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Perforated peptic ulcer and cachexia associated with unsuspected severe hyperparathyroidism from an occult giant parathyroid adenoma.

Sarah Pearlstein, MD, Daniel Kuriloff, MD, FACS, ECNU, Rebecca Kowalski, MD, FACS. Northwell Health

Introduction: Giant parathyroid adenomas (>3.5gm) are a rare cause of primary hyperparathyroidism (PHPT). Despite having elevated calcium and PTH levels, they usually present with asymptomatic disease, especially with the widespread use of biochemical assays in screening exams. Symptomatic hyperparathyroidism classically can present as fatigue, muscle weakness, memory loss/confusion, bone pain, abdominal pain, constipation, and nephrolithiasis. We present a case of abdominal pain and cachexia from a perforated peptic ulcer (PPU) as the first presenting sign of occult primary hyperparathyroidism from a giant parathyroid adenoma.

Case Description: A 59 year-old cachectic male presented with two days of worsening abdominal pain and nausea. The patient had no history of gastroesophageal reflux or peptic ulcer disease (PUD). On admission, serum calcium was elevated to 12.3mg/dL (upper limit 10.5mg/dL).  CT scan of the abdomen/pelvis demonstrated duodenal wall thickening with perforation and pneumoperitoneum.  There were no renal calcifications.  He was taken to the OR for a laparoscopic Graham patch and abdominal washout.  On POD1 (post-operative day 1), serum calcium remained elevated at 12.5mg/dL A PTH on POD2 was 1184 pg/mL (normal:up to 65pg/mL) confirming primary hyperparathyroidism. He was treated with intravenous fluids and furosemide, but the serum calcium remained elevated.  A SPECT/CT Sestamibi scan showed a giant left extrathyroidal mass with intense uptake, consistent with giant parathyroid adenoma. Ultrasound of the neck revealed a 5.4×2.7x 2.8cm mass. DEXA scan showed osteoporosis in the lumbar spine and left femoral neck. Serum gastrin level was normal 39pg/mL (4-200pg/mL). He underwent a parathyroidectomy. Calcium and PTH returned to normal by POD1 (9.8mg/dL, 22.6pg/dL). Pathology confirmed a giant parathyroid adenoma (3.6×3.0x1.2cm and 12gm).

Discussion: PPU is associated with a mortality of up to 30%, and morbidity of 50%. The etiology of PUD includes H pylori, NSAIDs and smoking. The association of PUD and hyperparathyroidism is well known, and studies have shown that improvement in peptic ulcer symptoms can occur after parathyroidectomy. It has been suggested that increased calcium levels due to hyperparathyroidism can lead to gastric acid hypersecretion and therefore PUD.  Peptic ulcer perforation as the first manifestation of PHPT is rare and to our knowledge the first reported case caused by giant parathyroid adenoma.

Conclusion: In patients with a perforated peptic ulcer without obvious cause, we recommend obtaining a serum calcium level, and if elevated, a PTH to rule out hyperparathyroidism. 


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 85618

Program Number: P166

Presentation Session: iPoster Session (Non CME)

Presentation Type: Poster

129

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