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Kouladouros K, Schneider K, Kubicka S, Hoerner C, Hirth M. Endoscopic Submucosal Dissection of a Giant Rectal Adenoma Manifesting as McKittrick-Wheelock Syndrome. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:944-951. [PMID: 37751770 DOI: 10.1055/a-2163-5913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
McKittrick-Wheelock syndrome (MKWS) is an uncommon clinical manifestation of large, villous, epithelial lesions of the distal colon and rectum. Excessive secretion of electrolyte-rich mucus from these lesions leads to secretory diarrhea, electrolyte disorders and acute renal failure. Several cases of MKWS have been reported since its initial description in 1954. The definitive treatment for the great majority of MKWS cases has consisted of surgical resection of the affected part of the colorectum, usually in the form of a low anterior resection or an abdominoperineal resection with the formation of an ostomy. Recent developments in endoscopic resection techniques now offer new, minimally invasive treatment alternatives for MKWS patients. We present the first reported case in the Western world of MKWS caused by a rectal adenoma with a size of 19 × 10 cm, treated through endoscopic submucosal dissection. Through the lessons learned by this case, as well as by a thorough review of the literature, we discuss this uncommon syndrome, focusing on treatment alternatives.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Klaus Schneider
- Medizinische Klinik 1, Klinikum am Steinenberg, Reutlingen, Germany
| | - Stefan Kubicka
- Medizinische Klinik 1, Klinikum am Steinenberg, Reutlingen, Germany
| | - Christian Hoerner
- Institute of Pathology, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Hirth
- Department of Medicine II, University Medical Centre Mannheim, Mannheim, Germany
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Marcinkevičiūtė K, Kryžauskas M, Poškus T. McKittrick-Wheelock Syndrome: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59030633. [PMID: 36984634 PMCID: PMC10056017 DOI: 10.3390/medicina59030633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023]
Abstract
An adenoma is the most typical large bowel tumor found in 30% of all screening colonoscopies. However, it is often asymptomatic but sometimes might lead to abdominal pain or bleeding of the rectum. Critical electrolyte disbalance and acute kidney injury caused by secretory diarrhea is an untypical clinical manifestation of adenoma. It has rarely been reported in the literature and is defined as McKittrick-Wheelock syndrome. A 61-year-old patient was hospitalized for heavy dyselectrolytemia, diarrhea, acute kidney injury, sepsis, and fever. After the renal function was corrected and electrolyte imbalance persisted, visual instrumental diagnostics tests revealed a large tumor in the sigmoid colon. Subsequently, the patient underwent surgical resection, which exhibited evidence of tubulovillous adenoma on pathology. The atypical signs of McKittrick-Wheelock syndrome and comorbidities can make the diagnostics challenging. When severe hyponatremia and hypokalemia are followed by persistent mucous diarrhea, the clinicians should suspect MWS as a possible reason for it.
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Affiliation(s)
| | - Marius Kryžauskas
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
| | - Tomas Poškus
- Clinic of Gastroenterology, Nephrourology, and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
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de Sousa Miranda I, Ferreira JR, Rocha S, Monteiro M, Guillerme J, Domingos R. McKittrick-Wheelock Syndrome: A Neoplastic Cause of Electrolyte Imbalance. Eur J Case Rep Intern Med 2022; 9:003231. [PMID: 35402344 PMCID: PMC8988500 DOI: 10.12890/2022_003227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/08/2022] [Indexed: 11/25/2022] Open
Abstract
UNLABELLED The authors present the case of a 79-year-old woman who presented with chronic secretory diarrhoea and severe electrolyte imbalance. A large rectal tubulovillous adenoma was discovered, leading to surgical resection of the tumour with complete resolution of the diarrhoea and electrolyte imbalance. The diagnosis of McKittrick-Wheelock syndrome was made. We hope this case report will contribute to a greater awareness among health professionals about this clinical condition. A multidisciplinary approach is essential for the best outcome. LEARNING POINTS McKittrick-Wheelock syndrome is an important differential diagnosis in patients presenting with electrolyte abnormalities and secretory diarrhoea.A multidisciplinary approach from the beginning is important for a timely diagnosis and better outcome.Surgical removal of the hypersecretory villous adenoma is the definitive treatment for McKittrick-Wheelock syndrome and can be life-saving.
