McKittrick-Wheelock Syndrome Research Articles

A119 ACUTE COLONOC PSEUDO-OBSTRUCTION AFTER ENDOSCOPIC RESECTION OF A FULLY CIRCUMFERENTIAL LARGE NON-PEDUNCULATED COLORECTAL POLYP

Abstract Background Complex large non-pedunculated colorectal polyps (LNPCPs), including those involving the full circumference of the bowel, are now readily managed by minimally invasive endoscopic resection techniques. Established procedure-related adverse events include sedation related adverse events, deep mural injury, clinically significant post-resection bleeding, delayed perforation and serositis. An appreciation for potential procedure-related adverse events is critical to the effective implementation of these techniques. Aims To describe a case of acute colonic pseudo-obstruction after endoscopic resection of a fully circumferential LNPCP. Methods Case report and review of the literature Results A 91-year-old male with a history of atrial fibrillation, chronic kidney disease and suspected McKittrick-Wheelock syndrome underwent successful endoscopic mucosal resection (EMR) of a 100mm fully circumferential LNPCP in the sigmoid colon. Histopathology diagnosed a tubulovillous adenoma with high-grade dysplasia. After elective admission, he suffered from clinically significant post-EMR bleeding requiring 2 units of packed red blood cells. On post-operative day 1 he began to suffer from nausea, abdominal pain and obstipation. On examination, he was visibly distended. Abdominal X-ray revealed extensive gas-filled loops of small and large bowel with the absence of gas in the rectum. He was managed conservatively with nasogastric tube decompression. Total duration of hospital stay was 9 days. Conclusions Critical to the continued expansion of minimally invasive endoscopic resection techniques is an awareness for potential procedure-related adverse events. To our knowledge this is the first description of acute colonic pseudo-obstruction after endoscopic resection Funding Agencies None

Laparoscopic Approach in the Surgical Management of McKittrick–Wheelock Syndrome

Mckittrick-Wheelock syndrome is a pathological entity that is represented by the presence of a large rectal tumour with histopathological findings of tubular-villous adenoma that associates important secretion of electrolyte-rich mucin.

Mckittrick-Wheelock syndrome: An infrequent cause of diarrhea in a patient with complicated necrotizing acute pancreatitis

Mckittrick-Wheelock syndrome: An infrequent cause of diarrhea in a patient with complicated necrotizing acute pancreatitis

S3343 McKittrick-Wheelock Syndrome: Chronic Diarrhea Due to a Giant Tubulovillous Adenoma With Endoscopic Management

S3343 McKittrick-Wheelock Syndrome: Chronic Diarrhea Due to a Giant Tubulovillous Adenoma With Endoscopic Management

Endoscopic Submucosal Dissection of a Giant Rectal Adenoma Manifesting as McKittrick-Wheelock Syndrome.

McKittrick-Wheelock syndrome (MKWS) is an uncommon clinical manifestation of large, villous, epithelial lesions of the distal colon and rectum. Excessive secretion of electrolyte-rich mucus from these lesions leads to secretory diarrhea, electrolyte disorders and acute renal failure. Several cases of MKWS have been reported since its initial description in 1954. The definitive treatment for the great majority of MKWS cases has consisted of surgical resection of the affected part of the colorectum, usually in the form of a low anterior resection or an abdominoperineal resection with the formation of an ostomy. Recent developments in endoscopic resection techniques now offer new, minimally invasive treatment alternatives for MKWS patients. We present the first reported case in the Western world of MKWS caused by a rectal adenoma with a size of 19 × 10 cm, treated through endoscopic submucosal dissection. Through the lessons learned by this case, as well as by a thorough review of the literature, we discuss this uncommon syndrome, focusing on treatment alternatives.

