{"id":4446,"date":"2017-03-27T09:00:27","date_gmt":"2017-03-27T09:00:27","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/alergia-contraste-em-cpre\/"},"modified":"2022-01-11T11:14:21","modified_gmt":"2022-01-11T11:14:21","slug":"alergia-contraste-em-cpre","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/alergia-contraste-em-cpre\/","title":{"rendered":"Alergia a Contraste em CPRE"},"content":{"rendered":"<p>&nbsp;<\/p>\n<p style=\"text-align: justify;\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2017\/03\/contraste.png\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\"aligncenter size-medium wp-image-7572\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/contraste.png\" alt=\"contraste\" width=\"300\" height=\"160\" \/><\/a><\/p>\n<p style=\"text-align: justify;\">Contrastes iodados s\u00e3o fundamentais para uma boa qualidade de imagem na CPRE. No entanto, \u00e9 muito comum recebermos pacientes com antecedente de rea\u00e7\u00e3o al\u00e9rgica a contraste iodado em procedimentos radiol\u00f3gicos (ex: tomografia computadorizada). Por outro lado, a ocorr\u00eancia de rea\u00e7\u00e3o al\u00e9rgica em pacientes submetidos a CPRE \u00e9 extremamente rara.<\/p>\n<p style=\"text-align: center;\"><strong>Qual o risco de rea\u00e7\u00e3o al\u00e9rgica ao contraste iodado na CPRE?<\/strong><\/p>\n<p style=\"text-align: center;\"><strong>O que fazer em casos de antecedente de rea\u00e7\u00e3o al\u00e9rgica?<\/strong><\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: justify;\">V\u00e1rios estudos j\u00e1 confirmaram que ocorre absor\u00e7\u00e3o sist\u00eamica de contraste ap\u00f3s a CPRE. A concentra\u00e7\u00e3o s\u00e9rica de iodo ap\u00f3s CPRE pode aumentar at\u00e9 90 x, o que \u00a0corresponde a cerca de 1% da eleva\u00e7\u00e3o observada com administra\u00e7\u00e3o endovenosa em procedimentos radiol\u00f3gicos e cerca de 0.6% da observada durante uma coronariografia.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Felizmente, a ocorr\u00eancia de rea\u00e7\u00e3o adversa em CPRE \u00e9 extremamente rara:<\/strong><\/p>\n<ul>\n<li>Bilbao et al reportaram 3 rea\u00e7\u00f5es adversas manifestadas como eritema e rash, em 8.681 CPREs;<\/li>\n<li>Sable et al n\u00e3o encontraram\u00a0manifesta\u00e7\u00f5es al\u00e9rgicas p\u00f3s CPRE, apesar de antecedente de hipersensibilidade intravascular em 2 pacientes;<\/li>\n<li>Draganov e col realizaram estudo prospectivo envolvendo 601 pacientes submetidos a CPRE com contraste hiperosmolar. Destes, 80 tinham antecedente de rea\u00e7\u00e3o al\u00e9rgica (39 leve, 21 moderada e 20 grave). Nenhum paciente recebeu profilaxia e n\u00e3o houve relato de manifesta\u00e7\u00f5es al\u00e9rgicas em nenhum destes pacientes.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>A pancreatografia parece estar associada a maior absor\u00e7\u00e3o sist\u00eamica de iodo do que a colangiografia.<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>Tipos de Contraste<\/strong><\/h2>\n<p>Contrastes iodados s\u00e3o \u00e1cidos benzoicos hidrof\u00edlicos, com baixa afinidade por prote\u00ednas e baixa solubilidade aos lip\u00eddeos.<\/p>\n<p>Podem ser divididos em <strong>i\u00f4nicos<\/strong> (geralmente s\u00e3o de alta osmolaridade) e <strong>n\u00e3o i\u00f4nicos<\/strong> (baixa osmolaridade)<\/p>\n<ul>\n<li>Alta osmolaridade: custo menor<\/li>\n<li>Baixa osmolaridade: menor chance de rea\u00e7\u00f5es adversas.