Hướng dẫn chẩn đoán điều trị bệnh tiêu chảy cấp tính

Chăm sóc bệnh nhân tiêu chảy cấpĐể giúp cộng đồng có thêm kiến thức phòng chống dịch bệnh tiêu chảy cấp tính đang diễn biến phức tạp chúng tôi trích đăng: Hướng dẫn chẩn đoán điều trị bệnh tiêu chảy cấp của Bộ Y tế.

I. CHẨN ĐOÁN
1. Chẩn đoán xác định
a) Lâm sàng
- Thời kỳ ủ bệnh: Từ vài giờ đến 5 ngày.
- Thời kỳ khởi phát: Biểu hiện bằng sôi bụng đầy bụng tiêu chảy vài lần.
- Thời kỳ toàn phát
     + Tiêu chảy liên tục rất nhiều lần với khối lượng lớn có khi hàng chục lít một ngày. Phân tả điển hình toàn nước màu trắng lờ đục như nước vo gạo không có nhầy máu.
     + Nôn bệnh nhân nôn rất dễ dàng lúc đầu ra thức ăn sau toàn nước.
     + Bệnh nhân thường không sốt ít khi đau bụng.
     + Tình trạng mất nước và điện giải gây mệt lả chuột rút...

Bảng 1. Các mức độ mất nước
Các dấu hiệuMất nước độ 1Mất nước độ 2Mất nước độ 3
Khát nướcÍtVừaNhiều
Tình trạng daBình thườngKhôNhăn nheo mất đàn hồi da mắt trũng
Mạch< 100 lần/phútNhanh nhỏ (100-120 lần/phút)Rất nhanh khó bắt (> 120 lần/phút)
Huyết ápBình thường< 90 mmHgRất thấp có khi không đo được
Nước tiểuÍtThiểu niệuVô niệu
Tay chân lạnhBình thườngTay chân lạnhLạnh toàn thân
Lượng nước mất5-6% trọng lượng cơ thể7-9% trọng lượng cơ thểTừ 10% trọng lượng cơ thể trở lên

- Thời kỳ hồi phục: Bệnh diễn biến từ 1-3 ngày nếu được bù đủ nước và điều trị kháng sinh.

b) Cận lâm sàng
- Soi phân: Giúp chẩn đoán nhanh. Có thể soi phân dưới kính hiển vi nền đen sẽ thấy phẩy khuẩn tả di động mạnh. Nhuộm Gram thấy hình ảnh phẩy khuẩn không bắt màu Gram.
- Cấy phân:
     + Phải lấy phân sớm khi xuất hiện tiêu chảy lần đầu tiên và trước khi điều trị.
     + Nên dùng ống thông lấy phân qua hậu môn tốt hơn. Trường hợp phải gửi bệnh phẩm đi xa để làm xét nghiệm cần phải cho phân vào môi trường Cary-Blair để chuyên chở.
     + Cấy phân vào môi trường chuyên biệt. Phẩy khuẩn tả mọc rất nhanh và có thể xác định sau 24 giờ.
- Kỹ thuật PCR tìm gen CTX: giúp chẩn đoán nhanh (nếu có điều kiện).
- Tình trạng cô đặc máu: Hematocrit tăng.
- Tình trạng rối loạn điện giải: Giảm kali giảm bicarbonat thậm chí pH thấp.
- Suy thận: urê và creatinin máu tăng trong những trường hợp nặng.

c) Dịch tễ học
- Cư trú tại vùng dịch tễ lưu hành hoặc đang có dịch tả.
- Tiếp xúc với người bị tả hoặc tiêu chảy mà chưa xác định được nguyên nhân.
- Ăn uống thực phẩm chưa nấu chín bị ô nhiễm như hải sản sống mắm tôm sống...

CHÚ Ý: Trong vụ dịch chẩn đoán trường hợp bệnh dựa chủ yếu vào các biểu hiện lâm sàng.

