{"id":18604,"date":"2024-05-07T07:30:00","date_gmt":"2024-05-07T07:30:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=18604"},"modified":"2024-06-06T15:49:09","modified_gmt":"2024-06-06T15:49:09","slug":"volvo-de-transverso-em-paciente-com-sindrome-de-west","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/volvo-de-transverso-em-paciente-com-sindrome-de-west\/","title":{"rendered":"Volvo de transverso em paciente com S\u00edndrome de West"},"content":{"rendered":"\n

Autores: Fl\u00e1vio Ferreira, Elba Alves, Diego Malta, Ewandson Pedroza, Rebecca Rushansky<\/em><\/strong><\/h2>\n\n\n\n

Paciente de 16 anos, feminina, portadora de s\u00edndrome de West, desnutrida com importante sequela motora e retardo mental em decorr\u00eancia de doen\u00e7a de base caracterizada por crises convulsivas frequentes desde a inf\u00e2ncia. Genitora relata que a paciente foi admitida em unidade de emerg\u00eancia com quadro de v\u00f4mitos, dor abdominal, diarreia h\u00e1 cerca de 4 dias, tendo recebido tratamento com hidrata\u00e7\u00e3o, analgesia e lavagem retal, sendo liberada em sequ\u00eancia. A paciente permaneceu com os mesmos sintomas, tendo evolu\u00eddo com piora importante da distens\u00e3o abdominal levando a novo atendimento em unidade de emerg\u00eancia ap\u00f3s 3 dias.\u00a0<\/p>\n\n\n\n

Na admiss\u00e3o a paciente encontrava-se caqu\u00e9tica, com posi\u00e7\u00e3o viciosa de membros,  taquipneica, murm\u00fario vesicular abolido em bases, padr\u00e3o respirat\u00f3rio de esfor\u00e7o, taquic\u00e1rdica, hipotensa com distens\u00e3o abdominal severa sendo poss\u00edvel identificar mosqueamento cut\u00e2neo em regi\u00e3o do abd\u00f4men, dor abdominal difusa sem sinais de irrita\u00e7\u00e3o peritoneal, aus\u00eancia de ru\u00eddos hidroa\u00e9reos, toque retal sem fezes ou les\u00f5es.<\/p>\n\n\n\n

Os principais exames laboratoriais evidenciam hemoglobina 7,7 g\/dl, leucograma  26.850 com 8% de bast\u00f5es, plaquetas 173.000  Ur\u00e9ia 20 Creatinina 0,5. Na gasometria arterial pH 7,48 com PCO2 19,8 bicarbonato de 19,1 e lactato de 3,5mmol\/l.<\/p>\n\n\n\n

Radiografia simples de abdome demonstra congest\u00e3o pulmonar, redu\u00e7\u00e3o dos espa\u00e7os\u00a0 intervertebrais em t\u00f3rax, distens\u00e3o abdominal severa, aus\u00eancia de pneumoperit\u00f4nio (Figura 1). A tomografia de abdome corrobora os achados do raio X simples de abdome, evidenciando ainda di\u00e2metro do c\u00f3lon de aproximadamente 13cm (Figura 2).\u00a0<\/p>\n\n\n

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Figura 1: Radiografia de t\u00f3rax e abdome PA<\/em><\/figcaption><\/figure>\n<\/div>\n\n
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Figura 2: tomografia de abdome sem contraste (A: distens\u00e3o col\u00f4nica exercendo efeito de massa sobre pulm\u00f5es e cora\u00e7\u00e3o ;\u00a0 B: distens\u00e3o col\u00f4nica em pelve; C e D distens\u00e3o com detalhe para aspecto em formato de U invertido com n\u00edvel hidroa\u00e9reo \u00e0 direita e esquerda)<\/em><\/figcaption><\/figure>\n<\/div>\n\n\n

