B GIO DC V O TO B Y T TRNG I HC Y H NI V TH THY NHậN XéT HIệU QUả ĐIềU TRị U MạCH MáU GAN TRẻ EM BằNG PROPRANOLOL LUN VN THC S Y HC H NI 2016 B GIO DC V O TO B Y T TRNG I HC Y H NI V TH THY NHậN XéT HIệU QUả ĐIềU TRị U MạCH MáU GAN TRẻ EM BằNG PROPRANOLOL Chuyờn ngnh: Nhi khoa Mó s: 06720135 LUN VN THC S Y HC Ngi hng dn khoa hc: TS Nguyn Phm Anh Hoa H NI 2016 LI CM N Tụi xin by t lũng bit n sõu sc ti Ban Giỏm Hiu, Phũng Qun lý o to sau i hc, cỏc thy cụ B mụn Nhi trng i hc Y H Ni ó ging dy nhng bi hc quý giỏ, to iu kin giỳp v nhit tỡnh úng gúp giỳp tụi hon thin lun tt nghip Tụi xin by t lũng bit n sõu sc ti TS Nguyn Phm Anh Hoa l ngi thy ó hng dn tn tỡnh, giỳp v ch dy cn k cho tụi sut quỏ trỡnh hc v hon thin lun tt nghip Tụi xin chõn thnh cm n Ban lónh o bnh vin, Khoa Gan Mt Bnh vin Nhi Trung ng ó to iu kin, giỳp cho tụi sut quỏ trỡnh hc cng nh quỏ trỡnh lm lun tt nghip Tụi xin chõn thnh cm n Lónh o bnh vin cựng Khoa Tiờu Húa Bnh vin Tr Em Hi Phũng ó to iu kin, h tr v giỳp tụi sut quỏ trỡnh hc V cui cựng tụi xin by t lũng bit n sõu sc ti ngi thõn, gia ỡnh v bn bố ó luụn l ch da vng chc, ng viờn tụi sut quỏ trỡnh hc v hon thin lun ny H Ni, ngy 01 thỏng 12 nm 2016 Hc viờn V Th Thỳy LI CAM OAN Tụi l V Th Thỳy, cao hc khúa 23 Trng i hc Y H Ni, chuyờn ngnh Nhi khoa, xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca TS Nguyn Phm Anh Hoa Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp nhn ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 01 thỏng 12 nm 2016 Hc viờn V Th Thỳy DANH MC CH VIT TT bFGF : basic Fibroblast Growth Factor (Yu t tng trng nguyờn bo si c bn) CHT : Cng hng t CLVT : Ct lp vi tớnh UMMTE : U mch mỏu tr em VEGF : Vascular Endothelial Growth Factor (Yu t tng trng ni mụ mch mỏu) MC LC I LIU THAM KHO PH LC DANH MC CC BNG DANH MC CC BIU DANH MC HèNH T VN U mch mỏu tr em (UMMTE) l bnh lý ph bin chim 10% tr di tui [1] U mch mỏu gp ch yu trờn da, cỏc u mch mỏu ni tng him gp hn Trong cỏc u mch mỏu ni tng thỡ gan l hay gp nht [2] U mch mỏu gan thuc dng u lnh tớnh, l loi ph bin nht ca gan giai on phụi thai [3],[4] U mch mỏu gan gp tt c cỏc la tui, ngi ln nhiu hn tr em, t l n nhiu hn nam v ớt cú nguy c ung th húa [5], [6] Cỏc u mch mỏu gan cú th cú hoc khụng cú triu chng lõm sng, mt s trng hp c phỏt hin tỡnh c trờn chn oỏn hỡnh nh a phn l u n c cú ng kớnh < cm, ch cú khong 10% l nhiu Cỏc triu chng lõm sng ca u mch mỏu gan khụng c hiu v ớt cú giỏ tr chn oỏn: gan to, au bng h sn phi, thiu mỏu, vng da tc mt Cỏc bin chng ca u mch mỏu gan thng him gp, suy tim, v u t phỏt gõy chy mỏu bng l bin chng cú t l t vong cao nht chim 65 70% [7] Hin cú nhiu phng phỏp chn oỏn u mch mỏu gan, cỏc k thut chn oỏn hỡnh nh nh siờu õm, chp ct lp vi tớnh (CLVT), cng hng t (CHT) rt cú giỏ tr vic sng lc, phỏt hin v theo dừi tin trin cỏc u mch mỏu gan vi nhy v c hiu cao [8],[9] Cú khong 10% cỏc u mch mỏu gan ln cú triu chng v bin chng cn iu tr [2] Cú nhiu phng phỏp iu tr u mch mỏu gan nh phu thut, nỳt mch