{"id":18293,"date":"2024-02-28T12:00:54","date_gmt":"2024-02-28T12:00:54","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=18293"},"modified":"2024-02-28T16:15:53","modified_gmt":"2024-02-28T16:15:53","slug":"sindrome-de-lemmel","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/sindrome-de-lemmel\/","title":{"rendered":"S\u00edndrome de Lemmel"},"content":{"rendered":"\n

Introdu\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n

A incid\u00eancia de divert\u00edculos duodenais \u00e9 rara e varia entre 1-27%, sendo mais frequente a localiza\u00e7\u00e3o periampular (70-75%). A s\u00edndrome de Lemmel trata-se da obstru\u00e7\u00e3o do ducto biliar devido a a\u00e7\u00e3o de um divert\u00edculo duodenal periampular quando o mesmo comprime ou obstrui a via biliar, podendo ocasionar sintomas como icter\u00edcia, dor abdominal e altera\u00e7\u00f5es nos n\u00edveis de enzimas hep\u00e1ticas na aus\u00eancia de coledocolit\u00edase (vide Figura 1). \u00c9 uma condi\u00e7\u00e3o que precisa ser considerada em casos de obstru\u00e7\u00e3o biliar inexplicada, especialmente em pacientes com divert\u00edculos duodenais.<\/p>\n\n\n

\n
\"\"<\/a>
Fig 1. Divert\u00edculo duodenal. Ilustra\u00e7\u00e3o cedida pela Dra. Fernanda Prado Logiudice (SP).<\/em><\/figcaption><\/figure>\n<\/div>\n\n\n

Classifica\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n

Pode ser classificada de acordo com a posi\u00e7\u00e3o da papila em rela\u00e7\u00e3o ao divert\u00edculo: tipo I (intradiverticular), II (peridiverticular) ou III (pr\u00f3ximo ao divert\u00edculo). Em nosso caso foi identificada atrav\u00e9s de duodenoscopia o tipo II, conforme ilustrado na imagem abaixo (Figura 2).<\/p>\n\n\n

\n
\"\"<\/a>
Fig 2. Duodenoscopia da papila duodenal maior peridiverticular (esq).
Imagem cedida por Dr. Diego Rangel (BA) e Dra. S\u00e2mara Martins (BA).<\/em><\/figcaption><\/figure>\n<\/div>\n\n\n

Sintomatologia<\/strong><\/h2>\n\n\n\n

A maioria dos casos \u00e9 assintom\u00e1tica e diagnosticada incidentalmente durante exames endosc\u00f3picos, mas complica\u00e7\u00f5es podem ocorrer em 5% dos casos, como colangite, icter\u00edcia obstrutiva, sangramento, perfura\u00e7\u00e3o, diverticulite, pancreatite e coledocolit\u00edase.<\/p>\n\n\n\n

Diagn\u00f3stico<\/strong><\/h2>\n\n\n\n

Exames laboratoriais podem estar alterados, como n\u00edvel de bilirrubinas e enzimas canaliculares e hep\u00e1ticas, entretanto, n\u00e3o s\u00e3o determinantes para o diagn\u00f3stico da S\u00edndrome de Lemmel, pois podem estar dentro dos n\u00edveis da normalidade. Dentre os exames de imagem, a colangiopancreatografia retr\u00f3grada endosc\u00f3pica (CPRE) demonstra-se mais abrangente, j\u00e1 que utiliza a endoscopia de vis\u00e3o lateral (duodenoscopia) para identifica\u00e7\u00e3o do divert\u00edculo periampular e a colangiografia para avaliar a dilata\u00e7\u00e3o da via biliar, al\u00e9m de possibilitar a terap\u00eautica. Apesar disso, os exames de tomografia computadorizada, resson\u00e2ncia magn\u00e9tica e endoscopia digestiva alta s\u00e3o inicialmente mais utilizados devido ao f\u00e1cil acesso. Al\u00e9m deles, outros exames de imagem tamb\u00e9m podem ser utilizados, como exame radiol\u00f3gico contrastado, ultrassonografia endosc\u00f3pica ou mesmo a laparoscopia. No caso em quest\u00e3o, a paciente j\u00e1 havia realizado exame de resson\u00e2ncia de abdome (Figura 3) e ecoendoscopia, ambos corroborando a hip\u00f3tese diagn\u00f3stica.<\/p>\n\n\n

