{"id":3778,"date":"2015-09-16T10:21:15","date_gmt":"2015-09-16T10:21:15","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/caso-clinico-estenose-de-coledoco-distal\/"},"modified":"2022-06-15T14:41:52","modified_gmt":"2022-06-15T14:41:52","slug":"caso-clinico-estenose-de-coledoco-distal","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/caso-clinico-estenose-de-coledoco-distal\/","title":{"rendered":"Estenose de col\u00e9doco distal"},"content":{"rendered":"

Paciente do sexo masculino, com 55 anos de idade e  hist\u00f3ria de icter\u00edcia e desconforto abdominal ha 2 semanas.<\/p>\n

\"Laborat\u00f3rio<\/a><\/p>\n

O paciente realizou resson\u00e2ncia de abdome com colangiorresson\u00e2ncia que evidenciou dilata\u00e7\u00e3o das vias biliares intra e extra hep\u00e1ticas com imagem sugestiva de c\u00e1lculo impactado no col\u00e9doco distal.<\/p>\n

Devido \u00e0 este achado foi indicada a realiza\u00e7\u00e3o de CPRE<\/p>\n

CPRE<\/strong><\/p>\n

\"Colangioca1\"<\/a><\/p>\n

(Clique na imagem para ampliar) Dilata\u00e7\u00e3o do col\u00e9doco e ducto pancre\u00e1tico associado \u00e0 estenose de col\u00e9doco distal.<\/p>\n

\"Colangioca2\"<\/a><\/p>\n

(Clique na imagem  para ampliar) Extens\u00e3o da estenose.<\/p>\n

 <\/p>\n

Na CPRE foi observada  dilata\u00e7\u00e3o do hepatocol\u00e9doco com at\u00e9 18 mm associada \u00e0 dilata\u00e7\u00e3o do ducto pancre\u00e1tico (5 mm) e \u00e1rea de redu\u00e7\u00e3o do calibre do col\u00e9doco em sua por\u00e7\u00e3o intrapancre\u00e1tica. Devido \u00e0 este achado, bastante sugestivo de colangiocarcinoma distal (j\u00e1 que n\u00e3o foi vista les\u00e3o de massa na CPRM), foi optado por tentar obter material para diagn\u00f3stico histocitol\u00f3gico atrav\u00e9s de bi\u00f3psias intraductais e escovado. Ap\u00f3s estes procedimentos foi realizada passagem de pr\u00f3tese pl\u00e1stica de 10 F x 7  cm.<\/p>\n

 <\/p>\n

\"Colangio<\/a><\/p>\n

(Clique na imagem para ampliar). Pin\u00e7a de bi\u00f3psia introduzida atrav\u00e9s da papila com bi\u00f3psias guiadas por radioscopia. Escovado com escova citol\u00f3gica guiada.<\/p>\n

\"Colangio<\/a><\/p>\n

(Clique na imagem para ampliar). Dilata\u00e7\u00e3o com dilatadar de Soehendra at\u00e9 11 mm. Passagem de pr\u00f3tese pl\u00e1stica de 10 F.<\/p>\n

 <\/p>\n

Evolu\u00e7\u00e3o<\/strong><\/p>\n

O paciente evoluiu com redu\u00e7\u00e3o da icter\u00edcia e iniciou dieta imunomoduladora (preparo para prov\u00e1vel cirurgia) enquanto aguardava o resultado das bi\u00f3psias.  Ap\u00f3s uma semana tanto a citologia quanto as bi\u00f3psias intraductais vieram negativas.<\/p>\n

Baseado nos achados da CPRM e CPRE associado \u00e0 hist\u00f3ria cl\u00ednica foi optado por ressec\u00e7\u00e3o cir\u00fargica mesmo sem a confirma\u00e7\u00e3o histol\u00f3gica.<\/p>\n

