Milk-Alkali Syndrome: A Historical Review and Description of the Modern Version of the Syndrome

Another case of milk–alkali syndrome or a learning opportunity?

Summary

Milk–alkali syndrome (MAS) is a triad of hypercalcaemia, metabolic alkalosis and renal insufficiency. In this study, we present a case of milk–alkali syndrome secondary to concurrent use of over-the-counter (OTC) calcium carbonate-containing antacid tablets (Rennie®) for dyspepsia and calcium carbonate with vitamin D3 (Adcal D3) for osteoporosis. A 72-year-old woman presented with a 2-day history of nausea, vomiting, epigastric pain, constipation, lethargy and mild delirium. Past medical history included osteoporosis treated with daily Adcal D3. Initial blood tests showed elevated serum-adjusted calcium of 3.77 mmol/L (normal range, 2.2–2.6) and creatinine of 292 µmol/L (45–84) from a baseline of 84. This was corrected with i.v. pamidronate and i.v. fluids. She developed asymptomatic hypocalcaemia and rebound hyperparathyroidism. Myeloma screen, vasculitis screen and serum angiotensin-converting enzyme (ACE) were normal, while the CT of the chest, abdomen and pelvis showed renal stones but no malignancy. A bone marrow biopsy showed no evidence of malignancy. Once the delirium resolved, we established that prior to admission, she had been excessively self-medicating with over-the-counter antacids (Rennie®) as required for epigastric pain. The increasing use of calcium preparations for the management of osteoporosis in addition to easily available OTC dyspepsia preparations has made MAS the third most common cause of hypercalcaemia hospitalisations. Educating patients and healthcare professionals on the risks associated with these seemingly safe medications is required. Appropriate warning labels on both calcium preparations used in the management of osteoporosis and OTC calcium-containing preparations would prevent further similar cases and unnecessary morbidity and hospital admission.

Learning points

Calcium-Alkali Syndrome: Historical Review, Pathophysiology and Post-Modern Update

Milk-alkali syndrome or calcium-alkali syndrome (CAS) is the triad of hypercalcemia, metabolic alkalosis and renal impairment. It is often related to ingestion of high amounts of calcium carbonate, which was used historically for the treatment of peptic ulcer disease. The incidence of the syndrome decreased dramatically after the introduction of newer peptic ulcer medications such as proton pump inhibitors and histamine blocking agents. However, a resurgence was seen in the late 1980s with the wide use of over-the-counter calcium supplements, mainly by females for osteoporosis prophylaxis. The modern version of the syndrome continues to evolve along with medical management. This review focuses on the historical context of CAS, pathogenesis, resurgence of the condition with variable presentations, and contemporary management.

A 39 year-old woman with milk-alkali syndrome complicated by posterior reversible encephalopathy syndrome

Milk-alkali syndrome (MAS) is characterized by the triad of hypercalcemia, metabolic alkalosis, and acute kidney injury. Once thought to be a rare condition, there has been a resurgence of cases due to the consumption of calcium-containing supplements for osteoporosis prevention and dyspepsia in the general population. We describe the case of a female who presented with acute encephalopathy, hypercalcemia, and new-onset seizure. An extensive hypercalcemia workup and ruling out of other causes led to the diagnosis of MAS from excessive intake of calcium carbonate. Brain magnetic resonance imaging revealed signal abnormalities in the occipital and posterior parietal lobes that were indicative of posterior reversible encephalopathy syndrome. The patient's encephalopathy resolved after treatment of her hypercalcemia with fluid resuscitation and cessation of her calcium supplements. We present our case to highlight this unusual presentation of MAS, challenges in diagnosis, and briefly discuss the pathophysiology underlying hypercalcemia-induced encephalopathy.

