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9/6/2010 20:53:23
Bệnh bướu giáp đơn thuần
(Yduocvn.com) - Bệnh bướu giáp đơn thuần

Bướu giáp đơn thuần là tình trạng bệnh lý về hình thái tuyến giáp thay đổi. kích thước tuyến to lên toàn bộ hoặc một phần mà chức năng giáp không hề thay đổi. Đây không phảI là một bệnh nhiễm trùng, cũng không phải là ung thư .

1. Nguyên nhân và cơ chế bệnh sinh.

      Thiếu iod cho nhu cầu của cơ thể

 + Thiếu iod từ nguồn dinh dưỡng: Thức ăn, nước uống vv… dẫn đến tuyến giáp phì đại ( Bướu giáp địa phưong)

+ Giảm chức năngchuyển hoá và hấp thu iod. điều kiện kinh tế- xã hội kém, ngoài ra còn có các yếu tố thể địa, chủng tộc,giới tính cũng ảnh hương đến hệ men chuyển hoá iod

1.2. Rối loạn tự miễn dịch . Người ta phát hiện thấy có nhiêu tự kháng thể kháng tuyến giáp ở bệnh nhân bướu cổ.

2. Giải phẫu bệnh lý.

2.1 Bướu giáp

+ vị trí: bướu ở 1thuỳ hoặc cả 2 thuỳ tuyến giáp, cũng có khi nằm lạc chỗ sau xương ức hoặc trong lồng ngực

+ Hình thái:

-    Thể nhân: Nhu mô (Adenome) keo hoặc nang.

-    Thể lan toả : nhu mô hoặc keo

-    Thể hỗn hợp. Nhiều nhân nhỏ lẫn vói lan toả tuyến.

2.2 Tổ chức quanh bướu khi bướu giáp to ra có thể chin ép vào cáctổ chức xung quanh như khí quản, thực quản, thần kinh X, dây thần kinh quặt ngược, bó mạch cảnh. . .

3. Lâm sàng

+ Các hình thái bướu giáp rất đa dạng về kích thước và vị trí . cần xác định thêm khả năng di động, dính vào da ,đau khi sờ nắn, nghe có tiếng thổi để phân biệt bướu đơn thuần hay bướu độc

+ Các triệu chưng chin ép:

-    khó thở,thở rít khi bướu chin vào khí quản

-    chèn ép vào thực quản : Khó nuốt, nuốt vướng

-    Chèn ép thần kinh : nói khàn, nấc

-    Chèn ép mạch máu: tĩnh mạch cổ nông nổi to

4. Cận lâm sàng

 + Các xét nghiệm sinh hoá máu và thăm dò chức năng tuyến giáp đều ở giới hạn bình thường

+ Các thăm khám về hình tháI tuyến giáp cho biết vị trí, kích thước,khối lượng, mức độ chèn ép các cơ quan xung quanh tuyến

-                         Siêu âm tuyến giáp

-                         Chụp xạ hình tuyến giáp ( ít áp dụng )

+ Các xét nghiệm tế bào học như chọc sinh thiết tuyến hoặc nang tuyến cho phép chẩn đoán phân biệt với ung thư giáp và một số bệnh viêm tuyến giáp

5. Chẩn đoán

5.1 Chẩn đoán xác định dựa vào :

-  Có bướu giáp

-  Mọi xét nghiêm vè chức năng tuyến giáp đều bình thường

5.2 Chẩn đoán phân biệt

+ Với các bệnh của tuyến giáp

-    Bệnh Basedow

-    Ung thư tuyến giáp

-    Các bệnh viêm tuyến giáp

-    U độc tuyến giáp

+  Với các bệnh khác ở vùng cổ

-    Các nang bẩm sinh ở vùng cổ như nang mang, nang giáp móng

-    Hạch vùng cổ ;Lymphosarcom,Hodgkin,

-    Một số hình tháI bệnh giả u như phồng động mạch, phồng tĩnh mạch cảnh.

6. Phân loại

      Theo hoàn cảnh phát sinh:

-    Bướu cổ địa phương ( có trên 10% dân số bị bệnh bướu cổ )

-    Bướu cổ dịch tễ

-    Bướu cổ tản mát

6.2  Theo vị trí

-   Bướu cổ ở vị trí bình thường

-   Bướu cổ lạc chỗ

-   Bướu chìm sau xương ức hoặc trong lồng ngực

6.3  Theo hình thái đại thể

- Bướu cổ thể nhân

- Bướu cổ lan toả

_  Bướu cổ hỗn hợp

            Theo độ lớn

-    Độ 1 : Nhìn khó phát hiện, sờ nắn kỹ mới thấy

-    Độ 2: Nhìn và sờ nắn thấy rõ

-    Độ 3: Bướu đã lồi ra khỏi vùng cổ, sờ nắn có thể xác định được kích thước

-    Độ 4: Bướu to làm biến dạng vùng cổ, lấn ra quá bờ trước của xương ức.

-    Độ 5: Bướu quá to, bướu khổng lồ

7. Tiến triển và biến chứng

            Tiến triển

 Nếu không được điều trị kịp thời, bướu sẽ to dần ra và có thể chin ép vào các cơ quan lân cận và các biến chứng tại bướu

7.2 Các biến chứng

-  Chèn ép gây khó nuốt, nói khàn

- Biến chứng tại bướu: Chảy máu trong bướu, viêmbội nhiễm, ung thư hoá, Basedow hoá

8. Điều trị

8.1 Nội khoa

+ Cách tiến hành: Mỗi tháng uống thuốc 20 ngày, nghỉ 10 ngày liên tục 6-12 tháng. Các thuốc thường dùng là:

-    Thyreoidine 50-200mg/ngày

-    Dung dịch lugol 1% 1- 2mg / ngày

+ Kết quả: Với bướu cổ lan toả độ 1,2 tỷ lệ khỏi có thể đến 60% . Với các loại bướu nhân, bướu hỗn hợp điêuù trị nội khoa ít kết quả

8.2 Ngoại khoa

+ Chỉ định mổ

-    Bướu cổ thể nhân, thể hỗn hợp có chỉ định mổ sớm

-    Bướu cổ có biến chứng : Chèn ép khó nuốt, nói khàn ; Có trường hợp phảI mổ cấp cứu như chảy máu trong nang gây chin ép cấp tính vùng cổ

-    Bướu cổ lạc chỗ, bướu cổ chìm , bướu trong lồng ngực cần mổ sớm để tránh biến chứng chèn ép và ung thư hoá

-    Bướu cổ lan toả quá to có chỉ định mổ tương đối

-    Bướu cổ lan toả độ 1,2 ; bướu cổ ở tuổi dây thì không có chỉ định mổ. Bướu cổ ở trẻ em cần thận trong khi chỉ định mổ vì dễ bị nhược giáp sau mổ

+ Các phương pháp mổ

-    Cắt nhân cùng với một phần tuyến lành

-    Cắt một thuỳ tuyến giáp nếu bướu chiếm hết cả thuỳ

-    Cắt gần hoàn toàn tuyến giáp ( để lại chừng 30-35g nhu mô giáp lành) với bướu hỗn hợp  hoặc lan toả

+ Các biến chứng sau mổ

-    Chảy máu

-    Tổn thương thần kinh quặt ngược

-    Tetani

-    Suy hô hấp cấp do xẹp khí quản

-    Nhược giáp sau mổ

Nhiễm trùng vết mổ ; rò vết mổ lâu liền; sẹo co kéo

 

 

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