{"id":6325,"date":"2023-07-13T06:30:52","date_gmt":"2023-07-13T09:30:52","guid":{"rendered":"https:\/\/gastropedia.pub\/pt\/?p=6325"},"modified":"2025-03-03T18:25:42","modified_gmt":"2025-03-03T21:25:42","slug":"aumento-de-enzimas-pancreaticas-no-sangue-como-investigar-ou-conduzir","status":"publish","type":"post","link":"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/pancreas\/aumento-de-enzimas-pancreaticas-no-sangue-como-investigar-ou-conduzir\/","title":{"rendered":"Aumento de enzimas pancre\u00e1ticas no sangue &#8211; como investigar ou conduzir?"},"content":{"rendered":"<div class=\"pdfprnt-buttons pdfprnt-buttons-post pdfprnt-top-right\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/6325?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\/6325?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 class=\"yoast-reading-time__wrapper\"><span class=\"yoast-reading-time__icon\"><svg aria-hidden=\"true\" focusable=\"false\" data-icon=\"clock\" width=\"20\" height=\"20\" fill=\"none\" stroke=\"currentColor\" style=\"display:inline-block;vertical-align:-0.1em\" role=\"img\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 24 24\"><path stroke-linecap=\"round\" stroke-linejoin=\"round\" stroke-width=\"2\" d=\"M12 8v4l3 3m6-3a9 9 0 11-18 0 9 9 0 0118 0z\"><\/path><\/svg><\/span><span class=\"yoast-reading-time__spacer\" style=\"display:inline-block;width:1em\"><\/span><span class=\"yoast-reading-time__reading-time\">7<\/span><span class=\"yoast-reading-time__time-unit\"> minutos<\/span><\/p>\n\n\n\n<p>Por vezes nos deparamos com pacientes que, mesmo sem um motivo aparente, apresentam aumento de enzimas pancre\u00e1ticas (lipase ou amilase) no sangue. Quando valorizar esse achado? A dosagem das enzimas fora do contexto de dor abdominal \u00e9 indicada?<\/p>\n\n\n\n<p>Chamamos de hiperenzinemia pancre\u00e1tica o aumento das enzimas no sangue. S\u00e3o v\u00e1rias as poss\u00edveis causas para esse aumento, que geralmente envolvem um desbalan\u00e7o entre a libera\u00e7\u00e3o de enzimas na corrente sangu\u00ednea e o clearance delas, que pode se apresentar diminu\u00eddo.&nbsp;<\/p>\n\n\n\n<p>A primeira quest\u00e3o a ser lembrada \u00e9 que a amilase \u00e9 uma enzima produzida por diversos tecidos, sendo os de maior destaque as gl\u00e2ndulas salivares e o p\u00e2ncreas. A lipase \u00e9 bem mais espec\u00edfica do p\u00e2ncreas, embora alguns s\u00edtios possam produzir lipase tamb\u00e9m, como o est\u00f4mago, duodeno, c\u00f3lon e f\u00edgado.&nbsp;<\/p>\n\n\n\n<p>Essas enzimas s\u00e3o parcialmente eliminadas pelos rins e pelo sistema ret\u00edculo-endotelial (especialmente pelo f\u00edgado). \u00c9 dessa forma que as enzimas s\u00e3o retiradas do sangue em situa\u00e7\u00f5es fisiol\u00f3gicas.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-causas-de-hiperenzinemia-pancreatica\"><strong>Causas de Hiperenzinemia Pancre\u00e1tica<\/strong><\/h2>\n\n\n\n<p>Sem d\u00favida a principal causa de eleva\u00e7\u00e3o de enzimas pancre\u00e1ticas \u00e9 a pancreatite aguda (PA). Esse \u00e9 um dos crit\u00e9rios para o diagn\u00f3stico da PA definidos pelo Consenso de Atlanta Modificado em 2012, conforme tabela 1.<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><img fetchpriority=\"high\" decoding=\"async\" width=\"615\" height=\"105\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2023\/06\/WhatsApp-Image-2023-06-20-at-07.30.45.png\" alt=\"\" class=\"wp-image-6329\" srcset=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2023\/06\/WhatsApp-Image-2023-06-20-at-07.30.45.png 615w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2023\/06\/WhatsApp-Image-2023-06-20-at-07.30.45-300x51.png 300w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2023\/06\/WhatsApp-Image-2023-06-20-at-07.30.45-585x100.png 585w\" sizes=\"(max-width: 615px) 100vw, 615px\" \/><figcaption class=\"wp-element-caption\">Tabela 1.