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Affiliation(s)
- Inês de Sousa Miranda
- Internal Medicine Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Joana Rodrigues Ferreira
- General Surgery Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Sara Rocha
- Internal Medicine Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Marta Monteiro
- Internal Medicine Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - José Guillerme
- General Surgery Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Raquel Domingos
- Internal Medicine Department, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
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Jyala A, Mehershahi S, Shah N, Shaikh DH, Patel H. McKittrick-Wheelock Syndrome: A Rare Cause of Chronic Diarrhea. Cureus 2021; 13:e13308. [PMID: 33732563 PMCID: PMC7956013 DOI: 10.7759/cureus.13308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Diarrhea is the principal cause of the majority of healthcare utilization. When diarrhea lasts longer than four weeks, it is considered chronic diarrhea. There are several causes of chronic diarrhea, but here we focus on one of the rare causes, known as McKittrick-Wheelock syndrome (MWS). We here present the case of a patient in his seventies with chronic diarrhea, found to have tubulovillous adenoma and diagnosed with McKittrick-Wheelock syndrome. We also discuss the clinical presentation, pathophysiology, and management of MWS.
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Affiliation(s)
| | | | - Niel Shah
- Internal Medicine, Bronx-Lebanon Hospital Center, Bronx, USA
| | | | - Harish Patel
- Internal Medicine, Bronx-Lebanon Hospital Center, Bronx, USA
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Sacks J, Atlas S, Enno A, Santos L, Humphries J, Kirwan A. Giant villous adenoma of the sigmoid colon: an unusual cause of homogeneous, segmental bowel wall thickening. BJR Case Rep 2020; 6:20200016. [PMID: 33299583 PMCID: PMC7709061 DOI: 10.1259/bjrcr.20200016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 12/04/2022] Open
Abstract
Colonic adenomas are commonly encountered lesions that are a precursor of colorectal cancer. Of these, villous adenomas are a rarer, more advanced subtype that are larger in size than tubular adenomas and have a higher risk of malignant transformation. We present a patient with a giant villous adenoma of the sigmoid colon identified on CT as homogeneous segmental bowel wall thickening.
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Affiliation(s)
| | | | - Alar Enno
- Department of Pathology, Liverpool Hospital, Sydney, NSW, Australia
| | - Leonardo Santos
- Department of Pathology, Liverpool Hospital, Sydney, NSW, Australia
| | - Jeremy Humphries
- Department of Gastroenterology, Bankstown-Lidcombe Hospital, Sydney, NSW, Australia
| | - Alexander Kirwan
- Department of Radiology, Westmead Hospital, Sydney, NSW, Australia
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Fukase M, Oshio H, Murai S, Kawana T, Saito Y, Kono E, Oshima Y, Yunome G, Teshima S, Ito M. Transanal total mesorectal excision of giant villous tumor of the lower rectum with McKittrick-Wheelock syndrome: a case report of a novel surgical approach. Surg Case Rep 2019; 5:173. [PMID: 31696325 PMCID: PMC6834797 DOI: 10.1186/s40792-019-0728-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/10/2019] [Indexed: 12/28/2022] Open
Abstract
Background McKittrick–Wheelock syndrome (MKWS) is caused by a villous tumor of the rectosigmoid colon with hypersecretion of mucus containing electrolytes. Complete resection of the tumor is needed to cure this disease. Transanal total mesorectal excision (TaTME) is currently a promising treatment for lower rectal tumor because of the reliability of its resection margin especially in bulky tumor. We present this first case report of a TaTME for MKWS with a lower rectal tumor. Case presentation An 81-year-old woman was admitted to our hospital with diarrhea and acute renal failure. Computed tomography and magnetic resonance imaging examinations revealed an 80-mm-sized enhanced tumor located in her lower rectum without lymph node swelling and distant metastasis. A giant villous tumor secreting mucus was seen in the lower rectum to the anal canal during colonoscopy. The result of tumor biopsy was adenocarcinoma. To preserve the anal function and ensure distal margin, we chose TaTME for curative resection. After improving the electrolyte imbalance, TaTME was performed successfully and R0 resection was achieved. There was no sign of recurrence or electrolyte depletion for 1 year after the surgery. Conclusion TaTME could be a promising surgical approach for giant villous tumor with MKWS in the lower rectum.
