{"id":5808,"date":"2023-05-25T06:30:38","date_gmt":"2023-05-25T09:30:38","guid":{"rendered":"https:\/\/gastropedia.pub\/pt\/?p=5808"},"modified":"2025-03-03T18:26:21","modified_gmt":"2025-03-03T21:26:21","slug":"insuficiencia-pancreatica-exocrina-um-olhar-alem-do-obvio","status":"publish","type":"post","link":"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/insuficiencia-pancreatica-exocrina-um-olhar-alem-do-obvio\/","title":{"rendered":"Insufici\u00eancia Pancre\u00e1tica Ex\u00f3crina: um olhar al\u00e9m do \u00f3bvio"},"content":{"rendered":"<div class=\"pdfprnt-buttons pdfprnt-buttons-post pdfprnt-top-right\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/5808?print=pdf\" class=\"pdfprnt-button pdfprnt-button-pdf\" target=\"_blank\" ><img decoding=\"async\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/plugins\/pdf-print\/images\/pdf.png\" alt=\"image_pdf\" title=\"Ver PDF\" \/><\/a><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/5808?print=print\" class=\"pdfprnt-button pdfprnt-button-print\" target=\"_blank\" ><img decoding=\"async\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/plugins\/pdf-print\/images\/print.png\" alt=\"image_print\" title=\"Conte\u00fado de impress\u00e3o\" \/><\/a><\/div>\n<p>Quando pensamos em Insufici\u00eancia Pancre\u00e1tica Ex\u00f3crina &#8211; IEP (diminui\u00e7\u00e3o na atividade das enzimas pancre\u00e1ticas na luz intestinal, abaixo dos valores para uma digest\u00e3o normal) automaticamente relacionamos com problemas prim\u00e1rios do p\u00e2ncreas, como pancreatite cr\u00f4nica ou neoplasia pancre\u00e1tica. E isso \u00e9 correto, essas patologias s\u00e3o sim causa de IEP. Entretanto temos diversas outras causas que devem ser lembradas pelo gastroenterologista.<\/p>\n\n\n\n<p>Para entendermos corretamente, vamos recorrer a fisiologia pancre\u00e1tica. A produ\u00e7\u00e3o de enzimas digestivas pelo p\u00e2ncreas n\u00e3o \u00e9 dependente apenas da morfologia da gl\u00e2ndula. Inicialmente o p\u00e2ncreas \u00e9 estimulado por vias neurais derivadas do nervo vago, e posteriormente tem sua principal via de estimula\u00e7\u00e3o atrav\u00e9s da passagem do quimo pelo duodeno. Nesta fase, a libera\u00e7\u00e3o de secretina e colecistoquinina (CCK) \u00e9 respons\u00e1vel por cerca de 70% de toda a produ\u00e7\u00e3o de suco pancre\u00e1tico daquela refei\u00e7\u00e3o. Portanto, \u00e9 correto afirmar que qualquer falha nesse circuito pode ser a causa de IEP.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-hoje-classificamos-as-etiologias-da-iep-como-de-causas-pancreaticas-e-extra-pancreaticas\"><strong>Hoje classificamos as etiologias da IEP como de causas pancre\u00e1ticas e extra-pancre\u00e1ticas<\/strong>:<\/h2>\n\n\n\n<p><strong>Dentre as causas pancre\u00e1ticas, temos:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">\n<li>Pancreatite cr\u00f4nica<\/li>\n\n\n\n<li>Neoplasias pancre\u00e1ticas<\/li>\n\n\n\n<li>Fibrose C\u00edstica<\/li>\n\n\n\n<li>Ressec\u00e7\u00f5es Pancre\u00e1ticas<\/li>\n\n\n\n<li>Hemocromatose<\/li>\n\n\n\n<li>Pancreatite aguda grave, cursando com necrose extensa do par\u00eanquima glandular<\/li>\n<\/ul>\n\n\n\n<p><strong>E dentre as causas extra-pancre\u00e1ticas, podemos listar:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">\n<li>Doen\u00e7a Cel\u00edaca<\/li>\n\n\n\n<li>Doen\u00e7a de Crohn de acometimento de intestino delgado alto<\/li>\n\n\n\n<li>Diabetes tipo I e II<\/li>\n\n\n\n<li>Envelhecimento pancre\u00e1tico<\/li>\n\n\n\n<li>Cirurgias gastroduodenais<\/li>\n<\/ul>\n\n\n\n<p>As causas pancre\u00e1ticas s\u00e3o mais conhecidas, e s\u00e3o causadas por doen\u00e7as que levam a