Tweak Thyroid 052014
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Transcript of Tweak Thyroid 052014
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CC BC KHO ST TUYN GIP (*)- Ct ngang mi thy t cc trncc di- Ct dc mi thy vi chiu cao ln nht- o th tich TG, bnh thng 7-11cm/thy.
- Eo gip ct ngang v dc vi k trc-sau ln nht.- C T, c P: hch, M cnh, TM hu.- TG bnh thng: Khng thy bnh l 2 mt ct khc nhau, bao gmc hi m, s o, phn b mch mu.
TG BNH THNG (**): Kch thc, hnh thi v th tch thay itheo tui v gii.-18-20mm chiu cao v 8-9mm b dy (AP) lc mi sanh.-25 mm chiu cao v 12-15 mm AP lc 1 tui.
- 40-60 mm chiu cao v 13-18 mm AP lc trng thnh.Th tch bnh thng (khng k eo gip) 10-15ml/n v 12-18ml/nam.
(*) ULTRASOUND OF THE THYROIDNormal http://www.ultrasoundpaedia.com/normal-thyroid
(**) Thyroid ultrasound. Vikas Chaudhary, Shahina Bano. Indian Journal of Endocrinology andMetabolism / Mar-Apr 2013 / Vol 17 | Issue 2
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ULTRASOUND OF THE THYROIDNormal http://www.ultrasoundpaedia.com/normal-thyroid/
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1,2,3: ct ngang thy P,eo gip, thy T.4: ct dc eo gip.5: ct dc mi thy gip
Tuyn c tr nh
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1- Tuyn gip; 2- Kh qun; 3- Tuyn cn gip; 4- Tnh mch hu trong;5- ng mch cnh gc; 6- TK hu qut ngc; 7- M gip di
8- C c gip; 9- C vai mng; 10- C c mng; 11- C c n chm;13- Thc qun; 14- C di c; 15- Ct sng.
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910
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KHO ST MCH MU TG- TG c phn b bi M gip trn v di.- Bnh thng RI thp v PSV cao 15-30cm/s cho m trong nhu m gip.a. TG bnh thng, b. M gip di (), c. Ph M vi RI thp, PSVca
a
bc
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- Th tch tuyn gip o c hai thy 8,53cm1,82, trung bnh n7,58cm3 v nam 9,72cm3 ,th tch thy P thng > T (4,48cm3so vi4,07 cm3). V= ngang x dy x cao x 0,49
The Internet Journal of Radiology,Volume 4, Number 2Ultrasound Determination Of Thyroid Gland Volume Among Adult Nigerians
A Ahidjo, A Tahir, M Tukur
TNHTH TCH TUYN GIPCch tnh th tch tuyn gip cha c nht qun, nn c nhiu cch tnty theo trng phi:
- Th tch tuyn gip = tng th tch hai thy, khng bao gm eo gipVthy= ngang x dy x cao x 0,479
Method for determining thyroid size by ultrasonographyhttp://www.iccidd.org/cm_data/thyroid_size.pdf
- Th tch ca mi thy v eo gip tnh theo cng thc hnh bu dc(ngang x dy x cao x /6)Thyroid Volumetric Quantification. J Ultrasound Med 2008; 27:17271733
http://ispub.com/IJRAhttp://ispub.com/IJRA/4http://ispub.com/IJRA/4/2http://ispub.com/IJRA/4/2/8932http://ispub.com/IJRA/4/2/8932http://ispub.com/IJRA/4/2http://ispub.com/IJRA/4http://ispub.com/IJRA -
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VAI TR C A SI U M- Xc nh khi s thy c/LS nm trong hay ngoi tuyn gip.- phn loi khi s c/LS: nang, c hay hn hp- nh gi cu trc m cn li ca tuyn gip
-Nhn nh nguyn nhn cng gip, suy gip.- Bin chng sau phu thut: p-xe, ph n- Phnh gip a ht: theo di nhn- Hng dn chc ht t bo, rt dch, sinh thit
CHN ON PHN BiTNu bnh nhn c khi c v di ng theo nut, cc chn on ngoituyn gip c th c:- Cun m phn y ca c.
- Hch- Nang khe mang-Nang gip thit (ng gia trn xng mng)- Khi ca tuyn cn gip
ULTRASOUND OF THE THYROIDNormalhttp://www.ultrasoundpaedia.com/normal-thyroid/
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CH NH SIU M TG (Theo AACE v AME*)1. Xc nhc nhn gip khi khm lm sng nghi ng.2. Tnh chtca(1 hay nhiu) nhn gip, kch thc, him v phn
bmchmu.