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Affiliation(s)
- Masahiko Fukase
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi-ken, 983-8520, Japan.
| | - Hiroshi Oshio
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi-ken, 983-8520, Japan
| | - Sho Murai
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi-ken, 983-8520, Japan
| | - Tomomi Kawana
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi-ken, 983-8520, Japan
| | - Yusuke Saito
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi-ken, 983-8520, Japan
| | - Emiko Kono
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi-ken, 983-8520, Japan
| | - Yukiko Oshima
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi-ken, 983-8520, Japan
| | - Gen Yunome
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi-ken, 983-8520, Japan
| | - Shin Teshima
- Department of Surgery, Sendai Medical Center, 2-11-12 Miyagino, Miyagino-ku, Sendai, Miyagi-ken, 983-8520, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
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Bains L, Lal P, Vindal A, Singh M. Giant villous adenoma of rectum- what is the malignant potential and what is the optimal treatment? A case and review of literature. World J Surg Oncol 2019; 17:109. [PMID: 31238922 PMCID: PMC6593568 DOI: 10.1186/s12957-019-1650-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/19/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction Villous adenomas are dubiously benign lesions, which are difficult to interpret because of their malignant potential. Distal villous adenomas present with bleeding or mucus discharge. Giant adenomas are not amenable for endoscopic or transanal resection. Only few isolated cases have been reported by laparoscopic resection. We present our case of a circumferential giant villous adenoma of the rectum managed successfully by laparoscopic ultra-low anterior resection with colo-anal anastomosis with a review of literature in regard to their malignant potential. Case report A 62-year-old lady presented with complaints of painless bleeding per rectum and a fleshy mass protruding from the anal canal which on digital rectal examination appeared a large soft velvety flat mass with mucus discharge. Colonoscopy showed circumferential irregular, friable, edematous mucosa in rectum extending for 15 cm. Computed tomography showed a large heterogeneously enhancing polypoid mass lesion in the rectal wall involving the entire rectum. The patient underwent laparoscopic low anterior resection with colo-anal anastomosis and protecting loop ileostomy. Histopathological examination of the resected specimen revealed villous adenoma of the rectum with moderate to severe dysplasia. Discussion Villous adenomas are sessile growths lined by dysplastic glandular epithelium, whose risk of malignancy is especially high up to 50% when greater than 2 cm in size. Large size, villous content, and distal location are all associated with severe dysplasia in colorectal adenomas. Large villous rectal tumors, particularly of circumferential type pose a great challenge for endoscopic or transanal removal. Henceforth, open or laparoscopic surgery is required for these cases. Conclusion Giant rectal villous polyps are usually unresectable by endoscopic methods or transanal endoscopic microsurgery and are associated with a high rate of unsuspected cancer which requires a formal radical oncologic resection. As per current data, the combined risk of dysplasia/malignancy is about 83% with 50% risk of dysplasia and frank malignancy in 33% of cases of giant rectal villous adenomas of more than 8 cm in size. Laparoscopic colorectal resection is safe and effective.
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Affiliation(s)
- Lovenish Bains
- Department of Surgery, Maulana Azad Medical College, New Delhi, India.
| | - Pawanindra Lal
- Department of Surgery, Maulana Azad Medical College, New Delhi, India
| | - Anubhav Vindal
- Department of Surgery, Maulana Azad Medical College, New Delhi, India
| | - Meeta Singh
- Department of Pathology, Maulana Azad Medical College, New Delhi, India
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Orchard MR, Hooper J, Wright JA, McCarthy K. A systematic review of McKittrick-Wheelock syndrome. Ann R Coll Surg Engl 2018; 100:1-7. [PMID: 30322287 PMCID: PMC6204505 DOI: 10.1308/rcsann.2018.0184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION McKittrick-Wheelock syndrome describes the condition of extreme electrolyte and fluid depletion caused by large distal colorectal tumours, usually the benign villous adenoma. Patients generally present critically unwell with severe hyponatraemia, hypokalaemia and/or acute kidney injury. METHODS A structured literature review was undertaken to discover what is known about this condition, which is almost universally described as rare. Important features of the syndrome were identified, including common presenting symptoms, blood results, tumour location and size. FINDINGS Our literature search identified 257 cases reported across all languages. The most remarkable features were the long duration of symptoms (median 24 months) and the significant electrolyte derangements (median sodium of 122mmol/l and median potassium of 2.7mmol/l at initial presentation). Five key recommendations are made to improve diagnosis, including aggressive fluid resuscitation to match rectal losses and surgical intervention on the index admission. The advantages and disadvantages of different treatment options are discussed, including minimally invasive alternatives to traditional resectional surgery. CONCLUSIONS McKittrick-Wheelock syndrome describes a normally benign condition that can cause patients to become critically unwell and so it behoves all clinicians to be aware of it. By publishing recommendations based on a comprehensive literature review, we aim to improve diagnosis and management of this life threatening condition.
