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Gallbladder Wall Thickening at Ultrasonography: How to Interpret It?

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Gallbladder Wall Thickening at Ultrasonography: How to Interpret It? Barbosa ABR et al. EspessamentoARTIGO DE parietal REVISÃO da vesícula• REVIEW biliar ARTICLE Espessamento parietal da vesícula biliar no exame ultrassonográfico: como interpretar?* Gallbladder wall thickening at ultrasonography: how to interpret it? Aldo Benjamim Rodrigues Barbosa1, Luis Ronan Marquez Ferreira de Souza2, Rogério Silva Pereira3, Giuseppe D’Ippolito4 Resumo O objetivo desta revisão é fornecer auxílio na interpretação correta do espessamento das paredes da vesícula biliar e seus possíveis diagnósticos diferenciais. O espessamento da vesícula biliar é um achado frequente em exame de ul- trassonografia e um tema de grande interesse, por ter sido considerado durante muito tempo como sinal específico de colecistite aguda, apesar de se reconhecer que ocorre em uma série de outras situações clínicas. A adequada carac- terização e interpretação desse achado é de grande importância, pois o diagnóstico correto tem impacto direto no tratamento, que em alguns casos inclui intervenção cirúrgica. Neste artigo procuramos apresentar um conjunto de sinais ultrassonográficos que, associados ao quadro clínico e laboratorial do paciente, permitem restringir as alterna- tivas diagnósticas e estabelecer, com maior precisão, a causa do espessamento parietal da vesícula biliar, através de uma avaliação racional dos dados obtidos. Unitermos: Vesícula biliar; Ultrassonografia; Inflamação; Neoplasia. Abstract The present review was aimed at providing help for correct interpretation of gallbladder wall thickening and differential diagnosis at ultrasonography. Gallbladder wall thickening is a frequent sonographic finding and has been subject of great interest for being considered as a hallmark feature of acute cholecystitis, despite the fact that such a finding is observed in a number of other medical conditions. An appropriate characterization and interpretation of this finding is of great importance, considering that the correct diagnosis has a direct impact on the treatment that in some cases includes surgery. In the present article, the authors describe a set of sonographic signs that, in association with clinical and laboratory findings can reduce the number of diagnostic hypotheses allowing a more accurate establishment of the cause for gallbladder wall thickening through a rational data evaluation. Keywords: Gallbladder; Ultrasonography; Inflammation; Neoplasm. Barbosa ABR, Souza LRMF, Pereira RS, D’Ippolito G. Espessamento parietal da vesícula biliar no exame ultrassonográfico: como in- terpretar? Radiol Bras. 2011 Nov/Dez;44(6):381–387. INTRODUÇÃO ter sido considerado um sinal altamente seguro, inócuo e de baixo custo. Possibilita sugestivo de colecistite aguda. Este con- um estudo detalhado em tempo real da VB, O espessamento da vesícula biliar (VB) ceito, porém, tem-se modificado, principal- além de permitir a avaliação de outros acha- é um tema polêmico entre os ultrassonogra- mente em decorrência de uma maior expe- dos que contribuem para o diagnóstico fi- fistas, por ser frequente e por muito tempo riência dos profissionais envolvidos no nal, evitando, assim, colecistectomias des- diagnóstico por imagem e uma expressiva necessárias e suas complicações(3–5). Além * Trabalho realizado nos Departamentos de Diagnóstico por evolução tecnológica dos equipamentos de disso, a US pré-operatória (24 a 48 horas Imagem da Santa Casa de Misericórdia de Ituverava, Ituverava, (1) SP, e da Universidade Federal do Triângulo Mineiro (UFTM), Ube- ultrassonografia (US) . antes da cirurgia) pode ser utilizada como raba, MG, Brasil. Entre as diversas doenças que provocam método seguro e eficaz para evitar a colan- 1. Médico Radiologista da Santa Casa de Misericórdia de Itu- verava, Aluno Especial do Curso de Pós-Graduação em Patolo- espessamento das paredes da VB, podemos giopancreatografia retrógrada endoscópica gia da Universidade Federal do Triângulo Mineiro (UFTM), Ube- citar, além da colecistite aguda, a pancrea- (CPRE) intraoperatória(6). Neste artigo o raba, MG, Brasil. 2. Doutor, Professor Adjunto da Universidade Federal do Triân- tite, a diverticulite, a insuficiência cardíaca, espessamento parietal da VB é contextua- gulo Mineiro (UFTM), Uberaba, MG, Brasil. a pielonefrite e a hepatite. A adequada ca- lizado de modo a orientar sua precisa inter- 3. Médico Radiologista do Departamento de Diagnóstico por Imagem da Santa Casa de Misericórdia de Ituverava, Ituverava, racterização e interpretação desse achado pretação à luz dos dados clínicos e a per- SP, Brasil. é de grande importância. O diagnóstico mitir a escolha da terapêutica pertinente. 