- crit\u00e9rios diagn\u00f3sticos para Pancreatite Aguda<\/figcaption><\/figure>\n<\/div>\n\n\n<p>Faz sentido, portanto, a dosagem das enzimas no contexto de dor epig\u00e1strica (que pode irradiar para hipoc\u00f4ndrios e dorso), acompanhada de n\u00e1useas e v\u00f4mitos. Neste caso, o aumento superior a 3x o limite superior da normalidade concluiria o diagn\u00f3stico de PA, sem a necessidade do exame de imagem.&nbsp;<\/p>\n\n\n\n<p>A dosagem das enzimas fora do contexto de dor ainda podem representar algum problema pancre\u00e1tico. Qualquer processo patol\u00f3gico na gl\u00e2ndula pode se manifestar com aumento de enzimas. Alguns exemplos s\u00e3o:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Neoplasias pancre\u00e1ticas<\/li>\n\n\n\n<li>Neoplasias peri-ampulares<\/li>\n\n\n\n<li>Dilata\u00e7\u00f5es ductais, como as encontradas nos IPMNs<\/li>\n\n\n\n<li>Pancreatite cr\u00f4nica<\/li>\n\n\n\n<li>Disfun\u00e7\u00e3o do esf\u00edncter de Oddi<\/li>\n\n\n\n<li>Anormalidades anat\u00f4micas, como Santorinocele ou <em>Pancreas divisum<\/em><\/li>\n\n\n\n<li>Coledococele<\/li>\n\n\n\n<li>Manipula\u00e7\u00e3o da papila, como nas CPREs<\/li>\n<\/ul>\n\n\n\n<p>Sabendo disso, faz-se necess\u00e1ria uma boa imagem pancre\u00e1tica para exclus\u00e3o dessas etiologias, especialmente as neoplasias.&nbsp;<\/p>\n\n\n\n<p>Existem causas extra-pancre\u00e1ticas de aumento de libera\u00e7\u00e3o de enzimas, tais como: infec\u00e7\u00f5es por v\u00edrus pancreatotr\u00f3picos (Hepatite B, Hepatite C, HIV), cistos ovarianos rotos, gravidez ect\u00f3pica e dist\u00farbios alimentares. Quadros vasculares podem levar a isquemia das c\u00e9lulas acinares e eleva\u00e7\u00e3o das enzimas no sangue (mesmo sem pancreatite aguda). Mesmo diante dessas situa\u00e7\u00f5es, \u00e9 sempre necess\u00e1ria a visualiza\u00e7\u00e3o da gl\u00e2ndula pancre\u00e1tica.&nbsp;<\/p>\n\n\n\n<p>Como j\u00e1 foi dito, o clearance das enzimas \u00e9 parcialmente realizado pelos rins, f\u00edgado e ba\u00e7o. Portanto, qualquer preju\u00edzo na fun\u00e7\u00e3o desses \u00f3rg\u00e3os pode acarretar a hiperenzinemia, como nos casos da doen\u00e7a renal cr\u00f4nica, insufici\u00eancia hep\u00e1tica e pacientes esplenectomizados.&nbsp;<\/p>\n\n\n\n<p>Pacientes submetidos a cirurgia pancre\u00e1tica, e at\u00e9 outras cirurgias (como pulmonar e card\u00edaca) tamb\u00e9m podem ter eleva\u00e7\u00e3o das enzimas de forma tempor\u00e1ria.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-medicamentos\"><strong>Medicamentos<\/strong><\/h2>\n\n\n\n<p>Assim como alguns medicamentos podem causar pancreatite aguda, existem tamb\u00e9m medicamentos que levam a hiperenzinemia sem a presen\u00e7a dos crit\u00e9rios de PA. Dentre as principais associa\u00e7\u00f5es est\u00e3o: azatioprina, didanosina, ciclosporina, paracetamol, efedrina, pentamidina, dentre outros. Mais recentemente, os agonistas de receptor de GLP-1 (medica\u00e7\u00f5es utilizadas para tratamento de diabetes e obesidade) foram relacionados com aumento s\u00e9rico de enzimas pancre\u00e1ticas.&nbsp;<\/p>\n\n\n\n<p class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">Diferentemente do que ocorre com os casos de pancreatite aguda, os medicamentos causadores de hiperenzinemia (sem PA) <strong>n\u00e3o requerem a suspens\u00e3o do uso.