{"id":3975,"date":"2018-08-13T09:41:37","date_gmt":"2018-08-13T09:41:37","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/pancreas_anular\/"},"modified":"2022-05-27T00:07:46","modified_gmt":"2022-05-27T00:07:46","slug":"pancreas_anular-2","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/pancreas_anular-2\/","title":{"rendered":"P\u00e2ncreas anular"},"content":{"rendered":"

Paciente feminina, 42 anos, com hist\u00f3rico de 8 meses de dor abdominal, localizada em todo abdome superior, predominantemente p\u00f3s-prandial, associada \u00e0 empachamento e v\u00f4mitos tardios, com alivio dos sintomas ap\u00f3s os v\u00f4mitos. Relata ainda raros epis\u00f3dios de diarreia. Perdeu 9Kg no per\u00edodo, reduzindo seu peso de 57 para 48 Kg.<\/p>\n

Solicitada endoscopia digestiva alta para investiga\u00e7\u00e3o. Foram realizados dois exames, no primeiro foi identificado grande volume de estase g\u00e1strica, com res\u00edduos s\u00f3lidos, n\u00e3o aspir\u00e1veis, que determinou interrup\u00e7\u00e3o do exame pelo risco de broncoaspira\u00e7\u00e3o. Para o segundo exame fez uso de dois dias de dieta liquida exclusiva como preparo.<\/p>\n

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

Achado est\u00f4mago de volume aumentado, bulbo dilatado e estenose da segunda por\u00e7\u00e3o que permitia a passagem justa do aparelho de 9,8mm.<\/p>\n

Com a identifica\u00e7\u00e3o da estenose da segunda por\u00e7\u00e3o foi solicitada tomografia de abdome total, que identificou o p\u00e2ncreas anular.<\/p>\n

 <\/p>\n

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

 <\/p>\n

Revis\u00e3o:<\/strong><\/p>\n

O p\u00e2ncreas anular \u00e9 uma anomalia cong\u00eanita rara, na qual h\u00e1 um anel de tecido pancre\u00e1tico circulando a segunda por\u00e7\u00e3o duodenal. Consequ\u00eancia de falha na rota\u00e7\u00e3o completa do broto pancre\u00e1tico ventral durante o per\u00edodo embrion\u00e1rio.<\/p>\n

Por se tratar de problema cong\u00eanito acreditava-se que a grande maioria se manifestava na inf\u00e2ncia, com obstru\u00e7\u00e3o duodenal; contudo algumas s\u00e9ries de casos tem demonstrado at\u00e9 50% de acometimento de adultos, com sintomas de dor, pancreatite ou massa na cabe\u00e7a do p\u00e2ncreas. Estima-se que at\u00e9 dois ter\u00e7os dos portadores dessa condi\u00e7\u00e3o permanecer\u00e3o assintom\u00e1ticos a vida toda.<\/p>\n

Habitualmente os sintomas ocorrem com obstru\u00e7\u00e3o duodenal na inf\u00e2ncia ou dor no adulto, principalmente nas terceira e quarta d\u00e9cadas de vida; o \u00fanico relato na literatura de paciente que apresentou sintomas nas duas fases da vida \u00e9 de um brasileiro atendido no Grupo de Cirurgia das Vias Biliares e P\u00e2ncreas do Departamento de Gastroenterologia do Hospital das Clinicas da Faculdade de Medicina da USP. Dessa forma, o caso aqui relatado, foge do lugar comum, com predom\u00ednio de sintomas obstrutivos no paciente adulto.<\/p>\n

O tratamento dos sintomas na inf\u00e2ncia consiste na deriva\u00e7\u00e3o: duodeno jejunal, gastro jejunal ou duodeno duodenal. A sec\u00e7\u00e3o do anel foi totalmente abandonada pela ocorr\u00eancia de pancreatites e f\u00edstulas duodenais em incid\u00eancia proibitiva.<\/p>\n

