{"id":4458,"date":"2017-05-08T09:00:38","date_gmt":"2017-05-08T09:00:38","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/manejo-endoscopico-da-sindrome-de-mallory-weiss\/"},"modified":"2021-09-21T19:35:04","modified_gmt":"2021-09-21T19:35:04","slug":"manejo-endoscopico-da-sindrome-de-mallory-weiss","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/manejo-endoscopico-da-sindrome-de-mallory-weiss\/","title":{"rendered":"Manejo endosc\u00f3pico da S\u00edndrome de Mallory Weiss"},"content":{"rendered":"<p>A s\u00edndrome de Mallory-Weiss (SMW) \u00e9 caracterizada por hemorragia digestiva alta (HDA) associada a presen\u00e7a de lacera\u00e7\u00e3o mucosa na regi\u00e3o da jun\u00e7\u00e3o esofagog\u00e1strica (lacera\u00e7\u00e3o de Mallory-Weiss). Usualmente associada a v\u00f4mitos repetidos, SMW \u00e9 uma causa comum de sangramento digestivo, podendo representar at\u00e9 15% do total de casos de HDA.<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2017\/05\/ML02.jpg\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone size-medium wp-image-7751\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/ML02.jpg\" alt=\"\" width=\"300\" height=\"225\" \/><\/a><\/p>\n<p>Figura 1. Lacera\u00e7\u00e3o de Mallory-Weiss em transi\u00e7\u00e3o esofagog\u00e1strica com prolongamento em pequena curvatura<\/p>\n<p>A patog\u00eanese da s\u00edndrome de Mallory-Weiss n\u00e3o \u00e9 completamente entendida, tendo sido proposto que o aumento s\u00fabito de press\u00e3o intra-abdominal possa levar a forma\u00e7\u00e3o de lacera\u00e7\u00f5es na transi\u00e7\u00e3o esofagog\u00e1strica e les\u00e3o do plexo venoso e\/ou arterial local.<\/p>\n<p>Entre algumas das situa\u00e7\u00f5es comumente associadas a SMW, cita-se: abuso de \u00e1lcool, v\u00f4mitos de repeti\u00e7\u00e3o, tosse intensa, convuls\u00f5es, trauma abdominal fechado, pr\u00e1tica esportiva de levantamento de peso, passagem de sonda nasog\u00e1strica e realiza\u00e7\u00e3o de procedimentos de endoscopia digestiva alta.<\/p>\n<p>Casos de lacera\u00e7\u00e3o de Mallory Weiss iatrog\u00eanicos durante endoscopia digestiva alta tem sido relatados com incid\u00eancia estimada entre 0.007\u200a% a 0.49\u200a% do total de procedimentos.<\/p>\n<p>A manifesta\u00e7\u00e3o cl\u00ednica mais comum \u00e9 hemat\u00eamese, \u00a0que pode ser acompanhada por dor epig\u00e1strica. Na maioria dos casos, h\u00e1 relato de n\u00e1useas com esfor\u00e7o de v\u00f4mito, epis\u00f3dios em\u00e9ticos sem sangue associado ou tosse intensa antecedendo o quadro.<\/p>\n<p>O manejo inicial se d\u00e1 com a estabiliza\u00e7\u00e3o cl\u00ednica do paciente, suporte, reposi\u00e7\u00e3o vol\u00eamica quando necess\u00e1ria, e introdu\u00e7\u00e3o de inibidor de bomba de pr\u00f3ton venoso, duas vezes ao dia.<\/p>\n<p>O estabelecimento diagn\u00f3stico da SMW se d\u00e1 com a realiza\u00e7\u00e3o de endoscopia digestiva alta com evid\u00eancia de lacera\u00e7\u00e3o localizada na jun\u00e7\u00e3o esofagog\u00e1strica. As lacera\u00e7\u00f5es de Mallory-Weiss s\u00e3o usualmente \u00fanicas e longitudinais, contudo, lacera\u00e7\u00f5es m\u00faltiplas s\u00e3o descritas em at\u00e9 27% dos casos.<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2017\/05\/ML01.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\"alignnone size-medium wp-image-7750\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/ML01.jpg\" alt=\"\" width=\"300\" height=\"225\" \/><\/a><\/p>\n<p>Figura 2. Apresenta\u00e7\u00e3o de lacera\u00e7\u00e3o de Mallory-Weiss em seu local mais comum (parede lateral direita).