{"id":19516,"date":"2023-04-17T20:06:25","date_gmt":"2023-04-17T13:06:25","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=19516"},"modified":"2023-04-18T11:58:19","modified_gmt":"2023-04-18T04:58:19","slug":"tiep-can-dieu-tri-viem-dai-trang-cap","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/04\/17\/tiep-can-dieu-tri-viem-dai-trang-cap\/","title":{"rendered":"Ti\u1ebfp c\u1eadn \u0111i\u1ec1u tr\u1ecb vi\u00eam \u0111\u1ea1i tr\u00e0ng c\u1ea5p"},"content":{"rendered":"

Ng\u01b0\u1eddi b\u1ec7nh c\u00f3 tri\u1ec7u ch\u1ee9ng ti\u00eau ch\u1ea3y, \u0111au qu\u1eb7n b\u1ee5ng, m\u00f3t, \u0111i ti\u00eau nhi\u1ec1u l\u1ea7n v\u00e0 ti\u00eau ph\u00e2n \u0111\u00e0m m\u00e1u n\u00ean \u0111\u01b0\u1ee3c nghi ng\u1edd m\u1eafc vi\u00eam \u0111\u1ea1i tr\u00e0ng. Ch\u1ea9n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh vi\u00eam \u0111\u1ea1i tr\u00e0ng<\/a> khi th\u1ea5y h\u00ecnh \u1ea3nh vi\u00eam lan t\u1ecfa \u0111\u1ea1i tr\u00e0ng tr\u00ean n\u1ed9i soi.\u00a0 Trong vi\u00eam \u0111\u1ea1i tr\u00e0ng c\u1ea5p (ti\u00eau ch\u1ea3y \u226414 ng\u00e0y), nguy\u00ean nh\u00e2n nhi\u1ec5m tr\u00f9ng th\u01b0\u1eddng g\u1eb7p nh\u1ea5t \u0111\u1eb7c bi\u1ec7t l\u00e0 vi khu\u1ea9n. Trong vi\u00eam \u0111\u1ea1i tr\u00e0ng m\u1ea1n (k\u00e9o d\u00e0i >30 ng\u00e0y), c\u00e1c b\u1ec7nh l\u00fd ru\u1ed9t vi\u00eam t\u1ef1 mi\u1ec5n th\u01b0\u1eddng g\u1eb7p h\u01a1n m\u00e0 d\u00f9 ch\u01b0a lo\u1ea1i tr\u1eeb vi\u00eam \u0111\u1ea1i tr\u00e0ng do C.difficile <\/em>t\u00e1i ph\u00e1t.<\/strong><\/p>\n

 <\/p>\n

1. Ti\u1ebfp c\u1eadn b\u1ec7nh nh\u00e2n vi\u00eam \u0111\u1ea1i tr\u00e0ng c\u1ea5p.<\/strong><\/h2>\n

\u00a0<\/strong>Khai th\u00e1c ti\u1ec1n s\u1eed, b\u1ec7nh s\u1eed to\u00e0n di\u1ec7n bao g\u1ed3m: \u0111i\u1ec1u tr\u1ecb li\u1ec7u ph\u00e1p mi\u1ec5n d\u1ecbch, h\u00f3a tr\u1ecb li\u1ec7u ho\u1eb7c kh\u00e1ng sinh g\u1ea7n \u0111\u00e2y; ho\u1eb7c ti\u1ec1n s\u1eed suy gi\u1ea3m mi\u1ec5n d\u1ecbch\/HIV, du l\u1ecbch qu\u1ed1c t\u1ebf, m\u1edbi nh\u1eadp vi\u1ec7n g\u1ea7n \u0111\u00e2y ho\u1eb7c ph\u01a1i nhi\u1ec5m v\u1edbi th\u1ef1c ph\u1ea9n\/n\u01b0\u1edbc ch\u1ee9a m\u1ea7m b\u1ec7nh, ti\u1ebfp x\u00fac \u0111\u1ed9ng v\u1eadt hoang d\u00e3.<\/p>\n

