Electrolyte depletion syndrome (McKittrick–Wheelock syndrome) successfully treated by endoscopic submucosal dissection

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.

Chronic Diarrhea with Renal Insufficiency and Electrolyte Disturbances due to a Large Rectal Polyp

“…It is defined by the triad of electrolyte disorders, kidney injury secondary to fluid depletion and chronic secretory diarrhea caused by a large rectal neoplasm [1][2][3][4][5][6][7][8][9][10]. Renal adaption and increased oral intake may initially compensate for the fluid and electrolyte losses.…”

“…In addition adenoma's can degenerate into an adenocarcinoma. The majority of McKittrick-Wheelock syndromes are due to large (>3-4cm), mucus-rich villous adenoma in the distal part of the colon [1][2][3][4]7]. In a recent case review performed by Sarthak M et al [1], out of 35 found cases 22 had a villous adenoma, 8 had an underlying adenocarcinoma, one had a hyperplastic polyp and one had a neuro-endocrine tumor with liver metastases.…”

“…Elevated Cl -secretion will in turn stimulate intraluminal loss of sodium (Na + ) since the increased Cl -efflux creates a more lumen negative transepithelial voltage, which promotes paracellular secretion of Na + and water [14,15]. Furthermore, the electroneutral NaCl absorption by the dual Na + /H + and Cl -/ HCO 3 -exchange pumps at the apical membrane of the colonic epithelium is dependent on cAMP activity. Elevated levels of cAMP will therefore also reduce this NaCl absorption [15,18].…”

“…Proportional to the size, these secretory polyps can produce an abundant amount of rectal discharge and consequentially can cause hypovolemia, renal insufficiency and profound electrolyte disturbances. This rare disorder is known as the McKittrick-Wheelock syndrome (MWS) [1][2][3][4][5][6][7][8][9][10]. Treatment is initially based on volume resuscitation and on correction of the electrolyte disturbances.…”

Malignant McKittrick-Wheelock syndrome as a cause of acute kidney injury and hypokalemia: Report of a case and review of literature

“…The reported complications in the literature included associated endocarditis (19), pseudoobstruction (32), rhabdomyolysis (20), clostridium difficle induced diarrhea (33), intussception and rectal prolapse (12). Postoperative complications such as postoperative stricture (29) have been reported which require multiple sessions of rectal dilatations.…”