Aplicabilidade e acurácia do enema opaco na investigação diagnóstica da doença de Hirschsprung
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2017-06-29
Autores
Valerini, Felipe Gilberto [UNESP]
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Universidade Estadual Paulista (Unesp)
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Introdução: O diagnóstico da Doença de Hirschsprung (DH) realizado através de biópsias de reto possui alta sensibilidade e especificidade, mas é invasivo, com riscos de complicações. Desta forma, exames de triagem, menos invasivos, servem para indicar quais pacientes devem ser submetidos às biópsias. A identificação da zona de transição (ZT) ao enema opaco permite identificar a transição entre o segmento espástico agangliônico e o cólon dilatado, determinando a extensão da zona agangliônica. Essa análise é subjetiva e relacionada a resultados falsos positivos. Pochaczevsky e Leonidas (1975) propuseram o uso do índice retossigmóide (IRS) ≤ 1,0 (maior diâmetro do reto/ maior diâmetro do sigmóide) para o diagnóstico da DH. O IRS apresenta como vantagem a obtenção de uma medida objetiva e numérica, que pode ser utilizada em conjunto com a identificação da ZT. Após mais de 60 anos de sua descrição inicial e apesar do uso cotidiano na prática clínica, os poucos estudos sobre a capacidade diagnóstica do enema opaco na DH apresentam resultados divergentes. Objetivo: Avaliar a acurácia e aplicabilidade do enema opaco na investigação diagnóstica da DH, pela determinação da ZT e do IRS, comparando seus resultados com os das biópsias de reto. Pacientes e Métodos: Foi realizado um estudo retrospectivo e comparativo, incluindo 43 pacientes submetidos à biópsia de reto para investigação diagnóstica de DH, entre 2010 e 2015, que haviam realizado também enema opaco. Os exames radiológicos contrastados foram analisados, sem o conhecimento do resultado do exame histopatológico das biópsias de reto, por 2 examinadores experientes: um cirurgião pediátrico e um radiologista, com a identificação da ZT e o cálculo do IRS. Os resultados desta análise foram comparados aos resultados das biópsias de reto (padrão-ouro), para determinação dos indicadores de capacidade diagnóstica. Resultados: A identificação da ZT apresentou, para os dois examinadores, demonstrou maior capacidade diagnóstica do que o IRS ≤ 1,0, evidenciada pelos valores obtidos para as áreas sob a Curva ROC. A associação entre estes dois métodos, por sua vez, promoveu aumento dos valores de sensibilidade e VPN, ao reduzir ainda mais o número de resultados falso-negativos, valorizando o poder da utilização conjunta destas duas medidas, na triagem diagnóstica de pacientes com DH. Conclusão: A sensibilidade diagnóstica do enema opaco, quando se associa a identificação da ZT e a determinação do IRS ≤ 1,0 foi próxima de 100%, o que justifica a utilização deste exame como método de triagem na investigação diagnóstica da Doença de Hirschsprung.
Introduction: The diagnosis of Hirschsprung's disease (HD) performed by rectal biopsies has high sensitivity and specificity, but is invasive, with risks of complications. In this way, less invasive screening tests are used to indicate which patients should undergo biopsies. The identification of the transition zone (TZ) by barium enema allows to identify the transition between the aganglionic spastic segment and the dilated colon, determining the extension of the aganglionic zone. This analysis is subjective and related to false positive results. Pochaczevsky and Leonidas (1975) proposed the use of the rectosigmoid index (RSI) ≤ 1.0 (greater diameter of the rectum / larger diameter of the sigmoid) for the diagnosis of HD. The RSI has the advantage of obtaining an objective and numerical measure, which can be used in conjunction with the TZ identification. After more than 60 years of its initial description and despite daily use in clinical practice, the few studies on the diagnostic capacity of barium enema in HD show divergent results. Objective: To evaluate the accuracy and applicability of the barium enema in the diagnostic investigation of HD, by determining the ZT and the RSI, comparing its results with those of the rectal biopsies. Patients and methods: A retrospective and comparative study was conducted, including 43 patients submitted to rectal biopsy for diagnostic investigation of DH, between 2010 and 2015, who had also performed barium enema. The contrasted radiological examinations were analyzed, without knowledge of the results of the histopathological examination of rectal biopsies, by 2 experienced examiners: a pediatric surgeon and a radiologist, with the identification of the YZ and the calculation of the RSI. The results of this analysis were compared to the results of the rectal biopsies (gold standard method), to determine the indicators of diagnostic capacity. Results: The TZ identification showed, for the two examiners, a greater diagnostic capacity than the IRS ≤ 1.0, evidenced by the values obtained for the areas under the ROC curve. The association between these two methods promoted increased sensitivity and NPV values, further reducing the number of false-negative results, valuing the power of the joint use of these two measures, in the diagnostic screening of patients with HD. Conclusion: The diagnostic sensitivity of the barium enema, when associated the identification of the TZ and the determination of the RSI ≤ 1.0 was close to 100%, which justifies the use of this test as a screening method in the diagnostic investigation of Hirschsprung's disease.
Introduction: The diagnosis of Hirschsprung's disease (HD) performed by rectal biopsies has high sensitivity and specificity, but is invasive, with risks of complications. In this way, less invasive screening tests are used to indicate which patients should undergo biopsies. The identification of the transition zone (TZ) by barium enema allows to identify the transition between the aganglionic spastic segment and the dilated colon, determining the extension of the aganglionic zone. This analysis is subjective and related to false positive results. Pochaczevsky and Leonidas (1975) proposed the use of the rectosigmoid index (RSI) ≤ 1.0 (greater diameter of the rectum / larger diameter of the sigmoid) for the diagnosis of HD. The RSI has the advantage of obtaining an objective and numerical measure, which can be used in conjunction with the TZ identification. After more than 60 years of its initial description and despite daily use in clinical practice, the few studies on the diagnostic capacity of barium enema in HD show divergent results. Objective: To evaluate the accuracy and applicability of the barium enema in the diagnostic investigation of HD, by determining the ZT and the RSI, comparing its results with those of the rectal biopsies. Patients and methods: A retrospective and comparative study was conducted, including 43 patients submitted to rectal biopsy for diagnostic investigation of DH, between 2010 and 2015, who had also performed barium enema. The contrasted radiological examinations were analyzed, without knowledge of the results of the histopathological examination of rectal biopsies, by 2 experienced examiners: a pediatric surgeon and a radiologist, with the identification of the YZ and the calculation of the RSI. The results of this analysis were compared to the results of the rectal biopsies (gold standard method), to determine the indicators of diagnostic capacity. Results: The TZ identification showed, for the two examiners, a greater diagnostic capacity than the IRS ≤ 1.0, evidenced by the values obtained for the areas under the ROC curve. The association between these two methods promoted increased sensitivity and NPV values, further reducing the number of false-negative results, valuing the power of the joint use of these two measures, in the diagnostic screening of patients with HD. Conclusion: The diagnostic sensitivity of the barium enema, when associated the identification of the TZ and the determination of the RSI ≤ 1.0 was close to 100%, which justifies the use of this test as a screening method in the diagnostic investigation of Hirschsprung's disease.
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Palavras-chave
Hirschsprung, Doença de, Precisão da medição dimensional, Diagnóstico, Megacolon