<\/li>\n<li>Qualidade de imagem: semelhante<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p style=\"text-align: justify;\">A qualidade de imagem dos meios i\u00f4nicos e n\u00e3o i\u00f4nicos s\u00e3o muito semelhantes. A dilui\u00e7\u00e3o do agente com \u00e1gua diminui sua atenua\u00e7\u00e3o.\u00a0Em geral, prefere-se o contraste um pouco dilu\u00eddo para o diagn\u00f3stico de c\u00e1lculos em col\u00e9doco dilatado. Para estudo de estenoses e do p\u00e2ncreas, preferimos utilizar contraste puro.<\/p>\n<p>&nbsp;<\/p>\n<h4><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2017\/03\/meios-contraste.png\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" class=\"aligncenter wp-image-7563 size-large\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/meios-contraste.png\" alt=\"meios contraste\" width=\"670\" height=\"318\" \/><\/a><\/h4>\n<h4><\/h4>\n<p><strong>Obs:<\/strong> o <strong>Gadol\u00edneo<\/strong> \u00e9 um agente <strong>n\u00e3o iodado<\/strong> usado em radiologia para casos com antecedente de rea\u00e7\u00f5es graves ao agentes iodados. Seu uso j\u00e1 foi descrito em colangiografia. No entanto, o custo \u00e9 mais elevado, a apresenta\u00e7\u00e3o do frasco \u00e9 de 15-20 ml e a atenua\u00e7\u00e3o \u00e9 menor do que os contrastes iodados.<\/p>\n<h2><\/h2>\n<h2><strong>Rea\u00e7\u00f5es Al\u00e9rgicas<\/strong><\/h2>\n<p>Muito do que se sabemos sobre rea\u00e7\u00f5es al\u00e9rgicas a contraste s\u00e3o conhecimentos dos estudos de radiologia.<\/p>\n<p>A incid\u00eancia\u00a0de rea\u00e7\u00f5es adversas com contraste hiperosmolar \u00e9 de 5-12%, com os de baixa osmolaridade 1-3% e com gadol\u00ednio \u00e9 de 0.07-2.4%.<\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"text-decoration: underline;\"><strong>Existem 2 tipos principais de rea\u00e7\u00f5es adversas:<\/strong><\/span><\/p>\n<ol>\n<li>\n<h3><strong>Anafilactoide (idiossincr\u00e1ticas)<\/strong><\/h3>\n<\/li>\n<\/ol>\n<ul>\n<li>S\u00e3o as verdadeiras alergias. N\u00e3o dependem nem da dose, nem da velocidade de infus\u00e3o.<\/li>\n<li>Maioria ocorre dentro de 5 minutos da administra\u00e7\u00e3o.<\/li>\n<li>Patog\u00eanese pouco compreendida. Acredita-se que n\u00e3o seja mediada por IgE (como as verdadeiras rea\u00e7\u00f5es anafil\u00e1ticas)\u00a0.<\/li>\n<li>Mecanismo mais importante envolve libera\u00e7\u00e3o de histamina de bas\u00f3filos e eosin\u00f3filos<\/li>\n<li>Libera\u00e7\u00e3o de compostos vasoativos provocando hipotens\u00e3o<\/li>\n<li>Administra\u00e7\u00e3o pr\u00e9via de corticoides e anti-histam\u00ednicos pode diminuir sua incid\u00eancia, por\u00e9m uma pequena fra\u00e7\u00e3o dos pacientes pode ter uma verdadeira anafilaxia mediada por IgE<\/li>\n<li>Sintomas incluem urtic\u00e1ria, prurido, edema cut\u00e2neo, coceira na garganta, congest\u00e3o nasal, podendo em casos graves evoluir para edema de laringe, broncoespasmo e choque anafil\u00e1tico (ver tabela)<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h3><strong>2. N\u00e3o anafilactoide (quimiot\u00f3xica)<\/strong><\/h3>\n<ul>\n<li>Tamb\u00e9m chamadas de rea\u00e7\u00f5es fisiol\u00f3gicas, s\u00e3o causadas pela propriedades qu\u00edmicas dos meios de contraste e s\u00e3o dependentes da dose e da velocidade de infus\u00e3o.