A 65-year-old patient with a history of alcoholism and chronic ethylic liver disease.
The patient was operated on in January 2008 for a stenosing adenocarcinoma of the sigmoid colon, performing a subtotal colectomy and a terminal ileostomy in the right iliac fossa.
Eight months later intestinal transit reconstruction was performed with end-to-end anastomosis and ileostomy closure.
Shortly after (November 2008) the patient was admitted for fecal peritonitis, performing a resection of 1.5 meters of small intestine leaving definitive terminal ileostomy with rectal stump abandoned in the pelvis, without possibility of subsequent reconstruction.
Two months after the second intervention (January 2009), the patient was admitted again to the hospital due to acute renal failure and secondary electrolyte disturbances, together with an ileostomy output greater than 1500 ml/day.
At that time he was treated with Tramadol, Paracetamol, Oral Iron and a loop diuretic (Furosemide) due to the presence of lower limb edema.
Subsequently, the patient came back to the hospital on several occasions, being the emergency service affected by renal failure and lack of awareness, hospitalization and electrolyte disturbances, which resolved in the service itself and did not require hospitalization.
In July 2009, the patient came to the emergency department again due to worsening of her general condition, with significant asthenia, prostration, difficulty walking and oliguria.
Blood tests performed in the emergency department showed: Creatinine: 4 mg/dl (LN 0.6-1.40); Sodium: 113 meq (LN 135-145); Potassium: 6.7 mg / lP
After several days of parenteral rehydration, the patient is discharged.
Then, the diuretic was discontinued and treatment was initiated with orally disintegrating salts, Loperamide (2 mg/8 hours) and Magnesium salts (Lactato Magq a dose of 8 mmol/ l) per dose.
One week later, the patient suffered syncope at home with a fall to the ground and mild head trauma in the right frontal region.
Upon arrival to the emergency department, the patient presented two episodes of tonic-clonic seizures with diazepam IV.
A few minutes later she suffered a third crisis, which is why she began treatment with intravenousphenytoin and was admitted to the Intensive Care Unit (ICU).
A cranial CT scan showed minimal subarachnoid hemorrhage in the left suprasylvian region secondary to CT.
ECG and chest X-ray showed no significant changes.
Analytical analysis showed ion Ca: 2.3 mg/dl (LN 3.9-5.2); 25-hydroxyvitamin D: 10 ng/ml (LioN 2.8 meq; Ponesium 0.5 mg/dl; Sodium 125 mg/dl).
IV treatment was initiated with rehydration therapy, as well as intravenous treatment with magnesium sulfate, calcium gluconate and potassium chloride to correct electrolyte deficits.
During his stay in the ICU he did not present new episodes of crisis or neurological focality, and at discharge in this service magnesium, calcium and potassium levels had normalized.
Interconsultation with the Nutrition Unit was then requested, aiming at the physical examination a weight of 63 Kg (usual weight one year before: 74 Kg), height 1.68 m, BMI 22.3 Kg/m2, along with signs of fat mass decrease.
During the 3 weeks that the patient was hospitalized, he was treated with dietary measures such as: stront diet, low fat and simple sugars, rest of 30 minutes after meals, fluid intake outside meals.
In addition, treatment was established with oral rehydration salts (Sueroral®), Loperamide (14 mg/day), Codeine (90 mg/day), oral Magnesium supplements (account for cardiac failure 60 meq).
The output by the ileostomy was at the beginning of 1500-2000 ml/day and at discharge 800-1000 ml/day.
Their nutritional status improved normalizing the following nutritional parameters: cholesterol, albumin, Prealbumin and protein binding.
Weight decreased from 63 kg to 61 kg, and there were no signs of malignant and pretibial edema.
At discharge, Mg levels were below normal, although relatively "safe" (Mg 1.3); with magnesiuria of 14.7 (LN 50-150), Sodium, Potassium, i Total Calcium.
In the last days of admission, it was decided to change Colecalciferol to Calcitriol (0.25 micrograms/day), in order to promote and improve magnesium absorption, maintaining oral calcium doses (1500 mg/day).
PTH levels at discharge were normalized (38pg/ml), as well as vitamin D levels (20ng/ml).
Currently the patient performs revisions in Nutrition consultation, presenting good general condition, debits for the ileostomy of 1000 + 200 ml/day; with medication levels of Mg within the normal range (1.9 mg/dl gradually reducing the rest of lactate).