2. Chẩn đoán phân biệt
a) Nhiễm trùng nhiễm độc thức ăn do Salmonella
Sau ăn thức ăn nhiễm khuẩn 12-14 giờ sốt cao đau bụng tiêu chảy và nôn có thể gây mất nước phân có thể nước hoặc nước máu.
b) Lỵ trực khuẩn
Sốt đau quặn bụng mót rặn và phân có máu mũi.
c) Escherichia coli gây bệnh
Các chủng nhóm huyết thanh O124 O136 O144 gây tiêu chảy và nôn do độc tố ruột.
d) Do độc tố của tụ cầu
Ủ bệnh ngắn trong vài giờ sau khi ăn. Bệnh cấp tính như đau bụng dữ dội kiểu viêm dạ dày ruột cấp nôn và tiêu chảy phân lỏng. Bệnh nhân không sốt và có khuynh hướng truỵ mạch.
e) Do ăn phải nấm độc
Không sốt đau bụng nhiều nôn và tiêu chảy sau khi ăn phải nấm độc. Trường hợp nặng có thể gây nôn ra máu đi ngoài ra máu vàng da và mê sảng. Cần hỏi kỹ tiền sử ăn uống.
g) Tiêu chảy do ngộ độc hoá chất
Do ăn thức ăn có nhiễm hoá chất như hoá chất bảo vệ thực vật.
3. Thể lâm sàng
a) Thể không triệu chứng
b) Thể nhẹ
Giống như tiêu chảy thường.
c) Thể điển hình
Diễn biến cấp tính như đã mô tả ở trên.
d) Thể tối cấp
Bệnh diễn biến nhanh chóng mỗi lần tiêu chảy mất rất nhiều nước vô niệu toàn thân suy kiệt nhanh chóng sau vài giờ và tử vong do truỵ mạch.
e) Bệnh tả ở trẻ em
Gặp phổ biến thể nhẹ giống như tiêu chảy thường. Ở trẻ lớn tiêu chảy và nôn giống như người lớn thường có sốt nhẹ.
g) Tả ở người già
Hay gặp biến chứng suy thận mặc dù đã được bù dịch đầy đủ.

II. ĐIỀU TRỊ
1. Nguyên tắc
- Cách ly bệnh nhân.
- Bồi phụ nước và điện giải nhanh chóng và đầy đủ.
- Dùng kháng sinh để diệt vi khuẩn.

2. Điều trị cụ thể
a) Bồi phụ nước và điện giải
- Bù nước bằng đường uống: Áp dụng cho những trường hợp nhẹ giai đoạn đầu chưa mất nước nhiều và giai đoạn hồi phục. Có thể áp dụng tại nhà hoặc ở các cơ sở y tế.
     + Các loại dịch dùng đường uống: Oresol (ORS) (gồm NaCl 3 5g NaHCO3 2 5g KCl 1 5g và glucose 20g) pha với một lít nước đun sôi để nguội.Có thể pha dịch thay thế: 8 thìa nhỏ (thìa cà-phê) đường 1 thìa nhỏ muối pha trong 1 lít nước; hoặc nước cháo 50g gạo và một nhúm (3 5g) muối hoặc nước dừa non có pha một nhúm muối.
     + Nên cho uống theo nhu cầu. Nếu nôn nhiều nên uống từng ngụm nhỏ.
- Bồi phụ khối lượng tuần hoàn bằng truyền tĩnh mạch:
     + Tổng lượng dịch truyền trong ngày:
     Tổng lượng dịch truyền trong ngày = A + B + M
     Trong đó A: Lượng dịch mất trước khi đến viện (theo mức độ mất nước).
                    B: Lượng phân và chất nôn mất tiếp khi nằm viện.
                   M: Lượng nước duy trì trong ngày.
     + Các loại dịch truyền:Natri clorid 0 9% hoặc Ringer lactat (4 phần)Natri bicarbonat 1 4% (1 phần)Glucose 5% (1 phần)
     + Bổ sung thêm kali clorid (KCl): mỗi 1 lít dịch truyền pha thêm 1g KCl. Khi bệnh nhân uống được thay bằng đường uống.
- Cách thức truyền dịch:
     + Giai đoạn 1: Từ 4-6 giờ đầu bù nước và điện giải đã mất trước khi đến bệnh viện dựa vào mức độ mất nước.
     + Giai đoạn 2: Bù nước và điện giải đã mất trong khi nằm viện và lượng dịch duy trì.
     + Cần phải truyền nhanh bằng nhiều tĩnh mạch lớn hoặc truyền vào tĩnh mạch trung tâm.
     + Cần theo dõi các dấu hiệu sinh tồn hematocrit áp lực tĩnh mạch trung tâm (nếu có điều kiện) để điều chỉnh tốc độ truyền dịch cho thích hợp. Những trường hợp nặng cần theo dõi điện giải đồ để điều chỉnh cho phù hợp.
     + Khi hết nôn và uống được thì dùng dung dịch uống.