3. Phnbitnhn gip lnhc datrn cimSA.4. Phnbitnhn gip vicc khingoi TG: hch, nang gip thit,
nang mchbchhuyt.5. nhgi thay ilan tatrong nhu m gip.
6. nhgi m gip cn lisauphuthut, ti pht gingTG, dicnhchc.7. Theo di nhngBN nguy cK gip: tincngia nh, au nitit
nhm II (multiple endocrine neoplasia (MEN) type II ), xtrvngc.
8. HngdnFNA.
(*) American Association of Clinical Endocrinologists (AACE) and Associazione MediciEndocrinologi (AME)
Thyroid ultrasound. Vikas Chaudhary, Shahina Bano. Indian Journal of Endocrinology andMetabolism / Mar-Apr 2013 / Vol 17 | Issue 2
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Bnhl lan ta Bnhl khu tr ChcnngTG
Phnh gip
Bulnhgip
K gip
Vim gip
Basedow
Phnh gip lan ta,
1 hay 2 thy
-----
K gip lan ta
1 hay 2 thy
2 thy
-Phnh gip n(a) nhn.
- 1 hay nhiunang gipkeo/ 1 hay 2 thy.
1bu/ 1 thyNhn c(ngnhthay
khng)
Nhn cecho km (ccnhn lnc hoitbntrong)
Vim toht: 1 haynhiuht/ 1 hay 2 thy
--------
Bnh gip +++
Cnggip +
Bnh gip +++Cnggip + (c
tnh)
Bnh gip
Bnh gipCnggip (thongqua)Suy gip
Cnggip
BNH HC TUYN GIP
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NANG
GIAP
KEO +++
NANG DO
K hiem)
PGH
+++)
BU LANH
ADENOMA)
hiem
K GIAP VIEM
CNG GIAP
BASEDOW
THUOC
SUY GIAP
BNH GIAP
NHN GIP(LS HAY DI LS)
NHN GIP DNG NANG# NANG GIP
NHN GIP DNG C
SAU T LM GiM THTCH TUYN GAP
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NHN GIP(LS HAY DI LS)
NHN GIP DNG NANG# NANG GIP
NHN GIP DNG C
NANGGIP
KEO+++
NANGDO K
(him)
PGH
+++)
BU LNH(ADENOMA)
(him)K GIP
VIEM
Bnhl khu trPhnh gip
Bulnhgip
Phnh gip n(a)nhn. Nang gip keo/1 hay 2 thy.1bu/ 1 thy
Nhn c(ngnht
hay khng)
Bnhl khu trK gip
Vim gip
Nhn cecho km(cc nhn lnc hoitbn trong)
Vim toht
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M t v tr, s lng, hnhthi, kch thc ca 1 haynhiu nhn
B h h i
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Benh hocac iem
Lanh Ac
1. Cau truc echo
ac
Nang
Hon hp
2. oecho
Kem
ong
Day
3. Gii han
Gii han ro
Gii han khong ro4. Halo
Day / khong toan ven
Mong / toan ven
5. Voi hoa **
Ngoai bien (voso)
Ben trongTo
Nho
(1)
(2)
(2)
(1)
(3)
(4)
(2)
(2)
(4)
(3)
(1)
(1)*
(3)
(2)
(2)
(3)
(2)
(1): Kh xc nh, c th gp. (2): c th, thng gp.(3): Kh xc nh, t gp. (4): c th.xc sut xy ra >85%.
(*): mc d hu ht nhn c u echo km, phn ln cc nhn echo km l lnh tnh.(**): Vi ha: 13% vi ha i km vi nhn, s phn b & kiu vi ha rt quan trng.
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1/. HT GIP DNG NANG = NANG GIP KEO:Phnlnnang gip thunggpl nang keo do kttdchkeo
trong cc ti nang, dchstvng (Lugol). C thc 1 haynhiunang
Lu : K gp khng bao gi biu hin di dng nang han tan
Nang echo trng ngnht hoc c th vi
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Nang nh, trong gii hn bnh thng, cth vi dng ui sao chi, rt hay gp
Nang to, i khi cn thy c mt phn m gip vch nang (), c rt nhiu th vi dng ui saochi, rt hay gp
Nhn gipdng nang#Nang gip
keo
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Nang gip keo xut huyt: dch echo km, c cn, vch ngn trong nang.
