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Adult pyloric stenosis—a forgotten entity

Adult pyloric stenosis—a forgotten entity Age and Ageing 2006; 35: 448 © The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org Clinical Reminders Table 1. Laboratory tests Two months after A 73-year-old man was admitted to the medical admission Liver tests Normal values On niacin stopping niacin unit with severe metabolic alkalosis (pH 7.62, bicarbonate . ... .... ... .... .... .... .... .... ... .... .... .... .... .... .... ... .... .... .... .... .... .... . T. Bilirubin 0.3–1.5 (mg/dl) 6.9 (mg/dl) 1.0 (mg/dl) 53 mmol/l, base excess +30, chloride 93 μmol/l) and acute Direct Bili 0–0.3 (mg/dl) 4.6 (mg/dl) renal failure (urea 44 mmol/l, creatinine 567 mmol/l) because GGTP 1–50 (U/l) 2,807 (U/l) 68 (U/l) of persistent vomiting. Before 7 years, a narrow pyloric Alkaline canal was noted on endoscopy while he was investigated for phosphotase 37–147 (U/l) 2,315 (U/l) 113 (U/l) weight loss. He took Lansoprazole intermittently for epigas- AST 1–55 (U/l) 127 (U/l) 19 (U/l) tric pain. Shortly after admission, he died from ventricular ALT 5–45 (U/l) 86 (U/l) 25 (U/l) fibrillation. CA19-9 0–36 (U/l) 241 (U/l) 24 (U/l) CEA 0–5 (ng/ml) 22.8 (ng/ml) 5.3 (ng/ml) The prevalence of peptic ulcer disease is decreasing among British population over the years because of Helico- ALT, alanine aminotransferase; AST, aspartate aminotransferase; CA19-9, bacter pylori eradication and widespread use of acid suppres- carbohydrate antigen 19-9; CEA, carcinoembryonic antigen; GGTP, gamma sants [1]. Consequently, elective surgery has also declined glutamyltranspeptidase. dramatically [2]. However, there are older people with com- plications from previous peptic ulcers whose symptoms will remain at bay with proton pump inhibitors. Severe alkalosis because of pyloric stenosis should be managed in a critical patient did have an endoscopic retrograde cholangiopancre- care setting, administering hydrochloric acid through central atography, abdominal computerised tomography scan and venous access [3]. colonoscopy that were normal. The patient later revealed that he was taking non-prescription niacin, which was dis- ABHAY KUMAR DAS*, VIVEKANAND PATIL continued, and the patient’s liver tests, CEA and CA19-9 Pontefract General Infirmary, Medicine for the Elderly, levels returned to normal (Table 1). He continued to Friarwood Lane, Pontefract, WF8 1PL, UK improve and gain weight. *To whom correspondence should be addressed at: Niacin is used to treat certain types of dyslipidaemias [1]. Email: abhaylopa@yahoo.co.uk Flushing, hyperglycaemia, hyperuricaemia, thrombocytope- 1. Kang JY, Tinto A, Higham J et al. Peptic ulceration in general nia, acanthosis nigricans, ichthyosis and hepatic dysfunction practice in England and Wales 1994–98: period prevalence and are some of the adverse effects [2]. Niacin has not been drug management. Aliment Pharmacol Ther 2002; 16:1067–74. reported to cause elevation of tumour-associated antigens 2. Bardhan KD, Williamson M, Royston C et al. Admission rates with symptoms and signs suggestive of underlying malig- for peptic ulcer in the Trent region, UK, 1972–2000: changing nancy. Physicians need to be aware of this rare presentation pattern, a changing disease? Dig Liver Dis 2004; 36:577–88. mimicking malignancy caused by niacin to avoid expensive 3. Naka T, Bellomo R. Bench-to-bedside review: treating acid- and potentially harmful procedures. base abnormalities in the intensive care unit-the role of renal replacement therapy. Crit Care 2004; 8:108–14. 1 2 2 ABRAHAM JOSEPH *, TARUN KOTHARI , SUNDAR VENKATESH doi:10.1093/ageing/afl021 Fairmont Medical Center, 800 Clinic Circle, Fairmont, MN 56031, USA Unity Health System, 1560 Long Pond Road, Rochester, New York, NY 14626, USA Niacin toxicity: a rare presentation *To whom correspondence should be addressed mimicking malignancy at: joseph.abraham@mayo.edu A 79-year-old male patient presented with a 3-month his- 1. Britton ML, Bradberry JC, Letassy NA et al. ASHP therapeutic tory of significant weight loss and jaundice. Liver tests position statement on the safe use of niacin in the manage- revealed significant elevation in alkaline phosphotase, ment of dyslipidemias. American Society of Health-System gamma glutamyltranspeptidase and bilirubin levels. Carci- Pharmacists. Am J Health Syst Pharm 1997; 54: 2815–19. noembryonic antigen (CEA) and carbohydrate antigen 19-9 2. Knopp RH. Drug treatment of lipid disorders. N Engl J Med 1999; 341: 498–511. (CA19-9) levels were also markedly elevated (Table 1). Pain- less jaundice and weight loss with elevated CA19-9 levels in an elderly patient led us to suspect pancreatic cancer. The doi:10.1093/ageing/afl029 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Age and Ageing Oxford University Press

Adult pyloric stenosis—a forgotten entity

Age and Ageing , Volume 35 (4) – Jul 1, 2006

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References (3)

