Hot Flashes and Abdominal Pain

Jennifer Snyder

During a routine physical examination, a 45-year-old woman complained to her gynecologist of a 3-month history of transient burning sensations in her face and chest that would last for a few minutes, and then pass. She stated that she experienced these "hot flashes" between 7 and 8 times per day, and often they disrupted her sleep. She had no other physical complaints, and she denied any menstrual cycle irregularities. To determine whether she was menopausal, the physician ordered a serum follicle stimulating hormone (FSH) test which was 10.9 IU/L (premenopausal reference interval: 1-10 IU/ L) on day three of the patient's menstrual cycle. Suspecting the woman's symptoms were due to perimenopausal transition, her doctor prescribed venlafaxine (a selective serotonin reuptake inhibitor), to minimize her hot flashes.

Despite treatment, the patient continued to have hot flashes, and one month later developed postprandial upper right quadrant pain, occasionally accompanied by abdominal distension and what she referred to as "excessive flatulence." She was referred to a gastroenterologist, who performed an abdominal ultrasound that revealed a 5-mm mass embedded in the wall of the gallbladder, thought to represent either a polyp or a gallstone. Despite normal liver function tests, the patient elected to undergo a laparoscopic cholecys-tectomy. Pathology on the gallbladder revealed a 3-mm stone.

One month after the surgery, the patient reported she was feeling much better; however, 4 months after surgery, she returned again to the gastroenterologist with stomach complaints. This time, she stated that she was having intermittent "episodes" where she became disoriented, then experienced hot flashes, right upper quadrant pain, vomiting, and diarrhea. These episodes began approximately one month after the cholecystectomy, but had recently become more frequent. She had lost 15 lb because of a decrease in appetite during and after these attacks.

Laboratory data included the following:

Value,

Reference

Reference

Conventional

Range,

Value,

Range,

Analyte

Units

Conventional Units

SI Units

SI Units

AST

40 U/L

14-38

0.68 mkat/dL

0.24-0.65

ALT

61 U/L

15-48

1.04 mkat/dL

0.26-0.82

ALP

133 U/L

38-126

2.26 mkat/dL

0.65-2.14

Value,

Reference

Reference

Conventional

Range,

Value,

Range,

Analyte

Units

Conventional Units

SI Units

SI Units

Bilirubin, total

0.3 mg/dL

0.0-1.2

5.1 mmol/L

0.0-20.5

Amylase

32 U/L

30-110

0.54 mkat/dL

0.51-1.87

Lipase

107 U/L

44-232

1.82 mkat/dL

0.75-3.94

Carcinoembryonic

0.9 ng/mL

<5

0.9 mg/L

<5

antigen

CA 19-9

8 U/mL

<37

8 kU/L

<37

To rule out a bowel obstruction, radiographic examination included an upright chest, plus supine and upright abdominal films. These revealed multiple air fluid levels with dilated loops of small bowel. As these results indicated a possible small bowel obstruction, a small bowel follow-through with barium contrast was done that showed evidence of a circumferential smooth-walled narrowing in the mid-to-distal ileum. A laparoscopic small bowel exploration was performed, and a 5-cm mass was removed from the ileum along with five mesenteric lymph nodes. These specimens were sent to pathology for immunohistochemistry, which demonstrated reactivity with chromogranin A and synapto-physin, two markers for neuroendocrine tumors. On the basis of this result, the physician ordered serum chromogranin A and 24-hour urine 5-hydroxyindoleacetic acid (5-HIAA) measurements one week after the surgery. The results were

Chromogranin A 150 ng/mL (normal = 0-51 ng/mL)

5-HIAA (24-hour urine) 161.4 mg/24 hours (normal = 2-8 mg/24 hours)

Additionally, an Octreoscan using radiolabeled octreotide (a somatostatin analog that binds to somatostatin receptors expressed on the surface of carcinoid tumors) and abdominal computed tomography (CT) were performed that revealed lesions in the liver compatible with metastatic disease.

On the basis of these findings, the patient was diagnosed with carcinoid syndrome due to metastatic carcinoid tumor. She was placed on octreotide therapy, and her 5-HIAA concentrations decreased, as did her "episodes," now noted to be consistent with carcinoid syndrome.

From PMS To PPD

From PMS To PPD

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