{"id":8038,"date":"2024-02-29T06:53:00","date_gmt":"2024-02-29T09:53:00","guid":{"rendered":"https:\/\/gastropedia.pub\/pt\/?p=8038"},"modified":"2025-03-03T18:17:26","modified_gmt":"2025-03-03T21:17:26","slug":"megacolon-chagasico-diagnostico-e-tratamento","status":"publish","type":"post","link":"https:\/\/gastropedia.pub\/pt\/cirurgia\/colorretal\/megacolon-chagasico-diagnostico-e-tratamento\/","title":{"rendered":"Megacolon Chagasico: Diagn\u00f3stico e Tratamento"},"content":{"rendered":"<div class=\"pdfprnt-buttons pdfprnt-buttons-post pdfprnt-top-right\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/8038?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\/8038?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<h2 class=\"wp-block-heading\" id=\"h-diagnostico-e-investigacao\"><strong>Diagn\u00f3stico e Investiga\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n<p><strong>Testes sorol\u00f3gicos<\/strong>: na fase cr\u00f4nica da doen\u00e7a deve-se utilizar pelo menos dois m\u00e9todos de princ\u00edpios diferentes para a confirma\u00e7\u00e3o do diagn\u00f3stico, com sensibilidade de 100% e especificidade de 96,5%. S\u00e3o eles: hemoaglutina\u00e7\u00e3o indireta, imunofluoresc\u00eancia indireta e teste imunoenzim\u00e1tico. <\/p>\n\n\n\n<p><strong>Exame contrastado: <\/strong>Considera-se que o di\u00e2metro do sigm\u00f3ide distal maior que 6 cm caracteriza megac\u00f3lon. No entanto, atrav\u00e9s do enema opaco, grupo brasileiro, fez estudo com proposta de uma classifica\u00e7\u00e3o do di\u00e2metro transverso do reto alto\/sigm\u00f3ide distal na altura das cristas p\u00f3stero-superiores ou ao n\u00edvel da quarta v\u00e9rtebra lombar. Dessa forma, subdividiu em:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Grau 0: pacientes sem MC: eixo transversal entre 2,0 e 5,0cm<\/li>\n\n\n\n<li>Grau I: intersec\u00e7\u00e3o entre pessoas com e sem MC. Eixo entre 5,1 e 9,0cm<\/li>\n\n\n\n<li>Grau II: eixo transverso entre 9,1 e 13,0cm<\/li>\n\n\n\n<li>Grau III: eixo maior que 13,1cm<\/li>\n<\/ul>\n\n\n\n<p><strong>Manometria anorretal:<\/strong> exame reprodut\u00edvel e examinador dependente com avalia\u00e7\u00e3o dos esf\u00edncteres interno e externo do \u00e2nus, relaxamento do m\u00fasculo puborretal, sensibilidade e capacidade do reto e, na suspeita de MC. A aus\u00eancia reflexo inibit\u00f3rio retoanal (RIRA), significando comprometimento da inerva\u00e7\u00e3o da transi\u00e7\u00e3o anorretal e acalasia do esf\u00edncter interno do \u00e2nus, embora seu papel nessa doen\u00e7a ainda permane\u00e7a controverso.<\/p>\n\n\n\n<p>Nesse aspecto, grupo brasileiro avaliou a presen\u00e7a do RIRA em 39 portadores de MC e verificou sua ocorr\u00eancia em 43,6% dos pacientes, entretanto com necessidade de maior insufla\u00e7\u00e3o do bal\u00e3o retal com uma m\u00e9dia de 196 ml, ao passo que em pessoas sem MC a m\u00e9dia de infus\u00e3o foi de 18,8 ml. Assim, ao injetar 30 ml de ar a probabilidade de detectar o RIRA foi de 12,8%, com 60ml de 15,4% e com 250ml de 43,6%.<\/p>\n\n\n\n<p><strong>Colonoscopia: <\/strong>exame com objetivo fundamentalmente de rastreio de c\u00e2ncer colorretal, devendo sua indica\u00e7\u00e3o obedecer as diretrizes vigentes na literatura nacional e internacional quanto \u00e0 idade e fatores de risco principalmente.