gan, x tr, dựng súng cao tn, dựng thuc corticoid, interferon vi nhng hiu qu khỏc Tuy nhiờn mi phng phỏp li tn ti nhng hn ch nht nh Vỡ vy m la chn phng phỏp iu tr thớch hp l cn nghiờn cu 10 Nm 2008 vic s dng propranolol ng ung ln u tiờn thnh cụng iu tr UMMTE c bỏo cỏo [10] Nhiu nghiờn cu khỏc cng chng minh tỏc dng ca propranolol iu tr u mch mỏu [10],[11], [12] Vic iu tr u mch mỏu bng propranolol l mt phỏt hin mi trờn th gii, ỏp ng nhu cu iu tr cỏc dng u mch mỏu tr em bng bin phỏp r tin, hiu qu v ớt tỏc dng ph Propranolol cng c bỏo cỏo hiu qu vi iu tr u mch mỏu gan tr em [13],[14],[15] Vit Nam, propranolol ó c s dng iu tr UMMTE núi chung v em li nhiu kt qu kh quan Tuy nhiờn cha cú nhiu nghiờn cu v hiu qu ca propranolol vi u mch mỏu gan tr em núi riờng Xut phỏt t tỡnh hỡnh thc t, chỳng tụi tin hnh nghiờn cu ti: Nhn xột hiu qu iu tr u mch mỏu gan tr em bng propranolol vi hai mc tiờu sau: Mụ t c im lõm sng, cn lõm sng ca u mch mỏu gan tr em Nhn xột hiu qu iu tr u mch mỏu gan bng propranolol 73 KHUYN NGH Propranolol iu tr u mch mỏu gan tr em vi liu mg/kg/ ngy l la chn hng u vỡ tớnh hiu qu cao, ớt tỏc dng ph v kinh t Cn nhng nghiờn cu chuyờn sõu hn v u mch mỏu gan xỏc nh hiu qu lõu di v tớnh an ton ca propranolol iu tr u mch mỏu gan tr em TI LIU THAM KHO Beth A Drolet, Nancy B Esterly, Ilona J Frieden (1999) Hemangiomas in children The New England Journal of Medicine, 314, 173-181 Yasaman R Shayan, Julie S Prendiville, Ran D Goldman (2011) Use of propranolol in treating hemangiomas Canadian Family Physician, 57 (3), 302-303 Ann M Kulungowskia, Ahmad I Alomarib, Aditya Chawlaa et al (2012) Lessons from a liver hemangioma registry: subtype classification Journal of Pediatric Surgery, 47, 165-170 Masaki Maruyama, Osamu Isokawa, Koki Hoshiyama (2013) Diagnosis and management of giant hepatic hemangioma: the usefulness of contrGOT-enhanced ultrasonography International Journal of Hepatology, 2013, 1-6 Marcelo AF Ribeiro Jr, Francine Papaiordanou, Juliana M Gonỗalves et al (2010) Spontaneous rupture of hepatic hemangiomas: a review of the literature World J Hepatol, 2, 428-433 Mỏrcio Martins Machado, Ana Clỏudia Ferreira Rosa, Marcella Stival Lemes (2006) Liver hemangiomas: ultrasound and clinical features Radiologia Brasileira, 39, 441-446 Jỳlio Cezar Uili Coelho, Christiano M.P Claus, Priscilla Balbinot et al (2011) Indication and treatment of benign hepatic tumors Arq Bras Cir Dig, 24 (4), 318-323 Valộrie Vilgrain, Leila Boulos, Marie-Pierre Vullierme (2000) Imaging of Atypical Hemangiomas of the Liver with Pathologic Correlation RadioGraphics, 20, 379-397 Adriana Toro, Ahmed-Emad Mahfouz, Annalisa Ardiri et al (2014) What is changing in indications and treatment of hepatic hemangiomas: A review Ann Hepatol, 13, 327-339 10 Christine Lộautộ-Labrốze, Eric Dumas de la Roque,Thomas Hubiche (2008) Propranolol for Severe Hemangiomas of Infancy The New England Journal of Medicine, 358, 2649-2651 11 Ann L