Hospital: Hospital Universitario Virgen Macarena.
Aut@r o Autores: M. Roquette Mateos, J. Herrero Lara, M. Mayorga Pineda, T. Busquier Cerdán, X. Cortés Sañudo, R. Estelles López.
resent the case of a 55-year-old man which was admitted to emergency department with a three days history of malaise, diarrhea and decreased urine output. He had no significant past medical history. Physical examination showed no abdominal abnormalities and laboratory tests revealed acute renal failure (ARF) with elevated serum creatinine (7.42 mg/dl), increased blood urea nitrogen (239 mg/dl), metabolic acidosis, hyponatremia, hypokalemia, hypochloremia, hypocalcemia and slight leukocytosis with neutrophilia. The patient continued with oligoanuria and no improvement after hydroelectrolytic replacement, therefore clinicians requested for abdominal ultrasound (US) exam. US findings did not show significant alterations in the kidneys and urinary tract, however it revealed an important dilated rectum with liquid content, consequently an abdominal and pelvis CT without contrast (due to ARF) was performed. CT confirmed incidentally US findings and also showed a large diffuse and concentric rectal wall thickening. It did not show perirectal fat stranding, free intraperitoneal fluid, enlarged lymph nodes or bowel obstruction. It was established the differential diagnosis of rectal mass. During hospital admission rectal MRI and colonoscopy was advised, which demonstrated a polypoid mass measuring 12 centimeters, with a peripheral solid component and cyst or necrotic central area. No extension to mesorectal fat or sphincter complex. Findings were indicative of giant villous adenoma and was confirmed by biopsy.
Villous adenomas are a neoplastic adenomatous polyp of epithelial gastrointestinal (GI), although are histologically benign, they have high risk of malignancy (adenocarcinomas). Adenomas are most frequent in colon and are typically asymptomatic, however, exceptionally some large villous adenomas may be hypersecretory involving dehydratation hypovolemic shock, ARF associated to hyponatremia, hypokalemia, hypochloremia, hypocalcemia and metabolic acidosis, as well as in our case report. This set of symptoms is called McKittrick-Wheelock syndrome. Differential diagnosis should include the adenomas (tubular or tubulovillous), polyps (mucosal, juvenile, hamartomatous or inflammatory) or submucosal lesions (leiomyoma or GI stromal tumors). Radiological findings are nonspecificic and it is a challenge to establish an anatomopathological correlation, although there is some findings suggesting villous adenoma in MRI or CT exams. Villous adenoma could be longer than other adenomas, cauliflower-like or cerebriform appearance and surrounded by fluid.
McKittrick-Wheelock syndrome is an uncommon cause of ARF secondary to villous adenoma, so it is essential to describe radiological incidental findings in the emergency department and associate them with clinical-analytical data. This findings even be the cause of exceptional syndromes.
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