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-tratamento\"><strong>Tratamento<\/strong><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-a-clinico\"><strong>a) Cl\u00ednico:<\/strong><\/h3>\n\n\n\n<p>Inicia-se o tratamento do portador de MC sintom\u00e1tico para constipa\u00e7\u00e3o intestinal com medidas cl\u00ednica, como:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Estimular ingesta h\u00eddrica: exce\u00e7\u00e3o aos pacientes cardiopatas com restri\u00e7\u00e3o de l\u00edquidos;<\/li>\n\n\n\n<li>Evitar dieta rica em fibras e formadores de bolo fecal pois aumentam a chance de impacta\u00e7\u00e3o fecal;<\/li>\n\n\n\n<li>Uso de medicamentos laxativos: lactulose, polietilenoglicol, picossulfato de s\u00f3dio. Em situa\u00e7\u00f5es de n\u00e3o evacua\u00e7\u00e3o por tempo mais prolongado pode-se utilizar o bisacodil e o uso de suposit\u00f3rios de glicerina a cada 3 a 5 dias<\/li>\n\n\n\n<li>Fisioterapia do assoalho p\u00e9lvico e biofeedback: para casos em que se associa dissinergia p\u00e9lvica.<\/li>\n\n\n\n<li>Lavagem intestinal: naquelas situa\u00e7\u00f5es de n\u00e3o evacua\u00e7\u00e3o por longo tempo, mais de 5 dias com as medidas acima, orienta-se a realiza\u00e7\u00e3o de enteroclisma, sempre antecedido de toque retal para a avalia\u00e7\u00e3o de fecalomas. Essa, inclusive, \u00e9 uma das principais indica\u00e7\u00f5es de cirurgia eletiva em portadores de MC, ou seja, a refratariedade aos laxantes por via oral e necessidade frequente de idas ao pronto-socorro ou pronto-atendimento para a realiza\u00e7\u00e3o de lavagens intestinais.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-b-cirurgico\"><strong>b) Cir\u00fargico:<\/strong><\/h3>\n\n\n\n<p>As indica\u00e7\u00f5es de cirurgia s\u00e3o: refratariedade do tratamento cl\u00ednico com necessidade frequente de lavagens intestinais e as complica\u00e7\u00f5es agudas, como o volvo de sigm\u00f3ide principalmente. A cirurgia, quando bem indicada, proporciona importante al\u00edvio e melhora do principal sintoma do MC que \u00e9 a constipa\u00e7\u00e3o intestinal de tal forma, que a frequ\u00eancia dessa queixa \u00e9 de 76% entre os pacientes n\u00e3o operados e de 39% entre os pacientes submetidos ao tratamento cir\u00fargico (p&lt;0,01). Al\u00e9m disso, estudos demonstram melhora significativa do escore de gravidade de constipa\u00e7\u00e3o ap\u00f3s a cirurgia.<\/p>\n\n\n\n<p>Entretanto, \u00e9 preciso ter em mente e, transparecer isso aos pacientes e familiares, que a cirurgia para o MC n\u00e3o cura a doen\u00e7a. Os principais objetivos s\u00e3o a melhora da constipa\u00e7\u00e3o e a redu\u00e7\u00e3o dos riscos de complica\u00e7\u00f5es, como o volvo de sigmoide e a impacta\u00e7\u00e3o fecal com consequente forma\u00e7\u00e3o de fecalomas.