McKittrick-Wheelock syndrome: chronic diarrhea and electrolyte abnormalities due to a large rectal polyp with endoscopic management

McKittrick-Wheelock syndrome: chronic diarrhea and electrolyte abnormalities due to a large rectal polyp with endoscopic management

McKittrick Wheelock Syndrome Secondary to Adenocarcinoma of the Rectum. Case Report and Diagnostic Considerations

Abstract Introduction McKittrick-Wheelock syndrome is a rare entity characterized by chronic diarrhea, acute kidney injury, and hydroelectrolytic imbalance associated with a large rectal tumor, frequently a villous adenoma. Case report A 69-year-old male with chronic diarrhea with mucus. He underwent a colonoscopy with biopsies, reporting adenocarcinoma of the rectum in situ, and underwent a robot assisted intersphincteric resection with colo-anal anastomosis and a protecitive ileostomy. Discussion Described in 1954, this syndrome is manifested by electrolyte imbalance and acute renal injury secondary to diarrhea associated with a rectal villous adenoma, often with long lasting symptoms. The most frequent symptom being watery diarrhea with mucus. The definitive treatment consists of surgical resection. Conclusion Although this is a rare pathology, it should be considered as a differential diagnosis in cases of chronic diarrhea associated with water and electrolyte disorders.

Mckittrick- Wheelock syndrome (MKWS) - Rare cause of recurrent electrolyte derangements with hypotension and falls in elderly patients

We report a case of an 82-year-old gentleman presenting with recurrent hypokalaemia, renal impairment, postural hypotension and falls. Further investigations revealed large villous recto-sigmoid tumour associated with secretary diarrhoea in the closed bowel loop causing electrolyte depletion leading to hypotension and falls.

McKittrick-Wheelock syndrome presenting with presumed paraneoplastic syndrome extra-ocular muscle enlargement masquerading as thyroid eye disease.

Paraneoplastic syndromes (PS) are uncommon and are known to mimic other clinical entities, often carrying significant morbidity and mortality. The commonest cause of extra-ocular muscle enlargement (EOME) is thyroid eye disease (TED). Rarely, PS can cause EOME and masquerade as TED. We describe a 52-year-old female who presented with diarrhoea, acute kidney injury and electrolyte imbalance. An ophthalmic review identified right upper lid retraction. MRI orbits showed increased thickness of the inferior and medial recti bilaterally, presumed as TED. Whilst investigating her diarrhoea, imaging revealed a large rectosigmoid tumour which required surgical excision. In the context of electrolyte disturbance and acute kidney injury, a diagnosis of McKittrick-Wheelock syndrome (MWS) was made. Following successful surgery, electrolyte imbalance, diarrhoea and eyelid retraction improved. Repeat MRI orbits displayed complete resolution of EOME. To our knowledge, this is the first case of MWS presenting with PS-EOME masquerading as TED. McKittrick-Wheelock syndrome (MWS) is a rare disorder, although likely under-recognised, which is characterised by diarrhoea, dehydration and electrolyte depletion that results from a hypersecretory colorectal neoplasm. Definitive treatment of MWS involves the resection of the colorectal neoplasm. Bilateral ophthalmopathy that appears to be Graves' ophthalmopathy on imaging, though clinical and biochemical evidence fails to identify a thyroid pathology, has been associated with malignancy on rare occasions. Such patients should be investigated for potential malignant causes of their ophthalmopathy.

Severe hyponatremia secondary to rectal adenocarcinoma: Mckittrick–Wheelock syndrome

Severe hyponatremia secondary to rectal adenocarcinoma: Mckittrick–Wheelock syndrome