Marqueling, Vikash Oza, Ilona J Frieden (2013) Propranolol and infantile hemangiomas four years Later: A systematic review Pediatric Dermatology, 30, 182-191 12 D Hermans, C.G Bauland, J Zweegers et al (2013) Propranolol in a case series of 174 patients with complicated infantile haemangioma: indications, safety and future directions British Journal of Dermatology, 168, 837-843 13 Swee Thong Tan, Tinte Itinteang, Philip Leadbitter (2011) Low-dose propranolol for multiple hepatic and cutaneous hemangiomas with deranged liver function PEDIATRICS, 127, 772-776 14 Sheilagh M Maguiness, Ilona J Frieden (2010) Current Management of Infantile Hemangiomas Semin Cutan Med Surg, 29, 106-114 15 Shehla Admani, Stephanie Feldstein, Ernesto M Gonzalez (2014) Beta blockers an innovation in the treatment of infantile hemangiomas J Clin Aesthet Dermatol, (7), 37-45 16 ỡnh Thun, Trn Thit Sn (2007) Quan nim mi v u mỏu tr em Y Hc Vit Nam, 2, 51- 60 17 Nguyn Quc Hi, Trng Anh Mu, Lờ Vn Tựng (2011) iu tr bu mỏu tr em bng propranolol Y Hc TP H Chớ Minh, 15 (3), 155159 18 Anita N Haggstrom, Beth A Drolet, Eulalia Baselga (2007) Prospective Study of Infantile Hemangiomas: Demographic, Prenatal, and Perinatal Characteristics J Pediatr , 150, 291-294 19 H Mnh Tun,Trng Quang nh (2013) Phỏc iu tr ngoi nhi 2013, Nh xut bn Y Hc, Thnh ph H Chớ Minh, 249 - 253 20 So-Young Jin (2010) Sclerosed hemangioma of the liver The Korean Journal of Hepatology, 16, 410-413 21 Prasanth M Prasanna, Scott E Fredericks, Steven S Winn (2010) Giant cavernous hemangioma RadioGraphics, 30, 1139-1144 22 Jie-Yang Jhuang, Long-Wei Lin, Min-Shu Hsieh (2011) Adult capillary hemangioma of the liver: case report and literature review Kaohsiung Journal of Medical Sciences, 27, 344-347 23 Emily R Christison-Lagay, Patricia E Burrows, Ahmad Alomari (2007) Hepatic hemangiomas: subtype classification and development of a clinical practice algorithm and registry Journal of Pediatric Surgery, 42, 62-68 24 Todd S Regier, Faridali G Ramji (2004) Best Cases from the AFIP RadioGraphics, 24, 1719-1724 25 on Ngc Giao, Lờ Trung Hi (2009) Nghiờn cu chn oỏn v c im tn thng u mỏu ln gan Y hc thc hnh, 694, 34-36 26 V Vn Tuyờn (2010) Mụ t c im hỡnh nh cng hng t v siờu õm ca u mỏu gan, Lun thc s y hc, Trng i hc Y H Ni 27 Arash Etemadi, Asieh Golozar, Akhgar Ghassabian (2011) Cavernous hemangioma of the liver: factors affecting disease progression in general hepatology practice Eur J GGOTroenterol Hepatol, 23 (4), 354- 358 28 Paulo Herman, Marcelo L.V Costa, Marcel Cesar Machado (2005) Management of hepatic hemangiomas: A 14-year experience Journal of gGOTrointestinal surgery, 9, 853-859 29 Hong K (2007) Bi ging chn oỏn hỡnh nh, Nh xut bn Y hc, H Ni, 113 30 Hui-Yu Ho, Tsung-Han Wu, Ming-Chin Yu (2012) Surgical management of giant hepatic hemangiomas: complications and review of the literature Chang Gung Med J, 35, 70-78 31 Wernecke K (1992) The distinction between benign and