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Nang gip keo xut huyt: cc mu ngc (A) v khng c (B) th vi.
Nang gip keo xut huyt: th vi trini khp nangCPB vi vi vi ha.
A B
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2/. HT GIP DNG C :
SA nh gi v tr, kch thc, hi m, cu trc echo, b vin, halo, vi ha
v phn b mch mu
-Nhn di v bao khi khng c m gip bao chung quanh.- Cc nhnphn bit r vi m gip cn li s c hi m: echo dy, ngecho, echo km hay echo hn hp.
- ng vin b: u hay khng u.- Cu trc echo: ng nht hay khng ng nht.- Halo l ng vin echo trng hay echo km bao quanh nhn- Vi ha to hay nh nm trong nhn, ra nhn hay c hai- Phn tch cng v loi mch mu phn b cho cc nhn gm: loi I: khngc tn hiu mch mu; loi II: c mch mu quanh nhn, loi III: tng mch mutrong v ngoi nhn.
Diagnosis of Thyroid Cancer in Children: Value of Gray- Scale and Power DopplerUS. Andrej Lyshchik, MD. Radiology 2005; 235:604613
BNH HC
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BNH HCNhn gip : thng gp l PHNH GIP A HT (PGH) nhng c tnh vs lnh tnh: khng c 1 c im SA no gip phn bit bnh l lnh hay cnn cn kt hp nhiu c im :
-Nang vs c- n c hay a nhn- Echo km vs cc hi m khc- Halo- Vi ha to vs vi vi ha- Phn b mch mu
TUY N GIP C TNH :- Chim 1% trong cc nhn gip, thng gp l carcinm dng nh hay nh-nang.-T l k gip gia tng khi c iu tr tia x vo vng u c.- K biu m dng nh 78%, K biu m cc tn thng dng nang 17%, K biu m dngty 4%, K biu m dng khng bit ha 1%, lymphm v di cn TG him gp.
ULTRASOUND OF THE THYROIDNormal http://www.ultrasoundpaedia.com/normal-thyroid
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Do tnh trng thiu it , l tn thng tng sn lnh tnh.
PG n ht hay a ht (nodular goiter): Ht c cu trc echo rt a dng
(tui): echo dy, ng echo, hi km hay rt km so vi ch m gip. Gii
hn ro hay khng r khu tr 1 hay 2 thy. ng nht hay khng do ckm theo tnh trng vi ha (to trong nhn hay ngoi bin) hay ha nangtrong nhn.
Chn an phn bit PG tuyn (adenomatous goiter) vi bu lnh TG
hay k gip da va hnh nh SA nhiu khi khng th c.
PG A (N) HT.
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PG ht:ha nangt ong
vc th
vi
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PG ht:khng hanang tong
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PGH:nhn vi
ha
PG tuyn Ad t it
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PG tuyn Adenomatous goiter
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B i l h t h
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Bu gip lnh tnhGm bu tuyn nang (Follicular adenomas) thng gp v bu tuyn nh(papillary adenomas) t gp. Bu tuyn nang gm nhiu dang m hc: dng c timnng vi xm ln: dng phi (microfollicular), dng thai (atypical), bu t bo
Hurthle: v dng khng c xm lm: dng keo (macrofollicular), dng b trong sut(Hyalinizing trabecular).Kho CPB ton thng lanh tnh nay vi ung th giap dang nang.
Go lbu chc nng(c tnh) # nhn nng khi bu tng chuyn ha lm tngtit hormone TG, gy hi chng cng gip.
N,hn c n c, ng nht, c halo u quanh nhn l do v bao x, b uhnh bu dc # gi tinh hon, t l nhn echo km, hay echo dy nhiu>> nhn ngecho vi ch m gip.
Khi cc nhn ln thng ckm theo vng ha nang bn trong: nu th tch phn
nang < 2/3 th tch ca phn c (c > nang) #nhn gip hoa t; ngc li nu >2/3 # nang gip c chi.
Bu nm trong nhm TN THNG DNG NANG, bao gm PG tuyn, butuyn nang, Car. dng nang, Car. dng nh bin th nang.