B\u1ec7nh nh\u00e2n c\u00f3 bi\u1ec3u hi\u1ec7n vi\u00eam \u0111\u1ea1i tr\u00e0ng, d\u1ef1a tr\u00ean m\u1ed9t trong c\u00e1c \u0111\u1eb7c \u0111i\u1ec3m sau \u0111\u00e2y: (1) h\u1ed9i ch\u1ee9ng l\u1ef5 (ti\u00eau ph\u00e2n \u0111\u00e0m m\u00e1u), (2) n\u1ed9i soi th\u1ea5y h\u00ecnh \u1ea3nh vi\u00eam lan t\u1ecfa \u0111\u1ea1i tr\u00e0ng, (3) h\u00ecnh \u1ea3nh d\u00e0y th\u00e0nh ni\u00eam m\u1ea1c tr\u00ean CT scan, (4) b\u1ea1ch c\u1ea7u ho\u1eb7c t\u0103ng c\u00e1c marker vi\u00eam trong ph\u00e2n nh\u01b0 calprotectin, lactoferrrin. Khi \u0111\u00f3, g\u1ee3i \u00fd nguy\u00ean nh\u00e2n khi ng\u01b0\u1eddi b\u1ec7nh c\u00f3 c\u00e1c y\u1ebfu t\u1ed1 sau:<\/p>\n

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  • B\u1ec7nh nh\u00e2n vi\u00eam \u0111\u1ea1i tr\u00e0ng c\u1ea5p m\u1edbi ho\u1eb7c \u0111ang \u0111i\u1ec1u tr\u1ecb li\u1ec7u ph\u00e1p mi\u1ec5n d\u1ecbch g\u1ea7n \u0111\u00e2y, vi\u00eam \u0111\u1ea1i tr\u00e0ng do mi\u1ec5n d\u1ecbch n\u00ean \u0111\u01b0\u1ee3c nghi ng\u1edd.<\/li>\n
  • Ng\u01b0\u1eddi b\u1ec7nh suy gi\u1ea3m mi\u1ec5n d\u1ecbch c\u00f3 ti\u00eau ch\u1ea3y, s\u1ed1t, gi\u1ea3m b\u1ea1ch c\u1ea7u h\u1ea1t trong v\u00f2ng 2 \u2013 3 tu\u1ea7n sau h\u00f3a tr\u1ecb c\u1ea7n ngh\u0129 nhi\u1ec1u vi\u00eam \u0111\u1ea1i tr\u00e0ng do gi\u1ea3m b\u1ea1ch c\u1ea7u h\u1ea1t.<\/li>\n
  • B\u1ec7nh nh\u00e2n m\u1edbi \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh ph\u1ed5 r\u1ed9ng (ph\u1ed5 tr\u00ean gram \u00e2m) g\u1ea7n \u0111\u00e2y ho\u1eb7c nh\u1eadp vi\u1ec7n c\u1ea7n ngh\u0129 \u0111\u1ebfn C.difficile.<\/li>\n
  • Du l\u1ecbch \u0111\u1ebfn c\u00e1c n\u01b0\u1edbc \u0111ang ph\u00e1t tri\u1ec3n: c\u1ea7n ngh\u0129 \u0111\u1ebfn c\u00e1c t\u00e1c nh\u00e2n g\u00e2y ti\u00eau ch\u1ea3y x\u00e2m nh\u1eadp; c\u00e2n nh\u1eafc \u0111i\u1ec1u tr\u1ecb Azithromycin 1g li\u1ec1u duy nh\u1ea5t, n\u1ebfu kh\u00f4ng \u0111\u00e1p \u1ee9ng ti\u1ebfp c\u1eadn h\u01b0\u1edbng ti\u1ebfp theo.<\/li>\n
  • Kh\u00f4ng c\u00f3 nguy\u00ean nh\u00e2n g\u1ee3i \u00fd: t\u1ea7m so\u00e1t t\u00e1c nh\u00e2n b\u1eb1ng PCR \u0111a m\u1ed3i t\u00ecm vi khu\u1ea9n v\u00e0 k\u00ed sinh tr\u00f9ng r\u1ed3i \u0111i\u1ec1u tr\u1ecb theo nguy\u00ean nh\u00e2n.<\/li>\n<\/ul>\n