No adulto a abordagem mais frequente envolve a pancreatoduodenectomia com incis\u00e3o cef\u00e1lica para remo\u00e7\u00e3o dos c\u00e1lculos, seguida de oclus\u00e3o com al\u00e7a jejunal para garantir a drenagem adequada do segmento anular. \u00a0Por\u00e9m parece haver uma tend\u00eancia a favor da realiza\u00e7\u00e3o da duodenopancreatectomia com preserva\u00e7\u00e3o pil\u00f3rica, j\u00e1 que nessa fase os sintomas costumam estar relacionados \u00e0 ocorr\u00eancia de pancreatite cef\u00e1lica por dificuldade de drenagem do segmento com v\u00edcio rotacional, dificuldade essa que por vezes n\u00e3o \u00e9 plenamente resolvida pela pancreatoduodenectomia. Al\u00e9m disso h\u00e1 que se atentar aos relatos de neoplasias peri ampulares associadas ao p\u00e2ncreas anular, h\u00e1 relatos de cinco casos de neoplasia de papila e tr\u00eas de cabe\u00e7a de p\u00e2ncreas.<\/p>\n

A pancreatografia endosc\u00f3pica tem sua atua\u00e7\u00e3o limitada pela presen\u00e7a de estenose duodenal ou pela m\u00e1 forma\u00e7\u00e3o em si. Durante um per\u00edodo foi considerado m\u00e9todo diagn\u00f3stico valioso mas atualmente j\u00e1 foi plenamente substitu\u00eddo pela resson\u00e2ncia.<\/p>\n

Existe uma classifica\u00e7\u00e3o, proposta por Yogi et al, que divide os tipos de p\u00e2ncreas anular em 6, conforme a drenagem do ducto de Wirsung, mas at\u00e9 o momento ela n\u00e3o tem utilidade cl\u00ednica.<\/p>\n

Diante de um bulbo dilatado e alongado com estreitamento da segunda por\u00e7\u00e3o duodenal devemos lembrar dessa entidade que na maioria das vezes passa sem diagn\u00f3stico (considerando sempre que a endoscopia n\u00e3o \u00e9 o exame de elei\u00e7\u00e3o para o diagn\u00f3stico).<\/p>\n

 <\/p>\n

Referencias:<\/strong><\/p>\n

    \n
  1. Green JD Fieber SS, Buniak B. Annular pancreas with dilated biliary and pancreatic ducts. Am J Gastroenterol 1993;88:467-8<\/li>\n
  2. Brickford BJ, Williamson JCF Annular pancreas. Br J Surg 1952;39:49-52<\/li>\n
  3. Cunha JE<\/a>1<\/sup>,\u00a0de Lima MS<\/a>,\u00a0Jukemura J<\/a>,\u00a0Penteado S<\/a>,\u00a0Jureidini R<\/a>,\u00a0Patzina RA<\/a>,\u00a0Siqueira SA<\/a>. Unusual clinical presentation of annular pancreas in the adult. 2005;5(1):81-5. Epub 2005 Mar 16.<\/li>\n
  4. Yogi Y, Shibue T, Hashimoto S. Annular pancreas detected in adults, diagnosed by endoscopic retrograde cholangiopancreatography: report of four cases. Gastroenterol Jpn 1987;22:92-9<\/li>\n
  5. Chen YC, Yeh CN, Tseng JH. Symptomatic adult annular pancreas. J Clin Gastroenterol 2003;36:446-50<\/li>\n<\/ol>\n
    …………………………………………………………………………………………………………..<\/h6>\n
    Como citar esse artigo:<\/strong><\/h6>\n

    Lima MS. P\u00e2ncreas anular. Endoscopia Terap\u00eautica; 2018. Dispon\u00edvel em:\u00a0https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/pancreas_anular<\/span>\/<\/span><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

    Paciente feminina, 42 anos, com hist\u00f3rico de 8 meses de dor abdominal, localizada em…<\/p>\n","protected":false},"author":3364,"featured_media":3976,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[],"ano":[],"tipo":[153],"volume":[],"class_list":["post-3975","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","tipo-endoscopia-digestiva-alta"],"yoast_head":"\nP\u00e2ncreas anular • 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\/pancreas_anular-2\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" 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