A case of persistent diarrhoea. Dr. Miles Levy, Dr. Jenny Prouten, Priya Jalota

Transcription

1 A case of persistent diarrhoea Dr. Miles Levy, Dr. Jenny Prouten, Priya Jalota

2 Presentation 58 year old male with 3/12 history of persistent change in bowel habit following trip to India in January 2012 Watery loose diarrhoea No weight loss or rectal bleeding Examination was unremarkable No significant past medical history No remarkable family history No drug history Non- smoker and only drinks very occasionally

3 Differential diagnosis? Which is most likely?

4 Causes of diarrhoea Infective bacterial, viral, parasitic? Malabsorption Enzyme deficiencies/mucosal abnormality Lack of pancreatic secretions Drugs Irritable Bowel Syndrome Inflammatory Bowel disease Other Ischaemic bowel disease Microscopic colitis Hormone secreting tumours Hyperthyroidism

5 Investigations & Initial management Metronidazole started (Giardia?) Stool culture Parasitology FBC U+E Haematinics LFT TFT CRP Anti TTG Ab

6 Results ALL NORMAL CRP 18 (0-10mg/L) March Colonoscopy & biopsy to rule out IBD Hypoplastic polyps but with no background inflammation

7 June 2012 Still complaining of persistent watery diarrhoea (upto 15x/day) Started on Pentasa ( 5 ASA) Repeat CRP and faecal elastase CRP <5 Faecal elastase 90µgEl/g (normal value >200µgEl/g) Started on Creon 10,000 before each main meal

8 September 2012 Presented to A+E after a collapse at home Admitted to feeling tired and lethargic with muscle cramps Na 135 K 2.3 Urea 8 Creatinine 109 egfr 64 Treated with amiloride and Sando- K tablets Referred back to gastro clinic and CT requested

9 How would you investigate his hypokalaemia?

10 How would you investigate his hypokalaemia? ECG BP Acid base balance Electrolytes and glucose Urine potassium Endocrine Cause of diarrhoea

11 GI loss Renal loss Cellular shift Reduced intake vomiting diuretics alkalosis NBM diarrhoea Intrinsic disease insulin anorexia High output stoma Hyperaldosteronism B agonists malnutrition Laxative abuse Barters/Gitelmans

12 CT: - large, distended bowel and a 4cm mass in the tail of the pancreas with peri-tumoral lymph nodes. Part of the tumour was shown to be entering into the splenic vein; there was also a probable 35mm umbilicated liver metastasis present.

13 Next steps.. Gut Hormone Profile = NEURO- ENDOCRINE TUMOUR VIP level 191pmol/L (0-30pmol/L) Chromogranin A 101 (0-60) MDT meeting discussion Laparoscopy to image and biopsy abdomen & pelvis Confirmed neuro-endocrine tumour November 2012

14 Surgery December 2012 Lanreotide and Ocreotide infusion pre-operatively to restore K+ Underwent Subtotal pancreatectomy Splenectomy Extensive Lymphadenoctomy Liver resection Incision hernia repair Macroscopic clearance of all the tumour apart from the posterior aspect of the pancreas Post operative VIP 43 pmol/l

15 Histology of liver metastases confirming VIPoma

16 VIPoma Rare neruo-endocrine tumour typically arising from pancreas Incidence 1 per 10,000,000 Actively secretes Vasoactive Intestinal peptide - stimulates the secretion and inhibits the absorption of sodium, chloride, potassium and water within the small intestine and increases bowel motility - secretory diarrhoea, hypokalaemia (low potassium), and dehydration Stool volumes of greater than 3L/day occur in 70% of these patients

17 April months later Presented with watery diarrhoea (up to 20x/day) similar to first presentation Repeat CT Ocreotide scan

18 CT in July 2014: 4.2 x 3.5 cm lesion causing indrawing of liver capsule Presumed liver metastasis from the primary neuroendocrine tumour

19 Ocreotide scan confirming liver metasteses by demonstrating single focus of abnormal uptake in the liver

20 Disease relapse Admitted in November 2014 to A&E following symptomatic hypokalaemia Serum K+ on admission 2.2mmol/L Unable to move limbs IV fluids and IV potassium replacement Ocreotide commenced Medically optimised for surgery

21 Surgical management Underwent resection of large simple liver lesion Several further lesions were noted intraoperatively Histology confirmed metastatic neuroendocrine tumour. Discharged home on octreotide. Referred to the oncology for adjuvant therapy.

22 K+ level from presentation to present day

23 Therapeutic options in metastatic disease odebulking surgery may be helpful in controlling the symptoms and prolongs survival osomatostatin analogues suppress VIP secretion and control diarrhoea in up to 90%. othey also show anti-proliferative effects and tumour shrinkage (1-5). oglucocorticoid may be helpful in Octreoide resistant patients (6) ocytoxic chemotherapy has a radiological response rate of 10-40%. otherapy combinations include streptozocin, doxorubicin and temozolomide. ohepatic artery embolization may reduce hormone secretion, control symptoms and show radiological improvement (7).

24 Relevant reading & references Accessed 4/12/14: The VIPoma syndrome ; Stephen E Goldfinger, MD; uptodate.com 3. Pavel M, Baudin E, Couvelard A, et al. ENETS Consensus Guidelines for the management of patients with liver and other distant metastases from neuroendocrine neoplasms of foregut, midgut, hindgut, and unknown primary. Neuroendocrinology 2012; 95: Aparicio T, Ducreux M, Baudin E, et al. Antitumour activity of somatostatin analogues in progressive metastatic neuroendocrine tumours. Eur J Cancer 2001; 37: Sidéris L, Dubé P, Rinke A. Antitumor effects of somatostatin analogs in neuroendocrine tumors. Oncologist 2012; 17: Strosberg J, Kvols L. Antiproliferative effect of somatostatin analogs in gastroenteropancreatic neuroendocrine tumors. World J Gastroenterol 2010; 16: Verslype C, Carton S, Borbath I, et al. The antiproliferative effect of somatostatin analogs: clinical relevance in patients with neuroendocrine gastro-entero-pancreatic tumours. Acta Gastroenterol Belg 2009; 72: Medical therapy of VIPomas. O'Dorisio TM, Mekhjian HS, Gaginella TS; Endocrinol Metab Clin North Am. 1989;18(2): Gupta S, Johnson MM, Murthy R, et al. Hepatic arterial embolization and chemoembolization for the treatment of patients with metastatic neuroendocrine tumors: variables affecting response rates and survival. Cancer 2005; 104:1590.