Publisher
Oxford University Press
Copyright
© The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
ISSN
0002-0729
eISSN
1468-2834
DOI
10.1093/ageing/afl021
pmid
16788085
Publisher site
See Article on Publisher Site

Abstract

Age and Ageing 2006; 35: 448 © The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org Clinical Reminders Table 1. Laboratory tests Two months after A 73-year-old man was admitted to the medical admission Liver tests Normal values On niacin stopping niacin unit with severe metabolic alkalosis (pH 7.62, bicarbonate . ... .... ... .... .... .... .... .... ... .... .... .... .... .... .... ... .... .... .... .... .... .... . T. Bilirubin 0.3–1.5 (mg/dl) 6.9 (mg/dl) 1.0 (mg/dl) 53 mmol/l, base excess +30, chloride 93 μmol/l) and acute Direct Bili 0–0.3 (mg/dl) 4.6 (mg/dl) renal failure (urea 44 mmol/l, creatinine 567 mmol/l) because GGTP 1–50 (U/l) 2,807 (U/l) 68 (U/l) of persistent vomiting. Before 7 years, a narrow pyloric Alkaline canal was noted on endoscopy while he was investigated for phosphotase 37–147 (U/l) 2,315 (U/l) 113 (U/l) weight loss. He took Lansoprazole intermittently for epigas- AST 1–55 (U/l) 127 (U/l) 19 (U/l) tric pain. Shortly after admission, he died from ventricular ALT 5–45 (U/l) 86 (U/l) 25 (U/l) fibrillation. CA19-9 0–36 (U/l) 241 (U/l) 24 (U/l) CEA 0–5 (ng/ml) 22.8 (ng/ml) 5.3 (ng/ml) The prevalence of peptic ulcer disease is decreasing among British population over the years because of Helico- ALT, alanine aminotransferase; AST, aspartate aminotransferase; CA19-9, bacter pylori eradication and widespread use of acid suppres- carbohydrate antigen 19-9; CEA, carcinoembryonic antigen; GGTP, gamma sants [1]. Consequently, elective surgery has also declined glutamyltranspeptidase. dramatically [2]. However, there are older people with com- plications from previous peptic ulcers whose symptoms will remain at bay with proton pump inhibitors. Severe alkalosis because of pyloric stenosis should be managed in a critical patient did have an endoscopic retrograde cholangiopancre- care setting, administering hydrochloric acid through central atography, abdominal computerised tomography scan and venous access [3]. colonoscopy that were normal. The patient later revealed that he was taking non-prescription niacin, which was dis- ABHAY KUMAR DAS*, VIVEKANAND PATIL continued, and the patient’s liver tests, CEA and CA19-9 Pontefract General Infirmary, Medicine for the Elderly, levels returned to normal (Table 1). He continued to Friarwood Lane, Pontefract, WF8 1PL, UK improve and gain weight. *To whom correspondence should be addressed at: Niacin is used to treat certain types of dyslipidaemias [1]. Email: abhaylopa@yahoo.co.uk Flushing, hyperglycaemia, hyperuricaemia, thrombocytope- 1. Kang JY, Tinto A, Higham J et al. Peptic ulceration in general nia, acanthosis nigricans, ichthyosis and hepatic dysfunction practice in England and Wales 1994–98: period prevalence and are some of the adverse effects [2]. Niacin has not been drug management. Aliment Pharmacol Ther 2002; 16:1067–74. reported to cause elevation of tumour-associated antigens 2. Bardhan KD, Williamson M, Royston C et al. Admission rates with symptoms and signs suggestive of underlying malig- for peptic ulcer in the Trent region, UK, 1972–2000: changing nancy. Physicians need to be aware of this rare presentation pattern, a changing disease? Dig Liver Dis 2004; 36:577–88. mimicking malignancy caused by niacin to avoid expensive 3. Naka T, Bellomo R. Bench-to-bedside review: treating acid- and potentially harmful procedures. base abnormalities in the intensive care unit-the role of renal replacement therapy. Crit Care 2004; 8:108–14. 1 2 2 ABRAHAM JOSEPH *, TARUN KOTHARI , SUNDAR VENKATESH doi:10.1093/ageing/afl021 Fairmont Medical Center, 800 Clinic Circle, Fairmont, MN 56031, USA Unity Health System, 1560 Long Pond Road, Rochester, New York, NY 14626, USA Niacin toxicity: a rare presentation *To whom correspondence should be addressed mimicking malignancy at: joseph.abraham@mayo.edu A 79-year-old male patient presented with a 3-month his- 1. Britton ML, Bradberry JC, Letassy NA et al. ASHP therapeutic tory of significant weight loss and jaundice. Liver tests position statement on the safe use of niacin in the manage- revealed significant elevation in alkaline phosphotase, ment of dyslipidemias. American Society of Health-System gamma glutamyltranspeptidase and bilirubin levels. Carci- Pharmacists. Am J Health Syst Pharm 1997; 54: 2815–19. noembryonic antigen (CEA) and carbohydrate antigen 19-9 2. Knopp RH. Drug treatment of lipid disorders. N Engl J Med 1999; 341: 498–511. (CA19-9) levels were also markedly elevated (Table 1). Pain- less jaundice and weight loss with elevated CA19-9 levels in an elderly patient led us to suspect pancreatic cancer. The doi:10.1093/ageing/afl029

Journal

Age and AgeingOxford University Press

Published: Jul 1, 2006

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