{"id":15635,"date":"2023-04-25T06:30:23","date_gmt":"2023-04-25T06:30:23","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=15635"},"modified":"2023-06-03T14:29:32","modified_gmt":"2023-06-03T14:29:32","slug":"diverticulo-intraduodenal-windsock-diverticulum-uma-causa-rara-de-obstrucao-intestinal-alta","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/diverticulo-intraduodenal-windsock-diverticulum-uma-causa-rara-de-obstrucao-intestinal-alta\/","title":{"rendered":"Divert\u00edculo Intraduodenal (\u201cWindsock Diverticulum\u201d): uma causa rara de obstru\u00e7\u00e3o intestinal alta"},"content":{"rendered":"\n<p>Paciente feminina, 19 anos, previamente h\u00edgida, iniciou com quadro de distens\u00e3o abdominal e v\u00f4mitos p\u00f3s-alimentares recorrentes h\u00e1 cerca de 30 dias. Referia perda ponderal de 3 Kg no per\u00edodo.&nbsp;<\/p>\n\n\n\n<p>Negava outras comorbidades, uso de medicamentos ou cirurgias pr\u00e9vias.<\/p>\n\n\n\n<p>Ao exame f\u00edsico mostrava-se emagrecida, desidratada e com abdome distendido em regi\u00e3o epig\u00e1strica. Sem outras altera\u00e7\u00f5es.<\/p>\n\n\n\n<p>Tomografia de abdome evidenciava espessamento inespec\u00edfico em segunda por\u00e7\u00e3o duodenal promovendo dilata\u00e7\u00e3o do bulbo e da c\u00e2mara g\u00e1strica.<\/p>\n\n\n\n<p>Foi ent\u00e3o submetida \u00e0 endoscopia digestiva alta que mostrou septo espesso na transi\u00e7\u00e3o do bulbo para a segunda por\u00e7\u00e3o duodenal, com forma\u00e7\u00e3o de grande divert\u00edculo intraduodenal, com pequeno orif\u00edcio no fundo diverticular, que n\u00e3o permitia a passagem do endosc\u00f3pio. A papila duodenal maior encontrava-se na borda do septo e era poss\u00edvel transpor o aparelho para a segunda por\u00e7\u00e3o duodenal, pela lateral do divert\u00edculo, sem dificuldades.<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_1.jpg\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" width=\"404\" height=\"329\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_1.jpg\" alt=\"\" class=\"wp-image-15769\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_1.jpg?v=1681350186 404w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_1-300x244.jpg?v=1681350186 300w\" sizes=\"(max-width: 404px) 100vw, 404px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 1: imagem endosc\u00f3pico do divert\u00edculo intraduodenal. Seta verde: divert\u00edculo. Seta preta: septo do divert\u00edculo. Seta azul: segunda por\u00e7\u00e3o duodenal.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><img decoding=\"async\" width=\"417\" height=\"331\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_2.jpg\" alt=\"\" class=\"wp-image-15770\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_2.jpg?v=1681350459 417w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_2-300x238.jpg?v=1681350459 300w\" sizes=\"(max-width: 417px) 100vw, 417px\" \/><figcaption class=\"wp-element-caption\"><strong>Figura 2: imagem endosc\u00f3pica do fundo do divert\u00edculo. Seta preta: orif\u00edcio no fundo diverticular.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_3.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" width=\"413\" height=\"326\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_3.jpg\" alt=\"\" class=\"wp-image-15771\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_3.jpg?v=1681350504 413w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_3-300x237.jpg?v=1681350504 300w\" sizes=\"(max-width: 413px) 100vw, 413px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 3: imagem endosc\u00f3pica mostrando a rela\u00e7\u00e3o entre o divert\u00edculo e a papila duodenal maior (seta preta).<br><\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<p>Ap\u00f3s discuss\u00e3o com a paciente e com a equipe cir\u00fargica sobre as possibilidades terap\u00eauticas, foi optado pela tentativa de tratamento endosc\u00f3pico.