{"id":4085,"date":"2020-08-21T09:00:13","date_gmt":"2020-08-21T09:00:13","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/caso-clinico-biopsia-hepatica-por-ecoendoscopia\/"},"modified":"2023-08-22T19:44:45","modified_gmt":"2023-08-22T19:44:45","slug":"caso-clinico-biopsia-hepatica-por-ecoendoscopia","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/caso-clinico-biopsia-hepatica-por-ecoendoscopia\/","title":{"rendered":"Caso cl\u00ednico &#8211; Bi\u00f3psia hep\u00e1tica por ecoendoscopia"},"content":{"rendered":"<p>Paciente sexo feminino, 54 anos, com antecedentes de transtorno depressivo e dislipidemia, iniciou em novembro de 2019 quadro de icter\u00edcia, col\u00faria e hipocolia fecal, sem dor abdominal, febre ou perda de peso. Etilista de 5 doses\/semana e tabagista com baixa carga tab\u00e1gica (2 anos\/ma\u00e7o). Fazia uso de sertralina h\u00e1 2 anos e havia iniciado o uso de sinvastatina em outubro de 2019, tendo interrompido o uso quando ficou ict\u00e9rica.<\/p>\n<ul>\n<li>Exames laboratoriais (janeiro\/2020): AST: 70\/ ALT: 24\/ Fosfatase alcalina: 552 (refer\u00eancia: &lt;110)\/ Gama-GT: 706\/ Bilirrubinas: 4,9 (Direta: 3,3)\/ Alb: 3,1\/ INR: 1,0.<\/li>\n<li>Sorologias virais e autoanticorpos negativos, incluindo anti-mitoc\u00f4ndria.<\/li>\n<li>Colangiorresson\u00e2ncia (dezembro\/2019): f\u00edgado com redistribui\u00e7\u00e3o volum\u00e9trica e sinal heterog\u00eaneo, com ves\u00edcula e vias biliares sem altera\u00e7\u00f5es.<\/li>\n<\/ul>\n<p>Feita hip\u00f3tese de les\u00e3o hep\u00e1tica induzida por sinvastatina e optado por seguimento cl\u00ednico-laboratorial.<\/p>\n<p>Houve persist\u00eancia do quadro, sendo realizada ecoendoscopia em julho de 2020 para afastar causas obstrutivas, com achado de regi\u00e3o hipoecog\u00eanica, heterog\u00eanea, limites irregulares, medindo 2,5 x 1,5 cm na cabe\u00e7a pancre\u00e1tica (Figura 1), sem dilata\u00e7\u00e3o de col\u00e9doco \u00e0 montante (5,8 mm).<\/p>\n<p>Realizada pun\u00e7\u00e3o com agulha de bi\u00f3psia (FNB) de 20G da les\u00e3o pancre\u00e1tica e, no mesmo procedimento, bi\u00f3psia de lobo esquerdo hep\u00e1tico (Figura 2). Para a bi\u00f3psia hep\u00e1tica, foi utilizada tamb\u00e9m uma agulha de FNB de 20G, 2 passagens, com 3 oscila\u00e7\u00f5es lentas em cada, sem uso de v\u00e1cuo. Obtida quantidade satisfat\u00f3ria de material (Figura 3). N\u00e3o houve intercorr\u00eancias durante ou ap\u00f3s o procedimento.<\/p>\n<p>Anatomopatol\u00f3gico da les\u00e3o pancre\u00e1tica revelou tecido acinar pancre\u00e1tico sem atipias e do f\u00edgado hepatopatia cr\u00f4nica colest\u00e1tica padr\u00e3o biliar, com fibrose grau 2 e colestase moderada\/acentuada, compat\u00edvel com a\u00e7\u00e3o medicamentosa.<\/p>\n<p>Iniciado uso de \u00e1cido ursodesoxic\u00f3lico, com melhora inicial do quadro cl\u00ednico-laboratorial.<\/p>\n<div id=\"attachment_7949\" style=\"width: 442px\" class=\"wp-caption aligncenter\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-7949\" class=\"wp-image-7949\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2020\/08\/Imagem1-1-300x212.jpg\" alt=\"\" width=\"432\" height=\"305\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2020\/08\/Imagem1-1-300x212.jpg 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2020\/08\/Imagem1-1.jpg 425w\" sizes=\"(max-width: 432px) 100vw, 432px\" \/><p id=\"caption-attachment-7949\" class=\"wp-caption-text\">Figura 1. Regi\u00e3o hipoecog\u00eanica, heterog\u00eanea, limites irregulares, medindo 2,5 x 1,5 cm, localizada na cabe\u00e7a pancre\u00e1tica.<\/p><\/div>\n<p><strong>\u00a0<\/strong><\/p>\n<div id=\"attachment_11312\" style=\"width: 435px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Imagem2-1.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" aria-describedby=\"caption-attachment-11312\" class=\"size-full wp-image-11312\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Imagem2-1.jpg\" alt=\"\" width=\"425\" height=\"299\" \/><\/a><p id=\"caption-attachment-11312\" class=\"wp-caption-text\">Figura 2. Bi\u00f3psia de lobo esquerdo hep\u00e1tico guiada por ecoendoscopia (agulha de FNB de 20G)<\/p><\/div>\n<div id=\"attachment_11313\" style=\"width: 257px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Imagem3-1.