{"id":10457,"date":"2021-11-09T06:00:18","date_gmt":"2021-11-09T06:00:18","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=10457"},"modified":"2022-07-11T07:46:05","modified_gmt":"2022-07-11T07:46:05","slug":"caso-clinico-sindrome-arteria-mesenterica-superior","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/caso-clinico-sindrome-arteria-mesenterica-superior\/","title":{"rendered":"Caso cl\u00ednico: s\u00edndrome de art\u00e9ria mesenterica superior"},"content":{"rendered":"

Paciente, feminina, 20 anos, com diagn\u00f3stico de l\u00fapus eritematoso sist\u00eamico h\u00e1 2 meses, em uso prednisona 40 mg\/dia. Evoluiu com n\u00e1useas e v\u00f4mitos refrat\u00e1rios \u00e0 terapia medicamentosa, associados \u00e0 inapet\u00eancia, desidrata\u00e7\u00e3o e perda ponderal de 8 kg nesse per\u00edodo. Apresentava IMC 17.2 e hipocalemia ao exame laboratorial. Durante investiga\u00e7\u00e3o, realizou tomografia de abdome <\/span>(Figuras 1 e 2)<\/b> com evid\u00eancia de hiperdistens\u00e3o g\u00e1strica, obstru\u00e7\u00e3o em 3\u00aa por\u00e7\u00e3o duodenal e diminui\u00e7\u00e3o do \u00e2ngulo aortomesent\u00e9rico, tendo como principal suspeita diagn\u00f3stica a s\u00edndrome da art\u00e9ria mesent\u00e9rica superior. Realizou tamb\u00e9m enteroscopia <\/span>(Figura 3)<\/b>, mostrando estase alimentar moderada e abaulamento puls\u00e1til entre segunda e terceira por\u00e7\u00e3o duodenal, provocando redu\u00e7\u00e3o da luz do \u00f3rg\u00e3o, achados que tamb\u00e9m eram compat\u00edveis com a suspeita cl\u00ednica inicial. <\/span><\/p>\n

\"An\u00e1lise

Figura 1: An\u00e1lise comparativa entre tomografias de abdome realizadas com 21 dias de diferen\u00e7a, com redu\u00e7\u00e3o do \u00e2ngulo aortomesent\u00e9rico provocando obstru\u00e7\u00e3o duodenal (direita). AMS: art\u00e9ria mesent\u00e9rica superior; AA: art\u00e9ria aorta.<\/p><\/div>\n

\"Hiperdistens\u00e3o

Figura 2: Hiperdistens\u00e3o g\u00e1strica e obstru\u00e7\u00e3o em 3\u00aa por\u00e7\u00e3o duodenal em tomografia de abdome.<\/p><\/div>\n

\"Enteroscopia

Figura 3: Enteroscopia \u2013 abaulamento entre segunda e terceira por\u00e7\u00e3o duodenal, provocando redu\u00e7\u00e3o da luz do \u00f3rg\u00e3o.<\/p><\/div>\n

Ap\u00f3s medidas cl\u00ednicas para sintomas de obstru\u00e7\u00e3o intestinal alta \u2013 dieta zero, passagem de sonda nasog\u00e1strica sob aspira\u00e7\u00e3o, hidrata\u00e7\u00e3o venosa, corre\u00e7\u00e3o de dist\u00farbios hidroeletrol\u00edticos e otimiza\u00e7\u00e3o de antiem\u00e9ticos \u2013, paciente evoluiu sem melhora dos sintomas, retornando o quadro de n\u00e1useas, v\u00f4mitos e distens\u00e3o abdominal.<\/span><\/p>\n

Optado, ent\u00e3o, por tratamento cir\u00fargico, sendo submetida \u00e0 duodenojejunostomia videolaparosc\u00f3pica. Cursou com plenitude p\u00f3s-prandial e novos epis\u00f3dios em\u00e9ticos no 2\u00ba dia do p\u00f3s-operat\u00f3rio, sendo iniciadas medidas cl\u00ednicas com passagem de sonda nasog\u00e1strica sob aspira\u00e7\u00e3o e, posteriormente, sendo iniciada dieta por sonda nasoenteral e nutri\u00e7\u00e3o parenteral total, por\u00e9m paciente persistiu com sintomas obstrutivos.<\/span><\/p>\n