<\/p>\n<p>Na endoscopia, a lacera\u00e7\u00e3o aparece como uma les\u00e3o longitudinal avermelhada na mucosa, algumas vezes estendendo-se at\u00e9 a muscular da mucosa. Presen\u00e7a de co\u00e1gulos, ou mesmo sangramento ativo, podem ser evidenciados.<\/p>\n<h2>Tratamento endosc\u00f3pico S\u00edndrome de Mallory Weiss:<\/h2>\n<p>A terapia endosc\u00f3pica \u00e9 indicada no tratamento de sangramento ativo das lacera\u00e7\u00f5es de Mallory-Weiss. Entre os recursos potencialmente utilizados cita-se: inje\u00e7\u00e3o endosc\u00f3pica, coagula\u00e7\u00e3o t\u00e9rmica, hemoclipes e ligadura com banda el\u00e1stica. A utiliza\u00e7\u00e3o de p\u00f3s hemost\u00e1ticos \u00a0(Hemospray) \u00e9 descrita com sucesso na SMW em s\u00e9ries de caso.<\/p>\n<ul>\n<li>\n<h3>Inje\u00e7\u00e3o endosc\u00f3pica<\/h3>\n<\/li>\n<\/ul>\n<p>A terap\u00eautica por inje\u00e7\u00e3o \u00e9 simples, facilmente aplic\u00e1vel e relativamente barata como primeira linha. A adrenalina \u00e9 a solu\u00e7\u00e3o mais comumente usada e melhora os resultados em termos de taxa de ressangramento, tempo de hospitaliza\u00e7\u00e3o e necessidade de transfus\u00e3o, quando comparada a realiza\u00e7\u00e3o de medidas de suporte isoladas. Possui efeito hemost\u00e1tico por induzir vasoconstric\u00e7\u00e3o, por compress\u00e3o vascular associado ao volume de inje\u00e7\u00e3o, e por induzir agrega\u00e7\u00e3o plaquet\u00e1ria.<\/p>\n<div id=\"__sec4\" class=\"sec\">\n<p>O efeito hemost\u00e1tico da adrenalina como terapia de inje\u00e7\u00e3o isolada na SMW \u00e9 controverso. Alguns estudos t\u00eam demonstrado que a inje\u00e7\u00e3o de adrenalina, em casos de sangramento ativo, pode levar a um aumento das taxas de ressangramento quando comparada a hemostasia mec\u00e2nica ou terapia combinada.<\/p>\n<\/div>\n<ul>\n<li>\n<h3>Eletrocoagula\u00e7\u00e3o<\/h3>\n<\/li>\n<\/ul>\n<p>A eletrocoagula\u00e7\u00e3o promove controle hemost\u00e1tico pela aplica\u00e7\u00e3o de calor e press\u00e3o por contato ao s\u00edtio de sangramento de forma simult\u00e2nea. Contudo, em vig\u00eancia de sangramento ativo, a dissipa\u00e7\u00e3o r\u00e1pida do calor no sangue pode levar a maior dificuldade t\u00e9cnica. A eletrocoagula\u00e7\u00e3o multipolar parece melhorar a hemostasia de modo significativo, reduzindo risco de cirurgia em pacientes com SMW.\u00a0 O uso de coagula\u00e7\u00e3o agrega risco, no entanto, associado a possibilidade les\u00e3o t\u00e9rmica transmural e perfura\u00e7\u00e3o do \u00f3rg\u00e3o.<\/p>\n<p>O plasma de arg\u00f4nio tamb\u00e9m tem seu uso descrito em SMW, com a vantagem de ter bom poder hemost\u00e1tico associado com menor dano t\u00e9rmico e consequentemente menor risco de perfura\u00e7\u00e3o.<\/p>\n<ul>\n<li>\n<h3>Hemoclipe<\/h3>\n<\/li>\n<\/ul>\n<p>A aplica\u00e7\u00e3o de hemoclipes \u00e9 um procedimento simples para tratar les\u00f5es em tecido n\u00e3o fibr\u00f3tico como na SMW e nas les\u00f5es de Dieulafoy. Contudo, a aplica\u00e7\u00e3o de hemoclipes na transi\u00e7\u00e3o esofagog\u00e1strica agrega dificuldade t\u00e9cnica.\u00a0 Em um estudo japon\u00eas com uso de hemoclipes met\u00e1licos para SMW iatrog\u00eanica, e de outras naturezas, foi demonstrada hemostasia inicial de 100% e baixas taxas de ressangramento (Shimoda <em>et al<\/em>, 2009).