\n
\"\"<\/a>
Fig 3. Colangiorresson\u00e2ncia demonstrando dilata\u00e7\u00e3o da via biliar extra-hep\u00e1tica e divert\u00edculo duodenal identificado pela seta.<\/em><\/figcaption><\/figure>\n<\/div>\n\n\n

Tratamento<\/strong><\/h2>\n\n\n\n

O tratamento, apesar de ainda n\u00e3o bem estabelecido pela literatura, \u00e9 baseado na sintomatologia e, portanto, sendo recomendada abordagem conservadora em pacientes assintom\u00e1ticos. A esfincterotomia atrav\u00e9s de CPRE com ou sem coloca\u00e7\u00e3o de stent<\/em> pode ser uma excelente op\u00e7\u00e3o terap\u00eautica para pacientes com obstru\u00e7\u00e3o da via biliar ou mesmo colangite. Outra op\u00e7\u00e3o terap\u00eautica poss\u00edvel \u00e9 o tratamento cir\u00fargico atrav\u00e9s da diverticulectomia, entretanto, com elevada morbimortalidade. No caso ilustrado (Figuras 4-6), a paciente foi tratada com esfincterotomia e esfincteroplastia com bal\u00e3o, seguida de drenagem da via biliar com pr\u00f3tese biliar pl\u00e1stica.<\/p>\n\n\n

\n
\"\"<\/a>
Fig 4. Imagem colangiogr\u00e1fica da CPRE exibindo dilata\u00e7\u00e3o importante da via biliar principal.
Imagem cedida por Dr. Diego Rangel (BA) e Dra. S\u00e2mara Martins (BA).<\/em><\/figcaption><\/figure>\n<\/div>\n\n
\n
\"\"
Fig 5. Papilotomia endosc\u00f3pica (esq.). Dilata\u00e7\u00e3o endosc\u00f3pica da papila com bal\u00e3o (dir.).
Imagens cedidas por Dr. Diego Rangel (BA) e Dra. S\u00e2mara Martins (BA).<\/em><\/figcaption><\/figure>\n<\/div>\n\n
\n
\"\"
Fig 6. Drenagem endosc\u00f3pica da via biliar com pr\u00f3tese pl\u00e1stica: imagem endosc\u00f3pica (esq.) e imagem colangiogr\u00e1fica (dir.). Imagens cedidas por Dr. Diego Rangel (BA) e Dra. S\u00e2mara Martins (BA).<\/em><\/figcaption><\/figure>\n<\/div>\n\n\n

Refer\u00eancias<\/strong><\/h2>\n\n\n\n
    \n
  1. Love JS, Yellen M, Melitas C, et al.<\/em> Diagnosis and Management of Lemmel Syndrome: An Unusual Presentation and Literature Review. Case Rep Gastroenterol 2022; Dec 16;16(3):663-674. doi:10.1159\/000528031.<\/li>\n\n\n\n
  2. Battah A, Farouji I, DaCosta TR, et al<\/em>. Lemmel’s Syndrome: A Rare Complication of Periampullary Diverticula. Cureus 2023; Mar 16;15(3):e36236. doi: 10.7759\/cureus.36236.<\/li>\n<\/ol>\n\n\n\n

    Como citar este artigo<\/strong><\/h2>\n\n\n\n

    Martins S. e Logiudice FP. Endoscopia Terapeutica, 2024 vol I. Dispon\u00edvel em: https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/sindrome-de-lemmel\/<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

    Introdu\u00e7\u00e3o A incid\u00eancia de divert\u00edculos duodenais \u00e9 rara e varia entre 1-27%, sendo mais…<\/p>\n","protected":false},"author":5616,"featured_media":18294,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[294,747,746],"ano":[742],"tipo":[155],"volume":[263],"class_list":["post-18293","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","tag-cpre","tag-diverticulo-duodenal","tag-lemmel","ano-742","tipo-cpre","volume-volume-i"],"yoast_head":"\nS\u00edndrome de Lemmel • Endoscopia Terapeutica<\/title>\n<meta name=\"description\" content=\"Conhe\u00e7a mais sobre a S\u00edndrome de Lemmel, seus sintomas, diagn\u00f3stico e tratamento!\" \/>\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\/assuntosgerais\/sindrome-de-lemmel\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"S\u00edndrome de Lemmel\" \/>\n<meta property=\"og:description\" content=\"Introdu\u00e7\u00e3o A incid\u00eancia de divert\u00edculos duodenais \u00e9 rara e varia entre 1-27%, sendo mais frequente a localiza\u00e7\u00e3o periampular (70-75%). 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