    \u0110a s\u1ed1 nguy\u00ean nh\u00e2n c\u1ee7a vi\u00eam \u0111\u1ea1i tr\u00e0ng c\u1ea5p l\u00e0 do nhi\u1ec5m khu\u1ea9n. G\u1ed3m 2 nh\u00f3m ch\u00ednh: vi khu\u1ea9n v\u00e0 k\u00ed sinh tr\u00f9ng (E.histolytica, B. coli v\u00e0 strongyloidiasis). H\u1ecfi b\u1ec7nh s\u1eed, ti\u1ec1n s\u1eed v\u00e0 th\u0103m kh\u00e1m l\u00e2m s\u00e0ng \u0111\u1ec3 \u0111\u1ecbnh h\u01b0\u1edbng m\u1ed9t s\u1ed1 t\u00e1c nh\u00e2n sau \u0111\u00e2y.<\/p>\n

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    • Campylobacter spp. Nguy\u00ean nh\u00e2n ti\u00eau ch\u1ea3y nhi\u1ec5m tr\u00f9ng h\u00e0ng \u0111\u1ea7u tr\u00ean to\u00e0n c\u1ea7u. Ngu\u1ed3n nhi\u1ec5m ch\u00ednh t\u1eeb th\u1ef1c ph\u1ea9m kh\u00f4ng n\u1ea5u ch\u00edn k\u0129, s\u1eefa v\u00e0 n\u01b0\u1edbc u\u1ed1ng ch\u01b0a ti\u1ec7t tr\u00f9ng\/nhi\u1ec5m khu\u1ea9n ho\u1eb7c ti\u1ebfp x\u00fac v\u1edbi \u0111\u1ed9ng v\u1eadt. Th\u01b0\u1eddng g\u1eb7p v\u00e0o m\u00f9a h\u00e8 c\u00e1c c\u00e1c \u0111\u1ed1i t\u01b0\u1ee3ng du l\u1ecbch qu\u1ed1c t\u1ebf. C. jejuni th\u01b0\u1eddng g\u1eb7p \u1edf c\u00e1c n\u01b0\u1edbc ph\u00e1t tri\u1ec3n. Giai \u0111o\u1ea1n \u1ee7 b\u1ec7nh ng\u1eafn. L\u00e2m s\u00e0ng: h\u1ed9i ch\u1ee9ng l\u1ef5 th\u01b0\u1eddng k\u00e8m s\u1ed1t v\u00e0 \u0111au b\u1ee5ng quanh r\u1ed1n lan h\u1ed1 ch\u1eadu ph\u1ea3i, \u0111\u00f4i khi c\u00f3 n\u00f4n. Bi\u1ebfn ch\u1ee9ng: nhi\u1ec5m tr\u00f9ng huy\u1ebft, h\u1ed9i ch\u1ee9ng ru\u1ed9t k\u00edch th\u00edch (9-13%), vi\u00eam kh\u1edbp ph\u1ea3n \u1ee9ng (2 \u2013 5%), h\u1ed9i ch\u1ee9ng Guillain Barre (0.1%). Test: PCR \u0111a m\u1ed3i, ELISA t\u00ecm kh\u00e1ng nguy\u00ean Campylobacter, c\u1ea5y ph\u00e2n.<\/li>\n
    • Nontyphoidal Salmonella spp. Ngu\u1ed3n nhi\u1ec5m t\u1eeb th\u1ef1c ph\u1ea9m. L\u00e2m s\u00e0ng: ti\u00eau ph\u00e2n \u0111\u00e0m m\u00e1u (50%), th\u01b0\u1eddng k\u00e8m s\u1ed1t, \u0111au qu\u1eb7n b\u1ee5ng v\u00e0 \u0111\u00f4i khi n\u00f4n. C\u00f3 th\u1ec3 t\u1ef1 kh\u1ecfi \u1edf c\u01a1 \u0111\u1ecba mi\u1ec5n d\u1ecbch t\u1ed1t. Y\u1ebfu t\u1ed1 nguy c\u01a1 nhi\u1ec5m tr\u00f9ng huy\u1ebft nh\u01b0: tu\u1ed5i >65, suy gi\u1ea3m mi\u1ec5n d\u1ecbch, HIV, s\u1ed1t r\u00e9t. Ch\u1ea9n \u0111o\u00e1n: PCR, c\u1ea5y ph\u00e2n.<\/li>\n
