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.
References
McKittrick LS, Wheelock FC, Charles Thomas C. Carcinoma of colon. Illinois: Springfield; 1954.
Pucci G, Rondelli F, Avenia N, Schillaci G. Acute renal failure and metabolic alkalosis in a patient with colorectal villous adenoma (McKittrick–Wheelock syndrome). Surgery 2013 (in press).
Martins HS, Brandão-Neto RA, de Carvalho AL, Santana AN, Aguiar FJ, Scalabrini-Neto A, Velasco IT. McKittrick–Wheelock syndrome: a cause of severe hydro-electrolyte disorders in ED. Am J Emerg Med. 2007;25:1083.e1–3.
Miles LF, Wakeman CJ, Farmer KC. Giant villous adenoma presenting as McKittrick–Wheelock syndrome and pseudo-obstruction. Med J Aust. 2010;192:225–7.
Winstanley V, Little MA, Wadsworth C, Cohen P, Martin NM. The McKittrick–Wheelock syndrome: a case of acute renal failure due to neoplastic cholera. Ren Fail. 2008;30:469–73.
Lepur D, Klinar I, Mise B, Himbele J, Vranjican Z, Barsić B. McKittrick–Wheelock syndrome: a rare cause of diarrhoea. Eur J Gastroenterol Hepatol. 2006;18:557–9.
Koning GG, Rensma PL, van Milligen de Wit AW, van Laarhoven CJ. In-one-continuity rectal excision and anal mucosectomy of a giant villous adenoma: an alternative surgical approach. Case Rep Gastroenterol. 2008;2:175–80.
Popescu A, Orban-Schiopu AM, Becheanu G, Diculescu M. Rom McKittrick–Wheelock syndrome––a rare cause of acute renal failure. J Gastroenterol. 2005;14:63–6.
Albareda M, Merce MD, Corcoy R. Reversible impairment of renal function associated with enalapril in a diabetic patients. CMAJ. 1998;159:1279–81.
Cruz CS, Cruz LS, Silva GR, Marcillio de Souza CA. Incidence and predictors of development of acute renal failure related to treatment of congestive heart failure with ACE inhibitors. Nephron. 2007;105:C77–83.
Stirling C, Houston J, Robertson S, Boyle J, Allan A, Norris J, Isles C. Diarrhea, vomiting and ACE inhibitors: an important cause of acute renal failure. J Hum Hypertens. 2003;17:419–23.
Cassel D, Selinger Z. Mechanism of adenylate cyclase activation by cholera toxin: inhibition of GTP hydrolysis at the regulatory site. Proc Natl Acad Sci USA. 1977;74:3307–11.
Kimberg DV, Field M, Johnson J, Henderson A, Gershon E. Stimulation of intestinal mucosal adenyl cyclase by cholera enterotoxin and prostaglandins. J Clin Invest. 1971;50:1218–30.
Peterson JW, Ochoa LG. Role of prostaglandins and cAMP in the secretory effects of cholera toxin. Science. 1989;245:857–9.
Jacob H, Schlondorff D, St Onge G, Bernstein LH. Villous adenoma depletion syndrome. Evidence for a cyclic nucleotide-mediated diarrhea. Dig Dis Sci. 1985;30:637–41.
Steven K, Lange P, Bukhave K, Rask-Madsen J. Prostaglandin E2-mediated secretory diarrhea in villous adenoma of rectum: effect of treatment with indomethacin. Gastroenterology. 1981;80:1562–6.
Eberhart CE, Coffey RJ, Radhika A, Giardiello FM, Ferrenbach S, DuBois RN. Up-regulation of cyclooxygenase 2 gene expression in human colorectal adenomas and adenocarcinomas. Gastroenterology. 1994;107:1183–8.
Smelt AH, Meinders AE, Hoekman K, Noort WA, Keirse MJ. Secretory diarrhea in villous adenoma of rectum: effect of treatment with somatostatin and indomethacin. Prostaglandins. 1992;43:567–72.
Stürmer T, Glynn RJ, Lee IM, Manson JE, Buring JE, Hennekens CH. Aspirin use and colorectal cancer: post-trial follow-up data from the Physicians Health Study. Ann Intern Med. 1998;128:713–20.
Benamouzig R, Deyra J, Martin A, Girard B, Jullian E, Piednoir B, Couturier D, Coste T, Little J, Chaussade S. Daily soluble aspirin and prevention of colorectal adenoma recurrence: one-year results of the APACC trial. Gastroenterology. 2003;125:328–36.
Cole BF, Logan RF, Halabi S, Benamouzig R, Sandler RS, Grainge MJ, Chaussade S, Baron JA. Aspirin for the chemoprevention of colorectal adenomas: meta-analysis of the randomized trials. J Natl Cancer Inst. 2009;101:256–66.
Goldfarb WB. Villous adenomas of the right colon. Cancer. 1964;17:264–71.
DaCruz GM, Gardner FJ, Peskin GW. Mechanism of diarrhea of villous adenomas. Am J Surg. 1968;115:203–8.
Devroede GJ, Phillips SF. Failure of the human rectum to absorb electrolytes and water. Gut. 1970;11:438–42.
Williams B, Pearson HJ, Barrie WW, Walls J. Recurrent acute renal failure due to a rectal villous adenoma. Postgrad Med J. 1988;64:631–3.
Berrill WT. Villous papilloma of the rectum (with unusual complications). Br J Surg. 1973;60:919–21.
Emrich J, Niemeyer C. The secreting villous adenoma as a rare cause of acute renal failure. Med Klin (Munich). 2002;97:619–23.
Stulc JP, Petrelli NJ, Herrera L, Mittelman A. Colorectal villous and tubulovillous adenomas equal to or greater than four centimeters. Ann Surg. 1988;207:65–71.
Ah Soune P, Ménard C, Salah E, Desjeux A, Grimaud JC, Barthet M. Large endoscopic mucosal resection for colorectal tumors exceeding 4 cm. World J Gastroenterol. 2010;16:588–95.
Cole BF, Logan RF, Halabi S, Benamouzig R, Sandler RS, Grainge MJ, Chaussade S, Baron JA. Risk factors for delirium in hospitalized elderly. JAMA. 1992;267:827–31.
O’Keeffe S, Lavan J. The prognostic significance of delirium in older hospital patients. J Am Geriatr Soc. 1997;45:174–8.
Conflict of interest
All the authors have declared no competing interest.
Author information
Authors and Affiliations
Corresponding author
About this article
Cite this article
Maeshiro, Y., Yamaji, Y., Inoue, S. et al. Prerenal uremia induced by severe diarrhea due to colon adenoma: a case of McKittrick–Wheelock syndrome in an elderly patient. CEN Case Rep 3, 75–79 (2014). https://doi.org/10.1007/s13730-013-0089-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s13730-013-0089-7