CASE STUDY OF TRANSIENT PSEUDO-HYPOALDOSTERONISM SECONDARY TO RIGHT HEMICOLECTOMY

A 38 years’ lady is admitted as a referral due to suspected intestinal obstruction, previously diagnosed with grade III hiatal hernia. Patient is known to have valvular heart disease for 10 years on management with digoxin 0.125mg and carvedilol 3.25mg. 

Had history of abdominal pains with on and off abdominal distention. Significant rumbling abdominal sound present. Bowel habits reported to have changed in last 2 months.  Had not passed stool in 3 days but was passing flatus.  Anorexia.Significant weight loss reported. No history of night sweats.

Examination.

 Middle aged, obvious wasting. Alert

Mild palmar and conjunctival pallor

CVS-Systolic murmur radiating to the apex

P/A-Scaffold, MWR, Overactive bowel sounds with visible peristaltic activity (Patient severely wasted), no organomegally. DRE-Empty rectum

Resp/Pelvic/CNS-Normal finding.

Lab works

FHG- Hb 10.4 MCV-58.9 WBC-2.9 (Differentials all within normal ranges), PLT-251

UECS-NA-139, Cl-110.9 K-4.13, Urea-3.4, Creatinine-64.47

TFTs-TSH-0.97(N), T3-2.18(N), T4-14.7 (N) 

INR-1.22

LFTs-Albumin 35.89, Total Protein 69.39, SGOT-32, ALP-564, Total Bilirubin 14.1 Direct Bilirubin-9.08, SGPT-17, GGT-84

Imaging

Erect abdominal X-ray-multiple air fluid levels on ascending colon. No sigmoid volvulus. Small gut –no air fluid levels

Management

Patient kept nill per oral

NG tube inserted-bilious fluid aspirated

Maintained on digoxin 0.125mg, Carvedilol 3.25mg, I.V Ceftriaxone 1g Bd, I.V Metronidazole 500mg TDS and IVF RL alternating with D5. 

After 48 hours, clinical resolution of intestinal obstruction observed as characterized by history of passing stool and flatus.

Patient started on liquid diet. After 48 hours no history of passing flatus or stool. Still anorexic.

Decision made to take patient to theatre for explorative laparotomy. ECG Review pre-op, features of left ventricular hypertrophy-cleared for surgery

Pre-op UECS

Na-136, CL-112, K-4.74, Urea-4.10, Creatinine-54.02

Intra-op Findings

Mass at cecum found-intraluminal approx 4* 3 cm. Mass resected whole for biopsy. Right hemicolectomy done. Distal ileum, cecum and ascending colon resected.  Reversal of anesthesia uneventful

Post OP Follow-up

Day 1 and 2, patient recovering well, Feeding started, colostomy site satisfactory. Ambulation started.

Day 3

Dizziness reported. Hypotensive with BPs  88/50mmHg HR 100beats/min. Bolus of NS 1 L given over 1 hour and maintained with 3 L of RL alternating with D5. Carvedilol withheld but digoxin continued 

UECS

Na- 122, Cl 104, K-6.75, Urea-7.28, Creatinine 73.53

Heart stabilized with Calcium gluconate, shifting of potassium done with insulin and D50.

Day 4

Na -122, K-4.97, Urea-8.01 Creatinine 37.9

Patient still hypotensive and lethargic despite being on maintenance fluids 3L and tolerating feeds well. No hyperactivity of colostomy site.

 Day 5

 Na-114.9, Cl 101.6, K-7.41, Urea 13.1, Creatinine 88.32

Heart further stabilized with calcium gluconate, Potassium shifted with insulin and D50 and patient nebulized with salbutamol.

Causes of hyperkalemia reviewed, no direct cause of electrolyte imbalance identified from medications given. A diagnosis of Pseudo-hypo-aldosteronism entertained due to the clinical features of adrenal insufficiency

Patient started on Hydrocortisone as below:

ü  100mg IV bolus then

ü  200mg over 24 hours by continuous infusion day 1

ü  100mg over 24 hours for 2 days

Review of UECS on day 2 after initiation of hydrocortisone

Na-127, K-4.97, Creatinine 37.9 Urea 8.3

On day 3: UECS Na-129, K-4.2, Creatinine 57.0 Urea 7.4

From day 4 hydrocortisone was tapered to P.O 50mg 12 hourly for 3 days. Hypotension resolved to a range of 110-126 systolic and 64-88 diastolic. Heart rate 70-100. Carvedilol was re-introduced.

UECs day 4

Na-135, K-4.25, Urea 6.93, Creatinine 96

Patient was discharged 11 days after operation and 5 days after initiation of hydrocortisone.

 Discharge UECS were: Na-141.9, K-3.86, Urea 3.5, Creatinine-63.49

Medications on discharge: Digoxin 0.125mg, Carvedilol 3.25mg, 50mg of hydrocortisone P.O daily for 4 days, Iron and nutritional supplements.

Colostomy was mature and having normal range output.

Review of Patient three weeks after discharge. 

She was in good general state. Had added weight by 3kgs. BP 118/86 mmhg, HR 76 beats/min

UECS: Na-129, K+-4.6, Creatinine-93 and Urea 4.7

FHG-Hb-11.1, Mcv-62.7, PLT-277, WBC-9.0

Patient was also booked for follow-up with an oncologist with the histology results from the biopsy taken.