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Bu tuyn nang khng hot ng
Bu tuyn nang c tnh: ln nhanh c ha nang nh bn trong tng sinh mch mu
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Nhn nng # bu lnh c tnh: nhn tng sinh mch mu nhiu vng ngoi bin: vntc M gip di ca thy coa nhn l 50cm/s, so vi bn bnh thng l 20cm/s
a. Nhn echo dy,
halo du, vi chha nang nh.b. Tng sinh mchmu ngoi bin vtrung tm hnh nan
hoa
Bu tuyn nang c tnh: ln nhanh, c ha nang nh bn trong, tng sinh mch munhiu.
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Bu t bo Hurtle
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Tn thng c tnh:
Carcinm:Dng xut pht t biu m nang gipgm k gip dng nh, dngnang, v dng khng bit ha. Dng xut pht t t bo cnh tuyn gip:k gipdng ty.
a/. Car. dng nh:75-90%, tin lng tt,mt hay a , nhn pht trin rt
chm, di cn xa him v di cn hch sm (i hch). L ung th gip duy nht tr em, n > nam. 1 s trng hp c hch c di cn do ung th gip nhngkhng thy nhn gip trn i th v SA.Khi nhn kch thc ln, thy cn lid b ung th nn cn ct gip gn trn.
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86,7% la nhan ac echo kem,khi ln hn 1 cm nhan tr nen khong ong
nhat, gii han khong ro, 50% co vi voi hoa, t thay c hnh dang nhu trong
nang.
a nhn echo km 2 thy, gii hn khng r khng ng nht c
nhng chm echo dy bn trong tng ng vi cc nt vi vi ha
K gip dng nh c vi vi ha
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Cc nhn echo km, gii hn khng r khngng nht c nhng chm echo dy bn trongtng ng vi cc nt vi vi ha
K gip dng nh c vi vi ha
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Nhn echo km, gii hn khng r kh ng nht, xm ln cn mc trc (A,C), cbao bc hon ton bi m gip (B), hay nm ngay st cn mc nhng cha xm ln (D)
A B
C
K gipdng nhkhng vivi ha
D
K gip dng nh xm ln
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Nhn echo dy bng m gipchim ht b dy ca thy, gii hn
khng r xm ln cn mc truc vsau, khng ng nht c nhngchm ecgo dy () bn trongtng ng vi cc nt vi vi ha
Nhn echo km, gii hn khng r,khng ng nht c nhng vnghoi t echo rt km bn trong vnhiu chm echo dy ri rc tngng vi cc nt vi vi ha, c dut on do xm ln cn mc vm chung quanh
K gip dng nh xm ln
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K gip dng nh hoi tto nang nhiu, trongphn m bu c vi viha to thnh cc vng
echo rt dy (A,C) haykhng co vi vi ha (B)d lm vi nang gip keo
A
B
C
ac iem hach di can: mat hnh bau duc, thng hnh tron, khong con ron
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g g
hach echo day vung trung tam du hach kch thc nho.oi khi hach co cau truc
echo day hn c, ong nhat, hay hoai t, co the co vi voi hoa trong hach. oi khi
hach mang hnh anh giong nh nhan ung th nguyen phat cua TG.
Hch di cn c vi ha t k gip dng nh
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Hch di cn khngc vi ha, +/- c hoi t tk gip dng nh
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Hch dicn choi tt k gipdng nh
K giplan ta 2
thy:nhnecho dydo vi viha
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Phn bit cc chm echo dy trong nhn c tuyn gip: A. Cc chm echo dt trongnhn khng c du ui sao chinghi ng c tnh. B. Nhn c ch ha nang vicc chm echo dy c du ui sao chinhn lnh tnh.
Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound Consensus Conference
Statement. Published online 10.1148/radiol.2373050220 Radiology 2005; 237:794800
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b/. Car. dang nang:5-15%, ve mat hnh anh va te bao hoc kho phan biet vi cac
u tuyen dang nang lanh tnh, PG tuyen, ung th giap dang nhu bien the nang;ch
phan biet c bu lanh hay ac da tren vi the nh hnh anh xam lan vo bao
va mach mau cua cac te bao nang giap.U phat trien cham, di can en phoi va
xng nhieu hn hach co. Tien lng xau hn.
2/3 trng hp kem theo PGnen can SA mau trong PG a hat e loai tr ung th.
Nhan thng to, ong echohay gap hn echo kem, b halo khong eu,khong co
vi voi hoa i kem.
TN THNG DNG NANG (Follicular lesions): kh th h bit
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TN THNG DNG NANG (Follicular lesions):khng th phn bitc bng siu m v t bo hc
- Phnh gip tuyn (adenomatous goiter).