    • Shigella spp. Ch\u1ee7 y\u1ebfu l\u00e2y t\u1eeb ng\u01b0\u1eddi qua ng\u01b0\u1eddi (\u0111\u01b0\u1eddng ph\u00e2n mi\u1ec7ng), \u0111\u00f4i khi c\u00f3 v\u1ee5 d\u1ecbch do th\u1ef1c ph\u1ea9m nhi\u1ec5m. Ch\u1ee7ng \u0111a kh\u00e1ng th\u01b0\u1eddng g\u1eb7p \u1edf nh\u00f3m men sex men. L\u00e2m s\u00e0ng: h\u1ed9i ch\u1ee9ng l\u1ef5 n\u1eb7ng (30 \u2013 50%), ti\u00eau ph\u00e2n 10 \u2013 20 l\u1ea7n\/ng\u00e0y th\u01b0\u1eddng k\u00e8m s\u1ed1t, \u0111au qu\u1eb7n b\u1ee5ng, m\u00f3t r\u1eb7n, \u0111\u00f4i khi n\u00f4n. Nhi\u1ec5m tr\u00f9ng huy\u1ebft hi\u1ebfm, c\u00f3 th\u1ec3 x\u1ea3y ra \u1edf ng\u01b0\u1eddi cao tu\u1ed5i nhi\u1ec1u b\u1ec7nh n\u1ec1n. X\u00e9t nghi\u1ec7m: PCR, ELISA t\u00ecm kh\u00e1ng nguy\u00ean, c\u1ea5y ph\u00e2n.<\/li>\n
    • coli ti\u1ebft \u0111\u1ed9c t\u1ed1 Shiga: trong c\u00e1c v\u1ee5 d\u1ecbch do nhi\u1ec5m th\u1ef1c ph\u1ea9m, l\u00e2y ng\u01b0\u1eddi qua ng\u01b0\u1eddi v\u00e0 t\u1eeb \u0111\u1ed9ng v\u1eadt. L\u00e2m s\u00e0ng: ti\u1ec3u ch\u1ea3y l\u1ecfng n\u01b0\u1edbc d\u1ea7n chuy\u1ec3n c\u00f3 m\u00e1u k\u00e8m s\u1ed1t nh\u1eb9 ho\u1eb7c kh\u00f4ng, n\u00f4n (50%), \u0111au b\u1ee5ng. H\u1ed9i ch\u1ee9ng t\u00e1n huy\u1ebft ure m\u00e1u cao g\u1eb7p \u1edf ng\u01b0\u1eddi cao tu\u1ed5i, suy gi\u1ea3m mi\u1ec5n d\u1ecbch v\u00e0 tr\u1ebb em. Ti\u00eau ph\u00e2n m\u00e1u th\u01b0\u1eddng g\u1eb7p \u1edf ch\u1ee7ng O157:H7. Ch\u1ea9n \u0111o\u00e1n: PCR, ELISA t\u00ecm \u0111\u1ed9c t\u1ed1 shiga, c\u1ea5y ph\u00e2n (th\u1ea1ch MacConkey).<\/li>\n
    • coli x\u00e2m nh\u1eadp. L\u00e2m s\u00e0ng: h\u1ed9i ch\u1ee9ng l\u1ef5 gi\u1ed1ng shigella th\u01b0\u1eddng g\u1eb7p n\u00f4n, bu\u1ed3n n\u00f4n, s\u1ed1t v\u00e0 \u0111au qu\u1eb7n b\u1ee5ng.<\/li>\n
    • difficile. Y\u1ebfu t\u1ed1 nguy c\u01a1: s\u1eed d\u1ee5ng kh\u00e1ng sinh g\u1ea7n \u0111\u00e2y, tu\u1ed5i >65, nhi\u1ec1u b\u1ec7nh n\u1ec1n, nh\u1eadp vi\u1ec7n, suy gi\u1ea3m mi\u1ec5n d\u1ecbch, b\u1ec7nh l\u00fd ru\u1ed9t vi\u00eam, b\u1ec7nh th\u1eadn, d\u00f9ng PPI. L\u00e2m s\u00e0ng: ti\u00eau l\u1ecfng n\u01b0\u1edbc nhi\u1ec1u l\u1ea7n (10 \u2013 12 l\u1ea7n\/ng\u00e0y) c\u00f3 th\u1ec3 c\u00f3 m\u00e1u, \u0111au qu\u1eb7n b\u1ee5ng, n\u00f4n, m\u00f3t r\u1eb7n, s\u1ed1t nh\u1eb9, ch\u00e1n \u0103n, s\u1ee5t c\u00e2n.<\/li>\n
    • Entamoeba histolytica. Ch\u1ee7 y\u1ebfu l\u00e2y qua th\u1ef1c ph\u1ea9m, \u0111\u01b0\u1eddng ph\u00e2n mi\u1ec7ng. Nhi\u1ec1u \u1edf c\u00e1c n\u01b0\u1edbc \u0111ang ph\u00e1t tri\u1ec3n. L\u00e2m s\u00e0ng: h\u1ed9i ch\u1ee9ng l\u1ef5, \u0111au b\u1ee5ng, s\u1ed1t (38%), s\u1ee5t c\u00e2n (50%). C\u00f3 th\u1ec3 g\u00e2y nhi\u1ec5m ngo\u00e0i ru\u1ed9t (10%) \u1edf ng\u01b0\u1eddi suy gi\u1ea3m mi\u1ec5n d\u1ecbch, d\u00f9ng corticosteroid, ung th\u01b0, suy dinh d\u01b0\u1ee1ng, nghi\u1ec7n r\u01b0\u1ee3u. Ch\u1ea9n \u0111o\u00e1n: PCR \u0111a m\u1ed3i, ELISA t\u00ecm kh\u00e1ng nguy\u00ean.<\/li>\n<\/ul>\n