fibrose progressiva do p\u00e2ncreas, como a pancreatite cr\u00f4nica; \u00e0 atrofia pancre\u00e1tica somada a obstru\u00e7\u00e3o do ducto pancre\u00e1tico principal (como as neoplasias, especialmente da regi\u00e3o cef\u00e1lica) e a perda de par\u00eanquima pancre\u00e1tico, secund\u00e1ria a pancreatite aguda ou ressec\u00e7\u00f5es pancre\u00e1ticas. Al\u00e9m delas, a fibrose c\u00edstica \u00e9 a principal doen\u00e7a de causa gen\u00e9tica e causa a lipossubstitui\u00e7\u00e3o do par\u00eanquima pancre\u00e1tico, al\u00e9m de altera\u00e7\u00e3o no transporte do suco pancre\u00e1tico atrav\u00e9s dos ductos.<\/p>\n\n\n\n<p>As causas n\u00e3o pancre\u00e1ticas mais bem estabelecidas s\u00e3o: a doen\u00e7a cel\u00edaca (devido a atrofia duodenal e a perda da estimula\u00e7\u00e3o pelos horm\u00f4nios duodenais &#8211; secretina e CCK), o<em> diabetes mellitus<\/em> e as cirurgias derivativas.<\/p>\n\n\n\n<p>Nos estudos mais recentes, o diabetes tem sido apontado como causa de IEP, tanto o DM-1 quanto o DM-2. As raz\u00f5es para isso s\u00e3o diversas e envolvem:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Atrofia do par\u00eanquima ex\u00f3crino devido a falta da insulina: o horm\u00f4nio produzido pelas c\u00e9lulas end\u00f3crinas pancre\u00e1ticas exerce uma a\u00e7\u00e3o tr\u00f3fica par\u00e1crina nas c\u00e9lulas acinares. A diminui\u00e7\u00e3o da insulina ocasiona diminui\u00e7\u00e3o no trofismo do par\u00eanquima ex\u00f3crino.<\/li>\n\n\n\n<li>O diabetes pode levar a neuropatia auton\u00f4mica, prejudicando as vias vagais e a estimula\u00e7\u00e3o da acetilcolina sobre as c\u00e9lulas pancre\u00e1ticas.<\/li>\n\n\n\n<li>A microangiopatia que leva a um curso de isquemia cr\u00f4nica na gl\u00e2ndula, diminuindo a produ\u00e7\u00e3o enzim\u00e1tica.<\/li>\n\n\n\n<li>A infiltra\u00e7\u00e3o de adip\u00f3citos no p\u00e2ncreas, al\u00e9m de linf\u00f3citos, aumenta a a\u00e7\u00e3o de fibroblastos e ocasiona uma maior deposi\u00e7\u00e3o de col\u00e1geno no \u00f3rg\u00e3o.<\/li>\n<\/ul>\n\n\n\n<p>A frequ\u00eancia de IEP nos diab\u00e9ticos ainda \u00e9 incerta, e ao que parece \u00e9 maior nos pacientes com DM-1 (30-56%) e menor nos pacientes com DM-2 (30-40%). Apesar da heterogeneidade dos estudos, a preval\u00eancia de IEP nos pacientes diab\u00e9ticos n\u00e3o deve ser menosprezada.<\/p>\n\n\n\n<p>Em rela\u00e7\u00e3o aos&nbsp; procedimentos cir\u00fargicos de abdome superior, observamos uma frequ\u00eancia cada vez maior de IEP em gastrectomias, duodenopancreatectomias e cirurgias derivativas, como o bypass gastrojejunal.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Nas gastrectomias parciais ou totais temos estudos mostrando 30-73% de IEP ap\u00f3s 3 meses da cirurgia. <\/li>\n\n\n\n<li>J\u00e1 ap\u00f3s as duodenopancreatectomias esse percentual pode chegar a 100%, entretanto a m\u00e9dia p\u00f3s-procedimento indicado por neoplasia pancre\u00e1tica ou periampular foi de 74%. <\/li>\n\n\n\n<li>Esse percentual \u00e9 maior do que o encontrado em duodenopancreatectomias por doen\u00e7as benignas (53%). <\/li>\n\n\n\n<li>H\u00e1 um trabalho que evidencia 16% de IEP p\u00f3s esofagectomia, embora tenha um N pequeno.<\/li>\n<\/ul>\n\n\n\n<p>Por fim, a frequ\u00eancia de IEP p\u00f3s bypass gastrojejunal tem se mostrado uma preocupa\u00e7\u00e3o no seguimento desses pacientes. Especialmente ap\u00f3s alguns anos de cirurgia, uma porcentagem desses pacientes pode apresentar IEP. Em uma coorte retrospectiva, 20,6% dos pacientes tinham esteatorreia, mas apenas 10,3% deles foram diagnosticados com IEP p\u00f3s bypass com reconstru\u00e7\u00e3o em Y-Roux. Entretanto, apesar da frequ\u00eancia n\u00e3o ser alta, o tratamento dos pacientes com IEP diagnosticada \u00e9 crucial para uma evolu\u00e7\u00e3o nutricional satisfat\u00f3ria.