- Bu tuyn nang (Follicular adenoma )- Ung th tuyn gip dng nang (Follicular carcinoma)
- Ung th tuyn gip dng nh bin th nang (Follicular-papilary carcinoma)
Phnh gip tuyn
Bu tuyn nang
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K giap dang nang
K GIAP DANGNANG
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Nhn gii hn r
Nhn c ch gii hn r
Nhn gii hn khng r, c
ch xm ln m chung quanh
c/.Car. dang khong biet hoa:1%, ngoi ln tuoi, tien lng xau do dien tien
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nhanh. Bou cng, ln nhanh va xam lan vao cac c quan lan canc, TQ, mach
mau, hach, gay t vong do chen ep kh quan.SA: Nhan ac echo kem hay hon
hp, khong halo, gii han khong ro
d/. Car. dang tuy:
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Carcinm TG dng tykhng vi ha
CARCINM KHNGBiT HA
Carcinm TG dng tyc vi ha
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NANG
GIAP
KEO +++
NANG
DO K
hiem)
PGH
+++)
BU
LANH
ADENOMA)
hiem
K GIAP VIEM
CNG GIAP
BASEDOWHUOCSUY GIAP
BNH GIAP
SAU T LM GiM TH
TCH TUYN GAP
BNH L CHC NNG TUYN GIP
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VIEM GIAP VA
ROI LOAN CHC NANG TUYEN GIAP
I. VIEM:
hay gap tren lam sang,bieu hien rat a dang va de gay lam lan.
1. Viem giap ban cap (De Quervain):
Theo mua, sau nhiem sieu vi ng ho hap tren/ n 20-25t.Co the co giai oan
nhiem giap oc to giai oan khi benh # 4-8w (do nang tuyen giap b pha huy) roi
t het.
S thay TG cng va au. Hach co thng co. Dien tien suy giap hiem (5-10%),
tuy nhien co the e lai vai nhan lanh tren xa hnh giap. Benh co the tai phat.
SA giai oan au TG to phu ne echo kem lan toa khong ro nhan, hach co dang
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viem. oi khi ton thng viem ch khu tru tren mot thuy hay mot vung nho cua
thuy giap (de lam vi k) . Hnh anh viem thng ton tai trong mot thi gian dai
nen sau ieu tr the tch TG tr ve bnh thng nhngbat thng ve hnh thai van
con.
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2. Viem giap lympho bao man tnh (Hashimoto):
Benh t mien, co khuynh hng di truyen, chan oan kho.
Dang ien hnhla TG to b khong eu, phu niem t phat, khang the khang
giap cao, xet nghiem chc nang co tnh trang nhc giap, bat chat phong xa yeu
va khong eu. Dien tien suy giap la khong the tranh c vi tnh trang x hoa,
teo TG.
Dang khong ien hnhTG to ong nhat, b hi khong eu, hormone TG bnh
thng, TG bat xa bnh thng hay khong ong nhat, ch co TSH luon luon cao.
Nhiem oc giap thng thoang qua, nhng co khi ton tai lau (Hashitoxicose) =
the benh chuyen tiep gia viem giap t mien va Basedow.
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SA: TG cngkhong to hay to t, echo kem lan toa, co the co cachat echo day
tren nen giap echo kemdung SA mau e phan biet vi. the tien trien,
khong con thay c cau truc echo bnh thng cua TG, ma c thay the bang
mo echo rat kem hay echo rat day va hap thu song am manh.
Tang nguy c ung th giap dang nhu va lymphom/ Viem co suy giap: FNAC khi
tang nhanh the tch TG.
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57Hashimoto khng in hnh: to nt , dy x, tng sin mch mu v
Hashimoto c
to ht
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Cng gip/vim gipkhng inhnh
3. Viem giap tao x man tnh Riedel:
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Hiem. Viem man co tnh trang hoa x lan toa, tan pha 1 phan hay toan bo TG
& xam lan cau truc ke can. Dien tien suy giap trong 1/3 trng hp khi mo x thay
the het mo tuyen giap. Co the ket hp vi x hoa ni khac: sau phuc mac, ng
mat, trung that. Sieu am khong ac hieu, co the thay 1 hay nhieu ton thng dang bu echo
kem 1 thuy xam nhiem vao c ke can, hiem vao mach mau, thong thong de
lam vi K.