<\/p>\n\n\n\n<p>Grande parte dos cirurgi\u00f5es colorretais mais antigos tiveram seus relevantes aprendizados t\u00e9cnicos com a realiza\u00e7\u00e3o de procedimentos para o tratamento do MC, sendo que as principais abordagens para o tratamento dessa doen\u00e7a foram descritas por renomados profissionais do nosso pa\u00eds e as cirurgias poss\u00edveis compreendem uma infinidade de t\u00e9cnicas que envolvem diferentes extens\u00f5es de ressec\u00e7\u00e3o do c\u00f3lon, n\u00edveis e formas de anastomose, resultando em morbidade e recorr\u00eancia p\u00f3s-operat\u00f3ria vari\u00e1veis. O racional do tratamento cir\u00fargico \u00e9 ressecar toda a \u00e1rea de sigm\u00f3ide dilatada (sigmoidectomia completa) e evitar a regi\u00e3o da transi\u00e7\u00e3o retossigmoideana para a realiza\u00e7\u00e3o das anastomoses, a fim de evitar a recidiva precoce dos sintomas.<\/p>\n\n\n\n<p>Sendo assim, dentre as principais t\u00e9cnicas descritas historicamente, pode-se citar:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>T\u00e9cnica de Swenson e Soave:<\/strong> abaixamento de c\u00f3lon transretal com ressec\u00e7\u00e3o de mucosa retal e telescopagem, descrita no final dos anos 1940.<\/li>\n\n\n\n<li><strong>T\u00e9cnica de Duhamel-Haddad:<\/strong> abaixamento de c\u00f3lon retro-retal posterior com exterioriza\u00e7\u00e3o do coto e anastomose retardada, descrita entre os anos 1950 e 1960.<\/li>\n\n\n\n<li><strong>T\u00e9cnica de Duhamel-Haddad modificada:<\/strong> abaixamento de c\u00f3lon retro-retal posterior com tentativa de anastomose prim\u00e1ria e utiliza\u00e7\u00e3o de pin\u00e7as esmagadoras.<\/li>\n\n\n\n<li><strong>T\u00e9cnica de Habr-Gama: <\/strong>nos anos 1990, ap\u00f3s surgimento e aprimoramento dos grampeadores e suturas mec\u00e2nicos foi proposta a retossigmoidectomia com ressec\u00e7\u00e3o do reto abaixo do promont\u00f3rio e subsequente anastomose prim\u00e1ria na parede posterior do reto distal, t\u00e9rmino-lateral mec\u00e2nica extraperitoneal com grampeador de 33 mm (acima do anel anorretal a cerca de 5-7cm da borda anal \u2013 Figura 3). O racional da t\u00e9cnica \u00e9 exclus\u00e3o boa parte do reto doente do tr\u00e2nsito intestinal, evitando assim a manipula\u00e7\u00e3o anterior, que teoricamente teria probabilidade de denerva\u00e7\u00e3o auton\u00f4mica e risco de les\u00e3o de \u00f3rg\u00e3os e estruturas p\u00e9lvicas, como a vagina, bexiga, pr\u00f3stata, ves\u00edculas seminais e uretra.<\/li>\n<\/ul>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/02\/Anastomose-termino-lateral-posterior-mecanica.jpg\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" width=\"467\" height=\"646\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/02\/Anastomose-termino-lateral-posterior-mecanica.jpg\" alt=\"\" class=\"wp-image-8000\" srcset=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/02\/Anastomose-termino-lateral-posterior-mecanica.jpg?v=1707742242 467w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/02\/Anastomose-termino-lateral-posterior-mecanica-217x300.jpg?v=1707742242 217w\" sizes=\"(max-width: 467px) 100vw, 467px\" \/><\/a><figcaption class=\"wp-element-caption\"><br>Figura 3: Anastomose t\u00e9rmino-lateral posterior mec\u00e2nica.<\/figcaption><\/figure>\n<\/div>\n\n\n<p>Essa \u00e9 a t\u00e9cnica mais utilizada atualmente, sendo ainda mais difundida com o advento da videolaparoscopia. Apresenta taxa m\u00e9dia de recorr\u00eancia de 15-20%, certamente relacionada ao tempo de seguimento, que quanto maior apresenta maiores taxas.