Ap\u00f3s discuss\u00e3o multidisciplinar, optou-se pela tentativa de colonoscopia descompressiva, com equipe cir\u00fargica em sala para abordagem em caso de n\u00e3o resolu\u00e7\u00e3o ou complica\u00e7\u00f5es.<\/p>\n\n\n\n

Durante a colonoscopia percebe-se presen\u00e7a de res\u00edduos fecais em moderada quantidade, distens\u00e3o n\u00e3o importante de reto e sigmoide. Progress\u00e3o do aparelho por um segmento relevante sendo evidenciados res\u00edduos fecais, mucosa com \u00e1reas de enantema e certa friabilidade. Em determinado ponto, n\u00e3o sendo poss\u00edvel identificar qual segmento col\u00f4nico, o aparelho atingiu uma \u00e1rea de tor\u00e7\u00e3o com mucosa difusamente viol\u00e1cea, congesta. Ap\u00f3s a transposi\u00e7\u00e3o desta \u00e1rea o aparelho atinge c\u00f3lon extremamente distendido com mucosa enegrecida, fri\u00e1vel, indicando isquemia e necrose (Figura 3). Aspirado mais de 2000ml de l\u00edquido de estase e g\u00e1s com evidente redu\u00e7\u00e3o do volume abdominal da paciente (Figura 4).\u00a0\u00a0<\/p>\n\n\n

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Figura 3: Imagens da colonoscopia (A e B – sigm\u00f3ide e descendente; C a F – isquemia e necrose em transverso)\u00a0<\/em><\/figcaption><\/figure>\n<\/div>\n\n
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Figura 4: paciente antes e depois da colonoscopia descompressiva<\/em><\/figcaption><\/figure>\n<\/div>\n\n\n

Equipe cir\u00fargica procedeu ent\u00e3o laparotomia de emerg\u00eancia com achado de l\u00edquido citrino em cavidade abdominal, c\u00f3lon sigm\u00f3ide e descendente preservados; volvo em c\u00f3lon transverso o qual apresentava isquemia irrevers\u00edvel e necrose; ceco e c\u00f3lon ascendente distendidos por\u00e9m sem evid\u00eancias de isquemia (Figura 5). O procedimento cir\u00fargico realizado foi a ressec\u00e7\u00e3o do c\u00f3lon transverso com colostomia e sepultamento do coto distal.<\/p>\n\n\n

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Figura 5 – imagens da cirurgia<\/em><\/figcaption><\/figure>\n<\/div>\n\n\n

Paciente encaminhada para UTI no p\u00f3s operat\u00f3rio, j\u00e1 em uso de drogas vasoativas, mantendo taquicardia, hipotens\u00e3o e necessidade de ventila\u00e7\u00e3o mec\u00e2nica. Durante sua evolu\u00e7\u00e3o manteve-se com abdome fl\u00e1cido, colostomia de bom aspecto e funcionante. Seu quadro cl\u00ednico no entanto sempre persistiu grave, com tentativas falhas de desmame de ventila\u00e7\u00e3o mec\u00e2nica, agravamento das crises convulsivas j\u00e1 frequentes antes do internamento hospitalar. Neste cen\u00e1rio, considerando gravidade de doen\u00e7a de base em si com paciente apresentando convuls\u00f5es frequentes, totalmente dependente para cuidados, com disfagia, dupla incontin\u00eancia e a gravidade da paciente no momento, equipe m\u00e9dica e familiares optaram por manter medidas proporcionais de cuidado. Paciente faleceu no 11\u00ba dia de internamento hospitalar.<\/p>\n\n\n\n

Discuss\u00e3o<\/strong><\/h2>\n\n\n\n

A s\u00edndrome de West<\/strong> corresponde a uma encefalopatia caracterizada em sua forma cl\u00e1ssica por crises convulsivas na inf\u00e2ncia, hipsarrtimia (altera\u00e7\u00f5es de atividade el\u00e9trica na eletroencefalografia) e retardo do desenvolvimento psicomotor. No caso da paciente, a falta de acesso aos sistemas de sa\u00fade levaram a diagn\u00f3stico tardio e tratamento irregular determinando desenvolvimento de uma forma severa da doen\u00e7a com qualidade de vida limitada.<\/p>\n\n\n\n