<\/li>\n<li>As caracter\u00edsticas i\u00f4nicas dos meios de contraste provocam altera\u00e7\u00f5es de sinaliza\u00e7\u00e3o neuronal e card\u00edaca, ao passo que sua osmolaridade interfere no balan\u00e7o de fluidos.<\/li>\n<li>Sintomas incluem: n\u00e1usea, cefaleia, flush, hipertens\u00e3o, tontura, calafrio, ansiedade, altera\u00e7\u00f5es no gosto (altered taste), sintomas vago-vagais e nefrotoxicidade.<\/li>\n<li>Casos graves podem cursar com\u00a0arritmia, convuls\u00e3o e emerg\u00eancia hipertensiva.<\/li>\n<li>Geralmente s\u00e3o autolimitadas e n\u00e3o necessita tratamento espec\u00edfico. Tampouco s\u00e3o preven\u00edveis com administra\u00e7\u00e3o de esteroides.<\/li>\n<li>Visto ser dose-dependente e visto a absor\u00e7\u00e3o sist\u00eamica p\u00f3s-CPRE ser muito baixa, n\u00e3o deve ser uma preocupa\u00e7\u00e3o nos pacientes submetidos a CPRE.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2>Quanto a <strong>gravidade<\/strong>, podem ser classificadas em:<\/h2>\n<ol>\n<li><strong>Leve:<\/strong> autolimitada, sem progress\u00e3o<\/li>\n<li><strong>Moderada:<\/strong> mais difusas e geralmente necessitam interven\u00e7\u00e3o medicamentosa<\/li>\n<li><strong>Intensa:<\/strong>\u00a0risco de morte<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<div class=\"pcrstb-wrap\"><table width=\"607\">\n<tbody>\n<tr>\n<td width=\"182\"><strong>Rea\u00e7\u00e3o leve<\/strong><\/td>\n<td width=\"222\"><strong>Rea\u00e7\u00e3o moderada<\/strong><\/td>\n<td width=\"202\"><strong>Rea\u00e7\u00e3o intensa<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"182\">Urticaria\/prurido limitado<\/p>\n<p>Edema cut\u00e2neo limitado<\/p>\n<p>Garganta \u201carranhando\u201d<\/p>\n<p>Congest\u00e3o nasal<\/p>\n<p>Espirro<\/td>\n<td width=\"222\">Urticaria difusa<\/p>\n<p>Eritema difuso sem hipotens\u00e3o.<\/p>\n<p>Edema facial sem dificuldade respirat\u00f3ria<\/p>\n<p>Sensa\u00e7\u00e3o de aperto na garganta, mas sem dificuldade respirat\u00f3ria<\/p>\n<p>Broncoespasmo com leve dispneia<\/td>\n<td width=\"202\">Edema difuso ou edema facial<\/p>\n<p>Eritema difuso com hipotens\u00e3o<\/p>\n<p>Edema de laringe com estridor e\/ou hip\u00f3xia<\/p>\n<p>Broncoespasmo com hip\u00f3xia<\/p>\n<p>Choque anafil\u00e1tico<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n<h4><\/h4>\n<h2><strong>Preven\u00e7\u00e3o:<\/strong><\/h2>\n<p style=\"text-align: justify;\">A administra\u00e7\u00e3o profil\u00e1tica de corticoides e anti-histam\u00ednicos tem se mostrado eficaz na redu\u00e7\u00e3o das manifesta\u00e7\u00f5es al\u00e9rgicas aos meios de contraste. No entanto, o efeito\u00a0destes medicamentos se administrados em\u00a0menos de 4-6h\u00a0antes do procedimento \u00e9 insignificante.<\/p>\n<p>Esquema mais utilizado entre os radiologistas \u00e9 a seguinte associa\u00e7\u00e3o:<\/p>\n<p style=\"text-align: center;\"><strong>Prednisona:<\/strong> 50 mg VO 13h, 7h e 1h antes da inje\u00e7\u00e3o de contraste<\/p>\n<p style=\"text-align: center;\">+<\/p>\n<p style=\"text-align: center;\"><strong>Difenidramina:<\/strong> 50 mg VO, EV ou IM 1 h antes<\/p>\n<p>&nbsp;<\/p>\n<h2><strong>Recomenda\u00e7\u00f5es da ASGE<\/strong><\/h2>\n<p style=\"text-align: justify;\">As evid\u00eancias de seguran\u00e7a provenientes dos estudos do uso endovascular na radiologia n\u00e3o podem ser extrapolados para a endoscopia, visto a baixa incid\u00eancia de rea\u00e7\u00f5es adversas, especialmente de rea\u00e7\u00f5es graves na CPRE.