Endocrine Abstracts

Introduction: The defecatory strain in constipated people can raise the blood pressure and occasionally trigger cardiovascular events.

Methods: Review of the patient’s clinical records and the relevant literature.

Results: Clinical Case: A 53-year old woman with history of breast surgery for adenocarcinoma and chronical constipation had severe resistant hypertension in the previous three years; she had hypertensive crises with SBP up to 260 mmHg with headache but no vegetative symptoms; often these crises had been elicited by the defecation strain. In a extension study five years after breast surgery the CT showed a heterogeneous, dense (mean density 110 UH) right adrenal mass measuring 39–43 mm suggestive of metastasis; she was referred to our Hypertension Clinic for evaluation. Under treatment with amlodipine and doxazosine lab tests were obtained, with normal cortisol, ACTH, LH, FSH, aldosterone, renin activity and A/RA ratio (10.5); plasma metanephrine was 104 pg/ml and normetanephrine >2400 pg/ml. A 125-I-MIBG SPECT-CT showed intense activity in the right adrenal without additional findings. After routine presurgical preparation with doxazosine followed by bisoprolol, a 24 h ABPM was performed showing a diurnal mean BP of 127/65 mmHg, HR 87 bpm, and nocturnal 120/64 mmHg, HR 83 bpm (non- dipper) without any SBP data >130 except for a peak (148/76 mmHg) at 21:34 coincident with strained defecation. The right adrenal was laparoscopically removed without complications. The pathology diagnosis was a 6 cm pheochromocytoma without apparent malignancy (Ki-67 <2%). After the surgery the patient remains normotensive without medication and her plasma metanephrines are normal (32/64 pg/ml) but remains constipated.

Conclusions: The defecation strain associated to chronic constipation might squeeze a large non-metastatic pheochromocytoma and cause hypertensive crises. Although raised blood pressure in connection with constipation has often been reported, the triggering of hypertensive crises by defecation strain in a patient with pheochromocytoma had not been previously reported in our knowledge.