A diagnostician's field guide to crystalline nephropathies

The kidney's role in filtration of blood and production of urine occurs via a combination of size and charge filtration at the glomerular basement membrane and resorption and excretion of molecules through a complex tubular system embedded within an ion gradient. This delicate system provides the kidney with a unique propensity for substrate saturation and crystal nucleation within the nephron. While crystalline nephropathies may seem exotic to the uninitiated, they are comprised of easily recognizable morphologies and generally lack complicated classification schemas. Additionally, unlike many intrinsic kidney diseases, crystalline nephropathies are often associated with systemic conditions that, upon further investigation, may elucidate critically important information. This review focuses on practical, diagnostically relevant and high yield information that can be utilized by diagnosticians. Our hope is to equip the reader who reviews renal tissue with a practical toolkit that they feel empowered to use when faced with crystal formation in a kidney biopsy, pre-implantation biopsy, or nephrectomy specimen. Short Abstract The kidney's role in filtration of blood and production of urine provides a unique propensity for substrate saturation and crystal nucleation within the nephron. While crystalline nephropathies may seem exotic to the uninitiated, they are comprised of easily recognizable morphologies and generally lack complicated classification. Additionally, crystalline nephropathies are often associated with systemic conditions that, upon further investigation, may elucidate critically important information.

Acute milk-alkali syndrome

A 74-year-old woman presented with progressive lethargy, confusion, poor appetite and abdominal pain. She was found to have non-PTH-mediated severe hypercalcemia with renal failure and metabolic alkalosis. Extensive workup for hypercalcemia to rule out alternate etiology was unrevealing. Upon further questioning, she was taking excess calcium carbonate (Tums) for her worsening heartburn. She was diagnosed with milk-alkali syndrome (MAS). Her hypercalcemia and alkalosis recovered completely with aggressive hydration along with improvement in her renal function. High index of suspicion should be maintained and history of drug and supplements, especially calcium ingestion, should be routinely asked in patients presenting with hypercalcemia to timely diagnose MAS and prevent unnecessary tests and treatments.

Learning points:

Suspect milk-alkali syndrome in patients with hypercalcemia, metabolic alkalosis and renal failure, especially in context of ingestion of excess calcium-containing supplements.

Careful history of over-the-counter medications, supplements and diet is crucial to diagnose milk-alkali syndrome.

Milk-alkali syndrome may cause severe hypercalcemia in up to 25–30% of cases.

An unusual case of hypercalcemia in a patient of concomitant hypoparathyroidism and celiac disease

Milk alkali syndrome has shown resurgence with increase in use of (prescription or non prescription) calcium supplements. Cases of iatrogenic vitamin D intoxication has also increased due to increasing use of high doses of injectable vitamin D formulations by physicians, surgeons, orthopaedicians, gynecologists and other specialties inadvertently. Here, we present an unusual case of a 17-year-old boy who presented with iatrogenic hypercalcemia as a result of combination of milk alkali syndrome with vitamin D intoxication despite being a case of hypoparathyroidism and concomitantly suffering from celiac disease.

Determination of (210)Po in calcium supplements and the possible related dose assessment to the consumers

The aim of this pioneer study was to investigate the most popular calcium supplements as a potential additional source of polonium (210)Po in human diet. The analyzed calcium pharmaceutics contained organic or inorganic calcium compounds; some from natural sources as mussels' shells, fish extracts, or sedimentary rocks. The objectives of this research were to investigate the naturally occurring (210)Po activity concentrations in calcium supplements, find the correlations between (210)Po concentration in medicament and calcium chemical form, and calculate the effective radiation dose connected to analyzed calcium supplement consumption. As results showed, (210)Po concentrations in natural origin calcium supplements (especially sedimentary rocks) were higher than the other analyzed. Also the results of (210)Po analysis obtained for inorganic forms of calcium supplements were higher. The highest (210)Po activity concentrations were determined in mineral tablets made from sedimentary rocks: dolomite and chalk - 3.88 ± 0.22 and 3.36 ± 0.10 mBq g(-1) respectively; while the lowest in organic calcium compounds: calcium lactate and calcium gluconate - 0.07 ± 0.02 and 0.17 ± 0.01 mBq g(-1). The annual effective radiation doses from supplements intake were estimated as well. The highest annual radiation dose from (210)Po taken with 1 tablet of calcium supplement per day was connected to sample made from chalk - 2.5 ± 0.07 μSv year(-1), while the highest annual radiation dose from (210)Po taken with 1 g of pure calcium per day was connected to dolomite - 12.7 ± 0.70 μSv year(-1).

