1
|
McKittrick-Wheelock Syndrome Presenting with Acute Kidney Injury and Metabolic Alkalosis: Case Report and Narrative Review. Case Rep Gastrointest Med 2019; 2019:3104187. [PMID: 30838142 PMCID: PMC6374786 DOI: 10.1155/2019/3104187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/09/2019] [Indexed: 11/18/2022] Open
Abstract
A rare combination of severe volume depletion and electrolyte imbalance caused by a rectal villous adenoma is often referred to as the McKittrick-Wheelock syndrome. Patients usually seek medical care because of chronic hypersecretory diarrhea and display renal failure, metabolic acidosis, hyponatremia, and hypokalemia. We report the case of a 68-year-old woman who presented with this condition but showed unusual features such as severe hypokalemia and metabolic alkalosis, without diarrhea. She subsequently underwent transanal endoscopic microsurgery (TEMS), an innovative procedure in the management of large rectal adenomas. We also provide a narrative review of the literature on this rare entity.
Collapse
|
2
|
van der Pool AEM, de Graaf EJR, Vermaas M, Barendse RM, Doornebosch PG. McKittrick Wheelock Syndrome Treated by Transanal Minimally Invasive Surgery: A Single-Center Experience and Review of the Literature. J Laparoendosc Adv Surg Tech A 2017; 28:204-208. [PMID: 28657837 DOI: 10.1089/lap.2017.0195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION McKittrick Wheelock Syndrome (MKWS) is a rare syndrome characterized by secretory diarrhea, dehydration, prerenal acute kidney injury, and severe electrolyte abnormalities caused by a large hypersecretory villous adenoma located in the rectum or rectosigmoid junction. Transabdominal (laparoscopic) procedures are the most described procedures in the treatment of MKWS. We report an alternative surgical approach, transanal minimally invasive surgery (TAMIS), to solve this syndrome. MATERIALS AND METHODS All patients who underwent transanal endoscopic microsurgery or TAMIS were included in a prospectively collected database in our center. Between 1996 and 2015, 3 patients were found to have MKWS and treated by TAMIS. Demographics, characteristics of the adenoma, surgery-related data, and outcome were analyzed. RESULTS The first patient had a villous adenoma 0-12 cm from the anal verge. After TAMIS, she complained of a stenosis that was successfully treated by dilatation. The second patient had an impressive bulky tumor in the rectum. An endoscopic mucosal resection was attempted twice, but incompletely. Pathology analysis showed villous adenoma with high-grade dysplasia and intramucosal carcinoma. One year after TAMIS, a recurrence was detected and treated by an abdominal-perineal resection. A TAMIS was performed in the third patient because of a giant villous circular adenoma, but because of high mucus and fluid production, no proper overview could be obtained. Together with opening of the peritoneum, this prompted us to convert to a laparoscopic Hartmann procedure. Besides this technical difficulty, the patient recovered uneventful. CONCLUSIONS MKWS is a rare syndrome and missed diagnosis could result in life-threatening situations. Different endoscopic and surgical treatments are described to solve this syndrome. TAMIS should be considered as a rectum-preserving surgical treatment option for such extensive adenomas.
Collapse
Affiliation(s)
| | | | - Maarten Vermaas
- 1 Department of Surgery, IJsselland Hospital , Capelle Ad IJssel, The Netherlands
| | | | | |
Collapse
|
3
|
López Pardo P, Jiménez Rojas C, Castro Cristóbal C, Díaz Vila A. McKittrick-Wheelock syndrome in centenarian patient. Conservative treatment. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2016.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
4
|
Kagan MD, Schmidt K, Sangha G. Indomethacin therapy effective in a patient with depletion syndrome from secretory villous adenoma. BMJ Case Rep 2017; 2017:bcr-2016-217211. [PMID: 28188165 DOI: 10.1136/bcr-2016-217211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This paper details the case of a 26-year-old woman with depletion syndrome and the effectiveness of her treatment with indomethacin. Villous adenomas are benign neoplasms with a high incidence of becoming malignant. A small percentage of villous adenomas are known to cause depletion syndrome, also referred to as the McKittrick-Wheelock syndrome, a condition characterised by secretory diarrhoea, dehydration, hyponatremia, hypokalaemia, hypochloraemia, metabolic acidosis and acute renal failure. Prostaglandin-E2 mediates the hypersecretion mechanism observed in depletion syndrome, and can be inhibited by cyclo-oxygenase inhibitors. This case study measured the effectiveness of prostaglandin inhibition on a patient with oral and parenteral electrolyte replacement refractory depletion syndrome. Fluid loss and prostaglandin levels were measured before and after pharmacological treatment. This case demonstrates a 49% decrease in rectal effluent and a marked commensurate decrease in daily replenishment requirements within 48 hours of indomethacin treatment initiation, resulting in subsequent electrolyte stabilisation.
