{"id":3955,"date":"2018-03-19T09:00:48","date_gmt":"2018-03-19T09:00:48","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/caso-clinico-fistula-biliar-pos-trauma-abdominal-fechado\/"},"modified":"2022-06-15T14:38:13","modified_gmt":"2022-06-15T14:38:13","slug":"caso-clinico-fistula-biliar-pos-trauma-abdominal-fechado","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/caso-clinico-fistula-biliar-pos-trauma-abdominal-fechado\/","title":{"rendered":"Caso Cl\u00ednico – F\u00edstula biliar p\u00f3s trauma abdominal fechado"},"content":{"rendered":"
Relato do caso:<\/strong><\/h6>\n

Paciente do sexo masculino, com 43 anos de idade, deu entrada no pronto socorro, ap\u00f3s ter evadido de outro hospital .<\/p>\n

Tinha antecedente de trauma abdominal fechado, ap\u00f3s queda de andaime (7 metros), estando internado com conduta n\u00e3o cir\u00fargica por cerca de 18 dias. Ap\u00f3s este per\u00edodo, \u201cfugiu\u201d do hospital de origem e procurou atendimento no PS-HC Mar\u00edlia.<\/p>\n

Na entrada, apresentava-se est\u00e1vel hemodinamicamente, por\u00e9m  emagrecido (estava em jejum desde o trauma), com dor em andar superior de abd\u00f4men, sinais de ascite volumosa, al\u00e9m de anasarca e leve icter\u00edcia. Foi submetido a tomografia de abd\u00f4men com contraste, que evidenciou lacera\u00e7\u00e3o hep\u00e1tica Grau III, cole\u00e7\u00f5es subcapsulares  e volumosa ascite. Optou-se por realizar paracentese, com sa\u00edda de cerca de 11 litros de secre\u00e7\u00e3o biliar.<\/p>\n

\"\"<\/a>

Lacera\u00e7\u00e3o hep\u00e1tica Grau III<\/p><\/div>\n

 <\/p>\n

\"\"<\/a>

Volumosa ascite<\/p><\/div>\n

\"\"<\/a>

Paracentese com bile<\/p><\/div>\n

 <\/p>\n

Diagnosticada a f\u00edstula biliar, paciente foi submetido a Colangiopancreatografia Retr\u00f3grada Endosc\u00f3pica (CPRE), com papilotomia, sendo evidenciada f\u00edstula biliar em ramos secund\u00e1rios a direita. N\u00e3o foi poss\u00edvel a coloca\u00e7\u00e3o de pr\u00f3tese (em falta no servi\u00e7o).<\/p>\n

\"\"<\/a>

F\u00edstula biliar<\/p><\/div>\n

\"\"<\/a>

F\u00edstula biliar<\/p><\/div>\n

Ap\u00f3s a CPRE, paciente ainda realizou outra paracentese com sa\u00edda de cerca de 2 litros de bile. Neste momento, foi submetido a laparoscopia, com coloca\u00e7\u00e3o de dreno perihep\u00e1tico com dificuldade (muitas ader\u00eancias), para auxiliar na drenagem.<\/p>\n

Mesmo com a drenagem externa paciente evoluiu com febre, e dor abdominal, sendo submetido a laparotomia exploradora, com drenagem de m\u00faltiplas cole\u00e7\u00f5es cavit\u00e1rias. Foi necess\u00e1rio realizar peritoniostomia, para lavagens frequentes da cavidade. Em nenhuma das abordagens foi poss\u00edvel avaliar a les\u00e3o hep\u00e1tica ou tentar alguma terap\u00eautica adicional sobre as vias biliares.<\/p>\n

Ap\u00f3s boa evolu\u00e7\u00e3o, com parada de drenagem de bile e secre\u00e7\u00e3o purulenta, paciente foi submetido a fechamento da cavidade, pode ser realimentado oralmente, teve boa evolu\u00e7\u00e3o e posterior alta, encontrando-se atualmente bem, trabalhando e sem altera\u00e7\u00f5es biliares.<\/p>\n

 <\/p>\n

Discuss\u00e3o:<\/strong><\/h6>\n

Recentemente vem ganhando terreno as terapias n\u00e3o invasivas para traumas abdominais fechados, em especial de v\u00edsceras maci\u00e7as, como rins, ba\u00e7o e f\u00edgado. As melhores condi\u00e7\u00f5es de cuidados em UTI, associadas a evolu\u00e7\u00e3o dos procedimentos diagn\u00f3sticos e interven\u00e7\u00f5es minimalistas, fazem com que terapias n\u00e3o operativas sejam a escolha em pacientes com les\u00f5es graves, antes sempre cir\u00fargicas, como les\u00f5es hep\u00e1ticas acima de grau III.<\/p>\n

A escolha da terapia n\u00e3o operativa em paciente com trauma abdominal fechado n\u00e3o reside apenas no grau de les\u00e3o das v\u00edsceras envolvidas (no caso v\u00edsceras maci\u00e7as), mas na estabilidade hemodin\u00e2mica do paciente. Pacientes inst\u00e1veis, s\u00e3o encaminhados imediatamente a cirurgia. Pacientes est\u00e1veis, s\u00e3o submetidos a exame de imagem, diagn\u00f3stico do tipo de les\u00e3o, e acompanhamento em UTI.<\/p>\n

Especificamente no trauma hep\u00e1tico fechado, a principal preocupa\u00e7\u00e3o e complica\u00e7\u00e3o \u00e9 o sangramento. As f\u00edstulas biliares s\u00e3o incomuns, ocorrendo nos casos mais graves (graus de les\u00e3o maiores), com incid\u00eancia estimada em cerca de 2,8 a 7,4% dos casos. Podem ocorrer de imediato, junto ao trauma, ou serem tardias, ap\u00f3s cirurgias de controle de dano, ou ap\u00f3s necrose de par\u00eanquima ou ruptura de biliomas.<\/p>\n