Drug-induced acid-base disorders

The incidence of acid-base disorders (ABDs) is high, especially in hospitalized patients. ABDs are often indicators for severe systemic disorders. In everyday clinical practice, analysis of ABDs must be performed in a standardized manner. Highly sensitive diagnostic tools to distinguish the various ABDs include the anion gap and the serum osmolar gap. Drug-induced ABDs can be classified into five different categories in terms of their pathophysiology: (1) metabolic acidosis caused by acid overload, which may occur through accumulation of acids by endogenous (e.g., lactic acidosis by biguanides, propofol-related syndrome) or exogenous (e.g., glycol-dependant drugs, such as diazepam or salicylates) mechanisms or by decreased renal acid excretion (e.g., distal renal tubular acidosis by amphotericin B, nonsteroidal anti-inflammatory drugs, vitamin D); (2) base loss: proximal renal tubular acidosis by drugs (e.g., ifosfamide, aminoglycosides, carbonic anhydrase inhibitors, antiretrovirals, oxaliplatin or cisplatin) in the context of Fanconi syndrome; (3) alkalosis resulting from acid and/or chloride loss by renal (e.g., diuretics, penicillins, aminoglycosides) or extrarenal (e.g., laxative drugs) mechanisms; (4) exogenous bicarbonate loads: milk-alkali syndrome, overshoot alkalosis after bicarbonate therapy or citrate administration; and (5) respiratory acidosis or alkalosis resulting from drug-induced depression of the respiratory center or neuromuscular impairment (e.g., anesthetics, sedatives) or hyperventilation (e.g., salicylates, epinephrine, nicotine).

Acute kidney injury associated with androgenic steroids and nutritional supplements in bodybuilders(†)

Four bodybuilders who injected anabolic steroids and ingested commercial protein (78–104 g/day) and creatine (15 g/day) products presented with serum creatinine levels between 229.84 and 335.92 µmol/L (2.6–3.8 mg/dL). Renal biopsies revealed acute tubular necrosis. Four weeks after discontinuing injections and supplements, serum creatinine was in the normal range and estimated glomerular filtration rate > 1.00 mL/s (60 mL/min), including two patients with biopsies showing >30% interstitial fibrosis and tubular atrophy. The findings highlight a risk for acute and potentially chronic kidney injury among young men abusing anabolic steroids and using excessive amounts of nutritional supplements.

Hypercalcemia Associated with Calcium Supplement Use: Prevalence and Characteristics in Hospitalized Patients

BACKGROUND

The ingestion of large amounts of milk and antacids to treat peptic ulcer disease was a common cause of hypercalcemia in the past (the "milk-alkali syndrome"). The current popularity of calcium and supplements has given rise to a similar problem.

OBJECTIVES

To evaluate the prevalence and characteristics of hypercalcemia induced by calcium intake ("calcium supplement syndrome"; or CSS) in hospitalized patients.

METHODS

We conducted a retrospective; electronic health record (EHR)-based review of patients with hypercalcemia over a 3-year period. Diagnosis of CSS was based on the presence of hypercalcemia; a normal parathyroid hormone (PTH) level; renal insufficiency; metabolic alkalosis; a history of calcium intake; and documented improvement with treatment.

RESULTS

Of the 72 patients with non-PTH mediated hypercalcemia; 15 (20.8%) satisfied all the criteria for the diagnosis of CSS. Calcium; vitamin D; and multivitamin ingestion were significantly associated with the diagnosis (p values < 0.0001; 0.014; and 0.045 respectively); while the presence of hypertension; diabetes; and renal insufficiency showed a trend towards statistical significance. All patients received intravenous fluids; and six (40%) received calcium-lowering drugs. The calcium level at discharge was normal 12 (80%) of patients. The mean serum creatinine and bicarbonate levels decreased from 2.4 and 35 mg/dL on admission respectively; to 1.6 mg/dL and 25.6 mg/dL at discharge respectively.

CONCLUSION

The widespread use of calcium and vitamin D supplementation can manifest as hypercalcemia and worsening of kidney function in susceptible individuals. Awareness among health care professionals can lead to proper patient education regarding these health risks.

Calcium-alkali syndrome in the modern era

The ingestion of calcium, along with alkali, results in a well-described triad of hypercalcemia, metabolic alkalosis, and renal insufficiency. Over time, the epidemiology and root cause of the syndrome have shifted, such that the disorder, originally called the milk-alkali syndrome, is now better described as the calcium-alkali syndrome. The calcium-alkali syndrome is an important cause of morbidity that may be on the rise, an unintended consequence of shifts in calcium and vitamin D intake in segments of the population. We review the pathophysiology of the calcium-alkali syndrome.