<\/p>\n\n\n\n<p>O procedimento foi realizado com a paciente sob anestesia geral, sendo incialmente identificada a papila duodenal maior e iniciado o corte longe da sua localiza\u00e7\u00e3o. Foi realizada sec\u00e7\u00e3o de todo o septo do divert\u00edculo, com aux\u00edlio de cateter tipo \u201cneedle-knife\u201d, da sua por\u00e7\u00e3o inicial na transi\u00e7\u00e3o do bulbo para a segunda por\u00e7\u00e3o duodenal at\u00e9 o seu orif\u00edcio distal. Em seguida foi realizada hemostasia das duas bordas com aplica\u00e7\u00e3o de clipes met\u00e1licos. Procedimento transcorreu sem intercorr\u00eancias e a paciente foi encaminhada para o quarto.<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_4.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" width=\"386\" height=\"380\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_4.jpg\" alt=\"\" class=\"wp-image-15772\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_4.jpg?v=1681350543 386w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_4-300x295.jpg?v=1681350543 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_4-70x70.jpg?v=1681350543 70w\" sizes=\"(max-width: 386px) 100vw, 386px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 4: imagem endosc\u00f3pica ap\u00f3s a sec\u00e7\u00e3o do septo do divert\u00edculo.<br><\/strong><\/figcaption><\/figure>\n<\/div>\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_5.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" width=\"398\" height=\"382\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_5.jpg\" alt=\"\" class=\"wp-image-15773\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_5.jpg?v=1681350610 398w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_5-300x288.jpg?v=1681350610 300w\" sizes=\"(max-width: 398px) 100vw, 398px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 5: imagem endosc\u00f3pica da hemostasia do septo do divert\u00edculo.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<p>No segundo dia de p\u00f3s-operat\u00f3rio, a paciente apresentou epis\u00f3dio de hemat\u00eamese volumosa, com instabilidade hemodin\u00e2mica, sendo ent\u00e3o encaminhada para a unidade de tratamento intensivo. Foi submetida a nova endoscopia digestiva alta que mostrou sangramento ativo nas bordas seccionadas do divert\u00edculo, apesar dos clipes met\u00e1licos posicionados. Foi optado, ent\u00e3o, pelo tratamento combinado com inje\u00e7\u00e3o de solu\u00e7\u00e3o de adrenalina e coloca\u00e7\u00e3o de mais clipes met\u00e1licos, com parada do sangramento.<\/p>\n\n\n\n<p>Paciente n\u00e3o apresentou recorr\u00eancia do sangramento sendo reiniciada dieta por via oral, com boa aceita\u00e7\u00e3o, 48 horas ap\u00f3s a segunda endoscopia.&nbsp;Recebeu alta no 6 PO, com boa toler\u00e2ncia alimentar, sem queixas.<\/p>\n\n\n\n<p>Paciente retornou 30 dias ap\u00f3s o procedimento, assintom\u00e1tica, para realiza\u00e7\u00e3o de endoscopia digestiva alta de controle. Procedimento evidenciou apenas pequenos septos seccionados remanescentes na transi\u00e7\u00e3o do bulbo para a segunda por\u00e7\u00e3o duodenal, sem forma\u00e7\u00e3o diverticular residual, com f\u00e1cil transposi\u00e7\u00e3o do endosc\u00f3pio para a segunda por\u00e7\u00e3o duodenal.<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_6.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" width=\"435\" height=\"353\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_6.jpg\" alt=\"\" class=\"wp-image-15774\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_6.jpg?v=1681350669 435w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/04\/fig_6-300x243.jpg?v=1681350669 300w\" sizes=\"(max-width: 435px) 100vw, 435px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 6: imagem endosc\u00f3pica do controle ap\u00f3s 30 dias do procedimento.<br><\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<h2 class=\"wp-block-heading\"><strong>Discuss\u00e3o<\/strong><\/h2>\n\n\n\n<p>O divert\u00edculo intraduodenal, tamb\u00e9m chamado de \u201cwindsock diverticulum\u201d, \u00e9 uma anomalia cong\u00eanita rara, secund\u00e1ria a recanaliza\u00e7\u00e3o incompleta do intestino anterior durante o desenvolvimento embrion\u00e1rio. Inicialmente ele teria o aspecto de uma membrana ou diafragma duodenal e que, com o passar dos anos e com a peristalse, passaria a ter um aspecto mais alongado, formando o divert\u00edculo. Seu nome \u201cwindsock diverticulum\u201d seria devido a semelhan\u00e7a de seu formato com uma biruta, windsock em ingl\u00eas (1).