Evoluiu com abdome agudo obstrutivo no 13\u00ba dia do p\u00f3s-operat\u00f3rio, realizando laparotomia exploradora, que evidenciou anastomose duodenojejunal sanfonada com acotovelamento em al\u00e7a eferente por bridas em mesoc\u00f3lon transverso, sendo realizada gastroenteroanastomose. Evoluiu com melhora cl\u00ednica progressiva, resolu\u00e7\u00e3o completa do quadro de v\u00f4mitos e ganho gradativo de peso.<\/span><\/p>\n

S\u00edndrome da art\u00e9ria mesent\u00e9rica superior<\/h2>\n

A s\u00edndrome da art\u00e9ria mesent\u00e9rica superior (SAMS) \u00e9 uma causa incomum de obstru\u00e7\u00e3o intestinal alta caracterizada pela compress\u00e3o da terceira por\u00e7\u00e3o duodenal devido ao estreitamento do espa\u00e7o entre a art\u00e9ria mesent\u00e9rica superior e a aorta. \u00c9 tamb\u00e9m conhecida como s\u00edndrome de Wilkie, tendo sido descrita pela primeira vez em 1861 por Von Rokitansky [1].<\/span><\/p>\n

Na maioria dos pacientes, o \u00e2ngulo aortomesent\u00e9rico mede entre 38\u00b0 e 65\u00b0, podendo ser reduzido at\u00e9 6\u00b0 na SAMS, estando essa redu\u00e7\u00e3o relacionada com o \u00edndice de massa corporal, sendo a perda significativa de peso o seu principal fator de risco [2,3].<\/span><\/p>\n

Apresenta-se clinicamente com sintomas de obstru\u00e7\u00e3o intestinal alta, podendo o paciente cursar com dor epig\u00e1strica p\u00f3s-prandial e saciedade precoce em quadros mais leves, h\u00e1 n\u00e1useas, v\u00f4mitos biliosos e perda ponderal em casos mais severos. Para o diagn\u00f3stico, \u00e9 necess\u00e1rio um alto \u00edndice de suspei\u00e7\u00e3o, visto que os sintomas s\u00e3o inespec\u00edficos e pode fazer diagn\u00f3stico diferencial com outras causas de obstru\u00e7\u00e3o intestinal.<\/span><\/p>\n

A realiza\u00e7\u00e3o de exames de imagem, como estudos contrastados, ultrassonografia, tomografia computadorizada, resson\u00e2ncia magn\u00e9tica e arteriografia, pode fornecer uma s\u00e9rie de sinais compat\u00edveis com a SAMS, como \u00e2ngulo aortomesent\u00e9rico <\/span> 25\u00b0 e afilamento abrupto na terceira por\u00e7\u00e3o duodenal com peristalse ativa [4,5,6].<\/span><\/p>\n

O principal componente da terapia conservadora \u00e9 o suporte nutricional, associado \u00e0 descompress\u00e3o gastrointestinal atrav\u00e9s da passagem de uma sonda nasog\u00e1strica e corre\u00e7\u00e3o dos dist\u00farbios hidroeletrol\u00edticos. A nutri\u00e7\u00e3o parenteral total (NPT) pode ser necess\u00e1ria caso a alimenta\u00e7\u00e3o enteral n\u00e3o seja uma op\u00e7\u00e3o [7]. Em caso de falha do tratamento conservador, a duodenojejunostomia laparosc\u00f3pica \u00e9 o procedimento cir\u00fargico mais utilizado e com resultados superiores \u00e0s outras t\u00e9cnicas [8], entre elas, o procedimento de Strong e a gastrojejunostomia.<\/span><\/p>\n

Existem poucos relatos de resultados a longo prazo no p\u00f3s-cir\u00fargico de pacientes com SAMS. Uma s\u00e9rie incluiu 16 pacientes que foram acompanhados sete anos ap\u00f3s a cirurgia, sendo a perda ponderal corrigida em todos os pacientes, por\u00e9m os sintomas praticamente se mantiveram, com exce\u00e7\u00e3o dos v\u00f4mitos, que apresentaram diminui\u00e7\u00e3o significativa<\/span>8<\/span>. Em outra s\u00e9rie, foram inclu\u00eddos oito pacientes, com melhora dos sintomas, por\u00e9m sem ganho significativo de peso [9].<\/span><\/p>\n