Collapse
Affiliation(s)
| | - Kara Schmidt
- Department of Internal Medicine, University of California San Francisco Fresno Center for Medical Education and Research, Fresno, California, USA
| | - Gurtej Sangha
- Ross University School of Medicine, North Brunswick, New Jersey, USA
| |
Collapse
|
5
|
Malik S, Mallick B, Makkar K, Kumar V, Sharma V, Rana SS. Malignant McKittrick-Wheelock syndrome as a cause of acute kidney injury and hypokalemia: Report of a case and review of literature. Intractable Rare Dis Res 2016; 5:218-21. [PMID: 27672546 PMCID: PMC4995412 DOI: 10.5582/irdr.2016.01011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Colonic polyps are usually asymptomatic, and are commonly detected during screening colonoscopy. Severe hypokalemia secondary to secretory diarrhea is a rare presentation of rectal polyps. We present a 70 years old female with hypokalemia and acute kidney injury secondary to secretory diarhea due to moderately differentiated adenocarcinoma of rectum, all of which is syndromically sometimes referred to as McKittrick and Wheelock syndrome. The case is presented because McKittrick-Wheelock syndrome is still more uncommon with malignancy. The syndrome may be associated with other features of hypersecretory diarrhea. Though very rare, clinical suspicion would often lead to diagnosis and appropriate management. We also review the previously published reports of this entity.
Collapse
Affiliation(s)
- Sarthak Malik
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bipadabhanjan Mallick
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kunaal Makkar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Kumar
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Address correspondence to: Dr. Vishal Sharma, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E-mail:
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
6
|
Maeshiro Y, Yamaji Y, Inoue S, Nakazato Y. Prerenal uremia induced by severe diarrhea due to colon adenoma: a case of McKittrick-Wheelock syndrome in an elderly patient. CEN Case Rep 2014; 3:75-79. [PMID: 28509250 PMCID: PMC5411540 DOI: 10.1007/s13730-013-0089-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 07/05/2013] [Indexed: 12/21/2022] Open
Abstract
McKittrick-Wheelock syndrome can be successfully treated by emergent dialysis, prescription of bicarbonate, and endoscopic submucosal dissection, which allow elderly people suffering from this syndrome to maintain their activities of daily living. In patients with this syndrome, a large colonic villous adenoma secretes excessive amounts of mucus and causes severe electrolyte depletion and dehydration. An 81-year-old man who had been suffering from chronic renal failure (creatinine 256.4 μmol/L), hypertension, and arrhythmia presented with frequent mucous diarrhea for a month. He was hospitalized for appetite loss, vomiting, general fatigue, and acute renal failure. His blood tests and blood gas analysis revealed urea nitrogen 58.9 mmol/L, creatinine 954.7 μmol/L, pH 7.13, and a base excess of -20.1 mmol/L. Although his symptoms were improved by the emergent dialysis and rehydration, he suffered a relapse only 4 days after he was discharged. At the second admission, a near-circumferential tumor was found in the rectum by the colonoscopy, which was pathologically confirmed as a villous adenoma. Considering his age and complications, endoscopic submucosal dissection was selected, and internal use of sodium bicarbonate was prescribed. Diarrhea and appetite loss were improved by these treatments, and the creatinine level was also improved to 168.0 μmol/L.