      2. Ch\u1ea9n \u0111o\u00e1n.<\/strong><\/h2>\n
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      • Khai th\u00e1c \u0111\u1eb7c \u0111i\u1ec3m l\u00e2m s\u00e0ng g\u1ee3i \u00fd c\u00e1c t\u00e1c nh\u00e2n n\u00eau tr\u00ean.<\/li>\n
      • Vi\u00eam \u0111\u1ea1i tr\u00e0ng c\u00f3 h\u1ed9i ch\u1ee9ng l\u1ef5 do vi khu\u1ea9n x\u00e2m nh\u1eadp th\u01b0\u1eddng k\u00e8m s\u1ed1t, \u0111au qu\u1eb7n b\u1ee5ng. Yersinia v\u00e0 Campylobacter th\u01b0\u1eddng khu tr\u00fa v\u00f9ng h\u1ed3i manh tr\u00e0ng (\u0111au b\u1ee5ng h\u1ed1 ch\u1eadu ph\u1ea3i) gi\u1ed1ng vi\u00eam ru\u1ed9t th\u1eeba. Nhi\u1ec5m STEC th\u01b0\u1eddng ti\u00eau l\u1ecfng n\u01b0\u1edbc chuy\u1ec3n ti\u00eau m\u00e1u.<\/li>\n
      • X\u00e9t nghi\u1ec7m: PCR \u0111a m\u1ed3i, ELISA, c\u1ea5y ph\u00e2n, n\u1ed9i soi \u0111\u1ea1i tr\u00e0ng.<\/li>\n<\/ul>\n