<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2017\/05\/ML4.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\"alignnone size-medium wp-image-7745\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/ML4.jpg\" alt=\"\" width=\"300\" height=\"225\" \/><\/a><\/p>\n<p>Figura 3. Aplica\u00e7\u00e3o de hemoclipe em lacera\u00e7\u00e3o de Mallory-Weiss.<\/p>\n<ul>\n<li>\n<h3>Ligadura el\u00e1stica<\/h3>\n<\/li>\n<\/ul>\n<p>A principal vantagem da ligadura el\u00e1stica por banda \u00e9 a facilidade t\u00e9cnica comparada com outros procedimentos endosc\u00f3picos hemost\u00e1ticos. O uso do cap de ligadura propicia uma boa visualiza\u00e7\u00e3o tangencial da les\u00e3o e, ao tocar e realizar leve compress\u00e3o da lacera\u00e7\u00e3o, leva a imobiliza\u00e7\u00e3o, permitindo uma adequada terap\u00eautica.<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2017\/05\/ML3.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-7744\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/ML3.jpg\" alt=\"\" width=\"300\" height=\"225\" \/><\/a><\/p>\n<p>Figura 4. Realiza\u00e7\u00e3o de ligadura el\u00e1stica em lacera\u00e7\u00e3o de Mallory-Weiss.<\/p>\n<p>Poucos estudos realizam compra\u00e7\u00f5es diretas entre as t\u00e9cnicas hemost\u00e1ticas. Um dos trabalhos de maior representatividade, realizada de forma retrospectiva em 168 pacientes com lacera\u00e7\u00e3o de Mallory-Weiss, a terapia baseada em hemoclipes e a ligadura el\u00e1stica apresentaram maior taxa de sucesso na preven\u00e7\u00e3o do ressangramento comparado com a terapia por inje\u00e7\u00e3o isolada (96, 89 e 71%, respectivamente)(Lee <em>et al<\/em>, 2016).<\/p>\n<p>Considera\u00e7\u00f5es finais:<\/p>\n<p>SMW \u00e9 uma importante causa de sangramento digestivo alto, com boa parte do casos cessando de forma espont\u00e2nea. Nos pacientes com sangramento ativo, as t\u00e9cnicas endosc\u00f3picas mais frequentes s\u00e3o: inje\u00e7\u00e3o de adrenalina, coagula\u00e7\u00e3o com plasma de arg\u00f4nio, hemoclipes e banda el\u00e1stica.\u00a0 A sele\u00e7\u00e3o da melhor estrat\u00e9gia hemost\u00e1tica depende da habilidade do executor do procedimento e do contexto cl\u00ednico apresentado. A realiza\u00e7\u00e3o de terapia injetora isolada deve ser evitada.<\/p>\n<p>A maioria dos pacientes com sangramento ativo durante a endoscopia podem ser controlados endoscopicamente com taxa de ressangramento de at\u00e9 7%. Diante do ressangramento, nova endoscopia com hemostasia pode ser tentada. Caso haja falha endosc\u00f3pica, o uso da arteriografia com emboliza\u00e7\u00e3o ou mesmo a abordagem cir\u00fargica podem ser opc\u00f5es t\u00e9cnicas.<\/p>\n<div id=\"__sec7\" class=\"sec sec-last\"><\/div>\n<p>Refer\u00eancias:<\/p>\n<ol>\n<li>Knauer CM. Mallory-Weiss syndrome. Characterization of 75 Mallory-weiss lacerations in 528 patients with upper gastrointestinal hemorrhage. Gastroenterology 1976; 71:5.<\/li>\n<li>Fishman ML, Thirlwell MP, Daly DS. Mallory-Weiss tear. A complication of cancer chemotherapy. Cancer 1983; 52:2031.<\/li>\n<li>Sugawa C, Benishek D, Walt AJ. Mallory-Weiss syndrome. A study of 224 patients. Am J Surg 1983; 145:30.<\/li>\n<li><span class=\"element-citation\">Laine L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial. <span class=\"ref-journal\">N Engl J Med. <\/span>1987;<span class=\"ref-vol\">316<\/span>:1613\u20131617.