malignant liver tumors on sonography: value of a hypoechoic Halo AJR, 159, 10051009 32 Abbasi A, Bhutto AR, Butt N (2012) Corelation of serum alpha fetoprotein and tumor size in hepatocellular carcinoma J Pak Med Assoc, 62 (1), 33-36 33 Pavai Arunachalam, V R Ravi Kumar, Divya Swathi (2012) Kasabach Merritt syndrome with large cutaneous vascular tumors Journal Indian Assoc Pediatr Surg, 17 (1), 33-36 34 H A Kayaoglu, S Hazinedaroglu, N Ozkan et al (2004) Surgical treatment of symptomatic cavernous hemangiomas of the liver Acta chir belg, 104, 172-174 35 on Ngc Giao, Lờ Trung Hi (2009) Kt qu iu tr phu thut u mỏu ln gan Y hc thc hnh, 12, 7-9 36 P Berloco, P Bruzzone, G Mennini et al (2006) Giant hemangiomas of the liver: surgical strategies and technical aspects Hepato pancreato billiary association, 8, 200-201 37 Vaibhav Jain, Vijay Ramachandran, Rachana Garg (2010) Spontaneous rupture of a giant hepatic hemangioma sequential management with transcatheter arterial embolization and resection Saudi J Gastroenterol, 16 (2), 116-119 38 Kavous Firouznia, Hossein Ghanaati, Seyed Moayed Alavian (2014) Management of liver hemangioma using trans-catheter arterial embolization Hepatitis Monthly, 14 (12), 1-4 39 Zeng Q, Li Y, Chen Y et al (2004) Gigantic cavernous hemangioma of the liver treated by intra-arterial embolization with pingyangmycinlipiodol emulsion: a multi-center study Cardiovasc Intervent Radiol, 27 (5), 481-485 40 Srivastava DN, Gandhi D, Seith A et al (2001) Transcatheter arterial embolization in the treatment of symptomatic cavernous hemangiomas of the liver: a prospective study Abdom Imaging, 26 (5), 510-514 41 Tina S Chen, Lawrence F Eichenfield, Sheila Fallon Friedlander (2013) Infantile Hemangiomas: An Update on Pathogenesis and Therapy PEDIATRICS, 131, 99-108 42 Beth A Drolet, Peter C Frommelt, Sarah L Chamlin et al (2013) Initiation and use of propranolol for infantile hemangioma: report of a consensus conference Pediatrics, 131, 128-140 43 Nivedita Gunturi, Sriram Ramgopal, Subramanian Balagopal et al (2013) Propranolol Therapy for Infantile Hemangioma Indian pediatrics, 50, 307-313 44 Marcia Hogeling, Susan Adams, Orli Wargon et al (2011) A randomized controlled trial of propranolol for infantile hemangiomas Pediatrics 128, 259-266 45 Susan Adams Marcia Hogeling, Orli Wargon (2011) A Randomized Controlled Trial of Propranolol for Infantile Hemangiomas PEDIATRICS, 128 (2), 259-266 46 Cynthia J Price, Carol Lattouf, Bertha Baum (2011) Propranolol vs corticosteroids for infantile hemangiomas Arch Dermatol, 147 (12), 1371- 1376 47 Mazereeuw-Hautier J, Hoeger PH, Benlahrech S (2010) Efficacy of propranolol in hepatic infantile hemangiomas with diffuse neonatal hemangiomatosis J Pediatr, 157 (2), 340-342 48 Amal Mhanna, Wayne H Franklin, Anthony J Mancini (2011) Hepatic infantile hemangiomas treated with oral propranolol - A case series Pediatric Dermatology, 28 (1), 39-45 49 ng Hong Thm, Nguyn