Antacid-induced acute pancreatitis

OBJECTIVE

To report a case of acute pancreatitis associated with the administration of high doses of over-the-counter (OTC) antacids containing calcium carbonate.

SETTING

An acute care 276-bed community hospital.

CASE SUMMARY

In this case report, a 68-year-old male was admitted to the hospital for nausea, vomiting, and stomach pain. Patient reported taking 15-20 OTC calcium carbonate (4.5-6.0 g elemental calcium) tablets for four to five days prior to admission. Patient's calcium level upon admission was 18.5 mg/dL. Laboratory values of amylase and lipase peaked at 2,768 U/L and 7,091 U/L, respectively. An abdominal computed tomography confirmed acute pancreatitis. For a period of 45 days, treatment in the intensive care unit for acute pancreatitis and latter for necrotizing pancreatitis was conducted.

CONCLUSION

This case study supports an association between hypercalcemia and pancreatitis in patients who take greater than recommended dosages of calcium-containing antacids. OTC antacids are popular, but can cause serious adverse events when not used as directed.

The calcium-alkali syndrome

The milk-alkali syndrome was a common cause of hypercalcemia, metabolic alkalosis, and renal failure in the early 20th century. It was caused by the ingestion of large quantities of milk and absorbable alkali to treat peptic ulcer disease. The syndrome virtually vanished after introduction of histamine-2 blockers and proton pump inhibitors. More recently, a similar condition called the calcium-alkali syndrome has emerged as a common cause of hypercalcemia and alkalosis. It is usually caused by the ingestion of large amounts of calcium carbonate salts to prevent or treat osteoporosis and dyspepsia. We describe a 78-year-old woman who presented with weakness, malaise, and confusion. She was found to have hypercalcemia, acute renal failure, and metabolic alkalosis. Upon further questioning, she reported use of large amounts of calcium carbonate tablets to treat recent heartburn symptoms. Calcium supplements were discontinued, and she was treated with intravenous normal saline. After 5 days, the calcium and bicarbonate levels normalized and renal function returned to baseline. In this article, we review the pathogenesis of the calcium-alkali syndrome as well as the differences between the traditional and modern syndromes.

Hypercalcemic encephalopathy due to milk alkali syndrome and injection teriparatide

An 82-year-old male, a known case of severe osteoporosis with vertebral fracture and prostatic carcinoma, was treated with gonadotropin releasing hormone analogue, calcium carbonate, cholecalciferol sachet and injection teriparatide. His diet consisted of milk and curd. He developed altered behavior and generalized weakness, and on investigation, hypercalcemia, hypokalemia, and metabolic alkalosis with low parathyroid hormone levels were detected. Injection teriparatide was stopped and he was managed with forced saline diuresis and injection zoledronic acid. He was diagnosed as a case of milk alkali syndrome in whom teriparatide and prolonged immobilization played a permissive role in the development of hypercalcemic encephalopathy.

No more milk in milk-alkali syndrome: a case report

This is a case of Milk-AlKali syndrome in a patient who presented with the classical triad of hypercalcemia, metabolic alkalosis and renal impairment. The source of calcium was over-the-counter calcium-containing antacid (Tums®). Milk-alkali syndrome was first recognized secondary to treatment of peptic ulcer disease with milk and absorbable alkali. Its incidence fell after the introduction of H2-blocker and proton pump inhibitor. However, it is one of the leading causes of hypercalcemia nowadays because of the wide availability, increased marketing and use of calcium carbonate especially in osteoporosis prevention and treatment. The demographics of milk-alkali syndrome have changed compared to when it was initially described. The presentation could be acute, subacute or chronic. Early diagnosis, discounting calcium supplement and intravenous hydration are the mainstay of MAS management.

Crystalline nephropathies

CONTEXT

The kidney is a favored site for crystal deposition because of the high concentration of ions and molecules reached at the level of the renal tubules in the course of filtration. This review focuses on crystalline nephropathies in 4 broad categories: (1) dysproteinemia- associated, (2) drug-induced, (3) calcium-containing, and (4) metabolic or genetic.

OBJECTIVE

To provide a framework for accurate identification of the diverse types of crystals encountered in the kidney in order to formulate an appropriate differential diagnosis and guide additional testing and treatment.

