{"id":3784,"date":"2015-10-14T10:00:05","date_gmt":"2015-10-14T10:00:05","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/caso-clinico-sangramento-digestivo-medio\/"},"modified":"2022-06-17T15:36:57","modified_gmt":"2022-06-17T15:36:57","slug":"caso-clinico-sangramento-digestivo-medio","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/caso-clinico-sangramento-digestivo-medio\/","title":{"rendered":"Sangramento digestivo m\u00e9dio"},"content":{"rendered":"<h2><strong>CASO CL\u00cdNICO<\/strong><\/h2>\n<p>Paciente 56 anos, sexo feminino, evoluindo h\u00e1 cerca de 2 semanas com quadro de melena e queda de hemoglobina com necessidade de m\u00faltiplas hemotransfus\u00f5es. Antecedentes m\u00e9dicos de hipertens\u00e3o arterial sist\u00eamica, diabetes mellitus insulino-dependente e insufici\u00eancia renal cr\u00f4nica dial\u00edtica.<\/p>\n<p>Realizou durante a interna\u00e7\u00e3o endoscopia digestiva alta, colonoscopia e exames de tomografia de abdome sem esclarecimento diagn\u00f3stico. Submetida a c\u00e1psula endosc\u00f3pica com evid\u00eancia de ectasias vasculares tipo 1a de Yano-Yamamoto em jejuno e \u00edleo. Observado&nbsp;presen\u00e7a de sangue vivo em duodeno, sem&nbsp;identica\u00e7\u00e3o da les\u00e3o respons\u00e1vel.<\/p>\n<p>Solicitada enteroscopia anter\u00f3grada&nbsp;que evidenciou tal achado:<\/p>\n<div style=\"width: 960px;\" class=\"wp-video\"><video class=\"wp-video-shortcode\" id=\"video-3784-1\" width=\"960\" height=\"540\" preload=\"metadata\" controls=\"controls\"><source type=\"video\/mp4\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/10\/ECTASIA-VASCULAR.mp4?_=1\" \/><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/10\/ECTASIA-VASCULAR.mp4\">https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/10\/ECTASIA-VASCULAR.mp4<\/a><\/video><\/div>\n<p>Realizada terap\u00eautica da les\u00e3o com aplica\u00e7\u00e3o de hemoclipe.<\/p>\n<p><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone size-medium wp-image-3306\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/CLIPE.jpg\" alt=\"CLIPE\" width=\"300\" height=\"169\"><img decoding=\"async\" class=\"alignnone size-medium wp-image-3307\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/CLIPE-2.jpg\" alt=\"CLIPE 2\" width=\"300\" height=\"169\"><\/p>\n<p>Tamb\u00e9m foram evidenciadas ectasias vasculares tipo 1a e 1b de Yano-Yamamoto que foram tratadas com coagula\u00e7\u00e3o por <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/plasma-de-argonio\/\" target=\"_blank\" rel=\"noopener\">plasma de arg\u00f4nio<\/a>.<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/10\/c\u00f3pia-de-Ectasia-Yano.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\"alignnone wp-image-3232 size-medium\" title=\"Ectasia Yano - Sangramento gastrointestinal\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/cC3B3pia-de-Ectasia-Yano.jpg\" alt=\"Ectasia Yano - Sangramento gastrointestinal\" width=\"300\" height=\"169\"><\/a><\/p>\n<p>A paciente evoluiu subsequentemente sem recorr\u00eancia do sangramento.<\/p>\n<h2><strong>CONSIDERA\u00c7\u00d5ES<\/strong><\/h2>\n<p>O sangramento digestivo do intestino m\u00e9dio \u00e9 caracterizada pelo sangramento proveniente do trato digestivo localizado entre a papila duodenal at\u00e9 o \u00edleo terminal, (locais inacess\u00edveis a endoscopia digestiva alta e colonoscopia) sendo respons\u00e1vel por cerca de 5% dos casos de hemorragia digestiva. Destes 5% n\u00e3o esclarecidos, o sangramento, na grande maioria dos casos tem origem no intestino delgado (90%).<\/p>\n<p>As les\u00f5es de intestino delgado tiveram seu estudo e potenciais terap\u00eauticas amplamente expandidos em 1997 com a introdu\u00e7\u00e3o da enteroscopia de duplo bal\u00e3o (DBE) que suplantou outros m\u00e9todos at\u00e9 ent\u00e3o dispon\u00edveis para tal avalia\u00e7\u00e3o.<\/p>\n<p>A DBE \u00e9 uma t\u00e9cnica que visa a avalia\u00e7\u00e3o de todo o intestino delgado com a utiliza\u00e7\u00e3o de um sistema que inclui um aparelho de endoscopia longo (200cm) equipado com um bal\u00e3o adaptado em sua extremidade, um &#8220;overtube&#8221; e uma bomba de controle de insufla\u00e7\u00e3o dos bal\u00f5es. O exame do trato digestivo pode ser realizada por via retr\u00f3grada, via anter\u00f3grada, ou combinada, na depend\u00eancia da situa\u00e7\u00e3o cl\u00ednica.<\/p>\n<p>Atrav\u00e9s da combina\u00e7\u00e3o de ambas as abordagens , a observa\u00e7\u00e3o endosc\u00f3pica de todo o intestino delgado \u00e9 poss\u00edvel em mais de 85 % de casos. A hemorragia gastrointestinal obscura \u00e9 a indica\u00e7\u00e3o mais frequente para a realiza\u00e7\u00e3o&nbsp;de enteroscopia de duplo bal\u00e3o no nosso meio.