Complete Endoscopic Submucosal Dissection of a Giant Rectal Villous Adenocarcinoma with Electrolyte Depletion Syndrome

Kumazawa, Kazumasa; Kawai, Masaya; Ishiyama, Shun; Kamiyama, Hirohiko; Tomiki, Yuichi; Sakamoto, Kazuhiro; Arakawa, Atsushi; Yao, Takashi

doi:10.1159/000382070

Cited by 12 publications

(11 citation statements)

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“…2 Definitive treatment remains resection of the underlying lesion either surgically or endoscopically. 3 Our patient had resolution of diarrhea after endoscopic resection of the polyps with restoration of potassium to normal value without further need for supplementation. He has been counselled regarding the need for surveillance colonoscopies as per recommendations for high-grade dysplasia in a tubulovillous adenoma.…”

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confidence: 59%

An Unusual Gastrointestinal Cause of Hypokalemia

2019

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Question: A 60-year-old male man came to emergency with history of painless protracted watery diarrhea for past 4 weeks associated with generalized weakness and swelling of both feet. He denied passing mucus or blood per rectum. His past medical history was insignificant. He denied consumption of laxatives or over-the-counter drugs for constipation. He seemed to be dehydrated and had tachycardia, pallor, and pedal edema. His stool microscopy revealed no leukocytes, ova, blood, or red blood cells. Renal function revealed a normal creatinine with a potassium of 2.81 mEq/L. His serum albumin was 3.1 g. Urine examination revealed no proteinuria and echocardiography revealed good ejection fraction with normal sized chambers. Serum potassium failed to correct despite supplementation and remained below the normal range. Transtubular potassium gradient was 1.7, suggestive of extrarenal losses. His tissue transglutaminase serology was negative and gastroduodenoscopy revealed normal duodenal folds. Duodenal biopsy was also inconclusive. A contrast-enhanced computed tomography scan of the abdomen revealed an enhancing mucosal lesion in the sigmoid colon (Figure A).Colonoscopy revealed a large pedunculated polyp in the sigmoid colon (Figure B [white light] and Figure C [narrow band imaging]) and a small pedunculated polyp in ascending colon (Figure D [narrow band imaging]). Hot

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confidence: 59%

An Unusual Gastrointestinal Cause of Hypokalemia

2019

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“…A meta-analysis of 18 studies showed that the prevalence of villous adenoma as the pathological type among all colonic polyps was 5.7% 9. Of these villous adenomas, a range from 0.76 to 2.4% of them will become secretory in nature,8 making the prevalence of secretory villous adenoma 0.01% of all colonic polyps.…”

Section: Discussionmentioning

confidence: 99%

“…In the past, the mainstay surgical option was complete resection of the involved area of the colon or rectum. Today, numerous surgical options are being researched and considered, including endoscopic submucosal dissection 8. Even though surgical management is the definitive treatment, it is necessary to correct the severe electrolyte abnormalities that these patients exhibit.…”

Section: Discussionmentioning

confidence: 99%

“…Studies have shown that Prostaglandin-E2 is the mediator for the hypersecretion mechanism observed in depletion syndrome, and that the hypersecretory state can be inhibited by cyclo-oxygenase inhibitors 5–7. While the only definitive cure for the McKittrick-Wheelock syndrome is surgical resection of the adenoma,3 8 surgical resection is not always feasible or prompt.…”

Section: Introductionmentioning

confidence: 99%

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Indomethacin therapy effective in a patient with depletion syndrome from secretory villous adenoma

Kagan¹,

Schmidt

Sangha³

2017

BMJ Case Reports

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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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“…The definitive treatment is partial colectomy followed by fluid and electrolyte replacement. An endoscopic approach is a limited option because of its circumference, malignancy, and location [2–4]. Especially in the case of tumors located in the lower rectum, we cannot avoid choosing abdominal–peritoneal resection, which reduces the patients’ quality of life drastically.…”

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confidence: 99%

Transanal total mesorectal excision of giant villous tumor of the lower rectum with McKittrick–Wheelock syndrome: a case report of a novel surgical approach

et al. 2019

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BackgroundMcKittrick–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 presentationAn 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.ConclusionTaTME could be a promising surgical approach for giant villous tumor with MKWS in the lower rectum.

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Complete Endoscopic Submucosal Dissection of a Giant Rectal Villous Adenocarcinoma with Electrolyte Depletion Syndrome

Cited by 12 publications

References 12 publications

An Unusual Gastrointestinal Cause of Hypokalemia

An Unusual Gastrointestinal Cause of Hypokalemia

Indomethacin therapy effective in a patient with depletion syndrome from secretory villous adenoma

Transanal total mesorectal excision of giant villous tumor of the lower rectum with McKittrick–Wheelock syndrome: a case report of a novel surgical approach

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