Villous Adenoma Causing Renal Failure and Hypokalemia: 1431

We report a rare case of McKittrick-Wheelock syndrome. 46-year-old woman with history of irritable bowel syndrome presented with nausea and dizziness for a week. She had on and off Watery diarrhea for few weeks associated with mild lower abdominal discomfort. She also had 10 pounds weight loss in last 1 year. Denied any fever, chills, vomiting, headache, vision changes or focal weakness. On exam patient was orthostatic positive with supine blood pressure of 101/60 mmhg, heart rate 108 /min and had dry mucous membranes. She was afebrile with normal saturation on room air. Rest of the exam was normal. On Initial lab tests, she was found to have blood urea nitrogen of 132 mg/dl (normal 7-20 mg/dl), creatinine of 4. 6 mg/dl (normal 0.5-1.1mg/dl), Sodium 128 mEq/l (normal 135- 146 mEq/l), Potassium of 3.0 mmol/l (normal 3.5- 5.5 mmol/l), lactic acid level of 3.8 mmol/l (normal 0.5 - 1.0 mmol/l) and leukocyte count 12,000 / mcl (normal 4400 - 1100 / mcl). Urine analysis was negative for casts and signs of infection. Patient was started on aggressive fluid resuscitation and electrolytes were replaced. Stool studies, Including WBC, Culture, Ova parasites and Clostridium difficile toxin were negative. By day four renal function was improving and electrolytes were corrected, however patient continued to have diarrhea. Colonoscopy revealed a 6cm mass in the rectum. Histopathology showed the mass to be a secretory villous adenoma. In the setting of chronic diarrhea kidney injury and hypokalemia, Patient was diagnosed with possible McKittrick- Wheelock syndrome. Eventually patients renal function improved and she underwent a resection. McKittrick-Wheelock syndrome, is a rare condition resulting in acute kidney failure, electrolyte imbalance secondary to secretory diarrhea from villous adenoma of the colon. Large secretory villous adenomas especially in the rectum lead to large volume diarrhea, given less surface area for reabsorption further down the gastrointestinal tract. Volume depletion leads to pre-renal kidney failure evidenced by the high blood urea and creatinine. Also associated are electrolyte abnormalities like hyponatremia and hypokalemia as in our patient. Without aggressive fluid and electrolyte replacement the condition is life-threatening. Once electrolyte abnormalities are corrected definitive treatment is endoscopic or surgical resection.