<\/p>\n<p>As ectasias vasculares s\u00e3o as causas mais comuns de sangramento do intestino delgado, correspondendo a cerca de 50% dos casos. Tais achados contrastam com a baixa incid\u00eancia de hemorragias por ectasias vasculares no trato digest\u00f3rio alto (20%) e baixo (5%). Sabe-se que algumas situa\u00e7\u00f5es cl\u00ednicas possuem uma maior preval\u00eancia de ectasias vasculares associadas, entre elas chama-se aten\u00e7\u00e3o a doen\u00e7a de von Willebrand, insufici\u00eancia renal cr\u00f4nica (como no caso apresentado) e estenose a\u00f3rtica.<\/p>\n<p>Em 2008, Yano &nbsp;e colaboradores propuseram uma nova classifica\u00e7\u00e3o para les\u00f5es vasculares de intestino delgado. Essa classifica\u00e7\u00e3o \u00e9 \u00fatil para determinar a conduta terap\u00eautica, pois les\u00f5es classificadas como do tipo 1 s\u00e3o venosas e pass\u00edveis de tratamento com plasma de arg\u00f4nio ou m\u00e9todos t\u00e9rmicos. Les\u00f5es tipo 2 caracterizadas como arteriais (Dieulafoy) e tipo 3 como m\u00e1 forma\u00e7\u00f5es arteriovenosas com componente arterial e venoso, devendo ser tratadas preferencialmente com clips hemost\u00e1ticos ou at\u00e9 mesmo cirurgia.<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/classificacao-de-lesoes-vasculares-yano-yamamoto\/\" target=\"_blank\" rel=\"noopener noreferrer\">Classifica\u00e7\u00e3o de les\u00f5es vasculares (Yano Yamamoto)<\/a>.<\/p>\n<p>Em paciente com achado de ectasias vasculares e suspeita de sangramento digestivo, se faz mandat\u00f3rio a realiza\u00e7\u00e3o de tratamento de tais les\u00f5es.<\/p>\n<p>O tratamento das ectasias vasculares pode ser realizado de diversos modos, como os j\u00e1 citados coagula\u00e7\u00e3o com plasma de arg\u00f4nio, eletrocoagula\u00e7\u00e3o e hemostasia mec\u00e2nica com clipe. H\u00e1 relatos na literatura do uso de solu\u00e7\u00f5es esclerosantes como etanolamina, uso de Nd-YAG laser e de ligadura el\u00e1stica.<\/p>\n<h2><strong>REFER\u00caNCIAS<\/strong><\/h2>\n<p>Yano T, Yamamoto H, Sunada K, Miyata T, Iwamoto M, Hayashi Y, Arashiro M, Sugano. Endoscopic classification of vascular lesions of the small intestine (with videos). Gastrointest Endosc. 2008 Jan;67(1):169-72.<\/p>\n<p class=\"cit\">Fisher L, Lee Krinsky M, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, Cash BD, Decker GA, Fanelli RD,Friis C, Fukami N, Harrison ME, Ikenberry SO, Jain R, Jue T, Khan K, Maple JT, Strohmeyer L, Sharaf R, Dominitz JA.&nbsp;The role of endoscopy in the management of obscure GI bleeding. Gastrointest Endosc. 2010 Sep;72(3):471-9.<\/p>\n<p class=\"cit\">Okazaki H, Fujiwara Y, Sugimori S, Nagami Y, Kameda N, Machida H, Yamagami H, Tanigawa T, Shiba M, Watanabe K, Tominaga K, Watanabe T, Oshitani N, Arakawa T. Prevalence of mid-gastrointestinal bleeding in patients with acute overt gastrointestinal bleeding: multi-center experience with 1,044 consecutive patients. J Gastroenterol. 2009;44(6):550-5.<\/p>\n<p class=\"cit\">Gerson LB, Batenic MA, Newsom SL, Ross A, Semrad CE.&nbsp;Long-term outcomes after double-balloon enteroscopy for obscure gastrointestinal bleeding.&nbsp;Clin Gastroenterol Hepatol. 2009 Jun;7(6):664-9.<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>ASSUNTOS RELACIONADOS<\/strong><\/h2>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/qual-a-sua-suspeita-diante-desta-lesao-no-intestino-delgado\/\" target=\"_blank\" rel=\"noopener noreferrer\">Qual a sua suspeita diante desta les\u00e3o no intestino delgado?<\/a><\/p>\n<p class=\"titulo-principal\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/artigo-comentado-tratamento-de-ectasia-vascular-antral-com-ligadura-elastica\/\" target=\"_blank\" rel=\"noopener noreferrer\">ARTIGO COMENTADO \u2013 Tratamento de ectasia vascular antral com ligadura el\u00e1stica<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>CASO CL\u00cdNICO Paciente 56 anos, sexo feminino, evoluindo h\u00e1 cerca de 2 semanas com&hellip;<\/p>\n","protected":false},"author":726,"featured_media":3785,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[],"ano":[282],"tipo":[157],"volume":[147],"class_list":["post-3784","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","ano-282","tipo-intestino-delgado","volume-volume-ii"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Sangramento digestivo m\u00e9dio &#8226; 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