S1973 A Rare Case of McKittrick Wheelock Syndrome

Introduction: McKittrick Wheelock Syndrome (MWS) is a rare disorder characterized by distal colorectal tumors, most commonly benign secretory villous adenoma leading to secretory diarrhea with electrolyte depletion syndrome. Patients present with volume depletion, severe electrolyte derangement, specifically hyponatremia and hypokalemia, along with acute kidney injury (AKI). We present a rare case of an elderly female with severe electrolyte derangement in setting of MWS. Case Description/Methods: A 71-year-old woman with history of 4 months of watery diarrhea, fatigue, and anorexia presented after a syncopal episode. Notable labs Na 114 mEq/L, K 2.2 mEq/L, WBC 23.5K, and Cr 2.91 mg/dL. Stool electrolytes resulted in Stool Osm Gap 48 mOsm/kg consistent with secretory diarrhea. Of note, patient was hospitalized 3 times in the past 2 months for hyponatremia, hypokalemia, and AKI requiring temporary dialysis secondary to profuse diarrhea. A colonoscopy revealed a large rectal polypoid lesion with pathology consistent with a tubulovillous adenoma (Figure). She had aggressive electrolyte and fluid repletion with a robot assisted abdominoperineal resection. Subsequently, noted to have resolution of her symptoms and complete electrolyte correction upon follow up (Table). Discussion: Villous adenomas, normally a benign condition, can present with a life-threatening electrolyte derangements and volume depletion which makes the ability to diagnose and adequately treat MWS critical. Patients typically have multiple admissions with watery or mucous diarrhea, nausea, and vomiting. Labs significant for hyponatremia, hypokalemia, AKI, and leukocytosis. The tumors are large and often past the splenic flexure and low in the rectum, therefore flexible sigmoidoscopy can be reliably used rather than colonoscopy, which often delays diagnosis due to patients’ inability to prep. Treatment includes aggressive fluid and electrolyte repletion until tumor can be surgically resected. Few case reports suggest using indomethacin or octreotide as a bridge to surgery or as medical management for patients who are not surgical candidates. However, patients who are managed medically have a mortality rate up to ∼61-100%. Surgical management to definitively resolve symptoms, although minimally invasive options are being explored. A high index of suspicion and a systematic approach is critical to diagnose and provide life-saving treatment for MWS patients. Table 1. - Electrolytes: Comparison of Initial Admission vs. Post-Surgical Resection Electrolytes Initial Admission Post-surgical Resection Na 114 137 K+ 2.2 4.8 Cl 79 106 Creatinine 2.91 1.06 Figure 1.: Large rectal polypoid lesion with pathology consistent with a tubulovillous adenoma.

S1963 McKittrick-Wheelock Syndrome: A Case Report and Review of Literature

S1963 McKittrick-Wheelock Syndrome: A Case Report and Review of Literature

McKittrick-Wheelock Syndrome Secondary to Rectal Adenocarcinoma

Abstract Introduction McKittrick-Wheelock syndrome is a rare condition that arises from a hypersecretory state secondary to large colorectal tumors, mainly villous adenomas, leading to an electrolytic disorder associated with chronic diarrhea that usually persists for years. It is a relatively unknown disease that can lead to severe complications such as acute kidney injury, severe hyponatremia, and hypokalemia. In fact, it causes death in most untreated cases. Surgical removal of the tumor is the most successful treatment, and symptoms tend to disappear after proper management. Case Report A 62-year-old man with a 2-year history of mucoid diarrhea preceded by abdominal pain presented with acute kidney injury, hyponatremia, and hypokalemia. A digital rectal examination and sigmoidoscopy were performed, and revealed a large laterally-spreading tumor in the rectum. Further investigation showed a rectal tubulovillous adenoma with secondary McKittrick-Wheelock syndrome. An anterior resection of the rectum with a colonic J-pouch and a diverting ileostomy were performed, and the patient improved with the resolution of the renal failure and electrolyte disturbances. The histopathological analysis revealed an invasive rectal adenocarcinoma. Discussion McKittrick-Wheelock syndrome is a condition with a low incidence that needs early intervention and proper diagnosis. It is of extreme importance that this disease is included in the differential diagnoses for chronic diarrhea associated with an electrolytic disorder.

McKittrick-Wheelock Syndrome: A Neoplastic Cause of Electrolyte Imbalance.

The authors present the case of a 79-year-old woman who presented with chronic secretory diarrhoea and severe electrolyte imbalance. A large rectal tubulovillous adenoma was discovered, leading to surgical resection of the tumour with complete resolution of the diarrhoea and electrolyte imbalance. The diagnosis of McKittrick-Wheelock syndrome was made.We hope this case report will contribute to a greater awareness among health professionals about this clinical condition. A multidisciplinary approach is essential for the best outcome.LEARNING POINTSMcKittrick-Wheelock syndrome is an important differential diagnosis in patients presenting with electrolyte abnormalities and secretory diarrhoea.A multidisciplinary approach from the beginning is important for a timely diagnosis and better outcome.Surgical removal of the hypersecretory villous adenoma is the definitive treatment for McKittrick–Wheelock syndrome and can be life-saving.

