Endocrine Abstracts

Case history: 58 year old man presented with collapse secondary to profuse water diarrhoea. He had severe AKI, hypokalaemia, metabolic acidosis, hyponatraemia and hypercalcaemia. He had fluid and electrolyte replacement he in ICU, but profuse diarrhoea persisted and with it, was in hypotension and delerium. He had been having progressive diarrhoea and weight loss for 2 years while he was in South Africa.

Investigations: Upper and lower GI endoscopies had been negative. CT abdomen showed a lesion in the pancreas with liver and lung metastasis. His liver biopsy was suggestive of G2 Neuroendocrine tumour (NET). His blood tests showed Na 116 mmol/l, K 2.9 mmol/l, Ca 3.4 mmol/l, Creatinine 395 micromol/l, pH 7.01, and bicarbonate 3 mmol/l. His chromogranin A was 6104(0-59pmol/l) and chromogranin B was 1122 (0-149 pmol/l), VIP 118(0-30pmol/l), somatostatin 7116pmol/l (0-150pmol/l). His FDG PET CT showed uptake in the pancreatic, liver and lung lesions, but the lesions were not very avid on Gallium Dotatate PET CT.

Results and treatment: In ICU, he was given an octreotide infusion at 200 mg/ hour, with creon and loperamide. Diarrhoea improved, but calcium increased to 3.9 mmol/l inspite of aggressive hydration. So he had bisphosphonates and 3 days of ultrafiltration after which AKI and hypercalcaemia resolved. Octreotide was reduced to 6 hourly and he had a staging CT to consider chemotherapy and radiofrequency ablation of liver lesions. Unfortunately his functional status was PS3/4, so couldn”t have systemic chemotherapy or ablation. He had 120 mg s/c Lanreotide which is a long acting somatostatin analogue.

Conclusions and points for discussion: We present here a patient who had a functioning pancreatic NET with VIPoma and somatostatinoma features. It also illustrates the catastrophic metabolic derangements such conditions can present with. Octreotide infusion can help reduce the severity of the diarrhoea by binding to the somatostatin receptors and reducing the output of the functioning peptides.