A patient’s newly discovered malignancy was evidently accompanied by a sodium deficit. The 48-year-old man presented to the Emergency Department for evaluation of abdominal pain and weight loss. He described gradual onset of severe, burning, epigastric pain with radiation to the back. In addition, he reported a 70-lb weight loss over 2 months, yellowing of the eyes and skin, darkening of the urine, and occasional clay-colored stools. He had not experienced fevers, nausea, vomiting, or diarrhea. His abdominal discomfort had caused him to eat less in recent days than he would have previously.
The patient admitted that over the previous 2 months, he had been using heroin, which partially relieved the pain. His medical history included chronic low back pain and hypertension, for which he took lisinopril, 10 mg daily, and hydrochlorothiazide, 25 mg daily. His serum sodium was low at 121 mmol/L. He was admitted to the General Medicine department for further evaluation and management of his hyponatremia and abdominal pain.
Assessment
On examination, the patient’s vital signs were within normal limits. He was cachectic with jaundice of the sclerae and skin. His jugular venous pressure waveform was not elevated, and the rest of his cardiopulmonary examination was normal as well. A palpable mass was identified in his right upper quadrant, and severe tenderness was elicited by both light and deep palpation. No peritoneal signs were present. He had no lower-extremity edema and no stigmata suggestive of chronic liver disease or endocarditis. The neurological examination was normal.
In addition to hyponatremia, the patient had the following laboratory results: potassium level 3.2 mg/dL; blood glucose level 106 mg/dL; blood urea nitrogen level 21 mg/dL; serum osmolality 272 mOsm/kg; total bilirubin level 32.9 mg/dL; alkaline phosphatase level 2134 U/L; aspartate aminotransferase level 276 U/L; and alanine aminotransferase level 197 U/L. Urine osmolality was 537 mOsm/kg, and a random urine sodium was 71 mEq/L.
Abdominal ultrasound revealed a hypoechoic, heterogeneous mass, measuring 4.8 cm × 3.3 cm × 2 cm, at the head of the pancreas, as well as pancreatic ductal dilation, narrowing of the splenic vein confluence, diffuse biliary intrahepatic dilation, and mild pancreatic duct dilation. The findings were confirmed on abdominal computed tomography, which also demonstrated a tumor surrounding the superior mesenteric artery (Figure). The findings, combined with the patient’s symptoms, pointed toward malignancy. No evidence of distant metastasis was seen.
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-Michael L. Adashek, DO, Bennett W. Clark, MD, C. John Sperati, MD, MHS, Colin J. Massey, MD
This article originally appeared in the December 2017 issue of The American Journal of Medicine.