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" aria-describedby=\"caption-attachment-11313\" class=\"size-full wp-image-11313\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Imagem3-1.jpg\" alt=\"\" width=\"247\" height=\"287\" \/><\/a><p id=\"caption-attachment-11313\" class=\"wp-caption-text\">Figura 3. Material obtido da bi\u00f3psia hep\u00e1tica guiada por ecoendoscopia.<\/p><\/div>\n<p><strong>Discuss\u00e3o<\/strong><\/p>\n<p>A bi\u00f3psia hep\u00e1tica \u00e9 ferramenta \u00fatil no diagn\u00f3stico e estadiamento de doen\u00e7as do f\u00edgado como hepatites virais, doen\u00e7a hep\u00e1tica gordurosa associada a disfun\u00e7\u00e3o metab\u00f3lica e hepatopatias autoimunes. Apesar do avan\u00e7o de t\u00e9cnicas n\u00e3o invasivas como a elastografia hep\u00e1tica, estas permitem o estadiamento apenas do grau de fibrose, n\u00e3o fornecendo dados importantes para confirma\u00e7\u00e3o etiol\u00f3gica a avalia\u00e7\u00e3o do grau de atividade inflamat\u00f3ria, por exemplo.<\/p>\n<p>As vias mais utilizadas para bi\u00f3psia hep\u00e1tica s\u00e3o a percut\u00e2nea, cir\u00fargica e transjugular. Cada uma delas possui limita\u00e7\u00f5es e riscos importantes como dor abdominal, sangramento, complica\u00e7\u00f5es da anestesia geral (bi\u00f3psia cir\u00fargica) e alto custo (bi\u00f3psia transjugular).<\/p>\n<p>A bi\u00f3psia hep\u00e1tica por ecoendoscopia vem ganhando espa\u00e7o nos \u00faltimos anos, com publica\u00e7\u00f5es recentes de s\u00e9ries de casos com mais de 200 pacientes e metan\u00e1lises incluindo mais de 400 pacientes. Tem como potenciais vantagens:<\/p>\n<ul>\n<li>Maior conforto para o paciente.<\/li>\n<li>Maior facilidade t\u00e9cnica em pacientes obesos (comparada com a via percut\u00e2nea).<\/li>\n<li>Possibilidade de avalia\u00e7\u00e3o endosc\u00f3pica simult\u00e2nea para rastreamento de varizes.<\/li>\n<li>Realiza\u00e7\u00e3o simult\u00e2nea de medida do gradiente de press\u00e3o venosa hep\u00e1tica por ecoendoscopia.<\/li>\n<\/ul>\n<p>A efic\u00e1cia em se obter material adequado para an\u00e1lise histol\u00f3gica na bi\u00f3psia hep\u00e1tica por ecoendoscopia \u00e9 de 93,9 a 100%. O comprimento m\u00e9dio total dos fragmentos obtidos nos diferentes estudos \u00e9 de 2,4 a 5,5 cm (com fragmentos \u00fanicos de 0,4 a 1,1 cm) e o n\u00famero m\u00e9dio de espa\u00e7os porta obtidos de 21 a 42. A bi\u00f3psia dos dois lobos hep\u00e1ticos est\u00e1 associada a maior comprimento da amostra e maior n\u00famero de espa\u00e7os porta.<\/p>\n<p>Em rela\u00e7\u00e3o \u00e0s complica\u00e7\u00f5es<\/p>\n<ul>\n<li>O \u00edndice m\u00e9dio dos estudos \u00e9 de 2,3%, que \u00e9 compar\u00e1vel \u00e0quele descrito para os outros m\u00e9todos de bi\u00f3psia hep\u00e1tica.<\/li>\n<li>O evento adverso mais comum \u00e9 a dor abdominal (2 a 15%), na quase totalidade dos casos leve e de resolu\u00e7\u00e3o espont\u00e2nea.<\/li>\n<li>H\u00e1 descri\u00e7\u00e3o de sangramento em cerca de 1,2% dos pacientes e raros casos de febre e sangramento fatal (este \u00faltimo ocorrido em um paciente cr\u00edtico).<\/li>\n<\/ul>\n<p>A bi\u00f3psia hep\u00e1tica por ecoendoscopia pode ser feita com agulhas de pun\u00e7\u00e3o aspirativa (FNA) de 19G, bem como agulhas de FNB de 19G e 22G, com \u00edndice de sucesso semelhante. A pun\u00e7\u00e3o pode ser feita no lobo hep\u00e1tico esquerdo (via transg\u00e1strica) e\/ou direito (via transduodenal) geralmente sem v\u00e1cuo, 1 a 3 passagens, 3 a 4 oscila\u00e7\u00f5es, utilizando-se o Doppler para evitar vasos no trajeto. A retirada do fragmento da agulha pode ser feita com estilete ou flush com heparina, com cuidado para n\u00e3o curvar a agulha e fragmentar a amostra, que deve ser colocada em formalina 10%.