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Affiliation(s)
- MR Orchard
- Gloucestershire Hospitals NHS Foundation Trust, UK
| | - J Hooper
- University Hospitals Bristol NHS Foundation Trust, UK
| | - JA Wright
- The Chinese University of Hong Kong, China
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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.
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Affiliation(s)
| | | | - Maarten Vermaas
- 1 Department of Surgery, IJsselland Hospital , Capelle Ad IJssel, The Netherlands
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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.
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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
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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.
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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
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Agnes A, Novelli D, Doglietto GB, Papa V. A case report of a giant rectal adenoma causing secretory diarrhea and acute renal failure: McKittrick-Wheelock syndrome. BMC Surg 2016; 16:39. [PMID: 27267899 PMCID: PMC4895885 DOI: 10.1186/s12893-016-0153-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/23/2016] [Indexed: 11/27/2022] Open
Abstract
Background The McKittrick-Wheelock syndrome is a rare depletion syndrome caused by a secretory villous adenoma or a carcinoma of the rectosigmoid tract. An aggressive hydroelectrolyte rebalancing is often needed, and curative treatment is obtained only with complete removal of the lesion, by endoscopy or surgery. Low clinical suspicion often delays the diagnosis, resulting in detrimental complications. Case presentation We report the case of a 75-year-old woman, presenting to the emergency department with acute renal failure and electrolyte imbalance, reporting an history of recurrent episodes of dehydration and chronic diarrhea. After being admitted to the nephrology department she underwent diagnostic investigation that revealed the presence of a giant adenoma of the rectum. The patients received supportive therapy and was subsequently treated with surgery, with a favorable outcome. Conclusions A prompt diagnosis plays an important role in the treatment of McKittrick-Wheelock syndrome. We describe a case of this condition in detail and review the related literature, underlining the typical diagnostic features and exploring the possible therapeutic options.
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Affiliation(s)
- Annamaria Agnes
- Division of Surgery, Miulli General Hospital, S.P. 127 Acquaviva-Santeramo km 4, 70021, Acquaviva delle Fonti, Italy. .,Catholic University, School of Medicine, Largo Agostino Gemelli n.8, 00168, Rome, Italy.
| | - Domenico Novelli
- Division of Surgery, Miulli General Hospital, S.P. 127 Acquaviva-Santeramo km 4, 70021, Acquaviva delle Fonti, Italy
| | - Giovanni Battista Doglietto
- Division of Digestive Surgery, Gemelli Hospital, Catholic University, School of Medicine, Largo Agostino Gemelli n.8, 00168, Rome, Italy
| | - Valerio Papa
- Division of Surgery, Miulli General Hospital, S.P. 127 Acquaviva-Santeramo km 4, 70021, Acquaviva delle Fonti, Italy.,Catholic University, School of Medicine, Largo Agostino Gemelli n.8, 00168, Rome, Italy
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Mois EI, Graur F, Sechel R, Al-Hajjar N. McKittrick-Wheelock syndrome: a rare case report of acute renal failure. ACTA ACUST UNITED AC 2016; 89:301-3. [PMID: 27152085 PMCID: PMC4849392 DOI: 10.15386/cjmed-536] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 09/21/2015] [Accepted: 09/24/2015] [Indexed: 11/28/2022]
Abstract
Giant tubular-villous adenoma of the rectum can determine secretory diarrhea, associated with a depleting syndrome of prerenal acute renal failure, hyponatremia, hypokalemia and hypoproteinemia. These symptoms are known as the McKittrick-Wheelock syndrome, and there are about 50 cases reported in literature. We present the case of a 59-year-old woman presented to our emergency department with abdominal pain, prerenal azotemia, and electrolyte disturbances with a background of chronic diarrhea, caused by a giant rectal tumor. Conservative therapy initially improved and normalized renal function, and made surgical resection of the tumor possible.