S2543 Vanishing Diarrhea Post-ESD: McKittrick-Wheelock Syndrome

S2543 Vanishing Diarrhea Post-ESD: McKittrick-Wheelock Syndrome

A case of rectal villous tumor with shortness of breath in a 70-year-old woman-Uncommon symptom of McKittrick-Wheelock syndrome.

Diagnosis of McKittrick‐Wheelock syndrome (MWS) is sometimes difficult because the symptoms are sometimes nonspecific. Physician should be considered MWS in case of severe hyponatremia and hypokalemia are accompanied by prolonged mucous diarrhea.

Does Attenuated Mckittrick-Wheelock Syndrome Exists?

Does Attenuated Mckittrick-Wheelock Syndrome Exists?

Does Attenuated Mckittrick-Wheelock Syndrome Exists?

Does Attenuated Mckittrick-Wheelock Syndrome Exists?

A systematic review of McKittrick-Wheelock syndrome.

McKittrick-Wheelock syndrome describes the condition of extreme electrolyte and fluid depletion caused by large distal colorectal tumours, usually the benign villous adenoma. Patients generally present critically unwell with severe hyponatraemia, hypokalaemia and/or acute kidney injury. A structured literature review was undertaken to discover what is known about this condition, which is almost universally described as rare. Important features of the syndrome were identified, including common presenting symptoms, blood results, tumour location and size. Our literature search identified 257 cases reported across all languages. The most remarkable features were the long duration of symptoms (median 24 months) and the significant electrolyte derangements (median sodium of 122mmol/l and median potassium of 2.7mmol/l at initial presentation). Five key recommendations are made to improve diagnosis, including aggressive fluid resuscitation to match rectal losses and surgical intervention on the index admission. The advantages and disadvantages of different treatment options are discussed, including minimally invasive alternatives to traditional resectional surgery. McKittrick-Wheelock syndrome describes a normally benign condition that can cause patients to become critically unwell and so it behoves all clinicians to be aware of it. By publishing recommendations based on a comprehensive literature review, we aim to improve diagnosis and management of this life threatening condition.

A Rare Presentation of a Rectal Sessile Serrated Adenoma

Colorectal polyps are typically asymptomatic unless advanced in size or malignant. Infrequently, colorectal polyps can present with overt or occult bleeding, abdominal pain or changes in bowel habits. We present a case of a patient with rectal urgency that improved after removal of a sessile serrated adenoma. A 53 year old female with a past medical history of peptic ulcer disease, GERD and a recent small bowel obstruction managed conservatively at an outside hospital presented to our GI outpatient clinic for screening colonoscopy. The patient reported the sensation of anorectal blockage, fullness and urgency. She also reported a change in the caliber and shape of her stool. During the first colonoscopy, our patient was found to have eight 1 to 4 mm polyps in the rectum and recto-sigmoid junction and three diminutive polyps in the rectum, which were biopsied and removed. The pathology showed hyperplastic polyps. However, the preparation was poor so a repeat colonoscopy was done two months later. During the second colonoscopy, a 9 mm sessile polyp was seen in the rectum and ten 1 to 7 mm hyperplastic polyps were seen in the recto-sigmoid colon. The pathology showed a serrated adenoma in the rectum and fragments of normal colonic mucosa in the recto-sigmoid colon. We recommended a repeat screening colonoscopy in 5 years. Anorectal urgency and fullness has been described in multiple gastrointestinal disorders such as IBS, pelvic organ prolapse, solitary rectal ulcer syndrome, and IBD. However, there is little to no literature describing these symptoms in association with colorectal polyps. There are cases of large villous adenomas in the rectum or recto-sigmoid junction causing secretory diarrhea. The severity of disease is typically determined by the size of the lesion and the location in the distal colon, as larger lesions located more distally can cause severe presentations, such as McKittrick-Wheelock syndrome. It is possible that our patient may have been experiencing anorectal urgency and fullness secondary to a sessile serrated adenoma with hypersecretory function. Our patient improved after polyp removal highlighting that colorectal polyps can explain vague, nonspecific gastrointestinal symptoms and polypectomy can be curative.1605_A Figure 1. Rectum: sessile polyp.1605_B Figure 2. Sigmoid colon: hyperplastic polyps.