Volvos col\u00f4nicos<\/strong> correspondem \u00e0 rota\u00e7\u00e3o de um segmento de c\u00f3lon determinando tor\u00e7\u00e3o de seu mesent\u00e9rio com consequente isquemia e distens\u00e3o \u00e0 montante. Volvo de sigm\u00f3ide \u00e9 a forma mais frequente correspondendo a cerca 80% dos casos, seguido de ceco\/c\u00f3lon ascendente (menos de 20%) e raros casos de volvo de transverso.\u00a0 Os principais sintomas s\u00e3o dor e distens\u00e3o abdominal, constipa\u00e7\u00e3o, v\u00f4mitos, interrup\u00e7\u00e3o de elimina\u00e7\u00e3o de fezes e flatos. Nos casos mais graves h\u00e1 perfura\u00e7\u00e3o de al\u00e7a com sinais de peritonite e choque s\u00e9ptico. A evolu\u00e7\u00e3o pode ser lenta com epis\u00f3dios recorrentes de dor alternados com remiss\u00e3o sintom\u00e1tica por distor\u00e7\u00e3o espont\u00e2nea do volvo.<\/p>\n\n\n\n

A radiografia simples de abdome pode evidenciar o sinal cl\u00e1ssico em \u201cgr\u00e3o de feij\u00e3o\u201d al\u00e9m de permitir a avalia\u00e7\u00e3o da extens\u00e3o da obstru\u00e7\u00e3o, distens\u00e3o concomitante de delgado e presen\u00e7a ou n\u00e3o de pneumoperit\u00f4nio. A tomografia de abdome pode evidenciar os mesmos sinais e trazer maior detalhamento dos segmentos col\u00f4nicos com medidas precisas do calibre do \u00f3rg\u00e3o, fato este relevante pois h\u00e1 risco aumentado de perfura\u00e7\u00e3o quando o di\u00e2metro cecal \u00e9 superior a 12 cm.<\/p>\n\n\n\n

Pacientes sem sintomas ou sinais radiol\u00f3gicos sugestivos de perfura\u00e7\u00e3o devem ser submetidos a colonoscopia<\/strong> para desobstru\u00e7\u00e3o do volvo<\/strong>. O preparo anter\u00f3grado \u00e9 contraindicado, no entanto a lavagem retal pode ser utilizada. O exame deve ser realizado com m\u00ednima insufla\u00e7\u00e3o sendo necess\u00e1rio ultrapassar a regi\u00e3o da tor\u00e7\u00e3o, descomprimir o c\u00f3lon (aspirando o conte\u00fado l\u00edquido e removendo o g\u00e1s). A avalia\u00e7\u00e3o da viabilidade da mucosa \u00e9 essencial, buscando sinais de isquemia ou perfura\u00e7\u00e3o para determinar se ser\u00e1 necess\u00e1rio realizar tratamento cir\u00fargico imediato ou n\u00e3o. A taxa de sucesso da colonoscopia descompressiva \u00e9 alta (60-95%), no entanto a taxa de recorr\u00eancia a longo prazo \u00e9 elevada (43 a 75%) caso o paciente n\u00e3o seja submetido a tratamento cir\u00fargico posteriormente.<\/p>\n\n\n\n

Pacientes com sinais de perfura\u00e7\u00e3o, com insucesso t\u00e9cnico na descompress\u00e3o endosc\u00f3pica ou que apresentem sinais de inviabilidade do c\u00f3lon durante colonoscopia devem ser submetidos a cirurgia de urg\u00eancia com ressec\u00e7\u00e3o do segmento com isquemia irrevers\u00edvel.<\/p>\n\n\n\n