Collapse
Affiliation(s)
- Yuri Maeshiro
- Internal Medicine, Saitama Social Insurance Hospital, 4-9-3 Kitaurawa, Urawa-ku, Saitama-City, Saitama, 330-0074, Japan.
| | - Yasuyoshi Yamaji
- Kidney Disease Center and Internal Medicine, Saitama Social Insurance Hospital, 4-9-3 Kitaurawa, Urawa-ku, Saitama-City, Saitama, 330-0074, Japan
| | - Shuji Inoue
- Kidney Disease Center and Internal Medicine, Saitama Social Insurance Hospital, 4-9-3 Kitaurawa, Urawa-ku, Saitama-City, Saitama, 330-0074, Japan
| | - Yuichi Nakazato
- Kidney Disease Center and Internal Medicine, Saitama Social Insurance Hospital, 4-9-3 Kitaurawa, Urawa-ku, Saitama-City, Saitama, 330-0074, Japan
| |
Collapse
|
7
|
Podestà MA, Cucchiari D, Merizzoli E, Elmore U, Angelini C, Badalamenti S. McKittrick-Wheelock syndrome: a rare cause of acute renal failure and hypokalemia not to be overlooked. Ren Fail 2014; 36:811-3. [PMID: 24564376 DOI: 10.3109/0886022x.2014.890056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
McKittrick-Wheelock syndrome is a rare disorder in which a colorectal tumor (usually a villous adenoma) determines secretory mucous diarrhea, which in turn leads to prerenal acute renal failure, hyponatremia, hypokalemia and metabolic acidosis. Even though the outcome is usually favorable with complete recovery after surgery, the diagnosis is often delayed, making the patient susceptible to life-threatening complications, mainly severe acidosis and hypokalemia. We present two paradigmatic cases with extreme electrolytes imbalance and complete recovery following the appropriate treatment. The pathogenesis of this degenerative condition is discussed in detail.
Collapse
Affiliation(s)
- Manuel Alfredo Podestà
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center , Rozzano, Milan , Italy and
| | | | | | | | | | | |
Collapse
|
8
|
Hashash JG, Holder-Murray J, Aoun E, Yadav D. The McKittrick-Wheelock syndrome: a rare cause of chronic diarrhoea. BMJ Case Rep 2013; 2013:bcr-2013-009208. [PMID: 23592821 DOI: 10.1136/bcr-2013-009208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The McKittrick-Wheelock syndrome, a rare disorder, is caused by fluid and electrolyte hypersecretion from a rectal tumour and patients can develop a depletion syndrome characterised by severe dehydration, hyponatraemia, hypokalaemia and metabolic acidosis. We present a case of a 62-year-old man who presented with chronic diarrhoea that had resulted in numerous previous hospital admissions. On physical exam, the patient showed signs of volume depletion. A soft polypoid mass was appreciated on digital rectal examination. Laboratory tests showed renal failure and significant electrolyte abnormalities. Colonoscopy revealed a large, friable mass in the rectosigmoid region. Biopsies were consistent with tubolovillous adenoma. Subsequently, the patient underwent surgical resection, which on pathology exhibited evidence of high-grade dysplasia, and the patient was diagnosed with McKittrick-Wheelock syndrome. It is essential to identify this condition in a timely manner as it is associated with high morbidity and complications, some of which may be life threatening.
Collapse
Affiliation(s)
- Jana G Hashash
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | |
Collapse
|
9
|
Chen YH, Kang JC, Lai HJ. Rectal Villous Adenoma with McKittrick-Wheelock Syndrome: Report of a Rare Case. Visc Med 2013. [DOI: 10.1159/000348494] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background: </i></b>McKittrick-Wheelock syndrome mostly results from colorectal villous adenoma and is characterized by dehydration, hyponatremia, hypokalemia, and prerenal azotemia. <b><i>Case Report: </i></b>We report the case of an 84-year-old patient with rectal villous adenoma, presenting with chronic mucous diarrhea for 2 years and subsequent prerenal azotemia. After fluid and electrolyte replenishment, the patient underwent proctectomy and recovered completely. <b><i>Conclusion: </i></b>According to a review of the literature, we suggest that surgical resection can achieve a complete recovery.