DATA SOURCES

Review of pertinent published literature along with practical experience gained in a high-volume renal pathology laboratory.

CONCLUSIONS

Accurate identification of crystals encountered in the kidney is essential in detecting conditions ranging from hematologic malignancy to drug toxicity to metabolic disorders. Detailed clinical-pathologic correlation is needed to accurately diagnose the underlying cause of most crystalline nephropathies.

Gastroesophageal reflux disease in children and adolescents: when and how to treat

Gastroesophageal reflux (GER) is a common presenting complaint in children and adults, and is a frequent reason for physician consultation. GER disease (GERD), whilst benign in the majority of cases, is frequently a chronic condition that has been shown to result in significantly reduced quality of life in children and adolescents. Furthermore, there is emerging evidence that the prevalence of GERD is rising and may have links to adult obesity and other morbidities. Consequently, accurate diagnosis, appropriate management strategies, and timely referral to specialist services are important principles in the effective management of GERD. Acid-suppressive drugs are effective therapies but are one of the most costly classes of drugs prescribed. Therefore, not only is an accurate diagnosis important to the patient, but it is also of significant interest from a public health and resource utilization standpoint.

Antacids, Altered Mental Status, and Milk-Alkali Syndrome

The frequency of milk-alkali syndrome decreased rapidly after the development of histamine-2 antagonists and proton pump inhibitors for the treatment of peptic ulcer disease; however, the availability and overconsumption of antacids and calcium supplements can still place patients at risk (D. P. Beall et al., 2006). Here we describe a patient who presented with altered mental status, hypercalcemia, metabolic alkalosis, and acute renal failure in the context of ingesting large amounts of antacids to control dyspepsia.

Hypercalcemia in pregnancy: a case of milk-alkali syndrome

Milk-alkali syndrome is a rare cause of hypercalcemia characterized by the triad of hypercalcemia, renal insufficiency, and metabolic alkalosis that results from the overconsumption of calcium containing products. In the setting of pregnancy where there is a physiologic increase in calcium absorption, milk-alkali syndrome can be potentially life threatening. We report a case of a 26-year-old woman in her second trimester of pregnancy who presented with 2 weeks of flank pain, nausea, vomiting, anorexia, headache, and lightheadedness. The history revealed consumption of a large quantity of milk, calcium carbonate antacid, and calcium-containing prenatal vitamins. Her symptoms and hypercalcemia resolved with intravenous fluids and a loop diuretic. With the increased use of calcium carbonate for peptic ulcer disease, gastroesophageal reflux disease, and osteoporosis, milk-alkali syndrome has experienced a resurgence and must be considered in the differential diagnosis of hypercalcemia. In this clinical vignette we review the literature on milk-alkali syndrome in pregnancy and discuss important diagnostic and therapeutic considerations when managing the pregnant patient with hypercalcemia.

Got calcium? Welcome to the calcium-alkali syndrome

We recommend changing the name of the milk-alkali syndrome to the calcium-alkali syndrome, because the new terminology better reflects the shifting epidemiology and understanding of this disorder. The calcium-alkali syndrome is now the third most common cause of hospital admission for hypercalcemia, and those at greatest risk are postmenopausal or pregnant women. The incidence of the calcium-alkali syndrome is growing in large part as a result of the widespread use of over-the-counter calcium and vitamin D supplements. Advertising for treatment or prevention of osteoporosis has long encouraged this use. Intricate mechanisms mediating the calcium-alkali syndrome depend on interplay among intestine, kidney, and bone. New insights regarding its pathogenesis focus on the key role of calcium-sensing receptors and TRPV5 channels in the modulation of renal calcium excretion. Restoring extracellular blood volume, increasing GFR and calcium excretion, and discontinuing calcium supplementation provide best treatment.

Vitamin/mineral supplements and calcium-based antacids increase maternal calcium intake

OBJECTIVE

The contributions of over-the-counter (OTC) calcium-based antacid medications and calcium-containing vitamin/mineral supplements to total calcium intake during pregnancy, have rarely been assessed. This study estimates the contributions of calcium-based antacids and vitamin/mineral supplements to maternal calcium intake.