Como citar este artigo<\/h2>\n

Amaral K, Medrado B. Caso cl\u00ednico: s\u00edndrome de art\u00e9ria mesenterica superior. Endoscopia Terap\u00eautica; 2021. Dispon\u00edvel em:<\/span> https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/caso-clinico-sindrome-arteria-mesenterica-superior\/<\/span><\/p>\n

Refer\u00eancias bibliogr\u00e1ficas<\/h2>\n
    \n
  1. Cohen LB, et al. The Superior mesenteric artery syndrome. J Clin Gastr 1985; 7: 113-116.<\/span><\/li>\n
  2. Derrick Jr. Anatomia cir\u00fargica da art\u00e9ria mesent\u00e9rica superior. Am Surg 1965; 31:545.<\/span><\/a><\/li>\n
  3. Ozkurt H, Cenker MM, Bas N, et al. Medi\u00e7\u00e3o da dist\u00e2ncia e \u00e2ngulo entre a aorta e a art\u00e9ria mesent\u00e9rica superior: valores normais em diferentes categorias de IMC. Surg Radiol Anat 2007; 29:595.<\/span><\/a><\/li>\n
  4. Cohen LB, Field SP, Sachar DB. A s\u00edndrome da art\u00e9ria mesent\u00e9rica superior. A doen\u00e7a que n\u00e3o \u00e9, ou \u00e9? J Clin Gastroenterol 1985; 7:113.<\/span><\/a><\/li>\n
  5. Neri S, Signorelli SS, Mondati E, et al. Ultrassom de imagem no diagn\u00f3stico de s\u00edndrome arterial mesent\u00e9rica superior. J Intern Med 2005; 257:346.<\/span><\/a><\/li>\n
  6. Unal B, Akta\u015f A, Kemal G, et al. S\u00edndrome da art\u00e9ria mesent\u00e9rica superior: TC e ultrassonografia. Diagn Interv Radiol 2005; 11:90.<\/span><\/a><\/li>\n
  7. Munns SW, Morrissy RT, Golladay ES, McKenzie CN. Hiperalimenta\u00e7\u00e3o para s\u00edndrome mesent\u00e9rica superior (elenco) ap\u00f3s corre\u00e7\u00e3o da deformidade espinhal. J Bone Joint Surg Am 1984; 66:1175.<\/span><\/a><\/li>\n
  8. Ylinen P, Kinnunen J, H\u00f6ckerstedt K. S\u00edndrome da art\u00e9ria mesent\u00f3rica superior. Um estudo de acompanhamento de 16 pacientes operados. J Clin Gastroenterol 1989; 11:386.<\/span><\/a><\/li>\n
  9. Merrett ND, Wilson RB, Cosman P, Biankin AV. S\u00edndrome da art\u00e9ria mesent\u00e9rica superior: estrat\u00e9gias de diagn\u00f3stico e tratamento. J Gastrointest Surg 2009; 13:287.<\/span><\/a><\/li>\n<\/ol>\n

    Acesse o <\/span>Endoscopia Terap\u00eautica<\/span><\/a> para tomar contato com mais <\/span>artigos comentados<\/span><\/a>, <\/span>assuntos gerais<\/span><\/a>, <\/span>casos cl\u00ednicos<\/span><\/a>, <\/span>quizzes<\/span><\/a>, <\/span>classifica\u00e7\u00f5es<\/span><\/a> e mais!<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

    Paciente, feminina, 20 anos, com diagn\u00f3stico de l\u00fapus eritematoso sist\u00eamico h\u00e1 2 meses, em…<\/p>\n","protected":false},"author":726,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[],"ano":[262],"tipo":[153],"volume":[147],"class_list":["post-10457","post","type-post","status-publish","format-standard","hentry","category-casosclinicos","ano-262","tipo-endoscopia-digestiva-alta","volume-volume-ii"],"yoast_head":"\nCaso cl\u00ednico: s\u00edndrome de art\u00e9ria mesenterica superior • Endoscopia Terapeutica<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/caso-clinico-sindrome-arteria-mesenterica-superior\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Caso cl\u00ednico: s\u00edndrome de art\u00e9ria mesenterica superior\" \/>\n<meta property=\"og:description\" content=\"Paciente, feminina, 20 anos, com diagn\u00f3stico de l\u00fapus eritematoso sist\u00eamico h\u00e1 2 meses, em uso prednisona 40 mg\/dia. 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