X ha m mm chung quanh, kh qunX ha quanh M cnh
C i kh
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4. Cac viem khac:
Viem cap tao mu.
Sieu am :vung mo giap khong to chc hoa cha dch khong ong
nhat echo kem hay hon hp tren nen TG to echo kem lan toa.
Nguyen nhan: viem hau hong, nhiem trung vung au co, do dng
tieu hoa, hay suy giam mien dch, ng mau . VN con do cat le.
Viem giap hau san: benh t mien do co khang the chong TG (= viem
giap limpho bao ban cap): co hoi chng cng giap thoang qua, 1/3 ca suy
giap phai T.
Viem giang mai, lao , nam, xa tr.
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II. Benh ly chc nang:
1. Cng giap:la hien tng tang san xuat hormone TG lam nong o
hormone/mau tang cao va gay nhiem oc giap
Cng giap do tang s kch thch(nam ben ngoai TG): benh Basedow, thai trng
hay choriocarcinoma, ung th (TSH-like) gay tang lng hormone giap lu hanh trong mau
va c che TSH noi sinh.
Cng giap t chu:mot phan mo giap tang sinh va tr nen cng giap nen
kiem soat t tuyen yen b c che va lam cho mo giap nam ngoai vung ton
thng b c che theo: u oc giap (u Plummer= nhan cng nang t chu oc tuyen),
viem giap:mo viem phong thch nhieu hormone TG.
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1.1/. Basedow:
SA co 2 kieu hnh anh:_ Tang san lan toa ong nhatvi vai vung mach mau dan .
_ 86 % TG khong ong nhat khong to chc hoa,echo kem giong nh viem gap
hay hnh anh nhan gia.
o at the tch tuyen giap rat can thiet sau phau thuat cat giap(tai phat 20%),
khi co ch nh T bang iot phong xa.
Suy giap sau phau thuat 1%, sau T iot phong xa25%.
Ket hp vi K chiem 0,3 16,6%, dang nhu >> dang nang.
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Basedow cha ieu tr
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Basedow cha
ieu tr
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SA dung anh gia s ap ng ieu tr va tien lng kha nang tai phat.
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Basedow a ieu tr bang thuoc KGTHPhong xa
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1.2/. Nhan gap oc:
Nhan nong / xa hnh TG va tang sinh mach mau / SA mau.
Tnh oc cua nhan khong phai luon ro rang ma no co the tiem an trong
nhieu nam.Mot so trng hp mo TG con lai b teo nho.
SA thay c cac vung xuat huyet trong nhan, la dau hieu chng to nhan angtien trien;ong thi cho biet o teo nho cua chu mo giap.
ieu tr: chch alcool hay nhiet tr lieu.
Bu tuyn nang c tnh: bu ln nhanh
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Bu tuyn nang c tnh: bu ln nhanhnn to nhiu vng hoi t bn trong, tngsinh mch nhiu
2. Suy giap:
a so thng khong co bu giap
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Suy giap tien phatviem giap Hashimoto, viem ban cap, tai bien do T iot
phong xa T thuoc khang giap hay phau thuat cat giap, roi loan chuyen hoa,
thieu men tong hp hormone giap, chat khang giap trong thc an, Lithium thuoc
T tam than.
Suy giap th phat suy tuyen yen do u, phau thuat, do tuyen yen b pha huy
(h/c Sheehan)
Suy giap e tam cap roi loan chc nang ha oi
Suy giap nguyen nhan ac biete khang ngoai vi vi tac dung hormone TG,bat thng thu the v T4 te bao.
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Sieu am:
TG nho, echo kem, khong bat xa.
FNAC neu nghi suy giap do viem De Quervain hay Hashimoto.
NHN GIP(LS HAY DI LS)
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NANG
GIAP
KEO +++
NANG DO
K hiem)
PGH
+++)
BU LANH
ADENOMA)
hiem
K GIAP VIEM
CNG GIAP
BASEDOW
THUOC
SUY GIAP
BNH GIAP
NHN GIP DNG NANG# NANG GIP
NHN GIP DNG C
SAU T LM GiM TH
TCH TUYN GAP
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KET LUAN
Sieu am la phng tien n gian, nhanh, re, khong oc hai, hieuqua cao.
Giup phan biet c cac loai benh ly TG: nhan, viem, RL chc
nang.
Ket hp viSA mau & choc hut te bao bang kim nho nang hieu
qua chan oan.