Thanh Liờm (2012) Nghiờn cu c im lõm sng v ỏnh giỏ kt qu iu tr u mỏu Kassabach Meritt bng Bleomycin v propranolol 50 Nguyn Duy Hu (2001), Siờu õm gan v ng mt, Siờu õm tng quỏt, 82-84 51 on Ngc Giao (2009) Nghiờn cu chn oỏn, ch nh phu thut v kt qu iu tr u mỏu gan ngi ln Lun tin s, Hc vin quõn y 52 Schwartz L.H, DeCorato D.R (2000), Magnetic resonance imaging of the liver and biliary tract Surgery of the liver and biliary tract, 227-262 53 Stanley P Iyer, Mahour GH (1996) Hepatic hemangiomas in infants and children: a review of 30 cases Am Surg, 62, 356-360 54 Starzl T.E et al (1980) Excisional treatment of cavrernous hemangioma of the liver Ann Surg, 192 (1), 25-27 55 Takagi H (1985) Diagnosis and management of the cavernous hemangoma of the liver Seminars in surgical oncology, 1, 12-22 56 John A (1994) Hepatic Cavernous Hemangiomas : Lack of enlargement over time Radiolophy, 191, 111-113 57 V Glinkova, O Shevah, M Boaz et al (2004) Hepatic haemangiomas: possible association with female sex hormones 53, 1352-1355 58 Nelson RC,Chezmar JL (1990) Diagnostic approach to hepatic hemangiomas Radiology, 176, 11-13 59 Yeh I, Bruckner AL, Sanchez R et al (2011) Diffuse infantile hepatic hemangiomas: a report of four cases successfully managed with medical therapy Pediatr Dermatol, 28 (3), 267-275 60 Goodman Z, Okuda K, Ishak KG et al (1987) Benign tumors of the liver Springer-Verlag, 105-125 61 Hamaloglu E (2005) Giant liver hemangioma: therapy by enucleation or liver resection World J Surg, 29, 890-893 62 Ibrahim S, Chen C.L, Wang C.H et al (2007) Liver resection for benign liver tumors: indications and outcome Am J Surg, 193, 5-9 63 Trn Võn Khỏnh,Trn Thỳy Nga, Vi cht dinh dng-thc trng v gii phỏp hin nay, 64 Smyrniotis V (2000) Liver hemangioma with systemic inflammatory manifestations AJG, 95(3), 830-832 65 Nguyn Hoi Nam (2007) Nghiờn cu biu hin lõm sng v x hỡnh u mch mỏu gan, Lun bỏc s ni trỳ, i hc Y H Ni 66 Erdogan D (2007) Management of liver hemangiomas according to size and symptoms J Gastroenterol Hepatol, 22, 1953-1958 67 Alvin C (2009) MR Imaging of Hypervascular Liver Masses: A Review of Current Techniques RadioGraphics, 39, 385-402 68 Hani Y Hasan, J Louis Hinshaw, Edward J Borman et al (2014) Assessing Normal Growth of Hepatic Hemangiomas During Long-term Follow-up JAMA Surg, 149 (12), 1266-1271 69 Yu.I Kucherov, Yu.V Zhirkova, A.N Getman et al (2014) Clinical case of treatment of hepatic haemangioma by propranolol in the newborn Vestn Ross Akad Med Nauk, 5-6, 81-85 70 Nguyn Vn Sn (2013) ỏnh giỏ kt qu bc u iu tr u mch mỏu tr em vựng u mt c bng propranolol, Lun thc s y hc, i hc Y H Ni 71 Schiestl C, Neuhaus K, Zoller S et al (2011) Efficacy and safety of propranolol as first-line treatment for infantile hemangiomas Eur J Pediatr, 170, 493-501 72 Trn Thanh Tỳ (2014) Nghiờn cu tỏc dng ph ca propranolol iu tr u mỏu tr em Y hc thc hnh, 6, 94-96 PH LC BNH N NGHIấN CU Ngy khỏm: / ./20 Ln khỏm