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Affiliation(s)
- Emil Ioan Mois
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania; Department of Surgery, Regional Institute of Gastroenterology and Hepatology Prof. O. Fodor, Cluj-Napoca, Romania
| | - Florin Graur
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania; Department of Surgery, Regional Institute of Gastroenterology and Hepatology Prof. O. Fodor, Cluj-Napoca, Romania
| | - Roxana Sechel
- Department of Pathology, Regional Institute of Gastroenterology and Hepatology Prof. O. Fodor, Cluj-Napoca, Romania
| | - Nadim Al-Hajjar
- Department of Surgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania; Department of Surgery, Regional Institute of Gastroenterology and Hepatology Prof. O. Fodor, Cluj-Napoca, Romania
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Hsieh MC, Chen CJ, Huang WS. McKittrick-Wheelock Syndrome. Clin Gastroenterol Hepatol 2016; 14:e41-2. [PMID: 26370570 DOI: 10.1016/j.cgh.2015.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 09/03/2015] [Accepted: 09/03/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Meng-Chiao Hsieh
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chih-Jung Chen
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Wen-Shih Huang
- Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Graduate Institutes of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Ohara Y, Toyonaga T, Watanabe D, Hoshi N, Adachi S, Yoshizaki T, Kawara F, Tanaka S, Ishida T, Okuno T, Ikehara N, Morita Y, Umegaki E, Yokozaki H, Azuma T. Electrolyte depletion syndrome (McKittrick-Wheelock syndrome) successfully treated by endoscopic submucosal dissection. Clin J Gastroenterol 2015; 8:280-4. [PMID: 26304954 DOI: 10.1007/s12328-015-0597-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 07/28/2015] [Indexed: 12/28/2022]
Abstract
A 66-year-old woman presented to us with malaise, anorexia and rectal mucous discharge, and her laboratory data showed severe hyponatremia, hypokalemia, hypochloremia and renal failure. Computed tomography revealed massive occupation of the rectum by a large tumor. Colonoscopy revealed a mucus-rich villous tumor in the rectum. As there were no other factors that could cause an electrolyte disorder, she was diagnosed with McKittrick-Wheelock syndrome (MWS). The current standard treatment for MWS is partial surgical colectomy. However, surgeries are invasive and postoperative complications sometimes become an issue. After confirming no signs of submucosal invasion of the tumor by magnifying chromoendoscopic examination, endoscopic submucosal dissection (ESD) was indicated. The tumor was completely removed en bloc without adverse events. The histology showed a mucosal adenocarcinoma containing a villous component, 24.5 x 17.0 cm in size. This removal dramatically improved the patient's symptoms and the electrolyte abnormalities without medication. Although several sessions of endoscopic balloon dilation were required to treat postoperative stricture, she has been symptom-free and had no recurrence for 4 years after treatment. We experienced a case of MWS treated by ESD instead of surgery. ESD should be feasible and beneficial for the treatment of MWS.
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Affiliation(s)
- Yoshiko Ohara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
| | | | - Daisuke Watanabe
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Namiko Hoshi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Soichiro Adachi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tetsuya Yoshizaki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Fumiaki Kawara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinwa Tanaka
- Department of Endoscopy, Kobe University Hospital, Kobe, Japan
| | - Tsukasa Ishida
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tatsuya Okuno
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobunao Ikehara
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshinori Morita
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Eiji Umegaki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Yokozaki
- Division of Pathology, Department of Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Azuma
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Kapoor S. Mckittrick-Wheelock syndrome: an often, overlooked complication of rectal adenomas. Surg Endosc 2014; 28:2247. [PMID: 24671351 DOI: 10.1007/s00464-014-3462-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 12/27/2013] [Indexed: 11/29/2022]
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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.
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Affiliation(s)
- Manuel Alfredo Podestà
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center , Rozzano, Milan , Italy and
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