METHODS

Over an 8-month period, a cohort of 724 prenatal class attendees (out of a possible 1100 participants) at >28 weeks gestation in Calgary, Alberta, completed an anonymous questionnaire on vitamin/mineral supplement intake and the use of calcium-based antacids. A subset of 264 women completed a self-reported calcium-modified food frequency questionnaire.

RESULTS

The use of prenatal vitamins/minerals increased during pregnancy as did use of the single nutrients calcium and iron. Calcium-based antacids were used by 52% (n = 365) of pregnant women. Median intake of calcium from maternal diet alone was 1619 mg/d (mean intake, 1693 +/- 94), which rose to 2084 mg/d (mean intake, 2228 +/- 116) when diet, vitamin/mineral supplements, and antacids were considered. From diet alone, 18% had less than adequate intake (AI = 1000 mg/d) of calcium and 12% exceeded the tolerable upper intake level (UL = 2500 mg/d). Adding antacids reduced to 5% those below the AI and increased those surpassing the UL to 33%. No adverse events were reported at calcium intakes above the UL.

CONCLUSIONS

Vitamin/mineral supplements and calcium-based antacids increased total maternal calcium intake, resulting in fewer women with intakes < AI but also increasing the number of those with intakes > UL. It is suggested that health care providers discuss all sources of nutrient intake with pregnant clients, as cumulative intakes may unintentionally exceed recommended levels.

Hypercalcemia and acute renal failure in milk-alkali syndrome: a case report

Historically, the milk-alkali syndrome developed as an adverse reaction to the Sippy regimen of milk, cream and alkaline powders as treatment for peptic ulcer disease. The classic description includes hypercalcemia, metabolic alkalosis, and renal failure. Over the past 20 years, milk-alkali syndrome has had a resurgence, as consumption of supplements containing calcium has increased. A 46-year-old man presented to the emergency department after outpatient labs to evaluate his fatigue. He was found to have acute renal failure and hypercalcemia (total serum calcium was 15.9 mg/dL). Subsequent laboratory evaluation excluded both hyperparathyroidism and malignancy as causes. A detailed history led to the diagnosis of milk-alkali syndrome. With hydration and cessation of calcium carbonate ingestion, his renal function and serum calcium levels returned to normal. Physicians should have a high index of suspicion for milk-alkali syndrome in patients with hypercalcemia. Milk-alkali syndrome is no longer a merely a historical curiosity; it is currently the third most common cause of hypercalcemia.

Calcium-alkali syndrome-like symptoms manifested by daily alphacalcidol and thiazide

A 73-year-old man was admitted with complaints of a 2-month history of generalized weakness and numbness. Laboratory examination revealed hypercalcemia, metabolic alkalosis, and kidney injury, similar to the traditional milk-alkali syndrome. The clinical history and the response to therapy indicated that alphacalcidol and thiazide taken daily were the cause. Recently, it has been recommended the term "milk-alkali syndrome" be replaced by "calcium-alkali syndrome", which broadens the definition of the condition. This case suggests that the calcium-alkali syndrome can occur without calcium and alkali, but rather with alphacalcidol and a thiazide diuretic.

Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)

OBJECTIVE

To develop a North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) international consensus on the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

METHODS

An international panel of 9 pediatric gastroenterologists and 2 epidemiologists were selected by both societies, which developed these guidelines based on the Delphi principle. Statements were based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies. The committee convened in face-to-face meetings 3 times. Consensus was achieved for all recommendations through nominal group technique, a structured, quantitative method. Articles were evaluated using the Oxford Centre for Evidence-based Medicine Levels of Evidence. Using the Oxford Grades of Recommendation, the quality of evidence of each of the recommendations made by the committee was determined and is summarized in appendices.

RESULTS

More than 600 articles were reviewed for this work. The document provides evidence-based guidelines for the diagnosis and management of gastroesophageal reflux and gastroesophageal reflux disease in the pediatric population.

CONCLUSIONS

This document is intended to be used in daily practice for the development of future clinical practice guidelines and as a basis for clinical trials.

Hypercalcemia, metabolic alkalosis and renal failure secondary to calcium bicarbonate intake for osteoporosis prevention--'modern' milk alkali syndrome: a case report

We report a case of a patient presenting with a triad of hypercalcemia, metabolic alkalosis and renal failure secondary to calcium bicarbonate intake for osteoporosis prevention. It is the classical presentation of the "modern" milk alkali syndrome that presents several characteristics distinguishing it from the "old" syndrome described secondary to peptic ulcer disease treatment. Milk alkali syndrome affects middle-aged female patients taking over-the-counter calcium carbonate. Clinically, these patients present in an acute hypercalcemia crisis, responding rapidly to hydration. The phosphorus level is normal to low. Bisphosphonate should be used cautiously due to the risk of symptomatic hypocalcemia.

