 25-75mg/ng

Mazindol 10 1-2mg lc i ng, 1-2mg/ng

Phentermine HCL 7-24 8mg hoc 15-37.5mg trc ba n, 15-37.5mg/ng

Phenylpropanolamine 25mg trc ba n, 25-75mg/ng

TC DNG SEROTONERGIC

Dexfenfluramine 11-30 15mg, 2ln/ng, 30mg/ng

Fenfluramine 11-30 20mg trc ba n, 60-120mg/ng

3. Phu thut:Ngoi l, chp dng bo ph qu trm trng, e dssng (>50%trng lng l tng bnh nhn < 40 - 50 tui.


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BASEDOWMc tiu1. Trnh by c nh ngha, cchbnh sinh v bnh nguyn ca bnh.

2. Nu c nhng triu chng lm sng v cn lm sng lin quan n bnh.

3. Bit cch chn on bnh Basedow.4. Trnh by c cch iu trbnh Basedow.5. Xtr c nhng bin chng chnh ca bnh

Ni dung

I.NH NGHABasedow l mt trong nhng bnh l cng gip thng gp trn lm sng vi ccbiu hin chnh: nhim c gip km bu gip ln lan ta, li mt v tn thng ngoi bin.Bnh Basedow mang nhiu tn gi khc nhau Bnh Graves. Bnh Parry. Bu gip

c lan ta. Bnh cng gip tmin. Nhstin bca min dch hc, ngy cngnhiu khng thhin din trong huyt tng ngi bnh c pht hin, v thhinnay bnh c xp vo nhm bnh lin quan tmin.

II. BNH NGUYNBnh xy ra mi tui, nht l tui 20 - 40 tui, u thphn, tlnam /n= 1/5 - 1/7 vng khng bbu ca phng. Tuy nhin, vng dch ttlny thp hn. Theo Volp c llin quan n skhim khuyt ca tbo lympho Tc ch, l yu tcbn trong bnh l tmin tuyn gip. Mt vi yu tghi nhnc thgy p ng min dch trong Basedow nh- Thai nghn nht l giai on chu sinh (hu sn)

- Dng nhiu iod, c bit dn csng trong vng thiu iod, c thiod lm khi phtbnh Basedow tim tng.- Dng lithium lm thay i p ng min dch.- Nhim trng v nhim virus.

- Ngng corticoid t ngt.- Ngi c HLA B8, DR3 (dn vng Caucase) HLA BW 46, B5 (Trung Quc) v HLAB17 (da en).

- Vai tr Stress cha c khng nh.- Lin quan di truyn vi 15% bnh nhn c ngi thn mc bnh tng t vkhong chng 50% ngi thn ca bnh nhn c t khng th khng gip trong

mu.III. BNH SINHC skhim khuyt ca tbo lympho T c ch(Ts, T8), cho php tbo lympho Thtr(T H) kch thch tbo lympho B tng hp cc khng thchng li tuyn gip.Globulin min dch kch thch tuyn gip (TSI: Thyroid stimulating immunoglobulinhoc TSH. R Ab (Stim): khng thkch thch ththTSH) gy tnh trng nhim cgip. Ngoi ra cn tm thy nhiu loi khn

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