O tratamento cir\u00fargico de escolha, posterior a colonoscopia descompressiva bem sucedida,  \u00e9 a ressec\u00e7\u00e3o do segmento col\u00f4nico envolvido. Tratamento cir\u00fargico sem ressec\u00e7\u00e3o (pexia) possui taxa de recorr\u00eancia vari\u00e1vel na literatura podendo chegar a 29-36%, devendo ser considerado apenas em casos selecionados. <\/p>\n\n\n\n

Clique aqui<\/a> para saber mais sobre o assunto com outras imagens<\/a> como o sinal do \u201cgr\u00e3o de caf\u00e9\u201d e publica\u00e7\u00f5es sobre volvo col\u00f4nico.\u00a0<\/p>\n\n\n\n

Refer\u00eancias<\/strong><\/h2>\n\n\n\n
    \n
  1. Bayileyegn NS, Merga OT. Simultaneous cecal and transverse colon volvulus: An exceedingly rare case of intestinal obstruction from Ethiopia: A case report and review of literatures. Int J Surg Case Rep. 2023 Oct;111:108725. doi: 10.1016\/j.ijscr.2023.108725. Epub 2023 Sep 4. PMID: 37769412; PMCID: PMC10539922.<\/li>\n\n\n\n
  2. Tian BWCA, Vigutto G, Tan E, van Goor H, Bendinelli C, Abu-Zidan F, Ivatury R, Sakakushev B, Di Carlo I, Sganga G, Maier RV, Coimbra R, Lepp\u00e4niemi A, Litvin A, Damaskos D, Broek RT, Biffl W, Di Saverio S, De Simone B, Ceresoli M, Picetti E, Galante J, Tebala GD, Beka SG, Bonavina L, Cui Y, Khan J, Cicuttin E, Amico F, Kenji I, Hecker A, Ansaloni L, Sartelli M, Moore EE, Kluger Y, Testini M, Weber D, Agnoletti V, Angelis ND, Coccolini F, Sall I, Catena F. WSES consensus guidelines on sigmoid volvulus management. World J Emerg Surg. 2023 May 15;18(1):34. doi: 10.1186\/s13017-023-00502-x. PMID: 37189134; PMCID: PMC10186802.<\/li>\n\n\n\n
  3. Bouali M, Yaqine K, Elbakouri A, Bensardi F, Elhattabi K, Fadil A. Ischemic volvulus of the transverse colon caused by intestinal malrotation: A case report. Int J Surg Case Rep. 2021 Jun;83:105971. doi: 10.1016\/j.ijscr.2021.105971. Epub 2021 May 18. PMID: 34023547; PMCID: PMC8163956.<\/li>\n\n\n\n
  4. Alavi K, Poylin V, Davids JS, Patel SV, Felder S, Valente MA, Paquette IM, Feingold DL; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2021 Sep 1;64(9):1046-1057. doi: 10.1097\/DCR.0000000000002159. PMID: 34016826.<\/li>\n<\/ol>\n\n\n\n

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

    Ferreira F. Volvo de transverso em paciente com S\u00edndrome de West. Endoscopia Terapeutica 2024 vl. 01. Dispon\u00edvel em: https:\/\/endoscopiaterapeutica.net\/pt\/?p=18604<\/a><\/p>\n\n\n\n


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    Autores: Fl\u00e1vio Ferreira, Elba Alves, Diego Malta, Ewandson Pedroza, Rebecca Rushansky Paciente de 16…<\/p>\n","protected":false},"author":1897,"featured_media":18605,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151,741],"tags":[],"ano":[742],"tipo":[156],"volume":[263],"class_list":["post-18604","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","category-traduzir","ano-742","tipo-colonoscopia","volume-volume-i"],"yoast_head":"\nVolvo de transverso em paciente com S\u00edndrome de West • Endoscopia Terapeutica<\/title>\n<meta name=\"description\" content=\"Volvo de transverso em paciente com S\u00edndrome de West\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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