<\/p>\n<p>A principal limita\u00e7\u00e3o para a maior utiliza\u00e7\u00e3o da bi\u00f3psia hep\u00e1tica por ecoendoscopia no Brasil \u00e9 seu maior custo comparado \u00e0 via mais utilizada (percut\u00e2nea). Por\u00e9m, em casos em que a ecoendoscopia est\u00e1 indicada por outros motivos (como o caso em quest\u00e3o) ou quando outras vias n\u00e3o s\u00e3o poss\u00edveis (obesidade grau 3, por exemplo), esta via parece ser fact\u00edvel e segura.<\/p>\n<h3><a href=\"https:\/\/gastropedia.com.br\/gastroenterologia\/figado\/abordagem-de-pacientes-com-alteracoes-de-enzimas-hepaticas\/\">Para saber mais sobre este tema e outros relacionados, acesse o site Gastropedia clicando aqui!<\/a><\/h3>\n<p><em>Refer\u00eancias<\/em><\/p>\n<ol>\n<li>Dellatore P, Sarkar A, Rustgi VK et al. REVIEW OF ENDOSCOPIC ULTRASOUND GUIDED LIVER BIOPSY: A MULTICENTER EXPERIENCE. P\u00f4ster, DDW 2020.<\/li>\n<li>Hasan MK, Kadkhodayan K, Idrisov E et al. Endoscopic ultrasound-guided liver biopsy using a 22-G fine needle biopsy needle: a prospective study. Endoscopy 2019;51:818-824.<\/li>\n<li>Mohan BP, Shakhatreh M, Garg R et al. Efficacy and safety of EUS-guided liver biopsy: a systematic review and meta-analysis. Gastrointest Endosc 2019;89:238-46<\/li>\n<li>Bazerbachi F, Vargas EJ, Matar R et al. EUS-guided core liver biopsy sampling using a 22-gauge fork-tip needle: a prospective blinded trial for histologic and lipidomic evaluation in nonalcoholic fatty liver disease. Gastrointest Endosc 2019;90:926-32.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>Paciente sexo feminino, 54 anos, com antecedentes de transtorno depressivo e dislipidemia, iniciou em&hellip;<\/p>\n","protected":false},"author":4491,"featured_media":4083,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[],"ano":[146],"tipo":[153],"volume":[147],"class_list":["post-4085","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","ano-146","tipo-endoscopia-digestiva-alta","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>Caso cl\u00ednico - Bi\u00f3psia hep\u00e1tica por ecoendoscopia &#8226; 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-biopsia-hepatica-por-ecoendoscopia\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Caso cl\u00ednico - Bi\u00f3psia hep\u00e1tica por ecoendoscopia\" \/>\n<meta property=\"og:description\" content=\"Paciente sexo feminino, 54 anos, com antecedentes de transtorno depressivo e dislipidemia, iniciou em novembro de 2019 quadro de icter\u00edcia, col\u00faria e\" \/>\n<meta property=\"og:url\" content=\"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/caso-clinico-biopsia-hepatica-por-ecoendoscopia\/\" \/>\n<meta property=\"og:site_name\" content=\"Endoscopia Terapeutica\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/endoscopiaterapeutica\" \/>\n<meta property=\"article:published_time\" content=\"2020-08-21T09:00:13+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2023-08-22T19:44:45+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Imagem2-1.jpg?v=1628170615\" \/>\n\t<meta property=\"og:image:width\" content=\"425\" \/>\n\t<meta property=\"og:image:height\" content=\"299\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/jpeg\" \/>\n<meta name=\"author\" content=\"Rafael Oliveira Ximenes\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Escrito por\" \/>\n\t<meta name=\"twitter:data1\" content=\"Rafael Oliveira Ximenes\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. tempo de leitura\" \/>\n\t<meta name=\"twitter:data2\" content=\"6 minutos\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/endoscopiaterapeutica.net\\\/pt\\\/casosclinicos\\\/caso-clinico-biopsia-hepatica-por-ecoendoscopia\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/endoscopiaterapeutica.net\\\/pt\\\/casosclinicos\\\/caso-clinico-biopsia-hepatica-por-ecoendoscopia\\\/\"},\"author\":{\"name\":\"Rafael Oliveira Ximenes\",\"@id\":\"https:\\\/\\\/endoscopiaterapeutica.net\\\/pt\\\/#\\\/schema\\\/person\\\/012b917ba309f407010bbd5ea71f4c2b\"},\"headline\":\"Caso cl\u00ednico &#8211; 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