Case Presentation

Dana Assis, MD Tuesday October 10th

• HPI: CR 71 year old male with duodenal adenoma

• PMH: hepatitis C (untreated), latent Tb, Crohn’s disease, COPD, IDDM, CAD, HFpEF

• PSH: open cholecystectomy • All: haldol, primaquine • Social: denied toxic habits, former smoker quit

>10 years ago

Outpatient Medications • Alendronate, Aspirin, benztropine, calcium

carbonate, cholecalciferol, gabapentin, insulin, mesalamine, metoprolol, olanzapine, pantoprazole, rifampin, simvastatin, venlafaxine, infliximab

Hospital Course • 9/2015: duodenal adenoma, high grade

dysplasia, underwent pancreaticoduodenectomy

• 10/2015: ileus, pancreatic leak, attempted trials advancing diet failed, vomiting, delayed gastric emptying, NGT and GT placement

• Altered mental status, sirs criteria, transferred SICU

Physical Exam Tm 101.7 HR 100-120 BP 98/56-116/73 O2 92% 4L NC wt 211 lbs Gen: acutely sick, alert, oriented to self Heent: dry mucus membranes, jvp not elevated, NGT suction copious drainage Pulm: lungs clear without wheeze or crackles CV: tachycardic without murmurs Abd: distended, bs positive, tympanic, no ttp Ext: no pedal edema, wwp, distal pulses 2+ Neuro: strength intact, following simple commands

Laboratory Findings Baseline Na 137 K 3.7 Cl 105 CO2 24 Bun 19 Cr 0.8 Two days prior to transfer Na 140 K 3.4 Cl 94 CO2 36 Bun 39 Cr 1.2 SICU 6am Na 147 K 3.6 Cl 73 CO2 41 Bun 92 Cr 3.3 pH 7.650 pO2 65.8 pCO2 54 HCO3 60.5 BE 32.6

1:30pm Na 150 K 3.2 Cl 72 CO2 > 40 Bun 104 Cr 4 pH 7.610 pO2 73.5 pCO2 56.5 HCO3 57 BE 30 8pm Na 152 K 3.3 Cl 76 CO2 54 Bun 108 Cr 4.1 pH 7.561 pO2 91 pCO2 64 HCO3 58 BE 30

Urine Na 37 K 106 Cl 5 Neg: glucose, ketones, blood Protein 100mg/dl pH 9 (10/12) pH 6 (10/13) Liver Tp 7.9 Albumin 3.1 Tb 1 Db 0.7 Ast 83 Alt 38 Alk P 96

Summary

• Metabolic alkalosis with respiratory compensation

• Cause: GI losses 2/2 NGT drainage • AKI non oliguric

Whipple procedure

GI Tract

Metabolic Alkalosis

• Volume depletion: – secondary hyperaldosteronism leads to stimualtion

H-ATPase in collecting tubules and also stimulates ENac

• Hypokalemia: – Stimulates H-K ATPase pump

• Hypochloremia: – Type B intercalated cells H-ATPase on basolateral

rather than luminal membrane – NaK2Cl carrier in macula densa

Treatment

Treatment

Case follow up 2days post SICU tx pH 7.4 pCO2 67 pO2 78 Na 150 K 3.5 Cl 107 CO2 36 Bun 78 Cr 2.9 6days post SICU tx Na 139 K 3.5 Cl 111 CO2 18 Bun 38 Cr 1.3