Milk-alkali syndrome

Milk-alkali syndrome (MAS) consists of hypercalcemia, various degrees of renal failure, and metabolic alkalosis due to ingestion of large amounts of calcium and absorbable alkali. This syndrome was first identified after medical treatment of peptic ulcer disease with milk and alkali was widely adopted at the beginning of the 20th century. With the introduction of histamine2 blockers and proton pump inhibitors, the occurrence of MAS became rare; however, a resurgence of MAS has been witnessed because of the wide availability and increasing use of calcium carbonate, mostly for osteoporosis prevention. The aim of this review was to determine the incidence, pathogenesis, histologic findings, diagnosis, and clinical course of MAS. A MEDLINE search was performed with the keyword milk-alkali syndrome using the PubMed search engine. All relevant English language articles were reviewed. The exact pathomechanism of MAS remains uncertain, but a unique interplay between hypercalcemia and alkalosis in the kidneys seems to lead to a self-reinforcing cycle, resulting in the clinical picture of MAS. Treatment is supportive and involves hydration and withdrawal of the offending agents. Physicians and the public need to be aware of the potential adverse effects of ingesting excessive amounts of calcium carbonate.

Milk-alkali syndrome

Milk-alkali syndrome (MAS) consists of hypercalcemia, various degrees of renal failure, and metabolic alkalosis due to ingestion of large amounts of calcium and absorbable alkali. This syndrome was first identified after medical treatment of peptic ulcer disease with milk and alkali was widely adopted at the beginning of the 20th century. With the introduction of histamine2 blockers and proton pump inhibitors, the occurrence of MAS became rare; however, a resurgence of MAS has been witnessed because of the wide availability and increasing use of calcium carbonate, mostly for osteoporosis prevention. The aim of this review was to determine the incidence, pathogenesis, histologic findings, diagnosis, and clinical course of MAS. A MEDLINE search was performed with the keyword milk-alkali syndrome using the PubMed search engine. All relevant English language articles were reviewed. The exact pathomechanism of MAS remains uncertain, but a unique interplay between hypercalcemia and alkalosis in the kidneys seems to lead to a self-reinforcing cycle, resulting in the clinical picture of MAS. Treatment is supportive and involves hydration and withdrawal of the offending agents. Physicians and the public need to be aware of the potential adverse effects of ingesting excessive amounts of calcium carbonate.

Control of gastric acid secretion in health and disease

Recent milestones in the understanding of gastric acid secretion and treatment of acid-peptic disorders include the (1) discovery of histamine H(2)-receptors and development of histamine H(2)-receptor antagonists, (2) identification of H(+)K(+)-ATPase as the parietal cell proton pump and development of proton pump inhibitors, and (3) identification of Helicobacter pylori as the major cause of duodenal ulcer and development of effective eradication regimens. This review emphasizes the importance and relevance of gastric acid secretion and its regulation in health and disease. We review the physiology and pathophysiology of acid secretion as well as evidence regarding its inhibition in the management of acid-related clinical conditions.

Milk alkali syndrome associated with excessive ingestion of Rennie: case reports

Milk alkali syndrome is a cause of hypercalcaemia, renal failure and alkalosis, and is potentially reversible if detected early and the calcium and alkali source withdrawn. It was originally described in patients ingesting large amounts of calcium containing milk for the treatment of peptic ulcer disease. We present a modern day version of the syndrome in three cases which were associated with excessive intake of Rennie, a calcium carbonate containing antacid.

Hypercalcemia

Laboratory reports of elevated serum calcium are common in both inpatient and outpatient settings. Distinguishing between measurements likely to cause symptoms and that require correction from those that are benign poses a challenge to the physician. Calcium stores, serum measurement, and regulation are reviewed as an introduction to understanding the etiology and treatment of hypercalcemia.

Milk alkali syndrome without the milk

Milk alkali syndrome is easily missed and should be considered in all patients who present with hypercalcaemia