&nbsp;<\/p>\n\n\n\n<p>Ele foi inicialmente descrito em 1885 por Silock e consiste em uma forma\u00e7\u00e3o diverticular alongada, localizada na segunda por\u00e7\u00e3o duodenal, adjacente \u00e0 papila duodenal maior (2). Um orif\u00edcio na sua por\u00e7\u00e3o distal pode ou n\u00e3o estar presente.<\/p>\n\n\n\n<p>Em geral, o divert\u00edculo intraduodenal \u00e9 assintom\u00e1tico e identificado incidentalmente. Sua sintomatologia pode ser muito vari\u00e1vel como n\u00e1useas, v\u00f4mitos, empachamento, distens\u00e3o ou dor abdominal e, mais raramente, hemorragia digestiva alta, pancreatite aguda ou obstru\u00e7\u00e3o intestinal (3).<\/p>\n\n\n\n<p>O diagn\u00f3stico pode ser feito atrav\u00e9s da endoscopia digestiva alta ou de exames radiol\u00f3gicos, como tomografia computadorizada com contraste oral ou raio X contrastado de es\u00f4fago, est\u00f4mago e duodeno (4).<\/p>\n\n\n\n<p>O tratamento pode ser cir\u00fargico ou endosc\u00f3pico, n\u00e3o existindo recomenda\u00e7\u00e3o quanto a melhor t\u00e9cnica devido a baixa preval\u00eancia do divert\u00edculo intraduodenal. Tem se dado prefer\u00eancia ao endosc\u00f3pico pela sua menor morbidade (1).&nbsp;&nbsp;<\/p>\n\n\n\n<p>Existem diferentes t\u00e9cnicas descritas para o tratamento endosc\u00f3pico, variando desde a diverticulectomia com aux\u00edlio de al\u00e7a de polipectomia at\u00e9 a diverticulotomia com a utiliza\u00e7\u00e3o do \u201cneedle-knife\u201d (1). Independente da t\u00e9cnica escolhida, dois cuidados s\u00e3o fundamentais, a identifica\u00e7\u00e3o da papila previamente \u00e0 realiza\u00e7\u00e3o do procedimento, devido a proximidade do divert\u00edculo com a papila maior, e a realiza\u00e7\u00e3o de hemostasia cuidadosa, uma vez que o divert\u00edculo \u00e9 muito vascularizado e a chance de sangramento p\u00f3s-procedimento \u00e9 alta (1).<\/p>\n\n\n\n<p>Apesar de ser uma entidade rara, o m\u00e9dico endoscopista deve estar atento ao diagn\u00f3stico do divert\u00edculo intraduodenal em pacientes com sintomas gastrointestinais altos. O tratamento endosc\u00f3pico apresenta bons resultados e deve ser considerado em pacientes sintom\u00e1ticos.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Law R, Topazian M, Baron TH. Endoscopic treatment of intraluminal duodenal (\u201cwindsock\u201d) diberticulum: varying techniques from five cases. Endoscopy 2012;44:1161-1164.<\/li>\n\n\n\n<li>Silock AQ. Ephithelioma of de ascending colon: enterocolitis, congenital duodenal septum with internal diverticulum. Trans Pathol Soc London 1885;36:207.<\/li>\n\n\n\n<li>Odemis B, Baspinar B, Erdogan C, et al. A rare case of a windsock-shaped intraluminal duodenal diverticulum treated successfully with endoscopic diverticulectomy. Endoscopy 2022;54:E914-E915.<\/li>\n\n\n\n<li>Karagyozov P, Tishkov I, Gdeorgieva Z, et al. Endoscopy International Open 2019;07:E87-E89.<\/li>\n<\/ol>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Como citar este arquivo<\/strong><\/h2>\n\n\n\n<p class=\"has-background\" style=\"background-color:#ddddea\">Retes FA. Divert\u00edculo Intraduodenal (\u201cWindsock Diverticulum\u201d): uma causa rara de obstru\u00e7\u00e3o intestinal alta. Endoscopia Terapeutica 2023 Vol 1. Dispon\u00edvel em: <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/?p=15635\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/endoscopiaterapeutica.net\/pt\/diverticulo-intraduodenal-windsock-diverticulum-uma-causa-rara-de-obstrucao-intestinal-alta\/<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Paciente feminina, 19 anos, previamente h\u00edgida, iniciou com quadro de distens\u00e3o abdominal e v\u00f4mitos&hellip;<\/p>\n","protected":false},"author":5650,"featured_media":15644,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[],"ano":[555],"tipo":[153,157],"volume":[263],"class_list":["post-15635","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","ano-555","tipo-endoscopia-digestiva-alta","tipo-intestino-delgado","volume-volume-i"],"yoast_head":"<!-- This site is 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