Collapse
|
10
|
van Esch S, van Milligen de Wit M, van Laarhoven K, Rensma PL. Episodic electrolyte disorders and renal failure due to a rare disease: the McKittrick-Wheelock syndrome. Clin Kidney J 2012; 5:166-167. [PMID: 29497521 PMCID: PMC5783205 DOI: 10.1093/ckj/sfr178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 12/19/2011] [Indexed: 11/18/2022] Open
Abstract
We describe a patient with intermittent bouts of malaise and muscle weakness due to profound electrolyte disturbances. Colonoscopy showed a giant villous adenoma of the sigmoid. The patient was diagnosed with a McKittrick–Wheelock syndrome with pre-renal disease and electrolyte disorders due to periodic rectal fluid loss. The diagnosis was delayed by the patient’s misinterpretation of the doctor’s questions. In cases where the patient’s history is contrary to what the data reveal, the expected culprit organ should be investigated early in the course of the disease. Extracting relevant and guiding information out of the patient’s history remains an important skill.
Collapse
Affiliation(s)
- Sadie van Esch
- Department of Internal Medicine, St Elisabeth Hospital Tilburg, Tilburg, The Netherlands
| | | | - Kees van Laarhoven
- Department of Surgery, St Elisabeth Hospital Tilburg, Tilburg, The Netherlands
| | - Pieter L Rensma
- Department of Internal Medicine, St Elisabeth Hospital Tilburg, Tilburg, The Netherlands
| |
Collapse
|
11
|
Learney RM, Ziprin P, Swift PA, Faiz OD. Acute Renal Failure in Association with Community-Acquired Clostridium difficile Infection and McKittrick-Wheelock Syndrome. Case Rep Gastroenterol 2011; 5:438-44. [PMID: 21960946 PMCID: PMC3180660 DOI: 10.1159/000330478] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We report the case of a 65-year-old Caucasian woman who experienced two separate episodes of acute renal failure within an 18-month period, both requiring emergency admission and complicated treatment. Each episode was precipitated by hypovolaemia from intestinal fluid losses, but from two rare and independent pathologies. Her first admission was attributed to community-acquired Clostridium difficile-associated diarrhoea (CDAD) and was treated in the intensive therapy unit. She returned 18 months later with volume depletion and electrolyte disturbances, but on this occasion a giant hypersecretory villous adenoma of the rectum (McKittrick-Wheelock syndrome) was diagnosed following initial abnormal findings on digital rectal examination by a junior physician. Unlike hospital-acquired C. difficile, community-acquired infection is not common, although increasing numbers are being reported. Whilst community-acquired CDAD can be severe, it rarely causes acute renal failure. This case report highlights the pathological mechanisms whereby C. difficile toxin and hypersecretory villous adenoma of the rectum can predispose to acute renal failure, as well as the values of thorough clinical examination in the emergency room, and early communication with intensivist colleagues in dire situations.
Collapse
Affiliation(s)
- Robert M Learney
- Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London
| | | | | | | |
Collapse
|
12
|
The mckittrick-wheelock syndrome: a rare cause of severe hydroelectrolyte disorders and acute renal failure. Case Rep Nephrol 2011; 2011:765689. [PMID: 24533197 PMCID: PMC3914135 DOI: 10.1155/2011/765689] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 08/08/2011] [Indexed: 12/02/2022] Open
Abstract
The McKittrick-Wheelock syndrome is a rare cause of severe hydroelectrolyte disorders and fluid depletion as a result of rectal tumor hypersecretion, which can lead to acute renal failure. We report the case of a 70-year-old female who presented with hyponatremia, hypokalemia, hypochloremia, and acute renal failure, due to a watery, mucinous diarrhea. A large rectal villous adenoma was discovered on ileocolonoscopy, and definitive management was achieved by removal of the tumor. In conclusion, reversal of the biochemical derangement is the cornerstone of successful management of the McKittrick-Wheelock syndrome. Then, immediate surgical resection of the tumor is the treatment of choice.
Collapse
|