O diagn\u00f3stico de complica\u00e7\u00f5es biliares nos casos de trauma hep\u00e1tico fechado pode ser dif\u00edcil. Em geral podem aparecer sinais indiretos, como piora do quadro, febre e dor em hipoc\u00f4ndrio direito, e tamb\u00e9m, um sinal mais espec\u00edfico, a icter\u00edcia. Sugere-se que exames seriados de tomografia computadorizada podem evidenciar aumento de cole\u00e7\u00f5es com baixa atenua\u00e7\u00e3o, ou cole\u00e7\u00f5es perihep\u00e1ticas tardias. Deve-se lembrar de que mesmo a tomografia computadorizada com contraste n\u00e3o \u00e9 especifica para altera\u00e7\u00f5es biliares, com alguns autores sugerindo o estudo das vias biliares com t\u00e9cnicas de radiois\u00f3topos.<\/p>\n

O tratamento inclui o suporte, antibioticoterapia e diagn\u00f3stico precoce. Como em geral as complica\u00e7\u00f5es biliares s\u00e3o tardias, os pacientes podem ser submetidos a t\u00e9cnicas minimamente invasivas. Inicialmente, pode-se colocar um dreno cavit\u00e1rio, no local da cole\u00e7\u00e3o, ou bilioma, transformando uma les\u00e3o biliar em uma f\u00edstula controlada, evitando-se a contamina\u00e7\u00e3o da cavidade e acumulo de flu\u00eddos.<\/p>\n

Outra t\u00e9cnica j\u00e1 estabelecida \u00e9 a realiza\u00e7\u00e3o de CPRE.  A id\u00e9ia do uso de tal terap\u00eautica \u00e9 que, devido a papilotomia, h\u00e1 diminui\u00e7\u00e3o da press\u00e3o biliar, deixando a bile de seguir pela f\u00edstula, causando o fechamento desta. Inicialmente ap\u00f3s a papilotomia, pode haver ainda alguma dificuldade em drenagem da bile pela papila, secund\u00e1ria ao edema pela manipula\u00e7\u00e3o. Assim, hoje se indica o tratamento de f\u00edstulas biliares traum\u00e1ticas com CPRE e pr\u00f3teses, principalmente em f\u00edstulas distais. A presen\u00e7a da pr\u00f3tese anula totalmente a press\u00e3o na via biliar, aumentando a taxa de fechamento de f\u00edstulas.<\/p>\n

A evolu\u00e7\u00e3o ap\u00f3s a CPRE em geral \u00e9 positiva, com o fechamento da f\u00edstula. Casos mais graves podem vir a necessitar de posterior cirurgia. Deve-se sempre acompanhar o paciente, principalmente quando da coloca\u00e7\u00e3o de pr\u00f3teses, para evitar uma futura colangite por n\u00e3o retirada desta.<\/p>\n

Voc\u00ea j\u00e1 tratou algum paciente assim? Como realizou o diagn\u00f3stico? Qual foi o tratamento e evolu\u00e7\u00e3o?<\/p>\n

 <\/p>\n

Agrade\u00e7o aos colegas Dr. Roberto Tucci Junior, pelo aux\u00edlio na condu\u00e7\u00e3o do caso, e Dra. Flavia Ferreira Magalini na constru\u00e7\u00e3o do relato.<\/p>\n

 <\/p>\n

Bibliografia:<\/p>\n

Kulaylat AN, et at. Traumatic bile leaks from blunt liver injury in children: a multidisciplinary and minimally invasive approach to management. J Pediatr Surg. 2014;49(3):424-7.<\/a><\/p>\n

Al-Hassani A, et al. Delayed bile leak in a patient with grade IV blunt liver trauma: A case report and review of the literature. Int J Surg Case Rep. 2015;14:156-9.<\/a><\/p>\n

Ragavan M, et al.Posttraumatic Intrahepatic Bilioma. Indian J Surg. 2015;77:1399-400. <\/a><\/p>\n

Tiwari C, et al. Management of Traumatic Liver and Bile Duct Laceration. Euroasian J Hepatogastroenterol. 2017;7(2):188-190.   <\/a><\/p>\n

 <\/p>\n

Como citar esse artigo:<\/strong><\/p>\n

Sauniti, G. Caso Cl\u00ednico – F\u00edstula biliar p\u00f3s trauma abdominal fechado. Endoscopia Terap\u00eautica; 2018. Dispon\u00edvel em: https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/caso-clinico-fistula-biliar-pos-trauma-abdominal-fechado\/<\/a><\/em><\/p>\n

 <\/p>\n

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

Relato do caso: Paciente do sexo masculino, com 43 anos de idade, deu entrada…<\/p>\n","protected":false},"author":2221,"featured_media":3953,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[],"ano":[270],"tipo":[155],"volume":[263],"class_list":["post-3955","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","ano-270","tipo-cpre","volume-volume-i"],"yoast_head":"\nCaso Cl\u00ednico - F\u00edstula biliar p\u00f3s trauma abdominal fechado • 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-fistula-biliar-pos-trauma-abdominal-fechado\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Caso Cl\u00ednico - F\u00edstula biliar p\u00f3s trauma abdominal fechado\" \/>\n<meta property=\"og:description\" content=\"Relato do caso: Paciente do sexo masculino, com 43 anos de idade, deu entrada no pronto socorro, ap\u00f3s ter evadido de outro hospital . 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