<\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-macroamilasemia\"><strong>Macroamilasemia<\/strong><\/h2>\n\n\n\n<p>Uma condi\u00e7\u00e3o j\u00e1 reconhecida h\u00e1 algum tempo \u00e9 a macroamilasemia. Nesses casos, a amilase produzida pelo indiv\u00edduo se liga a outras prote\u00ednas s\u00e9ricas ou sofrem um processo de polimeriza\u00e7\u00e3o que tornam maior a mol\u00e9cula de amilase (que normalmente tem em torno de 50 kDa), assim chamada de macroamilase (que pode variar de tamanho entre 150 kDa at\u00e9 2.000 kDa).&nbsp;<\/p>\n\n\n\n<p>Nesses casos, a macromol\u00e9cula acaba n\u00e3o sendo filtrada corretamente pelos t\u00fabulos renais, e permanece circulando na corrente sangu\u00ednea, causando um aumento s\u00e9rico nos n\u00edveis de amilase.&nbsp;<\/p>\n\n\n\n<p>O diagn\u00f3stico de macroamilasemia \u00e9 feito com o c\u00e1lculo do clearance de amilase na urina, ou com a dosagem da macroamilase na corrente sangu\u00ednea. Essa condi\u00e7\u00e3o n\u00e3o \u00e9 patol\u00f3gica e n\u00e3o traz nenhum preju\u00edzo para o indiv\u00edduo, embora seja associada com algumas patologias, como a&nbsp; <a href=\"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/intestino\/patogenese-da-doenca-celiaca\/\" target=\"_blank\" rel=\"noreferrer noopener\">Doen\u00e7a Cel\u00edaca<\/a>, por exemplo.&nbsp;<\/p>\n\n\n\n<p>Nesses casos a dosagem de lipase \u00e9 normal. \u00c9 descrita a macrolipasemia, embora seja muito mais rara do que a macroamilasemia.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-como-investigar\"><strong>Como investigar?<\/strong><\/h2>\n\n\n\n<p>Aqui apresentamos um algoritmo de como investigar os casos de hiperenzinemia pancre\u00e1tica.<\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2023\/06\/WhatsApp-Image-2023-06-20-at-07.53.34.png\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" width=\"718\" height=\"409\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2023\/06\/WhatsApp-Image-2023-06-20-at-07.53.34.png\" alt=\"\" class=\"wp-image-6334\" srcset=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2023\/06\/WhatsApp-Image-2023-06-20-at-07.53.34.png 718w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2023\/06\/WhatsApp-Image-2023-06-20-at-07.53.34-300x171.png 300w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2023\/06\/WhatsApp-Image-2023-06-20-at-07.53.34-585x333.png 585w\" sizes=\"(max-width: 718px) 100vw, 718px\" \/><\/a><figcaption class=\"wp-element-caption\"><em>Adaptado de Frullonni, L et al. 2005<\/em><\/figcaption><\/figure>\n\n\n\n<p>Por fim, se o paciente tiver altera\u00e7\u00e3o de enzimas pancre\u00e1ticas, com exame de imagem normal, e sem exposi\u00e7\u00e3o relevante a \u00e1lcool e medicamentos e exclu\u00edda a hip\u00f3tese de macroamilasemia, e se essas altera\u00e7\u00f5es se sustentarem por um per\u00edodo maior que 2 anos, pode-se firmar o diagn\u00f3stico de<strong> Hiperenzinemia Pancre\u00e1tica Benigna<\/strong> ou <strong>S\u00edndrome de Gullo<\/strong>.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-mensagens-para-casa\"><strong>Mensagens para Casa:<\/strong><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>A Hiperenzinemia Pancre\u00e1tica pode ter rela\u00e7\u00e3o com patologias pancre\u00e1ticas (pancreatite aguda, pancreatite cr\u00f4nica ou neoplasias pancre\u00e1ticas) e tamb\u00e9m com problemas extra-pancre\u00e1ticos (disfun\u00e7\u00e3o renal, insufici\u00eancia hep\u00e1tica dentre outros).