b) Điều trị kháng sinh
- Thuốc được dùng ưu tiên:
     + Nhóm fluoroquinolon (Ciprofloxacin 1g/ngày Norfloxacin 800mg/ngày Ofloxacin 400mg/ngày) uống chia hai lần/ngày trong 3 ngày (Không dùng cho trẻ em dưới 12 tuổi phụ nữ có thai và cho con bú. Thận trọng khi dùng cho trẻ từ 12 đến 18 tuổi).
     + Azithromycin 10 mg/kg/ngày uống trong 3 ngày.
     + Cloramphenicol 30 mg/kg/ngày uống chia 3 lần dùng trong 3 ngày.
- Đối với trẻ em < 12 tuổi phụ nữ có thai và cho con bú: Dùng azithromycin.
- Nếu không có sẵn các thuốc trên có thể dùng:
     + Erythromycin 1g/ngày uống chia 4 lần/ngày (trẻ em 40 mg/kg/ngày) dùng trong 3 ngày; hoặc
     + Doxycyclin 300 mg uống 1 liều (dùng trong trường hợp vi khuẩn còn nhạy cảm).

CHÚ Ý: Không được dùng các thuốc làm giảm nhu động ruột như morphin opizoic atropin loperamide...

c) Dinh dưỡng
- Nên cho bệnh nhân ăn sớm ăn thức ăn lỏng dễ tiêu. Trẻ còn bú tăng cường bú mẹ.

3. Phân loại bệnh nhân để điều trị
- Căn cứ vào lâm sàng có thể xếp thành 4 loại để xử trí.

Bảng 2. Bảng phân loại bệnh nhân để điều trị
LoạiCác triệu chứng chínhNơi điều trịPhương pháp điều trị
I- Tiêu chảy vài lần phân ít nhão- Không nôn- Mạch huyết áp bình thường chưa có dấu hiệu mất nướcTại tuyến cơ sở (xã phường hoặc tại nhà)- Uống kháng sinh- Uống dung dịch Oresol
II- Tiêu chảy nhiều nhưng tự chủ được- Không nôn tự nhiên- Mất nước nhẹ- Mạch huyết áp bình thườngTại trạm y tế xã phường hoặc trung tâm y tế quận/huyện- Uống kháng sinh- Uống dung dịch Oresol- Truyền dịch
III- Tiêu chảy nhiều- Nôn dễ dàng- Có triệu chứng mất nước trung bình- Huyết áp hơi hạ- Mạch nhanh yếu- Mệt lảTại trung tâm y tế quận/huyện hoặc tuyến tỉnh. Nếu tại trạm y tế xã cần có sự hỗ trợ của bác sỹ và điều dưỡng tuyến trên- Truyền dịch là chính. Nếu mạch và huyết áp trở về bình thường bài niệu tốt còn tiêu chảy nhẹ cần duy trì bằng dung dịch uống (ORS)- Uống kháng sinh
IV- Tiêu chảy và nôn nhiều gây nên mất nước nặng thiểu niệu hoặc vô niệu- Truỵ mạch: Huyết áp không đo được mạch nhỏ khó bắtBệnh viện tuyến tỉnh hoặc trung ương. Có thể điều trị tại tuyến huyện nhưng cần có bác sỹ tuyến tỉnh hỗ trợ- Truyền dịch với tốc độ nhanh- Theo dõi mạch huyết áp lượng nước tiểu áp lực tĩnh mạch trung tâm- Uống kháng sinh

- Khi có dịch tả xảy ra số lượng bệnh nhân đông việc phân loại bệnh nhân để có thái độ xử trí đúng đắn sẽ làm giảm được tổn phí và hạ được tỷ lệ tử vong.
- Trường hợp bệnh tả nặng mạch huyết áp không đo được phải cấp cứu tại chỗ (tuyến xã tuyến huyện). Nếu trong tình trạng này mà vận chuyển lên bệnh viện tuyến trên quá xa thì tiên lượng càng nặng thêm. Do đó khi có dịch tả xảy ra tại cơ sở nên tổ chức cấp cứu tại chỗ cần tăng cường bác sỹ và điều dưỡng tuyến trên hỗ trợ chuẩn bị đầy đủ thuốc men dịch truyền dây truyền...