th: Sau thỏng iu tr Hnh chớnh H v tờn bnh nhõn: Ngy sinh: / ./ Tui: Gii: a ch: H v tờn b hoc m: S in thoi liờn lc: Mó s bnh nhõn lu tr: Lý i khỏm Hi bnh: 3.1 Tin s sn khoa Thai kỡ bỡnh thng Sinh non: Khụng Cú Nh cõn: ( tun) < 1500 gr 1500 gr 2500 gr M b nhim virus quỏ trỡnh mang thai: Khụng Cú (tun thai ) 3.2 Tin s u mch mỏu gia ỡnh Khụng Cú ( c th ) 3.3 Cỏc phng phỏp ó iu tr Khụng Lõm sng 4.1 Triu chng lõm sng Cú ( c th ) Triu chng lõm sng au thng v, HSP Sỳt cõn Mt mi St Chng bng Thiu mỏu Vng da Gan to U mch mỏu v trớ khỏc 4.2 Cú Khụng Bin chng Bin chng Nhim trựng Chốn ộp cỏc c quan lõn cn Chy mỏu bng V t phỏt Suy tim Suy giỏp Ung th húa Cú Khụng Cn lõm sng 5.1 Xột nghim: Cỏc ch s xột nghim Hng cu Hemoglobin Bch cu Tiu cu ng mỏu GOT GPT AFP APTT PT Fibrinogen n v T/L g/l G/l G/l mmol/l U/l U/l UI/mL S % g/L Kt qu Siờu õm tim: Bỡnh thng Bt thng (c th ) in tõm : Bỡnh thng Bt thng 5.2 (c th ) Chn oỏn hỡnh nh: Siờu õm: c im Tng õm Gim õm Hn hp õm Tng õm phớa sau Vũng gim õm quanh u CLVT Cú Khụng - Trc tiờm thuc cn quang c im hỡnh nh Cú Khụng Gim t trng ng nht Gim t trng khụng ng nht Tng t trng - Sau tiờm thuc cn quang Thỡ ng mch c im hỡnh nh Ngm thuc sm ngoi vi Ngm chm, khụng rừ Khụng ngm thuc Tnh mch ca Ngm thuc hng tõm Khụng rừ Khụng ngm thuc Mun Ngm thuc hon ton Cú Khụng Ngm thuc khụng hon ton Khụng ngm thuc Cng hng t - Tớn hiu trc tiờm c im Tớn hiu trờn T1 Cú Khụng Cú Khụng Tng tớn hiu Gim tớn hiu ng tớn hiu Tng tớn hiu Gim tớn hiu ng tớn hiu Tớn hiu trờn T2 - Tớn hiu sau tiờm Thỡ ng mch c im hỡnh nh Ngm thuc sm ngoi vi Ngm chm, khụng rừ Khụng ngm thuc Tnh mch ca Ngm thuc hng tõm Khụng rừ Khụng ngm thuc Mun Ngm thuc hon ton Ngm thuc khụng hon ton Khụng ngm thuc S lng u mch mỏu gan: V trớ: Gan trỏi Gan phi Kớch thc: (mm) Phõn loi: U mch mỏu gan n U mch mỏu gan a U mch mỏu gan lan ta iu tr u mch mỏu gan bng propranolol ng ung 6.1 Ch nh iu tr Ch nh Cỏc u mch mỏu gan ln 40 mm Cỏc u mch mỏu gan tng kớch thc quỏ trỡnh theo dừi U mch mỏu gan a , lan ta 6.2 6.3 6.4 6.5 Ngy bt u iu tr: Liu u: .(mg /kg/ngy) Liu trỡ: .(mg /kg/ngy) Thi gian dựng thuc: Tỏc dng ph iu tr propranolol Tỏc dng ph Nhp tim chm H huyt ỏp H ng mỏu Ri lon gic ng Ri lon tiờu húa Co tht ph qun Cú Khụng 6.6 Ch nh dng iu tr : Cú Khụng Nu cú: Khụng cũn u Kớch thc < 10 mm, cú vụi húa Khi u khụng tin trin, chuyn phng phỏp khỏc ( c th ) Do tỏc dng ph ca thuc ... TRNG I HC Y H NI V TH THY NHậN XéT HI U QUả ĐI U TRị U MạCH M U GAN TRẻ EM BằNG PROPRANOLOL Chuyờn ngnh: Nhi khoa Mó s: 06720135 LUN VN THC S Y HC Ngi hng dn khoa hc: TS Nguyn Phm Anh Hoa H NI 2016... m u gan tr em bng propranolol vi hai mc ti u sau: Mụ t c im lõm sng, cn lõm sng ca u mch m u gan tr em Nhn xột hiu qu iu tr u mch m u gan bng propranolol 11 CHNG TNG QUAN 1.1 U mch m u tr em. .. ca u U mch m u gan c chia lm loi chớnh: u mch m u th hang (cavernous hemangioma) v u mch m u mao mch (capillary hemangioma), ú hu ht u mch m u gan u l th hang [5] + U mch m u th hang ca gan U