<\/li>\n\n\n\n<li>Frente a altera\u00e7\u00e3o de enzimas pancre\u00e1ticas devemos sempre ter um bom exame de imagem da gl\u00e2ndula.<\/li>\n\n\n\n<li>Faz-se necess\u00e1rio descartar macroamilasemia nos casos de aumento isolado de amilase.<\/li>\n\n\n\n<li>Na anamnese, sempre avaliar uso de medica\u00e7\u00f5es, que podem causar o aumento de enzimas &#8211; na aus\u00eancia de pancreatite aguda, n\u00e3o \u00e9 necess\u00e1ria a suspens\u00e3o das medica\u00e7\u00f5es.<\/li>\n\n\n\n<li>Frente ao diagn\u00f3stico de Hiperenzinemia Pancre\u00e1tica Benigna &#8211; ou S\u00edndrome de Gullo &#8211; tranquilizar o paciente, pois essa condi\u00e7\u00e3o n\u00e3o predisp\u00f5e a altera\u00e7\u00f5es pancre\u00e1ticas futuras.<\/li>\n<\/ul>\n\n\n\n<details class=\"wp-block-details has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background is-layout-flow wp-block-details-is-layout-flow\"><summary>Leia tamb\u00e9m sobre aumento de CA19-9<\/summary>\n<p><a href=\"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/pancreas\/elevacao-do-marcador-ca-19-9\/\">Eleva\u00e7\u00e3o do marcador CA 19-9<\/a><\/p>\n<\/details>\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<ul class=\"wp-block-list\">\n<li>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<\/li>\n<\/ul>\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>Banks PA. et al. Classification of acute pancreatitis\u2014 2012: revision of the Atlanta classification and definitions by international consensus. <em>Gut. <\/em>2013, pp. 102-111.<\/li>\n\n\n\n<li>Frullonni, L et al. Pancreatic Hyperenzymemia: Clinical Significance and Diagnostic Approach. JOP. J Pancreas (Online) 2005; 6(6):536-551.<\/li>\n\n\n\n<li>Chen, Y et al. Risk factors associated with elevated serum pancreatic amylase levels during hemodialysis. Hemodialysis International 2011; 15:79\u201386<\/li>\n\n\n\n<li>Lando HM, Alattar M, Dua AP .Elevated amylase and lipase levels in patients using glucagon like peptide-1 receptor agonists or dipeptidyl-Peptidase-4 inhibitors in the outpatient setting. Endocr Pract (2012)18(4):472<\/li>\n\n\n\n<li>Gossum, AV. Macroamylasemia: a Biochemical or Clinical Problem? Dig Dis 1989; 7:19-27.<\/li>\n\n\n\n<li>Gullo, L et al. Benign pancreatic hyperenzymemia or Gullo\u2019s syndrome. Advances in Medical Sciences \u00b7 Vol. 53(1) \u00b7 2008 \u00b7 pp 1-5<\/li>\n<\/ol>\n\n\n\n<p><\/p>\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-background\" style=\"background-color:#cad5e1\">Marzinotto M. Aumento de enzimas pancre\u00e1ticas no sangue &#8211; como investigar ou conduzir? Gastropedia 2023, vol 2. Disponivel em: gastropedia.pub\/pt\/gastroenterologia\/pancreas\/aumento-de-enzimas-pancreaticas-no-sangue-como-investigar-ou-conduzir\/<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Por vezes nos deparamos com pacientes que, mesmo sem um motivo aparente, apresentam aumento de enzimas pancre\u00e1ticas (lipase ou amilase) no sangue. Quando valorizar esse achado? A dosagem das enzimas&hellip;<\/p>\n","protected":false},"author":3341,"featured_media":6609,"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":[44],"class_list":["post-6325","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-gastroenterologia","category-pancreas","ano-137","tipo-assuntos-gerais","volume-volume-ii"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Aumento de enzimas pancre\u00e1ticas no sangue - como investigar ou conduzir? - Gastropedia<\/title>\n<meta name=\"description\" content=\"Por vezes nos deparamos com pacientes que apresentam aumento de enzimas pancre\u00e1ticas no sangue. 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