        3. Ti\u1ebfp c\u1eadn \u0111i\u1ec1u tr\u1ecb theo nguy\u00ean nh\u00e2n.<\/strong><\/h2>\n

        \u0110i\u1ec1u tr\u1ecb theo t\u00e1c nh\u00e2n.<\/strong><\/p>\n

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        • Campylobacter spp. Azithromycin 500mg 1 l\u1ea7n\/ng\u00e0y 3 \u2013 5 ng\u00e0y.<\/li>\n
        • Nontyphoidal Salmonella spp. Ciprofloxacin ho\u1eb7c levofloxacin 500mg 1 l\u1ea7n\/ng\u00e0y 7 \u2013 14 ng\u00e0y \u1edf ng\u01b0\u1eddi suy gi\u1ea3m mi\u1ec5n d\u1ecbch. Thay th\u1ebf: Azithromycin 500\/d, 3-5d. Nhi\u1ec5m tr\u00f9ng huy\u1ebft: Cefixime 200mg 2 l\u1ea7n\/ng\u00e0y 7 ng\u00e0y ho\u1eb7c ceftriaxone 1 \u2013 2g\/d, 7 \u2013 10d.<\/li>\n
        • Shigella spp. Ciprofloxacin 500mg 2 l\u1ea7n\/d, 3d. Thay th\u1ebf: azithromycin 500mg\/d, 3d; Cefixime 400mg\/d ho\u1eb7c ceftriaxone 1g\/d, 3d.<\/li>\n
        • coli ti\u1ebft shiga. Kh\u00f4ng khuy\u1ebfn c\u00e1o d\u00f9ng kh\u00e1ng sinh.<\/li>\n
        • difficile. Vancomycin 125mg, 4 l\u1ea7n\/d, 10 \u2013 14 ng\u00e0y ho\u1eb7c fidaxomicin 200mg 2 l\u1ea7n\/d, 10d. C\u00f3 bi\u1ebfn ch\u1ee9ng: metronidazone 500mg x3\/d, IV.<\/li>\n
        • coli x\u00e2m nh\u1eadp, Yersinia enterocolitica, Aeromonas spp, P. shigelloides t\u01b0\u01a1ng t\u1ef1 shigella.<\/li>\n
        • Nonchelera Vibrio spp. Doxycycline 100mg 2 l\u1ea7n\/d trong 5d ho\u1eb7c ciprofloxacin 750mg 2 l\u1ea7n\/ng\u00e0y trong 3 ng\u00e0y. Nhi\u1ec5m tr\u00f9ng huy\u1ebft: Doxycycline ho\u1eb7c ciprofloxacine + cefotaxime 2g IV 3 l\u1ea7n\/d ho\u1eb7c ceftriaxone 1 \u2013 2g\/d, 7 \u2013 10 ng\u00e0y.<\/li>\n
        • histolytica. Metronidazole 750mg 3 l\u1ea7n\/d, trong 5 ng\u00e0y. Sau \u0111\u00f3 Diloxanide furoate 500mg x3x10 ng\u00e0y ho\u1eb7c paromomycin 25 \u2013 35mg\/kg chia 3 li\u1ec1u 5 \u2013 10d.<\/li>\n
        • Schistosoma mansoni. Praziquantil 40mg\/kg 1 li\u1ec1u.<\/li>\n
        • Cytomegalovirus: Ganciclovir 5 mg\/kg IV 2 l\u1ea7n\/d, 14 d ho\u1eb7c u\u1ed1ng Valganciclovir 900 mg 2 l\u1ea7n\/ng\u00e0y 21d.<\/li>\n<\/ul>\n

           <\/p>\n

          T\u00e0i li\u1ec7u tham kh\u1ea3o:<\/p>\n

          Iqbal, Tehseen; DuPont, Herbert L. Approach to the patient with infectious colitis: clinical features, work-up and treatment. Current Opinion in Gastroenterology 37(1):p 66-75, January 2021.<\/p>\n

           <\/p>\n

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