4. Tiêu chuẩn ra viện:
- Hết tiêu chảy.
- Tình trạng lâm sàng ổn định.
- Kết quả xét nghiệm cấy phân âm tính 3 lần liên tiếp. Ở những cơ sở không có điều kiện cấy phân thì cho bệnh nhân ra viện sau khi ổn định về mặt lâm sàng được 1 tuần.  

III. PHÒNG BỆNH
1. Các biện pháp khi có dịch
- Khi có bệnh nhân tả phải thông báo dịch cho y tế cấp trên và hệ y học dự phòng.
- Thực hiện nghiêm ngặt các biện pháp cách ly bệnh nhân ở buồng riêng theo đường tiếp xúc.
- Xử lý phân và chất thải bằng cloramin B 10% tỷ lệ 1:1 hoặc vôi bột.
- Khử khuẩn quần áo chăn màn dụng cụ của bệnh nhân phương tiện chuyên chở bệnh nhân bằng dung dịch cloramin B 1-2% nước Javen 1-2% hoặc nước sôi.
- Ngâm tay bằng dung dịch cloramin B hoặc rửa tay bằng các dung dịch khử khuẩn sau khi thăm khám chăm sóc bệnh nhân.
- Vệ sinh buồng bệnh ít nhất 2 lần/ngày bằng các dung dịch cloramin B nước Javen 1-2% hoặc các chế phẩm khử khuẩn khác.
- Các chất thải phát sinh trong buồng cách ly phải được thu gom xử lý như chất thải y tế lây nhiễm.
- Tử thi phải được liệm trong quan tài có vôi bột bọc thi thể bằng vải không thấm nước và phải được chôn sâu 2m hoặc hoả thiêu. Phương tiện chuyên chở tử thi phải được khử khuẩn.
- Điều trị dự phòng cho những người tiếp xúc trực tiếp không áp dụng các biện pháp phòng hộ với bệnh nhân bằng các kháng sinh được chỉ định để điều trị với liều duy nhất (riêng azithromycin 20mg/kg).
- Cơ quan y tế dự phòng tiến hành điều tra xử lý ổ dịch.
- Hạn chế đi lại giao lưu hàng hoá.

2. Các biện pháp dự phòng chung
- Vệ sinh môi trường đảm bảo cung cấp nước sạch.
- Vệ sinh thực phẩm: Ăn chín uống sôi kiểm tra vệ sinh an toàn thực phẩm nước đá nước giải khát. Không nên ăn các hải sản tươi sống mắm tôm sống vì nguồn bệnh có thể ở trong đó và lây bệnh.
- Sử dụng vắc-xin tả uống cho những vùng có nguy cơ dịch theo chỉ đạo của cơ quan y tế dự phòng.

xiaojun

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20170930 junda

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Chào Bs : Phan Duy Hoàng
Thời gian gần đây tôi bị : đắng miệng lưỡi trắng mắt giảm thị lực tiêu hóa kô ổn định lúc bón lúc tiêu chảy. Và còn mắc chứng bệnh gout ( Thấp khớp do dư đạm )
Xin chỉ dẫn cách phòng ngừa và xin Bs cho hai toa thuốc về thấp khớp . Cảm ơn bác sỹ nhiều.
Chúc gia đình Bs mùa giáng sinh an bình

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Lâu quá không gặp anh bốn Hoàng
Một mình trên mạng cứ lang thang
Thèm ăn thịt chó không người gọi
Hoá ra bác sợ món nhuận tràng!

Nghe nói bệnh này là bệnh tả
Phải kiêng thịt chó cùng mắm tôm
Bây giờ lại nghe tiêu chảy cấp
Anh bốn nhà ta chắc mất hồn!
(He he lâu ngày quá! Chọc anh bốn Hoàng xíu!)

4 Hoàng

Cám ơn Năm nhiều!
Bốn sẽ chỉnh sửa lại. Mục góp ý chung Blog không có phần này Bốn đang nghiên cứu.