<\/p>\n<p style=\"text-align: justify;\">N\u00e3o h\u00e1 evid\u00eancia na literatura\u00a0para recomendar contrastes n\u00e3o i\u00f4nicos\u00a0como m\u00e9todo de preven\u00e7\u00e3o de complica\u00e7\u00f5es em CPRE (existe evid\u00eancia para o uso EV, mas n\u00e3o existe esta comprova\u00e7\u00e3o para colangiografia).<\/p>\n<p style=\"text-align: justify;\">Em pacientes considerads de alto risco (rea\u00e7\u00e3o anafilactoide grave com contraste EV) pr\u00e9-medica\u00e7\u00f5es ou substitui\u00e7\u00e3o do meio de contraste podem ser considerados uma op\u00e7\u00e3o, baseado em considera\u00e7\u00f5es te\u00f3ricas.<\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><strong>Voc\u00ea j\u00e1 teve algum problema com rea\u00e7\u00e3o al\u00e9rgica em CPRE? Qual agente de contraste tem utilizado no seu servi\u00e7o? Como conduz os casos com antecedente de rea\u00e7\u00e3o al\u00e9rgica a contraste?<\/strong><\/p>\n<hr \/>\n<h5 style=\"text-align: left;\">.<\/h5>\n<h2 style=\"text-align: left;\"><strong>Refer\u00eancias:<\/strong><\/h2>\n<p>1: Rose TA Jr, Choi JW. Intravenous Imaging Contrast Media Complications: The\u00a0Basics That Every Clinician Needs to Know. Am J Med. 2015 Sep;128(9):943-9.<\/p>\n<p>2: Pan JJ, Draganov PV. Adverse reactions to iodinated contrast media\u00a0administered at the time of endoscopic retrograde cholangiopancreatography\u00a0(ERCP). Inflamm Allergy Drug Targets. 2009 Mar;8(1):17-20.<\/p>\n<p>3: Mishkin D, Carpenter S, Croffie J, Chuttani R, DiSario J, Hussain N, Liu J,\u00a0Somogyi L, Tierney W, Petersen BT; Technology Assessment Committee, American\u00a0Society for Gastrointestinal Endoscopy.. ASGE Technology Status Evaluation\u00a0Report: radiographic contrast media used in ERCP. Gastrointest Endosc. 2005\u00a0Oct;62(4):480-4.<\/p>\n<p>4: Bilbao MK, Dotter CT, Lee TG, Katon RM. Complications of endoscopic retrograde\u00a0cholangiopancreatography (ERCP). A study of 10,000 cases. Gastroenterology. 1976\u00a0Mar;70(3):314-20.<\/p>\n<p>5: Sable RA, Rosenthal WS, Siegel J, Ho R, Jankowski RH. Absorption of contrast\u00a0medium during ERCP. Dig Dis Sci. 1983 Sep;28(9):801-6.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; Contrastes iodados s\u00e3o fundamentais para uma boa qualidade de imagem na CPRE. No&hellip;<\/p>\n","protected":false},"author":712,"featured_media":5159,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[307,308,294],"ano":[276],"tipo":[155],"volume":[263],"class_list":["post-4446","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","tag-alergia","tag-contraste","tag-cpre","ano-276","tipo-cpre","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Alergia a Contraste em CPRE &#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\/assuntosgerais\/alergia-contraste-em-cpre\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Alergia a Contraste em CPRE\" \/>\n<meta property=\"og:description\" content=\"&nbsp; Contrastes iodados s\u00e3o fundamentais para uma boa qualidade de imagem na CPRE. 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