Case
Presentation
An 81 y/o woman was admitted to our hospital due to bloody
stool noted for 2 weeks.
The patient was a case of end-stage renal disease. She had
been treated with hemodialysis trice a week regularly at a
local clinic for one and a half year. Generalized bone pain
had been complained of since about 3 months ago. Constipation,
nausea, poor appetite, and body weight loss developed
gradually, and she became totally bedridden afterwards. Bloody
stool was noted 2 weeks before admission, and hemorrhoid
bleeding was initially impressed. As bloody stool persisted
and bone pain became more severe, she was sent to our hospital
for further management. Tracing back her past history, she was
a hepatitis B carrier without regular follow-up, and she had
not taken any drug.
She looked weak and stupor at admission. The body
temperature was 35.5 ℃, the pulse was 90 beats per minute, and
the respiration rate was 18 per minutes. Her blood pressure
was 129/58 mmHg. Her conjunctivae were pale and her neck was
supple. A grade III/VI systolic ejection murmur was noted at
left lower sternal border. Diffuse abdominal tenderness and
generalized edema were found. Bloody stool was noted by
digital examination. Other physical check-up was not
significant.
Table 1. Hematologic Laboratory
Values.
RBC |
Hb |
Hct |
MCV |
PLT |
WBC |
Seg |
M/μL |
g/dL |
% |
fL |
K/μL |
K/μL |
% |
3.05 |
9.4 |
30.5 |
100 |
102 |
14.1 |
89 |
Table 2. Blood Chemical
Values.
Alb |
Glo |
Sugar |
Bil (T) |
GOT |
GPT |
BUN |
Cr |
g/dL |
g/dL |
mg/dL |
mg/dL |
U/L |
U/L |
mg/dL |
mg/dL |
2.2 |
3.7 |
103 |
0.6 |
49 |
21 |
87 |
3.5 |
P |
Na |
K |
Ca |
Cl |
mg/dL |
mmol/L |
mmol/L |
mg/dL |
mmol/L |
3.9 |
148 |
3.8 |
15.76 |
113 |
Stool routine: parasite ova (-), O.B. (+++) CEA 16.5
ng/mL αFP 4.76 ng/mL intact parathyroid hormone 12 pg/mL
As the patient had hypercalcemia and inadequate
intravascular volume, 2.5% glucose-saline 250 mL was infused
after hospitalization. Hemodialysis with low-calcium dialysate
was prescribed. Empirical antibiotics with cefazolin and
gentamycin were given for possible infection. Supine chest
film showed mild infiltration at right lower lung area and
small amount of right side pleural effusion. Abdominal
sonography showed liver cirrhosis with multiple liver tumors,
left renal stones, and moderate amount of ascites.
Colonofibroscopic examination revealed a cauliflower-like
tumor mass 10 cm above anal verge which was later confirmed to
be adenocarcinoma pathologically.
The family preferred supportive treatment only as the
patient was old and suffered from colon cancer with multiple
metastases. Therefore the patient was discharged when her
condition became stable.
病案分析 本病人患有高血鈣症,並出現部份高血鈣症的典型症狀,包括便秘、食慾不振、全身無力及意識遲鈍。至於病人發生高血鈣症的原因,分析可能有四:
(一) 病人食慾不振及血清白蛋白過低,使血管內有效容積不足; (二) 病人長期臥床,使骨骼中的鈣質流失; (三)
病人患有大腸癌合併骨骼轉移; (四)
高鈣透析液的使用。治療方面,需針對高血鈣症的原因對症下藥。至於降血鈣的方法,除了給予病人低鈣飲食外,一般為補充水份和使用furosemide類的利尿劑來減少尿鈣的吸收,但本病人為末期腎病的患者,幾乎無尿,而且已有全身水腫,不適合大量補充水份,加上使用利尿劑的效果也不佳,故在病人住院後只給與適量的輸液補充而已。Pamidronate等biphosphonates類藥物可有效抑制骨骼再吸收,但其作用時間較慢;
pamidronate及clodronate在腎衰竭病人不適合使用。Calcitonin的作用時間較快但很短,它能有效抑制骨骼再吸收,也可以增加尿鈣的排泄。類固醇藥物一般使用在患有如淋巴癌及多發性骨髓瘤的病人身上,但需注意類固醇的各項副作用。在接受透析治療的病人,則可使用無鈣或低鈣透析液。
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