<\/p>\n\n\n\n<p>Como pudemos observar, as causas de Insufici\u00eancia Ex\u00f3crina Pancre\u00e1tica v\u00e3o al\u00e9m de problemas estruturais na gl\u00e2ndula. \u00c9 imperativo que o gastroenterologista lembre da IEP nos contextos apresentados acima, e que n\u00e3o deixe passar a oportunidade do tratamento correto desses pacientes.<\/p>\n\n\n\n<blockquote class=\"wp-block-quote has-pale-ocean-gradient-background has-background is-layout-flow wp-block-quote-is-layout-flow\">\n<p>Conhe\u00e7a nosso curso <strong><a href=\"https:\/\/gastropedia.pub\/pt\/cursos\/gastroenterologia-do-consultorio\/\" target=\"_blank\" rel=\"noreferrer noopener\">Gastroenterologia do Consult\u00f3rio<\/a><\/strong> e saiba como lidar com as queixas mais comuns que encontramos no dia a dia<\/p>\n<\/blockquote>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-referencias\"><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Vikesh K Singh, Mark E Haupt, David E Geller, Jerry A Hall, Pedro M Quintana Diez. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol 2017 October 21; 23(39): 7059-7076<\/li>\n\n\n\n<li>Martha Campbell-Thompson, Teresa Rodriguez-Calvo, and Manuela Battaglia. Abnormalities of the Exocrine Pancreas in Type 1 Diabetes. Curr Diab Rep. 2015 October ; 15(10): 79.<\/li>\n\n\n\n<li>J. R. Huddy, F. M. S. Macharg, A. M. Lawn, S. R. Preston. Exocrine pancreatic insufficiency following esophagectomy. Diseases of the Esophagus (2013) 26, 594\u2013597<\/li>\n\n\n\n<li>Miroslav Vujasinovic, Roberto Valente, Anders Thorell, Wiktor Rutkowski, Stephan L. Haas, Urban Arnelo,&nbsp; Lena Martin and J.-Matthias L\u00f6hr. Pancreatic Exocrine Insufficiency after Bariatric Surgery. Nutrients 2017, 9, 1241;<\/li>\n\n\n\n<li>Joshua Y Kwon , <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=Nelson+A&amp;cauthor_id=35931645\">Alfred Nelson<\/a> , Ahmed Salih , Jose Valery,&nbsp; Dana M Harris, <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/?term=Stancampiano+F&amp;cauthor_id=35931645\">Fernando Stancampiano<\/a> , Yan Bi. Exocrine pancreatic insufficiency after bariatric surgery. Pancreatology, 2022 Nov;22(7):1041-1045.<\/li>\n<\/ol>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-como-citar-este-artigo\"><strong>Como citar este artigo<\/strong><\/h2>\n\n\n\n<p class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\" style=\"background-color:#c6e3d5\">Marzinotto M. Insufici\u00eancia Pancre\u00e1tica Ex\u00f3crina: um olhar al\u00e9m do \u00f3bvio. Gastropedia 2023, vol 1. Disponivel em: <a href=\"https:\/\/gastropedia.pub\/pt\/?p=5808\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/gastropedia.pub\/pt\/sem-categoria\/insuficiencia-pancreatica-exocrina-um-olhar-alem-do-obvio<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Quando pensamos em Insufici\u00eancia Pancre\u00e1tica Ex\u00f3crina &#8211; IEP (diminui\u00e7\u00e3o na atividade das enzimas pancre\u00e1ticas na luz intestinal, abaixo dos valores para uma digest\u00e3o normal) automaticamente relacionamos com problemas prim\u00e1rios do&hellip;<\/p>\n","protected":false},"author":3341,"featured_media":2875,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[18,23],"tags":[],"ano":[137],"tipo":[121],"volume":[57],"class_list":["post-5808","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-gastroenterologia","category-pancreas","ano-137","tipo-assuntos-gerais","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.2) - 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