4. Pós-Doutorado, Professor Associado do Departamento de Diagnóstico por Imagem da Universidade Federal de São Paulo correto tem impacto direto no tratamento, (Unifesp), São Paulo, SP, Brasil. e algumas destas enfermidades requerem ANATOMIA E TÉCNICA Endereço para correspondência: Dr. Luis Ronan M. F. de intervenção cirúrgica(2). Souza. Radiologia e Diagnóstico por Imagem. Avenida Frei Pau- ULTRASSONOGRÁFICA lino, 30, Bairro Abadia. Uberaba, MG, Brasil, 38080-793. E-mail: A US é o método de imagem inicial para [email protected] a abordagem diagnóstica e avaliação do sis- A VB é uma víscera oca em formato de Recebido para publicação em 23/1/2011. Aceito, após revi- são, em 3/6/2011. tema biliar, pois é amplamente disponível, pera, de paredes finas e regulares, situada Radiol Bras. 2011 Nov/Dez;44(6):381–387 381 0100-3984 © Colégio Brasileiro de Radiologia e Diagnóstico por Imagem Barbosa ABR et al. Espessamento parietal da vesícula biliar na fossa vesicular entre os segmentos IV e V do fígado, uma área “nua” do fígado, não recoberta pelo peritônio visceral(7). A VB divide-se em: infundíbulo, corpo e fundo (Figura 1). Ela possui quatro camadas: uma mucosa, formada por epitélio colunar sim- ples e por uma lâmina basal; uma segunda camada, constituída por tecido muscular irregular; uma terceira camada, de tecido conjuntivo frouxo; e uma última camada, formada pela serosa(8–10). Possui a função de armazenar a bile e apresenta um volume de 30 a 50 ml(6). O estudo ultrassonográfico da VB é rea- lizado rotineiramente com transdutor con- vexo. Para obtenção de imagens adequa- das, o ideal é que seja feito um exame sis- tematizado com cortes longitudinais e transversais do órgão, avaliando sua forma, dimensões, espessura, regularidade e pa- Figura 1. Anatomia laparoscópica (a,b,c) comparada com anatomia ultrassonográfica (d) demonstrando drão textural de suas paredes, conteúdo, o infundíbulo, o corpo e o fundo vesicular. além de alterações locorregionais e dop- plervelocimétricas(8). Para auxiliar a ava- jejum prolongado(9). Outra causa de “pseu- menos expressivos, ao contrário de lesões liação ultrassonográfica, os equipamentos doespessamento” está relacionada à inso- tumorais que provocam espessamentos fo- possuem recursos que elevam a acurácia nação errônea do transdutor. Nesta condi- cais e mais exuberantes, frequentemente do método, como, por exemplo, a imagem ção, a realização de manobras de mudan- maiores que 10 mm(7). Alguns sinais asso- harmônica, que possibilita um aumento na ças de decúbito auxilia na definição da ver- ciados permitem direcionar o diagnóstico resolução lateral, relação sinal-ruído e con- dadeira espessura da parede da VB. Um para uma etiologia mais específica(9–11). traste-ruído(9). diagnóstico diferencial importante nestes Entre eles podem ser citados: dilatação das As imagens ultrassonográficas permi- casos é a alteração funcional da VB(10,11) vias biliares, presença de cálculo fixo, lí- tem uma representação fidedigna da VB, (Figura 2). quido perivesicular, linfonodomegalias podendo-se correlacioná-las com a sua es- O espessamento parietal da VB é clas- hilares, heterogeneidade da gordura perive- trutura anatômica. É possível a identifica- sificado em discreto (entre 4 e 7 mm) ou sicular e aumento do diâmetro transversal ção ultrassonográfica de três camadas: a acentuado (maior que 7 mm) e em focal ou da VB. As doenças que provocam espessa- mais interna corresponde à mucosa, é li- difuso. Em regra, doenças sistêmicas tais mento da parede da VB podem ser classifi- near, ecogênica e apresenta superfície re- como insuficiência cardíaca, renal ou he- cadas em inflamatórias, neoplásicas e sistê- gular; a segunda camada corresponde à ca- pática promovem espessamentos difusos e micas, e sua diferenciação pode ser obtida mada muscular, é fina e discretamente hi- poecogênica; e a mais externa corresponde à serosa do órgão, é linear, ecogênica e re- gular(1,9). Segundo diversos autores(1,2), o limite superior da normalidade para a espessura da parede da VB é de 3 mm. Entretanto, em pacientes com jejum inadequado, a espes- sura parietal pode exceder esse limite em razão da contração da musculatura lisa do órgão(8). Recomenda-se, então, um jejum de 8 horas antecedendo ao exame, princi- palmente naqueles casos nos quais a VB é o foco de atenção do estudo. O principal diagnóstico diferencial de espessamento ab parietal é o de alterações funcionais do ór- Figura 2. Paciente apresentando dispepsia. Nota-se vesícula de paredes espessadas e murcha (seta) gão, em que se observa VB murcha persis- na primeira avaliação (a), que se mantém com jejum prolongado de 12 horas (pontas de setas em b). tentemente, mesmo após a reavaliação em O aspecto ultrassonográfico sugere representar dismotilidade vesicular. 382 Radiol Bras. 2011 Nov/Dez;44(6):381–387 Barbosa ABR et al. Espessamento parietal da vesícula biliar através de uma avaliação combinada dos parede da vesícula, semelhante à colecis- mor da cabeça
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