<\/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>Santos J\u00fanior JCM. Megac\u00f3lon &#8211; Parte II: Doen\u00e7a de Chagas.&nbsp;Rev Bras Coloproct, 2002(4):266-277<\/li>\n\n\n\n<li>Alves RMA, Thomaz RP, Almeida EA, Wanderley JS, Guariento ME. Chagas\u2019 disease and ageing: the coexistence of other chronic diseases with Chagas\u2019 disease in elderly patients. Revista da Sociedade Brasileira de Medicina Tropical. 2009; 42(6):622-8<\/li>\n\n\n\n<li>Nahas SC, Dias AR, Dainezi MA, Ara\u00fajo SEA, Nahas CSR. A V\u00eddeo-Cirurgia no Tratamento do Megac\u00f3lon Chag\u00e1sico. Rev bras Coloproct, 2006;26(4): 470-4<\/li>\n\n\n\n<li>Kamiji MM, Oliveira RB. O perfil dos portadores de doen\u00e7a de Chagas, com \u00eanfase na forma digestiva, em hospital terci\u00e1rio de Ribeir\u00e3o Preto, SP. Revista da Sociedade Brasileira de Medicina Tropical. 2005; 38(4):305-9<\/li>\n\n\n\n<li>Ara\u00fajo SEA, Dumarco RB, Rawet V, Seid VE, Bocchini SF, Nahas SC. Depopulation of intersticial cells of Cajal in chagasic megacolon: towards tailored surgery? Arq Bras Cir Dig. 2010;32(2):81-5<\/li>\n\n\n\n<li>Silva AL, Giacomin RT, Quirino VA, Miranda ES. Proposta de classifica\u00e7\u00e3o do megac\u00f3lon chag\u00e1sico atrav\u00e9s de enema opaco. Rev Col Bras Cir. 2003;30(1):4-10<\/li>\n\n\n\n<li>Cavenaghi S, Felicio OCS, Ronchi LS, Cunrath GS, Melo MMC, Netinho JG. Prevalence of rectoanal inhibitory reflex in chagasic megacolon. Arq Gastroenterol. 2008;45(2):128-31<\/li>\n\n\n\n<li>Nahas SC. Tratamento cir\u00fargico do megac\u00f3lon chag\u00e1sico pela retossigmoidectomia abdominal com anastomose mec\u00e2nica colorretal t\u00e9rmino-lateral posterior imediata. Tese Professor Livre Docente, USP, S\u00e3o Paulo, 2000.<\/li>\n\n\n\n<li>Nahas SC, Pinto RA, Dias AR, Nahas CSR, Ara\u00fajo SEA, Marques CFS, Cecconello I. Long-term follow up of abdominal rectosigmoidectomy with posterior end-to-side stapled anastomosis for Chagas megacolon. Olorectal Dis. 2011;13(3):317-22.<\/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\">Pinto RA, Neto IJFC, Camargo MGM, Nahas SC, Marques CFS. Megacolon Chagasico: Diagn\u00f3stico e Tratamento Gastropedia 2024, Vol.1 Dispon\u00edvel em: gastropedia.pub\/pt\/cirurgia\/colorretal\/megacolon-chagasico-diagnostico-e-tratamento\/<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Diagn\u00f3stico e Investiga\u00e7\u00e3o Testes sorol\u00f3gicos: na fase cr\u00f4nica da doen\u00e7a deve-se utilizar pelo menos dois m\u00e9todos de princ\u00edpios diferentes para a confirma\u00e7\u00e3o do diagn\u00f3stico, com sensibilidade de 100% e especificidade&hellip;<\/p>\n","protected":false},"author":5726,"featured_media":8000,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[24,26],"tags":[],"ano":[396],"tipo":[121],"volume":[57],"class_list":["post-8038","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-cirurgia","category-colorretal","ano-396","tipo-assuntos-gerais","volume-volume-i"],"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>Megacolon Chagasico: Diagn\u00f3stico e Tratamento - Gastropedia<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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