O paciente foi submetido \u00e0 duodenopacreatectomia laparosc\u00f3pica. Ap\u00f3s a ressec\u00e7\u00e3o e abertura da pe\u00e7a foi identificada a presen\u00e7a de les\u00e3o no col\u00e9doco distal. A histologia confirmou colangiocarcinoma.<\/p>\n

\"Colangioca<\/a><\/p>\n

(Clique na imagem para ampliar) Realiza\u00e7\u00e3o de incis\u00e3o de Pfannenstiel para remo\u00e7\u00e3o da pe\u00e7a. Aspecto da pe\u00e7a antes da abertura. Abertura do duodeno e col\u00e9doco notando-se les\u00e3o no col\u00e9doco distal. Les\u00e3o do col\u00e9doco distal em detalhe.<\/p>\n

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

As estenoses biliares representam  um grande desafio para se chegar \u00e0 um diagn\u00f3stico preciso e para se indicar  o tratamento correto.  As causas mais comuns de estenoses biliares s\u00e3o os tumores periampulares como o colangiocarcinoma e o c\u00e2ncer de p\u00e2ncreas.<\/p>\n

O diagn\u00f3stico precoce melhora bastante  o progn\u00f3stico mas geralmente necessita uma conduta agressiva. A cirurgia nestes casos est\u00e1 associada a uma alta morbidade p\u00f3s operat\u00f3ria e aproximadamente 7-10% dos pacientes que se submetem \u00e0 duodenopancreatectomia por estenoses biliares suspeitas de malignidade apresentam doen\u00e7as benignas como causa da estenose. Devido \u00e0 isso, a confirma\u00e7\u00e3o da malignidade antes da cirurgia \u00e9 importante.<\/p>\n

A sensibilidade do escovado biliar, das bi\u00f3psias intraductais e da associa\u00e7\u00e3o das duas t\u00e9cnicas gira em torno de apenas  40-60%, fazendo com que grande parte dos pacientes n\u00e3o tenha uma confirma\u00e7\u00e3o histol\u00f3gica antes da cirurgia.<\/p>\n

O uso da ecoendoscopia nestes casos \u00e9 um boa op\u00e7\u00e3o para prosseguir a investiga\u00e7\u00e3o. \u00c9 um m\u00e9todo seguro e efetivo para avaliar pequenos tumores pancre\u00e1ticos e o colangiocarcinoma distal. A dificuldade \u00e9 que este exame ainda n\u00e3o \u00e9 amplamente dispon\u00edvel no nosso meio e boa parte dos paciente j\u00e1 chegam com pr\u00f3tese biliar dificultando o diagn\u00f3stico ecoendosc\u00f3pico do coloangiocarcinoma distal.<\/p>\n

 <\/p>\n

Assuntos relacionados<\/strong><\/p>\n

\n

Artigo comentado – compara\u00e7\u00e3o entre escovado e bi\u00f3psias intraductais no diagn\u00f3stico do colangiocarcinoma distal<\/a><\/p>\n

\n

Caso cl\u00ednico – IPMN de ducto principal<\/a><\/p>\n

\n

Imagens – Neoplasia de cabe\u00e7a de p\u00e2ncreas – pun\u00e7\u00e3o ecoendosc\u00f3pica<\/a><\/p>\n

\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Paciente do sexo masculino, com 55 anos de idade e  hist\u00f3ria de icter\u00edcia e…<\/p>\n","protected":false},"author":2464,"featured_media":3774,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[],"ano":[282],"tipo":[155],"volume":[147],"class_list":["post-3778","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","ano-282","tipo-cpre","volume-volume-ii"],"yoast_head":"\nEstenose de col\u00e9doco distal • 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-estenose-de-coledoco-distal\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Estenose de col\u00e9doco distal\" \/>\n<meta property=\"og:description\" content=\"Paciente do sexo masculino, com 55 anos de idade e  hist\u00f3ria de icter\u00edcia e desconforto abdominal ha 2 semanas. 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