<\/span><\/li>\n<li>De Vries AJ, van der Maaten JM, Laurens RR. Mallory-Weiss tear following cardiac surgery: transoesophageal echoprobe or nasogastric tube? Br J Anaesth 2000; 84:646.<\/li>\n<li><span class=\"element-citation\">Peng YC, Tung CF, Chow WK, et al. Efficacy of endoscopic isotonic saline-epinephrine injection for the management of active Mallory-Weiss tears. <span class=\"ref-journal\">J Clin Gastroenterol. <\/span>2001;<span class=\"ref-vol\">32<\/span>:119\u2013122.<\/span><\/li>\n<li>Shimoda R, Iwakiri R, Sakata H, et al. Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory-Weiss tear caused by endoscopic examination. Dig Endosc 2009; 21:20.<\/li>\n<li><span class=\"element-citation\">Lecleire S, Antonietti M, Iwanicki-Caron I, et al. Endoscopic band ligation could decrease recurrent bleeding in Mallory-Weiss syndrome as compared to haemostasis by hemoclips plus epinephrine. <span class=\"ref-journal\">Aliment Pharmacol Ther. <\/span>2009;<span class=\"ref-vol\">30<\/span>:399\u2013405.<\/span><\/li>\n<li><span class=\"mixed-citation\">Akhtar A J, Padda M S. Natural history of Mallory-Weiss tear in African American and Hispanic patients. <span class=\"ref-journal\">J Natl Med Assoc. <\/span>2011;<span class=\"ref-vol\">103<\/span>:412\u2013415.\u00a0<\/span><\/li>\n<li><span class=\"mixed-citation\">Ljubicic N, Budimir I, Pavic T. et al. Mortality in high-risk patients with bleeding Mallory-Weiss syndrome is similar to that of peptic ulcer bleeding. Results of a prospective database study. . <span class=\"ref-journal\">Scand J Gastroenterol. <\/span>2014;<span class=\"ref-vol\">49<\/span>:458\u2013464.\u00a0<\/span><\/li>\n<li>Giles H, Lal D, Gerred S, Casey P, Patrick A, Luo D, Ogra R. Efficacy and safety of TC-325 (HemosprayTM) for non-variceal upper gastrointestinal bleeding at Middlemore Hospital: the early New Zealand experience.N Z Med J. 2016 Dec 2;129(1446):38-43.<\/li>\n<li>Lee S, Ahn JY, Jung HY, et al. Effective endoscopic treatment of Mallory-Weiss syndrome using Glasgow-Blatchford score and Forrest classification. J Dig Dis 2016; 17:676.<\/li>\n<\/ol>\n<div class=\"ref-cit-blk half_rhythm\"><\/div>\n","protected":false},"excerpt":{"rendered":"<p>s\u00edndrome de Mallory-Weiss \u00e9 uma importante causa de sangramento digestivo alto, com boa parte do casos cessando de forma espont\u00e2nea. Nos pacientes com sangramento ativo, as t\u00e9cnicas endosc\u00f3picas mais frequentes s\u00e3o: inje\u00e7\u00e3o de adrenalina, coagula\u00e7\u00e3o com plasma de arg\u00f4nio, hemoclipes e banda el\u00e1stica<\/p>\n","protected":false},"author":726,"featured_media":4454,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[276],"tipo":[153],"volume":[263],"class_list":["post-4458","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-276","tipo-endoscopia-digestiva-alta","volume-volume-i"],"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>Manejo endosc\u00f3pico da S\u00edndrome de Mallory Weiss &#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\/manejo-endoscopico-da-sindrome-de-mallory-weiss\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Manejo endosc\u00f3pico da S\u00edndrome de Mallory Weiss\" \/>\n<meta property=\"og:description\" content=\"s\u00edndrome de Mallory-Weiss \u00e9 uma importante causa de sangramento digestivo alto, com boa parte do casos cessando de forma espont\u00e2nea. 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